title: CHALLENGES IN MANAGEMENT OF WARFARIN ANTI-COAGULATION IN ADVANCED HIV/AIDS PATIENTS WITH VENOUS THROMBOTIC EVENTS--A CASE SERIES FROM A RESEARCH CLINIC IN RURAL KERICHO, KENYA.
abstract: BACKGROUND
  Venous thrombotic events (VTE) occur at high ratesin HIV/AIDS patients and are likely under-diagnosed in rural sub-Saharan Africa.
  
  
  OBJECTIVE
  To describe clinical presentations and challenges in the management of VTE in patients with advanced HIV/AIDS.
  
  
  METHODS
  Case series from patients enrolled in a prospective observational cohort study.
  
  
  METHODS
  A clinical research centre in rural Kericho, Kenya.
  
  
  METHODS
  Two hundred patients with median age 38 (30-47) years, BMI 16.9 (12.4-20.3) kg/m2, haemoglobin 9.3 (6.8-13.4) g/dL, CD4+ T-cell count 27 (4-77) cells/mm and plasma HIV RNA 5.23 (3.70-5.88) log10 copies/mL.
  
  
  METHODS
  VTE cases were diagnosed by clinical presentation and Doppler/ radiographic confirmation. Anti-coagulation therapy was managed by a multidisciplinary team; patients were initiated on enoxaparin or heparin followed by warfarin.
  
  
  RESULTS
  Over two years,11patients (5.5%) experienced VTE. All but one (10/11,90.9%) case occurred within six months of starting ART. Nine patients had peripheral VTE (five popliteal, four femoral) and two had cerebral sinus thromboses. VTE was diagnosed 52 (1-469) days after ART initiation, and 81.8% of cases were outpatients at presentation. All patients received at least one concomitant medication that could significantly interact with warfarin (efavirenz, nevirapine, lopinavir/ritonavir, rifampicin, trimethoprim-sulfamethoxazole, and fluconazole). A median of 39 (10-180) days and eight (4-22) additional clinic visits were required to achieve/maintain a therapeutic INR of 2-3. Two minor bleeding complications occurred. No recurrent VTE cases were observed.
  
  
  CONCLUSIONS
  Consideration of VTE and preparedness for management in patients with advanced HIV/AIDS starting ART is critical in sub-Saharan Africa. Overcoming challenges in anti-coagulation is possible in rural settings using a multidisciplinary team approach.
authors: Kenya Medical Research Institute/Walter Reed Project, Kericho, Kenya.
authors: N K
authors: NK
authors: Tarus
authors: A K
authors: AK
authors: Pau
authors: I
authors: I
authors: Sereti
authors: F K
authors: FK
authors: Kirui
authors: F K
authors: FK
authors: Sawe
authors: B K
authors: BK
authors: Agan
authors: L M
authors: LM
authors: Momanyi
authors: H C
authors: HC
authors: Ngeno
authors: G K
authors: GK
authors: Koskei
authors: D N
authors: DN
authors: Shaffer
mesh_terms: D000328:Adult; D000925:Anticoagulants / Q000008:administration & dosage / Q000494:pharmacology; D023241:Antiretroviral Therapy, Highly Active / Q000379:methods*; D018791:CD4 Lymphocyte Count / Q000379:methods; D019468:Disease Management; D004347:Drug Interactions; D016903:Drug Monitoring; D005260:Female; D015658:HIV Infections / Q000150:complications / Q000453:epidemiology / Q000503:physiopathology; D006801:Humans; D019934:International Normalized Ratio / Q000379:methods; D007630:Kenya / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D062072:Patient Acuity; D010348:Patient Care Team; D012424:Rural Population / Q000706:statistics & numerical data; D018616:Ultrasonography, Doppler, Duplex / Q000379:methods; D020246:Venous Thrombosis / Q000175:diagnosis / Q000188:drug therapy / Q000453:epidemiology / Q000209:etiology; D014859:Warfarin / Q000008:administration & dosage / Q000493:pharmacokinetics
chemical_list: D000925:Anticoagulants; D014859:Warfarin