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Objectives and Method: There are growing concerns of tenofovir disoproxil fumarate (TDF)-associated renal toxicity. We evaluated the effect of long-term TDF exposure on renal function in a cohort of HIV-1-infected Nigerians between 2006 and 2015. Multivariate logistic regression was used to identify predictors of renal impairment at different time over 144 weeks of antiretroviral therapy (ART)., Results: Data of 4897 patients, median age 42 years (interquartile range: 36-49), and 61% females were analyzed. The prevalence of renal impairment increased from 10% at week 24 to 45% at 144 weeks in TDF-exposed participants compared to an increase from 8% at 24 weeks to 14% at 144 weeks in TDF-unexposed participants. Tenofovir disoproxil fumarate exposure predicted the risk of renal impairment at 144 weeks of ART (odds ratio: 2.36; 95% confidence interval: 1.28-4.34)., Conclusion: Long-term exposure to TDF-based ART significantly increases the likelihood of renal impairment. The continued use of TDF-based regimen in our setting should be reviewed. We recommend the urgent introduction of tenofovir alafenamide-based regimen in the HIV treatment guidelines of Nigeria and other resource-limited countries.

We compared the prevalence of menopause symptoms between women living with HIV to their HIV-negative peers and determined predictors of severe menopause symptoms in Jos, Nigeria. This descriptive cross-sectional study included 714 women aged 40-80 years. We compared prevalence and severity of menopause symptoms using the menopause rating scale (MRS). Logistic regression analysis was used to determine the predictors of severe symptoms. Six-hundred and seven (85.0%) were HIV-positive, with a mean duration of infection of 5.6 ± 2.7 years. The mean age of the cohort was 46 ± 5 years. The most prevalent menopause symptoms were hot flushes (67.2%), joint and muscle discomfort (66.2%), physical/mental exhaustion (65.3%), heart discomfort (60.4%), and anxiety (56.4%). The median MRS score was higher for HIV-positive compared to HIV-negative women (p = 0.01). Factors associated with severe menopause symptoms included HIV-positive status (aOR: 3.01, 95% CI: 1.20-7.54) and history of cigarette smoking (aOR: 4.18, 95% CI: 1.31-13.26). Being married (aOR: 0.49, 95% CI: 0.32-0.77), premenopausal (aOR: 0.60, 95% CI: 0.39-0.94), and self-reporting good quality of life (aOR: 0.62. 95% CI: 0.39-0.98) were protective against severe menopause symptoms. We found HIV infection, cigarette smoking, quality of life, and stage of the menopause transition to be associated with severe menopause symptoms. As HIV-positive populations are aging, additional attention should be given to the reproductive health of these women.

Objective: To describe the prevalence of female sexual dysfunction (FSD) and its determinants among women with HIV infection enrolled for care and treatment in an ambulatory care setting., Methods: A questionnaire-based cross-sectional survey was conducted among women attending the HIV clinic of Jos University Teaching Hospital, Nigeria, between March 2013 and February 2014. The self-administered Female Sexual Function Index (FSFI) was used to assess FSD; a score of less than 26.55 indicated FSD. Pearson coefficient was used to assess interdomain correlation, and multiple linear regression was used to identify factors associated with FSD., Results: Among 370 participants, 330 (89.2%, 95% confidence interval [CI] 85.6%-92.2%) had FSD. The overall median FSFI score was 19.2 (interquartile range [IQR] 6.4-23.9). The arousal domain had the lowest subscore (median 2.7, IQR 0.0-3.6). The highest interdomain correlations were between lubrication and orgasm (r=0.87), arousal and lubrication (r=0.84), and arousal and orgasm (r=0.81) domains. Satisfactory health (β=3.34, 95% CI 1.16-5.52) and history of alcohol use (β=2.38, 95% CI 0.28-4.47) were independently associated with FSD., Conclusion: FSD was prevalent among women with HIV infection. Care providers need to routinely address FSD as part of a comprehensive care package in the study setting., (© 2017 International Federation of Gynecology and Obstetrics.)

Background: Individuals with HIV, especially those on antiretroviral therapy (ART), may have increased risk of hypertension. We investigated the prevalence of hypertension at enrolment and 12 months after commencing ART in a Nigerian HIV clinic., Methods: Data from patients enrolled for ART from 2011 to 2013 were analysed, including 2310 patients at enrolment and 1524 re-evaluated after 12 months of ART. The presence of hypertension, demographic, clinical and biochemical data were retrieved from standardized databases. Bivariate and logistic regressions were used to identify baseline risk factors for hypertension., Results: Prevalence of hypertension at enrolment was 19.3% (95% CI 17.6-20.9%), and age (p<0.001), male sex (p=0.004) and body mass index (BMI) (p<0.001) were independent risk factors for hypertension. Twelve months after initiating ART, a further 31% (95% CI 17.6-20.9%) had developed hypertension. Total prevalence at that point was 50.2%. Hypertension among those on ART was associated with age (p=0.009) and BMI (p=0.008), but not with sex. There were no independently significant associations between hypertension and CD4+ counts, viral load or type of ART., Conclusions: Hypertension is common in HIV infected individuals attending the HIV clinic. Patients initiating ART have a high risk of developing hypertension in the first year of ART. Since BMI is modifiable, life-style advice aimed at weight reduction is strongly advisable., (© The Author 2017. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Older age at initiation of combination antiretroviral therapy (cART) has been associated with poorer clinical outcomes. Our objectives were to compare outcomes between older and younger patients in our clinical cohort in Jos, Nigeria., Methods: This retrospective cohort study evaluated patients enrolled on cART at the Jos University Teaching Hospital, Nigeria between 2004 and 2012. We compared baseline and treatment differences between older (≥50 years) and younger (15-49 years) patients. Kaplan-Meier analysis and Cox proportional hazard models estimated survival and loss to follow-up (LTFU) and determined factors associated with these outcomes at 24 months., Results: Of 8352 patients, 643 (7.7%) were aged ≥50 years. The median change in CD4 count from baseline was 151 vs 132 ( P = .0005) at 12 months and 185 vs 151 cells/mm 3 ( P = .03) at 24 months for younger and older patients, respectively. A total of 68.9% vs 71.6% ( P = .13) and 69.6% vs 74.8% ( P = .005) of younger and older patients achieved viral suppression at 12 and 24 months, with similar incidence of mortality and LTFU. In adjusted hazard models, factors associated with increased risk of mortality were male sex, World Health Organization (WHO) stage III/IV, and having a gap in care, whereas being fully suppressed was protective. The risk of being LTFU was lower for older patients, those fully suppressed virologically and with adherence rates >95%. Male sex, lack of education, WHO stage III/IV, body mass index <18.5 kg/m 2 , and having a gap in care independently predicted LTFU., Conclusions: Older patients achieved better viral suppression, and older age was not associated with increased mortality or LTFU in this study., (© The Author 2017. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Background: Mortality data, including the risk factors for mortality in HIV-infected children with pulmonary TB (PTB) being treated for PTB and who are on antiretroviral therapy (ART), are scarce in Nigeria. We determined the mortality rate and risk factors for mortality among such children, at the pediatric HIV clinic of the Jos University Teaching Hospital (JUTH) in Jos, Nigeria., Methods: We performed a retrospective cohort study on 260 PTB-HIV-1 co-infected children, aged 2 months to 13 years, being treated for PTB and on ART from July 2005 to March 2013. The mortality rate and associated risk factors were determined using multivariate Cox proportional hazards modelling., Results: The mortality rate for the study cohort was 1.4 per 100 child-years of follow-up. Median follow-up time was 5.2 years (IQR, 3.5-6.0 years) with total study time being 1159 child-years. The median age of those who died was lower than that of survivors, 1.9 years (IQR, 0.6-3.6 years) versus 3.8 years (IQR, 1.8-6.0 years), p=0.005). The majority of the deaths occurred in males (13, 81.2%), those <5 years of age (14, 87.4%) and those who had severe immunosuppression (11, 68.8%). Risk factors for death were age (with the risk of dying decreasing by 25% for every 1 year increase in age, adjusted hazard ratio (AHR)=0.75 [0.58-0.98], p=0.032), male gender (AHR=3.80 [1.07-13.5], p=0.039) and severe immunosuppression (AHR=3.35 [1.16-9.66], p=0.025)., Conclusion: In our clinic setting, mortality among our PTB-HIV co-infected children being treated for PTB and on ART was low. However, those presenting with severe immunosuppression and who are males and very young, should be monitored more closely during follow-up in order to further reduce mortality., Competing Interests: All authors – none to declare.

Background: Human immunodeficiency virus (HIV) infection and the use of antiretroviral therapy (ART) may increase the risk of type 2 diabetes mellitus (T2DM). However, data from regions with a high burden of HIV/AIDS are limited. We determined the prevalence of T2DM at the time of presentation to a large HIV clinic in Nigeria, as well as the incidence of diabetes 12 months following ART initiation., Methods: Data from patients enrolled for ART from 2011 to 2013 was analyzed, including 2632 patients on enrollment and 2452 reevaluated after 12 months of ART commencement. The presence of diabetes, and demographic, clinical, and biochemical data were retrieved from standardized databases. CD4(+), HIV RNA load, and hepatitis C virus status were noted. Bivariate and logistic regressions were used to identify risk factors for T2DM., Results: Baseline T2DM prevalence was 2.3% (95% confidence interval, 1.8%-2.9%); age, but not body mass index (BMI), was a risk factor for diabetes. After 12 months of ART, an additional 5.3% had developed T2DM. Newly developed diabetes was not associated with age, but was associated with BMI. There were no significant associations between prevalent or incident diabetes and CD4(+), viral load, or type of ART., Conclusions: Diabetes is not uncommon in HIV-infected individuals at the time of presentation to HIV services. Patients initiating ART have a high risk of developing diabetes in the first year of ART. Excessive weight gain should be avoided, as incident diabetes was associated with a BMI ≥25.0 kg/m(2)., (© The Author 2016. Published by Oxford University Press for the Infectious Diseases Society of America.)

Introduction: Studies on the prevalence of and risk factors for tuberculosis (TB) among newly diagnosed human immunodeficiency virus (HIV)-infected children in sub-Saharan Africa are scarce and in Nigeria there is paucity of reported data. We determined the prevalence of and risk factors for pulmonary TB (PTB) in newly diagnosed (treatment-naïve) HIV-1 infected children at the pediatric HIV clinic of the Jos University Teaching Hospital (JUTH) in Nigeria., Methods: We performed a retrospective analysis of 876 children, aged 2 months - 13 years, diagnosed with HIV-1 infection between July 2005 and December 2012, of which 286 were diagnosed with PTB at presentation after TB screening. The study site was the AIDS Prevention Initiative in Nigeria (APIN)-supported Pediatric HIV clinic at JUTH, Jos. A multivariate forward logistic regression modelling was used to identify risk factors for PTB-HIV co-infection., Results: The prevalence of PTB-HIV co-infection was 32% (286/876). Severe immunosuppression (SI) and World Health Organization (WHO) HIV clinical stage 3/4 were identified as independent risk factors for PTB-HIV co-infection in HIV infected children. The odds of PTB-HIV co-infection was increased two-fold in HIV-infected children with WHO clinical stage 3/4 compared to those with stage 1/2 (adjusted odds ratio (AOR) 1.76 [1.31-2.37], p<0.001) and 1.5-fold in children with SI compared to those without SI (AOR 1.52 [1.12-2.06], p=0.007)., Conclusion: In our setting, the burden of PTB was high among newly diagnosed HIV-infected children, and late WHO HIV clinical stage and severe immunosuppression were associated with PTB-HIV co-infection. Therefore there is a clear need to improve strategies for early diagnosis of both HIV and PTB to optimize clinical outcomes.

Introduction: Adverse drug reactions associated with efavirenz (EFV) therapy are poorly described beyond the first year of treatment. We aimed to describe the incidence and predictors of EFV-related adverse drug reactions (ADRs) in a cohort of adult Nigerian HIV-infected patients on antiretroviral therapy (ART)., Methods: This retrospective cohort study utilized clinical data of HIV-1 infected adults (aged ≥15 years), commenced on efavirenz containing-regimen between January 2004 and December 2011. The time-dependent occurrence of clinical adverse events as defined by the World Health Organization was analyzed by Cox regression analysis., Results: A total of 2920 patients with baseline median (IQR) age of 39 (33-46) years, largely made up of men (78%) were included in the study. During 8834 person-years of follow up, 358 adverse drug events were reported; the incidence rate was 40.3 ADRs per 1000 person-years of treatment. Lipodystrophy and neuropsychiatric disorders were the most common ADRs with incidences of 63 and 30 per 1000 patients respectively. About one-third of the neuropsychiatric adverse events were within 12 months of commencement of ART. The risk of neuropsychiatric ADRs was independently predicted for women [adjusted hazard ratio (aHR) 9.05; 95% CI: 5.18-15.82], those aged <40 years (aHR 2.59; 95% CI: 1.50-4.45), advanced HIV disease (WHO stage 3 or 4) [aHR 2.26; 95% CI: 1.37-3.72], and zidovudine [aHR 2.21; 95% CI: 1.27-3.83] or stavudine [aHR 4.22; 95% CI: 1.99-8.92] containing regimen compared to tenofovir., Conclusion: Neuropsychiatric adverse drug events associated with efavirenz-based ART had both early and late onset in our clinical cohort of patients on chronic EFV therapy. Continuous neuropsychiatric assessment for improved detection and management of neuropsychiatric ADRs is recommended in resource-limited settings where the use of efavirenz-based regimens has been scaled up.

Background: Retention in care and treatment services is critical to health outcomes of individuals diagnosed and living with HIV. We evaluated the incidence of and risk factors for treatment discontinuation (TD) in a large adult HIV population on ART in Nigeria., Method: A retrospective cohort study of adult HIV patients initiated on first-line ART between 2004 and 2011 at the Jos University Teaching Hospital (JUTH) in Nigeria. Follow up information of participants was retrieved from various sources (patient visit database, pharmacy data and patients charts) up to the end of 2012. The primary study endpoint was TD, defined as discontinuation of ART for any reason, including death or loss to follow-up (lack of pharmacy pick-up for periods≥12 months). The Incidence and hazard for TD were estimated by Kaplan-Meier and Cox proportional regression analysis, respectively., Result: Overall, 3,362 (28%) patients discontinued treatment during 49,436 person-years (py) of follow-up (incidence rate (IR) 6.8 TD per 100 py). The hazard of treatment discontinuation decreased with increasing age (adjusted hazard ratio (aHR 0.99; 95% CI 0.98-0.99). Other independent risk factors for treatment discontinuation were: being unmarried (aHR 1.24; 95% CI: 1.12-1.38), having primary or secondary level of education as compared to tertiary level education (aHR 1.24; 95% CI: 1.12-1.40) and average percent adherence to drug refill visits<95% (adjusted hazard ratio (aHR) 2.13; 95% CI: 1.9-2.40). Compared to tenofovir, greater hazard of TD was noted in patients initiated on ART containing didanosine (aHR) 1.73; 95% CI: 1.03-2.91), but lower in those initiated on zidovudine containing regimen (aHR 0.77; 95% CI: 0.69-0.86)., Conclusion: Long-term treatment discontinuation rate in this study was comparable to estimates in resource-rich countries. Younger patients, as well as patients with lower educational levels and those with poor adherence had significant hazards for treatment discontinuation and should be the target of interventions to reduce treatment discontinuation and improve retention, especially within the first year of ART.

Background: The prevalence of High-Risk Human papilloma virus (HR-HPV), a necessary cause of invasive cervical cancer (ICC) is relatively high in HIV infected women. Gaps exist in our knowledge of the optimal approaches for managing women who have HR-HPV with normal cervical cytology (NCC) particularly in settings of HIV infection., Methods: Between May 2012 and June 2013 we conducted a colposcopic assessment of HIV-infected women with prior (NCC) and known HR-HPV status to compare cervical abnormalities in women with and without HR-HPV. Colposcopic examinations were done at the Operation Stop Cervical Cancer (OSCC) unit of the Jos University Teaching Hospital (JUTH), Jos, Nigeria. Abnormal colposcopic finding (ACF) was defined as areas of aceto-white epithelium involving the squamo-coulumnar junction, areas of punctation, mosaic pattern or atypical vessels. We compared proportions of ACF as well as histologic grades of cervical intra-epithelial neoplasia (CIN) in women with or without HR-HPV. Statistical analysis was done on STATA., Results: We conducted colposcopic examinations in 78 out of 89 (86.5%) eligible women. The mean age of the cohort was 32.4 years (SD ±4.6) with a median 32 years (IQR 29-36). After a mean follow up time of 20.1 months from the initial cervical pap cytology and HR-HPV testing, we found 12 of 78 (15.4%) women with ACF. The odds for an ACF was statistically higher [OR = 4.0 (95% CI: 1.1-14.7)] in women with HR-HPV compared to those without. Of the twelve women with ACF, subsequent histologic examination of colposcopically directed cervical biopsies confirmed CIN 1 in 4 cases (33.3%), CIN 2 in 1 case (8.3%), CIN 3 in 2 cases (16.7%), carcinoma-in-situ (CIS) in 2 cases (16.7%), and normal cervix in 3 (25.0%). Overall, the proportion of women detected with any grade of CIN was 11.5% (9/78) and 6.4% (5/78) were CIN 2 or greater lesion (CIN2+)., Conclusion: HIV-infected women with NCC and HR-HPV had a four-fold higher likelihood for an ACF. The practice of early colposcopic examination of HIV-infected women with prior NCC and HR-HPV may increase early detection of higher grade CIN and CIS cancer stages in our setting.

Background: Mortality among human immunodeficiency virus-1 (HIV-1) infected children initiated on antiretroviral therapy (ART) though on a decline still remains high in resource-limited countries (RLC). Identifying baseline factors that predict mortality could allow their possible modification in order to improve pediatric HIV care and reduce mortality., Methods: We conducted a retrospective cohort study analyzing data on 691 children, aged 2 months-15 years, diagnosed with HIV-1 infection and initiated on ART between July 2005 and March 2013 at the pediatric HIV clinic of Jos University Teaching Hospital. Lost to follow-up children were excluded from the analyses. A multivariate Cox proportional hazards model was fitted to identify predictors of mortality., Results: Median follow-up time for the 691 children initiated on ART was 4.4 years (interquartile range (IQR), 1.8-5.9) and at the end of 2752 person-years of follow-up, 32 (4.6%) had died and 659 (95.4%) survived. The mortality rate was 1.0 per 100 child-years of follow-up period. The median age of those who died was about two times lower than that of survivors [1.7 years (IQR, 0.6-3.6) versus 3.9 years (IQR, 3.9-10.3), p<0.001]. On unadjusted Cox regression, the risk of dying was about three and half times more in children <5 years of age compared to those >5 years (p=0.02) Multivariate modeling identified age as the main predictor of death with mortality decreasing by 24% for every 1 year increase in age (Adjusted Hazard Ratio (AHR)=0.76 [0.62-0.94], p=0.013., Conclusion: The lower mortality rate for our study suggests that even in RLC, mortality rates could be reduced given a good standard of care. Early initiation of ART in younger children with close monitoring during follow-up could further reduce mortality.

Background. Decentralization of antiretroviral therapy (ART) services is a key strategy to achieving universal access to treatment for people living with HIV/AIDS. Our objective was to assess clinical and laboratory outcomes within a decentralized program in Nigeria. Methods. Using a tiered hub-and-spoke model to decentralize services, a tertiary hospital scaled down services to 13 secondary-level hospitals using national and program guidelines. We obtained sociodemographic, clinical, and immunovirologic data on previously antiretroviral drug naïve patients aged ≥15 years that received HAART for at least 6 months and compared treatment outcomes between the prime and satellite sites. Results. Out of 7,747 patients, 3729 (48.1%) were enrolled at the satellites while on HAART, prime site patients achieved better immune reconstitution based on CD4+ cell counts at 12 (P < 0.001) and 24 weeks (P < 0.001) with similar responses at 48 weeks (P = 0.11) and higher rates of viral suppression (<400 c/mL) at 12 (P < 0.001) and 48 weeks (P = 0.03), but similar responses at 24 weeks (P = 0.21). Mortality was 2.3% versus 5.0% (P < 0.001) at prime and satellite sites, while transfer rate was 8.7% versus 5.5% (P = 0.001) at prime and satellites. Conclusion. ART decentralization is feasible in resource-limited settings, but efforts have to be intensified to maintain good quality of care.

Background: Cervical cancer is strongly linked to high-risk human papillomavirus (HR-HPV) and is typically preceded by cytological abnormalities. Less is known in patients with normal cervical cytology (NCC). We investigated the epidemiology of HR-HPV among HIV-infected women with NCC., Methodology: We conducted a cross-sectional study between January and June 2011 among HIV-infected women with NCC at an adult HIV clinic in Jos, Nigeria. Cervical sampling and analysis for HR-HPV by hybrid capture (HC2) with signal amplification was done to determine presence of one or more of the following HR-HPV types: 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59 or 68. Epidemiologic factors associated with HR-HPV were determined using bivariate statistics and multivariate logistic regression., Results: We evaluated 103 HIV-infected women with Pap cytology. The median age of the women was 32 years (range 21-49). Ninety-seven (94.2%) had NCC. Cervical samples for HR-HPV DNA testing were available from 89/97 (91.8%) of the HIV-infected women with NCC. Of the 89 women with cervical samples for HR-HPV DNA testing, 40 (44.9%) had detectable HR-HPV by HC2 giving a HR-HPV prevalence of 44.9% (95% CI 33.9-55.5%). Age < 30 years was associated with HR-HPV (OR 2.69 [95% CI 1.05-6.91, p = 0.039]) while history of previous abortion showed an inverse association with HR-HPV (OR 0.33[95% CI 0.15-0.94, p = 0.039])., Conclusion: The prevalence of HR-HPV is seemingly high among HIV-infected women with NCC in our clinical setting. These data provide support for further investigation of the clinical implications of positive HR-HPV among HIV-infected women with NCC report in cervical cancer prevention programs in Nigeria.

Background: Sub-Saharan Africa (SSA) has the highest burden of HIV in the world and a rising prevalence of cardiometabolic disease; however, the interrelationship between HIV, antiretroviral therapy (ART) and cardiometabolic traits is not well described in SSA populations., Methods: We conducted a systematic review and meta-analysis through MEDLINE and EMBASE (up to January 2012), as well as direct author contact. Eligible studies provided summary or individual-level data on one or more of the following traits in HIV+ and HIV-, or ART+ and ART- subgroups in SSA: body mass index (BMI), systolic blood pressure (SBP), diastolic blood pressure (DBP), high-density lipoprotein (HDL), low-density lipoprotein (LDL), triglycerides (TGs) and fasting blood glucose (FBG) or glycated hemoglobin (HbA1c). Information was synthesized under a random-effects model and the primary outcomes were the standardized mean differences (SMD) of the specified traits between subgroups of participants., Results: Data were obtained from 49 published and 3 unpublished studies which reported on 29 755 individuals. HIV infection was associated with higher TGs [SMD, 0.26; 95% confidence interval (CI), 0.08 to 0.44] and lower HDL (SMD, -0.59; 95% CI, -0.86 to -0.31), BMI (SMD, -0.32; 95% CI, -0.45 to -0.18), SBP (SMD, -0.40; 95% CI, -0.55 to -0.25) and DBP (SMD, -0.34; 95% CI, -0.51 to -0.17). Among HIV+ individuals, ART use was associated with higher LDL (SMD, 0.43; 95% CI, 0.14 to 0.72) and HDL (SMD, 0.39; 95% CI, 0.11 to 0.66), and lower HbA1c (SMD, -0.34; 95% CI, -0.62 to -0.06). Fully adjusted estimates from analyses of individual participant data were consistent with meta-analysis of summary estimates for most traits., Conclusions: Broadly consistent with results from populations of European descent, these results suggest differences in cardiometabolic traits between HIV-infected and uninfected individuals in SSA, which might be modified by ART use. In a region with the highest burden of HIV, it will be important to clarify these findings to reliably assess the need for monitoring and managing cardiometabolic risk in HIV-infected populations in SSA.

Background: Human immunodeficiency virus (HIV) and malaria co-infection has become an important public health problem in sub-Saharan Africa. Data on HIV and malaria interaction in Nigerian adults is scanty. We determined the prevalence of malaria parasitaemia in HIV-infected adults and further investigated the role of immune status in the HIV/malaria association., Methods: This was a cross-sectional study involving 100 newly-diagnosed HIV-infected adults and 100 age and sex-matched HIV negative controls. Malaria parasitaemia was diagnosed by blood film microscopy using Giemsa staining technique and was defined as the presence of malaria parasites irrespective of species or parasite density. HIV infection was confirmed by western blot assay and CD4 T-lymphocyte count of the HIV-infected patients was quantified by flow cytometry., Results: The prevalence of malaria parasitaemia was higher in HIV-infected adults (24%) than in the controls (9%) (chi2 = 8.17, p = 0.04). Participants residing in rural areas had higher prevalence of malaria parasitaemia than urban dwellers both for HIV-infected patients (34.1% Vs. 16.1%, chi2 = 4.3, p = 0.04) and controls (18.4%, Vs. 6.5%, chi2 = 3.4, p = 0.04). HIV-infected male patients tended to have malaria parasitemia more than their female counterparts (33.3% Vs. 17.2%, chi2 = 3.4, p = 0.06). Among HIV-infected patients, the prevalence of malaria parasitaemia progressively increased at lower CD4 cell counts, 10.3% for CD4 cell count of = 500, 17.5% for 200-499 and 45.2% for < 200 cells/microL (chi2 = 11.5, p = 0.003)., Conclusion: HIV is likely to fuel malaria infection in tropical countries where both diseases are endemic. Malaria control practices should be further intensified in HIV-infected populations.

Background: Kidney disease is a common complication of human immunodeficiency virus (HIV) infection even in the era of antiretroviral therapy, with kidney function being abnormal in up to 30% of HIV-infected patients. We determined the predictors of impaired renal function in HIV-infected adults initiating highly active antiretroviral therapy (HAART) in Nigeria., Materials and Methods: This was a retrospective study among HIV-1 infected patients attending the antiretroviral clinic at the Jos University Teaching Hospital (JUTH), between November 2005 and November 2007. Data were analysed for age, gender, weight, WHO clinical stage, CD4 count, HIV-1 RNA viral load, HBsAg and anti-HCV antibody status. Estimated glomerular filtration rate (eGFR) was calculated using the Cockcroft-Gault equation. Statistical analysis was done using Epi Info 3.5.1., Results: Data for 491 (294 females and 197 males) eligible patients were abstracted. The mean age of this population was 38.8±8.87 years. One hundred and seventeen patients (23.8%; 95% CI, 20.2-27.9%) had a reduced eGFR (defined as <60 mL/min), with more females than males (28.6% vs. 16.8%; P=0.02) having reduced eGFR. Age and female sex were found to have significant associations with reduced eGFR. Adjusted odds ratios were 1.07 (95% CI, 1.04, 1.10) and 1.96 (95% CI, 1.23, 3.12) for age and female sex, respectively., Conclusions: Older age and female sex are independently associated with a higher likelihood of having lower eGFRs at initiation of HAART among our study population. We recommend assessment of renal function of HIV-infected patients prior to initiation of HAART to guide the choice and dosing of antiretroviral drugs.

Introduction: Human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) is a chief cause of death in sub-Saharan Africa. In this study, the clinical characteristics and predictors of mortality among hospitalized HIV infected adult Nigerians are reported., Methodology: The records of 354 patients were reviewed for demographic and clinical characteristics. Predictors of mortality using logistic regression in a retrospective study were also reviewed., Results: A total of 109 (30.8%) males and 245 (69.2%) females participated in the study. The mean age of all participants was 35 ± 8 years. Median baseline CD4 cell counts and viral load were 91 cells/mm³ and 63,438 copies/ml respectively. There was a total of 123 (34.8%) deaths while 231 (65.2%) patients were discharged home. Tuberculosis (TB) was the most common diagnosis on admission as well as the leading cause of death. Among all subjects, only male gender (adjusted odds ratio [AOR] 4.67, 95% confidence interval [CI]: 2.63-8.29); CD4 cell count ≤ 200 cells/mm³ (AOR 5.28, 95% CI: 2.99-9.31); length of hospital stay < 3 days (AOR 4.77, 95% CI: 1.35-16.86); and age ≥ 35 years (AOR 2.43, 95% CI: 1.41-4.19) were predictive of death., Conclusion: These findings illustrate the need for early diagnosis of HIV infection, appropriate treatment and prevention of opportunistic infections, and improved access to highly active antiretroviral therapy (HAART).

Background: Reports of renal dysfunction in Tenofovir Disoproxil Fumarate (TDF)-treated HIV-1 infected patients have raised concerns about potential nephrotoxicity., Objective: To compare the effects on renal function of TDF-containing highly active anti-retroviral therapy (HAART) with a non-TDF-containing HAART., Methods: This was an observational study.Clinical and laboratory data of 186 HIV-1 infected adult Nigerians on first-line HAART for at least 48 weeks were reviewed. Eighty-four patients whose nucleos(t)ide reverse transcriptase inhibitor (NRTI) backbone included TDF were compared to 102 patients on other NRTI backbones. Creatinine clearance (CLcr) was estimated using the Cockcroft-Gault equation. Changes in serum creatinine and CLcr from the baseline for each patient were compared between the TDF-treated and the TDF-free patients. We also assessed the associations of other variables with change in CLcr..., Results: Baseline median serum creatinine (mmol/L) was 77 and 84 in the TDF-treated and TDF-free groups, respectively (p=0.59). Baseline median CLcr (mls/min) was 83 in the TDF-treated patients vs 78 in the TDF-free group. At 48 weeks, serum creatinine increased by 18.1% and 1.2% in the TDF-treated and TDF-free arms, respectively. There was a decrease of 4.8% in GFR in the TDF arm compared to a gain 5.1% in the TDF-free arm., Conclusion: Tenofovir Disoproxil Fumarate-containing HAART is associated with a slight decline in the medium term in CLcr compared with HAART regimens containing alternative Nucleosid(t) Reverse Transcriptase Inhibitors.

Background: Cryptococcal meningitis (CM) is the most common severe life threatening fungal infection in AIDS patients. It is an important cause of morbidity and mortality There is paucity of data on the prevalence of CM in Nigeria. We aimed to determine the frequency of CM, the clinical presentation and immunological profile., Methods: A cross sectional study was carried out at the Jos University Teaching Hospital (JUTH). A total of 100 HIV-1 infected patients suspected of having meningitis or meningoencephalitis were subjected to cerebrospinal fluid (CSF) analysis (including Indian ink preparation and fungal culture by conventional methods) and CD4 count was determined using flow cytometry (count bit Y-R 1004 Partec Muster Germany)., Results: The freguency of CM was 36% in our cohort. The commonest clinical presentation included headache (100.0%), neck stiffness (77.8%), fever (72.0%), vomiting 55.6%), personality changes (55.6%), photophobia (27.8%) and convulsions (27.8%). The mean duration of symptoms was 24 +/- 22 days with a median of 17 days. The mean CD4 count was 89 +/- 60 cells/mm3 with a median of 82 cells/mm3., Conclusion: The high prevalence of CM and the associated severe immunosuppression underscores the importance of early diagnosis of HIV infection which may reduce the incidence of CM. There is the urgent need for access to Amphotericin B and fluconazole in resource constrained settings in addition to a wide access to HAART.

Objective: To determine the efficacy of patient-selected treatment partners on virologic and adherence outcomes during first-line antiretroviral therapy., Design: Randomized controlled trial. SETTING AND ANALYTICAL APPROACH: Between June 2006 and December 2007, 499 HIV-infected adults in Jos, Nigeria, were randomized to standard of care (SOC) or patient-selected treatment partner-assisted therapy (TPA). Each patient was followed for 48 weeks. Virologic outcomes, adherence to drug pick-up, CD4 cell counts, and mortality are reported., Results: At week 24, undetectable viral load was achieved by 61.7% of patients in the TPA arm versus 50.2% of those receiving SOC [odds ratio (OR) = 1.58, 95% CI: 1.11 to 2.26, P < 0.05]. There was no significant difference at week 48: 65.3% versus 59.4% for TPA and SOC, respectively (OR = 1.28, 95% CI: 0.89 to 1.84, P > 0.05). The TPA group had more than 3 times the odds of at least 95% drug pickup adherence through week 24 (OR = 3.06, 95% CI: 1.89 to 4.94, P < 0.01) and almost twice the odds through week 48 (OR = 1.95, 95% CI: 1.29 to 2.93, P < 0.01). At week 48, there were no significant differences in CD4 cell count increases (t = -0.09, df = 404, P > 0.05) or mortality (10.6% vs. 6.1%) between TPA vs. SOC, respectively. Residence-to-clinic distance was significantly associated with virologic and adherence outcomes., Conclusions: Use of patient-selected treatment partners was associated with improved drug pickup adherence and initial virologic success but had no durable effect on attaining undetectable viral load.

Objective: To determine the prevalence of and risk factors for cervical dysplasia in HIV-positive women receiving care at the Jos University Teaching Hospital in Nigeria., Methods: A total of 369 HIV-positive women had cervical cytology performed; HIV-1 RNA viral load and CD4 counts were measured., Results: Of 369 participants, cervical dysplasia was present in 107 (29.0%) women. However, cervical cytology was abnormal in 252 (68.3%). Among those with abnormal cytology, 145 (57.5%) women had ASCUS, 56 (22.2%) had LSIL, and 51 (20.2%) had HSIL. Median CD4 lymphocyte count was lower in women with dysplasia compared with those without (142 vs 170 cells/mm(3); P=0.04), while median HIV RNA viral load was higher in women with dysplasia (101781 vs 77479 copies/mL; P=0.002). Low CD4 count (<200 cells/mm(3)) and evidence of HPV infection were significantly associated with cervical dysplasia., Conclusion: A high prevalence of cervical dysplasia was found among HIV-positive Nigerian women, which was associated with increased immune suppression.

AIDS-related Kaposi's sarcoma (AIDS-KS) remains a significant cause of morbidity and mortality. We describe the pattern of presentation and survival in Jos, Nigeria. We identified 48 HIV-positive patients with AIDS-KS and matched them for age and sex with an equal number of HIV-positive patients without AIDS-KS. We compared their clinical, immunological, virological characteristics and survival. They were similar in age and body mass index profile but patients with AIDS-KS had more tuberculosis co-infection (P, 0.02), lower median CD4 count (P, 0.003) and higher mortality (P, 0.002). Surprisingly, patients with AIDS-KS had lower levels of median viral load (29,347 copies/mL) compared with controls (80,533 copies/mL). We recommend specific AIDS-KS therapy in addition to highly active antiretroviral therapy in order to improve survival.

Background: The clinical characteristics and consequences of HIV-I infection observed in studies from developed countries cannot be generalized across the multiple virus subtypes that circulate in sub-Saharan Africa in general and Nigeria in particular. This study was therefore conducted to determine the commonest symptoms and signs at presentation in HIV-infected individuals at the Jos University Teaching Hospital., Method: This descriptive study was conducted at the antiretroviral clinic of the Jos University Teaching Hospital, Jos, between May and October 2004. Two hundred (200) newly diagnosed and laboratory confirmed adult cases of HIV infection without prior antiretroviral drug use were recruited after obtaining informed consent. Each qualified patient had a comprehensive history taken with emphasis on the clinical symptoms and detailed physical examination performed by the researchers. The data collected were analyzed using a multipurpose computer programme, Epi-info 2000 version 1.1.3 (Atlanta GA, USA)., Results: There were 86 (43.0%) males and 114 (57.0%) females whose mean ages were 39.0 +/- 7.8 and 32.0 +/- 8.1 years, respectively. The major symptoms in the study population were: weight loss (65.5%), fever (41.5%), chronic cough (38.5%), diarrhea (32.0%), pruritus (13.0%) and body rash (12.5%). The major signs were pallor (25.0%), oral thrush (20.5%), wasting (20.0%), lymphadenopathy (18.0%), dermatitis (16.0%), hyperpigmented nails (13.5%) and finger clubbing (8.5%)., Conclusion: The symptoms and signs of HIV/AIDS obtained were similar to those obtained by other workers from different parts of the world; however, the findings of hyperpigmented nails and finger clubbing have not been frequently reported for other populations.

This study examines the use of various direct observation therapy-HAART treatment support modalities in Jos, Nigeria. A 12-month observational study enrolling 175 antiretroviral naïve patients into four arms of direct observation therapy-HAART (highly active antiretroviral therapy); daily observed therapy (DOT), twice weekly observed therapy (TWOT), weekly observed therapy (WOT) and self-administered therapy (SAT), examined community treatment support using family and community members. Treatment outcomes were much better in the treatment-supported groups compared with the control self-therapy group. CD4 cell increases were 218/microL (DOT), 267/microL (TWOT), 205/microL (WOT) versus 224/microL (SAT), whereas plasma HIV-1 RNA reached undetectable levels (<400 copies/mL) in 91%, 88%, 84% versus 79% of patients in the DOT, TWOT, WOT versus SAT groups, respectively, at 48 weeks. We, therefore, strongly support the use of treatment support in our settings.

Partner consent and support can substantially enhance adherence to PMTCT interventions. This study explores the issues concerning disclosure of HIV status to partners of HIV sero-positive mothers in a PMTCT programme in Jos, Northern Nigeria. Previously field-tested questionnaires were administered by trained counsellors to 570 consenting HIV positive mothers who were participating in the PMTCT programme at Jos University Teaching Hospital (JUTH), Jos. The findings were entered into Epi Info and analysed using frequencies. The median age of respondents was 29 years while that of their partners was 37 years. Five hundred and fifty-five (99.5%) of respondents were married. Majority of the women were Christians (82.9%) while 16.9% were Moslems. Seventy four percent (419/563) of the mothers were aware of their husband's HIV sero-status. Of these, 65.4% (274/419) of the partners were HIV positive while 34.6% were sero-negative. Eighty nine percent (500/560) of the women have disclosed their HIV status to their partners. Of these, 39.6% (199/502) required the assistance of health workers while 59.4% (298/502) did it by themselves. Following disclosure of HIV status, 86.9% (430/495) of the partners were supportive, 5.7% were indifferent, 6.7% were quarrelsome and abusive while 1.0% was violent. The reactions of partners of HIV positive mothers to disclosure of their wives' HIV status are predominantly supportive. This should strengthen strategies to promote partner disclosure.

Background: The brunt of the human immunodeficiency virus infection/the acquired immunodeficiency syndrome is largely borne by communities in sub-Saharan Africa. We describe renal disease in Nigerians with the acquired immunodeficiency syndrome., Methods: Consecutive patients with the acquired immunodeficiency syndrome (AIDS) seen in the infections unit of the Jos University Teaching Hospital and a similar group of healthy controls were evaluated for renal disease. Subjects with past history of renal disease, hypovolemia, hypertension, diabetes mellitus and/or a documented fever were excluded from the study., Results: Of the 79 patients with the acquired immunodeficiency syndrome and 57 controls studied, renal disease was present in 41 (51.8%) of the patients in the AIDS group and 7 (12.2%) of controls. While 15 (19%) of the AIDS group had azotemia alone and 20 (25.3%) had proteinuria alone, 6 (7.6%) had azotemia and proteinuria. The mean protein excretion/24 hours was significantly higher in the AIDS group compared to controls, (2.99 +/- 54 g and 0.56 +/- 0.12 g respectively, p = 0.001), while the GFR was significantly higher in controls compared to the study group (103.30 +/- 37.78 and 68.03 +/- 37.55 respectively, p = 0.004). Subjects in the AIDS group with renal disease had a significantly longer duration of illness compared to those without (12.33 +/- 8.67 months and 7.28 +/- 7.78 months respectively, p = 0.008). Age and serum CD4+ cell counts were similar in patients with and without renal disease in the AIDS group., Conclusion: Renal disease is a common complication of acquired immunodeficiency syndrome, the duration of illness being strongly associated with its presence.

Summary Forty (40) HIV positive patients with CD4 cell counts between 100 - 500 cellh/mm3 were recruited from 8 different centres in Nigeria including a research centre and specialist and teaching hospitaLs They were enrolled into an open, non-comparative study of a triple combination regimen containing the Protease Inhibitor (PI), Nelfinavir and two Reverse Transcriptase Inhibitors (RTIs), Zakitabine (Hivid) and Zidovudine for a period of 24 weeks. Thirty-one (31) patients completed the study. Nine (9) patients withdrew from the study. Two of these because of Adverse Events (AE), 2 others because they developed tuberculosis and had to withdraw because of rifampicin therapy. The remaining five (5), withdrew voluntarily. Efficacy of the PI containing triple regimen was evaluated using viral load and absolute CD4 changes, weight gain and clinical response during the course of the triaL Twenty-two (22) patients had plasma viral loads measured at the beginning and at the end of the trial (24 weeks). Seventeen (17) out of the 22 patients (77%), experienced a significant reduction in their plasma viral loads (p<0.05 There was 1 log reduction in plasma viral load in 6 patients (25%), 2 log in 4 patients (17%). In 2 patients (8%), plasma viral load was reduced below the level of detection. The viral load increased over the treatment period in five patients (21%). Similarly 22 out of the 26 patients (85%) experienced increase in the level of their CD4 lymphocyte counts at the end of the study. The average CD4 counts of all 26 patients rose from 272.94 +/- 137.71/dl to 414 +/- 243.71/ul over 24 weeks (p<0.05). There was monthly rise of 27 CD4 cells/microl. Four (4) patients (15%) had a fall in their CD4 lymphocyte counts. Twenty (20) out of the 26 patients (77%), who completed the study were observed to have weight gains ranging from 1.5 to 31 kilograms over the 24 week study period. In 4 patients, there was no weight gain during the study period. Two patients (5%) were withdrawn due to adverse events from the viracept combination. One of these was because of life threatening diarrhoea while the other patient had severe peripheral neuropathy and severe weakness in the lower limbs. Eight (8) other patients had diarrhoea but not severe enough to stop them from continuing with the triaL Other adverse events seen include anaemia (1 patient), pancytopenia (1 patient), and transient elevation of serum urea and creatinine (1 patient). None of these adverse events was severe enough to warrant withdrawal from therapy. The study has therefore demonstrated the significant efficacy and tolerability of (Nelfinavir/Zalcitabine/ Zidovudine combination in suppressing viral replication, increasing the CD4 cell counts and improving the quality of life in Nigeria patients with HIV.

In Nigeria, the most populous country in Africa, the characterization of HIV-1 strains has been limited. In this study we evaluated the genetic diversity of the protease coding region, one of the anti-retroviral therapy target, and investigated the presence of mutations related to resistance to HIV protease inhibitors. We analyzed samples collected during 1996 and all patients were anti-retroviral drug naïves. Ten samples were evaluated by sequencing of the protease gene. The majority, 80%, were classified as subtype A and the two others were unclassified-divergent strains, something in between A and G subtypes. The gag region from these outliners were sequenced and the phylogenetic analysis classified them as subtype G. The protease amino acid consensus sequence of the Nigerian subtype A are in complete agreement with the consensus A differing from the USA subtype B consensus in 10 positions (L10V, I13V, K14R, I15V, K20I, M36I, R41K, P63L, H69K and L89M). The secondary substitutions associated with protease inhibitor resistance were observed in all Nigerian sequences at the positions L10V, M36I and L89M. The majority of sequence variation was concentrated in the interval between aminoacids 70-90 where the protease substrate binding region is located.

A study of determine the seroprevalence rate and clinical presentation of HIV-associated pulmonary tuberculosis was carried out in Jos between October 1990 and September 1991. Out of the 180 newly diagnosed pulmonary tuberculosis patients, 11(6.1%) were confirmed seropositive for HIV-1 and 2. The peak age range for both tuberculosis and HIV infection in both sexes is 20-40 years. The risk of HIV infection was associated with multiple sex partners and blood transfusion. There was no significant difference in the clinical presentation of pulmonary tuberculosis between HIV-seropositive and seronegative patients (P > 0.1). However, diarrhoea, lymphadenopathy and marked weight loss were found to be significantly associated with HIV infection (P < 0.05). The mean lymphocyte count of HIV seropositives was significantly lower than seronegatives (P < 0.01).

An open non-comparative clinical study to determine the efficacy and tolerance of Roxithromycin 150 mg twice daily was carried out amongst Nigerian patients with acute upper and lower respiratory tract infections. Twenty-four (24) patients (mean age 21.6 years, male 13; females 11 who completed the study presented with acute tonsillitis (33.3%, acute bronchitis (12.5%), lober pneumonia (12.5%), Otitis media (8%), acute pharyngitis (4%) and acute sinusitis (4%). Most of the patients had normal bacterial flora isolated (50.3%). Pathogens isolated included streptococcus pyogenes (21%), moraxella catarhalis (8.3%), streptococcus pneumonia (8.3%) and Klebsiella pneumonia (4%). The quick clinical response, lack of major adverse drug reactions and susceptibility of the bacterial isolates to Roxithromycin were very significant attributes of the drug. In addition, there was complete recovery in 95.8% of the patients. Roxithromycin is therefore a well tolerated and effective drug for the treatment of acute respiratory tract infections in Nigerian patients.

Serum and urinary zinc were assessed in 53 patients with a variety of chronic liver diseases (CLD) and 59 healthy volunteers using atomic absorption spectrophotometry. Liver zinc was also assessed in 18 patients and 10 controls. All patients had significantly lower serum zinc (mean = 36.3 +/- 2.9 ug/dl) than controls (79.3 +/- 4.0 ug/dl) and higher urinary excretion (651.0 +/- 53 ug/24 hrs) than controls (316.0 +/- 26 ug/24 hrs). Mean liver zinc was also lower in cirrhotic patients (85.10 +/- 21.31 ug/g) than control values (112.40 +/- 31.72 ug/g) but patients with schistosomiasis had identical values with controls. Decreasing levels were noted from chronic hepatitis through cirrhosis to primary liver cancer and decompensated patients had lower levels than well-compensated disease. No difference was seen between alcoholic and non-alcoholic cirrhotics. This study indicates that hyperzincuria occurs in association with zinc deficiency in CLD, an abnormality which may be important in the genesis of some features of the disease.