Inner City HIV Care in Joburg

Francois Venter, one of South Africa’s leading HIV physicians, introduced me to HIV care for people living in the heart of Johannesburg. As well as doing academic work at Wits University, Francois works at a collection of HIV community clinics in Hillbrow, just above the central business district, and also at Johannesburg Hospital, the main unit for the centre of the city.

Hillbrow used to be a busy business and residential area of Joburg. However over the last 20 years, most businesses and longstanding residents moved out, and were replaced by poor, disadvantaged, often homeless people. Today Hillbrow has a reputation as a dangerous no-go area; indeed Francois thought it best not to drive into certain parts. About half a million people are crammed into an area of one square kilometre. Most of the old office tower blocks are squatted; they are boarded up, without electricity or water, with many thousands of people living in each building. People living in these terrible conditions face disease and malnutrition. TB and food and water borne infections are rife, and about one-third of Hillbrow residents are estimated to be living with HIV. In addition to disease, fire is a real danger, and indeed whilst I was there two fire engines were racing through the streets to deal with another incident. Many if not the majority of Hillbrow residents are not South African. This area acts as a magnet for people displaced from other countries, particularly Zimbabwe at the moment. Sex workers and brothels are to be found everywhere.

On one side street there is an odd collection of clinics and businesses. The main HIV community clinic is straddled by an abortion clinic and a funeral parlour, and across the street is an NGO for sex workers.

Nutrition is a problem in Hillbrow. As far as I am aware there are no community dietitians working there. NGOs and churches do give out food parcels and provide soup kitchens, but little else is on offer.

There is some hope, however. Gradually some of the former office blocks are being renovated, with water and electricity supplied. Indeed some of the former business buildings remain in excellent structural condition; hopefully they will provide more comfortable accommodation for some of Joburg’s most marginalised people.

Dr Venter kindly let me observe his HIV clinic at Johannesburg Hospital. We discussed lipodystrophy – the side effect of ARVs often presenting with peculiar body shape changes. As discussed in previous posts, two of the medicines most closely associated with lipodystrophy – AZT and d4T – remain the cornerstone of ARV therapy in Southern Africa. Francois was hopeful that alternatives such as Abacavir and Tenofovir will be widely available soon. Indeed two patients we saw in that clinic were already being considered for these medicines.

A group of patients attending clinic were prisoners from Leeuwkop Correctional Centre. Their HIV care seemed to be excellent. ARVs were not only administered, but virtually observed being taken. There had been a review of prison food, and special provision had been made to ensure adequate nutrition for those on ARVs. Leuuwkop houses some of South Africa’s maximum security prisoners, and so many prison guards were in attendance at the hospital. The prisoners remained shackled throughout their clinic visit. The prisoners are no longer told when their next clinic visit is due, but are brought without warning. This follows an incident last year when a fatal shoot-out occurred at the HIV clinic at Johannesburg Hospital when some prisoners were sprung by some accomplices, with many clinic staff hurt or traumatised as a result.

With such large numbers of patients initiating onto ARVs in South Africa, patterns are beginning to emerge with side effects occurring shortly after starting therapy. In the UK we have seen some peculiar responses as the immune system begins to reconstitute. Colonies of bugs or viruses quietly growing in the body are now attacked by a resurgent immune system, often leading to dramatic and sometimes potentially fatal inflammatory responses. This condition is called IRIS – Immune Reconstitution and Inflammation Syndrome. Francois Venter talked about a pattern he has seen where patients lose weight shortly after commencing ARVs. Clearly this is not the expected outcome, and indeed most people gain weight after initiating ARVs. But this loss of weight is seen amongst those starting ARVs with a low CD4 count. Francois was wondering if this weight loss might be explained by IRIS occurring in the intestine. An immune-modulated inflammatory response at this stage might lead to malabsorption of nutrients, and an associated loss of weight. This is a potentially exciting area of research.