Perceptions, facilitators and barriers of physical activity among people living with HIV: a qualitative study.

BACKGROUND: People living with HIV (PLWH) have low levels of physical activity. Using the social ecological model to understand perceptions, facilitators and barriers of physical activity in this population is of importance for developing contextualised interventions to improve physical activity in PLWH. METHOD: This was a qualitative sub-study conducted between august and November 2019 as part of a cohort study on diabetes and associated complications in HIV infected in Mwanza, Tanzania. Sixteen in-depth interviews and three focus groups with nine participants in each were conducted. The interviews and focus groups were audio recorded, transcribed and translated into English. The social ecological model was considered during the coding and interpretation of the results. Transcripts were discussed, coded and analyzed using deductive content analysis. RESULTS: Forty-three PLWH aged 23-61 years participated in this study. The findings showed that most PLWH perceived physical activity as beneficial to their health. However, their perceptions of physical activity were rooted within existing gender stereotypes and roles in the community. Running and playing football were perceived as activities for men while household chores activities were for women. Further, men were perceived to do more physical activity than women. For women, household chores and income-generating activities were perceived as sufficient physical activity. Social support and engagement of family members and friends in physical activity were reported as facilitators of physical activity. Reported barriers of physical activity were lack of time, money, availability of physical activity facilities and social support groups, and poor information on physical activity from health care providers in HIV clinics. Human-immunodeficiency virus (HIV) HIV infection was not perceived by PLWH as a barrier for doing physical activity but most family members did not support them to do physical activity, fearing that it might worsen their condition. CONCLUSION: The findings demonstrated differing perceptions, facilitators and barriers of physical activity among PLWH. Interventions addressing awareness, gender stereotypes and roles related to physical activity from individual to community level are needed. Supportive environment and infrastructures are needed to improve physical activity levels in PLWH in Tanzania.

Levels and correlates of physical activity and capacity among HIV-infected compared to HIV-uninfected individuals.

INTRODUCTION: In the HIV-infected individuals, physical activity improves physical strength, quality of life and reduces the risk of developing non-communicable diseases. In Sub-Saharan Africa, HIV-infected patients report being less active compared to HIV-uninfected individuals. We assessed the levels and correlates of objectively measured physical activity and capacity among HIV-infected antiretroviral therapy (ART)-naive individuals compared to HIV-uninfected individuals in Mwanza, Tanzania. METHOD: We conducted a cross-sectional study among newly diagnosed HIV-infected ART-naive individuals and HIV-uninfected individuals frequency-matched for age and sex. Socio-demographic data, anthropometrics, CD4 counts, haemoglobin level, and C-reactive protein (CRP) were collected. Physical activity energy expenditure (PAEE) was assessed as measure of physical activity whereas sleeping heart rate (SHR) and grip strength were assessed as measures of physical capacity. Multivariable linear regression was used to assess the correlates associated with physical activity and capacity. RESULTS: A total of 272 HIV-infected and 119 HIV-uninfected individuals, mean age 39 years and 60% women participated in the study. Compared to HIV-uninfected individuals, HIV-infected had poorer physical activity and capacity: lower PAEE (-7.3 kj/kg/day, 95% CI: -11.2, -3.3), elevated SHR (7.7 beats/min, 95%CI: 10.1, 5.3) and reduced grip strength (-4.7 kg, 95%CI: -6.8, -2.8). In HIV-infected individuals, low body mass index, moderate-severe anaemia, low CD4 counts and high CRP were associated with lower physical activity and capacity. In HIV-uninfected individuals, abdominal obesity and moderate anaemia were associated with lower physical activity and capacity. CONCLUSION: HIV-infected participants had lower levels of physical activity and capacity than HIV-uninfected participants. Correlates of physical activity and capacity differed by HIV status. Management of HIV and related conditions needs to be provided effectively in health care facilities. Interventions promoting physical activity in these populations will be of importance to improve their health and reduce the risk of non-communicable diseases.

Association of schistosome infection with adiposity in Tanzania.

Background: Observational studies in humans have reported a link between schistosome infection and lower adiposity, but this may be explained by socioeconomic and demographic factors, intensity of infection, or common co-infections such as HIV. Methods: This was a cross-sectional study that investigated the relationship between schistosome infection and adiposity in a large, well-described cohort of Tanzanian adults living with and without HIV. Cross-sectional data were collected among adults living in Mwanza, Tanzania who were enrolled in the Chronic Infections, Co-morbidities and Diabetes in Africa (CICADA) cohort study. Schistosome circulating anodic antigen, secreted by both Schistosoma mansoni and haematobium which are endemic to Tanzania, was quantified from stored samples. Schistosome infection diagnosed by serum circulating anodic antigen levels. The primary outcome was fat mass measured by bioimpedance analysis. Secondary outcomes included fat-free mass, waist circumference, mid-upper arm circumference, and body mass index. Results: The study enrolled 1,947 adults, of whom 1,923 (98.8%) had serum available for schistosome testing. Of these, 873 (45.4%) had a serum circulating anodic antigen ≥30 pg/mL, indicating schistosome infection. Compared to uninfected individuals, those with schistosome infections had -1.1 kg [95% CI -1.9 to -0.3] lower fat mass after adjusting for age, sex, physical activity, tobacco use, education level, and socioeconomic status. Infected participants also had lower waist circumference, mid-upper arm circumference, and body mass index. Fat-free mass was not different between the two groups. Neither being HIV-infected, nor receiving antiretroviral therapy, modified associations between schistosome infection and adiposity. These associations were also not affected by Schistosoma worm burden. Conclusions: Schistosome infection was associated with lower fat mass and less central adiposity without a difference in muscle mass, irrespective of confounders, HIV status, or the intensity of schistosome infection. Future studies should adjust for socioeconomic and demographic factors that are associated with schistosome infection and adiposity. Identifying mechanistic pathways by which schistosome infection reduces adiposity while preserving muscle mass could yield new strategies for obesity control and cardiovascular disease prevention.

Risk factors for impaired renal function in HIV-infected and HIV-uninfected adults: cross-sectional study in North-Western Tanzania.

BACKGROUND: Although the burden of impaired renal function is rising in sub-Saharan Africa (SSA), little is known about correlates of impaired renal function in the region. We determined factors associated with estimated glomerular filtration rate (eGFR) and impaired renal function in HIV-infected and HIV-uninfected adults. METHODS: We undertook cross-sectional analysis of data from 1947 adults at enrolment for a cohort study on diabetes and associated complications in HIV patients in Mwanza, north-western Tanzania. A structured questionnaire was used to collect data on sociodemography, smoking, alcohol, physical activity, antiretroviral therapy (ART) and anthropometry. We measured blood pressure, tested blood samples for creatinine, glucose and HIV, and performed Kato Katz for Schistosoma mansoni. Correlates of eGFR (mL/min/1.73 m2) and impaired renal function (eGFR< 60 mL/min/1.73 m2) were determined using linear regression and logistic regression, respectively. RESULTS: 655 (34%) participants were HIV-uninfected, 956 (49%) were ART-naive HIV-infected and 336 (17%) were HIV-infected adults on ART. The mean age was 41 years (SD12) and majority (59%) were females. Overall, the mean eGFR was 113.6 mL/min/1.73 m2 but 111.2 mL/min/1.73 m2 in HIV-uninfected, 109.7 mL/min/1.73 m2 in ART-naive HIV-infected and 129.5 mL/min/1.73 m2 in HIV-infected ART-experienced adults, and respective prevalence of impaired renal function was 7.0, 5.7, 8.1 and 6.3%. Correlates of lower eGFR were increasing age, higher socioeconomic status, unhealthy alcohol drinking, higher body mass index and diabetes mellitus. Anaemia was associated with 1.9 (95% Confidence Interval (CI):1.2, 2.7, p = 0.001) higher odds of impaired renal function compared to no anaemia and this effect was modified by HIV status (p value 0.02 for interaction). CONCLUSION: Impaired renal function is prevalent in this middle-aged study population. Interventions for prevention of impaired renal function are needed in the study population with special focus in HIV-infected adults and those with high socioeconomic status. Interventions targeting modifiable risk factors such as alcohol and weight reduction are warranted.

Hypertension: Do Inflammation and Immunity Hold the Key to Solving this Epidemic?

Elevated cardiovascular risk including stroke, heart failure, and heart attack is present even after normalization of blood pressure in patients with hypertension. Underlying immune cell activation is a likely culprit. Although immune cells are important for protection against invading pathogens, their chronic overactivation may lead to tissue damage and high blood pressure. Triggers that may initiate immune activation include viral infections, autoimmunity, and lifestyle factors such as excess dietary salt. These conditions activate the immune system either directly or through their impact on the gut microbiome, which ultimately produces chronic inflammation and hypertension. T cells are central to the immune responses contributing to hypertension. They are activated in part by binding specific antigens that are presented in major histocompatibility complex molecules on professional antigen-presenting cells, and they generate repertoires of rearranged T-cell receptors. Activated T cells infiltrate tissues and produce cytokines including interleukin 17A, which promote renal and vascular dysfunction and end-organ damage leading to hypertension. In this comprehensive review, we highlight environmental, genetic, and microbial associated mechanisms contributing to both innate and adaptive immune cell activation leading to hypertension. Targeting the underlying chronic immune cell activation in hypertension has the potential to mitigate the excess cardiovascular risk associated with this common and deadly disease.

Sustained high blood pressure and 24-h ambulatory blood pressure monitoring in Tanzanian adolescents.

Estimates for prevalence of high blood pressure (BP) among adolescents in Africa vary widely and few studies, if any, have documented the results of the recommended stepwise BP screening. In this cross-sectional study in Tanzania, we aimed to estimate prevalence of sustained high BP in 3 public secondary schools using the American Academy of Pediatrics BP screening strategy. On Day 1, one screening automated office BP (AOBP) measurement (Step 1) was followed by two more AOBP measurements (Step 2). Repeat AOBP measurements were obtained after about one month on adolescents with high AOBP measurements on Day 1 (Step 3). Participants with sustained high BP underwent 24-h ambulatory BP monitoring (step 4). Of all 500 enrolled participants, the prevalence of high blood pressure at each step in the process was 36.6% (183), 25.6% (128), 10.2% (51), and 2.6%(13) respectively for Steps 1-4. All except 6 students completed all 4 steps of the BP screening algorithm as indicated. We conclude that diagnosis of hypertension in African adolescents should use multiple AOBP measurements over multiple days followed by 24-h ABPM. Screening for high BP in school settings appears to be feasible and could provide a platform for cardiovascular disease education and health promotion.

Hypertensive Urgency in Tanzanian Adults: A 1-Year Prospective Study.

BACKGROUND: Hypertensive urgency is associated with a high risk for cardiovascular events and mortality in the United States and Europe, but data from low-income countries and interventions to improve outcomes are lacking. METHODS: We conducted a 1-year prospective study of the prevalence and outcomes of hypertensive urgency (blood pressure (BP) ≥180 mm Hg/120 mm Hg without end-organ damage) in a busy outpatient clinic in Tanzania. RESULTS: Of 7,600 consecutive adult outpatients screened with 3 unattended automated BP measurements according to standard protocol, the prevalence of hypertensive crisis was 199/7,600 (2.6%) (BP ≥180 mm Hg/120 mm Hg) and the prevalence of hypertensive urgency was 164/7,600 (2.2%). Among 150 enrolled patients with hypertensive urgency, median age was 62 years (54-68), 101 (67.3%) were women, and 53 (35%) were either hospitalized or died within 1 year. In a multivariate model, the strongest predictor of hospitalization/death was self-reported medication adherence on a 3 question scale (hazard ratio: 0.06, P < 0.001); 90% of participants with poor adherence were hospitalized or died within 1 year. CONCLUSIONS: Patients with hypertensive urgency in Africa are at high risk of poor outcomes. Clinicians can identify the patients at highest risk for poor outcomes with simple questions related treatment adherence. New interventions are needed to improve medication adherence in patients with hypertensive urgency.

Hypertension prevalence and risk factors among residents of four slum communities: population-representative findings from Port-au-Prince, Haiti.

OBJECTIVES: The aim of this study was to estimate the prevalence of hypertension and its risk factors among adults in four slum communities in Port-au-Prince. METHODS: Cluster area random sampling was used to select adults for a health and demographic survey, including anthropometric measurements. Hypertension was defined as SBP at least 140 mmHg and/or DBP at least 90 mmHg, or current hypertension treatment, and was age-standardized to WHO world population. Correlates of hypertension were tested using sex-stratified logistic regression. RESULTS: Overall, 20.3% of adults had hypertension (28.5% age-standardized), including 22.3% of men and 18.9% of women. Three percent of participants reported current hypertension treatment, and 49.5% of them had their hypertension controlled. Overweight/obesity (BMI ≥25) was the most common risk factor (20.6% among men, 48.5% among women), while smoking was less common (11.8 and 3.9%, respectively). Increasing age and hypertension prevalence in immediate surroundings were associated with greater odds of hypertension. Among men, having in-migrated in the 3 years prior (versus ≥3 years) was also associated with hypertension [adjusted odds ratio (aOR)=3.32, 95% confidence interval (95% CI): 1.79-6.17], as was overweight and obesity (aOR = 1.90, 95% CI: 1.09-3.33, and aOR = 5.73, 95% CI: 2.49-13.19, respectively) and nonreceipt of needed medical care in the preceding 6 months (aOR = 2.82, 95% CI: 1.35-5.88) among women. CONCLUSION: Hypertension prevalence was high across the age spectrum, in addition to substantial levels of overweight/obesity and unmet healthcare needs. It is important to better understand the possible effects of intraurban migration and environmental risk factors on hypertension and ensure that the benefits of increasingly cost-effective prevention and treatment programmes extend to slum residents.

Post-hospital mortality in children aged 2-12 years in Tanzania: A prospective cohort study.

BACKGROUND: Sub-Saharan Africa has the highest rates of child mortality worldwide. Little is known about post-hospital outcomes after an index hospitalization for older children. We determined 12-month post-hospital mortality rate and identified factors associated with higher mortality. METHODS: In this prospective cohort study, we enrolled children 2-12 years of age admitted to the pediatric wards of two public hospitals in northwestern Tanzania. Participants or proxies were contacted at 3, 6 and 12 months post-hospitalization. The primary outcome measured was mortality. Factors associated with mortality were determined using Cox regression analysis. RESULTS: A total of 506 participants were enrolled. In-hospital mortality rate was 7.7% (39/506). Of the 467 participants discharged, the post-hospital mortality rate was 10.1% (47/467). Sickle cell disease (Hazard Ratio (HR) 3.32, 95% CI 1.44-7.68), severe malnutrition (HR 3.19, 95% CI 1.18-8.57), neurologic diseases (HR 3.51, 95% CI 1.35-9.11), heart disease (HR 7.11, 95% CI, 2.89-17.51), cancer (HR 11.79, 95% CI 4.95-28.03), and septic shock (HR 4.64, 95% CI 1.42-15.08) had higher association with mortality compared to other diagnoses. The risk factors significantly associated with mortality included older age (HR 1.01, 95% CI 1.00-1.08), lower hemoglobin level (HR 0.83, 95% CI 0.76-0.90), lower Glasgow Coma Scale (HR 0.66, 95% CI 0.59-0.74), history of decreased urine output (HR 2.87, 95% CI 1.49-5.53), higher respiratory rate (HR 1.02, 95% CI 1.00-1.03), estimated glomerular filtration rate less than 60 ml/min/1.73m2 (binary) (HR 1.84, 95% CI 1.10-3.10), and lower oxygen saturation (HR 0.96, 95% CI 0.92-0.99). CONCLUSIONS: Post-hospital mortality is disturbingly high among children 2-12 years of age in Tanzania. Post-hospital interventions are urgently needed especially for older children with chronic illnesses.

Blood pressure and mortality in a prospective cohort of HIV-infected adults in Port-au-Prince, Haiti.

OBJECTIVE: The objective of this study was to determine how baseline blood pressure and incident hypertension related to antiretroviral therapy (ART) initiation, HIV-related inflammation and mortality in HIV-infected adults in a low-income country. METHODS: We conducted long-term follow-up of HIV-infected adults who had participated in a trial of early vs. delayed initiation of ART in Port-au-Prince, Haiti. Between 2005 and 2008, 816 HIV-infected adults were randomized to early (N = 408) vs. delayed ART (when CD4 cell count <200 cells/µl or AIDS-defining condition; N = 408). Blood pressure was measured every 3 months. Hypertension was diagnosed according to the Joint National Committee (JNC-7) guidelines. Biomarkers of inflammation and coagulation were measured from banked enrolment plasma samples. Survival analyses were performed using Stata 14. RESULTS: The median age at enrolment was 39 years. The median follow-up time was 7.3 years. The hypertension incidence rate was 3.41 per 100 person-years, and was similar in early and delayed ART groups. In multivariable models, independent predictors of incident hypertension were older age, higher BMI and plasma interleukin (IL)-6 levels (adjusted hazard ratio, aHR = 1.23, P < 0.001). Systolic pressure more than 140 mmHg at enrolment was associated with increased mortality (aHR = 2.47, P = 0.03) as was systolic pressure less than 90 mmHg (aHR = 2.25, P = 0.04). Prevalent and incident hypertension were also significantly associated with mortality. CONCLUSION: In a large prospective study of HIV-infected adults, we found a high incidence of hypertension associated with HIV-related inflammation. Baseline hypertension conferred a more than two-fold increased risk of death. Among HIV-infected adults in low-income countries, hypertension should be considered a serious threat to long-term survival.

High birth prevalence of sickle cell disease in Northwestern Tanzania.

BACKGROUND: Worldwide, hemoglobinopathies affect millions of children. Identification of hemoglobin disorders in most sub-Saharan African countries is delayed until clinical signs of the disease are present. Limited studies have been conducted to understand their prevalence and clinical presentation among newborns in resource-limited settings. METHODOLOGY: This was a prospective cohort study. Newborns (aged 0-7 days) at two hospitals in Northwestern Tanzania were enrolled and followed prospectively for 6 months. Clinical and laboratory information were collected at baseline. Participants were screened for hemoglobinopathies using high-performance liquid chromatography. Clinical and laboratory follow-up was performed at 3 and 6 months for those with hemoglobinopathies as well as a comparison group of participants without hemoglobinopathies. RESULTS: A total of 919 newborns were enrolled. Among these, 1.4% (13/919) had sickle cell anemia or Hb S/ß0 -thalassemia (Hb FS), and 19.7% (181/919) had sickle cell trait or Hb S/ß+ thalassemia (Hb FAS). Furthermore, 0.2% (two of 919) had ß+ -thalassemia. Red cell indices compared between Hb FS, Hb FAS, and Hb FA were similar at baseline, but hemoglobin was lower and red cell distribution width was higher in children with Hb FS at 3- and 6-month follow-up. Febrile episodes were more common for children with Hb FS at 3- and 6-month follow-up. CONCLUSION: The prevalence of sickle cell disease among neonates born in Northwestern Tanzania is one of the highest in the world. Newborn screening is needed early in life to identify neonates with hemoglobinopathies so that clinical management may commence and morbidity and mortality related to hemoglobinopathies be reduced.

Global health training among U.S. residency specialties: a systematic literature review.

BACKGROUND: Interest in global health training during residency is increasing. Global health knowledge is also becoming essential for health-care delivery today. Many U.S. residency programs have been incorporating global health training opportunities for their residents. We performed a systematic literature review to evaluate global health training opportunities and challenges among U.S. residency specialties. METHODS: We searched PubMed from its earliest dates until October 2015. Articles included were survey results of U.S. program directors on global health training opportunities, and web-based searches of U.S. residency program websites on global health training opportunities. Data extracted included percentage of residency programs offering global health training within a specialty and challenges encountered. RESULTS: Studies were found for twelve U.S. residency specialties. Of the survey based studies, the specialties with the highest percentage of their residency programs offering global health training were preventive medicine (83%), emergency medicine (74%), and surgery (71%); and the lowest were orthopaedic surgery (26%), obstetrics and gynecology (28%), and plastic surgery (41%). Of the web-based studies, the specialties with the highest percentage of their residency programs offering global health training were emergency medicine (41%), pediatrics (33%), and family medicine (22%); and the lowest were psychiatry (9%), obstetrics and gynecology (17%), and surgery (18%). The most common challenges were lack of funding, lack of international partnerships, lack of supervision, and scheduling. CONCLUSION: Among U.S. residency specialties, there are wide disparities for global health training. In general, there are few opportunities in psychiatry and surgical residency specialties, and greater opportunities among medical residency specialties. Further emphasis should be made to scale-up opportunities for psychiatry and surgical residency specialties.

Predictors of Mortality Among Pediatric Burn Patients in East Africa.

Little is known about the outcomes of pediatric burn patients in resource-limited and rural locations of the developing world. In March 2013, our pediatric burn unit existing in this setting established an electronic registry of all patients. The authors analyzed the registry to determine overall mortality rates and predictors of mortality, including that of underweight status and body part burned. The secure electronic database of all admissions was reviewed for age, gender, weight, burn percentage (TBSA%), body part burned, cause/place of injury, length of stay, underweight status, surgery performed, reason for discharge, and mortality. Univariable and multivariable logistic regression was used to determine the variables associated with mortality. Kaplan-Meier curves were also analyzed. A total of 211 cases (59.7% male) admitted from March 2013 to June 2014 were reviewed. The median age, %TBSA, and length of stay were 2.0 years (1.3-3.3), 8.0% (5.0-13.4), and 8.5 days (4-14). The overall mortality rate was 15/211 (7.1%). Most injuries were unintentional (93.8%) scalds (85.3%) occurring in the home (98.1%). Two factors were significantly associated with mortality in the final multivariable model: %TBSA (odds ratio = 1.31 for 1% increase in %TBSA; 95% confidence interval = 1.17-1.46) and younger age (odds ratio = 0.20; 0.07-0.63). This study characterizes mortality among patients at a pediatric burn unit serving a rural population in the developing world. The majority of pediatric burns were unintentional scalds occurring in the home. %TBSA and lower age were the strongest predictors of mortality. Burn location and underweight status were not independent predictors of mortality. Overall mortality was 7.1%. These data are applicable to improving outcomes for patients in this burn unit and similar settings of its kind.

High prevalence of hypertension and of risk factors for non-communicable diseases (NCDs): a population based cross-sectional survey of NCDS and HIV infection in Northwestern Tanzania and Southern Uganda.

BACKGROUND: The burden of non-communicable diseases (NCDs) is increasing in sub-Saharan Africa, but data available for intervention planning are inadequate. We determined the prevalence of selected NCDs and HIV infection, and NCD risk factors in northwestern Tanzania and southern Uganda. METHODS: A population-based cross-sectional survey was conducted, enrolling households using multistage sampling with five strata per country (one municipality, two towns, two rural areas). Consenting adults (≥18 years) were interviewed using the WHO STEPS survey instrument, examined, and tested for HIV and diabetes mellitus (DM). Adjusting for survey design, we estimated population prevalences of hypertension, DM, obstructive pulmonary disease, cardiac failure, epilepsy and HIV, and investigated factors associated with hypertension using logistic regression. RESULTS: Across strata, hypertension prevalence ranged from 16 % (95 % confidence interval (CI): 12 % to 22 %) to 17 % (CI: 14 % to 22 %) in Tanzania, and from 19 % (CI: 14 % to 26 %) to 26 % (CI: 23 % to 30 %) in Uganda. It was high in both urban and rural areas, affecting many young participants. The prevalence of DM (1 % to 4 %) and other NCDs was generally low. HIV prevalence ranged from 6 % to 10 % in Tanzania, and 6 % to 12 % in Uganda. Current smoking was reported by 12 % to 23 % of men in different strata, and 1 % to 3 % of women. Problem drinking (defined by Alcohol Use Disorder Identification Test criteria) affected 6 % to 15 % men and 1 % to 6 % women. Up to 46 % of participants were overweight, affecting women more than men and urban more than rural areas. Most patients with hypertension and other NCDs were unaware of their condition, and hypertension in treated patients was mostly uncontrolled. Hypertension was associated with older age, male sex, being divorced/widowed, lower education, higher BMI and, inversely, with smoking. CONCLUSIONS: The high prevalence of NCD risk factors and unrecognized and untreated hypertension represent major problems. The low prevalence of DM and other preventable NCDs provides an opportunity for prevention. HIV prevalence was in line with national data. In Tanzania, Uganda and probably elsewhere in Africa, major efforts are needed to strengthen health services for the PREVENTION, early detection and treatment of chronic diseases.

Impact of antiretroviral therapy on renal function among HIV-infected Tanzanian adults: a retrospective cohort study.

BACKGROUND: Data regarding the outcomes of HIV-infected adults with baseline renal dysfunction who start antiretroviral therapy are conflicting. METHODS: We followed up a previously-published cohort of HIV-infected adult outpatients in northwest Tanzania who had high prevalence of renal dysfunction at the time of starting antiretroviral therapy (between November 2009 and February 2010). Patients had serum creatinine, proteinuria, microalbuminuria, and CD4(+) T-cell count measured at the time of antiretroviral therapy initiation and at follow-up. We used the adjusted Cockroft-Gault equation to calculate estimated glomerular filtration rates (eGFRs). RESULTS: In this cohort of 171 adults who had taken antiretroviral therapy for a median of two years, the prevalence of renal dysfunction (eGFR <90 mL/min/1.73 m(2)) decreased from 131/171 (76.6%) at the time of ART initiation to 50/171 (29.2%) at the time of follow-up (p<0.001). Moderate dysfunction (eGFR<60 mL/min/1.73 m(2)) decreased from 21.1% at antiretroviral therapy initiation to 1.1% at follow-up (p<0.001), as did the prevalence of microalbuminuria (72% to 44%, p<0.001). Use of tenofovir was not associated with renal dysfunction at follow-up. CONCLUSION: Mild and moderate renal dysfunction were common in this cohort of HIV-infected adults initiating antiretroviral therapy, and both significantly improved after a median follow-up time of 2 years. Our work supports the renal safety of antiretroviral therapy in African adults with mild-moderate renal dysfunction, suggesting that these regimens do not lead to renal damage in the majority of patients and that they may even improve renal function in patients with mild to moderate renal dysfunction.

Cryptococcal meningitis management in Tanzania with strict schedule of serial lumber punctures using intravenous tubing sets: an operational research study.

BACKGROUND: Cryptococcal meningitis (CM) has a mortality rate of ∼70% among HIV-infected adults in low-income countries. Controlling intracranial pressure (ICP) is essential in CM, but it is difficult in low-income countries because manometers and practical ICP management protocols are lacking. METHODS: As part of a continuous quality improvement project, our Tanzanian hospital initiated a new protocol for ICP management for CM. All adult inpatients with CM are included in a prospective patient registry. At the time of analysis, this registry included data from 2 years before the initiation of this new ICP management protocol and for a 9-month period after. ICP was measured at baseline and at days 3, 7, and 14 by both manometer and intravenous (IV) tubing set. All patients were given IV fluconazole according to Tanzanian treatment guidelines and were followed until 30 days after admission. RESULTS: Among adult inpatients with CM, 32 of 35 patients (91%) had elevated ICP on admission. Cerebrospinal fluid pressure measurements using the improvised IV tubing set demonstrated excellent agreement (r = 0.96) with manometer measurements. Compared with historical controls, the new ICP management protocol was associated with a significant reduction in 30-day mortality (16/35 [46%] vs. 48/64 [75%] in historical controls; hazard ratio = 2.1 [95% CI: 1.1 to 3.8]; P = 0.018]. CONCLUSIONS: Increased ICP is almost universal among HIV-infected adults admitted with CM in Tanzania. Intensive ICP management with a strict schedule of serial lumbar punctures reduced in-hospital mortality compared with historical controls. ICP measurement with IV tubing sets may be a good alternative in resource-limited health facilities where manometers are not available.

Detectable urogenital schistosome DNA and cervical abnormalities 6 months after single-dose praziquantel in women with Schistosoma haematobium infection.

We explored response to single-dose praziquantel therapy in a cohort of 33 women with Schistosoma haematobium infection in rural Mwanza, Tanzania. Women with S. haematobium infection confirmed both by eggs in urine and by polymerase chain reaction (PCR) received single-dose praziquantel and treatment of concomitant sexually transmitted infections. Macroscopic cervical abnormalities were also quantified. After 6 months, microscopically detectable egg excretion was eliminated, but 8 of 33 women (24%) were persistently positive for S. haematobium by PCR, and 11 (33%) had cervical abnormalities potentially attributable to schistosomiasis. This suggests that praziquantel treatment more frequently than every 6 months may be necessary for complete elimination of the parasite and prevention of genital tissue pathology. This aggressive therapy may in turn play a key role decreasing HIV susceptibility in millions of people living in regions in which S. haematobium is endemic.