Early infant diagnosis and outcomes in HIV-exposed infants at a central and a district hospital, Northern Malawi.

Setting: Mzuzu Central Hospital (MZCH), Mzuzu, and Chitipa District Hospital (CDH), Chitipa, Malawi. Objective: To compare management and outcomes of human immunodeficiency virus (HIV) exposed infants in early infant diagnosis (EID) programmes at MZCH, where DNA polymerase chain reaction (PCR) testing is performed on site, and CDH, where samples are sent to MZCH, between 2013 and 2014. Design: Retrospective cohort study. Results: Of infants enrolled at MZCH (n = 409) and CDH (n = 176), DNA PCR results were communicated to the children's guardians in respectively 56% and 51% of cases. The median time from sample collection to guardians receiving results was 34 days for MZCH and 56 days for CDH. In both hospitals, only half of the dried blood spot (DBS) samples were collected between 6 and 8 weeks. More guardians from MZCH than CDH received test results within 1 month of sample collection (25% vs. 10%). Among the HIV-positive infants, a higher proportion at MZCH (92%) started antiretroviral therapy than at CDH (46%). The relative risk (RR) of death was higher among infants with late DBS collection (RR 1.3, 95%CI 1.0-1.7) or no collection (RR 5.8, 95%CI 4.6-7.2), and when guardians did not receive test results (RR 8.3, 95%CI 5.7-11.9). Conclusion: EID programmes performed equally poorly at both hospitals, and might be helped by point-of-care DNA PCR testing. Better programme implementation and active follow-up might improve infant outcome and retention in care.

Contexte: Hôpital central Mzuzu (MZCH), Mzuzu, et hôpital de district de Chitipa (CDH), Chitipa, Malawi.Objectif: Comparer la prise en charge et les résultats des nourrissons exposés au virus de l'immunodéficience humaine (VIH) dans les programmes de Diagnostic précoce du nourrisson (EID) au MZCH (test ADN réaction polymérase en chaîne [PCR] fait sur place) et au CDH (échantillons envoyés au MZCH) entre 2013 et 2014.Schéma: Etude rétrospective de cohorteRésultats: Parmi les nourrissons enrôlés au MZCH (n = 409) et au CDH (n = 176), les résultats d'ADN PCR ont été communiqués aux responsables des enfants dans 56% et 51% des cas, respectivement. Le délai médian du recueil de l'échantillon à la réception des résultats par les parents a été de 34 jours pour le MZCH et de 56 jours pour le CDH. Dans les deux hôpitaux, seulement la moitié des échantillons de sang séché (DBS) a été recueillie entre 6 et 8 semaines. Plus de parents du MZCH que du CDH ont reçu les résultats du test dans le mois suivant le recueil de l'échantillon (25% contre 10%). Parmi les nourrissons VIH positifs, une proportion plus élevée au MZCH (92%) a mis en route le traitement antirétroviral comparée au CDH (46%). Le risque relatif de décès a été plus élevé parmi les nourrissons ayant eu un recueil tardif de DBS (RR 1,3 ; IC95% 1,0­1,7) ou pas de recueil (RR 5,8 ; IC95% 4,6­7,2) et quand les parents n'ont pas reçu les résultats du test (RR 8,3 ; IC95% 5,7­11,9).Conclusion: Les programmes d'EID ont été aussi peu performants dans les deux hôpitaux et pourraient être améliorés par la possibilité de réaliser sur place le test PCR ADN. Une meilleure mise en œuvre du programme et un suivi actif pourraient améliorer les résultats pour les nourrissons et leur rétention en soins.

Marco de referencia: El Hospital Central de Mzuzu (MZCH) y el Hospital Distrital de Chitipa (CDH), en Malawi.Objetivo: Comparar el manejo y los desenlaces clínicos de los lactantes expuestos al virus de la inmunodeficiencia humana (VIH) en los programas de diagnóstico temprano del lactante (EID) en el MZCH (realización local de pruebas mediante la reacción en cadena de la polimerasa a partir de ADN [PCR-ADN]) y el CDH (muestras enviadas al MZCH) del 2013 al 2014.Método: Fue este un estudio retrospectivo de cohortes.Resultados: De los lactantes inscritos en el MZCH (n = 409), el resultado de la prueba PCR-ADN se comunicó a la persona encargada del niño en un 56% de los casos; esta proporción fue 51% en los lactantes inscritos en el CDH (n = 176). La mediana del lapso entre la obtención de la muestra y la entrega de los resultados a los encargados fue 34 días en el MZCH y 56 días en el CDH. En ambos hospitales, solo la mitad de las muestras de sangre seca (DBS) se recogió en 6 a 8 semanas. Más tutores de los lactantes en el MZCH que en el CDH recibieron el resultado de la prueba en el primer mes después de haber aportado la muestra (25% contra 10%). De los lactantes con resultado positivo frente al VIH, inició tratamiento antirretrovírico una mayor proporción de los niños atendidos en el MZCH (92%) que en el CDH (46%). El riesgo relativo (RR) de mortalidad fue más alto en los lactantes en quienes se obtuvo la muestra de DBS tardíamente (RR 1,3; IC95% de 1,0 a 1,7), en quienes no se obtuvo (RR 5,8; IC95% de 4,6 a 7,2) y cuando los tutores no recibieron los resultados (RR 8,3; IC95% de 5,7 a 11,9).Conclusión: El desempeño de los programas EID fue igualmente deficiente en ambos hospitales y se podría mejorar con la práctica de la prueba PCR-ADN en el momento de la atención. Una mejor ejecución del programa y un seguimiento activo contribuiría a obtener desenlaces clínicos más favorables en los lactantes y a retenerlos en los servicios de atención.

Outcomes in HIV-infected patients who develop tuberculosis after starting antiretroviral treatment in Malawi.

A retrospective review was conducted of patients starting antiretroviral treatment (ART) at Mzuzu Central Hospital, Malawi, to identify those who developed tuberculosis (TB) within 6 months of commencing ART and document their treatment outcomes. Of 2933 patients, 22 (0.75%) developed active TB, 17 (77%) of whom had commenced ART as a result of unexplained weight loss and/or fever. Of those who developed TB, 41% successfully completed anti-tuberculosis treatment, with lower survival probabilities than patients who did not develop TB. Easier methods are needed to diagnose TB in human immunodeficiency virus-infected patients and to prevent patients from developing TB while on ART.

Outcomes of HIV-infected children with tuberculosis who are started on antiretroviral therapy in Malawi.

SETTING: Mzuzu Central Hospital, in the northern region of Malawi, which provides free antiretroviral therapy (ART) to human immunodeficiency virus (HIV) infected adults and children, including those with tuberculosis (TB). OBJECTIVES: To compare outcomes in HIV-infected children who have been started on ART because of 1) active TB, 2) a past history of TB in the last 2 years and 3) a non-TB diagnosis. DESIGN: Retrospective data collection using ART patient master cards and ART patient registers. RESULTS: Between July 2004 and September 2006, 439 (11%) children of a total 3908 patients were started on ART. There were 29 with active TB, 56 with a past history of TB in the last 2 years and 354 with a non-TB diagnosis. The three groups were similar in nutritional indices and CD4-lymphocyte percentages. The 6-month probability of survival was 0.86 in the active TB group, 0.94 in the past history of TB group and 0.89 in the non-TB group. 12-month survival probability for the same groups was 0.86, 0.86 and 0.88, respectively. CONCLUSION: HIV-infected children with active and previous TB who are started on ART have good outcomes that are similar to those of children started on ART due to a non-TB diagnosis.

Outcomes of tuberculosis patients who start antiretroviral therapy under routine programme conditions in Malawi.

SETTING: Public sector facilities in Malawi providing antiretroviral therapy (ART) to human immunodeficiency virus (HIV) positive patients, including those with tuberculosis (TB). OBJECTIVES: To compare 6-month and 12-month cohort treatment outcomes of HIV-positive TB patients and HIV-positive non-TB patients treated with ART. DESIGN: Retrospective data collection using ART patient master cards and ART patient registers. RESULTS: Between July and September 2005, 7905 patients started ART, 6967 with a non-TB diagnosis and 938 with a diagnosis of active TB. 6-month cohort outcomes of non-TB and TB patients censored on 31 March 2006 showed significantly more TB patients alive and on ART (77%) compared with non-TB patients (71%) (P < 0.001). Between January and March 2005, 4580 patients started ART, 4179 with a non-TB diagnosis and 401 with a diagnosis of active TB. 12-month cohort outcomes of non-TB and TB patients censored on 31 March 2006 showed significantly more TB patients alive and on ART (74%) compared with non-TB patients (66%) (P < 0.001). Other outcomes of default and transfer out were also significantly less frequent in TB compared with non-TB patients. CONCLUSION: HIV-positive TB patients on ART in Malawi have generally good treatment outcomes, and more patients need to access this HIV treatment.