Unhomely

As winter’s dusk encroaches on The Rocks, under the shadowy reach of the Sydney Harbour Bridge, anonymous and unnoticed by the lively crowds, the shutters open, and the blank upper windows flash alive in vacant Reynold’s Cottage. Through the unraveling night the cottage innards twist and flutter, spit and ooze with glimpses of disarray, despair and turmoil, the windows spirit-lenses on the turbulent world of mid-twentieth century Sydney

Management of HIV infection in Malawi.

Contains fulltext : 69127.pdf (Publisher’s version ) (Open Access)RU Radboud Universiteit Nijmegen, 22 december 2008Promotores : Meer, J.W.M. van der, Zijlstra, E.E192 p

Can the initial success of the Malawi ART scale-up programme be sustained? The example of Queen Elizabeth Central Hospital, Blantyre.

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Challenges in HIV post-exposure prophylaxis for occupational injuries in a large teaching hospital in Malawi.

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Nevirapine-based antiretroviral therapy started early in the course of tuberculosis treatment in adult Malawians.

Contains fulltext : 52812.pdf (publisher's version ) (Closed access)BACKGROUND: The tuberculosis (TB) mortality rate of registered TB patients in Malawi is 23%, and 59% of the deaths occur in the first 2 months of treatment. HIV-related complications appear to be an important cause. Starting antiretroviral therapy early during tuberculosis treatment may improve outcome but problems often arise with drug interactions, adherence, toxicity and immune reconstitution disease (IRD). METHODS: We prospectively followed 27 HIV-infected adult Malawians after starting Triomune (a generic fixed drug combination of stavudine, lamivudine and nevirapine) in the second week of tuberculosis treatment. RESULTS: At baseline, 88% had CD4+ T-cell counts 1 week beforehand

Observational cohort study of HIV-infected African children.

Item does not contain fulltextBACKGROUND: Most information about children living with HIV is based on follow up from children identified through mother-to-child transmission studies. Children identified through voluntary counseling and testing (VCT) represent a unique cohort that has not been previously described in the literature. METHODS: Children who were found to have HIV infection through VCT were offered enrollment in this study. They were evaluated monthly and encouraged to return to the clinic any time they were ill. Thorough evaluation was performed for every illness. RESULTS: Forty-five children were enrolled in the study. Many of the participants (33%) had a serious acute disease at the time of enrollment. The most common diagnoses were symptomatic malaria and pneumonia. The children were more ill than adults who were enrolled in a simultaneous study and had a higher death rate (37 versus 15 deaths per 100 person-years of observation). The mortality rate was 22%. Undernutrition and low CD4 cell count were independently associated with increased risk of death. CONCLUSIONS: Malawian children found to be HIV-infected through VCT had a high morbidity and mortality rate, highlighting the potential benefit of trimethoprim-sulfamethizole prophylaxis and available antiretroviral therapy

Impact of HIV-associated immunosuppression on malaria infection and disease in Malawi.

Item does not contain fulltextBACKGROUND: Human immunodeficiency virus (HIV) infection and malaria coexist in much of Africa. Previous studies differ in their findings on the interactions between the 2 infections. METHODS: Adults living with HIV infection in Blantyre, Malawi, were enrolled in a longitudinal observational study from September 2002 to August 2004. Malaria blood smears were obtained monthly and for any illness suggestive of malaria. Complete evaluations of all illness episodes were conducted, regardless of malaria smear results. RESULTS: The incidence of clinical malaria episodes was higher in participants with CD4 cell counts 500 cells/mm3. The trend was preserved when increasingly specific definitions of malaria disease were used. The prevalence of malaria infection was not associated with CD4 cell count. In per-visit analysis, lower CD4 cell counts were associated with higher incidences of pneumonia, sepsis, and tuberculosis but not of malaria. Severe malaria was rare, with only 3 cases in 591 person-years of observation. Parasite density and CD4 cell count were independent risk factors for fever. CONCLUSIONS: Profoundly immunosuppressed adults with HIV infection require more-frequent treatment for uncomplicated malaria, but malaria infection and disease are less strongly associated with HIV-associated immunosuppression than are other opportunistic infections. Where malaria is common, the high incidence of fever found among immunosuppressed adults may lead to misclassification of illness episodes as malaria

Hypoadrenalism is not associated with early mortality during tuberculosis treatment in Malawi.

Item does not contain fulltextSETTING: In the developing world, early mortality within 1 month of commencing tuberculosis (TB) treatment is high, particularly with human immunodeficiency virus (HIV) co-infection. In Malawi, 40% of those who die do so in the first month of treatment. Reasons remain unclear and may include delayed diagnosis, opportunistic infections, immune restoration inflammatory syndrome (IRIS) or malnutrition. One possible contributing factor is underlying hypoadrenalism associated with TB-HIV, exacerbated by rifampicin (RMP) induction of P450 and glucocorticoid metabolism. OBJECTIVE: To assess the prevalence of hypoadrenalism in TB patients before and after commencement of TB treatment, and relationship with early mortality. DESIGN: Prospective descriptive study assessing hypoadrenalism before and after anti-tuberculosis treatment, HIV status and outcome up to 3 months post-treatment. RESULTS: Of 51 patients enrolled, 29 (56.9%) were female (median age 32 years, range 18-62). Of 43 patients HIV-tested, 38 (88.3%) were HIV-positive and 15.7% died within the first month. At 3 months, 11 (21.6%) were known to have died. Adequate cortisol levels were found in 49/51 (95.9%) before commencing RMP. Neither of the two with reduced response died. All 34 patients revealed adequate cortisol responses at 2 weeks. CONCLUSION: No evidence of hypoadrenalism was found in this first study to assess adrenal function and outcome of anti-tuberculosis treatment

A community-based study of the incidence of trimethoprim-sulfamethoxazole-preventable infections in Malawian adults living with HIV.

Item does not contain fulltextThe benefits of trimethoprim-sulfamethoxazole (TS) prophylaxis reported for persons living with HIV in Cote d'Ivoire are difficult to extrapolate to sub-Saharan African countries where bacterial resistance to TS is higher and cross-resistance between TS and sulfadoxine-pyrimethamine (SP) may impair SP efficacy for malaria treatment. We conducted a community-based cohort study to measure the incidence of potentially TS-preventable illnesses in Blantyre, Malawi. We found a high incidence of malaria, invasive bacterial infections, and probable bacterial pneumonias but low rates of Pneumocystis jiroveci pneumonia, isosporiasis, and Toxoplasma encephalitis. Most bacterial isolates were resistant to TS but sensitive to azithromycin, a possible alternative to TS. Clinical trials are needed to determine the role of TS or alternative regimens for prophylaxis against secondary infections among people living with HIV in sub-Saharan Africa. These should also assess benefit in patients receiving antiretroviral therapy