5 No, I am not on sabbatical on a tropical island! How- ever, it has been a great pleasure to have the Journal guest-edited again for the last edition of 2009 by a superb duo: Leon Levin and Mark Cotton. Mark Cotton is a specialist in paediatric infectious diseases at Tygerberg Children’s Hospital and head of its Paediatric Infectious Diseases Unit, affectionately known as Kidcru. His main focus is to extend and en- hance care through research, with a special interest in children affected by HIV. Mark has been involved in some key studies that have shaped paediatric practices and guidelines in southern Africa. He also serves as advisor and investigator to a number of international institutions and networks. Dr Leon J Levin graduated MB BCh at the University of the Witwatersrand in 1987. After training in paedi- atrics at the Wits group of hospitals in Johannesburg, he obtained his FCPaed (SA) in 1994. In February 1996 he founded the Paediatric HIV Clinic at Johannesburg Hospital, and more recently he has run the paediatric division of Right To Care. Leon has been Chairman of the Paediatric Subcommittee of the SA HIV Clinicians Society since 1999 and runs the Society´s Paediatric Discussion Group, an Internet-based forum for paedia- tricians to discuss and learn about problems in children with HIV. In this edition, besides a fabulous array of paediatric material, we publish the updated paediatric guidelines. With so much positive energy around better HIV sup- port recently, from the highest level, we are confident that we can do better, especially in the important area of paediatric AIDS. We will kick 2010 off with our usual diverse submit- ted copy, so please keep sending. Review processes will also be improved. We hope it will be a bumper year in many ways, with record numbers of people start- ing and staying on ART, a decreasing incidence of HIV, and millions of South Africans testing. We also hope to have four bumper editions of the Southern African Journal of HIV Medicine in 2010, which is set to be a memorable year for South Africa. LINDA-GAIL BEKKER Editor F R O M  T H E  E DI TORF R O M T H E E DI TOR The Journal is starting to feel like Men’s Health, what with posters, guidelines and now a state-of-the art science update, HIV Treatment Bulletin, falling out of it. Exco is pleased to announce an important and strategic partnership with HIV i- Base, who publish HIV Treatment Bulletin. We are distributing the southern African version of their excellent newsletter, which will exclusively focus on the scientific reports and resources that have local relevance – with a strong focus on paediatrics and maternal health. HIV Treatment Bulletin neatly complements the Journal, providing the snobbish clinician and scientist with the most hot-off-the-press analysis of recent clinical trials and basic science research. Policy makers can authoritatively pronounce at their guidelines meetings, clinicians can expand their patients’ options, and, most importantly, you can show off at ward rounds. Thanks to all the people at i-Base, this is a major step forward for quality information sharing. We wish the new Health Minister, Barbara Hogan, all the best. She has very small shoes to fill, but a mammoth task ahead of her to repair South Africa’s woeful health service. At the time of writing, she and her deputy, Dr Molefi Sefularo, have been very impressive, dealing with a cholera disaster, drug stock-outs, issues of prevention, releasing controversial reports that were stuck on her predecessor’s desk for months, and a dozen other complex health problems. Finally, the EXCO welcomes two new members based in Durban, Professor Yunus Moosa and Dr Henry Sunpath, both highly respected clinicians and part of the team responsible for an excellent HIV clinical conference held in October. FRANCOIS VENTER President This Spring edition brings 2008 to a close. And what a year it has been. Not many breakthroughs in HIV or TB, but a lot of activity in terms of understanding early infection better, really getting to grips with early immune responses, and again thinking through our prevention options. In 2008 the concept of antiretrovirals for prevention as well as treatment has come to the fore with second-generation microbicides, pre-exposure prophylaxis and the notion that we may be able to ‘treat our way out of the epidemic’ becoming possibilities. Gratifyingly, this year also saw a record number of people being tested and accessing ART, and roll-out for both testing and treatment is truly scaling up. As chairperson of the 4th Southern African HIV Conference I must encourage EVERY ONE of you to think seriously about coming to Durban on 31 March. It promises to be a critical conference where we will really formulate the key steps in getting PMTCT, treatment, testing and prevention out there on a scale that will begin to turn the SA statistics around. (I promise that it will also be loads of fun!) Please note the early date this year: 31 March to 3 April. This is to ensure brilliant KZN weather! In this edition, we already begin to examine some of these key scale-up questions: Jerome Singh explores the ethics and legality of traditional healers performing HIV testing (I know many have asked why this HAS to be the domain of nurses only). Francesca Esposito and her team examine changes in body composition in women taking antivirals in a KZN clinic. We look at the role of mobile phones in the HIV response with William Mapham, and Polly Clayden gives us pointers to starting infants on ART. The role of a liver biopsy in diagnosis of opportunistic infections is described by Mark Sonderup and colleagues. The vexed question of when it is deemed safe to start HAART in patients co-infected with TB is discussed by Robin Wood, and Francois Venter and colleagues give a practical view on new antiretrovirals on the horizon for South African practitioners. No guidelines in this issue, but I will whet your appetites – look out for guidelines on prevention of TB occupational exposure for HIV-infected health care workers and on the non-infertile HIV infected couple, hot stuff coming up in the new year! Happy reading and every best wish for a restful and peaceful festive season from the whole editorial team. See you next year! LINDA-GAIL BEKKER Editor m e s s a g e f r o m t h e e x e c u t i v e Msg from the executive.indd 5 12/17/08 3:16:23 PM TREATING HIV-INFECTED CHILDREN This edition sees the publication of the fourth SA HIV Clinicians Society paediatric antiretroviral therapy (ART) guidelines. Previously it has not been possible to have one guideline for the whole country because of wide discordance between the government and private sectors. This year, for the first time, our guideline is applicable to both the private and public sectors. In- evitably some differences remain and are addressed in the document. They include choice of first-line regi- men and genotyping recommendations. The nation- al Department of Health (NDoH) is still updating its guidelines, hopefully for publication in early 2010. We hope you will find the Society’s guidelines pragmatic and helpful. We have the potential to save and improve many young lives. We thank all those involved in the writing of the guide- lines, especially our fellow member of the writing com- mittee, Dr Tammy Meyers, and our overseas reviewers. As has been done previously when paediatric guidelines have appeared, the entire issue is devoted to paediat- rics. We hope it will be useful as a ready reference on paediatric HIV management for all health care workers caring for children. e di tor i a l THE SOUTHERN AFRICAN JOURNAL OF HIV MEDICINE                                                      December  2009 m e s s a g e   f r o m    t h e   e x e c u t i v e The global recession has thrown the problem of fund- ing for AIDS programmes to the fore, with Botswana’s president saying his country’s programme is unsustain- able, and donors sounding warnings that rationing may need to be implemented. This is very alarming – we have made big strides in terms of antiretroviral access in the last few years, and these are suddenly looking very fragile. It is time to take stock of our programmes and make them as lean and mean as possible, ensuring maximum access to care while ensuring acceptable levels of qual- ity. We need to look critically at the labs we ask for and the drugs we need, while keeping up pressure on the donor community to maintain support. However, we should not let our governments off the hook. Health in southern Africa has been consistently underfunded as a function of the gross domestic prod- uct, in almost every one of our countries. Guns, presi- dential inaugurations and motorcades never seem to be a problem to fund, and we need to do a better job at THE SOUTHERN AFRICAN JOURNAL OF HIV MEDICINE                                                      december  20096 We begin with an opinion piece by Heather Jaspan, Rachel Li, Leigh Johnson and Linda-Gail Bekker on the urgent need to develop skills and infrastructure to meet the needs of HIV-infected adolescents, especially given our success in treating children with ART. We then address prevention of vertical transmission of HIV, the key to the elimination of HIV infection in chil- dren. The paper by Laurie Schowalter, Ashraf Coovadia and Ameena Goga is a plea for action. It is followed by an analysis of vertical transmission data (Mark Cotton, Soyeon Kim, Helena Rabie, Joan Coetzee and Sharon Nachman, from the PACTG 1041 team), emphasising again the importance of a good antenatal antiretroviral component. Infant feeding is integral to child survival and development. There are risks and benefits for breast and replacement feeding. The paper by Ameena Goga is essential reading for anyone caring for infants and pro- vides the key data to inform rational decision making. The guideline document emphasises the importance of and pitfalls in maintaining adherence. A number of articles provide background information to help in un- derstanding the rationale of recommendations in the guidelines. These include articles on when to start (Mark Cotton, Helena Rabie, Ute Feucht and Avy Violari), es- sential pharmacokinetic information (Helen McIlleron and Hermien Gous) and how the weight-based dosage recommendations were derived (James Nuttall). What do you do when children starting ART deteriorate instead of improve? Helena Rabie, Tammy Meyers and Mark Cotton delve into the paradoxical world of im- mune reconstitution inflammatory syndrome (IRIS). We then highlight two adverse events of ART, one com- mon and the other rare. The NDoH guidelines do not advocate using abacavir (ABC) in the first-line regimen in the absence of ad- verse effects from other drugs. They still recommend d4T, increasingly implicated in lipodystrophy. Lipodys- trophy can be reversible if the offending agent (usually d4T) is replaced with ABC (or tenofovir in adults) in the early stages. Steve Innes, Leon Levin and Mark Cotton provide background information and useful diagnostic and management advice for lipodystrophy. The SA Clinicians Society advocates 3TC and ABC as the NRTI backbone for the first-line regimen. There is much fear of the infamous ABC hypersensitivity reac- tion (HSR). To the best of our knowledge, no one has ever died from the reaction, but people have died from ABC rechallenge. Fortunately the HSR is rare in black Africans. Helena Rabie, Kristin Henning, Pierre Schoe- man, Nico de Villiers, Gert H J (Oubaas) Pretorius and Mark Cotton provide guidelines for using ABC and re- count their experience with suspected ABC HSR. Treatment failure is becoming increasingly complex. Fortunately, there are quite a few new antiretrovirals registered overseas and about to be registered in South Africa. Leon Levin takes us through the minefield of paediatric salvage therapy. Finally, Polly Clayden presents us with some cutting- edge reports from the recent International AIDS Soci- ety Conference in Cape Town, again informing readers of the type of research needed to continually improve our guidelines. MARK CottoN LEoN LEvIN Guest Editors drawing attention to how health budgets are allocated. In South Africa it seems that Jacob Zuma’s government has declared war on overall wasteful expenditure, and at the same time there has been increasing embarrass- ing public exposure of ministerial spending on large cars. A new and energetic health minister, Aaron Mot- soaledi, seems intent on reversing the terrible sins of the past under Mbeki’s regimen, and to be determined that health resources get used better. Please let the Society know if you see any indication of rationing! We have active advocacy work, with good partners, and it is to be hoped that we can stop unnec- essary restrictions on health care. FRANCoIS vENtER President Southern African HIV Clinicians  Society Paediatric Discussion  Group (PDG) The Southern African HIV Clinicians Society Paediat- ric Discussion Group (PDG) began in December 2001. The concept was born after Dr (now adjunct Profes- sor) Ashraf Coovadia of the Rahima Moosa Mother and Child Hospital, Coronationville, Johannesburg, sent an e-mail to 5 or 6 local HIV ‘experts’ and Professor Mark Kline of the Baylor College of Medicine, Houston, Texas, seeking advice on how to manage a child with severe disfiguring parotomegaly but who had a normal CD4 count, so antiretroviral therapy (ART) was not indicat- ed. The answer came back that there was no indication for ART for a purely cosmetic condition! I found the concept fascinating and wondered if there was any value in using e-mails as a vehicle for educat- ing health care providers about paediatric HIV. I con- tacted the South African HIV Clinicians Society, who were happy with the concept and provided me with a list of their members. The list in those days was very short (unlike today), and I tried to fathom out who was a paediatrician or treated paediatric cases and added them to the mailing list. The first few cases hardly garnered a response. I sus- pect people were too shy to answer. After a few weeks I would send out an expert opinion. The cases were all real cases (mostly from my own practice), and all had excellent lessons to teach. Gradually, as knowledge and familiarity with PDG grew, so the number of responses increased. Currently it’s not unusual to have over 100 responses to a case. The cases have spanned the whole range of paediatric HIV issues including opportunistic infections, side-ef- fects of ART and ethical issues. At the moment we are concluding PDG No. 51. Some notable cases include: n One of the earliest cases in South Africa of Cushing’s syndrome caused by an interaction between ritona- vir and inhaled fluticasone for asthma. n A child from a neighbouring country who was diag- nosed as HIV-positive on two different tests and turned out to be HIV negative. n An HIV-positive child with marked failure to thrive and a normal CD4 count who turned out to have an oesophageal stricture and is now thriving after oesophageal dilatation. n Cases of lymphoma and Kaposi’s sarcoma. n A case where a mother with end-stage HIV had a negative HIV ELISA test, having lost the ability to make antibodies due to her poor immunity. n A case of a young infant treated with ART very early on who became HIV ELISA negative after losing her maternal antibodies. She did, however, remain PCR positive. n Interestingly, PDG No. 47 in April 2008 again dis- cussed a patient with disfiguring parotomegaly and a normal CD4 count. This time the opinion was over- whelmingly in favour of starting ART. The response to the PDG has been phenomenal. The mailing list currently stands close to 1 500. Subscrib- ers are predominantly from South Africa but also in- clude Namibia, Zimbabwe, Botswana, Zambia, Angola, Malawi, Kenya, Rwanda and other countries. Subscrib- ers are predominantly doctors but also include nurses, pharmacists, and counsellors. There is no doubt that the PDG has succeeded because of the very active participation of our subscribers and our wonderful panel of local and overseas experts, all of whom deserve my heartfelt thanks. I have merely been the conduit between the two. If you would like to subscribe to the PDG, please send an e-mail to leonlevin@54.co.za. I am also constantly on the lookout for new cases to discuss. They can be sent to the same e-mail address. Leon Levin Head, Paediatric programmes Right to Care m e s s a g e   f r o m   t h e   Pa e di at r ic    s u b - c o m m i t t e e THE SOUTHERN AFRICAN JOURNAL OF HIV MEDICINE                                                      December  20098