Ahmad M. Yakasai

Neurocognitive impairment in HIV-1-infected adults in Sub-Saharan Africa: a systematic review and meta-analysis

OBJECTIVE To estimate the burden of HIV neurocognitive impairment (NCI) among adult patients on and off antiretroviral therapy (ART) in Sub-Saharan Africa. METHODS Estimates were derived from a random effects meta-analysis of prospective studies reporting HIV status, utilization of ART, and the presence of NCI determined using the International HIV Dementia Scale. RESULTS Sixteen studies with quality data from seven countries in Sub-Saharan Africa up to June 2012 were included. Among HIV patients, the frequency of NCI pre-ART was 42.37% (95% confidence interval (CI) 32.18-52.56%), and among those on ART for ≥6 months was 30.39% (95% CI 13.17-47.61%). Respective NCI estimates in studies from Uganda were 46.49% (95% CI 30.62-62.37%) and 28.50% (95% CI -1.31-58.30%). NCI was more common among patients with a concomitant psychiatric ailment. HIV-positive patients compared to HIV-negative controls were predisposed to NCI (odds ratio (OR) 6.49, 95% CI 1.68-25.08); the estimated unadjusted attributable risk of HIV infection leading to NCI was 85%. Meta-regression showed no associations between age, gender, CD4 cell counts, or years of education with NCI. Patients on ART were less likely to have NCI compared to HIV-infected pre-ART patients, with OR 0.36 (95% CI 0.19-0.69). In longitudinal studies with the same patients followed before and at ≥6 months after ART, the OR of NCI after ART compared to pre-ART was 0.23 (95% CI 0.14-0.37). The combined burden of NCI among pre-ART and on-ART patients in Sub-Saharan Africa was estimated at 8,121,910 (95% CI 5,772,140-10,471,680). No publication bias was observed, although residual confounding from differing environmental factors, stages of HIV infection, and viral clades might be a limitation. CONCLUSIONS HIV strongly predisposes to NCI leading to a huge burden in Sub-Saharan Africa, and scale-up of ART can substantially reduce it.

Adherence to Artemisinin-Based Combination Therapy for the Treatment of Uncomplicated Malaria: A Systematic Review and Meta-Analysis.

Adherence to artemisinin-based combination therapy (ACT) is not clearly defined. This meta-analysis determines the prevalence and predictors of adherence to ACT. Twenty-five studies and six substudies met the inclusion criteria. The prevalence of ACT adherence in the public sector was significantly higher compared to retail sector (76% and 45%, resp., P < 0.0001). However, ACT adherence was similar across different ACT dosing regimens and formulations. In metaregression analysis prevalence estimates of adherence significantly decrease with increasing year of study publication (P = 0.046). Factors found to be significant predictors of ACT adherence were years of education ≥ 7 {odds ratio (OR) (95% CI) = 1.63 (1.05–2.53)}, higher income {2.0 (1.35–2.98)}, fatty food {4.6 (2.49–8.50)}, exact number of pills dispensed {4.09 (1.60–10.7)}, and belief in traditional medication for malaria {0.09 (0.01–0.78)}. The accuracy of pooled estimates could be limited by publication bias, and differing methods and thresholds of assessing adherence. To improve ACT adherence, educational programs to increase awareness and understanding of ACT dosing regimen are interventions urgently needed. Patients and caregivers should be provided with an adequate explanation at the time of prescribing and/or dispensing ACT.

Prevalence of hepatitis B and C virus infections among HIV-infected patients in a tertiary hospital in North-Western Nigeria

Introduction: Infections from HIV, Hepatitis B and to some extent Hepatitis C viruses constitute a major public health challenge in sub-Saharan Africa, and there are evidences to suggest that there is faster progression of HIV in those co-infected with either HBV or HCV. The aim of this study was to determine the prevalence of HBV and HCV infections among HIV-infected patients, and describe the socio-demographic features and correlates of HIV and HBV/HCV co-infected patients at Aminu Kano Teaching Hospital (AKTH), Kano, Nigeria. Materials and Methods: This was a cross-sectional study carried out among HIV-positive individuals seen at the adult HIV clinic of AKTH. Four Hundred and forty (440) consecutive HIV-positive adult patients who consented to the study were screened for markers of HBV and HCV using Enzyme-linked Immunosorbent Assay (ELISA) technique. CD 4 Count and serum ALT were also obtained from the recruited patients. Socio-demographic characteristics and Body Mass Index (BMI) were obtained. Differences and relationships between groups were determined using students t-test and Chi-square test where appropriate, and a P < 0.05 was regarded as significant. Results: Prevalence rates of Hepatitis B and C virus infections obtained were 12.3% and 1.6%, respectively. Individuals who were 40 years or younger were the most affected. HBV co-infection was more common among males than females (16.9% vs 9.2%, respectively, P = 0.0153). Mean serum ALT among participants with HIV alone was 31.6 International Units (IU), but was significantly higher (45.3 IU) for those with HIV/HBV co-infection, P = 0.048. Mean CD 4 count for HIV/HBV co-infected participants (259.7 c/mm 3 ) was significantly higher than that for participants with HIV alone (240.0 c/mm 3 ), P = 0.0170 whereas the mean BMI was not significantly different between participants with HIV alone (21.3 kg/m 2 ) versus HIV/HBV co-infected participants (22.2 kg/m 2 ), P = 0.1385. Conclusion: Co-infection with hepatitis B virus is common among HIV-infected patients in our setting and this further reaffirms the need for routine baseline screening for this marker, as it is a major consideration in the initiation and choice of highly active antiretroviral therapy. Furthermore, those found to be negative should be immunized with HBV vaccine to improve the prognosis of their HIV status.

Prevalence and Correlates of HIV-Associated Neurocognitive Disorders (HAND) in Northwestern Nigeria

HIV-associated Neurocognitive Disorders (HAND) are common among HIV-positive individuals. This study explored the prevalence and correlates of HAND in Nigeria. 80 HIV-positive and 40 HIV-negative adults selected from Aminu Kano Teaching Hospital (AKTH) received comprehensive evaluations. A multidomain neuropsychological test (MDNPT) battery assessing 7 domains was administered to the participants and their performance was combined with measures of functional status to classify impairments into various grades of HAND. Univariate and multivariate analyses were performed to identify correlates of symptomatic HAND. Among the HIV-positive individuals, 50% were highly active antiretroviral therapy-experienced (HAART+) and 50% were highly active antiretroviral therapy naive (HAART−). Symptomatic HAND was found among 40% of the HAART− individuals and 30% of the HAART+ individuals. Respective prevalence of HIV-associated dementia (HAD) was 23% and 5%, respectively (p = 0.0002). In a binary logistic regression model, only fewer years of education independently predicted symptomatic HAND [Odds Ratio (OR) = 1.2, 95% confidence interval (CI) = 1.04–1.44, p = 0.016]. The prevalence of HAND in Nigeria is high with HAD being commoner among HAART− patients. Provision of HAART and strict monitoring of patients at risk of HAND are needed to scale down the burden of the disease.

Prevalence and burden of human immunodeficiency virus and hepatitis B virus co-infection in Nigeria: a systematic review and meta-analysis.

Background: Studies on HIV/HBV co-infection in Nigeria yielded prevalence ranging between 10% and 70%, giving the widest variation in prevalence of HIV/HBV co-infection from studies emanating from any country all over the world. However, estimation of clinical and public health impacts of HIV/HBV co-infection requires a robust and reliable epidemiological data for an appropriate estimation of the logistical, economic, and humanitarian impact of the two viruses in Nigeria. Objective: The aim of this review was to estimate the prevalence and burden of HBV infections in HIV-infected patients in Nigeria. Methods: Estimates were derived from a random effects meta-analysis of observational studies reporting the prevalence of HBV/HIV in Nigeria. The derived estimate for the prevalence of HBV/HIV co-infection was applied to the total HIV-infected populations in Nigeria to give an estimated burden of HBV/HIV co-infection in Nigeria. Result: Thirty three studies with quality data from seventeen states in Nigeria, up to December 16, 2013, were included. I-squared heterogeneity was 98%. Random effect model (REM) estimate of prevalence among HIV-infected patients from the 33 studies was 15% (95% CI 13-17). The prevalence of HIV/HB co-infection among attendees of HIV clinics was 17% [95% CI 13-20], among pregnant HIV-infected patients were 10% [95% CI 6-15], 12% [95% CI 6-17] among HIV-infected children and among newly discovered HIV-infected voluntary blood donor (VBD) patients 10% [95% CI 6-15]. Meta- regression showed no significant associations between the mean age of the patients, the proportion of female patients, year of the study and prevalence of co-infection. The burden of HBV/HIV co-infection in Nigeria, based on the estimate, was 984 000 C.I. [852 800-1115 200]. Conclusion: In Nigeria, the estimated prevalence of HBV/HIV infection is 15% resulting in a substantial burden for the country.

Performance of Community Screening Instrument for Dementia in Screening for HIV-Associated Neurocognitive Disorders in Nigeria

Background: Cognitive function of HIV-infected patients in Nigeria has been studied using the community screening instrument for dementia (CSI-D) battery. However, its ability to detect HIV-associated neurocognitive disorders (HAND) is unclear. The study assessed the CSI-D battery in detecting HAND. Methods: Age, sex and education matched 30 HIV-positive and 30 HIV-negative subjects were administered the CSI-D battery. An extensive multi-domain neuropsychological tests (MDNPT) battery was used as gold standard. Measures of functional status including personal assessment of own functioning inventory (PAOFI), instrumental activities of daily living (IADL) and Beck depression inventory (BDI) were also administered. Diagnostic accuracy indices of the CSI-D were determined from a receiver operator characteristic (ROC) curve. Linear associations were explored using correlation coefficient. Results: HIV-positive subjects performed significantly worse than HIV-negative subjects in several domains across the 2 batteries. Large effect sizes were found in verbal fluency (COWAT), verbal learning, memory recall and language comprehension. Significant correlations between the two batteries were seen in all the domains except motor function. Subjects with HAND but normal on CSI-D scored poorly on motor function test. The area under the ROC curve was 0.79; 95 % confidence interval (CI) of 0.68-0.90, p < 0.0001. At cut-off score of ≤ 63, the CSI-D had sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of 77%, 63%, 55% and 61% respectively. Conclusion: CSI-D has good psychometric properties for use as a screening tool for HAND. The addition of test of motor function is advisable to complement it.

Gram-negative bacilli are a major cause of secondary pneumonia in patients with pulmonary tuberculosis: evidence from a cross-sectional study in a tertiary hospital in Nigeria

Background This study was aimed at describing the profile of bacterial aetiology of secondary pneumonia in pulmonary tuberculosis (PTB) patients. Methods A 22-month analysis of patients with PTB and secondary bacterial pneumonia was conducted. Data on isolates recovered and the antimicrobial susceptibility profile were recorded. Results Of the 141 patients, there were 79 (56%) males and the mean age was 35.98±15.93. Gram-negative bacilli were isolated with equal frequency as Streptococcus pneumoniae (63 [44.7%]). Most of the isolates tested were sensitive to levofloxacin, ceftriaxone or chloramphenicol. Conclusion Gram-negative bacilli are a major cause of pneumonia in patients with PTB on treatment.

Metabolic syndrome among HIV infected patients: A comparative cross sectional study in northwestern Nigeria

INTRODUCTION The increasing availability of antiretroviral drugs has made HIV-positive patients to live longer, and conditions that are associated with longevity such as metabolic syndrome and other cardiovascular related conditions have become relevant in them. This is less well studied among African populations. Therefore the study aimed at estimating and comparing the prevalence of and associated risk factors for the metabolic syndrome (MS) among African HIV infected patients. METHOD In this comparative cross-sectional study, we analyzed the data of 300 participants matched for age and gender who satisfied the inclusion criteria with half of the subjects on HAART, while the other half was HAART naïve. The MS was diagnosed using ATP-III criteria. RESULTS The mean age of the patients was 34.8±9.9years. The majority of the patients were females 64%. The prevalence of MS among HAART-exposed patients was found to be 19.3%, while it was 5.3% among HAART naïve patients (p=0.001). Raised triglyceride and elevated blood pressure were the criteria with the highest occurrence among HAART-exposed, 82.8% for each. Advanced age, longer duration of HIV diagnosis and HAART exposure, increased BMI, weight gain after HAART exposure, exposure to PIs and increased mean CD4 cell count were found to be significantly associated with MS (p<0.05). However, only age (OR 4.3, 95% CI 1.6-11.8, p=0.005) and BMI (OR 4.2, 95% CI 1.5-11.9, p=0.007) were found to be independently associated with the development of MS. CONCLUSION Exposure to HAART particularly protease inhibitor based regimen increases the risk of MS among HIV-infected patients.

Impact of Symptomatic HIV- Related Neurocognitive Disorders in Survivalof HIV- Infected Individuals: A Systematic Review and Meta-Analyses

Background: HIV- related symptomatic neurocognitive disorders (SNCD) negatively influence the survival of affected patients. We conducted this meta-analysis to provide pooled estimates of mortality risk attributable to SNCD. Methods: MEDLINE, Google scholar, Cochrane library PsycINFO and EMBASE were the data bases thoroughly searched up to April 2014. Two parallel meta-analyses were performed to derive hazard ratio (HR) and relative risk (RR) of mortality from 7 and 6 studies respectively. The level statistical heterogeneity in the included studies was assessed using I-squared (I2) statistic while metaregression and subgroup analyses mainly explored clinical and methodological heterogeneity. Other assessments were analyses for publication bias, small study effect, single study effect and study quality. Results: Thirteen studies with satisfactory quality met the inclusion criteria. A total of 84 421 HIV+ individuals across 21 countries from Europe and America were involved. Subjects with SNCD have more than twice risk of death compared to subjects without SNCD: HR=2.1, 95% confidence interval (CI)=1.52-2.58; RR=2.46, 95% CI=1.63-3.69. The estimated HR translates in to 72% probability of subjects with SNCD dying earlier than subjects without SNCD. Risk of mortality is associated with declining CD4 cell count (p=0.038) and neurocognitive impairment in psychomotor and memory domains. In subgroup analyses, there was no significant difference in mortality risk with respect to HAART utilization, type of SNCD and availability of demographically adjusted normative scores. Despite limiting generalizability of findings to sub-Saharan Africa, inclusion of studies conducted in developed countries reduces confounding and increases the accuracy of defining pooled estimates. Conclusion: HIV- related SNCD negatively influence survival in affected patients. Routine care of these patients should include neurocognitive screening preferably with a battery assessing domains that are predictive of mortality such as psychomotor and memory domains.