Journal of AIDS & Clinical Research

There is increasing recognition that the ongoing replication of Human Immunodeficiency Virus (HIV) within the central nervous system can have important prognostic implications, both in terms of HIV control and neurological symptoms. We present a case of loss of HIV virological control in a patient receiving unintended protease inhibitor monotherapy.

Background: In Uganda in 2008, about 121,218 people were on Antiretroviral therapy, which was 40% of all persons eligible for it then. Despite increasing availability and accessibility to HIV/AIDS care services, there are limited data on the effect of this scale-up on the quality of care in Uganda. Little information is available on clients’ thoughts about the services. This paper examines client satisfaction with quality of HIV/AIDS care services in a public and a private health facility. Methods: In total, 216 client exit interviews were conducted in two clinics in Kabale district, south western Uganda using the SERVQUAL tool. Data were analyzed by looking at differences in mean scores between clients’ expectations and perceptions. Paired t-tests and chi-square tests were done. Results: Overall, clients were dissatisfied with HIV/AIDS care, in both the public and private health facility. In both facilities and overall, tangibles was rated worst and responsiveness was rated best. Drug shortages were frequent and caused dissatisfaction. Conclusion: The findings suggested that quality of HIV/AIDS care in Kabale was lacking. They indicate that managers and policy makers need to pay more attention to it, especially physical facilities, equipment, ability of service providers to perform the service accurately, and drug shortages. Future research can be done on a larger scale within the district and beyond.

Background: HIV continues to impact African American women at alarming rates. Yet, few researchers have examined the relationship factors promoting unprotected sex within African American communities, especially instances in which women are aware that their male partners are engaging in high risk behaviors. This qualitative study explored the sexual behaviors, relationship characteristics, and HIV prevention strategies utilized by African American women in relationships with African American men at-risk for HIV.

Method: To understand the issues that should be addressed in a sexual risk-reduction intervention, data were collected from three, two-hour focus group discussions (n=24) comprised primarily of low-income African American women with histories of at-risk male sex partners. At-risk partners included specifically men who had sex with other men or with transgender individuals, used crack cocaine or injection drugs, had lengthy incarceration periods, or an unknown sexual history. Discussion questions examined external factors affecting sexual risk behaviors such as societal pressures, peer norms, and financial vulnerability. Discussions were audiotaped, transcribed, and analyzed using a consensual qualitative research approach.

Results: Five themes, including self-esteem, social influences on behavior, relationship fidelity, sexual risk behavior, and partners\' sexual behaviors, were identified as placing women at increased risk for HIV. Reasons for inconsistent condom use included concern for maintaining the relationship and substance use before and during sex. African American women also believed that men who have sex with men and women (MSMW) were dishonest about their sexuality due to stigma towards homosexuality/bisexuality. Despite these challenges, participants indicated that African American women have a strong sense of pride that can positively impact behaviors in relationships.

Conclusion: The findings of this study support that social and contextual factor such as emotional and financial issues, culture, history, and relationship dynamics need to be considered when developing tailored sexual health interventions for this population.

Background: Co-infection with tuberculosis and human immunodeficiency virus (TB-HIV) remains a major global health problem, with about 1.1 million new cases of TB in HIV-positive persons reported in 2011; 79% of the reported cases were amongst patients living in Africa. Advanced immune suppression remains the most important risk factor for tuberculosis in those with HIV, but epidemiological and clinical factors have also been identified. We sought to determine the prevalence and factors associated with pulmonary tuberculosis (PTB) in antiretroviral therapy (ART)- naive HIV-infected patients seeking HIV care services at a tertiary health facility in North Central Nigeria.

Methods: We compared clinical and laboratory data for 218 HIV-1 positive adults with and without a diagnosis of pulmonary tuberculosis. Results from univariate analyses informed the selection of predictors to conduct multivariate analysis to determine which factors were associated with presence of PTB-HIV co-infection.

Results: The prevalence of PTB-HIV co-infection in the evaluated cohort was 9.6%. Lower CD4+ cell count and the presence of oropharyngeal candidiasis were independently associated with PTB-HIV co-infection. CD4+ cell count was strongly associated with PTB-HIV co-infection (p=0.002) with the odds of co-infection reduced by 85% in those with a CD4+ cell count >100 cells/mm3 compared to those with <100 cells/ mm3. There was a strong association between oropharyngeal candidiasis and PTB-HIV co-infection, where the odds of co-infection are about 4.5 times higher in those with oropharyngeal candidiasis than those without candidiasis (p=0.008).

Conclusion: PTB was prevalent among HIV patients seeking care in our setting. Severe immune suppression and oropharyngeal candidiasis were associated with PTB-HIV co-infection in our patients at presentation. Potential implications for severe immune suppression and advanced HIV disease are a poor clinical outcome and further spread of PTB. Strategies to encourage the early diagnosis of both HIV and TB should be considered

Objective: African-American/Black and Latino/Hispanic persons living with HIV/AIDS (i.e., “PLHA of color”) are under-represented in HIV/AIDS medical studies (HAMS). A crucial entry point into HAMS is screening, but PLHA of color face serious barriers to screening compared to Whites. Recently we evaluated a social/behavioral intervention that substantially increased rates of HAMS screening among PLHA of color. Yet very little is known about the actual screening experience for these under-represented subgroups. Thus, the objectives of the present study were to explore participants’ motivations for and experiences of HAMS screening.

Methods: A total of 186 participants in the larger study’s intervention arm were screened for HAMS, 35 of whom also participated in qualitative interviews. Participants engaged in a structured interview about the screening experience at 4- and 12- months post-baseline (14 items, Cronbach\\\'s α=0.72). Further, from a qualitative data set we purposively selected a set of three case studies to contextualize and enrich quantitative findings on screening experiences.

Results: The screening experience was overwhelmingly positive. Almost all participants reported being treated with dignity and respect, did not feel they were being treated like a “guinea pig,” and experienced a high level of trust in the setting and the screener, with no gender or racial/ethnic differences, and no differences based on whether participants were found eligible for HAMS during screening. A number of areas where screening could be improved were also identified.

Conclusions: Despite the complex barriers PLHA of color experience to screening for HAMS, the experience of screening was positive. Moreover, HAMS screening experiences were positive regardless of gender, race/ethnicity, or HAMS eligibility. HAMS screening can therefore be a productive learning experience that may reduce patient concerns about participating in HAMS. As such, fostering screening among PLHA of color can be an important component of reducing racial/ethnic disparities in HAMS.

This study investigates the efficacy of a health promotion educational program on improving cardiovascular risk factors of weight, Body Mass Index, and waist to hip ratio in 76 predominately African American HIV-infected women. The health promotion educational program was the control group (that focused on improving self-efficacy for nutrition, exercise, stress reduction and women’s health behaviors) of a NIH-funded study. The majority of participants was overweight, obese, or at high risk based on waist hip ratio at the beginning of the study. There were no statistically significant improvements in body mass index or waist hip ratio from pre intervention to up to 9 months post intervention. There were significant changes in waist hip ratio and body mass index in both directions (improvement and worsened) for a small group of participants. The health promotion program did not affect significant changes in cardiovascular risk and should be revised, lengthened, and refocused on nutrition, diet, exercise, and long term goal commitments to reduce the high risk for cardiovascular disease in this group.

In research ethics community, the ‘bright line’ between health care and health research continues to be emphasized as important. While this distinction may be clear for many health researchers and practitioners, it may not be clear to research participants. In the case of HIV/AIDS care in resource-limited settings where healthcare is not affordable, individuals and communities are burdened with high rates of infectious diseases, inadequate health conditions, and insufficient or inaccessible medical care. Under these circumstances people are desperate to access better healthcare through any possible means. Participating in clinical research may be seen as one way of accessing care. Even though measures are taken to ensure that participants in health research get into this activity only after a consenting process, some may enter into research for the purpose of accessing treatment or health care. The objective of the study was to investigate specific reasons why participants engage in ongoing IREC/ IRB-approved international HIV research in Western Kenya. The main reasons given for participating in research were contextual: the HIV/AIDS condition, access to better healthcare, and financial poverty were identified. Clinical researchers indicated that their research projects had provisions for healthcare and better services and facilities than in the standard healthcare in terms of individual attention and follow up. Study participants in ongoing research in Western Kenya believe that their participation in HIV/AIDS research enables them to access better healthcare. In the context of limited resources and HIV/AIDS, patients’ beliefs, extra-medical attention and follow up translate into better healthcare. These observations suggest that in practice there may not be a bright line between research and clinical care (no “therapeutic misconception”) and suggest the need for more stringent efforts to make this distinction clear in processes of informed consent in such settings.

Introduction: Antiretroviral therapy improves time to death of people living with HIV; however, little is known about its effect on improving time of recurrence of opportunistic infections after treatment of any preceding infection. Hence, this study was aimed at assessing time to recurrence of any opportunistic infection after treatment of any preceding opportunistic infection, its magnitude and associated factors.

Methods: Retrospective cohort study was used and the required sample size was 536. Study participants were selected randomly from the list of adult people living with HIV attending the public health facilities for ART. Univariate analysis was used to describe patients’ baseline and follow up characteristics. Kaplan-meier survival and log rank test were used to estimate survival and compare survival curves respectively. Cox proportional-hazard regression model was used to calculate hazard rate and to determine independent predictors of time to recurrence.

Results: During a median of 43 person weeks follow up, opportunistic infections recurred in 75.7% the participants and the proportion was not significantly different (p=0.614) in pre-ART and ART people living with HIV. The incidence rate of any opportunistic infection recurrence was 1.31 per 100 person weeks which differs by ART exposure status which was 1.57 and 1.13 per 100 person weeks in pre-ART and ART PLHIV respectively. The median time of survival was 57 weeks; however, it was different in pre-ART and ART PLHIV that was 52 and 64 weeks respectively. Marital status, occupational status, follow up CD4 count, base line hemoglobin value, ART exposure, base line ART adherence, base line and follow up prophylaxis exposure and adherence were predictors of survival.

Conclusion: The incidence rate of any opportunistic infection recurrence was 1.31 per 100 person weeks. Attention should be given for widowed, ART/prophylaxis non-adhering patients while continuing HIV care for all people living with the virus.

Background: Detection of serum cryptococcal antigen (sCrAg) in HIV-infected patients is associated with 3-6 fold increased mortality. Studies on the feasibility and effectiveness of sCrAg-screening and pre-emptive therapy before antiretroviral treatment (ART) are limited. Amongst antiretroviral treatment-naïve adults with baseline CD4 counts <100 cells/μL undergoing pre-ART sCrAg screening, without previous cryptococcal meningitis (CM), we report on the 1) prevalence of sCrAg-positivity; 2) proportion with concurrent CM; 3) six-month patient outcomes.

Methods: This is a retrospective hospital-based cohort study evaluating a “screen-and-treat” protocol implemented between 10/2008 and 8/2012 in Phnom Penh, Cambodia. All sCrAg(+) patients underwent lumbar puncture (LP). After ruling-out CM, fluconazole was started (400mg/d-10 weeks; 200mg/d secondary prophylaxis) immediately. sCrAg(-) patients received primary prophylaxis (fluconazole 100mg/d). CM was treated with amphotericin-B (0.7mg/ kg-2 weeks, followed by fluconazole 400mg/day for 8 weeks).

Results: A total of 357 patients were enrolled with a median age of 38 (IQR 31-43) years and median CD4 count of 28 (IQR 14-53) cells/μL; 54% were male, 20% had BMI <16 kg/m2. Thirty (8.4%) of 357 tested were sCrAg(+). Six (20%) of the 30 sCrAg(+) patients had concurrent CM with no/minimal symptoms. Two were treated as CM without LP done. Amongst sCrAg(+) patients, the following 6-month outcomes were noted: 25 (83.3%) were retained and on ART, 1 (3.3%) patient died and 4 (13.3%) were lost-to-follow-up. Excluding those treated for CM (n=8), one case (1/22; 4.5%) of incident CM was detected by month six. Corresponding 6-month outcomes amongst the 327 CrAg(-) patients were: 269 (82.3%) retained and on ART, 23 (7%) deaths, 29 (9%) lost-to-follow-up, 6 (1.8%) transferred-out. One case (1/327; 0.3%) of incident CM was documented.

Conclusion: Outcomes of sCrAg(+) patients with the “screen-and-treat” approach were good. Fluconazole at 400mg/day appears appropriate for treatment of sCrAg(+) patients. Routine LP in sCrAg(+) might be indicated.

In 2011, an estimated 34 million people globally were living with HIV, 2.5 million people became newly infected, and 1.7 million people died from AIDS-related illnesses. Although there has been a reduction of 700,000 new HIV cases since 2001, HIV/AIDS remains one of the leading causes of death globally. Since there is no known cure or vaccine currently present, preventing infection has become central to controlling the HIV/AIDS epidemic. With the United Nation’s goal of “Getting to Zero” for the next generation, it may be warranted to review other successful global eradication strategies. The most well known global eradication may be the smallpox eradication program. Although both strategies aim to eradicate diseases, eradication of the HIV/AIDS epidemic has remained much more elusive. This paper will strive to demonstrate the similarities of the smallpox and HIV/AIDS global eradication programs, and the unique challenges HIV/AIDS poses for successful eradication.