World Health Organization Clinical Stage Research Articles

Outcome of Ready to Use Food Therapy among Patients on HIV/AIDS Care in Mekelle Hospital, Northern Ethiopia: Retrospective Cohort Study

Background: According to the World Health Organization (WHO), Nutritional support is an integral part of a comprehensive response to HIV/AIDS. Receiving appropriate nutrition can help improve the health and quality of life of HIV-infected individuals. So, Nutritional support is increasingly recognized as a critical part of the essential package of patients care among acquired immune deficiency syndrome (AIDS) patients. However, the outcome of ready to use nutritional support and factors affecting it among HIV/AIDS patients are not yet well investigated. So, this study aims to determine the nutritional outcome of ready-to-use food therapy (RUFT) and factors affecting it among peoples on HIV/AIDS care. Methods: Retrospective cohort study was conducted among patients on food by prescription and HIV/AIDS care. Data was collected from a total of 531 patient records selected by systematic random sampling method using food by prescription registers as sampling frame. After determining the outcome of ready to use food therapy among HIV/AIDS patients on HIV care, Multivariate analysis was used to determine the independent predictors of outcome of food by prescription. Results: In this study 62.2% of patients on ready to use food therapy were recovered. Severity of malnutrition Adjusted odds ratio [AOR (95% CI)=2.594 (1.251-5.377)], sex [AOR (95%CI)=2.157 (1.340-3.473)], WHO stage [AOR (95% CI)=(3.345 (1.652-6.772)],education [AOR (95% CI) =1.820 (1.110-2.983)], and presence of opportunistic infection [AOR (95%CI)=2.791 (1.047-7.439)] were the independent predictors of outcome of ready to use food therapy. Conclusions: In this study 62.2% of patients admitted to ready to use food therapy were recovered from malnutrition. The factors that affect Outcome of ready to use therapeutic food by prescription was severity of malnutrition, sex, WHO clinical stage, education, and opportunistic infection. For this reason, regular and comprehensive nutritional screening of patients on HIV chronic care and strengthening of nutritional adherence counseling for patients on ready to use therapeutic food is very crucial to improve the outcome of ready to use food therapy among HIV patients.

Survival and Predictors of Mortality among Adults on Antiretroviral Therapy in Selected Public Hospitals in Harar, Eastern Ethiopia

In resource-poor countries, access to ART has improved during the last years and mortality rates among treated patients have declined substantially. However, compared to patients in high-income countries, patients in resourcepoor countries are at higher risk of death in the early months of treatment. To avoid such early deaths, the identification of possible risk factors and potential causes of deaths are important. A retrospective cohort study was conducted among a cohort of 655 People Living with HIV/AIDS (PLWHA) on ART in three in selected public hospitals in Harar, Eastern Ethiopia. From the total PLWHA participants, 438 (66.9%) were female and the median age of patients were 33 years. The median follow-up period was 38 months. During the follow up period, 74 (11.4%) patients were deceased. The cohort was followed for 1913 Person-Years of observation. Total mortality rate over the follow up period was 3.9 per 100 person-years. Most of deaths (n=36, 49%) occurred in the first 3 months of ART initiation. Three baseline factors could be independently identified: World Health Organization (WHO) clinical stage III and IV (Hazard Ratio (HR) =2.13), CD4 counts lower than 50cells/µl (HR=2.34), not taking base line Cotrimoxazole Prophylaxis Treatment (CPT) (HR=2.46). Despite optimizing ART delivery in Ethiopia, a proportion of early deaths among patients with very advanced disease are not likely to be preventable with ART. This may require extensive and detailed study in resource poor countries. Thus, a more fundamental issue and the greater challenge is the need for early HIV diagnosis and provision of appropriate longitudinal HIV care prior to ART eligibility.

Determinants of Survival in Adult HIV Clients on Antiretroviral Therapy in Lawra and Jirapa Districts of Upper West Region, Ghana

We describe the rate of death and identify the determinants of survival in a cohort of adults starting antiretroviral therapy (ART) in 2 hospitals in Upper West Region, Ghana. Kaplan-Meier model was used to estimate the survival probability after ART initiation and Cox proportional hazard model used to assess the relationship between baseline variables and mortality. A total of 91 clients who were initiated on ART in both hospitals participated in the study. Clients staged in the World Health Organization (WHO) clinical stage III/IV had a higher risk of mortality than those staging I/II (hazard ratio [HR] of 3.93). Hemoglobin value at baseline with a cutoff ≥12 g/dL for women (and ≥13 for men) was strongly associated with mortality in participants with an HR of 3.87 (95% confidence interval [CI]: 0.71-21.19) for severe anemia, 2.11 (95% CI: 0.45-9.93) for moderate anemia, and 0.88 (95% CI: 0.16-4.82) for mild anemia. Anemia and WHO staging were independent predictors of mortality.

Common opportunistic infections and their CD4 cell correlates among HIV-infected patients attending at antiretroviral therapy clinic of Gondar University Hospital, Northwest Ethiopia

BackgroundHuman immunodeficiency virus (HIV) pandemic is among the greatest health crises ever faced by humanity. Morbidity and mortality in HIV disease is due to immunosuppression leading to life-threatening opportunistic infections (OIs) during the natural course of the disease. This study was aimed to assess the prevalence and CD4 correlates of OIs among adult HIV-infected patients attending at Gondar University Hospital.MethodsCross sectional study was conducted on 360 adult HIV-infected patients attending antiretroviral therapy clinic from February 2012-April 2012. Patients’ OI status was determined through clinical diagnosis and laboratory investigations. CD4 count was determined using flow cytometry technique. Sociodemographic and clinical data were obtained from interview and patients’ medical records. Bivariate and multivariate logistic regression analysis was done using SPSS version 16 statistical soft ware and odds ratio was used as the measure of association. P-value less than 0.05 was considered statistically significant for all tests.ResultsIn this study, 360 HIV-infected patients were included; of whom (n = 216/360, 60%) were females. The majority of patients (n = 153/360, 42.5%) were 25-34 years old with mean age of 35.5+ 8.8 standard deviation. The overall prevalence of OIs was (n = 71/360, 19.7%). Tuberculosis (n = 35/360, 9.72%) followed by oral candidiasis (n = 18/360, 5%) and diarrhea (n = 12/360, 3.3%) were the most frequently observed OIs. CD4 count less than 200/mm3 (OR = 4.933, P < 0.001), World Health Organization (WHO) clinical stage III (OR = 9.418, P < 0.001) and IV (OR = 22.665, P < 0.001) were found to have strong association with acquisition of OIs.ConclusionsTuberculosis, oral candidiasis and diarrhea were the leading OIs encountered by HIV-infected patients. CD4 count less than 200/mm3 and advanced WHO clinical stages of the disease were found to be predictors of OIs. Interventions aimed at preventing and treating HIV associated OIs are crucial. Initiation of ART before the CD4 count drops below 350 should be encouraged.

Early infant diagnosis of HIV in three regions in Tanzania; successes and challenges

BackgroundBy the end of 2009 an estimated 2.5 million children worldwide were living with HIV-1, mostly as a consequence of vertical transmission, and more than 90% of these children live in sub-Saharan Africa. In 2008 the World Health Organization (WHO), recommended early initiation of Highly Active Antiretroviral Therapy (HAART) to all HIV infected infants diagnosed within the first year of life, and since 2010, within the first two years of life, irrespective of CD4 count or WHO clinical stage. The study aims were to describe implementation of EID programs in three Tanzanian regions with differences in HIV prevalences and logistical set-up with regard to HIV DNA testing.MethodsData were obtained by review of the prevention from mother to child transmission of HIV (PMTCT) registers from 2009–2011 at the Reproductive and Child Health Clinics (RCH) and from the databases from the Care and Treatment Clinics (CTC) in all the three regions; Kilimanjaro, Mbeya and Tanga. Statistical tests used were Poisson regression model and rank sum test.ResultsDuring the period of 2009 – 2011 a total of 4,860 exposed infants were registered from the reviewed sites, of whom 4,292 (88.3%) were screened for HIV infection. Overall proportion of tested infants in the three regions increased from 77.2% in 2009 to 97.8% in 2011. A total of 452 (10.5%) were found to be HIV infected (judged by the result of the first test). The prevalence of HIV infection among infants was higher in Mbeya when compared to Kilimanjaro region RR = 1.872 (95%CI = 1.408 – 2.543) p < 0.001. However sample turnaround time was significantly shorter in both Mbeya (2.7 weeks) and Tanga (5.0 weeks) as compared to Kilimanjaro (7.0 weeks), p=<0.001. A substantial of loss to follow-up (LTFU) was evident at all stages of EID services in the period of 2009 to 2011. Among the infants who were receiving treatment, 61% were found to be LFTU during the review period.ConclusionThe study showed an increase in testing of HIV exposed infants within the three years, there is large variations of HIV prevalence among the regions. Challenges like; sample turnaround time and LTFU must be overcome before this can translate into the intended goal of early initiation of lifelong lifesaving antiretroviral therapy for the infants.

P3.330 Prevalence and Immunological Correlates of Opportunistic Infections Among HIV Patients Attending at ART Clinic of University of Gondar Hospital

IntroductionHuman immunodeficiency virus (HIV) pandemic is among the greatest health crises ever faced by humanity. Morbidity and mortality in HIV disease is due to immunosuppression leading to life-threatening opportunistic infections...

Malnutrition: Prevalence and its associated factors in People living with HIV/AIDS, in Dilla University Referral Hospital.

BackgroundLiteratures on prevalence and factors associated with malnutrition among peoples living with HIV/AIDS are limited in Ethiopia and not well documented either. The proper implementation of nutritional support and its integration with the routine highly active antiretroviral therapy package demands a clear picture of the magnitude and associated factors of malnutrition. The objective of this study is, therefore, to assess the prevalence and factors associated with malnutrition among peoples living with HIV/AIDS.MethodsInstitution based cross sectional study was conducted in Dilla University referral Hospital including adult HIV patients who were in highly active anti retroviral therapy. Interview administered questionnaires were used to collect data on socio demographic factors. Besides, HIV related clinical information was extracted from anti retro viral therapy data base and clinical charts. The nutritional status of the patients was determined by Body Mass Index (BMI) where BMI < 18kg/m2 was defined as malnutrition according to World Health Organization (WHO). Binary logistic regression was used to assess association between different risk factors and malnutrition. Confidence interval of 95% was considered to see the precision of the study and the level of significance was taken at α <0.05.ResultsA total of 520 patients were included in the analysis. The overall prevalence of malnutrition was 12.3% (95% CI 9.5–15.0). After full control of all variables; unemployment (OR = 3.61, 95% CI: 3.6 − 7.76), WHO clinical stage four (OR = 12.9, 95% CI: 2.49− 15.25), gastrointestinal symptoms (OR = 5.3, 95% CI: 2.56 − 10.78) and previous (one) opportunistic infection (OR = 3.1, 95% CI 2.06 − 5.46), and two & above previous opportunistic infections (OR = 4.5, 95% CI: 3.38 − 10.57) were significantly associated with malnutrition. However, moderately poor economic condition was found to be protective factor for malnutrition (OR = 0.4, 95% CI: 0.14 − 0.95).ConclusionUnemployment, WHO clinical AIDS stage four, one & more number of previous opportunistic infections and gastrointestinal symptoms were found to be important risk factors for malnutrition among People Living with HIV/AIDS. From this study it has been learnt that nutritional programs should be an integral part of HIV/AIDS continuum of care. Furthermore, it needs to improve household income of PLHIV with employment opportunity and to engage them in income generating activities as well.

Determinant Factors Associated with Occurrence of Tuberculosis among Adult People Living with HIV after Antiretroviral Treatment Initiation in Addis Ababa, Ethiopia: A Case Control Study

IntroductionTuberculosis (TB) is a leading morbidity and mortality, and the first presenting sign in majority of people living with Human Immune deficiency Virus (PLWH). Determinants of active TB among HIV patients on anti retroviral treatment (ART) are not well described in resource limited settings. The aim of this study was to assess determinant factors for the occurrence of TB among people living with HIV after ART initiation in public hospitals and health centers in Addis Ababa, Ethiopia.Methods and FindingsA case control study was conducted from December 2011 to February 2012 in 2 public hospitals and 13 health centers in Addis Ababa. The study population consisted of 204 cases and 409 controls. Cases were adult people living with HIV who developed TB after ART initiation and controls were adult people living with HIV who did not develop TB after ART initiation. An interviewer administered structured questionnaire was used to collect information.After adjustment for potential confounders, presence of isoniazid prophylaxis (adjusted odd ratio [AOR] 0.35, 95% confidence interval [CI] 0.125, 0.69) and cotrimoxazole prophylaxis (AOR = 0.19; 95% CI: 0.06, 0.62) had protective benefit against risk of TB. In contrary, bedridden (AOR = 9.36; 95% CI: 3.39, 25.85), having World Health Organization (WHO) clinical stage III/IV (AOR = 3.40; 95% CI: 1.69, 6.87) and hemoglobin level <10 mg/dl (AOR = 7.43; 95% CI; 3.04, 18.31) at enrollment to ART care were predictors for increased risk of tuberculosis in PLWH after ART initiation.ConclusionIncreasing coverage of isoniazid preventive therapy and cotrimoxazole preventive therapy reduced risk of TB among HIV patients who started treatment. All PLWH should be screened for TB, but for patients who have advanced disease condition (WHO clinical stage III/IV, being bedridden and having hemoglobin level <10 mg/dl) intensified screening is highly recommended during treatment follow up.

Task Shifting HIV Care in Rural District Hospitals in Cameroon

Task shifting to nurses for antiretroviral therapy (ART) is promoted by the World Health Organization to compensate for the severe shortage of physicians in Africa. We assessed the effectiveness of task shifting from physicians to nurses in rural district hospitals in Cameroon. We performed a cohort study using data from the Stratall trial, designed to assess monitoring strategies in 2006-2010. ART-naive patients were followed up for 24 months after treatment initiation. Clinical visits were performed by nurses or physicians. We assessed the associations between the consultant ratio (ie, the ratio of the number of nurse-led visits to the number of physician-led visits) and HIV virological success, CD4 recovery, mortality, and disease progression to death or to the World Health Organization clinical stage 4 in multivariate analyses. Of the 4141 clinical visits performed in 459 patients (70.6% female, median age 37 years), a quarter was task shifted to nurses. The consultant ratio was not significantly associated with virological success [odds ratio 1.00, 95% confidence interval (CI): 0.59 to 1.72, P = 0.990], CD4 recovery (coefficient -3.6, 95% CI: -35.6; 28.5, P = 0.827), mortality (time ratio 1.39, 95% CI: 0.27 to 7.06, P = 0.693), or disease progression (time ratio 1.60, 95% CI: 0.35 to 7.37, P = 0.543). This study brings important evidence about the comparability of ART-related outcomes between HIV models of care based on physicians or nurses in resource-limited settings. Investing in nursing resources for the management of noncomplex patients should help reduce costs and patient waiting lists while freeing up physician time for the management of complex cases, for mentoring and supervision activities, and for other health interventions.

CD4 Counts in Laboratory Monitoring of HIV Disease—Experience from Western India

CD4 counts vary in different populations. The present study was conducted to determine CD4 counts in different World Health Organization (WHO) clinical stages in antiretroviral therapy naive individuals and to find out optimum CD4 cutoffs. Data of adult HIV seropositive patients who underwent CD4 count and total lymphocyte count (TLC) testing were included for analysis. The severity of immunosuppression was graded based on WHO criteria. To establish optimum CD4 cutoff values, receiver-operator characteristics (ROC) curves were generated. Of 754 patients, 52.2% had CD4 counts <200 cells/mm3, but only 2.3% belonged to WHO stage IV. Newer CD4 cutoffs generated were 280, 120-280, <120 cells/mm3. Spearman rank correlation between CD4 counts and TLC was found to be weak (r = .32). The cutoff values of CD4 counts for HIV disease may need to be revised for India. Regular CD4 count estimation is a must for monitoring disease progression in people living with HIV/AIDS.

Early Outcomes of Darunavir- and/or Raltegravir-Based Antiretroviral Therapy in Children with Multidrug-Resistant HIV at a Pediatric Center in Botswana

Data on the use of ritonavir-boosted darunavir (DRV/r) and/or raltegravir (RAL) in resource-limited settings are rare and there is currently no published data regarding their use among African children. Botswana has recently made DRV/r and RAL available for patients failing second-line antiretroviral therapy (ART). Retrospective chart review of 4 multidrug-resistant pediatric patients on DRV/r- and/or RAL-based regimens. Viral load, CD4 count, adherence by pill count, and World Health Organization (WHO) clinical stage prior to and after switch to DRV/r- and/or RAL-based regimen were assessed. Antiretroviral therapy history, duration of virologic failure, and time to viral suppression were also noted. Genotypic resistance assays reviewed for mutations present prior to switch. All patients achieved viral suppression, showed improved/stable CD4 counts, and obtained or maintained WHO clinical treatment stage I, even after long-standing virologic/immunologic failure. Well tolerated by and effective in our patients, DRV/r and RAL provide potentially lifesaving ART options for children and adolescents in resource-limited settings failing ART due to ritonavir-boosted lopinavir (LPV/r) resistance.

Prevalence and Risk Factors for Opportunistic Infections in HIV Patients Receiving Antiretroviral Therapy in a Resource-Limited Setting in Nigeria

Background: The introduction of Highly Active Antiretroviral Therapy (HAART) has led to decline in HIV-related opportunistic infections in high-income settings. We determined the prevalence and risk factors for opportunistic infections among patients receiving HAART in a resource-limited setting in Nigeria. Methodology: A descriptive and analytical cross-sectional study among adult HIV-infected patients receiving HAART for a median duration of 3 years at the Federal Medical Centre, Owerri, Nigeria was conducted. Data on pre- HAART socio-demographic, clinical and laboratory characteristics were obtained. Post-HAART data were collected through history, physical examination and laboratory investigations. Result: The mean age of the participants was 41.1 ± 10.0 years; and females were in the majority (65.8%). Half (50.4%) belonged to the lower socio-economic class. At baseline (pre-HAART), 72.3% of the participants belonged to World Health Organization (WHO) clinical stage 1 or 2. The median pre-HAART CD4 cell count of the patients was 200 (110-263) cells/μl while the median post-HAART CD4 cell count was 357 (211-496) cells/μl. The majority (77.6%) were adherent on HAART. Out of 339 patients, 76 (22.4%) had opportunistic infections. The leading conditions were candidiasis (8.6%), tuberculosis (7.7%), dermatitis (5.6%), chronic diarrhea (1.5%) and sepsis (1.5%). The independent risk factors for opportunistic infections were household income < 20,000 (Adjusted odds ratio [AOR] = 2.70, 95% CI 1.18-6.18), advanced baseline WHO clinical stage (AOR=9.49, 95% CI 4.20-21.42), baseline hemoglobin <10 g/dl (AOR= 3.50, 95% CI 1.47-8.36), post-HAART CD4 cell count <200 cells/μl (AOR= 3.43, 95% CI 1.49-7.92), and HAART non-adherence (AOR= 5.28, 95% CI 2.52-11.08). Conclusion: Opportunistic infections remain a challenge in patients receiving HAART in resource-limited settings. There is need to intensify the management of opportunistic infections despite HAART use.

The Influence of Clinical Staging and Use of Antiretroviral Therapy on Cognitive Functioning of School-Aged Nigerian Children with HIV Infection

Objective: To find out how the World Health Organization Clinical Stages of HIV infection and use of antiretroviral therapy influence cognitive functioning of school-aged HIV-infected Nigerian children. Method: Cognitive assessments of 69 HIV positive children aged 6–15 years were performed using Raven’s Standard Progressive Matrices. Thirty children were on Highly Active Antiretroviral Therapy. The children were subdivided for the purpose of analysis into two cognitive developmental stages using Piaget’s developmental stage: the concrete operation stage (6–11 years) and the formal operation stage (12–15 years). Children on antiretroviral therapies were also compared with those not on therapies. HIV infection was staged using the revised World Health Organization Clinical Staging for Paediatric HIV/AIDS. Result: The overall mean cognitive score for HIV positive subjects on antiretroviral therapy was 20.9 which was significantly higher than the overall score for subjects not on therapies of 14.6 (p=0.007). In the age group 6–11 years, the mean cognitive scores became lower significantly with worsening clinical stage for subjects irrespective of use of anti-retroviral therapy. The mean scores for subjects on therapy were significantly higher than that of their counterparts not yet on therapy at the same clinical stage. There were no significant differences in the cognitive scores at different clinical stages among the children in the age group 12–15 years. Conclusion: Cognitive scores were lower with worsening clinical staging in the younger school-aged HIV-infected Nigerian children. Subjects on Highly Active Anti-retroviral Therapy had better cognitive scores than subjects not on therapy at the same clinical stage. Routine neuropsychological evaluation for school-aged HIV-infected children are recommended with an emphasiss on the younger children.

Pattern of mucocutaneous manifestations in human immunodeficiency virus-positive patients in North India

Mucocutaneous diseases are among the first-recognized clinical manifestations of acquired immune deficiency syndrome. They function as visual markers in assessing the progression of human immunodeficiency virus (HIV) infection. Given the relative ease of examination of skin, its evaluation remains an important tool in the diagnosis of HIV infection. To determine the pattern of mucocutaneous manifestations in HIV-positive patients and to correlate their presence with CD4 counts. This cross-sectional study included 352 HIV-infected patients seen at PGIMER, Chandigarh, India, over a period of 1 year. The patients were screened for mucocutaneous disorders by an experienced dermatologist. The patients were classified into different stages according to the World Health Organization clinical and immunological staging system. The most prevalent infection was candidiasis, seen in 57 patients (16.2%). Prevalence of candidiasis, dermatophytosis, herpes simplex, herpes zoster, molluscum contagiosum (MC), seborrheic dermatitis, adverse drug reaction, nail pigmentation, xerosis and diffuse hair loss differed statistically according to the clinical stages of HIV infection. There was a statistically significant association between immunological stages of HIV infection and dermatophytosis. Results of our study suggest that mucocutaneous findings occur throughout the course of HIV infection. Dermatoses like MC and dermatophytosis show an inverse relation with CD4 cell count, and these dermatoses can be used as a proxy indicator of advanced immunosuppression to start highly active anti-retroviral therapy in the absence of facilities to carry out CD4 cell count.

Pattern of mucocutaneous manifestations in human immunodeficiency virus-positive patients in North India

Background:Mucocutaneous diseases are among the first-recognized clinical manifestations of acquired immune deficiency syndrome. They function as visual markers in assessing the progression of human immunodeficiency virus (HIV) infection. Given the relative ease of examination of skin, its evaluation remains an important tool in the diagnosis of HIV infection.Objective:To determine the pattern of mucocutaneous manifestations in HIV-positive patients and to correlate their presence with CD4 counts.Materials and Methods:This cross-sectional study included 352 HIV-infected patients seen at PGIMER, Chandigarh, India, over a period of 1 year. The patients were screened for mucocutaneous disorders by an experienced dermatologist. The patients were classified into different stages according to the World Health Organization clinical and immunological staging system.Results:The most prevalent infection was candidiasis, seen in 57 patients (16.2%). Prevalence of candidiasis, dermatophytosis, herpes simplex, herpes zoster, molluscum contagiosum (MC), seborrheic dermatitis, adverse drug reaction, nail pigmentation, xerosis and diffuse hair loss differed statistically according to the clinical stages of HIV infection. There was a statistically significant association between immunological stages of HIV infection and dermatophytosis.Conclusion:Results of our study suggest that mucocutaneous findings occur throughout the course of HIV infection. Dermatoses like MC and dermatophytosis show an inverse relation with CD4 cell count, and these dermatoses can be used as a proxy indicator of advanced immunosuppression to start highly active anti-retroviral therapy in the absence of facilities to carry out CD4 cell count.

Impact of immune reconstitution inflammatory syndrome on antiretroviral therapy adherence

ObjectiveWe determined the impact of immune reconstitution inflammatory syndrome (IRIS) on antiretroviral therapy (ART) adherence in a cohort of 274 human immunodeficiency virus (HIV)-infected South African adults initiating ART.MethodsWe carried out a secondary analysis of data from a randomized controlled trial of partially supervised ART in Cape Town, South Africa. Monthly pill count adherence, viral suppression (HIV viral load < 50 c/mL), and IRIS events were documented. Poisson regression was used to identify variables associated with ART adherence below the median in the first 6 months of ART.ResultsWe enrolled 274 patients: 58% women, median age 34 years, median CD4 count 98 cells/μL, 46% World Health Organization clinical stage IV, and 40% on treatment for tuberculosis (TB). IRIS and TB-IRIS developed in 8.4% and 6.6% of patients, respectively. The median cumulative adherence at 6 months for those with an IRIS event vs no IRIS was 95.5% vs 98.2% (P = 0.04). Although not statistically significant, patients developing IRIS had a lower 6-month viral load suppression than those without IRIS (68% vs 80%, P = 0.32). ART adherence below the median of 98% was independently associated with alcohol abuse (relative risk [RR] 1.5; 95% confidence interval [CI] 1.2–1.9; P = 0.003) and IRIS events (RR 1.7; 95% CI 1.2–2.2; P = 0.001).ConclusionAlthough IRIS events were associated with slightly lower adherence rates, overall adherence to ART remained high in this study population. Concerns about IRIS should not deter clinicians from early ART initiation.

Prevalence and Risk Factors of Low Bone Mineral Density Among Perinatally HIV-Infected Thai Adolescents Receiving Antiretroviral Therapy

Low bone mineral density (BMD) has been reported among 10%-54% of HIV-infected adolescents in developed countries. We studied the prevalence and predictors of low BMD among HIV-infected Thai adolescents receiving antiretroviral therapy. A cross-sectional study of lumbar spine (L2-L4) BMD as measured by dual-energy X-ray absorptiometry in Thai HIV-infected adolescents aged 12-20 years was performed. The BMD Z score was analyzed using age-matched healthy Thai children as a reference. Serum 25-hydroxyvitamin D was performed. Osteopenia was defined as BMD Z score ≤ -2. From October 2010 to February 2011, 101 adolescents, 50% male, with a median age of 14.3 (range: 13.0-15.7) years were enrolled. The median [interquartile range (IQR)] current CD4 T-cell count was 646 (506-796) cells per cubic millimeter and 90% had plasma HIV-1 RNA <50 copies per milliliter. The mean BMD among HIV-infected adolescents and controls were 0.855 and 0.980 g/cm (P < 0.001). The median (IQR) L2-L4 spine BMD Z score was -1.0 (-1.9 to -0.1), of which 24% had BMD Z score ≤ -2.0. The median (IQR) of 25-hydroxyvitamin D level was 24.8 (20.0-31.4) ng/mL, of which 25% had vitamin D level < 20 ng/mL. In multivariate analysis, the height for age Z score < -1.5 (adjusted odds ratio: 6.2; 95% confidence interval: 2.2 to 17.7) and history of World Health Organization clinical stage 4 before antiretroviral therapy (adjusted odds ratio: 3.7; 95% confidence interval: 1.3 to 10.7) were significantly associated with osteopenia. One fourth of HIV-infected Thai adolescents have osteopenia. Children with history of advanced-staging or having low height for age are at risk of osteopenia. Preventive measures to prevent osteopenia should be incorporated in routine care for these adolescents.

Programmatic Impact of the Evolution of WHO Pediatric Antiretroviral Treatment Guidelines for Resource-Limited Countries (Tukula Fenna Project, Uganda)

World Health Organization (WHO) recommendations for the initiation of antiretroviral therapy (ART) in children were revised in 2010, but the programmatic impact has had limited study. We used a cohort of 985 Ugandan children followed since 2003 by the Tukula Fenna project to model the differential impact of the 2006, 2008, and 2010 WHO pediatric ART inititation criteria on the proportion of children eligible for ART at enrollment and over time. Using the WHO 2006, 2008, and 2010 ART criteria, 40%, 57%, and 66% of children, respectively, would have been eligible for ART at enrollment and 76%, 84%, and 88% 2 years later. Evaluating the entire cohort followed for 6 years using the 2006, 2008, and 2010 guidelines, the proportion in need of ART was found to be 70%, 82%, and 87%, respectively. Between 2006 and 2008, the proportions of eligible children starting ART within 6 and 12 months were 39% and 50%, respectively; after this, the proportions starting within 6 and 12 months were 50% and 52%. Before 2008, the most common criterion met in children who did not start ART was WHO clinical stage (odds ratio = 2.0, CI 95% = 1.2 to 3.2); after the 2008 recommendations, the most common eligibility criterion in children who did not start ART was age <12 months (odds ratio = 10.5, CI 95% = 3.8 to 31.1). An overall increase of 17% (from 70% to 87%) in children in need of ART was observed in our cohort comparing the 2006 and 2010 guidelines; this increase was primarily driven by the introduction of universal treatment for infants <12 months in 2008.

Risk factors for discordant immune response among HIV-infected patients initiating antiretroviral therapy: A retrospective cohort study

Background. The therapeutic goal of antiretroviral therapy (ART) is sustained immune recovery and viral suppression. However, some patients experience poor CD4 cell count responses despite achieving viral suppression. Such discordant immune responses have been associated with poor clinical outcomes. Objective. We aimed to determine the prevalence of discordant immune response and explore associated factors in a retrospective cohort of patients attending 2 large public sector clinics, during the 6 months following ART initiation. Methods. Data were analysed from 810 HIV-infected adults initiated on first-line ART at 2 clinics in Johannesburg, between 1 November 2008 and 31 December 2009. Multivariate logistic regression models were used to estimate adjusted odds ratios (AORs) to determine associations between discordant immune response and clinical and demographic factors. Results. At ART initiation, 65% (n=592) of participants were female, with a mean age of 38.5 years. Median baseline CD4 cell count was 155 cells/mm3, 70% (n=645) of patients had a haemoglobin level >11 g/dl and 88% (n=803) were initiated on stavudine-lamivudine-efavirenz/nevirapine (D4T-3TC-EFV/NVP). Six months after ART initiation, 24% (n=220) of patients had a discordant immune response and 7% (n=67) a discordant virological response. On multivariate analysis, baseline CD cell count ≥200 cells/mm3 (AOR 3.02; 95% confidence interval (CI) 2.08 - 4.38; p<0.001) and moderate anaemia (8.0 - 9.4 g/dl) at baseline (AOR 2.30; 95% CI 1.25 - 4.59; p=0.007) were independently associated with the development of discordant immune response, after adjustment for education level, World Health Organization (WHO) clinical stage and ART regimen. Conclusions. Discordant immune response following ART initiation was common and associated with baseline anaemia and CD4 cell count in our cohort. Intensive monitoring of at-risk individuals may improve clinical outcomes.

Frequency and Predictors for Late Start of Antiretroviral Therapy in Primary Care Clinics, Kampala, Uganda

Access to antiretroviral treatment (ART) has improved greatly in many parts of the world, including Uganda, yet, many patients delay to start ART even when registered within the HIV services. We assessed, in a routine ambulatory care setting, what proportion of patients start ART late and the associated factors. We conducted a cross-sectional study from a cohort of adult, HIV-infected, ART-naive patients seeking care at 3 primary care centers in Kampala, Uganda. ART eligibility at the time was World Health Organization clinical stage 4 or CD4 <200 cells/μL. We defined late start of ART as starting ART at CD4 count <100 cells/μL and analyzed associated factors using multivariable logistic regression. Between May 2008 and August 2009, 326 adults were studied. Two hundred eighteen (67%) were women; the median age was 34 years (range, 18-71). The median CD4 count was 132 cells/μL (range, 1-505). Thirty-one patients (10%) were in World Health Organization stage 4. One hundred twenty-three patients (37.7%) were initiated on ART with CD4 cells <100 cells/μL. Being male [adjusted OR (aOR): 2.4; 95% confidence interval: 1.3 to 4.2, P = 0.002] and having no employment (aOR: 1.9; 95% confidence interval: 1.2 to 3.3, P = 0.012) were associated with late start of ART. Being older, being married, and showing signs of alcohol dependence were associated with an earlier start of ART. A considerable proportion of patients started ART at very low CD4 counts. Male and unemployed patients were more likely and married people and those aged 40 years or older were less likely to start ART late.