Antiretroviral treatment among co-infected tuberculosis patients in integrated and non-integrated facilities

Background: South Africa has the second worst tuberculosis-human immunodeficiency virus (TB-HIV) syndemic in the world: in 2011, the TB-HIV co-infection rate was estimated at 65%. Integration of TB and HIV health-care services was implemented to increase antiretroviral treatment (ART) uptake among eligible patients.Aim: To evaluate whether integrated TB and HIV facilities had better ART uptake among eligible patients compared to non-integrated facilities.Methods: A cross-sectional study using routine TB programme data from January to December 2010. ART eligibility was defined as a CD4+ cell count <350 cells/μl.Results: Respectively 2761 (86.8%) and 3611 (84.7%) patients were eligible for ART at integrated and non-integrated facilities (P < 0.001). The proportion of patients started on ART at integrated facilities did not differ significantly from that of non-integrated facilities (35.9% vs. 37.1%, P = 0.340), but the proportion with unknown HIV status (31.8% vs. 24.5%, P < 0.001) and unknown CD4+ cell count (40.9% vs. 30.4%, P < 0.001) did.Conclusion: Integration of TB and HIV services in the Free State (2009–2010) was not associated with improved ART uptake. The reasons why are not clear. Of concern are the high proportions of unknown HIV status and CD4+ cell count results, especially at integrated facilities, and the small proportion of patients on ART, which may indicate poor implementation of integration.     

Integrating tuberculosis and HIV services in rural Kenya: uptake and outcomes

Setting: Seventeen rural public health facilities in Western Kenya that introduced three models of integrated care for tuberculosis (TB) and human immunodeficiency virus (HIV) patients.Objective: To assess the uptake and timing of cotrimoxazole preventive therapy (CPT) and antiretroviral treatment (ART) as well as anti-tuberculosis treatment outcomes among HIV-infected TB patients before (March–October 2010) and after (March–October 2012) the introduction of integrated TB-HIV care.Design: A before-and-after cohort study using programme data.Results: Of 501 HIV-infected TB patients, 357 (71%) were initiated on CPT and 178 (39%) on ART in the period before the introduction of integrated TB-HIV care. Following the integration of services, respectively 316 (98%) and 196 (61%) of 323 HIV-infected individuals were initiated on CPT and on ART (P < 0.001). The median time to CPT and ART initiation dropped from 7 to 2 days and from 42 to 34 days during the pre- and post-integration phases, respectively. Overall TB success rates did not vary with integration or with type of model instituted.Conclusion: Integration of TB and HIV services enhanced uptake and reduced delay in instituting CPT and ART in rural health facilities. There is a need to increase impetus in these efforts.     

HIV/AIDS合并梅毒患者 临床特征及长期抗病毒治疗研究

[摘要]　目的　探讨HIV/AIDS合并梅毒患者临床特征及长期抗反转录病毒治疗（anti-retroviral therapy, ART）的病毒学、免疫学效果以及梅毒复发和/或再感染情况。方法?收集2017年1月1日—2019年12月31日在首都医科大学附属北京佑安医院进行初始ART的HIV/AIDS患者的基本信息和实验室检测数据,分析患者的临床特征及其ART后病毒学、免疫学效果以及梅毒复发及再感染情况。结果?共纳入728例HIV合并梅毒感染者,其中99.6%为男性,97.7%为同性性传播感染者,ART时间中位数为950（691,1217） d,从诊断到开始ART的中位时间为15.5（8.0,41.0） d,诊断至开始ART时间≥180 d以上的患者占14.7%（107/728）。经过治疗,患者CD4+ T淋巴细胞计数增加了242（130,369）个/μl,99.3%（723/728）的患者HIV载量控制在400拷贝ml以内。经足量、规律驱梅治疗6～12个月后,梅毒复发和/或再感染率为18.4%（134/728）。结论?HIV/AIDS合并梅毒患者经长期ART后病毒学、免疫学效果良好,梅毒的复发和/或再感染率较高,梅毒足量规则治疗的同时,加强性健康宣教和定期随访复查至关重要。     

Timing of antiretroviral therapy and effects on tuberculosis treatment outcomes in HIV-co-infected patients in Malawi

Setting:

Queen Elizabeth Central Hospital, Blantyre, Malawi.

Objectives:

To determine 1) the proportion of human immunodeficiency virus (HIV) infected tuberculosis (TB) patients started on antiretroviral therapy (ART), 2) the timing of ART and 3) the effect of the timing on TB treatment outcomes.

Design:

A retrospective record review of HIV-infected TB patients registered from January to December 2009.

Results:

A total of 3376 TB patients were registered, of whom 2665 (79%) were HIV-tested and 2042 (77%) were HIV-infected. A total of 1190 HIV-infected TB patients who were not on ART at the time of starting TB treatment were studied. Of 688 (58%) who started ART, 61% started therapy within 2 months of anti-tuberculosis treatment and 39% started later (≥2 months). Treatment success for patients with TB who started ART within 2 months was higher than for those starting ART later (RR 1.6, 95%CI 1.4–1.8), and death rates were lower (RR 0.25, 95%CI 0.19–0.35).

Conclusion:

Under routine programme conditions in Malawi, a higher proportion of HIV-infected TB patients who started ART did so within 2 months of starting TB treatment, and early ART intervention was associated with better treatment outcomes. This confirms recommendations that co-infected TB patients should start ART early.     

Simplified methods of determining treatment retention in Malawi: ART cohort reports vs. pharmacy stock cards

Setting:

Rapid scale-up of antiretroviral therapy (ART) has challenged the health system in Malawi to monitor large numbers of patients effectively.

Objective:

To compare two methods of determining retention on treatment: quarterly ART clinic data aggregation vs. pharmacy stock cards.

Design:

Between October 2010 and March 2011, data on ART outcomes were extracted from monitoring tools at five facilities. Pharmacy data on ART consumption were extracted. Workload for each method was observed and timed. We used intraclass correlation and Bland-Altman plots to compare the agreeability of both methods to determine treatment retention.

Results:

There is wide variability between ART clinic cohort data and pharmacy data to determine treatment retention due to divergence in data at sites with large numbers of patients. However, there is a non-significant trend towards agreeability between the two methods (intraclass correlation coefficient > 0.9; P > 0.05). Pharmacy stock card monitoring is more time-efficient than quarterly ART data aggregation (81 min vs. 573 min).

Conclusion:

In low-resource settings, pharmacy records could be used to improve drug forecasting and estimate ART retention in a more time-efficient manner than quarterly data aggregation; however, a necessary precondition would be capacity building around pharmacy data management, particularly for large-sized cohorts.     

Decline in national tuberculosis notifications with national scale-up of antiretroviral therapy in Malawi

From 2000 to 2012, Malawi scaled up antiretroviral therapy (ART) from <3000 to 404 905 persons living with HIV/AIDS (human immunodeficiency virus/acquired immune-deficiency syndrome), representing an ART coverage of 40.6% among those living with HIV. During this time, annual tuberculosis (TB) notifications declined by 28%, from 28 234 to 20 463. Percentage declines in annual TB case notifications were as follows: new TB (26%), recurrent TB (40%), new smear-positive pulmonary TB (19%), new smear-negative pulmonary TB (42%), extra-pulmonary TB (19%), HIV-positive TB (30%) and HIV-negative TB (10%). The decline in TB notifications is associated with ART scale-up, supporting its value in controlling TB in high HIV prevalence areas in sub-Saharan Africa.     

Characteristics and treatment outcomes of tuberculosis retreatment cases in three regional hospitals,Uganda

Setting:

Three regional referral hospitals in Uganda with a high burden of tuberculosis (TB) and human immunodeficiency virus (HIV) cases.

Objective:

To determine the treatment outcomes of TB retreatment cases and factors influencing these outcomes.

Design:

A retrospective cohort study of routinely collected National Tuberculosis Programme data between 1 January 2009 and 31 December 2010.

Results:

The study included 331 retreatment patients (68% males), with a median age of 36 years, 93 (28%) of whom were relapse smear-positive, 21 (6%) treatment after failure, 159 (48%) return after loss to follow-up, 26 (8%) relapse smear-negative and 32 (10%) relapse cases with no smear performed. Treatment success rates for all categories of retreatment cases ranged between 28% and 54%. Relapse smear-positive (P = 0.002) and treatment after failure (P = 0.038) cases were less likely to have a successful treatment outcome. Only 32% of the retreatment cases received a Category II treatment regimen; there was no difference in treatment success among patients who received Category II or Category I treatment regimens (P = 0.73).

Conclusion:

Management of TB retreatment cases and treatment success for all categories in three referral hospitals in Uganda was poor. Relapse smear-positive or treatment after failure cases were less likely to have a successful treatment outcome.     

Targeting CD4 testing to a clinical subgroup of patients could limit unnecessary CD4 measurements, premature antiretroviral treatment and costs in Thyolo District, Malawi

Malawi offers antiretroviral treatment (ART) to all HIV-positive adults who are clinically classified as being in WHO clinical stage III or IV without 'universal' CD4 testing. This study was conducted among such adults attending a rural district hospital HIV/AIDS clinic (a) to determine the proportion who have CD4 counts >or=350 cells/microl, (b) to identify risk factors associated with such CD4 counts and (c) to assess the validity and predictive values of possible clinical markers for CD4 counts >or=350 cells/microl. A CD4 count >or=350 cells/microl was found in 36 (9%) of 401 individuals who are thus at risk of being placed prematurely on ART. A body mass index (BMI) >22 kg/m(2), the absence of an active WHO indicator disease at the time of presentation for ART, and a total lymphocyte count >1,200 cells/microl were significantly associated with such a CD4 count. The first two of these variables could serve as clinical markers for selecting subgroups of patients who should undergo CD4 testing. In a resource-limited district setting, assessing the BMI and checking for active opportunistic infections are routine clinical procedures that could be used to target CD4 measurements, thereby minimising unnecessary CD4 measurements, unnecessary (too early) treatment and costs.     

Preferential adherence to antiretroviral therapy over tuberculosis treatment: A qualitative study of drug-resistant TB/HIV co-infected patients in South Africa

Adherence to antiretroviral therapy (ART) and second-line antituberculosis medications is essential to achieve successful outcomes among individuals co-infected with HIV and multi or extensively drug-resistant TB (M/XDR-TB). In 2012–2013, we designed a qualitative study to explore barriers to adherence in KwaZulu-Natal, South Africa. We conducted six focus groups comprising 23 adults receiving treatment for either MDR-TB (n = 2) or XDR-TB (n = 21); 17 were on concurrent ART. Participants expressed a preference for ART over M/XDR-TB treatment as a result of greater tolerability, lower pill burden and a commitment to ART. Treatment outcomes and the social morbidity associated with M/XDR-TB, characterised by public notification, stigma and social isolation, were perceived to be worse than with HIV. Poor communication, low patient involvement and provider supervision of treatment exacerbated participants' negative experiences with TB care. To improve adherence, it is critical that new regimens for drug-resistant TB be developed with better efficacy, lower pill burden and fewer adverse effects. For the first time, such improved regimens are on the horizon. In parallel and equally important is the implementation of a cohesive approach that promotes patient involvement, empowerment and treatment literacy for HIV and for TB.     

Decline in adverse outcomes and death in tuberculosis patients in Malawi: association with HIV interventions

Between 2000 and 2012, the annual numbers of patients treated for tuberculosis (TB) in Malawi declined by 28%, from 28 234 to 20 463. During this time, the proportion of TB patients tested for the human immunodeficiency virus (HIV) increased from 6% to 87%. Most HIV-infected patients received cotrimoxazole preventive therapy, and the proportion receiving antiretroviral therapy increased to 88%. Between 2000 and 2008 there was a significant decline in all adverse outcomes (from 31% to 14%), and particularly in deaths (from 23% to 10%) and loss to follow-up (from 5.2% to 1.9%, P < 0.001). After 2008, there was no decrease in any adverse outcome. Ways to further reduce TB-associated mortality are discussed.     

Prevalence and indicators of HIV and AIDS among adults admitted to medical and surgical wards in Blantyre,Malawi

Despite high seroprevalence there are few recent studies of the effect of human immunodeficiency virus (HIV) on hospitals in sub-Saharan Africa. We examined 1226 consecutive patients admitted to medical and surgical wards in Blantyre, Malawi during two 2-week periods in October 1999 and January 2000: 70% of medical patients were HIV-positive and 45% had acquired immune deficiency syndrome (AIDS); 36% of surgical patients were HIV-positive and 8% had AIDS. Seroprevalence rose to a peak among 30-40 year olds; 91% of medical, 56% of surgical and 80% of all patients in this age group were HIV-positive. Seropositive women were younger than seropositive men (median age 29 vs. 35 years, P < 0.0001). Symptoms strongly indicative of HIV were history of shingles, chronic diarrhoea or fever or cough, history of tuberculosis (TB), weight loss and persistent itchy rash (adjusted odds ratios [AORs] all > 5). Clinical signs strongly indicative of HIV were oral hairy leukoplakia, shingles scar, Kaposi's sarcoma, oral thrush and hair loss (AORs all > 10). Of surgical patients with 'deep infections' (breast abscess, pyomyositis, osteomyelitis, septic arthritis and multiple abscesses), 52% were HIV-positive (OR compared with other surgical patients = 2.4). Severe bacterial infections, TB and AIDS caused 68% of deaths. HIV dominates adult medicine, is a major part of adult surgery, is the main cause of death in hospital and affects the economically active age group of the population.     

Point-of-use water treatment and use among mothers in Malawi

A national household survey was conducted in Malawi to determine awareness and use of a socially marketed water treatment product. In all, 64% of mothers were aware of the product, and 7% were using it. Both poor and rural mothers had lower awareness and use rates. Targeting promotion to rural populations could enhance program effectiveness.     

社会支持和羞辱歧视与HIV/AIDS抗病毒治疗的关联分析

目的 探讨社会支持和艾滋病相关羞辱歧视对艾滋病病毒感染者和艾滋病病人(HIV/AIDS)抗病毒治疗(antiretroviral therapy, ART)的影响,为进一步提高ART覆盖率提供指导依据。方法 对山东省现存活HIV/AIDS进行问卷调查,了解其社会人口学特征、艾滋病及ART相关知识知晓情况、社会支持及艾滋病相关羞辱与歧视情况,运用逐步logistic回归模型分析上述因素与HIV/AIDS接受ART间的关系。结果 本研究共调查1 294例HIV/AIDS,其中接受ART的有1 047人,治疗率为80.9%。Logistic回归结果显示,主观支持分数高的HIV/AIDS比分数低者更愿意接受ART (OR=1.06, 95%CI:1.03～1.08);与不知晓ART副作用的HIV/AIDS相比,知晓者更愿意接受ART (OR=1.49, 95%CI:1.12～2.00);与家庭歧视分数高的HIV/AIDS相比,分数低者更愿意接受ART (OR=0.98, 95%CI:0.96～0.99);与未婚HIV/AIDS相比,已婚有配偶(OR=1.49, 95%CI:1.09～2.04)...     

The missing cases of tuberculosis in Malawi: the contribution from cross-border registrations

Low case detection rates of new smear-positive pulmonary tuberculosis (PTB) patients globally are a cause for concern. The aim of this study was to determine for patients registered for TB in Malawi the number and percentage who lived in a neighbouring country and the registration, recording and reporting practices for these 'foreign' patients. All 44 non-private hospitals, which register and treat all TB patients in the public health sector in Malawi, were visited. Ten (23%) hospitals in 2001 and 14 (32%) in 2002 maintained a separate register for cross-border TB cases. Patients recorded in these registers were not formally reported to the Malawi National TB Programme (NTP), the neighbouring country's NTP, nor to WHO. They therefore constitute missing cases. In Malawi, the number of cross-border new smear-positive PTB cases was 77 in 2001 and 91 in 2002, constituting about 3% of missing smear-positive cases in those hospitals that maintain cross-border registers and about 1% of missing cases nationally.     

序贯治疗中ART启动时间对TB/HIV患者的免疫学影响分析

目的　探讨抗反转录病毒治疗（antiretroviral therapy, ART）序贯抗结核治疗（antituberculosis therapy, ATT）中ART启动时间对结核病（tuberculosis, TB）/HIV患者CD4+ T、CD8+ T细胞计数及CD4/CD8比值的影响。方法　收集云南省传染病医院2014年1月—2017年12月间收治入院的TB/HIV患者病历资料。根据ART启动时间分为A组（ART基础上启动ATT）、B组（ATT 8周内启动ART）、C组（ATT 8周后启动ART）。分析比较48周随访期内3组的免疫学指标差异。结果　共收集TB/HIV患者193例,分为A组90例、B组77例和C组26例。基线时B组的CD4+ T细胞计数低于A组和C组（P均＜0.05）。3组患者在48周随访期内CD4+ T细胞计数、CD4/CD8比值均呈不同程度上升趋势（P均＜0.05）。A组和B组的CD4+ T细胞计数在序贯治疗后开始上升（P均＜0.05）,而C组则延迟至24周开始上升（P＜0.05）。24周、48周时3组的CD4+ T细胞计数差异均无统计学意义（P均＞0.05）,B组的CD4+ T细胞计数增幅高于A组和C组（P均＜0.05）。48周时,3组中仅少数患者的CD4+ T细胞计数恢复至≥500 cells/μl,以B组恢复最为明显（12.99%）。 24周和48周时,CD4+ T细胞计数≥500 cells/μl患者所占比例在3组之间差异均无统计学意义（P均＞0.05）。结论　尚未开始ART的TB/HIV患者应尽早接受ART,以恢复免疫功能,ATT 8周内启动ART,免疫重建效果最佳。     

The effect of marriage and HIV risks on condom use acceptability in rural Malawi

A large and increasing proportion of HIV transmissions in sub-Saharan Africa occur within marriage. Condom use within marriage could, therefore, be an important prevention strategy, but there is considerable debate about whether married couples would be willing to use condoms. This paper contributes to this debate by identifying key factors that affect the acceptability of condom use within marriage and actual condom use among men and women in rural Malawi, using three waves of longitudinal data from 2004, 2006 and 2008. Specifically, we focused on the effect of (1) entry into first marriage, (2) respondent's HIV status, HIV perceptions, and risk behaviors, and (3) spouse's HIV characteristics on condom use acceptability within marriage and actual condom use with a spouse or steady partner. Using fixed-effects regression, we found that getting married coincides with a pronounced attitudinal shift regarding the acceptability of condom use within marriage that cannot be explained by differences in fertility status or selection into marriage. In addition, we found that, for women, perceived HIV status of the respondent and spouse generally had greater influence than actual HIV status on the acceptability of condom use within marriage and actual condom use with a spouse or steady partner, even after HIV status is known; while actual HIV status and HIV risk behaviors are generally more important among men. Although condom use within marriage remained low, these findings suggest that attitudes about and use of condoms are susceptible to change and that both marital status and perceptions of risk are important influences on condom use.     

Diagnostic management and outcomes of pulmonary tuberculosis suspects admitted to a central hospital in Malawi

Setting:

Zomba Central Hospital, Malawi.

Objective:

To determine diagnostic management and outcomes of pulmonary tuberculosis (PTB) suspects admitted to adult wards.

Design:

A retrospective, cross-sectional review of medical records of patients admitted to hospital between July and September 2010.

Results:

There were 141 PTB suspects. Sputum examination was requested and performed in 67 (48%) suspects, but none were smear-positive. Chest X-ray (CXR) was requested and performed in 26 (39%) suspects whose sputum smears were negative. Eleven suspects had a CXR suggestive of PTB: two were started on TB treatment and eight died before treatment started. Human immunodeficiency virus (HIV) status was known for 50 patients (35% of all suspects) on admission, all of whom were HIV-positive. HIV testing was requested for 37 patients, but was only performed in 12, five of whom were HIV-positive. Only one patient was referred for antiretroviral treatment. There were 41 (29%) deaths, eight of whom had probable TB and were not treated. In the remaining 33 patients who died, only nine (27%) had sputum smears examined and four (12%) had a CXR.

Conclusion:

The study shows inadequacies in the diagnostic management of PTB suspects in the Zomba Central Hospital, but suggests opportunities for improvement.     

中国部分地区人类免疫缺陷病毒感染者/艾滋病患者合并感染HBV或/和HCV的研究进展

分析德宏傣族景颇族自治州（简称“德宏州”）人类免疫缺陷病毒（HIV）双阳性夫妻合并丙型肝炎病毒（HCV）感染特征和影响因素。

利用2016—2019年德宏州新报告的HIV双阳性夫妻病例疫情卡片,收集不同性别配偶的一般人口学信息、接触史、HCV感染情况等资料,探究HIV双阳性夫妻特征和合并HCV感染的情况。

纳入的160对HIV双阳性夫妻中,有46例（28.8%）男性、14例（8.8%）女性HIV感染者合并感染HCV。单因素分析显示,HIV确诊年龄<40岁、景颇族、缅甸籍、未接受系统教育、农民和有注射毒品史的男性配偶合并HCV感染率更高;HIV确诊年龄<40岁、景颇族和缅甸籍的女性配偶合并HCV感染率更高。男性配偶的多因素logistic回归分析显示,景颇族（OR=3.76,95%CI：1.14~12.39）和注射毒品史（OR=29.46,95%CI：2.42~358.42）会增加HCV合并感染率。

德宏州HIV双阳性夫妻HCV合并感染率较高,应针对民族特异性因素和HIV双阳性夫妻不同性别配偶的暴露特点,制定有效的干预策略以减少疾病负担。