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1.
EBioMedicine ; 85: 104309, 2022 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-36283285

RESUMO

BACKGROUND: After initiating antiretroviral therapy (ART), approximately 25% of people with HIV (PWH) may develop Immune Reconstitution Inflammatory Syndrome (IRIS), which is associated with increased morbidity and mortality. Several reports have demonstrated that low haemoglobin (Hb) levels are a risk factor for IRIS. To what extent the severity of anaemia contributes to the risk of IRIS and/or death is still insufficiently explored. METHODS: We investigated both the presence and severity of anaemia in PWH in a multinational cohort of ART-na..ve patients. A large panel of plasma biomarkers was measured pre-ART and patients were followed up for 6 months. IRIS or deaths during this period were considered as outcomes. We performed multidimensional analyses, logistic regression, and survival curves to delineate associations. FINDINGS: Patients with severe anaemia (SA) presented a distinct systemic inflammatory profile, characterized by higher TNF, IL-6, and IL-27 levels. SA was independently associated with IRIS, with a higher risk of both early IRIS onset and death. Among IRIS patients, those with SA had a higher risk of mycobacterial IRIS. INTERPRETATION: PWH with SA display a more pronounced inflammatory profile, with an elevated risk of developing IRIS earlier and a statistically significant higher risk of death. FUNDING: Intramural Research Program of National Institute of Allergy and Infectious Diseases/National Institutes of Health (NIAID/NIH). Coordena...·o de Aperfei..oamento de Pessoal de N.ível Superior (Finance code: 001) and the Conselho Nacional de Desenvolvimento Cient.ífico e Tecnol..gico (CNPq), Brazil.


Assuntos
Anemia , Infecções por HIV , Síndrome Inflamatória da Reconstituição Imune , Humanos , Estudos de Coortes , Síndrome Inflamatória da Reconstituição Imune/etiologia , Infecções por HIV/complicações , Infecções por HIV/tratamento farmacológico , Inflamação/complicações , Anemia/complicações
2.
J Acquir Immune Defic Syndr ; 89(2): 178-182, 2022 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-34693933

RESUMO

BACKGROUND: HIV protease inhibitors anti-Plasmodium falciparum activity in adults remains uncertain. METHODS: Adults with HIV CD4+ counts >200 cells/mm3 starting antiretroviral therapy (ART) with P. falciparum subclinical parasitemia (Pf SCP) were randomized 1:1 to (step 1) protease inhibitor lopinavir/ritonavir (LPV/r)-based (arm A) or nonnucleoside reverse transcriptase inhibitor (nNRTI)-based ART (arm B) for 15 days. In step 2, participants received nNRTI-based ART and trimethoprim/sulfamethoxazole prophylaxis for 15 days. P. falciparum SCP clearance was measured by polymerase chain reaction. The Fisher exact test [95% exact confidence interval (CI)] was used to compare proportions of P. falciparum SCP clearance (<10 parasites/µL on 3 occasions within 24 hours) between LPV/r and nNRTI arms at day 15. The Kaplan-Meier method and log-rank test were used to compare time-to-clearance. RESULTS: Fifty-two adults from Kenya, Malawi, and Uganda with a median age = 31 (Q1, Q3: 24-39) years, 33% women, with baseline median CD4+ counts of 324 (259-404) cells/mm3, median HIV-1 RNA viremia of 5.18 log10 copies/mL (4.60-5.71), and median estimated P. falciparum density of 454 parasites/µL (83-2219) enrolled in the study. Forty-nine (94%) participants completed the study. At day 15, there was no statistically significant difference in the proportions of P. falciparum SCP clearance between the LPV/r (23.1% clearance; 6 of the 26) and nNRTI (26.9% clearance; 7 of the 26) arms [between-arm difference 3.9% (95% CI, -21.1% to 28.4%; P = 1.00)]. No significant difference in time-to-clearance was observed between the arms (P = 0.80). CONCLUSIONS: In a small randomized study of adults starting ART with P. falciparum SCP, no statistically significant differences were seen between LPV/r- and nNRTI-based ART in P. falciparum SCP clearance after 15 days of treatment.


Assuntos
Fármacos Anti-HIV , Infecções por HIV , Inibidores da Protease de HIV , Adulto , Feminino , Infecções por HIV/complicações , Infecções por HIV/tratamento farmacológico , Inibidores da Protease de HIV/uso terapêutico , Humanos , Lopinavir , Masculino , Parasitemia/tratamento farmacológico , Plasmodium falciparum , Inibidores da Transcriptase Reversa/uso terapêutico , Ritonavir
3.
Am J Trop Med Hyg ; 104(1): 12-25, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-33241783

RESUMO

The Walter Reed Army Institute of Research (WRAIR) supports more than 350,000 people on lifesaving HIV treatment in Kenya, Nigeria, Tanzania, and Uganda through funding from the U.S. President's Emergency Plan for AIDS Relief (PEPFAR). Here, we review and synthesize the range of impacts WRAIR's implementation science portfolio has had on PEPFAR service delivery for military and civilian populations since 2003. We also explore how investments in implementation science create institutional synergies within the U.S. Department of Defense, contributing to broad global health engagements and improving health outcomes for populations served. Finally, we discuss WRAIR's contributions to PEPFAR priorities through use of data to drive and improve programming in real time in the era of HIV epidemic control and public health messaging that includes prevention, the 95-95-95 goals, and comorbidities.


Assuntos
Síndrome da Imunodeficiência Adquirida/epidemiologia , Síndrome da Imunodeficiência Adquirida/prevenção & controle , África Subsaariana , Saúde Global , Cooperação Internacional , Serviços de Saúde Militar , África Subsaariana/epidemiologia , Programas Governamentais , HIV-1 , Política de Saúde , Humanos , Ciência da Implementação , Julgamento Moral Retrospectivo , Estados Unidos
4.
Clin Infect Dis ; 71(3): 652-660, 2020 07 27.
Artigo em Inglês | MEDLINE | ID: mdl-31504347

RESUMO

BACKGROUND: Patients living with human immunodeficiency virus (PLWH) with low CD4 counts are at high risk for immune reconstitution inflammatory syndrome (IRIS) and death at antiretroviral therapy (ART) initiation. METHODS: We investigated the clinical impact of IRIS in PLWH and CD4 counts <100 cells/µL starting ART in an international, prospective study in the United States, Thailand, and Kenya. An independent review committee adjudicated IRIS events. We assessed associations between baseline biomarkers, IRIS, immune recovery at week 48, and death by week 48 with Cox models. RESULTS: We enrolled 506 participants (39.3% were women). Median age was 37 years, and CD4 count was 29 cells/µL. Within 6 months of ART, 97 (19.2%) participants developed IRIS and 31 (6.5%) died. Participants with lower hemoglobin at baseline were at higher IRIS risk (hazard ratio [HR], 1.2; P = .004). IRIS was independently associated with increased risk of death after adjustment for known risk factors (HR, 3.2; P = .031). Being female (P = .004) and having a lower body mass index (BMI; P = .003), higher white blood cell count (P = .005), and higher D-dimer levels (P = .044) were also significantly associated with increased risk of death. Decision-tree analysis identified hemoglobin <8.5 g/dL as predictive of IRIS and C-reactive protein (CRP) >106 µg/mL and BMI <15.6 kg/m2 as predictive of death. CONCLUSIONS: For PLWH with severe immunosuppression initiating ART, baseline low BMI and hemoglobin and high CRP and D-dimer levels may be clinically useful predictors of IRIS and death risk.


Assuntos
Infecções por HIV , Síndrome Inflamatória da Reconstituição Imune , Linfopenia , Adulto , Contagem de Linfócito CD4 , Feminino , HIV , Infecções por HIV/complicações , Infecções por HIV/tratamento farmacológico , Humanos , Síndrome Inflamatória da Reconstituição Imune/epidemiologia , Incidência , Quênia , Linfopenia/epidemiologia , Masculino , Estudos Prospectivos , Tailândia
5.
PLoS One ; 10(8): e0135124, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-26287814

RESUMO

Characterization of HIV-1 subtype diversity in regions where vaccine trials are conducted is critical for vaccine development and testing. This study describes the molecular epidemiology of HIV-1 within a tea-plantation community cohort in Kericho, Kenya. Sixty-three incident infections were ascertained in the HIV and Malaria Cohort Study conducted in Kericho from 2003 to 2006. HIV-1 strains from 58 of those individuals were full genome characterized and compared to two previous Kenyan studies describing 41 prevalent infections from a blood bank survey (1999-2000) and 21 infections from a higher-risk cohort containing a mix of incident and prevalent infections (2006). Among the 58 strains from the community cohort, 43.1% were pure subtypes (36.2% A1, 5.2% C, and 1.7% G) and 56.9% were inter-subtype recombinants (29.3% A1D, 8.6% A1CD, 6.9% A1A2D, 5.2% A1C, 3.4% A1A2CD, and 3.4% A2D). This diversity and the resulting genetic distance between the observed strains will need to be addressed when vaccine immunogens are chosen. In consideration of current vaccine development efforts, the strains from these three studies were compared to five candidate vaccines (each of which are viral vectored, carrying inserts corresponding to parts of gag, pol, and envelope), which have been developed for possible use in sub-Saharan Africa. The sequence comparison between the observed strains and the candidate vaccines indicates that in the presence of diverse recombinants, a bivalent vaccine is more likely to provide T-cell epitope coverage than monovalent vaccines even when the inserts of the bivalent vaccine are not subtype-matched to the local epidemic.


Assuntos
Vacinas contra a AIDS/imunologia , DNA Viral/genética , Infecções por HIV/epidemiologia , HIV-1/classificação , HIV-1/genética , Sequência de Bases , Estudos de Coortes , Epitopos de Linfócito T/imunologia , Infecções por HIV/complicações , Infecções por HIV/virologia , HIV-1/imunologia , Humanos , Quênia/epidemiologia , Malária/complicações , Malária/epidemiologia , Malária/parasitologia , Epidemiologia Molecular , Dados de Sequência Molecular , Filogenia , Recombinação Genética , Análise de Sequência de DNA , Produtos do Gene env do Vírus da Imunodeficiência Humana/imunologia , Produtos do Gene gag do Vírus da Imunodeficiência Humana/imunologia , Produtos do Gene pol do Vírus da Imunodeficiência Humana/imunologia
6.
PLoS One ; 10(2): e0116299, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-25706652

RESUMO

BACKGROUND: Prospective clinical trial data regarding routine HIV-1 viral load (VL) monitoring of antiretroviral therapy (ART) in non-research clinics of Sub-Saharan Africa are needed for policy makers. METHODS: CLinic-based ART Diagnostic Evaluation (CLADE) is a randomized, controlled trial (RCT) evaluating feasibility, superiority, and cost-effectiveness of routine VL vs. standard of care (clinical and immunological) monitoring in adults initiating dual nucleoside reverse transcriptase inhibitor (NRTI)+non-NRTI ART. Participants were randomized (1:1) at 7 predominately rural, non-research, district-level clinics of western Kenya. Descriptive statistics present accrual patterns and baseline cohort characteristics. RESULTS: Over 15 months, 820 adults enrolled at 7 sites with 86-152 enrolled per site. Monthly site enrollment ranged from 2-92 participants. Full (100%) informed consent compliance was independently documented. Half (49.9%) had HIV diagnosed through voluntary counseling and testing. Study arms were similar: mostly females (57.6%) aged 37.6 (SD = 9.0) years with low CD4 (166 [SD = 106]) cells/m3). Notable proportions had WHO Stage III or IV disease (28.7%), BMI <18.5 kg/m2 (23.1%), and a history of tuberculosis (5.6%) or were receiving tuberculosis treatment (8.2%) at ART initiation. In the routine VL arm, 407/409 (99.5%) received baseline VL (234,577 SD = 151,055 copies/ml). All participants received lamivudine; 49.8% started zidovudine followed by 38.4% stavudine and 11.8% tenofovir; and, 64.4% received nevirapine as nNRTI (35.6% efavirenz). CONCLUSIONS: A RCT can be enrolled successfully in rural, non-research, resource limited, district-level clinics in western Kenya. Many adults presenting for ART have advanced HIV/AIDS, emphasizing the importance of universal HIV testing and linkage-to-care campaigns. TRIAL REGISTRATION: ClinicalTrials.gov NCT01791556.


Assuntos
Fármacos Anti-HIV/uso terapêutico , Infecções por HIV/tratamento farmacológico , Infecções por HIV/virologia , Inibidores da Transcriptase Reversa/uso terapêutico , Carga Viral , Adulto , Análise Custo-Benefício , Feminino , HIV-1 , Humanos , Quênia , Masculino , Pessoa de Meia-Idade , Nevirapina/uso terapêutico , Estudos Prospectivos , Projetos de Pesquisa , Resultado do Tratamento , Zidovudina/uso terapêutico
7.
BMC Infect Dis ; 14: 331, 2014 Jun 17.
Artigo em Inglês | MEDLINE | ID: mdl-24938526

RESUMO

BACKGROUND: A subset of HIV-1 infected patients starting highly active antiretroviral treatment (HAART) experience suboptimal CD4 response (SCR) despite virologic suppression. We studied the rate of and risk factors for SCR among women starting HAART in the ACTG A5208 study conducted in 7 African countries. 741 HAART-naive women with screening CD4 count <200 cells/µL were randomized to start HAART with Tenofovir/Emtricitabine plus either Nevirapine or Lopinavir/Ritonavir. METHODS: This analysis includes the 625 women who remained on-study through 48 weeks without experiencing protocol-defined virologic failure. We defined SCR as<100 CD4 cells/µL increase from baseline and absolute CD4 cell count<350 cells/µL, both at 48 weeks after HAART initiation. RESULTS: The baseline characteristics for the 625 women prior to HAART initiation were: median age 33 years, screening CD4 count 134 cells/µL, and HIV-1 RNA 5.1 log10 copies/mL; 184 (29%) were WHO Stage 3 or 4.Seventy one (11%) of these 625 women experienced SCR. Baseline factors independently associated with increased odds of SCR included older age, lower HIV-1 RNA, positive Hepatitis B surface antigen, and site location. At 96 weeks, only 6% of the SCR group had CD4 ≥ 350 cells/µL compared with 67% in the non SCR group. CONCLUSION: After starting HAART, 11% of women with virologic suppression through 48 weeks experienced SCR. These patients were also less likely to achieve CD4 ≥ 350 cells/µL by 96 weeks. The underlying causes and long term clinical implications of SCR deserve further investigation. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT00089505.


Assuntos
Fármacos Anti-HIV/uso terapêutico , Linfócitos T CD4-Positivos/imunologia , Infecções por HIV/tratamento farmacológico , Adenina/análogos & derivados , Adenina/uso terapêutico , Adulto , África , Contagem de Linfócito CD4 , Linfócitos T CD4-Positivos/efeitos dos fármacos , Desoxicitidina/análogos & derivados , Desoxicitidina/uso terapêutico , Emtricitabina , Feminino , Infecções por HIV/imunologia , Infecções por HIV/virologia , HIV-1/genética , HIV-1/isolamento & purificação , Humanos , Lopinavir/uso terapêutico , Nevirapina/uso terapêutico , Organofosfonatos/uso terapêutico , Ritonavir/uso terapêutico , Tenofovir , Resultado do Tratamento
8.
J Acquir Immune Defic Syndr ; 66(2): 155-63, 2014 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-24562349

RESUMO

BACKGROUND: Limited comparative, prospective data exist regarding cardiovascular risk factors in HIV-infected women starting antiretroviral therapy in Africa. METHODS: In 7 African countries, 741 women with CD4 <200 cells/mm were randomized to tenofovir/emtricitabine (TDF/FTC) plus either nevirapine (NVP, n = 370) or lopinavir/ritonavir (LPV/r, n = 371). Lipids and blood pressure (BP) were evaluated at entry, 48, 96, and 144 weeks. Multivariable linear and logistic regression models were used to evaluate mean risk factor changes and clinically relevant risk factor changes. RESULTS: At entry, both NVP and LPV/r groups were similar regarding age [mean = 33.5 (SD = 7.1) years], CD4 [129 (67) cells/mm], and HIV-1 RNA [5.1 (0.6) log10 copies/mL]. Nearly, all women had normal lipids and BP except for high-density lipoprotein (HDL)-cholesterol. Over 144 weeks, the LPV/r compared with NVP group had significantly greater mean lipid increases (eg, non-HDL: +29 vs. +13 mg/dL) and smaller HDL increases (+12 vs. +21 mg/dL). In contrast, the NVP compared with LPV/r group had greater mean increases in BP (eg, diastolic BP: +5 vs. -0.5 mm Hg). Significantly, more women assigned LPV/r had week 144 "abnormal" lipid levels (eg, HDL 29.7% vs. 14.8% and triglycerides 28.6% vs. 8.2%), and significantly, more women assigned NVP had "abnormal" BP (eg, diastolic BP 22.7% vs. 6.5%). Most differences remained significant when adjusted for baseline risk factor, age, CD4, and HIV-1 RNA. CONCLUSIONS: In HIV-infected women initiating antiretroviral therapy in Africa, LPV/r + TDF/FTC was associated with less favorable changes in lipids, and use of NVP + TDF/FTC was associated with less favorable changes in BP.


Assuntos
Doenças Cardiovasculares/epidemiologia , Infecções por HIV/tratamento farmacológico , Lopinavir/efeitos adversos , Nevirapina/efeitos adversos , Ritonavir/efeitos adversos , Adenina/efeitos adversos , Adenina/análogos & derivados , Adenina/uso terapêutico , Adulto , África Subsaariana , Fármacos Anti-HIV/efeitos adversos , Fármacos Anti-HIV/uso terapêutico , Terapia Antirretroviral de Alta Atividade/efeitos adversos , Pressão Sanguínea/efeitos dos fármacos , Índice de Massa Corporal , Linfócitos T CD4-Positivos , HDL-Colesterol/sangue , LDL-Colesterol/sangue , Desoxicitidina/efeitos adversos , Desoxicitidina/análogos & derivados , Desoxicitidina/uso terapêutico , Emtricitabina , Determinação de Ponto Final , Feminino , Infecções por HIV/complicações , HIV-1/crescimento & desenvolvimento , HIV-1/isolamento & purificação , Humanos , Modelos Lineares , Modelos Logísticos , Lopinavir/uso terapêutico , Análise Multivariada , Nevirapina/uso terapêutico , Organofosfonatos/efeitos adversos , Organofosfonatos/uso terapêutico , Estudos Prospectivos , RNA Viral/isolamento & purificação , Fatores de Risco , Ritonavir/uso terapêutico , Tenofovir , Triglicerídeos/sangue
10.
J Int AIDS Soc ; 16: 18026, 2013 Jan 02.
Artigo em Inglês | MEDLINE | ID: mdl-23305696

RESUMO

INTRODUCTION: After almost 10 years of PEPFAR funding for antiretroviral therapy (ART) treatment programmes in Kenya, little is known about the cost of care provided to HIV-positive patients receiving ART. With some 430,000 ART patients, understanding and managing costs is essential to treatment programme sustainability. METHODS: Using patient-level data from medical records (n=120/site), we estimated the cost of providing ART at three treatment sites in the Rift Valley Province of Kenya (a clinic at a government hospital, a hospital run by a large agricultural company and a mission hospital). Costs included ARV and non-ARV drugs, laboratory tests, salaries to personnel providing patient care, and infrastructure and other fixed costs. We report the average cost per patient during the first 12 months after ART initiation, stratified by site, and the average cost per patient achieving the primary outcome, retention in care 12 months after treatment initiation. RESULTS: The cost per patient initiated on ART was $206, $252 and $213 at Sites 1, 2 and 3, respectively. The proportion of patients remaining in care at 12 months was similar across all sites (0.82, 0.80 and 0.84). Average costs for the subset of patients who remained in care at 12 months was also similar (Site 1, $229; Site 2, $287; Site 3, $237). Patients not retained in care cost substantially less (Site 1, $104; Site 2, $113; Site 3, $88). For the subset of patients who remained in care at 12 months, ART medications accounted for 51%, 44% and 50% of the costs, with the remaining costs split between non-ART medications (15%, 11%, 10%), laboratory tests (14%, 15%, 15%), salaries to personnel providing patient care (9%, 11%, 12%) and fixed costs (11%, 18%, 13%). CONCLUSIONS: At all three sites, 12-month retention in care compared favourably to retention rates reported in the literature from other low-income African countries. The cost of providing treatment was very low, averaging $224 in the first year, less than $20/month. The cost of antiretroviral medications, roughly $120 per year, accounted for approximately half of the total costs per patient retained in care after 12 months.


Assuntos
Antirretrovirais/administração & dosagem , Terapia Antirretroviral de Alta Atividade/métodos , Infecções por HIV/tratamento farmacológico , Custos de Cuidados de Saúde/estatística & dados numéricos , Adesão à Medicação/estatística & dados numéricos , Adulto , Instituições de Assistência Ambulatorial , Antirretrovirais/economia , Terapia Antirretroviral de Alta Atividade/economia , Estudos de Coortes , Feminino , Infecções por HIV/economia , Humanos , Quênia , Masculino , População Rural , Adulto Jovem
11.
AIDS ; 27(1): 115-23, 2013 Jan 02.
Artigo em Inglês | MEDLINE | ID: mdl-23014516

RESUMO

OBJECTIVE: To estimate the impact of antiretroviral therapy (ART) on labor productivity and income using detailed employment data from two large tea plantations in western Kenya for HIV-infected tea pluckers who initiated ART. DESIGN: Longitudinal study using primary data on key employment outcomes for a group of HIV-infected workers receiving antiretroviral therapy (ART) and workers in the general workforce. METHODS: We used nearest-neighbor matching methods to estimate the impacts of HIV/AIDS and ART among 237 HIV-positive pluckers on ART (index group) over a 4-year period (2 years pre-ART and post-ART) on 4 monthly employment outcomes - days plucking tea, total kilograms (kgs) harvested, total days working, and total labor income. Outcomes for the index group were compared with those for a matched reference group from the general workforce. RESULTS: We observed a rapid deterioration in all four outcomes for HIV-infected individuals in the period before ART initiation and then a rapid improvement after treatment initiation. By 18-24 months after treatment initiation, the index group harvested 8% (men) and 19% (women) less tea than reference individuals. The index group earned 6% (men) and 9% (women) less income from labor than reference individuals. Women's income would have dropped further if they had not been able to offset their decline in tea plucking by spending more time on nonplucking assignments. CONCLUSION: HIV-infected workers experienced long-term income reductions before and after initiating ART. The implications of such long-term impacts in low-income countries have not been adequately addressed.


Assuntos
Síndrome da Imunodeficiência Adquirida/epidemiologia , Agricultura , Fármacos Anti-HIV/uso terapêutico , Eficiência , Soropositividade para HIV/epidemiologia , Chá , Trabalho , Absenteísmo , Síndrome da Imunodeficiência Adquirida/tratamento farmacológico , Síndrome da Imunodeficiência Adquirida/economia , Adulto , Fármacos Anti-HIV/economia , Contagem de Linfócito CD4 , Estudos de Coortes , Emprego , Feminino , Soropositividade para HIV/tratamento farmacológico , Soropositividade para HIV/economia , Humanos , Renda , Quênia/epidemiologia , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Formulação de Políticas , Distribuição por Sexo , Carga de Trabalho/economia
12.
PLoS Med ; 9(6): e1001236, 2012.
Artigo em Inglês | MEDLINE | ID: mdl-22719231

RESUMO

BACKGROUND: Nevirapine (NVP) is widely used in antiretroviral treatment (ART) of HIV-1 globally. The primary objective of the AA5208/OCTANE trial was to compare the efficacy of NVP-based versus lopinavir/ritonavir (LPV/r)-based initial ART. METHODS AND FINDINGS: In seven African countries (Botswana, Kenya, Malawi, South Africa, Uganda, Zambia, and Zimbabwe), 500 antiretroviral-naïve HIV-infected women with CD4<200 cells/mm(3) were enrolled into a two-arm randomized trial to initiate open-label ART with tenofovir (TDF)/emtricitabine (FTC) once/day plus either NVP (n = 249) or LPV/r (n = 251) twice/day, and followed for ≥48 weeks. The primary endpoint was time from randomization to death or confirmed virologic failure ([VF]) (plasma HIV RNA<1 log(10) below baseline 12 weeks after treatment initiation, or ≥400 copies/ml at or after 24 weeks), with comparison between treatments based on hazard ratios (HRs) in intention-to-treat analysis. Equivalence of randomized treatments was defined as finding the 95% CI for HR for virological failure or death in the range 0.5 to 2.0. Baseline characteristics were (median): age = 34 years, CD4 = 121 cells/mm(3), HIV RNA = 5.2 log(10)copies/ml. Median follow-up = 118 weeks; 29 (6%) women were lost to follow-up. 42 women (37 VFs, five deaths; 17%) in the NVP and 50 (43 VFs, seven deaths; 20%) in the LPV/r arm reached the primary endpoint (HR 0.85, 95% CI 0.56-1.29). During initial assigned treatment, 14% and 16% of women receiving NVP and LPV/r experienced grade 3/4 signs/symptoms and 26% and 22% experienced grade 3/4 laboratory abnormalities. However, 35 (14%) women discontinued NVP because of adverse events, most in the first 8 weeks, versus none for LPV/r (p<0.001). VF, death, or permanent treatment discontinuation occurred in 80 (32%) of NVP and 54 (22%) of LPV/r arms (HR = 1.7, 95% CI 1.2-2.4), with the difference primarily due to more treatment discontinuation in the NVP arm. 13 (45%) of 29 women tested in the NVP versus six (15%) of 40 in the LPV/r arm had any drug resistance mutation at time of VF. CONCLUSIONS: Initial ART with NVP+TDF/FTC demonstrated equivalent virologic efficacy but higher rates of treatment discontinuation and new drug resistance compared with LPV/r+TDF/FTC in antiretroviral-naïve women with CD4<200 cells/mm(3). TRIAL REGISTRATION: ClinicalTrials.gov NCT00089505.


Assuntos
Fármacos Anti-HIV/uso terapêutico , Infecções por HIV/tratamento farmacológico , Infecções por HIV/virologia , HIV-1/fisiologia , Lopinavir/uso terapêutico , Nevirapina/uso terapêutico , Ritonavir/uso terapêutico , Adulto , África , Fármacos Anti-HIV/efeitos adversos , Fármacos Anti-HIV/farmacologia , Contagem de Linfócito CD4 , Morte , Farmacorresistência Viral/efeitos dos fármacos , Farmacorresistência Viral/genética , Determinação de Ponto Final , Feminino , Infecções por HIV/diagnóstico , Infecções por HIV/imunologia , HIV-1/efeitos dos fármacos , Humanos , Estimativa de Kaplan-Meier , Lopinavir/efeitos adversos , Lopinavir/farmacologia , Adesão à Medicação , Mutação/genética , Nevirapina/efeitos adversos , Nevirapina/farmacologia , Ritonavir/efeitos adversos , Ritonavir/farmacologia
13.
AIDS Res Treat ; 2012: 238012, 2012.
Artigo em Inglês | MEDLINE | ID: mdl-22400104

RESUMO

Objective. To describe TB/HIV clinic outcomes in a rural, Ministry of Health hospital. Design. Retrospective, secondary analyses. Descriptive statistics and logistic regression analyses evaluated baseline characteristics and outcomes. Results. Of 1,911 patients, 89.8% were adults aged 32.0 (±12.6) years with baseline CD4 = 243.3 (±271.0), 18.2% < 50 cells/mm(3). Pulmonary (84.8%, (32.2% smear positive)) exceeded extrapulmonary TB (15.2%). Over 5 years, treatment success rose from 40.0% to 74.6%, lost to follow-up dropped from 36.0% to 12.5%, and deaths fell from 20.0% to 5.4%. For patients starting ART after TB treatment, those with CD4 ≥ 50 cells/mm(3) were twice as likely to achieve treatment success (OR = 2.0, 95% CI = 1.3-3.1) compared to those with CD4 < 50 cells/mm(3). Patients initiating ART at/after 2 months were twice as likely to achieve treatment success (OR = 2.0, 95% CI = 1.3-3.3). Yearly, odds of treatment success improved by 20% (OR = 1.2, 95% CI = 1.0-1.5). Conclusions. An integrated TB/HIV clinic with acceptable outcomes is a feasible goal in resource-limited settings.

14.
AIDS Behav ; 15(2): 454-68, 2011 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-21110078

RESUMO

Contraceptive choice and discontinuation are poorly understood among HIV-positive women, and HIV disease and culture may influence decisions. We assessed factors influencing contraceptive decision-making among HIV-positive women in three countries. This qualitative assessment of 108 HIV-positive women (36/site, selected by age and parity strata) was conducted in Rio de Janeiro, Brazil; Kericho, Kenya; and Soweto, South Africa. Freelist interviews assessed knowledge and attitudes towards contraception and were analyzed enumerating frequency and saliency of mentions. There was intersite consensus around list items but priority and themes varied. Site-specific factors influencing contraceptive choice were male partner wishes and fertility desire (Brazil), side-effects (South Africa), and impact on health and HIV progression (Kenya). Age, parity, and taking antiretroviral therapy (ART) impacted some themes. Contraceptive use among HIV-positive women is substantially influenced by culture and other factors. Counseling efforts should consider individual factors in method selection and offer method variety to accommodate changing needs.


Assuntos
Comportamento Contraceptivo/psicologia , Anticoncepção/estatística & dados numéricos , Cultura , Fertilidade , Infecções por HIV/psicologia , Adolescente , Adulto , Brasil , Comportamento Contraceptivo/etnologia , Comparação Transcultural , Feminino , Infecções por HIV/tratamento farmacológico , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Entrevistas como Assunto , Quênia , Masculino , Menstruação/psicologia , Pessoa de Meia-Idade , Gravidez , Pesquisa Qualitativa , Parceiros Sexuais , África do Sul , Adulto Jovem
15.
N Engl J Med ; 363(16): 1499-509, 2010 Oct 14.
Artigo em Inglês | MEDLINE | ID: mdl-20942666

RESUMO

BACKGROUND: Peripartum administration of single-dose nevirapine reduces mother-to-child transmission of human immunodeficiency virus type 1 (HIV-1) but selects for nevirapine-resistant virus. METHODS: In seven African countries, women infected with HIV-1 whose CD4+ T-cell counts were below 200 per cubic millimeter and who either had or had not taken single-dose nevirapine at least 6 months before enrollment were randomly assigned to receive antiretroviral therapy with tenofovir­emtricitabine plus nevirapine or tenofovir-emtricitabine plus lopinavir boosted by a low dose of ritonavir. The primary end point was the time to confirmed virologic failure or death. RESULTS: A total of 241 women who had been exposed to single-dose nevirapine began the study treatments (121 received nevirapine and 120 received ritonavir-boosted lopinavir). Significantly more women in the nevirapine group reached the primary end point than in the ritonavir-boosted lopinavir group (26% vs. 8%) (adjusted P=0.001). Virologic failure occurred in 37 (28 in the nevirapine group and 9 in the ritonavir-boosted lopinavir group), and 5 died without prior virologic failure (4 in the nevirapine group and 1 in the ritonavir-boosted lopinavir group). The group differences appeared to decrease as the interval between single-dose nevirapine exposure and the start of antiretroviral therapy increased. Retrospective bulk sequencing of baseline plasma samples showed nevirapine resistance in 33 of 239 women tested (14%). Among 500 women without prior exposure to single-dose nevirapine, 34 of 249 in the nevirapine group (14%) and 36 of 251 in the ritonavir-boosted lopinavir group (14%) had virologic failure or died. CONCLUSIONS: In women with prior exposure to peripartum single-dose nevirapine (but not in those without prior exposure), ritonavir-boosted lopinavir plus tenofovir­emtricitabine was superior to nevirapine plus tenofovir­emtricitabine for initial antiretroviral therapy. (Funded by the National Institute of Allergy and Infectious Diseases and the National Research Center; ClinicalTrials.gov number, NCT00089505.).


Assuntos
Antirretrovirais/uso terapêutico , Infecções por HIV/tratamento farmacológico , HIV-1 , Nevirapina/administração & dosagem , Complicações Infecciosas na Gravidez/tratamento farmacológico , Adenina/análogos & derivados , Adenina/uso terapêutico , Adulto , Fármacos Anti-HIV/administração & dosagem , Contagem de Linfócito CD4 , Desoxicitidina/análogos & derivados , Desoxicitidina/uso terapêutico , Quimioterapia Combinada , Emtricitabina , Feminino , Seguimentos , Infecções por HIV/mortalidade , Infecções por HIV/transmissão , Humanos , Transmissão Vertical de Doenças Infecciosas/prevenção & controle , Estimativa de Kaplan-Meier , Modelos Lineares , Lopinavir , Organofosfonatos/uso terapêutico , Gravidez , Pirimidinonas/uso terapêutico , Ritonavir/uso terapêutico , Estatísticas não Paramétricas , Tenofovir , Falha de Tratamento , Adulto Jovem
16.
AIDS Care ; 22(2): 137-45, 2010 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-20390492

RESUMO

Improvements in physical wellbeing during the first six months on antiretroviral therapy (ART) are well known, but little is known regarding long-term follow-up. We conducted a prospective cohort study among 222 HIV-positive adult tea plantation workers in western Kenya to assess wellbeing over their first two years on ART. Study subjects completed a standardized questionnaire during repeat ART clinic visits. A 30-day recall period was used to elicit the number of days when subjects experienced poor health and the number of days that pain made it difficult to complete usual activities at home and work. A seven-day recall period was used to assess the severity of bodily pain, nausea, fatigue, and rash. Prevalence of most symptoms declined over time. A median of seven days poor health during the first month on ART declined to three days in the 24th month (p=0.043). For pain making usual activities difficult, a median of seven days during the first month on ART fell to zero by 12 months (p< or =0.0001) but increased to three days by two years. Any bodily pain (range 59-83%) and fatigue (range 51-84%) over the past seven days were common through two years. However, pain and fatigue often over the past seven days declined over two years (from 24-10% (p=0.067) and 41-15% (p=0.002)). Skin rash was rare at all times, though higher at two years (8.6%) than any other time. Initial improvements in physical wellbeing were sustained over two years, however, increased pain and skin rash at year two may indicate problems as treatment programs mature. These improvements in physical wellbeing will be important in sustaining the long-term success of HIV treatment programs.


Assuntos
Terapia Antirretroviral de Alta Atividade , Infecções por HIV , Nível de Saúde , Adulto , Agricultura , Fármacos Anti-HIV/uso terapêutico , Terapia Antirretroviral de Alta Atividade/efeitos adversos , Eficiência , Exantema , Fadiga , Feminino , Infecções por HIV/tratamento farmacológico , Humanos , Quênia , Masculino , Pessoa de Meia-Idade , Dor , Qualidade de Vida , Fatores Socioeconômicos , Inquéritos e Questionários , Chá , Resultado do Tratamento , Adulto Jovem
17.
J Infect Dis ; 201(4): 600-7, 2010 Feb 15.
Artigo em Inglês | MEDLINE | ID: mdl-20078213

RESUMO

BACKGROUND: Human immunodeficiency virus (HIV) vaccine development remains a global priority. We describe the safety and immunogenicity of a multiclade DNA vaccine prime with a replication-defective recombinant adenovirus serotype 5 (rAd5) boost. METHODS: The vaccine is a 6-plasmid mixture encoding HIV envelope (env) subtypes A, B, and C and subtype B gag, pol, and nef, and an rAd5 expressing identical genes, with the exception of nef. Three hundred and twenty-four participants were randomized to receive placebo (n=138), a single dose of rAd5 at 10(10) (n = 24) or 10(11) particle units (n = 24), or DNA at 0, 1, and 2 months, followed by rAd5 at either 10(10) (n= 114) or 10(11) particle units (n = 24) boosting at 6 months. Participants were followed up for 24 weeks after the final vaccination. RESULTS: The vaccine was safe and well tolerated. HIV-specific T cell responses were detected in 63% of vaccinees. Titers of preexisting Ad5 neutralizing antibody did not affect the frequency and magnitude of T cell responses in prime-boost recipients but did affect the response rates in participants that received rAd5 alone (P = .037). CONCLUSION: The DNA/rAd5 vaccination regimen was safe and induced HIV type 1 multi-clade T cell responses, which were not significantly affected by titers of preexisting rAd5 neutralizing antibody. Trial Registration. ClinicalTrials.gov identifier: NCT00123968 .


Assuntos
Vacinas contra a AIDS/administração & dosagem , Adenoviridae/imunologia , DNA Viral/imunologia , Infecções por HIV/prevenção & controle , HIV-1/imunologia , Plasmídeos/imunologia , Vacinas de DNA/administração & dosagem , Vacinas contra a AIDS/efeitos adversos , Vacinas contra a AIDS/genética , Vacinas contra a AIDS/imunologia , Adenoviridae/genética , Adolescente , Adulto , África Oriental , Anticorpos Neutralizantes/sangue , Anticorpos Neutralizantes/imunologia , Anticorpos Antivirais/sangue , Anticorpos Antivirais/imunologia , Antígenos Virais/imunologia , Linfócitos T CD4-Positivos/imunologia , Linfócitos T CD8-Positivos/imunologia , Células Cultivadas , DNA Viral/genética , Método Duplo-Cego , Ensaio de Imunoadsorção Enzimática , Feminino , Infecções por HIV/imunologia , HIV-1/genética , Proteínas do Vírus da Imunodeficiência Humana/genética , Proteínas do Vírus da Imunodeficiência Humana/imunologia , Humanos , Interferon gama/metabolismo , Leucócitos Mononucleares/imunologia , Masculino , Pessoa de Meia-Idade , Plasmídeos/genética , Vacinas de DNA/efeitos adversos , Vacinas de DNA/genética , Vacinas de DNA/imunologia , Adulto Jovem
18.
Afr J Reprod Health ; 14(4 Spec no.): 98-109, 2010 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-21812203

RESUMO

This study explored perceptions towards and utilization of contraception among HIV-positive, reproduction-age women in Kericho, Kenya, an area with high HIV and low contraceptive prevalence rates. Qualitative methods were used in three focus group discussions and 15 in-depth interviews to gather data from 46 HIV-positive women ages 18 to 45, purposively selected by age strata. Analysis was performed using ATLAS-ti (ATLAS-ti Center, Berlin). Most participants reported familiarity with modern contraceptives. Participants generally perceived that men opposed contraception. Some women indicated that their HIV status dictated contraceptive decisions, particularly with regard to abstinence. Women reported method discontinuation because of side effects, having met desired parity, and menstrual changes. Findings suggested that perceptions about side effects, opinions of the male partner, and HIV disease progression play important roles in contraceptive decisions. Counseling can dispel incorrect information and optimize contraceptive practice in this setting.


Assuntos
Comportamento de Escolha , Anticoncepção/estatística & dados numéricos , Soropositividade para HIV/psicologia , Adolescente , Adulto , Feminino , Grupos Focais , Soropositividade para HIV/epidemiologia , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Entrevistas como Assunto , Quênia/epidemiologia , Pessoa de Meia-Idade , Aceitação pelo Paciente de Cuidados de Saúde , Prevalência , Inquéritos e Questionários
19.
J Acquir Immune Defic Syndr ; 53(4): 514-21, 2010 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-19855286

RESUMO

BACKGROUND: Incidence data from prospective cohort studies using rigorous laboratory methods are important in designing and evaluating HIV vaccine and therapeutic clinical trials and health care programs. We report 36-month HIV-1 incidence rates and demographic and psychosocial risks from the Kericho cohort in rural Kenya's southern Rift Valley Province. METHODS: Thirty-six month, prospective, closed, observational cohort study of adult plantation workers and dependents followed biannually. HIV-1 incidence rates per 100 person-years (py) were calculated, and Cox regression analyses were used to estimate hazards ratios (HR) associated with seroconversion. RESULTS: Two thousand four hundred volunteers (mean age +/- SD = 30.1 +/- 8.5 years; 36.5% women) participated. Twenty-nine new HIV cases were identified in year 1 of follow-up, which increased to cumulative totals of 49 and 63 cases in years 2 and 3, respectively. The corresponding 1-, 2-, and 3-year incidence rates were 1.41 [95% confidence interval (CI) = 0.95-2.02], 1.16 (95% CI = 0.86-1.54), and 1.00 (95% CI = 0.77-1.28) per 100 py. Risk factors associated with HIV seroconversion included the following: of the Luo tribe (HR = 3.31; 95% CI = 1.65-6.63), marriage more than once (HR = 2.83; 95% CI = 1.20-6.69), self-reported male circumcision (HR = 0.32; 95% CI = 0.17-0.60), history of sexually transmitted infection (HR = 2.40; 95% CI = 1.09-5.26), history of substance abuse during sex (HR = 2.44; 95% CI = 1.16-5.13), and history of transactional sex (HR = 3.30; 95% CI = 1.79-6.09). CONCLUSIONS: HIV-1 incidence rates were relatively low in adult plantation workers and dependents in rural Kenya. Cohorts including higher risk populations (eg, commercial sex workers) warrant consideration for regional HIV preventive vaccine trials. Even low incidence, well-described cohorts generate valuable epidemiological clinical trial data.


Assuntos
Infecções por HIV/epidemiologia , HIV-1/isolamento & purificação , Adolescente , Adulto , Agricultura , Estudos de Coortes , Saúde da Família , Infecções por HIV/virologia , Humanos , Incidência , Quênia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , População Rural , Adulto Jovem
20.
AIDS Res Hum Retroviruses ; 25(11): 1061-4, 2009 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-19943788

RESUMO

In preparation for HIV-1 vaccine trials in Kenya, 2801 study volunteers, from a tea plantation in Kericho, were recruited as part of a prospective vaccine cohort development study. Cryopreserved plasma was available from 401 HIV-positive volunteers, and was the source of viral RNA for genotyping by the multiregion hybridization assay (MHA). Logistic regression was performed to determine association of risk factors and HIV-1 recombinant and dual infections. At baseline, HIV-1 subtype A was the dominant circulating pure subtype (56%), followed by subtype D (10%) and C (5%). Recombinant HIV-1 strains accounted for almost one-third of all infections (29%), with 7% infected with a dual strain of the HIV-1 variants described. A higher number of HIV-1 recombinant and dual infections was observed among volunteers who were 18-24 and 25-29 years of age, affiliated with the Luo tribe, had been married two or more times, reported not being circumcised, and had STI symptoms in the past 6 months. Adjusted odds ratios (AOR) significantly associated with HIV-1 recombinant and dual infection were age difference from current spouse (5-9 years; AOR = 2.5, 95% CI = 1.2-5.3 and > or = 10 years; AOR = 3.1, 95% CI = 1.5-6.4) and reported STI symptoms in the past 6 months (AOR = 4.8, 95% CI = 2.0-11.6), respectively. In conclusion, our results suggest that there is considerable heterogeneity with respect to HIV-1 subtype diversity in this population that should be considered in the planning for future vaccine trials in the region.


Assuntos
Variação Genética , Infecções por HIV , HIV-1/genética , População Rural , Vacinas contra a AIDS/genética , Adolescente , Adulto , Etnicidade , Feminino , Infecções por HIV/epidemiologia , Infecções por HIV/etnologia , Infecções por HIV/virologia , HIV-1/classificação , Humanos , Quênia/epidemiologia , Quênia/etnologia , Masculino , Epidemiologia Molecular , Mutação , Prevalência , Recombinação Genética , Fatores de Risco , Adulto Jovem
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