Cutaneous cryptococcosis erroneously diagnosed as histoplasma capsulatum infection

A 31-year-old patient with stage 4 HIV/AIDS presented with recurrent painful skin ulcers for more than 8 months. These would start as subcutaneous skin nodules, later becoming fluctuant and suppurating and then healing spontaneously (Fig. 1). The patient had lesions on the left wrist, left posterior thigh, right axilla, right posterior calf and right upper eyelid. He had also been diagnosed with extrapulmonary tuberculosis and had been on highly active antiretroviral therapy (HAART) for 8 months and antituberculosis medication (continuation phase). After initial poor adherence to both groups of drugs, compliance had improved. The CD4 count at baseline was 16 cells/µl and the latest result was 80 cells/µl. Histological analysis of a biopsy specimen taken from the right upper eyelid lesion showed granulation tissue with some acute inflammation. Fungal spores were seen in the exudates and stains revealed ‘capsule-deficient’ fungi that were first thought to be Histoplasma, and were reported as such

Multiple behaviour change intervention for diarrhoea control in Lusaka, Zambia: a cluster randomised trial

Background Eff ective prevention and control of diarrhoea requires caregivers to comply with a suite of proven measures, including exclusive breastfeeding, handwashing with soap, correct use of oral rehydration salts, and zinc administration. We aimed to assess the eff ect of a novel behaviour change intervention using emotional drivers on caregiver practice of these behaviours. Methods We did a cluster randomised controlled trial in Lusaka Province, Zambia. A random sample of 16 health centres (clusters) were selected from a sampling frame of 81 health centres in three of four districts in Lusaka Province using a computerised random number generator. Each cluster was randomly assigned 1:1 to either the intervention— clinic events, community events, and radio messaging—or to a standard care control arm, both for 6 months. Primary outcomes were exclusive breastfeeding (self-report), handwashing with soap (observation), oral rehydration salt solution preparation (demonstration), and zinc use in diarrhoea treatment (self-report). We measured outcome behaviours at baseline before start of intervention and 4–6 weeks post-intervention through repeat cross-sectional surveys with mothers of an infant younger than 6 months and primary caregivers of a child younger than 5 years with recent diarrhoea. We compared outcomes on an intention-to-treat population between intervention and control groups adjusted for baseline behaviour. The study was registered with ClinicalTrials.gov, number NCT02081521. Findings Between Jan 20 and Feb 3, 2014, we recruited 306 mothers of an infant aged 0–5 months (156 intervention, 150 standard care) and 343 primary caregiver of a child aged 0–59 months with recent diarrhoea (176 intervention, 167 standard care) at baseline. Between Oct 20 to Nov 7, 2014, we recruited 401 mothers of an infant 0–5 months (234 intervention, 167 standard care) and 410 primary caregivers of a child 0–59 months with recent diarrhoea (257 intervention, 163 standard care) at endline. Intervention was associated with increased prevalence of self-reported exclusive breastfeeding of infants aged 0–5 months (adjusted diff erence 10·5%, 95% CI 0·9–19·9). Other primary outcomes were not aff ected by intervention. Cluster intervention exposure ranged from 11–81%, measured by participant self-report with verifi cation questions. Comparison of control and intervention clusters with coverage greater than 35% provided strong evidence of an intervention eff ect on oral rehydration salt solution preparation and breastfeeding outcomes. Interpretation The intervention may have improved exclusive breastfeeding (assessed by self-reporting), but intervention eff ects were diluted in clusters with low exposure. Complex caregiver practices can improve through interventions built around human motives, but these must be implemented more intensely

TB and HIV stigma compounded by threatened masculinity: implications for TB health-care seeking in Malawi.

SETTING: Urban Blantyre, Malawi. OBJECTIVE: To understand why men with tuberculosis (TB) in the community remain undiagnosed. DESIGN: A multi-method qualitative study applying a modified grounded theory approach. Data were gathered from March 2011 to March 2012 from 134 men and women taking part in 1) focus group discussions with community members (n = 6) and health care workers (n = 2), and 2) in-depth interviews with TB patients (n = 20, females n = 14) and chronic coughers (n = 20, women n = 8). Data were analysed inductively to identify, refine and consolidate, and verify emerging concepts and themes. RESULTS: Two emerging themes highlighting compound stigma in this high human immunodeficiency virus (HIV) prevalence, low-income setting are presented. First, cough or any illness that portended a 'serious' condition were accompanied by portrayals of cough, TB and HIV as being interchangeable. Chronic coughers and TB patients described their illness in ways that foregrounded bodily decimation and rupture of social life and masculine identity. Second, 'resistance strategies' entailed resisting classification as (seriously) ill by evading or ambivalently approaching health care, or acknowledging the 'ill' status then actively pursuing health-appropriate behaviours, including changing lifestyle or adopting non-normative gender roles. CONCLUSIONS: Managing patients requires 1) going beyond syndromic management based on vital signs and clinical indicators to recognising and intervening on health care-seeking related tensions to retain individuals in care, and 2) understanding and addressing TB stigma as it manifests and affects men and women differently in specific settings

The occurrence and frequency of genomic mutations that mediate Isoniazid and Rifampicin resistance in Mycobacterium tuberculosis isolates from untreated pulmonary Tuberculosis cases in urban Blantyre, Malawi

This study was funded by the Helse Nord Tuberculosis Initiative (HNTI), a College of Medicine grant supported by the Helse Nord RHF and the University of Tromso.Background The emergence and spread of drug-resistant Tuberculosis (TB) is a major public health threat. TB resistance originates in the course of treatment due to genomic mutations in Mycobacterium tuberculosis (MTB). An increase in new cases with drug-resistant TB could be an indicator of high levels of circulating resistant strains. This study was conducted to determine the occurrence and frequency of genomic mutations that mediate Isoniazid (INH) and Rifampicin (RIF) resistance among isolates from untreated TB cases in urban Blantyre, Malawi. Methods A cross-sectional retrospective study was conducted on a panel of 141(n=141) MTB clinical isolates recovered between June 2010 and January 2012 from ≥2+ Ziehl-Neelsen smear positive new pulmonary-TB patients with no history of treatment. Frozen isolates were revived using the BACTEC MGIT detection system. DNA was extracted using GenoLyse DNA extraction kit and detection of genomic mutations was carried out using the GenoType MTBDRplus Ver 2.0 assay. Results Out of the 141 isolates studied, 3 (2.1%) were found carrying mutations in the katG gene that confer resistance to Isoniazid (INH). No mutations were detected in the inhA promoter region gene that confer weak INH resistance or in the rpoB gene that confer Rifampicin resistance. All katG mutant genes had a S315T1 single point mutation, a genomic alteration that mediates high INH resistance. Conclusion The katG mutant gene conferring resistance to INH was the only genomic mutation observed among the isolates studied and the frequency of occurrence was low. Our findings suggest low levels of circulating drug-resistant MTB strains in urban Blantyre, Malawi.Publisher PDFPeer reviewe

Alcohol reduction outcomes following brief counseling among adults with HIV in Zambia: A sequential mixed methods study

Data from sub-Saharan Africa on the impact of alcohol on the HIV epidemic in sub-Saharan Africa is limited. In this region, it is not well understood how people with HIV (PLWHA) respond to alcohol reduction counseling while they are linked to HIV clinical care. We conducted an explanatory sequential mixed-methods study to understand patterns of alcohol use among adults (18+ years) within a prospective HIV cohort at two urban public-sector clinics in Zambia. At antiretroviral therapy (ART) start and one year later, we measured alcohol use with Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) and those reporting any alcohol use were provided brief counseling. We conducted focus groups at 1 year with participants who had any alcohol use and 20 in-depth interviews among the subgroup with unhealthy use pre-ART and who either reduced or did not reduce their use by 1 year to moderate levels or abstinence. Focus group Discussions (FGDs) (n = 2) were also held with HIV clinic staff. Qualitative data were analyzed using thematic analysis. The data obtained from 693 participants was analyzed (median age 34 years, 45% men), it revealed that unhealthy alcohol use (AUDIT-C >3 for men; >2 for women) was reported among 280 (40.4%) at baseline and 205 (29.6%) at 1 year on ART. Reduction from unhealthy to moderate use or abstinence was more common with older age, female, non-smoking, and at Clinic B (all P<0.05). Qualitative data revealed ineffective alcohol support at clinics, social pressures in the community to consume alcohol, and unaddressed drivers of alcohol use including poverty, poor health status, depression, and HIV stigma. Healthcare workers reported a lack of training in alcohol screening and treatment, which led to mixed messages provided to patients ('reduce to safe levels' versus 'abstain'). In summary, interventions to reduce unhealthy alcohol use are needed within HIV clinics in Zambia as a substantial population have persistent unhealthy use despite current HIV clinical care. A better understanding is needed regarding the implementation challenges related to screening for unhealthy alcohol use integrated with HIV services

Fertility outcomes following obstetric fistula repair: a prospective cohort study

Abstract Background Obstetric fistula (OF) is a maternal morbidity associated with high rates of stillbirth, amenorrhea, and sexual dysfunction. Limited data exists on the reproductive outcomes of women in the years following a fistula repair. The objective of this study is to describe the fertility outcomes and family planning practices in a population of Malawian women 1–4 years after fistula repair. Methods Women who had enrolled into a clinical database of OF patients and undergone OF repair between January 1, 2012 and July 31, 2014 were recruited and enrolled to complete a home-based survey of their demographic and reproductive health data 1–4 years after their repair. Pregnancy, amenorrhea, and sexual function were described using frequency analysis, and we compared antimüllerian hormone (AMH) concentrations between women with menses or pregnancy with women with amenorrhea or no pregnancy using Wilcoxon rank sum tests. Results Of 297 women with a prior OF repair, 148 had reproductive potential and were included in this analysis. Overall 30 women of these women (21%) became pregnant since their fistula repair, with most pregnancies ending with cesarean delivery. Of the 32 women who were amenorrheic at the time of repair, 25 (78.1%) had resumption of menses. Only 11 (8.6%) of sexually active women reported dyspareunia, and among women who were not trying to conceive, 53.1% were currently using a method of family planning. No significant differences were found in AMH concentrations between those who were pregnant or had menses versus those without pregnancy or menses, respectively. Conclusions In this long-term follow-up study of women after OF repair, many women were able to achieve a pregnancy with a live birth, have normal menses, be sexually active, and access contraception. These achievements will further assist a population of women whose reintegration and restoration of dignity is closely tied to their ability to achieve their reproductive goals. Trial registration ClinicalTrials.gov Identifier: NCT02685878

Building a sustainable sweetpotato seed system in Malawi: Experiences from the "Rooting out hunger in Malawi" project.

The project “Rooting out Hunger in Malawi with Nutritious Orange-Fleshed Sweetpotato (OFSP)” was launched in October 2009 for the benefit of women and children in the country. This 4.5-year effort targets 115,000 households to improve vitamin A and energy intake using improved sweetpotato varieties. It also seeks to boost yields by 50% and improve incomes by 20%. The project aligns with the Agriculture Sector Wide Approach to food and nutrition security and crop diversification. With Irish Aid support, CIP initially worked in partnership with government agencies and three NGOs as implementing partners (IPs) and targeted 4 districts. The project established a “1-2-3” seed multiplication system, with clean planting material produced at a primary multiplication site, and decentralized vine multiplication sites (DVMs) doing multiplication at the community level. DVMs run by individuals or groups of farmers with access to irrigation were established by the IPs and supervised by district Extension staff. Mutiplication at the DVMs was termed secondary (vine production using rapid multiplication) or tertiary (production of both roots and vines, particularly during the hungry season). A subsidized voucher system was used by partners to allow at-risk households to purchase sweetpotato planting material from DVMs. Promotion and awareness campaigns were conducted in each district to stimulate demand for OFSP. By February 2012, the project had reached 36,403 households in 5 districts with subsidized vouchers, and an additional 19,331 beneficiaries through non-voucher sales. Seven IPs in 14 districts partnered in the effort. Lessons learned and sustainability of the system will be discussed

Virological Findings and Treatment Outcomes of Cases That Developed Dolutegravir Resistance in Malawi’s National HIV Treatment Program

Millions of Africans are on dolutegravir-based antiretroviral therapy (ART), but few detailed descriptions of dolutegravir resistance and its clinical management exist. We reviewed HIV drug resistance (HIVDR) testing application forms submitted between June 2019 and October 2022, data from the national HIVDR database, and genotypic test results. We obtained standardized ART outcomes and virological results of cases with dolutegravir resistance, and explored associations with dolutegravir resistance among individuals with successful integrase sequencing. All cases were on two nucleoside reverse transcriptase inhibitors (NRTIs)/dolutegravir, and had confirmed virological failure, generally with prolonged viremia. Among 89 samples with successful integrase sequencing, 24 showed dolutegravir resistance. Dolutegravir resistance-associated mutations included R263K (16/24), E138K (7/24), and G118R (6/24). In multivariable logistic regression analysis, older age and the presence of high-level NRTI resistance were significantly associated with dolutegravir resistance. After treatment modification recommendations, four individuals (17%) with dolutegravir resistance died, one self-discontinued ART, one defaulted, and one transferred out. Of the 17 remaining individuals, 12 had follow-up VL results, and 11 (92%) were <1000 copies/mL. Twenty-four cases with dolutegravir resistance among 89 individuals with confirmed virological failure suggests a considerable prevalence in the Malawi HIV program. Successful management of dolutegravir resistance was possible, but early mortality was high. More research on the management of treatment-experienced individuals with dolutegravir resistance is needed

Early Diagnosis of HIV Infection in Infants - One Caribbean and Six Sub-Saharan African Countries, 2011-2015.

Pediatric human immunodeficiency virus (HIV) infection remains an important public health issue in resource-limited settings. In 2015, 1.4 million children aged 50% decline. The most common challenges for access to testing for early infant diagnosis included difficulties in specimen transport, long turnaround time between specimen collection and receipt of results, and limitations in supply chain management. Further reductions in HIV mortality in children can be achieved through continued expansion and improvement of services for early infant diagnosis in PEPFAR-supported countries, including initiatives targeted to reach HIV-exposed infants, ensure access to programs for early infant diagnosis of HIV, and facilitate prompt linkage to treatment for children diagnosed with HIV infection