Sexual Risk Behaviour among HIV-Positive Individuals in Clinical Care in Urban KwaZulu-Natal, South Africa

Objectives: To assess the prevalence and predictors of unprotected sex among HIV+ individuals in clinical care in urban KwaZulu-Natal, South Africa. Design: Cross-sectional survey of 152 HIV+ individuals attending a hospital-based HIV-clinic. Methods: Structured interviews were conducted by bilingual interviewers. Sexual risk behaviour in the preceding 3 months was assessed via event counts. Results: In one of the first studies of its kind in South Africa we found that nearly half of the sample reported vaginal or anal sex during the preceding 3 months, and 30% of these patients reported unprotected vaginal or anal sex. Among sexually active patients, a total of 171 unprotected sex events were reported, 40% of which were with partners perceived to be HIV negative or HIV-status unknown. Nine such partners were potentially exposed to HIV. Alcohol use during sex, being forced to have sex, sex with a perceived HIV+ partner, and sex with a casual partner predicted more unprotected sex, whereas HIV-status disclosure was related to less unprotected sex. Conclusions: HIV+ individuals in clinical care in South Africa may engage in unprotected sex that place others at risk of HIV infection and themselves at risk for infection with STIs. With a national ARV rollout currently underway in South Africa, increasing numbers of HIV+ individuals are entering care. This affords a crucial opportunity to link HIV prevention with HIV care, an approach that aims to reduce transmission risk behaviour among HIV+ individuals and is consistent with international agencies’ current prevention priorities

Diagnosis of childhood tuberculosis and host RNA expression in Africa

Improved diagnostic tests for tuberculosis in children are needed. We hypothesized that transcriptional signatures of host blood could be used to distinguish tuberculosis from other diseases in African children who either were or were not infected with the human immunodeficiency virus (HIV

HIV transmission risk behavior among HIV-positive patients receiving antiretroviral therapy in KwaZulu-Natal, South Africa.

CAPRISA, 2014.The aim of this investigation was to identify factors associated with HIV transmission risk behavior among HIV-positive women and men receiving antiretroviral therapy (ART) in KwaZulu-Natal, South Africa. Across 16 clinics, 1,890 HIV? patients on ART completed a risk-focused audio computer-assisted self-interview upon enrolling in a prevention-with-positives intervention trial. Results demonstrated that 62% of HIV-positive patients’ recent unprotected sexual acts involved HIV-negative or HIV status unknown partners. For HIV-positive women, multivariable correlates of unprotected sex with HIV-negative or HIV status unknown partners were indicative of poor HIV prevention-related information and of sexual partnership-associated behavioral skills barriers. For HIV positive men, multivariable correlates represented motivational barriers, characterized by negative condom attitudes and the experience of depressive symptomatology, as well as possible underlying information deficits. Findings suggest that interventions addressing gender-specific and culturally-relevant information, motivation, and behavioral skills barriers could help reduce HIV transmission risk behavior among HIV-positive South Africans

The Medical Education Partnership Initiative (MEPI): Innovations and Lessons for Health Professions Training and Research in Africa

MEPI was a $130 million competitively awarded grant by President's Emergency Plan for AIDS Relief (PEPFAR) and National Institutes of Health (NIH) to 13 Medical Schools in 12 Sub-Saharan African countries and a Coordinating Centre (CC). Implementation was led by Principal investigators (PIs) from the grantee institutions supported by Health Resources and Services Administration (HRSA), NIH and the CC from September, 2010 to August, 2015. The goals were to increase the capacity of the awardees to produce more and better doctors, strengthen locally relevant research, promote retention of the graduates within their countries and ensure sustainability. MEPI ignited excitement and stimulated a broad range of improvements in the grantee schools and countries. Through in-country consortium arrangements African PIs expanded the programme from the 13 grantees to over 60 medical schools in Africa, creating vibrant South–South and South–North partnerships in medical education, and research. Grantees revised curricular to competency based models, created medical education units to upgrade the quality of education and established research support centres to promote institutional and collaborative research. MEPI stimulated the establishment of ten new schools, doubling of the students’ intake, in some schools, a three-fold increase in post graduate student numbers, and faculty expansion and retention. Sustainability of the MEPI innovations was assured by enlisting the support of universities and ministries of education and health in the countries thus enabling integration of the new programs into the regular national budgets. The vibrant MEPI annual symposia are now the largest medical education events in Africa attracting global participation. These symposia and innovations will be carried forward by the successor of MEPI, the African Forum for Research and Education in Health (AFREhealth). AFREhealth promises to be more inclusive and transformative bringing together other health professionals including nurses, pharmacists, and dentists.<p

Continued Elevation of Interleukin-18 and Interferon-γ After Initiation of Antiretroviral Therapy and Clinical Failure in a Diverse Multicountry Human Immunodeficiency Virus Cohort.

Background.  We assessed immune activation after antiretroviral therapy (ART) initiation to understand clinical failure in diverse settings. Methods.  We performed a case-control study in ACTG Prospective Evaluation of Antiretrovirals in Resource-Limited Settings (PEARLS). Cases were defined as incident World Health Organization Stage 3 or 4 human immunodeficiency virus (HIV) disease or death, analyzed from ART weeks 24 (ART24) to 96. Controls were randomly selected. Interleukin (IL)-6, interferon (IFN)-γ-inducible protein-10, IL-18, tumor necrosis factor-α, IFN-γ, and soluble CD14 (sCD14) were measured pre-ART and at ART24 in plasma. Continued elevation was defined by thresholds set by highest pre-ART quartiles (>Q3). Incident risk ratios (IRRs) for clinical progression were estimated by Poisson regression, adjusting for age, sex, treatment, country, time-updated CD4+ T-cell count, HIV ribonucleic acid (RNA), and prevalent tuberculosis. Results.  Among 99 cases and 234 controls, median baseline CD4+ T-cell count was 181 cells/µL, and HIV RNA was 5.05 log10 cp/mL. Clinical failure was independently associated with continued elevations of IL-18 (IRR, 3.03; 95% confidence interval [CI], 1.27-7.20), sCD14 (IRR, 2.17; 95% CI, 1.02-4.62), and IFN-γ (IRR, 0.08; 95% CI, 0.01-0.61). Among 276 of 333 (83%) who were virologically suppressed at ART24, IFN-γ was associated with protection from failure, but the association with sCD14 was attenuated. Conclusions.  Continued IL-18 and sCD14 elevations were associated with clinical ART failure. Interferon-γ levels may reflect preserved immune function

Antiretroviral initiation at ≥800 CD4+ cells/ mm 3 associated with lower HIV reservoir size.

BACKGROUND: Identifying factors that determine the frequency of latently infected CD4+ T-cells on antiretroviral therapy (ART) may inform strategies for HIV cure. We investigated the role of CD4 count at ART initiation for HIV persistence on ART. METHODS: Among participants of the Strategic Timing of Antiretroviral Treatment (START) Study, we enrolled people with HIV (PWH) who initiated ART with CD4+ T-cell counts of 500-599, 600-799 or ≥800 cells/mm 3. After 36-44 months on ART, we quantified levels of total HIV-DNA, cell-associated unspliced HIV-RNA (CA-US HIV-RNA) and 2-long terminal repeat HIV-DNA in CD4+ T-cells and measured plasma HIV-RNA by single-copy assay. We measured T-cell expression of HLA-DR, programmed death-1, phosphorylated signal transducer and activator of transcription-5 (pSTAT5). Virological and immunological measures were compared across CD4+ strata. RESULTS: We enrolled 146 PWH, 36 in the 500-599, 60 in the 600-799 and 50 in the ≥800 CD4 strata. After 36-44 months of ART, total HIV-DNA, plasma HIV-RNA and HLA-DR expression were significantly lower in PWH with CD4+ T-cell count ≥800 cells/mm 3 at ART initiation compared to 600-799 or 500-599 cells/mm 3. The median level of HIV-DNA after 36-44 months of ART was lower by 75% in participants initiating ART with ≥800 vs. 500-599 cells/mm 3 [median (IQR): 16.3 (7.0-117.6) vs. 68.4 (13.7-213.1) copies/million cells, respectively). Higher pSTAT5 expression significantly correlated with lower levels of HIV-DNA and CA-US HIV-RNA. Virological measures were significantly lower in females.. CONCLUSION: Initiating ART with a CD4+ count ≥800 cells/mm 3 compared to 600-799 or 500-599 cells/mm 3 was associated with achieving a substantially smaller HIV reservoir on ART

Long-Term Benefits from Early Antiretroviral Therapy Initiation in HIV Infection

BACKGROUND: For people with HIV and CD4+ counts >500 cells/mm3, early initiation of antiretroviral therapy (ART) reduces serious AIDS and serious non-AIDS (SNA) risk compared with deferral of treatment until CD4+ counts are 500 cells/mm3, excess risk of AIDS and SNA associated with delaying treatment initiation was diminished after ART initiation, but persistent excess risk remained. (Funded by the National Institute of Allergy and Infectious Diseases and others.)

Predictors of site choice and eventual learning experiences in a decentralised training programme designed to prepare medical students for careers in underserved areas in South Africa

Background. There is a dire need for medical schools in South Africa to train medical doctors who have the capacity and willingness to work in primary healthcare facilities, particularly in rural areas. Objectives. To assess the effect of students’ gender, race, place of birth and place of high school completion on their choice of training site location and to assess the extent to which the training programme enhanced students’ learning experiences relevant to primary care across training sites.Methods. A survey design involving six cohorts of 4th-year undergraduate medical students (N=187) who were part of the 2013 Family Medicine rotation at the Nelson R Mandela School of Medicine. Self-administered questionnaires were completed by students at the end of each rotation. Data analyses involved descriptive computations and inferential statistical tests, including non-parametric tests for group comparison and generalised polynomial logistic regression. Results. Students believed that their knowledge and skills relevant to primary care increased after the rotation (p&lt;0.0001). There were statistically significant differences between rural and urban sites on certain measures of perceived programme effectiveness. Male students were less likely to choose urban sites. Black students were less likely to choose rural sites compared with their white and Indian counterparts, as were students who attended rural high schools (odds ratio (OR) 9.3; p&lt;0.001). Students from a rural upbringing were also less likely to choose rural sites (OR 14; p&lt;0.001).Conclusion. Based on the findings, an objective approach for student allocation that considers students’ background and individual-level characteristics is recommended to maximise learning experiences

Implementation and outcome evaluation of the Medical Education Partnership Initiative biostatistical reasoning workshops for faculty and postgraduate students at the University of KwaZuluNatal Durban South Africa

Background. There is a shortage of biostatistics expertise at the University of KwaZulu-Natal (UKZN), Durban, South Africa and in the African region.This constrains the ability to carry out high-quality health research in the region. Objectives. To quantitatively and qualitatively evaluate a programme designed to improve the conceptual and critical understanding of biostatistical concepts of UKZN health researchers. Methods. A 40-hour workshop in biostatistical reasoning was conducted annually between 2012 and 2015. The workshops were structured around interpretation and critical assessment of nine articles from the medical literature, with a mix of in-class sessions and small group discussions. Quantitative evaluation of the knowledge gained from the workshops was carried out using a pre- and post-workshop quiz, and qualitative evaluation of the workshop process was done using a mid-workshop questionnaire and focus group discussions. Results. For each year that the workshop was conducted, post-workshop quiz scores were significantly higher than pre-workshop scores. When quiz assessments from all 4 years of training were combined, the pretest median score was 55% (interquartile range (IQR) 40 - 62%) and the post-test median score was 68% (IQR 62 - 76%), with p&lt;0.0001 for the overall comparison of pre- v. post-scores. There was a general consensus among participants that the workshop improved their reasoning skills in biostatistics. Participants also recognised the value of the workshop in building biostatical capacity at UKZN. Conclusion. The workshops were well received and improved the critical and conceptual understanding of the participants. This education mode offers the opportunity for health researchers to advance their knowledge in settings where there are few professional biostatistician collaborators

Prolonged Delivery of Ciprofloxacin and Diclofenac Sodium from a Polymeric Fibre Device for the Treatment of Peridontal Disease

In vitro analysis of drug release and antimicrobial activity of the coblended crosslinked polymeric fibre device (PFD) were investigated. The fibre loaded with ciprofloxacin and diclofenac sodium was comprised of alginate and glycerol crosslinked with barium cations. The pH dependent drug release was evident with ciprofloxacin and diclofenac sodium diffusing from the fibre at pH 4.0 compared to pH 6.8, where the fibre swelled and eroded resulting in zero-order drug release. Agar diffusion studies followed by minimum inhibitory assays were conducted to determine the antimicrobial activity of the device against Escherichia coli, Enterococcus faecalis, and Streptococcus mutans. The antimicrobial activity of the PFD was confirmed in both test assays against all test pathogens. The MIC ranges at pH 4.0 for E. coli, E. faecalis, and S. mutans were 0.5–0.8, 0.4–1.1, and 0.7–2.1 g/mL, respectively. At pH 6.8, similar efficacies (0.3–0.5 g/mL for E. coli and E. faecalis and 0.6–1.0 g/mL for S. mutans) were observed. The effect of varying the plasticizer and crosslinking ion concentration on drug release profile of the fibers was further elucidated and conceptualized using molecular mechanics energy relationships (MMER) and by exploring the spatial disposition of geometrically minimized molecular conformations