Immunological and virological response to haart in HIV-1 patients co-infected with hepatitis B and C viruses.

BACKGROUND: Among the countries highly endemic for viral hepatitis, Nigeria is found. Information on how triple infected persons (HIV, HBV, and HCV) fare on HAART in the country is lacking. Laboratory based investigation was carried out to assess the virological and immunological parameters of HIV-1 infected patients co-infected with Hepatitis B and C, accessing care at the Nigerian Institute of Medical Research. It was a case controlled study. OBJECTIVES: The study aimed to compare the laboratory data of HIV-HBV-HCV patients seen between 2006 and 2009 with HIV-1 monoinfected patients in the same period, on HAART according to the national guideline and followed up for 12 months. METHODS: Detection of Hepatitis B surface Antigen (HBsAg) and Hepatitis C Virus Antibody (HCVAb) were assayed using ELISA techniques (Bio Rad and DIA PRO respectively). The CD4 and HIV viral load were determined using the Cyflow Counter/Kits (Partec) and the Amplicor HIV-1 Monitor Test V1.5 (Roche) techniques respectively. RESULTS: Forty-one (0.4%) of the 10,214 HIV-1 patients seen during the period were co-infected with both HBV and HCV. Over the 12 month-period, median HIV-1 viral load and CD4 count reduced and increased respectively (12,205-200 RNA copies/mL; 210-430 cells/mL from baseline - 12th month), and for the HIV-1 monoinfected patients (36,794-200 RNA copies/mL [p=0.5485] and 206-347 cells/mL [p=0.7703] from baseline - 12th month). CONCLUSION: There seems to be no significant influence of hepatitis B and C in HIV infection on HAART judging by the CD4 and viral load profiles which were similar in the two groups.

Genetic studies in the Nigerian population implicate an MSX1 mutation in complex oral facial clefting disorders.

BACKGROUND: Orofacial clefts are the most common malformations of the head and neck, with a worldwide prevalence of 1 in 700 births. They are commonly divided into CL(P) and CP based on anatomic, genetic, and embryologic findings. A Nigerian craniofacial anomalies study (NigeriaCRAN) was set up in 2006 to investigate the role of gene-environment interaction in the origin of orofacial clefts in Nigeria. SUBJECTS AND METHODS: DNA isolated from saliva from Nigerian probands was used for genotype association studies and direct sequencing of cleft candidate genes: MSX1 , IRF6 , FOXE1, FGFR1 , FGFR2 , BMP4 , MAFB, ABCA4 , PAX7, and VAX1 , and the chromosome 8q region. RESULTS: A missense mutation A34G in MSX1 was observed in nine cases and four HapMap controls. No other apparent causative variations were identified. Deviation from Hardy Weinberg equilibrium (HWE) was observed in these cases (p = .00002). A significant difference was noted between the affected side for unilateral CL (p = .03) and bilateral clefts and between clefts on either side (p = .02). A significant gender difference was also observed for CP (p = .008). CONCLUSIONS: Replication of a mutation previously implicated in other populations suggests a role for the MSX1 A34G variant in the development of CL(P).

Establishment of reference values of CD4 and CD8 lymphocyte subsets in healthy Nigerian adults.

A total of 2,570 apparently healthy human immunodeficiency virus-negative adults from the six geopolitical zones in the country were enrolled in our study in 2006. The samples were assayed using the Cyflow technique. Data were analyzed using the Statistical Package for Social Scientists (SPSS). The majority (64%) of the participants had CD4 counts within the range of 501 to 1,000 cells/microl. The reference range for CD4 was 365 to 1,571 cells/microl, while the reference range for CD8 was 145 to 884 cells/microl.

Comparison of Dynabeads and Capcellia methods with FACScount for the estimation of CD4 T-lymphocyte levels in HIV/AIDS patients in Lagos, Nigeria.

OBJECTIVE: To compare the efficacy of the Capcellia assay and the Dynabeads technique against the FACScount technique in the estimation of CD4 T-lymphocytes within a Nigerian setting. DESIGN: Prospective study. SETTING: Urban area in Nigeria. SUBJECTS: Ninety seven subjects (51 HIV seronegative and 46 HIV seropositive adults) seen in the blood banks and two out patient clinics in Lagos within the study period. MAIN OUTCOME MEASURES: Dynadeads technique with a higher correlation coefficient is a feasible alternative to the FACScount method. RESULTS: There was an overall correlation coefficient of r = 0.75 for CD4 cell counts as determined by the Dynabeads technique in comparison with the FACScount method. Also, an overall correlation coefficient of r = 0.17 for CD4 cell counts as determined by the Capcellia technique against the FACScount method. CONCLUSION: Dynabeads technique is simple to carry out and cheaper in terms of demand for human expertise and infrastructural requirements than the FACScounts. Therefore, it was recommended for use in the laboratory for monitoring of ARV therapy in Nigeria and any other resource poor

Limitations to Access and Use of Antiretroviral Therapy (ART) Among HIV Positive Persons in Lagos, Nigeria.

The study was designed to examine the knowledge and perception of HIV positive persons about the antiretroviral therapy (ART) program and to determine their ability to pay for ART and the treatment of other opportunistic infections in Nigeria. This is aimed at identifying factors that may impede effective delivery and utilization of ART in the country. One hundred and twenty-five HIV positive persons seeking ART at the Nigerian Institute of Medical Research (NIMR) clinic, Lagos, were studied using questionnaires. Respondents' average monthly income was N11,253.00 (US$90.00). Almost 26% (25.6%) were unwilling to seek ART at the nearest hospital because of fear of stigmatization. While 9% wanted the therapy for free, the majority was willing to pay N500.00 (US$4.00) per month. The average affordable price based on the subjects' assessment was N905.00 (US$7.24), while the median was N500.00 (US$4.00) per month. Eighty-eight percent believed ART would prolong their lives. The ART drugs need to be affordable and building on the positive perceptions of ART is imperative.

Evaluation of the Nigerian national antiretroviral (ARV) treatment training programme.

There is an understanding that greater availability of HIV treatment for the 40.3 million people currently infected with HIV is a humanitarian imperative that could prolong the lives of millions, restore economic productivity, and stabilise societies in some of the world's hardest-hit regions. The Nigerian government recognises that the country has the third highest burden of infection, with people living with HIV estimated to total 4.0 million, and so in 2002 commenced the implementation of one of Africa's largest antiretroviral (ARV) treatment programmes. A successful ARV programme requires that all components of a functional management system be put in place for effective and efficient functioning. This would include logistics, human resources, financial planning, and monitoring and evaluation systems, as well as sustainable institutional capacities. The Nigerian national ARV treatment training programme was conceived to meet the human resource needs in hospitals providing ARV therapy. This paper reports on the evaluation of the training programme. It examines knowledge and skills gained, and utilisation thereof. Recommendations are made for improved training effectiveness and for specific national policy on training, to meet the demand for scaling up therapy to the thousands who need ARV.

Estimation of the rate of mother to child transmission of HIV in Nigeria.

Definitive diagnosis of HIV infection in infants < 18 months of age who were born to HIV-infected mothers is still posing some difficulty in Nigeria and other developing countries. Within this age definitive diagnosis can only be carried out by antigen based techniques which are indeed not available in these developing countries. This has resulted in the absence of authoritative data on the rate of mother-to-child transmission in these countries. Nigeria inclusive. The present pilot study was therefore carried out to generate some information on the rate of mother to child transmission in Nigeria using the PCR technique. Plasma samples were obtained from 68 children of both sexes less than 18 months of age and who were born to HIV infected mothers. The samples were collected from two pediatric departments. in Lagos and in Benin. The presence of HIV 1 RNA in each of the samples. was determined using the Amplicor Monitor V 1.5 technique (Roche Diagnostics). Data showed that HIV-1 RNA was detected in 15 of the 68 samples tested. This gave an HIV-1 RNA detection rate of 22%. Among women who had some intervention, the rate of transmission of infection was 11% while the rate among those without intervention was 30%. The 22% transmission rate recorded in this study is close to the range of 25 to 35% that has been reported in several developed and a few developing countries. A multicenter nationwide study will still be needed to determine the national mother to child transmission rate in Nigeria.

Aetiological agents of vaginitis in Nigerian women.

This study focuses on the identification of aetiological agents of vaginitis in Nigerian women. Study subjects are drawn from patients presenting with lower abdominal pain, vaginal discharge and itching at the gynaecology clinic of Lagos University Teaching Hospital and at the Clinical Centre of the Nigerian Institute of Medical Research, Yaba, Lagos, between January 2001 and July 2002. A total of 250 patients gave informed consent to participate in the study. The patients also had pre- and post-test human immunodeficiency virus (HIV) counselling. Each patient completed a questionnaire in order to provide biographical data, past clinical history and socio-economic background information. A cervical swab (CS) and a high-vaginal swab (HVS) were obtained from each patient. Swab samples were examined for pH and under light microscopy by Gram's stain and as wet preparations in 10% potassium hydroxide. Subsequently, samples were cultured on appropriate media at optimal conditions and a drug sensitivity profile for all isolates was determined by standard methods. Blood samples were screened and confirmed for HIV antibodies. Bacterial, fungal and parasitic pathogens were identified or isolated in samples from 241 (96.4%) of the women. Bacterial agents (Neisseria, Streptococcus and Staphylococcus species) were predominant in 128 (51.2%) patients, followed by fungi in 108 (43.2%) and parasites (Trichomonas vaginalis) in five (2.0%). Sensitivity to ciprofloxacin was seen in 40% of Staphylococcus species and in 90% of Neisseria species. Positive HIV serology was seen in 25 (10%) of the 250 women studied, 20 (80%) of which had concurrent microbial infections. Overall, a broad spectrum of microbial agents were shown to be responsible for vaginitis in the group of patients studied.

Diagnostic methods for typhoid fever in Nigeria.

In this study, 65 patients are screened for Salmonella typhi by conventional culture and the Widal test. In addition, the patients undergo full blood count are screened for malaria parasites. Of the 65 patients, 50 report febrile conditions, while the remaining 15 are used as a control population. In the febrile group, 13 (26%) were positive for S. typhi, while in the control group only one (7%) was positive for S. typhi. Overall, 36 (64.3%) patients had malaria parasites. Patients with a higher O antibody titre (> or = 1 in 80) by Widal test were found to have consumed both tap water and pure water. More females (10/14; mean age: 33) had typhoid fever as a result of S. typhi infection, the majority of which were isolated from stool samples (57%). Nine of the isolates were also positive for malaria parasites, seven of which were in the trophozoite stage. Plasmodium falciparum was the predominant parasite (78%), the remainder being P. malariae. The majority of patients (12/14) with typhoid fever had normal PCV values. In conclusion, it is recommended that tests for the diagnosis of typhoid fever in Nigeria should include malaria parasites, S. typhi culture from faecal samples, and the Widal test.

HIV association with conventional STDS (sexual transmitted diseases) in Lagos State, Nigeria.

The study examined a possible association between HIV infection and conventional sexually transmitted diseases (STDS) in a population of 700 patients seen in some hospitals and clinics in Lagos State between November 1997 and December 1999. The patients were drawn mainly from LUTH and Jolad hospitals in Lagos State. In these hospitals, patients who presented with symptoms of STDS were screened clinically and microbiologically for agents of STDS and HIV antibodies. Screening was carried out using conventional methods. A total of 150 (21.5%) were found positive for various STDS while 550 (78.5%) were negative Also, 109 (15.8%) were sero-positive for HIV while 591 (84.4%) were sero-negative. The frequency of STDS diagnosed were, Treponema pallidum, 38(25.3%), Neisseria gonorrhoea 3(2.0%), Chlamydia trachomatis 26(17.3), Hepatitis B virus 60(40.0%) Staphylococcus aureaus, 20 (13.3%) and Candida albicans 3(2.0%). Data showed that Syphillis was the most prevalent STDS diagnosed while Calbicans and N. gonorrhoea are the least. Amongst the 150 (21.5%) patients positive with STDS, 82(54.65%) were found to be positive for HIV antibodies. The remaining 68(45.3%) patients were negative for HIV. The difference in sero-prevalence on the true group of patients rates was significant. The higher rate in the STDS patients strongly suggest some association between HIV infections andSTDS amongst the patients studied p = 0.05. It was also recorded that HIV-1 infection is four times more prevalent than HIV-2 in these patients.

Prevalent bacterial species and novel phylotypes in advanced noma lesions.

The purpose of this study was to determine the bacterial diversity in advanced noma lesions using culture-independent molecular methods. 16S ribosomal DNA bacterial genes from DNA isolated from advanced noma lesions of four Nigerian children were PCR amplified with universally conserved primers and spirochetal selective primers and cloned into Escherichia coli. Partial 16S rRNA sequences of approximately 500 bases from 212 cloned inserts were used initially to determine species identity or closest relatives by comparison with sequences of known species or phylotypes. Nearly complete sequences of approximately 1,500 bases were obtained for most of the potentially novel species. A total of 67 bacterial species or phylotypes were detected, 25 of which have not yet been grown in vitro. Nineteen of the species or phylotypes, including Propionibacterium acnes, Staphylococcus spp., and the opportunistic pathogens Stenotrophomonas maltophilia and Ochrobactrum anthropi were detected in more than one subject. Other known species that were detected included Achromobacter spp., Afipia spp., Brevundimonas diminuta, Capnocytophaga spp., Cardiobacterium sp., Eikenella corrodens, Fusobacterium spp., Gemella haemoylsans, and Neisseria spp. Phylotypes that were unique to noma infections included those in the genera Eubacterium, Flavobacterium, Kocuria, Microbacterium, and Porphyromonas and the related Streptococcus salivarius and genera Sphingomonas and TREPONEMA: Since advanced noma lesions are infections open to the environment, it was not surprising to detect species not commonly associated with the oral cavity, e.g., from soil. Several species previously implicated as putative pathogens of noma, such as spirochetes and Fusobacterium spp., were detected in at least one subject. However, due to the limited number of available noma subjects, it was not possible at this time to associate specific species with the disease.

Care-seeking behavioural patterns, awareness and diagnostic processes in patients with smear- and culture-positive pulmonary tuberculosis in Lagos, Nigeria.

This study was carried out in 2 chest referral clinics in Lagos, Nigeria, between February 2000 and May 2001 to assess the effects of knowledge, attitude, and practice of 168 newly diagnosed tuberculosis (TB) patients on their care-seeking behaviour. At the onset of symptoms patients sought treatment from one or more of the local private orthodox and traditional health providers, and patent medicine dealers before presenting at a chest clinic. There was a correlation between the level of knowledge and awareness of TB with time of presentation at the chest clinic. Of the 32 patients who presented and were diagnosed at the chest clinics within 4 weeks of onset of symptoms, 50% had knowledge of the aetiological agent of the disease and 60% had some idea of the mode of transmission. Of the 105 patients who presented and were diagnosed 12 weeks after the onset of symptoms, 97% had no knowledge of the aetiological agent and 95% had no idea of the mode of transmission. Overall there was a low level of knowledge and awareness of the disease as well as an apparently high level of improper health care-seeking behaviour amongst the patients studied which probably contributed significantly to the delay in early and accurate diagnosis of most of the cases. These findings indicate an urgent need to educate communities and care providers on the cause and mode of transmission of TB, and the need to attend designated health facilities for early diagnosis and proper treatment.

Isolation of fusobacteria from the oral cavities of malnourished Nigerian children living in agricultural and herding villages.

A previous study demonstrated the presence and possible involvement of Fusobacterium necrophorum in the pathogenesis of noma lesions of children living in agricultural and herding villages in northwestern Nigeria. In order to determine if F. necrophorum was part of the oral flora of malnourished children with no noma lesions, a study of the fusobacteria present in the oral cavities of 30 children, 2-6 years of age in Sokoto State, was undertaken. Swabs taken of the oral cavity were cultured on selective fusobacteria medium using conventional anaerobic microbiological techniques. F. nucleatum was recovered from each child and F. necrophorum was isolated from the oral cavity of only one child. The presence of F. nucleatum and the lack of F. necrophorum, except in one case, suggests that the latter is not normal flora in the children at risk for noma. F. necrophorum, a putative trigger organism for noma may gain a foothold only when certain staging conditions (i.e., lowered host resistance and/or oral lesion) are present.

Increased plasma levels of histidine and histamine in falciparum malaria: relevance to severity of infection.

Severe falciparum malaria, with its associated hyperpyrexia, distorts plasma levels of large neutral amino acids (NAA) and consequently, brain uptake of individual NAA. Since brain levels of NAA determine cerebral synthesis of monoamines (serotonin, histamine, catecholamines), we measured plasma concentrations of NAA, and also plasma histamine (Hm) in children with falciparum malaria and in uninfected controls. Malaria elicited a marked (P < 0.025) increase in plasma histidine (His) with a 5-fold significant (P < 0.001) elevation in histamine, as well as a 2.5-fold increase (P < 0.005) in plasma phenylalanine (Phe), with no changes in the other NAA. Using kinetic parameters of NAA transport at human blood-brain barrier (BBB), we showed that malaria significantly altered calculated brain uptake of His (+30%), Phe (+96%), Trp (-30%) and Ile (-27%), with no change in the other NAA, compared with controls. Our data suggested enhanced cerebral synthesis of Hm with impaired production of serotonin and the catecholamines in the patients, and therefore, the need to evaluate the encephalopathy in severe malaria within the context of abnormalities in metabolism of Hm and other monoamines resulting from imbalance in plasma levels of the large neutral amino acids. Of clinical relevance also is the impaired inactivation of increased brain Hm by antimalarials such as the widely used aminoisoquinolines leading to elevated brain levels of imidazole-4-acetic acid (IAA), a potent inducer of a sleep-like state often accompanied by seizures, analgesia, decreased blood pressure and other effects.

Oro-facial gangrene (noma/cancrum oris): pathogenetic mechanisms.

Cancrum oris (Noma) is a devastating infectious disease which destroys the soft and hard tissues of the oral and para-oral structures. The dehumanizing oro-facial gangrenous lesion affects predominantly children ages 2 to 16 years, particularly in sub-Saharan Africa, where the estimated frequency in some communities varies from 1 to 7 cases per 1000 population. The risk factors are poverty, malnutrition, poor oral hygiene, residential proximity to livestock in unsanitary environments, and infectious diseases, particularly measles and those due to the herpesviridae. Infections and malnutrition impair the immune system, and this is the common denominator for the occurrence of noma. Acute necrotizing gingivitis (ANG) and oral herpetic ulcers are considered the antecedent lesions, and ongoing studies suggest that the rapid progression of these precursor lesions to noma requires infection by a consortium of micro-organisms, with Fusobacterium necrophorum (Fn) and Prevotella intermedia (Pi) as the suspected key players. Additional to production of a growth-stimulating factor for Pi, Fn displays a classic endotoxin, a dermonecrotic toxin, a cytoplasmic toxin, and a hemolysin. Without appropriate treatment, the mortality rate from noma is 70-90%. Survivors suffer the two-fold afflictions of oro-facial mutilation and functional impairment, which require a time-consuming, financially prohibitive surgical reconstruction.

Noma (cancrum oris): questions and answers.

Noma (cancrum oris) is an infectious disease which destroys the oro-facial tissues and other neighboring structures in its fulminating course. It affects predominantly children aged 2-16 years in sub-Saharan Africa where the estimated frequency in some communities may vary from one to seven cases per 1000 children. The key risk factors are poverty, malnutrition, poor oral hygiene, deplorable environmental sanitation, close residential proximity to livestock, and infectious diseases, particularly measles. Malnutrition acts synergistically with endemic infections in promoting an immunodeficient state, and noma results from the interaction of general and local factors with a weakened immune system as the common denominator. Acute necrotizing gingivitis (ANG) is considered the antecedent lesion. Current studies suggest that evolution of ANG to noma requires infection by a consortium of microorganisms with Fusobacterium necrophorum and Prevotella intermedia as the suspected key players. Without appropriate treatment, mortality rate is 70-90%. Survivors suffer the two-fold affliction of oro-facial disfigurement and functional impairment. Reconstructive surgery of the resulting deformity is time-consuming and financially prohibitive for the victims who are poor.

Microbiological understandings and mysteries of noma (cancrum oris).

The microbiologic history of noma was reviewed. Studies have associated the disease process with large numbers of fusiform bacilli and spirochetal organisms. In order to study the microbiology of the staging and infection periods of noma 62 Nigerian children, aged 3-14 years, 22 children had acute necrotizing ulcerative gingivitis (ANUG) and were also malnourished, 20 exhibited no acute necrotizing ulcerative gingivitis but were malnourished and 20 were free of acute necrotizing ulcerative gingivitis and in good nutritional state) were evaluated for the presence of viruses and oral microorganisms. The ANUG cases in the malnourished children had a higher incidence of Herpesviridae, the main virus being detected was cytomegalovirus. There were more anaerobic microorganisms recovered, with Prevotella intermedia as the predominant isolate, in the malnourished children as compared to the healthy children. A study of the predominant microflora in active sites of noma lesions was carried out in eight noma patients, 3-15 years of age, in Sokoto State, northwestern Nigeria. Fusobacterium necrophorum was recovered from 87.5% of the noma lesions. Oral microorganisms isolated included Prevotella intermedia, alpha-hemolytic streptococci and Actinomyces spp. which were isolated from 75.0, 50.0 and 37.5% of the patients, respectively. Peptostreptococcus micros, Veillonella parvula, Staphylococcus aureus and Pseudomonas spp. were each recovered from one lesion. All strains were observed to be sensitive to all of the antibiotics tested with the exception of one strain of P. intermedia which showed resistance to penicillin. The pathogenic mechanisms of F. necrophorum as a trigger organism were discussed. The isolation from human noma lesions of F. necrophorum, a pathogen primarily associated with animal diseases, may have important etiologic and animal transmission implications.

Living conditions of children at risk for noma: Nigerian experience.

The study reported in this paper was carried out in the Northwestern and Southwestern regions of Nigeria, between October 1996 and April 1998. The study examined the possible contributory role of living conditions in the development of acute necrotizing gingivitis (ANG) or noma from oral lesions. Questionnaire data obtained from 42 fresh noma cases seen in the Northwest and four fresh cases seen in the Southwest were examined. In addition 46 cases of advanced ANG from the Southwest were included. The main focus was to compare some of the environmental living conditions of cases with advanced ANG and those with noma in these regions. All the noma and ANG cases were seen in children aged 2-12 years. The level of good oral hygiene practices and general environmental living conditions were significantly higher in the Southwest than in the Northwest. Data also showed that living in close proximity with livestock was significantly higher in the Northwest than in the Southwest (P < 0.05). The environmental living conditions of children in the Northwest were further compounded by poor sanitary faecal disposal practices as well as minimal access to potable water. The overall data indicated that living in substandard accommodations, exposure to debilitating childhood diseases, living in close proximity to livestock, poor oral hygiene, limited access to potable water and poor sanitary disposal of human and animal faecal waste could have put the children in the Northwest at higher risk for noma than the children in the Southwest. These could have been responsible for the higher prevalence of noma in the Northwest than in the Southwest.

Pathogenesis of cancrum oris (noma): confounding interactions of malnutrition with infection.

This study showed that impoverished Nigerian children at risk for cancrum oris (noma) had significantly reduced plasma concentrations of zinc (< 10.8 micromol/L), retinol (< 1.05 micromol/L), ascorbate (< 11 micromol/L), and the essential amino acids, with prominently increased plasma and saliva levels of free cortisol, compared with their healthy counterparts. The nutrient deficiencies, in concert with previously reported widespread viral infections (measles, herpesviruses) in the children, would impair oral mucosal immunity. We postulate, subject to additional studies, that evolution of the oral mucosal ulcers including acute necrotizing gingivitis to noma is triggered by a consortium of microorganisms of which Fusobacterium necrophorum is a key component. Fusobacterium necrophorum elaborates several dermonecrotic toxic metabolites and is acquired by the impoverished children via fecal contamination resulting from shared residential facilities with animals and very poor environmental sanitation.