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A publication of the Southern African HIV Clinicians Society
Optimising ART in the 21st century
Dolutegravir: The game changer?
Safer conception service for HIV-affected couples
Two breakthrough studies in TB health care
May 2017 Vol. 8 No. 1
SOUTHERN AFRICAN HIV CLINICIANS SOCIETY CONFERENCE 2018
JOHANNESBURG, SOUTH AFRICA | 24 - 27 OCTOBER 2018
ABOUT THE CONFERENCE
The Conference programme is being carefully designed to benefit all health
care practitioners. There will be a wealth of current and thought-provoking
academic presentations, fascinating ethics sessions as well as practical
sessions such as case studies and skills-building workshops.
CONFERENCE PROGRAMME FOCUS AREAS
ARVs • Women’s Health • Paediatric & Adolescent • Basic Science •
Monitoring & Evaluation • Prevention • Operations Research •
PHC & Nursing • TB • Opportunistic Infections • HIV Resistance
EARN CPD POINTS
The Conference will be fully CPD-accredited, providing delegates with an
opportunity to accumulate clinical and ethical points. Level One: 30 points
including ethics. Level Two: 45 points including ethics (subject to completion
of an online multiple choice test).
WHO SHOULD ATTEND?
Infectious diseases physicians, NIMART-trained (or interested) nurses, general
practitioners, HIV specialists, academics and other health care professionals.
JOIN US IN 2018 FOR THE SOUTHERN AFRICAN HIV
CLINICIANS SOCIETY 4TH BIENNIAL CONFERENCE!
Website: www.sahivsoc.org
Telephone: +27 (0)11 728 7365
2 18
Email: conference@sahivsoc.org
HIV Nursing
Matters
inside
focuses on
innovation
2 Guest editorial
Lauren Jankelowitz
TB corner
20 Nix-TB: A turning point in treating
On the cover
XDR-TB
• Optimising ART in the 21st century
3 Message from the president 21 Pred-ART: Towards preventing
• Dolutegravir: The game changer?
Francesca Conradie TB-IRIS
• Safer conception service for
HIV-affected couples
News 22 C
ontinuous QI
• Two breakthrough studies in
4 Nurses need debriefing and Data – friend or foe?
TB health care
counselling
5 From the heart of rural health to 26 P
ersonal story
the minds of the DoH Pushing boundaries
8 A road trip to off-the-beaten-track
clinics 28 Competition
Current issues 30 What to do
10 Optimising ART in the 21st century
13 Dolutegravir: The game changer? 31 Where to go
Clinical updates 32 Dear clinician column
16 Safer conception clinic for
HIV-affected couples
HIV Nursing Matters | May 2017 | page 1
Guest editorial
As I write this, it is a sad and uncertain An article on safer conception (page
time for our country. It is hard to write 16) reflects the desire for HIV-affected
about innovation, which represents light, couples to have children, and explains
change and movement, when to me, the how far we have come in supporting
future seems so dark and indeterminate. these couples to make this desire a
Health care leaders are anxiously trying reality. The article discusses strategies
to plan for the continuation of HIV, TB and used in order to ensure safe conception,
other critical services as money is starting while keeping both the HIV-negative
to dry up. It is in this context that we truly partner and unborn child safe and
require innovative thinking to obtain new uninfected.
and more effective ways to keep the HIV
sector moving forward. Two great new breakthrough studies in
TB health care were presented recently at
We have already seen profound growth the annual Conference on Retroviral and
in HIV medicine which such innovative Opportunistic Infections (CROI 2017).
thinking. Thinking back to the beginning of These studies are not only truly innovative,
HIV treatment, who would have imagined but will ensure better treatment outcomes
that we would one day have exciting new for those with TB, cost-saving benefits for
drugs that can be co-formulated into tiny, those in resource-limited settings, and
once-a-day tablets, with a superior barrier many more lives saved (pages 20 and
to genetic resistance that makes it easier 21).
for patients to adhere to treatment for their
Lauren Jankelowitz
whole lives? The importance of the effective use of
data in the delivery of quality services
CEO: Southern African HIV Clinicians
Society, Johannesburg, South Africa This edition of HIV Nursing Matters pre is unpacked in the article titled ‘Data –
sents a range of interesting articles. At first friend or foe?’ (page 22).
glance, the topics may appear disparate.
However, what links all the articles is the Finally, the personal story on page 26,
common theme of innovation. The treat ‘pushing boundaries’, depicts the career
ment optimisation focus (pages 10 and journey of a nurse, her achieve ments,
13) highlights the importance of striving and the challenges she has faced and
for new and better treatment regimens that overcome. We hope it will be inspirational
can help decrease pill burden, improve to you all.
treatment adherence, and improve safety
and tolerability. We wish you happy reading.
HIV Nursing Matters | May 2017 | page 2
Message from the
The Team
president
Guest editorial
Ms Lauren Jankelowitz
President
Dr Francesca Conradie
Editorial Advisory Board
Dr Elizabeth Mokoka
Dr Natasha Davies
Dr Michelle Moorhouse
Dr Sindisiwe VanZyl
Ms Nelouise Geyer
Ms Talitha Crowley
Ms Maserame Mojapele Dr Francesca Conradie
Mr Siphiwo Qila
President: Southern African HIV Clinicians Society
Ms Rosemary Mukuka
Advertising When I started working in HIV treatment and research, while we did have
E-mail: sahivsoc@sahivsoc.org antiretrovirals (ARVs), they had to be taken more than once a day. Some of
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effects were awful – ranging from nausea, vomiting, diarrhoea to a severe
Article/Letter submission and life-threatening condition called lactic acidosis. Then the era of tenofovir
E-mail: sahivsoc@sahivsoc.org began and the medicines were easier to take. Led by our minster of health,
Tel: +27 (0) 11 728 7365 we adopted the fixed-dose combination: one pill taken once a day for most
patients. I have to admit that I thought this was as good as it was going to get.
For more information Now, with the ‘test and treat’ era firmly underway, I was sure that it would not
SA HIV Clinicians Society
get better. While some patients do have side-effects, in comparison to days of
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But as always in HIV treatment, the field has evolved. And as Southern
www.sahivsoc.org Africans, we are likely to lead the way. It is exciting to be at the forefront of
new evidence being generated to replace the current standard of care for first-
Tel: +27 (0) 11 728 7365 line HIV treatment. Dolutegravir (DTG) and tenofovir alafenamide (TAF) have
Fax: +27 (0) 11 728 1251 demonstrated increased robustness and safety, in addition to better patient
E-mail: sahivsoc@sahivsoc.org tolerability and reduced costs. A switch to a DTG/TAF-based regimen could
enable South Africa, within its current ARV budget, to treat all people living
The opinions expressed are the with HIV in the country by the year 2019, suggesting the power of this regimen
opinions of the writers and do not to enable the country to meet the increasing treatment demands under the
necessarily portray the opinion of the ‘treat all’ approach, and to achieve the UNAIDS 90-90-90 targets.
Editorial Staff of HIV Nursing Matters
or the Southern African HIV Clinicians In the field of HIV, we have made huge gains and have seen the number of
Society. The Society does not accept tuberculosis (TB) cases drop as we have started over 3.5 million individuals on
any responsibility for claims made in antiretroviral therapy. But we are still plagued with TB, including a very difficult
advertisements. form called extensively drug-resistant (XDR) TB. Until recently, most people
infected with this form died; but once again, South Africans are leading the
All rights reserved. No part of this
pack in treatment. Read about this development in this issue; as well as an
publication may be reproduced in any
interesting means to prevent TB-IRIS (immune reconstitution inflammatory
form without prior consent from the Editor.
syndrome) presented by Graeme Meintjes.
The fight is not over. There is still much to do. But we remain dedicated health
care workers with our own stories.
HIV Nursing Matters | May 2017 | page 3
News
Nurses need debriefing and counselling
Mpho Lekgetho
The original article was published in Health-e News on 20 April 2017 and is available at:
https://www.health-e.org.za/2017/04/20/nurses-need-debriefing-counselling-denosa/
NORTHERN CAPE – Nurses in the They would debrief staff when they en Nurses in the Northern Cape have
public health sector, faced with countered a bad experience, like the loss occasionally been assisting patients with
extreme situations beyond their of a patient. Today the need for that kind transport money after being frequently
control every day, are in need of thing is even more, especially now that faced with sick people who have no way
of counselling and debriefing we are experiencing a severe shortage of of getting home after receiving treatment.
sessions that are no longer provi nurses,” Delihlazo said.
ded for them. Mapule Busang a 29-year-old woman
‘Seen as heartless’ from a farm near Manyeding recently
Communications Manager Sibongiseni arrived at Kuruman Hospital, having
Delihlazo from Denosa (the Democratic Nurses who don’t receive care and been brought in by ambulance with an
Nurses Association of South Africa), says support could become hardened. 18-month old baby who was vomiting
nurses who don’t receive support are at and had diarrhoea.
risk of becoming either hardened to the “Nurses are sometimes seen as heartless
plight of those in their care, or else overly people who don’t always care.” As she arrived at the hospital she was
involved in the challenges of their patients. directed to the reception area to open a
Denosa offers a programme title Health file, but got lost in the massive building.
“They get extremely hurt when one of Workers for Change, through which There were no porters to help her, and
their patients dies in a facility where they nurses are encouraged to identify difficult eventually, she arrived at the Kuruman
work,” said Delihlazo. issued within the different health care Clinic, situated in the hospital yard.
facilities, and not to take their anger out
He said it was unfortunate that the on patients. Tearfully she placed her sick baby on the
counselling services that were once provi observation table, and wept as she told
ded were no longer available to nurses. “This has assisted them in the way they the duty nurse: “Sister, I don’t have taxi
deal with systematic challenges and fare to go back home.”
“Previously there used to be counsellors they realise they are at work to help the
for nurses and doctors in the facilities. vulnerable,” said Delihlazo.
HIV Nursing Matters | May 2017 | page 4
news
Dependency syndrome regularly faced and how they regularly I sometimes share my lunch box with
spent their own money to help those in them if there is a need.”
The nurse, who asked not to be identified, their care.
said this was not the first time she had According to the chairperson of Civil
ended up in this kind of situation. Delihlazo said this kind of selfless service Society in the Northern Cape, Beau
was an active expression of the nursing Nkaelang, the public should be made
service pledge. aware of what health care workers in the
“They develop a bond public system go through.
with every patient that they He said, however, that it could also create
a dependency syndrome because nurses “We would like to see all the district
care for, to such an extent had entered the profession because of civil society forums having a sector
that it is difficult for them to their passion. that represents health care workers,
not act when they see the something that at the moment is only seen
“They develop a bond with every patient at a provincial level,” he said.
patients in desperate need of that they care for, to such an extent that it
assistance.” is difficult for them to not act when they Recognition of the plight of the health
see the patients in desperate need of care providers would help patients
assistance.” understand the challenges faced by
“We are used to dealing with cases of this those who care for them and would help
kind. We sometimes go as far as buying The unidentified nurse who spoke to the public have more understanding
patients toiletries when the hospital Health-e News said: “I always put myself for nurses and what they go through
supplies don’t arrive on time,” she said, in the patient’s shoes, and that is why I and the fact that they themselves need
explaining some of the dilemmas nurses cannot leave them without helping them. support.
From the heart of rural health to the minds of the DoH
Taryn Springhall
This article was originally published in ehealthnews on 10 April 2017 and is available at:
http://ehealthnews.co.za/dr-william-mapham/
WESTERN CAPE — Ophthal going to be ‘fixed’, and we needed
mology Registrar at Stellen systemic change. In 2005/2006 I
bosch Uni versity and Found moved into public health and started
er of Vula Mobile, Dr William working with Soul City using media for
Mapham, talks about the health payer change. It was around
development of the award the same time that mobile phones were
winning mHealth app and how starting to gather momentum as a form
it’s helping to transform rural of mass media, which led to me going
health care in Southern Africa. to the U.S. to do a fellowship looking
He also dispels some of the at mobile applications for health care
myths around the ‘Uberisation at Columbia University. I ended up
of health care’ and discusses the working for a start-up in Washington,
fundamentals to solving health but my passion was still rural health
care challenges. care in South Africa (SA). So I quit my
job, moved back to SA and worked
Tell us the story behind Vula. for the South African National AIDS
Council (SANAC) on policy work
As a junior doctor stationed at a rural before deciding to go back to my roots
hospital in the Transkei, I experienced of clinical medicine.
first-hand what it was like to have no
support and access to specialist opinions. That decision resulted in me volunteering Screen shot of the Vula Mobile app
I recognised that the problem wasn’t for 10 months at an eye clinic in Swazi (source: www.vulamobile.com).
HIV Nursing Matters | May 2017 | page 5
From the specialists’ perspective, Vula
also takes their experience into the
design. Instead of getting a phone call
from a rural clinic asking for advice,
they now digitally receive a package of
relevant information that includes pictures,
a vision test result and the patient’s history
structured in a way that enables them to
reply quickly.
What about the data Vula has
generated since its inception?
We’ve noted that about 25% of all
cases, across all specialties, are actually
managed at the primary level in the
rural setting. This is important because it
shows that Vula has helped to minimise
unnecessary referrals and, more than
that, if patients do get referred they are
given a specific date to visit the hospital
to ensure that they are seen to properly.
Using that data, we were able to start a
land. It was there that I saw patients So talk us through a Vula conversation with the School of Public
coming in far too late with symptoms user experience. Health to initiate an economic study to
too advanced to be treated effectively understand how much money is saved by
with the resources at our disposal. And Imagine you’re a newly qualified junior reducing referrals by 25%.
although there were health workers in doctor and you’ve just been sent out to
the community who could screen people, the boarder of Lesotho. You’re the only This data is also valuable because
they didn’t really know what cases should doctor there and patients are queuing up we now have a better idea of what’s
be referred. It was where I could see at the door. And while you’ve learnt a lot happening and we can track how the
clearly how a mobile phone could be at medical school you’ll still come across rural health workers are learning case
used to improve patient eye care in a rural a case that you just don’t know what it is. by case. To give one example, there
public health setting. You can look up the case in your books was a child whose eye was accidently
but you’ll only get so far. So inevitably you burnt by boiling water and we taught
And it started with just would make a phone call to someone or the doctor how to manage the case on
Ophthalmology? send them a picture on WhatsApp asking Vula. Although he referred the patient
for advice, but that method is informal anyway in the end, at least he ensured
The eye is obviously very important and undocumented. the right thing had been done at the coal
to me and it was a great way to start face. A while later he saw a similar case,
because it’s such a good visual specialty. With Vula, that same doctor is able although this time the patient was a baby,
Most health workers only have two to follow the referral workflow we’ve and the doctor knew what to do. So Vula
weeks of eye training at medical school developed for each of the specialties. For is also being used as a teaching tool,
so there’s a huge skills gap between example, with Ophthalmology there’s a which is something we didn’t predict. It’s
them and specialists. And with general vision test and a specific questionnaire been fascinating to watch the data come
medicine, case transfers are more about the patient that must be completed in and see how people are learning from
complicated because a whole bunch before sending it to the on-call specialist it and how junior doctors are using it to
of other data is required, like ECGs, to evaluate. manage more complicated cases on their
etc. So Ophthalmology was where we own with support.
began, but we’ve since added a number We’ve specifically built an on-call system
of specialties on the app to broaden so it doesn’t just go to a random doctor to Let’s touch on the ‘Uberisation
its application in the real-world setting. answer but instead it goes to the doctor of health care.’ New coverage
Vula now includes Ophthalmology; on-call whose job it is to answer these recently will probably go a long
Orthopaedics; Dermatology; Burns; HIV; kinds of questions. The average response way in deterring people from
Family Medicine; Internal Medicine; time from a specialist is about 15 minutes, using the term but there was a
Neurosurgery; ENT; Cardiology; and so instead of being put on hold or wasting time when it was readily used
Oncology. And in the near future we’ll time finding a second opinion, the health to illustrate the automation of
be adding Surgery; Obs and Gynae; care worker is free to continue seeing processes in health care. Do you
and Paediatrics. other patients. have any comment on that?
HIV Nursing Matters | May 2017 | page 6
news
There’s actually a brilliant article called person, she had specific expertise on we’re in the process of setting up a Board
‘Why there is no Uber for health care’ how to make complicated things simple. with a view to operate as a professional
which I found absolutely fascinating. In Her advice was clear: if you’re going to enterprise but even still, our value doesn’t
short, you might use Uber say 100 times design this app you need to look at who’s just come down to profits and losses. Vula
a year. But you’ll only see a doctor four going to use it; why would they use it; how has grown way beyond what I dreamed it
times a year. Catching an Uber will cost would it make their life easier; and if it was could be. We’re carving out our value by
you R50 a time, whereas seeing a doctor going to make their life easier what would facilitating collaboration between public
will cost you R500. Your commodity in it look like. She gave me a lot of guidance and private health care, we’re actively
Uber is your taxi drivers, who are skilled which helped me to know exactly what I reducing unnecessary referrals which has
drivers but they haven’t gone through 10 wanted. an impact on the cost of delivering care
years of training, or at the very least a and in February of this year, we set a new
minimum of six years of training as is the I used a system called Productivity on record for the number of patients helped,
case when you see a doctor. As a result Paper, which has since been bought which was over 1 000.
Uber can go viral far more easily than by a company called Marvel, which
any disruptive technology in the health basically allowed me to create a non- Lastly, give us your real-world
sector. functioning app which I could then send take on collaboration between
to developers and ask for quotes. And developers and clinicians to
Health care is a very complicated sector although I couldn’t afford them at least create mHealth apps.
and as a result, innovation moves very I had an idea of how much money we
slowly. If you’re going to release a new needed. And then I got lucky again I was very fortunate to have a foot in both
drug or surgical tool it’ll take years to get because Debré phoned me and said that camps. And even more fortunate to have
approval. Like with Vula, despite having one of their designers had available time the support of people like Debré and a
tons of support within hospitals it still to work on Vula for a couple of months. few other entrepreneurs who were willing
took us two years to get any recognition This was amazing because they donated to share their advice and expertise with
from the Department of Health. And that around R200 000 worth of design time me. So I think the collaboration stretches
is right because tools and innovation, which produced a real Android demo further than the developer and the
like medicines and devices, need to be which went on to win the SAB Innovation clinician.
rigorously tested and proven before Award in 2013, which was worth
exposing the majority of patients to it. R1 million. We’ve kind of bankrolled our Vula is expensive to build and maintain
In health care, it’s a priority to protect prize money since then; we won a big and, certainly initially, we just didn’t
people and technologies have to be prize in Morocco and then another big know that because we didn’t have any
designed with that objective in mind. competition last year in London which has experience in developing or building
really kept us going. software. While you do get the odd
Vula has been the recipient of exception of a clinician who has taught
numerous awards and accolades At the same time when we won the award themselves how to program, it’s still not
over the last couple of years. in Morocco, Debré sold her company to their core function. What clinicians are
Give us the winning formulae Deloitte Digital and initially helped us on really good at is thinking about what
for designing and launching a part time basis which turned into full would help them. But building software
mHealth solutions based on your time. I’ve been very lucky to have her on is really, really hard – something we
experience. the team and if you look at Vula’s growth completely underestimate as doctors. On
it’s very obvious that it grew exponentially the other hand, from a developers’ point
The initial version of Vula was basically once she came on-board. When Sara of view it’s sometimes easy to think you’ve
built on a power point template. I was Hilliard Garrett, Strategist and ex- got the perfect system but in reality it’s not
very fortunate to get R50 000 in funding Advocate, came on board in early 2016 practical. Working in the public health
from the Shuttleworth Foundation. And Vula stared to grow even faster. The three sector for most of my life I understand
while the funding was nice what it really of us with vastly different skills enables how precious time is in a clinic and how
gave me was some credibility and the a cauldron of debate which produces simple things have to be. The minute tools
confidence to phone around although robust solutions. get complicated or onerous it’s just not
most developers laughed at my budget. going to happen because at the end of
I then contacted Gary Marsden, who So to answer your question, I think the the day, we want to help the patient – that
used to run the UCT Centre in ICT for formulae for Vula can be distilled down is why we’re there. Tools have to support
Development, and asked if he knew to funding, people and more than that, that purpose unequivocally.
anyone who could help me. He was experts in their field and a problem to
extremely helpful and gave me a list of key solve. Vula was designed to solve a mHealth development needs a combined
people, one being Debré Barrett who, at problem; it wasn’t built as a business approach, with numerous collaborators
the time, was running a company called where we looked at the market and and contributors who are all aligned to
Flow Interactive, which was South Africa’s how much money we could generate. solving a problem for an individual, a
first ever user-experience company. So Obviously we’ve matured since our start- community, a region and eventually, an
not only was she a talented business up days in a number of ways and currently, entire health system.
HIV Nursing Matters | May 2017 | page 7
A road trip to off-the-beaten-track clinics
Briony Chisholm
National HIV & TB Hotline for Health Care Workers, Cape Town, South Africa
The toll-free National HIV & TB Hotline for Africa, visiting clinics to spread the word: car and headed off to Oranjeville to be
Health Care Workers has been operating me, an information pharmacist from ready to start early on Monday morning.
since 2008. Based at the Medicines the MIC and Hotline, and my assistant, And that’s where we learnt our first of
Information Centre (MIC) in the Division of Gouni, as I’m in a wheelchair. many travelling lessons: always bring
Clinical Pharmacology at the University of snacks. Small town South Africa closes
Cape Town (UCT), it is staffed by specially I spent weeks plotting routes, contacting down on Sunday evenings. We were
trained drug information pharmacists facilities, researching places to stay in the only guests at the hotel, and the
who handle almost 500 clinical queries tiny dorps, and putting together seven restaurant was closed. The lovely hotel
a month from health care workers dealing itineraries. Then we spent a week to ten owner offered us toasted sandwiches, but
with HIV- and/or TB-infected patients. days a month, in each province (excluding we opted to shop at the only shop open
Gauteng and the Western Cape) over the in town – a little café which provided us
Queries are answered using the latest six months. with bread, cheese, avo and tomato. We
information databases and reference made sandwiches using the teaspoon
sources and, where necessary, clinical Visiting as many clinics as possible, provided for tea and coffee and ate them
input is obtained from consultants at the handing out our posters and encouraging on the beautiful bank of the Wilge River. It
UCT’s Faculty of Health Sciences and health care workers to use the hotline, we was wonderful.
Groote Schuur, Red Cross War Memorial drove 9 950 km (much of it on dust roads),
Children’s and Tygerberg Hospitals. visited 260 hospitals and clinics, delivered The Free State was exquisite, and we
over 800 poster packs, met hundreds of quickly realised that the busy nurses at the
Each year, we bemoan the fact that, wonderful health care workers and had clinics had no time to break and chat with
despite numerous mailings of flyers, uncountable adventures, including two us, so we canned the ‘perfectly planned’
inserts in journals and attendances at flat tyres. And learnt, very quickly, that plan and instead asked in each settlement
conferences, we struggle to get word out itineraries are just guidelines and Google we came across where the clinic was,
to the rural clinics – those with little access maps aren’t always accurate! then dropped posters and flyers with the
to clinical support – who we think could sisters at each one. At the hospitals, we
benefit most from the service. Lightbulb Our first trip, to the Free State in April, got out and met with staff and chatted.
moment: We’ll go to them! was a steep learning curve. I planned the Doing this, we reached far more clinics.
route, phoned clinics and hospitals we
And so it came to be, that from April to hoped to visit (three a day, for five days), In May, we headed to the Eastern Cape
September 2016 we embarked on seven booked places to stay and we flew to and drove over 1 500 km, seeing more
trips through the back roads of South Joburg on the Sunday, picked up our hire than 50 clinics and hospitals. Our trip
HIV Nursing Matters | May 2017 | page 8news
took us from East London up to Aliwal good infrastructure in the North West, What a privilege to travel through our
North, through the Karoo and back down and drove just under 900 km, visiting 37 beautiful country and be reminded of how
to fly out of Port Elizabeth, over a 10-day clinics and hospitals en route. much good work there is going on out
period. there. Hopefully the hotline will provide
Limpopo, too, proved to be a challenge, some relief and back-up to these ama
Beautiful scenery, extreme temperatures map-wise, but we drove over 1 000 km zing, hard-working health care workers.
(both cold and unseasonably hot – it was – much of it on dust roads – to visit 40
30 degrees in PE on the 1st of June!), clinics and hospitals. The people in
many back roads, potholes and ‘Stop ‘n Limpopo were wonderful and welcoming
Go’s’ took us to clinics with wonderful, and, thank goodness, like angels. This
welcoming staff who loved the posters. proved most handy when we found
Most of the health care workers we met ourselves in the middle of nowhere, on
had not heard of the hotline, so hopefully a dust road in the sweltering heat, with a
we were reaching the right target! flat tyre! Along the deserted road came
Agnes and Thendo, who kindly helped
In June, we travelled 1 300 km through us, and we were soon back on our way.
northern KZN from St Lucia to Jozini to
Pongola and Vryheid and then back The Northern Cape was the perfect end
down to the coast via Melmoth and to our road-tripping. We spent ten days
Eshowe. Throughout our first three there, starting with a wonderful turn-out Cafe near Jozini, KwaZulu-Natal
trips, we managed to narrowly miss in Kimberley – over 50 people in two
service-delivery protests, with tyres still sessions, including doctors, pharmacists,
smouldering at the entrance to one of the nurses and people from the Department
clinics near Eshowe. of Health, at Kimberley Hospital.
We travelled through vast fields of sugar From there we travelled over 2 000 km
cane being harvested and hundreds of (much of it on dust roads, with another flat
trucks carrying said sugar cane (they’re tyre to test our tenacity!), up to Kuruman
messy things, and heavy, causing HUGE and then down to Upington, across to
potholes!) to the mills, and visited busy Springbok and down to Garies, seeing
rural clinics with dedicated staff. 50 hospitals and clinics. We found the
health care workers working hard and
Our trip to Mpumalanga in July proved incredibly welcoming and made many
to be the toughest but, hopefully, still friends along the way. Oh dear ... near Ha-Ribungwani, Limpopo
productive. Mpumalanga is not big on
signage for their clinics, so we spent a lot Through desert landscapes and
of time lost (despite our careful planning surprisingly hilly mountain passes, we
and maps!), and met many people, what saw the end of the flower season and
with asking directions a million times. marvelled at the beauty and friendliness
Regardless, we managed to visit over of this vast and often forgotten province.
30 clinics and hospitals, and travelled We’ve met wonderful people and have
1 204 km in our five days there. been welcomed most graciously, and the
health care workers loved the posters, so
From Lydenburg to Bushbuckridge, hopefully the trips are having the desired
Sku kuza to Mbombela, Emgwena effect – to get word of the hotline out Maphutha L Malatji Hospital, Limpopo
to Emalahleni, we saw the beauty of there, to where it’s needed most! We’re
Mpumalanga and the devastating waiting to see the stats until year-end, and
drought and visited bustling and busy then will write that up.
clinics both in rural and urban areas,
meeting the dedicated health care It was a wonderful, eye-opening
workers in them. We even managed to experi
ence, in equal parts devastating
bump into a herd of elephant on our route and encouraging. From tiny, old and
– lucky us! desperately-in-need-of-upgrading clinics
to smart, new ones, what amazed us most
We were busy-busy in August, visiting was the dedication of health care workers
North West at the beginning of the working under difficult conditions, often
month, and heading north to Limpopo under-staffed and with little support and
at the end. We were surprised by the drug supply issues. Cows outside Alice, Eastern Cape
HIV Nursing Matters | May 2017 | page 9Optimising ART in the
21st century
Celicia M Serenata, BA (Hons), MBA
Hermien Gous, PharmD
Janet Grab, BPharm
Michelle Moorhouse, MB BCh, DA (SA)
Ellisha Maharaj , BSc (Hons)
Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
New and better treatment regimens that can help decrease pill burden,
improve treatment adherence, and improve safety and tolerability
HIV treatment has come a long way drugs (ARVs) have on the lives of PLHIV, Since the first Conference on ARV Dose
since the discovery of the human and people with bleak health outcomes Optimisation (CADO) in June 2010,
immunodeficiency virus in 1983. Within in the 21st century can now live long there has been a concerted effort from
4 years of that discovery, we had the first and productive lives. We are now in researchers and clinicians to simplify
drug available to treat people living with an era of what a colleague calls “an antiretroviral therapy (ART). The main
HIV (PLHIV): zidovudine (AZT), used embarrassment of riches” – powerful aim of the first CADO meeting was to
as monotherapy. By 1995, two drugs new drugs, including new integrase discuss how “value for money” could
were used in combination to suppress inhibitors, and the recent findings on the be maximised to reduce the cost of ART
HIV: AZT and lamivudine (3TC), and viability of long-acting injectables brings – and allow greater access to treatment
by 1996, triple-drug therapy became in another era of exciting possibilities considering budgetary pressures. That
the new standard of care for treating for making treatment easier to take and first meeting considered important factors
PLHIV. Since 1996, we have seen the manage for both patients and health for achieving drug-related cost reductions
remarkable impact that antiretroviral care workers (HCWs). through improved manufacturing pro
HIV Nursing Matters | May 2017 | page 10current issue cesses, better formulations of existing Two of the main studies to address the Africa, and in other LMICs. Benefits of drugs, or reduced doses.[1] A second question of optimised first- and second- DTG include an excellent resistance CADO meeting was held in 2013. The line regimens are ‘ADVANCE’, and a profile, lower cost, and that it is more success of these efforts was evidenced by second-line switch study investigating tolerable due to fewer side-effects. the shifts in World Health Organization lower-dose darunavir/ritonavir (DRV/r), ADVANCE is a 48-week study (primary (WHO) ARV guidelines between 2002 which would be an alternative regimen endpoint), with follow-up until 96 weeks. and 2016. For instance, WHO guidelines to lopinavir/ritonavir (LPV/r). The study is taking place at three sites in 2002 called for a CD4 eligibility of in Region F of Johannesburg, including below 200 cells/µl, and had at least ADVANCE is a phase 3 non-inferiority one site that caters specifically for eight different drug options to consider randomised controlled trial comparing the adolescents and pregnant women. for first-line treatment (although AZT was current standard of care of tenofovir (TDF), preferred). Even as late as 2010, WHO emtricitabine (FTC) or lamivudine (3TC), Despite all that is known about DTG and guidelines had six drug regimen options, and efavirenz (EFV) (TDF/XTC/EFV) to its good resistance profile, there are still including fixed-dose combinations (one two alternative regimens: one replacing unanswered questions about the use of pill, once a day). By 2013, this had the EFV with dolutegravir (DTG), and TAF and DTG in pregnant women, and in been consolidated to CD4 eligibility the second replacing the EFV with DTG TB co-infected individuals. For this reason,
(Mylan, Gilead, ViiV), and even the visit to give an indication of participants’ tolerable and robust first-line regimen.
government (Department of Health, and adherence to their prescribed study Fewer tablets will be easier and less
Department of Science and Technology). regimen. Being initiated on a chronic noticeable to take with them when they
Discussing a study at such an early medication can seem overwhelming to go out.
stage of design ensures that the study patients, especially adolescents who are
addresses not just a research question, already dealing with transitioning through The second study being implemented
but informs policy and practice. a period of identity formation, and often under OPTIMIZE is a second-line switch
engage in behavioural experimentation study to confirm the non-inferiority of a
ADVANCE enrolled its first patient in and significant risk-taking.[3] It is vitally lower dose of DRV/r compared with
February 2017. To date, approximately important to provide adherence LPV/r used in second-line ART. A second-
100 participants have enrolled – all are counselling before initiating treatment, line regimen containing DRV/r has the
adults over the age of 18 years, although and to follow up at every visit, with pill potential to reduce the pill burden and
ADVANCE hopes to enrol about 100 counts, adherence counselling and home have a better toxicity profile.
children and adolescents aged 12 - 18 visits. If a participant feels a diary card
years. Adolescents have rapidly become will help them to remember to take their Both studies also have the potential
a high-risk population in the HIV/ medicine, then it will be provided. to reduce the cost of first- and second-
AIDS landscape, with adolescent girls line treatment drastically. With close to
contributing 25% of new infections.[2] The importance of this was demonstrated 4 million people on ART in South Africa,
Adolescents are known to exhibit poorer by a 15-year-old participant at one of the the financial burden on the fiscus is
adherence to ART, with higher rates of study clinics participating in another study, enormous (approximately $350 million,
virological failure and increased mortality who consistently had 100% adherence or R5 billion, per annum). A recent
in comparison to children and adults. on the current standard of care, but was article indicated that the OPTIMIZE
Performing this separate analysis will help showing signs of clinical and virological studies have the potential to reduce the
to gather invaluable data in support of a failure. At every visit she received cost to the South African health budget
treatment approach for this group. counselling, and despite describing dramatically, allowing the country to
distressing social circumstances and double the number of people on ART with
showing signs of depression, she assured the same budget as in 2016.[5] The article
An essential component the clinical team that she was taking also highlights the potential savings to be
her medication with out fail. When gained from lower manufacturing costs,
of the OPTIMIZE project the Wits RHI counsellor paid a visit to as smaller tablets will require less active
is to work with treatment her home to follow up, however, the pharmaceutical ingredients.
activists and health care participant brought out two plastic bags
workers to describe the of medications that she admitted to hiding Finally, an essential component to
under her bed. She had been taking out OPTIMIZE and these studies, is to work
value of ART optimisation, her medications each day and throwing with treatment activists and HCWs to
and specifically the role them in the bag instead of swallowing describe the value of ART optimisation,
of DTG, TAF and DRV/r in them! and specifically the role of DTG, TAF
and DRV/r in future first- and second-
future first- and second-line Taking stock of the barriers that many line treatment for PLHIV. Through its
treatment for people living patients face in adhering to their daily implementing partners – TAC and
with HIV medication regimens helps us to develop SAHIVSoc – OPTIMIZE aims to train
strategies to support them through these communities, HCWs and patients on
challenges, which may arise at any time. ART optimisation, and specifically the
In addition to establishing a robust Barriers to good adherence include: potential switch within the next 1 - 2
and enhanced treatment approach, patient factors (e.g. socio -economic, years of optimised regimens containing
adherence monitoring and providing education, substance abuse); treatment DTG and DRV/r. These efforts, funded
participants with adequate adherence regimen factors (e.g. complexity, pill through OPTIMIZE, will be rolled out
support are also core elements of the burden, side-effects etc.); disease over the next year, and more information
OPTIMIZE studies. An optimised regimen characteristics and co-morbidities; will likely be made available as study
will only be truly successful if the drug and the relationship between patients results for the two clinical trials, and those
regimens are potent and safe, and and providers.[4] The ADVANCE study funded outside of OPTIMIZE (especially
patients find these regimens easy to take, hopes to provide data that will lead to through UNITAID), start releasing results.
thereby simplifying adherence. A pill improvement of the treatment regimen The first interim analysis of DRV/r will be
count will be performed at every study factors by providing a simplified, more available in 2017, and for DTG in 2018.
HIV Nursing Matters | May 2017 | page 12current issue
The U.S. Agency for International De and malaria quickly and more affordably. 2. Shisana O, et al. South African National
velopment (USAID) invests in OPTIMIZE It takes game-changing ideas and turns HIV Prevalence, Incidence and Behaviour
through its support of a global Survey, 2012. Cape Town: HSRC Press, 2014.
those into practical solutions that can help
http://www.hsrc.ac.za/en/research-outputs/
consortium, led by Wits RHI, that includes accelerate the end of the three diseases. view/6871
ICAP at Columbia University‚ Mylan Established in 2006 by Brazil, Chile,
Laboratories‚ the University of Liverpool 3. Reisner S, et al. A review of HIV antiretroviral
France, Norway and the United Kingdom, adherence and intervention studies among
and the Medicines Patent Pool. USAID UNITAID plays an important part in the HIV-infected youth. Topics HIV Med
is a key implementing agency of the U.S. global effort to defeat HIV, tuberculosis 2009;17:14.
President’s Emergency Plan for AIDS and malaria. For more information, 4. Gokarn A, et al. Adherence to antiretroviral
Relief (PEPFAR) and is responsible for please visit: www.unitaid.org therapy. JAPI 2012;60:16-20.
over half of all PEPFAR programs with
5. Venter WF, et al. Cutting the cost of South
activities focused in 35 priority countries
References African antiretroviral therapy using newer,
and regions, mainly in sub-Saharan Africa safer drugs. S Afr Med J 2016;107(12):28-
and Asia. For more information, please 1. Crawford KW, et al. Optimising the manufacture,
30. http://dx.doi.org/10.7196/SAMJ.2016.
formulation, and dose of antiretroviral drugs
visit: www.usaid.gov for more cost-efficient delivery in resource-
v107.i1.12058
limited settings: A consensus statement. Lancet
UNITAID finds new and better ways to Infect Dis 2012;12(7):550-560. http://dx.doi.
prevent, test and treat HIV, tuberculosis org/10.1016/S1473-3099(12)70134-2
Dolutegravir: The game
changer?
F O A Nabeemeeah, MB BCh, HIV Dip (SA)
T Masemola, MB BCh
M A Moorhouse, MB BCh, DA (SA)
Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa
The treatment of HIV infection is complex the viral life cycle that they inhibit MCC approval of dolutegravir
and changes rapidly as advances are (viz. fusion/entry inhibitors; reverse
made in basic sciences and clinical transcriptase inhibitors; integrase DTG-containing drugs approved by the
experience. An understanding of the inhibitors; maturation inhibitors and Medicines Control Council (MCC) in
different stages of viral replication protease inhibitors).[2] Dolutegravir South Africa include Tivicay® 50 mg and
and the different enzymes used by the (DTG) is an example of an integrase Trelavue®.
virus for replication has helped identify inhibitor as it prevents the integration
different agents that block the function of of viral DNA into that of the infected When should dolutegravir
such enzymes and thereby impede viral cell.[3] Once prevented from integration be taken?
replication inside host cells.[1] into host cell DNA, the virus is rendered
incapable of replicating. DTG (formerly DTG can be taken with or without food
What is dolutegravir? the patent drug S/GSK1265744) is and at any time of day. It should, however,
manufactured by ViiV Healthcare under be taken 2 hours before or 6 hours after
Antiretroviral (ARV) agents are classi the trade name Tivicay® in a 50 mg having taken certain polyvalent cation-
fied in accordance with the step in formulation for adults.[4] containing antacids (for example Phillips’®
HIV Nursing Matters | May 2017 | page 13Milk of Magnesia or Gaviscon®), of liver disease or underlying hepatitis B 2. It binds very strongly to the inte
laxatives, sucralfate, oral calcium or or C infection.[3] Appropriate laboratory grase enzyme, thereby compro
iron-containing supplements, or buffered testing prior to initiating DTG, and moni mising its activity.
medications. Taking DTG with food can toring of hepatotoxicity during DTG 3. It is formulated as a small tablet
help overcome these challenges.[5] therapy, are recommended. that is taken once daily.
4. No booster is required, unlike with
Dolutegravir in pregnancy What should be done if a dose protease inhibitors.
of dolutegravir is missed? 5. Drug interactions are few.
There is inadequate medical evidence 6. It is well tolerated in most patients.
concerning the use of DTG in pregnant If a dose of DTG is missed, then the
women. DTG was shown to cross the missed dose should be taken as soon as
placenta in animal studies, but because remembered. But, if it is within 4 hours
animal reproduction studies are not of the next dose, then the missed dose
always predictive of human response, it should be skipped and the next dose Currently, data for DTG
should only be used in pregnant women taken at the regular time. Two doses of use in South Africa and
if clearly needed (e.g. if the pregnant DTG should not be taken at the same other lower- and middle-
woman in question cannot tolerate time to make up for a missed dose. income countries are
efavirenz (EFV)).[3]
Clinical trials and research
lacking. The landmark
Drug interactions ADVANCE study,
Landmark clinical trials such as SPRING launched 16 January
DTG is metabolised in the body by the 2 and SINGLE have shown very promi 2017, will hopefully
UGT1A/CYP3A enzyme families. Drugs sing results in terms of the efficacy of generate evidence to
that increase the activity of these enzyme DTG. The SINGLE trial comparing daily
families, e.g. rifampicin, decrease the DTG vs. EFV showed the superiority of replace the current
levels of DTG in plasma. In these cases the the drug: patients in the DTG arm had standard of care for first-
recommended daily DTG dose should be fewer side-effects, did not stop taking line HIV treatment with a
doubled to 50 mg twice daily.[5] There are the drug and did not develop drug DTG-based regimen.
other drug interactions to be aware of: resistance. ‘Virological failure with
DTG increases metformin concentrations resist
ance mutations in treatment-naïve
and dose adjustment of metformin should patients treated with DTG has not been
be considered when starting and stopping reported.’[8] SPRING 2, with more than
co-administration of DTG. 800 enrolled patients, showed that once- DTG’s superiority over EFV has been
daily DTG was as effective as twice-daily shown in clinical trials. EFV has a low
Adverse reactions raltegravir; and reported no developed resistance barrier and its toxic effects
resistance in patients.[9] have caused it to be replaced by other
The most commonly reported adverse ARVs in first-line regimens in many higher-
effects are mild to moderate and Currently, data for DTG use in South income countries. As safety and efficacy
predominantly include insomnia and Africa and other lower- and middle- data are not yet available for the use of
neuropsychiatric symptoms. In the income countries are lacking. The DTG in pregnant women, people with
SINGLE study, 17% of patients receiving landmark ADVANCE study, launched 16 HIV/TB co-infection and children aged
DTG reported insomnia, 10% nightmares January 2017, will hopefully generate younger than 12 years, the World Health
or abnormal dreams, 8% depression evidence to replace the current standard Organization (WHO) still recommends
and 7% anxiety. These rates were lower of care for first-line HIV treatment with a TDF/XTC/EFV (tenofovir, emtricitabine
than those seen among patients taking DTG-based regimen. or lamivudine, and efavirenz) as a fixed-
the comparator drug, EFV.[6,7] dose combination as the preferred option
DTG has been called a ‘game changer’ to initiate antiretroviral therapy (ART).
What to be careful of? ARV drug and for good reason. It has DTG has been added as an alternative
clear advantages over previous ARVs to EFV in the WHO guidelines, but
Hypersensitivity reactions characterised (even those in the same class): it remains to be implemented in low-
by a rash with constitutional symptoms income countries.
have been reported incurrent issue
not tolerate the drug. DTG has been treatment guidelines, and may soon be 5. Aids Info. Fact Sheet Number 467. http://
associated with significant central added to guidelines for lower-income www.aidsinfonet.org (accessed 10 June
2016).
nervous system side-effects, such as countries as low-cost, generic versions of
headache and insomnia. In a large DTG become available. Botswana has 6. Quercia R, et al. Psychiatric adverse events
clinical trial in Amsterdam, 16% of already taken the lead in Africa and is from the DTG ART-naïve phase 3 clinical trials.
International Congress on Drug Therapy in
patients stopped taking DTG because using DTG as first-line therapy. Evidence HIV Infection (HIV Glasgow), Glasgow, 2016.
of sleeping, gastrointestinal tract and is needed to change guidelines in Abstract P210.
neuropsychiatric problems as well as South Africa – the ADVANCE study
7. Sabranski M, et al. Higher rates of
headaches and fatigue.[10] will hopefully provide this by the end of neuropsychiatric adverse events leading to
2018. The results obtained will be used dolutegravir discontinuation in women and
Studies from the Netherlands and France as evidence in order to switch millions of older patients. International Congress on
presented at the 2017 Conference people on ARVs to a new safer regimen. Drug Therapy in HIV Infection (HIV Glasgow),
on Retroviruses and Opportunistic Hence, we can aspire to use this new Glasgow, 2016. Abstract 0214.
Infections (CROI) suggest that HIV drug as part of a powerful regimen 8. Wainberg MA, et al. What if HIV were unable
integrase inhibitors such as DTG may to adhere to the ‘treat all’ approach to develop resistance against a new therapeutic
agent? BMC Medicine 2013;1:24.
increase the risk of immune reconstitution and to achieve the UNAIDS 90-90-90
inflammatory syndrome (IRIS).[11,12] A treatment targets. 9. Raffi F, et al. Once-daily dolutegravir versus
very rapid viral load reduction is thought twice-daily raltegravir in antiretroviral-naive
adults with HIV-1 infection (SPRING-2 study):
to increase the risk of developing IRIS 96 week results from a randomised, double-
due to a more rapid reconstitution of References blind, non-inferiority trial. Lancet Infect Dis
the immune system. Early vigilance for 1. Collins S. Why dolutegravir might get us closer 2013;13(11):927-935.
IRIS may be warranted, especially in to ending AIDS: Next step, further research. 10. Van Den Berk G, et al. Unexpectedly High
people who have low CD4 cell counts HIV Treatment Bulletin. October 2015. http://i- Rate of Intolerance for Dolutegravir in Real
during the first 3 - 6 months after starting base.info/htb/31289 (accessed 30 October Life Setting. Conference on Retroviruses and
2015).
treatment when initiating treatment with Opportunistic Infections (CROI), 2017. Poster
an integrase inhibitor. 2. Palmisano L, et al. A brief history of 948.
antiretroviral therapy of HIV infection: 11. Duterte M, et al. Initiation of ART based on
Success and challenges. Ann Ist Super Santa integrase inhibitors increases the risk of IRIS.
The WHO promotes a public health
2011;47(1):44-48. Conference on Retroviruses and Opportunistic
approach to ART involving less toxic,
3. Tivicay® (dolutegravir) US Prescribing Infections (CROI), 2017. Abstract 732.
more convenient and simplified ARV
Information. https://www.gsksource.com/ 12. Wijting I, et al. Integrase inhibitors are an
regimens. DTG is better tolerated, is pharma/content/dam/GlaxoSmithKline/ independent risk factor for IRIS; an ATHENA-
administered at a lower dose and is US/en/Prescribing_Information/Tivicay/pdf/ Cohort study. Conference on Retroviruses
less prone to development of resistance TIVICAY-PI-PIL.PDF (accessed 1 June 2016). and Opportunistic Infections (CROI), 2017.
than EFV. Hence, integrase inhibitors 4. Wei X, et al. Viral dynamics in human Abstract 731.
are a preferred component of first-line immunodeficiency virus type 1 infection.
ART in the European and United States Nature 1995;373(6510):117-122.
HIV Nursing Matters | May 2017 | page 15Safer conception clinic
Helping couples affected by HIV plan their
pregnancies safely
Nokuthula P Sikhosana, DN, DCNS, BCur (I et A)
Safer Conception Clinic; on behalf of Wits Reproductive Health and HIV Institute, Johannesburg, South Africa
Of the 6.4 million people living with HIV transmission from someone on fully her hips raised up on a pillow. The
in South Africa (SA), 5.4 million are of suppressive HIV therapy is widely syringe is inserted as far as it will go
reproductive age and 1.8 million desire a considered to be close to zero, as (if it hits the cervix, then it is backed
child now or in the near future.[1] In 2012, long as they adhere to treatment.[3] out a little). The syringe is depressed
safer conception services (SCS) were • If the female is HIV-infected, slowly, releasing semen into the
embedded in the national contraceptive then ensure a CD4 count of vaginal canal. There is no risk of
and fertility planning policy as well as in >300 cells/µl to reduce the risk of infecting the HIV-negative male
HIV clinical guidelines.[2] SCS have been complications during pregnancy due partner. The method is safe, easy to
provided as a primary health care (PHC)- to opportunistic infections. use, and done at a convenient time
based service by the Wits Reproductive • Adult male medical circumci for the couple, in the comfort of their
Health and HIV Institute in collaboration sion reduces the risk of acquiring own home (Fig. 1)
with the Department of Health, at Hillbrow HIV by 50 - 60%.[4] • Timing of condom-less sex,
clinic in Johannesburg. This 2-year project • Ensure that the HIV-negative using the menstrual cycle calendar
started in June 2015 and is expected to partner receives pre-exposure to estimate the four days of ovulation
run until September 2017. prophylaxis (PrEP). (peak fertility; evidenced by the
• Self-insemination using a woman having vaginal discharge
Aims of the project syringe – when the male client is that is thin, profuse, transparent and
HIV-negative with an HIV-positive stretchy, resembling egg white).
The service is provided as an implement partner. Following sex with a • Couples are only followed up for 6
ation science project that is focused on condom, semen is withdrawn using months while trying to conceive.
supporting HIV-affected couples and a syringe. The female lies down with
individuals planning to have children.
HIV-affected couples include concordant
(both positive), sero-discordant (one
positive and one negative) or unknown
partner status relationships – the latter
being where one partner may not
be willing to test or perhaps has not
disclosed. The service seeks to eliminate
mother-to-child HIV transmission and
prevent partner-to-partner transmission.
The intention is to test the feasibility and
acceptability of using low-cost and low-
technology services, with the aim of scale
up to other health care institutions.
Safer conception strategies used
• Ensure viral suppression for all
HIV-positive clients. The risk of Figure 1: Self-insemination with a syringe.
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