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Alvarez-Uria G.,Rural Development Trust Hospital | Pakam R.,Rural Development Trust Hospital | Midde M.,Rural Development Trust Hospital | Naik P.K.,Rural Development Trust Hospital
Interdisciplinary Perspectives on Infectious Diseases | Year: 2013

HIV treatment, care, and support programmes in low- and middle-income countries have traditionally focused more on patients remaining in care after the initiation of antiretroviral therapy (ART) than on earlier stages of care. This study describes the cumulative retention from HIV diagnosis to the achievement of virological suppression after ART initiation in an HIV cohort study in India. Of all patients diagnosed with HIV, 70% entered into care within three months. 65% of patients ineligible for ART at the first assessment were retained in pre-ART care. 67% of those eligible for ART initiated treatment within three months. 30% of patients who initiated ART died or were lost to followup, and 82% achieved virological suppression in the last viral load determination. Most attrition occurred the in pre-ART stages of care, and it was estimated that only 31% of patients diagnosed with HIV engaged in care and achieved virological suppression after ART initiation. The total mortality attributable to pre-ART attrition was considerably higher than the mortality for not achieving virological suppression. This study indicates that early entry into pre-ART care along with timely initiation of ART is more likely to reduce HIV-related mortality compared to achieving virological suppression. © 2013 Gerardo Alvarez-Uria et al.


Studies fromsub-Saharan Africa have shown that a substantial proportion of patients diagnosed with HIV enter into HIV medical care late. However, data from low or middle-income countries outside Africa are scarce. In this study, we investigated risk factors associated with delayed entry into care stratified by gender in a large cohort study in India. 7701 patients were diagnosed with HIV and 5410 entered into care within three months of HIV diagnosis. Nearly 80% entered into care within a year, but most patients who did not enter into care within a year remained lost to follow up or died. Patient with risk factors related to having a low socio-economic status (poverty, being homeless, belonging to a disadvantaged community and illiteracy) were more likely to enter into care late. In addition, male gender and being asymptomatic at the moment of HIV infection were factors associated with delayed entry into care. Substantial gender differences were found. Younger age was found to be associated with delayed entry in men, but not in women. Widows and unmarried men were more likely to enter into care within three months. Women belonging to disadvantaged communities or living far from a town were more likely to enter into care late. The results of this study highlight the need to improve the linkage between HIV diagnosis and HIV treatment in India. HIV programmes should monitor patients diagnosed with HIV until they engage in HIV medical care, especially those at increased risk of attrition. © 2013 Alvarez-Uria.


Alvarez-Uria G.,Rural Development Trust Hospital | Naik P.K.,Rural Development Trust Hospital | Pakam R.,Rural Development Trust Hospital | Midde M.,Rural Development Trust Hospital
Global Health Action | Year: 2013

Background: Studies from sub-Saharan Africa have shown high incidence of attrition due to mortality or loss to follow-up (LTFU) after initiating antiretroviral therapy (ART). India is the third largest country in the world in terms of HIV infected people, but predictors of attrition after ART initiation are not well known. Design: We describe factors associated with attrition, mortality, and LTFU in 3,159 HIV infected patients who initiated ART between 1 January 2007 and 4 November 2011 in an HIV cohort study in India. The study included 6,852 person-years with a mean follow-up of 2.17 years. Results: After 5 years of follow-up, the estimated cumulative incidence of attrition was 37.7%. There was no significant difference between attrition due to mortality and attrition due to LTFU. Having CD4 counts <100 cells/ml and being homeless [adjusted hazard ratio (aHR) 3.1, 95% confidence interval (CI) 2.6-3.8] were associated with a higher risk of attrition, and female gender (aHR 0.64, 95% CI 0.6-0.8) was associated with a reduced risk of attrition. Living near a town (aHR 0.82, 95% CI 0.7-0.999) was associated with a reduced risk of mortality. Being single (aHR 1.6, 95% CI 1.2-2.3), illiteracy (aHR 1.3, 95% CI 1.1-1.6), and age <25 years (aHR 1.3, 95% CI 1-1.8) were associated with an increased risk of LTFU. Although the cumulative incidence of attrition in patients diagnosed with tuberculosis after ART initiation was 47.4%, patients who started anti-tuberculous treatment before ART had similar attrition to patients without tuberculosis (36 vs. 35.2%, P=0.19) after four years of follow-up. Conclusions: In this cohort study, the attrition was similar to the one found in sub-Saharan Africa. Earlier initiation of ART, improving the diagnosis of tuberculosis before initiating ART, and giving more support to those patients at higher risk of attrition could potentially reduce the mortality and LTFU after ART initiation. © 2013 Gerardo Alvarez-Uria et al.


Alvarez-Uria G.,Rural Development Trust Hospital
Current Opinion in Pulmonary Medicine | Year: 2010

Purpose of Review: Although the incidence of tuberculosis has reduced in developed countries, there is a growing interest in nontuberculous mycobacteria (NTM) as a cause of lung disease. However, NTM are a heterogeneous group and most of the data come from only three species: Mycobacterium avium complex, Mycobacterium kansasii and Mycobacterium abscessus. Still, information about these three species is confusing because it is based mainly on retrospective studies and series of clinical cases performed in developed countries. In recent years, new information has appeared about other species and the pathogenesis of NTM. Recent Findings: Epidemiological studies show that NTM infection is a worldwide phenomenon with an increasing presence in developing countries perhaps because of the implementation of tap water. Women with characteristic phenotype are at higher risk of acquiring NTM infection along with patients with defects on cystic fibrosis transmembrane conductance regulators. New studies on Mycobacterium fortuitum, Mycobacterium xenopi, Mycobacterium szulgai and Mycobacterium simiae indicate that the American Thoracic Society criteria for diagnosing NTM disease may not be useful for all species of NTM. Summary: New multicentric and prospective studies are needed to clarify the pathogenesis and treatment of NTM. These organisms form a numerous and heterogeneous group and each species should be studied separately. © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins.


Alvarez-Uria G.,Rural Development Trust Hospital | Midde M.,Rural Development Trust Hospital | Pakam R.,Rural Development Trust Hospital | Naik P.K.,Rural Development Trust Hospital
Infectious Disease Reports | Year: 2012

Despite 67% of HIV infected people in India are rural residents, the epidemiology of HIV in rural areas is not well known. This is an observational cohort study of 11,040 HIV infected people living in a rural district of India. The prevalence of hepatitis B, hepatitis C and syphilis of HIV infected patients were compared to the seroprevalence in 16,641 blood donors from the same area. The age of diagnosis in adults was below 35 years in 70% of cases and 56% were illiterate. One third of women were widows and only 3.6% of adults had a permanent job. Women were diagnosed at earlier age, had lower level of education, had poorer employment conditions and depended more on their relatives than men. In a survey performed to a subgroup of patients, 81% of women referred to have acquired HIV from their spouse, whereas 51% of men acquired HIV from commercial sex. Patients with HIV had significantly higher prevalence of hepatitis B, hepatitis C and syphilis than blood donors. Seroprevalence of HIV-2, hepatitis C and toxoplasmosis were low compared to other sites. Six percent were children (<15 years) and almost half of them had lost one or both of their parents. The study shows the poor socioeconomical situation and the high level of illiteracy of people living with HIV in rural India, especially women. Future health programmes of HIV in India should take into account the particularities of the HIV epidemic in rural areas. © G. Alvarez-Uria et al., 2012.


In low- and middle-income countries, the attrition across the continuum of care of HIV infected children is not well known. The aim of this study was to investigate predictors of mortality and loss to follow up (LTFU) in HIV infected children from a cohort study in India and to describe the cascade of care from HIV diagnosis to virological suppression after antiretroviral therapy (ART) initiation. Multivariable analysis was performed using competing risk regression. The cumulative incidence of attrition due to mortality or LTFU after five year of follow-up was 16% fromentry into care to ART initiation and 24.9% after ART initiation. Of all children diagnosed with HIV, it was estimated that 91.9% entered into care, 77.2% were retained until ART initiation, 58% stayed in care after ART initiation, and 43.4% achieved virological suppression on ART. Approximately half of the attrition occurred before ART initiation, and the other half after starting ART. Belonging to socially disadvantaged communities and living >90 min from the hospital were associated with a higher risk of attrition. Being >10 years old and having higher 12-month risk of AIDS (calculated using the absolute CD4 lymphocyte count and the age) were associated with an increased risk of mortality. These findings indicate that we should consider placing more emphasis on promoting research and implementing interventions to improve the engagement of HIV infected children in pre-ART care. The results of this study can be used by HIV programmes to design interventions aimed at reducing the attrition across the continuum of care of HIV infected children in India. © 2014 Alvarez-Uria.


Alvarez-Uria G.,Rural Development Trust Hospital | Midde M.,Rural Development Trust Hospital | Naik P.K.,Rural Development Trust Hospital
International Journal of Infectious Diseases | Year: 2012

Objectives: To study the trends of the HIV epidemic and risk factors associated with HIV in a rural area of India. We utilized HIV prevalence among young pregnant women as an indicator of population trends in HIV infection. Methods: This was an observational study of pregnant women aged less than 25 years who were counseled and tested for HIV infection in a rural hospital between August 2007 and June 2011. Information on age, education, occupation, and community were collected prospectively from all of the women. Results: The HIV prevalence in young pregnant women decreased from 1.22% in 2007 to 0.35% in 2011. Comparing the periods 2007-2009 and 2010-2011, a reduction in HIV prevalence was seen in all subgroups except in women from forward castes. Women whose job was not related to agriculture and women who had only completed primary education were more likely to be HIV-infected. Conclusions: These results indirectly indicate that the incidence of HIV infection is decreasing in this rural setting. However, an increase in the HIV prevalence in women from forward castes was observed. In rural areas, HIV testing of pregnant women who have only completed primary education or who are working in a field not related to agriculture should be encouraged, because of their higher risk of HIV infection. © 2011 International Society for Infectious Diseases.


Alvarez-Uria G.,Rural Development Trust Hospital | Pakam R.,Rural Development Trust Hospital | Midde M.,Rural Development Trust Hospital | Naik P.K.,Rural Development Trust Hospital
Journal of the International AIDS Society | Year: 2014

RESULTS: A total of 4590 patients and 3133 person-years (py) of follow-up were included in the pre-ART group, and 3784 patients and 4756 py were included in the on-ART group. In the pre-ART group, the incidence of TB was high during the first month after HIV diagnosis and dropped nearly four times soon after. In the on-ART group, the incidence of TB increased after ART initiation reaching a peak in the third month. The probability of having TB within 30 months was 22.3% (95% confidence interval [CI], 21.1-23.6) in the pre-ART group and 17.8% (95% CI, 16.3-19.3) in the on-ART group. In a multivariable analysis, women had a lower risk of TB in both groups. Poor socio-economical conditions were associated with an increased risk of TB in the pre-ART group, but not in the group on-ART. While the association between low CD4 counts and TB was strong in the pre-ART group, this association was weaker in the on-ART group, and the highest risk of TB was seen in those patients with CD4 counts around 110 cells/mm3. The cumulative incidence of mortality at 12 months in patients with TB was 29.6% (95% CI, 26.9-32.6) in pre-ART TB and 34.9% (95% CI, 31-39.1) in on-ART TB. Half deaths before ART initiation and two thirds of deaths after ART initiation occurred in patients with TB.CONCLUSIONS: The high incidence and mortality of TB seen in this study underscore the urgent need to improve the prevention and diagnosis of HIV-associated TB in India. We found substantial differences between TB before and after ART initiation.INTRODUCTION: India has the highest burden of tuberculosis (TB) in the world, but the epidemiology of HIV-associated TB is not well known.METHODS: We describe the incidence and the mortality of TB from HIV diagnosis to antiretroviral therapy (ART) initiation (pre-ART group) and after ART initiation (on-ART group) in an HIV cohort study in Anantapur, India. Multivariable analysis of factors associated with TB was performed using competing risk regression and restricted cubic spline methods.


Alvarez-Uria G.,Rural Development Trust Hospital | Naik P.K.,Rural Development Trust Hospital | Pakam R.,Rural Development Trust Hospital | Midde M.,Rural Development Trust Hospital
Tropical Medicine and International Health | Year: 2012

Objectives To evaluate the performance of a single determination of HIV viral load (VL) 6-12months after starting antiretroviral therapy (ART) for identifying patients who will subsequently develop virological failure. Methods We selected HIV-infected patients with at least two VL determinations after 6months of ART from an HIV cohort study in India. Patients were divided in two groups depending on whether the first VL was below (Group 1) or above (Group 2) 1000copies/ml. Cut-off for virological failure was defined according to World Health Organization recommendation (>5000copies/ml). Results The study included 584 patients and 560.1 person-years of follow-up. Of all virological failures, 83% were diagnosed at the first VL determination. The cumulative incidence of virological failure after 1 and 2years since the first VL was 0.9% [95% confidence interval (CI), 0.3-2.7] and 1.7% (95% CI, 0.6-5), respectively, for Group 1, and 58.2% (95% CI, 47-69.7) and 63.1% (95% CI, 49.8-76.4), respectively, for Group 2. Compared with Group 1, patients from Group 2 had a hazard ratio for virological failure of 78.3 (95% CI, 27.8-220.2). Conclusions A single VL determination after 6months of ART was able to identify patients with high risk of virological failure. © 2012 Blackwell Publishing Ltd.


Alvarez-Uria G.,Rural Development Trust Hospital | Midde M.,Rural Development Trust Hospital | Pakam R.,Rural Development Trust Hospital | Naik P.K.,Rural Development Trust Hospital
BioImpacts | Year: 2013

Introduction: Tuberculosis is difficult to diagnose and it is the leading cause of death in HIV infected individuals in developing countries. There is an urgent need of low-cost diagnostic markers for resource-limited settings. Methods: The study involved 1571 patients from an HIV cohort study in India with known serum albumin concentrations at the time of becoming eligible for antiretroviral therapy (ART). We investigated the diagnostic accuracy of serum albumin to predict tuberculosis within six months of ART eligibility and the prognostic value in patients who experienced tuberculosis. Results: The diagnostic accuracy of serum albumin, measured by the area under the receiver operating characteristic curve, to predict tuberculosis was 0.81 (95% confidence interval 0.78-0.83). Serum albumin concentrations <3.2 g/dL were associated with 85% specificity and <4.1 g/dL were associated with negative predictive values >90%, even in settings with high tuberculosis prevalence. Hypoalbuminemia was associated with an increased risk of mortality in patients with tuberculosis. Conclusion: Serum albumin can be a useful low-cost diagnostic marker for tuberculosis in HIV infected patients eligible for ART. However, we failed to find thresholds to rule out or rule in tuberculosis. If these results are confirmed by other studies, serum albumin could be used to improve the diagnostic accuracy of intensive case finding algorithms for HIV-related tuberculosis. In patients who experience tuberculosis, hypoalbuminemia is associated with poor prognosis. © 2013 by Tabriz University of Medical Sciences.

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