Virologic Outcomes and ARV Switch Profiles 2 Years After National Rollout of Dolutegravir to Children Less Than 15 Years in Southern Mozambique

BACKGROUND

Dolutegravir (DTG) was scaled up globally to optimize treatment for children living with HIV. We evaluated the rollout and virological outcomes after DTG introduction in Mozambique.

METHODS

Data from children 0-14 years with visits from September 2019 to August 2021 were extracted from records in 16 facilities in 12 districts. Among children ever on DTG, we report treatment switches, defined as changes in anchor drug, regardless of changes to nucleoside reverse transcriptase inhibitor (NRTI) backbones. Among those on DTG for ≥6 months, we described viral load suppression rates by children newly initiating and switching to DTG and by the NRTI backbone at the time of the DTG switch.

RESULTS

Overall, 3,347 children were ever on DTG-based treatment (median age 9.5 years; 52.8% female). Most children (3,202, 95.7%) switched to DTG from another antiretroviral regimen. During the 2-year follow-up, 9.9% never switched from DTG; 52.7% had 1 regimen change, of which 97.6% were switched to DTG. However, 37.2% of children experienced ≥2 anchor drug changes. Overall median time on DTG was 18.6 months; nearly all children ≥5 years (98.6%) were on DTG at the last visit. Viral suppression was 79.7% (63/79) for children newly initiating DTG and 85.8% (1,775/2,068) for those switching to DTG. Suppression rates were 84.8% and 85.7% among children who switched and maintained NRTI backbones, respectively.

CONCLUSIONS

Viral suppression rates of ≥80% with minor variations by backbone were achieved during the 2-year DTG rollout. However, there were multiple anchor drug switches for over one-third of children, which may be attributable in part to drug stockouts. Long-term pediatric HIV management will only be successful with immediate and sustainable access to optimized child-friendly drugs and formulations.

Measuring the burden of SARS-CoV-2 infection among persons living with HIV and healthcare workers and its impact on service delivery in Mozambique: protocol of a prospective cohort study

INTRODUCTION

As COVID-19 continues to spread globally and within Mozambique, its impact among immunosuppressed persons, specifically persons living with HIV (PLHIV), and on the health system is unknown in the country. The 'COVid and hIV' (COVIV) study aims to investigate: (1) the seroprevalence and seroincidence of SARS-CoV-2 among PLHIV and healthcare workers providing HIV services; (2) knowledge, attitudes, practices and perceptions regarding SARS-CoV-2 infection; (3) the pandemic's impact on HIV care continuum outcomes and (4) facility level compliance with national COVID-19 guidelines.

METHODS AND ANALYSIS

A multimethod study will be conducted in a maximum of 11 health facilities across Mozambique, comprising four components: (1) a cohort study among PLHIV and healthcare workers providing HIV services to determine the seroprevalence and seroincidence of SARS-CoV-2, (2) a structured survey to assess knowledge, attitudes, perceptions and practices regarding COVID-19 disease, (3) analysis of aggregated patient data to evaluate retention in HIV services among PLHIV, (4) an assessment of facility implementation of infection prevention and control measures.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the National Health Bioethics Committee, and institutional review boards of implementing partners. Study findings will be discussed with local and national health authorities and key stakeholders and will be disseminated in clinical and scientific forums.

TRIAL REGISTRATION NUMBER

NCT05022407.

HIV community index testing reaches proportionally more males than facility-based testing and is cost-effective: A study from Gaza province, Mozambique

BACKGROUND

In Mozambique, 38.7% of women and 60.4% of men ages 15-59 years old living with HIV do not know their HIV status. A pilot home-based HIV counseling and testing program based on index cases in the community was implemented in eight districts in Gaza province (Mozambique). The pilot targeted the sexual partners, biological children under 14 years old living in the same household, and parents (for pediatric cases) of people living with HIV. The study aimed to estimate the cost-efficiency and effectiveness of community index testing and compare the HIV testing outputs with facility-based testing.

METHODS

Community index testing costs included the following categories: human resources, HIV rapid tests, travel and transportation for supervision and home visits, training, supplies and consumables, and review and coordination meetings. Costs were estimated from a health systems perspective using a micro-costing approach. All project costs were incurred between October 2017 and September 2018 and converted to U.S. dollars ($) using the prevailing exchange rate. We estimated the cost per individual tested, per new HIV diagnosis, and per infection averted.

RESULTS

A total of 91,411 individuals were tested for HIV through community index testing, of which 7,011 were newly diagnosed with HIV. Human resources (52%), purchase of HIV rapid tests (28%) and supplies (8%) were the major cost drivers. The cost per individual tested was $5.82, per new HIV diagnosis was $65.32, and per infection averted per year was $1,813. Furthermore, the community index testing approach proportionally tested more males (53%) than facility-based testing (27%).

CONCLUSION

These data suggest that expansion of the community index case approach may be an effective and efficient strategy to increase the identification of previously undiagnosed HIV-positive individuals, particularly males.

Determinants of antiretroviral treatment success and adherence in people with HIV treated for tuberculosis

Introduction

In people living with HIV (PWH) with advanced disease, rates of virologic success may be lower than expected. The Reflate TB2 trial did not show non-inferiority of raltegravir versus efavirenz in PWH with tuberculosis. We aimed to identify factors associated with virologic success and higher adherence in the trial.

Methods

In this analysis, we included participants enrolled in the Reflate TB 2 trial with adherence data available. The primary outcome was virologic success (HIV-1 RNA < 50 copies/mL) at week 48 and the secondary outcome was adherence as assessed by the pill count adherence ratio. We used logistic regression to study determinants of virologic success and optimal adherence in 2 separate analyses.

Results

444 participants were included in the present analysis. Over the 48-week follow-up period, 290/444 (65%) participants had a pill count adherence ratio ≥95%. At week 48, 288/444 (65%) participants were in virologic success. In the multivariate analysis, female sex (aOR 1·77 (95%CI 1·16 - 2·72), p = 0·0084), lower baseline HIV-1 RNA levels (<100,000, aOR 2·29 (95%CI 1·33 - 3·96), p = 0·0087) and pill count adherence ratio ≥95% (aOR 2·38 (95%CI 1·56 - 3·62), p < 0·0001), were independently associated with virologic success. Antiretroviral pill burden was the only factor associated with pill count adherence ratio ≥95% (OR 0·81 (95% CI 0·71-0·92), p = 0·0018).

Conclusions

In PWH with tuberculosis receiving raltegravir or efavirenz-based regimens, female sex, optimal adherence and baseline HIV-1 RNA <100,000 copies/mL were associated with virologic success and the number of antiretroviral tablets taken daily was a strong predictor of adherence.

Performance improvement and advancement studies of mixed-mode solar thermal dryers: a review

Solar thermal dryers are solar-operated gadgets utilized to dehumidify various products, especially food items and rubber sheets. This article provides detailed design, parametric studies, and an in-depth review of mixed-mode solar dryers (MMSD) with a case study of fish drying near coastal lines. Due to several advantages compared to open sun drying and prominent performance index compared to indirect and direct type solar dryers, mixed-mode solar dryers have large adaptability on the field. Moreover, mixed-mode solar thermal dryers with different augmentations are reviewed, for instance, mixed-mode solar dryers with evacuated tube collectors, phase change materials, ultraviolet rays stabilized housing, and dehumidifiers. The case study of fish drying near the coastal line of Gujarat, India has been carried out to study the present scenario of the drying activities. Hence, the objective of this review is to identify the capable mixed-mode solar dryer with heat recovery systems. Substantial reviews within the article suggest an essential need to implement the hybrid mixed-mode solar dryer cum distiller technology for small-scale enterprises that can simultaneously provide potable water near coastal lines along with drying of fishes from the solar dryer. Furthermore, future research demands such hybrid mixed-mode solar drying systems that strongly fulfill the requirements of local communities near coastal lines involved in fish drying activities.

Testing Herzberg’s two factor theory on millennials

This study tests Herzberg’s two-factor theory of motivation on working millennials. The purpose of the study is to evaluate what the assumptions and the findings of the original study hold for millennials. With the increasing trend of amalgamation of work life and personal life, job satisfaction and general job happiness have never been more on an individual’s personal life. This impact is far-reaching, with strong indications of affecting the employees’ physical, mental, and social health. In such a scenario, organizations need to keep their employees motivated and satisfied. For studying Herzberg’s two-factor theory of motivation on working millennials, we have selected respondents with work experience of at least one year. We have not restricted the study to any particular industry; hence our sample is across all industries. The type of sampling used was convenient sampling. From the analysis, we have found that for the concerned sample, hygiene factors tower above the motivating factors in terms of job satisfaction for millennials. From the data collection and analysis, we proved that both motivators and hygiene factors affect job satisfaction, unlike what has been said by Herzberg. This study will contribute to the exciting literature on motivation.

Helios expressing regulatory T cells are correlated with decreased IL-2 producing CD8 T cells and antibody diversity in Mozambican individuals living chronically with HIV-1

Background

Human immunodeficiency virus type 1 (HIV-1) causes impairment of T and B cell responses, which begins during the acute phase of infection and is not completely restored by antiretroviral treatment. Regulatory T cell (Tregs) can improve overall disease outcome by controlling chronic inflammation but may also suppress beneficial HIV-1 specific immune responses. We aimed to analyze the profile of Tregs and their correlation with the status of T cells activation, the expression of IL-2 and IFNγ and the profile of HIV-1 specific antibodies response in Mozambican people living chronically with HIV-1 (PLWH-C).

Results

In PLWH-C, the proportion of total Tregs was positively correlated with the proportion of IL-2⁺CD4 T cells (r = 0.647; p = 0.032) and IL-2⁺IFNγ⁺CD8 T cells (r = 0.551; p = 0.014), while the proportions of Helios⁺Tregs correlated inversely with levels of IL-2⁺CD8 T cells (r = − 0.541; p = 0.017). Overall, PLWH-C, with (82%) or without virologic suppression (64%), were seronegative for at least HIV-1 p31, gp160 or p24, and the breadth of antibody responses was positively correlated with proportions of CD38⁺HLA-DR⁺CD8 T cells (r = 0.620; p = 0.012), viral load (r = 0.452; p = 0.040) and inversely with absolute CD4 T cells count (r = − 0.481; p = 0.027). Analysis of all individuals living HIV-1 showed that the breadth of HIV-1 antibody responses was inversely correlated with the proportion of Helios⁺Tregs (r = − 0.45; p = 0.02).

Conclusion

Among Mozambican people living with HIV-1, seronegativity to some HIV-1 proteins is common, particularly in virologically suppressed individuals. Furthermore, lower diversity of HIV-specific antibodies is correlated to lower immune activation, lower viral replication and higher CD4 counts, in PLWH-C. Elevation in the proportion of Helios⁺Tregs is related to a reduction of CD8 T expressing intracellular IL-2, in PLWH-C, but may contribute to impairment of B cell function.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12865-022-00487-3.

Nevirapine hair and plasma concentrations and HIV-1 viral suppression among HIV infected ante-partum and post-partum women attended in a mother and child prevention program in Maputo city, Mozambique

INTRODUCTION

Prevention of mother to child transmission of HIV (PMTCT) is frequently challenged by irregular access to more effective anti-retroviral therapy. Nevirapine single dose (sdNVP), sdNVP+AZT+3TC for MTCT prophylaxis and NVP+ AZT+3TC for treatment and PMTCT were withdrawn due to low genetic resistance barrier and low efficacy. However current PMTCT lines in Mozambique include DTG+3TC+TDF, TDF+3TC+EFV, DTG +ABC+3TC, and AZT + NVP syrup prophylaxis for exposed babies. We assessed NVP hair and plasma concentrations and association with HIV-1RNA suppression among HIV+ ante-partum and post-partum women under PMTCT in Maputo, Mozambique.

METHODS

From December 2013 to November 2014, prospectively were enrolled 200 HIV+ ante-partum women on 200mg nevirapine and zidovudine 300 plus lamivudine 150mg twice daily at least with 3 months treatment and seen again at 24 weeks post-partum. Self-reported pill-taking adherence, NVP concentrations in hair, plasma, hemoglobin, CD4 cell count, HIV-1 RNA load was evaluated. NVP concentration in hair and plasma was analyzed as categorical quartile variable based on better data fit. NVP concentration was set between ≤3.77 ng/ml in plasma and ≤17,20 ng/mg in hair in quartile one to ≥5.36 ng/ml in plasma and ≥53.21 ng/mg in hair in quartile four. Logistic regression models for repeated measures were calculated. Following the World Health Organization (WHO) guidelines we set viral suppression at HIV-1RNA < 1000 c/mL. Outcome was HIV-1 RNA<1000 copies/ml. Predictor was NVP concentration in hair categorized in quartiles.

RESULTS

In total 369 person-visits (median of 1.85) were recorded. Self-reported adherence was 98% (IQR 97-100%) at ante-partum. In 25% person visits, NVP concentrations were within therapeutic levels (3.77 ng/ml to 5.35 ng/ml) in plasma and (17.20 ng/mg to 53.20 ng/mg) in hair. In 50% person visits NVP concentrations were above 5.36 ng/ml in plasm and 53.21 ng/mg in hair. HIV-1 RNA suppression was found in 34.7% of women with two viral loads, one at enrollment and another in post-partum. Odds of HIV-1 RNA suppression in quartile 4, was about 6 times higher than in quartile 1 (p-value = 0.006) for NVP hair concentration and 7 times for NVP plasma concentration (p-value = 0.012).

CONCLUSIONS

The study results alert for potential low efficacy of current PMTCT drug regimens in use in Mozambique. Affordable means for individual monitoring adherence, ART plasma and hair levels, drug resistant and HIV-1 RNA levels monitoring are recommended for prompt identification of inadequate drug regimens exposure patterns and adjust accordingly.

Reduction of blood C-reactive protein concentration complements the resolution of sputum bacillary load in patients on anti-tuberculosis therapy

Background

Tuberculosis (TB) is a difficult-to-treat disease requiring the combination of four antibiotics for a minimum of 6 months. Rapid and quantitative biomarkers to monitor treatment response are urgently needed for individual patient management and clinical trials. C-reactive protein (CRP) is often used clinically as a rapid marker of inflammation caused by infection. We assessed the relationship of TB bacillary load and CRP as biomarkers of treatment response.

Methods

Xpert MTB/RIF-confirmed pulmonary TB cases were enrolled for treatment response assessment in Mozambique. Treatment response was measured using the Tuberculosis Molecular Bacterial Load Assay (TB-MBLA) in comparison with standard-of-care Mycobacterium Growth Indicator Tube (MGIT) culture at baseline and at weeks 1, 2, 4, 8, 12, 17, and 26 of treatment. Blood CRP concentration was measured at baseline, week 8, and week 26. Treatment response was defined as increase in MGIT culture time to positivity (TTP), and reduction in TB-MBLA-measured bacillary load and blood CRP concentration.

Results

Out of the 81 screened presumptive TB cases, 69 were enrolled for 6-month treatment follow-up resulting in 94% treatment completion rate. Four participants did not complete TB treatment and 22 participants had missing CRP or TB-MBLA results and were excluded from TB-MBLA-CRP analysis. The remaining 43 participants-median age, 31 years old [interquartile range (IQR): 18-56]; 70% (30/43) male; and 70% (30/43) infected with HIV-were considered for analysis. Culture TTP and bacillary load were inversely correlated, Spearman's r = -0.67, p < 0.0001. Resolution of sputum bacillary load concurred with reduction of blood CRP, r = 0.70, p < 0.0001. At baseline, bacillary load had a median (IQR) of 6.4 (5.5-7.2), which reduced to 2.4 (0.0-2.9) and 0.0 (0.0-0.0) log₁₀ CFU/ml at months 2 and 6 of treatment, respectively. Correspondingly, blood CRP reduced from 1.9 (1.6-2.1) at baseline to 1.3 (0.9-1.7) and 0.4 (0.1-0.8) log₁₀ mg/dl at months 2 and 6 of treatment, respectively. CRP reduction trialed bacteriological resolution at a rate of -0.06 log₁₀ mg/dl compared to a bacillary load of 0.23 log₁₀ CFU/ml per week. Consequently, 14 (33%) and 37 (88%) patients had reduced CRP to normal concentration and bacillary load to zero by the end of treatment, respectively. Pre-treatment CRP concentration and bacillary load, and resolution during treatment were slightly lower in HIV co-infected patients but not significantly different from HIV-uninfected TB patients.

Conclusion

TB-MBLA-measured bacillary load and blood CRP complement each other in response to anti-TB therapy. Slow CRP reduction probably reflects residual TB bacilli in the lung not expectorated in sputum. Combining both measures can improve the accuracy of these biomarkers for monitoring TB treatment response and shorten turnaround time since the results of both assays could be available in 24 h.

HIV infection in Eastern and Southern Africa: Highest burden, largest challenges, greatest potential

BACKGROUND

The burden of HIV is especially concerning for Eastern and Southern Africa (ESA), as despite expansion of test-and-treat programmes, this region continues to experience significant challenges resulting from high rates of morbidity, mortality and new infections. Hard-won lessons from programmes on the ground in ESA should be shared.

OBJECTIVES

This report summarises relevant evidence and regional experts' recommendations regarding challenges specific to ESA.

METHOD

This commentary includes an in-depth review of relevant literature, progress against global goals and consensus opinion from experts.

RESULTS

Recommendations include priorities for essential research (surveillance data collection, key and vulnerable population education and testing, in-country testing trials and evidence-based support services to improve retention in care) as well as research that can accelerate progress towards the prevention of new infections and achieving ambitious global goals in ESA.

CONCLUSION

The elimination of HIV in ESA will require continued investment, commitment to evidence-based programmes and persistence. Local research is critical to ensuring that responses in ESA are targeted, efficient and evaluated.

377 Global Recruitment for The RESECT Study (Transurethral Resection and Single-Instillation Intravesical Chemotherapy Evaluation in Bladder Cancer Treatment): An International Observational Cohort Study Aiming to Improve the Quality of Surgery for Non-Muscle Invasive Bladder Cancer

Introduction

Non-muscle invasive bladder cancer (NMIBC) can be curatively treated with ‘good quality’ transurethral resection of the bladder tumour (TURBT). However, despite evidence-based international guidelines, there is anecdotal evidence that practice varies widely, and this may affect oncological outcomes. Launching in 2020, RESECT aims to measure and report variation in TURBT quality globally, and determine if outcome reporting improves outcomes.

Method

RESECT was advertised internationally through social media, mailing lists, websites, and in person. Collaborators at each registered site will collect data about current practice and the experience of local TURBT surgeons. The primary outcome is the rate of achievement of key TURBT quality indicators.

Results

As of August 27, 508 collaborators have registered to participate. Collaborators represent 321 centres from 54 countries, with the highest number from the United Kingdom (54.5%), Spain (5.9%), and Argentina (3.7%). 51.2% are trainees, 29.9% consultants, and 17.5% medical students. Based on current registrations, patient recruitment will far exceed initial projections and considerably improve statistical power.

Conclusions

RESECT has attracted a large number of collaborators globally and from all training levels. Therefore, the RESECT study has the potential to improve the quality of TURBT surgery across the world.

P57 Global recruitment for the RESECT study (transurethral REsection and Single-instillation intravesical chemotherapy Evaluation in bladder Cancer Treatment) - an international observational cohort study aiming to improve the quality of surgery for non-muscle invasive bladder cancer

Introduction

Non-muscle invasive bladder cancer (NMIBC) is one of the most expensive cancers to treat, driven by high recurrence rates and disease progression. Mortality rates in the UK for all bladder cancers have remained relatively stable over the past decade. NMIBC can be curatively treated with transurethral resection of the bladder tumour (TURBT). Despite international evidence-based guidelines on the TURBT procedure and postoperative single instillation of mitomycin-C, TURBT quality continues to vary widely. RESECT will be the first ever international study of TURBT surgery evaluating the achievement of TURBT quality indicators globally and assessing if audit and performance feedback can improve surgical outcomes.

Methods

RESECT is a prospective, multicentre international observational cohort study. Collaborators at each site will collect data using REDCap about local TURBT practice, early recurrence rates and the experience of local TURBT surgeons. The primary outcome is the rate of achievement of key TURBT quality indicators. Advertisement for the study launched in 2020.

Results

As of October 1st, 2020, 524 collaborators have registered to participate. Collaborators represent 334 centres from 54 countries, with the highest number of centres from the United Kingdom (133), Spain (17), and India (16). 50.8% are trainees, 30.3% consultants, and 17.2% medical students. Based on current registrations, patient recruitment will far exceed initial projections and considerably improve statistical power.

Conclusion

RESECT has attracted many collaborators internationally from consultants and trainees at all stages. RESECT has significant potential to positively impact TURBT practice, health economics and ultimately improve outcomes for patients with NMIBC globally.

Standard dose raltegravir or efavirenz-based antiretroviral treatment for patients co-infected with HIV and tuberculosis (ANRS 12 300 Reflate TB 2): an open-label, non-inferiority, randomised, phase 3 trial

BACKGROUND

In patients co-infected with HIV and tuberculosis, antiretroviral therapy options are limited due to drug-drug interactions with rifampicin. A previous phase 2 trial indicated that raltegravir 400 mg twice a day or efavirenz 600 mg once a day might have similar virological efficacy in patients given rifampicin. In this phase 3 trial, we assessed the non-inferiority of raltegravir to efavirenz.

METHODS

We did a multicentre, open-label, non-inferiority, randomised, phase 3 trial at six sites in Côte d'Ivoire, Brazil, France, Mozambique, and Vietnam. We included antiretroviral therapy (ART)-naive adults (aged ≥18 years) with confirmed HIV-1 infection and bacteriologically confirmed or clinically diagnosed tuberculosis who had initiated rifampicin-containing tuberculosis treatment within the past 8 weeks. Using computerised random numbers, we randomly assigned participants (1:1; stratified by country) to receive raltegravir 400 mg twice daily or efavirenz 600 mg once daily, both in combination with tenofovir and lamivudine. The primary outcome was the proportion of patients with virological suppression at week 48 (defined as plasma HIV RNA concentration <50 copies per mL). The prespecified non-inferiority margin was 12%. The primary outcome was assessed in the intention-to-treat population, which included all randomly assigned patients (excluding two patients with HIV-2 infection and one patient with HIV-1 RNA concentration of <50 copies per mL at inclusion), and the on-treatment population, which included all patients in the intention-to-treat population who initiated treatment and were continuing allocated treatment at week 48, and patients who had discontinued allocated treatment due to death or virological failure. Safety was assessed in all patients who received at least one dose of the assigned treatment regimen. This study is registered with ClinicalTrials.gov, NCT02273765.

FINDINGS

Between Sept 28, 2015, and Jan 5, 2018, 460 participants were randomly assigned to raltegravir (n=230) or efavirenz (n=230), of whom 457 patients (230 patients in the raltegravir group; 227 patients in the efavirenz group) were included in the intention-to-treat analysis and 410 (206 patients in the raltegravir group; 204 patients in the efavirenz group) in the on-treatment analysis. At baseline, the median CD4 count was 103 cells per μL and median plasma HIV RNA concentration was 5·5 log₁₀ copies per mL (IQR 5·0-5·8). 310 (68%) of 457 participants had bacteriologically-confirmed tuberculosis. In the intention-to-treat population, at week 48, 140 (61%) of 230 participants in the raltegravir group and 150 (66%) of 227 patients in the efavirenz had achieved virological suppression (between-group difference -5·2% [95% CI -14·0 to 3·6]), thus raltegravir did not meet the predefined criterion for non-inferiority. The most frequent adverse events were HIV-associated non-AIDS illnesses (eight [3%] of 229 patients in the raltegravir group; 21 [9%] of 230 patients in the efavirenz group) and AIDS-defining illnesses (ten [4%] patients in the raltegravir group; 13 [6%] patients in the efavirenz group). 58 (25%) of 229 patients in raltegravir group and 66 (29%) of 230 patients in the efavirenz group had grade 3 or 4 adverse events. 26 (6%) of 457 patients died during follow-up: 14 in the efavirenz group and 12 in the raltegravir group.

INTERPRETATION

In patients with HIV given tuberculosis treatment, non-inferiority of raltegravir compared with efavirenz was not shown. Raltegravir was well tolerated and could be considered as an option, but only in selected patients.

FUNDING

National French Agency for AIDS Research, Ministry of Health in Brazil, Merck.

TRANSLATIONS

For the Portuguese and French translations of the abstract see Supplementary Materials section.

Evaluation of the Ogawa-Kudoh method for tuberculosis isolation in two health units in Mozambique

Background

Mozambique is among the highest tuberculosis, tuberculosis–HIV and multidrug-resistant-tuberculosis burden countries. Although molecular technologies are available in-country, mycobacterial isolation through culture remains an important tool for tuberculosis diagnostics and drug susceptibility testing.

Objective

We evaluated the use of the Ogawa-Kudoh (OK) mycobacterial culture, a simple technique, to isolate Mycobacterium tuberculosis in two health units, in Maputo City, Mozambique.

Methods

From May to December 2014, 122 patient samples were collected in Chamanculo General Hospital and Polana Caniço General Hospital. The specimens were first tested in the health units using the OK method and afterwards shipped to the National Tuberculosis Reference Laboratory for mycobacterial culture using the NALC-NaOH-Citrate (NALC) decontamination method followed by inoculation in Lowenstein Jensen (LJ) solid media as the reference standard.

Results

Among 107 samples with valid results, 98 (91.6%) had concordant results in both methods; 9 (8.4%) had discordant results. The contamination rate was 4.1% (5/122) for the OK and 9.0% (11/122) for the NALC/LJ methods. The sensitivity of OK was 80% (95% confident interval [CI]: 51.4–94.7) and the specificity was 94% (95% CI: 85.8–97.3). The degree of agreement between both methods was moderate (Kappa: 0.68; 95% CI: 0.48–0.89).

Conclusion

The OK method showed satisfactory sensitivity and specificity. The method also had a lower contamination rate when compared to the NALC/LJ. Similar to other studies in resource-limited settings, our findings showed that the OK method can effectively be implemented in settings with limited laboratory capacity to isolate tuberculosis bacteria by culture for further testing.

Lung Function Testing and Prediction Equations in Adult Population from Maputo, Mozambique

Background: Local spirometric prediction equations are of great importance for interpreting lung function results and deciding on the management strategies for respiratory patients, yet available data from African countries are scarce. The aim of this study was to collect lung function data using spirometry in healthy adults living in Maputo, Mozambique and to derive first spirometric prediction equations for this population. Methods: We applied a cross-sectional study design. Participants, who met the inclusion criteria, underwent a short interview, anthropometric measurements, and lung function testing. Different modelling approaches were followed for generating new, Mozambican, prediction equations and for comparison with the Global Lung Initiative (GLI) and South African equations. The pulmonary function performance of participants was assessed against the different reference standards. Results: A total of 212 males and females were recruited, from whom 155 usable spirometry results were obtained. The mean age of participants was 35.20 years (SD 10.99) and 93 of 155 (59.35%) were females. The predicted values for forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1) and the FEV1/FVC ratio based on the Mozambican equations were lower than the South African—and the GLI-based predictions. Conclusions: This study provides first data on pulmonary function in healthy Mozambican adults and describes how they compare to GLI and South African reference values for spirometry.

Development of chronic lung impairment in Mozambican TB patients and associated risks

BACKGROUND

Pulmonary tuberculosis (PTB) is frequently associated with chronic respiratory impairment despite microbiological cure. There are only a few clinical research studies that describe the course, type and severity as well as associated risk factors for lung impairment (LI) in TB patients.

METHODS

A prospective cohort study was conducted at TB Research Clinic of Instituto Nacional de Saúde in Mavalane, Maputo, from June 2014 to June 2016. PTB patients were prospectively enrolled and followed for 52 weeks after TB diagnosis. Lung function was evaluated by spirometry at 8, 26 and 52 weeks after TB treatment initiation, and spirometric values of below the lower limit of normality were considered as LI. Descriptive statistical analysis was performed to summarize the proportion of patients with different lung outcomes at week 52, including type and severity of LI. Risk factors were analysed using multinomial regression analysis.

RESULTS

A total of 69 PTB patients were enrolled, of which 62 had a valid spirometry result at week 52 after TB treatment start. At week 8, 26 and 52, the proportion of patients with LI was 78, 68.9 and 64.5%, respectively, and 35.5% had moderate or severe LI at week 52. The majority of patients with LI suffered from pulmonary restriction. Female sex, low haemoglobin and heavy smoking were significantly associated with LI.

CONCLUSION

Moderate or severe LI can be observed in a third of cured TB patients. Further research is urgently needed to gain deeper insight into the characteristics of post TB LI, the causal pathways and potential treatment strategies.

Tuberculosis bacillary load, an early marker of disease severity: the utility of tuberculosis Molecular Bacterial Load Assay

In this comparative biomarker study, we analysed 1768 serial sputum samples from 178 patients at 4 sites in Southeast Africa. We show that tuberculosis Molecular Bacterial Load Assay (TB-MBLA) reduces time-to-TB-bacillary-load-result from days/weeks by culture to hours and detects early patient treatment response. By day 14 of treatment, 5% of patients had cleared bacillary load to zero, rising to 58% by 12th week of treatment. Fall in bacillary load correlated with mycobacterial growth indicator tube culture time-to-positivity (Spearmans r=−0.51, 95% CI (−0.56 to −0.46), p<0.0001). Patients with high pretreatment bacillary burdens (above the cohort bacillary load average of 5.5log₁₀eCFU/ml) were less likely to convert-to-negative by 8th week of treatment than those with a low burden (below cohort bacillary load average), p=0.0005, HR 3.1, 95% CI (1.6 to 5.6) irrespective of treatment regimen. TB-MBLA distinguished the bactericidal effect of regimens revealing the moxifloxacin—20 mg rifampicin regimen produced a shorter time to bacillary clearance compared with standard-of-care regimen, p=0.008, HR 2.9, 95% CI (1.3 to 6.7). Our data show that the TB-MBLA could inform clinical decision making in real-time and expedite drug TB clinical trials.

Nintedanib in patients with progressive fibrosing interstitial lung diseases-subgroup analyses by interstitial lung disease diagnosis in the INBUILD trial: a randomised, double-blind, placebo-controlled, parallel-group trial

BACKGROUND

The INBUILD trial investigated the efficacy and safety of nintedanib versus placebo in patients with progressive fibrosing interstitial lung diseases (ILDs) other than idiopathic pulmonary fibrosis (IPF). We aimed to establish the effects of nintedanib in subgroups based on ILD diagnosis.

METHODS

The INBUILD trial was a randomised, double-blind, placebo-controlled, parallel group trial done at 153 sites in 15 countries. Participants had an investigator-diagnosed fibrosing ILD other than IPF, with chest imaging features of fibrosis of more than 10% extent on high resolution CT (HRCT), forced vital capacity (FVC) of 45% or more predicted, and diffusing capacity of the lung for carbon monoxide (DLco) of at least 30% and less than 80% predicted. Participants fulfilled protocol-defined criteria for ILD progression in the 24 months before screening, despite management considered appropriate in clinical practice for the individual ILD. Participants were randomly assigned 1:1 by means of a pseudo-random number generator to receive nintedanib 150 mg twice daily or placebo for at least 52 weeks. Participants, investigators, and other personnel involved in the trial and analysis were masked to treatment assignment until after database lock. In this subgroup analysis, we assessed the rate of decline in FVC (mL/year) over 52 weeks in patients who received at least one dose of nintedanib or placebo in five prespecified subgroups based on the ILD diagnoses documented by the investigators: hypersensitivity pneumonitis, autoimmune ILDs, idiopathic non-specific interstitial pneumonia, unclassifiable idiopathic interstitial pneumonia, and other ILDs. The trial has been completed and is registered with ClinicalTrials.gov, number NCT02999178.

FINDINGS

Participants were recruited between Feb 23, 2017, and April 27, 2018. Of 663 participants who received at least one dose of nintedanib or placebo, 173 (26%) had chronic hypersensitivity pneumonitis, 170 (26%) an autoimmune ILD, 125 (19%) idiopathic non-specific interstitial pneumonia, 114 (17%) unclassifiable idiopathic interstitial pneumonia, and 81 (12%) other ILDs. The effect of nintedanib versus placebo on reducing the rate of FVC decline (mL/year) was consistent across the five subgroups by ILD diagnosis in the overall population (hypersensitivity pneumonitis 73·1 [95% CI -8·6 to 154·8]; autoimmune ILDs 104·0 [21·1 to 186·9]; idiopathic non-specific interstitial pneumonia 141·6 [46·0 to 237·2]; unclassifiable idiopathic interstitial pneumonia 68·3 [-31·4 to 168·1]; and other ILDs 197·1 [77·6 to 316·7]; p=0·41 for treatment by subgroup by time interaction). Adverse events reported in the subgroups were consistent with those reported in the overall population.

INTERPRETATION

The INBUILD trial was not designed or powered to provide evidence for a benefit of nintedanib in specific diagnostic subgroups. However, its results suggest that nintedanib reduces the rate of ILD progression, as measured by FVC decline, in patients who have a chronic fibrosing ILD and progressive phenotype, irrespective of the underlying ILD diagnosis.

FUNDING

Boehringer Ingelheim.

Compromise of Second-Line Antiretroviral Therapy Due to High Rates of Human Immunodeficiency Virus Drug Resistance in Mozambican Treatment-Experienced Children With Virologic Failure

BACKGROUND

Virologic failure (VF) is highly prevalent in sub-Saharan African children on antiretroviral therapy (ART) and is often associated with human immunodeficiency virus drug resistance (DR). Most children still lack access to routine viral load (VL) monitoring for early identification of treatment failure, with implications for the efficacy of second-line ART.

METHODS

Children aged 1 to 14 years on ART for ≥12 months at 6 public facilities in Maputo, Mozambique were consecutively enrolled after informed consent. Chart review and caregiver interviews were conducted. VL testing was performed, and specimens with ≥1000 copies/mL were genotyped.

RESULTS

Of the 715 children included, the mean age was 103 months, 85.8% had no immunosuppression, 73.1% were taking stavudine/lamivudine/nevirapine, and 20.1% had a history prevention of mother-to-child transmission exposure. The mean time on ART was 60.0 months. VF was present in 259 patients (36.3%); 248 (95.8%) specimens were genotyped, and DR mutations were found in 238 (96.0%). Severe immunosuppression and nutritional decline were associated with DR. M184V and Y181C were the most common mutations. In the 238 patients with DR, standard second-line ART would have 0, 1, 2, and 3 effective antiretrovirals in 1 (0.4%), 74 (31.1%), 150 (63.0%), and 13 (5.5%) patients, respectively.

CONCLUSION

This cohort had high rates of VF and DR with frequent compromise of second-line ART. There is urgent need to scale-up VL monitoring and heat-stable protease inhibitor formulations or integrase inhibitorsfor a more a durable first-line regimen that can feasibly be implemented in developing settings.

Methicillin-Resistant Staphylococcus Aureus Nasal Carriers among Laboratory Technical Staff of Tertiary Hospital in Eastern Nepal

Background Methicillin-resistant Staphylococcus aureus (MRSA) has been the leading cause of nosocomial and community infections worldwide. In particular, healthcare workers are at constant risk to develop MRSA carriage. There is a paucity of data regarding the epidemiology of MRSA in laboratory workers who are constantly in contact with these pathogens in almost every hospital. Objective This study was undertaken to identify the burden of MRSA nasal carriers and the antibiotic susceptibility pattern of the isolates among laboratory technical staff. Method Sterile nasal swabs were taken from 50 laboratory technical staff working in the Central and Emergency laboratory of BP Koirala Institute of Health Sciences (BPKIHS). Standard procedures were followed for isolation, identification and antibiotic sensitivity testing. Antibiotic susceptibility tests were performed using disc diffusion and growth on Oxacillin screen agar based on Clinical and Laboratory Standards Institute (CLSI) guidelines. Result Out of 50 isolates of Staphylococcus aureus, 44 (88%) were Methicillin-sensitive (MSSA) while six (12%) were Methicillin-resistant (MRSA). All 50 isolates of S. aureus were found resistant to Penicillin while all were found sensitive to Teicoplanin, Linezolid, and Levofloxacin. Only five (10%) were sensitive to Erythromycin while 49 (98%) were sensitive to both Amikacin and Gentamicin. However, none of the MRSA isolates were found sensitive to all tested antimicrobial agents. Conclusion This repertoire portrays the emergence of MRSA in laboratory workers which clearly indicates the necessity of complying with the sanitary and antibacterial guidelines and adhering to the rational use of antibiotics to prevent nosocomial infections.

Self-reported non-receipt of HIV test results: A silent barrier to HIV epidemic control in Mozambique

Introduction

People living with HIV (PLHIV) and who are aware of their HIV status can access and benefit from antiretroviral therapy (ART) with subsequent individual and public health benefits; however, many PLHIV are unaware of their HIV status. We assessed the magnitude and determinants of self-reported non-receipt of HIV test results in adults aged 15–59 years old in Mozambique.

Methods

We performed a secondary analysis of data from the 2015 Mozambique Immunization indicators, Malaria and HIV/AIDS (IMASIDA 2015). Eligible adults (15–59 years) from each selected household were interviewed and data on sociodemographic characteristics, HIV knowledge, attitudes and behaviors, and HIV testing history were collected. Multivariable logistic regression assessed factors associated with self-reported non-receipt of HIV test results. Population representative estimates were calculated.

Results

13,028 (90.8%) of 14,343 eligible participants were interviewed. A total of 6,654 (51.1%) respondents had previously been tested for HIV and were included in the analysis. Of these, 308 (4.6%; 95% CI: 3.70–5.77) self-reported not having received HIV test results. In the multivariable analysis, previous sexually transmitted infection (aOR: 2.76; 95% CI: 1.44–5.31), HIV stigmatizing attitudes (aOR: 1.96; 95% CI: 1.14–3.37), and lack of decision-making power towards health care seeking (aOR: 2.51; 95% CI: 1.39–4.52) were associated with non-receipt of HIV test results. Whereas, secondary or higher education (aOR: 0.25; 95% CI: 0.12–0.54), higher HIV knowledge (aOR: 0.47; 95% CI: 0.26–0.86), and age between 30–34 and 35–39 years old (aOR 0.47; 95% CI: 0.28–0.80; and aOR: 0.49; 95% CI: 0.27–0.90, respectively), were associated with receipt of HIV test results.

Conclusions

In this nationally representative survey, self-reported non-receipt of HIV test results was high and of public health relevance. These findings suggest adaptation of HIV counseling and testing programs emphasizing individualized approaches that target the youngest, least educated and the poorest individuals, especially those living in rural areas.

HIV prevalence and risk behavior among male and female adults screened for enrolment into a vaccine preparedness study in Maputo, Mozambique

INTRODUCTION

Mozambique continues to have a significant burden of HIV. Developing strategies to control the HIV epidemic remains a key priority for the Mozambican public health community. The primary aim of this study was to determine HIV prevalence and risk behavior among males and females screened for a HIV vaccine preparedness study in Maputo, Mozambique.

METHODS

Male and female participants between 18-35 years old were recruited from the general community and from female sex worker (FSW) and lesbian, gay, bisexual, and transgender (LGBT) associations in Maputo. All participants were screened for HIV and a questionnaire was administered to each participant to assess HIV risk behavior.

RESULTS

A total of 1125 adults were screened for HIV infection, among whom 506 (45%) were male. Among men, 5.7% reported having had sex with men (MSM) and 12% of female participants reported having exchanged sex for money, goods or favors in the past 3 months. The overall HIV prevalence was 10.4%; 10.7% of women, and 10.1% of men were HIV infected; 41.4% of MSM were seropositive. HIV infection was associated with older age (25-35 years old) (OR: 6.13, 95% CI: 3.01, 12.5), MSM (OR: 9.07, 95% CI: 3.85, 21.4), self-perception of being at high-risk for HIV (OR: 3.99, 95% CI: 1.27, 12.5) and self-report of a history of a diagnosis of sexually transmitted infection (OR: 3.75, 95% CI: 1.57, 8.98).

CONCLUSION

In our cohort, HIV prevalence was much higher among MSM compared to the overall prevalence. Behavioral factors were found to be more associated with HIV prevalence than demographic factors. The study findings demonstrate the critical importance of directing services to minority communities, such as MSM, when prevention strategies are being devised for the general population.

OC 8561 RAPAED TB: AN INNOVATIVE CHILD TB DIAGNOSTIC VALIDATION STUDY

Background

Children account for an estimated 1 million new cases of TB every year, representing roughly 7% of the total disease burden. Every year, around 2 09 000 children die from TB, half of those cases are in Africa. The main issue continues to be timely and accurate diagnosis, as treatment outcomes – even in the case of drug resistance – are significantly better than in adults.

Clinical diagnosis in the absence of laboratory confirmation is hampered by non-specificity of symptoms. Diagnostics validation studies in children are difficult – in most studies, very few of the symptomatic children achieved microbiological disease confirmation, resulting in imprecise estimates for test sensitivity.

Design/methods

With the RaPaed TB study funded by EDCTP, we are preparing an improved diagnostic validation study design to improve on the traditional approach of a single-gate, double diagnostic study in the target population. The project will evaluate multiple new tests on the same patients, to determine algorithms of screening and confirmatory tests. Most novel tests in this study use non-sputum samples and are therefore more suitable for children.

Allocation of patients to standardised groups will follow the recommendations of the NIH-convened consensus panel on case definitions of paediatric TB diagnostic studies. Using an endpoint review committee will allow blinded review of those new-positive cases, plus matched controls, and determine their likelihood of disease based on clinical data including follow-up, and X-ray. This will improve the quality of evaluation of false positive vs. true positive results of new tests and therefore improve the assessment of specificity.

To improve on sensitivity assessment, the study includes partners with a high number of confirmed cases in past studies and plans to draw in cases of confirmed disease from other diagnostic facilities.

Conclusion

This improved methodology will lead to more meaningful and applicable results of diagnostic validation studies.

Hepatocellular carcinoma: Clinical-pathological features and HIV infection in Mozambican patients<sup/>

BACKGROUND AND AIMS

Mozambique had been ranked among the countries with the highest global incidence of HCC with chronic hepatitis B infection and high exposure to aflatoxin-B1 (AFB1) being major risk factors. Indeed, HCC remains one of the most frequent cancer in Maputo. On the other hand, Mozambique has a high prevalence of infection with Human Immunodeficiency virus (HIV). Our study aims to describe the epidemiology, clinicopathological and serological features of patients with HCC in Maputo Central Hospital and its relationship with HIV.

METHODS

A series of 206 patients, diagnosed with HCC via fine needle aspiration, were consecutively included in the study. Patient data was collected using a questionnaire and all patients were tested for HBV, HCV, HIV.

RESULTS

Median age was 49 years old and the M: F sex ratio was 2.4. A total of 114 (56.2%) of the patients were HBsAg positive. Hepatitis C antibodies were present in 8.9% of cases, and co-infection with HBV and HCV (HBsAg/anti-HCV) was observed in 4 (2.0%) cases. The remainder, 36.3%, were neither hepatitis B- nor C-related. HIV was detected in 34 cases (18.0%) cases. HIV-HBV or HIV-HCV co-infections were observed in 22 (68.8%) and 2 (6.2%) cases. Overall, positivity for HIV was associated with younger age, and especially in patients with HBsAg+/anti-HCV+.

CONCLUSIONS

Our data emphasize the need for a reinforcement of secondary prevention measures in Mozambique. Serological screening for HBV in people born before universal anti-hepatitis B immunization (2001), effective screening, and specific management in HIV(+) patients are urgently needed.

TB sequel: incidence, pathogenesis and risk factors of long-term medical and social sequelae of pulmonary TB - a study protocol

Background

Up to fifty percent of microbiologically cured tuberculosis (TB) patients may be left with permanent, moderate or severe pulmonary function impairment. Very few studies have systematically examined pulmonary outcomes in patients to understand the pathophysiologic basis and long-term socio-economic consequences of this injury. The planned multi-country, multi-centre observational TB cohort study, aims to advance the understanding of the clinical, microbiological, immunological and socio-economic risk factors affecting long-term outcome of pulmonary TB. It will also determine the occurrence of reversible and irreversible socio-economic consequences to patients, their households and the health sector related to pulmonary TB disease and its treatment.

Methods

We will enrol up to 1.600 patients with drug sensitive and multidrug-resistant pulmonary TB who are treated according to the local standard of care by the respective National TB Program. Recruitment is taking place at the time of TB diagnosis at four African study clinics located in The Gambia, Mozambique, South Africa and Tanzania. The primary outcome is the proportion of TB patients with severe lung impairment measured by spirometry at 24 months after TB treatment initiation. Biological samples, including sputum, urine and blood, for studying host- and pathogenic risk factors will be collected longitudinally and examined in a nested case-control fashion. A standardized quality of life questionnaire will be used together with a novel version of WHO’s generic patient cost instrument which has been adapted for the longitudinal study design.

Discussion

This study is an integral part of an overall strategy to fill a knowledge gap needed to improve TB treatment outcomes globally. The main scientific goal is to identify the major pathogenic mechanisms associated with poor TB treatment outcomes, so that such pathways can be interrupted to avert long term TB sequelae. National as well as supra-national stakeholders and decision makers have been integrated early in the study planning process to inform future treatment guidelines and national health policies.

Trial registration

ClinicalTrials.gov: NCT03251196, August 16, 2017.

Electronic supplementary material

The online version of this article (10.1186/s12890-018-0777-3) contains supplementary material, which is available to authorized users.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Regulatory T cell abundance and activation status before and after priming with HIVIS-DNA and boosting with MVA-HIV/rgp140/GLA-AF may impact the magnitude of the vaccine-induced immune responses

BACKGROUND

Little is known about regulatory CD4 T cells (Tregs) in the context of HIV vaccines. Tregs can be differentiated into resting (FoxP3⁺CD45RA⁺ - rTregs), activated (FoxP3^HighCD45RA^- - aTregs) and memory (FoxP3^LowCD45RA^- - mTregs). Tregs, as CD4 T cells, are also frequent targets for HIV infection. We studied how the abundance and phenotypes of Tregs in terms of activation status and expression of HIV-1 binding molecules would have changed during vaccination in healthy volunteers participating in a phase IIa HIV vaccine clinical trial. Subjects were primed three times with HIVIS-DNA and boosted twice with MVA-CMDR-HIV alone (n = 12) or MVA-CMDR combined with protein CN54rgp140 (n = 13). The proportions of β7 integrin in all CD4 T cells and in the Tregs subset decreased moderately after the final vaccination (p = 0.001 and p = 0.033, respectively) and the rTregs proportion within the total Tregs were also decreased after the final vaccination (p = 0.038). All these proportions returned to normal values within the three months after the final vaccination. The magnitude of HIV-Envelope-specific IFNγ + T cells after vaccination (r = 0.66; p = 0.021) correlated directly with the proportion of Tregs, and correlated inversely correlated with ratios of Th17/Tregs (r = -0.75; p = 0.0057) and Th17/mTregs (r = -0.78; p = 0.0065). Higher titers of IgG gp140 antibodies were observed in subjects with higher mTregs proportions (r = 0.52; p = 0.022). Interestingly, pre-vaccination levels of mTregs correlated with vaccine-induced Env-binding antibodies (r = 0.57; p = 0.01) and presence of neutralizing antibodies (r = 0.61; p = 0.01), while the pre-vaccination Th17/mTregs ratio correlated inversely with the magnitude of cellular IFN-γ ELISpot responses (r = -0.9; p = 0.002). Taken together, these results suggest that pre- and post-vaccination Tregs, their activation status, the Th17/Tregs ratio and other host factors affecting Treg abundance, have an impact on the magnitude of HIV vaccine-induced immune responses. Moreover, the DNA-HIVIS/MVA-HIV regimen, alone or in combination with CN54rgp140 induced moderate and temporary alterations of the Tregs activation status. We also show a decrease in expression of the HIV-1 ligand β7 integrin on Tregs and all CD4 T cells.

Pleuroparenchymal sarcoidosis - A recognised but rare manifestation of disease

Pleural involvement is rare in sarcoidosis. The presence of a large symptomatic effusion in a patient with sarcoidosis should therefore prompt further investigation for an alternate aetiology. Here we present a case of confirmed pleuro-parenchymal sarcoidosis. We discuss the important differential diagnoses and review the current literature.

Optimising molecular diagnostic capacity for effective control of tuberculosis in high-burden settings

The World Health Organization's 2035 vision is to reduce tuberculosis (TB) associated mortality by 95%. While low-burden, well-equipped industrialised economies can expect to see this goal achieved, it is challenging in the low- and middle-income countries that bear the highest burden of TB. Inadequate diagnosis leads to inappropriate treatment and poor clinical outcomes. The roll-out of the Xpert(®) MTB/RIF assay has demonstrated that molecular diagnostics can produce rapid diagnosis and treatment initiation. Strong molecular services are still limited to regional or national centres. The delay in implementation is due partly to resources, and partly to the suggestion that such techniques are too challenging for widespread implementation. We have successfully implemented a molecular tool for rapid monitoring of patient treatment response to anti-tuberculosis treatment in three high TB burden countries in Africa. We discuss here the challenges facing TB diagnosis and treatment monitoring, and draw from our experience in establishing molecular treatment monitoring platforms to provide practical insights into successful optimisation of molecular diagnostic capacity in resource-constrained, high TB burden settings. We recommend a holistic health system-wide approach for molecular diagnostic capacity development, addressing human resource training, institutional capacity development, streamlined procurement systems, and engagement with the public, policy makers and implementers of TB control programmes.

Helios + Regulatory T cell frequencies are correlated with control of viral replication and recovery of absolute CD4 T cells counts in early HIV-1 infection

BACKGROUND

The acute phase of HIV infection is characterized by massive depletion of CD4 T cells, high viral plasma levels and pronounced systemic immune activation. Regulatory T cells (Tregs) have the potential to control systemic immune activation but also to suppress antigen specific T and B cell response. The co-expression of FoxP3 and Helios transcription factors, has been described for identification of highly suppressive Tregs. The aim of this study was to characterize the phenotype of classic Tregs during early HIV infection, and to assess the correlations between the frequencies and phenotype of Tregs with the plasma viral load, CD4 counts, immune activation and the frequency of antibodies reactive to HIV-1 proteins, measured by an immunochromatographic test.

RESULTS

The relative frequency of classic Tregs cells in peripheral blood correlated positively with HIV viral load and immune activation of CD8 T cells, and inversely with absolute CD4 counts and development of anti-HIV antibodies in subjects with early HIV infection. However, the expression of Helios in classic Tregs was inversely correlated with viral replication and immune activation, and positively with recovery of CD4 T cell counts and appearance of antibodies reactive to HIV-1 proteins.

CONCLUSION

These results raise the hypothesis that classic Tregs are inefficient at controlling systemic immune activation in subjects with early HIV infection and may be associated with delayed production of antibodies against HIV proteins, delaying the control of viral replication. Conversely, Helios expressing Tregs might contribute to control of viral replication by mechanisms involving the limitation of systemic immune activation.

Seroepidemiology of leptospirosis among febrile patients in a rapidly growing suburban slum and a flood-vulnerable rural district in Mozambique, 2012-2014: Implications for the management of fever

OBJECTIVE

Leptospirosis is one of the most widespread zoonoses in the world and is caused by spirochetes of the genus Leptospira. In Mozambique, the disease is largely ignored and its epidemiology is unknown. The objective of this study was to investigate the occurrence of leptospirosis in febrile patients.

METHODS

This cross-sectional study was performed between July 2012 and September 2015 among febrile patients. A total of 373 paired serum samples were drawn from febrile patients; 208 were from Caia District Hospital (rural setting) in Sofala Province and 165 were from Polana Caniço General Hospital (suburban setting) in Maputo City. Samples were initially screened using an in-house ELISA for IgM and IgG antibodies. Double positive samples were confirmed using a microagglutination test (MAT).

RESULTS

Of the 373 febrile patients, five (1.3%) had acute leptospirosis (MAT ≥400) and 38 (10.2%) had a presumptive infection (IgM-positive/MAT <400). While most of the patients with a presumptive infection lived in the rural setting (84.2%, 32/38), the majority of patients with acute infections (60%, 3/5) and with negative results (60.3%, 199/330) lived in the suburban setting (p=0.000). Contact with rodents was significantly higher in patient with acute leptospirosis (100%, 5/5) than in those with a presumptive infection (39.5%, 15/38) or negative results (41.8%, 138/330) (p=0.031). Four out of the five patients (80%) with acute leptospirosis were treated with antimalarial drugs although malaria results were negative. The prevailing serogroup, according to MAT results, was Australis (40%; 4/10), followed by Icterohaemorrhagiae (30%, 3/10).

CONCLUSIONS

This study found that leptospirosis is prevalent among Mozambicans, and most cases are misdiagnosed as malaria.

HBV infection in untreated HIV-infected adults in Maputo, Mozambique

Background

HIV/ HBV coinfected patients are at high risk of developing chronic HBV infection, liver cirrhosis and hepatocellular carcinoma. In Mozambique, where HIV prevalence is one of the highest in the world, HIV-infected patients are scarcely characterized in terms of HBV coinfection and 3TC-resistance mutations profile.

Methods

To characterize ART-naïve HIV-infected adults, with and without HBV coinfection, a cross-sectional study was conducted between May and November 2012 in two health centers from Maputo city, Mozambique. Subjects were consecutively enrolled in the study and, then, tested for hepatitis B surface antigen (HBsAg). Moreover, CD4⁺ T cells count, HBV DNA in plasma, HBV genotyping and 3TC-resistance mutations profile of HBV were assessed in HIV/HBV coinfected patients.

Results

In total, 518 patients were enrolled in the study. The median age was 33 years old and 66.8% were women. The median CD4⁺ T cells count was 361 cells/mm³ and 47 (9.1%) were coinfected with HBV. Out of 46 coinfected patients, 24 (55.2%) had HBV DNA ≥ 20 - < 20 000 and 12 (26.1%) had HBV-DNA ≥20 000. APRI > 2.0 was reported in 4.3% of coinfected and 1.7% of monoinfected patients (p = 0.228), while FIB-4 > 3.25 was reported in 4.4% of coinfected and 1.3% of monoinfected patients (p = 0.112). Genotype A was the most frequent, identified in 25/27 (92.6%) patients, whereas genotype E was present in 2/27 (7.4%) patients. No patient had 3TC-resistance mutations.

Conclusions

This study showed that HBV coinfection was prevalent among ART-naïve HIV-infected adults in Mozambique. Overall, these data highlight the importance of screening HBV coinfection as an integrated measure of HIV routine care to improve health conditions and treatment of HIV/HBV coinfected patients.

Performance characteristics of finger-stick dried blood spots (DBS) on the determination of human immunodeficiency virus (HIV) treatment failure in a pediatric population in Mozambique

Quantitative plasma viral load (VL) at 1000 copies /mL was recommended as the threshold to confirm antiretroviral therapy (ART) failure by the World Health Organization (WHO). Because of ongoing challenges of using plasma for VL testing in resource-limited settings (RLS), especially for children, this study collected 717 DBS and paired plasma samples from children receiving ART ≥1 year in Mozambique and compared the performance of DBS using Abbott’s VL test with a paired plasma sample using Roche’s VL test. At a cut-off of 1000 copies/mL, sensitivity of DBS using Abbott DBS VL test was 79.9%, better than 71.0% and 63.9% at 3000 and 5000 copies/mL, respectively. Specificities were 97.6%, 98.8%, 99.3% at 1000, 3000, and 5000 copies/mL, respectively. The Kappa value at 1000 copies/mL, 0.80 (95% CI: 0.73, 0.87), was higher than 0.73 (95% CI: 0.66, 0.80) and 0.66 (95% CI: 0.59, 0.73) at 3000, 5000 copies/mL, respectively, also indicating better agreement. The mean difference between the DBS and plasma VL tests with 95% limits of agreement by Bland-Altman was 0.311 (-0.908, 1.530). Among 73 children with plasma VL between 1000 to 5000 copies/mL, the DBS results were undetectable in 53 at the 1000 copies/mL threshold. While one DBS sample in the Abbott DBS VL test may be an alternative method to confirm ART failure at 1000 copies/mL threshold when a plasma sample is not an option for treatment monitoring, because of sensitivity concerns between 1,000 and 5,000 copies/ml, two DBS samples may be preferred accompanied by careful patient monitoring and repeat testing.

First description of HTLV-1/2 seroprevalence in HIV-infected inmates in Mozambique

No study has yet been conducted to estimate the burden of co-infection of HIV and HTLV-1/2 in inmates in sub-Saharan Africa. To investigate prevalence of co-infection in inmates in Mozambique, a total of 2140 inmates were screened for HIV, of which 515 were HIV seropositive. All HIV seropositive inmates were further screened for HTLV infection, and eight (1.55%) were co-infected. Co-infection was higher in females (3.45% [2/58; CI: 0.42-11.91]) as compared to males (1.35% [6/445; CI: 0.55-3.06]). Early screening of HTLV in prisons is urgently needed in Mozambique in order to improve the care provided to incarcerated individuals, including initiation of ART.

An unusual mediastinal mass

We report a case of a mediastinal mass indenting the left lateral tracheal wall of a 35-year-old male who presented with weight loss, cough and breathlessness. Flow volume loop and thyroid function tests were normal and thyroid peroxidase antibodies were negative. Technetium scintigraphy and positron emission tomography both showed no uptake. Endobronchial ultrasound-guided fine needle aspiration confirmed ectopic mediastinal thyroid tissue. Mediastinal ectopic thyroid tissue is very rare. Most patients are asymptomatic and euthyroid with positive signals on scintigraphy. False negative technetium scintigraphy can occur in areas of necrosis, carcinoma and from substernal tissue. Ectopic thyroid tissue is a rare but important differential diagnosis when investigating mediastinal lesions and should be considered even if scintigraphy is negative in the right clinical context. Endobronchial ultrasound-guided fine needle aspiration can be used when scintigraphy is not diagnostic.