Youth, unemployment, and male gender predict mortality in AIDS patients started on HAART in Nigeria

A randomized stepped wedge trial of an intensive combination approach to roll back the HIV epidemic in Nigerian adolescents: iCARE Nigeria treatment support protocol

BACKGROUND

Nigeria is one of six countries with half the global burden of youth living with HIV. Interventions to date have been inadequate as AIDS-related deaths in Nigeria's youth have remained unchanged in recent years. The iCARE Nigeria HIV treatment support intervention, a combination of peer navigation and SMS text message medication reminders to promote viral suppression, demonstrated initial efficacy and feasibility in a pilot trial among youth living with HIV in Nigeria. This paper describes the study protocol for the large-scale trial of the intervention.

METHODS

The iCARE Nigeria-Treatment study is a randomized stepped wedge trial of a combination (peer navigation and text message reminder) intervention, delivered to youth over a period of 48 weeks to promote viral suppression. Youth receiving HIV treatment at six clinical sites in the North Central and South Western regions of Nigeria were recruited for participation. Eligibility criteria included registration as a patient at participating clinics, aged 15-24 years, on antiretroviral therapy for at least three months, ability to understand and read English, Hausa, Pidgin English, or Yoruba, and intent to remain a patient at the study site during the study period. The six clinic sites were divided into three clusters and randomized to a sequence of control and intervention periods for comparison. The primary outcome is plasma HIV-1 viral load suppression, defined as viral load ≤ 200 copies/mL, in the intervention period versus the control period at 48 weeks of intervention.

DISCUSSION

Evidence-based interventions to promote viral load suppression among youth in Nigeria are needed. This study will determine efficacy of a combination intervention (peer navigation and text message reminder) and collect data on potential implementation barriers and facilitators to inform scale-up if efficacy is confirmed.

TRIAL REGISTRATION

ClinicalTrials.gov number, NCT04950153, retrospectively registered July 6, 2021, https://clinicaltrials.gov/.

Attrition from Care Among Men Initiating ART in Male-Only Clinics Compared with Men in General Primary Healthcare Clinics in Khayelitsha, South Africa: A Matched Propensity Score Analysis

Men have higher rates of attrition from antiretroviral therapy (ART) programs than women. In Khayelitsha, a high HIV prevalence area in South Africa, two public sector primary healthcare clinics offer services, including HIV testing and treatment, exclusively to men. We compared attrition from ART care among men initiating ART at these clinics with male attrition in six general primary healthcare clinics in Khayelitsha. We described baseline characteristics of patients initiating ART at the male and general clinics from 1 January 2014 to 31 March 2018. We used exposure propensity scores (generated based on baseline health and age) to match male clinic patients 1:1 to males at other clinics. The association between attrition (death or loss to follow-up, defined as no visits for nine months) and clinic type was estimated using Cox proportional hazards regression. Follow-up time began at ART initiation and ended at attrition, clinic transfer, or dataset closure. Before matching, patients from male clinics (n = 784) were younger than males from general clinics (n = 2726), median age: 31.2 vs 35.5 years. Those initiating at male clinics had higher median CD4 counts at ART initiation [Male Clinic 1: 329 (IQR 210-431), Male Clinic 2: 364 (IQR 260-536), general clinics 258 (IQR 145-398), cells/mm³]. In the matched analysis (1451 person-years, 1568 patients) patients initiating ART at male clinics had lower attrition (HR 0.71; 95% CI 0.60-0.85). In separate analyses for each of the two male clinics, only the more established male clinic showed a protective effect. Male-only clinics reached younger, healthier men, and had lower ART attrition than general services. These findings support clinic-specific adaptations to create more male-friendly environments.

Effect of Text Messaging Plus Peer Navigation on Viral Suppression Among Youth With HIV in the iCARE Nigeria Pilot Study

BACKGROUND

Consistent with the global trend, youth with HIV (YWH) in Nigeria have high rates of viral nonsuppression. Hence, novel interventions are needed.

SETTING

Infectious Diseases Institute, College of Medicine, University of Ibadan, Nigeria.

METHODS

In a single-arm trial, participants aged 15-24 years received 48 weeks of a combination intervention, comprising daily 2-way text message medication reminders plus peer navigation. The primary outcome measure was viral suppression less than 200 copies/mL. The secondary outcome measures included self-reported adherence on a visual analog scale and medication possession ratio, each dichotomized as ≥90% (good) or <90% (poor) adherence. The outcomes were analyzed using McNemar test. Retention in care, intervention feasibility and acceptability, and participants' satisfaction were also assessed.

RESULTS

Forty YWH (50% male participants) were enrolled: mean age 19.9 years (SD = 2.5), 55% perinatally infected, and 35% virologically suppressed at baseline. Compared with baseline, the odds of virologic suppression was higher at 24 weeks (odds ratio = 14.00, P < 0.001) and 48 weeks (odds ratio = 6.00, P = 0.013). Self-reported adherence (≥90%) increased from baseline at 24 weeks (63%, P = 0.008) and 48 weeks (68%, P = 0.031). Medication possession ratio ≥90% increased at weeks 24 and 48 (85% and 80%, respectively), achieving statistical significance at 24 weeks alone (P = 0.022). Retention in care at 48 weeks was 87.5%. All (37/37) participants at week 48 were fully or mostly satisfied with the intervention.

CONCLUSION

Daily 2-way text message reminders plus peer navigation is a promising combination intervention to improve viral suppression among YWH in Nigeria.

Strategies for retention of heterosexual men in HIV care in sub-Saharan Africa: A systematic review

Expansion of Antiretroviral Therapy (ART) programs in sub-Saharan Africa (SSA) has increased the number of people accessing treatment. However, the number of males accessing and being retained along the human immunodeficiency virus (HIV) care cascade is significantly below the UNAIDS target. Male gender has been associated with poor retention in HIV care programs, and little is known about strategies that reduce attrition of men in ART programs. This review aimed to summarize any studies on strategies to improve retention of heterosexual males in HIV care in SSA. An electronic search was conducted through Ovid^® for three databases (MEDLINE^®, Embase and Global Health). Studies reporting interventions aimed at improving retention among heterosexual men along the HIV care cascade were reviewed. The inclusion criteria included randomized-controlled trials (RCTs), prospective or retrospective cohort studies that studied adult males (≥15years of age), conducted in SSA and published between January 2005 and April 2019 with an update from 2019 to 2020. The search returned 1958 articles, and 14 studies from eight countries met the inclusion criteria were presented using the PRISMA guidelines. A narrative synthesis was conducted. Six studies explored community-based adherence support groups while three compared use of facility versus community-based delivery models. Three studies measured the effect of national identity cards, disclosure of HIV status, six-monthly clinic visits and distance from the health center. Four studies measured risk of attrition from care using hazard ratios ranging from 1.2–1.8, four studies documented attrition proportions at an average of 40.0% and two studies an average rate of attrition of 43.4/1000PYs. Most (62%) included studies were retrospective cohorts, subject to risk of allocation and outcome assessment bias. A pooled analysis was not performed because of heterogeneity of studies and outcome definitions. No studies have explored heterosexual male- centered interventions in HIV care. However, in included studies that explored retention in both males and females, there were high rates of attrition in males. More male-centered interventions need to be studied preferably in RCTs. Registry number: PROSPERO2020 CRD42020142923 Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020142923.

Long-term virologic responses to antiretroviral therapy among HIV-positive patients entering adherence clubs in Khayelitsha, Cape Town, South Africa: a longitudinal analysis

INTRODUCTION

In South Africa, an estimated 4.6 million people were accessing antiretroviral therapy (ART) in 2018. As universal Test and Treat is implemented, these numbers will continue to increase. Given the need for lifelong care for millions of individuals, differentiated service delivery models for ART services such as adherence clubs (ACs) for stable patients are required. In this study, we describe long-term virologic outcomes of patients who have ever entered ACs in Khayelitsha, Cape Town.

METHODS

We included adult patients enrolled in ACs in Khayelitsha between January 2011 and December 2016 with a recorded viral load (VL) before enrolment. Risk factors for an elevated VL (VL >1000 copies/mL) and confirmed virologic failure (two consecutive VLs >1000 copies/mL one year apart) were estimated using Cox proportional hazards models. VL completeness over time was assessed.

RESULTS

Overall, 8058 patients were included in the analysis, contributing 16,047 person-years of follow-up from AC entry (median follow-up time 1.7 years, interquartile range [IQR]:0.9 to 2.9). At AC entry, 74% were female, 46% were aged between 35 and 44 years, and the median duration on ART was 4.8 years (IQR: 3.0 to 7.2). Among patients virologically suppressed at AC entry (n = 8058), 7136 (89%) had a subsequent VL test, of which 441 (6%) experienced an elevated VL (median time from AC entry 363 days, IQR: 170 to 728). Older age (adjusted hazard ratio [aHR] 0.64, 95% confidence interval [CI] 0.46 to 0.88), more recent year of AC entry (aHR 0.76, 95% CI 0.68 to 0.84) and higher CD4 count (aHR 0.67, 95% CI 0.54 to 0.84) were protective against experiencing an elevated VL. Among patients with an elevated VL, 52% (150/291) with a repeat VL test subsequently experienced confirmed virologic failure in a median time of 112 days (IQR: 56 to 168). Frequency of VL testing was constant over time (82 to 85%), with over 90% of patients remaining virologically suppressed.

CONCLUSIONS

This study demonstrates low prevalence of elevated VLs and confirmed virologic failure among patients who entered ACs. Although ACs were expanded rapidly, most patients were well monitored and remained stable, supporting the continued rollout of this model.

Survival Time and Prognostic Factors of Mortality among Patients with Acquired Immunodeficiency Syndrome in North-East Peninsular Malaysia

BACKGROUND

Death resulting from the acquired immunodeficiency syndrome (AIDS) is a worldwide concern. This study is aimed at determining the overall median survival time, and the prognostic factors of mortality among AIDS-infected patients in North-East Peninsular Malaysia.

METHODS

In 2018, a retrospective cohort study stretching from January to April was conducted. This study involved a review of data obtained from the National AIDS Registry. A total of 1,073 AIDS cases diagnosed from 1 January 2010 to 31 December 2014 were selected, and follow-up procedures were conducted until 31 March 2015 (a 3-month follow-up). The Kaplan-Meier plot and Cox's proportional hazard regression were used for data analyses.

RESULTS

564 (52.5%) patients died due to AIDS, while the remaining 509 (47.4%) were censored. The overall median survival time was 11 months. The probability of survival in 1-year, 2-year, 3-year, 4-year and 5-year periods were 49.1%, 47.8%, 47.3%, 47.0% and 46.7%, respectively. Multiple Cox regression revealed that the significant prognostic factors were age 30-49 years [adjusted hazard ratio (Adj. HR) 1.57; 95% CI: 1.14, 2.16; P = 0.006], male (Adj. HR 1.39; 95% CI: 1.07, 1.79; P = 0.012), unemployed (Adj. HR 1.40; 95% CI: 1.12, 1.75; P = 0.003) and HIV-TB co-infection (Adj. HR 1.78; 95% CI: 1.37, 2.31; P < 0.001).

CONCLUSION

The overall median survival time among AIDS patients in North-East Peninsular Malaysia was revealed to be short, in comparison to the other studies. The chances for survival can be improved with more emphasis on early detection (to ensure early treatment) and social support, particularly for HIV-TB co-infected patients, as well as for younger and unemployed patients.

On the Epidemiology and Statistical Analysis of HIV/AIDS Patients in the Insurgency Affected States of Nigeria

BACKGROUND:

The effect of insurgencies on a nation regarding the economy, education, health and infrastructure cannot be overemphasised.

AIM:

This research is therefore focused on analysing the incidence of HIV/AIDS disease in states affected by the activities of the Boko Haram insurgency in Nigeria.

MATERIAL AND METHODS:

The data collected refer to the period from 2004 to 2017, reporting information on 16,102 patients and including the age, gender, year of diagnosing and status of the patients. Descriptive, Chi-square test of independence and Correlation analyses were performed using Statistical Package for Social Sciences (SPSS) version 20.

RESULTS:

It was discovered that the majority of those living with HIV/AIDS in these Boko Haram ravaged areas are females between the age group of 30 years to 39 years. Reported cases of HIV/AIDS started increasing significantly from age 20, and the highest number of reported cases of HIV/AIDS was recorded in the year 2017.

CONCLUSION:

The status of the patient was found to be dependent on both the gender and age of the patients’ treatment, though the strength of the linear relationship between status and age is not significantly different from zero.

Twelve-year mortality in adults initiating antiretroviral therapy in South Africa

Introduction: South Africa has the largest number of individuals living with HIV and the largest antiretroviral therapy (ART) programme worldwide. In September 2016, ART eligibility was extended to all 7.1 million HIV-positive South Africans. To ensure that further expansion of services does not compromise quality of care, long-term outcomes must be monitored. Few studies have reported long-term mortality in resource-constrained settings, where mortality ascertainment is challenging. Combining site records with data linked to the national vital registration system, sites in the International Epidemiology Databases to Evaluate AIDS Southern Africa collaboration can identify >95% of deaths in patients with civil identification numbers (IDs). This study used linked data to explore long-term mortality and viral suppression among adults starting ART in South Africa.

Methods: The study was a cohort analysis of routine data on adults with IDs starting ART 2004–2015 in five large ART cohorts. Mortality was estimated overall and by gender using the Kaplan-Meier estimator and Cox’s proportional hazards regression. Standardized mortality ratios (SMRs) were calculated by dividing observed numbers of deaths by numbers expected if patients had been HIV-negative. Viral suppression in patients with viral loads (VLs) in their last year of follow-up was the secondary outcome.

Results: Among 72,812 adults followed for 350,376 person years (pyrs), the crude mortality rate was 3.08 (95% CI 3.02–3.14)/100 pyrs. Patients were predominantly female (67%) and the percentage of men initiating ART did not increase. Cumulative mortality 12 years after ART initiation was 23.9% (33.4% male and 19.4% female). Mortality peaked in patients enrolling in 2007–2009 and was higher in men than women at all durations. Observed mortality rates were higher than HIV-negative mortality, decreasing with duration. By 48 months, observed mortality was close to that in the HIV-negative population, and SMRs were similar for all baseline CD4 strata. Three-quarters of patients had VLs in their last year, and 86% of these were virally suppressed.

Conclusions: The South African ART programme has shown a remarkable ability to initiate and manage patients successfully over 12 years, despite rapid expansion. With further scale-up, testing and initiating men on ART must be a national priority.

Sex disparities in outcomes among adults on long-term antiretroviral treatment in northern Nigeria

BACKGROUND

There are conflicting reports of sex differences in HIV treatment outcomes in Africa. We investigated sex disparities in treatment outcomes for adults on first line antiretroviral treatment (ART) in Nigeria.

METHODS

We compared clinical and immunologic responses to ART between HIV-infected men (n=205) and women (n=140) enrolled in an ART program between June 2004 and December 2007, with follow-up through June 2014. We employed Kaplan-Meier estimates to examine differences in time to immunologic failure and loss to follow-up (LTFU), and generalized estimating equations to assess changes in CD4+ count by sex.

RESULTS

Men had lower baseline mean CD4+ count compared to women (327.6 cells/µL vs 413.4, respectively, p<0.01). Women had significantly higher rates of increase in CD4+ count than men, even after adjusting for confounders, p<0.0001. There was no significant difference in LTFU by sex: LTFU rate was 2.47/1000 person-months (95% CI 1.6-3.9) in the first five years for men vs 1.98/1000 person-months (95% CI (1.3-3.0) for women. There was no difference in time to LTFU by sex over the study period.

CONCLUSIONS

Women achieved better long-term immune response to ART at baseline and during treatment, but had similar rates of long-term retention in care to men. Targeted efforts are needed to improve immune outcomes in men in our setting.

Marked sex differences in all-cause mortality on antiretroviral therapy in low- and middle-income countries: a systematic review and meta-analysis

Introduction

While women and girls are disproportionately at risk of HIV acquisition, particularly in low- and middle-income countries (LMIC), globally men and women comprise similar proportions of people living with HIV who are eligible for antiretroviral therapy. However, men represent only approximately 41% of those receiving antiretroviral therapy globally. There has been limited study of men’s outcomes in treatment programmes, despite data suggesting that men living with HIV and engaged in treatment programmes have higher mortality rates. This systematic review (SR) and meta-analysis (MA) aims to assess differential all-cause mortality between men and women living with HIV and on antiretroviral therapy in LMIC.

Methods

A SR was conducted through searching PubMed, Ovid Global Health and EMBASE for peer-reviewed, published observational studies reporting differential outcomes by sex of adults (≥15 years) living with HIV, in treatment programmes and on antiretroviral medications in LMIC. For studies reporting hazard ratios (HRs) of mortality by sex, quality assessment using Newcastle–Ottawa Scale (cohort studies) and an MA using a random-effects model (Stata 14.0) were conducted.

Results

A total of 11,889 records were screened, and 6726 full-text articles were assessed for eligibility. There were 31 included studies in the final MA reporting 42 HRs, with a total sample size of 86,233 men and 117,719 women, and total time on antiretroviral therapy of 1555 months. The pooled hazard ratio (pHR) showed a 46% increased hazard of death for men while on antiretroviral treatment (1.35–1.59). Increased hazard was significant across geographic regions (sub-Saharan Africa: pHR 1.41 (1.28–1.56); Asia: 1.77 (1.42–2.21)) and persisted over time on treatment (≤12 months: 1.42 (1.21–1.67); 13–35 months: 1.48 (1.23–1.78); 36–59 months: 1.50 (1.18–1.91); 61 to 108 months: 1.49 (1.29–1.71)).

Conclusions

Men living with HIV have consistently and significantly greater hazards of all-cause mortality compared with women while on antiretroviral therapy in LMIC. This effect persists over time on treatment. The clinical and population-level prevention benefits of antiretroviral therapy will only be realized if programmes can improve male engagement, diagnosis, earlier initiation of therapy, clinical outcomes and can support long-term adherence and retention.

Are there differences in disease progression and mortality among male and female HIV patients on antiretroviral therapy? A meta-analysis of observational cohorts

Studies examining the sex differences in morbidity and mortality among HIV/AIDS patients have yielded inconsistent results. We conducted a meta-analysis of sex differences in disease progression and mortality among HIV/AIDS patients. Medical literature databases from inception to August 2014 were searched for published observational studies assessing sex differences in immunologic and virologic response, disease progression and mortality among HIV-infected patients. Random effects meta-analyses of 115 eligible studies were conducted to obtain pooled estimates of outcomes and heterogeneity was explored in sub-group analyses. Pooled estimates showed an increased risk of progression to AIDS (relative risk [RR]=1.11,95% CI=1.02-1.21) and all-cause mortality (RR=1.23, 95% CI=1.17-1.29) among males compared to females. All-cause mortality differed by sex only in low and middle income countries. The risk of AIDS-related mortality (RR=1.03, 95% CI=0.82-1.30), immunologic failure (RR=1.19,95% CI: 0.97-1.47), virologic suppression (RR=0.98, 95% CI=0.84-1.14), virologic failure (RR=1.26, 95% CI=0.99-1.61) and the change in CD4 cell count (Weighted mean difference [WMD] = -5.15, 95% CI= -13.57 to 3.28) did not differ by sex. These findings were modified by disease severity, adherence and use of highly active antiretroviral therapy. We conclude that HIV-related disease progression and survival outcomes are poorer in males.

Persons Living With HIV/AIDS: Employment as a Social Determinant of Health

Purpose: For persons living with HIV/AIDS (PLWHA), the advent of highly active antiretroviral therapy has increased their longevity and quality of life. As HIV progresses, many PLWHA present declined domains of functioning that impede their ability to work. The authors explore employment as a social determinant of health to identify issues impacting employment outcomes for PLWHA.

Methods: The authors reviewed the literature addressing HIV across the domains of mental health functioning, neurocognitive functioning, and physical function and employment.

Results: When providing employment services to PLWHA, considerations for rehabilitation practitioners and educators include HIV/AIDS education, functional assessment, social support, considerations for women with HIV, highly active antiretroviral therapy (HAART), HIV/AIDS stigma, and employment resources for PLWHA.

Conclusion: With more than 1.2 million PLWHA in the United States, and most of new infections among persons 25–44 years of age, the prevalence of PLWHA seeking employment and inclusive of the U.S. workforce will continue to increase. Proving employment services for PLWHA is a complex process that is best served by an integrative service approach.

A Second Look at the Association between Gender and Mortality on Antiretroviral Therapy

Objective

We assessed the association between gender and mortality on antiretroviral therapy (ART) using identical models with and without sex-specific categories for weight and hemoglobin.

Design

Cohort study of adult patients on ART.

Setting

GHESKIO Clinic in Port-au-Prince, Haiti.

Participants

4,717 ART-naïve adult patients consecutively enrolled on ART at GHESKIO from 2003 to 2008.

Main Outcome Measure

Mortality on ART; multivariable analyses were conducted with and without sex-specific categories for weight and hemoglobin.

Results

In Haiti, male gender was associated with mortality (OR 1.61; 95% CI: 1.30–2.00) in multivariable analyses with hemoglobin and weight included as control variables, but not when sex-specific interactions with hemoglobin and weight were used.

Conclusions

If sex-specific categories are omitted, multivariable analyses indicate a higher risk of mortality for males vs. females of the same weight and hemoglobin. However, because males have higher normal values for weight and hemoglobin, the males in this comparison would generally have poorer health status than the females. This may explain why gender differences in mortality are sometimes observed after controlling for differences in baseline variables when gender-specific interactions with weight and hemoglobin are omitted.

Temporal distribution of baseline characteristics and association with early mortality among HIV-positive patients at University College Hospital, Ibadan, Nigeria

The first six months of HIV care and treatment are very important for long-term outcome. Early mortality (within 6 months of care initiation) undermines care and treatment goals. This study assessed the temporal distribution in baseline characteristics and early mortality among HIV patients at the University College Hospital, Ibadan, Nigeria from 2006-2013. Factors associated with early mortality were also investigated. This was a retrospective analysis of data from 14 857 patients enrolled for care and treatment at the adult antiretroviral clinic of the University College Hospital, Ibadan, Nigeria. Effects of factors associated with early mortality were summarised using a hazard ratio with a 95% confidence interval obtained from Cox proportional hazard regression models. The mean age of the subjects was 36.4 (SD=10.2) years with females being in the majority (68.1%). While patients' demographic characteristics remained virtually the same over time, there was significant decline in the prevalence of baseline opportunistic infections (2006-2007=55.2%; 2011-2013=38.0%). Overall, 460 (3.1%) patients were known to have died within 6 months of enrollment in care/treatment. There was no significant trend in incidence of early mortality. Factors associated with early mortality include: male sex, HIV encephalopathy, low CD4 count (< 50 cells), and anaemia. To reduce early mortality, community education should be promoted, timely access to care and treatment should be facilitated and the health system further strengthened to care for high risk patients.

Employment as a Social Determinant of Health: A Systematic Review of Longitudinal Studies Exploring the Relationship Between Employment Status and Physical Health

Purpose:To explore employment as a social determinant of health through examining the relationship between employment status and physical health.

Method:The authors explored the causal relationship between employment status and physical health through conducting a systematic review of 22 longitudinal studies conducted in Finland, France, the Netherlands, Nigeria, Sweden, United Kingdom, and the United States.

Results:Five common trajectories were identified as employment, unemployment, job loss, reemployment, and retired. Unemployment and job loss were associated with poorer physical health. Employment and reemployment were associated with better physical health.

Conclusion:To enhance employment outcomes, it is important for service providers to acknowledge the interaction between the client’s physical health and employment status, and assess client physical functioning. Additional research is necessary to further elucidate this interaction.

Factors associated with mortality in HIV-infected people in rural and urban South Africa

Background

Factors associated with mortality in HIV-infected people in sub-Saharan Africa are widely reported. However rural–urban disparities and their association with all-cause mortality remain unclear. Furthermore, commonly used classical Cox regression ignores unmeasured variables and frailty.

Objective

To incorporate frailty in assessing factors associated with mortality in HIV-infected people in rural and urban South Africa.

Design

Using data from a prospective cohort following 6,690 HIV-infected participants from Soweto (urban) and Mpumalanga (rural) enrolled from 2003 to 2010; covariates of mortality were assessed by the integrated nested Laplace approximation method.

Results

We enrolled 2,221 (33%) rural and 4,469 (67%) urban participants of whom 1,555 (70%) and 3,480 (78%) were females respectively. Median age (IQR) was 36.4 (31.0–44.1) in rural and 32.7 (28.2–38.1) in the urban participants. The mortality rate per 100 person-years was 11 (9.7–12.5) and 4 (3.6–4.5) in the rural and urban participants, respectively. Compared to those not on HAART, rural participants had a reduced risk of mortality if on HAART for 6–12 (HR: 0.20, 95% CI: 0.10–0.39) and >12 months (HR: 0.10, 95% CI: 0.05–0.18). Relative to those not on HAART, urban participants had a lower risk if on HAART >12 months (HR: 0.35, 95% CI: 0.27–0.46).

The frailty variance was significant and >1 in rural participants indicating more heterogeneity. Similarly it was significant but <1 in the urban participants indicating less heterogeneity.

Conclusion

The frailty model findings suggest an elevated risk of mortality in rural participants relative to the urban participants potentially due to unmeasured variables that could be biological, socio–economic, or healthcare related. Use of robust methods that optimise data and account for unmeasured variables could be helpful in assessing the effect of unknown risk factors thus improving patient management and care in South Africa and elsewhere.

The effect of tuberculosis treatment at combination antiretroviral therapy initiation on subsequent mortality: a systematic review and meta-analysis

OBJECTIVE

We aimed to perform a systematic review and meta-analysis examining the impact of TB treatment at the time of combination antiretroviral therapy (cART) initiation on subsequent mortality.

METHODS

We searched PubMed, EMBASE, and selected conference proceedings for studies that report adult mortality on cART, stratified by TB treatment status at cART initiation. Stratified random-effects and meta-regression analyses were used to examine the influence of study and population characteristics.

RESULTS

22 eligible cohort studies reported data on 98,350 (range 74-15,225) adults, of whom 14,779 (15%) were receiving TB treatment at cART initiation. Studies of those receiving vs. not receiving TB treatment had an average mortality relative risk of 1.10 (95% confidence interval 0.87-1.40) at 1-3 months (based upon 8 estimates), 1.15 (0.94-1.41) at 6-12 months (11 estimates), and 1.33 (1.02-1.75) at 18-98 months (10 estimates) following cART initiation. However, there was a wide range of estimates and those at later time points were markedly heterogeneous. Meta-regression identified factors associated with elevated average risk estimates: lower median baseline CD4 counts and adjustment for baseline hemoglobin at 1-3 months; longer length of follow-up and women-only studies at 6-12 months; and not adjusting for BMI/weight at 18-98 months.

CONCLUSIONS

Patients receiving TB treatment at cART initiation did not have a statistically significant estimated increase in short-term risk of all-cause mortality as compared to those not receiving TB treatment. TB treatment was significantly associated with increased mortality after about a year of cART, suggesting that patients with concurrent TB treatment at cART initiation may benefit from continued support after TB treatment completion.

Impact of definitions of loss to follow-up (LTFU) in antiretroviral therapy program evaluation: variation in the definition can have an appreciable impact on estimated proportions of LTFU

OBJECTIVE

To examine the impact of different definitions of loss to follow-up (LTFU) on estimates of program outcomes in cohort studies of patients on antiretroviral therapy (ART).

STUDY DESIGN AND SETTING

We examined the impact of different definitions of LTFU using data from the International Epidemiological Databases to Evaluate AIDS-Southern Africa. The reference approach, Definition A, was compared with five alternative scenarios that differed in eligibility for analysis and the date assigned to the LTFU outcome. Kaplan-Meier estimates of LTFU were calculated up to 2 years after starting ART.

RESULTS

Estimated cumulative LTFU were 14% and 22% at 12 and 24 months, respectively, using the reference approach. Differences in the proportion LTFU were reported in the alternative scenarios with 12-month estimates of LTFU varying by up to 39% compared with Definition A. Differences were largest when the date assigned to the LTFU outcome was 6 months after the date of last contact and when the site-specific definition of LTFU was used.

CONCLUSION

Variation in the definitions of LTFU within cohort analyses can have an appreciable impact on estimated proportions of LTFU over 2 years of follow-up. Use of a standardized definition of LTFU is needed to accurately measure program effectiveness and comparability between programs.

The role of host gender in the pathogenesis of Cryptococcus neoformans infections

Cryptococcus neoformans (Cn) is a pathogenic yeast and the cause of cryptococcal meningitis. Prevalence of disease between males and females is skewed, with males having an increased incidence of disease. Based on the reported gender susceptibility differences to Cn in the literature, we used clinical isolates from Botswanan HIV-infected patients to test the hypothesis that different gender environments exerted different selective pressures on Cn. When we examined this data set, we found that men had significantly higher risk of death despite having significantly higher CD4⁺ T lymphocyte counts upon admittance to the hospital. These observations suggested that Cn strains are uniquely adapted to different host gender environments and that the male immune response may be less efficient in controlling Cn infection. To discriminate between these possibilities, we tested whether there were phenotypic differences between strains isolated from males and females and whether there was an interaction between Cn and the host immune response. Virulence phenotypes showed that Cn isolates from females had longer doubling times and released more capsular glucoronoxylomannan (GXM). The presence of testosterone but not 17-β estradiol was associated with higher levels of GXM release for a laboratory strain and 28 clinical isolates. We also measured phagocytic efficiency, survival of Cn, and amount of killing of human macrophages by Cn after incubation with four isolates. While macrophages from females phagocytosed more Cn than macrophages from males, male macrophages had a higher fungal burden and showed increased killing by Cn. These data are consistent with the hypothesis that differential interaction between Cn and macrophages within different gender environments contribute to the increased prevalence of cryptococcosis in males. This could be related to differential expression of cryptococcal virulence genes and capsule metabolism, changes in Cn phagocytosis and increased death of Cn-infected macrophages.

Effects of physical tracing on estimates of loss to follow-up, mortality and retention in low and middle income country antiretroviral therapy programs: a systematic review

BACKGROUND

A large proportion of patients receiving antiretroviral therapy (ART) in low and middle income countries (LMICs) have unknown treatment outcomes and are classified as lost to follow-up (LTFU). Physical tracing of patients classified as LTFU is common; however, effects of tracing on outcomes remains unclear. The objective of this systematic review is to compare estimates of LTFU, mortality and retention in LMIC in cohorts of patients with and without physical tracing.

METHODS AND FINDINGS

We systematically identified studies in LMIC programmatic settings using MEDLINE (2003-2011) and HIV conference abstracts (2009-2011). Studies reporting the proportion LTFU 12-months after ART initiation were included. Tracing activities were determined from manuscripts or by contacting study authors. Studies were classified as "tracing studies" if physical tracing was available for the majority of patients. Summary estimates from the 2 groups of studies (tracing and non-tracing) for LTFU, mortality, stop of ART, transfers out, and retention on ART were determined. 261 papers and 616 abstracts were identified of which 39 studies comprising 54 separate cohorts (n = 187,666) met inclusion criteria. Of those, physical tracing was available for 46% of cohorts. Treatment programs with physical tracing activities had lower estimated LTFU (7.6% vs. 15.1%; p<.001), higher estimated mortality (10.5% vs. 6.6%; p = .006), higher retention on ART (80.0 vs. 75.8%; p = .04) and higher retention at the original site (80.0% vs. 72.9%; p = .02).

CONCLUSIONS

Knowledge of patient tracing is critical when interpreting program outcomes of LTFU, mortality and retention. The reduction of the proportion LTFU in tracing studies was only partially explained by re-classification of unknown outcomes. These data suggest that tracing may lead to increased re-engagement of patients in care, rather than just improved classification of unknown outcomes.

Male sex and the risk of mortality among individuals enrolled in antiretroviral therapy programs in Africa: a systematic review and meta-analysis

BACKGROUND

HIV/AIDS has historically had a sex and gender-focused approach to prevention and care. Some evidence suggests that HIV-positive men have worse treatment outcomes than their women counterparts in Africa.

METHODS

We conducted a systematic review and meta-analysis of the effect of sex on the risk of death among participants enrolled in antiretroviral therapy (ART) programs in Africa since the rapid scale-up of ART. We included all cohort studies evaluating the effect of sex (male, female) on the risk of death among participants enrolled in regional and national ART programs in Africa. We identified these studies by searching MedLine, EMBASE, and Cochrane CENTRAL. We used a DerSimonian-Laird random-effects method to pool the proportions of men receiving ART and the hazard ratios for death by sex.

RESULTS

Twenty-three cohort studies, including 216 008 participants (79 892 men) contributed to our analysis. The pooled proportion of men receiving ART was 35% [95% confidence interval (CI): 33-38%]. The pooled hazard ratio estimate indicated a significant increase in the risk of death for men when compared to women [hazard ratio: 1.37 (95% CI: 1.28-1.47)]. This was consistent across sensitivity analyses.

INTERPRETATION

The proportion of men enrolled in ART programs in Africa is lower than women. Additionally, there is an increased risk of death for men enrolled in ART programs. Solutions that aid in reducing these sex inequities are needed.

Women experience a better long-term immune recovery and a better survival on HAART in Lao People's Democratic Republic

Background

In April 2003, Médecins Sans Frontières launched an HIV/AIDS programme to provide free HAART to HIV-infected patients in Laos. Although HIV prevalence is estimated as low in this country, it has been increasing in the last years. This work reports the first results of an observational cohort study and it aims to identify the principal determinants of the CD4 cells evolution and to assess mortality among patients on HAART.

Methods

We performed a retrospective database analysis on patients initiated on HAART between 2003 and 2009 (CD4<200cells/μL or WHO stage 4). We excluded from the analysis patients who were less than 16 years old and pregnant women. To explore the determinants of the CD4 reconstitution, a linear mixed model was adjusted. To identify typical trajectories of the CD4 cells, a latent trajectory analysis was carried out. Finally, a Cox proportional-hazards model was used to reveal predictors of mortality on HAART including appointment delay greater than 1 day.

Results

A total of 1365 patients entered the programme and 913 (66.9%) received an HAART with a median CD4 of 49 cells/μL [IQR 15–148]. High baseline CD4 cell count and female gender were associated with a higher CD4 level over time. In addition, this gender difference increased over time. Two typical latent CD4 trajectories were revealed showing that 31% of women against 22% of men followed a high CD4 trajectory. In the long-term, women were more likely to attend appointments without delay. Mortality reached 6.2% (95% CI 4.8-8.0%) at 4 months and 9.1% (95% CI 7.3-11.3%) at 1 year. Female gender (HR=0.17, 95% CI 0.07-0.44) and high CD4 trajectory (HR=0.19, 95% CI 0.08-0.47) were independently associated with a lower death rate.

Conclusions

Patients who initiated HAART were severely immunocompromised yielding to a high early mortality. In the long-term on HAART, women achieved a better CD4 cells reconstitution than men and were less likely to die. This study highlights important differences between men and women regarding response to HAART and medical care, and questions men’s compliance to treatment.

Gender inequality: Bad for men's health

Men's increased risk of death in ART programmes in sub-Saharan Africa is widely reported but poorly understood. Some studies have attributed this risk to men's poorer health-seeking behaviour, which may prevent them from accessing ART, being adherent to treatment, or remaining in care. In a multicentre analysis of 46 201 adults starting ART in urban and rural settings in South Africa, these factors only partly explained men's increased mortality while receiving ART. Importantly, the gender difference in mortality among patients receiving ART (31% higher for men than women) was substantially smaller than that among HIV-negative South Africans, where men had twice the risk of death compared with women. Yet, this extreme gender inequality in mortality, both within and outside of ART programmes, has not given rise to widespread action. Here it is argued that, despite their dominance in society, men may be subject to a wide range of unfair discriminatory practices, which negatively affect their health outcomes. The health needs of men and boys require urgent attention.

Predictors of death in Malaysian HIV-infected patients on anti-retroviral therapy

OBJECTIVE

To determine the predictors of death in Malaysian HIV-infected patients undergoing antiretroviral therapy (ART).

METHODS

Data from 845 HIV-infected patients aged ≥ 20 years on ART in a large teaching hospital in Malaysia from 1989 to 2009 were analyzed using Kaplan-Meier and Cox regression analyses.

RESULTS

72.7% of the patients survived. Multivariate Cox regression showed that significant predictors of death were age ≥ 50 years (HR 1.76; 95% CI 1.18-2.64), secondary education (HR 3.57; 95% CI 1.12-11.37), tertiary education (HR 3.57; 95% CI 1.09-11.70), being unemployed (HR 1.49; 95% CI 1.07-2.09), AIDS on initial presentation (HR 5.75; 95% CI 3.29-10.07), single-drug ART (HR 1.84; 95% CI 1.27, 2.66), double-drug ART (HR 1.63; 95% CI 1.19-2.25) and inability to achieve viral load ≤ 50 copies/ml (HR 10.22; 95% CI 7.26-14.37).

CONCLUSION

Every effort needs to be made to ensure that all HIV patients have access to triple drug ART, to lower viral load to ≤ 50 copies/ml and to treat HIV patients before they progress to AIDS as these are significant modifiable predictors of death in Malaysian HIV patients.

Incorporating loss to follow-up in estimates of survival among HIV-infected individuals in sub-Saharan Africa enrolled in antiretroviral therapy programs

BACKGROUND

Measuring the survival of human immunodeficiency virus-infected adult patients enrolled in antiretroviral therapy (ART) programs is complicated by short observation periods and loss to follow-up. We synthesized data from treatment cohorts in sub-Saharan Africa to estimate survival over 5 years after initiation of ART.

METHODS

We used data on retention, mortality, and loss to follow-up from 34 cohorts, including a total of 102,306 adult patients from 18 sub-Saharan African countries. These data were augmented by data from 13 sub-Saharan African studies tracking death rates among adult patients who were lost to follow-up (LTFU). We used a Poisson regression model to estimate survival over time, incorporating predicted mortality among LTFU patients.

RESULTS

Across studies, the median CD4(+) cell count at ART initiation was 104 cells/mm(3), 65% of patients were female, and the median age was 37 years. Survival at 1 year and 5 years were estimated to be 0.87 (95% confidence interval [CI], 0.72-0.94) and 0.70 (95% CI, 0.36-0.86), respectively, after adjustment for loss to follow-up. The life-years gained by a patient during the 5-year period after starting ART were estimated at 2.1 (95% CI, 1.6-2.3) in the adjusted model, compared with 1.7 (95% CI, 1.1-2.0) if there was 100% mortality among LTFU patients and with 2.4 (1.7-2.7) if there was 0% mortality among LTFU patients.

CONCLUSIONS

Accounting for loss to follow-up produces substantial changes in the estimated life-years gained during the first 5 years of ART receipt.

Morbidity and Mortality Patterns of Hospitalised Adult HIV/AIDS Patients in the Era of Highly Active Antiretroviral Therapy: A 4-year Retrospective Review from Zaria, Northern Nigeria

Background. This study, undertaken in major tertiary hospital in northern Nigeria, examined the morbidity and mortality patterns of hospitalised adult HIV/AIDS patients in the HAART era. Methods. Between January 2006 and December 2009, admission records and causes of deaths of hospitalised medical HIV-infected patients were retrieved and analysed according to antiretroviral (ART) status. Results. Of the 207 HIV/AIDS patients reviewed, majority were newly diagnosed (73.4%), and most were hospitalised and died from various AIDS-defining illnesses, mainly disseminated tuberculosis and sepsis. Immune-inflammatory-reconstitution-syndrome, ART-toxicity and ART-failure, contributed to morbidity and mortality in patients receiving ART. Sixty six (31.9%) patients died, with higher mortality in males and in those with lower CD4-cell count, lower PCV, and shorter hospital stay. However, hospital stay ≤3 days and severe anaemia (PCV < 24%) were independent predictors of mortality. Conclusion. In the current HAART era, late presentation and tuberculosis continue to fuel the HIV/AIDS pandemic in Africa, with emerging challenges due to ART-related complications.

Psychological stress is associated with high levels of IL-6 in HIV-1 infected individuals on effective combined antiretroviral treatment

This study explores the role of psychological stress in the circulating levels of interleukin-6 (IL-6) in a group of HIV-1 infected individuals on effective cART. We developed a cross-sectional study with 50 individuals with confirmed diagnosis of HIV-1 infection ≥1 and ≤8 years, on continuous cART for >1 and <8 years and with plasma viral load <50 copies/mL for at least 1 year. Clinical, behavioral and psychological variables were collected to control their possible indirect contribution in the relationship between psychological stress and IL-6. Pearson correlation and univariate/multivariate logistic regressions were performed. Eighty-eight percent of the subjects were male: median (IQR) age: 39.0 (32.7-42.2), years since HIV-1 infection: 3.4 (2.1-7.0), years on cART: 2.5 (1.6-5.7), CD4 cell count: 709.0 (573.5-881.0) cell/mm(3), plasma levels of IL-6: 7.0 (0-12.2) pg/ml. A strong correlation between IL-6 and psychological stress was found (r=.81). Psychological stress (coef: 0.49; SD: 0.05), anxiety/depression (0.37; 0.08) and unhealthy diet (2.94; 1.38) were associated with higher levels of IL-6. In the multivariate model psychological stress remained strongly associated with IL-6 (R(2): 59%). In conclusion, individuals with psychological stress presented high levels of IL-6 and psychological stress was the only variable which remained strongly associated with IL-6. This strong relationship suggests evidence for a mechanism through which psychological stress might contribute to the health's impairment of HIV-infected individuals on effective cART.

Sex differences in antiretroviral treatment outcomes among HIV-infected adults in an urban Tanzanian setting

OBJECTIVE

To determine the relationship between sex and antiretroviral therapy (ART) outcomes in an urban Tanzanian setting.

DESIGN

Longitudinal analysis of a cohort of HIV-infected adult men and women on ART enrolled at the Management and Development for Health (MDH)-President's Emergency Plan For AIDS Relief (PEPFAR) HIV care and treatment program in Dar es Salaam, Tanzania.

METHODS

Clinical and immunologic responses to ART were compared between HIV-infected men and women enrolled from November 2004 to June 2008. Cox regression analyses were used to study sex differences with regard to mortality, immunologic failure (WHO, 2006) and loss to follow-up, after adjusting for other risk factors for the outcomes.

RESULTS

Four thousand, three hundred and eighty-three (34%) men and 8459 (66%) women were analyzed. Men were significantly more immunocompromised than women at enrollment in terms of stage IV disease (27 vs. 23%, P < 0.001) and mean CD4⁺ cell count (123 vs. 136 cells/μl, P < 0.001). In multivariate analyses, men had a significantly higher risk of overall mortality [hazard ratio 1.19, 95% confidence interval (CI) 1.05-1.30, P < 0.001], immunologic nonresponse defined as CD4 cell count less than 100 cells/μl after at least 6 months of initiating ART (hazard ratio 1.74, 95% CI 1.44-2.11, P < 0.001) and loss to follow-up (hazard ratio 1.19, 95% CI 1.10-1.30, P < 0.001) than that in women. Associations did not change significantly when restricting analyses to the period of good adherence for all patients.

CONCLUSION

Nonadherence to care and advanced immunodeficiency at enrollment explained only 17% of the inferior mortality in HIV-infected men in this resource-limited setting. Additional study of behavioral and biologic factors that may adversely impact treatment outcomes in men is needed to reduce these sex disparities.

Masculinity as a barrier to men's use of HIV services in Zimbabwe

BACKGROUND

A growing number of studies highlight men's disinclination to make use of HIV services. This suggests there are factors that prevent men from engaging with health services and an urgent need to unpack the forms of sociality that determine men's acceptance or rejection of HIV services.

METHODS

Drawing on the perspectives of 53 antiretroviral drug users and 25 healthcare providers, we examine qualitatively how local constructions of masculinity in rural Zimbabwe impact on men's use of HIV services.

RESULTS

Informants reported a clear and hegemonic notion of masculinity that required men to be and act in control, to have know-how, be strong, resilient, disease free, highly sexual and economically productive. However, such traits were in direct conflict with the 'good patient' persona who is expected to accept being HIV positive, take instructions from nurses and engage in health-enabling behaviours such as attending regular hospital visits and refraining from alcohol and unprotected extra-marital sex. This conflict between local understandings of manhood and biopolitical representations of 'a good patient' can provide a possible explanation to why so many men do not make use of HIV services in Zimbabwe. However, once men had been counselled and had the opportunity to reflect upon the impact of ART on their productivity and social value, it was possible for some to construct new and more ART-friendly versions of masculinity.

CONCLUSION

We urge HIV service providers to consider the obstacles that prevent many men from accessing their services and argue for community-based and driven initiatives that facilitate safe and supportive social spaces for men to openly discuss social constructions of masculinity as well as renegotiate more health-enabling masculinities.

Barriers to initiation of antiretrovirals during antituberculosis therapy in Africa

Background

In the developing world, the principal cause of death among HIV-infected patients is tuberculosis (TB). The initiation of antiretroviral therapy (ART) during TB therapy significantly improves survival, however it is not known which barriers prevent eligible TB patients from initiating life-saving ART.

Method

Setting. A South African township clinic with integrated tuberculosis and HIV services. Design. Logistic regression analyses of a prospective cohort of HIV-1 infected adults (≥18 years) who commenced TB therapy, were eligible for ART, and were followed for 6 months.

Findings

Of 100 HIV-1 infected adults eligible for ART during TB therapy, 90 TB patients presented to an ART clinic for assessment, 66 TB patients initiated ART, and 15 TB patients died. 34% of eligible TB patients (95%CI: 25–43%) did not initiate ART. Male gender and younger age (<36 years) were associated with failure to initiate ART (adjusted odds ratios of 3.7 [95%CI: 1.25–10.95] and 3.3 [95%CI: 1.12–9.69], respectively). Death during TB therapy was associated with a CD4+ count <100 cells/µL.

Conclusion

In a clinic with integrated services for tuberculosis and HIV, one-third of eligible TB patients – particularly young men – did not initiate ART. Strategies are needed to promote ART initiation during TB therapy, especially among young men.

Patient retention in antiretroviral therapy programs up to three years on treatment in sub-Saharan Africa, 2007-2009: systematic review

Objectives

To estimate the proportion of all-cause adult patient attrition from antiretroviral therapy (ART) programs in service delivery settings in sub-Saharan Africa through 36 months on treatment.

Methods

We identified cohorts within Ovid Medline, ISI Web of Knowledge, Cochrane Database of Systematic Reviews and four conference abstract archives. We summarized retention rates from studies describing observational cohorts from sub-Saharan Africa reporting on adult HIV 1- infected patients initiating first-line three-drug ART. We estimated all-cause attrition rates for 6, 12, 18, 24, or 36 months after ART initiation including patients who died or were lost to follow-up (as defined by the author), but excluding transferred patients.

Results

We analysed 33 sources describing 39 cohorts and 226 307 patients. Patients were more likely to be female (median 65%) and had a median age at initiation of 37 (range 34–40). Median starting CD4 count was 109 cells/mm³. Loss to follow-up was the most common cause of attrition (59%), followed by death (41%). Median attrition at 12, 24 and 36 months was 22.6% (range 7%–45%), 25% (range 11%–32%) and 29.5% (range 13%–36.1%) respectively. After pooling data in a random-effects meta-analysis, retention declined from 86.1% at 6 months to 80.2% at 12 months, 76.8% at 24 months and 72.3% at 36 months. Adjusting for variable follow-up time in a sensitivity analysis, 24 month retention was 70.0% (range: 66.7%–73.3%), while 36 month retention was 64.6% (range: 57.5%–72.1%).

Conclusions

Our findings document the difficulties in retaining patients in care for lifelong treatment, and the progress being made in raising overall retention rates.

Gender-related mortality for HIV-infected patients on highly active antiretroviral therapy (HAART) in rural Uganda

The purpose of this study was to examine gender differences in mortality for human immunodeficiency virus (HIV) patients in rural Western Uganda after six months of highly active antiretroviral therapy (HAART). Three hundred eighty five patients were followed up for six months after initiating HAART. Statistical analysis included descriptive, univariate and multivariate methods, using Kaplan-Meier estimates of survival distribution and Cox proportional hazards regression. Mortality in female patients (9.0%) was lower than mortality in males (13.5%), with the difference being almost statistically significant (adjusted hazard ratio for females 0.55; 95% confidence interval [CI]: 0.28-1.07; P = 0.08). At baseline, female patients had a significantly higher CD4+ cell count than male patients (median 147 cells/μL vs 120 cells/μL; P < 0.01). A higher CD4+ cell count and primary level education were strongly associated with better survival. The higher CD4+ cell count in females may indicate that they accessed HAART services at an earlier stage of their disease progression than males. A borderline statistically significant lower mortality rate in females shows that females fare better on treatment in this context than males. The association between lower mortality and higher CD4+ levels suggest that males are not accessing treatment early enough and that more concerted efforts need to be made by HAART programs to reach male HIV patients.

Gender-related power differences, beliefs and reactions towards people living with HIV/AIDS: an urban study in Nigeria

BACKGROUND

Although there are an increasing number of studies on HIV-related stigma in Nigeria, very little research has focused on how power differences based on gender perpetuate the stigmatization of people living with HIV/AIDS (PLWHA) and how these gender differences affect the care that PLWHA receive in health care institutions. We explore gender-related beliefs and reactions of society, including health care professionals (HCPs), with regard to PLWHA, using Connell's theoretical framework of gender and power (1987). With Connell's structural theory of gender and power (financial inequality, authority and structure of social norms), we can describe gender differences in stigmatization of PLWHA.

METHOD

We conducted in-depth semi-structured interviews, lasting 60 to 90 minutes, with 100 persons (40 members of the general public, 40 HCPs and 20 PLWHA) in Port Harcourt, Nigeria. The interviews were tape-recorded and transcribed verbatim. The Nvivo 7 computer package was used to analyze the data.

RESULTS

There are similarities and differences between the general public and HCPs towards PLWHA in gender-related beliefs and reactions. For instance, although association with promiscuity and power differences were commonly acknowledged in the different groups, there are differences in how these reactions are shown; such as HCPs asking the female PLWHA to inform their partners to ensure payment of hospital bills. Women with HIV/AIDS in particular are therefore in a disadvantaged position with regard to the care they receive.

CONCLUSION

Despite the fact that men and women with HIV/AIDS suffer the same illness, clear disparities are apparent in the negative reaction women and men living with HIV/AIDS experience in society. We show that women's generally low status in society contributes to the extreme negative reactions to which female PLWHA are subject. The government should create policies aimed at reducing the power differences in family, society and health care systems, which would be important to decrease the gender-related differences in stigma experienced by PLWHA. Interventions should be directed at the prevailing societal norms through appropriate legislation and advocacy at grassroots level with the support of men to counter laws that put women in a disadvantaged position. Furthermore, development of a policy that encourages equality in access to health care for all patients with HIV/AIDS by applying the same conditions to both men and women in health care institutions is recommended. There is a need to protect women's rights through implementing support policies, including paying attention to gender in the training of HCPs.

Impact of hepatitis B virus infection on human immunodeficiency virus response to antiretroviral therapy in Nigeria

BACKGROUND

As highly active antiretroviral therapy (ART) is introduced into areas of the world in which hepatitis B virus (HBV) infection is highly endemic, it is important to determine the influence of HBV on persons with human immunodeficiency virus (HIV) and HBV coinfection who are receiving ART.

METHODS

We studied 1564 HIV-infected patients in Jos, Nigeria, who initiated ART. Participants with HIV-HBV coinfection had hepatitis B e antigen (HBeAg) and HBV DNA status determined. CD4+ T cell count and HIV load at ART initiation were compared between individuals with HIV monoinfection and those with HIV-HBV coinfection with use of univariate methods. Regression analyses were used to determine if HBeAg status or HBV DNA at ART initiation were associated with baseline HIV parameters or ART response.

RESULTS

The median CD4+ T cell count of the 262 participants with HIV-HBV coinfection (16.7%) was 107 cells/mL, compared with 130 cells/mL for participants with HIV monoinfection at ART initiation (P = .001). Participants with HIV-HBV coinfection also had higher HIV loads than did patients with HIV monoinfection (4.96 vs 4.75 log10 copies/mL; p = .02 ). Higher HBV DNA and detectable HBeAg levels were independently associated with lower CD4+ T cell counts at ART initiation but not with higher HIV loads. In a multivariable model, HBeAg-positive patients were less likely than HBeAg-negative patients to suppress HIV replication to <or= 400 copies/mL (odds ratio, 0.54; P = .03 ) at 24 weeks, but they had similar CD4+ T cell increases. At 48 weeks, there was no significant effect of HBeAg status on ART response.

CONCLUSIONS

Among HIV-infected Nigerian individuals, HBV coinfection, especially among those with high levels of HBV replication, was associated with lower CD4+ T cell counts at ART initiation, independent of HIV RNA level. Patients with HBeAg-positive status had a slower virological response to ART, compared with HBeAg-negative patients. Further work is needed to understand the effects of HBV on CD4+ T cells.