Prevalence of chronic conditions and multimorbidity among healthcare workers in Zimbabwe: Results from a screening intervention

The burden of non-communicable diseases (NCDs) in southern Africa is expanding and is superimposed on high HIV prevalence. Healthcare workers are a scarce resource; yet are vital to health systems. There are very limited studies on the burden of chronic conditions among healthcare workers in Africa, and none exploring multimorbidity (≥2 chronic conditions). We describe the epidemiology of infectious (HIV) and non-communicable chronic conditions, and multimorbidity, among Zimbabwean healthcare workers. Healthcare workers (≥18 years) in eight Zimbabwean provinces were invited to a voluntary, cross-sectional health-check, including HIV, diabetes, hypertension and mental health screening. Statistical analyses described the prevalence and risk factors for multimorbidity (two or more of HIV, diabetes, hypertension or common mental disorder) and each condition. Missing data were handled using multiple imputation. Among 6598 healthcare workers (July 2020-July 2022) participating in the health-check, median age was 37 years (interquartile range 29-44), 79% were women and 10% knew they were living with HIV. Half had at least one chronic condition: 11% were living with HIV, 36% had elevated blood pressure, 12% had elevated HbA1c and 11% had symptoms of common mental disorder. The overall prevalence of multimorbidity was 15% (95% CI: 13-17%); 39% (95% CI: 36-43%) among people aged 50 and older. Whilst most HIV was diagnosed and treated, other chronic conditions were usually undiagnosed or uncontrolled. Limiting our definition of multimorbidity to two or more screened conditions sought to reduce bias due to access to diagnosis, however, may have led to a lower reported prevalence than that found using a wider definition. Half of healthcare workers screened were living with a chronic condition; one in seven had multimorbidity. Other than HIV, most conditions were undiagnosed or untreated. Multisectoral action to implement contextually relevant, chronic disease services in Africa is urgently needed. Specific attention on health workers is required to protect and retain this critical workforce.

Evaluation of a comprehensive health check offered to frontline health workers in Zimbabwe

Health workers are essential for a functioning healthcare system, and their own health is often not addressed. During the COVID-19 pandemic health workers were at high risk of SARS-CoV-2 infection whilst coping with increased healthcare demand. Here we report the development, implementation, and uptake of an integrated health check combining SARS-CoV-2 testing with screening for other communicable and non-communicable diseases for health workers in Zimbabwe during the COVID-19 pandemic. Health checks were offered to health workers in public and private health facilities from July 2020 to June 2022. Data on the number of health workers accessing the service and yield of screening was collected. Workshops and in-depth interviews were conducted to explore the perceptions and experiences of clients and service providers. 6598 health workers across 48 health facilities accessed the service. Among those reached, 5215 (79%) were women, the median age was 37 (IQR: 29-44) years and the largest proportion were nurses (n = 2092, 32%). 149 (2.3%) healthcare workers tested positive for SARS-CoV-2. Uptake of screening services was almost 100% for all screened conditions except HIV. The most common conditions detected through screening were elevated blood pressure (n = 1249; 19%), elevated HbA1c (n = 428; 7.7%) and common mental disorder (n = 645; 9.8%). Process evaluation showed high acceptability of the service. Key enablers for health workers accessing the service included free and comprehensive service provision, and availability of reliable point-of-care screening methods. Implementation of a comprehensive health check for health workers was feasible, acceptable, and effective, even during a pandemic. Conventional occupational health programmes focus on infectious diseases. In a society where even health workers cannot afford health care, free comprehensive occupational health services may address unmet needs in prevention, diagnosis, and treatment for chronic non-communicable conditions.

Exploring COVID-19 vaccine uptake among healthcare workers in Zimbabwe: A mixed methods study

With COVID-19 no longer categorized as a public health emergency of international concern, vaccination strategies and priority groups for vaccination have evolved. Africa Centres for Diseases Prevention and Control proposed the '100-100-70%' strategy which aims to vaccinate all healthcare workers, all vulnerable groups, and 70% of the general population. Understanding whether healthcare workers were reached during previous vaccination campaigns and what can be done to address concerns, anxieties, and other influences on vaccine uptake, will be important to optimally plan how to achieve these ambitious targets. In this mixed-methods study, between June 2021 and July 2022 a quantitative survey was conducted with healthcare workers accessing a comprehensive health check in Zimbabwe to determine whether and, if so, when they had received a COVID-19 vaccine. Healthcare workers were categorized as those who had received the vaccine 'early' (before 30.06.2021) and those who had received it 'late' (after 30.06.2021). In addition, 17 in-depth interviews were conducted to understand perceptions and beliefs about COVID-19 vaccines. Of the 3,086 healthcare workers employed at 43 facilities who participated in the study, 2,986 (97%, 95% CI [92%-100%]) reported that they had received at least one vaccine dose. Geographical location, older age, higher educational attainment and having a chronic condition was associated with receiving the vaccine early. Qualitatively, (mis)information, infection risk perception, quasi-mandatory vaccination requirements, and legitimate concerns such as safety and efficacy influenced vaccine uptake. Meeting the proposed 100-100-70 target entails continued emphasis on strong communication while engaging meaningfully with healthcare workers' concerns. Mandatory vaccination may undermine trust and should not be a substitute for sustained engagement.

Exploring COVID-19 vaccine uptake among healthcare workers in Zimbabwe: A mixed methods study

With COVID-19 no longer categorized as a public health emergency of international concern, vaccination strategies and priority groups for vaccination have evolved. Africa Centers for Diseases Prevention and Control proposed the '100-100-70%' strategy which aims to vaccinate all healthcare workers, all vulnerable groups, and 70% of the general population. Understanding whether healthcare workers were reached during previous vaccination campaigns and what can be done to address concerns, anxieties, and other influences on vaccine uptake, will be important to optimally plan how to achieve these ambitious targets. In this mixed-methods study, between June 2021 and July 2022 a quantitative survey was conducted with healthcare workers accessing a comprehensive health check in Zimbabwe to determine whether and, if so, when they had received a COVID-19 vaccine. Healthcare workers were categorized as those who had received the vaccine 'early' (before 30.06.2021) and those who had received it 'late' (after 30.06.2021). In addition, 17 in-depth interviews were conducted to understand perceptions and beliefs about COVID-19 vaccines. Of the 2905 healthcare workers employed at 37 facilities who participated in the study, 2818 (97%, 95% CI [92%-102%]) reported that they had received at least one vaccine dose. Geographical location, older age, higher educational attainment and having a chronic condition was associated with receiving the vaccine early. Qualitatively, (mis)information, infection risk perception, quasi-mandatory vaccination requirements, and legitimate concerns such as safety and efficacy influenced vaccine uptake. Meeting the proposed 100-100-70 target entails continued emphasis on strong communication while engaging meaningfully with healthcare workers' concerns. Mandatory vaccination may undermine trust and should not be a substitute for sustained engagement.

Cost-effectiveness of single, high-dose, liposomal amphotericin regimen for HIV-associated cryptococcal meningitis in five countries in sub-Saharan Africa: an economic analysis of the AMBITION-cm trial

BACKGROUND

HIV-associated cryptococcal meningitis is a leading cause of AIDS-related mortality. The AMBITION-cm trial showed that a regimen based on a single high dose of liposomal amphotericin B deoxycholate (AmBisome group) was non-inferior to the WHO-recommended treatment of seven daily doses of amphotericin B deoxycholate (control group) and was associated with fewer adverse events. We present a five-country cost-effectiveness analysis.

METHODS

The AMBITION-cm trial enrolled patients with HIV-associated cryptococcal meningitis from eight hospitals in Botswana, Malawi, South Africa, Uganda, and Zimbabwe. Taking a health service perspective, we collected country-specific unit costs and individual resource-use data per participant over the 10-week trial period, calculating mean cost per participant by group, mean cost-difference between groups, and incremental cost-effectiveness ratio per life-year saved. Non-parametric bootstrapping and scenarios analyses were performed including hypothetical real-world resource use. The trial registration number is ISRCTN72509687, and the trial has been completed.

FINDINGS

The AMBITION-cm trial enrolled 844 participants, and 814 were included in the intention-to-treat analysis (327 from Uganda, 225 from Malawi, 107 from South Africa, 84 from Botswana, and 71 from Zimbabwe) with 407 in each group, between Jan 31, 2018, and Feb 17, 2021. Using Malawi as a representative example, mean total costs per participant were US$1369 (95% CI 1314-1424) in the AmBisome group and $1237 (1181-1293) in the control group. The incremental cost-effectiveness ratio was $128 (59-257) per life-year saved. Excluding study protocol-driven cost, using a real-world toxicity monitoring schedule, the cost per life-year saved reduced to $80 (15-275). Changes in the duration of the hospital stay and antifungal medication cost showed the greatest effect in sensitivity analyses. Results were similar across countries, with the cost per life-year saved in the real-world scenario ranging from $71 in Botswana to $121 in Uganda.

INTERPRETATION

The AmBisome regimen was cost-effective at a low incremental cost-effectiveness ratio. The regimen might be even less costly and potentially cost-saving in real-world implementation given the lower drug-related toxicity and the potential for shorter hospital stays.

FUNDING

European Developing Countries Clinical Trials Partnership, Swedish International Development Cooperation Agency, Wellcome Trust and Medical Research Council, UKAID Joint Global Health Trials, and the National Institute for Health Research.

TRANSLATIONS

For the Chichewa, Isixhosa, Luganda, Setswana and Shona translations of the abstract see Supplementary Materials section.

Psychological distress among healthcare workers accessing occupational health services during the COVID-19 pandemic in Zimbabwe

BACKGROUND

Healthcare workers (HCWs) have experienced anxiety and psychological distress during the COVID-19 pandemic. We established and report findings from an occupational health programme for HCWs in Zimbabwe that offered screening for SARS-CoV-2 with integrated screening for comorbidities including common mental disorder (CMD) and referral for counselling.

METHODS

Quantitative outcomes were fearfulness about COVID-19, the Shona Symptom Questionnaire (SSQ-14) score (cutpoint 8/14) and the number and proportion of HCWs offered referral for counselling, accepting referral and counselled. We used chi square tests to identify factors associated with fearfulness, and logistic regression was used to model the association of fearfulness with wave, adjusting for variables identified using a DAG. Qualitative data included 18 in-depth interviews, two workshops conducted with HCWs and written feedback from counsellors, analysed concurrently with data collection using thematic analysis.

RESULTS

Between 27 July 2020-31 July 2021, spanning three SARS-CoV-2 waves, the occupational health programme was accessed by 3577 HCWs from 22 facilities. The median age was 37 (IQR 30-43) years, 81.9% were women, 41.7% said they felt fearful about COVID-19 and 12.1% had an SSQ-14 score ≥ 8. A total of 501 HCWs were offered referral for counselling, 78.4% accepted and 68.9% had ≥1 counselling session. Adjusting for setting and role, wave 2 was associated with increased fearfulness over wave 1 (OR = 1.26, 95% CI 1.00-1.60). Qualitative data showed high levels of anxiety, psychosomatic symptoms and burnout related to the pandemic. Mental wellbeing was affected by financial insecurity, unmet physical health needs and inability to provide quality care within a fragile health system.

CONCLUSIONS

HCWs in Zimbabwe experience a high burden of mental health symptoms, intensified by the COVID-19 pandemic. Sustainable mental health interventions must be multisectoral addressing mental, physical and financial wellbeing.

Single-Dose Liposomal Amphotericin B Treatment for Cryptococcal Meningitis

BACKGROUND

Cryptococcal meningitis is a leading cause of human immunodeficiency virus (HIV)-related death in sub-Saharan Africa. Whether a treatment regimen that includes a single high dose of liposomal amphotericin B would be efficacious is not known.

METHODS

In this phase 3 randomized, controlled, noninferiority trial conducted in five African countries, we assigned HIV-positive adults with cryptococcal meningitis in a 1:1 ratio to receive either a single high dose of liposomal amphotericin B (10 mg per kilogram of body weight) on day 1 plus 14 days of flucytosine (100 mg per kilogram per day) and fluconazole (1200 mg per day) or the current World Health Organization-recommended treatment, which includes amphotericin B deoxycholate (1 mg per kilogram per day) plus flucytosine (100 mg per kilogram per day) for 7 days, followed by fluconazole (1200 mg per day) for 7 days (control). The primary end point was death from any cause at 10 weeks; the trial was powered to show noninferiority at a 10-percentage-point margin.

RESULTS

A total of 844 participants underwent randomization; 814 were included in the intention-to-treat population. At 10 weeks, deaths were reported in 101 participants (24.8%; 95% confidence interval [CI], 20.7 to 29.3) in the liposomal amphotericin B group and 117 (28.7%; 95% CI, 24.4 to 33.4) in the control group (difference, -3.9 percentage points); the upper boundary of the one-sided 95% confidence interval was 1.2 percentage points (within the noninferiority margin; P<0.001 for noninferiority). Fungal clearance from cerebrospinal fluid was -0.40 log10 colony-forming units (CFU) per milliliter per day in the liposomal amphotericin B group and -0.42 log10 CFU per milliliter per day in the control group. Fewer participants had grade 3 or 4 adverse events in the liposomal amphotericin B group than in the control group (50.0% vs. 62.3%).

CONCLUSIONS

Single-dose liposomal amphotericin B combined with flucytosine and fluconazole was noninferior to the WHO-recommended treatment for HIV-associated cryptococcal meningitis and was associated with fewer adverse events. (Funded by the European and Developing Countries Clinical Trials Partnership and others; Ambition ISRCTN number, ISRCTN72509687.).

Community SARS-CoV-2 seroprevalence before and after the second wave of SARS-CoV-2 infection in Harare, Zimbabwe

BACKGROUND

By the end of July 2021 Zimbabwe, has reported over 100,000 SARS-CoV-2 infections. The true number of SARS-CoV-2 infections is likely to be much higher. We conducted a seroprevalence survey to estimate the prevalence of past SARS-CoV-2 in three high-density communities in Harare, Zimbabwe before and after the second wave of SARS-CoV-2.

METHODS

Between November 2020 and April 2021 we conducted a cross-sectional study of randomly selected households in three high-density communities (Budiriro, Highfield and Mbare) in Harare. Consenting participants answered a questionnaire and a dried blood spot sample was taken. Samples were tested for anti-SARS-CoV-2 nucleocapsid antibodies using the Roche e801 platform.

FINDINGS

A total of 2340 individuals participated in the study. SARS-CoV-2 antibody results were available for 70·1% (620/885) and 73·1% (1530/2093) of eligible participants in 2020 and 2021. The median age was 22 (IQR 10-37) years and 978 (45·5%) were men. SARS-CoV-2 seroprevalence was 19·0% (95% CI 15·1-23·5%) in 2020 and 53·0% (95% CI 49·6-56·4) in 2021. The prevalence ratio was 2·47 (95% CI 1·94-3·15) comparing 2020 with 2021 after adjusting for age, sex, and community. Almost half of all participants who tested positive reported no symptoms in the preceding six months.

INTERPRETATION

Following the second wave, one in two people had been infected with SARS-CoV-2 suggesting high levels of community transmission. Our results suggest that 184,800 (172,900-196,700) SARS-CoV-2 infections occurred in these three communities alone, greatly exceeding the reported number of cases for the whole city. Further seroprevalence surveys are needed to understand transmission during the current third wave despite high prevalence of past infections.

FUNDING

GCRF, Government of Canada, Wellcome Trust, Bavarian State Ministry of Sciences, Research, and the Arts.

The transient effect of a peer support intervention to improve adherence among adolescents and young adults failing antiretroviral therapy in Harare, Zimbabwe: a randomized control trial

Background

Adolescents and young adults living with HIV in sub Saharan Africa are at high risk of poor adherence to antiretroviral therapy (ART) and virologic failure (VF).

Methods

We conducted a randomized control trial among adolescents and young adults on ART with VF to assess the effectiveness of a community-based peer support intervention aimed at improving VF. Viral load (VL) levels were obtained at 12, 24 and 36 weeks. A subset of the participants had baseline HIV drug resistance (HIVDR) genotyped using Sanger sequencing.

Results

The participants’ median (interquartile range (IQR)) age was 18.1 (IQR: 15.1–20.0) years and half (50.5%, n = 107) were male. At week 24, the proportion of subjects with a detectable viremia was significantly lower in the intervention arm than in the standard of care (SOC) arm (76.0% (n = 79) vs. 89.0% (n = 96), p = 0.013). At Week 36, there remained a difference in the proportion of subjects with a detectable VL between the intervention arm (68.3%, n = 71) and SOC arm (79.6%, n = 86), which was trending towards statistical significance (p = 0.059). There was no difference in the probability of having a detectable VL over time between the intervention and SOC groups (adjusted odds ratio: 1.14, p = 0.439). Baseline HIVDR was observed in 44.0% of the participants in the intervention and 56.0% in the SOC group (p = 0.146).

Conclusion

A transient effect of the peer support intervention in improving VF was observed among adolescents and young people failing ART.

Trial registration: This study is registered with www.clinicaltrials.gov under the reference number: NCT02833441

Supplementary Information

The online version contains supplementary material available at 10.1186/s12981-021-00356-w.

Tenofovir-associated kidney disease in Africans: a systematic review

BACKGROUND

Data on chronic kidney disease development in HIV infection is important towards building a comprehensive knowledge of HIV, ageing and polypharmacy in Africa. Several previous studies on tenofovir-associated kidney disease in Africa have shown conflicting results. This review summarises what is known about the development of kidney disease in HIV-positive African patients on tenofovir disoproxil fumarate (TDF)-containing ART. We set out to document the occurrence of kidney disease in HIV-positive Africans on TDF-containing ART in population-based studies and to evaluate the renal safety of TDF in Africans.

METHODS

We conducted a systemic review using published studies which were identified through a computerized search of original research using the Medline/PubMed database, EMBASE, EBM Reviews, Proquest Google Scholar and Global Health reported from inception until 5 October 2017. Two reviewers independently abstracted the data and performed quality assessment of the included studies. We screened 595 articles and included 31 in the qualitative analysis performed.

RESULTS

A total of 106 406 patients (of whom 66,681 were on Tenofovir) were involved in these 31 studies with sample sizes ranging from 30 to 62,230. Duration on tenofovir-containing ART ranged from those initiating ART at baseline to those who received TDF for up to 9 years. All but one of the studies involved only patients 16 years and older. The studies had differing definitions of kidney dysfunction and were of variable study design quality. The documented outcomes had substantial discrepancies across the studies, most likely due to methodological differences, study size and disparate outcome definitions.

CONCLUSIONS

Our review identified studies in Africans reporting statistically significant renal function decline associated with TDF use but the clinical significance of this effect was not enough to contraindicate its continued use in ART regimens. Consistent with studies in other populations, patients are at greater risk if they have pre-existing renal disease and are more advanced in age. More research is needed on paediatric populations under 16 years of age. Trial registration This review was registered on Prospero (registration number CRD42018078717).

AMBIsome Therapy Induction OptimisatioN (AMBITION): High dose AmBisome for cryptococcal meningitis induction therapy in sub-Saharan Africa: economic evaluation protocol for a randomised controlled trial-based equivalence study

INTRODUCTION

Cryptococcal meningitis is responsible for around 15% of all HIV-related deaths globally. Conventional treatment courses with amphotericin B require prolonged hospitalisation and are associated with multiple toxicities and poor outcomes. A phase II study has shown that a single high dose of liposomal amphotericin may be comparable to standard treatment. We propose a phase III clinical endpoint trial comparing single, high-dose liposomal amphotericin with the WHO recommended first-line treatment at six sites across five counties. An economic analysis is essential to support wide-scale implementation.

METHODS AND ANALYSIS

Country-specific economic evaluation tools will be developed across the five country settings. Details of patient and household out-of-pocket expenses and any catastrophic healthcare expenditure incurred will be collected via interviews from trial patients. Health service patient costs and related household expenditure in both arms will be compared over the trial period in a probabilistic approach, using Monte Carlo bootstrapping methods. Costing information and number of life-years survived will be used as the input to a decision-analytic model to assess the cost-effectiveness of a single, high-dose liposomal amphotericin to the standard treatment. In addition, these results will be compared with a historical cohort from another clinical trial.

ETHICS AND DISSEMINATION

The AMBIsome Therapy Induction OptimisatioN (AMBITION) trial has been evaluated and approved by the London School of Hygiene and Tropical Medicine, University of Botswana, Malawi National Health Sciences, University of Cape Town, Mulago Hospital and Zimbabwe Medical Research Council research ethics committees. All participants will provide written informed consent or if lacking capacity will have consent provided by a proxy. The findings of this economic analysis, part of the AMBITION trial, will be disseminated through peer-reviewed publications and at international and country-level policy meetings.

TRIAL REGISTRATION

ISRCTN 7250 9687; Pre-results.

Antibody Responses in HIV-Infected Patients With Advanced Immunosuppression and Asymptomatic Cryptococcal Antigenemia

Background

There are no host biomarkers of risk for HIV-associated cryptococcal meningitis (CM) except CD4+ T-cell deficiency. At present, serum cryptococcal antigen (CrAg) screening of those with CD4 <100 cells/µL is used to identify persons at risk for HIV-associated CM. We determined if plasma antibody profiles could discriminate CrAg+ from CrAg- patients.

Methods

We performed serological analyses of 237 HIV-infected asymptomatic Zimbabwean patients with CD4 <100 cells/µL; 125 CrAg- and CrAg+ but cerebrospinal fluid CrAg- by CrAg lateral flow assay. We measured plasma immunoglobulin M (IgM), immunoglobulin G (IgG) 1, and IgG2 concentrations by Luminex, and titers of Cryptococcus neoformans (Cn) glucuronoxylomannan (GXM) polysaccharide and naturally occurring Laminarin (natural Lam, a β-(1–3)-glucan linked polysaccharide)-binding IgM and IgG by enzyme-linked immunosorbent assay.

Results

GXM-IgG, -IgM, and -IgG2 levels were significantly higher in CrAg+ patients, whereas natural Lam-IgM and Lam-IgG were higher in CrAg- patients before and after adjustment for age, sex, and CD4 T-cell count, despite overlap of values. To address this variability and better discriminate the groups, we used Akaike Information Criteria to select variables that independently predicted CrAg+ status and included them in a receiver operating characteristic curve to predict CrAg status. By inclusion of CD4, GXM-IgG, GXM-IgM, and Lam-IgG, -IgG2, and -IgM, this model had an 80.4% probability (95% confidence interval, 0.75–0.86) of predicting CrAg+ status.

Conclusions

Statistical models that include multiple serological variables may improve the identification of patients at risk for CM and inform new directions in research on the complex role that antibodies may play in resistance and susceptibility to CM.

AMBIsome Therapy Induction OptimisatioN (AMBITION): High Dose AmBisome for Cryptococcal Meningitis Induction Therapy in sub-Saharan Africa: Study Protocol for a Phase 3 Randomised Controlled Non-Inferiority Trial

BACKGROUND

Cryptococcal meningitis (CM) is a major cause of mortality in HIV programmes in Africa despite increasing access to antiretroviral therapy (ART). Mortality is driven in part by limited availability of amphotericin-based treatment, drug-induced toxicities of amphotericin B deoxycholate and prolonged hospital admissions. A single, high-dose of liposomal amphotericin (L-AmB, Ambisome) on a fluconazole backbone has been reported as non-inferior to 14 days of standard dose L-AmB in reducing fungal burden. This trial examines whether single, high-dose L-AmB given with high-dose fluconazole and flucytosine is non-inferior to a seven-day course of amphotericin B deoxycholate plus flucytosine (the current World Health Organization [WHO] recommended treatment regimen).

METHODS

An open-label phase III randomised controlled non-inferiority trial conducted in five countries in sub-Saharan Africa: Botswana, Malawi, South Africa, Uganda and Zimbabwe. The trial will compare CM induction therapy with (1) a single dose (10 mg/kg) of L-AmB given with 14 days of fluconazole (1200 mg/day) and flucytosine (100 mg/kg/day) to (2) seven days amphotericin B deoxycholate (1 mg/kg/day) given alongside seven days of flucytosine (100 mg/kg/day) followed by seven days of fluconazole (1200 mg/day). The primary endpoint is all-cause mortality at ten weeks with a non-inferiority margin of 10% and 90% power. Secondary endpoints are early fungicidal activity, proportion of grade III/IV adverse events, pharmacokinetic parameters and pharmacokinetic/pharmacodynamic associations, health service costs, all-cause mortality within the first two and four weeks, all-cause mortality within the first ten weeks (superiority analysis) and rates of CM relapse, immune reconstitution inflammatory syndrome and disability at ten weeks. A total of 850 patients aged ≥ 18 years with a first episode of HIV-associated CM will be enrolled (425 randomised to each arm). All patients will be followed for 16 weeks. All patients will receive consolidation therapy with fluconazole 800 mg/day to complete ten weeks of treatment, followed by fluconazole maintenance and ART as per local guidance.

DISCUSSION

A safe, sustainable and easy to administer regimen of L-AmB that is non-inferior to seven days of daily amphotericin B deoxycholate therapy may reduce the number of adverse events seen in patients treated with amphotericin B deoxycholate and shorten hospital admissions, providing a highly favourable and implementable alternative to the current WHO recommended first-line treatment.

TRIAL REGISTRATION

ISRCTN, ISRCTN72509687 . Registered on 13 July 2017.

Medical Education Partnership Initiative (MEPI) in Zimbabwe: Outcomes and Challenges

The 5-year medical education and research strengthening initiative in Zimbabwe increased faculty retention and student enrollment, improved information technology infrastructure, provided mentoring for postgraduates and clinical training in specialty areas, instituted a competency-based curriculum reform process, and created new departments and centers to institutionalize health education and research implementation. A comprehensive review of the curriculum is still underway and uptake of technology-assisted teaching has been slower than expected.

Background:

Sub-Saharan Africa has an inadequate number of health professionals, leading to a reduced capacity to respond to health challenges, including HIV/AIDS. From 2010 to 2015, the Medical Education Partnership Initiative (MEPI)—sponsored by the U.S. Presidents Emergency Plan for AIDS Relief (PEPFAR) and the National Institutes of Health (NIH)—was enthusiastically taken up by the University of Zimbabwe College of Health Sciences (UZCHS) and 12 other sub-Saharan African universities to develop models of training to improve medical education and research capacity. In this article, we describe the outcomes and challenges of MEPI in Zimbabwe.

Methods:

UZCHS in partnership with the University of Colorado, Denver; Stanford University; University of Cape Town; University College London; and King's College London designed the Novel Education Clinical Trainees and Researchers (NECTAR) program and 2 linked awards addressing cardiovascular disease and mental health to pursue MEPI objectives. A range of medical education and research capacity-focused programs were implemented, including faculty development, research support, mentored scholars, visiting professors, community-based education, information and technology support, cross-cutting curricula, and collaboration with partner universities and the ministries of health and education. We analyzed quantitative and qualitative data from several data sources, including annual surveys of faculty, students, and other stakeholders; workshop exit surveys; and key informant interviews with NECTAR administrators and leaders and the UZCHS dean.

Findings:

Improved Internet connectivity and electronic resource availability were early successes of NECTAR. Over the 5-year period, 69% (115 of 166) of faculty members attended at least 1 of 15 faculty development workshops. Forty-one faculty members underwent 1-year advanced faculty development training in medical education and leadership. Thirty-three mentored research scholars were trained under NECTAR, and 52 and 12 in cardiovascular and mental health programs, respectively. Twelve MEPI scholars had joined faculty by 2015. Full-time faculty grew by 36% (122 to 166), annual postgraduate and medical student enrollment increased by 61% (75 to 121) and 71% (123 to 210), respectively. To institutionalize and sustain MEPI innovations, the Research Support Center and the Department of Health Professions Education were established at UZCHS.

Conclusion:

MEPI has synergistically revitalized medical education, research capacity, and leadership at UZCHS. Investments in creating a new research center, health professions education department, and, programs have laid the foundation to help sustain faculty development and research capacity in the country.

A Simple Phosphate-Buffered-Saline-Based Extraction Method Improves Specificity of HIV Viral Load Monitoring Using Dried Blood Spots

Although Roche COBAS Ampliprep/COBAS TaqMan (CAP/CTM) systems are widely used in sub-Saharan Africa for early infant diagnosis of HIV from dried blood spots (DBS), viral load monitoring with this system is not practical due to nonspecific extraction of both cell-free and cell-associated viral nucleic acids. A simplified DBS extraction technique for cell-free virus elution using phosphate-buffered saline (PBS) may provide an alternative analyte for lower-cost quantitative HIV virus load (VL) testing to monitor antiretroviral therapy (ART). We evaluated the CAP/CTM v2.0 assay in 272 paired plasma and DBS specimens using the cell-free virus elution method and determined the level of agreement, sensitivity, and specificity at thresholds of target not detected (TND), target below the limit of quantification (BLQ) (<20 copies/ml in plasma or <400 copies/ml in DBS), and VL of <1,000 copies/ml, and VL of <5,000 copies/ml. Reported plasma VL ranged from TND, or <20, to 5,781,592 copies/ml, and DBS VL ranged from TND, or <400, to 467,600 copies/ml. At <1000 copies/ml, agreement between DBS and plasma was 96.7% (kappa coefficient, 0.93; P < 0.0001). The mean difference between DBS and plasma VL values was -1.06 log10 copies/ml (95% confidence interval [CI], -1.17, -0.97; P < 0.0001). At a treatment failure threshold of >1,000 copies/ml, the sensitivities, specificities, positive predictive values (PPV), and negative predictive values (NPV) were 92.7%, 100%, 100%, and 94.3%, respectively. PBS elution of DBS offers a sensitive and specific method for monitoring plasma viremia among adults and children on ART at the WHO-recommended threshold of >1,000 copies/ml on the Roche CAP/CTM system.

Access, attitudes and training in information technologies and evidence-based medicine among medical students at University of Zimbabwe College of Health Sciences

BACKGROUND

The Medical Education Partnership Initiative, has helped to mitigate the digital divide in Africa. The aim of the study was to assess the level of access, attitude, and training concerning meaningful use of electronic resources and EBM among medical students at an African medical school.

METHODS

The study involved medical students at the University of Zimbabwe College of Health Sciences, Harare. The needs assessment tool consisted of a 21-question, paper-based, voluntary and anonymous survey.

RESULTS

A total of 61/67 (91%), responded to the survey. 60% of the medical students were 'third-year medical students'. Among medical students, 85% of responders had access to digital medical resources, but 54% still preferred printed medical textbooks. Although 25% of responders had received training in EBM, but only 7% found it adequate. 98% of the participants did not receive formal training in journal club presentation or analytical reading of medical literature, but 77 % of them showed interest in learning these skills.

CONCLUSION

Lack of training in EBM, journal club presentation and analytical reading skills have limited the impact of upgraded technology in enhancing the level of knowledge. This impact can be boosted by developing a curriculum with skills necessary in using EBM.

AMBITION-cm: intermittent high dose AmBisome on a high dose fluconazole backbone for cryptococcal meningitis induction therapy in sub-Saharan Africa: study protocol for a randomized controlled trial

BACKGROUND

Cryptococcal meningitis (CM) is a leading cause of mortality among HIV-infected individuals in Africa. Poor outcomes from conventional antifungal therapies, unavailability of flucytosine, and difficulties administering 14 days of amphotericin B are key drivers of this mortality. Novel treatment regimes are needed. This study examines whether short-course high-dose liposomal amphotericin B (AmBisome), given with high dose fluconazole, is non-inferior (in terms of microbiological and clinical endpoints) to standard-dose 14-day courses of AmBisome plus high dose fluconazole for treatment of HIV-associated CM.

METHODOLOGY/DESIGN

This is an adaptive open-label phase II/III randomised non-inferiority trial comparing alternative short course AmBisome regimens. Step 1 (phase II) will compare four treatment arms in 160 adult patients (≥ 18 years old) with a first episode of HIV-associated CM, using early fungicidal activity (EFA) as the primary outcome: 1) AmBisome 10 mg/kg day one (single dose); 2) AmBisome 10 mg/kg day one and AmBisome 5 mg/kg day three (two doses); 3) AmBisome 10 mg/kg day one, and AmBisome 5 mg/kg days three and seven (three doses); and 4) AmBisome 3 mg/kg/d for 14 days (control); all given with fluconazole 1200 mg daily for 14 days. STEP 2 (phase III) will enrol 300 participants and compare two treatment arms using all-cause mortality within 70 days as the primary outcome: 1) the shortest course AmBisome regimen found to be non-inferior in terms of EFA to the 14-day control arm in STEP 1, and 2) AmBisome 3 mg/kg/d for 14 days (control), both given with fluconazole 1200 mg daily for 14 days. STEP 2 analysis will include all patients from STEP 1 and STEP 2 taking the STEP 2 regimens. All patients will be followed for ten weeks, and mortality and safety data recorded. All patients will receive consolidation therapy with fluconazole 400-800 mg daily and ART in accordance with local guidelines. The primary analysis (for both STEP 1 and STEP 2) will be intention-to-treat.

TRIAL REGISTRATION

ISRCTN10248064. Date of Registration: 22 January 2014.

Association of HIV and ART with cardiometabolic traits in sub-Saharan Africa: a systematic review and meta-analysis

Background Sub-Saharan Africa (SSA) has the highest burden of HIV in the world and a rising prevalence of cardiometabolic disease; however, the interrelationship between HIV, antiretroviral therapy (ART) and cardiometabolic traits is not well described in SSA populations.

Methods We conducted a systematic review and meta-analysis through MEDLINE and EMBASE (up to January 2012), as well as direct author contact. Eligible studies provided summary or individual-level data on one or more of the following traits in HIV+ and HIV-, or ART+ and ART- subgroups in SSA: body mass index (BMI), systolic blood pressure (SBP), diastolic blood pressure (DBP), high-density lipoprotein (HDL), low-density lipoprotein (LDL), triglycerides (TGs) and fasting blood glucose (FBG) or glycated hemoglobin (HbA1c). Information was synthesized under a random-effects model and the primary outcomes were the standardized mean differences (SMD) of the specified traits between subgroups of participants.

Results Data were obtained from 49 published and 3 unpublished studies which reported on 29 755 individuals. HIV infection was associated with higher TGs [SMD, 0.26; 95% confidence interval (CI), 0.08 to 0.44] and lower HDL (SMD, −0.59; 95% CI, −0.86 to −0.31), BMI (SMD, −0.32; 95% CI, −0.45 to −0.18), SBP (SMD, −0.40; 95% CI, −0.55 to −0.25) and DBP (SMD, −0.34; 95% CI, −0.51 to −0.17). Among HIV+ individuals, ART use was associated with higher LDL (SMD, 0.43; 95% CI, 0.14 to 0.72) and HDL (SMD, 0.39; 95% CI, 0.11 to 0.66), and lower HbA1c (SMD, −0.34; 95% CI, −0.62 to −0.06). Fully adjusted estimates from analyses of individual participant data were consistent with meta-analysis of summary estimates for most traits.

Conclusions Broadly consistent with results from populations of European descent, these results suggest differences in cardiometabolic traits between HIV-infected and uninfected individuals in SSA, which might be modified by ART use. In a region with the highest burden of HIV, it will be important to clarify these findings to reliably assess the need for monitoring and managing cardiometabolic risk in HIV-infected populations in SSA.

Hepatitis B and C infection at a large public sector hospital clinic: is it a burden?

BACKGROUND

Co-infections have become significant causes of morbidity and mortality in Human Immunodeficiency Virus (HIV) infected people. Due to shared routes of transmission, co-infection of HIV with Hepatitis B (HBV) and/or Hepatitis C (HCV) should be expected. In Zimbabwe, screening for both viruses in HIV infected people prior to treatment is not routinely practised despite the World Health Organisation (WHO) guidelines (2013) prioritising treatment where these co-infections exist.

OBJECTIVE

To determine the prevalence of HBV and HCV infection in HIV infected adults at a public sector HIV clinic in Zimbabwe and to determine risk factors associated with these infections.

DESIGN AND SETTING

An analytical cross-sectional survey carried out among systematically randomly sampled HIV infected patients coming for treatment between March and July 2012 at Parirenyatwa Hospital Opportunistic Infection Clinic.

MATERIALS AND METHODS

Blood samples were tested for hepatitis B surface antigen (HBsAg) and hepatitis C virus antibodies (anti-HCV). Demographic data and exposure to risk factors were collected.

RESULTS

228 antiretroviral therapy (ART) naive adults were enrolled. 7.9% (18/228) were HBsAg positive and 0.9% (2/228) were anti-HCV positive. None of the participants were infected with both viruses.

CONCLUSIONS

The prevalence of HBV has not changed during this HIV era and there is no significant HCV infection in this public sector clinic which serves quite a large sector of the population that lives in Harare, Zimbabwe. Based on these results, there is no need for HCV screening but HBV screening prior to ART initiation may be required. -

Innovations to enhance the quality of health professions education at the University of Zimbabwe College of Health Sciences--NECTAR program

The University of Zimbabwe College of Health Sciences (UZCHS) is Zimbabwe's premier health professions training institution. However, several concerns were raised during the past decade over the quality of health education at UZCHS. The number of faculty and students declined markedly until 2010, when there was a medical student intake of 147 while the faculty comprised only 122 (39%) of a possible 314 positions. The economic and political crises that the country experienced from 1999 to 2009 compounded the difficulties faced by the institution by limiting the availability of resources. The Medical Education Partnership Initiative funding opportunity has given UZCHS the stimulus to embark on reforms to improve the quality of health education it offers. UZCHS, in partnership with the University of Colorado School of Medicine, the University of Colorado Denver Evaluation Center, and Stanford University, designed the Novel Education Clinical Trainees and Researchers (NECTAR) program to implement a series of health education innovations to meet this challenge. Between 2010 and 2013, innovations that have positively affected the quality of health professions education at UZCHS include the launch of comprehensive faculty development programs and mentored clinical and research programs for postgraduate students. A competency-based curriculum reform process has been initiated, a health professions department has been established, and the Research Support Center has been strengthened, providing critical resources to institutionalize health education and research implementation at the college. A core group of faculty trained in medical education has been assembled, helping to ensure the sustainability of these NECTAR activities.

Acquired epidermodysplasia verruciformis due to multiple and unusual HPV infection among vertically-infected, HIV-positive adolescents in Zimbabwe

BACKGROUND

We have previously described the presentation of epidermodysplasia verruciformis (EV)-like eruptions in almost a quarter of hospitalized adolescents with vertically-acquired human immunodeficiency virus (HIV) infection in Harare, Zimbabwe, a region with a high prevalence of HIV infection.

METHODS

We performed a clinical case note review and skin biopsy from affected sites in 4 HIV-infected adolescents with EV-like lesions in Harare. Biopsies were processed for histology and for human papillomavirus (HPV) typing.

RESULTS

All patients had long-standing skin lesions that pre-dated the diagnosis of HIV by several years. The histology of skin biopsies from all patients was consistent with EV. In each biopsy, EV-associated β-HPV type 5 was identified (additionally, type 19 was found in 1 biopsy). Cutaneous wart-associated HPV types 1 and 2 were detected in all biopsies, together with genital lesion-associated HPV types 6, 16, and 52, (as well as ≥3 other genital lesion-associated HPV types). Despite immune reconstitution with combination antiretroviral therapy (cART), there was no improvement in EV-like lesions in any patient.

CONCLUSIONS

EV is a disfiguring and potentially stigmatizing condition among this patient group and is difficult to treat; cART appears to have no impact on the progression of skin disease. Among adolescents with longstanding HIV-induced immunosuppression and with high levels of sun exposure, close dermatological surveillance for potential skin malignancy is required.

Chronic lung disease in adolescents with delayed diagnosis of vertically acquired HIV infection

A high burden of chronic lung disease (CLD) was found among 116 consecutive adolescents with vertically acquired human immunodeficiency virus in Zimbabwe. The main cause of HIV-associated CLD appears to be obliterative bronchiolitis, which has not previously been recognized among this patient group.

Background. Long-term survivors of vertically acquired human immunodeficiency virus (HIV) infection are reaching adolescence in large numbers in Africa and are at high risk of delayed diagnosis and chronic complications of untreated HIV infection. Chronic respiratory symptoms are more common than would be anticipated based on the HIV literature.

Methods. Consecutive adolescents with presumed vertically acquired HIV attending 2 HIV care clinics in Harare, Zimbabwe, were recruited and assessed with clinical history and examination, CD4 count, pulmonary function tests, Doppler echocardiography, and chest radiography (CXR). Those with suspected nontuberculous chronic lung disease (CLD) were scanned using high-resolution computed tomography (HRCT).

Results. Of 116 participants (43% male; mean age, 14 ± 2.6 years, mean age at HIV diagnosis, 12 years), 69% were receiving antiretroviral therapy. Chronic cough and reduced exercise tolerance were reported by 66% and 21% of participants, respectively; 41% reported multiple respiratory tract infections in the previous year, and 10% were clubbed. More than 40% had hypoxemia at rest (13%) or on exercise (29%), with pulmonary hypertension (mean pulmonary artery pressure >25 mm Hg) in 7%. Forced expiratory volume in 1 second (FEV₁) was <80% predicted in 45%, and 47% had subtle CXR abnormalities. The predominant HRCT pattern was decreased attenuation as part of a mosaic attenuation pattern (31 of 56 [55%]), consistent with small airway disease and associated with bronchiectasis (Spearman correlation coefficient (r² = 0.8) and reduced FEV₁ (r² = −0.26).

Conclusions. Long-term survivors of vertically acquired HIV in Africa are at high risk of a previously undescribed small airway disease, with >40% of unselected adolescent clinic attendees meeting criteria for severe hypoxic CLD. This condition is not obvious at rest. Etiology, prognosis, and response to treatment are currently unknown.

Perception of risk of vertically acquired HIV infection and acceptability of provider-initiated testing and counseling among adolescents in Zimbabwe

OBJECTIVES

We investigated attitudes toward provider-initiated HIV testing and counseling (PITC) in the suburbs of Harare, Zimbabwe, where late presentation after mother-to-child HIV transmission (MTCT) is a major cause of adolescent mortality.

METHODS

Adolescents (10-18 years) attending 2 primary clinics were offered PITC. Participants completed a questionnaire investigating acceptability of PITC, and in-depth interviews with 41 adolescents and 30 guardians explored understanding of long-term survival after MTCT.

RESULTS

Of 506 participants, 16 were known to be HIV-positive; of the remaining 490, only 5 (1%) declined HIV testing. Infected adolescents and their guardians often anticipated a positive result and reported being advised by relatives (but not health workers) to be tested because of chronic illness, especially if parents or siblings had died or were HIV-infected. However, HIV-negative participants were not aware that long-term survival following MTCT could occur. All adolescents felt that HIV diagnosed at their age would be assumed to have been sexually acquired regardless of the true mode of transmission.

CONCLUSIONS

Including late diagnosis of MTCT in pretest counseling and health educational messages may facilitate PITC for older children and adolescents, especially for those who have not had their sexual debut.

Renal dysfunction among anti-retroviral therapy naïve HIV infected patients in Zimbabwe

BACKGROUND

The prevalence and determinants of renal dysfunction among HIV infected adults in the outpatient in Zimbabwe setting is unknown.

OBJECTIVE

To determine the proportion of patients with evidence of renal dysfunction among anti-retroviral treatment naive HIV infected patients in a tertiary outpatient setting.

DESIGN

Cross sectional study.

SETTING

HIV outpatients' clinic (Family Care Centre) at Parirenyatwa hospital.

SUBJECTS

159 Anti-retroviral therapy (ART) naive HIV infected adults.

METHODS

A cross-sectional study was carried out on ART-naive HIV infected willing adult participants, > or = 18 years old. WHO clinical staging was conducted on all participants. Urine was examined using urinary dipsticks and proteinuria quantification by calculating its protein: creatinine ratio. Serum creatinine and CD4 cell counts were measured. Creatinine clearance (CrCl) was calculated using the Cockcroft-Gault formula.

MAIN OUTCOME MEASURES

The primary endpoint was renal dysfunction defined as CrCl < 60 ml/min. Protenuria, defined as > or = + dipstick positive and/or protein to creatinine ratio > 20 mg/mg was a secondary outcome.

RESULTS

Renal dysfunction defined as CrCl < 60 ml/min was found in 7.5% [95% CI 3.4-11.7] (12/159) of the participants. Risk factors for renal dysfunction were age [OR 1.14, (95% CI 1.06-1.22)], BMI [OR 0.77 (95% CI 0.61-0.94)] andproteinuria [OR 7.45 (95% CI 1.58-35.26)]. Proteinuria was common, occurring in 45.9% of the participants.

CONCLUSIONS

[corrected] A high prevalence of proteinuria (45.9%) was found in this study, while the prevalence of reduced creatinine clearance was relatively low (7.5%). Screening for proteinuria is strongly recommended in ART naive HIV infected patients and should be complemented by measurement of serum creatinine and calculation ofcreatinine clearance.

A primary care level algorithm for identifying HIV-infected adolescents in populations at high risk through mother-to-child transmission

Objective

To present an algorithm for primary-care health workers for identifying HIV-infected adolescents in populations at high risk through mother-to-child transmission.

Methods

Five hundred and six adolescent (10–18 years) attendees to two primary care clinics in Harare, Zimbabwe, were recruited. A randomly extracted ‘training’ data set (n = 251) was used to generate an algorithm using variables identified as associated with HIV through multivariable logistic regression. Performance characteristics of the algorithm were evaluated in the remaining (‘test’) records (n = 255) at different HIV prevalence rates.

Results

HIV prevalence was 17%, and infection was independently associated with client-reported orphanhood, past hospitalization, skin problems, presenting with sexually transmitted infection and poor functional ability. Classifying adolescents as requiring HIV testing if they reported >1 of these five criteria had 74% sensitivity and 80% specificity for HIV, with the algorithm correctly predicting the HIV status of 79% of participants. In low-HIV-prevalence settings (<2%), the algorithm would have a high negative predictive value (≥99.5%) and result in an estimated 60% decrease in the number of people needing to test to identify one HIV-infected individual, compared with universal testing.

Conclusions

Our simple algorithm can identify which individuals are likely to be HIV infected with sufficient accuracy to provide a screening tool for use in settings not already implementing universal testing policies among this age-group, for example immigrants to low-HIV-prevalence countries.

Undiagnosed HIV infection among adolescents seeking primary health care in Zimbabwe

BACKGROUND

Mother-to-child transmission of human immunodeficiency virus (HIV) infection was extremely common in southern Africa during the 1990s, and a substantial minority of infected infants have survived to reach adolescence undiagnosed. Studies have shown a high prevalence of HIV infection in hospitalized adolescents who have features associated with long-standing HIV infection, including stunting and frequent minor illnesses. We therefore investigated the epidemiology of HIV infection at the primary care level.

METHODS

Adolescents (aged 10-18 years) attending two primary care clinics underwent HIV and Herpes simplex virus-2 (HSV-2) serological testing, clinical examination, and anthropometry. All were offered routine HIV counseling and testing. Patients attending for acute primary care (APC) who were HIV infected were asked about their risk factors.

RESULTS

Five hundred ninety-four participants were systematically recruited (97% participation), of whom 88 (15%) were attending for antenatal care. HIV infection prevalence was higher among APC attendees than among antenatal care attendees (17% vs 6%; P < .007), but for the prevalence of HSV-2 infection, a marker of sexually acquired HIV, the converse was true (4% vs 14%; P < .002). Seventy (81%) of 86 HIV-positive APC attendees were previously undiagnosed. They had a broad range of presenting complaints, with a median CD4 cell count of 329 cells/microL (interquartile range, 176-485 cells/microL) and a high prevalence of stunting, compared with the corresponding prevalence among HIV-negative attendees (40% vs 12%; P < .001). Maternal transmission was considered to be likely by 69 (80%) of the 86 HIV-positive APC attendees, only one of whom was HSV-2 positive.

CONCLUSIONS

Unrecognized HIV infection was a common cause of primary care attendance. Routine HIV counseling and testing implemented at the primary care level may provide a simple and effective way of identifying older long-term survivors of mother-to-child transmission before the onset of severe immunosuppression and irreversible complications.

Early versus delayed initiation of antiretroviral therapy for concurrent HIV infection and cryptococcal meningitis in sub-saharan Africa

BACKGROUND. Cryptococcal meningitis (CM) remains a leading cause of acquired immunodeficiency syndrome-related death in sub-Saharan Africa. The timing of the initiation of antiretroviral therapy (ART) for human immunodeficiency virus (HIV)-associated CM remains uncertain. The study aimed to determine the optimal timing for initiation of ART in HIV-positive individuals with CM. METHODS. A prospective, open-label, randomized clinical trial was conducted at a tertiary teaching hospital in Zimbabwe. Participants were aged > or = 18 years, were ART naive, had received a first CM diagnosis, and were randomized to receive early ART (within 72 h after CM diagnosis) or delayed ART (after 10 weeks of treatment with fluconazole alone). Participants received 800 mg of fluconazole per day. The ART regimen used was stavudine, lamivudine, and nevirapine given twice daily. The duration of follow-up was up to 3 years. The primary end point was all-cause mortality. RESULTS. Fifty-four participants were enrolled in the study (28 in the early ART arm and 26 in the delayed ART arm). The median CD4 cell count at enrollment was 37 cells/mm(3) (interquartile range, 17-69 cells/mm(3)). The 3-year mortality rate differed significantly between the early and delayed ART groups (88% vs 54%; P < .006); the overall 3-year mortality rate was 73%. The median durations of survival were 28 days and 637 days in the early and delayed ART groups, respectively (P = .031, by log-rank test). The risk of mortality was almost 3 times as great in the early ART group versus the delayed ART group (adjusted hazard ratio, 2.85; 95% confidence interval, 1.1-7.23). The study was terminated early by the data safety monitoring committee. CONCLUSIONS. In resource-limited settings where CM management may be suboptimal, when compared with a delay of 10 weeks after a CM diagnosis, early initiation of ART results in increased mortality. Trial registration. ClinicalTrials.gov identifier: NCT00830856.

The prevalence of diabetic nephropathy in adult patients with insulin dependent diabetes mellitus attending Parirenyatwa Diabetic Clinic, Harare

OBJECTIVE

The objective of this study was to determine the prevalence of diabetic nephropathy in a diabetic clinic in a tertiary hospital setting in Zimbabwe.

DESIGN

Descriptive cross sectional study.

SETTING

Diabetic clinic in a tertiary hospital.

SUBJECTS

75 insulin dependent diabetic consenting adults aged over 18 years.

METHODS

Consecutive sampling of 75 insulin dependent consenting subjects presenting at the Parirenyatwa Diabetic Clinic was conducted over a four month period. Patients were tested for proteinuria using dipsticks and were divided into dipstick positive and dipstick negative. The dipstick positive samples were sent to the laboratory for protein quantification. The dipstick negative samples were tested for microalbuminuria. Urine albumin creatinine ratios were utilised to quantify the proteinuria.

MAIN OUTCOME MEASURES

Prevalence of overt proteinuria and the prevalence of microalbuminuria.

RESULTS

Overt proteinuria was found in 16 (21%) patients. Microalbuminuria was found in 9 (12%) of the patients. Nephropathy was, therefore, found in 25 (33%).

CONCLUSION

There is a high prevalence of diabetic nephropathy in adult patients with insulin dependent diabetis mellitus attending Parirenyatwa Diabetic Clinic.

An uncommon presentation of cysticercosis

This is a report of a sudden death which turned out to be an unexpected case of neurocysticercosis. Most doctors nowadays expect cerebral cysticercosis to present with seizures and have forgotten its other clinical manifestations.

Serum albumin concentrations in rural Zimbabweans

Primary infections, protein malnutrition or simply poor food intake which decrease albumin synthesis often prevail in rural Zimbabwe. Therefore, we postulated that serum albumin levels in rural folk may not compare with published values. To investigate this, blood samples were collected from 1,502 consenting participants aged between 16 and 90 years from randomly selected rural areas in Mashonaland West, Midlands, Matebeleland South and Matebeleland North provinces in Zimbabwe. The effects of smoking, alcohol consumption and pregnancy on serum albumin levels were also investigated. The mean age in years did not differ significantly between females and males (32.5 +/- 0.44, n = 943 vs 33.84 +/- 0.62, n = 559). Serum preserved with sodium azide at -4 degrees C was analyzed for albumin using a Quick Lab 2 Analyzer (Ames Quick Lab) by the bromocresol green dye binding method. Only small differences of albumin concentrations (means +/- S.E.M.) were noted for each studied area and results were pooled. The normal serum albumin ranges were 27 to 52 g/L for females and 26 to 52 g/L for males and were different from those reported for developed countries. The albumin levels in females were significantly (p < 0.01) lower than in males (39.29 +/- 0.20 g/L, n = 943 vs 40.09 +/- 0.25 g/L, n = 559). However, the concentrations of the protein in males who smoked (38.66 +/- 0.38 g/L, n = 174) were significantly low (p < 0.01) by comparison with non smokers. Smoking did not alter albumin levels in females (38.27 +/- 0.53 g/L, n = 87) perhaps because they smoked fewer cigarettes.(ABSTRACT TRUNCATED AT 250 WORDS)

Renal fluid and electrolyte handling in streptozotocin-diabetic rats

Male Sprague-Dawley rats (300-400 g) were made diabetic by an i.p. injection of streptozotocin (STZ, 60 mg/kg in citrate buffer, n = 8) to examine renal function in well-established diabetes mellitus. Vehicle-injected animals (n = 8) acted as controls. The mean weekly total amounts of food taken by control and STZ-diabetic rats did not differ, but diabetic rats exhibited diarrhea and drank more water. STZ-diabetic rats progressively lost weight from the first to the third week but gained weight in the fourth week. At 5 weeks the weight stabilized, plasma glucose concentration was elevated, and this was associated with increased kidney weight. The weekly urine volume from STZ-diabetic rats was elevated throughout the 5-week period of study and this was associated with significantly lower urinary outputs of Na+ and higher outputs of K+ than those of control animals. After 5 weeks of STZ diabetes, plasma corticosterone and aldosterone concentrations in unanesthetized rats did not differ significantly from values seen in controls. To examine renal function in more detail, groups of Inactin-anesthetized 5-week STZ-diabetic rats (n = 7) and control rats (n = 7) were placed on continuous jugular infusion of 0.077 M NaCl at 150 microL/min for 8.5 h. Following a 3.5-h equilibration period, urine flow and Na+, K+, and Cl- outputs were determined for the subsequent 5-h period, with mean arterial pressure and glomerular filtration rate (GFR). STZ-diabetic rats voided significantly less of the infused fluid and the urinary excretions of Na+ and K+ were lower than those of controls. Mean arterial blood pressure and GFR values in STZ-diabetic rats did not differ statistically from those seen in controls. Following hypotonic saline infusion for 8.5 h the levels of aldosterone were elevated significantly (p < 0.01) in STZ-diabetic rats by comparison with control animals (5.36 +/- 1.58 nmol/L, n = 7 vs. 2.36 +/- 0.12 nmol/L, n = 7). It is concluded that a challenge of hypotonic saline load to rats with 5 weeks of STZ diabetes mellitus elevates plasma aldosterone to reduce the ability to excrete Na+.

Interaction of aldosterone and oxytocin to influence renal sodium excretion in rats

The possibility of an interaction between oxytocin and aldosterone to influence renal Na+ excretion was investigated in Inactin-anaesthetized male Sprague-Dawley rats. Endogenous plasma concentrations of aldosterone were suppressed by either adrenalectomy or bicarbonate infusion. The effects of 2 h intravenous administration of oxytocin (0.04 pmol/min) and/or aldosterone (42 pmol/min) on renal Na+ handling were studied in 0.077 M NaCl-infused adrenalectomized (Adx) rats and groups of intact animals that were infused with 0.077 M NaHCO3. Aldosterone alone significantly (P < 0.01) reduced Na+ excretion from pretreatment peak value of 5.0 +/- 1.0 to 1.5 +/- 0.4 mumol/min in Adx animals (n = 8) and 9.2 +/- 1.2 to 5.2 +/- 1.2 mumol/min in NaHCO3-infused rats (n = 8) by 2 h after the start of administration. However, combined administration of aldosterone and oxytocin was associated with a significantly (P < 0.01) increased Na+ excretion rate from a peak pretreatment value of 6.8 +/- 0.7 mumol/min to a peak value of 11.5 +/- 1.1 mumol/min by 1 h 40 min after the start of treatment in Adx rats (n = 7). In bicarbonate-infused rats (n = 8) Na+ excretion rose within 20 min of the start of treatment from a pretreatment peak of 9.0 +/- 0.8 mumol/min to a peak value of 13.5 +/- 0.8 mumol/min in response to combined hormone administration. In conclusion, we have shown that concomitant administration of aldosterone and oxytocin increased the rate of excretion of Na+ in two different preparations, which supports the idea of an interaction between the steroid and oxytocin to promote Na+ loss.

The effects of oral chloroquine administration on kidney function

The effects of 3 consecutive days of oral chloroquine (1 mg/100 g body weight) on kidney function and blood pressure were studied in male Sprague-Dawley rats that were challenged with hypotonic saline infusion 24 h after the last chloroquine administration. The rats were anesthetized with Inactin [5 ethyl-5-(1'-methylpropyl)-2-thiobarbiturate, Byk Gulden] and continuously infused with 0.077 M NaCl for 8 h; urine flow and electrolyte excretion rates were monitored during the last 5 h. Blood pressure and glomerular filtration rates were also measured. Kidney function was compromised in chloroquine-treated rats, which retained significantly more of the infused Na+ and Cl- by comparison to control-vehicle-treated rats. Throughout the experimental period, chloroquine-treated rats exhibited low blood pressure (80 mm Hg vs. 127 mm Hg) which was associated with low glomerular filtration rate. The plasma aldosterone concentrations were significantly (p < 0.01) elevated in rats pretreated with chloroquine at the end of the 8-h infusion of hypotonic saline, but corticosterone levels were significantly (p < 0.01) lower in the treated rats. It is concluded that chloroquine administration impairs kidney function, resulting in inappropriate Na+ and Cl- retention. This effect is likely to be mediated via chloroquine-induced increases in plasma aldosterone concentration and lowering of GFR.

Acute chloroquine administration increases renal sodium excretion

The effect of a 2-hour intravenous chloroquine infusion (0.015, 0.030 and 1.25 micrograms min-1) on renal fluid and electrolyte handling was investigated in the saline infused, Inactin anaesthetized rat. Blood pressure and glomerular filtration rate were not affected by chloroquine administration, remaining around 128 mmHg and 2.4 ml min-1, respectively throughout the 5-hour post-equilibration period. Chloroquine produced an increase in Na+ and Cl- excretion without affecting the urine flow. By 1 hour after the start of treatment (0.03 micrograms chloroquine min-1) the Na+ excretion rate had increased to 14.5 +/- 2.1 mumol min-1 (n = 6), and was significantly (P < 0.01) greater than in control animals (8.6 +/- 1.0 mumol min-1) at the corresponding time. Parallel but lesser increases in Cl- excretion rates were also observed. The plasma aldosterone and corticosterone levels following either 10, 30 or 120 minutes infusion of chloroquine at 0.03 micrograms min-1 did not differ statistically from each other or from control values. It is concluded that acute chloroquine administration induces an increase in Na+ excretion. The mechanism of this natriuresis cannot be established from the present study, but is likely to involve altered tubular handling of Na+.