The associations between cervicovaginal HIV shedding, sexually transmitted diseases and immunosuppression in female sex workers in Abidjan, Côte d'Ivoire.

OBJECTIVE: To measure the frequency and associated factors of cervicovaginal HIV shedding and to determine the impact of sexually transmitted disease (STD) treatment on HIV shedding. DESIGN: Cross-sectional study with 1-week follow-up. SETTING: Confidential clinic for female sex workers in Abidjan, Côte d'Ivoire. PARTICIPANTS: A total of 1201 female sex workers. INTERVENTIONS: STD treatment based on clinical signs. MAIN OUTCOME MEASURES: HIV serostatus; cervicovaginal HIV shedding at enrollment and at 1-week follow-up; STD status at enrollment and at 1-week follow-up. RESULTS: Cervicovaginal shedding of HIV-1 in HIV-1-seropositive women was more frequent (96 out of 404, 24%) than shedding of HIV-2 in HIV-2-seropositive women [one out of 21, 5%; odds ratio (OR), 6.2; 95% confidence interval (CI), 1.0-261]. Among 609 HIV-1-seropositive or dually seroreactive women, HIV-1 shedding was significantly more frequent in immunosuppressed women [adjusted OR (AOR), 6.3; 95% CI, 3.4-11.9; and AOR, 2.9; 95% CI, 1.6-5.0 for CD4 < 14% and CD4 14-28%, respectively, versus CD4 > 28%], and in women with Neisseria gonorrhoeae (AOR, 1.9; 95% CI, 1.2-3.0), those with Chlamydia trachomatis (AOR, 2.5; 95% CI, 1.1-5.8), and with a cervical or vaginal ulcer (AOR, 3.9; 95% CI, 2.1-7.4). HIV-1 shedding decreased from 42 to 21% (P < 0.005) in women whose STD were cured. CONCLUSIONS: These data help to explain the difference in transmissibility between HIV-1 and HIV-2 and the increased infectiousness of HIV in the presence of immunosuppression and STD. In addition, they lend biological plausibility to arguments for making STD control an integral part of HIV prevention strategies in Africa.

Genital ulcers associated with human immunodeficiency virus-related immunosuppression in female sex workers in Abidjan, Ivory Coast.

A cross-sectional study among female sex workers in Abidjan was conducted to study the association between sexually transmitted diseases and human immunodeficiency virus (HIV) infection and HIV-related immunosuppression. Among 1209 women tested for HIV, 962 (80%) were seropositive. HIV infection was independently associated with a longer duration of sex work, a lower price for intercourse, being an immigrant, and having a positive Treponema pallidum hemagglutination test (P < .05). Genital ulcers (25% vs. 5%), genital warts (14% vs. 4%), Neisseria gonorrhoeae (32% vs. 16%), Trichomonas vaginalis (27% vs. 17%), and syphilis (27% vs. 17%) were more frequent (P < .05) in HIV-infected than -uninfected women. Among HIV-infected women, the proportions with a genital ulcer were 17%, 25%, and 36% for those with > 28%, 14%-28%, and < 14% CD4 cells, respectively (P < .001). This study suggests that genital ulcers are an opportunistic disease in female sex workers in Abidjan.

HIV status of female sex partners of men reactive to HIV-1, HIV-2 or both viruses in Abidjan, Côte d'Ivoire.

OBJECTIVES: To compare rates of serologic concordance in the female sex partners of men with HIV-1 and HIV-2 infections, and to determine the serologic status of sex partners of men who reacted serologically to both viruses. DESIGN: Cross-sectional study. SETTING: Infectious diseases service in a University Hospital in Abidjan, Côte d'Ivoire (West Africa). PARTICIPANTS: Hospitalized men reactive on synthetic peptide-based tests to HIV-1, HIV-2 or both viruses (dually reactive), and their spouses visiting them in hospital. OUTCOME MEASURES: Serologic status of female spouses of seropositive men. RESULTS: The serologic status of 540 spouses of 490 HIV-1- and/or HIV-2-positive, hospitalized men was studied. Similar proportions of spouses of HIV-1-infected men (49%) and HIV-2-infected men (44%) were concordantly seropositive. The overall prevalence of infection in spouses of dually reactive men (72%) was significantly higher than in spouses of other men; 44% of these spouses were infected with HIV-1, 8% with HIV-2, and 20% were themselves dually reactive. Considering only the seropositive female spouses of men monotypically reactive to HIV-1 or HIV-2, and the male spouses of women monotypically infected, rates of serologic discordance were significantly greater in men (24%) than women (7%). CONCLUSIONS: Men were likely to have been infected earlier than women because of their HIV-associated illness; also, men more frequently had serologic profiles indicative of infection outside of the union. Rates of serologic concordance in spouses of men with advanced HIV-1 or HIV-2 infection were similar (44-49%). Dually reactive hospitalized men frequently (72%) had seropositive sex partners, most of whom were HIV-1-positive. Dual reactivity was also frequent in these spouses, suggesting transmission of both HIV-1 and HIV-2, or of a cross-reactive strain, and a minority of partners were infected with HIV-2 alone. Prospective studies of discordant couples using quantitative molecular diagnostic techniques are required for better understanding of dual reactivity and transmission of HIV-1 and HIV-2.

Dual seroreactivity to HIV-1 and HIV-2 in female sex workers in Abidjan, Côte d'Ivoire.

OBJECTIVE: To determine the absolute and proportional prevalence of dual seroreactivity to HIV-1 and HIV-2 in female sex workers in Abidjan, to determine risk determinants for this serologic profile, and to describe the associated clinical and immunological characteristics. DESIGN: Cross-sectional study. SETTING: Confidential clinic for female sex workers in Abidjan. PARTICIPANTS: Female sex workers. MAIN OUTCOME MEASURES: HIV serostatus, CD4+ counts, women with AIDS, behavioural and sociodemographic characteristics. RESULTS: Among 1209 women tested, the overall HIV seroprevalence was 80%, while the prevalence of dual seroreactivity was 30%. Dual seroreactivity accounted for 38% of all HIV infections. Compared with women reacting to HIV-1 only, dually seroreactive women were significantly more likely to have been in sex work for a longer period, to be aged > or = 20 years, and to charge less money for intercourse. No difference in mean CD4+ count was noted between women with dual seroreactivity (561 x 10(6)/l) and HIV-1-seropositive women (558 x 10(6)/l). CONCLUSIONS: Female sex workers in Abidjan had the highest absolute (30%) and proportional rate (38%) of dual seroreactivity yet described in any population. Increased sexual exposure is associated with an increased risk of dual seroreactivity. Although better molecular diagnostic techniques are required, a substantial proportion of female sex workers in Abidjan is likely to be infected with both HIV-1 and HIV-2.

The mortality and pathology of HIV infection in a west African city.

BACKGROUND: HIV disease is epidemic in Africa, but associated mortality, underlying pathology and CD4+ T-lymphocyte counts have not previously been evaluated in a representative study. Such data help to determine the management of HIV-positive people. Both HIV-1 and HIV-2 infections are prevalent in Côte d'Ivoire, and the pathology of HIV-2 infection in Africa is unclear. METHODS: Consecutive adult medical admissions to a large city hospital in Côte d'Ivoire were studied in 1991, and a sample of HIV-positive deaths autopsied. RESULTS: Of 5401 patients evaluated, 50% were HIV-positive; 38% of these died, with a median survival of 1 week. At autopsy (n = 294, including 24% of HIV-positive deaths in hospital), tuberculosis (TB), bacteraemia (predominantly Gram-negative rods) and cerebral toxoplasmosis caused 53% of deaths. TB was seen in 54% of cadavers with AIDS-defining pathology and Pneumocystis pneumonia in 4%. The median CD4+ T-lymphocyte counts in those who died was < 90 x 10(6)/l. Compared with HIV-1-positives, patients with HIV-2-positivity had a greater frequency of severe cytomegalovirus infection, HIV encephalitis and cholangitis. CONCLUSIONS: In this population, HIV-positive adults present to hospital with advanced disease associated with high mortality. The three major underlying pathologies (TB, toxoplasmosis and bacteraemia) are either preventable or treatable. TB is an underestimated cause of the 'slim' syndrome in Africa. The patterns of pathology in HIV-2-positive patients suggest a more prolonged terminal course compared with HIV-1. There is an urgent need for attention towards the issues of therapy and care for HIV disease in developing countries.

Pathogens and predictors of fatal septicemia associated with human immunodeficiency virus infection in Ivory Coast, west Africa.

In East Africa, bacteremia is more common in hospitalized human immunodeficiency virus (HIV) type 1-positive than -negative patients. In 1991, blood cultures and clinical and laboratory data were obtained from 319 patients in Ivory Coast, where both HIV-1 and -2 infections occur. Forty-three bacterial, 10 mycobacterial, and 8 fungal pathogens were isolated from blood of 54 patients (17%). Pathogens isolated significantly (P < or = .05) more frequently from HIV-positive than -negative patients were nonmycobacterial bacteria, particularly Salmonella enteritidis; mycobacteria, particularly Mycobacterium tuberculosis-Mycobacterium bovis; and yeast or fungus. HIV-1 or -2 positivity was associated with a 3-fold increased risk for septicemia (P < .02). HIV-positive patients with fever or with lymphocyte counts < 1000 were more likely to be septicemic than those without these characteristics. Mortality increased significantly with HIV positivity (40% vs. 14%, P < .001) and, among HIV-positive patients, with having pathogens isolated from blood (63% vs. 33%, P < .001).