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Background Global reduction in new infant HIV infections is largely due to the expansion of prevention of mother-to-child transmission (PMTCT) programs. Identification of gaps in healthcare services is paramount in targeting interventions that identify high-risk populations and healthcare barriers that could lead to increased risk of mother to child transmission (MTCT) of HIV. Methods HIV infected women from 5 regions of Africa enrolled in the African Cohort Study (AFRICOS) were followed prospectively with assessments performed every 6 months. Sociodemographic factors, pregnancy outcomes, and access of PMTCT resources were reviewed for retrospectively reported pregnancies and those followed prospectively from study enrollment. Statistical analysis compared the impact of clinical factors on infant mortality and preterm delivery. Results The study reported 5591 pregnancies from January 2013 to June 2019 of which 5363 were retrospectively reported prior to study enrollment and 228 occurred after enrollment. Pregnancies followed prospectively had higher rates of linkage to PMTCT services prenatally (92.5% vs 6.8%, P< 0.001), intrapartum (64.5% vs 3.5%, P< 0.001), and post-partum (64.5% vs 2.9%, P< 0.001). This group had higher rates of delivery by a skilled birth attendant (93.4% vs 66.7%, P< 0.001) and antiretroviral therapy (ART) prescribed antepartum (96.1% vs 5.5%, P< 0.001) and post-partum (74.6% vs 3.6%, P< 0.001). Both groups had similar rates of prescriptions for intrapartum ART (98.7% vs 97.9%). The majority of women reported ART adherence (96.5%, P< 0.001) which was associated with a decrease in both preterm delivery and infant mortality (adjusted OR 0.24, 95% CI 0.15-0.39). A significant proportion of women followed prospectively reported their infants received ART with good adherence (51.8% vs 0.3% and 93.4% vs 6.3%, respectively P< 0.001). Conclusion Participation in AFRICOS increased linkage to PMTCT programs which resulted in increased likelihood of skilled delivery and appropriate ART use for women and their infants. It highlights that linkage to care continues to be a crucial factor in limiting MTCT of HIV especially in resource-limited settings. Limitations in this study exist due to the low number of prospectively followed pregnancies. Disclosures All Authors: No reported disclosures

Lassa virus (LASV) causes Lassa fever (LF), a viral hemorrhagic fever endemic in West Africa. LASV strains are clustered into six lineages according to their geographic location. To confirm a diagnosis of LF, a laboratory test is required. Here, a reverse transcription loop-mediated isothermal amplification (RT-LAMP) assay using a portable device for the detection of LASV in southeast and south-central Nigeria using three primer sets specific for strains clustered in lineage II was developed. The assay detected in vitro transcribed LASV RNAs within 23 min and was further evaluated for detection in 73 plasma collected from suspected LF patients admitted into two health settings in southern Nigeria. The clinical evaluation using the conventional RT-PCR as the reference test revealed a sensitivity of 50% in general with 100% for samples with a viral titer of 9500 genome equivalent copies (geq)/mL and higher. The detection limit was estimated to be 4214 geq/mL. The assay showed 98% specificity with no cross-reactivity to other viruses which cause similar symptoms. These results suggest that this RT-LAMP assay is a useful molecular diagnostic test for LF during the acute phase, contributing to early patient management, while using a convenient device for field deployment and in resource-poor settings.

Lassa fever is a viral haemorrhagic fever endemic in West Africa, especially in: Guinea, Liberia, Nigeria and Sierra Leone. It is transmitted by the multimammate rat Mastomy natalensis, though additional rodent reservoir may contribute to infections. The virus was first identified in 1969 in the town of Lassa, North-East Nigeria from where it derived its name. Since then, several epidemics have occurred in endemic communities, including recent outbreaks with higher fatalities. There is evidence of expanding epidemiology within Africa, imported cases in Europe and North America, and potential for bioterrorism remains a global concern. In this Chapter, we describe the epidemiology and management of Lassa fever in the West African sub-region with a focus on overcoming the socio-cultural challenges. In memory of several healthcare workers who have lost their lives while providing care for Lassa fever patients, we start with a case vignette that describes the confusion and sadness the disease and its complications often bring. The chapter then goes on to discuss the epidemiology, virology, pathogenesis, clinical and laboratory characteristics of the disease with a highlight of the sociocultural challenges that perpetuate the epidemics of Lassa fever in most endemic communities 50 years after its characterisation. The chapter ends with suggestions on how to improve surveillance, prevention and control.

Lassa virus (LASV) is endemic in parts of West Africa where it causes Lassa fever (LF), a viral hemorrhagic fever with frequent fatal outcomes. The diverse LASV strains are grouped into six major lineages based on the geographical location of the isolated strains. In this study, we have focused on the lineage II strains from southern Nigeria. We determined the viral sequences from positive cases of LF reported at tertiary hospitals in Ebonyi and Enugu between 2012 and 2016. Reverse transcription-polymerase chain reaction (RT-PCR) showed that 29 out of 123 suspected cases were positive for the virus among which 11 viral gene sequences were determined. Phylogenetic analysis of the complete coding sequences of the four viral proteins revealed that lineage II strains are broadly divided into two genetic clades that diverged from a common ancestor 195 years ago. One clade, consisting of strains from Ebonyi and Enugu, was more conserved than the other from Irrua, although the four viral proteins were evolving at similar rates in both clades. These results suggested that the viruses of these clades have been distinctively evolving in geographically separate parts of southern Nigeria. Furthermore, the epidemiological data of the 2014 outbreak highlighted the role of human-to-human transmission in this outbreak, which was supported by phylogenetic analysis showing that 13 of the 16 sequences clustered together. These results provide new insights into the evolution of LASV in southern Nigeria and have important implications for vaccine development, diagnostic assay design, and LF outbreak management., Author summary Lassa fever (LF) is a viral hemorrhagic fever caused by Lassa virus (LASV). The different LASV strains are grouped into lineages based on the geographical location of the isolated strains. The aim of our study was to characterize the lineage II strains in southern Nigeria. We sequenced LASV RNA genome from positive cases of LF between 2012 and 2016 which were reported at tertiary hospitals in Ebonyi and Enugu in southeastern Nigeria. Phylogenetic analysis of the viral proteins showed the division of lineage II strains into two genetic clades with one clade being more conserved than the other despite evolving at similar rates. Also, our phylogenetic analysis supported the role of human to human transmission in the 2014 outbreak, in keeping with the epidemiological data. These results provide additional information on the evolution of LASV in southern Nigeria and LF outbreak management.

Background: Electrocardiogram (ECG) is a simple, readily affordable, and noninvasive tool for the evaluation of cardiac disorders. There is a dearth of information on the utility of ECG in general practice in Nigeria. We assessed the knowledge and utilization of ECG among family medicine residents in Nigeria. Materials and Methods: A cross‑sectional evaluation was conducted between November 2011 and May 2012 in four family medicine training centers in Nigeria. A self‑administered questionnaire was used to obtain information from the resident doctors regarding their ECG requests, preferred source of interpretation, most common ECG diagnosis, and update of ECG knowledge. Results: Only 61 out of 120 questionnaires (50.8%) were returned. The respondents were mostly between 31 and 40 years (54.7%) and were predominantly males (73.8%) and senior residents (65.6%). Fifty‑four (88.3%) respondents made

Background In Sub-Saharan African (SSA) women living with HIV, pregnancy creates unique stressors that may induce or exacerbate depression. We described the prevalence of depression during the perinatal period among women living with HIV that became pregnant (P-WLWH) as compared with those that did not (NP-WLWH). Methods We analyzed data from WLWH, age < 45 years, across 11 HIV clinics in Kenya, Nigeria, Uganda, and Tanzania, within the African Cohort Study (AFRICOS). Depression screening was performed via the Center for Epidemiological Studies-Depression (CESD) scale at enrollment and every 6 months in the study. For these analyses, the CESD score was assessed during three periods in time. For P-WLWH, these periods were: (1) enrollment, (2) during pregnancy and (3) the study visit following delivery. For NP-WLWH, three sequential evaluations were analyzed, with visit 1 being enrollment. We compared the prevalence of depression between groups at each period using χ 2 analysis and calculated adjusted odds ratios (OR) using logistic regression for variables associated with positive depression screening (CESD score ≥16). Results There were 764 WLWH selected for analysis, including 164 P-WLWH and 600 NP-WLWH. At enrollment, P-WLWH tended to be younger than NP-WLWH (mean age=30 vs. 34, P < 0.01). Neither group differed significantly with respect to marital status, employment, education, viral load, or duration of HIV. The crude prevalence of depression during periods 1 thru 3 for P-WLWH and NP-WLWH was: 20% (in both groups, P = 0.99), 10% and 13% (P = 0.26), and 4% and 10% (P = 0.01), respectively (figure). P-WLWH had 74% lower odds [OR = 0.26 [0.09–0.75], P = 0.01] of positive depression screening during period 3 than NP-WLWH, when controlling for age, marital status, educational level, viral load, and duration of HIV. Conclusion Surprisingly, our analyses demonstrate P-WLWH were less likely to have positive screening for depression following their pregnancies. These findings may highlight the strength of comprehensive maternal health initiatives in SSA. Additionally, these women will be followed further longitudinally to evaluate patterns of depression in the months following pregnancy. Disclosures All authors: No reported disclosures.

Classical Kaposi’s sarcoma (KS) typically affects elderly men of Mediterranean and Jewish origin. We present an unusual case of classical KS in a human immunodeficiency virus (HIV) negative elderly farmer from rural Nigeria. He had multiple brownish nodules and plaques on both lower extremities associated with lymphoedema. Histopathological examination of a biopsy of the skin nodule confirmed the diagnosis of KS. The lesions only showed marginal improvement on chemotherapy which necessitated a referral for radiotherapy. There is a need to look beyond the traditional geographical distinction of KS variants as we continue to experience a dynamic role for environmental co-factors in the development of KS.

Introduction: Metabolic abnormalities are often common among human immunodeficiency virus (HIV) patients. The atherogenic index of plasma (AIP) is increasingly being used as a screening tool for dyslipidemia as it predicts the presence of small, dense, and highly atherogenic low density lipoprotein (LDL) and high density lipoprotein (HDL) particles. The aim of this study was to identify the pattern and predictors of an abnormal atherogenic index in highly active antiretroviral therapy (HAART)-naïve HIV patients. Materials and Methods: HAART-naïve patients with HIV infection were recruited for this cross-sectional study. Anthropometric indices, blood pressure, CD4 count, viral load, fasting blood glucose, and lipid profiles were determined. Total cholesterol (TCH)/HDL, triglyceride (TG)/HDL, and LDL/HDL ratios were calculated. The AIP was calculated as log (TG/HDL). The correlations between AIP and the other lipoprotein ratios and predictors of AIP were determined using stepwise multiple linear regression. P < 0.05 was considered as significant. Results: A total of 353 patients with a mean age of 37.3 (9.6) years were recruited for this study. Low HDL level was the most common abnormality in 222 (62.9%) patients while elevated TCH was seen in 54 (15.3%) patients. Those with medium risk (AIP 0.1-0.24) and high risk category (AIP > 0.24) constituted up to 226 (64%) of the patients. There were significant correlations between AIP and CD4 count, body mass index, LDL, TCH/HDL, and LDL/HDL. Predictors of AIP were CD4 count, TCH/HDL, and LDL/HDL. Conclusion: Abnormal AIP is frequent in HAART-naïve HIV patients and is inversely related to their level of immunity. We recommend that AIP estimation should be part of baseline assessment of HIV patients before the commencement of therapy.

Introduction: Human immunodeficiency virus (HIV) negatively impacts the natural history of hepatitis B virus (HBV) infection, including replication. We determined the prevalence of HBeAg in HIV/HBV co-infected patients compared to HBV mono-infected controls and further investigated the relationship between HBeAg seropositivity and the degree of HIV-induced immunosuppression in co-infected patients. Methodology: The study design was cross-sectional. One hundred HBsAg-positive HIV-infected adults and 100 age and sex matched HBsAg-positive HIV negative controls were consecutively recruited between May and November 2010. Relevant demographic and HBV-related information was obtained. HBeAg was assayed by semi-quantitative third generation ELISA. The HIV/HBV co-infected patients also had CD4+ cell and HIV viral load quantification measured using flow cytometry and polymerase chain reaction techniques respectively. Results: In each group, the mean age was 34 ± 8 years and the majority (61%) was female. The prevalence of HBeAg was significantly higher among co-infected patients (n = 28; 28%) than in the controls (n = 15; 15%; p = 0.03). HBeAg seropositivity was independently associated with age < 40 years (AOR = 2.83, 95% = CI 1.29-6.17) and HIV seropositivity (AOR = 2.44, 95% C.I = 1.17-5.07). The prevalence of HBeAg was significantly higher in co-infected patients with CD4 cell count < 200 cell/µL (41.3%) compared to those with 200-499 cell/µL (18.6%) and ≥500 cell/µL (9.1%), p = 0.006. Conclusion: HIV/HBV co-infected patients have a significantly higher prevalence of HBeAg than HBV mono-infected individuals. HBV-infected patients should be routinely assessed for HBeAg, especially if they are co-infected with HIV.

BACKGROUND We investigated predictors of in-hospital mortality and length of hospital stay among adults with community-acquired pneumonia (CAP) in Nigeria in order to provide recommendations to improve CAP outcomes in developing countries. METHODS This was a multi-centre case control study of patients ≥18 years who were admitted with CAP between 2008 and 2012. Case notes of 100 consecutive patients who died (cases) and random sample of 300 patients discharged (controls) were selected. RESULTS Mean ages were 55.4±19.6 (cases) and 49.3±19.2 (controls). Independent predictors of mortality were CURB-65 score ≥3: adjusted odds ratio (aOR) 24.3, late presentation: aOR 8.6, co-morbidity: aOR 3.9, delayed first dose antibiotics (>4 hours): aOR 3.5, need for supplemental oxygen: aOR 4.9, multilobar pneumonia: aOR 4.0, non-pneumococcal aetiology: aOR 6.5, anaemia: aOR 3.8 and hyperglycemia: aOR 8.6. CURB-65 ≥3 predicted mortality with a high specificity (96.1%) but low sensitivity (75%); positive predictive value of 88.2% and negative predictive value of 90.8%. Care in hospital A and B: aOR 3.3 and 2.2 respectively, male gender aOR 2.1, co-morbidity aOR 3.0, anaemia aOR 2.1 and elevated serum creatinine aOR 6.3 independently predicted length of hospital stay >10 days among survivors. CONCLUSIONS Several modifiable patient-related and process-of-care factors predicted in-hospital mortality, and length of hospital stay among survivors. Our findings should be used to improve CAP outcomes in developing countries.

Opportunistic infections (OIs) cause significant morbidity/mortality in human immunodeficiency virus (HIV)‑infected individuals globally. Disparities between high‑income countries (HICs) and low/middle‑income countries (LMICs) in the magnitude of HIV‑related OIs in pre-highly active antiretroviral therapy (HAART) populations was reviewed, and HAART‑induced decline in OIs was further compared between the two settings. Studies published in English from onset of HIV epidemic up to December 2013 were searched in PubMed, Google, Google Scholar, and African Journal online. An article was included if (a) the study was conducted in HIC or LMIC, (b) the age of the participants was ≥12 years, (c) the HAART status of the participants was stated, and (d) various types of OIs were investigated. In predominantly pre‑HAART populations, the incidence and prevalence of overall HIV‑related OIs in HIC ranged from 5.5 to 50.0 per 100 person‑years (PY) and 27.4–56.7%, respectively. In LMIC, the respective overall incidence and prevalence of OIs were 12.2–93.9 per 100 PY and 32.0–77.7%. Pneumocystis jirovecii pneumonia, candidiasis, Cytomegalovirus disease, Mycobacterium avium complex disease, and Kaposi’s sarcoma were the most frequent OIs in HICs while tuberculosis, candidiasis, chronic diarrhea, and cryptococcosis were predominant in LMICs. The introduction of HAART led to substantial reduction in the incidence of OIs with more impressive percentage decline in HICs (43–97%) compared to 30–79% in LMICs. Disparities in the magnitude of HIV‑related OIs between HICs and LMICs are evident both in the pre‑HAART and post‑HAART era. Efforts to optimize HAART‑induced decline in HIV‑related OIs should become a global health priority irrespective of prevailing socioeconomic circumstances.Keywords: Acquired immune deficiency syndrome, Disparities, High‑income country, Highly active antiretroviral therapy, Human immunodeficiency virus, Low‑income country, Middle‑income country, Opportunistic infections

Background In Nigeria, where malaria is endemic, greater than 70% of febrile illnesses are treated presumptively as malaria, often without a laboratory evaluation for other possible causes of fever. This cross-sectional study evaluated the presence of dengue virus infection in febrile patients, presumptively diagnosed of malaria infections in the clinic. Methodology Blood samples were collected from 529 febrile patients (246 in Jos and 283 in Maiduguri) attending the general outpatient clinics of the Jos University Teaching Hospital (JUTH) and the University of Maiduguri Teaching Hospital (UMTH) and tested for anti-dengue immunoglobulin M (IgM) and immunoglobulin G (IgG), as well as anti-non-structural protein (NS1) by ELISA. The samples were also evaluated for presence of P. falciparum malaria parasites by microscopic examination of Giemsa-stained blood smears. Results The prevalence of confirmed, highly suggestive and probable dengue virus infections categorized in relation to duration of illness since onset of fever were 2.3%, 5.5% and 1.5% respectively, while the prevalence of anti-flavivirus IgG and IgM seropositivity was 11.7%. In a total of 117 (22.1%) patients (32 in Jos, 85 in Maiduguri), malaria parasites were detected by blood smear microscopy, out of which 7 (6%) also had a positively confirmed, highly suggestive or probable dengue test result. Conclusion Although the high cross-reactivity of anti-flavivirus antibodies should be taken into account in the interpretation of the seroprevalence data, our findings suggest a significant presence of dengue virus in this environment, some of which may otherwise be misdiagnosed as malaria. These findings are strong enough to recommend serological screening for anti-dengue virus titer and NS1 antigen for all febrile patients, as part of fever diagnostic protocols in tropical regions. Given the prevalence of dengue virus infections, there is also a need for a dengue control program and public education to prevent outbreaks and occurrence of severe dengue complications.

Objective To describe our experiences in the management of a case of Lassa fever (LF) and follow-up of nosocomial primary contacts during the 2014 Ebola outbreak in West Africa. Methods Clinical management of the index case and infection control/surveillance activities for primary contacts are described. Laboratory confirmation was by Lassa virus-specific reverse-transcriptase PCR. Results A 28-year-old man with a 10-day history of febrile illness was referred to a major tertiary hospital in south-east Nigeria from a city that previously experienced a LF outbreak and was recently affected by Ebola. On observation of haemorrhagic features, clinicians were at a crossroads. Diagnosis of LF was confirmed at a National Reference Centre. The patient died despite initiation of ribavirin therapy. Response activities identified 121 primary contacts comprising 78 (64.5%) hospital staff/interns, 19 (15.7%) medical students, 18 (14.9%) inpatients and 6 (5.0%) relatives. Their mean age was 32.8 ± 6.6 years, and 65.3% were women. Twenty (16.5%) had high-risk exposure and were offered ribavirin as post-exposure prophylaxis. No secondary case of LF occurred. Fatigue (43.8%) and dizziness (31.3%) were the commonest side effects of ribavirin. Conclusions Response activities contained nosocomial spread of LF, but challenges were experienced including lack of a purpose-built isolation facility, absence of local Lassa virus laboratory capacity, failure to use appropriate protective equipment and stigmatisation of contacts. A key lesson is that the weak health systems of Africa should be comprehensively strengthened; otherwise, we might win the Ebola battle but lose the one against less virulent infections for which effective treatment exists. Objectif Decrire nos experiences dans la prise en charge d'un cas de fievre de Lassa (FL) et le suivi des contacts primaires d'infections nosocomiales lors de l’epidemie d'Ebola en 2014 en Afrique de l'Ouest. Methodes La prise en charge clinique du cas index et les activites de lutte/surveillance de l'infection pour les contacts primaires sont decrites. La confirmation de laboratoire a ete obtenue par la PCR basee sur la transcriptase inverse specifique du virus Lassa. Resultats Un homme de 28 ans avec une histoire de maladie febrile de 10 jours a ete refere dans un hopital tertiaire majeur dans le sud-est du Nigeria, dans une ville qui a precedemment connu une epidemie de FL et avait recemment ete affectee par le virus Ebola. Suivant l'observation des caracteristiques hemorragiques, les cliniciens sont arrives a differentes voies possibles. Le diagnostic de la FL a ete confirme dans un centre national de reference. Le patient est decede malgre l'instauration du traitement au ribavirine. Les activites de reponse ont identifie 121 contacts primaires comprenant 78 (64,5%) membres/stagiaires du personnel de l'hopital, 19 (15,7%) etudiants en medecine, 18 (14,9%) patients hospitalises et 6 (5,0%) parents. Leur âge moyen etait de 32,8 ± 6,6 ans et 65,3% etaient des femmes. Vingt (16,5%) avaient subi une forte exposition au risque et ont recu du ribavirine comme prophylaxie post-exposition. Aucun cas secondaire de FL n'est survenu. La fatigue (43,8%) et des malaises (31,3%) etaient les effets secondaires les plus courants du ribavirine. Conclusions Les activites d'intervention ont contenu la propagation nosocomiale de la FL mais des defis ont ete rencontres notamment l'absence d'un espace d'isolement construit a cet effet, l'absence de capacites locales de laboratoire pour le virus de Lassa, le defaut d'utilisation de l’equipement approprie de protection et la stigmatisation des contacts. Une lecon a retenir est la faiblesse des systemes de sante en Afrique qui devraient etre renforces globalement, sinon nous pourrions gagner la bataille contre Ebola mais perdre celle contre des infections moins virulentes pour lesquelles un traitement efficace existe. Objetivo Describir nuestras experiencias en el manejo de un caso de Fiebre de Lassa (FL) y el seguimiento de los contactos nosocomiales primarios durante el brote del virus de Ebola del 2014 en Africa Occidental. Metodos Se describe el manejo clinico del caso indexado y las actividades de control/vigilancia de la infeccion entre los contactos primarios. La confirmacion en el laboratorio se realizo mediante una PCR transcriptasa inversa especifica para el VL. Resultados Un hombre de 28 anos con una historia de 10 dias de fiebre fue referido a un hospital terciario del sudeste de Nigeria desde una ciudad en la que previamente se habia declarado un brote de FL y que recientemente habia sido afectada por el Ebola. Al observar caracteristicas hemorragicas, los clinicos se encontraron en una encrucijada. El diagnostico de FL se confirmo en el Centro de Referencia Nacional. El paciente murio a pesar de iniciar tratamiento con Ribavirin. Las actividades de respuesta identificaron 121 contactos primarios que incluian 78 (64.5%) sanitarios / internos hospitalarios, 19 (15.7%) estudiantes de medicina, 18 (14.9%) pacientes ingresados y 6 (5.0%) familiares. La edad media era de 32.8 ± 6.6 anos y un 65.3% eran mujeres. Veinte (16.5%) tenian un alto riesgo de exposicion y se les ofrecio una profilaxis post-exposicion con Ribavirin. No hubo un caso secundario de FL. Fatiga (43.8%) y mareos (31.3%) fueron los principales efectos secundarios de Ribavirin. Conclusiones Las actividades de respuesta consiguieron contener la propagacion del VL pero se experimentaron retos incluyendo la falta de una instalacion de aislamiento especificamente disenada y construida, falta de capacidad de laboratorio local para la deteccion del VL, falta de uso de equipos de proteccion apropiados y estigmatizacion de los contactos. Una leccion clave es que los debiles sistemas de salud del Africa deberian fortalecerse de forma integral, o de lo contrario puede que se gane la batalle contra el Ebola pero se pierdan otras contra infecciones menos virulentas para las cuales existen tratamientos efectivos.

A clear knowledge of the pathogens responsible for community-acquired pneumonia (CAP) in a given region and their antibiotic sensitivity patterns is necessary for optimal treatment. We determined the common bacterial pathogens causing CAP in Nigeria and further reviewed their antibiotic senstivity patterns with a view to providing recommendations to improve antibiotic management of CAP.Case notes of all adult patients who were 18 years or more admitted to four major tertiary hospitals in South East Nigeria with a diagnosis of CAP between 2008 and 2012 were retrospectively studied. To be eligible, patients were required to have sputum culture and sensitivity results available. Socio-demographic, clinical, pre-admission and in-hospital treatment data were also obtained.Of 400 patients with a radiologically confirmed diagnosis of CAP, 232 fulfilled the study criteria; 122 (52.6%) were women and the mean age was 50.6 ± 18.8 years. Aetiological agents were identified from sputum in 189 (81.5%) patients. Streptococcus pneumoniae (n = 90, 47.6%) was the most frequent isolate followed by Klebsiella pneumoniae (n = 62, 32.8%), Staphylococcus aureus (n = 24, 12.7%) and Streptococcus pyogenes (n = 13, 6.9%). The pathogens were most sensitive to levofloxacin (77%), ceftazidime (75.5%) and ofloxacin (55.8%). The susceptibility of the isolates to antibiotics most frequently presecribed for empirical therapy was low (co-amoxiclav, 47.6%; ciprofloxacin, 45.9% and ceftriaxone, 47.6%) and this was associated with higher mortality and/or longer duration of hospital stay in survivors.Strep. pneumoniae and K. pneumoniae were the most common causes of CAP. The pathogens were most sensitive to levofloxacin and ceftazidime. We suggest that these antibiotics should increasingly be considered as superior options for empirical treatment of CAP in Nigeria.

Background/Aim: To evaluate the prevalence of pulmonary hypertension among patients living with HIV/AIDS and to determine its contribution to cardiac dysfunction. Method: A hospital based cross sectional study was carried out over a 6-month period at the Jos University Teaching Hospital. The subjects were 200 confirmed HIV positive patients, ≥18 years of age who consented to the study. Physical examination, laboratory investigations, 2 dimensional and Doppler echocardiography were conducted on the subjects. Results: The mean age of the patients was 38 ± 9 years, and there were 142 females (71%). Females were younger, mean age 36 ± 8 years versus 41 ± 10 years for males (p-value

Summary Data on baseline hepatic function of HIV and hepatitis B virus (HBV) co-infected patients are limited in sub-Saharan Africa. We assessed liver function test (LFT) abnormalities in Nigerian patients with HIV/HBV co-infection to highlight the impact of HIV on HBV-related liver disease in sub-Saharan Africa. A cross-sectional study involving 100 HIV/HBV co-infected patients and 100 age- and sex-matched HBV mono-infected controls. Blood testing for HIV antibodies, CD4+ cell count, hepatitis B surface antigen (HBsAg), hepatitis B e antigen (HBeAg), LFTs, platelet count, fasting blood glucose and lipid profile were carried out. Non-invasive hepatic fibrosis scores (aspartate aminotransferase-platelet ratio index [APRI] and FIB-4) were also calculated. Co-infected patients had deranged liver enzymes more than the controls (77% versus 64%, P = 0.04). The predominant patterns of enzyme derangement in co-infected patients were either predominantly ↑ALP (30% versus 4%, P < 0.0001) or mixed (30% versus 15%, P = 0.01) but predominantly ↑AST/ALT in the controls (25% versus 9%, P = 0.003). Co-infected patients had higher fibrosis scores for both APRI ( P = 0.002) and FIB-4 ( P = 0.0001). On further analysis, LFT abnormalities and fibrosis scores were only significantly higher in co-infected patients in the immune clearance and HBeAg-negative chronic hepatitis phases. LFT abnormalities are common in Nigerians with HBV infection and co-infection with HIV negatively impacts on hepatic function.

BACKGROUND Second-line antiretroviral therapy (ART) accounts for less than 5% of total ART in resource-limited settings. We described the baseline characteristics, reasons for switch and treatment outcomes of Nigerian patients receiving second-line ART. METHODS In this retrospective cohort study we recorded the baseline characteristics of HIV-infected adults whose treatment regimen was switched from a non-nucleoside reverse transcriptase inhibitor, a first-line agent, to a protease inhibitor-based second-line regimen. The duration of follow-up was 12 months. RESULTS Of 4229 patients who started first-line therapy, 186 (4.4%) were switched to second-line therapy after a mean duration of 16.6 ± 7.6 months. Their mean age was 41.8 ± 9.6 years and 59.1% were women. The median (range) viral load and CD4 cell counts at switch were 4.7 (4.1-6.3) log10 copies/ml and 71 (6-610) cells/µl, respectively. The predominant reason for switch was virological failure (79.0%). Only 55.4% and 36.6% of patients had CD4 cell count and viral load at 12 months. About 82%, 79% and 82% of patients with available data achieved virological suppression at 3 months, 6 months and 12 months respectively (p = 0.81). The proportion of patients who achieved ≥50% rise in CD4 cell count increased from 55.8% at 3 months to 78.6% at 12 months (p = 0.0002). CONCLUSION The rate of switch to second-line therapy was low but there were good treatment outcomes among patients with available data. Attrition rate was high. Regular viral load monitoring, improved availability/affordability of second-line regimens and retention in care should become priorities in resource-limited settings.

Despite the growing body of evidence on the interaction between HIV and malaria in sub-Saharan Africa, there is a dearth of data on clinical malaria in HIV-infected patients in Nigeria. We determined the burden of clinical malaria in HIVinfected adult Nigerians and further investigated the association between their immunological status and the rates of clinical malaria. Ninety seven antiretroviral treatment-naïve HIV-infected adults were enrolled in a cross-sectional study from August to December, 2009. The participants had a complete clinical evaluation, thick and thin blood films for malaria parasites and CD4 cell count quantification. Clinical malaria was defined as having fever (temperature ≥ 37.5oC or history of fever within 48 hours) and a malaria parasite density above the median value obtained for subjects with co-existing fever and parasitaemia. Clinical malaria was diagnosed in 10 out of 97 patients (10.3%). Lower CD4 cell counts were associated with increasing rates of clinical malaria which was 0% at CD4 cell count of ≥ 500, 2.6% at 200-499 and 30% at

The aim of the present study was to evaluate the determinants of HIV-related cardiac disease (HRCD) among adults in north central Nigeria. This was a hospital-based cross-sectional study recruiting patients who were HIV positive attending the HIV clinic at Jos University teaching Hospital, Nigeria.A total of 200 adults who were HIV positive and aged ≥18 years were consecutively recruited. All patients were administered a questionnaire and underwent clinical examination, laboratory investigation for haemoglobin estimation, CD4 cell count, viral load, serum lipid profile, hepatitis B surface antigen, anti-hepatitis C virus antibody, electrocardiogram and two-dimensional echocardiography Doppler studies. The outcome measure was echocardiography-defined cardiac disease, such as systolic dysfunction, diastolic dysfunction, isolated left ventricular dilatation, right ventricular dysfunction or pulmonary hypertension.The mean age of the study population was 38±9 years. The majority (71%) were women and were on average younger than the men (36±8 years vs 47±9 years, p0.0002). Highly active anti-retroviral therapy (HAART) use was seen in 84.4% of subjects. The median CD4 cell count for the study population was 358 cells/µL; the count was 459 (95% CI 321 to 550) cells/µL for subjects without HRCD and 193 (95% CI 126 to 357) cells/µL for subjects with HRCD (p0.001). HAART-naive subjects with HRCD had a mean CD4 cell count of 121 cells/µL vs 200 cells/µL for those on HAART (p0.01). CD4 cell count (OR = 0.25, 95% CI 0.15 to 0.45) and duration of diagnosis (OR=3.88, 95% CI 1.20 to 13.71) were the significant determinants of HRCD on multivariate analysis.Duration of HIV diagnosis and degree of immunosuppression were the significant determinants of HRCD. There is therefore a need to reduce cardiovascular morbidity in patients infected with HIV through early diagnosis/sustained use of HAART, early screening for HRCD and prompt intervention.

Background: The introduction of Highly Active Antiretroviral Therapy (HAART) has led to decline in HIV-related opportunistic infections in high-income settings. We determined the prevalence and risk factors for opportunistic infections among patients receiving HAART in a resource-limited setting in Nigeria. Methodology: A descriptive and analytical cross-sectional study among adult HIV-infected patients receiving HAART for a median duration of 3 years at the Federal Medical Centre, Owerri, Nigeria was conducted. Data on pre- HAART socio-demographic, clinical and laboratory characteristics were obtained. Post-HAART data were collected through history, physical examination and laboratory investigations. Result: The mean age of the participants was 41.1 ± 10.0 years; and females were in the majority (65.8%). Half (50.4%) belonged to the lower socio-economic class. At baseline (pre-HAART), 72.3% of the participants belonged to World Health Organization (WHO) clinical stage 1 or 2. The median pre-HAART CD4 cell count of the patients was 200 (110-263) cells/μl while the median post-HAART CD4 cell count was 357 (211-496) cells/μl. The majority (77.6%) were adherent on HAART. Out of 339 patients, 76 (22.4%) had opportunistic infections. The leading conditions were candidiasis (8.6%), tuberculosis (7.7%), dermatitis (5.6%), chronic diarrhea (1.5%) and sepsis (1.5%). The independent risk factors for opportunistic infections were household income < 20,000 (Adjusted odds ratio [AOR] = 2.70, 95% CI 1.18-6.18), advanced baseline WHO clinical stage (AOR=9.49, 95% CI 4.20-21.42), baseline hemoglobin

Aim Previous studies on the relationship between hepatitis B virus (HBV) infection and type 2 diabetes mellitus (DM) are conflicting. We aimed to elucidate the relationship by investigating the prevalence and predictors of impaired fasting glucose (IFG) in HBV-infected patients. Methods A total of 204 consecutive patients with hepatitis B surface antigen (HBsAg) seropositivity for ≥6 months were recruited in a cross-sectional study. Patients with DM were excluded. Information regarding age, gender, ethnicity, residence, family history of DM, alcohol use, and cigarette smoking were obtained using a structured questionnaire. Fasting plasma glucose, lipid profile, liver enzymes and hepatitis Be antigen (HBeAg) were tested. Results The participants had a mean age of 33.6 ± 8.4 years and included 123 (60.3%) females, 40 (19.6%) with HBeAg seropositivity, and 29 (14.2%) with family history of DM. The prevalence of IFG was 52 (25.5%). On multivariate analysis, the independent predictors of IFG were family history of DM (OR = 8.23, 95% CI = 2.78–24.31), male gender (OR = 2.83, 95% CI = 1.17–6.64), HBeAg seropositivity (OR = 4.97, 95% CI = 1.87–13.18) and elevated GGT (OR = 7.27, 95% C.I = 2.88–18.35). Conclusion The prevalence of IFG among HBV-infected patients is high. Targeted screening and follow-up of HBV-infected patients for abnormalities of glucose metabolism is recommended.

Background The attitude of healthcare workers (HCW) towards organ donation is cardinal to the successful implementation and sustainability of transplant programs. We present the outcome of a survey among HCW in a single tertiary institution in Nigeria regarding their willingness to be living-related kidney donors. Methods Self-administered questionnaires were randomly distributed to HCW evaluating their attitude towards living-related kidney donation. Results Of the 650 questionnaires distributed only 502 responded (clinical medical students 51%, physicians 31.7% and nurses 17.3%); 75.6% of respondents were willing to be living donors while 5.8% were against it, and 18.5% were undecided. Multivariate analysis identified willingness to receive, perceived risk associated with kidney donation, and attitude towards cadaveric donation as independent predictors of willingness of HCW to be living donors. Conclusion Nigerian HCW have a positive attitude toward kidney donation.

Background: Tuberculosis (TB) causes significant morbidity/mortality among human immunodeficiency virus‑infected individuals in Africa. Reducing TB burden in the era of highly active antiretroviral therapy (HAART) is a public health priority. Aim : We determined the factors associated with prevalent TB among patients receiving HAART. Subjects and Methods : We conducted a cross‑sectional study of adult patients who had received HAART for ≥12 weeks in a Nigerian tertiary hospital. Patients whose TB diagnosis predated HAART were excluded from the study. Pre‑HAART data were collected from the clinic records, whereas post‑HAART data were obtained through medical history, physical examination, and laboratory investigations. Standard TB screening/diagnostic algorithms as applicable in Nigeria were used. Logistic regression analysis was used to determine factors independently associated with prevalent TB. Results : about 65.8% (222/339) were women. The mean age was 41.1 (10.0) years and 23.6% (73/339) had past history of TB. The prevalence of active TB was 7.7% (26/339). Among these patients, 42.3% (11/26) had pulmonary TB, 34.6% (9/26) had disseminated TB, whereas 23.1% (6/26) had only extra‑pulmonary disease. Only 45% (9/20) of patients with pulmonary involvement had positive sputum smear. Factors independently associated with prevalent TB were lower social class (adjusted odds ratio [aOR]: 31.7; 95% confidence interval [CI]: 1.1–1417.3), HAART non‑adherence (aOR125.5; 95% CI: 9.6–1636.3), baseline CD4

Background: The metabolic syndrome is closely related to insulin resistance (IR) and cardiovascular disease. This study examined the prevalence of IR and metabolic syndrome as well as factors associated with IR among Nigerian women.Materials and Methods: Eighty‑six women living in an urban area in Enugu, South‑East Nigeria, were assessed. Demographic information included age, residence, physical activity, alcohol and tobacco intake and were collected with questionnaires. Blood pressure and anthropometric parameters were measured using standard methods. Fasting lipids, blood glucose, and insulin were measured. IR was calculated with homeostasis model assessment of IR formula. The ratios; triglyceride/ high‑density lipoprotein (TG/HDL), total cholesterol (TC)/HDL, and atherogenic index of plasma; log (TG/HDL) were calculated and compared with IR. Metabolic syndrome was sought for using both the WHO and the harmonized joint criteria.Results: The mean age was 44.4 (13.1) years. Hypertension, obesity/overweight, and abdominal obesity were present in 31.5%, 81.1%, and 92.2%, respectively. There was elevated TC (62.2%), elevated low‑density lipoprotein (45.6%), low HDL (40%), and elevated TG (14.4%) levels. IR was present in 39 (45.3%). Metabolic syndrome was present in 25 (29.1%) and 17 (19.8%) using the joint criteria and the WHO criteria, respectively. The sensitivity and specificity of the joint revised criteria in identifying IR individuals were 48.7% and 87.2%, respectively, and for the WHO criteria, were 38.5% and 95.7%, respectively. The only significant predictor of IR was the presence of diabetes; P = 0.03, odds ratio = 7.2 (95% confidence interval = 1.19–41.88).Conclusion: IR and metabolic syndrome were common. They were not related to any of the lipoprotein ratios. Metabolic syndrome had a low sensitivity in detecting IR.Keywords: Insulin resistance, metabolic syndrome, triglycerides, women

Background : Human immunodeficiency virus (HIV) infection and its treatment are associated with lipid abnormalities. Data on lipid profile of treatment-naοve HIV-infected patients in Nigeria are limited, and available studies did not exclude the role of major host-related risk factors for dyslipidemia. Aim: We assessed the lipid profile of normotensive, non-diabetic, and non-obese treatment-naοve HIV-infected patients to identify their abnormalities in comparison with age- and sex-matched HIV-negative control. Subjects and Methods : One hundred and six normotensive, non-diabetic, and non-obese HIV positive patients and 98 age-and sex-matched HIV-negative controls had lipid profile estimation in the fasting state. The CD4+ cell count of the HIV-infected patients was also quantified. Results : The median (IQR) triglyceride was significantly higher in HIV-positive patients than in the controls [1.75 (1.30-2.40) mmol/L vs. 1.55 (1.30-1.90) mmol/L, P = 0.01]. HIV-positive patients also had significantly lower mean total cholesterol, TC [4.18 (1.04) mmol/L vs. 4.64 (1.01) mmol/L, P = 0.001] and HDL-C [1.17 (0.35) mmol/L vs. 1.29 (0.43) mmol/L, P = 0.03]. The mean LDL-C [2.20 (0.87) mmol/L vs. 2.19 (0.75) mmol/L, P = 0.97] and TC/HDL-C ratio [3.95 (1.42) vs. 3.84 (1.14) mmol/L, P = 0.52] were similar between the HIV-positive patients and controls. The HIV-infected patients had a significantly higher proportion of subjects with low HDL-C [36.8% (39/106) vs. 23.5% (23/98), P = 0.04] and hypertriglyceridemia [31.1% (33/106) vs. 11.2% (11/98), P = 0.001] while the controls had significantly higher proportion of subjects with hypercholesterolemia [22.4% (22/98) vs. 10.4% (11/106), P = 0.02]. Lower HDL-C was associated with CD4+ cell count P = 0.02). Conclusion : Lipid abnormalities are common in treatment-naοve HIV-infected patients even in the absence of major host-related risk factors for dyslipidemia. HIV-infected patients should, therefore, be routinely screened for lipid disorders before commencement of anti-retroviral therapy.