pre-ART Group Research Articles

Human growth hormone, a marker for HIV infection among adult Igbo Nigerians: relationship between human growth hormone and CD4+ count with viral load.

Routine viral load and CD4+ testing is key to monitoring the extent of danger caused by HIV and response to antiretroviral therapy (ART) for HIV individuals, but its availability has been limited in low and middle-income countries. The study sort to ascertain relationship between serum Human Growth Hormone (HGH) gold standard with CD4 cells and viral load in HIV-infected patients. CD4+ T-cells, HIV viral load, and HGH were assayed in HIV- infected patients from May to December 2020. 460 subjects were engaged and separated into two groups: the HIV-infected untreated (Pre-ART) and the control groups. An interventional study was conducted for the Pre-Art group after six months. Serum HGH was assayed by the ELISA method, CD4 cell count was examined by BD-FACScan flow cytometer, and HIV viral load was assessed using RT-PCR. The CD4 count and serum HGH of Pre-ART HIV-infected subjects were significantly low (p<0.05), while the viral load was significantly high compared to those treated with ART for 6months (p<0.05). CD4 count and serum HGH were significantly higher (p<0.05) in females than in males. It also reveals that CD4 count correlates positively with HGH level (r= 0.191**). Serum HGH could serve as a surrogate marker and valuable index in monitoring HIV patients.

The Popularization Power and Hot Spots of ART by Analyzing the Dataset for Doctor from “Hao Daifu” Platform

Objective: To indicate the spreading power and content for science popularization works, the science popularization works for the text and video forms of one author in the field of ART were analyzed here, which would provide for the plausible reference for the transmission of science popularization knowledge in the field of ART. Methods: A total of 176 science popularization works published by the same doctor in the field of ART on "Hao Daifu" platform from May to June 2019 were selected and analyzed here. According to the forms. the works were divided into video group (109 cases) and text group (67 cases), respectively, and the transmission competence power for works of the two groups were analyzed. According to the contents, the works were also divided into pre-ART stage group (83 cases), ART stage group (56 cases) and after ART stage group (37 cases), the top 10 hot spots of the works and the top 9 issues with the number of liking works were also detected. Results: The transmission competence power of video group was significantly higher than that of text group (<I>P<0.001</I>). No significant difference in transmission competence power between the pre-ART stage group and other two groups was detected, the hots issues of stage pre-ART and that of after ART stage group (<I>P>0.05</I>) were paid more attention, the transmission competence power of the ART stage group was lower than that of the after ART stage group (<I>P<0.05</I>), there was no significant differences among the other groups (<I>P>0.05</I>). Conclusion: Compared with text, videos were much more popular. In terms of popularization of ART, the topics for pre-ART stage group and after ART stage group were more popular than that of stage for ART.

Reaching the Unreached: Providing Quality Care to HIV-Infected Children through Telemedicine-An Innovative Pilot Initiative from Maharashtra, India.

Background The National AIDS Control Organization (NACO) of India created the Regional Pediatric Antiretroviral Therapy (ART) Center; this was subsequently upgraded to seven Pediatric Centers of Excellence (PCoEs) to strengthen the quality of treatment and care of children living with HIV/AIDS (CLHAs). In October 2013, the pediatric HIV telemedicine initiative, an e-decentralized (care provided by local healthcare providers and support provided by a central agency through telemedicine facilities) model of expert pediatric HIV care and referral services, was established as a pilot project at the Pediatric Center of Excellence for HIV Care in Maharashtra. We designed the present study to compare management, compliance to ART, and mortality in children in the ART centers linked to the PCoE through telemedicine versus those that are not linked to the PCoE. Methods It was a retrospective cross-sectional study of secondary data from CLHAs from October 2013 through August 2015 in the ART centers to document the intermediate outcomes and to determine if the initiative has improved the quality of care for the CLHAs enrolled in the linked ART centers with nonlinked ART centers. The centers in which the telemedicine sessions were conducted regularly were called linked-regular centers and in whom it was conducted irregularly (less than the median of 12 videoconference cases), it was called a linked-irregular center. Data from 2803 children in 31 linked (1365 in irregular and 1438 in regular centers) and 2608 children in 28 nonlinked centers were analyzed. The outcomes in children in the pre-ART group (ART naïve) were (1) alive on pre-ART, (2) lost to follow-up on pre-ART, (3) death during the pre-ART period, (4) eligible but not initiated on ART, and (5) missing baseline and latest CD4 counts. The outcomes of children on ART were (1) alive on ART, (2) lost to follow-up on ART, (3) death on ART, and (4) missing baseline and latest CD4 counts. Results We found that a higher proportion of children in the linked-regular centers (79% vs. 70%, p < 0.001) and linked-irregular centers (76% vs. 70%, p = 0.04) was alive compared with that in the nonlinked centers in the pre-ART group. In this group, the proportion of children with missing baseline CD4 counts and latest CD4 counts was significantly low in linked (regular centers) centers. In the ART group, we found that a higher proportion of children in the linked-regular centers was alive compared with that in the linked-irregular centers (77% vs. 69%, p < 0.001); the proportion was not significantly different in nonlinked centers (77% vs. 78%, p = 0.56). In this group, the proportion of missing baseline CD4 counts was significantly lower in the linked-regular centers (3% vs 13%, p<0.001) and linked-irregular centers (1% vs. 13%, p < 0.001) compared with that in the nonlinked centers. Furthermore, the latest CD4 counts were missing in a significantly lower proportion of children in the linked-regular centers compared with those in the linked-irregular centers (6% vs. 18%, p < 0.001) and nonlinked centers (6% vs. 18%, p < 0.001). Conclusion Our study shows that the centers linked through telemedicine performed better in terms of patient care and treatment, with a lesser loss to follow-up and lesser deaths in CLHA. Overall, this pilot project of telemedicine for pediatric HIV has been proven to be acceptable, feasible, and effective in improving the quality of care for children living with HIV across the state of Maharashtra.

An Institutional Academic and Research Track Curriculum for Radiology Residents: Development, Implementation, and Outcomes Assessment at 6 Years

We report the creation of a voluntary research development curriculum for radiology residents at our institution, detailing outcomes after 6 years of existence. We developed a comprehensive Academic and Research Track (ART) curriculum for radiology residents in our department, including mentorship, monthly meetings, didactic curriculum, ongoing evaluation/feedback, protected academic time, and financial support. A literature review identified all indexed publications for our residency graduates from 6 years pre- (2007-2012) to 6 years post-ART (2013-2018) intervention. We also documented career outcomes (academic versus private practice). Summary statistics, Chi-square, and Poisson regression analyses were performed. ART group demonstrated significantly greater publication likelihood versus pre-ART predecessors (odds ratio [OR]: 3.59, 95% confidence intervals [CI]: 1.40-9.19; risk ratios [RR]: 1.58, 95% CI: 1.19-2.11; p= 0.01), contemporaneous non-ART cohort (OR: 3.03, 95% CI: 1.12-8.33; RR: 1.45, 95% CI: 1.08-1.96; p = 0.04), and combined pre-ART plus non-ART group (OR: 3.34, 95% CI: 1.35-8.22; RR: 1.41, 95% CI: 0.87-2.29; p = 0.012). In Poisson regression, ART was a significant factor for total, first author, and senior author publications among all graduates and among the subset which remained in academics (all p-values < 0.05). Estimators were positive in all regressions, indicating a positive effect of ART for increasing numbers of publications. ART membership was associated with significantly increased indexed publications. A greater proportion of ART members remained in academics compared to non-ART members, but did not reach statistical significance. We detail our ART structure and curriculum, which may be used as a malleable template for other radiology departments.

Prevalence And Predictors Of Opportunistic Infections Among HIV Positive Adults On Antiretroviral Therapy (On-ART) Versus Pre-ART In Addis Ababa, Ethiopia: A Comparative Cross-Sectional Study.

PurposeData comparing the burden of the opportunistic infections among the Pre-ART and On-ART HIV-infected patients in Ethiopia are scarce. Therefore, this study aimed to compare the prevalence and predictors of opportunistic infections in Pre-ART and On-ART HIV-infected patients.MethodsA comparative cross-sectional study was conducted among adult patients infected with HIV and who were on Pre-ART or On-ART and followed up from 2012 to 2016 in Zewditu Memorial Hospital, Addis Ababa. Those patients who were infected with HIV, but not eligible for ART were categorized under Pre-ART follow-up (n=192) and those patients who started taking ART were categorized under the On-ART follow-up group (n=192). Patients were included in the study by using simple random sampling technique from the list of the patients registered in the ART follow-up database. The presence of opportunistic infections along with clinical findings and baseline laboratory data was extracted from the ART follow-up database and the medical records of the patients using a standardized checklist. Factors associated with the development of opportunistic infections were analyzed using multi-variable binary logistic regression analysis.ResultsThe overall prevalence of opportunistic infections was found to be 33.6% (95% CI; 28.9–38.5). The prevalence of opportunistic infections among the Pre-ART group (38%) was higher than On-ART group (29.2%) (P-value = 0.04). Pulmonary tuberculosis was the most common opportunistic infection observed in both Pre-ART and On-ART groups. Being in the WHO clinical Stage III (AOR = 2.1; 95% CI 1.1–3.9) or Stage IV (AOR = 3.6; 95% CI 1.7–7.7) were independent predictors for the development of opportunistic infections.ConclusionThe prevalence of opportunistic infections among the HIV-infected patients who were in Pre-ART was higher than On-ART group. This finding reinforces the need for early initiation of ART for HIV-infected patients irrespective of their CD4 counts.

A clinico-epidemiological study of HIV infected children in western Rajasthan

Background: Assessment of clinico demographic characteristics of HIV infected children in western Rajasthan.Methods:All the children who were attending Antiretroviral treatment (ART) center for one year period were enrolled for study as pre-ART and ART group. All the data pertaining to clinical and demographic characteristics were recorded. They were further classified into clinical staging as per WHO guideline and immunological staging based on CD4 count in accordance with CDC classification of immunodeficiency.Results: Perinatal transmission is the most common mode of acquiring HIV in Pediatric age, who most commonly presented with Fever and diarrhoea along with failure to thrive. Tuberculosis and oral candidiasis were the commonest opportunistic infections in this geographic area. Conclusions: A proper history, detailed clinical examination and high index of suspicion would therefore help in making early diagnosis to institute an appropriate management plan.

Nutritional assessment of children infected with HIV on Pre-ART on ART

Introduction: PEM is one of the commonest manifestations of HIV in India. Malnutrition has a major impact on the outcome of HIV as it not only increases mortality but also results in an impaired response to ART. Nutritional status of children in HIV may affect the outcome of patients taking ART, hence this study was planned. In India there are very less studies to compare various anthropometrical measurements in children on ART and without ART. In this study nutrition of children on ART was compared with those without ART. Methods: All children who were confirmed HIV seropositive were included in this study. Nutritional assessment was done as per WHO classification and categorize as normal, stunting, wasting and under nutrition. Data was obtained and difference in proportion of wasting, stunting and underweight between ART and pre-ART group were analyzed by using SPSS software. It was Prospective case-control study. 1) Total 600 children below 12 years were registered in ART centre, out of which 125 pre-ART and 125 children on ART which came for follow up in ART OPD were enrolled in the study. Results: Underweight was most common type of malnutrition in both group, prevalence of underweight and wasting were more common in ART group as compared to pre–ART group. No difference in prevalence of stunting in both groups. Conclusion: There was statistically significant improvement in nutritional status (underweight and wasting) in ART group at the end of one year with no significant effect on stunting.

Diabetes mellitus among HIV-infected individuals in follow-up care at University of Gondar Hospital, Northwest Ethiopia

ObjectiveTo assess the prevalence of diabetes mellitus (DM) and associated factors among HIV-infected adults in northwest Ethiopia.DesignHospital-based cross-sectional study.SettingHIV clinic of the University of Gondar Hospital, Ethiopia.ParticipantsAll HIV-infected adults who...

Missed opportunities for retention in pre-ART care in Cape Town, South Africa.

BackgroundFew studies have evaluated access to and retention in pre-ART care.ObjectivesTo evaluate the proportion of People Living With HIV (PLWH) in pre-ART and ART care and factors associated with retention in pre-ART and ART care from a community cohort.MethodsA cross sectional survey was conducted from February – April 2011. Self reported HIV positive, negative or participants of unknown status completed a questionnaire on their HIV testing history, access to pre-ART and retention in pre-ART and ART care.Results872 randomly selected adults who reported being HIV positive in the ZAMSTAR 2010 prevalence survey were included and revisited. 579 (66%) reconfirmed their positive status and were included in this analysis. 380 (66%) had initiated ART with 357 of these (94%) retained in ART care. 199 (34%) had never initiated ART of whom 186 (93%) accessed pre-ART care, and 86 (43%) were retained in pre-ART care. In a univariable analysis none of the factors analysed were significantly associated with retention in care in the pre-ART group. Due to the high retention in ART care, factors associated with retention in ART care, were not analysed further.ConclusionRetention in ART care was high; however it was low in pre-ART care. The opportunity exists, if care is better integrated, to engage with clients in primary health care facilities to bring them back to, and retain them in, pre-ART care.

Incidence and mortality of tuberculosis before and after initiation of antiretroviral therapy: an HIV cohort study in India.

IntroductionIndia has the highest burden of tuberculosis (TB) in the world, but the epidemiology of HIV-associated TB is not well known.MethodsWe describe the incidence and the mortality of TB from HIV diagnosis to antiretroviral therapy (ART) initiation (pre-ART group) and after ART initiation (on-ART group) in an HIV cohort study in Anantapur, India. Multivariable analysis of factors associated with TB was performed using competing risk regression and restricted cubic spline methods.ResultsA total of 4590 patients and 3133 person-years (py) of follow-up were included in the pre-ART group, and 3784 patients and 4756 py were included in the on-ART group. In the pre-ART group, the incidence of TB was high during the first month after HIV diagnosis and dropped nearly four times soon after. In the on-ART group, the incidence of TB increased after ART initiation reaching a peak in the third month. The probability of having TB within 30 months was 22.3% (95% confidence interval [CI], 21.1–23.6) in the pre-ART group and 17.8% (95% CI, 16.3–19.3) in the on-ART group. In a multivariable analysis, women had a lower risk of TB in both groups. Poor socio-economical conditions were associated with an increased risk of TB in the pre-ART group, but not in the group on-ART. While the association between low CD4 counts and TB was strong in the pre-ART group, this association was weaker in the on-ART group, and the highest risk of TB was seen in those patients with CD4 counts around 110 cells/mm3. The cumulative incidence of mortality at 12 months in patients with TB was 29.6% (95% CI, 26.9–32.6) in pre-ART TB and 34.9% (95% CI, 31–39.1) in on-ART TB. Half deaths before ART initiation and two thirds of deaths after ART initiation occurred in patients with TB.ConclusionsThe high incidence and mortality of TB seen in this study underscore the urgent need to improve the prevention and diagnosis of HIV-associated TB in India. We found substantial differences between TB before and after ART initiation.

Sexual risk after HIV diagnosis: a comparison of pre‐ART individuals with CD4&gt;500 cells/µl and ART‐eligible individuals in a HIV treatment and care programme in rural KwaZulu‐Natal, South Africa

IntroductionLittle is known about people diagnosed as HIV-positive who access HIV care early in their disease. In pre-ART studies published to date, only a minority of the participants have CD4>500 cells/µl.MethodsThis cross-sectional study compared individuals presenting for HIV care with CD4>500 cells/µl, “pre-ART” (N=247), with individuals who had CD4<200 cells/µl or WHO Stage IV, “ART-eligible” (N=385). Baseline characteristics were contrasted between the two groups and logistic regression models used to explore group differences in: (a) being sexually active in the last month; (b) disclosure of HIV status to current partner; (c) knowing the HIV status of one's current partner; and (d) condom use at last sex.ResultsPre-ART and ART-eligible individuals were similar in terms of a wide range of socio-demographic characteristics. Controlling for gender, only current sexual behaviour and HIV-testing history were significantly different between ART groups. In multivariable models, participants in the pre-ART group were twice as likely to be sexually active in the last month, OR 2.06 95% CI (1.32, 3.21), and to know their partner's status, OR 1.95 (1.18, 3.22) compared to those in the ART-eligible group. Self-reported disclosure of HIV status to current sexual partner (71%), condom use at last sex (61%) and HIV concordancy within relationships were not significantly different between the two ART groups. Overall, 39% of the study participants reported knowing that they were in concordant HIV-positive relationships. Fifty-five percent of all participants reported not knowing their partner's HIV status, only half of whom reported using a condom at last sex. Pre-ART individuals were significantly less likely to have tested HIV-positive for the first time in the last year and to have tested for sickness-related reasons than the ART-eligible group.ConclusionsReported sexual risk behaviours by pre-ART individuals with CD4>500 cells/µl suggest a continued risk of onward HIV transmission. There is a need for positive prevention efforts to target this group given that current treatment guidelines do not provide them with ART. Strengthening support regarding disclosure, partner HIV testing and consistent condom use, and further promotion of HIV testing in the community to assist earlier diagnosis are urgently required.

Effect of Antiretroviral Therapy on the Diagnostic Accuracy of Symptom Screening for Intensified Tuberculosis Case Finding in a South African HIV Clinic

Current symptom screening algorithms for intensified tuberculosis case finding or prior to isoniazid preventive therapy (IPT) in patients infected with human immunodeficiency virus (HIV) were derived from antiretroviral-naive cohorts. There is a need to validate screening algorithms in patients on antiretroviral therapy (ART). We performed cross-sectional evaluation of the diagnostic accuracy of symptom screening, including the World Health Organization (WHO) algorithm, to rule out tuberculosis in HIV-infected individuals pre-ART and on ART undergoing screening prior to IPT. A total of 1429 participants, 54% on ART, had symptom screening and a sputum culture result available. Culture-positive tuberculosis was diagnosed in 126 patients (8.8%, 95% confidence interval [CI], 7.4%-10.4%). The WHO symptom screen in the on-ART compared with the pre-ART group had a lower sensitivity (23.8% vs 47.6%), but higher specificity (94.4% vs 79.8%). The effect of ART was independent of CD4(+) count in multivariable analyses. The posttest probability of tuberculosis following a negative WHO screen was 8.9% (95% CI, 7.4%-10.8%) and 4.4% (95% CI, 3.7%-5.2%) for the pre-ART and on-ART groups, respectively. Addition of body mass index to the WHO screen significantly improved discriminatory ability in both ART groups, which was further improved by adding CD4 count and ART duration. The WHO symptom screen has poor sensitivity, especially among patients on ART, in a clinic where regular tuberculosis screening is practiced. Consequently, a significant proportion of individuals with tuberculosis would inadvertently be placed on isoniazid monotherapy despite high negative predictive values. Until more sensitive methods of ruling out tuberculosis are established, it would be prudent to do a sputum culture prior to IPT where this is feasible.

Providing universal access to antiretroviral therapy in Thyolo, Malawi through task shifting and decentralization of HIV/AIDS care

To describe how district-wide access to HIV/AIDS care was achieved and maintained in Thyolo District, Malawi. In mid-2003, the Ministry of Health and Médecins Sans Frontières developed a model of care for Thyolo district (population 587, 455) based on decentralization of care to health centres and community sites and task shifting. After delegating HIV testing and counseling to lay counsellors, uptake of testing increased from 1300 tests per month in 2003 to 6500 in 2009. Shifting responsibility for antiretroviral therapy (ART) initiations to non-physician clinicians almost doubled ART enrollment, with a majority of initiations performed in peripheral health centres. By the end 2009, 23, 261 people had initiated ART of whom 11, 042 received ART care at health-centre level. By the end of 2007, the universal access targets were achieved, with nearly 9000 patients alive and on ART. The average annual cost for achieving these targets was € 2.6 per inhabitant/year. The Thyolo programme has demonstrated the feasibility of district-wide access to ART in a setting with limited resources for health. Expansion and decentralization of HIV/AIDS service-capacity to the primary care level, combined with task shifting, resulted in increased access to HIV services with good programme outcomes despite staff shortages.

Reducing the Burden of Tuberculosis Presenting during the Initial Months of Antiretroviral Therapy in Resource‐Limited Settings

SIR-The high burden of tuberculosis (TB) within antiretroviral treatment (ART) programs in resource-limited settings is challenging [1,2]. We read with interest the article by Koenig and colleagues from Haiti in which they reported a very high mortality rate (27% at one year) among patients with TB diagnosed during the first 3 months of ART [3]. This observation is important and entirely consistent with other data from sub-Saharan Africa [1, 2]. It was also reported, however, that in both adjusted and unadjusted analyses, the mortality in this patient group was substantially greater than that of patients with either prevalent TB diagnosed pre-ART or incident TB diagnosed at some time beyond 3 months of ART [3]. Data from the latter two groups were pooled to form a combined comparator group with low overall TB risk. The much higher mortality risk of patients with TB presenting in early ART compared to that of patients with TB at baseline differs from the findings of previous studies [1,2] and we are concerned that this observation could be misinterpreted as showing a deleterious impact of ART on survival. We wonder whether this may be the result of patient selection. The mortality rate of patients with advanced immunodeficiency just prior to starting ART in resource limited settings is extremely high and TB in this period is difficult and time-consuming to diagnose [4–7]. Thus, many deaths occur in this period among patients with either diagnosed TB or unrecognised TB. Only selected patients in whom TB diagnosis was possible and who survived long enough to start ART could form the pre-ART group. Such patient selection may have substantially diminished the observed mortality risk of the pre-ART group. This would be consistent with the Kaplan Meier plot, which shows an unusually low frequency of deaths in the first 6 weeks of TB treatment in the comparator arm containing this patient group. Notwithstanding this potential limitation, we agree that TB is very likely to be an important contributor to early mortality in ART services [4]. The key question is how to tackle this problem. Koenig and colleagues suggested that many patients with incident TB during early ART are likely to have active TB that was present at baseline but remained undiagnosed. In agreement with this, we recently estimated that in our South African ART cohort, approximately 40% of the TB cases presenting in this period is due to ‘unmasking’ of asymptomatic or minimally symptomatic disease present at baseline [8]. Moreover, in a more recent study, all patients entering our program without a pre-existing TB diagnosis were (regardless of symptoms) systematically screened by culturing induced sputum samples. The yield of culture-confirmed TB diagnoses in these patients at baseline was extremely high (25%) [9] and was more that 2-fold higher than had been diagnosed during routine program screening in preceding years [1]. Of note, during the period of this study, the proportion of patients who presented with TB in the first 3 months of ART was correspondingly more than two-fold lower than previously observed. Thus, following the observation by Koenig and colleagues of the very high mortality rate among patients presenting with TB in the first 3 months of ART, we have found that effective baseline screening substantially reduces incident TB during this period. This suggests a need for routine pre-ART TB screening using high sensitivity tests, such automated liquid culture of sputum, and highlights an urgent need for much more rapid and sensitive diagnostics for use in this clinical setting. It remains to be demonstrated, however, whether this strategy would reduce mortality risk.