HIV Infection and the way forward for South Sudan

Author(s): Prof. James G. Hakim, MBChB, MMed, MMedSci, FRCP, PGDipHPE

Department of Medicine, College of Health Sciences, University of Zimbabwe

[email protected]

In the last thirty-three years HIV infection has spread to all corners of the world, but the largest concentration of the epidemic is in Sub-Saharan Africa where 70% of the 35 million people living with HIV/AIDS in 2013 are found. The advent of peace and independence in South Sudan brought a rush to rebuild the nation. The potential wealth from oil brought back South Sudanese from the diaspora and attracted migrants from the region, and the intermingling of populations created an environment ripe for the transmission of HIV. The epidemic in South Sudan is generalized with a prevalence rate of 3%. There are high risk populations such as commercial sex workers with much higher prevalence rates. The push to reduce the spread of new HIV infections and to put more people on treatment remains a huge challenge. There is still lack of information and public awareness about transmission, prevention and treatment.

In this issue of the SSMJ important aspects of HIV infection including the safety of blood products, TB/HIV co-infection, prevention of mother to child transmission (PMTCT) and impaired bone healing are presented. At the outset of the HIV epidemic haemophiliacs were one of the earliest groups that suffered as a result of unsafe blood. The safety of blood and blood products is a critical aspect of HIV prevention, which in South Sudan leaves much to be desired. The prevention strategy has advanced greatly and includes: HIV testing and counselling, behaviour change, condom use, voluntary medical male circumcision, pre-exposure prophylaxis and the use of antiretroviral therapy (ART). Moreover the distinction between prevention and treatment has become blurred. An example is that now PMTCT is achieved with triple ART including agents such as efavirenz which only a few years ago were considered potentially teratogenic and contraindicated in pregnancy. The PMTCT option B+, in which all HIV positive women identified during pregnancy, labour or while breastfeeding are started on ART for life irrespective of CD4 counts or WHO clinical stage, is seen as a cornerstone of the elimination of HIV in children while ensuring that mothers get optimal ART care.

In South Sudan there is a paucity of information about basic opportunistic infections in HIV infected patients including tuberculosis, pneumocystis jiroveci pneumonia, cryptococcal disease, bacterial infections, Kaposi’s sarcoma and carcinoma of the cervix which have hitherto been considered the sine-qua-non of AIDS. The country must invest in research in understanding how widespread these co-infections are in order to inform policies and strategies needed to counter their effects. South Sudan is at the beginning of a steep learning curve. Knowledge, attitudes and practice must drive appropriate behaviour change and implementation of biomedical strategies if we are to prevent a spiralling of the epidemic. South Sudan must urgently adopt strategies which elsewhere have changed HIV infection from a deadly infection to a chronic disease.