Hypertension and immune activation in antiretroviral therapy naïve people living with human immunodeficiency virus.

BACKGROUND: The pathogenesis of hypertension (HTN) in people living with HIV/AIDS (PLHIV) is complex and remains not fully understood. Chronic immune activation (IA) is postulated to be one of the culprits. This notion is derived from studies in HIV-uninfected populations and/or animals while data on HTN and how it relates to IA in PLHIV remains scarce. We determined the relationship between HTN and IA among antiretroviral therapy (ART) naïve PLHIV. METHODS: We analysed baseline data of 365 out of 430 clinical trial participants whose main aim was to investigate the effect of low-dose aspirin on HIV disease progression in PLHIV starting ART. Soluble CD14 (sCD14), T cells co-expressing CD38 and HLA-DR, and PD-1 were the IA and exhaustion markers, respectively studied and were analysed by flow cytometry. Mann-Whitney U-test was used for comparison of the markers by HTN status. A robust Poisson regression model was used to determine the predictors for HTN. RESULTS: A quarter of the 365 were hypertensive (25.3%, 95% CI 20.9-29.8%), and, had higher median (IQR) body mass index (kg/m2) (23.4 (19.6, 28.0) versus 21.9 (19.3, 25.1)) and lower median (IQR) estimated glomerular filtration rate (mL/min/1.73m2) (101.2 (79.4, 126.9) versus 113.6 (92.7, 138.8)) than normotensive participants (p < 0.05). Participants with HTN had higher median frequencies of all markers of IA and exhaustion but lower sCD14 (p > 0.05). None of these markers significantly predicted the occurrence of HTN. CONCLUSION: Studied markers of IA and exhaustion were higher in PLHIV with HTN than those without but were unpredictive of HTN. Larger multicentre studies with a wider range of markers are needed to confirm the role of IA in HIV-associated HTN.

Hypertension and traditional risk factors for cardiovascular diseases among treatment naïve HIV- infected adults initiating antiretroviral therapy in Urban Tanzania.

BACKGROUND: Cardiovascular diseases (CVDs) have become an important cause of ill health and death among people living with HIV and/or AIDS (PLHIV) in the antiretroviral therapy (ART) era. There is scarce data on the burden of hypertension (HTN) and risk factors for CVDs among PLHIV in developing countries, including Tanzania during the ART era. OBJECTIVE(S): To determine the prevalence of HTN and risk factors for CVDs among ART naïve PLHIV initiating ART. METHODS: We analysed baseline data of 430 clinical trial participants on the effect of low-dose aspirin on HIV disease progression among HIV-infected individuals initiating ART. HTN was the outcome CVD. Traditional risk factors for CVDs studied were age, alcohol consumption, cigarette smoking, individual and family history of CVDs, diabetes mellitus (DM), obesity/overweight, and dyslipidaemia. A generalized linear model (robust Poisson regression) was used to determine the predictors for HTN. RESULTS: The median (IQR) age was 37 (28, 45) years. Females were the majority contributing 64.9% of all participants. The prevalence of HTN was 24.8%. The most prevalent risk factors for CVDs were dyslipidaemia (88.3%), alcohol consumption (49.3%), and overweight or obesity (29.1%). Being overweight or obese predicted the occurrence of HTN, aPR 1.60 (95% CI 1.16-2.21) while WHO HIV clinical stage 3 was protective against HTN, aPR 0.42(95% CI 0.18-0.97). CONCLUSION: The prevalence of HTN and traditional risk factors for CVDs in the treatment naïve PLHIV initiating ART are significant. Identifying these risk factors and managing them at the time of ART initiation may lower future CVDs among PLHIV.

Patient reported experience measures on HIV viral load testing at public health facilities in Dar es Salaam, Tanzania: A convergent mixed method study.

While viral load (VL) testing is critical to effective treatment of human immunodeficiency virus (HIV), little is known about patients' experiences with, and barriers to VL-testing in the context of HIV infection. We assessed patient reported experience measures (PREMs) on VL-testing in public HIV clinics in Tanzania. In a cross-sectional convergent mixed method study, we collected information on VL test related PREMs, clinical and sociodemographic factors. PREMs were measured using a 5-point Likert scale. Focus Group Discussions (FGDs) explored on experience, access, and barriers to VL-testing. Descriptive statistics summarized patients' factors and PREMs. Logistic regression was used to explore association of patient factors, PREMs and satisfaction with VL-testing services. Thematic analysis was used for qualitative data. A total of 439 (96.48%) respondents completed the survey, 331 (75.40%) were female, median (IQR) age was 41(34, 49) years. A total of 253(57.63%) had a VL test at least once in the past 12 months, of whom 242(96.0%) had VL<1000 copies/ml. Investigating barriers to VL-testing, most participants (>92.0%) reported good or very good health services responsiveness (HSR). A scale of very good was chosen by the majority for being treated with respect 174(39.6%), listened to 173(39.4%), following advice 109(24.8%), being involved in decisions 101(23.0%), and for communication 102(23.3%). Satisfaction on VL-testing services was significantly associated with respondents following care providers' advice, (aOR) = 2.07 [95%CI 1.13-3.78], involvement in decisions aOR = 4.16 [95%CI 2.26-7.66], and communication aOR = 2.27 [95%CI 1.25-4.14]. FGDs findings converged with the survey data, with identified barriers to VL test including lack of autonomy in decision making, little awareness on the benefits of the test, long waiting time, stigma, competing priorities for those with comorbidities and transport costs. Satisfaction on VL-testing was largely a result of involvement in decision making, following care provider's advice and good communication; entities needing universal improvement across the country.

Inhaler Non-Adherence, Associated Factors and Asthma Control among Asthma Patients in a Tertiary Level Hospital in Tanzania.

Background: Inhaled medications including corticosteroids are the most effective long-term controller medicines for asthma-related chronic airway inflammation. Despite this fact, 30% to 70% of the uncontrolled asthma patients report non-adherence to their inhalers. This study investigated factors affecting inhaler non-adherence among outpatient asthma patients in Muhimbili National Hospital, Dar es Salaam Tanzania and related the level of inhaler adherence to the extent of asthma control. Methods: A cross-sectional hospital-based study was conducted among patients with bronchial asthma in the pulmonology clinic of Muhimbili National Hospital in Dar-es-salaam, Tanzania. Patients' demographic, clinical and socio-economic factors were collected using a structured questionnaire. Medication adherence was self-reported using a 10-item Test of Adherence to Inhalers (TAI) questionnaire. Adherence was gauged as good when the score was 50, intermediate (score 46-49) or poor (score ≤ 45). Asthma control was assessed using a 5-question Asthma Control Test (ACT). A score of ≥20 meant well controlled asthma while a score of ≤19 meant poorly controlled asthma. Patients' inhaler use technique was assessed using a 10-step checklist. Patient's technique was regarded correct when all the steps were performed correctly. Categorical data were summarised as proportions. Binary logistic regression was performed to identify factors associated with inhaler non-adherence. Significance level was set at p-value less than .05. Results: A total of 385 asthma patients were enrolled in the study. Females were 206 (53.5%), 232(60.3%) were non-adherent to medications and 283(73.5%) had poorly controlled asthma. Lack of health insurance, fear of medication side effects, being too busy, having alternative medication for asthma and incorrect inhaler technique were significantly associated with non-adherence to inhalers, all p-values <.05. Conclusion: The magnitude of inhaler non-adherence and poorly controlled asthma were very high. Promoting adherence through patients' education on asthma and its management, emphasis on patients' insurance coverage and setting aside time to care for ones' self are fundamental in optimising asthma care and treatment.

Predictors of mortality among adolescents and young adults living with HIV on antiretroviral therapy in Dar es Salaam, Tanzania: a retrospective cohort study.

INTRODUCTION: Global AIDS-related deaths have declined by only 10% among adolescents since its peak in 2003. This is disproportionately low compared to a decline of 74% among children aged 0-9 years old. We determined the magnitude of, and predictors of mortality among adolescents and young adults living with HIV on antiretroviral therapy (ART) in Dar-es-Salaam, Tanzania. METHODS: A retrospective cohort study was conducted among adolescents (aged 10-19) and young adults (aged 20-24) living with HIV and enrolled in care and treatment centres in Dar es Salaam, Tanzania between January 2015 and December 2019. Data were analysed using STATA version 16. Cumulative hazard curves were used to estimate and illustrate 1-year mortality. Predictors for mortality were assessed by the Fine and Gray competing risk regression model. Sub-hazard ratios (SHR) and 95% confidence intervals (95% CI) were then reported. RESULTS: A total of 15,874 young people living with HIV were included: 4916 (31.3%) were adolescents and 10,913 (68.7%) were young adults. A total of 3843 (77.5%) adolescents and 9517 (87.2%) young adults were female. Deaths occurred in 2.3% (114/4961) of adolescents and 1.2% (135/10,913) of young adults (p < 0.001). Over a follow-up of 9292 person-years, the mortality rate was 3.8 per 100 person years [95% CI 3.2-4.6/100 person-years] among adolescents and 2.1 per 100 person-years among young adults [95% CI 1.8-2.5/100 person-years]. Independent predictors of mortality among adolescents were male sex (adjusted (SHR) aSHR = 1.90, 95% CI: 1.3-2.8), CD4 count < 200 cells/mm3 (aSHR = 2.7, 95% CI: 1.4-5.0) and attending a private health facility (aSHR = 1.7, 95% CI: 1.1-2.5). Predictors of mortality among young adults were CD4 count < 200 cells/mm3 (aSHR = 2.8, 95% CI 1.7-4.5), being underweight (aSHR = 2.1, 95% CI: 1.4-3.3) and using nevirapine-based therapy (aHR = 8.3, 95% CI: 3.5-19.5). CONCLUSIONS: The mortality rate for persons living with HIV and on ART in Tanzania was significantly higher in adolescents than young adults. Age- and sex-specific risk factors identify targets for intervention to reduce mortality among affected adolescents and young adults.

Trends in Hospitalisation for Human Immunodeficiency Virus in a Tertiary Hospital in Dar es Salaam, Tanzania: A Case study.

BACKGROUND: Reports on systematic evaluation of the impact of antiretroviral therapy(ART) on patients' hospitalisation in Sub Saharan Africa (SSA) and Tanzania in particular are scarce. We aimed at documenting the trends of hospital admissions at Muhimbili National Hospital (MNH) following scale up of free access to ART in Tanzania. METHODS: Records for all admissions at MNH from June 2005 to June 2015 were reviewed. We extracted data from Hospital Information Management System as well as from patients' charts. Data extracted included diagnosis at discharge, reason for admission and thereafter assessed admission trends over the decade. We summarised the data as frequency and percentages. We compared proportions using Chi squared test, P<0.05 was deemed significant. RESULTS: Overall there were 209,101 admissions during the study period (June 2005 to June 2015) and 7864/209,101 (3.8%) were due to HIV infection. Whereas 598/4,519 (13.2%) of all admissions in 2005 were due to HIV, only 345/13,119 (2.6%) of admissions in 2015 were HIV-related; showing a significant drop over time (P value for trend < .001). Generally, females 3887/6679 (58.2%) were more likely to be admitted than males (41.8%). Median CD4 count for admitted HIV patients was 143 cells/µl. Majority of admissions occured in the medical wards 3643/5310 (68.6%). Discharge diagnoses were Tuberculosis 1396/6482 (21.5%), anaemias 1016/6482 (15.6 %), malignancies 789/6482(12.2%), CNS infections 541/6482 (8.3%) and chronic kidney disease 308/6482 (4.8%). Three leading AIDS defining malignancies among hospitalised patients included Kaposi's sarcoma 380/789 (48.2%), carcinoma of the cervix 77/789 (9.8%), and Non-Hodgkin's lymphoma 44/789 (5.6%). CONCLUSION: Despite drastic drop of HIV related admissions at Muhimbili National Hospital over the years, the infection remains a problem of the adults, largely females suffering from medical conditions and presenting with severe immunosuppression. Tuberculosis remained the most common opportunistic infection among hospitalized HIV infected patients. Anaemia and cancers became more important causes of admission than was diarrhoea which had been the most common among HIV infected patients in pre- ART era.

Diagnoses from lung specimen collected through flexible bronchoscopy from patients in a tertiary hospital in Dar es Salaam Tanzania: a retrospective cross-sectional study.

BACKGROUND: Flexible bronchoscopy enables visualization of the respiratory airway mucosa from the oropharynx to third generation branching of the tracheobronchial tree. Bronchoscopic diagnoses vary from one locality to the other in accordance to the locality specific risk factors for lung diseases. This study aimed at describing diagnoses of all specimen of patients who underwent flexible bronchoscopy at Muhimbili National Hospital from January 2013 to November 2017. METHODS: A retrospective hospital-based cross sectional study was conducted among 451 patients. Data was collected from archives and included both demographic and clinical variables. Descriptive statistics were used to summarize the study findings. RESULTS: There was a 3 fold increase in the number of patients who underwent flexible bronchoscopy from 57 cases in 2013 to 180 cases in 2017. About 39% (174/451) of patients underwent lung biopsies while 64.5% (291/451) underwent bronchioalveolar lavage, bronchial washings or brush cytology, alone or in combination with biopsy. Generally, 64.4% (112/174) of all lung biopsies were malignant. Adenocarcinoma was the most common diagnosis seen in 33.9% (59/174). Of 76 cytological samples which were sent for bacterial culture and sensitivity, 11/76 (11.8%) were culture positive. A total of 6 (10.7%) out of 56 samples which were sent for GeneXpert MTB/RIF tested positive for M.tuberculosis. CONCLUSION: Adenocarcinoma was the most common diagnosis. Bacterial and mycobacterial infections were among the most reported findings in cytological samples. Suspicious tuberculosis lesions during bronchoscopy made it possible to diagnose tuberculosis which was hard to diagnose before patients were sent for bronchoscopy.

Cost-Effectiveness of isoniazid preventive therapy among HIV-infected patients clinicaly screened for latent tuberculosis infection in Dar es Salaam, Tanzania: A prospective Cohort study.

BACKGROUND: One of the reasons why Isoniazid preventive therapy (IPT) for Tuberculosis (TB) is not widely used in low income countries is concerns on cost of excluding active TB. We analyzed the cost-effectiveness of IPT provision in Tanzania having ruled out active TB by a symptom-based screening tool. METHODS: Data on IPT cost-effectiveness was prospectively collected from an observational cohort study of 1283 HIV-infected patients on IPT and 1281 controls; followed up for 24 months. The time horizon for the analysis was 2 years. Number of TB cases prevented and deaths averted were used for effectiveness. A micro costing approach was used from a provider perspective. Cost was estimated on the basis of clinical records, market price or interviews with medical staff. We annualized the cost at a discount of 3%. A univariate sensitivity analysis was done. Results are presented in US$ at an average annual exchange rate for the year 2012 which was Tanzania shillings 1562.4 for 1 US $. RESULTS: The number of TB cases prevented was 420/100,000 persons receiving IPT. The number of deaths averted was 979/100,000 persons receiving IPT. Incremental cost due to IPT provision was US$ 170,490. The incremental cost effective ratio was US $ 405.93 per TB case prevented and US $ 174.15 per death averted. These costs were less than 3 times the 768 US $ Gross Domestic Product (GDP) per capita for Tanzania in the year 2014, making IPT provision after ruling out active TB by the symptom-based screening tool cost-effective. The results were robust to changes in laboratory and radiological tests but not to changes in recurrent, personnel, medication and utility costs. CONCLUSION: IPT should be given to HIV-infected patients who screen negative to symptom-based TB screening questionnaire. Its cost-effectiveness supports government policy to integrate IPT to HIV/AIDS care and treatment in the country, given the availability of budget and the capacity of health facilities.

Acceptability and adherence to Isoniazid preventive therapy in HIV-infected patients clinically screened for latent tuberculosis in Dar es Salaam, Tanzania.

BACKGROUND: Proper adherence to isoniazid preventive therapy (IPT) may depend upon the results of tuberculosis (TB) screening test and patients' understanding of their risk of developing active TB. We conducted a study to assess the acceptability, adherence and completion profile of IPT among HIV-infected patients who were clinically screened for latent TB Infection (LTBI). METHODS: A multicenter observational study was conducted in Dar es Salaam, Tanzania between February 2012 and March 2014. HIV-infected patients 10 years or older were clinically screened using a validated symptom-based screening tool to rule out active TB. Patients found to have no symptoms in the screening tool were given 300 mg of isoniazid (INH) daily for 6 months. Patients were followed up monthly at the National and Municipal hospital HIV clinics for INH refill and assessment of treatment adherence. Adherence was defined as consumption of 90 % or more of the monthly prescription of INH. RESULTS: All 1303 invited patients agreed to participate in the study. Of 1303 invited HIV-infected patients, 1283 (98.5 %) were recruited into the study. Twenty eight (2.2 %) did not complete treatment. Those who did not complete the treatment were exclusively adults aged 18 years or older, p = 0.302. The overall mean (±SD) adherence was 98.9 % (±2.9). Adherence level among children aged <18 years (92.2 %) was significantly lower than adherence level among patients aged 18-29 years (98.3 %), 30-49 years (98.8 %) and ≥ 50 years (98.5), p-value = 0.011. Sex, occupation, socio-economic status, duration of HIV infection, being on antiretroviral drugs (ARV) and duration of ARV use were not associated with adherence. CONCLUSION: IPT is highly accepted by HIV infected patients. Patients demonstrated high level of adherence to IPT. The level of adherence among children was slightly lower than that among adults. IPT non-completers were exclusively adults. Children might need adult supervision in taking IPT.

Prevalence and risk factors for skin diseases among antiretroviral-naïve HIV-infected pregnant women in Dar es Salaam, Tanzania.

BACKGROUND: Reduced cell-mediated immunity associated with pregnancy may cause a flaring or exacerbation of some skin conditions. Little is known about the magnitude of and risk factors for skin diseases among human immunodeficiency virus (HIV)-infected antiretroviral therapy-naïve pregnant women. METHODS: Cross-sectional study of 1078 HIV-infected antiretroviral therapy-naïve pregnant women was conducted in Dar es Salaam, Tanzania. Skin diagnoses were mainly clinical. Log-binomial regression models were used to explore factors associated with the outcomes. RESULTS: About 84% of the women were in World Health Organization (WHO) HIV stage I. Median CD4(+) count was 405 × 10(6)  cells/l. The prevalence of any skin disease was 18%. Fungal infections (11%), genital ulcers (7%), and viral infections (5%) were the most common skin conditions. Skin infections were 2.64 times more common in HIV stage III (95% CI 1.51-4.62) compared to stage I. Fungal infections were 1.77 times common among single, divorced, and widowed women than among married women (95% CI 1.16-2.69), 2.8 times common among women in HIV stage III (95% CI 1.18-6.64) compared to stage I. Genital ulcers were significantly more common among women whose source of income was their own compared with those who got full support from partners, and among WHO HIV stage III disease compared to stage I. CONCLUSION: The burden of skin diseases was relatively low. Advanced HIV stage was associated with a range of skin conditions. CD4(+) cell count was not related to skin infection prevalence.

Symptom-based screening tool in ruling out active tuberculosis among HIV-infected patients eligible for isoniazid preventive therapy in Tanzania.

OBJECTIVES: We assessed the usefulness of the National TB and Leprosy Control Program (NTLP) symptom-based tuberculosis (TB) screening tool in identifying HIV-infected patients eligible for isoniazid preventive therapy in Muhimbili National Hospital, Dar es Salaam Tanzania. METHODS: Descriptive cross-sectional study. Data collected included socio-demographic and clinical data. Chest X-ray, sputum for acid-fast bacilli (AFB) microscopy, mycobacterial culture, CD4 + count and complete blood count were performed. Patients were considered not having active TB if they presented with no symptom in the screening tool, which comprised these symptoms: cough, fever and excessive night sweats for ≥2 weeks; weight loss of ≥3 kg in 4 weeks and haemoptysis of any duration. The reference standard was a negative culture for Mycobacterium tuberculosis. RESULTS: We enroled 373 patients, of whom 72.1% were females. Active pulmonary TB was found in 4.1% (14/338) of the participants as defined by a positive culture. The sensitivity and specificity of the NTLP screening tool were 71.4% (10/14) and 75.9% (246/324), respectively. False-negative rate was 28.6% (4/10). Cough, fever for ≥2 weeks and weight loss were independent predictors of NTLP-defined TB. Cough ≥2 weeks predicted TB when a positive culture was used to define TB. CONCLUSION: The screening tool had fairly good sensitivity and specificity for TB screening; however, there is a possibility that about 29% of the screened population will be given IPT while they are supposed to receive a full course of TB treatment.

Prevalence of obesity and associated risk factors among adults in Kinondoni municipal district, Dar es Salaam Tanzania.

BACKGROUND: Obesity is on the rise worldwide, not sparing developing countries. Both demographic and socio-economic factors play parts in obesity causation. Few surveys have been conducted in Tanzania to determine the magnitude of obesity and its association with these risk factors. This study aimed at determining the prevalence of obesity and its associated risk factors among adults aged 18 - 65 years in Kinondoni municipality, Dar es Salaam, Tanzania from April 2007 to April 2008. METHODS: Random sampling of households was performed. Interviews and anthropometric measurement were carried out to eligible and consenting members of the selected households. Obesity was defined using Body Mass Index (BMI). RESULTS: Out of 1249 subjects recruited, 814 (65.2%) were females. The overall prevalence of obesity was 19.2% (240/1249). However, obesity was significantly more prevalent in women (24.7%) than men (9%), p < 0.001, among respondents with high socio-economic status (29.2%) as compared to those with medium (14.3%) and low socio-economic status (11.3%), p value for trend < 0.001, and among respondents with light intensity activities (26.0%), p value for trend < 0.001. CONCLUSION: This study revealed a higher prevalence of obesity among Kinondoni residents than previously reported in other parts of the country. Independent predictors of obesity in the population studied were increasing age, marriage and cohabitation, high SES, female sex and less vigorous physical activities.