High population frequencies of APOL1 risk variants are associated with increased prevalence of non-diabetic chronic kidney disease in the Igbo people from south-eastern Nigeria.

BACKGROUND: Continental Africa is facing an epidemic of chronic kidney disease (CKD). APOL1 risk variants have been shown to be strongly associated with an increased risk for non-diabetic kidney disease including HIV nephropathy, primary non-monogenic focal and segmental glomerulosclerosis, and hypertension-attributed nephropathy among African ancestry populations in the USA. The world's highest frequencies of APOL1 risk alleles have been reported in West African nations, overlapping regions with a high incidence of CKD and hypertension. One such region is south-eastern Nigeria, and therefore we sought to quantify the association of APOL1 risk alleles with CKD in this region. METHODS: APOL1 risk variants were genotyped in a case-control sample set consisting of non-diabetic, CKD patients (n = 44) and control individuals (n = 43) from Enugu and Abakaliki, Nigeria. RESULTS: We found a high frequency of two APOL1 risk alleles in the general population of Igbo people of south-eastern Nigeria (23.3%). The two APOL1 risk allele frequency in the CKD patient group was 66%. Logistic regression analysis under a recessive inheritance model showed a strong and significant association of APOL1 two-risk alleles with CKD, yielding an odds ratio of 6.4 (unadjusted p = 1.2E-4); following correction for age, gender, HIV and BMI, the odds ratio was 4.8 (adjusted p = 5.1E-03). CONCLUSION: APOL1 risk variants are common in the Igbo population of south-eastern Nigeria, and are also highly associated with non-diabetic CKD in this area. APOL1 may explain the increased prevalence of CKD in this region.

The CURB-65 scoring system in severity assessment of Eastern Nigerian patients with community-acquired pneumonia: a prospective observational study.

BACKGROUND: Community-acquired pneumonia (CAP) is a major cause of morbidity and mortality in Nigeria. Severity assessment is a major starting point in the proper management of CAP. The BTS guideline for managing this condition is simple and does not require sophisticated equipment. Adherence to this guideline will improve CAP management in Nigeria. AIMS: To assess the usefulness of the CURB-65 score in the management of CAP patients in Nigeria and to determine the outcome in relation to the degree of severity using CURB-65. METHODS: A prospective observational study of 80 patients with CAP was carried out in the University of Nigeria Teaching Hospital Enugu, Nigeria from December 2008 to June 2009. The patients were classified into three risk groups and the ability of the CURB-65 score to predict the 30-day mortality rate and the need for ICU admission was determined. RESULTS: Eighty patients were recruited, 39 of whom were men, giving a male to female ratio of 1:1.05. The mean age was 56 ± 18 years. Thirty-seven patients (46.3%) were outpatients, 13 with CURB score 0, 21 with CURB score 1, two with CURB score 2, and one with CURB score 3. Of the 43 patients (53.7%) admitted to hospital, six, 13, 14, and 10 had scores of 4, 3, 2, and 1, respectively. The ICU admission rate was 10%. Twelve patients died, 2.2% in the low-risk group, 12.5% in the intermediate-risk group, and 45% in the high-risk group. CONCLUSIONS: The CURB-65 score is a simple method of assessing and risk stratifying CAP patients. It is particularly useful in a busy emergency department because of its ability to identify a reasonable proportion of low-risk patients for potential outpatient care.

Effect of dolutegravir-based drug combinations on the level of medication adherence and viral load among adolescents living with HIV in resource-limited setting: a pre-post design.

OBJECTIVES: The use of antiretroviral drugs among HIV-infected adolescents has been challenged with poor medication adherence, leading to an unsuppressed viral load and ultimately to drug resistance. Recently, dolutegravir has been approved for use in adolescents with HIV, but the evidence on medication adherence and viral load suppression is limited. The study determined the effect of dolutegravir-based drug regimens on the level of medication adherence and viral load among treatment-experienced adolescents. METHODS: A longitudinal pre-post design study was done among adolescents living with HIV at a paediatrics clinic in Nigeria. Assessment of medication adherence and viral load testing was done before and at six months of transitioning to dolutegravir-based regimens. McNemar-chi-square was used to determine the effectiveness of the drug on adherence and viral load suppression. Multivariate logistic regression analysis was performed to determine the predictors of drug adherence and viral suppression. RESULTS: The mean age of the participants was 14.7 years (SD=3.2), and 53.3 % were males. The mean duration of ART use was 10.3 years (SD=3.2). Six months after transitioning to dolutegravir, there was a significant decrease in viral load (Z=-7.947, p<0.001) and an increase in medication adherence score (Z=-7.554, p<0.001), among the treatment-experienced adolescents. Viral suppression was 13 times higher among respondents with good medication adherence as compared to those with poor medication adherence (AOR=13.24, CI=3.25-53.90). CONCLUSIONS: Dolutegravir is effective in improving medication adherence and viral suppression among Adolescents living with HIV. Thus, the need to transition eligible adolescents to dolutegravir to sustain better treatment outcomes.

Effect of Sickle Cell Trait on Human Immunodeficiency Virus Type 1 Infection.

Introduction: Whereas several studies show that homozygous (HbSS) sickle cell disease protects against human immunodeficiency virus infection, it is not clear if human immunodeficiency virus infection is affected by the heterozygous state of the sickle globin gene (HbAS or sickle cell trait). Objective: To evaluate the effects of sickle cell trait on the prevalence and severity of human immunodeficiency virus type 1 infection in a large patient population. Methods: Hemoglobin genotype was determined by high performance liquid chromatography (HPLC) in 1,226 HIV-1 patients in Nigeria. Their demographic data were documented. Blood CD4+ cell counts and HIV-1 viral load previously determined on the same blood samples to guide clinical care were used as indices of severity of HIV-1 infection. Statistical analysis of the data was done to evaluate the effects of sickle cell trait on the severity and prevalence of HIV-1 infection, relative to the prevalence of 1.4% in the general population of Nigeria. Results and Discussion: The distribution of hemoglobin genotypes among the HIV-1 patients was comparable to that in the general population of Nigeria (Chi-squared statistic =1.025; p value = 0.31, not significant). Neither viral load (p = 0.32) nor blood CD4+ cell count (p = 0.30) was significantly different between all HbAS versus all HbAA patients. There was a trend towards lower viral load in females and a significant interaction between gender and HbAS for viral load (P = 0.018), suggesting that sickle cell trait might be associated with the severity of HIV-1 infection in females. Conclusion: The findings suggest that sickle cell trait might be associated with severity of HIV-1 infection in female, but not all, patients. Larger, prospective studies are required to further investigate the effect of sickle cell trait on HIV-1 infection.

Examining catastrophic costs and benefit incidence of subsidized antiretroviral treatment (ART) programme in south-east Nigeria.

OBJECTIVES: To examine the extent to which costs of subsidized antiretrovirals treatment (ART) programmes are catastrophic and the benefit incidence that accrues to different population groups. METHODS: Data on expenditures to patients for receiving treatment from a government subsidized ART clinic was collected using a questionnaire. The patient costs excluded time and other indirect costs. Catastrophic cost was determined as the percentage of total expenditure on ART treatment as a proportion of household non-food expenditures on essential items. RESULTS: On average, patients spent 990 Naira (US$ 8.3) on antiretroviral (ARV) drugs per month. They also spent an average of $8.2 on other drugs per month. However, people that bought ARV drugs from elsewhere other than the ART clinic spent an average of $88.8 per month. Patients spent an average of $95.1 on laboratory tests per month. Subsidized ARV drugs depleted 9.8% of total household expenditure, other drugs (e.g. for opportunistic infections) depleted 9.7%, ARV drugs from elsewhere depleted 105%, investigations depleted 112.9% and total expenditure depleted 243.2%. The level of catastrophe was generally more with females, rural dwellers and most poor patients. Females and urbanites had more benefit incidence than males and rural dwellers. CONCLUSION: Subsidized ART programme lowers the cost of ARV drugs but other major costs are still incurred, which make the overall cost of accessing and consuming ART treatment to be excessive and catastrophic. The costs of laboratory tests and other drugs should be subsidized and there should also be targeting of ART programme to ensure that more rural dwellers and the most-poor people have increased benefit incidence.

Effectiveness of a Comprehensive 4-Week Course in HIV Medicine for Postgraduate Doctors at University of Nigeria: A Preservice Education Initiative.

There is a critical shortage of trained human immunodeficiency virus (HIV) providers in resource-limited settings. To strengthen preservice HIV training for postgraduate health care providers, University of Maryland's Institute of Human Virology and Center for Clinical Care and Research Nigeria collaborated with University of Nigeria to plan and implement a comprehensive 4-week course in HIV medicine. The first course was piloted with 30 postgraduate doctors. Mean objective structured clinical examinations (OSCE), pretest, and posttest scores score were 51%, 53%, and 75%, respectively; follow-up examination at 6 months showed mean score of 74%. In multivariate regression analysis, pretest score was positively associated with posttest score (22.03, P < .001) and OSCE (0.29, P = .04), age negatively associated with pretest score (-0.94, P = .001), and female gender positively associated with OSCE score (6.15, P = .05). Six- and 18-month online surveys revealed trainees continued to apply knowledge and skills gained. North-south university collaborations to develop practicum-based preservice curricula offer a sustainable way to strengthen preservice evidence-based HIV medicine training with long-lasting retention of skills and knowledge.

Comparison of calculated versus directly-measured low-density lipoprotein-cholesterol: An evaluation of ten formulas for an HIV-positive population in Sub-Saharan Africa.

BACKGROUND: Low-density lipoprotein cholesterol (LDLC) is a modifiable risk factor for atherosclerotic cardiovascular disease, therefore needs to be assessed and monitored. Direct homogeneous assays and various formulas exist to determine LDLC. We aimed to compare the directly measured LDL (dLDLC) with ten formulas for estimating LDLC. MATERIALS AND METHODS: This was a 2-year retrospective study of fasting lipid profile results obtained from HIV-positive patients attending an outpatient clinic at the University of Nigeria Teaching Hospital, Enugu, Nigeria, using homogeneous direct assays. Estimated LDLC was determined using ten formulas. Pearson's correlation, Bland-Altman plots, and linear regression were performed. Statistical significance was P < 0.05. RESULTS: Three thousand four hundred and eighty-two lipid results with mean ± standard deviation (SD) dLDLC of 2.1 ± 1.1 mmol/L were included in this study. There was a strong, positive correlation between Friedewald's LDLC and dLDLC n = 3412, r = 0.84, P < 0.001, but linear regression demonstrated a proportional bias P = 0.005. Ahmadi's equation showed the worst correlation n = 3482, r = 0.35, P < 0.001, but when applied to samples with triglyceride (TG) <1.13 mmol/L (100 mg/dl), the correlation showed a strong, positive relationship n = 1395, r = 0.80, P < 0.001, and no proportional bias P = 0.86. Teerankanchana's equation was the only formula that showed no difference between its LDLC and dLDLC (n = 3482, P = 0.056). It also demonstrated strong, positive correlation (n = 3482, r = 0.84, P < 0.001) and had a mean difference ± SD of -0.68 ± 0.63. CONCLUSION: Teerankanchana's formula showed good correlation and minimal bias with dLDLC at all TG levels. Moreover, linear regression showed no difference in the two. It seems to be the most suitable formula for estimating LDLC in our HIV-positive population.

Brief Report: Geographical Variation in Prevalence of Cryptococcal Antigenemia Among HIV-Infected, Treatment-Naive Patients in Nigeria: A Multicenter Cross-Sectional Study.

OBJECTIVE: Worldwide, HIV-associated cryptococcal meningitis affects approximately 1 million persons and causes 600,000 deaths each year mostly in sub-Saharan Africa. Limited data exist on cryptococcal meningitis and antigenemia in Nigeria, and most studies are geographically restricted. We determined the prevalence of cryptococcal antigenemia (CrAg) among HIV-infected, treatment-naive individuals in Nigeria. DESIGN/METHODS: This was a retrospective, cross-sectional study across 4 geographic regions in Nigeria. We performed CrAg testing using a lateral flow immunoassay on archived whole-blood samples collected from HIV-infected participants at US President's Emergency Plan for AIDS Relief (PEPFAR)-supported sites selected to represent the major geographical and ethnic diversity in Nigeria. Eligible samples were collected from consenting patients (>15 years) naive to antiretroviral therapy with CD4 count less than 200 cells per cubic millimeter and were stored in an -80°C freezer. RESULTS: A total of 2752 stored blood samples were retrospectively screened for CrAg. Most of the samples were from participants aged 30-44 years (57.6%), and 1570 (57.1%) were from women. The prevalence of CrAg positivity in specimens with CD4 <200 cells per cubic millimeter was 2.3% (95% confidence interval: 1.8% to 3.0%) and varied significantly across the 4 regions (P < 0.001). At 4.4% (3.2% to 5.9%), the South East contained the highest prevalence. CONCLUSIONS: The significant regional variation in CrAg prevalence found in Nigeria should be taken into consideration as plans are made to integrate routine screening into clinical care for HIV-infected patients.

Atherogenic index of plasma in highly active antiretroviral therapy-naïve patients with human immunodeficiency virus infection in Southeast Nigeria.

INTRODUCTION: Metabolic abnormalities are often common among human immunodeficiency virus (HIV) patients. The atherogenic index of plasma (AIP) is increasingly being used as a screening tool for dyslipidemia as it predicts the presence of small, dense, and highly atherogenic low density lipoprotein (LDL) and high density lipoprotein (HDL) particles. The aim of this study was to identify the pattern and predictors of an abnormal atherogenic index in highly active antiretroviral therapy (HAART)-naïve HIV patients. MATERIALS AND METHODS: HAART-naïve patients with HIV infection were recruited for this cross-sectional study. Anthropometric indices, blood pressure, CD4 count, viral load, fasting blood glucose, and lipid profiles were determined. Total cholesterol (TCH)/HDL, triglyceride (TG)/HDL, and LDL/HDL ratios were calculated. The AIP was calculated as log (TG/HDL). The correlations between AIP and the other lipoprotein ratios and predictors of AIP were determined using stepwise multiple linear regression. P < 0.05 was considered as significant. RESULTS: A total of 353 patients with a mean age of 37.3 (9.6) years were recruited for this study. Low HDL level was the most common abnormality in 222 (62.9%) patients while elevated TCH was seen in 54 (15.3%) patients. Those with medium risk (AIP 0.1-0.24) and high risk category (AIP > 0.24) constituted up to 226 (64%) of the patients. There were significant correlations between AIP and CD4 count, body mass index, LDL, TCH/HDL, and LDL/HDL. Predictors of AIP were CD4 count, TCH/HDL, and LDL/HDL. CONCLUSION: Abnormal AIP is frequent in HAART-naïve HIV patients and is inversely related to their level of immunity. We recommend that AIP estimation should be part of baseline assessment of HIV patients before the commencement of therapy.

Physiotherapy intervention as a complementary treatment for people living with HIV/AIDS.

BACKGROUND: The advent of highly active antiretroviral therapy has dramatically extended the life expectancy of people living with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome. Despite this increased longevity, HIV disease and its pharmacological treatment can cause long-term and acute health complications, many of which can be treated successfully by physiotherapy. The purpose of this paper is to report the effect of a 12-week rehabilitation program on several health-related markers in a 43-year-old woman living with HIV. METHODS: This case study examined the effect of a 12-week exercise and manual therapy intervention on morphology, pain, cardiopulmonary fitness, strength, neurological balance, immune markers (CD4 cell count), and quality of life in a 43-year-old woman living with HIV. RESULTS: The results showed complete elimination of pain and shortness of breath on exertion. There was also a reduction in resting heart rate, waist circumference, exercise duration, muscle strength, and endurance. The patient showed an increase in peak expiratory flow rate, maximal heart rate attained, upper arm, forearm, and thigh circumference, and CD4+ cell count. The patient also showed improvements in the quality of life domains of general health, pain, energy/fatigue, social and physical functioning, and emotional well-being. CONCLUSION: Physiotherapy interventions consisting of exercise and manual therapy appear beneficial in several areas as an adjunct therapy in HIV management.

Enhancement of health research capacity in Nigeria through north-south and in-country partnerships.

Research productivity in Sub-Saharan Africa has the potential to affect teaching, student quality, faculty career development, and translational country-relevant research as it has in developed countries. Nigeria is the most populous country in Africa, with an academic infrastructure that includes 129 universities and 45 medical schools; however, despite the size, the country has unacceptably poor health status indicators. To further develop the research infrastructure in Nigeria, faculty and research career development topics were identified within the six Nigerian universities of the nine institutions of the Medical Education Partnership Initiative in Nigeria (MEPIN) consortium. The consortium identified a training model that incorporated multi-institutional "train-the-trainers" programs at the University of Ibadan, followed by replication at the other MEPIN universities. More than 140 in-country trainers subsequently presented nine courses to more than 1,600 faculty, graduate students, and resident doctors throughout the consortium during the program's first three years (2011-2013). This model has fostered a new era of collaboration among the major Nigerian research universities, which now have increased capacity for collaborative research initiatives and improved research output. These changes, in turn, have the potential to improve the nation's health outcomes.

Profile of HIV-infected patients receiving second-line antiretroviral therapy in a resource-limited setting in Nigeria.

BACKGROUND: Second-line antiretroviral therapy (ART) accounts for less than 5% of total ART in resource-limited settings. We described the baseline characteristics, reasons for switch and treatment outcomes of Nigerian patients receiving second-line ART. METHODS: In this retrospective cohort study we recorded the baseline characteristics of HIV-infected adults whose treatment regimen was switched from a non-nucleoside reverse transcriptase inhibitor, a first-line agent, to a protease inhibitor-based second-line regimen. The duration of follow-up was 12 months. RESULTS: Of 4229 patients who started first-line therapy, 186 (4.4%) were switched to second-line therapy after a mean duration of 16.6 ± 7.6 months. Their mean age was 41.8 ± 9.6 years and 59.1% were women. The median (range) viral load and CD4 cell counts at switch were 4.7 (4.1-6.3) log10 copies/ml and 71 (6-610) cells/µl, respectively. The predominant reason for switch was virological failure (79.0%). Only 55.4% and 36.6% of patients had CD4 cell count and viral load at 12 months. About 82%, 79% and 82% of patients with available data achieved virological suppression at 3 months, 6 months and 12 months respectively (p = 0.81). The proportion of patients who achieved ≥50% rise in CD4 cell count increased from 55.8% at 3 months to 78.6% at 12 months (p = 0.0002). CONCLUSION: The rate of switch to second-line therapy was low but there were good treatment outcomes among patients with available data. Attrition rate was high. Regular viral load monitoring, improved availability/affordability of second-line regimens and retention in care should become priorities in resource-limited settings.

Baseline Renal Function among Antiretroviral Therapy-Naive, HIV-Infected Patients in South East Nigeria.

Background:Renal insufficiency has been shown to be a significant, independent risk factor for mortality among HIV-infected patients. Unfortunately, little is known about the prevalence and nature of renal impairment in African populations initiating antiretroviral treatment. This study aims to find the prevalence of abnormal renal function among antiretroviral therapy (ART)-naive, HIV-infected patients in the South Eastern geopolitical zone of Nigeria.Method:This is a cross-sectional hospital-based study, involving 300 ART-naive HIV-positive patients, seen over a 1-year period, aged from 18 years and older, presenting to the clinic for the first time.Results:A total of 300 patients were included in the study, 104 (34.7%) males and 196 (65.3%) females. The prevalence of significant renal disease was 24.3% (73 of 300), while 38.3% (115 of 300) had mild renal impairment. Using logistic regression, age, CD4 count, urea, creatinine, and hemoglobin were significantly associated with renal impairment.Conclusion:The authors observed a high prevalence of significant renal impairment among HIV-infected patients at the time of ART initiation.

HIV Postexposure Prophylaxis (PEP) in a Nigerian Tertiary Health Institution.

BACKGROUND: Use of PEP drugs is useful in preventing seroconversion following accidental occupational or nonoccupational exposures, thereby limiting further spread of HIV. OBJECTIVE: This study aims to evaluate the clinicodemographic characteristics of patients accessing PEP services in a tertiary health institution. STUDY DESIGN: This was a retrospective review of patients who obtained postexposure prophylaxis from the HIV clinic of a University Teaching Hospital in Nigeria. RESULTS: A total of 116 clients sought for PEP services during the study period. The commonest setting of exposure was needle injury (44.8%). Half of the clients presented within 24 hours following exposure. Being a male and knowing HIV status of source patient independently increased the likelihood of early presentation following exposure (P < .05). None of the patients that obtained the PEP drugs came for follow-up visits. Conclusion/Recommendation: Late presentation for PEP services following exposure means that more awareness needs to be created to facilitate early presentation.