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Ghislain MR, Mushebenge GAA, Magula N. Cause of hospitalization and death in the antiretroviral era in Sub-Saharan Africa published 2008-2018: A systematic review. Medicine (Baltimore) 2021; 100:e27342. [PMID: 34713822 PMCID: PMC8556022 DOI: 10.1097/md.0000000000027342] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 09/09/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Worldwide despite the availability of antiretroviral therapy, human immunodeficiency virus/acquired immunodeficiency syndrome still causes morbidity and mortality among patients. In Sub-Saharan Africa, human immunodeficiency virus/acquired immunodeficiency syndrome remains a major public health concern. The aim of this study was to identify the causes of morbidity and mortality in the modern antiretroviral therapy era in Sub-Saharan Africa. METHODS We conducted a systematic review according to the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. We searched relevant studies from 3 databases which are Google Scholar, PubMed, and CINAHL. Two review authors independently screened titles, abstracts, and full-text articles in duplicate, extracted data, and assessed bias. Discrepancies were resolved by discussion or arbitration of a third review author. R software version 3.6.2 was used to analyze the data. Maximum values were used in order to show which disease was mostly spread out by looking at the highest prevalence reported. This systematic review protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO). RESULTS A total of 409 articles were obtained from the database search, finally 12 articles met the inclusion criteria and were eligible for data extraction. Among them, 3 were conducted in Nigeria, 2 were conducted in Uganda, 3 were conducted in South Africa, 1 in Gabon, 1 in Ethiopia, 1 in Ghana, and 1 in Burkina Faso. In most of the included studies, tuberculosis was the leading cause of hospitalization which accounted for between 18% and 40.7% and it was also the leading cause of death and accounted for between 16% and 44.3%, except in 1 which reported anemia as the leading cause of hospitalization and in 2 which reported wasting syndrome and meningitis respectively as the leading causes of death. Opportunistic malignancies accounted between for 1.8% to 5% of hospitalization and 1.2% to 9.8% of deaths. CONCLUSIONS Tuberculosis is the commonest cause of hospitalization and death in Sub-Saharan Africa, but it is always followed by other infectious disease and other non-AIDS related causes.
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Affiliation(s)
- Manimani Riziki Ghislain
- Department of Internal Medicine, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, South Africa
| | | | - Nombulelo Magula
- Department of Internal Medicine, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, South Africa
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Liebenberg C, Luies L, Williams AA. Metabolomics as a Tool to Investigate HIV/TB Co-Infection. Front Mol Biosci 2021; 8:692823. [PMID: 34746228 PMCID: PMC8565463 DOI: 10.3389/fmolb.2021.692823] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 10/04/2021] [Indexed: 12/28/2022] Open
Abstract
The HIV/AIDS (human immunodeficiency virus/acquired immunodeficiency syndrome) and tuberculosis (TB) pandemics are perpetuated by a significant global burden of HIV/TB co-infection. The synergy between HIV and Mycobacterium tuberculosis (Mtb) during co-infection of a host is well established. While this synergy is known to be driven by immunological deterioration, the metabolic mechanisms thereof remain poorly understood. Metabolomics has been applied to study various aspects of HIV and Mtb infection separately, yielding insights into infection- and treatment-induced metabolic adaptations experienced by the host. Despite the contributions that metabolomics has made to the field, this approach has not yet been systematically applied to characterize the HIV/TB co-infected state. Considering that limited HIV/TB co-infection metabolomics studies have been published to date, this review briefly summarizes what is known regarding the HIV/TB co-infection synergism from a conventional and metabolomics perspective. It then explores metabolomics as a tool for the improved characterization of HIV/TB co-infection in the context of previously published human-related HIV infection and TB investigations, respectively as well as for addressing the gaps in existing knowledge based on the similarities and deviating trends reported in these HIV infection and TB studies.
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Li L, Li J, Chai C, Liu T, Li P, Qu M, Zhao H. Association of CD4 T cell count and optimal timing of antiretroviral therapy initiation with immune reconstitution inflammatory syndrome and all-cause mortality for HIV-infected adults with newly diagnosed pulmonary tuberculosis: a systematic review and meta-analysis. INTERNATIONAL JOURNAL OF CLINICAL AND EXPERIMENTAL PATHOLOGY 2021; 14:670-679. [PMID: 34239668 PMCID: PMC8255206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 03/07/2021] [Indexed: 06/13/2023]
Abstract
AIMS CD4 T cell count and optimal timing of antiretroviral therapy (ART) during tuberculosis (TB) treatment are challenging. We conducted a meta-analysis to assess the association of CD4 T cell count and timing of ART initiation with immune reconstitution inflammatory syndrome (IRIS) and all-cause mortality of patients co-infected with HIV/TB. METHODS We conducted an electronic search of clinical studies dated from January 1980 to December 2019 in PubMed and EMBASE. Randomized, controlled trials evaluating low-base CD4 T cell count (< 50 cells/μL) versus high-base CD4 T cell count (≥ 50 cells/μL), and/or early ART initiation (1 to 28 days after starting TB treatment) versus delayed ART initiation (≥ 28 days after starting TB treatment) were included. The primary endpoints were all-cause mortality and TB-related immune reconstitution inflammatory syndrome (IRIS-TB). The risk ratio (RR) was calculated as a measure of intervention effect. Mantel-Haenszel method was used to estimate the RR. RESULTS Ten trials (n = 5226) were conducted in North America, Africa, and Asia. We found that low-baseline CD4 T cell count increased the incidence of TB-associated IRIS (RR, 1.47; 95% CI, 1.24-1.75; I2 = 58%) and all-cause mortality (RR, 2.42; 95% CI, 1.71-3.42; I2 = 41%) compared with high baseline CD4 T cell count, and early ART initiation increased the incidence of TB-associated IRIS compared with delayed ART initiation (RR, 1.80; 95% CI, 1.57-2.07; I2 = 74%). However, early ART initiation did not reduce all-cause mortality (RR, 0.91; 95% CI, 0.74-1.12; I2 = 49%) compared with delayed ART initiation. CONCLUSIONS The present study demonstrates that low-baseline CD4 T cell count (< 50 cells/μL) in patients co-infected with TB-HIV increases the incidence of TB-associated IRIS and all-cause mortality. Early ART initiation (≤ 28 days) in patients co-infected with TB-HIV increases the incidence of TB-associated IRIS. However, evidence is insufficient to refute or support a survival benefit conferred by the comparison between early ART initiation (≤ 28 days) and delayed ART initiation.
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Affiliation(s)
- Lifang Li
- Department of Respiratory Medicine, The Second Hospital of Shanxi Medical UniversityTaiyuan 030001, Shanxi Province, P. R. China
| | - Jianqiang Li
- Department of Respiratory Medicine, The Second Hospital of Shanxi Medical UniversityTaiyuan 030001, Shanxi Province, P. R. China
| | - Chunwei Chai
- Department of Internal Medicine, The Fourth People’s Hospital of Shanxi Medical UniversityTaiyuan 030001, Shanxi Province, P. R. China
| | - Tanzhen Liu
- Department of Respiratory Medicine, The Second Hospital of Shanxi Medical UniversityTaiyuan 030001, Shanxi Province, P. R. China
| | - Pingping Li
- Department of Respiratory Medicine, The Second Hospital of Shanxi Medical UniversityTaiyuan 030001, Shanxi Province, P. R. China
| | - Mengrui Qu
- Department of Respiratory Medicine, The Second Hospital of Shanxi Medical UniversityTaiyuan 030001, Shanxi Province, P. R. China
| | - Hui Zhao
- Department of Respiratory Medicine, The Second Hospital of Shanxi Medical UniversityTaiyuan 030001, Shanxi Province, P. R. China
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Zhang L, Xing W, Zhou J, Zhang R, Cheng Y, Li J, Wang G, Liu S, Li Y. Characteristics of tuberculosis patients in the integrated tuberculosis control model in Chongqing, China: a retrospective study. BMC Infect Dis 2020; 20:576. [PMID: 32758169 PMCID: PMC7404911 DOI: 10.1186/s12879-020-05304-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 07/27/2020] [Indexed: 12/25/2022] Open
Abstract
Background China ranks second in the world in terms of numbers of tuberculosis (TB) cases and is one of the top three countries with the largest number of multidrug-resistant and rifampicin-resistant TB (MDR/RR-TB). It also has high mortality and low cure rates of human immunodeficiency virus (HIV)-positive TB patients. This study aimed to analyse, under the integrated TB control model, the characteristics of TB patients seeking healthcare in the largest designated TB hospital in Chongqing. Methods This was a retrospective study of TB registers in a health facility. Record data of 1827 TB patients who had attended the Chongqing Public Health Medical Center (CPHMC) from 1 January to 31 December 2018 were included. The Statistical Package for Social Science (SPSS 18.0; IBM Corporation, Armonk, NY, USA) was used to analyse the data. Counting data were compared using the chi-square test or Fisher’ s exact test. Among the results of the univariate analysis, the variables with statistical significance were included in the binomial stepwise logistic regression, with odds ratio and 95% confidence interval calculated. A two-tailed probability level of P < 0.05 was considered statistically significant. Results The majority of registered patients were men (1197), of Han ethnicity (1670), aged 21–60 years (1331), farmer/unemployed (1075), and living in county/district (1207). Approximately 24.9% of patients (455/1827) contracted DR-TB, 6% (110/1827) were co-infected with HIV, and 41.0% (749/1827) had drug-related hepatotoxicity. Among those patients, DR-TB was more likely to develop among farmers who received retreatment and had drug-related hepatotoxicity (P < 0.05). Women who received retreatment and lived in county/district were less likely to be HIV positive (P < 0.05). Compared with farmers, patients who were unemployed were more likely to be HIV positive, and those aged 21–60 years had a higher risk of being tested as HIV positive (P < 0.05). Conclusion Farmers who received retreatment and had drug-related hepatotoxicity are more susceptible to DR-TB; young unemployed men have a higher risk of contracting HIV-positive TB. The demographic and clinical characteristics of TB patients should be taken into consideration in DR-TB and HIV-positive TB screening in the future.
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Affiliation(s)
- Liwen Zhang
- Department of Social Medicine and Health Service Management, Army Medical University (Third Military Medical University), No.30 Gaotanyan Road, Shapingba District, Chongqing, 400038, China.,Chongqing Public Health Medical Center (CPHMC), Chongqing, China
| | - Wei Xing
- Department of Social Medicine and Health Service Management, Army Medical University (Third Military Medical University), No.30 Gaotanyan Road, Shapingba District, Chongqing, 400038, China
| | - Jiani Zhou
- Department of Social Medicine and Health Service Management, Army Medical University (Third Military Medical University), No.30 Gaotanyan Road, Shapingba District, Chongqing, 400038, China
| | - Rui Zhang
- Department of Social Medicine and Health Service Management, Army Medical University (Third Military Medical University), No.30 Gaotanyan Road, Shapingba District, Chongqing, 400038, China
| | - Yong Cheng
- Department of Social Medicine and Health Service Management, Army Medical University (Third Military Medical University), No.30 Gaotanyan Road, Shapingba District, Chongqing, 400038, China
| | - Jin Li
- Department of Social Medicine and Health Service Management, Army Medical University (Third Military Medical University), No.30 Gaotanyan Road, Shapingba District, Chongqing, 400038, China
| | - Geng Wang
- Department of Social Medicine and Health Service Management, Army Medical University (Third Military Medical University), No.30 Gaotanyan Road, Shapingba District, Chongqing, 400038, China
| | - Shili Liu
- Department of Social Medicine and Health Service Management, Army Medical University (Third Military Medical University), No.30 Gaotanyan Road, Shapingba District, Chongqing, 400038, China
| | - Ying Li
- Department of Social Medicine and Health Service Management, Army Medical University (Third Military Medical University), No.30 Gaotanyan Road, Shapingba District, Chongqing, 400038, China.
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Abstract
BACKGROUND Neurological disorders in HIV infection are a common cause of morbidity and mortality. The aim of this paper is to provide a narrative overview of up to date information concerning neurological disorders affecting HIV infected persons in Africa. METHODS Seminal research concerning neurological disorders among HIV-infected adults in sub-Saharan Africa from prior to 2000 was combined with an in-depth search of PubMed to identify literature published from 2000 to 2017. The following Mesh terms were used. "Nervous System Diseases" "HIV Infections" and "Africa South of the Sahara" and "Seizures" or "Spinal Cord Diseases" or "Peripheral Nervous System Diseases" or "AIDS Dementia Complex" or "Opportunistic Infections" or "Immune Reconstitution Inflammatory Syndrome" or "Stroke". Only those articles written in English were used. A total of 352 articles were identified, selected and reviewed and 180 were included in the study. These included case series, observational studies, interventional studies, guidelines and reviews with metanalyses. The author also included 15 publications on the subject covering the earlier phase of the HIV epidemic in Africa from 1987 to 1999 making a total of 195 references in the study. This was combined with extensive personal experience diagnosing and treating these neurological disorders. RESULTS Neurological disorders were common, typically occurring in WHO stages III/IV. These were in three main categories: those arising from opportunistic processes mostly infections, direct HIV infection and autoimmunity. The most common were those arising from direct HIV infection occurring in >50%. These included HIV-associated neurocognitive dysfunction (HAND), neuropathy and myelopathy. Opportunistic infections occurred in >20% and frequently had a 6-9-month mortality rate of 60-70%. The main causes were cryptococcus, tuberculosis, toxoplasmosis and acute bacterial meningitis. Concurrent systemic tuberculosis occurred in almost 50%. CONCLUSION Neurological disorders are common in HIV in Africa and the main CNS opportunistic infections result in high mortality rates. Strategies aimed at reducing their high burden, morbidity and mortality include early HIV diagnosis and anti-retroviral therapy (ART), screening and chemoprophylaxis of main opportunistic infections, improved clinical diagnosis and management and programme strengthening.
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Affiliation(s)
- William P Howlett
- Department of Internal Medicine, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Center for International Health, University of Bergen, Norway
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Esmail H, Riou C, Bruyn ED, Lai RPJ, Harley YXR, Meintjes G, Wilkinson KA, Wilkinson RJ. The Immune Response to Mycobacterium tuberculosis in HIV-1-Coinfected Persons. Annu Rev Immunol 2018; 36:603-638. [PMID: 29490165 DOI: 10.1146/annurev-immunol-042617-053420] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Globally, about 36.7 million people were living with HIV infection at the end of 2015. The most frequent infection co-occurring with HIV-1 is Mycobacterium tuberculosis-374,000 deaths per annum are attributable to HIV-tuberculosis, 75% of those occurring in Africa. HIV-1 infection increases the risk of tuberculosis by a factor of up to 26 and alters its clinical presentation, complicates diagnosis and treatment, and worsens outcome. Although HIV-1-induced depletion of CD4+ T cells underlies all these effects, more widespread immune deficits also contribute to susceptibility and pathogenesis. These defects present a challenge to understand and ameliorate, but also an opportunity to learn and optimize mechanisms that normally protect people against tuberculosis. The most effective means to prevent and ameliorate tuberculosis in HIV-1-infected people is antiretroviral therapy, but this may be complicated by pathological immune deterioration that in turn requires more effective host-directed anti-inflammatory therapies to be derived.
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Affiliation(s)
- Hanif Esmail
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town 7925, Republic of South Africa; .,Department of Medicine, Imperial College London, London W2 1PG, United Kingdom.,Radcliffe Department of Medicine, University of Oxford, Oxford OX3 9DU, United Kingdom
| | - Catherine Riou
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town 7925, Republic of South Africa;
| | - Elsa du Bruyn
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town 7925, Republic of South Africa;
| | | | - Yolande X R Harley
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town 7925, Republic of South Africa;
| | - Graeme Meintjes
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town 7925, Republic of South Africa;
| | - Katalin A Wilkinson
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town 7925, Republic of South Africa; .,The Francis Crick Institute, London NW1 2AT, United Kingdom
| | - Robert J Wilkinson
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town 7925, Republic of South Africa; .,Department of Medicine, Imperial College London, London W2 1PG, United Kingdom.,The Francis Crick Institute, London NW1 2AT, United Kingdom
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Sattler FR, Chelliah D, Wu X, Sanchez A, Kendall MA, Hogg E, Lagat D, Lalloo U, Veloso V, Havlir DV, Landay A. Biomarkers Associated with Death After Initiating Treatment for Tuberculosis and HIV in Patients with Very Low CD 4 Cells. Pathog Immun 2018; 3:46-62. [PMID: 29770360 PMCID: PMC5951172 DOI: 10.20411/pai.v3i1.235] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Background The risk of short-term death for treatment naive patients dually infected with Mycobacterium tuberculosis and HIV may be reduced by early anti-retroviral therapy. Of those dying, mechanisms responsible for fatal outcomes are unclear. We hypothesized that greater malnutrition and/or inflammation when initiating treatment are associated with an increased risk for death. Methods We utilized a retrospective case-cohort design among participants of the ACTG A5221 study who had baseline CD4 < 50 cells/mm3. The case-cohort sample consisted of 51 randomly selected participants, whose stored plasma was tested for C-reactive protein, cytokines, chemokines, and nutritional markers. Cox proportional hazards models were used to assess the association of nutritional, inflammatory, and immunomodulatory markers for survival. Results The case-cohort sample was similar to the 282 participants within the parent cohort with CD4 <50 cells/mm3. In the case cohort, 7 (14%) had BMI < 16.5 (kg/m2) and 17 (33%) had BMI 16.5-18.5(kg/m2). Risk of death was increased per 1 IQR width higher of log10 transformed level of C-reactive protein (adjusted hazard ratio (aHR) = 3.42 [95% CI = 1.33-8.80], P = 0.011), interferon gamma (aHR = 2.46 [CI = 1.02-5.90], P = 0.044), MCP-3 (3.67 [CI = 1.08-12.42], P = 0.037), and with IL-15 (aHR = 2.75 [CI = 1.08-6.98], P = 0.033) and IL-17 (aHR = 3.99 [CI = -1.06-15.07], P = 0.041). BMI, albumin, hemoglobin, and leptin levels were not associated with risk of death. Conclusions Unlike patients only infected with M. tuberculosis for whom malnutrition and low BMI increase the risk of death, this relationship was not evident in our dually infected patients. Risk of death was associated with significant increases in markers of global inflammation along with soluble biomarkers of innate and adaptive immunity.
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Affiliation(s)
- Fred R Sattler
- Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Daniel Chelliah
- Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Xingye Wu
- Harvard School of Public Health, Boston, Massachusetts
| | - Alejandro Sanchez
- Keck School of Medicine of the University of Southern California, Los Angeles, California
| | | | - Evelyn Hogg
- Social & Scientific Systems Inc., Silver Springs, Maryland
| | - David Lagat
- Moi University Clinical Research Center, Eldoret, Kenya
| | - Umesh Lalloo
- Enhancing Care Foundation, Durban University of Technology, Durban, South Africa
| | - Valdilea Veloso
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Diane V Havlir
- University of California San Francisco, San Francisco, California
| | - Alan Landay
- Rush Presbyterian Medical Center, Chicago, Illinois
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Grimaldi A, De Concilio A, Marsero L, Odida M. Cardiac cachexia in sub-Saharan Africa. Indian Heart J 2017; 69:784-787. [PMID: 29174259 PMCID: PMC5717311 DOI: 10.1016/j.ihj.2017.08.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 08/07/2017] [Accepted: 08/23/2017] [Indexed: 11/28/2022] Open
Abstract
Cachexia is a public health challenge around the Globe but data on prevalence rates in developing countries are very scarce. In sub-Saharan Africa wasting syndrome is mainly related to malaria, HIV infections, tuberculosis and end-stage heart disease and always associated with high-mortality and dismal quality of life regardless of age, urban or rural setting. We report two different cases affected by cardiac cachexia related to end-stage heart disease. The large age gap between patients highlights the current impact of medical services in Uganda ranging from low-resource rural settings to urban areas of the capital city under epidemiologic transition. The wasting syndrome occurring in both patients emphasizes as cachexia remains largely neglected and underestimated in most sub-Saharan African countries.
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Affiliation(s)
- Antonio Grimaldi
- St. Mary's Lacor Hospital, Gulu, Uganda; San Raffaele Scientific Institute, Università Vita-Salute, Milan, Italy; St Raphael of St Francis, Nsambya Hospital, Kampala, Uganda.
| | - Annalisa De Concilio
- San Raffaele Scientific Institute, Università Vita-Salute, Milan, Italy; St Raphael of St Francis, Nsambya Hospital, Kampala, Uganda
| | - Luca Marsero
- St Raphael of St Francis, Nsambya Hospital, Kampala, Uganda; San Luigi Gonzaga Hospital, University of Torino, Italy
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Raised Venous Lactate and Markers of Intestinal Translocation Are Associated With Mortality Among In-Patients With HIV-Associated TB in Rural South Africa. J Acquir Immune Defic Syndr 2016; 70:406-13. [PMID: 26186506 PMCID: PMC4625603 DOI: 10.1097/qai.0000000000000763] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Supplemental Digital Content is Available in the Text. Case fatality among in-patients with HIV-associated tuberculosis (HIV-TB) in Africa is high. We investigated the factors associated with mortality in a rural South African hospital.
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10
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Uthman OA, Okwundu C, Gbenga K, Volmink J, Dowdy D, Zumla A, Nachega JB. Optimal Timing of Antiretroviral Therapy Initiation for HIV-Infected Adults With Newly Diagnosed Pulmonary Tuberculosis: A Systematic Review and Meta-analysis. Ann Intern Med 2015; 163:32-9. [PMID: 26148280 DOI: 10.7326/m14-2979] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Initiation of antiretroviral therapy (ART) during tuberculosis (TB) treatment remains challenging. PURPOSE To assess evidence from randomized, controlled trials of the timing of ART initiation in HIV-infected adults with newly diagnosed pulmonary TB. DATA SOURCES PubMed, EMBASE, Cochrane Central Register of Controlled Trials, conference abstracts, and ClinicalTrials.gov (from January 1980 to May 2015). STUDY SELECTION Randomized, controlled trials evaluating early versus delayed ART initiation (1 to 4 weeks vs. 8 to 12 weeks after initiation of TB treatment) or deferred ART initiation (after the end of TB treatment). DATA EXTRACTION Three reviewers independently extracted data and assessed risk of bias. The main outcome measures were all-cause mortality and the TB-associated immune reconstitution inflammatory syndrome (TB-IRIS). DATA SYNTHESIS The 8 included trials (n = 4568) were conducted in Africa, Asia, and the United States and were generally at low risk of bias for the assessed domains. Overall, early ART reduced mortality compared with delayed ART (relative risk [RR], 0.81 [95% CI, 0.66 to 0.99]; I2 = 0%). In a prespecified subgroup analysis, early ART reduced mortality compared with delayed ART among patients with baseline CD4+ T-cell counts less than 0.050 × 109 cells/L (RR, 0.71 [CI, 0.54 to 0.93]; I2 = 0%). However, a mortality benefit from early ART was not found among those with CD4+ T-cell counts greater than 0.050 × 109 cells/L (RR, 1.05 [CI, 0.68 to 1.61]; I2 = 56%). Early ART was associated with a higher incidence of TB-IRIS than delayed ART (RR, 2.31 [CI, 1.87 to 2.86]; I2 = 19%). LIMITATION Few trials provided sufficient data for subgroup analysis. CONCLUSION Early ART in HIV-infected adults with newly diagnosed TB improves survival in those with CD4+ T-cell counts less than 0.050 × 109 cells/L, although this is associated with a 2-fold higher frequency of TB-IRIS. In patients with CD4+ T-cell counts greater than 0.050 × 109 cells/L, evidence is insufficient to support or refute a survival benefit conferred by early versus delayed ART initiation. PRIMARY FUNDING SOURCE None. (PROSPERO registration: CRD42012001884).
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Affiliation(s)
- Olalekan A. Uthman
- From Warwick Medical School, Warwick University, Coventry, United Kingdom; Liverpool School of Tropical Medicine, International Health Group, Liverpool, United Kingdom; Stellenbosch University, Stellenbosch, South Africa; South African Medical Research Council, Tygerberg, South Africa; University Medical Center Utrecht, Utrecht, The Netherlands; Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; University College London, London, United Kingdom
- and University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Charles Okwundu
- From Warwick Medical School, Warwick University, Coventry, United Kingdom; Liverpool School of Tropical Medicine, International Health Group, Liverpool, United Kingdom; Stellenbosch University, Stellenbosch, South Africa; South African Medical Research Council, Tygerberg, South Africa; University Medical Center Utrecht, Utrecht, The Netherlands; Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; University College London, London, United Kingdom
- and University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Kayode Gbenga
- From Warwick Medical School, Warwick University, Coventry, United Kingdom; Liverpool School of Tropical Medicine, International Health Group, Liverpool, United Kingdom; Stellenbosch University, Stellenbosch, South Africa; South African Medical Research Council, Tygerberg, South Africa; University Medical Center Utrecht, Utrecht, The Netherlands; Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; University College London, London, United Kingdom
- and University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Jimmy Volmink
- From Warwick Medical School, Warwick University, Coventry, United Kingdom; Liverpool School of Tropical Medicine, International Health Group, Liverpool, United Kingdom; Stellenbosch University, Stellenbosch, South Africa; South African Medical Research Council, Tygerberg, South Africa; University Medical Center Utrecht, Utrecht, The Netherlands; Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; University College London, London, United Kingdom
- and University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - David Dowdy
- From Warwick Medical School, Warwick University, Coventry, United Kingdom; Liverpool School of Tropical Medicine, International Health Group, Liverpool, United Kingdom; Stellenbosch University, Stellenbosch, South Africa; South African Medical Research Council, Tygerberg, South Africa; University Medical Center Utrecht, Utrecht, The Netherlands; Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; University College London, London, United Kingdom
- and University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Alimuddin Zumla
- From Warwick Medical School, Warwick University, Coventry, United Kingdom; Liverpool School of Tropical Medicine, International Health Group, Liverpool, United Kingdom; Stellenbosch University, Stellenbosch, South Africa; South African Medical Research Council, Tygerberg, South Africa; University Medical Center Utrecht, Utrecht, The Netherlands; Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; University College London, London, United Kingdom
- and University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Jean B. Nachega
- From Warwick Medical School, Warwick University, Coventry, United Kingdom; Liverpool School of Tropical Medicine, International Health Group, Liverpool, United Kingdom; Stellenbosch University, Stellenbosch, South Africa; South African Medical Research Council, Tygerberg, South Africa; University Medical Center Utrecht, Utrecht, The Netherlands; Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; University College London, London, United Kingdom
- and University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
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11
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Lucas S, Nelson AM. HIV and the spectrum of human disease. J Pathol 2015; 235:229-41. [PMID: 25251832 DOI: 10.1002/path.4449] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 09/12/2014] [Accepted: 09/15/2014] [Indexed: 01/18/2023]
Abstract
Infection with the human immunodeficiency virus (HIV) causes systemic T cell destruction and reduced cell-mediated immunity that leads to a wide range of opportunistic infections and cancers. Second, it directly damages many tissues - gut, brain, lung - through mononuclear cell infection and activation. Third, through immune activation and effects on endothelia, it can cause more subtle systemic organ damage, such as chronic cardiovascular, hepatic, pulmonary and central nervous system disease. Antiretroviral treatment has enabled HIV-infected persons to live with chronic infection, although with some side-effects and mortality, including reactions due to the immune reconstitution inflammatory syndrome (IRIS). As cohorts of infected people get older, age-related diseases will combine with chronic HIV infection to produce disabilities whose scale is not yet understood. HIV is detectable in tissues by immunohistochemistry when infection loads are high, such as at first presentation. Pathologists should proactively consider HIV disease in routine diagnostic work, so as to identify more HIV-infected patients and enable their optimal management.
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Affiliation(s)
- Sebastian Lucas
- Department of Histopathology, St Thomas' Hospital, London, UK
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Mupere E, Malone L, Zalwango S, Okwera A, Nsereko M, Tisch DJ, Parraga IM, Stein CM, Mugerwa R, Boom WH, Mayanja HK, Whalen CC. Wasting among Uganda men with pulmonary tuberculosis is associated with linear regain in lean tissue mass during and after treatment in contrast to women with wasting who regain fat tissue mass: prospective cohort study. BMC Infect Dis 2014; 14:24. [PMID: 24410970 PMCID: PMC3922730 DOI: 10.1186/1471-2334-14-24] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Accepted: 01/07/2014] [Indexed: 01/10/2023] Open
Abstract
Background Nutritional changes during and after tuberculosis treatment have not been well described. We therefore determined the effect of wasting on rate of mean change in lean tissue and fat mass as measured by bioelectrical impedance analysis (BIA), and mean change in body mass index (BMI) during and after tuberculosis treatment. Methods In a prospective cohort study of 717 adult patients, BMI and height-normalized indices of lean tissue (LMI) and fat mass (FMI) as measured by BIA were assessed at baseline, 3, 12, and 24 months. Results Men with wasting at baseline regained LMI at a greater rate than FMI (4.55 kg/m2 (95% confidence interval (CI): 1.26, 7.83 versus 3.16 (95% CI: 0.80, 5.52)) per month, respectively during initial tuberculosis therapy. In contrast, women with wasting regained FMI at greater rate than LMI (3.55 kg/m2 (95% CI: 0.40, 6.70) versus 2.07 (95% CI: -0.74, 4.88)), respectively. Men with wasting regained BMI at a rate of 6.45 kg/m2 (95% CI: 3.02, 9.87) in the first three months whereas women, had a rate of 3.30 kg/m2 (95% CI: -0.11, 6.72). There were minimal changes in body composition after month 3 and during months 12 to 24. Conclusion Wasted tuberculosis patients regain weight with treatment but the type of gain differs by gender and patients may remain underweight after the initial phase of treatment.
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Affiliation(s)
- Ezekiel Mupere
- Department of Paediatrics & Child Health College of Health Sciences, Makerere University Kampala, Kampala, Uganda.
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P K C, Nagaral J, M N N, G P, B R H, Vinaykumar MV. TB-DOTS Outcome in Relation to HIV Status: Experience in a Medical College. J Clin Diagn Res 2014; 8:74-6. [PMID: 24596728 DOI: 10.7860/jcdr/2014/7416.3975] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Accepted: 11/24/2013] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVE There is scarce information regarding TB associated with Human Immunodeficiency Virus (HIV) infection treated under routine program conditions in medical colleges of India. This study evaluates the clinical profile and outcome of TB-DOTS treatment by HIV status. METHODS Total two hundred and eighty TB patients registered under Revised National Tuberculosis Control Program Revised National TB Control Program (RNTCP) during January 2011 and December 2012 in a teaching hospital of South India were enrolled in the study. The demographic profile, treatment related data of these patients was obtained from RNTCP treatment card and the DOTS outcome of all enrolled cases depending on their HIV status was evaluated. Data was analysed using descriptive statistics and chi-square test. RESULTS Among 280 TB patients enrolled 41 were HIV positive patients and 239 HIV negative. About 21% patients were retreatment patients. Over all, pulmonary TB was still the commonest form of TB among the registered patients. However, Extra Pulmonary (EPTB) was high among HIV positive TB patients. Treatment success among HIV positive TB patients was lower than HIV negative TB patients (61% vs. 79%). Further, 19.5% HIV positive and 8.3% HIV negative patients died. The proportions of defaulters and failures were similar in HIV positive and HIV negative patients. CONCLUSION HIV co-infected TB patients responded poorly to DOTS as evidenced by lower success rates and higher mortality than HIV negative TB patients. A significant proportion of retreatment patients in our study is the matter of concern.
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Affiliation(s)
- Chennaveerappa P K
- Associate Professor, Department of Pulmonary Medicine, Hassan Institute of Medical Sciences , Hassan, Karnataka, India
| | - Jayashree Nagaral
- Assistant Professor, Department of Pharmacology, Hassan Institute of Medical Sciences , Hassan, Karnataka, India
| | - Nareshkumar M N
- Junior Resident, Department of Pulmonary Medicine, Hassan Institute of Medical Sciences , Hassan, Karnataka, India
| | - Praveen G
- Assistant Professor, Department of Community Medicine, Hassan Institute of Medical Sciences , Hassan, Karnataka, India
| | - Halesha B R
- Assistant Professor, Department of General Medicine, Hassan Institute of Medical Sciences , Hassan, Karnataka, India
| | - M V Vinaykumar
- Assistant Professor, Department of ENT, Hassan Institute of Medical Sciences , Hassan, Karnataka, India
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Akanbi MO, Achenbach CJ, Feinglass J, Taiwo B, Onu A, Pho MT, Agbaji O, Kanki P, Murphy RL. Tuberculosis after one year of combination antiretroviral therapy in Nigeria: a retrospective cohort study. AIDS Res Hum Retroviruses 2013; 29:931-7. [PMID: 23316724 DOI: 10.1089/aid.2012.0231] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Our objective was to determine tuberculosis (TB) incidence and evaluate TB risk in adults after one or more years of use of combination antiretroviral therapy (cART) through a retrospective cohort study in Jos, Nigeria. We studied a cohort of HIV-infected adults treated with ART for at least 1 year. Based on immunologic and virologic responses to ART, patients were categorized into four groups: CD4 T cell count ≥350 cells/mm(3) and HIV-1 RNA level ≤400 copies/ml (group 1), CD4 T cell count ≥350 cells/mm(3) and HIV-1 RNA level >400 copies/ml (group 2), CD4 T cell count <350 cells/mm(3) and HIV-1 RNA level ≤400 copies/ml (group 3), and CD4 T cell count <350 cells/mm(3) and HIV-1 RNA level >400 copies/ml (group 4). Time to incident TB for the four groups was analyzed using the Kaplan-Meier method. Cox regression models were used to evaluate predictors of incident TB. In this cohort of 5,093 HIV-infected adults, of which 68.4% were female, with a mean age 35.1 years (standard deviation 9.1 years), we observed 98 cases of incident TB during 4 years and 3 months of follow-up. The overall TB incidence rate was 8.7 cases/1,000 patient-years of follow-up. Adjusted hazards for incident TB were 2.11 (95% CI 0.97-4.61), 2.05 (95% CI 1.10-3.79), and 3.65 (95% CI 1.15-5.06) in group 2, 3, and 4 patients, respectively, compared to group 1. Tuberculosis incidence in patients on ART is driven by poor immunologic and/or virologic response. Optimization of HIV treatment should be prioritized to reduce the burden of TB in this high-risk population.
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Affiliation(s)
- Maxwell O. Akanbi
- APIN Center, Jos University Teaching Hospital, Jos, Nigeria
- Department of Medicine, Jos University Teaching Hospital, Jos, Nigeria
- University of Jos, Jos, Nigeria
| | - Chad J. Achenbach
- Department of Medicine, Division of Infectious Diseases and Center for Global Health, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Joe Feinglass
- Division of General Internal Medicine and the Institute of Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Babafemi Taiwo
- Department of Medicine, Division of Infectious Diseases and Center for Global Health, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Adamu Onu
- APIN Center, Jos University Teaching Hospital, Jos, Nigeria
| | - Mai T. Pho
- Department of Medicine, Section of Hospital Medicine, University of Chicago, Chicago, Illinois
| | - Oche Agbaji
- APIN Center, Jos University Teaching Hospital, Jos, Nigeria
- Department of Medicine, Jos University Teaching Hospital, Jos, Nigeria
- University of Jos, Jos, Nigeria
| | - Phyllis Kanki
- Harvard School of Public Health, Boston, Massachusetts
| | - Robert L. Murphy
- Department of Medicine, Division of Infectious Diseases and Center for Global Health, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Mupere E, Parraga IM, Tisch DJ, Mayanja HK, Whalen CC. Low nutrient intake among adult women and patients with severe tuberculosis disease in Uganda: a cross-sectional study. BMC Public Health 2012; 12:1050. [PMID: 23217171 PMCID: PMC3537524 DOI: 10.1186/1471-2458-12-1050] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Accepted: 11/28/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Information regarding dietary nutrient intake during tuberculosis disease is lacking. We established the relationship between disease severity or wasting during pulmonary tuberculosis and nutrient intake. METHODS In a cross-sectional study of 131 adults with or without pulmonary tuberculosis were screened for human immune-deficiency virus (HIV), wasting, disease severity using 13 item validated clinical TBscore, and 24-hour dietary intake recall. RESULTS Of the 131 participants, 61 were males and 70 females. Overall men and women had similar age. In average 24-hour nutrient intake, the following nutrients: energy, protein, total fat, carbohydrate, calcium, vitamin A, and folate were low among patients with severe tuberculosis disease. Patients with moderate-to-severe clinical TBscore had lower average energy intake than patients with mild TBscores (6.11 vs. 9.27 MJ, respectively) (p<0.05). The average 24-hour nutrient intakes between wasted and non-wasted tuberculosis patients were comparable. Nutrient intake among men was higher when compared to women regardless of wasting and severity of tuberculosis. Among those with wasting, men had higher average energy intake than women (8.87 vs. 5.81 MJ, respectively) (p<0.05). Among patients with mild disease, men had higher average energy intake than women with mild disease (12.83 vs. 7.49 kcal, respectively) (p<0.001). CONCLUSIONS Findings suggest that severity of pulmonary tuberculosis and female gender had reduced nutrient intake. Early tuberculosis diagnosis and nutritional support may be important in management of tuberculosis patients.
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Affiliation(s)
- Ezekiel Mupere
- Department of Paediatrics & Child Health School of Medicine College of Health Sciences, Makerere University Kampala, Kampala, Uganda
| | - Isabel M Parraga
- Department of Nutrition, Case Western Reserve University Cleveland Ohio, Cleveland, USA
| | - Daniel J Tisch
- Department of Epidemiology & Biostatistics, Case Western Reserve University Cleveland Ohio, Cleveland, USA
| | - Harriet K Mayanja
- Department of Internal Medicine School of Medicine College of Health Sciences, Makerere University, Kampala, Uganda
| | - Christopher C Whalen
- Department of Epidemiology & Biostatistics, College of Public Health, University of Georgia, Athens, USA
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Bedell RA, Anderson STB, van Lettow M, Akesson A, Corbett EL, Kumwenda M, Chan AK, Heyderman RS, Zachariah R, Harries AD, Ramsay AR. High prevalence of tuberculosis and serious bloodstream infections in ambulatory individuals presenting for antiretroviral therapy in Malawi. PLoS One 2012; 7:e39347. [PMID: 22761767 PMCID: PMC3382251 DOI: 10.1371/journal.pone.0039347] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Accepted: 05/23/2012] [Indexed: 11/29/2022] Open
Abstract
Background Tuberculosis (TB) and serious bloodstream infections (BSI) may contribute to the high early mortality observed among patients qualifying for antiretroviral therapy (ART) with unexplained weight loss, chronic fever or chronic diarrhea. Methods and Findings A prospective cohort study determined the prevalence of undiagnosed TB or BSI among ambulatory HIV-infected adults with unexplained weight loss and/or chronic fever, or diarrhea in two routine program settings in Malawi. Subjects with positive expectorated sputum smears for AFB were excluded. Investigations Bacterial and mycobacterial blood cultures, cryptococcal antigen test (CrAg), induced sputum (IS) for TB microscopy and solid culture, full blood count and CD4 lymphocyte count. Among 469 subjects, 52 (11%) had microbiological evidence of TB; 50 (11%) had a positive (non-TB) blood culture and/or positive CrAg. Sixty-five additional TB cases were diagnosed on clinical and radiological grounds. Nontyphoidal Salmonellae (NTS) were the most common blood culture pathogens (29 cases; 6% of participants and 52% of bloodstream isolates). Multivariate analysis of baseline clinical and hematological characteristics found significant independent associations between oral candidiasis or lymphadenopathy and TB, marked CD4 lymphopenia and NTS infection, and severe anemia and either infection, but low positive likelihood ratios (<2 for all combinations). Conclusions We observed a high prevalence of TB and serious BSI, particularly NTS, in a program cohort of chronically ill HIV-infected outpatients. Baseline clinical and hematological characteristics were inadequate predictors of infection. HIV clinics need better rapid screening tools for TB and BSI. Clinical trials to evaluate empiric TB or NTS treatment are required in similar populations.
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Harries AD, Lawn SD, Getahun H, Zachariah R, Havlir DV. HIV and tuberculosis--science and implementation to turn the tide and reduce deaths. J Int AIDS Soc 2012; 15:17396. [PMID: 22905358 PMCID: PMC3499795 DOI: 10.7448/ias.15.2.17396] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Accepted: 07/05/2012] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Every year, HIV-associated tuberculosis (TB) deprives 350,000 mainly young people of productive and healthy lives.People die because TB is not diagnosed and treated in those with known HIV infection and HIV infection is not diagnosed in those with TB. Even in those in whom both HIV and TB are diagnosed and treated, this often happens far too late. These deficiencies can be addressed through the application of new scientific evidence and diagnostic tools. DISCUSSION A strategy of starting antiretroviral therapy (ART) early in the course of HIV infection has the potential to considerably reduce both individual and community burden of TB and needs urgent evaluation for efficacy, feasibility and broader social and economic impact. Isoniazid preventive therapy can reduce the risk of TB and, if given strategically in addition to ART, provides synergistic benefit. Intensified TB screening as part of the "Three I's" strategy should be conducted at every clinic, home or community-based attendance using a symptoms-based algorithm, and new diagnostic tools should increasingly be used to confirm or refute TB diagnoses. Until such time when more sensitive and specific TB diagnostic assays are widely available, bolder approaches such as empirical anti-TB treatment need to be considered and evaluated. Patients with suspected or diagnosed TB must be screened for HIV and given cotrimoxazole preventive therapy and ART if HIV-positive. Three large randomized trials provide conclusive evidence that ART initiated within two to four weeks of start of anti-TB treatment saves lives, particularly in those with severe immunosuppression. The key to ensuring that these collaborative activities are delivered is the co-location and integration of TB and HIV services within the health system and the community. CONCLUSIONS Progress towards reducing HIV-associated TB deaths can be achieved through attention to simple and deliverable actions on the ground.
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Affiliation(s)
- Anthony D Harries
- International Union Against Tuberculosis and Lung Disease, Paris, France.
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Lawn SD, Wood R. Tuberculosis in antiretroviral treatment services in resource-limited settings: addressing the challenges of screening and diagnosis. J Infect Dis 2011; 204 Suppl 4:S1159-67. [PMID: 21996698 PMCID: PMC3192543 DOI: 10.1093/infdis/jir411] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
The high burden of tuberculosis (TB) among patients accessing antiretroviral treatment (ART) services in resource-limited settings is a major cause of morbidity and mortality and is associated with nosocomial transmission risk. These risks are greatly compounded by multidrug-resistant disease. Screening and diagnosis of TB in this clinical setting is difficult. However, progress has been made in defining a high-sensitivity, standardized symptom screening tool that assesses a combination of symptoms, rather than relying on report of cough alone. Moreover, newly emerging diagnostic tools show great promise in providing more rapid diagnosis of TB, which is predominantly sputum smear–negative. These include culture-based systems, simplified versions of nucleic acid amplification tests (such as the Xpert MTB/RIF assay), and detection of lipoarabinomannan antigen in urine. In addition, new molecular diagnostics now permit rapid detection of drug resistance. Further development and implementation of these tools is vital to permit rapid and effective screening for TB in ART services, which is an essential component of patient care.
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Affiliation(s)
- Stephen D Lawn
- Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
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Kouanda S, Meda I, Nikiema L, Tiendrebeogo S, Doulougou B, Kaboré I, Sanou M, Greenwell F, Soudré R, Sondo B. Determinants and causes of mortality in HIV-infected patients receiving antiretroviral therapy in Burkina Faso: a five-year retrospective cohort study. AIDS Care 2011; 24:478-90. [DOI: 10.1080/09540121.2011.630353] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Affiliation(s)
- S. Kouanda
- a Institut de Recherche en Sciences de la Santé , Ouagadougou , Burkina Faso
| | - I.B. Meda
- a Institut de Recherche en Sciences de la Santé , Ouagadougou , Burkina Faso
| | - L. Nikiema
- a Institut de Recherche en Sciences de la Santé , Ouagadougou , Burkina Faso
| | - S. Tiendrebeogo
- a Institut de Recherche en Sciences de la Santé , Ouagadougou , Burkina Faso
| | - B. Doulougou
- a Institut de Recherche en Sciences de la Santé , Ouagadougou , Burkina Faso
| | - I. Kaboré
- b Family Health International (FHI) , Arlington , Virginia , USA
| | - M.J. Sanou
- c Ministère de la santé, CMLS, santé , Ouagadougou , Burkina Faso
| | | | - R. Soudré
- e Université de Ouagadougou, UFR/SDS , Ouagadougou , Burkina Faso
| | - B. Sondo
- a Institut de Recherche en Sciences de la Santé , Ouagadougou , Burkina Faso
- e Université de Ouagadougou, UFR/SDS , Ouagadougou , Burkina Faso
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Geng EH, Glidden DV, Emenyonu N, Musinguzi N, Bwana MB, Neilands TB, Muyindike W, Yiannoutsos CT, Deeks SG, Bangsberg DR, Martin JN. Tracking a sample of patients lost to follow-up has a major impact on understanding determinants of survival in HIV-infected patients on antiretroviral therapy in Africa. Trop Med Int Health 2011; 15 Suppl 1:63-9. [PMID: 20586962 DOI: 10.1111/j.1365-3156.2010.02507.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To date, data regarding the determinants of mortality in HIV-infected patients starting antiretroviral therapy (ART) in Africa have been primarily derived from routine clinical care settings practicing the public health approach. Losses to follow-up, however, are high in these settings and may lead to bias in understanding the determinants of mortality. METHODS We evaluated HIV-infected adults initiating ART between January 1, 2004 and September 30th, 2007 in an ART clinic in southwestern Uganda. Clinical and demographic characteristics were obtained through routine clinical care. In evaluating determinants of mortality, a 'naïve' analysis used only deaths known through routine processes. A 'sample-corrected' approach incorporated, through probability weights, outcomes from a representative sample of patients lost to follow-up whose vital status was ascertained through tracking in the community. RESULTS In 3,628 patients followed for up to 3.75 years after ART initiation, the 'naïve' approach identified male sex and lower pre-ART CD4 count as independent determinants of mortality. The 'sample-corrected' approach found lower pre-ART CD4 count, older age, lower weight and calendar year of ART initiation, but not male sex, to be independent determinants of mortality. CONCLUSIONS Analyses to identify determinants of mortality in HIV-infected patients on ART in Africa that do not account for losses to follow-up can identify spurious associations and miss actual relationships - both with the potential to mislead public health efforts. A sampling-based approach to account for losses to follow-up represents a feasible and potentially scalable method to strengthen the evidence available for implementation of ART delivery in Africa.
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Affiliation(s)
- Elvin H Geng
- Division of HIV/AIDS, Department of Medicine, San Francisco General Hospital, San Francisco, CA, USA.
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Koole O, Thai S, Khun KE, Pe R, van Griensven J, Apers L, Van den Ende J, Mao TE, Lynen L. Evaluation of the 2007 WHO guideline to improve the diagnosis of tuberculosis in ambulatory HIV-positive adults. PLoS One 2011; 6:e18502. [PMID: 21494694 PMCID: PMC3071837 DOI: 10.1371/journal.pone.0018502] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2010] [Accepted: 03/02/2011] [Indexed: 11/28/2022] Open
Abstract
Background In 2007 WHO issued a guideline to improve the diagnosis of smear-negative and extrapulmonary tuberculosis (EPTB) in HIV-positive patients. This guideline relies heavily on the acceptance of HIV-testing and availability of chest X-rays. Methods and Findings Cohort study of TB suspects in four tuberculosis (TB) clinics in Phnom Penh, Cambodia. We assessed the operational performance of the guideline, the incremental yield of investigations, and the diagnostic accuracy for smear-negative tuberculosis in HIV-positive patients using culture positivity as reference standard. 1,147 (68.9%) of 1,665 TB suspects presented with unknown HIV status, 1,124 (98.0%) agreed to be tested, 79 (7.0%) were HIV-positive. Compliance with the guideline for chest X-rays and sputum culture requests was 97.1% and 98.3% respectively. Only 35 of 79 HIV-positive patients (44.3%) with a chest X-ray suggestive of TB started TB treatment within 10 days. 105 of 442 HIV-positive TB suspects started TB treatment (56.2% smear-negative pulmonary TB (PTB), 28.6% smear-positive PTB, 15.2% EPTB). The median time to TB treatment initiation was 5 days (IQR: 2–13 days), ranging from 2 days (IQR: 1–11.5 days) for EPTB, over 2.5 days (IQR: 1–4 days) for smear-positive PTB to 9 days (IQR: 3–17 days) for smear-negative PTB. Among the 34 smear-negative TB patients with a confirmed diagnosis, the incremental yield of chest X-ray, clinical suspicion or abdominal ultrasound, and culture was 41.2%, 17.6% and 41.2% respectively. The sensitivity and specificity of the algorithm to diagnose smear-negative TB in HIV-positive TB suspects was 58.8% (95%CI: 42.2%–73.6%) and 79.4% (95%CI: 74.8%–82.4%) respectively. Conclusions Pending point-of-care rapid diagnostic tests for TB disease, diagnostic algorithms are needed. The diagnostic accuracy of the 2007 WHO guideline to diagnose smear-negative TB is acceptable. There is, however, reluctance to comply with the guideline in terms of immediate treatment initiation.
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PrayGod G, Range N, Faurholt-Jepsen D, Jeremiah K, Faurholt-Jepsen M, Aabye MG, Jensen L, Jensen AV, Grewal HMS, Magnussen P, Changalucha J, Andersen AB, Friis H. Daily multi-micronutrient supplementation during tuberculosis treatment increases weight and grip strength among HIV-uninfected but not HIV-infected patients in Mwanza, Tanzania. J Nutr 2011; 141:685-91. [PMID: 21346105 DOI: 10.3945/jn.110.131672] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Undernutrition is common among tuberculosis (TB) patients. The objective of this study was to assess the effect of multi-micronutrient supplementation during TB treatment on weight, body composition, and handgrip strength. A total of 865 patients with smear-positive (PTB+) or -negative (PTB-) pulmonary TB were randomly allocated to receive a daily biscuit with or without multi-micronutrients for 60 d during the intensive phase of TB treatment. Weight, arm fat area, arm muscle area, and handgrip strength were assessed at baseline and after 2 and 5 mo. At 2 mo, the multi-micronutrient supplementation led to a higher handgrip gain (1.22 kg; 95% CI = 0.50, 1.94; P = 0.001) but had no effects on other outcomes. The effects of multi-micronutrient supplementation were modified by HIV infection (P-interaction = 0.002). Among HIV- patients, multi-micronutrient supplementation increased weight gain by 590 g (95% CI = -40, 1210; P = 0.07) and handgrip strength by 1.6 kg (95% CI = 0.78, 2.47; P < 0.001), whereas among HIV+ patients, it reduced weight gain by 1440 g (95% CI = 290, 2590; P = 0.002) and had no effect on handgrip strength (0.07 kg; 95% CI = -1.30, 1.46; P = 0.91). The reduced weight gain among HIV+ patients receiving multi-micronutrient supplementation seemed to be explained by a higher proportion of patients reporting fever. At 5 mo, the effects on weight were sustained, whereas there was no effect on handgrip strength. In conclusion, multi-micronutrient supplementation given as a biscuit is beneficial among HIV- PTB patients and may be recommended to TB programs. More research is needed to develop an effective supplement for HIV+ PTB patients.
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Affiliation(s)
- George PrayGod
- National Institute for Medical Research, Mwanza Centre Mwanza, Tanzania.
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Tayler-Smith K, Zachariah R, Manzi M, Kizito W, Vandenbulcke A, Dunkley S, von Rege D, Reid T, Arnould L, Suleh A, Harries AD. Demographic characteristics and opportunistic diseases associated with attrition during preparation for antiretroviral therapy in primary health centres in Kibera, Kenya. Trop Med Int Health 2011; 16:579-84. [DOI: 10.1111/j.1365-3156.2011.02740.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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25
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PrayGod G, Range N, Faurholt-Jepsen D, Jeremiah K, Faurholt-Jepsen M, Aabye MG, Jensen L, Jensen AV, Grewal HMS, Magnussen P, Changalucha J, Andersen AB, Friis H. Weight, body composition and handgrip strength among pulmonary tuberculosis patients: a matched cross-sectional study in Mwanza, Tanzania. Trans R Soc Trop Med Hyg 2011; 105:140-7. [PMID: 21239027 DOI: 10.1016/j.trstmh.2010.11.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2010] [Revised: 11/15/2010] [Accepted: 11/15/2010] [Indexed: 10/18/2022] Open
Abstract
This study aimed to estimate deficits in weight, arm fat area (AFA), arm muscle area (AMA) and handgrip strength among smear-positive pulmonary TB (PTB+) patients starting treatment. We conducted a cross-sectional study among PTB+ patients and age- and sex-matched neighborhood controls. HIV status, anthropometric measurements and handgrip strength were determined. Deficits in weight, AFA, AMA and handgrip strength associated with PTB+ and HIV were estimated using multiple regression analysis. We recruited 355 pairs of PTB+ patients and controls. PTB+ was associated with deficits of 10.0kg (95% CI 7.3; 12.7) in weight and 6.8kg (95% CI 5.2; 8.3) in handgrip strength among females and 9.1kg (95% CI 7.3; 10.9) in weight and 6.8kg (95% CI 5.2; 8.4) in handgrip strength among males. In both sexes, PTB+ was associated with deficits in AFA and AMA. Among females, HIV was associated with deficits in AMA and handgrip strength, but the deficit in handgrip strength was larger among PTB+ patients (3.2kg 95% CI 1.3; 5.2) than controls (-1.6kg 95% CI -4.8; 1.5) (interaction, P=0.009). These findings suggest that deficits in weight and handgrip strength among patients starting TB treatment are severe. Thus, nutritional support may be necessary to ensure reversal of the deficits, and may improve treatment outcomes.
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Affiliation(s)
- George PrayGod
- National Institute for Medical Research, Mwanza Centre, P.O. Box 1462, Mwanza, Tanzania.
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Changing concepts of "latent tuberculosis infection" in patients living with HIV infection. Clin Dev Immunol 2010; 2011. [PMID: 20936108 PMCID: PMC2948911 DOI: 10.1155/2011/980594] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2010] [Accepted: 08/25/2010] [Indexed: 01/21/2023]
Abstract
One third of the world's population is estimated to be infected with Mycobacterium tuberculosis, representing a huge reservoir of potential tuberculosis (TB) disease. Risk of progression to active TB is highest in those with HIV coinfection. However, the nature of the host-pathogen relationship in those with “latent TB infection” and how this is affected by HIV coinfection are poorly understood. The traditional paradigm that distinguishes latent infection from active TB as distinct compartmentalised states is overly simplistic. Instead the host-pathogen relationship in “latent TB infection” is likely to represent a spectrum of immune responses, mycobacterial metabolic activity, and bacillary numbers. We propose that the impact of HIV infection might better be conceptualised as a shift of the spectrum towards poor immune control, higher mycobacterial metabolic activity, and greater organism load, with subsequent increased risk of progression to active disease. Here we discuss the evidence for such a model and the implications for interventions to control the HIV-associated TB epidemic.
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Mupere E, Zalwango S, Chiunda A, Okwera A, Mugerwa R, Whalen C. Body composition among HIV-seropositive and HIV-seronegative adult patients with pulmonary tuberculosis in Uganda. Ann Epidemiol 2010; 20:210-6. [PMID: 20159491 DOI: 10.1016/j.annepidem.2009.11.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2009] [Revised: 10/18/2009] [Accepted: 11/21/2009] [Indexed: 01/10/2023]
Abstract
PURPOSE We determined whether human immunodeficiency virus (HIV) infection affects body cell mass and fat mass wasting among adults with pulmonary tuberculosis (PTB). METHODS We screened 967 Ugandan adults for PTB and HIV infection in a cross-sectional study. We compared anthropometric and bioelectric impedance analysis (BIA) body composition parameters among HIV-seropositive and HIV-seronegative men and women with or without PTB by using a non-parametric test. RESULTS We found that poor nutritional status associated with TB differed among men and women. Anthropometric and BIA body composition did not differ between HIV-seropositive and HIV-seronegative patients regardless of gender. Average weight group difference in men consisted of body cell mass and fat mass in equal proportions of 43%. In women, average weight group difference consisted predominantly of fat mass of 73% and body cell mass of 13%. Compared to individuals without TB, patients with TB had lower body mass index, weight, body cell mass, and fat mass regardless of gender and HIV status. CONCLUSIONS Gender, but not HIV status, was associated with body composition changes in TB. TB appears to be the dominant factor driving the wasting process among co-infected patients.
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Affiliation(s)
- Ezekiel Mupere
- Department of Paediatrics and Child Health, School of Medicine, Makerere University, Kampala, Uganda
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Early antiretroviral therapy mortality in resource-limited settings: what can we do about it? Curr Opin HIV AIDS 2009; 2:346-51. [PMID: 19372910 DOI: 10.1097/coh.0b013e3281e72cbd] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Highly active antiretroviral therapy has markedly reduced HIV morbidity and mortality in industrialized countries. Expanded access to the 6.5 million individuals in immediate need of antiretroviral therapy using a public-health-systems approach is now promulgated as an international policy. An approximate 1.6 million individuals have already accessed antiretroviral therapy within programs in resource-poor settings. RECENT FINDINGS Early studies from these treatment programs confirm similar virologic and immunologic responses to antiretroviral therapy as were observed earlier in industrialized settings. While medium-term reductions in morbidity and mortality also parallel those reported from Europe and North America, of particular concern is the observation that mortality immediately after starting antiretroviral therapy in resource-poor settings is several-fold higher than that of similar patients initiating antiretroviral therapy in industrialized settings. SUMMARY This early mortality is multifactorial and is both a reflection of a very high preantiretroviral therapy mortality and a variety of factors such as comorbid conditions, late presentation, immune restoration disease, together with limited treatment and diagnostic options. Causes of mortality immediately prior to and during early antiretroviral therapy are reviewed and strategies to reduce mortality are identified and discussed.
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Massaquoi M, Zachariah R, Manzi M, Pasulani O, Misindi D, Mwagomba B, Bauernfeind A, Harries AD. Patient retention and attrition on antiretroviral treatment at district level in rural Malawi. Trans R Soc Trop Med Hyg 2009; 103:594-600. [DOI: 10.1016/j.trstmh.2009.02.012] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2008] [Revised: 02/16/2009] [Accepted: 02/16/2009] [Indexed: 11/26/2022] Open
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Zachariah R, Harries K, Moses M, Manzi M, Line A, Mwagomba B, Harries AD. Very early mortality in patients starting antiretroviral treatment at primary health centres in rural Malawi. Trop Med Int Health 2009; 14:713-21. [PMID: 19497082 DOI: 10.1111/j.1365-3156.2009.02291.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To report on the cumulative proportion of deaths occurring within 3 months of starting antiretroviral treatment (ART) and to identify factors associated with such deaths, among adults at primary health centres in a rural district of Malawi. METHODS Retrospective cohort study: from June 2006 to April 2008, deaths occurring over a 3-month period were determined and risk factors examined. RESULTS A total of 2316 adults (706 men and 1610 women; median age 35 years) were included in the analysis and followed up for a total of 1588 person-years (PY); 277 (12%) people died, of whom 206 (74%) people died within 3 months of initiating ART (cumulative incidence: 13.0; 95% confidence interval: 11.3-14.8 per 100 PY of follow-up). Significant risk factors associated with early deaths included male sex, WHO stage 4 disease, oesophageal or persistent oral candidiasis and unexplained presumed or measured weight loss >10%. One in every 3 patients who either died or was lost to follow up had unexplained weight loss >10%, and survival in this group was significantly different from patients without this condition. CONCLUSIONS Seven in 10 individuals initiating ART at primary health centres die early. Specific groups of patients are at higher risk of such mortality and should receive priority attention, care and support.
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Affiliation(s)
- Rony Zachariah
- Medecins sans Frontieres, Medical department, Brussels, Belgium.
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Sinkala E, Gray S, Zulu I, Mudenda V, Zimba L, Vermund SH, Drobniewski F, Kelly P. Clinical and ultrasonographic features of abdominal tuberculosis in HIV positive adults in Zambia. BMC Infect Dis 2009; 9:44. [PMID: 19374757 PMCID: PMC2678139 DOI: 10.1186/1471-2334-9-44] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2008] [Accepted: 04/17/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The diagnosis of abdominal tuberculosis (TB) is difficult, especially so in health care facilities in developing countries where laparoscopy and colonoscopy are rarely available. There is little information on abdominal TB in HIV infection. We estimated the prevalence and clinical features of abdominal (excluding genitourinary) TB in HIV infected adults attending the University Teaching Hospital, Zambia. METHODS We screened 5,609 medical inpatients, and those with fever, weight loss, and clinical features suggestive of abdominal pathology were evaluated further. A clinical algorithm was used to specify definitive investigations including laparoscopy or colonoscopy, with culture of biopsies and other samples. RESULTS Of 140 HIV seropositive patients with these features, 31 patients underwent full evaluation and 22 (71%) had definite or probable abdominal TB. The commonest presenting abdominal features were ascites and persistent tenderness. The commonest ultrasound findings were ascites, para-aortic lymphadenopathy (over 1 cm in size), and hepatomegaly. Abdominal TB was associated with CD4 cell counts over a wide range though 76% had CD4 counts <100 cells/microL. CONCLUSION The clinical manifestations of abdominal TB in our HIV-infected patients resembled the well-established pattern in HIV-uninfected adults. Patients with fever, weight loss, abdominal tenderness, abdominal lymphadenopathy, ascites and/or hepatomegaly in Zambia have a high probability of abdominal TB, irrespective of CD4 cell count.
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Affiliation(s)
- Edford Sinkala
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Lusaka, Zambia.
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Abstract
The global impact of the converging dual epidemics of tuberculosis (TB) and human immunodeficiency virus (HIV) is one of the major public health challenges of our time. The World Health Organization (WHO) reports 9.2 million new cases of TB in 2006 of whom 7.7% were HIV-infected. Tuberculosis is the most common opportunistic infection in HIV-infected patients as well as the leading cause of death. Further,there has been an increase in rates of drug resistant tuberculosis, including multi-drug (MDRTB) and extensively drug resistant TB (XDRTB), which are difficult to treat and contribute to increased mortality. The diagnosis of TB is based on sputum smear microscopy, a 100-year old technique and chest radiography,which has problems of specificity. Extra-pulmonary, disseminated and sputum smear negative manifestations are more common in patients with advanced immunosuppression. Newer diagnostic tests are urgently required that are not only sensitive and specific but easy to use in remote and resourc-poor settings. Treatment of HIV-TB co-infection is complex and associated with high pill burden, overlapping drug toxicities,risk of immune reconstitution inflammatory syndrome (IRIS) and challenges related to adherence. From a programmatic point of view, screening of all HIV-infected persons for tuberculosis and vice-versa will help identify co-infected patients who require treatment for both infections. This requires good coordination and communication between the TB and AIDS control programs, in India.
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Affiliation(s)
- Soumya Swaminathan
- Deptartment of Clinical Research,Tuberculosis Research Centre, Mayor VR Ramanathan Road, Chetput, Chennai 600 031, India.
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Abstract
Asia is a highly heterogeneous region with vastly different cultures, social constitutions and populations affected by a wide spectrum of respiratory diseases caused by tropical pathogens. Asian patients with community‐acquired pneumonia differ from their Western counterparts in microbiological aetiology, in particular the prominence of Gram‐negative organisms, Mycobacterium tuberculosis, Burkholderia pseudomallei and Staphylococcus aureus. In addition, the differences in socioeconomic and health‐care infrastructures limit the usefulness of Western management guidelines for pneumonia in Asia. The importance of emerging infectious diseases such as severe acute respiratory syndrome and avian influenza infection remain as close concerns for practising respirologists in Asia. Specific infections such as melioidosis, dengue haemorrhagic fever, scrub typhus, leptospirosis, salmonellosis, penicilliosis marneffei, malaria, amoebiasis, paragonimiasis, strongyloidiasis, gnathostomiasis, trinchinellosis, schistosomiasis and echinococcosis occur commonly in Asia and manifest with a prominent respiratory component. Pulmonary eosinophilia, endemic in parts of Asia, could occur with a wide range of tropical infections. Tropical eosinophilia is believed to be a hyper‐sensitivity reaction to degenerating microfilariae trapped in the lungs. This article attempts to address the key respiratory issues in these respiratory infections unique to Asia and highlight the important diagnostic and management issues faced by practising respirologists.
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Affiliation(s)
- Kenneth W Tsang
- LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, China.
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Outcome and Predictive Factors of Mortality in Hospitalized HIV-Patients in Burkina Faso. Infection 2009; 37:142-7. [DOI: 10.1007/s15010-008-7406-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2007] [Accepted: 04/28/2008] [Indexed: 10/21/2022]
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Lawn SD, Harries AD, Anglaret X, Myer L, Wood R. Early mortality among adults accessing antiretroviral treatment programmes in sub-Saharan Africa. AIDS 2008; 22:1897-908. [PMID: 18784453 PMCID: PMC3816249 DOI: 10.1097/qad.0b013e32830007cd] [Citation(s) in RCA: 501] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Two-thirds of the world's HIV-infected people live in sub-Saharan Africa, and more than 1.5 million of them die annually. As access to antiretroviral treatment has expanded within the region; early pessimism concerning the delivery of antiretroviral treatment using a large-scale public health approach has, at least in the short term, proved to be broadly unfounded. Immunological and virological responses to ART are similar to responses in patients treated in high-income countries. Despite this, however, early mortality rates in sub-Saharan Africa are very high; between 8 and 26% of patients die in the first year of antiretroviral treatment, with most deaths occurring in the first few months. Patients typically access antiretroviral treatment with advanced symptomatic disease, and mortality is strongly associated with baseline CD4 cell count less than 50 cells/mul and WHO stage 4 disease (AIDS). Although data are limited, leading causes of death appear to be tuberculosis, acute sepsis, cryptococcal meningitis, malignancy and wasting syndrome. Mortality rates are likely to depend not only on the care delivered by antiretroviral treatment programmes, but more fundamentally on how advanced disease is at programme enrollment and the quality of preceding healthcare. In addition to improving delivery of antiretroviral treatment and providing it free of charge to the patient, strategies to reduce mortality must include earlier diagnosis of HIV infection, strengthening of longitudinal HIV care and timely initiation of antiretroviral treatment. Health systems delays in antiretroviral treatment initiation must be minimized, especially in patients who present with advanced immunodeficiency.
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Affiliation(s)
- Stephen D. Lawn
- The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Clinical Research Unit, Department of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Anthony D. Harries
- Clinical Research Unit, Department of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
- HIV Unit, Ministry of Health, Lilongwe, Malawi
- Family Health International, Malawi country office, Lilongwe, Malawi
| | - Xavier Anglaret
- Programme PAC-CI, Abidjan, Ivory Coast
- INSERM, Unité 897, Centre de Recherche ≪ Epidémiologie et Biostatistique ≫, Bordeaux, France
| | - Landon Myer
- Infectious Diseases Epidemiology Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, USA
| | - Robin Wood
- The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Ngowi BJ, Mfinanga SG, Bruun JN, Morkve O. Pulmonary tuberculosis among people living with HIV/AIDS attending care and treatment in rural northern Tanzania. BMC Public Health 2008; 8:341. [PMID: 18826574 PMCID: PMC2566981 DOI: 10.1186/1471-2458-8-341] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2008] [Accepted: 09/30/2008] [Indexed: 12/01/2022] Open
Abstract
Background Tuberculosis is the commonest opportunistic infection and the number one cause of death in HIV/AIDS patients in developing countries. To address the extent of the tuberculosis HIV coinfection in rural Tanzania we conducted a cross sectional study including HIV/AIDS patients attending care and treatment clinic from September 2006 to March 2007. Methods Sputum samples were collected for microscopy, culture and drug susceptibility testing. Chest X-ray was done for those patients who consented. Blood samples were collected for CD4+ T cells count. Results The prevalence of tuberculosis was 20/233 (8.5%). Twenty (8.5%) sputum samples were culture positive. Eight of the culture positive samples (40%) were smear positive. Fifteen (75%) of these patients neither had clinical symptoms nor chest X-ray findings suggestive of tuberculosis. Nineteen isolates (95%) were susceptible to rifampicin, isoniazid, streptomycin and ethambutol (the first line tuberculosis drugs). One isolate (5%) from HIV/tuberculosis coinfected patients was resistant to isoniazid. No cases of multi- drug resistant tuberculosis were identified. Conclusion We found high prevalence of tuberculosis disease in this setting. Chest radiograph suggestive of tuberculosis and clinical symptoms of fever and cough were uncommon findings in HIV/tuberculosis coinfected patients. Tuberculosis can occur at any stage of CD4+T cells depletion.
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Affiliation(s)
- Bernard J Ngowi
- Haydom Lutheran Hospital, Mbulu District, Manyara Region, Tanzania.
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Uthman OA. Prevalence and pattern of HIV-related malnutrition among women in sub-Saharan Africa: a meta-analysis of demographic health surveys. BMC Public Health 2008; 8:226. [PMID: 18597680 PMCID: PMC2459165 DOI: 10.1186/1471-2458-8-226] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2007] [Accepted: 07/02/2008] [Indexed: 01/20/2023] Open
Abstract
Background The world's highest HIV infection rates are found in Sub-Saharan Africa (SSA), where adult prevalence in most countries exceeds 25%. Food shortages and malnutrition have combined with HIV/AIDS to bring some countries to the brink of crisis. The aim of this study was to describe prevalence of malnutrition among HIV-infected women and variations across socioeconomic status using data from 11 countries in SSA. Methods This study uses meta-analytic procedures to synthesize the results of most recent data sets available from Demographic and Health Surveys of 11 countries in SSA. Pooled prevalence estimates and 95% confidence intervals were calculated using random-and fixed-effects models. Subgroup and leave-one-country-out sensitivity analyses were also carried out. Results Pooling the prevalence estimates of HIV-related malnutrition yielded an overall prevalence of 10.3% (95% CI 7.4% to 14.1%) with no statistically significant heterogeneity (I2 = 0.0%, p = .903). The prevalence estimates decreased with increasing wealth index and education attainment. The pooled prevalence of HIV-related malnutrition was higher among women residing in rural areas than among women residing in urban areas; and lower among women that were professionally employed than unemployed or women in agricultural or manual work. Conclusion Prevalence of HIV-related malnutrition among women varies by wealth status, education attainment, occupation, and type of residence (rural/urban). The observed socioeconomic disparities can help provide more information about population subgroups in particular need and high risk groups, which may in turn lead to the development and implementation of more effective intervention programs.
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Affiliation(s)
- Olalekan A Uthman
- Center for Evidence-Based Global Health, Save the Youth Initiative, Nigeria.
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Souza SLSD, Feitoza PVS, Araújo JRD, Andrade RVD, Ferreira LCDL. Causas de óbito em pacientes com síndrome da imunodeficiência adquirida, necropsiados na Fundação de Medicina Tropical do Amazonas. Rev Soc Bras Med Trop 2008; 41:247-51. [DOI: 10.1590/s0037-86822008000300005] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2007] [Accepted: 06/13/2008] [Indexed: 11/21/2022] Open
Abstract
O objetivo deste estudo foi verificar em 129 pacientes com AIDS, necropsiados na Fundação de Medicina Tropical do Amazonas de 1996 a 2003, as causas do óbito, observando o grau de concordância entre os diagnósticos necroscópicos com os diagnósticos clínicos. A doença mais freqüente que causou o óbito foi tuberculose 28%, seguida de pneumonia bacteriana 17%, histoplasmose 13%, toxoplasmose 10%, pneumocistose 8%, criptococose 5%, sepse bacteriana 4% e 15% outras causas. A concordância entre o diagnóstico clínico antemortem e a necropsia foi de 51,9%. O principal órgão acometido foi o pulmão 82,2%. O tempo de sobrevivência após o diagnóstico laboratorial até o óbito variou entre um mês e 120 meses. A média de sobrevivência foi 15 dias e 56% morreram menos de um mês após o diagnóstico, 15 pacientes morreram na mesma data do diagnóstico. Esses resultados demonstram a importância da necropsia na causa mortis em pacientes com AIDS.
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Kaile T, Zulu I, Lumayi R, Ashman N, Kelly P. Inappropriately low aldosterone concentrations in adults with AIDS-related diarrhoea in Zambia: a study of response to fluid challenge. BMC Res Notes 2008; 1:10. [PMID: 18710534 PMCID: PMC2518272 DOI: 10.1186/1756-0500-1-10] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2008] [Accepted: 04/17/2008] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Chronic diarrhoea is one of the most debilitating consequences of HIV infection in sub-Saharan Africa and it carries a high mortality rate. We report unexpectedly low concentrations of circulating aldosterone in 12 patients (6 men, 6 women) in the University Teaching Hospital, Lusaka, who all had diarrhoea for over one month. Changes in serum electrolytes, blood pressure, Karnofsky score and serum aldosterone concentration were being monitored during a short study of responses to saline infusion (3 litres/24 h) over 72 hours. FINDINGS At baseline, 9/12 (75%) of the patients were hyponatraemic, 10/11 (91%) were hypokalaemic, and 6/12 (50%) had undetectable aldosterone concentrations. Blood pressure and Karnofsky score rose and creatinine concentration fell in response to the infusion. CONCLUSION Circulating aldosterone concentrations were inappropriately low and complicate the profound electrolyte deficiencies resulting from chronic diarrhoea. Management of these deficiencies needs to be more aggressive than is currently practised and consideration should be given to a formal clinical trial of mineralocorticoid replacement in these severely ill patients. If the inappropriately low aldosterone reflects a general adrenal failure, it may explain a considerable proportion of the high mortality seen both before and after initiation of anti-retroviral therapy.
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Affiliation(s)
- Trevor Kaile
- Tropical Gastroenterology and Nutrition group, University of Zambia School of Medicine, Lusaka, Zambia
| | - Isaac Zulu
- Tropical Gastroenterology and Nutrition group, University of Zambia School of Medicine, Lusaka, Zambia
- Institute of Cell and Molecular Science, Barts & The London School of Medicine, London UK
| | - Ruth Lumayi
- Tropical Gastroenterology and Nutrition group, University of Zambia School of Medicine, Lusaka, Zambia
| | - Neil Ashman
- Renal Unit, Barts and The London NHS Trust, London, UK
| | - Paul Kelly
- Tropical Gastroenterology and Nutrition group, University of Zambia School of Medicine, Lusaka, Zambia
- Institute of Cell and Molecular Science, Barts & The London School of Medicine, London UK
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Abstract
AbstractUndernutrition and infection are the major causes of morbidity and mortality in the developing world. These two problems are interrelated. Undernutrition compromises barrier function, allowing easier access by pathogens, and compromises immune function, decreasing the ability of the host to eliminate pathogens once they enter the body. Thus, malnutrition predisposes to infections. Infections can alter nutritional status mediated by changes in dietary intake, absorption and nutrient requirements and losses of endogenous nutrients. Thus, the presence of infections can contribute to the malnourished state. The global burden of malnutrition and infectious disease is immense, especially amongst children. Childhood infections impair growth and development. There is a role for breast-feeding in protection against infections. Key nutrients required for an efficient immune response include vitamin A, Fe, Zn and Cu. There is some evidence that provision of the first three of these nutrients does improve immune function in undernourished children and can reduce the morbidity and mortality of some infectious diseases including measles, diarrhoeal disease and upper and lower respiratory tract infections. Not all studies, however, show benefit of single nutrient supplementation and this might be because the subjects studied have multiple nutrient deficiencies. The situation regarding Fe supplementation is particularly complex. In addition to immunization programmes and improvement of nutrient status, there are important roles for maternal education, improved hygiene and sanitation and increased supply of quality water in the eradication of infectious diseases.
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Zachariah R, Fitzgerald M, Massaquoi M, Pasulani O, Arnould L, Makombe S, Harries AD. Risk factors for high early mortality in patients on antiretroviral treatment in a rural district of Malawi. AIDS 2006; 20:2355-60. [PMID: 17117022 DOI: 10.1097/qad.0b013e32801086b0] [Citation(s) in RCA: 213] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Among adults started on antiretroviral treatment (ART) in a rural district hospital (a) to determine the cumulative proportion of deaths that occur within 3 and 6 months of starting ART, and (b) to identify risk factors that may be associated with such mortality. DESIGN AND SETTING A cross-sectional analytical study set in Thyolo district, Malawi. METHODS Over a 2-year period (April 2003 to April 2005) mortality within the first 3 and 6 months of starting ART was determined and risk factors were examined. RESULTS A total of 1507 individuals (517 men and 990 women), whose median age was 35 years were included in the study. There were a total of 190 (12.6%) deaths on ART of which 116 (61%) occurred within the first 3 months (very early mortality) and 150 (79%) during the first 6 months of initiating ART. Significant risk factors associated with such mortality included WHO stage IV disease, a baseline CD4 cell count under 50 cells/mul and increasing grades of malnutrition. A linear trend in mortality was observed with increasing grades of malnutrition (chi for trend = 96.1, P </= 0.001) and decreasing CD4 cell counts (chi for trend = 72.4, P </= 0.001). Individuals who were severely malnourished [body mass index (BMI) < 16.0 kg/m] had a six times higher risk of dying in the first 3 months than those with a normal nutritional status. CONCLUSIONS Among individuals starting ART, the BMI and clinical staging could be important screening tools for use to identify and target individuals who, despite ART, are still at a high risk of early death.
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Affiliation(s)
- Rony Zachariah
- Medecins sans Frontieres, Operational Research, Brussels Operational Center, Belgium.
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Paton NI, Ng YM. Body composition studies in patients with wasting associated with tuberculosis. Nutrition 2006; 22:245-51. [PMID: 16500551 DOI: 10.1016/j.nut.2005.06.009] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2004] [Accepted: 06/16/2005] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Wasting is a well-recognized manifestation of tuberculosis (TB), but little is known about the alterations in body composition that occur. Therefore, we measured regional and whole-body composition in patients with TB and wasting. METHODS Body composition was measured by dual-energy x-ray absorptiometry in 18 patients with newly diagnosed TB and wasting (10 coinfected with human immunodeficiency virus [HIV]) and 22 controls (10 coinfected with HIV). RESULTS Patients with TB and wasting had significantly lower body weight (48.6 versus 62.0 kg), lean body mass (39.6 versus 45.6 kg), and fat mass (6.2 versus 12.6 kg) than did controls. Patients with TB had significantly reduced lean tissue in the limbs (15.2 versus 19.1 kg) and trunk (21.3 versus 23.2 kg) and significantly higher trunk-to-limb lean ratio (1.41 versus 1.22) compared with controls. Patients with TB had significantly reduced fat in the limbs (3.4 versus 6.1 kg) and trunk (2.1 versus 5.7 kg) and significantly lower trunk-to-limb fat ratio (0.52 versus 0.92) compared with controls. Body composition measurements were no different in patients with and without HIV coinfection. CONCLUSIONS Wasting in TB is associated with depletion of whole-body lean and fat tissue in approximately equal proportions overall, but lean tissue depletion is greater in the limbs and fat tissue depletion is greater in the trunk. HIV coinfection does not affect the magnitude or distribution of the body composition changes.
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Affiliation(s)
- Nicholas I Paton
- Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore.
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Wester CW, Kim S, Bussmann H, Avalos A, Ndwapi N, Peter TF, Gaolathe T, Mujugira A, Busang L, Vanderwarker C, Cardiello P, Johnson O, Thior I, Mazonde P, Moffat H, Essex M, Marlink R. Initial response to highly active antiretroviral therapy in HIV-1C-infected adults in a public sector treatment program in Botswana. J Acquir Immune Defic Syndr 2005; 40:336-43. [PMID: 16249709 DOI: 10.1097/01.qai.0000159668.80207.5b] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe the response to highly active antiretroviral treatment (HAART) in a public sector pilot antiretroviral (ARV) treatment program in Botswana. METHODS The response to HAART is described in adult HIV-infected ARV-naive patients initiating treatment from April 2001 to January 2002 at Princess Marina Hospital in Gaborone, Botswana. Patients had medical and laboratory evaluations before initiating ARV treatment and were followed longitudinally. For analysis, data were collected from charts and patient management records. RESULTS One hundred fifty-three ARV-naive patients initiated HAART. Most received didanosine plus stavudine (ddI + d4T) with efavirenz or nevirapine. The mean CD4 cell count increase was 149 cells/mm at 24 weeks and 204 cells/mm at 48 weeks. The percentage of patients with an HIV-1 RNA level < or =400 copies/mL was 87.0% at 24 weeks and 78.8% at 48 weeks. The Kaplan-Meier 1-year survival estimate was 84.7% (79.0%, 90.8%), with a 3.2-fold increased risk (P = 0.004) of mortality among patients with a CD4 cell count <50 cells/mm. The 1-year Kaplan-Meier estimate of toxicity-related drug switches was 32.2% (20.3%, 40.4%). The most common toxicity was peripheral neuropathy, occurring more frequently in patients with a preexisting diagnosis of peripheral neuropathy and among those placed on ddI + d4T-containing regimens. CONCLUSIONS An excellent response to HAART was observed among HIV-1C-infected patients, paralleling those seen elsewhere. Despite excellent responses, high rates of toxicity were observed for ddI + d4T-containing regimens.
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Affiliation(s)
- C William Wester
- Botswana-Harvard School of Public Health AIDS Initiative Partnership for Research and Education, Gaborone, Botswana
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Watters DAK. Surgery for tuberculosis before and after human immunodeficiency virus infection: A tropical perspective. Br J Surg 2005. [DOI: 10.1046/j.1365-2168.1997.02687.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Lawn SD, Myer L, Orrell C, Bekker LG, Wood R. Early mortality among adults accessing a community-based antiretroviral service in South Africa: implications for programme design. AIDS 2005; 19:2141-8. [PMID: 16284464 DOI: 10.1097/01.aids.0000194802.89540.e1] [Citation(s) in RCA: 275] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To determine rates, risk factors and causes of death among patients accessing a community-based antiretroviral treatment (ART) programme both prior to and following initiation of treatment. METHODS All in-programme deaths were ascertained between September 2002 and March 2005 among treatment-naive patients enrolled into a prospective community-based ART cohort in Cape Town, South Africa. RESULTS Of 712 patients (median CD4 cell count, 94 cells/microl), 578 (81%) started triple ART a median of 29 days after enrollment. 68 (9.5%) patients died during 563 person-years of observation. The high pretreatment mortality rate of 35.6 deaths/100 person-years [95% confidence interval (CI), 23.0-55.1) decreased to 2.5/100 person-years (95% CI, 0.9-6.6) at 1 year among those who received ART. However, within the first 90 days from enrollment, 29 of 44 (66%) deaths occurred among patients awaiting ART; these would not be identified by an on-treatment analysis. Multivariate analysis showed that risk of death (both pre-treatment and on-treatment) was independently associated with baseline CD4 cell count and World Health Organization (WHO) clinical stage; stage 4 disease was the strongest risk factor. Major attributed causes of death were wasting syndrome, tuberculosis, acute bacterial infections, malignancy and immune reconstitution disease. CONCLUSIONS Most early in-programme deaths occurred among patients with advanced immunodeficiency but who had not yet started ART. Programme evaluation using on-treatment analyses greatly underestimated early mortality. This mortality would be reduced by minimizing unnecessary in-programme delays in treatment initiation and by starting ART before development of WHO stage 4 disease.
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Affiliation(s)
- Stephen D Lawn
- The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Cape Town, South Africa.
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Anabwani G, Navario P. Nutrition and HIV/AIDS in sub-Saharan Africa: an overview. Nutrition 2005; 21:96-9. [PMID: 15661483 DOI: 10.1016/j.nut.2004.09.013] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2004] [Accepted: 09/06/2004] [Indexed: 10/25/2022]
Abstract
HIV/AIDS is most prevalent in Sub-Saharan Africa where, exacerbated by the presence of other common conditions such as malnutrition and opportunistic infections, it is wreaking devastation on families, communities, and nations. Just as epidemics vary by country, so do national responses to this complex emergency. This is illustrated by the cases of Botswana, South Africa, and Uganda. Nutritional and micronutrient deficiencies play an important additive role in immune degradation and impaired development in children. Careful implementation of antiretroviral drugs, complemented by simultaneous efforts to ensure proper nutrition among HIV-infected children and adults are essential components of an effective response to the HIV/AIDS pandemic in Africa and elsewhere.
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Affiliation(s)
- Gabriel Anabwani
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA.
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Modjarrad K, Zulu I, Karita E, Kancheya N, Funkhouser E, Allen S. Predictors of HIV serostatus among HIV discordant couples in Lusaka, Zambia and female antenatal clinic attendants in Kigali, Rwanda. AIDS Res Hum Retroviruses 2005; 21:5-12. [PMID: 15665639 DOI: 10.1089/aid.2005.21.5] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Clinical manifestations of HIV disease in Africa are nonspecific and easily confused with other endemic diseases. Several studies have compared the prevalence of HIV-related signs and symptoms in infected versus uninfected populations, but little is known about differences in HIV disease manifestations between African men and women across geographic areas. We conducted a cross-sectional study to define predictors of HIV status and assess their differences by gender and country in two African cohorts: 1351 heterosexual couples recruited from a voluntary HIV counseling and testing center in Lusaka, Zambia, and 1458 women recruited from antenatal and pediatric clinics in Kigali, Rwanda. HIV-positive Zambian men and women differed most with respect to prevalence of wasting syndrome (48.1% vs. 35.5%, p < 0.01). Zambian women were more likely to have a disseminated adenopathy than Rwandan women (33.2% vs. 7.8%, p < 0.01) and had a much higher median erythrocyte sedimentation rate (ESR) than either of the two other groups (78 mm/hr vs. 47 mm/hr, p < 0.01). Multivariable logistic regression modeling showed a history of tuberculosis [odds ratio (OR): 2.8-20.7], adenopathy on examination (OR: 4.0-6.3), and an ESR of >65 mm/hr (OR: 3.1-5.9) to be strongly predictive of HIV status in all groups. These screening tools, though highly predictive of HIV infection, were insensitive, as most infected persons were asymptomatic. Given these differences in HIV disease manifestation, screening tools based on signs and symptoms should be adapted accordingly. Additional studies are required to evaluate clinical markers as predictors of HIV disease progression and adjust them according to regional and gender differences.
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Affiliation(s)
- Kayvon Modjarrad
- School of Public Health, University of Alabama at Birmingham, Birmingham, AL 35294, USA.
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van Lettow M, Harries AD, Kumwenda JJ, Zijlstra EE, Clark TD, Taha TE, Semba RD. Micronutrient malnutrition and wasting in adults with pulmonary tuberculosis with and without HIV co-infection in Malawi. BMC Infect Dis 2004; 4:61. [PMID: 15613232 PMCID: PMC544350 DOI: 10.1186/1471-2334-4-61] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2004] [Accepted: 12/21/2004] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Wasting and micronutrient malnutrition have not been well characterized in adults with pulmonary tuberculosis. We hypothesized that micronutrient malnutrition is associated with wasting and higher plasma human immunodeficiency virus (HIV) load in adults with pulmonary tuberculosis. METHODS In a cross-sectional study involving 579 HIV-positive and 222 HIV-negative adults with pulmonary tuberculosis in Zomba, Malawi, anthropometry, plasma HIV load and plasma micronutrient concentrations (retinol, alpha-tocopherol, carotenoids, zinc, and selenium) were measured. The risk of micronutrient deficiencies was examined at different severity levels of wasting. RESULTS Body mass index (BMI), plasma retinol, carotenoid and selenium concentrations significantly decreased by increasing tertile of plasma HIV load. There were no significant differences in plasma micronutrient concentrations between HIV-negative individuals and HIV-positive individuals who were in the lowest tertile of plasma HIV load. Plasma vitamin A concentrations <0.70 micromol/L occurred in 61%, and zinc and selenium deficiency occurred in 85% and 87% respectively. Wasting, defined as BMI<18.5 was present in 59% of study participants and was independently associated with a higher risk of low carotenoids, and vitamin A and selenium deficiency. Severe wasting, defined as BMI<16.0 showed the strongest associations with deficiencies in vitamin A, selenium and plasma carotenoids. CONCLUSIONS These data demonstrate that wasting and higher HIV load in pulmonary tuberculosis are associated with micronutrient malnutrition.
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Affiliation(s)
| | | | | | | | - Tamara D Clark
- Johns Hopkins University School of Medicine, Baltimore, USA
| | - Taha E Taha
- Johns Hopkins University School of Public Health, Baltimore, USA
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Affiliation(s)
- Rashid Fuad Kysia
- Division of Emergency Medicine, Harvard Affiliated Emergency Medicine Residency, Harvard Medical School, Boston, Massachusetts, USA
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