Gilly Arthur

Trends in Bloodstream Infections among Human Immunodeficiency Virus-Infected Adults Admitted to a Hospital in Nairobi, Kenya, during the Last Decade

Bloodstream infections are a frequent complication in human immunodeficiency virus (HIV)-infected adults in Africa and usually associated with a poor prognosis. We evaluated bloodstream infections across a decade in 3 prospective cross-sectional surveys of consecutive medical admissions to the Kenyatta National Hospital, Nairobi, Kenya. Participants received standard clinical care throughout. In 1988-1989, 29.5% (28 of 95) of HIV-positive patients had bloodstream infections, compared with 31.9% (46 of 144) in 1992 and 21.3% (43 of 197) in 1997. Bacteremia and mycobacteremia were significantly associated with HIV infection. Infections with Mycobacterium tuberculosis, non-typhi species of Salmonella (NTS), and Streptococcus pneumoniae predominated. Fungemia exclusively due to Cryptococcus neoformans was uncommon. Clinical features at presentation remained similar. Significant improvements in the survival rate were recorded among patients with NTS bacteremia (20%-83%; P<.01) and mycobacteremia (0%-73%; P<.01). Standard clinical management can improve outcomes in resource-poor settings.

Suicidal ideation in Uk Hiv clinic attenders

Background:HIV has been associated with elevated suicidal ideation. Although new treatments have changed prognosis, they also bring new challenges. This study measured suicidal ideation in HIV clinic attenders in the United Kingdom (London/Southeast) and explored associated factors. Method:All 1006 attenders at five HIV clinics were approached, of which 903 met inclusion criteria and 778 participated (86% response). Participants provided detailed information on suicidal ideation, demographics, treatment, adherence, symptoms (psychological and physical on Memorial Symptom Assessment Schedule), quality of life (EuroQol) information, HIV disclosure, clinical variables, sexual risk behaviour and treatment optimism. Results:There was a 31% prevalence of suicidal ideation. Factors associated with suicidal ideation were being a heterosexual man, black ethnicity, unemployment, lack of disclosure of HIV status, having stopped antiretroviral treatment (compared to treatment or treatment naive), physical symptoms, psychological symptoms and poorer quality of life. There was no association with sexual risk behaviour. Sex/sexuality and ethnicity were independently associated with suicidal ideation: the odds of suicidal ideation increased almost two-fold for heterosexual men compared with gay men or women and for black respondents compared with White or Asian respondents. Lack of disclosure was independently associated with a two-fold increase in odds of suicidal ideation. Elevated physical and psychological symptoms were strong independent predictors of suicidal ideation. Independent predictors of suicidal ideation were very similar among the subgroup of 492 patients on antiretroviral treatment. Conclusion:Despite advances in treatment, suicidal ideation rates among HIV-positive clinic attenders are high. Emotional support and attention to mental health provision and social context are strongly endorsed.

Adherence to antiretroviral treatment in patients with HIV in the UK: a study of complexity

Abstract Adherence to HIV treatment regimes is a core element to viral suppression. Yet measurement of adherence is complex. Although adherence levels are good predictors of outcome, they do not always provide full explanations of observed variations in responses. This study was set up to examine the complexity of adherence measurement and to examine rates of adherence in the presence of complex measurement. A total of 502 consecutive attenders at HIV clinics in the UK (80.5% response rate) provided detailed measurement on adherence in the preceding 7 days, setting out dose adherence, as well as measures of timing and dietary conditions. In addition, a range of psychological, demographic and relationship data were gathered to understand predictors of full and partial adherence. Although 79.1% reported dose adherence in the previous 7 days, 42.8% had not taken the dose at the correct time, and 27.2% had not taken the dose under the correct circumstances. Using a more complex composite measure of full adherence, rates reduced from 79.1% to 41.5%. Comparisons of those deemed fully adherent, partially adherent and non-adherent were carried out. Those that were fully adherent were significantly more likely to be older (F=7.8, p<0.001), UK born (F=6.8, p=0.03), code ethnicity as white (F=5.3, p=0.07), record higher quality of life (χ 2=8.7, p=0.01), lower psychological symptoms (χ 2=15.2, p=0.001) and lower global distress symptoms (χ 2=6.9, p=0.03). There were no differences according to education, behavioural and attitudinal variables (disclosure, stable relationship, STI diagnosed, number of sexual partners, unprotected sex, optimism or treatment switching). Fully adherent groups were significantly more likely to be in agreement with their doctor on treatment initiation (χ 2=6.2, p=0.045), satisfied with the amount of involvement in the decision-making process (χ 2=7.3, p=.026), their wishes were considered (χ 2=12.5, p=0.002) and had monitoring of their condition (χ 2=7.1, p=0.028). Multivariate analysis showed that variables which contributed significantly at a 5% criterion level to complex adherence were physical symptoms (OR=0.56, p=0.05), psychological symptoms (OR=2.37, p<0.001), age (OR=0.96, p=0.02), education (OR=0.54, p=0.03), having more than one sexual partner (OR=0.46, p=0.03), having risky sex (OR=4.30, p=0.002) and being optimistic about treatments (OR=0.42, p=0.01). The softer markers of adherence are not usually measured in follow up and may account for variations in treatment responses. The complexity of adherence needs to be understood and addressed to maximise treatment efficacy.

Behaviour change in clients of health centre‐based voluntary HIV counselling and testing services in Kenya

Objective: To explore behaviour change, baseline risk behaviour, perception of risk, HIV disclosure and life events in health centre-based voluntary counselling and testing (VCT) clients. Design and setting: Single-arm prospective cohort with before–after design at three (one urban and two rural) government health centres in Kenya; study duration 2 years, 1999–2001. Subjects: Consecutive eligible adult clients. Main outcome measures: Numbers of sexual partners, partner type, condom use, reported symptoms of sexually transmitted infection, HIV disclosure and life events. Results: High rates of enrolment and follow-up provided a demographically representative sample of 401 clients with mean time to follow-up of 7.5 months. Baseline indicators showed that clients were at higher risk than the general population, but reported a poor perception of risk. Clients with multiple partners showed a significant reduction of sexual partners at follow-up (16% to 6%; p<0.001), and numbers reporting symptoms of sexually transmitted infection decreased significantly also (from 40% to 15%; p<0.001). Condom use improved from a low baseline. Low rates of disclosure (55%) were reported by HIV-positive clients. Overall, no changes in rates of life events were seen. Conclusion: This study suggests that significant prevention gains can be recorded in clients receiving health centre-based VCT services in Africa. Prevention issues should be considered when refining counselling and testing policies for expanding treatment programmes.

The changing impact of HIV/AIDS on Kenyatta National Hospital, Nairobi from 1988/89 through 1992 to 1997.

ObjectiveConsequences of the growing HIV/AIDS epidemic for health services in sub-Saharan Africa remain poorly defined. Longitudinal data from the same centre are scarce. We aimed to describe the impact of a rapidly rising HIV/AIDS disease burden on an urban hospital over the last decade. Design and settingCross-sectional observational study in 1997, compared to similar data from 1988/89 and 1992. The study was carried out in the Kenyatta National Hospital, Nairobi, Kenya. MethodConsecutive adult medical patients were enrolled on admission and then followed up until death or discharge. The main outcome measures were clinical stage, HIV status, bacteraemia, length of stay, bed occupancy, final diagnosis and outcome of hospital admission. ResultsIn 1997, 518 patients, 493 with HIV serology, were enrolled: HIV prevalence was 40.0%, bed occupancy 190%, the mean length of stay 9.5 days (SD 12) and overall mortality 18.5%. The mean number of HIV-positive admissions per day steadily rose from 4.3 [95% confidence interval (CI), 0.6] patients in 1988/89, through 9.6 (95% CI, 1.4) in 1992, to 13.1 (95% CI, 2.8) or 13.9 adjusted for those enrolled without HIV serology in 1997. In contrast the mean number admitted with clinical AIDS, 1.7 in 1988/89 and 3.3 in 1992, fell to 2.6 cases per day in 1997. With HIV-negative admissions increasing by 37% and bed occupancy nearly doubling in 1997, HIV prevalence appeared to be stabilizing (19 then 39 and 40% respectively). Over time fewer HIV-infected patients were bacteraemic (26, 24 and 14%;P < 0.01); had clinical AIDS (39, 34 and 24% respectively;P < 0.01); or died (36, 35 and 22.6%;P < 0.02). HIV-negative mortality, 14% in 1988/89, rose to 23% in 1992 but fell to 15% in 1997. The mean length of hospital stay (9.5–10 days) did not differ according to HIV status nor did it change across the decade. ConclusionThe HIV/AIDS disease burden in Kenyatta National Hospital medical wards has risen inexorably over the last decade. Most recently, the number of HIV-uninfected patients has also risen, leading to bed occupancy figures of 190%. Despite overcrowding and irrespective of HIV status, in-patient mortality has fallen. Time trends suggest fewer clinical AIDS patients are presenting for hospital care, implying a rising community burden of chronic HIV/AIDS disease. Although widely predicted, it is not inevitable that medical services in urban African hospitals dealing with large volumes of HIV/AIDS disease, will collapse or become overwhelmed with chronic, end-stage disease and death.

United Kingdom acquisition of HIV infection in African residents in London: more than previously thought.

Between a quarter to a third of HIV-positive African residents in the UK, and nearly half of HIV-positive African men who have sex with men, may have acquired their HIV infection in the UK, which is substantially higher than previously estimated. These estimates are likely to worsen given the increasing HIV prevalence and assortative sexual mixing in this community, especially among heterosexuals. HIV prevention interventions for Africans must focus on reducing transmission within the UK as well as addressing infections acquired abroad.

Costs of hospital care for HIV-positive and HIV-negative patients at Kenyatta National Hospital, Nairobi, Kenya.

ObjectiveTo record the costs of hospital care for HIV-positive and -negative patients in Nairobi, and identify costs paid by patients per admission. DesignCost data were collected on inpatients enrolled in a linked clinical study using standardized costing methods. SettingKenyatta National Hospital, Nairobis main district hospital. PatientsConsecutive adult medical admissions to one ward over 14 weeks who consented to enrolment; tertiary referrals were excluded. Main outcome measureAverage length of stay and cost per patient admission. ResultsThe hospital costs of 398 patients (163 HIV positive; 33 with clinical AIDS) were analysed. The mean length of stay was 9.3 days and the mean cost per patient admission was US

Successive switching of antiretroviral therapy is associated with high psychological and physical burden

163. There was no significant difference in costs or mean lengths of stay between HIV-positive and -negative groups, nor were the costs and lengths of stay for clinical AIDS patients significantly different to those for HIV-positive patients without AIDS. The patient charges paid to the hospital per admission, recorded for 344 patients, were on average US

Clinical and behavioural aspects of aging with HIV infection

61; and did not differ by HIV status. ConclusionThe similar cost patterns for inpatient care irrespective of HIV status or clinical AIDS probably reflects the limited provision of care beyond basic clinical services. Length of stay rather than differing treatment regimes thus appears to be the main cost driver. Private costs of medical care were high and were likely to pressurize households. When resources are limited, the introduction of new, more costly therapies needs careful planning. The study provides cost information for planning care services in resource-poor settings.

The role for government health centers in provision of same-day voluntary HIV counseling. and testing in Kenya

HIV treatment and management is constantly evolving. This is as a result of more treatment options coming on stream, tolerance changes and progress in treatment management. HIV infection today, in resource-rich countries and in the presence of combination therapies, is experienced as lifelong treatment punctuated by adjustments to antiretroviral therapy (ART) regimens. People who are diagnosed as HIV positive face a number of challenges and changes around the decision to commence treatment, responses to treatment and changes in treatment regimens. This study was set up to examine the experience of switching treatments and the impact of such switches on psychological parameters. The method used was a cross-sectional questionnaire study. A group of 779 HIV-positive clinic attendees at four clinics in London and South East England participated in the study (86% response rate). They provided detail of their treatment switching experiences as well as demographic details, risk and optimism evaluations, quality of life, symptom burden, adherence and disclosure information. The sample (n=779) comprised 183 (24%) females, 76 (10%) heterosexual males and 497 gay males (66%). Self-reported ethnicity was 67% white, 25% black, 3% Asian and 5% mixed/other ethnicity. One hundred and fifty-five (21%) were ART-naïve and 624 (79%) were ART experienced; 161 (22%) were receiving their first regimen, 135 (18%) had experienced one regimen switch, 196 (26%) had multiple switches and 99 (13.3%) had stopped treatment. Treatment naïve, non-switchers and single switchers generally reported lower symptom burden and higher quality of life. Multiple switchers reported higher physical symptom burden and higher global symptom distress scores. Those who had stopped treatment had significantly lower quality-of-life scores than all other groups. Suicidal ideation was high across the groups and nearly a fifth of all respondents had not disclosed their HIV status to anyone. Reported adherence was suboptimal – 79% of subjects were at least 95% adherent on self-report measures of doses taken over the preceding week. In conclusion, nearly half this clinic sample will have switched treatments. A holistic approach is needed to understand the psychological effects of such switches if lifelong treatment is to be maintained and those on antiretroviral treatment are to attain good quality of life and minimize symptom burden.