1
|
Ayebare A, Bebell LM, Bazira J, Ttendo S, Katawera V, Bangsberg DR, Siedner MJ, Firth PG, Boum Ii Y. Comparative assessment of methicillin resistant Staphylococcus aureus diagnostic assays for use in resource-limited settings. BMC Microbiol 2019; 19:194. [PMID: 31438852 PMCID: PMC6704615 DOI: 10.1186/s12866-019-1566-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 08/05/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The rise of methicillin-resistant Staphylococcus aureus (MRSA) is a global health concern. Paucity of data on MRSA carriage prevalence and diagnostic methods in resource-limited settings hampers efforts to define the problem and plan an appropriate response. Additionally, high variability in cost and logistical characteristics of MRSA screening methods may impede infection control efforts. We compared the performance of locally-available chromogenic agar BD CHROMagar MRSA II and two PCR-based assays (Hain GenoQuick MRSA and Cepheid Xpert SA Complete) for the detection of asymptomatic MRSA carriage in nasal swabs. RESULTS During 2015, we enrolled 500 patients from five hospital wards at a Ugandan regional referral hospital. We found 30% prevalence of methicillin-sensitive Staphylococcus aureus (MSSA) nasal carriage, and 5.4% MRSA nasal carriage prevalence. Compared to a composite reference standard defined as a positive test result on any one of the three assays, Hain GenoQuick MRSA demonstrated the highest sensitivity (96%) followed by direct plating on CHROMagar at (70%), with the lowest sensitivity observed with Xpert SA Complete (52%). Cepheid Xpert provided the most rapid results (< 1 h) but was the most expensive (US $45-50/test). Substantially more labor was required for the Hain GenoQuick MRSA compared to Xpert SA Complete or CHROMagar tests. CONCLUSION MRSA nasal carriage prevalence rates were low, and high diagnostic sensitivity was achieved using Hain GenoQuick MRSA. Chromogenic media had significantly lower sensitivity, but may represent a viable local option given its lower cost compared to PCR-based assays.
Collapse
Affiliation(s)
- A Ayebare
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda. .,Epicentre Mbarara Research Centre, Mbarara, Uganda.
| | - L M Bebell
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA.,Massachusetts General Hospital Center for Global Health, Boston, MA, USA
| | - J Bazira
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - S Ttendo
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - V Katawera
- World Health Organization, Monrovia, Liberia
| | - D R Bangsberg
- Oregon Health & Science University-Portland State University School of Public Health, Portland, OR, USA
| | - M J Siedner
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA.,Massachusetts General Hospital Center for Global Health, Boston, MA, USA
| | - P G Firth
- Massachusetts General Hospital Department of Anesthesia, Critical Care and Pain Medicine, Boston, MA, USA
| | - Y Boum Ii
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda. .,Epicentre Mbarara Research Centre, Mbarara, Uganda.
| |
Collapse
|
2
|
Muyanja D, Allen JG, Vallarino J, Valeri L, Kakuhikire B, Bangsberg DR, Christiani DC, Tsai AC, Lai PS. Kerosene lighting contributes to household air pollution in rural Uganda. Indoor Air 2017; 27:1022-1029. [PMID: 28267233 PMCID: PMC5568944 DOI: 10.1111/ina.12377] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Accepted: 02/24/2017] [Indexed: 05/21/2023]
Abstract
The literature on the contribution of kerosene lighting to indoor air particulate concentrations is sparse. In rural Uganda, kitchens are almost universally located outside the main home, and kerosene is often used for lighting. In this study, we obtained longitudinal measures of particulate matter 2.5 microns or smaller in size (PM2.5 ) from living rooms and kitchens of 88 households in rural Uganda. Linear mixed-effects models with a random intercept for household were used to test the hypotheses that primary reported lighting source and kitchen location (indoor vs outdoor) are associated with PM2.5 levels. During initial testing, households reported using the following sources of lighting: open-wick kerosene (19.3%), hurricane kerosene (45.5%), battery-powered (33.0%), and solar (1.1%) lamps. During follow-up testing, these proportions changed to 29.5%, 35.2%, 18.2%, and 9.1%, respectively. Average ambient, living room, and kitchen PM2.5 levels were 20.2, 35.2, and 270.0 μg/m3 . Living rooms using open-wick kerosene lamps had the highest PM2.5 levels (55.3 μg/m3 ) compared to those using solar lighting (19.4 μg/m3 ; open wick vs solar, P=.01); 27.6% of homes using open-wick kerosene lamps met World Health Organization indoor air quality standards compared to 75.0% in homes using solar lighting.
Collapse
Affiliation(s)
- D Muyanja
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - J G Allen
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - J Vallarino
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - L Valeri
- Harvard Medical School, Boston, MA, USA
- McLean Hospital, Belmont, MA, USA
| | - B Kakuhikire
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - D R Bangsberg
- Oregon Health & Science University - Portland State University School of Public Health, Portland, OR, USA
| | - D C Christiani
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Massachusetts General Hospital, Boston, MA, USA
| | - A C Tsai
- Harvard Medical School, Boston, MA, USA
- Massachusetts General Hospital, Boston, MA, USA
- Harvard Center for Population and Development Studies, Cambridge, MA, USA
| | - P S Lai
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Massachusetts General Hospital, Boston, MA, USA
| |
Collapse
|
3
|
O'Donnell MR, Daftary A, Frick M, Hirsch-Moverman Y, Amico KR, Senthilingam M, Wolf A, Metcalfe JZ, Isaakidis P, Davis JL, Zelnick JR, Brust JCM, Naidu N, Garretson M, Bangsberg DR, Padayatchi N, Friedland G. Re-inventing adherence: toward a patient-centered model of care for drug-resistant tuberculosis and HIV. Int J Tuberc Lung Dis 2017; 20:430-4. [PMID: 26970149 DOI: 10.5588/ijtld.15.0360] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite renewed focus on molecular tuberculosis (TB) diagnostics and new antimycobacterial agents, treatment outcomes for patients co-infected with drug-resistant TB and human immunodeficiency virus (HIV) remain dismal, in part due to lack of focus on medication adherence as part of a patient-centered continuum of care. OBJECTIVE To review current barriers to drug-resistant TB-HIV treatment and propose an alternative model to conventional approaches to treatment support. DISCUSSION Current national TB control programs rely heavily on directly observed therapy (DOT) as the centerpiece of treatment delivery and adherence support. Medication adherence and care for drug-resistant TB-HIV could be improved by fully implementing team-based patient-centered care, empowering patients through counseling and support, maintaining a rights-based approach while acknowledging the responsibility of health care systems in providing comprehensive care, and prioritizing critical research gaps. CONCLUSION It is time to re-invent our understanding of adherence in drug-resistant TB and HIV by focusing attention on the complex clinical, behavioral, social, and structural needs of affected patients and communities.
Collapse
Affiliation(s)
- M R O'Donnell
- Division of Pulmonary Allergy and Critical Care Medicine, Columbia University Medical Center, New York, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA; Centre for the AIDS Programme of Research in South Africa, South African Medical Research Council TB HIV Pathogenesis Extramural Unit, Durban, South Africa
| | - A Daftary
- Centre for the AIDS Programme of Research in South Africa, South African Medical Research Council TB HIV Pathogenesis Extramural Unit, Durban, South Africa; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - M Frick
- Treatment Action Group, New York, USA
| | - Y Hirsch-Moverman
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA; International Center for AIDS Care and Treatment Programs, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - K R Amico
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | | | - A Wolf
- Division of Pulmonary Allergy and Critical Care Medicine, Columbia University Medical Center, New York, USA
| | - J Z Metcalfe
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, California, USA
| | | | - J L Davis
- Division of Pulmonary Allergy and Critical Care Medicine, Columbia University Medical Center, New York, USA
| | - J R Zelnick
- Touro College Graduate School of Social Work, New York, New York, USA
| | - J C M Brust
- Montefiore Medical Center & Albert Einstein College of Medicine, Bronx, New York, USA
| | - N Naidu
- Centre for the AIDS Programme of Research in South Africa, South African Medical Research Council TB HIV Pathogenesis Extramural Unit, Durban, South Africa
| | - M Garretson
- Division of Pulmonary Allergy and Critical Care Medicine, Columbia University Medical Center, New York, USA
| | | | - N Padayatchi
- Centre for the AIDS Programme of Research in South Africa, South African Medical Research Council TB HIV Pathogenesis Extramural Unit, Durban, South Africa
| | - G Friedland
- Yale University School of Public Health, New Haven, Connecticut, USA; Yale University School of Medicine, New Haven, Connecticut, USA
| |
Collapse
|
4
|
Holodniy M, Charlebois ED, Bangsberg DR, Zolopa AR, Schulte M, Moss AR. Prevalence of antiretroviral drug resistance in the HIV-1-infected urban indigent population in San Francisco: a representative study. Int J STD AIDS 2016; 15:543-51. [PMID: 15307966 DOI: 10.1258/0956462041558212] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We determined the prevalence of antiretroviral (ARV) resistance in HIV-1 infected indigent persons in San Francisco, California. Three hundred and twenty-seven subjects (159 (49%) ARV naïve, and 168 (51%) ARV-experienced), were recruited during 1996–97 and 1999–2000. Plasma HIV-1 viral load quantification and genotypic resistance testing were performed. Twice as many subjects received nucleoside reverse transcriptase inhibitors (NRTIs) as non-nucleoside reverse transcriptase inhibitors (NNRTIs) or protease inhibitors (PIs); resistance mutation prevalences were 30%, 14% and 16% respectively. Risk of any resistance mutations was strongly and independently associated with prior ARV exposure (OR = 1.3 per year of exposure, P < 0.0001) and with ARV exposure prior to HAART (OR = 2.5, P = 0.015). Prevalences of primary ARV resistance mutations among both treatment-naive and treatment-experienced subjects in this indigent urban population are low compared to other observational cohorts, are directly related to length and type of prior ARV exposure, and did not increase significantly between recruitment periods.
Collapse
Affiliation(s)
- M Holodniy
- AIDS Research Center, VA Palo Alto Health Care System, Palo Alto, USA
| | | | | | | | | | | |
Collapse
|
5
|
Byakika-Tusiime J, Oyugi JH, Tumwikirize WA, Katabira ET, Mugyenyi PN, Bangsberg DR. Adherence to HIV antiretroviral therapy in HIV+ Ugandan patients purchasing therapy. Int J STD AIDS 2016; 16:38-41. [PMID: 15705271 DOI: 10.1258/0956462052932548] [Citation(s) in RCA: 145] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Our objective was to determine the level of adherence and reasons for non-adherence to antiretroviral therapy (ART) among HIV-positive (HIV+) people on ART in a resource-limited setting. Patients receiving ART were recruited into the cross-sectional study from three treatment centres in Kampala, Uganda. The number of missed doses over the last three days was assessed by structured patient interviews and dichotomized at ±95% adherence. Reasons for non-adherence were assessed with both structured patient interviews and unstructured qualitative interviews. Independent predictors of non-adherence were assessed with multivariate logistic regression. In all, 304 HIV-infected persons on ART were enrolled into the study. Factors associated with non-adherence were marital status (odds ratio (OR) = 2.93, 95% confidence interval (CI) 1.32–6.50) and low monthly income <50 US$ [OR = 2.77, 95% CI 1.64–4.67]. We concluded that levels of self-reported adherence in patients receiving ART in Kampala are comparable to levels in resource-rich settings with inability to purchase and secure a stable supply as a major barrier to adherence.
Collapse
Affiliation(s)
- J Byakika-Tusiime
- Makerere University School of Medicine, Kampala and Academic Alliance for AIDS Care and Prevention in Africa, Kampala, Uganda
| | | | | | | | | | | |
Collapse
|
6
|
Matthews LT, Smit JA, Moore L, Milford C, Greener R, Mosery FN, Ribaudo H, Bennett K, Crankshaw TL, Kaida A, Psaros C, Safren SA, Bangsberg DR. Periconception HIV Risk Behavior Among Men and Women Reporting HIV-Serodiscordant Partners in KwaZulu-Natal, South Africa. AIDS Behav 2015; 19:2291-303. [PMID: 26080688 PMCID: PMC4926315 DOI: 10.1007/s10461-015-1050-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
HIV-infected men and women who choose to conceive risk infecting their partners. To inform safer conception programs we surveyed HIV risk behavior prior to recent pregnancy amongst South African, HIV-infected women (N = 209) and men (N = 82) recruited from antenatal and antiretroviral clinics, respectively, and reporting an uninfected or unknown-HIV-serostatus pregnancy partner. All participants knew their HIV-positive serostatus prior to the referent pregnancy. Only 11 % of women and 5 % of men had planned the pregnancy; 40 % of women and 27 % of men reported serostatus disclosure to their partner before conception. Knowledge of safer conception strategies was low. Around two-thirds reported consistent condom use, 41 % of women and 88 % of men reported antiretroviral therapy, and a third of women reported male partner circumcision prior to the referent pregnancy. Seven women (3 %) and two men (2 %) reported limiting sex without condoms to peak fertility. None reported sperm washing or manual insemination. Safer conception behaviors including HIV-serostatus disclosure, condom use, and ART at the time of conception were not associated with desired pregnancy. In light of low pregnancy planning and HIV-serostatus disclosure, interventions to improve understandings of serodiscordance and motivate mutual HIV-serostatus disclosure and pregnancy planning are necessary first steps before couples or individuals can implement specific safer conception strategies.
Collapse
Affiliation(s)
- L T Matthews
- Division of Infectious Disease and Center for Global Health, Massachusetts General Hospital, 100 Cambridge Street, 15th Floor, Boston, MA, 02114, USA.
| | - J A Smit
- MatCH Research [Maternal, Adolescent and Child Health Research], Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
- School of Pharmacy and Pharmacology, Faculty of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - L Moore
- MatCH Research [Maternal, Adolescent and Child Health Research], Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - C Milford
- MatCH Research [Maternal, Adolescent and Child Health Research], Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - R Greener
- MatCH Research [Maternal, Adolescent and Child Health Research], Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - F N Mosery
- MatCH Research [Maternal, Adolescent and Child Health Research], Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - H Ribaudo
- Center for Biostatistics in AIDS Research, Harvard School of Public Health, Boston, MA, USA
| | - K Bennett
- Bennett Statistical Consulting, Inc., Ballston Lake, NY, USA
| | - T L Crankshaw
- Health Economics and HIV and AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa
| | - A Kaida
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - C Psaros
- Behavioral Medicine, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - S A Safren
- Behavioral Medicine, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - D R Bangsberg
- Division of Infectious Disease and Center for Global Health, Massachusetts General Hospital, 100 Cambridge Street, 15th Floor, Boston, MA, 02114, USA
| |
Collapse
|
7
|
MacCarthy S, Bangsberg DR, Fink G, Reich M, Gruskin S. Late presentation to HIV/AIDS testing, treatment or continued care: clarifying the use of CD4 evaluation in the consensus definition. HIV Med 2013; 15:130-4. [PMID: 24024559 DOI: 10.1111/hiv.12088] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2013] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Late presentation to HIV/AIDS services compromises treatment outcomes and misses opportunities for biomedical and behavioural prevention. There has been significant heterogeneity in how the term 'late presentation' (LP) has been used in the literature. In 2011, a consensus definition was reached using CD4 counts to define and measure late presenters and, while it is useful for clinical care, the consensus definition has several important limitations that we discuss in this article. METHODS Using the spectrum of engagement in HIV care presented by Gardner and colleagues, this article highlights issues and opportunities associated with use of the consensus definition. RESULTS The consensus definition is limited by three principal factors: (1) the CD4 count threshold of 350 cells/μL is being increasingly questioned as the biomedical justification grows for earlier initiation of treatment; (2) CD4 evaluations are conducted at multiple services providing HIV care; thus it remains unclear to which service the patient is presenting late; and (3) the limited availability of CD4 evaluation restricts its use in determining the prevalence of LP in many settings. CONCLUSIONS The consensus definition is useful because it describes the level of disease progression and allows for consistent evaluation of the prevalence and determinants of LP. Suggestions are provided for improving the application of the consensus definition in future research.
Collapse
Affiliation(s)
- S MacCarthy
- Alpert Medical School of Brown University and The Miriam Hospital, Providence, RI, USA
| | | | | | | | | |
Collapse
|
8
|
Rosen MI, Black AC, Arnsten JH, Goggin K, Remien RH, Simoni JM, Golin CE, Bangsberg DR, Liu H. Association between use of specific drugs and antiretroviral adherence: findings from MACH 14. AIDS Behav 2013; 17:142-7. [PMID: 22246513 DOI: 10.1007/s10461-011-0124-7] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
To determine the association between individual substances of abuse and antiretroviral adherence, analyses require a large sample assessed using electronic data monitoring (EDM). In this analysis, EDM data from 1,636 participants in 12 US adherence-focused studies were analyzed to determine the associations between recent use of various substances and adherence during the preceding 4 weeks. In bivariate analyses comparing adherence among patients who had used a specific substance to those who had not, adherence was significantly lower among those who had recently used cocaine, other stimulants or heroin but not among those who had used cannabis or alcohol. In multivariate analyses controlling for sociodemographics, amount of alcohol use and recent use of any alcohol, cocaine, other stimulants and heroin each was significantly negatively associated with adherence. The significant associations of cocaine, other stimulants, heroin, and alcohol use with adherence suggest that these are important substances to target with adherence-focused interventions.
Collapse
Affiliation(s)
- M I Rosen
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
9
|
Fenner L, Forster M, Boulle A, Phiri S, Braitstein P, Lewden C, Schechter M, Kumarasamy N, Pascoe M, Sprinz E, Bangsberg DR, Sow PS, Dickinson D, Fox MP, McIntyre J, Khongphatthanayothin M, Dabis F, Brinkhof MWG, Wood R, Egger M. Tuberculosis in HIV programmes in lower-income countries: practices and risk factors. Int J Tuberc Lung Dis 2011; 15:620-7. [PMID: 21756512 DOI: 10.5588/ijtld.10.0249] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) is a common diagnosis in human immunodeficiency virus (HIV) infected patients on antiretroviral treatment (ART). OBJECTIVE To describe TB-related practices in ART programmes in lower-income countries and identify risk factors for TB in the first year of ART. METHODS Programme characteristics were assessed using standardised electronic questionnaire. Patient data from 2003 to 2008 were analysed and incidence rate ratios (IRRs) calculated using Poisson regression models. RESULTS Fifteen ART programmes in 12 countries in Africa, South America and Asia were included. Chest X-ray, sputum microscopy and culture were available free of charge in respectively 13 (86.7%), 14 (93.3%) and eight (53.3%) programmes. Eight sites (53.3%) used directly observed treatment and five (33.3%) routinely administered isoniazid preventive treatment (IPT). A total of 19 413 patients aged ≥ 16 years contributed 13,227 person-years of follow-up; 1081 new TB events were diagnosed. Risk factors included CD4 cell count (>350 cells/μl vs. <25 cells/μl, adjusted IRR 0.46, 95%CI 0.33-0.64, P < 0.0001), sex (women vs. men, adjusted IRR 0.77, 95%CI 0.68-0.88, P = 0.0001) and use of IPT (IRR 0.24, 95%CI 0.19-0.31, P < 0.0001). CONCLUSIONS Diagnostic capacity and practices vary widely across ART programmes. IPT prevented TB, but was used in few programmes. More efforts are needed to reduce the burden of TB in HIV co-infected patients in lower income countries.
Collapse
Affiliation(s)
- L Fenner
- Institute of Social and Preventive Medicine, Berne, Switzerland.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Kaida A, Gray G, Bastos FI, Andia I, Maier M, McIntyre J, Grinsztejn B, Strathdee SA, Bangsberg DR, Hogg R. The relationship between HAART use and sexual activity among HIV-positive women of reproductive age in Brazil, South Africa, and Uganda. AIDS Care 2008; 20:21-5. [PMID: 18278611 DOI: 10.1080/09540120701426540] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The purpose of this study was to determine whether current HAART use is associated with recent sexual intercourse among HIV-infected women (18-49 years) from Brazil, South Africa and Uganda. We conducted an analysis of survey data from a cross-sectional study, which enrolled 179 HIV-infected women receiving regular care from the Mbarara Hospital HIV Clinic in Uganda (n=85); the Perinatal HIV Research Unit in Soweto, South Africa (n=50); and the IPEC-Fiocruz cohort in Rio de Janeiro, Brazil (n=44). The primary outcome was sexual intercourse in the previous month. Secondary outcomes were protected sex and contraceptive use. We found that overall, 46% reported recent sexual intercourse. After adjusting for covariates, recent sexual intercourse was not associated with HAART use (AOR: 0.76; 95%CI: 0.34-1.72); however, it was significantly associated with being currently married, wanting to have more children and having higher HAART optimism. Among women reporting recent sexual intercourse (n=83), HAART users were significantly more likely to practice protected sex (crude OR: 3.64; 95%CI: 1.41-9.38) and non-significantly more likely to use contraceptive methods (crude OR: 2.15; 95%CI: 0.77-5.99). In summary, self-reported recent sexual intercourse is not more likely among women on HAART. Moreover, sexually active HAART users may be more likely to practice protected sex and use contraceptives.
Collapse
Affiliation(s)
- A Kaida
- Department of Healthcare and Epidemiology, Faculty of Medicine, University of British Columbia, Vancouver, Canada.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Abstract
BACKGROUND Standard two-step HIV testing is limited by poor return-for-results rates and misses high-risk individuals who do not access conventional testing facilities. METHODS We describe a community-based rapid HIV testing programme in which homeless and marginally housed adults recruited from shelters, free meal programmes and single room occupancy hotels in San Francisco received OraQuick Rapid HIV-1 Antibody testing (OraSure Technologies, Bethlehem, PA, USA). RESULTS Over 8 months, 1614 adults were invited to participate and 1213 (75.2%) underwent testing. HIV seroprevalence was 15.4% (187 of 1213 individuals) overall and 3.5% (37 of 1063) amongst high-risk individuals reporting no previous testing, a prior negative test, or previous testing without result disclosure. All 1213 participants received their results. Of 30 newly diagnosed persons who received confirmatory results, 26 (86.7%) reported at least one contact with a primary healthcare provider in the 6 months following diagnosis. CONCLUSIONS We conclude that community-based rapid testing is feasible, acceptable and effective based on the numbers of high-risk persons tested over a short period, the participation rate, the prevalence of new infection, the rate of result disclosure, and the proportion linked to care.
Collapse
Affiliation(s)
- J B Buchér
- University of California, San Francisco (UCSF) School of Medicine, San Francisco, CA 94143, USA
| | | | | | | | | | | |
Collapse
|
12
|
Baker CAR, Clark R, Ventura F, Jones NG, Guzman D, Bangsberg DR, Cao H. Peripheral CD4 loss of regulatory T cells is associated with persistent viraemia in chronic HIV infection. Clin Exp Immunol 2007; 147:533-9. [PMID: 17302904 PMCID: PMC1810503 DOI: 10.1111/j.1365-2249.2006.03319.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Chronic HIV infection is associated with T cell abnormalities and altered effector function. Regulatory T cells (Treg) are CD4+ T cells that play a critical role in regulating the immune system. The impact of regulatory T cells on HIV infection and disease progression may be highly significant. We hypothesize that chronic antigenic stimulation from a persistent, high viraemic state may promote a population of Treg that contributes to HIV-associated immune dysfunction. We evaluated the pattern of Treg in chronically infected, HIV-positive individuals over a course of 6 months. Treg are depleted at a distinct rate from that of absolute CD4 cells and loss of Treg is slower in the presence of viral suppression. In vitro depletion of CD25+ CD4+ cells resulted in increased Gag-specific CD4 and CD8 responses. A significant correlation between ex vivo measurement of Treg and Gag-specific CD4 T cell responses was observed (r=-0 x 41, P=0 x 018) with a trend observed with Gag-specific CD8 T cell responses (P=0 x 07). The impact of HIV infection on the Treg population directly complicates the measured effect of Treg on the immune dysfunction although our data support the important role of Treg on modulating the effector T cell response in chronic infection.
Collapse
Affiliation(s)
- C A R Baker
- California Department of Health Services, Richmond, CA 94804, USA
| | | | | | | | | | | | | |
Collapse
|
13
|
Braithwaite RS, Shechter S, Roberts MS, Schaefer A, Bangsberg DR, Harrigan PR, Justice AC. Explaining variability in the relationship between antiretroviral adherence and HIV mutation accumulation. J Antimicrob Chemother 2007. [DOI: 10.1093/jac/dkm027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
|
14
|
Wolfe WR, Weiser SD, Bangsberg DR, Thior I, Makhema JM, Dickinson DB, Mompati KF, Marlink RG. Effects of HIV-related stigma among an early sample of patients receiving antiretroviral therapy in Botswana. AIDS Care 2007; 18:931-3. [PMID: 17012082 DOI: 10.1080/09540120500333558] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Botswana, with its estimated HIV prevalence of 37%, instituted a policy of universal access to antiretroviral therapy (ART) in 2002. Initial enrolment lagged behind expectations, with a shortfall in voluntary testing that observers have attributed to HIV-related stigma - although there are no published data on stigma among HIV-positive individuals in Botswana. We interviewed 112 patients receiving ART in 2000, finding evidence of pervasive stigma in patterns of disclosure, social sequelae, and delays in HIV testing. Ninety-four percent of patients reported keeping their HIV status secret from their community, while 69% withheld this information even from their family. Twenty-seven percent of patients said that they feared loss of employment as a result of their HIV status. Forty percent of patients reported that they delayed getting tested for HIV; of these, 51% cited fear of a positive test result as the primary reason for delay in seeking treatment, which was often due to HIV-related stigma. These findings suggest that success of large-scale national ART programmes will require initiatives targeting stigma and its social, economic and political correlates.
Collapse
Affiliation(s)
- W R Wolfe
- Psychiatric Institute, University of California, San Francisco, CA 94143-0984, USA.
| | | | | | | | | | | | | | | |
Collapse
|
15
|
Braithwaite RS, Shechter S, Roberts MS, Schaefer A, Bangsberg DR, Harrigan PR, Justice AC. Explaining variability in the relationship between antiretroviral adherence and HIV mutation accumulation. J Antimicrob Chemother 2006; 58:1036-43. [PMID: 17023498 DOI: 10.1093/jac/dkl386] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES Determining the relationship between antiretroviral adherence and resistance accumulation is important for the design and evaluation of adherence interventions. Our objective was to explain heterogeneity observed in this relationship. METHODS We first conducted a systematic review to locate published reports describing the relationship between adherence and resistance. We then used a validated computer simulation to simulate the patient populations in these reports, exploring the impact of changes in individual patient characteristics (age, CD4, viral load, prior antiretroviral experience) on the shape of the adherence-resistance (A-R) curve. RESULTS The search identified 493 titles, of which 3 contained relevant primary data and 2 had sufficient follow-up for inclusion (HOMER and REACH cohorts). When simulating HOMER, the A-R curve had a high peak with a greatly increased hazard ratio (HR) of accumulating mutations at partial compared to complete adherence (simulation, HR 2.9; HOMER, HR 2.7). When simulating REACH, the A-R curve had a shallow peak with a slightly increased hazard of accumulating mutations at partial adherence (simulation, HR 1.2; REACH, HR 1.4). This heterogeneity was primarily attributable to differences in antiretroviral experience between the cohorts. CONCLUSIONS Our computer simulation was able to explain much of the heterogeneity in observed A-R curves.
Collapse
Affiliation(s)
- R S Braithwaite
- Section of General Internal Medicine, Yale University School of Medicine and VA Connecticut Healthcare System, New Haven, CT, USA.
| | | | | | | | | | | | | |
Collapse
|
16
|
Crane JT, Kawuma A, Oyugi JH, Byakika JT, Moss A, Bourgois P, Bangsberg DR. The price of adherence: qualitative findings from HIV positive individuals purchasing fixed-dose combination generic HIV antiretroviral therapy in Kampala, Uganda. AIDS Behav 2006; 10:437-42. [PMID: 16636892 PMCID: PMC2386888 DOI: 10.1007/s10461-006-9080-z] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Contrary to early expectations, recent studies have shown near-perfect adherence to HIV antiretrovirals in sub-Saharan Africa We conducted qualitative interviews with patients purchasing low-cost, generic antiretroviral therapy to better understand the social dynamics underlying these findings. We found that concerns for family well-being motivate adherence, yet, the financial sacrifices necessary to secure therapy may paradoxically undermine family welfare. We suggest that missed doses may be more due to a failure to access medication rather than a failure to adhere to medications, and that structural rather than behavioral interventions may be most useful to insure optimal treatment response.
Collapse
Affiliation(s)
- J. T. Crane
- Department of Anthropology, History and Social Medicine, UCSF, San Francisco, California
| | - A. Kawuma
- Epidemiology and Prevention Interventions Center, Division of Infectious Diseases, San Francisco General Hospital, UCSF, San Francisco, California
| | - J. H. Oyugi
- Epidemiology and Prevention Interventions Center, Division of Infectious Diseases, San Francisco General Hospital, UCSF, San Francisco, California
- Academic Alliance for AIDS Care and Prevention, Kampala, Uganda
| | - J. T. Byakika
- Academic Alliance for AIDS Care and Prevention, Kampala, Uganda
- Makerere University School of Medicine, Kampala, Uganda
| | - A. Moss
- Department of Epidemiology and Biostatistics, UCSF, San Francisco, California
| | - P. Bourgois
- Department of Anthropology, History and Social Medicine, UCSF, San Francisco, California
| | - D. R. Bangsberg
- Epidemiology and Prevention Interventions Center, Division of Infectious Diseases, San Francisco General Hospital, UCSF, San Francisco, California
- Academic Alliance for AIDS Care and Prevention, Kampala, Uganda
- Positive Health Program, San Francisco General Hospital, UCSF, San Francisco, California
- Correspondence should be directed to D. R. Bangsberg, University of California at San Francisco, Epidemiology and Prevention Interventions Center, SFGH Building, 100 Room 301, PO Box 1347, San Francisco, California 94143; e-mail:
| |
Collapse
|
17
|
Kushel MB, Colfax G, Ragland K, Heineman A, Palacio H, Bangsberg DR. Case management is associated with improved antiretroviral adherence and CD4+ cell counts in homeless and marginally housed individuals with HIV infection. Clin Infect Dis 2006; 43:234-42. [PMID: 16779752 DOI: 10.1086/505212] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2006] [Accepted: 04/04/2006] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Case management (CM) coordinates care for persons with complex health care needs. It is not known whether CM is effective at improving biological outcomes among homeless and marginally housed persons with human immunodeficiency virus (HIV) infection. Our goal was to determine whether CM is associated with reduced acute medical care use and improved biological outcomes in homeless and marginally housed persons with HIV infection. METHODS We conducted a prospective observational cohort study in a probability-based community sample of HIV-infected homeless and marginally housed adults in San Francisco, California. The primary independent variable was CM, defined as none or rare (any CM in <or=25% of quarters in the study), moderate (>25% but <or=75%), or consistent (>75%). The dependent variables were 3 self-reported health service use measures (receipt of primary care, emergency department visits and hospitalizations, and antiretroviral therapy adherence) and 2 biological measures (increase in CD4(+) cell count of >or=50% and geometric mean HIV load of <or=400 copies/mL). RESULTS In multivariate models, CM was not associated with increased primary care, emergency department use, or hospitalization. Moderate CM, compared with no or rare CM, was associated with an adjusted beta coefficient of 0.13 (95% confidence interval [CI], 0.02-0.25) for improved antiretroviral adherence. Consistent CM (adjusted odds ratio [AOR], 10.7; 95% CI, 2.3-49.6) and moderate CM (AOR, 6.5; 95% CI, 1.3-33.0) were both associated with >or=50% improvements in CD4(+) cell count. CM was not associated with geometric HIV load <400 copies/mL when antiretroviral therapy adherence was included in the model. Study limitations include a lack of randomization. CONCLUSION CM may be a successful method to improve adherence to antiretroviral therapy and biological outcomes among HIV-infected homeless and marginally housed adults.
Collapse
Affiliation(s)
- M B Kushel
- Division of General Internal Medicine, San Francisco General Hospital Medical Center, University of California, San Francisco 94143-1372, USA
| | | | | | | | | | | |
Collapse
|
18
|
Kagay CR, Porco TC, Liechty CA, Charlebois E, Clark R, Guzman D, Moss AR, Bangsberg DR. Modeling the Impact of Modified Directly Observed Antiretroviral Therapy on HIV Suppression and Resistance, Disease Progression, and Death. Clin Infect Dis 2004; 38 Suppl 5:S414-20. [PMID: 15156432 DOI: 10.1086/421406] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A simulation model that used Markov assumptions with Monte Carlo uncertainty analysis was evaluated 1500 times at 10,000 iterations. Modified directly observed therapy (MDOT) for human immunodeficiency virus was assumed to improve adherence to therapy to 90% of prescribed doses. The impact of MDOT interventions on modeled biological and clinical outcomes was compared for populations with mean rates of adherence (i.e., the mean percentage of prescribed doses taken by each member of the population who had not discontinued therapy) of 40%, 50%, 60%, and 70%. MDOT reduced the risk of virological failure, development of opportunistic infections, and death, yet increased the risk of drug resistance, for each adherence distribution among persons with detectable plasma virus loads. Over 1500 trials, for a population with 50% adherence to therapy and a 12-month period, MDOT increased the median rate of virological suppression from 13.2% to 37.0% of patients, decreased the rate of opportunistic infection from 5.7% to 4.3% of patients, and decreased the death rate from 2.9% to 2.2% of patients. In the same population, however, MDOT increased the rate of new drug resistance mutations from 1.00 to 1.41 per person during the 12-month period. The impact of MDOT was smaller in populations with higher levels of adherence. MDOT interventions will likely improve clinical outcomes in populations with low levels of adherence but may not be effective at preventing drug resistance in treatment-experienced populations. MDOT may be more effective in preventing drug resistance with potent regimens in treatment-naive patients.
Collapse
Affiliation(s)
- C R Kagay
- University of California, San Francisco, School of Medicine, San Francisco, California 94110, USA
| | | | | | | | | | | | | | | |
Collapse
|
19
|
Riley ED, Bangsberg DR, Perry S, Clark RA, Moss AR, Wu AW. Reliability and validity of the SF-36 in HIV-infected homeless and marginally housed individuals. Qual Life Res 2004; 12:1051-8. [PMID: 14651422 DOI: 10.1023/a:1026166021386] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To assess the reliability and validity of the Short-Form 36 (SF-36) health survey as a health status indicator among HIV-infected homeless and marginally housed (HMH) individuals. METHODS Between July 1996 and May 2000, a sample of HMH individuals completed interviews that included the SF-36. Responses to the SF-36 were analyzed for missing data, range, internal consistency, and construct validity. RESULTS Among 330 individuals interviewed, 83% were male, 43% were African-American, and the median age was 39 years. All internal consistency reliability coefficients exceeded 0.70, all item-scale correlations exceeded 0.40, all items were more strongly correlated with their hypothesized scale than any other scale, and all reliability coefficients exceeded inter-scale correlations for the same scale. Three of four physical health scales were significantly associated with CD4 cell count and HIV viral load. All scales were significantly associated with depression. DISCUSSION We found that scales were internally consistent, items correlated to an acceptable degree with their hypothesized scales, items were distinct from other scales, physical scales were associated with CD4 cell count and viral load, and all scales were associated with depression. These analyses provide evidence for the reliability and validity of the SF-36 as a measure of health status in HIV-positive HMH individuals.
Collapse
Affiliation(s)
- E D Riley
- Epidemiology and Prevention Interventions Center, University of California, San Francisco General Hospital, San Francisco, CA 94110, USA.
| | | | | | | | | | | |
Collapse
|
20
|
Bangsberg DR, Bronstone A, Hofmann R. A computer-based assessment detects regimen misunderstandings and nonadherence for patients on HIV antiretroviral therapy. AIDS Care 2002; 14:3-15. [PMID: 11798401 DOI: 10.1080/09540120220097892] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Accurately assessing nonadherence is a necessary first step toward improving adherence to highly active antiretroviral therapy (HAART). Patient self report is the most practical method for assessing adherence in clinical settings, but may produce unreliable and invalid results unless optimally performed. A computer-assisted, self-administered interview (CASI) may improve the disclosure of medication nonadherence by providing a neutral and seemingly private interview. One hundred and ten patients completed a computer program which assessed their understanding of and adherence to HIV medications and produced a report for their providers. Eleven providers of these patients completed a questionnaire describing their patients' medication regimens and estimating adherence. Patients completed a written exit survey and providers completed an exit interview to assess the acceptability of our CASI-based assessment. More than half of patients (54%) made at least one error in reporting their medication regimen. Providers tended to overestimate their patients' adherence and correctly classified only 24% of nonadherent patients at the 80% adherence level. Computerized HIV medication adherence assessment is feasible and acceptable to patients and providers. Clinical tools that can accurately and efficiently detect important medication errors and nonadherence, and alert providers to these problems, will help ensure the health of HIV-seropositive patients.
Collapse
Affiliation(s)
- D R Bangsberg
- Epidemiology and Prevention Interventions Center, Division of Infectious Diseases and the Positive Health Program, San Francisco General Hospital, University of California San Francisco, CA, USA
| | | | | |
Collapse
|
21
|
Kellogg TA, McFarland W, Perlman JL, Weinstock H, Bock S, Katz MH, Gerberding JL, Bangsberg DR. HIV incidence among repeat HIV testers at a county hospital, San Francisco, California, USA. J Acquir Immune Defic Syndr 2001; 28:59-64. [PMID: 11579278 DOI: 10.1097/00042560-200109010-00009] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To estimate HIV incidence, characterize correlates of HIV seroconversion, and monitor temporal trends in HIV transmission among patients repeatedly tested for HIV by a county hospital in San Francisco. DESIGN Retrospective longitudinal study. METHODS HIV incidence was retrospectively calculated among persons voluntarily tested for HIV antibody more than once at San Francisco's county hospital or one of its affiliated satellite community clinics between 1993 and 1999. Linkage of HIV test results in computerized databases identified "seroconverters" as individuals who had a negative antibody test followed by a positive test. The interval between tests was used as the person-time at risk. Cox proportional hazards analysis identified correlates of HIV seroconversion. RESULTS A total of 84 HIV seroconversions were identified among 2893 eligible patients repeatedly tested for HIV antibody over a cumulative 5860 person-years (PYs) (incidence of 1.4 per 100 PYs, 95% confidence interval [CI]: 1.2-1.7). The majority of seroconversions (71 [84.5%]) were among injection drug users (IDUs) (incidence of 2.0 per 100 PYs, CI: 1.6-2.4). HIV incidence was highest among men who have sex with men (MSM) who were also IDUs (incidence of 3.8 per 100 PYs, CI: 2.7-5.1) and lowest among non-IDUs, heterosexual men, and non-IDU women (incidence of 0.3 per 100 PYs, CI: 0.1-0.6). In multivariate analysis, correlates of HIV seroconversion were age 25 to 29 years (hazard ratio [HR] = 3.9, CI: 2.4-6.3), MSM (HR = 2.9, CI: 1.9-4.4), and IDU (HR = 3.2, CI: 1.8-5.8). Overall, no temporal trend in annual HIV incidence was noted during the study period; however, HIV incidence among MSM IDUs increased from 2.9 per 100 PYs in 1996 to 4.7 per 100 PYs in 1998. CONCLUSIONS The rate of seroconversion in this hospital and affiliated clinic population is unexpectedly high. Moreover, HIV transmission among IDU patients has not decreased over the last several years. The San Francisco county hospital provides a high-risk sentinel population to monitor emerging trends in HIV transmission, especially among IDUs, and presents multiple opportunities for prevention interventions, because these patients are being seen repeatedly by clinicians.
Collapse
Affiliation(s)
- T A Kellogg
- HIV Seroepidemiology, Department of Public Health, San Francisco, California 94102-6033, USA.
| | | | | | | | | | | | | | | |
Collapse
|
22
|
Affiliation(s)
- D R Bangsberg
- Epidemiology and Prevention Interventions Center, Division of Infectious Diseases, San Francisco General Hospital, University of California, USA
| | | | | | | | | | | | | |
Collapse
|
23
|
|
24
|
Abstract
BACKGROUND Adherence assessment is an essential component of monitoring HIV antiretroviral therapy. Prior studies suggest that medical providers frequently estimate individual patient adherence inaccurately. OBJECTIVE We compared provider estimates of nonadherence to antiretroviral therapy with unannounced pill counts and structured patient interviews to determine the accuracy of adherence information obtained by providers and patients. DESIGN, SETTING, AND PARTICIPANTS Comparison of three adherence measures in homeless or marginally housed persons receiving HIV antiretroviral therapy (n = 45) and their providers (n = 35). MEASUREMENTS Provider estimate of percentage of pills taken; three successive patient structured reports of number of doses missed in the last 3 days; and three successive unannounced pill counts. RESULTS 13% (95% confidence interval [CI], 4%-22%) of patients were not following their regimen as directed. Provider-adherence estimate explained only 26% (95% CI, 6%-47%) of the variation in pill count adherence, whereas patient report explained 72% (95% CI, 52%-96%). The sensitivity and specificity of provider estimates of nonadherence, defined as <80% of pills taken by pill count, were 40% and 85%, respectively. The sensitivity and specificity of patient interview were 72% and 95%, respectively. CONCLUSIONS Provider estimate of adherence was inaccurate whereas structured patient report was more closely related to pill count. Structured assessment over several short intervals may improve accuracy of adherence assessment in clinical practice.
Collapse
Affiliation(s)
- D R Bangsberg
- Epidemiology and Prevention Interventions Center, Division of Infectious Diseases and the Positive Health Program, San Francisco General Hospital/University of California, San Francisco (UCSF) 94110, USA.
| | | | | | | | | | | | | |
Collapse
|
25
|
Abstract
OBJECTIVES This study determined infection risk for HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV) from needle reuse at a phlebotomy center that possibly exposed 3810 patients to infection. METHODS We used a model for the risk of infection per blood draw, supplemented by subsequent testing results from 1699 patients. RESULTS The highest risk of transmission was for HBV infection: 1.1 x 10(-6) in the best case and 1.2 x 10(-3) in the (unlikely) worst case. Subsequent testing yielded prevalence rates of 0.12%, 0.41%, and 0.88% for HIV, HBV, and HCV, respectively, lower than National Health and Nutrition Examination Survey III prevalence estimates. CONCLUSIONS The infection risk was very low; few, if any, transmissions are likely to have occurred.
Collapse
Affiliation(s)
- T C Porco
- Community Health Epidemiology, Epidemiology and Effectiveness Research Unit, San Francisco Department of Public Health, San Francisco, Calif., USA
| | | | | | | | | | | | | |
Collapse
|
26
|
Dorsey G, Borneo HT, Sun SJ, Wells J, Steele L, Howland K, Perdreau-Remington F, Bangsberg DR. A heterogeneous outbreak of Enterobacter cloacae and Serratia marcescens infections in a surgical intensive care unit. Infect Control Hosp Epidemiol 2000; 21:465-9. [PMID: 10926397 DOI: 10.1086/501789] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To investigate an outbreak of invasive disease due to Enterobacter cloacae and Serratia marcescens in a surgical intensive care unit (ICU). DESIGN Pulsed-field gel electrophoresis (PFGE) analysis of restriction fragments was used to characterize the outbreak isolate genotypes. A retrospective cohort study of surgical ICU patients was conducted to identify risk factors associated with invasive disease. Unit staffing data were analyzed to compare staffing levels during the outbreak to those prior to and following the outbreak. SETTING An urban hospital in San Francisco, California. PATIENTS During the outbreak period, December 1997 through January 1998, there were 52 patients with a minimum ICU stay of > or = 72 hours. Of these, 10 patients fit our case definition of recovery of E. cloacae or S. marcescens from a sterile site. RESULTS PFGE analysis revealed a highly heterogeneous population of isolates. Bivariate analysis of patient-related risk factors revealed duration of central lines, respiratory colonization, being a burn patient, and the use of gentamicin or nafcillin to be significantly associated with invasive disease. Both respiratory colonization and duration of central lines remained statistically significant in a multivariate analysis. Staffing data suggested a temporal correlation between understaffing and the outbreak period. CONCLUSIONS Molecular epidemiological techniques provided a rapid means of ruling out a point source or significant cross-contamination as modes of transmission. In this setting, patient-related risk factors, such as respiratory colonization and duration of central lines, may provide a focus for heightened surveillance, infection control measures, and empirical therapy during outbreaks caused by common nosocomial pathogens. In addition, understaffing of nurses may have played a role in this outbreak, highlighting the importance of monitoring staffing levels.
Collapse
Affiliation(s)
- G Dorsey
- Epidemiology and Prevention Interventions Center at San Francisco General Hospital, University of California-San Francisco, 94110, USA
| | | | | | | | | | | | | | | |
Collapse
|
27
|
Bangsberg DR, Hecht FM, Charlebois ED, Zolopa AR, Holodniy M, Sheiner L, Bamberger JD, Chesney MA, Moss A. Adherence to protease inhibitors, HIV-1 viral load, and development of drug resistance in an indigent population. AIDS 2000; 14:357-66. [PMID: 10770537 DOI: 10.1097/00002030-200003100-00008] [Citation(s) in RCA: 791] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine the relationship between adherence, viral suppression and antiretroviral resistance in HIV-infected homeless and marginally housed people on protease inhibitor (PI) therapy. DESIGN AND SETTING A cross-sectional analysis of subjects in an observational prospective cohort systematically sampled from free meal lines, homeless shelters and low-income, single-room occupancy (SRO) hotels. PARTICIPANTS Thirty-four HIV-infected people with a median of 12 months of PI therapy. MAIN OUTCOMES Adherence measured by periodic unannounced pill counts, electronic medication monitoring, and self-report; HIV RNA viral load; and HIV-1 genotypic changes associated with drug resistance. RESULTS Median adherence was 89, 73, and 67% by self-report, pill count, and electronic medication monitor, respectively. Thirty-eight per cent of the population had over 90% adherence by pill count. Depending on the measure, adherence explained 36-65% of the variation in concurrent HIV RNA levels. The three adherence measures were closely related. Of 20 genotyped patients who received a new reverse transcriptase inhibitor (RTI) when starting a PI, three had primary protease gene substitutions. Of 12 genotyped patients who received a PI without a new RTI, six had primary protease gene substitutions (P < 0.03). CONCLUSION A substantial proportion of homeless and marginally housed individuals had good adherence to PI therapy. A strong relationship was found between independent methods of measuring adherence and concurrent viral suppression. PI resistance was more closely related to the failure to change RTI when starting a PI than to the level of adherence.
Collapse
Affiliation(s)
- D R Bangsberg
- Epidemiology and Prevention Interventions Center, Division of Infectious Diseases, San Francisco General Hospital, University of California San Francisco, 94110, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
28
|
|
29
|
Bangsberg DR, Crowley K, Moss A, Dobkin JF, McGregor C, Neu HC. Reduction in tuberculin skin-test conversions among medical house staff associated with improved tuberculosis infection control practices. Infect Control Hosp Epidemiol 1997; 18:566-70. [PMID: 9276238 DOI: 10.1086/647673] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To assess the efficacy of an infection control program as measured by tuberculin skin-test (TST) conversion rates in medical house staff. DESIGN Observational study. SETTING University-based hospital in New York City serving a large indigent population. PARTICIPANTS Medical house staff. INTERVENTIONS TST conversions were measured every 6 months in medical house staff from June 1992 to June 1994. Compliance with the isolation policy was measured by identifying room locations 24 hours after admission of patients who had Mycobacterium tuberculosis recovered from respiratory specimens. RESULTS The TST conversion rate decreased from 5.8 to 0, 2.3, and 0 per 100 person years of exposure in successive 6-month periods. The estimated annual TST conversion rate among interns fell from 7 per 100 person years in June 1992 to 0 per 100 person years in June 1993 and 0 per 100 person years in June 1994 (P < .029). The proportion of patients with pulmonary tuberculosis who were isolated in negative-pressure rooms increased from 38% to 75% over the study period (P < .01). CONCLUSION Development of a multifaceted infection control program can decrease the risk of nosocomial tuberculosis infection in medical house staff.
Collapse
Affiliation(s)
- D R Bangsberg
- Columbia-Presbyterian Medical Center, New York City, USA
| | | | | | | | | | | |
Collapse
|
30
|
Levine JE, Norman RL, Gliessman PM, Oyama TT, Bangsberg DR, Spies HG. In vivo gonadotropin-releasing hormone release and serum luteinizing hormone measurements in ovariectomized, estrogen-treated rhesus macaques. Endocrinology 1985; 117:711-21. [PMID: 3893989 DOI: 10.1210/endo-117-2-711] [Citation(s) in RCA: 141] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The push-pull perfusion technique was used to measure GnRH release in unanesthetized female rhesus macaques (Macaca mulatta) and to examine the dynamic relationship between GnRH release and LH levels during the estrogen-induced LH surge. Each ovariectomized macaque was anesthetized and stereotaxically fitted with a push-pull cannula directed into the median eminence (ME). After at least 1 week of recovery, each animal received an estradiol benzoate (E2B) injection (42 micrograms/kg BW) or an oil (OIL) injection and underwent push-pull perfusion of the ME and blood sampling for at least 5 h between 28 and 56 h postinjection. Continuous 10-min push-pull perfusates were collected and prepared for GnRH RIA. Peripheral venous blood samples were obtained either hourly or every 10 min, and serum LH levels were determined by Leydig cell bioassay. GnRH release was detectable and pulsatile in areas in or adjacent to the ME or arcuate nucleus. In eight OIL monkeys, GnRH pulses were regular (approximately one pulse every 60 min) and of low amplitude (14.7 +/- 12.0 pg), with a mean GnRH release rate of 4.0 +/- 1.7 pg/10 min. In five E2B-treated monkeys, GnRH release during the rising phase of the LH surge occurred as an apparent burst of high amplitude GnRH pulses. The mean GnRH release rate (37.5 +/- 17.9 pg/10 min) and mean GnRH pulse amplitude (170.0 +/- 90.0 pg) during the 5 h before the peak LH level in E2B-treated monkeys were greater than OIL values (P less than 0.025, mean release; P less than 0.05, mean amplitude). Within individual E2B-treated monkeys, hourly mean GnRH release rates were significantly correlated with LH levels during the ascending limb of the LH surge (r = 0.75 +/- 0.11; P less than 0.025). We have concluded that an increase in GnRH neurosecretion occurs in E2B-treated monkeys and that it is associated with generation of the LH surge. On the basis of our observations, we hypothesize that the primate hypothalamus, through changes in GnRH secretion, actively participates in the E2B-induced LH surge.
Collapse
|