Page 17 - HIVMED_v21_i1.indb

Page 7 of 8 Editorial

an optimistic report that focuses on antiretroviral treatment 19. Dunlop JL, Slemming W, Schnippel K, et al. Breast
and the prevention of vertical transmission of HIV. abnormalities in adolescents receiving antiretroviral
therapy. S Afr J HIV Med. 2019;20(1):a1017. https://doi.
New antiretrovirals and a new delivery system: GS-6207 is org/10.4102/sajhivmed.v20i1.1017
the first of the capsid-inhibitor ARV class but currently no
paediatric studies have been reported. Adult trials are Editor’s comment: This is a retrospective report of abnormal
promising. Treatment = long-acting, s/c administration breast development in adolescents aged 10–19 years. All were
every 3 months. MK-8591, the first nucleoside reverse on antiretroviral therapy (ART). The article reflects January–
transcriptase TRANSLOCATION-inhibitor. No paediatric December 2014 clinical records of 631 Johannesburg-based
data but adult studies = prolonged intracellular half-life and adolescents living with HIV (ALWH). Of the patients, 37
low once a week dosing. No cross-resistance to other (5.9%) had ‘abnormal’ breasts. Of those with abnormal
nucleoside-reverse transcritpase inhibitors (NRTIs). An adult breasts, most (24; 65%) were men (p = 0.043). Median duration
fixed-dose combination (FDC) in trials: MK-8591+doravirine. of ART was 4.9 years. The older adolescents (p < 0.0005) and
A paediatric formulation is possible. Tenofovir alafenamide those on efavirenz (EFB)-based ART (p = 0.016) were more
(TAF) in children, a new NRTI with lower renal and bone likely to have breast problems. Ninety-two per cent (34/37)
demineralisation risk and an FDC formulation for were on EFV, whilst the remaining 8% were on lamivudine
children aged > 6 years and weighing ≥ 25 Kg: TAF/FTC/ (3TC) monotherapy, that is, they were likely to have been on
elvitegravir+cobicistat. Of a variety of novel drug delivery EFV previously. (The prevalence of EFV use amongst those
systems, the adult transdermal adhesive micro-needle skin with normal breasts – the comparator group – was lower,
patches that deliver monthly cabotegravir offer new namely n = 384/594;74.3%). The use of boosted-protease
therapeutic or prevention options with potential for inhibitors, such as lopinavir or ritonavir, atazanavir and
paediatric application. darunavir, was not associated with breast changes. Although
lipodystrophy was recorded in 46.3% and gynecomastia in
Antiretroviral drug efficacy and safety: Birth defects. The 29% of those with breast changes, body mass index-confirmed
risk of neural tube defects in infants exposed to dolutegravir overweight or obesity was found in only eight (19.5%)
(DTG) during periconception (first-trimester of pregnancy) participants. More than 70% had viral suppression
appears to be confirmed with updated data from Botswana’s (VL < 50 copies/mL) and immune reconstitution (CD4 count
Tsepamo Birth Surveillance Study. Nevertheless, the World ≥ 500 cells/mm ). Most of the 37 adolescents took their pills.
3
Health Organization recommends DTG-based antiretroviral The file review indicated that clinic physicians ‘corrected’ the
therapy (ART) for all women of child-bearing potential who problem by replacing EFV with nevirapine (NVP). This
are living with HIV. Women who are not pregnant must be hardly solved the problem. The authors remark that few
counselled regarding contraception. And counselling of all were referred for additional breast care. And of the three who
women MUST ensure that the decision for either a DTG or were referred, none received any definitive intervention. This
an efavirenz (EFV)-based ART is a fully INFORMED article has also limitations. Retrospective studies have a
DECISION and decided ahead of the start of ART. Children tendency to accumulate data gaps with the passage of time.
who are HIV-exposed but uninfected (CHEU) enrolled in Did the breast abnormalities ever resolve? The use of EFV is
the International Antiretroviral Pregnancy Registry (APR) widespread in sub-Saharan Africa. Are these toxicities still
had lower birth weight- and length-for-age compared to being seen? Is anyone culpable? After all, these are iatrogenic
unexposed, uninfected children. Zimbabwe’s SHINE study adverse events.
also reported stunting and mortality risk to CHEU (see 20. Govender NP, Meintjes G, Mangena P, et al. Southern
comment summary 13 above).
African HIV Clinicians Society guideline for the
prevention, diagnosis and management of cryptococcal
Metabolic effects of ART. Exposure of adults to ART (the disease among HIV-infected persons: 2019 update. S Afr J
South African ADVANCE study) uncovered significant HIV Med. 2019;20(1):a1030. https://doi.org/10.4102/
weight gain in all study arms but especially those given both
DTG+TAF/FTC. What drug-related toxicity is emerging and sajhivmed.v20i1.1030
what does this mean for children on these drugs?
Editor’s comments: I recommend this guideline paper to all.
It is a must-read and is up there with the best.
Public health, ART and children. Paediatric retention in care
and viral load (VL) suppression rates are suboptimal in 21. Spencer DC, Krause R, Rossouw T, et al. Palliative care
southern Africa. Adolescent mortality and morbidity risk is guidelines for the management of HIV-infected people in
too high. According to the International Epidemiologic South Africa. S Afr J HIV Med. 2019;20(1):a1013. https://
Databases to Evaluate AIDS – Southern Africa (IeDEA-SA) doi.org/10.4102/sajhivmed.v20i1.1013
collaboration data 2004–2017, ‘children lag behind’.
Editor’s comment: This is a guideline paper and I thank the
Readers are encouraged to check out this ‘Opinion Piece’ for colleagues who helped me with this one. If you are interested
themselves. Its background is the success of the prevention of in this field of HIV medicine, please contact the HIV Clinicians
mother-to-child transmission of HIV. Its reality is the day-to- Society. We are eager to start an interest group to develop the
day management of young people living with HIV. field further.

http://www.sajhivmed.org.za 9 Open Access