Nonadherence to primary prophylaxis against Pneumocystis jirovecii pneumonia

High prevalence of Pneumocystis jirovecii pneumonia among Mozambican children <5 years of age admitted to hospital with clinical severe pneumonia

We aimed to describe Pneumocystis jirovecii pneumonia (PCP) prevalence and features in children from sub-Saharan Africa and to investigate PCP-associated risk factors. During 2006-2007 we used molecular methods to test children younger than 5 years old admitted with severe pneumonia to a hospital in southern Mozambique for Pneumocystis infection. We recruited 834 children. PCP prevalence was 6.8% and HIV prevalence was 25.7%. The in-hospital and delayed mortality were significantly higher among children with PCP (20.8% vs. 10.2%, p 0.021, and 11.5% vs. 3.6%, p 0.044, respectively). Clinical features were mostly overlapping between the two groups. Independent risk factors for PCP were age less than a year (odds ratio (OR) 6.34, 95% confidence interval (CI) 1.86-21.65), HIV infection (OR 2.99, 95% CI 1.16-7.70), grunting (OR 2.64, 95% CI 1.04-6.73) and digital clubbing (OR 10.75, 95% CI 1.21-95.56). PCP is a common and life-threatening cause of severe pneumonia in Mozambican children. Mother-to-child HIV transmission prevention should be strengthened. Better diagnostic tools are needed.

Cotrimoxazole prophylaxis and antiretroviral therapy: an observational cohort study in China

Objective

To assess if cotrimoxazole prophylaxis administered early during antiretroviral therapy (ART) reduces mortality in Chinese adults who are infected with human immunodeficiency virus (HIV).

Methods

We did a retrospective observational cohort study using data from the Chinese national free antiretroviral database. Patients older than 14 years who started ART between 1 January 2010 and 31 December 2012 and had baseline CD4+ T-lymphocyte (CD4+ cell) count less than 200 cells/µL were followed until death, loss to follow-up or 31 December 2013. Hazard ratios (HRs) for several variables were calculated using multivariate analyses.

Findings

The analysis involved 23 816 HIV-infected patients, 2706 of whom died during the follow-up. Mortality in patients who did and did not start cotrimoxazole during the first 6 months of ART was 5.3 and 7.0 per 100 person–years, respectively. Cotrimoxazole was associated with a 37% reduction in mortality (hazard ratio, HR: 0.63; 95% confidence interval, CI: 0.56–0.70). Cotrimoxazole in addition to ART reduced mortality significantly over follow-up lasting 6 months (HR: 0.65; 95% CI: 0.59–0.73), 12 months (HR: 0.58; 95% CI: 0.49–0.70), 18 months (HR: 0.49; 95% CI: 0.38–0.63) and 24 months (HR: 0.66; 95% CI: 0.48–0.90). The mortality reduction was evident in patients with baseline CD4+ cell counts less than 50 cells/µL (HR: 0.60; 95% CI: 0.54–0.67), 50–99 cells/µL (HR: 0.66; 95% CI: 0.56–0.78) and 100–199 cells/µL (HR: 0.78; 95% CI: 0.62–0.98).

Conclusion

Cotrimoxazole prophylaxis started early during ART reduced mortality and should be offered to HIV-infected patients in low- and middle-income countries.

ADHERENCE IN PREGNANCY: A SYSTEMATIC REVIEW OF THE LITERATURE

“Clinical decisions and research programs ultimately depend on the reliable and valid measurement of adherence. Yet, 50 years of research in this field have not provided the data necessary to answer critical measurement questions.”.

Substance use: impact on adherence and HIV medical treatment

Substance use is highly prevalent among people living with HIV/AIDS, is often comorbid with other mental health problems, related to poor HIV medical outcomes, and, is associated with poor medication and treatment adherence. The current review reports on the recent state of the literature in terms of substance use and its relation to HIV medication and treatment adherence, and offers recommendations for advancing treatment and secondary HIV prevention efforts. Identifying substance users within HIV primary care and developing, evaluating, and refining integrative substance use-mental health-adherence interventions may be clinically important targets for effective disease management and may contribute to secondary HIV prevention efforts.

Relationship between CD4+ T-cell counts/HIV-1 RNA plasma viral load and AIDS-defining events among persons followed in the ACTG longitudinal linked randomized trials study

BACKGROUND

AIDS-defining events (ADEs) decreased in the era of highly active antiretroviral therapy but still lead to hospitalizations and deaths. Understanding factors related to ADEs is important to mitigate events.

METHODS

We examined the relationship between demographics, behaviors, comorbidities, laboratory, clinical measurements, and ADEs diagnosed among subjects randomized to antiretroviral treatments (ART)/strategies and followed prospectively. Logistic regression models using generalized estimating equations generated odds ratios (ORs) focusing on the relationship between current CD4 T-cell count (CD4)/HIV-1 RNA viral load (VL) and ADEs in the subsequent 16-week study period.

RESULTS

Among the 2948 subjects in the analysis, overall incidence of ADEs was 1.53 per 100 person-years. Multivariate regression models adjusted for demographics, body mass index, and ADE history. A 6-level time-varying variable examined VL (>100,000 copies/mL, < or =100,000) at CD4 levels (0-50, 51-200, >200 cells/microL); reference level was CD4 >200/VL < or =100,000. Among ART naives, odds of having an ADE in the subsequent 16-week interval were greater among subjects with lower CD4 counts; this relationship was modified by VL level (CD4 < or =50/VL >100,000: OR 37.2; CD4 < or =50/VL < or =100,000: OR 30.5; CD4 51-200/VL >100,000: OR 13.0; CD4 51-200/VL < or =100,000: OR 4.5; all P values <0.001). Similar results were seen among ART-experienced subjects.

CONCLUSIONS

Recent CD4 and VL values are closely associated with development of ADEs even after examining a multitude of potential factors.