Factors influencing treatment failure in HIV positive adult patients on first line antiretroviral therapy.

BACKGROUND: Risk factors for treatment failure in HIV positive adults have not been studied extensively in Zimbabwe. AIM: To investigate socio-demographic, psychosocial and antiretroviral drug related factors as possible risk factors for treatment failure. OBJECTIVE: To compare the accuracy and reliability of CD4 count results in diagnosing treatment failure versus viral load results. DESIGN: A descriptive cross-sectional survey. SETTING: Harare Central Hospital adult opportunistic infections clinic. PARTICIPANTS: One hundred and eighteen (118) HIV positive participants on 1st line antiretroviral therapy (any 1 of stavudine, tenofovir or zidovudine combined with lamivudine and nevirapine or efavirenz) for at least 1 year. Participants were conveniently sampled. MAIN OUTCOME MEASURES: First line treatment failure as defined according to World Health Organisation (WHO) 2010 guidelines. RESULTS: Factors associated with higher odds of treatment failure were severe depression [OR 3.7; p-value 0.002; 95% CI 1.6-8.5] and discontinuing ART [OR 4.4; p-value 0.02; 95% CI 1.3-14.7]. Factors associated with lower odds of treatment failure were age = 42 [OR 0.3; p-value 0.007; 95% CI 0.1-0.7], taking ART on time [OR 0.2; p-value 0.02; 95% CI 0.05-0.8], time on ART > 4 years [OR 0.6; p-value 0.02; 95% CI 0.3-0.9] and female sex [OR 0.4; p-value 0.02; 95% CI 0.2-0.8]. There was statistically significant difference between CD4 count and viral load results in diagnosing treatment failure [OR 8.7; p-value 0.0005; 95% CI 3.6-21.2]. CONCLUSION: Severe depression and discontinuing ART predisposed to treatment failure. CD4 counts were not as reliable as viral load measurements in diagnosing treatment failure.

A simple qualitive procedure for the detection of chloroquine in urine for use in clinical analytical toxicology in resource poor settings.

Objective: To develop and validate a simple procedure for the qualitative determination of chloroquine in urine with potential for use in developing countries lacking sophisticated analytical equipment and expensive reagents. Design: This was a laboratory based study making use of which combines a colorimetric test, Dill-Glazko's test, and UV/Visible absorbance spectrometry to confirm the presence of chloroquine. The spectrophotometric method was cross validated with the standard Baselt's method for quantification of chloroquine in biological fluids. Setting: Pharmacology laboratory at the Department of Clinical Pharmacology, College of Health Sciences, University of Zimbabwe. Main Outcome Measures: Recovery of the methods was assessed by comparing the peak absorbances and the resolution of the peaks at 329nm and 343nm. Sensitivity and specificity was determined by analysing in a blinded manner. The limits of detection of both the Dill-Glazko's test and the confirmatory test was determined. Results: In the prevalidation procedures increasing the volume of the ethylacetate and the volume of the lower aqueous layer extracted was found to increase the recovery of the confirmatory test. There was a significant difference between both the peak absorbances and the peak resolution for the two methods (p<0.0001). The confirmatory test had a sensitivity of 90% and a specificity of 100%, whereas the Baselt's method had a sensitivity of 83.3% and a specificity of 96.7%. The limit of detection of the Dill-Glazko's test was 15mg/Land that of the confirmatory test was 5mg/L. Conclusions: The confirmatory test had better recovery and was more sensitivity compared with the Baselt's method. The limit of detection of the combination method (Dill-Glazko's plus confirmatory test) was 15mg/L. The combination test showed appreciable sensitivity to be suitable for application to clinical toxicology.

Snakebite admissions in Zimbabwe: pattern, clinical presentation and management.

OBJECTIVE: To describe the toxicoepidemiology of snakebite admissions to eight major referral hospitals in Zimbabwe. DESIGN: Retrospective and descriptive case review. SETTING: Four central hospitals (i.e., Harare, Parirenyatwa, Mpilo and United Bulawayo Hospitals) and four provincial hospitals (i,e., Gwanda, Bindura, Gweru and Mutare hospitals). MAIN OUTCOME MEASURES: Parameters assessed for included patient demographics e.g. age and gender, length of hospital stay, circumstances leading to snakebite, season and time of day of bite, culprit species, clinical presentation, management before and after admission, and outcome. RESULTS: There were a total of 273 admissions due to snakebite. Over 60% of bites were to the feet and about 36% were to the arms and hands. The type of snake involved was recorded in 14.6% (40) the cases with puff adders (Bitis arietans) being the most commonly implicated species. First aid and other pre-hospital treatments were recorded in 38 cases with tourniquets employed in 24 cases (63.2%) and 13 patients visiting a traditional medical practitioner before going to hospital. There were similar proportions of males to females admitted with snakebite and the case fatality rate in this study was 2.9%. CONCLUSION: Most bites from snakes in Zimbabwe occur to the feet and are probably from puff adders. The torniquet appears to be the most commonly employed first aid measure for snakebite in Zimbabwe, and snakebite victims still consult traditional healers.

Use of cotrimoxazole prophylaxis in HIV infected in patients at a referral hospital.

OBJECTIVE: To assess the extent of use of cotrimoxazole prophylaxis in the prevention of opportunistic infections in HIV infected patients. SETTING: Parirenyatwa Hospital, a major referral and teaching hospital. DESIGN: A retrospective study. SUBJECTS: 234 HIV infected patients admitted between January and June 2004, with a history of symptoms falling into the WHO stage 3 AIDS, were included. MAIN OUTCOME MEASURES: Cotrimoxazole prophylaxis, PCP prevalence, and mortality. RESULTS: 234 patients' records were reviewed and 19% of the patients had received cotrimoxazole prophylaxis. PCP prevalence was 36% which was diagnosed mainly by clinical examination and sometimes with the additional help of chest X-rays. Of those who were on prophylaxis, 75% were on primary prophylaxis and the rest on secondary prophylaxis. All patients on prophylaxis were using cotrimoxazole, with the 960 mg once daily dosing being the most common regimen (96%). Receiving prophylaxis was associated with being female (p = 0.0067), widowed (p = 0.012), and taking ARV therapy (p = 0.0026). Prophylaxis significantly reduced mortality (p = 0.0017). The development of PCP was associated with a history oftuberculosis relapse (p = 0.022). CONCLUSION: Cotrimoxazole prophylaxis is important in reducing hospital admissions due to opportunistic infections and increasing survival especially in areas with limited access to antiretroviral therapy.

Differences and similarities in poisoning admissions between urban and rural health centers in Zimbabwe.

BACKGROUND: Toxicoepidemiological data from rural areas of developing countries is scarce. Most studies examine admissions to urban referral hospitals and extrapolate to lower level health facilities. The validity of this approach was examined in this work. METHODS: A retrospective review of all poisoning admissions was conducted at the provincial hospital (PH) and six district hospitals (DH) in Mashonaland Central province, Zimbabwe for the period January 1998 to December 1999 (inclusive). Patient records were traced by hand from medical ward registers. Relevant information was collected using a standard data collection tool. RESULTS: There were 711 poisoning admissions to the DH and 341 to the PH. Case demographic details were similar at both the PH and DH, with a male to female ratio of 1:1 and most cases in the 0-5, 16-20 and 21-25 year age groups. Most admissions resulted from accidental poisoning (>60%) at both levels of care. However, the important causes of admission differed with animal envenomation (especially snakebite) predominating at DH (43.6% of admissions; 99% CI 38.9%-46.5%), whilst pesticide poisoning (26.1%; CI 20.0%-32.2%) predominated at the PH. Pharmaceutical exposures were common at the PH (15.2%; CI 10.2%-20.3%), but not at the DH (3.7%; CI 2.1%-5.1%). Despite this, patient demographics and reasons leading to poisoning were similar for animal, pesticide and pharmaceutical exposures. CONCLUSION: Important differences existed between provincial and district poisoning data in Zimbabwe. Caution must be used when using urban referral hospital data to describe prevalence of poisoning in rural areas.

Toxicoepidemiology in Zimbabwe: admissions resulting from exposure to paraffin (kerosene).

INTRODUCTION: Paraffin (kerosene) ingestion is the most common form of childhood poisoning in most developing countries. Despite this, there is a paucity of toxicoepidemiological data which could potentially be used in measures to reduce preventable exposures. This article reports on the patterns of hospital admissions resulting from paraffin exposure in Zimbabwe. METHODS: All cases of paraffin ingestion admitted to eight major referral hospitals in Zimbabwe from January 1998 to December 1999 (inclusive), were identified using ICD-9 codes and ward registers and relevant information recorded on a standard data collection sheet. RESULTS: There were a total of 327 admissions due to oral exposure to paraffin. This represented 11.8% of all the poisoning admissions to the eight study hospitals. Most exposures (300; 91.7%) occurred accidentally, with only 6.7% resulting from deliberate ingestion of the chemical. The median age on admission was 2 years (interquartile range [IQR] 1-2 yrs) with over 85% of cases in the 0-5 year age range and less than 10% above the age of 12 years. The median age on admission was much higher for deliberate self poisoning (23 yrs; IQR 19-26 yrs) compared to that for accidental poisoning (1.5 yrs; IQR 1-2 yrs). Accidental poisoning from paraffin occurred throughout the year. Over three-quarters of patients received an antibiotic either alone, or in combination with another antibiotic or drug. Paracetamol (24.3%) was the next most commonly encountered treatment. The case fatality rate (CFR) was therefore 0.3 deaths per 100 admissions (95% Confidence Interval 0.0-1.7). CONCLUSION: Paraffin ingestion remains an important cause of poisoning morbidity in Zimbabwe throughout the year, particularly in children. Clinical management appears adequate with a low mortality, although there may be overuse of prophylactic antibiotics. Further study specific to this area is warranted to prevent unnecessary antibiotic use and wastage of resources.

Chloroquine poisoning in Zimbabwe: a toxicoepidemiological study.

Chloroquine is commonly implicated in pharmaceutical poisonings in Zimbabwe. A retrospective hospital record review was performed to describe the epidemiology of chloroquine poisoning compared with that of other medicines. All records of admissions to eight referral hospitals in Zimbabwe due to poisoning with single pharmaceutical agents were collated and separated into those involving either chloroquine or other medicines. Case characteristics were compared and a retrospective cohort study performed to investigate the association of pregnancy with chloroquine overdose. Of 544 cases, antimalarials accounted for the largest proportion of admissions (53.1%), with chloroquine accounting for 96.2% (279 cases) of these. The latter were compared with the remaining 265 cases. The median length of hospital stay for the chloroquine group was significantly lower (1 vs 2 days; P = 0.001) and a greater proportion of patients took chloroquine deliberately (80.3% vs 68.7%; P < 0.05). The mortality rate due to chloroquine poisoning was significantly higher than that of poisoning due to other drugs (5.7% vs 0.7%; P < 0.0001). There was no significant gender bias in mortality. Women of childbearing age admitted with chloroquine poisoning (188 cases) were twice as likely to be found pregnant (relative risk = 2.3, 95% CI = 1.2-4.5) than similar women admitted due to other medicines (157 cases). In conclusion, chloroquine is the most common cause of pharmaceutical poisoning admission at referral hospitals in Zimbabwe. It is normally taken deliberately with significant mortality. In women of childbearing age admitted with chloroquine poisoning, pregnancy should be suspected.

Effects of DDT on paracetamol half-life in highly exposed mothers in Zimbabwe.

After assessment of the levels of DDT residues in the milk samples, 1 g paracetamol was administered p.o. to 28 breastfeeding mothers selected from a population of 116, according to DDT residues in their milk (the 14 with the highest values and the 14 least exposed). Post dose blood samples were taken from the basilic veins of the mothers at time intervals up to 4 h, post dose. The paracetamol blood concentrations were determined. A significantly shorter paracetamol half-life was found in mothers with higher DDT body burden, who also exhibited lower paracetamol concentrations in blood. The results highlighted concern for the highly exposed mothers taking paracetamol (NSAID) as an analgesic, or as an antipyretic.

Poisoning in Zimbabwe: a survey of eight major referral hospitals.

A retrospective study of the pattern of poisoning cases admitted to eight major urban referral hospitals in Zimbabwe over a 2-year period (1998-1999 inclusive) was conducted to describe the pattern of poisoning at these centres. There were a total of 2764 hospital admissions due to poisoning, involving a total of 2846 toxic agents. Accidental poisoning (AP) and deliberate self-poisoning (DSP) accounted for 48.9% (1352 cases) and 41.3% (1142 cases), respectively. With AP, the highest number of cases (45.9%) occurred in children below the age of 5 years, with half of these due to chemicals, mainly paraffin. In the DSP group, however, more than 60% of all cases occurred in the 16-25-year age group. In addition, twice as many females as males were admitted for DSP compared with an overall male/female ratio of 1 : 1.2. Pesticides (31.4%) and pharmaceuticals (30.4%) were the most common groups of toxic agents responsible for the hospital admissions. Unknown toxins, natural toxins and pesticides showed the highest mortality rates (15.4%, 8.3% and 6.7%, respectively). Compared with the last major survey of poisoning in Zimbabwe, the pattern of poisoning at referral hospitals has changed over the last decade, with an increase in pesticide and pharmaceutical cases and a marked fall in cases of traditional medicine poisoning. Educational and legislative interventions may be required to address these changes. There is the need also to investigate further the high mortality rates associated with traditional medicine poisoning.

Traditional medicine poisoning in Zimbabwe: clinical presentation and management in adults.

Traditional medicines (TMs) have been reported as major causes of hospital admissions in some African countries including Zimbabwe. There is, however, still a paucity of information with regards to their clinical presentations. We carried out a retrospective case series of all cases of traditional medicine poisoning (TMP) at eight main referral hospitals in Zimbabwe January 1998-December 1999 inclusive) to describe the most common signs and symptoms, reasons for, and management of TMP in adults. Where the reasons for taking the TM were known, most cases had taken the medicine for either abdominal pains or aphrodisiac purposes. Nonspecific adverse effects including vomiting, abdominal pains, and diarrhoea were the most commonly encountered. A large proportion of patients with TMP also suffered from genito-urinary tract adverse outcomes especially haematuria and dysuria. Intravenous fluids were the most commonly employed therapeutic modality for TMP, probably in an effort to dilute or increase excretion of the toxins. Further research is required to elucidate the toxic components responsible for the observed ill effects and whether these effects are due to the medicines themselves or to co-existing illnesses.