Facteurs associés à la létalité chez les patients hospitalisés pour le VIH avancé

CONTEXT

A unit supported by Médecins Sans Frontières (MSF) cares for patients with advanced HIV at Donka National Hospital, Conakry, Guinea.

OBJECTIVE

To determine the factors associated with the occurrence of death in patients hospitalised in the unit between 2017 and 2021.

DESIGN

This was a retrospective analysis of routine data from patients hospitalised with advanced HIV.

RESULTS

A total of 3,718 patients were included, with a median age of 40 years (IQR 33-51), of whom 2,241 (60.3%) were women. The mean mortality rate was 33.6% (n = 1,240), down from 40% in 2017 to 29% in 2021, but this was not statistically significant. The period most at risk of death was the first 25 days of hospitalisation. Among these patients, TB (43.8%) and toxoplasmosis (11.4%) were the most frequent diagnoses. After multivariate analysis using Cox regression, the factors associated with death were age 25-49 years (adjusted hazard ratio [aHR] 1.60; P = 0.002) or ≥50 years (aHR 1.80; P < 0.001), the presence of respiratory (aHR 1.23; P = 0.001) or abdominal symptoms (aHR 1.26; P < 0.001) and readmission (aHR 0.54; P < 0.001).

CONCLUSION

Patients aged 25-49 years or older, or those presenting with respiratory or abdominal signs require increased surveillance, as they are at the greatest risk of dying from the disease, especially during the first 25 days of hospitalisation.

Clinical standards for drug-susceptible TB in children and adolescents

BACKGROUND: These clinical standards aim to provide guidance for diagnosis, treatment, and management of drug-susceptible TB in children and adolescents.METHODS: Fifty-two global experts in paediatric TB participated in a Delphi consensus process. After eight rounds of revisions, 51/52 (98%) participants endorsed the final document.RESULTS: Eight standards were identified: Standard 1, Age and developmental stage are critical considerations in the assessment and management of TB; Standard 2, Children and adolescents with symptoms and signs of TB disease should undergo prompt evaluation, and diagnosis and treatment initiation should not depend on microbiological confirmation; Standard 3, Treatment initiation is particularly urgent in children and adolescents with presumptive TB meningitis and disseminated (miliary) TB; Standard 4, Children and adolescents should be treated with an appropriate weight-based regimen; Standard 5, Treating TB infection (TBI) is important to prevent disease; Standard 6, Children and adolescents should receive home-based/community-based treatment support whenever possible; Standard 7, Children, adolescents, and their families should be provided age-appropriate support to optimise engagement in care and clinical outcomes; and Standard 8, Case reporting and contact tracing should be conducted for each child and adolescent.CONCLUSION: These consensus-based clinical standards, which should be adapted to local contexts, will improve the care of children and adolescents affected by TB.

Clinical utility of target-based next-generation sequencing for drug-resistant TB

BACKGROUND: In high TB burden countries, access to drug susceptibility testing is a major bottleneck. Targeted next-generation sequencing (tNGS) is a promising technology for rapid resistance detection. This study assessed the role of tNGS for the diagnosis of drug-resistant TB (DR-TB).METHODS: A total of 161 samples from bacteriologically confirmed TB cases were subjected to tNGS using the Deeplex^® Myc-TB kit and sequenced using the MiSeq platform. These samples were also processed for conventional phenotypic DST (pDST) using 13 drugs on Mycobacteria Growth Indicator Tube and line-probe assays (MTBDRplus and MTBDRsl).RESULTS: There were 146 DR-TB and 15 drug-susceptible TB (DS-TB) samples. About 70% of patients with DR-TB had no previous TB treatment history. Overall, 88.2% had rifampicin-resistant/multidrug-resistant TB (RR/MDR-TB), 58.5% pre-extensively drug-resistant TB (pre-XDR-TB) and 9.2% had XDR-TB as defined by the WHO (2020). Around 8% (n = 13) of samples were non-culturable; however, identified 8 were resistant to first and second-line drugs using tNGS. Resistance frequency was similar across methods, with discordance in drugs less reliable using pDST or with limited mutational representation within databases. Sensitivities were aligned with literature reports for most drugs. We observed 10% heteroresistance, while 75% of strains were of Lineages 2 and 3.CONCLUSIONS: Programme data supported tNGS in the diagnosis of DR-TB for early treatment using individualised regimens.

TB screening, prevention and treatment cascade in a Malawi prison

BACKGROUND Incarcerated individuals, especially in high HIV and TB burden settings, are at increased risk of latent TB infection and/or TB disease. We implemented a comprehensive HIV-TB intervention in a Malawi prison and studied its feasibility.METHODS Between February and December 2019, consenting individuals underwent screening for HIV, TB infection and TB disease. HIV-positive individuals without TB disease were treated with a fixed-dose combination of isoniazid, cotrimoxazole and vitamin B6 (INH-CTX-B6). HIV-negative persons with TB infection received 12 weeks of isoniazid and rifapentine (3HP).RESULTS Of 1,546 consenting individuals, 1,498 (96.9%) were screened and 1,427 (92.3%) included in the analysis: 96.4% were male, the median age was 31 years (IQR 25-38). Twenty-nine (2.1%) participants were diagnosed with TB disease, of whom 89.7% started and 61.5% completed TB treatment. Of the 1,427 included, 341 (23.9%) were HIV-positive, of whom 98.5% on antiretroviral therapy and 95% were started on INH-CTX-B6. Among 1,086 HIV-negative participants, 1,015 (93.5%) underwent the tuberculin skin test (TST), 670 (65.9%) were TST-positive, 666 (99.4%) started 3HP and 570 (85.5%) completed 3HP treatment.CONCLUSION A comprehensive TB screening and treatment package among incarcerated individuals was acceptable and feasible, and showed high prevalence of HIV, TB disease and TB infection. Treatment uptake was excellent, but treatment completion needs to be improved. Greater investment in comprehensive HIV-TB services, including access to shorter TB regimens and follow-up upon release, is needed for incarcerated individuals.

New TB drugs for the treatment of children and adolescents with rifampicin-resistant TB in Mumbai, India

SETTING: Médecins Sans Frontières (MSF) clinic in Mumbai, India.OBJECTIVE: To determine the final treatment outcomes, culture conversion and adverse events (AEs) during treatment among children and adolescents (0-19 years) with rifampicin-resistant tuberculosis (RR-TB) who received ambulatory injectable-free treatment, including bedaquiline (BDQ) and/or delamanid (DLM) during September 2014-January 2020.DESIGN: This was a retrospective cohort study based on review of routinely collected programme data.RESULTS: Twenty-four patients were included; the median age was 15.5 years (min-max 3-19) and 15 (63%) were females. None were HIV-coinfected. All had fluoroquinolone resistance. Twelve received treatment, including BDQ and DLM, 11 received DLM and one BDQ. The median exposure to BDQ (n = 13) and DLM (n = 23) was 82 (IQR 80-93) and 82 (IQR 77-96) weeks, respectively. Seventeen (94%) patients with positive culture at baseline (n = 18) had negative culture during treatment; median time for culture-conversion was 7 weeks (IQR 5-11). Twenty-three (96%) had successful treatment outcomes: cured (n = 16) or completed treatment (n = 7); one died. Eleven (46%) had 17 episodes of AEs. Two of 12 serious AEs were associated with new drugs (QTcF >500 ms).CONCLUSION: Based on one of the largest global cohorts of children and adolescents to receive new TB drugs, this study has shown that injectable-free regimens containing BDQ and/or DLM on ambulatory basis were effective and well-tolerated among children and adolescents and should be made routinely accessible to these vulnerable groups.

Impact of the implementation of new guidelines on the management of patients with HIV infection at an advanced HIV clinic in Kinshasa, Democratic Republic of Congo (DRC)

BACKGROUND

HIV continues to be the main determinant morbidity with high mortality rates in Sub-Saharan Africa, with a high number of patients being late presenters with advanced HIV. Clinical management of advanced HIV patients is thus complex and requires strict adherence to updated, empirical and simplified guidelines. The current study investigated the impact of the implementation of a new clinical guideline on the management of advanced HIV in Kinshasa, Democratic Republic of Congo (DRC).

METHODS

A retrospective analysis of routine clinical data of advanced HIV patients was conducted for the periods; February 2016 to March 2017, before implementation of new guidelines, and November 2017 to July 2018, after the implementation of new guidelines. Eligible patients were patients with CD4 < 200 cell/μl and presenting with at least 1 of 4 opportunistic infections. Patient files were reviewed by a medical doctor and a committee of 3 other doctors for congruence. Statistical significance was set at 0.05%.

RESULTS

Two hundred four and Two hundred thirty-one patients were eligible for inclusion before and after the implementation of new guidelines respectively. Sex and age distributions were similar for both periods, and median CD4 were 36 & 52 cell/μl, before and after the new guidelines implementation, respectively. 40.7% of patients had at least 1 missed/incorrect diagnosis before the new guidelines compared to 30% after new guidelines, p < 0.05. Clinical diagnosis for TB and toxoplasmosis were also much improved after the implementation of new guidelines. In addition, only 63% of patients had CD4 count test results before the new guidelines compared to 99% of patients after new guidelines. Death odds after the implementation of new guidelines were significantly lower than before new guidelines in a multivariate regression model that included patients CD4 count and 10 other covariates, p < 0.05.

CONCLUSIONS

Simplification and implementation of a new and improved HIV clinical guideline coupled with the installation of laboratory equipment and point of care tests potentially helped reduce incorrect diagnosis and improve clinical outcomes of patients with advanced HIV. Regulating authorities should consider developing simplified versions of guidelines followed by the provision of basic diagnostic equipment to health centers.

Preparedness of outpatient health facilities for ambulatory treatment with all–oral short DR–TB treatment regimens in Zhytomyr, Ukraine: a cross–sectional study

Introduction

Ukraine has a high burden of drug-resistant tuberculosis (DR-TB). Mental health problems, including alcohol use disorder (AUD), are common comorbidities. As part of health reform, the country is moving from inpatient-care to ambulatory primary care for tuberculosis (TB). This study describes the preparedness of ambulatory care facilities in Zhytomyr oblast, Ukraine.

Methods

This is a cross-sectional study in which routine program data was collected during June 2018 and February 2020. Before discharge of every patient from the hospital, MSF teams assess outpatient facilities available using a standardized checklist. The assessment evaluates access, human-resources, availability of medicines, infection control, laboratory and diagnostic services, and psychosocial support.

Results

We visited 90 outpatient facilities in 23 districts and 1 city between June 2018 and February 2020. Forty health posts, 27 TB-units, 23 ambulatories including two family doctors and one polyclinic were included. All facilities provided DOT, but only nine (10%) provided weekend-services. All facilities had at least one medical staff member, but TB-training was insufficient and limited to TB-doctors. TB-medicines and storage space were available in all facilities, but only twenty two (24%) stored ancillary medicines. HIV-patients had to visit a separate facility to access HIV-care. Personal protective equipment for infection control was unavailable in 41 (46%) facilities. Basic laboratory services were available in TB-units, but only 3 (11%) performed audiometry. Only twenty (22%) TB-units had psychosocial support available, and 1 (4%) psychiatric support.

Conclusions

Outpatient facilities in Zhytomyr oblast are not yet fully prepared to provide comprehensive care for DR-TB patients. Integration of psychosocial services, treatment of co-morbidities and adverse events at the same facility are essential to establish high quality, patient-centered care.

Adverse events among people on delamanid for rifampicin-resistant tuberculosis in a high HIV prevalence setting

SETTING: Patients with rifampicin-resistant tuberculosis (RR-TB) in the township of Khayelitsha, South Africa, were offered delamanid (DLM) within a decentralised RR-TB treatment programme.OBJECTIVE: To describe adverse events (AEs) among HIV-positive and negative people receiving DLM for RR-TB in a programmatic setting.DESIGN: Patients were followed up monthly for blood, electrocardiography and clinical monitoring and AEs were assessed for severity grade, seriousness and relationship to DLM.RESULTS: Fifty-eight patients (55% male; median age 35 years, interquartile range [IQR] 28-42) started DLM; 46 (79%) were HIV-positive, median CD4 count 173 cells/mm³ (IQR 70-294). Fifty (86%) patients experienced ≥1 new or worsening AE after starting DLM, most commonly vomiting, QTcB >450 ms and/or myalgia. Serious and/or severe AEs were experienced by 22 (38%) patients; three HIV-positive patients died (not related to DLM). HIV status was not significantly associated with number (P = 0.089) or severity/seriousness (P = 0.11) of AEs during exposure to DLM. Two (3%) patients had DLM withdrawn due to AEs.CONCLUSION: AEs during RR-TB treatment, both before and during DLM exposure, were common, with relatively few serious/severe AEs considered related to DLM and no significant association with HIV status. Clinical and electrocardiography monitoring should be prioritised in the first two months after starting DLM.

Scaling up HIV viral load monitoring in Manicaland, Zimbabwe: challenges and opportunities from the field

Background

Demand for viral load (VL) monitoring is expected to increase; however, implementation of the multifaceted VL testing poses numerous challenges. We report experiences from Médecins Sans Frontiéres (MSF) and partners in the scale-up of HIV VL in collaboration with the Ministry of Health and Child Care (MoHCC) of Zimbabwe.

Methods

A retrospective data review of routine reports from MSF-supported health facilities in Manicaland Province (Zimbabwe) was conducted. These secondary aggregate data were triangulated, and emerging themes of lessons learnt from VL monitoring were shared.

Results

A VL testing coverage of 63% (5966/9456) was achieved among the 40 health facilities, together with a switch rate to second-line antiretroviral therapy (ART) of 46.4% (108/233). The key enablers to scaling-up the VL monitoring were well-equipped and supported VL laboratories, the operationalisation of the on-the-job clinical mentoring and systematic weaning off of better performing health facilities. Concerted efforts from different implementing partners and funders in the HIV programme, and close collaboration with MoHCC were pivotal.

Conclusion

Our experience indicates that clinical mentoring is effective, and resulted in high VL testing coverage and up-skilling primary health care workers in VL monitoring. Attention must be focused on innovations for improving VL result utilisation, especially the identification and management of patients who fail ART.

Barriers and solutions to finding rifampicin-resistant tuberculosis cases in older children and adolescents

Little is known about the barriers to post-exposure management of rifampicin-resistant tuberculosis (RR-TB) in older children and adolescents. We report on implementation lessons from a pilot programme targeting household-exposed individuals aged 6-18 years in Khayelitsha, South Africa. Barriers included misperceptions regarding risk of exposure, multiple research and implementation stakeholders, additional workload for an overburdened healthcare system, logistical issues faced by families, and insufficient human and financial resources. Solutions to these barriers are possible, but creativity and persistence are required. Our experience can guide others looking to roll-out care for children and adolescents exposed to RR-TB.

'I didn't know so many people cared about me': support for patients who interrupt drug-resistant TB treatment

SETTING

Early interventions for patients who interrupt their treatment for drug-resistant tuberculosis (DR-TB) are rarely reported and assessed. A novel, patient-centred intervention for patients at risk of loss to follow-up (LTFU) from DR-TB treatment was implemented in Khayelitsha, South Africa, in September 2013.

OBJECTIVE

To explore the experiences and perceptions of patients, key support persons, health care workers (HCWs) and programme managers of a patient-centred model.

DESIGN

This was a qualitative study consisting of 18 in-depth interviews with patients, key support persons, HCWs, key informants and one focus group discussion with HCWs, between July and September 2017. Data were coded and thematically analysed.

RESULTS

The model was well perceived and viewed positively by patients, care providers and programme managers. 'Normalisation' and tolerance of occasional treatment interruptions, tracing, tailored management plans and peer support were perceived to be beneficial for retaining patients in care. Although the model was resource-demanding, health workers were convinced that it 'needs to be sustained,' and proposed solutions for its standardisation.

CONCLUSION

An intervention based on early tracing of patients who interrupt treatment, peer-delivered counselling and individualised management plans by a multidisciplinary team was considered a beneficial and acceptable model to support patients at risk of LTFU from DR-TB treatment.

I have heard about it for the first time from you! Implementation of tobacco control law by police personnel in India

Setting and Objetives: Police personnel, alongside other key stakeholders, are responsible for implementing the Cigarettes and Other Tobacco Products Act (COTPA) in India. This study aimed to assess knowledge and attitudes about COTPA among police personnel and explore enablers and barriers in implementing it. Design: This convergent parallel mixed-methods study used a self-administered questionnaire (quantitative) and key informant interviews (qualitative). Of 300 police personnel across all eight police stations in Daman, 155 participated. Quantitative data were analysed using descriptive statistics and the χ² test. Qualitative data from in-depth interviews of six key informants from all coordinating departments were analysed thematically. Results: Overall, 63.2% of responders were aware of any tobacco control law in India, and only 12.9% were trained in its implementation. One person had conducted inspections for COTPA compliance in the last 12 months. The majority (78.1%) of the police personnel, and significantly more tobacco non-users than users (81.2% vs. 52.9%, P = 0.016), felt that enforcing anti-tobacco regulations is one of their most important functions. Perceived benefits of the act and formal authority to act were the two main enablers of COTPA implementation. Lack of awareness and coordination, competing priorities, concentration of authority with higher-ranking officials and evasion of the law by retailers and the public hampered effective implementation of the law. Conclusion: Knowledge about the COTPA was average and implementation poor. Sensitisation and training of implementers, systematic transparent reporting and creating awareness among public are recommended for effective implementation.

Re-inventing adherence: toward a patient-centered model of care for drug-resistant tuberculosis and HIV

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.

Surgical interventions for pulmonary tuberculosis in Mumbai, India: surgical outcomes and programmatic challenges

Setting: While surgery for pulmonary tuberculosis (PTB) is considered an important adjunct for specific cases, including drug-resistant tuberculosis, operational evidence on its feasibility and effectiveness is limited. Objective: To describe surgical outcomes and programmatic challenges of providing surgery for PTB in Mumbai, India. Design: A descriptive study of routinely collected data of surgical interventions for PTB from 2010 to 2014 in two Mumbai hospitals, one public, one private. Results: Of 85 patients, 5 (6%) died and 17 (20%) had complications, with wound infection being the most frequent. Repeat operation was required in 12 (14%) patients. Most procedures were performed on an emergency basis, and eligibility was established late in the course of treatment. Median time from admission to surgery was 51 days. Drug susceptibility test (DST) patterns and final treatment outcomes were not systematically collected. Conclusion: In a high-burden setting such as Mumbai, important data on surgery for PTB were surprisingly limited in both the private and public sectors. Eligibility for surgery was established late, culture and DST were not systematically offered, the interval between admission and surgery was long and TB outcomes were not known. Systematic data collection would allow for proper evaluation of surgery as adjunctive therapy for all forms of TB under programmatic conditions.

Intensified tuberculosis case finding amongst vulnerable communities in southern India

India mainly uses passive case finding to detect tuberculosis (TB) patients through the Revised National Tuberculosis Control Programme (RNTCP). An intensified case finding (ICF) intervention was conducted among vulnerable communities in two districts of Karnataka during July-December 2013; 658 sputum smear-positive TB cases were detected. The number of smear-positive cases detected increased by 8.8% relative to the pre-intervention period (July-December 2012) in intervention communities as compared to an 8.6% decrease in communities without the ICF intervention. ICF activities brought TB services closer to vulnerable communities, moderately increasing TB case detection rates.

Infection control in households of drug-resistant tuberculosis patients co-infected with HIV in Mumbai, India

BACKGROUND

Mumbai has a population of 21 million, and an increasingly recognised epidemic of drug-resistant tuberculosis (DR-TB).

OBJECTIVE

To describe TB infection control (IC) measures implemented in households of DR-TB patients co-infected with the human immunodeficiency virus (HIV) under a Médecins Sans Frontières programme.

METHODS

IC assessments were carried out in patient households between May 2012 and March 2013. A simplified, standardised assessment tool was utilised to assess the risk of TB transmission and guide interventions. Administrative, environmental and personal protective measures were tailored to patient needs.

RESULTS

IC assessments were carried out in 29 houses. Measures included health education, segregating sleeping areas of patients, improving natural ventilation by opening windows, removing curtains and obstacles to air flow, installing fans and air extractors and providing surgical masks to patients for limited periods. Environmental interventions were carried out in 22 houses.

CONCLUSIONS

TB IC could be a beneficial component of a comprehensive TB and HIV care programme in households and communities. Although particularly challenging in slum settings, IC measures that are feasible, affordable and acceptable can be implemented in such settings using simplified and standardised tools. Appropriate IC interventions at household level may prevent new cases of DR-TB, especially in households of patients with a lower chance of cure.

Open access for operational research publications from low- and middle-income countries: who pays?

Open-access journal publications aim to ensure that new knowledge is widely disseminated and made freely accessible in a timely manner so that it can be used to improve people's health, particularly those in low- and middle-income countries. In this paper, we briefly explain the differences between closed- and open-access journals, including the evolving idea of the 'open-access spectrum'. We highlight the potential benefits of supporting open access for operational research, and discuss the conundrum and ways forward as regards who pays for open access.

Screening patients with tuberculosis for diabetes mellitus in Ampara, Sri Lanka

Given the well-known linkage between diabetes mellitus (DM) and tuberculosis (TB), the World Health Organization recommends bidirectional screening. Here we report the first screening effort of its kind from a chest clinic in the Ampara district of Sri Lanka. Of 112 TB patients registered between January 2013 and October 2014, eight had pre-existing DM. Of those remaining, 83 (80%) underwent fasting plasma glucose testing, of whom two (2%) and 17 (20%) were found to have diabetes and impaired fasting glucose, respectively. All of these were enrolled in care. Screening TB patients for DM was found to be feasible at the district level. Further studies at the provincial/country level are required before making any decision to scale up bidirectional screening.

Is screening for diabetes among tuberculosis patients feasible at the field level?

SETTING

Seventeen peripheral health institutions (PHI) in Kolar district (population: 0.5 million), South India.

OBJECTIVE

To assess the feasibility and results of screening patients with tuberculosis (TB) for diabetes mellitus (DM) at peripheral level.

DESIGN

From January to September 2012, all TB patients were assessed for DM. Those with unknown DM status were screened for the disease (free of charge) by trained laboratory technicians at each PHI, using a glucometer supplied by the national programme on a capillary blood sample. Those with fasting blood glucose (FBG) ≥ 126 mg/dl (≥7 mM) were diagnosed as DM-positive.

RESULTS

Of 362 TB patients, 358 (99%) were assessed for DM and 62 (17.1%) had the diseases-53 (14.6%) had a previous history of DM and 9 (2.9%) were newly diagnosed. All new DM patients were enrolled into DM care. Higher DM prevalence was found among TB patients aged ≥40 years, smokers and those with smear-positive pulmonary TB. To detect a new case of DM, the number needed to screen (NNS) among TB patients was 40.

CONCLUSION

Screening of TB patients for DM was feasible and effective in a peripheral setting. The availability of trained laboratory technicians and free services at every PHI made the intervention feasible. The study has contributed towards a national policy decision in this regard.

Burden, characteristics, management and outcomes of HIV-infected patients with Kaposi's sarcoma in Zomba, Malawi

SETTING

Antiretroviral treatment (ART) clinic at Zomba Central Hospital, Malawi.

DESIGN

Retrospective analysis of records (2004-2011) of human immunodeficiency virus (HIV) infected patients with Kaposi's sarcoma (KS).

OBJECTIVES

To determine the number and characteristics of HIV-infected adult patients with KS on ART and vincristine (VCR) therapy and their treatment outcomes.

RESULTS

A total of 545 HIV-infected patients with KS (58% male, median age 33 years) were included in the study. The baseline median CD4 count was 180 cells/µl (interquartile range 111-287). Cumulative outcomes were as follows: 168 (31%) were still alive, 133 (24%) had died, 172 (32%) were lost to follow-up and 71 (13%) had transferred out; 229 had received at least one course of VCR, 171 had received less than one full course and 145 had not received VCR. The survival probability for 229 patients who received at least one course of VCR was 65% at 1 year, 42% at 2 years and 13% by 6 years. Patients who started VCR therapy before or concurrently with ART had a higher risk of death and generally a higher risk of death and loss to follow-up than those who started VCR after ART.

CONCLUSION

Poor outcomes were noted in HIV-infected patients with KS in a programme setting in Malawi. Other treatment interventions, including combination and/or second-line chemotherapy and earlier ART initiation, are needed to reduce morbidity and mortality.

High prevalence of undiagnosed diabetes among tuberculosis patients in peripheral health facilities in Kerala

SETTING

Two tertiary care hospitals and 12 peripheral health institutions (PHIs) in Trivandrum, Kerala, India.

OBJECTIVE

To determine factors associated with the prevalence of diabetes mellitus (DM) among tuberculosis (TB) patients and examine differences in the proportion of new DM cases among TB patients diagnosed at tertiary care centres and PHIs.

DESIGN

A descriptive study: TB patients diagnosed during March-September 2012 were screened for known DM. Those with unknown DM status were tested for random blood glucose and fasting blood glucose (FBG); FBG ≥ 126 mg/dl was diagnosed as new DM.

RESULTS

Of 920 TB patients, 689 (72%) were male and the mean (standard deviation) age was 47.6 (16.4) years. Of these, 298 (32.4%) were diabetic: 235 (26%) had previously known DM and 63 (7%) were newly diagnosed. During the screening at PHIs and tertiary care hospitals, respectively 30/183 (16.4%) and 33/737 (4.5%) were newly diagnosed with DM (OR 3.71; 95%CI 2.17-6.32). Overall, age >50 years and pulmonary tuberculosis were independently associated with a higher prevalence of diabetes.

CONCLUSION

As nearly one in three TB patients had DM, we recommend that TB patients should be routinely screened for DM in Kerala. As the proportion of new DM was higher among TB patients diagnosed at PHIs, we would recommend that specific attention and investment be directed to PHIs.

Diabetes mellitus and smoking among tuberculosis patients in a tertiary care centre in Karnataka, India

Diabetes mellitus (DM) and smoking are risk factors for adverse outcomes in the treatment of tuberculosis (TB). In a tertiary care hospital at Belgaum in the South Indian State of Karnataka, all TB patients aged ≥18 years consecutively diagnosed from February to September 2012 were evaluated for DM and smoking. Of 307 TB patients, 35.5% were found to have DM, 9.8% were current smokers, and 3.6% had DM and were also smokers. Measures to assess and address both these factors need to be taken into account during TB treatment.

Epidemiology and interaction of diabetes mellitus and tuberculosis and challenges for care: a review

The global burden of diabetes mellitus (DM) is immense, with numbers expected to rise to over 550 million by 2030. Countries in Asia, such as India and China, will bear the brunt of this unfolding epidemic. Persons with DM have a significantly increased risk of developing active tuberculosis (TB) that is two to three times higher than in persons without DM. This article reviews the epidemiology and interactions of these two diseases, discusses how the World Health Organization and International Union Against Tuberculosis and Lung Disease developed and launched the Collaborative Framework for the care and control of TB and DM, and examines three important challenges for care. These relate to 1) bi-directional screening of the two diseases, 2) treatment of patients with dual disease, and 3) prevention of TB in persons with DM. For each area, the gaps in knowledge and the priority research areas are highlighted. Undiagnosed, inadequately treated and poorly controlled DM appears to be a much greater threat to TB prevention and control than previously realised, and the problem needs to be addressed. Prevention of DM through attention to unhealthy diets, sedentary lifestyles and childhood and adult obesity must be included in broad non-communicable disease prevention strategies. This collaborative framework provides a template for action, and the recommendations now need to be implemented and evaluated in the field to lay down a firm foundation for the scaling up of interventions that work and are effective in tackling this dual burden of disease.

Tuberculosis-diabetes mellitus bidirectional screening at a tertiary care centre, South India

SETTING

Tuberculosis (TB) and diabetes mellitus (DM) clinics at Bowring and Lady Curzon Hospital, a tertiary care centre in Bangalore, India.

OBEJCTIVE

To assess the feasibility and results of TB-DM bidirectional screening.

METHODS

A descriptive study conducted from 1 March to 30 September 2012, in which all TB patients were assessed for DM and vice versa. Fasting blood glucose values of ≥126 mg/dl and 110-125 mg/dl were considered as DM and pre-diabetes, respectively.

RESULTS

Of 510 TB patients, 32 (6.3%) had been previously diagnosed with DM. Screening among the remaining 478 patients yielded 15 (2.9%) with pre-diabetes and 15 (2.9%) newly diagnosed cases of DM. A higher prevalence of DM was found among patients aged ≥40 years, patients with pulmonary TB and smokers. Of the 47 TB-DM patients, 45 were enrolled in DM care. Of 1670 DM patients followed up in DM clinics, 45 already had TB. Among the remaining 1625 patients screened, 152 (9%) had symptoms suggestive of TB; two of these were found to have the disease.

CONCLUSION

Bidirectional screening for DM and TB is feasible and produces a high yield for DM among TB patients. The yield of TB among DM patients was low and needs future research using new, improved TB diagnostic tools.

Double trouble: tuberculosis and substance abuse in Nagaland, India

The diagnosis and treatment of tuberculosis (TB) in people who use and/or inject illicit drugs (PWUIDs) remains a barrier to achieving universal coverage for TB in India and globally. This report describes treatment outcomes in PWUIDs who received treatment for drug-susceptible TB at the Mon District Hospital in Nagaland, India, during 2012-2013. The median age of the patients was 39 years, and most (92%) were male. Two thirds (33/49) of the patients had a successful TB treatment outcome. A previous TB episode and residence in a semi-urban area were associated with unsuccessful treatment outcomes. Separate diagnostic and treatment algorithms, including regular adherence counselling and opioid substitution therapies, should be considered for PWUIDs.

'I'm fed up': experiences of prior anti-tuberculosis treatment in patients with drug-resistant tuberculosis and HIV

OBJECTIVES

To understand the impact of past experiences of anti-tuberculosis treatment among patients co-infected with the human immunodeficiency virus and multidrug-resistant tuberculosis (MDR-TB) on perceptions and attitudes towards treatment.

METHODS

Qualitative study using in-depth interviews with 12 HIV-MDR-TB co-infected patients in Mumbai, India.

RESULTS

Patients reported unnecessarily long pathways to care and fatigue with diagnostic and treatment procedures. In particular, they expressed concerns over the lack of efficacy of their current treatment regimen based on their experiences with anti-tuberculosis treatment regimens in the past.

CONCLUSION

Patients reported negative experiences with previous HIV and anti-tuberculosis treatment. Access to early diagnosis and rapid initiation of integrated care for HIV-MDR-TB co-infected patients, with a strong, patient-centered support system, could help to combat the low morale and lack of faith in treatment described in this group of patients.

Oops, what about ethics?

Ethics approval of research studies is essential for the protection and rights of study subjects, whether this is for prospective research or record reviews. This article shares a painful lesson learned from a field experience where the appropriate steps for obtaining ethics approval were not followed by a young researcher. This researcher had embarked on an operational research project, but had omitted to seek ethics approval from a local ethics committee. Young researchers, particularly from low- and middle-income countries, need to learn about the importance and value of ethics.

Does the type of treatment supporter influence tuberculosis treatment outcomes in Zimbabwe?

Zimbabwe National Tuberculosis Guidelines advise that direct observation of anti-tuberculosis treatment (DOT) can be provided by a family member/relative as a last resort. In 2011, in Nkayi District, of 763 registered tuberculosis (TB) patients, 59 (8%) received health facility-based DOT, 392 (51%) received DOT from a trained community worker and 306 (40%) from a family member/relative. There were no differences in TB treatment outcomes between the three DOT groups, apart from a higher frequency rate of 'no reported outcomes' for those receiving family-based DOT. Family members should be trained to use a suitable DOT support package.

Treatment of hypertension in rural Cambodia: results from a 6-year programme

This study was aimed to describe the outcomes of a hypertension treatment programme in two outpatient clinics in Cambodia. We determined proportions of patients who met the optimal targets for blood pressure (BP) control and assessed the evolution of mean systolic and diastolic BP (SBP/DBP) over time. Multivariate analyses were used to identify predictors of BP decrease and risk factors for LTFU. A total of 2858 patients were enrolled between March 2002 and June 2008 of whom 69.2% were female, 30.5% were aged ≥64 years and 32.6% were diabetic. The median follow-up time was 600 days. By the end of 2008, 1642 (57.4%) were alive-in-care, 8 (0.3%) had died and 1208 (42.3%) were lost to follow-up. On admission, mean SBP and DBP were 162 and 94 mm Hg, respectively. Among the patients treated, a significant SBP reduction of 26.8 mm Hg (95% CI: 28.4-25.3) was observed at 6 months. Overall, 36.5% of patients reached the BP targets at 24 months. The number of young adults, non-overweight patients and non-diabetics reaching the BP targets was more. Older age (>64 years), uncontrolled DBP (≥90 mm Hg) on last consultation and coming late for the last consultation were associated with LTFU, whereas non-diabetic patients were 1.5 times more likely to default than diabetics (95% CI: 1.3-1.7). Although the definite magnitude of the BP decrease due to antihypertension medication over time cannot be assessed definitely without a control group, our results suggest that BP reduction can be obtained with essential hypertension treatment in a large-scale programme in a resource-limited setting.

Coexistence of myelodysplastic syndrome and multiple myeloma

We describe the simultaneous presentation of myelodysplastic syndrome (MDS) and multiple myeloma (MM). Our patient had MDS (RAEB type) and bone marrow infiltration (40% plasma cells), as well as biclonal paraprotein. Patients with MM, MDS have been reported after chemotherapy but few cases documenting the coexistence of MDS and MM at diagnosis have been reported in the literature.