HIV clinical stage progression of patients at 241 outpatient clinics in Democratic Republic of Congo: Disparities by gender, TB status and rurality

Background: HIV clinical care programs are increasingly cognizant of the importance of customizing services according to patients’ clinical stage progression (WHO\u27s four-tiered staging) and other risk assessments. Understanding factors associated with Persons Living with HIV (PLHIV) patients’ progression through the treatment cascade and clinical stages is essential for programs to provide patient-centered, evidence-based services. Methods and materials: To analyze patient characteristics associated with disease progression stages for PLHIV on antiretroviral therapy (ART), this quantitative study used data, from January 2014–June 2019, from 49,460 PLHIV on ART from 241 HIV/AIDS outpatient clinics in 23 health zones in Haut-Katanga and Kinshasa provinces, Democratic Republic of Congo. To assess bivariate and multivariate associations, we performed Chi-square and multinomial logistic regression. Results: Among PLHIV receiving ART, 4.4% were at stage 4, and 30.7% at stage 3. Those at the less severe stages 2 and 1 constituted 22.9% and 41.9%. After controlling for covariates, patients with no TB were significantly more likely than those with TB (p\u3c = .05) to be at stage 1, rather than 3 or 4 (adjusted odds ratio or AOR, 5.73; confidence interval or CI, 4.98–6.59). Other characteristics significantly associated with higher odds of being at stage 1 included being female (AOR, 1.35; CI, 1.29–1.42), and shorter duration on ART (vs. \u3e 40.37 months); for ART duration less than 3.23 months the AOR was 2.47, for 3.23–14.52 months duration the AOR was 2.60, and for 14.53–40.37 months duration the AOR was 1.77 (quartile cut points used). Compared to patients in urban health zones, those in rural (AOR, 0.32) and semi-rural health zones (AOR, 0.79) were less likely to be at stage 1. Conclusion: Significant and substantial variation in HIV clinical progression stage by geographic location and demographic characteristics existed, indicative of the need for targeted efforts to improve the effectiveness of HIV care. Patients with TB coinfection compared to those without coinfection had a much greater risk of being at stage 3 or 4, implying a need for customized approaches and clinical regimens for this high-risk population

Socioeconomic status and other factors associated with HIV status among OVC in Democratic Republic of Congo (DRC)

Background: Orphans and vulnerable children (OVC) are a high-risk group for HIV infection, particularly in Sub-Saharan Africa. Purpose: This study aims to portray the socioeconomic profile of OVC and examine the association of household and parent/guardian characteristics with the HIV status of OVC. Methods: For this quantitative retrospective study, we obtained data from ICAP/DRC for a total of 1,624 OVC from households enrolled for social, financial, and clinical services between January 2017 and April 2020 in two provinces of the Democratic Republic of Congo, Haut-Katanga and Kinshasa. We computed descriptive statistics for OVC and their parents\u27 or guardians\u27 characteristics. We used the chi-square test to determine bivariate associations of the predictor variables with the dichotomous dependent variable, HIV positivity status. To analyze the association between these independent variables and the dichotomous dependent variable HIV status after controlling for other covariates, we performed firth\u27s logistic regression. Results: Of the OVC included in this study, 18% were orphans, and 10.9% were HIV+. The chi-square analysis showed that among parents/guardians that were HIV+, a significantly lower proportion of OVC (11.7%) were HIV+ rather than HIV- (26.3%). In contrast, for parents/guardians with HIV- status, 9.0% of OVC were HIV-negative, and 11.7% of OVC were OVC+. The firth\u27s logistic regression also showed the adjusted odds of HIV+ status were significantly lower for OVC with parents/guardians having HIV+ status themselves (AOR, 0.335; 95% CI, 0.171–0.656) compared with HIV-negative parents/guardians. The adjusted odds of HIV+ status were significantly lower for OVC with a monthly household income of \u3c $30 (AOR, 0.421; 95$30. Conclusions: Our results suggest that, with the exception of a few household and parent/guardian characteristics, the risk of HIV+ status is prevalent across all groups of OVC within this study, which is consistent with the existing body of evidence showing that OVC are in general vulnerable to HIV infection. With a notable proportion of children who are single or double orphans in DRC, HIV+ OVC constitute a high-risk group that merits customized HIV services. The findings of this study provide data-driven scientific evidence to guide such customization of HIV services

The roles of cats and dogs in the transmission of Toxoplasma infection in Kuna and Embera children in eastern Panama El papel de los perros y gatos en la transmisión de la infección por Toxoplasma en niños kunas y emberas del este de Panamá

OBJECTIVE: To examine the relationship between antibody status and various hypothesized risk factors for Toxoplasma gondiiinfection among two different Amerindian populations in eastern Panama. Following up on earlier research that we conducted, we now explore the role of dogs in the natural transmission of Toxoplasma,the role that dogs play in promoting transmission, the interactive effect of cats and dogs, and the accessibility of infective material to children. METHODS: In 1991, 10 Panamanian medical students conducted interviews and took blood samples from 760 Kuna and Embera children aged 2 through 12 years in the Upper Bayano River Basin and the San Blas Islands. Serologic assays were performed using direct agglutination. The data analyses in the 1990s included univariate, bivariate, and multivariate analyses, without regard to data on dogs. Further bivariate and multivariate analyses were performed in 2003 to examine the contribution of dogs. RESULTS: In communities with high Toxoplasmaantibody prevalence in children, logistic regression suggested that the factors predictive of antibody presence were: compacted soil floors of huts (P= 0.001), having a dog (P= 0.038), and the interviewer seeing a cat in the house (P= 0.049). Our results suggest that the villagers' dogs play a significant role in facilitating the transmission of Toxoplasma gondiito humans, most often in the presence of cats in the houses, and only in those communities with higher Toxoplasmas eroprevalence in children. CONCLUSIONS: Dogs may act as mechanical vectors, by rolling in foul-smelling substances and by ingesting fecal material. In areas of high Toxoplasma prevalence in children and where dogs and cats are plentiful, immunocompromised individuals and pregnant women should be warned of the possibility of acquiring Toxoplasma gondii from dogs as well as from soil contaminated by cats. People should be encouraged to wash their hands after contact with soil, dogs, or cats as well as before eating.<br>OBJETIVO: Examinar la relación entre la presencia o ausencia de anticuerpos y los diversos factores de riesgo hipotéticos asociados con la infección por Toxoplasma gondii en dos poblaciones amerindias diferentes del este de Panamá. Como secuela a una investigación preliminar, en este trabajo se explora el papel de los perros en la transmisión natural de Toxoplasma y en la facilitación de la transmisión, así como el efecto interactivo de los perros y gatos y el acceso de los niños a materiales infecciosos. MÉTODOS: En 1991, 10 estudiantes de medicina panameños llevaron a cabo entrevistas y les tomaron muestras de sangre a 760 niños kunas y emberas de 2 a 12 años de edad en la cuenca superior del río Bayano y en las islas de San Blas. Se hicieron pruebas serológicas mediante aglutinación directa. Todos los datos, menos los de los perros, se estudiaron mediante análisis unifactorial, bifactorial y multifactorial. En 2003 se efectuaron nuevos análisis bifactoriales y multifactoriales para examinar la contribución de los perros. RESULTADOS: En comunidades con una alta prevalencia de anticuerpos contra Toxoplasma en niños, la regresión logística indicó que los siguientes factores tenían valor pronóstico en relación con la presencia de anticuerpos: pisos de tierra compacta en las chozas (P = 0,001), tener perro (P = 0,038), y que el investigador hubiera visto un gato dentro de la vivienda (P = 0,049). Según nuestros resultados, los perros de los habitantes de las aldeas desempeñan un papel importante en la facilitación de la transmisión de Toxoplasma gondii a los seres humanos, la mayor parte de las veces en presencia de gatos dentro de la vivienda y solamente en comunidades con una alta seroprevalencia de Toxoplasma en niños. CONCLUSIONES: Los perros pueden ser vectores mecánicos debido a su hábito de revolcarse en sustancias fétidas y de comer heces. En zonas donde la prevalencia de Toxoplasma en niños es alta y donde hay muchos perros y gatos, a las personas inmunodeprimidas y las mujeres embarazadas se les debe advertir del peligro de infectarse con Toxoplasma gondii por contacto con perros o con tierra contaminada por gatos. Se debe alentar a las personas a lavarse las manos después de tocar tierra, perros o gatos y antes de comer

Consequences of COVID-19 Crisis for Persons with HIV: The Impact of Social Determinants of Health

Background With the indiscriminate spread of COVID-19 globally, many populations are experiencing negative consequences such as job loss, food insecurity, and inability to manage existing medical conditions and maintain preventive measures such as social distancing and personal preventative equipment. Some of the most disadvantaged in the COVID-19 era are people living with HIV/AIDS and other autoimmune diseases. Discussion As the number of new HIV infections decrease globally, many subpopulations remain at high risk of infection due to lack of or limited access to prevention services, as well as clinical care and treatment. For persons living with HIV or at higher risk of contracting HIV, including persons who inject drugs or men that have sex with men, the risk of COVID-19 infection increases if they have certain comorbidities, are older than 60 years of age, and are homeless, orphaned, or vulnerable children. The risk of COVID-19 is also more significant for those that live in Low- and Middle-Income Countries, rural, and/or poverty-stricken areas. An additional concern for those living the HIV is the double stigma that may arise if they also test positive for COVID-19. As public health and health care workers try to tackle the needs of the populations that they serve, they are beginning to realize the need for a change in the infrastructure that will include more efficient partnerships between public health, health care, and HIV programs. Conclusion Persons living with HIV that also have other underlying comorbidities are a great disadvantage from the negative consequences of COVID-19. For those that may test positive for both HIV and COVID-19, the increased psychosocial burdens stemming from stress and isolation, as well as, experiencing additional barriers that inhibit access to care, may cause them to become more disenfranchised. Thus, it becomes very important during the current pandemic for these challenges and barriers to be addressed so that these persons living with HIV can maintain continuity of care, as well as, their social and mental support systems

Retention and predictors of attrition among children living with HIV on antiretroviral therapy (ART) in Côte d’Ivoire between 2012 and 2016

Background: In Côte d’Ivoire a retrospective national-level cohort study conducted in 2009 indicated that 77%, 72% and 75% of children living with HIV (CLHIV) remained in care at 12, 36, and 48 months after starting ART, respectively. The CDC-sponsored Improving HIV Surveillance and Program Evaluation in Côte d’Ivoire project assessed retention progress since that study. Methods and materials: A retrospective review of medical records was conducted using 2-stage cluster sampling. HIV care and treatment centers (CTC) were sampled based on patient caseload, then records of patients under 15 years of age who initiated ART between 2012–2016 were randomly selected. Time-to-event analysis was performed to estimate the cumulative attrition rates per total number of person-years (PYs) of observation. Cox proportional hazard regressions were conducted to identify factors associated with attrition. Results: 1198 patient records from 33 CTC were reviewed. At time of ART initiation, CLHIVs’ mean age was 5.8 years, 609 (51%) were male, median CD4 count was 529 cells/μL (interquartile range: 270-910), and 210 (21%) were severely undernourished. Retention was 91%, 84%, 74%, 72%, and 70% at 12, 24, 36, 48 and 60 months after ART initiation, respectively. 309 attrition events occurred over 3,169 PYs of follow-up, with 266 lost to follow-up (LTFU), 29 transfers and 14 deaths. Multivariate analyses showed determinants for LTFU included attending a CTC with a mixed (public-private) status [adjusted hazard ratio (aHR) 6.05, 95% confidence interval (CI): 4.23–8.65], a CTC with no on-site laboratory (aHR 4.01, 95% CI: 1.70–9.46), and a CTC without an electronic medical record system (aHR 2.22, 95% CI: 1.59–3.12). Age, clinical and immunological status at ART initiation, and parent\u27s HIV status were not related to attrition. Conclusion: Attrition rates were high, with no substantial improvement since 2009 for time periods longer than 12 months since ART initiation. Retention improvements in Cote d’Ivoire would require a focus on scaling up innovative service delivery models such as decentralization of services to the community, coordination with local or regional labs for facilities without an on-site laboratory, and rigorous tracking systems for patients in care

HIV clinical stage progression of patients at 241 outpatient clinics in DRC: Disparities by gender, TB status and rurality

Presentation given at APHA Annual Meeting and Expo. Background: HIV clinical care programs are increasingly customizing services to patients’ clinical stage progression (WHO’s four-tiered staging). Understanding factors associated with Persons Living with HIV (PLHIV)’s stage progression is essential for patient-centered services. Methods: To analyze PLHIV on antiretroviral therapy (ART) patients’ characteristics associated with progression stages, we used data, from 1/2014--6/2019, from 49,460 ART patients from 241 outpatient clinics in 23 health zones in Haut-Katanga and Kinshasa provinces, Democratic Republic of Congo. Chi-square and multinomial logistic regression assessed bivariate and multivariate associations. Results: ART patients were stage 4 (4.4%) and stage 3 (30.7%), with less severe stages 2 (22.9%) and 1 (41.9%). After covariate control, patients without TB were more likely than those with TB (p40.37 months); for ART duration \u3c 3.23 months the AOR was 2.47, for 3.23-14.52 months it was 2.60, and for 14.53-40.37 months it was 1.77 (quartile cut-points used). Compared to patients in urban health zones, those in rural (AOR, 0.32) and semi-rural zones (AOR, 0.79) were less likely to be stage 1. Conclusion: Significant variations in progression stage by location and demographic characteristics are indicative of the need for targeted efforts to improve HIV care. TB/HIV co-infected patients’ great risk of being stage 3 or 4 implies a particular need for customized approaches for this population

TB-HIV Co-infection and Risk of Death, Loss to Follow Up, and Viral Load Suppression in Democratic Republic Of Congo

Presentation given at APHA Annual Meeting and Expo. Background: To provide efficient, equitable, patient-centered care to people living with HIV/AIDS (PLWH), this study analyzes two aspects of TB coinfection in PLWH: (a) variation in TB/HIV coinfection by demographic and clinical characteristics of patients; and (b) risks of negative outcomes among PLWH with TB coinfection compared to those without such coinfection. Methods: This quantitative study used data on 49,460 PLWH on ART from 241 HIV/AIDS clinics in two provinces of Democratic Republic of Congo, Haut-Katanga and Kinshasa. Chi-square and logistic regression analysis were performed. Results: TB coinfection existed in 3.6% of the patients. Significantly higher proportions of patients with TB/HIV coinfection were males (4.5% vs. 3.3%); new patients rather than transferred-in (3.7% vs. 1.6%) resided in the Kinshasa province rather than Haut-Katanga (4.0% vs. 2.7%) and were in an urban health zone (3.9%) and semi-rural (3.1%) rather than rural (1.2%) health zone. The logistic regression models showed that after controlling for other demographic and clinical variables, TB/HIV coinfection raised the risk of death (AOR, 2.26; CI, 1.94 to 2.64) and loss to follow up (AOR, 2.06; CI, 1.82 to 2.34). TB/HIV coinfection lowered the odds of viral load suppression below 1,000 copies per ml of blood (AOR, 0.58; CI, 0.46 TO 0.74). Conclusions: TB/HIV coinfection raises the risk of negative outcomes. HIV clinics in DRC and other African countries may consider these findings when customizing their interventions to improve HIV care and reduce disparities in PLWH

Risk Factors for TB/HIV Coinfection and Consequences for Patient Outcomes: Evidence from 241 Clinics in the Democratic Republic of Cong

(1) Background: In resource-limited countries, patients with tuberculosis (TB)/HIV coinfection commonly face economic, sociocultural, and behavioral barriers to effective treatment. These barriers manifest from low treatment literacy, poverty, gender inequality, malnutrition, societal stigmas regarding HIV, and an absence of available care. It is critical for intervention programs to understand and assist in overcoming these barriers and any additional risks encountered by patients with TB/HIV coinfection. This study analyzes variation in TB/HIV coinfection and risks of negative outcomes among patients with TB/HIV coinfection compared to those without coinfection. (2) Methods: This quantitative study used data from 49,460 patients receiving ART from 241 HIV/AIDS clinics in Haut-Katanga and Kinshasa, two provinces in the Democratic Republic of Congo. Chi-square and logistic regression analysis were performed. (3) Results: Significantly higher proportions of patients with TB/HIV coinfection were men (4.5%; women, 3.3%), were new patients (3.7%; transferred-in, 1.6%), resided in the Kinshasa province (4.0%; Haut-Katanga, 2.7%), and were in an urban health zone (3.9%) or semi-rural health zone (3.1%; rural, 1.2%). Logistic regression analysis showed that after controlling for demographic and clinical variables, TB/HIV coinfection increased the risk of death (adjusted odds ratio (AOR), 2.26 (95% confidence interval (CI): 1.94–2.64)) and LTFU (AOR, 2.06 (95% CI: 1.82–2.34)). TB/HIV coinfection decreased the odds of viral load suppression (AOR, 0.58 (95% CI: 0.46–0.74)). (4) Conclusions: TB/HIV coinfection raises the risk of negative outcomes such as death, LTFU, and lack of viral load suppression. Our findings can help HIV clinics in Democratic Republic of Congo and other African countries to customize their interventions to improve HIV care and reduce care disparities among patients

TB/HIV Coinfection and Patient Outcomes: Evidence from 241 Clinics in the Democratic Republic of Congo

Presentation given at the 19th International Congress on Infectious Diseases