Review of human immunodeficiency virus type 1-related opportunistic infections in sub-Saharan Africa

A comparison of the surgical outcomes of ventriculoperitoneal versus lumbar peritoneal shunts in the management of intracranial hypertension secondary to cryptococcal meningitis in HIV infected adult patients

OBJECTIVE

Cryptococcal meningitis (CM), an AIDS-defining illness, significantly impacts morbidity and mortality. This study aims to compare complications arising from ventriculoperitoneal shunt (VPS) and lumbar peritoneal shunt (LPS) procedures used to manage refractory intracranial hypertension (IH) secondary to CM in HIV-infected patients.

METHODS

Retrospective data were collected from January 2003 to January 2015 for HIV-infected adults diagnosed with refractory IH secondary to CM and subsequently shunted. Demographics, clinical characteristics, antiretroviral therapy, laboratory findings (including CD4 count and CSF results), CT brain scan results, shunt-related complications, and mortality were compared between VPS and LPS groups.

RESULTS

This study included 83 patients, with 60 (72%) undergoing VPS and 23 (28%) receiving LPS. Mean ages were comparable between VPS (32.5) and LPS (32.2) groups (p = 0.89). Median CD4+ counts were 76 cells/µl (IQR= 30-129) in VPS versus 54 cells/µl (IQR= 31-83) in LPS (p=0.45). VPS group showed a higher mean haemoglobin of 11.5 g/dl compared to 9.9 g/dl in the LPS group (p=0.001). CT brain scans showed hydrocephalus in 55 VPS and 13 LPS patients respectively. Shunt complications were observed in 17 (28%) VPS patients versus 10 (43.5%) LPS patients (p=0.5). Patients developing shunt sepsis in the VPS group exhibited a median CD4+ count of 117 cells/µl (IQR= 76-129) versus 48 cells/µl (IQR= 31- 66) in the LPS group (p=0.03). Early shunt malfunction occurred more frequently in the LPS group compared to VPS group (p=0.044). The mean hospital stay was 6.2 days for VPS versus 5.4 days for LPS patients (p=0.9). In-hospital mortality was 6%, occurring in three VPS and two LPS patients respectively.

CONCLUSION

Shunting procedures remain important surgical interventions for refractory IH secondary to HIV-related CM. However, cautious consideration is warranted for patients with CD4 counts below 200 cells/µL due to increased shunt complications. This study suggests a trend toward higher complication rates in patients undergoing LPS insertion.

Synthesis and Antimicrobial Activity of New Mannich Bases with Piperazine Moiety

A series of novel Mannich bases were designed, synthesized, and screened for their antimicrobial activity. The target compounds were synthesized from 4-(3-chlorophenyl)-5-(3-fluorophenyl)-2,4-dihydro-3H-1,2,4-triazole-3-thione and different piperazine derivatives. The structures of the products were confirmed by ¹H and ¹³C NMR and elemental analysis. The activity of piperazine derivatives against bacteria (Gram-positive: Staphylococcus epidermidis, Staphylococcus aureus, Micrococcus luteus, Bacillus cereus, and Bacillus subtilis; Gram-negative: Escherichia coli, Pseudomonas aeruginosa, Klebsiella pneumoniae, and Proteus mirabilis) and yeasts (Candida glabrata, Candida krusei, and Candida parapsilosis) was determined by the minimum inhibitory concentration and minimum bactericidal concentration values. Significant activity was observed against Gram-positive bacteria, mainly staphylococci (PG7-PG8) and bacteria of the genes of Micrococcus and Bacillus (PG1-3), as well as selected strains of Gram-negative bacteria, including bacteria of the Enterobacteriaceae family (PG7), while all tested compounds showed high fungistatic activity against Candida spp. yeasts, especially C. parapsilosis, with MICs ranging from 0.49 µg/mL (PG7) to 0.98 µg/mL (PG8) and 62.5 µg/mL (PG1-3). In conclusion, the results obtained confirm the multidirectional antimicrobial activity of the newly synthesized piperazine derivatives. Furthermore, in silico studies suggest that the tested compounds are likely to have good oral bioavailability. The results obtained will provide valuable data for further research into this interesting group of compounds. The library of compounds obtained is still the subject of pharmacological research aimed at finding new interesting biologically active compounds.

Synthesis and Biological Evaluation of New Schiff Bases Derived from 4-Amino-5-(3-fluorophenyl)-1,2,4-triazole-3-thione

The treatment of infectious diseases is a challenging issue faced by the medical community. The emergence of drug-resistant strains of bacteria and fungi is a major concern. Researchers and medical professionals are working to develop new and innovative treatments for infectious diseases. Schiff bases are one a promising class of compounds. In this work, new derivatives were obtained of the 4-amino-5-(3-fluorophenyl)-2,4-dihydro-3H-1,2,4-triazole-3-thione reaction, with corresponding benzaldehydes with various substituents at position 4. The antibacterial and antifungal activities of all synthesized compounds were tested. Several new substances have shown moderate antifungal activity against Candida spp. The highest activity directed against C. albicans was shown by compound RO4, with a 4-methoxyphenyl moiety and an MIC value of 62.5 µg/mL. In order to check the toxicity of the synthesized compounds, their effect on cell lines was examined. Additionally, we tried to elucidate the mechanism of the antibacterial and antifungal activity of the tested compounds using molecular docking to topoisomerase IV, D-Alanyl-D-Alanine Ligase, and dihydrofolate reductase.

Mean Temperature and Drought Projections in Central Africa: A Population-Based Study of Food Insecurity, Childhood Malnutrition and Mortality, and Infectious Disease

The Central African Region is an agricultural and fishing-based economy, with 40% of the population living in rural communities. The negative impacts of climate change have caused economic/health-related adverse impacts and food insecurity. This original article aims to research four key themes: (i) acute food insecurity (AFI); (ii) childhood malnutrition and mortality; (iii) infectious disease burden; and (iv) drought and mean temperature projections throughout the twenty-first century. Food insecurity was mapped in Central Africa based on the Integrated Food Security Phase Classification (IPC) for AFI. The global hunger index (GHI) was presented along with the proportion of children with undernourishment, stunting, wasting, and mortality. Data for infectious disease burden was computed by assessing the adjusted rate of change (AROC) of mortality due to diarrhea among children and the burden of death rates due to pneumonia across all age groups. Finally, the mean drought index was computed through the year 2100. This population-based study identifies high levels of hunger across a majority of the countries, with the mean drought index suggesting extreme ends of wet and dry days and an overall rise of 1-3 °C. This study is a source of evidence for stakeholders, policymakers, and the population residing in Central Africa.

Analyses of the Global Multilocus Genotypes of the Human Pathogenic Yeast Cryptococcus neoformans Species Complex

Cryptococcus neoformans species complex (CNSC) is a globally distributed human opportunistic yeast pathogen consisting of five major molecular types (VNI, VNII, VNB, VNIII and VNIV) belonging to two species, C. neoformans (VNI, VNII and VNB, collectively called serotype A) and C. deneoformans (VNIV, commonly called serotype D), and their hybrids (VNIII, serotype AD). Over the years, many studies have analyzed the geographical distribution and genetic diversity of CNSC. However, the global population structure and mode of reproduction remain incompletely described. In this study, we analyze the published multilocus sequence data at seven loci for CNSC. The combined sequences at the seven loci identified a total of 657 multilocus sequence types (STs), including 296 STs with known geographic information, representing 4200 non-redundant isolates from 31 countries and four continents. Among the 296 STs, 78 and 52 were shared among countries and continents, respectively, representing 3643 of the 4200 isolates. Except for the clone-corrected serotype D sample among countries, our analysis of the molecular variance of the 4200 isolates revealed significant genetic differentiations among countries and continents in populations of CNSC, serotype A, and serotype D. Phylogenetic analyses of the concatenated sequences of all 657 STs revealed several large clusters corresponding to the major molecular types. However, several rare but distinct STs were also found, representing potentially novel molecular types and/or hybrids of existing molecular types. Phylogenetic incompatibility analyses revealed evidence for recombination within all four major molecular types-VNI, VNII, VNIV and VNB-as well as within two VNB subclades, VNBI and VNBII, and two ST clusters around the most common STs, ST5 and ST93. However, linkage disequilibrium analyses rejected the hypothesis of random recombination across most samples. Together, our results suggest evidence for historical differentiation, frequent recent gene flow, clonal expansion and recombination within and between lineages of the global CNSC population.

Temporal and Spatial Distribution of Opportunistic Infections Associated with the Human Immunodeficiency Virus (HIV) in Uganda

The human immunodeficiency virus (HIV) remains one of the greatest challenges of the twenty-first century in the absence of an effective vaccine or cure. It is estimated globally that close to 38 million people are currently living with the HIV virus and more than 36 million have succumbed to this deadly virus from the time the first case was reported in early 1980s. The virus degrades the human body immunity and makes it more vulnerable to different kinds of opportunistic infections (OIs). However, with the introduction of highly active anti-retroviral therapy (HAART) in 2003, the pattern and frequency of OIs has been progressively changing though with variations in the different parts of the World. So this chapter discusses the temporal and spatial patterns of OIs in Uganda.

The Blood of the HIV-Infected Patients Contains κ-IgG, λ-IgG, and Bispecific κλ-IgG, Which Possess DNase and Amylolytic Activity

Though hundreds of thousands of papers are currently being published on HIV/AIDS, only tens of hundreds of them are devoted to the antibodies generated during the disease. Most of these papers discuss antibodies in HIV/AIDS as a diagnostic tool, and some articles describe neutralizing antibodies as a promising treatment. In this paper, we used affinity chromatography and ELISA to isolate natural IgG from the blood of 26 HIV-infected patients. IgG preparations were separated into the subfractions containing different types of light chains, and catalytic activities of subfractions were analyzed. Here, we show for the first time that the blood of HIV patients contains ~20% of bispecific κλ-IgG, presented with all IgG subclasses. Analysis of DNA-hydrolyzing and amylolytic activity show that most IgG preparations and subfractions are catalytically active. Our results expand the possible biological functions of natural IgG in HIV infection.

Rates of refusal of clinical autopsies among HIV-positive decedents and an overview of autopsies in Uganda

Background: Human immunodeficiency virus (HIV)-related mortality remains high in sub-Saharan Africa. Clinical autopsies can provide invaluable information to help ascertain the cause of death. We aimed to determine the rate and reasons for autopsy refusal amongst families of HIV-positive decedents in Uganda. Methods: We consented the next-of-kin for post-mortem examinations among Ugandan decedents with HIV from 2017-2020 at Kiruddu National Referral Hospital. For those who refused autopsies, reasons were recorded. Results: In this analysis, 165 decedents with HIV were included from three selected wards at Kiruddu National Referral Hospital.  Autopsy was not performed in 45% of the deceased patients; the rate of autopsy refusal was 36%. The most common reasons for autopsy refusal were time constraints (30%), family satisfaction with clinical diagnosis (15%), fear of disfigurement of the remains (15%), and lack of perceived benefit (15%). By seeking consent from multiple family members and clearly explaining to them the purpose of performing the autopsy, we found a reduction in the rate of autopsy refusal among relatives of the deceased patients at this hospital compared to previous studies at the same site (36% vs. 60%). Conclusions: We found lower rates of autopsy refusal compared to previous studies at the same site. This underscores the importance of clearly explaining the purpose of autopsies as they increase active sensitization about their relevance and dispel myths related to autopsies among the general population. Good, culturally sensitive, and timely explanations to the family of the benefits of autopsy increase the rate of obtaining permission. Building capacity for performing autopsies by training more pathologists and increasing laboratory resources to decrease the turn-around-time for autopsy reports and extending these services to peripheral health facilities could improve autopsy acceptance rates.

Rates of refusal of clinical autopsies among HIV-positive decedents and an overview of autopsies in Uganda

Background: Human immunodeficiency virus (HIV)-related mortality remains high in sub-Saharan Africa. Clinical autopsies can provide invaluable information to help ascertain the cause of death. We aimed to determine the rate and reasons for autopsy refusal amongst families of HIV-positive decedents in Uganda. Methods: We consented the next-of-kin for post-mortem examinations among Ugandan decedents with HIV from 2017-2020 at Kiruddu National Referral Hospital. For those who refused autopsies, reasons were recorded. Results: In this analysis, 165 decedents with HIV were included from three selected wards at Kiruddu National Referral Hospital.  Autopsy was not performed in 45% of the deceased patients; the rate of autopsy refusal was 36%. The most common reasons for autopsy refusal were time constraints (30%), family satisfaction with clinical diagnosis (15%), fear of disfigurement of the remains (15%), and lack of perceived benefit (15%). By seeking consent from multiple family members and clearly explaining to them the purpose of performing the autopsy, we found a reduction in the rate of autopsy refusal among relatives of the deceased patients at this hospital compared to previous studies at the same site (36% vs. 60%). Conclusions: We found lower rates of autopsy refusal compared to previous studies at the same site. This underscores the importance of clearly explaining the purpose of autopsies as they increase active sensitization about their relevance and dispel myths related to autopsies among the general population. Good, culturally sensitive, and timely explanations to the family of the benefits of autopsy increase the rate of obtaining permission. Building capacity for performing autopsies by training more pathologists and increasing laboratory resources to decrease the turn-around-time for autopsy reports and extending these services to peripheral health facilities could improve autopsy acceptance rates.

Meningitis Caused by Cryptococcus neoformans in an Apparently Immunocompetent Patient

Cryptococcal meningitis (CM), as a life-threatening opportunistic infection, often is among cases with cell-mediated immunodeficiencies, such as AIDS, hematologic malignancies, and solid organ transplant recipients. Cryptococcal meningitis in healthy individuals is uncommon, and its detection in immunocompetent cases may be tricky because the presentation is generally more indolent than the traditional meningitis presentation, leading to late diagnosis and potential sequels. We present a CM case in an immunocompetent Iranian male patient who was treated successfully.

The effect of antiretroviral therapy guideline change on health outcomes among youth living with HIV in Uganda

ABSTRACTOpportunistic infections (OIs) are the primary cause of HIV-related morbidity and mortality. To reduce the risk, the ART eligibility criteria were revised to start treatment before advanced disease onset. We evaluated the effect of 2014 HIV clinical guideline changes in Uganda on opportunistic infections and survival among Youth Living with HIV (YLWH). This retrospective cohort analysis used administrative data from the District Health Information System (DHIS2) and the national referral hospital, to compare YLWH, 15-24 years old, who started ART pre-guideline (January 2012-June 2014) and post-guideline (July 2014-December 2016). We assessed the effect using multivariable logistic and Cox Proportional Hazards regression models, respectively. Post-guideline youth had 18% and 30% lower adjusted odds of having an OI at 6 (aOR: 0.82, 95%CI: 0.67, 0.99), and 12 months (aOR: 0.70, 95%CI: 0.58, 0.85) after ART initiation, compared to pre-guideline youth. No significant differences were observed in survival probabilities (Z = 2.56, P-value = 0.11) and adjusted hazard ratios (aHR: 1.55, 95%CI: 0.46, 5.28). Early ART initiation reduced the risk of OIs among YLWH. However, given the existence of geographical and clinical variations in the endemicity, morbidity and mortality associated with different OIs, additional research is still needed.

Stress proteins: the biological functions in virus infection, present and challenges for target-based antiviral drug development

Stress proteins (SPs) including heat-shock proteins (HSPs), RNA chaperones, and ER associated stress proteins are molecular chaperones essential for cellular homeostasis. The major functions of HSPs include chaperoning misfolded or unfolded polypeptides, protecting cells from toxic stress, and presenting immune and inflammatory cytokines. Regarded as a double-edged sword, HSPs also cooperate with numerous viruses and cancer cells to promote their survival. RNA chaperones are a group of heterogeneous nuclear ribonucleoproteins (hnRNPs), which are essential factors for manipulating both the functions and metabolisms of pre-mRNAs/hnRNAs transcribed by RNA polymerase II. hnRNPs involve in a large number of cellular processes, including chromatin remodelling, transcription regulation, RNP assembly and stabilization, RNA export, virus replication, histone-like nucleoid structuring, and even intracellular immunity. Dysregulation of stress proteins is associated with many human diseases including human cancer, cardiovascular diseases, neurodegenerative diseases (e.g., Parkinson’s diseases, Alzheimer disease), stroke and infectious diseases. In this review, we summarized the biologic function of stress proteins, and current progress on their mechanisms related to virus reproduction and diseases caused by virus infections. As SPs also attract a great interest as potential antiviral targets (e.g., COVID-19), we also discuss the present progress and challenges in this area of HSP-based drug development, as well as with compounds already under clinical evaluation.

Factors Associated With Cryptosporidium Infection Among Adult HIV Positive Population in Contact With Livestock in Namwala District, Zambia

Cryptosporidium spp. is one of the leading causes of diarrhoeal disease globally. In Zambia, the burden of Cryptosporidium infection in the general human population is unknown and factors associated with it are unclear. A study was conducted to determine the prevalence of Cryptosporidium spp. and identify factors associated with its infection among Human Immunodeficiency Virus (HIV) positive individuals in contact with livestock in Namwala district of Zambia. Three hundred and twenty six stool samples were collected from HIV infected individuals presenting at local health centers in Namwala district of Zambia between August 2015 and June 2016. The Meriflour Cryptosporidium/Giardia test kit was used to test for presence of oocysts. Demographic information such as age and sex and information on hypothesized risk factors was collected using a structured questionnaire. Overall prevalence of Cryptosporidium infection was 9.5% (95% CI = 6.7–13.2%); 13.3% and 7.1% among male and female participants, respectively. Males were 2.5 times more likely to be infected than females whereas the divorced had higher odds of being infected (OR = 14.8). Participants who kept animals had a higher prevalence (11.4%) than those that did not (7.0%). Those that shared water with neighbors were 5.7 times more likely to be infected than those who did not. We conclude that Cryptosporidium infection is prevalent among HIV positive adults in Namwala district and infection is associated with sex, marital status and sharing water sources among neighbors. Community sensitization is required to create awareness and reduce human exposure to Cryptosporidium infection.

Impact of chemorophylaxis policy for AIDS-immunocompromised patients on emergence of bacterial resistance

Chemoprophylaxis (antibiotic prophylaxis) is a long relied-upon means of opportunistic infection management among HIV/AIDS patients, but its use represents an evolutionary tradeoff: Despite the benefits of chemoprophylaxis, widespread use of antibiotics creates a selective advantage for drug-resistant bacterial strains. Especially in the developing world, with combined resource limitations, antibiotic misuse, and often-poor infection control, the emergence of antibiotic resistance may pose a critical health risk. Extending previous work that demonstrated that this risk is heightened when a significant proportion of the population is HIV/AIDS-immunocompromised, we work to address the relationship between HIV/AIDS patients' use of antibiotic chemoprophylaxis and the emergence of resistance. We apply an SEIR compartmental model, parameterized to reflect varying percentages of chemoprophylaxis use among HIV/AIDS+ patients in a resource-limited setting, to investigate the magnitude of the risk of prophylaxis-associated emergence versus the individual-level benefits it is presumed to provide. The results from this model suggest that, while still providing tangible benefits to the individual, chemoprophylaxis is associated with negligible decreases in population-wide morbidity and mortality from bacterial infection, and may also fail to provide assumed efficacy in reduction of TB prevalence.

Physiologically-Based Pharmacokinetic Modeling for Optimal Dosage Prediction of Quinine Coadministered With Ritonavir-Boosted Lopinavir

The coformulated lopinavir/ritonavir significantly reduces quinine concentration in healthy volunteers due to potential drug-drug interactions (DDIs). However, DDI information in malaria and HIV coinfected patients are lacking. The objective of the study was to apply physiologically-based pharmacokinetic (PBPK) modeling to predict optimal dosage regimens of quinine when coadministered with lopinavir/ritonavir in malaria and HIV coinfected patients with different conditions. The developed model was validated against literature. Model verification was evaluated using the accepted method. The verified PBPK models successfully predicted unbound quinine disposition when coadministered with lopinavir/ritonavir in coinfected patients with different conditions. Suitable dose adjustments to counteract with the DDIs have identified in patients with various situations (i.e., a 7-day course at 1,800 mg t.i.d. in patients with malaria with HIV infection, 648 mg b.i.d. in chronic renal failure, 648 mg t.i.d. in hepatic insufficiency except for severe hepatic insufficiency (324 mg b.i.d.), and 648 mg t.i.d. in CYP3A4 polymorphism).

Indigenous traditional knowledge of medicinal plants used by herbalists in treating opportunistic infections among people living with HIV/AIDS in Uganda

ETHNOPHARMACOLOGICAL RELEVANCE

Currently, more than two thirds of the world's 36.9 million people living with HIV/AIDS reside in Sub-Saharan Africa. Opportunistic infections (OI) associated with HIV are the single most important cause of mortality and morbidity among HIV/AIDS patients in poor countries. There is widespread use of medicinal plant species to manage the HIV infection and it's associated OI in Uganda, even by patients already on antiretroviral drugs (ARV). However, much of this information remains undocumented and unverified.

AIM OF STUDY

The aim of this study was to systematically and comprehensively document the traditional indigenous knowledge and practices associated with the management of HIV/AIDS infections by herbalists in Uganda.

METHODS

Ethnobotanical data were collected using semi-structured interviews and questionnaires. Ninety traditional medicine practitioners (TMP) or herbalists were interviewed in Arua, Dokolo, Mbale, Bushenyi, Iganga, Rakai, Luwero and Kaabong districts to gather information on the plant species used. Data were analysed and presented using descriptive statistics and the Informant Consensus Factor.

RESULTS

We documented 236 medicinal plant species from 70 families and 201 genera. Acacia was the most widely represented genus with five species. The most frequently used medicinal plant species for treating various OI were Erythrina abyssinica (45), Warburgia ugandensis (43), Zanthoxylum chalybeum (38), Acacia hockii (37), Mangifera indica (36), Aloe vera (35), Albizia coriaria (34), Azadirachta indica (32), Psorospermum febrifugum (27) Vernonia amygdalina (22) and Gymnosporia senegalensis (21). Some of the plant species were used for treating all the OI mentioned. There is a high degree of consensus among the TMP on which plant species they use for the different OI, even though they are geographically separated. Herbalists contribute to the widespread practice of simultaneously using herbal medicines and ARV. Some TMP are also engaged in dangerous practices like injecting patients with herbs and encouraging simultaneous use of herbs and ARV. Although the TMP relied on biomedical laboratory diagnoses for confirming the patients' HIV sero status, they were familiar with the signs and symptoms of HIV/AIDS.

CONCLUSION

There is wide spread use of a rich diversity of medicinal plants species and practices by TMP to manage OI in HIV/AIDS patients in Uganda.

Prediction of Multi peptides Vaccination from VP10,VP21, VP51 against Reverse Transcriptase Human immunodeficiency Viruses Using Immuno-informatics Approach.. [DOI: 10.1101/2019.12.16.877555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

The human immunodeficiency virus-(HIV) is group of the genus Lentivirus within the family of Retroviridae, subfamily Ortho retrovirinae. Based on genetic characteristics and differences in the viral antigens, HIV is classified into the types 1 and 2 (HIV-1, HIV-2). HIV is identical single – stranded RNA molecule that are enclosed within the core of the virus particle proteins, the genome of the HIV Provirus, also known as DNA, is generated by the Protease against reverse transcriptase RNA genome into DNA, degradation of the RNA and integration of the double – stranded HIV DNA into the human genome. The aim of this study is to determine antigenic peptides from p10, p21, and p51 proteins that can be used for multiple peptide vaccine design using In-Silico study. A total of 73 sequences of three proteins were obtained from NCBI and subjected to multiple sequence alignments using CLUSTALW tool to determine conserved regions.

Immune Epitope Data Base tools were used to determine B cell epitopes, these tools are Bepipred Linear B cell epitopes prediction, surface accessibility and antigenicity prediction. Epitope binding to MHC class I and class II and their population coverage were also determined using IEDB software. The analysis results are as follow, for B cell binding from p10 (708QGYSP712), from p21 (704QGYSP708,73CVPTDPNPQ81) and (346“FKNL349) from p51. All these peptides have high score in Linear B cell epitopes prediction, surface accessibility and antigenicity prediction. On another hand peptides that reacted to MHC class I were (47EANTTLFCA55,53FCASDAKAY61,55,ASDAKAYET63) form p10,(38YYGVPVWKE46,10PQEVFLVNV18and29AAGSTMGAA37) from p21 and (63“EWEFVNTPP71,70PPLVKLWYQ78and79EKEPIVGA87) from p51 protein respectively. It worth noting that the peptides (119IISLWDQSL127,108CVKLTPLCV116) from p10, (38YYGVPVWKE46,20LLQYWSQEL34,16FNMWKNNMV30) from p21 and (7WKGSPAIFQ21,11WEFVNTPPL25and58FLWMGYELH72) protein is also binds to MHC class II with high affinity. All T cell peptides had highest population coverage, and the combined coverage for all peptides in this study was found to be 100%. Using In-Silico studies will ensure less risk of virulence and side effects. Evaluation of antibodies response in animal models is needed to confirm efficacy of these epitopes in inducing protective immune response.

Estimated Burden of Fungal Infections in Namibia

Namibia is a sub-Saharan country with one of the highest HIV infection rates in the world. Although care and support services are available that cater for opportunistic infections related to HIV, the main focus is narrow and predominantly aimed at tuberculosis. We aimed to estimate the burden of serious fungal infections in Namibia, currently unknown, based on the size of the population at risk and available epidemiological data. Data were obtained from the World Health Organization (WHO), Joint United Nations Programme on HIV/AIDS (UNAIDS), and published reports. When no data existed, risk populations were used to estimate the frequencies of fungal infections, using the previously described methodology. The population of Namibia in 2011 was estimated at 2,459,000 and 37% were children. Among approximately 516,390 adult women, recurrent vulvovaginal candidiasis (≥4 episodes /year) is estimated to occur in 37,390 (3003/100,000 females). Using a low international average rate of 5/100,000, we estimated 125 cases of candidemia, and 19 patients with intra-abdominal candidiasis. Among survivors of pulmonary tuberculosis (TB) in Namibia 2017, 112 new cases of chronic pulmonary aspergillosis (CPA) are likely, a prevalence of 354 post-TB and a total prevalence estimate of 453 CPA patients in all. Asthma affects 11.2% of adults, 178,483 people, and so allergic bronchopulmonary aspergillosis (ABPA) and severe asthma with fungal sensitization (SAFS) were estimated in approximately 179/100,000 and 237/100,000 people, respectively. Invasive aspergillosis (IA) is estimated to affect 15 patients following leukaemia therapy, and an estimated 0.13% patients admitted to hospital with chronic obstructive pulmonary disease (COPD) (259) and 4% of HIV-related deaths (108) — a total of 383 people. The total HIV-infected population is estimated at 200,000, with 32,371 not on antiretroviral therapy (ART). Among HIV-infected patients, 543 cases of cryptococcal meningitis and 836 cases of Pneumocystis pneumonia are estimated each year. Tinea capitis infections were estimated at 53,784 cases, and mucormycosis at five cases. Data were missing for fungal keratitis and skin neglected fungal tropical diseases such as mycetoma. The present study indicates that approximately 5% of the Namibian population is affected by fungal infections. This study is not an epidemiological study—it illustrates estimates based on assumptions derived from similar studies. The estimates are incomplete and need further epidemiological and diagnostic studies to corroborate, amend them, and improve the diagnosis and management of these diseases.

Effects of cotrimoxazole prophylaxis on Talaromyces marneffei infection in HIV/AIDS patients receiving antiretroviral therapy: a retrospective cohort study

The dimorphic fungus Talaromyces marneffei (TM) is a common cause of HIV-associated opportunistic infections in Southeast Asia. Cotrimoxazole (CTX) inhibits folic acid synthesis which is important for the survival of many bacteria, protozoa, and fungi and has been used to prevent several opportunistic infections among HIV/AIDS patients. We question whether CTX is effective in preventing TM infection. To investigate this question, we conducted an 11-year (2005-2016) retrospective observational cohort study of all patients on the Chinese national antiretroviral therapy (ART) programme in Guangxi, a province with high HIV and TM burden in China. Survival analysis was conducted to investigate TM cumulative incidence, and Cox regression and propensity score matching (PSM) were used to evaluate the effect of CTX on TM incidence. Of the 3359 eligible individuals contributing 10,504.66 person-years of follow-up, 81.81% received CTX within 6 months after ART initiation, and 4.73% developed TM infection, contributing 15.14/1,000 person-year TM incidence rate. CTX patients had a significantly lower incidence of TM infection than non-CTX patients (4.11% vs. 7.53%; adjusted hazard ratio (aHR) = 0.50, 95% CI 0.35-0.73). CTX reduced TM incidence in all CD4⁺ cell subgroups (<50 cells/μL, 50-99 cells/μL, 100-199 cells/μL), with the highest reduction observed in patients with a baseline CD4⁺ cell count <50 cells/μL in both Cox regression and the PSM analyses. In conclusion, in addition to preventing other HIV-associated opportunistic infections, CTX prophylaxis has the potential to prevent TM infection in HIV/AIDS patients receiving ART.

A Comparison of the Clinical Characteristics and Outcomes of Cryptococcal Meningitis in HIV-negative Individuals With and Without Immunosuppression

Cryptococcal meningitis (CM) is found to occur in immunosuppressed patients and those who are immunocompetent. This study aimed to compare the presentation and outcome of CM in patients who are human immunodeficiency virus (HIV) negative with and without immunosuppression. We reviewed 255 clinical records from patients with CM who are HIV negative. The demographic and clinical characteristics, cerebrospinal fluid profiles, brain magnetic resonance imaging, treatment, and outcomes of these individuals were retrospectively analyzed. Among the 255 patients with CM, 91 (35.7%) appeared immunocompetent. CM was present in a younger population in the immunocompetent group (above 50 y, 19.8% vs. 32.3%, P=0.026), with higher initial complaints of visual and auditory symptoms (45.1% vs. 27.4%, P=0.004; 19.8% vs. 9.1%, P=0.016; respectively) and higher cerebrospinal fluid white blood cell counts (30.8% vs. 45.1%, P=0.009) compared with the immunocompromised patients. In addition, the immunocompetent patients had a higher proportion of normal brain images than did the immunocompromised patients (10% vs. 2%, P=0.028). There were no differences in hospital mortality and satisfactory outcomes between the groups (mortality: 10.9% vs. 7.0%, P=0.416; satisfactory outcomes: 76.4% vs. 80.2%, P=0.585). We found significant differences between the immunocompetent and HIV-negative immunocompromised patients; however, there were fewer differences between the groups than expected. Further studies assessing the immune responses in both groups should be performed.

Epidemiology of Opportunistic Infections in HIV Infected Patients on Treatment in Accredited HIV Treatment Centers in Cameroon

BACKGROUND

The African continent accounts for over 70% of people infected with Human Immunodeficiency Virus (HIV). The HIV sero-prevalence rate in Africa is estimated at 4.3%. In developed countries, such as France, pneumocystis is indicative of AIDS in 30% of patients; however, in Africa, pulmonary tuberculosis (TB) is the most-documented opportunistic infection (OI) and the leading cause of death in HIV-infected patients. In 2016, Cameroon had 32,000 new cases of OI and 29,000 deaths as a result of these infections. However, there is little existing data on the epidemiological profile of OIs in Cameroon, which is why we conducted this study in accredited HIV treatment centers and care/treatment units in the two cities of Douala and Yaounde, Cameroon.

METHODS

This was a retrospective descriptive and analytical study carried out in 12 accredited HIV treatment centers in the cities of Yaoundé and Douala, Cameroon, over a period of seven months from October 2017 to April 2018. A stratified sampling method was used with three sampling levels: the city, type of health facility and size of active files. Ethical clearance and administrative authorization were obtained from the appropriate authorities and data were collected using a pre-tested survey form. The data collected was entered and analyzed using Epi Info version 3.5.4.

RESULTS

Out of a total of 1,617 HIV-infected patients sampled, 419 (25.9%) had at least one OI. Of these patients with an OI, 246 or 65% had a baseline CD4 count of <200/mm³. There was a significant relationship between the male gender and the onset of OI (OR = 1.47; p = 0.01). Age ≥ 50 years was associated with the occurrence of OI (OR = 2.57; p = 0.01). A CD4 count of <200/mm³ was also associated with the risk of developing an OI (OR = 3.12; p = <0.01).

CONCLUSION AND GLOBAL HEALTH IMPLICATIONS

The prevalence of OI is high among people living with HIV (25.9%). Shingles was the most common OI found followed by pulmonary tuberculosis. Male gender, age ≥ 50 years, and CD4 <200/mm³ were the most common factors associated with the occurrence of these OI. These findings suggest that public health interventions for reducing HIV related co-morbidities (and implicitly mortality) should especially target the male gender for greater impact in addition to other measures.

Malaria and HIV coinfection in sub-Saharan Africa: prevalence, impact, and treatment strategies

Malaria and HIV, two of the world's most deadly diseases, are widespread, but their distribution overlaps greatly in sub-Saharan Africa. Consequently, malaria and HIV coinfection (MHC) is common in the region. In this paper, pertinent publications on the prevalence, impact, and treatment strategies of MHC obtained by searching major electronic databases (PubMed, PubMed Central, Google Scholar, ScienceDirect, and Scopus) were reviewed, and it was found that the prevalence of MHC in SSA was 0.7%-47.5% overall. Prevalence was 0.7%-47.5% in nonpregnant adults, 1.2%-27.8% in children, and 0.94%-37% in pregnant women. MHC was associated with an increased frequency of clinical parasitemia and severe malaria, increased parasite and viral load, and impaired immunity to malaria in nonpregnant adults, children, and pregnant women, increased in placental malaria and related outcomes in pregnant women, and impaired antimalarial drug efficacy in nonpregnant adults and pregnant women. Although a few cases of adverse events have been reported in coinfected patients receiving antimalarial and antiretroviral drugs concurrently, available data are very limited and have not prompted major revision in treatment guidelines for both diseases. Artemisinin-based combination therapy and cotrimoxazole are currently the recommended drugs for treatment and prevention of malaria in HIV-infected children and adults. However, concurrent administration of cotrimoxazole and sulfadoxine-pyrimethamine in HIV-infected pregnant women is not recommended, because of high risk of sulfonamide toxicity. Further research is needed to enhance our understanding of the impact of malaria on HIV, drug-drug interactions in patients receiving antimalarials and antiretroviral drugs concomitantly, and the development of newer, safer, and more cost-effective drugs and vaccines to prevent malaria in HIV-infected pregnant women.

HIV viral load as an independent risk factor for tuberculosis in South Africa: collaborative analysis of cohort studies

Introduction: Chronic immune activation due to ongoing HIV replication may lead to impaired immune responses against opportunistic infections such as tuberculosis (TB). We studied the role of HIV replication as a risk factor for incident TB after starting antiretroviral therapy (ART).

Methods: We included all HIV-positive adult patients (≥16 years) in care between 2000 and 2014 at three ART programmes in South Africa. Patients with previous TB were excluded. Missing CD4 cell counts and HIV-RNA viral loads at ART start (baseline) and during follow-up were imputed. We used parametric survival models to assess TB incidence (pulmonary and extrapulmonary) by CD4 cell and HIV-RNA levels, and estimated the rate ratios for TB by including age, sex, baseline viral loads, CD4 cell counts, and WHO clinical stage in the model. We also used Poisson general additive regression models with time-updated CD4 and HIV-RNA values, adjusting for age and sex.

Results: We included 44,260 patients with a median follow-up time of 2.7 years (interquartile range [IQR] 1.0–5.0); 3,819 incident TB cases were recorded (8.6%). At baseline, the median age was 34 years (IQR 28–41); 30,675 patients (69.3%) were female. The median CD4 cell count was 156 cells/µL (IQR 79–229) and the median HIV-RNA viral load 58,000 copies/mL (IQR 6,000–240,000). Overall TB incidence was 26.2/1,000 person-years (95% confidence interval [CI] 25.3–27.0). Compared to the lowest viral load category (0–999 copies/mL), the adjusted rate ratio for TB was 1.41 (95% CI 1.15–1.75, p < 0.001) in the highest group (>10,000 copies/mL). Time-updated analyses for CD4/HIV-RNA confirmed the association of viral load with the risk for TB.

Conclusions: Our results indicate that ongoing HIV replication is an important risk factor for TB, regardless of CD4 cell counts, and underline the importance of early ART start and retention on ART.

Phylogenetic Analysis and Antimicrobial Profiles of Cultured Emerging Opportunistic Pathogens (Phyla Actinobacteria and Proteobacteria) Identified in Hot Springs

Hot spring water may harbour emerging waterborne opportunistic pathogens that can cause infections in humans. We have investigated the diversity and antimicrobial resistance of culturable emerging and opportunistic bacterial pathogens, in water and sediment of hot springs located in Limpopo, South Africa. Aerobic bacteria were cultured and identified using 16S ribosomal DNA (rDNA) gene sequencing. The presence of Legionella spp. was investigated using real-time polymerase chain reaction. Isolates were tested for resistance to ten antibiotics representing six different classes: β-lactam (carbenicillin), aminoglycosides (gentamycin, kanamycin, streptomycin), tetracycline, amphenicols (chloramphenicol, ceftriaxone), sulphonamides (co-trimoxazole) and quinolones (nalidixic acid, norfloxacin). Gram-positive Kocuria sp. and Arthrobacter sp. and gram-negative Cupriavidus sp., Ralstonia sp., Cronobacter sp., Tepidimonas sp., Hafnia sp. and Sphingomonas sp. were isolated, all recognised as emerging food-borne pathogens. Legionella spp. was not detected throughout the study. Isolates of Kocuria, Arthrobacter and Hafnia and an unknown species of the class Gammaproteobacteria were resistant to two antibiotics in different combinations of carbenicillin, ceftriaxone, nalidixic acid and chloramphenicol. Cronobacter sp. was sensitive to all ten antibiotics. This study suggests that hot springs are potential reservoirs for emerging opportunistic pathogens, including multiple antibiotic resistant strains, and highlights the presence of unknown populations of emerging and potential waterborne opportunistic pathogens in the environment.

Brief Report: Flow Rate of Cerebrospinal Fluid Through a Spinal Needle Can Accurately Predict Intracranial Pressure in Cryptococcal Meningitis

BACKGROUND

Patients with HIV-associated cryptococcal meningitis (CM) commonly present with raised intracranial pressure (ICP). Aggressive management of raised ICP reduces mortality but requires manometers, which are unavailable in most resource-limited settings. The law of Poiseuille states that the rate of flow of liquid through a tube is directly proportional to the difference in pressure between each end, and it may be possible to indirectly determine ICP by measuring flow of CSF through a spinal needle rather than using a manometer.

METHODS

A convenience sample of CM patients requiring lumbar puncture (LP) (with 22-G spinal needle) for ICP measurement and control were enrolled. ICP was first measured using a narrow bore manometer. After removing the manometer, the number of drops of CSF flowing from the spinal needle in 15 seconds was counted.

RESULTS

Thirty-two patients had 89 LPs performed (range, 1-23). Fifty-four had high opening pressure with a CSF flow rate of 16-200 drops/min, and 35 had normal pressure with a CSF flow rate of 8-140 drops/min. Area under the fitted receiver operator character curve was 0.89. A flow rate cutoff to define high pressure of ≥40 drops/min correctly classified 75 of 89 LPs (accuracy 84%).

CONCLUSIONS

It is technically feasible to indirectly estimate CSF pressure to an accuracy that is clinically useful by counting drops of CSF flowing from a spinal needle. The optimal cutoff value for defining high pressure using a standard 22-G spinal needle is ≥40 drops/min. These findings have the potential to improve CM management in resource-limited settings.

Morbidity and nutrition status of rural drug-naïve Kenyan women living with HIV

This paper describes morbidity in a group of HIV-positive drug-naïve rural women in western Kenya. A total of 226 drug-naïve HIV-positive women were evaluated for baseline morbidity, immune function, and anthropometry before a food-based nutrition intervention. Kenyan nurses visited women in their homes and conducted semi-structured interviews regarding symptoms and physical signs experienced at the time of the visit and during the previous week and physical inspection. Blood and urine samples were examined for determination of immune function (CD4, CD8, and total lymphocyte counts), anaemia, malaria, and pregnancy status. Intradermal skin testing with tuberculin (PPD), candida, and tetanus toxoid antigens was also performed to evaluate cell-mediated immunity. Anthropometry was measured, and body mass index (BMI) was calculated. Seventy-six per cent of the women reported being sick on the day of the interview or within the previous week. Illnesses considered serious were reported by 13.7% of women. The most frequent morbidity episodes reported were upper respiratory tract infections (13.3%), suspected malaria (5.85%), skeletal pain (4.87%), and stomach pain (4.42%). The most common morbidity signs on physical inspection were respiratory symptoms, most commonly rhinorrhea and coughing. Confirmed malaria and severe diarrhea were significantly associated with a higher BMI.

[Fluconazole 1200mg or 800mg for cryptococcal meningitis treatment in Ivory Coast]

OBJECTIVE

Assessing the use of high-dose fluconazol monotherapy (1200mg or 800mg) in the treatment and prognosis of HIV-associated cryptococcal meningitis in Ivory Coast.

PATIENTS AND METHODS

A retrospective study carried out from August 2008 to August 2011 based on patients charts suffering from CM in the Abidjan Tropicals and Infectious Disease Unit. Mortality rate and associated factors were analyzed.

RESULTS

Forty-six cases of cryptococcal meningitis (2.5% of hospitalizations) were included. The sex-ratio was of 1.2. The median age was 40.5 [35-47] years. The symptomatology was subacute (93.5%). The main clinical symptoms were syndrome of pure meningeal irritation (65%), fever (100%); 35% of patients had encephalomeningits. Twenty-one (45.7%) was ART-naïve patients. Fluconazole 1200mg was prescribed to 29 (63%) patients. Therapeutic lumbar punctures were performed in 42 (91.3) patients. The mortality rate was 50%. Significant predictors of mortality were encephalomeningitis and therapeutic lumbar puncture.

CONCLUSION

Cryptococcal meningitis associated mortality remains high despite the use of high-dose fluconazole monotherapy. Therapeutic lumbar punctures help to improving the prognosis.

Frequency and distribution patterns of opportunistic infections associated with HIV/AIDS in Uganda

Background

We conducted a study to assess the frequency and distribution patterns of selected opportunistic infections (OIs) and opportunistic cancers (OCs) in different geographical areas before and after HAART in Uganda.

Methods

This was a cross-sectional serial review of observation data for adult HIV positive patients (≥15 years) enrolled with the AIDS support organization (TASO) in Uganda covering the period from January 2001 to December 2013. Both AIDS defining OIs/OCs and non-AIDS defining OIs were analyzed. The study period was structured into three time periods: “pre- HAART” (2001–2003), “early-HAART” (2004–2008) and “late-HAART” (2009–2013). Descriptive statistics were used to summarize the data by time period, age, gender and geographical location. Chi squared test used to test the significance of the differences in proportions.

Results

A total of 108,619 HIV positive patients were included in the analysis. 64% (64,240) were female with median age of 33 years (IQR 27–40). The most frequent OIs before HAART were oral candida (34.6%) diarrhoeal infection (<1 month) (30.6%), geohelminths (26.5%), Mycobacterium tuberculosis (TB) (17.7%), malaria (15.1%) and bacterial pneumonia (11.2%). In early HAART (2004–2008), the most frequent OIs were geohelminths (32.4%), diarrhoeal infection (25.6%), TB (18.2%) and oral candida (18.1%). In late HAART (2009–2013), the most frequent OIs were geohelminths (23.5%) and diarrhoeal infection (14.3%). By gender, prevalence was consistently higher in women (p < 0.05) before and after HAART for geohelminths, candidiasis, diarrhoeal infection, bacterial pneumonia and genital ulcer disease but consistently higher in men for TB and Kaposi’s sarcoma (p < 0.05). By age, prevalence was consistently higher in older age groups (>30 years) before and after HAART for oral candida and TB (p < 0.05) and higher in young age groups (<30 years) for malaria and genital ulcers (p < 0.05). By geographical location, prevalence was consistently higher in Eastern and Northern Uganda before and after HAART for diarrheal infection and geohelminths (p < 0.0001).

Conclusions

The frequency and pattern of OIs before and after HAART differs by gender, age and geographical location. Prevalence of geohelminths and diarrhea infection(<1 month) remains high especially in Northern and Eastern Uganda even after HAART and should therefore be given special attention in HIV/AIDS care programmes in these settings.

Estimated Prevalence of Cryptococcus Antigenemia (CrAg) among HIV-Infected Adults with Advanced Immunosuppression in Namibia Justifies Routine Screening and Preemptive Treatment

Background

Cryptococcal meningitis is common and associated with high mortality among HIV infected persons. The World Health Organization recommends that routine Cryptococcal antigen (CrAg) screening in ART-naïve adults with a CD4⁺ count <100 cells/μL followed by pre-emptive antifungal therapy for CrAg-positive patients be considered where CrAg prevalence is ≥3%. The prevalence of CrAg among HIV adults in Namibia is unknown. We estimated CrAg prevalence among HIV-infected adults receiving care in Namibia for the purpose of informing routine screening strategies.

Methods

The study design was cross-sectional. De-identified plasma specimens collected for routine CD4⁺ testing from HIV-infected adults enrolled in HIV care at 181 public health facilities from November 2013 to January 2014 were identified at the national reference laboratory. Remnant plasma from specimens with CD4⁺ counts <200 cells/μL were sampled and tested for CrAg using the IMMY^® Lateral Flow Assay. CrAg prevalence was estimated and assessed for associations with age, sex, and CD4⁺ count.

Results

A total of 825 specimens were tested for CrAg. The median (IQR) age of patients from whom specimens were collected was 38 (32–46) years, 45.9% were female and 62.9% of the specimens had CD4 <100 cells/μL. CrAg prevalence was 3.3% overall and 3.9% and 2.3% among samples with CD4⁺ counts of CD4⁺<100 cells/μL and 100–200 cells/μL, respectively. CrAg positivity was significantly higher among patients with CD4+ cells/μL < 50 (7.2%, P = 0.001) relative to those with CD4 cells/μL 50–200 (2.2%).

Conclusion

This is the first study to estimate CrAg prevalence among HIV-infected patients in Namibia. CrAg prevalence of ≥3.0% among patients with CD4⁺<100 cells/μL justifies routine CrAg screening and preemptive treatment among HIV-infected in Namibia in line with WHO recommendations. Patients with CD4⁺<100 cells/μL have a significantly greater risk for CrAg positivity. Revised guidelines for ART in Namibia now recommend routine screening for CrAg.

Burden of pneumocystis pneumonia in HIV-infected adults in sub-Saharan Africa: a systematic review and meta-analysis

Background

Seroprevalence data and clinical studies in children suggest that the burden of pneumocystis pneumonia (PCP) in Africa may be underestimated. We performed a systematic review to determine the prevalence and attributable mortality of PCP amongst HIV-infected adults in sub-Saharan Africa.

Methods

We searched Pubmed, Web of Science, Africa-Wide: NiPAD and CINAHL, from Jan 1 1995 to June 1 2015, for studies that reported the prevalence, mortality or case fatality of PCP in HIV-infected adults living in sub-Saharan African countries. Prevalence data from individual studies were combined by random-effects meta-analysis according to the Mantel-Haenszel method. Data were stratified by clinical setting, diagnostic method, and study year.

Results

We included 48 unique study populations comprising 6884 individuals from 18 countries in sub-Saharan Africa. The pooled prevalence of PCP among 6018 patients from all clinical settings was 15 · 4 % (95 % CI 12 · 9–18 · 0), and was highest amongst inpatients, 22 · 4 % (95 % CI 17 · 2–27 · 7). More cases were identified by bronchoalveolar lavage, 21 · 0 % (15 · 0–27 · 0), compared with expectorated, 7 · 7 % (4 · 4–11 · 1), or induced sputum, 11 · 7 % (4 · 9–18 · 4). Polymerase chain reaction (PCR) was used in 14 studies (n = 1686). There was a trend of decreasing PCP prevalence amongst inpatients over time, from 28 % (21–34) in the 1990s to 9 % (8–10) after 2005. The case fatality rate was 18 · 8 % (11 · 0–26 · 5), and PCP accounted for 6 · 5 % (3 · 7–9 · 3) of study deaths.

Conclusions

PCP is an important opportunistic infection amongst HIV-infected adults in sub-Saharan Africa, particularly amongst patients admitted to hospital. Although prevalence appears to be decreasing, improved access to antiretroviral therapy and non-invasive diagnostics, such as PCR, are needed.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-016-1809-3) contains supplementary material, which is available to authorized users.

Incidence of Opportunistic Infections and the Impact of Antiretroviral Therapy Among HIV-Infected Adults in Low- and Middle-Income Countries: A Systematic Review and Meta-analysis

BACKGROUND

To understand regional burdens and inform delivery of health services, we conducted a systematic review and meta-analysis to evaluate the effect of antiretroviral therapy (ART) on incidence of key opportunistic infections (OIs) in human immunodeficiency virus (HIV)-infected adults in low- and middle-income countries (LMICs).

METHODS

Eligible studies describing the cumulative incidence of OIs and proportion on ART from 1990 to November 2013 were identified using multiple databases. Summary incident risks for the ART-naive period, and during and after the first year of ART, were calculated using random-effects meta-analyses. Summary estimates from ART subgroups were compared using meta-regression. The number of OI cases and associated costs averted if ART was initiated at a CD4 count ≥200 cells/µL were estimated using Joint United Nations Programme on HIV/AIDS (UNAIDS) country estimates and global average OI treatment cost per case.

RESULTS

We identified 7965 citations, and included 126 studies describing 491 608 HIV-infected persons. In ART-naive patients, summary risk was highest (>5%) for oral candidiasis, tuberculosis, herpes zoster, and bacterial pneumonia. The reduction in incidence was greatest for all OIs during the first 12 months of ART (range, 57%-91%) except for tuberculosis, and was largest for oral candidiasis, Pneumocystis pneumonia, and toxoplasmosis. Earlier ART was estimated to have averted 857 828 cases in 2013 (95% confidence interval [CI], 828 032-874 853), with cost savings of $46.7 million (95% CI, $43.8-$49.4 million).

CONCLUSIONS

There was a major reduction in risk for most OIs with ART use in LMICs, with the greatest effect seen in the first year of treatment. ART has resulted in substantial cost savings from OIs averted.

Evolution of Cryptococcal Antigen Testing: What is new?

Over the last decade, an upsurge in both the frequency and severity of fungal infections due to the HIV/AIDS epidemic and the use of immunosuppressive therapy has occurred. Even diagnostic methods like culture and microscopy, which have low sensitivity and longer turn-around-times are not widely available, leading to delays in timely antifungal therapy and detrimental patient outcomes. The evolution of cryptococcal antigen (CrAg) testing to develop inexpensive and more sensitive methods to detect cryptococcal antigen is significant. These newer tests employ immunoassays as part of point-of-care platforms, which do not require complex laboratory infrastructure and they have the potential to detect early disease and reduce time to diagnosis of cryptococcal infection. Advocacy for widely available and efficacious life-saving antifungal treatment should be the only remaining challenge.

ISOLATION OF Cryptococcus neoformans FROM ENVIRONMENTAL SAMPLES COLLECTED IN SOUTHEASTERN NIGERIA

Cryptococcosis caused by Cryptococcus neoformans is the second most common fungal opportunistic pathogen and a life-threatening infection with serious clinical manifestations especially in HIV/AIDS and other immunocompromised patients. In Nigeria, HIV/AIDS infection has reached an alarming level. Despite this, information on the presence of this fungus in clinical and environmental samples is very scanty in Nigeria and many other parts of Africa. We set out to evaluate the presence of Cryptococcus neoformans or C. gattiiin pigeon droppings obtained from Southeastern Nigeria. One hundred and seventy-seven samples of pigeon droppings from six sample types were collected. The area covered comprised of ten cities and other locations spanning across five States in Nigeria. Using established techniques, Cryptococcus neoformans was isolated from 39 of the 177 (22.0%) samples overall. No C. gattiiwas isolated. Most of the isolates (32.4%) were recovered from dovecotes (11 of 34) followed closely by samples taken from markets (31.8%; seven of 22) and least from the church (4.0%; one of 25). The highest isolation rate (38.9%) was found in samples from Enugu-Ezike(seven of 23) while the least came from Afikpo and the other locations each with 9.1% isolation rate. This is the first large-scale screening of Cryptococcus neoformans from pigeon droppings in Nigeria. The ecological and epidemiological significance of these findings are discussed.

Impact of HIV infection on the haemostatic response during sepsis and malaria

Patients positive for the human immunodeficiency virus (HIV) are more susceptible to sepsis and malaria, two conditions known to activate the coagulation system. As chronic HIV infection also influences haemostatic mechanisms, we determined the influence of HIV co-infection on coagulation, anticoagulation and the endothelium during sepsis or malaria. We performed a prospective observational study in 325 subjects with or without HIV infection (103 with sepsis, 127 with malaria and 95 asymptomatic controls) in an HIV endemic area in Central Africa. We measured plasma biomarkers indicative of activation of distinct haemostatic mechanisms. Sepsis and malaria had similar effects with elevated markers of coagulation, reduced anticoagulation markers and activation of endothelium. In particular, asymptomatic HIV infection reduced the plasma levels of the anticoagulant co-factor free protein S, and increased activation of the vascular endothelium, which were not normalized by combination antiretroviral therapy. HIV co-infection during sepsis and malaria caused more profound changes in free protein S and von Willebrand factor in sepsis and malaria, and ADAMTS13 in sepsis, while not influencing sepsis- or malaria-induced coagulation activation. These results show for the first time that HIV infection augments selective haemostatic changes during sepsis and malaria, which may contribute to the enhanced morbidity of these conditions in HIV patients.

Cryptococcal Antigen Screening in Patients Initiating ART in South Africa: A Prospective Cohort Study

BACKGROUND

Retrospective data suggest that cryptococcal antigen (CrAg) screening in patients with late-stage human immunodeficiency virus (HIV) initiating antiretroviral therapy (ART) may reduce cryptococcal disease and deaths. Prospective data are limited.

METHODS

CrAg was measured using lateral flow assays (LFA) and latex agglutination (LA) tests in 645 HIV-positive, ART-naive patients with CD4 counts ≤100 cells/µL in Cape Town, South Africa. CrAg-positive patients were offered lumbar puncture (LP) and treated with antifungals. Patients were started on ART between 2 and 4 weeks and followed up for 1 year.

RESULTS

A total of 4.3% (28/645) of patients were CrAg positive in serum and plasma with LFA. These included 16 also positive by urine LFA (2.5% of total screened) and 7 by serum LA (1.1% of total). In 4 of 10 LFA-positive cases agreeing to LP, the cerebrospinal fluid (CSF) CrAg LFA was positive. A positive CSF CrAg was associated with higher screening plasma/serum LFA titers.Among the 28 CrAg-positive patients, mortality was 14.3% at 10 weeks and 25% at 12 months. Only 1 CrAg-positive patient, who defaulted from care, died from cryptococcal meningitis (CM). Mortality in CrAg-negative patients was 11.5% at 1 year. Only 2 possible CM cases were identified in CrAg-negative patients.

CONCLUSIONS

CrAg screening of individuals initiating ART and preemptive fluconazole treatment of CrAg-positive patients resulted in markedly fewer cases of CM compared with historic unscreened cohorts. Studies are needed to refine management of CrAg-positive patients who have high mortality that does not appear to be wholly attributable to cryptococcal disease.

[Monitoring HIV infection morbidity in Moscow based on the data of forensic medical expertise]

The objective of the present study was the retrospective analysis of the cases of rapid diagnostics of the HIV status of the corpses referred to the pathologo-anatomical departments of Moscow. The standard statistical methods were used for this purpose. The structure of H IV infections is described in terms of age and sex of the affected subjects as well as stages of the disease. It was shown that cooperation of forensic medical services with AIDS control and prevention centres is of primary importance for the substantiation of the diagnosis, improvement of the quality of the relevant statistical information about the causes of death, enhancement of the objective value of epldemiological data on the occurrence of HIV infection and HIV-associated diseases in the city of Moscow.

[Cryptococcosis: a potential aetiology of facial ulceration]

Cutaneous cryptococcosis is an uncommon aetiology of chronic facial ulceration but which may be associated to a potentially lethal focus of cryptococcosis.

OBSERVATION

A 35-year-old AIDS patient under antiretroviral therapy, presented with a chronic facial ulceration. Histopathological examination of a biopsy of the facial ulceration showed an inflammatory granuloma and masses of yeasts. Mycological culture of the cerebrospinal fluid revealed Cryptococcus neoformans. The diagnosis of AIDS-related cutaneous cryptococcosis of the face and cryptococcal meningitis was concluded.

DISCUSSION

Cryptococcosis should be thought as a potential aetiology of a chronic facial ulceration in an AIDS patient. Screening of other foci of the cryptococcosis such as that of the central nervous system is mandatory. Mycological examinations are of great interest for the diagnosis in rare resources setting.

Comparison of biotyping methods as alternative identification tools to molecular typing of pathogenic Cryptococcus species in sub-Saharan Africa

Cryptococcal meningitis is the leading fungal infection and AIDS defining opportunistic illness in patients with late stage HIV infection, particularly in South-East Asia and sub-Saharan Africa. Given the high mortality, clinical differences and the extensive ecological niche of Cryptococcus neoformans and Cryptococcus gattii species complexes, there is need for laboratories in sub-Sahara African countries to adopt new and alternative reliable diagnostic algorithms that rapidly identify and distinguish these species. We biotyped 74 and then amplified fragment length polymorphism (AFLP) genotyped 66 Cryptococcus isolates from a cohort of patients with HIV-associated cryptococcal meningitis. C. gattii sensu lato was isolated at a prevalence of 16.7% (n = 11/66) and C. neoformans sensu stricto was responsible for 83.3% (n = 55/66) of the infections. l-Canavanine glycine bromothymol blue, yeast-carbon-base-d-proline-d-tryptophan and creatinine dextrose bromothymol blue thymine were able to distinguish pathogenic C. gattii sensu lato from C. neoformans sensu stricto species when compared with AFLP genotyping. This study demonstrates high C. gattii sensu lato prevalence in Zimbabwe. In addition, biotyping methods can be used as alternative diagnostic tools to molecular typing in resource-limited areas for differentiating pathogenic Cryptococcus species.

Recent advances on anti-HIV vaginal delivery systems development

A review of the recent outcomes regarding technologies to prevent vaginal transmission of HIV, mainly by using antiretroviral (ARV) drugs formulated as microbicides. An introduction about the HIV transmission mechanisms by the vaginal route is included, together with the recent challenges faced for development of successful microbicide products. The outcomes of clinical evaluations are mentioned, and the different formulation strategies studied to-date, with the requirements, advantages, disadvantages and limitations of each dosage-form type, are presented. Finally, the recent attempts to apply various types of nanotechnologies in order to develop advanced microbicide-products and overcome existing limitations, are discussed.

Trends in prevalence of diarrhoea, Kaposi's sarcoma, bacterial pneumonia, malaria and geohelminths among HIV positive individuals in Uganda

BACKGROUND

Trends in prevalence of opportunistic infections (OIs) associated with the human immunodeficiency virus (HIV) in resource poor settings have previously not been well documented. The objective of this study was to describe the trends in prevalence of Diarrhoea, Bacterial pneumonia, Kaposi's sarcoma, Malaria and Geohelminths among HIV positive individuals over a 12 year period in Uganda.

METHODS

Observation data for 5972 HIV positive individuals enrolled with the AIDS support organisation (TASO) in Uganda were analysed. Study participants were drawn from three HIV clinics located in different geographical areas of Uganda and followed from January 2002 to December 2013. The prevalence trends for the above OIs were plotted using the Box Jenkins moving average technique. X (2)-test for trend was used to test for the significance of the trends and Pearson's correlation coefficient used to test for the strength of linear relationship between OI prevalence and calendar time. Mixed effect linear regression was used to estimate average monthly change in prevalence with monthly variation modelled as a random effect.

RESULTS

A total of 204,871 monthly medical reports were retrieved and analysed. 73 % (4301/5972) were female with a median age of 32 years (inter-quartile range 26-39). Overall, significant decreasing mean annual prevalence trends (p < 0.05, X(2) trend) were observed for Diarrhoea (<1 month) with Pearson's correlation coefficient (r = -0.89), Malaria (r = -0.75), Bacterial Pneumonia (r = -0.52), and Geohelminth (r = -0.32). Non-significant increasing mean annual prevalence trend was observed for Kaposis sarcoma (p = 0.20, X(2) trend; r = +0.26). After adjusting for age, sex and clinic in a mixed effects linear regression model, average monthly prevalence declined significantly at a rate of 0.4 % for Kaposis sarcoma, 0.3 % for Geohelminths, 2 % for Malaria, 1 % for Bacterial Pneumonia and 3 % for Diarrhoea(<1 month). However, the rate of decline per month differed significantly (p < 0.05) by HIV clinic for Diarrhoea (<1 month), and age, sex and clinic for malaria.

CONCLUSIONS AND RECOMMENDATIONS

Overall, decreasing trends were observed in the above OIs. However the trends differed significantly by OI, geographical location and demographic characteristics. There is urgent need to integrate interventions targeting malaria and geohelminths in HIV programmes.

Cryptococcal meningitis screening and community-based early adherence support in people with advanced HIV infection starting antiretroviral therapy in Tanzania and Zambia: an open-label, randomised controlled trial

BACKGROUND

Mortality in people in Africa with HIV infection starting antiretroviral therapy (ART) is high, particularly in those with advanced disease. We assessed the effect of a short period of community support to supplement clinic-based services combined with serum cryptococcal antigen screening.

METHODS

We did an open-label, randomised controlled trial in six urban clinics in Dar es Salaam, Tanzania, and Lusaka, Zambia. From February, 2012, we enrolled eligible individuals with HIV infection (age ≥18 years, CD4 count of <200 cells per μL, ART naive) and randomly assigned them to either the standard clinic-based care supplemented with community support or standard clinic-based care alone, stratified by country and clinic, in permuted block sizes of ten. Clinic plus community support consisted of screening for serum cryptococcal antigen combined with antifungal therapy for patients testing antigen positive, weekly home visits for the first 4 weeks on ART by lay workers to provide support, and in Tanzania alone, re-screening for tuberculosis at 6-8 weeks after ART initiation. The primary endpoint was all-cause mortality at 12 months, analysed by intention to treat. This trial is registered with the International Standard Randomised Controlled Trial Number registry, number ISCRTN 20410413.

FINDINGS

Between Feb 9, 2012, and Sept 30, 2013, 1001 patients were randomly assigned to clinic plus community support and 998 to standard care. 89 (9%) of 1001 participants in the clinic plus community support group did not receive their assigned intervention, and 11 (1%) of 998 participants in the standard care group received a home visit or a cryptococcal antigen screen rather than only standard care. At 12 months, 25 (2%) of 1001 participants in the clinic plus community support group and 24 (2%) of 998 participants in the standard care group had been lost to follow-up, and were censored at their last visit for the primary analysis. At 12 months, 134 (13%) of 1001 participants in the clinic plus community support group had died compared with 180 (18%) of 998 in the standard care group. Mortality was 28% (95% CI 10-43) lower in the clinic plus community support group than in standard care group (p=0·004).

INTERPRETATION

Screening and pre-emptive treatment for cryptococcal infection combined with a short initial period of adherence support after initiation of ART could substantially reduce mortality in HIV programmes in Africa.

FUNDING

European and Developing Countries Clinical Trials Partnership.

Trends in prevalence of selected opportunistic infections associated with HIV/AIDS in Uganda

Background

After more than a decade of establishing and expanding access to highly active antiretroviral therapy (HAART), empirical evidence on its impact on trends of opportunistic infections (OIs) associated with the deadly human immunodeficiency virus (HIV) in resource poor settings is scarce. The primary objective of this study was to assess the effect of HAART coverage on trends of five most common OIs in Uganda.

Methods

Observational data from January 2002 to December 2013 for 5972 HIV positive individuals attending the AIDS Support Organisation (TASO) HIV/AIDS care programme in Uganda were extracted and analysed. Trends were analysed using autoregressive moving average time series and mixed effects linear regression models adjusting for all available potential confounders.

Results

A total of 204,871 monthly medical reports were retrieved and analysed. Majority of the participants were female (73%) with a median age of 32 years (inter-quartile range 26–39). Overall, significant decreasing mean annual prevalence trends were observed for Mycobacterium tuberculosis, herpes zoster, genital ulcer and oral candidiasis (p < 0.05, X²_trend). Non-significant declining mean annual prevalence trend was observed for cryptococcal meningitis (p = 0.181, X²_trend). The largest impact of HAART was observed in Oral candidiasis and TB whose average annual prevalence reduced by 61% and 43% respectively following the introduction of HAART. Monthly series for TB, Herpes zoster and genital ulcers differed significantly by age and clinic but only genital ulcer series differed significantly by sex (p < 0.05, kruskal wallis). After controlling for the effects of age, sex and clinic (fixed) and monthly clustering (random effect) in a mixed effects linear regression model, all the five OIs showed a significant monthly change in prevalence (p < 0.001).

Conclusion

Overall, prevalence of most OIs declined especially after the introduction of HAART. However significant variations exist in the trends of different OIs in different geographical areas in Uganda. It is therefore important that site specific factors are properly identified to enable the development of targeted interventions.

The impact of HIV on presentation and outcome of bacterial sepsis and other causes of acute febrile illness in Gabon

Purpose

HIV, bacterial sepsis, malaria, and tuberculosis are important causes of disease in Africa. We aimed to determine the impact of HIV on the presentation, causes and outcome of bacterial sepsis and other acute febrile illnesses in Gabon, Central Africa.

Methods

We performed a prospective observational study in new adult admissions with fever or hypothermia (≥38 or <36 °C). Blood cultures, as well as HIV and malaria testing were performed in all patients.

Results

We enrolled 382 patients, including 77 (20.2 %) with HIV infection. Malaria was the most frequent diagnosis (n = 130, 34 %), and was associated with a more severe presentation in HIV patients. Sepsis was also common (n = 107, 28 %), including 29 (7.6 %) patients with culture confirmed bacterial bloodstream infection. Bacterial bloodstream infections were more frequent in HIV patients, in particular with S. pneumoniae. Tuberculosis was observed in 29 (7.6 %) patients, and was also more common in HIV patients. The majority of HIV patients was newly diagnosed, and only 15 (19.5 %) were using combination antiretroviral therapy.

Conclusions

Our findings illustrate the impact of HIV co-infection on the burden of sepsis, malaria and tuberculosis in Gabon, as well as the need to scale up HIV counseling, testing and treatment.

Electronic supplementary material

The online version of this article (doi:10.1007/s15010-015-0753-2) contains supplementary material, which is available to authorized users.

Characteristics and predictors of death among hospitalized HIV-infected patients in a low HIV prevalence country: Bangladesh

BACKGROUND

Predictors of death in hospitalized HIV-infected patients have not been previously reported in Bangladesh.

OBJECTIVE

The primary aim of this study was to determine predictors of death among hospitalized HIV-infected patients at a large urban hospital in Bangladesh.

METHODS

A study was conducted in the HIV in-patient unit (Jagori Ward) of icddr,b's Dhaka Hospital. Characteristics of patients who died during hospitalization were compared to those of patients discharged from the ward. Bivariate analysis was performed to determine associations between potential risk factors and death. Multivariable logistic regression was used to identify factors independently associated with death.

RESULTS

Of 293 patients admitted to the Jagori Ward, 57 died during hospitalization. Most hospitalized patients (67%) were male and the median age was 35 (interquartile range: 2-65) years. Overall, 153 (52%) patients were diagnosed with HIV within 6 months of hospitalization. The most common presumptive opportunistic infections (OIs) identified were tuberculosis (32%), oesophageal candidiasis (9%), Pneumocystis jirovecii pneumonia (PJP) (8%), and histoplasmosis (7%). On multivariable analysis, independent predictors of mortality were CD4 count ≤200 cells/mm3 (adjusted odds ratio [aOR]: 16.6, 95% confidence interval [CI]: 3.7-74.4), PJP (aOR: 18.5, 95% CI: 4.68-73.3), oesophageal candidiasis (aOR: 27.5, 95% CI: 5.5-136.9), malignancy (aOR:15.2, 95% CI: 2.3-99.4), and bacteriuria (aOR:7.9, 95% CI: 1.2-50.5). Being on antiretroviral therapy prior to hospitalization (aOR: 0.2, 95% CI: 0.06-0.5) was associated with decreased mortality.

CONCLUSION

This study showed that most patients who died during hospitalization on the Jagori Ward had HIV-related illnesses which could have been averted with earlier diagnosis of HIV and proper management of OIs. It is prudent to develop a national HIV screening programme to facilitate early identification of HIV.

Cryptococcal meningitis management in Tanzania with strict schedule of serial lumber punctures using intravenous tubing sets: an operational research study

BACKGROUND

Cryptococcal meningitis (CM) has a mortality rate of ∼70% among HIV-infected adults in low-income countries. Controlling intracranial pressure (ICP) is essential in CM, but it is difficult in low-income countries because manometers and practical ICP management protocols are lacking.

METHODS

As part of a continuous quality improvement project, our Tanzanian hospital initiated a new protocol for ICP management for CM. All adult inpatients with CM are included in a prospective patient registry. At the time of analysis, this registry included data from 2 years before the initiation of this new ICP management protocol and for a 9-month period after. ICP was measured at baseline and at days 3, 7, and 14 by both manometer and intravenous (IV) tubing set. All patients were given IV fluconazole according to Tanzanian treatment guidelines and were followed until 30 days after admission.

RESULTS

Among adult inpatients with CM, 32 of 35 patients (91%) had elevated ICP on admission. Cerebrospinal fluid pressure measurements using the improvised IV tubing set demonstrated excellent agreement (r = 0.96) with manometer measurements. Compared with historical controls, the new ICP management protocol was associated with a significant reduction in 30-day mortality (16/35 [46%] vs. 48/64 [75%] in historical controls; hazard ratio = 2.1 [95% CI: 1.1 to 3.8]; P = 0.018].

CONCLUSIONS

Increased ICP is almost universal among HIV-infected adults admitted with CM in Tanzania. Intensive ICP management with a strict schedule of serial lumbar punctures reduced in-hospital mortality compared with historical controls. ICP measurement with IV tubing sets may be a good alternative in resource-limited health facilities where manometers are not available.

Estudio de los costos en que incurren las entidades promotoras de salud en Colombia por la prevención y el tratamiento del VIH/sida

<p>El presente artículo tiene por objetivo principal estudiar los costos en que incurren las entidades promotoras de salud en Colombia por la prevención y el tratamiento del VIH/sida. La metodología es investigación con enfoque mixto (cualitativa y cuantitativa). Se identificaron patrones de tarifas de atención y tratamientos de pacientes VIH positivos y se estimaron los precios anuales de atención a pacientes VIH/sida, según la etapa de la enfermedad. Por último, se realizó una descripción de gastos en etapa de latencia clínica respecto a los costos de atención a pacientes con esta afección. Se concluye que en Colombia se sobrepasa la capacidad de sostenimiento de las entidades promotoras de salud y las aseguradoras, dados los altos precios de los regímenes farmacéuticos necesarios, que son a su vez una consecuencia probable del poco control gubernamental que existe sobre el costo de los medicamentos.</p><br />

A case on streptococcal pneumonia associated with leptomeningitis, osteomyelitis and epidural abscess in a patient with AIDS

Patients with acquired immunodeficiency syndrome (AIDS) are at higher risks of bacterial pneumonia than the general population, and the pathogen is the most commonly involved Streptococcus pneumoniae. We hereby report a case of pneumococcal pneumonia associated with leptomeningitis, osteomyelitis and epidural abscess in a patient with AIDS. He is being successfully treated with ampicillin/sulbactam and clindamycin. And because the pneumococcal infection is usually associated with morbidity and mortality rates in the setting of AIDS, we should consider for pneumococcal vaccinations among the AIDS populations.