Immune System Diseases Commons^™

Delayed Switch Of Antiretroviral Therapy After Virologic Failure Associated With Elevated Mortality Among Hiv-Infected Adults In Africa, Maya L. Petersen, Linh Tran, Elvin H. Geng, Steven J. Reynolds, Andrew Kambugu, Robin Wood, David Bangsberg, Constantin T. Yiannoutsos, Steven G. Deeks, Jeffrey N. Martin

OHSU-PSU School of Public Health Faculty Publications and Presentations

Objective—Routine monitoring of plasma HIV RNA among HIV-infected patients on antiretroviral therapy (ART) is unavailable in many resource-limited settings. Alternative monitoring approaches correlate poorly with virologic failure and can substantially delay switch to second-line therapy. We evaluated the impact of delayed switch on mortality among patients with virologic failure in Africa.

Design—A cohort.

Methods—We examined patients with confirmed virologic failure on first-line non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimens from four cohorts with serial HIV RNA monitoring in Uganda and South Africa. Marginal structural models aimed to estimate the effect of delayed switch on mortality in a hypothetical trial in which …

High Medication Adherence During Periconception Periods Among Hiv-1–Uninfected Women Participating In A Clinical Trial Of Antiretroviral Pre-Exposure Prophylaxis, Lynn T. Matthews, Renee Heffron, Nelly R. Mugo, Craig R. Cohen, Craig W. Hendrix, Connie Celum, David Bangsberg, Jared M. Baten

OHSU-PSU School of Public Health Faculty Publications and Presentations

Introduction: Pre-exposure prophylaxis (PrEP) may be an important safer conception strategy for HIV-1–uninfected women with HIV-1–infected partners. Understanding medication adherence in this population may inform whether PrEP is a feasible safer conception strategy.

Methods: We evaluated predictors of pregnancy and adherence to study medication among HIV-1–uninfected women enrolled in a randomized placebo-controlled trial of PrEP among African HIV-1– serodiscordant couples. Participants were counseled on HIV-1 risk reduction, contraception, and adherence and tested for pregnancy at monthly study visits. Pill counts of dispensed drug were performed and, at a subset of visits, plasma was collected to measure active drug concentration.

Results: …

Empiric Deworming And Cd4 Count Recovery In Hiv-Infected Ugandans Initiating Antiretroviral Therapy, Alexander J. Lankowski, Alexander C. Tsai, Michael Kanyesigye, Mwebesa B. Bwana, Jessica E. Haberer, Megan Wenger, Jeffrey N. Martin, David Bangsberg, Peter W. Hunt, Mark J. Siedner

OHSU-PSU School of Public Health Faculty Publications and Presentations

Background: There is conflicting evidence on the immunologic benefit of treating helminth co-infections (‘‘deworming’’) in HIV-infected individuals. Several studies have documented reduced viral load and increased CD4 count in antiretroviral therapy (ART) naive individuals after deworming. However, there are a lack of data on the effect of deworming therapy on CD4 count recovery among HIV-infected persons taking ART.

Methodology/Principal Findings: To estimate the association between empiric deworming therapy and CD4 count after ART initiation, we performed a retrospective observational study among HIV-infected adults on ART at a publicly operated HIV clinic in southwestern Uganda. Subjects were assigned as having received …

South Africans With Recent Pregnancy Rarely Know Partner’S Hiv Serostatus: Implications For Serodiscordant Couples Interventions, Lynn T. Matthews, Lizzie Moore, Tamaryn L. Crankshaw, Cecilia Milford, Fortunate N. Mosery, Ross Greener, Christina Psaros, Steven A, Safren, David Bangsberg, Jennifer A. Smit

OHSU-PSU School of Public Health Faculty Publications and Presentations

Background: Implementation of safer conception strategies requires knowledge of partner HIV-serostatus. We recruited women and men in a high HIV-prevalence setting for a study to assess periconception risk behavior among individuals reporting HIV-serodiscordant partnerships. We report screening data from that study with the objective of estimating the proportion of individuals who are aware that they are in an HIV-serodiscordant relationship at the time of conception.

Methods: We screened women and men attending antenatal and antiretroviral clinics in Durban, South Africa for enrollment in a study of periconception risk behavior among individuals with serodiscordant partners. Screening questionnaires assessed for study eligibility …

Decreases In Self-Reported Alcohol Consumption Following Hiv Counseling And Testing At Mulago Hospital, Kampala, Uganda, Judith A. Hahn, Robin Fatch, Rhoda K. Wanyenze, Steven Baveewo, Moses R. Kamya, David Bangsberg, Thomas J. Coates

OHSU-PSU School of Public Health Faculty Publications and Presentations

Background: Alcohol use has a detrimental impact on the HIV epidemic, especially in sub-Saharan Africa. HIV counseling and testing (HCT) may provide a contact opportunity to intervene with hazardous alcohol use; however, little is known about how alcohol consumption changes following HCT.

Methods: We utilized data from 2056 participants of a randomized controlled trial comparing two methods of HCT and subsequent linkage to HIV care conducted at Mulago Hospital in Kampala, Uganda. Those who had not previously tested positive for HIV and whose last HIV test was at least one year in the past were eligible. Participants were asked at …

Tobacco Use Among Adults Initiating Treatment For Hiv Infection In Rural Uganda, Gina R. Kruse, David Bangsberg, Judith A. Hahn, Jessica E. Haberer, Peter Hunt, Conrad Muzoora, John P. Bennett, Jeffrey N. Martin, Nancy A, Rigotti

OHSU-PSU School of Public Health Faculty Publications and Presentations

We conducted a longitudinal study of tobacco use among adults initiating antiretroviral therapy (ART) in Mbarara, Uganda where 11% of men and 3% of women use tobacco according to the 2011 Demographic and Health Survey. In a prospective cohort, self-reported tobacco use was assessed before starting ART and reassessed every 3–4 months. Plasma cotinine, a nicotine metabolite, was measured in a subset of adults pre-ART to verify self-report. Among 496 subjects, 50 (10%) reported current tobacco use (20% of men, 6% of women). Most (53%) adults with elevated cotinine levels (>15 ng/mL) reported no tobacco use. By 6 months …

Impact Of Hiv On Cd8+ T Cell Cd57 Expression Is Distinct From That Of Cmv And Aging, Sulggi A. Lee, Elizabeth Sinclair, Hiroyu Hatano, Priscilla Y. Hsue, Lorrie Epling, Frederick M. Hecht, David Bangsberg, Jeffrey N. Martin, Joseph M. Mccune, Steven G. Deeks, Peter Hunt

OHSU-PSU School of Public Health Faculty Publications and Presentations

Background: Chronic antigenic stimulation by cytomegalovirus (CMV) is thought to increase ‘‘immunosenesence’’ of aging, characterized by accumulation of terminally differentiated CD28- CD8+ T cells and increased CD57, a marker of proliferative history. Whether chronic HIV infection causes similar effects is currently unclear.

Methods: We compared markers of CD8+ T cell differentiation (e.g., CD28, CD27, CCR7, CD45RA) and CD57 expression on CD28- CD8+ T cells in healthy HIV-uninfected adults with and without CMV infection and in both untreated and antiretroviral therapy (ART)-suppressed HIV-infected adults with asymptomatic CMV infection.

Results: Compared to HIV-uninfected adults without CMV (n = 12), those with asymptomatic …

The Dynamic Relationship Between Social Support And Hiv-Related Stigma In Rural Uganda, Sae Takada, Sheri D. Weiser, Elias Kumbakumba, Conrad Muzoora, Jeffrey N. Martin, Peter Hunt, Jessica E. Haberer, Annet Kawuma, David Bangsberg, Alexander C. Tsai

OHSU-PSU School of Public Health Faculty Publications and Presentations

Background—Cross-sectional studies show that human immunodeficiency virus (HIV) stigma is negatively correlated with social support.

Purpose—The purpose of this study is to examine the bidirectional relationship between social support and HIV stigma.

Methods—We collected quarterly data from a cohort of 422 people living with HIV in Uganda, followed for a median of 2.1 years. We used multilevel regression to model the contemporaneous and 3-month-lagged associations between social support and both enacted and internalized stigma.

Results—Lagged enacted stigma was negatively correlated with emotional and instrumental social support, and lagged instrumental social support was negatively correlated with enacted stigma. Internalized stigma and …

Harnessing Poverty Alleviation To Reduce The Stigma Of Hiv In Sub-Saharan Africa, Alexander C. Tsai, David Bangsberg, Sheri D. Weiser

OHSU-PSU School of Public Health Faculty Publications and Presentations

HIV is highly stigmatized throughout sub-Saharan Africa. In studies conducted among general population samples, stigma has been shown to impede uptake of HIV testing and increase sexual risktaking behavior. Among HIV-infected persons, stigma has also been associated with inhibited serostatus disclosure to sexual partners and potential treatment supporters, delays in HIV antiretroviral therapy (ART) initiation, and ART nonadherence. The stigma of HIV also intensifies the poverty, stress, and insecurity endemic to many resource-limited settings, resulting in worsened mental health, itself an important determinant of AIDS-related mortality. Until we can better understand how to effectively intervene to reduce the stigma of …

Factors Associated With Pruritic Papular Eruption Of Human Immunodeficiency Virus Infection In The Antiretroviral Therapy Era, S. L. Chua, E. H. Amerson, K. S. Leslie, T. H. Mccalmont, P. E. Leboit, J. N. Martin, David Bangsberg, T. A. Maurer

OHSU-PSU School of Public Health Faculty Publications and Presentations

Background—Pruritic papular eruption (PPE) of HIV is common in HIV-infected populations living in the tropics. Its aetiology has been attributed to insect bite reactions and it is reported to improve with antiretroviral therapy (ART). Its presence after at least 6 months of ART has been proposed as one of several markers of treatment failure.

Objectives—To determine factors associated with PPE in HIV-infected persons receiving ART.

Methods—A case–control study nested within a 500-person cohort from a teaching hospital in Mbarara, Uganda. Forty-five cases and 90 controls were enrolled. Cases had received ART for ≥ 15 months and had an itchy papular …

Optimizing Network Connectivity For Mobile Health Technologies In Sub-Saharan Africa, Mark J. Siedner, Alexander J. Lankowski, Derrick Musinga, Jonathan Jackson, Conrad Muzoora, Peter W. Hunt, Jeffrey N. Martin, David Bangsberg, Jessica E. Haberer

OHSU-PSU School of Public Health Faculty Publications and Presentations

Background: Mobile health (mHealth) technologies hold incredible promise to improve healthcare delivery in resourcelimited settings. Network reliability across large catchment areas can be a major challenge. We performed an analysis of network failure frequency as part of a study of real-time adherence monitoring in rural Uganda. We hypothesized that the addition of short messaging service (SMS+GPRS) to the standard cellular network modality (GPRS) would reduce network disruptions and improve transmission of data.

Methods: Participants were enrolled in a study of real-time adherence monitoring in southwest Uganda. In June 2011, we began using Wisepill devices that transmit data each time the …

Rethinking The “Pre” In Pre-Therapy Counseling: No Benefit Of Additional Visits Prior To Therapy On Adherence Or Viremia In Ugandans Initiating Arvs, Mark J. Siedner, Alexander J. Lankowski, Jessica E. Haberer, Annet Kembabazi, Nneka Emenyonu, Alexander C. Tsai, Conrad Muzoora, Elvin H. Geng, Jeffrey N. Martin, David Bangsberg

OHSU-PSU School of Public Health Faculty Publications and Presentations

Background: Many guidelines recommend adherence counseling prior to initiating antiretrovirals (ARVs), however the additional benefit of pre-therapy counseling visits on early adherence is not known. We sought to assess for a benefit of adherence counseling visits prior to ARV initiation versus adherence counseling during the early treatment period.

Methods: We performed a secondary analysis of data from a prospective cohort of HIV-infected patients in Mbarara, Uganda. Adults were enrolled upon initiation of ARVs. Our primary exposure of interest was ARV adherence counseling prior to initiating therapy (versus concurrent with initiation of therapy). Our outcomes of interest were: 1) average adherence …

High Acceptability For Cell Phone Text Messages To Improve Communication Of Laboratory Results With Hiv-Infected Patients In Rural Uganda: A Cross-Sectional Survey Study, Mark J. Siedner, Jessica E. Haberer, Mwebesa B. Bwana, Norma C. Ware, David Bangsberg

OHSU-PSU School of Public Health Faculty Publications and Presentations

Background: Patient-provider communication is a major challenge in resource-limited settings with large catchment areas. Though mobile phone usership increased 20-fold in Africa over the past decade, little is known about acceptability of, perceptions about disclosure and confidentiality, and preferences for cell phone communication of health information in the region.

Methods: We performed structured interviews of fifty patients at the Immune Suppression Syndrome clinic in Mbarara, Uganda to assess four domains of health-related communication: a) cell phone use practices and literacy, b) preferences for laboratory results communication, c) privacy and confidentiality, and d) acceptability of and preferences for text messaging to …

Mean Cd4 Cell Count Changes In Patients Failing A First-Line Antiretroviral Therapy In Resource-Limited Settings, Alexandra Calmy, Eric Balestre, Fabrice Bonnet, Andrew Boulle, Eduardo Sprinz, Robin Wood, Eric Delaporte, Eugène Messou, James Mcintyre, Kamal Marhoum El Filali, Mauro Schechter, N. Kumarasamy, David Bangsberg, Patrick Mcphail, Stefaan Van Der Borght, Carlos Zala, Matthias Egger, Rodolphe Thiébaut, François Dabis, Art-Linc Of Iedea Collaboration (Asia, South America, East, Southern And West Africa)

OHSU-PSU School of Public Health Faculty Publications and Presentations

Background: Changes in CD4 cell counts are poorly documented in individuals with low or moderate-level viremia while on antiretroviral treatment (ART) in resource-limited settings. We assessed the impact of on-going HIV-RNA replication on CD4 cell count slopes in patients treated with a first-line combination ART.

Method: Naïve patients on a first-line ART regimen with at least two measures of HIV-RNA available after ART initiation were included in the study. The relationships between mean CD4 cell count change and HIV-RNA at 6 and 12 months after ART initiation (M6 and M12) were assessed by linear mixed models adjusted for gender, age, …

Safety And Adherence To Intermittent Pre-Exposure Prophylaxis (Prep) For Hiv-1 In African Men Who Have Sex With Men And Female Sex Workers, Gaudensia Mutua, Eduard J. Sanders, Peter Mwangi Mugo, Omu Anzala, Jessica E. Haberer, David R. Bangsberg, Burc Barin, James F. Rooney, David Mark, Paramesh Chetty, Patricia Fast, Frances H. Priddy

OHSU-PSU School of Public Health Faculty Publications and Presentations

Background: Little is known about safety of and adherence to intermittent HIV PrEP regimens, which may be more feasible than daily dosing in some settings. We present safety and adherence data from the first trial of an intermittent PrEP regimen among Kenyan men who have sex with men (MSM) and female sex workers (FSW).

Methods/Principal Findings: MSM and FSW were randomized to daily oral FTC/TDF or placebo, or intermittent (Monday, Friday and within 2 hours after sex, not to exceed one dose per day) oral FTC/TDF or placebo in a 2:1:2:1 ratio; volunteers were followed monthly for 4 months. Adherence …

Social, Structural And Behavioral Determinants Of Overall Health Status In A Cohort Of Homeless And Unstably Housed Hiv-Infected Men, Elise D. Riley, Torsten B. Neilands, Kelly Moore, Jennifer Cohen, David Bangsberg, Diane Havler

OHSU-PSU School of Public Health Faculty Publications and Presentations

Background: Previous studies indicate multiple influences on the overall health of HIV-infected persons; however, few assess and rank longitudinal changes in social and structural barriers that are disproportionately found in impoverished populations. We empirically ranked factors that longitudinally impact the overall health status of HIV-infected homeless and unstably housed men.

Methods and Findings: Between 2002 and 2008, a cohort of 288 HIV+ homeless and unstably housed men was recruited and followed over time. The population was 60% non-Caucasian and the median age was 41 years; 67% of study participants reported recent drug use and 20% reported recent homelessness. At baseline, …

Potential For False Positive Hiv Test Results With The Serial Rapid Hiv Testing Algorithm, Steven Baveewo, Moses R. Kamya, Harriet Mayanja-Kizza, Robin Fatch, David Bangsberg, Thomas J. Coates, Judith A. Hahn, Rhoda K. Wanyenze

OHSU-PSU School of Public Health Faculty Publications and Presentations

Background: Rapid HIV tests provide same-day results and are widely used in HIV testing programs in areas with limited personnel and laboratory infrastructure. The Uganda Ministry of Health currently recommends the serial rapid testing algorithm with Determine, STAT-PAK, and Uni-Gold for diagnosis of HIV infection. Using this algorithm, individuals who test positive on Determine, negative to STAT-PAK and positive to Uni-Gold are reported as HIV positive. We conducted further testing on this subgroup of samples using qualitative DNA PCR to assess the potential for false positive tests in this situation.

Results: Of the 3388 individuals who were tested, 984 were …