Browsing by Author "Sande, Merle A."

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    Measuring the Outcomes of a Comprehensive HIV Care Course
    (JAIDS Journal of Acquired Immune Deficiency Syndromes, 2006) Weaver, Marcia R.; Nakitto, Cecilia; Schneider, Gisela; Kamya, Moses R.; Kambugu, Andrew; Lukwago, Robinah; Ronald, Allan; McAdam, Keith; Sande, Merle A.
    To evaluate the effects of the Infectious Diseases Institute's 4-week course for African doctors on comprehensive management of HIV including antiretroviral therapy on four outcomes: (1) clinical skills, (2) clinical activities, (3) monitoring of HIV patients, and (4) training activities Clinical exam at beginning and end of course and at follow-up 3 to 4 months later, and a cross-section telephone survey. Forty-seven doctors attending the course (October 2004, November 2004, March 2005, and April 2005) agreed to participate. A 17-item Clinical Exam Checklist was used to assess clinical skills. A telephone survey was conducted 1 month after the course to collect data in four areas: clinical activities, monitoring of HIV patients, case studies on initiation of ART, and training activities. The course improved the clinical skills of doctors. Between the beginning and end of the course, their clinical skills improved significantly in 11 of 17 areas (n = 34). Between the end of the course and follow-up, their skills improved significantly in three areas (n = 14). The trainees were practicing HIV care and training. The telephone survey (n = 46) showed that 93% of trainees treated HIV patients, 35% provided training on HIV, and 47% monitored the weight of the last HIV patient treated (patient's weight was a clinical end point to measure health status). At follow-up, everyone provided training and trained an average of 20 people per month.
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    Outcomes of Cryptococcal Meningitis in Uganda Before and After the Availability of Highly Active Antiretroviral Therapy
    (Clinical infectious diseases, 2008) Kambugu, Andrew; Meya, David B.; Rhein, Joshua; Kamya, Moses R.; Mayanja-Kizza, Harriet; Sande, Merle A.; Bohjanen, Paul R.; Boulwar, David R.
    Cryptococcal meningitis (CM) is the proximate cause of death in 20%–30% of persons with acquired immunodeficiency syndrome in Africa. Two prospective, observational cohorts enrolled human immunodeficiency virus (HIV)—infected, antiretroviral-naive persons with CM in Kampala, Uganda. The first cohort was enrolled in 2001–2002 (n=92), prior to the availability of highly active antiretroviral therapy (HAART), and the second was enrolled in 2006–2007 (n=44), when HAART was available.Ugandans presented with prolonged CM symptoms (median duration, 14 days; interquartile range, 7–21 days). The 14-day survival rates were 49% in 2001–2002 and 80% in 2006 (P<.001). HAART was started 35±13 days after CM diagnosis and does not explain the improved 14-day survival rate in 2006. In 2006–2007, the survival rate continued to decrease after hospitalization, with only 55% surviving to initiate HAART as an outpatient. Probable cryptococcal-related immune reconstitution inflammatory syndrome occurred in 42% of patients, with 4 deaths. At 6 months after CM diagnosis, 18 persons (41%) were alive and receiving HAART in 2007. The median cerebral spinal fluid (CSF) opening pressure was 330 mm H2O; 81% of patients had elevated pressure (>200 mm H2O). Only 5 patients consented to therapeutic lumbar puncture. There was a trend for higher mortality for pressures >250 mm H2O (odds ratio [OR], 2.1; 95% confidence interval [CI], 0.9–5.2; P=.09). Initial CSF WBC counts of <5 cells/mL were associated with failure of CSF sterilization (OR, 17.3; 95% CI, 3.1–94.3; P<.001), and protein levels <35 mg/dL were associated with higher mortality (OR, 2.0; 95% CI, 1.2–3.3; P=.007).Significant CM-associated mortality persists, despite the administration of amphotericin B and HIV therapy, because of the high mortality rate before receipt of HAART and because of immune reconstitution inflammatory syndrome—related complications after HAART initiation. Approaches to increase acceptance of therapeutic lumbar punctures are needed.