Diagnostic accuracy of cervical cancer screening and screening-triage strategies among women living with HIV-1 in Burkina Faso and South Africa: A cohort study.

BACKGROUND: Cervical cancer screening strategies using visual inspection or cytology may have suboptimal diagnostic accuracy for detection of precancer in women living with HIV (WLHIV). The optimal screen and screen-triage strategy, age to initiate, and frequency of screening for WLHIV remain unclear. This study evaluated the sensitivity, specificity, and positive predictive value of different cervical cancer strategies in WLHIV in Africa. METHODS AND FINDINGS: WLHIV aged 25-50 years attending HIV treatment centres in Burkina Faso (BF) and South Africa (SA) from 5 December 2011 to 30 October 2012 were enrolled in a prospective evaluation study of visual inspection using acetic acid (VIA) or visual inspection using Lugol's iodine (VILI), high-risk human papillomavirus DNA test (Hybrid Capture 2 [HC2] or careHPV), and cytology for histology-verified high-grade cervical intraepithelial neoplasia (CIN2+/CIN3+) at baseline and endline, a median 16 months later. Among 1,238 women (BF: 615; SA: 623), median age was 36 and 34 years (p < 0.001), 28.6% and 49.6% ever had prior cervical cancer screening (p < 0.001), and 69.9% and 64.2% were taking ART at enrolment (p = 0.045) in BF and SA, respectively. CIN2+ prevalence was 5.8% and 22.4% in BF and SA (p < 0.001), respectively. VIA had low sensitivity for CIN2+ (44.7%, 95% confidence interval [CI] 36.9%-52.7%) and CIN3+ (56.1%, 95% CI 43.3%-68.3%) in both countries, with specificity for ≤CIN1 of 78.7% (95% CI 76.0%-81.3%). HC2 had sensitivity of 88.8% (95% CI 82.9%-93.2%) for CIN2+ and 86.4% (95% CI 75.7%-93.6%) for CIN3+. Specificity for ≤CIN1 was 55.4% (95% CI 52.2%-58.6%), and screen positivity was 51.3%. Specificity was higher with a restricted genotype (HPV16/18/31/33/35/45/52/58) approach (73.5%, 95% CI 70.6%-76.2%), with lower screen positivity (33.7%), although there was lower sensitivity for CIN3+ (77.3%, 95% CI 65.3%-86.7%). In BF, HC2 was more sensitive for CIN2+/CIN3+ compared to VIA/VILI (relative sensitivity for CIN2+ = 1.72, 95% CI 1.28-2.32; CIN3+: 1.18, 95% CI 0.94-1.49). Triage of HC2-positive women with VIA/VILI reduced the number of colposcopy referrals, but with loss in sensitivity for CIN2+ (58.1%) but not for CIN3+ (84.6%). In SA, cytology high-grade squamous intraepithelial lesion or greater (HSIL+) had best combination of sensitivity (CIN2+: 70.1%, 95% CI 61.3%-77.9%; CIN3+: 80.8%, 95% CI 67.5%-90.4%) and specificity (81.6%, 95% CI 77.6%-85.1%). HC2 had similar sensitivity for CIN3+ (83.0%, 95% CI 70.2%-91.9%) but lower specificity compared to HSIL+ (42.7%, 95% CI 38.4%-47.1%; relative specificity = 0.57, 95% CI 0.52-0.63), resulting in almost twice as many referrals. Compared to HC2, triage of HC2-positive women with HSIL+ resulted in a 40% reduction in colposcopy referrals but was associated with some loss in sensitivity. CIN2+ incidence over a median 16 months was highest among VIA baseline screen-negative women (2.2%, 95% CI 1.3%-3.7%) and women who were baseline double-negative with HC2 and VIA (2.1%, 95% CI 1.3%-3.5%) and lowest among HC2 baseline screen-negative women (0.5%, 95% CI 0.1%-1.8%). Limitations of our study are that WLHIV included in the study may not reflect a contemporary cohort of WLHIV initiating ART in the universal ART era and that we did not evaluate HPV tests available in study settings today. CONCLUSIONS: In this cohort study among WLHIV in Africa, a human papillomavirus (HPV) test targeting 14 high-risk (HR) types had higher sensitivity to detect CIN2+ compared to visual inspection but had low specificity, although a restricted genotype approach targeting 8 HR types decreased the number of unnecessary colposcopy referrals. Cytology HSIL+ had optimal performance for CIN2+/CIN3+ detection in SA. Triage of HPV-positive women with HSIL+ maintained high specificity but with some loss in sensitivity compared to HC2 alone.

Time and risk factors for death among smear-positive pulmonary tuberculosis patients in the Health District of commune VI of Bamako, Mali, 2016.

BACKGROUND: The End Tuberculosis (TB) Strategy aims to achieve 90% reduction of deaths due to TB by 2030, compared with 2015. Mortality due to tuberculosis in Mali was 13 per 100,000 inhabitants in 2014 and 11 per 100,000 inhabitants in 2017. Risk factors for death are not known. The objective of this study was to determine the time and risk factors for death in pulmonary TB patients with positive microscopy. METHODS: We conducted a retrospective cohort study from October to December 2016 in Commune VI of Bamako. Smear positive cases pulmonary tuberculosis from 2011 to 2015 were included. We reviewed the treatment registers and collected sociodemographic, clinical, biological and therapeutic data. Median time to death and hazard ratio (HR) were estimated by the Kaplan-Meier method and a Cox regression model, respectively. RESULTS: In total, we analysed 1362 smear positive cases of pulmonary TB including 104 (8%) HIV positive and 90 (7%) deaths. The mean age was 36 ± 13 years, the sex ratio of males to females was 2:1. Among the deaths, 48 (53%) occurred during the first 2 months of treatment. Age ≥ 45 years (HR 2.09 95% CI [1.35-3.23]), weight <  40 kg (HR 2.20 95% CI [1.89-5.42]), HIV unknown status (HR 1.96, 95% CI [1.04-3.67]) and HIV-positive (HR 7.10 95% CI [3.53-14.26]) were significantly associated with death. CONCLUSIONS: The median time to death was 2 months from the start of treatment. Independent risk factors for death were age ≥ 45 years, weight <  40 kg, unknown and positive HIV status. We recommend close monitoring of patients over 45 years, HIV testing in those with unknown status, an adequate care for positive HIV status, as well as a nutritional support for those with weight below 40 kg during the intensive phase of TB treatment.

Risk factors of hepatitis B virus surface antigen carriage and serological profile of HBsAg carriers in Lomé Togo, 2016.

BACKGROUND: In Togo, the prevalence of Hepatitis B Virus Surface Antigen (HBsAg) among young people aged 15-24 years was estimated at 16.4% in 2010; however, risk factors for HBsAg carriage are poorly documented. We sought to identify risk factors for HBsAg carriage and the serological profile of HBsAg carriers in Lomé (capital city of Togo). METHOD: We conducted a case control study from October 2016 to March 2017 in Lomé. Cases and controls were randomly selected from a database of Institut National d'Hygiène (INH) of Lomé during a free screening campaign for hepatitis B. We calculated means, frequencies, proportions, odds ratios (OR), and 95% confidence interval (CI) and performed logistic regression. RESULTS: We included 83 confirmed cases and 249 controls. The median age was 31 years among cases and 30 years among the controls. The sex ratios (M/F) were 11/6 among cases and 4/3 for the controls. The independent risk factors for HBsAg carriage were the awareness of hepatitis B serological status (OR = 3.56, 95% CI [1.80-7.04]) and Kabyè-tem ethnic group (OR = 3.56, 95% CI [1.98-6.39]). Among HBsAg carriers, 13.3% were at the viral replication stage (all of whom were between 30 and 45 years of age) and 1.2% were at the acute stage of the disease. The prevalence of co-infection with hepatitis B and C was 4.80%. All co-infections were in women aged 24-28 years. CONCLUSION: The Kabyè-tem ethnic group is at risk of HBsAg carriage in Lomé. Of note, most HBsAg carriers in this ethnic group are aware of their HBsAg serological status. Furthermore, the prevalence of Hepatitis among adults of reproductive age is high and is cause for concern. We therefore recommend screening and vaccination campaigns at subsidized prices among people aged 30 years and older.

Performance of careHPV for detecting high-grade cervical intraepithelial neoplasia among women living with HIV-1 in Burkina Faso and South Africa: HARP study.

BACKGROUND: The careHPV assay is a test for high-risk (HR) human papillomaviruses (HPV) detection designed to be affordable in resource-poor settings. We evaluated the performance of careHPV screening among 1052 women living with HIV/AIDS included in the HARP (HPV in Africa Research Partnership) study in Burkina Faso (BF) and South Africa (SA). METHODS: Cervical samples were tested for HR-HPV by the careHPV and the INNO-LiPA HPV genotyping Extra assays. All women had Pap smear testing, visual inspection with acetic acid/Lugol's iodine (VIA/VILI) and colposcopy. Cervical biopsies were obtained for participants who were HR-HPV DNA positive by careHPV or who had abnormalities detected on cytology, VIA/VILI or colposcopy. RESULTS: Overall, 45.1% of women had a positive careHPV test (46.5% in BF, 43.8% in SA). The careHPV positivity rate increased with the grade of cytological lesions. Sensitivity and specificity of careHPV for the diagnosis of CIN2+ (n=60, both countries combined) were 93.3% (95% confidence interval (CI): 83.8-98.2) and 57.9% (95% CI: 54.5-61.2), respectively. Specificity increased with CD4 count. careHPV had a similar clinical sensitivity but higher specificity than the INNO-LiPA assay for detection of CIN2+. CONCLUSIONS: Our results suggest that careHPV testing is a reliable tool for cervical cancer screening in HIV-1-infected women in sub-Saharan Africa.

Detection of four human polyomaviruses (MCPyV, HPyV6, HPyV7 and TSPyV) in cervical specimens from HIV-infected and HIV-uninfected women.

OBJECTIVES: To investigate the presence of recently discovered human polyomaviruses in cervical specimens collected from African and French women, in relation to HIV serostatus, high-risk human papillomavirus infection (HR-HPV) and cervical disease. METHODS: Cervical specimens were collected from 140 HIV-1-seropositive African women and 50 HIV-seronegative French women. Presence of Merkel cell polyomavirus (MCPyV), human polyomavirus 6 (HPyV6), human polyomavirus 7 (HPyV7) and trichodysplasia spinulosa-associated polyomavirus (TSPyV) was detected by real-time PCR, and presence of HR-HPV DNA by Hybrid Capture 2 assay with subsequent HPV genotyping using the INNO-LiPA HPV Genotyping Extra assay. Cervical biopsies were analysed by histopathology. RESULTS: The detection rates were 55.3%, 3.2%, 2.1% and 0% for MCPyV, HPyV6, HPyV7 and TSPyV, respectively, with no significant difference by population. The MCPyV viral load ranged from 14 to 210 DNA copies/106 cells (median, 80 DNA copies/106 cells), with no difference between women with and without cervical precancerous lesions. There was no association between detection of human polyomaviruses in cervical specimens and geographical origin/HIV serostatus, HR-HPV coinfection or precancerous cervical lesions. CONCLUSIONS: These observations argue against a possible role of MCPyV as a cofactor in HPV-induced carcinogenesis. MCPyV and, to a lesser extent, HPyV6 and HPyV7 might belong to the female genital tract microbiota.

Comparison of careHPV and hybrid capture 2 assays for detection of high-risk human Papillomavirus DNA in cervical samples from HIV-1-infected African women.

The careHPV and HC2 assays were compared for high-risk human papillomavirus (HR-HPV) DNA detection in cervical samples from 149 HIV-1-infected African women. The HR-HPV DNA detection rates were 37.6% and 34.9% for careHPV and HC2, respectively. Agreement between the two tests was 94.6% (95% confidence interval [CI], 89.7% to 97.7%) with a kappa value of 0.88 (95% CI, 0.81 to 0.96), indicating an excellent agreement. careHPV may be considered as suitable as HC2 for cervical cancer screening among HIV-infected African women.

Capacity building at points of entry during COVID-19 pandemic: harmonising training curriculum for Economic Community of West African States.

This paper describes the process for developing, validating and disseminating through a train-the-trainer (TOT) event a standardised curriculum for public health capacity building for points of entry (POE) staff across the 15-member state Economic Community of West African States (ECOWAS) that reflects both international standards and national guidelines.A five-phase process was used in developing the curriculum: phase (1) assessment of existing materials developed by the US Centers for Disease Control and Prevention (CDC), Africa CDC and the West African Economic and Monetary Union, (2) design of retained and new, harmonised content, (3) validation by the national leadership to produce final content, (4) implementation of the harmonised curriculum during a regional TOT, and (5) evaluation of the curriculum.Of the nine modules assessed in English and French, the technical team agreed to retain six harmonised modules providing materials for 10 days of intensive training. Following the TOT, most participants (n=28/30, 93.3%) indicated that the International Health Regulations and emergency management modules were relevant to their work and 96.7% (n=29/30) reported that the training should be cascaded to POE staff in their countries.The ECOWAS harmonised POE curriculum provides a set of training materials and expectations for national port health and POE staff to use across the region. This initiative contributes to reducing the effort required by countries to identify emergency preparedness and response capacity-building tools for border health systems in the Member States in a highly connected region.

Prevalence and Molecular Characterization of Mycobacterium bovis in Slaughtered Cattle Carcasses in Burkina Faso; West Africa.

This cross-sectional study was conducted at the slaughterhouses/slabs of Oudalan and Ouagadougou in Burkina Faso, between August and September 2013. It aimed at determining the prevalence of bovine tuberculosis (bTB) suggestive lesions in slaughtered cattle carcasses and to identify and characterize the mycobacteria isolated from these lesions. A thorough postmortem examination was conducted on carcasses of a total of 2165 randomly selected cattle. The overall prevalence of bTB suggestive lesions was 2.7% (58/2165; 95% CI 2.1-3.5%). Due to the low number of positive samples, data were descriptively presented. The lesions were either observed localized in one or a few organs or generalized (i.e., miliary bTB) in 96.6% (n = 57) and 3.4% (n = 2), respectively. The identified mycobacteria were M. bovis (44.4%, n = 20), M. fortuitum (8.9%, n = 4), M. elephantis (6.7%, n = 3), M. brumae (4.4%, n = 2), M. avium (2.2%, n = 1), M. asiaticum (2.2%, n = 1), M. terrae (2.2%, n = 1), and unknown non-tuberculous mycobacteria (NTM) (11.1%, n = 5). Moreover, eight mixed cultures with more than one Mycobacterium species growing were also observed, of which three were M. bovis and M. fortuitum and three were M. bovis and M. elephantis. In conclusion, M. bovis is the predominant causative agent of mycobacterial infections in the study area. Our study has identified a base to broaden the epidemiological knowledge on zoonotic transmission of mycobacteria in Burkina Faso by future studies investigating further samples from humans and animals, including wild animals employing molecular techniques.

[Factors associated with scale-up human papillomavirus (HPV) vaccine in Senegal: a case-control survey of parents]. / Facteurs associés à la vaccination contre le virus du papillome humain dans un contexte de passage à l´échelle au Sénégal: enquête cas-témoins auprès des parents.

INTRODUCTION: after a pilot phase, Senegal is the first country in West Africa to introduce cervical cancer vaccine into its Expanded Program on Immunization. Despite the gratuity and availability of the vaccination, coverage was low. The purpose of this study was to identify factors associated with HPV vaccination coverage in girls . METHODS: we conducted a case-control analytical study from 4th to 20th January 2020 in Dakar. The study population consisted of parents or guardians of girls aged 9 to 10. We performed cluster sampling, direct structured interviews and a literature review. Socio-demographic features, parents/guardians' knowledges and information about vaccination procedure were collected using a standardized questionnaire. Logistic regression was used to estimate the odds ratio. RESULTS: during this study, 510 cases and 510 controls and 1020 parents/guardians were interviewed. Significant factors associated with vaccination of girls were: parents/guardians' education (OR=1,97; [1,81-2,25]), knowledge of the disease (OR=3,05; [2,75-4,53], high household income (OR=1,21; [1,13-1,85]), fear of side effects (OR=0,35;[ 0,27-0,44]), reception of messages via internet/social networks (OR=0,54; [0,41-0,92]) and vaccination schedules for the community (OR= 2,12 [1,59-2,64]). CONCLUSION: vaccination of girls can be improved by strengthening parents' knowledge through appropriate channels and a better organization of health services.

Costs and cost-effectiveness of cervical cancer screening strategies in women living with HIV in Burkina Faso: The HPV in Africa Research Partnership (HARP) study.

INTRODUCTION: This study estimated the costs and incremental cost per case detected of screening strategies for high-grade cervical intraepithelial neoplasia (CIN2+) in women living with HIV (WLHIV) attending HIV clinics in Burkina Faso. METHODS: The direct healthcare provider costs of screening tests (visual inspection with acetic acid (VIA), VIA combined visual inspection with Lugol's iodine (VIA/VILI), cytology and a rapid HPV DNA test (careHPV)) and confirmatory tests (colposcopy, directed biopsy and systematic four-quadrant (4Q) biopsy) were collected alongside the HPV in Africa Research Partnership (HARP) study. A model was developed for a hypothetical cohort of 1000 WLHIV using data on CIN2+ prevalence and the sensitivity of the screening tests. Costs are reported in USD (2019). RESULTS: The study enrolled 554 WLHIV with median age 36 years (inter-quartile range, 31-41) and CIN2+ prevalence of 5.8%. The average cost per screening test ranged from US$3.2 for VIA to US$24.8 for cytology. Compared to VIA alone, the incremental cost per CIN2+ case detected was US$48 for VIA/VILI and US$814 for careHPV. Despite higher costs, careHPV was more sensitive for CIN2+ cases detected compared to VIA/VILI (97% and 56%, respectively). The cost of colposcopy was US$6.6 per person while directed biopsy was US$33.0 and 4Q biopsy was US$48.0. CONCLUSION: Depending on the willingness to pay for the detection of a case of cervical cancer, decision makers in Burkina Faso can consider a variety of cervical cancer screening strategies for WLHIV. While careHPV is more costly, it has the potential to be cost-effective depending on the willingness to pay threshold. Future research should explore the lifetime costs and benefits of cervical cancer screening to enable comparisons with interventions for other diseases.

Building a new platform to support public health emergency response in Africa: the AFENET Corps of Disease Detectives, 2018-2019.

Public health emergency (PHE) response in sub-Saharan Africa is constrained by inadequate skilled public health workforce and underfunding. Since 2005, the African Field Epidemiology Network (AFENET) has been supporting field epidemiology capacity development and innovative strategies are required to use this workforce. In 2018, AFENET launched a continental rapid response team: the AFENET Corps of Disease Detectives (ACoDD). ACoDD comprises field epidemiology graduates and residents and was established to support PHE response. Since 2018, AFENET has deployed the ACoDD to support response to several PHEs. The main challenges faced during ACoDD deployments were financing of operations, ACoDD safety and security, resistance to interventions and distrust of the responders by some communities. Our experience during these deployments showed that it was feasible to mobilise and deploy ACoDD within 48 hours. However, the sustainability of deployments will depend on establishing strong linkages with the employers of ACoDD members. PHEs are effectively controlled when there is a fast deployment and strong linkages between the stakeholders. There are ongoing efforts to strengthen PHE preparedness and response in sub-Saharan Africa. ACoDD members are a competent workforce that can effectively augment PHE response. ACoDD teams mentored front-line health workers and community health workers who are critical in PHE response. Public health emergence response in sub-Saharan Africa is constrained by inadequacies in a skilled workforce and underfunding. ACoDD can be utilised to overcome the challenges of accessing a skilled public health workforce. To improve health security in sub-Saharan Africa, more financing of PHE response is needed.

Factors associated with multi-drug-resistant tuberculosis in Dakar, Senegal, 2010-2016.

According to the World Health Organization, multidrug-resistant tuberculosis (MDR-TB) represents a major obstacle towards successful TB treatment and control. In Dakar, MDR-TB management began in 2010 with the strengthening of diagnostic resources. The objective of this study was to identify the factors associated with multidrug-resistant tuberculosis in Dakar between 2010 and 2016. We conducted a case-control study from January 10 to February 28, 2017 in tuberculosis centers in Dakar. of 169 cases and 507 controls. We used logistic regression with Epi-info version 7.2.1. to estimate the odds ratios of association. Factors significantly associated with MDR-TB were: residing in a periurban area (ORa=1.8; 95% CI (1.5-4.9); p=0.024), presence of MDR-TB in the entourage of patient (ORa=7.0; 95% CI (6.1-9.5); p=0.002), previous treatment failure (ORa=29.5; 95% CI (27.3-30.1); p=0.000), treatment not directly observed by a health care provider (ORa=4.3; 95% CI (4.1-7,2); p=0.000) and irregularity of treatment (ORa=1.7; 95% CI (0.5-5.4); p=0.037). Focusing interventions on population at-risk will prevent MDR-TB.

Assessing risk factors for tuberculosis treatment failure among pulmonary tuberculosis patients in four health regions of Burkina Faso, 2009.

Conducting research studies is one of the competencies that epidemiology students should have after two years training as a crucial component to identifying and resolving public health problems. This case study is developed from a research study on assessing risks factors on tuberculosis treatment failure in Burkina Faso in 2009 to help students to cover these competences. This case study is ideal for reinforcing principles of conducting case-control studies for risk-factor assessment. The case study will help epidemiology learners outline a study proposal, reinforce knowledge about research design, data collection and data analysis issues, recognize the importance of ethics in research, and interpret results and use them to make conclusions and recommendations.

Associations of human gene EPB41L3 DNA methylation and cervical intraepithelial neoplasia in women living with HIV-1 in Africa.

OBJECTIVES: To evaluate associations of DNA methylation of the human tumour suppressor gene EPB41L3 with high-grade cervical intraepithelial neoplasia (CIN2+) and HIV-related factors among women living with HIV-1 (WLHIV) in Burkina Faso and South Africa. DESIGN: Case-control study of WLHIV aged 25-50 with histology-determined CIN2+ (cases, N = 152) and ≤CIN1 (controls, N = 210). METHODS: EPB41L3 methylation was measured by pyrosequencing of bisulphite converted DNA from exfoliated cervical specimens at baseline and 16 months later. Median methylation levels were compared across CIN grades using the Mann-Whitney test and Cuzick test for trend. EPB41L3 methylation levels were dichotomized into 'high' and 'low' using the 66.7 percentile point of the distribution in the controls. Associations of EPB41L3 methylation with HIV-related factors were estimated by logistic regression. RESULTS: Among 94 WLHIV in Burkina Faso and 268 in South Africa, median methylation levels at baseline for EPB41L3 increased with increasing CIN grade in both countries (P-trend <0.001).'High' methylation was more frequent among women with a longer time since HIV diagnosis in Burkina Faso [>5 years vs. ≤5 years; adjusted odds ratio (aOR) = 4.15, 95% CI 1.09-15.83, adjusted for age, CD4 count, high-risk HPV and CIN status], with low CD4 count in both countries (CD4 ≤200 vs. ≥350 cells/µl: aOR = 7.14, 95% CI 1.44-35.37 in Burkina Faso; aOR = 2.55, 95% CI 1.07-6.07 in South Africa), and with prolonged ART use in South Africa (ART >2 years vs. ART-naïve: aOR = 2.40, 95% CI: 1.23-4.69). CONCLUSION: Methylation of EPB41L3 DNA is elevated among WLHIV with CIN2+ and independently associated with lower CD4 count and ART use.

Cervical intraepithelial neoplasia (CIN) in African women living with HIV: role and effect of rigorous histopathological review by a panel of pathologists in the HARP study endpoint determination.

AIMS: To analyse the effect of the expert end-point committee (EPC) review on histological endpoint classification of cervical intraepithelial neoplasia (CIN). METHODS: A cohort of women living with HIV were recruited in Burkina Faso (BF) and South Africa (SA) and followed over 18 months. Four-quadrant cervical biopsies were obtained in women with abnormalities detected by at least one screening test. A central review by a panel of five pathologists was organised at baseline and at endline. RESULTS: At baseline the prevalence of high-grade CIN (CIN2+) was 5.1% (28/554) in BF and 23.3% (134/574) in SA by local diagnosis, and 5.8% (32/554) in BF and 22.5% (129/574) in SA by the EPC. At endline the prevalence of CIN2+ was 2.3% (11/483) in BF and 9.4% (47/501) in SA by local diagnosis, and 1.4% (7/483) in BF and 10.2% (51/501) in SA by EPC. The prevalence of borderline CIN1/2 cases was 2.8% (32/1128) and 0.8% (8/984) at baseline and endline. Overall agreement between local diagnosis and final diagnosis for distinguishing CIN2+ from ≤CIN1 was 91.2% (κ=0.82) and 88.9% (κ=0.71) for BF at baseline and endline, and 92.7% (κ=0.79) and 98.7% (κ=0.97) for SA at baseline and endline. Among the CIN1/2 cases, 12 (37.5%) were graded up to CIN2 and 20 (62.5%) were graded down to CIN1 at baseline, and 3 (37.5%) were graded up to CIN2 and 5 (62.5%) were graded down to CIN1 at endline. CONCLUSIONS: This study highlights the importance of a centralised rigorous re-reading with exchange of experiences among pathologists from different settings.

Prevalence, incidence and correlates of low risk HPV infection and anogenital warts in a cohort of women living with HIV in Burkina Faso and South Africa.

OBJECTIVE: To report the prevalence and incidence of low-risk human papillomavirus infection (LR-HPV) and anogenital warts (AGW) among women living with HIV (WLHIV) in Burkina Faso (BF) and South Africa (SA), and to explore HIV-related factors associated with these outcomes. METHODS: We enrolled 1238 WLHIV (BF = 615; SA = 623) aged 25-50 years and followed them at three time points (6, 12 and 16 months) after enrolment. Presence of AGW was assessed during gynaecological examination. Cervico-vaginal swabs for enrolment and month 16 follow-up visits were tested for HPV infection by Inno-LiPA® genotyping. Logistic regression was used to assess risk factors for prevalent infection or AGW. Cox regression was used to assess risk factors for incident AGW. RESULTS: Women in SA were more likely than those in BF to have prevalent LR-HPV infection (BF: 27.1% vs. SA: 40.9%; p<0.001) and incident LR-HPV infection (BF: 25.8% vs. SA: 31.6%, p = 0.05). Prevalence of persistent LR-HPV was similar in the two countries (BF: 33.3% vs. SA: 30.4%; p = 0.54), as were prevalence and incidence of AGW (Prevalence: BF: 7.5% vs. SA: 5.7%; p = 0.21; Incidence: BF: 2.47 vs. SA: 2.33 per 100 person-years; p = 0.41). HPV6 was associated with incident AGW (BF: adjusted Hazard Ratio (aHR) = 4.88; 95%CI: 1.36-17.45; SA: aHR = 5.02; 95%CI: 1.40-17.99). Prevalent LR-HPV (BF: adjusted Odds Ratio [aOR = 1.86]; 95%CI: 1.01-3.41; SA: aOR = 1.75; 95%CI: 0.88-3.48); persistent LR-HPV (BF: aOR = 1.92; 95%CI: 0.44-8.44; SA: aOR = 2.81; 95%CI: 1.07-7.41) and prevalent AGW (BF: aOR = 1.53; 95%CI: 0.61-3.87; SA: aOR = 4.11; 95%CI: 1.20-14.10) were each associated with low CD4+ counts (i.e. <200 vs. >500 cells/µL). Duration of ART and HIV plasma viral load were not associated with any LR-HPV infection or AGW outcomes. CONCLUSION: LR-HPV infection and AGW are common in WLHIV in sub-Saharan Africa. Type-specific HPV vaccines and effective ART with immunological reconstitution could reduce the burden of AGW in this population.

Epidemiology of high-risk human papillomavirus and cervical lesions in African women living with HIV/AIDS: effect of anti-retroviral therapy.

OBJECTIVE: To describe the effect of antiretroviral therapy (ART) and HIV-related factors on high-risk human papillomavirus (HR-HPV) and high-grade cervical intraepithelial neoplasia lesions (CIN2+) among women living with HIV/AIDS (WLHA) in sub-Saharan Africa. DESIGN: Prospective cohort of WLHA in Ouagadougou, Burkina Faso (BF) and Johannesburg, South Africa (SA). Recruitment was stratified by ART status. METHODS: At baseline and endline (median 16 months), cervical samples, and biopsies were analyzed for HPV genotyping (InnoLiPA) and by histology. Logistic regression was used to estimate associations of ART and HIV-related factors with HR-HPV and CIN2+ outcomes, and all results presented are adjusted for baseline CD4 cell count. RESULTS: Among 1238 enrolled WLHA (BF = 615; SA = 623), HR-HPV prevalence was 59.1% in BF and 79.1% in SA. CIN2+ prevalence was 5.8% in BF and 22.5% in SA. Compared with long-duration ART users (>2 years), HR-HPV prevalence was higher among short-duration ART users [≤2 years; adjusted prevalence ratio (aPR) = 1.24, 95% confidence interval (CI) 1.04-1.47] in BF, and CIN2+ prevalence was higher among short-duration ART users [adjusted odds ratio (aOR) = 1.99, 95% CI 1.12-3.54) and ART-naive participants (aOR = 1.87, 95% CI 1.11-3.17) in SA. Among 963 (77.8%) women seen at endline, HR-HPV persistence was 41.1% in BF and 30.2% in SA; CIN2+ incidence over 16-months was 1.2% in BF and 5.8% in SA. HR-HPV persistence was associated with being ART-naive in BF (aPR = 1.89, 95% CI 1.26-2.83), and with short-duration ART use (aPR = 1.78, 95% CI 1.11-2.86) and HIV-1 plasma viral load at least 1000 copies/ml (aPR = 2.87, 95% CI 1.63-5.05) in SA. CIN2+ incidence was reduced among women on ART in SA (aOR = 0.39, 95% CI 0.15-1.01). CONCLUSION: Prolonged and effective ART is important in controlling HR-HPV and the development of CIN2+.

Associations of Human Papillomavirus (HPV) genotypes with high-grade cervical neoplasia (CIN2+) in a cohort of women living with HIV in Burkina Faso and South Africa.

OBJECTIVE: To describe associations of high-risk human papillomavirus (HR-HPV) with high-grade cervical intraepithelial neoplasia (CIN2+) in women living with HIV (WLHIV) in Burkina Faso (BF) and South Africa (SA). METHODS: Prospective cohort of WLHIV attending HIV outpatient clinics and treatment centres. Recruitment was stratified by ART status. Cervical HPV genotyping using INNO-LiPA and histological assessment of 4-quadrant cervical biopsies at enrolment and 16 months later. RESULTS: Among women with CIN2+ at baseline, the prevalence of any HR-HPV genotypes included in the bi/quadrivalent (HPV16/18) or nonavalent (HPV16/18/31/35/45/52/58) HPV vaccines ranged from 37% to 90%. HPV58 was most strongly associated with CIN2+ (aOR = 5.40, 95%CI: 2.77-10.53). At 16-months follow-up, persistence of any HR-HPV was strongly associated with incident CIN2+ (aOR = 7.90, 95%CI: 3.11-20.07), as was persistence of HPV16/18 (aOR = 5.25, 95%CI: 2.14-12.91) and the additional HR types in the nonavalent vaccine (aOR = 3.23, 95%CI: 1.23-8.54). CONCLUSION: HR-HPV persistence is very common among African WLHIV and is linked to incident CIN2+. HPV vaccines could prevent between 37-90% of CIN2+ among African WLHIV.

Risk factors for tuberculosis treatment failure among pulmonary tuberculosis patients in four health regions of Burkina Faso, 2009: case control study.

INTRODUCTION: In Burkina Faso, the tuberculosis (TB) treatment failure rate increased from 2.5% in 2000 to 8.3% in 2006. The risk factors for TB treatment failure in the country are not well known. The study aims to determine the risk factors for treatment failure among pulmonary tuberculosis patients in four health region of Burkina Faso and to recommend appropriate interventions. METHODS: A case control study was conducted among pulmonary TB patients who began TB treatment in 2009. A case was any patient who remained smear-positive at fifth month of TB treatment and a control was a patient who tested smear-negative at fifth month of treatment. A structured questionnaire was administered to one hundred cases and one hundred controls to collect information on exposure factors. Odds ratio were calculated using bivariate and multivariate analysis to determine the association between exposures and outcome. RESULTS: Multivariate analysis showed that independent risk factors for TB treatment failure were fail to take TB drugs for more than 14 consecutive days (OR = 18.53; 95% CI:4.56 - 75.22), sputum smear-positive at two months of treatment (OR = 11.52; 95%CI:5.18-25.60), existence of comorbidity (OR = 5.74; 95%CI:1.69-19.44), and use of traditional medicines or herbs (OR = 2.97; 95%CI:1.12-7.85). CONCLUSION: Early identification of patients with the above risk factors for intense case management will improve TB treatment outcome. Patient with smear positive at 2nd(nd) month of treatment require more intense follow-up, and involving traditional healers who provide traditional medicines or herbs in the educational programme on TB are required. The national referral laboratory capacity needs to be strengthened to do drug susceptibility testing and routine drug monitoring on cases of non conversion at 2(nd) month of treatment.

Comparison of analytical and clinical performances of the digene HC2 HPV DNA assay and the INNO-LiPA HPV genotyping assay for detecting high-risk HPV infection and cervical neoplasia among HIV-positive African women.

OBJECTIVES: To compare the Hybrid Capture 2 human papillomaviruses (HPV) DNA assay (HC2) and the INNO-LiPA HPV Genotyping Extra assay (INNO-LiPA) for cervical cancer screening in HIV-1-infected African women. DESIGN: The tests were compared for agreement in detecting high-risk HPV (hr-HPV) and performance to detect squamous intraepithelial lesions (SIL), by cytology, and cervical intraepithelial neoplasia, by histology, in cervical samples from 1224 women in Burkina Faso (N = 604) and South Africa (N = 620). RESULTS: When considering the 13 hr-HPV types detected by HC2, 634 (51.8%) and 849 (69.4%) samples were positive by HC2 and INNO-LiPA, respectively. Agreement between assays was 73.9% [adjusted kappa coefficient value, 0.44 (95% confidence interval: 0.43 to 0.53)]. Agreement improved with analysis restricted to women with high-grade cervical lesions [adjusted kappa coefficient value, 0.83 (95% confidence interval: 0.74 to 0.91)]. The prevalence of hr-HPV, as determined by HC2 and INNO-LiPA, was 34.5% and 54.5%, respectively, in samples with normal cytology, 48.0% and 68.0%, respectively, in samples with atypical squamous cells of undetermined significance, 51.8% and 75.2%, respectively, in samples with low-grade SIL, and 86.3% and 89.8%, respectively, in samples with high-grade SIL/atypical squamous cells that cannot exclude HSIL. Sensitivity, specificity, positive, and negative predictive values for the diagnosis of histological high-grade lesions (CIN2+) were 88.8%, 55.2%, 24.7% and 96.7%, and 92.5%, 35.1%, 19.1% and 96.6% for HC2 and INNO-LiPA, respectively. CONCLUSIONS: HC2 has lower analytical sensitivity but higher specificity than INNO-LiPA for diagnosing high-grade lesions; the 2 tests presented a comparable clinical sensitivity. HC2 might be suitable for cervical cancer screening in HIV-1-infected African women, but its use in resource-limited settings merits to be further evaluated in comparison with other prevention strategies.