Gynecomastia in HIV-positive adult men receiving efavirenz-based antiretroviral therapy at Newlands clinic, Harare, Zimbabwe

Gynecomastia is a condition characterized by unusual enlargement of breast tissue in men. It is known to occur in some men taking antiretroviral therapy which contains efavirenz. We set out to investigate its frequency and outcomes at NewlandsClinic in Harare, Zimbabwe because these data haven’t been described. We analyzed data for 1,432 men with an average age of 40 years, all aged 18 years and older. Most of the men were of healthy weight with an average body mass index of 21. 

73 men (5%) experienced gynecomastia during the follow up period (average follow up time was 1.7 years). Three quarters of the gynecomastia cases occurred within the first two years. When efavirenz was withdrawn, gynecomastia resolved in 84% of the men within three months. 

Gynecomastia vs normal chest.
Picture credit: From https://www.healthdirect.gov.au/gynecomastia

Key Messages:

• The incidence (number of new cases each year) of gynecomastia was low   
• Half of the cases occurred within the first year of commencing efavirenz (75% within the first two years)   
• 84% of the cases resolved within 3 months after stopping efavirenz and replacing with another ARV        
• We did not find any factors significantly associated with developing gynecomastia

Read the full article on here

Sexually transmitted infections, the silent partner in HIV-infected women in Zimbabwe

Lessons from a study we conducted at Newlands Clinic

Did you know you can have a sexually transmitted illness (STI) and not show any symptoms? We screened a random group of 385 women living with HIV who were attending Newlands Clinic Women’s Health Centre. 87% of these women did not have any symptoms for STIs. We tested them for gonorrhea, syphilis, herpes (HSV 2), chlamydia and trichomoniasis. 

After conducting some laboratory tests, we found that 61% of these predominantly middle aged women (with an average age of 41 years) had at least one of the STIs we tested for. Herpes (HSV 2) was the most common STI with half the women (53%) testing positive for it, followed by syphilis (11%), trichomoniasis (8%), chlamydia (2%) and gonorrhea (1%). 62% of those who tested positive for an STI other than HSV 2 did not have any STI symptoms. Women with more than three lifetime sex partners were three times more likely to test positive for an STI other than herpes. Those with tertiary education (college or university) were 90% less likely to test positive for an STI other than herpes. This study showed a high burden of STIs in a largely asymptomatic group of women living with HIV. This provokes a few thoughts:

1. While the U=U mantra meaning Undetectable (viral load) = untransmittable (HIV infection) needs to reach as many people as possible, it must be interpreted with caution particularly in settings where the burden of STIs is high since the presence of an STI also increases the chances of HIV infection and onward transmission even when the HIV viral load is undetectable
2. The same mantra might in fact be true for HIV transmission, but unprotected sex still exposes people to STIs which were quite high in our study group. Using a condom is still a great idea! Condomize!
3. With such a high burden of asymptomatic infections, the syndromic approach used to treat STIs in many resource limited settings would have missed all the asymptomatic women. We recommend routine screening particularly in the high risk groups for early detection and treatment of STIs.
4. Education of women was protective against STIs. Probably women who are educated are more confident or empowered to negotiate for safer sex.
5. The fewer sex partners the better. Seems like a no-brainer, but maybe a reminder to think twice before jumping into bed with the next partner! Take note though that the first or second sex partner may be carrying an STI, so protected sex is of utmost importance all the time.

This study was published in the Southern African Journal of HIV Medicine. If interested, you can read the full article.

Outcomes of an HIV cohort after a decade of comprehensive care at Newlands Clinic in Harare, Zimbabwe: TENART cohort

You might be living with HIV or taking care of people living with HIV and you wonder what the long term outcomes of antiretroviral therapy are. You're not alone. Such a description would inform people living with HIV as well as HIV programs on what can be achieved when people living with HIV are cared for in the same manner as done at Newlands Clinic which is supported by the Ruedi Luethy Foundation.

We looked into our patient files for patient information, particularly those who initiated therapy under our care between 2004 when our clinic was opened, and 2006. These are patients who had been recruited into care at least 10 years before the time of analysis which was at the end of 2016. Our model of care at Newlands Clinic includes the provision of antiretroviral medicines, adherence counselling (which helps people to consistently take their medicines), food security support for those unable to consistently access enough food and laboratory monitoring. During the time in question, patient care was mostly led by nurses with the support of doctors.

We analyzed records of 605 patients with an average age of 34 years at the time they started therapy. Most of them were female (67%). 474 (78.3%) were still in care at the end of 2016, while 59 (9.8%) had been transferred to other clinics, 45 (7.4%) were lost to follow up, 25 (4.1%) died and two stopped antiretroviral therapy. Sixty-six (11%) developed pulmonary tuberculosis while in care. Of the 474 that were still in care, 428 (90%) had undetectable viral loads, which is the main goal of antiretroviral therapy.

Our results show that the model of care for people living with HIV as implemented by Newlands Clinic can lead to highly successful treatment outcomes and a reduced number of deaths. They also show that pulmonary tuberculosis was an important opportunistic infection affecting over a tenth of these patients while in care.

The Full Article is available for further information.