The Effect of Early Initiation of Antiretroviral Therapy in TB/HIV-Coinfected Patients: A Systematic Review and Meta-Analysis

BACKGROUND

The importance of early initiation of antiretroviral therapy (ART) for tuberculosis (TB) and HIV-coinfected patients is controversial. We conducted a systematic review and meta-analysis to assess the effect of early initiation of ART (within 2-4 weeks of TB treatment) on several treatment outcomes among TB/HIV-coinfected patients.

METHOD

A systematic search of clinical trials was performed in PubMed, Embase, Google Scholar, Science Direct, Medscape, and the Cochrane library. Clinical trials which were published in any language before the last date of search (March 31, 2015) were included. The qualities of the studies were assessed using criteria from the Cochrane Library. Heterogeneity test was conducted to assess the variations among study outcomes. For each study outcome, the risk ratio (RR) with 95% confidence interval (CI) was calculated as a measure of intervention effect. The Mantel-Haenszel method was used to estimate the RR using a fixed-effects model.

FINDINGS

A total of 2272 study participants from 6 trials were included in the meta-analysis. Early ART initiation during TB treatment was associated with reduced all-cause mortality (RR = 0.78; 95% CI = 0.63-0.98) and increased rate of TB-associated immune reconstitution inflammatory syndrome (TB-IRIS; RR = 2.19; 95% CI = 1.77- 2.70) and death related to TB-IRIS (RR = 6.94; 95% CI = 1.26-38.22). However, the time of ART initiation has no association with TB cure rate (RR = 0.99; 95% CI = 0.81-1.07), rate of drug toxicity (RR = 1.00; 95% CI = 0.93-1.08), death associated with drug toxicity (RR = 0.40; 95% CI = 0.14- 1.16), rate of low viral load (less than 400 copies/mL; RR = 1.00; 95% CI = 0.96-1.04), and rate of new AIDS-defining illness (RR = 0.84; 95% CI = 0.60-1.18). Immunological response in early ART arms of study participant in different trials showed a greater or equal response compared with late ART arms.

CONCLUSION

This systematic review presents conclusive evidence on the reduction of all-cause mortality as a result of early initiation of ART. However, this study also confirms the high rate of TB-IRIS and death associated with it. Operational and implementation research are required to maintain the benefit of early ART initiation and proper management of TB-IRIS. Studies on the timing of ART in extrapulmonary and multidrug-resistant TB are recommended.

Assessing coverage, equity and quality gaps in maternal and neonatal care in sub-saharan Africa: an integrated approach

Background

Gaps in coverage, equity and quality of health services hinder the achievement of the Millennium Development Goals 4 and 5 in most countries of sub-Saharan Africa as well as in other high-burden countries, yet few studies attempt to assess all these dimensions as part of the situation analysis. We present the base-line data of a project aimed at simultaneously addressing coverage, equity and quality issues in maternal and neonatal health care in five districts belonging to three African countries.

Methods

Data were collected in cross-sectional studies with three types of tools. Coverage was assessed in three hospitals and 19 health centres (HCs) utilising emergency obstetric and newborn care needs assessment tools developed by the Averting Maternal Death and Disability program. Emergency obstetrics care (EmOC) indicators were calculated. Equity was assessed in three hospitals and 13 HCs by means of proxy wealth indices and women delivering in health facilities were compared with those in the general population to identify inequities. Quality was assessed in three hospitals using the World Health Organization’s maternal and neonatal quality of hospital care assessment tool which evaluates the whole range of aspects of obstetric and neonatal care and produces an average score for each main area of care.

Results

All the three hospitals qualified as comprehensive EmOC facilities but none of the HCs qualified for basic EmOC. None of the districts met the minimum requisites for EmOC indicators. In two out of three hospitals, there were major quality gaps which were generally greater in neonatal care, management of emergency and complicated cases and monitoring. Higher access to care was coupled by low quality and good quality by very low access. Stark inequities in utilisation of institutional delivery care were present in all districts and across all health facilities, especially at hospital level.

Conclusion

Our findings confirm the existence of serious issues regarding coverage, equity and quality of health care for mothers and newborns in all study districts. Gaps in one dimension hinder the potential gains in health outcomes deriving from good performances in other dimensions, thus confirm the need for a three-dimensional profiling of health care provision as a basis for data-driven planning.

Evaluation of the modified Baermann's method in the laboratory diagnosis of Strongyloides stercoralis

This study compares the modified Baermann's method with the formol-ether concentration and the direct/saline techniques in the diagnosis of Strongyloides stercoralis larvae in stool specimens. This study was conducted at Wonji-Shewa Sugar Estate located at about 110 kms. south east of Addis Abeba. Of the 718 randomly selected and examined stool specimens, 125 were found positive for Strongyloides stercoralis. Of these 98% were recovered by the modified Baermann's method, 23% by the formol-ether, and 22% by the direct saline techniques. The rate of recovery by the modified Baermann's method was significantly different (p less than 0.001) compared with those of the direct and the formol-ether concentration techniques. There was no difference (p greater than 0.1) between the direct saline and the formol-ether methods. The modified Baermann's method accounted for over 60% of the total positive findings. Furthermore, the sensitivity of the method excelled the other two techniques by four fold. Thus, the modified Baermann's method by the Merck and Sharp Dohme Company is effective, cheap and simple to use and hence recommended for routine use and epidemiological surveys.

Cryptosporidiosis in children seen at the children's clinic of Yekatit 12 Hospital, Addis Ababa

The stools of 214 children under five years of age with diarrhoea were examined for Cryptosporidium oocysts using the Modified Ziehl Nelson Technique. Twelve (5.6%) of the children had Cryptosporidium oocysts in their faeces. All of these were above 6 months of age and were either partially or fully weaned. There were 15 exclusively breast fed children of whom 11 were less than 6 months of age. None of these cases had the evidence of Cryptosporidial infection. The present study indicates the importance of Cryptosporidium as a possible etiologic agent in patients with diarrhoeal diseases. However, a comprehensive investigation is needed in order to rule out other enteropathogens.

Efficiency of TB service provision in the public and private health sectors in Ethiopia

BACKGROUND: The Ethiopian Government has identified efficiency of TB services as a key priority in planning and budgeting. Understanding the magnitude and sources of inefficiencies is key to ensuring value for money and improved service provision, and a requirement from donors to justify resource needs. This study identifies the cost of providing a wide range of TB services in public and private facilities in Ethiopia.METHODS: Financial and economic unit costs were estimated from a health provider´s perspective, and collected retrospectively in 26 health facilities using both top-down (TD) and bottom-up (BU) costing approaches for each TB service output. Capacity inefficiency was assessed by investigating the variation between TD and BU unit costs where the factor was 2.0 or more.RESULTS: Overall, TD unit costs were two times higher than BU unit costs. There was some variation across facility ownership and level of care. Unit costs in urban facilities were on average 3.8 times higher than in rural facilities.CONCLUSION: We identified some substantial inefficiencies in staff, consumable and capital inputs. Addressing these inefficiencies and rearranging the TB service delivery modality would be important in ensuring the achievement of the country´s End TB strategy.

Parasight-F dipstick antigen test in the diagnosis of falciparum malaria in Ethiopia

OBJECTIVE

To determine the shelf life, rapidity and diagnostic performance of ParaSight-F.

DESIGN

Prospective randomised study.

SETTINGS

Malaria diagnostic and treatment posts and health centres in central-southern part of the Ethiopian Rift Valley.

SUBJECTS

Three hundred and eighty two subjects randomly selected.

MAIN OUTCOME MEASURES

Double blind evaluation of the sensitivity, specificity and predictive values of PFT versus CBF.

RESULTS

The point prevalence was found to be 29.7% with species dominance of P. falciparum to P. vivax in the ratio of 4:1. The ParaSight-F test showed, considering P. falciparum only, a sensitivity of 92.5% and specificity of 93%. A remarkably high positive predictive value (PPV) of 82% as well as a negative predictive value (NPV) of 99% was obtained. Considering all species of Plasmodium, sensitivity was 78.6% and specificity 93%, with PPV and NPV of 82% and 91% respectively. Moreover, PFT was found to be rapid with a batch of ten-strips--a rack completed in 30 to 50 minutes, which was five to six times faster than CBF reading. In shelf-life studies, after one year of storage at room temperature, results were found similar to the original readings, indicating the stability and long durability of the test strips.

CONCLUSION

In their durability and high diagnostic performances, both the microscopic slide readings and PFT were found comparable and interchangeable, and advantage in endemic areas where laboratory facilities are not available. The rapidity of PFT may be of greater value during malaria epidemics. But during non-epidemic seasons, the inability of PFT not to detect all forms of malaria remains a draw back.

A new suspected focus of Schistosoma haematobium in the Metema area, Gonder administrative region, north-west Ethiopia

Two cases of Schistosoma haematobium, one in a 10 year old boy who was born in Metema and had never left the area, and another from a Sudaness refugee, are reported. Further investigation is required to verify if S. haematobium has been imported from Sudan or is being transmitted in Metema.

Hookworm infection among the Melka Sedi banana plantation residents, middle Awash Valley, Ethiopia

A study of intestinal parasites was done among the people who lived within the banana plantation zone of the Melka Sedi Agricultural Enterprise, Awash Valley, Ethiopia in April 1987. The methods of parasite detection were the Ritchie formal ether and the charcoal culture method for hookworm larvae species identification. From the total 633 population, 311 were examined at random of whom 60.8% were positive for one or more intestinal parasites. Eight parasites were encountered, Ascaris lumbricoides in 1.3%, Trichuris trichiura in 6.4%, Strongyloides stercoralis in 3.9%, hookworm in 53.1%, Taenia sp. in 3.5%, Schistosoma mansoni in 1.9%, Entamoeba histolytica in 0.6% and Hymenolepis sp. in 0.6%. Prevalence of hookworm infection was significantly higher than that of any of the other parasites (p less than 0.001). In the hookworm infected individuals there were more males than females, and the 25 to 34 year age group had significantly higher infection rates (p less than 0.05). The majority of those with hookworm were banana plantation workers. This communication emphasizes the basic guidelines for control and prevention of hookworm and other related faecal/soil-borne infections in this and similar agricultural settings.