Faculty Bibliography

BACKGROUND: Contributors to fatal outcomes in TB/HIV co-infected patients actively undergoing TB treatment are poorly characterized. The aim was to assess factors associated with death in TB/HIV co-infected patients during the initial 6 months of TB treatment. METHODS: We conducted a hospital-based retrospective cohort study from January 2006 to December 2013 at the Yaounde Central Hospital, Cameroon. We reviewed medical records to identify hospitalized co-infected TB/HIV patients aged 15 years and older. Death was defined as any death occurring during TB treatment, as per the World Health Organization's recommendations. We conducted logistic regression analysis to identify factors associated with a fatal outcome. Magnitudes of associations were expressed by adjusted odds ratio (aOR) with 95% confidence interval. RESULTS: The 337 patients enrolled had a mean age of 39.3 (standard deviation 10.3) years and 54.3% were female. TB treatment outcomes were distributed as follows: 205 (60.8%) treatment success, 99 (29.4%) deaths, 18 (5.3%) not evaluated, 14 (4.2%) lost to follow-up, and 1 (0.3%) failed. After exclusion of patients lost to follow-up and not evaluated, death in TB/HIV co-infected patients during TB treatment was associated with a TB diagnosis made before 2010 (aOR = 2.50 [1.31-4.78]; p = 0.006), the presence of other AIDS-defining diseases (aOR = 2.73 [1.27-5.86]; p = 0.010), non-AIDS comorbidities (aOR = 3.35 [1.37-8.21]; p = 0.008), not receiving cotrimoxazole prophylaxis (aOR = 3.61 [1.71-7.63]; p = 0.001), not receiving antiretroviral therapy (aOR = 2.45 [1.18-5.08]; p = 0.016), and CD4 cells count <50 cells/mm3 (aOR = 16.43 [1.05-258.04]; p = 0.047). CONCLUSIONS: The TB treatment success rate among TB/HIV co-infected patients in our setting is low. Mortality was high among TB/HIV co-infected patients during TB treatment and is strongly associated with clinical and biological factors, highlighting the urgent need for specific interventions focused on enhancing patient outcomes.

BACKGROUND: A better understanding of why HIV-exposed/infected children fail to attend their scheduled follow-up medical appointments for HIV-related care would allow for interventions to enhance the delivery of care. The aim of this study was to determine characteristics of the caregiver-child dyad (CCD) associated with children's non-adherence to scheduled follow-up medical appointments in HIV programs in Cameroon. METHODS: We conducted a case-control analysis of the usual-care group of CCDs from the MORE CARE trial, in which the effect of mobile phone reminders for HIV-exposed/infected children in attending follow-up appointments was assessed from January to March 2013. For this study, the absence of a child at their appointment was considered a case and the presence of a child at their appointment was defined as a control. We used three multivariate binary logistic regression analyses. The best-fit model was the one which had the smallest chi-square value with the Hosmer-Lemeshow test (HLchi(2)). Magnitudes of associations were expressed by odds ratio (OR), with a p-value <0.05 considered as statistically significant. RESULTS: We included 30 cases and 31 controls. Our best-fit model which considered the sex of the adults and children separately (HL chi(2)=3.5) showed that missing scheduled medical appointments was associated with: lack of formal education of the caregiver (OR 29.1, 95% CI 1.1-777.0; p=0.044), prolonged time to the next appointment/follow-up (OR [1 week increase] 1.4, 95% CI 1.03-2.0; p=0.032), and being a female child (OR 5.2, 95% CI 1.2-23.1; p=0.032). One model (HLchi(2)=10.5) revealed that woman-boy pairs adhered less to medical appointments compared to woman-girl pairs (OR 4.9, 95% CI 1.05-22.9; p=0.044). Another model (HLchi(2)=11.1) revealed that man-boy pairs were more likely to attend appointments compared to woman-girl pairs (OR 0.23, 95% CI 0.06-0.93; p=0.039). There were no statistical associations for the ages of the children or the caregivers, the study sites, or the HIV status (confirmed vs. suspected) of the children. CONCLUSION: The profile of children who would not attend follow-up medical appointments in an HIV program was: a female, with a caregiver who has had no formal education, and with a longer follow-up appointment interval. There is a possibility that female children are favored by female caregivers and that male children are favored by male caregivers when they come to medical care.

BACKGROUND: In Cameroon, only two-thirds of children with HIV exposure or infection receive appropriate HIV-directed medical care. Mortality, antiretroviral therapy resistance and suboptimal virological response are strongly related to missed opportunities for treatment, and, more specifically, to skipped scheduled medical appointments. The present trial, MORE CARE (Mobile Reminders for Cameroonian Children Requiring HIV Care) seeks to determine if reminders sent by text message (SMS), phone call, or concomitant SMS and phone calls most increase the presence at medical appointments of HIV-infected or -exposed children (efficacy), and which is the most efficient related to working time and financial cost (efficiency). METHODS: We will carry out a multicenter single-blind, randomized, factorial controlled trial. A randomization list will be electronically generated using random block sizes. Central allocation will be determined by sequentially numbered. A total of 224 subjects will be randomized into four groups (SMS, Call, SMS + Call, and Control) with an allocation ratio of 1:1:1:1. SMS and calls will be sent between 48 and 72 hours before the scheduled appointment. A medical assistant will send out text messages and will call participants. Our primary outcome is appointment measured by efficacy and efficiency of interventions. We hypothesize that two reminders (concomitant use of SMS and phone calls) as an appointment reminder is more effective to improve appointment compared to one reminder (only SMS or only call), and that the most efficient is use of only SMS. The analysis will be intention to treat. DISCUSSION: This trial investigates the potential of SMS and phone calls as motivational reminders to improve children's adherence to medical appointments for HIV-related care in Cameroon. The intervention will act to end missed appointment due to forgetfulness.Trial registration: Pan African Clinical Trials Registry: PACTR201304000528276.

Current knowledge is insufficient to explain why only a proportion of individuals exposed to environmental carcinogens or carrying a genetic predisposition to cancer develop disease. Clearly, other factors must be important, and one such element that has recently received attention is the human microbiome, the residential microbes including Bacteria, Archaea, Eukaryotes, and viruses that colonize humans. Here, we review principles and paradigms of microbiome-related malignancy, as illustrated by three specific microbial-host interactions. We review the effects of the microbiota on local and adjacent neoplasia, present the estrobolome model of distant effects, and discuss the complex interactions with a latent virus leading to malignancy. These are separate facets of a complex biology interfacing all the microbial species we harbor from birth onward toward early reproductive success and eventual senescence