Implementation and evaluation of a Project ECHO telementoring program for the Namibian HIV workforce.

BACKGROUND: The Namibian Ministry of Health and Social Services (MoHSS) piloted the first HIV Project ECHO (Extension for Community Health Outcomes) in Africa at 10 clinical sites between 2015 and 2016. Goals of Project ECHO implementation included strengthening clinical capacity, improving professional satisfaction, and reducing isolation while addressing HIV service challenges during decentralization of antiretroviral therapy. METHODS: MoHSS conducted a mixed-methods evaluation to assess the pilot. Methods included pre/post program assessments of healthcare worker knowledge, self-efficacy, and professional satisfaction; assessment of continuing professional development (CPD) credit acquisition; and focus group discussions and in-depth interviews. Analysis compared the differences between pre/post scores descriptively. Qualitative transcripts were analyzed to extract themes and representative quotes. RESULTS: Knowledge of clinical HIV improved 17.8% overall (95% confidence interval 12.2-23.5%) and 22.3% (95% confidence interval 13.2-31.5%) for nurses. Professional satisfaction increased 30 percentage points. Most participants experienced reduced professional isolation (66%) and improved CPD credit access (57%). Qualitative findings reinforced quantitative results. Following the pilot, the Namibia MoHSS Project ECHO expanded to over 40 clinical sites by May 2019 serving more than 140 000 people living with HIV. CONCLUSIONS: Similar to other Project ECHO evaluation results in the United States of America, Namibia's Project ECHO led to the development of ongoing virtual communities of practice. The evaluation demonstrated the ability of the Namibia HIV Project ECHO to improve healthcare worker knowledge and satisfaction and decrease professional isolation.

Evaluation of the uptake of tuberculosis preventative therapy for people living with HIV in Namibia: a multiple methods analysis.

BACKGROUND: In 2016, Namibia had ~ 230,000 people living with HIV (PLHIV) and 9154 new tuberculosis (TB) cases, including 3410 (38%) co-infected cases. TB preventative therapy (TPT), consisting of intensive case finding and isoniazid preventative therapy, is critical to reducing TB disease and mortality. METHODS: Between November 2014 and February 2015, data was abstracted from charts of PLHIV enrolled in HIV treatment. Fifty-five facilities were purposively selected based on patient volume, type and location. Charts were randomly sampled. The primary outcome was to estimate baseline TPT in PLHIV, using nationally weighted proportions. Qualitative surveys were conducted and summarized to evaluate TPT practices and quantify challenges encountered by health care workers (HCW). RESULTS: Among 861 PLHIV sampled, 96% were eligible for TPT services, of which 87.1% were screened for TB at least once. For PLHIV eligible for preventative therapy (646/810; 82.6%), 45.4% (294/646) initiated therapy and 45.7% (139/294) of those completed therapy. The proportion of eligible PLHIV completing TB screening, initiating preventative therapy and then completing preventative therapy was 20.7%. Qualitative surveys with 271 HCW identified barriers to TPT implementation including: lack of training (61.3% reported receiving training on TPT); misunderstandings about timing of TPT initiation (46.7% correctly reported TPT should be started with antiretroviral therapy); and variable screening practices and responsibilities (66.1% of HCWs screened for TB at every encounter). Though barriers were evident, 72.2% HCWs surveyed described their clinical performance as very good, often placing responsibility of difficulties on patients and downplaying challenges like staff shortages and medication stock outs. CONCLUSIONS: In this study, only 1 in 5 eligible PLHIV completed the TPT cascade in Namibia. Lack of training, irregularities with TB screening and timing of TPT, unclear prescribing and recording responsibilities, and a clinical misperception may have contributed to suboptimal programmatic implementation. Addressing these challenges will be critical with continued TPT scale-up.

Pretreatment HIV drug resistance among adults initiating ART in Namibia.

Background: Continued use of standardized, first-line ART containing NNRTIs and NRTIs may contribute to ongoing emergence of HIV drug resistance (HIVDR) in Namibia. Methods: A nationally representative cross-sectional survey was conducted during 2015-16 to estimate the prevalence of significant pretreatment HIV drug resistance (PDR) and viral load (VL) suppression rates 6-12 months after initiating standardized first-line ART. Consenting adult patients (≥18 years) initiating ART were interviewed about prior antiretroviral drug (ARV) exposure and underwent resistance testing using dried blood spot samples. PDR was defined as mutations causing low-, intermediate- and high-level resistance to ARVs according to the 2014 WHO Surveillance of HIV Drug Resistance in Adults Initiating ART. The prevalence of PDR was described by patient characteristics, ARV exposure and VL results. Results were weighted to be nationally representative. Results: Successful genotyping was performed for 381 specimens; 144 (36.6%) specimens demonstrated HIVDR, of which 54 (12.7%) demonstrated PDR. Resistance to NNRTIs was most prevalent (11.9%). PDR was higher in patients with previous ARV exposure compared with no exposure (30.5% versus 9.6%) (prevalence ratio = 3.17; P < 0.01). Conclusions: This survey demonstrated overall PDR at >10% among adults initiating ART in Namibia. Patients with prior ARV exposure had higher rates of PDR. Introducing a non-NNRTI-based regimen for first-line ART should be considered to maximize benefit of ART and minimize the emergence of HIVDR.

Mycobacterium bovis BCG osteoarticular infection complicating immune therapy for bladder cancer: a case report.

Osteoarticular infection with Mycobacterium bovis (M. bovis) is a rare complication of bladder cancer treatment with intravesical Bacillus Calmette-Guèrin (BCG). We describe a case of disseminated Mycobacterium bovis BCG infection masquerading as a chronic prosthetic joint infection in a patient with several risk factors for progressive mycobacterial infection.

Evaluation of the Abbott BinaxNOW COVID-19 Test Ag Card for rapid detection of SARS-CoV-2 infection by a local public health district with a rural population.

SARS-CoV-2 RT-PCR, the gold standard for diagnostic testing, may not be readily available or logistically applicable for routine COVID-19 testing in many rural communities in the United States. In this validation study, we compared the BinaxNOW™ COVID-19 Test Ag Card with SARS-CoV-2 RT-PCR in 214 participants who sought COVID-19 testing from a local public health district in Idaho, USA. The median age of participants was 35 and 82.7% were symptomatic. Thirty-seven participants (17.3%) had positive RT-PCR results. Results between the two tests were 94.4% concordant. The sensitivity of the BinaxNOW™ COVID-19 Test Ag Card was 67.6% (95% CI: 50.2-81.9%), and the specificity was 100.0% (95% CI: 97.9-100.0%). The positive predictive value (PPV) for the BinaxNOW™ COVID-19 Test Ag Card was 100.0% (95% CI: 86.2-100.0%), and the negative predictive value (NPV) was 93.6% (95% CI: 89.1-96.6%). Although the sensitivity of BinaxNOW™ COVID-19 Test Ag Card was lower than RT-PCR, rapid results and high specificity support its use for early detection of COVID-19, especially in settings where SARS-CoV-2 RT-PCR testing is not readily available. Rapid antigen tests, such as the BinaxNOW™ COVID-19 Test Ag Card, may be a more convenient tool in quickly identifying and preventing COVID-19 transmission, especially in rural settings.

Human Immunodeficiency Virus-1 Drug Resistance Patterns Among Adult Patients Failing Second-Line Protease Inhibitor-Containing Regimens in Namibia, 2010-2015.

Three hundred sixty-six adult patients in Namibia with second-line virologic failures were evaluated for human immunodeficiency virus drug-resistant (HIVDR) mutations. Less than half (41.5%) harbored ≥1 HIVDR mutations to standardized second-line antiretroviral therapy (ART) regimen. Optimizing adherence, viral load monitoring, and genotyping are critical to prevent emergence of resistance, as well as unnecessary switching to costly third-line ART regimens.

Creating a National HIV Curriculum.

In recent years, the HIV care provider workforce has not kept pace with an expanding HIV epidemic. To effectively address this HIV workforce shortage, a multipronged approach is needed that includes high-quality, easily accessible, up-to-date HIV education for trainees and practicing providers. Toward this objective, the University of Washington, in collaboration with the AIDS Education and Training Center National Coordinating Resource Center, is developing a modular, dynamic curriculum that addresses the entire spectrum of the HIV care continuum. Herein, we outline the general principles, content, organization, and features of this federally funded National HIV Curriculum, which allows for longitudinal, active, self-directed learning, as well as real-time evaluation, tracking, and feedback at the individual and group level. The online curriculum, which is in development, will provide a free, comprehensive, interactive HIV training and resource tool that can support national efforts to expand and strengthen the United States HIV clinical care workforce.

Behçet's disease diagnosed after acute HIV infection: viral replication activating underlying autoimmunity?

Behçet's disease is an autoimmune systemic vasculitis that can occur after exposure to infectious agents. Behçet's disease also has been associated with HIV infection, including de novo development of this condition during chronic HIV infection and resolution of Behçet's disease symptoms following initiation of antiretroviral therapy. We describe a patient who presented with systemic vasculitis with skin and mucous membrane ulcerations in the setting of acute HIV infection, who was eventually diagnosed with Behçet's disease, demonstrating a possible link between acute HIV infection, immune activation and development of autoimmunity.

Poliovirus immunity in newly resettled adult refugees in Idaho, United States of America.

BACKGROUND: In the United States, vaccines have eliminated wild poliovirus (WPV) infection, though resettling refugees may lack immunity and importation of WPV remains a concern. METHODS: A cross-sectional survey was performed to determine the prevalence of poliovirus immunity in adult refugees resettling in Boise, Idaho, U.S.A.; immunity was evaluated using two definitions: serotypes 1, 2 and 3 positive, or serotypes 1 and 3 positive. RESULTS: This survey evaluated 795 adult refugees between August 2010 and November 2012. Poliovirus immunity in adults >18 years was 55.3% for serotypes 1, 2 and 3 combined, and 60% for serotypes 1 and 3 only. CONCLUSION: This study demonstrated a WPV immunity rate of <60% in a recently resettled adult refugee population in the United States, reinforcing the need to ensure poliovirus immunity in all newly arrived adult refugees, either by expanding pre-departure immunization or by screening for immunity at resettlement and vaccinating when indicated.

Carbon monoxide exposure on Denali: comparing the 2004 and 2005 climbing seasons.

OBJECTIVE: This study assessed a potential relationship between elevated carboxyhemoglobin (COHb) levels and the presence of acute mountain sickness (AMS) at 4300 m on Denali and evaluated the relationship between COHb levels, AMS, and climber characteristics and behaviors. Building on our research done in 2004, in this article we report further data gathered during the 2005 climbing season and evaluate the combined results. METHODS: Participants were screened for AMS using the Lake Louise Self-Report Questionnaire and answered questions focusing on AMS symptoms, AMS prevention, and previous history of altitude illness. Carboxyhemoglobin levels were measured by serum co-oximetry. Additional questions assessed stove practices, climbing practices, and climber behaviors. Nonparametric statistical analyses were performed to examine potential relationships between COHb levels, AMS symptoms, and climber behaviors across the 2 years and with years combined. RESULTS: Overall, 317 climbers participated in the 2-year study. As in 2004, the combined data demonstrated no relationship between positive carbon monoxide (CO) exposure and positive criteria for AMS (P = .276). Climbers in 2005 were 1.92 times more likely to meet positive criteria for AMS, compared to climbers in 2004 (P = .028). On the contrary, climbers in 2004 were 3.93 times more likely to be CO exposed than climbers in 2005 (P = .003). Overall, climbers descending the mountain were more likely to be positive for CO exposure (5.56 times more likely than ascending climbers, P = .002) and to have higher overall mean COHb levels (2.26% descending vs 0.93% ascending, P = .006). The previous association between increased stove use and climbers who met positive criteria for AMS was not observed in the 2005 or in the combined data (P = .715). A relationship was observed between increased hours of operating stoves and increased COHb levels (P = .002). Female climbers were 2.041 times more likely to meet criteria for AMS (P = .043). CONCLUSIONS: No relationship between AMS symptoms and CO exposure was observed. As found in our initial study, descending climbers had higher overall COHb levels and an increased risk of CO exposure (COHb of >3% in nonsmokers and >10% in smokers). Also, increased hours of stove operation was linked to climbers who had elevated COHb levels.

Investigating carbon monoxide exposure on Denali.

OBJECTIVE: This exploratory study assessed a potential relationship between elevated carboxyhemoglobin (COHb) levels and acute mountain sickness (AMS) at 4300 m on Denali. Additional analysis assessed the relationship among COHb levels, AMS, and climber characteristics and behaviors. METHODS: Participants were screened for AMS with the Lake Louise Self-Report questionnaire and answered questions focusing on AMS symptoms, prevention, and previous altitude illness. Levels of COHb were measured by serum cooximetry. Additional questions assessed stove practices, climbing practices, and climber behaviors. Nonparametric statistical analyses were performed to examine potential relationships among COHb levels, AMS symptoms, and climber behaviors. RESULTS: A total of 146 climbers participated in the study. Eighteen climbers (12.5%) were positive for carbon monoxide (CO) exposure and 20 (13.7%) met criteria for AMS. No significant relationship was observed between positive CO exposure and positive criteria for AMS. Climbers descending the mountain were 3.6 times more likely to meet the study criteria for positive CO exposure compared with those ascending the mountain (P = .42). In addition, COHb levels were significantly higher for those descending the mountain (P = .012) and for those taking prophylactic medications (P = .010). Climbers meeting positive criteria for AMS operated their stoves significantly longer (P = .047). CONCLUSIONS: No significant relationship between AMS symptoms and CO exposure was observed. This may have been affected by the low percentage of climbers reporting AMS symptoms, as well as limited power. Descending climbers had a 3.6 times increased risk of CO exposure compared with ascending climbers and had significantly higher COHb scores. Increased hours of stove operation was significantly linked to climbers who also met criteria for AMS.

Tick-borne relapsing fever.

Tick-borne relapsing fever is characterized by recurring fevers separated by afebrile periods and is accompanied by nonspecific constitutional symptoms. It occurs after a patient has been bitten by a tick infected with a Borrelia spirochete. The diagnosis of tick-borne relapsing fever requires an accurate characterization of the fever and a thorough medical, social, and travel history of the patient. Findings on physical examination are variable; abdominal pain, vomiting, and altered sensorium are the most common symptoms. Laboratory confirmation of tick-borne relapsing fever is made by detection of spirochetes in thin or thick blood smears obtained during a febrile episode. Treatment with a tetracycline or macrolide antibiotic is effective, and antibiotic resistance is rare. Patients treated for tick-borne relapsing fever should be monitored closely for Jarisch-Herxheimer reactions. Fatalities from tick-borne relapsing fever are rare in treated patients, as are subsequent Jarisch-Herxheimer reactions. Persons in endemic regions should avoid rodent- and tick-infested areas and use insect repellents and protective clothing to prevent tick bites.