Morbidity and nutritional impairment in relation to CD4 count in a Zambian population with high HIV prevalence

HIV, Tuberculosis, and Food Insecurity in Africa—A Syndemics-Based Scoping Review

The double burden of HIV/AIDS and tuberculosis (TB), coupled with endemic and problematic food insecurity in Africa, can interact to negatively impact health outcomes, creating a syndemic. For people living with HIV/AIDS (PWH), food insecurity is a significant risk factor for acquiring TB due to the strong nutritional influences and co-occurring contextual barriers. We aim to synthesize evidence on the syndemic relationship between HIV/AIDS and TB co-infection and food insecurity in Africa. We conducted a scoping review of studies in Africa that included co-infected adults and children, with evidence of food insecurity, characterized by insufficient to lack of access to macronutrients. We sourced information from major public health databases. Qualitative, narrative analysis was used to synthesize the data. Of 1072 articles screened, 18 articles discussed the syndemic effect of HIV/AIDS and TB co-infection and food insecurity. Reporting of food insecurity was inconsistent, however, five studies estimated it using a validated scale. Food insecure co-infected adults had an average BMI of 16.5–18.5 kg/m². Negative outcomes include death (n = 6 studies), depression (n = 1 study), treatment non-adherence, weight loss, wasting, opportunistic infections, TB-related lung diseases, lethargy. Food insecurity was a precursor to co-infection, especially with the onset/increased incidence of TB in PWH. Economic, social, and facility-level factors influenced the negative impact of food insecurity on the health of co-infected individuals. Nutritional support, economic relief, and psychosocial support minimized the harmful effects of food insecurity in HIV–TB populations. Interventions that tackle one or more components of a syndemic interaction can have beneficial effects on health outcomes and experiences of PWH with TB in Africa.

Nutrition indicators as potential predictors of AIDS-defining illnesses among ARV-naïve HIV-positive adults in Kapiri Mposhi, Zambia 2008-2009

Early changes in nutritional status may be predictive of subsequent HIV disease progression in people living with HIV (PLHIV). In addition to conventional anthropometric assessment using body mass index (BMI) and mid-upper arm circumferences (MUAC), measures of strength and fatigability may detect earlier changes in nutrition status which predict HIV disease progression. This study aims to examine the association between various nutritional metrics relevant in resource-scarce setting and HIV disease progression. The HIV disease progression outcome was defined as any occurrence of an incident AIDS-defining illnesses (ADI) among antiretroviral treatment (ART)-naïve PLHIV. From 2008–2009, HIV+ Zambian adult men and non-pregnant women were followed for 9 months at a Doctors without Borders (Medecins Sans Frontiers, MSF) HIV clinic in Kapiri Mposhi, Zambia. Since the study was conducted in the time period when former WHO recommendations on ART (i.e., ≤200 CD4 cell count as opposed to treating all individuals regardless of CD4 cell count or disease stage) were followed, caution should be applied when considering the implications from this study’s results to improve HIV case management under current clinical guidelines, or when comparing findings from this study with studies conducted in recent years. Bivariable and multivariable logistic regression was used to assess the associations between baseline nutritional measurements and the outcome of incident ADI. Self-reported loss of appetite study (AOR 1.90, 95% CI 1.04, 3.45, P = 0.036) and moderate wasting based on MUAC classification (AOR 2.40, 95% CI 1.13, 5.10, P = 0.022) were independently associated with increased odds of developing incident ADI within 9 months, while continuous increments (in psi) of median handgrip strength (AOR 0.74, 95%CI 0.60, 0.91, P = 0.004) was independently associated with decreased odds of incident ADI only among women. The association between low BMI and the short-term outcome of ADI was attenuated after controlling for these nutritional indicators. These findings warrant further research to validate the consistency of these observed associations among larger ART-naïve HIV-infected populations, as well as to develop nutritional assessment tools for identifying disease progression risk among ART-naïve PLHIV.

Impact of body fat changes in mediating the effects of antiretroviral therapy on blood pressure in HIV-infected persons in a sub-Saharan African setting

Background

Previous studies of HIV-infected patients have shown significant associations between highly active antiretroviral therapy (HAART) and increased blood pressure; however, the mechanisms involved are less clear. Therefore, we sought to investigate the potential impact of body fat changes in mediating the effects of HAART on blood pressure changes among people living with HIV.

Methods

Four hundred six consenting patients (≥18 years of age) attending a tertiary HIV clinic in semi-urban Nigeria were recruited between August and November 2014 as part of a cross-sectional study. We performed bias-corrected bootstrap tests of mediation using 95 % confidence intervals (CI) to determine the mediating effects of body mass index and waist circumference (mediators) on the total effects of HAART exposure (primary predictor) on blood pressure (outcome), while controlling for age, sex and other potential confounders.

Results

Waist circumference remained a significant partial mediator of the total effects of HAART exposure on increasing systolic blood pressure (coefficient: 1.01, 95 % CI: 0.33 to 2.52, 11 % mediated) and diastolic blood pressure (coefficient: 0.68, 95 % CI: 0.26 to 1.89, 9 % mediated) after adjusting for age, sex, smoking status, CD4 count and duration of HIV infection. No significant mediating effect was observed with body mass index alone or in combination with waist circumference after adjusting for all potential confounders.

Conclusion

Waist circumference significantly mediates the effects of HAART on blood pressure in persons living with HIV, independent of the role of traditional risk factors. The use of waist circumference as a complementary body fat measure to body mass index may improve the clinical prediction of hypertension in HIV-infected patients on antiretroviral therapy.

Electronic supplementary material

The online version of this article (doi:10.1186/s40249-016-0152-7) contains supplementary material, which is available to authorized users.

CD4 Cell Count: Declining Value for Antiretroviral Therapy Eligibility

Antiretroviral therapy (ART) policy for people living with human immunodeficiency virus (HIV) has historically been based on clinical indications, such as opportunistic infections and CD4 cell counts. Studies suggest that CD4 counts early in HIV infection do not predict relevant public health outcomes such as disease progression, mortality, and HIV transmission in people living with HIV. CD4 counts also vary widely within individuals and among populations, leading to imprecise measurements and arbitrary ART initiation. To capture the clinical and preventive benefits of treatment, the global HIV response now focuses on increasing HIV diagnosis and ART coverage. CD4 counts for ART initiation were necessary when medications were expensive and had severe side effects, and when the impact of early ART initiation was unclear. However, current evidence suggests that although CD4 counts may still play a role in guiding clinical care to start prophylaxis for opportunistic infections, CD4 counts should cease to be required for ART initiation.

Association of HIV and ART with cardiometabolic traits in sub-Saharan Africa: a systematic review and meta-analysis

Background Sub-Saharan Africa (SSA) has the highest burden of HIV in the world and a rising prevalence of cardiometabolic disease; however, the interrelationship between HIV, antiretroviral therapy (ART) and cardiometabolic traits is not well described in SSA populations.

Methods We conducted a systematic review and meta-analysis through MEDLINE and EMBASE (up to January 2012), as well as direct author contact. Eligible studies provided summary or individual-level data on one or more of the following traits in HIV+ and HIV-, or ART+ and ART- subgroups in SSA: body mass index (BMI), systolic blood pressure (SBP), diastolic blood pressure (DBP), high-density lipoprotein (HDL), low-density lipoprotein (LDL), triglycerides (TGs) and fasting blood glucose (FBG) or glycated hemoglobin (HbA1c). Information was synthesized under a random-effects model and the primary outcomes were the standardized mean differences (SMD) of the specified traits between subgroups of participants.

Results Data were obtained from 49 published and 3 unpublished studies which reported on 29 755 individuals. HIV infection was associated with higher TGs [SMD, 0.26; 95% confidence interval (CI), 0.08 to 0.44] and lower HDL (SMD, −0.59; 95% CI, −0.86 to −0.31), BMI (SMD, −0.32; 95% CI, −0.45 to −0.18), SBP (SMD, −0.40; 95% CI, −0.55 to −0.25) and DBP (SMD, −0.34; 95% CI, −0.51 to −0.17). Among HIV+ individuals, ART use was associated with higher LDL (SMD, 0.43; 95% CI, 0.14 to 0.72) and HDL (SMD, 0.39; 95% CI, 0.11 to 0.66), and lower HbA1c (SMD, −0.34; 95% CI, −0.62 to −0.06). Fully adjusted estimates from analyses of individual participant data were consistent with meta-analysis of summary estimates for most traits.

Conclusions Broadly consistent with results from populations of European descent, these results suggest differences in cardiometabolic traits between HIV-infected and uninfected individuals in SSA, which might be modified by ART use. In a region with the highest burden of HIV, it will be important to clarify these findings to reliably assess the need for monitoring and managing cardiometabolic risk in HIV-infected populations in SSA.

A 12 week longitudinal study of microbial translocation and systemic inflammation in undernourished HIV-infected Zambians initiating antiretroviral therapy

Background

Undernourished, HIV-infected adults in sub-Saharan Africa have high levels of systemic inflammation, which is a risk factor for mortality and other adverse health outcomes. We hypothesized that microbial translocation, due to the deleterious effects of HIV and poor nutrition on intestinal defenses and mucosal integrity, contributes to heightened systemic inflammation in this population, and reductions in inflammation on antiretroviral therapy (ART) accompany reductions in translocation.

Methods

HIV-infected, Zambian adults with a body mass index <18.5 kg/m² were recruited for a pilot study to assess the relationships between microbial translocation and systemic inflammation over the first 12 weeks of ART. To assess microbial translocation we measured serum lipopolysaccharide binding protein (LBP), endotoxin core IgG and IgM, and soluble CD14, and to assess intestinal permeability we measured the urinary excretion of an oral lactulose dose normalized to urinary creatinine (Lac/Cr ratio). Linear mixed models were used to assess within-patient changes in these markers relative to serum C-reactive protein (CRP), tumor necrosis factor-α receptor 1 (TNF-α R1), and soluble CD163 over 12 weeks, in addition to relationships between variables independent of time point and adjusted for age, sex, and CD4+ count.

Results

Thirty-three participants had data from recruitment and at 12 weeks: 55% were male, median age was 36 years, and median baseline CD4+ count was 224 cells/μl. Over the first 12 weeks of ART, there were significant decreases in serum levels of LBP (median change -8.7 μg/ml, p = 0.01), TNF-α receptor 1 (-0.31 ng/ml, p < 0.01), and CRP (-3.5 mg/l, p = 0.02). The change in soluble CD14 level over 12 weeks was positively associated with the change in CRP (p < 0.01) and soluble CD163 (p < 0.01). Pooling data at baseline and 12 weeks, serum LBP was positively associated with CRP (p = 0.01), while endotoxin core IgM was inversely associated with CRP (p = 0.01) and TNF-α receptor 1 (p = 0.04). The Lac/Cr ratio was not associated with any serum biomarkers.

Conclusions

In undernourished HIV-infected adults in Zambia, biomarkers of increased microbial translocation are associated with high levels of systemic inflammation before and after initiation of ART, suggesting that impaired gut immune defenses contribute to innate immune activation in this population.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2334-14-521) contains supplementary material, which is available to authorized users.

Improving validity of informed consent for biomedical research in Zambia using a laboratory exposure intervention

Background

Complex biomedical research can lead to disquiet in communities with limited exposure to scientific discussions, leading to rumours or to high drop-out rates. We set out to test an intervention designed to address apprehensions commonly encountered in a community where literacy is uncommon, and where complex biomedical research has been conducted for over a decade. We aimed to determine if it could improve the validity of consent.

Methods

Data were collected using focus group discussions, key informant interviews and observations. We designed an intervention that exposed participants to a detailed demonstration of laboratory processes. Each group was interviewed twice in a day, before and after exposure to the intervention in order to assess changes in their views.

Results

Factors that motivated people to participate in invasive biomedical research included a desire to stay healthy because of the screening during the recruitment process, regular advice from doctors, free medical services, and trust in the researchers. Inhibiting factors were limited knowledge about samples taken from their bodies during endoscopic procedures, the impact of endoscopy on the function of internal organs, and concerns about the use of biomedical samples. The belief that blood can be used for Satanic practices also created insecurities about drawing of blood samples. Further inhibiting factors included a fear of being labelled as HIV positive if known to consult heath workers repeatedly, and gender inequality. Concerns about the use and storage of blood and tissue samples were overcome by a laboratory exposure intervention.

Conclusion

Selecting a group of members from target community and engaging them in a laboratory exposure intervention could be a useful tool for enhancing specific aspects of consent for biomedical research. Further work is needed to determine the extent to which improved understanding permeates beyond the immediate group participating in the intervention.

Pycnogenol attenuates the symptoms of immune dysfunction through restoring a cellular antioxidant status in low micronutrient-induced immune deficient mice

BACKGROUND/OBJECTIVES

We investigated the effect of Pycnogenol (Pyc) on survival and immune dysfunction of C57BL/6 mice induced by low micronutrient supplementation.

MATERIALS/METHODS

Female C57/BL/6 mice were fed a diet containing 7.5% of the recommended amount of micronutrients for a period of 12 wks (immunological assay) and 18 wks (survival test). For immunological assay, lymphocyte proliferation, cytokine regulation, and hepatic oxidative status were determined.

RESLUTS

Pyc supplementation with 50 and 100 mg·kg^-1·bw·d^-1 resulted in partial extension of the median survival time. Pyc supplementation led to increased T and B cell response against mitogens and recovery of an abnormal shift of cytokine pattern designated by the decreased secretion of Th1 cytokine and increased secretion of Th2 cytokine. Hepatic vitamin E level was significantly decreased by micronutrient deficiency, in accordance with increased hepatic lipid peroxidation level. However, Pyc supplementation resulted in a dose-dependent reduction of hepatic lipid peroxidation, which may result from restoration of hepatic vitamin E level.

CONCLUSION

Findings of this study suggest that Pyc supplementation ameliorates premature death by restoring immune dysfunction, such as increasing lymphocyte proliferation and regulation of cytokine release from helper T cells, which may result from the antioxidative ability of Pyc.

Seroepidemiology of hepatitis E virus infection in an urban population in Zambia: strong association with HIV and environmental enteropathy

BACKGROUND

Hepatitis E virus (HEV) infection causes major epidemics of infectious hepatitis, with high mortality rates in pregnant women. Recent reports indicate that HEV coinfections with human immunodeficiency virus (HIV) may have a more protracted course. However, the impact of HEV infections in communities heavily affected by HIV remains poorly studied. We set out to examine age-related seroprevalence in a community where we have previously carried out studies on environmental enteropathy.

METHODS

Blood samples from 194 children and 106 adults were examined for immunoglobulin G and immunoglobulin M antibodies for HEV. HEV data were correlated with HIV status and morphometric analysis of small intestinal biopsies.

RESULTS

Seroprevalence rose throughout childhood, from 8% in children aged 1-4 years, to 36% in children aged 10-14 years. In adults, the overall prevalence was 42%, with 28% in HIV-seronegative adults and 71% in HIV-seropositive adults (odds ratio, 6.2; 95% confidence interval, 2.2-18; P = .0001). In adults, villous height and crypt depth measurements showed that HEV seropositivity was associated with worse enteropathy (P = .05 and P = .005, respectively).

CONCLUSIONS

HEV infection is common in Zambia. In adults it is strongly associated with HIV status, and also with environmental enteropathy.

Association between nutritional status and the immune response in HIV + patients under HAART: protocol for a systematic review

BACKGROUND

Over 850 million people worldwide and 200 million adults in Sub-Saharan Africa suffer from malnutrition. Countries most affected by HIV are also stricken by elevated rates of food insecurity and malnutrition. HIV infection and insufficient nutritional intake are part of a vicious cycle that contributes to immunodeficiency and negative health outcomes. However, the effect of the overlap between HIV infection and undernutrition on the immune response following antiretroviral initiation remains unclear. A possible explanation could be the lack of consensus concerning the definition and assessment of nutritional status. Our objectives are to investigate the existence of an association between undernutrition and immune response at antiretroviral treatment initiation and the following year in low- and middle-income countries where malnutrition is most prevalent.

METHODS/DESIGN

Our systematic review will identify studies originating from low- and middle-income countries (LMICs) published from 1996 onwards, through searches in MEDLINE (PubMed interface), EMBASE (OVID interface), Cochrane Central (OVID interface) and grey literature. No language restrictions will be applied. We will seek out studies of any design investigating the association between the nutritional status (for example, undernourished versus well nourished) and the immune response, either in terms of CD4 count or immune failure, in seropositive patients initiating antiretroviral therapy or in their first year of treatment. Two reviewers will independently screen articles, extract data and assess scientific quality using standardized forms and published quality assessment tools tailored for each study design. Where feasible, pooled measures of association will be obtained through meta-analyses. Results will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement. This protocol has been registered in the PROSPERO database (registration number: CRD42014005961).

CONCLUSION

Undernutrition and weight loss are prevalent amongst highly active antiretroviral therapy (HAART)-treated patients in LMICs and contribute to excess early mortality. A possible intermediate pathway could be poor immune reconstitution secondary to deficient nutritional status. In the face of limited access to second line treatments, raising HIV resistance and cut backs to HIV programs, it is crucial to identify the factors associated with suboptimal response and therapeutic failure in order to better customize the care strategies employed in LMICs.

Community viral load and CD4 count distribution among people living with HIV in a South African Township: implications for treatment as prevention

INTRODUCTION

The goals of scale-up of antiretroviral therapy (ART) have expanded from prevention of morbidity and death to include prevention of transmission. Morbidity and mortality risk are associated with CD4 count; transmission risk depends on plasma viral load (VL). This study aimed to describe CD4 count and VL distributions among HIV-infected individuals in a South African township to gain insights into the potential impact of ART scale-up on community HIV transmission risk.

METHODS

A random sample of 10% of the adult population was invited to attend an HIV testing service. Study procedures included a questionnaire, HIV testing, CD4 count, and VL testing.

RESULTS

One thousand one hundred forty-four (88.0%) of 1300 randomly selected individuals participated in the study. Two hundred sixty tested positive, giving an HIV prevalence of 22.7% [95% confidence interval (CI): 20.3 to 25.3]. A third of all HIV-infected individuals (33.5%, 95% CI: 27.8 to 39.6) reported taking ART. The median CD4 count was 417 cells per microliter (interquartile range, 285-627); 33 (12.7%, 95% CI: 8.9 to 17.4) had a CD4 count of ≤200 cells per microliter. VL measurements were available for 219 individuals (84.2%) and were undetectable in 72 (33.9%), >1500 copies per milliliter in 127 (58.0%) and >10,000 copies per milliliter in 96 (43.8%). Of those reporting they were receiving ART, 30.4% had a VL >1500 copies per milliliter compared with 58.0% of those reporting they were not receiving ART.

CONCLUSIONS

A small proportion of those living with HIV in this community had a CD4 count of <200 cells per microliter; more than half had a VL high enough to be associated with considerable transmission risk. A substantial proportion of HIV-infected individuals remained at risk of transmitting HIV even after starting ART.

Cardiovascular disease risk factors among HIV-infected Nigerians receiving highly active antiretroviral therapy

Background:

Highly active antiretroviral therapy (HAART) has become more accessible to Human immunodeficiency virus infection/Acquired Immunodeficiency Syndrome (HIV/AIDS) patients worldwide. There is growing concern that the metabolic complications associated with HIV and HAART may increase cardiovascular risk and lead to cardiovascular diseases. We, therefore, set out to describe the cardiovascular risk profile of HIV/AIDS patients receiving HAART at a health facility in northern part of Nigeria.

Materials and Methods:

This cross-sectional study was conducted at the Aminu Kano Teaching Hospital, Kano, Nigeria. Consenting patients, who had been receiving HAART, were compared with age and sex matched HAART-naive subjects. Questionnaire interview, electrocardiography, anthropometric and blood pressure measurements were conducted under standard conditions. Blood samples were obtained for the determination of plasma glucose, uric acid and lipid levels.

Results:

Two hundred subjects were studied, 100 were on HAART (group 1) and the other 100 (group 2) were HAART-naive. Subjects’ mean age for all the participants was 32.5 (7.6) years. The prevalence of hypertension was 17% in group 1 and 2% in group 2 (P < 0.001). Similarly, 11% and 21% of group 1 subjects were obese or had metabolic syndrome compared with 2% and 9% of group 2 patients (P < 0.05 for both).

Conclusion:

HAART treatment was associated with significantly higher prevalences of hypertension, obesity and metabolic syndrome.

Population-based CD4 counts in a rural area in South Africa with high HIV prevalence and high antiretroviral treatment coverage

Background

Little is known about the variability of CD4 counts in the general population of sub-Saharan Africa countries affected by the HIV epidemic. We investigated factors associated with CD4 counts in a rural area in South Africa with high HIV prevalence and high antiretroviral treatment (ART) coverage.

Methods

CD4 counts, health status, body mass index (BMI), demographic characteristics and HIV status were assessed in 4990 adult resident participants of a demographic surveillance in rural KwaZulu-Natal in South Africa; antiretroviral treatment duration was obtained from a linked clinical database. Multivariable regression analysis, overall and stratified by HIV status, was performed with CD4 count levels as outcome.

Results

Median CD4 counts were significantly higher in women than in men overall (714 vs. 630 cells/µl, p<0.0001), both in HIV-uninfected (833 vs. 683 cells/µl, p<0.0001) and HIV-infected adults (384.5 vs. 333 cells/µl, p<0.0001). In multivariable regression analysis, women had 19.4% (95% confidence interval (CI) 16.1–22.9) higher CD4 counts than men, controlling for age, HIV status, urban/rural residence, household wealth, education, BMI, self-reported tuberculosis, high blood pressure, other chronic illnesses and sample processing delay. At ART initiation, HIV-infected adults had 21.7% (95% CI 14.6–28.2) lower CD4 counts than treatment-naive individuals; CD4 counts were estimated to increase by 9.2% (95% CI 6.2–12.4) per year of treatment.

Conclusions

CD4 counts are primarily determined by sex in HIV-uninfected adults, and by sex, age and duration of antiretroviral treatment in HIV-infected adults. Lower CD4 counts at ART initiation in men could be a consequence of lower CD4 cell counts before HIV acquisition.

Safety of live, attenuated oral vaccines in HIV-infected Zambian adults: oral vaccines in HIV

Background

Current recommendations are that HIV-infected persons should not be given live vaccines. We set out to assess potential toxicity of three live, attenuated oral vaccines (against rotavirus, typhoid and ETEC) in a phase 1 study.

Methods

Two commercially available oral vaccines against rotavirus (Rotarix) and typhoid (Vivotif) and one candidate vaccine against Enterotoxigenic Escherichia coli (ACAM2017) were given to HIV seropositive (n = 42) and HIV seronegative (n = 59) adults. Gastrointestinal symptoms were sought actively by weekly interview up to 1 month of vaccination. In rotavirus vaccine recipients, intestinal biopsies were collected by endoscopy and evaluated for expression of IL-8 and pro-inflammatory cytokines.

Results

No difference was observed between symptoms in HIV infected and HIV uninfected vaccinees, except for diarrhoea reported more than 7 days after the last dose of vaccine. If only diarrhoea episodes within 7 days of vaccination are included, diarrhoea was not more frequent in HIV seropositive than in HIV seronegative vaccinees (OR 6.7, 95% CI 1.2–67; P = 0.09). However, if later episodes of diarrhoea are included, a significant increase in diarrhoea was demonstrated (OR 5.3, 95% CI 0.98–53; P = 0.04). All episodes were mild and transient. IL-8 was slowly up-regulated over the week following vaccination (P = 0.02), but IL-β, IFNγ or TNFα were not.

Conclusions

No evidence was found of adverse events following administration of these three vaccines, except for late episodes of diarrhoea which may not be attributable to vaccination. Our data do not support the need for a prohibition on oral administration of live, attenuated vaccines to all HIV infected adults, though further work on severely immunocompromised adults and children are required.

Nevirapine-associated hepatotoxicity was not predicted by CD4 count ≥250 cells/μL among women in Zambia, Thailand and Kenya

OBJECTIVE

The aim of the study was to determine risk factors for developing severe hepatotoxicity (grade 3 or 4 hepatotoxicity) and rash-associated hepatotoxicity (rash with ≥ grade 2 hepatotoxicity) among women initiating nevirapine-based antiretroviral therapy (ART).

METHODS

The Non-Nucleoside Reverse Transcriptase Inhibitor Response Study was a prospective cohort study carried out in Zambia, Thailand and Kenya. Between May 2005 and January 2007, we enrolled antiretroviral-naïve HIV-infected women initiating nevirapine-based ART. At enrollment and at weeks 2, 4, 8, 16 and 24, participants had serum alanine transferase (ALT) and aspartate transaminase (AST) measured and were evaluated clinically for hepatitis and rash.

RESULTS

Nevirapine-based ART was initiated in 820 women and baseline ALT or AST results were abnormal (≥ grade 1) in 113 (14%) women. After initiating nevirapine-based ART, severe hepatotoxicity occurred in 41 (5%) women and rash-associated hepatotoxicity occurred in 27 (3%) women. In a multivariate logistic regression model, severe hepatotoxicity and rash-associated hepatotoxicity were both associated with baseline abnormal (≥ grade 1) ALT or AST results, but not with a baseline CD4 cell count ≥250 cells/μL. Three participants (0.4%) died with symptoms suggestive of fatal hepatotoxicity; all three women had baseline CD4 count <100 cells/μL and were receiving anti-tuberculosis therapy.

CONCLUSION

Among women taking nevirapine-based ART, severe hepatotoxicity and rash-associated hepatotoxicity were predicted by abnormal baseline ALT or AST results, but not by a CD4 count ≥250 cells/μL. In resource-limited settings where transaminase testing is available, testing should focus on early time-points and on women with abnormal baseline ALT or AST results.

Reliability of anthropometric measures in a longitudinal cohort of patients initiating ART in West Africa

Background

Anthropometric measurements are a non invasive, inexpensive, and suitable method for evaluating the nutritional status in population studies with relatively large sample sizes. However, anthropometric techniques are prone to errors that could arise, for example, from the inadequate training of personnel. Despite these concerns, anthropometrical measurement error is seldom assessed in cohort studies. We describe the reliability and challenges associated with measurement of longitudinal anthropometric data in a cohort of West African HIV+ adults .

Methods

In a cohort of patients initiating antiretroviral treatment in Mali, we evaluated nutritional status using anthropometric measurements(weight, height, mid-upper arm circumference, waist circumference and triceps skinfold). Observers with no prior experience in the field of anthropometry were trained to perform anthropometrical measurements. To assess the intra- and inter-observer variability of the measurements taken in the course of the study, two sub-studies were carried out: one at the beginning and one at the end of the prospective study. Twelve patients were measured twice on two consecutive days by the same observer on both study occasions. The technical error of measurement (TEM) (absolute and relative value), and the coefficient of reliability (R) were calculated and compared across reliability studies.

Results

According to the R and relative TEM, inter-observer reliabilities were only acceptable for height and weight. In terms of intra-observer precision, while the first and second anthropometrists demonstrated better reliability than the third, only height and weight measurements were reliable. Looking at total TEM, we observed that while measurements remained stable between studies for height and weight, circumferences and skinfolds lost precision from one occasion to the next.

Conclusions

Height and weight were the most reliable measurements under the study's conditions. Circumferences and skinfolds demonstrated less reliability and lost precision over time, probably as a result of insufficient supervision over the entire length of the study. Our results underline the importance of a careful observer's selection, good initial preparation, as well as the necessity of ongoing training and supervision over the entire course of a longitudinal nutritional study. Failure to do so could have major repercussions on data reliability and jeopardize its utilization.

Clinical prognostic value of RNA viral load and CD4 cell counts during untreated HIV-1 infection--a quantitative review

Background

The prognostic value of CD4 counts and RNA viral load for identifying treatment need in HIV-infected individuals depends on (a) variation within and among individuals, and (b) relative risks of clinical progression per unit CD4 or RNA difference.

Methodology/Principal Findings

We reviewed these measurements across (a) 30 studies, and (b) 16 cohorts of untreated seropositive adults. Median within-population interquartile ranges were 74,000 copies/mL for RNA with no significant change during the course of infection; and 330 cells/µL for CD4, with a slight proportional increase over infection. Applying measurement and physiological fluctuations observed on chronically infected patients, we estimate that 45% of population-level variation in RNA, and 25% of variation in CD4, were due to within-patient fluctuations. Comparing a patient with RNA at upper 75^th centile with a patient at median RNA, 5-year relative risks were 1.4 (95% CI 1.2–1.7) for AIDS and 1.5 (1.3–1.9) for death, without change over the course of infection. In contrast, for a patient with CD4 count at the lower 75^th centile, relative risks increased from 1.0 at seroconversion to maxima of 6.3 (4.4–8.9) for AIDS and 5.5 (2.7–10.1) for death by year 6, when the population median had fallen to 300 cells/µL. Below 300 cells/µL, prognostic power did not increase, due to a narrower CD4 range.

Conclusions

Findings support the current WHO recommendation (used with clinical criteria) to start antiretroviral treatment in low-income settings at CD4 thresholds of 200–350 cells/µL, without pre-treatment RNA monitoring – while not precluding earlier treatment based on clinical, socio-demographic or public health criteria.

Susceptibility to intestinal infection and diarrhoea in Zambian adults in relation to HIV status and CD4 count

BACKGROUND

The HIV epidemic in sub-Saharan Africa has had a major impact on infectious disease, and there is currently great interest in the impact of HIV on intestinal barrier function. A three year longitudinal cohort study in a shanty compound in Lusaka, Zambia, carried out before anti-retroviral therapy was widely available, was used to assess the impact of HIV on susceptibility to intestinal infectious disease. We measured the incidence and seasonality of intestinal infection and diarrhoea, aggregation of disease in susceptible individuals, clustering by co-habitation and genetic relatedness, and the disease-to-infection ratio.

METHODS

Adults living in a small section of Misisi, Lusaka, were interviewed every two weeks to ascertain the incidence of diarrhoea. Monthly stool samples were analysed for selected pathogens. HIV status and CD4 count were determined annually.

RESULTS

HIV seroprevalence was 31% and the prevalence of immunosuppression (CD4 count 200 cells/microL or less) was 10%. Diarrhoea incidence was 1.1 episodes per year and the Incidence Rate Ratio for HIV infection was 2.4 (95%CI 1.7-3.3; p < 0.001). The disease-to-infection ratio was increased at all stages of HIV infection. Aggregation of diarrhoea in susceptible individuals was observed irrespective of immunosuppression, but there was little evidence of clustering by co-habitation or genetic relatedness. There was no evidence of aggregation of asymptomatic infections.

CONCLUSION

HIV has an impact on intestinal infection at all stages, with an increased disease-to-infection ratio. The aggregation of disease in susceptible individuals irrespective of CD4 count suggests that this phenomenon is not a function of cell mediated immunity.

Factors associated with CD4 lymphocyte counts in HIV-negative Senegalese individuals

CD4+ lymphocytes are a primary target of the human immunodeficiency virus (HIV), and CD4 counts are one of the factors used to measure disease progression in HIV-positive individuals. CD4 counts vary in uninfected individuals and across populations due to a variety of demographic, environmental, immunological and genetic factors that probably persist throughout the course of HIV infection. This study sought to determine reference levels and identify factors that influence lymphocyte counts in 681 HIV-uninfected adults in Senegal, where residents are exposed to a variety of infectious diseases and other conditions that may affect CD4 counts. Lymphocyte counts were assessed in commercial sex workers, symptomatic men and women presenting to the University of Dakar infectious disease clinic for out-patient care and women seeking family planning services. CD4 and CD3 lymphocyte counts differed between the four study groups (P < 0.01). Men had the lowest mean CD4 count (711.6 cells/microl), while commercial sex workers had the highest levels (966.0 cells/microl). After adjustment for age and other behavioural and clinical factors, the difference in CD4 counts between the three groups of women did not remain. However, both gender and smoking were associated independently with CD4 counts, as men maintained lower mean CD4 counts (beta = -156.4 cells/microl, P < 0.01) and smokers had higher mean CD4 counts (beta = 124.0 cells/microl, P < 0.01) than non-smokers in multivariable analyses. This study is the first to explore factors that may influence CD4 levels in Senegal and to estimate baseline CD4 levels among HIV-negatives, information that may guide clinicians in interpreting CD4 counts.

Malaria attributable to the HIV-1 epidemic, sub-Saharan Africa

The HIV-1 epidemic has increased the malaria disease and death rate in southern Africa.

We assessed the impact of HIV-1 on malaria in the sub-Saharan African population. Relative risks for malaria in HIV-infected persons, derived from literature review, were applied to the HIV-infected population in each country, by age group, stratum of CD4 cell count, and urban versus rural residence. Distributions of CD4 counts among HIV-infected persons were modeled assuming a linear decline in CD4 after seroconversion. Averaged across 41 countries, the impact of HIV-1 was limited (although quantitatively uncertain) because of the different geographic distributions and contrasting age patterns of the 2 diseases. However, in Botswana, Zimbabwe, Swaziland, South Africa, and Namibia, the incidence of clinical malaria increased by <28% (95% confidence interval [CI] 14%–47%) and death increased by <114% (95% CI 37%–188%). These effects were due to high HIV-1 prevalence in rural areas and the locally unstable nature of malaria transmission that results in a high proportion of adult cases.

Targeting antiretroviral therapy: lessons from a longitudinal study of morbidity and treatment in relation to CD4 count in Thailand

The aim of the study was to quantify the incidence of illness and treatment behaviour in relation to CD4 count, age, and gender among a cohort of persons living with HIV/AIDS in Thailand. 464 participants with a CD4 count between 50 and 550 cells/mm3 were followed up for 12 months. Multiple Poisson regression was used to model the adjusted incidence rate ratio of illness and care seeking at different levels. The incidence of morbidity and treatment pattern were significantly different among participants with different CD4 count, age and gender. For example, morbidity incidence was significantly higher among participants with CD4 count of less than 200 cells/mm3, among female participants, and participants aged 35 years or over. Females made significantly higher use of hospital ambulatory care and private clinics than males and males made significantly more use of private pharmacies. The potential opportunity cost of not providing ART to these different groups can be estimated and used to inform further economic evaluation and policy decisions on whether to provide ART at all and which patient groups to prioritise.

Reduced gene expression of intestinal alpha-defensins predicts diarrhea in a cohort of African adults

BACKGROUND

Human defensin (HD) 5 and HD6, both Paneth cell alpha-defensins, contribute to the antimicrobial barrier against intestinal infection. We have previously demonstrated that levels of both HD5 and HD6 mRNA were reduced in adults living in urban Zambia, compared with those in adults living in London. The aim of the present study was to determine, during 2 years of follow-up, whether alpha-defensin expression in Zambian adults is related to susceptibility to diarrhea.

METHODS

We analyzed intestinal biopsy samples from a longitudinal cohort study conducted in 83 Zambian adults by quantitative reverse-transcription polymerase chain reaction, Western blotting, immunohistochemistry, and in situ hybridization, and we measured the incidence of diarrhea.

RESULTS

Levels of HD5 and HD6 mRNA in Paneth cells varied between participants, over time, and seasonally and were strongly correlated with mucosal architecture. Gene expression was almost exclusively restricted to Paneth cells. The median (interquartile range) HD5 mRNA level was 6.0 (5.6-6.7) log10 transcripts/microg of total RNA among 18 participants who experienced diarrhea within 2 months after biopsy-sample collection, compared with 6.8 (6.2-7.3) log10 transcripts/microg of total RNA among 94 participants who did not (P=.006). A similar observation was made for HD6.

CONCLUSIONS

These data indicate that intestinal alpha-defensin expression is dynamic and seasonal and suggest that susceptibility to intestinal infection is related to alpha-defensin expression.

Priorities for antiretroviral therapy research in sub-Saharan Africa: a 2002 consensus conference in Zambia

BACKGROUND

A consensus conference was held to discuss priorities for antiretroviral therapy (ART) research in Zambia, one of the world's most heavily HIV-afflicted nations. Zambia, like other resource-limited settings, has increasing access to highly active antiretroviral therapy (HAART) because of declining drug costs, use of government-purchased generic medications, and increased global donations. For sustained delivery of care with HAART in a resource-constrained medical and public health context, operational research is required and clinical trials are desirable. The priority areas for research are most relevant today given the increasing availability of HAART.

METHODS

A conference was held in Lusaka, Zambia, in January 2002 to discuss priority areas for ART research in Zambia, with participants drawn from a broad cross section of Zambian society. State-of-the-art reviews and 6 intensive small group discussions helped to formulate a suggested research agenda.

RESULTS

Conference participants believed that the most urgent research priorities were to assess how therapeutic resources could be applied for the greatest overall benefit and to minimize the impact of nonadherence and viral resistance. Identified research priorities were as follows:Conference participants recommended that HIV-related clinical care and research be integrated within home-based care services and operated within the existing health delivery structures to ensure sustainability, reduce costs, and strengthen the structures.

CONCLUSION

Our consensus was that antiretroviral clinical trials and operational research are essential for Zambia to address the new challenges arising from increasing ART availability. There is global consensus that antiretroviral clinical trials in resource-constrained countries are possible, and the capacity for such trials should be developed further in Africa.

Paneth cell granule depletion in the human small intestine under infective and nutritional stress

Paneth cells are important contributors to the intestinal antimicrobial barrier through synthesis and release of antimicrobial peptides and proteins. Animal studies indicate that Paneth cell numbers, location and granule morphology are altered by infection and zinc status. We examined human tissue to determine whether Paneth cell numbers, distribution or granule morphology are altered in infective, inflammatory and nutritional disorders. Archival sections from infective disorders (giardiasis, cryptosporidiosis, HIV, helminth infection) were compared with active inflammatory conditions (coeliac, Crohn's and graft-versus-host diseases) and histologically normal tissues. A subset of tissues was studied by electron microscopy and TUNEL staining for apoptosis. Human defensin-5 (HD5) peptide and mRNA was analysed by immunohistochemistry, in situ hybridization and quantitative reverse transcription polymerase chain reaction. Sections from a tropical population cohort study were then analysed to determine the relationship of granule depletion to infection, nutritional status and plasma zinc concentration. In HIV-related cryptosporidiosis, but not other disorders, Paneth cells were reduced in number and markedly depleted of granules. Paneth cell granule depletion was associated with reduced HD5 immunoreactivity, but this was not due to apoptosis and there was no reduction in mRNA transcripts. In the tropical population studied, depletion of granules was associated with reduced body mass index, reduced plasma zinc levels and HIV infection. Paneth cell granules in human small intestine may be depleted in response to infective and nutritional stress. We postulate that this is one mechanism through which zinc status influences host susceptibility to intestinal infection.

Elevated blood pressure in HIV-infected individuals receiving highly active antiretroviral therapy

OBJECTIVE

We examined the effects of antiretroviral regimens on blood pressure (BP).

METHOD

This retrospective study examined systolic and diastolic BP (SBP and DBP) measurements among participants of a State of Hawaii Department of Health program from January 1995 to July 2001. The change in BP during four consecutive 6-month visits was estimated using linear regression and was interpreted as the change in BP per year. BP changes among the antiretroviral treatment groups were compared to untreated controls.

RESULTS

Of 1,601 patients identified, 286 met the criteria for inclusion. After adjustment for baseline age, BP, and CD4+ count, there was an increase in SBP by 4.71 mmHg/year (p =.005) and DBP by 2.26 mmHg/year (p =.076) among patients initiating HAART. Among these patients, an increase of 4.75 mmHg/year in SBP (p =.002) and 1.96 mmHg/year in DBP (p =.042) was seen with HAART regimens containing a protease inhibitor (PI) but no nonnucleoside reverse transcriptase inhibitor (NNRTI). In NNRTI-containing HAART regimens without PIs, an increase of 3.21 mmHg/year in SBP (p =.011) and 2.62 mmHg/year in DBP (p =.050) was observed. No significant BP changes were noted with patients on regimens containing only nucleoside reverse transcriptase inhibitors (NRTIs).

CONCLUSION

The use of NNRTI- or PI-containing HAART is associated with elevation of both SBP and DBP in HIV-infected individuals.

Intestinal defensin gene expression in human populations

Defensins are thought to play a major role in the defence of small intestinal crypts against colonisation by potential pathogens. In humans two alpha-defensins, HD5 and HD6 and two beta-defensins, hBD1 and hBD2, probably contribute to the antimicrobial barrier, but there are no data to indicate how the expression of these defensin genes might vary in individuals and in populations. To begin to address this question we developed a competitive reverse transcriptase polymerase chain reaction (RT-PCR) assay to quantify HD5 and HD6 mRNA and used it to measure transcripts in small intestinal biopsy tissue from adults living in London, UK, or in Lusaka, Zambia. We also measured alpha- and beta-defensin mRNA in biopsies collected in London from different regions of the small intestine. Jejunal biopsies (n=169) from 83 adults in Lusaka contained approximately one order of magnitude less HD5 and HD6 mRNA than biopsies (n=33) obtained from 27 adults in London. HD5 and HD6 transcript levels were high throughout duodenum, jejunum and ileum. hBD1 and hBD2 mRNA were detected in some, but not all, biopsies from normal small intestine. These data suggest that alpha-defensin expression is down-regulated in tropical populations, and that there are distinct pathways regulating transcription of alpha- and beta-defensins.

Escherichia coli enterovirulent phenotypes in Zambians with AIDS-related diarrhoea

Persistent diarrhoea is a major cause of morbidity and mortality in AIDS patients, and consequently an important public health problem in sub-Saharan Africa. Although intestinal protozoa and bacteria are detected in many of these patients, a substantial proportion of disease remains unexplained even after intensive investigation. HEp-2 cell adherent Escherichia coli have been described in AIDS patients with persistent diarrhoea, but their contribution to the overall burden of disease is not yet defined. We studied HEp-2 cell adherence of E. coli isolates from 116 adult Zambian AIDS patients and 153 healthy controls obtained in 1993 or 1998-99. Enteroaggregative, enteropathogenic, and diffusely adherent phenotypes were observed in E. coli isolates from both AIDS patients and controls, but cytotoxic phenotypes were only isolated from the AIDS patients. There was no evidence of seasonality in the frequency of isolation, and there was no evidence of long-term carriage. Light and electron microscopy of distal duodenal biopsies did not reveal any bacteria closely associated with the brush border. Isolates were less susceptible to amoxycillin, tetracycline, and sulfonamides than to newer antibiotics. Enterovirulent E. coli appear to contribute to intestinal disease in AIDS patients in Zambia but asymptomatic carriage is common. Antibiotic trials should be carried out.