The Diagnostic Laboratory Hub: A New Health Care System Reveals the Incidence and Mortality of Tuberculosis, Histoplasmosis, and Cryptococcosis of PWH in Guatemala.

BACKGROUND: A Diagnostic Laboratory Hub (DLH) was set up in Guatemala to provide opportunistic infection (OI) diagnosis for people with HIV (PWH). METHODS: Patients newly presenting for HIV, PWH not receiving antiretrovirals (ARVs) for >90 days but returned to care (Return/Restart), and PWH on ARVs with symptoms of OIs (ARV treatment) were prospectively included. Screening for tuberculosis, nontuberculous mycobacteria (NTM), histoplasmosis, and cryptococcosis was done. Samples were couriered to the DLH, and results were transmitted electronically. Demographic, diagnostic results, disease burden, treatment, and follow-up to 180 days were analyzed. RESULTS: In 2017, 1953 patients were included, 923 new HIV infections (an estimated 44% of all new HIV infections in Guatemala), 701 on ARV treatment, and 315 Return/Restart. Three hundred seventeen (16.2%) had an OI: 35.9% tuberculosis, 31.2% histoplasmosis, 18.6% cryptococcosis, 4.4% NTM, and 9.8% coinfections. Histoplasmosis was the most frequent AIDS-defining illness; 51.2% of new patients had <200 CD4 cells/mm3 with a 29.4% OI incidence; 14.3% of OIs in new HIV infections occurred with CD4 counts of 200-350 cells/mm3. OIs were the main risk factor for premature death for new HIV infections. At 180 days, patients with OIs and advanced HIV had 73-fold greater risk of death than those without advanced disease who were OI-free. CONCLUSIONS: The DLH OI screening approach provides adequate diagnostic services and obtains relevant data. We propose a CD4 screening threshold of <350 cells/mm3. Mortality remains high, and improved interventions are required, including expansion of the DLH and access to antifungal drugs, especially liposomal amphotericin B and flucytosine.

Burden of serious fungal infections in Guatemala.

Guatemala is a developing country in Central America with a high burden of HIV and endemic fungal infections; we attempted to estimate the burden of serious fungal infections for the country. A full literature search was done to identify epidemiology papers reporting fungal infections from Guatemala. We used specific populations at risk and fungal infection frequencies in the population to estimate national rates. The population of Guatemala in 2013 was 15.4 million; 40% were younger than 15 and 6.2% older than 60. There are an estimated 53,000 adults with HIV infection, in 2015, most presenting late. The estimated cases of opportunistic fungal infections were: 705 cases of disseminated histoplasmosis, 408 cases of cryptococcal meningitis, 816 cases of Pneumocystis pneumonia, 16,695 cases of oral candidiasis, and 4,505 cases of esophageal candidiasis. In the general population, an estimated 5,568 adult asthmatics have allergic bronchopulmonary aspergillosis (ABPA) based on a 2.42% prevalence of asthma and a 2.5% ABPA proportion. Amongst 2,452 pulmonary tuberculosis patients, we estimated a prevalence of 495 for chronic pulmonary aspergillosis in this group, and 1,484 for all conditions. An estimated 232,357 cases of recurrent vulvovaginal candidiasis is likely. Overall, 1.7% of the population are affected by these conditions. The true fungal infection burden in Guatemala is unknown. Tools and training for improved diagnosis are needed. Additional research on prevalence is needed to employ public health measures towards treatment and improving the reported data of fungal diseases.

A cross-sectional study of risk factors for HIV among pregnant women in Guatemala City, Guatemala: lessons for prevention.

Although the Central American HIV epidemic is concentrated in high-risk groups, HIV incidence is increasing in young women. From 2005 to 2007, we conducted a cross-sectional study of pregnant women in a large public hospital and an HIV clinic in Guatemala City to describe risk factors for HIV infection and inform prevention strategies. For 4629 consenting patients, HIV status was laboratory-confirmed and participant characteristics were assessed by interviewer-administered questionnaires. Lifetime number of sexual partners ranged from 1 to 99, with a median (interquartile range) of 1 (1, 2). 2.6% (120) reported exchanging sex for benefits; 0.1% (3) were sex workers, 2.3% (106) had used illegal drugs, 31.1% (1421) planned their pregnancy and 31.8% (1455) experienced abuse. In logistic regression analyses, HIV status was predicted by one variable describing women's behaviour (lifetime sexual partners) and three variables describing partner risks (partner HIV+, migrant worker or suspected unfaithful). Women in our sample exhibited few behavioural risks for HIV but significant vulnerability via partner behaviours. To stem feminization of the epidemic, health authorities should complement existing prevention interventions in high-risk populations with directed efforts towards bridging populations such as migrant workers. We identify four locally adapted HIV prevention strategies.

Can a clinical prediction tool guide HIV-testing decisions? Experience at a national hospital in Guatemala.

The USA and international recommendations no longer emphasize using risk factors to target groups for HIV-testing. Using a Guatemalan database of HIV tests, we developed a clinical prediction rule to guide decisions on HIV-testing. Prior to HIV-testing, data were collected on demographics, risk factors and prior testing. Based on a theoretical construct incorporating demographics, known HIV risk factors and symptoms, we developed a logistic regression model to predict HIV seropositivity. Between 2000 and 2005, 16,471 tests were performed, of which 19.8% were positive. The algorithm successfully predicted 1883 of 2489 HIV-positive tests (sensitivity 76%, likelihood ratio [LR]-positive 2.45) and 6282 of 9086 HIV-negative tests (specificity 69%, LR-negative 0.35). Although the model indices are robust, applying the model in a clinical setting would have little impact on improving selective testing practices. Our findings support current recommendations for universal HIV-testing, not selective testing based on risk factors. Before these recommendations can be adopted widely in Guatemala, treatment access needs to be assured and protections put in place for people diagnosed with HIV infection.

Antigonorrhoeal activity of plants used in Guatemala for the treatment of sexually transmitted diseases.

Plants popularly used in Guatemala for the treatment of gonorrhoea were macerated in 50% alcohol and the tincture tested for in vitro activity against Neisseria gonorrhoeae using strains isolated from symptomatic patients and confirmed by standard bacteriological procedures. From 46 plants investigated, 13 (28.3%) showed evident inhibition zones (> 9 mm), seven (15.2%) showed small activity (6.1-8.9 mm) and 26 (56.5%) showed no activity; nine of these plants inhibited five strains of N. gonorrhoea freshly isolated. The most active plants of American origin were: bark of Bixa orellana fruits of Parmentiera edulis, leaf of Diphysa robinioides, Eupatorium odoratum, Gliricidia sepium, Physalis angulata, Piper aduncum and Prosopis juliflora, root of Casimiroa edulis, and whole Clematis dioica.

Epidemic gram-negative bacteremia in a neonatal intensive care unit in Guatemala.

BACKGROUND: Nosocomial bloodstream infection is an important cause of morbidity and mortality among neonates. From September 1 through December 5, 1990 (epidemic period), gram-negative bacteremia developed in 26 neonates after their admission to the neonatal intensive care unit (NICU) of Hospital General, a 1000-bed public teaching hospital in Guatemala with a 16-bed NICU. Twenty-three of the 26 patients (88%) died. METHODS: To determine risk factors for and modes of transmission of gram-negative bacteremia in the NICU, we conducted a cohort study of NICU patients who had at least one blood culture drawn at least 24 hours after admission to the NICU and performed a microbiologic investigation in the NICU. RESULTS: The rate of gram-negative bacteremia was significantly higher among patients born at Hospital General, delivered by cesarian section, and exposed to selected intravenous medications and invasive procedures in the NICU during the 3 days before the referent blood culture was obtained. During the epidemic period, the hospital's chlorinated well-water system malfunctioned; chlorine levels were undetectable and tap water samples contained elevated microbial levels, including total and fecal coliform bacteria. Serratia marcescens was identified in 81% of case-patient blood cultures (13/16) available for testing and from 57% of NICU personnel handwashings (4/7). Most S. marcescens blood isolates were serotype O3:H12 (46%) or O14:H12 (31%) and were resistant to ampicillin (100%) and gentamicin (77%), the antimicrobials used routinely in the NICU. CONCLUSIONS: We hypothesize that gram-negative bacteremia occurred after invasive procedures were performed on neonates whose skin became colonized through bathing or from hands of NICU personnel.

Plants used in Guatemala for the treatment of gastrointestinal disorders. 3. Confirmation of activity against enterobacteria of 16 plants.

Ethnobotanical surveys and literature review identified 408 plants used in Guatemala for the treatment of gastrointestinal disorders. The screening of 84 showed that 34 inhibit one or more enterobacteria; 16 of these were selected for further investigation. Extracts were obtained with three solvents of different polarity (n-hexane, acetone and alcohol) and the in vitro activity was demonstrated against enteropathogenic Escherichia coli, Salmonella enteritidis and Shigella flexneri. The activity of nine ethanolic extracts against enterobacteria, particularly Acalypha guatemalensis, Diphysa robinioides, Lippia dulcis, Psidium guajava and Spondias purpurea was confirmed. The plants with antibacterial activity are discussed.

[Characteristics of human immunodeficiency virus infection in the San Juan de Dios General Hospital]. / Caracterizacion de la infeccion por el virus de inmunodeficiencia humana, en el Hospital General San Juan de Dios.

PIP: A prospective clinical study was conducted between January 1991 and June 1992 of 92 HIV seropositive patients attending the Adult Outpatient Clinic of the San Juan de Dios General Hospital in Guatemala City. 52 of the patients met the US Centers for Disease Control clinical criteria for AIDS. Limitations in the diagnostic and laboratory facilities of the hospital hampered identification of some opportunistic infections. 74 of the 92 patients were male. 3 of the 18 infected women gave birth during the study period; the status of their children is not yet known. 87% of the cases were in adults aged 18-40. 25 of the patients died during the 18-month study period and 9 were lost to follow-up. 57 of the 92 had lived in the US or Mexico. 43 of the 74 men reported homosexual relations. 6 reported use of intravenous drugs. 3 had received blood transfusions as the only known risk factor. 56 had histories of sexually transmitted diseases. 3 patients reported always using condoms, 57 never did so, and the rest did so occasionally. 52 of the patients had opportunistic infections. 18 had proven and 5 had presumptive extrapulmonary mycobacteria, probably tuberculosis. 2 had salmonella in the blood. 4 had presumptive cytomegalovirus, 6 had chronic mucocutaneous herpes, and 3 had presumptive HIV encephalopathy. 12 had esophageal candidiasis, 6 had extrapulmonary cryptococcosis, and 14 had pneumocystis carinii pneumonia. 13 had proven intestinal cryptosporidiosis, and 1 each had presumptive cerebral toxoplasmosis and extraintestinal strongyloidiasis. 3 had proven Kaposi's sarcoma and 1 had proven immunoblastic lymphoma. 10 had HIV-related weight loss.^ieng

Plants used in Guatemala for the treatment of respiratory diseases. 1. Screening of 68 plants against gram-positive bacteria.

Respiratory ailments are important causes of morbidity and mortality in developing countries. Ethnobotanical surveys and literature reviews conducted in Guatemala during 1986-88 showed that 234 plants from 75 families, most of them of American origin, have been used for the treatment of respiratory ailments. Three Gram-positive bacteria causing respiratory infections (Staphylococcus aureus, Streptococcus pneumoniae and Streptococcus pyogenes) were used to screen 68 of the most commonly used plants for activity. Twenty-eight of these (41.2%) inhibited the growth of one or more of the bacteria tested. Staphylococcus aureus was inhibited by 18 of the plant extracts, while 7 extracts were effective against Streptococcus pyogenes. Plants of American origin which exhibited antibacterial activity were: Gnaphalium viscosum, Lippia alba, Lippia dulcis, Physalis philadelphica, Satureja brownei, Solanum nigrescens and Tagetes lucida. These preliminary in vitro results provide scientific basis for the use of these plants against bacterial respiratory infections.

Plants used in Guatemala for the treatment of gastrointestinal disorders. 1. Screening of 84 plants against enterobacteria.

Gastrointestinal disorders are important causes of morbidity in developing countries. Natural healing is the traditional way of treating these diseases in Guatemala. Ethnobotanical surveys and literature reviews showed that 385 plants from 95 families are used in Guatemala for the treatment of gastrointestinal disorders. The activity of 84 of the most commonly used plants was screened in vitro against five enterobacteria pathogenic to man (enteropathogenic Escherichia coli, Salmonella enteritidis, Salmonella typhi, Shigella dysenteriae and Shigella flexneri). Results indicate that 34 (40.48%) plants inhibit one or more of the enterobacteria tested. The most commonly inhibited bacterium was S. typhi (33.73%) and the most resistant was E. coli (7.35%). The plants of American origin which exhibited the best antibacterial activity were: Byrsonima crassifolia, Diphysa robinioides, Gnaphalium stramineum, Guazuma ulmifolia, Psidium guajava, Sambucus mexicana, Simarouba glauca, Smilax lundelii, Spondias purpurea and Tagetes lucida. These results indicate a scientific basis for use of these medicinal plants for attacking enterobacterial infections in man.