Iron deficiency and anemia predict mortality in patients with tuberculosis

Many studies have documented a high prevalence of anemia among tuberculosis (TB) patients and anemia at TB diagnosis has been associated with an increased risk of death. However, little is known about the factors contributing to the development of TB-associated anemia and their importance in TB disease progression. Data from a randomized clinical trial of micronutrient supplementation in patients with pulmonary TB in Tanzania were analyzed. Repeated measures of anemia with iron deficiency, anemia without iron deficiency, and iron deficiency without anemia were assessed as risk factors for treatment failure, TB recurrence, and mortality. The prevalence of anemia (hemoglobin < 110 g/L) at baseline was 64%, more than one-half of which was related to iron deficiency (mean corpuscular volume , 80 fL). We found no evidence of an association between anemia (with or without iron deficiency) or iron deficiency without anemia at baseline and the risk of treatment failure at 1 mo after initiation. Anemia without iron deficiency was associated with an independent, 4-fold increased risk of TB recurrence [adjusted RR = 4.10 (95% CI = 1.88, 8.91); P < 0.001]. Iron deficiency and anemia (with and without iron deficiency) were associated with a 2- to nearly 3-fold independent increase in the risk of death [adjusted RR for iron deficiency without anemia = 2.89 (95% CI = 1.53, 5.47); P = 0.001; anemia without iron deficiency = 2.72 (95% CI = 1.50, 4.93); P = 0.001; iron deficiency anemia = 2.13 (95% CI = 1.10, 4.11); P = 0.02]. Efforts to identify and address the conditions contributing to TB-associated anemia, including iron deficiency, could play an important role in reducing morbidity and mortality in areas heavily affected by TB.     

Quality of Life of People With HIV/AIDS Receiving Antiretroviral Therapy in Cuba: A Cross-Sectional Study of the National Population

Objectives. We studied the effect of antiretroviral therapy (ART) on the quality of life (QOL) of Cubans with HIV/AIDS.Methods. We conducted a cross-sectional study including administration of the Medical Outcomes Study–HIV Health Survey Questionnaire to a representative sample of the 1592 Cubans receiving ART in 2004. For univariate analyses, we compared mean HIV scale scores. We used logistic regression models to estimate the association between role function and year of diagnosis, between pain and sex, and between health transition and region of diagnosis, with adjustment for demographics, ART regimen, and clinical status.Results. There were 354 participants (73 women, 281 men). Scores for all functional activities showed means higher than 80 out of 100. Pain interfered more in women than in men (73.2 vs 81.9; P = .01). When HIV diagnosis occurred after 2001, the probability of experiencing difficulties performing work (odds ratio [OR] = 4.42; 95% CI = 1.83, 10.73) and pain (OR = 1.70; 95% CI = 1.01, 2.88) increased compared with earlier diagnosis. People treated with indinavir showed a greater perception of general health (58.9 vs 52.4; P = .045) and greater health improvement (78.6 vs 67.8; P = .002).Conclusions. Although Cubans receiving ART are maintaining a high QOL, we observed significant differences by sex and time of diagnosis. QOL assessment can serve as a health outcome and may allow identification of QOL reductions potentially related to ART side effects.In the Caribbean region, which is characterized by the highest prevalence of HIV outside of sub-Saharan Africa, AIDS is one of the main causes of adult death.1 Cuba has an estimated adult prevalence of HIV of 0.1%—the lowest in the Caribbean and the rest of the Americas—despite a rising HIV incidence.1 Transmission occurs fundamentally among men who have sexual intercourse with other men.2 Cuba is a country with a high development index and a low proportion of people below certain deprivation threshold levels in each of the dimensions of the high development index, as measured by the human poverty index.3Between 1986 and 1994, life in AIDS sanatoria was mandatory for all Cubans diagnosed with HIV—a contentious policy that generated multiple debates.4–7 Sanatoria were originated to provide medical and psychological care and to train people to live with HIV and to cope with the impact of the diagnosis.8,9 Whereas some authors argue that the quarantine contributed to the slow growth of the epidemic in Cuba,2,10 other studies have associated its low-level transmission with high condom use and an intensive policy of HIV testing, counseling, contact tracing, and active follow-up of all people diagnosed with HIV.2 Because of the human and social cost of quarantine, an outpatient care system was initiated in 199411 with the aim of reintroducing people with HIV back into society. By the end of 2008, 74% of those diagnosed with HIV in Cuba received ambulatory care and 26% either lived in sanatoria—now called Centers for Comprehensive Care for People with HIV/AIDS—or were staying there temporarily while they received training on how to live with HIV.12 This training, which is also provided to those in ambulatory care, consists mostly on how to eat a healthy diet, maintain good personal hygiene, keep medical appointments, complete examinations, adhere to treatment, avoid substance use, and prevent HIV transmission and reinfection. To ensure appropriate nutrition, people with HIV are entitled to additional food rations.11Until 1996, some patients received antiretroviral (ARV) monotherapy or dual therapy and, between 1996 and 2001, a small number of patients received triple antiretroviral therapy (ART), mostly through donations. Since 2001, after the Cuban government started to produce generic ARVs,11 ART became the standard regimen, free of cost to the patient.2,11 Nationally produced ARVs included zidovudine (AZT), lamivudine (3TC), stavudine (d4T), indinavir (IDV), didanosine (DDI), and nevirapine (NVP). A greater number of therapeutic combinations was introduced in 2003, when a grant from the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM) allowed the purchase of additional ARVs. In 2003, Cuba achieved universal access to ART11 for all those who met clinical eligibility criteria; that is, HIV infection with a CD4 count less than 350 cells per cubic millimeter with or without opportunistic infections; an AIDS-defining illness such as lymphoma, tuberculosis, or Kaposi’s sarcoma independent of viral load; or a viral load of at least 55 000 copies per milliliter. As of May 2009, 73.4% of patients receiving ART were treated with generic medications manufactured in Cuba, 0.8% with ARVs purchased through the GFATM, and 25.8% with a mix of Cuban generics and ARVs purchased through the GFATM.12In Cuba, the use of ART has proven to be effective, improving immunologic parameters, increasing survival, and diminishing the occurrence of opportunistic infections and AIDS-related mortality11,13—even though development of drug resistance and treatment failure, associated with nonadherence to ART, have been documented.14,15 Now that HIV infection is a chronic illness, quality of life (QOL) assessment can serve as a health outcome and may also allow clinicians and other health workers to identify any reductions in QOL potentially related to short- and long-term side effects of ART. Because nonadherence can be potentially related to reductions in QOL linked with side effects,16 its resulting increased viral load may also have a public health impact in terms of increasing the likelihood of transmission of HIV.17 Although the impact of ART on QOL was explored in a qualitative study among pregnant women in Cuba,18 this article presents the first quantitative study of the effect of the provision of ART on QOL of a nationally representative sample of people living with HIV/AIDS in Cuba.     

Psychosocial support intervention for HIV-affected families in Haiti: implications for programs and policies for orphans and vulnerable children

Given the increased access of antiretroviral therapy (ART) throughout the developing world, what was once a terminal illness is now a chronic disease for those receiving treatment. This requires a paradigmatic shift in service provision for those affected by HIV/AIDS in low-resource settings. Although there is a need for psychosocial support interventions for HIV-affected youth and their caregivers, to date there has been limited empirical evidence on the effectiveness of curriculum-based psychosocial support groups in HIV-affected families in low-income countries. Therefore, the purpose of this study is to examine the feasibility and assess the preliminary effectiveness of a psychosocial support group intervention for HIV-affected youth and their caregivers in central Haiti. The study was conducted at six Partners In Health-affiliated sites between February 2006 and September 2008 and included quantitative as well as qualitative methods. HIV-affected youth (n = 168) and their caregivers (n = 130) completed a baseline structured questionnaire prior to participation in a psychosocial support group intervention. Ninety-five percent of families completed the intervention and a follow-up questionnaire. Psychological symptoms, psychosocial functioning, social support, and HIV-related stigma at baseline were compared with outcomes one year later. Qualitative methods were also used to assess the participants' perspectives of the intervention. Comparing pre- and post-intervention assessment, youth affected by HIV experienced decreased psychological symptoms as well as improved psychosocial functioning and social support. Caregivers (95% HIV-positive) demonstrated a significant reduction in depressive symptoms, improved social support, and decreased HIV-related stigma. Although further study is needed to assess effectiveness in a randomized controlled trial, corroborative findings from qualitative data reflected reduced psychological distress, less social isolation and greater hope for the future for families affected by HIV/AIDS following the intervention.     

Randomized trial of vitamin supplements in relation to transmission of HIV-1 through breastfeeding and early child mortality

BACKGROUND: HIV-1 transmission through breastfeeding is a global problem and has been associated with poor maternal micronutrient status. METHODS: A total of 1078 HIV-infected pregnant women from Tanzania were randomly assigned to vitamin A or multivitamins excluding A from approximately 20 weeks' gestation and throughout lactation. RESULTS: Multivitamins excluding A had no effect on the total risk of HIV-1 transmission (RR 1.04, 95% CI 0.82-1.32, P= 0.76). Vitamin A increased the risk of transmission (RR 1.38, 95% CI 1.09-1.76, P = 0.009). Multivitamins were associated with non-statistically significant reductions in transmission through breastfeeding, and mortality by 24 months among those alive and not infected at 6 weeks. Multivitamins significantly reduced breastfeeding transmission in infants of mothers with low baseline lymphocyte counts (RR 0.37; 95% CI 0.16-0.85, P = 0.02) compared with infants of mothers with higher counts (RR 0.99, 95% CI 0.68-1.45, P = 0.97; -for-interaction 0.03). Multivitamins also protected against transmission among mothers with a high erythrocyte sedimentation rate (P-for-interaction 0.06), low hemoglobin (P-for-interaction 0.06), and low birthweight babies (P-for-interaction 0.04). Multivitamins reduced death and prolonged HIV-free survival significantly among children born to women with low maternal immunological or nutritional status. Vitamin A alone increased breastfeeding transmission but had no effect on mortality by 24 months. CONCLUSION: Vitamin A increased the risk of HIV-1 transmission. Multivitamin (B, C, and E) supplementation of breastfeeding mothers reduced child mortality and HIV-1 transmission through breastfeeding among immunologically and nutritionally compromised women. The provision of these supplements to HIV-infected lactating women should be considered.     

A new human immunodeficiency virus type 1 circulating recombinant form from Tanzania

It is becoming increasingly important to identify and to study human immunodeficiency virus type 1 (HIV-1) circulating recombinant forms (CRFs) with evidence of epidemic spread, since mosaic strains arise frequently, especially in populations where multiple subtypes cocirculate. We describe the almost complete nucleotide sequence of 3 subtype C and D recombinant viruses, selected from a pool of 13 D(gag)-D/C/D(env) perinatally infected infants from Dar es Salaam, Tanzania. All three genomes had cross-over points with approximately the same genomic localization. The subtype C-like sequences were located within pol, vif, vpr, vpu, the first exons of rev and tat, V3, and the U3-R regions of the LTR. Phylogenetic analyses of the full-length genomic sequences from these viruses showed the formation of a distinct subcluster on the HIV-1 subtype D branch. The pattern of recombination of genomes belonging to this new CRF, named CRF10_CD, might have resulted from independent recombination events occurring at high frequency or from a single source that originated earlier in this population. Future surveys will be needed to determine the potential of this CRF for epidemic spread.     

Molecular Basis of Thalassemia in Qatar

There is a paucity of information on the molecular basis of β-thalassemia (thal) in Qatar, a country in the southern part of the Arabian Gulf. To decipher the molecular spectrum of β- thalassemic alleles present in Qatar, we studied 31 clinically recognized patients, including three with sickle cell disease and β-thal, and an additional six cases referred for unexplained microcytic anemia. We found 12 different β-thalassemic alleles and two yet to be defined alleles, mutations likely occurring elsewhere than in the β-globin gene per se. This is quite striking, given the small size of the study population, and highlights not only the ethnic diversity, but also the necessity of further investigating the thalassemic spectrum.