Landon Myer

The impact of highly active antiretroviral therapy (HAART) on health-related quality of life has been widely researched in the developed world, but there are few data from sub-Saharan Africa, where the vast majority of HIV-infected individuals live. This study examined health-related quality of life among HIV-positive individuals initiating HAART in Cape Town, South Africa, and explored the impact of HAART-related drug toxicities on quality of life.

Serum concentrations of soluble urokinase-type plasminogen activator receptor (suPAR) have a strong independent association with HIV-1-related mortality. The practical utility of plasma suPAR in assessing short-term all-cause mortality risk was evaluated in patients with advanced immunodeficiency enrolling in an antiretroviral treatment (ART) programme in South Africa.

Despite the growth of biomedical research in South Africa, there are few insights into the operation of Research Ethics Committees (RECs) in this setting. We investigated the composition, operations and training needs of health RECs in South Africa against the backdrop of national and international guidelines. The 12 major health RECs in South Africa were surveyed using semi-structured questionnaires that investigated the composition and functions of each REC as well as the operational issues facing committees. Health RECs in SA have an average of 16 members and REC members are predominantly male and white. Overall, there was a large discrepancy in findings between under-resourced RECs and well resourced RECs. The majority of members (56%) are scientists or clinicians who are typically affiliated to the same institution as the health REC. Community representatives account for only 8% of membership. Training needs for health REC members varied widely. Most major health RECs in South Africa are well organized given the resource constraints that exist in relation to research ethics in developing countries. However, the gender, racial and occupational diversity of most of these RECs is suboptimal, and most RECs are not constituted in accordance with South African guidelines. Variability in the operations and training needs of RECs is a reflection of apartheid-entrenched influences in tertiary education in SA. While legislation now exists to enforce standardization of research ethics review systems, no provision has been made for resources or capacity development, especially to support historically-disadvantaged institutions. Perpetuation of this legacy of apartheid represents a violation of the principles of justice and equity.

To the Editor —The recent publication by Bradshaw et al. [1] highlights the high rates of recurrence of bacterial vaginosis (BV) in HIV‐negative women over the course of a 12‐month period after oral metronidazole therapy. Despite the significance of these findings, there is still little understanding about whether HIV infection affects the recurrence of BV. Longitudinal studies from the United States have shown that the prevalence of BV may be higher among HIV‐infected women [2–4 ]. However, there are few data about the occurrence of BV from developing countries, where the prevalences of both HIV and BV are substantially higher than those in developed countries. We examined the potential role that HIV plays in BV recurrence over the course of 12 months of follow‐up in South African women who received treatment for clinically defined bacterial vaginosis.

Background Many women using hormonal contraceptives are also at risk of sexually transmitted HIV infection, but data are mixed on whether hormonal contraception increases women's risk of HIV. We investigated associations between HIV incidence and use of combined oral contraceptives (COC), norethindrone enanthate (NET-EN) or depot medroxyprogesterone acetate (DMPA) in a cohort of South African women. Methods Participants were 4200 HIV-negative women aged 35–49 years enrolled into a cervical cancer screening trial. At enrollment, women were tested for sexually transmitted infections and reported on their sexual behaviour and contraceptive use. During the 24 months of follow-up, women reported on their sexual behaviours and contraceptive use and underwent repeat HIV testing. Results During the 5010 person-years of follow-up, 111 incident HIV infections were observed (HIV incidence, 2.2 infections/100 person-years). At enrollment, 21% of women reported using hormonal contraception, primarily DMPA (14% of all women) or NET-EN (5%). After adjusting for sexual risk behaviours and sexually transmitted infections, the incidence of HIV was similar among women using COC, NET-EN or DMPA compared with women not using any hormonal method [incidence rate ratios and 95% confidence intervals, 0.65, 0.16–2.66; 0.79, 0.31–2.02 and 0.96, 0.58–1.59, respectively]. There was also no association between increased duration of DMPA use and HIV incidence (P-value for trend, 0.51). Conclusions These findings contribute to the evidence from general population cohorts of women that hormonal contraceptive use is not associated with increased risk of HIV acquisition. Nonetheless, family planning services are an important venue for HIV prevention activities.

We appreciate the interest of McClelland et al. (1) in our recent analysis suggesting no association between women's intravaginal practices and incident human immunodeficiency virus (HIV) infection (2).

While the ability to lead a healthy sexual life and to choose whether and when to have children are well-established features of reproductive health and human rights, issues surrounding sexual activity and childbearing among HIV-infected women and men have received little attention in sub-Saharan Africa. We conducted a semi-structured, cross-sectional survey at 26 primary health care clinics in South Africa to investigate community attitudes towards sexual activity and reproduction by HIV-infected individuals. Of the 843 women interviewed, slightly less than half (43%, n = 361) thought that people living with HIV/AIDS should remain sexually active if they choose, while 13% (n = 113) said they thought that people living with HIV/AIDS should have children if they wished to do so. In multivariate analysis, negative attitudes towards both sexuality and childbearing were persistently associated with not knowing someone infected with HIV (p = 0.001 and 0.043, respectively). These findings suggest that the sexual and reproductive health rights of HIV-infected women and men may be an important target as part of efforts to reduce HIV/AIDS-related stigma. Health policies and services are required to reinforce the reproductive rights of HIV-infected individuals in South Africa and other countries in sub-Saharan Africa where HIV is most prevalent.

In order to ensure that legalized abortion in South Africa improves reproductive health, women must know that abortion is a legal option in the case of unwanted pregnancy. This study investigated knowledge of abortion legislation eight years after the introduction of legal abortion services in one province of South Africa. In 2004/2005, we conducted a cross-sectional study among 831 sexually-active women attending 26 public health clinics in one urban and one rural health region of the Western Cape Province. Thirty-two percent of women did not know that abortion is currently legal. Among those who knew of legal abortion, few had knowledge of the time restrictions involved. In South Africa there is an unmet need among women for information on abortion. Strategies should be developed to address this gap so that women are fully informed of their rights to a safe and legal termination of pregnancy.

Patients accessing antiretroviral treatment (ART) programmes in sub-Saharan Africa frequently have very advanced immunodeficiency. Previous data suggest that such patients may have diminished capacity for CD4 cell count recovery. Rates of CD4 cell increase were determined over 48 weeks among ART-naïve individuals (n = 596) commencing ART in a South African community-based ART programme. The CD4 cell count increased from a median of 97 cells/μl at baseline to 261 cells/μl at 48 weeks and the proportion of patients with a CD4 cell count <100 cells/μl decreased from 51% at baseline to just 4% at 48 weeks. A rapid first phase of recovery (0–16 weeks, median rate = 25.5 cells/μl/month) was followed by a slower second phase (16–48 weeks, median rate = 7.7 cells/μl/month). Compared to patients with higher baseline counts, multivariate analysis showed that those with baseline CD4 counts 500 cells/μl at 48 weeks, 19% had baseline CD4 cell counts <50 cells/μl. However, the proportion of these patients that attained a CD4 count 200 cells/μl at 48 weeks was lower than those with higher baseline CD4 cell counts. Patients in this cohort with baseline CD4 cell counts <50 cells/μl have equivalent or greater capacity for immunological recovery during 48 weeks of ART compared to those with higher baseline CD4 cell counts. However, their CD4 counts remain <200 cells/μl for a longer period, potentially increasing their risk of morbidity and mortality in the first year of ART.