World Health Organization Clinical Stage Research Articles

Do loss to follow-up and death rates from ART care vary across primary health care facilities and hospitals in south Ethiopia? A retrospective follow-up study.

BackgroundDecentralization and task shifting has significantly improved access to antiretroviral therapy (ART). Many studies conducted to determine the attrition rate in Ethiopia have not compared attrition rates between hospitals and health centers in a relatively recent cohort of patients. This study compared death and loss to follow-up (LTFU) rates among ART patients in hospitals and health centers in south Ethiopia.MethodsData routinely collected from patients aged older than 15 years who started ART between July 2011 and August 2012 in 20 selected health facilities (12 being hospitals) were analyzed. The outcomes of interest were LTFU and death. The data were entered, cleaned, and analyzed using Statistical Package for the Social Sciences version 20.0 and Stata version 12.0. Competing-risk regression models were used.ResultsThe service years of the facilities were similar (median 8 and 7.5 for hospitals and health centers, respectively). The mean patient age was 33.7±9.6 years. The median baseline CD4 count was 179 (interquartile range 93–263) cells/mm3. A total of 2,356 person-years of observation were made with a median follow-up duration of 28 (interquartile range 22–31) months; 24.6% were either dead or LTFU, resulting in a retention rate of 75.4%. The death rates were 3.0 and 1.5 and the LTFU rate were 9.0 and 10.9 per 100 person-years of observation in health centers and hospitals, respectively. The competing-risk regression model showed that the gap between testing and initiation of ART, body mass index, World Health Organization clinical stage, isoniazid prophylaxis, age, facility type, and educational status were independently associated with LTFU. Moreover, baseline tuberculous disease, poor functional status, and follow-up at a health center were associated with an elevated probability of death.ConclusionWe observed a higher death rate and a lower LTFU rate in health centers than in hospitals. Most of the associated variables were also previously documented. Higher LTFU was noticed for patients with a smaller gap between testing and initiation of treatment.

Magnitude of opportunistic infections and associated factors in HIV-infected adults on antiretroviral therapy in eastern Ethiopia.

PurposeThe aim of this study was to assess the prevalence of opportunistic infections (OIs) and associated factors among HIV-infected adults on anti-retroviral therapy (ART) in Hiwot Fana Specialized University Hospital, Eastern Ethiopia.Patients and methodsA hospital-based retrospective study was conducted in 358 HIV-infected adult patients on ART from April to June 2014. Data were collected through review of clinical records. The data was entered and analyzed by using SPSS version 16.0. Univariate and multivariate analyses were performed to determine the association of each independent variable with occurrence of OIs. A 95% confidence interval (CI) and P-value less than 0.05 were considered as significant association.ResultsA total of 358 patients were included in the study, in which majority (68.4%) were females. The mean age of patients was 34 (standard deviation [SD] ±9.8) years. The overall of prevalence of OIs among HIV/AIDS patients on ART was 48%. The highest prevalent rates of OIs observed were tuberculosis (TB) (21.23%), followed by Herpes zoster (11.2%) and oral candidiasis (9.5%). Baseline CD4 cell count <200 cells/mm3 (adjusted odds ratio [AOR] =1.645, 95% CI =2.187, 3.983), baseline World Health Organization (WHO) clinical stage III (AOR =2.801, 95% CI =1.958, 7.165) and IV (AOR =3.856; 95% CI =2.691, 10.390), and not using prophylaxis (AOR =1.912, 95% CI =1.444, 3.824) were found to have strong association with acquisition of OIs.ConclusionThere was a high prevalence of OIs observed in this study. Baselines CD4 count of <200 cells/mm3, advanced WHO clinical stages, and not using prophylaxis were found to be predictors of OIs. Interventions were aimed at promoting early HIV testing and enrollment of HIV-infected individuals into ART services needed before CD4 count decreased severely.

Enrolment trends in a comprehensive HIV programme in rural north-central Nigeria: improved care indices, but declining quality of clinical data over time

Background:Vanderbilt University affiliate Friends in Global Health was funded in 2008 to support comprehensive HIV/AIDS services in north-central Nigeria. We summarise programme characteristics and trends in enrolment and quality of data collection in this rural, resource-limited environment.Methods:We used routinely collected programme data in supported sites from June 1 2009 to September 30, 2013.Baseline characteristics were defined as those collected closest to a 90-day window period before and after enrolment. Summary characteristics were compared by site and enrolment year.Results:We enrolled 3,960 HIV-infected patients into care (68% women), median age of 32 years [interquartile range (IQR): 27–40]. Most clients were married (79%) and unemployed (60%). At enrolment, median CD4+ cell count was 230 cells/μL (IQR: 114–390) and haemoglobin was 10.7 g/dL (IQR: 9.3–11.9). Advanced clinical disease [World Health Organization (WHO) clinical stage III/IV] at enrolment was documented in 29% of clients. Cumulative enrolment increased from 377 patients in 2009 to 3,960 patients by 2013.With each successive year, more clients were enrolled at earlier stages of disease; in 2009, 37% of patients were identified as WHO clinical stage I, while in 2013, 55% of patients were so classified. While documentation of clinical staging remained stable, the completeness of CD4+ cell count and haemoglobin data declined with time.Conclusion:Expanded testing in a comprehensive HIV programme in rural Nigeria brought persons to care at earlier stages of illness. Yet, as clinical services expanded, data collection quality declined. The paradox of successful scaling up HIV services but deteriorating quality of data underscores the importance of data management training and quality improvement efforts.

The clock is ticking: the rate and timeliness of antiretroviral therapy initiation from the time of treatment eligibility in Kenya

IntroductionUnderstanding the determinants of timely antiretroviral therapy (ART) initiation is useful for HIV programmes intent on developing models of care that reduce delays in treatment initiation while maintaining a high quality of care. We analysed patient- and facility-level determinants of time to ART initiation among patients who initiated ART in Kenya.MethodsWe collected facility-level information and conducted a retrospective chart review of adults initiating ART between 2007 and 2012 at 51 health facilities in Kenya. We evaluated the association between patient- and facility-level covariates at the time of ART eligibility and time to ART initiation. We also explored the determinants associated with timeliness of ART initiation.ResultsThe analysis included 11,942 patients. The median age at the time eligibility was first determined was 37 years (interquartile range [IQR] 31–45). Overall, 75% of patients initiated ART within two months of eligibility. The median CD4 cell count at the time eligibility was first determined rose from 132 (IQR 51–217) in 2007 to 195 (IQR 91–286) in 2011 to 2012 (p<0.001). The cumulative probability of ART initiation among treatment-eligible patients increased over time: 87.1% (95% confidence interval [CI] 85.1–89.0%) in 2007; 96.8% (96.0–97.5%) in 2008; 97.1% (96.3–97.7%) in 2009; 98.5% (98.0 −98.9%) in 2010; and 99.7% (95% CI 99.4 −99.8%) in 2011 to 2012 (p<0.0001). In multivariate analyses, attending a health facility with high ART patient volumes within two months of eligibility was considered the key facility-level determinant of ART initiation (adjusted odds ratio 0.57, 95% CI 0.45–0.72, p<0.001). Patient-level determinants included being eligible for ART in the years subsequent to 2007, advanced World Health Organization clinical stage and low CD4 cell count at the time eligibility was first determined.ConclusionsOverall, the time between treatment eligibility and ART initiation decreased substantially in Kenya between 2007 and 2012, with uniform gains across different types of health facilities. Our findings highlight the slow increase in CD4 cell counts at the time of ART eligibility over time, indicating that a large number of patients are still beginning ART with advanced HIV disease. Our findings also support the decentralisation of ART services at all health facilities that have the capacity to initiate treatment. Continued evaluation of programme- and country-level data is needed to monitor timeliness of ART initiation as countries continue to expand treatment access.

Maternal Immunologic and Clinical Response to Antiretroviral Therapy Initiation Before or During Pregnancy in HIV-1 Infected Women and associated factors in Southwest Ethiopia

SUMMARY The aim of this study is to assess maternal treatment outcomes to antiretroviral therapy initiated before or during pregnancy in HIV-1 infected women and associated factors in southwest Ethiopia. Hospital based retrospective cohort study was conducted from January 1st 2008 to December 31st 2012.The data were processed using SPSS version 16 (Chicago: SPSS Inc., 2007). A p-value of < 0.05 was considered statistically significant. Among the 202 study participants, 169(83.6%) and 142(70.3%) had good immunological and clinical outcomes respectively. In adjusted logistic regression analysis, unknown HIV status prior to pregnancy (AOR=0.158, 95% CI=(0.041–0.602), P=0.007), Baseline CD4 count < 200 (AOR = 0.023, 95%CI= (0.003–0.190), P=0.000), baseline WHO clinical stage III (AOR=7.673, 95%CI=1.640–35.892, P=0.010), Highly Active Antiretroviral Therapy initiation during pregnancy (AOR=0.349,95% CI=0.157–0.776,P=0.010) were identified as independent predictors of maternal treatment outcomes. In conclusion, Women who started Highly Active Antiretroviral Therapy before pregnancy had good clinical outcome compared to those who started during pregnancy. The independent predictors of maternal outcomes were HIV status prior to pregnancy, baseline CD4 count before initiation of Highly Active Antiretroviral Therapy, time of Highly Active Antiretroviral Therapy initiation, world health organization clinical stage before initiation of Highly Active Antiretroviral Therapy and duration of treatment with Highly Active Antiretroviral Therapy.

Association of Oral Lesions and Immunosuppression in Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome Patients Not Taking Antiretroviral Therapy in Pakistan

Background: Oral lesions, especially oral candidiasis, oral hairy leukoplakia, necrotizing periodontal conditions and variety of other viral and bacterial infections are essentially presented in human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) patients due to low CD4+ count. Aims: This study was designed to determine various oral clinical and cytological mucosal changes seen in HIV/AIDS patients not taking antiretroviral therapy (ART) in Pakistan and their relation to CD4+ lymphocyte count as no study has been reported yet in our country. Materials and Methods: Patients were clinically examined and staged according to World Health Organization (WHO) staging system. Oral smears, from n = 25 patients not taking ART, were prepared and examined microscopically using hematoxylin and eosin, periodic acid-Schiff and Papanicolaou stains. The CD4+ lymphocyte count was determined using flow cytometry. Result: Oral lesions were present in 36% of the patients with chronic periodontitis in 20%, oral candidiasis in 12%, oral pigmentation in 8% and oral ulcers in 4% patients. On cytological examination, fungi were detected in 56% smears. Inflammation was seen in 60% smears, micronuclei in 72%, nuclear atypia in 44% and dysplastic changes in 16% (grade 1 in 12% and grade 2 in 4%) smears. The mean CD4+ lymphocyte count was 338.12 ΁ 127 cells/mm 3 . The CD4+ lymphocyte count was grouped as 350 cells/mm 3 (Group 2). Group 1 comprised of n = 15 while Group 2 had n = 10 patients. Most of the oral lesions were seen in CD4+ Group 1 having low CD4+ count. When the cytopathological variables were compared with WHO clinical stages, a statistically significant association (P < 0.05) was observed in the case of pseudomembranous candidiasis clinically and dysplasia and presence of fungi cytologicaly. Conclusion: This study highlights the importance of oral lesions as a marker of HIV/AIDS progression and immunosuppression as oral lesions were frequent with low CD4+ count especially < 350 cells/mm 3 .

Effect of HIV-1 Serostatus on the Prevalence of Asymptomatic Plasmodium falciparum Parasitemia Among Children Less Than 5 Years of Age in Benin City, Nigeria.

Human immunodeficiency virus (HIV) infection and Plasmodium falciparum malaria are 2 of the gravest health threats in sub-Saharan Africa. Multiple repeat infections with the malaria parasite as seen in endemic areas are necessary to develop specific malaria immunity. HIV is an immunosuppressive virus and in children aged <5 years, development of malaria-specific immunity may be impaired and malaria parasite clearance in theory will be delayed; hence the predisposition to increased incidence of asymptomatic malaria or severe malaria. This cross-sectional study was carried out to examine associations between immunosuppression and asymptomatic malaria parasitemia (ASMP) in HIV-infected children aged <5 years in Benin City. One hundred seventy-nine asymptomatic HIV-1-positive and 179 age- and sex-matched HIV-1-negative children aged <5 years were recruited. The malaria parasite was determined by Giemsa-stained blood film by certified microscopy while concomitant CD4(+) count was estimated in the HIV-infected children. The prevalence of ASMP in those who were HIV-infected of 34.1% was significantly higher than 17.3% in the HIV uninfected (P = .001). The prevalence of ASMP was highest (59.3%) among subjects who were severely immunosuppressed (CDC immunologic category 3). The prevalence of ASMP significantly increased with advanced immune disease in the subjects (P = .011). Severe (World Health Organization) clinical staging was also significantly associated with increased prevalence of ASMP (P = .031). The prevalence of ASMP is significantly higher among subjects not receiving cotrimoxazole, associated with threefold risk of having ASMP (P = .003: odds ratio = 3.5). ASMP is more common in HIV-positive children aged <5 years and is significantly associated with declining CD4(+) T-cell count and severe clinical disease. There is a need for integration of HIV- and malaria-control programs for stronger case management. Malaria-control programs may consider malaria prevention interventions and cotrimoxazole prophylaxis for preschool children who are HIV-infected and living in malaria-endemic regions.

High Incidence of Zidovudine Induced Anaemia in HIV Infected Patients in Southern Odisha.

Zidovudine (AZT), a nucleoside reverse transcriptase inhibitor was the first breakthrough in AIDS therapy in 1990.This study was conducted with an aim to determine prevalence of AZT induced anaemia in HIV infected patients initiated on AZT containing anti retroviral therapy(ART) regimen and also to find out any risk factor for causing AZT induced anaemia. Study was carried out in ART centre, M.K.C.G, MCH, Berhampur between Jan 2009 and Dec 2011. HIV infected patients registered at ART centre were treated according to National AIDS Control Organisation (NACO) guidelines. Patients (n=1221) with Hb >8gm/dl were prescribed AZT based ART regimen. Patients having anaemia (<8gm/dl) were excluded from the study. Correlation of baseline characteristics (age, sex, weight, Hb level, CD4 count, World Health Organization (WHO) clinical stage) with risk of developing anaemia was also calculated. 178 (14.6%) patients on AZT regimen developed anaemia. Patients with low CD4 count were more prone to develop severe anaemia. Age, sex, weight, WHO clinical stage had no relation with development of anaemia. Incidence of AZT induced anaemia was very high and patients having low CD4 count were more susceptible to develop anaemia.

Visceral leishmaniasis as an AIDS defining condition: towards consistency across WHO guidelines.

Given the detrimental interaction between both pathogens, visceral leishmaniasis (VL)–HIV co-infection has been identified as one of the emerging challenges for VL control [1]. The epidemiological impact of HIV on VL was most strikingly illustrated by the effect of the HIV epidemic in VL-endemic countries in southern Europe, with HIV contributing to the re-emergence of VL. By early 2000, almost 2,000 cases of VL–HIV co-infection (predominantly in intravenous drug users) had been identified, with up to 50%–60% of all VL cases being HIV co-infected [2]. Fortunately, with the wide-scale introduction of highly active antiretroviral therapy (ART), a gradual decline in VL incidence has been observed in Europe over the last decade [1], [3]. Currently, the burden of VL–HIV co-infection is most apparent in some regions in East Africa, like Northwest Ethiopia, where between 20%–40% of VL cases are co-infected with HIV [1]. The problem also seems to be emerging in India and Brazil [1]. There is abundant evidence that HIV strongly affects VL treatment response, including in the East African setting. Initial parasitological failure rates are typically below 2%–3% in immunocompetent individuals, but can be as high as 50% in co-infected patients [4]. Case fatality rates in East Africa are 3–9-fold higher in HIV co-infected patients, reaching up to 15%–33% [1], [5]. Whereas relapses are uncommon (<5%) in immunocompetent individuals, this can reach 50%–60% by one year in some high-risk HIV co-infected individuals [1], [6]. ART is apparently only partially protective against relapse [6]. Importantly, repeated relapses tend to become increasingly unresponsive to treatment, and secondary prophylaxis is often required until sufficient CD4 cell count recovery has taken place (at least in areas with zoonotic transmission) [1]. At an early stage, several meetings on VL–HIV co-infection were organized by the World Health Organization (WHO) trypanosomiasis and leishmaniasis unit (Division of Tropical Diseases), and an international surveillance system was put in place. Based on the evidence available, VL was proposed—in 1995—as an Acquired Immunodeficiency Syndrome (AIDS)–defining condition requiring ART initiation irrespective of CD4 counts [7], and this has remained so since then (see Table 1) [8]. VL is now included as an AIDS-defining condition in virtually all VL-treatment guidelines for use in countries where VL–HIV is prevalent. Table 1 Overview of integration of visceral leishmaniasis as an AIDS-defining condition in WHO guidelines. Early on in the HIV epidemic—in 1990—WHO developed an HIV clinical staging system adopted for use in low- and middle-income countries [9]. This WHO clinical staging system is widely used by the HIV medical community and forms the backbone of several important recommendations like cotrimoxazole prophylaxis and eligibility for ART. It has undergone several adaptations over the years, with the latest revision of the WHO staging system reported in 2007 [10]. This clinical staging system has also systematically been endorsed across all revised WHO ART guidelines over the last 10 years, up to the most recent version in 2013 [11]–[14]. Surprisingly, and in contrast with the latest recommendations coming out of the WHO Department of Neglected Tropical Disease and the WHO Expert Committee on the Control of Leishmaniases, VL is not systematically included as an AIDS-defining condition. Although VL appeared in the interim revised clinical staging recommendations (as a WHO stage 4 condition), the finalized version (2007) only stated “atypical disseminated leishmaniasis” as a stage 4 condition, and this was included in the 2006, 2010, and 2013 ART guidelines. This term (atypical disseminated leishmaniasis) is not clearly defined, with no presumptive clinical diagnosis proposed and as definitive diagnosis: “… histology (amastigotes visualized) or culture from any appropriate clinical specimen.” Disseminated cutaneous leishmaniasis is an established clinical entity, but “atypical disseminated leishmaniasis” is not. Strictly speaking, it is not even clear whether both VL and cutaneous leishmaniasis would be considered. Similarly to tuberculosis–HIV co-infection, successful management and control of VL–HIV co-infection will hinge on the effective coordination of both VL and HIV programs [15]. Coordination at the global level is likely to foster successful integration of national programs [15]. For instance, in Ethiopia—which has the highest VL–HIV co-infection rates—the national VL guidelines recommend routine ART for all VL cases, but the HIV/ART guidelines will follow the international HIV clinical staging system (only mentioning “atypical disseminated leishmaniasis;” http://www.who.int/hiv/pub/guidelines/ethiopia_art.pdf). The same is true in other VL-endemic countries such as India and Uganda. In contrast, VL is an AIDS-defining condition in the national ART guidelines in Brazil and Kenya. As to Sudan and South Sudan, both “atypical disseminated leishmaniasis” and VL are included. We call upon WHO to address this inconsistency and hope this can be rectified by the next revision of the WHO guidelines.

Impact of Antiretroviral Therapy on Opportunistic Infections of HIV-infected Children in the Therapeutic Research, Education and AIDS Training Asia Pediatric HIV Observational Database

There are limited data on opportunistic infections (OIs) and factors associated with their occurrence after highly active antiretroviral therapy (HAART) in Asian children. The use of HAART in Asia started much later than in developed countries and therefore reported findings may not be fully applicable to the pediatric HIV epidemic in Asia. Retrospective and prospectively collected data from the Therapeutic Research, Education and AIDS Training Asia Pediatric HIV Observational Database cohort study from March 1993 to March 2009 were analyzed. OIs were defined according to World Health Organization clinical staging criteria and incidence rates calculated. Factors associated with the incidence of severe OIs were analyzed using random effects Poisson regression modeling. Of 2280 children in the cohort, 1752 were ever reported to have received antiretroviral therapy, of whom 1480 (84%) started on HAART. Before commencing any antiretroviral therapy, OIs occurred at a rate of 89.5 per 100 person-years. The incidence rate was 28.8 infections per 100 person-years during mono- or dual-therapy and 10.5 infections per 100 person-years during HAART. The most common OIs both before and after antiretroviral therapy initiation were recurrent upper respiratory tract infections, persistent oral candidiasis and pulmonary tuberculosis. The incidence rates of World Health Organization clinical stage 3 or 4 OIs after HAART were highest among children <18 months of age and those with low weight-for-age z scores, CD4 cell % <15%, and World Health Organization stage 3 at HAART initiation. Despite dramatic declines in their incidence, OIs remained important causes of morbidity after HAART initiation in this regional cohort of HIV-infected children in Asia.

Socio-demographic and immunological profile of HIV patients attending ART clinic in a tertiary care hospital in North India

Background: The epidemiology of HIV should be understood especially with regard to various socio-demographic factors because the most effective approaches for its prevention and control are awareness and life style changes. Aim: This study was undertaken to determine the socio-demographic characteristics and immunological profile of HIV seropositive patients attending the antiretroviral therapy (ART) clinic of Lok Nayak hospital in New Delhi, India. Methods: Two hundred and fifty two, HIV seropositive subjects were enrolled in the study irrespective of their ART status. Subjects were staged as per the World Health Organization (WHO) staging system and the socio-demographic data and clinical signs and symptoms were recorded for all subjects on a predesigned performa. CD4+ T lymphocyte count was determined by the Fluorescent Activated Cell Sorting (FACSCount TM ) system . Results: Mean age of study subjects was 33.6 years ± 8.3 years, 66.3% were males, 73.4% were married, 27.7% were illiterate. 32.9 % of subjects were employed in unskilled and semiskilled occupations. Majority of patients belonged to upper lower social class as per the modified Kuppuswamy’s scale. 72.2% had acquired infection through the heterosexual route. 66.3% of the cases were in WHO clinical stage I & II of illness at the time of registration. The median CD4+ T lymphocyte count for all patients was 279 Cells/ µl.

Global Policy Review of Recommendations on Cotrimoxazole Prophylaxis among People Living with HIV.

The Joint United Nations Programme on HIV/AIDS (UNAIDS) Treatment 2015 calls for expanded access to HIV care and treatment, including cotrimoxazole preventive therapy (CPT), for prevention of HIV-related morbidity and mortality. We review 115 national guidelines from 92 countries for recommendations on CPT for adults and adolescents and determine the level of consistency with the World Health Organization (WHO) guidelines. Of the 66 countries with recommendations, 5 (8%) countries recommend lifelong CPT for people living with HIV; 19 (29%) countries recommend a CD4 count threshold of ≤350 cells/mm(3) or WHO clinical stages III and IV or II, III, and IV; and 19 (29%) countries recommend a CD4 count threshold of ≤200 cells/mm(3). Of the 48 countries with recommendations on discontinuing CPT, 25 (52%) countries recommend discontinuation of cotrimoxazole when the CD4 count is >200 cells/mm(3). World Health Organization guidelines offer countries flexibility on the use of CPT, and countries are recommending a wide range of CD4 counts and WHO clinical stage criteria for prophylaxis initiation and discontinuation.

Delayed antiretroviral therapy despite integrated treatment for tuberculosis and HIV infection.

Five primary health care clinics in Kinshasa, Democratic Republic of Congo. To examine timing and predictors of delayed initiation of antiretroviral therapy (ART) during anti-tuberculosis treatment. Prospective observational cohort of adult patients receiving integrated treatment for tuberculosis (TB) and human immunodeficiency virus (HIV) who are expected to initiate ART at 1 month if CD4 count is <100 cells/mm(3) or if patient is World Health Organization (WHO) Clinical Stage 4 for reasons other than extra-pulmonary TB, at 2 months if CD4 count is 100-350 cells/mm(3), or at completion of anti-tuberculosis treatment if subsequently CD4 count is ≤ 350 cells/mm(3) or patient has WHO Clinical Stage 4. Of 492 patients, 235 (47.8%) experienced delayed initiation of ART: 171 (72.8%) initiated ART late, after a median delay of 12 days (interquartile range [IQR] 4-27) and 64 (27.2%) never initiated ART. Contraindication to any antiretroviral drug (aOR 2.91, 95%CI 1.22-6.95), lower baseline CD4 count (aOR 1.20, 95%CI 1.08-1.33/100 cells/mm(3)), TB drug intolerance (aOR 1.93, 95%CI 1.23-3.02) and non-disclosure of HIV infection (aOR 1.50, 95%CI 1.03-2.18) predicted delayed ART initiation. Despite fully integrated treatment, half of all patients experienced delayed ART initiation. Pragmatic approaches to ensure timely ART initiation in those at risk of delayed ART initiation are needed.

Prognosis of children with HIV-1 infection starting antiretroviral therapy in Southern Africa: a collaborative analysis of treatment programs.

Prognostic models for children starting antiretroviral therapy (ART) in Africa are lacking. We developed models to estimate the probability of death during the first year receiving ART in Southern Africa. We analyzed data from children ≤10 years of age who started ART in Malawi, South Africa, Zambia or Zimbabwe from 2004 to 2010. Children lost to follow up or transferred were excluded. The primary outcome was all-cause mortality in the first year of ART. We used Weibull survival models to construct 2 prognostic models: 1 with CD4%, age, World Health Organization clinical stage, weight-for-age z-score (WAZ) and anemia and the other without CD4%, because it is not routinely measured in many programs. We used multiple imputation to account for missing data. Among 12,655 children, 877 (6.9%) died in the first year of ART. We excluded 1780 children who were lost to follow up/transferred from main analyses; 10,875 children were therefore included. With the CD4% model probability of death at 1 year ranged from 1.8% [95% confidence interval (CI): 1.5-2.3] in children 5-10 years with CD4% ≥10%, World Health Organization stage I/II, WAZ ≥ -2 and without severe anemia to 46.3% (95% CI: 38.2-55.2) in children <1 year with CD4% < 5%, stage III/IV, WAZ< -3 and severe anemia. The corresponding range for the model without CD4% was 2.2% (95% CI: 1.8-2.7) to 33.4% (95% CI: 28.2-39.3). Agreement between predicted and observed mortality was good (C-statistics = 0.753 and 0.745 for models with and without CD4%, respectively). These models may be useful to counsel children/caregivers, for program planning and to assess program outcomes after allowing for differences in patient disease severity characteristics.

Diffusion-weighted MR imaging in thymic epithelial tumors: correlation with World Health Organization classification and clinical staging.

To assess thymic epithelial tumors with diffusion-weighted magnetic resonance (MR) imaging. Informed consent from patients and institutional review board approval were obtained. Prospective study was conducted on 30 consecutive patients (21 men and nine women; age range, 35-71 years) with thymic epithelial tumors. They underwent true fast imaging with steady-state precession and single-shot echo-planar diffusion-weighted MR imaging of the mediastinum with b values of 0, 400, and 800 sec/mm(2). Apparent diffusion coefficient (ADC) of the thymic epithelial tumors was calculated by the same observer at two settings and was correlated with World Health Organization classification and clinical staging. There was significant difference in longest diameter (P = .001) and necrotic part of the tumor (P = .014) between low-risk thymoma, high-risk thymoma, and thymic carcinoma. Mean ADC value of both readings of thymic epithelial tumors (n = 30) was 1.24 × 10(-3) mm(2)/sec and 1.22 × 10(-3) mm(2)/sec, with good intraobserver agreement (κ = 0.732). There was significant difference in both readings (P = .01 and .20) of low-risk thymoma (1.30 × 10(-3) mm(2)/sec and 1.29 × 10(-3) mm(2)/sec), high-risk thymoma (1.16 × 10(-3) mm(2)/sec and 1.14 × 10(-3) mm(2)/sec), and thymic carcinoma (1.18 × 10(-3) mm(2)/sec and 1.06 × 10(-3) mm(2)/sec). Cutoff ADC values of both readings used to differentiate low-risk thymoma from high-risk thymoma and thymic carcinoma were 1.25 and 1.22 × 10(-3) mm(2)/sec with area under the curve of 0.804 and 0.851, respectively. There was significant difference in both readings of ADC value of early (stage I, II) and advanced stages (stage III, IV) of thymic epithelial tumors (P = .006 and .005, respectively). ADC value is a noninvasive, reliable, and reproducible imaging parameter that may help to assess and characterize thymic epithelial tumors.

EVALUATION OF CO-TRIMOXAZOLE AS PREVENTIVE THERAPY FOR PEOPLE LIVING WITH HIV/AIDS IN JIMMA HEALTH CENTER, SOUTHWEST ETHIOPIA

Co-trimoxazole is used as preventing therapy for many opportunistic infections in people living with HIV/AIDS. The main purpose of this study was to evaluate co-trimoxazole as preventive therapy in Jimma health center. A retrospective Cross-sectional method was used and data was collected from June 28 to July 08 2013. Form the total 320 patients, 185 (57.8 %) were females, 142 (98.4 %) were in the child bearing age. Most (90.3 %) of the patients were world health organization clinical stage I. There were not any cases in which co-timoxazole was used against contraindication; co-trimoxazole was used as per the recommended prophylactic dosage in 320 (100 %) of the patients. The treatment was discontinued in 11 patients, eight (2.5 %) of the discontinuations were due to CD4 count greater than 350 cell/mm. Co-trimoxazole preventive therapy was started prior to antiretroviral therapy in 260 (81.3 %), concurrently with Antiretroviral Therapy in 46 (14.4 %) and after Antiretroviral Therapy in 1 (0.3 %) of the patients. Only 29 (9.06 %) patients were monitored regularly and monitoring schedule or data was not recorded for 122 (38.13 %) patients. The evaluation of Co-trimoxazole as preventive therapy among people living with HIV/AIDS was in line with the WHO guideline for indication in all of the patients’. Dosage and observance of contraindication was also consistent with the guideline in most of the cases studied. Problems regarding patient monitoring and initiations of CPT relative to ART were identified in most of the patients.

Predictors of Treatment Failure in HIV-Positive Children Receiving Combination Antiretroviral Therapy: Cohort Data From Mozambique and Uganda.

Delays detecting treatment failure and switching to second-line combination antiretroviral therapy (cART) are often observed in human immunodeficiency virus (HIV)-infected children of low-middle-income countries (LMIC). An observational study included HIV-infected children attending the Beira Central Hospital (Mozambique) and the Nsambya Hospital, Home Care Department (Uganda) evaluated clinical and immunological failure according to World Health Organization (WHO) 2006 guidelines. Baseline predictors for cART failure and for drug substitution were explored in unadjusted and adjusted Cox proportional hazard models. Two hundred eighteen of 740 children with at least 24 weeks follow-up experienced treatment failure (29%; 95% confidence interval [CI] 26-33), with crude incidence of 20.0 events per 100 person-years (95% CI 17.5-22.9). Having tuberculosis co-infection or WHO stage 4, or starting a nontriple cART significantly increased risk of failure. Two hundred two of 769 (26.3%) children receiving cART substituted drug(s), with crude incidence of 15.4 events per 100 person-years (95% CI 13.4-17.7). Drug toxicity (18.3%), drug availability (17.3%), and tuberculosis drugs interaction (52, 25.7%) were main reported reasons, while only 9 (4%) patients switched cART for clinical or immunological failure. Children starting lamivudine-zidovudine-nevirapine or lamivudine-stavudine-efavirenz or lamivudine-zidovudine-efavirenz were more likely to have substitute drugs. Increased substitution was found in children with mild immunosuppression and tuberculosis co-infection at cART initiation as well as poor adherence before drug substitution. Considerable delay in switching to second-line cART may occur despite an observed high rate of failure. Factors including WHO clinical stage and tuberculosis co-infection should be evaluated before starting cART. Toxicity and drug adherence should be monitored to minimize drug substitution in LMIC.

Risk factors for intestinal parasitosis among antiretroviral-treated HIV/AIDS patients in Ethiopia

Summary A cross-sectional survey was conducted to determine the risk factors associated with intestinal parasitosis in HIV/AIDS patients receiving antiretroviral therapy (ART). Socio-demographic information was collected and faecal samples were analysed from 384 randomly selected patients on ART. Data on CD4+ T-cell counts and World Health Organization clinical staging were obtained from the medical records at the hospital. The overall prevalence of intestinal parasitosis was 56% (95% confidence interval [CI]: 51% to 61%). No opportunistic intestinal parasites or Schistosoma haematobium eggs were detected. Unavailability of latrine and lack of hand washing with soap were associated with Entamoeba histolytica/dispar (adjusted odds ratio [AOR], 2.75; 95% CI: 1.77 to 4.27 and AOR, 2.67; 95% CI: 1.60 to 4.44, respectively) and Giardia lamblia (AOR, 2.08; 95% CI: 1.08 to 3.99 and AOR, 2.46; 95% CI: 1.06 to 5.75, respectively) infections. Intestinal parasitosis was significantly associated with low CD4 cell count (p = 0.002). In contrast, intestinal parasitic infections were not associated (p > 0.05) with the World Health Organization disease staging. In summary, poor personal hygiene and sanitation practice contributed to the high prevalence of intestinal parasitosis. Routine diagnosis for intestinal parasitic infections should be performed in patients attending ART clinics in this setting.

A Novel Community Health Worker Tool Outperforms WHO Clinical Staging for Assessment of Antiretroviral Therapy Eligibility in a Resource-Limited Setting

:The accuracy of a novel community health worker antiretroviral therapy eligibility assessment tool was examined in community members in Blantyre, Malawi. Nurses independently performed World Health Organization (WHO) staging and CD4 counts. One hundred ten (55.6%) of 198 HIV-positive participants had a CD4 count of <350 cells per cubic millimeter. The community health worker tool significantly outperformed WHO clinical staging in identifying CD4 count of <350 cells per cubic millimeter in terms of sensitivity (41% vs. 19%), positive predictive value (75% vs. 68%), negative predictive values (53% vs. 47%), and area under the receiver–operator curve (0.62 vs. 0.54; P = 0.017). Reliance on WHO staging is likely to result in missed and delayed antiretroviral therapy initiation.

Diagnostic accuracy of the WHO clinical staging system for defining eligibility for ART in sub-Saharan Africa: a systematic review and meta-analysis.

IntroductionThe World Health Organization (WHO) recommends that HIV-positive adults with CD4 count ≤500 cells/mm3 initiate antiretroviral therapy (ART). In many countries of sub-Saharan Africa, CD4 count is not widely available or consistently used and instead the WHO clinical staging system is used to determine ART eligibility. However, concerns have been raised regarding its discriminatory ability to identify patients eligible to start ART. We therefore reviewed the accuracy of WHO stage 3 or 4 assessment in identifying ART eligibility according to CD4 count thresholds for ART initiation.MethodsWe systematically searched PubMed and Global Health databases and conference abstracts using a comprehensive strategy for studies that compared the results of WHO clinical staging with CD4 count thresholds. Studies performed in sub-Saharan Africa and published in English between 1998 and 2013 were eligible for inclusion according to our predefined study protocol. Two authors independently extracted data and assessed methodological quality and risk of bias using the Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS-2) tool. Summary estimates of sensitivity and specificity were derived for each CD4 count threshold and hierarchical summary receiver operator characteristic curves were plotted.ResultsFifteen studies met the inclusion criteria, including 25,032 participants from 14 countries. Most studies assessed individuals attending ART clinics prior to treatment initiation. WHO clinical stage 3 or 4 disease had a sensitivity of 60% (95% CI: 45–73%, Q=914.26, p<0.001) and specificity of 73% (95% CI: 60–83%, Q=1439.43, p<0.001) for a CD4 threshold of ≤200 cells/mm3 (11 studies); sensitivity and specificity for a threshold of CD4 count ≤350 cells/mm3 were 45% (95% CI: 26–66%, Q=1607.31, p<0.001) and 85% (95% CI: 69–93%, Q=896.70, p<0.001), respectively (six studies). For the threshold of CD4 count ≤500 cells/mm3 sensitivity was 14% (95% CI: 13–15%) and specificity was 95% (95% CI: 94–96%) (one study).ConclusionsWhen used for individual treatment decisions, WHO clinical staging misses a high proportion of individuals who are ART eligible by CD4 count, with sensitivity falling as CD4 count criteria rises. Access to accurate, accessible, robust and affordable CD4 count testing methods will be a pressing need for as long as ART initiation decisions are based on criteria other than seropositivity.