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HIV, Pathogens, Clean Water

HIV, Pathogens, Clean Water. Charles van der Horst, MD Professor of Medicine University of North Carolina Visiting Professor Witwatersrand University. UNC: 20 years in Lilongwe, Malawi. 13 million people GNI $181, the lowest in Africa Health Care Expenditure $58 per person

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HIV, Pathogens, Clean Water

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  1. HIV, Pathogens, Clean Water Charles van der Horst, MD Professor of Medicine University of North Carolina Visiting Professor Witwatersrand University

  2. 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

  3. UNC Project 25,000 Sq Ft High speed satellite internet Cell storage facility 300 employees

  4. 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)

  5. 39,879 children enrolled 6 wks Followed for 5 years 9,108 hospitalizations/6,328 Groome et al Vaccine 2012

  6. 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!

  7. BAN Pediatric Morbidity and Mortality Analysis Rainy season, low maternal Hgb, low infant WBC associates with increased risk of diarrhea/GF. Infant cotrimoxizole associated with decreased diarrhea/GF

  8. 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)

  9. Increased disease burden with lower CD4 counts

  10. 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).

  11. Microsporidiosis • 3 Stools stained with chromotrope or chemofluorescent stain (Calcifluor white) • A few strains respond to albendazole

  12. Cyclospora cayetanensis Coccidian parasite related to Eimeriasp 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)

  13. Isosporabelli • Found in travelers and residents from endemic areas • Watery diarrhea • Eosinophilia • Malabsorption • Dx with modified acid fast • Treatment/ prophylaxis with sulfonamides

  14. 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

  15. 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)

  16. 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

  17. 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

  18. 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

  19. 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

  20. 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

  21. Diarrhea Reported in last month of F/Un=357

  22. Reported Infant Diarrhea at 3 month F/UCompared to Malawi DHS 2004

  23. Limitations Diarrhea/ product use data is all self report Used historic data as our comparison group No data from those infants and mothers LTFU

  24. Safeguard the Family: A New Challenge 3.8 million people 130 antenatal clinics 153,000 pregnancies

  25. FP HIV 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 WASH TB MCH

  26. 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)

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