Prevalence of HIV Infection among Trauma Patients Admitted to\ud Bugando Medical Centre, Mwanza, Tanzania and its\ud Influence on Outcome

HIV infection, a major health problem worldwide, has been reported to be prevalent in trauma patients, thus presents an occupational hazard to health care workers who care for these patients. The purpose of this study was to establish the prevalence of HIV among trauma patients in our setting and to compare the outcome of these patients who are HIV positive with those who are HIV negative. This was a descriptive cross sectional study involving trauma patients aged 11 years and above, admitted to the surgical wards of Bugando Medical Centre in Mwanza, Tanzania over a six-month period from October 2008 to March 2009. All eligible patients were consecutively enrolled in the study. Data were collected using a pre-tested, coded questionnaire and analyzed using SPSS computer software. A total of 250 trauma patients were recruited and studied. The mean age of the study population was 36.37±15.35. Males accounted for the majority (N=202; 80.8%) of the study population. The prevalence of HIV among trauma patients was 11.6%. Among the HIV positive patients, 26 (89.7%) were males and majority aged 31-40 years. Seventy two percent of HIV positive patients had CD4+ count of ≥ 200 cells/μl. Overall length of hospital stays (LOS) ranged from 1 - 90 days with mean of 19.11 ± 15.84 days. Using multivariate logistic regression, injury severity score (ISS) (P=0.0026), revised trauma scores (RTS) (P= 0.002,), HIV seropositivity (P= 0.0012) and CD4+ count (P= 0.001) were significantly found to be associated with increased LOS. Mortality rate was 10.8% and was significantly associated with; the body region injured (P < 0.05), ISS (P = 0.026), RTS (P = 0.001), PTS (P= 0.01), HIV positivity (P= 0.0001) and CD4+ count (P= 0.035). HIV is prevalent among trauma patients in our setting. A substantial risk of exposure to HIV exists in health workers who care for these patients. Thus, all trauma health care workers in this region need to practice universal barrier precautions in order to reduce the risk of exposure to HIV infection. HIV positive patients with CD4+ count ≥200cells/μl have similar prognosis as HIV negative patients and therefore should be treated the same way

From HIV diagnosis to treatment: evaluation of a referral system to promote and monitor access to antiretroviral therapy in rural Tanzania

BACKGROUND: Individuals diagnosed with HIV in developing countries are not always successfully linked to onward treatment services, resulting in missed opportunities for timely initiation of antiretroviral therapy, or prophylaxis for opportunistic infections. In collaboration with local stakeholders, we designed and assessed a referral system to link persons diagnosed at a voluntary counselling and testing (VCT) clinic in a rural district in northern Tanzania with a government-run HIV treatment clinic in a nearby city. METHODS: Two-part referral forms, with unique matching numbers on each side were implemented to facilitate access to the HIV clinic, and were subsequently reconciled to monitor the proportion of diagnosed clients who registered for these services, stratified by sex and referral period. Delays between referral and registration at the HIV clinic were calculated, and lists of non-attendees were generated to facilitate tracing among those who had given prior consent for follow up.Transportation allowances and a "community escort" from a local home-based care organization were introduced for patients attending the HIV clinic, with supportive counselling services provided by the VCT counsellors and home-based care volunteers. Focus group discussions and in-depth interviews were conducted with health care workers and patients to assess the acceptability of the referral procedures. RESULTS: Referral uptake at the HIV clinic averaged 72% among men and 66% among women during the first three years of the national antiretroviral therapy (ART) programme, and gradually increased following the introduction of the transportation allowances and community escorts, but declined following a national VCT campaign. Most patients reported that the referral system facilitated their arrival at the HIV clinic, but expressed a desire for HIV treatment services to be in closer proximity to their homes. The referral forms proved to be an efficient and accepted method for assessing the effectiveness of the VCT clinic as an entry point for ART. CONCLUSION: The referral system reduced delays in seeking care, and enabled the monitoring of access to HIV treatment among diagnosed persons. Similar systems to monitor referral uptake and linkages between HIV services could be readily implemented in other settings

Sub therapeutic drug levels among HIV/TB co-infected patients receiving Rifampicin in northwestern Tanzania: A cross sectional clinic based study

Background: Tuberculosis/Human Immunodeficiency Virus (TB/HIV) is a very common co-infection which carries a high mortality rate. Though World Health Organization recommends co-treatment of TB/HIV to improve its outcome, Rifampicin potentially induces metabolism and sub-therapeutic antiretroviral plasma levels of non nucleoside reverse transcriptase inhibitors and protease inhibitors which may cause inadequate virological suppression if corrections are not timely done. In Tanzania Therapeutic drug monitoring is not done; so the proportion of sub-therapeutic ARV plasma levels among TB/HIV patients co-treated with anti-tuberculous drugs is not known. The aim of this study was therefore to determine the magnitude and risk factors of sub-therapeutic ARV plasma levels among adult HIV patients co-treated with anti tuberculous Medications.Materials and methods: A cross sectional hospital based study was conducted among adult HIV patients on ARV and TB co-treatment for at least one month. Patients were serially enrolled through routine HIV care and treatment services until the sample size was reached. The information about demographic, clinical and adherence level, Anti-TB duration, viral load, baseline and enrollment CD4 counts, Hepatitis B co-infection and ARV plasma levels was collected and analyzed using STATA 12 software.Results: In total 118 patients were included in this study; of whom 26 (22%) had sub-therapeutic ARV plasma levels. The sub-therapeutic ARV levels were independently associated with adherence &lt;95% (OR =6.8, p= 0.001), female gender (OR = 3.4, p= 0.028) and virological failure (OR= 3.8, p= 0.016). NVP based regimen was associated with sub-therapeutic drug levels on univariate model (OR = 2.1, p= 0.010).Conclusion: The magnitude of sub-therapeutic ARV plasma levels is high among adult HIV/TB coinfected patients on anti-TB co-treatment in Tanzania. These patients stand a high risk of inadequate virological suppression with a potential resistance development and a long term poor clinical outcome. Identifying at risk patients and adherence enhancement could potentially improve the overall outcome of this subgroup of patients in resource restricted setting like ours where TDM is not available.Keywords: HIV; HIV/TB co-infection; HIV/TB co-treatment Rifampicin; Antiretroviral therapy; Plasma ARV drug levels; Therapeutic drug monitorin

Universal screening of Tanzanian HIV-infected adult inpatients with the serum cryptococcal antigen to improve diagnosis and reduce mortality: an operational study

Cryptococcal meningitis is a leading cause of death among HIV-infected individuals in sub-Saharan Africa. Recent developments include the availability of intravenous fluconazole, cryptococcal antigen assays and new data to support fluconazole pre-emptive treatment. In this study, we describe the impact of screening HIV-positive adult inpatients with serum cryptococcal antigen (CRAG) at a Tanzanian referral hospital. All adults admitted to the medical ward of Bugando Medical Centre are counseled and tested for HIV. In this prospective cohort study, we consecutively enrolled HIV-positive patients admitted between September 2009 and January 2010. All patients were interviewed, examined and screened with serum CRAG. Patients with positive serum CRAG or signs of meningitis underwent lumbar puncture. Patients were managed according to standard World Health Organization treatment guidelines. Discharge diagnoses and in-hospital mortality were recorded.\ud Of 333 HIV-infected adults enrolled in our study, 15 (4.4%) had confirmed cryptococcal meningitis and 10 of these 15 (66%) died. All patients with cryptococcal meningitis had at least two of four classic symptoms and signs of meningitis: fever, headache, neck stiffness and altered mental status. Cryptococcal meningitis accounted for a quarter of all in-hospital deaths. Despite screening of all HIV-positive adult inpatients with the serum CRAG at the time of admission and prompt treatment with high-dose intravenous fluconazole in those with confirmed cryptococcal meningitis, the in-hospital mortality rate remained unacceptably high. Improved strategies for earlier diagnosis and treatment of HIV, implementation of fluconazole pre-emptive treatment for high-risk patients and acquisition of better resources for treatment of cryptococcal meningitis are needed

Hypertension, kidney disease, HIV and antiretroviral therapy among Tanzanian adults: a cross-sectional study.

BACKGROUND: The epidemics of HIV and hypertension are converging in sub-Saharan Africa. Due to antiretroviral therapy (ART), more HIV-infected adults are living longer and gaining weight, putting them at greater risk for hypertension and kidney disease. The relationship between hypertension, kidney disease and long-term ART among African adults, though, remains poorly defined. Therefore, we determined the prevalences of hypertension and kidney disease in HIV-infected adults (ART-naive and on ART >2 years) compared to HIV-negative adults. We hypothesized that there would be a higher hypertension prevalence among HIV-infected adults on ART, even after adjusting for age and adiposity. METHODS: In this cross-sectional study conducted between October 2012 and April 2013, consecutive adults (>18 years old) attending an HIV clinic in Tanzania were enrolled in three groups: 1) HIV-negative controls, 2) HIV-infected, ART-naive, and 3) HIV-infected on ART for >2 years. The main study outcomes were hypertension and kidney disease (both defined by international guidelines). We compared hypertension prevalence between each HIV group versus the control group by Fisher's exact test. Logistic regression was used to determine if differences in hypertension prevalence were fully explained by confounding. RESULTS: Among HIV-negative adults, 25/153 (16.3%) had hypertension (similar to recent community survey data). HIV-infected adults on ART had a higher prevalence of hypertension (43/150 (28.7%), P = 0.01) and a higher odds of hypertension even after adjustment (odds ratio (OR) = 2.19 (1.18 to 4.05), P = 0.01 in the best model). HIV-infected, ART-naive adults had a lower prevalence of hypertension (8/151 (5.3%), P = 0.003) and a lower odds of hypertension after adjustment (OR= 0.35 (0.15 to 0.84), P = 0.02 in the best model). Awareness of hypertension was ≤ 25% among hypertensive adults in all three groups. Kidney disease was common in all three groups (25.6% to 41.3%) and strongly associated with hypertension (P 2 years had two-fold greater odds of hypertension than HIV-negative controls. HIV-infected adults with hypertension were rarely aware of their diagnosis but often have evidence of kidney disease. Intensive hypertension screening and education are needed in HIV-clinics in sub-Saharan Africa. Further studies should determine if chronic, dysregulated inflammation may accelerate hypertension in this population

Short-term and long-term cardiovascular risk, metabolic syndrome and HIV in Tanzania.

OBJECTIVE: To compare short-term and long-term cardiovascular disease (CVD) risk scores and prevalence of metabolic syndrome in HIV-infected adults receiving and not receiving antiretroviral therapy (ART) to HIV-negative controls. METHODS: A cross-sectional study including 151 HIV-infected, ART-naive, 150 HIV-infected on ART and 153 HIV-negative adults. Traditional cardiovascular risk factors were determined by standard investigations. The primary outcome was American College of Cardiology/American Heart Association Atherosclerotic CVD (ASCVD) Risk Estimator lifetime CVD risk score. Secondary outcomes were ASCVD 10-year risk, Framingham risk scores, statin indication and metabolic syndrome. RESULTS: Compared with HIV-negative controls, more HIV-infected adults on ART were classified as high lifetime CVD risk (34.7% vs 17.0%, p<0.001) although 10-year risk scores were similar, a trend which was similar across multiple CVD risk models. In addition, HIV-infected adults on ART had a higher prevalence of metabolic syndrome versus HIV-negative controls (21.3% vs 7.8%, p=0.008), with two common clusters of risk factors. More than one-quarter (28.7%) of HIV-infected Tanzanian adults on ART meet criteria for statin initiation. CONCLUSIONS: HIV-infected ART-treated individuals have high lifetime cardiovascular risk, and this risk seems to develop rapidly in the first 3-4 years of ART as does the development of clusters of metabolic syndrome criteria. These data identify a new subgroup of low short-term/high-lifetime risk HIV-infected individuals on ART who do not currently meet criteria for CVD risk factor modification but require further study

Needle-stick injuries and splash exposures among health-care workers at a tertiary care hospital in north-western Tanzania

Background: Needle-stick injuries (NSIs) and splash exposures carry a risk of occupational acquisition of HIV and other blood borne pathogens to healthcare workers (HCWs) involved in clinical care. This study was carried out to determine the frequency and factors contributing to NSIs and splash exposures as well as post-exposure practices among HCWs in our centre. Methods: This was a cross-sectional study among healthcare workers which was conducted at Bugando Medical Centre (BMC) over a one-year period between April 2013 and March 2014. Results:  Out of 436 HCWs who participated in this study, 212 (48.6%) reported incidents of NSIs and splash exposures within the previous 12 months. NSIs were reported by 65.1% (n= 138) and splash exposures by 27.4% (n = 58). Sixteen (7.5%) respondents had both NSIs and splash exposures. High rates of NSIs were observed among nurses (71.0%), during procedures (53.6%) and occurred commonly in the Accident and Emergency department (33.3%). Hollow bore needles were responsible for 63.8% of NSIs.  Splash exposures occurred more commonly in operating theatre (41.4%). At the time of the exposure, 116 (54.7%) HCWs wore protective equipment. The most common action following exposure was washing the site with soap and water (55.6%). Only 68 (32.1%) reported the incident of exposure to the relevant authority.  Healthcare workers aged ≤ 40 years; those with work experience of ≤ 5 years and those not trained on issues related to infection prevention and occupational risk reduction were more likely to be exposed to any type of occupational injuries studied. While male healthcare workers were less likely to be exposed to NSIs, female were more likely to encounter both NSIs and mucocutaneous splashes (p &lt; 0.001). The majority of HCWs, 185 (87.3%) were not adequately immunized for hepatitis B virus and only 17 (8.0%) were fully vaccinated, having received three doses of the vaccine. Only 16.7% of exposed HCWs received post-exposure prophylaxis for HIV. Subsequent six-month follow-up for HIV showed zero seroconversion. Conclusion: NSIs and splash exposures are common among HCWs at our centre and are under-reported. Post-exposure management is generally poor. All HCWs should be trained on issues related to infection prevention and occupational risk reduction. The hospital should establish surveillance system for registering, reporting and management of occupational injuries and exposures.

Refining Diagnosis of Schistosoma haematobium Infections: Antigen and Antibody Detection in Urine

Background: Traditional microscopic examination of urine or stool for schistosome eggs lacks sensitivity compared to measurement of schistosome worm-derived circulating antigens in serum or urine. The ease and non-invasiveness of urine collection makes urine an ideal sample for schistosome antigen detection. In this study several user-friendly, lateral-flow (LF) based urine assays were evaluated against a composite reference that defined infection as detection of either eggs in urine or anodic antigen in serum.Method: In a Tanzanian population with a S. haematobium prevalence of 40–50% (S. mansoni prevalence &lt;2%), clinical samples from 44 women aged 18 to 35 years were analyzed for Schistosoma infection. Urine and stool samples were examined microscopically for eggs, and serum samples were analyzed for the presence of the anodic antigen. Urines were further subjected to a set of LF assays detecting (circulating) anodic (CAA) and cathodic antigen (CCA) as well as antibodies against soluble egg antigens (SEA) and crude cercarial antigen preparation (SCAP).Results: The urine LF anodic antigen assay utilizing luminescent upconverting reporter particles (UCP) confirmed its increased sensitivity when performed with larger sample volume. Qualitatively, the anodic antigen assay performed on 250 μL urine matched the performance of the standard anodic antigen assay performed on 20 μL serum. However, the ratio of anodic antigen levels in urine vs. serum of individual patients varied with absolute levels always higher in serum. The 10 μL urine UCP-LF cathodic antigen assay correlated with the commercially available urine POC-CCA (40 μL) test, while conferring better sensitivity with a quantitative result. Urinary antibodies against SEA and SCAP overlap and correlate with the presence of urinary egg and serum anodic antigen levels.Conclusions: The UCP-LF anodic antigen assay using 250 μL of urine is an expedient user-friendly assay and a suitable non-invasive alternative to serum-based antigen testing and urinary egg detection. Individual biological differences in the clearance process of the circulating antigens are thought to explain the observed high variation in the type and level of antigen (anodic or cathodic) measured in urine or serum. Simultaneous detection of anodic and cathodic antigen may be considered to further increase accuracy