Hepatitis B therapy as HIV prevention in Africa: a case series from Zambia.

In East and Southern Africa, where 5-10% have chronic hepatitis B virus (HBV) infection, incidence of human immunodeficiency virus (HIV) infection remains unacceptably high. This introduces challenges and opportunities for implementation of HBV care and treatment. We now describe new HIV diagnoses made within an HBV monoinfection cohort in Zambia and their relevance to broader HBV policy implementation. This article is protected by copyright. All rights reserved

Chronic Hepatitis B Virus Coinfection Is Associated With Renal Impairment Among Zambian HIV-Infected Adults

Among 6789 HIV-infected Zambian adults screened for hepatitis B virus (HBV) coinfection, estimated glomerular filtration rate (eGFR) was 50-90 mL/minute/1.73 m2 in 17.6% and <50 mL/minute/1.73 m2 in 2.5%. Human immunodeficiency virus/HBV coinfection was associated with eGFR <50 mL/minute/1.73 m2 (adjusted odds ratio, 1.96 [95% confidence interval, 1.34-2.86]), adjusted for age, sex, CD4+ count, and World Health Organization disease stag

Do all candidemic patients need an ophthalmic examination?

Intraocular candidiasis is a potentially sight-threatening complication of candidemia. While the incidence of candidemia in North America has increased, the prevalence of intraocular candidiasis appears to be decreasing. In the USA and Europe, an ophthalmic examination is recommended for all candidemic patients to rule out intraocular involvement. However, improvements in management, clarification of the diagnosis, and trends in the epidemiology of intraocular candidiasis suggest that some candidemia patients might be safely managed without the recommended dilated ophthalmic examination

Incidence and Clinical Features of Cerebrovascular Disease Among HIV-Infected Adults in the Southeastern United States

With aging of the HIV-infected population, non-AIDS conditions such as cardiovascular disease (CVD) now account for substantial mortality and morbidity. While myocardial infarction is the major outcome of interest in the field of HIV and CVD, cerebrovascular disease remains understudied, especially in the Southeastern United States. We determined the incidence and clinical features of cerebrovascular events (CVE) in a large HIV clinical cohort in North Carolina (NC). A total of 2,515 HIV-infected adults contributed a median of 4.5 years (IQR: 2.0, 7.8) of follow-up. Fifty-three CVEs were adjudicated for an incidence rate of 3.87 per 1,000 person-years (95% CI: 2.90, 5.06). The ischemic stroke incidence was 2.26 per 1,000 person-years (95% CI: 1.53, 3.21), approximately 1.5 times the rate of a population-based cohort in NC. At the time of CVE, the median age was 48 years (IQR: 42, 55). Of ischemic strokes 76% resulted from large artery atherosclerosis or small vessel (lacunar) disease. In multivariable analyses, age, hypertension, dyslipidemia, recent CD4+ cell count ≤200 cells/mm3, and recent HIV RNA >400 copies/ml were associated with an increased risk of CVE. Antiretroviral therapy (ART) was not associated with the risk of CVE. We concluded that in the post-ART era, HIV-infected individuals appear to be at moderately increased risk of stroke. Prevention of CVEs in this population will require modification of traditional CVD risk factors and early, effective treatment of HIV infection

Association between hepatitis B co-infection and elevated liver stiffness among HIV-infected adults in Lusaka, Zambia

In sub-Saharan Africa, liver disease epidemiology among HIV-infected individuals is not well described, in part due to limited access to diagnostic tests for liver fibrosis

Pediatric HIV–HBV Coinfection in Lusaka, Zambia: Prevalence and Short-Term Treatment Outcomes: Table 1.

Hepatitis B virus (HBV) is endemic in Africa, where it may occur as an HIV coinfection. Data remain limited on HIV–HBV epidemiology in Africa, particularly in children. Using programmatic data from pediatric HIV clinics in Lusaka, Zambia during 2011–2014, we analyzed the prevalence of chronic HBV coinfection (defined as a single positive hepatitis B surface antigen [HBsAg] test) and its impact on immune recovery and liver enzyme elevation (LEE) during the first year of antiretroviral therapy. Among 411 children and adolescents, 10.4% (95% confidence interval, 7.6–14.1) had HIV–HBV. Coinfected patients were more likely to have World Health Organization stage 3/4, LEE and CD4 <14% at care entry (all p < 0.05). During treatment, CD4 increases and LEE incidence were similar by HBsAg status. HBsAg positivity decreased (11.8% vs. 6.6%; p = 0.24) following HBV vaccine introduction. These findings support screening pediatric HIV patients in Africa for HBV coinfection. Dedicated cohorts are needed to assess long-term outcomes of coinfection

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

Effect of Baseline Renal Function on Tenofovir-Containing Antiretroviral Therapy Outcomes in Zambia

In this large cohort of human immunodeficiency virus-infected patients receiving first-line antiretroviral therapy in Zambia, individuals who started a tenofovir-containing regimen despite baseline renal dysfunction showed comparable mortality and renal function improvement to those not receiving tenofovi

Liver steatosis and metabolic dysfunction-associated fatty liver disease among HIV-positive and negative adults in urban Zambia.

INTRODUCTION The growing importance of non-communicable diseases (NCDs) and high HIV prevalence in urban African settings may increase the burden of metabolic dysfunction-associated fatty liver disease (MAFLD). We assessed liver steatosis among HIV-positive and negative adults in urban Zambia. METHODS Adults 30 years and older who were newly diagnosed with HIV, or tested HIV-negative at two primary care clinics in Lusaka, Zambia, were assessed for liver steatosis. Cardiometabolic data were collected through comprehensive clinical and laboratory assessments. Transient elastography was performed to measure controlled-attenuation parameter (≥248 dB/m). We used multivariable logistic regression models to determine the factors associated with the presence of steatosis. RESULTS We enrolled 381 patients, including 154 (40%) antiretroviral therapy-naïve people living with HIV (PLWH) with a median CD4+ count of 247 cells/mm3 and a mean body mass index (BMI) of 23.8 kg/m2. Liver steatosis was observed in 10% of participants overall and was more common among HIV-negative adults than in PLWH (15% vs 3%). The proportion of patients with steatosis was 25% among obese (BMI ≥30 kg/m2) participants, 12% among those overweight (BMI 25-29.9 kg/m2), and 7% among those with a BMI 25 kg/m2 and liver steatosis was attenuated after adjustment for potential confounders (aOR 1.96, 95% CI 0.88-4.40). Overall, 21 (9%) participants without HIV and 4 (3%) with HIV met the criteria for MAFLD. Among individuals with liver steatosis, 65% (95% CI 49% to 80%) fulfilled criteria of MAFLD, whereas 15 (39%) of them had elevated transaminases and 3 (8%) F2-F4 fibrosis. CONCLUSIONS The prevalence of liver steatosis in this urban cohort of HIV-positive and negative adults in Zambia was low, despite a large proportion of patients with high BMI and central obesity. Our study is among the first to report data on MAFLD among adults in Africa, demonstrating that metabolic risk factors are key drivers of liver steatosis and supporting the adoption of the criteria for MAFLD in African populations

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