A Markov model for the effects of virological failure on HIV/AIDS progression in tuberculosis co-infected patients receiving antiretroviral therapy in a rural clinic in northern South Africa

Background. The goal of antiretroviral therapy (ART) is to suppress viral replication to undetectable levels. These low viral load (VL) levels may not be attained in some patients, a situation representing potential virological failure during the course of treatment.Objectives. To present the results of a Markov model exploring how virological failure and active tuberculosis (TB) affect the progression of HIV in patients on ART.Methods. A continuous-time non-homogeneous Markov model was used to model the progression of HIV/AIDS in patients on combination ART (cART). We define seven states in our model. The first five states are based on VL levels and the other two are absorbing states: death and withdrawal from the study. The effects of TB co-infection, baseline VL, lactic acidosis and treatment failure on transition intensities were assessed.Results. The model shows that VL-based transition intensities do not follow a constant rate; rather, there are two different trends in HIV/AIDS progression. The first trend is an increase in the prevalence of state 1 (undetectable VL levels) in the first 0.5 years of treatment. The second trend follows thereafter and shows a slow decrease. Within the first 0.5 years of therapeutic intervention, the undetectable VL state is therefore attainable from any VL state. However, when virological failure occurs, there is an increased risk of death. Developing active TB while on cART increases the risk of viral rebound from undetectable levels to VLs between 50 and 10 000 copies/mL by ~1.03-fold. From a VL between 10 000 and 100 000 copies/mL, developing TB while on cART increases the rate of viral rebound by ~2.5-fold. However, if TB is detected and treated at enrolment, rates of viral rebound from undetectable levels are reduced.Conclusions. The model confirms that virological failure, coupled with developing active TB while on cART, increases mortality rates irrespective of patient CD4+ count status. It also suggests that while TB at the time of cART initiation does not increase the risk of viral rebound, development of active TB after cART initiation does increase this risk. These findings highlight the importance of strengthening VL monitoring, which should be performed every 2 months, especially in patients with TB, and addressing unsuppressed VLs appropriately if they are detected.

Global Research Priorities to Better Understand the Burden of Iatrogenic Harm in Primary Care: An International Delphi Exercise

There is a need to identify and reach agreement on key foci for patient safety research in primary care contexts and understand how these priorities differ between low-, middle-, and high-income settings. We conducted a modified Delphi exercise, which was distributed to an international panel of experts in patient safety and primary care. Family practice and pharmacy were considered the main contexts on which to focus attention in order to advance patient safety in primary care across all income categories. Other clinical contexts prioritised included community midwifery and nursing in low-income countries and care homes in high-income countries. The sources of patient safety incidents requiring further study across all economic settings that were identified were communication between health care professionals and with patients, teamwork within the health care team, laboratory and diagnostic imaging investigations, issues relating to data management, transitions between different care settings, and chart/patient record com- pleteness. This work lays the foundation for a range of research initiatives that aim to promote a more comprehensive appreciation of the burden of unsafe primary care, develop understanding of the main areas of risk, and identify interventions that can enhance the safety of primary care provision internationall

Factors influencing treatment default among tuberculosis patients in a high burden province of South Africa

Objective: To determine and describe the factors influencing treatment default of tuberculosis (TB) patients in the Free State Province of South Africa. Methods: A retrospective records review of pulmonary TB cases captured in the ETR.Net electronic TB register between 2003 and 2012 was performed. Subjects were >15 years of age and had a recorded pre-treatment smear result. The demographic and clinical characteristics of defaulters were described. Multivariate logistic regression analysis was used to determine factors associated with treatment default. The odds ratios (OR) together with their corresponding 95% confidence intervals (CI) were estimated. Statistical significance was considered at 0.05. Results: A total of 7980 out of 110 349 (7.2%) cases defaulted treatment. Significantly higher proportions of cases were male (8.3% vs. female: 5.8%; p 64 years: 3.9%; p 2 months: 4.8%; p 24 years old compared to younger cases (25–34 years: AOR 0.8, 95% CI 0.77–0.87; 35–44 years: AOR 0.6, 95% CI 0.50–0.64; 45–54 years: AOR 0.4, 95% CI 0.32–0.49; 55–64 years: AOR 0.3, 95% CI 0.21–0.43; >64 years: AOR 0.3, 95% CI 0.19–0.35). Co-infected cases receiving antiretroviral therapy (ART) were 40% less likely to default TB treatment relative to those whose ART status was unknown (AOR 0.6, 95% CI 0.46–0.57). Conclusions: Salient factors influence TB patient treatment default in the Free State Province. Therefore, the strengthening of clinical and programmatic interventions for patients at high risk of treatment default is recommended. In particular, ART provision to co-infected cases facilitates TB treatment adherence and outcomes

Unsuccessful TB treatment outcomes with a focus on HIV co-infected cases: a cross-sectional retrospective record review in a high-burdened province of South Africa

Abstract Background South Africa did not meet the MDG targets to reduce TB prevalence and mortality by 50% by 2015, and the TB cure rate remains below the WHO target of 85%. TB incidence in the country is largely fuelled by the HIV epidemic, and co-infected patients are more likely to have unsuccessful TB treatment outcomes. This paper analyses the demographic and clinical characteristics of new TB patients with unsuccessful treatment outcomes, as well as factors associated with unsuccessful treatment outcomes for HIV co-infected patients. Methods A cross-sectional retrospective record review of routinely collected data for new TB cases registered in the Free State provincial electronic TB database between 2009 and 2012. The outcome variable, unsuccessful treatment, was defined as cases ≥15 years that ‘died’, ‘failed’ or ‘defaulted’ as the recorded treatment outcome. The data were subjected to descriptive and logistic regression analyses. Results From 2009 to 2012 there were 66,940 new TB cases among persons ≥15 years (with a recorded TB treatment outcome), of these 61% were co-infected with HIV. Unsuccessful TB treatment outcomes were recorded for 24.5% of co-infected cases and 15.3% of HIV-negative cases. In 2009, co-infected cases were 2.35 times more at risk for an unsuccessful TB treatment outcome (OR: 2.35; CI: 2.06-2.69); this figure decreased to 1.8 times by 2012 (OR: 1.80; CI: 1.63-1.99). Among the co-infected cases, main risk factors for unsuccessful treatment outcomes were: ≥ 65 years (AOR: 1.71; CI: 1.25-2.35); receiving treatment in healthcare facilities in District D (AOR: 1.15; CI 1.05-1.28); and taking CPT (and not ART) (AOR: 1.28; CI: 1.05-1.57). Females (AOR: 0.93; CI: 0.88-0.99) and cases with a CD4 count >350 (AOR: 0.40; CI: 0.36-0.44) were less likely to have an unsuccessful treatment outcome. Conclusions The importance of TB-HIV/AIDS treatment integration is evident as co-infected patients on both ART and CPT, and those who have a higher CD4 count are less likely to have an unsuccessful TB treatment outcome. Furthermore, co-infected patients who require more programmatic attention are older people and males

Predictors of condom use and refusal among the population of Free State province in South Africa

<p>Abstract</p> <p>Background</p> <p>This study investigated the extent and predictors of condom use and condom refusal in the Free State province in South Africa.</p> <p>Methods</p> <p>Through a household survey conducted in the Free Sate province of South Africa, 5,837 adults were interviewed. Univariate and multivariate survey logistic regressions and classification trees (CT) were used for analysing two response variables ‘ever used condom’ and ‘ever refused condom’.</p> <p>Results</p> <p>Eighty-three per cent of the respondents had ever used condoms, of which 38% always used them; 61% used them during the last sexual intercourse and 9% had ever refused to use them. The univariate logistic regression models and CT analysis indicated that a strong predictor of condom use was its perceived need. In the CT analysis, this variable was followed in importance by ‘knowledge of correct use of condom’, condom availability, young age, being single and higher education. ‘Perceived need’ for condoms did not remain significant in the multivariate analysis after controlling for other variables. The strongest predictor of condom refusal, as shown by the CT, was shame associated with condoms followed by the presence of sexual risk behaviour, knowing one’s HIV status, older age and lacking knowledge of condoms (i.e., ability to prevent sexually transmitted diseases and pregnancy, availability, correct and consistent use and existence of female condoms). In the multivariate logistic regression, age was not significant for condom refusal while affordability and perceived need were additional significant variables.</p> <p>Conclusions</p> <p>The use of complementary modelling techniques such as CT in addition to logistic regressions adds to a better understanding of condom use and refusal. Further improvement in correct and consistent use of condoms will require targeted interventions. In addition to existing social marketing campaigns, tailored approaches should focus on establishing the perceived need for condom-use and improving skills for correct use. They should also incorporate interventions to reduce the shame associated with condoms and individual counselling of those likely to refuse condoms.</p