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Sustainability of programs to reach high risk and marginalized populations living with HIV in resource limited settings: implications for HIV treatment and prevention
No full textThe experiences of the past 10 years have shown that it is feasible to treat HIV infected patients with ART even in severely resource constrained settings. Achieving the levels of antiretroviral coverage necessary to impact the course of the HIV epidemic remains a challenge and antiretroviral therapy coverage in most nations remains short of even current recommendations. Though treatment as prevention and seek, test, treat and retain strategies are attractive, realization of the benefits of these strategies will require the ability to successfully engage key hard to reach populations such as sex workers. While the successes of engaging these populations in research settings as seen in the article by Huet et al are encouraging, key questions remain regarding the sustainability of these efforts as patients are transitioned back to national HIV control programs, many of which are struggling even to maintain the current panels in care in the face declining external funding for HIV care. To achieve the critical goals of increasing treatment uptake and retention and thereby curtail the epidemic of HIV, advocacy from both medicine and public health providers will be critical to generate the support and political will necessary to sustain and enhance the necessary HIV care programs worldwide
A five-year perspective on the situation of haemorrhagic fever with renal syndrome and status of the hantavirus reservoirs in Europe, 2005-2010
No full textFood insecurity and age at menarche among adolescent girls in Jimma Zone Southwest Ethiopia: a longitudinal study
No full textBACKGROUND: Age at menarche is the reflection of cumulative pre-adolescent exposure of girls to either adverse environment such as food insecurity or affluent living conditions. Food insecurity could result in inadequate nutrient intake and stress, both of which are hypothesized to have opposing effects on the timing of menarche through divergent pathways. It is not known whether food insecure girls have delayed menarche or early menarche compared with their food secure peers. In this study we test the competing hypothesis of the relationship between food insecurity and age at menarche among adolescent girls in the Southwest Ethiopia. METHODS: We report on 900 girls who were investigated in the first two rounds of the five year longitudinal survey. The semi-parametric frailty model was fitted to determine the effect of adolescent food insecurity on time to menarche after adjusting for socio-demographic and economic variables. RESULTS: Food insecure girls have menarche one year later than their food secure peer (median age of 15 years vs 14 years). The hazard of menarche showed a significant decline (P = 0.019) as severity of food insecurity level increased, the hazard ratio (HR) for mild food insecurity and moderate/severe food insecurity were 0.936 and 0.496, respectively compared to food secure girls. Stunted girls had menarche nearly one year later than their non-stunted peers (HR = 0.551, P < 0.001). CONCLUSION: Food insecurity is associated with delay of age at menarche by one year among girls in the study area. Stunted girls had menarche one year later than their non-stunted peers. Age at menarche reflects the development of girls including the timing of sexual maturation, nutritional status and trajectory of growth during the pre-pubertal periods. The findings reflect the consequence of chronic food insecurity on the development and well-being of girls in the study area
Urinary lipoarabinomannan as predictor for the tuberculosis immune reconstitution inflammatory syndrome
No full textBACKGROUND: Upon initiation of antiretroviral therapy (ART), 15.7% (95%CI: 9.7%-24.5%) of tuberculosis (TB)-HIV co-infected individuals experience paradoxical worsening of their clinical status with exuberant inflammation consistent with Immune Reconstitution Inflammatory Syndrome (IRIS). We investigated whether a positive urinary TB lipoarabinomannan (LAM) antigen ELISA-test prior to ART initiation was associated with development of paradoxical TB-IRIS. METHODS: In a prospective observational cohort in Mulago Hospital, Kampala, Uganda, we measured pre-ART urinary LAM concentrations in HIV-infected patients on TB treatment. Patients who developed TB-IRIS (according to the International Network for the Study of HIV-associated IRIS (INSHI) case-definition) were compared to patients who remained IRIS free for at least 3 months. RESULTS: Twenty-six individuals with TB-IRIS and 64 without IRIS were included in the analysis. The median time to TB-IRIS was 14 days (IQR: 11-14). Univariate analysis showed that a positive pre-ART urinary LAM test (OR: 4.6 [95%CI: 1.5-13.8], p=0.006) and a CD4 count <50 cells/ml (OR: 21 [95%CI: 2.6-169.4], p=0.004) were associated with an increased risk of TB-IRIS. In multivariate analysis only a baseline CD4 T-cell count <50 cells/ml was predictive of IRIS (p<0.004). Sensitivity and specificity of a positive pre-ART urinary LAM test to diagnose IRIS was 80.8% (95%CI: 60.6-93.4) and 52.4% (95%CI: 39.4-65.1), respectively. CONCLUSION: If CD4 T-cell count testing is available, a pre-HAART urinary LAM test has no added value to predict TB IRIS. When CD4 T-cell count is , a positive LAM test could identify patients at increased risk of TB IRIS
Attempting to explain heterogeneous HIV epidemics in sub-Saharan Africa: potential role of historical changes in risk behaviour and male circumcision
No full textBackground: A key conclusion of the Four Cities Study, carried out to explore reasons for heterogeneity in the HIV epidemic between two cities in sub-Saharan Africa with relatively low prevalence (Cotonou and Yaounde) and two with high prevalence (Kisumu and Ndola), was that differences in biological cofactors outweighed differences in sexual risk behaviours. The authors explore an alternative hypothesis, that risk behaviours were historically higher in the high-prevalence cities. They also investigate the effects of different prevalence of male circumcision on the HIV epidemics in the four cities.MethodsA transmission model was fitted to data from the Four Cities Study. Default scenarios included biological cofactor effects on HIV transmission. Counter-factual scenarios were simulated without biological cofactors, with and without higher historical sexual behaviours, and with various rates of male circumcision. Results: Simulated adult HIV prevalence in 1997 for the default scenarios was 3.1%, 7.8%, 28.9% and 27.1% in Cotonou, Yaounde, Kisumu and Ndola, respectively, in line with data. Without biological cofactors, even implausibly high historical levels of risk behaviour in East Africa could not reproduce the observed heterogeneity in the late 1990s. Increasing the proportion of men circumcised in Ndola from 10% to 100% reduced HIV prevalence in 1997 to 7%. Decreasing the proportion circumcised in Yaounde from 100% to 10% increased HIV prevalence to 26%. Conclusions: Differences in male circumcision rates are likely to have played a key role in the heterogeneous spread of HIV across Africa. The effect of circumcision interventions can vary depending on the epidemic setting, with a larger effect in more generalised epidemics
Evaluating AVAHAN's design, implementation and impact: lessons learned for the HIV prevention community
No full textA retrospective observational study on the efficacy of colistin by inhalation as compared to parenteral administration for the treatment of nosocomial pneumonia associated with multidrug-resistant Pseudomonas aeruginosa
No full textBACKGROUND: Colistin is used as last treatment option for pneumonia associated with multidrug-resistant (MDR) Pseudomonas spp.. Literature about the best administration mode (inhalation versus parenteral treatment) is lacking. METHODS: A retrospective study of 20 intensive care patients with a pneumonia associated with MDR P. aeruginosa receiving colistin sulphomethate sodium (Colistineb(R)) between 2007 and 2009 was performed. A strain was considered multidrug-resistant if it was resistant to at least 6 of the following antibiotics: piperacillin-tazobactam, ceftazidime, cefepime, meropenem, aztreonam, ciprofloxacin, and amikacin. The administration mode, predicted mortality based on the SAPS3 score, SOFA score at onset of the colistin treatment, clinical and microbiological response, and mortality during the episode of the infection were analysed. The non parametric Kruskal-Wallis and Fisher's Exact test were used for statistical analysis of respectively the predicted mortality/SOFA score and mortality rate. RESULTS: Six patients received colistin by inhalation only, 5 were treated only parenterally, and 9 by a combination of both administration modes. All patients received concomitant beta-lactam therapy. The mean predicted mortalities were respectively 72%, 68%, and 69% (p = 0.91). SOFA scores at the onset of the treatment were also comparable (p = 0.87). Clinical response was favorable in all patients receiving colistin by inhalation (6/6) and in 40% (2/5) of the patients receiving colistin parenterally (p = 0.06). In the patients with colistin administered both via inhalation and parenterally, clinical response was favorable in 78% of the patients (7/9) (p = 0.27 as compared to the treatment group receiving colistin only parenterally). When all patients with inhalation therapy were compared to the group without inhalation therapy, a favorable clinical response was present in respectively 87% and 40% (p = 0.06). In none of the patients, the Pseudomonas spp. was eradicated from the follow-up cultures.All patients in the parenterally treated group died. None of the patients receiving colistin by inhalation, and 3 of 9 patients of the combination group eventually died (p = 0.002 and p = 0.03 respectively as compared to the group receiving colistin only parenterally). CONCLUSIONS: Aerosolized colistin could be beneficial as adjunctive treatment for the management of pneumonia due to MDR P. aeruginosa
