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      Immuno-virologic outcomes and immuno-virologic discordance among adults alive and on anti-retroviral therapy at 12 months in Nigeria

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          Abstract

          Background

          Predictors of immuno-virologic outcomes and discordance and their associations with clinical, demographic, socio-economic and behavioral risk factors are not well described in Nigeria since HIV viral load testing is not routinely offered in public HIV treatment programs.

          Methods

          The HACART study was a multi-center observational clinic-based cohort study of 2585 adults who started HAART between April 2008 and February 2009. A total of 628 patients were randomly selected at 12 months for immuno-virologic analyses.

          Results

          Virologic suppression rate (<400 copies/ml) was 76.7%, immunologic recovery rate (CD4 change from baseline ≥50 cells/mm 3) was 77.4% and immuno-virologic discordance rate was 33%. In multivariate logistic regression, virologic failure was associated with age <30 years (OR 1.79; 95% CI: 1.17-2.67, p= 0. 03), anemia (Hemoglobin < 10 g/dl) (OR 1.71; 95% CI: 1.22-2.61, p= 0. 03), poor adherence (OR 3.82; 95% CI: 2.17-5.97, p= 0. 001), and post-secondary education (OR 0.60; 95% CI: 0.30-0.86, p= 0. 02). Immunologic failure was associated with male gender (OR 1.46; 95% CI: 1.04-2.45, p= 0. 04), and age <30 years (OR 1.50; 95% CI: 1.11-2.39, p= 0. 03). Virologic failure with immunologic success (VL -/CD4 +) was associated with anemia (OR 1.80; 95% CI: 1.13-2.88, p= 0. 03), poor adherence (OR 3.90; 95% CI: 1.92-8.24, p= 0. 001), and post-secondary education (OR 0.40; 95% CI: 0.22-0.68, p= 0. 005).

          Conclusions

          Although favorable immuno-virologic outcomes could be achieved in this large ART program, immuno-virologic discordance was observed in a third of the patients. Focusing on intensified treatment preparation and adherence, young patients, males, persons with low educational status and most importantly baseline anemia assessment and management may help address predictors of poor immuno-virologic outcomes, and improve overall HIV program impact. Viral load testing in addition to the CD4 testing should be considered to identify, characterize and address negative immuno-virologic outcomes and discordance.

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          Outcomes after two years of providing antiretroviral treatment in Khayelitsha, South Africa.

          David Coetzee, Katherine Hildebrand, Andrew Boulle … (2004)
          A community-based antiretroviral therapy (ART) programme was established in 2001 in a South African township to explore the operational issues involved in providing ART in the public sector in resource-limited settings and demonstrate the feasibility of such a service. Data was analysed on a cohort of patients with symptomatic HIV disease and a CD4 lymphocyte count or =50 x 10 cells/l, and 81.8% for those with a baseline CD4 lymphocyte count < 50 x 10 cells/l. The cumulative probability of changing a single antiretroviral drug by 24 months was 15.1% due to adverse events or contraindications, and 8.4% due to adverse events alone. ART can be provided in resource-limited settings with good patient retention and clinical outcomes. With responsible implementation, ART is a key component of a comprehensive response to the epidemic in those communities most affected by HIV.
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            Scaling up of highly active antiretroviral therapy in a rural district of Malawi: an effectiveness assessment.

            Nathan Ford, Limangeni Mankhambo, Gaëlle Fedida … (2006)
            The recording of outcomes from large-scale, simplified HAART (highly active antiretroviral therapy) programmes in sub-Saharan Africa is critical. We aimed to assess the effectiveness of such a programme held by Médecins Sans Frontières (MSF) in the Chiradzulu district, Malawi. We scaled up and simplified HAART in this programme since August, 2002. We analysed survival indicators, CD4 count evolution, virological response, and adherence to treatment. We included adults who all started HAART 6 months or more before the analysis. HIV-1 RNA plasma viral load and self-reported adherence were assessed on a subsample of patients, and antiretroviral resistance mutations were analysed in plasma with viral loads greater than 1000 copies per mL. Analysis was by intention to treat. Of the 1308 patients who were eligible, 827 (64%) were female, the median age was 34.9 years (IQR 29.9-41.0), and 1023 (78%) received d4T/3TC/NVP (stavudine, lamivudine, and nevirapine) as a fixed-dose combination. At baseline, 1266 individuals (97%) were HAART-naive, 357 (27%) were at WHO stage IV, 311 (33%) had a body-mass index of less than 18.5 kg/m2, and 208 (21%) had a CD4 count lower than 50 cells per muL. At follow-up (median 8.3 months, IQR 5.5-13.1), 967 (74%) were still on HAART, 243 (19%) had died, 91 (7%) were lost to follow-up, and seven (0.5%) discontinued treatment. Low body-mass index, WHO stage IV, male sex, and baseline CD4 count lower than 50 cells per muL were independent determinants of death in the first 6 months. At 12 months, the probability of individuals still in care was 0.76 (95% CI 0.73-0.78) and the median CD4 gain was 165 (IQR 67-259) cells per muL. In the cross-sectional survey (n=398), 334 (84%) had a viral load of less than 400 copies per mL. Of several indicators measuring adherence, self-reported poor adherence (<80%) in the past 4 days was the best predictor of detectable viral load (odds ratio 5.4, 95% CI 1.9-15.6). These data show that large numbers of people can rapidly benefit from antiretroviral therapy in rural resource-poor settings and strongly supports the implementation of such large-scale simplified programmes in Africa.
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              Impact of hookworm infection and deworming on anaemia in non-pregnant populations: a systematic review

              Jennifer Smith, Simon J. Brooker (2010)
              Objectives To summarise age- and intensity-stratified associations between human hookworm infection and anaemia and to quantify the impact of treatment with the benzimidazoles, albendazole and mebendazole, on haemoglobin and anaemia in non-pregnant populations. Methods Electronic databases (MEDLINE, EMBASE, PubMed) were searched for relevant studies published between 1980 and 2009, regardless of language, and researchers contacted about potential data. Haemoglobin concentration (Hb) was compared between uninfected individuals and individuals harbouring hookworm infections of different intensities, expressed as standardised mean differences (SMD) and 95% confidence intervals (CI). Meta-analysis of randomised control trials (RCTs) investigated the impact of treatment on Hb and anaemia. Results Twenty-three cross-sectional studies, six pre- and post-intervention studies and 14 trials were included. Among cross-sectional studies, moderate- and heavy-intensity hookworm infections were associated with lower Hb in school-aged children, while all levels of infection intensity were associated with lower Hb in adults. Among RCTs using albendazole, impact of treatment corresponded to a 1.89 g/l increase (95%CI: 0.13–3.63) in mean Hb while mebendazole had no impact. There was a positive impact of 2.37 g/l (95%CI: 1.33–3.50) on mean Hb when albendazole was co-administered with praziquantel, but no apparent additional benefit of treatment with benzimidazoles combined with iron supplementation. The mean impact of treatment with benzimidazoles alone on moderate anaemia was small (relative risk (RR) 0.87) with a larger effect when combined with praziquantel (RR 0.61). Conclusions Anaemia is most strongly associated with moderate and heavy hookworm infection. The impact of anthelmintic treatment is greatest when albendazole is co-administered with praziquantel.
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                Author and article information

                Journal
                Journal ID (nlm-ta): BMC Infect Dis
                Journal ID (iso-abbrev): BMC Infect. Dis
                Title: BMC Infectious Diseases
                Publisher: BioMed Central
                ISSN (Electronic): 1471-2334
                Publication date Collection: 2013
                Publication date (Electronic): 1 March 2013
                Volume: 13
                Page: 113
                Affiliations
                [1 ]Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland, USA
                [2 ]Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
                [3 ]University of Benin Teaching Hospital, Benin City, Edo State, Nigeria
                [4 ]Asokoro District Hospital, Abuja, Federal Capital Territory, Abuja, Nigeria
                [5 ]University of Abuja Teaching Hospital, Abuja, Federal Capital Territory, Abuja, Nigeria
                [6 ]Institute of Human Virology Nigeria, Abuja, Nigeria
                Article
                Publisher ID: 1471-2334-13-113
                DOI: 10.1186/1471-2334-13-113
                PMC ID: 3599241
                PubMed ID: 23452915
                SO-VID: ea1bf8ba-285b-49f2-a1bb-ae98bb9fed7d
                Copyright © Copyright ©2013 Anude et al; licensee BioMed Central Ltd.
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 3 April 2012
                Date accepted : 27 February 2013
                Categories
                Subject: Research Article

                ScienceOpen disciplines: Infectious disease & Microbiology
                Keywords: immuno-virologic outcomes,immuno-virologic discordance,anemia,treatment failure,sub-saharan africa,nigeria,pepfar,anti-retroviral therapy,viral load testing
                Data availability:
                ScienceOpen disciplines: Infectious disease & Microbiology
                Keywords: immuno-virologic outcomes, immuno-virologic discordance, anemia, treatment failure, sub-saharan africa, nigeria, pepfar, anti-retroviral therapy, viral load testing

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