Short Communication: Late Refills During the First Year of Antiretroviral Therapy Predict Mortality and Program Failure Among HIV-Infected Adults in Urban Zambia

We evaluated the association of the number of late antiretroviral therapy (ART) refills with patient outcomes in a large public-sector human immunodeficiency virus treatment program in Lusaka, Zambia. Using pharmacy data routinely collected during 2004–2010, we calculated the number of late refills during the initial year of ART. We used multivariable Cox proportional hazard regression to examine the association between the number of late refills and death or program failure (i.e., death, loss to follow-up, or program withdrawal) >12 months after ART initiation, with and without stratification by the medication possession ratio (MPR) during the initial year of ART. Of 53,015 adults who received ART for ≥12 months (median follow-up duration, 86.1 months; interquartile range, 53.2–128.2 months), 26,847 (50.6%) had 0 late refills, 16,762 (31.6%) had 1, 6,505 (12.3%) had 2, and 2,901 (5.5%) had ≥3. Kaplan–Meier analysis revealed that ≥3 late refills was associated with a greater mortality risk than 1 and 2 late refills (p<0.001, by the log-rank test). The mortality risk was greater for patients with 2 late refills [adjusted hazard ratio (HR), 1.17; 95% confidence interval (CI), 0.99–1.38] or ≥3 late refills (adjusted HR, 1.51; 95% CI, 1.23–1.87), compared with that for patients with 0–1 late refills. Program failure was associated with ≥2 late refills. An MPR of <80% was associated with similar increases in mortality risk across late-refill strata. Monitoring late refills during the initial period of ART may help resource- and time-constrained clinics identify patients at risk for program failure

A Phase I Double Blind, Placebo-Controlled, Randomized Study of a Multigenic HIV-1 Adenovirus Subtype 35 Vector Vaccine in Healthy Uninfected Adults

<div><h3>Background</h3><p>We conducted a phase I, randomized, double-blind, placebo-controlled trial to assess the safety and immunogenicity of escalating doses of two recombinant replication defective adenovirus serotype 35 (Ad35) vectors containing gag, reverse transcriptase, integrase and nef (Ad35-GRIN) and env (Ad35-ENV), both derived from HIV-1 subtype A isolates. The trial enrolled 56 healthy HIV-uninfected adults.</p> <h3>Methods</h3><p>Ad35-GRIN/ENV (Ad35-GRIN and Ad35-ENV mixed in the same vial in equal proportions) or Ad35-GRIN was administered intramuscularly at 0 and 6 months. Participants were randomized to receive either vaccine or placebo (10/4 per group, respectively) within one of four dosage groups: Ad35-GRIN/ENV 2×10⁹ (A), 2×10¹⁰ (B), 2×10¹¹ (C), or Ad35-GRIN 1×10¹⁰ (D) viral particles.</p> <h3>Results</h3><p>No vaccine-related serious adverse event was reported. Reactogenicity events reported were dose-dependent, mostly mild or moderate, some severe in Group C volunteers, all transient and resolving spontaneously. IFN-γ ELISPOT responses to any vaccine antigen were detected in 50, 56, 70 and 90% after the first vaccination, and in 75, 100, 88 and 86% of Groups A–D vaccine recipients after the second vaccination, respectively. The median spot forming cells (SFC) per 10⁶ PBMC to any antigen was 78–139 across Groups A–C and 158–174 in Group D, after each of the vaccinations with a maximum of 2991 SFC. Four to five HIV proteins were commonly recognized across all the groups and over multiple timepoints. CD4+ and CD8+ T-cell responses were polyfunctional. Env antibodies were detected in all Group A–C vaccinees and Gag antibodies in most vaccinees after the second immunization. Ad35 neutralizing titers remained low after the second vaccination.</p> <h3>Conclusion/Significance</h3><p>Ad35-GRIN/ENV reactogenicity was dose-related. HIV-specific cellular and humoral responses were seen in the majority of volunteers immunized with Ad35-GRIN/ENV or Ad35-GRIN and increased after the second vaccination. T-cell responses were broad and polyfunctional.</p> <h3>Trial Registration</h3><p>ClinicalTrials.gov <a href="http://clinicaltrials.gov/ct2/results?term=NCT00851383">NCT00851383</a></p> </div

The UTH-UMB Global Health Education Collaboration: Building a Bidirectional Exchange Based on Equity and Reciprocity

The global health exchange program between the University Teaching Hospitals (UTH) of Lusaka, Zambia and the University of Maryland, Baltimore (UMB) has been operating since 2015. As trainees and facilitators of this exchange program, we describe our experiences working in Lusaka and Baltimore, and strengths and challenges of the partnership. Since 2015, we have facilitated rotations for 71 UMB trainees, who spent four weeks on the Infectious Disease (ID) team at UTH. Since 2019 with funding from UMB, nine UTH ID trainee physicians spent up to six weeks each rotating on various ID consult services at University of Maryland Medical Center (UMMC). Challenges in global health rotations can include inadequate preparation or inappropriate expectations among high-income country trainees, low-value experiences for low- and middle-income country trainees, lack of appropriate mentorship at sites, and power imbalances in research collaborations. We try to mitigate these issues by ensuring pre-departure and on-site orientation for UMB trainees, cross-cultural mentored experiences for all trainees, and intentional sharing of authorship and credit on scientific collaborations. We present a description of our medical education collaboration as a successful model for building equitable and reciprocal collaborations between low- and middle-income countries and high-income countries, and offer suggestions for future program initiatives to enhance global health education equity among participants and organizations

Direct blood dry LAMP: a rapid, stable, and easy diagnostic tool for Human African Trypanosomiasis.

Loop-mediated isothermal amplification (LAMP) is a rapid and sensitive tool used for the diagnosis of a variety of infectious diseases. One of the advantages of this method over the polymerase chain reaction is that DNA amplification occurs at a constant temperature, usually between 60-65°C; therefore, expensive devices are unnecessary for this step. However, LAMP still requires complicated sample preparation steps and a well-equipped laboratory to produce reliable and reproducible results, which limits its use in resource-poor laboratories in most developing countries. In this study, we made several substantial modifications to the technique to carry out on-site diagnosis of Human African Trypanosomiasis (HAT) in remote areas using LAMP. The first essential improvement was that LAMP reagents were dried and stabilized in a single tube by incorporating trehalose as a cryoprotectant to prolong shelf life at ambient temperature. The second technical improvement was achieved by simplifying the sample preparation step so that DNA or RNA could be amplified directly from detergent-lysed blood samples. With these modifications, diagnosis of HAT in local clinics or villages in endemic areas becomes a reality, which could greatly impact on the application of diagnosis not only for HAT but also for other tropical diseases

The appearance of vitrified reagent of Dry HAT LAMP.

<p>(A) The drying process of Dry LAMP. The enzyme solution and primer/indicator mix were put on the inner side of the cap separately. (B) Close-up picture of dried LAMP solutions. The vitrified enzyme solution displayed several cracks.</p

A series of operations of 18S-rRNA RT-LAMP screening test.

<p>Two hundred μl of blood were diluted in 1,800 μl of lysis buffer (10× dilution), then 10 μl of lysed blood were transferred into a Dry LAMP tube with 15 μl of reaction buffer within 5 minutes. After a 45-min incubation at 60°C using a portable battery-supplied heat block, the LAMP reaction was evaluated by a portable reaction detector.</p

LAMP primers design for <i>T</i>. <i>b</i>. <i>rhodesiense</i> nucleotide detection.

<p>(A) Nucleotide sequence alignments of <i>18S-rRNA</i> genes of the seven Trypanosoma species. Representative<i>18S-rRNA</i> sequences in each species are aligned with clustalW. <i>T</i>. <i>brucei brucei</i> strain 927 (AL929603), <i>T</i>. <i>brucei rhodesiense</i> isolate UTRO 2509 (AJ009142), <i>T</i>. <i>brucei gambiense</i> DAL972 (FW554966), <i>T</i>. <i>evansi</i> isolate E110 (AJ009154), <i>T</i>. <i>equiperdum</i> isolate STIB 818 (AJ009153), <i>T</i>. <i>cruzi</i> marinkellei culture collection TCC/USP (FJ001665) and <i>Leishmania major</i> strain Friedlin (FR796423). Primer recognition sites are indicated with primer names. Gray boxes indicate non-conserved nucleotides. (B) Nucleotide sequence alignments of the target region in the two types of <i>SRA</i> genes. SRA type 1 was isolated in Kenya (AJ345057) and SRA type 2 was isolated in Zambia (AJ345058) [<a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003578#pntd.0003578.ref013" target="_blank">13</a>,<a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003578#pntd.0003578.ref014" target="_blank">14</a>]. Because previously reported primers [<a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003578#pntd.0003578.ref007" target="_blank">7</a>] had polymorphisms in SRA type 2 (shown by the dotted line), a conserved region was selected as the new primer recognition site.</p

Screening for Diabetes Mellitus among Tuberculosis Patients: Findings from a Study at a Tertiary Hospital in Lusaka, Zambia

Background. Diabetes mellitus (DM) is known to be associated with active tuberculosis (TB). Zambia is a low-income sub-Saharan African country with a high TB burden and increasing numbers of newly diagnosed DM patients. Materials and Methods. This was an observational study conducted at the University Teaching Hospital in Lusaka, Zambia, from October 2014 to February 2016. Adult patients with active TB were screened for DM. Results. A total of 127 individuals were enrolled in the study. Six patients (5%) were found to have diabetes. Of these, three had a prior diagnosis of diabetes and were on medication while three were newly diagnosed. Low education level was significantly associated with DM (p=0.001; 95% CI 0.001–0.148). Conclusion. The prevalence of DM among individuals with smear positive TB in our study population was similar to that of the general population in Zambia