[National coordination of the ambulatory treatment centers (ATC) in Gabon: a new process to conduct the scaling up of care for people living with HIV-AIDS]. / La coordination nationale des centres de traitement ambulatoire au Gabon : une expérience novatrice de décentralisation opérationnelle de la prise en charge du VIH-sida.

Gabonese authorities are strongly mobilized in the fight against AIDS. With a national seroprevalence of 5.9%, 54,000 people are living with HIV-AIDS. Starting from the experience conducted on three ambulatory treatment centers (ATC) [Libreville, Franceville, Port-Gentil] in collaboration with the French Red Cross, Gabonese authorities decided the scaling up of HIV patients' care to seven new ATC at a national level. The increasing number of structures conducted to standardize treatment's guidelines, training of caregivers, quality of care, coordination, monitoring and evaluation. Technical and medical supervision of the ten ATC were attributed to the French Red Cross by Gabonese authorities with the financial support of the French Agency for Development. The ten ATC, founded by the ministry of public health, were then organized within a network under the responsibility of a national coordination. This structure created in September 2007 represents the main organism to conduct, evaluate and follow-up activities and functioning of the ten ATC. All these activities are conducted in agreement with the national program of fight against AIDS. Within one year this structure of coordination allowed to organize the training of 208 caregivers, to elaborate a team of national and international experts, to start a process of national guidelines, to elaborate technical procedures and indicators for monitoring, follow-up and evaluation. In June 2007, 5 ATC were in function taking care of 7,062 PLWA. In November 2008, 9 ATC were in function taking care of 8,174 PLWA. This project is planned for four years. It might allow to structure and organize a national network of care for PLWA according to the national strategy. This procedure of scaling up under the responsibility of a national team of technical and operational coordination is a new process. It completes and strengthens the national organization process.

[Ten years of commitment to persons living with HIV-AIDS: evaluation of the management in three ambulatory treatment centers of the French Red Cross in Africa]. / Dix ans d'engagement auprès des personnes vivant avec le VIH-sida : évaluation de la prise en charge dans trois centres de traitement ambulatoire de la Croix-Rouge française en Afrique.

The French Red Cross (FRC) has developed a strategy for the follow-up of people living with HIV-AIDS in Africa by setting-up and managing healthcare centers specialized in the management of HIV infection. Nearly one hundred and seventy thousand patients have had access to care in fifteen Ambulatory Treatment Centers (ATCs). For the ten years anniversary of the FRC's AIDS programs, we present the results of the evaluation of three ATCs in Africa. These results which show a low mortality rate in the patients on antiretroviral therapy and a very low rate of second line patients (1.5%) confirm the efficiency of the management of people living with HIV in the ATCs and generally of the AIDS programs of the FRC. However, the mortality remains high in patients who have a CD4+ cell count of less than 50/mm3 when antiretrovirals (ARVs) initiation. Services and care dispensed in the ATCs and particularly the antiretroviral therapy have demonstrated their feasibility and efficiency. In ten years, the challenge of the management of HIV has changed. Today, there is a need to integrate additional actions in the area of the supply of primary healthcare, of training and of motivation of the care providers. In addition, the follow-up/evaluation of the patient management programs remains useful to determine the impact and long-term efficacy of ARVs in resource-limited countries.

Correlation between HIV provirus burden and in utero transmission.

OBJECTIVE: No predictive parameters of in utero or perinatal vertical transmission of HIV to newborns are known at present. Vertical transmission may be related to several biological parameters of maternal HIV infection: (1) immunological parameters (neutralizing antibodies); (2) the concentration of viral particles and/or infected cells; and (3) the selection of HIV subspecies of particular cellular tropism. The present study was designed to examine the relationship between cellular viral burden and transmission, and between maternal viral burden and CD4+ cell count and clinical status at delivery. METHOD: We investigated mother-to-infant HIV-1 transmission at delivery in a cohort of 51 pairs of mothers and newborns. Twelve infants were HIV-infected, as determined by successive polymerase chain reaction and culture determinations within the first 6 months of life, and nine of these were diagnosed as HIV-infected during the first week of life. We determined peripheral blood mononuclear cell proviral DNA burden using a quantitative polymerase chain reaction assay. Polymerase chain reaction was performed in the HIV-1 gag gene, using [32P]-end-labelled primers. External standard DNA samples were from the 85-14 F2 cell line, which contains a unique defective proviral DNA genome. RESULTS: There was a linear relationship between the logarithms of c.p.m. and the number of HIV-1 DNA copies. CONCLUSION: We have previously reported that the number of HIV provirus copies in maternal blood cells is related to transmission of the virus. Quantification of the HIV provirus by polymerase chain reaction may be used as a predictive parameter of vertical transmission if accompanied by an exhaustive clinical and biological follow-up during pregnancy.

Care of human immunodeficiency virus-infected children in developing countries. International Working Group on Mother-to-Child Transmission of HIV.

CONTEXT: There is urgent need to strengthen the area of pediatric HIV/AIDS care in developing countries. Clinical research in this area is also scarce. METHODOLOGY: A literature review and a postal survey were used to obtain updated information on mortality, morbidity and current standards of care of children born to HIV-infected mothers in developing countries. A 2-day workshop was organized to review the available data and to identify the key areas where clinical research should be conducted. MAIN FINDINGS: Rates of mortality and morbidity were very different from one study to another but generally higher than in industrialized countries. Prognostic studies for HIV-1-infected children in developing countries were not available. Based on the report of 14 teams from 11 countries, specific protocols for HIV-infected children with persistent diarrhea or severe malnutrition were documented in fewer than one-half of the cases. Secondary antimicrobial prophylaxis after interstitial pneumonia or recurrent infections was still infrequent, as primary prophylaxis of opportunistic infections. The following list of clinical research priorities was identified by the workshop participants: primary prophylaxis of opportunistic and bacterial infections; case management of persistent diarrhea; reassessment of the performance of p24 antigen for diagnostic and prognosis use; studies on the etiology of pulmonary infections; long term observational pediatric cohorts; current weaning practices and duration of breast-feeding; counseling and HIV testing of children and families; prevention of HIV sexual transmission in children and adolescents.

Virus isolation, polymerase chain reaction and in vitro antibody production for the diagnosis of pediatric human immunodeficiency virus infection.

Viral culture (VC), polymerase chain reaction (PCR) and in vitro antibody production (IVAP) by peripheral blood mononuclear cells were compared for the early diagnosis of HIV-1 infection in 46 infants born to HIV-1 seropositive mothers. The ten children considered infected on the basis of clinical signs and persistence of anti-HIV-1 antibodies had at least one positive viral culture and seven were always positive in both PCR and IVAP tests. PCR and IVAP tests were occasionally negative in three infected children. Among 30 healthy children who became seronegative and were always negative for viral culture, 22 (73.3%) were also repeatedly negative in PCR and IVAP. We report 6 cases of children classified as P2A at the term of this study but who had lost anti-HIV-1 antibodies. They presented at least one positive viral culture and occasional positive PCR and/or IVAP results. The results indicate that the combination of viral culture, PCR and IVAP tests improves the early diagnosis of pediatric HIV infection.

[Medical costs associated with the risk of maternal-fetal contamination by HIV. Results of a prospective survey]. / Coûts médicaux associés au risque de contamination maternofoetale par le VIH. Résultats d'une enquête prospective.

BACKGROUND: Assessment of economic implications of pediatric HIV infection allows to document efforts which are devoted by health care system to the care of children born to HIV infected women. This paper presents the results of the first analysis, in the French health care context, of direct medical costs related to HIV mother-to-child risk of transmission. MATERIAL AND METHODS: Statistical prospective analysis was performed on 853 files concerning 152 children followed in three medical centers. Because the medical consumptions data were linked to clinical status, average direct medical costs per medical contact could be defined for each center. RESULTS: Results were consistent with the hypothesis that more medical care is necessary when the clinical picture is uncertain (indeterminate status) or reflects health state deterioration. However, results are very different according to HIV clinical status and disparities may be so large that costs per clinical status hierarchy may be disrupted. Explicative factors for these variabilities are expressed in terms of patient recruitment, medical uncertainty management and resources disponibility.

[Ophthalmologic manifestations observed in a pediatric HIV-seropositive population]. / Manifestations ophtalmologiques observées dans une population pédiatrique séropositive au VIH.

PURPOSE: HIV positive children underwent ophthalmologic examination to evaluate prospectively the incidence, and type of ocular involvement in pediatric AIDS. METHOD: Two ophthalmologists examined the children during their pediatric examination, for two years. When possible, a retinography was performed. RESULTS: Among the 33 HIV positive children, 23 children developed AIDS according to CDC classification. The incidence was lower than reported in adult series. Retinal manifestations could be divided into two groups: 1. veinous dilatation and perivasculitis; 2. retinal opportunistic infections: Ocular Toxoplasmosis was the main finding. In addition we report one case of herpetic keratitis. Annexial complications were represented by conjonctivitis and molluscum contagiosum. CONCLUSION: Manifestations of HIV infection in children appears to be different from adults. We recommend ophthalmic screening in all AIDS pediatric patients to diagnose and treat the infectious complications.

[Early diagnosis and treatment of cytomegalovirus polyradiculoneuritis in a child infected by HIV]. / Diagnostic précoce et traitement d'une polyradiculonévrite à cytomégalovirus chez un enfant infecté par le VIH.

BACKGROUND: Axonal polyradiculopathy due to cytomegalovirus (CMV) in AIDS has been reported in adults but it is not well documented in children. OBJECTIVE: We describe the elements of diagnosis and the outcome after anti-CMV therapy in a pediatric case. CASE REPORT: A 11-year-old boy with post-transfusional AIDS and low CD4 count (< 50/mm3) suffered from bilateral leg pain and weakness progressing within 15 days to paraplegia and cauda equina syndrome. Electromyography showed pure axonal neuropathy. Examination of the CSF showed increased proteins, low glucose concentration, neutrophilic pleiocytosis and positive detection of CMV by polymerase-chain reaction. The CMV viremia was positive. Treatment with ganciclovir and foscarnet allowed dramatical clinical improvement. Retinitis occurred during the maintenance therapy and was cured after reintroduction of the initial doses of ganciclovir and foscarnet. The child died five months later from a bacterial pneumopathy. CONCLUSIONS: Children with advanced AIDS may benefit from early recognition and treatment of CMV polyradiculopathy. The interactions and cumulated toxicities between anti-CMV and anti-retroviral drugs must be considered. The prognosis remains poor for CMV neuropathy due to the severe immunodepression caused by the HIV infection.

[Hemophagocytic syndrome in children infected by HIV. Apropos of 3 cases]. / Syndrome d'activation macrophagique chez l'enfant infecté par le VIH. A propos de trois cas.

BACKGROUND: The hemophagocytic syndrome has previously been reported in different infectious diseases (EBV, CMV, tuberculosis...) but rarely in adults with AIDS and never in children suffering from AIDS. CASE REPORTS: A hemophagocytic syndrome was recognized during the follow-up of 3 children with AIDS. The first, a 9-year-old girl developed an acute EBV coinfection and was treated with shots of corticosteroids and vepesid but died shortly afterwards. The second patient, a 3-year-old girl was infected with Aspergillus fumigatus for which she was given amphotericin B with a rapid improvement. The third patient, an 8-year-old boy had multi-resistant Streptococcus pneumoniae otitis and pneumonitis; his condition improved rapidly with adapted antibiotherapy. DISCUSSION: The HIV-hemophagocytic syndrome is not exceptional in HIV infection because of the association of immunodeficiency and resulting superinfections. Its diagnosis and treatment should be etiologic. Severe cases without etiology could benefit from chemotherapy. CONCLUSION: Management and outcome of this potentially lethal syndrome might depend on the identification of a curable infectious cause.

[Role of neutralizing antibodies in protection of the fetal from an HIV positive mother]. / Rôle des anticorps neutralisants dans la protection du foetus de mère VIH positive.

The goal of this study is to compare serum Titers of Neutralizing antibodies in HIV 1 infected mothers to the virological status of their newborns. 38 infant-mothers couples were tested. Serum Neutralizing antibodies Titers of the mothers were tested the day of birth. Virological status of new borns was determined by peripheric blood mononuclear cells culture and PCR. 18 Newborns were HIV 1 infected. In 9 cases mothers had no neutralizing antibodies: 7 newborns were HIV 1 infected. In 4 cases mothers had high level of neutralizing antibodies (< 640): none of the newborns was infected. In 25 cases mothers had intermediate value of neutralizing antibodies (between 80 and 320): 11 newborns were HIV 1 infected. Women with neutralizing antibodies to HIV 1, were less likely to transmit HIV 1 to their infants than pregnant women without neutralizing antibodies. Serum neutralizing antibodies titers of pregnant women might be of predictive value in vertical transmission of HIV 1. Further investigations are needed.

[Importance of measurement of plasma viral load for the therapeutic follow-up of children infected with HIV-1. Study of its evolution according to modifications of treatment in 55 children]. / Intérêt de la mesure de la charge virale plasmatique pour le suivi thérapeutique des enfants infectés par le VIH1. Etude de son évolution en fonction des modifications du traitement chez 55 enfants.

Since 1987 we started to treat all vertically HIV-1 infected newborns by an antiretroviral therapy as soon as the diagnosis was confirmed. From the study of 55 HIV-1 infected children followed at Armand Trousseau Hospital (Paris, France) we retrospectively evaluated the use of the plasma viral load as a marker of the treatment efficiency. This parameter and CD4 counts were measured the day of any modification in antiviral therapy (Day 0), 1 and 3 months later (M1 and M3) and every 3 months as long as possible. In the 3 groups of treatment modifications a decrease in plasma viral load was observed. A statistically significant increase in CD4 counts was only observed in the group treated with the association of 2 nucleoside analogues and 1 proteinase inhibitor. This group demonstrated the most important decrease in plasma viral load (> 0.7 log 10 Eq Cop/ml). This leads us to propose to the "ANRS" a protocol study for the treatment of all vertically HIV-1 infected children by the association of 3 nucleoside analogues and 1 proteinase inhibitor as early as 8 weeks post natal when the HIV infection is confirmed.

[Prevalence and factors associated with renal disease among patients with newly diagnoses of HIV in Brazzaville, Republic of Congo]. / Prévalence et facteurs associés à l'insuffisance rénale chez les patients nouvellement dépistés VIH-positifs à Brazzaville (République du Congo).

BACKGROUND: The aim of this study was to determine the prevalence of kidney disease in patients newly diagnosed as HIV-positive in Brazzaville and to identify the associated risk factors. METHODS: Descriptive and analytical study of patients diagnosed with HIV infection at the Ambulatory Treatment Center in Brazzaville, Republic of Congo, from January 1, 2009, through December 31, 2010. Estimated glomerular filtration rate (eGFR) was assessed with the Modification of Diet in Renal Disease equation (MDRD-GFR), and kidney disease was defined by an eGFR less than 60 mL/min/1.73 m(2). We conducted a univariate and then a multivariate logistic regression analysis to determine the factors associated with kidney disease in this population. RESULTS: The study included 562 patients newly identified as HIV-infected, 66.13% of whom were women. Their median age was 38.84 years interquartile range (IQR): 33.18-46.23) and their median body mass index (BMI) 20.31 kg/m(2) (IQR: 17.97-22.89). Their median CD4 count was 192 cells/mm(3) (IQR: 81-350), and 70.8% were at WHO stage III/IV. Finally, the median MDRD-GFR was 95.59 (IQR: 78.76-114.92) mL/min/1.73 m(2) and 8.5% had a GFR less than 60 mL/min/1.73 m(2), that is, moderate impairment of kidney function. The only factor associated with kidney disease in the multivariate analysis was a BMI less than 18.5 kg/m(2) (adjusted odds ratio: 2.54, 95% confidence interval: 1.25-5.15, p = 0.01). CONCLUSIONS: The prevalence of kidney disease in patients newly diagnosed with HIV in Brazzaville is relatively high. The only factor associated with it in the multivariate analysis was a BMI less than 18.5 kg/m(2).