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Vermund S.H.,Vanderbilt University | Vermund S.H.,Vanderbilt Institute for Global Health | Hodder S.L.,Rutgers University | Justman J.E.,Columbia University | And 8 more authors.
Clinical Infectious Diseases | Year: 2010

More than half a million Americans became newly infected with human immunodeficiency virus (HIV) in the first decade of the new millennium. The domestic epidemic has had the heaviest impact on men who have sex with men and persons from racial and ethnic minority populations, particularly black persons. For example, black men who have sex with men represent <1% of the US population but 25% of new HIV infections, according to Centers for Disease Control and Prevention estimates published in 2008. Although black and Hispanic women constitute 24% of all US women, they accounted for 82% of HIV infections among women in 2005, according to data from 33 states with confidential name-based reporting. There is a nearly 23-fold higher rate of AIDS diagnoses among black women (45.5 diagnoses per 100,000 women) and a nearly 6-fold higher rate among Hispanic women (11.2 diagnoses per 100,000 women), compared with the rate among white women (2.0 diagnoses per 100,000 women). Investigators from the HIV Prevention Trials Network, a National Institutes of Health-sponsored collaborative clinical trials group, have crafted a domestic research agenda with community input. Two new domestic studies are in progress (2009), and a community-based clinical trial feasibility effort is in development (2010 start date). These studies focus on outreach, testing, and treatment of infected persons as a backbone for prevention of HIV infection. Reaching persons not receiving health messages and services with novel approaches to both prevention and treatment is an essential priority for control of HIV infection in the United States; our research is designed to guide the best approaches and assess the impact of bridging treatment and prevention. © 2010 by the Infectious Diseases Society of America. All rights reserved.


Hickey M.C.,University of California at Davis | Jandrey K.,University of California at Davis | Farrell K.S.,University of California at Davis | Carlson-Bremer D.,Vanderbilt Institute for Global Health
Journal of Veterinary Internal Medicine | Year: 2014

Background: Renal infarcts identified without definitive association with any specific disease process. Objective: Determine diseases associated with diagnosis of renal infarcts in cats diagnosed by sonography or necropsy. Animals: 600 cats underwent abdominal ultrasonography, necropsy, or both at a veterinary medical teaching hospital. Methods: Information obtained from electronic medical records. Cats classified as having renal infarct present based on results of sonographic evaluation or necropsy. Time-matched case-controls selected from cats that underwent the next scheduled diagnostic procedure. Results: 309 of 600 cats having diagnosis of renal infarct and 291 time-matched controls. Cats 7-14 years old were 1.6 times (odds ratio, 95% CI: 1.03-2.05, P = .03) more likely to have renal infarct than younger cats but no more likely to have renal infarct than older cats (1.4, 0.89-2.25, P = .14). All P = .14 are statistically significant. Cats with renal infarcts were 4.5 times (odds ratio, 95% CI: 2.63-7.68, P < .001) more likely to have HCM compared to cats without renal infarcts. Cats with renal infarcts were 0.7 times (odds ratio, 95% CI: 0.51-0.99, P = .046) less likely to have diagnosis of neoplasia compared to cats without renal infarcts. Cats with diagnosis of hyperthyroidism did not have significant association with having renal infarct. Cats with renal infarcts were 8 times (odds ratio, 95% CI: 2.55-25.40, P ≤ .001) more likely to have diagnosis of distal aortic thromboembolism than cats without renal infarcts. Conclusions and Clinical Importance: Cats with renal infarcts identified on antemortem examination should be screened for occult cardiomyopathy. © 2014 by the American College of Veterinary Internal Medicine.


Aliyu M.H.,West Health Institute | Aliyu M.H.,Vanderbilt Institute for Global Health | Blevins M.,Vanderbilt Institute for Global Health | Parrish D.D.,Vanderbilt Institute for Global Health | And 10 more authors.
Journal of Acquired Immune Deficiency Syndromes | Year: 2014

Background: Timely initiation of combination antiretroviral therapy (ART) in eligible HIV-infected patients is associated with substantial reduction in mortality and morbidity. Nigeria has the second largest number of persons living with HIV/AIDS in the world. We examined patient characteristics, time to ART initiation, retention, and mortality at 5 rural facilities in Kwara and Niger states of Nigeria. Methods: We analyzed program-level cohort data for HIV-infected ART-naive clients (15 years) enrolled from June 2009 to February 2011.We modeled the probability of ART initiation among clients meeting national ART eligibility criteria using logistic regression with splines. Results: We enrolled 1948 ART-naive adults/adolescents into care, of whom, 1174 were ART eligible (62% female). Only 74% of the eligible patients (n = 869) initiated ART within 90 days after enrollment. The median CD4+ count for eligible clients was 156 cells/mL (interquartile range: 81-257), with 67% in WHO stage III/IV disease. Adjusting for CD4+ count, WHO stage, functional status, hemoglobin, body mass index, sex, age, education, marital status, employment, clinic of attendance, and month of enrollment, we found that immunosuppression [CD4 350 vs. 200, odds ratio (OR) = 2.10, 95% confidence interval (CI): 1.31 to 3.35], functional status [bedridden vs. working, OR = 4.17 (95% CI: 1.63 to 10.67)], clinic of attendance [Kuta Hospital vs. referent: OR = 5.70 (95% CI: 2.99 to 10.89)], and date of enrollment [December 2010 vs. June 2009: OR = 2.13 (95% CI: 1.19 to 3.81)] were associated with delayed ART initiation. Conclusions: Delayed initiation of ART was associated with higher CD4+ counts, lower functional status, clinic of attendance, and later dates of enrollment among ART-eligible clients. Our findings provide targets for quality improvement efforts that may help reduce attrition and improve ART uptake in similar settings. Copyright © 2013 by Lippincott Williams and Wilkins.


Moon T.D.,Vanderbilt Institute for Global Health | Moon T.D.,Friends in Global Health LLC | Silva-Matos C.,Ministry of Health | Cordoso A.,Friends in Global Health LLC | And 4 more authors.
Journal of the International AIDS Society | Year: 2013

Background: In order to maximize the benefits of HIV care and treatment investments in sub-Saharan Africa, programs can broaden to target other diseases amenable to screening and efficient management. We nested cervical cancer screening into family planning clinics at select sites also receiving PEPFAR support for antiretroviral therapy (ART) rollout. This was done using visual inspection with acetic acid (VIA) by maternal child health nurses. We report on achievements and obstacles in the first year of the program in rural Mozambique. Methods: VIA was taught to clinic nurses and hospital physicians, with a regular clinical feedback loop for quality evaluation and retraining. Cryotherapy using carbon dioxide as the refrigerant was provided at clinics; loop electrosurgical excision procedure (LEEP) and surgery were provided at the provincial hospital for serious cases. No pathology services were available. Results: Nurses screened 4651 women using VIA in Zambézia Province in year one of the program, more than double the Ministry of Health service target. VIA was judged positive for squamous intraepithelial lesions in 8% (n = 380) of the women (9% if age ≥30 years (n = 3154) and 7% if age <30 years (n = 1497); p = 0.02). Of the 380 VIA-positive women, 4% ( n = 16) had lesions (0.3% of 4651 total screened) requiring referral to Quelimane Provincial Hospital. Fourteen (88%) of these 16 women were seen at the hospital, but records were inadequate to judge outcomes. Of women screened, 2714 (58%) either had knowledge of their HIV status prior to VIA or were subsequently sent for HIV testing, of which 583 (21%) were HIV positive. Conclusions: Screening and clinical services were successfully provided on a large scale for the first time ever in these rural clinics. However, health manpower shortages, equipment problems, poor paper record systems and a limited ability to follow-up patients inhibited the quality of the cervical cancer screening services. Using prior HIV investments, chronic disease screening and management for cervical cancer is feasible even in severely resource-constrained rural Africa. © 2012 Moon TD et al; licensee International AIDS Society.


PubMed | University of Zimbabwe, World Health Organization, Vanderbilt Institute for Global Health, Zimbabwe Ministry of Health and Child Care and University of Connecticut
Type: | Journal: Health policy and planning | Year: 2017

Despite notable progress reducing global under-five mortality rates, insufficient progress in most sub-Saharan African nations has prevented the achievement of Millennium Development Goal four (MDG#4) to reduce under-five mortality by two-thirds between 1990 and 2015. Country-level assessments of factors underlying why some African countries have not been able to achieve MDG#4 have not been published. Zimbabwe was included in a four-country study examining barriers and facilitators of under-five survival between 2000 and 2013 due to its comparatively slow progress towards MDG#4. A review of national health policy and strategy documents and analysis of qualitative data identified Zimbabwes critical shortage of health workers and diminished opportunities for professional training and education as an overarching challenge. Moreover, this insufficient health workforce severely limited the availability, quality, and utilization of life-saving health services for pregnant women and children during the study period. The impact of these challenges was most evident in Zimbabwes persistently high neonatal mortality rate, and was likely compounded by policy gaps failing to authorize midwives to deliver life-saving interventions and to ensure health staff make home post-natal care visits soon after birth. Similarly, the lack of a national policy authorizing lower-level cadres of health workers to provide community-based treatment of pneumonia contributed to low coverage of this effective intervention and high child mortality. Zimbabwe has recently begun to address these challenges through comprehensive policies and strategies targeting improved recruitment and retention of experienced senior providers and by shifting responsibility of basic maternal, neonatal and child health services to lower-level cadres and community health workers that require less training, are geographically broadly distributed, and are more cost-effective, however the impact of these interventions could not be assessed within the scope and timeframe of the current study.


Koethe J.R.,Vanderbilt University | Koethe J.R.,Center for Infectious Disease Research in Zambia | Heimburger D.C.,Vanderbilt Institute for Global Health | Heimburger D.C.,Center for Infectious Disease Research in Zambia | Heimburger D.C.,University of Alabama at Birmingham
American Journal of Clinical Nutrition | Year: 2010

The twin global epidemics of HIV infection and food scarcity disproportionately affect sub-Saharan Africa, and a significant proportion of patients who require antiretroviral therapy (ART) are malnourished because of a combination of HIV-associated wasting and inadequate nutrient intake. Protein-calorie malnutrition, the most common form of adult malnutrition in the region, is associated with significant morbidity and compounds the immunosuppressive effects of HIV. A low body mass index (BMI), a sign of advanced malnutrition, is an independent predictor of early mortality (<6 mo) after ART initiation in several analyses, and recent studies show an association between early weight gain when receiving ART and improved treatment outcomes. The cause of the observed increase in mortality is uncertain, but it is likely due in part to malnutritioninduced immune system dysfunction, a higher burden of opportunistic infections, and metabolic derangements. In this article, we describe the epidemiology of HIV infection and malnutrition in sub-Saharan Africa, potential causes of increased mortality after ART initiation among patients with a low BMI, recent studies on post-ART weight gain and treatment outcome, and trials of macronutrient supplementation from the region. We close by highlighting priority areas for future research. © 2010 American Society for Nutrition.


BACKGROUND: Undernourished, HIV-infected adults in sub-Saharan Africa have high levels of systemic inflammation, which is a risk factor for mortality and other adverse health outcomes. We hypothesized that microbial translocation, due to the deleterious effects of HIV and poor nutrition on intestinal defenses and mucosal integrity, contributes to heightened systemic inflammation in this population, and reductions in inflammation on antiretroviral therapy (ART) accompany reductions in translocation.METHODS: HIV-infected, Zambian adults with a body mass index <18.5 kg/m2 were recruited for a pilot study to assess the relationships between microbial translocation and systemic inflammation over the first 12 weeks of ART. To assess microbial translocation we measured serum lipopolysaccharide binding protein (LBP), endotoxin core IgG and IgM, and soluble CD14, and to assess intestinal permeability we measured the urinary excretion of an oral lactulose dose normalized to urinary creatinine (Lac/Cr ratio). Linear mixed models were used to assess within-patient changes in these markers relative to serum C-reactive protein (CRP), tumor necrosis factor-α receptor 1 (TNF-α R1), and soluble CD163 over 12 weeks, in addition to relationships between variables independent of time point and adjusted for age, sex, and CD4+ count.RESULTS: Thirty-three participants had data from recruitment and at 12 weeks: 55% were male, median age was 36 years, and median baseline CD4+ count was 224 cells/μl. Over the first 12 weeks of ART, there were significant decreases in serum levels of LBP (median change -8.7 μg/ml, p = 0.01), TNF-α receptor 1 (-0.31 ng/ml, p < 0.01), and CRP (-3.5 mg/l, p = 0.02). The change in soluble CD14 level over 12 weeks was positively associated with the change in CRP (p < 0.01) and soluble CD163 (p < 0.01). Pooling data at baseline and 12 weeks, serum LBP was positively associated with CRP (p = 0.01), while endotoxin core IgM was inversely associated with CRP (p = 0.01) and TNF-α receptor 1 (p = 0.04). The Lac/Cr ratio was not associated with any serum biomarkers.CONCLUSIONS: In undernourished HIV-infected adults in Zambia, biomarkers of increased microbial translocation are associated with high levels of systemic inflammation before and after initiation of ART, suggesting that impaired gut immune defenses contribute to innate immune activation in this population.


Andrews J.C.,Vanderbilt University | Andrews J.C.,Vanderbilt Institute for Global Health
Obstetrical and Gynecological Survey | Year: 2011

Introduction: State of the art guidance exists for management of vulvodynia, but the scientific basis for interventions has not been well described. Although there are many interventional therapies, and their use is increasing, there is also uncertainty or controversy about their efficacy. Objective: To systematically assess benefits and harms of interventional therapies for vulvodynia and vestibulodynia. Methods: The following databases were searched, using MeSH terms for studies related to the treatment of vulvodynia or vulva pain/pruritus/dysesthesia/hyperesthesia/hypersensitivity: MEDLINE, PsycINFO, Scopus, Cochrane Library, EBSCO Academic, and Google Scholar. Using Medical Subject Reference sections of relevant original articles, reviews, and evidence-based guidelines were screened manually. Manual searching for indirect evidence supporting interventions was done whenever no direct evidence was found for a treatment described within a review or guideline. Each modality is assessed with a grading system similar to the Grades of Recommendation, Assessment, Development, and Evaluation system. The grading system assesses study quality, effect size, benefits, risks, burdens, and costs. Results: For improvement of pain and/or function in women with vestibulodynia (provoked localized vulvodynia), there was fair evidence that vestibulectomy was of benefit, but the size of the effect cannot be determined with confidence. There was good evidence of a placebo effect from multiple studies of nonsurgical interventions. There was fair evidence of lack of efficacy for several nonsurgical interventions. There were several interventions for which there were insufficient evidence to reliably evaluate. There was insufficient evidence to judge harms or to judge long-term benefits.For clinically meaningful improvement of pain in women with generalized unprovoked vulvodynia, there was insufficient evidence for benefit of any intervention. There was fair evidence of a placebo effect in people with neuropathic pain and functional pain syndromes, from multiple studies of interventions. Based on indirect evidences from studies of patients with other pain disorders, interventions may be selected for future research. Conclusion: There is fair evidence for effectiveness of vestibulectomy for vestibulodynia; however, there is uncertainty about the size of the absolute effect, because of the risk of bias inherent in studies of pain interventions without a placebo control group. Providers and patients looking for evidence-based interventions for generalized unprovoked vulvodynia may need to rely on indirect evidences from studies of neuropathic pain and functional pain syndromes. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this educational activity, the obstetrician/gynecologist should be better able to identify potential causes of vulvar pain to facilitate diagnosis of vulvodynia and vestibulodynia, distinguish between the symptoms of localized, provoked vulvodynia and generalized unprovoked vulvodynia to select the most appropriate therapies, evaluate the efficacy of surgical and nonsurgical interventions for the treatment of generalized unprovoked and localized, provoked vulvodynia. In addition, assess the benefits and risks of interventional therapies for vulvodynia and vestibulodynia to improve patient care. © 2011 by Lippincott Williams & Wilkins.


Pitts R.J.,Vanderbilt University | Pitts R.J.,Vanderbilt Institute for Global Health | Derryberry S.L.,Vanderbilt University | Pulous F.E.,Vanderbilt University | And 2 more authors.
PLoS ONE | Year: 2014

The principal Afrotropical malaria vector mosquito, Anopheles gambiae remains a significant threat to human health. In this anthropophagic species, females detect and respond to a range of human-derived volatile kairomones such as ammonia, lactic acid, and other carboxylic acids in their quest for blood meals. While the molecular underpinnings of mosquito olfaction and host seeking are becoming better understood, many questions remain unanswered. In this study, we have identified and characterized two candidate ammonium transporter genes, AgAmt and AgRh50 that are expressed in the mosquito antenna and may contribute to physiological and behavioral responses to ammonia, which is an important host kairomone for vector mosquitoes. AgAmt transcripts are highly enhanced in female antennae while a splice variant of AgRh50 appears to be antennal-specific. Functional expression of AgAmt in Xenopus laevis oocytes facilitates inward currents in response to both ammonium and methylammonium, while AgRh50 is able to partially complement a yeast ammonium transporter mutant strain, validating their conserved roles as ammonium transporters. We present evidence to suggest that both AgAmt and AgRh50 are in vivo ammonium transporters that are important for ammonia sensitivity in An. gambiae antennae, either by clearing ammonia from the sensillar lymph or by facilitating sensory neuron responses to environmental exposure. Accordingly, AgAmt and AgRh50 represent new and potentially important targets for the development of novel vector control strategies. © 2014 Pitts et al.


Davis T.O.M.,Vanderbilt University | Fischer E.,Vanderbilt University | Rohloff P.,Brigham and Women's Hospital | Heimburger D.,Vanderbilt Institute for Global Health
Human Organization | Year: 2014

Ready To Use Therapeutic Food (RUTF) and Ready To Use Supplementary Food (RUSF) have proliferated in recent years to treat acute and chronic malnutrition. Bio Medical research has established the efficacy of these products, yet little is known about their actual effectiveness in real world settings. This article reports on an ethnographic study of the acceptance and use of RUSF within households in a rural Maya co Mmunity in Guatemala (a country with the world's third highest rate of chronic malnutrition). We find a number of surprising obstacles to RUSF effectiveness. There is a strong co Mmitment to breastfeeding (supported by public health messages of local NGOs as well as culturally perceived benefits) that leads to sub-optimal co Mplementary feeding after six months. We also found instances of off-label sharing and confusion over relative nutritional values. We present a framework for maximizing RUSF effectiveness that involves nutritional education, positive peer support, and the framing of the product as a medicine.

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