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Mnzava D, Okuma J, Ndege R, Kimera N, Ntamatungiro A, Nyuri A, Byakuzana T, Abilahi F, Mayeka P, Temba E, Fanuel T, Glass TR, Klimkait T, Vanobberghen F, Weisser M. Decentralization of viral load testing to improve HIV care and treatment cascade in rural Tanzania: observational study from the Kilombero and Ulanga Antiretroviral Cohort. BMC Infect Dis 2023; 23:222. [PMID: 37029356 PMCID: PMC10081287 DOI: 10.1186/s12879-023-08155-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 03/13/2023] [Indexed: 04/09/2023] Open
Abstract
INTRODUCTION Monitoring HIV viral load (HVL) in people living with HIV (PLHIV) on antiretroviral therapy (ART) is recommended by the World Health Organization. Implementation of HVL testing programs have been affected by logistic and organizational challenges. Here we describe the HVL monitoring cascade in a rural setting in Tanzania and compare turnaround times (TAT) between an on-site and a referral laboratory. METHODS In a nested study of the prospective Kilombero and Ulanga Antiretroviral Cohort (KIULARCO) we included PLHIV aged ≥ 15 years, on ART for ≥ 6 months after implementation of routine HVL monitoring in 2017. We assessed proportions of PLHIV with a blood sample taken for HVL, whose results came back, and who were virally suppressed (HVL < 1000 copies/mL) or unsuppressed (HVL ≥ 1000 copies/mL). We described the proportion of PLHIV with unsuppressed HVL and adequate measures taken as per national guidelines and outcomes among those with low-level viremia (LLV; 100-999 copies/mL). We compare TAT between on-site and referral laboratories by Wilcoxon rank sum tests. RESULTS From 2017 to 2020, among 4,454 PLHIV, 4,238 (95%) had a blood sample taken and 4,177 (99%) of those had a result. Of those, 3,683 (88%) were virally suppressed. In the 494 (12%) unsuppressed PLHIV, 425 (86%) had a follow-up HVL (102 (24%) within 4 months and 158 (37%) had virologic failure. Of these, 103 (65%) were already on second-line ART and 32/55 (58%) switched from first- to second-line ART after a median of 7.7 months (IQR 4.7-12.7). In the 371 (9%) PLHIV with LLV, 327 (88%) had a follow-up HVL. Of these, 267 (82%) resuppressed to < 100 copies/ml, 41 (13%) had persistent LLV and 19 (6%) had unsuppressed HVL. The median TAT for return of HVL results was 21 days (IQR 13-39) at the on-site versus 59 days (IQR 27-99) at the referral laboratory (p < 0.001) with PLHIV receiving the HVL results after a median of 91 days (IQR 36-94; similar for both laboratories). CONCLUSION Robust HVL monitoring is achievable in remote resource-limited settings. More focus is needed on care models for PLHIV with high viral loads to timely address results from routine HVL monitoring.
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Affiliation(s)
- Dorcas Mnzava
- Ifakara Health Institute, Ifakara Branch, Ifakara, United Republic of Tanzania
| | - James Okuma
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Robert Ndege
- Ifakara Health Institute, Ifakara Branch, Ifakara, United Republic of Tanzania
- St. Francis Referral Hospital, Ifakara, United Republic of Tanzania
| | - Namvua Kimera
- Ifakara Health Institute, Ifakara Branch, Ifakara, United Republic of Tanzania
| | - Alex Ntamatungiro
- Ifakara Health Institute, Ifakara Branch, Ifakara, United Republic of Tanzania
| | - Amina Nyuri
- Ifakara Health Institute, Ifakara Branch, Ifakara, United Republic of Tanzania
| | | | - Faraji Abilahi
- Ifakara Health Institute, Ifakara Branch, Ifakara, United Republic of Tanzania
| | - Paul Mayeka
- USAID Boresha Afya, Morogoro, United Republic of Tanzania
| | - Emmy Temba
- USAID Boresha Afya, Morogoro, United Republic of Tanzania
| | - Teddy Fanuel
- USAID Boresha Afya, Morogoro, United Republic of Tanzania
| | - Tracy Renée Glass
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Thomas Klimkait
- Department of Biomedicine, Molecular Virology, University of Basel, Basel, Switzerland
| | - Fiona Vanobberghen
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Maja Weisser
- Ifakara Health Institute, Ifakara Branch, Ifakara, United Republic of Tanzania.
- Swiss Tropical and Public Health Institute, Basel, Switzerland.
- University of Basel, Basel, Switzerland.
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, CH, Basel, Switzerland.
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Bircher RE, Ntamatungiro AJ, Glass TR, Mnzava D, Nyuri A, Mapesi H, Paris DH, Battegay M, Klimkait T, Weisser M. High failure rates of protease inhibitor-based antiretroviral treatment in rural Tanzania - A prospective cohort study. PLoS One 2020; 15:e0227600. [PMID: 31929566 PMCID: PMC6957142 DOI: 10.1371/journal.pone.0227600] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 12/24/2019] [Indexed: 01/12/2023] Open
Abstract
Background Poor adherence to antiretroviral drugs and viral resistance are the main drivers of treatment failure in HIV-infected patients. In sub-Saharan Africa, avoidance of treatment failure on second-line protease inhibitor therapy is critical as treatment options are limited. Methods In the prospective observational study of the Kilombero & Ulanga Antiretroviral Cohort in rural Tanzania, we assessed virologic failure (viral load ≥1,000 copies/mL) and drug resistance mutations in bio-banked plasma samples 6–12 months after initiation of a protease inhibitor-based treatment regimen. Additionally, viral load was measured before start of protease inhibitor, a second time between 1–5 years after start, and at suspected treatment failure in patients with available bio-banked samples. We performed resistance testing if viral load was ≥1000 copies/ml. Risk factors for virologic failure were analyzed using logistic regression. Results In total, 252 patients were included; of those 56% were female and 21% children. Virologic failure occurred 6–12 months after the start of a protease inhibitor in 26/199 (13.1%) of adults and 7/53 of children (13.2%). The prevalence of virologic failure did not change over time. Nucleoside reverse transcriptase inhibitors drug resistance mutation testing performed at 6–12 months showed a positive signal in only 9/16 adults. No cases of resistance mutations for protease inhibitors were seen at this time. In samples taken between 1–5 years protease inhibitor resistance was demonstrated in 2/7 adults. In adult samples before protease inhibitor start, resistance to nucleoside reverse transcriptase inhibitors was detected in 30/41, and to non-nucleoside reverse-transcriptase inhibitors in 35/41 patients. In 15/16 pediatric samples, resistance to both drug classes but not for protease inhibitors was present. Conclusion Our study confirms high early failure rates in adults and children treated with protease inhibitors, even in the absence of protease inhibitors resistance mutations, suggesting an urgent need for adherence support in this setting.
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Affiliation(s)
- Rahel E. Bircher
- Ifakara Health Institute, Ifakara, Tanzania
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Molecular Virology, Department Biomedicine Petersplatz, University of Basel, Basel, Switzerland
| | | | - Tracy R. Glass
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | | | | | - Herry Mapesi
- Ifakara Health Institute, Ifakara, Tanzania
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- St. Francis Referral Hospital, Ifakara, Tanzania
| | - Daniel H. Paris
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Manuel Battegay
- University of Basel, Basel, Switzerland
- Departments of Medicine and Clinical Research, Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Thomas Klimkait
- Molecular Virology, Department Biomedicine Petersplatz, University of Basel, Basel, Switzerland
| | - Maja Weisser
- Ifakara Health Institute, Ifakara, Tanzania
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Departments of Medicine and Clinical Research, Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
- * E-mail:
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Katende A, Mbwanji G, Faini D, Nyuri A, Kalinjuma AV, Mnzava D, Hullsiek KH, Rhein J, Weisser M, Meya DB, Boulware DR, Letang E. Short-course amphotericin B in addition to sertraline and fluconazole for treatment of HIV-associated cryptococcal meningitis in rural Tanzania. Mycoses 2019; 62:1127-1132. [PMID: 31461550 DOI: 10.1111/myc.12995] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 08/22/2019] [Accepted: 08/23/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Cryptococcal meningitis accounts for 15% of all AIDS mortality globally. Most cases in low- and middle-income countries are treated with fluconazole monotherapy, which is associated with a high mortality. New available therapies are needed. Short-course amphotericin B has been shown to be a safe and efficient therapeutic option. Sertraline has in vitro fungicidal activity against Cryptococcus and bi-directional synergy with fluconazole. METHODS We conducted an open-label clinical trial to assess the safety and efficacy of sertraline 400 mg/day and fluconazole 1200 mg/day (n = 28) vs sertraline, fluconazole and additional 5 days of amphotericin B deoxycholate 0.7-1 mg/kg (n = 18) for cryptococcal meningitis. RESULTS Two-week survival was 64% (18/28) without amphotericin and 89% (16/18) with amphotericin, and 10-week survival was 21% (6/28) vs 61% (11/18), respectively (P = .012). The cerebrospinal fluid (CSF) Cryptococcus clearance rate was 0.264 log10 colony-forming units (CFU)/mL of CSF/day (95% CI: 0.112-0.416) without amphotericin and 0.473 log10 CFU/mL/day (95% CI: 0.344-0.60) with short-course amphotericin (P = .03). Sertraline was discontinued in one participant due to side effects. Four participants receiving amphotericin B experienced hypokalemia <2.4 mEq/L. CONCLUSIONS Short-course amphotericin substantially increased CSF clearance and 10-week survival. Adjunctive sertraline improved 2-week CSF fungal clearance but did not improve 10-week mortality compared with published data using fluconazole 1200 mg/day monotherapy (early fungicidal activity 0.15 log10 CFU/mL/day).
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Affiliation(s)
- Andrew Katende
- Chronic Diseases Clinic of Ifakara, Ifakara Health Institute, Ifakara, Tanzania
| | - Gladys Mbwanji
- Chronic Diseases Clinic of Ifakara, Ifakara Health Institute, Ifakara, Tanzania
| | - Diana Faini
- Chronic Diseases Clinic of Ifakara, Ifakara Health Institute, Ifakara, Tanzania.,Muhimbili University of Health and Allied sciences, Dar es Salaam, Tanzania
| | - Amina Nyuri
- Chronic Diseases Clinic of Ifakara, Ifakara Health Institute, Ifakara, Tanzania
| | | | - Dorcas Mnzava
- Chronic Diseases Clinic of Ifakara, Ifakara Health Institute, Ifakara, Tanzania
| | - Katherine H Hullsiek
- Division of Infectious Diseases & International Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Joshua Rhein
- Division of Infectious Diseases & International Medicine, University of Minnesota, Minneapolis, MN, USA.,Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Maja Weisser
- Chronic Diseases Clinic of Ifakara, Ifakara Health Institute, Ifakara, Tanzania.,Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - David B Meya
- Division of Infectious Diseases & International Medicine, University of Minnesota, Minneapolis, MN, USA.,Infectious Diseases Institute, Makerere University, Kampala, Uganda.,School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - David R Boulware
- Division of Infectious Diseases & International Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Emilio Letang
- Chronic Diseases Clinic of Ifakara, Ifakara Health Institute, Ifakara, Tanzania.,Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland.,ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain.,Service of Infectious Diseases, Hospital del Mar, Hospital del Mar Research Institute (IMIM), Barcelona, Spain
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Mkindi CG, Marandu EA, Masawa N, Bani F, Nyuri A, Byakuzana T, Klimkait T, Ding S, Pantaleo G, Battegay M, Orlova-Fink N, Weisser-Rohacek M, Daubenberger C. Safety and tolerance of lymph node biopsies from chronic HIV-1 volunteers in rural Tanzania. BMC Res Notes 2019; 12:561. [PMID: 31492170 PMCID: PMC6729032 DOI: 10.1186/s13104-019-4600-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 09/03/2019] [Indexed: 11/29/2022] Open
Abstract
Objective HIV-1 rapidly establishes a persistent infection that can be contained under life-long antiretroviral therapy (ART) but not cured. One major viral reservoir is the peripheral lymph node (LN) follicles. Studying the impact of novel HIV-1 treatment and vaccination approaches on cells residing in germinal centers is essential for rapid progress towards HIV-1 prevention and cure. Results We enrolled 9 asymptomatic adult volunteers with a newly diagnosed HIV-1 infection and CD4 T cell counts ≥ 350/ml. The patients underwent venous blood collection and inguinal lymph node excision surgery in parallel. Mononuclear cells were extracted from blood and tissues simultaneously. Participants were followed up regularly for 2 weeks until complete healing of the surgical wounds. All participants completed the lymph node excision surgery without clinical complications. Among the 9 volunteers, one elite controller was identified. The number of mononuclear cells recovered from lymph nodes ranged from 68 to 206 million and correlated positively with lymph node size. This is the first study to show that lymph node biopsy is a safe procedure and can be undertaken with local experts in rural settings. It provides a foundation for detailed immune response investigations during future clinical trials.
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Affiliation(s)
- Catherine Gerald Mkindi
- Department of Medical Parasitology and Infection Biology, Clinical Immunology, Swiss Tropical and Public Health Institute, Socinstr. 57, 4002, Basel, Switzerland.,University of Basel, Basel, Switzerland.,Ifakara Health Institute, Bagamoyo, Tanzania
| | | | | | - Farida Bani
- Ifakara Health Institute, Bagamoyo, Tanzania
| | - Amina Nyuri
- Ifakara Health Institute, Bagamoyo, Tanzania
| | | | | | - Song Ding
- EuroVacc Foundation, Amsterdam, The Netherlands
| | - Giuseppe Pantaleo
- Service of Immunology and Allergy, Lausanne University Hospital, Lausanne, Switzerland.,Swiss Vaccine Research Institute, Lausanne, Switzerland
| | - Manuel Battegay
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Nina Orlova-Fink
- Department of Medical Parasitology and Infection Biology, Clinical Immunology, Swiss Tropical and Public Health Institute, Socinstr. 57, 4002, Basel, Switzerland.,Ifakara Health Institute, Bagamoyo, Tanzania
| | - Maja Weisser-Rohacek
- Department of Medical Parasitology and Infection Biology, Clinical Immunology, Swiss Tropical and Public Health Institute, Socinstr. 57, 4002, Basel, Switzerland.,Ifakara Health Institute, Bagamoyo, Tanzania.,Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Claudia Daubenberger
- Department of Medical Parasitology and Infection Biology, Clinical Immunology, Swiss Tropical and Public Health Institute, Socinstr. 57, 4002, Basel, Switzerland. .,Ifakara Health Institute, Bagamoyo, Tanzania.
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