This issue of the Journal continues discussions started in the December 2011 issue. Professor Kuhn responds to the concerns raised by Salojee about the national policy promoting breastfeeding in HIV-exposed infants; she discusses the scientific rationale for the policy revisions, and presents a population perspective rooted in overall child morbidity and mortality. For better or worse, infant feeding is likely to remain an important topic for years to come. Both viewpoints need careful consideration, and subsequent discussions in these pages hopefully can be informed by experiences from implementing the new infant feeding policies in different settings around the country.
Another matter is low-dose stavudine in HIV management. In the last Journal, Innes et al. presented a rationale for a trial investigating low-dose stavudine’s impact on therapeutic and toxicity endpoints. Given increasingly scarce resources for ART in much of sub-Saharan Africa, this proposal has intuitive appeal. We now publish a strong response by Andrieux-Meyer et al., who argue that further research into stavudine's use is untenable – with a clear rebuttal from Venter et al. There are important nuances – the use of stavudine in adults v. children; follow-up duration of a trial investigating long-term outcomes; and the changing costs of tenofovir and other more expensive medications – that evade oversimplified judgments.
More generally, these two ongoing debates raise important questions about what we know and how well we know it. Although we aim to practice ‘evidence-based medicine’, the evidence base for many policies and decisions may be surprisingly thin and malleable. The same body of evidence can lead to opposing interpretations, as seen in the debates on infant feeding and low-dose stavudine. The challenge and talent of skilled clinicians and good policymakers is to make sensible decisions in the face of flawed evidence. Fundamental to this is perceiving the likelihood of misjudging – and in turn the ability to acknowledge opposing viewpoints and the importance of continually trying to improve the evidence base on which our decisions are based. These challenges re-emerge constantly, and again in this issue of the Journal. They have been entwined in the theory and practice of medicine for millennia, as recorded in one of Hippocrates’ aphorisms on the art of medicine, from around 400 BC: ‘Life is short; the art is long; opportunity fleeting; experiment fallible; judgment difficult.’
The Journal presents other exciting pieces, including an important critique on the role of efavirenz in pregnancy from Pillay and Black, where clinical judgment has greatly outpaced policymaking. Johnson presents a model-based analysis of ART initiation across the country, and suggests that the scope of the ART roll-out approaches the targets set by the NSP for 2007 - 2011. This is a major accomplishment that underscores the ability of the public health system to achieve ambitious goals, given adequate capacity and resources. In addition, an opinion piece by Kenyon and colleagues calls into question the widely held belief that poverty alone drives the sexual transmission of HIV across South Africa (a contentious assertion that may give rise to more debate), and Katusiime presents an interesting case study on chronic genital ulcer disease in the context of HIV infection.
Good reading!
Landon Myer
School of Public Health & Family Medicine
University of Cape Town
Landon.Myer@uct.ac.za