Improved antiretroviral treatment outcome in a rural African setting is associated with cART initiation at higher CD4 cell counts and better general health condition.

BACKGROUND: Data on combination antiretroviral therapy (cART) in remote rural African regions is increasing. METHODS: We assessed prospectively initial cART in HIV-infected adults treated from 2005 to 2008 at St. Francis Designated District Hospital, Ifakara, Tanzania. Adherence was assisted by personal adherence supporters. We estimated risk factors of death or loss to follow-up by Cox regression during the first 12 months of cART. RESULTS: Overall, 1,463 individuals initiated cART, which was nevirapine-based in 84.6%. The median age was 40 years (IQR 34-47), 35.4% were males, 7.6% had proven tuberculosis. Median CD4 cell count was 131 cells/µl and 24.8% had WHO stage 4. Median CD4 cell count increased by 61 and 130 cells/µl after 6 and 12 months, respectively. 215 (14.7%) patients modified their treatment, mostly due to toxicity (56%), in particular polyneuropathy and anemia. Overall, 129 patients died (8.8%) and 189 (12.9%) were lost to follow-up. In a multivariate analysis, low CD4 cells at starting cART were associated with poorer survival and loss to follow-up (HR 1.77, 95% CI 1.15-2.75, p=0.009; for CD4<50 compared to >100 cells/µl). Higher weight was strongly associated with better survival (HR 0.63, 95% CI 0.51-0.76, p<0.001 per 10 kg increase). CONCLUSIONS: cART initiation at higher CD4 cell counts and better general health condition reduces HIV related mortality in a rural African setting. Efforts must be made to promote earlier HIV diagnosis to start cART timely. More research is needed to evaluate effective strategies to follow cART at a peripheral level with limited technical possibilities.

Impact of a national HIV voluntary counselling and testing (VCT) campaign on VCT in a rural hospital in Tanzania.

OBJECTIVE: To evaluate the impact of a national HIV voluntary counselling and testing (VCT) campaign on presentation to HIV care in a rural population in Tanzania. METHODS: Retrospective analysis of data of the VCT and of the National AIDS Control Programme registers of the St. Francis Designated District Hospital at Ifakara for the two 6-month periods before (2007) and after (2008) the National VCT Campaign. RESULTS: There were 4354 individuals presenting at St. Francis Hospital tested for HIV; 2065 (47.4%) before the VCT Campaign and 2289 (52.6%) afterwards. The overall HIV test positivity was 24.6% and higher in 2007 than in 2008 (26%vs. 23%, P = 0.034). This rate was much higher than the Tanzanian National HIV prevalence of 5.7%. Of 1069 individuals who tested HIV-positive, the proportion of married, divorced or widowed individuals and those who lived further than 10 km from the hospital increased from 2007 to 2008. In 356 HIV-infected persons with available data, the median CD4 cell count increased from 137 to 163 cells/mm(3) (P = 0.058), while the WHO clinical stage was similar in both periods. Enrolling into the National AIDS Control Programme was significantly more common in 2008 (42%vs. 30%, P < 0.001). In a multivariate analysis, the only positive predictor of testing HIV positive when presenting for care after the National VCT Campaign was being married (OR 1.61, 95%CI 1.21-2.15, P = 0.001) or divorced/widowed compared to single (OR 4.58, 95% CI 3.00-8.12, P < 0.001). CONCLUSIONS: Our results suggest that the National VCT Campaign raised awareness and readiness to test for HIV in a remote rural setting and that the HIV-positive test rate is much higher in conjunction with a specific HIV care programme.

Prevalence of different virulence factors and biofilm production in enteroaggregative Escherichia coli isolates causing diarrhea in children in Ifakara (Tanzania).

This study investigated the prevalence of 19 virulence factors and biofilm production in 86 EAEC isolates causing diarrhea in children less than 5 years of age from Ifakara, Tanzania. Virulence factors were detected by PCR, whereas biofilm production was determined using a microtiter plate assay. No virulence factor, with the exception of the aat gene used to identify EAEC, was detected in 11/86 isolates (12.8%). The most frequently detected virulence factor was the aggR gene in 53 (61.6%) EAEC, followed by antigen 43 in 33.7%, dispersin in 26.7%, yersiniabactin in 22.1%; autrotransporter Sat in 20.9%; Shigella enterotoxin-1 in 16.3%, and heat-stable toxin-1 in 15.1%. Biofilm was produced in 66/86 (76%) isolates. AggR was the most prevalent virulence factor in the biofilm-forming group (65% versus 38%, P = 0.032). These results again show the high heterogeneity of virulence factors among EAEC isolates causing diarrhea in children, and that biofilm may be an important virulence factor, strongly associated with the presence of AggR.