[Access to the management of HIV infected children: Overview of the healthcare supply in Cameroon in 2014]. / Accès à la prise en charge de l'infection VIH pédiatrique ­ État des lieux de l'offre des soins au Cameroun en 2014.

BACKGROUND: In Cameroon in 2012, the proportion (15%) of children eligible for antiretroviral treatment (ART) was one of the lowest among the 21 Global Fund priority countries. The objective of this study was to carry out a situational analysis of the existing care offer for pediatric HIV in Cameroon. METHODS: A descriptive cross-sectional study was conducted over a 4-month period (April to August 2014) in 12 healthcare facilities in 7 regions of Cameroon selected by systematic sampling. The data were collected in a self-administered questionnaire filled out by the caregiving and administrative personnel included in the study. RESULTS: All in all, 142 persons in charge of pediatric HIV treatment were included in the study, of whom 115 were working at the operational level: 59 (51.2%) health personnel, 44 (38.3%) community agents and 12 (10.4%) department heads; the other 27 exercised responsibilities at the regional (19) and the local (8) levels. An overwhelming majority of the caregivers involved in pediatric VIH treatment were nurses, a factor necessitating the delegation of medical tasks institutionalized in Cameroon. Few standardized nationwide documents take into account these treatment modalities. Inadequate dissemination of the documents at all levels of the healthcare pyramid may justify the non-compliance with the care protocols that has been observed in the training programs dedicated to the subject. CONCLUSION: The updating and large-scale dissemination of standardized nationwide documents taking into account the specificities of HIV-infected children are required to improve implementation at the operational level of the Cameroonian healthcare system of the existing guidelines for pediatric HIV treatment.

Yield of training exchanges between Europe and Sub-Saharan Africa.

Opportunities that allow neurologists-in-training from Western Europe and Sub-Saharan Africa to benefit from exchanges between their respective neurological departments are rare. In a pilot exchange program, we compare the patterns of neurological diseases encountered in neurological wards of public hospitals in Brussels and Yaoundé to underline educational benefits. For 5 months the age, sex, mortality, HIV cases and clinical characteristics of admitted patients were prospectively analyzed. Eighty Cameroonian and 105 Belgian patients were classified into the following neurological entities: infectious, vascular, immune-related, epileptic, degenerative, neoplastic, psychogenic and movement disorders. Means and proportions were compared using Student's test and Fisher's exact test, respectively. Patients were younger in Yaoundé (mean age 45.3 vs. 54.0 years, p = 0.002), but died four times more (23.75 vs. 4.75 % of admissions, p < 0.001). HIV proportion was 43.75 % in Yaoundé and nil in Brussels. Infectious complications were responsible for 100 % of deaths in HIV-positive patients against 44 % in HIV-negative patients (p = 0.0108). The proportions of vascular, neoplastic and movement disorders were comparable. Neurological complications of infections occurred ten times more in Yaoundé (69 vs. 6.7 %, p < 0.0001). Multiple sclerosis accounted for 11.4 % of admissions in Brussels but other immune-related diseases were more frequent in Yaoundé (8.75 vs. 2 %, p = 0.04). Epileptic, degenerative and psychogenic diseases were more frequent in Brussels: 38.1 versus 12.5 % (p < 0.001), 16.2 versus 5 % (p < 0.0194) and 3.75 versus 14.3 % (p < 0.0224), respectively. Exchanges between Western Europe and Sub-Saharan neurological wards could offer neurologists-in-training firsthand experience with diseases seldom met; otherwise, an understanding of different healthcare systems and a better understanding of the concept of neurology as a public health challenge.

[A case of vitiligo occurring after initiation of antiretroviral treatment and disappearing during this treatment: autoimmune IRIS syndrome?]. / Vitiligo régressif au début d'un traitement antirétroviral : syndrome de reconstitution immunitaire ?

BACKGROUND: Immune reconstitution inflammatory syndrome (IRIS) includes all signs occurring during the reconstitution of an extensive and insufficiently regulated immune response to an infective or a non-infective antigen and observed during the immune suppression phase in an individual. We report a case of vitiligo appearing after the initiation of antiretroviral treatment and with repigmentation during the course of the treatment. PATIENTS AND METHODS: A 30-year-old man, seropositive for HIV1-M, consulted for a diffuse eruption of hypopigmented and achromic macules. The lesions appeared 7 weeks after the start of antiretroviral therapy with zidovudine, lamivudine and efavirenz, starting on the forearm and spreading to the remainder of the skin. At control visits during the ensuing two months, gradual repigmentation of the achromic macules was noted. Plasma viral load, determined only during the treatment period, was less than 40 copies/ml (1.60(log)). DISCUSSION: This report concerns an original case of vitiligo occurring at the start of antiretroviral treatment in an HIV-positive patient, with spontaneous repigmentation during treatment. The chronology points to a hypothesis of immune reconstitution inflammatory syndrome (IRIS), despite the absence of any indication of the patient's viral load prior to therapy.

[Stevens-Johnson's syndrome following ingestion of gunpowder]. / Syndrome de Stevens-Johnson après ingestion de poudre à canon.

BACKGROUND: A cutaneous adverse drug reaction is a skin eruption secondary to the intake of a drug, be it prescribed by a medical practitioner or taken as auto-medication for a given ailment. In this document we present an original case of Stevens-Johnson's syndrome secondary to the ingestion of gunpowder. PATIENTS AND METHODS: A 22-year-old female student was hospitalised for diffuse and painful skin eruptions for the previous three days. She had complained six days earlier of an allergic reaction to pineapples, an allergy she had presented for quite a long time. In an attempt to remedy the situation, her mother made her drink a solution made of gunpowder bought at a market mixed with some water. On the third day of this "treatment", the patient noticed eruptions on her skin. These were initially maculopapular, later becoming erosive, and she had a mild fever. Later, a variety of eruptions appeared on the skin, from hyper-pigmented macular papules to blisters and erosive lesions with no Nicolsky sign. These lesions spared the palms of the hands and the soles of the feet. The mucosa of the conjunctivae, nose, buccal cavity, vulva, vagina and anus were severely affected. This clinical presentation was typical of Steven Johnson syndrome. The patient had stopped taking the "treatment" when she noticed the first lesions. On therapy, the outcome was favourable, except for severe complications such as synechiae with diffuse dyschromia. CONCLUSION: To the best of our knowledge this is the first time gunpowder has been incriminated in Stevens-Johnson's syndrome.

Concurrence of dermatological and ophthalmological morbidity in onchocerciasis.

Prevalence of skin and eye disorders in African onchocerciasis (river blindness) is well documented. However, less is known about their joint occurrence. Information on concurrence may improve our understanding of disease pathogenesis and is required to estimate the disease burden of onchocerciasis. We analysed data from 765 individuals from forest villages in the Kumba and Ngambe Health districts, Cameroon. These data were collected in 1998, as baseline data for the evaluation of the African Programme for Onchocerciasis Control. Concurrence of symptoms was assessed using logistic regression. Onchocerciasis was highly endemic in the study population (63% nodule prevalence among males aged ≥20). Considerable overall prevalences of onchocercal visual impairment (low vision or blindness: 4%), troublesome itch (15%), reactive skin disease (19%), and skin depigmentation (25%) were observed. The association between onchocercal visual impairment and skin depigmentation (OR 9.0, 95% CI 3.9-20.8) was partly explained by age and exposure to infection (OR 3.0, 95% CI 1.2-7.7). The association between troublesome itch and reactive skin disease was hardly affected by adjustment (adjusted OR 6.9, 95% CI 4.2-11.1). Concluding, there is significant concurrence of morbidities within onchocerciasis. Our results suggest a possible role of host characteristics in the pathogenesis of depigmentation and visual impairment. Further, we propose a method to deal with concurrence when estimating the burden of disease.

The African Programme for Onchocerciasis Control: impact on onchocercal skin disease.

OBJECTIVES: To assess the long-term impact of the African Programme for Onchocerciasis Control on itching and onchocercal skin disease (OSD). METHODS: Seven study sites in Cameroon, Sudan, Nigeria and Uganda participated. Two cross-sectional surveys were conducted of communities meso- and hyper-endemic for onchocerciasis before and after 5 or 6 years of community-directed treatment with ivermectin (CDTI). Individuals were asked about any general health symptoms including itching and underwent full cutaneous examinations. Onchocercal skin lesions were documented according to a standard classification. RESULTS: Five thousand one hundred and ninety three people were examined in phase I and 5,180 people in phase II. The presence of onchocercal nodules was a strongly significant (P < 0·001) risk factor for all forms of onchocercal skin disease: APOD (OR 1·66); CPOD (OR 2·84); LOD (OR 2·68); reactive skin lesions (OR 2·38) and depigmentation (OR 3·36). The effect of community-directed treatment with ivermectin was profound. At phase II, there were significant (P < 0·001) reductions in the odds of itching (OR 0·32), APOD (OR 0·28); CPOD (OR 0·34); reactive skin lesions (OR 0·33); depigmentation (OR 0·31) and nodules (OR 0·37). Reduction in the odds of LOD was also significant (OR 0.54, P < 0.03). CONCLUSIONS: This first multi-country report of the long-term impact of CDTI reveals a substantial reduction in itching and OSD. APOC operations are having a major effect in improving skin health in poor rural populations in Africa.

Risk factors for HIV-associated neurocognitive disorders (HAND) in sub-Saharan Africa: the case of Yaoundé-Cameroon.

BACKGROUND: The prevalence of HIV-associated neurocognitive disorders (HAND), especially HIV-associated dementia (HAD) is influenced by several risk factors. The prevalence as well as risk factors for HAD are not well known in sub-Saharan Africa (SSA). We have shown that the International HIV Dementia Scale (IHDS) is a useful screening tool for HAND in Yaoundé [Njamnshi AK, Djientcheu VdP, Fonsah JY, Yepnjio FN, Njamnshi DM, Muna WFT. The IHDS is a useful screening tool for HAD/Cognitive Impairment in HIV-infected adults in Yaoundé-Cameroon. Journal of Acquired Immune Deficiency Syndromes 2008;49(4):393-397], but no study in Cameroon has yet investigated the risk factors for HAND or HAD. PATIENTS AND METHODS: A cross-sectional study was conducted in Yaoundé, the capital of Cameroon from September to December 2006. One hundred and eighty-five HIV-positive subjects were included. Diagnosis of HAND was done using the IHDS with a score < or = 10 considered as abnormal. Age, sex, level of education, IV drug use, body mass index (BMI), CDC clinical stage, CD4 counts, hemoglobin levels, administration of highly active antiretroviral therapy (HAART) and type of regimen used, were considered in univariate analysis, with level of significance set at P < or = 0.05. A binary logistic regression was used to determine independent risk factors. RESULTS: The following factors were independent predictors of HAND: advanced clinical stage (OR=7.43, P=0.001), low CD4 count especially CD4 < or = 200 cells/microL (OR=4.88, P=0.045) and low hemoglobin concentration (OR=1.16, P=0.048). CONCLUSION: This first study of the risk factors for HAND in Yaoundé-Cameroon shows findings similar to those described in other studies. These results call for rapid action by policy makers to include HAND prevention strategies such as providing early universal access to HAART based on these risk factors, in the management of HIV patients at risk of HAND in resource-limited settings of SSA like ours.

Gender issues in the community-directed treatment with ivermectin (CDTI) of the African Programme for Onchocerciasis Control (APOC).

This paper reviews the issues relating to compliance and participation among the men and women of three countries within the remit of the African Programme for the Control of Onchocerciasis (APOC): Cameroon, Nigeria and Tanzania. Project-monitoring data from 109 focus-group discussions, 6069 household-survey respondents and 89 interviews with ivermectin distributors were analysed to gain an insight into the attitudes and behaviours of men and women in relation to ivermectin treatment and their participation in the programme. Although there are no statistically significant gender differences in coverages for ivermectin treatment, culturally prescribed gender relationships influence the ways in which men and women express and experience treatment-related behaviours. Gender roles also affect participation in the programme. Decision-making in communities on the selection of distributors tends to follow socio-cultural hierarchies based upon patriarchy and gerontocracy. Relatively few ivermectin distributors (21%) are women. Although they receive less support than their male counterparts, the female distributors are just as willing to continue ivermectin distribution in the community, and they perform as well or better than men in this regard. The terms 'community-directed', 'community participation' and even 'compliance' obfuscate important gender differences that are inherent in the implementation of onchocerciasis control. Development of strategies that recognize these gender differences will have important implications for long-term adherence to treatment and for the overall quality and sustainability of the programme.