Detection of trace aflatoxin M1 in human urine using a commercial ELISA followed by HPLC.

Aflatoxin is a liver carcinogen, and rapid, inexpensive methods to detect its urinary biomarkers are needed. We used a commercial enzyme-linked immuno-sorbent assay (ELISA) for aflatoxin M1 in urine (Helica Biosystems) to test 52 Haitian samples. Using this ELISA, we detected traces above the limit of detection (0.2 ng/ml urine) but below the limit of quantitation (0.4 ng/ml) in 14 samples. Liquid chromatography of all 52 Haitian urine samples revealed that only 11 had quantifiable AFM1 (mean: 29.5 pg/ml, standard error: 10.8, range: 2.94-96.5 pg/ml). The Helica ELISA may have detected forms of aflatoxin other than AFM1 in the Haitian samples, or matrix enhancement may have affected results at low AFM1 concentrations. This ELISA may serve as an initial, qualitative indicator of aflatoxin exposure for epidemiological purposes. But this method's utility as a precise and specific indicator of AFM1 concentrations will require additional refinement and validation.

Attributes of diagnostic tests to increase uptake of dual testing for syphilis and HIV in Port-au-Prince, Haiti.

Introduction Syphilis and HIV screening is highly recommended for pregnant women and those at risk for infection. We used conjoint analysis to identify factors associated with testing preferences for HIV and syphilis infection. Methods We recruited 298 men and women 18 years and over seeking testing or care at GHESKIO (Haitian Study Group for Kaposi's Sarcoma and Opportunistic Infections) clinics. We created eight hypothetical dual HIV-syphilis test profiles varying across six dichotomous attributes. Participants were asked to rate each profile using Likert preference scales. An impact score was generated for each attribute by taking the difference between the preference scores for the preferred and non-preferred level of each attribute. Two-sided one-sample t-test was used to generate p values. Results Of 298 study participants, 61 (20.5%) were male. Of 237 females, 49 (20.7%) were pregnant. Cost (free vs. US$4; p < .0001) had the highest impact on willingness to test, followed by number of blood draws (1 vs. 2; p < .0001), blood draw method (fingerprick vs. venipuncture; p < .0001), test type (rapid vs. laboratory; p = .0005), and time-to-result (20 minutes vs. 1 week; p = .0139). Conclusion HIV and syphilis testing preferences for this study sample in Port-au-Prince prioritized cost, single fingerprick, laboratory-based testing and timeliness.

Dual rapid lateral flow immunoassay fingerstick wholeblood testing for syphilis and HIV infections is acceptable and accurate, Port-au-Prince, Haiti.

BACKGROUND: Dual rapid tests for HIV and syphilis infections allow for detection of HIV infection and syphilis at the point-of-care. Those tests have been evaluated in laboratory settings and show excellent performance but have not been evaluated in the field. We evaluated the field performance of the SD BIOLINE HIV/Syphilis Duo test in Port-au-Prince, Haiti using whole blood fingerprick specimens. METHODS: GHESKIO (Haitian Study Group for Kaposi's Sarcoma and Opportunistic Infections) clinic attendees 18 years of age or older were invited to participate. Venipuncture blood specimens were used for reference testing with standard commercially available tests for HIV and syphilis in Haiti. The sensitivity and specificity of the Duo test compared to the reference standard were calculated. The exact binomial method was used to determine 95 % confidence intervals (CI). RESULTS: Of 298 study participants, 237 (79.5 %) were female, of which 49 (20.7 %) were pregnant. For the HIV test component, the sensitivity and specificity were 99.2 % (95 % CI: 95.8 %, 100 %) and 97.0 % (95 % CI: 93.2 %, 99.0 %), respectively; and for the syphilis component were 96.5 % (95 % CI: 91.2 %, 99.0 %) and 90.8 % (95 % CI: 85.7 %, 94.6 %), respectively. In pregnant women, the sensitivity and specificity of the HIV test component were 93.3 % (95 % CI: 68.0 %, 99.8 %) and 94.1 % (95 % CI: 80.3 %, 99.3 %), respectively; and for the syphilis component were 100 % (95 % CI:81.5 %, 100 %) and 96.8 % (95 % CI:83.3 %, 99.9 %), respectively. CONCLUSION: The Standard Diagnostics BIOLINE HIV/Syphilis Duo dual test performed well in a field setting in Haiti and should be considered for wider use.

Urinary aflatoxin M1 in Port-au-Prince and a rural community in north-east Haiti.

Aflatoxins (AFs) are hepatocarcinogenic mycotoxins that can contaminate grains and oil seeds in tropical and sub-tropical areas and have been detected in maize and peanut products of Haiti. The first objective was to assess human exposure to AFs among Haitians at an urban hospital (GHESKIO) and a rural health centre (HCBH). The second objective was to test the association between AF exposure and reported dietary intake of potentially contaminated foods, such as maize, peanut products and milk. Measurement of urinary AFM1 by HPLC revealed that among 367 participants 14% and 22% at GHESKIO and HCBH, respectively, had detectable AFM1. The maximum and median AFM1 concentrations for all detected samples were 700 pg AFM1 ml(-1) and 11.7 pg ml(-1), respectively. Detection of AFM1 was significantly associated with peanut consumption (p < 0.05). Controlling for diet and age group in a logit model, patients who reported peanut consumption the day of the survey and patients from HCBH had greater log odds of excreting detectable AFM1 (p < 0.001 and 0.002, respectively); females had lower log odds (p = 0.020). Recalled frequency of consuming non-dairy animal-sourced foods, an indicator of diet quality, approached significance (p = 0.056) as an inverse predictor of urinary AFM1 detection. The findings augur the need for interventions that will improve food safety in Haiti and limit exposure to AFs, particularly among rural communities.

"I am proud of myself, just the way I am" (Mwen fyé de tét mwen, jan mwen ye ya): a qualitative study among young Haitian women seeking care for sexually transmitted infections (STIs) in Haiti.

Haitian women are twice as likely as men to have HIV/AIDs. Factors underlying the feminization of HIV are complex. Self-esteem is an important correlate of sexual behavior. However, its meaning and impact on health behaviors may be influenced by cultural factors. This qualitative study took place in Haiti 4 months after the 2010 earthquake and examines the meaning of self-esteem among young Haitian women seeking treatment for a recurrent sexually transmitted infection (STI). The meaning of self-esteem was derived from a sense of gratitude and was rooted in their ability to provide for family. This may have led to behaviors such as not using condoms or having sex with partners in concurrent relationships. This article highlights the resilience and resourcefulness of Haitian women, provides insight into how women with apparent positive self-images were led to make choices that placed them at high risk for contracting HIV, and concludes with recommendations for future interventions.

Rapid-Testing Technology and Systems Improvement for the Elimination of Congenital Syphilis in Haiti: Overcoming the "Technology to Systems Gap".

Background. Despite the availability of rapid diagnostic tests and inexpensive treatment for pregnant women, maternal-child syphilis transmission remains a leading cause of perinatal morbidity and mortality in developing countries. In Haiti, more than 3000 babies are born with congenital syphilis annually. Methods and Findings. From 2007 to 2011, we used a sequential time series, multi-intervention study design in fourteen clinics throughout Haiti to improve syphilis testing and treatment in pregnancy. The two primary interventions were the introduction of a rapid point-of-care syphilis test and systems strengthening based on quality improvement (QI) methods. Syphilis testing increased from 91.5% prediagnostic test to 95.9% after (P < 0.001) and further increased to 96.8% (P < 0.001) after the QI intervention. Despite high rates of testing across all time periods, syphilis treatment lagged behind and only increased from 70.3% to 74.7% after the introduction of rapid tests (P = 0.27), but it improved significantly from 70.2% to 84.3% (P < 0.001) after the systems strengthening QI intervention. Conclusion. Both point-of-care diagnostic testing and health systems-based quality improvement interventions can improve the delivery of specific evidence-based healthcare interventions to prevent congenital syphilis at scale in Haiti. Improved treatment rates for syphilis were seen only after the use of systems-based quality improvement approaches.

Improving outcomes in infants of HIV-infected women in a developing country setting.

BACKGROUND: Since 1999 GHESKIO, a large voluntary counseling and HIV testing center in Port-au-Prince, Haiti, has had an ongoing collaboration with the Haitian Ministry of Health to reduce the rate of mother to child HIV transmission. There are limited data on the ability to administer complex regimens for reducing mother to child transmission and on risk factors for continued transmission and infant mortality within programmatic settings in developing countries. METHODS AND FINDINGS: We analyzed data from 551 infants born to HIV-infected mothers seen at GHESKIO, between 1999 and 2005. HIV-infected mothers and their infants were given "short-course" monotherapy with antiretrovirals for prophylaxis; and, since 2003, highly active antiretroviral therapy (HAART) when clinical or laboratory indications were met. Infected women seen in the pre-treatment era had 27% transmission rates, falling to 10% in this cohort of 551 infants, and to only 1.9% in infants of women on HAART. Mortality rate after HAART introduction (0.12 per year of follow-up [0.08-0.16]) was significantly lower than the period before the availability of such therapy (0.23 [0.16-0.30], P<0.0001). The effects of maternal health, infant feeding, completeness of prophylaxis, and birth weight on mortality and transmission were determined using univariate and multivariate analysis. Infant HIV-1 infection and low birth weight were associated with infant mortality in less than 15 month olds in multivariate analysis. CONCLUSIONS: Our findings demonstrate success in prevention of mother-to-child HIV transmission and mortality in a highly resource constrained setting. Elements contributing to programmatic success include provision of HAART in the context of a comprehensive program with pre and postnatal care for both mother and infant.