Search

BackgroundSame-day HIV testing and antiretroviral therapy (ART) initiation is being widely implemented. However, the optimal timing of ART among patients with tuberculosis (TB) symptoms is unknown. We hypothesized that same-day treatment (TB treatment for those diagnosed with TB; ART for those not diagnosed with TB) would be superior to standard care in this population.Methods and findingsWe conducted an open-label trial among adults with TB symptoms at initial HIV diagnosis at GHESKIO in Haiti; participants were recruited and randomized on the same day. Participants were randomized in a 1:1 ratio to same-day treatment (same-day TB testing with same-day TB treatment if TB diagnosed; same-day ART if TB not diagnosed) versus standard care (initiating TB treatment within 7 days and delaying ART to day 7 if TB not diagnosed). In both groups, ART was initiated 2 weeks after TB treatment. The primary outcome was retention in care with 48-week HIV-1 RNA

IntroductionLong-term mortality among TB survivors appears to be higher than control populations without TB in many settings. However, data are limited among persons with HIV (PWH). We assessed the association between cured TB and long-term mortality among persons with PWH in Haiti.MethodsA prospective cohort of PWH from the CIPRA HT-001 trial was followed from study enrolment (August 2005 to July 2008) to study closure (December 2018) to compare mortality between participants with and without TB. The index date for the survival analysis was defined as 240 days after TB diagnosis or randomization date. Time to death was described using Kaplan-Meier curves, and log-rank tests were used to compare time to death between the TB and no-TB cohorts. The association between TB and long-term mortality was estimated with multivariable Cox models.ResultsOf the 816 participants in the CIPRA HT-001 trial, 77 were excluded for a history of TB prior to study enrolment and 31 were excluded due to death or attrition prior to the index date, leaving 574 in the no-TB and 134 in the TB cohort. Twenty-four (17.9%) participants in the TB and 48 (8.4%) in the no-TB cohort died during follow-up. Five and 10-year mortality rates were 14.2% and 17.9% respectively, in the TB cohort, and 6.1% and 8.4% in the no-TB cohort. In Kaplan-Meier analysis, participants in the TB cohort had a significantly shorter time to death (log-rank p

Multidrug-resistant tuberculosis (MDR-TB) outcomes are poor partly because of the long treatment duration; the World Health Organization conditionally recommends a shorter course regimen to potentially improve treatment outcomes. Here, we describe the drug susceptibility patterns of a cohort of MDR-TB patients in Haiti and determine the number of likely effective drugs if they were treated with the recommended shorter course regimen. We retrospectively examined drug susceptibility patterns of adults initiating MDR-TB treatment between 2008 and 2015 at the Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections in Port-au-Prince, Haiti. First- and second-line drug susceptibility testing (DST) was analyzed and used to determine the number of presumed effective drugs. Of the 239 patients analyzed, 226 (95%), 183 (77%), 135 (57%), and 38 (16%) isolates were resistant to high-dose isoniazid, ethambutol, pyrazinamide, and ethionamide, respectively. Eight patients (3%) had resistance to either a fluoroquinolone or a second-line injectable and none had extensively resistant TB. Of the 239 patients, 132 (55%) would have fewer than five likely effective drugs in the intensive phase of the recommended shorter course regimen and 121 (51%) would have two or fewer likely effective drugs in the continuation phase. Because of the high rates of resistance to first-line TB medications, about 50% of MDR-TB patients would be left with only two effective drugs in the continuation phase of the recommended shorter course regimen, raising concerns about the effectiveness of this regimen in Haiti and the importance of using DST to guide treatment.

BackgroundTreatment outcomes for multidrug-resistant tuberculosis remain poor. We aimed to estimate the association of treatment success and death with the use of individual drugs, and the optimal number and duration of treatment with those drugs in patients with multidrug-resistant tuberculosis.MethodsIn this individual patient data meta-analysis, we searched MEDLINE, Embase, and the Cochrane Library to identify potentially eligible observational and experimental studies published between Jan 1, 2009, and April 30, 2016. We also searched reference lists from all systematic reviews of treatment of multidrug-resistant tuberculosis published since 2009. To be eligible, studies had to report original results, with end of treatment outcomes (treatment completion [success], failure, or relapse) in cohorts of at least 25 adults (aged >18 years). We used anonymised individual patient data from eligible studies, provided by study investigators, regarding clinical characteristics, treatment, and outcomes. Using propensity score-matched generalised mixed effects logistic, or linear regression, we calculated adjusted odds ratios and adjusted risk differences for success or death during treatment, for specific drugs currently used to treat multidrug-resistant tuberculosis, as well as the number of drugs used and treatment duration.FindingsOf 12 030 patients from 25 countries in 50 studies, 7346 (61%) had treatment success, 1017 (8%) had failure or relapse, and 1729 (14%) died. Compared with failure or relapse, treatment success was positively associated with the use of linezolid (adjusted risk difference 0·15, 95% CI 0·11 to 0·18), levofloxacin (0·15, 0·13 to 0·18), carbapenems (0·14, 0·06 to 0·21), moxifloxacin (0·11, 0·08 to 0·14), bedaquiline (0·10, 0·05 to 0·14), and clofazimine (0·06, 0·01 to 0·10). There was a significant association between reduced mortality and use of linezolid (-0·20, -0·23 to -0·16), levofloxacin (-0·06, -0·09 to -0·04), moxifloxacin (-0·07, -0·10 to -0·04), or bedaquiline (-0·14, -0·19 to -0·10). Compared with regimens without any injectable drug, amikacin provided modest benefits, but kanamycin and capreomycin were associated with worse outcomes. The remaining drugs were associated with slight or no improvements in outcomes. Treatment outcomes were significantly worse for most drugs if they were used despite in-vitro resistance. The optimal number of effective drugs seemed to be five in the initial phase, and four in the continuation phase. In these adjusted analyses, heterogeneity, based on a simulated I2 method, was high for approximately half the estimates for specific drugs, although relatively low for number of drugs and durations analyses.InterpretationAlthough inferences are limited by the observational nature of these data, treatment outcomes were significantly better with use of linezolid, later generation fluoroquinolones, bedaquiline, clofazimine, and carbapenems for treatment of multidrug-resistant tuberculosis. These findings emphasise the need for trials to ascertain the optimal combination and duration of these drugs for treatment of this condition.FundingAmerican Thoracic Society, Canadian Institutes of Health Research, US Centers for Disease Control and Prevention, European Respiratory Society, Infectious Diseases Society of America.

Paul Farmer was one of the fiercest social justice advocates for the poor and underserved in modern medicine. As a physician, anthropologist and activist, he witnessed the intricate interplay of [...]

Problem In 2010, Haiti sustained a devastating earthquake that crippled the health-care infrastructure in the capital city, Port-au-Prince, and left 1.5 million people homeless. Subsequently, there was an Increase in reported tuberculosis in the affected population. Approach We conducted active tuberculosis case finding in a camp for internally displaced persons and a nearby slum. Community health workers screened for tuberculosis at the household level. People with persistent cough were referred to a physician. The National Tuberculosis Program continued its national tuberculosis reporting system. Local setting Even before the earthquake, Haiti had the highest tuberculosis incidence in the Americas. About half of the tuberculosis cases occur in the Port-au-Prince region. Relevant changes The number of reported tuberculosis cases in Haiti has increased after the earthquake, but data are too limited to determine if this is due to an increase in tuberculosis burden or to improved case detection. Compared to previous national estimates (230 per 100000 population), undiagnosed tuberculosis was threefold higher in a camp for internally displaced persons (693 per 100000) and fivefold higher in an urban slum (1165 per 100000). With funding from the World Health Organization (WHO), active case finding is now being done systematically in slums and camps. Lessons learnt Household-level screening for prolonged cough was effective in identifying patients with active tuberculosis in this study. Without accurate data, early detection of rising tuberculosis rates is challenging; data collection should be incorporated into pragmatic disease response programmes. Probleme En 2010, Haiti a ete frappe par un seisme devastateur qui a ebranle les infrastructures sanitaires de la capitale, Port-au-Prince, et laisse 1,5 millions de personnes sans abri. On a par la suite observe une augmentation des cas de tuberculose recenses dans la population concernee. Approche Nous avons mene une recherche active des cas de tuberculose dans un camp de personnes deplacees ainsi que dans un bidonville voisin. Les agents de sante communautaires ont recherche les cas de tuberculose dans les foyers. Les personnes qui presentaient une toux persistante ont ete orientees vers un medecin. Le systeme national de signalement des cas de tuberculose a ete maintenu, dans le cadre du programme national de lutte contre la tuberculose. Environnement local Deja avant le seisme, Haiti presentait la plus forte incidence de tuberculose d'Amerlque. Pres de la moitie des cas de tuberculose sont recenses dans la region de Port-au-Prince. Changements significatifs Le nombre de cas de tuberculose signales en Haiti a augmente depuis le seisme, mais les donnees limitees ne permettent pas de determiner si cela est du a une augmentation de la charge de la maladie ou a une amelioration du depistage. Compares aux precedentes estimations nationales (230 cas pour 100 000 personnes), les cas de tuberculose non diagnostiques etalent trois fois plus importants dans le camp de personnes deplacees (693 cas pour 100 000 personnes) et cinq fois plus dans le bidonville (1165 cas pour 100 000 personnes). Grace a un financement de reorganisation mondiale de la Sante, un depistage actifest desormais effectue systematiquement dans les camps et les bidonvilles. Lecons tirees Dans cette etude, la recherche d'une toux prolongee dans les foyers a permis d'identifier les patients atteints de tuberculose active. Sans donnees predses, il est difficile de detecter precocement une augmentation du taux de tuberculose; un travail de collecte de donnees devrait etre integre aux programmes pratiques de reponse aux maladies. Problema En 2010, Haiti sufrio un devastadorterremoto que movilizo a toda la infraestructura sanitaria para socorrer a la capital, Puerto Principe, y dejo a 1,5 millones de personas sin hogar. Ademas, se produjo un aumento de los casos de tuberculosis notificados entre la poblacion afectada. Enfoque Se llevaron a cabo detecciones de casos activos de tuberculosis en un campamento para personas desplazadas de la ciudad y en un barrio pobre cercano. Los agentes de salud comunitarios investigaron los casos de tuberculosis a nivel domestico. Las personas con tos persistente fueron derivadas a un medico. El programa nacional contra la tuberculosis continuo su sistema nacional de informes sobre la tuberculosis. Contexto local Incluso antes del terremoto, Haiti tenia el mayor numero de casos de tuberculosis de todo el continente americano. Alrededor de la mitad de los casos de tuberculosis se encontraba en la region de Puerto Principe. Cambios pertinentes El numero de casos registrados de tuberculosis en Haiti aumento tras el terremoto, aunque no existen los suficientes datos para determinar si este suceso se debe a un aumento de la carga de tuberculosis o a un mejor sistema de deteccion de casos. En comparacion con los calculos nacionales (230 de cada 100.000 personas), la tuberculosis sin diagnosticar era el triple en un campamento para personas desplazadas de la dudad (693 de cada 100.000 personas) y cinco veces mayor en el barrio pobre urbano (1.165 de cada 100.000 personas). Con fondos de la Organizacion Mundial de la Salud, actualmente se realiza una busqueda de casos activos de forma sistematica en barrios pobres y campamentos. Leccion aprendida La busqueda a nivel domestico de tos persistente resulto eficaz a la hora de identificar a pacientes con tuberculosis activa en este estudio. Sin datos precisos, la deteccion temprana de mayores tasas de tuberculosis supone todo un reto. Los datos recogidos se incorporaran a programas de respuesta pragmatica contra enfermedades., Introduction On January 12, 2010, Haiti sustained a devastating earthquake. Total damages are estimated at 7.8 billion United States dollars, more than 120% of the country's 2009 gross domestic product. [...]

Background Attrition during the period from HIV testing to antiretroviral therapy (ART) initiation is high worldwide. We assessed whether same-day HIV testing and ART initiation improves retention and virologic suppression. Methods and findings We conducted an unblinded, randomized trial of standard ART initiation versus same-day HIV testing and ART initiation among eligible adults [greater than or equal to]18 years old with World Health Organization Stage 1 or 2 disease and CD4 count [less than or equal to]500 cells/mm.sup.3 . The study was conducted among outpatients at the Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic infections (GHESKIO) Clinic in Port-au-Prince, Haiti. Participants were randomly assigned (1:1) to standard ART initiation or same-day HIV testing and ART initiation. The standard group initiated ART 3 weeks after HIV testing, and the same-day group initiated ART on the day of testing. The primary study endpoint was retention in care 12 months after HIV testing with HIV-1 RNA Conclusions Same-day HIV testing and ART initiation is feasible and beneficial in this setting, as it improves retention in care with virologic suppression among patients with early clinical HIV disease. Trial registration This study is registered with ClinicalTrials.gov number NCT01900080, Author(s): Serena P. Koenig 1,2,*, Nancy Dorvil 1, Jessy G. Dévieux 3, Bethany L. Hedt-Gauthier 4, Cynthia Riviere 1, Mikerlyne Faustin 1, Kerlyne Lavoile 1, Christian Perodin 1, Alexandra Apollon [...]

To the Editor: A 29-year-old woman at 23 weeks' gestation during her first pregnancy came to our hospital's obstetrics clinic after 6 days of vaginal bleeding and abdominal pain. She [...]

Abstract Background We determined direct medical costs, overhead costs, societal costs, and personnel requirements for the provision of antiretroviral therapy (ART) to patients with AIDS in Haiti. Methods We examined data from 218 treatment-naïve adults who were consecutively initiated on ART at the GHESKIO Center in Port-au-Prince, Haiti between December 23, 2003 and May 20, 2004 and calculated costs and personnel requirements for the first year of ART. Results The mean total cost of treatment per patient was $US 982 including $US 846 in direct costs, $US 114 for overhead, and $US 22 for societal costs. The direct cost per patient included generic ART medications $US 355, lab tests $US 130, nutrition $US 117, hospitalizations $US 62, pre-ART evaluation $US 58, labor $US 51, non-ART medications $US 39, outside referrals $US 31, and telephone cards for patient retention $US 3. Higher treatment costs were associated with hospitalization, change in ART regimen, TB treatment, and survival for one year. We estimate that 1.5 doctors and 2.5 nurses are required to treat 1000 patients in the first year after initiating ART. Conclusion Initial ART treatment in Haiti costs approximately $US 1,000 per patient per year. With generic first-line antiretroviral drugs, only 36% of the cost is for medications. Patients who change regimens are significantly more expensive to treat, highlighting the need for less-expensive second-line drugs. There may be sufficient health care personnel to treat all HIV-infected patients in urban areas of Haiti, but not in rural areas. New models of HIV care are needed for rural areas using assistant medical officers and community health workers.