Effect of cotrimoxazole prophylaxis on malaria occurrence in HIV-infected patients on antiretroviral therapy in sub-Saharan Africa.

OBJECTIVE: To systematically review the evidence on the effect of cotrimoxazole (CTX) on malaria in HIV-positive individuals on antiretroviral therapy (ART). METHODS: Web of Science, PubMed and MEDLINE, EMBASE, Global Health and Cochrane Library databases were searched using terms for malaria, HIV and CTX. Studies meeting the inclusion criteria were reviewed and assessed for bias and confounding. RESULTS: Six studies (in Uganda, Kenya, Malawi, Zambia and Zimbabwe) had relevant data on the effect of CTX on malaria in patients on ART: four were observational cohort studies (OCS) and two were randomised controlled trials (RCTs); two were in children and one in women only. Samples sizes ranged from 265 to 2200 patients. Four studies compared patients on ART and CTX with patients on ART alone; 2 (RCTs) found a significant increase in smear-positive malaria on ART alone: (IRR 32.5 CI = 8.6-275.0 and HR 2.2 CI = 1.5-3.3) and 2 (OCS) reported fewer parasitaemia episodes on CTX and ART (OR 0.85 CI = 0.65-1.11 and 3.6% vs. 2.4% of samples P = 0.14). One OCS found a 76% (95% CI = 63-84%) vs. 83% (95% CI = 74-89%) reduction in malaria incidence in children on CTX and ART vs. on CTX only, when both were compared with HIV-negative children. The other reported a 64% reduction in malaria incidence after adding ART to CTX (RR = 0.36, 95% CI = 0.18-0.74). The 2 RCTs were unblinded. Only one study reported adherence to CTX and ART, and only two controlled for baseline CD4 count. CONCLUSION: Few studies have investigated the effect of CTX on malaria in patients on ART. Their findings suggest that CTX is protective against malaria even among patients on ART.

Early Alcohol Use and Problem Drinking among Students in Zambia and Uganda

Excessive alcohol use is a serious public health concern worldwide; but less attention has been given to the prevalence; risk and protective factors; and consequences of early alcohol use in low-income; developing countries.The purpose of this study was to determine the associations between early alcohol use; before age 13; and problem drinking among adolescents in Uganda and Zambia. Data from students in Zambia (n=2257; 2004) and Uganda (n=3215; 2003) were obtained from the cross-sectional Global School-Based Student Health Survey (GSHS). The self-administered questionnaires were completed by students primarily 13 to 16 years of age. Multiple statistical models were computed using logistic regression analyses to test the associations between early alcohol initiation and problem drinking; while controlling for possible confounding factors (e.g.; current alcohol use; bullying victimization; sadness; lack of friends; missing school; lack of parental monitoring; and drug use). Results show that early alcohol initiation was associated with problem drinking in both Zambia (AOR=1.28; 95CI:1.02-1.61) and Uganda (AOR=1.48; 95CI: 1.11- 1.98) among youth after controlling for demographic characteristics; risky behaviors; and other possible confounders.The study shows that there is a significant association between alcohol initiation before 13 years of age and problem drinking among youth in these two countries. These findings underscore the need for interventions and strict alcohol controls as an important policy strategy for reducing alcohol use and its dire consequences among vulnerable youth

Routine versus clinically driven laboratory monitoring of HIV antiretroviral therapy in Africa (DART): a randomised non-inferiority trial.

BACKGROUND: HIV antiretroviral therapy (ART) is often managed without routine laboratory monitoring in Africa; however, the effect of this approach is unknown. This trial investigated whether routine toxicity and efficacy monitoring of HIV-infected patients receiving ART had an important long-term effect on clinical outcomes in Africa. METHODS: In this open, non-inferiority trial in three centres in Uganda and one in Zimbabwe, 3321 symptomatic, ART-naive, HIV-infected adults with CD4 counts less than 200 cells per microL starting ART were randomly assigned to laboratory and clinical monitoring (LCM; n=1659) or clinically driven monitoring (CDM; n=1662) by a computer-generated list. Haematology, biochemistry, and CD4-cell counts were done every 12 weeks. In the LCM group, results were available to clinicians; in the CDM group, results (apart from CD4-cell count) could be requested if clinically indicated and grade 4 toxicities were available. Participants switched to second-line ART after new or recurrent WHO stage 4 events in both groups, or CD4 count less than 100 cells per microL (LCM only). Co-primary endpoints were new WHO stage 4 HIV events or death, and serious adverse events. Non-inferiority was defined as the upper 95% confidence limit for the hazard ratio (HR) for new WHO stage 4 events or death being no greater than 1.18. Analyses were by intention to treat. This study is registered, number ISRCTN13968779. FINDINGS: Two participants assigned to CDM and three to LCM were excluded from analyses. 5-year survival was 87% (95% CI 85-88) in the CDM group and 90% (88-91) in the LCM group, and 122 (7%) and 112 (7%) participants, respectively, were lost to follow-up over median 4.9 years' follow-up. 459 (28%) participants receiving CDM versus 356 (21%) LCM had a new WHO stage 4 event or died (6.94 [95% CI 6.33-7.60] vs 5.24 [4.72-5.81] per 100 person-years; absolute difference 1.70 per 100 person-years [0.87-2.54]; HR 1.31 [1.14-1.51]; p=0.0001). Differences in disease progression occurred from the third year on ART, whereas higher rates of switch to second-line treatment occurred in LCM from the second year. 283 (17%) participants receiving CDM versus 260 (16%) LCM had a new serious adverse event (HR 1.12 [0.94-1.32]; p=0.19), with anaemia the most common (76 vs 61 cases). INTERPRETATION: ART can be delivered safely without routine laboratory monitoring for toxic effects, but differences in disease progression suggest a role for monitoring of CD4-cell count from the second year of ART to guide the switch to second-line treatment. FUNDING: UK Medical Research Council, the UK Department for International Development, the Rockefeller Foundation, GlaxoSmithKline, Gilead Sciences, Boehringer-Ingelheim, and Abbott Laboratories.

HIV Risk Behaviour among Street Children Attending U.Y.D.E.L Clinic in Bakuli - Kampala

Introduction: A study was undertaken to investigate the nature; pattern and correlates of high HIV risk behaviour among street children attending the Uganda Youth Development Link (U.Y.D.E.L) Clinic in Bakuli; Kampala. Methodology: A total of 136 street children were consecutively interviewed with a semi-structured questionnaire. This instrument contained; socio-demographic variables; reasons for leaving home; nature of street childr career; previous attempts at resettlement; substance abuse behaviour; knowledge and attitudes about HIV/AIDS; high HIV risk behaviour and medical illness. Data analysis was undertaken using EPI-Info statistical package 6.0; this involved generating frequencies and frequency tables. Results: Most of the street children seen were male 129(94.8) with a male to female ratio of 18:1 and were largely 130(95.6) between the ages of 10-19 years of age. Mistreatment 66(48.5) and poverty leading to premature discontinuation of formal education 62(52.6) appears to be the main social factors underlying the decision to opt for the street. Substance abuse behaviour was reported 99(72.8) with the following substances abused; aviation fuel (tina) 90(66.2); cigarettes 31(22.8); marijuana 21(15.4); khat 14(10.3) and alcohol 11(8.1). Some of the children 20(20.2) abused more than one substance. Perceived causes of HIV/AIDS as reported by the children included organism 111(81.6) but 25(18.9) did not know the cause or reporting a wrong answer. For the perceived mode of transmission of HIV/AIDS; 105(77.2) correctly reported sex; 31(22.8) reported infected needles 29(21.3) blood transfusion and 10(7.4) mother to baby. The misperceived ideas about HIV transmission included; sharing food/drink 7(5.1) and hand shake 4(2.9) with 15(11) reporting ignorance about mode of transmission of HIV/AIDS. The majority of street children 100(73.5) were not sexually active. But those who were sexually active 36(26.5) displayed high HIV risk behaviour with; 27(58.3) reporting unprotected sex; 4(11.1) sex for money; 2(5.6) having suffered genital ulcers/discharge 2(5.6) multiple sexual partners. Only 6(16.6) reported regular use of a condom with 1(2.8) having taken an HIV test before. Conclusions and REcommendations: There is need for the design and development of HIV/AIDS awareness programmes that specifically target street children. These programmes need to address the deficits in knowledge and the small but high HIV risk group of sexually active children