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Loveday M, Hlangu S, Manickchund P, Govender T, Furin J. 'Not taking medications and taking medication, it was the same thing:' perspectives of antiretroviral therapy among people hospitalised with advanced HIV disease. BMC Infect Dis 2024; 24:819. [PMID: 39138390 PMCID: PMC11320996 DOI: 10.1186/s12879-024-09729-8] [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: 03/05/2024] [Accepted: 08/07/2024] [Indexed: 08/15/2024] Open
Abstract
BACKGROUND Despite HIV's evolution to a chronic disease, the burden of advanced HIV disease (AHD, defined as a CD4 count of < 200 cells/uL or WHO clinical Stage 3 or 4 disease), remains high among People Living with HIV (PLHIV) who have previously been prescribed antiretroviral therapy (ART). As little is known about the experiences of patients hospitalised with AHD, this study sought to discern social forces driving hospitalisation with AHD. Understanding such forces could inform strategies to reduce HIV-related morbidity and mortality. METHODS We conducted a qualitative study with patients hospitalised with AHD who had a history of poor adherence. Semi-structured interviews were conducted between October 1 and November 30, 2023. The Patient Health Engagement and socio-ecological theoretical models were used to guide a thematic analysis of interview transcripts. RESULTS Twenty individuals participated in the research. Most reported repeated periods of disengagement with HIV services. The major themes identified as driving disengagement included: 1) feeling physically well; 2) life circumstances and relationships; and 3) health system factors, such as clinic staff attitudes and a perceived lack of flexible care. Re-engagement with care was often driven by new physical symptoms but was mediated through life circumstances/relationships and aspects of the health care system. CONCLUSIONS Current practices fail to address the challenges to lifelong engagement in HIV care. A bold strategy for holistic care which involves people living with advanced HIV as active members of the health care team (i.e. 'PLHIV as Partners'), could contribute to ensuring health care services are compatible with their lives, reducing periods of disengagement from care.
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Affiliation(s)
- Marian Loveday
- HIV and Other Infectious Diseases Research Unit (HIDRU), South African Medical Research Council, 491 Peter Mokaba Ridge Road, Overport, Durban, KwaZulu-Natal, South Africa.
- Centre for Health Systems Research & Development, University of the Free State, Bloemfontein, South Africa.
- CAPRISA-MRC HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa.
| | - Sindisiwe Hlangu
- HIV and Other Infectious Diseases Research Unit (HIDRU), South African Medical Research Council, 491 Peter Mokaba Ridge Road, Overport, Durban, KwaZulu-Natal, South Africa
| | - Pariva Manickchund
- Internal Medicine, King Edward VIII Hospital, KwaZulu-Natal Department of Health, University of KwaZulu-Natal, Durban, South Africa
| | - Thiloshini Govender
- King Dinuzulu Hospital Complex, KwaZulu-Natal Department of Health, Durban, South Africa
| | - Jennifer Furin
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA
- Division of Infectious Diseases and HIV Medicine, Case Western Reserve University and University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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Zhu X, Patel EU, Berry SA, Grabowski MK, Abraham AG, Davy-Mendez T, Hogan B, Althoff KN, Redd AD, Laeyendecker O, Quinn TC, Gebo KA, Tobian AA. Hospital readmissions among adults living with and without HIV in the US: findings from the Nationwide Readmissions Database. EClinicalMedicine 2024; 73:102690. [PMID: 39007069 PMCID: PMC11246008 DOI: 10.1016/j.eclinm.2024.102690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 05/20/2024] [Accepted: 05/30/2024] [Indexed: 07/16/2024] Open
Abstract
Background Thirty-day hospital readmission measures quality of care, but there are limited data among people with HIV (PWH) and people without HIV (PWoH) in the era of universal recommendation for antiretroviral therapy. We descriptively compared 30-day all-cause, unplanned readmission risk between PWH and PWoH. Methods A retrospective cohort study was conducted using the 2019 Nationwide Readmissions Database (2019/01/01-2019/12/31), an all-payer database that represents all US hospitalizations. Index (initial) admissions and readmissions were determined using US Centers for Medicare & Medicaid Services definitions. Crude and age-adjusted risk ratios (aRR) comparing the 30-day all-cause, unplanned readmission risk between PWH to PWoH were estimated using random effect logistic regressions and predicted marginal estimates. Survey weights were applied to all analyses. Findings We included 24,338,782 index admissions from 18,240,176 individuals. The median age was 52(IQR = 40-60) years for PWH and 61(IQR = 38-74) years for PWoH. The readmission risk was 20.9% for PWH and 12.2% for PWoH (age-adjusted-RR:1.88 [95%CI = 1.84-1.92]). Stratified by age and sex, young female (age 18-29 and 30-39 years) PWH had a higher readmission risk than young female PWoH (aRR = 3.50 [95%CI = 3.11-3.88] and aRR = 4.00 [95%CI = 3.67-4.32], respectively). While the readmission risk increased with age among PWoH, the readmission risk was persistently high across all age groups among PWH. The readmission risk exceeded 30% for PWH admitted for hypertensive heart disease, heart failure, and chronic kidney disease. Interpretation PWH have a disproportionately higher risk of readmission than PWoH, which is concerning given the aging profile of PWH. More efforts are needed to address readmissions among PWH. Funding US National Institutes of Health.
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Affiliation(s)
- Xianming Zhu
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Eshan U. Patel
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Stephen A. Berry
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mary K. Grabowski
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Alison G. Abraham
- Department of Epidemiology, Colorado School of Public Heath, Aurora, CO, USA
| | - Thibaut Davy-Mendez
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Brenna Hogan
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Keri N. Althoff
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Andrew D. Redd
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, Baltimore, MD, USA
| | - Oliver Laeyendecker
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, Baltimore, MD, USA
| | - Thomas C. Quinn
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Division of Intramural Research, National Institute of Allergy and Infectious Diseases, Baltimore, MD, USA
| | - Kelly A. Gebo
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aaron A.R. Tobian
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Hoffmann CJ, Shearer K, Kekana B, Kerrigan D, Moloantoa T, Golub JE, Variava E, Martinson NA. Reducing HIV-Associated Post-Hospital Mortality Through Home-Based Care in South Africa: A Randomized Controlled Trial. Clin Infect Dis 2024; 78:1256-1263. [PMID: 38051643 PMCID: PMC11093672 DOI: 10.1093/cid/ciad727] [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: 08/15/2023] [Revised: 10/24/2023] [Accepted: 12/01/2023] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND Twenty-three percent of people with human immunodeficiency virus (HIV, PWH) die within 6 months of hospital discharge. We tested the hypothesis whether a series of structured home visits could reduce mortality. METHODS We designed a disease neutral home visit package with up to 6 home visits starting 1-week post-hospitalization and every 2 weeks thereafter. The home visit team used a structured assessment algorithm to evaluate and triage social and medical needs of the participant and provide nutritional support. We compared all-cause mortality 6 months following discharge for the intervention compared to usual care in a pilot randomized trial conducted in South Africa. To inform potential scale-up we also included and separately analyzed a group of people without HIV (PWOH). RESULTS We enrolled 125 people with HIV and randomized them 1:1 to the home visit intervention or usual care. Fourteen were late exclusions because of death prior to discharge or delayed discharge leaving 111 for analysis. The median age was 39 years, 31% were men; and 70% had advanced HIV disease. At 6 months among PWH 4 (7.3%) in the home visit arm and 10 (17.9%) in the usual care arm (P = .09) had died. Among the 70 PWOH enrolled overall 6-month mortality was 10.1%. Of those in the home visit arm, 91% received at least one home visit. CONCLUSIONS We demonstrated feasibility of delivering post-hospital home visits and demonstrated preliminary efficacy among PWH with a substantial, but not statistically significant, effect size (59% reduction in mortality). Coronavirus disease 2019 (COVID-19) related challenges resulted in under-enrollment.
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Affiliation(s)
- Christopher J Hoffmann
- Center for Tuberculosis Research, Johns Hopkins University, Baltimore, Maryland, USA
- Division of Infectious Diseases, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Kate Shearer
- Center for Tuberculosis Research, Johns Hopkins University, Baltimore, Maryland, USA
- Division of Infectious Diseases, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Boitumelo Kekana
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Deanna Kerrigan
- Milken Institute School of Public Health, George Washington University, Washington, District of Columbia, USA
| | - Tumelo Moloantoa
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Jonathan E Golub
- Center for Tuberculosis Research, Johns Hopkins University, Baltimore, Maryland, USA
- Division of Infectious Diseases, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Ebrahim Variava
- Department of Internal Medicine, Klerksdorp Tshepong Hospital Complex, North West Department of Health, Klerksdorp, South Africa
| | - Neil A Martinson
- Center for Tuberculosis Research, Johns Hopkins University, Baltimore, Maryland, USA
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
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Zadeh AV, Justicz A, Plate J, Cortelli M, Wang IW, Melvan JN. Human immunodeficiency virus infection is associated with greater risk of pneumonia and readmission after cardiac surgery. JTCVS OPEN 2024; 18:145-155. [PMID: 38690413 PMCID: PMC11056438 DOI: 10.1016/j.xjon.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 12/05/2023] [Accepted: 12/14/2023] [Indexed: 05/02/2024]
Abstract
Objective Human immunodeficiency virus infection (HIV+) is associated with a 2-fold increased risk of cardiovascular disease. Increasingly, patients who are HIV + are being evaluated to undergo cardiac surgery. Current risk-adjusted scoring systems, including the Society of Thoracic Surgeons Predicted Risk of Mortality score, fail to stratify HIV + risk. Unfortunately, there exists a paucity of cardiac surgery outcomes data in modern patients who are HIV+. Methods We conducted a retrospective review of PearlDiver, an all-payer claims administrative database. In total, 14,714,743 patients were captured between 2010 and 2020. Of these, 59,695 (0.4%) of patients had a history of HIV+, and 1759 (2.95%) of these patients underwent cardiac surgery. Patients who were HIV+ were younger, more often male, and had greater comorbidity, history of hypertension, chronic obstructive pulmonary disease, chronic liver disease, chronic kidney disease, chronic lung disease, and heart failure. Results Postoperatively, patients who were HIV + had significantly greater rates of pneumonia (relative risk, 1.70; P = .0003) and 30-day all-cause readmission (relative risk, 1.28, P < .0001). After linear regression analysis, these results remained significant. Data also show that a lesser proportion of patients with HIV + underwent coronary artery bypass grafting, aortic valve replacement, and any cardiac surgery compared with controls. Conclusions Patients who are HIV + undergoing cardiac surgery are at greater risk of pneumonia and readmission. Moreover, we discovered lower rates of cardiac surgery in patients who are HIV+, which may reflect limited access to surgery when indicated. Today's risk-adjusted scoring systems in cardiac surgery need to better account for the modern patient who is HIV+.
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Affiliation(s)
- Ali Vaeli Zadeh
- Division of Cardiology, Holy Cross Hospital, Fort Lauderdale, Fla
| | - Alexander Justicz
- Division of Cardiothoracic Surgery, Holy Cross Hospital, Fort Lauderdale, Fla
| | - Juan Plate
- Division of Cardiac Surgery, Memorial Cardiac and Vascular Institute, Memorial Healthcare System, Hollywood, Fla
| | - Michael Cortelli
- Division of Cardiac Surgery, Memorial Cardiac and Vascular Institute, Memorial Healthcare System, Hollywood, Fla
| | - I-wen Wang
- Division of Cardiac Surgery, Memorial Cardiac and Vascular Institute, Memorial Healthcare System, Hollywood, Fla
| | - John Nicholas Melvan
- Division of Cardiothoracic Surgery, Holy Cross Hospital, Fort Lauderdale, Fla
- Division of Cardiac Surgery, Memorial Cardiac and Vascular Institute, Memorial Healthcare System, Hollywood, Fla
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Peck RN, Issarow B, Kisigo GA, Kabakama S, Okello E, Rutachunzibwa T, Willkens M, Deogratias D, Hashim R, Grosskurth H, Fitzgerald DW, Ayieko P, Lee MH, Murphy SM, Metsch LR, Kapiga S. Linkage Case Management and Posthospitalization Outcomes in People With HIV: The Daraja Randomized Clinical Trial. JAMA 2024; 331:1025-1034. [PMID: 38446792 PMCID: PMC10918579 DOI: 10.1001/jama.2024.2177] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 02/09/2024] [Indexed: 03/08/2024]
Abstract
Importance Despite the widespread availability of antiretroviral therapy (ART), people with HIV still experience high mortality after hospital admission. Objective To determine whether a linkage case management intervention (named "Daraja" ["bridge" in Kiswahili]) that was designed to address barriers to HIV care engagement could improve posthospital outcomes. Design, Setting, and Participants Single-blind, individually randomized clinical trial to evaluate the effectiveness of the Daraja intervention. The study was conducted in 20 hospitals in Northwestern Tanzania. Five hundred people with HIV who were either not treated (ART-naive) or had discontinued ART and were hospitalized for any reason were enrolled between March 2019 and February 2022. Participants were randomly assigned 1:1 to receive either the Daraja intervention or enhanced standard care and were followed up for 12 months through March 2023. Intervention The Daraja intervention group (n = 250) received up to 5 sessions conducted by a social worker at the hospital, in the home, and in the HIV clinic over a 3-month period. The enhanced standard care group (n = 250) received predischarge HIV counseling and assistance in scheduling an HIV clinic appointment. Main Outcomes and Measures The primary outcome was all-cause mortality at 12 months after enrollment. Secondary outcomes related to HIV clinic attendance, ART use, and viral load suppression were extracted from HIV medical records. Antiretroviral therapy adherence was self-reported and pharmacy records confirmed perfect adherence. Results The mean age was 37 (SD, 12) years, 76.8% were female, 35.0% had CD4 cell counts of less than 100/μL, and 80.4% were ART-naive. Intervention fidelity and uptake were high. A total of 85 participants (17.0%) died (43 in the intervention group; 42 in the enhanced standard care group); mortality did not differ by trial group (17.2% with intervention vs 16.8% with standard care; hazard ratio [HR], 1.01; 95% CI, 0.66-1.55; P = .96). The intervention, compared with enhanced standard care, reduced time to HIV clinic linkage (HR, 1.50; 95% CI, 1.24-1.82; P < .001) and ART initiation (HR, 1.56; 95% CI, 1.28-1.89; P < .001). Intervention participants also achieved higher rates of HIV clinic retention (87.4% vs 76.3%; P = .005), ART adherence (81.1% vs 67.6%; P = .002), and HIV viral load suppression (78.6% vs 67.1%; P = .01) at 12 months. The mean cost of the Daraja intervention was about US $22 per participant including startup costs. Conclusions and Relevance Among hospitalized people with HIV, a linkage case management intervention did not reduce 12-month mortality outcomes. These findings may help inform decisions about the potential role of linkage case management among hospitalized people with HIV. Trial Registration ClinicalTrials.gov Identifier: NCT03858998.
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Affiliation(s)
- Robert N. Peck
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, New York
- Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania
- Department of Medicine, Weill Bugando School of Medicine, Mwanza, Tanzania
| | - Benson Issarow
- Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania
| | - Godfrey A. Kisigo
- Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Severin Kabakama
- Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania
| | - Elialilia Okello
- Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania
| | - Thomas Rutachunzibwa
- Ministry of Health, Community Development, Gender, Elderly, and Children, Mwanza, Tanzania
| | - Megan Willkens
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Derick Deogratias
- Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania
| | - Ramadhan Hashim
- Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania
| | - Heiner Grosskurth
- Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Daniel W. Fitzgerald
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Philip Ayieko
- Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Myung Hee Lee
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Sean M. Murphy
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Lisa R. Metsch
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, New York
| | - Saidi Kapiga
- Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Kim JY, Lee HY, Lee J, Oh DK, Lee SY, Park MH, Lim CM, Lee SM. Pre-Sepsis Length of Hospital Stay and Mortality: A Nationwide Multicenter Cohort Study. J Korean Med Sci 2024; 39:e87. [PMID: 38469963 PMCID: PMC10927387 DOI: 10.3346/jkms.2024.39.e87] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 01/08/2024] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND Prolonged length of hospital stay (LOS) is associated with an increased risk of hospital-acquired conditions and worse outcomes. We conducted a nationwide, multicenter, retrospective cohort study to determine whether prolonged hospitalization before developing sepsis has a negative impact on its prognosis. METHODS We analyzed data from 19 tertiary referral or university-affiliated hospitals between September 2019 and December 2020. Adult patients with confirmed sepsis during hospitalization were included. In-hospital mortality was the primary outcome. The patients were divided into two groups according to their LOS before the diagnosis of sepsis: early- (< 5 days) and late-onset groups (≥ 5 days). Conditional multivariable logistic regression for propensity score matched-pair analysis was employed to assess the association between late-onset sepsis and the primary outcome. RESULTS A total of 1,395 patients were included (median age, 68.0 years; women, 36.3%). The early- and late-onset sepsis groups comprised 668 (47.9%) and 727 (52.1%) patients. Propensity score-matched analysis showed an increased risk of in-hospital mortality in the late-onset group (adjusted odds ratio [aOR], 3.00; 95% confidence interval [CI], 1.69-5.34). The same trend was observed in the entire study population (aOR, 1.85; 95% CI, 1.37-2.50). When patients were divided into LOS quartile groups, an increasing trend of mortality risk was observed in the higher quartiles (P for trend < 0.001). CONCLUSION Extended LOS before developing sepsis is associated with higher in-hospital mortality. More careful management is required when sepsis occurs in patients hospitalized for ≥ 5 days.
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Affiliation(s)
- Joong-Yub Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Hong Yeul Lee
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jinwoo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Dong Kyu Oh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Su Yeon Lee
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Mi Hyeon Park
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chae-Man Lim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang-Min Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea.
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Owachi D, Akatukunda P, Nanyanzi DS, Katwesigye R, Wanyina S, Muddu M, Kawuma S, Kalema N, Kabugo C, Semitala FC. Mortality and associated factors among people living with HIV admitted at a tertiary-care hospital in Uganda: a cross-sectional study. BMC Infect Dis 2024; 24:239. [PMID: 38388345 PMCID: PMC10885437 DOI: 10.1186/s12879-024-09112-7] [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: 08/18/2023] [Accepted: 02/07/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND Hospital admission outcomes for people living with HIV (PLHIV) in resource-limited settings are understudied. We describe in-hospital mortality and associated clinical-demographic factors among PLHIV admitted at a tertiary-level public hospital in Uganda. METHODS We performed a cross-sectional analysis of routinely collected data for PLHIV admitted at Kiruddu National Referral Hospital between March 2020 and March 2023. We estimated the proportion of PLHIV who had died during hospitalization and performed logistic regression modelling to identify predictors of mortality. RESULTS Of the 5,827 hospitalized PLHIV, the median age was 39 years (interquartile range [IQR] 31-49) and 3,293 (56.51%) were female. The median CD4 + cell count was 109 cells/µL (IQR 25-343). At admission, 3,710 (63.67%) were active on antiretroviral therapy (ART); 1,144 (19.63%) had interrupted ART > 3 months and 973 (16.70%) were ART naïve. In-hospital mortality was 26% (1,524) with a median time-to-death of 3 days (IQR 1-7). Factors associated with mortality (with adjusted odds ratios) included ART interruption, 1.33, 95% confidence intervals (CI) 1.13-1.57, p 0.001; CD4 + counts ≤ 200 cells/µL 1.59, 95%CI 1.33-1.91, p < 0.001; undocumented CD4 + cell count status 2.08, 95%CI 1.73-2.50, p < 0.001; impaired function status 7.35, 95%CI 6.42-8.41, p < 0.001; COVID-19 1.70, 95%CI 1.22-2.37, p 0.002; liver disease 1.77, 95%CI 1.36-2.30, p < 0.001; co-infections 1.53, 95%CI 1.32-1.78, p < 0.001; home address > 20 km from hospital 1.23, 95%CI 1.04-1.46, p 0.014; hospital readmission 0.7, 95%CI 0.56-0.88, p 0.002; chronic lung disease 0.62, 95%CI 0.41-0.92, p 0.019; and neurologic disease 0.46, 95%CI 0.32-0.68, p < 0.001. CONCLUSION One in four admitted PLHIV die during hospitalization. Identification of risk factors (such as ART interruption, function impairment, low/undocumented CD4 + cell count), early diagnosis and treatment of co-infections and liver disease could improve outcomes.
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Affiliation(s)
- Darius Owachi
- Kiruddu National Referral Hospital, Kampala, P.O. BOX 6588, Uganda.
| | | | | | | | | | - Martin Muddu
- Makerere University Joint AIDS Program, Kampala, Uganda
| | - Samuel Kawuma
- Makerere University Joint AIDS Program, Kampala, Uganda
| | | | - Charles Kabugo
- Kiruddu National Referral Hospital, Kampala, P.O. BOX 6588, Uganda
| | - Fred C Semitala
- Makerere University Joint AIDS Program, Kampala, Uganda
- Department of Medicine, Makerere University, Kampala, Uganda
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Ahmed MH, Ahmed F, Abu-Median AB, Panourgia M, Owles H, Ochieng B, Ahamed H, Wale J, Dietsch B, Mital D. HIV and an Ageing Population-What Are the Medical, Psychosocial, and Palliative Care Challenges in Healthcare Provisions. Microorganisms 2023; 11:2426. [PMID: 37894084 PMCID: PMC10608969 DOI: 10.3390/microorganisms11102426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 09/24/2023] [Accepted: 09/26/2023] [Indexed: 10/29/2023] Open
Abstract
The continuing increase in patient numbers and improvement in healthcare provisions of HIV services in the UK, alongside the effectiveness of combined antiretroviral therapy (cART), has resulted in increasing numbers of the ageing population among people living with HIV (PLWH). It is expected that geriatricians will need to deal with many older people living with HIV (OPLWH) as life expectancy increases. Therefore, geriatric syndromes in OPLWH will be similar to the normal population, such as falls, cognitive decline, frailty, dementia, hypertension, diabetes and polypharmacy. The increase in the long-term use of cART, diabetes, dyslipidaemia and hypertension may lead to high prevalence of cardiovascular disease (CVD). The treatment of such conditions may lead to polypharmacy and may increase the risk of cART drug-drug interactions. In addition, the risk of developing infection and cancer is high. OPLWH may develop an early onset of low bone mineral density (BMD), osteoporosis and fractures. In this review, we have also provided potential psychosocial aspects of an ageing population with HIV, addressing issues such as depression, stigma, isolation and the need for comprehensive medical and psychosocial care through an interdisciplinary team in a hospital or community setting. OPLWH have a relatively high burden of physical, psychological, and spiritual needs and social difficulties, which require palliative care. The holistic type of palliative care that will improve physical, emotional and psychological wellbeing is discussed in this review.
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Affiliation(s)
- Mohamed H. Ahmed
- Department of Medicine and HIV Metabolic Clinic, Milton Keynes University Hospital NHS Foundation Trust, Eaglestone, Milton Keynes MK6 5LD, UK
- Department of Geriatric Medicine, Milton Keynes University Hospital NHS Foundation Trust, Eaglestone, Milton Keynes MK6 5LD, UK
| | - Fatima Ahmed
- Tele-Geriatric Research Fellowship, Geriatric Division, Family Medicine Department, Michigan State University, East Lansing, MI 48824, USA
| | - Abu-Bakr Abu-Median
- Leicester School of Allied Health Sciences, Faculty of Health and Life Sciences, De Montfort University, Leicester LE1 9BH, UK
| | - Maria Panourgia
- Department of Geriatric Medicine, Milton Keynes University Hospital NHS Foundation Trust, Eaglestone, Milton Keynes MK6 5LD, UK
| | - Henry Owles
- Department of Geriatric Medicine, Milton Keynes University Hospital NHS Foundation Trust, Eaglestone, Milton Keynes MK6 5LD, UK
| | - Bertha Ochieng
- Leicester School of Allied Health Sciences, Faculty of Health and Life Sciences, De Montfort University, Leicester LE1 9BH, UK
| | - Hassan Ahamed
- Tele-Geriatric Research Fellowship, Geriatric Division, Family Medicine Department, Michigan State University, East Lansing, MI 48824, USA
| | - Jane Wale
- Department of Palliative Medicine, Milton Keynes University Hospital NHS Foundation Trust, Eaglestone, Milton Keynes MK6 5LD, UK
| | - Benjamin Dietsch
- Department of Palliative Medicine, Milton Keynes University Hospital NHS Foundation Trust, Eaglestone, Milton Keynes MK6 5LD, UK
| | - Dushyant Mital
- Department of HIV and Blood Borne Virus, Milton Keynes University Hospital NHS Foundation Trust, Eaglestone, Milton Keynes MK6 5LD, UK
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9
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Lehman A, Ellis J, Nalintya E, Bahr NC, Loyse A, Rajasingham R. Advanced HIV disease: A review of diagnostic and prophylactic strategies. HIV Med 2023; 24:859-876. [PMID: 37041113 PMCID: PMC10642371 DOI: 10.1111/hiv.13487] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 03/13/2023] [Indexed: 04/13/2023]
Abstract
BACKGROUND Despite expanded access to antiretroviral therapy (ART) and the rollout of the World Health Organization's (WHO) 'test-and-treat' strategy, the proportion of people with HIV (PWH) presenting with advanced HIV disease (AHD) remains unchanged at approximately 30%. Fifty percent of persons with AHD report prior engagement to care. ART failure and insufficient retention in HIV care are major causes of AHD. People living with AHD are at high risk for opportunistic infections and death. In 2017, the WHO published guidelines for the management of AHD that included a comprehensive package of care for screening and prophylaxis of major opportunistic infections (OIs). In the interim, ART regimens have evolved: integrase inhibitors are first-line therapy globally, and the diagnostic landscape is evolving. The objective of this review is to highlight novel point-of-care (POC) diagnostics and treatment strategies that can facilitate OI screening and prophylaxis for persons with AHD. METHODS We reviewed the WHO guidelines for recommendations for persons with AHD. We summarized the scientific literature on current and emerging diagnostics, along with emerging treatment strategies for persons with AHD. We also highlight the key research and implementation gaps together with potential solutions. RESULTS While POC CD4 testing is being rolled out in order to identify persons with AHD, this alone is insufficient; implementation of the Visitect CD4 platform has been challenging given operational and test interpretation issues. Numerous non-sputum POC TB diagnostics are being evaluated, many with limited sensitivity. Though imperfect, these tests are designed to provide rapid results (within hours) and are relatively affordable for resource-poor settings. While novel POC diagnostics are being developed for cryptococcal infection, histoplasmosis and talaromycosis, implementation science studies are urgently needed to understand the clinical benefit of these tests in the routine care. CONCLUSIONS Despite progress with HIV treatment and prevention, a persistent 20%-30% of PWH present to care with AHD. Unfortunately, these persons with AHD continue to carry the burden of HIV-related morbidity and mortality. Investment in the development of additional POC or near-bedside CD4 platforms is urgently needed. Implementation of POC diagnostics theoretically could improve HIV retention in care and thereby reduce mortality by overcoming delays in laboratory testing and providing patients and healthcare workers with timely same-day results. However, in real-world scenarios, people with AHD have multiple comorbidities and imperfect follow-up. Pragmatic clinical trials are needed to understand whether these POC diagnostics can facilitate timely diagnosis and treatment, thereby improving clinical outcomes such as HIV retention in care.
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Affiliation(s)
- Alice Lehman
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jayne Ellis
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Nathan C. Bahr
- Division of Infectious Diseases, University of Kansas, Kansas City, Kansas, USA
| | - Angela Loyse
- Division of Infection and Immunity Research Institute, St George’s University of London, London, UK
| | - Radha Rajasingham
- Division of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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10
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Burke RM, Feasey N, Rangaraj A, Camps MR, Meintjes G, El-Sadr WM, Ford N. Ending AIDS deaths requires improvements in clinical care for people with advanced HIV disease who are seriously ill. Lancet HIV 2023; 10:e482-e484. [PMID: 37301220 PMCID: PMC7614731 DOI: 10.1016/s2352-3018(23)00109-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 04/12/2023] [Accepted: 05/04/2023] [Indexed: 06/12/2023]
Abstract
Over 4 million adults are living with advanced HIV disease with approximately 650 000 fatalities from HIV reported in 2021. People with advanced HIV disease have low immunity and can present to health services in two ways: those who are well but at high risk of developing severe disease, and those who are severely ill. These two groups require specific management approaches that place different demands on the health system. The first group can generally be supported in primary care settings but require differentiated care to meet their needs. The second group are at high risk of death and need focused diagnostics and clinical care, and possibly hospitalisation. Investments in high-quality clinical management of patients with advanced HIV disease who are seriously ill at primary care or hospital level (often only for a brief period of time during their acute illness) improves the likelihood that their condition will stabilise and that they will recover. Providing high-quality and safe clinical care that is accessible to these groups of people living with HIV who are at risk of severe illness and death is a key priority for reaching the global target of zero AIDS deaths.
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Affiliation(s)
- Rachael M Burke
- Malawi Liverpool Wellcome Research Programme, Blantyre, Malawi; Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
| | - Nicholas Feasey
- Malawi Liverpool Wellcome Research Programme, Blantyre, Malawi; Liverpool School of Tropical Medicine, Liverpool, UK
| | - Ajay Rangaraj
- Global HIV, STIs and Hepatitis Programme, WHO, Geneva, Switzerland
| | | | - Graeme Meintjes
- Department of Medicine, Wellcome Centre for Infectious Diseases Research in Africa and Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Wafaa M El-Sadr
- ICAP, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Nathan Ford
- Global HIV, STIs and Hepatitis Programme, WHO, Geneva, Switzerland; Centre for Infectious Disease and Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
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11
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Burke RM, Twabi HH, Johnston C, Nliwasa M, Gupta-Wright A, Fielding K, Ford N, MacPherson P, Corbett EL. Interventions to reduce deaths in people living with HIV admitted to hospital in low- and middle-income countries: A systematic review. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001557. [PMID: 36963024 PMCID: PMC10022356 DOI: 10.1371/journal.pgph.0001557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 01/11/2023] [Indexed: 02/24/2023]
Abstract
People living with HIV (PLHIV) admitted to hospital have a high risk of death. We systematically appraised evidence for interventions to reduce mortality among hospitalised PLHIV in low- and middle-income countries (LMICs). Using a broad search strategy with terms for HIV, hospitals, and clinical trials, we searched for reports published between 1 Jan 2003 and 23 August 2021. Studies of interventions among adult HIV positive inpatients in LMICs were included if there was a comparator group and death was an outcome. We excluded studies restricted only to inpatients with a specific diagnosis (e.g. cryptococcal meningitis). Of 19,970 unique studies identified in search, ten were eligible for inclusion with 7,531 participants in total: nine randomised trials, and one before-after study. Three trials investigated systematic screening for tuberculosis; two showed survival benefit for urine TB screening vs. no urine screening, and one which compared Xpert MTB/RIF versus smear microscopy showed no difference in survival. One before-after study implemented 2007 WHO guidelines to improve management of smear negative tuberculosis in severely ill PLHIV, and showed survival benefit but with high risk of bias. Two trials evaluated complex interventions aimed at overcoming barriers to ART initiation in newly diagnosed PLHIV, one of which showed survival benefit and the other no difference. Two small trials evaluated early inpatient ART start, with no difference in survival. Two trials investigated protocol-driven fluid resuscitation for emergency-room attendees meeting case-definitions for sepsis, and showed increased mortality with use of a protocol for fluid administration. In conclusion, ten studies published since 2003 investigated interventions that aimed to reduce mortality in hospitalised adults with HIV, and weren't restricted to people with a defined disease diagnosis. Inpatient trials of diagnostics, therapeutics or a package of interventions to reduce mortality should be a research priority. Trial registration: PROSPERO Number: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019150341.
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Affiliation(s)
- Rachael M. Burke
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Malawi Liverpool Wellcome Clinical Research Programme, Blanytre, Malawi
| | - Hussein H. Twabi
- Helse Nord Tuberculosis Initiative, Kamuzu University of Health Science, Blantyre, Malawi
| | - Cheryl Johnston
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Global HIV, Hepatitis, STI Programme, World Health Organisation, Geneva, Switzerland
| | - Marriott Nliwasa
- Helse Nord Tuberculosis Initiative, Kamuzu University of Health Science, Blantyre, Malawi
| | - Ankur Gupta-Wright
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Division of Infection and Immunity, University College London, London, United Kingdom
| | - Katherine Fielding
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Nathan Ford
- Global HIV, Hepatitis, STI Programme, World Health Organisation, Geneva, Switzerland
| | - Peter MacPherson
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Malawi Liverpool Wellcome Clinical Research Programme, Blanytre, Malawi
- School of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Elizabeth L. Corbett
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Malawi Liverpool Wellcome Clinical Research Programme, Blanytre, Malawi
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12
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Advanced HIV disease and health-related suffering-exploring the unmet need of palliative care. Lancet HIV 2023; 10:e126-e133. [PMID: 36427522 PMCID: PMC7614396 DOI: 10.1016/s2352-3018(22)00295-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 09/29/2022] [Accepted: 09/30/2022] [Indexed: 11/24/2022]
Abstract
With more than 38 million people living with HIV worldwide, the scale-up of antiretroviral therapy ensures nearly 28 million of them receive regular treatment. However, a substantial number of deaths still occur every year from AIDS-related complications, with approximately 680 000 deaths in 2021. Of the estimated 56·8 million people globally in need of palliative care in 2020, only 7 million can access services. Providing palliative care services can help alleviate health-related suffering, such as pain and disease-related symptoms, and improve wellbeing. This Viewpoint discusses the unrealised potential of palliative care in individuals with advanced HIV disease. Key areas of training for health-care workers include appropriate sensitisation, training in palliative care, and effective communication. Advance care planning supports both the individual and their family and is therefore of crucial importance. Integration of palliative care in HIV programmes is needed to address health-related suffering, particularly for advanced HIV disease.
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13
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Bakewell N, Kanitkar T, Dissanayake O, Symonds M, Rimmer S, Adlakha A, Lipman MC, Bhagani S, Agarwal B, Miller RF, Sabin CA. Estimating the risk of mortality attributable to recent late HIV diagnosis following admission to the intensive care unit: A single-centre observational cohort study. HIV Med 2022; 23:1163-1172. [PMID: 36404292 PMCID: PMC10099479 DOI: 10.1111/hiv.13436] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 10/18/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Despite improvements in survival of people with HIV admitted to the intensive care unit (ICU), late diagnosis continues to contribute to in-ICU mortality. We quantify the population attributable fraction (PAF) of in-ICU mortality for recent late diagnosis among people with HIV admitted to a London ICU. METHODS Index ICU admissions among people with HIV were considered from 2000 to 2019. Recent late diagnosis was a CD4 T-cell count < 350 cells/μL and/or AIDS-defining illness at/within 6 months prior to ICU admission. Univariate comparisons were conducted using Wilcoxon rank-sum/Cochran-Armitage/χ2 /Fisher's exact tests. We used Poisson regression (robust standard errors) to estimate unadjusted/adjusted (age, sex, calendar year of ICU admission) risk ratios (RRs) and regression standardization to estimate the PAF. RESULTS In all, 207 index admissions were included [median (interquartile range) age: 46 (38-53) years; 72% male]; 58 (28%) had a recent late diagnosis, all of whom had a CD4 count < 350 cells/μL, and 95% had advanced HIV (CD4 count < 200 cells/μL and/or AIDS at admission) as compared with 57% of those who did not have a recent late diagnosis (p < 0.001). In-ICU mortality was 27% (55/207); 38% versus 22% in those who did and did not have a recent late diagnosis, respectively (p = 0.02). Recent late diagnosis was independently associated with increased in-ICU mortality risk (adjusted RR = 1.75) (95% confidence interval: 1.05-2.91), with 17.08% (16.04-18.12%) of deaths being attributable to this. CONCLUSIONS There is a need for improved public health efforts focused on HIV testing and reporting of late diagnosis to better understand potentially missed opportunities for earlier HIV diagnosis in healthcare services.
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Affiliation(s)
- Nicholas Bakewell
- Institute for Global Health, University College London, London, UK.,National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Blood Borne and Sexually Transmitted Infections, University College London, London, UK
| | - Tanmay Kanitkar
- Intensive Care Unit, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK.,HIV services, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Oshani Dissanayake
- HIV services, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Maggie Symonds
- HIV services, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Stephanie Rimmer
- Intensive Care Unit, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Amit Adlakha
- Intensive Care Unit, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Marc C Lipman
- HIV services, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK.,UCL Respiratory, Division of Medicine, University College London, London, UK.,Respiratory Medicine, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Sanjay Bhagani
- HIV services, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Banwari Agarwal
- Intensive Care Unit, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Robert F Miller
- HIV services, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK.,Centre for Clinical Research in Infection and Sexual Health, Institute for Global Health, University College London, London, UK
| | - Caroline A Sabin
- Institute for Global Health, University College London, London, UK.,National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Blood Borne and Sexually Transmitted Infections, University College London, London, UK
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14
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Laher AE. Improving outcomes after hospitalisation in people with HIV. Lancet HIV 2022; 9:e140-e141. [PMID: 35245504 DOI: 10.1016/s2352-3018(22)00007-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 01/05/2022] [Indexed: 06/14/2023]
Affiliation(s)
- Abdullah E Laher
- Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2193, South Africa.
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