Demography and the dual epidemics of tuberculosis and HIV: Analysis of cross-sectional data from Sub-Saharan Africa.

BACKGROUND: Convergence of tuberculosis (TB) and HIV epidemics is associated with higher morbidity and mortality risks and understanding their distribution across key demographic factors is essential for prevention and control. This analysis examines the prevalence of TB, HIV and TB-HIV coinfection across age and gender in patients with presumptive TB seeking care at the National TB and Leprosy Training Center in Nigeria. METHODS: Samples from 1603 presumptive pulmonary TB cases who provided informed consent were evaluated with a sequential testing algorithm that included a smear microscopy, cultures in liquid and broth media and then genotyping by Hain line probe assays. HIV was serially tested with two HIV rapid assays and retested with a third assay in non-conclusive samples. RESULTS: Twenty-three percent (375/1603) had confirmed pulmonary TB infection, 23.6% (378/1603) were positive for HIV infection and 26.9% (101/375) of the confirmed TB cases were HIV co-infected. Males had a higher prevalence of TB: 27.6% vs. 18.0%, p < .0001; and a lower prevalence of HIV: 19.0% vs. 29.6%, p < .0001. In the age range of 25-29 years, males were twice as likely to have TB (OR = 2.2; 95% confidence interval [CI]: 1.3-3.9, p = 0.0032) while females were five times more likely to have HIV (OR = 4.8; 95% CI: 2.6-8.9, p < .0001). Persons with TB-HIV coinfection were more likely to be young, female and less likely to be married. CONCLUSION: Younger females with a high burden of HIV may be under-diagnosed and under-reported for TB in Nigeria. Community programs for intensified and early detection of TB and HIV targeting younger females are needed in this setting.

[Epidemiological survey of leprosy conducted in metropolitan France between 2009 and 2010]. / Enquête épidémiologique sur la lèpre en France métropolitaine en 2009 et 2010.

BACKGROUND: There is no official leprosy register in France. The last epidemiological survey on leprosy in metropolitan France was done between 1995 and 1998. We performed a new epidemiological study of leprosy in metropolitan France in 2009 and 2010. PATIENTS AND METHODS: We contacted 85 dermatology and infectious disease units by e-mail or by telephone in order to determine the number of leprosy patients either being followed up or newly diagnosed in 2009 and 2010. RESULTS: The response rate was 87%. In 2010, 127 patients were being followed up in metropolitan France, mostly at dermatology units (78%). Seventy-five patients were on anti-bacillary treatment and the prevalence was 0.011/10,000. There were 39 new cases diagnosed in 2009 and 2010 (mean 19 cases/year) (low case-detection rate: 0.003 per 10,000 inhabitants). Among the new cases, seven patients (18%) were of French origin, with two from metropolitan France and five from French overseas territories. DISCUSSION: Our study confirms the persistence of imported leprosy in France and shows no significant decrease in the number of new cases since 1998 (19 vs. 18 new cases/year) or in disease prevalence (0.013 vs. 0.011 per 10,000 inhabitants). This prevalence is very far removed from the one per 10,000 inhabitants proposed by the World Health Organization as the criteria for endemic disease. Most patients in our survey were immigrants (82%). Lepromatous forms (46%) were more frequent than the tuberculoid forms (33%). All patients had either travelled to or lived in areas of high leprosy prevalence, including metropolitan subjects. CONCLUSION: Leprosy remains present in metropolitan France, and it is still important to continue teaching about it at medical faculties in order to ensure diagnosis of new patients as early as possible.

Combination prevention: new hope for stopping the epidemic.

HIV research has identified approaches that can be combined to be more effective in transmission reduction than any 1 modality alone: delayed adolescent sexual debut, mutual monogamy or sexual partner reduction, correct and consistent condom use, pre-exposure prophylaxis with oral antiretroviral drugs or vaginal microbicides, voluntary medical male circumcision, antiretroviral therapy (ART) for prevention (including prevention of mother to child HIV transmission [PMTCT]), treatment of sexually transmitted infections, use of clean needles for all injections, blood screening prior to donation, a future HIV prime/boost vaccine, and the female condom. The extent to which evidence-based modalities can be combined to prevent substantial HIV transmission is largely unknown, but combination approaches that are truly implementable in field conditions are likely to be far more effective than single interventions alone. Analogous to PMTCT, "treatment as prevention" for adult-to-adult transmission reduction includes expanded HIV testing, linkage to care, antiretroviral coverage, retention in care, adherence to therapy, and management of key co-morbidities such as depression and substance use. With successful viral suppression, persons with HIV are far less infectious to others, as we see in the fields of sexually transmitted infection control and mycobacterial disease control (tuberculosis and leprosy). Combination approaches are complex, may involve high program costs, and require substantial global commitments. We present a rationale for such investments and cite an ongoing research agenda that seeks to determine how feasible and cost-effective a combination prevention approach would be in a variety of epidemic contexts, notably that in a sub-Saharan Africa.

Definition of an algorithm for the management of common skin diseases at primary health care level in sub-Saharan Africa.

In order to help primary health care (PHC) workers in developing countries in the care of common skin diseases, an algorithm for the management of pyoderma, scabies, superficial mycoses, contact dermatitis and referral of early leprosy cases (based on the identification of diseases through the presence of objective key signs, and on treatments by generic drugs) was elaborated. One thousand patients were seen by trained dermatologists, who established diagnoses and treatments; in addition, there was systematic recording of each key sign, according to the successive algorithm steps. We compared the diagnostics and treatments obtained for several combinations of diagnostic signs, with those of the dermatologists. Sensitivity, specificity, positive predictive value and negative predictive value of defined combinations were high for pyoderma, scabies and superficial mycoses. Values were less exact for dermatitis and leprosy, but were considered sufficient for the level of health care targeted. The apportionment of treatments between the algorithm and the dermatological approaches was considered appropriate in more than 80% of cases; mismanagement was possible in 7% of cases, with few predictable harmful consequences. The algorithm was found satisfactory for the management of the dermatological priorities according to the standards required at the PHC level.

Antiretroviral therapy in sub-Saharan Africa: adherence lessons from tuberculosis and leprosy.

Declining drug costs and increases in international donor interest are leading to greater availability of antiretroviral treatment programmes for persons living with the human immunodeficiency virus in parts of sub-Saharan Africa. Ensuring adequate adherence to antiretroviral drug therapy is one of the principal challenges facing successful implementation in Africa, where 70% of the world's infected persons live. Tuberculosis and leprosy are two diseases of global importance whose control programmes can provide important lessons for developing antiretroviral drug adherence strategies. This paper examines various approaches used in tuberculosis and leprosy control which could help enhance adherence to antiretroviral therapy in resource-limited settings.

Management of HIV in resource-poor countries, with a focus on sub-Saharan Africa.

HIV/AIDS is the modern world's greatest pandemic, the brunt of which falls on sub-Saharan Africa. HIV/AIDS control efforts have up till now focused mainly on prevention, with little attention paid to care. This approach must change, and prevention has to be linked with an essential package of care if there is to be any hope of reducing HIV incidence rates or curbing the morbidity and mortality associated with AIDS. The package of care includes psycho-social support, screening for sexually transmitted infections and tuberculosis, clinical care for opportunistic infections, palliative care for terminal illness, home based care, care and support for orphans, prevention of mother to child transmission of HIV, preventive therapy and the possibility of antiretroviral (ARV) drugs. Many countries in sub-Saharan Africa are developing plans to scale-up treatment and prevention programmes, including the use of ARV drugs. However, any meaningful challenge to the AIDS epidemic requires a huge scale-up of support from the international community, both for ARV drugs and for basic prevention and care packages.

Rheumatic disorders in Sub-saharan Africa

OBJECTIVE: To review prevalence of rheumatic disorders in Sub-saharan Africa and in the context of current medical practice in the region assess the need for service and educational provision. DATA SOURCES: Medline, (English, French). Pre-Medline literature review from the 1950's (Current contents). Various conference reports including attendance at all three AFLAR (African League Against Rheumatism) congresses in the 1990's. Author's personal database. All cited references read in full. CONCLUSIONS: The evidence shows rheumatoid arthritis and systemic lupus erythematosus to be increasing in frequency in the indigenous populations of East, Central and South Africa but remaining rare in West Africans. Gout is now more prevalent than ever throughout the subcontinent. HIV has spawned a variety of previously rare spondyloarthropathies (reactive arthritis, psoriatic arthritis, enthesopathy) and changed the epidemiology of pyomyositis and osteomyelitis. Osteoarthritis is a universal problem. Juvenile chronic arthritis is not rare and rheumatic fever is common. Acute and chronic locomotor problems associated with diverse entities such as leprosy, brucellosis, meningococcus, alpha viruses, parasites, fluorosis, rickets and haemoglobinopathies enhance diagnostic diversity and therapeutic and educational requirements. Suggestions made to address the challenge posed by the burden of rheumatic disorders.

Rheumatic disorders in Sub-saharan Africa.

OBJECTIVE: To review prevalence of rheumatic disorders in Sub-saharan Africa and in the context of current medical practice in the region assess the need for service and educational provision. DATA SOURCES: Medline, (English, French). Pre-Medline literature review from the 1950's (Current contents). Various conference reports including attendance at all three AFLAR (African League Against Rheumatism) congresses in the 1990's. Author's personal database. All cited references read in full. CONCLUSIONS: The evidence shows rheumatoid arthritis and systemic lupus erythematosus to be increasing in frequency in the indigenous populations of East, Central and South Africa but remaining rare in West Africans. Gout is now more prevalent than ever throughout the subcontinent. HIV has spawned a variety of previously rare spondyloarthropathies (reactive arthritis, psoriatic arthritis, enthesopathy) and changed the epidemiology of pyomyositis and osteomyelitis. Osteoarthritis is a universal problem. Juvenile chronic arthritis is not rare and rheumatic fever is common. Acute and chronic locomotor problems associated with diverse entities such as leprosy, brucellosis, meningococcus, alpha viruses, parasites, fluorosis, rickets and haemoglobinopathies enhance diagnostic diversity and therapeutic and educational requirements. Suggestions made to address the challenge posed by the burden of rheumatic disorders.

The impact of HIV on tuberculosis control--towards concerted action.

The well-established international control strategy for tuberculosis is based upon passive case-finding of the most infectious cases followed by effective chemotherapy with sufficient support to ensure and record a successful outcome. However, no country with a severe HIV epidemic is successfully controlling tuberculosis. HIV exerts a double blow. Not only must the health service manage a greatly increased number of patients (as many as fourfold higher in many African settings) but each individual patient needs to be managed more effectively if the control programme is to have a similar impact on transmission as it did in the pre-HIV era. In this paper, we discuss some of the effects of increased burden and stigmatization. We consider the potential of preventive therapy to reduce the impact of HIV on tuberculosis control and describe a more integrated approach to both infections that is being piloted in several sites in Southern Africa.

Blindness in Africa: present situation and future needs.

AIM: To review the prevalence and causes of blindness in sub-Saharan Africa, the existing services and limitations, and the Vision 2020 goals for the future. METHODS: Methodologically sound population based surveys published in the past 20 years are reviewed and results for prevalence and causes of blindness are tabulated. The current resources and needs according to recent publications and international working groups are described. CONCLUSIONS: Blindness prevalence rates vary widely but the evidence suggests that approximately 1% of Africans are blind. The major cause is cataract; trachoma and glaucoma are also important causes of blindness. The bulk of blindness in the region is preventable or curable. Efforts should focus on eye problems which are universally present and for which there are cost effective remedies, such as cataract and refractive problems and on those problems which occur focally and can be prevented by primary healthcare measures, such as trachoma, onchocerciasis, and vitamin A deficiency. Major development of staffing levels, infrastructure, and community programmes will be necessary to achieve Vision 2020 goals.

An overview of the global epidemiology of HIV/AIDS.

Over 5 million people continue to be newly infected with HIV every year, despite advances in understanding the factors that drive the epidemics. It is apparent that control of the HIV epidemics has often proved difficult due to the complex web of behavioural, biological, social and structural vulnerabilities to infection. In this paper we discuss the epidemiology and control of HIV in sub-Saharan Africa, and draw parallels with the emerging epidemic in South and South-East Asia. Prevalence of infection in sub-Saharan Africa has continued to increase overall, but a few countries have successfully reduced national infection rates by employing an integrated, multisectoral control strategy. Prevention of similar devastating epidemics in other regions will rely upon an openness in recognizing risk and upon a concerted multisectoral approach to reduction of risk of risk at the individual level and level and vulnerability at the societal and structural levels.

In sickness or in health: TDR's partners. 8. Kenya Medical Research Institute (KEMRI).

PIP: Since its establishment in 1979, the Kenya Medical Research Institute (KEMRI) has been one of the partner agencies working with the UN Development Program/World Bank/World Health Organization Special Program for Research and Training in Tropical Diseases (TDR). KEMRI consists of a secretariat and eight separate research centers devoted to alupe leprosy and skin diseases; biomedical, clinical, virus, microbiology, and medical research; vector biology and control; and traditional medicines and drugs. KEMRI also has a model clinic, an animal house, a library, a conference area, and a computer center serving 250 technical staff and 600 administrative staff. TDR has supported about 30 trainees, and KEMRI conducts research programs on all TDR diseases except trypanosomiasis, which is the responsibility of a sister institution. KEMRI's malaria research focuses on the vector, on control through the use of bednets impregnated with insecticide, and on clinical management. KEMRI is currently researching development of hard-wearing and cheaper bednets and alternatives to chloroquine. TDR has provided funding for KEMRI studies that focus on schistosomiasis treatment, prevention, and control; the distribution and impact of filariasis as well as treatment with ivermectin and anthelminthics; and control and treatment of leishmaniasis. Research into leprosy is seeking better drugs, better diagnostic tools, and ways to increase patient treatment compliance.^ieng

Risk analysis. HIV / AIDS country profile: Zambia.

PIP: The World Health Organization (WHO) estimates that, as of the end of 1994, 17% of adults in Zambia had been infected with HIV. The Ministry of Health's National AIDS/STD/TB and Leprosy Program's (NASTLP) prevalence estimates concur with those of the WHO. NASTLP surveillance covers women attending antenatal clinics, outpatients, and blood donors. Although available HIV prevalence data for the country are less than reliable, it is clear that HIV prevalence has increased over time to presently high levels and that prevalence is higher in urban areas than in rural areas. Very high levels of HIV prevalence have been found among some health care professionals tested at Lusaka University Teaching Hospital. The data on AIDS cases are of poor quality. 42% of urban and 33% of rural households in 1993 contained orphans. Projections of the course of the epidemic are presented along with discussion of the potential impact upon the economy, the agricultural sector, and the private sector. Zambia's background is outlined. Vulnerability is then considered with regard to sexually transmitted diseases, poverty, the loss of formal sector employment and structural adjustment programs, mobility within society, urbanization, social pressure upon girls to have sexual intercourse, and the traditional practice of cleansing surviving spouses through sexual intercourse with an in-law. Government and private sector responses and external assistance from the European Commission are noted.^ieng

Tuberculosis prevention: where do we go from here?

PIP: The Karonga (Malawi) Prevention Trial revealed that repeat BCG vaccinations did not protect against pulmonary tuberculosis (TB) but appeared to provide some protection against glandular TB. They increased protection against leprosy. In fact, a single BCG vaccination conferred 50% protection against leprosy and a repeat BCG vaccination increased protection by another 50%. This trial's findings confirm the need for maintaining BCG vaccination programs in countries where leprosy is a public health problem, for individuals at high risk of leprosy (i.e., contacts of leprosy cases), and because BCG provides some protection against severe forms of TB (i.e., miliary disease and TB meningitis). An alternative TB vaccine needs to be developed, however. The protective efficacy of BCG against pulmonary TB is higher at latitudes far from the equator (80% in northern Europe vs. 0% in India and Malawi). It appears that the immunologic effects of environmental mycobacteria compromise BCG's protective effect against pulmonary TB. There is heterologous immunity between various mycobacterial infections. Low-level delayed-type hypersensitivity (DTH) to tuberculin in non-BCG vaccinated people reflects exposure to environmental mycobacteria. These people are at lower risk of TB than are people with either no DTH or strong DTH to tuberculin. Intradermal exposure to different mycobacteria provides varying degrees of protection against TB in guinea pigs. The warmer and the wetter the environment, the more widespread is colonization by mycobacteria. An area of future research is mapping the distribution of environmental mycobacteria, correlating it with the pattern of DTH responses to tuberculin, and then laboratory work to isolate relevant antigens of the mycobacteria. Another approach is identifying mycobacterial antigens that elicit protective immune responses in vitro so researchers can then identify which antigens and responses are associated with patterns of DTH known to reflect low risk of TB and which response patterns are elicited by BCG against leprosy but not TB antigens. New vaccines are not on the imminent horizon, however.^ieng

AIDS -- how false positives affect Africa.

PIP: The World Health Organization (WHO) estimates of AIDS cases in Africa are based on the results of trials using the two main HIV serodiagnostic tests: the ELISA and the Western Blot. Some AIDS specialists believe that these tests are not accurate enough to confirm HIV positivity. In fact, they may be most meaningless in Africa because the widespread ill-health there contributes to false positive reactions. Malnutrition and associated chronic diseases are the key causes of ill-health in Africa. The US Centers for Disease Control and Prevention considers the ELISA to be only a screening test to detect suspicious blood samples and not a confirmatory test. In the US, the Western Blot is used as a confirmatory test. False positives could be avoided if scientists could use a suitable gold standard (i.e., HIV isolation). Yet HIV has yet to be unequivocally isolated. In fact, according to Neville Hodgkinson, the entire HIV story might be a monumental error. In Africa, due to cost considerations, most people are diagnosed with HIV based on the findings of a single test. Yet many supposedly HIV-infected persons may actually be suffering from influenza, malaria, or malnutrition, all of which can produce positive HIV results. During the second half of the 1980s, there was no public acknowledgment of inadequacies in the HIV test. In 1994, a professor of public health at Harvard, scientists at the University of Kinshasa, and the health ministry in Zaire found that a supposed association with leprosy and HIV infection as detected by the ELISA was actually due to false positives. When they retested using the Western Blot and radioimmunoprecipitation analysis, the number of the 57 leprosy patients found to be HIV positive fell from 37-41 to 2 and the number of contacts found to be HIV positive fell from 9-12 to 0. An non-validated test (i.e., ELISA) has technical problems and pitfalls in interpretation and is vulnerable to shipping, climatic and storage conditions, and subject to unmeasured and immeasurable cross-reactivities, and may give false positive results.^ieng

Leprosy care. The impact of multiple drug therapy.

PIP: There are currently an estimated 10-12 million cases of leprosy in the world. Until relatively recently, dapsone was the mainstay of drug therapy against this disease, but it had to be administered for very long periods of time and began to lose effectiveness in the face of growing disease resistance. New standard, multi-drug regimens were therefore recommended by WHO in 1982 and have since become the standard minimum necessary treatment in leprosy control programs. Multiple drug therapy (MDT), if administered early enough, can cure leprosy before deformity develops. Its cost and complexity, however, impede its widespread dissemination where needed. Much of rural Africa especially suffers from a lack of MDT due to financial constraints, geographic isolation, transport difficulties, and poor healthcare infrastructure. Dr, William Philip of the United Kingdom Aberdeen Royal Infirmary describes the introduction of MDT into and throughout rural northwestern Uganda over the period 1986-90. The introduction of MDT in West Nile has made a positive impact against leprosy. Most patients have been released from treatment or will be released soon after completing their regimes, so that only new cases will be receiving drug therapy. This large drop in case load will allow greater effort to be placed upon early case detection and treatment. MDT over time will reduce the number of patients needing drug therapy and leave only few disabled patients after a few decades. In so doing, MDT seems to be the approach needed to control and eventually eradicate leprosy. It is hoped that this program experience will help guide program implementation in other areas where MDT has yet to be introduced.^ieng

Leprosy: an urgent need to step up use of MDT in Africa.

PIP: 10-12 million people in the world have leprosy. India claims about 4 million of these cases. Overall at least 20% of the cases are children. In the 1940s, dapsone was the only drug used to treat leprosy. By the early 1970s, dapsone did not perform as expected and Mycobacterium leprae were beginning to exhibit resistance to dapsone. In 1982, WHO published results of its study which recommended fixed and relatively short duration regimens of multiple drug therapy (MDT) for all people with leprosy. It also listed recommendations on diagnosis, classification, and distribution of patients to either pauci or multibacillary groups. MDT depends on what type of leprosy patients have. For example, patients with multibacillary leprosy receive rifampicin, clofazimine, and dapsone whereas those with paucibacillary leprosy receive only rifampicin. In many African countries, however, MDT is not used. Yet cases of leprosy exist in 94% of Africa's countries. Moreover 37% have highly prevalent leprosy and the lowest percentage of patients on MDT (18% vs. world average of 56%). In fact, Nigeria is included in the group of 5 countries with 84% of all cases. Until the various countries in Africa can satisfy the ideal requirements for establishing a MDT program, they should begin MDT at least on a small scale. They do need, however, an adequate supply of the drugs. The other requirements include a good plan of action, laboratory facilities, transport, and referral centers. If the period of time needed to meet these requirements is long, then physicians should conduct pre MDT screenings to diagnose cases and determine who needs chemotherapy. The best way to diagnose cases is from clinical experience and paying particular attention to dermatological and neurological findings. Early identification is needed since leprosy cases are stigmatized. This article includes MDT dosages in adults and children.^ieng

Zambia's STD control programme: a model for Africa?

PIP: The annual incidence of sexually transmitted diseases (STD) in Zambia is 34 per 10,000 population with an 1.9:1 male:female ratio. Complaints related to STDs is the third most common reason for attending health establishments and constitute a significant burden upon limited financial health resources already overwhelmed by other programs such as leprosy and nutrition. STDs are therefore a major health problem in Zambia, constituting 10% of adult outpatient attendances in both hospitals and primary health care centers. Due to the enormous health, social, and economic consequences of STDs, the Zambian health ministry launched in 1980 the national STD control program, a program which is particularly important in recent years given the appearance of HIV infection and increasing evidence that concomitant STDs are significant cofactors in the sexual transmission of HIV. Program objectives are to assess the extent and nature of STDs in Zambia on the basis of existing institutional data and population sample surveys, to improve the management of STDs through the establishment of specialized STD clinics at provincial and district levels, to train in-service personnel to man STD clinics, to increase public awareness of STDs by health education and factual information, and to coordinate research, treatment, and preventive activities to reduce the incidence of STDs. Program implementation, program activities, and achievements thus far are discussed.^ieng