HIV, Pathogens, Clean Water
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Transcript of HIV, Pathogens, Clean Water
HIV, Pathogens, Clean Water
Charles van der Horst, MDProfessor of Medicine
University of North CarolinaVisiting Professor
Witwatersrand University
UNC: 20 years in
Lilongwe, Malawi
• 13 million people• GNI $181, the lowest in Africa• Health Care Expenditure $58
per person• Life expectancy: 39 years• 2 physicians/100,000 people
UNC Project25,000 Sq FtHigh speed satellite internetCell storage facility300 employees
2009 USAID Report Malawi
In Malawi (2004 DHS):47.8% children stunted (height for age)22% Underweight (weight for age)5.2% Wasted (weight for height)
Groome et al Vaccine 2012
39,879 children enrolled 6 wksFollowed for 5 years9,108 hospitalizations/6,328
HIV + vs HIV – Odds Ratio (95% CI)
Acute Gastrointestinestinal Infection (AGI) 5.4 (4.9, 6.0)AGI Prolonged Hospitalization 1.8 (1.4, 2.4)AGI Multiple hospitalizations 5.0 (2.9, 5.8)AGI Case fatality 4.0 (2.0, 7.8)
Proportion of infants hospitalized due to diarrhea
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Age in months
Prop
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K-M curve probability of first diarrhea among HIV-uninfected infants. Rainy season= November-March
Weaning: The BAN Study
Weaning is bad!So is the rainy season!
BAN Pediatric Morbidity and Mortality AnalysisRainy season, low maternal Hgb, low infant WBC associates with increased risk of diarrhea/GF.
Infant cotrimoxizole associated with decreased diarrhea/GF
Huge Differential of HIV Associated Diarrhea
• Few comprehensive studies in subSaharan Africa• Beware saprophyte/colonizer vs pathogen• Protozoa (Cryptosporidium, Microsporidia,
Cyclopspora, Isospora belli, Giardia, Entamoeba, Blastocystis, Dientamoeba
• Viruses (Rotavirus-Vaccine preventable!, CMV)• Bacteria (E Coli, Vibrio Cholera-vaccine, Salmonella,
Shigella, Campylobacter, Mycobacterium avium, C difficile)
Increased disease burden with lower CD4 counts
Cryptosporidia• Water-borne• Highly infectious• Refractory diarrhea• Multiple GI tract surfaces• Destroys enterocyte• Malabsorption• Found in water in hospitals
(Martins, C. A. P., 1995) and home (Aragon, T. J. 2003)
• Dx with single stool Acid fast stain• No studies on prevention and few
treatments work well (Abubakar, I. et al., 2007) (? Nitazoxanide (CIII).
Microsporidiosis
• 3 Stools stained with chromotrope or chemofluorescent stain (Calcifluor white)
• A few strains respond to albendazole
Cyclospora cayetanensis• Coccidian parasite related to
Eimeria sp• Ingestion of contaminated fruits
and vegetables• Infects enterocytes in proximal
small intestine– Chronic, non-bloody diarrhea
and weight loss• May be confused with
cryptosporidia, though spores are larger 8-10 µm)
• Dx with modified acid fast stain• Responds to sulfonamides
(TMP-SMX 160-800 for 7-10 days)
Isospora belli· Found in travelers and
residents from endemic areas
· Watery diarrhea · Eosinophilia· Malabsorption· Dx with modified acid fast · Treatment/ prophylaxis with
sulfonamides
Giardiasis• Diagnosis
– Stool O&Px3, 85% positive in acute cases, lower in chronic cases
– Fecal stool antigen• Treatment
– Metronidazole: 250 mg tid for 5-7 days
– Paromomycin in pregnancy?
– Treatment of asymptomatic carriers not recommended
MAC• Evidence that MAC spread through hospital water to
patients (Hillebrand-Haverkort, M. E. et al., 1999). – Increased risk of “induced disseminated
mycobacteremia rather than bacteria restricted to the lungs,” in PLHIV with MAC
– MAC is ubiquitous in soil and water and highly resistant to chlorine (Biet, F. et al., 2005)
P&G Packet Study: IntroductionXue J, Mhango Z, Hoffman IF, Mofolo I, Kamanga E, Campbell J, Allgood G,
Cohen MS, Martinson FE, Miller WC, Hosseinipour MC.Trop Med Int Health. 2010 Oct;15(10):1156-62
• Offer clean water to patients infected with HIV to reduce diarrheal illnesses
• UNC idea: the triple whammy– Provide packets to mothers with HIV to reduce
diarrheal illnesses– Treatment of the mother might reduce diarrheal
illnesses in the infants– The program, which requires multiple visits, will
allow better care for the infant
P& G Packet Study: Methods• 2 District health centers in Lilongwe where PMTCT
programs were ongoing (area 18 and area 25) • Monthly visits for HIV infected mother and exposed
or infected infant from 6 months to 18 months post-partum
• Prospective, observational design over 3 month F/U• Monthly self report about product use and diarrhea• Retention, diarrhea compared to historic values
Monthly service provided• Hygiene, nutrition, breastfeeding and
family planning counseling • 4kg of vitamin fortified porridge (VitaMeal, from Feed the Children)• P&G Packets with filter cloth• Water storage container with lid and spout
(once)• Bar soap • ART and primary care clinic referrals
Baseline Results (October 2008-March 2009)
• 474 mother infant pairs enrolled• Median age of infants: 11.7 months (2.4-24
months)• 34 (7.2%) infants were HIV infected• 16 (47.1%) infants on ART (universal for <12
mo)• 195 (41.1%) mothers on ART (CD4 <350)• 386 (81.4%) community tap water
Retention and Follow-up (initial, and 3 monthly visits) n=474
• 301(63.5%) completed 3 or more visits • 357 (75.3%) remained in F/U at 3 months • At the 3 month visit: • Only 48 (13.5%) of the infants had an unknown
HIV status• 355 women (99.4%) reported using the water and
hygiene products at home• 332 infants (93.0%) were on replacement feeding
Diarrhea Reported in last month of F/Un=357
# Diarrhea % Diarrhea 95% CI
Mothers 3 0.8% 0.2-2.4%
Infants 17 4.8% 2.8-7.5%
Reported Infant Diarrhea at 3 month F/UCompared to Malawi DHS 2004
Age (mo) Post natal program % Diarrhea /4 wks N=357
Malawi DHSDiarrhea/2 weeksN= 9777
<6 0 (n=1) 9.2 (n=1109)
6-11 7.6 (n=119) 41.2 (n=1188)
12-23 3.5 (n=231) 38.9 (n=2194)
>24 0 (n=6) 8.3-21.5 (n=5286)
Limitations • Diarrhea/ product use data is all self report • Used historic data as our comparison group• No data from those infants and mothers LTFU
3.8 million people130 antenatal clinics153,000 pregnancies
Safeguard the Family: A New Challenge
Introduce Comprehensive Care• Insecticide treated mosquito nets• Vaccinate all babies AND siblings• Routine HIV testing to entire family• Depoprovera and IUDs• Active TB screening • Clean water (P&G Packets)• Linkage to HIV Care• Electronic Medical Record
FPHIV TBMCH
WASH
Funding Provided by • National Institutes of Health
– ACTG, CFAR, ICORTA-TB/AIDS, Fogarty Global Health Fellows
• Centers for Disease Control and Prevention (The BAN Study)
• USAID (Safeguard the Family)