Metabolic syndrome in patients on first-line antiretroviral therapy containing zidovudine or tenofovir in rural Lesotho, Southern Africa.

OBJECTIVE: To assess the prevalence of metabolic syndrome (MetS) among patients in rural Lesotho who are taking first-line antiretroviral therapy (ART) containing either zidovudine or tenofovir disoproxil. METHODS: Cross-sectional survey in 10 facilities in Lesotho among adult (≥16 years) patients on non-nucleoside reverse transcriptase inhibitor (NNRTI)-based first-line ART for ≥6 months. MetS was defined according to the International Diabetes Federation criteria. RESULTS: Among 1166 patients (65.8% female), 22.2% (95% CI: 19.3-25.3) of women and 6.3% (4.1-9.1) of men met the IDF definition of MetS (P < 0.001). In both sexes, there was no significant difference in MetS prevalence between NNRTIs. However, in women taking zidovudine as nucleoside reverse transcriptase inhibitor (NRTI), MetS prevalence was 27.9%, vs. 18.8% in those taking tenofovir. In the multivariate logistic regression allowing for socio-demographic and clinical covariates, ART containing zidovudine was associated with MetS in women (aOR 2.17 (1.46-3.22), P < 0.001) but not in men. CONCLUSION: In this study, taking ART containing zidovudine instead of tenofovir disoproxil was an independent predictor of MetS in women but not in men. This finding endorses WHO's recommendation of tenofovir as preferred NRTI.

Higher rates of metabolic syndrome among women taking zidovudine as compared to tenofovir in rural Africa: preliminary data from the CART-1 study.

INTRODUCTION: Due to its side effects stavudine (D4T) has been replaced by zidovudine (AZT) and tenofovir (TDF) in most low- and middle-income countries (LMICs). In 2014 about 38% of adult first-line regimens contain AZT and 62% TDF [1]. Whereas the unfavourable metabolic outcomes of D4T in comparison to TDF have been described extensively, studies from LMICs comparing metabolic profiles between patients on AZT and TDF are scarce. Given the high number of patients in LMICs still taking AZT, data on their metabolic profile are needed. We present rates of metabolic syndrome (MS) in adult patients taking either AZT- or TDF-containing first-line, non-nucleoside reverse transcriptase (NNRTI)-based regimens. MATERIALS AND METHODS: Data derived from a cross-sectional multi-disease screening conducted in ten facilities in two rural districts of Lesotho, Southern Africa [2]. Patients were eligible if aged ≥25 years and on NNRTI-containing first-line ART ≥6 months. The MS definition for Africa of the International Diabetes Federation was applied [3]. Assessed potential predictors for MS were age, time on ART, virologic suppression, body-mass index (BMI), alcohol consumption, wealth quintile, NNRTI (nevirapine (NVP) or Efavirenz (EFV)), history of previous D4T exposure and ART-backbone (AZT or TDF). Statistical analyses - stratified for sex - comprised univariate logistic regression for each predictor variable with subsequent construction of a multivariate model including all predictors with an association to MS at a significance level<0.1 in univariate analysis. RESULTS: Out of 1026 patients, 660 (64.3%) were female. MS prevalence was 9.8% (95% CI 6.9-13.4) in men and 22.9% (19.7-26.3) in women. In women, aged ≥35 years, AZT-backbone, NVP-base, BMI ≥25kg/m2 and taking ART for ≥4.5 years were associated with MS in univariate analysis. In the multivariate model only AZT (adjusted odds-ratio: 2.2, 95% CI 1.4-3.6; p=0.001) and BMI ≥25kg/m2 (9.8; 2.8-34.1, p<0.001) were associated with MS. For men, age, higher wealth quintile, history of D4T exposure and BMI were associated with MS in univariate analysis. In the multivariate model only a BMI ≥25kg/m2 was associated with MS (8.9; 3.8-20.9, p<0.001). CONCLUSIONS: In rural Lesotho, Southern Africa, the use of AZT instead of TDF among women who are on ART for ≥6 months predisposes to the development of metabolic syndrome. Given that, still 38% of first-line regimens in LMIC contain AZT, this finding needs to be verified in other settings in Sub-Saharan Africa.

Clinical and socio-demographic predictors for virologic failure in rural Southern Africa: preliminary findings from CART-1.

INTRODUCTION: In 2013, the World Health Organization (WHO) recommended scaling up of routine viral load (VL) monitoring for patients on antiretroviral therapy (ART) in resource-limited settings [1]. During the transition phase from no VL-testing at all to routine VL-monitoring, targeted VL for groups at particular risk of virologic failure (VF) may be an option [2]. We present socio-demographic and clinical risk factors for VF in a cohort in rural Lesotho with no access to VL prior to the study. MATERIALS AND METHODS: Data derive from a cross-sectional study providing multi-disease screening as well as VL testing to adult patients (≥16 years old) on first-line ART ≥6 months [3]. VF was defined as VL≥1000 copies/mL. Assessed potential predictors of VF were: (1) socio-demographic (sex, age, wealth-quintile, education, employment status, disclosure of HIV status to environment, travel-time to facility); (2) treatment history (history of treatment interruption >2 days, previous drug substitution within first-line ART, time on ART, ART-base and -backbone); (3) adherence (pill count) and (4) clinical (clinical or immunological failure as defined by WHO guidelines [1], presence of papular pruritic eruption (PPE)). All variables with association to VF in univariate analysis were included in a multivariate logistic regression reporting adjusted Odds ratios (aOR). RESULTS: Data from 1,488 patients were analyzed. Overall VF-prevalence was 6.9% (95% CI 5.7-8.3). In univariate analysis, the following were associated with VF: age <30, lower wealth-quintile, no primary education, history of treatment interruption, nevirapine-base, zidovudine-backbone, history of drug substitution, travel-time to clinic ≥2 hours, disclosure of HIV status to <5 persons, clinical failure, presence of PPE and immunological failure. In multivariate analysis, 6 out of the above 12 variables were independent predictors: age <30 years (aOR: 2.4; 95% CI 1.1-5.3, p=0.029), history of treatment interruption (2.5; 1.3-4.7, p=0.005), PPE (6.9; 2.5-18.9, p<0.001), immunological failure (11.5; 5.7-23.2, p<0.001), history of drug substitution (1.9; 1.0-3.7, p=0.043), disclosure of HIV status to <5 persons (1.8; 1.1-3.1, p=0.03). CONCLUSION: In this cohort in rural Lesotho, several socio-demographic and clinical predictors were associated with VF. Particularly age <30 years, history of treatment interruption, PPE and immunological failure were strongly associated with VF. These patients may be prioritized for targeted VL-testing.

The effect of perioperative distal vasal lavage on subsequent semen analysis after vasectomy: a prospective randomized controlled trial.

OBJECTIVE: To determine the effect of perioperative distal vasal lavage with 50 mL of normal saline on subsequent time to azoospermia after vasectomy. PATIENTS AND METHODS: Seventy-two patients were prospectively enrolled and randomized to undergo vasectomy with or without vasal lavage. Infertility rates at 8, 10 and 12 weeks were compared for both groups and for those undergoing the procedure under local or general anaesthesia. Patient compliance for returning postoperative semen for analysis was also assessed. RESULTS: There was no statistically significant difference in infertility rates at 8, 10 or 12 weeks after vasectomy with or without vasal lavage. Vasectomies performed under local and general anaesthesia had comparable rates of infertility at 12 weeks after surgery. Compliance in providing semen for analysis was poor. CONCLUSION: The routine adoption of distal vasal lavage during vasectomy for contraception cannot be recommended. As compliance in providing semen for analysis was poor, the clinician has a responsibility to remind the patient of the consequences of such action.

Evolution of an inguinal hernia surgery practice.

BACKGROUND: Inguinal hernia surgery has undergone numerous advances in the last few years. This study analysed the changes in the practice of one surgeon in a district general hospital over a seven year interval. The effect of changing from Bassini to Lichtenstein repair in 1994 was evaluated. METHODS: The study involved two parts: first a search of a computerised database of inguinal hernia procedures, and second, postal audits of men who had an inguinal hernia repair in 1993 and 1994 with outpatient follow up for those with a possible recurrence. RESULTS: A total of 1037 hernias were repaired over the seven years. There was an increase in the proportion of day cases from 18% to 70% and the number of operations performed under local anaesthetic rose from 1% to 45%. The postal audits had response rates of 79% (1993) and 66% (1994). Some 5/98 (5%) recurrent hernias were identified from the 1993 (Bassini) patients compared with 1/67 (1.5%) from the 1994 (Lichtenstein) cohort. CONCLUSION: Lichtenstein hernia repair can be performed safely as a day case using local anaesthetic in the majority of patients and appears to have a lower recurrence rate than Bassini repair.

Pediatric ocular injuries in Lesotho.

One hundred and ten children were evaluated in a prospective study in Lesotho to determine the pattern of pediatric ocular injuries in a developing African country. The pattern was found to be the same as that of developed countries regarding increased incidence in boys, frequency of accidental, self-inflicted and assault injuries, and high incidence of corneal lacerations, traumatic cataracts, hyphemas, and lid lacerations. The pattern differed from developed countries in the absence of injuries due to arrows, airgun pellets (BBs), fireworks, toys and chemical burns, the absence of orbital fractures, intra-ocular metallic foreign bodies, and rarity of retinal detachment, and the generally poor visual results following perforating ocular injuries. An information campaign is advocated in Lesotho to aid in the prevention of pediatric ocular injuries.

Screening of pre-school and school children for ocular anomalies in Lesotho.

One thousand two hundred and ninety-six pre-school and school children were examined in the first screening programme for ocular anomalies in Maseru, Lesotho. One hundred and eighteen children (8.9%) were found to have significant ocular anomalies requiring treatment. The most common anomalies included refractive errors, squint, convergence insufficiency, amblyopia, vernalis, lid abnormalities, leukoma cornea, and cataract. The importance of school screening for ocular anomalies in a developing African nation is emphasized.

Diabetic retinopathy in Lesotho.

Diabetic retinopathy was found in 47.8% of 153 consecutive diabetic clinic patients examined in Maseru, Lesotho. Background retinopathy was present in 78% of patients with retinopathy, compared with 22% with proliferative changes. While no difference in prevalence of diabetic retinopathy could be demonstrated between the sexes, an association between diabetic retinopathy and hypertension and peripheral neuropathy was observed. The prevalence and severity of diabetic retinopathy was significantly related to the duration of disease. The pitfalls inherent in comparing the results of the current study with other published reports are considered. Better epidemiological surveys are required to determine the true prevalence of diabetic retinopathy among different racial, ethnic, religious, and tribal groups in Africa.

Adult ocular injuries in Lesotho.

Two hundred and fifty-two adults were evaluated in a prospective study in Lesotho to determine the pattern of ocular injuries in a developing African country. The pattern was found to be similar to that of developed countries regarding increased incidence in young males, high frequency of assault injuries, and high incidence of lacerations to lids, cornea and sclera. The pattern differed from developed countries in the low incidence of perforating ocular injuries associated with occupation, motor vehicles and sports, the absence of orbital fractures, metallic intra-ocular foreign bodies, the low incidence of retinal detachment, and the generally poor visual results following perforating ocular injuries. Additional ophthalmic facilities with improved medical transportation is advocated in Lesotho to improve the visual prognosis in ocular injuries.

Incidence of epibulbar tumors in lesotho.

A series of 18 epibulbar tumors are reported from Lesotho, a nontropical African country. The etiologic risk factors in epibulbar tumors are evaluated in termas of the environmental conditions present in Lesotho. The pathogenesis of epibulbar tumors is discussed in terms of histological progression from benign to malignant lesions following prolonged exposure to presumed etiologic risk factors.

Survey of ophthalmic conditions in rural Lesotho.

The first survey of ocular problems in rural Lesotho was conducted by a visiting eye team and consisted of an examination of 1266 ophthalmic clinic patients at 15 representative sites throughout the country. The most common ocular conditions encountered were: conjunctivitis, refractive error, vernalis, senile cataract, glaucoma, corneal opacities and trauma. This disease pattern differs from most developing African nations for reasons of climate, geography and diet. The absence of disciform macular degeneration, narrow-angle glaucoma, and rarity of retinal detachment was noted. The educational impact of the survey, and its importance for future planning are suggested.

Penetrating keratoplasty in Lesotho.

Sixty-four Basotho patients underwent therapeutic penetrating keratoplasty in Lesotho, a developing African nation. The overall long-term success rate of 60.7% was comparable to similar series in developed countries. Analysis of variables found to significantly affect graft outcome included size of graft, anterior segment pathology, postoperative iris adhesion to graft wound, and onset of graft rejection during hospitalization or after discharge. McCarey-Kaufman medium was found to be highly successful for corneal storage up to seven days, and corneal transplantation across racial lines was not associated with increased immune rejection reactions.

Penetrating keratoplasty in children.

Sixteen penetrating keratoplasties were performed in 14 patients less than 16 years old. Clear corneas were obtained in 62.5% of eyes with significantly improved vision in 56.2% of cases. The problems of postoperative treatments, complications, and amblyopia were found to be manageable. The visual benefits of corneal transplantation in selected cases in children appear to outweigh the difficulties and problems engendered by this procedure.