Male circumcision is associated with a lower prevalence of human papillomavirus-associated penile lesions among Kenyan men.

Human papillomavirus (HPV)-associated penile lesions in men may increase the risk of HPV transmission to their female partners. Risk factor data on HPV-associated penile lesions are needed from regions with a high burden of cervical cancer. Visual inspection of the penis was conducted using a colposcope at the 24-month visit among participants in a randomized controlled trial of male circumcision in Kenya, from May 2006 to October 2007. All photos were read independently by two observers for quality control. Penile exfoliated cells sampled from the glans/coronal sulcus and the shaft were tested for HPV DNA using GP5+/6+ PCR and for HPV16, 18 and 31 viral loads using a real time PCR assay. Of 275 men, 151 were circumcised and 124 uncircumcised. The median age was 22 years. Circumcised men had a lower prevalence of flat penile lesions (0.7%) versus uncircumcised (26.0%); adjusted odds ratio (OR) = 0.02; 95% confidence interval (CI) = 0.003-0.1. Compared to men who were HPV negative, men who were HPV DNA positive (OR = 6.5; 95% CI = 2.4-17.5) or who had high HPV16/18/31 viral load (OR = 5.2; 95% CI = 1.1-24.4) had higher odds of flat penile lesions. Among men with flat penile lesions, HPV56 (29.0%) and 16 (25.8%) were the most common types within single or multiple infections. Flat penile lesions are much more frequent in uncircumcised men and associated with higher prevalence of HPV and higher viral loads. This study suggests that circumcision reduces the prevalence of HPV-associated flat lesions and may ultimately reduce male-to-female HPV transmission.

Prevalence and risk factors of human papillomavirus infection by penile site in uncircumcised Kenyan men.

Human papillomavirus (HPV) prevalence was estimated from 2,705 sexually active, uncircumcised, human immunodeficiency virus seronegative men aged 17-28 years in Kisumu, Kenya. HPV prevalence was 51.1% (95% confidence interval: 49.2-53.0%) in penile cells from the glans/coronal sulcus and/or shaft. HPV prevalence varied by anatomical site, with 46.5% positivity in the glans/coronal sulcus compared with 19.1% in the shaft (p < 0.0001). High-risk HPV was detected in 31.2% of glans and 12.3% of shaft samples (p < 0.0001). HPV16 was the most common type and 29.2% of men were infected with more than one HPV type. Risk factors for HPV infection included presence of C. trachomatis, N. gonorrhea, self-reported sexually transmitted infections, and less frequent bathing. Lifetime number of sexual partners and herpes simplex virus type-2 seropositivity were also marginally associated with HPV infection.

Human papillomavirus detection by penile site in young men from Kenya.

BACKGROUND: Limited data are available on whether sampling from the penile shaft or urethra increases detection of penile HPV infection in men beyond that found in the glans and coronal sulcus. METHODS: Within a randomized clinical trial, a validation study of penile sampling was conducted in Kisumu, Kenya. Young men (18-24 years) were invited to provide penile exfoliated cells using prewetted Dacron swabs to determine the best site for HPV detection. beta-Globin gene PCR and HPV DNA type GP5+/6+ PCR status were ascertained from 3 anatomical sites. RESULTS: A total of 98 young HIV-seronegative, uncircumcised men participated. Penile HPV prevalence varied by anatomical site: 50% in penile exfoliated cells from the glans, coronal sulcus, and inner foreskin tissue; 43% in the shaft and external foreskin tissue; and 18% in the urethra (P <0.0001). For each anatomical site, over 87% of samples were beta-globin positive. Beyond that found in the glans/coronal sulcus, urethral sampling resulted in no increase in HPV positivity and shaft sampling resulted in an additional 7.3% of overall HPV positivity. The prevalence of high-risk HPV positivity varied by anatomical site: 39% in glans/coronal sulcus, 31% in shaft, and 13% in the urethra (P <0.0001). HPV 16 was the most common type identified. DISCUSSION: Penile HPV prevalence was approximately 50% among young men in Kisumu, Kenya. Urethral sampling for HPV detection in men added no sensitivity for HPV detection over that found from sampling the glans/coronal sulcus and penile shaft. These data will help inform studies on HPV transmission dynamics, and on the efficacy of HPV prophylactic vaccines on penile HPV carriage in men.

HIV-1 target cells in foreskins of African men with varying histories of sexually transmitted infections.

Numerous epidemiologic studies have found significant associations between lack of circumcision and HIV-1 acquisition in men. To our knowledge, this is the first study of human foreskin tissue that examines biologic mechanisms that increase susceptibility of uncircumcised African men to HIV-1. Foreskin specimens from 20 men with and 19 men with no history of sexually transmitted infections were examined for HIV-1 target cells. Most Langerhans cells were found in the epithelium; most CD4+ T cells and macrophages were in the submucosa. There were no differences in HIV-1 target cells between men with and those without history of sexually transmitted infections. However Langerhans cells and macrophages were more abundant in the group with a history of infection. The densities and positions of HIV-1 target cells in the foreskin tissue of these Kenyan men indicate that the inner mucosal surface of the human foreskin contains cells that make it highly susceptible to HIV infection.

Effects of human immunodeficiency virus 1 infection on microbial origins of pelvic inflammatory disease and on efficacy of ambulatory oral therapy.

OBJECTIVE: This study was undertaken to determine the effects of human immunodeficiency virus 1 infection on the clinical presentation, severity, causal organisms, and response to ambulatory therapy of pelvic inflammatory disease. STUDY DESIGN: Women 18 to 40 years old with lower abdominal pain for <1 month were recruited. Participants underwent a standardized questionnaire, physical examination, screening for human immunodeficiency virus 1 and other sexually transmitted infections, and endometrial biopsy to detect plasma cell endometritis. Reevaluations were performed at 1 and 4 weeks to assess response to therapy. RESULTS: Among 162 women with adequate endometrial biopsy specimens 63 (39%) had histologically confirmed endometritis. Endometritis was more frequent among women who were seropositive for human immunodeficiency virus 1 than among women who were seronegative (odds ratio, 3.0; 95% confidence interval, 1.5-5.9). Infections with either Neisseria gonorrhoeae or Chlamydia trachomatis, or both, were least common and bacterial vaginosis was most common among human immunodeficiency virus 1-infected women with CD4 T-lymphocyte counts <400 cells/microL (P <. 04, P <.03, respectively). After oral antibiotic therapy, similar proportions of both women who were seropositive and women who were seronegative for human immuno-deficiency virus 1 had a >/=75% reduction in clinical severity score (81% vs 86%). CONCLUSION: Outpatient treatment of pelvic inflammatory disease was successful regardless of human immunodeficiency virus 1 serostatus.

Declining syphilis prevalence in pregnant women in Nairobi since 1995: another success story in the STD field?

Untreated maternal syphilis during pregnancy will cause adverse pregnancy outcomes in more than 60% of the infected women. In Nairobi, Kenya, the prevalence of syphilis in pregnant women of 2.9% in 1989, showed a rise to 6.5% in 1993, parallel to an increase of HIV-1 prevalence rates. Since the early 1990s, decentralized STD/HIV prevention and control programmes, including a specific syphilis control programme, were developed in the public health facilities of Nairobi. Since 1992 the prevalence of syphilis in pregnant women has been monitored. This paper reports the findings of 81,311 pregnant women between 1994 and 1997. A total of 4244 women (5.3%) tested positive with prevalence rates of 7.2% (95% CI: 6.7-7.7) in 1994, 7.3% (95% CI: 6.9-7.7) in 1995, 4.5% (95% CI: 4.3-4.8) in 1996 and 3.8% (95% CI: 3.6-4.0) in 1997. In conclusion, a marked decline in syphilis seroprevalence in pregnant women in Nairobi was observed since 1995-96 (P<0.0001, Chi-square test for trend) in contrast to upward trends reported between 1990 and 1994-95 in the same population.

PIP: This study presents the trend in syphilis prevalence among 81,311 pregnant women in Nairobi, Kenya, from 1994 to 1997. Clinic nurses performed syphilis serology using a rapid plasma reagin (RPR) card test in 10 NCC clinics and Chi square; these were used to study trends over time. Results showed that a total of 4244 women (5.3%) tested positive with prevalence rates of 7.2% (95% CI: 6.7-7.7) in 1994, 7.3% (95% CI: 6.9-7.7) in 1995, 4.5% (95% CI: 4.3-4.8) in 1996, and 3.8% (95% CI: 3.6-4.0) in 1997. Thus, a significant decrease in syphilis seroprevalence among pregnant women in Nairobi was observed since 1995-96, by contrast with the rising trend in syphilis prevalence reported in 1990 and 1994-95 in the same population. This decline was attributable in large part to the syphilis control program initiated in Nairobi in June 1992, which focused on sexual behavior modifications, changes in health care seeking behavior and improved health care services.

Stable antenatal HIV-1 seroprevalence with high population mobility and marked seroprevalence variation among sentinel sites within Nairobi, Kenya.

OBJECTIVES: To monitor and analyse trends in HIV-1 seroprevalence among antenatal women in Nairobi, Kenya. DESIGN: Six sequential surveys were carried out among antenatal clinic attenders at four Nairobi City Council health centres between November 1991 and April 1997. METHODS: A total of 6828 women attending for first antenatal clinic visit were administered a standard questionnaire to obtain demographic information and were screened for HIV-1. RESULTS: HIV-1 seroprevalence rose from 12.1% in the first survey to 16.2% in the third, completed in October 1993. No rise was observed in subsequent surveys, and seroprevalence among women under the age of 20 declined after the third survey. Significant differences in seroprevalence (P < 0.001) were observed in all survey rounds between women who reported that their province of origin was Nyanza (22.4% overall), compared with those from other provinces in western Kenya (14.1%), and the eastern group of provinces (8.9%). The rise in HIV-1 seroprevalence observed between 1991 and 1993 was almost entirely attributable to the rising seroprevalence among women from Nyanza. There were considerable differences in HIV-1 seroprevalence among the four health centres, partly accounted for by differences in the proportion of clinic attenders from different provinces of origin, which also changed significantly over time. CONCLUSIONS: HIV-1 seroprevalence has stabilized in antenatal women attending these health centres in Nairobi, and may be declining among women in the youngest age group. This may reflect stabilization of HIV-1 incidence, but further observation is required. The levels of infection among Nairobi residents reflect the evolution of the HIV epidemic in their provinces of origin, and changing client composition influences HIV-1 seroprevalence at different clinics. HIV sentinel surveillance should be carried out at multiple sites in large urban centres to monitor accurately the evolution of the HIV epidemic and the impact of control efforts in reducing transmission.

The supermarket for women's reproductive health: the burden of genital infections in a family planning clinic in Nairobi, Kenya.

OBJECTIVES: To study the burden of disease of reproductive tract infections (RTIs) and cervical dysplasia in women attending a family planning clinic in Nairobi, Kenya, and to assess the acceptability of integrating reproductive healthcare services into existing family planning facilities. METHODS: In a family planning clinic in Nairobi, Kenya, 520 women were enrolled in a study on RTI and cervical dysplasia. RESULTS: RTI pathogens were detected in over 20% of women, the majority being asymptomatic. HIV-1 testing was positive in 10.2%. The diagnosis of cervical dysplasia was made on 12% of the cytology smears (mild in 5.8%, moderate in 3.5%, severe in 1.2%), and 1.5% had invasive cervical cancer. The intervention of case detection of RTI and Papanicolaou smear taking was well received by clients and considered feasible by the staff. CONCLUSIONS: Early detection and treatment of potentially curable cervical lesions and RTI provide a unique opportunity to improve women's health. In Kenya, where the current contraceptive prevalence rate is 33%, family planning clinics are excellent sites to introduce health interventions.

Effect of human immunodeficiency virus type 1 infection upon acute salpingitis: a laparoscopic study.

To determine the effect of human immunodeficiency virus type 1 (HIV-1) infection upon pelvic inflammatory disease (PID), a laparoscopic study of acute PID was conducted in Nairobi, Kenya. Subjects underwent diagnostic laparoscopy, HIV-1 serology, and testing for sexually transmitted diseases. Of the 133 women with laparoscopically verified salpingitis, 52 (39%) were HIV-1-seropositive. Tubo-ovarian abscesses (TOA) were found in 33% of HIV-1-infected and 15% of HIV-1-uninfected women (odds ratio [OR], 2.8; 95% confidence interval [CI], 1.2-6.5). Among seropositive women, TOA was found in 55% of those with CD4 cell percent <14% vs. 28% with CD4 cell percent>14% (OR 3.1, 95% CI 0.6-15.3). Neisseria gonorrhoeae was detected in 37 women (28%) and Chlamydia trachomatis in 12 (9%); neither was significantly related to HIV-1 seropositivity. Length of hospitalization was not affected by HIV-1 serostatus overall but was prolonged among HIV-1-infected women with CD4 cell percent <14%. Among patients with acute salpingitis, likelihood of TOA was related to HIV-1 infection and advanced immunosuppression. In general, HIV-1-seropositive women with acute salpingitis responded well to treatment.

Clinical and in situ cellular responses to Haemophilus ducreyi in the presence or absence of HIV infection.

We aimed to determine if the clinical and histological features of chancroid are altered by HIV infection. Male patients presenting to the Nairobi special treatment clinic with a clinical diagnosis of chancroid were eligible for the study. A detailed history, physical examination, swabs for Haemophilus ducreyi culture and blood for HIV serology, syphilis serology and CD4 counts were obtained from all patients. Punch biopsies from an ulcer were obtained from 10 patients and either fixed in 10% formalin or snap frozen in Optimum Cutting Temperature (OCT) medium compound at -70 degrees C. Patients were treated with erythromycin and followed for 3 weeks. Chi-square and Student's t-test were used to determine if the clinical and laboratory features of chancroid differed between HIV-seropositive and seronegative individuals. Cox regression survival analysis was used to determine if HIV infection altered cure rates of chancroid at 21 days. Immunohistochemical staining was performed using lymphocytic and macrophage markers and tissue sections were analysed by 2 pathologists in a blinded manner. Between February and November 1994, 109 HIV-seropositive and 211 HIV-seronegative individuals were enrolled in the study. HIV patients had ulcers of longer duration than HIV-seronegative patients (P=0.03). Although cure rates were similar at 3 weeks, HIV patients had lower cure rates at 1 week (23% v 54%, P=0.002). A dense interstitial and perivascular inflammatory infiltrate extending from the reticular to deep dermis was present in all biopsies. This consisted of equal amounts of CD4 and CD8 T-lymphocytes as well as macrophages. The histological and immunohistochemical picture was identical for HIV-positive and negative patients. HIV infection slows the healing rates of chancroid ulcers despite appropriate antibiotic therapy. This clinical difference cannot be attributed to an altered histopathological response to HIV infection. Additional studies are needed to elucidate the mechanisms responsible for this finding.

PIP: Chancroid is caused by infection with Hemophilus ducreyi, and is associated with an increased risk for the sexual transmission of HIV-1. The authors assessed whether the clinical and histological features of chancroid are changed by HIV infection, using 320 male patients who presented during February-November 1994 to the City of Nairobi Special Treatment Clinic with a clinical diagnosis of chancroid. 109 subjects were HIV seropositive and 211 were HIV seronegative. A detailed history, physical examination, swabs for Hemophilus ducreyi culture and blood for HIV serology, syphilis serology, and CD4 counts were obtained from all patients. Punch biopsies from an ulcer were obtained from 10 patients and either fixed in 10% formalin or snap frozen in Optimum Cutting Temperature (OCT) medium compound at -70 degrees Celsius. Patients were treated with erythromycin and followed for 3 weeks. HIV patients had ulcers of longer duration than did HIV-seronegative patients. Although cure rates were similar at 3 weeks, HIV patients had lower cure rates at 1 week (23% vs. 54%). A dense interstitial and perivascular inflammatory infiltrate extending from the reticular to deep dermis was present in all biopsies. The infiltrate consisted of equal amounts of CD4 and CD8 T-lymphocytes as well as macrophages. The histological and immunohistochemical picture was identical for HIV-positive and HIV-negative patients. Study findings therefore indicate that HIV infection slows the healing rates of chancroid ulcers despite appropriate antibiotic therapy. The clinical difference cannot be attributed to an altered histopathological response to HIV infection.

Decreased incidence of sexually transmitted diseases among trucking company workers in Kenya: results of a behavioural risk-reduction programme.

OBJECTIVE: To establish a cohort of high-risk individuals suitable for HIV-prevention trials, and to measure changes in sexual behaviour and sexually transmitted disease (STD) incidence after a behavioural intervention. DESIGN: Prospective cohort study in trucking company depots in Mombasa, Kenya. PARTICIPANTS: A total of 556 male HIV-seronegative employees of trucking companies. INTERVENTIONS: HIV serological testing, individual counselling, condom promotion, STD diagnosis and management. MAIN OUTCOME MEASURES: Sexual risk behaviour and symptomatic STD incidence. RESULTS: Using time-trend modelling, significant declines in self-reported high-risk sexual behaviour were demonstrated during a 1-year follow-up. The percentage of men reporting any extramarital sex during the 3-month period prior to a follow-up visit decreased from 49% durig the first quarter of follow-up to 36% during the last quarter (P < 0.001). The decline in reported female sex worker contact was from 12% to 6% (P = 0.001). Approximately 30% of men reported consistent condom use during extramarital sex and this percentage remained unchanged during the study period. The incidence of STD declined from 34 per 100 person years (PY) during the first quarter to 10 per 100 PY during the last quarter (P = 0.001). Significant reductions in gonorrhoea (15 to five cases per 100 PY, P = 0.04), non-gonococcal urethritis (10 to two cases per 100 PY, P = 0.05), and genital ulcer disease (nine to two cases per 100 PY, P = 0.02) were observed. CONCLUSIONS: Among truck company workers who participated in a cohort study in Mombasa, Kenya, there was a significant decrease in sex with high-risk partners, but no change in condom use. The change in heterosexual risk behaviour was accompanied by a significant decrease in incidence of gonorrhoea, non-gonococcal urethritis, and genital ulcer disease.

PIP: 556 male HIV-seronegative male employees of trucking companies in Mombasa, Kenya, were exposed to HIV serological testing, individual counseling, condom promotion, and sexually transmitted disease (STD) diagnosis and management, and returned for at least one follow-up visit in a prospective study to measure changes in sexual behavior and STD incidence after the intervention. There was a significant decrease in sex with high-risk partners over the 1-year period of follow-up, but no change in condom use among study participants; 30% of men reported consistent condom use during extramarital sex throughout the study period. The change in heterosexual risk behavior was accompanied by a significant decrease in the incidence of gonorrhea, nongonococcal urethritis, and genital ulcer disease. The percentage of men reporting extramarital sex decreased from 49% to 36%, while contact with female prostitutes declined from 12% to 6%.

An immunohistochemical analysis of naturally occurring chancroid.

Haemophilus ducreyi is a major cause of genital ulcer disease in many developing countries and is associated with augmented transmission of human immunodeficiency virus (HIV). However, the mechanisms through which H. ducreyi produces ulceration are poorly understood. The characteristics of the host response to H. ducreyi and the pathobiology of its potential contribution to increased HIV susceptibility are not known. Chancroid ulcer biopsies from 8 patients were analyzed histologically and immunohistochemically. All biopsies had perivascular and interstitial mononuclear cell infiltrates that extended deep into the dermis. The infiltrate, which contained macrophages and CD4 and CD8 lymphocytes, was consistent with a delayed hypersensitivity type cell-mediated immune response. The recruitment of CD4 T lymphocytes and macrophages may in part explain the facilitation of HIV transmission in patients with chancroid.

Presumptive specific clinical diagnosis of genital ulcer disease (GUD) in a primary health care setting in Nairobi.

Of 22,274 patients 12 years of age or older attending a primary health care clinic in Nairobi, 1076 (4.8%) complained of symptoms suggesting a sexually transmitted disease (STD). Of these, 518 females and 462 males underwent complete clinical evaluation, and 78% had objective microbiologic or clinical evidence of STD, including 168 (17.1%) with genital ulcer disease (GUD). Presumptive specific clinical diagnoses on initial physical examination in cases of GUD were chancroid (131 patients), syphilis (25), genital herpes (15) and lymphogranuloma venereum (LGV) (1). Clinical diagnoses correlated only weakly with microbiological and serological diagnoses. Haemophilus ducreyi was isolated from 51 (41%) of the 125 with a clinical diagnosis of chancroid, and 4 (22%) of 18 with a diagnosis of syphilis, herpes, or LGV (P = 0.13). The rapid plasma reagin (RPR) test was reactive in 6 (24%) of 25 with a clinical diagnosis of syphilis, 18 (12.3%) of 146 with a diagnosis of chancroid or herpes, and 37 (4.7%) of 786 without a genital ulcer (P < 0.001, GUD vs no GUD). Sensitivity, specificity, and positive predictive value for presumptive clinical diagnosis of chancroid, relative to H. ducreyi isolation, were 93%, 16%, and 41%; and for diagnosis of syphilis, relative to reactive RPR, were 25%, 88% and 25%. Specific treatment based on presumptive specific clinical diagnosis frequently was inadequate for syphilis among patients with GUD and reactive RPR test. Syndromic treatment of GUD with antimicrobial combinations active against both chancroid and syphilis would be preferable to treatment with single drugs based on presumptive specific clinical diagnoses for this population.

PIP: During a 12-month period in 1990-1991 in Kenya, 1076 of 22,274 patients (4.8% of all patients over 12 years of age) presented at the Langata Health Center in Nairobi with symptoms of a sexually transmitted disease (STD). Researchers analyzed data on 980 of these patients whose records had complete data to assess the use of presumptive specific clinical diagnosis in the management of STDs in a primary health clinic. 17.1% (168) had genital ulcer disease (GUD). Men were more likely to have a GUD than women (24.7% vs. 10.4%). Haemophilus ducreyi, the etiologic agent of chancroid, was isolated in the cultures of 40% of the patients with a presumptive specific clinical diagnosis of chancroid compared with 17% of those with a presumptive specific clinical diagnosis of syphilis, herpes, or lymphogranuloma venereum (LGV) (p = 0.02). The clinical diagnoses of these two GUDs had only a weak correlation with microbiological and serological diagnoses (p = 0.13). 24% of patients with a presumptive specific clinical diagnosis of syphilis, 31% of those with a presumptive specific clinical diagnosis of chancroid, 6% of those with a specific clinical diagnosis of genital herpes or LGV, and 4.7% of those who had no GUD disease tested positive for syphilis (p 0.001, GUD vs. no GUD). Among patients with syndromic diagnosis of GUD, the presumptive specific clinical diagnosis of chancroid had a high sensitivity (91%), low specificity (24%), and low positive predictive value (40%). Among patients with syndromic diagnosis of syphilis, the presumptive specific clinical diagnosis of syphilis had a low sensitivity (25%), higher specificity (87%), and low positive predictive value (24%). 13% of patients with positive cultures for H. ducreyi did not receive a recommended or effective drug for chancroid. 82% of patients who tested positive for syphilis did not receive a recommended drug for syphilis. Based on these findings, the researchers conclude that syndromic treatment of GUD with use of antimicrobial combinations active against both chancroid and syphilis is a better course of treatment than use of single drugs based on presumptive specific clinical diagnoses for this population.

Human immunodeficiency virus DNA in urethral secretions in men: association with gonococcal urethritis and CD4 cell depletion.

To evaluate the prevalence and correlates of human immunodeficiency virus (HIV)-infected cells in urethral secretions, samples were collected from 106 HIV-seropositive men with and without urethritis. HIV DNA was detected by polymerase chain reaction in 27% of 184 urethral specimens and was associated with CD4 cell depletion (P for trend, .03) and with urethritis (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.2-4.6) or gonorrhea (OR, 2.9; 95% CI, 1.5-5.8). Two multivariate models were constructed that included age, CD4 cell count < 200/mm3, and either urethritis or gonococcal infection. Detection of HIV-infected cells in urethral secretions was independently associated with < 200 CD4 cells/mm3 (OR, 2.2; 95% CI, 0.9-5.2; P = .05) and urethritis (OR, 2.7; 95% CI, 1.3-5.3; P = .003) in the first model and with gonococcal infection (OR, 3.2; 95% CI, 1.6-6.4; P < .001) in the second model. Successful treatment of gonococcal urethritis was associated with a 2-fold reduction in urethral HIV DNA (44% vs. 21%; P = .02). Thus, treatment of gonococcal urethritis may be an effective strategy for reducing HIV transmission.

Effect of human immunodeficiency virus on local immunity in children with diarrhoea.

The purpose of this study was to determine the relationship between intestinal mucosal immunity and diarrhoea. Stools were tested for total IgA by radial immunodiffusion, cultured for bacteria and examined for ova/cysts by microscopy. Peripheral blood was screened for HIV-1 antibody by ELISA, CD4 and CD8 enumerated by flow cytometry and phagocytic activity by C. albicans engulfment. A total of 271 children were enrolled with a mean age of 20.3 m (range 0.3-60.0 m). HIV exposed (born to HIV seropositive mothers) had more episodes of diarrhoea than HIV unexposed (born to HIV seronegative mothers) children in the first six months of life (26.0% versus 5.5%, p = 0.002). Exposed children had severe (16/44 versus 6/29, p = 0.02) and prolonged diarrhoea lasting more than nine days (11.0% versus 1.4%, p = 0.03) than unexposed. CD8 counts were significantly higher in exposed than unexposed children (1837.0 versus 1373.0 cells/mm3, p = p.01). Among children aged 15 months and over, HIV seropositive children had severe diarrhoea (4/6 versus 11/32, p<0.01), reduced phagocytic activity (phagocytic index 15.4 versus 28.9, p<0.01), total intestinal IgA (0.2 versus 0.7 mg/ml, p = 0.04) and CD4 counts (624.2 versus 1345.1 cells/mm3, p = 0.01) than seronegative. Reduction of CD4 was more significant in HIV seropositive children with severe diarrhoea (298.7 versus 1318.5 cells/mm3, p = 0.01). Isolation of enteric pathogens was independent of either maternal or child's HIV serostatus although E. coli was more frequent in children with low CD4 counts. These results highlight the importance of mucosal immunity in the intestinal infections. Exposure to HIV, reduced CD4 counts and IgA were associated with diarrhoea probably due to impaired intestinal mucosal immunity.

Breastfeeding and immunity to intestinal infections.

The purpose of this study was to compare immune response in breast and non breastfed children presenting with diarrhoea at Paediatric Observation Ward, Kenyatta National Hospital (KNH-POW) and Maternal and Child Health Clinic, Pumwani Maternity Hospital (PMH-MCH). Blood and stool samples were collected from the first four consecutive children aged 5 years and below per day, presenting with or without diarrhoea from January to December, 1992. The stools were tested for total IgA by single radial immunodiffusion (SRID) and specific IgA by enzyme linked immunosorbent assay (ELISA). Peripheral blood CD4 and CD8 enumeration was done by flow cytometry. Stools were cultured for bacteria on selective media while ova and cysts of parasites were identified by wet preparation microscopy. A total of 457 children were enrolled into the study, 69.6% of whom presented with diarrhoea. Breastfed children tended to have a shorter duration of diarrhoea than either mixed fed or bottle fed (8.3 vs 9.8 vs 11.2 days, p = 0.2). In general, E. coli were more commonly isolated from breastfed than mixed fed or bottle fed (56.7% vs 43.9% vs 28.9%, p = 0.004) while intestinal parasites were mostly in bottle fed than mixed or breastfed children (28.8% vs 8.2 vs 0.8, p < 0.004). However, when children with diarrhoea were considered, E. coli was more frequently isolated from bottle fed children who presented with diarrhoea than without (26.7% vs 7.7%, p = 0.03).(ABSTRACT TRUNCATED AT 250 WORDS)

Human immunodeficiency virus- 1 in leprosy patients attending Kenyatta National Hospital, Nairobi.

The purpose of this study was to determine if Mycobacterium leprae is an opportunistic pathogen in immunosuppressed subjects with HIV infection. Ninety six leprosy patients at Infectious Diseases Hospital (IDH), Nairobi were screened for, HIV-1 antibody between January 1991 and June 1992. The patients included 15 who were diagnosed during the study period and 81 who were previously diagnosed and were on anti-leprosy treatment. Blood was screened for HIV antibody by first ELISA and double positive samples were confirmed by a second ELISA. The HIV seronegative patients were re-tested serologically every 3 months. Smears from skin slits were used to determine bacterial index and the patients were classified according to criteria described by Ridley and Jopling. The patients were re-assessed clinically monthly. The mean age of the patients was 40 years and ranged from 13 to 78 years. Forty seven percent had paucibacillary and 53% had multibacillary leprosy. The HIV seroprevalence was 8% in previously diagnosed patients and zero in the newly diagnosed patients. There were no changes in clinical spectrum in HIV seropositive patients during follow up period; neither reversal reactions nor erythema nodosum leprosum were observed. The study suggests that M. leprae may not be an opportunistic pathogen in immunosuppressed subjects with HIV infection.

Standardization of an enzyme immunoassay for human antibody to Haemophilus ducreyi.

We standardized a serologic enzyme immunoassay (EIA) for human immunoglobulin G and M antibodies against Haemophilus ducreyi. We evaluated the performance of this test with respect to the time from acute chancroid and coinfection with human immunodeficiency virus (HIV). Antibody to a crude, soluble bacterial antigen of one H. ducreyi strain was detected in a panel of serum samples from clinically and microbiologically confirmed cases of chancroid and from controls. Test interpretation was standardized for optimal sensitivity and specificity. Performance of the EIA was enhanced in the period of early convalescence from acute primary chancroid and was not diminished in the presence of HIV coinfection. The EIA performed adequately as a serologic screening test for field evaluation and epidemiologic application in conjunction with sexually transmitted disease and HIV detection and control efforts.

Human immunodeficiency virus type 1 infection in women attending a sexually transmitted diseases clinic in Kenya.

A cross-sectional study was conducted among women attending a sexually transmitted diseases clinic in Nairobi, kenya, to determine the prevalence of and associated risk factors for human immunodeficiency virus (HIV) type 1 infection. HIV-1 antibody was detected in 13.8% of 600 women. This virus was found most frequently in prostitutes (odds ratio [OR], 7.2), in women reporting a history of genital ulcers (OR, 2.3), and in those with a current diagnosis of genital ulcers (OR, 5.1). Lifetime duration of oral contraceptive use was significantly greater in HIV-1-positive women. Multivariate analysis revealed an association between genital ulcers and HIV-1 infection (OR, 3.8). The strongest association for HIV-1 infection, however, occurred with genital ulcers in combination with the use of oral contraceptives (OR, 25.7).

Towards developing a diagnostic algorithm for Chlamydia trachomatis and Neisseria gonorrhoeae cervicitis in pregnancy.

C trachomatis and N gonorrhoeae are major causes of maternal and neonatal morbidity and mortality in developing countries. To identify characteristics predictive of cervical infection, we examined pregnant women attending an antenatal clinic in Nairobi, Kenya. C trachomatis was isolated from 14/178 (8%), and N gonorrhoeae from 17 (10%); cervical infection with either pathogen was present in 28 (16%). Two characteristics were independently predictive of cervical infection by logistic regression analysis; the presence of either endocervical mucopus or induced endocervical bleeding, relative risk 4.2 (95% confidence interval (CI) 2.2 to 8.0) and having more than one sexual partner during pregnancy, relative risk 3.3 (95% CI 1.4 to 7.6). A screening programme for cervical infection which tested women with one or both risk markers would have a sensitivity of 68% (95% CI 51 to 85%) and a positive predictive value of 0.35 (95% CI 0.22 to 0.47). In countries where resources are limited, diagnostic algorithms incorporating clinical signs and behavioural characteristics may be useful in identifying pregnant women at high risk of cervical infection.

PIP: Chlamydia trachomatis and Neisseria gonorrhoea are major causes of maternal and neonatal morbidity in developing countries. 178 pregnant women attending an antenatal clinic in Nairobi, Kenya, were therefore examined in the attempt to identify characteristics predictive of cervical infection. Chlamydia trachomatis was isolated from 14 (8%) and Neisseria gonorrhoea from 17 (10%); cervical infection with either pathogen was present in 28 (16%). Logistic regression analysis found that the presence of either endocervical mucopus or induced endocervical bleeding and having more than 1 sex partner during pregnancy were independently predictive of cervical infection. A screening program for cervical infection which tested women with 1 or both risk markers wold have a sensitivity of 68% and a positive predictive value of 0.35. The authors conclude that countries with limited resources may use diagnostic algorithms and incorporate clinical signs and behavioral characteristics to help identify pregnant women at high risk of cervical infection.