Natasha Davies

Adult antiretroviral therapy guidelines 2017

These guidelines are intended as an update to those published in the Southern African Journal of HIV Medicine in 2014 and the update on when to initiate antiretroviral therapy in 2015. Since the release of the previous guidelines, the scale-up of antiretroviral therapy (ART) in southern Africa has continued. New antiretroviral drugs have become available with improved efficacy, safety and robustness. The guidelines are intended for countries in the southern African region, which vary between lower and middle income.

Nurse and manager perceptions of nurse initiated and managed antiretroviral therapy (NIMART) implementation in South Africa: a qualitative study

Objective To explore nurse and facility and programme manager perceptions of nurse initiated and managed antiretroviral therapy (NIMART) implementation in Gauteng, South Africa. Design In this qualitative study, in-depth interviews and focus group discussions were conducted to gain insight into participants’ experiences of NIMART implementation. Setting Participants came from urban, peri-urban and rural primary healthcare clinics in two Gauteng Province municipalities. Participants 25 nurses and 18 managers who were actively involved in NIMART implementation were purposively sampled. Results The findings from this study reveal that, despite encountering numerous challenges including human resources, training and clinical mentoring and health systems issues, NIMART nurses and managers remained optimistic about their work. Study participants felt empowered by their expanded roles. Increased responsibilities associated with NIMART implementation encouraged better use of creative problem-solving and teamwork to facilitate integration of NIMART into existing clinic services. NIMART nurses perceived antiretroviral therapy (ART) patients to be more insightful about their illness, engaged in their HIV treatment and aware of the importance of adherence which enhanced nurse–patient relationships and increased their sense of job satisfaction. Conclusions Although the implementation of NIMART is complex, when NIMART is implemented well, ART access is increased and patient outcomes are improved. Supportive interventions which address the specific challenges faced by nurses providing NIMART now need to be implemented. Attempts should be made to replicate the positive aspects of NIMART implementation identified by participants as this may improve healthcare providers’ experiences of task-shifting.

A discussion of key values to inform the design and delivery of services for HIV-affected women and couples attempting pregnancy in resource-constrained settings

HIV‐affected women and couples often desire children and many accept HIV risk in order to attempt pregnancy and satisfy goals for a family. Risk reduction strategies to mitigate sexual and perinatal HIV transmission include biomedical and behavioural approaches. Current efforts to integrate HIV and reproductive health services offer prime opportunities to incorporate strategies for HIV risk reduction during pregnancy attempts. Key client and provider values about services to optimize pregnancy in the context of HIV risk provide insights for the design and implementation of large‐scale “safer conception” programmes.

Consensus statement: supporting safer conception and pregnancy for men and women living with and affected by HIV

Safer conception interventions reduce HIV incidence while supporting the reproductive goals of people living with or affected by HIV. We developed a consensus statement to address demand, summarize science, identify information gaps, outline research and policy priorities, and advocate for safer conception services. This statement emerged from a process incorporating consultation from meetings, literature, and key stakeholders. Three co-authors developed an outline which was discussed and modified with co-authors, working group members, and additional clinical, policy, and community experts in safer conception, HIV, and fertility. Co-authors and working group members developed and approved the final manuscript. Consensus across themes of demand, safer conception strategies, and implementation were identified. There is demand for safer conception services. Access is limited by stigma towards PLWH having children and limits to provider knowledge. Efficacy, effectiveness, safety, and acceptability data support a range of safer conception strategies including ART, PrEP, limiting condomless sex to peak fertility, home insemination, male circumcision, STI treatment, couples-based HIV testing, semen processing, and fertility care. Lack of guidelines and training limit implementation. Key outstanding questions within each theme are identified. Consumer demand, scientific data, and global goals to reduce HIV incidence support safer conception service implementation. We recommend that providers offer services to HIV-affected men and women, and program administrators integrate safer conception care into HIV and reproductive health programs. Answers to outstanding questions will refine services but should not hinder steps to empower people to adopt safer conception strategies to meet reproductive goals.

How ready are our health systems to implement prevention of mother to child transmission Option B

In January 2015, the South African National Department of Health released new consolidated guidelines for the prevention of mother to child transmission (PMTCT) of HIV, in line with the World Health Organizations (WHO) PMTCT Option B+. Implementing these guidelines should make it possible to eliminate mother to child transmission (MTCT) of HIV and improve long-term maternal and infant outcomes. The present article summarises the key recommendations of the 2015 guidelines and highlights current gaps that hinder optimal implementation; these include late antenatal booking (as a result of poor staff attitudes towards ‘early bookers’ and foreigners, unsuitable clinic hours, lack of transport to facilities, quota systems being applied to antenatal clients and clinic staff shortages); poor compliance with rapid HIV testing protocols; weak referral systems with inadequate follow-up; inadequate numbers of laboratory staff to handle HIV-related monitoring procedures and return of results to the correct facility; and inadequate supply chain management, leading to interrupted supplies of antiretroviral drugs. Additionally, recommendations are proposed on how to address these gaps. There is a need to evaluate the implementation of the 2015 guidelines and proactively communicate with ground-level implementers to identify operational bottlenecks, test solutions to these bottlenecks, and develop realistic implementation plans.

Establishing conception intentions and safer conception services for eliminating the vertical, and reducing the horizontal, transmission of HIV

conception services for eliminating the vertical, and reducing the horizontal, transmission of HIV V Black, N Davies, BG Williams, HV Rees, SR Schwartz a Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa b Clinical Microbiology and Infectious Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa c Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA Correspondence: Dr V Black, Department of Clinical Microbiology and Infectious Diseases, Faculty of Health Sciences, University of the Witwatersrand, 7 York Road, Parktown, South Africa. Emails vivian.black@nhls.ac.za, vblack@wrhi.ac.za

Supporting HIV prevention and reproductive goals in an HIV-endemic setting: taking safer conception services from policy to practice in South Africa.

Introduction: Safer conception care encompasses HIV care, treatment and prevention for persons living with HIV and their partners who desire children. In 2012, South Africa endorsed a progressive safer conception policy supporting HIV‐affected persons to safely meet reproductive goals. However, aside from select research‐supported clinics, widespread implementation has not occurred. Using South Africa as a case study, we identify key obstacles to policy implementation and offer recommendations to catalyse expansion of these services throughout South Africa and further afield.

Guidelines to support HIV-affected individuals and couples to achieve pregnancy safely: Update 2018

Read online: Scan this QR code with your smart phone or mobile device to read online. Authors: Natasha E.C.G. Davies1 Gail Ashford2 Linda-Gail Bekker3,4 Nomathemba Chandiwana1 Diane Cooper5 Silker J. Dyer6 Lauren Jankelowitz7 Otty Mhlongo8 Coceka N. Mnyani9 Muhangwi B. Mulaudzi7 Michelle Moorhouse1 Landon Myer10 Malika Patel6 Melanie Pleaner1 Tatiana Ramos7 Helen Rees1 Sheree Schwartz1,11 Jenni Smit9 Doreen S. van Zyl12

Appropriate clinical use of darunavir 800 mg

PREZISTA, in combination with low dose ritonavir (DRV/r) and with other antiretroviral medicines, is indicated for the treatment of human immunodeficiency virus (HIV) infection in antiretroviral treatment experienced adult patients who are protease-inhibitor-naïve or after exclusion of darunavir resistance associated mutations (DRV-RAMs: V11I, V32I, L33F, I47V, I50V, I54M, I54L, T74P, L76V, I84V and L89V). Genotypic or phenotypic testing should guide the use of DRV/r. (Prezista package insert)

Southern African HIV Clinicians Society Guidance on the use of dolutegravir in first-line antiretroviral therapy

In preliminary data from the Tsepamo study in Botswana, it was found that 0.94% (95% confidence interval [CI]: 0.37 – 2.4) of babies (4/426) born to women who were taking dolutegravir periconception had neural tube defects (NTDs), compared with 0.1% of babies (14/11 173) of women taking other antiretroviral drugs (ARVs) in the periconception period.1 No NTDs were observed in pregnancies where dolutegravir was initiated later in pregnancy. Further data from the Tsepamo study were presented at AIDS 2018: the updated number of NTDs with periconception dolutegravir exposure in the Tsepamo cohort is 4/596, 0.67% (95% CI: 0.26 to 1.7). The next formal analysis will occur after 31 March 2019 and will include women exposed to dolutegravir from conception before the recent change in guidance. Tsepamo plans to expand the number of study sites, increasing the coverage from 45% to 72% of births in Botswana with a projected denominator of over 1200 by March 2019.1