Tom Heller

Scale-up of a decentralized HIV treatment programme in rural KwaZulu-Natal, South Africa: does rapid expansion affect patient outcomes?

OBJECTIVE To describe the scale-up of a decentralized HIV treatment programme delivered through the primary health care system in rural KwaZulu-Natal, South Africa, and to assess trends in baseline characteristics and outcomes in the study population. METHODS The programme started delivery of antiretroviral therapy (ART) in October 2004. Information on all patients initiated on ART was captured in the programme database and follow-up status was updated monthly. All adult patients (> or = 16 years) who initiated ART between October 2004 and September 2008 were included and stratified into 6-month groups. Clinical and sociodemographic characteristics were compared between the groups. Retention in care, mortality, loss to follow-up and virological outcomes were assessed at 12 months post-ART initiation. FINDINGS A total of 5719 adults initiated on ART were included (67.9% female). Median baseline CD4+ lymphocyte count was 116 cells/microl (interquartile range, IQR: 53-173). There was an increase in the proportion of women who initiated ART while pregnant but no change in other baseline characteristics over time. Overall retention in care at 12 months was 84.0% (95% confidence interval, CI: 82.6-85.3); 10.9% died (95% CI: 9.8-12.0); 3.7% were lost to follow-up (95% CI: 3.0-4.4). Mortality was highest in the first 3 months after ART initiation: 30.1 deaths per 100 person-years (95% CI: 26.3-34.5). At 12 months 23.0% had a detectable viral load (> 25 copies/ml) (95% CI: 19.5-25.5). CONCLUSION Outcomes were not affected by rapid expansion of this decentralized HIV treatment programme. The relatively high rates of detectable viral load highlight the need for further efforts to improve the quality of services.

Poor long-term outcomes for cryptococcal meningitis in rural South Africa

OBJECTIVES To explore linkage to and retention in HIV care after an episode of cryptococcal meningitis (CM) in rural South Africa. Design. A retrospective case series of adult individuals (> or = 16 years old) with laboratory-confirmed CM from January - December 2007 at Hlabisa Hospital--a district hospital in northern KwaZulu-Natal. OUTCOME MEASURES Inpatient mortality and associated risk factors were analysed. The proportion alive and on antiretroviral therapy (ART) at 2 years was determined by linkage to the HIV treatment programme. RESULTS One hundred and four individuals were identified with laboratory diagnosis of CM; 74/104 (71.2%) with complete records were included in the analysis. Inpatient mortality was high (40.5%) and was significantly associated with reduced conscious level (aHR 3.09, 95% CI 1.30 - 7.33) and absence of headache (aHR 0.33 for headache, 95% CI 0.13 - 0.87). Only 8 individuals (10.8% of all study subjects) were alive and receiving ART 2 years after the CM episode. CONCLUSIONS Long-term outcomes of CM are poor in routine practice. Interventions to strengthen linkage to HIV treatment and care and continuation of secondary fluconazole prophylaxis are critical.

Short course for focused assessment with sonography for human immunodeficiency virus/tuberculosis: preliminary results in a rural setting in South Africa with high prevalence of human immunodeficiency virus and tuberculosis.

In Africa, human immunodeficiency virus (HIV)–associated extrapulmonary tuberculosis (TB) is common and poses diagnostic difficulties. Ultrasound is useful to find suggestive signs such as effusions or abdominal lymphadenopathy. Because trained radiologists are scarce in resource-poor settings, even this simple and relatively inexpensive diagnostic tool is frequently unavailable to patients in district hospitals in sub-Saharan Africa. We developed a focused protocol for assessment with sonography for HIV/TB and trained physicians in a rural district hospital in South Africa. In this pilot study, high levels of confidence in identifying specific signs were rapidly achieved and ultrasound was introduced into routine clinical practice.

Abdominal tuberculosis: sonographic diagnosis and treatment response in HIV-positive adults in rural South Africa.

Summary Objective To investigate the diagnostic value of abdominal ultrasound in HIV-positive inpatients in a rural African setting. Methods This was a prospective case series over 3 months of adult HIV-positive patients with symptoms suggestive of abdominal tuberculosis (TB). Diagnostic ultrasound was performed for all patients: sonographic criteria included abdominal lymph node enlargement (>1.5 cm) and focal splenic lesions; ascites was a supportive finding. Further diagnostic studies, e.g., aspiration or biopsy were not routinely performed. TB treatment was initiated on the basis of clinical and sonographic features. The patients were contacted after 4 months to evaluate the clinical outcome. Results One hundred and eighty adult HIV-positive patients were screened; 30 (16.7%) showed sonographic signs of abdominal TB. The median CD4 count was 78 cells/mm3. Presenting symptoms were weight loss (86.7%), abdominal pain (76.7%), and diarrhea (60%). Abdominal lymph node enlargement was the diagnostic finding in almost all cases (96.7%); hypoechoic lesions of the spleen were seen in 50% and ascites in 73.3%. Follow-up information was available for 25 patients: 24% had died and the remaining 76% reported symptomatic improvement and weight gain. Conclusions Characteristic sonographic features of abdominal TB are common in HIV-infected inpatients in a rural African setting. Ultrasound should be introduced into clinical algorithms for the diagnosis of extrapulmonary TB.

Focused assessment with sonography for HIV-associated tuberculosis (FASH): a short protocol and a pictorial review

BackgroundUltrasound can rapidly identify abnormal signs, which in high prevalence settings, are highly suggestive of extra-pulmonary tuberculosis (EPTB). Unfortunately experienced sonographers are often scarce in these settings.MethodsA protocol for focused assessment with sonography for HIV-associated tuberculosis (FASH) which can be used by physicians who are relatively inexperienced in ultrasound was developed.ResultsThe technique as well as normal and pathological findings are described and the diagnostic and possible therapeutic reasoning explained. The protocol is intended for settings where the prevalence of HIV/TB co-infected patients is high.ConclusionFASH is suitable for more rapid identification of EPTB even at the peripheral hospital level where other imaging modalities are scarce and most of the HIV and TB care will be delivered in the future.

Diagnostic value of FASH ultrasound and chest X-ray in HIV-co-infected patients with abdominal tuberculosis.

In human immunodeficiency virus (HIV) co-infected tuberculosis (TB) patients with negative acid-fast bacilli smears, chest radiography (CXR) is usually the first imaging step in the diagnostic work-up. Ultrasound, also in the form of focused assessment with sonography for TB-HIV (FASH), is an additional imaging modality used to diagnose extra-pulmonary TB (EPTB). Findings from 82 patients with abdominal TB diagnosed by ultrasound were analysed and compared with CXR results. Enlarged abdominal lymph nodes were seen in 75.6% of the patients, spleen abscesses in 41.2% and liver lesions in 30.6%. CXR showed a miliary pattern in 21.9% of the patients; 26.8% of the CXR had no radiological changes suggestive of pulmonary TB. This patient group would benefit from ultrasound in diagnostic algorithms for HIV-associated EPTB.In human immunodeficiency virus (HIV) co-infected tuberculosis (TB) patients with negative acid-fast bacilli smears, chest radiography (CXR) is usually the first imaging step in the diagnostic work-up. Ultrasound, also in the form of focused assessment with sonography for TB-HIV (FASH), is an additional imaging modality used to diagnose extra-pulmonary TB (EPTB). Findings from 82 patients with abdominal TB diagnosed by ultrasound were analysed and compared with CXR results. Enlarged abdominal lymph nodes were seen in 75.6% of the patients, spleen abscesses in 41.2% and liver lesions in 30.6%. CXR showed a miliary pattern in 21.9% of the patients; 26.8% of the CXR had no radiological changes suggestive of pulmonary TB. This patient group would benefit from ultrasound in diagnostic algorithms for HIV-associated EPTB.

High uptake of HIV testing for tuberculosis patients in an integrated primary health care HIV/TB programme in rural KwaZulu-Natal

Tuberculosis (TB) is the leading cause of morbidity and mortality in the HIV-infected African population. The need for improved integration of HIV and TB services was highlighted by the World Health Organization (WHO) several years ago, but implementation of recommendations has been slow. HIV testing for TB patients is the gateway for combined HIV and TB treatment, care and prevention yet, in 2007, only 37% of TB patients in the WHO African region were tested for HIV. While some countries reported testing rates above 75%, a testing rate of only 39% was reported in South Africa, the country with the largest burden of HIV/TB co-infection. We describe our efforts to ensure high HIV testing rates in TB patients via an integrated programme at primary health care level in rural KwaZulu-Natal.

Point-of-Care Ultrasound Assessment of Tropical Infectious Diseases—A Review of Applications and Perspectives

The development of good quality and affordable ultrasound machines has led to the establishment and implementation of numerous point-of-care ultrasound (POCUS) protocols in various medical disciplines. POCUS for major infectious diseases endemic in tropical regions has received less attention, despite its likely even more pronounced benefit for populations with limited access to imaging infrastructure. Focused assessment with sonography for HIV-associated TB (FASH) and echinococcosis (FASE) are the only two POCUS protocols for tropical infectious diseases, which have been formally investigated and which have been implemented in routine patient care today. This review collates the available evidence for FASH and FASE, and discusses sonographic experiences reported for urinary and intestinal schistosomiasis, lymphatic filariasis, viral hemorrhagic fevers, amebic liver abscess, and visceral leishmaniasis. Potential POCUS protocols are suggested and technical as well as training aspects in the context of resource-limited settings are reviewed. Using the focused approach for tropical infectious diseases will make ultrasound diagnosis available to patients who would otherwise have very limited or no access to medical imaging.

Tuberculosis pericarditis with cardiac tamponade: management in the resource-limited setting.

We report a case of human immunodeficiency virus–associated pericardial tuberculosis complicated by cardiac tamponade. Emergency management and subsequent therapeutic interventions are described and then discussed with particular focus on resource-limited settings. The paucity of evidence to support clinical decisions is emphasized and the need for well designed diagnostic and therapeutic studies is highlighted.

Chest ultrasonography in patients with HIV: a case series and review of the literature

IntroductionPulmonary disease is common in HIV-infected patients. Diagnostic means, however, are often scarce in areas where most HIV patients are living. Chest ultrasonography has recently evolved as a highly sensitive and specific imaging tool for diagnosing chest conditions such as pneumothorax, pneumonia and pulmonary edema in critically ill patients. This article addresses the issue of imaging and differentiating common pulmonary conditions in HIV-infected patients by chest ultrasonography.MethodsWe report chest ultrasound features of five different common pulmonary diseases in HIV-infected patients (bacterial pneumonia, Pneumocystis jirovecii pneumonia, tuberculosis, cytomegalovirus pneumonia and non-Hodgkin lymphoma) and review the respective literature.ConclusionsWe observed characteristic ultrasound patterns especially in Pneumocystis jirovecii pneumonia and pulmonary lymphoma. Further exploration of chest ultrasonography in HIV-infected patients appears promising and may translate into new diagnostic approaches for pulmonary conditions in patients living with HIV.