Rita Isaac

Incident depression symptoms are associated with poorer HAART adherence: a longitudinal analysis from the Nutrition for Healthy Living Study.

Objective:To determine the relationship between incident depression symptoms and suboptimal adherence to HIV highly active antiretroviral therapy (HAART). Methods:Participants in a cohort study of persons with HIV on HAART with at least 4 consecutive semiannual study visits were included (n = 225). Incident depression was defined as having 2 visits with a negative depression screening test followed by 2 visits with a positive test. Comparison group participants had 4 consecutive visits with a negative depression screening test. Suboptimal adherence was defined as missing >5% of HAART doses in the past 7 days. We compared suboptimal adherence rates in those with and without incident depression symptoms and estimated the relative risk and 95% confidence intervals of suboptimal adherence at visit 4 in those adherent at baseline (n = 177), controlling for sociodemographic, behavioral, and clinical variables. Results:Twenty-two percent developed depression symptoms. Those developing depression symptoms had higher rates of suboptimal adherence at follow-up (45.1% vs. 25.9%, P < 0.01). Among those with optimal baseline adherence, those with incident depression were nearly 2 times more likely to develop suboptimal adherence (Adjusted relative risk =1.8, 95% confidence interval =1.1 to 3.0) at follow-up. Conclusion:Incident depression symptoms were associated with subsequent suboptimal HAART adherence. Ongoing aggressive screening for, and treatment of, depression may improve HAART outcomes.

Risk factors for otitis media among preschool, rural Indian children

OBJECTIVE To establish the role of various risk factors for otitis media among preschool, rural Indian children. METHODS A cross sectional study of 800 children was undertaken to determine the prevalence of otitis media. Thereafter, using a case control study design, all the cases and an equal number of controls were compared in terms of various common risk factors for otitis media. The 13 risk factors studied were age, sex, socioeconomic status (SES), nutritional status, balwadi attendance, duration of breast feeding, passive smoking, exposure to household smoke, persistent rhinorrhoea,positive throat culture, snoring, seasonal rhinitis and allergic rhinitis. Bivariate association between these risk factors and otitis media was studied using chi-square test of proportions. Multivariate logistic regression analysis was done by including the variables which were significant at p=0.35 in the bivariate analysis. RESULTS From the cross sectional study, the prevalence of otitis media was found to be 8.6%, roughly half the prevalence obtained 10 years previously from the same region. Otitis media with effusion (OME) was the commonest manifestation of otitis media (6%) with 3.8% having bilateral disease. Ear wax was seen in 27.5% of subjects. Eighteen (2.3%) children failed the screening audiometry test set at 40 dB HL. Sociodemographic factors among cases and controls were comparable. The prime risk factors for otitis media identified by bivariate analysis included persistent rhinorrhoea, snoring and seasonal rhinitis. On multivariate logistic regression analysis, persistent rhinorrhoea (p<0.01,O.R.=7.56, 95%C.I. 2.73 - 20.92), snoring (p=0.01,O.R.=4.89, 95% C.I.1.32 - 18.17), seasonal rhinitis(p=0.02, OR=5.93,95% CI=1.33-26.51) and passive smoking (p=0.04, O.R.=3.29, 95%C.I. 1.05-10.33) were found to be important risk factors for otitis media. Age, sex, SES, parental education, seasonal or allergic rhinitis, inadequate breast feeding and exposure to household smoke were not significant risk factors. CONCLUSIONS Otitis media continues to have a high prevalence among South Indian children. Persistent rhinorrhea, snoring, seasonal rhinitis and passive smoking are the chief risk factors for the disease. Measures to reduce the prevalence of otitis media by addressing these risk factors are urgently required.

Metabolic Syndrome Predicts All-Cause Mortality in Persons with Human Immunodeficiency Virus

We examined the association between metabolic syndrome (MS) and its individual defining criteria on all-cause mortality in human immunodeficiency virus (HIV)-infected persons. We used data from 567 HIV-infected participants of the Nutrition for Healthy Living study with study visits between 9/1/2000 and 1/31/2004 and determined mortality through 12/31/2006. MS was defined using modified National Cholesterol Education Program guidelines. Cox proportional hazards for all-cause mortality were estimated for baseline MS status and for its individual defining criteria. There were 83 deaths with median follow-up of 63 months. Baseline characteristics associated with increased risk of mortality were: older age in years (univariate hazard ratio [HR] 1.04, p<0.01), current smoking (HR 1.99, p=0.02), current heroin use (HR 1.97, p=0.02), living in poverty (HR 2.0, p<0.01), higher mean HIV viral load (HR 1.81, p<0.01), and having a BMI <18 (HR 5.84, p<0.01). For MS and its criteria, only low HDL was associated with increased risk of mortality on univariate analysis (HR 1.84, p=0.01). However, metabolic syndrome (adjusted HR 2.31, p=0.02) and high triglycerides (adjusted HR 3.97, p<0.01) were significantly associated with mortality beyond 36 months follow-up. MS, low HDL, and high triglycerides are associated with an increased risk of mortality in HIV-infected individuals.

Knowledge, attitudes and practices with respect to risk factors for otitis media in a rural South Indian community

OBJECTIVES (a) To study knowledge, attitudes and practices with respect to risk factors of otitis media in a rural South Indian Community where the prevalence of otitis media is high. (b) To discover the association between parental education, socioeconomic status (SES) and family type (nuclear or joint) with knowledge, attitudes and practices regarding risk factors for otitis media. METHODS Using a cluster sampling design, the caregivers of 150 children attending daycare were interviewed to note knowledge, attitudes and practices with respect to risk factors for otitis media. Data on level of education of the caregiver, house type (an indicator of SES) and type of family structure were noted. A questionnaire was administered to collect all the relevant data. Statistical analysis of the data obtained was performed to note frequencies. Correlations between sociodemographic parameters and knowledge, attitudes and practices were studied using Chi-square test of proportions. RESULTS Over 50% of the population showed knowledge deficits with regard to the various risk factors for otitis media. Caregivers from nuclear families were slightly less knowledgeable regarding lack of immunization and household smoke as risk factors for the disease. There was no correlation between any of the sociodemographic factors and attitudes. However, educated mothers were more likely than illiterate mothers to clean their childrens ears of wax on a regular basis with the belief that it would prevent ear disease (p=0.05). Treatment practices in the community were more or less uniform in that earache was either disregarded (26.4%) or treated with home remedies (67.2%) by most caregivers, while a doctors opinion was often sought for ear discharge (50%). Parents of higher SES were more likely to use home remedies than those of lower SES (p=0.008). CONCLUSIONS Sociodemographic factors as well as poor knowledge and attitudes and unhealthy practices with respect to risk factors of otitis media contribute to the high prevalence of otitis media in this rural South Indian community. Health education regarding risk factors and provision of accessible health care is essential to reduce the disease burden.

Knowledge, Beliefs, and Health Care Practices Relating to Treatment of HIV in Vellore, India

In India, little is known about health care-seeking behavior among HIV-infected individuals. Similarly, little is known about how HIV is being treated in the community, in particular by Indian Systems of Medicine (ISM) providers. Therefore, while ART implementation programs continue to expand, it is important to determine whether the knowledge, attitudes, and treatment practices of HIV-infected individuals and their health care providers are aligned with current treatment recommendations. We conducted in-depth qualitative interviews with persons with HIV (n = 9 men and 17 women), family members of persons with HIV (n = 14 men and 3 women), and ISM providers (n = 7). Many of the patients we studied turned at some point to ISM providers because they believed that such practitioners offer a cure for HIV. ISM treatments sometimes had negative impacts including side effects, unchecked progression of an underlying illness, and financial depletion. Indian women tended to be less knowledgeable about HIV and HIV treatments, and had less access to financial and other resources, than men. Finally, most of the ISM providers reported dangerous misconceptions about HIV transmission, diagnosis, and treatment. While the existence of ART in India is potentially of great benefit to those with HIV infection, this study shows that a variety of social, cultural and governmental barriers may interfere with the effective use of these therapies. Partnerships between the allopathic and traditional/complementary health sectors in research, policy, and practice are essential in building comprehensive HIV/AIDS treatment strategies.

Infection Surveillance Protocol for a Multicountry Population-based Study in South Asia to Determine the Incidence Etiology and Risk Factors for Infections Among Young Infants of 0 to 59 Days Old.

Background: Insufficient knowledge of the etiology and risk factors for community-acquired neonatal infection in low-income countries is a barrier to designing appropriate intervention strategies for these settings to reduce the burden and treatment of young infant infection. To address these gaps, we are conducting the Aetiology of Neonatal Infection in South Asia (ANISA) study among young infants in Bangladesh, India and Pakistan. The objectives of ANISA are to establish a comprehensive surveillance system for registering newborns in study catchment areas and collecting data on bacterial and viral etiology and associated risk factors for infections among young infants aged 0–59 days. Methods: We are conducting active surveillance in 1 peri-urban and 4 rural communities. During 2 years of surveillance, we expect to enroll an estimated 66,000 newborns within 7 days of their birth and to follow-up them until 59 days of age. Community health workers visit each young infant in the study area 3 times in the first week of life and once a week thereafter. During these visits, community health workers assess the newborns using a clinical algorithm and refer young infants with signs of suspected infection to health care facilities where study physicians reassess them and provide care if needed. On physician confirmation of suspected infection, blood and respiratory specimens are collected and tested to identify the etiologic agent. Conclusions: ANISA is one of the largest initiatives ever undertaken to understand the etiology of young infant infection in low-income countries. The data generated from this surveillance will help guide evidence-based decision making to improve health care in similar settings.

Declines in dietary macronutrient intake in persons with HIV infection who develop depression.

BACKGROUND The effect of depression on dietary intake has not, to our knowledge, been examined in persons with HIV infection. METHODS We conducted a longitudinal analysis of participants in the Nutrition for Healthy Living Study (NFHL). We measured changes in dietary macronutrient intake in participants who developed depression and, using multiple regression analysis, compared the changes with a control group of patients who did not become depressed. RESULTS Ninety patients developed depression during the observation period, and we compared these with 152 non-depressed controls. The two groups had similar age and body mass index (BMI) at baseline, but those who developed depression were more likely to be female, less educated and had lower incomes. After adjustment, compared with non-depressed participants, those who developed depression had significantly greater decreases in the following daily intakes: total energy (-341 kcal, P = 0.006), protein (-12.3 g, P = 0.02), total fat (-18.5 g, P = 0.008), carbohydrate (-36.8 g, P = 0.02), total fibre (-4.3 g, P = 0.001) and saturated fat (-6.7 g, P = 0.01). There were no significant differences in the daily intakes of simple sugars and long-chain n-3 fatty acids, or BMI. CONCLUSION Depression is associated with decreases in total daily energy intake and in six of the eight dietary components we measured. Clinicians should be aware that depression-associated nutritional deficiencies may complicate the care of persons with HIV.

Community perception of child drowning in South India: a qualitative study

Abstract Background: World-wide, drowning is one of the leading causes of death in children between 1 and 12 years of age, especially in low- and middle-income countries. Aim: To assess the communitys perceptions of the common causes of death in children, the level of awareness of drowning as a major cause and the reasons for the high rate of drowning, and to discuss preventive measures. Method: Five focus group discussions were conducted with representatives from five different categories of people in the community. The groups included health aides, extension workers and part-time community health workers in the peripheral health care team of the Department of Community Health, Christian Medical College, Vellore and land owners/village leaders. The data were analysed using content analysis to detect themes and trends. Results: Drowning was not perceived as a major cause of childhood death. Unprotected bodies of water was acknowledged as a reason for the high rate of drowning. The groups suggested some preventive measures including intensive education on the causes of drowning, the introduction of more balwadis (day nurseries) in the villages, and the identification of resources to protect open bodies of water. Conclusions: There is an urgent need among rural communities to create awareness of the high rate of drowning in children and to motivate and facilitate individuals, communities, organisations and government agencies to make the communities safer for children.

Malabsorption in wasting HIV disease: diagnostic and management issues in resource-poor settings.

In resource-poor countries with limited access to highly active antiretroviral therapy (HAART), the number of people dying from AIDS is expanding rapidly. The alarming death rates are a consequence of the combined effects of opportunistic infections, malnutrition and wasting in HIV disease. Several studies have shown that weight loss and wasting (usually defined as loss of at least 10% of body weight) is significantly associated with accelerated disease progression and increased mortality in HIV infection. In addition, with significant wasting, affected individuals are unable to carry out their normal activities which may worsen the stigma of already marginalized HIV-infected individuals. A significant risk factor for wasting in HIV disease is intestinal dysfunction and subsequent nutrient malabsorption. Malabsorption causes decreased appetite as a consequence of the ‘enterogastrone’ effects including dry mouth, decreased gastric acid secretion, decreased gastric emptying rate and slowed intestinal transit. Decreased appetite leads to poor intake of food that further jeopardizes maintenance of weight. We wish to draw the attention of clinicians treating HIV-infected individuals to malabsorption as a potential contributory cause of wasting in HIV disease. In HIV disease, the small intestine is typically affected either as a result of opportunistic enteric infections leading to intestinal dysfunction, or due to the direct effects of the HIV virus, causing malabsorption of most nutrients and subsequent wasting. Cryptosporidium, as well as Microsporidia and Isospora, are common opportunistic parasites that may cause serious gastrointestinal infections, intestinal damage and chronic malabsorption. Intestinal opportunistic infections are more common in patients with CD4 counts less than 180 cells/mm. Further studies have shown that fat malabsorption is the most frequent problem in HIV disease (seen in 25–90% of infected people) and the frequency of fat malabsorption increases as the disease progresses. Fat malabsorption impairs utilization of dietary fats which are food with a high calorie density. It causes abdominal symptoms such as diarrhoea and bloating which may further reduce food intake, and may be associated with micronutrient deficiencies from loss of fat-soluble vitamins. Micronutrient deficiencies further contribute to impaired immunity, rapid disease progression and increased mortality. It is imperative to prevent wasting in HIV-infected patients to reduce morbidity and mortality and improve the patient’s quality of life.. In resource rich countries, the physician would have access to sophisticated laboratory investigations to assess intestinal function and be able to administer the most appropriate treatments, whereas in resource-poor settings malabsorption is often not recognized due to the lack of diagnostic facilities. Even without specific diagnostic facilities, it is possible to treat the common causes of malabsorption, maintain energy balance and improve nutritional status by taking into consideration the loss of specific nutrients such as fat-soluble vitamins due to malabsorption. Every episode of diarrhoea should be carefully assessed with a detailed clinical history. If available, simple laboratory tests should be performed on stool samples including: examination for ova, cysts and parasites using wet saline mounts; a formol ether concentration method with Lugol’s iodine for the detection of cysts, ova, trophozoites and larvae of intestinal parasites; and a modified Ziehl-Nielsen staining of stool smears to identify Cryptosporidum parvum and Isospora belli. Nutritional therapy, including aggressive dietary counselling and oral supplements, are the mainstay in the management of wasting associated with HIV. An increase in energy intake of 500 kilocalories above the daily requirements will result in an average gain of 1 lb per week. The recommended dietary allowance of protein for persons aged 25–50 who are in good health is 0.8 g/kg body weight per day. For HIV-infected people with significant wasting, a protein intake up to 1.5 g/kg body weight may be advised. However, Carbonnel et al. demonstrated that what differentiates HIV-infected people with malabsorption from HIV negative patients with malabsorption is their inability to increase energy intake enough to overcome intestinal losses. Thus, an HIV-infected person may appear to consume an adequate amount of calories but still not increase his oral intake sufficiently to overcome intestinal losses. Those patients with inadequate oral intake may benefit from six or more small meals throughout the day, rather than three large ones. For those with diarrhoea, a lactose-free, low fibre, semi-solid diet should be recommended. In order for any person to maintain a stable weight, the energy intake must equal energy losses and total energy expenditure over time. However, HIV-infected patients in resource-poor countries commonly confront difficulties with access to sufficient good food because of financial constraints and poor social support. Issues relating to access to good food and social support should be addressed by individual countries with social and food security schemes for HIV-infected individuals. Micronutrient supplements are believed to protect the integrity of the gastrointestinal epithelia irrespective of whether the damage is caused by enteropathogens, or by HIV disease per se. Zinc plays a crucial role in maintaining the integrity of epithelial cells that line the intestine and preventing diarrhoea in HIV-infected individuals. In conclusion, nutrient malabsorption as a cause of wasting in the context of HIV infection should be addressed with close attention to treatment of opportunistic enteric infections, and to energy intake and weight gain. Addressing the underlying HIV infection and immunosuppression with appropriate antiretroviral therapy will further improve intestinal function, reduce the burden of disease and promote an improved quality of life in HIV-infected individuals.

Translating Evidence into Practice in Low Resource Settings: Cervical Cancer Screening Tests are Only Part of the Solution in Rural India

BACKGROUND The majority of women in rural India have poor or no access to cervical cancer screening services, although one-quarter of all cervical cancers in the world occur there. Several large trials have proven the efficacy of low-tech cervical cancer screening methods in the Indian context but none have documented the necessary components and processes of implementing this evidence in a low-resource setting. METHODS This paper discusses a feasible model of implementation of cervical cancer screening programme in low-resource settings developed through a pilot research project carried out in rural Tamilnadu, India. The programme used visual inspection of cervix after acetic acid application (VIA) as a screening tool, nurses in the primary care centres as the primary screeners and peer educators within Self-Help Women groups to raise community awareness. RESULTS The uptake of screening was initially low despite the access to a screening programme. However, the programme witnessed an incremental increase in the number of women accessing screening with increasing community awareness. CONCLUSIONS The investigators recommend 4 key components to programme implementation in low-resource setting: 1) Evidence-based, cost-effective test and treatment available within the reach of the community; 2) Appropriate referral pathways; 3) Skilled health workers and necessary equipment; and 4) Optimisation of health literacy, beliefs, attitudes of the community.