Changing HIV infection-related mortality rate and causes of death among persons with HIV infection before and after the introduction of highly active antiretroviral therapy: analysis of all HIV-related deaths in Barbados, 1997-2005.

OBJECTIVES: To compare the trends in death rates and the causes of deaths before and after the introduction of highly active antiretroviral therapy. METHODS: This is a retrospective study based on chart review of all HIV-related deaths between January 1997 and December 2005. RESULTS: The HIV-specific death rate declined from 34.12 per 100,000 adult population during 1997-1999 to 17.21 per 100,000 adult population during 2003-2005 when highly active anti-retroviral therapy was available. The proportion of all HIV-related deaths among persons newly diagnosed with HIV during the terminal hospitalization decreased from 93% during 1997-1999 to 28% during 2003-2005. Opportunistic infection was at least one of the causes of death in nearly half of all cases. CONCLUSIONS: Although, the HIV-specific death rates have declined significantly since the introduction of highly active antiretroviral therapy, HIV infection continues to contribute to the premature deaths among adults, mainly because of the late presentation.

Stigma, discrimination, and HIV/AIDS knowledge among physicians in Barbados

OBJETIVOS: Dilucidar el alcance de los conocimientos prácticos que tienen los médicos de Barbados sobre el VIH y el sida y su actitud hacia las personas que padecen la enfermedad. MÉTODOS: En el año 2000 la Asociación de Médicos Generales de Barbados llevó a cabo una encuesta para evaluar las opiniones de los socios en torno a asuntos relacionados con el VIH y el sida. Durante un período de dos meses se entrevistó a 203 médicos (76% de los que ejercen en el país). En la encuesta se incluyeron tanto médicos del sector público como de consultorios privados. Las entrevistas fueron individuales y versaron sobre sus actitudes hacia la orientación de los pacientes, conocimientos prácticos, nociones de prácticas inocuas, temor de exponerse al contagio, modo de ver las cuestiones éticas, experiencia con el tratamiento de pacientes con VIH o sida y formación médica continua en el campo de VIH/sida. RESULTADOS: Comparados con los médicos egresados más tarde, los graduados en 1984 o antes habían tratado a menos pacientes con infección por VIH o sida, tenían menos conocimientos de la enfermedad, se inclinaban más a administrar la prueba diagnóstica sin el consentimiento válido del paciente y era menos probable que hubieran asistido a algún curso de formación continua sobre el VIH y el sida. En general, tenían poco conocimiento del tratamiento indicado y 76% no se consideraban capacitados adecuadamente para orientar a los pacientes. Más de 80% dijeron que se sentían bastante seguros atendiendo a pacientes con infección por VIH o sida. De los encuestados, 95% declararon que no entregarían los resultados diagnósticos a terceros sin el consentimiento del paciente, mientras que 33% dijeron que administrarían la prueba detectora sin consentimiento a un paciente grave y 15%, que lo harían si tuvieran que realizar una intervención invasora a un paciente de una población de alto riesgo, como las de homosexuales y trabajadores de la industria sexual. Solo 53% de los médicos habían participado en programas de adiestramiento en el servicio entre 1995 y 1999. CONCLUSIONES: Es preciso que la formación médica en Barbados comprenda la atención de pacientes con infección por VIH o sida, incluidos todos los aspectos, tanto clínicos como afectivos. Para los médicos del sector público debe ser obligatorio asistir a ese tipo de adiestramiento; además, es necesario examinar los planes de estudio de las escuelas de medicina para cerciorarse de que sean completos y actualizados.

Stigma, discrimination, and HIV/AIDS knowledge among physicians in Barbados.

OBJECTIVE: To determine the extent of clinical knowledge of HIV/AIDS that physicians in Barbados have and their attitudes towards persons living with HIV/AIDS. METHODS: In 2000 the Barbados Association of Medical Practitioners conducted a survey in order to assess its members' views on HIV/AIDS issues. Over a two-month period 203 physicians (76% of all those practicing in the country) were interviewed. The survey included physicians working in private practice and the public sector. They were surveyed individually concerning their attitudes towards counseling as well as their clinical knowledge, perception of safe practices, fear of occupational exposure, views on ethical issues, experience treating HIV/AIDS patients, and background with HIV/AIDS continuing education. RESULTS: In comparison to physicians who had graduated in later years, physicians who had graduated in 1984 or earlier had seen fewer HIV/AIDS clients, had lower levels of knowledge about the disease, were more likely to test for HIV/AIDS without informed consent, and were less likely to have ever attended a continuing education training course on HIV/AIDS. Overall, knowledge of the clinical indications of HIV/AIDS was low, and 76% of the physicians did not think they had adequate counseling skills. Over 80% of the physicians were comfortable looking after HIV/AIDS patients. While 95% of the physicians would not release HIV test results without a patient's consent, 33% would test, without consent, a seriously ill patient, and 15% would test without consent a patient upon whom they had to perform an invasive procedure if they perceived the patient to be from a high-risk population such as gay men or commercial sex workers. Only 53% of the physicians had attended an HIV/AIDS in-service training program between 1995 and 1999. CONCLUSIONS: Physician training in Barbados should focus on all aspects of HIV/AIDS care, including clinical and emotional factors. Attendance at such training should be mandatory for public sector physicians, and medical school curricula need to be examined to ensure their HIV/AIDS content is current and comprehensive.

Randomized, placebo-controlled trial of product R, a peptide-nucleic acid immunomodulator, in the treatment of adults infected with HIV.

OBJECTIVE: The efficacy of Product R, a nontoxic peptide-nucleic acid, was tested in 43 HIV-infected adults naïve to antiretroviral therapy. METHOD: Patients were randomized to receive Product R (21 patients) or placebo (22 patients). Dosage was two 1 mL subcutaneous injections daily on days 1-14, followed by 1 mL daily on days 22-28, 36-42, and 50-56. The follow-up period lasted until day 120. RESULTS: Mean root CD4 count increased in the Product R group during treatment and was significantly higher (p =.013) by the end of follow-up. Four Product R-treated patients, but none of the control patients, experienced declines in viral load of >0.5 log. At the end of follow-up, the Product R group experienced a mean weight increase (p =.003), whereas the placebo group experienced a mean weight loss. The number of deaths and opportunistic infections were lower in the Product R group than in the placebo group (p =.076). No toxic effects were observed in any of the patients administered Product R. CONCLUSION: These findings suggest that Product R may have efficacy in the treatment of HIV-infected individuals.

Molecular analysis of HIV-1 infection in Barbados

OBJECTIVE: To determine the sub-type(s) of HIV-1 in patients with advanced disease in Barbados. DESIGN AND METHODS: A molecular analysis was performed in sequences obtained from 38 HIV-1 infected persons. A 375 base pair fragment was amplified from the V3 loop of the env region of the HIV genome, using a nested RT-PCR method. The resulting fragment was sequenced directly and alignment was performed using the BLAST (Basic Local Alignment Search Tool) search. RESULTS: Of 38 patients with advanced HIV-1 infection, all were found to be infected with HIV-1 subtype B, which closely relates to a similar subtype found in North America and Europe. This is the first time that HIV subtypes have been described from Barbadian patients with advanced HIV disease. CONCLUSIONS: Our findings support the hypothesis that HIV infection in Barbados was derived initially from North America and Europe, where type B HIV infection is most common. Moreover, these findings indicate that vaccines suitable for use in North America will probably be effective in our population.(Au)

Clustering of cases of mycobacterium fortuitum infection investigated by molecular typing

Organisms of the mycobacterium fortuitum complex are recognised but uncommon causes of pulmonary disease, primary cutaneous disease and a wide spectrum of nosocomial infections. M fortuitum was isolated from 20 patients over a 15 month period, with a apparent clustering of isolates occurring from January to March 1994. The molecular epidemiology of this clustering eas investigated using an arbitrary primer polymerase chain reaction method (AP-PCR). 21 isolates were studied, which yielded 13 distinct profiles. Multiple isolates from a single patient yielded identical profiles. All of seven isolates recovered during the six week period from January to March 1994 shared a common profile which was distinct from all other isolates, suggesting that a single strain was isolated from specimens from all seven patients. The source of this cluster in uncertain. We can find no epidemilogical basis for an episode of cross-infection within the hospital environment, and it is assumed that contamination of the specimens during collection, transport or processing was responsible for the "pseudo-outbreak" of M fortuitum

Prevalence of asthma and wheezing illnesses in Barbadian school children: the Barbados national asthma and allergy study

In Barbados, there has been a fourfold increase in the number of asthmatic visits to the Accident and Emergency department of the Queen Elizabeth Hospital between 1980 and 1994. However, there are no data on the prevalence of asthma in Barbados. This study was done to determine the prevalence of childhood asthma using the International Study of Asthma and Allergy in Childhood (ISAAC) questionnaires. Questionnaires were distributed to parents of 3,894 pupils (age group 6-7 years) in all 91 primary schools in Barbados, and 3,500 questionnaires were completed by pupils (age 13-14 years) in all 46 secondary schools. The data analysis was carried out by Systems Caribbean Limited utilising SPSS. In the 6-7 years olds, the prevalence of self-reported asthma was 16.8 percent with doctor diagnosed asthma of 16.5 percent wheeze had occurred at some time in 30.7 percent and in the previous 12 months in 18.3 percent. In the 13-14 year-olds, self reported asthma was 17 percent, doctor diagnosed asthma 15.9 percent, wheeze occurring at some time was 30.1 percent and wheeze in the previous 12 months was 17.7 percent. Of the 6-7 year-olds, of those who wheezed in the previous 12 months, 78 percent had 1-3 attacks, 18.5 percent had 4-12 attacks and 3.5 percent had more than 12 attacks. In the 13-14 year-olds, 76.5 percent had 1-3 attacks in the previous 12 months, 18.2 percent had 4-12 attacks, 5.3 percent had more than 12 attacks. There was no difference in frequency of smokers in the household between those who wheezed in the previous 12 months and those who never wheezed. Overall, wheezing was more frequent in boys than in girls. The prevalence of asthma in Barbados is high for a tropical island with relatively little atmospheric pollution. The increase has coincided with increasing affluence and trend toward urbanisation and modernisation of the domestic environment.(AU)

Severe primary HIV-1 infection among black persons in Barbados

Descriptions of primary HTV-1 infection have so far been based on Caucasians living in industrialized nations. Due to studies of leptospirosis in predominantly black population of Barbados, serum was available for patients admitted with acute febrile illnesses to the Queen Elizabeth Hospital (QEH). By searching the medical records of 510 adult patients with known HIV-1 infection we identified 10 patients who had stored serum from an admission for an acute febrile illness that predated or coincided with their first HIV-1-positive test. Serological testing confirmed primary HIV-1 infection in 9 and was suggestive in the 10th patient. The clinical features of these 10 patients were in keeping with previous descriptions of primary HIV-1 infection but differed from leptospirosis cases seen at the QEH. One patient died during the seroconversion illness and another died 3 months after seroconversion. The findings suggest that severe primary HIV-1 infection could be a relatively uncommon occurence, that the condition may be misdiagnosed, and that cases may not occur until the AIDS epidemic is established.(AU)

The Barbados AIDS audit: patient contact with surgical services and accident and emergency - abstract

The records of 653 adult HIV-positive patients, covering the period July 1984 to June 1995, were reviewed to determine patient contact with surgical services at the Queen Elizabeth Hospital (QEH). The relationship of the Accident & Emergency (A&E) attendance prior to admission and survival was also assessed for first respiratory admissions. The balance of care between the HIV clinic at the QEH and the A&E department was also assessed. Surgical outpatient contact chiefly comprised consultations for ano-genital warts and follow appointment after admissions. There were 50 admissions (5 deaths) on the surgical wards out of a total of 1059 admissions. Ischiorectal abcesses were the cause of eight admissions and five patients were admitted after a fight; other admissions were for a wide range of reasons. Eight patients had a lymph node biopsy (4 whilst on medical wards) reflecting the conservative approach to lymphadenopathy in Barbados. Admission from the A&E was the most frequent route of admission associated with a worse outcome. There was no trend to decrease involvement in ambulatory care by A&E over time. In conclusion, the audit has shown that the A&E Department must be a focus for improving care. (AU)

Prevalence of atopic eczema in Barbadian schoolchildren: preliminary findings from the Barbados National Asthma and Allergy Study - abstract

In 1995 and 1996 the Barbados National Asthma and Allergy Study, a questionnaire survey of all schoolchildren 6 - 7 years and aged 13 - 14 year, was conducted. The aim of the survey was to describe the prevalence and severity of asthma, rhinitis and eczema in children living in Barbados, to make meaningful comparisions with other countries (e.g Jamaica) and to obtain baseline measures for asessment of future trends in the prevalence and severity of this disease. The questionnaire sought to discover the presence of an itchy rash, persisting for more than six months, and in the typical anatomical distribution of atopic eczema. In addition, doctor diagnosed eczema was sought. Three thousand, eight hundred and ninety-four (3894) questionnaires were returned in the 6 - 7 years old age group (97 percent) and 3552 in the 13 - 14 year- old age group (88 percent). The prevalence of atopic eczema in the 6 - 7 year-old age group was 10.6 percent and in the 13 - 14 year-old age group was 10.0 percent. Diagnosis by a doctor reduced the prevalence to 6.2 percent in the primary school group and 3.6 percent in the secondary school group. This study has demonstrated for the first time in a Caribbean country the prevalence of this common childhood complaint. (AU)

The Barbados AIDS audit: a profile of first respiratory admissions

Lower respiratory tract infections (LRTI) are the commonest cause of HIV-related hospital admissions to the Queen Elizabeth Hospital in Barbados. The medical records and available chest X-rays of 225 patients with LRT1 on their first admission during the period 1989-1995 were reviewed. The mortality among the patients was 26 percent and did not vary over the period under study. The radiologist's report on the CXR film was present in the records of 122 patients and eighty-six (70 percent) were reported as showing bilateral interstitial infiltrates. Twenty-one out of 28 (75 percent) deaths occurred in patients with bilateral interstitial infiltrates treated with the recommended dose of co-trimoxazole for Pneumocystis carinii pneumonia (PCP). Review of CXR films for nine patients with proven PCP confirmed that all had a "classical PCP" on CXR (i.e., bilateral mid-zone / diffuse fine reticulonadular or "ground glass" appearances). However, five of 11 patients with proven bacterial LRT1 (5 coliforms, 3 S.aureus, and 3 Pseudomonas sp.) also had "classical PCP" on CXR. We conclude that the high mortality may relate in part to the treatment of bacterial LRT1 with high dose co-trimoxazole. Empirical treatment should begin with gentamicin and ampicillin, with a switch to high-dose co-trimoxazole if patients fail to improve (AU)

The Barbados AIDS audit: a profile of first neurological admissions

Conditions affecting the CNS are the commonest cause of HIV-related death at the Queen Elizabeth Hospital. The medical records were reviewed for 185 HIV-positive patients on their first admission for a neurological problem (covering the period 1994-1995). Mortality was 70 percent and did not change overtime. Mortality was highest (81 percent) when no firm diagnosis was reached but was still high (45 percent) in the 77 cases where a CT and/or LP confirmed the diagnosis. The commonest confirmed diagnoses were cerebral toxoplasmosis (20 deaths out of 50 first admissions) and crytococcal meningitis (7 deaths out of 16 admissions). Currently, the favoured diagnostic strategy for neurological presentations is to obtain a CT and then do LP. Due to the apparent relationship between a CT and mortality in our population this strategy needs to be reconsidered. The presence of symptoms and/or signs of lower respiratory tract infection in a patient with no focal deficit appears to have a high predictive value for cryptococcal meningitis. An appropriate management strategy of neurological presentations in our setting may be to perform LP on admission in such patients with all others treated empirically for cerebral toxoplasmosis. We will prospectively evaluate this algorithm (AU)

Clustering of cases of mycobacterium fortuitum infection investigated by molecular typing

Organisms of the Mycobacterium fortuitum complex are recognized, but uncommon, causes of pulmonary disease, primary cutaneous disease and a wide spectrum of nosocomial infections. M.fortuitum was isolated from 20 patients over a 15-month period, with an apparent clustering of isolates of M.fortuitum occurring from January to March 1994. The molecular epidemiology of this clustering was investigated using an arbitrary primer-polymerase chain reaction method (AP-PCR). Twenty-two isolates were studied and yielded 14 distinct profiles. Multiple isolates from a single patient yielded identical profiles. All of seven isolates of M.fortuitum recovered during the six-weeks period from January to March 1994 shared a common profile which was distinct from all other isolates, suggesting that a single strain was located from specimens from all seven patients. The source of the cluster of isolates of M.fortuitum is uncertain. We can find no epidemiological link upon which to suppose an episode of cross-infection within the hospital environment. Therefore it seems likely that contamination of the specimens during collection, transport or processing was responsible for the "pseudo-outbreak" of M.fortuitum observed in this study (AU)

Further findings of the Barbados AIDS audit - abstract

An audit was conducted of the notes of 162 patients with HIV infection who were alive on July 31, 1993. The length of hospital admissions, pattern of diagnoses, results of routine serological testing and quality of history taking were examined. Sixty-two (38 percent) of patients had been admitted to hospital. There was a trend toward shorter admissions over time: mean length of admission was 12.4 days in 1992 and 9.3 in 1993. Thirty-seven percent (37 percent) of the discharge diagnoses were respiratory and 30 percent were defining AIDS diagnoses. The most common diagnosis was PCP (18 diagnoses) followed by pneumonia due to proven or suspected bacterial infection (17 diagnoses). AL1 patients had serological evidence of past exposure to Herpes simplex I/II. Seventy-three per cent of patients had serological evidence of past exposure to toxoplasma, with 50 per cent of all patients having high titres. Thirty-one per cent of patients had positive syphilis serology but only 7 per cent of all patients had a VDRL titre of 1/8 or higher. Eleven per cent were positive for HTLV-1, 1.4 per cent for HBV sAg, and 99 per cent for IgG antibody to CMV. The audit of history taking demonstrated the need for a more careful history of presenting complaint as well as a more thorough past medical history. In summary, the audit continues to provide useful information to guide future clinical care (AU)

SCUBA diving accidents in the Caribbean - abstract

The compression chamber facility at the Barbados Defence Force has treated 150 SCUBA diving accidents, since it began operation in 1985. Nineteen women and 131 men were treated. The average age of the victims was 34 years. There were 67 sports diving accidents and 83 occupational or work-related accidents. Patients were referred from many of the islands of the Eastern Caribbean, from the Dominican Republic in the north to Trinidad and Tobago in the south. The majority of the sports accidents occurred amongst vacationing tourists and the majority of the work-related accidents were among commercial fishermen from Puerto Rico and St. Vincent and the Grenadines. All three major diving-related diseases, decompression sickness types 1 and 2 and arterial gas embolism, were seen, with the majority presenting with serious (type 2) decompression sickness. SCUBA-related diving accidents are seen in virtually all of the Caribbean Islands and represent a serious occupational and recreational disorder. Such accidents occur in young adults and may have devastating consequences with paralysis and disability leading to loss of income and consequent reduction in the standard of living of those affected (AU)