Understanding health systems challenges in providing Advanced HIV Disease (AHD) care in a hub and spoke model: a qualitative analysis to improve AHD care program in Malawi

BACKGROUND

Despite tremendous progress in antiretroviral therapy (ART) and access to ART, many patients have advanced human immunodeficiency virus (HIV) disease (AHD). Patients on AHD, whether initiating ART or providing care after disengagement, have an increased risk of morbidity and mortality. The Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) launched an enhanced care package using a hub-and-spoke model to optimize AHD care in Malawi. This model improves supply availability and appropriate linkage to care. We utilized a hub-and-spoke model to share health facility challenges and recommendations on the AHD package for screening and diagnosis, prophylaxis, treatment, and adherence support.

METHODS

This qualitative study assessed the facility-level experiences of healthcare workers (HCWs) and lay cadres (LCs) providing AHD services to patients through an intervention package. The study population included HCWs and LCs supporting HIV care at four intervention sites. Eligible study participants were recruited by trained Research Assistants with support from the health facility nurse to identify those most involved in supporting patients with AHD. A total of 32 in-depth interviews were conducted. Thematic content analysis identified recurrent themes and patterns across participants' responses.

RESULTS

While HCWs and LCs stated that most medications are often available at both hub and spoke sites, they reported that there are sometimes limited supplies and equipment to run samples and tests necessary to provide AHD care. More than half of the HCWs stated that AHD training sufficiently prepared them to handle AHD patients at both the hub and spoke levels. HCWs and LCs reported weaknesses in the patient referral system within the hub-and-spoke model in providing a linkage of care to facilities, specifically improper referral documentation, incorrect labeling of samples, and inconsistent availability of transportation. While HCWs felt that AHD registers were time-consuming, they remained motivated as they thought they provided better patient services.

CONCLUSIONS

These findings highlight the importance of offering comprehensive AHD services. The enhanced AHD program addressed weaknesses in service delivery through decentralization and provided services through a hub-and-spoke model, improved supply availability, and strengthened linkage to care. Additionally, addressing the recommendations of service providers and patients is essential to improve the health and survival of patients with AHD.

Spontaneous nosocomial Proteus mirabilis meningitis in a Human Immunodeficiency Virus (HIV)-infected adult patient: a case report

BACKGROUND

Gram-negative bacillary meningitis remains a rare occurrence, even in patients with human immunodeficiency virus. Current literature only describes anecdotal cases of spontaneous nosocomial Proteus mirabilis meningitis. This report describes the clinical manifestations and management of a patient with healthcare-associated spontaneous Gram-negative bacillary meningitis in a patient with advanced human immunodeficiency virus disease.

CASE PRESENTATION

A 23-year-old Congolese female was hospitalized in a human immunodeficiency virus specialized center for ongoing weight loss, chronic abdominal pain, and vomiting 9 months after initiation of treatment for tuberculosis meningitis. Hospitalization was complicated by healthcare-associated Gram-negative bacillary meningitis on day 18. Blood and cerebrospinal fluid cultures confirmed Proteus mirabilis. Antibiotic susceptibility testing showed extended spectrum beta-lactamase resistant to common antibiotics, and sensitive to meropenem. Despite initiation of high-dose meropenem by intravenous infusion (2 g every 8 hours), the patient did not improve, and died after 4 days of meropenem treatment. Gram-negative bacillary meningitis remains rare and is associated with an unfavorable prognosis.

CONCLUSIONS

This case report highlights the importance of microbiological identification of pathogens in resource-limited settings. As Gram-negative bacillary meningitis does not present with pleocytosis in patients with advanced human immunodeficiency virus, a negative lumbar puncture cannot exclude this diagnosis. Access to clinical bacteriology in resource-limited settings is essential to enable correct antibiotic treatment and avoid overuse of antibiotics to which there is already resistance. It further plays an essential role in public health by identifying antibiotic susceptibilities. Infection prevention and control measures must be reinforced in order to protect patients from such avoidable healthcare-associated infections.

Slipping through the cracks: a qualitative study to explore pathways of HIV care and treatment amongst hospitalised patients with advanced HIV in Kenya and the Democratic Republic of the Congo

Advanced HIV causes substantial mortality in sub-Saharan Africa despite widespread antiretroviral therapy coverage. This paper explores pathways of care amongst hospitalised patients with advanced HIV in rural Kenya and urban Democratic Republic of the Congo, with a view to understanding their care-seeking trajectories and poor health outcomes. Thirty in-depth interviews were conducted with hospitalised patients with advanced HIV who had previously initiated first-line antiretroviral therapy, covering their experiences of living with HIV and care-seeking. Interviews were audio-recorded, transcribed and translated before being coded inductively and analysed thematically. In both settings, participants' health journeys were defined by recurrent, severe symptoms and complex pathways of care before hospitalisation. Patients were often hospitalised after multiple failed attempts to obtain adequate care at health centres. Most participants managed their ill-health with limited support networks, lived in fragile economic situations and often experienced stress and other mental health concerns. Treatment-taking was sometimes undermined by strict messaging around adherence that was delivered in health facilities. These findings reveal a group of patients who had "slipped through the cracks" of health systems and social support structures, indicating both missed opportunities for timely management of advanced HIV and the need for interventions beyond hospital and clinical settings.

Predictors of late presentation and advanced HIV disease among people living with HIV in Oman (2000-2019)

Background

The aim of this study was to determine the proportions and predictors of late presentation (LP) and advanced HIV disease (AD) in Oman. LP and AD were defined as presenting with a baseline CD4 count of < 350 and < 200 cells/mm3, respectively.

Methods

We conducted a retrospective database analysis of the National HIV Surveillance System to identify Omani people (≥ 13 years old) who were diagnosed with HIV in the period between January 2000 and December 2019 and had a documented baseline CD4 cell count. We calculated the rates and trend over time of LP and AD. A logistic regression was carried out to determine the predictors of LP and AD.

Results

A total of 1418 patients, who were diagnosed with HIV in the period from January 2000 to December 2019, were included; 71% were male and 66% were heterosexuals. The median (IQR) age at diagnosis was 33 (25–39) years. Overall, 71% (95% CI: 68–73) and 46% (95% CI: 44–49) of patients had LP and AD at presentation, respectively. The LP percentage decreased from 76% in 2000–2004 to 69% in 2015–2019; AD percentage decreased from 57 to 46% over the same period. The proportions of men with LP and AD were higher than women (74% vs. 62 and 50% vs. 36%, respectively). The percentages of persons with LP among people aged 13–24, 25–49, and ≥ 50 years were 65, 71, and 84%, respectively. The proportions of persons with AD among people aged 13–24, 25–49, and ≥ 50 years were 39, 46, and 65%, respectively. Logistic regression showed that male sex, older age, having an “unknown” HIV risk factor, and living outside Muscat were independent predictors of AD. Male sex also independently predicted LP.

Conclusions

This analysis indicates that a significant proportion of new HIV cases in Oman continue to present late. This study identified patient subgroups at greatest risk of late HIV diagnosis such as men and older people. Targeted interventions and greater efforts to scale up HIV testing services in Oman are needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12048-1.

HIV-Associated Disseminated Histoplasmosis and Rare Adrenal Involvement: Evidence of Absence or Absence of Evidence

Adrenal histoplasmosis and primary adrenal insufficiency are mostly described in immunocompetent patients. This particular tropism is attributed to the presence of cortisol within the adrenal gland, a privileged niche for Histoplasma growth. In French Guiana, disseminated histoplasmosis is the main opportunistic infection in HIV patients. Our objective was to search in our HIV-histoplasmosis cohorts to determine how frequent adrenal insufficiency was among these patients. Between January 1, 1981 and October 1, 2014, a multicentric retrospective, observational study of histoplasmosis was conducted. Patients co-infected by HIV and histoplasmosis were enrolled in French Guiana’s histoplasmosis and HIV database. Among 349 cases of disseminated histoplasmosis between 1981 and 2014, only 3 had adrenal insufficiency (0.85%). Their respective CD4 counts were 10, 14 and 43 per mm3. All patients had regular electrolyte measurements and 234/349 (67%) had abdominal ultrasonography and 98/349 (28%) had abdominopelvic CT scans. None of these explorations reported adrenal enlargement. Overall, these numbers are far from the 10% reports among living patients and 80-90% among histoplasmosis autopsy series. This suggests 2 conflicting hypotheses: First, apart from acute adrenal failure with high potassium and low sodium, less advanced functional deficiencies, which require specific explorations, may have remained undiagnosed. The second hypothesis is that immunosuppression leads to different tissular responses that are less likely to incapacitate the adrenal function. Furthermore, given the general immunosuppression, the adrenal glands no longer represent a particular niche for Histoplasma proliferation.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Emergomycosis (Emergomyces africanus) in Advanced HIV Disease

In 2013, a novel thermally dimorphic fungal pathogen was described to cause disseminated disease among persons living with advanced HIV/AIDS in South Africa. Although the organism was initially described as an Emmonsia-like fungus, it is now known to belong to a new genus of thermally dimorphic fungi and was recently named Emergomyces africanus. There is considerable clinical and histopathological overlap between emergomycosis and histoplasmosis. This review addresses taxonomic, clinical, diagnostic, and therapeutic aspects of Es. africanus disease, a condition which has, to date, only been reported from southern Africa.

Advanced HIV disease at presentation to care in Nairobi, Kenya: late diagnosis or delayed linkage to care?--a cross-sectional study

Background

Presenting to care with advanced HIV is common in sub-Saharan Africa and increases the risk of severe disease and death; however, it remains unclear whether this is a consequence of late diagnosis or a delay in seeking care after diagnosis. The objectives of this cross-sectional study were to determine factors associated with advanced HIV at presentation to care and whether this was due to late diagnosis or delays in accessing care.

Methods

Between 2013 and 2015, adults presenting to care were recruited at two clinics in low-income areas of Nairobi, Kenya. Participants were considered to have advanced HIV if their CD4 count was below 200 cells/μL, or they were in WHO stage 4. Information on previous HIV diagnoses was collected using interviewer-administered questionnaires. Logistic regression was used to determine the association between clinical and socio-demographic factors and advanced HIV.

Results

Of 753 participants presenting to HIV care, 248 (33 %) had advanced HIV. Almost 60 % (146/248) of those presenting with advanced HIV had been previously diagnosed, most of whom (102/145; 70 %) presented to care within three months of their initial diagnosis. The median time to presentation to HIV care after an initial diagnosis was 22 days (IQR 6-147) for those with advanced HIV, compared to 19 days (IQR 4-119) for those with non-advanced HIV (p = 0.716). Clinic (adjusted odds ratio [AOR] 1.55, 95 % CI 1.09–2.20) and age (AOR 1.72 per unit increase in age category, 95 % CI 1.45–2.03) were associated with presenting with advanced HIV.

Conclusions

Presentation to care with advanced HIV was primarily due to delayed diagnosis, rather than delayed linkage to care after diagnosis. Variation by clinic suggests that outreach and other community-based efforts may drive earlier testing and linkage to care. Our findings highlight the ongoing importance of implementing strategies to encourage earlier HIV diagnosis, particularly among adults 30 years and older.