Two-year follow-up of persons with HIV-1- and HIV-2-associated pulmonary tuberculosis treated with short-course chemotherapy in West Africa.

OBJECTIVE: To assess the response to therapy for tuberculosis using rifampicin-containing short-course chemotherapy, and to compare recurrence and mortality rates in seronegative persons and those with HIV-1, HIV-2, and dual serologic reactivity in West Africa. METHODS: A cohort of 835 adult patients (167 HIV-1-positive, 143 HIV-2-positive, 243 dual-reactive, 282 HIV-negative) with smear-positive pulmonary tuberculosis was followed for 2 years under programme conditions. Standard self-administered treatment was daily rifampicin and isoniazid for 6 months, and in addition pyrazinamide during the first 2 months. Outcomes evaluated were rates of completion of therapy, cure, failure of treatment, recurrence after cure, and mortality. RESULTS: HIV-positive patients had lower rates of completion of therapy (65-73%) than seronegative patients (79%), mainly because of increased mortality. Among patients completing therapy, failure of treatment was similarly low in HIV-positive (2%) and seronegative patients (1%). Recurrence rates after cure did not differ significantly in the 18 months of follow-up in the four serologic groups (3-7%). The respective mortality rates for HIV-1-positive, HIV-2-positive, and dually reactive patients were 20.3, 8.3, and 25.5 per 100 person-years (PY), compared with 2.2 per 100 PY among seronegatives. CONCLUSIONS: Rifampicin-containing short-course chemotherapy for pulmonary tuberculosis is associated with similar cure and recurrence rates in HIV-positive and HIV-negative persons completing 6 months of therapy. HIV-2 infection is associated with more favourable survival than HIV-1 infection or dual reactivity, even when AIDS-defining illness is already present. However, mortality is significantly increased in all seropositive groups compared with HIV-negative tuberculosis patients; thus, establishing the causes of this increased mortality is a priority.

HIV infection and primary resistance to antituberculosis drugs in Abidjan, Côte d'Ivoire.

OBJECTIVE: To determine the prevalence of Mycobacterium tuberculosis resistance to antituberculosis drugs, and to relate this resistance to HIV serologic status. DESIGN: Cross-sectional prevalence study. SETTING: The two major outpatient tuberculosis clinics in Abidjan, Côte d'Ivoire, West Africa. PATIENTS: Sixty individuals with newly diagnosed pulmonary tuberculosis and sputum smears positive for acid-fast bacilli. MAIN OUTCOME MEASURES: HIV serologic status and in vitro testing for susceptibility of M. tuberculosis isolates to antituberculosis drugs. RESULTS: M. tuberculosis was isolated from 82% (49 out of 60) of sputum specimens. Thirty-five per cent (17 out of 49) were obtained from HIV-seropositive and 65% (32 out of 49) from HIV-seronegative patients. There was no statistically significant difference in the proportion of resistant isolates from HIV-seropositive versus HIV-seronegative patients, although the relatively small sample size limited power. Of the total number of isolates, 17% were resistant to isoniazid; resistance was less to streptomycin (7%), rifampin (2%), pyrazinamide (0%), and ethambutol (0%). Eighteen and 21% of mycobacterial isolates from HIV-seropositive and HIV-seronegative individuals, respectively, were resistant to one or more of these drugs. CONCLUSIONS: Surveys of this type are useful in planning and evaluating tuberculosis preventive therapy in individuals with dual infection.

Autopsy-proven causes of death in HIV-infected patients treated for tuberculosis in Abidjan, Côte d'Ivoire.

OBJECTIVE: To determine autopsy-proven causes of death in HIV-infected patients treated for tuberculosis in Abidjan, Côte d'Ivoire. METHODS: A computerized listing of 9523 patients diagnosed with tuberculosis and tested for HIV infection at Abidjan's two large tuberculosis treatment centers from July 1989 to December 1991 was matched against a listing of 496 patients who were autopsied in Abidjan's largest public hospital in 1991-1992. RESULTS: Fifteen matching patients were identified including 11 adults with smear-positive pulmonary tuberculosis, three adults with extrapulmonary tuberculosis, and one child with smear-negative pulmonary tuberculosis. The autopsy-proven causes of death among the adults were tuberculosis (n = 4), bacterial infections (n = 3), cerebral toxoplasmosis (n = 2), pulmonary nocardiosis (n = 2), Pneumocystis carinii pneumonia (n = 1), atypical mycobacteriosis (n = 1), and wasting syndrome (n = 1). Tuberculosis was the primary cause of death in two of five smear-positive patients who had not completed therapy, in none of the six patients with smear-positive disease who had completed therapy, and in two of the three patients with extrapulmonary tuberculosis. CONCLUSIONS: Chemoprophylaxis with trimethoprim-sulfamethoxazole (TMP-SMX) might have provided benefit to eight (57%) of the 14 adults in this series who died either of bacterial infections, toxoplasmosis, nocardiosis, or pneumocystosis. Prospective studies are required to elucidate further the causes of increased mortality, and to evaluate the benefits of TMP-SMX prophylaxis in HIV-infected African patients with tuberculosis.

Impact of the 1994 expanded World Health Organization AIDS case definition on AIDS surveillance in university hospitals and tuberculosis centers in Côte d'Ivoire.

OBJECTIVE: To assess the impact of the 1994 expanded World Health Organization (WHO) AIDS case definition on AIDS surveillance in Côte d'Ivoire. DESIGN: Prospective AIDS case surveillance. METHODS: From March 1994 through December 1996, passive AIDS case surveillance was conducted at the three university hospitals in Abidjan, and active AIDS case surveillance was conducted at the eight tuberculosis (TB) centers in Côte d'Ivoire. Standardized questionnaires were administered and blood samples for HIV serologic testing were collected from the patients evaluated. The numbers of persons who met the modified 1985 WHO clinical AIDS case definition (Bangui definition) and the 1994 expanded WHO AIDS case definition were determined, and the clinical characteristics of these patients were assessed. RESULTS: Of 8648 university hospital patients, 3658 (42.3%) met the clinical and/or the expanded case definition: 744 (20.3%) HIV-seropositive persons met only the expanded definition, 44 (1.2%) HIV-seropositive persons met only the clinical definition, 2334 (63.8%) HIV-seropositive persons met both definitions, and 536 (14.7%) HIV-seronegative persons met only the clinical definition. Of 18,661 TB center patients, 9664 (51.8%) met the clinical and/or the expanded definition: 5685 (58.8%) HIV-seropositive persons met only the expanded definition, none of the HIV-seropositive persons met only the clinical definition (by definition), 2625 (27.2%) HIV-seropositive persons met both definitions, and 1354 (14.0%) HIV-seronegative persons met only the clinical definition. CONCLUSIONS: Because of the inclusion of multiple severe HIV-related illnesses into the expanded definition, the number of reportable AIDS cases in HIV-seropositive patients increased 31.3% in the university hospitals, and 217% in the TB centers. The inclusion of HIV seropositivity as a criterion for the expanded definition also enhanced the specificity of AIDS case reporting, eliminating 536 cases in the university hospitals and 1354 cases in the TB centers in HIV-seronegative patients who had clinical signs of AIDS. The use of the 1994 expanded definition for surveillance purposes should be encouraged in areas of the developing world where HIV serologic testing is available.

Cervicovaginal anti-HIV antibodies in HIV-seronegative female sex workers in Abidjan, Côte d'Ivoire.

OBJECTIVE: To detect anti-HIV antibodies in cervicovaginal secretions of HIV-seronegative female sex workers and to evaluate whether the presence of these antibodies is associated with increased sexual exposure. METHODS: A cross-sectional study was carried out at a confidential clinic for female sex workers in Abidjan, Côte d'Ivoire. The participants were 342 HIV-seronegative female sex workers in whom a cervicovaginal lavage was collected. The main outcome measures were the detection of antibodies to HIV-1 in cervicovaginal lavages using an in-house and a commercial (Seradyn Sentinel; Calypte Biomedical Corporation, Berkeley, California, USA) enzyme immunoassay; the detection of semen in cervicovaginal lavages; and the assessment of epidemiological and biological markers of sexual exposure to HIV. RESULTS: Cervicovaginal anti-HIV antibodies were detected in 7.3 and 29.8% of women using in-house enzyme-linked immunosorbent assay (ELISA) and Seradyn Sentinel respectively. All cervicovaginal secretions found to be positive by in-house ELISA were also positive by Seradyn Sentinel. In a minority of women, ranging from 2.9% by in-house ELISA to 12.3% by Seradyn Sentinel, the anti-HIV antibodies were present in vaginal fluids that did not contain semen. Sexual exposure to HIV was similar in women with anti-HIV antibodies in their semen-free cervicovaginal secretions compared with women without anti-HIV antibodies in their cervicovaginal secretions. CONCLUSIONS: Cervicovaginal HIV-specific antibodies were detected in a minority of sexually exposed HIV-seronegative female sex workers in Abidjan. The lack of association between increased sexual exposure to HIV and presence of cervicovaginal HIV-specific antibodies suggests that the production of genital HIV-specific antibodies in exposed seronegative women depends on the ability of individual women to mount specific mucosal immunity to HIV antigens, the determinants of which are currently unknown.

Impact of HIV infection on the development, clinical presentation, and outcome of tuberculosis among children in Abidjan, Côte d'Ivoire.

OBJECTIVE: To assess the impact of HIV infection upon the development, clinical presentation, and outcome of tuberculosis (TB) among children. DESIGN: Case-control study and prospective cohort study. METHODS: From March 1994 to November 1995, children aged 0-9 years with newly diagnosed TB were enrolled at the two outpatient TB centers and the two principal university hospitals in Abidjan, Côte d'Ivoire. Children were examined, blood samples were collected for HIV serology and lymphocyte phenotyping, chest radiography was performed, and gastric aspirates and sputum samples were collected for acid-fast bacilli smear and culture. Children were then followed every 2 months during a standard 6-month course of anti-TB therapy. To examine risk factors for TB, age- and sex-matched healthy control children were enrolled from among the siblings of children referred for TB skin testing. RESULTS: Overall, 161 children with TB were enrolled, including 39 (24%) with culture-confirmed pulmonary TB, 80 (50%) with clinically diagnosed pulmonary TB, and 42 (26%) with extrapulmonary TB. Children with TB were significantly more likely than 161 control children to be HIV-seropositive (19 versus 0%), to have a past TB contact (55 versus 16%) and to live in very low socioeconomic status housing (24 versus 6%). No significant differences between HIV-seropositive and seronegative children were found in the distribution of radiologic abnormalities for pulmonary TB or in the site of extrapulmonary TB. The mortality rate in HIV-seropositive children was significantly higher than in seronegative children (23 versus 4%; relative risk, 3.6; 95% confidence interval, 2.0-6.6), and all deaths in HIV-seropositive children with available lymphocyte subtyping results occurred in those with a CD4 percentage of < 10%. CONCLUSIONS: This study documents the importance of HIV infection as an independent risk factor for the development of TB in children, and demonstrates that HIV-related immunosuppression is a critical risk factor for mortality in this population.

The associations between cervicovaginal HIV shedding, sexually transmitted diseases and immunosuppression in female sex workers in Abidjan, Côte d'Ivoire.

OBJECTIVE: To measure the frequency and associated factors of cervicovaginal HIV shedding and to determine the impact of sexually transmitted disease (STD) treatment on HIV shedding. DESIGN: Cross-sectional study with 1-week follow-up. SETTING: Confidential clinic for female sex workers in Abidjan, Côte d'Ivoire. PARTICIPANTS: A total of 1201 female sex workers. INTERVENTIONS: STD treatment based on clinical signs. MAIN OUTCOME MEASURES: HIV serostatus; cervicovaginal HIV shedding at enrollment and at 1-week follow-up; STD status at enrollment and at 1-week follow-up. RESULTS: Cervicovaginal shedding of HIV-1 in HIV-1-seropositive women was more frequent (96 out of 404, 24%) than shedding of HIV-2 in HIV-2-seropositive women [one out of 21, 5%; odds ratio (OR), 6.2; 95% confidence interval (CI), 1.0-261]. Among 609 HIV-1-seropositive or dually seroreactive women, HIV-1 shedding was significantly more frequent in immunosuppressed women [adjusted OR (AOR), 6.3; 95% CI, 3.4-11.9; and AOR, 2.9; 95% CI, 1.6-5.0 for CD4 < 14% and CD4 14-28%, respectively, versus CD4 > 28%], and in women with Neisseria gonorrhoeae (AOR, 1.9; 95% CI, 1.2-3.0), those with Chlamydia trachomatis (AOR, 2.5; 95% CI, 1.1-5.8), and with a cervical or vaginal ulcer (AOR, 3.9; 95% CI, 2.1-7.4). HIV-1 shedding decreased from 42 to 21% (P < 0.005) in women whose STD were cured. CONCLUSIONS: These data help to explain the difference in transmissibility between HIV-1 and HIV-2 and the increased infectiousness of HIV in the presence of immunosuppression and STD. In addition, they lend biological plausibility to arguments for making STD control an integral part of HIV prevention strategies in Africa.

Effect of interventions to control sexually transmitted disease on the incidence of HIV infection in female sex workers.

OBJECTIVE: To compare the seroincidence of HIV infection among female sex workers in Abidjan, Côte d'Ivoire before and during an intervention study to control sexually transmitted diseases (STD) and to study the effect of two STD diagnosis and treatment strategies on the prevalence of STD and on the seroincidence of HIV infection. METHOD: A screening facility for STD and HIV had been available since October 1992 for female sex workers. From June 1994, women who were HIV seronegative or HIV-2 positive during the screening could enroll in the intervention study in which participants reported once a month to a confidential clinic where they received health education, condoms and STD treatment if indicated. Women in the study were randomized either to a basic STD diagnosis and treatment strategy, which included a gynecologic examination when symptomatic, or to an intensive strategy that included a gynecologic examination regardless of symptoms. An outcome assessment every 6 months included a gynecologic examination, HIV serology and laboratory tests for STD. RESULTS: Of 542 women enrolled in the study, 225 (42%) had at least one outcome assessment. The HIV-1 seroincidence rate during the intervention study was significantly lower than before the study (6.5 versus 16.3 per 100 person-years; P = 0.02). During the study, the HIV-1 seroincidence rate was slightly lower in the intensive than in the basic strategy (5.3 versus 7.6 per 100 person-years; P = 0.5). CONCLUSION: National AIDS control programs should consider adopting as policy the type of integrated approach used in this intervention study for HIV prevention in female sex workers.

Improved detection of HIV-2 proviral DNA in dually seroreactive individuals by PCR.

OBJECTIVE: To improve the detection rate of HIV-2 proviral DNA in primary uncultured peripheral blood mononuclear cells (PBMC) of HIV-2-seroreactive and HIV-1-HIV-2 dually seroreactive individuals. MATERIALS AND METHODS: Two newly designed HIV-2 PCR primer pairs in the long terminal repeat (LTR) gag and gag-pol regions and a previously described env and LTR HIV-2 PCR primer pairs were tested on samples from 66 confirmed HIV-2-seropositive individuals (The Gambia, 40; Côte d'Ivoire, 17; Guinea-Bissau, nine), 209 dually seroreactive individuals (The Gambia, 82; Côte d'Ivoire, 127), 24 genetically characterized isolated HIV-1 strains (group M subtypes A-H and group O), one simian immunodeficiency virus (SIV) strain cpz, 10 HIV-2 isolates (subtype A, B and unidentified), two SIVsm isolates, and 10 seronegative samples. RESULTS: All HIV-2 primers evaluated showed 100% specificity since there was no amplification observed with 24 HIV-1, one SIVcpz and 10 seronegative samples. One single copy of the HIV-2 genome could be detected with all outer primer pairs as well as all inner primer pairs on one PCR round used. Sensitivity of primers (at least one of the four primer pairs was positive) to HIV-2-seropositive samples was 100% (all nine) in Guinea-Bissau, 71% (12/17) in Côte d'Ivoire, 100% (all 20) in Gambian AIDS patients, and 85% (17/20) in Gambian pregnant women. Doubling the PBMC of dually seroreactive individuals from 7.5 x 10(4) to 1.5 x 10(5) in the PCR revealed the presence of both HIV-1 and 2 proviral DNA in 72% (92/127) in Côte d'Ivoire and 72% (59/82) in The Gambia. By doubling the number of PBMC, HIV-2 detection in dually seroreactive individuals by PCR was increased from 65 to 77% in Côte d'Ivoire and from 67 to 83% in The Gambia. CONCLUSIONS: The use of 1.5 x 10(5) primary uncultured PBMC and the newly designed HIV-2 primer pairs allowed us to document the highest percentage (72%) ever reported of HIV-1-HIV-2 dual infections amongst HIV-1-HIV-2 dually seroreactive individuals in Côte d'Ivoire and The Gambia. Improved detection of HIV-2 proviral DNA, rather than exposure to both viruses, infection with only one virus, or infection with a unique third virus containing epitopes common to both HIV-1 and HIV-2, contributes to a more accurate monitoring of the prevalence of HIV-1-HIV-2 dual infections.

The Côte d'Ivoire national HIV counseling and testing program for tuberculosis patients: implementation and analysis of epidemiologic data.

OBJECTIVES: To describe the implementation of a free, voluntary and confidential HIV counseling and testing program for patients with newly diagnosed tuberculosis at the eight large outpatient tuberculosis centers in Côte d'Ivoire, and to present epidemiologic findings on participating patients. DESIGN: HIV counseling and testing program with ongoing HIV serosurveillance. METHODS: HIV counseling and testing services were established at the two tuberculosis centers in Abidjan in 1989 and were extended to six centers in the Côte d'Ivoire interior in the first half of 1994. Characteristics of counseled patients, acceptance rates of HIV testing, and HIV serologic results were analyzed for all eight centers from 1994 to 1996. Temporal trends in HIV seropositivity rates were examined for the two centers of Abidjan from 1989 to 1996. RESULTS: From July 1994 through December 1996, 17 946 (91.8%) out of 19 594 patients who were counseled at the eight centers in Côte d'Ivoire consented to HIV testing, of whom 7749 (43.2%) were HIV-seropositive. The highest rates of 47.0 and 45.6% were found in the two centers in Abidjan, with rates ranging from 32.9 to 42.4% in the six centers in the interior. HIV-seropositive tuberculosis patients from each of the 50 districts in Côte d'Ivoire were identified. In Abidjan, the HIV seropositivity rate remained relatively stable among men (46.7% in 1989, 48.5% in 1991, 43.6% in 1996), but rose sharply among women from 32.7% in 1989 to 50.1% in 1996. CONCLUSIONS: The high HIV seropositivity rates among tuberculosis patients in all geographic regions of Côte d'Ivoire indicate that the HIV epidemic has now spread throughout the country. However, the successful implementation of an extensive HIV counseling and testing program for more than 37000 tuberculosis patients to date demonstrates the commitment of the Côte d'Ivoire Ministry of Health to integrating HIV/AIDS prevention activities with tuberculosis control efforts. When logistically and economically feasible, the extension of HIV-related social and clinical services to HIV-seropositive tuberculosis patients should be considered by other national tuberculosis control programs in Africa.

Genetic analysis of human immunodeficiency virus in Abidjan, Ivory Coast reveals predominance of HIV type 1 subtype A and introduction of subtype G.

To better understand the molecular epidemiology of HIV genetic diversity in Abidjan, Ivory Coast, we performed a genetic analysis of 170 HIV-1-seropositive specimens representing newly diagnosed tuberculosis patients (n = 143) and women monitored in a mother-to-child transmission cohort study (n = 27). Preliminary screening with RFLP presumptively classified 162 (95.3%) of these as subtype A. The envelope region of 108 specimens was subtyped by sequence analysis: 102 (94.4%) were subtype A, 2 (1.9%) were subtype D, and 4 (3.7%) were subtype G. Subtyping gag and env regions of the genome suggested that five of the six nonsubtype A isolates exhibited a potentially mosaic structure. A comparative phylogenetic analysis of HIV-1 subtype A C2V3 from 27 Ivory Coast and 21 Ugandan sequences revealed a striking clustering among Ivory Coast variants, and an independent segregation from Ugandan subtype A. Despite independent clustering with other subtype A specimens, limited variability of the V3 loop apex was observed; the globally predominant V3 motif, GPGQ, represented 90.1% of the HIV-1 strains. This study demonstrates that clade A is the predominant HIV-1 subtype in HIV-seropositive individuals in Abidjan, Ivory Coast and that these strains are phylogenetically distinct from other subtype A strains observed in East Africa.

What is the meaning of repeated isolation of Mycobacterium africanum?

Mycobacterium africanum is a member of the tuberculosis complex, together with M. tuberculosis and M. bovis. Its morphological growth is quite different from that of M tuberculosis. It is a causative agent of the same tuberculosis disease, and its precise identification seems important only for epidemiological purposes. We report here the repetitive isolation of 17 M. africanum strains (among 321 TB complex strains) during a national primary resistance survey in C te d'Ivoire in 1995. All of the M. africanum strains were isolated in four regions located in the same geographical area. They showed biochemical heterogeneity yielding three patterns, none of which was specific to one region. Molecular analysis by RFLP for 14 strains showed identical patterns for four strains, two by two, and a clustering of 62-77% homology for eight of the 14 strains (57%). This report confirms that M. africanum is less frequent than M. tuberculosis. Its repeated isolation may reflect inter-human transmission. Biochemical similarities between strains may not always be associated with a common geographical origin.

Effect of an HIV counseling and testing program on AIDS-related knowledge and practices in tuberculosis clinics in Abidjan, Côte d'Ivoire.

SETTING: Two out-patient tuberculosis treatment centers, Abidjan, Côte d'Ivoire. OBJECTIVE: To assess the effect of a human immunodeficiency virus (HIV) counseling and testing program on acquired immune-deficiency syndrome (AIDS) related knowledge and behaviors among persons with newly diagnosed tuberculosis. DESIGN: Since 1994, patients with newly diagnosed tuberculosis have received individual or group HIV pretest counseling, informed consent, free HIV testing for those who consent, and post test counseling. From January 1995 through August 1996 in Abidjan's two largest tuberculosis clinics, knowledge and beliefs about HIV/AIDS were assessed before and immediately after the group pretest sessions, and again 4 months later. RESULTS: Prior to pretest counseling, 68.9% and 68.0% of the 559 enrolled subjects could correctly identify five modes of HIV transmission and five modes of HIV prevention. These proportions increased significantly immediately after pretest counseling (90.0%, 86.6%, respectively), and remained higher 4 months later (83.7%, 87.7%) (all P < 0.01). Among men, consistent condom use during the preceding 4 months with a partner who was not a commercial sex worker increased from 9.9% at enrollment to 23.6% at the 4-month visit (P = 0.001), but not for women (6.3% vs. 9.5%, P = 0.40). CONCLUSIONS: An HIV pretest counseling program conducted in an out-patient tuberculosis clinic was well accepted, and significantly increased the level of HIV/AIDS knowledge and, among men, self-reported condom use.

Primary resistance to antituberculosis drugs: a national survey conducted in Côte d'Ivoire in 1995-1996. Ivoirian Study Group on Tuberculosis Resistance.

SETTING: A national survey of resistance to the antituberculosis drugs used in Côte d'Ivoire was conducted in 1995-1996. OBJECTIVE: To determine the rate of primary resistance to antituberculosis drugs. METHODS: Consecutive new tuberculous patients with positive smear were recruited from tuberculosis centres and rural health centres. Drug susceptibility testing was performed according to the proportion method. Positive cultures were tested against streptomycin, isoniazid, rifampicin, and ethambutol. All resistant strains and 10% of all randomly sampled cultures were sent to an external laboratory for quality control. Human immunodeficiency virus (HIV) tests were performed for consenting patients at the tuberculosis centres. RESULTS: Among the 430 samples, 320 were available for analysis. Primary resistance to antituberculosis drugs was observed for 13.4% of the patients (43/320); multidrug resistance (to at least isoniazid and rifampicin) was observed for 5.3% of the patients; 14.2% of HIV-negative and 16.2% of HIV-positive patients were resistant to at least one antituberculosis drug (P = 0.70). CONCLUSION: This study is representative of antituberculosis drug resistance in Côte d'Ivoire. The rate of primary resistance is high and emphasises the need for a sentinel survey of tuberculous resistance. The National Tuberculosis Control Programme needs to make improvements in its management of tuberculosis cases.

Tuberculin skin testing to assess the occupational risk of Mycobacterium tuberculosis infection among health care workers in Abidjan, Côte d'Ivoire.

SETTING: Tuberculin skin test (TST) survey of health care workers (HCWs) in selected clinical services in Abidjan, Côte d'Ivoire. OBJECTIVE: To assess whether HCWs in Abidjan are at increased risk for occupationally acquired Mycobacterium tuberculosis infection. DESIGN: From October 1996 to January 1997, consenting HCWs from four services where tuberculosis (TB) prevalence among patients was high and two services where it was low were evaluated with a questionnaire, TST (including evaluation of anergy) and chest radiograph. RESULTS: Of the 512 participants, 405 (79%) had a TST reaction of > or =10 mm, eight (2%) were anergic, five (1%) had a radiograph compatible with TB, and two had confirmed TB. Using a cut-off of 10 mm, we found a higher prevalence of TST positivity in services with high TB prevalence than in those with low TB prevalence (92% vs 72%; odds ratio [OR] 4.3; 95% confidence interval [CI] 2.3-8.0]) and among HCWs with direct (87%; OR 2.9; 95%CI 1.6-5.1) and indirect patient contact (80%, OR 1.7; 95%CI 1.0-2.3) than among those with minimal patient contact (69%). CONCLUSION: These findings indicate that TST positivity among HCWs is related to level of exposure to TB patients, and suggest that HCWs in Abidjan are at risk for the nosocomial transmission of TB.

Tuberculosis and HIV infection in children in Abidjan, Côte d'Ivoire.

Of 5180 consecutive outpatients diagnosed with tuberculosis in Abidjan, Côte d'Ivoire (West Africa), between July 1989 and December 1990, 289 (6%) were children aged less than 15 years. The overall prevalence of human immunodeficiency virus (HIV) 1 and/or HIV-2 infection in children with tuberculosis was 11.8% (HIV-1, 10.0%; HIV-2, 0.7%; reactivity to both viruses, 1%). The highest overall age-specific prevalence was in children aged 1-4 years (23.4%), significantly higher than the rate in attenders at a well child clinic (0.5%) (odds ratio 58.2). Of children with tuberculosis, 26% had sputum smear-positive disease (HIV seroprevalence 2.7%), 20% extrapulmonary disease (HIV seroprevalence 5.2%), and 54% were categorized as having 'clinical tuberculosis' (HIV seroprevalence 18.6%) based on clinical signs and chest X-ray abnormalities with negative sputum smears. Clinical tuberculosis was most frequent in seropositive children, irrespective of age, and in younger seronegative children. Extrapulmonary tuberculosis was equally distributed across age groups, and pulmonary tuberculosis was concentrated in older, seronegative children. HIV-positivity was significantly associated with other features related to the acquired immune deficiency syndrome such as wasting, chronic diarrhoea, oral candidiasis, and negative tuberculin skin tests. Tuberculosis seems to be associated with HIV infection in children in sub-Saharan Africa, but better diagnostic techniques for paediatric tuberculosis are urgently needed.

A comparison of clinical features in tuberculosis associated with infection with human immunodeficiency viruses 1 and 2.

Between July 1989 and December 1990, 4504 new adult patients with tuberculosis were screened for antibodies to human immunodeficiency viruses (HIV) 1 and 2 in Abidjan's 2 tuberculosis treatment centres. The prevalence levels of HIV-1 and HIV-2 infections were 30.2% and 4.2% respectively, a further 9.3% of patients reacting serologically to both viruses. Patients in all 3 seropositive groups differed significantly from seronegatives in having a higher frequency of AIDS-related features such as wasting, chronic diarrhoea, oral candidiasis and generalized lymphadenopathy. These data support earlier work showing an association between HIV-2 infection and similar opportunistic diseases which complicate HIV-1 infection, including tuberculosis. Despite the differences between seropositive and seronegative groups, symptoms and signs of tuberculosis may mimic those of AIDS. HIV testing should be more widely available for the clinical care of tuberculosis patients in Africa, as well as for epidemiological surveillance.

PIP: Tuberculosis (TB) is the most important opportunistic disease complicating HIV-1 infection in sub-Saharan Africa. Since the discovery of HIV-2, speculation has existed over how aggressively it leads to debilitating illness and the nature of its association with TB. If HIV-2 is associated with AIDS, one could expect TB to be a consequence of HIV-2 infection. Work in Cote d'Ivoire has shown an increased prevalence of HIV-2 infection in ambulatory TB patients. To gain insight into this potential association, the clinical, features of TB patients infected with HIV-1, HIV-2, and both are compared with those of seronegative persons. A total of 4504 new adult patients with tuberculosis were screened during 1989-90 for antibodies to HIV-1 and HIV-2 in Abidjan's tuberculosis treatment centers. 30.2% of the sample tested seropositive for HIV-1, 4.2% for HIV-2, and 9.3% to both. Individuals testing seropositive to either or both viruses had a significantly higher frequency compared with seronegatives of AIDS - related features like wasting, chronic diarrhea, oral candidiasis, and generalized lymphadenopathy. These findings definitely support earlier work demonstrating an association between HIV-2 infection and tuberculosis. It should be noted, however, that since the wasting and fever signs and symptoms of TB may mimic those of AIDS and that it is extremely difficult to distinguish between HIV+ and HIV- TB in Africa, blood testing for HIV is ultimately needed. Accordingly, HIV testing should be made widely available for the clinical care of TB patients in Africa as well as for epidemiological surveillance.

Risk of tuberculosis in patients with HIV-I and HIV-II infections in Abidjan, Ivory Coast.

OBJECTIVE: To examine the association between HIV-II infection and tuberculosis. DESIGN: Cross sectional study comparing the prevalence of HIV-I and HIV-II infections in patients with tuberculosis and in blood donors. SETTING: Abidjan, Ivory Coast, west Africa. PATIENTS: 2043 consecutive ambulant patients with tuberculosis (confirmed pulmonary, presumed pulmonary, or extrapulmonary) and 2127 volunteer blood donors. MAIN OUTCOME MEASURE: Prevalence of HIV-I and HIV-II infections as assessed by presence of serum antibodies. RESULTS: Overall rates of HIV infection were 40.2% in patients with tuberculosis (26.4% positive for HIV-I, 4.7% for HIV-II, and 9.0% for both); and 10.4% in blood donors (7.2% positive for HIV-I, 1.9% for HIV-II, and 1.3% for both). HIV-II infection was significantly more common in patients with all types of tuberculosis than in blood donors (97/2043, 4.7% v 40/2127, 1.9%; odds ratio 3.8%, 95% confidence interval 2.6 to 5.6). CONCLUSION: Both HIV-I and HIV-II infections are associated with tuberculosis in Abidjan. 35% of adult tuberculosis in Abidjan is attributable to HIV infection and 4% specifically to HIV-II.

[Efficacy of a short 6 month therapeutic coursefor HIV infected tuberculosis patients in Abidjan, Côte d'Ivoire]. / Efficacité du régime thérapeutique court de six mois chez les tuberculeux infectés par le VIH à Abidjan, Côte d'Ivoire.

From December 1992 to February 1993, 104 newly diagnosed pulmonary tuberculosis patients were enrolled in a prospective cohort study to assess the response to the 6 month-short-course regimen implemented in Cote d'Ivoire. This treatment encompassed the daily intake of Rifampicin and Pyrazinamide for 2 months followed by Rifampicin and Isoniazid for the remaining 4 months. All the patients were enrolled at the Treichville Tuberculosis Treatment Centre in Abidjan, and a follow-up of 6 months was observed for each patient. All in all, 41 patients were HIV-positive whereas 63 where HIV-negative. No statistical difference was noted between HIV-positive and HIV-negative patients with regard to the completion of therapy (85% versus 87%). The cure rate after an effective 6 month-therapy was similar among HIV-positive and HIV-negative patients (83% versus 84%) as well as the treatment failure rate which was 2.4% and 3% respectively. The results clearly indicate that the 6 month-short-course regimen policy implemented in Côte d'Ivoire is as effective for the treatment of HIV-associated tuberculosis as for the treatment of tuberculosis.

[Seroprevalence of HIV among pregnant women in the ten regions of the Ivory Coast]. / Séroprévalence du VIH chez les femmes enceintes dans dix régions de Côte d'Ivoire.

UNLABELLED: Ivory Coast, a sub-Saharan African country, has 14 million inhabitants. Two AIDS cases were reported to the WHO in 1985. By December 31st 1996, there were a total of 37,878 AIDS cases in Ivory Coast, 6,727 of which were new cases reported in 1996. Heterosexual transmission is the predominant means of HIV infection in Africa and women of childbearing age account for a substantial proportion of the individuals infected. The aim of this study was to follow the progression of infection in the various regions of the country by comparing data from two time periods: Period I: 1986 to 1989; Period II: 1994 to 1996. LOCATION: Samples were taken in regional maternal and child protection centers. Recruitment method: Women were recruited anonymously, during their antenatal care. BIOLOGICAL ANALYSIS: Period I (1986 to 1989), 2,604 pregnant women. Anti-HIV antibodies were detected with: Abbott HIV-1 EIA Recombinant (Chicago) used initially, for 1,200 sera; Abbott HIV-1/HIV-2 Recombinant (Chicago) used later for the remaining sera. There was no commercially available test for HIV-2 during this first period, so all samples with Rm0.8 (R = optical density/cut-off) were also tested by western blotting. Period II (1994 to 1996), 2,935 pregnant women. All sera were tested with Enzygnost HIV-1-2 and Enzygnost HIV-1-2 Plus, produced by Behring (Germany). All sera testing positive in EIA were also tested by western blotting. RESULTS: The prevalence of HIV infection was 4.23% for Period I and 12.53% for Period II. No region of Ivory Coast was completely free of these 2 viruses after the mid-1980s. Women aged 20 to 29 years of age were the most likely to be infected, for both periods. The highest prevalence of HIV-2 was that for women aged between 20 and 29 years and HIV-2 infection occurred mostly in the South, Southwest and West regions. DISCUSSION: The prevalence of HIV infection is now at least 10% in each region of the country. Abidjan is no longer the city with the highest levels of infection, as shown by the results for Period II. The East and West have the highest levels of HIV infection, and the prevalence of HIV in these areas is significantly higher than that for Abidjan (p = 0.007 for the East and p = 0.009 for the West).