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Geteneh A, Andualem H, Belay DM, Kiros M, Biset S. Immune reconstitution inflammatory syndrome, a controversial burden in the East African context: a systematic review and meta-analysis. Front Med (Lausanne) 2023; 10:1192086. [PMID: 37636563 PMCID: PMC10450628 DOI: 10.3389/fmed.2023.1192086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 07/18/2023] [Indexed: 08/29/2023] Open
Abstract
Introduction It is well established that starting antiretroviral therapy (ART) increases a patient's life expectancy among HIV-positive individuals. Considering the HIV pandemic, the major concern is initiation of ARTs to the large segment of HIV infected population, not adverse events from immune restoration. The prevalence of HIV-associated immune reconstitution inflammatory syndrome (IRIS) is poorly estimated due to Africa's underdeveloped infrastructure, particularly in Eastern Africa. Therefore, this study compiled data regarding the magnitude and associated factors of IRIS in the context of Eastern Africa. Methods The electronic databases such as Google Scholar, PubMed, Web of Science, and free Google access were searched till 5 June 2021, and the search was lastly updated on 30 June 2022 for studies of interest. The pooled prevalence, and associated factors with a 95% confidence interval were estimated using the random effects model. The I2 and Egger's tests were used for heterogeneity and publication bias assessment, respectively. Results The development of HIV-associated IRIS in Eastern Africa was estimated to be 18.18% (95% CI 13.30-23.06) in the current review. The two most common predictors of IRIS associated with Eastern Africa were the lower pre-ART CD4 T-cell count of 50 cells/μl and the low baseline body mass index level. Therefore, attention should be focused on the early detection and care of HIV-associated IRIS to reduce the morbidity and death caused by IRIS.
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Affiliation(s)
- Alene Geteneh
- Department of Medical Laboratory Science, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | - Henok Andualem
- Department of Medical Laboratory Science, College of Medicine and Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Demeke Mesfin Belay
- Department of Pediatrics and Child Health Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Mulugeta Kiros
- Department of Medical Laboratory Science, College of Medicine and Health Sciences, Aksum University, Aksum, Ethiopia
| | - Sirak Biset
- Department of Medical Microbiology, School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Zhao T, Xu XL, Lu YQ, Liu M, Yuan J, Nie JM, Yu JH, Liu SQ, Yang TT, Zhou GQ, Liu J, Qin YM, Chen H, Harypursat V, Chen YK. The Effect of Early vs. Deferred Antiretroviral Therapy Initiation in HIV-Infected Patients With Cryptococcal Meningitis: A Multicenter Prospective Randomized Controlled Analysis in China. Front Med (Lausanne) 2021; 8:779181. [PMID: 34869498 PMCID: PMC8639871 DOI: 10.3389/fmed.2021.779181] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 10/21/2021] [Indexed: 11/13/2022] Open
Abstract
Background: The optimal timing for initiation of antiretroviral therapy (ART) in HIV-positive patients with cryptococcal meningitis (CM) has not, as yet, been compellingly elucidated, as research data concerning mortality risk and the occurrence of immune reconstitution inflammatory syndrome (IRIS) in this population remains inconsistent and controversial. Method: The present multicenter randomized clinical trial was conducted in China in patients who presented with confirmed HIV/CM, and who were ART-naïve. Subjects were randomized and stratified into either an early-ART group (ART initiated 2-5 weeks after initiation of antifungal therapy), or a deferred-ART group (ART initiated 5 weeks after initiation of antifungal therapy). Intention-to-treat, and per-protocol analyses of data for these groups were conducted for this study. Result: The probability of survival was found to not be statistically different between patients who started ART between 2-5 weeks of CM therapy initiation (14/47, 29.8%) vs. those initiating ART until 5 weeks after CM therapy initiation (10/55, 18.2%) (p = 0.144). However, initiating ART within 4 weeks after the diagnosis and antifungal treatment of CM resulted in a higher mortality compared with deferring ART initiation until 6 weeks (p = 0.042). The incidence of IRIS did not differ significantly between the early-ART group and the deferred-ART group (6.4 and 7.3%, respectively; p = 0.872). The percentage of patients with severe (grade 3 or 4) adverse events was high in both treatment arms (55.3% in the early-ART group and 41.8% in the deferred-ART group; p=0.183), and there were significantly more grade 4 adverse events in the early-ART group (20 vs. 13; p = 0.042). Conclusion: Although ART initiation from 2 to 5 weeks after initiation of antifungal therapy was not significantly associated with high cumulative mortality or IRIS event rates in HIV/CM patients compared with ART initiation 5 weeks after initiation of antifungal therapy, we found that initiating ART within 4 weeks after CM antifungal treatment resulted in a higher mortality compared with deferring ART initiation until 6 weeks. In addition, we observed that there were significantly more grade 4 adverse events in the early-ART group. Our results support the deferred initiation of ART in HIV-associated CM. Clinical Trials Registration: www.ClinicalTrials.gov, identifier: ChiCTR1900021195.
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Affiliation(s)
- Ting Zhao
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Xiao-Lei Xu
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Yan-Qiu Lu
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Min Liu
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Jing Yuan
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Jing-Min Nie
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Jian-Hua Yu
- Division of Infectious Diseases, Xixi Hospital of Hangzhou, Zhejiang, China
| | - Shui-Qing Liu
- Division of Infectious Diseases, Guiyang Public Health Clinical Center, Guizhou, China
| | - Tong-Tong Yang
- Division of Infectious Diseases, Public Health Clinical Center of Chengdu, Sichuan, China
| | - Guo-Qiang Zhou
- Division of Infectious Diseases, The First Hospital of Changsha, Hunan, China
| | - Jun Liu
- Division of Infectious Diseases, Kunming Third People's Hospital, Yunnan, China
| | - Ying-Mei Qin
- Division of Infectious Diseases, The Fourth's Hospital of Nanning, Guangxi, China
| | - Hui Chen
- School of Biomedical Engineering, Capital Medical University, Beijing, China
| | - Vijay Harypursat
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Yao-Kai Chen
- Division of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
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Nicolau V, Cortes R, Lopes M, Virgolino A, Santos O, Martins A, Faria N, Reis AP, Santos C, Maltez F, Pereira ÁA, Antunes F. HIV Infection: Time from Diagnosis to Initiation of Antiretroviral Therapy in Portugal, a Multicentric Study. Healthcare (Basel) 2021; 9:797. [PMID: 34202051 PMCID: PMC8306717 DOI: 10.3390/healthcare9070797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 06/03/2021] [Accepted: 06/21/2021] [Indexed: 11/17/2022] Open
Abstract
The benefits of antiretroviral therapy (ART) for persons living with HIV (PLWH) are well established. Rapid ART initiation can lead to improved clinical outcomes. Portugal has one of the highest rates of new HIV diagnoses in the European Union, and an average time until ART initiation above the recommendations established by the national guideline according to data from the first two years after its implementation in 2015, with no more recent data available after that. This study aimed to evaluate time from the first hospital appointment until ART initiation among newly diagnosed HIV patients in Portugal between 2017 and 2018, to investigate differences between hospitals, and to understand the experience of patient associations in supporting the navigation of PLWH throughout referral and linkage to the therapeutic process. To answer to these objectives, a twofold design was followed: a quantitative approach, with an analysis of records from five Portuguese hospitals, and a qualitative approach, with individual interviews with three representatives of patient associations. Overall, 847 and 840 PLWH initiated ART in 2017 and in 2018, respectively, 21 days (median of the two years) after the first appointment, with nearly half coming outside the mainstream service for hospital referral, and with observed differences between hospitals. In 2017-2018, only 38.0% of PLWH initiated ART in less than 14 days after the first hospital appointment. From the interviews, barriers of administrative and psychosocial nature were identified that may hinder access to ART. Patient associations work to offer a tailored support to patients' navigation within the health system, which can help to reduce or overcome those potential barriers. Indicators related to time until ART initiation can be used to monitor and improve access to specialized care of PLWH.
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Affiliation(s)
- Vanessa Nicolau
- Escola Nacional de Saúde Pública, Universidade Nova de Lisboa, Av. Padre Cruz, 1600-560 Lisboa, Portugal
| | - Rui Cortes
- Lean Health Portugal, Campus da Faculdade de Ciências da Universidade de Lisboa, Campo Grande, 1749-016 Lisboa, Portugal; (R.C.); (M.L.)
| | - Maria Lopes
- Lean Health Portugal, Campus da Faculdade de Ciências da Universidade de Lisboa, Campo Grande, 1749-016 Lisboa, Portugal; (R.C.); (M.L.)
| | - Ana Virgolino
- Instituto de Saúde Ambiental, Faculdade de Medicina, Universidade de Lisboa, Av. Professor Egas Moniz, 1649-028 Lisboa, Portugal; (A.V.); (O.S.); (F.M.); (Á.A.P.); (F.A.)
- Laboratório Associado TERRA, Faculdade de Medicina, Universidade de Lisboa, Av. Professor Egas Moniz, 1649-028 Lisboa, Portugal
| | - Osvaldo Santos
- Instituto de Saúde Ambiental, Faculdade de Medicina, Universidade de Lisboa, Av. Professor Egas Moniz, 1649-028 Lisboa, Portugal; (A.V.); (O.S.); (F.M.); (Á.A.P.); (F.A.)
- Laboratório Associado TERRA, Faculdade de Medicina, Universidade de Lisboa, Av. Professor Egas Moniz, 1649-028 Lisboa, Portugal
- Unbreakable Idea Research, 2550-426 Painho, Portugal
| | - António Martins
- Centro Hospitalar Universitário de São João, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal;
| | - Nancy Faria
- Serviço de Saúde da Região Autónoma da Madeira, Av. Luís de Camões 6180, 9000-177 Funchal, Portugal; (N.F.); (A.P.R.)
| | - Ana Paula Reis
- Serviço de Saúde da Região Autónoma da Madeira, Av. Luís de Camões 6180, 9000-177 Funchal, Portugal; (N.F.); (A.P.R.)
| | - Catarina Santos
- Hospital de Cascais, Av. Brigadeiro Victor Novais Gonçalves, 2755-009 Alcabideche, Portugal;
| | - Fernando Maltez
- Instituto de Saúde Ambiental, Faculdade de Medicina, Universidade de Lisboa, Av. Professor Egas Moniz, 1649-028 Lisboa, Portugal; (A.V.); (O.S.); (F.M.); (Á.A.P.); (F.A.)
- Laboratório Associado TERRA, Faculdade de Medicina, Universidade de Lisboa, Av. Professor Egas Moniz, 1649-028 Lisboa, Portugal
- Centro Hospitalar de Lisboa Central, Hospital Curry Cabral, Rua da Beneficência, nº 8, 1069-166 Lisboa, Portugal
| | - Álvaro Ayres Pereira
- Instituto de Saúde Ambiental, Faculdade de Medicina, Universidade de Lisboa, Av. Professor Egas Moniz, 1649-028 Lisboa, Portugal; (A.V.); (O.S.); (F.M.); (Á.A.P.); (F.A.)
- Laboratório Associado TERRA, Faculdade de Medicina, Universidade de Lisboa, Av. Professor Egas Moniz, 1649-028 Lisboa, Portugal
- Centro Hospitalar Universitário Lisboa Norte, Hospital de Santa Maria, Av. Professor Egas Moniz, 1649-035 Lisboa, Portugal
| | - Francisco Antunes
- Instituto de Saúde Ambiental, Faculdade de Medicina, Universidade de Lisboa, Av. Professor Egas Moniz, 1649-028 Lisboa, Portugal; (A.V.); (O.S.); (F.M.); (Á.A.P.); (F.A.)
- Laboratório Associado TERRA, Faculdade de Medicina, Universidade de Lisboa, Av. Professor Egas Moniz, 1649-028 Lisboa, Portugal
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Zeng YM, Li Y, He XQ, Huang YQ, Liu M, Yuan J, Bai Y, Lu YQ, Li H, Chen YK. A study for precision diagnosing and treatment strategies in difficult-to-treat AIDS cases and HIV-infected patients with highly fatal or highly disabling opportunistic infections: Study protocol for antiretroviral therapy timing in AIDS patients with toxoplasma encephalitis. Medicine (Baltimore) 2020; 99:e21141. [PMID: 32702867 PMCID: PMC7373539 DOI: 10.1097/md.0000000000021141] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Toxoplasma encephalitis (TE) is one of the main opportunistic infections in acquired immunodeficiency syndrome (AIDS) patients, and represents a social burden due to its high prevalence and morbidity. Concomitant antiretroviral therapy (ART), together with effective anti- toxoplasma combination therapy, is an effective strategy to treat AIDS-associated TE (AIDS/TE) patients. However, the timing for the initiation of ART after diagnosis of TE remains controversial. We therefore designed the present study to determine the optimal timing for ART initiation in AIDS/TE patients. METHODS/DESIGN This trial is a 17-center, randomized, prospective clinical study with 2 parallel arms. A total of 200 participants will be randomized at a 1:1 ratio into the 2 arms: the early ART initiation (≤14 days after TE diagnosis) arm and the deferred ART (>14 days after TE diagnosis) arm. The primary outcome will be the difference of mortality between the 2 arms at 48 weeks. The secondary outcomes will be the differences between the 2 arms in the changes of CD4+ counts from baseline to week 48, the rate of virologic suppression (HIV ribonucleic acid <50 copies/mL) from baseline to week 48, the incidence of TE-associated immune reconstitution inflammatory syndrome during the study period, and the incidence of adverse effects during the study period. DISCUSSION This present trial aims to evaluate the optimal timing for ART initiation in AIDS/TE patients, and will provide strong evidence for AIDS/TE treatment should it be successful. TRIAL REGISTRATION This trial was registered as one of the 12 trials under the name of a general project at the chictr.gov (http://www.chictr.org.cn/showproj.aspx?proj=35362) on February 1, 2019, and the registration number of the general project is ChiCTR1900021195.
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Vidal JE. HIV-Related Cerebral Toxoplasmosis Revisited: Current Concepts and Controversies of an Old Disease. J Int Assoc Provid AIDS Care 2019; 18:2325958219867315. [PMID: 31429353 PMCID: PMC6900575 DOI: 10.1177/2325958219867315] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 06/14/2019] [Accepted: 06/28/2019] [Indexed: 01/06/2023] Open
Abstract
Cerebral toxoplasmosis is the most common cause of expansive brain lesions in people living with HIV/AIDS (PLWHA) and continues to cause high morbidity and mortality. The most frequent characteristics are focal subacute neurological deficits and ring-enhancing brain lesions in the basal ganglia, but the spectrum of clinical and neuroradiological manifestations is broad. Early initiation of antitoxoplasma therapy is an important feature of the diagnostic approach of expansive brain lesions in PLWHA. Pyrimethamine-based regimens and trimethoprim-sulfamethoxazole (TMP-SMX) seem to present similar efficacy, but TMP-SMX shows potential practical advantages. The immune reconstitution inflammatory syndrome is uncommon in cerebral toxoplasmosis, and we now have more effective, safe, and friendly combined antiretroviral therapy (cART) options. As a consequence of these 2 variables, the initiation of cART can be performed within 2 weeks after initiation of antitoxoplasma therapy. Herein, we will review historical and current concepts of epidemiology, diagnosis, and treatment of HIV-related cerebral toxoplasmosis.
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Affiliation(s)
- José Ernesto Vidal
- Departamento de Neurologia, Instituto de Infectologia Emílio Ribas, São
Paulo, Brazil
- Departamento de Moléstias Infecciosas e Parasitárias, Hospital das Clínicas
HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
- Laboratório de Investigação Médica em Protozoologia, Bacteriologia e
Resistência Antimicrobiana (LIM 49), Instituto de Medicina Tropical, Universidade de São
Paulo, São Paulo, Brazil
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6
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Abstract
Human immunodeficiency virus (HIV)-associated neurocognitive disorders (HAND) remain a common end-organ manifestation of viral infection. Subclinical and mild symptoms lead to neurocognitive and behavioral abnormalities. These are associated, in part, with viral penetrance and persistence in the central nervous system. Infections of peripheral blood monocytes, macrophages, and microglia are the primary drivers of neuroinflammation and neuronal impairments. While current antiretroviral therapy (ART) has reduced the incidence of HIV-associated dementia, milder forms of HAND continue. Depression, comorbid conditions such as infectious liver disease, drugs of abuse, antiretroviral drugs themselves, age-related neurodegenerative diseases, gastrointestinal maladies, and concurrent social and economic issues can make accurate diagnosis of HAND challenging. Increased life expectancy as a result of ART clearly creates this variety of comorbid conditions that often blur the link between the virus and disease. With the discovery of novel biomarkers, neuropsychologic testing, and imaging techniques to better diagnose HAND, the emergence of brain-penetrant ART, adjunctive therapies, longer life expectancy, and better understanding of disease pathogenesis, disease elimination is perhaps a realistic possibility. This review focuses on HIV-associated disease pathobiology with an eye towards changing trends in the face of widespread availability of ART.
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HIV-positive women have higher risk of human papilloma virus infection, precancerous lesions, and cervical cancer. AIDS 2018; 32:795-808. [PMID: 29369827 DOI: 10.1097/qad.0000000000001765] [Citation(s) in RCA: 217] [Impact Index Per Article: 36.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE HIV-positive women have higher human papillomavirus (HPV) prevalence and cervical cancer incidence than HIV-negative women, partly because of HIV's modifying effect on HPV pathogenesis. We synthesized the literature on the impact of HIV on HPV natural history. DESIGN Systematic review and meta-analysis. METHODS We searched the literature for studies evaluating HPV acquisition and persistence or precancer progression by HIV status. Data on HPV natural history by HIV status, CD4 cell counts, viral load, and antiretroviral therapy (ART) were summarized using fixed effect models. RESULTS Overall, 38 of 1845 abstracts identified met inclusion criteria. HIV-positive women had higher HPV acquisition [relative risk (RRpooled) 2.64, 95% confidence interval (CI) 2.04-3.42] and lower HPV clearance (hazard ratiopooled 0.72, 95% CI 0.62-0.84) than HIV-negative women. HPV acquisition was higher with declining CD4 cell count and was lower in those virally suppressed on ART. HIV was associated with higher incidence of low-grade squamous intraepithelial lesions (LSIL; RRpooled 3.73, 95% CI 2.62-5.32) and high-grade squamous intraepithelial lesions (HSIL; hazard ratiopooled 1.32, 95% CI 1.10-1.58), largely because of increased HPV persistence. ART lowered progression from normal cytology to LSIL (hazard ratiopooled 0.65, 95% CI 0.52-0.82), but not HSIL. Cervical cancer incidence was associated with HIV positivity (RR 4.1, 95% CI 2.3-6.6), but not with ART. CONCLUSION HIV-positive women have higher risk of acquiring HPV, with risk inversely associated with CD4 cell count. ART lowered HPV acquisition, increased clearance, and reduced precancer progression, likely via immune reconstitution. Although some of our results are limited by small number of studies, our study can inform screening guidelines and mathematical modeling for cervical cancer prevention.
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Goswami ND, Colasanti J, Khoubian JJ, Huang Y, Armstrong WS, Del Rio C. A Minority of Patients Newly Diagnosed with AIDS Are Started on Antiretroviral Therapy at the Time of Diagnosis in a Large Public Hospital in the Southeastern United States. J Int Assoc Provid AIDS Care 2017; 16:174-179. [PMID: 28198210 DOI: 10.1177/2325957417692679] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Prompt antiretroviral therapy (ART) initiation after AIDS diagnosis, in the absence of certain opportunistic infections such as tuberculosis and cryptococcal meningitis, delays disease progression and death, but system barriers to inpatient ART initiation at large hospitals in the era of modern ART have been less studied. We reviewed hospitalizations for persons newly diagnosed with AIDS at Grady Memorial Hospital in Atlanta, Georgia in 2011 and 2012. Individual- and system-level variables were collected. Logistic regression models were used to estimate the odds ratios (ORs) for ART initiation prior to discharge. With Georgia Department of Health surveillance data, we estimated time to first clinic visit, ART initiation, and viral suppression. In the study population (n = 81), ART was initiated prior to discharge in 10 (12%) patients. Shorter hospital stay was significantly associated with lack of ART initiation at the time of HIV diagnosis (8 versus 24 days, OR: 1.14, 95% confidence interval: 1.04-1.25). Reducing barriers to ART initiation for newly diagnosed HIV-positive patients with short hospital stays may improve time to viral suppression.
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Affiliation(s)
- Neela D Goswami
- 1 Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA.,2 Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Jonathan Colasanti
- 1 Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Jonathan J Khoubian
- 1 Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Yijian Huang
- 3 Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Wendy S Armstrong
- 1 Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Carlos Del Rio
- 1 Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA.,4 Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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Perry ME, Kalenga K, Watkins LF, Mukaya JE, Powis KM, Bennett K, Mmalane M, Makhema J, Shapiro RL. HIV-related mortality at a district hospital in Botswana. Int J STD AIDS 2016; 28:277-283. [PMID: 27164967 DOI: 10.1177/0956462416646492] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We reviewed mortality data among medical inpatients at a tertiary hospital in Botswana to identify risk factors for adverse inpatient outcomes. This review was a prospective analysis of inpatient admissions. All medical admissions to male and female medical wards were recorded over a six-month period between 1 November 2011 and 30 April 2012. Data collected included patient demographics, HIV status (positive, negative, unknown), HIV testing history, HIV related treatment and serological history, admission and discharge diagnoses, and mortality status at final discharge or transfer. Of 972 patients admitted during the surveillance period, 427 (43.9%) were known to be HIV-positive on admission, 144 (14.8%) were known to be HIV-negative, and 401 (41.3%) had an unknown HIV status. Of those with unknown status, 131 (32.7%) were tested for HIV during admission and among these 35 (27.5%) were HIV-positive. Including patients with known mortality status following transfer, 172 (17.9%) patients died during the hospitalization. Death occurred in 105 (23%) of known HIV-positive patients, compared with 31 (13%) of known HIV-negative patients (p = 0.002, HR = 1.56 in adjusted analyses). Among HIV-positive patients who died, a low CD4 cell count (<200 cells/mm3) was associated with death. Overall, patients who died had significantly more neurological and respiratory-related presenting complaints than patients who survived. In conclusion, we identified higher overall mortality among HIV-positive patients at a tertiary hospital in Botswana, and low rates of in-hospital HIV testing and antiretroviral therapy initiation. These data demonstrate that despite available antiretroviral therapy in the population for over a decade, HIV continues to add excess burden to the hospital system and adds to inpatient mortality in Botswana.
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Affiliation(s)
- Melissa Eo Perry
- 1 Botswana-Harvard AIDS Institute Partnership for HIV Research and Education, Gaborone, Botswana.,2 Guy's and St Thomas' NHS Hospital Foundation Trust, London, UK
| | | | | | | | - Kathleen M Powis
- 1 Botswana-Harvard AIDS Institute Partnership for HIV Research and Education, Gaborone, Botswana.,5 Department of Immunology and Infectious Diseases, Harvard TH Chan School of Public Health, Boston, MA, USA.,6 Departments of Medicine and Pediatrics, Massachusetts General Hospital, Boston, MA, USA
| | - Kara Bennett
- 7 Bennett Statistical Consulting, Inc., Ballston Lake, NY, USA
| | - Mompati Mmalane
- 1 Botswana-Harvard AIDS Institute Partnership for HIV Research and Education, Gaborone, Botswana
| | - Joseph Makhema
- 1 Botswana-Harvard AIDS Institute Partnership for HIV Research and Education, Gaborone, Botswana
| | - Roger L Shapiro
- 1 Botswana-Harvard AIDS Institute Partnership for HIV Research and Education, Gaborone, Botswana.,5 Department of Immunology and Infectious Diseases, Harvard TH Chan School of Public Health, Boston, MA, USA.,8 Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, MA, USA
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10
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Schafer JJ, Gill TK, Sherman EM, McNicholl IR. ASHP Guidelines on Pharmacist Involvement in HIV Care. Am J Health Syst Pharm 2016; 73:468-94. [PMID: 26892679 DOI: 10.2146/ajhp150623] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Jason J Schafer
- Department of Pharmacy Practice, Jefferson School of Pharmacy, Thomas Jefferson University, Philadelphia, PA
| | - Taylor K Gill
- Internal Medicine, Via Christi Hospitals Wichita, Wichita, KS
| | - Elizabeth M Sherman
- College of Pharmacy, Nova Southeastern University, Fort Lauderdale, FL, and South Broward Community Health Services, Memorial Healthcare System, Hollywood, FL
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11
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Pettersen KD, Pappas PG, Chin-Hong P, Baxi SM. A paradoxical decline: intracranial lesions in two HIV-positive patients recovering from cryptococcal meningitis. BMJ Case Rep 2015; 2015:bcr-2015-212108. [PMID: 26475880 DOI: 10.1136/bcr-2015-212108] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Cryptococcal immune reconstitution inflammatory syndrome (C-IRIS) is an increasingly important manifestation among patients with HIV/AIDS, especially as the use of antiretroviral therapy (ART) is expanding worldwide. Cryptococcus and associated C-IRIS are common causes of meningitis. While intracranial lesions are common in HIV/AIDS, they are rarely due to cryptococcosis or C-IRIS. We describe two cases of paradoxical C-IRIS associated with the development of intracranial cryptococcomas in HIV/AIDS. Both patients had an initial episode of cryptococcal meningitis treated with antifungal therapy. At the time, they had initiated or modified ART with subsequent evidence of immune reconstitution. Two months later, they developed aseptic meningitis with intracranial lesions. After exhaustive work ups, both patients were diagnosed with paradoxical C-IRIS and biopsy confirmed intracranial cryptococcomas. We review the important clinical, diagnostic and therapeutic features of cryptococcomas associated with C-IRIS in HIV/AIDS.
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Affiliation(s)
- Kenneth D Pettersen
- Department of Internal Medicine, University of California San Francisco, San Francisco, California, USA
| | - Peter G Pappas
- Department of Medicine, Division of Infectious Diseases, University of Alabama, Birmingham, Birmingham, Alabama, USA
| | - Peter Chin-Hong
- Department of Internal Medicine, Division of Infectious Diseases, University of California San Francisco, San Francisco, California, USA
| | - Sanjiv M Baxi
- Department of Internal Medicine, Division of Infectious Diseases, University of California San Francisco, San Francisco, California, USA Division of Epidemiology, School of Public Health, University of California Berkeley, Berkeley, CA, USA
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Nijhawan AE, Kitchell E, Etherton SS, Duarte P, Halm EA, Jain MK. Half of 30-Day Hospital Readmissions Among HIV-Infected Patients Are Potentially Preventable. AIDS Patient Care STDS 2015; 29:465-73. [PMID: 26154066 DOI: 10.1089/apc.2015.0096] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Thirty-day readmission rates, a widely utilized quality metric, are high among HIV-infected individuals. However, it is unknown how many 30-day readmissions are preventable, especially in HIV patients, who have been excluded from prior potentially preventable readmission analyses. We used electronic medical records to identify all readmissions within 30 days of discharge among HIV patients hospitalized at a large urban safety net hospital in 2011. Two independent reviewers assessed whether readmissions were potentially preventable using both published criteria and detailed chart review, how readmissions might have been prevented, and the phase of care deemed suboptimal (inpatient care, discharge planning, post-discharge). Of 1137 index admissions, 213 (19%) resulted in 30-day readmissions. These admissions occurred among 930 unique HIV patients, with 130 individuals (14%) experiencing 30-day readmissions. Of these 130, about half were determined to be potentially preventable using published criteria (53%) or implicit chart review (48%). Not taking antiretroviral therapy (ART) greatly increased the odds of a preventable readmission (OR 5.9, CI:2.4-14.8). Most of the preventable causes of readmission were attributed to suboptimal care during the index hospitalization. Half of 30-day readmission in HIV patients are potentially preventable. Increased focus on early ART initiation, adherence counseling, management of chronic conditions, and appropriate timing of discharge may help reduce readmissions in this vulnerable population.
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Affiliation(s)
- Ank E. Nijhawan
- Department of Medicine/Division of Infectious Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ellen Kitchell
- Department of Medicine/Division of Infectious Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Piper Duarte
- Performance Improvement Analyst HIV Services, Parkland Health and Hospital Systems, Dallas, Texas
| | - Ethan A. Halm
- Department of Internal Medicine/Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Mamta K. Jain
- Department of Medicine/Division of Infectious Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
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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: 327] [Impact Index Per Article: 32.7] [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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15
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González-Serna A, Abad-Fernández M, Soriano-Sarabia N, Leal M, Vallejo A. CD8 TCR β chain repertoire expansions and deletions are related with immunologic markers in HIV-1-infected patients during treatment interruption. J Clin Virol 2013; 58:703-9. [PMID: 24210957 DOI: 10.1016/j.jcv.2013.10.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Revised: 08/27/2013] [Accepted: 10/06/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND HIV-1-infected individuals progressively loss CD4(+) T cells leading to immunosuppression and raising the risk of opportunistic infections. CD8(+) T-cells play an important role in the immune response against virus infections through their TCR. OBJECTIVE To evaluate the CD8-TCR repertoire and immunologic markers in HIV-1-infected patients. STUDY DESIGN Ten chronic HIV-1-infected individuals on prolonged effective antiretroviral treatment (ART) were analyzed at baseline (before treatment interruption), after at least one year of treatment interruption (TI) and after at least one year from ART resume (TR). Twenty-four TCR-Vβ gene families were analyzed by a modified CDR3 spectratyping method in isolated CD8(+) T-cells. Immune activation, exhaustion and subpopulation markers were analyzed by flow cytometry. RESULTS Expansion of Vβ10, Vβ14 and Vβ15 families, associated with low cell activation and stable exhaustion markers, were found at TI. Moreover, an increment of effector memory cells was found. Besides, depletion of Vβ20, Vβ28, and Vβ29 families, associated with an increase in cell activation and exhaustion markers, at TI were also found. These alterations seemed to be more pronounced in patients who had longer time from diagnosis. ART seemed to restore altered CD8(+) T-cell repertoire and most of the immunologic markers. CONCLUSIONS During TI (that was more pronounced in patients with longer HIV-1 infection) it was observed the expansion of Vβ families correlated with decreased cell activation, while Vβ families correlated with cell activation and exhaustion were depleted. These specific repertoire alterations reverted after ART resume.
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Affiliation(s)
- Alejandro González-Serna
- Laboratory of Immunovirology, Department of Infectious Diseases, Hospital Virgen del Rocio, IBIS, Seville 41013, Spain
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Ganesan A, Masur H. Critical care of persons infected with the human immunodeficiency virus. Clin Chest Med 2013; 34:307-23. [PMID: 23702179 DOI: 10.1016/j.ccm.2013.01.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Antiretroviral therapy (ART) has transformed the prognosis for patients infected with the human immunodeficiency virus (HIV). With effective ART, these individuals can expect to live almost as long as their HIV-negative counterparts. Given that more than a million people infected with HIV currently live in the United States, the likelihood that the practicing intensivist will manage a patient infected with HIV is high. This review discusses the challenges associated with management of critically ill patients infected with HIV, including the immune reconstitution inflammatory syndrome (a complication associated with ART initiation), ART-related toxicities, and the management of some common opportunistic infections.
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Affiliation(s)
- Anuradha Ganesan
- Department of Medicine, Division of Infectious Diseases, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD 20889, USA.
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Njei B, Kongnyuy EJ, Kumar S, Okwen MP, Sankar MJ, Mbuagbaw L. Optimal timing for antiretroviral therapy initiation in patients with HIV infection and concurrent cryptococcal meningitis. Cochrane Database Syst Rev 2013:CD009012. [PMID: 23450595 DOI: 10.1002/14651858.cd009012.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Currently, initiation of antiretroviral therapy (ART) in most patients with human immunodeficiency virus (HIV) infection is based on the CD4-positive-t-lymphocyte count. However, the point during the course of HIV infection at which ART should be initiated in patients with concurrent cryptococcal meningitis remains unclear. The aim of this systematic review was to summarise the evidence on the optimal timing of ART initiation in patients with cryptococcal meningitis for use in clinical practice and guideline development. OBJECTIVES To compare the clinical and immunologic outcomes for early initiation ART (less than four weeks after starting antifungal treatment) versus later initiation of HAART (four weeks or more after starting antifungal treatment) in HIV-positive patients with concurrent cryptococcal meningitis. SEARCH METHODS We searched the following databases from January 1980 to February 2011: PubMed, EMBASE, and WHO International Clinical Trials Registry Platform, AEGIS database for conference abstracts, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews. A total of 35 full text articles were identified and supplemented by a bibliographic search. We contacted researchers and relevant organizations and checked reference lists of all included studies. SELECTION CRITERIA Randomized controlled trials that compared the effect of ART (consisting of three drug combinations) initiated early or delayed in HIV patients with cryptococcal meningitis. DATA COLLECTION AND ANALYSIS Two review authors independently assessed study eligibility, extracted data, and graded methodological quality. Data extraction and methodological quality were checked by a third author who resolved differences when these arose. Where clinically meaningful, we performed a meta-analysis of dichotomous outcomes using the relative risk (RR) and report the 95% confidence intervals (95% CIs). MAIN RESULTS Two eligible randomized controlled trials were included (N = 89). In our pooled analysis, we combined the clinical data for both trials comparing early initiation ART versus delayed initiation of ART. There was no statistically significant difference in mortality (RR=1.40, 95% CI [0.42, 4.68]) in the group with early initiation of ART compared to the group with delayed initiation of ART. AUTHORS' CONCLUSIONS This systematic review shows that there is insufficient evidence in support of either early or late initiation of ART. For the moment, because of the high risk of immune reconstitution syndrome in patients with cryptococcal meningitis, we recommend that ART initiation should be delayed until there is evidence of a sustained clinical response to antifungal therapy. However, large studies with appropriate comparison groups, and adequate follow-up are warranted to provide the evidence base for effective decision making.
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Affiliation(s)
- Basile Njei
- Department of Medicine, University of Connecticut School of Medicine, Farmington, Connecticut, USA.
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