Improving management of HIV-infected patients in Africa

The Human Immunodeficiency Virus (HIV) pandemic remains a public health issue of immense dimensions. Tuberculosis (TB) remains the most important opportunistic infection and the number one killer among HIV-infected individuals. In this thesis, we demonstrate that challenges remain, despite adequate treatment being available for both infectious diseases.
In the first part of this thesis we describe programmatic challenges in HIV and TB management in the Central African country Gabon. Factors associated to (high rates of) loss to follow up to HIV care are identified, and therapeutic issues such as the immune reconstitution inflammatory syndrome are described.
In the last part of this thesis we focus on HIV-TB co-infection. We discuss a novel tool in diagnosing TB in HIV-infected individuals, by using a simplified protocol of point-of-care ultrasound, remotely supervised by a specialist. As mortality in patients with severe HIV-associated TB remains unacceptably high despite adequate treatment for both infections being available, we focus on pathophysiologic mechanisms underlying this high mortality in Cape Town, South Africa. An immunologic phenotype similar to that seen in bacterial sepsis was associated with mortality in this patient group. Coagulation and endothelial activation and dysfunction were associated with mortality in severe HIV-TB. Coagulation abnormalities were apparent in severe HIV-TB, whereas in an ambulatory population coagulation abnormalities were mostly driven by HIV itself and less so by TB.
Overall, this thesis gives an extensive overview on remaining challenges in management of HIV and TB in Africa, defining several interventions for improvement of care.