Prevalence of Chronic Kidney Disease among Patients Attending an HIV Outpatient Clinic in Kingston, Jamaica / Prevalencia de la enfermedad renal crónica entre los pacientes que asisten a una clínica ambulatoria de VIH en Kingston, Jamaica

ABSTRACT The medical records of 983 patients diagnosed with the human immunodeficiency virus (HIV) were reviewed, 501 of whom were female and 482 were male. The mean age was 42.1 years, the mean number of years since diagnosis of HIV was 7.4, and the average duration of highly active antiretroviral therapy (HAART) was 51.7 months. The mean CD4 count at diagnosis was 268.5 cells/μL, but the most recent CD4 count was 461 cells/μL, and 85.8% of the patients were on HAART. The mean CD4 count was lower in those with a glomerular filtration rate (GFR) of < 60 ml/minute/1.73m2 compared to those patients with only proteinuria and a GFR of > 60 ml/minute/1.73m2. In the sample population, 76.9% of the patients had chronic kidney disease stage 3, 7.7% were in stage 4 and 15.4% in stage 5. There were 3.1% of patients with persistent proteinuria. Hypertension and diabetes mellitus were co-morbidities.

RESUMEN Se revisaron las historias clínicas de 983 pacientes diagnosticados con el virus de la inmunodeficiencia humana (VIH), 501 de los cuales eran mujeres, y 482 hombres. La edad promedio fue de 42.1 años, el número promedio de años a partir del diagnóstico de VIH fue 7.4, y la duración promedio de la terapia antirretroviral altamente activa (TARAA) fue de 51.7 meses. El conteo de CD4 promedio en el momento del diagnóstico fue de 268.5 células/μl pero el más reciente conteo de CD4 fue de 461 células/μl y el 85.8% de los pacientes se encontraban bajo terapia TARAA. El conteo de CD4 promedio fue menor en aquellos pacientes con una tasa de filtrado glomerular (TFG) de < 60 ml/minuto/1.73 m2, en comparación con los pacientes que tenían sólo proteinuria y una TFG de > 60 ml/minute/1.73 m2. En la población de la muestra, el 76.9% de los pacientes tenía enfermedad renal crónica en etapa 3, el 7.7% estaba en la etapa 4, y el 15.4% en la etapa 5. Había 3.1% de pacientes con proteinuria persistente. La hipertensión y la diabetes mellitus fueron comorbilidades.

A review of the HIV-infected homeless sub-population at the Centre for HIV/AIDS Research, Education and Services, Department of Medicine, University Hospital of the West Indies.

OBJECTIVE: The twin epidemics of HIV and homelessness present several challenging aspects to the development of programmes for the provision of treatment and care. This paper describes the characteristics of this population being managed by a collaborative effort between the Centre for HIV/AIDS Research, Education and Services, Department of Medicine, University Hospital of the West Indies and the National Council on Drug Abuse. SUBJECTS AND METHODS: A retrospective descriptive study was conducted via review of patients'medical files. Demographic and clinical data of the HIV-infected homeless population were summarized, highlighting issues related to the provision of care, rates of antiretroviral therapy (ART) uptake and subsequent adherence to treatment and known factors associated with HIV transmission. RESULTS: A total of 12 cases were included in the analysis. There was an average age of 38.0 years (IQR 32.5-49.25) with the majority being female, nine (75.0%). Late stage diagnosis was a common feature. The majority of cases were eligible for ART on first contact, with CD4 counts on average being 284.4 (95% CI 10.9.0, 459.8). Significant risk factors for HIV transmission were also identified as all cases reported being sexual active with limited condom use reported and high reported numbers of lifetime partners, 30 (IQR 25.0-100.0). Other factors identified include eight (66.6%) cases reporting sexually transmitted infection (STI) symptoms, 10 (83.3%) reporting substance abuse and nine (75.0%) reporting sex work. CONCLUSION: The implementation of combination interventions providing a comprehensive package of services that address the multitude of issues facing the HIV-infected homeless population is required in order to appropriately manage this population.

What are the benefits and barriers of communicating parental HIV status to seronegative children and the implications for Jamaica? A narrative review of the literature in low/middle income countries.

OBJECTIVE: To examine the benefits/barriers for HIV positive parents of communicating their status to seronegative children in low/middle income countries in order to inform policy and practice in Jamaica. METHODS: The authors carried out a systematic search of published literature on parental disclosure in low/middle income countries written in the English language between January 1991 and September 2012, identified from databases: Academic Search Complete, CINAHL, EBSCOhostEJS, Gender Studies Database, Health Policy Reference Centre, MEDLINE (includes the West Indian Medical Journal), PsycARTICLES , PsycINFO , SocINDEX, AMED, Global Health, Embase, Social Policy and Practice, Maternity and Infant Care. The authors also refer to articles on parental disclosure in high income countries which appeared in peer-reviewed journals and conducted a local search in Jamaica for articles on HIV disclosure in the Caribbean region. RESULTS: Global estimates of parental disclosure rates were 20-97% in high income countries and 11-44% in resource constrained countries. Mean age of children at disclosure was age 10-18 years. Mothers were more likely to disclose to older children, female children, and when they had strong support networks. Barriers included fear of stigma/discrimination, not knowing how to tell the child, fear of the child disclosing to others and believing a child was too young to cope. Of the 16 articles identified which met the search criteria, 10 studies and three reviews noted positive benefits of disclosure on parental health and the parent-child relationship. CONCLUSION: Significant differences in attitudes and rates of maternal disclosure in low/middle income countries compared to high income countries reflect the impact of cultural, structural, economic and social factors and highlight the need for culturally-specific research. Implications for policy and practice in Jamaica are discussed.

A case of systemic cryptococcal disease in HIV infection.

Globally, Cryptococcosis is the most common invasive mycosis in HIV disease. Incidence rates vary widely by geographical region and resource availability and reportedly range from 0.04 to 12% per year (1). Sub-Saharan Africa accounts for the greatest burden with a median incidence of 3.2% per year (1). Since the advent of widespread use of antiretroviral therapy (ART), incidence rates of opportunistic infections have been significantly declining (2).

What are the benefits and barriers of communicating parental HIV status to seronegative children and the implications for Jamaica? A narrative review of the literature in low/middle income countries / ¿Cuáles son los beneficios que se producen y las barreras que se erigen cuando los padres comunican su condición de VIH a sus hijos seronegativos, y cuáles son las implicaciones para Jamaica? Una revisión narrativa de la literatura en los países de ingresos bajos/medios

OBJECTIVE: To examine the benefits/barriers for HIV positive parents of communicating their status to seronegative children in low/middle income countries in order to inform policy and practice in Jamaica. METHODS: The authors carried out a systematic search of published literature on parental disclosure in low/middle income countries written in the English language between January 1991 and September 2012, identified from databases: Academic Search Complete, CINAHL, EBSCOhostEJS, Gender Studies Database, Health Policy Reference Centre, MEDLINE (includes the West Indian Medical Journal), PsycARTICLES , PsycINFO , SocINDEX, AMED, Global Health, Embase, Social Policy and Practice, Maternity and Infant Care. The authors also refer to articles on parental disclosure in highincome countries which appeared in peer-reviewed journals and conducted a local search in Jamaica for articles on HIV disclosure in the Caribbean region. RESULTS: Global estimates of parental disclosure rates were 20-97% in high income countries and 11-44% in resource constrained countries. Mean age of children at disclosure was age 10-18 years. Mothers were more likely to disclose to older children, female children, and when they had strong support networks. Barriers included fear of stigma/discrimination, not knowing how to tell the child, fear of the child disclosing to others and believing a child was too young to cope. Of the 16 articles identified which met the search criteria, 10 studies and three reviews noted positive benefits of disclosure on parental health and the parent-child relationship. CONCLUSION: Significant differences in attitudes and rates of maternal disclosure in low/middle income countries compared to high income countries reflect the impact of cultural, structural, economic and social factors and highlight the need for culturally-specific research. Implications for policy and practice in Jamaica are discussed.

OBJETIVO: Examinar los beneficios y las barreras que se producen cuando los padres comunican su condición de VIH a sus hijos seronegativos en los países de ingresos bajos/medios, y disponer de información para conformar las políticas y la práctica en Jamaica. MÉTODOS: Los autores realizaron una búsqueda sistemática de la literatura publicada sobre revelaciones de los padres en los países de ingresos bajos/medios, escritas en idioma inglés entre enero de 1991 y septiembre de 2012, e identificadas en las bases de datos siguientes: Academic Search Complete, CINAHL, EBSCOhostEJS, Base de datos de estudios de género, Centro de referencia de políticas de salud, MEDLINE (incluyendo West Indian Medical Journal), PsycARTICLES, PsycINFO, SocINDEX, AMED, Glo-bal Health, Embase, Política y práctica social, Maternidad y atención infantil. Los autores también consultaron artículos sobre las revelaciones hechas por padres en países de altos ingresos, las que aparecieron en revistas arbitradas, y realizaron una investigación local en Jamaica, en busca de artículos sobre revelación del VIH en la región del Caribe. RESULTADOS: Los estimados mundiales de las tasas de revelación de los padres fueron 20-97% en los países de ingresos altos, y 11-44% en los países de recursos limitados. La edad promedio de los niños a la hora de escuchar la revelación fue 10 -18 años de edad. Las madres eran más propensas a revelar a los niños mayores, y a las niñas, así como a hacer revelaciones cuando tenían fuerte apoyo de las redes. Las barreras incluyeron temor al estigma/discriminación, no saber cómo decirle al menor, el miedo de que el menor revelara la condición a otros, y el creer al niño o la niña demasiado joven hacer frente a la información. De los 16 artículos identificados que cumplieron los criterios de búsqueda, 10 estudios y tres reseñas señalaron beneficios positivos con respecto al revelar la salud de los padres, y a la relación padre-hijo. CONCLUSIÓN: Las diferencias significativas en actitudes así como en tasas de revelación por parte de las madres en los países de ingresos bajos/medios en comparación con los países de altos ingresos, reflejan el impacto de los factores culturales, estructurales, económicos y sociales, y destacan la necesidad de realizar investigaciones orientadas a culturas específicas. Se discuten las implicaciones para las políticas y la práctica en Jamaica. Palabras claves: VIH/SIDA, revelación de los padres, Jamaic.

A review of the HIV-infected homeless sub-population at the Centre for HIV/AIDS Research, Education and Services, Department of Medicine, University Hospital of the West Indies / Una revisión de la subpoblación sin hogar de infectados por el VIH en el Centro para la Investigación, Educación y Servicios del VIH/SIDA, del Departamento de Medicina del Hospital Universitario de West Indies

OBJECTIVE: The twin epidemics of HIV and homelessness present several challenging aspects to the development of programmes for the provision of treatment and care. This paper describes the characteristics of this population being managed by a collaborative effort between the Centre for HIV/AIDS Research, Education and Services, Department of Medicine, University Hospital of the West Indies and the National Council on Drug Abuse. SUBJECTS AND METHODS: A retrospective descriptive study was conducted via review of patients'medical files. Demographic and clinical data of the HIV-infected homeless population were summarized, highlighting issues related to the provision of care, rates of antiretroviral therapy (ART) uptake and subsequent adherence to treatment and known factors associated with HIV transmission. RESULTS: A total of 12 cases were included in the analysis. There was an average age of 38.0 years (IQR 32.5-49.25) with the majority being female, nine (75.0%). Late stage diagnosis was a common feature. The majority of cases were eligible for ART on first contact, with CD4 counts on average being 284.4 (95% CI 10.9.0, 459.8). Significant risk factors for HIV transmission were also identified as all cases reported being sexual active with limited condom use reported and high reported numbers of lifetime partners, 30 (IQR 25.0-100.0). Other factors identified include eight (66.6%) cases reporting sexually transmitted infection (STI) symptoms, 10 (83.3%) reporting substance abuse and nine (75.0%) reporting sex work. CONCLUSION: The implementation of combination interventions providing a comprehensive package of services that address the multitude of issues facing the HIV-infected homeless population is required in order to appropriately manage this population.

OBJETIVO: Las epidemias gemelas del VIH y las personas sin hogar, presentan varios aspectos desafiantes para el desarrollo de programas que ofrecen atención y tratamiento. Este trabajo describe las características de esta población, y su manejo como parte de un esfuerzo de colaboración entre el Centro para la investigación, educación y servicios del VIH/SIDA, del Departamento de Medicina del Hospital Universitario de West Indies, y el Consejo Nacional para el Abuso de Drogas. SUJETOS Y MÉTODOS: Se realizó un estudio descriptivo retrospectivo mediante revisión de expedientes médicos de los pacientes. Se resumieron los datos clínicos y demográficos de la población sin hogar infectada por el VIH, destacando las cuestiones relacionadas con la prestación de asistencia, las tasas de adopción de terapia antirretroviral (TAR), y la posterior adherencia al tratamiento, además de factores conocidos, asociados con la transmisión del VIH. RESULTADOS: Un total de 12 casos se incluyeron en el análisis. La edad promedio fue de 38.0 años (IQR 32.5-49.25), siendo mujeres la mayoría, 9 (75.0%). El diagnóstico en etapa tardía fue una característica común. La mayoría de los casos fueron elegibles para TAR desde el primer contacto, con conteos CD4 de 284.4 (95% CI 10.9.0, 459.8) como promedio. También se identificaron factores de riesgo significativos para la transmisión del VIH, ya que todos los casos reportaron actividad sexual con un uso limitado de condón, y un gran número de parejas sexuales durante toda la vida, 30 (IQR 25.0-100.0). Otros factores identificados incluyen 8 (66,6%) casos que reportaron síntomas de infección de transmisión sexual (ITS), 10 (83,3%) que reportaron abuso de sustancias, y 9 (75.0%) que reportaron trabajo sexual. CONCLUSIÓN: Se requiere la implementación de intervenciones de combinación que ofrezcan un paquete integral de servicios que respondan a los numerosos problemas que enfrenta la población sin hogar infectada por VIH, a fin de tratar adecuadamente a esta población.

Depression among persons attending a HIV/AIDS outpatient clinic in Kingston, Jamaica / La depresión entre las personas que asisten a la clínica para pacientes externos de VIH/SIDA en Kingston, Jamaica

OBJECTIVES: To determine the prevalence of depression among persons attending a HIV/AIDS clinic in Kingston, Jamaica, and to explore the possible role of patient-specific clinical and social issues as intermediary factors in the relationship between HIV/ AIDS and depression. SUBJECTS AND METHODS: Over a three-month period, all eligible and consenting patients from a HIV/AIDS clinic in Kingston, Jamaica, were invited to participate in the study. They were interviewed using the Patient Health Questionnaire (PHQ-9), an instrument validated for the detection of depression in primary care settings. Clinical and socio-demographic data were retrieved for all participating patients from a pre-existing clinic database. Depression prevalence rates were calculated and the association between depression and age, gender, antiretroviral treatment, CD4 count, living arrangement, marital status and major stressors explored. RESULTS: Sixty-three patients participated in the study and 43% (n = 36) of them were depressed. No significant differences in depression rates were found with respect to any of the sociodemographic or clinical factors explored (p > 0.05). CONCLUSION: The relatively high prevalence of depression among attendees at the HIV/AIDS clinic underscores the need for depression screening in these patients.

OBJETIVOS: Determinar la prevalencia de la depresión entre personas que asisten a una clínica de VIH/SIDA en Kingston, Jamaica, y explorar el posible papel de los problemas clínicos específicos y los problemas sociales de los pacientes, como factores intermediarios en la relación entre VIH/SIDA y depresión. SUJETOS Y MÉTODOS: Por un periodo de más de tres meses, todos los pacientes elegibles y con consentimiento informado de una clínica de VIH/SIDA en Kingston, Jamaica, fueron invitados a participar en el estudio. A tal fin, fueron entrevistados mediante el Cuestionario sobre la Salud del Paciente (PHQ-9), un instrumento validado para la detección de la depresión en los centros de atención primaria. De una base de datos clínicos pre-existente, se obtuvieron datos clínicos y sociodemográficos de todos los pacientes participantes Se calcularon las tasas de prevalencia de depresión y se exploró la asociación entre depresión y edad, género, tratamiento antiretroviral, conteos de CD4, orden de vida, estado civil y estresores principales. RESULTADOS: Sesenta y tres pacientes participaron en el estudio y el 43% (n = 36) de ellos estaban deprimidos. No se hallaron diferencias significativas en las tasas de depresión con respecto a ninguno de los factores sociodemográficos o clínicos explorados (p > 0.05). CONCLUSIÓN: La prevalencia relativamente alta de depresión entre los asistentes a la clínica de VIH/SIDA subraya la necesidad de realizar pruebas de tamizaje de la depresión para estos pacientes.

An analysis of three opportunistic infections in an outpatient HIV Clinic in Jamaica / Análisis de tres infecciones oportunistas en un paciente externo de la Clínica de VIH en Jamaica

OBJECTIVES: To determine the occurrence of opportunistic infection (OI) in HIV-positive patients and to identify any risk factors which may be associated with such. METHODS: A cross-sectional study of all patients attending the HIV out-patient clinic was conducted. Their hospital notes were examined between January 1 and December 31, 2007 inclusive, to identify any occurrence of opportunistic infection. In addition, the patient list was also cross-referenced with all patients hospitalized on the medical wards during the same time period. Clinical and demographic data were collected for all participants. The occurrence of opportunistic infections and the variables of age, gender, CD4 counts and viral loads: (first ever, last in 2007 and at diagnosis of OI [or within six months]), the use of primary and secondary prophylaxis, the discontinuation of prophylactic regimens and the HAART regime at diagnosis of an OI and the diagnostic and treatment protocols of these infections were calculated. RESULTS: Six hundred and three patients participated in the study and 4.7% (n = 28) were found to have experienced at least one opportunistic infection in 2007. Significant associations were found between first and last CD4 cell count, viral load in 2007, year of entry into the clinic and death (p < 0.05). CONCLUSIONS: Opportunistic infections continue to cause significant morbidity and mortality in the HIV-patient population in this study. Earlier entry to treatment facilities and the use of HAART and appropriate prophylaxis can reduce this impact and lead to improved quality of life for HIV-positive individuals.

OBJETIVOS: Determinar la ocurrencia de infecciones oportunistas (IO) en pacientes VIH-positivos e identificar factores de riesgo que puedan estar asociados con ellas. MÉTODOS: Se llevó a cabo un estudio transversal de todos los pacientes que asisten a la clínica externa de VIH. Sus apuntes de hospital fueron examinados entre el 1 de enero y el 31 de diciembre de 2007 inclusive, a fin de identificar cualquier manifestación de infección oportunista. Además, la lista de pacientes fue creada con referencias cruzadas en relación con todos los pacientes hospitalizados en las salas del hospital durante el periodo en cuestión. Se recogieron los datos clínicos y demográficos de todos los participantes. Se realizaron cálculos de la ocurrencia de infecciones oportunistas y las variables de edad, género, conteos de CD4 y las cargas virales: (la primeray la última en 2007 y en el diagnóstico de IO [o dentro de seis meses]), el uso de profilaxis primaria y secundaria, la descontinuación de los regimenes profilácticos y el régimen de TARGA en el diagnóstico de una IO, así como los protocolos de diagnóstico y tratamiento de estas infecciones. RESULTADOS: Seiscientos tres pacientes participaron en el estudio y se halló que 4.7% (n = 28) habían parecido por lo menos una infección oportunista en 2007. Se hallaron asociaciones significativas entre elprimer y el último conteo celular CD4, la carga viral en el 2007, el ano de entrada en la clínica y la muerte (p < 0.05). CONCLUSIONES: Las infecciones oportunistas continúan siendo la causa de morbilidad y mortalidad significativas entre la población de pacientes de VIH de acuerdo a este estudio. El ingreso temprano a los centros de tratamiento y el uso de la terapia de TARGA así como una profilaxis adecuada, puede reducir este impacto y llevar a una mejor calidad de vida de los individuos VIH positivos.

Sociodemographics and clinical presentation of HIV in Jamaica over 20 years: a comparative analysis of surveillance data / Sociodemografía y presentación clínica del VIH en Jamaica por más de 20 años: análisis comparativo de datos de vigilancia

OBJECTIVE: To delineate changes in the epidemiology of HIV including morbidity and mortality patterns based on three key time points in Jamaica s HIV response. METHOD: Surveillance data from Jamaica s HIV/AIDS Tracking system (HATS) were analysed and distribution of cases by age, gender, sexual practice, risk factors and clinical features were determined for three time periods (1988 - 1994: formal establishment of HIV surveillance at the national level; 1995-2003: introduction ofHAART globally; 2004 -June2008: introduction of HAART and HIV rapid testing in Jamaica). Factors that predicted late stage diagnosis (AIDS or AIDS death) were also determined. RESULTS: 22 603 persons with HIV were reported to the Ministry of Health, Jamaica, between 1988 and June 2008. Between the first and last time blocks, the modal age category remained constant (25-49 years) and the proportion of women reported with HIV non-AIDS increased from 32.5% to 61.4% (p < 0.001). However, the male: female ratio for persons reported with AIDS remained at 1.3:1 between 1995 and 2008. Although heterosexual transmission was the most frequent mode of transmission in each time period, sexual behaviour was consistently under-reported (4769 persons or 21% of all cases ever reported). Late stage diagnosis (AIDS or AIDS death) decreased significantly between the first and last time blocks (16% decline, p < 0.0001) with men, older persons and persons with unknown risk history being more likely to be diagnosed at AIDS or AIDS death. CONCLUSION: HIV testing and treatment programmes have improved timely diagnosis and reduced morbidity associated with HIV infection in Jamaica. However, new strategies must be developed to target men and older persons who are often diagnosed at a late stage ofdisease. Surveillance systems must be strengthened to improve understanding ofpersons reported with unknown risk behaviours and unknown sexual practices.

OBJETIVO: Delinear los cambios en la epidemiologia del VIH incluyendo patrones de morbilidad y mortalidad sobre la base de tres momentos claves de la respuesta de Jamaica frente al VIH. MÉTODO: Se analizaron datos de vigilancia del sistema de rastreo epidemiológico del VIH/SIDA (HATS) en Jamaica, y se determinó la distribución de casos por edad, género, práctica sexual, factores de riesgo, y características clinicas en los tres periodos de tiempo siguientes. (1988-1994): Establecimiento formal de vigilancia del VIH a nivel nacional. (1995 - 2003): Introducción de la terapia TARGA a nivel global. (2004 - junio 2008): Introducción de la terapia TARGA y pruebas rápidas de VIH en Jamaica. Asimismo se determinaron los factores que predijeron el diagnóstico en fase tardia (SIDA o muerte por SIDA). RESULTADOS: Entre 1988 y junio de 2008, se reportaron 22 603 personas con VIH al Ministerio de Salud de Jamaica. Entre el primer y el último bloque de tiempo, la categoria modal edad permaneció constante (25-49 anos) y el número de mujeres reportadas con VIH sin SIDA aumentó de 32.5% a 61.4% (p < 0.001). Sin embargo, la proporción varón:hembra entre las personas reportadas con SIDA permaneció en 1.3:1 entre 1995 y 2008. Aunque la transmisión heterosexual fue el modo de transmisión más frecuente en cada periodo del tiempo, los reportes sobre comportamiento sexual fueron persistentemente insuficientes (sólo 4769 personas o 21% de todos los casos reportaron alguna vez). El diagnóstico de fase tardia (SIDA o muerte por SIDA) disminuyó significativamente entre el primer y el último bloque de tiempo (una disminución del 16%, p < 0.0001), con una mayor probabilidad de diagnóstico de SIDA o muerte por SIDA entre los hombres, las personas de más edad y las personas con una historia de riesgo desconocida. CONCLUSIÓN: La prueba de VIHy los programas de tratamiento han mejorado el diagnóstico oportuno y reducido la morbilidad asociada con la infección por VIH en Jamaica. Sin embargo, se hace imprescindible desarrollar nuevas estrategias destinadas a hombres y personas de edad que a menudo reciben el diagnóstico en una etapa avanzada de la enfermedad. Deben fortalecerse los sistemas de vigilancia para mejorar la comprensión de las personas reportadas con conductas de riesgo desconocidas y prácticas sexuales desconocidas.

Response to first line HAART using CD4 cell counts: experience in a University Hospital in Kingston / Respuesta a la terapia TARGA de primera línea usando conteos CD4: experiencia en el Hospital Universitario en Kingston

OBJECTIVES: To assess the extent to which the current practice for first line therapy concurs with the recommended guidelines and to examine the response of treatment naïve patients to first line Highly Active Antiretroviral Therapy (HAART) at the University Hospital of the West Indies, using CD4 cell counts. METHODS: Over a three-month period, a cross-sectional study design was instituted and data were collected on all patients on HAART at the University Hospital ofthe West Indies (UHWI) outpatient HIV clinic. Information was collected by reviewing patient medical records using data collection sheets. The data obtained from the medical records included: age, gender, date of diagnosis of HIV, date at which HAART was commenced, CD4 cell counts prior to the commencement of antiretrovirals, the initial HAART regimes and subsequent CD4 cell counts. RESULTS: A total of 165 persons who met the criteria of being on HAART therapy were enrolled in the study. The average time span between diagnosis of HIV and commencement of antiretroviral therapy was 1.92 years and the range for this was 0 to 12.29 years. The average CD4 count prior to initiation of HAART was 186 cells/mm³. The most common regime used at the UHWI for first line therapy was combivir and efavirenz, n = 78 (47.3%), followed by combivir and nevirapine, n = 29 (17.6%). The average difference between the initial CD4 count prior to the initiation of HAART and first repeated CD4 count was 102 cells/mm³. The mean time between the first and repeated CD4 cell counts was 376 days. CONCLUSION: The recommended guidelines were adhered to for the majority of patients initiated on antiretrovirals at the UHWI. The treatment outcomes achieved at the UHWI were similar to those achieved in developed countries. This gives substantial evidence in support of international efforts to make antiretroviral therapy available in developing countries.

OBJETIVOS: Evaluar hasta que punto la práctica actual de la terapia de primera línea concuerda con las normas recomendadas y examinar la respuesta al tratamiento por parte de los pacientes nunca antes sometidos a la terapia antiretroviral altamente activa, (TARGA) en el Hospital Universitario, usando conteos de células CD4. MÉTODOS: Por un periodo de tres meses, se instituyó un diseno de estudio transversal, y se recogieron datos de todos los pacientes sometidos a TARGA en la clínica de VIH para pacientes externos en el Hospital Universitario de West Indies (UHWI). La información fue obtenida revisando las historias clínicas de todos pacientes, usando hojas de recogida de datos. Los datos obtenidos de las historias clínicas incluían: edad, género, fecha de diagnóstico de VIH, fecha de comienzo de TARGA, conteo de células CD4 antes del comienzo de los antiretrovirales, los regimenes iniciales de TARGA y los subsecuentes conteos de células CD4. RESULTADOS: Un total de 165 personas que satisfacían los criterios de la terapia TARGA fueron enroladas en el estudio. El tiempo promedio que medió entre el diagnóstico de VIHy el comienzo de la terapia antiretroviral fue 1.92 anos, en tanto el rango para esta fue de 0 a 12.29 anos. El conteo promedio de conteo de CD4 antes del comienzo de TARGA fue 186 células/mm3. El régimen más común usado en UHWIpara la terapia de primera línea fue combivir y efavirenz, n = 78 (47.3%), seguido por el combivir y nevirapine, n = 29 (17.6%). La diferencia promedio entre el conteo inicial de CD4 antes del comienzo de TARGA y elprimer conteo repetido de CD4 fue 102 células/mm3. El tiempo promedio entre los primeros conteos CD4 y los repetidos fue 376 días. CONCLUSIÓN: Se siguieron las normas recomendadas en relación con la mayoría de los pacientes iniciados en el tratamiento con antiretrovirales en UHWI. Los resultados del tratamiento logrados en UHWI fueron similares a los logrados en los países desarrollados. Esto ofrece sólidas evidencias en apoyo a los esfuerzos internacionales por poner la terapia antiretroviral a disposición de los países en vías de desarrollo.

Disclosure of HIV status among HIV Clinic attendees in Jamaica / Revelación del estado de VIH entre los pacientes que asisten a la Clínica de VIH en Jamaica

OBJECTIVE: This study aimed to examine factors related to disclosure of HIV serostatus among clinic attendees in an outpatient HIV clinic at the University Hospital of the West Indies (UHWI). METHODS: This was a cross-sectional survey of 107 attendees to a HIV clinic at the University Hospital of the West Indies. Participants were selected on a convenience basis. The instrument was developed for this study and covered socio-demographic data and self-report of disclosure and other variables related to HIV experience such as perceptions of family support. Data were analysed using non-parametric tests. RESULTS: Findings demonstrate a 49% disclosure rate among males and 60% among females. The results further indicate that age, sexual orientation, mode of transmission, and perception of family support were significantly associated with disclosure. Age and perception of family support were found to be significantly associated with consistent condom use. Age and perception of family support were the factors demonstrating the most significant correlations with age being significantly associated with disclosure to partner. Perception of family support was significantly associated with disclosure to family. CONCLUSION: Findings from this study demonstrate a low disclosure rate among HIV clinic attendees. Given that disclosure of HIV serostatus is critical in the control of the spread of HIV, this report highlights the need for the development of prevention interventions focussed on de-stigmatization for both infected and non-infected persons.

OBJETIVO: Este estudio tiene por objeto examinar factores relacionados con el dar a conocer el seroestado de VIH entre los pacientes externos que asisten a la clínica de VIH en el Hospital Universitario de West Indies (UHWI). MÉTODOS: Se realizó un estudio transversal de 107 asistentes a una clínica de VIH en el Hospital Universitario de West Indies. Se seleccionaron los participantes de acuerdo con las conveniencias. El instrumento fue desarrollado para este estudio y abarcó los datos sociodemográficos así como autoreportes de la revelación del estado y otras variables relacionados con la experiencia del VIH, tales como las percepciones de apoyo familiar. Los datos fueron analizados usando pruebas no paramétricas. RESULTADOS: Los resultados muestran una tasa de revelación de 49% entre los varones y 60% entre las hembras. Los resultados también indican que la edad, la orientación sexual, el modo de transmisión, y la percepción de apoyo familiar, estuvieron significativamente asociados con la revelación de esta condición. La edady la percepción del apoyo familiar estuvieron significativamente asociadas con el uso consistente del condón. La edad y la percepción del apoyo familiar fueron los factores que demostraron las correlaciones más significativas, hallándose la edad significativamente asociada con la revelación de la condición a las parejas. La percepción del apoyo familiar estuvo significativamente asociada con la revelación de la condición a la familia. CONCLUSIÓN: Los resultados de este estudio demuestran una baja tasa de revelación entre los asistentes a la clínica de VIH. Puesto que dar a conocer el seroestado de VIH es un aspecto crítico en el control de la diseminación del VIH, este informe resalta la necesidad de desarrollar intervenciones de prevención encaminadas a la desestigmatización tanto para los infectados como para los no infectados.

Depression among persons attending a HIV/AIDS outpatient clinic in Kingston, Jamaica.

OBJECTIVES: To determine the prevalence of depression among persons attending a HIV/AIDS clinic in Kingston, Jamaica, and to explore the possible role of patient-specific clinical and social issues as intermediary factors in the relationship between HIV/AIDS and depression. SUBJECTS AND METHODS: Over a three-month period, all eligible and consenting patients from a HIV/ AIDS clinic in Kingston, Jamaica, were invited to participate in the study. They were interviewed using the Patient Health Questionnaire (PHQ-9), an instrument validated for the detection of depression in primary care settings. Clinical and socio-demographic data were retrieved for all participating patients from a pre-existing clinic database. Depression prevalence rates were calculated and the association between depression and age, gender, antiretroviral treatment, CD4 count, living arrangement, marital status and major stressors explored. RESULTS: Sixty-three patients participated in the study and 43% (n = 36) of them were depressed. No significant differences in depression rates were found with respect to any of the sociodemographic or clinicalfactors explored (p > 0.05). CONCLUSION: The relatively high prevalence of depression among attendees at the HIV/AIDS clinic underscores the need for depression screening in these patients.

An analysis of three opportunistic infections in an outpatient HIV clinic in Jamaica.

OBJECTIVES: To determine the occurrence of opportunistic infection (OI) in HIV-positive patients and to identify any risk factors which may be associated with such. METHODS: A cross-sectional study of all patients attending the HIV out-patient clinic was conducted. Their hospital notes were examined between January 1 and December 31, 2007 inclusive, to identify any occurrence of opportunistic infection. In addition, the patient list was also cross-referenced with all patients hospitalized on the medical wards during the same time period. Clinical and demographic data were collected for all participants. The occurrence of opportunistic infections and the variables of age, gender CD4 counts and viral loads: (first ever last in 2007 and at diagnosis of OI [or within six months]), the use of primary and secondary prophylaxis, the discontinuation of prophylactic regimens and the HAART regime at diagnosis of an OI and the diagnostic and treatment protocols of these infections were calculated. RESULTS: Six hundred and three patients participated in the study and 4.7% (n = 28) were found to have experienced at least one opportunistic infection in 2007. Significant associations were found between first and last CD4 cell count, viral load in 2007, year of entry into the clinic and death (p < 0.05). CONCLUSIONS: Opportunistic infections continue to cause significant morbidity and mortality in the HIV-patient population in this study. Earlier entry to treatment facilities and the use of HAART and appropriate prophylaxis can reduce this impact and lead to improved quality of life for HIV-positive individuals.

Sociodemographics and clinical presentation of HIV in Jamaica over 20 years. A comparative analysis of surveillance data.

OBJECTIVE: To delineate changes in the epidemiology of HIV including morbidity and mortality patterns based on three key time points in Jamaica's HIV response. METHOD: Surveillance data from Jamaica's HIV/AIDS Tracking system (HATS) were analysed and distribution of cases by age, gender sexual practice, risk factors and clinical features were determined for three time periods (1988-1994: formal establishment of HIV surveillance at the national level, 1995-2003: introduction of HAART globally; 2004-June 2008: introduction of HAART and HIV rapid testing in Jamaica). Factors that predicted late stage diagnosis (AIDS or AIDS death) were also determined RESULTS: 22 603 persons with HIV were reported to the Ministry of Health, Jamaica, between 1988 and June 2008. Between the first and last time blocks, the modal age category remained constant (25-49 years) and the proportion of women reported with HIV non-AIDS increased from 32.5% to 61.4% (p < 0.001). However the male:female ratio for persons reported with AIDS remained at 1.3:1 between 1995 and 2008. Although heterosexual transmission was the most frequent mode of transmission in each time period, sexual behaviour was consistently under-reported (4769 persons or 21% of all cases ever reported). Late stage diagnosis (AIDS or AIDS death) decreased significantly between the first and last time blocks (16% decline, p < 0.0001) with men, older persons and persons with unknown risk history being more likely to be diagnosed at AIDS or AIDS death. CONCLUSION: HIV testing and treatment programmes have improved timely diagnosis and reduced morbidity associated with HIV infection in Jamaica. However new strategies must be developed to target men and older persons who are often diagnosed at a late stage of disease. Surveillance systems must be strengthened to improve understanding of persons reported with unknown risk behaviours and unknown sexual practices.

Response to first line HAART using CD4 cell counts experience in a university hospital in Kingston.

OBJECTIVES: To assess the extent to which the current practice for first line therapy concurs with the recommended guidelines and to examine the response of treatment naïve patients to first line Highly Active Antiretroviral Therapy (HAART) at the University Hospital of the West Indies, using CD4 cell counts. METHODS: Over a three-month period, a cross-sectional study design was instituted and data were collected on all patients on HAARTat the University Hospital of the West Indies (UHWI) outpatient HIV clinic. Information was collected by reviewing patient medical records using data collection sheets. The data obtained from the medical records included: age, gender date of diagnosis of HIV date at which HAART was commenced, CD4 cell counts prior to the commencement of antiretrovirals, the initial HAART regimes and subsequent CD4 cell counts. RESULTS: A total of 165 persons who met the criteria of being on HAART therapy were enrolled in the study The average time span between diagnosis of HIV and commencement of antiretroviral therapy was 1.92 years and the range for this was 0 to 12.29 years. The average CD4 count prior to initiation of HAART was 186 cells/mm3. The most common regime used at the UHWI for first line therapy was combivir and efavirenz, n = 78 (47.3%), followed by combivir and nevirapine, n = 29 (17.6%). The average difference between the initial CD4 count prior to the initiation of HAART and first repeated CD4 count was 102 cells/mm3. The mean time between the first and repeated CD4 cell counts was 376 days. CONCLUSION: The recommended guidelines were adhered to for the majority of patients initiated on antiretrovirals at the UHWI. The treatment outcomes achieved at the UHWI were similar to those achieved in developed countries. This gives substantial evidence in support of international efforts to make antiretroviral therapy available in developing countries.

Disclosure of HIV status among HIV clinic attendees in Jamaica.

OBJECTIVE: This study aimed to examine factors related to disclosure of HIV serostatus among clinic attendees in an outpatient HIV clinic at the University Hospital of the West Indies (UHWI). METHODS: This was a cross-sectional survey of 107 attendees to a HIV clinic at the University Hospital of the West Indies. Participants were selected on a convenience basis. The instrument was developed for this study and covered socio-demographic data and self-report of disclosure and other variables related to HIV experience such as perceptions of family support. Data were analysed using nonparametric tests. RESULTS: Findings demonstrate a 49% disclosure rate among males and 60% among females. The results further indicate that age, sexual orientation, mode of transmission, and perception of family support were significantly associated with disclosure. Age and perception of family support were found to be significantly associated with consistent condom use. Age and perception of family support were the factors demonstrating the most significant correlations with age being significantly associated with disclosure to partner. Perception of family support was significantly associated with disclosure to family. CONCLUSION: Findings from this study demonstrate a low disclosure rate among HIV clinic attendees. Given that disclosure of HIV serostatus is critical in the control of the spread of HIV this report highlights the need for the development of prevention interventions focussed on de-stigmatization for both infected and non-infected persons.