Drug behaviors, sexually transmitted infection prevention, and sexual consent during chemsex: insights generated in the Budd app after each chemsex session

Chemsex refers to the intentional use of drugs before or during sex in a specific context, typically involving prolonged sex sessions with multiple partners. Engaging in chemsex is associated with a wide range of health risks and related risk behaviors. We developed a mobile phone application ('Budd-app') to support and inform chemsex participants, reduce potential negative impacts associated with chemsex (e.g., physical, psychological and social health harms), and encourage more reasoned participation. During Budd's development process, 11 participants completed a survey after each chemsex session they attended. This data collection approach provided precise experiences on drug related behavior, prevention measures for sexually transmitted infection and sexual consent on 63 chemsex sessions. The mean duration of chemsex sessions was 17.5 h. Polydrug use was reported during 95% of chemsex sessions with an average of 3.5 agents per session. Unsafe dosing occurred at 49% of chemsex sessions, and 9/11 participants dosed unsafely at least once. Seven participants did not consistently take measures to prevent STI transmission. Nine had experienced peer pressure, both regarding drug use and sexual health. The same number reported sex without consent, not respecting others' boundaries as well as their own boundaries not being respected. Many participants experienced negative impact of their chemsex behavior during (7/9) and after (8/9) chemsex. Through participants' behavior assessment during multiple chemsex sessions, 'within-person' variability can be clarified. This clarification provides valuable insights in personal, emotional and contextual vulnerabilities. These insights can direct an individualized care and support trajectory aimed at addressing those vulnerabilities.

Characteristics of confirmed mpox cases among clinical suspects: A prospective single-centre study in Belgium during the 2022 outbreak

Background

The presentation of mpox clade IIb during the 2022 outbreak overlaps with a range of other diseases. Understanding the factors associated with mpox is important for clinical decision making.

Methods

We described the characteristics of mpox patients who sought care at Belgian sexual health clinic. Furthermore we compared their characteristics to those of patients with a clinical suspicion of mpox but who tested negative on polymerase chain reaction.

Results

Between May 23 and September 20, 2022, 155 patients were diagnosed with mpox, and 51 patients with suspected symptoms tested negative. All mpox patients self-identified as men and 148/155 (95.5%) as gay or bisexual MSM. Systemic symptoms were present in 116/155 (74.8%) patients. All but 10 patients (145/155, 93.5%) presented with skin lesions. Other manifestations were lymphadenopathy (72/155, 46.5%), proctitis (50/155, 32.3%), urethritis (12/155, 7.7%), tonsillitis (2/155, 1.3%). Complications involved bacterial skin infection (13/155, 8.4%) and penile oedema with or without paraphimosis (4/155, 2.6%). In multivariable logistic regression models, the presence of lymphadenopathy (OR 3.79 95% CI 1.44-11.49), skin lesions (OR 4.35 95% CI 1.15-17.57) and proctitis (OR 9.41 95% CI 2.72-47.07) were associated with the diagnosis of mpox. There were no associations with age, HIV status, childhood smallpox vaccination, number of sexual partners and international travel.

Conclusions

The presence of proctitis, lymphadenopathies and skin lesions should increase clinical suspicion of mpox in patients with compatible symptoms.

Efficiency of the EmERGE Pathway of Care in Five European HIV Centres

OBJECTIVE

We aimed to calculate the efficiency of the EmERGE Pathway of Care in five European HIV clinics, developed and implemented for medically stable people living with HIV.

METHODS

Participants were followed up for 1 year before and after implementation of EmERGE, between April 2016 and October 2019. Micro-costing studies were performed in the outpatient services of the clinics. Unit costs for outpatient services were calculated in national currencies and converted to US$ 2018 OECD purchasing parity prices to enable between clinic comparisons in terms of outcomes and costs. Unit costs were linked to the mean use of services for medically stable people living with HIV,  before and after implementation of EmERGE. Primary outcome measures were CD4 count and viral load; secondary outcomes were patient activation (PAM13) and quality of life (PROQOL-HIV). Out-of-pocket expenditure data were collected.

RESULTS

There were 2251 participants: 87-93% were male, mean age at entry was 41-47 years. Medically stable people living with HIV had outpatient visits in four sites which decreased by 9-31% and costs by 5-33%; visits and costs increased by 8% in one site, which had to revert back to face-to-face visits. Antiretroviral drugs comprised 83-91% of annual costs: the Portuguese site had the highest antiretroviral drug costs in US$ purchasing parity prices. Primary and secondary outcome measures of participants did not change during the study.

CONCLUSIONS

EmERGE is acceptable and provided cost savings in different socio-economic settings. Antiretroviral drug costs remain the main cost drivers in medically stable people living with HIV. While antiretroviral drug prices in local currencies did not differ that much between countries, conversion to US$ purchasing parity prices revealed antiretroviral drugs were more expensive in the least wealthy countries. This needs to be taken into consideration when countries negotiate drug prices with pharmaceutical vendors. Greater efficiencies can be anticipated by extending the use of the EmERGE Pathway to people with complex HIV infection or other chronic diseases. Extending such use should be systematically monitored, implementation should be evaluated and funding should be provided to monitor and evaluate future changes in service provision.

A cross-sectional assessment of frailty, falls and perceptions of ageing in people living with HIV using an mHealth platform

OBJECTIVE

To evaluate frailty, falls and perceptions of ageing among clinically stable individuals with HIV, engaged with remote healthcare delivered via a novel smartphone application.

METHODS

This was a multi-centre European cross-sectional, questionnaire-based sub-study of EmERGE participants. Frailty was assessed using the five-item FRAIL scale. Present criteria were summed and categorized as follows: 0, robust; 1-2, pre-frail; 3-5, frail. Falls history and EQ-5D-5L quality of life measure were completed. Participants were asked their felt age and personal satisfaction with ageing.

RESULTS

A total of 1373 participated, with a mean age of 45 (± 9.8) years. Frailty was uncommon at 2%; 12.4% fell in the previous year, 58.8% of these recurrently. Mood symptoms and pain were prevalent, at 43.3% and 31.8%, respectively. Ageing satisfaction was high at 76.4%, with 74.6% feeling younger than their chronological age; the mean felt age was 39.3 years. In multivariable analysis, mood symptoms and pain were positively associated with frailty, falls and ageing dissatisfaction. An increase in pain severity and mood symptoms were respectively associated with 34% and 63% increased odds of pre-frailty/frailty. An increment in pain symptoms was associated with a 71% increase in odds of falling. Pain was associated with ageing poorly, as were mood symptoms, with odds of dissatisfaction increasing by 34% per increment in severity.

CONCLUSIONS

Although uncommon, frailty, falls and ageing dissatisfaction were seen in a younger cohort with medically stable HIV infection using a remote care model, promoting screening as advocated by European guidelines. These were more common in those with pain or mood symptoms, which should be proactively managed in clinical care and explored further in future research.

Lessons Learnt From the Experiences of Primary Care Physicians Facing COVID-19 in Benin: A Mixed-Methods Study

Introduction

In sub-Saharan Africa, there is a need to better understand and guide the practice of primary care physicians (PCPs), especially in a crisis context like the COVID-19 pandemic. This study analyses the experiences of PCPs facing COVID-19 in Benin and draws policy lessons.

Methods

The study followed a fully mixed sequential dominant status design. Data were collected between April and August 2020 from a sample of PCPs in Benin. We performed descriptive analyses on the quantitative data. We also performed bivariate analyses for testing associations between various outcomes and the public/private status of the PCPs, their localization within or outside the cordon sanitaire put in place at the beginning of COVID-19, and their practice' category. A thematic content analysis was done on qualitative data. Results from both analyses were triangulated.

Results

Ninety PCPs participated in the quantitative strand, and 14 in the qualitative. The median percentage of the COVID-19 control measures implemented in the health facilities, as reported by the PCPs, was 77.8% (interquartile range = 16.7%), with no difference between the various groups. While 29.4% of the PCPs reported being poorly/not capable of helping the communities to deal with COVID-19, 45.3% felt poorly/not confident in dealing with an actual case. These percentages were bigger in the private sector. The PCP's experiences were marked by anxiety and fear, with 80.2% reporting stress. Many PCPs (74.1%) reported not receiving support from local health authorities, and 75.3% felt their concerns were not adequately addressed. Both percentages were higher in the private sector. The PCPs especially complained of insufficient training, insufficient coordination, and less support to private providers than the public ones. For 72.4 and 79.3% of the PCPs, respectively, the pandemic impacted services utilization and daily work. There were negative impacts (like a decrease in the services utilization or the quality of care), but also positive ones (like improved compliance to hygiene measures and new opportunities).

Conclusion

Our study highlighted the need for more structured support to PCPs for optimizing their contribution to epidemics control and good primary healthcare in Benin. Efforts in this direction can build on several good practices and opportunities.

Impact of PrEP on a STI clinic in a Belgian context: a provider's perspective

Objectives: To assess the impact of Pre-Exposure Prophylaxis (PrEP) to avoid HIV infection as an additional service in a routine Sexually Transmitted Infections (STI) clinic.Methods: We used routinely obtained retrospective data to estimate the increased workload on the existing facilities. We focussed on STI registration through the laboratory registration system and put this in a national perspective. A critical appraisal was made of the national HIV notifications, as an indicator of the impact of PrEP. Additional challenges were identified via face-to-face interviews with clinicians with at least five years experience in the STI clinic.Results: PrEP delivery puts a substantial burden on a routine STI clinic, in terms of counselling users and prescribing drugs, and regular screening and treating of STIs. Psycho-social aspects need to be incorporated as part of a comprehensive approach of the PrEP user. This requires skills and resources that are not yet always available in a clinic, specialised in HIV and STI care. The increasing demand for this service calls for a careful and critical appraisal of the existing service model.Conclusion: PrEP has gained an important and irreplaceable position in the prevention of HIV infection. New models of care need to be studied, preferably in close collaboration with the users, to make this intervention sustainable for the health system in which it is introduced.

The expanding movement of primary care physicians operating at the first line of healthcare delivery systems in sub-Saharan Africa: A scoping review

INTRODUCTION

In sub-Saharan Africa (SSA), the physicians' ratio is increasing. There are clear indications that many of them have opted to work at the first-line of healthcare delivery systems, i.e. providing primary care. This constitutes an important change in African healthcare systems where the first line has been under the responsibility of nurse-practitioners for decades. Previous reviews on primary care physicians (PCPs) in SSA focused on the specific case of family physicians in English-speaking countries. This scoping review provides a broader mapping of the PCPs' practices in SSA, beyond family physicians and including francophone Africa. For this study, we defined PCPs as medical doctors who work at the first-line of healthcare delivery and provide generalist healthcare.

METHODS

We searched five databases and identified additional sources through purposively selected websites, expert recommendations, and citation tracking. Two reviewers independently selected studies and extracted and coded the data. The findings were presented to a range of stakeholders.

FINDINGS

We included 81 papers, mostly related to the Republic of South Africa. Three categories of PCPs are proposed: family physicians, "médecins généralistes communautaires", and general practitioners. We analysed the functioning of each along four dimensions that emerged from the data analysis: professional identity, governance, roles and activities, and output/outcome. Our analysis highlighted several challenges about the PCPs' governance that could threaten their effective contribution to primary care. More research is needed to investigate better the precise nature and performance of the PCPs' activities. Evidence is particularly needed for PCPs classified in the category of GPs and, more generally, PCPs in African countries other than the Republic of South Africa.

CONCLUSIONS

This review sheds more light on the institutional, organisational and operational realities of PCPs in SSA. It also highlighted persisting gaps that remain in our understanding of the functioning and the potential of African PCPs.

The impact of physical restriction measures imposed during the two waves of COVID-19 on chlamydia and gonorrhea diagnoses in Belgium. Results of an sexually transmitted infection clinic

Background: During the first two waves of COVID-19, several physical restriction measurements were imposed in Belgium. Our aim was to explore the impact of these restriction measures on the number of tests and positivity rate of Chlamydia trachomatis (CT)/Neisseria gonorrhoeae (NG) before, during, and after the two lockdowns in Belgium. Methods: Chlamydia trachomatis/Neisseria gonorrhoeae molecular data of a Belgian STI clinic were extracted for 2019 and 2020, and both years were divided into four periods (pre-lockdown 1, lockdown 1, after lockdown 1, and lockdown 2). Weekly testing rates and positivity rate for both STIs were estimated, and mixed-effects logistic regression was used to explore statistical significant changes between both years, and the different periods were compared with the corresponding time period in 2019. The same analysis was done for pre-exposure prophylaxis(PrEP) users only. Results: No overall significant changes in positivity rate were found for either CT (8.0% in 2019 and 7.8% in 2020) or NG (4.5% in 2019 and 5.5% in 2020). Besides a significant drop in the number of CT/NG tests during lockdown 1 (decrease of 87%) and a subsequent increase in NG positivity rate (p > 0.05), no changes in CT/NG positivity rate were found in the other periods. The highest positivity rate for either CT or NG was found in lockdown 2 (15.1% vs 12.4% in 2019). The number of CT/NG tests in lockdown 2 was still 25% lower than 2019 levels. Subanalysis of only PrEP users revealed the same trend; however, the number of CT/NG tests in lockdown 2 was exactly the same as in 2019. Conclusion: Despite a significant decline in absolute CT or NG cases in lockdown 1, which was most likely a consequence of both physical distancing and reduced testing, CT/NG testing and positivity rates returned to pre-corona levels in lockdown 2, which may depict physical distancing fatigue.

Identifying key elements to inform HIV-testing interventions for primary care in Belgium

General practitioners (GPs) play a key role in reducing the hidden HIV-epidemic, but many diagnostic opportunities are missed in primary care. This study aimed at informing the development of an HIV-testing intervention for GPs in Flanders (Belgium) using formative research with a participatory approach. Through the active involvement of an advisory board and 16 group discussions with 122 Flemish GPs, GPs’ current HIV-testing practices and perceived practical relevance of 2 distinct HIV-testing strategies (i.e. provider-initiated testing of key populations and indicator condition-based testing) were explored in terms of their relevance and feasibility in routine primary care. Self-reported HIV-testing practices revealed that most tests performed were patient-initiated, pretest counseling was rarely done, and post-test counseling was offered mainly for patients with an HIV-diagnosis. GPs reported multiple barriers to provider-initiated HIV-testing, i.e. personal discomfort, fear of offending their patient, limited knowledge of benefits of early HIV-diagnosis, misconceptions about HIV-risks, lack of guidelines and time. Difficulties to identify patient’s sexual orientation or ethical concerns were mentioned as barriers for target group-based HIV testing. GPs assessed the current list of 64 indicator conditions as too difficult to integrate in routine care, deeming a reduced list of GP-relevant conditions as more feasible. Combined strategies (i.e. target group- and indicator-based testing) supported by official screening recommendations were perceived as successful strategies for provider-initiated HIV-testing in primary care. This formative research delivered qualitative evidence for the development of an HIV-testing intervention for primary care settings.

Eliminating viral hepatitis C in Belgium: the micro-elimination approach

Background

Hepatitis C virus is one of the leading causes of chronic liver disease and liver-related deaths worldwide. The estimated prevalence of chronic hepatitis C viral infection among the general Belgian population was 0.57% (n = 64,000) in 2015. Although Belgium has had a ‘Hepatitis C Plan’ since 2014, elimination efforts are unclear. This study employs the best available data and modelling estimates to define the burden of hepatitis C viral infection among key subgroups in Belgium, identify information gaps and propose potential approaches to screening, linkage to care and treatment, and cure.

Methods

We examined the peer-reviewed and grey literature since 2012 for data on the prevalence of hepatitis C viral infection in Belgium in key subgroups identified by national experts and in the literature. Ultimately, this research is primarily based on data provided by the key stakeholders themselves due to a lack of reliable data in the literature. Based on this, we modelled the treatment rates required to reach elimination of hepatitis C in several subgroups.

Results

Eleven potential subgroups were identified. There were no data available for two subgroups: generational cohorts and men who have sex with men. In six subgroups, fewer than 3000 people were reported or estimated to have hepatitis C infection. Migrants and people who inject drugs were the most affected subgroups, and children were the least affected subgroup. Only two subgroups are on target to achieve elimination by 2030: patients living with haemophilia and transplant recipients.

Conclusions

Removing Belgian treatment reimbursement restrictions in January 2019 was a big step towards eliminating HCV. In addition, increasing surveillance, including with a national registry, treatment prescription by other health-care providers and availability of treatment in local pharmacies are central to improving the current situation and getting on track to reach the 2030 WHO hepatitis C elimination targets in Belgium.

HIV testing for key populations in Europe: A decade of technological innovation and patient empowerment complement the role of health care professionals

OBJECTIVES

With persisting high numbers of new HIV diagnoses in Europe, HIV testing remains an important aspect of HIV prevention. The traditional centralized and medicalized HIV testing approach has been complemented with newly developed and evaluated non-traditional approaches. Two important factors guided this process: technological innovation and empowerment of the patient.

METHODS

We present a matrix to develop an HIV testing approach, and elaborate on three commonly used ones: community based testing, self-testing, and self-sampling. Despite non-traditional HIV testing approaches, barriers for testing remain. A potential disadvantage for users is the risk for false-reactive test results. As users receive an orientation test result, a reactive result should be confirmed. Another issue is the window phase, which is longer for some orientation tests compared to a traditional, laboratory-based test.

RESULTS

Future implementation of non-traditional HIV testing approaches will depend on legal frameworks throughout Europe. Community testing centers may additionally improve empowerment of key populations by expanding their portfolio to testing and treatment for sexually transmitted infections. Community engagement and ownership may imply a shrinking role for health care providers, but they remain crucial actors for personalized information, counselling and referral to specialized HIV-care for many people.

CONCLUSIONS

A highly effective HIV testing strategy to reduce undiagnosed people living with HIV in Europe is needed. Any approach, chosen according to the principles outlined in this paper, should reach the right people, diagnose them in the most accurate way, and optimize linkage to care.

A study of outpatient healthcare use by ageing people with HIV

BACKGROUND

Antiretroviral treatment has turned HIV infection into a chronic condition with a near normal life expectancy and an ageing patient population. For a well-defined proportion of these patients, HIV-care could pass from specialty care to primary care, especially for prevention and treatment of additional chronic diseases. A better understanding of the complex health needs of this particular proportion is needed to determine the optimal way to integrate specialist and primary care.

OBJECTIVES

Our objective was to examine the health-seeking behaviour of ageing HIV patients. We investigated which physicians they consulted and the reasons for encounter. We also explored patients' participation in preventive healthcare activities.

METHODS

We conducted a retrospective descriptive cohort study among adults, 60 years of age or older living with HIV, who came for a routine consultation visit at the HIV clinic of the Institute of Tropical Medicine (ITM) over a period of 9 months. Those who met the inclusion criteria were offered a self-administered questionnaire. The responses were manually coded, exported into Excel and subsequently imported into SPSS for descriptive statistical analysis.

RESULTS

We analysed questionnaires from 74 patients, 11 women and 63 men. Since their last consultation visit at the ITM, 48 patients consulted their general practitioner (GP), 35 patients consulted a specialist and 7 went to the emergency department over a period of 6 months. Forty-nine patients (66%) had done a faecal occult blood test and 8 women (73% of female patients) had a screening mammography in the past 2 years, 8 women (73% of female patients) had a PAP smear in the past 3 years. Sixty-three participants (85%) declared that their vaccinations were up-to-date. Thirty-eight patients (51%) take antihypertensive medication, 35 patients (47%) cholesterol medication and 9 participants (12%) are on oral antihyperglycemic medication.

CONCLUSIONS

A large proportion of patients are seeking healthcare from their GP and specialists, other than the HIV specialist. They do so both for curative and preventive health needs. This calls for a more structured collaboration between the various care providers, whereby communication plays a pivotal role.

PO 8168 CLINICAL UTILITY OF XPERT MTB/RIF ASSAY FOR THE DIAGNOSIS OF EXTRAPULMONARY TUBERCULOSIS IN ETHIOPIA

Background

The diagnosis of extrapulmonary tuberculosis (EPTB) is often made on clinical suspicion alone, and many people receive the wrong diagnosis leading to unnecessary TB treatment or poor outcomes from untreated EPTB. In this study, we evaluated the clinical utility of the Xpert MTB/RIF assay on routinely collected extra-pulmonary specimens in Ethiopia.

Methods

This study was carried out at Jimma University Specialized Hospital, Southwest Ethiopia from September 2015 to June 2017. Extra-pulmonary specimens were collected from 572 patients clinically suspected of suffering from EPTB. All specimens were tested for TB by smear-microscopy, culture and Xpert MTB/RIF. The diagnostic accuracy of Xpert MTB/RIF was calculated compared to a composite reference standard (CRS), composed of liquid culture and anti-TB treatment response.

Results

In total, 572 extra-pulmonary specimens (279 lymph node, 159 pleural, 80 peritoneal, 45 cerebrospinal and 9 pericardial fluids) were tested. The pooled sensitivity and specificity of Xpert MTB/RIF were calculated to be 91% and 90.6% respectively when compared to culture. The pooled sensitivity of Xpert MTB/RIF was decreased to 75% and the specificity was improved to 98% when Xpert MTB/RIF was compared to the CRS. The sensitivities among the specimen types differed markedly. The highest sensitivity was documented for lymph node (90%), moderate sensitivity for cerebrospinal (53%), while the sensitivity was lowest for pleural (30%) and peritoneal (32%) fluids. Xpert MTB/RIF, in addition, detected rifampicin resistance in 13 patients in perfect agreement with line probe assay.

Conclusion

Our study showed that Xpert MTB/RIF is likely to be of greatest utility when testing lymph node specimens. A negative Xpert MTB/RIF result on fluid specimens does not exclude the diagnosis of EPTB and patients with a high clinical probability of EPTB should be started on anti-TB treatment.

Lymphogranuloma venereum is on the rise in Belgium among HIV negative men who have sex with men: surveillance data from 2011 until the end of June 2017

Background

The number of cases of Lymphogranuloma venereum (LGV) is increasing in Europe. The described epidemic is mostly confined to HIV positive men who have sex with men (MSM). However, dissemination of LGV from HIV positive to HIV negative MSM could take place due to the implementation of pre-exposure prophylaxis (PrEP) and subsequent possible decrease in condom use. We describe here the LGV epidemiology in Belgium before the PrEP-era, starting from 2011 up to the end of the first half of 2017.

Methods

A descriptive analysis of the socio-demographic and clinical characteristics of all LGV cases was performed. Fisher’s exact test was used to compare symptomatic to asymptomatic patients. Logistic regression models were used to check for trends over time for: number of LGV cases, HIV status and symptoms.

Results

The number of LGV cases rose by a factor four, from 21 in 2011 to 88 in 2016, and regression models showed a positive trend estimate of 14% increase per half year (p < 0.001). LGV decreased among HIV positive cases (odds ratio (OR): 0.79, p < 0.001) and increased among HIV negative cases (OR: 1.27, p < 0.001). In addition, a rise in the number of asymptomatic LGV cases (6.7%) was observed (OR:1.39, p = 0.047). Asymptomatic cases were also less likely to be HIV (p = 0.046) or Hepatitis C positive (p = 0.027).

Conclusions

The rise of LGV in HIV negative MSM has now been documented. If we aim to halt the epidemic in HIV negative MSM, future public health strategies should include LGV testing of all Chlamydia trachomatis positive samples from MSM.

Repeat Syphilis Is More Likely to Be Asymptomatic in HIV-Infected Individuals: A Retrospective Cohort Analysis With Important Implications for Screening

There is conflicting evidence as to whether repeat syphilis is more likely to present asymptomatically than initial syphilis. If it is, then this would motivate more frequent and long-term syphilis screening in persons with a history of multiple episodes of syphilis. We conducted detailed folder reviews of all individuals with 4 or more diagnoses of syphilis between 2000 and 2017 at the Institute of Tropical Medicine, Antwerp, and assessed if there was a difference in the proportion presenting with symptomatic (primary and secondary) vs asymptomatic (latent) syphilis in initial vs repeat syphilis. Forty-five clients with 4 or more episodes of syphilis were included in the study. All were HIV-infected. Repeat episodes of syphilis were less likely to be symptomatic than initial episodes (35/160 [21.9%] vs 28/45 [62.2%]; P < .001). Frequent screening in those with HIV infection may be the only way to diagnose repeat episodes of syphilis. Care providers can use this information to motivate persons with multiple episodes of syphilis to be screened every 3 to 6 months.

Lymphogranuloma venereum among patients presenting at the HIV/STI clinic in Antwerp, Belgium : a case series

Objective of this study was to describe the patient characteristics and clinical presentation of laboratory confirmed lymphogranuloma venereum (LGV) cases, diagnosed at the Institute of Tropical Medicine (ITM), Antwerp, Belgium. Demographic and biomedical characteristics of all patients with chlamydia-positive sample results were retrieved for the years 2013 and 2014. Samples were obtained from both symptomatic and asymptomatic patients who consulted at the HIV/STI clinic. Fifty four patients with laboratory confirmed LGV were detected among 3885 nucleic acid amplification tests (NAATs) performed for the detection of chlamydia during the two years under review. Fifty three were men and equally fifty three had sex with men only (MSM). HIV (87%) and HCV (31.5%) were common concomitant infections, whilst anal gonorrhoea and syphilis were detected at the moment of the LGV diagnosis among 19 (35.2%) and 6 (11.0%) cases respectively. All cases were symptomatic, except one. The most frequent symptoms that were recorded could be categorised as proctitis (in 40 patients (74%)). Lymphadenopathy, anal and genital ulcers were signs that were present in 7 (13.0%), 4 (7.4%) and 2 patients (3.7%) respectively. LGV remains an important sexually transmitted disease among MSM. In this retrospective study, the far majority of LGV was detected amongst symptomatic persons. HCV, HIV, anal gonorrhoea and syphilis were associated co-infections. Proctitis in a high risk patient should alert the clinician for the possibility of an STI.

Cost-effectiveness of screening for active cases of tuberculosis in Flanders, Belgium

OBJECTIVE

To assess the cost-effectiveness of the tuberculosis screening activities currently funded by the Flemish government in Flanders, Belgium.

METHODS

After estimating the expenses for 2013-2014 of each of nine screening components - which include high-risk groups, contacts and people who are seeking tuberculosis consultation at a centre for respiratory health care - and the associated costs per active case of tuberculosis identified between 2007 and 2014, we compared the cost-effectiveness of each component. The applied perspective was that of the Flemish government.

FINDINGS

The three most cost-effective activities appeared to be the follow-up of asylum seekers who were found to have abnormal X-rays in initial screening at the Immigration Office, systematic screening in prisons and contact investigation. The mean costs of these activities were 5564 (95% uncertainty interval, UI: 3791-8160), 11 603 (95% UI: 9010-14 909) and 13 941 (95% UI: 10 723-18 201) euros (€) per detected active case, respectively. The periodic or supplementary initial screening of asylum seekers and the screening of new immigrants from high-incidence countries - which had corresponding costs of €51 813 (95% UI: 34 855-76 847), €126 236 (95% UI: 41 984-347 822) and €418 359 (95% UI: 74 975-1 686 588) - appeared much less cost-effective. Between 2007 and 2014, no active tuberculosis cases were detected during screening in the juvenile detention centres.

CONCLUSION

In Flanders, tuberculosis screening in juvenile detention centres and among new immigrants and the periodic or supplementary initial screening of asylum seekers appear to be relatively expensive ways of detecting people with active tuberculosis.

GeneXpert MTB/RIF Assay for the Diagnosis of Tuberculous Lymphadenitis on Concentrated Fine Needle Aspirates in High Tuberculosis Burden Settings

INTRODUCTION

The diagnosis of tuberculous lymphadenitis (TBL) remains challenging. The routinely used methods (cytology and smear microscopy) have sub-optimal sensitivity. Recently, WHO recommends GeneXpert to be used as the initial diagnostic test in patients suspected of having extra-pulmonary tuberculosis (EPTB). However, this was a conditional recommendation due to very low-quality evidence available and more studies are needed. In this study we evaluated the performance of Xpert for the diagnosis of TBL on concentrated fine needle aspirates (FNA) in Southwest Ethiopia.

METHODS

FNA was collected from presumptive TBL cases. Two smears were prepared from each aspirate and processed for cytology and conventional microscopy. The remaining aspirate was treated with N-acetyl-L-cysteine-NaOH and centrifuged for 15minutes at 3000g. The concentrated sediment was used for culture and Xpert test. Capilia TB-Neo test was used to differentiate M. tuberculosis complex (MTBC) from non-tuberculous mycobacteria (NTM). Composite bacteriological methods (culture and/or smear microscopy) were considered as a reference standard.

RESULT

Out of 143 enrolled suspects, 64.3% (92/143) were confirmed TBL cases by the composite reference standard (CRS). Xpert detected M. tuberculosis complex (MTBC) in 60.1% (86/143) of the presumptive TBL cases. The sensitivity of Xpert compared to CRS was 87.8% [95% CI: 81.0-94.5] and specificity 91.1% [95% CI: 82.8-99.4]. The sensitivity was 27.8% for smear microscopy and 80% for cytology compared to CRS. Cytology showed the lowest specificity (57.8%). Xpert was positive in 4 out of 45 culture- and smear-negative cases. Among 47 cytomorphologically non-TBL cases, 15 were positive on Xpert. More than half of Xpert-positive cases were in the range of very low cut-off threshold values (28

CONCLUSION

Xpert test showed a high sensitivity and specificity for the diagnosis of TBL on concentrated FNA samples. In addition, Xpert offered rapid detection of rifampicin-resistant M. tuberculosis strains from lymph node aspirates.

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MESH Headings

• Adolescent
• Adult
• Bacteriological Techniques/methods
• Biopsy, Fine-Needle
• Ethiopia
• Female
• Humans
• Lymph Nodes/microbiology
• Lymph Nodes/pathology
• Male
• Middle Aged
• Mycobacterium tuberculosis/chemistry
• Mycobacterium tuberculosis/cytology
• Prognosis
• Rifampin/chemistry
• Sputum/microbiology
• Tuberculosis, Lymph Node/diagnosis
• Young Adult

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Swab2know: An HIV-Testing Strategy Using Oral Fluid Samples and Online Communication of Test Results for Men Who Have Sex With Men in Belgium

Background

As HIV remains a public health concern, increased testing among those at risk for HIV acquisition is important. Men who have sex with men (MSM) are the most important group for targeted HIV testing in Europe. Several new strategies have been developed and implemented to increase HIV-testing uptake in this group, among them the Swab2know project.

Objective

In this project, we aim to assess the acceptability and feasibility of outreach and online HIV testing using oral fluid samples as well as Web-based delivery of test results.

Methods

Sample collection happened between December 2012 and April 2014 via outreach and online sampling among MSM. Test results were communicated through a secured website. HIV tests were executed in the laboratory. Each reactive sample needed to be confirmed using state-of-the-art confirmation procedures on a blood sample. Close follow-up of participants who did not pick up their results, and those with reactive results, was included in the protocol. Participants were asked to provide feedback on the methodology using a short survey.

Results

During 17 months, 1071 tests were conducted on samples collected from 898 men. Over half of the samples (553/1071, 51.63%) were collected during 23 outreach sessions. During an 8-month period, 430 samples out of 1071 (40.15%) were collected from online sampling. Additionally, 88 samples out of 1071 (8.22%) were collected by two partner organizations during face-to-face consultations with MSM and male sex workers. Results of 983 out of 1071 tests (91.78%) had been collected from the website. The pickup rate was higher among participants who ordered their kit online (421/430, 97.9%) compared to those participating during outreach activities (559/641, 87.2%; P<.001). MSM participating during outreach activities versus online participants were more likely to have never been tested before (17.3% vs 10.0%; P=.001) and reported more sexual partners in the 6 months prior to participation in the project (mean 7.18 vs 3.23; P<.001). A total of 20 participants out of 898 (2.2%) were confirmed HIV positive and were linked to care. Out of 1071 tests, 28 (2.61%) with a weak reactive result could not be confirmed, and were thereby classified as false reactive results. Most of the 388 participants who completed posttest surveys (388/983, 39.5%) were very positive about their experience. The vast majority (371/388, 95.6%) were very satisfied, while 17 out of 388 (4.4%) reported mixed feelings.

Conclusions

Despite a high yield and a considerable number of false reactive results, satisfaction was high among participants. The project helped us to reach the target population, both in numbers of tests executed and in newly diagnosed HIV infections. Further optimization should be considered in the accuracy of the test, the functionalities of the website (including an online counseling tool), and in studying the cost effectiveness of the methodology.

Bacteriological methods as add on tests to fine-needle aspiration cytology in diagnosis of tuberculous lymphadenitis: can they reduce the diagnostic dilemma?

BACKGROUND

The diagnostic accuracy of fine-needle aspiration (FNA) cytology for the diagnosis of tuberculous lymphadenitis (TBLN) is confounded by mimicking cytomorphologic disorders. The objective of this study was to determine whether supplementing FNA cytology with bacteriological methods improves the overall accuracy of TBLN diagnosis.

METHODS

Two hundred presumptive TBLN cases were included in the study. FNA specimens were collected and examined for cytomorphologic changes, for acid-fast bacilli (AFB) by microscopy and for mycobacterial growth on culture. Culture was done using Lowenstein-Jensen (LJ) medium and mycobacteria growth indicator tube (BACTEC MGIT 960 TB detection system). Differentiation between M. tuberculosis complex (MTBc) and non-tuberculous mycobacteria (NTM) was done by using 500 μg/ml para-nitrobenzoic acid (PNB) susceptibility testing.

RESULTS

Cytomorphology detected TBLN among 80% (160/200) of the presumptive cases. Culture results were available for 188 cases. Twelve samples were excluded due to contamination on both culture methods. Culture confirmed cases accounted for 78% (147/188) of which MTBc constituted 97.3% (143/147). Among presumptive cases, classified by FNA cytology as 'abscess', 11 were culture positive. Microscopy detected 31.3% (46/147) of culture confirmed mycobacterial lymphadenitis of which 11% (4/37) were diagnosed non-suggestive for tuberculosis (TB) by FNA cytology. Compared to culture (LJ & BACTEC MGIT 960) and AFB microscopy as composite gold standard, FNA cytology had a sensitivity of 88.4% and a specificity of 48.8%. The positive predictive value was 86.1% while the negative predictive value was 54.1%. The confirming power and the ROC curve area was 1.73 and 0.69, respectively.

CONCLUSION

FNA cytology showed a relatively high sensitivity but a low specificity. Combining bacteriological methods with FNA cytology in an endemic region like Ethiopia improves the overall accuracy of the diagnosis of mycobacterial lymphadenitis, which in turn may lead to better patient management.

Syphilis reinfections pose problems for syphilis diagnosis in Antwerp, Belgium - 1992 to 2012

Persons with multiple syphilis reinfections may play an important role in syphilis transmission. We analysed all syphilis tests carried out for people attending the HIV/sexually transmitted infection (STI) clinic at the Institute of Tropical Medicine, Antwerp, Belgium, from 1992 to 2012 to evaluate the extent to which syphilis reinfections were contributing to the syphilis epidemic in Antwerp. We then characterised the features of the syphilis infections in individuals with five or more episodes of syphilis. A total of 729 syphilis episodes were diagnosed in 454 persons. The majority of syphilis episodes occurred in people who had more than one episode of syphilis (445/729; 61%). A total of 10 individuals had five or more episodes of syphilis diagnosed over this period. All were men who have sex with men, HIV positive and on antiretroviral therapy. They had a total of 52 episodes of syphilis diagnosed and treated. In 38/42 of the episodes of repeat syphilis in these 10 individuals, they presented without any signs or symptoms of syphilis. Given that the majority of cases of incident syphilis in our clinic were persons with reinfections and that they frequently presented without signs of symptoms of syphilis, there is a strong case for frequent and repeated screening in all persons with a diagnosis of syphilis.

Concentration of lymph node aspirate improves the sensitivity of acid fast smear microscopy for the diagnosis of tuberculous lymphadenitis in Jimma, southwest Ethiopia

Background

Tuberculous lymphadenitis (TBLN) is the most common form of extrapulmonary tuberculosis. The cytomorphological features of lymph node smears have reduced specificity for the diagnosis of tuberculosis. The diagnosis of TBLN with direct smear microscopy lacks sensitivity due to the limited number of bacilli in lymph node aspirate. Therefore, we aimed to assess whether the concentration of lymph node aspirate improves the sensitivity of acid fast smear microscopy for the diagnosis of tuberculous lymphadenitis.

Methods

A cross-sectional comparative study was conducted on 200 patients clinically suspected for tuberculous lymphadenitis in Jimma, Ethiopia. Lymph node aspirate was collected. The first two drops were used for cytomorphological study and direct acid fast staining. The remaining aspirate was treated with N-acetyl-L-cysteine (NALC) and concentrated by centrifugation at 3000 g for 15 minutes. The sediment was used for acid fast staining and culture. Differentiation of M. tuberculosis complex (MTBC) from non-tuberculous mycobacteria (NTM) was done by para-nitrobenzoic acid susceptibility test.

Result

Complete data were available for 187 study subjects. 68% (127/187) were positive for M. tuberculosis on culture. Four isolates, 2.1% (4/187), were identified as NTM. The detection rate of direct smear microscopy was 25.1% and that of the concentration method 49.7%. Cytomorphologically, 79.7% of cases were classified as TBLN. The sensitivity of direct smear microscopy was 34.6%, for concentrated smear microscopy 66.1%, and for cytomorphology 89.8%. Two AFB positive cases on concentration method were non-tuberculosis mycobacteria (NTM). The concentration method yielded a positive result from seven cases diagnosed as suppurative abscess by cytology. Both for the direct and concentration methods the highest rate of AFB positivity was observed in smears showing caseous necrosis alone. Smear positivity rate decreased with the appearance of epithelioid cell aggregates.

Conclusion

The concentration of lymph node aspirates for acid fast smear microscopy had significantly higher sensitivity than direct microscopy.

Incidence of HCV and sexually transmitted diseases among hiv positive msm in antwerp, belgium, 2001-2011

Recurrent Sexually Transmitted Infections (STIs) are an indication of unsafe sexual practices and may be associated with HCV-infection among HIV-positive men who have sex with men. In a retrospective study we analysed the laboratory data of 99 HIV-positive MSM who acquired HCV during the observation period (cases) and 176 HIV-positive MSM who remained HCV negative during the observation period (controls), all followed at the HIV/STI-clinic in Antwerp, Belgium. All laboratory confirmed STI-episodes were recorded since the date of first consultation at our clinic, until the date of HCV-diagnosis of the cases. The HCV incidence varied between 0.24 (2001) and 1.36 (2011) new cases per hundred person-years, with a peak of 2.93 new cases per hundred person-years in 2009. The number of STI-episodes per person-year follow-up was significantly higher for the cases as compared to the controls for syphilis, non-LGV and LGV Chlamydia infections (p < 0.005). When considering the incidence of STIs that occurred 1 year prior to HCV conversion, all laboratory confirmed STIs remained more frequent among cases, but only the difference in syphilis incidence was statistically significant (p < 0.01). Recurrent STIs among HIV positive MSM should be considered as a behavioural and biological risk factor for acquiring HCV and should lead to intensified screening for HCV and counselling of the patient.

Evaluation of the 2007 WHO guideline to diagnose smear negative tuberculosis in an urban hospital in Ethiopia

Background

The 2007 World Health Organization (WHO) guideline to diagnose smear-negative tuberculosis (TB) in HIV-prevalent settings was mainly based on expert advice and therefore requires evaluation in real life situations.

Methods

In 2009, this guideline was introduced at the ALERT hospital in Ethiopia. From October 2009 to January 2011, the accuracy of the guideline was evaluated using Mycobacterium tuberculosis culture positivity as reference standard in HIV positive TB suspects.

Results

A total of 459 TB suspects were enrolled during the study period; 336 (73.2%) were HIV positive. Acid fast bacilli sputum smear microscopy was done for 74.7% (251/336) HIV positive TB suspects; 94.4% (237/251) were smear negative. A chest X-ray was performed in 92.8% (220/237) and a Mycobacterium tuberculosis culture in 63.7% (151/237). The median TB diagnostic delay for smear negative cases was 3 days (interquartile range 3–4 days). Of the 75 patients diagnosed with smear negative pulmonary TB, 89. 4% (67/75) were diagnosed by chest X-ray, 9.4% (7/75) by culture and 1.3% (1/75) by clinical suspicion only. In 147 smear negative TB suspects Mycobacterium tuberculosis culture and chest X-ray results were available. Among these 147 patients, the sensitivity of the chest X-ray to diagnose smear negative TB in HIV-positive TB suspects was 53.3% (95% CI: 26.7-78.7); the specificity 67.4% (95% CI: 58.7-75.3).

Conclusion

The 2007 WHO diagnostic algorithm for the diagnosis of smear negative TB is likely to reduce the diagnostic delay and therefore decrease morbidity and mortality of TB in a HIV prevalent settings like Ethiopia.

Sexually transmitted infections: what's new?

Since the beginning of the third millennium the incidence of Sexually Transmitted Infections (STIs) is rising in Europe and in Belgium, and this after a steady decline in the second half of last century. It concerns new or lesser known diseases such as Hepatitis C and Lymphogranuloma venereum (LGV) and 'old' diseases such as gonorrhoea and syphilis, occurring in specific risk groups. In this article we give an update of the diagnostic means and therapeutic challenges that are of interest for the clinician. Besides these (re)-emerging diseases we touch on Human Papillomavirus (HPV) and Herpes Simplex (HSV). This selection of diseases is based on the daily experience of the clinicians working in the STI clinic of the Institute of Tropical Medicine in Antwerp. Data and clinical guidelines are derived from the Scientific Institute of Public Health in Brussels, the European and American Centers for Disease Control and Prevention, and the Guidelines of the Flemish Agency for Care and Health. New evolutions in diagnostics, prevention and treatment options make it necessary to regularly update the knowledge of this group of diseases, especially when they are complicated by HIV co-infection. As the incidence of neither HIV nor STIs seem to decrease in Belgium and Europe, it remains necessary to stay aware of the state-of-the-art management.

Voluntary outreach counselling and testing for HIV and STI among men who have sex with men in Antwerp

BACKGROUND

High risk settings for transmission of HIV and sexually transmitted infections (STI) offer an opportunity for screening of difficult to reach risk groups.

METHODS

Free, anonymous counselling and testing for HIV, syphilis, Chlamydia and hepatitis B/C were offered to visitors in two selected gay venues in Antwerp, by a multidisciplinary team. Participants completed an anonymous questionnaire. The STI-test results were communicated by cell phone using standardised text messages.

RESULTS

In total, 137 MSM were tested. Facilitators of risky sexual behaviour (alcohol and drug use) were reported by 34 and 21%, respectively. Four men (3%) were newly diagnosed with HIV; 25 men (18%) had an active, transmittable STI. Infected MSM were significantly less often registered with a fixed general practitioner (GP).

CONCLUSIONS

Outreach testing in gay venues is a suitable method to detect MSM at risk for HIV/STI. Although the outreach approach is very labour intensive, it shows a high yield of new STI-diagnoses that are not detected in the regular health system.

Tuberculosis lymphadenitis in Southwest Ethiopia: a community based cross-sectional study

BACKGROUND

In Ethiopia where there is no strong surveillance system and diagnostic facilities are limited, the real burden of tuberculosis (TB) lymphadenitis is not well known. Therefore, we conducted a study to estimate the prevalence of TB lymphadenitis in Southwest Ethiopia.

METHODS

A community based cross-sectional study was conducted from February to March 2009 in the Gilgel Gibe field research area. A total of 30,040 individuals 15 years or older in 10,882 households were screened for TB lymphadenitis. Any individual 15 years or older with lumps in the neck, armpits or groin up on interview were considered TB lymphadenitis suspect. The diagnosis of TB lymphadenitis was established when acid fast bacilli (AFB) smear microscopy of fine needle aspiration (FNA) sample, culture or cytology suggested TB. HIV counseling and testing was offered to all TB lymphadenitis suspects. Descriptive and bivariate analysis was done using SPSS version 15.

RESULTS

Complete data were available for 27,597 individuals. A total of 87 TB lymphadenitis suspects were identified. Most of the TB lymphadenitis suspects were females (72.4%). Sixteen cases of TB lymphadenitis were confirmed. The prevalence of TB lymphadenitis was thus 58.0 per 100,000 people (16/27,597) (95% CI 35.7-94.2). Individuals who had a contact history with chronic coughers (OR 5.58, 95% CI 1.23-25.43) were more likely to have TB lymphadenitis. Lymph nodes with caseous FNA were more likely to be positive for TB lymphadenitis (OR 5.46, 95% CI 1.69-17.61).

CONCLUSION

The prevalence of TB lymphadenitis in Gilgel Gibe is similar with the WHO estimates for Ethiopia. Screening of TB lymphadenitis particularly for family members who have contact with chronic coughers is recommended. Health extension workers could be trained to screen and refer TB lymphadenitis suspects using simple methods.

Relatively low primary drug resistant tuberculosis in southwestern Ethiopia

Background

The prevalence of drug resistant tuberculosis (TB) in Ethiopia in general, and Jimma area in particular, is not well documented. We conducted a study at Jimma University specialized hospital in southwest Ethiopia among new cases of smear positive TB patients to determine the pattern of resistance to first-line drugs.

Methods

A health institution based cross sectional study was conducted from November 2010 to September 2011. Any newly diagnosed smear positive TB patient 18 years and above was included in the study. Demographic and related data were collected by trained personnel using a pretested structured questionnaire. Mycobacterial drug susceptibility testing (DST) to the first line drugs isoniazid (INH), rifampicin (RIF), ethambutol (EMB) and streptomycin (STM) was performed on cultures using the indirect proportion method. M. tuberculosis complex (MTBC) was identified with the Capilia TB-Neo test.

Results

136 patients were enrolled in the study. Resistance to at least one drug was identified in 18.4%. The highest prevalence of resistance to any drug was identified against INH (13.2%) followed by STM (8.1%). There was no statistically significant difference in the proportion of any resistance by sex, age, HIV status and history of being imprisoned. The highest mono resistance was observed against INH (7.4%). Mono resistance to streptomycin was associated with HIV infection (crude OR 15.63, 95%CI: 1.31, 187). Multidrug-resistance TB (MDR-TB) was observed in two patients (1.5%).

Conclusion

Resistance to at least one drug was 18.4% (INH-13.2% and STM-8.1%). STM resistance was associated with HIV positivity. There was relatively low prevalence of MDR-TB yet INH resistance was common around Jimma. The capacity of laboratories for TB culture and DST should be strengthened, in order to correctly manage TB patients and avoid amplification of drug resistance.

Prevalence of pulmonary TB and spoligotype pattern of Mycobacterium tuberculosis among TB suspects in a rural community in Southwest Ethiopia

Background

In Ethiopia where there is no strong surveillance system and state of the art diagnostic facilities are limited, the real burden of tuberculosis (TB) is not well known. We conducted a community based survey to estimate the prevalence of pulmonary TB and spoligotype pattern of the Mycobacterium tuberculosis isolates in Southwest Ethiopia.

Methods

A total of 30040 adults in 10882 households were screened for pulmonary TB in Gilgel Gibe field research centre in Southwest Ethiopia. A total of 482 TB suspects were identified and smear microscopy and culture was done for 428 TB suspects. Counseling and testing for HIV/AIDS was done for all TB suspects. Spoligotyping was done to characterize the Mycobacterium tuberculosis isolates.

Results

Majority of the TB suspects were females (60.7%) and non-literates (83.6%). Using smear microscopy, a total of 5 new and 4 old cases of pulmonary TB cases were identified making the prevalence of TB 30 per 100,000. However, using the culture method, we identified 17 new cases with a prevalence of 76.1 per 100,000. There were 4.3 undiagnosed pulmonary TB cases for every TB case who was diagnosed through the passive case detection mechanism in the health facility. Eleven isolates (64.7%) belonged to the six previously known spoligotypes: T, Haarlem and Central-Asian (CAS). Six new spoligotype patterns of Mycobacterium tuberculosis, not present in the international database (SpolDB4) were identified. None of the rural residents was HIV infected and only 5 (5.5%) of the urban TB suspects were positive for HIV.

Conclusion

The prevalence of TB in the rural community of Southwest Ethiopia is low. There are large numbers of undiagnosed TB cases in the community. However, the number of sputum smear-positive cases was very low and therefore the risk of transmitting the infection to others may be limited. Active case finding through health extension workers in the community can improve the low case detection rate in Ethiopia. A large scale study on the genotyping of Mycobacterium tuberculosis in Ethiopia is crucial to understand transmission dynamics, identification of drug resistant strains and design preventive strategies.

Evaluation of the 2007 WHO guideline to improve the diagnosis of tuberculosis in ambulatory HIV-positive adults

Background

In 2007 WHO issued a guideline to improve the diagnosis of smear-negative and extrapulmonary tuberculosis (EPTB) in HIV-positive patients. This guideline relies heavily on the acceptance of HIV-testing and availability of chest X-rays.

Methods and Findings

Cohort study of TB suspects in four tuberculosis (TB) clinics in Phnom Penh, Cambodia. We assessed the operational performance of the guideline, the incremental yield of investigations, and the diagnostic accuracy for smear-negative tuberculosis in HIV-positive patients using culture positivity as reference standard. 1,147 (68.9%) of 1,665 TB suspects presented with unknown HIV status, 1,124 (98.0%) agreed to be tested, 79 (7.0%) were HIV-positive. Compliance with the guideline for chest X-rays and sputum culture requests was 97.1% and 98.3% respectively. Only 35 of 79 HIV-positive patients (44.3%) with a chest X-ray suggestive of TB started TB treatment within 10 days. 105 of 442 HIV-positive TB suspects started TB treatment (56.2% smear-negative pulmonary TB (PTB), 28.6% smear-positive PTB, 15.2% EPTB). The median time to TB treatment initiation was 5 days (IQR: 2–13 days), ranging from 2 days (IQR: 1–11.5 days) for EPTB, over 2.5 days (IQR: 1–4 days) for smear-positive PTB to 9 days (IQR: 3–17 days) for smear-negative PTB. Among the 34 smear-negative TB patients with a confirmed diagnosis, the incremental yield of chest X-ray, clinical suspicion or abdominal ultrasound, and culture was 41.2%, 17.6% and 41.2% respectively. The sensitivity and specificity of the algorithm to diagnose smear-negative TB in HIV-positive TB suspects was 58.8% (95%CI: 42.2%–73.6%) and 79.4% (95%CI: 74.8%–82.4%) respectively.

Conclusions

Pending point-of-care rapid diagnostic tests for TB disease, diagnostic algorithms are needed. The diagnostic accuracy of the 2007 WHO guideline to diagnose smear-negative TB is acceptable. There is, however, reluctance to comply with the guideline in terms of immediate treatment initiation.

Uptake of provider-initiated counselling and testing among tuberculosis suspects, Ethiopia

SETTING

Twenty-seven health centres in Addis Ababa, Ethiopia.

OBJECTIVE

To assess the uptake of human immunodeficiency virus (HIV) testing among tuberculosis (TB) suspects in Addis Ababa, and to determine reasons for non-acceptance of the test.

DESIGN

From February to March 2009, new TB suspects identified in 27 health centres in Addis Ababa were offered HIV testing. Patients were interviewed by trained nurses using a pretested questionnaire.

RESULT

Of the 506 TB suspects, 59% were tested for HIV and accepted the test result. Individuals with knowledge about HIV counselling and testing procedures were 2.5 times more likely to be tested than individuals with poor knowledge. TB suspects who had previously been tested for HIV were twice as likely to accept HIV testing and to receive the result of the test (OR = 2.0, 95%CI 1.4-2.9). Government employees (OR = 2.8, 95%CI 1.2-6.3) and merchants (OR = 2.7, 95%CI 1.2-5.7) were more likely to be tested for HIV as compared to jobless individuals.

CONCLUSION

The TB control programme in Ethiopia should increase its educational efforts among all TB suspects, but especially among jobless individuals, to increase the uptake of HIV testing.

Knowledge, health seeking behavior and perceived stigma towards tuberculosis among tuberculosis suspects in a rural community in southwest Ethiopia

BACKGROUND

Perceived stigma and lack of awareness could contribute to the late presentation and low detection rate of tuberculosis (TB). We conducted a study in rural southwest Ethiopia among TB suspects to assess knowledge about and stigma towards TB and their health seeking behavior.

METHODS

A community based cross sectional survey was conducted from February to March 2009 in the Gilgel Gibe field research area. Any person 15 years and above with cough for at least 2 weeks was considered a TB suspect and included in the study. Data were collected by trained personnel using a pretested structured questionnaire. Logistic regression analysis was done using SPSS 15.0 statistical software.

RESULTS

Of the 476 pulmonary TB suspects, 395 (83.0%) had ever heard of TB; "evil eye" (50.4%) was the commonly mentioned cause of TB. Individuals who could read and write were more likely to be aware about TB [(crude OR = 2.98, (95%CI: 1.25, 7.08)] and more likely to know that TB is caused by a microorganism [(adjusted OR = 3.16, (95%CI: 1.77, 5.65)] than non-educated individuals. Males were more likely to know the cause of TB [(adjusted OR = 1.92, (95%CI: 1.22, 3.03)] than females. 51.3% of TB suspects perceived that other people would consider them inferior if they had TB. High stigma towards TB was reported by 199(51.2%). 220 (46.2%) did not seek help for their illness. Individuals who had previous anti-TB treatment were more likely to have appropriate health seeking behavior [(adjusted OR = 3.65, (95%CI: 1.89, 7.06)] than those who had not.

CONCLUSION

There was little knowledge about TB in the Gilgel Gibe field research area. We observed inappropriate health seeking behavior and stigma towards TB. TB control programs in Ethiopia should educate rural communities, particularly females and non-educated individuals, about the cause and the importance of early diagnosis and treatment of TB.

Hepatitis C virus infection in HIV-infected men who have sex with men: sustained rising incidence in Antwerp, Belgium, 2001–2009

During the last decade, outbreaks of acute hepatitis C virus (HCV) infection have been reported among human immunodeficiency virus (HIV)-infected men who have sex with men (MSM) in several European countries. To study this emerging infection in MSM in Antwerp, Belgium, we reviewed all cases of newly acquired HCV infection in HIV-positive MSM followed from 2001 to 2009 at the HIV/sexually transmitted infection (STI) reference clinic of the Institute of Tropical Medicine in Antwerp. Newly acquired HCV infection was considered as certain or probable according to local definitions. During the study period, 69 episodes of newly acquired HCV infection (40 certain and 29 probable) were diagnosed in 67 HIV-infected MSM. In only 10 episodes (14%) were the patients symptomatic. The annual incidence of HCV infection in our population of HIV-infected MSM rose steadily from 0.2% in 2001 to 1.51% in 2008, and then peaked to 2.9% in 2009. For 60 episodes (87%), another STI (mainly syphilis and lymphogranuloma venereum) had been diagnosed within the six months before the diagnosis of HCV infection. All but one patient with available genotyping (n=54) were found to be infected with the difficult-to-treat HCV genotypes 1 or 4. Our results therefore demonstrate the rising incidence of HCV infection in HIV-positive MSM in Antwerp, since 2001, which reached an alarming level in 2009. Targeted awareness campaigns and routine screening are urgently needed to limit further HCV spread and its expected long-term consequences.

Hepatitis C virus infection in HIV-infected men who have sex with men: sustained rising incidence in Antwerp, Belgium, 2001-2009

During the last decade, outbreaks of acute hepatitis C virus (HCV) infection have been reported among human immunodeficiency virus (HIV)-infected men who have sex with men (MSM) in several European countries. To study this emerging infection in MSM in Antwerp, Belgium, we reviewed all cases of newly acquired HCV infection in HIV-positive MSM followed from 2001 to 2009 at the HIV/sexually transmitted infection (STI)reference clinic of the Institute of Tropical Medicine in Antwerp. Newly acquired HCV infection was considered as certain or probable according to local definitions. During the study period, 69 episodes of newly acquired HCV infection (40 certain and 29 probable) were diagnosed in 67 HIV-infected MSM. In only 10 episodes (14%) were the patients symptomatic. The annual incidence of HCV infection in our population of HIV-infected MSM rose steadily from 0.2% in 2001 to 1.51% in 2008, and then peaked to 2.9% in 2009. For 60 episodes (87%), another STI (mainly syphilis and lymphogranuloma venereum) had been diagnosed within the six months before the diagnosis of HCV infection. All but one patient with available genotyping (n=54) were found to be infected with the difficult to-treat HCV genotypes 1 or 4. Our results therefore demonstrate the rising incidence of HCV infection in HIV-positive MSM in Antwerp, since 2001, which reached an alarming level in 2009. Targeted awareness campaigns and routine screening are urgently needed to limit further HCV spread and its expected long-term consequences.

Common mental disorders in TB/HIV co-infected patients in Ethiopia

Background-

The relationship between TB/HIV co-infection and common mental disorders (CMD) has been scarcely investigated. In this study, we compared the occurrence of CMD in TB/HIV co-infected and non-co-infected HIV patients in Ethiopia.

Methods-

We conducted a cross sectional study in three hospitals in Ethiopia from February to April, 2009. The study population consisted of 155 TB/HIV co-infected and 465 non-co-infected HIV patients. CMD was assessed through face to face interviews by trained clinical nurses using the Kessler 10 scale. Several risk factors for CMD were assessed using a structured questionnaire.

Results-

TB/HIV co-infected patients had significantly (p = 0.001) greater risk of CMD (63.7%) than the non-co-infected patients (46.7%). When adjusted for the effect of potential confounding variables, the odds of having CMD for TB/HIV co-infected individuals was 1.7 times the odds for non-co-infected patients [OR = 1.7, (95%CI: 1.0, 2.9)]. Individuals who had no source of income [OR = 1.7, (95%CI: 1.1, 2.8)], and day labourers [OR = 2.4, 95%CI: 1.2, 5.1)] were more likely to have CMD as compared to individuals who had a source of income and government employees respectively. Patients who perceived stigma [OR = 2.2, 95%CI: 1.5, 3.2)] and who rate their general health as "poor" [OR = 10.0, 95%CI: 2.8, 35.1)] had significantly greater risk of CMD than individual who did not perceive stigma or who perceived their general health to be "good".

Conclusion-

TB/HIV control programs should develop guidelines to screen and treat CMD among TB/HIV co-infected patients. Screening programs should focus on individuals with no source of income, jobless people and day labourers.

Prejudice and misconceptions about tuberculosis and HIV in rural and urban communities in Ethiopia: a challenge for the TB/HIV control program

Background

In Ethiopia, where HIV and tuberculosis (TB) are very common, little is known about the prejudice and misconceptions of rural communities towards People living with HIV/AIDS (PLHA) and TB.

Methods

We conducted a cross sectional study in Gilgel Gibe Field Research area (GGFRA) in southwest Ethiopia to assess the prejudice and misconceptions of rural and urban communities towards PLHA and TB. The study population consisted of 862 randomly selected adults in GGFRA. Data were collected by trained personnel using a pretested structured questionnaire. To triangulate the findings, 8 focus group discussions among women and men were done.

Results

Of the 862 selected study participants, 750(87%) accepted to be interviewed. The mean age of the respondents was 31.2 (SD ± 11.0). Of the total interviewed individuals, 58% of them were females. More than half of the respondents did not know the possibility of transmission of HIV from a mother to a child or by breast feeding. For fear of contagion of HIV, most people do not want to eat, drink, and share utensils or clothes with a person living with HIV/AIDS. A higher proportion of females [OR = 1.5, (95% CI: 1.0, 2.2)], non-literate individuals [OR = 2.3, (95%CI: 1.4, 3.6)], rural residents [OR = 3.8, (95%CI: 2.2, 6.6)], and individuals who had poor knowledge of HIV/AIDS [OR = 2.8, (95%CI: 1.8, 2.2)] were more likely to have high prejudice towards PLHA than respectively males, literates, urban residents and individuals with good knowledge. Exposure to cold air was implicated as a major cause of TB. Literates had a much better knowledge about the cause and methods of transmission and prevention of TB than non-literates. More than half of the individuals (56%) had high prejudice towards a patient with TB. A larger proportion of females [OR = 1.3, (95% CI: 1.0, 1.9)] and non-literate individuals [OR = 1.4, (95% CI: 1.1, 2.0)] had high prejudice towards patients with TB than males and literate individuals.

Conclusion

TB/HIV control programs in collaboration with other partners should invest more in social mobilization and education of the communities to rectify the widespread prejudice and misconceptions.

Tuberculosis and HIV co-infection: its impact on quality of life

Background-

Very little is known about the quality of life of tuberculosis (TB) and HIV co-infected patients. In this study in Ethiopia, we compared the quality of life HIV positive patients with and without TB.

Methods-

A cross sectional study was conducted from February to April, 2009 in selected hospitals in Oromiya Regional state, Ethiopia. The study population consisted of 467 HIV patients and 124 TB/HIV co-infected patients. Data on quality of life was collected by trained nurses through face to face interviews using the short Amharic version of the World Health Organization Quality of Life Instrument for HIV clients (WHOQOL HIV). Depression was assessed using a validated version of the Kessler scale. Data was collected by trained nurses and analyzed using SPSS 15.0 statistical software.

Results

TB/HIV co-infected patients had a lower quality of life in all domains as compared to HIV infected patients without active TB. Depression, having a source of income and family support were strongly associated with most of the Quality of life domains. In co-infected patients, individuals who had depression were 8.8 times more likely to have poor physical health as compared to individuals who had no depression, OR = 8.8(95%CI: 3.2, 23). Self-stigma was associated with a poor quality of life in the psychological domain.

Conclusion-

The TB control program should design strategies to improve the quality of life of TB/HIV co-infected patients. Depression and self-stigma should be targeted for intervention to improve the quality of life of patients.

Drug-resistant TB and HIV in resource-limited settings: what TB/HIV programmes can learn from each other

Although management of drug resistance in tuberculosis (TB) and HIV in poor settings is in its infancy, lessons learned from TB may be relevant to HIV and vice versa. The experience with HIV has shown that rapid scale-up and lower drug pricing are achievable goals. The current prerequisites for obtaining drugs to treat multidrug-resistant TB (MDR-TB) may be too stringent given the immediacy of the MDR-TB problem. We call for a more rapid roll-out of treatment for MDR-TB with fewer administrative encumbrances and a greater sense of urgency in national TB control programmes. On the other hand, antiretroviral roll-out programmes should learn from the genesis of the MDR-TB problem; laboratory monitoring should be enhanced and compliance optimized to avoid the acquisition of additional drug resistance in HIV.

Predominance of a single genotype of Mycobacterium tuberculosis in regions of Southern Africa

SETTING

Zimbabwe and Zambia.

OBJECTIVE

To determine the genetic diversity of Mycobacterium tuberculosis strains isolated from tuberculosis (TB) patients in Zimbabwe and Zambia.

DESIGN

M. tuberculosis isolates cultured from TB patients presenting at referral hospitals in Zimbabwe and health care clinics in Zambia were characterised by IS6110 genotyping and/or spoligotyping using internationally standardised methods. Genotypic data were compared to those from Cape Town and the SpolDB3.0 database.

RESULTS

A predominant group of strains could be identified among 116/246 (47.2%) Zimbabwean isolates by their characteristic IS6110-banding pattern and unique spoligotype signature, where spacers 21-24, 27-30 and 33-36 were deleted. Comparison with strains from Cape Town showed that they were closely related to a family of strains present in 2.3% of Cape Town patients. Comparison of the spoligotypes with those obtained from 114 isolates from Zambia showed that 74 (65%) of these isolates had the same spoligotype signature. Spoligotypes in the SpolDB3.0 database showed that this group of strains was rarely isolated in other parts of the world, but was commonly isolated in Southern Africa.

CONCLUSION

A predominant group of strains infecting approximately half of the patients in the study are major contributors to the TB epidemic in this region. We have designated this group of strains the Southern Africa 1 (SAF1) family.

Tuberculosis in resource poor countries

Better access to antiretroviral therapy and isoniazid prophylaxis offer new opportunities for control

Simultaneous activation of viral antigen-specific memory CD4+ and CD8+ T-cells using mRNA-electroporated CD40-activated autologous B-cells

Recently, it has become obvious that not only CD8 T-cells, but also CD4 T-helper cells are required for the induction of an effective, long-lasting cellular immune response. In view of the clinical importance of cytomegalovirus (CMV) and human immunodeficiency virus (HIV) infection, we developed 2 strategies to simultaneously reactivate viral antigen-specific memory CD4 and CD8 T-cells of CMV-seropositive and HIV-seropositive subjects using mRNA-electroporated autologous CD40-activated B cells. In the setting of HIV, we provide evidence that CD40-activated B cells can be cultured from HAART-naive HIV-1 seropositive patients. These cells not only express and secrete the HIV p24 antigen after electroporation with codon-optimized HIV-1 gag mRNA, but can also be used to in vitro reactivate Gag antigen-specific interferon-gamma-producing CD4 and CD8 autologous T-cells. For the CMV-specific approach, we applied mRNA coding for the pp65 protein coupled to the lysosomal-associated membrane protein-1 to transfect CD40-activated B cells to induce CMV antigen-specific CD4 and CD8 T-cells. More detailed analysis of the activated interferon-gamma-producing CMV pp65 tetramer positive CD8 T-cells revealed an effector memory phenotype with the capacity to produce interleukin-2. Our findings clearly show that the concomitant activation of both CD4 and CD8 (memory) T-cells using mRNA-electroporated CD40-B cells is feasible in CMV and HIV-1-seropositive persons, which indicates the potential value of this approach for application in cellular immunotherapy of infectious diseases.

Review editorial: prevention of tuberculosis in resource-poor countries with increasing access to highly active antiretroviral treatment

The administration of isoniazid (INH) has been proposed, evaluated and implemented to prevent tuberculosis (TB) disease among patients who are infected with the human immunodeficiency virus (HIV). This strategy has been developed in communities where TB is highly endemic and at a time when antiretroviral (ARV) treatment was not, or was rarely available. Although INH prevention programmes were somewhat pushed to the background due to the worldwide advocacy for ARV drugs, prevention of TB remains of paramount importance. The dual HIV-TB infection poses problems, not only for the individual and his/her clinician but also for the programme manager. We review various aspects of TB preventive treatment in countries with a high prevalence of HIV-TB co-infection and limited resources but with increasing access to ARV treatment.