Updating a patient-level ART database covering remote health facilities in Zomba district, Malawi: lessons learned.

SETTING: A non-governmental organization, Dignitas International, working in partnership with the Ministry of Health in Malawi, adopted innovative, low-technology methods to collect, capture, and manage patient-level antiretroviral therapy (ART) data in a district database covering 26 remote low-resource facilities in Zomba District, Malawi. OBJECTIVE: To establish a longitudinal, observational database of routinely collected program data that could serve as a program monitoring and evaluation tool as well as a platform to conduct effective operational research. DESIGN: This article describes the processes developed for digital capture of paper-based ART clinical records at health facilities and updating them in a central electronic database. It documents and focuses on lessons learned during the implementation and review of processes. CONCLUSIONS: Data quality can only be ensured with regular review of, and compliance with, clearly delineated workflow protocols and adequate staffing and supervision. Through the implementation of this procedure, we expect to improve data quality, completeness, and use of routine ART clinical data in low-resource settings.

Burden, characteristics, management and outcomes of HIV-infected patients with Kaposi's sarcoma in Zomba, Malawi.

SETTING: Antiretroviral treatment (ART) clinic at Zomba Central Hospital, Malawi. DESIGN: Retrospective analysis of records (2004-2011) of human immunodeficiency virus (HIV) infected patients with Kaposi's sarcoma (KS). OBJECTIVES: To determine the number and characteristics of HIV-infected adult patients with KS on ART and vincristine (VCR) therapy and their treatment outcomes. RESULTS: A total of 545 HIV-infected patients with KS (58% male, median age 33 years) were included in the study. The baseline median CD4 count was 180 cells/µl (interquartile range 111-287). Cumulative outcomes were as follows: 168 (31%) were still alive, 133 (24%) had died, 172 (32%) were lost to follow-up and 71 (13%) had transferred out; 229 had received at least one course of VCR, 171 had received less than one full course and 145 had not received VCR. The survival probability for 229 patients who received at least one course of VCR was 65% at 1 year, 42% at 2 years and 13% by 6 years. Patients who started VCR therapy before or concurrently with ART had a higher risk of death and generally a higher risk of death and loss to follow-up than those who started VCR after ART. CONCLUSION: Poor outcomes were noted in HIV-infected patients with KS in a programme setting in Malawi. Other treatment interventions, including combination and/or second-line chemotherapy and earlier ART initiation, are needed to reduce morbidity and mortality.

The CD45RA+ (quiescent) cellular phenotype is overabundant relative to the CD45RA- phenotype within the involuted splenic T cell population of weanling mice subjected to wasting protein-energy malnutrition.

The objective of this investigation was to determine whether an imbalance between naive- and memory-phenotype cells occurs within CD4+ and/or CD8+ splenic T cell subsets in models of protein-energy malnutrition (PEM) which produce wasting disease (loss of approximately 1.6% of body weight per day for 14 d) and profound depression in thymus-dependent immunity. Male and female weanling mice of disparate inbred strains, CBA/J and C57BL/6J, were allocated to the following groups: zero-time control (23 d old and 19 d old, respectively), ad libitum intake of a complete purified diet (19% crude protein, 17 kJ/g gross energy), restricted intake of the complete diet, and (C57BL/6J, only) ad libitum intake of an isocaloric low protein diet (0.6% crude protein). Surface expression of isoforms of CD45, a component of the T cell receptor complex, as well as of the accessory molecule, CD2, were assessed by flow cytometry of splenic mononuclear cell suspensions. Both major T cell subsets in the malnourished groups contained a significantly higher proportion of cells expressing the surface marker, CD45RA, than was found in the spleen cells of the control groups. CD45RA+ (naive-phenotype) T cells represent the extreme of quiescence and stringent activation requirements among thymic lymphocytes. The results provide the first clear evidence of a T cell subset imbalance in PEM which is consistent with depression in acquired immunity and which occurs, apart from antigenic challenge, in a site wherein immune responses take place. The T cell receptor complex may emerge as a focal point of the depressive influence of PEM on the competence of thymic lymphocytes.