The prevalence and outcomes of depression in older HIV-positive adults in Northern Tanzania: a longitudinal study.

Studies of depression and its outcomes in older people living with HIV (PLWH) are currently lacking in sub-Saharan Africa. This study aims to investigate the prevalence of psychiatric disorders in PLWH aged ≥ 50 years in Tanzania focussing on prevalence and 2-year outcomes of depression. PLWH aged ≥ 50 were systematically recruited from an outpatient clinic and assessed using the Mini-International Neuropsychiatric Interview (MINI). Neurological and functional impairment was assessed at year 2 follow-up. At baseline, 253 PLWH were recruited (72.3% female, median age 57, 95.5% on cART). DSM-IV depression was highly prevalent (20.9%), whereas other DSM-IV psychiatric disorders were uncommon. At follow-up (n = 162), incident cases of DSM-IV depression decreased from14.2 to 11.1% (χ2: 2.48, p = 0.29); this decline was not significant. Baseline depression was associated with increased functional and neurological impairment. At follow-up, depression was associated with negative life events (p = 0.001), neurological impairment (p < 0.001), and increased functional impairment (p = 0.018), but not with HIV and sociodemographic factors. In this setting, depression appears highly prevalent and associated with poorer neurological and functional outcomes and negative life events. Depression may be a future intervention target.

Prevalence and 1-year incidence of HIV-associated neurocognitive disorder (HAND) in adults aged ≥50 years attending standard HIV clinical care in Kilimanjaro, Tanzania.

OBJECTIVES: HIV-associated neurocognitive disorders (HANDs) are prevalent in older people living with HIV (PLWH) worldwide. HAND prevalence and incidence studies of the newly emergent population of combination antiretroviral therapy (cART)-treated older PLWH in sub-Saharan Africa are currently lacking. We aimed to estimate HAND prevalence and incidence using robust measures in stable, cART-treated older adults under long-term follow-up in Tanzania and report cognitive comorbidities. DESIGN: Longitudinal study. PARTICIPANTS: A systematic sample of consenting HIV-positive adults aged ≥50 years attending routine clinical care at an HIV Care and Treatment Centre during March-May 2016 and followed up March-May 2017. MEASUREMENTS: HAND by consensus panel Frascati criteria based on detailed locally normed low-literacy neuropsychological battery, structured neuropsychiatric clinical assessment, and collateral history. Demographic and etiological factors by self-report and clinical records. RESULTS: In this cohort (n = 253, 72.3% female, median age 57), HAND prevalence was 47.0% (95% CI 40.9-53.2, n = 119) despite well-managed HIV disease (Mn CD4 516 (98-1719), 95.5% on cART). Of these, 64 (25.3%) were asymptomatic neurocognitive impairment, 46 (18.2%) mild neurocognitive disorder, and 9 (3.6%) HIV-associated dementia. One-year incidence was high (37.2%, 95% CI 25.9 to 51.8), but some reversibility (17.6%, 95% CI 10.0-28.6 n = 16) was observed. CONCLUSIONS: HAND appear highly prevalent in older PLWH in this setting, where demographic profile differs markedly to high-income cohorts, and comorbidities are frequent. Incidence and reversibility also appear high. Future studies should focus on etiologies and potentially reversible factors in this setting.

Risk factors for symptomatic HIV-associated neurocognitive disorder in adults aged 50 and over attending a HIV clinic in Tanzania.

OBJECTIVES: HIV-associated neurocognitive disorder (HAND), although prevalent, remains a poorly researched cause of morbidity particularly in sub-Saharan Africa (SSA). We aimed to explore the risk factors for HAND in people aged 50 and over under regular follow-up at a government HIV clinic in Tanzania. METHODS: HIV-positive adults aged 50 years and over were approached for recruitment at a routine HIV clinic appointment over a 4-month period. A diagnostic assessment for HAND was implemented, including a full medical/neurological assessment and a collateral history from a relative. We investigated potential risk factors using a structured questionnaire and by examination of clinic records. RESULTS: Of the cohort (n = 253), 183 (72.3%) were female and the median age was 57 years. Fifty-five individuals (21.7%) met the criteria for symptomatic HAND. Participants were at a greater risk of having symptomatic HAND if they lived alone [odds ratio (OR) = 2.566, P = .015], were illiterate (OR 3.171, P = .003) or older at the time of HIV diagnosis (OR = 1.057, P = .015). Age was correlated with symptomatic HAND in univariate, but not multivariate analysis. CONCLUSIONS: In this setting, HIV-specific factors, such as nadir CD4 count, were not related to symptomatic HAND. The "legacy theory" of early central nervous system damage prior to initiation of anti-retroviral therapy initiation may contribute, only in part, to a multifactorial aetiology of HAND in older people. Social isolation and illiteracy were associated with symptomatic HAND, suggesting greater cognitive reserve might be protective.

Cysticercosis and epilepsy in rural Tanzania: a community-based case-control and imaging study.

OBJECTIVE: To assess the contribution of neurocysticercosis (NCC) to the burden of epilepsy in a rural Tanzanian population. METHODS: We identified adult people with epilepsy (PWE) in a door-to-door study in an established demographic surveillance site. PWE and community controls were tested for antibodies to Taenia solium, the causative agent of NCC, and all PWE were offered a computed tomography (CT) head scan. Data on household occupancy and sanitation, pig-keeping and pork consumption were collected from PWE and controls and associations with epilepsy were assessed using chi-square or Fisher's exact tests. RESULTS: Six of 218 PWE had antibodies to T. solium (2.8%; 95% CI 0.6-4.9), compared to none of 174 controls (Fisher's exact test, P = 0.04). Lesions compatible with NCC were seen in eight of 200 CT scans (4.0%; 95% CI 1.3-6.7). A total of 176 PWE had both investigations of whom two had positive serology along with NCC-compatible lesions on CT (1.1%; 95% 0.3-4.0). No associations between epilepsy and any risk factors for NCC were identified. CONCLUSIONS: Neurocysticercosis is present in this population but at a lower prevalence than elsewhere in Tanzania and sub-Saharan Africa. Insights from low-prevalence areas may inform public health interventions designed to reduce the burden of preventable epilepsy.

Cognition and behavior in a prevalent cohort of children with epilepsy in rural northern Tanzania: A three-year follow-up study.

OBJECTIVES: Eighty-five percent of the 33 million children with epilepsy (CWE) worldwide live in low- and middle-income countries (LMICs). There is limited research into epilepsy-related comorbidities in LMICs, and there are no studies of the long-term progression of behavioral and intellectual difficulties in childhood epilepsy in sub-Saharan Africa. We aimed to assess behavior and cognition at three-year follow-up in CWE in rural Tanzania. METHODS: In 2010, a cross-sectional study identified 112 CWE 6 to 14years of age and 113 age- and sex-matched controls in the Hai district of northern Tanzania. From March to June 2013, cases and controls (now 10 to 18years of age) were followed up. At baseline, behavior was assessed using the Rutter A Questionnaire and cognition using the Goodenough-Harris Drawing Test. Details of current seizure frequency and antiepileptic drug (AED) use among CWE were collected. RESULTS: At follow-up, cases had significantly more behavioral difficulties compared with controls (48% of 108 cases versus 14% of 103 controls (p<0.001)). Additionally, 69% of the cases and 16% of the controls had cognitive impairment (p<0.001). In CWE with decreased seizure frequency from baseline to follow-up, behavior had improved significantly. At follow-up, there was no significant difference in behavior between CWE with decreased seizure frequency and those with good seizure control throughout. SIGNIFICANCE: Behavioral difficulties and cognitive impairment are common among CWE in this population. Improved access to AED treatment and subsequent improved seizure control may reduce the frequency of behavioral difficulties seen in this population.

Epilepsy in Tanzanian children: association with perinatal events and other risk factors.

PURPOSE: To define the prevalence and risk factors for epilepsy in children in a rural district of Tanzania by conducting a community-based case-control study. METHODS: Children aged 6-14 years with active epilepsy (at least two unprovoked seizures in the last 5 years) were identified in a cross-sectional survey in Tanzania. Cases were compared with age-matched controls. KEY FINDINGS: Overall 112 children with epilepsy (CWE) were identified; the unadjusted prevalence of epilepsy was 2.91 per 1,000 (95% confidence interval [95% CI] 2.4-3.5). The main seizure types were focal motor with secondary generalization in 73 (65.2%) of 112 and generalized convulsive seizures in 19 (16.9%) of 112. Adverse perinatal events were present in 16 (14%) of 112 cases but in no controls. In multivariate analysis, epilepsy was associated with number of parents who were resident at home (odds ratio [OR] 6.2 for none vs. both resident, 95% CI 1.5-25.5), history of adverse perinatal events (OR 14.9, 95% CI 1.4-151.3), family history of afebrile seizures (OR 5.7, 95% CI 1.0-27.5), and poor scholastic attainment (OR 8.6, 95% CI 4.0-18.4). Electroencephalography (EEG) and computed tomography (CT) scans were abnormal in 44 (44%) of 101 and 26 (29%) of 90 cases, respectively. Overall, 98 (88%) of 112 cases had focal features on assessment. SIGNIFICANCE: In this study from sub-Saharan Africa, CWE predominantly had focal features that support the suggestion that most epilepsy in this region has a symptomatic etiology. Adverse perinatal events were strongly associated with epilepsy. Genetic and social factors may also be important. Epilepsy may be preventable in a significant proportion of children with better antenatal and perinatal care.

Behavioural comorbidity in Tanzanian children with epilepsy: a community-based case-control study.

AIM: The aim of this study was to define the prevalence of and risk factors for behavioural disorders in children with epilepsy from a rural district of Tanzania by conducting a community-based case-control study. METHOD: One hundred and twelve children aged 6 to 14 years (55 males, 57 females; median age 12 y) with active epilepsy (at least two unprovoked seizures in the last 5 y) were identified in a cross-sectional survey and included in this study. Children who were younger than 6 years were excluded in order to eliminate febrile seizures. Behaviour was assessed using the Rutter scale; children who scored 13 or more were considered to have disordered behaviour. A comparison group was made up of age- and sex-matched children without epilepsy (n = 113; 57 males, 56 females; median age 12 y). RESULTS: Behavioural disorders were diagnosed in 68 of 103 (66%) children with epilepsy and in 19 of 99 (19%) controls. Disordered behaviour was significantly more common in children with epilepsy than in the comparison group (univariate odds ratio 8.2; 95% confidence interval [CI] 4.3-15.6; p < 0.001) and frequent seizures and poor scholastic attainment were associated in children with epilepsy. Behavioural disorders were not associated with antiepileptic drug usage. Attention problems were present in 48 of 91 (53%) children with epilepsy and 16 of 97 (17%) controls (univariate odds ratio 5.7; 95% CI 2.9-11.1; p < 0.001). In children with epilepsy, attention problems were significantly more common in males and were associated with frequent seizures. INTERPRETATION: Children with epilepsy in a rural area of sub-Saharan Africa have a high prevalence of behavioural disorders and attention problems, both of which are associated with frequent seizures. Providing behaviour assessment and appropriate intervention programmes for children with epilepsy may reduce the burden of behaviour disorders in this setting.

Growth parameters and childhood epilepsy in Hai District, Tanzania: a community-based study.

AIM: This cross-sectional study examined whether growth parameters were associated with epilepsy in children living in a rural community in sub-Saharan Africa (SSA). MATERIALS AND METHODS: A cross-sectional study was performed in the Hai District Demographic Surveillance Site (HDSS), Tanzania in which 6-14 year old children with epilepsy (CWE) were identified. Age matched controls were randomly selected from the Hai census database for comparison. Anthropometric measurements were used to assess the nutritional status of the children and body mass index (BMI) calculated. Associations between social, demographic and nutritional factors and epilepsy were assessed using multivariable logistic regression. RESULTS: 112 CWE were identified and were compared with 113 controls. There was no significant difference in the BMI between cases and controls (T-test, p-value of 0.117). Amongst cases, there were no significant associations between BMI and motor difficulties, antiepileptic drug use, cognitive or behavioural problems, early-onset epilepsy or seizure frequency. In the whole group, BMI was significantly associated with socio-economic status (p=0.037) and age. DISCUSSION: There was no significant difference found between CWE and matched controls with respect to nutritional status. This suggests that there is no causal association between under nutrition and epilepsy in this community. Nutritional assessment is still important as part of the comprehensive care of CWE.

Co-morbidity of epilepsy in Tanzanian children: a community-based case-control study.

PURPOSE: To define the prevalence and associations of co-morbidity and school attendance in older children with epilepsy (CWE) from a rural district of Tanzania by conducting a community-based case-control study. METHODS: Children aged 6-14 years old with active epilepsy (at least two unprovoked seizures in the last five years) were identified in a cross-sectional survey in Tanzania. Co-morbidities were assessed and cases were compared with age-matched controls. RESULTS: Co-morbidity was very common amongst cases (95/112, 85%), with 62/112 (55%) having multiple co-morbidities. Co-morbidities consisted of cognitive impairment (72/112, 64%), behaviour disorder 68/112 (61%), motor difficulties 29/112 (26%), burns and other previous injuries (29/112, 26%). These complications were significantly more common in cases than in controls (odds ratio 14.8, 95%CI 7.6-28.6, p<0.001). Co-morbidity in CWE was associated with structural cause, abnormal electroencephalogram and early onset seizures. Cognitive impairment was very common in CWE (64%) and was not associated with Phenobarbital use but was associated with motor difficulties, early onset and recurrent seizures. Poor school attendance was found in 56/112 (50%) of CWE, but not in the controls: it was associated with the presence of multiple co-morbidities, especially with motor difficulties in CWE. CONCLUSION: Children with epilepsy in a rural area of sub-Saharan Africa had a high level of co-morbidity. Cognitive impairment and poor school attendance were very common. These associated difficulties in CWE in the region need to be addressed to reduce the negative impact of epilepsy on these children.