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Arpagaus A, Franzeck FC, Sikalengo G, Ndege R, Mnzava D, Rohacek M, Hella J, Reither K, Battegay M, Glass TR, Paris DH, Bani F, Rajab ON, Weisser M. Extrapulmonary tuberculosis in HIV-infected patients in rural Tanzania: The prospective Kilombero and Ulanga antiretroviral cohort. PLoS One 2020; 15:e0229875. [PMID: 32130279 PMCID: PMC7055864 DOI: 10.1371/journal.pone.0229875] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 02/15/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND In sub-Saharan Africa, diagnosis and management of extrapulmonary tuberculosis (EPTB) in people living with HIV (PLHIV) remains a major challenge. This study aimed to characterize the epidemiology and risk factors for poor outcome of extrapulmonary tuberculosis in people living with HIV (PLHIV) in a rural setting in Tanzania. METHODS We included PLHIV >18 years of age enrolled into the Kilombero and Ulanga antiretroviral cohort (KIULARCO) from 2013 to 2017. We assessed the diagnosis of tuberculosis by integrating prospectively collected clinical and microbiological data. We calculated prevalence- and incidence rates and used Cox regression analysis to evaluate the association of risk factors in extrapulmonary tuberculosis (EPTB) with a combined endpoint of lost to follow-up (LTFU) and death. RESULTS We included 3,129 subjects (64.5% female) with a median age of 38 years (interquartile range [IQR] 31-46) and a median CD4+ cell count of 229/μl (IQR 94-421) at baseline. During the median follow-up of 1.25 years (IQR 0.46-2.85), 574 (18.4%) subjects were diagnosed with tuberculosis, whereof 175 (30.5%) had an extrapulmonary manifestation. Microbiological evidence by Acid-Fast-Bacillus stain (AFB-stain) or Xpert® MTB/RIF was present in 178/483 (36.9%) patients with pulmonary and in 28/175 (16.0%) of patients with extrapulmonary manifestations, respectively. Incidence density rates for pulmonary Tuberculosis (PTB and EPTB were 17.9/1000person-years (py) (95% CI 14.2-22.6) and 5.8/1000 py (95% CI 4.0-8.5), respectively. The combined endpoint of death and LTFU was observed in 1058 (33.8%) patients, most frequently in the subgroup of EPTB (47.2%). Patients with EPTB had a higher rate of the composite outcome of death/LTFU after TB diagnosis than with PTB [HR 1.63, (1.14-2.31); p = 0.006]. The adjusted hazard ratios [HR (95% CI)] for death/LTFU in EPTB patients were significantly increased for patients aged >45 years [HR 1.95, (1.15-3.3); p = 0.013], whereas ART use was protective [HR 0.15, (0.08-0.27); p <0.001]. CONCLUSIONS Extrapulmonary tuberculosis was a frequent manifestation in this cohort of PLHIV. The diagnosis of EPTB in the absence of histopathology and mycobacterial culture remains challenging even with availability of Xpert® MTB/RIF. Patients with EPTB had increased rates of mortality and LTFU despite early recognition of the disease after enrollment.
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Affiliation(s)
- Armon Arpagaus
- Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Fabian Christoph Franzeck
- Division of Infectious Diseases & Hospital Epidemiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - George Sikalengo
- Ifakara Health Institute, Ifakara, United Republic of Tanzania
- Saint Francis Referral Hospital, Ifakara, United Republic of Tanzania
| | - Robert Ndege
- Ifakara Health Institute, Ifakara, United Republic of Tanzania
- Saint Francis Referral Hospital, Ifakara, United Republic of Tanzania
| | - Dorcas Mnzava
- Ifakara Health Institute, Ifakara, United Republic of Tanzania
| | - Martin Rohacek
- Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Ifakara Health Institute, Ifakara, United Republic of Tanzania
| | - Jerry Hella
- Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Ifakara Health Institute, Ifakara, United Republic of Tanzania
| | - Klaus Reither
- Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Manuel Battegay
- Division of Infectious Diseases & Hospital Epidemiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Tracy Renee Glass
- Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Daniel Henry Paris
- Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Farida Bani
- Ifakara Health Institute, Ifakara, United Republic of Tanzania
| | | | - Maja Weisser
- Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland
- Division of Infectious Diseases & Hospital Epidemiology, University Hospital Basel, University of Basel, Basel, Switzerland
- Ifakara Health Institute, Ifakara, United Republic of Tanzania
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Cichowitz C, Pellegrino R, Motlhaoleng K, Martinson NA, Variava E, Hoffmann CJ. Hospitalization and post-discharge care in South Africa: A critical event in the continuum of care. PLoS One 2018; 13:e0208429. [PMID: 30543667 PMCID: PMC6292592 DOI: 10.1371/journal.pone.0208429] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 11/17/2018] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES The purpose of this prospective cohort study is to characterize the event of acute hospitalization for people living with and without HIV and describe its impact on the care continuum. This study describes care-seeking behavior prior to an index hospitalization, inpatient HIV testing and diagnosis, discharge instructions, and follow-up care for patients for patients being discharged from a single hospital in South Africa. METHODS A convenience sample of adult patients was recruited from the medical wards of a tertiary care facility. Baseline information at the time of hospital admission, subsequent diagnoses, and discharge instructions were recorded. Participants were prospectively followed with phone calls for six months after hospital discharge. Descriptive analyses were performed. RESULTS A total of 293 participants were enrolled in the study. Just under half (46%) of the participants were known to be living with HIV at the time of hospital admission. Most participants (97%) were given a referral for follow-up care; often that appointment was scheduled within two weeks of discharge (64%). Only 36% of participants returned to care within the first month, 50% returned after at least one month had elapsed, and 14% of participants did not return for any follow up. CONCLUSIONS Large discrepancies were found between the type of post-discharge follow-up care recommended by providers and what patients were able to achieve. The period of time following hospital discharge represents a key transition in care. Additional research is needed to characterize patients' risk following hospitalization and to develop patient-centered interventions.
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Affiliation(s)
- Cody Cichowitz
- Johns Hopkins School of Medicine, Baltimore, MD, United States of America
| | - Rachael Pellegrino
- Johns Hopkins School of Medicine, Baltimore, MD, United States of America
| | | | | | - Ebrahim Variava
- Perinatal HIV Research Unit, Gauteng, South Africa
- Department of Medicine, Tshepong Hospital, Klerksdorp, South Africa
| | - Christopher J. Hoffmann
- Division of Infectious Disease, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
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Husain NE, Ahmed MH, Almobarak AO, Noor SK, Elmadhoun WM, Awadalla H, Woodward CL, Mital D. HIV-Associated Nephropathy in Africa: Pathology, Clinical Presentation and Strategy for Prevention. J Clin Med Res 2018; 10:1-8. [PMID: 29238427 PMCID: PMC5722038 DOI: 10.14740/jocmr3235w] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 11/06/2017] [Indexed: 01/28/2023] Open
Abstract
The human immunodeficiency virus (HIV) infection can lead to progressive decline in renal function known as HIV-associated nephropathy (HIVAN). Importantly, individuals of African ancestry are more at risk of developing HIVAN than their European descent counterparts. An in-depth search on Google Scholar, Medline and PubMed was conducted using the terms "HIVAN" and "pathology and clinical presentation", in addition to "prevalence and risk factors for HIVAN", with special emphasis on African countries for any articles published between 1990 and 2017. HIVAN is characterized by progressive acute renal failure, proteinuria and enlarged kidneys. A renal biopsy is necessary to establish definitive diagnosis. Risk factors are male gender, low CD4 counts, high viral load and long use of combined antiretroviral medication (cART). There is a wide geographical variation in the prevalence of HIVAN as it ranges from 4.7% to 38% worldwide and little published literature is available about its prevalence in African nations. Microalbuminuria is a common finding in African populations and is significantly associated with severity of HIV disease progression and CD4 count less than 350 cells/µL. Other clinical presentations in African populations include acute kidney injury (AKI), nephrotic syndrome and chronic kidney disease. The main HIV-associated renal pathological lesions were focal segmental glomerulosclerosis, mainly the collapsing form, acute interstitial nephritis (AIN), and immune complex-mediated glomerulonephritis (ICGN). HIV infection-induced transcriptional program in renal tubular epithelial cells as well as genetic factors is incriminated in the pathogenesis of HIVAN. This narrative review discusses the prevalence, presentation, pathogenesis and the management of HIVAN in Africa. In low resource setting countries in Africa, dealing with HIV complications like HIVAN may add more of a burden on the health system (particularly renal units) than HIV medication itself. Therefore, the obvious recommendation is early use of cART in order to decrease risk factors that lead to HIVAN.
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Affiliation(s)
- Nazik Elmalaika Husain
- Department of Pathology, Faculty of Medicine and Health Sciences, Omdurman Islamic University, Khartoum, Sudan
| | - Mohamed H. Ahmed
- Department of Medicine and HIV Metabolic Clinic, Milton Keynes University Hospital NHS Foundation Trust, Eaglestone, Milton Keynes, Buckinghamshire, UK
| | - Ahmed O. Almobarak
- Department of Pathology, Faculty of Medicine, University of Medical Sciences and Technology, Khartoum, Sudan
| | - Sufian K. Noor
- Department of Medicine, Faculty of Medicine and Health Sciences, Nile Valley University, Atbara, Sudan
| | - Wadie M. Elmadhoun
- Department of Pathology, Faculty of Medicine and Health Sciences, Nile Valley University, Atbara, Sudan
| | - Heitham Awadalla
- Department of Community Medicine, Faculty of Medicine, University of Khartoum, Khartoum, Sudan
| | - Clare L. Woodward
- Department of HIV and Blood Borne Viruses, Milton Keynes University Hospital, NHS Foundation Trust, Milton Keynes, UK
| | - Dushyant Mital
- Department of HIV and Blood Borne Viruses, Milton Keynes University Hospital, NHS Foundation Trust, Milton Keynes, UK
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