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Mungwira RG, Laurens MB, Nyangulu W, Divala TH, Nampota-Nkomba N, Buchwald AG, Nyirenda OM, Mwinjiwa E, Kanjala M, Galileya LT, Earland DE, Adams M, Plowe CV, Taylor TE, Mallewa J, van Oosterhout JJ, Laufer MK. High burden of malaria among Malawian adults on antiretroviral therapy after discontinuing prophylaxis. AIDS 2022; 36:1675-1682. [PMID: 35848575 PMCID: PMC9444947 DOI: 10.1097/qad.0000000000003317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Many individuals living with the human immunodeficiency virus (HIV) infection and receiving antiretroviral therapy (ART) reside in areas at high risk for malaria but how malaria affects clinical outcomes is not well described in this population. We evaluated the burden of malaria infection and clinical malaria, and impact on HIV viral load and CD4 + cell count among adults on ART. DESIGN We recruited Malawian adults on ART who had an undetectable viral load and ≥250 CD4 + cells/μl to participate in this randomized trial to continue daily trimethoprim-sulfamethoxazole (TS), discontinue daily co-trimoxazole, or switch to weekly chloroquine (CQ). METHODS We defined clinical malaria as symptoms consistent with malaria and positive blood smear, and malaria infection as Plasmodium falciparum DNA detected from dried blood spots (collected every 4-12 weeks). CD4 + cell count and viral load were measured every 24 weeks. We used Poisson regression and survival analysis to compare the incidence of malaria infection and clinical malaria. Clinicaltrials.gov NCT01650558. RESULTS Among 1499 participants enrolled, clinical malaria incidence was 21.4/100 person-years of observation (PYO), 2.4/100 PYO and 1.9/100 PYO in the no prophylaxis, TS, and CQ arms, respectively. We identified twelve cases of malaria that led to hospitalization and all individuals recovered. The preventive effect of staying on prophylaxis was approximately 90% compared to no prophylaxis (TS: incidence rate ratio [IRR] 0.11, 95% confidence interval [CI] 0.08, 0.15 and CQ: IRR 0.09, 95% CI 0.06, 0.13). P. falciparum infection prevalence among all visits was 187/1475 (12.7%), 48/1563 (3.1%), and 29/1561 (1.9%) in the no prophylaxis, TS, and CQ arms, respectively. Malaria infection and clinical malaria were not associated with changes in CD4 + cell count or viral load. CONCLUSION In clinically stable adults living with HIV on ART, clinical malaria was common after chemoprophylaxis stopped. However, neither malaria infection nor clinical illness appeared to affect HIV disease progression.
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Affiliation(s)
- Randy G Mungwira
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Matthew B Laurens
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Mrayland, USA
| | | | - Titus H Divala
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
| | | | - Andrea G Buchwald
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Mrayland, USA
| | - Osward M Nyirenda
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
| | | | - Maxwell Kanjala
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
| | | | - Dominique E Earland
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Mrayland, USA
| | - Matthew Adams
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Mrayland, USA
| | - Christopher V Plowe
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Mrayland, USA
| | | | - Jane Mallewa
- Department of Medicine, Kamuzu University of Health Sciences, Blantyre, Malawi
| | | | - Miriam K Laufer
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Mrayland, USA
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Laurens MB, Mungwira RG, Nampota N, Nyirenda OM, Divala TH, Kanjala M, Mkandawire FA, Galileya LT, Nyangulu W, Mwinjiwa E, Downs M, Tillman A, Taylor TE, Mallewa J, Plowe CV, van Oosterhout JJ, Laufer MK. Revisiting Co-trimoxazole Prophylaxis for African Adults in the Era of Antiretroviral Therapy: A Randomized Controlled Clinical Trial. Clin Infect Dis 2021; 73:1058-1065. [PMID: 33744963 DOI: 10.1093/cid/ciab252] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 03/18/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Daily co-trimoxazole is recommended for African adults living with human immunodeficiency virus (HIV) irrespective of antiretroviral treatment, immune status, or disease stage. Benefits of continued prophylaxis and whether co-trimoxazole can be stopped following immune reconstitution are unknown. METHODS We conducted a randomized controlled trial at 2 sites in Malawi that enrolled adults with HIV with undetectable viral load and CD4 count of >250/mm3 and randomized them to continue daily co-trimoxazole, discontinue daily co-trimoxazole and begin weekly chloroquine, or discontinue daily co-trimoxazole. The primary endpoint was the preventive effect of co-trimoxazole prophylaxis against death or World Health Organization (WHO) HIV/AIDS stage 3-4 events, using Cox proportional hazards modeling, in an intention-to-treat population. RESULTS 1499 adults were enrolled. The preventive effect of co-trimoxazole on the primary endpoint was 22% (95% CI: -14%-47%; P = .20) versus no prophylaxis and 25% (-10%-48%; P = .14) versus chloroquine. When WHO HIV/AIDS stage 2 events were added to the primary endpoint, preventive effect increased to 31% (3-51%; P = .032) and 32% (4-51%; P = .026), respectively. Co-trimoxazole and chloroquine prophylaxis effectively prevented clinical malaria episodes (3.8 and 3.0, respectively, vs 28/100 person-years; P < .001). CONCLUSIONS Malawian adults with HIV who immune reconstituted on ART and continued co-trimoxazole prophylaxis experienced fewer deaths and WHO HIV/AIDS stage 3-4 events compared with prophylaxis discontinuation, although statistical significance was not achieved. Co-trimoxazole prevented a composite of death plus WHO HIV/AIDS stage 2-4 events. Given poor healthcare access and lack of routine viral load monitoring, co-trimoxazole prophylaxis should continue in adults on ART after immune reconstitution in sub-Saharan Africa. Clinical Trials Registration. NCT01650558.
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Affiliation(s)
- Matthew B Laurens
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Randy G Mungwira
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi
| | - Nginache Nampota
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi
| | - Osward M Nyirenda
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi
| | - Titus H Divala
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi
| | - Maxwell Kanjala
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi
| | - Felix A Mkandawire
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi
| | | | | | | | | | - Amy Tillman
- Statistics Collaborative, Washington, DC, USA
| | - Terrie E Taylor
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi.,College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, USA
| | - Jane Mallewa
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi
| | - Christopher V Plowe
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Joep J van Oosterhout
- Dignitas International and University of Malawi College of Medicine, Blantyre, Malawi
| | - Miriam K Laufer
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Nyangulu W, Mungwira R, Nampota N, Nyirenda O, Tsirizani L, Mwinjiwa E, Divala T. Compensation of subjects for participation in biomedical research in resource - limited settings: a discussion of practices in Malawi. BMC Med Ethics 2019; 20:82. [PMID: 31727044 PMCID: PMC6857211 DOI: 10.1186/s12910-019-0422-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 11/06/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Compensating participants of biomedical research is a common practice. However, its proximity with ethical concerns of coercion, undue influence, and exploitation, demand that participant compensation be regulated. The objective of this paper is to discuss the current regulations for compensation of research participants in Malawi and how they can be improved in relation to ethical concerns of coercion, undue influence, and exploitation. MAIN TEXT In Malawi, national regulations recommend that research subjects be compensated with a stipend of US$10 per study visit. However, no guidance is provided on how this figure was determined and how it should be implemented. While necessary to prevent exploitation, the stipend may expose the very poor to undue influence. The stipend may also raise the cost of doing research disadvantaging local researchers and may have implications on studies where income stipend is the intervention under investigation. We recommend that development and implementation of guidelines of this importance involve interested parties such as the research community and patient groups. CONCLUSION Compensating human research subjects is important but can also act as a barrier to voluntary participation and good research efforts. Deliberate measures need to be put in place to ensure fair compensation of research participants, avoid their exploitation and level the field for locally funded research.
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Affiliation(s)
- Wongani Nyangulu
- Public Health Nutrition Research Group (PHNG), College of Medicine, Blantyre, Malawi
| | - Randy Mungwira
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi
| | - Nginanche Nampota
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi
| | - Osward Nyirenda
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi
| | - Lufina Tsirizani
- Malawi-Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | | | - Titus Divala
- Helse Nord Tuberculosis Initiative, University of Malawi College of Medicine, Blantyre, Malawi
- London School of Hygiene & Tropical Medicine, Keppel Street, Bloomsbury, London, WC1E 7HT UK
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Nyangulu WJ, Mwinjiwa E, Divala TH, Mungwira RG, Nyirenda O, Kanjala M, Mbambo G, Mallewa J, Taylor TE, Laurens MB, Laufer MK, van Oosterhout JJ. Frequent malaria illness episodes in two Malawian patients on antiretroviral therapy soon after stopping cotrimoxazole preventive therapy. Malawi Med J 2017; 29:57-60. [PMID: 28567199 DOI: 10.4314/mmj.v29i1.12] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
We describe two Malawian adults on successful antiretroviral therapy who experienced frequent malaria episodes after stopping cotrimoxazole prophylaxis. We argue that, in addition to stopping cotrimoxazole, diminished malaria immunity and drug interactions between efavirenz and artemether-lumefantrine may have played a causative role in the recurrent malaria our patients experienced.
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Affiliation(s)
| | | | - Titus H Divala
- Blantyre Malaria Project, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Randy G Mungwira
- Blantyre Malaria Project, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Osward Nyirenda
- Blantyre Malaria Project, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Maxwell Kanjala
- Blantyre Malaria Project, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Gillian Mbambo
- Division of Malaria Research, Institute for Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jane Mallewa
- Department of Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Terrie E Taylor
- Blantyre Malaria Project, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Matthew B Laurens
- Division of Malaria Research, Institute for Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Miriam K Laufer
- Division of Malaria Research, Institute for Global Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Joep J van Oosterhout
- Dignitas International, Zomba, Malawi.,Department of Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
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Landes M, Thompson C, Mwinjiwa E, Thaulo E, Gondwe C, Akello H, Chan AK. Task shifting of triage to peer expert informal care providers at a tertiary referral HIV clinic in Malawi: a cross-sectional operational evaluation. BMC Health Serv Res 2017; 17:341. [PMID: 28486980 PMCID: PMC5423418 DOI: 10.1186/s12913-017-2291-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 05/04/2017] [Indexed: 11/21/2022] Open
Abstract
Background HIV treatment models in Africa are labour intensive and require a high number of skilled staff. In this context, task-shifting is considered a feasible alternative for ART service delivery. In 2006, a lay health cadre of expert patients (EPs) at a tertiary referral HIV clinic in Zomba, Malawi was capacitated. There are few evaluations of EP program efficacy in this setting. Triage is the process of prioritizing patients in terms of the severity of their condition and ensures that no harmful delays occur to treatment and care. This study evaluates the safety of task-shifting triage, in an ambulatory low resource setting, to EPs. Methods As a quality improvement exercise in April 2010, formal triage training was conducted by adapting the World Health Organization Emergency Triage Assessment and Treatment Triage Module Guidelines. A cross sectional observation study was conducted 2 years after the intervention. Triage assessments performed by EPs were repeated by a clinical officer (gold standard) to assess sensitivities, specificities, positive and negative predictive values for EP triage scores. Proportions were calculated for categories of disposition by stratifying by EP and clinician triage scores. Results A total of 467 patients were triaged by 7 EPs and re-triaged by clinical officers. With combined triage scores for emergency and priority patients we report a sensitivity of 85% and specificity of 74% for the EP scoring, with a low positive predictive value (41%) and a high negative predictive value (96%). We calculate a serious miss rate of EP scoring (i.e. missed priority or emergency patients) as 2.2%. Admission rates to hospital were highest among those patients triaged as emergency cases either by the EP’s (21%) or the clinicians (83%). Fewer patients triaged as priority by either EPs (5%) or clinicians (15%) were admitted to hospital, however these patients had the highest prevalence of same day lab testing and/or specialty referral. Conclusions Our study provides reassurance that in the context of adequate training and ongoing supervision, task-shifting triage to lay health care workers does not necessarily lead to less accurate triaging. EPs have a tendency to be more conservative in over-triaging patients. Electronic supplementary material The online version of this article (doi:10.1186/s12913-017-2291-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Megan Landes
- Dignitas International-Malawi Country Program, Zomba, Malawi.,Department of Emergency Medicine, University Health Network, Toronto, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, Canada
| | - Courtney Thompson
- Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Canada.,London School of Tropical Medicine and Hygiene, London, UK
| | - Edson Mwinjiwa
- Dignitas International-Malawi Country Program, Zomba, Malawi.,Tisungane Clinic, Zomba Central Hospital, Malawi Ministry of Health, Zomba, Malawi
| | - Edith Thaulo
- Tisungane Clinic, Zomba Central Hospital, Malawi Ministry of Health, Zomba, Malawi
| | - Chrissie Gondwe
- Dignitas International-Malawi Country Program, Zomba, Malawi.,Tisungane Clinic, Zomba Central Hospital, Malawi Ministry of Health, Zomba, Malawi
| | - Harriet Akello
- Dignitas International-Malawi Country Program, Zomba, Malawi.,Tisungane Clinic, Zomba Central Hospital, Malawi Ministry of Health, Zomba, Malawi
| | - Adrienne K Chan
- Dignitas International-Malawi Country Program, Zomba, Malawi. .,Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Canada. .,Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, Canada. .,Institute for Health Policy, Management and Evaluation and Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
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6
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Brophy JC, Hawkes MT, Mwinjiwa E, Mateyu G, Sodhi SK, Chan AK. Survival Outcomes in a Pediatric Antiretroviral Treatment Cohort in Southern Malawi. PLoS One 2016; 11:e0165772. [PMID: 27812166 PMCID: PMC5094712 DOI: 10.1371/journal.pone.0165772] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2015] [Accepted: 10/18/2016] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Pediatric uptake and outcomes in antiretroviral treatment (ART) programmes have lagged behind adult programmes. We describe outcomes from a population-based pediatric ART cohort in rural southern Malawi. METHODS Data were analyzed on children who initiated ART from October/2003 -September/2011. Demographics and diagnoses were described and survival analyses conducted to assess the impact of age, presenting features at enrolment, and drug selection. RESULTS The cohort consisted of 2203 children <15 years of age. Age at entry was <1 year for 219 (10%), 1-1.9 years for 343 (16%), 2-4.9 years for 584 (27%), and 5-15 years for 1057 (48%) patients. Initial clinical diagnoses of tuberculosis and wasting were documented for 409 (19%) and 523 (24%) patients, respectively. Median follow-up time was 1.5 years (range 0-8 years), with 3900 patient-years of follow-up. Over the period of observation, 134 patients (6%) died, 1324 (60%) remained in the cohort, 345 (16%) transferred out, and 387 (18%) defaulted. Infants <1 year of age accounted for 19% of deaths, with a 2.7-fold adjusted mortality hazard ratio relative to 5-15 year olds; median time to death was also shorter for infants (60 days) than older children (108 days). Survival analysis demonstrated younger age at ART initiation, more advanced HIV stage, and presence of tuberculosis to each be associated with shorter survival time. Among children <5 years, severe wasting (weight-for-height z-score </ = -3.0) was also associated with reduced survival. CONCLUSIONS Cumulative incidence of mortality was 5.2%, 7.1% and 7.7% after 1, 3, and 5 years, respectively, with disproportionate mortality in infants <1 year of age and those presenting with tuberculosis. These findings reinforce the urgent need for early diagnosis and treatment in this population, but also demonstrate that provision of pediatric care in a rural setting can yield outcomes comparable to more resourced urban settings of poor countries.
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Affiliation(s)
- Jason C. Brophy
- Dignitas International, Zomba, Malawi
- Department of Pediatrics, University of Ottawa, Children’s Hospital of Eastern Ontario, Ottawa, Canada
- * E-mail:
| | - Michael T. Hawkes
- Department of Pediatrics, University of Alberta, Stollery Children’s Hospital, Edmonton, Canada
| | - Edson Mwinjiwa
- Zomba Central Hospital, Ministry of Health, Zomba, Malawi
| | | | - Sumeet K. Sodhi
- Dignitas International, Zomba, Malawi
- Department of Family and Community Medicine, University of Toronto, University Health Network, Toronto, Canada
| | - Adrienne K. Chan
- Dignitas International, Zomba, Malawi
- Department of Medicine, University of Toronto, Sunnybrook Hospital, Toronto, Canada
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Laurens MB, Mungwira RG, Nyirenda OM, Divala TH, Kanjala M, Muwalo F, Mkandawire FA, Tsirizani L, Nyangulu W, Mwinjiwa E, Taylor TE, Mallewa J, Blackwelder WC, Plowe CV, Laufer MK, van Oosterhout JJ. TSCQ study: a randomized, controlled, open-label trial of daily trimethoprim-sulfamethoxazole or weekly chloroquine among adults on antiretroviral therapy in Malawi: study protocol for a randomized controlled trial. Trials 2016; 17:322. [PMID: 27431995 PMCID: PMC4950772 DOI: 10.1186/s13063-016-1392-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 05/11/2016] [Indexed: 12/02/2022] Open
Abstract
Background Before antiretroviral therapy (ART) became widely available in sub-Saharan Africa, several studies demonstrated that daily trimethoprim-sulfamethoxazole (TS) prophylaxis reduced morbidity and mortality among HIV-infected adults. As a result, the World Health Organization (WHO) recommended administering TS prophylaxis to this group. However, the applicability of the results to individuals taking ART and living in sub-Saharan Africa has not been definitively evaluated. This study aims to determine if TS prophylaxis benefits HIV-infected Malawian adults after a good response to ART. If TS prophylaxis does indeed show benefit, it is important to determine if this is due to its antibacterial and/or antimalarial properties. Methods/design A randomized, controlled, open-label, phase III trial of continued standard of care prophylaxis with daily trimethoprim-sulfamethoxazole (TS) compared to discontinuation of standard of care TS prophylaxis and starting weekly chloroquine (CQ) prophylaxis or discontinuation of standard of care TS prophylaxis. The study will randomize 1400–1500 HIV-infected adults (equally divided over the three study arms) with a nondetectable viral load and a CD4 count of 250/mm3 or more from antiretroviral therapy clinics in Blantyre and Zomba. The expected rate of primary endpoint events of death and WHO stage 3 and 4 events is 6.8 per 100 person-years of follow-up in all participants. Assuming the number of events follows a Poisson distribution and average participant follow-up after 10 % loss to follow-up is 41.6 months, the study will have approximately 85 % power to rule out a reduction of 35 % or more in primary endpoint events in the TS or CQ arms compared to discontinuation of TS prophylaxis—i.e., to show that discontinuation of TS prophylaxis is noninferior to either TS or CQ, with a noninferiority margin of 35 %. Ethical and regulatory approvals were obtained from the University of Malawi College of Medicine Research Ethics Committee; the Malawi Pharmacy, Medicines and Poisons Board; and the University of Maryland Baltimore Institutional Review Board. Discussion The study began recruitment activities at the Ndirande site in November 2012. The sponsor agreed to extend and expand the study in early 2015, and a second site, Zomba, was added for recruitment and follow-up in mid-2015. Trial registration ClinicalTrials.gov Identifier: NCT01650558 (registered on 6 July 2012). Protocol version Letter of amendment #1 to the DAIDS-ES 10822 TSCQ Malawi Protocol, Version 4.0, 16 December 2014. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1392-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Matthew B Laurens
- Division of Malaria Research, Institute for Global Health, University of Maryland School of Medicine, 480 W Baltimore St, Room 480, Baltimore, MD, 21218, USA.
| | | | | | | | | | | | | | | | | | | | - Terrie E Taylor
- Blantyre Malaria Project, Blantyre, Malawi.,College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA
| | - Jane Mallewa
- University of Malawi College of Medicine, Blantyre, Malawi
| | - William C Blackwelder
- Institute for Global Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Christopher V Plowe
- Division of Malaria Research, Institute for Global Health, University of Maryland School of Medicine, 480 W Baltimore St, Room 480, Baltimore, MD, 21218, USA
| | - Miriam K Laufer
- Division of Malaria Research, Institute for Global Health, University of Maryland School of Medicine, 480 W Baltimore St, Room 480, Baltimore, MD, 21218, USA
| | - Joep J van Oosterhout
- Dignitas International, Zomba, Malawi.,University of Malawi College of Medicine, Blantyre, Malawi
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8
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Kwekwesa A, Kandionamaso C, Winata N, Mwinjiwa E, Joshua M, Garone D, Bedell R, van Oosterhout JJ. Breast enlargement in Malawian males on the standard first-line antiretroviral therapy regimen: Case reports and review of the literature. Malawi Med J 2016; 27:115-7. [PMID: 26715960 DOI: 10.4314/mmj.v27i3.11] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
| | | | - N Winata
- Dignitas International, Zomba, Malawi ; University of Calgary, Calgary, Canada
| | | | - M Joshua
- Zomba Central Hospital, Ministry of Health, Zomba, Malawi
| | - D Garone
- Dignitas International, Zomba, Malawi
| | - R Bedell
- Dignitas International, Zomba, Malawi
| | - J J van Oosterhout
- Dignitas International, Zomba, Malawi ; Department of Medicine, College of Medicine, Blantyre, Malawi
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Beardsley J, Wolbers M, Kibengo FM, Ggayi ABM, Kamali A, Cuc NTK, Binh TQ, Chau NVV, Farrar J, Merson L, Phuong L, Thwaites G, Van Kinh N, Thuy PT, Chierakul W, Siriboon S, Thiansukhon E, Onsanit S, Supphamongkholchaikul W, Chan AK, Heyderman R, Mwinjiwa E, van Oosterhout JJ, Imran D, Basri H, Mayxay M, Dance D, Phimmasone P, Rattanavong S, Lalloo DG, Day JN. Adjunctive Dexamethasone in HIV-Associated Cryptococcal Meningitis. N Engl J Med 2016; 374:542-54. [PMID: 26863355 PMCID: PMC4778268 DOI: 10.1056/nejmoa1509024] [Citation(s) in RCA: 211] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Cryptococcal meningitis associated with human immunodeficiency virus (HIV) infection causes more than 600,000 deaths each year worldwide. Treatment has changed little in 20 years, and there are no imminent new anticryptococcal agents. The use of adjuvant glucocorticoids reduces mortality among patients with other forms of meningitis in some populations, but their use is untested in patients with cryptococcal meningitis. METHODS In this double-blind, randomized, placebo-controlled trial, we recruited adult patients with HIV-associated cryptococcal meningitis in Vietnam, Thailand, Indonesia, Laos, Uganda, and Malawi. All the patients received either dexamethasone or placebo for 6 weeks, along with combination antifungal therapy with amphotericin B and fluconazole. RESULTS The trial was stopped for safety reasons after the enrollment of 451 patients. Mortality was 47% in the dexamethasone group and 41% in the placebo group by 10 weeks (hazard ratio in the dexamethasone group, 1.11; 95% confidence interval [CI], 0.84 to 1.47; P=0.45) and 57% and 49%, respectively, by 6 months (hazard ratio, 1.18; 95% CI, 0.91 to 1.53; P=0.20). The percentage of patients with disability at 10 weeks was higher in the dexamethasone group than in the placebo group, with 13% versus 25% having a prespecified good outcome (odds ratio, 0.42; 95% CI, 0.25 to 0.69; P<0.001). Clinical adverse events were more common in the dexamethasone group than in the placebo group (667 vs. 494 events, P=0.01), with more patients in the dexamethasone group having grade 3 or 4 infection (48 vs. 25 patients, P=0.003), renal events (22 vs. 7, P=0.004), and cardiac events (8 vs. 0, P=0.004). Fungal clearance in cerebrospinal fluid was slower in the dexamethasone group. Results were consistent across Asian and African sites. CONCLUSIONS Dexamethasone did not reduce mortality among patients with HIV-associated cryptococcal meningitis and was associated with more adverse events and disability than was placebo. (Funded by the United Kingdom Department for International Development and others through the Joint Global Health Trials program; Current Controlled Trials number, ISRCTN59144167.).
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Affiliation(s)
- Justin Beardsley
- From the Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme Vietnam (J.B., M.W., J.F., L.M., G.T., J.N.D.), Hospital for Tropical Diseases (N.T.K.C., N.V.V.C.), Cho Ray Hospital (T.Q.B., L.P.), Ho Chi Minh City, and the National Hospital for Tropical Diseases (N.V.K.) and Bach Mai Hospital (P.T.T.), Hanoi - all in Vietnam; Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford (J.B., M.W., J.F., L.M., G.T., M.M., D.D., J.N.D.), University College London, London (R.H.), and Liverpool School of Tropical Medicine, Liverpool (D.G.L.) - all in the United Kingdom; MRC/UVRI Uganda Research Unit on AIDS, Entebbe, Uganda (F.M.K., A.-B.M.G., A.K.); Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok (W.C.), Ubon Sappasithiprasong Hospital, Ubon (S.S., W.S.), and Udon Thani Hospital, Udon Thani (E.T., S.O.) - all in Thailand; Dignitas International, Zomba (A.K.C., E.M., J.J.O.), and Malawi-Liverpool-Wellcome Trust, Clinical Research Programme (R.H., D.G.L.), and University of Malawi College of Medicine (R.H., J.J.O.), Blantyre - all in Malawi; Sunnybrook Health Sciences Centre, University of Toronto, Toronto (A.K.C.); Cipto Mangunkusumo Hospital (D.I.) and Eijkman Oxford Clinical Research Unit (H.B.) - both in Jakarta, Indonesia; and Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Mahosot Hospital (M.M., D.D., P.P., S.R.), and University of Health Sciences (M.M.) - both in Vientiane, Laos
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van Lettow M, Bedell R, Maosa S, Phiri K, Chan AK, Mwinjiwa E, Kwekwesa A, Kawonga H, Joshua M, Harries AD, van Oosterhout JJ. Outcomes and Diagnostic Processes in Outpatients with Presumptive Tuberculosis in Zomba District, Malawi. PLoS One 2015; 10:e0141414. [PMID: 26556045 PMCID: PMC4640882 DOI: 10.1371/journal.pone.0141414] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 10/08/2015] [Indexed: 01/23/2023] Open
Abstract
Background In Malawi, outpatients who have presumptive tuberculosis (TB), i.e. fever, night sweats, weight loss and/or any-duration cough (HIV-infected) or cough of at least 2 weeks (HIV-uninfected), are registered in chronic cough registers. They should receive a diagnostic work-up with first-step provider-initiated HIV testing and sputum testing which includes XpertMTB/RIF, following a national algorithm introduced in 2012. Methods An operational study, in which we prospectively studied 6-month outcomes of adult outpatients who were registered in chronic cough registers in Zomba Central Hospital and Matawale peri-urban Health Center, between February and September 2013. We recorded implementation of the diagnostic protocol and outcomes at 6 months from registration. Results Of 348 patients enrolled, 165(47%) were male, median age was 40 years, 72(21%) had previous TB. At registration 154(44%) were known HIV-positive, 34(10%) HIV-negative (26 unconfirmed) and 160(46%) had unknown HIV status; 104(56%) patients with unknown/unconfirmed HIV status underwent HIV testing. At 6 months 191(55%) were HIV-positive, 87(25%) HIV-negative (26 unconfirmed) and 70(20%) still had unknown HIV status. Higher age and registration in Matawale were independently associated with remaining unknown HIV status after 6 months. 62% of patients had sputum tested, including XpertMTB/RIF, according to the algorithm. TB was diagnosed in 54(15%) patients. This was based on XpertMTB/RIF results in 8(15%) diagnosed cases. In 26(48%) TB was diagnosed on clinical grounds. Coverage of ART in HIV-positive patients was 89%. At 6 months, 236(68%) were asymptomatic, 48(14%) symptomatic, 25(7%) had been lost-to-follow-up and 39(11%) had died. Mortality among those HIV-positive, HIV-negative and with unknown HIV-status was 15%, 2% and 10%, respectively. Male gender, being HIV-positive-not-on-ART and not receiving antibiotics were independent risk factors for mortality. Conclusion HIV prevalence among patients with presumptive TB was high (55%). One quarter was not HIV tested and mortality in this group was substantial (10%). The impact of XpertMTB/RIF on TB diagnosis was limited.
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Affiliation(s)
- Monique van Lettow
- Dignitas International, Zomba, Malawi.,Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | | | | | | | - Adrienne K Chan
- Dignitas International, Zomba, Malawi.,Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.,Division of Infectious Diseases, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | | | | | | | - Martias Joshua
- Zomba Central Hospital, Ministry of Health, Zomba, Malawi
| | - Anthony D Harries
- The International Union against Tuberculosis and Lung Disease, Paris, France.,London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Joep J van Oosterhout
- Dignitas International, Zomba, Malawi.,Department of Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
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Mwinjiwa E, Isaakidis P, Van den Bergh R, Harries AD, Bezanson KD, Beyene T, Thompson C, Joshua M, Akello H, van Lettow M. Burden, characteristics, management and outcomes of HIV-infected patients with Kaposi's sarcoma in Zomba, Malawi. Public Health Action 2015; 3:180-5. [PMID: 26393024 DOI: 10.5588/pha.13.0003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Accepted: 04/14/2013] [Indexed: 01/22/2023] Open
Abstract
SETTING Antiretroviral treatment (ART) clinic at Zomba Central Hospital, Malawi. DESIGN Retrospective analysis of records (2004-2011) of human immunodeficiency virus (HIV) infected patients with Kaposi's sarcoma (KS). OBJECTIVES To determine the number and characteristics of HIV-infected adult patients with KS on ART and vincristine (VCR) therapy and their treatment outcomes. RESULTS A total of 545 HIV-infected patients with KS (58% male, median age 33 years) were included in the study. The baseline median CD4 count was 180 cells/µl (interquartile range 111-287). Cumulative outcomes were as follows: 168 (31%) were still alive, 133 (24%) had died, 172 (32%) were lost to follow-up and 71 (13%) had transferred out; 229 had received at least one course of VCR, 171 had received less than one full course and 145 had not received VCR. The survival probability for 229 patients who received at least one course of VCR was 65% at 1 year, 42% at 2 years and 13% by 6 years. Patients who started VCR therapy before or concurrently with ART had a higher risk of death and generally a higher risk of death and loss to follow-up than those who started VCR after ART. CONCLUSION Poor outcomes were noted in HIV-infected patients with KS in a programme setting in Malawi. Other treatment interventions, including combination and/or second-line chemotherapy and earlier ART initiation, are needed to reduce morbidity and mortality.
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Affiliation(s)
| | - P Isaakidis
- Operational Centre Brussels, Operational Research Unit, Médecins Sans Frontières-Brussels, Brussels, Belgium
| | - R Van den Bergh
- Operational Centre Brussels, Operational Research Unit, Médecins Sans Frontières-Brussels, Brussels, Belgium
| | - A D Harries
- Department of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK ; International Union Against Tuberculosis and Lung Disease, Paris, France
| | - K D Bezanson
- Dignitas International, Zomba, Malawi ; Temmy Latner Centre for Palliative Care, Mount Sinai Hospital, Department of Family & Community Medicine, University of Toronto, Toronto, Ontario, Canada ; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - T Beyene
- Dignitas International, Zomba, Malawi
| | - C Thompson
- School of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - M Joshua
- Ministry of Health, Zomba Central Hospital, Zomba, Malawi
| | - H Akello
- Dignitas International, Zomba, Malawi
| | - M van Lettow
- Dignitas International, Zomba, Malawi ; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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Kumwenda M, Tom S, Chan AK, Mwinjiwa E, Sodhi S, Joshua M, van Lettow M. Reasons for accepting or refusing HIV services among tuberculosis patients at a TB-HIV integration clinic in Malawi. Int J Tuberc Lung Dis 2012; 15:1663-9. [PMID: 22118175 DOI: 10.5588/ijtld.10.0741] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING In Malawi, human immunodeficiency virus (HIV) prevalence among newly registered tuberculosis (TB) patients is 60-70%. In 2008, an integrated TBHIV clinic was established at a central hospital in Zomba. Despite the integration of TB-HIV activities and improved HIV service uptake, unacceptably high proportions of HIV-positive TB patients are still not receiving antiretroviral therapy (ART). OBJECTIVE To identify factors that motivate or discourage TB patients from accepting HIV services. DESIGN Retrospective analysis of patients registered for TB treatment (not yet on ART) between April 2008 and March 2009; qualitative interviews of 99 patients on TB treatment. RESULTS Of 1773 newly registered TB patients who were not already on ART at the time of TB registration, 86% accepted HIV testing and counselling. Among HIV-positive TB patients, 38% started ART during or after anti-tuberculosis treatment. Young adults aged 15- 24 years were least likely to initiate ART. Motivation for accepting ART during TB treatment included prospects of regaining good health and longer life, and counselling by health care providers. Barriers to ART uptake included not being offered ART, high CD4 count, drug stockouts and fear of drug toxicities/interactions. CONCLUSION Several factors that undermine uptake of ART have been highlighted; targeted measures urgently need to be addressed by TB-HIV programmes to overcome these barriers.
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