HIV-1 viral load and resistance in genital secretions in patients taking protease-inhibitor-based second-line therapy in Africa.

BACKGROUND: HIV is transmitted primarily through sexual intercourse, and the objective of this study was therefore to assess whether there is occult viral replication and resistance in genital secretions in patients on protease inhibitor (PI)-based second-line therapy. METHODS: HIV-infected adults taking ritonavir-boosted lopinavir with either two nucleoside reverse transcriptase inhibitors (NRTIs), raltegravir or as monotherapy for 96 weeks, were enrolled at seven clinical sites in Uganda. Viral load (VL) was measured in cervico-vaginal secretions or semen and in a corresponding plasma sample. Genotypic resistance was assessed in genital secretion samples and plasma samples. Results were compared between compartments and with the plasma resistance profile at first-line failure. RESULTS: Of the 111 participants enrolled (91 female, 20 male), 16 (14%) and 30 (27%) had VL >1,000 and >40 copies/ml, respectively, in plasma; 3 (3%) and 23 (21%) had VL >1,000 copies/ml and >40 copies/ml, respectively, in genital secretions. There was 74% agreement between plasma and genital secretion VL classification above/below 40 copies/ml threshold (kappa-statistic =0.29; P=0.001). RT mutations (both NRTI and non-nucleoside reverse transcriptase inhibitor) were detected in genital secretions in four patients (similar profile to corresponding plasma sample at first-line failure) and PI mutations were detected in two (one polymorphism with no impact on resistance; one with high-level PI resistance). CONCLUSIONS: High level (>1,000 copies/ml) viral replication and development of new RT or PI resistance in the genital compartment were rare. The risks of transmission arising from resistance evolution in the genital compartment are likely to be low on PI-based second-line therapy.

Implementing a hospital based injury surveillance system in Africa: lessons learned.

A multinational injury surveillance pilot project was carried out in five African countries in the first half of 2007 (Democratic Republic of the Congo, Kenya, Nigeria, Uganda and Zambia). Hospitals were selected in each country and a uniform methodology was applied in all sites, including an injury surveillance questionnaire designed by a joint programme of the Pan American Health Organization and the United States Centres for Disease Control and Prevention. A total of 4207 injury cases were registered in all hospitals. More than half of all injury cases were due to road traffic accidents (58.3%) and 40% were due to interpersonal violence. Self-inflicted injuries were minimal (1.2% of all cases). This report provides an assessment of the implementation of the project and a preliminary comparison between the five African countries on the context in which inter-personal injury cases occurred. Strengths and weaknesses of the project as well as opportunities and threats identified by medical personnel are summarized and discussed. A call is made to transform this pilot project into a sustainable public health strategy.

A multinational injury surveillance system pilot project in Africa.

This paper describes the development of a pilot project to test the implementation of an epidemiological surveillance system for intentional (violent) and non-intentional injuries, at emergency departments in selected hospitals in five African countries applying the World Health Organization's guidelines. We outline obstacles and opportunities encountered during the process. By definition, a surveillance system systematically collects, reviews, and evaluates information to understand the context in which specific injuries occur. Implementation in diverse sociocultural environments in Zambia, Uganda, Democratic Republic of the Congo, Nigeria, and Kenya has provided an opportunity to gather reliable data on injuries for comparisons between these countries. Analysis of the detailed information may permit researchers to generate evidence-based recommendations. Addressed to public authorities, and health authorities in particular, they can help address injury incidence in their communities from a public health perspective.