Devang Patel

Linkage to and retention in care following healthcare transition from pediatric to adult HIV care

ABSTRACT Outcomes following healthcare transition (HCT) from pediatric to adult HIV care are not well described. We sought to describe clinical outcomes following HCT within our institution among young adults with behavioral-acquired (N = 31) and perinatally-acquired (N = 19) HIV. We conducted a retrospective cohort study among HIV-infected adults who attempted transition from pediatric to adult HIV care within our institution. The primary end point was retention in care, defined as the completion of at least two visits over 12 months following linkage to adult care. Additional end points include time to linkage to adult care, and changes in CD4 + T cell count and HIV RNA across time. Outcomes were compared between perinatal and behavioral HIV cohorts. Binary data were analyzed using the Fisher exact test and continuous data were analyzed using the Mann–Whitney test. Forty-three (86%) of 50 patients were successfully linked to adult care. The median time to linkage was 98 days. Fifty percent of patients achieved full retention in care at 12 months post-linkage. Though those with behavioral-acquired HIV attempted transfer at an older age, the groups did not differ in rates of linkage and retention in adult care. CD4 + T cell counts and rates of viral suppression did not differ between pre- and post-HCT periods. Despite high rates of successful linkage to adult care in our study population, rates of retention in adult HIV care following HCT were low. These results imply that challenges remain in the adult HIV care setting toward improving the HCT process.

Sepsis in Haiti: Prevalence, treatment, and outcomes in a Port-au-Prince referral hospital

Purpose: Developing countries carry the greatest burden of sepsis, yet few descriptive data exist from the Western Hemisphere. We conducted a retrospective cohort study to elucidate the presentation, treatment, and outcomes of sepsis at an urban referral hospital in Port‐au‐Prince, Haiti. Materials and methods: We studied all adult emergency department patient encounters from January through March 2012. We characterized presentation, management, and outcomes using univariable and multivariable analyses. Results: Of 1078 adult patients, 224 (20.8%) had sepsis and 99 (9.2%) had severe sepsis. In‐hospital mortality for severe sepsis was 24.2%. Encephalopathy was a predictor of intravenous fluid administration (adjusted odds ratio [OR], 5.63; 95% confidence interval [CI], 1.46‐21.76; P = .01), and lower blood pressures predicted shorter time to fluid administration. Increasing temperature and lower blood pressures predicted antibiotic administration. Encephalopathy at presentation (adjusted OR, 6.92; 95% CI, 1.94‐24.64; P = .003), oxygen administration (adjusted OR, 15.96; 95% CI, 3.05‐83.59; P = .001), and stool microscopy (adjusted OR, 45.84; 95% CI, 1.43‐1469.34; P = .03) predicted death in severe sepsis patients. Conclusions: This is the first descriptive study of sepsis in Haiti. Our findings contribute to the knowledge base of global sepsis and reveal similarities in independent predictors of mortality between high‐ and low‐income countries.

Influence of transportation cost on long-term retention in clinic for HIV patients in rural Haiti.

Background:With improved access to antiretroviral therapy in resource-constrained settings, long-term retention in HIV clinics has become an important means of reducing costs and improving outcomes. Published data on retention in HIV clinics beyond 24 months are, however, limited. In our clinic in rural Haiti, we hypothesized that individuals residing in locations with higher transportation costs to clinic would have poorer retention than those who had lower costs. Methods:We used a retrospective cohort design to evaluate potential predictors of HIV clinic retention. Patient information was abstracted from the electronic medical records. Cox proportional hazards regression was used to identify independent predictors of 4-year clinic retention. Results:There were 410 patients in our cohort, 266 (64.9%) females and 144 (35.1%) males. Forty-five (11%) patients lived in locations with transportation costs >

Treatment outcomes after implementation of an adapted WHO protocol for severe sepsis and septic shock in Haiti

2. Males were 1.5 times more likely to live in municipalities with transportation costs to clinic of >

Fever in immunocompromised hosts.

2. Multivariate analysis suggested that age <30 years, male gender, and transportation cost were independent predictors of loss to follow-up (LTFU): risk ratio of 2.98, 95% confidence interval (CI): 1.73 to 4.96, P < 0.001; 1.71, CI: 1.08 to 2.70, P = 0.02; and 1.91, CI: 1.08 to 3.36, P = 0.02, respectively. Conclusions:Patients with transportation costs greater than

Vitiligo immune reconstitution inflammatory syndrome (IRIS)—An incidental finding in a tertiary teaching hospital in southeast Nigeria

2 were 1.9 times more likely to be lost to care compared with those who paid less for transportation. HIV treatment programs in resource-constrained settings may need to pay closer attention to issues related to transportation cost to improve patient retention.

The Arc of Human Immunodeficiency Virus Capacity Development: Insights from a Decade of Partnership for Medical Education in Zambia

Purpose: The World Health Organization (WHO) has developed a simplified algorithm specific to resource‐limited settings for the treatment of severe sepsis emphasizing early fluids and antibiotics. However, this protocols clinical effectiveness is unknown. We describe patient outcomes before and after implementation of an adapted WHO severe sepsis protocol at a community hospital in Haiti. Materials and methods: Using a before‐and‐after study design, we retrospectively enrolled 99 adult Emergency Department patients with severe sepsis from January through March 2012. After protocol implementation in January 2014, we compared outcomes to 67 patients with severe sepsis retrospectively enrolled from February to April 2014. We defined sepsis according to the WHOs Integrated Management of Adult Illness guidelines and severe sepsis as sepsis plus organ dysfunction. Results: After protocol implementation, quantity of fluid administered increased and the physicians differential diagnoses more often included sepsis. Patients were more likely to have follow‐up vital signs taken sooner, a radiograph performed, and a lactic acid tested. There were no improvements in mortality, time to fluids or antimicrobials. Conclusions: Use of a simplified sepsis protocol based primarily on physiologic parameters allows for substantial improvements in process measures in the care of severely septic patients in a resource‐constrained setting. HIGHLIGHTSThe WHOs severe sepsis algorithm emphasizes early fluids and antibiotics.However, this protocols clinical efficacy in a real‐world setting is unknown.We describe patient outcomes after implementation of an adapted WHO severe sepsis protocol in Haiti.Post‐protocol, quantity of fluids given increased and the physicians differential diagnoses more often included sepsis.Post‐protocol patients had follow‐up vital signs taken sooner, a radiograph performed, and a lactic acid tested.There were no improvements in mortality, time from triage to fluids or antimicrobials.

A 58-Year-Old Man With a Cough and Fever

Fever is one of the most common reasons for the emergency department presentation of immunocompromised patients. Their differential diagnosis can be broad and includes rare or unexpected pathogens. Certain infectious causes of fever portend true emergencies; if they are not managed appropriately, rapid progression and death may ensue. This article reviews the diagnosis and management of fevers in patients immunocompromised by human immunodeficiency virus/AIDS, solid-organ and hematopoietic transplants, chemotherapy-induced neutropenia, and tumor necrosis factor-α inhibitors. Prompt recognition of the type of immunosuppression and delineation of possible causes of fever are critical for management of these complex patients.

HIV in Africa: Challenges and Directions for the Next Decade

ART: antiretroviral therapy HAART: highly active antiretroviral therapy IRIS: immune reconstitution inflammatory syndrome INTRODUCTION Skin diseases occur at every stage of HIV infection. They not only act as markers of disease, they may reflect the underlying immune status. An estimated 90% of HIV-infected individuals will have at least 1 dermatologic manifestation during the course of disease. These diseases may be infections, noninfectious inflammatory conditions, or neoplasms. Pigmentary abnormalities may occur as a side effect of antiretroviral therapy (ART) itself or from effects of drug treatment of opportunistic infections. Vitiligo in a patient with HIV/AIDS was first reported by Duvic et al in 1987. Since then, vitiligo has been reported frequently in HIV and may occur as a result of direct viral infection of melanocytes by HIV, polyclonal B-cell activation against melanocytes, production of g-interferon (toxic to melanocytes), or changes in the balance between helper and suppressor T cells. Some researchers postulate that increased numbers of CD8 cytotoxic T cells in lesional skin and peripheral blood, along with a decrease in CD4 T cells, leads to an increased CD8/CD4 ratio. Reduced numbers of CD4 peripheral T cells usually observed in AIDS patients may favor the development of vitiligo. Although antibodies in vitiligo are commonly directed against melanocyte antigens on the surface of the cells, Kemp et al, using phage display technology with a melanocyte cDNA phage display library, identified melanin-concentrating hormone

A Review of the 2010 WHO Adult Antiretroviral Therapy Guidelines: Implications and Realities of These Changes for Zambia.

AbstractZambia and other sub-Saharan nations suffer from a critical shortage of trained health-care professionals to combat the human immunodeficiency virus/acquired immunodeficiency syndrome crisis. The University of Maryland and the Zambian Ministry of Health have partnered over the past decade to develop health-care capacity among physicians, nurses, and community health workers. We describe novel interventions to train health-care workers at all levels and argue that our collaboration represents a successful model for such partnerships between western medical institutions and African governmental health agencies.