Etiology of Persistent Microalbuminuria in Nigeria (P_MICRO study): protocol and study design.

BACKGROUND: Microalbuminuria is an independent risk factor for cardiovascular and kidney disease and a predictor of end organ damage, both in the general population and in persons with HIV (PWH). Microalbuminuria is also an important risk factor for mortality in PWH treated with antiretroviral therapy (ART). In the ongoing Renal Risk Reduction (R3) study in Nigeria, we identified a high prevalence of microalbuminuria confirmed by two measurements 4-8 weeks apart in ART-experienced, virologically suppressed PWH. Although Stage 1 or 2 hypertension and exposure to potentially nephrotoxic antiretroviral medications were common in R3 participants, other traditional risk factors for albuminuria and kidney disease, including diabetes, APOL1 high-risk genotype, and smoking were rare. Co-infection with endemic pathogens may also be significant contributors to albuminuria, but co-infections were not evaluated in the R3 study population. METHODS: In Aim 1, we will cross-sectionally compare the prevalence of albuminuria and established kidney disease risk factors in a cohort of PWH to age- and sex-matched HIV-negative adults presenting for routine care at the Aminu Kano Teaching Hospital in Kano, Nigeria. We will leverage stored specimens from 2500 R3 participants and enroll an additional 500 PLWH recently initiated on ART (≤ 24 months) and 750 age- and sex-matched HIV-negative adults to determine the contribution of HIV, hypertension, and other comorbid medical conditions to prevalent albuminuria. In Aim 2, we will follow a cohort of 1000 HIV-positive, ART-treated and 500 HIV-negative normoalbuminuric adults for 30 months to evaluate the incidence and predictors of albuminuria. DISCUSSION: The findings from this study will support the development of interventions to prevent or address microalbuminuria in PWH to reduce kidney and cardiovascular morbidity and mortality. Such interventions might include more intensive monitoring and treatment of traditional risk factors, the provision of renin-angiotensin aldosterone system or sodium-glucose cotransporter-2 inhibitors, consideration of changes in ART regimen, and screening and treatment for relevant co-infections.

Differences in obstetric practices and outcomes of postpartum hemorrhage across Nigerian health facilities.

OBJECTIVE: To explore differences in obstetric practices and clinical outcomes of postpartum hemorrhage (PPH) in Nigerian facilities. METHODS: A descriptive cross-sectional study of public health facilities providing maternal healthcare services in Nigeria. Surveys were conducted across 38 purposively sampled facilities (January 2020-March 2021) to collect information on obstetric practices related to the management of the third stage of labor, treatment of postpartum hemorrhage, and clinical outcomes related to postpartum hemorrhage in the preceding 12 months. RESULTS: The median number of annual births per facility was 2230 (IQR, 1952-3283). The cesarean section rate was 21.6% (range 2.1%-52.6%). There was large variability in PPH rate (median 3%, range 0.4%-16.8%) and blood transfusions for PPH (median 2.8%, range 0.4%-48.6%) after vaginal birth. There was less variability for laparotomies (median 0.25%, range 0%-2.8%) and maternal deaths (median 0.11%, range 0%-0.64%) due to PPH after vaginal birth. The number of maternal deaths from all causes varied (median 0.27%, range 0%-3.5%). The rates of PPH and adverse maternal outcomes did not vary substantially between state or federal facilities, region, type of facility, and the number of clinical staff. CONCLUSION: Across the Nigerian facilities surveyed there was large variation in PPH rates and adverse maternal outcomes due to PPH. This variability remains largely unexplained and requires further insights and detailed data to gain a deeper understanding of the root causes and challenges to implement customized solutions to improve maternal outcomes.

Rapid, Cheap, and Effective COVID-19 Diagnostics for Africa.

BACKGROUND: Although comprehensive public health measures such as mass quarantine have been taken internationally, this has generally been ineffective, leading to a high infection and mortality rate. Despite the fact that the COVID-19 pandemic has been downgraded to epidemic status in many countries, the real number of infections is unknown, particularly in low-income countries. However, precision shielding is used in COVID-19 management, and requires estimates of mass infection in key groups. As a result, rapid tests for the virus could be a useful screening tool for asymptomatic virus shedders who are about to come into contact with sensitive groups. In Africa and other low- and middle-income countries there is high rate of COVID-19 under-diagnosis, due to the high cost of molecular assays. Exploring alternate assays to the reverse transcriptase polymerase chain reaction (RT-PCR) for COVID-19 diagnosis is highly warranted. AIM: This review explored the feasibility of using alternate molecular, rapid antigen, and serological diagnostic assays to accurately and precisely diagnose COVID-19 in African populations, and to mitigate severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RT-PCR diagnostic challenges in Africa. METHOD: We reviewed publications from internet sources and searched for appropriate documents available in English. This included Medline, Google Scholar, and Ajol. We included primary literature and some review articles that presented knowledge on the current trends on SARS-CoV-2 diagnostics in Africa and globally. RESULTS: Based on our analysis, we highlight the utility of four different alternatives to RT-PCR. These include two isothermal nucleic acid amplification assays (loop-mediated isothermal amplification (LAMP) and recombinase polymerase amplification (RPA)), rapid antigen testing, and antibody testing for tackling difficulties posed by SARS-CoV-2 RT-PCR testing in Africa. CONCLUSION: The economic burden associated COVID-19 mass testing by RT-PCR will be difficult for low-income nations to meet. We provide evidence for the utility and deployment of these alternate testing methods in Africa and other LMICs.

HIV-associated nephropathy: Protocol and rationale for an exploratory genotype-phenotype study in a sub-Saharan African population.

BACKGROUND: HIV-positive persons of African descent are disproportionately affected by chronic kidney disease (CKD). Deterioration to end-stage kidney disease (ESKD) also occurs in this population at a higher frequency. There remains a lot to learn about the genetic susceptibility to CKD in HIV positive patients, and the pathophysiology of progression to ESKD. OBJECTIVES: We will conduct an exploratory genotype-phenotype study in HIV-positive persons with CKD in Aminu Kano Teaching Hospital, Nigeria, to determine blood-based differential gene expression biomarkers in different kidney risk groups according to the KDIGO 2012 criteria. METHODS: We will consecutively screen 150 HIV-positive adults (≥18 years of age) attending the HIV clinic of Aminu Kano Teaching Hospital, Kano, Nigeria, for CKD based on proteinuria and elevation of estimated glomerular filtration rate. Among these, two separate groups of 16 eligible participants each (n = 32) will be selected in the four (4) KDIGO 2012 kidney risk categories. The groups will be matched for age, sex, viral suppression level and antiretroviral (ARV) regimen. In the first group (n = 16), we will determine differential gene expression markers in peripheral blood mononuclear cells using mRNA-sequencing (RNA-Seq). We will validate the differential expression markers in the second group (n = 16) using reverse transcription quantitative polymerase chain reaction (RT-qPCR). Using a systems-based approach, we will construct, visualize and analyze gene-gene interaction networks to determine the potential biological roles of identified differential expression markers based on published literature and publicly available databases. RESULTS: Our exploratory study will provide valuable information on the potential roles of differential expression biomarkers in the pathophysiology of HIV-associated kidney disease by identifying novel biomarkers in different risk categories of CKD in a sub-Saharan African population. The results of this study will provide the basis for population-based genome-wide association studies to guide future personalized medicine approaches. CONCLUSION: Validated biomarkers can be potential targets for the development of stage-specific therapeutic interventions, an essential paradigm in precision medicine.

COVID 19: Evaluating the Knowledge, Attitude and Preventive Practices of Healthcare Workers in Northern Nigeria.

BACKGROUND: Although much is known about the rapidly spreading COVID-19 disease, a lot of knowledge is still evolving. The knowledge, attitude and practice (KAP) of healthcare workers (HCWs) towards COVID-19 remain key in protecting themselves and in fighting the "war" against the disease. This study assessed the KAP of HCWs in Kano, northern Nigeria. METHODOLOGY: A cross-section of different cadre of healthcare workers was recruited online via google forms. Using a link, the participants completed an adapted from a similar study, pre-tested questionnaire on KAP regarding COVID-19. Predictors of KAP were assessed using logistic regression modelling. RESULTS: Among the 651 HCWs invited to participate, 233 respondents responded giving a response rate of 35.8%. Of these, 195 (83.7%) had good knowledge, 183 (78.9%) had a positive attitude and 180 (77.6%) had good practice towards prevention of COVID-19. The odds of having good knowledge were significantly lower among Community Health Officers/Community Health Extension workers (aOR=0.2, 95% CI: 0.1-0.6;p<0.001) and other health workers compared to doctors. Positive attitude was predicted by good knowledge (aOR=4.8, 95% CI:1.7-010.2;p=0.003), being in the fifth decade of life (aOR=5.5, 95% CI: 1.1-29.3, p=0.04), female gender (aOR=3.0, 95% CI: 1.1-8.3;p=0.04), Christian faith (aOR=7.0, 95% CI: 1.3-40.4; p=0.03), and having a bachelors' or medical degree (aOR=4.6, 95% CI: 1.3-16.5).The only predictor of good practice was good knowledge on COVID-19 (aOR=7.8, 95% CI 2.8-12.4;p<0.001). CONCLUSION AND GLOBAL HEALTH IMPLICATIONS: Majority of the HCWs at the study site have good knowledge, attitude and practice regarding COVID-19. Continuous dissemination of information on prevention of spread of COVID-19 to all HCWs will strengthen the health workforce in the fight against it.

Societal awareness on neonatal hyperbilirubinemia: A systematic review and meta-analysis.

Early recognition of neonatal hyperbilirubinemia is essential for prevention of bilirubin neurotoxicity and its long-term sequelae. High rates of home delivery in low- and middle-income countries (LMICs) as well as early discharge post-delivery (within 24hours) make community surveillance for neonatal hyperbilirubinemia highly important. Here, we performed a literature review to estimate the level of societal awareness of neonatal hyperbilirubinemia. We searched several databases for studies assessing the knowledge and awareness of neonatal hyperbilirubinemia. We retrieved 211 citations from 206 databases with five being in the grey literature. 52 selected articles were further reviewed. Data from these studies were then analyzed using Stata software (Statacorp® LLC Texas USA). We found that the pooled estimate of societal awareness of neonatal hyperbilirubinemia was 67% (95% confidence interval [CI]: 60, 74). There however was a publication bias (Begg test: P ≤ 0.01; Egger P = 0.06). Studies that scored or graded knowledge reported lower estimates [adjusted odds ratio (aOR) = -0.17; 95% CI: -0.32-0.02; P = 0.03]. Hospital location was an important determinant of awareness of complications [aOR = 0.30; 95% CI: 0.30-0.57; P = 0.03]. We therefore concluded that there is a significant need to improve societal awareness of neonatal hyperbilirubinemia.

SCOR: A secure international informatics infrastructure to investigate COVID-19.

Global pandemics call for large and diverse healthcare data to study various risk factors, treatment options, and disease progression patterns. Despite the enormous efforts of many large data consortium initiatives, scientific community still lacks a secure and privacy-preserving infrastructure to support auditable data sharing and facilitate automated and legally compliant federated analysis on an international scale. Existing health informatics systems do not incorporate the latest progress in modern security and federated machine learning algorithms, which are poised to offer solutions. An international group of passionate researchers came together with a joint mission to solve the problem with our finest models and tools. The SCOR Consortium has developed a ready-to-deploy secure infrastructure using world-class privacy and security technologies to reconcile the privacy/utility conflicts. We hope our effort will make a change and accelerate research in future pandemics with broad and diverse samples on an international scale.

Determinants of mortality among patients with drug-resistant tuberculosis in northern Nigeria.

BACKGROUND: Drug-Resistant tuberculosis (DR-TB) is estimated to cause about 10% of all TB related deaths. There is dearth of data on determinants of DR-TB mortality in Nigeria. Death among DR-TB treated cohorts in Nigeria from 2010 to 2013 was 30%, 29%, 15% and 13% respectively. Our objective was to identify factors affecting survival among DR-TB patients in northern Nigeria. METHODS: Demographic and clinical data of all DR-TB patients enrolled in Kano, Katsina and Bauchi states of Nigeria between 1st February 2015 and 30th November 2016 was used. Survival analysis was done using Kaplan-Meier and multiple regression with Cox proportional hazard modeling. RESULTS: Mean time to death during treatment is 19.2 weeks and 3.9 weeks among those awaiting treatment. Death was recorded among 38 of the 147 DR-TB patients assessed. HIV co-infection significantly increased probability of mortality, with an adjusted hazard ratio (aHR) of 2.35, 95% CI: 1.05-5.29, p = 0.038. Treatment delay showed significant negative association with survival (p = 0.000), not starting treatment significantly reduced probability of survival with an aHR of 7.98, 95% CI: 2.83-22.51, p = 0.000. Adjusted hazard ratios for patients started on treatment more than eight weeks after detection or within two to four weeks after detection, was beneficial though not statistically significant with respective p-values of 0.056 and 0.092. The model of care (facility vs. community-based) did not significantly influence survival. CONCLUSION: Both HIV co-infected DR-TB patients and DR-TB patients that fail to start treatment immediately after diagnosis are at significant risk of mortality. Our study showed no significant difference in mortality based on models of care. The study highlights the need to address programmatic and operational issues pertaining to treatment delays and strengthening DR-TB/HIV co-management as key strategies to reduce mortality.

Cost effectiveness of decentralised care model for managing MDR-TB in India.

BACKGROUND: In India, multidrug-resistant tuberculosis (MDR-TB) patients are usually treated in hospitals. Decentralised care model, however, has been suggested as a possible alternative by the World Health Organization (WHO). In the "End TB Strategy", the WHO highlights, as one of the key targets for 2035, that 'no TB-affected families should face catastrophic hardship due to the tuberculosis'. Removal of financial barriers to health-care access and mitigation of catastrophic expenditures are therefore considered vital to achieve the universal health coverage (UHC) goal. Since forgoing healthcare due to the financial constraints is a known fact in India, decentralised care as an intervention choice (as against hospital-based care) might enhance equity provided it is an affordable choice. Thus, an economic evaluation was conducted, from the perspective of the national health system in India, to assess the cost-effectiveness of decentralised care compared to centralised care for MDR-TB. METHODS: This study uses a decision-analytic model with a follow-up of two years to assess the expected costs of the decentralised versus the centralised approaches for MDR-TB treatment. A published systematic review of observational studies yielded the MDR-TB treatment outcomes, which included treatment success, treatment default, treatment failure, and mortality parameters. It was observed that these parameters did not vary significantly between the two alternatives. Treatment costs included the following costs: hospital admission costs, clinic costs, visits to laboratory and MDR-TB centre, drug therapy, injections and food. Costs data of drugs, diagnosis, hospital stay and travel to public facilities, based on a simple market survey, were taken from a recently published study on MDR-TB expenditures in the Chhattisgarh state of India. Potential cost savings related to the implementation of decentralised MDR-TB care for all patients who initiated MDR-TB treatment in India were additionally estimated. RESULTS: Estimated average expected total treatment cost was US$ 3390.56 for the hospital-based model and US$ 1724.1 for the decentralised model for a patient treated for MDR-TB in India, generating potential savings of US$1666.50 per case, with ICER US$ 2382.68 per QALY gained. One of the primary drivers of this difference was the significantly more intensive (thus expensive) stay charges in the hospital. If the costs and treatment probabilities are extrapolated to the whole country, with 48114 MDR-TB patients initiated on treatment in 2017, decentralised care would have additional 1058 patients cured, gain additional 3824 QALYs, and avert 2165 deaths, as compared to centralised care, in India. At various scenarios of coverage rates of decentralised and centralised care the cost difference would range between 23% and 94% for the country. CONCLUSION: Our study provides evidence of cost savings for MDR-TB patients if patients choose decentralised treatment in comparison to suggested hospitalisation of these patients for centralised treatment with similar outcomes. The economic evaluation presented in this study expected significant efficiency gains in choice of two treatment options and the cost savings may improve equity. In India, treatment of MDR-TB using decentralised care is expected to result in similar patient outcomes at markedly reduced public health costs compared with centralised care.

Lower than expected elevated tricuspid regurgitant jet velocity in adults with sickle cell disease in Nigeria.

Background: Cardiopulmonary disease is a major cause of morbidity and mortality in persons with sickle cell disease (SCD). Tricuspid regurgitant jet velocity (TRJV) and predicted forced expiratory volume in 1 s (FEV1%) predicted are independently associated with death in SCD. The goal of this study was to determine the prevalence of elevated TRJV and the association, if any, between TRJV and FEV1% predicted among persons with sickle cell anaemia (SCA) in Nigeria. Methods: Using a cross-sectional design, we enrolled 100 adult Nigerians (≥15 y) with SCA. We screened participants using Doppler echocardiogram to determine their TRJV and assessed their lung function with spirometry. Results: The prevalence of elevated TRJV was 6%, with 74% of participants having low FEV1% predicted (<70%). TRJV was negatively correlated with FEV1%, but this finding was not statistically significant (Spearman's ρ=-0.0263, p=0.8058). Conclusions: We found a low prevalence of elevated TRJV and a trend in association between TRJV and FEV1% predicted in Nigerian adults with SCA. Our findings underscore the need to explore further the relationship between SCD and cardiopulmonary disease in adults.

The impact of rural residence and HIV infection on poor tuberculosis treatment outcomes in a large urban hospital: a retrospective cohort analysis.

BACKGROUND: Successful tuberculosis (TB) treatment is essential to effective TB control. TB-HIV coinfection, social determinants and access to services influenced by rural residence can affect treatment outcome. We examined the separate and joint effects of rural residence and HIV infection on poor treatment outcome among patients enrolled in a large TB treatment centre in Kano, Nigeria. METHODS: We retrospectively analysed a cohort of patients with TB enrolled in a large urban TB clinic in northern Nigeria, from January 2010 to December 2014. Poor treatment outcome was defined as death, default or treatment failure. We used Poisson regression to model rates and determine the relative risks (and 95% confidence intervals, CI) of poor treatment outcomes. RESULTS: Among 1381 patients included in the analysis, 28.4% were rural residents; 39.8% were HIV-positive; and 46.1% had a poor treatment outcome. Approximately 65 and 38% of rural and urban residents, respectively, had a poor treatment outcome. Rural residents had 2.74 times (95% CI: 2.27-3.29) the risk of having a poor treatment outcome compared to urban residents. HIV-positive patients had 1.4 times (95% CI: 1.16-1.69) the risk of poor treatment outcome compared to HIV-negative patients. The proportion of poor treatment outcome attributable to rural residence (population attributable fraction, PAF) was 25.6%. The PAF for HIV infection was 11.9%. The effect of rural residence on poor treatment outcome among HIV-negative patients (aRR:4.07; 95%CI:3.15-5.25) was more than twice that among HIV-positive patients (aRR:1.99; 95%CI:1.49-2.64). CONCLUSION: Rural residents attending a large Nigerian TB clinic are at increased risk of having poor treatment outcomes, and this risk is amplified among those that are HIV-negative. Our findings indicate that rural coverage of HIV services may be better than TB services. These findings highlight the importance of expanding coverage of TB services to ensure prompt diagnosis and commencement of treatment, especially among rural-dwellers in resource-limited settings.

Trends in prevalence of multi drug resistant tuberculosis in sub-Saharan Africa: A systematic review and meta-analysis.

BACKGROUND: Multidrug resistant tuberculosis (MDR-TB), is an emerging public health problem in sub-Saharan Africa (SSA). This study aims to determine the trends in prevalence of MDR-TB among new TB cases in sub-Saharan Africa over two decades. METHODS: We searched electronic data bases and accessed all prevalence studies of MDR-TB within SSA between 2007 and 2017. We determined pooled prevalence estimates using random effects models and determined trends using meta-regression. RESULTS: Results: We identified 915 studies satisfying inclusion criteria. Cumulatively, studies reported on MDR-TB culture of 34,652 persons. The pooled prevalence of MDR-TB in new cases was 2.1% (95% CI; 1.7-2.5%). There was a non-significant decline in prevalence by 0.12% per year. CONCLUSION: We found a low prevalence estimate of MDR-TB, and a slight temporal decline over the study period. There is a need for continuous MDR-TB surveillance among patients with TB.

Deaths during tuberculosis treatment among paediatric patients in a large tertiary hospital in Nigeria.

BACKGROUND: Despite availability of effective cure, tuberculosis (TB) remains a leading cause of death in children. In many high-burden countries, childhood TB is underdiagnosed and underreported, and care is often accessed too late, resulting in adverse treatment outcomes. In this study, we examined the time to death and its associated factors among a cohort of children that commenced TB treatment in a large treatment centre in northern Nigeria. METHODS: This is a retrospective cohort study of children that started TB treatment between 2010 and 2014. We determined mortality rates per 100 person-months of treatment, as well as across treatment and calendar periods. We used Cox proportional hazards regression to determine adjusted hazard ratios (aHR) for factors associated with mortality. RESULTS: Among 299 children with a median age 4 years and HIV prevalence of 33.4%; 85 (28.4%) died after 1,383 months of follow-up. Overall mortality rate was 6.1 per 100 person-months. Deaths occurred early during treatment and declined from 42.4 per 100 person-months in the 1st week of treatment to 2.2 per 100 person-months after at the 3rd month of treatment. Mortality was highest between October to December period (9.1 per 100 pm) and lowest between July and September (2.8 per 100 pm). Risk factors for mortality included previous TB treatment (aHR 2.04:95%CI;1.09-3.84); HIV infection (aHR 1.66:95%CI;1.02-2.71), having either extra-pulmonary disease (aHR 2.21:95%CI;1.26-3.89) or both pulmonary and extrapulmonary disease (aHR 3.03:95%CI;1.70-5.40). CONCLUSIONS: Mortality was high and occurred early during treatment in this cohort, likely indicative of poor access to prompt TB diagnosis and treatment. A redoubling of efforts at improving universal health coverage are required to achieve the End TB Strategy target of zero deaths from TB.

Pattern of in-patient neurologic review: An experience from a Tertiary Hospital North-Western Nigeria.

BACKGROUND: Increase in neurologic diseases burden has increased the demand for neurology services globally, despite the shortcomings of shortage and maldistribution of neurologists worldwide, including Sub-Saharan Africa. This has placed significant pressure on the few available neurologists to provide optimal and effective services in our resource-challenged settings. METHODS: Neurology referrals were prospectively reviewed over a period of 3 months. Sociodemographic characteristics of the patients, the initial diagnosis by the requesting team, the reasons for the consult/referral, the requesting personnel, duration of hospital stay before request, the time interval between receiving the request and review, the working and final diagnosis after the review, and the diagnostic outcome of neurologic review were analyzed using Predictive Analytics Software® version 18.0.0 for Windows (Chicago, Illinois, USA). RESULTS: Fifty-three hand written in-patient requests were reviewed over the period of study given an average rate of 4.4/week. The mean age was 50.8 ± 16.1 years, and the median length of stay before a review was 1 day (interquartile range: 1-2.5 days). Diagnostic outcome of the reviews were; new diagnoses in 4 (11.3%), the incorrect diagnosis changed in 8 (15.1%), contribution to the differential diagnosis in 15 (28.3%), and contribution to management plans in 24 (45.3%) patients. The association between diagnostic outcomes and mortality in our study was not statistically significant (χ2 = 6.66, P = 0.08). CONCLUSION: Our study showed that in-patient neurologic reviews led to significant improvement in diagnostic and management plans. Appropriate policy guidelines should focus more on efficient ways of maximizing benefits of these reviews to patients without overburdening the few available neurologists in our environment.

Cost-optimization in the treatment of multidrug resistant tuberculosis in Nigeria.

OBJECTIVE: To compare the cost of facility-based MDR TB care (F) to home-based care (H) from the perspective of the Nigerian national health system. METHODS: We assessed the expected costs of the two MDR TB treatment approaches using a decision-analytic model with a follow-up of 6 months. MDR TB treatment outcomes were obtained from a systematic review of randomised clinical trials. The outcomes of interest included treatment success, treatment failure, treatment default and mortality and did not vary significantly between the two alternatives. Treatment costs included the cost of the following: drug therapy (F, H), hospital stay (F), nurse care (F, H), physician care (F), nursing facility (F) and transport to the healthcare provider (H). Finally, we estimated the potential cost savings associated with home-based treatment for all patients starting MDR TB treatment in Nigeria. RESULTS: The average expected total treatment cost for a Nigerian patient treated for MDR TB was estimated at US2095 for facility - based care and 1535 for home-based care, a potential saving of 25%. One of the major drivers of this difference is significantly more intensive, and therefore more costly, nursing care in hospitals. In 2013, a total of 426 patients were initiated on facility-based MDR TB treatment in Nigeria. Thus, the potential savings through home-based care are US$ 223 204 per year. CONCLUSION: In Nigeria, treatment of MDR TB using home-based care is expected to result in similar patient outcomes at markedly reduced public health costs as facility-based care.

Long-term outcomes of antiretroviral therapy in an adult HIV program: a 10-year retrospective cohort study in Kano, Nigeria.

BACKGROUND: Treatment outcomes from HIV/AIDS programs in resource-limited settings mostly describe short-term follow-up. We report 10-year treatment outcomes in an HIV clinic in Kano, Nigeria. METHODS: Using paper medical charts, the authors conducted a retrospective cohort study of patients that initiated ART from June 1, 2004 to December 31, 2007, and were followed up until June 30, 2014. The authors abstracted data from patient case files and did a time-to-event analysis on ART failure and loss to follow-up, and determined immunologic trends. RESULTS: The authors studied 345 patient records (29,860 person months of follow-up); 82 records (23.7%) indicated that patients failed their first-line ART regimen at the rate of 2.75 failures per 1000 person-months. The estimates of durability on first-line ART regimen were 99.1% at 1 year and 59.0% at 10 years. Of the studied patients, 83.0% were still in care at the end of the 10-year period. Only being on abacavir (hazard ratio: 8.0) was a positive predictor of ART failure. CD4 increment at 4 years (hazard ratio: 0.9) and 5 years (hazard ratio: 0.9) were negative predictors. CONCLUSION: A high rate of long-term ART durability and modest long-term retention in care were achieved among our cohort. Improved availability of low-cost virologic and immunologic monitoring tools and provision of resistance testing technology will go a long way in improving early detection of treatment failure in the developing world.

Incidence of tuberculosis and immunological profile of TB/HIV co-infected patients in Nigeria.

BACKGROUND: We obtained estimates of the incidence of tuberculosis (TB) among patients receiving HIV Treatment. We also modeled the relationship between incident TB and change in CD4 count over the follow-up period. METHODS: We analyzed the incidence of TB over 10 years from initiation of HIV treatment among 345 HIV treatment-naïve persons, who were enrolled in a cohort in Kano, Nigeria. We used Generalized Estimating Equation [GEE] to identify determinants of TB incidence and model the relationship between the occurrences of TB with change in CD4 count over the follow-up period. We created Kaplan-Meier curves stratified by anti-retroviral therapy (ART) treatment failure status to examine the effect of first line ART treatment failure on occurrence of TB. RESULT: During the 10-year period, 47(13.62%) had TB [incidence was 7.43 per (1,000) person year)]. It is associated with decreasing age (OR = 0.98), female gender (OR = 0.83), being on first line ART other than AZT (OR = 0.87), poor adherence (OR = 1.25), change in ART regimen (OR = 2.3) and ART treatment failure (OR = 1.51). Odds of TB occurrence was also associated with CD4 increment at 10 years (OR = 0.99). Those with TB/HIV co-infection tend to have statistically significant shorter time to failing first line ART regimen compared to those with HIV infection alone. CONCLUSION: There was high incidence of TB in the studied HIV cohort with a deleterious effect on the outcome of ART treatment. There is need for early TB screening and re-screening among all HIV patients.

Socio-Demographic and Adherence Factors Associated with Viral Load Suppression in HIV-Infected Adults Initiating Therapy in Northern Nigeria: A Randomized Controlled Trial of a Peer Support Intervention.

BACKGROUND: Virological suppression is the main goal of antiretroviral therapy. To achieve this goal, efficient interventions that promote treatment adherence are needed. This study was aimed at exploring the impact of peer-education on virological outcomes in Northern Nigeria. METHODS: A randomized controlled trial (RCT) among patients receiving antiretroviral treatment was conducted in 2 phases between August 2006 and January 2008 in the "largely Muslim" Northern Nigeria. Participants were randomized into one of three intervention arms: standard of care arm, a second arm which included daily reminders via alarm and follow-up calls from peer-educators, and adherence support by a home-based treatment partner; and a third arm which included second arm activities, plus home visits by peer-educators. We evaluated sociodemographic factors and adherence levels, measured using self-report and pharmacy (Rx) refill rates, as risk factors for viral load (VL) suppression. RESULTS: Of the 600 participants (43% males), 276 were observed till the end of the study. There were no significant differences in mean log 10 VL between the intervention groups. At the end of entire follow-up period, 83% (229/276) who were not lost to follow-up achieved undetectable VL (< 400 copies/ml). In the multivariable analysis, age between 30-34 years (vs 18-24 years) and both baseline CD4 ranges between 100-199 cells/mm(3) or 200-349 cells/mm(3) (vs CD4 <100 cells/mm(3)) as positively associated with VL suppression while poor self-reported adherence and <95% Rx refill rates were negatively associated with VL suppression. CONCLUSION: High levels of viral suppression and low prevalence of drug resistance mutations (DRMs) were seen in this cohort participating in an ART adherence study in Northern Nigeria. Self-reported good adherence and optimal Rx refill rates were reported as significant predictors of VL suppression. Our findings indicate that ART adherence will improve significantly regardless of whether HIV-infected adults received peer-education-based medication adherence interventions or standard of care services.

Systematic review and metanalysis on community based interventions in tuberculosis care in developing countries.

BACKGROUND: We aimed to evaluate the effectiveness of Lay Health Workers (LHW) in increasing case detection rate and treatment success outcome of Tuberculosis cases METHODS: PUBMED,; Google scholar, African Journal Online (AJOL) and other search engines were systematically searched, for literature from 2000 to 2012 for studies that are either: [randomized/cluster randomized/non randomized or prospective cohort study); assessing lay Health care worker participation in tuberculosis (TB) treatment, using the key words (LHW, TB and treatment). Studies were pooled using a random effect model. Of the thirteen studies that fulfilled the inclusion criteria for systemic review, only five were heterogeneous enough for a meta-analysis. RESULTS: There was a marginal effectiveness of LHW involvement in TB treatment success rate, RR 1.09 Confidence Interval. [0.98-1.21]. There was no publication bias; with {p = 0.135 for Eggar's weighed regression analysis}. Restrictive analysis showed a marginally higher summary relative risk in rural based studies RR 1.12, C.I. [1.01-1.24]; compared to urban studies RR 1.01, C.I. [0.91-1.13]. CONCLUSION: The use of Lay Health care workers is associated with a marginal benefit in improving TB treatment success compared to standard facility based TB care. Larger studies are needed to properly prove its superiority.

Immunological profile in persons under antiretroviral therapy in a rural Nigerian hospital.

Human immunodeficiency virus (HIV) contributes significantly to morbidity and mortality in sub-Saharan Africa, with Nigeria having the third highest burden of HIV infection globally; efforts are made to increases access to HIV/AIDS care and treatment. This has currently reached rural areas with limited manpower and laboratory evaluation capacity. This review is necessitated by the paucity of interim report on treatment profile in Nigerian rural areas. We report on the immunological profile of patients on antiretroviral therapy (ART) in Otukpo General Hospital, a rural Nigerian hospital. This is a retrospective cohort study of patients receiving ART treatment and care, on April 2009, when 2347 patients were under ART therapy. Out of these, 96 patients were selected by simple random sampling from hospital register, with their data abstracted from standardized Ministry of Health registers and facility documents kept at the hospital, and analyzed for descriptive and biometric measures. Ninty-six patients (29% males) with a median age of 35 years, median baseline CD4 lymphocyte count 221 cells/mL, median one year CD4 lymphocyte count of 356 cells/mL and median one year CD4 lymphocyte increment of 124 cells/mL were studied. There is no statistically significant difference in baseline CD4 lymphocyte count when data is disaggregated by type of drug regimen (AZT, D4T and TDF). Fourty-four percent, 23% and 33% of patients were on TDF, D4T & AZT based regimen, respectively (P=0.66). Increment of >100 cells/mL was seen in 64.58% of the reviewed patients. There was a higher CD4 lymphocyte count increment in patients on TDF & D4T compared with those in AZT based regimens (ANOVA; P<0.0003). Multivariate linear regression model showed one year CD4 lymphocyte count, one year increment in CD4 lymphocyte count, WBC count, and absolute neutrophil count to be significant correlates of baseline CD4 lymphocyte count (P<0.0001). Equally, multivariate logistic regression found age, platelet count and CD4 lymphocyte count at 12 months showed to be significant predictors of CD4 lymphocyte increment above 100 cells/µL (P<0.0001). Despite advanced disease presentation and a very large-scale program, high quality HIV/AIDS care was achieved as indicated by good short-term, immunologic outcomes, while TDF & D4T induce higher immunological recovery compared with AZT. This report suggests that quality HIV care and treatment can be effective despite the challenges of a resource-limited setting.