Impact of serious adverse drug reactions on the quality of life of patients on highly active antiretroviral therapy in Maiduguri, northeast Nigeria: a four-year retrospective study.

ABSTRACTSerious adverse drug reactions (sADRs) have a serious impact on the progress being made in providing antiretroviral therapy. The presence of HIV/AIDS and its complications associated with sADRs, has a negative effect on the quality of life (QoL) of people living with HIV/AIDS (PLWHA). This was a descriptive retrospective cohort study of 400 adult HIV patients in which the QoL of PLWHA with sADRs was compared to patients that did not experience ADR who had been on antiretroviral therapy (ART) was followed up for 48 months using the WHOQOL-HIV BREF to measure QoL. Out of 400 patients, 373 (93.25%) respondents completed the study with an overall mean age was 40.8 years (SD ± 8.64). One hundred and ninety-nine patients (53.4%) reported to have experiencing sADR. The response consistently showed significantly higher mean scores in the QoL of patients who had no ADRs in the psychological, social and environments state of health domains compared to those who had ADRs with mean scores (P = 0.000, 0.037 and 0.028), respectively. This study revealed significantly higher scores in patients who had no ADRs compared to those who had ADRs. Low QoL due to serious ADR may add additional burden to HIV disease and complications, and the related discrimination often faced by PLWHA. This study would help clinicians pay serious attention to identifying and promptly managing ADR.

Relation between some haematological abnormalities, degree of immunosuppression and viral load in treatment-naïve HIV-infected patients.

This cross-sectional study at a teaching hospital in north-eastern Nigeria estimated the prevalence of anaemia, leukopenia and thrombocytopenia in treatment-naïve HIV-infected patients (177 males and 316 females), and the associations with virological and immunological markers. The overall prevalences of anaemia, leukopenia and thrombocytopenia were 49.5%, 5.5% and 4.5% respectively. The prevalence of anaemia was significantly higher in males than females (61.6% versus 42.7%), while the rates of leukopenia (5.1% versus 5.7%) and thrombocytopenia (5.7% versus 3.8%) were similar. Almost two-thirds of the HIV treatment-naïve studied patients, 293/493 (59.4%), had cytopenia and would require antiretroviral drugs. AIDS was diagnosed by clinical or immunological criteria in 70% of patients. The degree of cytopenia was directly related to the degree of immunosuppression and clinical AIDS status. No relationship was observed between cytopenia and viral load.

The use of highly active antiretroviral therapy for the prevention of mother-to-child transmission of the human immunodeficiency virus in Nigeria.

Mother-to-child transmission of HIV accounts for 90% of paediatric HIV. The objective of this paper is to assess the outcome of preventing mother-to-child transmission of the human immunodeficiency virus (HIV), using highly active antiretroviral therapy (HAART). All pregnant women booking for antenatal care at the university of Maiduguri teaching hospital received voluntary counselling and testing for HIV. All HIV-positive mothers were placed on HAART for the prevention of mother-to-child transmission of HIV. All exposed babies received single dose nevirapine within 72 h of birth and zidovudine syrup for 6 weeks. The babies were then tested for viral DNA using the polymerase chain reaction (PCR) at 6 and 12 weeks of age. Among 5,461 mothers screened for HIV during the study period, 695 (12.7%) were confirmed HIV-positive. Out of 446 mother-baby pairs followed up to a minimum period of 6 months postpartum, only five (1.1%) babies were HIV-positive.

Should absolute lymphocyte count be used as a surrogate marker for CD4+ count in patients with HIV/AIDS?

The World Health Organization (WHO) has recommended the use of absolute lymphocyte count (ALC) as a potential marker for immunosuppression where CD4+ count is unavailable. However, there are conflicting reports on the usefulness of ALC as a surrogate marker for CD4+ counts in patients with HIV/AIDS, more so, in patients with HIV-associated tuberculosis (TB). To evaluate the usefulness of ALC as an alternative to CD4+ counts and to see whether TB affects the correlation of ALC with CD4+ counts in patients with HIV-associated TB. A total of 66 consecutive patients (33 with and 33 without TB) with a diagnosis of HIV infection were recruited into the study as cases. Another group of 66 subjects (33 subjects each) age- and sex-matched HIV-negative controls were recruited as controls and stratified in to two: a) HIV-negative PTB patients. b) apparently healthy HIV and PTB negative individuals. The age range was from 15-60 years (median: 32 years). The highest percentage (39%) of subjects fell in the age range of 25-29 years. The mean ALC for HIV-associated PTB was 3906 +/- 1092 cells/microl and for patients with HIV infection only. 4755 +/- 1049 cells/microl. There was no significant difference in mean ALC between males and females in both groups (P > 0.05). Patients with dual infection by M. tuberculosis and HIV had the lowest mean ALC (3906 +/- 1092 cells/microl). Healthy controls had mean ALC (+/- SD) of 5249 +/- 101 cells/microl. There was significant difference between the healthy controls and the other three groups. The observed difference was more in patients with HIV/ TB co-infection (P < 0.005) compared with patients with HIV alone (P < 0.05). No significant correlation was observed between CD4+ cell counts and ALC in all the age groups of the study population. When the CD4+ counts were divided into < 200 and > or = 200 cells/microl and the ALC into < 2000 and > or = 2000 cells/microl, the sensitivity, specificity and positive predictive values of the diagnostic usefulness of ALC in HIV-associated PTB were 52%. 56.3% and 78.8% while for HIV only patients the same values were 56.3%. 55.9% and 54.5%, respectively. We cannot recommend the use of ALC as a surrogate for CD4+ count in our environment as this study has clearly shown that the correlation between the two is weak. Patients with dual infection by HIV and M. tuberculosis are more likely to have lower CD4+ cell and AL counts than those with HIV infection occurring alone.

Mantoux reaction in patients with HIV-related pulmonary tuberculosis in Maiduguri, Nigeria.

Tuberculin skin testing is used for the identification of individuals with infection by Mycobacterium tuberculosis and other non-tuberculous mycobacteria. However, its value in immunosuppressed individuals due to human immunodeficiency virus (HIV) infection is controversial. This study was aimed at determining the relationship between Mantoux reaction and CD4+ cell counts; and whether the test can be used to predict CD4+ counts in patients dually infected with Human Immunodeficiency Virus and M. tuberculosis. Eighty patients, comprising 42 males (52.5%) and 38 females (47.5%) confirmed to be having antibodies to HIV who also had sputum smear positive pulmonary tuberculosis were recruited over a period of 16 months. They were Mantoux-tested with 0.1 ml of 5TU of PPD which was interpreted thus: <5 mm = negative, =5 mm = positive. CD4+ counts were determined using Dynabeads technique. The ages of all the patients ranged between 18 and 55 years (mean +/- SD: 33.9+/-8.42 years). The males had a mean age of 35.4 +/- 7.7 years while that of the females was 29.6+/-53 years (P<0.05). The CD4+ counts ranged between 73 and 512 cells/microl with a mean of 235.05 +/- 112.8 cells/microl. Fifty seven (71%) patients had negative PPD tests while 23 (29%) tested positive. Of the 37 with CD4+ counts <200 cells/microl, 32 (86.48%) had negative reaction (<5 mm) and 5 (13.51%) were positive (=5 mm) as compared to those with CD4 counts =200 cells/microl, among whom 25 (58.13%) were negative and 18 (41.86%) were positive (P<0.05). The positive predictive value was low at 56.14%. The difference in mean indurations between those with CD4+ count <200 cells/microl versus those with CD4+ count =200 cells/microl was statistically significant (P<0.05). On the whole, Mantoux indurations were noted to weakly correlate positively with CD4+ counts (Pearson's correlation, r=+0.36, P=0.001. It was concluded that there is a weak positive correlation between Mantoux reaction and CD4+ cell counts and that the Mantoux test is a poor predictor of CD4+ cell count.

Determination by Widal agglutination of the baseline titre for the diagnosis of typhoid fever in two Nigerian states.

This study was carried out in Borno and Plateau States of Nigeria to determine the baseline titre for the diagnosis of typhoid fever using a single Widal test. Of 172 patients with symptoms and signs of typhoid fever, 92.4% and 90.7% had reciprocal O and H antibody titres respectively of 160 or above. On the other hand, 95.3% and 66.3% of the 937 healthy control subjects had reciprocal O and H antibody titres respectively of 80 or less. The results of this study suggest that in Borno and Plateau States of Nigeria a reciprocal O antibody titre of 160 and above in persons with illness whose symptoms and signs are compatible with typhoid fever could be considered diagnostic using the single Widal test.

Fine needle aspiration cytology diagnosis of liver diseases in the University of Maiduguri Teaching Hospital, Maiduguri.

The study is aimed at classifying liver diseases diagnosed by fine needle aspiration cytology (FNAC) in our environment and to emphasize the importance of the procedure for management of our patients. Forty-two patients were referred by the physicians for fine needle aspiration cytology diagnosis in Histopathology Department, University of Maiduguri Teaching Hospital between January 2001 and December 2003. There were 30 males and 12 females (2.5:1) with mean age of 44.7 years. The peak age is in the 5th decade of life. The commonest hepatic disease is primary hepatic malignancy, which accounted for 78.6% (33 patients); 3 suspicious of malignancy, one case each of metastatic carcinoma, amoebic liver abscess; liver storage disease and large cell dysplasia. The technique has gained popularity in our center because it is cheap, convenient, minimally invasive, quick and has high precision in obtaining samples. We therefore recommend this procedure in centers where liver diseases are common as a means of initial investigation.

Helicobacter pylori infection in Nigerians with dyspepsia.

BACKGROUND: Helicobacter pylori is the most common chronic bacterial infection, and a significant aetiological factor in acid peptic diseases and gastric cancer. Dyspepsia is a common gastrointestinal disorder, and the most common indication for gastroscopy. Detection of this organism during endoscopy has become standard clinical practice. We determine the prevalence of H. pylori infection among dyspeptic patients using serology and histology. METHODS: Patients with dyspepsia underwent gastroscopy, and biopsies were taken from the antral portions of their stomach and processed. Their serum samples were tested for H. pylori infection using ELISA to detect anti-bodies. RESULTS: One hundred and twenty-five patients, comprising 49 (39.2%) males and 76 (60.8%) females were studied. A prevalence rate of 93.6% for H. pylori was found by serology while a rate of 80.0% was found by histology. CONCLUSION: There is a high prevalence of H. pylori infection in patients with dyspepsia; and a high percentage of detection by serological and histological tests.

Incidence of community-acquired meticillin resistant Staphylococcus aureus hand infections in Tayside, Scotland: a guide to appropriate antimicrobial prescribing.

The prevalence of community-acquired meticillin resistant Staphylococcus aureus (ca-MRSA) as an important cause of hand infections has gained much recognition. The clinical impact of this is less well documented in the United Kingdom. This study looks at the incidence of hand infections in an urban Scottish teaching hospital over a 12 month period.

Impact of HIV type 1 subtype on drug resistance mutations in Nigerian patients failing first-line therapy.

A diverse array of non-subtype B HIV-1 viruses circulates in Africa and dominates the global pandemic. It is important to understand how drug resistance mutations in non-B subtypes may develop differently from the patterns described in subtype B. HIV-1 reverse transcriptase and protease sequences from 338 patients with treatment failure to first-line ART regimens were evaluated. Multivariate logistic regression was used to examine the effect of subtype on each mutation controlling for regimen, time on therapy, and total mutations. The distribution of HIV-1 subtypes included CRF02_AG (45.0%), G (37.9%), CRF06_cpx (4.4%), A (3.6%), and other subtypes or recombinant sequences (9.2%). The most common NRTI mutations were M184V (89.1%) and thymidine analog mutations (TAMs). The most common NNRTI mutations were Y181C (49.7%), K103N (36.4%), G190A (26.3%), and A98G (19.5%). Multivariate analysis showed that CRF02_AG was less likely to have the M41L mutation compared to other subtypes [adjusted odds ratio (AOR) = 0.35; p = 0.022]. Subtype A patients showed a 42.5-fold increased risk (AOR = 42.5, p = 0.001) for the L210W mutation. Among NNRTI mutations, subtype G patients had an increased risk for A98G (AOR = 2.40, p = 0.036) and V106I (AOR = 6.15, p = 0.010), whereas subtype CRF02_AG patients had an increased risk for V90I (AOR = 3.16; p = 0.003) and a decreased risk for A98G (AOR = 0.48, p = 0.019). Five RT mutations were found to vary significantly between different non-B West African subtypes. Further study to understand the clinical impact of subtype-specific diversity on drug resistance will be critically important to the continued success of ART scale-up in resource-limited settings.

Cost effectiveness and quality of life considerations in the treatment of hepatitis C infection.

Chronic hepatitis C1 is a common cause of liver disease worldwide. It is a slow and progressive condition which can lead to decompensated cirrhosis and hepatocellular carcinoma. Hepatitis C virus1 impairs quality of life (QOL) even in the absence of chronic liver disease, but its relative silent nature can lead to a delay in diagnosis. The current standard of care of treatment is pegylated interferon and ribavarin. This achieves a sustained virological response (SVR), which is a cure of infection, in up to 80% of patients depending on viral genotype. The attainment of SVR improves survival, avoids long-term complications, and improves QOL. But treatment is not only expensive; there are issues of tolerability and adverse effects. This has led to a multitude of cost effective analysis and health technology assessment on HCV treatment. This overview discusses the natural history of the virus infection and its effect on the patients' QOL. It focuses on the treatment options available, their efficacy, and cost effectiveness. It reviews the evaluations that suggest combination therapy is cost effective and explores the assumptions and limitations of these studies in real world treatment arenas.

Sex and reproduction among HIV-infected people in Maiduguri, Nigeria.

For HIV-infected people, prevention of transmission of the virus to their spouses and other sexual partners can only be achieved through abstinence and safer sex practices using condoms. New drugs and technologies are now available that can prevent vertical transmission of the virus. A total of 262 people living with HIV/AIDS (PLWHA) were interviewed to explore their sexual and reproductive desires and practices. About 75.6% of them were sexually active and 62.2% never used condoms. Although only 26.3% had no living child, the majority of these (71.4%) wanted to have children. Their knowledge of mother-to-child transmission of HIV and how to prevent it was good. PLWHA engage in unprotected sexual intercourse with the desire to have more children. It is expected that more paediatric HIV infections will be seen in the future in a poor-resource setting like ours.

The value of highly active antiretroviral therapy in the prevention of mother-to-child transmission of HIV.

Over 90% of the children infected with HIV globally were as a result of mother-to-child transmission. With a high prevalence of HIV among women of reproductive age and a high fertility rate in Nigeria, the prevention of mother-to-child transmission of HIV is an important strategy to curb the menace of HIV. This paper examines the value of highly active antiretroviral treatment in the prevention of mother-to-child transmission of HIV. Pregnant women attending the antenatal clinic of the University of Maiduguri Teaching Hospital were offered voluntary counselling and testing for HIV. Seropositive women who fulfilled the criteria for administration of antiretroviral drugs were offered a triple combination of nevirapine, stavudine and lamivudine in pregnancy. Women who did not fulfil the criteria were offered single dose nevirapine in labour. The newborn of all HIV-positive women were offered nevirapine suspension within 72 h of delivery. Overall transmission rate for women who had combination treatment was 9.1% which was lowered to zero level among those that had elective caesarean section and infant formula in addition to the drugs. Those who had single dose nevirapine in labour had a transmission rate of 33.3%. It is recommended that the single dose nevirapine be abandoned in favour of combination treatment.

Cervical dysplasia in HIV infected women in Maiduguri, Nigeria.

The human immunodeficiency virus (HIV) infection has been shown to be a risk factor for premalignant and malignant conditions of the cervix. Patients attending the gynaecological clinic of the University of Maiduguri Teaching Hospital received voluntary counselling and testing (VCT) for HIV. All patients who were screened for HIV also had their pap smear taken. Cervical dysplasia was significantly commoner among HIV infected women than those that were HIV negative (31.3% vs 7.8%, respectively). The incidence of cervical dysplasia was also proportional to the degree of immunosuppression as women with low CD4 count had higher incidence of cervical dysplasia. The population studied was generally promiscuous irrespective of their HIV status, with over 90% of them having multiple sexual partners. It is recommended that health education in this population should be aimed at discouraging multiple sexual partners. Gynaecologists should be co-care providers to all HIV+ women in view of the menace of cervical dysplasia.

Hepatitis B viral markers in Nigerian patients with primary liver carcinoma.

Sera from 65 patients with primary liver carcinoma (PLC) and 69 sex- and age-matched controls were examined for Hepatitis B virus markers. Forty two of the patients (65%) and 25 controls (36%) were HBsAg positive. Anti-HBc was demonstrated in over 80% and in 84% of the study groups respectively. Over 70% of hepatitis B infection was anicteric and traditional surgical intervention correlated with prevalence of PLC. The data provide support for the etiological role of HBV in Nigerian patients with PLC; this is the first report that the incidence of PLC is highest in the northern Savannah region of Nigeria.

Impact of health education on prostitutes' awareness and attitudes to acquired immune deficiency syndrome (AIDS).

PIP: 767 female prostitutes in Maiduguri, Nigeria responded to a questionnaire on AIDS. Their motives and activities, awareness of HIV, transmission, prevention, and cure of AIDS and attitudes towards HIV carriers were examined. Researchers administered this questionnaire after the prostitutes had attended health education sessions on AIDS. Approximately 78% of the prostitutes were under 30 years old and 72.6% were married or had been married. 74.58% were mothers. 27% originated from neighboring countries. Patrons included civil servants, businessmen, petty traders, and craftsmen. On average, each prostitute entertained 3.3 customers/day and had sex with 1046 customers/year. 85.92% of the prostitutes claimed financial reasons such as supporting their children, for practicing prostitution. The majority of the women indicated that they generally received injections of antibiotics to prevent sexually transmitted diseases (STDs) via reused syringes and needles. 7.04% admitted to having had an STD in the past, but the researchers believe the percentage is too low. No prostitute claimed to use any hard drugs. Even though the prostitutes were receptive to health education, only 7.1% remembered that AIDS is caused by a virus and 84.3% just could not remember the causative agent. The majority (75.7%) did remember that sexual intercourse is a mode of transmission, but only 50% realized that infected blood and blood products were modes of transmission. The majority of the prostitutes indicated that they would use a condom when having sex. In addition, all stated that, if they later learn that they carry HIV, they would stop practicing prostitution. Most of the women wanted some form of restriction for HIV carriers, such as confinement or hospitalization until a cure is found. These results suggest that health education is needed and must reach the general population.^ieng

Subtype G and multiple forms of A/G intersubtype recombinant human immunodeficiency virus type 1 in Nigeria.

Multiple human immunodeficiency virus type 1 (HIV-1) genetic subtypes, intersubtype recombinants, and group O have been found in west central Africa. In Nigeria, where HIV-1 prevalence is rising rapidly, characterization of HIV-1 strains has been limited. Each of three full-length genome sequences acquired to date shows evidence of recombination: two are largely subtype G with subtype A segments in the midgenome accessory region; the third, IbNG, is subtype G with the long terminal repeats and two segments of pol from subtype A. In this study, peripheral blood mononuclear cells obtained in 1994-1995 from 10 patients hospitalized in northeastern Nigeria were evaluated by sequencing of the complete envelope and, from 7 patients, a portion of gag. Four patients harbored subtype G viruses and six patients had recombinant viruses. Two had strains sharing the A/G recombinant structure of IbNG. Two had a previously undescribed recombinant, mostly subtype A, whose carboxyl-terminal gp41 could not be classified. An A/G recombinant different from IbNG but similar to CA1, a Cameroonian strain, was found in one patient. The remaining patient had a strain that was otherwise subtype G but shared an unclassified carboxyl-terminal gp41 segment with the CA1-like strains. Other subtypes and group O were not found.