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Carlucci JG, Jin L, Sanders JE, Mohapi EQ, Mandalakas AM. Development of tuberculosis infection control guidelines in a pediatric HIV clinic in sub-Saharan Africa. Public Health Action 2015; 5:2-5. [PMID: 26400595 DOI: 10.5588/pha.14.0101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Accepted: 01/25/2015] [Indexed: 11/10/2022] Open
Abstract
SETTING A well-established pediatric human immunodeficiency virus (HIV) clinic in Lesotho with initial infection control (IC) measures prioritizing blood-borne disease. In line with international recommendations, services have been expanded to include the management of patients with tuberculosis (TB). The creation of comprehensive IC guidelines with an emphasis on TB has become a priority. OBJECTIVE To provide a model for developing and implementing IC guidelines in ambulatory care facilities in limited-resource settings with high HIV and TB prevalence. Activities: An IC plan that includes guidance covering both general IC measures and TB-specific guidelines was created by integrating local and international recommendations and emphasizing the importance of administrative measures, environmental controls, and disease-specific precautions. An interdisciplinary committee was established to oversee its implementation, monitoring, and evaluation. DISCUSSION Development and implementation of IC guidelines in resource-limited settings are feasible and should be a priority in high HIV and TB prevalence areas. Education should be the cornerstone of such endeavors. Many interventions can be implemented with minimal expertise and material resources. Administrative support and institutional investment are essential to the sustainability of an effective IC program.
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Affiliation(s)
- J G Carlucci
- Baylor College of Medicine Children's Foundation, Lesotho, Maseru, Lesotho ; Baylor International Pediatric AIDS Initiative at Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - L Jin
- Baylor College of Medicine Children's Foundation, Lesotho, Maseru, Lesotho ; Princeton in Africa, Princeton, New Jersey, USA
| | - J E Sanders
- Baylor College of Medicine Children's Foundation, Lesotho, Maseru, Lesotho ; Baylor International Pediatric AIDS Initiative at Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - E Q Mohapi
- Baylor College of Medicine Children's Foundation, Lesotho, Maseru, Lesotho ; Baylor International Pediatric AIDS Initiative at Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - A M Mandalakas
- Baylor International Pediatric AIDS Initiative at Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA ; Section on Retrovirology and Global Health, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA ; The Global TB Program, Texas Children's Hospital, Houston, Texas, USA
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152
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van Lettow M, Chan AK, Ginsburg AS, Tweya H, Gareta D, Njala J, Kanyerere H, Phiri S, Idana I. Timing and uptake of ART during treatment for active tuberculosis in HIV co-infected adults in Malawi. Public Health Action 2015; 1:6-9. [PMID: 26392926 DOI: 10.5588/pha.11.0003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2011] [Accepted: 07/11/2011] [Indexed: 11/10/2022] Open
Abstract
SETTING Uptake of antiretroviral therapy (ART) in patients co-infected with tuberculosis (TB) and the human immunodeficiency virus (HIV) has historically been low in Malawi. In response, the National TB Programme piloted the initiation of ART 2 weeks after initiation of TB treatment in 2008-2009, a change from the prior policy of 2 months. OBJECTIVE To determine at programme level if earlier initiation of ART in co-infected patients receiving TB treatment will increase the uptake and continuation of ART. DESIGN A prospective observational pilot programme evaluation using routinely collected monitoring data from the first two sites with integrated TB-HIV services in Malawi. RESULTS There was wide variability in the ART start time before and after the policy change. Before the policy change, 16% of patients initiated ART by 3 months compared to 24% after the policy change (P < 0.001). The proportion of all co-infected patients on ART increased from 32% before the policy change to 39% after (P < 0.001). Earlier initiation of ART did not increase the occurrence of side effects and did not reduce adherence to TB treatment. CONCLUSION Earlier initiation of ART in co-infected patients receiving TB treatment improved the uptake and continuation of ART. Malawi ART guidelines in 2011 were changed from initiating ART after 2 months to as soon as possible after starting anti-tuberculosis treatment.
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Affiliation(s)
- M van Lettow
- Dignitas International, Zomba, Malawi ; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - A K Chan
- Dignitas International, Zomba, Malawi ; Department of Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - H Tweya
- The Lighthouse Trust, Lilongwe, Malawi
| | - D Gareta
- The Lighthouse Trust, Lilongwe, Malawi
| | - J Njala
- Department of HIV and AIDS, Malawi Ministry of Health, Lilongwe, Malawi
| | - H Kanyerere
- National Tuberculosis Programme, Lilongwe, Malawi
| | - S Phiri
- The Lighthouse Trust, Lilongwe, Malawi
| | - I Idana
- National Tuberculosis Programme, Lilongwe, Malawi
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153
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Guwatudde D, Wang M, Ezeamama AE, Bagenda D, Kyeyune R, Wamani H, Manabe YC, Fawzi WW. The effect of standard dose multivitamin supplementation on disease progression in HIV-infected adults initiating HAART: a randomized double blind placebo-controlled trial in Uganda. BMC Infect Dis 2015; 15:348. [PMID: 26285704 PMCID: PMC4545778 DOI: 10.1186/s12879-015-1082-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 08/04/2015] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Efficacy trials investigating the effect of multivitamin (MV) supplementations among patients on Highly Active Antiretroviral Therapy (HAART) have so far been inconclusive. We conducted a randomized, double blind, placebo controlled trial to determine the effect of one recommended daily allowance (RDA) of MV supplementation on disease progression in patients initiating HAART. METHODS Eligible subjects were randomized to receive placebo or MV supplementation including vitamins B-complex, C and E. Participants were followed for up to 18 months. Primary endpoints were: change in CD4 cell count, weight and quality of life (QoL). Secondary endpoints were: i) development of a new or recurrent HIV disease progression event, including all-cause mortality; ii) switching from first- to second-line antiretroviral therapy (ART); and iii) occurrence of an adverse event. Intent-to-treat analysis, using linear regression mixed effects models were used to compare changes over time in the primary endpoints between the study arms. Kaplan-Meier time-to-event analysis and the log-rank test was used to compare HIV disease progression events and all-cause mortality. RESULTS Four hundred participants were randomized, 200 onto MV and 200 onto placebo. By month 18, the average change in CD4 cell count in the MV arm was 141 cells/uL compared to 147 cells/uL in the placebo arm, a mean difference of -6 · 17 [95 % CI -29 · 3, 16 · 9]. The average change in weight in the MV arm was 3 · 9 kg compared to 3 · 3 kg in the placebo arm, a mean difference of 0 · 54 [95 % CI -0 · 40, 1 · 48]; whereas average change in QoL scores in the MV arm was 6 · 8 compared to 8 · 8 in the placebo arm, a mean difference of -2.16 [95 % CI -4 · 59,0 · 27]. No significant differences were observed in these primary endpoints, or in occurrence of adverse events between the trial arms. CONCLUSIONS One RDA of MV supplementation was safe but did not have an effect on indicators of disease progression among HIV infected adults initiating HAART. TRIAL REGISTRATION Clinical trials NCT01228578 , registered on 15th October 2010.
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Affiliation(s)
- David Guwatudde
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda.
| | - Molin Wang
- Departments of Epidemiology and Biostatistics, Harvard School of Public Health, Channing Division of Network Medicine, Harvard Medical School, Boston, MA, USA.
| | - Amara E Ezeamama
- Department of Epidemiology and Biostatistics, University of Georgia, Athens, GA, USA.
| | - Danstan Bagenda
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda. .,Department of Global Health and Population, Harvard School of Public Health, Boston, MA, USA.
| | - Rachel Kyeyune
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda.
| | - Henry Wamani
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda.
| | - Yukari C Manabe
- Division of Infectious Diseases, Department of Medicine, John Hopkins University, Baltimore, MD, USA.
| | - Wafaie W Fawzi
- Departments of Global Health and Population, Nutrition and Epidemiology, Harvard School of Public Health, Boston, MA, USA.
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154
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Akinyemi JO, Adesina OA, Kuti MO, Ogunbosi BO, Irabor AE, Odaibo GN, Olaleye DO, Adewole IF. Temporal distribution of baseline characteristics and association with early mortality among HIV-positive patients at University College Hospital, Ibadan, Nigeria. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2015; 14:201-7. [PMID: 26282931 DOI: 10.2989/16085906.2015.1052526] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The first six months of HIV care and treatment are very important for long-term outcome. Early mortality (within 6 months of care initiation) undermines care and treatment goals. This study assessed the temporal distribution in baseline characteristics and early mortality among HIV patients at the University College Hospital, Ibadan, Nigeria from 2006-2013. Factors associated with early mortality were also investigated. This was a retrospective analysis of data from 14 857 patients enrolled for care and treatment at the adult antiretroviral clinic of the University College Hospital, Ibadan, Nigeria. Effects of factors associated with early mortality were summarised using a hazard ratio with a 95% confidence interval obtained from Cox proportional hazard regression models. The mean age of the subjects was 36.4 (SD=10.2) years with females being in the majority (68.1%). While patients' demographic characteristics remained virtually the same over time, there was significant decline in the prevalence of baseline opportunistic infections (2006-2007=55.2%; 2011-2013=38.0%). Overall, 460 (3.1%) patients were known to have died within 6 months of enrollment in care/treatment. There was no significant trend in incidence of early mortality. Factors associated with early mortality include: male sex, HIV encephalopathy, low CD4 count (< 50 cells), and anaemia. To reduce early mortality, community education should be promoted, timely access to care and treatment should be facilitated and the health system further strengthened to care for high risk patients.
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Affiliation(s)
- Joshua O Akinyemi
- a Department of Epidemiology and Medical Statistics, College of Medicine , University of Ibadan , Nigeria
| | - Olubukola A Adesina
- b Department of Obstetrics and Gynaecology, College of Medicine , University of Ibadan , Nigeria
| | - Modupe O Kuti
- c Department of Chemical Pathology, College of Medicine , University of Ibadan , Nigeria
| | - Babatunde O Ogunbosi
- d Department of Paediatrics, College of Medicine , University of Ibadan , Nigeria
| | - Achiaka E Irabor
- e Department of Family Medicine, University College Hospital, Ibadan , Nigeria
| | - Georgina N Odaibo
- f Department of Virology, College of Medicine , University of Ibadan , Nigeria
| | - David O Olaleye
- f Department of Virology, College of Medicine , University of Ibadan , Nigeria
| | - Isaac F Adewole
- b Department of Obstetrics and Gynaecology, College of Medicine , University of Ibadan , Nigeria
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155
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Drain PK, Losina E, Coleman SM, Bogart L, Giddy J, Ross D, Katz JN, Bassett IV. Social support and mental health among adults prior to HIV counseling and testing in Durban, South Africa. AIDS Care 2015; 27:1231-40. [PMID: 26213142 PMCID: PMC4607562 DOI: 10.1080/09540121.2015.1046417] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Poor social support and mental health may be important modifiable risk factors for HIV acquisition, but they have not been evaluated prior to HIV testing in South Africa. We sought to describe self-perceived mental health and social support and to characterize their independent correlates among adults who presented for voluntary HIV testing in Durban. We conducted a large cross-sectional study of adults (≥18 years of age) who presented for HIV counseling and testing between August 2010 and January 2013 in Durban, South Africa. We enrolled adults presenting for HIV testing and used the Medical Outcomes Study's Social Support Scale (0 [poor] to 100 [excellent]) and the Mental Health Inventory (MHI-3) to assess social support and mental health. We conducted independent univariate and multivariable linear regression models to determine the correlates of lower self-reported Social Support Index and lower self-reported MCH scores. Among 4874 adults surveyed prior to HIV testing, 1887 (39%) tested HIV-positive. HIV-infected participants reported less social support (mean score 66 ± 22) and worse mental health (mean score 66 ± 16), compared to HIV-negative participants (74 ± 21; 70 ± 18; p < 0.0001). In a multivariable analysis, significant correlates of less social support included presenting for HIV testing at an urban hospital, not having been tested previously, not working outside the home, and being HIV-infected. In a separate multivariable analysis, significant correlates of poor mental health were similar, but also included HIV testing at an urban hospital and being in an intimate relationship less than six months. In this study, HIV-infected adults reported poorer social support and worse mental health than HIV-negative individuals. These findings suggest that interventions to improve poor social support and mental health should be focused on adults who do not work outside the home and those with no previous HIV testing.
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Affiliation(s)
- Paul K Drain
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, USA
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, USA
| | - Elena Losina
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, USA
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, USA
- Boston University School of Public Health, Boston, USA
| | | | | | | | | | - Jeffrey N Katz
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, USA
| | - Ingrid V Bassett
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, USA
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, USA
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156
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McNairy ML, Gachuhi AB, Lamb MR, Nuwagaba-Biribonwoha H, Burke S, Ehrenkranz P, Mazibuko S, Sahabo R, Philip NM, Okello V, El-Sadr WM. The Link4Health study to evaluate the effectiveness of a combination intervention strategy for linkage to and retention in HIV care in Swaziland: protocol for a cluster randomized trial. Implement Sci 2015; 10:101. [PMID: 26189154 PMCID: PMC4506770 DOI: 10.1186/s13012-015-0291-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 07/09/2015] [Indexed: 11/30/2022] Open
Abstract
Background Gaps in the HIV care continuum contribute to suboptimal individual health outcomes and increased risk of HIV transmission at the population level. Implementation science studies are needed to evaluate clinic-based interventions aimed at improving retention of patients across the continuum. Methods/design Link4Health uses an unblended cluster site-randomized design to evaluate the effectiveness of a combination intervention strategy (CIS) as compared to standard of care on linkage to and retention in care among HIV-diagnosed adults in Swaziland. The CIS intervention targets a multiplicity of structural, behavioral, and biomedical barriers through five interventions: (1) point-of-care CD4 testing at time of HIV testing, (2) accelerated antiretroviral therapy (ART) initiation for eligible patients, (3) mobile phone appointment reminders, (4) care and prevention packages, and (5) non-cash financial incentives for linkage and retention. The unit of randomization is a network of HIV clinics inclusive of a secondary facility coupled with an affiliated primary facility. Ten study units were randomized based on implementing partner, geographic location, and historic volume of HIV patients. Target enrollment was 2200 individuals, each to be followed for 12 months. Eligibility criteria includes HIV-positive test, age >18 years, willing to receive HIV care at a clinic in the study unit and consent to study procedures. Exclusion criteria included previous HIV care in the past 6 months, planning to leave the community, and current pregnancy. The primary study outcome is linkage within 1 month and retention at 12 months after testing HIV positive. Secondary outcomes include viral load suppression at 12 months, time to ART eligibility and initiation, participant acceptability, and cost-effectiveness. The trial status is that study enrollment is complete and follow-up procedures are ongoing. Discussion Link4Health evaluates a novel and pragmatic combination intervention strategy to improve linkage to and retention in care among adults with HIV in Swaziland. If the strategy is found to be effective, this study has the potential to inform HIV service delivery in resource-limited settings. Trial registration Clinicaltrials.gov NCT01904994
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Affiliation(s)
- Margaret L McNairy
- ICAP, Mailman School of Public Health, Columbia University, 722 West 168th Street, New York, NY, 10032, USA. .,Weill Cornell Medical College, New York, NY, USA.
| | - Averie B Gachuhi
- ICAP, Mailman School of Public Health, Columbia University, 722 West 168th Street, New York, NY, 10032, USA.
| | - Matthew R Lamb
- ICAP, Mailman School of Public Health, Columbia University, 722 West 168th Street, New York, NY, 10032, USA.
| | - Harriet Nuwagaba-Biribonwoha
- ICAP, Mailman School of Public Health, Columbia University, 722 West 168th Street, New York, NY, 10032, USA. .,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.
| | - Sean Burke
- ICAP, Mailman School of Public Health, Columbia University, 722 West 168th Street, New York, NY, 10032, USA.
| | | | | | - Ruben Sahabo
- ICAP, Mailman School of Public Health, Columbia University, 722 West 168th Street, New York, NY, 10032, USA.
| | - Neena M Philip
- ICAP, Mailman School of Public Health, Columbia University, 722 West 168th Street, New York, NY, 10032, USA.
| | - Velephi Okello
- Ministry of Health, Kingdom of Swaziland, Mbabane, Swaziland.
| | - Wafaa M El-Sadr
- ICAP, Mailman School of Public Health, Columbia University, 722 West 168th Street, New York, NY, 10032, USA. .,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.
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157
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Minimal impact of an iron-fortified lipid-based nutrient supplement on Hb and iron status: a randomised controlled trial in malnourished HIV-positive African adults starting antiretroviral therapy. Br J Nutr 2015; 114:387-97. [PMID: 26179616 DOI: 10.1017/s0007114515001920] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Anaemia, redistribution of Fe, malnutrition and heightened systemic inflammation during HIV infection confer an increased risk of morbidity and mortality in HIV patients. We analysed information on Fe status and inflammation from a randomised, double blind, controlled phase-III clinical trial in Lusaka, Zambia and Mwanza, Tanzania. Malnourished patients (n 1815) were recruited at referral to antiretroviral therapy (ART) into a two-stage nutritional rehabilitation programme, randomised to receive a lipid-based nutrient supplement with or without added micronutrients. Fe was included in the intervention arm during the second stage, given from 2 to 6 weeks post-ART. Hb, serum C-reactive protein (CRP), serum ferritin and soluble transferrin receptor (sTfR) were measured at recruitment and 6 weeks post-ART. Multivariable linear regression models were used to assess the impact of the intervention, and the effect of reducing inflammation from recruitment to week 6 on Hb and Fe status. There was no effect of the intervention on Hb, serum ferritin, sTfR or serum CRP. A one-log decrease of serum CRP from recruitment to week 6 was associated with a 1.81 g/l increase in Hb (95% CI 0.85, 2.76; P< 0.001), and a 0.11 log decrease in serum ferritin (95% CI - 0.22, 0.03; P= 0.012) from recruitment to week 6. There was no association between the change in serum CRP and the change in sTfR over the same time period (P= 0.78). In malnourished, HIV-infected adults receiving dietary Fe, a reduction in inflammation in the early ART treatment period appears to be a precondition for recovery from anaemia.
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158
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Siedner MJ, Santorino D, Lankowski AJ, Kanyesigye M, Bwana MB, Haberer JE, Bangsberg DR. A combination SMS and transportation reimbursement intervention to improve HIV care following abnormal CD4 test results in rural Uganda: a prospective observational cohort study. BMC Med 2015; 13:160. [PMID: 26149722 PMCID: PMC4494725 DOI: 10.1186/s12916-015-0397-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 06/12/2015] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Up to 50 % of HIV-infected persons in sub-Saharan Africa are lost from care between HIV diagnosis and antiretroviral therapy (ART) initiation. Structural barriers, including cost of transportation to clinic and poor communication systems, are major contributors. METHODS We conducted a prospective, pragmatic, before-and-after clinical trial to evaluate a combination mobile health and transportation reimbursement intervention to improve care at a publicly operated HIV clinic in Uganda. Patients undergoing CD4 count testing were enrolled, and clinicians selected a result threshold that would prompt early return for ART initiation or further care. Participants enrolled in the pre-intervention period (January - August 2012) served as a control group. Participants in the intervention period (September 2012 - November 2013) were randomized to receive daily short message service (SMS) messages for up to seven days in one of three formats: 1) messages reporting an abnormal result directly, 2) personal identification number-protected messages reporting an abnormal result, or 3) messages reading "ABCDEFG" to confidentially convey an abnormal result. Participants returning within seven days of their first message received transportation reimbursements (about $6USD). Our primary outcomes of interest were time to return to clinic and time to ART initiation. RESULTS There were 45 participants in the pre-intervention period and 138 participants in the intervention period (46, 49, and 43 in the direct, PIN, and coded groups, respectively) with low CD4 count results. Median time to clinic return was 33 days (IQR 11-49) in the pre-intervention period and 6 days (IQR 3-16) in the intervention period (P < 0.001); and median time to ART initiation was 47 days (IQR 11-75) versus 12 days (IQR 5-19), (P < 0.001). In multivariable models, participants in the intervention period had earlier return to clinic (AHR 2.32, 95 %CI 1.53 to 3.51) and earlier time to ART initiation (AHR 2.27, 95 %CI 1.38 to 3.72). All three randomized message formats improved time to return to clinic and time to ART initiation (P < 0.01 for all comparisons versus the pre-intervention period). CONCLUSIONS A combination of an SMS laboratory result communication system and transportation reimbursements significantly decreased time to clinic return and time to ART initiation after abnormal CD4 test results. TRIAL REGISTRATIONS Clinicaltrials.gov NCT01579214 , approved 13 April 2012.
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Affiliation(s)
- Mark J Siedner
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, 100 Cambridge Street, 15th Floor, Boston, MA, 02114, USA.
| | - Data Santorino
- Mbarara University of Science and Technology, Mbarara, Uganda.
| | - Alexander J Lankowski
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, 02114, USA.
| | | | - Mwebesa B Bwana
- Mbarara University of Science and Technology, Mbarara, Uganda.
| | - Jessica E Haberer
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, and Harvard School of Public Health, Boston, MA, 02114, USA.
| | - David R Bangsberg
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, 100 Cambridge Street, 15th Floor, Boston, MA, 02114, USA.
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159
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Mekuria LA, Prins JM, Yalew AW, Sprangers MAG, Nieuwkerk PT. Retention in HIV Care and Predictors of Attrition from Care among HIV-Infected Adults Receiving Combination Anti-Retroviral Therapy in Addis Ababa. PLoS One 2015; 10:e0130649. [PMID: 26114436 PMCID: PMC4482764 DOI: 10.1371/journal.pone.0130649] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 05/22/2015] [Indexed: 02/07/2023] Open
Abstract
Background Patient retention in chronic HIV care is a major challenge following the rapid expansion of combination antiretroviral therapy (cART) in Ethiopia. Objective To describe the proportion of patients who are retained in HIV care and characterize predictors of attrition among HIV-infected adults receiving cART in Addis Ababa. Method A retrospective analysis was conducted among 836 treatment naïve patients, who started cART between May 2009 and April 2012. Patients were randomly selected from ten health-care facilities, and their current status in HIV care was determined based on routinely available data in the medical records. Patients lost to follow-up (LTFU) were traced by telephone. Kaplan-Meier technique was used to estimate survival probabilities of retention and Cox proportional hazards regression was performed to identify the predictors of attrition. Results Based on individual patient data from the medical records, nearly 80% (95%CI: 76.7, 82.1) of the patients were retained in care in the first 3 and half years of antiretroviral therapy. After successfully tracing more than half of the LTFU patients, the updated one year retention in care estimate became 86% (95% CI: 83.41%, 88.17%). In the multivariate Cox regression analyses, severe immune deficiency at enrolment in care/or at cART initiation and ‘bed-ridden’ or ‘ambulatory’ functional status at the start of cART predicted attrition. Conclusion Retention in HIV care in Addis Ababa is comparable with or even better than previous findings from other resource-limited as well as EU/USA settings. However, measures to detect and enroll patients in HIV care as early as possible are still necessary.
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Affiliation(s)
- Legese A. Mekuria
- Department of Medical Psychology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Department of Epidemiology, Netherlands Institute for Health Sciences/Erasmus University Medical Center, Rotterdam, The Netherlands
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
- * E-mail:
| | - Jan M. Prins
- Department of Internal Medicine, Division of Infectious Diseases, Trop Med & AIDS, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Mirjam A. G. Sprangers
- Department of Medical Psychology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Pythia T. Nieuwkerk
- Department of Medical Psychology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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160
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Plazy M, Orne-Gliemann J, Dabis F, Dray-Spira R. Retention in care prior to antiretroviral treatment eligibility in sub-Saharan Africa: a systematic review of the literature. BMJ Open 2015; 5:e006927. [PMID: 26109110 PMCID: PMC4479994 DOI: 10.1136/bmjopen-2014-006927] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE We aimed at summarising rates and factors associated with retention in HIV care prior to antiretroviral treatment (ART) eligibility in sub-Saharan Africa. DESIGN We conducted a systematic literature review (2002-2014). We searched Medline/Pubmed, Scopus and Web of Science, as well as proceedings of conferences. We included all original research studies published in peer-reviewed journals, which used quantitative indicators of retention in care prior to ART eligibility. PARTICIPANTS People not yet eligible for ART. PRIMARY AND SECONDARY OUTCOMES Rate of retention in HIV care prior to ART eligibility and associated factors. RESULTS 10 papers and 2 abstracts were included. Most studies were conducted in Southern and Eastern Africa between 2004 and 2011 and reported retention rates in pre-ART care up to the second CD4 measurement. Definition of retention in HIV care prior to ART eligibility differed substantially across studies. Retention rates ranged between 23% and 88% based on series ranging from 112 to 10,314 individuals; retention was higher in women, individuals aged >25 years, those with low CD4 count, high body mass index or co-infected with tuberculosis, and in settings with free cotrimoxazole use. CONCLUSIONS Retention in HIV care prior to ART eligibility in sub-Saharan Africa has been insufficiently described so far leaving major research gaps, especially regarding long-term retention rates and sociodemographic, economic, clinical and programmatic logistic determinants. The prospective follow-up of newly diagnosed individuals is required to better evaluate attrition prior to ART eligibility among HIV-infected people.
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Affiliation(s)
- Mélanie Plazy
- Centre de recherche Inserm U897 Epidémiologie et Biostatistique, Université de Bordeaux, Bordeaux, France
- Institut de Santé Publique, d'Epidémiologie et de Développement (ISPED), Université de Bordeaux, Bordeaux, France
| | - Joanna Orne-Gliemann
- Centre de recherche Inserm U897 Epidémiologie et Biostatistique, Université de Bordeaux, Bordeaux, France
- Institut de Santé Publique, d'Epidémiologie et de Développement (ISPED), Université de Bordeaux, Bordeaux, France
| | - François Dabis
- Centre de recherche Inserm U897 Epidémiologie et Biostatistique, Université de Bordeaux, Bordeaux, France
- Institut de Santé Publique, d'Epidémiologie et de Développement (ISPED), Université de Bordeaux, Bordeaux, France
| | - Rosemary Dray-Spira
- Department of Social Epidemiology, INSERM, UMR_S 1136, Pierre Louis Institute of Epidemiology and Public Health, Paris, France
- Department of Social Epidemiology, Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1136, Pierre Louis Institute of Epidemiology and Public Health, Paris, France
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161
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Chisenga CC, Filteau S, Siame J, Chisenga M, Prendergast AJ, Kelly P. T-Cell Subsets Predict Mortality in Malnourished Zambian Adults Initiating Antiretroviral Therapy. PLoS One 2015; 10:e0129928. [PMID: 26083409 PMCID: PMC4470912 DOI: 10.1371/journal.pone.0129928] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Accepted: 05/14/2015] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVE To estimate the prognostic value of T-cell subsets in Zambian patients initiating antiretroviral therapy (ART), and to assess the impact of a nutritional intervention on T-cell subsets. METHODS This was a sub-study of a randomised clinical trial of a nutritional intervention for malnourished adults initiating ART. Participants in a randomised controlled trial (NUSTART trial) were enrolled between April and December 2012. Participants received lipid-based nutritional supplement either with or without additional vitamins and minerals. Immunophenotyping was undertaken at baseline and, in survivors, after 12 weeks of ART to characterize T-cell subsets using the markers CD3, CD4, CD8, CD45RA, CCR7, CD28, CD57, CD31, α4β7, Ki67, CD25 and HLA-DR. Univariate and multivariate survival analysis was performed, and responses to treatment were analysed using the Wicoxon rank-sum test. RESULTS Among 181 adults, 36 (20%) died by 12 weeks after starting ART. In univariate analysis, patients who died had fewer proliferating, more naïve and fewer gut homing CD4+ T-cells compared to survivors; and more senescent and fewer proliferating CD8+ T-cells. In a multivariate Cox regression model high naïve CD4+, low proliferating CD4+, high senescent CD8+ and low proliferating CD8+ subsets were independently associated with increased risk of death. Recent CD4+ thymic emigrants increased less between recruitment and 12 weeks of ART in the intervention group compared to the control group. CONCLUSIONS Specific CD4+ T-cell subsets are of considerable prognostic significance for patients initiating ART in Zambia, but only thymic output responded to this nutritional intervention.
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Affiliation(s)
- Caroline C. Chisenga
- Tropical Gastroenterology and Nutrition group, University of Zambia School of Medicine, Lusaka, Zambia
- NUSTART project, University Teaching Hospital, Lusaka, Zambia
| | - Suzanne Filteau
- NUSTART project, University Teaching Hospital, Lusaka, Zambia
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Joshua Siame
- NUSTART project, University Teaching Hospital, Lusaka, Zambia
| | - Molly Chisenga
- NUSTART project, University Teaching Hospital, Lusaka, Zambia
| | - Andrew J. Prendergast
- Barts & The London School of Medicine, Queen Mary University of London, London, United Kingdom
| | - Paul Kelly
- Tropical Gastroenterology and Nutrition group, University of Zambia School of Medicine, Lusaka, Zambia
- NUSTART project, University Teaching Hospital, Lusaka, Zambia
- London School of Hygiene & Tropical Medicine, London, United Kingdom
- Barts & The London School of Medicine, Queen Mary University of London, London, United Kingdom
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162
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Affiliation(s)
- Radha Rajasingham
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA.
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163
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Mfinanga S, Chanda D, Kivuyo SL, Guinness L, Bottomley C, Simms V, Chijoka C, Masasi A, Kimaro G, Ngowi B, Kahwa A, Mwaba P, Harrison TS, Egwaga S, Jaffar S. Cryptococcal meningitis screening and community-based early adherence support in people with advanced HIV infection starting antiretroviral therapy in Tanzania and Zambia: an open-label, randomised controlled trial. Lancet 2015; 385:2173-82. [PMID: 25765698 DOI: 10.1016/s0140-6736(15)60164-7] [Citation(s) in RCA: 179] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Mortality in people in Africa with HIV infection starting antiretroviral therapy (ART) is high, particularly in those with advanced disease. We assessed the effect of a short period of community support to supplement clinic-based services combined with serum cryptococcal antigen screening. METHODS We did an open-label, randomised controlled trial in six urban clinics in Dar es Salaam, Tanzania, and Lusaka, Zambia. From February, 2012, we enrolled eligible individuals with HIV infection (age ≥18 years, CD4 count of <200 cells per μL, ART naive) and randomly assigned them to either the standard clinic-based care supplemented with community support or standard clinic-based care alone, stratified by country and clinic, in permuted block sizes of ten. Clinic plus community support consisted of screening for serum cryptococcal antigen combined with antifungal therapy for patients testing antigen positive, weekly home visits for the first 4 weeks on ART by lay workers to provide support, and in Tanzania alone, re-screening for tuberculosis at 6-8 weeks after ART initiation. The primary endpoint was all-cause mortality at 12 months, analysed by intention to treat. This trial is registered with the International Standard Randomised Controlled Trial Number registry, number ISCRTN 20410413. FINDINGS Between Feb 9, 2012, and Sept 30, 2013, 1001 patients were randomly assigned to clinic plus community support and 998 to standard care. 89 (9%) of 1001 participants in the clinic plus community support group did not receive their assigned intervention, and 11 (1%) of 998 participants in the standard care group received a home visit or a cryptococcal antigen screen rather than only standard care. At 12 months, 25 (2%) of 1001 participants in the clinic plus community support group and 24 (2%) of 998 participants in the standard care group had been lost to follow-up, and were censored at their last visit for the primary analysis. At 12 months, 134 (13%) of 1001 participants in the clinic plus community support group had died compared with 180 (18%) of 998 in the standard care group. Mortality was 28% (95% CI 10-43) lower in the clinic plus community support group than in standard care group (p=0·004). INTERPRETATION Screening and pre-emptive treatment for cryptococcal infection combined with a short initial period of adherence support after initiation of ART could substantially reduce mortality in HIV programmes in Africa. FUNDING European and Developing Countries Clinical Trials Partnership.
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Affiliation(s)
- Sayoki Mfinanga
- National Institute for Medical Research, Muhimbili Medical Research Centre, Dar es Salaam, Tanzania
| | - Duncan Chanda
- Institute for Medical Research and Training, University Teaching Hospital, Lusaka, Zambia
| | - Sokoine L Kivuyo
- National Institute for Medical Research, Muhimbili Medical Research Centre, Dar es Salaam, Tanzania
| | - Lorna Guinness
- Faculty of Public Health Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Christian Bottomley
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Victoria Simms
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Carol Chijoka
- Institute for Medical Research and Training, University Teaching Hospital, Lusaka, Zambia
| | - Ayubu Masasi
- National Institute for Medical Research, Muhimbili Medical Research Centre, Dar es Salaam, Tanzania
| | - Godfather Kimaro
- National Institute for Medical Research, Muhimbili Medical Research Centre, Dar es Salaam, Tanzania
| | - Bernard Ngowi
- National Institute for Medical Research, Muhimbili Medical Research Centre, Dar es Salaam, Tanzania
| | - Amos Kahwa
- National Institute for Medical Research, Muhimbili Medical Research Centre, Dar es Salaam, Tanzania
| | - Peter Mwaba
- Institute for Medical Research and Training, University Teaching Hospital, Lusaka, Zambia
| | - Thomas S Harrison
- Institute for Infection and Immunity, St Georges University of London, London, UK
| | - Saidi Egwaga
- National Tuberculosis and Leprosy Control Program, Ministry of Health and Socio-Welfare, Dar es Salaam, Tanzania
| | - Shabbar Jaffar
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK.
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164
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TB screening among people living with HIV/AIDS in resource-limited settings. J Acquir Immune Defic Syndr 2015; 68 Suppl 3:S270-3. [PMID: 25768866 DOI: 10.1097/qai.0000000000000485] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Tuberculosis (TB) continues to be the leading cause of morbidity and mortality among people living with HIV (PLHIV), making improved prevention and treatment of HIV-associated TB critical to ensuring long-term survival of PLHIV. TB screening among PLHIV is central to implementation of the World Health Organization's 3 I's interventions for reducing the impact of the TB and HIV syndemics. Effective TB screening will result in the identification of PLHIV with presumptive TB disease (ie, those with a positive symptom screen who require appropriate evaluation, including the use of diagnostic tools such as the Xpert MTB/RIF assay) and those eligible for isoniazid preventive therapy (ie, those who have a negative clinical symptom screen or who have a positive screen but are found not to have TB disease). Identification of PLHIV with presumptive TB also facilitates implementation of basic administrative measures for TB infection control, including fast tracking of coughing patients and separation from noncoughing PLHIV to reduce TB transmission. By contributing to the early diagnosis of TB disease among PLHIV, TB screening is also critical to facilitate early initiation of antiretroviral treatment among PLHIV diagnosed with TB disease who might not otherwise be eligible for antiretroviral treatment based on CD4 count or clinical staging. TB screening thus serves as a gateway for multiple TB/HIV interventions and is an integral part of routine clinical services for PLHIV at each clinic visit.
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165
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Implementation and operational research: Integrated pre-antiretroviral therapy screening and treatment for tuberculosis and cryptococcal antigenemia. J Acquir Immune Defic Syndr 2015; 68:e69-76. [PMID: 25761234 DOI: 10.1097/qai.0000000000000527] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To demonstrate the feasibility of integrated screening for cryptococcal antigenemia and tuberculosis (TB) before antiretroviral therapy (ART) initiation and to assess disease specific and all-cause mortality in the first 6 months of follow-up. METHODS We enrolled a cohort of HIV-infected, ART-naive adults with CD4 counts ≤250 cells per microliter in rural Uganda who were followed for 6 months after ART initiation. All subjects underwent screening for TB; those with CD4 ≤100 cells per microliter also had cryptococcal antigen (CrAg) screening. For those who screened positive, standard treatment for TB or preemptive treatment for cryptococcal infection was initiated, followed by ART 2 weeks later. RESULTS Of 540 participants enrolled, pre-ART screening detected 10.6% (57/540) with prevalent TB and 6.8% (12/177 with CD4 count ≤100 cells/μL) with positive serum CrAg. After ART initiation, 13 (2.4%) patients were diagnosed with TB and 1 patient developed cryptococcal meningitis. Overall 7.2% of participants died (incidence rate 15.6 per 100 person-years at risk). Death rates were significantly higher among subjects with TB and cryptococcal antigenemia compared with subjects without these diagnoses. In multivariate analysis, significant risk factors for mortality were male sex, baseline anemia of hemoglobin ≤10 mg/dL, wasting defined as body mass index ≤15.5 kg/m, and opportunistic infections (TB, positive serum CrAg). CONCLUSIONS Pre-ART screening for opportunistic infections detects many prevalent cases of TB and cryptococcal infection. However, severely immunosuppressed and symptomatic HIV patients continue to experience high mortality after ART initiation.
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166
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Meya D, Rajasingham R, Nalintya E, Tenforde M, Jarvis JN. Preventing Cryptococcosis-Shifting the Paradigm in the Era of Highly Active Antiretroviral Therapy. CURRENT TROPICAL MEDICINE REPORTS 2015; 2:81-89. [PMID: 25960942 PMCID: PMC4412515 DOI: 10.1007/s40475-015-0045-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Cryptococcosis remains a significant cause of morbidity and mortality among HIV-infected patients, especially in sub-Saharan Africa where it causes up to 20 % of AIDS-related deaths in HIV programs. A new, highly sensitive, and affordable point of care diagnostic test for cryptococcal infection, the lateral flow assay, can detect early sub-clinical cryptococcosis especially in areas with limited laboratory infrastructure. With a prevalence of detectable sub-clinical cryptococcal infection averaging 7.2 % (95 % CI 6.8-7.6 %) among 36 cohorts with CD4 <100 cells/μL in Africa, together with data showing that preemptive fluconazole prevents overt cryptococcal disease in this population, implementing a screen and treat strategy as part of HIV care practice among patients with CD4 <100 cells/μL could prevent the incidence of often fatal cryptococcal meningitis in the setting of the HIV pandemic.
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Affiliation(s)
- David Meya
- />Infectious Disease Institute, College of Health Sciences, Makerere University, Mulago Hill Road, # 22418, Kampala, Uganda
- />Department of Medicine, Center for Infectious Diseases and Microbiology Translational Research, University of Minnesota, 450 Delaware Street, MMC250, Minneapolis, MN 55455 USA
- />School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Radha Rajasingham
- />Department of Medicine, Center for Infectious Diseases and Microbiology Translational Research, University of Minnesota, 450 Delaware Street, MMC250, Minneapolis, MN 55455 USA
| | - Elizabeth Nalintya
- />Infectious Disease Institute, College of Health Sciences, Makerere University, Mulago Hill Road, # 22418, Kampala, Uganda
| | - Mark Tenforde
- />Botswana-UPenn Partnership, P.O. Box AC 157 ACH, Gaborone, Botswana
| | - Joseph N Jarvis
- />Botswana-UPenn Partnership, P.O. Box AC 157 ACH, Gaborone, Botswana
- />Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
- />London School of Hygiene and Tropical Medicine, London, UK
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167
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Telisinghe L, Hippner P, Churchyard GJ, Gresak G, Grant AD, Charalambous S, Fielding KL. Outcomes of on-site antiretroviral therapy provision in a South African correctional facility. Int J STD AIDS 2015; 27:1153-1161. [PMID: 25941052 DOI: 10.1177/0956462415584467] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 03/31/2015] [Indexed: 12/15/2022]
Abstract
We evaluated a novel on-site antiretroviral therapy (ART) programme in a South African correctional facility using routinely collected programme data, from a retrospective cohort of adult inmates starting ART between 03/2007 and 03/2009 followed-up to 09/2009. We report (1) mortality (using survival analysis); (2) retention in the programme (to 09/2009); and (3) virological suppression at six and 12 months (<400 copies/ml) following ART initiation. In total, 404 started ART (median age 33 years; 91.3% men; median baseline CD4 cell count 152 cells/µl [interquartile range 85-225]). Among 299 starting ART for the first time (ART-naïve), 23 deaths occurred during 252 person-years (median follow-up nine months). Mortality rates were 17.2 at 0-6 months (95% confidence interval 10.9-26.9) and 2.8 at >6 months (95% confidence interval 1.1-7.5)/100 person-years; p < 0.001. At 09/2009, 35.6% (144/404) remained in the correctional facility, with 94.4% (136/144) retained in the programme; 38.4% (155/404) were released; and 20.0% (81/404) transferred to another facility. ART-naïve patients in care six and 12 months after ART initiation, 94.7% (124/131) and 92.5% (74/80) were virologically suppressed, respectively. High early mortality warrants the early identification and management of HIV-positive inmates. The high mobility of inmates necessitates systems for facilitating continuity of care. Good virological responses and retention supports decentralising HIV care to correctional facilities.
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Affiliation(s)
- Lilanganee Telisinghe
- The Aurum Institute, Johannesburg, South Africa .,CAPRISA, University of KwaZulu-Natal, Durban, South Africa
| | | | - Gavin J Churchyard
- The Aurum Institute, Johannesburg, South Africa.,London School of Hygiene and Tropical Medicine, London, UK.,School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | | | - Alison D Grant
- London School of Hygiene and Tropical Medicine, London, UK
| | - Salome Charalambous
- The Aurum Institute, Johannesburg, South Africa.,School of Public Health, University of Witwatersrand, Johannesburg, South Africa
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168
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Effects on anthropometry and appetite of vitamins and minerals given in lipid nutritional supplements for malnourished HIV-infected adults referred for antiretroviral therapy: results from the NUSTART randomized controlled trial. J Acquir Immune Defic Syndr 2015; 68:405-12. [PMID: 25501607 PMCID: PMC4337586 DOI: 10.1097/qai.0000000000000483] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Supplemental Digital Content is Available in the Text. Background: The evidence base for effects of nutritional interventions for malnourished HIV-infected patients starting antiretroviral therapy (ART) is limited and inconclusive. Objective: We hypothesized that both vitamin and mineral deficiencies and poor appetite limit weight gain in malnourished patients starting ART and that vitamin and mineral supplementation would improve appetite and permit nutritional recovery. Design: The randomized controlled Nutritional Support for Africans Starting Antiretroviral Therapy trial was conducted in Mwanza, Tanzania, and Lusaka, Zambia. ART-naive adults referred for ART and with body mass index <18.5 kg/m2 received lipid-based nutritional supplements either without (LNS) or with added vitamins and minerals (LNS-VM), beginning before ART initiation. Participants were given 30 g/d LNS from recruitment until 2 weeks after starting ART and 250 g/d from weeks 2 to 6 of ART. Results: Of 1815 patients recruited, 365 (20%) died during the study and 813 (45%) provided data at 12 weeks. Controlling for baseline values, anthropometric measures were consistently higher at 12-week ART in the LNS-VM than in the LNS group but statistically significant only for calf and mid-upper arm circumferences and triceps skinfold. Appetite did not differ between groups. Using piecewise mixed-effects quadratic models including all patients and time points, the main effects of LNS-VM were seen after starting ART and were significant for weight, body mass index, and mid-upper arm circumference. Conclusions: Provision of high levels of vitamins and minerals to patients referred for ART, delivered with substantial macronutrients, increased nutritional recovery but did not seem to act through treatment group differences in appetite.
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169
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Abo Y, Zannou Djimon M, Messou E, Balestre E, Kouakou M, Akakpo J, Ahouada C, de Rekeneire N, Dabis F, Lewden C, Minga A. Severe morbidity after antiretroviral (ART) initiation: active surveillance in HIV care programs, the IeDEA West Africa collaboration. BMC Infect Dis 2015; 15:176. [PMID: 25885859 PMCID: PMC4396560 DOI: 10.1186/s12879-015-0910-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Accepted: 03/18/2015] [Indexed: 11/25/2022] Open
Abstract
Background The causes of severe morbidity in health facilities implementing Antiretroviral Treatment (ART) programmes are poorly documented in sub-Saharan Africa. We aimed to describe severe morbidity among HIV-infected patients after ART initiation, based on data from an active surveillance system established within a network of specialized care facilities in West African cities. Methods Within the International epidemiological Database to Evaluate AIDS (IeDEA) - West Africa collaboration, we conducted a prospective, multicenter data collection that involved two facilities in Abidjan, Côte d’Ivoire and one in Cotonou, Benin. Among HIV-infected adults receiving ART, events were recorded using a standardized form. A simple case-definition of severe morbidity (death, hospitalization, fever > 38°5C, Karnofsky index < 70%) was used at any patient contact point. Then a physician confirmed and classified the event as WHO stage 3 or 4 according to the WHO clinical classification or as degree 3 or 4 of the ANRS scale. Results From December 2009 to December 2011, 978 adults (71% women, median age 39 years) presented with 1449 severe events. The main diagnoses were: non-AIDS-defining infections (33%), AIDS-defining illnesses (33%), suspected adverse drug reactions (7%), other illnesses (4%) and syndromic diagnoses (16%). The most common specific diagnoses were: malaria (25%), pneumonia (13%) and tuberculosis (8%). The diagnoses were reported as syndromic in one out of five events recorded during this study. Conclusions This study highlights the ongoing importance of conventional infectious diseases among severe morbid events occurring in patients on ART in ambulatory HIV care facilities in West Africa. Meanwhile, additional studies are needed due to the undiagnosed aspect of severe morbidity in substantial proportion. Electronic supplementary material The online version of this article (doi:10.1186/s12879-015-0910-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yao Abo
- Programme PAC-CI, Centre Hospitalier Universitaire (CHU) de Treichville, 18 BP 1954, Abidjan 18, Côte d'Ivoire. .,Centre Médical de Suivi des Donneurs de Sang (CMSDS), Centre National de Transfusion Sanguine, Abidjan, Côte d'Ivoire.
| | - Marcel Zannou Djimon
- Centre de Traitement Ambulatoire (CTA), Centre National Hospitalier Universitaire (CNHU), Cotonou, Benin. .,Université d'Abomey-Calavi, Cotonou, Bénin.
| | - Eugène Messou
- University Bordeaux, ISPED, Bordeaux, France. .,Centre de Prise en charge de Recherche et de Formation (Aconda-CePReF), Abidjan, Côte d'Ivoire.
| | - Eric Balestre
- INSERM, Centre INSERM U897-Epidémiologie-Biostatistique, Bordeaux, France. .,University Bordeaux, ISPED, Bordeaux, France.
| | - Martial Kouakou
- Centre de Prise en charge de Recherche et de Formation (Aconda-CePReF), Abidjan, Côte d'Ivoire.
| | - Jocelyn Akakpo
- Centre de Traitement Ambulatoire (CTA), Centre National Hospitalier Universitaire (CNHU), Cotonou, Benin.
| | - Carin Ahouada
- Centre de Traitement Ambulatoire (CTA), Centre National Hospitalier Universitaire (CNHU), Cotonou, Benin.
| | - Nathalie de Rekeneire
- INSERM, Centre INSERM U897-Epidémiologie-Biostatistique, Bordeaux, France. .,University Bordeaux, ISPED, Bordeaux, France.
| | - François Dabis
- INSERM, Centre INSERM U897-Epidémiologie-Biostatistique, Bordeaux, France. .,University Bordeaux, ISPED, Bordeaux, France.
| | - Charlotte Lewden
- INSERM, Centre INSERM U897-Epidémiologie-Biostatistique, Bordeaux, France. .,University Bordeaux, ISPED, Bordeaux, France.
| | - Albert Minga
- Programme PAC-CI, Centre Hospitalier Universitaire (CHU) de Treichville, 18 BP 1954, Abidjan 18, Côte d'Ivoire. .,Centre Médical de Suivi des Donneurs de Sang (CMSDS), Centre National de Transfusion Sanguine, Abidjan, Côte d'Ivoire.
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Kerkhoff AD, Wood R, Cobelens FG, Gupta-Wright A, Bekker LG, Lawn SD. The predictive value of current haemoglobin levels for incident tuberculosis and/or mortality during long-term antiretroviral therapy in South Africa: a cohort study. BMC Med 2015; 13:70. [PMID: 25889688 PMCID: PMC4411796 DOI: 10.1186/s12916-015-0320-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Accepted: 03/11/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Low haemoglobin concentrations may be predictive of incident tuberculosis (TB) and death in HIV-infected patients receiving antiretroviral therapy (ART), but data are limited and inconsistent. We examined these relationships retrospectively in a long-term South African ART cohort with multiple time-updated haemoglobin measurements. METHODS Prospectively collected clinical data on patients receiving ART for up to 8 years in a community-based cohort were analysed. Time-updated haemoglobin concentrations, CD4 counts and HIV viral loads were recorded, and TB diagnoses and deaths from all causes were ascertained. Anaemia severity was classified using World Health Organization criteria. TB incidence and mortality rates were calculated and Poisson regression models were used to identify independent predictors of incident TB and mortality, respectively. RESULTS During a median follow-up of 5.0 years (IQR, 2.5-5.8) of 1,521 patients, 476 cases of incident TB and 192 deaths occurred during 6,459 person-years (PYs) of follow-up. TB incidence rates were strongly associated with time-updated anaemia severity; those without anaemia had a rate of 4.4 (95%CI, 3.8-5.1) cases/100 PYs compared to 10.0 (95%CI, 8.3-12.1), 26.6 (95%CI, 22.5-31.7) and 87.8 (95%CI, 57.0-138.2) cases/100 PYs in those with mild, moderate and severe anaemia, respectively. Similarly, mortality rates in those with no anaemia or mild, moderate and severe time-updated anaemia were 1.1 (95%CI, 0.8-1.5), 3.5 (95%CI, 2.7-4.8), 11.8 (95%CI, 9.5-14.8) and 28.2 (95%CI, 16.5-51.5) cases/100 PYs, respectively. Moderate and severe anaemia (time-updated) during ART were the strongest independent predictors for incident TB (adjusted IRR = 3.8 [95%CI, 3.0-4.8] and 8.2 [95%CI, 5.3-12.7], respectively) and for mortality (adjusted IRR = 6.0 [95%CI, 3.9-9.2] and adjusted IRR = 8.0 [95%CI, 3.9-16.4], respectively). CONCLUSIONS Increasing severity of anaemia was associated with exceptionally high rates of both incident TB and mortality during long-term ART. Patients receiving ART who have moderate or severe anaemia should be prioritized for TB screening using microbiological assays and may require adjunctive clinical interventions.
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Affiliation(s)
- Andrew D Kerkhoff
- George Washington University School of Medicine and Health Sciences, 2300 Eye St, NW, Washington, DC, 20037, USA. .,Department of Global Health, Academic Medical Center, Amsterdam Institute for Global Health and Development, University of Amsterdam, Amsterdam, the Netherlands. .,The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
| | - Robin Wood
- The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa. .,Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK.
| | - Frank G Cobelens
- Department of Global Health, Academic Medical Center, Amsterdam Institute for Global Health and Development, University of Amsterdam, Amsterdam, the Netherlands. .,KNCV Tuberculosis Foundation, The Hague, the Netherlands.
| | - Ankur Gupta-Wright
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK.
| | - Linda-Gail Bekker
- The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
| | - Stephen D Lawn
- The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa. .,Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK.
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Adeyemi BO, Ross A. Profile and acute mortality outcome of patients admitted with cryptococcal meningitis to an urban district hospital in KwaZulu-Natal, South Africa. S Afr Fam Pract (2004) 2015. [DOI: 10.1080/20786190.2014.976962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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172
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Predictors of Mortality among Adult Antiretroviral Therapy Users in Southeastern Ethiopia: Retrospective Cohort Study. AIDS Res Treat 2015; 2015:148769. [PMID: 25821596 PMCID: PMC4364127 DOI: 10.1155/2015/148769] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 01/31/2015] [Accepted: 02/15/2015] [Indexed: 11/18/2022] Open
Abstract
Background. Although efforts have been made to reduce AIDS-related mortality by providing antiretroviral therapy (ART) services, still people are dying while they are on treatment due to several factors. This study aimed to investigate the predictors of mortality among adult antiretroviral therapy (ART) users in Goba Hospital, Southeast Ethiopia. Methods. The medical records of 2036 ART users who enrolled at Goba Hospital between 2007 and 2012 were reviewed and sociodemographic, clinical, and ART-related data were collected. Multivariable Cox proportional hazards regression model was used to measure risk of death and identify the independent predictors of mortality. Results. The overall mortality incidence rate was 20.3 deaths per 1000 person-years. Male, bedridden, overweight/obese, and HIV clients infected with TB and other infectious diseases had higher odds of death compared with their respective counterparts. On the other hand, ART clients with primary and secondary educational level and early and less advanced WHO clinical stage had lower odds of death compared to their counterparts. Conclusion. The overall mortality incidence rate was high and majority of the death had occurred in the first year of ART initiation. Intensifying and strengthening early ART initiation, improving nutritional status, prevention and control of TB, and other opportunistic infections are recommended interventions.
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van Zyl MA, Brown LL, Pahl K. Using a call center to encourage linkage to care following mobile HIV counseling and testing. AIDS Care 2015; 27:921-5. [PMID: 25734697 DOI: 10.1080/09540121.2015.1015483] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Engaging newly diagnosed HIV+ individuals in treatment is a significant global challenge. As South Africa expands HIV counseling and testing (HCT) services, the growing numbers of people diagnosed with HIV will need innovative links to care approaches in order for treatment to be most effective. While definitions vary, we have defined "linkage to care" as connecting an HIV+ individual to medical care, so that CD4 cell test results are obtained and antiretroviral therapy (ART) eligibility assessed. The study is of HIV+ participants (n = 1096), from either Limpopo or Gauteng provinces from a "Links to Care" program. A two-pronged expanded HCT service was used, which included a community outreach approach to address HIV testing and a call center to encourage and track each patient's linkage to care post-HIV diagnosis. The majority of individuals (51%) were linked to care with a mean time to linkage of 31 days (with most individuals linked in less than 14 days). More females (54%) were linked to care than males (47%) and had higher CD4 cell counts than males; females had a mean CD4 cell count of 440, while males took longer to link to care and had a lower mean CD4 cell count of 331. Females of 23 years or younger had the lowest linkage rate of all females. Findings suggest that expanding HCT services to include innovative links to care approaches can improve linkage to care and subsequently impact HIV prevention.
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174
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De Wet N, Oluwaseyi S, Odimegwu C. Youth mortality due to HIV/AIDS in South Africa, 2001-2009: an analysis of the levels of mortality using life table techniques. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2015; 13:13-20. [PMID: 25174511 DOI: 10.2989/16085906.2014.886605] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
South Africa has one of the highest HIV/AIDS prevalence rates in the world. It is estimated that 5.38 million South Africans are living with HIV/AIDS. In addition, new infections among adults aged 15+ were reportedly 316 900 in 2011. New infections among children (0-14 years old) was also high in 2011 at 63 600. This paper examines South Africa's mortality due to HIV/AIDS among the youth (15-34 years old). This age group is of fundamental importance to the economic and social development of the country. However, the challenges of youth development remain vast and incomparable. One of these challenges is the impact of HIV/AIDS on mortality. Life table techniques are used to estimate among others, sex differentials in death rates for the youth population, probability of dying from HIV/AIDS before the age of 35 and life expectancy should HIV/AIDS be eradicated from the population. The study used data from the National Registry of Deaths, as collated by Statistics South Africa from 2001 to 2009. Results show that youth mortality due to HIV/AIDS has remained consistently higher among older youths than in younger ones. By sex, mortality due to this cause has also remained consistent over the period, with mortality due to HIV/AIDS being higher among females than males. Cause-specific mortality rates and proportional mortality ratios reflect the increased mortality of older youth (especially 30-34 years old) and females within the South African population. Probability of dying from HIV/AIDS shows that over the period, fluctuations in likelihood of mortality have occurred, but for both males and females (of all age groups) the chances of dying from this cause decreased in 2007-2009.
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Affiliation(s)
- Nicole De Wet
- a Demography and Population Studies , University of the Witwatersrand , 1 Jan Smuts Avenue, Braamfontein , Johannesburg , Gauteng 2050 , South Africa
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Teasdale CA, Wang C, Francois U, d’Amour Ndahimana J, Vincent M, Sahabo R, El-Sadr WM, Abrams EJ. Time to initiation of antiretroviral therapy among patients who Are ART eligible in Rwanda: improvement over time. J Acquir Immune Defic Syndr 2015; 68:314-21. [PMID: 25415291 PMCID: PMC5074335 DOI: 10.1097/qai.0000000000000432] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Delayed initiation of antiretroviral therapy (ART) in eligible patients is a concern in resource-limited countries. METHODS We analyzed data on HIV-positive patients ≥15 years enrolled at 41 ICAP-supported health care facilities in Rwanda, 2005-2010, to determine time to ART initiation among patients eligible at enrollment compared with those ineligible or of indeterminate eligibility who become eligible during follow-up. ART eligibility was based on CD4 cell count (CD4) and WHO staging; patients lacking CD4 and WHO stage were considered indeterminate. Cumulative incidence of reaching ART eligibility and to ART initiation after eligibility was generated using competing risk estimators. RESULTS A total of 31,033 ART-naive adults were enrolled; 64.2% were female. At enrollment, 10,158 (32.7%) patients were ART eligible, 13,372 (43.1%) were ineligible for ART, and 7503 (24.2%) patients were indeterminate. Among patients retained in care pre-ART eligibility, 17.9% [95% confidence interval (CI): 17.2 to 18.6] of ineligible and 22.8% (95% CI: 21.7 to 23.8) of indeterminate patients at enrollment reached ART eligibility within 12 months. Cumulative incidence of ART initiation within 3 months for patients eligible at enrollment was 77.2% (95% CI: 76.4 to 78.0) compared with 67.9% (95% CI: 66.4 to 69.3) for ineligible and 63.8% (95% CI: 61.9 to 65.8) for patients with indeterminate eligibility at enrollment (P < 0.05). Over the study period, there was more rapid ART initiation for patients who became ART eligible. CONCLUSIONS We found higher rates of ART initiation within 3 months among patients who were ART eligible at enrollment compared with those who reached eligibility during follow-up. From 2006 to 2011, earlier initiation of ART after eligibility was observed likely reflecting improved program quality.
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Affiliation(s)
- Chloe A. Teasdale
- ICAP-Columbia University, New York, NY
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | | | | | | | | | | | - Wafaa M. El-Sadr
- ICAP-Columbia University, New York, NY
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Elaine J. Abrams
- ICAP-Columbia University, New York, NY
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
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Govender NP, Roy M, Mendes JF, Zulu TG, Chiller TM, Karstaedt AS. Evaluation of screening and treatment of cryptococcal antigenaemia among HIV-infected persons in Soweto, South Africa. HIV Med 2015; 16:468-76. [PMID: 25689352 DOI: 10.1111/hiv.12245] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVES We retrospectively evaluated clinic-based screening to determine the prevalence of cryptococcal antigenaemia and management and outcome of patients with antigenaemia. METHODS Cryptococcal antigen (CrAg) screening of HIV-infected adults who attended the HIV clinic at Chris Hani Baragwanath Hospital was conducted over 19 months. Data collected from CrAg-positive patients included CD4 T-lymphocyte count at screening, prior or subsequent cryptococcal meningitis (CM), antifungal and antiretroviral treatment and outcome after at least 8 months. RESULTS Of 1460 patients with no prior CM, 30 (2.1%) had a positive CrAg test. The prevalence of antigenaemia among patients with a CD4 count < 100 cells/μl and no prior CM was 2.8% (20 of 708). Of 29 evaluable CrAg-positive patients with no prior CM, 14 (48%) did not return for post-screening follow-up. Of these 14, five developed CM and one (7%) was known to be alive at follow-up. Of 15 patients who returned for follow-up, two already had evidence of nonmeningeal cryptococcosis. Overall, 11 received fluconazole, one did not and fluconazole treatment was unknown for three. Among these 15, one developed CM and 10 (67%) were known to be alive at follow-up. Overall, 18 (62%) of 29 CrAg-positive patients died or were lost to follow-up. Seven (0.5%) of 1430 CrAg-negative patients developed CM a median of 83 days post-screening (range 34 to 219 days). CONCLUSIONS Loss to follow-up is the major operational issue relevant to scale-up of screen-and-treat. Patient outcomes may be improved by rapid access to CrAg results and focus on linkage to and retention in HIV care.
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Affiliation(s)
- N P Govender
- National Institute for Communicable Diseases (Centre for Opportunistic, Tropical and Hospital Infections), a Division of the National Health Laboratory Service, Johannesburg, South Africa.,Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - M Roy
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - J F Mendes
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Community Health, Gauteng Department of Health, Johannesburg, South Africa
| | - T G Zulu
- National Institute for Communicable Diseases (Centre for Opportunistic, Tropical and Hospital Infections), a Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - T M Chiller
- Mycotic Diseases Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - A S Karstaedt
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Division of Infectious Diseases, Department of Medicine, Chris Hani Baragwanath Hospital, Soweto, South Africa
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Ravimohan S, Tamuhla N, Steenhoff AP, Letlhogile R, Nfanyana K, Bellamy SL, MacGregor RR, Gross R, Weissman D, Bisson GP. Immunological profiling of tuberculosis-associated immune reconstitution inflammatory syndrome and non-immune reconstitution inflammatory syndrome death in HIV-infected adults with pulmonary tuberculosis starting antiretroviral therapy: a prospective observational cohort study. THE LANCET. INFECTIOUS DISEASES 2015; 15:429-38. [PMID: 25672566 DOI: 10.1016/s1473-3099(15)70008-3] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Patients co-infected with advanced HIV and tuberculosis are at risk of tuberculosis-associated immune reconstitution inflammatory syndrome (IRIS) and death soon after initiation of antiretroviral therapy (ART). Tuberculosis-associated IRIS has been associated with quicker recovery of cellular immune responses after ART initiation and early mortality with slower recovery of these responses. We aimed to assess whether patients who have these outcomes have distinct immunological profiles before and after ART initiation. METHODS We undertook this prospective cohort study at 22 public clinics and the main public hospital in Gaborone, Botswana, in ART-naive adults (aged ≥21 years) with advanced HIV (CD4 cell counts ≤125 cells per μL) and pulmonary tuberculosis. We obtained data for clinical variables and for levels of 29 plasma biomarkers, quantified by Luminex assay. We classified patients as having tuberculosis-associated IRIS, early mortality, or survival without a diagnosis of tuberculosis-associated IRIS (controls), on the basis of outcomes recorded in the 6 months after ART initiation. We used rank-sum or χ(2) tests, and logistic regression with odds ratios (OR) and 95% CIs, to assess the association between variables measured before and 4 weeks after ART initiation with death and tuberculosis-associated IRIS, compared with controls. FINDINGS Between Nov 12, 2009, and July 3, 2013, we enrolled 201 participants. 31 (15%) patients left the study before ART initiation, leaving 170 (85%) patients for analysis. Patients with tuberculosis-associated IRIS had reduced pre-ART concentrations of several pro-inflammatory biomarkers, including interleukin (IL)-6 (adjusted OR per 1 log10 increase 0·40 [95% CI 0·18-0·89]). However, patients with early death had increased pre-ART concentrations of inflammatory biomarkers, including monocyte chemoattractant protein-1 (adjusted OR 9·0 [95% CI 1·0-80·0]) and tumour necrosis factor (TNF)α (7·8 [1·1-55·2]). At week 4 after ART initation, tuberculosis-associated IRIS was independently associated with greater increases in several inflammatory biomarkers, including IL-6 (adjusted OR 1·7 [95% CI 1·2-2·5]) and TNFα (1·5 [1·0-2·2]), versus controls. Death was likewise associated with greater increases in systemic inflammatory markers, including granulocyte colony-stimulating factor (adjusted OR 2·8 [95% CI 1·3-6·1]), IL-12p40 (1·8 [1·0-3·4]), and IL-15 (2·0 [1·1-3·7]), versus controls. However, changes in CD4 cell count during ART, which were similar between controls and patients with tuberculosis-associated IRIS (p=0·45), were substantially lower in patients who died (p=0·006). INTERPRETATION Distinct immunological profiles before and after ART initiation characterise patients with advanced HIV and tuberculosis who have tuberculosis-associated IRIS and death. Interventions that decrease inflammation while promoting cellular immune recovery during ART should be considered in patients co-infected with HIV and tuberculosis. FUNDING National Institutes of Health and the Penn Center for AIDS Research.
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Affiliation(s)
- Shruthi Ravimohan
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA; Botswana-UPenn Partnership, Gaborone, Botswana.
| | - Neo Tamuhla
- Botswana-UPenn Partnership, Gaborone, Botswana
| | - Andrew P Steenhoff
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA; Botswana-UPenn Partnership, Gaborone, Botswana; The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | | | - Scarlett L Bellamy
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Rob Roy MacGregor
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Robert Gross
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA; Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA; Botswana-UPenn Partnership, Gaborone, Botswana
| | - Drew Weissman
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA; Botswana-UPenn Partnership, Gaborone, Botswana
| | - Gregory P Bisson
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA; Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA; Botswana-UPenn Partnership, Gaborone, Botswana
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Cheng W, Wu Y, Wen Y, Ma Y, Zhao D, Dou Z, Zhang W, Bulterys M, Zhang F. Cotrimoxazole prophylaxis and antiretroviral therapy: an observational cohort study in China. Bull World Health Organ 2015; 93:152-60. [PMID: 25838611 PMCID: PMC4371494 DOI: 10.2471/blt.14.142745] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2014] [Revised: 12/01/2014] [Accepted: 12/03/2014] [Indexed: 11/27/2022] Open
Abstract
Objective To assess if cotrimoxazole prophylaxis administered early during antiretroviral therapy (ART) reduces mortality in Chinese adults who are infected with human immunodeficiency virus (HIV). Methods We did a retrospective observational cohort study using data from the Chinese national free antiretroviral database. Patients older than 14 years who started ART between 1 January 2010 and 31 December 2012 and had baseline CD4+ T-lymphocyte (CD4+ cell) count less than 200 cells/µL were followed until death, loss to follow-up or 31 December 2013. Hazard ratios (HRs) for several variables were calculated using multivariate analyses. Findings The analysis involved 23 816 HIV-infected patients, 2706 of whom died during the follow-up. Mortality in patients who did and did not start cotrimoxazole during the first 6 months of ART was 5.3 and 7.0 per 100 person–years, respectively. Cotrimoxazole was associated with a 37% reduction in mortality (hazard ratio, HR: 0.63; 95% confidence interval, CI: 0.56–0.70). Cotrimoxazole in addition to ART reduced mortality significantly over follow-up lasting 6 months (HR: 0.65; 95% CI: 0.59–0.73), 12 months (HR: 0.58; 95% CI: 0.49–0.70), 18 months (HR: 0.49; 95% CI: 0.38–0.63) and 24 months (HR: 0.66; 95% CI: 0.48–0.90). The mortality reduction was evident in patients with baseline CD4+ cell counts less than 50 cells/µL (HR: 0.60; 95% CI: 0.54–0.67), 50–99 cells/µL (HR: 0.66; 95% CI: 0.56–0.78) and 100–199 cells/µL (HR: 0.78; 95% CI: 0.62–0.98). Conclusion Cotrimoxazole prophylaxis started early during ART reduced mortality and should be offered to HIV-infected patients in low- and middle-income countries.
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Affiliation(s)
- Wei Cheng
- Division of Treatment and Care, National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, 27 Nanwei Rd, Beijing 100050, China
| | - Yasong Wu
- Division of Treatment and Care, National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, 27 Nanwei Rd, Beijing 100050, China
| | - Yi Wen
- Division of Treatment and Care, National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, 27 Nanwei Rd, Beijing 100050, China
| | - Ye Ma
- Division of Treatment and Care, National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, 27 Nanwei Rd, Beijing 100050, China
| | - Decai Zhao
- Division of Treatment and Care, National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, 27 Nanwei Rd, Beijing 100050, China
| | - Zhihui Dou
- Division of Treatment and Care, National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, 27 Nanwei Rd, Beijing 100050, China
| | - Weiwei Zhang
- Division of Treatment and Care, National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, 27 Nanwei Rd, Beijing 100050, China
| | - Marc Bulterys
- Global AIDS Program, Centers for Disease Control and Prevention, United States Embassy, Beijing, China
| | - Fujie Zhang
- Division of Treatment and Care, National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, 27 Nanwei Rd, Beijing 100050, China
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Filteau S, PrayGod G, Kasonka L, Woodd S, Rehman AM, Chisenga M, Siame J, Koethe JR, Changalucha J, Michael D, Kidola J, Manno D, Larke N, Yilma D, Heimburger DC, Friis H, Kelly P. Effects on mortality of a nutritional intervention for malnourished HIV-infected adults referred for antiretroviral therapy: a randomised controlled trial. BMC Med 2015; 13:17. [PMID: 25630368 PMCID: PMC4308881 DOI: 10.1186/s12916-014-0253-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 12/10/2014] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Malnourished HIV-infected African adults are at high risk of early mortality after starting antiretroviral therapy (ART). We hypothesized that short-course, high-dose vitamin and mineral supplementation in lipid nutritional supplements would decrease mortality. METHODS The study was an individually-randomised phase III trial conducted in ART clinics in Mwanza, Tanzania, and Lusaka, Zambia. Participants were 1,815 ART-naïve non-pregnant adults with body mass index (BMI) <18.5 kg/m² who were referred for ART based on CD4 count <350 cells/μL or WHO stage 3 or 4 disease. The intervention was a lipid-based nutritional supplement either without (LNS) or with additional vitamins and minerals (LNS-VM), beginning prior to ART initiation; supplement amounts were 30 g/day (150 kcal) from recruitment until 2 weeks after starting ART and 250 g/day (1,400 kcal) from weeks 2 to 6 after starting ART. The primary outcome was mortality between recruitment and 12 weeks of ART. Secondary outcomes were serious adverse events (SAEs) and abnormal electrolytes throughout, and BMI and CD4 count at 12 weeks ART. RESULTS Follow-up for the primary outcome was 91%. Median adherence was 66%. There were 181 deaths in the LNS group (83.7/100 person-years) and 184 (82.6/100 person-years) in the LNS-VM group (rate ratio (RR), 0.99; 95% CI, 0.80-1.21; P = 0.89). The intervention did not affect SAEs or BMI, but decreased the incidence of low serum phosphate (RR, 0.73; 95% CI, 0.55-0.97; P = 0.03) and increased the incidence of high serum potassium (RR, 1.60; 95% CI, 1.19-2.15; P = 0.002) and phosphate (RR, 1.23; 95% CI, 1.10-1.37; P <0.001). Mean CD4 count at 12 weeks post-ART was 25 cells/μL (95% CI, 4-46) higher in the LNS-VM compared to the LNS arm (P = 0.02). CONCLUSIONS High-dose vitamin and mineral supplementation in LNS, compared to LNS alone, did not decrease mortality or clinical SAEs in malnourished African adults initiating ART, but improved CD4 count. The higher frequency of elevated serum potassium and phosphate levels suggests high-level electrolyte supplementation for all patients is inadvisable but the addition of micronutrient supplements to ART may provide clinical benefits in these patients. TRIAL REGISTRATION PACTR201106000300631, registered on 1st June 2011.
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Affiliation(s)
| | - Suzanne Filteau
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
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Cox JA, Lukande RL, Kalungi S, Van Marck E, Van de Vijver K, Kambugu A, Nelson AM, Manabe YC, Colebunders R. Needle autopsy to establish the cause of death in HIV-infected hospitalized adults in Uganda: a comparison to complete autopsy. J Acquir Immune Defic Syndr 2015; 67:169-76. [PMID: 25072614 DOI: 10.1097/qai.0000000000000290] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Minimal invasive but accurate methods to establish the cause of death in HIV-infected patients are needed. We studied the agreement in cause of death between blind and ultrasound-guided needle autopsy and complete autopsy in HIV-infected patients in Uganda. METHODS We subsequently performed a blind and ultrasound-guided needle autopsy followed by a complete autopsy in HIV-infected adults who died during hospitalization. Two teams of pathologists reviewed the tissue from either the needle autopsies or the complete autopsy and formulated the major diagnoses, that is, diseases directly contributing to death. The primary outcome was concordance in major diagnosis between needle and complete autopsies. RESULTS We performed 96 blind needle and complete autopsies and 95 ultrasound-guided needle autopsies. Concordance in major diagnosis between blind needle and complete autopsy was 50%. For the main major diagnosis, tuberculosis (TB) concordance was higher (71%; P < 0.01). Blind needle autopsy identified at least 1 major diagnosis in 60% of patients; and in 46%, there was complete concordance for all major diagnoses. The main reason for discordance was sampling error of the lesion. Concordance with the addition of ultrasound guidance was 52% for all major diagnoses and 79% for TB. Major diagnoses were mainly identified in tissue cores from the liver (76%) and the spleen (82%). DISCUSSION Blind needle autopsy identified half of the major diagnosis. The addition of ultrasound guidance did not significantly improve the performance of needle autopsy. Needle autopsy is a valuable method to confirm causes of death in HIV-infected patients, especially for highly prevalent diseases like TB.
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Affiliation(s)
- Janneke A Cox
- *Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium; †Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda; ‡Department of Pathology, College of Health Sciences, Makerere University, Kampala, Uganda; §Department of Pathology, Mulago Hospital Complex, Kampala, Uganda; ‖Department of Pathology, University Hospital Antwerp, University of Antwerp, Belgium; ¶Department of Diagnostic Oncology & Molecular Pathology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands; #Joint Pathology Center, Silver Spring, MD; **Division of Infectious Diseases, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD; and ††Faculty of Medicine, University of Antwerp, Belgium
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van Loggerenberg F, Grant AD, Naidoo K, Murrman M, Gengiah S, Gengiah TN, Fielding K, Abdool Karim SS. Individualised motivational counselling to enhance adherence to antiretroviral therapy is not superior to didactic counselling in South African patients: findings of the CAPRISA 058 randomised controlled trial. AIDS Behav 2015; 19:145-56. [PMID: 24696226 DOI: 10.1007/s10461-014-0763-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Concerns that standard didactic adherence counselling may be inadequate to maximise antiretroviral therapy (ART) adherence led us to evaluate more intensive individualised motivational adherence counselling. We randomised 297 HIV-positive ART-naïve patients in Durban, South Africa, to receive either didactic counselling, prior to ART initiation (n = 150), or an intensive motivational adherence intervention after initiating ART (n = 147). Study arms were similar for age (mean 35.8 years), sex (43.1 % male), CD4+ cell count (median 121.5 cells/μl) and viral load (median 119,000 copies/ml). Virologic suppression at 9 months was achieved in 89.8 % of didactic and 87.9 % of motivational counselling participants (risk ratio [RR] 0.98, 95 % confidence interval [CI] 0.90-1.07, p = 0.62). 82.9 % of didactic and 79.5 % of motivational counselling participants achieved >95 % adherence by pill count at 6 months (RR 0.96, 95 % CI 0.85-1.09, p = 0.51). Participants receiving intensive motivational counselling did not achieve higher treatment adherence or virological suppression than those receiving routinely provided didactic adherence counselling. These data are reassuring that less resource intensive didactic counselling was adequate for excellent treatment outcomes in this setting.
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Ebonyi AO, Oguche S, Meloni ST, Sagay SA, Kyriacou DN, Achenbach CJ, Agbaji OO, Oyebode TA, Okonkwo P, Idoko JA, Kanki PJ. Predictors of Mortality in a Clinic Cohort of HIV-1 Infected Children Initiated on Antiretroviral Therapy in Jos, Nigeria. ACTA ACUST UNITED AC 2014; 5. [PMID: 30416842 PMCID: PMC6223308 DOI: 10.4172/2155-6113.1000403] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Background: Mortality among human immunodeficiency virus-1 (HIV-1) infected children initiated on antiretroviral therapy (ART) though on a decline still remains high in resource-limited countries (RLC). Identifying baseline factors that predict mortality could allow their possible modification in order to improve pediatric HIV care and reduce mortality. Methods: We conducted a retrospective cohort study analyzing data on 691 children, aged 2 months-15 years, diagnosed with HIV-1 infection and initiated on ART between July 2005 and March 2013 at the pediatric HIV clinic of Jos University Teaching Hospital. Lost to follow-up children were excluded from the analyses. A multivariate Cox proportional hazards model was fitted to identify predictors of mortality. Results: Median follow-up time for the 691 children initiated on ART was 4.4 years (interquartile range (IQR), 1.8-5.9) and at the end of 2752 person-years of follow-up, 32 (4.6%) had died and 659 (95.4%) survived. The mortality rate was 1.0 per 100 child-years of follow-up period. The median age of those who died was about two times lower than that of survivors [1.7 years (IQR, 0.6-3.6) versus 3.9 years (IQR, 3.9-10.3), p<0.001]. On unadjusted Cox regression, the risk of dying was about three and half times more in children <5 years of age compared to those >5 years (p=0.02) Multivariate modeling identified age as the main predictor of death with mortality decreasing by 24% for every 1 year increase in age (Adjusted Hazard Ratio (AHR)=0.76 [0.62-0.94], p=0.013. Conclusion: The lower mortality rate for our study suggests that even in RLC, mortality rates could be reduced given a good standard of care. Early initiation of ART in younger children with close monitoring during follow-up could further reduce mortality.
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Affiliation(s)
- Augustine O Ebonyi
- Department of Paediatrics, University of Jos/ Jos University Teaching Hospital, Jos, Nigeria
| | - Stephen Oguche
- Department of Paediatrics, University of Jos/ Jos University Teaching Hospital, Jos, Nigeria
| | - Seema T Meloni
- Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, MA, USA
| | - Solomon A Sagay
- Department of Obstetrics and Gynaecology, University of Jos/Jos University Teaching Hospital, Jos, Nigeria
| | - Demetrios N Kyriacou
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Chad J Achenbach
- Division of Infectious Diseases and Center for Global Health, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Oche O Agbaji
- Department of Medicine, University of Jos/Jos University Teaching Hospital, Jos, Nigeria
| | - Tinuade A Oyebode
- Department of Obstetrics and Gynaecology, University of Jos/Jos University Teaching Hospital, Jos, Nigeria
| | - Prosper Okonkwo
- AIDS Prevention Initiative in Nigeria (APIN) LLC, Abuja, Nigeria
| | - John A Idoko
- National Agency for the Control of AIDS (NACA), Abuja, Nigeria
| | - Phyllis J Kanki
- Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, MA, USA
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183
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Jambo KC, Banda DH, Afran L, Kankwatira AM, Malamba RD, Allain TJ, Gordon SB, Heyderman RS, Russell DG, Mwandumba HC. Asymptomatic HIV-infected individuals on antiretroviral therapy exhibit impaired lung CD4(+) T-cell responses to mycobacteria. Am J Respir Crit Care Med 2014; 190:938-47. [PMID: 25225948 DOI: 10.1164/rccm.201405-0864oc] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
RATIONALE HIV-infected persons on antiretroviral therapy (ART) remain at higher risk of pulmonary tuberculosis (TB) than HIV-uninfected individuals. This increased susceptibility may be caused by impairment of alveolar macrophage (AM) function and/or mycobacteria-specific alveolar CD4(+) T-cell responses observed in HIV-infected ART-naive adults. OBJECTIVES To determine whether ART was associated with improvement in both AM function, assessed by phagosomal proteolysis, and alveolar CD4(+) T-cell responses to Mycobacterium in HIV-infected individuals. METHODS Peripheral blood was drawn and bronchoalveolar lavage (BAL) performed on healthy, 35 HIV-uninfected, 25 HIV-infected ART-naive, and 50 HIV-infected ART-treated asymptomatic adults. Phagosomal proteolysis of AM was assessed with fluorogenic beads. Mycobacteria-specific CD4(+) T-cell responses were measured by intracellular cytokine staining. MEASUREMENTS AND MAIN RESULTS HIV-infected adults on ART exhibited lower plasma HIV viral load and higher blood CD4(+) T-cell count than ART-naive adults. AM proteolysis and total mycobacteria-specific Th1 CD4(+) T-cell responses in individuals on ART for greater than or equal to 4 years were similar to HIV-uninfected control subjects but those on ART for less than 4 years had impaired responses. Total influenza-specific alveolar Th1 CD4(+) T-cell responses were intact in all individuals receiving ART. In contrast, BAL and blood mycobacteria-specific polyfunctional CD4(+) T-cell responses were impaired in adults on ART irrespective of duration. CONCLUSIONS AM and mycobacteria-specific alveolar CD4(+) T-cell responses in HIV-infected adults on ART for less than 4 years are impaired and may partly explain the high risk of TB in HIV-infected individuals on ART. Strategies to augment ART to improve lung immune cell function and reduce the high incidence of TB in HIV-infected adults who initiate ART should be investigated.
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Affiliation(s)
- Kondwani C Jambo
- 1 Malawi-Liverpool-Wellcome Trust Clinical Research Programme and
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Simplified severe sepsis protocol: a randomized controlled trial of modified early goal-directed therapy in Zambia. Crit Care Med 2014; 42:2315-24. [PMID: 25072757 DOI: 10.1097/ccm.0000000000000541] [Citation(s) in RCA: 131] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To assess the efficacy of a simple, goal-directed sepsis treatment protocol for reducing mortality in patients with severe sepsis in Zambia. DESIGN Single-center nonblinded randomized controlled trial. SETTING Emergency department, ICU, and medical wards of the national referral hospital in Lusaka, Zambia. PATIENTS One hundred twelve patients enrolled within 24 hours of admission with severe sepsis, defined as systemic inflammatory response syndrome with suspected infection and organ dysfunction INTERVENTIONS : Simplified Severe Sepsis Protocol consisting of up to 4 L of IV fluids within 6 hours, guided by jugular venous pressure assessment, and dopamine and/or blood transfusion in selected patients. Control group was managed as usual care. Blood cultures were collected and early antibiotics administered for both arms. MEASUREMENTS AND MAIN RESULTS Primary outcome was in-hospital all-cause mortality. One hundred nine patients were included in the final analysis and 88 patients (80.7%) were HIV positive. Pulmonary infections were the most common source of sepsis. In-hospital mortality rate was 64.2% in the intervention group and 60.7% in the control group (relative risk, 1.05; 95% CI, 0.79-1.41). Mycobacterium tuberculosis complex was isolated from 31 of 82 HIV-positive patients (37.8%) with available mycobacterial blood culture results. Patients in Simplified Severe Sepsis Protocol received significantly more IV fluids in the first 6 hours (2.7 L vs 1.7 L, p = 0.002). The study was stopped early because of high mortality rate among patients with hypoxemic respiratory failure in the intervention arm (8/8, 100%) compared with the control arm (7/10, 70%; relative risk, 1.43; 95% CI, 0.95-2.14). CONCLUSION Factors other than tissue hypoperfusion probably account for much of the end-organ dysfunction in African patients with severe sepsis. Studies of fluid-based interventions should utilize inclusion criteria to accurately capture patients with hypovolemia and tissue hypoperfusion who are most likely to benefit from fluids. Exclusion of patients with severe respiratory distress should be considered when ventilatory support is not readily available.
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185
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Ogbuagu O, Villanueva M. Extensive Central Nervous System Cryptococcal Disease Presenting as Immune Reconstitution Syndrome in a Patient with Advanced HIV: Report of a Case and Review of Management Dilemmas and Strategies. Infect Dis Rep 2014; 6:5576. [PMID: 25568756 PMCID: PMC4274402 DOI: 10.4081/idr.2014.5576] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Revised: 08/13/2014] [Accepted: 08/14/2014] [Indexed: 12/18/2022] Open
Abstract
One of the complications of the use of antiretroviral therapy (ART), immune reconstitution inflammatory syndrome (IRIS), is particularly problematic in the management of cryptococcal meningitis. We present the case of a 35-year-old male with acquired immune deficiency syndrome diagnosed with extensive central nervous system (CNS) cryptococcal disease, including meningitis and multiple intracranial cysts, diagnosed eight weeks after the initiation of ART. The patient experienced a relapsing and remitting clinical course despite repeated courses of potent antifungal therapy and aggressive management of raised intracranial pressure. This review highlights therapeutic dilemmas and strategies in the management of CNS cryptococcosis complicated with IRIS and highlights gaps in available treatment guidelines.
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Affiliation(s)
- Onyema Ogbuagu
- Yale HIV/AIDS Program, Section of Infectious Diseases, Yale University School of Medicine , New Haven, CT, USA
| | - Merceditas Villanueva
- Yale HIV/AIDS Program, Section of Infectious Diseases, Yale University School of Medicine , New Haven, CT, USA
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186
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Sierra-Madero JG, Ellenberg SS, Rassool MS, Tierney A, Belaunzarán-Zamudio PF, López-Martínez A, Piñeirúa-Menéndez A, Montaner LJ, Azzoni L, Benítez CR, Sereti I, Andrade-Villanueva J, Mosqueda-Gómez JL, Rodriguez B, Sanne I, Lederman MM. Effect of the CCR5 antagonist maraviroc on the occurrence of immune reconstitution inflammatory syndrome in HIV (CADIRIS): a double-blind, randomised, placebo-controlled trial. Lancet HIV 2014; 1:e60-7. [PMID: 26423989 DOI: 10.1016/s2352-3018(14)70027-x] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Immune reconstitution inflammatory syndrome (IRIS) is a common complication of antiretroviral therapy (ART) in patients with HIV. IRIS is associated with an increased risk of admission to hospital and death. We assessed whether CCR5 blockade with maraviroc reduces the risk of IRIS. METHODS The CADIRIS study was a double-blind, randomised, placebo-controlled trial that recruited participants from five clinical sites in Mexico and one in South Africa and followed them for 1 year. Patients were eligible if they were adults with HIV, who were naive to ART, had CD4 count lower than 100 cells per μL and HIV RNA greater than 1000 copies per mL. Participants were randomly assigned (1:1) by permuted block randomisation to receive either maraviroc (600 mg twice daily) or placebo in addition to an ART regimen that included tenofovir, emtricitabine, and efavirenz for 48 weeks. Patients, care providers, and members of the research team were masked to treatment allocation. Clinical and laboratory evaluations were done at baseline, and weeks 2, 4, 8, 12, 16, 24, 48, and 60. The primary outcome was time to an IRIS event by 24 weeks. All patients who were randomly assigned contributed to the primary time-to-event analysis from the date of ART initiation until week 24, the time of an IRIS event or death. This trial is registered with ClinicalTrials.gov, number NCT00988780. FINDINGS Between Dec 10, 2009, and Jan 17, 2012, we screened 362 patients; of whom 279 met the inclusion criteria and three refused to participate; thus 276 participants were randomly assigned (140 to receive maraviroc and 136 to receive placebo). 64 (23%) patients had IRIS events, 33 (24%) in the maraviroc group and 31 (23%) in the placebo group (p=0·74). No difference in the time to IRIS events was noted between the treatment groups (HR 1·08, 95% CI 0·66-1·77; log-rank test p=0·74). 37 participants (26%) in the maraviroc group had grade 3 or 4 adverse events compared with 24 (18%) in placebo group; p=0·072); 25 (18%) in the maraviroc group and 21 (15%) in the placebo group had serious treatment emergent adverse events (p=0·63). INTERPRETATION Maraviroc had no significant effect on development of IRIS after ART initiation. Inclusion of this CCR5 inhibitor in an initial treatment regimen does not confer a meaningful protection from the occurrence of IRIS in people with advanced HIV infection. FUNDING Pfizer.
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Affiliation(s)
- Juan G Sierra-Madero
- Departmento de Infectología, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", México DF, México
| | - Susan S Ellenberg
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Mohammed S Rassool
- Clinical HIV Research Unit, Department of Internal Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Ann Tierney
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Pablo F Belaunzarán-Zamudio
- Departmento de Infectología, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", México DF, México.
| | - Alondra López-Martínez
- Departmento de Infectología, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", México DF, México
| | - Alicia Piñeirúa-Menéndez
- Departmento de Infectología, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", México DF, México
| | - Luis J Montaner
- HIV-1 Immunopathogenesis Laboratory, The Wistar Institute, Philadelphia, PA, USA
| | - Livio Azzoni
- HIV-1 Immunopathogenesis Laboratory, The Wistar Institute, Philadelphia, PA, USA
| | | | - Irini Sereti
- HIV Pathogenesis Unit, Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases/National Institutes of Health, Bethesda, MD, USA
| | | | - Juan L Mosqueda-Gómez
- Centro Ambulatorio para la Prevención y Atención del SIDA e Infecciones de Transmisión Sexual, León, Guanajuato, México
| | - Benigno Rodriguez
- Center for AIDS Research, Case Western Reserve University, Cleveland, OH, USA
| | - Ian Sanne
- Clinical HIV Research Unit, Department of Internal Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Michael M Lederman
- Center for AIDS Research, Case Western Reserve University, Cleveland, OH, USA
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187
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Boulle A, Schomaker M, May MT, Hogg RS, Shepherd BE, Monge S, Keiser O, Lampe FC, Giddy J, Ndirangu J, Garone D, Fox M, Ingle SM, Reiss P, Dabis F, Costagliola D, Castagna A, Ehren K, Campbell C, Gill MJ, Saag M, Justice AC, Guest J, Crane HM, Egger M, Sterne JAC. Mortality in patients with HIV-1 infection starting antiretroviral therapy in South Africa, Europe, or North America: a collaborative analysis of prospective studies. PLoS Med 2014; 11:e1001718. [PMID: 25203931 PMCID: PMC4159124 DOI: 10.1371/journal.pmed.1001718] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 07/24/2014] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND High early mortality in patients with HIV-1 starting antiretroviral therapy (ART) in sub-Saharan Africa, compared to Europe and North America, is well documented. Longer-term comparisons between settings have been limited by poor ascertainment of mortality in high burden African settings. This study aimed to compare mortality up to four years on ART between South Africa, Europe, and North America. METHODS AND FINDINGS Data from four South African cohorts in which patients lost to follow-up (LTF) could be linked to the national population register to determine vital status were combined with data from Europe and North America. Cumulative mortality, crude and adjusted (for characteristics at ART initiation) mortality rate ratios (relative to South Africa), and predicted mortality rates were described by region at 0-3, 3-6, 6-12, 12-24, and 24-48 months on ART for the period 2001-2010. Of the adults included (30,467 [South Africa], 29,727 [Europe], and 7,160 [North America]), 20,306 (67%), 9,961 (34%), and 824 (12%) were women. Patients began treatment with markedly more advanced disease in South Africa (median CD4 count 102, 213, and 172 cells/µl in South Africa, Europe, and North America, respectively). High early mortality after starting ART in South Africa occurred mainly in patients starting ART with CD4 count <50 cells/µl. Cumulative mortality at 4 years was 16.6%, 4.7%, and 15.3% in South Africa, Europe, and North America, respectively. Mortality was initially much lower in Europe and North America than South Africa, but the differences were reduced or reversed (North America) at longer durations on ART (adjusted rate ratios 0.46, 95% CI 0.37-0.58, and 1.62, 95% CI 1.27-2.05 between 24 and 48 months on ART comparing Europe and North America to South Africa). While bias due to under-ascertainment of mortality was minimised through death registry linkage, residual bias could still be present due to differing approaches to and frequency of linkage. CONCLUSIONS After accounting for under-ascertainment of mortality, with increasing duration on ART, the mortality rate on HIV treatment in South Africa declines to levels comparable to or below those described in participating North American cohorts, while substantially narrowing the differential with the European cohorts. Please see later in the article for the Editors' Summary.
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Affiliation(s)
- Andrew Boulle
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Department of Health, Provincial Government of the Western Cape, Cape Town, South Africa
- * E-mail:
| | - Michael Schomaker
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Margaret T. May
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Robert S. Hogg
- Division of Epidemiology and Population Health, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
| | - Bryan E. Shepherd
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Susana Monge
- Centro Nacional de Epidemiología, Instituto de Salud Carlos III, Madrid, Spain
| | - Olivia Keiser
- University of Bern, Institute for Social and Preventive Medicine, Bern, Switzerland
| | - Fiona C. Lampe
- Research Department of Infection and Population Health, UCL Medical School, London, United Kingdom
| | | | - James Ndirangu
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa
| | | | - Matthew Fox
- Center for Global Health and Development, Boston University, Boston, Massachusetts, United States of America
| | - Suzanne M. Ingle
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Peter Reiss
- Stichting HIV Monitoring, Amsterdam, The Netherlands
- Department of Global Health and Division of Infectious Diseases, Academic Medical Center, University of Amsterdam, and Amsterdam Institute for Global health and Development, Amsterdam, the Netherlands
| | - Francois Dabis
- INSERM, Centre INSERM U897 “Epidémiologie et Biostatistique”, Bordeaux, France
- Université Bordeaux, Institut de Santé Publique Epidémiologie Développement (ISPED), Bordeaux, France
| | - Dominique Costagliola
- Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris, France
- INSERM, UMR_S 1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris, France
| | - Antonella Castagna
- Infectious Diseases Department, San Raffaele Scientific Institute, Milan, Italy
| | - Kathrin Ehren
- First Department of Internal Medicine, University Hospital of Cologne, Germany
| | - Colin Campbell
- Centre d'Estudis Epidemiològics sobre les Infeccions de Transmissió Sexual i Sida de Catalunya (CEEISCAT), Institut català d'Oncologia (ICO), Agència Salut Pública de Catalunya (ASPC), Generalitat de Catalunya, Badalona, Spain
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - M. John Gill
- Division of Infectious Diseases, University of Calgary, Calgary, Canada
| | - Michael Saag
- Division of Infectious Disease, Department of Medicine, University of Alabama, Birmingham, Alabama, United States of America
| | - Amy C. Justice
- Yale University School of Medicine, New Haven, Connecticut, United States of America
- VA Connecticut Healthcare System, West Haven, Connecticut, United States of America
| | - Jodie Guest
- HIV Atlanta VA Cohort Study (HAVACS), Atlanta Veterans Affairs Medical Center, Decatur, Georgia, United States of America
| | - Heidi M. Crane
- Center for AIDS Research, University of Washington, Seattle, Washington, United States of America
| | - Matthias Egger
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- University of Bern, Institute for Social and Preventive Medicine, Bern, Switzerland
| | - Jonathan A. C. Sterne
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
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Drain PK, Mayeza L, Bartman P, Hurtado R, Moodley P, Varghese S, Maartens G, Alvarez GG, Wilson D. Diagnostic accuracy and clinical role of rapid C-reactive protein testing in HIV-infected individuals with presumed tuberculosis in South Africa. Int J Tuberc Lung Dis 2014; 18:20-6. [PMID: 24505819 DOI: 10.5588/ijtld.13.0519] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE To determine the accuracy and role of rapid C-reactive protein (CRP) testing in human immunodeficiency virus (HIV) infected individuals with presumed tuberculosis (TB). DESIGN We enrolled HIV-infected adults (≥18 years)with a cough of ≥2 weeks and negative sputum smears for acid-fast bacilli in KwaZulu-Natal, South Africa. Participants were evaluated for pulmonary TB (PTB) by a nurse with rapid CRP, and independently by a physician by chest radiograph. Rapid CRP test results were compared with laboratory CRP and sputum sent for confirmation of TB. RESULTS Among 93 participants, 55 (59%) were female, the mean age was 35 years, and the median CD4 count was 177/mm3. Forty-five (54%) participants were diagnosed with PTB. Diagnostic sensitivity and specificity were respectively 95% (95%CI 74–99) and 51%(95%CI 35–66) for rapid CRP >8 mg/l, 87% (95%CI 73–96) and 53% (95%CI 38–68) for nurse assessment, and 69% (95%CI 52–83) and 76% (95%CI 61–87) for physician examination. Combining a negative rapid CRP(≤8 mg/l) with nurse and physician assessments reduced the post-test probability of PTB from 22% to 6% and from 32% to 6%, respectively. CONCLUSION Rapid CRP testing helped exclude PTB,and may be a valuable test in assisting nurses and physicians in TB-endemic regions.
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189
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Utility of urine and serum lateral flow assays to determine the prevalence and predictors of cryptococcal antigenemia in HIV-positive outpatients beginning antiretroviral therapy in Mwanza, Tanzania. J Int AIDS Soc 2014; 17:19040. [PMID: 25109284 PMCID: PMC4127809 DOI: 10.7448/ias.17.1.19040] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Revised: 06/08/2014] [Accepted: 06/26/2014] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Detection of subclinical cryptococcal disease using cryptococcal antigen screening among HIV-positive individuals presents a potential opportunity for prevention of both clinical disease and death if patients with detectable cryptococcal antigen are identified and treated pre-emptively. Recently developed point-of-care cryptococcal antigen tests may be useful for screening, particularly in resource-limiting settings, but few studies have assessed their utility. METHODOLOGY The objectives of this study were to determine the prevalence and factors associated with cryptococcal antigenemia in HIV-positive patients with CD4(+) T-cell counts ≤200 cells/µL who were initiating ART, and also to evaluate the utility of the point-of-care urine lateral flow assay (LFA) cryptococcal antigen test using two different diluents, compared to gold standard serum antigen testing, as a screening tool. Urine and serum of outpatients initiating antiretroviral therapy at two hospitals in Mwanza were tested for cryptococcal antigen, and demographic and clinical characteristics were obtained using structured questionnaires and patients' files. Patients with asymptomatic cryptococcal antigenemia received oral fluconazole in accordance with World Health Organization recommendations. RESULTS Among 140 patients screened, 10 (7.1%) had asymptomatic cryptococcal antigenemia with a positive serum cryptococcal antigen. Four of these ten patients had CD4 counts between 100 and 200 cells/µL. The prevalence of cryptococcal antigen detected in urine using a standard (older) and a test (newer) diluent were 44 (31.4%) and 19 (13.6%), with Kappa coefficients compared to serum of 0.28 and 0.51 (p<0.001 for both). Compared to the new LFA diluent for urine cryptococcal antigen, the standard diluent had higher sensitivity (100% versus 80%) but lower specificity (74% versus 92%) using serum cryptococcal antigen as a gold standard. CONCLUSIONS Our findings suggest that HIV-positive outpatients with CD4 counts <200 cells/µL, rather than 100, should be screened for asymptomatic cryptococcal antigenemia given its association with mortality if untreated. Agreement of the urine LFA with the serum LFA was not sufficient to recommend routine screening with urine LFA.
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190
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Krown SE, Borok MZ, Campbell TB, Casper C, Dittmer DP, Hosseinipour MC, Mitsuyasu RT, Mosam A, Orem J, Phipps WT. Stage-stratified approach to AIDS-related Kaposi's sarcoma: implications for resource-limited environments. J Clin Oncol 2014; 32:2512-3. [PMID: 25002726 DOI: 10.1200/jco.2014.55.8999] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Margaret Z Borok
- University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | | | - Corey Casper
- Fred Hutchinson Cancer Research Center and University of Washington, Seattle, WA
| | - Dirk P Dittmer
- Lineberger Comprehensive Cancer Center and University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Mina C Hosseinipour
- University of North Carolina Project, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Ronald T Mitsuyasu
- Center for Clinical AIDS Research and Education, University of California, Los Angeles, Los Angeles, CA
| | - Anisa Mosam
- Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Jackson Orem
- Uganda Cancer Institute, Mulago Hospital, and Makarere College of Health Sciences, Kampala, Uganda
| | - Warren T Phipps
- University of Washington and Fred Hutchinson Cancer Research Center, Seattle, WA; Uganda Cancer Institute/Hutchinson Cancer Center Alliance, Kampala, Uganda
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191
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Linkage to HIV care and antiretroviral therapy by HIV testing service type in Central Mozambique: a retrospective cohort study. J Acquir Immune Defic Syndr 2014; 66:e37-44. [PMID: 24326605 DOI: 10.1097/qai.0000000000000081] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Access to antiretroviral therapy (ART) has increased dramatically in resource-limited settings since its introduction a decade ago. However, ART coverage remains low in countries with the highest disease burden, which may be partially explained by poor testing to care linkages. HIV testing service may impact early attrition in the HIV treatment cascade. METHODS A retrospective cohort study was conducted in 18 clinics in central Mozambique using routine patient data and monthly reports. Patients referred from voluntary counseling and testing (VCT) were compared with those referred from prevention of mother-to-child transmission (PMTCT) for 3 outcomes: (1) enrollment at an HIV clinic ≤30 days after testing HIV positive, (2) CD4 test ≤30 days after enrollment, and (3) ART initiation ≤90 days after first CD4 test. RESULTS Patient retention in the HIV care system dropped at each step from HIV testing to ART initiation. Enrollment in HIV care was not significantly different between PMTCT and VCT [risk ratio (RR) = 0.84, 0.72 < RR < 1.02]. Women tested in PMTCT were less likely to have a CD4 test ≤30 days after enrollment when adjusting for age, education level, and marital status (adjusted RR = 0.84, 0.70 < RR < 1.00), and were less likely to initiate ART ≤90 days after their first CD4 test when adjusting for age, education, and marital status (adjusted RR = 0.56, 0.44 < RR < 0.71). CONCLUSIONS Poor linkages between HIV testing and care hamper efforts to improve coverage for HIV care and treatment services. Increased loss to follow-up among women diagnosed in PMTCT relative to VCT is worrisome and merits further qualitative research and programmatic attention.
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Lankowski AJ, Siedner MJ, Bangsberg DR, Tsai AC. Impact of geographic and transportation-related barriers on HIV outcomes in sub-Saharan Africa: a systematic review. AIDS Behav 2014; 18:1199-223. [PMID: 24563115 DOI: 10.1007/s10461-014-0729-8] [Citation(s) in RCA: 151] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Difficulty obtaining reliable transportation to clinic is frequently cited as a barrier to HIV care in sub-Saharan Africa (SSA). Numerous studies have sought to characterize the impact of geographic and transportation-related barriers on HIV outcomes in SSA, but to date there has been no systematic attempt to summarize these findings. In this systematic review, we summarized this body of literature. We searched for studies conducted in SSA examining the following outcomes in the HIV care continuum: (1) voluntary counseling and testing, (2) pre-antiretroviral therapy (ART) linkage to care, (3) loss to follow-up and mortality, and (4) ART adherence and/or viral suppression. We identified 34 studies containing 52 unique estimates of association between a geographic or transportation-related barrier and an HIV outcome. There was an inverse effect in 23 estimates (44 %), a null association in 26 (50 %), and a paradoxical beneficial impact in 3 (6 %). We conclude that geographic and transportation-related barriers are associated with poor outcomes across the continuum of HIV care.
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193
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Mayston R, Patel V, Abas M, Korgaonkar P, Paranjape R, Rodrigues S, Prince M. Psychological predictors for attendance of post-HIV test counselling and linkage to care: the Umeed cohort study in Goa, India. BMC Psychiatry 2014; 14:188. [PMID: 24981595 PMCID: PMC4083128 DOI: 10.1186/1471-244x-14-188] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 06/19/2014] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Successful linkage to care is increasingly recognised as a potentially important factor in determining the success of Antiretroviral Therapy treatment programmes. However, the role of psychological factors during the early part of the continuum of care has so far been under-investigated. The objective of the Umeed study was to evaluate the impact of Common Mental Disorder (CMD), hazardous alcohol use and low cognitive functioning upon attendance for post-test counselling and linkage to care among people attending for HIV-testing in Goa, India. METHODS The study was a prospective cohort design. Participants were recruited at the time of attending for testing and were asked to complete a baseline interview covering sociodemographic characteristics and mental health exposures. HIV status, post-test counselling (PTC) and Antiretroviral Treatment (ART) Centre data were extracted from clinical records. RESULTS Among 1934 participants, CMD predicted non-attendance for PTC (adjusted OR = 0.51, 0.21-0.82). There was tentative evidence of an association between hazardous alcohol use and non-attendance for PTC (adjusted OR = 0.69, 0.45-1.02). There was no evidence of an association between CMD caseness and attendance for ART. However, post-hoc analyses showed an association between increasing symptoms of CMD and non-attendance. CONCLUSIONS Although participation rates were high (86%), non-participation was a possible source of bias. Cognitive tests had not been previously validated in a young population in Goa. The context in which cognitive testing took place may have contributed to the high prevalence of low scores. Findings suggest the need to move towards a broader conceptualisation of the interrelationship between mental health and HIV. It may be important to consider the impact of symptoms of depression and anxiety at every stage of the continuum of care, including immediately after diagnosis and when initiating contact with treatment services.
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Affiliation(s)
- Rosie Mayston
- Health Service & Population Research Department, Institute of Psychiatry, Kings College London, London SE5 8AF, UK.
| | - Vikram Patel
- Department of Nutrition and Public Health Intervention Research, London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK,Sangath, North Goa: 841/1, Near Electricity Department, Alto Porvorim, Bardez-Goa, India
| | - Melanie Abas
- Health Service & Population Research Department, Institute of Psychiatry, Kings College London, London SE5 8AF, UK
| | - Priya Korgaonkar
- Sangath, North Goa: 841/1, Near Electricity Department, Alto Porvorim, Bardez-Goa, India
| | - Ramesh Paranjape
- National AIDS Research Institute, 73, 'G'-Block, MIDC, Bhosari Pune 411 026, India
| | - Savio Rodrigues
- Department of Microbiology, Goa Medical College and Hospital, Bambolim, Tiswadi Goa, India
| | - Martin Prince
- Health Service & Population Research Department, Institute of Psychiatry, Kings College London, London SE5 8AF, UK
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Boulware DR, Meya DB, Muzoora C, Rolfes MA, Huppler Hullsiek K, Musubire A, Taseera K, Nabeta HW, Schutz C, Williams DA, Rajasingham R, Rhein J, Thienemann F, Lo MW, Nielsen K, Bergemann TL, Kambugu A, Manabe YC, Janoff EN, Bohjanen PR, Meintjes G. Timing of antiretroviral therapy after diagnosis of cryptococcal meningitis. N Engl J Med 2014; 370:2487-98. [PMID: 24963568 PMCID: PMC4127879 DOI: 10.1056/nejmoa1312884] [Citation(s) in RCA: 331] [Impact Index Per Article: 33.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Cryptococcal meningitis accounts for 20 to 25% of acquired immunodeficiency syndrome-related deaths in Africa. Antiretroviral therapy (ART) is essential for survival; however, the question of when ART should be initiated after diagnosis of cryptococcal meningitis remains unanswered. METHODS We assessed survival at 26 weeks among 177 human immunodeficiency virus-infected adults in Uganda and South Africa who had cryptococcal meningitis and had not previously received ART. We randomly assigned study participants to undergo either earlier ART initiation (1 to 2 weeks after diagnosis) or deferred ART initiation (5 weeks after diagnosis). Participants received amphotericin B (0.7 to 1.0 mg per kilogram of body weight per day) and fluconazole (800 mg per day) for 14 days, followed by consolidation therapy with fluconazole. RESULTS The 26-week mortality with earlier ART initiation was significantly higher than with deferred ART initiation (45% [40 of 88 patients] vs. 30% [27 of 89 patients]; hazard ratio for death, 1.73; 95% confidence interval [CI], 1.06 to 2.82; P=0.03). The excess deaths associated with earlier ART initiation occurred 2 to 5 weeks after diagnosis (P=0.007 for the comparison between groups); mortality was similar in the two groups thereafter. Among patients with few white cells in their cerebrospinal fluid (<5 per cubic millimeter) at randomization, mortality was particularly elevated with earlier ART as compared with deferred ART (hazard ratio, 3.87; 95% CI, 1.41 to 10.58; P=0.008). The incidence of recognized cryptococcal immune reconstitution inflammatory syndrome did not differ significantly between the earlier-ART group and the deferred-ART group (20% and 13%, respectively; P=0.32). All other clinical, immunologic, virologic, and microbiologic outcomes, as well as adverse events, were similar between the groups. CONCLUSIONS Deferring ART for 5 weeks after the diagnosis of cryptococcal meningitis was associated with significantly improved survival, as compared with initiating ART at 1 to 2 weeks, especially among patients with a paucity of white cells in cerebrospinal fluid. (Funded by the National Institute of Allergy and Infectious Diseases and others; COAT ClinicalTrials.gov number, NCT01075152.).
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Affiliation(s)
- David R Boulware
- From the University of Minnesota, Minneapolis (D.R.B., D.B.M., M.A.R., K.H.H., D.A.W., R.R., J.R., M.W.L., K.N., T.L.B., P.R.B.); the Infectious Disease Institute (D.B.M., A.M., H.W.N., D.A.W., R.R., J.R., M.W.L., A.K., Y.C.M.) and School of Medicine, College of Health Sciences (D.B.M.), Makerere University, Kampala, and Mbarara University of Science and Technology, Mbarara (C.M., K.T.) - both in Uganda; the University of Cape Town, Cape Town, South Africa (C.S., F.T., G.M.); Johns Hopkins School of Medicine, Baltimore (Y.C.M.); the Mucosal and Vaccine Research Program Colorado (MAVRC), University of Colorado Denver, Aurora, and Denver Veterans Affairs Medical Center, Denver (E.N.J.); and Imperial College London, London (G.M.)
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195
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Mupfumi L, Makamure B, Chirehwa M, Sagonda T, Zinyowera S, Mason P, Metcalfe JZ, Mutetwa R. Impact of Xpert MTB/RIF on Antiretroviral Therapy-Associated Tuberculosis and Mortality: A Pragmatic Randomized Controlled Trial. Open Forum Infect Dis 2014; 1:ofu038. [PMID: 25734106 PMCID: PMC4324195 DOI: 10.1093/ofid/ofu038] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Accepted: 05/27/2014] [Indexed: 01/19/2023] Open
Abstract
Introduction. GeneXpert® MTB/RIF (Xpert) is now widely distributed in high human immunodeficiency virus (HIV)/tuberculosis (TB)-burden countries. Yet, whether the test improves patient-important outcomes within HIV treatment programs in limited resource settings is unknown. Methods. To investigate whether use of Xpert for TB screening prior to initiation of antiretroviral treatment (ART) improves patient-important outcomes, in a pragmatic randomized controlled trial we assigned 424 patients to Xpert or fluorescence sputum smear microscopy (FM) at ART initiation. The primary endpoint was a composite of 3-month mortality and ART-associated TB. Results. There was no difference in overall TB diagnosis at ART initiation (20% [n = 43] Xpert vs 21% [n = 45] FM; P = .80), with most patients in both groups treated empirically. There was no difference in time to TB treatment initiation {5 days (interquartile range [IQR], 3–13) vs 8 days [IQR, 3–23; P = .26]} or loss to follow-up (32 [15%] vs 38 [18%]; P = 0.38). Although a nonsignificant reduction in mortality occurred in the Xpert group (11 [6%] vs 17 [10%]; 95% CI, −9% to 2%; P = .19), there was no difference in the composite outcome (9% [n = 17] Xpert vs 12% [n = 21] FM; difference −3%; 95% CI, −9% to 4%). Conclusions. Among HIV-infected initiating ART, centralized TB screening with Xpert did not reduce the rate of ART-associated TB and mortality, compared with fluorescence microscopy.
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Affiliation(s)
- L Mupfumi
- University of Zimbabwe College of Health Sciences , Harare , Zimbabwe ; Biomedical Research and Training Institute , Zimbabwe
| | - B Makamure
- University of Zimbabwe College of Health Sciences , Harare , Zimbabwe ; Biomedical Research and Training Institute , Zimbabwe
| | - M Chirehwa
- Biomedical Research and Training Institute , Zimbabwe
| | - T Sagonda
- Biomedical Research and Training Institute , Zimbabwe
| | - S Zinyowera
- National Microbiology Reference Laboratory , Harare , Zimbabwe
| | - P Mason
- University of Zimbabwe College of Health Sciences , Harare , Zimbabwe ; Biomedical Research and Training Institute , Zimbabwe
| | - J Z Metcalfe
- Division of Pulmonary and Critical Care Medicine , San Francisco General Hospital, and Francis J. Curry International Tuberculosis Center, University of California , San Francisco, California
| | - R Mutetwa
- Biomedical Research and Training Institute , Zimbabwe
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Coelho L, Cardoso SW, Amancio RT, Moreira RI, Campos DP, Veloso VG, Grinsztejn B, Luz PM. Trends in AIDS-defining opportunistic illnesses incidence over 25 years in Rio de Janeiro, Brazil. PLoS One 2014; 9:e98666. [PMID: 24901419 PMCID: PMC4047074 DOI: 10.1371/journal.pone.0098666] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Accepted: 05/05/2014] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES To assess the temporal trends in incidence of AIDS-defining opportunistic illnesses in an urban cohort of a middle-income country. METHODS HIV infected patients aged ≥ 18 years at cohort entry were included in this analysis. We calculated incidence rates per 1000 persons-years of observation for the first opportunistic illness presented after cohort enrollment, from 1987 to 2012. Trends for overall and specific opportunistic illnesses were tested and incidence rate ratios for the most recent calendar period were calculated as the ratio between the incidence rate observed in the most recent period of the study (2009-2012) and the incidence rate observed in first period of the study (1987-1990). RESULTS Overall, 3378 patients were included in this analysis; of which 1119 (33%) patients presented an opportunistic illness during follow up. Incidence rates of all opportunistic illnesses decreased over time, and the overall opportunistic illness incidence rates fell from 295.4/1000 persons-years in 1987-1990 to 34.6/1000 persons-years in 2009-2012. Tuberculosis, esophageal candidiasis, cerebral toxoplasmosis and Pneumocystis jirovecii pneumonia were the most incident opportunistic illnesses in the cohort. Tuberculosis had the highest incidence rate in the study period. The peak in tuberculosis incidence occurred in 1991-1993 (80.8/1000 persons-years). Cerebral toxoplasmosis was the third most incident opportunistic illness in the study, with a peak of incidence of 43.6/1000 persons-year in 1987-1990. CONCLUSIONS All opportunistic illnesses incidence rates decreased over the years but they still occur in an unacceptable frequency. Tuberculosis co-infection among HIV-infected persists as an important challenge for health care professionals and policy makers in our setting. Impressively high rates of cerebral toxoplasmosis were found suggesting that its incidence among HIV-infected is linked to the high prevalence of Toxoplasma gondii infection in the general population.
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Affiliation(s)
- Lara Coelho
- Instituto de Pesquisa Clínica Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
| | - Sandra Wagner Cardoso
- Instituto de Pesquisa Clínica Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
| | | | | | - Dayse Pereira Campos
- Instituto de Pesquisa Clínica Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
| | | | - Beatriz Grinsztejn
- Instituto de Pesquisa Clínica Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
| | - Paula Mendes Luz
- Instituto de Pesquisa Clínica Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
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Zaeh S, Kempker R, Stenehjem E, Blumberg HM, Temesgen O, Ofotokun I, Tenna A. Improving tuberculosis screening and isoniazid preventive therapy in an HIV clinic in Addis Ababa, Ethiopia. Int J Tuberc Lung Dis 2014; 17:1396-401. [PMID: 24125440 DOI: 10.5588/ijtld.13.0315] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The World Health Organization (WHO) recommends active tuberculosis (TB) case finding among people living with human immunodeficiency virus (HIV) in resource-limited settings using a symptom-based algorithm; those without active TB disease should be offered isoniazid preventive therapy (IPT). OBJECTIVE To evaluate rates of adherence to WHO recommendations and the impact of a quality improvement intervention in an HIV clinic in Addis Ababa, Ethiopia. DESIGN A prospective study design was utilized to compare TB symptom screening and IPT administration rates before and after a quality improvement intervention consisting of 1) educational sessions, 2) visual reminders, and 3) use of a screening checklist. RESULTS A total of 751 HIV-infected patient visits were evaluated. The proportion of patients screened for TB symptoms increased from 22% at baseline to 94% following the intervention (P < 0.001). Screening rates improved from 51% to 81% (P < 0.001) for physicians and from 3% to 100% (P < 0.001) for nurses. Of the 281 patients with negative TB symptom screens and eligible for IPT, 4% were prescribed IPT before the intervention compared to 81% after (P < 0.001). CONCLUSIONS We found that a quality improvement intervention significantly increased WHO-recommended TB screening rates and IPT administration. Utilizing nurses can help increase TB screening and IPT provision in resource-limited settings.
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Affiliation(s)
- S Zaeh
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
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198
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Olsen MF, Abdissa A, Kæstel P, Tesfaye M, Yilma D, Girma T, Wells JCK, Ritz C, Mølgaard C, Michaelsen KF, Zerfu D, Brage S, Andersen AB, Friis H. Effects of nutritional supplementation for HIV patients starting antiretroviral treatment: randomised controlled trial in Ethiopia. BMJ 2014; 348:g3187. [PMID: 25134117 PMCID: PMC4022776 DOI: 10.1136/bmj.g3187] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVES To determine the effects of lipid based nutritional supplements with either whey or soy protein in patients with HIV during the first three months of antiretroviral treatment (ART) and to explore effects of timing by comparing supplementation at the start of ART and after three months delay. DESIGN Randomised controlled trial. SETTING Three public ART facilities in Jimma, Oromia region, Ethiopia. PARTICIPANTS Adults with HIV eligible for ART with body mass index (BMI) >16. INTERVENTION Daily supplementation with 200 g (4600 kJ) of supplement containing whey or soy during either the first three or the subsequent three months of ART. OUTCOME MEASURES Primary: lean body mass assessed with deuterium dilution, grip strength measured with dynamometers, and physical activity measured with accelerometer and heart rate monitors. Secondary: viral load and CD4 counts. Auxiliary: weight and CD3 and CD8 counts. RESULTS Of 318 patients enrolled, 210 (66%) were women, mean age was 33 (SD 9), and mean BMI was 19.5 (SD 2.4). At three months, participants receiving the supplements containing whey or soy had increased their lean body mass by 0.85 kg (95% confidence interval 0.16 kg to 1.53 kg) and 0.97 kg (0.29 kg to 1.64 kg), respectively, more than controls. This was accompanied by an increased gain of grip strength of 0.68 kg (-0.11 kg to 1.46 kg) for the whey supplement group and 0.93 kg (0.16 kg to 1.70 kg) for the soy supplement group. There were no effects on physical activity. Total weight gain increased by 2.05 kg (1.12 kg to 2.99 kg) and 2.06 kg (1.14 kg to 2.97 kg) for the whey and soy groups, respectively. In addition, in the whey supplement group overall CD3 counts improved by 150 cells/µL (24 to 275 cells/µL), of which 112 cells/µL (15 to 209 cells/µL) were CD8 and 25 cells/µL (-2 to 53 cells/µL) were CD4. Effects of the soy containing supplement on immune recovery were not significant. The effects of the two supplements, however, were not significantly different in direct comparison. Exploratory analysis showed that relatively more lean body mass was gained by patients with undetectable viral load at three months. Patients receiving delayed supplementation had higher weight gain but lower gains in functional outcomes. CONCLUSIONS Lipid based nutritional supplements improved gain of weight, lean body mass, and grip strength in patients with HIV starting ART. Supplements containing whey were associated with improved immune recovery. Trial registration Controlled-trials.com ISRCTN32453477.
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Affiliation(s)
- Mette F Olsen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 30, 1958 Frederiksberg C, Denmark
| | - Alemseged Abdissa
- Department of Laboratory Sciences and Pathology, Jimma University, Jimma, Ethiopia
| | - Pernille Kæstel
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 30, 1958 Frederiksberg C, Denmark
| | - Markos Tesfaye
- Department of Psychiatry, College of Public Health and Medical Sciences, Jimma University, Jimma, Ethiopia
| | - Daniel Yilma
- Department of Internal Medicine, Jimma University Specialized Hospital, Jimma, Ethiopia
| | - Tsinuel Girma
- Department of Paediatric and Child Health, Jimma University Specialized Hospital, Jimma, Ethiopia
| | - Jonathan C K Wells
- Childhood Nutrition Research Centre, UCL Institute of Child Health, London, UK
| | - Christian Ritz
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 30, 1958 Frederiksberg C, Denmark
| | - Christian Mølgaard
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 30, 1958 Frederiksberg C, Denmark
| | - Kim F Michaelsen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 30, 1958 Frederiksberg C, Denmark
| | - Dilnesaw Zerfu
- Ethiopian Health and Nutrition Research Institute, Addis Ababa, Ethiopia
| | - Søren Brage
- MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
| | - Ase B Andersen
- Department of Infectious Diseases, Odense University Hospital, Odense, Denmark
| | - Henrik Friis
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 30, 1958 Frederiksberg C, Denmark
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Abstract
Cryptococcal meningitis causes morbidity and mortality worldwide. The burden of disease is greatest in middle- and low-income countries with a high incidence of human immunodeficiency virus (HIV) infection. Patients taking immunosuppressive drugs and some immunocompetent hosts are also at risk. Treatment of cryptococcal meningitis consists of three phases: induction, consolidation, and maintenance. Effective induction therapy requires potent fungicidal drugs (amphotericin B and flucytosine), which are often unavailable in low-resource, high-endemicity settings. As a consequence, mortality is unacceptably high. Wider access to effective treatment is urgently required to improve outcomes. For human immunodeficiency virus-infected patients, judicious management of asymptomatic cryptococcal antigenemia and appropriately timed introduction of antiretroviral therapy are important.
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Affiliation(s)
- Derek J Sloan
- Tropical and infectious Disease Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Victoria Parris
- Tropical and infectious Disease Unit, Royal Liverpool University Hospital, Liverpool, UK
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200
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Missed opportunities for retention in pre-ART care in Cape Town, South Africa. PLoS One 2014; 9:e96867. [PMID: 24806474 PMCID: PMC4013078 DOI: 10.1371/journal.pone.0096867] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Accepted: 04/13/2014] [Indexed: 02/05/2023] Open
Abstract
Background Few studies have evaluated access to and retention in pre-ART care. Objectives To evaluate the proportion of People Living With HIV (PLWH) in pre-ART and ART care and factors associated with retention in pre-ART and ART care from a community cohort. Methods A cross sectional survey was conducted from February – April 2011. Self reported HIV positive, negative or participants of unknown status completed a questionnaire on their HIV testing history, access to pre-ART and retention in pre-ART and ART care. Results 872 randomly selected adults who reported being HIV positive in the ZAMSTAR 2010 prevalence survey were included and revisited. 579 (66%) reconfirmed their positive status and were included in this analysis. 380 (66%) had initiated ART with 357 of these (94%) retained in ART care. 199 (34%) had never initiated ART of whom 186 (93%) accessed pre-ART care, and 86 (43%) were retained in pre-ART care. In a univariable analysis none of the factors analysed were significantly associated with retention in care in the pre-ART group. Due to the high retention in ART care, factors associated with retention in ART care, were not analysed further. Conclusion Retention in ART care was high; however it was low in pre-ART care. The opportunity exists, if care is better integrated, to engage with clients in primary health care facilities to bring them back to, and retain them in, pre-ART care.
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