The Government of Botswana, the University of Botswana and the University of Pennsylvania formed the Botswana-UPenn Partnership to build capacity in Botswana in response to the HIV/AIDS epidemic. UPenn is taking a broad interdisciplinary approach to train health care personnel throughout Botswana in prevention and treatment of HIV/AIDS and its complications, to develop outstanding post-graduate training programs at the University of Botswana with an emphasis on Internal Medicine and its subspecialties, to offer experience in global health to Penn trainees, and to develop joint research programs that address issues relevant to the health and welfare of the citizens of Botswana.
PublicationUse of Mobile Telemedicine for Cervical Cancer Screening(2011-06-01) Quinley, Kelly E; Gormley, Rachel H; Ratcliffe, Sarah; Shih, Ting; Szep, Zsofia; Steiner, Ann; Ramogola-Masire, Doreen; Kovarik, CarrieVisual inspection of the cervix with application of 4% acetic acid (VIA) is an inexpensive alternative to cytology-based screening in areas where resources are limited, such as in many developing countries. We have examined the diagnostic agreement between off-site (remote) expert diagnosis using photographs of the cervix (photographic inspection with acetic acid, PIA) and in-person VIA. The images for remote evaluation were taken with a mobile phone and transmitted by MMS. The study population consisted of 95 HIV-positive women in Gaborone, Botswana. An expert gynaecologist made a definitive positive or negative reading on the PIA results of 64 out of the 95 women whose PIA images were also read by the nurse midwives. The remaining 31 PIA images were deemed insufficient in quality for a reading by the expert gynaecologist. The positive nurse PIA readings were concordant with the positive expert PIA readings in 82% of cases, and the negative PIA readings between the two groups were fully concordant in 89% of cases. These results suggest that mobile telemedicine may be useful to improve access of women in remote areas to cervical cancer screening utilizing the VIA `see-andtreat' method. PublicationEpidemiology of Methicillin‐Resistant Staphylococcus aureus Bacteremia in Gaborone, Botswana(2009-08-01) Wood, Sarah; Shah, Samir S; Bafana, Maragaret; Ratner, Adam J; Meaney, Peter A; Malefho, Kolaatamo C.S; Steenhoff, Andrew PThis cross‐sectional study at a tertiary‐care hospital in Botswana from 2000 to 2007 was performed to determine the epidemiologic characteristics of Staphylococcus aureus bacteremia. We identified a high prevalence (11.2% of bacteremia cases) of methicillin‐resistant S. aureus (MRSA) bacteremia. MRSA isolates had higher proportions of resistance to commonly used antimicrobials than did methicillin‐susceptible isolates, emphasizing the need to revise empiric prescribing practices in Botswana. PublicationDiabetes Mellitus in HIV-Infected Patients Receiving Antiretroviral Therapy(2013-10-11) Moyo, D; Tanthuma, G; Mushisha, O; Kwadiba, G; Chikuse, F; Cary, Mark S; Steenhoff, Andrew P; Reid, Michael J. ABackground. There is little in the literature on HIV and diabetes mellitus (DM) in sub-Saharan Africa. Objective. To assess the characteristics of HIV and DM in patients receiving antiretroviral therapy (ART) in Botswana. Methods. A retrospective case-control study was conducted at 4 sites. Each HIV-infected patient with DM (n=48) was matched with 2 HIV-infected controls (n=108) by age (±2 years) and sex. Primary analysis was conditional logistic regression to estimate univariate odds and 95% confidence intervals (CIs) for each characteristic. Results. There was no significant association between co-morbid diseases, tuberculosis, hypertension or cancer and risk of diabetes. DM patients were more likely to have higher pre-ART weight (odds ratio (OR) 1.09; 95% CI 1.04 - 1.14). HIV-infected adults >70 kg were significantly more likely to have DM (OR 12.30; 95% CI 1.40 - 107.98). Participants receiving efavirenz (OR 4.58; 95% CI 1.44 - 14.57) or protease inhibitor therapy (OR 20.7; 95% CI 1.79 - 240.02) were more likely to have DM. Neither mean pre-ART CD4 cell count (OR 1.0; 95% CI 0.99 - 1.01) nor pre-ART viral load >100 000 copies/ml (OR 0.71; 95% CI 0.21 - 2.43) were associated with a significant risk of diabetes. Conclusions. These findings suggest a complex interrelation among traditional host factors and treatment-related metabolic changes in the pathogenesis of DM inpatients receiving ART. Notably, pre-ART weight, particularly if >70 kg, is associated with the diagnosis of diabetes in HIV-infected patients in Botswana. PublicationOutcomes in HIV-Infected Adults With Tuberculosis at Clinics With and Without Co-Located HIV Clinics in Botswana(2013-10-01) Schwartz, Adam B; Tamuhla, Neo; Steenhoff, Andrew P; Nkakana, Kelebogile; Letlhogile, Rona; Chadborn, Tim R; Kestler, Mary; Zetola, Nicola M; Ravimohan, Shruthi; Bisson, Gregory PSETTING Gaborone, Botswana. OBJECTIVE To determine if starting anti-tuberculosis treatment at clinics in Gaborone without co-located human immunodeficiency virus (HIV) clinics would delay time to highly active antiretroviral therapy (HAART) initiation and be associated with lower survival compared to starting anti-tuberculosis treatment at clinics with on-site HIV clinics. DESIGN Retrospective cohort study. Subjects were HAART-naïve, aged ≥21 years with pulmonary tuberculosis (TB), HIV and CD4 counts ≤250 cells/mm3 initiating anti-tuberculosis treatment between 2005 and 2010. Survival at completion of anti-tuberculosis treatment or at 6 months post-treatment initiation and time to HAART after anti-tuberculosis treatment initiation were compared by clinic type. RESULTS Respectively 259 and 80 patients from clinics without and with on-site HIV facilities qualified for the study. Age, sex, CD4, baseline sputum smears and loss to follow-up rate were similar by clinic type. Mortality did not differ between clinics without or with on-site HIV clinics (20/250, 8.0% vs. 8/79, 10.1%, relative risk 0.79, 95%CI 0.36–1.72), nor did median time to HAART initiation (respectively 63 and 66 days, P = 0.53). CONCLUSION In urban areas where TB and HIV programs are separate, geographic co-location alone without further integration may not reduce mortality or time to HAART initiation among co-infected patients. PublicationEarly Mortality and AIDS Progression Despite High Initial Antiretroviral Therapy Adherence and Virologic Suppression in Botswana(2011-06-15) Steele, Katherine; Steenhoff, Andrew P; Newcomb, Craige W; Rantleru, Tumelo; Nthobatsang, Rudo; Lesetedi, Gloria; Bellamy, Scarlett L; Nachega, Jean B; Gross, Robert; Bisson, Gregory PBackground Adverse outcomes occurring early after antiretroviral therapy (ART) initiation are common in sub-Saharan Africa, despite reports of high levels of ART adherence in this setting. We sought to determine the relationship between very early ART adherence and early adverse outcomes in HIV-infected adults in Botswana. Methods This prospective cohort study of 402 ART-naïve, HIV-infected adults initiating ART at a public HIV clinic in Gaborone, Botswana evaluated the relationship between suboptimal early ART adherence and HIV treatment outcomes in the initial months after ART initiation. Early adherence during the interval between initial ART dispensation and first ART refill was calculated using pill counts. In the primary analysis patients not returning to refill and those with adherence <0.95 were considered to have suboptimal early adherence. The primary outcome was death or loss to follow-up during the first 6 months of ART; a secondary composite outcome included the primary outcome plus incident opportunistic illness (OIs) and virologic failure. We also calculated the percent of early adverse outcomes theoretically attributable to suboptimal early adherence using the population attributable risk percent (PAR%). Results Suboptimal early adherence was independently associated with loss to follow-up and death (adjusted OR 2.3, 95% CI 1.1–4.8) and with the secondary composite outcome including incident OIs and virologic failure (adjusted OR 2.6, 95% CI 1.4–4.7). However, of those with early adverse outcomes, less than one-third had suboptimal adherence and approximately two-thirds achieved virologic suppression. The PAR% relating suboptimal early adherence and primary and secondary outcomes were 14.7% and 17.7%, respectively. Conclusions Suboptimal early adherence was associated with poor outcomes, but most early adverse outcomes occurred in patients with optimal early adherence. Clinical care and research efforts should focus on understanding early adverse outcomes that occur despite optimal adherence. PublicationBartonella Infection in Immunocompromised Hosts: Immunology of Vascular Infection and Vasoproliferation(2012-01-01) Mosepele, Mosepele; Mazo, Dana; Cohn, JenniferMost infections by genus Bartonella in immunocompromised patients are caused by B. henselae and B. quintana. Unlike immunocompetent hosts who usually develop milder diseases such as cat scratch disease and trench fever, immunocompromised patients, including those living with HIV/AIDS and posttransplant patients, are more likely to develop different and severe life-threatening disease. This paper will discuss Bartonella's manifestations in immunosuppressed patients and will examine Bartonella's interaction with the immune system including its mechanisms of establishing infection and immune escape. Gaps in current understanding of the immunology of Bartonella infection in immunocompromised hosts will be highlighted. PublicationCT Before Lumbar Puncture in Suspected Meningitis in Botswana: How Established Guidelines May Not Apply / Tomodensitométrie Avant Ponction Lombaire en Cas de Suspicion de Méningite au Botswana: Comment les Directives Classiques Peuvent ne Pas s’Appliquer(2013-09-27) Kestler, Andrew; Caruso, Ngaire; Chandra, Amit; Goldfarb, David; Haas, MichelleEnglish Introduction According to established guidelines from high-income countries, computed tomography of the head (CT) is indicated before lumbar puncture (LP) in the evaluation of suspected meningitis in HIV patients. In Botswana, meningitis in HIV-infected patients is common but CT is not widely available. Objective Develop a rational, evidence-based approach to CT use in the emergency evaluation of suspected meningitis in a population with high HIV prevalence. Methods Emergency center (EC) staff at Princess Marina Hospital in Gaborone, Botswana, reviewed indications for CT and LP in suspected meningitis. The authors considered existing evidence for CT before LP (mostly from high-income countries) and considered the epidemiology of central nervous system infections in Southern Africa. Draft guidelines were circulated to emergency center doctors and nurses, and to specialists in other hospital departments for review and comment before finalization. Result Available literature seems to indicate that in Botswana it would be possible to significantly limit the use of head CT before LP in HIV positive patients without increasing the incidence or risk of herniation. The guideline includes scenarios where an LP might be indicated in the presence of focal neurological findings and in the absence of a CT, in contradiction to established guidelines. Discussion The applicability of established guidelines for CT use in suspected meningitis is dependent on local epidemiology and resources. French Introduction Selon les directives classiques provenant des pays à revenu élevé, la tomodensitométrie (TDM) de la tête est indiquée avant une ponction lombaire (PL) pour l’évaluation d’une possible méningite chez les patients infectés par le VIH. Au Botswana, la méningite chez les patients infectés par le VIH est courante mais la TDM n’est pas souvent disponible. Objectif Développer une approche rationnelle fondée sur des preuves relative à l’utilisation de la TDM en cas d’évaluation d’urgence d’une possible méningite au sein d’une population à forte prévalence du VIH. Méthodes Le personnel du Centre d’Urgences (CU) de l’hôpital Princess Marina à Gaborone, Botswana, a examiné des prescriptions de TDM et de PL en cas de suspicion de méningite. Les auteurs se sont penchés sur les cas existants de TDM avant PL (la plupart provenant de pays à revenus élevés) et ont examiné l’épidémiologie des infections du système nerveux central en Afrique australe. Des directives provisoires ont été distribuées à des médecins et des infirmières de centres d’urgences et à des spécialistes dans d’autres services hospitaliers pour examen et commentaires avant finalisation. Résultat Les publications disponibles semblent indiquer qu’au Botswana, il serait possible de limiter fortement l’utilisation de la TDM de la tête avant une PL chez les patients séropositifs sans augmenter l’incidence ou le risque d’engagement cérébral. La directive comprend des scénarios dans lesquels une PL pourrait être indiquée en présence de signes neurologiques focaux et en l’absence d’une TDM, contrairement à ce que préconisent les directives classiques. Discussion L’applicabilité des directives classiques relatives à l’utilisation de la TDM dans des cas de suspicion de méningite dépend de l’épidémiologie et des ressources locales. PublicationIsoniazid Resistance and Death in Patients With Tuberculous Meningitis: Retrospective Cohort Study(2010-07-12) Vinnard, Christopher; Winston, Carla A; Wileyto, E. Paul; MacGregor, Rob Roy; Bisson, Gregory PObjective To determine whether initial isoniazid resistance is associated with death during the treatment of tuberculous meningitis. Design Retrospective cohort study. Setting National Tuberculosis Surveillance System at the Centers for Disease Control in the United States. Participants Patients with a clinical diagnosis of tuberculous meningitis, reported to the National Tuberculosis Surveillance System between 1 January 1993 and 31 December 2005. Main outcome measure All cause mortality during antituberculous treatment. Results Between 1993 and 2005, 1896 patients had a clinical diagnosis of tuberculous meningitis and positive cultures from any site. In 123 (6%) of these patients, isoniazid resistance was present on initial susceptibility testing. The unadjusted association between initial isoniazid resistance and subsequent death among these 1896 patients did not reach statistical significance (odds ratio 1.38, 95% confidence interval 0.94 to 2.02). However, among 1614 patients with positive cerebrospinal fluid cultures, a significant unadjusted association was found between initial isoniazid resistance and subsequent death (odds ratio 1.61, 1.08 to 2.40). This association increased after adjustment for age, race, sex, and HIV status (odds ratio 2.07, 1.30 to 3.29). Conclusions Isoniazid resistance on initial susceptibility testing was associated with subsequent death among cases of tuberculous meningitis with positive cerebrospinal fluid cultures. Randomised controlled trials are needed to evaluate the optimal empirical regimen for treating patients with tuberculous meningitis who are at high risk for both initial isoniazid resistance and poor clinical outcomes. PublicationPrevalence of Hypothyroidism Among MDR-TB Patients in Botswana(2012-11-01) Modongo, Chawangwa; Zetola, Nicola M PublicationPain and Physical and Psychological Symptoms in Ambulatory HIV Patients in the Current Treatment Era(2012-03-01) Merlin, Jessica S; Cen, Liyi; Praestgaard, Amy; Turner, Michelle; Obando, Aura; Alpert, Craig; Woolston, Sophie; Casarett, David; Kostman, Jay R; Gross, Robert; Frank, IanContext HIV infection has become a manageable chronic disease. There are few studies of pain and symptoms in the current treatment era. Objectives The primary objective was to determine the prevalence of and risk factors for pain and physical and psychological symptoms in a population of ambulatory HIV patients. Methods We performed a cross-sectional study using the Brief Pain Inventory and the Memorial Symptom Assessment Scale. Results We evaluated 156 individuals with a median age of 47.5 years (range 21–71), median time since HIV diagnosis of 11 years (range 3(interquartile range [IQR] 308–683). The majority (125, 80.6%) had an undetectable viral load. Seventy-six (48.7%) reported pain, of whom 39 (51.3%) had moderate to severe pain, and 43 (57.3%) had pain that caused moderate to severe interference with their lives. The median number of symptoms was eight (IQR 5–14.5) of 32 queried. In multivariable analyses, patients with psychiatric illness were 39.8% more likely to have pain (P Conclusion Pain and other physical and psychological symptoms were common among ambulatory HIV patients. Pain and symptoms were strongly associated with psychiatric illness and IV drug use. Future investigation should evaluate interventions that include psychiatric and substance abuse components for HIV patients with pain.