Results:
A platform of clinical research trials with pragmatic design has been developed to further enhance clinical care and sustain training initiatives with partners in East Africa and the United States. An oral chemotherapy feasibility trial in AIDS lymphoma is near completion; a second lymphoma trial of byrostatin and vincristine is anticipated and a feasibility trial of indinavir for endemic Kaposi's sarcoma is planned.
Conclusions:
In the absence of published reports of evolving international partnerships dedicated to AIDS malignancy in resource constrained settings, we feel it important for such progress on similar or related international collaborative pursuits to be published. The success of this effort is realized by the long-term international commitment of the collaborating investigators and institutions to sustain this effort in keeping with ethical and NIH standards for the conduct of research; the provision of formal training of investigators and research personnel on clinical problems our East African partners are faced with in practice and the development of pragmatic clinical trials and therapeutic intervention to facilitate technology transfer and enhance clinical practice.
Understanding the differences between contrasting HIV epidemics in east and west Africa: results from a simulation model of the Four Cities Study.
Author: Orroth, K. K.; Freeman, E. E.; Bakker, R.; Buve, A.; Glynn, J. R.; Boily, M. C.; White, R. G.; Habbema, J. D., and Hayes, R. J.
Source: Sex Transm Infect. 2007 Aug; 83 Suppl 1:i5-16.
Abstract: Objective:
To determine if the differences in risk behaviours, the proportions of males circumcised and prevalences of sexually transmitted infections (STIs) observed in two African cities with low prevalence of HIV (Cotonou, Benin, and Yaounde, Cameroon) and two cities with high prevalence (Kisumu, Kenya, and Ndola, Zambia) could explain the contrasting HIV epidemics in the four cities.
Methods:
An individual-based stochastic model, STDSIM, was fitted to the demographic, behavioural and epidemiological characteristics of the four urban study populations based on data from the Four Cities Study and other relevant sources. Model parameters pertaining to STI and HIV natural history and transmission were held constant across the four populations. The probabilities of HIV, syphilis and chancroid acquisition were assumed to be doubled among uncircumcised males. A priori plausible ranges for model inputs and outputs were defined and sexual behaviour characteristics, including those pertaining to commercial sex workers (CSWs) and their clients, which were allowed to vary across the sites, were identified based on comparisons of the empirical data from the four sites. The proportions of males circumcised in the model, 100% in Cotonou and Yaounde, 25% in Kisumu and 10% in Ndola, were similar to those observed. A sensitivity analysis was conducted to assess how changes in critical parameters may affect the model fit.
Results:
Population characteristics observed from the study that were replicated in the model included younger ages at sexual debut and marriage in east Africa compared with west Africa and higher numbers of casual partners in the past 12 months in Yaounde than in the other three sites. The patterns in prevalence of STIs in females in the general population and CSWs were well fitted. HIV prevalence by age and sex and time trends in prevalence in the model were consistent with study data with the highest simulated prevalences in Kisumu and Ndola, intermediate in Yaounde and lowest in Cotonou. The sensitivity analysis suggested that the effect of circumcision on the development of the HIV epidemics may have been mediated indirectly by its effect on ulcerative STI.
Conclusions:
The contrasting HIV epidemics in east and west Africa could be replicated in our model by assuming that male circumcision reduced susceptibility to HIV, syphilis and chancroid. Varying rates of male circumcision may have played an important role in explaining the strikingly different HIV epidemics observed in different parts of sub-Saharan Africa.
Vasculitis in HIV: report of eight cases.
Author: Otedo, A. E.; Oyoo, G. O.; Obondi, J. O., and Otieno, C. F.
Source: East Afr Med J. 2005 Dec; 82(12):656-9.
Abstract: Objective:
To describe vasculitis in HIV patients, their CD4 levels, anatomical sites affected and clinical patterns.
Design: Prospective, descriptive study.
Setting:
Kisumu District Hospital and Nairobi Rheumatology Clinic between January 2002 and May 2005.
Subjects: Eight patients with HIV and vasculitis.
Results:
Eight patients (four males and four females) were recruited with an age range of 24-61 years, mean 33.13 years. Five had central nervous system vasculitis and three had peripheral vasculitis. The CD4 counts were low, range 2-200 cells/mm3 (mean of 79.25 cells/mm3), normal levels of CD4 are 355-1298 cells/mm3, indicating severe immunosuppression. Two patients tested positive for HBV (hepatitis B virus).
Conclusion:
HIV associated vasculitis is recognised and may be complicated by coinfection with hepatitis viruses. It occurs at low CD4 counts. Central nervous system involvement is a common site. Management is multidisciplinary.
Increased severe anemia in HIV-1-exposed and HIV-1-positive infants and children during acute malaria.
Author: Otieno, R. O.; Ouma, C.; Ong'echa, J. M.; Keller, C. C.; Were, T.; Waindi, E. N.; Michaels, M. G.; Day, R. D.; Vulule, J. M., and Perkins, D. J.
Source: AIDS. 2006 Jan 9; 20(2):275-80.
Abstract: Objective:
Since the primary hematological complication in both pediatric HIV-1 and malaria is anemia, co-infection with these pathogens may promote life-threatening severe malarial anemia (SMA). The primary objective of the study was to determine if HIV-1 exposure [HIV-1(exp)] and/or HIV-1 infection [HIV-1(+)] increased the prevalence of SMA in children with acute malaria.
Design:
The effect of HIV-1 exposure and HIV-1 infection on the prevalence of SMA (hemoglobin < 6.0 g/dl), parasitemia (parasites/microl), and high-density parasitemia (HDP, >or= 10 000 parasites/mul) was investigated in children
Methods:
Upon enrollment, a complete hematological and clinical evaluation was performed on all children. Malaria parasitemia was determined and children with acute P. falciparum malaria were evaluated for HIV-1 exposure and infection by two rapid serological antibody tests and HIV-1 DNA PCR, respectively.
Results:
Relative to HIV-1(-) group (n = 194), the HIV-1(exp) (n = 100) and HIV-1(+) (n = 23) groups had lower hemoglobin concentrations (P < 0.001 and P < 0.001, respectively), while parasitemia and HDP were equivalent between the three groups. Multivariate analyses demonstrated that the risk of SMA was elevated in HIV-1(exp) children (odds ratio, 2.17; 95% confidence interval, 1.25-3.78; P < 0.01) and HIV-1(+) children (odds ratio, 8.71; 95% confidence interval, 3.37-22.51; P < 0.0001). The multivariate model further revealed that HIV-1 exposure or infection were not significantly associated with HDP.
Conclusions:
Results presented here demonstrate that both HIV-1 exposure and HIV-1 infection are associated with increased prevalence of SMA during acute P. falciparum infection, independent of parasite density.
Improving national data collection systems from voluntary counselling and testing centres in Kenya.
Author: Otwombe, K. N.; Wanyungu, J.; Nduku, K., and Taegtmeyer, M.
Source: Bull World Health Organ. 2007 Apr; 85(4):315-8.
Abstract: Problem:
Voluntary counselling and testing (VCT) data from the registered sites in Kenya have been fraught with challenges, leading to insufficient statistics in the national office for planning purposes. An exercise was carried out to determine the barriers to the flow of data in VCT sites in Kenya.
Approach:
A record-based survey was conducted at 332 VCT sites in Kenya. Data from on-site records were compared with those in the national office. The exercise was conducted in 2004 between 5 September and 15 October.
Local Setting: All registered VCT sites in Kenya.
Relevant changes:
After the exercise, various measures to enhance VCT data collection and reporting were implemented. They include the provision of a uniform data collection and reporting tool to all the districts in the country, the strengthening of a feedback mechanism to update provinces and districts on their reporting status and increased support to the data component of the national quality assurance for VCT.
Lessons learned:
Periodical field visits by the national officials to offer on-the-job training about data management to data collectors and to address data quality issues can dramatically improve the quality and completeness of VCT reports. The perceived relevance of the data and the data collection process to those working at the sites is the critical factor for data quality and timeliness of reporting
Examination of a second region of the HIV type 1 genome reveals additional cases of superinfection.
Author: Piantadosi, A.; Ngayo, M. O.; Chohan, B., and Overbaugh, J.
Source: AIDS Res Hum Retroviruses. 2008 Sep; 24(9):1221.
Abstract: HIV-1 superinfection may occur at a rate similar to that of initial infection, raising concerns for HIV-1 vaccine strategies predicated on eliciting immune responses similar to those in natural infection. Because of the high rate of recombination during HIV-1 replication, studies examining only one region of the HIV-1 genome are likely to miss cases of HIV-1 superinfection. We examined HIV-1 gag sequences from 14 high-risk Kenyan women in whom superinfection was not detected in a previous study of env sequences. We detected two additional cases of HIV-1 superinfection: one intersubtype superinfection that occurred between 1046 and 1487 days postinfection (DPI) and one intrasubtype superinfection that occurred between 341 and 440 DPI. Our results suggest that studies that examine only small genome regions may lead to underestimates of the risk of superinfection, highlighting the need for more extensive studies examining multiple regions of the HIV-1 genome.
ABCs for HIV prevention in Kenya: messages, beliefs, and barriers. Research summary.
Abstract: A great deal of attention has been focused recently on the promotion of the "ABCs" of HIV prevention--being abstinent or delaying sex, remaining faithful to one sexual partner or reducing the number of sexual partners, and consistently using condoms during sex. Yet even as programs that focus on the ABCs to prevent sexual HIV transmission are rolled out, questions remain about how well different groups in varied cultural contexts actually understand the terms, as well as how best to address challenges to adopting the ABC behaviors. The Horizons Program and FHI/IMPACT developed a collaborative research study in 2004 to explore how adults and youth in Kenya define and perceive the ABC terms and behaviors. Additional objectives of the study were to identify attitudes and norms around the ABC behaviors that influence perceptions of them, and the role of important actors in transmitting messages about them. Findings highlight potential challenges in promoting each of the ABC behaviors, as well as some positive elements that can be built upon when developing programs. (excerpt)
Psychological distress symptoms of individuals seeking HIV-related psychosocial support in western Kenya.
Author: Reece, M.; Shacham, E.; Monahan, P.; Yebei, V.; Ong'or, W. O.; Omollo, O., and Ojwang, C.
Source: AIDS Care. 2007 Nov; 19(10):1194-200.
Abstract: While researchers in many western countries have documented the nature of psychological distress that is commonly present among individuals living with HIV, there has been virtually no research on the same topic among other high prevalence areas of the world, particularly in countries like Kenya. This study sought to document the nature of psychological distress among 397 individuals living with HIV in western Kenya and who were participating in psychosocial support groups in conjunction with their enrollment in HIV-related treatment. Psychological distress was assessed using the Brief Symptom Inventory (BSI), a 53-item self-report psychological inventory that asks individuals to recall symptoms experienced in the prior seven days. The levels of psychological distress in this sample were moderate with a substantial proportion of participants meeting the criteria that suggested a need for further psychiatric evaluation. Findings support the need for further assessments of the range and nature of psychological distress among the diverse communities of countries like Kenya and the need for greater attention to the inclusion of mental health services in the rapidly developing treatment and prevention programs in this region of the world.
HIV/AIDS: the first 25 years--a view from Nairobi.
Author: Rees, P. H.
Source: East Afr Med J. 2008 Jun; 85(6):292-300.
Abstract: HIV infections are zoonoses occurring in communities that hunt chimpanzees (HIV 1) and sooty mangabeys (HIV 2) in the forests of equatorial and West Africa respectively. Most cross species transmission to man probably fizzles out, but the transmission of HIV 1 type M around 1930 eventually resulted in a pandemic that has spread around the world. HIV 2 types A and B have caused epidemics in West Africa. HIV infections are characterised by three phases (i) an initial, primary infective phase with rising viraemia, asymptomatic and silent, lasting for some 10 weeks, (ii) a long quiescent phase with the viraemia and illness mostly held in check by the immune response and lasting some 10 years in HIV 1 and 20 years or so in HIV 2 and (iii) a terminal third phase lasting some 10 months with rising viraemia, falling CD4 levels and multiple opportunistic infections recognised in a community by the onset of a florid AIDS epidemic. The silent primary epidemic reached Nairobi around 1980, with the florid secondary AIDS epidemic peaking here around 1992 and overwhelming the hospitals and other health services. The introduction of highly active antiretroviral therapy (HAART) has dramatically improved the prognosis for individual patients with AIDS, but it has been education and a changing attitude to condoms that has led to a progressive fall in incidence, so that the worst of the epidemic may now be over. Modifying the immunological response during the quiescent phase with the hope of prolonging this phase indefinitely may be the way forward for those who are already infected. Steroids have been shown to have a possible role here rather than anti-retroviral drugs (ARVs) which are not curative and prone to the development of drug resistance. Limited personal experience suggests that steroids may also have a role in salvaging critically ill AIDS patients, who need to be treated as emergencies. With an educated public and attention to alternative routes of infection such as blood transfusion, the epidemic should be increasingly contained during the next 25 years, and may even fizzle out.
Cost-effectiveness of two interventions to avert HIV-positive births. Draft.
Author: Reynolds H; Janowitz B; Homan R, and Johnson, L.
Abstract: Prevention of mother-to-child transmission (PMTCT) of HIV efforts focus primarily on providing voluntary counseling and testing (VCT) services in prenatal care (PNC) and providing anti-retroviral (ARV) prophylaxis to HIV-infected mothers. However, HIV-positive births could be averted if HIV-infected women who did not want to get pregnant used effective contraception. We compare the cost-effectiveness of increasing contraceptive use among non-pregnant women versus increasing the coverage of services in PNC that provide and promote nevirapine for PMTCT. We estimated the number of HIV-positive births averted by simulating an increase in contraceptive use from none to 50% among non-contracepting women who do not want to get pregnant. We also simulated an increase in the availability of nevirapine for HIV-infected mothers in PNC from current levels (10%) to 50%. Costs included first-year costs of providing family planning services and outreach to stimulate demand. Program costs of nevirapine for HIV-infected mothers included costs of promotion, training, VCT, and nevirapine. At any level of expenditure, increasing contraceptive use among non-pregnant women averted more HIV-positive births than increasing the coverage of nevirapine for PMTCT. The relative cost-effectiveness depended on the cost of crucial services such as VCT and family planning services. Increasing contraceptive use among non-users of contraception who do not want to get pregnant is at least as cost-effective as an equivalent investment in PNC programs that provide and promote nevirapine to HIV-infected mothers. Our data underscore prevention of unintended pregnancies as a key strategy to prevent mother-to-child transmission of HIV. (author's)
Delivering antiretroviral therapy in resource-constrained settings: lessons from Ghana, Kenya and Rwanda.
Author: Ritzenthaler, R.
Abstract: At the United Nations General Assembly Special Session on HIV/AIDS, held in June 2001, the global community cited ART as a key component of effective HIV/AIDS programs. In their Declaration of Commitment, heads of state from 189 countries affirmed that "prevention, care, support and treatment for those infected and affected by HIV/AIDS are mutually reinforcing elements of an effective response and must be integrated in a comprehensive approach to combat the epidemic." Tragically, only a small fraction of the estimated 40 million people living with HIV worldwide has access to the full range of services, including treatment. In Africa, home to approximately 26 million HIV-infected people, only 8 percent of the more than 4 million people clinically eligible for ART (ages 15 -49) has access to it. Delivering ART in these settings presents significant challenges related to drug supply, health infrastructure, provider availability and capacity, equitable service provision, and drug adherence, toxicity and resistance. (excerpt)
The private sector and HIV/AIDS in Africa: taking stock of 6 years of applied research.
Author: Rosen, S.; Feeley, F.; Connelly, P., and Simon, J.
Source: AIDS. 2007 Jul; 21 Suppl 3:S41-51.
Abstract: Background:
Until recently, little was known about the costs of the HIV/AIDS epidemic to businesses in Africa or about business responses to the epidemic. This paper synthesizes the results of a set of studies conducted between 1999 and 2006.
Methods:
Data for the studies included were drawn from human resource, financial, and medical records of 16 large companies and from 7 surveys of small, medium-sized, and large companies in South Africa, Uganda, Kenya, Zambia, Ethiopia, and Rwanda.
Results:
Estimated workforce HIV prevalence ranged from 5 to 37%. The average cost per employee lost to AIDS varied from 0.5 to 5.6 times the average annual compensation of the employee affected. Labor cost increases were estimated at 0.6-10.8% but exceeded 3% at only two of 14 companies. Antiretroviral treatment at a cost of US$360/patient per year was found to have positive financial returns for most but not all companies. Managers of small and medium-sized enterprises (SME) reported low AIDS-related employee attrition, little concern about the impacts of AIDS, and relatively little interest in taking action. AIDS was estimated to increase the average operating costs of SME by less than 1%.
Conclusion:
For most companies, AIDS is causing a moderate increase in labor costs, with costs determined mainly by HIV prevalence, employee skill level, and employment policies. Treatment of HIV-positive employees is a good investment for many large companies. Small companies have less capacity to respond to workforce illness and little concern about it. Research on the effectiveness of workplace interventions is needed.
The future of HIV prevention: control of sexually transmitted infections and circumcision interventions.
Author: Sahasrabuddhe, V. V. and Vermund, S. H.
Source: Infect Dis Clin North Am. 2007 Mar; 21(1):241-57, xi.
Abstract: Prevention and control of sexually transmitted infections (STIs) has proven effective in reducing HIV infection when treatment is available promptly for symptomatic persons in conditions of an emerging epidemic. Biologically, it is assumed that reduced genital tract inflammation reduces infectiousness for HIV as well as reducing susceptibility in HIV-uninfected persons. Male circumcision has been demonstrated effective in reducing risk for HIV infection in three separate trials from South Africa, Kenya, and Uganda. Global expansion of STI treatment and male circumcision programs are vital tools for control of HIV infection; current evidence is reviewed and research priorities are presented.
Use of HIV / AIDS information in Kenya.
Author: Salentine S; Gichuhi W, and Hyslop, A.
Abstract: HIV/AIDS information is generated using substantial financial, technical and organizational resources. The investment in producing high quality HIV/AIDS data pays off when this information is used beyond reporting to governments and donors and informs program and policy decisions. The purpose of this assessment is to support the Kenyan National AIDS Control Council (NACC), the National AIDS and STD Control Program (NASCOP) and the President's Emergency Plan for HIV/AIDS Relief (PEPFAR) in Kenya in identifying opportunities for using information so that program managers and M&E officers can plan for facilitating the use of this data for better operational and strategic decision-making while engendering a local commitment to data quality. To achieve this purpose, the assessment has the following objectives: To identify gaps and synergies for use of HIV/AIDS information across all users; To identify existing best practices; To inform the development of strategies for local use of data; and To provide recommendation of next steps for implementing selected strategies. (excerpt
Short- and long-term efficacy of modified directly observed antiretroviral treatment in Mombasa, Kenya: a randomized trial.
Author: Sarna, A.; Luchters, S.; Geibel, S.; Chersich, M. F.; Munyao, P.; Kaai, S.; Mandaliya, K. N.; Shikely, K. S.; Temmerman, M., and Rutenberg, N.
Source: J Acquir Immune Defic Syndr. 2008 Aug 15; 48(5):611-9.
Abstract: Objectives:
To determine short- and long-term efficacy of modified directly observed therapy (m-DOT) on antiretroviral adherence.
Design: Randomized controlled trial.
Setting and analytic approach:
From September 2003 to November 2004, 234 HIV-infected adults were assigned m-DOT (24 weeks of twice weekly health center visits for nurse-observed pill ingestion, adherence support, and medication collection) or standard care. Follow-up continued until week 72. Self-reported and pill-count adherence and, secondarily, viral suppression and body mass index measures are reported. Generalized estimating equations adjusted for intraclient clustering and covariates were used.
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