The met and unmet health needs for HIV, hypertension, and diabetes in rural KwaZulu-Natal, South Africa: analysis of a cross-sectional multimorbidity survey.

BACKGROUND: The convergence of infectious diseases and non-communicable diseases in South Africa is challenging to health systems. In this analysis, we assessed the multimorbidity health needs of individuals and communities in rural KwaZulu-Natal and established a framework to quantify met and unmet health needs for individuals living with infectious and non-communicable diseases. METHODS: We analysed data collected between May 25, 2018, and March 13, 2020, from participants of a large, community-based, cross-sectional multimorbidity survey (Vukuzazi) that offered community-based HIV, hypertension, and diabetes screening to all residents aged 15 years or older in a surveillance area in the uMkhanyakude district in KwaZulu-Natal, South Africa. Data from the Vukuzazi survey were linked with data from demographic and health surveillance surveys with a unique identifier common to both studies. Questionnaires were used to assess the diagnosed health conditions, treatment history, general health, and sociodemographic characteristics of an individual. For each condition (ie, HIV, hypertension, and diabetes), individuals were defined as having no health needs (absence of condition), met health needs (condition that is well controlled), or one or more unmet health needs (including diagnosis, engagement in care, or treatment optimisation). We analysed met and unmet health needs for individual and combined conditions and investigated their geospatial distribution. FINDINGS: Of 18 041 participants who completed the survey (12 229 [67·8%] were female and 5812 [32·2%] were male), 9898 (54·9%) had at least one of the three chronic diseases measured. 4942 (49·9%) of these 9898 individuals had at least one unmet health need (1802 [18·2%] of 9898 needed treatment optimisation, 1282 [13·0%] needed engagement in care, and 1858 [18·8%] needed a diagnosis). Unmet health needs varied by disease; 1617 (93·1%) of 1737 people who screened positive for diabetes, 2681 (58·2%) of 4603 people who screened positive for hypertension, and 1321 (21·7%) of 6096 people who screened positive for HIV had unmet health needs. Geospatially, met health needs for HIV were widely distributed and unmet health needs for all three conditions had specific sites of concentration; all three conditions had an overlapping geographical pattern for the need for diagnosis. INTERPRETATION: Although people living with HIV predominantly have a well controlled condition, there is a high burden of unmet health needs for people living with hypertension and diabetes. In South Africa, adapting current, widely available HIV care services to integrate non-communicable disease care is of high priority. FUNDING: Fogarty International Center and the National Institutes of Health, the Bill & Melinda Gates Foundation, the South African Department of Science and Innovation, the South African Medical Research Council, the South African Population Research Infrastructure Network, and the Wellcome Trust. TRANSLATION: For the isiZulu translation of the abstract see Supplementary Materials section.

Convergence of infectious and non-communicable disease epidemics in rural South Africa: a cross-sectional, population-based multimorbidity study.

BACKGROUND: There has been remarkable progress in the treatment of HIV throughout sub-Saharan Africa, but there are few data on the prevalence and overlap of other significant causes of disease in HIV endemic populations. Our aim was to identify the prevalence and overlap of infectious and non-communicable diseases in such a population in rural South Africa. METHODS: We did a cross-sectional study of eligible adolescents and adults from the Africa Health Research Institute demographic surveillance area in the uMkhanyakude district of KwaZulu-Natal, South Africa. The participants, who were 15 years or older, were invited to participate at a mobile health camp. Medical history for HIV, tuberculosis, hypertension, and diabetes was established through a questionnaire. Blood pressure measurements, chest x-rays, and tests of blood and sputum were taken to estimate the population prevalence and geospatial distribution of HIV, active and lifetime tuberculosis, elevated blood glucose, elevated blood pressure, and combinations of these. FINDINGS: 17 118 adolescents and adults were recruited from May 25, 2018, to Nov 28, 2019, and assessed. Overall, 52·1% (95% CI 51·3-52·9) had at least one active disease. 34·2% (33·5-34·9) had HIV, 1·4% (1·2-1·6) had active tuberculosis, 21·8% (21·2-22·4) had lifetime tuberculosis, 8·5% (8·1-8·9) had elevated blood glucose, and 23·0% (22·4-23·6) had elevated blood pressure. Appropriate treatment and optimal disease control was highest for HIV (78·1%), and lower for elevated blood pressure (42·5%), active tuberculosis (29·6%), and elevated blood glucose (7·1%). Disease prevalence differed notably by sex, across age groups, and geospatially: men had a higher prevalence of active and lifetime tuberculosis, whereas women had a substantially high prevalence of HIV at 30-49 years and an increasing prevalence of multiple and poorly controlled non-communicable diseases when older than 50 years. INTERPRETATION: We found a convergence of infectious and non-communicable disease epidemics in a rural South African population, with HIV well treated relative to all other diseases, but tuberculosis, elevated blood glucose, and elevated blood pressure poorly diagnosed and treated. A public health response that expands the successes of the HIV testing and treatment programme to provide multidisease care targeted to specific populations is required to optimise health in such settings in sub-Saharan Africa. FUNDING: Wellcome Trust, Bill & Melinda Gates Foundation, the South African Department of Science and Innovation, South African Medical Research Council, and South African Population Research Infrastructure Network. TRANSLATION: For the isiZulu translation of the abstract see Supplementary Materials section.

Env gp120 sequence analysis of HIV type 1 strains from diverse areas of the brain shows preponderance of CCR5 usage.

In this study diverse areas of the autopsied brain of 12 HIV-infected patients with and without dementia were analyzed. All brain samples were obtained at autopsy through prior consent. Env C2-V5 region was PCR amplified and sequenced and compared between different brain regions within the same patient and also between patients to find changes, which can discriminate between patients with and without dementia and also identify motifs responsible for coreceptor-mediated entry of HIV into the CNS. For this, the Env gp120 hypervariable V3 region (35 amino acid residues) was subjected to position scoring matrix analyses (PSSM) for predicting coreceptor usage in the brain. These predictions based on the V3 loop sequence were absolutely consistent with the biologically determined viral phenotype at least for the samples, which were successful for virus culture. These data clearly show that the PSSM correlates can be unambiguously applied in determining viral phenotype for entry. The most notable observation is that of 69 V3 region sequences analyzed from 12 patients from diverse brain regions, 64 showed CCR5 usage (93%) as opposed to only five using CXCR4. Comparison of the V3 loop charge failed to show any correlation between charge and coreceptor usage. Given that cells of macrophage lineage predominate in the CNS and also facilitate HIV entry into the CNS, the preponderance of CCR5 usage in brain-derived HIV strains from patients with and without dementia may have important clinical implications.

HAART & the molecular biology of AIDS dementia complex.

The era of highly active antiretroviral therapy (HAART) has led to a considerable decline in the HIV disease progression rates and HIV-1-related opportunistic infections especially in developed countries. Unfortunately, antiretroviral treatment for almost 90 per cent of the HIV-infected population is not available because of cost concerns. Although a number of studies have shown uniform impact of HAART on disease progression, its effect on treating HIV infection of the brain and its manifestations, such as AIDS dementia complex (ADC), remains unclear. Along with the reasons why AIDS dementia complex continues to be a problem in the era of HAART, this review also discusses the changes in ADC patterns with HAART and its relevance in developing countries such as India. In addition, an overview of various biological, molecular and therapeutic aspects that may influence HIV dementia (HIV-D) is provided.

In vivo cross-protection to African horse sickness Serotypes 5 and 9 after vaccination with Serotypes 8 and 6.

The polyvalent African horsesickness (AHS) attenuated live virus (AHS-ALV) vaccine produced at Onderstepoort Biological Products incorporates 7 of the 9 known serotypes circulating in southern Africa. Serological cross-reaction has been shown in vitro to Serotypes 5 and 9 by Serotypes 8 and 6 respectively, but the degree of in vivo cross-protection between these serotypes in vaccinated horses has not previously been reported. Due to the increasing incidence of AHS Serotypes 5 and 9 in the field, over the last 3-4 seasons of AHS in South Africa, and the absence of Serotypes 5 and 9 in the AHS-ALV vaccine, it was necessary to conduct a vaccination-challenge study to determine in vivo cross-protection of vaccine-incorporated Serotypes 8 and 6 respectively. Groups of horses were vaccinated with either the polyvalent AHS-ALV vaccine or a monovalent Serotype 6 (vAHSV6) or 8 (vAHSV8) vaccine to determine the cross-protection of vaccinated horses following challenge with virulent AHS virus (AHSV) of either Serotype 5, 6, 8 or 9. Serial vaccination of naive horses with the polyvalent AHS-ALV vaccine generated a broad neutralizing antibody response to all vaccine strains as well as cross-neutralizing antibodies to Serotypes 5 and 9. Booster vaccination of horses with monovalent vaccine vAHSV6 or vAHSV8 induced an adequate protective immune response to challenge with homologous and heterologous virulent virus. In vivo cross-protection between AHSV6 and AHSV9 and AHSV8 and AHSV5 respectively, was demonstrated.

Evaluation of the pathogenicity of African Horsesickness (AHS) isolates in vaccinated animals.

BACKGROUND: The polyvalent African Horsesickness (AHS) attenuated live vaccine (ALV) produced by Onderstepoort Biological Products (OBP) Ltd., South Africa, has been associated with some safety concerns and alleged cases of vaccine failure or vaccine-induced disease. The risk of reassortment and reversion to virulence is a common concern associated with the use of ALVs, and a phenomenon reported for viruses with segmented RNA genomes. The purpose of this study was to determine whether or not reassortment of AHS vaccine strains could result in reassortants and reversion to virulence and therefore cause AHS in susceptible horses. METHODS: Clinical or field isolates of AHS were obtained from horses with AHS symptoms or disease post vaccination. AHS-naïve horses were inoculated with these isolates and monitored for clinical reactions. Laboratory tests were performed at intervals to determine immune responses and viraemia. Viral RNA extraction and complete genome amplification of monovalent AHS-ALV vaccine strains and isolates collected post-vaccination was conducted. cDNA of the genome segments were run on PAGE to determine mobility patterns and genome segments 2, 3, 4, 5 and 6 sequenced for phylogenetic analysis. RESULTS: No clinical symptoms typical of AHS were observed in inoculated horses and all showed a good immune response. A comparison of mobility patterns of the amplified cDNA genome on PAGE allowed the identification and differentiation of reassortants, which were confirmed by sequence and phylogenetic analysis of the nucleotide sequences. CONCLUSION: This study, however, showed no indications that vaccine reassortants were pathogenic or lethal after inoculation in susceptible horses. Assumptions of virulence or reversion to virulence of vaccine reassortants post-vaccination in horses could not be substantiated.

Independent evolution of human immunodeficiency virus (HIV) drug resistance mutations in diverse areas of the brain in HIV-infected patients, with and without dementia, on antiretroviral treatment.

AIDS dementia complex (ADC) in human immunodeficiency virus (HIV)-infected patients continues to be a problem in the era of highly active antiretroviral therapy (HAART). A better understanding of the drug resistance mutation patterns that emerge in the central nervous system (CNS) during HAART is of paramount importance as these differences in drug resistance mutations may explain underlying reasons for poor penetration of antiretroviral drugs into the CNS and suboptimal concentrations of the drugs that may reside in the brains of HIV-infected individuals during therapy. Thus, we provide a detailed analysis of HIV type 1 (HIV-1) protease and reverse transcriptase (RT) genes derived from different regions of the brains of 20 HIV-1-infected patients (5 without ADC, 2 with probable ADC, and 13 with various stages of ADC) on antiretroviral therapy. We show the compartmentalization and independent evolution of both primary and secondary drug resistance mutations to both RT and protease inhibitors in diverse regions of the CNS of HIV-infected patients, with and without dementia, on antiretroviral therapy. Our results suggest that the independent evolution of drug resistance mutations in diverse areas of the CNS may emerge as a consequence of incomplete suppression of HIV, probably related to suboptimal drug levels in the CNS and drug selection pressure. The emergence of resistant virus in the CNS may have considerable influence on the outcome of neurologic disease and also the reseeding of HIV in the systemic circulation upon failure of therapy.