Carina Marquez

Methamphetamine use, sexual activity, patient-provider communication, and medication adherence among HIV-infected patients in care, San Francisco 2004-2006.

Abstract While numerous studies examine methamphetamine use and associated risky sexual behaviors in HIV-uninfected individuals, few studies have surveyed HIV-infected individuals in the health care setting. To assess the frequency and trends of methamphetamine use, sexual activity, injection drug use, patient–provider communication, and medication adherence among HIV-infected persons in care, we administered a one-page anonymous survey in 2004 and 2006. The survey was conducted at the two University of California, San Francisco outpatient HIV clinics: at Moffitt Hospital (Moffitt), serving primarily privately insured patients, and at San Francisco General Hospital (SFGH), a county hospital serving primarily patients who are uninsured or publicly insured. In 2006, 39% of men who have sex with men (MSM), 33% of heterosexual men, and 11% of women reported methamphetamine use in the prior 12 months. Methamphetamine use was significantly associated with an increased number of sex partners among MSM and heterosexual men, and poor anti-retroviral medication adherence. Among MSM, methamphetamine use was more common at the SFGH clinic. Between 2004 and 2006, reported methamphetamine use in the last 12 months decreased among MSM at Moffitt (38 to 20%, p<0.01), but increased at SFGH (40 to 50%, p<0.05). Among methamphetamine users we found a high frequency of injection of methamphetamine, which increased at SFGH from 38 to 55%, p<0.05. Patient–provider communication regarding methamphetamine use has increased from 2004 to 2006 but no significant change has been found for providers asking patients about sexual activity. Overall, we found methamphetamine use to be common among HIV-infected patients in care, and associated with an increased number of sex partners, a high frequency of injection drug use, and poor adherence to anti-retroviral medications. These findings support the need for improved screening and clinic-based interventions to reduce and treat methamphetamine abuse and associated high risk sexual behaviors.

Increased Morbidity in Early Childhood Among HIV-exposed Uninfected Children in Uganda is Associated with Breastfeeding Duration

Human immunodeficiency virus (HIV)-exposed uninfected children (HEU) have an increased risk of morbidity and mortality compared with HIV-unexposed uninfected children (HUU); however, prior studies have not fully accounted for the role of both breastfeeding and age on this association. In this cohort of HEU and HUU in Uganda, non-breastfeeding HEU, from 6-11 months compared with non-breastfeeding HUU had a higher risk of hospitalizations [relative risk (RR): 10.1, 95% confidence interval (CI): 3.70-27.6], severe febrile illness (RR: 3.84, 95% CI: 2.06-7.17), severe diarrhea (RR: 6.37, 95% CI: 2.32-17.4) and severe malnutrition (RR: 18.4, 95% CI: 4.68-72.0). There were no differences between morbidity outcomes between breastfeeding HEU and HUU children, aged 6-11 months. In the 12-24 month age group, the only difference in morbidity outcomes among non-breast feeding children was an increased risk of severe malnutrition for HEU. These data suggest that the increased risk of morbidity among HEU aged 6-11 years is partially explained by early cessation of breastfeeding.

Identifying locations of recent TB transmission in rural Uganda: a multidisciplinary approach

Targeting high Tuberculosis (TB) transmission sites may offer a novel approach to TB prevention in sub‐Saharan Africa. We sought to characterise TB transmission sites in a rural Ugandan township.

Tuberculosis Infection in Early Childhood and the Association with HIV-exposure in HIV-uninfected Children in Rural Uganda.

Background: In high tuberculosis (TB) burden countries, a significant proportion of the latent TB reservoir is established by the age 5 years. There are critical knowledge gaps in our understanding of the age-specific prevalence of TB infection and the influence of HIV exposure on TB infection in the first 5 years of life among HIV-uninfected children in sub-Saharan Africa. Methods: We measured TB infection with the Quantiferon Gold-in-Tube (QFT) and tuberculin skin tests (TST) in 447 children ⩽60 months and their 284 HIV-infected and IV-uninfected mothers in rural Uganda. Results: The overall prevalence of TB infection in children ⩽60 months by TST was 24% (95% confidence intervals [CI]: 19.9–27.9). The prevalence of TST positivity was highest among children in their first year of life (36%; 95% CI: 26.0–45.9) and declined with age to 19% at 36–60 months of age, &khgr;2 test for trend P = 0.014. In contrast, 4% (95% CI: 1.9–5.87%) of children had a positive QFT, and there was no trend detected with age, P = 0.576. QFT positivity was detected as early as 5 months. HIV-exposed uninfected children had significantly higher odds of TB infection by QFT (odds ratio [OR]: 21.2; P = 0.008; 95% CI: 2.2–204.7) or positive TST or QFT (OR, 2.4; P = 0.020; 95% CI: 1.2–5.1) compared with HIV-unexposed uninfected children, adjusting for age, BCG vaccination and a positive maternal TST or QFT. Conclusions: An appreciable prevalence of TB infection was detected in early childhood. HIV-exposed uninfected children have a higher risk for TB infection compared with children born to HIV-uninfected mothers.

HIV-associated central nervous system tuberculosis.

Central nervous system tuberculosis (CNS TB) represents one of the most devastating manifestations of TB. HIV dramatically increases the risk of TB disease, including CNS TB. Early recognition and treatment of CNS TB, and TB meningitis in particular, is of critical importance to reducing disability and death associated with CNS TB. The diagnosis and treatment of HIV-associated CNS TB presents particular challenges for clinicians due to the increased risk of other CNS infections and malignancies, atypical cerebrospinal fluid characteristics, drug-drug interactions, timing of antiretroviral therapy and immune reconstitution inflammatory syndrome, and the increased risk of poor clinical outcomes in HIV-infected compared with HIV-uninfected CNS TB patients. The authors review recent updates and highlight challenges specific to CNS TB in the HIV-infected patient.

Trichomonas vaginalis infection among homeless and unstably housed adult women living in a resource-rich urban environment

Objective The social context of poverty is consistently linked to Trichomonas vaginalis infection, yet few studies regarding T. vaginalis have been conducted exclusively among low-income individuals. We identified social determinants of health associated with prevalent T. vaginalis infection among homeless and unstably housed adult women. Methods Between April and October of 2010, we conducted cross-sectional T. vaginalis screening and behavioural interviews in an existing cohort of San Francisco homeless and unstably housed women. Data were analysed using multivariable logistical regression. Results Among 245 study participants, the median age was 47 years and 72% were of non-Caucasian race/ethnicity. T. vaginalis prevalence was 12%, compared to 3% in the general population, and 33% of infected individuals reported no gynaecological symptoms. In adjusted analysis, the odds of T. vaginalis infection were lower among persons older than 47 years, the population median (OR=0.14, 95% CI 0.04 to 0.38), and higher among those reporting recent short-term homeless shelter stays (OR=5.36, 95% CI 1.57 to 18.26). Race and income did not reach levels of significance. Sensitivity analyses indicated that testing all women who report recent unprotected sex would identify more infections than testing those who report gynaecological symptoms (20/30 vs 10/30; p=0.01). Conclusions The prevalence of T. vaginalis is high among homeless and unstably housed adult women, over one-third of infected individuals have no gynaecological symptoms, and correlates of infection differ from those reported in the general population. Targeted screening and treatment among impoverished women reporting recent unprotected sex, particularly young impoverished women and all women experiencing short-term homelessness, may reduce complications related to this treatable infection.

Contribution of Maternal Antiretroviral Therapy and Breastfeeding to 24-Month Survival in Human Immunodeficiency Virus-Exposed Uninfected Children: An Individual Pooled Analysis of African and Asian Studies

Abstract Background Human immunodeficiency virus (HIV)–infected pregnant women increasingly receive antiretroviral therapy (ART) to prevent mother-to-child transmission (PMTCT). Studies suggest HIV-exposed uninfected (HEU) children face higher mortality than HIV-unexposed children, but most evidence relates to the pre-ART era, breastfeeding of limited duration, and considerable maternal mortality. Maternal ART and prolonged breastfeeding while on ART may improve survival, although this has not been reliably quantified. Methods Individual data on 19 219 HEU children from 21 PMTCT trials/cohorts undertaken from 1995 to 2015 in Africa and Asia were pooled to estimate the association between 24-month mortality and maternal/infant factors, using random-effects Cox proportional hazards models. Adjusted attributable fractions of risks computed using the predict function in the R package “frailtypack” were used to estimate the relative contribution of risk factors to overall mortality. Results Cumulative incidence of death was 5.5% (95% confidence interval, 5.1–5.9) by age 24 months. Low birth weight (LBW <2500 g, adjusted hazard ratio (aHR, 2.9), no breastfeeding (aHR, 2.5), and maternal death (aHR, 11.1) were significantly associated with increased mortality. Maternal ART (aHR, 0.5) was significantly associated with lower mortality. At the population level, LBW accounted for 16.2% of 24-month mortality, never breastfeeding for 10.8%, mother not receiving ART for 45.6%, and maternal death for 4.3%; combined, these factors explained 63.6% of deaths by age 24 months. Conclusions Survival of HEU children could be substantially improved if public health practices provided all HIV-infected mothers with ART and supported optimal infant feeding and care for LBW neonates.

Disabling Dactylitis and Tenosynovitis Due to Mycobacterium haemophilum in a Patient With Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome

A 44-year-old man with acquired immune deficiency syndrome (AIDS) and CD4 cell count of 8 cells/mm presented with painful and erythematous swollen hands 1 month after starting antiretroviral therapy (ART) after a 4-year hiatus from care. During his interrupted human immunodeficiency virus (HIV) treatment, he was living in Mexico and incarcerated for a period of time. For the year preceding presentation with hand swelling, he was working as a cook in a Mexican restaurant in San Francisco, California, where he had frequent finger trauma from opening metal cans and preparing shrimp. Thickened flexor tendons and dactylitis were present bilaterally with stiffness and severely limited flexion and extension of his fingers (Figures 1 and 2). He did not have systemic symptoms. Skin biopsies demonstrated granulomatous dermatitis and panniculitis (Figure 3), with negative stains for organisms. Polymerase chain reaction and immunohistochemical stains for mycobacteria were negative. TB treatment along with clarithromycin was initiated empirically. Cultures from a second excisional biopsy of deep palm soft tissue on chocolate agar incubated at 30°C grew Mycobacterium haemophilum, suggesting unmasking immune reconstitution inflammatory syndrome (IRIS) in setting of HIV treatment. Additional biopsies grew M. haemophilium from mycobacterial cultures. Treatment was changed to moxifloxacin, ethambutol, rifabutin, and azithromycin.

Implementation and Operational Research: Population-Based Active Tuberculosis Case Finding During Large-Scale Mobile HIV Testing Campaigns in Rural Uganda.

Background:Active tuberculosis (TB) screening outside clinics and in communities may reduce undiagnosed TB. Methods:To determine the yield of TB screening during community-based HIV testing campaigns (CHC) in 7 rural Ugandan communities within an ongoing cluster-randomized trial of universal HIV testing and treatment (SEARCH, NCT:01864603), we offered sputum microscopy to participants with prolonged cough (>2 weeks). We determined the number of persons needed to screen to identify one TB case, and the number of cases identified that linked to clinic and completed TB treatment. Results:Of 36,785 adults enumerated in 7 communities, 27,214 (74%) attended CHCs, and HIV testing uptake was >99%, with 941 (3.5%) HIV-infected adults identified. Five thousand seven hundred eighty-six adults (21%) reported cough and 2876 (11%) reported cough >2 weeks. Staff obtained sputum in 1099/2876 (38%) participants with prolonged cough and identified 10 adults with AFB-positive sputum; 9 new diagnoses and 1 known case already under treatment. The number needed to screen to identify one new TB case was 3024 adults overall: 320 adults with prolonged cough and 80 HIV-infected adults with prolonged cough. All 9 newly diagnosed AFB+ participants were linked to TB care within 2 weeks and were initiated TB treatment. Conclusions:In a rural Ugandan setting, TB screening as an adjunct to large-scale mobile HIV testing campaigns provides an opportunity to increase TB case detection.

E-portfolios for community projects: capturing the process.

Context and setting Many trainees participate in experiential learning as part of their medical education. At our university, residents in the Paediatric Leadership for the Underserved programme are expected to design, propose and implement a community-based project during their 3-year clinical residency training. Portfolios have been increasingly used in medical education to assess competencies. In addition, electronic portfolios offer the ability to create flexible and modular design templates, incorporate varied multimedia content, and employ web-based applications to address the needs of learners and faculty mentors. Why the idea was necessary Tools for the formative assessment of community-based projects are limited. The recognised educational value of these projects is often based disproportionately upon the final outcomes of the project, including presentations, papers and awards. However, the actual learning obtained from independent projects may not be reflected in the final product. What was done To determine the general need for project portfolios, we conducted a pre-pilot survey of 19 trainees engaged in community-based projects. We examined their self-reported achievement of 12 project competencies and their ability to provide evidence of competency (using a 5-point Likert scale ranging from strongly disagree to strongly agree). We also reviewed our curriculum and established specific community project competencies with input from community partners. Finally, we conducted a needs assessment to identify key features of the e-portfolio, and we piloted the e-portfolio with the 12 residents in our programme. Evaluation of results and impact Pre-pilot survey participants were more likely to report achieving rather than having evidence of competency in nine of 12 competencies; however, findings achieved statistical significance for only one competency. We established the following community-based project competencies: establish learning objectives; identify the problem and key stakeholders; know your target population and community; develop project goals and corresponding evaluation measures; create a feasible time-line of project activities to achieve goals, and establish a plan of sustainability and legacy. Our needs assessment identified several critical features of the e-portfolio, including: access control; simple technology, and advisor feedback. In response, we created web pages for each competency with identified sections for expectations, reflection and supporting evidence. Within each page, we embedded a two-way feedback window that allows learners and project mentors to engage in online discussions. These pages were then stitched together to create an individualised, user-edited, single, presentable webpage for each resident. The e-portfolio is being used by all the residents in our programme and is being disseminated to the broader medical school community.