Chapitre 3. Inégalités dans le dépistage et la prévention du VIH/SIDA.

Despite progress in the detection and treatment of the Human Immunodeficiency Virus (HIV), major challenges remain in developing countries due to insufficient resources and infrastructure. The number of people living with HIV who do not know their serostatus has fallen worldwide. However, a number of existing obstacles stand in the way of better results. The socio-cultural context in Africa hampers knowledge and understanding of the disease, leading to stigmatizing attitudes, reluctance to undergo screening and poor access to treatment.Inequalities also exist within the countries of the North, as in the case of the French West Indies, which benefit from a policy to combat HIV/AIDS, with results that fall short of those in mainland France. For this reason, we have chosen to compare the situation in the West Indies with that in Benin, in the context of African culture.Our analysis takes stock of the issues and prospects linked to the accessibility and use of screening care in sub-Saharan Africa and the French Departments of America (DFA).In both cases, fear of the disease, stigmatization, fear of a positive HIV test result and fear of disclosing the test result limit preventive and treatment actions for an effective fight against HIV.In sub-Saharan Africa, women are more likely to accept a screening test than men. Certain populations, including adolescents and homosexuals, are in a vulnerable position. The comparison reveals similar attitudes and suggests actions or recommendations in both countries that have produced results.Innovative strategies and specific programs must be implemented to turn the tide in the fight against the HIV epidemic.

Prevalence and determinants of high-risk human papilloma virus among men who have sex with men in Benin: a cross-sectional study embedded in a demonstration project on pre-exposure prophylaxis against HIV.

OBJECTIVES: This study aims to assess the prevalence and factors associated with anal high-risk human papilloma virus (HR-HPV). DESIGN: A cross-sectional study conducted from 24 August 2020 to 24 November 2020. SETTING: Primary care, Cotonou, Benin. PARTICIPANTS: 204 HIV-negative men who have sex with men initiating oral pre-exposure prophylaxis. PRIMARY OUTCOME MEASURE: Anal HR-HPV genotypes using GeneXpert HPV assay. Fourteen HR-HPV were evaluated: HPV-16 and HPV-18/45 in 2 distinct channels and the 11 other genotypes as a pooled result (31, 33, 35, 39, 51, 52, 56, 58, 59, 66 and 68). The potential independent variables analysed included anal gonorrhoea and chlamydia infections, and sociodemographic and sexual behaviour factors. To assess the determinants of HR-HPV, univariate and multivariate Poisson regression models were performed by using SAS V.9.4. RESULTS: Mean age±SD was 25.9±4.8 years. 131/204 men claimed insertive sex procured more pleasure. Thirty-two participants, accounting for 15.7% of the study sample, had gonorrhoea and/or chlamydia. The prevalence of any HR-HPV genotype was 36.3% (95% CI 30.0% to 43.0%). In total, 7.8% of men had HPV-16 and 7.4% had HPV-18/45. The prevalence for the pooled genotypes (31, 33, 35, 39, 51, 52, 56, 58, 59, 66 and 68) was 29.9%. Receptive anal sex during the last 6 months was strongly associated with prevalent HR-HPV infections. The adjusted proportion ratio (aPR) was 1.93 (95% CI 1.31 to 2.83). Gonorrhoea and chlamydia were also associated with the outcome of interest; p value for both infections was <0.05. The aPR comparing patients who perceived some risk of acquiring HIV to other men was 1.44 (95% CI 1.00 to 2.08). CONCLUSIONS: In Benin, anal HR-HPV was common among HIV-negative men who have sex with men. Among this highly vulnerable population, there is a need for integrated preventive and management strategies targeting HPV and other sexually transmitted infections.

Pre-exposure prophylaxis in real life: experience from a prospective, observational and demonstration project among men who have sex with men in Benin, West Africa.

INTRODUCTION: Since many countries in sub-Saharan Africa are willing to implement HIV oral pre-exposure prophylaxis (PrEP) for men who have sex with men (MSM), data are needed to assess its feasibility and relevance in real life. The study objectives were to assess drug uptake, adherence, condom use and number of sexual partners, HIV incidence and trends in the prevalence of gonorrhoea and chlamydia. METHODS: In this oral PrEP demonstration study conducted prospectively in Benin, a combination of tenofovir disoproxil fumarate-TDF 300 mg and emtricitabine-FTC 200 mg (TDF-FTC) was offered daily or on-demand to MSM. Participants were recruited from 24 August to 24 November 2020 and followed over 12 months. At enrolment, month-6 and month-12, participants answered to a face-to-face questionnaire, underwent a physical examination and provided blood samples for HIV, gonorrhoea and chlamydia. RESULTS: Overall, 204 HIV-negative men initiated PrEP. The majority of them (80%) started with daily PrEP. Retention rates at month-3, 6, 9 and 12 were 96%, 88%, 86% and 85%, respectively. At month-6 and month-12, respectively, 49% and 51% of the men on daily PrEP achieved perfect adherence (self-reported), that is seven pills taken during the last week. For event-driven PrEP, the corresponding proportions for perfect adherence (last seven at-risk sexual episodes covered) were 81% and 80%, respectively. The mean number (standard deviation) of male sexual partners over the last 6 months was 2.1 (1.70) at baseline and 1.5 (1.27) at month-12 (p-value for trend <0.001). Consistent condom use during the last 6 months was 34% (enrolment), 37% (month-6) and 36% (month-12). Three HIV seroconversions (2-daily and 1-event-driven) were recorded. Crude HIV incidence (95% confidence interval) was 1.53 (0.31-4.50)/100 person-years. Neisseria gonorrhoeae and/or Chlamydia trachomatis prevalence at the anal and/or pharyngeal and/or urethral sites was 28% at baseline and 18% at month-12 (p-value = 0.017). CONCLUSIONS: In West Africa, oral PrEP introduction in routine practice as a component of a holistic HIV prevention package is feasible and may not result in a significant increase in condomless sex among MSM. Since HIV incidence was still higher, additional interventions, such as culturally tailored adherence counselling, may be needed to optimize the benefits of PrEP.

[Prevalence of viral hepatitis B and C in men who have sex with men enrolled in a demonstration study of pre-exposure prophylaxis for HIV in Cotonou, Benin]. / Prévalence des hépatites virales B et C chez les hommes ayant des rapports sexuels avec d'autres hommes mobilisés pour une étude de démonstration de la prophylaxie préexposition au VIH à Cotonou, au Bénin.

Introduction: men who have sex with men (MSM) are disproportionately affected by hepatitis B virus (HBV) and hepatitis C virus (HCV) worldwide. In Benin, there are no data on MSM. The purpose of this study was to estimate HBV and HCV prevalence and HBV-associated factors in MSM who were HIV negative. Methods: we conducted an analytical cross-sectional study. A two-degree random sampling was used to recruit 204 MSM. An immunochromatographic rapid test and enzyme immunoassays were used to detect HBV and HCV antigens/antibodies. Log-binomial regression was used to identify factors associated with HBV. Results: HbsAg positivity, history of hepatitis B infection and hepatitis C prevalences were 37.7%, 8.8 %, and 0.9 %, respectively. HBsAg positivity and history of hepatitis B were more prevalent in MSM aged ≥30 years compared to younger subjects: 16.7% versus 6.4% (p<0.0001) and 66.7% versus 28.8% (p<0.0001), respectively. Sexual intercourse under the effect of drug or alcohol and living in couple were also associated with HBV. conclusion: the prevalence of hepatitis C was low, but hepatitis B was common, especially among older MSM. Screening and vaccination against hepatitis B should be strengthened in this population.

Challenge of gastro-intestinal stromal tumor management in low-income countries: example of Benin.

BACKGROUND: GISTs are rare tumors but the most frequent mesenchymal tumors of the digestive tract. Diagnosis and treatment are challenging in low-income countries due to relatively poor access to immunohistochemistry and targeted therapy. In Africa, there are few studies about it. Imatinib, an oral targeted therapy, has been available in Benin since 2010 and free since 2016. This study describes the diagnosis and therapeutic management of GIST in Cotonou, Benin. METHODS: This is a descriptive cross-sectional study, with retrospective data collection over a 10-year period from 2010 to 2020, focused on patients with histological confirmed gastro-intestinal stromal tumor (GIST). Cases were identified using the registry database and the archival files of the Hubert Koutoukou Maga National University Hospital of Cotonou (CNHU-HKM). RESULTS: Fifteen GISTs were identified during the study period. The median age was 52 and the sex ratio was 2:1 (10 males and 5 females). The most frequent symptom was abdominal pain (n = 12). Delay in care seeking after onset of symptoms ranged from 24 h to 15 years. The most common site for GISTs was the stomach (n = 8). The median tumor size was 11 cm and the majority (n=10) was metastatic or locally advanced at the time of diagnosis. The tumors were often spindle-shaped at histology (n = 13) and the majority expressed KIT (n = 14). Most of the tumors (n = 12) were at high risk of recurrence according to the Joensuu scoring system. The availability of imatinib has improved the outcome of GIST with response in all cases it was used in neoadjuvant setting (n = 7). CONCLUSION: GISTs are rare tumors and preferentially affect the stomach in Cotonou). Most of the tumors were large, unresectable at the time of diagnosis and at high risk of recurrence. Access to imatinib has revolutionized the management of those tumors in our country.

Knowledge, opinions and experiences of researchers regarding ethical regulation of biomedical research in Benin: a cross-sectional study.

BACKGROUND: Ethics in biomedical research is still a fairly new concept in Africa. This work aims to assess the knowledge, attitude and experiences of Beninese researchers with regard to the national ethical regulatory framework of biomedical research in Benin. METHODS: This was a cross-sectional and descriptive study, involving all the researchers fulfilling the inclusion criteria. Data were collected through a face-to-face interview using a questionnaire and analysed. Proportions and means were calculated with their confidence intervals and standard deviations, respectively. RESULTS: Of the 110 participants included in the study, 40.9% were medical lecturers and 71.1% had been involved in more than 10 biomedical research as researcher. Less than three quarters (69.1%) were able to correctly quote the basic principles from Belmont report. The quarter (25.45%) of them knew the attributions of the National Ethics Committee for Health Research (CNERS in French) and 38.2%, the content of the legislation on health research ethics in Benin. The common ethical rules were known by 69.1% of the participants. A quarter (25.5%) of participants said they always present the study's briefing note to their study participants and 62.7% said they systematically request informed consent. For those who do not present the briefing note to participants, the main reasons provided were the researchers' difficulties in writing the note in plain language and the participants' limitation in understanding it. CONCLUSIONS: The foundations of a good ethical framework for health research exist in Benin. However, the deployment and use of the various legal texts deserve to be improved.

[Epidemiological and histopathological aspects of sarcomas in Cotonou (Benin) from 2010 to 2020]. / Aspects épidémiologiques et histopathologiques des sarcomes à Cotonou (Bénin) de 2010 à 2020.

Aims: To study the epidemiological and histopathological characteristics of sarcomas. Procedure: This was a multi-center, descriptive, retrospective study realized over a 10-year period. We systematically recruited all medical reports of patients with histologically confirmed sarcoma. Results: 159 reports of sarcoma were retained. The average age was 38.9 years. There was a female predominance with a 0.9 estimated sex ratio. Soft tissue sarcomas were the most common (65.4%). The most frequent location was the lower limbs (30.2%). Conclusion: Better access to diagnosis would contribute to a better assessment of the burden of this pathology in Benin.

[Gamete intrafallopian transfer in the treatment of infertility: knowledge, attitude and perception of students at the Faculty of Health and Medical Sciences in Cotonou- Benin]. / Le don de gamètes dans la prise en charge de l'infertilité du couple: connaissances, attitudes et perception des étudiants en médecine de la Faculté des Sciences de la Santé de Cotonou-Bénin.

Introduction: infertility is a real public health problem. Medically Assisted Procreation (MAP) with donor gametes is one of the possible solutions. In Benin, despite a well-defined legislative framework (children´s code), MAP using donated gametes has not been studied. The purpose of this study was to assess knowledge, attitudes and perceptions of students at the Faculty of Health and Medical Sciences in Cotonou about the donation of gametes. Methods: we conducted a cross-sectional and descriptive study among second or third-year medical students at the Faculty of Health and Medical Sciences (FHMS) in Cotonou. Results: the surveyed sample consisted of 236 students, of whom 54% (n=127) were male and 46% (n=109) were female; the representative age range was between 18 and 24 years (87%). The knowledge of MAP using donated gametes was 90.6% (n=214). The possibility that this treatment might be performed in Benin was known to be 55.6% (n=131). More that eighty-eight percent (n=209) of respondents were unaware of the existence of legislation in force since 2015 on this matter and 69.5% (n=164) refused to donate gametes. Among the reasons mentioned, the ethical reason dominated. Conclusion: in Benin, students´ knowledge about MAP using donated gametes is adequate but there is a widespread refusal to donate their gametes among them, mainly because of ethical issues.

Contribution of the classical polymerase chain reaction in the diagnosis of a HIV-1 infected patient in Benin: a case report.

BACKGROUND: First ambitious target by 2020 of UNAIDS is that 90% of people living with HIV know their HIV status. In people older than 18 months of age, serological confirmation test is recommended to confirm HIV infection. CASE PRESENTATION: Here we report the case of a patient tested positive with HIV-1, ELISA, Murex® Ag/Ab Combination assay (OD450 = 0.802 and cutoff-OD = 0.279) and negative by using FIRST RESPONSE HIV1-2.O CARD TEST (version 2.0) RAPID HIV CARD TEST. Viral load performed with Cobas® TaqMan® 96/Cobas® Ampliprep® was 6.49log10. The virus could be sequenced in partial gag and pol genes and belonged to CRF02_AG clade. CONCLUSION: Conventional PCR is a complementary method for the diagnosis of inconclusive HIV-1 serologies by antibodies.

HIV Prevention and Treatment Cascades Among Female Sex Workers in Benin, West Africa.

BACKGROUND: Benin has a long-standing history of HIV prevention programs aimed at female sex workers (FSWs). We used data from a national survey among FSWs (2017) to assess the prevention and care cascades in this population. METHODS: Female sex workers were recruited through cluster sampling of sex work sites. A questionnaire was administered, and HIV tested. HIV-positive participants were asked to provide dried blood spots and were tested for antiretroviral and viral load. We assessed 2 prevention cascades (HIV testing and safer sex) and the treatment cascade, using a combination of self-reported and biological variables. RESULTS: Mean age of the 1086 FSWs was 30 years. Half of them were Beninese, and two-thirds had a primary school education level or less. Almost all FSWs had ever heard of HIV/AIDS. More than half (79.1%) had ever been tested, and 84.1% of the latter had been tested in the last year. In the previous 6 months, 90.1% were exposed to prevention messages. Women exposed to any HIV prevention message reported a higher level of consistent condom use in the last month (69.0%) than those who were not (48.5%, P < 0.0001). HIV prevalence was 7.7%. Among HIV-positive women, 60.6% knew their status; among those, 90.5% were on antiretroviral and 81.8% of them had a suppressed viral load. CONCLUSIONS: Despite long-standing HIV prevention programs for FSWs, the prevention indicators were often low. Linkage to care was good, viral suppression was suboptimal, but knowledge of HIV-positive status was low. Exposing women to prevention messages is necessary, as to increase HIV testing.

Determinants of HIV Preexposure Prophylaxis Adherence Among Female Sex Workers in a Demonstration Study in Cotonou, Benin: A Study of Behavioral and Demographic Factors.

BACKGROUND: HIV preexposure prophylaxis (PrEP) efficacy is closely linked to adherence, and factors associated with PrEP adherence are not well understood and may differ across populations. As PrEP demonstration projects and implementation are ongoing, it is essential to understand factors associated with adherence to oral PrEP to design effective adherence interventions and maximize the public health impact of PrEP. We thus aimed to assess demographic and behavioral factors associated with optimal PrEP adherence (100%) among female sex workers (FSWs) participating in a demonstration project in Cotonou, Benin. METHODS: Female sex workers were provided with daily Truvada and followed quarterly for 1 to 2 years. Sociodemographics, partners, and behaviors were collected through face-to-face questionnaires. Another questionnaire based on sexual the theory of planned behavior and the theory of interpersonal behavior was also administered. Generalized estimating equations were used to identify factors associated with optimal daily adherence. RESULTS: At baseline, 255 FSWs were followed up. One-year increase in age of FSWs was associated with a 3% increase in optimal adherence (prevalence ratio, 1.03; 95% confidence interval, 1.01-1.05; P for trend = 0.0003), and optimal adherence decreased by 31% for every 6 months of follow-up (prevalence ratio, 0.69; 95% confidence interval, 0.59-0.79; P for trend < 0.0001). For the participants who have completed the behavioral questionnaires, high intention to adhere to the treatment was also a predictor of optimal adherence. CONCLUSIONS: Efforts should be geared toward FSWs intending to use PrEP to help them reach adequate adherence levels for effective HIV protection.

Mathematical Model Impact Analysis of a Real-Life Pre-exposure Prophylaxis and Treatment-As-Prevention Study Among Female Sex Workers in Cotonou, Benin.

BACKGROUND: Daily pre-exposure prophylaxis (PrEP) and treatment-as-prevention (TasP) reduce HIV acquisition and transmission risk, respectively. A demonstration study (2015-2017) assessed TasP and PrEP feasibility among female sex workers (FSW) in Cotonou, Benin. SETTING: Cotonou, Benin. METHODS: We developed a compartmental HIV transmission model featuring PrEP and antiretroviral therapy (ART) among the high-risk (FSW and clients) and low-risk populations, calibrated to historical epidemiological and demonstration study data, reflecting observed lower PrEP uptake, adherence and retention compared with TasP. We estimated the population-level impact of the 2-year study and several 20-year intervention scenarios, varying coverage and adherence independently and together. We report the percentage [median, 2.5th-97.5th percentile uncertainty interval (95% UI)] of HIV infections prevented comparing the intervention and counterfactual (2017 coverages: 0% PrEP and 49% ART) scenarios. RESULTS: The 2-year study (2017 coverages: 9% PrEP and 83% ART) prevented an estimated 8% (95% UI 6-12) and 6% (3-10) infections among FSW over 2 and 20 years, respectively, compared with 7% (3-11) and 5% (2-9) overall. The PrEP and TasP arms prevented 0.4% (0.2-0.8) and 4.6% (2.2-8.7) infections overall over 20 years, respectively. Twenty-year PrEP and TasP scale-ups (2035 coverages: 47% PrEP and 88% ART) prevented 21% (17-26) and 17% (10-27) infections among FSW, respectively, and 5% (3-10) and 17% (10-27) overall. Compared with TasP scale-up alone, PrEP and TasP combined scale-up prevented 1.9× and 1.2× more infections among FSW and overall, respectively. CONCLUSIONS: The demonstration study impact was modest, and mostly from TasP. Increasing PrEP adherence and coverage improves impact substantially among FSW, but little overall. We recommend TasP in prevention packages.

Moderate rate of transmitted resistance mutations to antiretrovirals and genetic diversity in newly HIV-1 patients diagnosed in Benin.

OBJECTIVE: Seventeen years after the start of the IBAARV (Beninese initiative for access to antiretrovirals), transmitted drug resistance mutations in ARV-naïve patients and HIV-1 genetic diversity were investigated in Benin. RESULTS: Drug resistance mutations were detected in (27/248; 10.9%) according to the WHO SDRM 2009 list, with a predominance of mutations directed against NNRTIs drugs (24/248; 10%). Phylogenetic and recombination analyses showed a predominance of CRF02_AG strains (165/248; 66.5%) and a high genetic diversity with five other variants and 39 URFs (15.7%) which contained portions of strains that co-circulate in Benin. Eight recent transmission chains revealed active ongoing transmission of HIV-1 strains among ARV-naïve patients. Our study showed a moderate primary drug resistance mutations rate and also provided recent data on the HIV-1 variants that circulate in Benin. Regular monitoring of primary drug resistance is required to adapt HIV-1 treatment strategies and adoption of new WHO recommendations in Benin.

Comparison of adherence measurement tools used in a pre-exposure prophylaxis demonstration study among female sex workers in Benin.

BACKGROUND: Measuring adherence to PrEP (pre-exposure prophylaxis) remains challenging. Biological adherence measurements are reported to be more accurate than self-reports and pill counts but can be expensive and not suitable on a daily basis in resource-limited countries. Using data from a demonstration project on PrEP among female sex workers in Benin, we aimed to measure adherence to PrEP and compare self-report and pill count adherence to tenofovir (TFV) disoproxil fumarate (TDF) concentration in plasma to determine if these 2 measures are reliable and correlate well with biological adherence measurements. METHODS: Plasma TFV concentrations were analyzed in samples collected at day 14 follow-up visit and months 6, 12, 18, and 24 (or at last visit when follow-up was shorter). Self-reported adherence was captured at day 14 follow-up visit and then quarterly by asking participants to report the number of missed pills within the last week. For pill count, medications were refilled monthly and participants were asked to bring in their medication bottles at each follow-up visit. Using generalized estimating equations adherence measured by self-report and pill count was compared to plasma drug concentrations. RESULTS: Of 255 participants, 47.1% completed follow-up. Weighted optimal adherence combining data from all visits was 26.8% for TFV concentration, 56.0% by self-report and 18.9% by pill count. Adherence measured by both TFV concentrations and self-report decreased over time (P = .009 and P = .019, respectively), while the decreasing trend in adherence by pill count was not significant (P = .087). The decrease in adherence was greater using TFV concentrations than the other 2 adherence measures. CONCLUSION: With high levels of misreporting of adherence using self-report and pill count, the objective biomedical assessment of adherence via laboratory testing is optimal and more accurately reflects PrEP uptake and persistence. Alternative inexpensive and accurate approaches to monitor PrEP adherence should be investigated.

HIV treatment response among female sex workers participating in a treatment as prevention demonstration project in Cotonou, Benin.

OBJECTIVES: Female sex workers (FSWs) play a key role in HIV transmission in West Africa, while they have limited access to antiretroviral therapy (ART). In line with UNAIDS recommendations extending ART to all HIV-infected individuals, we conducted this demonstration project on immediate treatment as prevention (TasP) among FSWs in Cotonou, Benin. We report data on treatment response and its relation to adherence, as well as on ART-resistant genotypes. METHODS: Complete follow-up varied between 12 and 24 months. At each three-monthly visit, a questionnaire was administered, clinical examinations were carried out and blood samples collected. Adherence to treatment was estimated by self-report. Viral RNA was genotyped at baseline and final visits for drug resistance. Generalized estimating equations for repeated measures with a log-binomial link were used to analyze time trends and the association between adherence and virological response to treatment. RESULTS: One-hundred-seven HIV-positive and ART-naive FSWs were enrolled; 59.8% remained in the cohort till study completion and 62.6% had a final visit. Viral load<1000 (below quantification limit [<50]) was attained in 73.1% (64.6%) of participants at month-6, 84.8% (71.2%) at month-12, and 80.9% (65.1%) at the final visit. The proportion of women with suppressed (below quantification limit) viral load increased with increasing self-reported adherence (p = 0.06 (0.003), tests for trend). The proportion of participants with CD4≤500 also decreased drastically throughout follow-up (p < .0001). Twelve participants exhibited ART-resistant genotypes at baseline, but only two at their final visit. CONCLUSION: Our findings indicate that TasP is widely accepted among FSWs in Cotonou and could be implemented with relative success. However, due to mobility in this population, follow-up was sub-optimal, suggesting that large geographical coverage of FSW-friendly clinics is needed for sustained treatment implementation. We also fell short of the UNAIDS objective of 90% viral suppression among treated patients, underlining the need for better adherence support programs.

PrEP Use Among Female Sex Workers: No Evidence for Risk Compensation.

BACKGROUND: Little is known about risk compensation among female sex workers (FSW) on HIV pre-exposure prophylaxis (PrEP), and self-report of sexual behaviors is subject to bias. SETTING: Prospective observational PrEP demonstration study conducted among FSW in Cotonou, Benin. METHODS: Over a period of 24 months, we assessed and compared trends in unprotected sex as measured by self-report (last 2 or 14 days), by detection of sexually transmitted infections (STIs), and by vaginal detection of prostate-specific antigen and Y-chromosomal DNA, 2 biomarkers of semen exposure in the last 2 or 14 days, respectively. Trends were assessed and compared using a log-binomial regression that was simultaneously fit for all unprotected sex measures. RESULTS: Of 255 participants, 120 (47.1%) completed their follow-up. Prevalence of STI decreased from 15.8% (95% confidence interval: 11.8% to 21.0%) at baseline to 2.1% (95% confidence interval: 0.4% to 10.2%) at 24 months of follow-up (P-trend = 0.04). However, we observed no trend in self-report of unprotected sex in the last 2 (P = 0.42) or 14 days (P = 0.49), nor in prostate-specific antigen (P = 0.53) or Y chromosomal DNA (P = 0.25) over the same period. We observed no statistically significant difference between trends in self-report of unprotected sex and trends in biomarkers of semen exposure in the last 2 days (P = 0.14) or in the last 14 days (P = 0.29). CONCLUSIONS: We observed no evidence of risk compensation, and a decrease in STI among FSW on PrEP. PrEP intervention may be an opportunity to control STI among FSW. Future studies should assess risk compensation with biomarkers of semen exposure when possible.

Biological Validation of Self-Reported Unprotected Sex and Comparison of Underreporting Over Two Different Recall Periods Among Female Sex Workers in Benin.

BACKGROUND: Self-reported unprotected sex validity is questionable and is thought to decline with longer recall periods. We used biomarkers of semen to validate self-reported unprotected sex and to compare underreporting of unprotected sex between 2 recall periods among female sex workers (FSW). METHODS: At baseline of an early antiretroviral therapy and pre-exposure prophylaxis demonstration study conducted among FSW in Cotonou, Benin, unprotected sex was assessed with retrospective questionnaires, and with vaginal detection of prostate-specific antigen (PSA) and Y-chromosomal deoxyribonucleic acid (Yc-DNA). Underreporting in the last 2 or 14 days was defined as having reported no unprotected sex in the recall period while testing positive for PSA or Yc-DNA, respectively. Log-binomial regression was used to compare underreporting over the 2 recall periods. RESULTS: Unprotected sex prevalence among 334 participants was 25.8% (50.3%) according to self-report in the last 2 (or 14) days, 32.0% according to PSA, and 44.3% according to Yc-DNA. The proportion of participants underreporting unprotected sex was similar when considering the last 2 (18.9%) or 14 days (21.0%; proportion ratio = 0.90; 95% confidence interval, 0.72-1.13). Among the 107 participants who tested positive for PSA, 19 (17.8%) tested negative for Yc-DNA. CONCLUSIONS: Underreporting of unprotected sex was high among FSW but did not seem to be influenced by the recall period length. Reasons for discrepancies between PSA and Yc-DNA detection, where women tested positive for PSA but negative for Yc-DNA, should be further investigated.

Early antiretroviral therapy and daily pre-exposure prophylaxis for HIV prevention among female sex workers in Cotonou, Benin: a prospective observational demonstration study.

INTRODUCTION: In sub-Saharan Africa, HIV prevalence remains high, especially among key populations. In such situations, combination prevention including clinical, behavioural, structural and biological components, as well as adequate treatment are important. We conducted a demonstration project at the Dispensaire IST, a clinic dedicated to female sex workers (FSWs) in Cotonou, on early antiretroviral therapy (E-ART, or immediate "test-and-treat") and pre-exposure prophylaxis (PrEP). We present key indicators such as uptake, retention and adherence. METHODS: In this prospective observational study, we recruited FSWs from October 4th 2014 to December 31st 2015 and followed them until December 31st 2016. FSWs were provided with daily tenofovir disoproxil fumarate/emtricitabine (Truvada® ) for PrEP or received a first-line antiretroviral regimen as per Benin guidelines. We used generalized estimating equations to assess trends in adherence and sexual behaviour. RESULTS: Among FSWs in the catchment area, HIV testing coverage within the study framework was 95.5% (422/442). At baseline, HIV prevalence was 26.3% (111/422). Among eligible FSWs, 95.5% (105/110) were recruited for E-ART and 88.3% (256/290) for PrEP. Overall retention at the end of the study was 59.0% (62/105) for E-ART and 47.3% (121/256) for PrEP. Mean (±SD) duration of follow-up was 13.4 (±7.9) months for E-ART and 11.8 (±7.9) months for PrEP. Self-reported adherence was over 90% among most E-ART participants. For PrEP, adherence was lower and the proportion with 100% adherence decreased over time from 78.4% to 56.7% (p-trend < 0.0001). During the 250.1 person-years of follow-up among PrEP initiators, two seroconversions occurred (incidence 0.8/100 person-years (95% confidence interval: 0.3 to 1.9/100 person-years)). The two seroconverters had stopped using PrEP for at least six months before being found HIV-infected. In both groups, there was no evidence of reduced condom use. CONCLUSIONS: This study provides data on key indicators for the integration of E-ART and PrEP into the HIV prevention combination package already offered to FSWs in Benin. PrEP may be more useful as an individual intervention for adherent FSWs rather than a specific public health intervention. E-ART was a more successful intervention in terms of retention and adherence and is now offered to all key populations in Benin. STUDY REGISTRATION: ClinicalTrials.gov NCT02237.

[Fetopathological examination and congenital anomalies in the third trimester]. / Examens foetopathologiques et anomalies morphologiques au troisième trimestre de la grossesse.

The objective of this works to determine the frequency and nature of malformations detected by pathological study of aborted and stillborn third-trimester fetuses. The data were extracted from the files of the fetoplacental unit of Bordeaux University Hospital between January 2000 and December 2003. The study focused on fetuses with a gestational age corresponding to the third trimester (27 weeks to term). Death resulted from either induced abortion (IA) or spontaneous intrauterine death (IUD). A total of 1963 fetopathological examinations were performed during the study period, of which 524 involved third-trimester fetuses (109 IA, 49 IUD). The 109 IA represented nearly 15% of all abortions performed for medical reasons during the study period. The mean gestational age was 31.2 weeks in the IA group and 34.3 weeks in the IUD group (p < 1 per thousand). The abnormalities most frequently observed in the IA group consisted of neurological disorders (34 cases), cardiovascular disorders (26 cases), genetic syndromes (20 cases) and chromosomal aberrations (18 cases). In the IUDm group there were 20 minor malformations and 29 major malformations. The latter included 7 cardiac malformations, 7 central nervous system disorders, and 5 syndromes (Di George, n=3 ; Down's, n=2). The disorders indicating IA vere detected during the third trimester in 94 cases, and earlier in the other 15 cases. Despite the retrospective nature of this study, the results show that a significant number of major congenital malformations are only detected in the third trimester, by sonographic examination. This is compatible with the high frequency of major congenital malformations discovered at post mortem examination of third-trimester stillbirths.

Prenatal diagnosis and management of sex chromosome aneuploidy: a report on 98 cases.

OBJECTIVES: To analyse the management of pregnancy after prenatal diagnosis of sex chromosome aneuploidy (SCA) and the factors influencing genetic counselling and parental decision. METHODS: Between 1991 and 2001, 73 non-mosaic fetal SCA were diagnosed in our centre and 25 were referred to us from outside institutions. The same geneticist carried out genetic counselling. The outcome of pregnancies and the termination trend over time were determined according to the type of SCA. Clinical parental data were analysed in order to assess whether they influenced genetic counselling. RESULTS: 45,X was diagnosed in 41 fetuses. The main indication for karyotyping was abnormal ultrasound (83%). The termination rate was 93%. Sex chromosome polysomies (SCP) including 47,XXY, 47,XXX, and 47,XYY were diagnosed in 31, 16, and 10 fetuses respectively. The main indication for karyotyping was advanced maternal age (60%). The termination rate was 32, 25, and 20% respectively. The difference between the termination rate for local cases (25%) and referred cases (33%) was not significant. The termination rate for pregnancies with SCP was 38% in 1991 to 1994, 34% in 1995 to 1998, and 12% in 1999 to 2001. The parents' characteristics did not influence the outcome of pregnancy. CONCLUSIONS: The relatively low termination rate (28%) in pregnancies where the fetus was affected by SCP and the decreasing termination trend over time in our centre suggest an improved knowledge of the pathological conditions associated with SCP, influencing genetic counselling.