Journal Article > ResearchFull Text
JAMA. 2008 August 6; Volume 300 (Issue 5); 530-539.; DOI:10.1001/jama.300.5.530
Boulle A, van Cutsem G, Cohen K, Hilderbrand K, Mathee S, et al.
JAMA. 2008 August 6; Volume 300 (Issue 5); 530-539.; DOI:10.1001/jama.300.5.530
CONTEXT
Rifampicin-based antitubercular therapy reduces the plasma concentrations of nevirapine and efavirenz. The virological consequences of these interactions are not well described.
OBJECTIVE
To assess the effectiveness and tolerability of concomitant efavirenz- or nevirapine-based combination antiretroviral therapy and rifampicin-based antitubercular therapy.
DESIGN, SETTING, AND PARTICIPANTS
Cohort analysis of prospectively collected routine clinical data in a community-based South African antiretroviral treatment program. Antiretroviral treatment-naive adults enrolled between May 2001 and June 2006 were included in the analysis, and were followed up until the end of 2006.
INTERVENTIONS
Patients starting antiretroviral therapy with or without concurrent antitubercular therapy received either efavirenz or nevirapine at standard doses. Patients developing tuberculosis while taking antiretroviral therapy that included nevirapine were either changed to efavirenz or continued taking nevirapine.
MAIN OUTCOME MEASURES
Viral load of 400 copies/mL or more after 6, 12, and 18 months of antiretroviral therapy; time to the first viral load of 400 copies/mL or more; time to confirmed virological failure (2 consecutive values > or = 5000 copies/mL); time to death; and time to treatment-limiting toxicity were assessed.
RESULTS
The analysis included 2035 individuals who started antiretroviral therapy with efavirenz (1074 with concurrent tuberculosis) and 1935 with nevirapine (209 with concurrent tuberculosis). There were no differences in time to death or substitution of either antiretroviral drug for toxicity with and without concurrent tuberculosis. Patients starting nevirapine with concurrent tuberculosis were at a higher risk of elevated viral load most notably at 6 months (16.3%; 95% confidence interval [CI], 10.6%-23.5%) than those without tuberculosis (8.3%; 95% CI, 6.7%-10.0%; adjusted odds ratio [OR], 2.1; 95% CI, 1.2-3.4; and in the combined estimate, adjusted OR, 1.7; 95% CI, 1.2-2.6). In the time-to-event analysis of confirmed virological failure (2 consecutive values of > or = 5000 copies/mL), patients starting nevirapine with concurrent tuberculosis developed virological failure sooner (adjusted hazard ratio [HR] 2.2; 95% CI, 1.3-3.7). There were no differences between patients starting efavirenz with and without concurrent tuberculosis (adjusted OR, 1.1; 95% CI, 0.8-1.5 [combined estimate] and adjusted HR, 1.1; 95% CI, 0.6-2.0, respectively). There was no difference in time to virological rebound in patients free of tuberculosis and those developing tuberculosis during follow-up while taking nevirapine (adjusted HR, 1.0; 95% CI, 0.5-2.0) or efavirenz (adjusted HR, 0.8; 95% CI, 0.4-1.7).
CONCLUSION
In this cohort study, virological outcomes were inferior when nevirapine-based antiretroviral therapy was commenced while taking antitubercular treatment (vs without concurrent tuberculosis) but comparable when starting efavirenz-based antiretroviral therapy (vs without concurrent tuberculosis) or when tuberculosis developed while taking established nevirapine- or efavirenz-based therapies.
Rifampicin-based antitubercular therapy reduces the plasma concentrations of nevirapine and efavirenz. The virological consequences of these interactions are not well described.
OBJECTIVE
To assess the effectiveness and tolerability of concomitant efavirenz- or nevirapine-based combination antiretroviral therapy and rifampicin-based antitubercular therapy.
DESIGN, SETTING, AND PARTICIPANTS
Cohort analysis of prospectively collected routine clinical data in a community-based South African antiretroviral treatment program. Antiretroviral treatment-naive adults enrolled between May 2001 and June 2006 were included in the analysis, and were followed up until the end of 2006.
INTERVENTIONS
Patients starting antiretroviral therapy with or without concurrent antitubercular therapy received either efavirenz or nevirapine at standard doses. Patients developing tuberculosis while taking antiretroviral therapy that included nevirapine were either changed to efavirenz or continued taking nevirapine.
MAIN OUTCOME MEASURES
Viral load of 400 copies/mL or more after 6, 12, and 18 months of antiretroviral therapy; time to the first viral load of 400 copies/mL or more; time to confirmed virological failure (2 consecutive values > or = 5000 copies/mL); time to death; and time to treatment-limiting toxicity were assessed.
RESULTS
The analysis included 2035 individuals who started antiretroviral therapy with efavirenz (1074 with concurrent tuberculosis) and 1935 with nevirapine (209 with concurrent tuberculosis). There were no differences in time to death or substitution of either antiretroviral drug for toxicity with and without concurrent tuberculosis. Patients starting nevirapine with concurrent tuberculosis were at a higher risk of elevated viral load most notably at 6 months (16.3%; 95% confidence interval [CI], 10.6%-23.5%) than those without tuberculosis (8.3%; 95% CI, 6.7%-10.0%; adjusted odds ratio [OR], 2.1; 95% CI, 1.2-3.4; and in the combined estimate, adjusted OR, 1.7; 95% CI, 1.2-2.6). In the time-to-event analysis of confirmed virological failure (2 consecutive values of > or = 5000 copies/mL), patients starting nevirapine with concurrent tuberculosis developed virological failure sooner (adjusted hazard ratio [HR] 2.2; 95% CI, 1.3-3.7). There were no differences between patients starting efavirenz with and without concurrent tuberculosis (adjusted OR, 1.1; 95% CI, 0.8-1.5 [combined estimate] and adjusted HR, 1.1; 95% CI, 0.6-2.0, respectively). There was no difference in time to virological rebound in patients free of tuberculosis and those developing tuberculosis during follow-up while taking nevirapine (adjusted HR, 1.0; 95% CI, 0.5-2.0) or efavirenz (adjusted HR, 0.8; 95% CI, 0.4-1.7).
CONCLUSION
In this cohort study, virological outcomes were inferior when nevirapine-based antiretroviral therapy was commenced while taking antitubercular treatment (vs without concurrent tuberculosis) but comparable when starting efavirenz-based antiretroviral therapy (vs without concurrent tuberculosis) or when tuberculosis developed while taking established nevirapine- or efavirenz-based therapies.
Journal Article > LetterSubscription Only
JAMA. 2002 February 20; Volume 287 (Issue 7); 840-843.; DOI:10.1001/jama.287.7.840
Boelaert M, Lynen L, Van Damme W, Colebunders R
JAMA. 2002 February 20; Volume 287 (Issue 7); 840-843.; DOI:10.1001/jama.287.7.840
Journal Article > LetterSubscription Only
JAMA. 2002 September 11; Volume 288 (Issue 10); 1233-1234.; DOI:10.1001/jama.288.10.1233-a
Piola P, Tachon JL, Brown V, Ligozat L, Veyrier E, et al.
JAMA. 2002 September 11; Volume 288 (Issue 10); 1233-1234.; DOI:10.1001/jama.288.10.1233-a
To the Editor: In November 2001 the possibility of widespread malnutrition was reported in Ghor province, Afghanistan, particularly in the Chaghcharan district, which had received no external assistance for 3 months. We performed a rapid health assessment in Chaghcharan town in December 2001 to assess general mortality and acute malnutrition among children younger than 5 years.
Journal Article > ResearchFull Text
JAMA. 1994 August 3
Gessner BD
JAMA. 1994 August 3
OBJECTIVE--To determine the mortality and health effects from the current civil war in Kabul, Afghanistan. SUBJECTS--One resident population and one displaced population. DESIGN--Between November 22 and December 16, 1993, we conducted a retrospective, population-based, household survey, interviewing 312 displaced families and 300 resident families. RESULTS--During the 285 days before the survey, the highest average daily crude mortality rate and the mortality rate for those younger than 5 years (0.9 and 2.6 per 10,000 population per day, respectively) were among residents who had lived at their current location for 10 months or less. The average daily crude mortality rate and the mortality rate for those younger than 5 years were lower among displaced persons (0.6 and 1.9 per 10,000 per day) and lowest among residents who had lived at their current location for more than 10 months (0.5 and 0.6 per 10,000 per day). Overall, the most common cause of death for both groups was gunshot or other war trauma; for children younger than 5 years, deaths resulting from measles, diarrhea, and acute respiratory tract infection predominated. CONCLUSIONS--While provision of basic public health measures would likely decrease mortality among both displaced and resident populations, the most urgent health need is for a cessation of hostilities against the civilian population. During humanitarian relief operations, organizations should not focus exclusively on persons identified as displaced.
Journal Article > ResearchSubscription Only
JAMA. 2008 September 3; Volume 300 (Issue 9); 1024.; DOI:10.1001/jama.300.9.1024-a
Lynch S, Lethola P, Ford NP
JAMA. 2008 September 3; Volume 300 (Issue 9); 1024.; DOI:10.1001/jama.300.9.1024-a
Journal Article > ResearchSubscription Only
JAMA. 1991 August 21; Volume 266 (Issue 7); 905-906.; DOI:10.1001/jama.1991.03470070033004
Stitham S
JAMA. 1991 August 21; Volume 266 (Issue 7); 905-906.; DOI:10.1001/jama.1991.03470070033004
Journal Article > ResearchFull Text
JAMA. 1999 January 27
Pécoul B, Chirac P, Trouiller P, Pinel J
JAMA. 1999 January 27
Drugs offer a simple, cost-effective solution to many health problems, provided they are available, affordable, and properly used. However, effective treatment is lacking in poor countries for many diseases, including African trypanosomiasis, Shigella dysentery, leishmaniasis, tuberculosis, and bacterial meningitis. Treatment may be precluded because no effective drug exists, it is too expensive, or it has been withdrawn from the market. Moreover, research and development in tropical diseases have come to a near standstill. This article focuses on the problems of access to quality drugs for the treatment of diseases that predominantly affect the developing world: (1) poor-quality and counterfeit drugs; (2) lack of availability of essential drugs due to fluctuating production or prohibitive cost; (3) need to develop field-based drug research to determine optimum utilization and remotivate research and development for new drugs for the developing world; and (4) potential consequences of recent World Trade Organization agreements on the availability of old and new drugs. These problems are not independent and unrelated but are a result of the fundamental nature of the pharmaceutical market and the way it is regulated.
Journal Article > ResearchFull Text
JAMA. 2005 March 23; Volume 293 (Issue 12); 1490-1494.; DOI:10.1001/jama.293.12.1490
Grandesso F, Sanderson F, Kruijt J, Koene T, Brown V
JAMA. 2005 March 23; Volume 293 (Issue 12); 1490-1494.; DOI:10.1001/jama.293.12.1490
CONTEXT
Mass violence against civilians in the west of Sudan has resulted in the displacement of more than 1.5 million people (25% of the population of the Darfur region). Most of these people are camped in 142 settlements. There has been increasing international concern about the health status of the displaced population.
OBJECTIVE
To perform rapid epidemiological assessments of mortality and nutritional status at 3 sites in South Darfur for relief efforts.
DESIGN, SETTING, AND PARTICIPANTS
In August and September 2004, mortality surveys were conducted among 137,000 internally displaced persons (IDPs) in 3 sites in South Darfur (Kass [n = 900 households], Kalma [n = 893 households], and Muhajiria [n = 900 households]). A nutritional survey was performed concomitantly among children aged 6 to 59 months using weight for height as an index of acute malnutrition (Kass [n = 894], Kalma [n = 888], and Muhajiria [n = 896]). A questionnaire detailing access to food and basic services was administered to a subset of households (n = 210 in each site). MAIN
OUTCOME MEASURES
Crude and under 5-year mortality rates and nutritional status of IDPs in Kass, Kalma, and Muhajiria, South Darfur. RESULTS: Crude mortality rates, expressed as deaths per 10,000 per day, were 3.2 (95% confidence interval [CI], 2.2-4.1) in Kass, 2.0 (95% CI, 1.3-2.7) in Kalma, and 2.3 (95% CI, 1.2-3.4) in Muhajiria. Under 5-year mortality rates were 5.9 (95% CI, 3.8-8.0) in Kass, 3.5 (95% CI, 1.5-5.7) in Kalma, and 1.0 (95% CI, 0.03-1.9) in Muhajiria. During the period of displacement covered by our survey in Muhajiria, violence was reported to be responsible for 72% of deaths, mainly among young men. Diarrheal disease was reported to cause between 25% and 47% of deaths in camp residents and mainly affected the youngest and oldest age groups. Acute malnutrition was common, affecting 14.1% of the target population in Kass, 23.6% in Kalma, and 10.7% in Muhajiria.
CONCLUSION
This study provides epidemiological evidence of the high rates of mortality and malnutrition among the displaced population in South Darfur and reinforces the need to mount appropriate and timely humanitarian responses.
Mass violence against civilians in the west of Sudan has resulted in the displacement of more than 1.5 million people (25% of the population of the Darfur region). Most of these people are camped in 142 settlements. There has been increasing international concern about the health status of the displaced population.
OBJECTIVE
To perform rapid epidemiological assessments of mortality and nutritional status at 3 sites in South Darfur for relief efforts.
DESIGN, SETTING, AND PARTICIPANTS
In August and September 2004, mortality surveys were conducted among 137,000 internally displaced persons (IDPs) in 3 sites in South Darfur (Kass [n = 900 households], Kalma [n = 893 households], and Muhajiria [n = 900 households]). A nutritional survey was performed concomitantly among children aged 6 to 59 months using weight for height as an index of acute malnutrition (Kass [n = 894], Kalma [n = 888], and Muhajiria [n = 896]). A questionnaire detailing access to food and basic services was administered to a subset of households (n = 210 in each site). MAIN
OUTCOME MEASURES
Crude and under 5-year mortality rates and nutritional status of IDPs in Kass, Kalma, and Muhajiria, South Darfur. RESULTS: Crude mortality rates, expressed as deaths per 10,000 per day, were 3.2 (95% confidence interval [CI], 2.2-4.1) in Kass, 2.0 (95% CI, 1.3-2.7) in Kalma, and 2.3 (95% CI, 1.2-3.4) in Muhajiria. Under 5-year mortality rates were 5.9 (95% CI, 3.8-8.0) in Kass, 3.5 (95% CI, 1.5-5.7) in Kalma, and 1.0 (95% CI, 0.03-1.9) in Muhajiria. During the period of displacement covered by our survey in Muhajiria, violence was reported to be responsible for 72% of deaths, mainly among young men. Diarrheal disease was reported to cause between 25% and 47% of deaths in camp residents and mainly affected the youngest and oldest age groups. Acute malnutrition was common, affecting 14.1% of the target population in Kass, 23.6% in Kalma, and 10.7% in Muhajiria.
CONCLUSION
This study provides epidemiological evidence of the high rates of mortality and malnutrition among the displaced population in South Darfur and reinforces the need to mount appropriate and timely humanitarian responses.
Journal Article > LetterFull Text
JAMA. 2001 December 19; Volume 286 (Issue 23); 2943-2944.; DOI:10.1001/jama.286.23.2943
Ford NP, Torreele E
JAMA. 2001 December 19; Volume 286 (Issue 23); 2943-2944.; DOI:10.1001/jama.286.23.2943
To the Editor: We agree with Mr Folkers and Dr Fauci that the success of acquired immunodeficiency syndrome research over the last 2 decades shows what can be achieved if enough financial and human resources are provided.1 There was serious commitment from Western governments as well as major investments from the pharmaceutical industry that anticipated a hugely profitable market in developed countries.....
Journal Article > CommentaryFull Text
JAMA. 2020 March 16; Volume 323 (Issue 16); 1549-1550.; DOI:10.1001/jama.2020.4169
Hopman J, Allegranzi B, Mehta S
JAMA. 2020 March 16; Volume 323 (Issue 16); 1549-1550.; DOI:10.1001/jama.2020.4169