High Burden of Cryptococcal Meningitis Among ART-Experienced HIV-infected Patients in Northern Uganda in the era of “Test and Treat”: Implications for Cryptococcal Screening Programs

Background The impact of the "test-and-treat" program for HIV treatment in rural areas of Uganda on cryptococcal antigen (CrAg) screening or cryptococcal meningitis (CM) is poorly understood. Methods We retrospectively evaluated clinical factors in 212 HIV-infected patients diagnosed with CM from February of 2017 to November of 2019 at Lira Regional Referral Hospital (LRRH) in northern Uganda. Results Among 212 patients diagnosed with CM, 58.5% were male. Median age, CD4 count, and HIV viral load were 35 years, 86 cells/μL, and 9,463 copies/mL respectively. Only 10% of patients had a previous history of CM. We found that 190 of 209 (90.9%) patients were ART-experienced, and 19 (9.1%) were ART-naïve. Overall, 90 of 212 (42.5%) patients died while hospitalized with a median time to death of 14 days. Increased risk of death was associated with altered mental status (HR 6.6, 95% CI 2.411-18.219, p =<0.0001), and seizures (HR 5.23, 95% CI 1.245-21.991, p=0.024). Conclusion Current guidelines recommend CrAg screening based on low CD4 counts for ART-naïve patients and VL or clinical failure for ART-experienced patients. Using current guidelines for CrAg screening, some ART- experienced patients miss CrAg screening in resource limited settings, when CD4 or VL tests are unavailable. We found that the majority of HIV- infected patients with CM were ART- experienced (90.9%) at presentation. The high burden of CM in ART-experienced patients supports a need for improved CrAg screening of ART-exposed patients.

Determinants of improvement trends in health workers’ compliance with outpatient malaria case-management guidelines at health facilities with available “test and treat” commodities in Kenya

Background Health workers’ compliance with outpatient malaria case-management guidelines has been improving in Africa. This study examined the factors associated with the improvements. Methods Data from 11 national, cross-sectional health facility surveys undertaken from 2010–2016 were analysed. Association between 31 determinants and improvement trends in five outpatient compliance outcomes were examined using interactions between each determinant and time in multilevel logistic regression models and reported as an adjusted odds ratio of annual trends (T-aOR). Results Among 9,173 febrile patients seen at 1,208 health facilities and by 1,538 health workers, a higher annual improvement trend in composite “test and treat” performance was associated with malaria endemicity-lake endemic (T-aOR = 1.67 annually; p<0.001) and highland epidemic (T-aOR = 1.35; p<0.001) zones compared to low-risk zone; with facilities stocking rapid diagnostic tests only (T-aOR = 1.49; p<0.001) compared to microscopy only services; with faith-based/non-governmental facilities compared to government-owned (T-aOR = 1.15; p = 0.036); with a daily caseload of >25 febrile patients (T-aOR = 1.46; p = 0.003); and with under-five children compared to older patients (T-aOR = 1.07; p = 0.013). Other factors associated with the improvement trends in the “test and treat” policy components and artemether-lumefantrine administration at the facility included the absence of previous RDT stock-outs, community health workers dispensing drugs, access to malaria case-management and Integrated Management of Childhood Illness (IMCI) guidelines, health workers’ gender, correct health workers’ knowledge about the targeted malaria treatment policy, and patients’ main complaint of fever. The odds of compliance at the baseline were variable for some of the factors. Conclusions Targeting of low malaria risk areas, low caseload facilities, male and government health workers, continuous availability of RDTs, improving health workers’ knowledge about the policy considering age and fever, and dissemination of guidelines might improve compliance with malaria guidelines. For prompt treatment and administration of the first artemether-lumefantrine dose at the facility, task-shifting duties to community health workers can be considered.

Sharing With Patients the Uncertainties Regarding the Management of Dyspepsia

Background: The management of patients with dyspepsia is uncertain. Some authors advocate endoscopy for all; others restrict endoscopy only to patients at high risk of gastric cancer, namely to those above an age threshold, or with a family history, dysphagia, loss of weight, anemia, or a childhood in Asian countries. Still others recommend various combinations between test-and-treat for Helicobacter pylori, anti-secretory treatment, and/or endoscopy.Objective: To highlight the uncertainties in the choice between the various strategies and argue that these uncertainties should be shared with the patient.Method: An overview of reported life expectancy, patient satisfaction, gastric cancer detection rates, symptom relief, and cost effectiveness of the management strategies for dyspepsia.Main Findings: There are no randomized controlled trials of the effect of screening by endoscopy on mortality of patients with gastric cancer. Lower grades of evidence suggest that early diagnosis reduces this mortality. Analyses, which assume a survival benefit of early diagnosis, indicate that mass screening in countries of high incidence gastric cancer (&gt; 10 cases per 100,000) and targeted screening of high-risk persons in countries of low-intermediate incidence (&lt;10 cases per 100,000) is cost-effective at a willingness to pay of $20,000–50,000 per QALY. Prompt endoscopy appears to be best for patient satisfaction and gastric cancer detection, and test-and-treat for H pylori—for symptom relief and avoiding endoscopies.Conclusions: The gain in life expectancy is the main source of uncertainty in the choice between management strategies. This choice should be shared with the patients after explaining uncertainties and eliciting their preferences.

HIV-related stigma and uptake of antiretroviral treatment among incarcerated individuals living with HIV/AIDS in South African correctional settings: A mixed methods analysis

Background Stigma affects engagement with HIV healthcare services. We investigated the prevalence and experience of stigma among incarcerated people living with HIV (PLHIV) in selected South African correctional settings during roll-out of universal test and treat. Methods A cross-sectional mixed-methods study design included 219 incarcerated PLHIV and 30 in-depth interviews were conducted with four different types of PLHIV. HIV-related stigma was assessed through survey self-reporting and during the interviews. A descriptive analysis of HIV-related stigma was presented, supplemented with a thematic analysis of the interview transcripts. Results ART uptake was high (n = 198, 90.4%) and most reported HIV-related stigma (n = 192, 87.7%). The intersectional stigma occurring due to individual and structural stigma around provision of healthcare in these settings mostly contributed to perceived stigma through involuntary disclosure of HIV status. Interpersonal and intrapersonal factors led to negative coping behaviours. However, positive self-coping strategies and relationships with staff encouraged sustained engagement in care. Conclusion We encourage continuous peer support to reduce stigmatization of those infected with HIV and whose status may be disclosed inadvertently in the universal test and treat era.