McCord Hospital

Durban, South Africa

McCord Hospital

Durban, South Africa

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Murphy R.A.,Yeshiva University | Sunpath H.,McCord Hospital | Castilla C.,Brigham and Women's Hospital | Ebrahim S.,McCord Hospital | And 4 more authors.
Journal of Acquired Immune Deficiency Syndromes | Year: 2012

BACKGROUND: Currently, boosted protease inhibitor-containing regimens are the only option after first-line regimen failure available for patients in most resource-limited settings, yet little is known about long-term adherence and outcomes. METHODS: We enrolled patients with virologic failure (VF) who initiated lopinavir/ritonavir-containing second-line antiretroviral therapy (ART). Medication possession ratios were calculated using pharmacy refill dates. Factors associated with 12-month second-line virologic suppression [viral load (VL) <50 copies/mL] and adherence were determined. RESULTS: One hundred six patients (median CD4 count and VL at failure: 153 cells/mm and 28,548 copies/mL, respectively) were enrolled. Adherence improved after second-line ART switch (median adherence 6 months prior, 67%; median adherence during initial 6 months of second-line ART, 100%; P = 0.001). Higher levels of adherence during second-line ART was associated with virologic suppression at month 12 of ART (odds ratio 2.5 per 10% adherence increase, 95% CI 1.3 to 4.8, P = 0.01). Time to virologic suppression was most rapid among patients with 91%-100% adherence compared with patients with 80%-90% and <80% adherence (log rank test, P = 0.01). VF during 24 months of second-line ART was moderate (month 12: 25%, n = 32/126; month 18: 21%, n = 23/112; and month 24: 25%, n = 25/99). CONCLUSIONS: The switch to second-line ART in South Africa was associated with an improvement in adherence, however, a moderate ongoing rate of VF-among approximately 25% of patients receiving second-line ART patients at each follow-up interval-was a cause for concern. Adherence level was associated with second-line ART virologic outcome, helping explain why some patients achieved virologic suppression after switch and others did not. Copyright © 2012 by Lippincott Williams &Wilkins.


Johnson L.F.,University of Cape Town | Mossong J.,University of KwaZulu - Natal | Dorrington R.E.,University of Cape Town | Schomaker M.,University of Cape Town | And 12 more authors.
PLoS Medicine | Year: 2013

Background:Few estimates exist of the life expectancy of HIV-positive adults receiving antiretroviral treatment (ART) in low- and middle-income countries. We aimed to estimate the life expectancy of patients starting ART in South Africa and compare it with that of HIV-negative adults.Methods and Findings:Data were collected from six South African ART cohorts. Analysis was restricted to 37,740 HIV-positive adults starting ART for the first time. Estimates of mortality were obtained by linking patient records to the national population register. Relative survival models were used to estimate the excess mortality attributable to HIV by age, for different baseline CD4 categories and different durations. Non-HIV mortality was estimated using a South African demographic model. The average life expectancy of men starting ART varied between 27.6 y (95% CI: 25.2-30.2) at age 20 y and 10.1 y (95% CI: 9.3-10.8) at age 60 y, while estimates for women at the same ages were substantially higher, at 36.8 y (95% CI: 34.0-39.7) and 14.4 y (95% CI: 13.3-15.3), respectively. The life expectancy of a 20-y-old woman was 43.1 y (95% CI: 40.1-46.0) if her baseline CD4 count was ≥200 cells/μl, compared to 29.5 y (95% CI: 26.2-33.0) if her baseline CD4 count was <50 cells/μl. Life expectancies of patients with baseline CD4 counts ≥200 cells/μl were between 70% and 86% of those in HIV-negative adults of the same age and sex, and life expectancies were increased by 15%-20% in patients who had survived 2 y after starting ART. However, the analysis was limited by a lack of mortality data at longer durations.Conclusions:South African HIV-positive adults can have a near-normal life expectancy, provided that they start ART before their CD4 count drops below 200 cells/μl. These findings demonstrate that the near-normal life expectancies of HIV-positive individuals receiving ART in high-income countries can apply to low- and middle-income countries as well.Please see later in the article for the Editors' Summary. © 2013 Johnson et al.


Crankshaw T.,McCord Hospital | Corless I.B.,Massachusetts General Hospital | Giddy J.,McCord Hospital | Nicholas P.K.,Massachusetts General Hospital | And 2 more authors.
AIDS Patient Care and STDs | Year: 2010

In preparation for a proposed intervention at an antiretroviral therapy (ART) clinic in Durban, South Africa, we explored the dynamics and patterns of cellular phone use among this population, in order to ascertain whether clinic contact via patients' cellular phones was a feasible and acceptable modality for appointment reminders and adherence messages. Adults, who were more than 18 years old, ambulatory, and who presented for treatment at the clinic between October-December 2007, were consecutively recruited until the sample size was reached (n=300). A structured questionnaire was administered, including questions surrounding sociodemographics, cellular phone availability, patterns of use, and acceptability of clinic contact for the purpose of clinic appointment reminders and adherence support. Most respondents (n=242; 81%) reported current ownership of a cellular phone with 95% utilizing a prepaid airtime service. Those participants who currently owned a cellular phone reported high cellular phone turnover due to theft or loss (n=94, 39%) and/or damage (n=68, 28%). More females than men switched their cell phones off during the day (p=0.002) and were more likely to not take calls in certain social milieus (p≤0.0001). Females were more likely to share their cell phone with others (p=0.002) or leave it in a place where someone could access it (p=0.005). Most respondents were willing to have clinic contact via their cellular phones, either verbally (99%) or via text messages (96%). The use of cellular phones for intervention purposes is feasible and should be further investigated. The findings highlight the value of gender-based analyses in informing interventions. © 2010, Mary Ann Liebert, Inc.


Holtz T.H.,Centers for Disease Control and Prevention | Kabera G.,Medical Research Council | Mthiyane T.,Medical Research Council | Zingoni T.,St Marys Hospital | And 6 more authors.
The Lancet Infectious Diseases | Year: 2011

Background: In 2007, WHO released revised recommendations and an algorithm for the diagnosis and treatment of smear-negative pulmonary tuberculosis in seriously ill people living with HIV/AIDS. We aimed to assess the effect of the recommendations on clinical outcome in patients in South Africa. Methods: We enrolled seriously ill patients (aged ≥15 years) with HIV infection and suspected smear-negative pulmonary tuberculosis from three hospitals in KwaZulu-Natal, South Africa. Patients were consecutively enrolled into two cohorts: the first cohort was managed according to standard practice, and the second according to the WHO-recommended algorithm. The primary endpoints were rates of continued stay in hospital at 7 days after admission and survival at 8 weeks after admission. Findings: 338 patients were enrolled in the standard practice cohort between August, 2008, and February, 2009, and 187 were enrolled in the algorithm cohort between March, 2009, and December, 2009. 7 days after hospital admission, 27% (n=50) of patients in the algorithm cohort were still in hospital, compared with 38% (n=130) in the standard practice cohort (rate ratio 0·70, 95% CI 0·53-0·91; p=0·009). 8 weeks after admission, 83% (n=156) of patients in the algorithm cohort were alive, compared with 68% (n=230) in the standard practice cohort (1·23, 1·11-1·35; p=0·0001), with effect modified by hospital location. Interpretation: In seriously ill patients with HIV infection and suspected smear-negative pulmonary tuberculosis, early antituberculosis treatment according to the WHO algorithm could significantly reduce mortality in South Africa. Funding: US President's Emergency Plan for AIDS Relief. © 2011 Elsevier Ltd.


Quinlan D.,Victoria Gynecology and Continence Clinic | Quinlan D.K.,McCord Hospital
Journal of Obstetrics and Gynaecology Canada | Year: 2010

Objective: To demonstrate that increased uterine size should not be a deterrent to the vaginal approach for performing hysterectomy. Method: We performed a retrospective study of the medical records pertaining to 2769 hysterectomies performed by a single surgeon. For this study, we reviewed the surgical details and outcome of 85 women who had a vaginal hysterectomy for a symptomatic fibroid uterus that was estimated to be equivalent in size to a uterus of between 10 and 20 weeks' gestation. Results: The vaginal approach for hysterectomy was successful in all 85 cases and complication rates were low. Sixteen women had additional adnexal surgery besides hysterectomy. In 52 cases, morcellation of the uterus was required. Average operating time was 60 minutes. Conclusion: Increased uterine size should not be an automatic deterrent to the vaginal approach for hysterectomy. Nevertheless, individual surgeons should perform such challenging procedures only if they are properly trained and are comfortable doing so. Some surgeons may choose not to perform hysterectomies using the vaginal approach. © 2010 Society of Obstetricians and Gynaecologists of Canada.


Cohen G.M.,Beth Israel Deaconess Medical Center | Drain P.K.,Massachusetts General Hospital | Drain P.K.,Brigham and Women's Hospital | Noubary F.,Institute for Clinical Research and Health Policy Studies | And 4 more authors.
Journal of Acquired Immune Deficiency Syndromes | Year: 2014

Setting: We conducted a retrospective study among HIV-infected adult suspects (≥18 years) with pulmonary tuberculosis (TB), who underwent Xpert MTB/RIF (Xpert) testing at McCord Hospital and its adjoining HIV clinic in Durban, South Africa. Objective: To determine if Xpert testing performed at a centralized laboratory accelerated time to TB diagnosis. Design: We obtained data on sputum smear microscopy [acid-fast bacilli (AFB)], Xpert, and the rationale for treatment initiation from medical records. The primary outcome was "total diagnostic time," defined as time from sputum collection to clinicians' receipt of results. A linear mixed-effect model compared the duration of steps in the diagnostic pathway across testing modalities. Results: Among 403 participants, the median "total diagnostic time" for AFB and Xpert was 3.3 and 6.4 days, respectively (P < 0.001). When compared with AFB, the median delay for Xpert "laboratory processing" was 1.4 days (P < 0.001) and "result transfer to clinic" was 1.7 days (P < 0.001). Among 86 Xpert-positive participants who initiated treatment, 49 (57%) started treatment based on clinical suspicion or AFB-positive results, whereas only 32 (37%) started treatment based on Xpert-positive results. Conclusions: In our setting, Xpert results took twice as long as AFB results to reach clinicians. Replacing AFB with centralized Xpert may delay TB diagnoses in some settings. Copyright © 2014 by Lippincott Williams & Wilkins.


Zanoni B.C.,Massachusetts Institute of Technology | Zanoni B.C.,Harvard University | Zanoni B.C.,McCord Hospital | Phungula T.,McCord Hospital | And 4 more authors.
AIDS | Year: 2011

Objective: To evaluate the association between treatment of HIV-tuberculosis (TB) coinfection and primary virologic failure among children initiating antiretroviral therapy in South Africa. Design: We performed a retrospective cohort study of 1029 children initiating antiretroviral therapy at two medical centers in KwaZulu Natal, South Africa, a region of very high TB incidence. Methods: Data were extracted from electronic medical records and charts and the impact of TB cotreatment on viral suppression at 6 and 12 months was assessed using logistic regression. Results: The overall rate of virologic suppression (<400 HIV RNA copies/ml) was 85% at 6 months and 87% at 12 months. Children who received concurrent treatment for TB had a significantly lower rate of virologic suppression at 6 months (79 vs. 88%; P = 0.003). Those who received nonnucleoside reverse transcriptase inhibitor-based HAART had similar rates of viral suppression regardless of whether they received concurrent TB therapy. In contrast, children who received protease inhibitor-based HAART had significantly lower viral suppression rates at both 6 and 12 months if treated concurrently for TB (P = 0.02 and 0.03). Multivariate logistic regression revealed that age at initiation, protease inhibitor therapy, and TB coinfection were each independently associated with primary virologic failure. Conclusion: Concurrent treatment for TB is associated with lower rates of viral suppression among children receiving protease inhibitor-based HAART, but not among those receiving nonnucleoside reverse transcriptase inhibitor-based HAART. Guidelines for the care of young HIV-TB coinfected infants should be continually evaluated, as protease inhibitor-based antiviral therapy may not provide optimal viral suppression in this population. © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins.


Matthews L.T.,Massachusetts General Hospital | Matthews L.T.,Beth Israel Deaconess Medical Center | Crankshaw T.,McCord Hospital | Giddy J.,McCord Hospital | And 5 more authors.
AIDS and Behavior | Year: 2013

Understanding reproductive decisions and periconception behavior among HIV-discordant couples is important for designing risk reduction interventions for couples who choose to conceive. In-depth interviews were conducted to explore reproductive decision-making and periconception practices among HIV-positive women with recent pregnancy (n = 30), and HIV-positive men (n = 20), all reporting partners of negative or unknown HIV-status, and attending HIV services in Durban, South Africa. Transcripts were coded for categories and emergent themes. Participants expressed strong reasons for having children, but rarely knew how to reduce periconception HIV transmission. Pregnancy planning occurred on a spectrum ranging from explicitly intended to explicitly unintended, with many falling in between the two extremes. Male fertility desire and misunderstanding serodiscordance contributed to HIV risk behavior. Participants expressed openness to healthcare worker advice for safer conception and modified risk behavior post-conception, suggesting the feasibility of safer conception interventions which may target both men and women and include serodiscordance counseling and promotion of contraception. © 2012 Springer Science+Business Media, LLC.


Drain P.K.,Massachusetts General Hospital | Drain P.K.,Harvard University | Losina E.,Massachusetts General Hospital | Losina E.,Harvard University | And 6 more authors.
Journal of Acquired Immune Deficiency Syndromes | Year: 2015

Background: We assessed the role of urine lipoarabinomannan (LAM) grade and a second LAM test for HIV-associated pulmonary tuberculosis (TB) screening in outpatient clinics in South Africa. Methods: We enrolled newly diagnosed HIV-infected adults (≥18 years) at 4 clinics, excluding those on TB therapy. Participants provided sputum for acid-fast bacilli (AFB) microscopy and culture. Nurses conducted 2 rapid urine LAM tests at the point-of-care and graded positive results from low (faint) to high (5+). Culture-confirmed pulmonary TB was the gold standard. We used area under receiver operating curves (AUROC) to compare screening strategies. Results: Among 320 HIV-infected adults, median CD4 was 248 cells per cubic millimeter (interquartile range, 107-379/mm3); 54 (17%) were TB culture positive. Fifty-two (16%) of all participants were LAM positive by either test; correlation between LAM tests was high. Among 10 "faint" positive results, 2 (20%) had culture-positive TB. Using ≥1+ LAM grade as positive, 1 LAM test had sensitivity of 41% [95% confidence interval (CI): 28% to 55%] and specificity of 92% (95% CI: 88% to 95%). A 2 LAM test strategy had a sensitivity of 43% (95% CI: 29% to 57%). One LAM test ≥1+ grade (AUROC 0.66; 95% CI: 0.60 to 0.73) was significantly better than sputum AFB alone. The optimal strategy was sequentially performing 1 LAM test followed by sputum AFB if LAM grade <1+ (AUROC 0.70; 95% CI: 0.63 to 0.77), which had sensitivity of 48% (95% CI: 34% to 62%) and specificity of 91% (95% CI: 87% to 94%). Conclusions: In this clinic-based study, "faint" line was a false-positive second urine LAM test added no value, and an optimal screening strategy was 1 LAM test followed by sputum AFB microscopy for urine LAM-negative people. Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved.


Sunpath H.,McCord Hospital | Sunpath H.,Emory University | Wu B.,Emory University | Gordon M.,University of KwaZulu - Natal | And 6 more authors.
AIDS | Year: 2012

Objective: We sought to determine the rate of the K65R mutation in patients receiving tenofovir (TDF)-based antiretroviral therapy (ART) with subtype C HIV infection. Design: Retrospective cohort study. Methods: All patients initiated on stavudine (d4T) with lamivudine (3TC) or TDF with 3TC and a nonnucleoside reverse transcriptase inhibitor at McCord Hospital in Durban, South Africa had their charts reviewed. All patients with virologic failure, defined as a viral load more than 1000copies/ml after 5 months of a first ART regimen, had genotypic resistance testing performed prospectively using a validated in-house assay. Important resistance mutations were selected based upon published mutations in subtype B virus in the Stanford HIV Drug Resistance database. Results: A total of 585 patients were initiated on TDF-containing first-line ART from 3 August 2010 to 17 March 2011. Thirty-five (6.0%) of these patients had virologic failure and 23 of 33 (69.7%) of the virologic failure patients had the K65R mutation. The median (interquartile range) for the baseline CD4 cell count was 105cells/μl (49-209) and viral load at virologic failure was 47571copies/ml (20708-202000). During the same period, 53 patients were initiated on d4T-containing regimens. Two (3.8%) of these patients had virologic failure and one of the virologic failure patients had the K65R mutation. Conclusion: Preliminary data show very high rates (>65%) of K65R for patients failing TDF-based first-line regimens at McCord Hospital with few additional nucleoside reverse transcriptase inhibitor mutations compared with subtype B. These rates may reflect faster in-vivo selection, longer time on a failing regimen or transmitted drug resistance. © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins.

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