Morbidity before and after HAART initiation in Sub-Saharan African HIV-infected adults: a recurrent event analysis.

Programme PAC-CI, Abidjan, Côte d'Ivoire.
AIDS Research and Human Retroviruses (Impact Factor: 2.46). 11/2007; 23(11):1338-47. DOI: 10.1089/aid.2006.0308
Source: PubMed

ABSTRACT The incidence and determinants of severe morbidity recurrence in sub-Saharan African HIV-infected adults on antiretroviral therapy (ART) have never been reported. In a prospective cohort study of HIV-infected adults in Abidjan the association of severe morbidity occurrence and recurrence with follow-up CD4 counts and ART on/off status was analyzed by means of multivariate failure analysis for recurrent events (Prentice, Williams, and Peterson model). A total of 608 patients (median CD4 290/mm3 ) was followed off ART for 1824 person-years (PY). Of these 187 started HAART (median CD4 174/mm3 ) and were followed for 328 PY. The incidence of first, second, and third severe morbidity events was 40.6/100 PY, 68.4/100 PY, and 93.9/100 PY during the off-ART period, and 28.4/100 PY, 39.4/100 PY, and 37.6/100 PY during the on-ART period, respectively. The rates of recurrences were higher than the rates of first episodes for almost all diseases, even after stratifying by CD4 count and by ART on/off status. In multivariate analysis, the time-updated CD4 count was independently associated with increasing rates of morbidity first events and recurrences, after adjustment on other covariates (p > 10(4) ). By contrast, there was no association between the ART on/off status and the morbidity rates after adjustment for CD4 count (p = 0.37). Introducing ART led to a clear reduction in morbidity, mainly related to the ART-induced increase in CD4 count. In HIV-infected patients on ART, the incidence of severe morbidity varied with the past history of morbidity. The past history of morbidity should be taken into account when comparing HIV morbidity rates before and after ART initiation.

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    ABSTRACT: Background The causes of severe morbidity in health facilities implementing Antiretroviral Treatment (ART) programmes are poorly documented in sub-Saharan Africa. We aimed to describe severe morbidity among HIV-infected patients after ART initiation, based on data from an active surveillance system established within a network of specialized care facilities in West African cities. Methods Within the International epidemiological Database to Evaluate AIDS (IeDEA) - West Africa collaboration, we conducted a prospective, multicenter data collection that involved two facilities in Abidjan, Côte d’Ivoire and one in Cotonou, Benin. Among HIV-infected adults receiving ART, events were recorded using a standardized form. A simple case-definition of severe morbidity (death, hospitalization, fever > 38°5C, Karnofsky index < 70%) was used at any patient contact point. Then a physician confirmed and classified the event as WHO stage 3 or 4 according to the WHO clinical classification or as degree 3 or 4 of the ANRS scale. Results From December 2009 to December 2011, 978 adults (71% women, median age 39 years) presented with 1449 severe events. The main diagnoses were: non-AIDS-defining infections (33%), AIDS-defining illnesses (33%), suspected adverse drug reactions (7%), other illnesses (4%) and syndromic diagnoses (16%). The most common specific diagnoses were: malaria (25%), pneumonia (13%) and tuberculosis (8%). The diagnoses were reported as syndromic in one out of five events recorded during this study. Conclusions This study highlights the ongoing importance of conventional infectious diseases among severe morbid events occurring in patients on ART in ambulatory HIV care facilities in West Africa. Meanwhile, additional studies are needed due to the undiagnosed aspect of severe morbidity in substantial proportion. Electronic supplementary material The online version of this article (doi:10.1186/s12879-015-0910-3) contains supplementary material, which is available to authorized users.
    BMC Infectious Diseases 04/2015; 15(1). DOI:10.1186/s12879-015-0910-3 · 2.56 Impact Factor
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    ABSTRACT: Objective We aimed to describe the morbidity and mortality patterns in HIV-positive adults hospitalized in West Africa. Method We conducted a six-month prospective multicentre survey within the IeDEA West Africa collaboration in six adult medical wards of teaching hospitals in Abidjan, Ouagadougou, Cotonou, Dakar and Bamako. From April to October 2010, all newly hospitalized HIV-positive patients were eligible. Baseline and follow-up information until hospital discharge was recorded using standardized forms. Diagnoses were reviewed by a local event validation committee using reference definitions. Factors associated with in-hospital mortality were studied with a logistic regression model. Results Among 823 hospitalized HIV-positive adults (median age 40 years, 58% women), 24% discovered their HIV infection during the hospitalization, median CD4 count was 75/mm3 (IQR: 25–177) and 48% had previously received antiretroviral treatment (ART). The underlying causes of hospitalization were AIDS-defining conditions (54%), other infections (32%), other diseases (8%) and non-specific illness (6%). The most frequent diseases diagnosed were: tuberculosis (29%), pneumonia (15%), malaria (10%) and cerebral toxoplasmosis (10%). Overall, 315 (38%) patients died during hospitalization and the underlying cause of death was AIDS (63%), non-AIDS-defining infections (26%), other diseases (7%) and non-specific illness or unknown cause (4%). Among them, the most frequent fatal diseases were: tuberculosis (36%), cerebral toxoplasmosis (10%), cryptococcosis (9%) and sepsis (7%). Older age, clinical WHO stage 3 and 4, low CD4 count, and AIDS-defining infectious diagnoses were associated with hospital fatality. Conclusions AIDS-defining conditions, primarily tuberculosis, and bacterial infections were the most frequent causes of hospitalization in HIV-positive adults in West Africa and resulted in high in-hospital fatality. Sustained efforts are needed to integrate care of these disease conditions and optimize earlier diagnosis of HIV infection and initiation of ART.
    Journal of the International AIDS Society 04/2014; 17(1):18797. DOI:10.7448/IAS.17.1.18797 · 4.21 Impact Factor
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    ABSTRACT: Background: While tuberculosis (TB) is the most common opportunistic infection in HIV+ patients in India, treatment of latent TB infection (tLTBI) is not recommended. We examine the clinical and economic impact of alternative strategies for tLTBI with isoniazid-based therapy in ART-naive HIV+ patients. Methods: We used a state-transition model simulating HIV/TB coinfection to investigate 4 tLTBI strategies: 1) no tLTBI, 2) tLTBI for tuberculin skin testing (TST)+ patients, 3) tLTBI if TST+ or CD4 <200/µl, and 4) tLTBI for all HIV+ patients. Input data from India included a mean CD4 of 390/µl, TB incidence of 9.55/100PY without and 2.11/100PY with tLTBI, and a tLTBI cost of $6.90/mo (2008 US$); one ART regimen was available. We compared the incremental cost/life year saved (US$/YLS) among the strategies. Results: tLTBI for all HIV+ patients maximized life expectancy (LE, 97.4 mo), and lifetime costs ($2,490), and prevented the most acute TB cases. The cost-effectiveness ratio was $620/YLS, considered very cost-effective by WHO criteria for India. Strategy Mean LE/person (months) Mean cost/person (2008 US$) $/YLS TB cases /100 patients 1) No tLTBI 96.4 2460 -- 66 2) tLBI by TST status 96.9 2470 Dominated* 57 3) tLTBI by TST or CD4<200/µl 97.3 2480 350 48 4) tLTBI for all 97.4 2490 620 42 YLS = Year of life saved, *More costly and/or less effective compared to next best strategy Conclusions: Treatment of tLTBI will improve clinical outcomes and be cost-effective when provided to ART-naïve HIV+ patients in India, regardless of TST status or CD4 count.
    Infectious Diseases Society of America 2009 Annual Meeting; 10/2009

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