673 research outputs found

    Survival of South-African HIV infected patients

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    In sub-Saharan Africa, resource-limitation results in scarce availability of HIV prognostic tools such as CD4+ T-Lymphocyte (CD4) count and HIV viral load. To facilitate counselling and clinical decisions in this setting, widely available and inexpensive markers of prognosis are required. Chapter one gives an overview of the epidemiology and pathophysiology of HIV infection (with particular reference to sub-Saharan Africa), and its clinical manifestations. Staging systems for HIV infection and aspects of management in resource-poor environments are briefly discussed. Chapter two describes the epidemiological, pathophysiological and clinical aspects of tuberculosis (TB) in HIV infected patients, the commonest opportunistic infection in sub-Saharan Africa. It further provides HIV and TB prevalence data from the Western Cape, South Africa. In chapter three a study is presented demonstrating the usefulness of the total lymphocyte count (TLC) in combination with the World Health Organisation (WHO) clinical staging system to predict outcome in 831 HIV positive patients. A TLC of 1250/Ī¼L was found to be the equivalent of a CD4 count of 200/Ī¼L. Patients with early HIV disease (WHO stage 1&2) had low annual rates of progression to AIDS : 3-4% if the TLC was above 1250/Ī¼L, 12-14% if the TLC was below 1250/Ī¼L. Annual progression to AIDS increased to 25% and 46% in patients with clinical stage 3 and a TLC above or below 1250/Ī¼L respectively. Patients with AIDS had 30-55% one-year mortality rates depending on the TLC. Chapter four illustrates that pulmonary tuberculosis (PTB) in HIV infected patients presents with a radiographic spectrum reflecting the degree of HIV induced immune suppression. Chest radiographs and pre-treatment total lymphocyte counts provide prognostic information. Upper zone cavitatory infiltrates typical of reactivation PTB were associated with a preserved CD4 count (mean 389/Ī¼L) and predicted a 100% two-year survival. Pleural effusions were associated with a mean CD4 count of 184/Ī¼L and predicted 65% two-year survival. Patients with atypical radiographic presentation, including lower and mid-zone infiltrates, hilar and mediastinal adenopathy or interstitial patterns, had low CD4 counts (mean 105/Ī¼L) and a 36% survival at two years. Rather than classifying every patient with pleura-pulmonary tuberculosis as WHO stage 3, incorporation of the prognostic value of the chest radiograph into the clinical staging system, such that typical reactivation PTB becomes stage 2, tuberculous pleural effusion stage 3 and atypical PTB stage 4, would enhance the prognostic accuracy of HIV related tuberculosis. Chapter five demonstrates that patients with AIDS could be categorized accord ing to one of three survival patterns, relating to the type of opportunistic illness. One-year survival rates were highest for extra-pulmonary tuberculosis and herpes simplex virus infection (70% ); intermediate for oesophageal candidiasis, cryptococcal meningitis, kaposi sarcoma and pneumocystis carinii pneumonia (45%) ; and poorest for the HIV wasting syndrome, AIDS-dementia complex and performance status 4 (20%). Despite the overall poor prognosis associated with the acquired immunodeficiency syndrome, a substantial proportion of patients survive, even in the absence of anti-retroviral therapy, for a number of years. Chapter six concludes by proposing how the data presented in this thesis could be used in the clinical management of patients with HIV infection in a resource limited environment

    AIDS in Africa- survival according to AIDS-defining illness

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    Objective. Evaluation of prognostic significance of the typeĀ of AIDS-defining illness (ADI) and performance status in aĀ cohort of AIDS patients.Design, setting, subjects, outcome measures. A retrospectiveĀ analysis of 280 patients with AIDS, as defined by theĀ proposed World Health Organisation (WHO) clinicalĀ staging system, who attended two Cape Town-based HIVĀ clinics between 1984 and 1997. Patients were stratifiedĀ according to the type of initial ADI. Survival associatedĀ with each opportunistic event was determined by Kaplan-MeierĀ analysis. Cox proportional hazard analysis was usedĀ to determine relative risk for death associated with threeĀ strata of ADI.Results. Median survival associated with various initialĀ ADls varied from less than 3 months (encephalopathy andĀ wasting), to over 2 years (extrapulmonary tuberculosis andĀ herpes simplex virus infection). This effect of ADI onĀ outcome was most striking in patients with relativelyĀ preserved CD4 counts (CD4 > 50/Ī¼l). A performance statusĀ score 4 predicted 50% mortality at 1 month, irrespective ofĀ co-morbidity.Conclusion. The type of ADl is an important determinant ofĀ survival, particularly in patients with preserved CD4Ā counts. The stratification of patients by type of ADI andĀ performance status may be useful in the management ofĀ patients with advanced HIV infection in resource-limitedĀ environments

    Inflammatory Markers Associated With Subclinical Coronary Artery Disease: The Multicenter AIDS Cohort Study.

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    BackgroundDespite evidence for higher risk of coronary artery disease among HIV+ individuals, the underlying mechanisms are not well understood. We investigated associations of inflammatory markers with subclinical coronary artery disease in 923 participants of the Multicenter AIDS Cohort Study (575 HIV+ and 348 HIV- men) who underwent noncontrast computed tomography scans for coronary artery calcification, the majority (n=692) also undergoing coronary computed tomography angiography.Methods and resultsOutcomes included presence and extent of coronary artery calcification, plus computed tomography angiography analysis of presence, composition, and extent of coronary plaques and severity of coronary stenosis. HIV+ men had significantly higher levels of interleukin-6 (IL-6), intercellular adhesion molecule-1, C-reactive protein, and soluble-tumor necrosis factor-Ī± receptor (sTNFĪ±R) I and II (all P<0.01) and a higher prevalence of noncalcified plaque (63% versus 54%, P=0.02) on computed tomography angiography. Among HIV+ men, for every SD increase in log-interleukin-6 and log intercellular adhesion molecule-1, there was a 30% and 60% increase, respectively, in the prevalence of coronary stenosis ā‰„50% (all P<0.05). Similarly, sTNFĪ±R I and II in HIV+ participants were associated with an increase in prevalence of coronary stenosis ā‰„70% (P<0.05). Higher levels of interleukin-6, sTNFĪ±R I, and sTNFĪ±R II were also associated with greater coronary artery calcification score in HIV+ men (P<0.01).ConclusionsHigher inflammatory marker levels are associated with greater prevalence of coronary stenosis in HIV+ men. Our findings underscore the need for further study to elucidate the relationships of inflammatory pathways with coronary artery disease in HIV+ individuals

    Efficacy and safety of emtricitabine/tenofovir alafenamide (FTC/TAF) vs. emtricitabine/tenofovir disoproxil fumarate (FTC/TDF) as a backbone for treatment of HIV-1 infection in virologically suppressed adults: subgroup analysis by third agent of a randomized, double-blind, active-controlled phase 3 trial*

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    Background: FTC/TAF was shown to be noninferior to FTC/TDF with advantages in markers of renal and bone safety.Objective: To evaluate the efficacy and safety of switching to FTC/TAF from FTC/TDF by third agent (boosted protease inhibitor [PI] vs. unboosted third agent).Methods: We conducted a 48-week subgroup analysis based on third agent from a randomized, double blind study in virologically suppressed adults on a FTC/TDF-containing regimen who switched to FTC/TAF vs. continued FTC/TDF while remaining on the same third agent.Results: We randomized (1:1) 663 participants to either switch to FTC/TAF (N = 333) or continue FTC/TDF (N = 330), each with baseline third agent stratifying by class of third agent in the prior treatment regimen (boosted PI 46%, unboosted third agent 54%). At week 48, significant differences in renal biomarkers and bone mineral density were observed favoring FTC/TAF over FTC/TDF (p < 0.05 for all), with similar improvements in the FTC/TAF arm in those who received boosted PI vs. unb..

    Pain in people living with HIV and its association with healthcare resource use, well-being and functional status

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    Objective: We describe the prevalence of pain and its associations with healthcare resource utilisation and quality-of-life. Design: The POPPY Study recruited three cohorts: older PLWH (ā‰„50 years, n = 699), younger demographically/lifestyle similar PLWH (<50 years, n = 374) and older demographically/lifestyle similar HIV-negative (ā‰„50 years, n = 304) people from April 2013-February 2016. Methods: Current pain and pain-related healthcare use was collected via a self-reported questionnaire. Logistic regression assessed between-group differences in the prevalence of pain in the past month and current pain after controlling for potential confounders. Associations between current pain and healthcare resource use, reported joint problems, depressive symptoms, quality-of-life and functional status were assessed in PLWH using Mann-Whitney U and Chi-squared tests. Results: Pain in the past month was reported by 473/676 (70.0%) older PLWH, 224/357 (62.7%) younger PLWH and 188/295 (63.7%) older HIV-negative controls (p = 0.03), with current pain reported in 330 (48.8%), 134 (37.5%) and 116 (39.3%), respectively (p = 0.0007). Older PLWH were more likely to experience current pain, even after adjustment for confounders. Of those with pain in the past month, 56/412 (13.6%) had missed days of work or study due to pain, and 520 (59%) had seen a doctor about their pain. PLWH experiencing current painhad more depressive symptoms, poorer quality-of-life on all domains, and greater functional impairment, regardless of age group. Conclusions: Even in the effective ART era, pain remains common in PLWH and has a major impact on quality-of-life and associated healthcare and societal costs. Interventions are required to assist clinicians and PLWH to proactively manage pain

    Defining cognitive impairment in people-living-with-HIV: the POPPY study

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    Background The reported prevalence of cognitive impairment (CI) varies widely in cohorts of people living with HIV (PLWH); this may partly be due to the use of different diagnostic criteria. Agreement between diagnostic criteria of CI, the optimal definition to use, and associations with patient-reported cognitive symptoms have not been fully investigated. Methods Two hundred ninety PLWH aged >50 years and 97 matched negative controls completed a detailed assessment of cognitive function and three questions regarding cognitive symptoms. Age- and education-adjusted test scores (T-scores) determined if subjects met the following definitions of CI: Frascati, global deficit score (GDS) and the multivariate normative comparison (MNC) method. Results PLWH were more likely than controls to meet each definition of CI (ORs were 2.17, 3.12 and 3.64 for Frascati, GDS and MNC, respectively). Agreement of MNC with Frascati and GDS was moderate (Cohenā€™s kā€‰=ā€‰0.42 and 0.48, respectively), whereas that between Frascati and GDS was good (kā€‰=ā€‰0.74). A significant association was found between all the three criteria and reporting of memory loss but not with attention and reasoning problems. The 41 (14 %) PLWH meeting all the three criteria had the lowest median global T-score (36.9) and highest rate of symptom reporting (42 %). Conclusions Different CI criteria show fair diagnostic agreement, likely reflecting their ability to exclude CI in the same group of individuals. Given the lower overall cognitive performance and higher rates of symptom reporting in those meeting all three criteria of CI, further work assessing this as a definition of CI in PLWH is justified

    A Prospective Study of Return to Work Across Health Conditions: Perceived Work Attitude, Self-efficacy and Perceived Social Support

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    Background The aim of the present study was to conduct subgroup-analyses in a prospective cohort of workers on long-term sickness absence to investigate whether associations between perceived work attitude, self-efficacy and perceived social support and time to RTW differ across different health conditions. Methods The study was based on a sample of 926 workers on sickness absence (6ā€“12Ā weeks). The participants filled out a baseline questionnaire and were subsequently followed until the tenth month after listing sick. Perceived work attitude was measured with a Dutch language version of the Work Involvement Scale. Perceived social support was measured with a self-constructed standardized scale reflecting a personā€™s perception of social support regarding RTW. Self-efficacy was measured with the standardised Dutch version of the General self-efficacy scale, assessing the subjectsā€™ expectations of their general capacities. The sample was divided into three subgroups: musculoskeletal health conditions, other physical health conditions and mental health conditions. Anova analyses and Cox proportional hazards regression analyses were used to identify differences in association between the three factors and the time to RTW between different subgroups. Results The associations between the perceived work attitude, self-efficacy and perceived social support and the time to RTW vary across different health condition subgroups, not only with regard to the strength of the association but also for the type of factor. In the multivariate model, hazard ratios (HRs) of 1.33 (95% CI 1.01ā€“1.75) in the musculoskeletal subgroup, and 1.26 (95% CI 0.89ā€“1.78) in the other physical subgroup were found in perceived work attitude. With regard to perceived social support HRs of 1.39 (95% CI 1.12ā€“1.99) respectively 1.51 (1.05ā€“2.17) in the same subgroups were found. Only self-efficacy remained in the multivariate model in all subgroups with HRs of 1.49 (95% CI 1.12ā€“1.99) in the musculoskeletal subgroup, 1.53 (95% CI 1.07ā€“2.18) in the other physical subgroup and 1.60 (1.07ā€“2.40) in the mental subgroup. Conclusions The results of this study show that perceived work attitude, self-efficacy and perceived social support are relevant predictors with regard to the time to RTW in all types of health conditions, but that important differences are observed in type of factor and strengths of the relationships between physical and mental health conditions
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