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Background: Human immunodeficiency virus (HIV)-associated tuberculosis deaths have decreased worldwide over the past decade. We sought to evaluate the effect of HIV status on tuberculosis mortality among patients undergoing treatment for tuberculosis in Lima, Peru, a low HIV prevalence setting., Methods: We conducted a prospective cohort study of patients treated for tuberculosis between 2005 and 2008 in two adjacent health regions in Lima, Peru (Lima Ciudad and Lima Este). We constructed a multivariate Cox proportional hazards model to evaluate the effect of HIV status on mortality during tuberculosis treatment., Results: Of 1701 participants treated for tuberculosis, 136 (8.0%) died during tuberculosis treatment. HIV-positive patients constituted 11.0% of the cohort and contributed to 34.6% of all deaths. HIV-positive patients were significantly more likely to die (25.1 vs. 5.9%, P < 0.001) and less likely to be cured (28.3 vs. 39.4%, P = 0.003). On multivariate analysis, positive HIV status (hazard ratio [HR] = 6.06; 95% confidence interval [CI], 3.96-9.27), unemployment (HR = 2.24; 95% CI, 1.55-3.25), and sputum acid-fast bacilli smear positivity (HR = 1.91; 95% CI, 1.10-3.31) were significantly associated with a higher hazard of death., Conclusions: We demonstrate that positive HIV status was a strong predictor of mortality among patients treated for tuberculosis in the early years after Peru started providing free antiretroviral therapy. As HIV diagnosis and antiretroviral therapy provision are more widely implemented for tuberculosis patients in Peru, future operational research should document the changing profile of HIV-associated tuberculosis mortality.

Among tuberculosis patients, timely diagnosis of human immunodeficiency virus (HIV) co-infection and early antiretroviral treatment are crucial, but are hampered by a myriad of individual and structural barriers. Community-based models to provide counseling and rapid HIV testing are few but offer promise. During November 2009-April 2010, community health workers offered and performed HIV counseling and testing by using the OraQuick Rapid HIV-1/2 Antibody Test to new tuberculosis cases in 22 Ministry of Health establishments and their household contacts (n = 130) in Lima, Peru. Refusal of HIV testing or study participation was low (4.7%). Intervention strengths included community-based approach with participant preference for testing site, use of a rapid, non-invasive test, and accompaniment to facilitate HIV care and family disclosure. We will expand the intervention under programmatic auspices for rapid community-based testing for new tuberculosis cases in high incidence establishments. Other potential target populations include contacts of HIV-positive persons and pregnant women.

We examined the relationship between food insufficiency and antiretroviral therapy (ART) adherence. A cohort of HIV-infected adults in urban Peru was followed for a two-year period after ART initiation. ART adherence was measured using a 30-day self-report tool and classified as suboptimal if <95% adherence was reported. We conducted a repeated measures cohort analysis to examine whether food insufficiency was more common during months of suboptimal adherence relative to months with optimal adherence. 1,264 adherence interviews were conducted for 134 individuals. Participants who reported food insufficiency in the month prior to interview were more likely to experience suboptimal adherence than those who did not (odds ratio [O.R.]:2.4; 95% confidence interval [C.I.]:1.4, 4.1), even after adjusting for baseline social support score (O.R. per 5 point increase:0.91; C.I.:[0.85, 0.98]) and good baseline adherence self-efficacy (O.R.:0.25; C.I.:[0.09, 0.69]). Interventions that ensure food security for HIV-infected individuals may help sustain high levels of adherence.

From December 2005 to April 2007, we enrolled 60 adults starting antiretroviral therapy (ART) in Lima, Peru to receive community-based accompaniment with supervised antiretrovirals (CASA), consisting of 12 months of DOT-HAART, as well as microfinance assistance and/or psychosocial support group according to individuals' need. We matched 60 controls from a neighboring district, and assessed final clinical and psychosocial outcomes at 24 months. CASA support was associated with higher rates of virologic suppression and lower mortality. A comprehensive, tailored adherence intervention in the form of community-based DOT-HAART and matched economic and psychosocial support is both feasible and effective for certain individuals in resource-poor settings.

From December 2005 through August 2008, we provided community-based accompaniment with supervised antiretroviral therapy (CASA) to impoverished individuals starting highly active antiretroviral therapy. Adherence support was provided for 18 months by a community-based team comprised of several nurses and two types of community health workers: field supervisors and directly observed therapy (DOT) volunteers. To complement our quantitative data collection in 2008 using purposive sampling, we conducted two gender-mixed focus group discussions with 13 CASA patient participants and 13 DOT volunteers from Lima, Peru to identify the mediating mechanisms by which CASA improved well-being, and to understand the benefits of the intervention, as perceived by these individuals. Using standard qualitative methods for the review and analysis of transcripts and interview notes, we identified central themes and developed a coding scheme for categorising participants' statements. Two individuals blinded to each other's coding, coded interview transcripts for theme and content from which a third reviewer compared their coding to arbitrate discrepancies. Additional domains were added if necessary and all domains were integrated into a theoretical scheme. Among the forms of support delivered by the CASA team, DOT volunteers reported emotional support, instrumental support, directly observed therapy, building trust, education, advocacy, exercise of moral authority and preparation for transition off CASA support. CASA participants described outcomes of improved adherence, ability to resume social roles, increased self-efficacy, hopefulness, changes in non-HIV-related behaviour, reduced internalised and externalised stigma, as well as ability to disclose. Both sets of focus group participants highlighted remaining challenges after completion of CASA support: stigma in the community, difficulties achieving economic recovery and persistent barriers to health services. Based on our prior quantitative and qualitative outcomes reported here, we argue that DOT of highly active antiretroviral therapy could be designed to optimise psychosocial recovery during the period of DOT., (© 2010 Blackwell Publishing Ltd.)

Microfinance among people living with HIV/AIDS (PLWHA) faces some opposition and remains understudied. This literature review examines microfinance's evolution and impact on a variety of social and health indicators and its emerging implementation as a primary prevention tool for HIV and economic intervention for PLWHA. There is an abundance of literature supporting the apparent utility of microfinance. However, our understanding of the subject remains clouded by the heterogeneity and methodological limitations of existing impact studies, and access limitations to microfinance curbs our understanding of microfinance for this population. Existing literature suggests PLWHA could attain economic stability from microfinance and achieve successful repayment rates in some settings. The precarious socioeconomic and health issues of PLWHA pose unique challenges to minimizing loan default risk. Carefully-designed clinical studies are needed to assess whether PLWHA can be as successful with microfinance as healthy individuals.

From December 2005 to April 2007, we enrolled 60 adults starting antiretroviral therapy (ART) in a health district of Lima, Peru to receive community-based accompaniment with supervised antiretroviral (CASA). Paid community health workers performed twice-daily home visits to directly observe ART and offered additional medical, social and economic support to CASA participants. We matched 60 controls from a neighboring district by age, CD4 and primary referral criteria (TB status, female, neither). Using validated instruments at baseline and 12 months (time of DOT-HAART completion) we measured depression, social support, quality of life, HIV-related stigma and self-efficacy. We compared 12 month clinical and psychosocial outcomes among CASA versus control groups. CASA participants experienced better clinical and psychosocial outcomes at 12 months, including proportion with virologic suppression, increase in social support and reduction in HIV-associated stigma.

The purpose of this study was to validate the Spanish version of the Berger HIV Stigma Scale in an urban Spanish-speaking population in Peru and create a valid and reliable abridged version of the scale. Participants were HIV-infected adults enrolled in an observational study to examine the effectiveness of a community-based antiretroviral therapy adherence intervention. Approximately half of participants were female, and the median age at enrollment was 30.5 years. The Spanish version of the full HIV Stigma Scale was internally reliable, demonstrated good construct validity, and was sensitive to change over time. The full HIV Stigma Scale was abbreviated by removing items that impaired subscale internal reliability, did not correlate with other subscale items, or demonstrated low factor correlations. The resulting abridged scale contained 21 of the 40 original items and revealed properties similar to the full Spanish version.

Many countries with financial support for HIV treatment experience delays in scale-up because of bureaucratic, operational, and technical obstacles. The authors describe the Peruvian National HIV Program's response to such challenges. A team of consultants experienced in the scale-up of the Peruvian national program to treat multidrug-resistant tuberculosis worked with the national HIV program to identify and address key factors contributing to slow enrollment of HIV patients into the antiretroviral treatment program. The rate of enrollment into the antiretroviral treatment program increased from 124 patients/month in the first 9 months of the program to 226 patients/month in the last 7 months, an increase of 83%. This strategy achieved 38.5% coverage of the population in need. Effective programmatic expansion of the Peruvian National HIV Program was facilitated by a multidisciplinary collaboration in a systematized effort to overcome barriers to scale-up.

Summary: The Objective of this analysis was to identify predictors of death, failure, and default among MDR-TB patients treated with second-line drugs in DOTS-plus projects in Estonia, Latvia, Philippines, Russia, and Peru, 2000–2004. Risk ratios (RR) with 95% confidence intervals (CI) were calculated using multivariable regression. Of 1768 patients, treatment outcomes were: cure/completed – 1156 (65%), died – 200 (11%), default - 241 (14%), failure - 118 (7%). Independent predictors of death included: age>45 years (RR = 1.90 (95%CI 1.29–2.80), HIV infection (RR = 4.22 (2.65–6.72)), extrapulmonary disease (RR = 1.54 (1.04–2.26)), BMI<18.5 (RR = 2.71 (1.91–3.85)), previous use of fluoroquinolones (RR = 1.91 (1.31–2.78)), resistance to any thioamide (RR = 1.59 (1.14–2.22)), baseline positive smear (RR = 2.22 (1.60–3.10)), no culture conversion by 3rd month of treatment (RR = 1.69 (1.19–2.41)); failure: cavitary disease (RR = 1.73 (1.07–2.80)), resistance to any fluoroquinolone (RR = 2.73 (1.71–4.37)) and any thioamide (RR = 1.62 (1.12–2.34)), and no culture conversion by 3rd month (RR = 5.84 (3.02–11.27)); default: unemployment (RR = 1.50 (1.12–2.01)), homelessness (RR = 1.52 (1.00–2.31)), imprisonment (RR = 1.86 (1.42–2.45)), alcohol abuse (RR = 1.60 (1.18–2.16)), and baseline positive smear (RR = 1.35 (1.07–1.71)). Patients with biomedical risk factors for treatment failure or death should receive heightened medical attention. To prevent treatment default, management of patients who are unemployed, homeless, alcoholic, or have a prison history requires extra measures to insure treatment completion. [ABSTRACT FROM AUTHOR]