Lambert Tetteh Appiah

Efficacy and Acceptability of Rapid, Point-of-Care HIV Testing in Two Clinical Settings in Ghana

This study assessed the efficacy and acceptability of two rapid point-of-care HIV assays used in a voluntary counseling and testing (VCT) and a tuberculosis (TB) clinic in Kumasi, Ghana. Over a 4-week period in 2007, 95 individuals attending the VCT clinic and 35 patients with newly diagnosed TB were offered a rapid HIV test. Rates of return for positive results and attendance at the HIV clinic were compared with 471 individuals (395 attending the VCT clinic and 76 patients with TB), tested during an 8-week period 6 months earlier using standard testing procedures. All patients offered a rapid test in each clinic underwent testing, compared to 93% of VCT clients and 40% of TB patients offered a test 6 months earlier. In the rapid testing period, 37%, 60%, and 3% of the VCT clients and 26%, 74% and 0% of the TB patients had positive, negative, or indeterminate serology, respectively. There were no discordant results following retesting of patients with a positive test. All patients attending either the VCT or TB clinics who tested positive for HIV with the point-of-care test returned to the HIV clinic for care, while only 64% and 95%, respectively, of the patients previously testing positive had returned for follow-up. Both clients and staff showed high levels of satisfaction with the rapid testing procedure. In conclusion, rapid point-of-care testing in both of these settings was successful in improving diagnosis of HIV infection and engaging those testing positive in a clinical care program.

Liver Fibrosis by Transient Elastography and Virologic Outcomes After Introduction of Tenofovir in Lamivudine-Experienced Adults With HIV and Hepatitis B Virus Coinfection in Ghana

BACKGROUND Antiretroviral treatment (ART) programs in sub-Saharan Africa have for many years included lamivudine as the sole hepatitis B virus (HBV) inhibitor. Long-term outcomes and the effects of introducing tenofovir as part of ART in these populations have not been characterized. METHODS The study comprised a cross-sectional analysis of 106 human immunodeficiency virus (HIV)/HBV-coinfected subjects maintained on lamivudine, as well as a prospective analysis of 76 lamivudine-experienced subjects who introduced tenofovir. Patients underwent assessment of liver fibrosis by transient elastography (TE) and testing to characterize HIV type 1 (HIV-1) and HBV replication. RESULTS After a median of 45 months of lamivudine treatment, HIV-1 RNA and HBV DNA were detectable in 35 of 106 (33.0%) and 54 of 106 (50.9%) subjects, respectively, with corresponding drug resistance rates of 17 of 106 (16.0%) and 31 of 106 (29.2%), respectively. Median TE values were 5.7 kPa (interquartile range, 4.7-7.2 kPa) and independently associated with HBV DNA load, aspartate aminotransferase levels, and platelet counts; 13 of 106 (12.3%) subjects had TE measurements >9.4 kPa. Twelve months after the first assessment, and a median of 7.8 months after introducing tenofovir, HBV DNA levels declined by a mean of 1.5 log10 IU/mL (P < .001). TE values changed by a mean of -0.2 kPa (P = .097), and declined significantly in subjects who had pretenofovir HBV DNA levels >2000 IU/mL (mean, -0.8 kPa; P = .048) or TE values >7.6 kPa (mean, -1.2 kPa; P = .021). HIV-1 RNA detection rates remained unchanged. CONCLUSIONS A proportion of HIV/HBV-coinfected patients on long-term lamivudine-containing ART had poor HIV and HBV suppression, drug resistance, and TE values indicative of advanced liver fibrosis. Tenofovir improved HBV control and reduced liver stiffness in subjects with high HBV DNA load and TE values.

Phenotyping Stroke in Sub-Saharan Africa: Stroke Investigative Research and Education Network (SIREN) Phenomics Protocol

Background: As the second leading cause of death and the leading cause of adult-onset disability, stroke is a major public health concern particularly pertinent in Sub-Saharan Africa (SSA), where nearly 80% of all global stroke mortalities occur, and stroke burden is projected to increase in the coming decades. However, traditional and emerging risk factors for stroke in SSA have not been well characterized, thus limiting efforts at curbing its devastating toll. The Stroke Investigative Research and Education Network (SIREN) project is aimed at comprehensively evaluating the key environmental and genomic risk factors for stroke (and its subtypes) in SSA while simultaneously building capacities in phenomics, biobanking, genomics, biostatistics, and bioinformatics for brain research. Methods: SIREN is a transnational, multicentre, hospital and community-based study involving 3,000 cases and 3,000 controls recruited from 8 sites in Ghana and Nigeria. Cases will be hospital-based patients with first stroke within 10 days of onset in whom neurovascular imaging will be performed. Etiological and topographical stroke subtypes will be documented for all cases. Controls will be hospital- and community-based participants, matched to cases on the basis of gender, ethnicity, and age (±5 years). Information will be collected on known and proposed emerging risk factors for stroke. Study Significance: SIREN is the largest study of stroke in Africa to date. It is anticipated that it will shed light on the phenotypic characteristics and risk factors of stroke and ultimately provide evidence base for strategic interventions to curtail the burgeoning burden of stroke on the sub-continent.

Response to antiretroviral therapy in occult hepatitis B and HIV co-infection in West Africa.

This study evaluated the outcome of first-line antiretroviral therapy among 35 Ghanaians with occult HBV/HIV co-infection, comparing them over 2 years to 120 patients with HBsAg+ HBV/HIV co-infection and 230 patients without HBV co-infection. Increases in CD4 cell count and BMI were similar, whereas elevations of hepatic transaminases were more frequent in both the occult HBV and HBsAg+ patients. Occult HBV/HIV co-infection appears not to impact adversely on response to antiretroviral therapy in Ghana.

Short Communication: Low seroprevalence of cryptococcal antigenaemia in patients with advanced HIV infection enrolling in an antiretroviral programme in Ghana

Objectives  To determine the prevalence of cryptococcal antigenaemia in a clinic population with advanced HIV infection, with a view to giving antifungal therapy to those testing positive.

Outcomes of starting first-line antiretroviral therapy in hepatitis B virus/HIV-coinfected patients in Ghana

OBJECTIVES HIV/hepatitis B virus (HBV) coinfection is common in Ghana, where first-line antiretroviral therapy (ART) comprises lamivudine with zidovudine or stavudine and nevirapine or efavirenz. Little is known about ART outcomes in the context of coinfection. This study evaluated outcomes of ART among HIV/HBV-coinfected Ghanaians, focusing on locally available parameters. PATIENTS AND METHODS An observational study comparing clinical and virological outcomes in HIV-infected individuals who were either hepatitis B surface antigen (HBsAg) positive or HBsAg negative was conducted over 36 months. Clinical events, hepatic transaminases, CD4 count and body mass index (BMI) were evaluated among 143 HBsAg-positive and 228 HBsAg-negative patients. In a random subset of HBsAg-positive patients, HBV-DNA levels and polymerase sequences were analysed. RESULTS Comparing HBsAg-positive and HBsAg-negative patients, 44/143 (30.8%) and 83/228 (36.4%) defaulted follow-up, 15/143 (10.5%) and 30/228 (13.2%) experienced a new clinical event, and 8/143 (5.6%) and 11/228 (4.8%) discontinued their initial regimen, respectively. Transaminase levels were higher in HBsAg-positive patients, although elevations were low grade. HBV coinfection was associated with an adjusted 2.04 (95% CI 0.59-3.49) cells/mm(3)/month smaller CD4 cell increase; there was no significant effect on BMI changes. After a median of 9 months of ART, 64/66 (97.0%) patients showed detectable HBV-DNA (median 3.3 log(10) IU/mL; IQR 2.6-6.2); 12/53 (22.6%) of these showed lamivudine-associated resistance mutations. CONCLUSIONS HIV/HBV-coinfected Ghanaians tolerated first-line ART well, but experienced blunted CD4 cell responses. There was evidence of ongoing HBV replication, mild but persistent transaminase elevations and emerging lamivudine resistance in a proportion of treated patients, indicating the potential for progressive liver damage.

Multilingual Validation of the Questionnaire for Verifying Stroke-Free Status in West Africa

Background and Purpose— The Questionnaire for Verifying Stroke-Free Status (QVSFS), a method for verifying stroke-free status in participants of clinical, epidemiological, and genetic studies, has not been validated in low-income settings where populations have limited knowledge of stroke symptoms. We aimed to validate QVSFS in 3 languages, Yoruba, Hausa and Akan, for ascertainment of stroke-free status of control subjects enrolled in an on-going stroke epidemiological study in West Africa. Methods— Data were collected using a cross-sectional study design where 384 participants were consecutively recruited from neurology and general medicine clinics of 5 tertiary referral hospitals in Nigeria and Ghana. Ascertainment of stroke status was by neurologists using structured neurological examination, review of case records, and neuroimaging (gold standard). Relative performance of QVSFS without and with pictures of stroke symptoms (pictograms) was assessed using sensitivity, specificity, positive predictive value, and negative predictive value. Results— The overall median age of the study participants was 54 years and 48.4% were males. Of 165 stroke cases identified by gold standard, 98% were determined to have had stroke, whereas of 219 without stroke 87% were determined to be stroke-free by QVSFS. Negative predictive value of the QVSFS across the 3 languages was 0.97 (range, 0.93–1.00), sensitivity, specificity, and positive predictive value were 0.98, 0.82, and 0.80, respectively. Agreement between the questionnaire with and without the pictogram was excellent/strong with Cohen k=0.92. Conclusions— QVSFS is a valid tool for verifying stroke-free status across culturally diverse populations in West Africa.

Inadvertent non-nucleoside reverse transcriptase inhibitor (NNRTI)-based antiretroviral therapy in dual HIV-1/2 and HIV-2 seropositive West Africans: a retrospective study.

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Antibody screening tests variably overestimate the prevalence of hepatitis C virus infection among HIV-infected adults in Ghana

HIV coinfection with HCV has been poorly studied in sub‐Saharan Africa, and the reliability of available seroprevalence estimates remains uncertain. The study aim was to determine HCV RNA prevalence in HIV‐infected subjects receiving care in Kumasi, Ghana, and relate the findings to HCV antibody detection. From a population of 1520 HIV‐infected adults, all HBsAg‐positive subjects (n = 236) and a random subset of HBsAg‐negative subject (n = 172) were screened for HCV RNA using pooled plasma; positive samples were genotyped by core and NS5B sequencing. HCV antibodies were detected by three commercial screening assays and confirmed by the line immunoassay. HCV RNA was detected in 4/408 subjects (1.0%, 95% confidence interval 0.0–1.9%), comprising 3/236 (1.3%; 0.0–2.8%) HBsAg‐positive and 1/172 (0.6%; 0.0–1.8%) HBsAg‐negative subjects. HCV RNA‐positive subjects showed reactivity in all three antibody screening assays. Among HCV RNA‐negative subjects, 5/67 (7.5%), 5/67 (7.5%) and 19/67 (28.4%) showed antibody reactivity by each screening assay, respectively, including two (3.0%) with reactivity by all three assays. Only one sample (1.5%) had confirmed antibody reactivity by line immunoassay indicating past HCV infection. HCV‐positive subjects (three males, two females) were aged 30–46 years, by questionnaire‐based interview reported surgical procedures and blood transfusion as risk factors for infection. HCV genotypes were 2 (subtypes 2j, 2l, 2k/unassigned) and 1 (subtype unassigned). Without further testing, HCV antibody screening assays variably overestimated HCV prevalence among HIV‐infected subjects in Ghana. These findings inform the interpretation of previous seroprevalence estimates based upon screening assays alone.

Variations in hypertension awareness, treatment, and control among Ghanaian migrants living in Amsterdam, Berlin, London, and nonmigrant Ghanaians living in rural and urban Ghana-the RODAM study

Objectives: Hypertension is a major burden among African migrants, but the extent of the differences in prevalence, treatment, and control among similar African migrants and nonmigrants living in different contexts in high-income countries and rural and urban Africa has not yet been assessed. We assessed differences in hypertension prevalence and its management among relatively homogenous African migrants (Ghanaians) living in three European cities (Amsterdam, London, and Berlin) and nonmigrants living in rural and urban Ghana. Methods: A multicenter cross-sectional study was conducted among Ghanaian adults (n = 5659) aged 25–70 years. Comparisons between sites were made using prevalence ratios with adjustment for age, education, and BMI. Results: The age-standardised prevalence of hypertension was 22 and 28% in rural Ghanaian men and women. The prevalence was higher in urban Ghana [men, 34%; adjusted prevalence ratio = 1.37, 95% confidence interval (CI), 1.10–1.70]; and much higher in migrants in Europe, especially in Berlin (men, 57%; prevalence ratio = 2.21, 1.78–2.73; women, 51%; prevalence ratio = 1.74, 1.45–2.09) than in rural Ghana. Hypertension awareness and treatment levels were higher in Ghanaian migrants than in nonmigrant Ghanaians. However, adequate hypertension control was lower in Ghanaian migrant men in Berlin (20%; prevalence ratio = 0.43 95%, 0.23–0.82), Amsterdam (29%; prevalence ratio = 0.59, 0.35–0.99), and London (36%; prevalence ratio = 0.86, 0.49–1.51) than rural Ghanaians (59%). Among women, no differences in hypertension control were observed. About 50% of migrants to 85% of rural Ghanaians with severe hypertension (Blood pressure > 180/110) were untreated. Antihypertensive medication prescription patterns varied considerably by site. Conclusion: Hypertension prevalence, awareness, and treatment levels were generally higher in African migrants, but blood pressure control level was lower in Ghanaian migrant men compared with their nonmigrant peers. Further work is needed to identify key underlying factors to support prevention and management efforts. Supplement Figure 1, http://links.lww.com/HJH/A831.