Brian T. Chan

In Urban And Rural India, A Standardized Patient Study Showed Low Levels Of Provider Training And Huge Quality Gaps

This article reports on the quality of care delivered by private and public providers of primary health care services in rural and urban India. To measure quality, the study used standardized patients recruited from the local community and trained to present consistent cases of illness to providers. We found low overall levels of medical training among health care providers; in rural Madhya Pradesh, for example, 67 percent of health care providers who were sampled reported no medical qualifications at all. Whats more, we found only small differences between trained and untrained doctors in such areas as adherence to clinical checklists. Correct diagnoses were rare, incorrect treatments were widely prescribed, and adherence to clinical checklists was higher in private than in public clinics. Our results suggest an urgent need to measure the quality of health care services systematically and to improve the quality of medical education and continuing education programs, among other policy changes.

Persistent HIV-related Stigma in Rural Uganda During a Period of Increasing HIV Incidence Despite Treatment Expansion

Objective:Programme implementers have argued that the increasing availability of antiretroviral therapy (ART) will reduce the stigma of HIV. We analyzed data from Uganda to assess how HIV-related stigma has changed during a period of ART expansion. Design:Serial cross-sectional surveys. Methods:We analyzed data from the Uganda AIDS Rural Treatment Outcomes study during 2007–2012 to estimate trends in internalized stigma among people living with HIV (PLHIV) at the time of treatment initiation. We analyzed data from the Uganda Demographic and Health Surveys from 2006 to 2011 to estimate trends in stigmatizing attitudes and anticipated stigma in the general population. We fitted regression models adjusted for sociodemographic characteristics, with year of data collection as the primary explanatory variable. Results:We estimated an upward trend in internalized stigma among PLHIV presenting for treatment initiation [adjusted b = 0.18; 95% confidence interval (CI), 0.06–0.30]. In the general population, the odds of reporting anticipated stigma were greater in 2011 compared with 2006 [adjusted odds ratio (OR) = 1.80; 95% CI, 1.51–2.13], despite an apparent decline in stigmatizing attitudes (adjusted OR = 0.62; 95% CI, 0.52–0.74). Conclusion:Internalized stigma has increased over time among PLHIV in the setting of worsening anticipated stigma in the general population. Further study is needed to better understand the reasons for increasing HIV-related stigma in Uganda and its impact on HIV prevention efforts.

HIV stigma trends in the general population during antiretroviral treatment expansion: analysis of 31 countries in sub-Saharan Africa, 2003-2013.

Background:HIV-related stigma is associated with increased risk-taking behavior, reduced uptake of HIV testing, and decreased adherence to antiretroviral therapy (ART). Although ART scale-up may reduce HIV-related stigma, the extent to which levels of stigma in the general population have changed during the era of ART scale-up in sub-Saharan Africa is unknown. Methods:Social distance and anticipated stigma were operationalized using standard HIV-related stigma questions contained in the Demographic and Health Surveys and AIDS Indicator Surveys of 31 African countries between 2003 and 2013. We fitted multivariable linear regression models with cluster-correlated robust standard errors and country fixed effects, specifying social distance or anticipated stigma as the dependent variable and year as the primary explanatory variable of interest. Results:We estimated a statistically significant negative association between year and desires for social distance (b = −0.020; P < 0.001; 95% confidence interval: −0.026 to −0.015) but a statistically significant positive association between year and anticipated stigma (b = 0.023; P < 0.001; 95% confidence interval: 0.018 to 0.027). In analyses stratified by HIV prevalence above or below the sample median, declines in social distancing over time were more pronounced among countries with a higher HIV prevalence. Conclusions:Concomitant with ART scale-up in sub-Saharan Africa, anticipated stigma in the general population increased despite a decrease in social distancing toward people living with HIV. Although ART scale-up may help reduce social distancing toward people living with HIV, particularly in high-prevalence countries, other interventions targeting symbolic or instrumental concerns about HIV may be needed.

HIV Treatment Scale-Up and HIV-Related Stigma in Sub-Saharan Africa: A Longitudinal Cross-Country Analysis.

OBJECTIVES We estimated the association between antiretroviral therapy (ART) uptake and HIV-related stigma at the population level in sub-Saharan Africa. METHODS We examined trends in HIV-related stigma and ART coverage in sub-Saharan Africa during 2003 to 2013 using longitudinal, population-based data on ART coverage from the Joint United Nations Program on HIV/AIDS and on HIV-related stigma from the Demographic and Health Surveys and AIDS Indicator Surveys. We fitted 2 linear regression models with country fixed effects, with the percentage of men or women reporting HIV-related stigma as the dependent variable and the percentage of people living with HIV on ART as the explanatory variable. RESULTS Eighteen countries in sub-Saharan Africa were included in our analysis. For each 1% increase in ART coverage, we observed a statistically significant decrease in the percentage of women (b = -0.226; P = .007; 95% confidence interval [CI] = -0.383, -0.070) and men (b = -0.281; P = .009; 95% CI = -0.480, -0.082) in the general population reporting HIV-related stigma. CONCLUSIONS An important benefit of ART scale-up may be the diminution of HIV-related stigma in the general population.

Treatment of listeriosis in first trimester of pregnancy.

To the Editor: Foodborne infections with Listeria monocytogenes continue to be dangerous and disruptive. A 2011 outbreak in the United States, linked to cantaloupes, affected 147 persons; 33 persons died, and 1 pregnant woman experienced a miscarriage (1). Moreover, the incidence of listeriosis has been rising in several European countries (2). Compared with the general population, pregnant women are at markedly increased risk of acquiring listeriosis (3). Women who are infected with L. monocytogenes in the third trimester of pregnancy are typically treated with antimicrobial drugs until the child’s delivery (3). However, the optimal treatment regimen for listeriosis early in pregnancy is unknown. We cared for a 28-year-old, previously healthy woman who sought treatment at 12 weeks’ gestational age with fever, headache, and neck stiffness; blood cultures were positive for L. monocytogenes. Lumbar puncture on admission to our hospital in Boston, Massachusetts, in December 2011, revealed clear fluid and an opening pressure of 15 mm Hg; 1 leukocyte was observed per high-powered field, and cultures of the cerebrospinal fluid were sterile. Pelvic ultrasound showed no abnormalities of the fetus, gestational sac, or uterus. We treated the patient’s condition with intravenous ampicillin for 2 weeks, 2 g every 4 hours, and gentamicin, 100 mg every 8 hours, followed by ampicillin alone for 2 weeks. Shortly after the antimicrobial drugs were initiated, the patient defervesced and her blood cultures cleared. Her hospital course was complicated by spinal headache and transient acetaminophen-induced liver injury, but she was eventually discharged to her home in good condition. Blood cultures taken after discontinuation of antimicrobial agents were sterile, and the remainder of her pregnancy was unremarkable. She ultimately gave birth to a healthy 2,405-g boy with Apgar scores of 4 and 7 (at 1 and 5 min, respectively) at 35.1 weeks’ gestation by spontaneous vaginal delivery. Pathologic examination of the placenta showed no evidence of chorioamnionitis, villitis, or parenchymal abscesses, and placental cultures were sterile. The patient and her child are currently doing well without obvious sequelae of infection. Listeriosis in early pregnancy presents a unique challenge for the infectious diseases clinician. Up to 30% of L. monocytogenes infections in pregnancy result in stillbirth, miscarriage, or preterm labor, and approximately two thirds of surviving neonates are infected (4). L. monocytogenes uses 2 surface proteins, InlA and InlB, to invade host cells, including the placenta (5). Once established within the placenta, L. monocytogenes forms microabscesses, which can lead to recurrence of infection (6). A recent study in which researchers used a guinea pig model suggests that eradication of microabscesses from the placenta may be critical to achieving the cure of the mother and the prevention of fetal illness and death (7). What, then, is the optimal treatment strategy to cure the mother and sterilize the placenta? In a large case series of pregnant women with listeriosis, most patients were given a β-lactam antimicrobial drug, with or without gentamicin (6). However, most women in this case series were in their third trimester of pregnancy and received treatment until delivery. In women who are infected in the first or second trimester, continuing intravenous antimicrobial drugs until delivery is impractical, and the efficacy of oral antimicrobial agents in preventing recurrence of infection is unknown. Our case demonstrates that 4 weeks of intravenous therapy can sterilize the placenta and enable good maternal and fetal outcomes in a woman infected with listeriosis in the first trimester. We also identified 13 case reports of women in whom listeriosis developed in the first or second trimester of pregnancy (Technical Appendix). Among these 13 case-patients, 8 instances occurred in which both mother and neonate survived without sequelae; all 8 patients had received ampicillin/penicillin with or without gentamicin. The role of gentamicin in treatment of listeriosis in pregnancy is controversial. The combination of ampicillin and gentamicin has been thought to be synergistic, although in vivo evidence of clinical benefit, compared to that of treatment with ampicillin alone, is lacking (3,6). A particular concern in pregnancy is gentamicin’s poor penetration into the intracellular space, where L. monocytogenes is likely to reside, in the placenta (8). Furthermore, some concern exists that gentamicin use in pregnancy could cause fetal ototoxicity, although few such cases have been reported, and several small cohort studies have not shown this association (9,10). Our patient’s child had a normal result when standard audiology testing was performed several days after delivery. Infectious diseases clinicians will likely see patients with listeriosis in early pregnancy, given the increasing incidence of this infection in many countries and the ongoing threat of food-borne outbreaks. The collected experience from the cases reported here may be useful, particularly given the absence of high quality clinical data that support treatment recommendations for this population. Intravenous ampicillin, with or without gentamicin, effectively sterilizes the placenta and prevents maternal and fetal illness and death in cases of listeriosis in early pregnancy. Technical Appendix: Table that describes the treatment of listeriosis in 13 pregnant women in the first and second trimesters of pregnancy, 1961–2002 Click here to view.(113K, pdf)

Personal contact with HIV-positive persons is associated with reduced HIV-related stigma: cross-sectional analysis of general population surveys from 26 countries in sub-Saharan Africa

Introduction: HIV‐related stigma hampers treatment and prevention efforts worldwide. Effective interventions to counter HIV‐related stigma are greatly needed. Although the “contact hypothesis” suggests that personal contact with persons living with HIV (PLHIV) may reduce stigmatizing attitudes in the general population, empirical evidence in support of this hypothesis is lacking. Our aim was to estimate the association between personal contact with PLHIV and HIV‐related stigma among the general population of sub‐Saharan Africa.

Peritoneal Tuberculosis in a Pregnant Woman from Haiti, United States

To the Editor: A 29-year-old woman at 23 weeks’ gestation during her first pregnancy came to our hospital’s obstetrics clinic after 6 days of vaginal bleeding and abdominal pain. She had not experienced fever, sweats, weight loss, contractions, or other symptoms. She was otherwise healthy; she was taking no medications, but was taking iron and multivitamin supplements. She had legally immigrated to the United States from Haiti 8 months previously and had no known tuberculosis contacts. Physical examination disclosed brown vaginal discharge and a closed cervix. Obstetric ultrasound was normal, and vaginal swab samples were negative for Neisseria gonorrhea and Chlamydia trachomatis. Over the ensuing 2 weeks, her vaginal bleeding and abdominal pain worsened. She was admitted to the hospital. Physical examination revealed vaginal bleeding, but her condition was otherwise unchanged. Routine laboratory studies were normal. Repeat obstetric ultrasound showed a viable fetus, ascites, and a 15 × 15 × 3–cm rind of echogenic material anterior to the uterus. This abnormality was in the upper abdomen, an area not imaged on her previous ultrasound. Abdominal magnetic resonance imaging revealed moderate ascites and a 21 × 14 × 3–cm omental mass of intermediate intensity on T1 and T2 sequences; there was no lymphadenopathy (Figure). A tiny left pleural effusion was seen on chest radiograph. Routine HIV and tuberculin skin test results had been negative 4 months previously, and pre-immigration examination results and chest radiograph had been normal. Figure T2-weighted magnetic resonance imaging sequence of the abdomen of a pregnant woman from Haiti. An omental mass of intermediate intensity (white arrow) is shown anterior to the uterus. Fine-needle aspiration of the omental mass was nondiagnostic. The patient’s vaginal bleeding and abdominal pain persisted, and her cervix dilated. She had an oral temperature of 38.9° Celsius. Exploratory laparotomy demonstrated a friable omental mass with implants on the small bowel; a partial omentectomy was performed at 26 weeks’ gestation. During this procedure, the patient gave birth to a male infant. Multiple granulomata, some containing acid-fast bacilli, were identified upon histologic examination of the momentum (Technical Appendix Figure). Transcription-mediated amplification of the specimen was positive for Mycobacterium tuberculosis rRNA; cultures later grew M. tuberculosis susceptible to all first-line antituberculosis medications. Sputum smears and cultures were not performed. The patient’s treatment began with isoniazid, rifampin, ethambutol, and pyrazinamide; her fevers and abdominal pain resolved. Her son was admitted to the neonatal intensive care unit and was placed on antimycobacterial therapy. He also recovered and was discharged after 135 days. This case highlights several issues related to tuberculosis epidemiology and diagnosis. Although pulmonary disease is the most common manifestation of tuberculosis overall, extrapulmonary tuberculosis accounts for a significant and increasing proportion of cases in the United States (1). Pregnancy is associated with greater likelihood of extrapulmonary disease; extrapulmonary infection accounts for 13% of all cases worldwide (2) but 50% of cases in pregnancy, according to a recent study (3). The frequency of peritoneal tuberculosis in pregnancy is unknown; few cases have been reported in the literature (4–7), although we know of 3 additional cases from Haiti (online Technical Appendix Table). However, cases are likely underdiagnosed or diagnosed late in the course of illness. Underdiagnosis and delayed diagnosis may be caused by the nonspecific nature of symptoms, commonly abdominal pain and ascites, which can be attributed to pregnancy itself or obstetrical complications. These erroneous explanations for symptoms are reflected in this patient, whose symptoms were initially attributed to abruption and who was not diagnosed with tuberculosis until >3 weeks after seeking medical assistance. Such delays in diagnosis are typical of peritoneal tuberculosis and are associated with increased death rates (8). In many cases, clinical features cannot distinguish peritoneal tuberculosis from malignancy, necessitating more extensive evaluation (7). Failure to diagnose peritoneal tuberculosis, in pregnancy or otherwise, might also stem from the insensitivity of noninvasive diagnostic testing. Paracentesis with acid-fast staining detects only a minority of cases (8). The sensitivity of mycobacterial cultures of ascites fluid varies, and culture results are often not available for weeks (8). Ascites fluid adenosine deaminase has shown promise as a reliable, minimally invasive diagnostic test in resource-poor countries, but was insensitive in a United States study (9). In addition, although tuberculin skin testing and interferon gamma release assay performance are not affected by pregnancy (10), neither can distinguish active from latent infection. Without diagnostic clinical features or sensitive noninvasive tests, the diagnosis of peritoneal tuberculosis might only be confirmed through laparoscopy or laparotomy, as in our case. Such invasive testing methods and facilities, equipment, and personnel might not be readily available in resource-poor settings. This case also illustrates the ongoing threat of tuberculosis in countries of all income levels. It is not clear where our patient contracted tuberculosis; she was most likely exposed in Haiti, but transmission within her Haitian community in the United States, or from another source, is also possible. Regardless, as in her case, a majority of tuberculosis cases within the United States occur in foreign-born persons. Given the ease and frequency of travel, lapses in tuberculosis control in any locale are likely to have effects more broadly. Wherever they work, clinicians must maintain vigilance for tuberculosis in all of its protean forms. Technical Appendix: Case characteristics of peritoneal tuberculosis in pregnancy and diagnostic image. Click here to view.(166K, pdf)

Prevalence and correlates of psychosocial conditions among people living with HIV in southern India.

ABSTRACT Psychosocial conditions such as depression, intimate partner violence (IPV), and history of childhood sexual abuse (CSA) have been associated with poor HIV-related outcomes. In India, which has the third largest HIV epidemic in the world, little is understood about the impact of psychosocial conditions on people living with HIV (PLHIV). We aimed to understand the prevalence and correlates of psychosocial conditions among PLHIV entering into HIV care at the Y.R. Gaitonde Centre for AIDS Research and Education in Chennai, India. Thirteen questions were added to the standard voluntary counseling and testing questionnaire, including the Patient Health Questionnaire-9 (a depression scale) and questions assessing for CSA and IPV. We fitted logistic regression models, stratified by gender, with psychosocial condition as the outcome of interest and substance use variables and socio-demographic variables as the correlates of interest. Three hundred and eighty-three persons were enrolled into the study; of these, 253 (66%) tested positive for HIV, including 149 men and 104 women, and were included in the models. More than one-quarter (28%) of the men and 19% of the women reported at least one psychosocial condition (probable depression, CSA, or IPV). In adjusted analysis, current alcohol use was associated with greater than two times higher odds of a psychosocial condition (Adjusted Odds Ratio = 2.24, 95% CI, 1.04–4.85) among men. In conclusion, we estimated the prevalence of probable depression, CSA, and IPV among PLHIV presenting for HIV care in southern India and found that, among male PLHIV, alcohol use was associated with a markedly higher odds of reporting a psychosocial condition. Further study is needed to characterize alcohol use among male PLHIV and the possible deleterious impact of psychosocial conditions and alcohol use on HIV-related outcomes in India.

HIV knowledge trends during an era of rapid antiretroviral therapy scale-up: an analysis of 33 sub-Saharan African countries

Population‐level improvements in knowledge about HIV may reduce the stigma attached to HIV and ensure maximal uptake of HIV prevention initiatives. The extent to which levels of HIV knowledge in the general population of sub‐Saharan Africa have changed in the current era of antiretroviral therapy (ART) scale‐up remains unknown.

Internalized HIV stigma, ART initiation and HIV-1 RNA suppression in South Africa: exploring avoidant coping as a longitudinal mediator

Cross‐sectional evidence suggests that internalized HIV stigma is associated with lower likelihoods of antiretroviral therapy (ART) initiation and HIV‐1 RNA suppression among people living with HIV (PLWH). This study examined these associations with longitudinal data spanning the first nine months following HIV diagnosis and explored whether avoidant coping mediates these associations.