Effects of Age, Level of Education and HIV Status on Cognitive Performance in West African Older Adults: The West Africa IeDEA Cohort Collaboration.

An in-depth understanding of the impact of aging, cognitive reserve, and HIV status on cognitive function is needed in older West African adults. Ninety-nine HIV-negative and 334 HIV-positive adults aged ≥ 50 years were enrolled in three clinics (Senegal and Côte d'Ivoire) participating in the IeDEA West Africa collaboration. All subjects underwent the Free and Cued Selective Reminding Test (FCSRT) and the Isaacs Set Test (IST). Age (both linear and quadratic), education level, and HIV status effects on Z-scores were assessed using multivariate linear regression models. Interactions between HIV status and age or educational level were tested. In the present cohort of older West African adults, the role of age and educational level on episodic memory and verbal fluency was observed without revealing an interaction between HIV status and age effect. As age had quadratic effects, older HIV-positive adults should not be considered as a unique group irrespective of their age. Low-educated HIV-positive patients had the lowest verbal fluency performance compared to others. Further studies are needed to duplicate these results. In clinical settings, screening and adapted programs focusing on improving cognition in those patients are needed.

Validation of the D:A:D chronic kidney disease risk score in people living with HIV: the IeDEA West Africa Cohort Collaboration.

OBJECTIVES: A risk score for long-term prediction of chronic kidney disease (CKD) in people living with HIV (PLHIV) has been developed using data from the D:A:D cohort. We assessed the performance of the D:A:D risk score in a cohort of PLHIV in West Africa. METHODS: Data from PLHIV starting antiretroviral treatment in four clinics in Burkina Faso, Côte d'Ivoire and Togo participating in the IeDEA West Africa collaboration were analysed. CKD was defined as two consecutive estimated glomerular filtration rates (eGFRs) of ≤ 60 mL/min/1.73 m2 . The D:A:D score (short version) was calculated using age, gender, nadir CD4 and baseline eGFR and was categorized into low, medium, and high-risk groups. RESULTS: In 14 930 participants (70% female, median age = 38 years; median nadir CD4 count = 183 cells/µL) followed for a median duration of 5.7 years, 660 (4.4%) progressed to CKD, with an incidence [95% confidence interval (CI)] of 7.8 (7.2-8.4) per 1000 person-years (PY). CKD incidence rates were 2.4 (2.0-2.8), 8.1 (6.8-9.6) and, 30.9 (28.0-34.1) per 1000 PY in the low-, medium- and high-risk groups, respectively. In the high-risk group, 14.7% (95% CI: 13.3; 16.3) had progressed to CKD at 5 years. Discrimination was good [C-statistics = 0.81 (0.79-0.83)]. In all, 79.4% of people who progressed to CKD were classified in the medium- to high-risk group at baseline (sensitivity) and 66.5% of people classified in the low risk group at baseline did not progress to CKD (specificity). CONCLUSIONS: These findings confirm the validity of the D:A:D score in identifying individuals at risk of developing CKD who could benefit from enhanced kidney monitoring in West African HIV clinics.

Changes in viral hepatitis B screening practices over time in West African HIV clinics.

BACKGROUND: We aimed to describe changes in hepatitis B screening practices over a 3-year period among HIV-infected patients in West Africa. METHODS: A medical chart review was conducted in urban HIV treatment centers in Ivory Coast (3 sites), Benin, Burkina Faso, Senegal, and Togo (1 site each). Among patients who started antiretroviral treatment between 2010 and 2012, 100 per year were randomly selected from each clinic. Demographic, clinical, and laboratory data was collected using a standardized questionnaire. We assessed changes in the proportion of patients screened over time and identified predictors of screening in a multivariable logistic regression. RESULTS: A total of 2097 patients were included (median age: 37 years, 65.4% of women). Overall, 313 (14.9%) patients had been screened for hepatitis B, with an increase from 10.6% in 2010 to 18.9% in 2012 (P<0.001) and substantial differences across countries. In multivariable analysis, being aged over 45 years (adjusted odds ratio: 1.34 [1.01-1.77]) and having an income-generating activity (adjusted odds ratio: 1.82 [1.09-3.03]) were associated with screening for hepatitis B infection. Overall, 62 HIV-infected patients (19.8%, 95% confidence interval: 15.5-24.7) were HBsAg-positive and 82.3% of them received a tenofovir-containing drug regimen. CONCLUSION: Hepatitis B screening among HIV-infected patients was low between 2010 and 2012. The increasing availability of HBsAg rapid tests and tenofovir in first-line antiretroviral regimen should improve the rates of hepatitis B screening.

Screening for active tuberculosis before isoniazid preventive therapy among HIV-infected West African adults.

SETTING: TEMPRANO was a multicentre, open-label trial in which human immunodeficiency virus (HIV) infected adults with high CD4 counts were randomised into early or deferred antiretroviral therapy (ART) arms with or without 6-month isoniazid preventive therapy (IPT) in a setting where the World Health Organization (WHO) recommends IPT in HIV-infected patients. Despite the WHO recommendation, IPT coverage remains low due to fear of the presence of undiagnosed active TB before prescribing IPT, and the related risk of drug resistance. OBJECTIVE: To report the frequency of undiagnosed TB in patients enrolled for IPT and describe the results of a 1-month buffer period to avoid prescribing IPT for active TB cases. DESIGN: Patients were screened using a clinical algorithm and chest X-ray at Day 0 and started on isoniazid at Month 1 if no sign/symptom suggestive of TB appeared between Day 0 and Month 1. RESULTS: Of 1030 patients randomised into IPT arms. 10% never started IPT at Month 1. Of these, 23 had active TB, including 16 with prevalent TB. Among the 927 patients who started IPT, 6 had active TB, including 1 with prevalent TB. Only 1 patient with active TB received IPT due to the 1-month buffer period between Day 0 and IPT initiation. CONCLUSION: In this study, 1.6% of adults considered free of active TB based on clinical screening at pre-inclusion actually had active TB.

[Time trends in demographic and clinical characteristics of adult patients on HAART initiation in West Africa]. / Evolution des conditions d'initiation du traitement antirétroviral des patients infectés par le VIH en Afrique de l'Ouest.

OBJECTIVE: We studied the evolution of drug combinations used, as well as the clinical and immunological profile of patients at initiation of highly active antiretroviral therapy (HAART) between 1996 and 2006 in West Africa. SETTINGS AND METHOD: IeDEA West Africa is a network of HIV care programs established in 2006. We analyzed data from 12 clinical centers treating adults in five countries: Benin, Cote d'Ivoire, Senegal, Gambia, and Mali. Patients 16 years of age or over were included in the study and the following was documented: sex, date of birth and date of initiation of HAART. RESULTS: We included 14,496 adult patients having started HAART, among these 55 % had started HAART between 2005-2006. The proportion of HIV-infected women increased from 46 % in 1996-2000 to 63 % in 2005-2006. The median age at HAART initiation remained constant: 35 years for women and 40 years for men. The proportion of patients having started HAART with a CD4 count<200 cells/microl was 54 % in 1996-2000, and 64 % in 2005-2006. The most frequently prescribed HAART was: AZT/3TC (or d4T/DDI)/IDV (27 %) in 1996-2000; d4T (or AZT)/3TC/EFV (49 %) in 2003-2004, and d4T/3TC/NVP (49 %) in 2005-2006. CONCLUSION: The first line HAART regimen recommended by WHO was initiated in 83 % of cases in 2005-2006. New approaches to an earlier initiation of ART should be explored to reduce mortality in HIV-infected patients on HAART.

Tobacco use and its determinants in HIV-infected patients on antiretroviral therapy in West African countries.

BACKGROUND: Tobacco smoking is common in human immunodeficiency virus (HIV) infected patients from industrialised countries. In West Africa, few data concerning tobacco consumption exist. METHODS: A cross-sectional survey of the International Epidemiological Database to Evaluate AIDS (IeDEA) network in West Africa was conducted. Health workers administered a questionnaire assessing tobacco and cannabis consumption among patients receiving antiretroviral treatment. Regular smokers were defined as current smokers who smoked >1 cigarette per day for >or=1 year. RESULTS: Overall, 2920 patients were enrolled in three countries. The prevalence of ever smokers and regular smokers were respectively 46.2% (95%CI 42.8-49.5) and 15.6% (95%CI 13.2-18.0) in men and 3.7% (95%CI 2.9-4.5) and 0.6% (95%CI 0.3-0.9) in women. Regular smoking was associated with being from Côte d'Ivoire or Mali compared to Benin (OR 4.6, 95%CI 2.9-7.3 and 7.7, 95%CI 4.4-13.6), severely impaired immunological status at highly active antiretroviral treatment initiation (OR 1.5, 95%CI 1.1-2.2) and history of tuberculosis (TB; OR 1.8, 95%CI 1.1-3.0). CONCLUSION: There are marked differences in smoking prevalence among these West African countries. This survey approach also provides proof of the association between cigarette smoking and TB in HIV-infected patients, a major public health issue in this part of the world.

CD4+ T-lymphocytes natural decrease in HAART-naïve HIV-infected adults in Abidjan.

OBJECTIVE: To study the CD4 natural decrease and its determinants in sub-Saharan African HIV-infected adults. METHOD: We performed a 7-year prospective cohort study, with biannual CD4 measurement. Follow-up was censored at the first severe morbidity event or at HAART initiation. Changes in CD4 values were studied by jointly modelling (a) the correlation between repeated measures through a linear mixed model and (b) the time to drop-out through a survival model. RESULTS: 690 patients were followed up during 1,382 person-years. Contrasting with the baseline CD4 count and percentage, which were associated with numerous variables, the slopes of both CD4 count and CD4 percentage in the absence of severe morbidity episode were only associated with the follow-up time and with the baseline body mass index (BMI). The mean annual natural decrease in CD4 count (CD4%) was estimated at -81/mm3 (-2.2%), -69/mm3 (-1.7%), and -55/mm3 (-1.2%) for patients with baseline BMI at 16 kg/m2, 20.4 kg/m2, and 25 kg/m2, respectively (p < .001). A steeper decline in the CD4 count was independently associated with a shorter event-free follow-up time. CONCLUSION: These estimates of the CD4 natural decrease in sub-Saharan African patients, while they did not experience any episode of severe morbidity and before they initiate HAART, are in the bracket of those previously reported in industrialized countries. In sub-Saharan African settings with CD4 count being measured less frequently than in industrialized countries, the CD4 should be monitored more closely among adults with low BMI.

Child-Pugh-Turcott versus Meld score for predicting survival in a retrospective cohort of black African cirrhotic patients.

AIM: To compare the performance of the Child-Pugh-Turcott (CPT) score to that of the model for end-stage liver disease (MELD) score in predicting survival of a retrospective cohort of 172 Black African patients with cirrhosis on a short and mid-term basis. METHODS: Univariate and multivariate (Cox model) analyses were used to identify factors related to mortality. Relationship between the two scores was appreciated by calculating the correlation coefficient. The Kaplan Meier method and the log rank test were used to elaborate and compare survival respectively. The Areas Under the Curves were used to compare the performance between scores at 3, 6 and 12 mo. RESULTS: The study population comprised 172 patients, of which 68.9% were male. The mean age of the patient was 47.5 +/- 13 years. Hepatitis B virus infection was the cause of cirrhosis in 70% of the cases. The overall mortality was 31.4% over 11 years of follow up. Independent factors significantly associated with mortality were: CPT score (HR = 3.3, 95% CI [1.7-6.2]) (P < 0.001) (stage C vs stage A-B); Serum creatine (HR = 2.5, 95% CI [1.4-4.3]) (P = 0.001) (Serum creatine > 1.5 mg/dL versus serum creatine < 1.5 mg/dL); MELD score (HR = 2.9, 95% CI [1.63-5.21]) (P < 0.001) (MELD > 21 vs MELD < 21). The area under the curves (AUC) that predict survival was 0.72 and 0.75 at 3 mo (P = 0.68), 0.64 and 0.62 at 6 mo (P = 0.67), 0.69 and 0.64 at 12 mo (P = 0.38) respectively for the CPT score and the MELD score. CONCLUSION: The CPT score displays the same prognostic significance as does the MELD score in black African patients with cirrhosis. Moreover, its handling appears less cumbersome in clinical practice as compared to the latter.

Impact of opportunistic diseases on chronic mortality in HIV-infected adults in Côte d'Ivoire.

OBJECTIVE: To estimate incidence rates of opportunistic diseases (ODs) and mortality for patients with and without a history of OD among HIV-infected patients in Côte d'Ivoire. METHODS: Using incidence density analysis, we estimated rates of ODs and chronic mortality by CD4 count in patients in a cotrimoxazole prophylaxis trial in Abidjan before the highly active antiretroviral therapy (HAART) era. Chronic mortality was defined as death without a history of OD or death more than 30 days after an OD diagnosis. We used Poisson's regression to examine the effect of OD history on chronic mortality after adjusting for age, gender, and current CD4 count. RESULTS: Two hundred and seventy patients (40% male, mean age 33 years, median baseline CD4 count 261 cells/microl) were followed up for a median of 9.5 months. Bacterial infections and tuberculosis were the most common severe ODs. Of 47 patients who died, 9 (19%) died within 30 days of an OD, 26 (55%) died more than 30 days after an OD, and 12 (26%) died with no OD history. The chronic mortality rate was 31.0/100 person-years for those with an OD history, and 11.1/100 person-years for those with no OD history (rate ratio (RR) 2.81, 95% confidence interval (CI): 1.43 - 5.54). Multivariate analysis revealed that OD history remained an independent predictor of mortality (RR 2.15, 95% CI: 1.07 - 4.33) after adjusting for CD4 count, age and gender. CONCLUSIONS: Before the HAART era, a history of OD was associated with increased chronic HIV mortality in Côte d'Ivoire, even after adjusting for CD4 count. These results provide further evidence supporting OD prophylaxis in HIV-infected patients.

Effect of early chemoprophylaxis with co-trimoxazole on nutritional status evolution in HIV-1-infected adults in Abidjan, Côte d'Ivoire.

BACKGROUND: In sub-Saharan Africa, malnutrition is a major complication of HIV disease. Measuring accurately the nutritional benefits of a therapeutic intervention could be an easy-to-monitor secondary outcome. METHODS: Anthropometric data were analysed from patients participating in a placebo-controlled trial of co-trimoxazole prophylaxis in adults recruited at early stages of HIV-1 infection in Côte d'Ivoire (COTRIMO-CI ANRS 059 trial). Body mass index (BMI), arm muscle circumference (AMC) and percentage of fat mass (FM) were measured at baseline and quarterly during the follow up. Percentage of variation from the baseline value was compared between treatment groups and within the groups using Student t-test. RESULTS: An improvement of all anthropometric indicators was observed in the first 3 months of follow up in both treatment groups, significant in the co-trimoxazole group (P < or = 0.0006) but not in the placebo group (P > or = 0.06). In the co-trimoxazole group, this improvement was maintained for up to 24 months for BMI (P = 0.007), 21 months for AMC (P = 0.02) and only up to 12 months for FM (P = 0.04). The placebo group had a stable anthropometric status up to the end of the trial. Differences between treatment groups were significant for up to 15 months for BMI and AMC and 12 months for FM. CONCLUSION: As co-trimoxazole prophylaxis is now recommended in Africa as part of a minimum package of care for HIV-infected symptomatic subjects, the short-term improvement of these anthropometric indicators in adults who start co-trimoxazole prophylaxis should be considered as an effective clinical outcome.

[Causes of fever in adults infected by HIV-1. Ambulatory follow-up in the ANRS 059 trial in Abidjan, Ivory Coast]. / Causes de fièvre chez des adultes infectés par le VIH-1. Suivi en ambulatoire dans le cadre de l'essai ANRS 059 à Abidjan, Côte d'Ivoire.

OBJECTIVE: Describe the causes of fever in HIV-1 infected adults in Abidjan, Ivory Coast. METHODS: Exhaustive analysis of all the morbid episodes with raise in temperature to above 37.5 degrees C in patients followed-up prospectively, within the framework of the ANRS 059 study from April 1996 to March 1998. RESULTS: One hundred and four patients presented 269 episodes of fever. At the start of these episodes, the mean CD4 count was of 311/mm3, fever had lasted a mean of 3.4 days and mean body temperature was 38.7 degrees C. The 269 episodes lead to 288 diagnoses: 152 specific etiologic diagnoses and 136 non-specific syndrome diagnoses. Community bacterial infections represented 55% of the specific diagnoses, followed by malaria (16%) and tuberculosis (12%). The mean CD4 count during the bacterial episodes was 208/mm3, in malaria 384/mm3 and in tuberculosis 245/mm3. Non-typhi salmonella, pneumococci and Escherischia coli represented 37%, 32%, and 15% respectively of the bacteria isolated. The mean duration between the first and last day of fever was 8.4 days. This time lapse was superior or equal to 30 days in 22 episodes (8%), 50% of which were mycobacterioses (36% tuberculosis and 14% atypic mycobacterioses). Nineteen episodes (7%) lead to death within a mean delay of 58 days. The first cause of death was atypic mycobacteriosis (26%). Death was significantly associated with a CD4 count < 200/mm3 and to prolongation of fever for more than 30 days. CONCLUSION: Other than the frequently described role of tuberculosis in HIV morbidity in sub-Saharian Africa, the role of bacterial diseases, responsible for early death, potentially severe, but curable should be underlined. The diffusion of antibiotic treatment algorithms adapted to the principle clinical syndromes encountered, might improve the treatment of adults infected by HIV consulting in sub-Saharian Africa.

[Effect of hygiene measures, water sanitation and oral rehydration therapy on diarrhea in children less than five years old in the south of Ivory Coast]. / Effet de l'observance des mesures d'hygiène, d'approvisionnement en eau et de la thérapie par voie orale sur les diarrhées chez les enfants de moins de 5 ans dans le sud de la Côte d'Ivoire.

The purpose is to assess the impact of compliance with measures of hygiene and water supply and oral rehydration on the diarrhoea with under 5 years of age in four villages of southern Côte d'Ivoire. The method used is to compare morbidity and mortality of children, firstly between two groups of villages without such measures, secondly in two villages before and after implementing them. Initially, an exhaustive survey has determined the incidence rate of diarrhoea, the proportion of deaths resulting from such diarrhoea as well as the mortality rate 1988. Two similar survey were made in 1990 and 1992. The results show a 50% reduction of the incidence rate of diarrhoea and a 85% reduction of the proportion of deaths related to diarrhoea in the villages with intervention. The mortality rate to diarrhoea was likewise reduced by 85%. These results show the importance of the improvement and accessibility to drinkable water and hygiene in the prevention of diarrhoea in areas children.

[Impact of improved sanitary conditions and domestic hygiene on the incidence of ascaridiasis and ancylostomiasis in children two to four years old in the rural zones of Ivory Coast]. / Impact de l'assainissement et de l'hygiène domestique sur l'incidence de l'ascaridiose et de l'ankylostomose chez les enfants de 2 à 4 ans dans les zones rurales de Côte d'Ivoire.

The purpose of this study is to assess the impact of improvement measures for hygiene and water supply, installation of latrines and health education on the incidence of ascaridiasis and ankylostomiasis with 2 to 4 years old children in some villages of southern Côte d'Ivoire. The method used is the comparison of children carrying parasites before and after intervention. Initially in 1988, the stools of all children aged from 2 to 4 were collected and examined in order to look for the presence of parasites in the stools. Two identical inquiries were made in 1990 and 1992. The results show a reduction of the rate of incidence for ascaridiasis by 75% and ankylostomiasis by 82%. They demonstrate the importance of an appropriate evacuation of excreta, of an education of mothers and of domestic hygiene in the process of prevention of children parasitosis.

[Water supply, excrement disposal and diarrheal diseases in rural zones of Ivory Coast]. / Approvisionnement en eau, evacuation des excreta et maladies diarrhéiques dans les zones rurales de Côte d'Ivoire.

This study was designed to determine the incidence of diarrhea over a 15 day period in children below 4 years living in villages in a rural area of Côte d'Ivoire and to identify possible correlation with water supply and excrement disposal. In this exhaustive cross-sectional household survey, each person caring for a child between the ages of 0 and 4 years was interviewed at home using an open, pretested survey with questions concerning diarrhea, water supply, and excrement disposal. Responses were authenticated by on-site observations made by surveyors. The study population included 1151 care providers and 1260 children between 0 and 4 years of age. Diarrhea had occurred in 27.7% of children within the 15 days prior to questioning, i.e. an annual incidence rate of 3.1 episodes per child after seasonal correction. Age was a risk factor for diarrhea since the incidence of diarrhea was inversely proportional to age. The number of episodes increases up to 6 months, stabilizes at a maximum of 37 to 38% until 36 months, and then gradually decreases to 6% between 53 and 59 months. Diarrhea was more common in children whose care provider was illiterate, the relative risk being 1.22. There was also a correlation between occurrence of diarrhea and age of the care provider since older providers were more likely to be illiterate. Use of a technique to prevent water from splashing out during transport was correlated with diarrhea. Children whose care providers used leaves or plastic covers to prevent splashing during transport had more episodes of diarrhea (30%) than the those whose care providers did not use these techniques (23%). The place where stool pots were emptied was also related to diarrhea. Disposal behavior was strongly correlated with literacy of the care provider, with the site of disposal being relevant only if the provider was illiterate. In view of these findings, we conclude that educating women, teaching child care providers about healthy eating habits in children as young as 5 months, and informing families about proper water storage and excrement disposal would reduce the incidence of diarrheal disease in village children.