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Schuldt AL, Bern H, Hart M, Gompels M, Winston A, Clarke A, Chen F, Stöhr W, Heslegrave A, Paton NI, Petzold A, Arenas-Pinto A. Peripheral Neuropathy in Virologically Suppressed People Living with HIV: Evidence from the PIVOT Trial. Viruses 2023; 16:2. [PMID: 38275937 PMCID: PMC10818628 DOI: 10.3390/v16010002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 12/15/2023] [Accepted: 12/16/2023] [Indexed: 01/27/2024] Open
Abstract
The aim of this study is to identify the factors associated with peripheral neuropathy and to explore neurofilament light chain (NfL) as a biomarker for peripheral neuropathy (PN) in effectively virologically suppressed adults living with HIV. All protease inhibitor monotherapy versus ongoing triple therapy in the long-term management of HIV infection (PIVOT) trial participants with data on PN at baseline were included in the study. NfL plasma levels (pNfL) were measured in a sub-set of participants. Multivariable logistic regression was used to examine the associations of PN with potential risk factors (including age, sex, nadir CD4 cell count, history of dideoxynucleoside (d-drugs) exposure, and blood glucose levels) and NfL levels. Of the 585 participants included, 131 (22.4%) reported PN during the study period (median of 44 months). The participants were predominantly male (76.6%), White (68.2%), and virologically suppressed for a median period of 37 months (range of 20-63) before recruitment. The age at baseline was 44.3 years (standard deviation (SD) of 9.2). PN was independently associated with age (adjusted odds ratio (aOR) = 1.35, 95% CI of 1.20-1.52; additional 5 years), history of d-drugs (aOR 1.88, 95% CI of 1.12-3.16), height (aOR 1.19, 95% CI of 1.05-1.35; additional 5 cm), nadir CD4 cell count (aOR 1.10 CI of 1.00-1.20; 50 cells fewer), and metabolic syndrome (aOR 2.31, 95% CI of 1.27 4.20), but not pNfL. The excess risk for PN associated with d-drug use remains after the exposure has stopped for years, suggesting non-reversible toxicity. In people with HIV, metabolic syndrome is independently associated with PN. There was no additional value for pNfL as a screening test for peripheral neuropathy in effectively virologically suppressed adults living with HIV.
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Affiliation(s)
- Anna L. Schuldt
- Institute for Global Health, University College London, London WC1E 6JB, UK
| | - Henry Bern
- MRC Clinical Trials Unit at UCL, University College London, London WC1V 6LJ, UK (W.S.)
| | - Melanie Hart
- Queen Square Institute of Neurology, University College London, London WC1N 3BG, UK; (M.H.); (A.H.); (A.P.)
| | - Mark Gompels
- Service of Immunology, Southmead Hospital, Bristol BS10 5NB, UK
| | - Alan Winston
- Faculty of Medicine, Imperial College London, London SW7 2BX, UK;
| | - Amanda Clarke
- Department of HIV, Sexual Health and Contraception, Brighton and Sussex University Hospitals NHS Trust, Brighton BN11 2DH, UK;
| | - Fabian Chen
- Florey Unit Clinic for Sexual Health, Royal Berkshire Hospital, Reading RG1 5AN, UK;
| | - Wolfgang Stöhr
- MRC Clinical Trials Unit at UCL, University College London, London WC1V 6LJ, UK (W.S.)
| | - Amanda Heslegrave
- Queen Square Institute of Neurology, University College London, London WC1N 3BG, UK; (M.H.); (A.H.); (A.P.)
| | - Nicholas I. Paton
- MRC Clinical Trials Unit at UCL, University College London, London WC1V 6LJ, UK (W.S.)
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
| | - Axel Petzold
- Queen Square Institute of Neurology, University College London, London WC1N 3BG, UK; (M.H.); (A.H.); (A.P.)
| | - Alejandro Arenas-Pinto
- Institute for Global Health, University College London, London WC1E 6JB, UK
- MRC Clinical Trials Unit at UCL, University College London, London WC1V 6LJ, UK (W.S.)
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Kuka WP, Shah J, Alam U, Shah R, Sokhi DS. Clinical Characteristics of Peripheral Neuropathy in Kenyan Patients with HIV Infection Compared with Patients with Concurrent HIV Infection and Diabetes Mellitus. Diabetes Ther 2022; 13:441-451. [PMID: 35157232 PMCID: PMC8934803 DOI: 10.1007/s13300-022-01205-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 01/14/2022] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Persons living with human immunodeficiency virus (HIV) are living longer and at risk of non-communicable diseases, including diabetes mellitus (DM). Both HIV and DM place patients at risk of peripheral neuropathy (PN). Our aim was to demonstrate the prevalence and characteristics of PN in our population of patients with HIV infection compared with concomitant HIV and DM. METHODS A prospective cross-sectional study was performed at the Aga Khan Hospital in Nairobi, Kenya. Data were collected on demographics and characteristics of DM and HIV. Symptoms and signs of PN were evaluated by Neuropathy Symptom Score, Neuropathy Disability Score, and 10 g monofilament testing. RESULTS Two groups were recruited, each consisting of 68 patients: (1) HIV only, (2) HIV and DM. The median age of patients was 51 years (IQR 42.8-58.6) and 55% were male. Median duration for HIV was 10 years (IQR 5-12) with a median CD4 count of 524 cells/mm3 (IQR 369-731). Median duration for DM was 1 year with a median glycosylated hemoglobin of 6.7% (IQR 6.6-7.6). Sixty-nine percent of patients with HIV had suppressed viral loads, and 9 patients (6.6%) had a history neurotoxic antiretroviral therapy use. PN was detected in 11 (16%) HIV-only patients, and in 17 (25%) participants who had both HIV and DM (Fisher exact test chi-square = 0.4). Univariate analysis demonstrated older age, high body mass index, and long duration of HIV were associated with an OR of 1.07 (95% CI 1.02-1.11), 1.21 (95% CI 0.46-3.11), and 1.07 (95% CI 0.99-1.15) in the overall group, respectively. CONCLUSION Our study demonstrates a higher but non-significant prevalence of PN in patients with both HIV and DM when compared to HIV alone. HIV disease control had no association with PN presence.
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Affiliation(s)
- Werimo Pascal Kuka
- Department of Medicine, Aga Khan University Medical College East Africa, 4th Floor East Tower Block, Third Avenue Parklands, P.O. Box 30270, Nairobi, 00100, GPO, Kenya.
| | - Jasmit Shah
- Department of Medicine, Aga Khan University Medical College East Africa, 4th Floor East Tower Block, Third Avenue Parklands, P.O. Box 30270, Nairobi, 00100, GPO, Kenya
| | - Uazman Alam
- Division of Endocrinology, Diabetes and Gastroenterology, University of Manchester, Manchester, UK
- Diabetes and Endocrinology Research, Institute of Life Course and Medical Sciences and the Pain Research Institute, University of Liverpool and Liverpool University Hospital NHS Foundation Trust, Liverpool, UK
| | - Reena Shah
- Department of Medicine, Aga Khan University Medical College East Africa, 4th Floor East Tower Block, Third Avenue Parklands, P.O. Box 30270, Nairobi, 00100, GPO, Kenya
| | - Dilraj Singh Sokhi
- Department of Medicine, Aga Khan University Medical College East Africa, 4th Floor East Tower Block, Third Avenue Parklands, P.O. Box 30270, Nairobi, 00100, GPO, Kenya
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Tran A, Thakur KT, Nakasujja N, Nakigozi G, Kisakye A, Batte J, Mayanja R, Anok A, Gray RH, Wawer MJ, Rubin LH, Sacktor N, Saylor D. Evaluation of a screening tool for the identification of neurological disorders in rural Uganda. J Neurol Sci 2020; 421:117273. [PMID: 33423010 DOI: 10.1016/j.jns.2020.117273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 12/14/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Neurological disorders are common in sub-Saharan African, but accurate neuroepidemiologic data are lacking from the region. We assessed a neuroepidemiological screening tool in a rural Ugandan cohort with high HIV prevalence. METHODS Participants were recruited from the Rakai Neurology Study in rural Rakai District, Uganda. A nurse administered the tool and a sociodemographic survey. 100 participants returned for validation examinations by a neurologist (validation cohort). The diagnostic utility and validity of the instrument were calculated and characteristics of those with and without neurological disorders compared. RESULTS The tool was administered to 392 participants, 48% female, 33% people with HIV, average age 35.1 ± 8.5 years. 33% of the study cohort screened positive for neurologic disorders. These participants were older [mean (SD): 38.3 (9.7) vs. 33.5 (7.1) years, p < 0.001], had a lower Karnofsky score [89.8 (8.4) vs. 93.9 (7.5), p < 0.001] and had a lower body mass index [21.8 (3.3) vs. 22.8 (3.7), p = 0.007] than those who screened negative. Amongst the validation cohort, 54% had a neurological abnormality of which 46% were symptomatic. The tool was 57% sensitive and 74% specific for detecting any neurological abnormality and 80% sensitive and 69% specific for symptomatic abnormalities. CONCLUSIONS We found a lower sensitivity and similar specificity for the screening tool compared with two previous studies. The lower validity in this study was likely due in part to the high percentage of asymptomatic neurological abnormalities detected. This screening tool will require further refinement and cultural contextualization before it can be widely implemented across new populations.
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Affiliation(s)
- Andy Tran
- University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Kiran T Thakur
- Department of Neurology, Columbia University, New York City, NY, USA
| | - Noeline Nakasujja
- Department of Psychiatry, Makerere University College of Health Sciences, Kampala, Uganda
| | | | | | - James Batte
- Rakai Health Sciences Program, Kalisizo, Uganda
| | | | - Aggrey Anok
- Rakai Health Sciences Program, Kalisizo, Uganda
| | - Ronald H Gray
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Maria J Wawer
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Leah H Rubin
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA; Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ned Sacktor
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Deanna Saylor
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Medicine, University Teaching Hospital, Lusaka, Zambia.
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Kallianpur AR, Wen W, Erwin AL, Clifford DB, Hulgan T, Robbins GK. Higher iron stores and the HFE 187C>G variant delay onset of peripheral neuropathy during combination antiretroviral therapy. PLoS One 2020; 15:e0239758. [PMID: 33057367 PMCID: PMC7561201 DOI: 10.1371/journal.pone.0239758] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 09/13/2020] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE People with HIV (PWH) continue to experience sensory neuropathy and neuropathic pain in the combination antiretroviral therapy (cART) era for unclear reasons. This study evaluated the role of iron in a previously reported association of iron-loading hemochromatosis (HFE) gene variants with reduced risk of neuropathy in PWH who received more neurotoxic cART, since an iron-related mechanism also might be relevant to neuropathic symptoms in PWH living in low-resource settings today. DESIGN This time-to-event analysis addressed the impact of systemic iron levels on the rapidity of neuropathy onset in PWH who initiated cART. METHODS Soluble transferrin receptor (sTFR), the sTFR-ferritin index of iron stores, and high-sensitivity C-reactive protein (hsCRP) levels were determined in stored baseline sera from participants of known HFE genotype from AIDS Clinical Trials Group (ACTG) Study 384, a multicenter randomized clinical trial that evaluated cART strategies. Associations with incident neuropathy were evaluated in proportional-hazards, time-to-event regression models, adjusting for potential confounders. RESULTS Of 151 eligible participants with stored serum who were included in the original genetic study, 43 had cART-associated neuropathy; 108 had sufficient serum for analysis, including 30 neuropathy cases. Carriers of HFE variants had higher systemic iron (lower sTFR and sTFR-ferritin index) and lower hsCRP levels than non-carriers (all p<0.05). Higher sTFR or iron stores, the HFE 187C>G variant, and lower baseline hsCRP were associated with significantly delayed neuropathy in self-reported whites (n = 28; all p-values<0.05), independent of age, CD4+ T-cell count, plasma HIV RNA, and cART regimen. CONCLUSIONS Higher iron stores, the HFE 187C>G variant, and lower hsCRP predicted delayed onset of neuropathy among self-reported white individuals initating cART. These findings require confirmation but may have implications for cART in HIV+ populations in areas with high endemic iron deficiency, especially those PWH in whom older, more neurotoxic antiretroviral drugs are occasionally still used.
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Affiliation(s)
- Asha R. Kallianpur
- Genomic Medicine Institute, Cleveland Clinic/Lerner Research Institute, Cleveland, Ohio, United States of America
- Department of Molecular Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, United States of America
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America
- * E-mail:
| | - Wanqing Wen
- Division of Epidemiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Angelika L. Erwin
- Genomic Medicine Institute, Cleveland Clinic/Lerner Research Institute, Cleveland, Ohio, United States of America
| | - David B. Clifford
- Division of Infectious Diseases, Departments of Medicine and Neurology, Washington University School of Medicine, Saint Louis, Missouri, United States of America
| | - Todd Hulgan
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Gregory K. Robbins
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
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Guidon AC, Amato AA. COVID-19 and neuromuscular disorders. Neurology 2020; 94:959-969. [PMID: 32284362 DOI: 10.1212/wnl.0000000000009566] [Citation(s) in RCA: 200] [Impact Index Per Article: 50.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 04/09/2020] [Indexed: 01/13/2023] Open
Abstract
The coronavirus 2019 (COVID-19) pandemic has potential to disproportionately and severely affect patients with neuromuscular disorders. In a short period of time, it has already caused reorganization of neuromuscular clinical care delivery and education, which will likely have lasting effects on the field. This article reviews (1) potential neuromuscular complications of COVID-19, (2) assessment and mitigation of COVID-19-related risk for patients with preexisting neuromuscular disease, (3) guidance for management of immunosuppressive and immunomodulatory therapies, (4) practical guidance regarding neuromuscular care delivery, telemedicine, and education, and (5) effect on neuromuscular research. We outline key unanswered clinical questions and highlight the need for team-based and interspecialty collaboration. Primary goals of clinical research during this time are to develop evidence-based best practices and to minimize morbidity and mortality related to COVID-19 for patients with neuromuscular disorders.
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Affiliation(s)
- Amanda C Guidon
- From the Division of Neuromuscular Medicine, Department of Neurology, Massachusetts General Hospital (A.C.G.), and Division of Neuromuscular Medicine, Department of Neurology, Brigham and Woman's Hospital (A.A.A.), Harvard Medical School, Boston, MA.
| | - Anthony A Amato
- From the Division of Neuromuscular Medicine, Department of Neurology, Massachusetts General Hospital (A.C.G.), and Division of Neuromuscular Medicine, Department of Neurology, Brigham and Woman's Hospital (A.A.A.), Harvard Medical School, Boston, MA.
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Zhu Z, Zhao R, Hu Y. Symptom Clusters in People Living With HIV: A Systematic Review. J Pain Symptom Manage 2019; 58:115-133. [PMID: 30951828 DOI: 10.1016/j.jpainsymman.2019.03.018] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 03/23/2019] [Accepted: 03/26/2019] [Indexed: 01/02/2023]
Abstract
CONTEXT An increasing number of studies regarding symptom management have begun to shift their focus from managing a single symptom to multiple symptom clusters. However, there is a lack of consistency of compositions among different studies and even in two different analyses reported in a single study within the same population. OBJECTIVES The aim of this systematic review was to summarize the compositions, measures, and data analysis techniques of symptom clusters in people living with HIV (PLWH). METHODS We conducted a comprehensive search to identify published studies about symptom clusters among PLWH. Databases including PubMed/MEDLINE, MEDLINE (Ovid), EMBASE (Ovid), CINAHL (EBSCO), Web of Science, and ProQuest Dissertations and Thesis were searched for studies published between January 2000 and December 2018. RESULTS Thirteen articles were eligible for inclusion. Five most commonly reported symptom clusters were found: 1) sad/depressed/loss of interest and nervous/anxious/worrying; 2) difficulty sleeping, problems with having sex, and fatigue/loss of energy; 3) fever/chills/sweat, nausea/vomiting, and loss of appetite; 4) numbness, muscle aches, and joint pain; and 5) dizziness and headache. CONCLUSION This systematic review summarized the compositions, measures, and analytical techniques of symptom clusters for PLWH. Although this review found unstable results on the compositions of symptom clusters and it was difficult to reach a definitive conclusion, the results still implicate the necessity of developing a threshold to decide what symptoms should be included in the clusters and the use of multiple data analysis techniques to obtain stable results.
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Affiliation(s)
- Zheng Zhu
- Fudan University School of Nursing, Shanghai, China; Fudan University Centre for Evidence-based Nursing: A Joanna Briggs Institute Centre of Excellence, Shanghai, China
| | - Rui Zhao
- Children's Hospital of Fudan University, Shanghai, China
| | - Yan Hu
- Fudan University School of Nursing, Shanghai, China; Fudan University Centre for Evidence-based Nursing: A Joanna Briggs Institute Centre of Excellence, Shanghai, China.
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Abstract
BACKGROUND Neurological disorders in HIV infection are a common cause of morbidity and mortality. The aim of this paper is to provide a narrative overview of up to date information concerning neurological disorders affecting HIV infected persons in Africa. METHODS Seminal research concerning neurological disorders among HIV-infected adults in sub-Saharan Africa from prior to 2000 was combined with an in-depth search of PubMed to identify literature published from 2000 to 2017. The following Mesh terms were used. "Nervous System Diseases" "HIV Infections" and "Africa South of the Sahara" and "Seizures" or "Spinal Cord Diseases" or "Peripheral Nervous System Diseases" or "AIDS Dementia Complex" or "Opportunistic Infections" or "Immune Reconstitution Inflammatory Syndrome" or "Stroke". Only those articles written in English were used. A total of 352 articles were identified, selected and reviewed and 180 were included in the study. These included case series, observational studies, interventional studies, guidelines and reviews with metanalyses. The author also included 15 publications on the subject covering the earlier phase of the HIV epidemic in Africa from 1987 to 1999 making a total of 195 references in the study. This was combined with extensive personal experience diagnosing and treating these neurological disorders. RESULTS Neurological disorders were common, typically occurring in WHO stages III/IV. These were in three main categories: those arising from opportunistic processes mostly infections, direct HIV infection and autoimmunity. The most common were those arising from direct HIV infection occurring in >50%. These included HIV-associated neurocognitive dysfunction (HAND), neuropathy and myelopathy. Opportunistic infections occurred in >20% and frequently had a 6-9-month mortality rate of 60-70%. The main causes were cryptococcus, tuberculosis, toxoplasmosis and acute bacterial meningitis. Concurrent systemic tuberculosis occurred in almost 50%. CONCLUSION Neurological disorders are common in HIV in Africa and the main CNS opportunistic infections result in high mortality rates. Strategies aimed at reducing their high burden, morbidity and mortality include early HIV diagnosis and anti-retroviral therapy (ART), screening and chemoprophylaxis of main opportunistic infections, improved clinical diagnosis and management and programme strengthening.
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Affiliation(s)
- William P Howlett
- Department of Internal Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Center for International Health, University of Bergen, Norway
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Puplampu P, Ganu V, Kenu E, Kudzi W, Adjei P, Grize L, Käser M. Peripheral neuropathy in patients with human immunodeficiency viral infection at a tertiary hospital in Ghana. J Neurovirol 2019; 25:464-474. [PMID: 31028691 PMCID: PMC6746675 DOI: 10.1007/s13365-019-00743-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 02/01/2019] [Accepted: 03/21/2019] [Indexed: 01/11/2023]
Abstract
Peripheral neuropathy (PN) is the most frequent neurological complication in people living with HIV/AIDS. Neurological damage was identified to not only be caused by the viral infection itself but also through neurotoxic antiretroviral therapy (ART). PN is associated with a variety of risk factors; however, detailed knowledge is scarce for sub-Saharan African populations, bearing among the highest HIV/AIDS infection burden. In a cross-sectional study, we assessed the prevalence of PN in 525 adult outpatients suffering from HIV/AIDS and admitted to the largest tertiary hospital in Ghana. Through a detailed questionnaire and clinical examination including neurologic assessment and laboratory blood sample testing, this study investigated associations of PN with demographic and health determinants and identified risk factors associated with sensory neuropathy. The prevalence of PN in the Ghanaian cohort was 17.7% and increased odd ratios (OR) when patients were taller (> 1.57 m; OR = 3.84; 95% CI 1.38–10.66) or reached the age > 34 years (p = 0.124). Respondents with longer education duration had significantly less PN (≥ 9 years of education; OR = 0.49; 95% CI 0.26–0.92). The study also identified significant association of PN to both waist and hip girth and neutrophil counts. Curiously, higher adjusted odd ratios (aOR) of PN of patients under ART treatment were observed when CD4 lymphocytes were elevated (aOR = 0.81; 95% CI 0.36–1.83 and aOR = 2.17; 95% CI 0.93–5.05, for 300 and 600 counts, respectively). For patients on ART, an increase of 10 CD4 cell count units increased their chance of developing PN by 1% (aOR = 1.01; 95% CI 1.00 to 1.03). Despite current drug application regulations, prevalence of PN is still unacceptably high in sub-Saharan African populations. Reduction in chronic morbidity through a health system with routine monitoring, early diagnosis and prompt intervention, and effective case management can improve people living with HIV/AIDS’ quality of life.
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Affiliation(s)
- Peter Puplampu
- Department of Medicine, School of Medicine and Dentistry, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Vincent Ganu
- Department of Medicine, Korle-Bu Teaching Hospital, Accra, Ghana
| | - Ernest Kenu
- Department of Epidemiology, School of Public Health, University of Ghana, Accra, Ghana
| | - William Kudzi
- Centre for Tropical Clinical Pharmacology and Therapeutics, School of Medicine and Dentistry, College of Health Sciences, Accra, Ghana
| | - Patrick Adjei
- Department of Medicine, School of Medicine and Dentistry, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Leticia Grize
- Swiss Tropical and Public Health Institute, Socinstr. 57, 4002, Basel, Switzerland.,University of Basel, Petersplatz 1, 4003, Basel, Switzerland
| | - Michael Käser
- Swiss Tropical and Public Health Institute, Socinstr. 57, 4002, Basel, Switzerland. .,University of Basel, Petersplatz 1, 4003, Basel, Switzerland.
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Abstract
Introduction Understanding the occurrence of antiretroviral (ARV)-related adverse events (AEs) among patients receiving second-line antiretroviral therapy (ART) is important in preventing switches to more limited and expensive third-line regimens. Objective This study aimed to estimate the rates and examine predictors of AEs among adult HIV-1-infected patients receiving second-line ART in the Right to Care (RTC) clinical cohort in South Africa. Methods This was a cohort study of HIV-1-infected adult patients (≥ 18 years of age) initiating standard second-line ART in South Africa from 1 April 2004 to 10 January 2016. Our primary outcome was the development of an AE within 24 months of initiating second-line therapy. We used Kaplan–Meier survival analysis to determine AE incidence in the first 24 months of second-line ART. Predictors of AEs were modelled using a Cox proportional hazards model. Results A total of 7708 patients initiated second-line ART, with 44.5% developing at least one AE over the first 24 months of second-line treatment. The highest AE incidence was observed among patients receiving abacavir (ABC) + lamivudine (3TC) + ritonavir-boosted lopinavir/atazanavir (LPVr/ATVr) (52.7/100 person-years (PYs), 95% confidence interval (CI): 42.9–64.8), while patients initiated on a tenofovir (TDF) + emtricitabine (FTC)/3TC + LPVr regimen had the lowest rate of AEs (26.4/100 PYs, 95% CI: 24.9–28.3). Clinical predictors of AEs included experiencing AEs when receiving first-line ART (adjusted hazard ratio (aHR) 2.3, 95% CI: 1.9–2.8), lower CD4 cell count (0–199 vs. ≥ 350 cells/mm3; aHR 1.4, 95% CI: 1.4–1.8), and switching to second-line therapy from an ABC-base first-line regimen (ABC + 3TC + efavirenz/nevirapine [EFV/NVP] vs. TDF + 3TC/FTC + EFV/NVP; aHR 3.4, 95% CI: 1.1–11.1). Conclusions The rates of AEs were lowest among patients receiving a TDF-based second-line regimen. Patients with poorer health at the time of switch were at higher risk of AEs when receiving second-line ART and may require closer monitoring to improve the durability of second-line therapy.
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Epidemiology and factors associated with peripheral neuropathy among HIV infected patients in Gondar, Ethiopia: A cross-sectional study. PLoS One 2019; 14:e0211354. [PMID: 30695060 PMCID: PMC6350981 DOI: 10.1371/journal.pone.0211354] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 01/13/2019] [Indexed: 01/23/2023] Open
Abstract
Background Antiretroviral therapy has surely increased the life expectancy of people living with HIV. However, long term complications like HIV associated sensory neuropathy has a negative impact on quality of life among people living with HIV (PLHIV). In Ethiopia, lack of data on magnitude of the burden and predictors of HIV associated sensory neuropathy in many resource limited setting has led to under diagnosis and eventually under management of HIV-SN. Hence, this study was set out to establish the burden of HIV-associated sensory neuropathy and, its association with demographic, health and clinical characteristics among people living with HIV in Ethiopia. Methods Cross-sectional study was conducted to assess the prevalence of HIV-associated sensory neuropathy and the associated factors among adult HIV patients at University of Gondar Teaching Hospital, Gondar, Ethiopia. Brief Peripheral Neuropathy Screening tool validated by AIDs Clinical trial group was used for screening HIV-associated sensory neuropathy. Data were analyzed descriptively and through uni- and multivariate logistic regression. Results In total 359 adult PLHIV with a mean age of 36.5± 9.07 years participated, their median duration of HIV infection was 60 months (IQR 36–84) and their median CD4 count 143cells/μL (IQR 69.5–201.5). Age above 40 years, anti-tuberculosis regimen, tallness, and exposure to didanosine contained antiretroviral therapy were found to be associated with HIV-associated sensory neuropathy (AOR 1.82, 1.84, 1.98 and 4.33 respectively). Conclusions More than half of the HIV patients who attended HIV care clinic at University of Gondar hospital during the study period were found to present with peripheral sensory neuropathy. Higher age, tallness, TB medication, and didanosine in ART were significantly associated with HIV-SN as screened by effective diagnostic (BPNS) tool.
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Comley-White N, Potterton J, Ntsiea V. The physical sequelae of perinatally acquired HIV in adolescents: a research proposal. BMC Res Notes 2019; 12:62. [PMID: 30691534 PMCID: PMC6350387 DOI: 10.1186/s13104-019-4079-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 01/11/2019] [Indexed: 12/24/2022] Open
Abstract
Objectives As the global access of antiretrovirals for HIV-infected infants improves, so the body of perinatally HIV-infected adolescents (PHIVA) grows. The neurological and physical complications of HIV, both in children and in adults, are well established, however there is a paucity of data pertaining to PHIVA, a group of people who have had a lifetime exposure to the virus and to antiretrovirals. There has been a resounding call for further research in this area, as well as for the development of policies and programmes for this population. The aim of this study is to determine the physical sequelae in PHIVA and to propose a model of care for this population. Methods Through interviews with PHIVA, the perceived physical challenges will be established. Thereafter a cohort study with age-matched participants will determine if PHIVA have any limitations in fatigue, endurance, motor function and muscle strength, body mass index, peripheral neuropathy, level of disability and quality of life. Using these results, a model of care will be proposed through the nominal group technique with both PHIVA and clinicians working in HIV and adolescence.
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Affiliation(s)
- Nicolette Comley-White
- Department of Physiotherapy, School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, 7 York Road, Johannesburg, 2193, South Africa.
| | - Joanne Potterton
- Department of Physiotherapy, School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, 7 York Road, Johannesburg, 2193, South Africa
| | - Veronica Ntsiea
- Department of Physiotherapy, School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, 7 York Road, Johannesburg, 2193, South Africa
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12
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Octaviana F, Safri AY, Setiawan DD, Estiasari R, Imran D, Ranakusuma T, Price P. Neuropathic pain in HIV patients receiving ART without stavudine in an Indonesia Referral Hospital. J Neurol Sci 2019; 397:146-149. [PMID: 30634130 DOI: 10.1016/j.jns.2018.12.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 12/29/2018] [Accepted: 12/31/2018] [Indexed: 11/25/2022]
Abstract
Lower limb neuropathic pain in HIV patients is a common manifestation of sensory neuropathy (HIV-SN), but can be seen in patients who do not meet standard definitions of HIV-SN. The drug stavudine is a risk factor for HIV-SN, but some patients treated without stavudine experience HIV-SN, and the prevalence and risk factors influencing neuropathic pain in this setting are unknown. A cross sectional study at Cipto Mangunkusumo Hospital Jakarta tested 197 HIV patients treated for >12 months without stavudine. HIV-SN was defined using the AIDS Clinical Trial Group Brief Peripheral Neuropathy Screening Test (ACTG-BPNST). A validated Indonesia translation of Douleur Neuropathique en 4 (DN4) questionnaire was used to assess lower limb neuropathic pain. Nerve conduction studies assessed large nerve fiber function and Stimulated Skin Wrinkle (SSW) tests were performed to assess small nerve fibers. The prevalence of neuropathic pain was 6.6%. BPNST+HIV-SN was diagnosed in 14.2% of the cohort and 38.5% of patients with pain. Use of protease inhibitors and ART duration <2 years associated with neuropathic pain in univariate (p = .036, p = .002, resp.) and multivariable analyses (model p < .001). SSW tests were abnormal in 53.8% of subjects with neuropathic pain and only 25.5% without pain (p = .05). Patients with pain without BPNST+HIV-SN had begun ART more recently than those with both diagnoses. Overall this preliminary study showed that neuropathic pain associated with protease inhibitors and a shorter duration of ART in Indonesian HIV patients, and may be an early symptom of small fiber neuropathy in this context.
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Affiliation(s)
- Fitri Octaviana
- Neurology Department, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia; Neurology Department, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Ahmad Yanuar Safri
- Neurology Department, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia; Neurology Department, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | | | - Riwanti Estiasari
- Neurology Department, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia; Neurology Department, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Darma Imran
- Neurology Department, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia; Neurology Department, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Teguh Ranakusuma
- Neurology Department, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia; Neurology Department, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Patricia Price
- Neurology Department, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia; School of Biomedical Sciences, Curtin University, Bentley, Australia; School of Physiology, University of the Witwatersrand, Johannesburg, South Africa.
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13
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Asahchop EL, Branton WG, Krishnan A, Chen PA, Yang D, Kong L, Zochodne DW, Brew BJ, Gill MJ, Power C. HIV-associated sensory polyneuropathy and neuronal injury are associated with miRNA-455-3p induction. JCI Insight 2018; 3:122450. [PMID: 30518697 DOI: 10.1172/jci.insight.122450] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 10/24/2018] [Indexed: 11/17/2022] Open
Abstract
Symptomatic distal sensory polyneuropathy (sDSP) is common and debilitating in people with HIV/AIDS, leading to neuropathic pain, although the condition's cause is unknown. To investigate biomarkers and associated pathogenic mechanisms for sDSP, we examined plasma miRNA profiles in HIV/AIDS patients with sDSP or without sDSP in 2 independent cohorts together with assessing related pathogenic effects. Several miRNAs were found to be increased in the Discovery Cohort (sDSP, n = 29; non-DSP, n = 40) by array analyses and were increased in patients with sDSP compared with patients without sDSP. miR-455-3p displayed a 12-fold median increase in the sDSP group, which was confirmed by machine learning analyses and verified by reverse transcription PCR. In the Validation Cohort (sDSP n = 16, non-DSP n = 20, healthy controls n = 15), significant upregulation of miR-455-3p was also observed in the sDSP group. Bioinformatics revealed that miR-455-3p targeted multiple host genes implicated in peripheral nerve maintenance, including nerve growth factor (NGF) and related genes. Transfection of cultured human dorsal root ganglia with miR-455-3p showed a concentration-dependent reduction in neuronal β-III tubulin expression. Human neurons transfected with miR-455-3p demonstrated reduced neurite outgrowth and NGF expression that was reversed by anti-miR-455-3p antagomir cotreatment. miR-455-3p represents a potential biomarker for HIV-associated sDSP and might also exert pathogenic effects leading to sDSP.
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Affiliation(s)
- Eugene L Asahchop
- Department of Medicine (Neurology), University of Alberta, Edmonton, Alberta, Canada
| | - William G Branton
- Department of Medicine (Neurology), University of Alberta, Edmonton, Alberta, Canada
| | - Anand Krishnan
- Department of Medicine (Neurology), University of Alberta, Edmonton, Alberta, Canada
| | - Patricia A Chen
- Department of Medicine (Neurology), University of Alberta, Edmonton, Alberta, Canada
| | - Dong Yang
- Department of Mathematical and Statistical Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Linglong Kong
- Department of Mathematical and Statistical Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Douglas W Zochodne
- Department of Medicine (Neurology), University of Alberta, Edmonton, Alberta, Canada.,Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Bruce J Brew
- Departments of Neurology and HIV, St. Vincent's Hospital, and Peter Duncan Neurosciences Unit, St. Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia
| | - M John Gill
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Christopher Power
- Department of Medicine (Neurology), University of Alberta, Edmonton, Alberta, Canada.,Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Alberta, Canada.,Department of Medicine, University of Calgary, Calgary, Alberta, Canada
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14
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Pillay P, Wadley AL, Cherry CL, Karstaedt AS, Kamerman PR. Psychological Factors Associated With Painful Versus Non-Painful HIV-Associated Sensory Neuropathy. AIDS Behav 2018; 22:1584-1595. [PMID: 28710709 DOI: 10.1007/s10461-017-1856-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
HIV-associated sensory neuropathy (HIV-SN) is a common, and frequently painful complication of HIV, but factors that determine the presence of pain are unresolved. We investigated: (i) if psychological factors associated with painful (n = 125) versus non-painful HIV-SN (n = 72), and (ii) if pain and psychological factors affected quality of life (QoL). We assessed anxiety and depression using the Hopkins Symptoms Checklist-25. Pain catastrophizing and QoL were assessed using the Pain Catastrophizing Scale and Euroqol-5D, respectively. Presence of neuropathy was detected using the Brief Neuropathy Screening Tool, and pain was characterised using the Wisconsin Brief Pain Questionnaire. Overall, there was a high burden of pain, depression and anxiety in the cohort. None of the psychological variables associated with having painful HIV-SN. Greater depressive symptoms and presence of pain were independently associated with lower QoL. In those participants with painful HIV-SN, greater depressive symptom scores were associated with increased pain intensity. In conclusion, in a cohort with high background levels of psychological dysfunction, psychological factors do not predict the presence of pain, but both depression and presence of pain are associated with poor quality of life.
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Affiliation(s)
- Prinisha Pillay
- Brain Function Research Group, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, 7 York Rd, Parktown, Johannesburg, 2193, South Africa.
| | - Antonia L Wadley
- Brain Function Research Group, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, 7 York Rd, Parktown, Johannesburg, 2193, South Africa
| | - Catherine L Cherry
- Brain Function Research Group, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, 7 York Rd, Parktown, Johannesburg, 2193, South Africa
- International Clinical Research Laboratory, Centre for Biomedical Research, Burnet Institute, Melbourne, Australia
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Australia
| | - Alan S Karstaedt
- Department of Medicine, Chris Hani Baragwanath Hospital, Johannesburg, South Africa
| | - Peter R Kamerman
- Brain Function Research Group, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, 7 York Rd, Parktown, Johannesburg, 2193, South Africa
- School of Biomedical Sciences, Faculty of Health Sciences, Curtin University, Perth, Australia
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15
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Factors associated with distal symmetric polyneuropathies in adult Zambians: A cross-sectional, observational study of the role of HIV, non-antiretroviral medication exposures, and nutrition. J Neurol Sci 2018; 388:61-69. [PMID: 29627032 DOI: 10.1016/j.jns.2018.02.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 02/19/2018] [Accepted: 02/21/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Non-antiretroviral (ART) drug exposures and poor nutrition may be important modifiable risk factors for distal symmetric polyneuropathies (DSP) in sub-Saharan Africa. METHODS We conducted a cross-sectional study of DSP prevalence and factors associated with DSP among clinic attendees in urban and rural Zambia. All participants underwent neurologist-performed examination. Laboratory investigations seeking comorbid risk factors for DSP were performed for DSP cases. RESULTS We identified 31/137 (22.6%) HIV+ and 21/177 (11.9%) HIV- DSP cases. DSP prevalence did not differ by urbanicity, although rural participants were significantly more likely to have one asymptomatic DSP sign. Low dietary diversity, history of syphilis, history of tuberculosis, and prior metronidazole and ciprofloxacin use were associated with DSP amongst HIV+ cases, while age and education were associated with DSP in HIV- participants (all p-values < 0·05). In a multivariate logistic regression model, HIV (p = 0·0001) and age (p < 0·0001), and ciprofloxacin exposure (p = 0·01) remained independently associated with DSP. While diabetes was rare, supoptimal micronutrients levels were common among DSP cases regardless of HIV status. CONCLUSIONS While HIV infection is strongly associated with DSP in Zambia, history of non-ART drug exposures and low dietary diversity are also important determinants of DSP in HIV+ individuals. Treatable micronutrient deficiencies were common.
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16
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Ex-vivo expression of chemokine receptors on cells surrounding cutaneous nerves in patients with HIV-associated sensory neuropathy. AIDS 2018; 32:431-441. [PMID: 29239897 DOI: 10.1097/qad.0000000000001714] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE HIV-associated sensory neuropathy (HIV-SN) remains common in HIV+ individuals receiving antiretroviral therapy (ART), even though neurotoxic antiretroviral drugs (e.g. stavudine) have been phased out of use. Accumulating evidence indicates that the neuropathy is immune-mediated. We hypothesize that chemokines produced locally in the skin promote migration of macrophages and T cells into the tissue, damaging cutaneous nerves causing HIV-SN. DESIGN We assessed chemokine receptor expression on infiltrating CD14 and CD3 cells around cutaneous nerves in standardized skin biopsies from HIV-SN+ patients (n = 5), HIV-SN- patients (n = 9) and healthy controls (n = 4). METHODS The AIDS Clinical Trials Group Brief Peripheral Neuropathy Screen was used to assess Indonesian HIV+ patients receiving ART without stavudine (case definition: bilateral presence of at least one symptom and at least one sign of neuropathy). Distal leg skin biopsies were stained to visualize chemokine receptors (CCR2, CCR5, CXCR3, CXCR4, CX3CR1), infiltrating CD3 and CD14 cells, and protein-gene-product 9.5 on nerves, using immunohistochemistry and 4-colour confocal microscopy. RESULTS Intraepidermal nerve fibre density was variable in patients without HIV-SN and generally lower in those with HIV-SN. CX3CR1 was more evident on CD14 cells whereas CCR2, CCR5, CXCR3 and CXCR4 were more common on CD3 cells. Expression of CX3CR1, CCR2 and CCR5 was more common in HIV-SN+ patients than those without HIV-SN. CXCR3 and CXCR4 were upregulated in all HIV+ patients, compared with healthy controls. CONCLUSION Inflammatory macrophages expressing CX3CR1 and T cells expressing CCR2 and CCR5 may participate in peripheral nerve damage leading to HIV-SN in HIV+ patients treated without stavudine. Further characterization of these cells is warranted.
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17
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Hakim JG, Thompson J, Kityo C, Hoppe A, Kambugu A, van Oosterhout JJ, Lugemwa A, Siika A, Mwebaze R, Mweemba A, Abongomera G, Thomason MJ, Easterbrook P, Mugyenyi P, Walker AS, Paton NI. Lopinavir plus nucleoside reverse-transcriptase inhibitors, lopinavir plus raltegravir, or lopinavir monotherapy for second-line treatment of HIV (EARNEST): 144-week follow-up results from a randomised controlled trial. THE LANCET. INFECTIOUS DISEASES 2018; 18:47-57. [PMID: 29108797 PMCID: PMC5739875 DOI: 10.1016/s1473-3099(17)30630-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Revised: 09/05/2017] [Accepted: 09/26/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Millions of HIV-infected people worldwide receive antiretroviral therapy (ART) in programmes using WHO-recommended standardised regimens. Recent WHO guidelines recommend a boosted protease inhibitor plus raltegravir as an alternative second-line combination. We assessed whether this treatment option offers any advantage over the standard protease inhibitor plus two nucleoside reverse-transcriptase inhibitors (NRTIs) second-line combination after 144 weeks of follow-up in typical programme settings. METHODS We analysed the 144-week outcomes at the completion of the EARNEST trial, a randomised controlled trial done in HIV-infected adults or adolescents in 14 sites in five sub-Saharan African countries (Uganda, Zimbabwe, Malawi, Kenya, Zambia). Participants were those who were no longer responding to non-NRTI-based first-line ART, as assessed with WHO criteria, confirmed by viral-load testing. Participants were randomly assigned to receive a ritonavir-boosted protease inhibitor (lopinavir 400 mg with ritonavir 100 mg, twice per day) plus two or three clinician-selected NRTIs (protease inhibitor plus NRTI group), protease inhibitor plus raltegravir (400 mg twice per day; protease inhibitor plus raltegravir group), or protease inhibitor monotherapy (plus raltegravir induction for first 12 weeks, re-intensified to combination therapy after week 96; protease inhibitor monotherapy group). Randomisation was by computer-generated randomisation sequence, with variable block size. The primary outcome was viral load of less than 400 copies per mL at week 144, for which we assessed non-inferiority with a one-sided α of 0·025, and superiority with a two-sided α of 0·025. The EARNEST trial is registered with ISRCTN, number 37737787. FINDINGS Between April 12, 2010, and April 29, 2011, 1837 patients were screened for eligibility, of whom 1277 patients were randomly assigned to an intervention group. In the primary (complete-case) analysis at 144 weeks, 317 (86%) of 367 in the protease inhibitor plus NRTI group had viral loads of less than 400 copies per mL compared with 312 (81%) of 383 in the protease inhibitor plus raltegravir group (p=0·07; lower 95% confidence limit for difference 10·2% vs specified non-inferiority margin 10%). In the protease inhibitor monotherapy group, 292 (78%) of 375 had viral loads of less than 400 copies per mL; p=0·003 versus the protease inhibitor plus NRTI group at 144 weeks. There was no difference between groups in serious adverse events, grade 3 or 4 adverse events (total or ART-related), or events that resulted in treatment modification. INTERPRETATION Protease inhibitor plus raltegravir offered no advantage over protease inhibitor plus NRTI in virological efficacy or safety. In the primary analysis, protease inhibitor plus raltegravir did not meet non-inferiority criteria. A regimen of protease inhibitor with NRTIs remains the best standardised second-line regimen for use in programmes in resource-limited settings. FUNDING European and Developing Countries Clinical Trials Partnership (EDCTP), UK Medical Research Council, Instituto de Salud Carlos III, Irish Aid, Swedish International Development Cooperation Agency, Instituto Superiore di Sanita, Merck, ViiV Healthcare, WHO.
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Affiliation(s)
- James G Hakim
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | | | - Cissy Kityo
- Joint Clinical Research Centre (JCRC) Kampala, Kampala, Uganda
| | - Anne Hoppe
- MRC Clinical Trials Unit at University College London, London, UK
| | | | - Joep J van Oosterhout
- Department of Medicine, University of Malawi College of Medicine, Blantyre, Malawi; Dignitas International, Zomba, Malawi
| | | | | | | | | | | | | | | | - Peter Mugyenyi
- Joint Clinical Research Centre (JCRC) Kampala, Kampala, Uganda
| | - A Sarah Walker
- MRC Clinical Trials Unit at University College London, London, UK
| | - Nicholas I Paton
- MRC Clinical Trials Unit at University College London, London, UK; Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
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18
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Mhariwa PC, Myezwa H, Galantino ML, Maleka D. The relationship between lower limb muscle strength and lower extremity function in HIV disease. SOUTH AFRICAN JOURNAL OF PHYSIOTHERAPY 2017; 73:360. [PMID: 30135905 PMCID: PMC6093131 DOI: 10.4102/sajp.v73i1.360] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 07/11/2017] [Indexed: 11/01/2022] Open
Abstract
Background Human immunodeficiency virus (HIV) negatively impacts muscle strength and function. This study aimed to establish the relationship between lower limb muscle strength and lower extremity function in HIV disease. Method A cross-sectional study was undertaken with a sample of 113 HIV-positive participants. Lower limb muscle strength and self-reported function were established using dynamometry and the Lower Extremity Functional Scale (LEFS), respectively. Muscle strength and functional status were established in a subset of 30 HIV-negative participants to determine normative values. Results Muscle strength for participants with HIV ranged from an ankle dorsiflexion mean of 9.33 kg/m2 to 15.79 kg/m2 in hip extensors. In the HIV-negative group, ankle dorsiflexors recorded 11.17 kg/m2, whereas hip extensors were the strongest, generating 17.68 kg/m2. In the HIV-positive group, linear regression showed a positive relationship between lower limb muscle strength and lower extremity function (r = 0.71, p = 0.00). Fifty per cent of the changes in lower extremity function were attributable to lower limb muscle strength. A simple linear regression model showed that lower limb ankle plantar flexors contributed the most to lower extremity function in this cohort, contrary to the literature which states that hip and trunk muscles are the most active in lower limb functional activities. Conclusion Lower extremity strength impacts perceived function in individuals stabilised on antiretroviral therapy for HIV disease. These findings demonstrate that ankle plantar flexors produce more force over hip flexors. Careful attention should be paid to the implications for strength training in this population.
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Affiliation(s)
- Peter C Mhariwa
- Department of Physiotherapy, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Hellen Myezwa
- Department of Physiotherapy, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| | - Mary L Galantino
- Stockton University Physical Therapy Program, Galloway, New Jersey, United States.,School of Medicine - CCEB, University of Pennsylvania, United States
| | - Douglas Maleka
- Department of Physiotherapy, Faculty of Health Sciences, University of the Witwatersrand, South Africa
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19
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Saylor D, Nakigozi G, Nakasujja N, Robertson K, Gray RH, Wawer MJ, Sacktor N. Peripheral neuropathy in HIV-infected and uninfected patients in Rakai, Uganda. Neurology 2017; 89:485-491. [PMID: 28679596 PMCID: PMC5539731 DOI: 10.1212/wnl.0000000000004136] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 05/11/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine the prevalence, risk factors, and functional impairment associated with peripheral neuropathy in a prospective cohort of adults in rural Uganda. METHODS Eight hundred participants (400 HIV- and 400 antiretroviral-naive HIV+) in the Rakai Community Cohort Study underwent detailed neurologic evaluations including assessment of neuropathy symptoms, functional measures (Patient Assessment of Own Functioning Inventory and Karnofsky Performance Status scores), and neurologic evaluation by a trained medical officer. Neuropathy was defined as ≥1 subjective symptom and ≥1 sign of neuropathy on examination. Neuropathy risk factors were assessed using log binomial regression. RESULTS Fifty-three percent of participants were men, with a mean (SD) age of 35 (8) years. Neuropathy was present in 13% of the cohort and was more common in HIV+ vs HIV- participants (19% vs 7%, p < 0.001). Older age (relative risk [RR] 1.04, 95% confidence interval [CI] 1.02-1.06), female sex (RR 1.49, 95% CI 1.04-2.15), HIV infection (RR 2.82, 95% CI 1.86-4.28), tobacco use (RR 1.59, 95% CI 1.02-2.48), and prior neurotoxic medication use (RR 2.08, 95% CI 1.07-4.05) were significant predictors of neuropathy in the overall cohort. Only older age was associated with neuropathy risk in the HIV+ (RR 1.03, 95% CI 1.01-1.05) and HIV- (RR 1.06, 95% CI 1.02-1.10) cohorts. Neuropathy was associated with impaired functional status on multiple measures across all participant groups. CONCLUSIONS Peripheral neuropathy is relatively common and associated with impaired functional status among adults in rural Uganda. Older age, female sex, and HIV infection significantly increase the risk of neuropathy. Neuropathy may be an underrecognized but important condition in rural Uganda and warrants further study.
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Affiliation(s)
- Deanna Saylor
- From the Department of Neurology (D.S., N.S.), Johns Hopkins University School of Medicine, Baltimore, MD; Rakai Health Sciences Program (G.N.), Kalisizo, Uganda; Department of Psychiatry (N.N.), Makerere University, Kampala, Uganda; Department of Neurology (K.R.), University of North Carolina-Chapel Hill; and Department of Epidemiology (R.H.G., M.J.W.), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
| | - Gertrude Nakigozi
- From the Department of Neurology (D.S., N.S.), Johns Hopkins University School of Medicine, Baltimore, MD; Rakai Health Sciences Program (G.N.), Kalisizo, Uganda; Department of Psychiatry (N.N.), Makerere University, Kampala, Uganda; Department of Neurology (K.R.), University of North Carolina-Chapel Hill; and Department of Epidemiology (R.H.G., M.J.W.), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Noeline Nakasujja
- From the Department of Neurology (D.S., N.S.), Johns Hopkins University School of Medicine, Baltimore, MD; Rakai Health Sciences Program (G.N.), Kalisizo, Uganda; Department of Psychiatry (N.N.), Makerere University, Kampala, Uganda; Department of Neurology (K.R.), University of North Carolina-Chapel Hill; and Department of Epidemiology (R.H.G., M.J.W.), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Kevin Robertson
- From the Department of Neurology (D.S., N.S.), Johns Hopkins University School of Medicine, Baltimore, MD; Rakai Health Sciences Program (G.N.), Kalisizo, Uganda; Department of Psychiatry (N.N.), Makerere University, Kampala, Uganda; Department of Neurology (K.R.), University of North Carolina-Chapel Hill; and Department of Epidemiology (R.H.G., M.J.W.), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Ronald H Gray
- From the Department of Neurology (D.S., N.S.), Johns Hopkins University School of Medicine, Baltimore, MD; Rakai Health Sciences Program (G.N.), Kalisizo, Uganda; Department of Psychiatry (N.N.), Makerere University, Kampala, Uganda; Department of Neurology (K.R.), University of North Carolina-Chapel Hill; and Department of Epidemiology (R.H.G., M.J.W.), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Maria J Wawer
- From the Department of Neurology (D.S., N.S.), Johns Hopkins University School of Medicine, Baltimore, MD; Rakai Health Sciences Program (G.N.), Kalisizo, Uganda; Department of Psychiatry (N.N.), Makerere University, Kampala, Uganda; Department of Neurology (K.R.), University of North Carolina-Chapel Hill; and Department of Epidemiology (R.H.G., M.J.W.), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Ned Sacktor
- From the Department of Neurology (D.S., N.S.), Johns Hopkins University School of Medicine, Baltimore, MD; Rakai Health Sciences Program (G.N.), Kalisizo, Uganda; Department of Psychiatry (N.N.), Makerere University, Kampala, Uganda; Department of Neurology (K.R.), University of North Carolina-Chapel Hill; and Department of Epidemiology (R.H.G., M.J.W.), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Centner CM, Little F, Van Der Watt JJ, Vermaak JR, Dave JA, Levitt NS, Heckmann JM. Evolution of sensory neuropathy after initiation of antiretroviral therapy. Muscle Nerve 2017; 57:371-379. [PMID: 28561925 DOI: 10.1002/mus.25710] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 05/04/2017] [Accepted: 05/27/2017] [Indexed: 11/07/2022]
Abstract
INTRODUCTION We studied the evolution of sensory neuropathy after antiretroviral therapy (ART) in human immunodeficiency virus-infected South Africans. METHODS Enrolment commenced before ART with 6-monthly follow-ups for 24 months. Symptomatic distal sensory polyneuropathy (SDSP) was defined as one symptom and sign. Symptom/sign scores were compared between visits. RESULTS We enrolled 184 participants. Pre-ART, 16% had SDSP. After 18 months of ART, pain prevalence decreased in those with pre-ART SDSP (odds ratio [OR], 0.09; 95% confidence interval [95%CI], 0.03-0.29). Symptoms improved in 50% ever experiencing pain (mean improvement = 4.5 on 11-point scale). Participants SDSP-free pre-ART developed SDSP at a rate of 18 per 100 person-years. After 24 months (n = 102), 18% had SDSP. Stavudine (60% of cohort) did not predict incident SDSP, but associated with increased prevalence of reduced/absent reflexes at 18 months (OR, 2.24; 95% CI, 1.08-4.65). DISCUSSION Painful symptoms improved during ART. Evolving sensory neuropathy was due to increasing small and large fiber dysfunction. Muscle Nerve 57: 371-379, 2018.
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Affiliation(s)
- Chad M Centner
- Neurology Research Group, Department of Medicine, University of Cape Town, South Africa
| | - Francesca Little
- Department of Statistical Sciences, University of Cape Town, South Africa
| | - Johan J Van Der Watt
- Neurology Research Group, Department of Medicine, University of Cape Town, South Africa
| | - John-Randel Vermaak
- Neurology Research Group, Department of Medicine, University of Cape Town, South Africa
| | - Joel A Dave
- Division of Endocrinology & Diabetic Medicine, Department of Medicine, University of Cape Town, South Africa
| | - Naomi S Levitt
- Division of Endocrinology & Diabetic Medicine, Department of Medicine, University of Cape Town, South Africa
| | - Jeannine M Heckmann
- Neurology Research Group, Department of Medicine, University of Cape Town, South Africa.,E8-74, Division of Neurology, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, 7925, South Africa
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Nucleoside reverse transcriptase inhibitors (NRTIs) induce proinflammatory cytokines in the CNS via Wnt5a signaling. Sci Rep 2017. [PMID: 28646196 PMCID: PMC5482870 DOI: 10.1038/s41598-017-03446-w] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
HAART is very effective in suppressing HIV-1 replication in patients. However, patients staying on long-term HAART still develop various HIV-associated neurological disorders, even when the viral load is low. The underlying pathogenic mechanisms are largely unknown. Emerging evidence implicated that persistent neuroinflammation plays an important role in NeuroAIDS. Although residual virus or viral proteins are commonly thought as the causal factors, we are interested in the alternative possibility that HAART critically contributes to the neuroinflammation in the central nervous system (CNS). To test this hypothesis, we have determined the effect of NRTIs on the expression of proinflammatory cytokines in the various CNS regions. Mice (C57Bl/6) were administered with AZT (Zidovudine 100 mg/kg/day), 3TC (Lamivudine 50 mg/kg/day) or D4T (Stavudine 10 mg/kg/day) for 5 days, and cortices, hippocampi and spinal cords were collected for immunoblotting. Our results showed that NRTI administration up-regulated cytokines, including IL-1β, TNF-α and IL-6 in various CNS regions. In addition, we found that NRTIs also up-regulated Wnt5a protein. Importantly, BOX5 attenuated NRTI-induced cytokine up-regulation. These results together suggest that NRTIs up-regulate proinflammatory cytokines via a Wnt5a signaling-dependent mechanism. Our findings may help understand the potential pathogenic mechanisms of HAART-associated NeuroAIDS and design effective adjuvants.
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Benevides MLACDSE, Filho SB, Debona R, Bergamaschi ENC, Nunes JC. Prevalence of Peripheral Neuropathy and associated factors in HIV-infected patients. J Neurol Sci 2017; 375:316-320. [PMID: 28320159 DOI: 10.1016/j.jns.2017.02.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Revised: 01/13/2017] [Accepted: 02/06/2017] [Indexed: 10/20/2022]
Abstract
The progress on HIV infection treatment has allowed a longer survival for HIV-infected patients. However, chronic comorbidities are emerging. Peripheral Neuropathy (PN) represents one of the most prevalent neurologic disorders among these patients, and comprehensive studies may contribute to a reduction in the morbidity of this condition. This is a cross-sectional analytic study conducted in a tertiary referral hospital in southern Brazil. This study investigates the prevalence of PN among HIV-infected patients and associated demographic, clinical and laboratory variables. A number of 150 HIV-infected patients admitted between January and May 2016 were interviewed, submitted to physical and neurological examination, and data from their medical records were obtained. The prevalence of PN was 31.3%. It was increased among older patients (p=0.02), patients with higher CD4 lymphocytes levels (p=0.02), and smokers (OR=3.4; 95% CI 1.6-6.9; p<0.01). The research identified a high prevalence of PN in HIV-infected patients. Older age and higher CD4 levels have been associated with PN. To the best of our knowledge, this was one of the first studies reporting an association between tobacco use and PN among HIV-infected patients. Further studies are necessary to elucidate the pathological mechanisms linking PN and tobacco.
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Affiliation(s)
| | - Sérgio Beduschi Filho
- Hospital Nereu Ramos (HNR), Rua Rui Barbosa, Agronômica, Florianópolis, Santa Catarina (SC), Brazil
| | - Rodrigo Debona
- Division of Neurology, UFSC, Rua Professora Maria Flora Pausewang, Trindade, Florianópolis, Brazil
| | | | - Jean Costa Nunes
- Division of Neuropathology, Universidade Federal de Santa Catarina (UFSC), Rua Professora Maria Flora Pausewang, Trindade, Florianópolis, Santa Catarina (SC), Brazil; Neurodiagnostic Brasil-Diagnósticos em Neuropatologia, Rua Santos Saraiva, Estreito, Florianópolis, Santa Catarina (SC), Brazil.
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Kaddumukasa M, Mugenyi L, Kaddumukasa MN, Ddumba E, Devereaux M, Furlan A, Sajatovic M, Katabira E. Prevalence and incidence of neurological disorders among adult Ugandans in rural and urban Mukono district; a cross-sectional study. BMC Neurol 2016; 16:227. [PMID: 27855635 PMCID: PMC5114749 DOI: 10.1186/s12883-016-0732-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 10/25/2016] [Indexed: 11/11/2022] Open
Abstract
Background The burden of neurological diseases is increasing in developing countries. However, there is a prominent scarcity of literature on the incidence of neurological diseases in sub-Saharan Africa. This study was therefore undertaken to determine the prevalence and incidence of neurological diseases in this setting to serve as a baseline for planning and care for neurological disorders in Uganda. Methods The study was conducted within rural and urban Mukono district, east of Kampala city of Uganda, central region. Over a period of six months, a cross sectional survey was conducted and screening was performed using a standardized questionnaire. All subjects with neurological symptoms and signs were reviewed by a team of neurologists and neurological diagnoses made. Results Of the 3000 study subjects, 50.3% (1510/3000) were from the rural setting. Out of the participants screened, 67.4% were female, with a median age of 33 years. Among the 98 subjects with confirmed neurological disorders, the frequency of diseases was as follows; peripheral neuropathy (46.2%), chronic headaches (26.4%), and epilepsy (8.5%), followed by pain syndromes (7.5%), stroke (6.6%) and tremors/Parkinson disease (3.8%). The crude prevalence rates of these disorders (95% CI) were 14.3% (8.5–24.1); 13.3% (7.7–22.8); 33.7% (23.9–47.4) for stroke, epilepsy and peripheral neuropathy respectively. Peripheral neuropathy followed by chronic headaches had the highest estimated incidence/1000 years. Stroke had an estimated incidence of 3.6 new cases with 95% CI of (2.1–6.1)/1000 years. Conclusion Peripheral neuropathy, chronic headaches and epilepsy disorders are major causes of morbidity in Sub-Saharan settings. There is an urgent need of more robust and powered studies to determine the incidence of these diseases. Electronic supplementary material The online version of this article (doi:10.1186/s12883-016-0732-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mark Kaddumukasa
- Department of Medicine, School of Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda.
| | - Leviticus Mugenyi
- Infectious Diseases Research Collaboration, Mulago Hill Road, MUJHU3 Building, P.O. Box 7475, Kampala, Uganda.,Interuniversity Institute for Biostatistics and Statistical Bioinformatics, Hasselt University, Diepenbeek, Belgium
| | - Martin N Kaddumukasa
- Department of Medicine, School of Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
| | - Edward Ddumba
- Department of Medicine, St Raphael of St Francis Nsambya Hospital, Nkozi University, P.O. Box 7146, Kampala, Uganda
| | - Michael Devereaux
- University Hospitals Case Medical Center, Neurological Institute Case Western Reserve University, 11100 Euclid Avenue, 44106, Cleveland, OH, USA
| | - Anthony Furlan
- University Hospitals Case Medical Center, Neurological Institute Case Western Reserve University, 11100 Euclid Avenue, 44106, Cleveland, OH, USA
| | - Martha Sajatovic
- Neurological and Behavioral Outcomes Center, University Hospitals Case Medical Center, 11100 Euclid Avenue, 44106, Cleveland, OH, USA
| | - Elly Katabira
- Department of Medicine, School of Medicine, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
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Woldeamanuel YW, Kamerman PR, Veliotes DGA, Phillips TJ, Asboe D, Boffito M, Rice ASC. Development, Validation, and Field-Testing of an Instrument for Clinical Assessment of HIV-Associated Neuropathy and Neuropathic Pain in Resource-Restricted and Large Population Study Settings. PLoS One 2016; 11:e0164994. [PMID: 27764177 PMCID: PMC5072607 DOI: 10.1371/journal.pone.0164994] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Accepted: 10/04/2016] [Indexed: 02/02/2023] Open
Abstract
HIV-associated sensory peripheral neuropathy (HIV-SN) afflicts approximately 50% of patients on antiretroviral therapy, and is associated with significant neuropathic pain. Simple accurate diagnostic instruments are required for clinical research and daily practice in both high- and low-resource setting. A 4-item clinical tool (CHANT: Clinical HIV-associated Neuropathy Tool) assessing symptoms (pain and numbness) and signs (ankle reflexes and vibration sense) was developed by selecting and combining the most accurate measurands from a deep phenotyping study of HIV positive people (Pain In Neuropathy Study–HIV-PINS). CHANT was alpha-tested in silico against the HIV-PINS dataset and then clinically validated and field-tested in HIV-positive cohorts in London, UK and Johannesburg, South Africa. The Utah Early Neuropathy Score (UENS) was used as the reference standard in both settings. In a second step, neuropathic pain in the presence of HIV-SN was assessed using the Douleur Neuropathique en 4 Questions (DN4)-interview and a body map. CHANT achieved high accuracy on alpha-testing with sensitivity and specificity of 82% and 90%, respectively. In 30 patients in London, CHANT diagnosed 43.3% (13/30) HIV-SN (66.7% with neuropathic pain); sensitivity = 100%, specificity = 85%, and likelihood ratio = 6.7 versus UENS, internal consistency = 0.88 (Cronbach alpha), average item-total correlation = 0.73 (Spearman’s Rho), and inter-tester concordance > 0.93 (Spearman’s Rho). In 50 patients in Johannesburg, CHANT diagnosed 66% (33/50) HIV-SN (78.8% neuropathic pain); sensitivity = 74.4%, specificity = 85.7%, and likelihood ratio = 5.29 versus UENS. A positive CHANT score markedly increased of pre- to post-test clinical certainty of HIV-SN from 43% to 83% in London, and from 66% to 92% in Johannesburg. In conclusion, a combination of four easily and quickly assessed clinical items can be used to accurately diagnose HIV-SN. DN4-interview used in the context of bilateral feet pain can be used to identify those with neuropathic pain.
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Affiliation(s)
- Yohannes W. Woldeamanuel
- Pain Research, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, United Kingdom
- Department of Neurology, Addis Abäba University School of Medicine, College of Health Sciences, Addis Abäba, Ethiopia
- Advanced Clinical Consultation & Research Center, Addis Abäba, Ethiopia
- * E-mail:
| | - Peter R. Kamerman
- Brain Function Research Group, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Demetri G. A. Veliotes
- Division of Neurology, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Tudor J. Phillips
- Pain Research, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, United Kingdom
- The Pain Relief Unit, The Churchill Hospital, Oxford, United Kingdom
| | - David Asboe
- The Pain Relief Unit, The Churchill Hospital, Oxford, United Kingdom
| | - Marta Boffito
- HIV Medicine and Sexual Health, Chelsea and Westminster Hospital, London, United Kingdom
| | - Andrew S. C. Rice
- Pain Research, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, United Kingdom
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