Tuberculosis is Associated with Chronic Hypoxemia among Kenyan Adults (CHAKA): A Case-Control Study.

RATIONALE: Data on risk factors for chronic hypoxemia in low and middle-income countries are lacking. OBJECTIVE: We aimed to quantify the association between potential risk factors and chronic hypoxemia among adults hospitalized in Kenya. METHODS: A hospital-based case-control study was conducted at Moi Teaching and Referral Hospital in Eldoret, Kenya. Adult inpatients were screened on admission and enrolled in a 1:2 case to control ratio. Cases were patients with chronic hypoxemia, defined as a resting oxygen saturation (SpO2) < 88% on admission and either a one-month post discharge SpO2 < 88% or, if they died prior to follow-up, a documented SpO2 < 88% in the 6 months prior to enrollment. Controls were randomly selected, stratified by sex, among non-hypoxemic inpatients. Data were collected via questionnaires and structured chart review. Regression was used to assess the association between chronic hypoxemia and age, sex, smoking status, biomass fuel use, elevation, and self-reported history of tuberculosis and HIV diagnosis. Odds ratios (ORs) and 95% confidence intervals (CIs) are reported. RESULTS: The study enrolled 108 chronically hypoxemic cases and 240 non-hypoxemic controls. In multivariable analysis, as compared to controls, chronically hypoxemic cases had significantly higher odds of older age (OR 1.2 per 5-year increase; 95% CI: 1.1-1.3), female sex (OR 3.6, 95% CI: 1.8-7.2), current or former tobacco use (OR 4.7, 95% CI: 2.3-9.6) and prior tuberculosis (OR 11.8, 95% CI: 4.7-29.6), but no increase in odds of HIV diagnosis and biomass fuel use. CONCLUSION: These findings highlight the potential impact of prior tuberculosis on chronic lung disease in Kenya and the need for further studies on post-tuberculosis lung disease.

Patient and provider perspectives on barriers to myocardial infarction care among persons with human immunodeficiency virus in Tanzania: A qualitative study.

INTRODUCTION: People with HIV (PLWH) have an increased risk myocardial infarction (MI), and evidence suggests that MI is under-diagnosed in Tanzania. However, little is known about barriers to MI care among PLWH in the region. METHODS: In this qualitative study grounded in phenomenology, semi-structured interviews were conducted in northern Tanzania. Purposive sampling was used to recruit a diverse group of providers who care for PLWH and patients with HIV and electrocardiographic evidence of prior MI. Emergent themes were identified via inductive thematic analysis. RESULTS: 24 physician and patient participants were interviewed. Most participants explained MI as caused by emotional shock and were unaware of the association between HIV and increased MI risk. Providers described poor provider training regarding MI, high out-of-pocket costs, and lack of diagnostic equipment and medications. Patients reported little engagement with and limited knowledge of cardiovascular care, despite high engagement with HIV care. Most provider and patient participants indicated that they would prefer to integrate cardiovascular care with routine HIV care. CONCLUSIONS: PLWH face many barriers to MI care in Tanzania. There is a need for multifaceted interventions to educate providers and patients, improve access to MI diagnosis, and increase engagement with cardiovascular care among this population.

Feasibility, Acceptability, and Potential Cost-Effectiveness of a Novel Mobile Phone Intervention to Promote Human Immunodeficiency Virus Testing Within Social Networks in Tanzania.

ABSTRACT: Among 145 individuals surveyed in Tanzania, 42% indicated willingness to test for human immunodeficiency virus in response to a confidential, phone-based text message. On average, participants were likely to provide contact information for 1.5 members of their social networks, suggesting high feasibility and moderate acceptability of a novel mHealth human immunodeficiency virus testing intervention.

Increasing the Uptake of HIV Testing among Men in Tanzania: A Novel Intervention for Bar Patrons.

We investigated a novel community-based HIV testing and counseling (HTC) strategy by recruiting men from bars in northern Tanzania in order to identify new HIV infections. All bars in the town of Boma Ng'ombe were identified and male patrons were systematically invited to participate in a health study. HIV testing was offered to all enrolled participants. Outputs included HIV test yield, cost per diagnosis, and comparison of our observed test yield to that among male patients contemporaneously tested at five local facility-based HTC. We enrolled 366 participants and identified 17 new infections - providing a test yield of 5.3% (95% Confidence interval [CI] 3.3-8.4). The test yield among men contemporaneously tested at five local HTC centers was 2.1% (95% CI 1.6-2.8). The cost-per-diagnosis was $634. Our results suggest that recruiting male bar patrons for HIV testing is efficient for identifying new HIV infections. The scalability of this intervention warrants further evaluation.

RESUMEN: Investigamos una novedosa estrategia comunitaria de asesoramiento y pruebas de VIH (HTC) reclutando hombres de los bares del norte de Tanzania para identificar nuevas infecciones de VIH. Se identificaron todos los bares de la ciudad de Boma Ng'ombe y se invitó sistemáticamente a los clientes varones a participar en un estudio de salud. Se ofrecieron pruebas de VIH a todos los participantes inscritos. Los resultados incluyeron los resultados de las pruebas de VIH, el costo por diagnóstico y la comparación de nuestros resultados observados con los de los pacientes varones que simultáneamente se sometieron a pruebas en cinco centros locales de HTC. Se inscribieron 366 participantes y se identificaron 17 nuevas infecciones, proporcionando un resultado en las pruebas del 5.3% (intervalo de confianza [IC] del 95%: 3.3-8.4). Los resultados de las pruebas realizadas simultáneamente en cinco centros locales de HTC fue del 2.1% (IC del 95%: 1.6-2.8). El costo por diagnóstico fue de $634. Nuestros resultados sugieren que el reclutamiento de clientes masculinos para las pruebas de VIH fue eficiente para identificar nuevas infecciones de VIH. La escalabilidad de esta intervención merece una evaluación adicional.

Early cardiac dysfunction in children and young adults with perinatally acquired HIV.

OBJECTIVE: To define the prevalence of early cardiac dysfunction in children and young adults with perinatally acquired HIV and predictors of cardiac function. DESIGN: Cross-sectional design. METHODS: Early cardiac dysfunction was defined as left ventricular (LV) global longitudinal strain z-score less than -2 or myocardial performance index at least 0.5 with normal LV ejection fraction. Regression models were fitted to assess the relationship between measures of cardiac function and HIV RNA levels, clinical variables, and markers of inflammation. RESULTS: Six hundred and forty-three individuals (mean age 14.1 ±â€Š5.2 years) were enrolled. The average time on combination antiretroviral treatment was 6.8 ±â€Š3.6 years. Nearly 28% of individuals met criteria for early cardiac dysfunction. Individuals with early cardiac dysfunction were older (15.3 vs. 13.5 years, P < 0.001), had more frequently detectable HIV RNA (52.5 vs. 41.7%, P = 0.018), were more likely exposed to azidothymidine or zidovudine (ZDV) (55.6 vs. 41.2%, P = 0.002), and had higher median level of plasma IL-6 concentrations (1.00 vs. 0.88 pg/ml, P = 0.011). Multivariable models show LV ejection fraction negatively associated with HIV RNA levels [ß -0.18; 95% confidence interval (CI) -0.33, -0.03] and ZDV exposure (ß -1.75; 95% CI -2.62, -0.88) and positively associated with proportion of life on combination antiretroviral treatment (ß 2.65; 95% CI 0.90, 4.41). Higher myocardial performance index was positively associated with serum inflammation marker (IL-6 ß 0.01; 95% CI 0.0001, 0.001). Left ventricular global longitudinal strain was not significantly associated with clinical and laboratory variables of interest. CONCLUSION: Over one-quarter of children and young adults living with HIV demonstrated evidence of cardiac dysfunction, which may be associated with increasing levels of systemic inflammation.

Pulmonary blastomycosis presenting as primary lung cancer.

BACKGROUND: Blastomycosis is an endemic mycosis in North America that is caused by the dimorphic fungus Blastomyces dermatitidis. The illness is a systemic disease with a wide variety of pulmonary and extra-pulmonary manifestations. The initial presentation of blastomycosis may easily be mistaken for other infectious or non-infectious etiologies. CASE PRESENTATION: We present the case of a 52-year-old African-American male and former smoker that presented to his primary care provider with a 2-week history of non-productive cough, night sweats and weight loss. Initially diagnosed with primary lung malignancy, the patient was subsequently found to have pulmonary blastomycosis mimicking lung cancer. The patient underwent a successful course of treatment with posaconazole. CONCLUSIONS: Chronic blastomycosis can present with clinical and radiographic features indistinguishable from thoracic malignancies. There is no clinical syndrome specific for blastomycosis, thus a high degree of suspicion is required for early diagnosis. In this case report, we review recent evidence in radiographic features, diagnostic considerations and treatment of the disease.

Apheresis for collection of Ebola convalescent plasma in Liberia.

PURPOSE: This report describes initiation of apheresis capability in Liberia, Africa to support a clinical trial of convalescent plasma therapy for Ebola Virus Disease. METHODS: A bloodmobile was outfitted in the United States as a four-bed apheresis unit with capabilities including pathogen reduction, electronic blood establishment computer system, designated areas for donor counseling and laboratory testing, and onboard electrical power generation. After air transport to Liberia, the bloodmobile was positioned at ELWA Hospital, Monrovia, and connected to the hospital's power grid. Liberian staff were trained to conduct donor screening, which included questionnaire and onsite blood typing and transfusion transmitted infection (TTI) testing, and plasma collection and processing. RESULTS: The bloodmobile was operational within 3 weeks after arrival of the advance team. Of 101 donors who passed the pre-screening questionnaire, 32 were deferred. Twenty-eight of ninty-nine tested survivors were deferred for positive transfusion transmitted infection (TTI) tests; twenty-one were positive for hepatitis B, hepatitis C, or human immunodeficiency virus. The majority of donors had type O blood; all but one were Rh positive. Forty-three survivors donated at least once; eighty-nine apheresis attempts resulted in eighty-one successful collections. CONCLUSIONS: Apheresis capability was emergently established in Liberia to support an efficacy trial of Ebola Convalescent Plasma. Extensive cooperation among multinational team members, engineers, logisticians, and blood safety technical personnel at the operational site was required to surmount challenges to execution posed by logistical factors. The high proportion of positive TTI tests supported the use of a pathogen reduction system to enhance product safety. J. Clin. Apheresis 32:175-181, 2017. © 2016 Wiley Periodicals, Inc.

Test site predicts HIV care linkage and antiretroviral therapy initiation: a prospective 3.5 year cohort study of HIV-positive testers in northern Tanzania.

BACKGROUND: Linkage to HIV care is crucial to the success of antiretroviral therapy (ART) programs worldwide, loss to follow up at all stages of the care continuum is frequent, and long-term prospective studies of care linkage are currently lacking. METHODS: Consecutive clients who tested HIV-positive were enrolled from four HIV testing centers (1 health facility and 3 community-based centers) in the Kilimanjaro region of Tanzania as part of the larger Coping with HIV/AIDS in Tanzania (CHAT) prospective observational study. Biannual interviews were conducted over 3.5 years, assessing care linkage, retention, and mental health. Bivariable and multivariate logistic regression analyses were conducted to determine associations with early death (prior to the second follow up interview) and delayed (>6 months post-test) or failed care linkage. RESULTS: A total of 263 participants were enrolled between November, 2008 and August, 2009 and 240 participants not already linked to care were retained in the final dataset. By 6 months after enrollment, 169 (70.4 %) of 240 participants had presented to an HIV care and treatment facility; 41 (17.1 %) delayed more than 6 months, 15 (6.3 %) died, and 15 (6.3 %) were lost to follow up. Twenty-six patients died before their second follow up visit and were analyzed in the early death group (10.8 %). Just 15 (9.6 %) of those linked to care had started ART within 6 months, but 123 (89.1 %) of patients documented to be ART eligible by local guidelines had started ART by the end of 3.5 years. On multivariate analysis, male gender (OR 1.72; 95 % CI 1.08, 2.75), testing due to illness (OR 1.63; 95 % CI 1.01, 2.63), and higher mean depression scale scores (4 % increased risk per increase in depression score; 95 % CI 1 %, 8 %) were associated with early death. Testing at a community versus a hospital-based site (OR 2.89; 95 % CI 1.79, 4.66) was strongly associated with delaying or never entering care. CONCLUSIONS: Nearly 30 % of the cohort did not have timely care linkage, ART initiation was frequently delayed, and testing at a hospital outpatient department versus community-based testing centers was strongly associated with successful care linkage.

Changes in HIV risk behavior and seroincidence among clients presenting for repeat HIV counseling and testing in Moshi, Tanzania.

While HIV counseling and testing (HCT) has been considered an HIV preventive measure in Africa, data are limited describing behavior changes following HCT. This study evaluated behavior changes and estimated HIV seroincidence rate among returning HCT clients. Repeat and one-time testing clients receiving HCT services in Moshi, Tanzania were identified. Information about sociodemographic characteristics, HIV-related behaviors and testing reasons were collected, along with HIV serostatus. Six thousand seven hundred and twenty-seven clients presented at least once for HCT; 1235 (18.4%) were HIV seropositive, median age was 29.7 years and 3712 (55.3%) were women. 1382 repeat and 4272 one-time testers were identified. Repeat testers were more likely to be male, older, married, or widowed, and testing because of unfaithful partner or new sexual partner. One-time testers were more likely to be students and testing due to illness. At second test, repeat testers were more likely to report that partners had received HIV testing, not have concurrent partners, not suspect partners have HIV, and have partners who did not have other partners. Clients who intended to change behaviors after the first test were more likely to report having changed behaviors by remaining abstinent (OR 2.58; p<0.0001) or using condoms (OR 2.00; p=0.006) at the second test. HIV seroincidence rate was 1.49 cases/100 person-years (PY). Clients presenting for repeat HCT reported some reduction of risky behavior and improved knowledge of sexual practices and HIV serostatus of their partners. Promoting behavior change through HCT should continue to be a focus of HIV prevention efforts in sub-Saharan Africa.

Relation of lifetime trauma and depressive symptoms to mortality in HIV.

OBJECTIVE: In an era of highly active antiretroviral therapies, the authors needed to confirm previous findings showing that stress and depression have an impact on HIV disease progression. The goal of the current study was to examine the effects of lifetime trauma, recent stressful events, and depression on all-cause and AIDS-related mortality among HIV-infected men and women. The authors hypothesized that these psychosocial variables would predict significantly faster HIV-specific and all-cause mortality. METHOD: The authors consecutively sampled HIV-infected men and women who received care at one of eight infectious diseases clinics in five Southeastern states. The sample included 490 patients who were followed by interview for 27 months and followed with their medical records for up to 41 months. RESULTS: There were 29 deaths; 16 were AIDS-related. More lifetime trauma and antigenic marker on helper/inducer T cells (CD4)<200 significantly predicted faster all-cause and AIDS-related mortality. For those at or above the median in trauma, the all-cause death rate was 3.54 per 100 person-years, compared to 1.72 for those below the median. For those at or above the median in trauma, the AIDS-related death rate was 2.13 per 100 person-years, compared to 0.77 for those below the median. Depressive symptoms and higher baseline viral load were significantly related to greater risk of AIDS-related mortality. CONCLUSIONS: Further research is needed to determine if interventions to address trauma and depression can modify these detrimental effects on HIV.

Diarrhea in patients with AIDS.

Diarrhea in patients with AIDS is a worldwide problem that can have a devastating impact on quality of life for the patient. Chronic diarrhea, usually defined as at least 4 weeks' duration, is more common in patients with low CD4-positive T-lymphocyte counts, signaling advanced immunosuppression. Some organisms, such as Microsporidia, usually cause diarrhea only in the immunosuppressed; others, such as Cryptosporidium, Salmonella, Shigella, and Campylobacter, which are capable of causing diarrhea in the immunocompetent population, produce more severe or prolonged infections in people living with AIDS. Familiarity with the most common pathogens in the clinician's region will help with diagnosis and treatment. Because treatment options vary widely depending upon the infectious agent, thorough microbiologic evaluation is warranted. A stepped diagnostic approach of stool cultures and specialized microscopy and stains for protozoa, followed by sigmoidoscopy or colonoscopy and duodenoscopy with biopsies for histopathological examination is recommended in all patients with persistent, disabling diarrhea who have a CD4 count of less than 200/mm3, and should be considered for those with higher counts on an individual basis. Treatment, tailored to the specific pathogen, may need to be prolonged in the most severely immunocompromised patients to prevent relapse or recrudescence. For patients taking antiretroviral therapy (especially protease inhibitors) in whom no infectious agent can be found, diarrhea may be due to the medications. Nonspecific antidiarrheal agents should be tried until one that suits the patient is found. The most essential component of any therapeutic strategy for a patient with AIDS-associated diarrhea is restoration of the underlying immunologic defect using highly active antiretroviral therapy.

AIDS-associated diarrhea and wasting in northeast Brazil is associated with subtherapeutic plasma levels of antiretroviral medications and with both bovine and human subtypes of Cryptosporidium parvum

Advanced HIV infection is frequently complicated by diarrhea, disruption of bowel structure and function, and malnutrition. Resulting malabsorption of or pharmacokinetic changes in antiretroviral agents might lead to subtherapeutic drug dosing and treatment failure in individual patients, and could require dose adjustment and/or dietary supplements during periods of diarrheal illness. We determined the plasma levels of antiretroviral medications in patients that had already been started on medication by their physicians in an urban infectious diseases hospital in northeast Brazil. We also obtained blood samples from patients hospitalized for diarrhea or AIDS-associated wasting, and we found reduced stavudine and didanosine levels in comparison with outpatients without diarrhea or wasting who had been treated at the same hospital clinic. There was a predominance of the protozoal pathogens Cryptosporidium and Isospora belli, typical opportunistic pathogens of AIDS-infected humans, in the stool samples of inpatients with diarrhea. We conclude that severe diarrhea and wasting in this population is associated with both protozoal pathogens and subtherapeutic levels of antiretroviral medications

Update on Traveler's Diarrhea.

Diarrhea is one of the most common health problems among travelers. Although enterotoxigenic Escherichia coli is implicated most commonly, enteroaggregative E. coli has recently been described as a major pathogen. Shigella, Campylobacter, and Salmonella organisms are less common causes of acute diarrhea, and intestinal protozoa are typical causes of protracted diarrhea. Although education is the mainstay of prevention measures, behavior modification has been shown to be difficult. Chemoprevention is rarely required with the availability of effective treatment, but there has been some interest in the use of vaccines. Maintenance of hydration is most important in children. In addition to bismuth preparations and loperamide, newer agents being developed for symptomatic relief include zaldaride maleate and racecadotril. Fluoroquinolones effectively treat severe traveler's diarrhea, and even a single dose may be sufficient. However, with the emergence of resistance, particularly in Campylobacter infection, other agents are required; interest has focused on azithromycin and rifaximin.