THE SOUTHERN AFRICAN JOURNAL OF HIV MEDICINE                                                        october  2009 5 I am delighted to introduce you to our guest editors, who have done a sterling job in pulling together this ‘Mental Health in HIV’ edition. They are two Capetonian colleagues who I am also for- tunate to consider friends: John Joska is a psychiatrist and Landon Myer is a public health specialist. John Joska is a senior specialist and lecturer in the Department of Psychiatry and Mental Health at the University of Cape Town. He is head of the Division of Neuropsychiatry, Western Cape provincial programme manager for HIV Psychiatry, and director of the GSH- HIV Mental Health Group. The latter is a newly formed group of mental health professionals who are providing service and investigating the effects of HIV on people living with HIV/AIDS (PLWHA) from a mental health point of view. Current research projects include inves- tigations into neurocognitive disorders in HIV, screen- ing for mental disorders in HIV, and brief psychological interventions in PLWHA with depression. Landon Myer is an associate professor in the School of Public Health and Family Medicine at the University of Cape Town. His research focuses on the roles of HIV/ AIDS and other infectious diseases in shaping individual and population health in southern Africa. He is particu- larly interested in how the HIV epidemic influences other areas of population health, including mental health and women’s reproductive health. In investigating these top- ics, his research incorporates biological mechanisms, in- dividual behaviours and exposures, as well as structural socio-economic and health service conditions. I am sure you will agree that with their colleagues they have provided a feast of important reading for you all in this edition. 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 addressing mental health in routine hiv care and treatment As this journal’s readers are well aware, HIV has complex and wide-ranging impacts on the health of infected in- dividuals. Much of this complexity is due to the nature of host-virus interactions and the pathophysiology of the virus and its sequelae in different organ systems over time. Other aspects are linked to the profound impact an HIV diagnosis has on the life of an infected individual, both through physical morbidity and the psychological and social consequences of a lifelong illness. The area of mental health is a critical example of the di- verse impacts of HIV on patients’ health and well-being. The links between HIV and mental health are multiple: risk taking associated with HIV acquisition is more com- mon among individuals with mental disorders; common mental disorders (such as anxiety, depression and alco- hol/substance disorders) are often caused in part by the stress of an HIV diagnosis and related stigma; psychotic states are a relatively common presentation of HIV- infected individuals; and neurocognitive manifesta- tions of HIV infection such as HIV-associated dementia emerge later in the course of disease. Taken together, mental disorders may be viewed as their own class of ‘opportunistic’ conditions affecting HIV-infected indi- viduals in a unique manner. Dealing with the various mental health impacts of HIV infection is a core component of effective HIV care and treatment. Anxiety and depression among HIV-infected individuals can negatively impact on medication adher- ence; in these situations, management of mental disor- ders can help facilitate the management of HIV disease over the long term. The neurocognitive manifestations of HIV disease are a significant cause of morbidity; in- creasingly we are recognising that these disorders may e di tor i a l m e s s a g e   f r o m    t h e   e x e c u t i v e The large International AIDS Society meeting has come and gone from Cape Town. The agenda was dominated by a New Big Idea, an audacious mathematical model by a group of brave World Health Organization model- lers showing that giving antiretroviral therapy to every- one with HIV, immediately, could make the epidemic disappear. We’ve known for a long time that viral load corre- lates with infectiousness, whether it is sexual contact, PMTCT or other forms of exposure. ART is so highly ef- fective in reducing viral load that the Swiss created an uproar a year ago by claiming that someone on ART with an undetectable viral load (and no STD) could not transmit HIV sexually. The WHO researchers essentially argue that if we diag- nose HIV quickly and treat everyone who is HIV positive, irrespective of CD4 count, we can arrest sexual trans- mission early and pretty much eradicate HIV within 10 years. Subsequent papers have even postulated that we could reverse the TB epidemic, as HIV drives this like fuel on a fire. Finally, early economic work has shown ‘test and treat’ to be cost saving, despite significant initial investment. There is broad acknowledgment that HIV prevention programmes have been very disappointing, and that even effective interventions such as male circumcision and good PMTCT are unlikely to eradicate the epidemic alone. It is exciting that researchers are thinking crea- tively, and that models showing we can reverse things are out there. But to implement this incredibly ambitious model would require a complete restructuring of health sys- tems. We would need to do HIV testing aggressively and provide adequate, easily available ART services, as broadly as possible. The health system would have to be transformed from the lumbering unfriendly giant it is at the moment to a responsive and effective service deliverer. The reality is that we need this anyway, even if the modellers are wrong. FRANCOIS VENTER President be managed effectively, including by early initiation of antiretroviral therapy, to improve the prognosis of af- fected individuals. In short, basic mental health care is part of good HIV management. In this context, there is a clear need to make the diag- nosis and management of mental disorders more feasi- ble in general HIV care and treatment settings. At the primary and secondary levels of the health care system, medical officers and physicians must be able to identify patients with a possible mental disorder and work up these patients to arrive at a preliminary diagnosis, make management decisions, and follow up patients over time. Support from specialist psychiatrists is necessary in some instances, but most cases do not require spe- cialist referral, and the availability of psychiatric services to support HIV care and treatment is limited in most set- tings across the region. This special issue of the journal aims to address this need through a series of focused contributions from leaders in HIV mental health from across South Africa. The first two pieces focus on anxiety and depression in HIV in broad terms (Thom) and post-traumatic stress disorder specifically (Pingo). Following this, the topic of psy- chotic presentations in HIV is dealt with by an algorithm for the diagnosis and management of psychosis in HIV (Jonsson) and then an extended case study (Boyles) to help reinforce key concepts. The topic of neurocognitive impairment in HIV/AIDS is discussed in detail (Singh) with a short report on the white matter changes that take place in the brain over the course of HIV disease (Hoare) as well as a piece of empirical research inves- tigating the clinical utility of one commonly used tool to identify neurocognitive deficits in HIV (Ogunrin). The final piece deals with cross-cutting issues of prescribing psychotropic medications in the context of HIV infection (Parker). Throughout, these pieces aim to address issues in mental health faced by front-line HIV clinicians on a daily basis, with practical strategies for investigation and management. It is our hope that the contents of this issue may make some contribution towards helping HIV clinicians to better recognise and treat mental disorders in their patients. LANDON MYER JOHN JOSKA Guest Editors THE SOUTHERN AFRICAN JOURNAL OF HIV MEDICINE                                                          october  20096