[Prevalence and factors associated with renal disease among patients with newly diagnoses of HIV in Brazzaville, Republic of Congo]. / Prévalence et facteurs associés à l'insuffisance rénale chez les patients nouvellement dépistés VIH-positifs à Brazzaville (République du Congo).

BACKGROUND: The aim of this study was to determine the prevalence of kidney disease in patients newly diagnosed as HIV-positive in Brazzaville and to identify the associated risk factors. METHODS: Descriptive and analytical study of patients diagnosed with HIV infection at the Ambulatory Treatment Center in Brazzaville, Republic of Congo, from January 1, 2009, through December 31, 2010. Estimated glomerular filtration rate (eGFR) was assessed with the Modification of Diet in Renal Disease equation (MDRD-GFR), and kidney disease was defined by an eGFR less than 60 mL/min/1.73 m(2). We conducted a univariate and then a multivariate logistic regression analysis to determine the factors associated with kidney disease in this population. RESULTS: The study included 562 patients newly identified as HIV-infected, 66.13% of whom were women. Their median age was 38.84 years interquartile range (IQR): 33.18-46.23) and their median body mass index (BMI) 20.31 kg/m(2) (IQR: 17.97-22.89). Their median CD4 count was 192 cells/mm(3) (IQR: 81-350), and 70.8% were at WHO stage III/IV. Finally, the median MDRD-GFR was 95.59 (IQR: 78.76-114.92) mL/min/1.73 m(2) and 8.5% had a GFR less than 60 mL/min/1.73 m(2), that is, moderate impairment of kidney function. The only factor associated with kidney disease in the multivariate analysis was a BMI less than 18.5 kg/m(2) (adjusted odds ratio: 2.54, 95% confidence interval: 1.25-5.15, p = 0.01). CONCLUSIONS: The prevalence of kidney disease in patients newly diagnosed with HIV in Brazzaville is relatively high. The only factor associated with it in the multivariate analysis was a BMI less than 18.5 kg/m(2).

[National coordination of the ambulatory treatment centers (ATC) in Gabon: a new process to conduct the scaling up of care for people living with HIV-AIDS]. / La coordination nationale des centres de traitement ambulatoire au Gabon : une expérience novatrice de décentralisation opérationnelle de la prise en charge du VIH-sida.

Gabonese authorities are strongly mobilized in the fight against AIDS. With a national seroprevalence of 5.9%, 54,000 people are living with HIV-AIDS. Starting from the experience conducted on three ambulatory treatment centers (ATC) [Libreville, Franceville, Port-Gentil] in collaboration with the French Red Cross, Gabonese authorities decided the scaling up of HIV patients' care to seven new ATC at a national level. The increasing number of structures conducted to standardize treatment's guidelines, training of caregivers, quality of care, coordination, monitoring and evaluation. Technical and medical supervision of the ten ATC were attributed to the French Red Cross by Gabonese authorities with the financial support of the French Agency for Development. The ten ATC, founded by the ministry of public health, were then organized within a network under the responsibility of a national coordination. This structure created in September 2007 represents the main organism to conduct, evaluate and follow-up activities and functioning of the ten ATC. All these activities are conducted in agreement with the national program of fight against AIDS. Within one year this structure of coordination allowed to organize the training of 208 caregivers, to elaborate a team of national and international experts, to start a process of national guidelines, to elaborate technical procedures and indicators for monitoring, follow-up and evaluation. In June 2007, 5 ATC were in function taking care of 7,062 PLWA. In November 2008, 9 ATC were in function taking care of 8,174 PLWA. This project is planned for four years. It might allow to structure and organize a national network of care for PLWA according to the national strategy. This procedure of scaling up under the responsibility of a national team of technical and operational coordination is a new process. It completes and strengthens the national organization process.

[Ten years of commitment to persons living with HIV-AIDS: evaluation of the management in three ambulatory treatment centers of the French Red Cross in Africa]. / Dix ans d'engagement auprès des personnes vivant avec le VIH-sida : évaluation de la prise en charge dans trois centres de traitement ambulatoire de la Croix-Rouge française en Afrique.

The French Red Cross (FRC) has developed a strategy for the follow-up of people living with HIV-AIDS in Africa by setting-up and managing healthcare centers specialized in the management of HIV infection. Nearly one hundred and seventy thousand patients have had access to care in fifteen Ambulatory Treatment Centers (ATCs). For the ten years anniversary of the FRC's AIDS programs, we present the results of the evaluation of three ATCs in Africa. These results which show a low mortality rate in the patients on antiretroviral therapy and a very low rate of second line patients (1.5%) confirm the efficiency of the management of people living with HIV in the ATCs and generally of the AIDS programs of the FRC. However, the mortality remains high in patients who have a CD4+ cell count of less than 50/mm3 when antiretrovirals (ARVs) initiation. Services and care dispensed in the ATCs and particularly the antiretroviral therapy have demonstrated their feasibility and efficiency. In ten years, the challenge of the management of HIV has changed. Today, there is a need to integrate additional actions in the area of the supply of primary healthcare, of training and of motivation of the care providers. In addition, the follow-up/evaluation of the patient management programs remains useful to determine the impact and long-term efficacy of ARVs in resource-limited countries.

Care of human immunodeficiency virus-infected children in developing countries. International Working Group on Mother-to-Child Transmission of HIV.

CONTEXT: There is urgent need to strengthen the area of pediatric HIV/AIDS care in developing countries. Clinical research in this area is also scarce. METHODOLOGY: A literature review and a postal survey were used to obtain updated information on mortality, morbidity and current standards of care of children born to HIV-infected mothers in developing countries. A 2-day workshop was organized to review the available data and to identify the key areas where clinical research should be conducted. MAIN FINDINGS: Rates of mortality and morbidity were very different from one study to another but generally higher than in industrialized countries. Prognostic studies for HIV-1-infected children in developing countries were not available. Based on the report of 14 teams from 11 countries, specific protocols for HIV-infected children with persistent diarrhea or severe malnutrition were documented in fewer than one-half of the cases. Secondary antimicrobial prophylaxis after interstitial pneumonia or recurrent infections was still infrequent, as primary prophylaxis of opportunistic infections. The following list of clinical research priorities was identified by the workshop participants: primary prophylaxis of opportunistic and bacterial infections; case management of persistent diarrhea; reassessment of the performance of p24 antigen for diagnostic and prognosis use; studies on the etiology of pulmonary infections; long term observational pediatric cohorts; current weaning practices and duration of breast-feeding; counseling and HIV testing of children and families; prevention of HIV sexual transmission in children and adolescents.

Neutralizing antibodies and complement-mediated, antibody-dependent enhancement (C'-ADE) of human immunodeficiency virus infection in its vertical transmission.

PROBLEM: Mother-to-child transmission is a major route for the spread of human immunodeficiency virus (HIV) worldwide. Our understanding of its mechanisms and parameters is still limited. Among the factors possibly involved in virus passage determination are the level and quality of antiviral humoral response. METHOD OF STUDY: Anti-HIV-1/Lai neutralizing activity in sera from 35 mother-infant pairs (in which 13 transmission cases occurred) was investigated, as was the complement-mediated antibody-dependent enhancement capacity of the same sera. RESULTS: Neutralization titers of 640 or more were found only in four mothers of uninfected children, but this result was not significant. No significant link was obtained with the occurrence of complement-mediated, antibody-dependent enhancement. CONCLUSIONS: As suggested by a synthesis of the literature, vertical transmission of HIV is probably the result of multiple active and/or stochastic parameters in the mother, the fetal structures, and the viral population. The precise definition of cellular mechanisms involved in in utero infection would help to better define which immune activity in the mother should be more carefully considered.

[Importance of measurement of plasma viral load for the therapeutic follow-up of children infected with HIV-1. Study of its evolution according to modifications of treatment in 55 children]. / Intérêt de la mesure de la charge virale plasmatique pour le suivi thérapeutique des enfants infectés par le VIH1. Etude de son évolution en fonction des modifications du traitement chez 55 enfants.

Since 1987 we started to treat all vertically HIV-1 infected newborns by an antiretroviral therapy as soon as the diagnosis was confirmed. From the study of 55 HIV-1 infected children followed at Armand Trousseau Hospital (Paris, France) we retrospectively evaluated the use of the plasma viral load as a marker of the treatment efficiency. This parameter and CD4 counts were measured the day of any modification in antiviral therapy (Day 0), 1 and 3 months later (M1 and M3) and every 3 months as long as possible. In the 3 groups of treatment modifications a decrease in plasma viral load was observed. A statistically significant increase in CD4 counts was only observed in the group treated with the association of 2 nucleoside analogues and 1 proteinase inhibitor. This group demonstrated the most important decrease in plasma viral load (> 0.7 log 10 Eq Cop/ml). This leads us to propose to the "ANRS" a protocol study for the treatment of all vertically HIV-1 infected children by the association of 3 nucleoside analogues and 1 proteinase inhibitor as early as 8 weeks post natal when the HIV infection is confirmed.

[Ophthalmologic manifestations observed in a pediatric HIV-seropositive population]. / Manifestations ophtalmologiques observées dans une population pédiatrique séropositive au VIH.

PURPOSE: HIV positive children underwent ophthalmologic examination to evaluate prospectively the incidence, and type of ocular involvement in pediatric AIDS. METHOD: Two ophthalmologists examined the children during their pediatric examination, for two years. When possible, a retinography was performed. RESULTS: Among the 33 HIV positive children, 23 children developed AIDS according to CDC classification. The incidence was lower than reported in adult series. Retinal manifestations could be divided into two groups: 1. veinous dilatation and perivasculitis; 2. retinal opportunistic infections: Ocular Toxoplasmosis was the main finding. In addition we report one case of herpetic keratitis. Annexial complications were represented by conjonctivitis and molluscum contagiosum. CONCLUSION: Manifestations of HIV infection in children appears to be different from adults. We recommend ophthalmic screening in all AIDS pediatric patients to diagnose and treat the infectious complications.

[Early diagnosis and treatment of cytomegalovirus polyradiculoneuritis in a child infected by HIV]. / Diagnostic précoce et traitement d'une polyradiculonévrite à cytomégalovirus chez un enfant infecté par le VIH.

BACKGROUND: Axonal polyradiculopathy due to cytomegalovirus (CMV) in AIDS has been reported in adults but it is not well documented in children. OBJECTIVE: We describe the elements of diagnosis and the outcome after anti-CMV therapy in a pediatric case. CASE REPORT: A 11-year-old boy with post-transfusional AIDS and low CD4 count (< 50/mm3) suffered from bilateral leg pain and weakness progressing within 15 days to paraplegia and cauda equina syndrome. Electromyography showed pure axonal neuropathy. Examination of the CSF showed increased proteins, low glucose concentration, neutrophilic pleiocytosis and positive detection of CMV by polymerase-chain reaction. The CMV viremia was positive. Treatment with ganciclovir and foscarnet allowed dramatical clinical improvement. Retinitis occurred during the maintenance therapy and was cured after reintroduction of the initial doses of ganciclovir and foscarnet. The child died five months later from a bacterial pneumopathy. CONCLUSIONS: Children with advanced AIDS may benefit from early recognition and treatment of CMV polyradiculopathy. The interactions and cumulated toxicities between anti-CMV and anti-retroviral drugs must be considered. The prognosis remains poor for CMV neuropathy due to the severe immunodepression caused by the HIV infection.

Characterization of human immunodeficiency virus type 1 p17 matrix protein motifs associated with mother-to-child transmission.

In order to determine if viral selection occurs during mother-to-child transmission of human immunodeficiency virus type 1 (HIV-1), we used a direct solid-phase sequencing method to sequence the p17 matrix protein-encoding regions of viral isolates from 12 HIV-1-infected mother-and-child pairs, 4 infected infants, 4 transmitting mothers, and 22 nontransmitting mothers and compared the sequences. The blood samples were collected during the delivery period for the mothers and during the first month of life for most of the children. The p17 nucleic sequences were distributed among several clades corresponding to the HIV-1 A, B, and G subtypes. At the amino acid level, no significant differences within the known p17 functional regions were observed among the subtypes. Statistical analyses could be performed with the B subtype. Within the major p17 antibody binding site, a constant KIEEEQN motif (amino acids 103 to 109) was found in all mother-and-child isolates from the B subtype. On the other hand, 9 of 17 nontransmitting mother isolates were variable in this 103 to 109 region. Thus, this motif was significantly associated with the transmitting status (chi square, P = 0.0034). A valine residue at position 104 was significantly associated with the nontransmitting phenotype (chi square, P = 0.014), suggesting that it has a protective role during vertical transmission. The C-terminal end of p17 was globally conserved among nontransmitting mother isolates (chi square, P = 0.0037). These results might improve the understanding of the pathogenesis of HIV-1 vertical transmission and might allow the screening of seropositive mothers by a rapid molecular or peptide test.

Separation between HIV-positive women and their children: the French prospective study, 1986 through 1993.

OBJECTIVES: We studied the risk and circumstances of separation (due to either maternal death or drug use) between women infected by human immunodeficiency virus (HIV) type 1 and their children. METHODS: This analysis was based on the French Prospective Study of Infants Born to HIV-seropositive Women (1986 through 1993). Data recorded at each follow-up visit included the mother's effective presence with the child and the child's care after separation. RESULTS: A child's cumulative risk of long-term or permanent separation from his or her mother was 37% at 60 months. Maternal drug use was associated with an added risk during the child's first years (adjusted relative risk [RR]=3.4, 95% confidence interval [CI]=2.3, 5.0). The risk among drug users was even higher when the mother used injection drugs during pregnancy (adjusted RR=2.9, 95% CI=1.9, 4.3). Risk of early separation related to drug use tended to diminish since survey initiation. After separation, 57% of the children were placed through child welfare services and 43% were cared for by relatives. CONCLUSIONS: In the French Prospective Study, 2% to 3% of HIV-infected children were separated each year from their mothers as a result of the mothers death from acquired immunodeficiency syndrome (AIDS). Separations related to drug use have decreased over the years, and the family is becoming the most frequent carer after separation.

Relationships between humoral factors in HIV-1-infected mothers and the occurrence of HIV infection in their infants.

Based on what is known about the biology of HIV-1 vertical transmission, the HIV burden of the mother, maternal immune factors and the integrity of the placental barrier are likely to play major roles. We therefore sought to determine whether the presence of antibodies in sera from 47 HIV-1-infected mothers, including 30 non-transmitting and 17 transmitting mothers, affected the risk of HIV-1 transmission to infants. Our findings showed no significant correlation between the capacity of antibodies to mediate antibody-dependent cell-mediated cytotoxicity (ADCC) and their capacity to induce protection of the child from HIV-1 infection (P = 0.14). Furthermore, no correlation was found between the capacity of maternal antibodies to neutralize in vitro lymphocyte or macrophage heterologous viral infection and the occurrence of in vivo HIV-1 infection in the infant. Sera recovered from five of 12 transmitting mothers and from five of 11 non-transmitting mothers were compared in their capacity to neutralize the viruses drawn from the same individuals. Four out of five maternal isolates from transmitting mothers and all maternal isolates from non-transmitting mothers were sensitive to enhancement of infection mediated by the maternal serum.

[Medical costs associated with the risk of maternal-fetal contamination by HIV. Results of a prospective survey]. / Coûts médicaux associés au risque de contamination maternofoetale par le VIH. Résultats d'une enquête prospective.

BACKGROUND: Assessment of economic implications of pediatric HIV infection allows to document efforts which are devoted by health care system to the care of children born to HIV infected women. This paper presents the results of the first analysis, in the French health care context, of direct medical costs related to HIV mother-to-child risk of transmission. MATERIAL AND METHODS: Statistical prospective analysis was performed on 853 files concerning 152 children followed in three medical centers. Because the medical consumptions data were linked to clinical status, average direct medical costs per medical contact could be defined for each center. RESULTS: Results were consistent with the hypothesis that more medical care is necessary when the clinical picture is uncertain (indeterminate status) or reflects health state deterioration. However, results are very different according to HIV clinical status and disparities may be so large that costs per clinical status hierarchy may be disrupted. Explicative factors for these variabilities are expressed in terms of patient recruitment, medical uncertainty management and resources disponibility.

[Hemophagocytic syndrome in children infected by HIV. Apropos of 3 cases]. / Syndrome d'activation macrophagique chez l'enfant infecté par le VIH. A propos de trois cas.

BACKGROUND: The hemophagocytic syndrome has previously been reported in different infectious diseases (EBV, CMV, tuberculosis...) but rarely in adults with AIDS and never in children suffering from AIDS. CASE REPORTS: A hemophagocytic syndrome was recognized during the follow-up of 3 children with AIDS. The first, a 9-year-old girl developed an acute EBV coinfection and was treated with shots of corticosteroids and vepesid but died shortly afterwards. The second patient, a 3-year-old girl was infected with Aspergillus fumigatus for which she was given amphotericin B with a rapid improvement. The third patient, an 8-year-old boy had multi-resistant Streptococcus pneumoniae otitis and pneumonitis; his condition improved rapidly with adapted antibiotherapy. DISCUSSION: The HIV-hemophagocytic syndrome is not exceptional in HIV infection because of the association of immunodeficiency and resulting superinfections. Its diagnosis and treatment should be etiologic. Severe cases without etiology could benefit from chemotherapy. CONCLUSION: Management and outcome of this potentially lethal syndrome might depend on the identification of a curable infectious cause.