From the editor.html


    
        
            FROM THE EDITOR

            
                This issue of the Journal
                continues discussions started in the December 2011 issue. Professor
                Kuhn responds to the concerns raised by Salojee about the national
                policy promoting breastfeeding in HIV-exposed infants; she discusses
                the scientific rationale for the policy revisions, and presents a
                population perspective rooted in overall child morbidity and mortality.
                For better or worse, infant feeding is likely to remain an important
                topic for years to come. Both viewpoints need careful consideration,
                and subsequent discussions in these pages hopefully can be informed by
                experiences from implementing the new infant feeding policies in
                different settings around the country.

                
                

                Another matter is low-dose stavudine in HIV management. In the last Journal, Innes et al.
                presented a rationale for a trial investigating low-dose
                stavudine’s impact on therapeutic and toxicity endpoints. Given
                increasingly scarce resources for ART in much of sub-Saharan Africa,
                this proposal has intuitive appeal. We now publish a strong response by
                Andrieux-Meyer et al., who argue that further research into stavudine's use is untenable – with a clear rebuttal from Venter et al.
                There are important nuances – the use of stavudine in adults v.
                children; follow-up duration of a trial investigating long-term
                outcomes; and the changing costs of tenofovir and other more expensive
                medications – that evade oversimplified judgments.

                
                

                More generally, these two
                ongoing debates raise important questions about what we know and how
                well we know it. Although we aim to practice ‘evidence-based
                medicine’, the evidence base for many policies and decisions may
                be surprisingly thin and malleable. The same body of evidence can lead
                to opposing interpretations, as seen in the debates on infant feeding
                and low-dose stavudine. The challenge and talent of skilled clinicians
                and good policymakers is to make sensible decisions in the face of
                flawed evidence. Fundamental to this is perceiving the likelihood of
                misjudging – and in turn the ability to acknowledge opposing
                viewpoints and the importance of continually trying to improve the
                evidence base on which our decisions are based. These challenges
                re-emerge constantly, and again in this issue of the Journal. They have
                been entwined in the theory and practice of medicine for millennia, as
                recorded in one of Hippocrates’ aphorisms on the art of medicine,
                from around 400 BC: ‘Life is short; the art is long; opportunity
                fleeting; experiment fallible; judgment difficult.’

                
                

                The Journal presents other
                exciting pieces, including an important critique on the role of
                efavirenz in pregnancy from Pillay and Black, where clinical judgment
                has greatly outpaced policymaking. Johnson presents a model-based
                analysis of ART initiation across the country, and suggests that the
                scope of the ART roll-out approaches the targets set by the NSP for
                2007 - 2011. This is a major accomplishment that underscores the
                ability of the public health system to achieve ambitious goals, given
                adequate capacity and resources. In addition, an opinion piece by
                Kenyon and colleagues calls into question the widely held belief that
                poverty alone drives the sexual transmission of HIV across South Africa
                (a contentious assertion that may give rise to more debate), and
                Katusiime presents an interesting case study on chronic genital ulcer
                disease in the context of HIV infection.

                
                

                Good reading!

                
                

                
                    Landon Myer
                

                School of Public Health & Family Medicine

                University of Cape Town

                Landon.Myer@uct.ac.za