Pretreatment and Acquired Drug Resistance in Children With Human Immunodeficiency Virus Type 1 in Jos, Nigeria

We determined pretreatment and acquired human immunodeficiency virus (HIV) drug resistance among children with HIV type 1 (HIV-1) in Jos, Nigeria. The majority (71%) of those who failed first-line antiretroviral therapy were on a nevirapine-containing regimen. The prevalence of pretreatment (48%) and acquired (76%) HIV drug resistance mutations was high in our study. Wider access to HIV drug resistance testing after treatment failure is necessary to optimize second-line treatment options among children with HIV in Nigeria.

Molecular detection of hepatitis B virus genotype E with immune escape mutations in chronic hepatitis B patients on long-term antiviral therapy in Jos, Nigeria

Background

Previous studies in Nigeria have reported the presence of hepatitis B virus (HBV) genotype E and the availability of immune escape mutants. There is a paucity of data on chronic patients on long-term antiviral therapy for HBV infection.

Objective

This study assessed HBV genotypes and drug resistance variants among patients with chronic HBV infection receiving tenofovir in Jos, Nigeria.

Methods

This cross-sectional study consecutively enrolled 101 patients (51 with HIV/HBV co-infection and 50 with HBV infection only) on antiviral therapy from February 2018 to May 2019 at four hospitals in Jos, Nigeria. DNA quantification of HBV was performed on all samples; 30 samples with detectable viral load were selected for genotyping using Sanger sequencing by targeting the full-length sequences of reverse transcriptase gene of the HBV genome. Phylogenetic analysis was performed with reference sequences from GenBank. Escape mutant and drug resistance analysis were performed using HBV drug resistance interpretation and Geno2pheno.

Results

Only 30 (29.7%) of the 101 study participants had detectable HBV DNA. Of these, six (20.0%) isolates were successfully amplified and sequenced. The identified genotype was E, including escape mutations L127R (16.7%) and G145A (16.7%).

Conclusion

This study revealed exclusive dominance of genotype E in Nigeria. The S gene mutations G145A and L271R are known to be associated with modified antigenicity and impaired serologic assays, which may cause false negatives in the detection of anti-HBV surface antigen. The presence of mutants that are associated with vaccine immune escape may also have diagnostic and vaccine immune response implications.

Knowledge, attitudes and practices towards Covid-19 among Nigerian healthcare workers during the Covid-19 pandemic: A single centre survey

Background

The COVID-19 pandemic has led to hundreds of thousands of deaths worldwide.

Aims

Being a novel viral disease, we sought to evaluate the knowledge and practice of doctors and nurses in a tertiary hospital regarding the disease.

Subjects and Methods

Using a self-administered questionnaire, respondents were asked questions on the cause, clinical features, and prevention of COVID-19.

Results

: We studied 409 respondents (238 doctors and 171 nurses) with a mean age of 34 ± 7 years and a median length of experience of five (IQR 2-9) years. The mean knowledge score was 9.6 ± 1.2 out of a maximum of 12 points with 337 (82.4%) respondents having good knowledge. The majority of respondents (62.8%) had not been trained on infection prevention and control since the outbreak of the pandemic. Only 95 (23.2%) had seen COVID-19 Standard Operating Procedures (SOP) displayed in the hospital. The use of the personal protective equipment (PPE) kit comprising the N-95 mask, face shield, gown, and shoes was seen by 194 (47.4%) respondents in recent times. A total of 397 (97.0%) respondents felt they were at an increased risk of contracting COVID-19 relative to the general populace. Measures taken to prevent COVID-19 included: wearing of face mask (68.7%), hand gloves (78.2%), frequent use of hand sanitizers (84.1%), frequent hand washing (84.8%), the daily wash of uniforms and ward coats (44.5%), daily cleaning of footwear (31.7%), and avoidance of taking home clothing and footwear worn in the hospital (54.2%).

Conclusion

Despite having good knowledge of transmission and clinical features of SARS-CoV 2, the utilization of protective measures by HCW in this study is unsatisfactory.

HBV co-infection is associated with persistently elevated liver stiffness measurement in HIV-positive adults: A 6-year single-centre cohort study in Nigeria

Background

In Nigeria, the effect of Hepatitis B virus (HBV) on long-term liver outcomes in persons with HIV (PLH) has not been described. We determined changes in liver stiffness measure (LSM) using transient elastography over 6 years in HIV mono-infected and HIV-HBV co-infected Nigerians initiating antiretroviral therapy (ART) and factors associated with LSM decline.

Methods

This single centre, cohort study enrolled ART-naïve HIV mono- and HIV-HBV co-infected adults (≥18 years) at the APIN Public Health Initiatives–supported HIV Care and Treatment Centre at Jos University Teaching Hospital, Nigeria, from 7/2011 to 2/2012. LSM at baseline, Years 3 and 6 were analysed using longitudinal models to estimate changes over time and their predictors.

Results

Data from 100 (31%) HIV-HBV co-infected and 225 (69%) HIV mono-infected participants were analysed. Median LSM at baseline was 6.10 (IQR: 4.60–7.90) kPa in co-infected and 5.10 (IQR: 4.40–6.10) kPa in mono-infected participants. In adjusted analyses, average LSM was not significantly different between Year 0 and 3 (β = 0.02, −0.22 to 0.26, p = 0.87 and Year 0 and 6 (β = −0.02, −0.23 to 0.27, p = 0.88) in both groups ( p>0.05), but co-infected participants had significantly higher LSM than mono-infected throughout follow-up (β = 0.018, 0.019–0.28, p < 0.001). Year 3 LSM differed according to ART initiation status by Year 3 (initiators - non-initiators: −0.87, −1.70 to −0.29).

Conclusion

In this cohort, LSM remained higher among HIV-HBV co-infected versus HIV mono-infected participants throughout follow-up. Our findings emphasize the continuing need for monitoring of liver outcomes in HIV-HBV co-infected populations on ART and the importance of preventing HBV infection among PLH to optimize liver health.

Comparative incidence of adverse drug reaction during the first and subsequent year of antiretroviral therapy in a Nigerian HIV infected Cohort

Background

Despite close to two decades of antiretroviral therapy (ART) in Nigeria, data on late on-onset ART-associated adverse drug reactions (ADRs) are sparse.

Objectives

To describe early and late-onset ADRs and compare their incidence in an outpatient HIV positive Cohort on ART.

Method

We described the incidence of clinical ADRs identified and documented in an outpatient clinic cohort of HIV-positive patients treated between June 2004 and December 2015 at a tertiary health facility in Nigeria. Incidence rates of ADRs during the first and subsequent years of ART were compared.

Results

of the 13,983 patients' data analyzed, 9317 were females (66%), and those in the age bracket of 25 to 45 years made up 78% of the studied population. During 52,411 person-years (py) of ART, 1485 incident ADRs were recorded; Incidence rate (IR) 28.3 (95% confidence interval [CI] 26.9:29.8) ADRs per 1000 person-years (py) of ART. The IR of ADRs was about two times higher in the first year of ART compared to subsequent years of treatment; crude incidence rate ratio (IRR) 1.77 (95% CI 1.59:1.97). Anemia, hypersensitivity reactions, and nervous system disorders had 7, 23, and 5 times higher incidence, respectively, in the first year of therapy, compared to subsequent years.

Conclusion

The first year of ART is the period of highest risk of ADRs. Individual and programmatic treatment success in resource-limited settings requires strategies for early identification and management of ADR during the period of greatest risk of ADRs.

Long Term Exposure to Tenofovir Disoproxil Fumarate-Containing Antiretroviral Therapy Is Associated with Renal Impairment in an African Cohort of HIV-Infected Adults

OBJECTIVES AND METHOD

There are growing concerns of tenofovir disoproxil fumarate (TDF)-associated renal toxicity. We evaluated the effect of long-term TDF exposure on renal function in a cohort of HIV-1-infected Nigerians between 2006 and 2015. Multivariate logistic regression was used to identify predictors of renal impairment at different time over 144 weeks of antiretroviral therapy (ART).

RESULTS

Data of 4897 patients, median age 42 years (interquartile range: 36-49), and 61% females were analyzed. The prevalence of renal impairment increased from 10% at week 24 to 45% at 144 weeks in TDF-exposed participants compared to an increase from 8% at 24 weeks to 14% at 144 weeks in TDF-unexposed participants. Tenofovir disoproxil fumarate exposure predicted the risk of renal impairment at 144 weeks of ART (odds ratio: 2.36; 95% confidence interval: 1.28-4.34).

CONCLUSION

Long-term exposure to TDF-based ART significantly increases the likelihood of renal impairment. The continued use of TDF-based regimen in our setting should be reviewed. We recommend the urgent introduction of tenofovir alafenamide-based regimen in the HIV treatment guidelines of Nigeria and other resource-limited countries.

Absence of human leukocyte antigen-B*57:01 amongst patients on antiretroviral therapy in Nigeria: Implications for use of abacavir

Background

The presence of human leukocyte antigen (HLA) B*57:01 allele predicts hypersensitivity reaction (HSR) to abacavir (ABC), a nucleoside reverse-transcriptase inhibitor used for human immunodeficiency virus (HIV) treatment. However, the prevalence of this allele amongst Nigerians with HIV is yet to be established. We aimed to determine the prevalence of HLA-B*57:01 allele amongst Nigerians with HIV infection.

Methods

We conducted a multicentre cross-sectional epidemiologic survey. Between April 2016 and April 2017, patients were enrolled across five HIV treatment facilities in Nigeria. Participants' demographic information and their history of ABC exposure were obtained, and venous blood was obtained for HLA typing.

Results

One thousand five hundred and four (1504) adults were enrolled, with a mean age of 44.6 ± 10.7 years, 1078 (71.7%) were female. 1463 (97.3%) were on antiretroviral therapy. ABC use was reported by 12 (0.8%) participants and none reported HSR. Of 1500 blood samples that were processed, 1458 (97.2%) were successfully typed. Of these, 132 (9.1%) were HLA-B*57 positive using non-specific low-resolution HLA-B*5701 primer mix. On further analysis, none of the 132 samples (0%) had the HLA-B*5701 allele.

Conclusion

HLA-B*5701allele is rare amongst Nigerians.

Incidence and predictors of tenofovir disoproxil fumarate-induced renal impairment in HIV infected Nigerian patients

Introduction

The use of tenofovir disoproxil fumarate (TDF) in the treatment of HIV infection has been associated with renal dysfunction. In Nigeria, data on the incidence and risk factors of TDF nephrotoxicity is sparse. We determined the cumulative incidence of and risk factors for TDF-induced renal impairment in HIV-infected individuals accessing care at the antiretroviral therapy (ART) clinic of Jos University Teaching Hospital, Nigeria.

Methods

This retrospective cohort analysis included patients aged ≥16 years that initiated ART between January 2008 and December 2011. Renal impairment, defined as glomerular filtration rate GFR <60 mL/min/1.73 sqm using the Modification of Diet in Renal Disease (MDRD) equation was assessed at baseline and at 48 weeks on ART. Logistic regression was performed to determine factors associated with incident renal impairment.

Results

The mean age was 39±9 years, and 67.1% were female. The cumulative incidence of renal impairment among the TDF-exposed and TDF-unexposed groups was 4.6% and 2.3% respectively (p<0.001). TDF exposure was significantly associated with renal impairment [OR=2.0, 95%CI=(1.48-2.89), p<0.001] in bivariate analysis. In multivariate analysis, older age (aOR=1.06, 95%CI=(1.05-1.08), p<0.001), TDF exposure [aOR=1.85, 95%CI=(1.31-2.60), p<0.001] and co-morbidities [aOR=2.71, 95%CI=(1.72-4.25), p<0.001] were significantly associated with renal impairment.

Conclusion

TDF exposure, aging and comorbidities were predictors of renal toxicity among HIV positive patients. Regular monitoring of renal function in such high-risk individuals is recommended.

Presentation and survival in patients with hematologic malignancies in Jos, Nigeria: A retrospective cohort analysis

Background

Haematologic malignancies cause significant morbidity and mortality and are not uncommon in resource-limited-low income countries. However, the types, pattern of presentation and treatment outcomes vary across regions. We assessed the presentation and overall survival over an 11-year period in adult patients presenting with haematologic cancers in Jos, North Central Nigeria.

Materials and Methods

This retrospective outcome study evaluated patients who presented with haematologic malignancies between 2005-2015 at the Jos University Teaching Hospital (JUTH), Jos. Variables of interest were abstracted through chart reviews. Descriptive statistics were used to evaluate baseline and follow-up parameters. Overall survival (OS) was assessed using Kaplan-Meier method.

Results

Sixty patients, contributing 25,994 person-days of follow-up were evaluated. The mean age was 43+17 years and 61.7% were males. Thirty-one patients (51.7%) presented with leukemia, 45.0% with lymphoma, and 3.3% with multiple myeloma. Forty-two (70.0%) presented with advanced disease, 5 (5.2%) were HIV positive and 4 (6.7%) had died at the end of follow-up. OS was 84.3% (95% CI: 58.1-94.7). Survival differed by disease group (p=0.01) and having fever at presentation (p=0.02).

Conclusion

We found long-term OS to be impacted by disease type and status of fever at presentation. Disease-specific Strategies to improve early diagnosis and therapies are needed to ensure optimal outcomes in Nigerian patients.

Retention in Differentiated Care: Multiple Measures Analysis for a Decentralized HIV Care and Treatment Program in North Central Nigeria

Objective

Differentiated care refers collectively to flexible service models designed to meet the differing needs of HIV-infected persons in resource-scarce settings. Decentralization is one such service model. Retention is a key indicator for monitoring the success of HIV treatment and care programs. We used multiple measures to compare retention in a cohort of patients receiving HIV care at “hub” (central) and “spoke” (decentralized) sites in a large public HIV treatment program in north central Nigeria.

Methods

This retrospective cohort study utilized longitudinal program data representing central and decentralized levels of care in the Plateau State Decentralization Initiative, north central Nigeria. We examined retention with patient- level (retention at fixed times, loss-to-follow-up [LTFU]) and visit-level (gaps-in-care, visit constancy) measures. Regression models with generalized estimating equations (GEE) were used to estimate the effect of decentralization on visit-level measures. Patient-level measures were examined using survival methods with Cox regression models, controlling for baseline variables.

Results

Of 15,650 patients, 43% were enrolled at the hub. Median time in care was 3.1 years. Hub patients were less likely to be LTFU (adjusted hazard ratio (AHR)=0.91, 95% CI: 0.85-0.97), compared to spoke patients. Visit constancy was lower at the hub (−4.5%, 95% CI: −3.5, −5.5), where gaps in care were also more likely to occur (adjusted odds ratio=1.95, 95% CI: 1.83-2.08).

Conclusion

Decentralized sites demonstrated better retention outcomes using visit-level measures, while the hub achieved better retention outcomes using patient-level measures. Retention estimates produced by incorporating multiple measures showed substantial variation, confirming the influence of measurement strategies on the results of retention research. Future studies of retention in HIV care in sub-Saharan Africa will be well-served by including multiple measures.

Erratum to: Outcome of HIV-associated lymphoma in a resource-limited setting of Jos, Nigeria

[This corrects the article DOI: 10.1186/s13027-017-0144-7.].

Outcome of HIV-associated lymphoma in a resource-limited setting of Jos, Nigeria

BACKGROUND

Lymphoma is a leading cause of cancer-related death among human immunodeficiency virus (HIV)-infected individuals in the current era of potent anti-retroviral therapy (ART). Globally, mortality after HIV-associated lymphoma has profound regional variation. Little is known about HIV-associated lymphoma mortality in Nigeria and other resource-limited setting in sub-Saharan Africa. Therefore, we evaluated the all-cause mortality after lymphoma and associated risk factors including HIV at the Jos University Teaching Hospital (JUTH) Nigeria.

METHODS

We conducted a ten-year retrospective cohort study of lymphoma patients managed in JUTH. The main outcome measured was all-cause mortality and HIV infection was the main exposure variable. Overall death rate was estimated using the total number of death events and cumulative follow up time from lymphoma diagnosis to death. Cox proportional hazard regression was used to assess factors associated with mortality after lymphoma diagnosis.

RESULTS

Out of 40 lymphoma patients evaluated, 8(20.0%) were HIV positive and 32(80.0%) were HIV negative. After 127.63 person- years of follow-up, there were 16 deaths leading to a crude mortality rate of 40.0 per 100 person-years. The 2-year probability of survival was 30% for HIV-infected patients and 74% for HIV-uninfected. Median survival probability for HIV-infected patients was 2.1 years and 7.6 years for those without HIV. Unadjusted hazard of death was associated with late stage, HR 11.33(95% CI 2.55, 50.26,p = 0.001); low cumulative cycles of chemotherapy, HR 6.43(95% CI 1.80, 22.89,p = 0.004); greater age, HR 5.12(95% CI 1.45,18.08,p = 0.01); presence of comorbidity, HR 3.43(95% CI 1.10,10.78,p = 0.03); and HIV-infection, HR 3.32(95% CI 1.05, 10.51,p = 0.04). In an adjusted model only stage was significantly associated with death, AHR 5.45(1.14-26.06, p = 0.03).

CONCLUSION

Our findings suggest that HIV- infection accounted for three times probability of death in lymphoma patients compared to their HIV-uninfected counterparts due to late stage of lymphoma presentation in this population. Also initiation of chemotherapy was associated with lower probability of death among lymphoma patients managed at JUTH, Nigeria. Earlier stage at lymphoma diagnosis and prompt therapeutic intervention is likely to improve survival in these patients. Future research should undertake collaborative studies to obtain comprehensive regional data and identify unique risk factors of poor outcomes among HIV-infected patients with lymphoma in Nigeria.

Treatment Outcomes Among Older Human Immunodeficiency Virus-Infected Adults in Nigeria

Background

Older age at initiation of combination antiretroviral therapy (cART) has been associated with poorer clinical outcomes. Our objectives were to compare outcomes between older and younger patients in our clinical cohort in Jos, Nigeria.

Methods

This retrospective cohort study evaluated patients enrolled on cART at the Jos University Teaching Hospital, Nigeria between 2004 and 2012. We compared baseline and treatment differences between older (≥50 years) and younger (15–49 years) patients. Kaplan-Meier analysis and Cox proportional hazard models estimated survival and loss to follow-up (LTFU) and determined factors associated with these outcomes at 24 months.

Results

Of 8352 patients, 643 (7.7%) were aged ≥50 years. The median change in CD4 count from baseline was 151 vs 132 (P = .0005) at 12 months and 185 vs 151 cells/mm³ (P = .03) at 24 months for younger and older patients, respectively. A total of 68.9% vs 71.6% (P = .13) and 69.6% vs 74.8% (P = .005) of younger and older patients achieved viral suppression at 12 and 24 months, with similar incidence of mortality and LTFU. In adjusted hazard models, factors associated with increased risk of mortality were male sex, World Health Organization (WHO) stage III/IV, and having a gap in care, whereas being fully suppressed was protective. The risk of being LTFU was lower for older patients, those fully suppressed virologically and with adherence rates >95%. Male sex, lack of education, WHO stage III/IV, body mass index <18.5 kg/m², and having a gap in care independently predicted LTFU.

Conclusions

Older patients achieved better viral suppression, and older age was not associated with increased mortality or LTFU in this study.

Mortality among pulmonary tuberculosis and HIV-1 co-infected Nigerian children being treated for pulmonary tuberculosis and on antiretroviral therapy: a retrospective cohort study

BACKGROUND

Mortality data, including the risk factors for mortality in HIV-infected children with pulmonary TB (PTB) being treated for PTB and who are on antiretroviral therapy (ART), are scarce in Nigeria. We determined the mortality rate and risk factors for mortality among such children, at the pediatric HIV clinic of the Jos University Teaching Hospital (JUTH) in Jos, Nigeria.

METHODS

We performed a retrospective cohort study on 260 PTB-HIV-1 co-infected children, aged 2 months to 13 years, being treated for PTB and on ART from July 2005 to March 2013. The mortality rate and associated risk factors were determined using multivariate Cox proportional hazards modelling.

RESULTS

The mortality rate for the study cohort was 1.4 per 100 child-years of follow-up. Median follow-up time was 5.2 years (IQR, 3.5-6.0 years) with total study time being 1159 child-years. The median age of those who died was lower than that of survivors, 1.9 years (IQR, 0.6-3.6 years) versus 3.8 years (IQR, 1.8-6.0 years), p=0.005). The majority of the deaths occurred in males (13, 81.2%), those <5 years of age (14, 87.4%) and those who had severe immunosuppression (11, 68.8%). Risk factors for death were age (with the risk of dying decreasing by 25% for every 1 year increase in age, adjusted hazard ratio (AHR)=0.75 [0.58-0.98], p=0.032), male gender (AHR=3.80 [1.07-13.5], p=0.039) and severe immunosuppression (AHR=3.35 [1.16-9.66], p=0.025).

CONCLUSION

In our clinic setting, mortality among our PTB-HIV co-infected children being treated for PTB and on ART was low. However, those presenting with severe immunosuppression and who are males and very young, should be monitored more closely during follow-up in order to further reduce mortality.

Prevalence of and risk factors for pulmonary tuberculosis among newly diagnosed HIV-1 infected Nigerian children

INTRODUCTION

Studies on the prevalence of and risk factors for tuberculosis (TB) among newly diagnosed human immunodeficiency virus (HIV)-infected children in sub-Saharan Africa are scarce and in Nigeria there is paucity of reported data. We determined the prevalence of and risk factors for pulmonary TB (PTB) in newly diagnosed (treatment-naïve) HIV-1 infected children at the pediatric HIV clinic of the Jos University Teaching Hospital (JUTH) in Nigeria.

METHODS

We performed a retrospective analysis of 876 children, aged 2 months - 13 years, diagnosed with HIV-1 infection between July 2005 and December 2012, of which 286 were diagnosed with PTB at presentation after TB screening. The study site was the AIDS Prevention Initiative in Nigeria (APIN)-supported Pediatric HIV clinic at JUTH, Jos. A multivariate forward logistic regression modelling was used to identify risk factors for PTB-HIV co-infection.

RESULTS

The prevalence of PTB-HIV co-infection was 32% (286/876). Severe immunosuppression (SI) and World Health Organization (WHO) HIV clinical stage 3/4 were identified as independent risk factors for PTB-HIV co-infection in HIV infected children. The odds of PTB-HIV co-infection was increased two-fold in HIV-infected children with WHO clinical stage 3/4 compared to those with stage 1/2 (adjusted odds ratio (AOR) 1.76 [1.31-2.37], p<0.001) and 1.5-fold in children with SI compared to those without SI (AOR 1.52 [1.12-2.06], p=0.007).

CONCLUSION

In our setting, the burden of PTB was high among newly diagnosed HIV-infected children, and late WHO HIV clinical stage and severe immunosuppression were associated with PTB-HIV co-infection. Therefore there is a clear need to improve strategies for early diagnosis of both HIV and PTB to optimize clinical outcomes.

Treatment Discontinuation in Adult HIV-Infected Patients on First-Line Antiretroviral Therapy in Nigeria

BACKGROUND

Retention in care and treatment services is critical to health outcomes of individuals diagnosed and living with HIV. We evaluated the incidence of and risk factors for treatment discontinuation (TD) in a large adult HIV population on ART in Nigeria.

METHOD

A retrospective cohort study of adult HIV patients initiated on first-line ART between 2004 and 2011 at the Jos University Teaching Hospital (JUTH) in Nigeria. Follow up information of participants was retrieved from various sources (patient visit database, pharmacy data and patients charts) up to the end of 2012. The primary study endpoint was TD, defined as discontinuation of ART for any reason, including death or loss to follow-up (lack of pharmacy pick-up for periods≥12 months). The Incidence and hazard for TD were estimated by Kaplan-Meier and Cox proportional regression analysis, respectively.

RESULT

Overall, 3,362 (28%) patients discontinued treatment during 49,436 person-years (py) of follow-up (incidence rate (IR) 6.8 TD per 100 py). The hazard of treatment discontinuation decreased with increasing age (adjusted hazard ratio (aHR 0.99; 95% CI 0.98-0.99). Other independent risk factors for treatment discontinuation were: being unmarried (aHR 1.24; 95% CI: 1.12-1.38), having primary or secondary level of education as compared to tertiary level education (aHR 1.24; 95% CI: 1.12-1.40) and average percent adherence to drug refill visits<95% (adjusted hazard ratio (aHR) 2.13; 95% CI: 1.9-2.40). Compared to tenofovir, greater hazard of TD was noted in patients initiated on ART containing didanosine (aHR) 1.73; 95% CI: 1.03-2.91), but lower in those initiated on zidovudine containing regimen (aHR 0.77; 95% CI: 0.69-0.86).

CONCLUSION

Long-term treatment discontinuation rate in this study was comparable to estimates in resource-rich countries. Younger patients, as well as patients with lower educational levels and those with poor adherence had significant hazards for treatment discontinuation and should be the target of interventions to reduce treatment discontinuation and improve retention, especially within the first year of ART.

Mother-to-Child Transmission Outcomes of HIV-Exposed Infants Followed Up in Jos North-Central Nigeria

OBJECTIVE

Since 2010, Nigeria has adopted World Health Organization (WHO) 'Option B' which requires administration of triple antiretroviral prophylaxis or treatment (ART) to all HIVinfected pregnant women. We studied the transmission outcomes of HIV-exposed children up to 18 months of age.

DESIGN

This was a retrospective, observational study of HIV-infected pregnant women and their exposed infants who accessed prevention of mother to child transmission (PMTCT) services at Jos University Teaching Hospital, Jos, North-central Nigeria.

METHODS

HIV-infected women were enrolled during antenatal care or at labor/delivery between January 1, 2010 and December 31, 2012. Antiretroviral (ARV) prophylaxis/therapy was provided according to the 2010 Nigerian PMTCT guidelines (adapted WHO 2010 guidelines); Infant HIV diagnosis was performed at 6 weeks and at 6 months. HIV antibody diagnosis was used for exposed children at 18 months.

RESULTS

A total of 996 HIV-exposed children were followed up. Of those children, 140 (14.1%) were lost to follow up by 18 months of age. Twelve children (1.4%) died (all HIV negative) before 18 months of age and six infants (0.7%) were confirmed to be HIV-infected (4 by the age of 6 months and 2 thereafter) and were referred for treatment. A total of 838 (84.1%) children tested HIV negative at 18 months and were discharged. Mother-to-child transmission (MTCT) of HIV by 18 months was lower among women on ART before pregnancy compared to those women who started ART/Triple ARV prophylaxis during pregnancy/delivery. (0.4%; 3/700 vs 2.0%; 3/150 P=0.05). Home delivery was associated with higher transmission than facility delivery (p=0.03). Mode of delivery or method of infant feeding had no significant impact on vertical transmission by 18 months.

CONCLUSION

In North-central Nigeria where HIV is prevalent, ART started before pregnancy is enormously effective in preventing mother-to-child transmission. Adoption of WHO 'Option B+' deserves serious consideration in such settings.

Superior Effectiveness of Zidovudine Compared With Tenofovir When Combined With Nevirapine-based Antiretroviral Therapy in a Large Nigerian Cohort

BACKGROUND

Despite sparse efficacy data, tenofovir-emtricitabine or tenofovir-lamivudine plus nevirapine is used in many resource-constrained settings.

METHODS

This retrospective cohort study included patients initiating nevirapine-based antiretroviral therapy (ART) with either tenofovir-emtricitabine or lamivudine (tenofovir group) or zidovudine-lamivudine (zidovudine group). Clinical, virologic, and immunologic evaluations were performed at baseline and every 6 months. Virologic failure was defined as 2 consecutive human immunodeficiency virus (HIV)-RNA values >1000 copies/mL. Patients were included from ART initiation until time of failure, regimen switch, discontinuation, or last HIV-RNA measurement. Cox proportional hazards regression was used to model factors influencing time to failure. Bias due to dependent censoring was investigated via inverse probability weighted pooled logistic regression.

RESULTS

A total of 5547 patients were evaluated; 1484 (26.8%) were in the tenofovir group and 4063 (73.2%) were in the zidovudine group. In the adjusted model, tenofovir regimen (hazard ratio [HR], 1.47; 95% confidence interval [CI], 1.21-1.79) and higher baseline log10 HIV-RNA (HR, 1.15; 95% CI, 1.03-1.28) were associated with virologic failure. Higher baseline log10 CD4+ cell count (HR, 0.50; 95% CI, .40-.63) and increasing age (HR, 0.98; 95% CI, .97-.99) decreased the risk of virologic failure. Inverse probability weighting results were consistent with the primary analysis.

CONCLUSIONS

Compared with zidovudine-lamivudine, the use of tenofovir-lamivudine or emtricitabine in combination with nevirapine was a strong predictor of virologic failure in our cohort, which was not explained by other risk factors or criteria for regimen selection.

HIV Associated Chronic Obstructive Pulmonary Disease in Nigeria

OBJECTIVE

To determine the prevalence and risk factors for chronic obstructive pulmonary disease (COPD) among HIV-infected adults in Nigeria.

DESIGN

Cross-sectional study.

METHODS

HIV-infected adults aged ≥ 30 years with no acute ailments accessing care at the antiretroviral therapy clinic of Jos University Teaching Hospital were enrolled consecutively. Participants were interviewed to obtain pertinent demographic and clinical information, including exposure to risk factors for COPD. Post-bronchodilator spirometry was carried out. HIV related information was retrieved from the clinic medical records. COPD case-definition was based on the Global Initiative for Obstructive Lung Disease (GOLD) criteria using post-bronchodilator FEV₁/FVC <0.7. COPD prevalence was also calculated using the lower limit of normal for FEV₁/FVC criteria (LLN) from the European Respiratory Society normative equation. Factors associated with COPD were determined using logistic regression models.

RESULTS

Study population comprised 356 HIV infected adults with mean age of 44.5 (standard deviation, 7.1) years and 59% were female. The mean time elapsed since HIV diagnosis was 7.0 (SD, 2.6) years and 97.5% of the respondents were on stable ART with virologic suppression present in 67.2%. Prevalence of COPD were 15.4% (95% confidence interval [CI] 11.7-19.2), 12.07% (95% CI 8.67-15.48), 22.19% (95% CI 18.16-26.83) using GOLD, ERS LLN and GLI LLN diagnostic criteria respectively. In multivariate analyses adjusting for gender, exposure to cigarette smoke or biomass, history of pulmonary tuberculosis, use of antiretroviral therapy, current CD4 T-cell count and HIV RNA, only age > 50 years was independently associated with COPD with OR 3.4; 95% CI 1.42-8.17 when compared to ages 30-40 years.

CONCLUSION

HIV-associated COPD is common in our population of HIV patients.

Predictors of Mortality in a Clinic Cohort of HIV-1 Infected Children Initiated on Antiretroviral Therapy in Jos, Nigeria

Background:

Mortality among human immunodeficiency virus-1 (HIV-1) infected children initiated on antiretroviral therapy (ART) though on a decline still remains high in resource-limited countries (RLC). Identifying baseline factors that predict mortality could allow their possible modification in order to improve pediatric HIV care and reduce mortality.

Methods:

We conducted a retrospective cohort study analyzing data on 691 children, aged 2 months-15 years, diagnosed with HIV-1 infection and initiated on ART between July 2005 and March 2013 at the pediatric HIV clinic of Jos University Teaching Hospital. Lost to follow-up children were excluded from the analyses. A multivariate Cox proportional hazards model was fitted to identify predictors of mortality.

Results:

Median follow-up time for the 691 children initiated on ART was 4.4 years (interquartile range (IQR), 1.8-5.9) and at the end of 2752 person-years of follow-up, 32 (4.6%) had died and 659 (95.4%) survived. The mortality rate was 1.0 per 100 child-years of follow-up period. The median age of those who died was about two times lower than that of survivors [1.7 years (IQR, 0.6-3.6) versus 3.9 years (IQR, 3.9-10.3), p<0.001]. On unadjusted Cox regression, the risk of dying was about three and half times more in children <5 years of age compared to those >5 years (p=0.02) Multivariate modeling identified age as the main predictor of death with mortality decreasing by 24% for every 1 year increase in age (Adjusted Hazard Ratio (AHR)=0.76 [0.62-0.94], p=0.013.

Conclusion:

The lower mortality rate for our study suggests that even in RLC, mortality rates could be reduced given a good standard of care. Early initiation of ART in younger children with close monitoring during follow-up could further reduce mortality.

Pharmaceutical care outcomes in an outpatient human immunodeficiency virus treatment center in Jos, Nigeria

RATIONALE

Pharmacotherapy for patients infected with human immunodeficiency virus (HIV) is complex and increases the potential for drug therapy problems (DTPs). We described the frequency and type of DTPs in a Nigerian cohort of HIV infected patients on antiretroviral therapy (ART), as well as the changes in HIV clinical outcomes after pharmacists' intervention.

METHODS

A prospective 1-year descriptive study was conducted from July 2010 to June 2011, at the adult HIV clinic of Jos University Teaching Hospital, Nigeria. DTPs and the associated pharmacist-initiated interventions were documented. Chi-square and Wilcoxon signed ranks test was used as appropriate, to compare the main outcome measures of pre- and post-intervention levels of viral load and CD+ cell count.

RESULTS

A total of 64,839 prescriptions were dispensed to 9320 patients. Interventions were documented for 85 unique patients (incidence of 1.31 interventions/1000 prescriptions), of which 62 (73%) and 3 (3.5%) were on first- and second-line ART, respectively, while 20 (23.5%) were yet to commence ART. Reasons for pharmacist intervention included failure to initiate therapy for HIV or hepatitis B infection; therapeutic failure (25.9%); and drug toxicity (24.7%). After intervention, the percentage of patients with HIV ribonucleic acid level <400 copies/mL rose from 29.4% to 67.1% (P < 0.001), while median (interquartile range) CD4+ cell count increased from 200 (123-351) to 361 (221-470) cells/mm(3) (P < 0.001).

CONCLUSION

Pharmacist intervention resulted in clinically significant improvements in patients HIV virological and immunological outcomes. This highlights an important role for the pharmacist in the treatment and care of HIV-infected patients, in a multidisciplinary team.

Patients who present late to HIV care and associated risk factors in Nigeria

OBJECTIVES

Our objectives were to assess trends in late presentation and advanced HIV disease (AHD) and determine associated risk factors.

METHODS

We conducted a retrospective cohort analysis of patients who had received care and treatment at the AIDS Prevention Initiative Nigeria Plus (APIN)/Harvard School of Public Health-President's Emergency Plan for AIDS Relief (PEPFAR) programme at the Jos University Teaching Hospital, Jos, Nigeria from 2005 to 2010. We used the European Consensus Definition to assess trends in late presentation (CD4 count < 350 cells/μL or AIDS-defining illness) and AHD (CD4 count < 200 cells/μL or AIDS-defining illness) and evaluated associated risk factors using logistic regression methods.

RESULTS

Among 14,487 eligible patients, 12,401 (85.6%) were late presenters and 9127 (63.0%) presented with AHD. Late presentation decreased from 88.9% in 2005 to 80.1% in 2010 (P < 0.001). Similarly, AHD decreased from 67.8% in 2005 to 53.6% in 2010 (P < 0.001). In logistic regression models adjusting for sociodemographic and biological variables, male sex [adjusted odds ratio (aOR) = 1.80; 95% confidence interval (CI) 1.60-2.04], older age (aOR = 1.37; 95% CI 1.22-1.54), civil service employment (aOR = 1.48; 95% CI 1.00-2.21), referral from out-patient (aOR = 2.18; 95% CI 1.53-3.08) and in-patient (aOR = 1.55; 95% CI 1.11-2.17) services, and hepatitis B virus (aOR = 1.43; 95% CI 1.26-1.63) and hepatitis C virus (aOR = 1.18; 95% CI 1.02-1.37) coinfections were associated with late presentation. Predictors of AHD were male sex (aOR = 1.67; 95% CI 1.54-1.82), older age (aOR = 1.26; 95% CI 1.16-1.36), unemployment (aOR = 1.34; 95% CI 1.00-1.79), referral from out-patient (aOR = 2.40; 95% CI 1.84-3.14) and in-patient (aOR = 1.97; 95% CI 1.51-2.57) services and hepatitis B virus coinfection (aOR = 1.30; 95% CI 1.19-1.42).

CONCLUSIONS

Efforts to reduce the proportion of patients who first seek care at late stages of disease are needed. The identified risk factors should be utilized in formulating targeted public health interventions to improve early diagnosis and presentation for HIV care.

Prevalence of hepatitis B e antigen among human immunodeficiency virus and hepatitis B virus co-infected patients in Jos, Nigeria

INTRODUCTION

Human immunodeficiency virus (HIV) negatively impacts the natural history of hepatitis B virus (HBV) infection, including replication. We determined the prevalence of HBeAg in HIV/HBV co-infected patients compared to HBV mono-infected controls and further investigated the relationship between HBeAg seropositivity and the degree of HIV-induced immunosuppression in co-infected patients.

METHODOLOGY

The study design was cross-sectional. One hundred HBsAg-positive HIV-infected adults and 100 age and sex matched HBsAg-positive HIV negative controls were consecutively recruited between May and November 2010. Relevant demographic and HBV-related information was obtained. HBeAg was assayed by semi-quantitative third generation ELISA. The HIV/HBV co-infected patients also had CD4+ cell and HIV viral load quantification measured using flow cytometry and polymerase chain reaction techniques respectively.

RESULTS

In each group, the mean age was 34 ± 8 years and the majority (61%) was female. The prevalence of HBeAg was significantly higher among co-infected patients (n = 28; 28%) than in the controls (n = 15; 15%; p = 0.03). HBeAg seropositivity was independently associated with age < 40 years (AOR = 2.83, 95% = CI 1.29-6.17) and HIV seropositivity (AOR = 2.44, 95% C.I = 1.17-5.07). The prevalence of HBeAg was significantly higher in co-infected patients with CD4 cell count < 200 cell/µL (41.3%) compared to those with 200-499 cell/µL (18.6%) and ≥500 cell/µL (9.1%), p = 0.006.

CONCLUSION

HIV/HBV co-infected patients have a significantly higher prevalence of HBeAg than HBV mono-infected individuals. HBV-infected patients should be routinely assessed for HBeAg, especially if they are co-infected with HIV.

Association of HIV-Induced Immunosuppression and Clinical Malaria in Nigerian Adults

Despite the growing body of evidence on the interaction between HIV and malaria in sub-Saharan Africa, there is a dearth of data on clinical malaria in HIV-infected patients in Nigeria. We determined the burden of clinical malaria in HIV-infected adult Nigerians and further investigated the association between their immunological status and the rates of clinical malaria. Ninety seven antiretroviral treatment-naïve HIV-infected adults were enrolled in a cross-sectional study from August to December, 2009. The participants had a complete clinical evaluation, thick and thin blood films for malaria parasites and CD4 cell count quantification. Clinical malaria was defined as having fever (temperature ≥ 37.5°C or history of fever within 48 hours) and a malaria parasite density above the median value obtained for subjects with co-existing fever and parasitaemia. Clinical malaria was diagnosed in 10 out of 97 patients (10.3%). Lower CD4 cell counts were associated with increasing rates of clinical malaria which was 0% at CD4 cell count of ≥ 500, 2.6% at 200-499 and 30% at <200 cells/µL (χ(2) = 18.3, p = 0.0001). This association remained significant after controlling for other factors in a multivariate analysis (AOR=22.98, 95% C.I: 2.62-20.14, p = 0.005). An inverse relationship between CD4 cell count and parasite density was demonstrated (regression co-efficient = - 0.001, p = 0.0002). More aggressive malaria control measures are highly needed in severely immunosuppressed HIV-infected patients.

Liver function test abnormalities in Nigerian patients with human immunodeficiency virus and hepatitis B virus co-infection

Data on baseline hepatic function of HIV and hepatitis B virus (HBV) co-infected patients are limited in sub-Saharan Africa. We assessed liver function test (LFT) abnormalities in Nigerian patients with HIV/HBV co-infection to highlight the impact of HIV on HBV-related liver disease in sub-Saharan Africa. A cross-sectional study involving 100 HIV/HBV co-infected patients and 100 age- and sex-matched HBV mono-infected controls. Blood testing for HIV antibodies, CD4+ cell count, hepatitis B surface antigen (HBsAg), hepatitis B e antigen (HBeAg), LFTs, platelet count, fasting blood glucose and lipid profile were carried out. Non-invasive hepatic fibrosis scores (aspartate aminotransferase-platelet ratio index [APRI] and FIB-4) were also calculated. Co-infected patients had deranged liver enzymes more than the controls (77% versus 64%, P = 0.04). The predominant patterns of enzyme derangement in co-infected patients were either predominantly ↑ALP (30% versus 4%, P < 0.0001) or mixed (30% versus 15%, P = 0.01) but predominantly ↑AST/ALT in the controls (25% versus 9%, P = 0.003). Co-infected patients had higher fibrosis scores for both APRI (P = 0.002) and FIB-4 (P = 0.0001). On further analysis, LFT abnormalities and fibrosis scores were only significantly higher in co-infected patients in the immune clearance and HBeAg-negative chronic hepatitis phases. LFT abnormalities are common in Nigerians with HBV infection and co-infection with HIV negatively impacts on hepatic function.

Hepatitis B Co-Infection is Associated with Poorer Survival of HIV-Infected Patients on Highly Active Antiretroviral Therapy in West Africa

BACKGROUND

Hepatitis B has been reported to be high in HIV-infected African populations. However, the impact of this co-infection on the survival of HIV-infected Africans on long-term highly active antiretroviral therapy (HAART) remains poorly characterised. We investigated the impact of HBV/HIV co-infection on survival of HIV infected patients undergoing antiretroviral therapy in a West African population.

METHODS

This was a clinic-based cohort study of HIV-infected adults enrolled in Nigeria, West Africa. Study subjects (9,758) were screened for hepatitis B and hepatitis C at HAART initiation. Kaplan-Meier survival and Cox proportional hazards models were used to estimate probability of survival and to identify predictors of mortality respectively, based on hepatitis B surface antigen status. All patients had signed an informed written consent before enrolment into the study; and we additionally obtained permission for secondary use of data from the Harvard institutional review board.

RESULTS

Patients were followed up for a median of 41 months (interquartile range: 30-62 months) during which, 181 (1.9%) patients died. Most of the deaths; 143 (79.0%) occurred prior to availability of Tenofovir. Among those that were on antiretroviral therapy, hepatitis B co-infected patients experienced a significantly lower survival than HIV mono-infected patients at 74 months of follow up (94% vs. 97%; p=0.0097). Generally, hepatitis B co-infection: HBsAg-positive/HIV-positive (Hazards Rate [HR]; 1.5: 95% CI 1.09-2.11), co-morbid tuberculosis (HR; 2.2: 95% CI 1.57-2.96) and male gender (HR; 1.5: 95% CI 1.08-2.00) were significantly predictive of mortality. Categorising the patients based on use of Tenofovir, HBV infection failed to become a predictor of mortality among those on Tenofovir-containing HAART.

CONCLUSIONS

HBsAg-positive status was associated with reduced survival and was an independent predictor of mortality in this African HIV cohort on HAART. However, Tenofovir annulled the impact of HBV on mortality of HIV patients in the present study cohort.

Predictors of impaired renal function among HIV infected patients commencing highly active antiretroviral therapy in Jos, Nigeria

Background:

Kidney disease is a common complication of human immunodeficiency virus (HIV) infection even in the era of antiretroviral therapy, with kidney function being abnormal in up to 30% of HIV-infected patients. We determined the predictors of impaired renal function in HIV-infected adults initiating highly active antiretroviral therapy (HAART) in Nigeria.

Materials and Methods:

This was a retrospective study among HIV-1 infected patients attending the antiretroviral clinic at the Jos University Teaching Hospital (JUTH), between November 2005 and November 2007. Data were analysed for age, gender, weight, WHO clinical stage, CD4 count, HIV-1 RNA viral load, HBsAg and anti-HCV antibody status. Estimated glomerular filtration rate (eGFR) was calculated using the Cockcroft-Gault equation. Statistical analysis was done using Epi Info 3.5.1.

Results:

Data for 491 (294 females and 197 males) eligible patients were abstracted. The mean age of this population was 38.8±8.87 years. One hundred and seventeen patients (23.8%; 95% CI, 20.2-27.9%) had a reduced eGFR (defined as <60 mL/min), with more females than males (28.6% vs. 16.8%; P=0.02) having reduced eGFR. Age and female sex were found to have significant associations with reduced eGFR. Adjusted odds ratios were 1.07 (95% CI, 1.04, 1.10) and 1.96 (95% CI, 1.23, 3.12) for age and female sex, respectively.

Conclusions:

Older age and female sex are independently associated with a higher likelihood of having lower eGFRs at initiation of HAART among our study population. We recommend assessment of renal function of HIV-infected patients prior to initiation of HAART to guide the choice and dosing of antiretroviral drugs.

Clinical characteristics and predictors of mortality in hospitalized HIV-infected Nigerians

INTRODUCTION

Human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) is a chief cause of death in sub-Saharan Africa. In this study, the clinical characteristics and predictors of mortality among hospitalized HIV infected adult Nigerians are reported.

METHODOLOGY

The records of 354 patients were reviewed for demographic and clinical characteristics. Predictors of mortality using logistic regression in a retrospective study were also reviewed.

RESULTS

A total of 109 (30.8%) males and 245 (69.2%) females participated in the study. The mean age of all participants was 35 ± 8 years. Median baseline CD4 cell counts and viral load were 91 cells/mm³ and 63,438 copies/ml respectively. There was a total of 123 (34.8%) deaths while 231 (65.2%) patients were discharged home. Tuberculosis (TB) was the most common diagnosis on admission as well as the leading cause of death. Among all subjects, only male gender (adjusted odds ratio [AOR] 4.67, 95% confidence interval [CI]: 2.63-8.29); CD4 cell count ≤ 200 cells/mm³ (AOR 5.28, 95% CI: 2.99-9.31); length of hospital stay < 3 days (AOR 4.77, 95% CI: 1.35-16.86); and age ≥ 35 years (AOR 2.43, 95% CI: 1.41-4.19) were predictive of death.

CONCLUSION

These findings illustrate the need for early diagnosis of HIV infection, appropriate treatment and prevention of opportunistic infections, and improved access to highly active antiretroviral therapy (HAART).

Temporal changes in renal glomerular function associated with the use of Tenofovir Disoproxil Fumarate in HIV-infected Nigerians

BACKGROUND

Reports of renal dysfunction in Tenofovir Disoproxil Fumarate (TDF)-treated HIV-1 infected patients have raised concerns about potential nephrotoxicity.

OBJECTIVE

To compare the effects on renal function of TDF-containing highly active anti-retroviral therapy (HAART) with a non-TDF-containing HAART.

METHODS

This was an observational study.Clinical and laboratory data of 186 HIV-1 infected adult Nigerians on first-line HAART for at least 48 weeks were reviewed. Eighty-four patients whose nucleos(t)ide reverse transcriptase inhibitor (NRTI) backbone included TDF were compared to 102 patients on other NRTI backbones. Creatinine clearance (CLcr) was estimated using the Cockcroft-Gault equation. Changes in serum creatinine and CLcr from the baseline for each patient were compared between the TDF-treated and the TDF-free patients. We also assessed the associations of other variables with change in CLcr...

RESULTS

Baseline median serum creatinine (mmol/L) was 77 and 84 in the TDF-treated and TDF-free groups, respectively (p=0.59). Baseline median CLcr (mls/min) was 83 in the TDF-treated patients vs 78 in the TDF-free group. At 48 weeks, serum creatinine increased by 18.1% and 1.2% in the TDF-treated and TDF-free arms, respectively. There was a decrease of 4.8% in GFR in the TDF arm compared to a gain 5.1% in the TDF-free arm.

CONCLUSION

Tenofovir Disoproxil Fumarate-containing HAART is associated with a slight decline in the medium term in CLcr compared with HAART regimens containing alternative Nucleosid(t) Reverse Transcriptase Inhibitors.

Presentation and survival of patients with AIDS-related Kaposi's sarcoma in Jos, Nigeria

AIDS-related Kaposi's sarcoma (AIDS-KS) remains a significant cause of morbidity and mortality. We describe the pattern of presentation and survival in Jos, Nigeria. We identified 48 HIV-positive patients with AIDS-KS and matched them for age and sex with an equal number of HIV-positive patients without AIDS-KS. We compared their clinical, immunological, virological characteristics and survival. They were similar in age and body mass index profile but patients with AIDS-KS had more tuberculosis co-infection (P, 0.02), lower median CD4 count (P, 0.003) and higher mortality (P, 0.002). Surprisingly, patients with AIDS-KS had lower levels of median viral load (29,347 copies/mL) compared with controls (80,533 copies/mL). We recommend specific AIDS-KS therapy in addition to highly active antiretroviral therapy in order to improve survival.

Arteriovenous fistula for patients on long term haemodialysis in jos, Nigeria

BACKGROUND

The introduction of haemodialysis has prolonged the lives of patients with end-stage-renal disease (ESRD). To maintain them on long-term dialysis, vascular access procedures are required.

OBJECTIVES

To describe the experience with arteriovenous fistula (AVF) from a developing country.

METHODS

Eighty-two AVF were created in 74 patients on maintenance haemodialysis. They all had side-to-end AVF using prolene 7/0 monofilament suture for anastomoses.

RESULTS

There were 55 males and 19 females with a male: female ratio of 2.9:1. The ages ranged from 18 to 70 years with a mean of 43.4 "12.1 years. Most of the AVF created were on the left upper limbs with the radio-cephalic and brachio-cephalic accounting for more than 70% . Eight patients developed thrombosis of the veins used for the AVF and one developed a pseudo aneurysm.

CONCLUSIONS

Arteriovenous fistula makes long-term haemodialysis feasible. It can be created easily and has a low rate of complications.