Page 12 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 5 of 6 Editorial

Editor’s comment: This retrospective study involving 36 HIV- the EFV arm (4.7%), (n = 27). This appeared to have been
positive patients reports the outcome of Stevens–Johnson driven by an increase in adverse events (3.3% vs. 0.5%) in the
syndrome (SJS), toxic epidermal necrolysis (TEN) and the SJS– RPV arm and an unanticipated closure of one of the study
TEN ‘overlap’ syndrome during the 18-month period, January sites. The number of discontinuations is small. The increase
2010–July 2011. Short-term (3-day) oral steroids and in adverse events has not been previously reported in similar
intravenous immunoglobulins (IVIG) were used in all. Active RPV versus EFV studies. Dr Moorhouse and Dr Cohen
debridement of bullae, de-roofing of blisters among others, provide an Opinion Piece on RPV Use in South Africa in the
was avoided in favour of careful skin cleansing. Out of the 36 SAJHIVMED of the 29th May this year. (See item no. 5
patients 32 were female. Sixteen were pregnant. Almost all discussed earlier).
(93.8%) were on nevirapine at the time of admission and the
mean CD4 count of the group was 267 cells/mm³ (SD 60.6). Moorhouse et al. focus on the limitations of RPV in first-line
Ten (27.8%) were also taking anti-tuberculosis drugs, isoniazid ART in SA viz. baseline viral loads are unchecked in the
(n = 2) and rifafour (n = 8). One pregnant patient died. No public sector, many needing to start ART in SA present with
adverse steroid-related events were identified. Unfortunately, low CD4 counts < 200 c/mm³, many in SA are already
the study has not provided more recent data. I would love to undergoing TB (rifampicin) therapy and the recording of
know if the disappearance of nevirapine from most ART baseline QT-intervals in South Africans initiating ART is not
programmes has resulted in the disappearance of these life- routine. Nevertheless, Munderi’s paper suggests that a novel
threatening skin conditions? Nevirapine is no longer a regular role for RVP, for example first-line switch studies, remains an
part of local and international ART guidelines. (Meintjes G, option in those who satisfy the criteria. This is a thoughtful
Moorhouse MA, Carmona S, et al. Adult antiretroviral therapy and well-written paper.
guidelines 2017. S Afr J HIV Med. 2017;18(1):a776. https://doi. 17. Lilian RR, Rees K, Mabitsi M, McIntrye JA, Struthers HE,
org/10.4102/sajhivmed.v18i1.776) Peters RPH. Baseline CD4 and mortality trends in the South
16. Munderi P, Were E, Avihingsanon A, et al. Switching at African human immunodeficiency virus programme:
low HIV-RNA-1 RNA into fixed-dose combinations: Analysis of routine data. South Afr J HIV Med. 2019;
TDF/FTC/ RPV is non-inferior to TDF/FTC/EFV in 20(1):a963. https://doi.org/10.4102/sajhivmed.v20i1.963
first-line suppressed patients living with HIV. South Afr J
HIV Med. 2019;20(1):a949. https://doi.org/10.4102/ Editor’s comment: Highly recommended. This paper
sajhivmed.v20i1.949 reviews HIV changes viz. in mortality and CD4 numbers at
presentation, in South Africa from 2004 to 2016. The tables
Editor’s comment: Highly recommended. This paper details and figures provide a very clear window as to what is
the results of the SALIF study (SALIF = switching at low happening in this region. The University of Cape Town’s
HIV-1 RNA into fixed-dose combinations). The study was TIER.Net database provided the n = 203,131 and n = 101,814
conducted between August 2012 and October 2015 in five anonymised patient records of the respective Johannesburg
sub-Saharan countries viz. Cameroon, Kenya, Senegal, South (JHB) and Mopani (MPI, Limpopo, rural) regions analysed.
Africa and Uganda and one Asian country, Thailand. It is a The paper focuses on mortality in relation to CD4 counts <
phase 3b, randomised, open-label, non-inferiority first-line 200 c/mm³. It also draws attention to the post-2013 decline in
ART switch-study that introduced RPV to virologically ART initiations in both regions – despite the fact that neither
suppressed (HIV-RNA < 50 cp/mL) patients who had has yet achieved the 90-90-90 goals of the UNAID and the
completed ± 12 months of either efavirenz (55%) or nevirapine World Health Organization (WHO). In both regions, it is
(45%). The backbone Nucleoside reverse transcriptase women who outnumber men with regard to ART initiations
inhibitors (NRTI) component of the regimen was tenofovir viz. 63–67% JHB and 68% MPI. In their analysis of the
(TDF) + emtricitabine (FTC) before and after the switch. The meaning of a low baseline, that is, CD4 count < 200 c/mm³ at
RPV switch required the following: virological suppression ART initiation, this is the group with the highest early
(viral load < 50 cp/mL), CD4 count > 200 c/mm³, a normal mortality after starting ART and over a 5-year period. The data
baseline electrocardiograph (ECG) and the absence of are significant (p < 0.001) whether urban or rural. The risk is
concurrent tuberculosis (TB) therapy. Of the total cohort of still present in the 2016/2017 data. The percentage of those
426 subjects, half (n = 211), that is the comparator arm, either initiating ART at these low levels remains high at this time
continued with TDF+FTC+EFV throughout the study or viz. ± 40% in JHB and 35% in MPI. Who are the ones who are
switched to EFV from nevirapine (NVP) after an initial ± 12 at greatest risk of initiating ART at low CD4 levels? Men, the
months on TDF + FTC + NVP. The RPV arm, n = 213, switched elderly, the hospitalised. The authors make the point – not
to RPV + TDF + FTC having completed an initial 12 months new – that these citizens of SA are not invisible to society.
on TDF + FTC + EFV. Both drug combinations were This is a very thought-provoking study. For those among us
administered as single-tablet combination regimens (STRs). who teach medicine, this paper has robust data, excellent
The RPV arm met the 48 week efficacy viz. ≥ 10% non- tables and figures and a great deal to talk about. This paper
inferiority criteria and rate of virological failure requirements is a must-read for all our HIV Clinicians’ Society members.
viz. viral suppression (< 400 cp/mL); RPV arm, n = 200/213 18. Rossouw TM, Van Dyk G, Van Zyl G. Rapid emergence
(93.8%) and EFV arm, n = 203/211 (96.2%). More subjects of resistance to antiretroviral treatment after
discontinued the study in the RPV arm (8%) as compared to undisclosed prior experience: A case report. South Afr

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