With the introduction of highly active antiretroviral therapy (HAART), Human Immunodeficiency Virus (HIV) infected patients live longer and many have co-infections with chronic hepatitis B (HBV) or hepatitis C (HCV) that complicates their care. Treatment of HBV and HCV in the HIV positive co-infected patient requires careful consideration of the timing of initiation of HAART treatment, drug-drug interactions and drug and immune effects. It is an exciting era due to the introduction of new medications available to treat both HBV and HCV infections. Knowledge of the complex interactions between these viruses as well as the effect of various treatment modalities on each virus is the key to understanding and treating these patients effectively
Background: The introduction of Highly Active Antiretroviral Therapy (HAART) has led to decline in HIV-related opportunistic infections in high-income settings. We determined the prevalence and risk factors for opportunistic infections among patients receiving HAART in a resource-limited setting in Nigeria.
Methodology: A descriptive and analytical cross-sectional study among adult HIV-infected patients receiving HAART for a median duration of 3 years at the Federal Medical Centre, Owerri, Nigeria was conducted. Data on pre- HAART socio-demographic, clinical and laboratory characteristics were obtained. Post-HAART data were collected through history, physical examination and laboratory investigations.
Result: The mean age of the participants was 41.1 ± 10.0 years; and females were in the majority (65.8%). Half (50.4%) belonged to the lower socio-economic class. At baseline (pre-HAART), 72.3% of the participants belonged to World Health Organization (WHO) clinical stage 1 or 2. The median pre-HAART CD4 cell count of the patients was 200 (110-263) cells/μl while the median post-HAART CD4 cell count was 357 (211-496) cells/μl. The majority (77.6%) were adherent on HAART. Out of 339 patients, 76 (22.4%) had opportunistic infections. The leading conditions were candidiasis (8.6%), tuberculosis (7.7%), dermatitis (5.6%), chronic diarrhea (1.5%) and sepsis (1.5%). The independent risk factors for opportunistic infections were household income < 20,000 (Adjusted odds ratio [AOR] = 2.70, 95% CI 1.18-6.18), advanced baseline WHO clinical stage (AOR=9.49, 95% CI 4.20-21.42), baseline hemoglobin <10 g/dl (AOR= 3.50, 95% CI 1.47-8.36), post-HAART CD4 cell count <200 cells/μl (AOR= 3.43, 95% CI 1.49-7.92), and HAART non-adherence (AOR= 5.28, 95% CI 2.52-11.08).
Conclusion: Opportunistic infections remain a challenge in patients receiving HAART in resource-limited settings. There is need to intensify the management of opportunistic infections despite HAART use.
Despite improvements in the antifungal regimens and the roll out of antiretroviral therapy (ART) in sub- Saharan Africa, mortality due to cryptococcal meningitis remains high. Relapse of an initially successfully treated infection contributes to this mortality and is often a clinical dilemma in differentiating between paradoxical immune reconstitution inflammatory syndrome (IRIS) and culture-positive relapse or treatment failure. Herein, we present a clinical case scenario and review the case definitions, differential diagnosis, and management of relapse with an emphasis on the current diagnostic and management strategies. We also highlight the challenges of resistance testing and management of refractory relapse cases. The risk of relapse is influenced by: 1) the choice of induction therapy, with higher mortality risk with fluconazole monotherapy which can select for resistance; 2) non-adherence to or lack of secondary prophylaxis; 3) failure of linkage-to-care or retention-in-care of HIV ART programs
There is evidence that HIV-positive women in Catalonia are at high risk for cervical cancer and have a high prevalence of oncogenic genotypes. Catalonia’s screening protocol recommends that HIV-positive women undergo Pap smear at least annually, and more frequently depending on CD4 count. The objective of the present study is to describe the cervical cancer screening among HIV-positive women in Catalonia, with an emphasis on screening coverage. This study included 479 HIV-positive women from the PISCIS cohort. Participants completed a clinicalepidemiological survey that included sociodemographic, behavioral, clinical, and screening history variables. All patients also underwent a gynecological exam, including endocervical sampling for conventional or liquid cytology (Papanicolau). 50.6% of the women reported annual PAP screenings; 11% had never had a Pap smear; and screening coverage for the last two-year was only 60.0%. The finding of low screening coverage is consistent with the high prevalence of cervical cancer in HIV-positive women in Catalonia. It is important to educate both medical professionals and HIV-positive women on the consequences of failure to screen for cervical cancer, diagnostic techniques to detect asymptomatic HPV, and methods of primary prevention.
Superinfection refers to a second viral infection in the context of a pre-existing adaptive immune response to prior infection with a viral strain that has not been cleared, the two viruses being genetically distinct yet belonging to the same genus. As such, this phenomenon provides unique settings to gain insights into the immune correlates of protection against HIV-1. The focus of this review is to discuss the current knowledge about immune responses to HIV-1 and to other viruses that are associated with partial or complete immunity to superinfection, or lack thereof, and how that could be applied to future HIV-1 vaccine strategies
Background: Hepatitis B has been reported to be high in HIV-infected African populations. However, the impact of this co-infection on the survival of HIV-infected Africans on long-term highly active antiretroviral therapy (HAART) remains poorly characterised. We investigated the impact of HBV/HIV co-infection on survival of HIV infected patients undergoing antiretroviral therapy in a West African population.
Methods: This was a clinic-based cohort study of HIV-infected adults enrolled in Nigeria, West Africa. Study subjects (9,758) were screened for hepatitis B and hepatitis C at HAART initiation. Kaplan-Meier survival and Cox proportional hazards models were used to estimate probability of survivaland toidentify predictors of mortality respectively, based on hepatitis B surface antigen status. All patients had signed an informed written consent before enrolment into the study; and we additionally obtained permission for secondary use of data from the Harvard institutional review board.
Results: Patients were followed up for a median of 41 months (interquartile range: 30-62 months) during which, 181 (1.9%) patients died. Most of the deaths; 143 (79.0%) occurred prior to availability of Tenofovir. Among those that were on antiretroviral therapy, hepatitis B co-infected patients experienced a significantly lower survival than HIV mono-infected patients at 74 months of follow up (94% vs. 97%; p=0.0097). Generally, hepatitis B co-infection: HBsAg-positive/HIV-positive (Hazards Rate [HR]; 1.5: 95% CI 1.09-2.11), co-morbid tuberculosis (HR; 2.2: 95% CI 1.57-2.96) and male gender (HR; 1.5: 95% CI 1.08-2.00) were significantly predictive of mortality. Categorising the patients based on use of Tenofovir, HBV infection failed to become a predictor of mortality among those on Tenofovircontaining HAART.
Conclusions: HBsAg-positive status was associated with reduced survival and was an independent predictor of mortality in this African HIV cohort on HAART. However, Tenofovir annulled the impact of HBV on mortality of HIV patients in the present study cohort.
Background: Even though highly effective drugs are available in South Africa, multidrug resistant tuberculosis (MDR-TB) patients with HIV infection have higher mortality compared to HIV-uninfected MDR-TB patients. This trend has been observed in similar countries with high HIV prevalence. This study sought to ermine excess mortality attributable to HIV among MDR-TB patients in South Africa using relative survival methods.
Methods: Data available were from a cohort of 2079 MDR-TB patients enrolled in a Standardized Programmatic Management of MDR-TB from 2000 to 2004 in South Africa. A Poisson-based model adjusted for age, gender, year of diagnosis, TB history, and resistance to ethambutol, anti-TB injectable drugs and fluoroquinolones antibiotics was constructed to assess the excess mortality among HIV co-infected MDR-TB patients. Excess hazard ratios (EHRs) were used to describe the effect of the predictors on net mortality, controlling for the general mortality in the South African population.
Results: Death was recorded on 1619 patients, of whom 367 (22.7%) had died within 2 years. Out of the 1413 patients that tested for HIV infection, 554 (39.2%) tested positive. Excess mortality was higher in HIV infected, compared to HIV uninfected, MDR-TB patients (adjusted excess hazard ratio, 5.6 [95% CI, 3.2-9.7]); in patients whose TB isolates’ resistance to ethambutol and kanamycin was unknown (3.7 [2.1-6.2] and 4.87 [1.9-13.3], respectively) vs. known. There were no differences in excess mortality between age and gender of the patient, year of diagnosis and TB history.
Conclusion: Adjusting for some important predictors, MDR-TB patients with HIV infection experienced higher excess mortality compared to HIV-uninfected MDR-TB patients, after accounting for the general mortality in South Africa. An appropriate, though complex method has produced predictor effect estimates similar to those obtained from classical methods. Thus, the use of relative survival methods should be encouraged in the analysis of causespecific mortality, when ascertainment of cause of death is inaccurate or unknown.