Trends in HIV-related morbidity among patients admitted to a South Indian tertiary hospital between 1997 and 2003

Trends in Hospitalisation for Human Immunodeficiency Virus in a Tertiary Hospital in Dar es Salaam, Tanzania: A Case study

Background:

Reports on systematic evaluation of the impact of antiretroviral therapy(ART) on patients' hospitalisation in Sub Saharan Africa (SSA) and Tanzania in particular are scarce. We aimed at documenting the trends of hospital admissions at Muhimbili National Hospital (MNH) following scale up of free access to ART in Tanzania.

Methods:

Records for all admissions at MNH from June 2005 to June 2015 were reviewed. We extracted data from Hospital Information Management System as well as from patients' charts. Data extracted included diagnosis at discharge, reason for admission and thereafter assessed admission trends over the decade. We summarised the data as frequency and percentages. We compared proportions using Chi squared test, P<0.05 was deemed significant.

Results:

Overall there were 209,101 admissions during the study period (June 2005 to June 2015) and 7864/209,101 (3.8%) were due to HIV infection. Whereas 598/4,519 (13.2%) of all admissions in 2005 were due to HIV, only 345/13,119 (2.6%) of admissions in 2015 were HIV-related; showing a significant drop over time (P value for trend < .001). Generally, females 3887/6679 (58.2%) were more likely to be admitted than males (41.8%). Median CD4 count for admitted HIV patients was 143 cells/µl. Majority of admissions occured in the medical wards 3643/5310 (68.6%). Discharge diagnoses were Tuberculosis 1396/6482 (21.5%), anaemias 1016/6482 (15.6 %), malignancies 789/6482(12.2%), CNS infections 541/6482 (8.3%) and chronic kidney disease 308/6482 (4.8%). Three leading AIDS defining malignancies among hospitalised patients included Kaposi's sarcoma 380/789 (48.2%), carcinoma of the cervix 77/789 (9.8%), and Non-Hodgkin's lymphoma 44/789 (5.6%).

Conclusion:

Despite drastic drop of HIV related admissions at Muhimbili National Hospital over the years, the infection remains a problem of the adults, largely females suffering from medical conditions and presenting with severe immunosuppression. Tuberculosis remained the most common opportunistic infection among hospitalized HIV infected patients. Anaemia and cancers became more important causes of admission than was diarrhoea which had been the most common among HIV infected patients in pre- ART era.

Toxoplasma gondii - Prevalence and Risk Factors in HIV-infected Patients from Songklanagarind Hospital, Southern Thailand

Toxoplasmosis is one of the most common opportunistic parasitic diseases in patients living with HIV/AIDS. This study aimed to determine the seroprevalence of Toxoplasma infection in HIV-infected patients and to identify associated risk factors in Toxoplasma seropositive patients. This study was conducted at a regional public hospital in Hat Yai, southern Thailand during October 2009 to June 2010. Blood samples were collected from 300 HIV-infected patients. Each subject also answered a socio-demographic and risk factors associated with Toxoplasma infection. The prevalence of anti-Toxoplasma IgG antibodies in HIV-infected patients was 109 (36.3%), of which 83 (76.2%) had past infection and 26 (23.9%) had recently acquired Toxoplasma infection as indicated by their IgG avidity. Multivariate analysis using logistic regression showed that gender difference (adjusted OR = 1.69, 95% CI = 1.05-2.72) was the only factor associated with Toxoplasma infection. From the results obtained, these HIV-infected patients could be at high risk of developing clinical evidence of severe toxoplasmosis. Therefore, it is necessary to introduce primary behavioral practices to prevent Toxoplasma infection among HIV-infected patients.

Pneumocystis jirovecii pneumonia in tropical and low and middle income countries: a systematic review and meta-regression

Objective

Pneumocystis jirovecii pneumonia (PCP), the commonest opportunistic infection in HIV-infected patients in the developed world, is less commonly described in tropical and low and middle income countries (LMIC). We sought to investigate predictors of PCP in these settings.

Design

Systematic review and meta-regression.

Methods

Meta-regression of predictors of PCP diagnosis (33 studies). Qualitative and quantitative assessment of recorded CD4 counts, receipt of prophylaxis and antiretrovirals, sensitivity and specificity of clinical signs and symptoms for PCP, co-infection with other pathogens, and case fatality (117 studies).

Results

The most significant predictor of PCP was per capita Gross Domestic Product, which showed strong linear association with odds of PCP diagnosis (p<0.0001). This was not explained by study design or diagnostic quality. Geographical area, population age, study setting and year of study also contributed to risk of PCP. Co-infection was common (444 episodes/1425 PCP cases), frequently with virulent organisms. The predictive value of symptoms, signs or simple tests in LMIC settings for diagnosis of PCP was poor. Case fatality was >30%; treatment was largely appropriate. Prophylaxis appeared to reduce the risk for development of PCP, however 24% of children with PCP were receiving prophylaxis. CD4 counts at presentation with PCP were usually <200×10^3/ml.

Conclusions

There is a positive relationship between GDP and risk of PCP diagnosis. Although failure to diagnose infection in poorer countries may contribute to this, we also hypothesise that poverty exposes at-risk patients to a wide range of infections and that the relatively non-pathogenic P. jirovecii is therefore under-represented. As LMIC develop economically they eliminate the conditions underlying transmission of virulent infection: P. jirovecii, ubiquitous in all settings, then becomes a greater relative threat.

Necrotising granulomatous lymphadenitis

Extrapulmonary tuberculosis (EPTB) is defined as Mycobacterium TB through Ziehl-Neelsen acid-fast stain and culture in Loewenstein-Jensen in a tissue from a site other than lung parenchyma, in association with clinical or imaging findings compatible with infection locally. The authors report a case of a patient who presented with asthenia, anorexia and weight loss. He complained of fever, chills and night sweats of 1-week duration. The thoracic scan reveals lymph node enlargement in the left axilla and pleural effusion and the histological study revealed a necrotising granulomatous lymphadenitis. It was decided to initiate antituberculous drugs with a good response. EPTB is a difficult diagnostic because lymph nodes contain few tubercle bacilli, leading to a low sensitivity of smear microscopy detection. The introduction of antituberculous agents is the cornerstone of management of such infections and, occasionally, it is the only way to make a diagnosis.

The Interface between the Family and the Health Care System in the Care of People with HIV/AIDS

Family care experiences of caregivers and care receivers in the context of HIV/AIDS were studied in Mumbai, India, following van Manen’s hermeneutic phenomenological approach. Data were gathered through conversational interviews and were subjected to holistic and highlighting thematic analyses. The findings underscore that interactions with the formal health care system contributed to the essential meaning of participants’ experiences even though the context of care was primarily familial. These interactions included instances of violations of testing and confidentiality guidelines and refusals to provide treatment in private, and some public health centres and the provision of instrumental and affective support by the voluntary sector. The poor quality of care in public sector hospitals serving HIV positive individuals was also described.

Rural Epidemiology of HIV Positive Tribal Patients from Chhattisgarh in India

OBJECTIVE

The primary objective was to study the epidemiology of Human Immunodeficiency Virus (HIV) positive tribal patients, and the secondary objective was to study the associated comorbidities in a tertiary care hospital in the tribal (Bastar) region of Chhattisgarh, India, between December 2006 and November 2008, and their relation to CD4 counts.

MATERIALS AND METHODS

In this study 90 tribal HIV positive subjects were enrolled. Information on demographics, that is, weight, height, age, educational status, sex, clinical finding, and laboratory parameters (CD4 counts) were noted.

RESULTS

Among 90 HIV patients, 54 (60%) were males and 36 (40%) were females. Among these, most patients, 37 (41.1%), were in the age group of 30 to 39 years. Among these patients, 79.56% belonged to the lower socioeconomic status, whereas, only 1.45% were from a high socioeconomic status. The largest group was made up of drivers (32.2%), with the second largest group being housewives (27.7%) and laborers (17.7%), respectively. A majority of the patients had a low education, 35.5% were educated only up to the fifth standard and 31.8% up to high school, while 18.8% were illiterate. The predominant mode of transmission was heterosexual contact (78.8%), only one patient (1.1%) was infected through transfusion of infected blood, five (5.5%) patients acquired infection via vertical (mother to child) transmission, and in 13 patients the transmission history was not clear.

CONCLUSION

There was a high frequency of behavioral risk factors, together with unawareness, and very little health infrastructure, thus creating an impending risk for the rapid spread of HIV/AIDS (acquired immunodeficiency syndrome).

HIV-associated extrapulmonary tuberculosis in Thailand: epidemiology and risk factors for death

BACKGROUND

We conducted a prospective, multicenter observational cohort study in Thailand to characterize the epidemiology of extrapulmonary tuberculosis (TB) in HIV-infected persons and to identify risk factors for death.

METHODS

From May 2005 to September 2006, we enrolled, interviewed, examined, and performed laboratory tests on HIV-infected adult TB patients and followed them from TB treatment initiation until the end of TB treatment. We conducted multivariate proportional hazards analysis to identify factors associated with death.

RESULTS

Of the 769 patients, pulmonary TB only was diagnosed in 461 (60%), both pulmonary and extrapulmonary TB in 78 (10%), extrapulmonary TB at one site in 223 (29%), and extrapulmonary TB at more than one site in seven (1%) patients. Death during TB treatment occurred in 59 of 308 patients (19%) with any extrapulmonary involvement. In a proportional hazards model, patients with extrapulmonary TB had an increased risk of death if they had meningitis, and a CD4+ T-lymphocyte count <200 cells/microl. Patients who received co-trimoxazole, fluconazole, and antiretroviral therapy during TB treatment had a lower risk of death.

CONCLUSIONS

Among HIV-infected patients with TB, extrapulmonary disease occurred in 40% of the patients, particularly in those with advanced immune suppression. Death during TB treatment was common, but the risk of death was reduced in patients who took co-trimoxazole, fluconazole, and antiretroviral therapy.

Comparison of pulmonary and extrapulmonary tuberculosis in Nepal- a hospital-based retrospective study

Background

Studies from developed countries have reported on host-related risk factors for extra-pulmonary tuberculosis (EPTB). However, similar studies from high-burden countries like Nepal are lacking. Therefore, we carried out this study to compare demographic, life-style and clinical characteristics between EPTB and PTB patients.

Methods

A retrospective analysis was carried out on 474 Tuberculosis (TB) patients diagnosed in a tertiary care hospital in western Nepal. Characteristics of demography, life-style and clinical features were obtained from medical case records. Risk factors for being an EPTB patient relative to a PTB patient were identified using logistic regression analysis.

Results

The age distribution of the TB patients had a bimodal distribution. The male to female ratio for PTB was 2.29. EPTB was more common at younger ages (< 25 years) and in females. Common sites for EPTB were lymph nodes (42.6%) and peritoneum and/or intestines (14.8%). By logistic regression analysis, age less than 25 years (OR 2.11 95% CI 1.12–3.68) and female gender (OR 1.69, 95% CI 1.12–2.56) were associated with EPTB. Smoking, use of immunosuppressive drugs/steroids, diabetes and past history of TB were more likely to be associated with PTB.

Conclusion

Results suggest that younger age and female gender may be independent risk factors for EPTB in a high-burden country like Nepal. TB control programmes may target young and female populations for EPTB case-finding. Further studies are necessary in other high-burden countries to confirm our findings.

Use of an HIV-1 reverse-transcriptase enzyme-activity assay to measure HIV-1 viral load as a potential alternative to nucleic acid-based assay for monitoring antiretroviral therapy in resource-limited settings

An inexpensive and technically less-demanding methodology to quantify HIV-1 viral load would be of great value for resource-limited settings, where the nucleic-acid amplification technique (NAAT) is impractical and/or resource-prohibitive. In this study, an HIV-1 reverse-transcriptase enzyme-activity assay (ExaVir Load assay, version 1) was compared with the gold standard RT-PCR assay, Roche HIV-1 Amplicor Monitor, version 1.5. A total of 121 plasma specimens were used for the evaluation. ExaVir Load had a sensitivity of 97 % and a specificity of 71 % in identifying specimens with <400 copies ml−1 in the Roche RT-PCR assay as being less than the detection limit of the assay (5500 copies ml−1). The mean difference (95 % limits of agreement) between Roche RT-PCR and ExaVir Load was –0.23 (−1.59 to 1.13) log10(copies ml−1) by Bland–Altman analysis. Significant negative correlations were seen between CD4+ T-cell counts and the ExaVir Load assay (r=−0.32, P<0.05), and between CD4+ T-cell counts and the Roche RT-PCR (r=−0.38, P<0.01). The present study with HIV-1 showed a strong correlation between the ExaVir Load assay and the RT-PCR assay. Hence, the ExaVir Load assay could be considered for use in resource-limited settings as an alternative viral-load assay to the standard NAAT-based assay after further evaluation with prospective specimens.

Correlation of immune activation with HIV-1 RNA levels assayed by real-time RT-PCR in HIV-1 subtype C infected patients in Northern India

BACKGROUND

Assays with specificity and cost effectiveness are needed for the measurement of HIV-1 burden to monitor disease progression or response to anti-retroviral therapy (ART) in HIV-1 subtype C infected patients.

OBJECTIVES

The objective of this study was to develop and validate an affordable one step real-time RT-PCR assay with high specificity and sensitivity to measure plasma HIV-1 loads in HIV-1 subtype C infected patients.

RESULTS

We developed an RT-PCR assay to detect and quantitate plasma HIV-1 levels in HIV-1 subtype C infected patients. An inverse correlation between plasma viral loads (PVL) and CD4+ T-cell numbers was detected at all CDC stages. Significant correlations were found between CD8+ T-cell activation and PVL, as well as with the clinical and immunological status of the patients.

CONCLUSIONS

This RT-PCR assay provides a sensitive method to measure PVL in HIV-1 subtype C infected patients. Viral loads correlated with immune activation and can be used to monitor HIV care in India.