Factors associated with viral load non-suppression in people living with HIV on ART in Nigeria: cross-sectional analysis from 2017 to 2021

OBJECTIVES

Identify factors (demographic and clinical) associated with a non-suppressed viral load (VL) of people living with HIV (PLHIV) on antiretroviral therapy (ART) in Nigeria.

DESIGN

Cross-sectional study.

SETTING

Sixteen US Agency for International Development supported states in Nigeria.

PARTICIPANTS

585 632 PLHIV on ART.

PRIMARY OUTCOME MEASURES

VL non-suppression (defined as having a VL of at least 1000 HIV RNA copies per mL of plasma). χ² testing and multivariable modified Poisson regression with robust variance estimates were conducted on routinely collected ART programme data.

RESULTS

Sixty-six per cent of the study population were females. The largest age groups were 25-34 and 35-44, accounting for 32.1% and 31.1%, respectively. Males had a 9% greater likelihood (adjusted prevalence ratio, APR=1.09) of being non-suppressed. The age groups below 60+ (APR=0.67) had a higher likelihood of a non-suppressed VL, with the highest in the 0-14 age group (APR=2.38). Clients enrolled at tertiary and secondary level facilities had the greatest likelihood of a non-suppressed VL. Clients who started ART between 2010 and 2015 had the greatest likelihood of viral non-suppression (APR=6.19). A shorter time on ART (<1 year (APR=3.92)) was associated with a higher likelihood of a non-suppressed VL. Clients receiving care at private facilities had a lower likelihood of viral non-suppression in the adjusted model. Clients in the Edo (APR=2.66) and Niger (APR=2.54) states had the greatest likelihood of viral non-suppression.

CONCLUSIONS

Targeting males, clients of younger age, those on treatment for less than 3 years, clients at tertiary and secondary health facilities, small and medium facilities, and clients in the Edo, Niger and Borno states for interventions could lead to improvements in VL suppression in Nigeria. The independent factors associated with a non-suppressed VL can guide improvements in ART programme development and VL suppression of PLHIV on ART in Nigeria.

Investing to prevent: Description of an innovative approach to commissioning a supervised toothbrushing programme across multiple local authorities in England

INTRODUCTION

The NHS Long Term Plan prioritises NHS action to reduce health inequalities and give children a good start in life. A Sustainability and Transformation Partnership (STP) is a collaborative working arrangement between local authorities and the NHS covering a defined population and geography. Within the STP in Devon, England, all three local authorities had separate supervised toothbrushing programmes; all were precariously funded. Devon has limited access to routine NHS dentistry and children in deprived areas have high rates of general anaesthetics for dental extractions. Consolidating the supervised toothbrushing programmes presented an opportunity to address oral health inequalities across Devon STP.

OBJECTIVES

1. Reduce oral health inequalities for children in deprived areas. 2. Reduce treatment need for children who have limited access to routine NHS dentistry. 3. Invest in prevention.

METHODS

A proposal, supported by local authorities in Devon STP, was developed for a targeted supervised toothbrushing programme at early years sites across the most deprived 50% of areas in Devon. Return on investment was estimated using a national resource. Methods are described for identifying eligible sites and defining procurement lots. The NHS dental services commissioner agreed to support this proposal using an innovative approach to commissioning.

RESULTS

Three lots, totalling 525 sites, were awarded to two providers. Mobilisation over summer 2019 led to implementation from September 2019.

CONCLUSION

Partnership working and innovative commissioning can enable NHS England to invest in prevention at scale where options to increase dental access are limited. Implementation across a large geographical area creates challenges but facilitates equitable programme delivery.

A Qualitative Comparative Analysis of the Drivers of HIV Status Knowledge in Orphans and Vulnerable Children in Mozambique

We identified combinations of modifiable factors that HIV programs supporting orphans, vulnerable children, and their families may be able to act on to increase the proportion of beneficiaries who know their HIV status.

In Mozambique, more than a million children are living with HIV or are otherwise vulnerable due to HIV. In response to this crisis, the US President’s Emergency Plan for AIDS Relief funds programs that serve orphans and vulnerable children affected by HIV and their families. These programs retain case workers, known as activistas, who provide and refer beneficiaries to services to increase beneficiaries’ knowledge of their HIV status and to improve retention in care among those living with HIV. To improve program effectiveness, implementing organizations need to understand how different case management attributes affect beneficiary outcomes. We applied fuzzy-set qualitative comparative analysis (QCA), based on 119 interviews, to identify the combinations of case management attributes that led to (1) increased knowledge of HIV status, and (2) high percentages of beneficiaries with known HIV status. We identified 6 pathways for the first outcome and 5 pathways for the second outcome. Each pathway demonstrates an alternative combination of conditions that positively influences the outcome and is equally sufficient in achieving the outcome. To improve knowledge of HIV status, programs in a similar context as this study may select any of the identified pathways based on their existing resources and work on ensuring the presence of each of the conditions in the pathway. Overall, based on the presence of some of the factors in multiple pathways, we conclude that to improve knowledge of HIV status it is important that programs implement a formal process to assign cases considering case complexity and existing caseload to reduce overwork; provide activistas with external support such as weekly care team meetings, weekly supervisor meetings, and/or low supervision ratios; hire experienced activistas; provide all activistas with follow-up trainings so they have the tools to address challenging cases; expand the financial resources offered to activistas; and reimburse activistas for work-related expenses.

Dentists' perceptions of their professional roles regarding referrals within primary dental care in England: a qualitative study

OBJECTIVE

To describe dentists' perceptions of their professional roles, including the reasons why they make, accept or decline patient referrals within primary dental care in England.

BASIC RESEARCH DESIGN

Qualitative semi-structured interviews, conducted via Skype, telephone or face-to-face. Transcripts were analysed using thematic analysis and typologies were developed.

PARTICIPANTS

Ten general dental practitioners (GDPs) and 12 community dentists working in England.

RESULTS

Five main themes were identified: professional independence, the nature of dental care, the business of dentistry, obscure rules and 'no man's land'. This final theme described a notional gap between GDPs' and community dentists' responsibilities towards vulnerable people, who were perceived by participants to include frail older people, anxious and socially marginalised adults and children with high levels of disease. Three typologies of dentists were generated. 'Entrepreneurs' felt no allegiance to the National Health Service and no obligation to treat vulnerable patients. 'Altruistic carers' were committed to caring for exceptionally deserving patients. 'Pragmatic carers' tried to provide relational dental care (time and emotional support) for vulnerable patients but encountered discouraging systemic barriers.

CONCLUSION

Dentists' perceptions of their roles may influence whether and how they provide access to primary dental care for vulnerable people through referral systems. Access issues may exacerbate the oral health inequalities experienced by vulnerable groups. Based upon the findings, approaches are proposed that may encourage and enable the dental workforce to support vulnerable people actively to receive primary dental care.

Effect of obesity on overall survival following permanent prostate brachytherapy

15576

Background: To evaluate the impact of obesity on cause-specific (CSS), biochemical progression-free (bPFS) and overall survival (OS) following prostate brachytherapy. Methods: From April 1995 through March 2003, 1,093 consecutive patients underwent brachytherapy for clinical T1b-T3a (2002 AJCC) prostate cancer. The median follow up was 5.6 years. All patients were implanted at least 3 years prior to analysis. Evaluated body mass index (BMI) subgroups were < 25 (n=258), 25.0 to 29.9 (n=547), 30.0 to 34.9 (n=214) and = 35 (n=74) kg/m2, respectively. Four-hundred and thirty (39.9%) and 589 (53.9%) of the patients received androgen deprivation therapy or supplemental external beam radiation therapy, respectively. Multiple clinical, treatment and dosimetric parameters were evaluated as predictors of CSS, bPFS and OS. Results: The 11 year CSS, bPFS and OS for the entire cohort were 97.5%, 95.6% and 77.6% respectively. BMI did not impact CSS or bPFS for any of the BMI cohorts. However, OS was statistically lower in patients with a BMI < 25 kg/m2 (p = 0.014). A Cox linear regression analysis demonstrated that Gleason score was the best predictor of CSS while percent-positive biopsies, risk group,V100 and hypertension predicted for bPFS. Patient age and tobacco use were the strongest predictors of OS. One-hundred and twenty-eight patients have died with 108 (84.4%) of the deaths the result of cardiovascular/pulmonary disease (73) and second malignancies (35). To date, 12 patients have died of metastatic prostate cancer. Conclusions: Following brachytherapy, obesity did not impact CSS, bPFS or OS. Cardiovascular or pulmonary disease and second malignancies substantially outweighed prostate cancer as competing causes of death.

No significant financial relationships to disclose.

The impact of primary Gleason pattern on survival following brachytherapy for Gleason score 7 prostate cancer

15588

Background: A recent radical prostatectomy series reported lower rates of biochemical control and cause-specific survival in Gleason score 7 patients with primary Gleason pattern 4. In this study, we evaluated the impact of Gleason 4+3 versus 3+4 on cause-specific, biochemical progression-free and overall survival in patients managed with permanent prostate brachytherapy. Methods: From April 1995 to June 2003, 530 prostate cancer patients underwent brachytherapy for clinical stage T1b-T3c (2002 AJCC) prostate cancer with Gleason score 3+4 (n=300) or Gleason score 4+3 (n=230) histology. All patients underwent brachytherapy more than three years prior to analysis. The mean and median follow-up was 6.0 and 5.7 years, respectively (range 3.2–11.2 years). Of the evaluated cohort, 412 (77.7%) received supplemental XRT and 177 (33.4%) received androgen deprivation therapy. No statistical differences were discerned between the use of XRT, however, Gleason 4+3 patients were more likely (37.4% versus 30.3%, p=0.002) to receive ADT. Multiple clinical, treatment and dosimetric parameters were evaluated as predictors of cause-specific, biochemical progression-free and overall survival. Results: At 10 years, primary Gleason 3+4 versus 4+3 did not predict for cause-specific survival (96.7% versus 93.3%, p=0.506), biochemical progression-free (97.0 versus 92.9%, p=0.085) or overall survival (77.0% versus 78.0%, p=0.9333). Cox linear regression analysis demonstrated no significant predictors for cause-specific survival while pre-treatment PSA, prostate volume and clinical stage predicted for biochemical progression-free survival. Patient age, tobacco use and diabetes were the strongest predictor for overall survival. To date, 57 patients have died (25 with Gleason 4+3 and 32 with Gleason 3+4). Of the deaths, 76% were due to cardiovascular events or second malignancies. To date, 4 patients (2 in each cohort) have died of metastatic prostate cancer. Conclusions: Following brachytherapy, the primary Gleason pattern did not impact cause-specific, biochemical progression-free or overall survival in Gleason score 7 prostate cancer. Cardiovascular disease and second malignancies were responsible for 9 times more deaths than prostate cancer.

No significant financial relationships to disclose.

Androgen deprivation therapy does not impact cause-specific or overall survival in high-risk prostate cancer treated with brachytherapy and supplemental external beam

15578

Background: To determine cause-specific (CSS), biochemical progression-free (bPFS) and overall survival (OS) in high risk prostate cancer patients undergoing brachytherapy with or without supplemental therapies. Methods: From April 1995 through July 2002, 204 patients with high risk prostate cancer (Gleason score = 8 and/or PSA > 20 ng/mL and/or clinical stage = T2c) underwent brachytherapy with or without supplemental therapies. Of the 204 patients, 193 (94.6%) received supplemental XRT and 119 (58.3%) received ADT (ADT = 6 months n=40 and ADT > 6 months n = 79). Median follow-up was 7.0 years. All patients were implanted at least 4 years prior to analysis. BPFS was defined by a PSA = 0.40 ng/mL after nadir. Multiple clinical, treatment and dosimetric parameters were evaluated for the impact on survival. Results: The ten-year CSS, bPFS and OS were 88.9%, 86.6% and 68.6%, respectively. A statistically significant difference in bPFS was discerned between hormone naïve, ADT = 6 months and ADT > 6 month cohorts (79.7% vs. 95.0% vs. 89.9%, p= 0.032). ADT did not impact CSS (94.0% vs. 87.1%, p=0.983 ) or OS (65.2% vs. 70.3%, p = 0.713). For bPFS patients, the median post-treatment PSA was < 0.04 ng/mL. A Cox linear regression analysis demonstrated that Gleason score was the best predictor of CSS while percent positive biopsies and duration of ADT best predicted for bPFS. OS was best predicted by Gleason score and diabetes. Thirty-eight patients have died with 26 of the deaths due to cardiovascular/pulmonary disease or second malignancy. Eleven patients have died of metastatic prostate cancer. Conclusions: Androgen deprivation therapy improved 10-year bPFS without statistical impact on CSS or OS. Death as a result of cardiovascular/pulmonary disease and second malignancies were more than twice as common as prostate cancer deaths. Strategies to improve cardiovascular health should positively impact overall survival.

No significant financial relationships to disclose.

Prostate cancer distribution in patients diagnosed by transperineal template-guided saturation biopsy: Implications for brachytherapy treatment planning

15533

Background: Prostate cancer remains undetected in approximately one-third of patients following standard transrectal ultrasound-guided biopsy. In this study, we evaluated prostate cancer incidence, anatomic distribution, Gleason score profile and tumor burden in patients diagnosed by transperineal template-guided saturation biopsy (TTSB). Methods: One hundred and seventeen patients underwent TTSB. TTSB was performed under general anesthesia. All but one patient had undergone at least one prior negative TRUS biopsy. Criteria for inclusion included an elevated PSA and/or the diagnosis of ASAP or high-grade PIN on prior biopsy. The prostate gland was divided into 24 regional biopsy locations with 1–3 biopsies per region. The median number of biopsy cores was 50. Multiple clinical parameters were evaluated as predictors for prostate cancer diagnosis. Results: The mean patient age was 64.8 years with a mean PSA of 9.1 ng/mL and a prostate volume of 78.6 cm3. On average, patients had undergone 2.1 prior negative TRUS biopsies with a mean of 22.4 core biopsies. Prostate cancer was diagnosed in 49 patients (41.9%) with a Gleason score distribution of 6–9. Patients with a prostate volume of = 60 cm3 had a higher rate of cancer diagnosis compared to patients with larger glands (66% vs. 30%). Although no anatomic region of the prostate gland was spared of cancer, there was a preponderance of anterior-based malignancies. In patients with prostate cancer, an average of 9.9 cores were involved. In multivariate analysis, pre-saturation biopsy diagnosis and prostate volume were the best predictors for prostate cancer diagnosis. Conclusions: Transperineal template-guided saturation biopsy diagnosed prostate cancer in 41.9% of previously biopsied patients. Considerable anatomic variability in prostate cancer distribution was documented. Based on this and other reports, cancer eradication will be dependent on treatment of the entire prostate gland.

No significant financial relationships to disclose.

Prediction of PSA spikes by isotope and patient age following permanent prostate brachytherapy

15535

Background: To evaluate prostate specific antigen (PSA) spikes (bounces) following permanent prostate brachytherapy in low-risk patients randomized to Pd-103 or I-125. Methods: The study population consisted of 164 prostate cancer patients who were part of a prospective randomized trial comparing Pd-103 with I-125 for low-risk disease. Sixty-one patients (37.2%) received short course cytoreductive androgen deprivation therapy (ADT). No patient received supplemental XRT. The median follow-up was 5.4 years. All patients were implanted at least 3 years prior to analysis. On average, 10.1 post-treatment PSA’s were obtained per patient. Biochemical disease-free survival was defined as a PSA = 0.40 ng/mL after nadir. A PSA spike was defined as a rise of = 0.2 ng/mL followed by a durable decline to pre- spike levels. Multiple clinical, treatment and dosimetric parameters were evaluated as predictors for a PSA spike. Results: Forty- four patients (26.9%) developed a PSA spike including 45.7% (21/46) of the hormone naïve I-125 patients and 14.0% (8/57) of the hormone naïve Pd-103 patients. In hormone naïve patients, the mean time between implant and spike was 22.6 months and 18.7 months for I-125 and Pd-103 patients, respectively. In patients receiving neoadjuvant ADT, the incidence of spikes was comparable between isotopes (28.1% for I- 125 and 20.7% for Pd-103). The incidence of spikes was substantially different in patients < 65 vs = 65 years of age (16.3% vs. 38.5%). In multivariate Cox regression analysis, patient age at implant (p < 0.001) and isotope (p = 0.002) were significant predictors for spike. Conclusions: In low-risk prostate cancer patients, PSA spikes are most common in patients implanted with I-125 and/or younger than 65 years of age. Differences in isotope-related spikes are most pronounced in hormone naïve patients.

No significant financial relationships to disclose.

Neonatal infraorbital nerve transection in rat results in peripheral trigeminal sprouting

Retrograde tracing techniques were employed to determine whether transection of the infraorbital (IO) nerve in either newborn or adult rats resulted in peripheral sprouting by undamaged trigeminal (V) axons. The IO nerve was sectioned just behind the vibrissa pad, either on the day of birth or when animals reached at least 60 days of age. After an additional 60 days, the same nerve was retransected in the orbit; horseradish peroxidase (HRP) or diamidino yellow (DY) was injected into the central portion of the vibrissa pad; and animals were killed 2-3 days later. In the neonatally nerve-damaged rats, this procedure invariably labelled primary afferent neurons in both the ipsilateral and contralateral V ganglia. On the ipsilateral side, these cells were located in the caudal portion of the ophthalmic-maxillary region and, less often, in the mandibular division. Their average diameter was 22.6 micron (s.d. = 5.6). On the contralateral side, most labelled ganglion cells were visible in the anteromedial part of the ophthalmic-maxillary region but a few could also be seen in the mandibular division. Their average diameter was 21.1 micron (s.d. = 5.5). No labelled ganglion cells were observed in adult rats subjected to the same series of manipulations. In a separate series of neonatally nerve-damaged animals, the above-described procedures were combined with neonatal injection of capsaicin in an effort to determine whether the observed sprouting was dependent upon the presence of large numbers of unmyelinated axons. The addition of this treatment reduced the number of labelled cells in both the ipsilateral and contralateral ganglia, but it did not alter either their distribution or average soma diameter. In a final experiment, sequential double-labelling techniques were used to determine whether the V axons that projected to the vibrissa pad via non-IO nerve branches were the result of sprouting by undamaged ganglion cells or arose from neurons that had originally projected into the IO nerve, were axotomized by our lesions, and regenerated to the vibrissa pad via another V branch. Here, the long-lived retrograde tracer true blue (TB) was injected into the vibrissa pad 6-8 hours before the neonatal nerve cut and DY was deposited into the pad after transection of the regenerate IO nerve in adulthood. Double-labelled cells in this experiment would have projected to the vibrissa pad via the IO nerve at birth and regenerated to it via another V branch in adulthood. Nearly 55% of the DY-labelled cells in this experiment also contained TB.(ABSTRACT TRUNCATED AT 400 WORDS)

The projection from the superficial to the deep layers of the superior colliculus: an intracellular horseradish peroxidase injection study in the hamster

Intracellular recording and horseradish peroxidase (HRP) injection techniques were employed to examine the projections of superficial layer [stratum griseum superficiale (SGS) and stratum opticum (SO)] superior collicular (SC) neurons in the hamster that sent axon collaterals into the deep laminae (those ventral to the SO) of this structure. Sixty-nine neurons were studied, selected from a sample of over 185 HRP-filled superficial layer cells on the basis of having heavily stained axons. Of the 69 cells included in the study, 43.4% (n = 30) sent at least one axon collateral to the deep laminae. Not all cell types in the superficial layers contributed equally to this interlaminar projection: 78.6% (n = 11) of the recovered wide-field vertical cells, 55.0% (n = 11) of the narrow-field vertical cells, 16.7% (n = 2) of the stellate cells, 40.0% (n = 2) of the marginal cells, 18.2% (n = 2) of the horizontal cells, and 28.6% (n = 2) of neurons we could not classify on the basis of their somadendritic morphology projected to the deep layers. Within a given cell class, there were no significant morphological or physiological differences between the neurons that possessed deep axon collaterals and those that did not. The deep axon collaterals of most of the interlaminar projection neurons were restricted to the stratum griseum intermediate (SGI). In this layer, the largest segment of the axon arbor was located lateral to a projection line that was orthogonal to the SC surface and that passed through the soma of the cell in question. These results, along with those of a previous study (Mooney et al., 1984), which demonstrated that the dendrites of deep layer cells may extend through the SO and into the SGS, indicate that there is an extensive anatomical substrate by which sensory information may be communicated from superficial to deep layer SC neurons.

Prostaglandin synthesis inhibitors block alcohol-induced fetal hypoplasia

Alcohol-induced growth retardation is a fetal effect consistently associated with maternal ethanol consumption. In humans, those infants whose mothers consume even a limited amount of ethanol during pregnancy have a significant incidence of growth inhibition. The molecular mechanism responsible for this growth deficiency is unknown, and prevention depends on maternal abstinence during pregnancy. The data reported here suggest that ethanol-mediated increases in tissue prostaglandin (PG) E levels (PGE1 plus PGE2) are correlated with the growth retardation. Further, simultaneous administration of PG synthesis inhibitors with the alcohol blocks the rise in tissue PG levels and protects against the alcohol-induced hypoplasia.