Renal impairment in a rural African antiretroviral programme

Background: There is little knowledge regarding the prevalence and nature of renal impairment in African populations initiating antiretroviral treatment, nor evidence to inform the most cost effective methods of screening for renal impairment. With the increasing availability of the potentially nephrotixic drug, tenofovir, such information is important for the planning of antiretroviral programmes Methods: (i) Retrospective review of the prevalence and risk factors for impaired renal function in 2189 individuals initiating antiretroviral treatment in a rural African setting between 2004 and 2007 (ii) A prospective study of 149 consecutive patients initiating antiretrovirals to assess the utility of urine analysis for the detection of impaired renal function. Severe renal and moderately impaired renal function were defined as an estimated GFR of ≤ 30 mls/min/1.73 m2 and 30–60 mls/min/1.73 m2 respectively. Logistic regression was used to determine odds ratio (OR) of significantly impaired renal function (combining severe and moderate impairment). Co-variates for analysis were age, sex and CD4 count at initiation. Results: (i) There was a low prevalence of severe renal impairment (29/2189, 1.3% 95% C.I. 0.8–1.8) whereas moderate renal impairment was more frequent (287/2189, 13.1% 95% C.I. 11.6–14.5) with many patients having advanced immunosuppression at treatment initiation (median CD4 120 cells/μl). In multivariable logistic regression age over 40 (aOR 4.65, 95% C.I. 3.54–6.1), male gender (aOR 1.89, 95% C.I. 1.39–2.56) and CD4<100 cells/ul (aOR 1.4, 95% C.I. 1.07–1.82) were associated with risk of significant renal impairment (ii) In 149 consecutive patients, urine analysis had poor sensitivity and specificity for detecting impaired renal function. Conclusion: In this rural African setting, significant renal impairment is uncommon in patients initiating antiretrovirals. Urine analysis alone may be inadequate for identification of those with impaired renal function where resources for biochemistry are limited

Injuries among adolescents in Greenland: behavioural and socio-economic correlates among a nationally representative sample

Background: Injuries are among the most important threats to adolescent health, making examination of the patterns and risk factors a critical area of research. There exists a paucity of information on the health and injury experience of school-attending adolescents in Greenland. Consenting Greenlandic schoolchildren (n = 2,254) aged 9-19 years were included in the Health Behavior in School-Aged Children study 2005/2006. The aim of this study was to examine the socio-economic and behavioural correlates that were associated with injury occurrence among school-attending Greenlandic adolescents.Methods: This study made use of two multinomial regression models to examine injury occurrence regarding potential influencing factors such as physical activity, risk behaviours, bullying and family socio-economic status (SES).Results: Those self-reporting 1-2 injuries within the recall period were more likely to be male (OR = 1.70; CI [1.39-2.09]), involved in physical fighting (OR = 1.82; CI [1.33-2.47]), bullied (OR = 1.81; CI [1.47-2.24]) and participated in bullying others (OR = 1.53; CI [1.25-1.89]). Those reporting three or more injuries were again mostly male (OR = 2.13; CI [1.44-3.14]), involved in physical fighting at higher rates (OR = 4.47; CI [2.86-7.01]), bullied more often (OR = 2.43; CI [1.65-3.57]) and were more likely to bully others (OR = 1.67; CI [1.13-2.45]). Living without a mother proved to be significantly correlated with suffering 3 or more injuries during the recall period (OR = 1.63; CI [1.05-2.52]). The study results support the idea that factors that were found to be associated with injury occurrence, such as bullying and aggressive behaviour, should be taken into account when conducting future research on the nature of injuries among Greenlandic adolescents. More research on this topic is needed to identify factors that might modify the associations between injuries and adolescent behaviour and SES

Errors in ‘BED’-Derived Estimates of HIV Incidence Will Vary by Place, Time and Age

The BED Capture Enzyme Immunoassay, believed to distinguish recent HIV infections, is being used to estimate HIV incidence, although an important property of the test--how specificity changes with time since infection--has not been not measured.We construct hypothetical scenarios for the performance of BED test, consistent with current knowledge, and explore how this could influence errors in BED estimates of incidence using a mathematical model of six African countries. The model is also used to determine the conditions and the sample sizes required for the BED test to reliably detect trends in HIV incidence.If the chance of misclassification by BED increases with time since infection, the overall proportion of individuals misclassified could vary widely between countries, over time, and across age-groups, in a manner determined by the historic course of the epidemic and the age-pattern of incidence. Under some circumstances, changes in BED estimates over time can approximately track actual changes in incidence, but large sample sizes (50,000+) will be required for recorded changes to be statistically significant.The relationship between BED test specificity and time since infection has not been fully measured, but, if it decreases, errors in estimates of incidence could vary by place, time and age-group. This means that post-assay adjustment procedures using parameters from different populations or at different times may not be valid. Further research is urgently needed into the properties of the BED test, and the rate of misclassification in a wide range of populations

The cost-of-illness due to rheumatic heart disease: national estimates for Fiji

Background Rheumatic heart disease (RHD) is a chronic valvular heart disease that is responsible for a heavy burden of premature mortality in low- and middle-income countries. The total costs of RHD are important to health policy and research investment decisions. We estimate for the first time the total cost of RHD for Fiji (2008–2012) using a cost-of-illness approach and novel primary data on RHD disease burden and costs. Methods RHD cases were identified using probabilistic record linkage across four routine data sources: (1) the Fiji RHD Control Program, (2) national hospital admissions records, (3) the Ministry of Health database of cause-specific deaths and (4) hospital ECG clinic registers. For each individual with RHD, we obtained information on RHD hospital admissions, treatment and death. We conducted a prevalence-based cost-of-illness analysis, including bottom-up assessment of indirect and direct (healthcare) costs. Results The estimated cost of RHD in Fiji for 2008–2012 was year-2010 $FJ91.6 million (approximately US$47.7 million). Productivity losses from premature mortality constituted the majority of costs (71.4%). Indirect costs were 27-fold larger than the direct costs. Conclusions RHD leads to a heavy economic burden in Fiji. Improved prevention strategies for RHD will likely confer substantial economic benefits to the country

Need for timely paediatric HIV treatment within primary health care in rural South Africa

&lt;p&gt;Background: In areas where adult HIV prevalence has reached hyperendemic levels, many infants remain at risk of acquiring HIV infection. Timely access to care and treatment for HIV-infected infants and young children remains an important challenge. We explore the extent to which public sector roll-out has met the estimated need for paediatric treatment in a rural South African setting.&lt;/p&gt; &lt;p&gt;Methods: Local facility and population-based data were used to compare the number of HIV infected children accessing HAART before 2008, with estimates of those in need of treatment from a deterministic modeling approach. The impact of programmatic improvements on estimated numbers of children in need of treatment was assessed in sensitivity analyses.&lt;/p&gt; &lt;p&gt;Findings: In the primary health care programme of HIV treatment 346 children &#60;16 years of age initiated HAART by 2008; 245(70.8%) were aged 10 years or younger, and only 2(&#60;1%) under one year of age. Deterministic modeling predicted 2,561 HIV infected children aged 10 or younger to be alive within the area, of whom at least 521(20.3%) would have required immediate treatment. Were extended PMTCT uptake to reach 100% coverage, the annual number of infected infants could be reduced by 49.2%.&lt;/p&gt; &lt;p&gt;Conclusion: Despite progress in delivering decentralized HIV services to a rural sub-district in South Africa, substantial unmet need for treatment remains. In a local setting, very few children were initiated on treatment under 1 year of age and steps have now been taken to successfully improve early diagnosis and referral of infected infants.&lt;/p&gt

Socio-Demographic Determinants of Condom Use Among Sexually Active Young Adults in Rural KwaZulu-Natal, South Africa

AIM: To investigate patterns, levels and socio-demographic determinants of condom use and consistency of use among young adults aged 15-24 years.BACKGROUND: Condoms are known to prevent HIV infection. However, HIV prevalence and incidence remain high.METHODS: This study was conducted in the Africa Centre Demographic Surveillance Area (ACDSA) in rural KwaZulu-Natal. Analysis focused on resident young adults aged 15-24 years in 2005. In univariable and multivariable analyses, determinants of condom use and consistency of use among 15-24 year olds were estimated using data collected in 2005. 'Ever' condom use was defined as the proportion who reported having used a condom; consistent use among those ever using as "always" using condoms with most recent partner in the last year.RESULTS: 3,914 participants aged 15-24 years reported ever having sex, of whom 52% reported condom use. Adjusting for age, sex, number of partners, residence of partner, partner age difference, type of partner and socio-economic status (SES), having an older partner decreased likelihood (aOR=0.69, p&lt;0.01), while belonging to a household in a higher SES increased likelihood of ever using condoms (aOR=1.82, p&lt;0.01). Being female (aOR=0.61 p&lt;0.01) and having a regular partner (aOR=0.65 p&lt;0.01) were independently associated with low consistent condom use.CONCLUSIONS: In this rural South African setting, condom use remains low, especially among females and with an older partner, situations commonly associated with increased HIV acquisition. Targeted supportive interventions to increase condom use need to be developed if HIV prevention programmes are to be successful

Population uptake of antiretroviral treatment through primary care in rural South Africa

<p>Abstract</p> <p>Background</p> <p>KwaZulu-Natal is the South African province worst affected by HIV and the focus of early modeling studies investigating strategies of antiretroviral treatment (ART) delivery. The reality of antiretroviral roll-out through primary care has differed from that anticipated and real world data are needed to inform the planning of further scaling up of services. We investigated the factors associated with uptake of antiretroviral treatment through a primary healthcare system in rural South Africa.</p> <p>Methods</p> <p>Detailed demographic, HIV surveillance and geographic information system (GIS) data were used to estimate the proportion of HIV positive adults accessing antiretroviral treatment within northern KwaZulu-Natal, South Africa in the period from initiation of antiretroviral roll-out until the end of 2008. Demographic, spatial and socioeconomic factors influencing the likelihood of individuals accessing antiretroviral treatment were explored using multivariable analysis.</p> <p>Results</p> <p>Mean uptake of ART among HIV positive resident adults was 21.0% (95%CI 20.1-21.9). Uptake among HIV positive men (19.2%) was slightly lower than women (21.8%, P = 0.011). An individual's likelihood of accessing ART was not associated with level of education, household assets or urban/rural locale. ART uptake was strongly negatively associated with distance from the nearest primary healthcare facility (aOR = 0.728 per square-root transformed km, 95%CI 0.658-0.963, <it>P </it>= 0.002).</p> <p>Conclusions</p> <p>Despite concerns about the equitable nature of antiretroviral treatment rollout, we find very few differences in ART uptake across a range of socio-demographic variables in a rural South African population. However, even when socio-demographic factors were taken into account, individuals living further away from primary healthcare clinics were still significantly less likely to be accessing ART</p