Your browser doesn't support javascript.
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 23
Filtrar
Mais filtros










Base de dados
Intervalo de ano de publicação
1.
Lancet Infect Dis ; 16(4): 493-9, 2016 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-26907735

RESUMO

Choroidal tuberculosis is present in 5-20% of patients with disseminated tuberculosis, and point-of-care dilated binocular indirect ophthalmoscopy eye examination can provide immediate diagnosis. In geographical areas of high tuberculosis prevalence and in susceptible patients (CD4 counts less than 200 cells per µL) detection of choroidal granulomas should be accepted as evidence of disseminated tuberculosis. With training and proper support, eye screening can be done by HIV/AIDS clinicians, allowing early tuberculosis treatment. In regions with a high burden of tuberculosis, we recommend that eye screening be a standard part of the initial assessment of susceptible patients, including at a minimum all patients with HIV/AIDS with CD4 less than 100 cells per µL with or without eye symptoms, and with or without suspicion of disseminated tuberculosis.


Assuntos
Infecções Oportunistas Relacionadas com a AIDS/diagnóstico , Síndrome de Imunodeficiência Adquirida/complicações , Doenças da Coroide/diagnóstico , Granuloma/diagnóstico , Tuberculose/diagnóstico , Infecções Oportunistas Relacionadas com a AIDS/complicações , Infecções Oportunistas Relacionadas com a AIDS/microbiologia , Síndrome de Imunodeficiência Adquirida/microbiologia , Doenças da Coroide/microbiologia , Diagnóstico Precoce , Olho/microbiologia , Granuloma/microbiologia , Humanos , Oftalmoscopia , Disco Óptico/patologia , Sistemas Automatizados de Assistência Junto ao Leito , Prevalência , Tuberculose/complicações , Tuberculose/microbiologia , Tuberculose Ocular/complicações , Tuberculose Ocular/diagnóstico , Tuberculose Ocular/microbiologia
2.
PLoS One ; 10(12): e0144656, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-26670929

RESUMO

BACKGROUND: The Xpert® MTB/RIF (Xpert) is an automated molecular test for simultaneous detection of tuberculosis (TB) and rifampicin resistance, recommended by the World Health Organization as the preferred diagnostic method for individuals presumed to have multi-drug resistant TB (MDR-TB) or HIV-associated TB. We describe the performance of Xpert and key lessons learned during two years of implementation under routine conditions in 33 projects located in 18 countries supported by Médecins Sans Frontières across varied geographic, epidemiological and clinical settings. METHODS: Xpert was used following three strategies: the first being as the initial test, with microscopy in parallel, for all presumptive TB cases; the second being only for patients at risk of MDR-TB, or with HIV- associated TB, or presumptive paediatric TB; and the third being as the initial test for these high-risk patients plus as an add-on test to microscopy in others. Routine laboratory data were collected, using laboratory registers. Qualitative data such as logistic aspects, human resources, and tool acceptance were collected using a questionnaire. FINDINGS: In total, 52,863 samples underwent Xpert testing from April 2011 to December 2012. The average MTB detection rate was 18.5%, 22.3%, and 11.6% for the three different strategies respectively. Analysis of the results on samples tested in parallel showed that using Xpert as add-on test to microscopy would have increased laboratory TB confirmation by 49.7%, versus 42.3% for Xpert replacing microscopy. The main limitation of the test was the high rate of inconclusive results, which correlated with factors such as defective modules, cartridge version (G3 vs. G4) and staff experience. Operational and logistical hurdles included infrastructure renovation, basic computer training, regular instrument troubleshooting and maintenance, all of which required substantial and continuous support. CONCLUSION: The implementation of Xpert was feasible and significantly increased TB detection compared to microscopy, despite the high rate of inconclusive results. Xpert implementation was accompanied by considerable operational and logistical challenges. To further decentralize diagnosis, simpler, low-cost TB technologies well-suited to low-resource settings are still urgently needed.


Assuntos
Testes Diagnósticos de Rotina , Farmacorresistência Bacteriana , Kit de Reagentes para Diagnóstico , Rifampina/uso terapêutico , Tuberculose/diagnóstico , Tuberculose/tratamento farmacológico , Adulto , Criança , Farmacorresistência Bacteriana/efeitos dos fármacos , Humanos , Rifampina/farmacologia , Fatores de Risco , Escarro/microbiologia , Inquéritos e Questionários , Resultado do Tratamento
3.
PLoS One ; 10(1): e0116798, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-25606853

RESUMO

BACKGROUND: While the high burden of multidrug-resistant tuberculosis (MDR-TB) itself is a matter of great concern, the emergence and rise of advanced forms of drug-resistance such as extensively drug-resistant TB (XDR-TB) and extremely drug-resistant TB (XXDR-TB) is more troubling. The aim of this study was to investigate the trends over time of patterns of drug resistance in a sample of MDR-TB patients in greater metropolitan Mumbai, India. METHODS: This was a retrospective, observational study of drug susceptibility testing (DST) results among MDR-TB patients from eight health care facilities in greater Mumbai between 2005 and 2013. We classified resistance patterns into four categories: MDR-TB, pre-XDR-TB, XDR-TB and XXDR-TB. RESULTS: A total of 340 MDR-TB patients were included in the study. Pre-XDR-TB was the most common form of drug-resistant TB observed overall in this Mumbai population at 56.8% compared to 29.4% for MDR-TB. The proportion of patients with MDR-TB was 39.4% in the period 2005-2007 and 27.8% in 2011-2013, while the proportion of those with XDR-TB and XXDR-TB was changed from 6.1% and 0% respectively to 10.6% and 5.6% during the same time period. During the same periods, the proportions of patients with ofloxacin, moxifloxacin and ethionamide resistance significantly increased from 57.6% to 75.3%, from 60.0% to 69.5% and from 24.2% to 52.5% respectively (p<0.05). DISCUSSION: The observed trends in TB drug-resistance patterns in Mumbai highlight the need for individualized drug regimens, designed on the basis of DST results involving first- and second-line anti-TB drugs and treatment history of the patient. A drug-resistant TB case-finding strategy based on molecular techniques that identify only rifampicin resistance will lead to initiation of suboptimal treatment regimens for a significant number of patients, which may in turn contribute to amplification of resistance and transmission of strains with increasingly advanced resistance within the community.


Assuntos
Antituberculosos/farmacologia , Mycobacterium tuberculosis/efeitos dos fármacos , Mycobacterium tuberculosis/isolamento & purificação , Tuberculose Resistente a Múltiplos Medicamentos/epidemiologia , Tuberculose Resistente a Múltiplos Medicamentos/microbiologia , Adolescente , Adulto , Idoso , Criança , Pré-Escolar , Farmacorresistência Bacteriana Múltipla , Etionamida/farmacologia , Feminino , Fluoroquinolonas/farmacologia , Humanos , Índia/epidemiologia , Lactente , Masculino , Testes de Sensibilidade Microbiana , Pessoa de Meia-Idade , Moxifloxacina , Ofloxacino/farmacologia , Medicina de Precisão , Estudos Retrospectivos , Tuberculose Resistente a Múltiplos Medicamentos/classificação , Adulto Jovem
4.
PLoS One ; 9(10): e110461, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-25333696

RESUMO

BACKGROUND: Drug-resistant tuberculosis (DR-TB) is a looming threat to tuberculosis control in India. However, no countrywide prevalence data are available. The burden of DR-TB in HIV-co-infected patients is likewise unknown. Undiagnosed and untreated DR-TB among HIV-infected patients is a major cause of mortality and morbidity. We aimed to assess the prevalence of DR-TB (defined as resistance to any anti-TB drug) in patients attending public antiretroviral treatment (ART) centers in greater metropolitan Mumbai, India. METHODS: A cross-sectional survey was conducted among adults and children ART-center attendees. Smear microscopy, culture and drug-susceptibility-testing (DST) against all first and second-line TB-drugs using phenotypic liquid culture (MGIT) were conducted on all presumptive tuberculosis patients. Analyses were performed to determine DR-TB prevalence and resistance patterns separately for new and previously treated, culture-positive TB-cases. RESULTS: Between March 2013 and January 2014, ART-center attendees were screened during 14135 visits, of whom 1724 had presumptive TB. Of 1724 attendees, 72 (4%) were smear-positive and 202 (12%) had a positive culture for Mycobacterium tuberculosis. Overall DR-TB was diagnosed in 68 (34%, 95% CI: 27%-40%) TB-patients. The proportions of DR-TB were 25% (29/114) and 44% (39/88) among new and previously treated cases respectively. The patterns of DR-TB were: 21% mono-resistant, 12% poly-resistant, 38% multidrug-resistant (MDR-TB), 21% pre-extensively-drug-resistant (MDR-TB plus resistance to either a fluoroquinolone or second-line injectable), 6% extensively drug-resistant (XDR-TB) and 2% extremely drug-resistant TB (XDR-TB plus resistance to any group-IV/V drug). Only previous history of TB was significantly associated with the diagnosis of DR-TB in multivariate models. CONCLUSION: The burden of DR-TB among HIV-infected patients attending public ART-centers in Mumbai was alarmingly high, likely representing ongoing transmission in the community and health facilities. These data highlight the need to promptly diagnose drug-resistance among all HIV-infected patients by systematically offering access to first and second-line DST to all patients with 'presumptive TB' rather than 'presumptive DR-TB' and tailor the treatment regimen based on the resistance patterns.


Assuntos
Infecções por HIV/diagnóstico , Mycobacterium tuberculosis/isolamento & purificação , Tuberculose/epidemiologia , Adolescente , Adulto , Antituberculosos/uso terapêutico , Grupo com Ancestrais do Continente Asiático , Criança , Estudos Transversais , Demografia , Quimioterapia Combinada , Feminino , Infecções por HIV/complicações , Humanos , Índia , Masculino , Prevalência , Tuberculose/complicações , Tuberculose/tratamento farmacológico , Tuberculose Resistente a Múltiplos Medicamentos/complicações , Tuberculose Resistente a Múltiplos Medicamentos/tratamento farmacológico , Tuberculose Resistente a Múltiplos Medicamentos/epidemiologia , Tuberculose Pulmonar/complicações , Tuberculose Pulmonar/tratamento farmacológico , Tuberculose Pulmonar/epidemiologia
5.
PLoS One ; 9(9): e108186, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-25259868

RESUMO

BACKGROUND: Multiple strategies are being adopted by national tuberculosis (TB) programmes to achieve universal coverage of tuberculosis treatment. However, populations living in 'hard-to-reach' areas of north-east India have poor access to health services. Our study aimed to detail treatment outcomes in TB program supported by Médecins Sans Frontières (MSF) and using an alternative model of TB treatment delivery in Mon district, Nagaland, India. METHODS: This was a retrospective cohort study of TB patients, initiated on self-administered therapy (SAT) through Mon District Hospital, Nagaland, India between April 2012 and March 2013. RESULTS: A total of 238 tuberculosis patients had final TB treatment outcomes during the study period, including 82 and 156 from semi-urban and rural areas respectively. The majority of patients (62%, 147/238) were suffering from pulmonary, smear-positive tuberculosis. Overall, 74% of patients (175/238) had successful outcomes, being cured or having completed their treatment. Females (81%), pulmonary TB patients (75%) and those on a Category I regimen (79%) had better treatment success rates than males (67%), extra-pulmonary TB patients (62%) and patients on a Category II regimen (61%). The univariate and bivariate analyses found age, sex and TB treatment regimen significantly associated with unsuccessful TB treatment outcomes (defined as death, loss-to-follow-up and failure). However, only older age showed significance in a multivariate binary logistic regression model. CONCLUSION: Our study suggests that self-administered TB treatment is feasible for patients living in areas with limited or no access to health services. The relatively low number of patients with adverse outcomes suggests that SAT models are safe; other advantages include the need for fewer resources and less frequent movements by patients. National TB programmes should consider allowing SAT strategies for delivery of TB treatment to 'hard-to-reach' populations, which could in turn help to achieve universal coverage and contribute to global TB elimination by 2050.


Assuntos
Antituberculosos/uso terapêutico , Tuberculose/tratamento farmacológico , Adolescente , Adulto , Antituberculosos/administração & dosagem , Criança , Pré-Escolar , Feminino , Humanos , Índia/epidemiologia , Lactente , Recém-Nascido , Masculino , Pessoa de Meia-Idade , Vigilância em Saúde Pública , Estudos Retrospectivos , Fatores de Risco , Autoadministração , Falha de Tratamento , Resultado do Tratamento , Tuberculose/diagnóstico , Tuberculose/epidemiologia , Adulto Jovem
6.
Glob Health Action ; 7: 24861, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-25084835

RESUMO

BACKGROUND: There are limited data on the failure of second-line antiretroviral therapy (ART) and the use of third-line ART in people living with HIV in resource-limited settings. Since 2011, the Médecins Sans Frontières (MSF) HIV/tuberculosis programme in Mumbai, India, has been providing third-line ART to patients in care. OBJECTIVE: To describe the experiences and programmatic challenges during management of suspected second-line ART failure and third-line ART therapy for patients living with HIV, including the use of HIV viral load (VL) testing. DESIGN: This was a retrospective, observational cohort study of patients with suspected second-line ART treatment failure, who were followed for at least 12 months between January 2011 and March 2014. RESULTS: A total of 47 patients with suspected second-line failure met the inclusion criteria during the study period. Twenty-nine of them (62%) responded to enhanced adherence support, had a subsequent undetectable VL after a median duration of 3 months and remained on second-line ART. The other 18 patients had to be initiated on a third-line ART regimen, which consisted of darunavir-ritonavir, raltegravir, and one or more appropriate nucleoside or nucleotide reverse transcriptase inhibitors, based on the results of HIV genotype testing. Of the 13 patients for whom follow-up VL results were available, 11 achieved virological suppression after a median duration of 3 months on third-line ART (interquartile range: 2.5-3.0). No serious treatment-related adverse events were recorded. CONCLUSIONS: With intensive counselling and adherence support in those suspected of failing second-line ART, unnecessary switching to more expensive third-line ART can be averted in the majority of cases. However, there is an increasing need for access to third-line ART medications such as darunavir and raltegravir, for which national ART programmes should be prepared. The cost of such medications and inadequate access to VL monitoring and HIV genotype testing are currently major barriers to optimal management of patients failing second-line ART.


Assuntos
Fármacos Anti-HIV/uso terapêutico , Infecções por HIV/tratamento farmacológico , Adulto , Contagem de Linfócito CD4 , Feminino , Humanos , Índia/epidemiologia , Masculino , Adesão à Medicação , Pessoa de Meia-Idade , Estudos Retrospectivos , Falha de Tratamento , Resultado do Tratamento , Carga Viral
8.
BMC Res Notes ; 7: 537, 2014 Aug 15.
Artigo em Inglês | MEDLINE | ID: mdl-25128289

RESUMO

BACKGROUND: The second-line anti-tuberculosis drugs used in the treatment of multidrug-resistant tuberculosis often cause adverse events, especially in patients co-infected with the human immunodeficiency virus. Severe hypersensitivity reactions due to these drugs are rare and there is little published experience to guide their management. CASE PRESENTATION: A 17-year old Indian female multidrug-resistant tuberculosis patient co-infected with human immunodeficiency virus developed a hypersensitivity reaction after starting second-line anti-tuberculosis treatment in Mumbai, India. The patient was being treated with kanamycin, moxifloxacin, para-aminosalicylic acid, cycloserine, clofazimine, and amoxicillin-clavulanic acid. Twenty-four hours later, the patient developed generalized urticaria, morbilliform rash and fever. All drugs were suspended and the patient was hospitalised for acute management. Skin patch-testing was used to identify drugs that potentially caused the hypersensitivity reaction; results showed a strong reaction to clofazimine, moderate reaction to kanamycin and mild reaction to cycloserine. An interim second-line anti-tuberculosis regimen was prescribed; cycloserine and kanamycin were then re-challenged one-by-one using incremental dosing, an approach that allowed clinicians to re-introduce these drugs promptly and safely. The patient is currently doing well. CONCLUSIONS: This is the first case-report of a multidrug-resistant tuberculosis patient co-infected with the human immunodeficiency virus with hypersensitivity reaction to multiple second-line anti-tuberculosis drugs. Skin patch-testing and controlled re-challenge can be a useful management strategy in such patients. There is an urgent need for second-line anti-tuberculosis regimens that are more effective, safe and better tolerated.


Assuntos
Antituberculosos/efeitos adversos , Antituberculosos/uso terapêutico , Hipersensibilidade a Drogas/etiologia , Testes do Emplastro , Tuberculose/tratamento farmacológico , Adolescente , Terapia Antirretroviral de Alta Atividade , Ciclosserina/uso terapêutico , Relação Dose-Resposta a Droga , Feminino , Humanos , Canamicina/uso terapêutico , Infecções Oportunistas/tratamento farmacológico , Infecções Oportunistas/prevenção & controle , Tuberculose/prevenção & controle
9.
Bull World Health Organ ; 92(12): 903-8, 2014 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-25552774

RESUMO

PROBLEM: Acquired immunodeficiency syndrome (AIDS)-related cytomegalovirus (CMV) retinitis continues to be a neglected source of blindness in resource-poor settings. The main issue is lack of capacity to diagnose CMV retinitis in the clinical setting where patients receive care and all other opportunistic infections are diagnosed. APPROACH: We developed and implemented a four-day workshop to train clinicians working in human immunodeficiency virus (HIV) clinics how to perform binocular indirect ophthalmoscopy and diagnose CMV retinitis. Workshops comprised both classroom didactic instruction and direct clinical eye examinations in patients with advanced AIDS. Between 2007 and 2013, 14 workshops were conducted in China, Myanmar and the Russian Federation. LOCAL SETTING: Workshops were held with local clinicians at HIV clinics supported by nongovernmental organizations, public-sector municipal hospitals and provincial infectious disease referral hospitals. Each setting had limited or no access to locally- trained ophthalmologists, and an HIV-infected population with advanced disease. RELEVANT CHANGES: Clinicians learnt how to do binocular indirect ophthalmoscopy and to diagnose CMV retinitis. One year after the workshop, 32/38 trainees in Myanmar did systematic eye examination for early diagnosis of CMV retinitis as standard care for at-risk patients. In China and the Russian Federation, the success rates were lower, with 10/15 and 3/5 trainees, respectively, providing follow-up data. LESSONS LEARNT: Skills necessary for screening and diagnosis of CMV retinitis can be taught in a four-day task-oriented training workshop. Successful implementation depends on institutional support, ongoing training and technical support. The next challenge is to scale up this approach in other countries.


Assuntos
Retinite por Citomegalovirus/diagnóstico , Oftalmologia/educação , Oftalmologia/métodos , Oftalmoscopia/métodos , Infecções Oportunistas Relacionadas com a AIDS/complicações , China , Competência Clínica , Retinite por Citomegalovirus/complicações , Educação Médica Continuada/métodos , Infecções por HIV/complicações , Humanos , Mianmar , Avaliação de Programas e Projetos de Saúde , Federação Russa , Testes Visuais/métodos
10.
Pan Afr Med J ; 19: 136, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-25767656

RESUMO

INTRODUCTION: Malawi has one of the highest HIV prevalences in Sub-Saharan Africa. The rate of eligible HIV-infected people being initiated on antiretroviral therapy (ART) and retained in HIV-care is currently far from adequate. Consequently, many people continue present with advanced immunosuppression at public health facilities, often with undiagnosed opportunistic infections (OIs). METHODS: In this context, mHealth was the innovation chosen to assist Eye Clinical Officers in early diagnosis of HIV-related diseases having eye manifestations in a rural hospital in Thyolo, Southern Malawi. RESULTS: The mTeleophthalmology program began in October 2013, but was stopped prematurely due to organizational and technological barriers that compromised its feasibility. CONCLUSION: Sharing these barriers might be useful to inform the design of similar innovations in other resource-limited settings with a high HIV prevalence and a dearth of eye specialists with capacity to diagnose HIV-related retinopathies.


Assuntos
Infecções Oportunistas Relacionadas com a AIDS/diagnóstico , Oftalmopatias/diagnóstico , Infecções por HIV/complicações , Telemedicina/organização & administração , Infecções Oportunistas Relacionadas com a AIDS/epidemiologia , Fármacos Anti-HIV/uso terapêutico , Diagnóstico Precoce , Oftalmopatias/virologia , Infecções por HIV/tratamento farmacológico , Infecções por HIV/epidemiologia , Hospitais Rurais/organização & administração , Humanos , Malaui/epidemiologia , Projetos Piloto
12.
PLoS One ; 8(10): e78313, 2013.
Artigo em Inglês | MEDLINE | ID: mdl-24194919

RESUMO

BACKGROUND: Adverse events (AEs) among HIV-infected patients with multidrug-resistant tuberculosis (MDR-TB) receiving anti-TB and antiretroviral treatments (ART) are under-researched and underreported. Hypothyroidism is a common AE associated with ethionamide, p-aminosalicylic acid (PAS), and stavudine. The aim of this study was to determine the frequency of and risk factors associated with hypothyroidism in HIV/MDR-TB co-infected patients. METHODS: This was a prospective, observational cohort study, using routine laboratory data in a Médecins Sans Frontières (MSF) clinic in collaboration with Sewri TB Hospital, Mumbai, India. Hypothyroidism was defined as a thyroid stimulating hormone (TSH) result >10 mIU/L at least once during treatment. Patients having a baseline result and one additional result after 3 months were eligible for enrolment. RESULTS: Between October 2006 and March 2013, 116 patients were enrolled, 69 of whom were included. The median (IQR) age was 38 years (34-43) and 61% were male. By March 2013, 37/69 (54%) had hypothyroidism after at least 90 days of treatment. Age, gender, CD4 counts and stavudine-based ART were not associated with the occurrence of hypothyroidism in multivariate models. The co-administration of PAS and ethionamide was found to double the risk of hypothyroidism (RR: 1.93, 95% CI: 1.06-3.54). DISCUSSION: High rate of hypothyroidism was recorded in a Mumbai cohort of MDR-TB/HIV co-infected patients on treatment. This is a treatable and reversible AE, however, it may go undiagnosed in the absence of regular monitoring. Care providers should not wait for clinical symptoms, as this risks compromising treatment adherence. Simple, affordable and reliable point-of-care tools for measuring TSH are needed, especially in high MDR-TB burden countries. Our findings suggest the need for TSH screening at baseline, three months, six months, and every six months thereafter for HIV-infected patients on MDR-TB treatment regimens containing PAS and/or ethionamide, until newer, safer and more efficacious MDR-TB regimens become available.


Assuntos
Ácido Aminossalicílico/efeitos adversos , Etionamida/efeitos adversos , Infecções por HIV/tratamento farmacológico , Hipotireoidismo/induzido quimicamente , Hipotireoidismo/epidemiologia , Estavudina/efeitos adversos , Tuberculose Resistente a Múltiplos Medicamentos/tratamento farmacológico , Adulto , Ácido Aminossalicílico/uso terapêutico , Estudos de Coortes , Coinfecção/tratamento farmacológico , Etionamida/uso terapêutico , Feminino , Humanos , Incidência , Índia/epidemiologia , Masculino , Análise Multivariada , Estudos Prospectivos , Fatores de Risco , Estavudina/uso terapêutico , Tireotropina/sangue
13.
Clin Infect Dis ; 57(9): 1351-61, 2013 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-23899681

RESUMO

BACKGROUND: Cytomegalovirus (CMV) is a late-stage opportunistic infection in people living with human immunodeficiency virus (HIV)/AIDS. Lack of ophthalmological diagnostic skills, lack of convenient CMV treatment, and increasing access to antiretroviral therapy have all contributed to an assumption that CMV retinitis is no longer a concern in low- and middle-income settings. METHODS: We conducted a systematic review and meta-analysis of published and unpublished studies reporting prevalence of CMV retinitis in low- and middle-income countries. Eligible studies assessed the occurrence of CMV retinitis by funduscopic examination within a cohort of at least 10 HIV-positive adult patients. RESULTS: We identified 65 studies from 24 countries, mainly in Asia (39 studies, 12 931 patients) and Africa (18 studies, 4325 patients). By region, the highest prevalence was observed in Asia with a pooled prevalence of 14.0% (11.8%-16.2%). Almost a third (31.6%, 95% confidence interval [CI], 27.6%-35.8%) had vision loss in 1 or both eyes. Few studies reported immune status, but where reported CD4 count at diagnosis of CMV retinitis was <50 cells/µL in 73.4% of cases. There was no clear pattern of prevalence over time, which was similar for the period 1993-2002 (11.8%; 95% CI, 8%-15.7%) and 2009-2013 (17.6%; 95% CI, 12.6%-22.7%). CONCLUSIONS: Prevalence of CMV retinitis in resource low- and middle-income countries, notably Asian countries, remains high, and routine retinal screening of late presenting HIV-positive patients should be considered. HIV programs must ensure capacity to manage the needs of patients who present late for care.


Assuntos
Infecções Oportunistas Relacionadas com a AIDS/epidemiologia , Retinite por Citomegalovirus/epidemiologia , Infecções por HIV/complicações , África/epidemiologia , Ásia/epidemiologia , Países em Desenvolvimento , Humanos , Prevalência
14.
PLoS One ; 8(7): e68869, 2013.
Artigo em Inglês | MEDLINE | ID: mdl-23894358

RESUMO

BACKGROUND: Little is known about the treatment of multidrug-resistant tuberculosis (MDR-TB) in HIV-co-infected adolescents. This study aimed to present the intermediate outcomes of HIV-infected adolescents aged 10-19 years receiving second-line anti-TB treatment in a Médecins Sans Frontières (MSF) project in Mumbai, India. METHODS: A retrospective review of medical records of 11 adolescents enrolled between July 2007 and January 2013 was undertaken. Patients were initiated on either empirical or individualized second-line ambulatory anti-TB treatment under direct observation. RESULTS: The median age was 16 (IQR 14-18) years and 54% were female. Five (46%) adolescents had pulmonary TB (PTB), two (18%) extrapulmonary disease (EPTB) and four (36%) had both. Median CD4 count at the time of MDR-TB diagnosis was 162.7 cells/µl (IQR: 84.8-250.5). By January 2013, eight patients had final and 3 had interim outcomes. Favourable results were seen in four (36.5%) patients: one was cured and three were still on treatment with negative culture results. Seven patients (64%) had poor outcomes: four (36.5%) died and three (27%) defaulted. Three of the patients who died never started on antiretroviral and/or TB treatment and one died 16 days after treatment initiation. Two of the defaulted died soon after default. All patients (100%) on-treatment experienced adverse events (AEs): two required permanent discontinuation of the culprit drug and two were hospitalized due to AEs. No patient required permanent discontinuation of the entire second-line TB or antiretroviral regimens. CONCLUSIONS: Early mortality and mortality after default were the most common reasons for poor outcomes in this study. Early mortality suggests the need for rapid diagnosis and prompt treatment initiation, and adolescents might benefit from active contact-tracing and immediate referral. Default occurred at different times, suggesting the need for continuous, intensified and individualized psychosocial support for co-infected adolescents. Operational research among co-infected adolescents will be especially important in designing effective interventions for this vulnerable group.


Assuntos
Antituberculosos/uso terapêutico , Coinfecção , Infecções por HIV , Tuberculose Resistente a Múltiplos Medicamentos/tratamento farmacológico , Adolescente , Antituberculosos/efeitos adversos , Contagem de Linfócito CD4 , Criança , Feminino , Humanos , Índia , Masculino , Estudos Retrospectivos , Resultado do Tratamento , Tuberculose Resistente a Múltiplos Medicamentos/mortalidade , Adulto Jovem
15.
BMC Infect Dis ; 13: 225, 2013 May 20.
Artigo em Inglês | MEDLINE | ID: mdl-23687908

RESUMO

BACKGROUND: The prevalence and the patterns of ocular inflammatory disease and ocular tuberculosis (TB) are largely undocumented among Multidrug Resistant TB (MDR-TB) patients co-infected with Human Immunodeficiency Virus (HIV) and on antituberculosis and antiretroviral therapy (ART). METHODS: Lilavati Hospital and Research Center and Médecins Sans Frontières (MSF) organized a cross-sectional ophthalmological evaluation of HIV/MDR-TB co-infected patients followed in an MSF-run HIV-clinic in Mumbai, India, which included measuring visual acuity, and slit lamp and dilated fundus examinations. RESULTS: Between February and April 2012, 47 HIV/MDR-TB co-infected patients (including three patients with extensively drug-resistant TB) were evaluated. Sixty-four per cent were male, mean age was 39 years (standard deviation: 8.7) and their median (IQR) CD4 count at the time of evaluation was 264 cells/µL (158-361). Thirteen patients (27%) had detectable levels of HIV viremia (>20 copies/ml). Overall, examination of the anterior segments was normal in 45/47 patients (96%). A dilated fundus examination revealed active ocular inflammatory disease in seven eyes of seven patients (15.5%, 95% Confidence Intervals (CI); 5.1-25.8%). 'These included five eyes of five patients (10%) with choroidal tubercles, one eye of one patient (2%) with presumed tubercular chorioretinitis and one eye of one patient (2%) with evidence of presumed active CMV retinitis. Presumed ocular tuberculosis was thus seen in a total of six patients (12.7%, 95% CI; 3.2-22.2%). Two patients who had completed anti-TB treatment had active ocular inflammatory disease, in the form of choroidal tubercles (two eyes of two patients). Inactive scars were seen in three eyes of three patients (6%). Patients with extrapulmonary TB and patients<39 years old were at significantly higher risk of having ocular TB [Risk Ratio: 13.65 (95% CI: 2.4-78.5) and 6.38 (95% CI: 1.05-38.8) respectively]. CONCLUSIONS: Ocular inflammatory disease, mainly ocular tuberculosis, was common in a cohort of HIV/MDR-TB co-infected patients in Mumbai, India. Ophthalmological examination should be routinely considered in HIV patients diagnosed with or suspected to have MDR-TB, especially in those with extrapulmonary TB.


Assuntos
Infecções por HIV/microbiologia , Tuberculose Resistente a Múltiplos Medicamentos/virologia , Tuberculose Ocular/microbiologia , Tuberculose Ocular/virologia , Adolescente , Adulto , Criança , Estudos Transversais , Feminino , Infecções por HIV/epidemiologia , Humanos , Índia/epidemiologia , Inflamação/complicações , Inflamação/epidemiologia , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Tuberculose Resistente a Múltiplos Medicamentos/epidemiologia , Tuberculose Resistente a Múltiplos Medicamentos/microbiologia , Tuberculose Ocular/epidemiologia
18.
PLoS One ; 7(7): e40781, 2012.
Artigo em Inglês | MEDLINE | ID: mdl-22792406

RESUMO

BACKGROUND: Significant adverse events (AE) have been reported in patients receiving medications for multidrug- and extensively-drug-resistant tuberculosis (MDR-TB & XDR-TB). However, there is little prospective data on AE in MDR- or XDR-TB/HIV co-infected patients on antituberculosis and antiretroviral therapy (ART) in programmatic settings. METHODS: Médecins Sans Frontières (MSF) is supporting a community-based treatment program for drug-resistant tuberculosis in HIV-infected patients in a slum setting in Mumbai, India since 2007. Patients are being treated for both diseases and the management of AE is done on an outpatient basis whenever possible. Prospective data were analysed to determine the occurrence and nature of AE. RESULTS: Between May 2007 and September 2011, 67 HIV/MDR-TB co-infected patients were being treated with anti-TB treatment and ART; 43.3% were female, median age was 35.5 years (Interquartile Range: 30.5-42) and the median duration of anti-TB treatment was 10 months (range 0.5-30). Overall, AE were common in this cohort: 71%, 63% and 40% of patients experienced one or more mild, moderate or severe AE, respectively. However, they were rarely life-threatening or debilitating. AE occurring most frequently included gastrointestinal symptoms (45% of patients), peripheral neuropathy (38%), hypothyroidism (32%), psychiatric symptoms (29%) and hypokalaemia (23%). Eleven patients were hospitalized for AE and one or more suspect drugs had to be permanently discontinued in 27 (40%). No AE led to indefinite suspension of an entire MDR-TB or ART regimen. CONCLUSIONS: AE occurred frequently in this Mumbai HIV/MDR-TB cohort but not more frequently than in non-HIV patients on similar anti-TB treatment. Most AE can be successfully managed on an outpatient basis through a community-based treatment program, even in a resource-limited setting. Concerns about severe AE in the management of co-infected patients are justified, however, they should not cause delays in the urgently needed rapid scale-up of antiretroviral therapy and second-line anti-TB treatment.


Assuntos
Fármacos Anti-HIV/efeitos adversos , Antituberculosos/efeitos adversos , Infecções por HIV/tratamento farmacológico , Tuberculose Resistente a Múltiplos Medicamentos/tratamento farmacológico , Adulto , Fármacos Anti-HIV/uso terapêutico , Antituberculosos/uso terapêutico , Coinfecção , Feminino , Infecções por HIV/diagnóstico , Humanos , Índia , Masculino , Estudos Prospectivos , Resultado do Tratamento , Tuberculose Resistente a Múltiplos Medicamentos/diagnóstico
19.
Int Health ; 4(3): 170-5, 2012 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-24029396

RESUMO

The latest WHO guidelines (2010) for antiretroviral therapy (ART) in adults and adolescents recommend that countries should progressively reduce the use of stavudine in favour of tenofovir or zidovudine and that ART initiation commence at an earlier CD4 threshold of <350 cell/mm(3). In Lesotho, a high-burden, resource-limited setting, these two changes had been recommended since late 2007. A number of practical steps were taken to support implementation of Lesotho's national ART guidelines at the program level including: development of guidelines tailored to nurses working in primary care settings; training and clinical mentorship of different levels of health care workers; laboratory support; pharmacy support; and monitoring and evaluation. Clinical and programmatic benefits included decreased mortality, toxicity, and simplified patient management that was supportive of the decentralized, nurse-led model of care. This experience demonstrates that, despite limited resources, it was feasible to provide a standard of care similar to that of western guidelines and that these changes were supportive of simplified patient management.

20.
PLoS One ; 6(12): e28066, 2011.
Artigo em Inglês | MEDLINE | ID: mdl-22145022

RESUMO

BACKGROUND: India carries one quarter of the global burden of multi-drug resistant TB (MDR-TB) and has an estimated 2.5 million people living with HIV. Despite this reality, provision of treatment for MDR-TB is extremely limited, particularly for HIV-infected individuals. Médecins Sans Frontières (MSF) has been treating HIV-infected MDR-TB patients in Mumbai since May 2007. This is the first report of treatment outcomes among HIV-infected MDR-TB patients in India. METHODS: HIV-infected patients with suspected MDR-TB were referred to the MSF-clinic by public Antiretroviral Therapy (ART) Centers or by a network of community non-governmental organizations. Patients were initiated on either empiric or individualized second-line TB-treatment as per WHO recommendations. MDR-TB treatment was given on an ambulatory basis and under directly observed therapy using a decentralized network of providers. Patients not already receiving ART were started on treatment within two months of initiating MDR-TB treatment. RESULTS: Between May 2007 and May 2011, 71 HIV-infected patients were suspected to have MDR-TB, and 58 were initiated on treatment. MDR-TB was confirmed in 45 (78%), of which 18 (40%) were resistant to ofloxacin. Final treatment outcomes were available for 23 patients; 11 (48%) were successfully treated, 4 (17%) died, 6 (26%) defaulted, and 2 (9%) failed treatment. Overall, among 58 patients on treatment, 13 (22%) were successfully treated, 13 (22%) died, 7 (12%) defaulted, two (3%) failed treatment, and 23 (40%) were alive and still on treatment at the end of the observation period. Twenty-six patients (45%) experienced moderate to severe adverse events, requiring modification of the regimen in 12 (20%). Overall, 20 (28%) of the 71 patients with MDR-TB died, including 7 not initiated on treatment. CONCLUSIONS: Despite high fluoroquinolone resistance and extensive prior second-line treatment, encouraging results are being achieved in an ambulatory MDR-T- program in a slum setting in India. Rapid scale-up of both ART and second-line treatment for MDR-TB is needed to ensure survival of co-infected patients and mitigate this growing epidemic.


Assuntos
Assistência Ambulatorial , Antituberculosos/uso terapêutico , Infecções por HIV/microbiologia , Tuberculose Resistente a Múltiplos Medicamentos/tratamento farmacológico , Tuberculose Resistente a Múltiplos Medicamentos/etiologia , Tuberculose Pulmonar/tratamento farmacológico , Tuberculose Pulmonar/etiologia , Adolescente , Adulto , Criança , Terapia Diretamente Observada , Feminino , Seguimentos , Infecções por HIV/complicações , Infecções por HIV/terapia , Humanos , Índia , Masculino , Pessoa de Meia-Idade , Áreas de Pobreza , Estudos Prospectivos , Taxa de Sobrevida , Resultado do Tratamento , Tuberculose Resistente a Múltiplos Medicamentos/mortalidade , Tuberculose Pulmonar/mortalidade , Adulto Jovem
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA