Clinical Differences between Younger and Older Adults with HIV/AIDS Starting Antiretroviral Therapy in Uganda and Zimbabwe: A Secondary Analysis of the DART Trial

Objective: Clinical and immunological data about HIV in older adults from low and middle income countries is scarce. We aimed to describe differences between younger and older adults with HIV starting antiretroviral therapy in two low–income African countries. Methods: Setting:: HIV clinics in Uganda and Zimbabwe. Design:: Secondary exploratory cross-sectional analysis of the DART randomized controlled trial. Outcome Measures: Clinical and laboratory characteristics were compared between adults aged 18-49 years (younger) and ≥ 50 years (older), using two exploratory multivariable logistic regression models, one with HIV viral load (measured in a subset pre-ART) and one without. Results: A total of 3316 eligible participants enrolled in DART were available for analysis; 219 (7%) were ≥ 50 years and 1160 (35%) were male. Across the two adjusted regression models, older adults had significantly higher systolic blood pressure, lower creatinine clearance and were consistently less likely to be females compared to younger adults with HIV. Paradoxically, the models separately suggested that older adults had statistically significant (but not clinically important) higher CD4+ cell counts and higher plasma HIV–1 viral copies at initiation. Crude associations between older age and higher baseline hemoglobin, body mass index, diastolic blood pressure and lower WHO clinical stage were not sustained in the adjusted analysis. Conclusions: Our study found clinical and immunological differences between younger and older adults, in a cohort of Africans starting antiretroviral therapy. Further investigations should explore how these differences could be used to ensure equity in service delivery and affect outcomes of antiretroviral therapy

Traditional Herbal Medicine Use Associated with Liver Fibrosis in Rural Rakai, Uganda

Background: Traditional herbal medicines are commonly used in sub-Saharan Africa and some herbs are known to be hepatotoxic. However little is known about the effect of herbal medicines on liver disease in sub-Saharan Africa. Methods: 500 HIV-infected participants in a rural HIV care program in Rakai, Uganda, were frequency matched to 500 HIV-uninfected participants. Participants were asked about traditional herbal medicine use and assessed for other potential risk factors for liver disease. All participants underwent transient elastography (FibroScan®) to quantify liver fibrosis. The association between herb use and significant liver fibrosis was measured with adjusted prevalence risk ratios (adjPRR) and 95% confidence intervals (CI) using modified Poisson multivariable logistic regression. Results: 19 unique herbs from 13 plant families were used by 42/1000 of all participants, including 9/500 HIV-infected participants. The three most-used plant families were Asteraceae, Fabaceae, and Lamiaceae. Among all participants, use of any herb (adjPRR = 2.2, 95% CI 1.3–3.5, p = 0.002), herbs from the Asteraceae family (adjPRR = 5.0, 95% CI 2.9–8.7, p<0.001), and herbs from the Lamiaceae family (adjPRR = 3.4, 95% CI 1.2–9.2, p = 0.017) were associated with significant liver fibrosis. Among HIV infected participants, use of any herb (adjPRR = 2.3, 95% CI 1.0–5.0, p = 0.044) and use of herbs from the Asteraceae family (adjPRR = 5.0, 95% CI 1.7–14.7, p = 0.004) were associated with increased liver fibrosis. Conclusions: Traditional herbal medicine use was independently associated with a substantial increase in significant liver fibrosis in both HIV-infected and HIV-uninfected study participants. Pharmacokinetic and prospective clinical studies are needed to inform herb safety recommendations in sub-Saharan Africa. Counseling about herb use should be part of routine health counseling and counseling of HIV-infected persons in Uganda

Sub-Optimal Vitamin B-12 Levels among ART-Naïve HIV-Positive Individuals in an Urban Cohort in Uganda

Malnutrition is common among HIV-infected individuals and is often accompanied by low serum levels of micronutrients. Vitamin B-12 deficiency has been associated with various factors including faster HIV disease progression and CD4 depletion in resource-rich settings. To describe prevalence and factors associated with sub-optimal vitamin B-12 levels among HIV-infected antiretroviral therapy (ART) naïve adults in a resource-poor setting, we performed a cross-sectional study with a retrospective chart review among individuals attending either the Mulago-Mbarara teaching hospitals’ Joint AIDS Program (MJAP) or the Infectious Diseases Institute (IDI) clinics, in Kampala, Uganda. Logistic regression was used to determine factors associated with sub-optimal vitamin B-12. The mean vitamin B-12 level was 384 pg/ml, normal range (200–900). Sub-optimal vitamin B-12 levels (<300 pg/ml) were found in 75/204 (36.8%). Twenty-one of 204 (10.3%) had vitamin B-12 deficiency (<200 pg/ml) while 54/204 (26.5%) had marginal depletion (200–300 pg/ml). Irritable mood was observed more among individuals with sub-optimal vitamin B-12 levels (OR 2.5, 95% CI; 1.1–5.6, P = 0.03). Increasing MCV was associated with decreasing serum B-12 category; 86.9 fl (±5.1) vs. 83 fl (±8.4) vs. 82 fl (±8.4) for B-12 deficiency, marginal and normal B-12 categories respectively (test for trend, P = 0.017). Compared to normal B-12, individuals with vitamin B-12 deficiency had a longer known duration of HIV infection: 42.2 months (±27.1) vs. 29.4 months (±23.8; P = 0.02). Participants eligible for ART (CD4<350 cells/µl) with sub-optimal B-12 had a higher mean rate of CD4 decline compared to counterparts with normal B-12; 118 (±145) vs. 22 (±115) cells/µl/year, P = 0.01 respectively. The prevalence of a sub-optimal vitamin B-12 was high in this HIV-infected, ART-naïve adult clinic population in urban Uganda. We recommend prospective studies to further clarify the causal relationships of sub-optimal vitamin B-12, and explore the role of vitamin B-12 supplementation in immune recovery

Clinical differences between younger and older adults with HIV/AIDS starting antiretroviral therapy in Uganda and Zimbabwe: a secondary analysis of the DART trial

Clinical and immunological data about HIV in older adults from low and middle income countries is scarce. We aimed to describe differences between younger and older adults with HIV starting antiretroviral therapy in two low-income African countries

Hypertension and associated risk factors in individuals infected with HIV on antiretroviral therapy at an urban HIV clinic in Uganda

Background: Scale-up of antiretroviral therapy (ART) might precipitate an increase in non-communicable diseases (NCDs) in adults infected with HIV in sub-Saharan Africa based on data from resource-rich settings. Hypertension is a major modifiable risk factor for cerebrovascular and cardiovascular NCDs. We estimated prevalence, incidence, and risk factors for incident hypertension in adults infected with HIV on ART at an urban clinic in Uganda. Methods: From a cohort of adults infected with HIV (>18 years) who initiated ART between Jan 1, 2005, and Jan 3, 2012, at the Infectious Diseases Institute clinic in Kampala, we report the prevalence, incidence, and cumulative incidence (with death as a competing risk) of hypertension (≥140/90 mm Hg). Risk factors for hypertension were evaluated with Cox proportional hazards regression. Findings: Of 9806 individuals who initiated ART, 6351 (64·8%) were women, median age was 36 years (IQR 31–42), and median follow-up was 3·9 years (2·2–5·9). Overall prevalence of hypertension was 15·1% (1472 individuals); older individuals (>50 years) had higher prevalence (299, 38·6%). By year 1, cumulative incidence was 1% and by year 5, it was 3·6%. Overall incidence was 19 cases per 1000 person-years. Multivariate regression showed male sex, older age, increasing body-mass index, and use of stavudine at initiation was associated with an increased rate of hypertension. Interpretation: Of our patients, we noted a prevalence of hypertension between 14·6% and 28·5%, similar to the general Ugandan population. Besides traditional risk factors for hypertension, use of stavudine was also identified. Awareness of NCD comorbidity and AIDS-associated risk factors are increasingly important for clinicians caring for adults on ART in sub-Saharan Africa. Funding: University of California Global Health Institute (UCGHI) supported GloCal Fellowship funded by the Fogarty International Center (FIC) at the National Institutes of Health (NIH) R25TW009343

Assessing the impact of delivering messages through intimate partners to create demand for voluntary medical male circumcision in Uganda

De-identified dataset used in the final report to 3ie on the project, "Assessing the impact of delivering messages through intimate partners to create demand for voluntary medical male circumcision in Uganda" (project code TW3.06). This project was funded through the Thematic Window 3

Risk factors for sub-optimal vitamin B-12 among adult HIV-infected ART naïve individuals at two urban HIV clinics in Uganda, in April 2010.

a<p>Adjusted for age, sex, BMI, supplement use, MCV, occupation, irritable mood, known duration with HIV, WHO disease stage and current CD4.</p>b<p>Adjusted for,age, sex, BMI, WHO stage, supplement use.</p><p><b>BMI</b>- Body Mass Index, <b>MCV</b>-Mean Corpuscular Volume, <b>OR</b> Odds Ratio, <b>WHO</b>-World health Organization.</p

Risk factors for sub-optimal serum vitamin B-12 among adult HIV-infected ART naïve participants who did not report using vitamin B-12 containing supplements at two urban HIV clinics in Uganda, in April 2010.

a<p>Adjusted for age, sex, BMI, supplement use, MCV, occupation, irritable mood, known duration with HIV, WHO disease stage and current CD4.</p>b<p>Adjusted for,age, sex, BMI, WHO stage, supplement use.</p><p><b>BMI</b>- Body Mass Index, <b>MCV</b>-Mean Corpuscular Volume, <b>OR</b> Odds Ratio, <b>WHO</b>-World health Organization.</p