The Scourge of HIV Infection in Sub-Saharan Africa — A Rheumatological Perspective

HIV Infection and Osteoarticular Tuberculosis: Strange Bedfellows

We report the case of a 47-year-old female patient with rheumatoid arthritis and HIV infection presenting with a 3-week history of a painful swollen knee, increased serum inflammatory markers, and a low CD4 lymphocyte count. The diagnosis of TB arthritis was made by synovial fluid culture, GeneXpert/PCR, and confirmed by histopathology of a synovial biopsy. A mini literature review suggests that although HIV infection is associated with extrapulmonary TB, osteoarticular TB is a relatively unusual presentation in an HIV positive patient. The diagnostic utility of the GeneXpert test is explored. We also describe the patient's good response to an intra-articular corticosteroid injection in combination with standard anti-TB therapy.

The specialist physician's approach to rheumatoid arthritis in South Africa

Rheumatoid arthritis (RA) is expected to increase in Africa and South Africa. Due to the low numbers of rheumatologists in South Africa, specialist physicians also have to care for patients with RA. Furthermore several new developments have taken place in recent years which improved the management and outcome of RA. Classification criteria were updated, assessment follow-up tools were refined and above all, several new biological disease-modifying anti-rheumatic drugs were developed. Therefore it is imperative for specialist physicians to update themselves with the newest developments in the management of RA. This article provides an overview of the newest developments in the management of RA in the South African context. This approach may well apply to countries with similar specialist to patient ratios and disease profiles.

The African Lupus Genetics Network (ALUGEN) registry: standardized, prospective follow-up studies in African patients with systemic lupus erythematosus

Background

The prevalence and severity of systemic lupus erythematosus (SLE) differs between ethnic groups and geographical regions. Although initially reported as rare, there is growing evidence that SLE is prevalent and runs a severe course in Africa. There is a paucity of prospective studies on African SLE patients.

Objective

The African Lupus Genetics Network (ALUGEN) is a multicentred framework seeking to prospectively assess outcomes in SLE patients in Africa. Outcomes measured will be death, hospital admission, disease activity flares, and SLE-related damage. We will explore predictors for these outcomes including clinical, serological, socio-demographic, therapeutic and genetic factors. Further, we will investigate comorbidities and health-related quality of life amongst these patients.

Methods

Data of patients recently (≤5 yrs) diagnosed with SLE will be collected at baseline and annual follow-up visits, and captured electronically. The ALUGEN project will facilitate standardized data capture for SLE cases in Africa, allowing participating centres to develop their own SLE registries, and enabling collaboration to enrich our understanding of inter-ethnic and regional variations in disease expression.

Conclusion

Comprehensive, high-quality multi-ethnic data on African SLE patients will expand knowledge of the disease and inform clinical practice, in addition to augmenting research capacity and networking links and providing a platform for future biomarker and interventional studies.

Effect of human immunodeficiency virus infection on disease activity in rheumatoid arthritis: a retrospective study in South Africans

OBJECTIVE

To determine the effect of human immunodeficiency virus (HIV) infection on disease activity in rheumatoid arthritis (RA).

METHODS

A retrospective records review of patients who contracted HIV infection subsequent to RA diagnosis (HIV group), compared to an HIV-negative group of patients with RA (control group), for 28-joint Disease Activity Score (DAS28) scores at initial presentation (T0) and last clinic visit (TL), and at diagnosis of HIV infection (TH) in the HIV group.

RESULTS

Of 1712 patients with RA, 85 were HIV-positive (4.9%), 43 of them contracting HIV subsequent to RA diagnosis. The mean (SD) age, RA disease duration, and duration following diagnosis of HIV were 47.1 (10.1), 10.5 (8.4), and 2.9 (2.0) years, respectively, for the HIV group. Both the HIV and control groups showed similar improvement in joint counts and C-reactive protein (CRP) at visit TL, in spite of methotrexate (MTX) being withdrawn in most patients in the HIV group by visit TL (11.6% in the HIV group were still taking MTX vs 83.7% in the control group, p = 0.0002), but a minority (13.9%) had ongoing moderate to high disease activity at visit TL. In the HIV group, the mean DAS28-erythrocyte sedimentation rate (ESR) and DAS28-CRP scores were similar at baseline, but at visits TH and TL the mean DAS28-ESR scores were significantly higher than the mean DAS28-CRP scores (31% and 31.8%, p < 0.0005 and p < 0.004, respectively), mainly resulting from ESR increase following HIV seroconversion.

CONCLUSION

Disease activity improved in most patients in the HIV group in spite of stopping the MTX as the "anchor drug." The DAS28-ESR overestimates disease activity compared to the DAS28-CRP in the setting of HIV infection.