Correlates of and barriers to ART adherence among adherence-challenged people living with HIV in southern India

Suboptimal adherence to Antiretroviral Therapy (ART) regimens can lead to the development of drug resistance, virologic and clinical failure, and, on the community level, the spread of drug-resistant HIV. To design effective interventions, it is crucial to understand locally specific barriers to optimal adherence. Self-report data from a cross-sectional sample of 527 adherence-challenged people living with HIV (PLWH) in the South-Indian state of Karnataka showed that they took on average 68% of prescribed doses in the past month. Large majorities of participants encountered individual (95%), social/structural (88%), and clinic/regimen (80%) adherence barriers. Multivariate linear regression analyses of past month adherence showed that disclosure to all adults in the household was positively related to adherence, as was employing a larger number of adherence strategies, perceiving more benefits of ART, and having been on ART for longer. Fears of stigmatization upon disclosure of HIV-status to friends and people at work were negatively related to adherence. These results suggest that some barriers, especially individual-level barriers like forgetfulness are very common and can be targeted with relatively simple individual-level strategies. Other barriers, related to fear of stigma and lack of disclosure may require family- or community-level interventions.

Prevalence of respiratory syncytial virus infection among children hospitalized with acute lower respiratory tract infections in Southern India

BACKGROUND

Respiratory syncytial virus (RSV) is a leading cause of lower respiratory infections among children.

AIM

To investigate the proportion of RSV and non-RSV respiratory viral infections among hospitalized children ≤ 5 years.

METHODS

Hospitalized children aged < 5 years, with a diagnosis of acute lower respiratory infections (ALRI), admitted between August 2011-August 2013, were included. Cases were defined as laboratory-confirmed RSV and non-RSV respiratory viruses by direct fluorescence assay from the nasopharyngeal wash.

RESULTS

Of 383 1-59 mo old children hospitalized with an acute lower respiratory infection, 33.9% (130/383) had evidence of viral infection, and RSV was detected in 24.5% (94/383). Co-infections with RSV and other respiratory viruses (influenza A or B, adenovirus, para influenza 1, 2 or 3) were seen in children 5.5% (21/383). Over 90% of the RSV-positive children were under 2 years of age. RSV was detected throughout the year with peaks seen after the monsoon season. Children hospitalized with RSV infection were more likely to have been exposed to a shorter duration of breastfeeding of less than 3 mo. RSV positive children had a shorter hospital stay, although there were significant complications requiring intensive care. Use of antibiotics was high among those with RSV and non-RSV viral infections.

CONCLUSION

Our study provides evidence of a high proportion of RSV and other virus-associated ALRI among hospitalized children in India. RSV infection was associated with fewer days of hospital stay compared to other causes of lower respiratory infections. A high level of antibiotic use was seen among all respiratory virus-associated hospitalizations. These results suggest the need for implementing routine diagnostics for respiratory pathogens in order to minimize the use of unnecessary antibiotics and plan prevention strategies among pediatric populations.

Suboptimal adherence associated with virological failure and resistance mutations to first-line highly active antiretroviral therapy (HAART) in Bangalore, India

This study was conducted to examine the relationship between adherence, viral load (VL) and resistance among outpatients receiving highly active antiretroviral therapy (HAART) in Bangalore, India. In total, 552 outpatients were recruited and VL testing was conducted for all study participants. HIV-1 genotypic resistance testing was performed for 92 participants with a VL ≥ 1000 copies/ml. Interpretation of resistance mutations was performed according to the Stanford database. Past-month adherence and treatment interruptions for >48 h were assessed via self-report. At baseline, 34 participants (6%) reported <95% past-month adherence and 110 (20%) reported a history of >48 h treatment interruptions. Combining the two adherence measures, 22% of participants were classified as 'suboptimally adherent'. In total, 24% of study participants (n = 132) had a detectable VL. Among the 92 samples sent for resistance testing, 68% had at least one nucleoside reverse transcriptase inhibitor (NRTI) mutation, with M184V being the most common (62%) and with 48% having thymidine analogue mutations. Moreover, 72% had at least one non-nucleoside reverse transcriptase inhibitor (NNRTI) mutation and 23% had three or more NNRTI mutations. Both adherence measures were significantly associated with VL (P < 0.001). Suboptimal adherence was significantly associated with resistance mutations (P < 0.02). The findings illustrate for the first time the strong association between suboptimal adherence, treatment failure and drug resistance to first-line HAART in India. The predictive value of standard adherence measures was improved by including treatment interruption data. The observed mutations can jeopardise future treatment options, especially in light of limited access to second-line treatments. To develop effective adherence interventions, research is needed to examine culturally-specific reasons for treatment interruptions.

Prevalence of respiratory syncytial virus infection among hospitalized children presenting with acute lower respiratory tract infections

OBJECTIVE

To evaluate the prevalence of RSV among hospitalized young children presenting with ALRI in Bangalore, India.

METHODS

Respiratory syncytial virus (RSV) antigen detection was performed by direct fluorescent antibody (DFA) staining on 77 nasopharyngeal wash samples collected from hospitalized children below 2 years of age with a diagnosis of acute lower respiratory tract infection (ALRI).

RESULTS

Out of 77 samples tested for RSV with DFA, 17 (22.1%) were found RSV-positive with a mean age of 8.24 ± 7.21 months (M:F = 1.8:1). Three children had congenital cardiac disease and one child had a history of prematurity. One child had re-infection within one month of primary infection. RSV-infected children were more likely to have a diagnosis of bronchiolitis than RSV-negative children (p < 0.001).

CONCLUSIONS

RSV infection is a significant cause of morbidity among children presenting with ALRI in southern India. In resource-limited settings, DFA can be used as an important tool for rapid detection of RSV and can potentially eliminate prolonged hospitalization and unnecessary use of antibiotics.

A passive haemagglutination test for rabies antibodies using rabies glycoprotein coupled erythrocytes

The presently recommended tests for assaying rabies antibodies like mouse neutralization test (MINT) and rapid fluorescent focus inhibition test (RFFIT) are either time consuming or expensive and are generally performed in reference laboratories. There is a need to develop a specific and rapid method for detection of rabies antibodies that can be used to monitor sero-conversion after pre-or post-exposure vaccination. In this study, we have developed a passive haemagglutination (PHA) using purified rabies virus glycoprotein coupled to sheep erythrocytes using chromium chloride (0.04%) as a coupling agent. Two hundred and fifty five serum samples from people vaccinated with different rabies vaccines, 16 paired serum and CSF samples from autopsy confirmed cases of paralytic rabies, and serum samples from 65 normal healthy controls were tested and evaluated in comparison to standard MNT. Among the vaccinees, 250 samples were positive both by MNT and PHA but 5 samples were negative by PHA and positive by MNT. The titres obtained by PHA were lower compared to MNT, but there was significant correlation between the two (r=0.885). The specificity of the test was 99.7% and sensitivity was 100% as compared to MNT. Thus this PHA test promises to be a rapid and specific test for assaying rabies antibodies and may be useful in screening large number of serum samples for sero conversion after vaccination. It may also assist in rapid laboratory confirmation of paralytic rabies cases, based on detection of antibodies in CSF and serum.

Comparative evaluation of a simple indirect immunofluorescence test and mouse neutralization test for assaying rabies antibodies

In this study, we have developed and evaluated a simple indirect immunofluorescence test (IIFT) to detect rabies antibodies in a two-step immunofluorescence assay. One hundred and eighty five serum samples from people who had taken different rabies vaccines and 8 pairs of serum and CSF samples from confirmed paralytic rabies cases were tested by IIFT and results evaluated in comparison to standard mouse neutralization test (MNT). Though the titres of rabies antibodies obtained with IIFT were 2-4 times lesser in comparison to MNT, a significant correlation was seen between the two tests (R = 0.883). The specificity of this IIFT was found to be 97.9% and the sensitivity was 97.2%. These results indicate that this simple and rapid IIFT can be used to screen large number of serum samples to monitor sero-conversion after pre or post exposure vaccination and may also assist in rapid ante-mortem diagnosis of atypical human rabies.

Evaluation of two intradermal vaccination regimens using purified chick embryo cell vaccine for post-exposure prophylaxis of rabies

BACKGROUND

Post-exposure prophylaxis for rabies with cell culture vaccines by the conventional intramuscular regimen is very expensive. The World Health Organization has advocated two cost-effective intradermal regimens with cell culture vaccines for use in developing countries. We evaluated these two regimens--the 2-site and the 8-site regimens--in terms of immunogenicity, safety and tolerance in people with category I exposure to rabies.

METHOD

Eighty-two subjects who had mild category I exposure to rabies were immunized using a purified chick embryo cell vaccine. The first regimen given to 43 subjects, consisted of intradermal administration of 0.2 ml of vaccine at 2 sites on days 0, 3 and 7 and at one site on days 28 and 90. The second regimen, given to 39 subjects, consisted of intradermal administration of 0.1 ml of vaccine at 8 sites on day 0, at 4 sites on day 7 and at one site on days 28 and 90. The mouse neutralization test was used to estimate titres of rabies neutralizing antibody in these subjects on different days after vaccination. The subjects were followed up for 1 year.

RESULTS

Both regimens produced adequate neutralizing antibody titres from day 14 onwards, though the second regimen produced a more rapid antibody response and significantly higher titres (p < 0.001) on all days tested. There were minimal side-effects and both regimens were well tolerated.

CONCLUSION

Both the 2-site and 8-site intradermal regimens with purified chick embryo cell vaccine produce adequate levels of neutralizing antibodies but the 8-site regimen appears to be more immunogenic. The feasibility of using these cost-effective regimens in routine practice needs to be further evaluated under the field conditions prevalent in India.