Journal Article > CommentaryFull Text
Trop Med Int Health. 2011 August 10; Volume 16 (Issue 11); DOI:10.1111/j.1365-3156.2011.02863.x
Tayler-Smith K, Zachariah R, Manzi M, Kizito W, Vandenbulcke A, et al.
Trop Med Int Health. 2011 August 10; Volume 16 (Issue 11); DOI:10.1111/j.1365-3156.2011.02863.x
Journal Article > LetterFull Text
Trop Med Int Health. 2013 May 30; Volume 18 (Issue 8); DOI:10.1111/tmi.12133
Zachariah R, Reid AJ, Van der Bergh R, Dahmane A, Kosgei RJ, et al.
Trop Med Int Health. 2013 May 30; Volume 18 (Issue 8); DOI:10.1111/tmi.12133
Journal Article > ResearchFull Text
Trop Med Int Health. 2017 December 15; Volume 23 (Issue 3); DOI:10.1111/tmi.13025
Bedell RA, van Lettow M, Meaney C, Corbett EL, Chan AK, et al.
Trop Med Int Health. 2017 December 15; Volume 23 (Issue 3); DOI:10.1111/tmi.13025
BACKGROUND:
C-reactive protein (CRP) is an inflammatory biomarker that may identify patients at risk of infections or death. Mortality among HIV-infected persons commencing antiretroviral therapy (ART) is often attributed to tuberculosis (TB) or bloodstream infections (BSI).
METHODS:
In two district hospitals in southern Malawi, we recruited HIV-infected adults with one or more unexplained symptoms present for at least one month (weight loss, fever or diarrhoea) and negative expectorated sputum microscopy for TB. CRP determination for 452 of 469 (96%) participants at study enrolment was analysed for associations with TB, BSI or death to 120 days post-enrolment.
RESULTS:
Baseline CRP was significantly elevated among patients with confirmed or probable TB (52), BSI (50) or death (60) compared to those with no identified infection who survived at least 120 days (269). A CRP value of >10 mg/L was associated with confirmed or probable TB (adjusted odds ratio 5.7; 95% CI 2.6, 14.3; 87% sensitivity) or death by 30 days (adjusted odds ratio 9.2; 95% CI 2.2, 55.1; 88% sensitivity). CRP was independently associated with TB, BSI or death, but the prediction of these endpoints was enhanced by including haemoglobin (all outcomes), CD4 count (BSI, death) and whether ART was started (death) in logistic regression models.
CONCLUSION:
High CRP at the time of ART initiation is associated with TB, BSI and early mortality and so has potential utility for stratifying patients for intensified clinical and laboratory investigation and follow-up. They may also be considered for empirical treatment of opportunistic infections including TB.
C-reactive protein (CRP) is an inflammatory biomarker that may identify patients at risk of infections or death. Mortality among HIV-infected persons commencing antiretroviral therapy (ART) is often attributed to tuberculosis (TB) or bloodstream infections (BSI).
METHODS:
In two district hospitals in southern Malawi, we recruited HIV-infected adults with one or more unexplained symptoms present for at least one month (weight loss, fever or diarrhoea) and negative expectorated sputum microscopy for TB. CRP determination for 452 of 469 (96%) participants at study enrolment was analysed for associations with TB, BSI or death to 120 days post-enrolment.
RESULTS:
Baseline CRP was significantly elevated among patients with confirmed or probable TB (52), BSI (50) or death (60) compared to those with no identified infection who survived at least 120 days (269). A CRP value of >10 mg/L was associated with confirmed or probable TB (adjusted odds ratio 5.7; 95% CI 2.6, 14.3; 87% sensitivity) or death by 30 days (adjusted odds ratio 9.2; 95% CI 2.2, 55.1; 88% sensitivity). CRP was independently associated with TB, BSI or death, but the prediction of these endpoints was enhanced by including haemoglobin (all outcomes), CD4 count (BSI, death) and whether ART was started (death) in logistic regression models.
CONCLUSION:
High CRP at the time of ART initiation is associated with TB, BSI and early mortality and so has potential utility for stratifying patients for intensified clinical and laboratory investigation and follow-up. They may also be considered for empirical treatment of opportunistic infections including TB.
Journal Article > ResearchFull Text
Trop Med Int Health. 2010 December 1; Volume 15 (Issue 12); DOI:10.1111/j.1365-3156.2010.02649.x
Bemelmans M, van den Akker T, Ford NP, Philips M, Zachariah R, et al.
Trop Med Int Health. 2010 December 1; Volume 15 (Issue 12); DOI:10.1111/j.1365-3156.2010.02649.x
Objective To describe how district-wide access to HIV/AIDS care was achieved and maintained in Thyolo District, Malawi. Method In mid-2003, the Ministry of Health and Médecins Sans Frontières developed a model of care for Thyolo district (population 587 455) based on decentralization of care to health centres and community sites and task shifting. Results After delegating HIV testing and counseling to lay counsellors, uptake of testing increased from 1300 tests per month in 2003 to 6500 in 2009. Shifting responsibility for antiretroviral therapy (ART) initiations to non-physician clinicians almost doubled ART enrolment, with a majority of initiations performed in peripheral health centres. By the end 2009, 23 261 people had initiated ART of whom 11 042 received ART care at health-centre level. By the end of 2007, the universal access targets were achieved, with nearly 9000 patients alive and on ART. The average annual cost for achieving these targets was €2.6 per inhabitant/year. Conclusion The Thyolo programme has demonstrated the feasibility of district-wide access to ART in a setting with limited resources for health. Expansion and decentralization of HIV/AIDS service-capacity to the primary care level, combined with task shifting, resulted in increased access to HIV services with good programme outcomes despite staff shortages.
Journal Article > ResearchFull Text
Int J STD AIDS. 2003 March 1; Volume 14 (Issue 3); DOI:10.1258/095646203762869197
Zachariah R, Spielmann M P, Harries AD, Nkhoma W, Chantulo A, et al.
Int J STD AIDS. 2003 March 1; Volume 14 (Issue 3); DOI:10.1258/095646203762869197
In Thyolo District, Malawi, a study was conducted among commercial sex workers (CSWs) attending mobile clinics in order to; determine the prevalence and pattern of sexually transmitted infections (STIs), describe sexual behaviour among those who have an STI and identify risk factors associated with 'no condom use'. There were 1817 CSWs, of whom 448 (25%) had an STI. Of these, the commonest infections included 237 (53%) cases of abnormal vaginal discharge, 109 (24%) cases of pelvic inflammatory disease and 95 (21%) cases of genital ulcer disease (GUD). Eighty-seven per cent had sex while symptomatic, 17% without condoms. Having unprotected sex was associated with being married, being involved with commercial sex outside a known rest-house or bar, having a GUD, having fewer than two clients/day, alcohol intake and having had no prior medication for STI. The high levels of STIs, particularly GUDs, and unprotected sex underlines the importance of developing targeted interventions for CSWs and their clients.
Journal Article > CommentaryFull Text
Trop Med Int Health. 2010 June 1; Volume 15; DOI:10.1111/j.1365-3156.2010.02506.x
Harries AD, Zachariah R, Lawn SD, Rosen S
Trop Med Int Health. 2010 June 1; Volume 15; DOI:10.1111/j.1365-3156.2010.02506.x
The scale-up of antiretroviral therapy (ART) has been one of the success stories of sub-Saharan Africa, where coverage has increased from about 2% in 2003 to more than 40% 5 years later. However, tempering this success is a growing concern about patient retention (the proportion of patients who are alive and remaining on ART in the health system). Based on the personal experience of the authors, 10 key interventions are presented and discussed that might help to improve patient retention. These are (1) the need for simple and standardized monitoring systems to track what is happening, (2) reliable ascertainment of true outcomes of patients lost to follow-up, (3) implementation of measures to reduce early mortality in patients both before and during ART, (4) ensuring uninterrupted drug supplies, (5) consideration of simple, non-toxic ART regimens, (6) decentralization of ART care to health centres and the community, (7) a reduction in indirect costs for patients particularly in relation to transport to and from clinics, (8) strengthening links within and between health services and the community, (9) the use of ART clinics to deliver other beneficial patient or family-orientated packages of care such as insecticide-treated bed nets, and (10) innovative (thinking 'out of the box') interventions. High levels of retention on ART are vital for individual patients, for credibility of programmes and for on-going resource and financial support.
Journal Article > ResearchFull Text
Trans R Soc Trop Med Hyg. 2006 January 1; Volume 100 (Issue 1); DOI:10.1016/j.trstmh.2005.06.018
Zachariah R, Teck R, Ascurra O, Humblet P, Harries AD
Trans R Soc Trop Med Hyg. 2006 January 1; Volume 100 (Issue 1); DOI:10.1016/j.trstmh.2005.06.018
Malawi offers antiretroviral treatment (ART) to all HIV-positive adults who are clinically classified as being in WHO clinical stage III or IV without 'universal' CD4 testing. This study was conducted among such adults attending a rural district hospital HIV/AIDS clinic (a) to determine the proportion who have CD4 counts >or=350 cells/microl, (b) to identify risk factors associated with such CD4 counts and (c) to assess the validity and predictive values of possible clinical markers for CD4 counts >or=350 cells/microl. A CD4 count >or=350 cells/microl was found in 36 (9%) of 401 individuals who are thus at risk of being placed prematurely on ART. A body mass index (BMI) >22 kg/m(2), the absence of an active WHO indicator disease at the time of presentation for ART, and a total lymphocyte count >1,200 cells/microl were significantly associated with such a CD4 count. The first two of these variables could serve as clinical markers for selecting subgroups of patients who should undergo CD4 testing. In a resource-limited district setting, assessing the BMI and checking for active opportunistic infections are routine clinical procedures that could be used to target CD4 measurements, thereby minimising unnecessary CD4 measurements, unnecessary (too early) treatment and costs.
Journal Article > ResearchFull Text
Trans R Soc Trop Med Hyg. 2009 September 23; Volume 104 (Issue 2); DOI:10.1016/j.trstmh.2009.08.012
Harries K, Zachariah R, Manzi M, Firmenich P, Mathela R, et al.
Trans R Soc Trop Med Hyg. 2009 September 23; Volume 104 (Issue 2); DOI:10.1016/j.trstmh.2009.08.012
In an urban district hospital in Burkina Faso we investigated the relative proportions of HIV-1, HIV-2 and HIV-1/2 among those tested, the baseline sociodemographic and clinical characteristics, and the response to and outcome of antiretroviral therapy (ART). A total of 7368 individuals (male=32%; median age=34 years) were included in the analysis over a 6 year period (2002-2008). The proportions of HIV-1, HIV-2 and dual infection were 94%, 2.5% and 3.6%, respectively. HIV-1-infected individuals were younger, whereas HIV-2-infected individuals were more likely to be male, have higher CD4 counts and be asymptomatic on presentation. ART was started in 4255 adult patients who were followed up for a total of 8679 person-years, during which time 469 deaths occurred. Mortality differences by serotype were not statistically significant, but were generally worse for HIV-2 and HIV-1/2 after controlling for age, CD4 count and WHO stage. Among severely immune-deficient patients, mortality was higher for HIV-2 than HIV-1. CD4 count recovery was poorest for HIV-2. HIV-2 and dually infected patients appeared to do less well on ART than HIV-1 patients. Reasons may include differences in age at baseline, lower intrinsic immune recovery in HIV-2, use of ineffective ART regimens (inappropriate prescribing) by clinicians, and poor drug adherence.
Journal Article > CommentaryFull Text
Public Health Action. 2013 September 21; Volume 3 (Issue 3); DOI:10.5588/pha.13.0066
Harries AD, Kumar AMV, Satyanarayana S, Bissell K, Hinderaker SG, et al.
Public Health Action. 2013 September 21; Volume 3 (Issue 3); DOI:10.5588/pha.13.0066
Journal Article > CommentaryFull Text
Public Health Action. 2014 September 21; Volume 4 (Issue 3); DOI:10.5588/pha.14.0028
Zachariah R, Kumar AMV, Reid A, Van der Bergh R, Isaakidis P, et al.
Public Health Action. 2014 September 21; Volume 4 (Issue 3); DOI:10.5588/pha.14.0028