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Kay A, Lukhele B, Dlamini S, Seeger A, Dlamini P, Ndabezitha S, Mthethwa N, Steffy T, Komba L, Amuge P, Ketangenyi E, Elyanu P, Munthali A, Msekandiana A, Maldonado Y, Chiao E, Kekitiinwa A, Thahane L, Mwita L, Kirchner HL, Mandalakas AM. Predicting mortality within 1 year of ART initiation in children and adolescents living with HIV in sub-Saharan Africa: a retrospective observational cohort study. Lancet Glob Health 2024; 12:e929-e937. [PMID: 38762295 PMCID: PMC11149103 DOI: 10.1016/s2214-109x(24)00091-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 01/26/2024] [Accepted: 02/22/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Differentiated service delivery (DSD) for children and adolescents living with HIV can improve targeted resource use. We derived a mortality prediction score to guide clinical decision making for children and adolescents living with HIV. METHODS Data for this retrospective observational cohort study were evaluated for all children and adolescents living with HIV and initiating antiretroviral therapy (ART); aged 0-19 years; and enrolled at Baylor clinics in Eswatini, Malawi, Lesotho, Tanzania, and Uganda between 2005 and 2020. Data for clinical prediction, including anthropometric values, physical examination, ART, WHO stage, and laboratory tests were captured at ART initiation. Backward stepwise variable selection and logistic regression were performed to develop predictive models for mortality within 1 year of ART initiation. Probabilities of mortality were generated, compared with true outcomes, internally validated, and evaluated against WHO advanced HIV criteria. FINDINGS The study population included 16 958 children and adolescents living with HIV and initiated on ART between May 18, 2005, and Dec 18, 2020. Predictive variables for the most accurate model included: age, CD4 percentage, white blood cell count, haemoglobin concentration, platelet count, and BMI Z score as continuous variables, and WHO clinical stage and oedema, abnormal muscle tone and respiratory distress on examination as categorical variables. The area under the curve (AUC) of the predictive model was 0·851 (95% CI 0·839-0·863) in the training set and 0·822 (0·800-0·845) in the test set, compared with 0·606 (0·595-0·617) for the WHO advanced HIV criteria (p<0·0001). INTERPRETATION This study evaluated a large, multinational population to derive a mortality prediction tool for children and adolescents living with HIV. The model more accurately predicted clinical outcomes than the WHO advanced HIV criteria and has the potential to improve DSD for children and adolescents living with HIV in high-burden settings. FUNDING National Institute of Health Fogarty International Center.
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Affiliation(s)
- Alexander Kay
- Baylor College of Medicine, Houston, TX, USA; Baylor College of Medicine Children's Foundation-Eswatini, Mbabane, Eswatini.
| | - Bhekumusa Lukhele
- Department of Health Policy and Organization, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sandile Dlamini
- Baylor College of Medicine Children's Foundation-Eswatini, Mbabane, Eswatini
| | | | - Phumzile Dlamini
- Baylor College of Medicine Children's Foundation-Eswatini, Mbabane, Eswatini
| | - Sandile Ndabezitha
- Baylor College of Medicine Children's Foundation-Eswatini, Mbabane, Eswatini
| | | | - Teresa Steffy
- Baylor College of Medicine, Houston, TX, USA; Baylor College of Medicine Children's Foundation-Lesotho, Maseru, Lesotho
| | - Lilian Komba
- Baylor College of Medicine Children's Foundation-Tanzania, Mbeya and Mwanza, Tanzania
| | - Pauline Amuge
- Baylor College of Medicine Children's Foundation-Uganda, Kampala, Uganda
| | - Eunice Ketangenyi
- Baylor College of Medicine Children's Foundation-Tanzania, Mbeya and Mwanza, Tanzania
| | - Peter Elyanu
- Baylor College of Medicine Children's Foundation-Uganda, Kampala, Uganda
| | - Adamson Munthali
- Baylor College of Medicine Children's Foundation-Malawi, Lilongwe, Malawi
| | - Amos Msekandiana
- Baylor College of Medicine Children's Foundation-Malawi, Lilongwe, Malawi
| | - Yvonne Maldonado
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | | | - Adeodata Kekitiinwa
- Baylor College of Medicine, Houston, TX, USA; Baylor College of Medicine Children's Foundation-Uganda, Kampala, Uganda
| | - Lineo Thahane
- Baylor College of Medicine, Houston, TX, USA; Baylor College of Medicine Children's Foundation-Lesotho, Maseru, Lesotho
| | - Lumumba Mwita
- Baylor College of Medicine, Houston, TX, USA; Baylor College of Medicine Children's Foundation-Tanzania, Mbeya and Mwanza, Tanzania
| | - H Lester Kirchner
- Baylor College of Medicine, Houston, TX, USA; Department of Population Health Sciences, Geisinger Health, Danville, VA, USA
| | - Anna Maria Mandalakas
- Baylor College of Medicine, Houston, TX, USA; Research Center Borstel, Sülfeld, Germany
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Nyandiko W, Enjema NA, Mugo R, Apondi E, Sang E, Mwangi A. Predictors of Mortality Among Children and Adolescents Living With HIV on Antiretroviral Therapy in Western Kenya. J Acquir Immune Defic Syndr 2024; 95:383-390. [PMID: 38133591 PMCID: PMC10896189 DOI: 10.1097/qai.0000000000003361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 11/14/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Antiretroviral therapy (ART) has decreased HIV-attributable deaths; however, children and adolescents continue to have high HIV-associated mortality. SETTING We determined the predictors of death among children and young adolescents living with HIV (CALWH) who died while in care in Western Kenya. METHODS This retrospective case-control study used electronically abstracted data of 6234 CALWH who received care in Academic Model Providing Access to Healthcare HIV clinics in Western Kenya between January 2002 and November 2022. The cases comprised CALWH who were reported dead by November 2022, while the controls constituted of matched CALWH who were alive and in care. Independent predictors of mortality were determined using univariable and multivariable Cox proportional hazard regression models. Kaplan-Meier analysis ascertained survival. RESULTS Of the 6234 participants enrolled, slightly more than half were male (51.7%). The mean (SD) age at the start of ART was significantly lower in cases than in controls at 6.01 (4.37) and 6.62 (4.11) ( P < 0.001), respectively. An age of 11 years or older at start of ART (adjusted Hazard Ratio [aHR]: 8.36 [3.60-19.40]), both parents being alive (aHR: 3.06 [1.67-5.60]), underweight (aHR: 1.82 [1.14-2.92]), and World Health Organization stages 3 (aHR: 2.63 [1.12-6.18]) and 4 (aHR: 2.20 [0.94-5.18]) increased mortality; while school attendance (aHR: 0.12 [0.06-0.21]), high CD4 + counts >350 cells/mm 3 (aHR: 0.79 [0.48-1.29]), and low first viral load <1000 copies/mL (aHR: 0.24 [0.14-0.40]) were protective. CONCLUSION Independent predictors of mortality were age 11 years or older at the start of ART, orphan status, underweight, and advanced HIV disease. Beyond the provision of universal ART, care accorded to CALWH necessitates optimization through tackling individual predictors of mortality.
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Affiliation(s)
- Winstone Nyandiko
- Department of Child Health and Paediatrics, Moi University School of Medicine, Eldoret, Kenya
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Njie Albertine Enjema
- Department of Child Health and Paediatrics, Moi University School of Medicine, Eldoret, Kenya
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Richard Mugo
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Edith Apondi
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
- Directorate of Paediatrics, Moi Teaching and Referral Hospital Eldoret, Kenya; and
| | - Edwin Sang
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Ann Mwangi
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
- Department of Mathematics, Physics and Computing, Moi University Eldoret, Kenya
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Bekolo C, Ndeso S, Gougue C, Moifo L, Mangala N, Tchendjou P, Mboh E, Ateudjieu J, Tendongfor N, Nsagha D, Halle-Ekane G, Choukem S. The effect of the Universal Test and Treat policy uptake on CD4 count testing and incidence of opportunistic infections among people living with HIV infection in Cameroon: a retrospective analysis of routine data. DIALOGUES IN HEALTH 2023; 2:100120. [PMID: 38515498 PMCID: PMC10954022 DOI: 10.1016/j.dialog.2023.100120] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 02/05/2023] [Accepted: 02/23/2023] [Indexed: 03/23/2024]
Abstract
Background Cameroon adopted and started implementing in 2016, the 'universal test and treat' (UTT) guidelines to fast-track progress towards the 95-95-95 ambitious targets to end the HIV epidemic. UTT has shown inconsistent results elsewhere and has not yet been assessed in Cameroon. We aimed to evaluate the effectiveness of this novel approach on the quality of care and health outcomes of people living with HIV (PLHIV). Methods A retrospective cohort design was conducted at The Nkongsamba Regional Hospital, using routine clinical service delivery data to measure uptake levels of UTT and CD4 testing, and to compare the incidence of opportunistic infections (OI) between PLHIV initiated on ART based on the "Universal Test and Treat" strategy and those initiated on ART based on the standard deferred approach between 2002 and 2020. Kaplan Meier plots and log-rank tests were used to compare OI events between the pre-UTT and post-UTT eras. The Cox regression model was used to screen for factors independently associated with the risk of acquisition of OI. Results The uptake of UTT ranged from 39.1% to 92.8% while baseline CD4 count testing reduced drastically from 89.4% to 0.4% between 2016 to 2020 respectively. The median delay in ART initiation declined significantly from 21 days (IQR: 9 - 113) in the pre-UTT era to the same day of diagnosis (IQR: 0 - 2) in the UTT era (p < 0.001). The incidence of all OI events reported was over five times higher during the UTT era than in the pre-UTT era [aHR = 5.55 (95% CI: 3.18 - 9.69), p < 0.001]. Conclusion The UTT policy has been effectively rolled out and has contributed to improved access to rapid and immediate ART initiation, but a higher incidence of OIs was observed with a rollback of baseline CD4 testing. We advocate for a return to routine baseline CD4 measurement to identify PLHIV who should benefit from interventions to prevent OIs for optimal outcomes under the UTT approach.
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Affiliation(s)
- C.E. Bekolo
- Department of Public Health, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
- Department of Public Health and Hygiene, Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - S.A. Ndeso
- Department of Public Health and Hygiene, Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - C.P. Gougue
- Department of Public Health, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
| | - L.L. Moifo
- Department of Public Health, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
| | - N. Mangala
- Department of Gynaecology and Obstetrics, University of Douala, Douala, Cameroon
| | - P. Tchendjou
- Elizabeth Glaser Pediatric AIDS Foundation, EGPAF Yaounde, Yaounde, Cameroon
| | - E. Mboh
- Cameroon Baptist Convention Health Services, Bamenda, Cameroon
| | - J. Ateudjieu
- Department of Public Health, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
| | - N. Tendongfor
- Department of Public Health and Hygiene, Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - D.S. Nsagha
- Department of Public Health and Hygiene, Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - G.E. Halle-Ekane
- Department of Obstetrics and Gynaecology, University of Buea, Buea, Cameroon
| | - S.P. Choukem
- Department of Internal Medicine and Specialities, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
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Akanbi MO, Bilaver LA, Achenbach C, Hirschhorn LR, Rivera AS, Adekolujo OS, Adekola KUA, Silas OA, Agaba PA, Agbaji O, Shehu NY, Sagay SA, Hou L, Murphy RL. Incident Kaposi sarcoma during the expansion of antiretroviral therapy eligibility in Nigeria: a retrospective cohort study. BMC Cancer 2023; 23:890. [PMID: 37735371 PMCID: PMC10512500 DOI: 10.1186/s12885-023-11402-3] [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: 01/26/2023] [Accepted: 09/13/2023] [Indexed: 09/23/2023] Open
Abstract
INTRODUCTION The expansion of antiretroviral therapy (ART) eligibility could lead to earlier initiation of Human Immunodeficiency Virus (HIV) treatment and consequently reduce the risk of HIV-associated Kaposi Sarcoma (KS). We investigated the impact of changes in the Nigerian HIV treatment guidelines on KS incidence among adults enrolled in HIV care in Nigeria. METHODS We analyzed data of adults who enrolled for HIV care from January 2006 to December 2016 at one of Nigeria's largest HIV treatment centers. Based on changes in HIV treatment guidelines, we classified 2006-2009 as the pre-expansion period and 2010-2016 as the post-expansion period. We used Kaplan Meier curves to compare the incidence of KS in the pre-expansion to the post-expansion period. We used Cox regression models to assess the hazard for incident KS between the two periods after adjusting for potential confounders. RESULTS Among 14,479 patients with HIV, the overall KS incidence was 2.35; 95% CI 2.01-2.74/1,000 person-years. The incidence of KS decreased from 2.53 to 1.58 per 1,000 person-years from 2006 to 2009 to 2010-2016. In models adjusting for age, sex, CD4-T cell count, and ART use, the risk for KS remained lower in 2010-2016 compared to 2006-2009. In analyses restricted to time on ART, there was no significant difference in KS incidence between HIV patients who enrolled in 2006-2009 and 2010-2016 after adjusting for age, sex, and CD4 T-cell count. CONCLUSION The expansion of ART eligibility was associated with a reduced incidence of HIV-associated KS among adults initiating HIV care in Jos, Nigeria. The reduction was likely driven by earlier enrollment for HIV care and ART initiation.
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Affiliation(s)
- Maxwell O Akanbi
- Department of Hematology & Clinical Oncology, Michigan State University/ McLaren Greater Lansing, 2900 Collins Road, Michigan, 48910, USA.
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
- Department of Medicine, McLaren Hospital, Flint, MI, USA.
- College of Medicine, University of Jos, Jos, Plateau State, Nigeria.
| | - Lucy A Bilaver
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Chad Achenbach
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Lisa R Hirschhorn
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Adovich S Rivera
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | | | | | | | - Patricia A Agaba
- College of Medicine, University of Jos, Jos, Plateau State, Nigeria
| | - Oche Agbaji
- College of Medicine, University of Jos, Jos, Plateau State, Nigeria
| | - Nathan Y Shehu
- College of Medicine, University of Jos, Jos, Plateau State, Nigeria
| | - Solomon A Sagay
- College of Medicine, University of Jos, Jos, Plateau State, Nigeria
| | - Lifang Hou
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Robert L Murphy
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Stöger L, Katende A, Mapesi H, Kalinjuma AV, van Essen L, Klimkait T, Battegay M, Weisser M, Letang E. Persistent High Burden and Mortality Associated With Advanced HIV Disease in Rural Tanzania Despite Uptake of World Health Organization "Test and Treat" Guidelines. Open Forum Infect Dis 2022; 9:ofac611. [PMID: 36540386 PMCID: PMC9757676 DOI: 10.1093/ofid/ofac611] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 11/11/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Information about burden, characteristics, predictors, and outcomes of advanced human immunodeficiency virus disease (AHD) is scarce in rural settings of sub-Saharan Africa. Human immunodeficiency virus (HIV) infections and associated deaths remain high despite specific guidelines issued by the World Health Organization (WHO). METHODS Burden of AHD and 6-month death/loss to follow-up (LTFU) were described among 2498 antiretroviral therapy (ART)-naive nonpregnant people with HIV (PWH) aged >15 years enrolled in the Kilombero Ulanga Antiretroviral Cohort in rural Tanzania between 2013 and 2019. Baseline characteristics associated with AHD and predictors of death/LTFU among those with AHD were analyzed using multivariate logistic and Cox regression, respectively. RESULTS Of the PWH, 62.2% had AHD at diagnosis (66.8% before vs 55.7% after national uptake of WHO "test and treat" guidelines in 2016). At baseline, older age, male sex, lower body mass index, elevated aminotransferase aspartate levels, severe anemia, tachycardia, decreased glomerular filtration rate, clinical complaints, impaired functional status, and enrollment into care before 2018 were independently associated with AHD. Among people with AHD, incidence of mortality, and LTFU were 16 and 34 per 100 person-years, respectively. WHO clinical stage 3 or 4, CD4 counts <100 cells/µL, severe anemia, tachypnea, and liver disease were associated with death/LTFU. CONCLUSIONS More than 50% of PWH enrolled in our cohort after test and treat implementation still had AHD at diagnosis. Increasing HIV testing and uptake and implementation of the WHO-specific guidelines on AHD for prevention, diagnosis, treatment of opportunistic infections, and reducing the risks of LTFU are urgently needed to reduce morbidity and mortality.
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Affiliation(s)
- Linda Stöger
- ISGlobal, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | | | - Herry Mapesi
- Ifakara Health Institute, Ifakara, Tanzania,Department Biomedicine-Petersplatz, University of Basel, Basel, Switzerland,Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Aneth V Kalinjuma
- Ifakara Health Institute, Ifakara, Tanzania,Faculty of Health Sciences, Department of Epidemiology and Biostatistics, University of the Witwatersrand, School of Public Health, Johannesburg, South Africa
| | - Liselot van Essen
- Gerion, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Thomas Klimkait
- Department Biomedicine-Petersplatz, University of Basel, Basel, Switzerland
| | - Manuel Battegay
- Department Biomedicine-Petersplatz, University of Basel, Basel, Switzerland,Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Maja Weisser
- Ifakara Health Institute, Ifakara, Tanzania,Department Biomedicine-Petersplatz, University of Basel, Basel, Switzerland,Swiss Tropical and Public Health Institute, Basel, Switzerland,Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Emilio Letang
- Correspondence: Emilio Letang, MD, MPH, PhD, Barcelona Institute for Global Health, Rosselló 132, 4.1, Barcelona 08036, Spain ()
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Katende A, Nakiyingi L, Andia-Biraro I, Katairo T, Muhumuza R, Ssemata AS, Nsereko C, Semitala FC, Meya DB. Antiretroviral therapy initiation and outcomes of hospitalized HIV-infected patients in Uganda—An evaluation of the HIV test and treat strategy. PLoS One 2022; 17:e0268122. [PMID: 35984779 PMCID: PMC9390910 DOI: 10.1371/journal.pone.0268122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 04/25/2022] [Indexed: 11/29/2022] Open
Abstract
Background Uganda adopted the HIV Test and Treat in 2016. There is paucity of data about its implementation among hospitalized patients. We aimed to determine the proportion of patients initiating anti-retroviral therapy (ART) during hospitalization, barriers and mortality outcome. Methods In this mixed methods cohort study, we enrolled hospitalized patients with a recent HIV diagnosis from three public hospitals in Uganda. We collected data on clinical characteristics, ART initiation and reasons for failure to initiate ART, as well as 30 day outcomes. Healthcare workers in-depth interviews were also conducted and data analyzed by sub-themes. Results We enrolled 234 patients; females 140/234 (59.8%), median age 34.5 years (IQR 29–42), 195/234 (83.7%) had WHO HIV stage 3 or 4, and 74/116 (63.8%) had CD4 ≤ 200 cell/μL. The proportion who initiated ART during hospitalization was 123/234 (52.6%) (95% CI 46.0–59.1), of these 35/123 (28.5%) initiated ART on the same day of hospitalization, while 99/123 (80.5%) within a week of hospitalization. By 30 days 34/234 (14.5%) (95% CI 10.3–19.7) died. Patients residing ≥ 35 kilometers from the hospital were more likely not to initiate ART during hospitalization, [aRR = 1.39, (95% CI 1.22–1.59). Inadequate patient preparation for ART initiation and advanced HIV disease were highlighted as barriers of ART initiation during hospitalization. Conclusion In this high HIV prevalence setting, only half of newly diagnosed HIV patients are initiated on ART during hospitalization. Inadequate pre-ART patient preparation and advanced HIV are barriers to rapid ART initiation among hospitalized patients in public hospitals.
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Affiliation(s)
- Andrew Katende
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Ifakara Health Institute, Ifakara, Tanzania
- * E-mail:
| | - Lydia Nakiyingi
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Irene Andia-Biraro
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
- Department of Clinical Research, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Thomas Katairo
- Infectious Disease Research Collaboration, Kampala, Uganda
| | - Richard Muhumuza
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Andrew S. Ssemata
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | | | - Fred C. Semitala
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Infectious Disease Research Collaboration, Kampala, Uganda
- Makerere University Joint AIDS Program (MJAP), Kampala, Uganda
| | - David B. Meya
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
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Lee CY, Lin YP, Wang SF, Lu PL. Late cART Initiation Consistently Driven by Late HIV Presentation: A Multicenter Retrospective Cohort Study in Taiwan from 2009 to 2019. Infect Dis Ther 2022; 11:1033-1056. [PMID: 35301666 PMCID: PMC9124249 DOI: 10.1007/s40121-022-00619-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 03/02/2022] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Late initiation (LI) of combination antiretroviral therapy (cART)-defined as having a CD4+ count of < 200 cells/μL or an AIDS-defining disease at cART initiation-has detrimental outcomes but remains prevalent worldwide, with LI trends and etiologies following the implementation of various HIV policies remaining underinvestigated. We assessed key concerns, characterized the determinants of various statuses at cART initiation, and evaluated the effects of those statuses on all-cause mortality after cART initiation. METHODS This multicenter retrospective cohort study enrolled 1198 patients with newly diagnosed HIV infection during 2009-2019 who were grouped by status at cART initiation: those without LI (non-LI group, 56.01%); those with LI but without late presentation (LP) of HIV (LP: a CD4 + count of < 200 cells/μL at HIV presentation or AIDS events ≤ 3 months of HIV diagnosis) [LILP(-) group, 4.51%]; and those with LI and with LP of HIV [LILP(+) group, 39.48%]. Joinpoint regression was used to identify changes in LI proportion. RESULTS The median CD4+ count at cART initiation increased significantly between 2009 (98 cells/μL) and 2015 (325 cells/μL) and stabilized thereafter (P for trend < 0.001). For LI, we identified one joinpoint in 2015: a substantial decrease from 77.14% in 2009 to 34.45% in 2015, followed by a nonsignificant increase to 39.1% in 2019. Overall, LILP(+) explained 89.8% of LI, without significant changes (92.59% in 2009 to 94.23% in 2019). In addition to HIV diagnosis during 2009-2012, multinomial logistic regression identified an age over 30 years and acute HIV infection as risk factors for LILP(+) and LILP(-), respectively. LILP(-) and LILP(+) were associated with a higher all-cause mortality risk. CONCLUSION Given the rise in LI from 2015 in the era of treat-all and rapid cART initiation, strategic interventions to increase earlier cART initiation must be intensified in Taiwan, especially among populations with delayed access to HIV testing services.
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Affiliation(s)
- Chun-Yuan Lee
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, No. 100, Ziyou 1st Rd., Sanmin Dist., Kaohsiung City, Taiwan ROC
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, No. 100, Ziyou 1st Rd., Sanmin Dist., Kaohsiung City, Taiwan ROC
- Department of Medicine, College of Medicine, Kaohsiung Medical University, No. 100, Ziyou 1st Rd., Sanmin Dist., Kaohsiung City, Taiwan ROC
| | - Yi-Pei Lin
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, No. 100, Ziyou 1st Rd., Sanmin Dist., Kaohsiung City, Taiwan ROC
| | - Sheng-Fan Wang
- Center for Tropical Medicine and Infectious Disease, Kaohsiung Medical University, No. 100, Ziyou 1st Rd., Sanmin Dist., Kaohsiung City, Taiwan ROC
- Department of Medical Laboratory Science and Biotechnology, Kaohsiung Medical University, No. 100, Ziyou 1st Rd., Sanmin Dist., Kaohsiung City, Taiwan ROC
- Department of Medical Research, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100, Ziyou 1st Rd., Sanmin Dist., Kaohsiung City, Taiwan ROC
| | - Po-Liang Lu
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, No. 100, Ziyou 1st Rd., Sanmin Dist., Kaohsiung City, Taiwan ROC
- School of Post-Baccalaureate Medicine, College of Medicine, Kaohsiung Medical University, No. 100, Ziyou 1st Rd., Sanmin Dist., Kaohsiung City, Taiwan ROC
- Center for Liquid Biopsy and Cohort Research, Kaohsiung Medical University, No. 100, Ziyou 1st Rd., Sanmin Dist., Kaohsiung City, Taiwan ROC
- College of Medicine, Kaohsiung Medical University Hospital, No. 100, Ziyou 1st Rd., Sanmin Dist., Kaohsiung City, Taiwan ROC
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Dat VQ, Lyss S, Dung NTH, Hung LM, Pals SL, Anh HTV, Kinh NV, Bateganya M. Prevalence of Advanced HIV Disease, Cryptococcal Antigenemia, and Suboptimal Clinical Outcomes Among Those Enrolled in Care in Vietnam. J Acquir Immune Defic Syndr 2021; 88:487-496. [PMID: 34446679 PMCID: PMC8575167 DOI: 10.1097/qai.0000000000002786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 08/12/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND People living with advanced HIV disease are at high risk of morbidity and mortality. We assessed the prevalence of cryptococcal antigenemia (CrAg) and clinical outcomes among patients newly presenting with CD4 ≤100 cells/μL in Vietnam. SETTING Twenty-two public HIV clinics in Vietnam. METHODS During August 2015-March 2017, antiretroviral therapy (ART)-naïve adults presenting for care with CD4 ≤100 cells/μL were screened for CrAg. Those who consented to study enrollment were followed up for up to 12 months and assessed for clinical outcomes. RESULTS Of 3504 patients with CD4 results, 1354 (38.6%) had CD4 ≤100 cells/μL, of whom 1177 (86.9%) enrolled in the study. The median age was 35 years (interquartile range 30-40); 872 (74.1%) of them were men, and 892 (75.8%) had CD4 <50 cells/μL. Thirty-six patients (3.1%) were CrAg-positive. Overall, 1151 (97.8%) including all who were CrAg-positive initiated ART. Of 881 patients (76.5%) followed up for ≥12 months, 623 (70.7%) were still alive and on ART at 12 months, 54 (6.1%) had transferred to nonstudy clinics, 86 (9.8%) were lost to follow-up, and 104 (11.8%) had died. Among all 1177 study participants, 143 (12.1%) died, most of them (123, 86.0%) before or within 6 months of enrollment. Twenty-seven patients (18.9%) died of pulmonary tuberculosis, 23 (16.1%) died of extrapulmonary tuberculosis, 8 (5.6%) died of Talaromyces marneffei infection, and 6 (4.2%) died of opioid overdose. Eight deaths (5.8%) occurred among the 36 CrAg-positive individuals. CONCLUSIONS Late presentation for HIV care was common. The high mortality after entry in care calls for strengthening of the management of advanced HIV disease.
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Affiliation(s)
- Vu Quoc Dat
- Department of Infectious Diseases, National Hospital for Tropical Diseases (NHTD), Hanoi, Vietnam
- Intensive Care Unit, Hanoi Medical University, Hanoi, Vietnam
| | - Sheryl Lyss
- U.S. Centers for Disease Control and Prevention (CDC), Hanoi, Vietnam
- Dr. Lyss Iis now with the Division of HIV/AIDS Prevention, U.S Centers for Disease Control & Prevention (CDC), Atlanta, GA
| | - Nguyen Thi Hoai Dung
- Department of Infectious Diseases, National Hospital for Tropical Diseases (NHTD), Hanoi, Vietnam
| | - Le Manh Hung
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Sherri L. Pals
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
- Division of Global HIV &TB (DGHT), U.S Centers for Disease Control & Prevention (CDC), Atlanta, GA; and
| | - Ho Thi Van Anh
- U.S. Centers for Disease Control and Prevention (CDC), Hanoi, Vietnam
| | - Nguyen Van Kinh
- Department of Infectious Diseases, National Hospital for Tropical Diseases (NHTD), Hanoi, Vietnam
| | - Moses Bateganya
- Division of Global HIV &TB (DGHT), U.S Centers for Disease Control & Prevention (CDC), Atlanta, GA; and
- FHI 360, Durham, NC
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9
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Michael HU, Youbi E, Ohadoma SC, Ramlall S, Oosthuizen F, Polyakova M. A Meta-Analytic Review of the Effect of Antiretroviral Therapy on Neurocognitive Outcomes in Adults Living with HIV-1 in Low-and Middle-Income Countries. Neuropsychol Rev 2021; 32:828-854. [PMID: 34757490 DOI: 10.1007/s11065-021-09527-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 08/11/2021] [Indexed: 01/29/2023]
Abstract
HIV-associated neurocognitive impairment remains a challenge even in the era of antiretroviral therapy (ART). Over 90% of people living with HIV are in low- and middle-income countries. Hence, it is not surprising that such countries bear a considerable burden of comorbidities like HIV-associated neurocognitive impairment despite an overall increase in life expectancy. The literature suggests differences in patient characteristics, clinical profile, prevalent HIV subtypes, treatment choices, pharmacogenetics, and socioeconomic factors between low- and middle-income countries compared with high-income countries. Therefore, we aimed to evaluate the effect of ART on neurocognitive outcomes in low- and middle-income countries. A comprehensive search of five databases (PubMed, CINAHL, CENTRAL, PsychInfo, Google scholar) for studies published between 1996 to 2020 was performed to identify studies that reported neurocognitive outcomes in ART-treated and ART naïve HIV positive individuals. Two independent reviewers conducted study screening, data extraction, and evaluation of the risk of bias. Pooled effect size estimates (Hedges' g) and 95% CI were computed using random-effects models. Sensitivity analysis, subgroup analysis, meta-regression, and evaluation of publication bias were also conducted. Forty studies (24 cross-sectional, 13 longitudinal studies, and two randomized controlled trials) contributed to a series of meta-analyses. We found significant small to moderate effects of antiretroviral therapy for global cognition (Hedges' g observed = 0.30; 95% CI: 0.15, 0.44; k = 25; p = 0.0003; I2 = 92.1%; tau = 0.32; Q = 305.1), executive function (Hedges' g = 0.24, 95%CI: 0.02,0.46; p-0.04; k = 8; I2 = 37.5%; tau = 0.23; Q = 11.2), and speed of information processing (Hedges' g = 0.25, 95% CI: 0.05, 0.45; k = 9; p = 0.02; I2 = 86.4%; tau = 0.21; Q = 58.9). We found no significant ART effect on attention-working memory, learning and memory, motor function, and verbal fluency. No significant effect was seen with the duration of therapy, efavirenz use, and Central Penetrating Effectiveness (CPE) of antiretroviral therapy. Subgroup analyses identified study design (between-group and within-group; cross-sectional and longitudinal) and normative scores as significant sources of heterogeneity. Meta-regression analysis indicated that nadir CD4 modified the magnitude of ART's effect on cognitive outcomes. Age, gender, and country income-group were not significant moderators. Our findings provide systematic evidence that antiretroviral therapy improves neurocognitive outcomes in the domains of global cognition, executive function and speed of information processing, of people living with HIV in low- and middle-income countries, especially those with advanced immunosuppression. However, these findings are not definitive as they are limited by the probability of publication bias, high heterogeneity, and exclusion of significant confounders. Prospero registration number: CRD42020203791.
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Affiliation(s)
- Henry Ukachukwu Michael
- Discipline of Pharmaceutical Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa.
| | - Emily Youbi
- Discipline of Pharmaceutical Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Sylvester Chika Ohadoma
- Department of Pharmacology, College of Medical Sciences, University of Calabar, Calabar, Nigeria
| | - Suvira Ramlall
- Department of Psychiatry, Nelson R. Mandela School of Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South, South Africa
| | - Frasia Oosthuizen
- Discipline of Pharmaceutical Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Maryna Polyakova
- Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany
- Clinic for Psychiatry and Psychotherapy, University of Leipzig, Leipzig, Germany
- LIFE-Leipzig Research Center for Civilization Diseases, University of Leipzig, Leipzig, Germany
- Clinic for Cognitive Neurology, University of Leipzig, Leipzig, Germany
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10
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Barabona G, Mahiti M, Toyoda M, Kamori D, Masoud S, Judicate GP, Sunguya B, Lyamuya E, Ueno T. Advanced baseline immunosuppression is associated with elevated levels of plasma markers of fungal translocation and inflammation in long-term treated HIV-infected Tanzanians. AIDS Res Ther 2021; 18:55. [PMID: 34446039 PMCID: PMC8394626 DOI: 10.1186/s12981-021-00381-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 08/17/2021] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND For over a decade, antiretroviral therapy (ART) in resource-limited countries was only recommended for patients with advanced HIV disease. We investigated this group of patients in order to determine any relationship between degree of immunosuppression during treatment initiation and the subsequent levels of inflammatory biomarkers, reservoir size and plasma marker of fungal translocation after achieving long-term virological control. METHODS We analyzed 115 virally suppressed (female 83.5%) and 40 untreated (female 70%) subjects from Dar es Salaam, Tanzania. The size of HIV latent reservoir (proviral DNA copy) was determined using quantitative PCR. Inflammatory biomarkers; IL-6, IL-10, and soluble CD14 (sCD14), were measured using multiplex cytometric beads array. Antibody titers for Cytomegalovirus (CMV) and Epstein Barr virus (EBV), plasma level of 1-3-beta-D-Glucan (BDG) was measured using ELISA. High-sensitivity C-reactive protein (hsCRP) was measured using nephelometric method. RESULTS The median age was 36 (IQR 32-44) and 47 (IQR 43-54) years in untreated and virally suppressed patients respectively. Median duration of treatment for virally suppressed patients was 9 years (IQR 7-12) and median baseline CD4 count was 147 cells/mm3 (IQR 65-217). Virally suppressed patients were associated with significantly lower plasma levels of IL-10, sCD14 and BDG (P < 0.05) when compared to untreated patients. However, plasma level of IL-6 was similar between the groups. Baseline advanced level of immunosuppression (CD4 < 100cells/cm3) was associated with significantly higher plasma level of IL-6 (P = 0.02), hsCRP (P = 0.036) and BDG (P = 0.0107). This relationship was not seen in plasma levels of other tested markers. Degree of baseline immunosuppression was not associated with the subsequent proviral DNA copy. In addition, plasma levels of inflammatory marker were not associated with sex, CMV or EBV antibody titers, treatment duration or regimen. CONCLUSIONS Our data suggest that advanced immunosuppression at ART initiation is associated with severity of inflammation and elevated fungal translocation marker despite long term virological control. Further studies are needed to evaluate the potential increased burden of non-AIDS comorbidities that are linked to elevated inflammatory and fungal translocation markers as a result of the policy of HIV treatment at CD4 count < 200 cells/cm3 implemented for over a decade in Tanzania.
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Affiliation(s)
- Godfrey Barabona
- Joint Research Center for Human Retrovirus Infection, Kumamoto University, 2-2-1 Chuo-ku, Honjo, Kumamoto, 860-0811, Japan
| | - Macdonald Mahiti
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Mako Toyoda
- Joint Research Center for Human Retrovirus Infection, Kumamoto University, 2-2-1 Chuo-ku, Honjo, Kumamoto, 860-0811, Japan
| | - Doreen Kamori
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Salim Masoud
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - George P Judicate
- Joint Research Center for Human Retrovirus Infection, Kumamoto University, 2-2-1 Chuo-ku, Honjo, Kumamoto, 860-0811, Japan
| | - Bruno Sunguya
- Joint Research Center for Human Retrovirus Infection, Kumamoto University, 2-2-1 Chuo-ku, Honjo, Kumamoto, 860-0811, Japan
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Eligius Lyamuya
- Joint Research Center for Human Retrovirus Infection, Kumamoto University, 2-2-1 Chuo-ku, Honjo, Kumamoto, 860-0811, Japan
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Takamasa Ueno
- Joint Research Center for Human Retrovirus Infection, Kumamoto University, 2-2-1 Chuo-ku, Honjo, Kumamoto, 860-0811, Japan.
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
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11
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Kelly C, Tinago W, Alber D, Hunter P, Luckhurst N, Connolly J, Arrigoni F, Garcia Abner A, Kamn’gona R, Sheha I, Chammudzi M, Jambo K, Mallewa J, Rapala A, Mallon PWG, Mwandumba H, Klein N, Khoo S. Inflammatory pathways amongst people living with HIV in Malawi differ according to socioeconomic status. PLoS One 2021; 16:e0256576. [PMID: 34432828 PMCID: PMC8386842 DOI: 10.1371/journal.pone.0256576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 08/11/2021] [Indexed: 11/18/2022] Open
Abstract
Background Non-communicable diseases (NCDs) are increased amongst people living with HIV (PLWH) and are driven by persistent immune activation. The role of socioeconomic status (SES) in immune activation amongst PLWH is unknown, especially in low-income sub-Saharan Africa (SSA), where such impacts may be particularly severe. Methods We recruited Malawian adults with CD4<100 cells/ul two weeks after starting ART in the REALITY trial (NCT01825031), as well as volunteers without HIV infection. Clinical assessment, socioeconomic evaluation, blood draw for immune activation markers and carotid femoral pulse wave velocity (cfPWV) were carried out at 2- and 42-weeks post-ART initiation. Socioeconomic risk factors for immune activation and arterial stiffness were assessed using linear regression models. Results Of 279 PLWH, the median (IQR) age was 36 (31–43) years and 122 (44%) were female. Activated CD8 T-cells increased from 70% amongst those with no education to 88% amongst those with a tertiary education (p = 0.002); and from 71% amongst those earning less than 10 USD/month to 87% amongst those earning between 100–150 USD/month (p = 0.0001). Arterial stiffness was also associated with higher SES (car ownership p = 0.003, television ownership p = 0.012 and electricity access p = 0.029). Conversely, intermediate monocytes were higher amongst those with no education compared to a tertiary education (12.6% versus 7.3%; p = 0.01) and trended towards being higher amongst those earning less than 10 USD/month compared to 100–150 USD/month (10.5% versus 8.0%; p = 0.08). Water kiosk use showed a protective association against T cell activation (p = 0.007), as well as endothelial damage (MIP1β, sICAM1 and sVCAM1 p = 0.047, 0.026 and 0.031 respectively). Conclusions Socioeconomic risk factors for persistent inflammation amongst PLWH in SSA differ depending on the type of inflammatory pathway. Understanding these pathways and their socioeconomic drivers will help identify those at risk and target interventions for NCDs. Future studies assessing drivers of inflammation in HIV should include an SES assessment.
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Affiliation(s)
- Christine Kelly
- Cente for Experimental Pathogen Host Research (CEPHR), University College Dublin, Dublin, Ireland
- Malawi Liverpool Wellcome Trust Clinical Research Program, Blantyre, Malawi
- Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
- * E-mail:
| | - Willard Tinago
- Cente for Experimental Pathogen Host Research (CEPHR), University College Dublin, Dublin, Ireland
| | - Dagmar Alber
- Institute of Child Health, University College London, London, United Kingdom
| | - Patricia Hunter
- Institute of Child Health, University College London, London, United Kingdom
| | | | | | | | - Alejandro Garcia Abner
- Cente for Experimental Pathogen Host Research (CEPHR), University College Dublin, Dublin, Ireland
| | - Raphael Kamn’gona
- Malawi Liverpool Wellcome Trust Clinical Research Program, Blantyre, Malawi
| | - Irene Sheha
- Malawi Liverpool Wellcome Trust Clinical Research Program, Blantyre, Malawi
| | - Mishek Chammudzi
- Malawi Liverpool Wellcome Trust Clinical Research Program, Blantyre, Malawi
| | - Kondwani Jambo
- Malawi Liverpool Wellcome Trust Clinical Research Program, Blantyre, Malawi
| | - Jane Mallewa
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Alicja Rapala
- Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Patrick W. G. Mallon
- Cente for Experimental Pathogen Host Research (CEPHR), University College Dublin, Dublin, Ireland
| | - Henry Mwandumba
- Malawi Liverpool Wellcome Trust Clinical Research Program, Blantyre, Malawi
| | - Nigel Klein
- Institute of Child Health, University College London, London, United Kingdom
| | - Saye Khoo
- Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
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12
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Yapa HM, Kim HY, Petoumenos K, Post FA, Jiamsakul A, De Neve JW, Tanser F, Iwuji C, Baisley K, Shahmanesh M, Pillay D, Siedner MJ, Bärnighausen T, Bor J. CD4+ T-Cell Count at Antiretroviral Therapy Initiation in the "Treat-All" Era in Rural South Africa: An Interrupted Time Series Analysis. Clin Infect Dis 2021; 74:1350-1359. [PMID: 34309633 PMCID: PMC9049265 DOI: 10.1093/cid/ciab650] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND South Africa implemented universal test and treat (UTT) in September 2016 in an effort to encourage earlier initiation of antiretroviral therapy (ART). METHODS We therefore conducted an interrupted time series (ITS) analysis to assess the impact of UTT on mean CD4 count at ART initiation among adults aged ≥16 years attending 17 public sector primary care clinics in rural South Africa, between July 2014 and March 2019. RESULTS Among 20 599 individuals (69% women), CD4 counts were available for 74%. Mean CD4 at ART initiation increased from 317.1 cells/μL (95% confidence interval [CI], 308.6 to 325.6) 1 to 8 months prior to UTT to 421.0 cells/μL (95% CI, 413.0 to 429.0) 1 to 12 months after UTT, including an immediate increase of 124.2 cells/μL (95% CI, 102.2 to 146.1). However, mean CD4 count subsequently fell to 389.5 cells/μL (95% CI, 381.8 to 397.1) 13 to 30 months after UTT but remained above pre-UTT levels. Men initiated ART at lower CD4 counts than women (-118.2 cells/μL, 95% CI, -125.5 to -111.0) throughout the study. CONCLUSIONS Although UTT led to an immediate increase in CD4 count at ART initiation in this rural community, the long-term effects were modest. More efforts are needed to increase initiation of ART early in those living with human immunodeficiency virus, particularly men.
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Affiliation(s)
- H Manisha Yapa
- The Kirby Institute, University of New South WalesSydney, NSW, Australia,Africa Health Research Institute, KwaZulu-Natal, South Africa,Correspondence: H. Manisha Yapa, Level 6, Wallace Wurth Building, University of New South Wales, High Street, Kensington NSW 2052, Australia ()
| | - Hae-Young Kim
- Africa Health Research Institute, KwaZulu-Natal, South Africa,New York University Grossman School of Medicine, New York, New York, USA
| | - Kathy Petoumenos
- The Kirby Institute, University of New South WalesSydney, NSW, Australia
| | - Frank A Post
- King’s College Hospital National Health Service Foundation Trust, London, United Kingdom
| | - Awachana Jiamsakul
- The Kirby Institute, University of New South WalesSydney, NSW, Australia
| | - Jan-Walter De Neve
- Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Frank Tanser
- Africa Health Research Institute, KwaZulu-Natal, South Africa,College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa,Lincoln International Institute for Rural Health, University of Lincoln, Lincoln, United Kingdom,Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
| | - Collins Iwuji
- Africa Health Research Institute, KwaZulu-Natal, South Africa,Department of Global Health and Infection, Brighton and Sussex Medical School, Brighton, United Kingdom
| | - Kathy Baisley
- Africa Health Research Institute, KwaZulu-Natal, South Africa,Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Maryam Shahmanesh
- Africa Health Research Institute, KwaZulu-Natal, South Africa,Institute for Global Health, University College London, London, United Kingdom
| | - Deenan Pillay
- Africa Health Research Institute, KwaZulu-Natal, South Africa,Division of Infection & Immunity, University College London, London, United Kingdom
| | - Mark J Siedner
- Africa Health Research Institute, KwaZulu-Natal, South Africa,College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa,Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Till Bärnighausen
- Africa Health Research Institute, KwaZulu-Natal, South Africa,Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital, University of Heidelberg, Heidelberg, Germany,Institute for Global Health, University College London, London, United Kingdom,Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Jacob Bor
- Africa Health Research Institute, KwaZulu-Natal, South Africa,Department of Global Health and Epidemiology, Boston University, Boston, Massachusetts, USA,Health Economics and Epidemiology Research Office, Wits Health Consortium, Faculty of Health Science, University of Witswatersrand, Johannesburg, Gauteng, South Africa
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13
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Kelly C, Tinago W, Alber D, Hunter P, Luckhurst N, Connolly J, Arrigoni F, Abner AG, Kamngona R, Sheha I, Chammudzi M, Jambo K, Mallewa J, Rapala A, Heyderman RS, Mallon PWG, Mwandumba H, Walker AS, Klein N, Khoo S. Inflammatory Phenotypes Predict Changes in Arterial Stiffness Following Antiretroviral Therapy Initiation. Clin Infect Dis 2021; 71:2389-2397. [PMID: 32103268 PMCID: PMC7713681 DOI: 10.1093/cid/ciaa186] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 02/24/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Inflammation drives vascular dysfunction in HIV, but in low-income settings causes of inflammation are multiple, and include infectious and environmental factors. We hypothesized that patients with advanced immunosuppression could be stratified into inflammatory phenotypes that predicted changes in vascular dysfunction on ART. METHODS We recruited Malawian adults with CD4 <100 cells/μL 2 weeks after starting ART in the REALITY trial (NCT01825031). Carotid femoral pulse-wave velocity (cfPWV) measured arterial stiffness 2, 12, 24, and 42 weeks post-ART initiation. Plasma inflammation markers were measured by electrochemiluminescence at weeks 2 and 42. Hierarchical clustering on principal components identified inflammatory clusters. RESULTS 211 participants with HIV grouped into 3 inflammatory clusters representing 51 (24%; cluster-1), 153 (73%; cluster-2), and 7 (3%; cluster-3) individuals. Cluster-1 showed markedly higher CD4 and CD8 T-cell expression of HLADR and PD-1 versus cluster-2 and cluster-3 (all P < .0001). Although small, cluster-3 had significantly higher levels of cytokines reflecting inflammation (IL-6, IFN-γ, IP-10, IL-1RA, IL-10), chemotaxis (IL-8), systemic and vascular inflammation (CRP, ICAM-1, VCAM-1), and SAA (all P < .001). In mixed-effects models, cfPWV changes over time were similar for cluster-2 versus cluster-1 (relative fold-change, 0.99; 95% CI, .86-1.14; P = .91), but greater in cluster-3 versus cluster-1 (relative fold-change, 1.45; 95% CI, 1.01-2.09; P = .045). CONCLUSIONS Two inflammatory clusters were identified: one defined by high T-cell PD-1 expression and another by a hyperinflamed profile and increases in cfPWV on ART. Further clinical characterization of inflammatory phenotypes could help target vascular dysfunction interventions to those at highest risk. CLINICAL TRIALS NETWORK NCT01825031.
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Affiliation(s)
- Christine Kelly
- Centre for Experimental Pathogen Host Research (CEPHR), University College Dublin, Dublin, Ireland.,Malawi Liverpool Wellcome Trust Clinical Research Program, Blantyre, Malawi.,Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Willard Tinago
- Centre for Experimental Pathogen Host Research (CEPHR), University College Dublin, Dublin, Ireland
| | - Dagmar Alber
- Institute of Child Health, University College London, London, United Kingdom
| | - Patricia Hunter
- Institute of Child Health, University College London, London, United Kingdom
| | | | | | | | - Alejandro Garcia Abner
- Centre for Experimental Pathogen Host Research (CEPHR), University College Dublin, Dublin, Ireland
| | - Ralph Kamngona
- Malawi Liverpool Wellcome Trust Clinical Research Program, Blantyre, Malawi
| | - Irene Sheha
- Malawi Liverpool Wellcome Trust Clinical Research Program, Blantyre, Malawi
| | - Mishek Chammudzi
- Malawi Liverpool Wellcome Trust Clinical Research Program, Blantyre, Malawi
| | - Kondwani Jambo
- Malawi Liverpool Wellcome Trust Clinical Research Program, Blantyre, Malawi.,College of Medicine, University of Malawi, Blantyre, Malawi.,Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Jane Mallewa
- College of Medicine, University of Malawi, Blantyre, Malawi
| | - Alicja Rapala
- Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Robert S Heyderman
- Institute of Child Health, University College London, London, United Kingdom
| | - Patrick W G Mallon
- Centre for Experimental Pathogen Host Research (CEPHR), University College Dublin, Dublin, Ireland
| | - Henry Mwandumba
- Malawi Liverpool Wellcome Trust Clinical Research Program, Blantyre, Malawi.,College of Medicine, University of Malawi, Blantyre, Malawi.,Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - A Sarah Walker
- 9MRC Clinical Trials Unit, University College London, London, United Kingdom
| | - Nigel Klein
- Institute of Child Health, University College London, London, United Kingdom
| | - Saye Khoo
- Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
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14
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Pett SL, Spyer M, Haddow LJ, Nhema R, Benjamin LA, Najjuka G, Bilima S, Daud I, Musoro G, Kitabalwa J, Selemani G, Kandie S, Cornelius KM, Katemba C, Berkley JA, Hassan AS, Kityo C, Hakim J, Heyderman RS, Gibb DM, Walker AS. Benefits of enhanced infection prophylaxis at antiretroviral therapy initiation by cryptococcal antigen status. AIDS 2021; 35:585-594. [PMID: 33306556 PMCID: PMC7613319 DOI: 10.1097/qad.0000000000002781] [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] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To assess baseline prevalence of cryptococcal antigen (CrAg) positivity; and its contribution to reductions in all-cause mortality, deaths from cryptococcus and unknown causes, and new cryptococcal disease in the REALITY trial. DESIGN Retrospective CrAg testing of baseline and week-4 plasma samples in all 1805 African adults/children with CD4+ cell count less than 100 cells/μl starting antiretroviral therapy who were randomized to receive 12-week enhanced-prophylaxis (fluconazole 100 mg/day, azithromycin, isoniazid, cotrimoxazole) vs. standard-prophylaxis (cotrimoxazole). METHODS Proportional hazards models were used to estimate the relative impact of enhanced-prophylaxis vs. standard-cotrimoxazole on all, cryptococcal and unknown deaths, and new cryptococcal disease, through 24 weeks, by baseline CrAg positivity. RESULTS Excluding 24 (1.4%) participants with active/prior cryptococcal disease at enrolment (all treated for cryptococcal disease), 133/1781 (7.5%) participants were CrAg-positive. By 24 weeks, 105 standard-cotrimoxazole vs. 78 enhanced-prophylaxis participants died. Of nine standard-cotrimoxazole and three enhanced-prophylaxis cryptococcal deaths, seven and two, respectively, were CrAg-positive at baseline. Among deaths of unknown cause, only 1/46 standard-cotrimoxazole and 1/28 enhanced-prophylaxis were CrAg-positive at baseline. There was no evidence that relative reductions in new cryptococcal disease associated with enhanced-prophylaxis varied between baseline CrAg-positives [hazard-ratio = 0.36 (95% confidence interval 0.13-0.98), incidence 19.5 vs. 56.5/100 person-years] and CrAg-negatives [hazard-ratio = 0.33 (0.03-3.14), incidence 0.3 vs. 0.9/100 person-years; Pheterogeneity = 0.95]; nor for all deaths, cryptococcal deaths or unknown deaths (Pheterogeneity > 0.3). CONCLUSION Relative reductions in cryptococcal disease/death did not depend on CrAg status. Deaths of unknown cause were unlikely to be cryptococcus-related; plausibly azithromycin contributed to their reduction. Findings support including 100 mg fluconazole in an enhanced-prophylaxis package at antiretroviral therapy initiation where CrAg screening is unavailable/impractical.
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Affiliation(s)
- Sarah L. Pett
- Institute for Global Health
- MRC CTU at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK
- Kirby Institute for Infection and Immunity in Society, University of New South Wales, Sydney, New South Wales, Australia
| | - Moira Spyer
- MRC CTU at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK
| | | | - Ruth Nhema
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | - Laura A. Benjamin
- Institute of Neurology, UCL, London
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | | | - Sithembile Bilima
- Department/College of Medicine and Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | | | - Godfrey Musoro
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | | | - George Selemani
- Department/College of Medicine and Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | | | | | | | | | | | - Cissy Kityo
- Joint Clinical Research Centre, Kampala, Uganda
| | - James Hakim
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | - Robert S. Heyderman
- Department/College of Medicine and Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Division of Infection and Immunity, UCL, London, UK
| | - Diana M. Gibb
- MRC CTU at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK
| | - Ann S. Walker
- MRC CTU at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK
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De Castro N, Marcy O, Chazallon C, Messou E, Eholié S, N'takpe JB, Bhatt N, Khosa C, Timana Massango I, Laureillard D, Chau GD, Domergue A, Veloso V, Escada R, Wagner Cardoso S, Delaugerre C, Anglaret X, Molina JM, Grinsztejn B. Standard dose raltegravir or efavirenz-based antiretroviral treatment for patients co-infected with HIV and tuberculosis (ANRS 12 300 Reflate TB 2): an open-label, non-inferiority, randomised, phase 3 trial. THE LANCET. INFECTIOUS DISEASES 2021; 21:813-822. [PMID: 33667406 DOI: 10.1016/s1473-3099(20)30869-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 09/16/2020] [Accepted: 11/03/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND In patients co-infected with HIV and tuberculosis, antiretroviral therapy options are limited due to drug-drug interactions with rifampicin. A previous phase 2 trial indicated that raltegravir 400 mg twice a day or efavirenz 600 mg once a day might have similar virological efficacy in patients given rifampicin. In this phase 3 trial, we assessed the non-inferiority of raltegravir to efavirenz. METHODS We did a multicentre, open-label, non-inferiority, randomised, phase 3 trial at six sites in Côte d'Ivoire, Brazil, France, Mozambique, and Vietnam. We included antiretroviral therapy (ART)-naive adults (aged ≥18 years) with confirmed HIV-1 infection and bacteriologically confirmed or clinically diagnosed tuberculosis who had initiated rifampicin-containing tuberculosis treatment within the past 8 weeks. Using computerised random numbers, we randomly assigned participants (1:1; stratified by country) to receive raltegravir 400 mg twice daily or efavirenz 600 mg once daily, both in combination with tenofovir and lamivudine. The primary outcome was the proportion of patients with virological suppression at week 48 (defined as plasma HIV RNA concentration <50 copies per mL). The prespecified non-inferiority margin was 12%. The primary outcome was assessed in the intention-to-treat population, which included all randomly assigned patients (excluding two patients with HIV-2 infection and one patient with HIV-1 RNA concentration of <50 copies per mL at inclusion), and the on-treatment population, which included all patients in the intention-to-treat population who initiated treatment and were continuing allocated treatment at week 48, and patients who had discontinued allocated treatment due to death or virological failure. Safety was assessed in all patients who received at least one dose of the assigned treatment regimen. This study is registered with ClinicalTrials.gov, NCT02273765. FINDINGS Between Sept 28, 2015, and Jan 5, 2018, 460 participants were randomly assigned to raltegravir (n=230) or efavirenz (n=230), of whom 457 patients (230 patients in the raltegravir group; 227 patients in the efavirenz group) were included in the intention-to-treat analysis and 410 (206 patients in the raltegravir group; 204 patients in the efavirenz group) in the on-treatment analysis. At baseline, the median CD4 count was 103 cells per μL and median plasma HIV RNA concentration was 5·5 log10 copies per mL (IQR 5·0-5·8). 310 (68%) of 457 participants had bacteriologically-confirmed tuberculosis. In the intention-to-treat population, at week 48, 140 (61%) of 230 participants in the raltegravir group and 150 (66%) of 227 patients in the efavirenz had achieved virological suppression (between-group difference -5·2% [95% CI -14·0 to 3·6]), thus raltegravir did not meet the predefined criterion for non-inferiority. The most frequent adverse events were HIV-associated non-AIDS illnesses (eight [3%] of 229 patients in the raltegravir group; 21 [9%] of 230 patients in the efavirenz group) and AIDS-defining illnesses (ten [4%] patients in the raltegravir group; 13 [6%] patients in the efavirenz group). 58 (25%) of 229 patients in raltegravir group and 66 (29%) of 230 patients in the efavirenz group had grade 3 or 4 adverse events. 26 (6%) of 457 patients died during follow-up: 14 in the efavirenz group and 12 in the raltegravir group. INTERPRETATION In patients with HIV given tuberculosis treatment, non-inferiority of raltegravir compared with efavirenz was not shown. Raltegravir was well tolerated and could be considered as an option, but only in selected patients. FUNDING National French Agency for AIDS Research, Ministry of Health in Brazil, Merck. TRANSLATIONS For the Portuguese and French translations of the abstract see Supplementary Materials section.
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Affiliation(s)
- Nathalie De Castro
- Department of Infectious Diseases, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris, Paris, France; Bordeaux Population Health Research Center, UMR 1219, INSERM, University of Bordeaux, French National Research Institute for Sustainable Development, Bordeaux, France.
| | - Olivier Marcy
- Bordeaux Population Health Research Center, UMR 1219, INSERM, University of Bordeaux, French National Research Institute for Sustainable Development, Bordeaux, France
| | - Corine Chazallon
- Bordeaux Population Health Research Center, UMR 1219, INSERM, University of Bordeaux, French National Research Institute for Sustainable Development, Bordeaux, France
| | - Eugène Messou
- Centre de Prise en charge de Recherche et de Formation, Abidjan, Côte d'Ivoire; Programme PACCI/ANRS Research Center, Abidjan, Cote d'Ivoire; Département de Dermatologie et d'Infectiologie, Unite de Formation et de Recherche des Sciences Médicales, Université Félix Houphouët Boigny, Abidjan, Cote d'Ivoire
| | - Serge Eholié
- Programme PACCI/ANRS Research Center, Abidjan, Cote d'Ivoire; Département de Dermatologie et d'Infectiologie, Unite de Formation et de Recherche des Sciences Médicales, Université Félix Houphouët Boigny, Abidjan, Cote d'Ivoire
| | | | - Nilesh Bhatt
- Instituto Nacional de Saúde, Marracuene, Mozambique
| | - Celso Khosa
- Instituto Nacional de Saúde, Marracuene, Mozambique
| | | | - Didier Laureillard
- Research Unit 1058 Pathogenesis and Control Chronical Infections, INSERM, French Blood Center, University of Montpellier, Montpellier, France; Department of Infectious and Tropical Diseases, Nimes University Hospital, Nimes, France
| | - Giang Do Chau
- General Planning Department, Pham Ngoc Thach Hospital, Ho Chi Minh City, Vietnam
| | - Anaïs Domergue
- National Agency for Research on AIDS and Viral Hepatitis Research Site, Pham Ngoc Thach Hospital, Ho Chi Minh City, Vietnam
| | - Valdilea Veloso
- National Institute of Infectious Diseases Evandro Chagas, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Rodrigo Escada
- National Institute of Infectious Diseases Evandro Chagas, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Sandra Wagner Cardoso
- National Institute of Infectious Diseases Evandro Chagas, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Constance Delaugerre
- Department of Virology, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris, Paris, France; INSERM U944, Université de Paris, Paris, France
| | - Xavier Anglaret
- Bordeaux Population Health Research Center, UMR 1219, INSERM, University of Bordeaux, French National Research Institute for Sustainable Development, Bordeaux, France; Centre de Prise en charge de Recherche et de Formation, Abidjan, Côte d'Ivoire
| | - Jean-Michel Molina
- Department of Infectious Diseases, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris, Paris, France; INSERM U944, Université de Paris, Paris, France
| | - Beatriz Grinsztejn
- National Institute of Infectious Diseases Evandro Chagas, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
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Balachandra S, Rogers JH, Ruangtragool L, Radin E, Musuka G, Oboho I, Paulin H, Parekh B, Birhanu S, Takarinda KC, Hakim A, Apollo T. Concurrent advanced HIV disease and viral load suppression in a high-burden setting: Findings from the 2015-6 ZIMPHIA survey. PLoS One 2020; 15:e0230205. [PMID: 32584821 PMCID: PMC7316262 DOI: 10.1371/journal.pone.0230205] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Accepted: 02/24/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND As Zimbabwe approaches epidemic control of HIV, programs now prioritize viral load over CD4 monitoring, making it difficult to identify persons living with HIV (PLHIV) suffering from advanced disease (AD). We present an analysis of cross-sectional ZIMPHIA data, highlighting PLHIV with AD and concurrent viral load suppression (VLS). METHODS ZIMPHIA collected blood specimens for HIV testing from 22,501 consenting adults (ages 15 years and older); 3,466 PLHIV had CD4 and VL results. Household HIV testing used the national serial algorithm, and those testing positive then received point-of-care CD4 enumeration with subsequent VL testing. We used logistic regression analysis to explore factors associated with concurrent AD and VLS (<1000 copies/mL). All analyses were weighted to account for complex survey design. RESULTS Of the 3,466 PLHIV in the survey with CD4 and VL results, 17% were found to have AD (CD4<200cells/mm3). Of all AD patients, 30% had VLS. Concurrent AD and VLS was associated with male sex (aOR 2.45 95%CI 1.61-3.72), older age (35-49 years [aOR 2.46 95%CI 1.03-5.91] and 50+ years [aOR 4.82 95%CI 2.02-11.46] vs 15-24 years), and ART duration (<6 months [aOR 0.46 95%CI 0.29-0.76] and 6-24 months [aOR 2.07 95%CI 1.35-3.17] vs more than 2 years). The relationship between sex and AD is driven by age with significant associations among men aged 25-34, (aOR 3.37 95%CI 1.35-8.41), 35-49 (aOR 5.13 95%CI 2.16-12.18), and 50+ (aOR 12.56 95%CI 4.82-32.72) versus men aged 15-24. CONCLUSIONS The percentage of PLHIV with AD and VLS illustrates the conundrum of decreased support for CD4 monitoring, as these patients may not receive appropriate clinical services for advanced HIV disease. In high-prevalence settings such as Zimbabwe, CD4 monitoring support warrants further consideration to differentiate care appropriately for the most vulnerable PLHIV. Males may need to be prioritized, given their over-representation in this sub-population.
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Affiliation(s)
- S. Balachandra
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Bluffhill, Harare, Zimbabwe
| | - J. H. Rogers
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Bluffhill, Harare, Zimbabwe
| | - L. Ruangtragool
- PHI/CDC Global Epidemiology Fellowship, U.S. Centers for Disease Control and Prevention, Bluffhill, Harare, Zimbabwe
| | - E. Radin
- ICAP New York, New York, NY, United States of America
| | - G. Musuka
- ICAP Zimbabwe, Avondale, Harare, Zimbabwe
| | - I. Oboho
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - H. Paulin
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - B. Parekh
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - S. Birhanu
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | | | - A. Hakim
- Division of Global HIV and Tuberculosis, U.S. Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - T. Apollo
- Ministry of Health and Child Care, Harare, Zimbabwe
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17
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van Schalkwyk E, Mhlanga M, Maphanga TG, Mpembe RS, Shillubane A, Iyaloo S, Tsotetsi E, Pieton K, Karstaedt AS, Sahid F, Menezes CN, Tsitsi M, Motau A, Wadula J, Seetharam S, van den Berg E, Sriruttan C, Govender NP. Screening for invasive fungal disease using non-culture-based assays among inpatients with advanced HIV disease at a large academic hospital in South Africa. Mycoses 2020; 63:478-487. [PMID: 32125004 DOI: 10.1111/myc.13071] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 02/24/2020] [Accepted: 02/26/2020] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Despite widespread access to antiretroviral therapy (ART), the burden of advanced HIV disease in South Africa is high. This translates into an increased risk of AIDS-related opportunistic infections, including invasive mycoses. METHODS Using a limited number of non-culture-based diagnostic assays, we aimed to determine the prevalence of invasive mycoses and tuberculosis among hospitalised adults with very advanced HIV (CD4 counts < 100 cells/µL) at a large academic hospital. We conducted interviews and prospective medical chart reviews. We performed point-of-care finger stick and serum cryptococcal antigen lateral flow assays; serum (1 → 3) ß-D-glucan assays; urine Histoplasma galactomannan antigen enzyme immunoassays and TB lipoarabinomannan assays. RESULTS We enrolled 189 participants from 5280 screened inpatients. Fifty-eight per cent were female, with median age 37 years (IQR: 30-43) and median CD4 count 32 cells/µL (IQR: 13-63). At enrolment, 60% (109/181) were receiving ART. Twenty-one participants (11%) had a diagnosis of an invasive mycosis, of whom 53% (11/21) had cryptococcal disease. Thirteen participants (7%) had tuberculosis and a concurrent invasive mycosis. ART-experienced participants were 60% less likely to have an invasive mycosis than those ART-naïve (adjusted OR: 0.4; 95% CI 0.15-1.0; P = .03). Overall in-hospital mortality was 13% (invasive mycosis: 10% [95% CI 1.2-30.7] versus other diagnoses: 13% (95% CI 8.4-19.3)). CONCLUSIONS One in ten participants had evidence of an invasive mycosis. Diagnosis of proven invasive fungal disease and differentiation from other opportunistic infections was challenging. More fungal-specific screening and diagnostic tests should be applied to inpatients with advanced HIV disease.
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Affiliation(s)
- Erika van Schalkwyk
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Mabatho Mhlanga
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Tsidiso G Maphanga
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa.,Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
| | - Ruth S Mpembe
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Amanda Shillubane
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Samantha Iyaloo
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Ernest Tsotetsi
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Kim Pieton
- Division of Infectious Diseases, Department of Internal Medicine, Chris Hani Baragwanath Academic Hospital, Soweto, South Africa
| | - Alan S Karstaedt
- Division of Infectious Diseases, Department of Internal Medicine, Chris Hani Baragwanath Academic Hospital, Soweto, South Africa.,Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Faieza Sahid
- Division of Infectious Diseases, Department of Internal Medicine, Chris Hani Baragwanath Academic Hospital, Soweto, South Africa
| | - Colin N Menezes
- Division of Infectious Diseases, Department of Internal Medicine, Chris Hani Baragwanath Academic Hospital, Soweto, South Africa.,Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Merika Tsitsi
- Division of Infectious Diseases, Department of Internal Medicine, Chris Hani Baragwanath Academic Hospital, Soweto, South Africa.,Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ayanda Motau
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Division of Dermatology, Department of Internal Medicine, Chris Hani Baragwanath Academic Hospital, Soweto, South Africa
| | - Jeannette Wadula
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
| | - Sharona Seetharam
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
| | - Eunice van den Berg
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
| | - Charlotte Sriruttan
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa.,Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nelesh P Govender
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, A Division of the National Health Laboratory Service, Johannesburg, South Africa.,Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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18
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Rupasinghe D, Kiertiburanakul S, Kamarulzaman A, Zhang F, Kumarasamy N, Chaiwarith R, Merati TP, Do CD, Khusuwan S, Avihingsanon A, Lee MP, Ly PS, Yunihastuti E, Nguyen KV, Ditangco R, Chan YJ, Pujari S, Ng OT, Choi JY, Sim B, Tanuma J, Sangle S, Ross J, Law M. Early mortality after late initiation of antiretroviral therapy in the TREAT Asia HIV Observational Database (TAHOD) of the International Epidemiologic Databases to Evaluate AIDS (IeDEA) Asia-Pacific. HIV Med 2019; 21:397-402. [PMID: 31852025 DOI: 10.1111/hiv.12836] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/19/2019] [Indexed: 01/29/2023]
Abstract
OBJECTIVES Early mortality among those still initiating antiretroviral therapy (ART) with advanced stages of HIV infection in resource-limited settings remains high despite recommendations for universal HIV treatment. We investigated risk factors associated with early mortality in people living with HIV (PLHIV) starting ART at low CD4 levels in the Asia-Pacific. METHODS PLHIV enrolled in the Therapeutics, Research, Education and AIDS Training in Asia (TREAT Asia) HIV Observational Database (TAHOD) who initiated ART with a CD4 count < 100 cells/μL between 2003 and 2018 were included in the study. Early mortality was defined as death within 1 year of ART initiation. PLHIV in follow-up for > 1 year were censored at 12 months. Competing risk regression was used to analyse risk factors with loss to follow-up as a competing risk. RESULTS A total of 1813 PLHIV were included in the study, of whom 74% were male. With 73 (4%) deaths, the overall first-year mortality rate was 4.27 per 100 person-years (PY). Thirty-eight deaths (52%) were AIDS-related, 10 (14%) were immune reconstituted inflammatory syndrome (IRIS)-related, 13 (18%) were non-AIDS-related and 12 (16%) had an unknown cause. Risk factors included having a body mass index (BMI) < 18.5 [sub-hazard ratio (SHR) 2.91; 95% confidence interval (CI) 1.60-5.32] compared to BMI 18.5-24.9, and alanine aminotransferase (ALT) ≥ 5 times its upper limit of normal (ULN) (SHR 6.14; 95% CI 1.62-23.20) compared to ALT < 5 times its ULN. A higher CD4 count (51-100 cells/μL: SHR 0.28; 95% CI 0.14-0.55; and > 100 cells/μL: SHR 0.12; 95% CI 0.05-0.26) was associated with reduced hazard for mortality compared to CD4 count ≤ 25 cells/μL. CONCLUSIONS Fifty-two per cent of early deaths were AIDS-related. Efforts to initiate ART at CD4 counts > 50 cell/μL are associated with improved short-term survival rates, even in those with late stages of HIV disease.
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Affiliation(s)
- D Rupasinghe
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | - S Kiertiburanakul
- Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - A Kamarulzaman
- University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - F Zhang
- Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - N Kumarasamy
- CART CRS, Voluntary Health Services, Chennai, India
| | - R Chaiwarith
- Research Institute for Health Sciences, Chiang Mai, Thailand
| | - T P Merati
- Faculty of Medicine Udayana University & Sanglah Hospital, Bali, Indonesia
| | - C D Do
- Bach Mai Hospital, Hanoi, Vietnam
| | - S Khusuwan
- Chiangrai Prachanukroh Hospital, Chiang Rai, Thailand
| | - A Avihingsanon
- HIV-NAT/Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - M P Lee
- Queen Elizabeth Hospital, Hong Kong SAR, China
| | - P S Ly
- National Center for HIV/AIDS, Dermatology & STDs, Phnom Penh, Cambodia
| | - E Yunihastuti
- Faculty of Medicine Universitas Indonesia, Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | - K V Nguyen
- National Hospital for Tropical Diseases, Hanoi, Vietnam
| | - R Ditangco
- Research Institute for Tropical Medicine, Muntinlupa City, Philippines
| | - Y J Chan
- Taipei Veterans General Hospital, Taipei, Taiwan
| | - S Pujari
- Institute of Infectious Diseases, Pune, India
| | - O T Ng
- Tan Tock Seng Hospital, Singapore City, Singapore
| | - J Y Choi
- Division of Infectious Diseases, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Blh Sim
- Hospital Sungai Buloh, Sungai Buloh, Malaysia
| | - J Tanuma
- National Center for Global Health and Medicine, Tokyo, Japan
| | - S Sangle
- BJ Government Medical College and Sassoon General Hospitals, Pune, India
| | - J Ross
- TREAT Asia, amfAR-The Foundation for AIDS Research, Bangkok, Thailand
| | - M Law
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
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19
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Inflammatory biomarkers prior to antiretroviral therapy as prognostic markers of 12-month mortality in South Africa and Uganda. AIDS 2019; 33:2043-2048. [PMID: 31274541 PMCID: PMC6774817 DOI: 10.1097/qad.0000000000002305] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The aim of this study was to determine the utility of biomarkers of immune activation, systemic inflammation and coagulopathy prior to antiretroviral therapy to predict mortality during the first year of antiretroviral therapy (ART) in sub-Saharan Africa. DESIGN A prospective, observational cohort. METHODS We measured soluble CD14, interleukin-6 and D-dimer in nonpregnant individuals initiating ART in South Africa and Uganda in the Measuring Early Treatment Adherence (META) Study. We used survival analysis methods to estimate their association with 12-month mortality, and fit receiver operator curves (ROC) to assess the prognostic value of each biomarker. RESULTS Six-hundred and sixty individuals were enrolled and had pretreatment biomarkers measured. Approximately 60% were women, with a median CD4 cell count of 187 cells/μl [interquartile range (IQR) 111-425] and approximately half were enrolled each from South Africa and Uganda. We observed 34 deaths for a crude mortality of 5.3 deaths/100 person-years (py) (95% confidence interval 3.8-7.4), which ranged from 0/100 py to 13.7/100 py in the lowest and highest tertile of pretreatment sCD14, respectively. In Cox models, all three biomarkers were strongly predictive of the hazard of death (adjusted hazard ratio 3-6, all P < 0.01). In multivariable models including biomarkers, both pretreatment CD4 cell count and pretreatment viral load became borderline or nonsignificantly associated with mortality. The c-statistic for area under ROC was higher for all three biomarkers than for CD4 cell count (P < 0.01). CONCLUSION Biomarkers of immune activation, systemic inflammation and coagulopathy prior to ART initiation are strongly predictive of early death on treatment after adjustment for CD4 cell count. Such biomarkers might serve as important prognostic indicators for patient triage in this population.
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20
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Post FA, Szubert AJ, Prendergast AJ, Johnston V, Lyall H, Fitzgerald F, Musiime V, Musoro G, Chepkorir P, Agutu C, Mallewa J, Rajapakse C, Wilkes H, Hakim J, Mugyenyi P, Walker AS, Gibb DM, Pett SL. Causes and Timing of Mortality and Morbidity Among Late Presenters Starting Antiretroviral Therapy in the REALITY Trial. Clin Infect Dis 2019. [PMID: 29514234 PMCID: PMC5850430 DOI: 10.1093/cid/cix1141] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background In sub-Saharan Africa, 20%-25% of people starting antiretroviral therapy (ART) have severe immunosuppression; approximately 10% die within 3 months. In the Reduction of EArly mortaLITY (REALITY) randomized trial, a broad enhanced anti-infection prophylaxis bundle reduced mortality vs cotrimoxazole. We investigate the contribution and timing of different causes of mortality/morbidity. Methods Participants started ART with a CD4 count <100 cells/µL; enhanced prophylaxis comprised cotrimoxazole plus 12 weeks of isoniazid + fluconazole, single-dose albendazole, and 5 days of azithromycin. A blinded committee adjudicated events and causes of death as (non-mutually exclusively) tuberculosis, cryptococcosis, severe bacterial infection (SBI), other potentially azithromycin-responsive infections, other events, and unknown. Results Median pre-ART CD4 count was 37 cells/µL. Among 1805 participants, 225 (12.7%) died by week 48. Fatal/nonfatal events occurred early (median 4 weeks); rates then declined exponentially. One hundred fifty-four deaths had single and 71 had multiple causes, including tuberculosis in 4.5% participants, cryptococcosis in 1.1%, SBI in 1.9%, other potentially azithromycin-responsive infections in 1.3%, other events in 3.6%, and unknown in 5.0%. Enhanced prophylaxis reduced deaths from cryptococcosis and unknown causes (P < .05) but not tuberculosis, SBI, potentially azithromycin-responsive infections, or other causes (P > .3); and reduced nonfatal/fatal tuberculosis and cryptococcosis (P < .05), but not SBI, other potentially azithromycin-responsive infections, or other events (P > .2). Conclusions Enhanced prophylaxis reduced mortality from cryptococcosis and unknown causes and nonfatal tuberculosis and cryptococcosis. High early incidence of fatal/nonfatal events highlights the need for starting enhanced-prophylaxis with ART in advanced disease. Clinical Trials Registration ISRCTN43622374.
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Affiliation(s)
- Frank A Post
- King's College Hospital NHS Foundation Trust, London
| | | | | | | | | | - Felicity Fitzgerald
- University College London Great Ormond Street Institute of Child Health, United Kingdom
| | | | | | | | - Clara Agutu
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi
| | - Jane Mallewa
- Department of Medicine, College of Medicine and Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre
| | | | - Helen Wilkes
- Medical Research Council Clinical Trials Unit at University College London
| | | | | | - A Sarah Walker
- Medical Research Council Clinical Trials Unit at University College London
| | - Diana M Gibb
- Medical Research Council Clinical Trials Unit at University College London
| | - Sarah L Pett
- Medical Research Council Clinical Trials Unit at University College London.,Institute for Global Health, University College London, United Kingdom.,Kirby Institute for Infection and Immunity in Society, University of New South Wales, Sydney, Australia
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21
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Calmy A, Ford N, Meintjes G. The Persistent Challenge of Advanced HIV Disease and AIDS in the Era of Antiretroviral Therapy. Clin Infect Dis 2019. [PMID: 29514231 PMCID: PMC5850411 DOI: 10.1093/cid/cix1138] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Alexandra Calmy
- Division of Infectious Diseases, HIV Unit, Department of Internal Medicine Specialties, Geneva University Hospitals and Faculty of Medicine
| | - Nathan Ford
- Department of HIV, World Health Organization, Geneva, Switzerland
| | - Graeme Meintjes
- Wellcome Trust Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine.,Department of Medicine, Faculty of Health Sciences, University of Cape Town, South Africa
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22
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The missed potential of CD4 and viral load testing to improve clinical outcomes for people living with HIV in lower-resource settings. PLoS Med 2019; 16:e1002820. [PMID: 31141516 PMCID: PMC6541248 DOI: 10.1371/journal.pmed.1002820] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
In a Policy Forum, Peter Ehrenkranz and colleagues discuss the contribution of CD4 and viral load testing to outcomes for people with HIV in low- and middle-income countries.
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23
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Ten years of antiretroviral therapy: Incidences, patterns and risk factors of opportunistic infections in an urban Ugandan cohort. PLoS One 2018; 13:e0206796. [PMID: 30383836 PMCID: PMC6211746 DOI: 10.1371/journal.pone.0206796] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 10/22/2018] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Despite increased antiretroviral therapy (ART) coverage and the raised CD4 threshold for starting ART, opportunistic infections (OIs) are still one of the leading causes of death in sub-Saharan Africa. There are few studies from resource-limited settings on long-term reporting of OIs other than tuberculosis. METHODS Patients starting ART between April 2004 and April 2005 were enrolled and followed-up for 10 years in Kampala, Uganda. We report incidences, patterns and risk factors using Cox proportional hazards models of OIs among all patients and among patients with CD4 cell counts >200 cells/μL. RESULTS Of the 559 patients starting ART, 164 patients developed a total of 241 OIs during 10 years of follow-up. The overall incidence was highest for oral candidiasis (25.4, 95% confidence interval (CI): 20.5-31.6 per 1000 person-years of follow-up), followed by tuberculosis (15.3, 95% CI: 11.7-20.1), herpes zoster (12.3, 95% CI: 9.1-16.6) and cryptococcal meningitis (3.0, 95% CI: 1.7-5.5). Incidence rates for all OIs were highest in the first year after ART initiation and decreased with the increase of the current CD4 cell count. Factors independently associated with development of OIs were baseline nevirapine-based regimens, time-varying higher viral load, time-varying lower CD4 cell count and time-varying lower hemoglobin. In patients developing OIs at a current CD4 cell count >200 cells/μL, factors independently associated with OI development were time-varying increase in viral load and time-varying decrease in hemoglobin, whereas a baseline CD4 cell count <50 cells/μL was protective. CONCLUSION We report high early incidences of OIs, decreasing with increasing CD4 cell count and time spent on ART. Ongoing HIV replication and anemia were strong predictors for OI development independent of the CD4 cell count. Our findings support the recommendation for early initiation of ART and suggest close monitoring for OIs among patients recently started on ART, with low CD4 cell count, high viral load and anemia.
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