International response to the HIV/AIDS epidemic: planning for success.

More assertive political leadership in the global response to AIDS in both poor and rich countries culminated in June 2001 at the UN General Assembly Special Session on AIDS. Delegates made important commitments there, and endorsed a global strategy framework for shifting the dynamics of the epidemic by simultaneously reducing risk, vulnerability and impact. This points the way to achievable progress in the fight against HIV/AIDS. Evidence of success in tackling the spread of AIDS comes from diverse programme areas, including work with sex workers and clients, injecting drug users, and young people. It also comes from diverse countries, including India, the Russian Federation, Senegal, Thailand, the United Republic of Tanzania, and Zambia. Their common feature is the combination of focused approaches with attention to the societywide context within which risk occurs. Similarly, building synergies between prevention and care has underpinned success in Brazil and holds great potential for sub-Saharan Africa, where 90% reductions have been achieved in the prices at which antiretroviral drugs are available. Success also involves overcoming stigma, which undermines community action and blocks access to services. Work against stigma and discrimination has been effectively carried out in both health sector and occupational settings. Accompanying attention to the conditions for success against HIV/AIDS is global consensus on the need for additional resources. The detailed estimate of required AIDS spending in low- and middle-income countries is US$ 9.2 billion annually, compared to the $ 2 billion currently spent. Additional spending should be mobilized by the new global fund to fight AIDS, tuberculosis and malaria, but needs to be joined by additional government and private efforts within countries, including from debt relief. Commitment and capacity to scale up HIV prevention and care have never been stronger. The moment must be seized to prevent a global catastrophe.

AIDS caused by HIV1 and HIV2 infection: are there clinical differences? Results of AIDS surveillance 1986-97 at Fann Hospital in Dakar, Senegal.

OBJECTIVE: To compare the clinical manifestations observed in AIDS patients infected with HIV2 and HIV1 infection. METHODS: The medical records of AIDS patients hospitalized between January 1986 and July 1997 at the Department of Infectious Diseases of Fann Hospital, Dakar, were reviewed. RESULTS: 599 hospitalizations (76%) were HIV1 seropositive patients, 137 (17%) were HIV2 seropositive patients and 54 (7%) were patients serologically dually reactive to HIV1 and HIV2. There was no significant difference in medium CD4 lymphocyte count between patients with HIV1 and HIV2 infection. Chronic diarrhoea and diarrhoea caused by bacterial infections were more frequently observed in HIV2-infected individuals. Oral candidiasis and chronic fever were more often noted in patients with HIV1 infection. Bacterial and cryptococcal meningitis was only observed among patients with HIV1 infection. CONCLUSIONS: Certain clinical differences were observed comparing AIDS patients with HIV1 and those with HIV2 infection. As there is no clear physiopathological explanation for these differences, additional studies with larger numbers of AIDS patients are needed to determine whether these differences are real.

Risk factors for negative sputum acid-fast bacilli smears in pulmonary tuberculosis: results from Dakar, Senegal, a city with low HIV seroprevalence.

SETTING: Two teaching hospitals in Dakar, Senegal, a West African country with a low prevalence of human immunodeficiency virus (HIV) infection. OBJECTIVE: To determine whether patients with HIV-associated pulmonary tuberculosis have fewer acid-fast bacilli (AFB) in their sputum as assessed by routine microscopy, and to correlate the findings with systematically obtained clinical, radiographic and laboratory variables. DESIGN: Prospective study from November 1995 to October 1996 of 450 consecutive patients diagnosed with pulmonary tuberculosis. RESULTS: Tuberculosis was diagnosed in 380 patients (84.4%) by positive bacteriology, in 61 (13.6%) by a favorable response to anti-tuberculosis chemotherapy, and in nine (2.0%) by the presence of a miliary radiographic pattern. Forty (8.9%) patients were HIV-seropositive. AFB-negative smears were found in 14/40 (35.0%) of the HIV-seropositive patients with pulmonary tuberculosis compared with 71/410 (17.3%) of the seronegative patients (risk ratio [RR] = 2.02, 95% confidence interval [CI] 1.26-3.24, P = 0.01). Multivariate analysis revealed that AFB smear negativity was associated with absence of cavitation (P = 0.002), lack of cough (P = 0.005), the presence of HIV seropositivity (P = 0.02), a CD4+ cell count above 200/mm3 (P = 0.02), and age over 40 years (P = 0.03). CONCLUSIONS: Compared with HIV-seronegative patients with pulmonary tuberculosis, seropositive patients in Dakar, Senegal, are more likely to have negative sputum-AFB smears. This phenomenon has now been observed in seven of eight sub-Saharan African countries with varying HIV seroprevalence from which reports are available.

Detection by PCR of human papillomavirus genotypes in cervical lesions of Senegalese women.

In order to analyse human papillomavirus (HPV) infection in the Senegalese population, HPV DNA was sought in 65 women with evidence of cervical cytological abnormality and in 72 pregnant women. Ninety-four percent of the patients were positive for HPV DNA as compared to 24% of pregnant women. HPV 16 was detected in cervical smears in 42% of cases, HPV 18 in 39%, HPV 6 in 26%, HPV 11 in 15%, HPV 45 in 10%, HPV 52 in 3%, and HPV 31, HPV 33 and HPV 68 in 1.5%. HPV 16 and HPV 18 were detected in 16% and 7% respectively of pregnant women. HPV DNA of unknown type was detected in 6% of cases, and multiple HPV infections were observed in 28% of cases. Low risk genital HPVs (6/11) were detected in smaller proportions (17%) among high grade squamous intraepithelial lesions (SILs) than the low grade SILs (43%). High risk HPVs (16/18) were detected in high proportions both in low and high grade SIL lesions, though the highest frequency (70%) was observed among patients with high grade lesions. In conclusion, the results confirm that HPV infections are frequent in Senegal and that HPV 18 and 45 are detected in a high proportion of patients in Africa.

Detection of antibodies to L1, L2, and E4 proteins of human papillomavirus types 6, 11, and 16 by ELISA using synthetic peptides.

Antibodies against eight synthetic peptides spanning different epitopes located on L1, L2, and E4 proteins of human papillomavirus (HPV) types 16, 6, and 11 were examined in sera from 73 women infected by HPV and from 139 healthy controls. Only three of these peptides were reactive. Two located on proteins L2 and E4 of HPV 16 seem type specific since antibodies to these peptides were detected, respectively, in 21% and 15% of the HPV 16 infected patients and in 2.5% and none of women infected by other HPVs. The third peptide located on the L1 protein of HPV 6 bears a common epitope since antibodies to this peptide were detected not only in 85% of women infected by HPV 6 or 11, but also in 82% of women infected by other HPVs, and in 74% and 71% of the control groups (10-12-year-old children and adults, respectively). In conclusion, none of the peptides investigated seems useful to develop ELISAs for serological diagnosis of HPV infection.

[Maxillary fissure cysts in Senegal. Analysis of a series of 14 cases]. / Les kystes fissuraires des maxillaires au Sénégal. Analyse d'une série de 14 cas.

The fissurary cyst is an non-odontogene and epithelial cyst. Their frequency in Senegal compared to the epidemiological records in European countries had led the authors to carry out a study. Around 14 fissurary cysts have been recorded in a seven year period. The teeth affected by the tumour could be saved in case of an early diagnosis.

[Benign maxillary tumors. Epulis in Senegal]. / Les tumeurs bénignes des maxillaires. Les épulis au Sénégal.

The epulis is a hyperplasic tumour restricted to the gum. It is the most widely spread tumour among the benin gum tumours. It has various etiologies. The authors emphasize the epidemiological and clinical aspects of 96 cases. Four types of epulis are observed, the most common type being the acquired epulis. On an etiological level, the factor related to oral hygiene is the most criticized. Their frequency in the oral pathology should lead the dental surgeon to master his treatment.

Etiology of acute sporadic hepatitis in adults in Senegal and Tunisia.

Markers for acute hepatitis A, B, C and E virus infections were examined in the sera of 72 patients suffering from acute hepatitis in Senegal and Tunisia. Hepatitis B was responsible for 36% and hepatitis C for 21% of the cases. Acute hepatitis A was not diagnosed. HEV infection was not observed in Senegal and represents only 4% of the acute hepatitis cases in Tunisia.

Twelve-year follow-up study of hepatitis B immunization of Senegalese infants.

Numerous studies have documented the efficacy and safety of plasma-derived and recombinant hepatitis B vaccines. However, little is known about the long-term protection of hepatitis B vaccine, when anti-HBs declines to low or undetectable levels. This study reports results from a 9-12-year period follow up of infants immunized against hepatitis B in Senegal. At the end of the follow-up period anti-HBs were detected in 81% of children who received a booster dose at school age and in 68% of those who did not. HBsAg was detected in 19% of infants from the control group compared to only 2% of immunized infants, corresponding to a protective efficacy of 88%. The results show that long-term protection against HBsAg carriage of hepatitis B vaccination is very high and that a booster dose at school age does not significantly increase this protection.

[HIV infection: a new concern in dental public health]. / L'infection à VIH: nouvelle préoccupation en santé publique dentaire.

The authors report the results of a seroepidemiological study, conducted in Senegal on dental personnel. This study allows them to confirm that professional dental practice is a factor of risk for the HIV infection. This study recommends work methods to the dental profession.

PIP: During January-March 1990, at 26 of 38 dental facilities throughout Senegal, health workers took blood samples from 10 dental surgeons, 60 nurse specialists in dentistry, and 21 dental health agents so researchers could determine the prevalence of HIV infection among dental public health providers. There were 2.67 men for every woman. Women were more likely to be dental surgeons than men. Most subjects were 26-35 years old and worked in the Dakar region. Five persons (3.81%) were infected with HIV. Three had HIV-1 infection (2.29%), one had HIV-2 infection (0.76%), and one had dual infection (HIV-1 and HIV-2) (0.76%). All three HIV-1 infection cases were women as well as dental surgeons. The remaining cases were men as well as nurse specialists in dentistry. The age of all HIV infected persons but one fell between 25 and 35. The age of the other case fell within the 36-45 age group. Four of the HIV infected persons were married and monogamous. The remaining case was single. All HIV positive persons had been practicing their profession for at least four years. The sole HIV-2 positive person had been practicing his profession for 10 years. Since there is the case of an HIV positive dentist in Florida (USA) who had transmitted HIV to five patients, one should not rule out the possibility of HIV transmission from dental professionals to patients. Thus, dental professionals should use bleaching solution diluted to 10% for 10 minutes. This solution should be available for all dental services. Dental providers should wear gloves, masks, and goggles with all patients. They should use single-use sterile material for each patient. Adequate emergency measures to prevent nosocomial transmission of HIV must be established in Senegal.

[Prevalence of Cryptosporidium sp and Isospora belli in patients with acquired immunodeficiency syndrome (AIDS) in Dakar (Senegal]. / Prévalence de Cryptosporidium sp et d'Isospora belli chez des patients atteints du syndrome d'immunodéficience acquise (SIDA) à Dakar (Senegal).

72 patients with AIDS, having diarrhoea and admitted in the Unit of Infectious diseases, Fann Hospital from 1989 to 1991 were investigated for Cryptosporidium sp. and Isospora belli isolation by the modified Ziehl-Neelsen technique, after stolls' concentration by Ritchie technique. The prevalence were 13.9% for Cryptosporidium sp, and 15.3% for I. belli. In two patients (2.8%), these 2 coccidiae were associated. Cryptosporidium sp. and I. belli were the single parasites found respectively in 6 (8.3% and 7 (9.7%) of the patients. In the other faecal samples with a positive result for Cryptosporidium sp. or I. belli, they were associated with A. lumbricoides, G. intestialis, E. histolytica or S. stecoralis. According to these results, Cryptosporidium sp. and I. belli were more frequently observed in AIDS patients from Dakar than those from Zaire, Congo and Côte d'Ivoire.

[Tetanus and traditional practices in Dakar (report of 141 cases)]. / Tétanos et pratiques traditionnelles à Dakar (à propos de 141 cas).

In this study undertaken in the Infectious Diseases department CHU Fann Dakar, between january 1982 and december 1990 the authors report their observations about 141 cases of tetanus occurred by traditional practices: circumcision, excision, tattooing, scarification, ears piercing. The annual incidence of tetanus occurred by traditional practices was 15.6 cases. It represents 3.6% of all tetanus cases during the study period (n = 3844). The circumcision represents 59.4% (n = 84), the ears piercing 34.4% (n = 48), excision 2.8% (n = 4), scarification 2.1% (n = 3) and tattooing 2 cases. The mortality of tetanus occurred by traditional practices was 8.5%. Health education, information and vaccination against tetanus for all ages according to WHO recommendations will help to eradiquate tetanus in developing countries.

[Fluconazole in oro-pharyngeal candidiasis in retroviral infection (experience in Dakar)]. / Le fluconazole dans les candidoses bucco-pharyngées au cours de l'infection rétrovirale (expérience dakaroise).

Oral candidiasis is a frequent opportunistic infection in AIDS patients. High risk of dissemination and frequent relapses are common. The autors in Dakar at the Infectious Diseases Department Fann Hospital conduct an open non randomized trial with Fluconazole for the treatment of oral candidiasis in HIV seropositive patients. They find a clinical efficacy of 84.14% a biological efficacy of 63.3% and a good excellent tolerance (100%). But, the high price of this product limits its utilisation in developing countries.

[Ocular manifestations of AIDS in Dakar]. / Manifestations oculaires au cours du SIDA à Dakar.

In this prospective study undertaken between november 1989 and december 1991, the authors report their observations of ocular lesions seen in a cohort of 67 AIDS patients hospitalised in the Infectious Diseases department CHU Fann Dakar. Ocular lesions were discovered in 52.23%. These lesions were observed in both HIV-1 and HIV-2 positive patients, however they were much more common in the former group (77.14%). Rétinal pathology was by far the most frequently observed (63%) and yet classic retinis was not discovered in our series. We feel that the ophtalmologist should play a key role in the routine care of AIDS patients especially in surveillance of retinal changes.

PIP: During November 1989 to December 1991 in Senegal, physicians regularly followed 67 HIV infected patients aged 20-76 (46 men and 21 women) who had been admitted to Fann University Hospital in Dakar. The HIV infection had progressed to AIDS in all but one case. 52.33% had ocular lesions, of which the most frequent were cotton-like nodules (14.2%), retinal bleeding and Roth's spots (8.5%), and ophthalmic herpes zoster (8.5%). Most lesions (63%) were located in the retina. Yet, there were no cases of classic retinitis. Among 21 AIDS patients with a known lymphocyte count, 62.5% of those with a CD4 count of less than 200 had a normal ophthalmological examination. Patients with CD4 counts between 0 and 200 had macular edema, hyalitis, cotton-like nodules, retinal uveitis, and microangiopathy, while those with higher CD4 counts had none of these ocular lesions. Patients with CD4 counts greater than 400 had conjunctivitis (one case, Kaposi sarcoma-related conjunctivitis), ophthalmic herpes zoster, and ocular dryness. The only ocular lesion in patients with CD4 counts between 200 and 400 was ophthalmic herpes zoster. 77.14% of HIV infected patients with ocular lesions were infected with HIV-1. The three ophthalmic herpes zoster cases were less than 30 and homosexual. During the two years of follow-up, only one case died. Based on these findings, the authors suggest that ophthalmologists should systematically be involved in the routine care of AIDS patients, particularly by screening for changes in the retina.

[Preliminary study of pneumocystis carinii pneumonia diagnosed by induced expectoration in HIV positive patients in Dakar]. / Etude préliminaire de la pneumopathie à Pneumocystis carinii diagnostiquée par expectoration induite chez des patients VIH positifs à Dakar.

Rapid noninvasive diagnosis of Pneumocystis carinii from induced liquefied sputum is a very easy and not costly method. It was using for a first time at the Infectious Diseases Department at Dakar in 27 HIV seropositive patients from July to November 1992. Six cases of Pneumocystis carinii pneumonia (PCP) was diagnosed, with a prevalence of 22.2%. In this study PCP was found in both HIV-1 and HIV-2 patients. Clinical and radiological aspects are not specific. PCP was also found in patients with CD4 below than 200 per cubic millimeter. Co-infection with Mycobacterium tuberculosis is possible.

PIP: Between July and November 1992, in Senegal, health workers took sputum samples from 27 HIV-positive patients (19 men and 8 women) aged 20-66 at the infectious disease service of Fann University Hospital Center in Dakar so researchers could determine the prevalence of Pneumocystis carinii pneumonia among HIV-positive patients and specify the characteristics of P. carinii pneumonia among HIV-positive patients in Dakar. The simple, effective, and low-cost technique used was coloration of the sputum with Toluidine O. 70.3% had HIV-1 infection, 26% had HIV-2 infection, and 3.7% had both HIV-1 and HIV-2 infection. 55.5% had CD4 counts under 200/cu. mm. 40.7% had higher CD4 counts. The CD4 count could not be measured in one patient. Six (22.2%) tested positive for P. carinii. Four of the patients with P. carinii pneumonia were HIV-1 positive. The other two were HIV-2 positive. 83.3% had fever and were becoming thinner. 33.3% had a cough. 16.6% had difficulty breathing. One patient with P. carinii infection was asymptomatic. Two pneumocystis patients had diffuse interstitial infiltration and perihilar infiltration. Another patient also had pulmonary tuberculosis. The CD4 count for 80% of HIV-infected patients who tested positive for P. carinii pneumonia was less than 200/cu. mm.

Detection of hepatitis B virus DNA by polymerase chain reaction in vaccinated and non-vaccinated Senegalese children.

An hepatitis B immunization programme was initiated in Senegal in 1978, and infants included in this controlled study have been followed for a period of 2-12 years after immunization. During this period HBV infections have been observed both in vaccinated and non-vaccinated infants. The polymerase chain reaction was used to search for HBV DNA sequences in the sera of 153 children with evidence of serum markers of past or present HBV replication. Amplified HBV DNA sequences were detected in 93% of the HBsAg positive individuals, in 58% of those only positive for antiHBc antibodies and in 7.8% of antiHBs and antiHBc positive infants. The results confirm the high efficiency and long-lasting effectiveness of HB vaccine.