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ABSTRACT: The Groupe Haitien d'Etude du Sarcome de Kaposi et des Infections Opportunistes (the GHESKIO AIDS and TB Center) in Port-au-Prince, Haiti.
To measure the effectiveness of the standard TB retreatment regimen (2HRZES/1HRZE/5HRE) in human immunodeficiency virus (HIV) infected adults.
Cohort study.
Of 1318 HIV-infected patients with access to antiretroviral therapy following World Health Organization guidelines, 56 were diagnosed with recurrent pulmonary TB and retreated with the standard retreatment regimen: 10 patients (18%) died during retreatment, 3 (5%) defaulted, and 2 (4%) failed treatment. Forty-one patients (73%) achieved retreatment 'success' (cure, treatment completed). Of these, 8 (20%) died during follow-up, 5 (12%) were lost, and 5 (12%) had a second recurrence of TB. Only 26 (46%) of the 56 patients remained alive, in care, and TB-free after a median of 36 months of follow-up.
HIV-infected patients treated for recurrent TB with the standard retreatment regimen have high mortality and poor long-term outcomes.
The international journal of tuberculosis and lung disease: the official journal of the International Union against Tuberculosis and Lung Disease 04/2012; 16(6):841-5. · 2.73 Impact Factor
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A J Herring,
R C Ballard,
V Pope,
R A Adegbola,
J Changalucha,
D W Fitzgerald,
E W Hook,
A Kubanova,
S Mananwatte, J W Pape,
A W Sturm,
B West,
Y P Yin,
R W Peeling
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ABSTRACT: To evaluate nine rapid syphilis tests at eight geographically diverse laboratory sites for their performance and operational characteristics.
Tests were compared "head to head" using locally assembled panels of 100 archived (50 positive and 50 negative) sera at each site using as reference standards the Treponema pallidum haemagglutination or the T pallidum particle agglutination test. In addition inter-site variation, result stability, test reproducibility and test operational characteristics were assessed.
All nine tests gave good performance relative to the reference standard with sensitivities ranging from 84.5-97.7% and specificities from 84.5-98%. Result stability was variable if result reading was delayed past the recommended period. All the tests were found to be easy to use, especially the lateral flow tests.
All the tests evaluated have acceptable performance characteristics and could make an impact on the control of syphilis. Tests that can use whole blood and do not require refrigeration were selected for further evaluation in field settings.
Sexually Transmitted Infections 01/2007; 82 Suppl 5:v7-12. · 2.85 Impact Factor
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ABSTRACT: Intestinal parasites and human immunodeficiency virus (HIV) are major health problems in Haiti. Both entities are known to interact strongly with cell-mediated immunity. The purpose of this study undertaken in Port-au-Prince, Haiti was to evaluate the risk of enteric parasite transmission between HIV-infected patients and family members. Routine examination of stool specimens for parasites was conducted in 90 HIV-infected undergoing treatment for intestinal disorders due mainly to Cryptosporidium sp. (62%) and 123 healthy family member volunteers. A stool sample preserved in 10% formalin solution was examined to detect protozoa (MIF, modified Ziehl-Neelsen stain, Uvibio fluorescence technique, Weber stain) and helminth ova (Bailenger technique). In addition to Cryptosporidium sp., 14 parasitic species were identified: 6 Rhizopoda, 3 Flagellata (including Giardia duodenalis), 1 Coccidia (Cyclospora cayetanensis), 3 Nematoda (mainly Ascaris lumbricoides) and 1 Cestoda (Hymenolepis nana). This is the first time that 5 protozoa, i.e., Blastocystis hominis, Entamoeba hartmanni, E. polecki, Chilomastix mesnili, and Enteromonas hominis, have been reported in Haiti. As expected, enteric parasites were less common in HIV-infected subjects undergoing medical treatment (11.1%) than in uninfected family members (41.5%) (p = 0.0000). Multiple intestinal parasitism (infection by 2 to 4 parasites) was observed in 19.5% of family members. The findings of this study indicate that detecting and treating intestinal parasites in subjects living in close contact with HIV-infected patients as well as informing family members of the importance of personal hygiene in Haiti are highly recommended measures to preserve the health of AIDS patients.
Médecine tropicale: revue du Corps de santé colonial 11/2006; 66(5):461-4.
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ABSTRACT: The mechanisms by which Cryptosporidium parvum cause persistent diarrhea and increased morbidity and mortality are poorly understood. Three groups of Haitian children <18 months old were studied: case patients, children with diarrhea not due to Cryptosporidium, and healthy control subjects. Compared with both control groups, children with acute cryptosporidiosis were more malnourished (including measures of stunting [P=.03] and general malnutrition [P=.01]), vitamin A deficient (P=.04), and less often breast-fed (P=.04). Markers of a proinflammatory immune response, interleukin (IL)-8 and tumor necrosis factor-alpha receptor I, were significantly elevated in the case population (P=.02 and P<.01, respectively), as was fecal lactoferrin (P=.01) and the T helper (Th)-2 cytokine IL-13 (P=.03). The counterregulatory cytokine IL-10 was exclusively elevated in the case population (P<.01). A Th1 cytokine response to infection was not detected. This triple cohort study demonstrates that malnourished children with acute cryptosporidiosis mount inflammatory, Th-2, and counterregulatory intestinal immune responses.
The Journal of Infectious Diseases 07/2002; 186(1):94-101. · 6.41 Impact Factor
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JAIDS Journal of Acquired Immune Deficiency Syndromes 12/2001; 28(3):305-7. · 4.43 Impact Factor
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ABSTRACT: To describe the integration of tuberculosis screening into the activities of an HIV voluntary counselling and testing (VCT) centre in a country with endemic tuberculosis.
An HIV VCT centre in Port au Prince, Haiti.
All patients presenting for HIV VCT who reported cough received same-day evaluation for active tuberculosis. Of the 1327 adults presenting to the centre for the first time between January and April 1997, 263 (20%) reported cough and of these 241 (92%) were evaluated.
Of the 241 patients evaluated for cough, 76 (32%) were diagnosed with pulmonary tuberculosis. Of the 76 patients diagnosed with pulmonary tuberculosis, 28 (37%) had a positive smear for acid-fast bacilli (AFB), 14 (18%) had a negative AFB smear but a positive sputum culture for Mycobacterium tuberculosis, and 34 (45%) had culture-negative tuberculosis. Also, 31 out of 241 (13%) VCT clients evaluated for cough were diagnosed with bacterial pneumonia.
This report confirms that in areas with a high HIV and tuberculosis prevalence, a high proportion of VCT clients have active pulmonary tuberculosis. The integration of tuberculosis screening offers several benefits, including the diagnosis and treatment of large numbers of individuals with tuberculosis, a decreased risk of nosocomial tuberculosis transmission, and the opportunity to provide tuberculosis prophylaxis to HIV-positive patients in whom tuberculosis has been excluded. Future studies are needed to determine the cost-effectiveness of integrated tuberculosis and HIV VCT services, and whether integration should be recommended in all countries with high HIV and tuberculosis rates.
AIDS 10/2001; 15(14):1875-9. · 6.24 Impact Factor
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J W Pape
Emerging infectious diseases 02/2001; 7(3 Suppl):547. · 6.17 Impact Factor
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ABSTRACT: This study evaluated a novel approach to the delivery of directly observed therapy (DOT) for tuberculosis in Haiti.
A total of 194 patients (152 HIV seropositive, 42 HIV seronegative) received daily unsupervised triple-drug therapy for 4 to 8 weeks, followed by twice-weekly 2-drug therapy for the remainder of the 6-month period. DOT was deferred until initiation of the twice-weekly phase.
A total of 169 of 194 patients (87.1%) completed the 6-month course. The program of deferred DOT had an effectiveness of 85%. Overall cost was reduced by approximately 40%.
Flexible approaches to DOT, integrating behavioral knowledge, cost considerations, and practicality may improve completion rates and program effectiveness.
American Journal of Public Health 02/2001; 91(1):138-41. · 3.93 Impact Factor
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ABSTRACT: A review was conducted in Haiti to determine the timing and outcome of active tuberculosis (TB) in human immunodeficiency virus (HIV)-positive patients who had previously received isoniazid (INH) prophylaxis. Of 1005 HIV-seropositive patients who completed INH prophylaxis, 14 (1.4%) subsequently had active TB diagnosed. The median interval between discontinuation of INH prophylaxis and TB diagnosis was 8 months for 6 patients receiving 6 months of INH, 22 months for 5 patients receiving 12-24 months of INH, and 40 months for 3 patients receiving 24-36 months of INH (P = .026). There is a postprophylaxis effect on INH that is dependent upon the duration of therapy.
Clinical Infectious Diseases 01/2001; 31(6):1495-7. · 9.15 Impact Factor
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ABSTRACT: A study was conducted to define the natural history and disease progression of HIV infection in a developing country.
A prospective longitudinal cohort study.
Forty-two patients with documented dates of HIV seroconversion were followed in Port-au-Prince, Haiti. Patients were seen at 3 month intervals or when ill. Patients were treated for bacterial, mycobacterial, parasitic, and fungal infections, but antiretroviral therapy was not available. Patients were followed until death or until 1 January 2000; median follow-up was 66 months.
By Kaplan-Meier analyses, the median time to symptomatic HIV disease (CDC category B or C) was 3.0 years [95% confidence interval (CI) 2.3-5.0 years]. The median time to AIDS (CDC category C) was 5.2 years (95% CI 4.7-6.5 years), and the median time to death was 7.4 years (95% CI 6.2-10.2 years). Community-acquired infections, including respiratory tract infections, acute diarrhea, and skin infections were common in the pre-AIDS period. AIDS-defining illnesses included tuberculosis, wasting syndrome, cryptosporidiosis, cyclosporiasis, candida esophagitis, toxoplasmosis, and cryptococcal meningitis. Rapid progression to death was associated with anemia at the time of seroconversion hazards ratio (HR) 4.1 (95% CI 1.1-15.0), age greater than 35 years at seroconversion HR 4.4 (95% CI 1.1-16.6), and lymphopenia at seroconversion HR 11.0 (95% CI 2.3-53.0).
This report documents rapid disease progression from HIV seroconversion until death among patients living in a developing country. Interventions, including nutritional support and prophylaxis of common community-acquired infections during the pre-AIDS period may slow disease progression and prolong life for HIV-infected individuals in less-developed countries.
AIDS 12/2000; 14(16):2515-21. · 6.24 Impact Factor
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ABSTRACT: Patients with HIV-1 infection respond well to treatment for active tuberculosis, but whether such patients are at increased risk of disease recurrence after complete cure is uncertain. We did a randomised trial in Port au Prince, Haiti, to determine whether recurrent tuberculosis after curative tuberculosis treatment is more common in HIV-1-infected individuals than HIV-1-uninfected individuals, and to determine whether post-treatment isoniazid prophylaxis decreases the risk of recurrent tuberculosis.
Patients older than 18 years who were diagnosed with a first episode of tuberculosis at the national HIV testing centre in Haiti, and who successfully completed a 6-month rifampicin-containing regimen for active pulmonary tuberculosis, were randomly assigned 1 year of post-treatment isoniazid prophylaxis or placebo. The primary outcome measure was rate of recurrent tuberculosis after at least 24 months. An intention-to-treat analysis was used.
Of 354 patients with active pulmonary tuberculosis, 274 successfully completed treatment, and 233 were randomised. Of 142 HIV-1-positive patients, 68 were assigned isoniazid and 74 placebo. Of 91 HIV-1-negative individuals, 51 were assigned isoniazid and 40 placebo. The rate of recurrent tuberculosis was 4.8 per 100 person-years in HIV-1-infected individuals and 0.4 per 100 person-years in uninfected individuals (relative risk 10.7 [95% CI 1.4-81.6]). Among HIV-1-positive patients receiving isoniazid, the tuberculosis recurrence rate was 1.4 per 100 person-years, and among HIV-1-positive patients receiving placebo, it was 7.8 per 100 person-years (0.18 [0.04-0.83]). Among HIV-1-positive individuals, all cases of recurrent tuberculosis occurred in individuals with a history of HIV-1-related symptoms before initial tuberculosis diagnosis.
The rate of recurrent tuberculosis is higher in HIV-1-positive individuals than in HIV-1-negative individuals, and is strongly associated with a history of symptomatic HIV-1 disease before initial tuberculosis diagnosis. Post-treatment isoniazid prophylaxis decreases the risk of recurrence in HIV-1-positive individuals, and should be considered for HIV-1-positive individuals with a history of HIV-1-related symptoms at the time of tuberculosis diagnosis.
The Lancet 11/2000; 356(9240):1470-4. · 38.28 Impact Factor
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ABSTRACT: In developing countries, Isospora belli and Cyclospora cayetanensis frequently cause chronic diarrhea in HIV-infected patients.
To compare 1 week of trimethoprim-sulfamethoxazole treatment and 1 week of ciprofloxacin treatment in HIV-infected patients with chronic diarrhea caused by I. belli and C. cayetanensis.
Randomized, controlled trial.
HIV clinic in Port-au-Prince, Haiti.
42 HIV-infected patients with chronic diarrhea due to I. belli (n = 22) or C cayetanensis (n = 20).
Patients were randomly assigned to receive oral trimethoprim-sulfamethoxazole (160 mg or 800 mg) or ciprofloxacin (500 mg) twice daily for 7 days. Patients who responded clinically and microbiologically received prophylaxis for 10 weeks (1 tablet orally, three times per week).
Treatment success was measured by cessation of diarrhea and negative stool examination at day 7. Prophylaxis success was measured by recurrent disease rate.
Diarrhea ceased in all 19 patients treated with trimethoprim-sulfamethoxazole. Eighteen of 19 patients had negative results on stool examination at day 7 (95%). Among the 23 patients who received ciprofloxacin, diarrhea ceased in 20 (87% [CI; 66% to 97%]) and 16 had negative results on stool examination at day 7 (70%). By survival analysis, diarrhea from isosporiasis and cyclosporiasis ceased more rapidly with trimethoprim-sulfamethoxazole than with ciprofloxacin. All patients receiving secondary prophylaxis with trimethoprim-sulfamethoxazole remained disease-free, and 15 of 16 patients receiving secondary prophylaxis with ciprofloxacin remained disease-free.
A 1-week course of trimethoprim-sulfamethoxazole is effective in HIV-infected patients with cyclosporiasis or isosporiasis. Although ciprofloxacin is not as effective, it is acceptable for patients who cannot tolerate trimethoprim-sulfamethoxazole.
Annals of internal medicine 07/2000; 132(11):885-8. · 16.73 Impact Factor
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ABSTRACT: The current study followed HIV-infected women through pregnancy and their infants through the first 2 years of life to determine the rate of vertical transmission of HIV infection from Haitian women, factors in maternal health and obstetrical history that might influence such transmission and the natural history of HIV infection in their affected offspring.
The medical histories of 81 infants born of HIV-infected women and of a control group of 88 infants born to uninfected women were documented with close clinical and serologic follow-up. In addition to standard tests for persistence of HIV antibodies, the use of acid-dissociated p24 assays enabled us to assign some additional infants to the HIV-infected cohort.
Transmission could be documented in 27% of infants born to HIV-infected women. Excess early deaths occurred in infants of HIV-infected women in Port-au-Prince with 60% of infected infants dead by 6 months of age. This is a more accelerated mortality than that in a group of 42 HIV-infected infants born of Haitian mothers living in Miami where 10% were dead at 6 months. Clinically, in 6 of 19 deaths in HIV-infected children in Haiti, failure to thrive and gastroenteritis lead to a systemic infection manifested as meningitis, sepsis or pneumonia as the immediate cause of death.
Early mortality attributable to perinatally acquired AIDS was identified in Haiti. The comparison of data from Miami and Port-au-Prince suggests that environmental exposures in developing countries may be more operative in this early mortality than viral strain or maternal host factors, both of which might be expected to be similar between the two groups of Haitian ethnicity.
The Pediatric Infectious Disease Journal 02/1999; 18(1):58-63. · 3.58 Impact Factor
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ABSTRACT: This study was designed to describe the characteristics of HIV-1 infection in children in Haiti and to assess its impact on morbidity and mortality.
Throughout the developing world the female-to-male ratio of HIV-1 infection approaches 1:1, leading to a tremendous burden of vertically transmitted HIV-1 infection. The frequency of transmission, progression of disease and AIDS-defining clinical illnesses are not as well-described in this setting as in the industrial world.
Children were identified as being HIV-1-seropositive from case findings among family members of individuals presenting for screening at the GHESKIO Centers in Port-au-Prince, Haiti. Children who were seronegative from the same population were also enrolled and both groups were followed at regular intervals. The clinical course and illnesses associated with HIV infection were documented.
Rapid progression to symptomatic disease and death was seen and a battery of physical findings enabled a clinician over time to assign with high sensitivity and specificity the diagnosis of AIDS to a child. Although many findings are similar, the presentation of HIV-1 infection in Haiti differed in significant ways from observations in the industrial world. In particular signs of malnutrition, failure to thrive and tuberculosis were more common in the Haitian population.
Pediatric HIV-1 infection in Haiti differs significantly from the illness in the industrial world. Early mortality poses a particular difficulty in diagnosing and ascribing mortality to HIV-1 infection.
The Pediatric Infectious Disease Journal 07/1997; 16(6):600-6. · 3.58 Impact Factor
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ABSTRACT: Despite the importance of human immunodeficiency virus (HIV) transmission through heterosexual contact, the incidence of HIV infection in heterosexual cohorts has not been well studied, particularly in the developing world.
To 1) determine the incidence of HIV infection in discordant heterosexual couples (couples in which one partner had HIV infection and the other did not) in Haiti and 2) assess risk factors for and methods of preventing HIV infection.
Prospective study.
National Institute for Laboratory Research, Portau-Prince, Haiti.
475 HIV-infected patients and their noninfected regular sex partners.
Patients and their partners were evaluated at 3- to 6-month intervals for HIV infection, sexually transmitted diseases, and sexual practices. The efficacy of counseling and provision of free condoms was also evaluated.
Among the 177 couples who remained sexually active during the prospective study period, 20 seroconversions to HIV positivity occurred, for an incidence rate of 5.4 per 100 person-years (95% CI, 5.16 to 5.64 per 100 person-years). Thirty-eight couples (21.5%) discontinued sexual activity during the study. Only 1 seroconversion occurred among the 42 sexually active couples (23.7% of the 177 sexually active couples) who always used condoms. In contrast, the incidence in sexually active couples who infrequently used or did not use condoms was 6.8 per 100 person-years (CI, 6.49 to 7.14 per 100 person-years). Transmission of HIV was associated with genital ulcer disease, syphilis, and vaginal or penile discharge in the HIV-negative partner and with syphilis in the HIV-infected partner.
Counseling and the provision of free condoms contributed to the institution of safe sex practices or abstinence in 45% of discordant heterosexual couples. However, 55% of couples reported that they continued to have unprotected sex, resulting in an incidence of HIV infection of 6.8 per 100 person-years.
Annals of internal medicine 09/1996; 125(4):324-30. · 16.73 Impact Factor
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Boletín de la Oficina Sanitaria Panamericana. Pan American Sanitary Bureau 03/1995; 118(2):161-9.
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Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology 03/1995; 8(2):214.
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ABSTRACT: To determine the prevalence and clinical manifestations of Cyclospora in Haitians infected with human immunodeficiency virus (HIV) who have diarrhea and to evaluate therapy and prophylaxis.
Cohort study. From 1990 to 1993, stool samples were collected from adults seropositive for HIV who had had diarrhea for at least 3 weeks.
A clinic in Haiti.
Stool samples were examined for enteric protozoa after acid-fast staining. Patients with Cyclospora infection were treated with trimethoprimsulfamethoxazole (160 mg and 800 mg, respectively) given orally four times a day for 10 days. After completion of therapy, patients were evaluated weekly and re-treated if clinical and parasitologic recurrences occurred, followed by trimethoprim-sulfamethoxazole prophylaxis three times a week.
804 of 2400 patients (33%) seropositive for HIV had a history of chronic or intermittent diarrhea; 502 of these 804 patients (62%) currently had diarrhea, and 450 patients each provided two stool specimens for examination. Enteric protozoa identified included Cryptosporidium (30%), Isospora belli (12%), Cyclospora species (11%), Giardia lamblia (3%), and Entamoeba histolytica (1%). Forty-three patients with diarrhea and Cyclospora infection were studied; their symptoms were indistinguishable from those seen in patients with isosporiasis or cryptosporidiosis. In all patients, diarrhea ceased and results from stool examinations were negative within 2.5 days after beginning oral trimethoprim-sulfamethoxazole therapy. Recurrent symptomatic cyclosporiasis developed in 12 of 28 patients (43%) followed for 1 month or more, but it also responded promptly to trimethoprim-sulfamethoxazole therapy. These 12 patients received trimethoprim-sulfamethoxazole three times a week as secondary prophylaxis, with only a single recurrence after 7 months.
Cyclospora infection is common in Haitian patients with HIV infection, responds to trimethoprim-sulfamethoxazole therapy, and has a high recurrence rate that can be largely prevented with long-term trimethoprim-sulfamethoxazole prophylaxis.
Annals of internal medicine 12/1994; 121(9):654-7. · 16.73 Impact Factor
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ABSTRACT: Human immunodeficiency virus (HIV) infection is spreading rapidly in Haiti with HIV seroprevalence rates of 10% and 3% in urban and rural areas, respectively. Since 1985, heterosexual transmission has been the primary mode of acquisition of HIV. From 1981 to the present, the Cornell-GHESKIO unit in Port-au-Prince, Haiti, has developed the infrastructure to recruit and retain large cohorts of individuals at risk for HIV infection. Among the populations studied, couples discordant for HIV infection appear most suitable for eventual HIV phase III vaccine trial. This paper describes the recruitment, retention, and characteristics of the discordant-couples cohort, as well as the limitations of interventions aimed at behavior modification.
AIDS Research and Human Retroviruses 02/1994; 10 Suppl 2:S231-3. · 2.25 Impact Factor
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ABSTRACT: Tuberculosis occurring with human immunodeficiency virus (HIV) infection is a serious and growing public health problem. We have carried out a randomised clinical trial of a 12-month course of isoniazid plus vitamin B6 versus vitamin B6 alone in Port-au-Prince, Haiti, to assess the efficacy of isoniazid in preventing active tuberculosis in symptom-free HIV-infected individuals. The effect of prophylaxis on the development of HIV disease, AIDS, and death was also investigated. 118 subjects were assigned treatment with isoniazid plus B6 (n = 58) or B6 alone (n = 60) between 1986 and 1989. The treatment groups were similar at study entry in demographic, clinical, and immunological characteristics. Interim analysis in 1990 revealed no significant difference in tuberculosis outcome measures. Follow-up was continued until 1992, at which time significant protection by isoniazid against the development of tuberculosis was apparent, both for the whole study population and for subjects positive for purified protein derivative of tuberculin (PPD). The incidence of tuberculosis was lower in isoniazid recipients than in patients who received B6 alone (2.2 vs 7.5 per 100 person-years). The relative risk of tuberculosis was 3.4 (95% CI 1.1-10.6) for B6 alone versus isoniazid plus B6 (p < 0.05). Isoniazid also delayed progression to HIV disease and AIDS and death. Thus isoniazid effectively decreases the incidence of tuberculosis and delays the onset of HIV-related disease in symptom-free HIV-seropositive individuals. Isoniazid prophylaxis should be considered for HIV-seropositive, PPD-positive subjects, and may also be appropriate for PPD-negative patients in areas where tuberculosis is highly endemic.
The Lancet 07/1993; 342(8866):268-72. · 38.28 Impact Factor
