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2.
AIDS Care ; 32(4): 495-499, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31550905

RESUMO

Caregivers of children with tuberculosis (TB) and HIV play a critical role in seeking healthcare for their children. To assess the perspectives of caregivers of pediatric TB patients, we conducted 76 in-depth interviews at 10 TB clinics in 5 districts of Tanzania in March 2016. We assessed how the child received their TB diagnosis, the decision-making process around testing the child for HIV, and the process of linking the child to HIV treatment in the event of an HIV diagnosis. Caregivers suspected TB due to cases in their family, or the child being ill and not improving. Most caregivers noted delays before confirmation of a TB diagnosis and having to visit multiple facilities before a diagnosis. Once diagnosed, some caregivers reported challenges administering TB medications due to lack of pediatric formulations. Reasons for accepting HIV testing included recurrent illness and HIV symptoms, history of HIV in the family, and recommendation of the clinical provider. Caregivers described a relatively seamless process for linking their child to HIV treatment, highlighting the success of TB/HIV integration efforts. The multiple clinic visits required prior to TB diagnosis suggests the need for additional training and sensitization of healthcare workers and better TB diagnostic tools.

3.
BMC Infect Dis ; 19(Suppl 1): 783, 2019 Sep 16.
Artigo em Inglês | MEDLINE | ID: mdl-31526371

RESUMO

BACKGROUND: The 2016 'Start Free, Stay Free, AIDS Free' global agenda, builds on the 2011-2015 'Global Plan'. It prioritises 22 countries where 90% of the world's HIV-positive pregnant women live and aims to eliminate vertical  transmission of HIV (EMTCT) and to keep mothers alive. By 2019, no Global Plan priority country had achieved EMTCT; however, 11 non-priority countries had. This paper synthesises the characteristics of the first four countries validated for EMTCT, and of the 21 Global Plan priority countries located in Sub-Saharan Africa (SSA). We consider what drives vertical transmission of HIV (MTCT) in the 21 SSA Global Plan priority countries. METHODS: A literature review, using PubMed, Science direct and the google search engine was conducted to obtain global and national-level information on current HIV-related context and health system characteristics of the first four EMTCT-validated countries and the 21 SSA Global Plan priority countries. Data representing only one clinic, hospital or region were excluded. Additionally, key global experts working on EMTCT were contacted to obtain clarification on published data. We applied three theories (the World Health Organisation's building blocks to strengthen health systems, van Olmen's Health System Dynamics framework and Baral's socio-ecological model for HIV risk) to understand and explain the differences between EMTCT-validated and non-validated countries. Additionally, structural equation modelling (SEM) and linear regression were used to explain associations between infant HIV exposure, access to antiretroviral therapy and two outcomes: (i) percent MTCT and (iii) number of new paediatric HIV infections per 100 000 live births (paediatric HIV case rate). RESULTS: EMTCT-validated countries have lower HIV prevalence, less breastfeeding, fewer challenges around leadership, governance within the health sector or country, infrastructure and service delivery compared with Global Plan priority countries. Although by 2016 EMTCT-validated countries and Global Plan priority countries had adopted a public health approach to HIV prevention, recommending lifelong antiretroviral therapy (ART) for all HIV-positive pregnant and lactating women, EMCT-validated countries had also included contact tracing such as assisted partner notification, and had integrated maternal and child health (MCH) and sexual and reproductive health (SRH) services, with services for HIV infection, sexually transmitted infections, and viral hepatitis. Additionally, Global Plan priority countries have limited data on key SRH indicators such as unmet need for family planning, with variable coverage of antenatal care, HIV testing and triple antiretroviral therapy (ART) and very limited contact tracing. Structural equation modelling (SEM) and linear regression analysis demonstrated that ART access protects against percent MTCT (p<0.001); in simple linear regression it is 53% protective against percent MTCT. In contrast, SEM demonstrated that the case rate was driven by the number of HIV exposed infants (HEI) i.e. maternal HIV prevalence (p<0.001). In linear regression models, ART access alone explains only 17% of the case rate while HEI alone explains 81% of the case rate. In multiple regression, HEI and ART access accounts for 83% of the case rate, with HEI making the most contribution (coef. infant HIV exposure=82.8, 95% CI: 64.6, 101.1, p<0.001 vs coef. ART access=-3.0, 95% CI: -6.2, 0.3, p=0.074). CONCLUSION: Reducing infant HIV exposure, is critical to reducing the paediatric HIV case rate; increasing ART access is critical to reduce percent MTCT. Additionally, our study of four validated countries underscores the importance of contact tracing, strengthening programme monitoring, leadership and governance, as these are potentially-modifiable factors.


Assuntos
Síndrome de Imunodeficiência Adquirida/epidemiologia , Síndrome de Imunodeficiência Adquirida/transmissão , HIV/imunologia , Transmissão Vertical de Doença Infecciosa/prevenção & controle , Complicações Infecciosas na Gravidez/epidemiologia , Saúde Reprodutiva , Síndrome de Imunodeficiência Adquirida/prevenção & controle , Adolescente , África ao Sul do Saara/epidemiologia , Aleitamento Materno , Criança , Pré-Escolar , Busca de Comunicante , Feminino , Soropositividade para HIV , Humanos , Lactente , Lactação , Modelos Lineares , Masculino , Programas de Rastreamento , Mães/educação , Gravidez , Cuidado Pré-Natal , Prevalência , Serviços de Saúde Reprodutiva , Organização Mundial da Saúde , Adulto Jovem
4.
J Int AIDS Soc ; 22(7): e25352, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31298496

RESUMO

INTRODUCTION: The unexpected identification of a neural tube defect (NTD) safety signal with preconception dolutegravir (DTG) exposure in the Botswana Tsepamo birth outcomes study brought into sharp focus the need for reliable data on use of new antiretrovirals in pregnancy, improved pharmacovigilance systems to evaluate safety of new drugs being introduced into populations including women of reproductive potential, and balanced risk-benefit messaging when a safety signal is identified. DISCUSSION: The Tsepamo study NTD safety signal and accompanying regulatory responses led to uncertainty about the most appropriate approach to DTG use among women of reproductive potential, affecting global DTG roll-out plans, and limiting DTG use in adolescent girls and women. It also revealed a tension between a public health approach to antiretroviral treatment (ART) and individual choice, and highlighted difficulties interpreting and messaging an unexpected safety signal with uncertainty about risk. This difficulty was compounded by the lack of high-quality data on pregnancy outcomes from women receiving ART outside the Tsepamo surveillance sites and countries other than Botswana, resulting in a prolonged period of uncertainty while data on additional exposures are evaluated to refute or confirm the initial safety signal. We discuss principles for evaluating and introducing new drugs in the general population that would ensure collection of appropriate data to inform drug safety in adolescent girls and women of reproductive potential and minimize confusion about drug use in this population when a safety signal is identified. CONCLUSIONS: The response to a signal suggesting a possible safety risk for a drug used in pregnancy or among women who may become pregnant needs to be rapid and comprehensive. It requires the existence of appropriately designed surveillance systems with broad population coverage; data analyses that examine risk-benefit trade-offs in a variety of contexts; guidance to transform this risk-benefit balance into effective and agreed-upon policy; involvement of the affected community and other key stakeholders; and a communication plan for all levels of knowledge and complexity. Implementation of this proposed framework for responding to safety signals is needed to ensure that any drug used in pregnancy can be rapidly and appropriately evaluated should a serious safety alert arise.

7.
J Acquir Immune Defic Syndr ; 78 Suppl 2: S107-S114, 2018 08 15.
Artigo em Inglês | MEDLINE | ID: mdl-29994832

RESUMO

Despite dramatic global progress with implementing prevention of mother-to-child HIV transmission (PMTCT) programs, there were 160,000 new pediatric HIV infections in 2016. More than 50% of infant HIV infections now occur in the postpartum period, reflecting the relatively high coverage of interventions in the antenatal period and the need for greater attention to the breastfeeding mother and her HIV-exposed infant (HEI). Early diagnosis and treatment are critical to prevent morbidity and mortality in HIV-infected children; however, early infant HIV testing rates remain low in most high HIV-burden countries. Furthermore, systematic retention and follow-up of HEI in the postpartum period and ascertainment of final HIV status remain major program gaps. Despite multiple calls to action to improve infant HIV testing rates, progress has been marginal due to a lack of focus on the critical health care needs of HEI coupled with health system barriers that result in fragmented services for HIV-infected mothers and their families. In this paper, we describe the available evidence on the health outcomes of HEI, define a comprehensive care package for HEI that extends beyond early HIV testing, and describe successful examples of integrated services for HEI.


Assuntos
Infecções por HIV/transmissão , HIV/isolamento & purificação , Transmissão Vertical de Doença Infecciosa/prevenção & controle , Complicações Infecciosas na Gravidez/diagnóstico , Diagnóstico Precoce , Feminino , Infecções por HIV/diagnóstico , Infecções por HIV/prevenção & controle , Humanos , Lactente , Recém-Nascido , Masculino , Serviços de Saúde Materna , Período Pós-Parto , Gravidez , Diagnóstico Pré-Natal
8.
Artigo em Inglês | MEDLINE | ID: mdl-29910691

RESUMO

This is a protocol for a Cochrane Review (Diagnostic test accuracy). The objectives are as follows: To assess the accuracy of the four-symptom screen (cough, fever, night sweats, or weight loss) for identifying active TB in pregnant PLHIV who are screened in an outpatient or community setting. To investigate potential sources of heterogeneity of the accuracy of the four-symptom screen between studies including: ART status, CD4 cell count, gestational age, pregnancy stage (pregnancy vs. postpartum), screening test definition of cough (any cough vs. cough greater than 2 weeks).To describe the accuracy of single symptoms included within the four-symptom screen, additioal symptoms or symptom combinations, for identifying active TB in pregnant PLHIV. For example, additional symptoms may include failure to gain weight or fatigue.


Assuntos
Infecções por HIV , Complicações Infecciosas na Gravidez , Revisão Sistemática como Assunto , Tuberculose , Feminino , Infecções por HIV/complicações , Humanos , Gravidez , Complicações Infecciosas na Gravidez/diagnóstico , Tuberculose/diagnóstico
9.
J Int AIDS Soc ; 21(1)2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-29356376

RESUMO

INTRODUCTION: With the rapid scale-up of antiretroviral treatment (ART) in the "Treat All" era, there has been increasing emphasis on using differentiated models of HIV service delivery. The gaps within the clinical cascade for mothers and their infants suggest that current service delivery models are not meeting families' needs and prompt re-consideration of how services are provided. This article will explore considerations for differentiated care and encourage the ongoing increase of ART coverage through innovative strategies while also addressing the unique needs of mothers and infants. DISCUSSION: Service delivery models should recognize that the timing of the mother's HIV diagnosis is a critical aspect of determining eligibility. Women newly diagnosed with HIV require a more intensive approach so that adequate counselling and monitoring of ART initiation and response can be provided. Women already on ART with evidence of virologic failure are also at high risk of transmitting HIV to their infants and require close follow-up. However, women stable on ART with a suppressed viral load before conception have a very low likelihood of HIV transmission and thus are strong candidates for multi-month ART dispensing, community-based distribution of ART, adherence clubs, community adherence support groups and longer intervals between clinical visits. A number of other factors should be considered when defining eligibility of mothers and infants for differentiated care, including location of services, viral load monitoring and duration on ART. To provide differentiated care that is client-centred and driven while encompassing a family-based approach, it will be critical to engage mothers, families and communities in models that will optimize client satisfaction, retention in care and quality of services. CONCLUSIONS: Differentiated care for mothers and infants represents an opportunity to provide client-centred care that reduces the burden on clients and health systems while improving the quality and uptake of services for families. However, with decreasing funding, stable HIV incidence, and aspirations for sustainability, it is critical to consider efficient, customized and cost-effective models of care for these populations as we aspire to eliminate mother-to-child transmission of HIV.


Assuntos
Fármacos Anti-HIV/uso terapêutico , Aleitamento Materno , Assistência à Saúde , Infecções por HIV/tratamento farmacológico , Transmissão Vertical de Doença Infecciosa/prevenção & controle , Complicações Infecciosas na Gravidez/tratamento farmacológico , Adulto , Aconselhamento , Feminino , Humanos , Lactente , Gravidez
10.
J Int AIDS Soc ; 20(1): 21858, 2017 Aug 04.
Artigo em Inglês | MEDLINE | ID: mdl-28782334

RESUMO

INTRODUCTION: HIV-infected pregnant and breastfeeding adolescents are a particularly vulnerable group that require special attention and enhanced support to achieve optimal maternal and infant outcomes. The objective of this paper is to review published evidence about antenatal care (ANC) service delivery and outcomes for HIV-infected pregnant adolescents in low-income country settings, identify gaps in knowledge and programme services and highlight the way forward to improve clinical outcomes of this vulnerable group. DISCUSSION: Emerging data from programmes in sub-Saharan Africa highlight that HIV-infected pregnant adolescents have poorer prevention of mother-to-child HIV transmission (PMTCT) service outcomes, including lower PMTCT service uptake, compared to HIV-infected pregnant adults. In addition, the limited evidence available suggests that there may be higher rates of mother-to-child HIV transmission among infants of HIV-infected pregnant adolescents. CONCLUSIONS: While the reasons for the inferior outcomes among adolescents in ANC need to be further explored and addressed, there is sufficient evidence that immediate operational changes are needed to address the unique needs of this population. Such changes could include integration of adolescent-friendly services into PMTCT settings or targeting HIV-infected pregnant adolescents with enhanced retention and follow-up activities.


Assuntos
Assistência à Saúde , Infecções por HIV , Complicações Infecciosas na Gravidez/tratamento farmacológico , Cuidado Pré-Natal , Adolescente , África ao Sul do Saara , Feminino , Infecções por HIV/diagnóstico , Infecções por HIV/tratamento farmacológico , Infecções por HIV/transmissão , Humanos , Transmissão Vertical de Doença Infecciosa/prevenção & controle , Gravidez , Complicações Infecciosas na Gravidez/diagnóstico , Adulto Jovem
11.
AIDS ; 31(10): 1489-1493, 2017 06 19.
Artigo em Inglês | MEDLINE | ID: mdl-28574966

RESUMO

: In 2015, the WHO recommended universal antiretroviral therapy (ART) for all people living with HIV after two randomized controlled trials revealed lower rates of mortality and serious illnesses among people living with HIV receiving immediate ART compared with those receiving deferred ART. Many countries in sub-Saharan Africa rapidly adopted this guidance and are implementing 'test and start' programs.As this work begins, lessons learned from prevention of mother-to-child transmission Option B+ programs can inform decisions for new universal HIV treatment programs. The Option B+ approach involved initiation of lifelong treatment for all HIV-infected pregnant and breastfeeding women. Since its inception in Malawi in 2011 and WHO endorsement in 2012, widespread scale-up of Option B+ prevention of mother-to-child transmission programs in most resource-limited countries has resulted in a dramatic increase in ART coverage for HIV-infected pregnant and breastfeeding women.Despite the overall success of the Option B+ universal lifelong treatment approach, program and operational research data highlight the need for additional focus on strategies to retain women in care. In this commentary, we highlight program considerations and lessons learned from Option B+ implementation experience in resource-limited countries, which may help guide decisions and enhance the quality of general 'test and start' programing.


Assuntos
Antirretrovirais/uso terapêutico , Aleitamento Materno , Gerenciamento Clínico , Infecções por HIV/tratamento farmacológico , Transmissão Vertical de Doença Infecciosa/prevenção & controle , Complicações Infecciosas na Gravidez/tratamento farmacológico , Feminino , Infecções por HIV/diagnóstico , Infecções por HIV/transmissão , Humanos , Aprendizagem , Malaui , Masculino , Gravidez , Complicações Infecciosas na Gravidez/diagnóstico
12.
J Acquir Immune Defic Syndr ; 75 Suppl 1: S76-S85, 2017 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-28399000

RESUMO

To meet the ambitious targets set by the Global Plan Towards the Elimination of New HIV Infections Among Children by 2015 and Keeping Their Mothers Alive (Global Plan), the initial 22 priority countries quickly developed innovative approaches for overcoming long-standing health systems challenges and providing HIV testing and treatment to pregnant and breastfeeding women and their infants. The Global Plan spurred programs for prevention of mother-to-child HIV transmission to integrate HIV-related care and treatment into broader maternal, newborn, and child health services; expand the effectiveness of the health workforce through task sharing; extend health services into communities; strengthen supply chain and commodity management systems; reduce diagnostic and laboratory hurdles; and strengthen strategic supervision and mentorship. The article reviews the ongoing challenges for prevention of mother-to-child HIV transmission programs as they continue to strive for elimination of vertical transmission of HIV infection in the post-Global Plan era. Although progress has been rapid, health systems still face important challenges, particularly follow-up and diagnosis of HIV-exposed infants, continuity of care, and the promotion of services that are respectful and client centered.


Assuntos
Diagnóstico Precoce , Infecções por HIV/diagnóstico , Infecções por HIV/tratamento farmacológico , Acesso aos Serviços de Saúde , Transmissão Vertical de Doença Infecciosa/prevenção & controle , Prevenção Secundária , Controle de Doenças Transmissíveis/organização & administração , Continuidade da Assistência ao Paciente/organização & administração , Feminino , Saúde Global , Infecções por HIV/prevenção & controle , Humanos , Recém-Nascido , Gravidez , Nações Unidas
13.
BMC Infect Dis ; 17(1): 191, 2017 Mar 06.
Artigo em Inglês | MEDLINE | ID: mdl-28264655

RESUMO

BACKGROUND: Diagnosis of tuberculosis is difficult among pregnant women because the signs and symptoms of the disease, such as fatigue, shortness of breath, sweating, cough, and mild fever are similar to some manifestations of pregnancy. It is particularly challenging among HIV-infected women as symptoms are often masked or atypical. Currently, WHO recommends a standard four-symptom screening tool for pregnant and lactating women. There is evidence from South Africa that this screening tool (which, despite complex symptomology in this population, recommends identification of patients with weight loss, fever, current cough and night sweats), may be missing true active TB cases. However there exist several laboratory and clinical procedures that have the potential to improve the sensitivity and specificity of this screening tool. METHODS: This study will evaluate the sensitivity and specificity of the current TB screening tool for pregnant and lactating women, both HIV positive and negative. We will also assess several different enhanced screening algorithm using LAM, IGRA, TST and chest radiography and clinical/laboratory procedures and tests. The study will use a cross-sectional analytical study design involving pregnant and lactating women up to six months post-delivery attending antenatal or postnatal care, respectively in one of three selected public health units in Swaziland. Participants will be consecutively enrolled and will be in one of four groups of interest: HIV infected pregnant women, non-HIV infected pregnant women, HIV infected lactating women and non-HIV infected lactating women. DISCUSSION: We expect in conducting all procedures on all participants regardless of result of the symptom screening we may experience a high refusal rate. However, this risk will be mitigated by the long data collection period of five or more months.


Assuntos
Cuidado Pós-Natal/métodos , Complicações Infecciosas na Gravidez/diagnóstico , Cuidado Pré-Natal/métodos , Tuberculose/diagnóstico , Adolescente , Adulto , Algoritmos , Protocolos Clínicos , Coinfecção/diagnóstico , Estudos Transversais , Feminino , Infecções por HIV/complicações , Humanos , Lactação , Gravidez , Sensibilidade e Especificidade , Tuberculose/complicações , Adulto Jovem
14.
AIDS Res Hum Retroviruses ; 33(3): 203-210, 2017 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-27758117

RESUMO

Early diagnosis of HIV infection in infants and children remains a challenge in resource-limited settings, with approximately half of all HIV-exposed infants receiving virological testing for HIV by the recommended age of 2 months in 2015. To reduce morbidity and mortality among HIV-infected children and close the treatment gap for HIV-infected children, there is an urgent need to evaluate existing programmatic and laboratory practices for early infant diagnosis and introduce strategies to improve identification of HIV-exposed infants and ensure access to systematic, early HIV testing, with early linkage to treatment for HIV-infected infants. This article describes progress made in follow-up of HIV-exposed infants since 2006, including remaining unmet laboratory and programmatic needs, and recommends strategies for improvement, especially those related to the implementation of point-of-care technology for early infant diagnosis.


Assuntos
Infecções por HIV/diagnóstico , Programas de Rastreamento/métodos , Programas de Rastreamento/organização & administração , Sistemas Automatizados de Assistência Junto ao Leito , Diagnóstico Precoce , Humanos , Lactente
15.
PLoS One ; 11(12): e0167685, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-27936146

RESUMO

OBJECTIVE: To assess the performance of symptom-based screening for tuberculosis (TB), alone and with chest radiography among people living with HIV (PLHIV), including pregnant women, in Western Kenya. DESIGN: Prospective cohort study. METHODS: PLHIV from 15 randomly-selected HIV clinics were screened with three clinical algorithms [World Health Organization (WHO), Ministry of Health (MOH), and "Improving Diagnosis of TB in HIV-infected persons" (ID-TB/HIV) study], underwent chest radiography (unless pregnant), and provided two or more sputum specimens for smear microscopy, liquid culture, and Xpert MTB/RIF. Performance of clinical screening was compared to laboratory results, controlling for the complex design of the survey. RESULTS: Overall, 738 (85.6%) of 862 PLHIV enrolled were included in the analysis. Estimated TB prevalence was 11.2% (95% CI, 9.9-12.7). Sensitivity of the three screening algorithms was similar [WHO, 74.1% (95% CI, 64.1-82.2); MOH, 77.5% (95% CI, 68.6-84.5); and ID-TB/HIV, 72.5% (95% CI, 60.9-81.7)]. Sensitivity of the WHO algorithm was significantly lower among HIV-infected pregnant women [28.2% (95% CI, 14.9-46.7)] compared to non-pregnant women [78.3% (95% CI, 67.3-86.4)] and men [77.2% (95% CI, 68.3-84.2)]. Chest radiography increased WHO algorithm sensitivity and negative predictive value to 90.9% (95% CI, 86.4-93.9) and 96.1% (95% CI, 94.4-97.3), respectively, among asymptomatic men and non-pregnant women. CONCLUSIONS: Clinical screening missed approximately 25% of laboratory-confirmed TB cases among all PLHIV and more than 70% among HIV-infected pregnant women. National HIV programs should evaluate the feasibility of laboratory-based screening for TB, such as a single Xpert MTB/RIF test for all PLHIV, especially pregnant women, at enrollment in HIV services.


Assuntos
Infecções por HIV/complicações , Tuberculose/complicações , Tuberculose/diagnóstico , Adolescente , Adulto , Feminino , Infecções por HIV/epidemiologia , Humanos , Quênia/epidemiologia , Masculino , Radiografia Pulmonar de Massa , Pessoa de Meia-Idade , Gravidez , Estudos Prospectivos , Tuberculose/epidemiologia , Adulto Jovem
16.
J Acquir Immune Defic Syndr ; 73(4): 454-462, 2016 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-27792684

RESUMO

BACKGROUND: Early antiretroviral therapy (ART) initiation in HIV-infected infants significantly improves survival but is often delayed in resource-limited settings. Adding HIV testing of infants at birth to the current recommendation of testing at age 4-6 weeks may improve testing rates and decrease time to ART initiation. We modeled the benefit of adding HIV testing at birth to the current 6-week testing algorithm. METHODS: Microsoft Excel was used to create a decision-tree model of the care continuum for the estimated 1,400,000 HIV-infected women and their infants in sub-Saharan Africa in 2012. The model assumed average published rates for facility births (42.9%), prevention of mother-to-child HIV transmission utilization (63%), mother-to-child-transmission rates based on prevention of mother-to-child HIV transmission regimen (5%-40%), return of test results (41%), enrollment in HIV care (52%), and ART initiation (54%). We conducted sensitivity analyses to model the impact of key variables and applied the model to specific country examples. RESULTS: Adding HIV testing at birth would increase the number of infants on ART by 204% by age 18 months. The greatest increase is seen in early ART initiations (543% by age 3 months). The increase would lead to a corresponding increase in survival at 12 months of age, with 5108 fewer infant deaths (44,550, versus 49,658). CONCLUSION: Adding HIV testing at birth has the potential to improve the number and timing of ART initiation of HIV-infected infants, leading to a decrease in infant mortality. Using this model, countries should investigate a combination of HIV testing at birth and during the early infant period.


Assuntos
Fármacos Anti-HIV/uso terapêutico , DNA Viral/isolamento & purificação , Países em Desenvolvimento , Infecções por HIV/diagnóstico , Modelos Teóricos , Reação em Cadeia da Polimerase/métodos , África ao Sul do Saara/epidemiologia , Feminino , Infecções por HIV/tratamento farmacológico , Infecções por HIV/epidemiologia , Custos de Cuidados de Saúde , Humanos , Lactente , Mortalidade Infantil , Recém-Nascido , Transmissão Vertical de Doença Infecciosa , Gravidez , Sensibilidade e Especificidade
17.
PLoS One ; 11(3): e0152364, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-27023213

RESUMO

BACKGROUND: Diagnosis followed by effective treatment of tuberculosis (TB) reduces transmission and saves lives in persons living with HIV (PLHIV). Sputum smear microscopy is widely used for diagnosis, despite limited sensitivity in PLHIV. Evidence is needed to determine the optimal diagnostic approach for these patients. METHODS: From May 2011 through June 2012, we recruited PLHIV from 15 HIV treatment centers in western Kenya. We collected up to three sputum specimens for Ziehl-Neelsen (ZN) and fluorescence microscopy (FM), GeneXpert MTB/RIF (Xpert), and culture, regardless of symptoms. We calculated the incremental yield of each test, stratifying results by CD4 cell count and specimen type; data were analyzed to account for complex sampling. RESULTS: From 778 enrolled patients, we identified 88 (11.3%) laboratory-confirmed TB cases. Of the 74 cases who submitted 2 specimens for microscopy and Xpert testing, ZN microscopy identified 25 (33.6%); Xpert identified those plus an additional 18 (incremental yield = 24.4%). Xpert testing of spot specimens identified 48 (57.0%) of 84 cases; whereas Xpert testing of morning specimens identified 50 (66.0%) of 76 cases. Two Xpert tests detected 22/24 (92.0%) TB cases with CD4 counts <100 cells/µL and 30/45 (67.0%) of cases with CD4 counts ≥100 cells/µl. CONCLUSIONS: In PLHIV, Xpert substantially increased diagnostic yield compared to smear microscopy and had the highest yield when used to test morning specimens and specimens from PLHIV with CD4 count <100 cells/µL. TB programs unable to replace smear microscopy with Xpert for all symptomatic PLHIV should consider targeted replacement and using morning specimens.


Assuntos
Testes Diagnósticos de Rotina , Infecções por HIV/complicações , Tuberculose/complicações , Tuberculose/diagnóstico , Adulto , Contagem de Linfócito CD4 , Demografia , Feminino , Infecções por HIV/imunologia , Humanos , Quênia , Masculino , Sensibilidade e Especificidade , Escarro/microbiologia , Adulto Jovem
18.
J Acquir Immune Defic Syndr ; 68 Suppl 3: S270-3, 2015 Apr 15.
Artigo em Inglês | MEDLINE | ID: mdl-25768866

RESUMO

Tuberculosis (TB) continues to be the leading cause of morbidity and mortality among people living with HIV (PLHIV), making improved prevention and treatment of HIV-associated TB critical to ensuring long-term survival of PLHIV. TB screening among PLHIV is central to implementation of the World Health Organization's 3 I's interventions for reducing the impact of the TB and HIV syndemics. Effective TB screening will result in the identification of PLHIV with presumptive TB disease (ie, those with a positive symptom screen who require appropriate evaluation, including the use of diagnostic tools such as the Xpert MTB/RIF assay) and those eligible for isoniazid preventive therapy (ie, those who have a negative clinical symptom screen or who have a positive screen but are found not to have TB disease). Identification of PLHIV with presumptive TB also facilitates implementation of basic administrative measures for TB infection control, including fast tracking of coughing patients and separation from noncoughing PLHIV to reduce TB transmission. By contributing to the early diagnosis of TB disease among PLHIV, TB screening is also critical to facilitate early initiation of antiretroviral treatment among PLHIV diagnosed with TB disease who might not otherwise be eligible for antiretroviral treatment based on CD4 count or clinical staging. TB screening thus serves as a gateway for multiple TB/HIV interventions and is an integral part of routine clinical services for PLHIV at each clinic visit.


Assuntos
Infecções Oportunistas Relacionadas com a AIDS/tratamento farmacológico , Antituberculosos/uso terapêutico , Infecções por HIV/complicações , Programas de Rastreamento , Tuberculose/diagnóstico , Infecções Oportunistas Relacionadas com a AIDS/complicações , Infecções Oportunistas Relacionadas com a AIDS/economia , Infecções Oportunistas Relacionadas com a AIDS/epidemiologia , Contagem de Linfócito CD4 , Infecções por HIV/tratamento farmacológico , Infecções por HIV/economia , Infecções por HIV/epidemiologia , Recursos em Saúde , Humanos , Isoniazida/uso terapêutico , Tuberculose/complicações , Tuberculose/mortalidade , Tuberculose/prevenção & controle , Organização Mundial da Saúde
19.
J Acquir Immune Defic Syndr ; 68 Suppl 3: S297-305, 2015 Apr 15.
Artigo em Inglês | MEDLINE | ID: mdl-25768869

RESUMO

BACKGROUND: Tuberculosis (TB) is the leading preventable cause of death in persons living with HIV (PLHIV), accounting for over a quarter of all HIV-associated deaths in 2012. Isoniazid preventive therapy (IPT) has the potential to decrease TB-related cases and deaths in PLHIV; however, implementation of this has been slow in many high HIV- and TB-burden settings. METHODOLOGY: We performed an assessment of the evidence for the use of IPT in adults living with HIV based on a review of the literature published from 1995 to 2013. Eligible articles included data on mortality, morbidity, or retention in care related to the provision of IPT to adults with HIV in low- or middle-income countries. Cost-effectiveness information was also abstracted. RESULTS: We identified 41 articles involving over 45,000 PLHIV. While there was little evidence to demonstrate that IPT reduced mortality in PLHIV, there was substantial evidence that IPT reduced TB incidence. While these findings were consistent irrespective of CD4 or antiretroviral therapy status, studies frequently demonstrated a greater benefit among patients with a positive TB skin test (TST). Duration of effectiveness and benefits of prolonged therapy varied across settings. CONCLUSIONS: This analysis supports World Health Organization recommendations for the provision of IPT to PLHIV to reduce TB-associated morbidity and serves to highlight the need to strengthen IPT implementation. While there appears to be a greater benefit of IPT among PLHIV who are TST positive, IPT should be provided to all PLHIV without presumptive TB when TST is not available.


Assuntos
Antituberculosos/uso terapêutico , Infecções por HIV/complicações , Isoniazida/uso terapêutico , Tuberculose/prevenção & controle , Adulto , Contagem de Linfócito CD4 , Países em Desenvolvimento , Infecções por HIV/tratamento farmacológico , Infecções por HIV/epidemiologia , Recursos em Saúde , Humanos , Tuberculose/complicações , Tuberculose/tratamento farmacológico , Tuberculose/epidemiologia
20.
AIDS ; 27 Suppl 2: S159-67, 2013 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-24361625

RESUMO

OBJECTIVE: Although antiretroviral treatment (ART) has reduced the incidence of HIV-related opportunistic infections among children living with HIV, access to ART remains limited for children, especially in resource-limited settings. This paper reviews current knowledge on the contribution of opportunistic infections and common childhood illnesses to morbidity and mortality in children living with HIV, highlights interventions known to improve the health of children, and identifies research gaps for further exploration. DESIGN AND METHODS: Literature review of peer-reviewed articles and abstracts combined with expert opinion and operational experience. RESULTS: Morbidity and mortality due to opportunistic infections has decreased in both developed and resource-limited countries. However, the burden of HIV-related infections remains high, especially in sub-Saharan Africa, where the majority of HIV-infected children live. Limitations in diagnostic capacity in resource-limited settings have resulted in a relative paucity of data on opportunistic infections in children. Additionally, the reliance on clinical diagnosis means that opportunistic infections are often confused with common childhood illnesseswhich also contribute to excess morbidity and mortality in these children. Although several preventive interventions have been shown to decrease opportunistic infection-related mortality, implementation of many of these interventions remains inconsistent. CONCLUSIONS: In order to reduce opportunistic infection-related mortality, early ART must be expanded, training for front-line clinicians must be improved, and additional research is needed to improve screening and diagnostic algorithms.


Assuntos
Infecções Oportunistas Relacionadas com a AIDS/mortalidade , Doenças Transmissíveis/mortalidade , Infecções por HIV/mortalidade , Recursos em Saúde/provisão & distribução , Acesso aos Serviços de Saúde , Infecções Oportunistas Relacionadas com a AIDS/diagnóstico , Infecções Oportunistas Relacionadas com a AIDS/prevenção & controle , Fármacos Anti-HIV/uso terapêutico , Antirretrovirais/uso terapêutico , Criança , Pré-Escolar , Controle de Doenças Transmissíveis , Doenças Transmissíveis/diagnóstico , Países em Desenvolvimento/estatística & dados numéricos , Feminino , Infecções por HIV/diagnóstico , Infecções por HIV/prevenção & controle , Humanos , Lactente , Recém-Nascido , Masculino , Determinantes Sociais da Saúde , Tempo para o Tratamento/normas , Tempo para o Tratamento/estatística & dados numéricos
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