People living with HIV (PLHIV) have an increased risk of tuberculosis (TB) and severe COVID-19. TB and COVID-19 present with overlapping symptoms and co-infection can lead to poor outcomes. We assessed the frequency of SARS-CoV-2 positive serology and SARS-CoV-2 infection and the risk of mortality at 6 months in PLHIV with TB disease and SARS-CoV-2 infection. This multi-country, prospective, observational study, conducted between 7th September 2020 and 7th April 2022, included ambulatory adult PLHIV investigated for TB (with symptoms of TB or advanced HIV disease) in Kenya, Uganda, and South Africa. Testing included CD4 cell count, Xpert MTB/RIF Ultra assay (sputum), Determine TB LAM Ag assay (urine), chest X-ray, blood SARS-CoV-2 serology test and SARS-CoV-2 PCR (only if TB or COVID-19 symptoms). Individuals were followed for 6 months. Among 1254 participants, 1204 participants had SARS-CoV-2 serology (54% women, median CD4 344 cells/µL [IQR 132–673]), and 487 had SARS-CoV-2 PCR. SARS-CoV-2 serology positivity was 27.0% (325/1204), lower in PLHIV with CD4 counts <200 cells/µL (19.9%, 99/497) than in those with CD4 counts ≥200 cells/µL (31.6%, 222/703), p<0.001. SARS-CoV-2 PCR positivity was 8.6% (42/487) and 27.7% (135/487) had probable or confirmed SARS-CoV-2 infection. Among PLHIV with symptoms of TB or of COVID-19, 6.6% (32/487) had SARS-CoV-2 infection and TB disease. In multivariable analyses, the risk of death was higher in PLHIV with both SARS-CoV-2 infection and TB compared to those with only SARS-CoV-2 infection (adjusted hazard ratio [aHR] 8.90, 95%CI 1.47-53.96, p=0.017), with only TB (aHR 3.70, 95%CI 1.00-13.72, p=0.050) or with none of them (aHR 6.83, 95%CI 1.75-26.72, p=0.006). These findings support SARS-CoV-2 testing in PLHIV with symptoms of TB, and SARS-CoV-2 vaccination, especially for those with severe immunosuppression. PLHIV with COVID-19 and TB have an increased risk of mortality and would benefit from comprehensive management and close monitoring.
Early psychosocial stimulation for infants in precarious situations can yield both short- and long-term benefits to cognitive and social development. Comprehensive programmes, covering health, nutrition, and psychosocial stimulation prove most effective in preventing cognitive impairment and enhancing treatment for children with severe acute malnutrition (SAM). The StimNut study assesses the effects of early psychosocial stimulation on maternal mental health and mother-child relationship, as well as the acceptability of integrating such an intervention into the existing Médecins Sans Frontières (MSF) nutrition programme in Koutiala, during a 5-week period.
METHODS
Mixed-methods data were collected through standardised pre- and post- intervention questionnaires and included: a ‘Dusukasi’ screening tool for local perinatal depression-like symptoms; observations of mother-child interactions using an adapted PICCOLO (Parenting Interactions with Children: Checklist of Observations Linked to Outcomes) tool; as well as semi-structured interviews with caregivers, MSF psychosocial workers, and healthcare staff.
RESULTS
149 psychosocial stimulation sessions were conducted with 36 families by three supervised MSF psychosocial workers. Perinatal depression symptoms were found in 53% of mothers before the intervention and 28% after the intervention (p=0.001). Positive changes in the mother-child relationship were observed in 83% of families after the 5-week intervention and more frequent and appropriate responses of the caregivers to the child’s emotional state were noted. Positive changes were also perceived by the mothers as the sessions progressed: their sense of parenting skills was strengthened, their children’s health improved, and the other family members became more involved in childcare practices. The intervention also dismantled healthcare staff prejudices towards mothers of children with SAM, fostering a trusting relationship between them.
CONCLUSIONS
This study demonstrates the positive impact of the early psychosocial stimulation of children with SAM on maternal mental health and the quality of mother-child relationship. As MSF pursues further endeavours in this direction, it is important to recognise the transformative potential these interventions hold for promoting the overall wellbeing of families of children with SAM in humanitarian and low-income countries.
Evidence on the acceptability of urine-based assays for tuberculosis (TB) diagnosis among patients remains limited. We sought to describe patients’ experiences and perceptions of urine sampling for TB testing at point of care.
SETTING
Study sites in Kenya, Uganda, Mozambique and South Africa.
PARTICIPANTS
Adult ambulatory HIV patients enrolled in a TB diagnostic study were selected purposively.
INTERVENTION
For this qualitative descriptive study, audiorecorded individual interviews conducted with consenting participants were translated, transcribed and analysed using content analysis. Ethical agreement was obtained from relevant ethical review committees.
RESULTS
Fifty-eight participants were interviewed. Three domains were identified. Overall, participants described urine sampling as easy, rapid and painless, with the main challenge being lacking the urge. Urine was preferred to sputum sampling in terms of simplicity, comfort, stigma reduction, convenience and practicality. While perceptions regarding its trustworthiness for TB diagnosis differed, urine sampling was viewed as an additional mean to detect TB and beneficial for early diagnosis. Participants were willing to wait for several hours for same-day results to allay the emotional, physical and financial burden of having to return to collect results, and would rather not pay for the test. Facilitators of urine sampling included cleanliness and perceived privacy of sampling environments, comprehensive sampling instructions and test information, as well as supplies such as toilet paper and envelopes ensuring confort and privacy when producing and returning samples. Participants motivation for accepting urine-based TB testing stemmed from their perceived susceptibility to TB, the value they attributed to their health, especially when experiencing symptoms, and their positive interactions with the medical team.
CONCLUSIONS
This study suggests that urine sampling is well accepted as a TB diagnostic method and provides insights on how to promote patients’ uptake of urine-based testing and improve their sampling experiences. These results encourage the future broad use of urine-based assays at point of care.
Early psychosocial stimulation with disadvantaged infants can lead to short- and long-term benefits in cognitive and social development. Programs with multiple
components, including health, nutrition, and psychosocial stimulation have shown to be the most successful at enhancing the rehabilitation of severe acute malnourished (SAM) children. The STIMNUT study assesses the feasibility of integrating an adapted version of the ‘Follow-Up of Severe Acute Malnourished children’ (FUSAM) protocol developed by Action Contre la Faim into the Médecins Sans Frontières (MSF) Therapeutic Feeding Programme in Koutiala (Mali) for SAM children aged 6-23 months and their primary caregivers.
METHODS
A convergent mixed methods study was implemented between July 2022 and May 2023 in two outpatient health facilities and the general hospital in Koutiala. An adaptation of the PRECEDE-PROCEED conceptual framework was used to adapt, implement and evaluate the psychosocial stimulation intervention. The study was
divided into 3 successive phases: (1) a mixed methods initial assessment at community level, (2) the contextual adaptation of the FUSAM protocol through a participatory approach (PAR) and (3) an assessment of its acceptability. For this assessment, 15 individual interviews with mothers were conducted. Qualitative and quantitative data were analyzed and interpreted concurrently.
RESULTS
During the PAR process, various stakeholders including, development workers and health professionals, parents of SAM children and traditional healers, worked together to practically adapt the intervention. They proposed for instance to include a community-level ceremony at the beginning of the intervention with traditional authorities, villages chiefs and other local stakeholders to increase its appropriation and to sensitize community members. During phase 3, a total of 149 psychosocial stimulation sessions (122 individual and 27 collective) were delivered by a team of 3 psychosocial workers to the 36 families included. The preliminary acceptability results showed that the sessions were well appreciated by the mothers. They became more acceptable as the intervention progressed because of the resulting positive changes in their children’s wellbeing, in theirs and their families’ relationship with their children, and in the mothers' relationships with their husbands and extended family.
CONCLUSION
The implementation of the adapted version of FUSAM protocol and its acceptability assessment at primary and secondary health care levels will now be used to inform the further deployment of the intervention. In particular, the results have allowed the development of a framework for the StimNut intervention to make it locally relevant and to guide its reproducibility in other contexts.
KEY MESSAGE
StimNut is a mixed method feasibility study on the integration of a psychosocial stimulation intervention into the standard nutritional care for SAM children aged 6-23 months In Koutiala, Mali.
This abstract is not to be quoted for publication.
Development of rapid biomarker-based tests that can diagnose tuberculosis using non-sputum samples is a priority for tuberculosis control. We aimed to compare the diagnostic accuracy of the novel Fujifilm SILVAMP TB LAM (FujiLAM) assay with the WHO-recommended Alere Determine TB-LAM Ag test (AlereLAM) using urine samples from HIV-positive patients.
METHODS
We did a diagnostic accuracy study at five outpatient public health facilities in Uganda, Kenya, Mozambique, and South Africa. Eligible patients were ambulatory HIV-positive individuals (aged ≥15 years) with symptoms of tuberculosis irrespective of their CD4 T-cell count (group 1), and asymptomatic patients with advanced HIV disease (CD4 count <200 cells per μL, or HIV clinical stage 3 or 4; group 2). All participants underwent clinical examination, chest x-ray, and blood sampling, and were requested to provide a fresh urine sample, and two sputum samples. FujiLAM and AlereLAM urine assays, Xpert MTB/RIF Ultra assay on sputum or urine, sputum culture for Mycobacterium tuberculosis, and CD4 count were systematically carried out for all patients. Sensitivity and specificity of FujiLAM and AlereLAM were evaluated against microbiological and composite reference standards.
FINDINGS
Between Aug 24, 2020 and Sept 21, 2021, 1575 patients (823 [52·3%] women) were included in the study: 1031 patients in group 1 and 544 patients in group 2. Tuberculosis was microbiologically confirmed in 96 (9·4%) of 1022 patients in group 1 and 18 (3·3%) of 542 patients in group 2. Using the microbiological reference standard, FujiLAM sensitivity was 60% (95% CI 51–69) and AlereLAM sensitivity was 40% (31–49; p<0·001). Among patients with CD4 counts of less than 200 cells per μL, FujiLAM sensitivity was 69% (57–79) and AlereLAM sensitivity was 52% (40–64; p=0·0218). Among patients with CD4 counts of 200 cells per μL or higher, FujiLAM sensitivity was 47% (34–61) and AlereLAM sensitivity was 24% (14–38; p=0·0116). Using the microbiological reference standard, FujiLAM specificity was 87% (95% CI 85–89) and AlereLAM specificity was 86% (95 CI 84–88; p=0·941). FujiLAM sensitivity varied by lot number from 48% (34–62) to 76% (57–89) and specificity from 77% (72–81) to 98% (93–99).
INTERPRETATION
Next-generation, higher sensitivity urine-lipoarabinomannan assays are potentially promising tests that allow rapid tuberculosis diagnosis at the point of care for HIV-positive patients. However, the variability in accuracy between FujiLAM lot numbers needs to be addressed before clinical use.