The Climate Change Burden on Immune Health: Are Persons Living with HIV More at Risk?

Climate change poses one of the most significant modern threats to overall human health,especially for vulnerable populations including persons living with HIV (PLWH). In this perspective, we specifically explore the concept of immune resilience in human health and how climate change phenomena - including extreme weather events, food insecurity, pollution, and emerging diseases - may exacerbate immune dysfunction and comorbidities faced by PLWH and hinder access to HIV treatment and prevention services. Multidisciplinary, collaborative efforts are urgently needed to quantify these impacts, develop mitigation strategies, and strengthen policies and funding to bolster immune resilience for PLWH in the face of accelerating climate change.

An educational initiative in response to identified PrEP prescribing needs among PCPs in the Southern U.S.

Pre-exposure prophylaxis (PrEP) is an effective HIV prevention method, but many primary care physicians (PCPs) have not incorporated PrEP into practice. While PrEP may be a key strategy to reducing high HIV transmission rates in the southern US, knowledge about PrEP prescribing patterns among PCPs in this region is lacking. An online survey was sent to a large network of PCPs at an academic medical center in North Carolina in October 2015. The survey was repeated in September 2016, after an educational intervention that included on-site trainings at 14 PCP offices. Chi-square tests were used to compare PrEP prescribing patterns among providers. The initial survey was sent to 389 PCPs, with 115 (30%) responding. Of these, 78% reported seeing men who have sex with men (MSM). Only 17% had prescribed PrEP. The most frequently identified barrier was lack of knowledge (60%). When the survey was repeated after the educational initiative, 79 PCPs (20%) responded. Of these, 90% reported seeing MSM, and 35% had prescribed PrEP. PCPs who had attended a training were more likely to have prescribed PrEP (OR 4.84, CI 1.77-13.21). In conclusion, PrEP prescribing among PCPs in the southern US is low. A survey among PCPs identified lack of knowledge as a barrier to prescribing, motivating an institutional-wide educational campaign in response. Further efforts are needed to continue to raise awareness and educate PCPs in the South about PrEP.

Closing the Gap? The HIV Continuum in Care for African-American Men Who Have Sex with Men, San Francisco, 2004-2014.

We examined trends in the HIV continuum in care in the National HIV Behavioral Surveillance surveys for MSM in San Francisco from 2004 to 2014. In 2004, HIV-positive African-American MSM were less likely to be diagnosed (42.9 vs. 87.5 %, p = 0.003), linked to care (42.9 vs. 85.7 %, p = 0.007), or to have ever used antiretroviral treatment (ART) (28.6 vs. 69.6 %, p = 0.032) compared to white MSM. By 2014, these gaps had narrowed but not closed, including diagnosis (85.7 vs. 100 %, Fisher's exact p = 0.106), linkage to care (85.7 vs. 96.8 %, Fisher's exact p = 0.290), and ART use (85.7 vs. 94.9 %, Fisher's exact p = 0.369).

Treatment of syphilis: a systematic review.

IMPORTANCE: The incidence of syphilis in the United States is increasing; it is estimated that more than 55,000 new infections will occur in 2014. Treatment regimens are controversial, especially in specific populations, and assessing treatment response based on serology remains a challenge. OBJECTIVE: To review evidence regarding penicillin and nonpenicillin regimens, implications of the "serofast state," and treatment of specific populations including those with neurosyphilis or human immunodeficiency virus (HIV) infection and pregnant women. EVIDENCE REVIEW: We searched MEDLINE for English-language human treatment studies dating from January 1965 until July 2014. The American Heart Association classification system was used to rate quality of evidence. FINDINGS: We included 102 articles in our review, consisting of randomized trials, meta-analyses, and cohort studies. Case reports and small series were excluded unless they were the only studies providing evidence for a specific treatment strategy. We included 11 randomized trials. Evidence regarding penicillin and nonpenicillin regimens was reviewed from studies involving 11,102 patients. Data on the treatment of early syphilis support the use of a single intramuscular injection of 2.4 million U of benzathine penicillin G, with studies reporting 90% to 100% treatment success rates. The value of multiple-dose treatment of early syphilis is uncertain, especially in HIV-infected individuals. Less evidence is available regarding therapy for late and late latent syphilis. Following treatment, nontreponemal serologic titers should decline in a stable pattern, but a significant proportion of patients may remain seropositive (the "serofast state"). Serologic response to treatment should be evident by 6 months in early syphilis but is generally slower (12-24 months) for latent syphilis. Evidence defining treatment for HIV-infected persons and for pregnant women is limited, but available data support penicillin as first-line therapy. CONCLUSIONS AND RELEVANCE: The mainstay of syphilis treatment is parenteral penicillin G despite the relatively modest clinical trial data that support its use.

Enhancing linkage and retention in HIV care: a review of interventions for highly resourced and resource-poor settings.

Given the widespread availability of effective antiretroviral therapy, engagement of HIV-infected persons in care is a global priority. We reviewed 51 studies, published in the past decade, assessing strategies for improving linkage to and retention in HIV care. The review included studies from highly resourced settings (HRS) and resource-poor settings (RPS), specifically the USA and sub-Saharan Africa. In HRS, strength-based case management was best supported for improving linkage and retention in care; peer navigation and clinic-based health promotion were supported for improving retention. In RPS, point of care CD4 testing was best supported for improving linkage to care; decentralization, and task-shifting for improving retention. Novel interventions continue to emerge in HRS and RPS, yet many strategies have not been adequately evaluated. Further consideration should be given to analyses that identify which interventions, or combinations of interventions, are most effective, cost-effective, scalable, and aligned with patient preferences for HIV care.

Role of raltegravir in the management of HIV-1 infection.

The development of multiple agents with potent antiretroviral activity against HIV has ushered in a new age of optimism in the management of patients infected with the virus. However, the viruses' dynamic ability to develop resistance against these agents necessitates the investigation of novel targets for viral suppression. Raltegravir represents a first-in-class agent targeting the HIV integrase enzyme, which is responsible for integration of virally encoded DNA into the host genome. Over the last 5 years, clinical trials data has demonstrated an increasing role for raltegravir in the management of both treatment-experienced and treatment-naïve HIV-1-infected patients. This review focuses on the evidence supporting raltegravir's efficacy in an array of clinical settings. Other HIV-1 integrase inhibitors in development are also briefly discussed.

Comparison of blood, bone marrow aspirate, stool and urine cultures in the diagnosis of enteric fever.

A total of 288 specimens made up of 84 specimens each of blood, stool, urine and 36 specimens of bone marrow aspirates were collected from enteric fever patients. The blood specimen was used for cultural diagnosis and malaria parasite (MP) test, while serum from the blood was screened by Widal test. The remaining specimens (bone marrow aspirate, stool and urine) were only used for cultural diagnosis, but their cultural diagnostic sensitivity were only calculated from the patients whose Widal tests were positive. The widal test showed that 21(25%) had significant reciprocal titre levels of > 80 and > 160 for O and H antigens respectively. Malaria parasites test also had 23(37.4%) cases positive with 1(4.4%) and 22(95.7%) of them positive and negative by widal test respectively. Stool, blood and bone marrow aspirate were 33%, 28.6% and 38.1% sensitive respectively, while the diagnostic sensitivity of urine was zero. In the diagnosis of enteric fever, it is suggested that the presumptive serology test (Widal) be carried out along with cultures from bone marrow aspirate and stool where the former is affordable and available. Malaria parasite microscopy should also be done because majority of the suspected enteric fevers may actually only be malaria fever in an environment like Nigeria which is endemic for the two diseases (malaria and typhoid fever).

The Imo State (Nigeria) Drinking Water Supply and Sanitation Project, 1. Description of the project, evaluation methods, and impact on intervening variables.

A health impact evaluation was conducted in conjunction with the Imo State Drinking Water Supply and Sanitation Project in Nigeria. The project consisted of a package of water supply, sanitation, and health and hygiene education given by village-based workers. The evaluation was a quasi-experimental study covering pre-, peri- and post-intervention periods. Data were collected from 3 intervention and 2 control villages. Baseline surveys indicated that the intervention and control areas were similar with respect to most socio-demographic variables. Use of the improved water supply was high, although this was influenced by borehole-to-population ratios and household-to-borehole distances. Water collection time was consequently greatly reduced. Data from a small sample of households showed that borehole water became heavily contaminated during collection and storage, and that there was no significant change in consumption of water per person. Adults in 46% of household units in the intervention area were using ventilated improved pit latrines by the end of the study period. Use by young children (2-5 years old), however, was low. Limitations in the success of the health education component of the project were found. Although changes were found in knowledge, attitudes and practices related to water and sanitation, and in management of childhood diarrhoea, this occurred in both the intervention and control areas.

The Imo State (Nigeria) Drinking Water Supply and Sanitation Project, 2. Impact on dracunculiasis, diarrhoea and nutritional status.

Morbidity due to dracunculiasis (guinea worm disease) and diarrhoea in persons of all ages, and nutritional status of young children, were used as health impact indicators in the evaluation of the Imo State Drinking Water Supply and Sanitation Project in south-eastern Nigeria. Data were collected using repeated cross-sectional surveys and longitudinal follow-up. The study area was found to have a low level of endemicity of dracunculiasis. While no impact could be demonstrated on overall period or point prevalence rates in the cross-sectional surveys, a prospective longitudinal survey showed a significant reduction in the percentage of person-fortnights positive for dracunculiasis in areas served by the project, while the control areas showed no such change. In the cross-sectional surveys it was found that, in the project villages, those persons drinking only borehole water had significantly lower period prevalence rates one year later than others. Moreover, those living further from the nearest borehole had higher rates of dracunculiasis. An impact of the project on diarrhoea morbidity was found only in limited sub-groups of the population. A greater association with water availability rather than quality was suggested for rates in young children. The prevalence of wasting (less than 80% weight-for-height) among children aged less than 3 years decreased significantly over time in all 3 intervention villages; there was no such decline in the control villages.

Disability from dracunculiasis: effect on mobility.

A study was conducted in northeastern Imo State to define the disability and restriction of mobility associated with dracunculiasis. The study was part of an evaluation of the UNICEF-assisted Drinking Water Supply and Sanitation Project in Imo State, Nigeria. A sample of household units (100 in year 1, 195 in year 2) was visited every two weeks to determine who was affected by dracunculiasis and to characterize the extent of related disability. The average duration of symptoms was 12.7 weeks (range 3-29 weeks). Fifty eight per cent of all episodes of disease resulted in severe disability (with the individual unable to leave the compound) lasting a mean of 4.2 weeks (range 2-12). The mean period of severe disability was significantly higher for those aged 50 years and over than for those less than 50 years old. In the area studied, the disease occurred during the peak yam and rice harvest time and the period of preparation for the planting season. This is the first study to document systematically and prospectively the marked restriction of normal activity in affected individuals and the long duration of the disability. These findings can assist in improving estimates of the costs associated with dracunculiasis and of potential economic benefits if the disease were eradicated.