Walter Sisulu University

PHALAMA, MANAKA PETER

English

ANTIOXIDANT EFFECTS OF Chenopodium album Linn AGAINST CADMIUM INDUCED OXIDATIVE STRESS IN MALE TESTES IN VIVO.

Benedicta Ngwenchi Nkeh‑Chungag1* , Godwill Azeh Engwa1 , Charles Businge2 , Mziwohlanga Mdondolo3 , Magdevy Pajaro Medina4 and Nandu Goswami5

Assessment of the impact of HIV infection and anti‑retroviral treatment on the cardiometabolic health of pregnant mothers and their ofspring (ARTMOMSBABES)

FUNGIWE HLUBIKAZI GXOLO, Fundiswa Hlubikazi

Burden of skin diseases in dermatology department inpatients at the Nelson Mandela Central Hospital, Mthatha, Eastern Cape Province in South Africa

Kaswa, Ramprakash

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Page 1 of 4 Scientific letters
https://www.safpj.co.za Open Access
South African Family Practice 
ISSN: (Online) 2078-6204, (Print) 2078-6190
Author:
Ramprakash Kaswa1 
Affiliation:
1Department of Family 
Medicine and Rural Health, 
Faculty of Health Sciences, 
Walter Sisulu University, 
Mthatha, South Africa
Corresponding author:
Ramprakash Kaswa,
rp.kaswa@gmail.com
Dates:
Received: 21 June 2021
Accepted: 08 Aug. 2021
Published: 27 Sept. 2021
How to cite this article:
Kaswa, R. The impact of 
the COVID-19 pandemic 
on accessing HIV care: A 
case report. S Afr Fam Pract. 
2021;63(1), a5344. https://
doi.org/10.4102/safp.
v63i1.5344
Copyright:
© 2021. The Authors. 
Licensee: AOSIS. This work 
is licensed under the 
Creative Commons 
Attribution License.
Introduction
The impact of the coronavirus disease 2019 (COVID-19) pandemic on the world is beyond our 
imagination. The perfect storm of economic, health and social crisis was created by the COVID-19 
pandemic.1 As most of the countries around the globe underwent lockdown periods, access to 
healthcare was severely impacted because of an interruption of supply, a diversion of resources 
and the overwhelm of healthcare systems.1,2
Like other countries around the world, South Africa also implemented a lockdown to slow the 
transmission rate and prepare the healthcare system for the COVID-19 pandemic. These 
provisions have had enormous consequences on healthcare service access for patients with 
chronic diseases, particularly for those living with HIV and AIDS.3,4 South Africa accounts for 
about one-fifth of the global HIV burden and has the world’s largest antiretroviral therapy 
(ART) programme.5 In recent years, South Africa has made enormous progress towards HIV 
management.
In the context of the COVID-19 pandemic, many patients changed their health-seeking behaviour, 
even to acquire essential drugs such as ART.1,5 Poor adherence to ART is associated with increased 
morbidity and mortality amongst people living with HIV.6 The purpose of this case report is to 
understand the profound effect of the COVID-19 pandemic on the continuity of care amongst 
people living with HIV.
Case
A 51-year-old female patient was brought to the Accident and Emergency (A&E) department of 
our regional hospital by her relatives with complaints of cough, fever and an inability to eat and 
walk. She was screened for severe acute respiratory syndrome (SARS) COVID-19 becausee she 
presented with possible COVID-19 symptoms. She tested positive for the rapid antigen test for 
SARS COVID-19 and the nasopharyngeal swab for severe acute respiratory syndrome coronavirus 
2 (SARS-CoV-2). A reverse transcription-polymerase chain reaction (RT-PCR) test was sent for 
laboratory testing.
On presentation to the A&E department, she was chronically ill-looking, dehydrated, with 
blood pressure (BP) of 83/59 mm of mercury (mmHg), a pulse of 78/min, oxygen saturation 
of 60% at room air and a body temperature of 37.3 °C. Figure 1 demonstrates her vital signs 
and laboratory results between 28th January 2021 and 3rd March 2021. An examination 
of the respiratory system revealed coarse crackles with decreased air entry in both lung 
fields. Cardiovascular, gastrointestinal, genitourinary and nervous system examinations were 
within normal limits. Upon oral examination, an active lesion of oropharyngeal candidiasis 
was noticed.
The coronavirus disease 2019 (COVID-19) pandemic has had an enormous impact on the 
provision of human immunodeficiency virus (HIV) services amongst people living with HIV. 
Many people have adopted different health-seeking behaviour in alignment with the lockdown 
provisions during the COVID-19 pandemic. These lockdown regulations have had a huge 
impact on healthcare access for people on chronic medication. The disruption of antiretroviral 
therapy (ART) has a profound effect on HIV-associated morbidity and mortality. The impact 
on HIV programmes as a result of the interruption in ART could be bigger than the HIV 
pandemic alone.
Keywords: COVID-19; pandemic; HIV; ART; lockdown; morbidity and mortality. 
The impact of the COVID-19 pandemic on 
accessing HIV care: A case report
Page 2 of 4 Scientific letters
https://www.safpj.co.za Open Access
According to the patient, she lived alone and had some 
support from distant relatives, who occasionally visited her. 
She was on ART since 2014 after an HIV diagnosis and, until 
the start of the COVID-19 pandemic lockdown in March 
2020, she was well compliant with her HIV treatment. During 
the lockdown, the local clinic was closed for a few days 
during April 2020 because of one of the staff members 
contracting the COVID-19 infection. As a result of the fear of 
COVID-19, she avoided visits to the health facility and 
defaulted on her ART from April 2020. The viral load of her 
laboratory results is summarised in Table 1. 
A clinical diagnosis of COVID-19 pneumonia and HIV with 
defaulted ART was made. She was rehydrated with normal 
saline and started with dexamethasone 6 mg, low molecular 
weight heparin 40 mg, nystatin, a stat dose of ceftriaxone 1 mg 
and baseline blood was sent for a laboratory test. She was 
admitted to the COVID-19 ward. Oxygen saturation was 
improved from 60% on room air to 94% on a face mask with 
oxygen. The following day, her blood investigation showed 
haemoglobin at 12.9 mmol/dL, a white cell count of 3.54 L × 
109/L, platelets at 64 L × 109/L, SARS-CoV-2 RT-PCR positive, 
C-Reactive Protein (CRP) at 148 mg/L, cluster of differentiation 
4 (CD4) count of 7 cells/mm3, viral load of 1 939 662 Copies/
mL, Hepatitis-B antigen-negative, Treponema pallidum antibody 
positive and rapid plasma reagin (RPR) nonreactive. A chest 
X-ray showed bilateral consolidations and she was unable to 
produce sputum. After a negative tuberculosis (TB) screening, 
she re-initiated ART and started tuberculosis prevention 
therapy (TPT) and co-trimoxazole prophylaxis. She improved 
clinically, initially, but presented with confusion after a week. 
Serum cryptococci antigen (CrAg) tested positive but the 
laboratory results of cerebral spinal fluid (CSF) reported 
negative for meningitis. The fluconazole protocol for 
cryptococci was started but she continued to deteriorate. The 
following week, she tested positive for GeneXpert 
mycobacterium tuberculosis (MTB)/rifampicin sensitivity 
and TPT was stopped whilst anti-TB treatment was initiated. 
The clinical diagnosis was revised to COVID-19 pneumonia, 
TB immune reconstruction inflammatory syndrome (IRIS) and 
HIV. As demonstrated in Figure 1, her PCR test for SARS-
Cov-2 remained positive on the 15th, 23rd and 32nd days since 
she was first tested and the CRP constantly increased over 
time. She continuously deteriorated despite optimum 
treatment and expired on 3rd March 2021.
Discussion
The COVID-19 pandemic has had a substantive negative 
impact on people living with HIV.1 They are less likely to seek 
BP, blood pressure; CRP, C-Reactive Protein; SARS-Cov-2, severe acute respiratory syndrome coronavirus 2; RT-PCR, reverse transcription-polymerase chain reaction; Ag, antigen; RPR, rapid plasma 
reagin; MTB, mycobacterium tuberculosis.
FIGURE 1: Vital sign and laboratory results between 28th January 2021 and 3rd March 2021. 
60
94 95 96
91
98
96 98
97
92
96
96
98
96
95
95
95
93
96
91
96
93 92
96
94
97
97
98
98
99
97
95
94
97
35,6
36
34,8
36,5
36,1 36,4
36
36,5
34,5
36,3
36,5
35,5 36,4
36,5
37,6
36,7
36,8
38,3
37,1
37,1
35,7
36
36,7
36,8
36,3
36,4
36,2
36,4
34,6
35,5
36,7
36,6
36,2
36,3
Systolic BP (mmHg) Diastolic BP (mmHg) Pulse rate Oxygen saturaon (%) Temperature (°C)
160
140
120
100
80
60
40
20
0
Ra
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d 
Ag
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AR
S-
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 p
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T. Pallidum Ab posive
RPR Non-reacve
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Cryptococcus
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GeneXpert MTB/
Rif posive
Time in days
N
um
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R 
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CRP-148 CRP-211 CRP-209 CRP-474
28
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29
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30
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31
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CRP-C 210
TABLE 1: Laboratory results of viral load between 2015 and 2021.
S. No Date and year Viral load Absolute CD4 
1 8th April 2015 Lower than detectable limit 143 cells/mm3
2 4th August 2017 Lower than detectable limit No record
3 23rd January 2018 Lower than detectable limit No record
4 9th January 2019 Lower than detectable limit No record
5 30th January 2020 Lower than detectable limit No record
6 28th January 2021 1 939 662 Copies/mL 7 cells/mm3
Page 3 of 4 Scientific letters
https://www.safpj.co.za Open Access
healthcare because of fear and uncertainty surrounding the 
COVID-19 pandemic, especially during lockdown when 
restrictions on movement are enforced.5 The unannounced 
closure of clinics because of COVID-19 infections amongst 
healthcare staff reduced service availability. Other measures, 
such as social distancing, that were put in place to combat 
the spread of COVID-19, disrupted the progress made by 
many existing healthcare programmes, including the HIV 
continuum of care.5,7 This disruption in healthcare access 
caused by COVID-19 has adverse health consequences for 
people beyond the health concerns caused by COVID-19 itself.5
A survey conducted by the Human Science Research Council 
(HSRC) amongst people living with HIV reported that about 
13% of people did not have access to their medication during 
the COVID-19 lockdown.8 Interruptions of ART amongst 
people living with HIV can precipitate virological failure and 
make them vulnerable to opportunistic infections.6,9 Our case 
reports the virological failure and severe immunosuppression 
with opportunistic infections. She was well compliant during 
the last 6 years with an undetectable viral load, but after the 
disruption of ART for the last 8 months, she presented with a 
viral load of 1 939 662 Copies/mL and a CD4 count of 
7 cells/mm3. These disruptions in HIV programmes because 
of the COVID-19 pandemic have had a substantial impact on 
HIV-associated morbidity and mortality.10 These negative 
impacts of the COVID-19 pandemic on access to healthcare 
services have started to emerge.5
According to national department of health guideline 
positive antigen test amongst symptomatic patient in high 
community prevalence is confirmed as COVID-19 and follow 
up RT-PCR test is not recommended.11 Our patient’s SARS-
CoV-2 RT-PCR test on day 32 remained positive after the 
initial detection. Several studies reported prolonged 
and recurrent detection of viral ribonucleic acid (RNA) by the 
RT-PCR tests from symptomatic and asymptomatic 
COVID-19 patients.9,12,13 Although most study reported that 
persistent viral RNA shading did not increase the risk of 
transmission but further research needed amongst people 
living with HIV. Immunosuppression also plays a major role 
in recurrent detection and prolonged viral shedding. There 
are several case reports demonstrating the isolation of 
infectious viral particles from immunosuppressed patients 
after several weeks to months from the initial infection.9,12 A 
non-Hodgkin’s lymphoma patient reported a positive 
nasopharyngeal swab SARS-CoV-2 RT-PCR after 8 months 
from the initial infection.13 A study conducted by Western 
Cape Department of Health in collaboration with the National 
Institute for Communicable Diseases not only reported 
HIVas an independent risk factor for mortality irrespective of 
viral load and CD4 count but study also accepted that it could 
be overestimated because of residual confounding factors.14 
One can speculate that an immunosuppressed patient is 
likely to have different pathogenesis of the COVID-19 than in 
immunocompetent individuals.
According to a survey conducted on HIV care in 65 South 
African primary care facilities, the fear of contracting 
COVID-19 was the main reason for not visiting healthcare 
facilities during the lockdown period.5 The current case 
subject also interrupted her ART because of the fear of 
contracting COVID-19 at the healthcare facility and ended 
up defaulting on her HIV treatment. Healthcare workers 
need to establish a clear engagement protocol to overcome 
the challenges involved in attending healthcare facilities 
during the lockdown period. Other reasons for not visiting 
healthcare facilities that were highlighted in the survey were 
disruption to public transportation services and stay-at-
home orders during lockdown.7 Some patients sought 
delayed care, whilst others no longer visited the healthcare 
facility because of a misinterpretation of the recommended 
changes that only essential visits be permitted during the 
COVID-19 lockdown.10 During the COVID-19 pandemic 
healthcare facilities adopted new approaches of healthcare 
management including the implementation of minimum 2 
month ART dispensation or refer the patient to external 
pickup point. When people have restricted access to 
healthcare facilities because of COVID-19 lockdown 
regulation than alternative approach is bringing the 
healthcare services to the doorstep of people. Home delivery 
of chronic medication including ART by community health 
workers in Western Cape province is such an example of 
strengthening chronic medication adherence during 
COVID-19 lockdown.15 
Conclusion
The study’s findings suggest that the poor access to healthcare 
services during the COVID-19 lockdown has had a serious 
impact on HIV care. In addition, immunodeficiency because 
of poor ART adherence amongst people living with HIV 
increases their vulnerability for severe COVID-19 and is 
associated with prolonged viral shedding. It is crucial to 
monitor patients with ART to ensure their adherence to the 
treatment and all efforts should be made to encourage people 
to seek healthcare to address the current and potential future 
COVID-19 outbreak.
Acknowledgements
The author would like to acknowledge all the healthcare staff 
working at the COVID-19 ward of Mthatha Regional Hospital 
for their support in writing this manuscript.
Competing interests
The author declares that he has no financial or personal 
relationships that may have inappropriately influenced him 
in writing this article.
Author’s contributions
R.K. is the sole contributor of this article.
Ethical considerations
This article followed all ethical standards for research without 
direct contact with human or animal subjects.
Page 4 of 4 Scientific letters
https://www.safpj.co.za Open Access
Funding information
This research received no specific grant from any funding 
agency in the public, commercial or not-for-profit sectors.
Data availability
The author confirms that the data supporting the findings of 
this manuscript are available within the article. The data are 
available from the author on request.
Disclaimer
The views and opinions expressed in this article are those of 
the author and do not necessarily reflect the official policy or 
position of any affiliated agency of the author.
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The impact of the COVID-19 pandemic on accessing HIV care: A case report

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ANTIOXIDANT EFFECTS OF Chenopodium album Linn AGAINST CADMIUM INDUCED OXIDATIVE STRESS IN MALE TESTES IN VIVO.

Assessment of the impact of HIV infection and anti‑retroviral treatment on the cardiometabolic health of pregnant mothers and their ofspring (ARTMOMSBABES)

Burden of skin diseases in dermatology department inpatients at the Nelson Mandela Central Hospital, Mthatha, Eastern Cape Province in South Africa

The impact of the COVID-19 pandemic on accessing HIV care: A case report

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