Effect of an HIV counseling and testing program on AIDS-related knowledge and practices in tuberculosis clinics in Abidjan, Côte d'Ivoire.

SETTING: Two out-patient tuberculosis treatment centers, Abidjan, Côte d'Ivoire. OBJECTIVE: To assess the effect of a human immunodeficiency virus (HIV) counseling and testing program on acquired immune-deficiency syndrome (AIDS) related knowledge and behaviors among persons with newly diagnosed tuberculosis. DESIGN: Since 1994, patients with newly diagnosed tuberculosis have received individual or group HIV pretest counseling, informed consent, free HIV testing for those who consent, and post test counseling. From January 1995 through August 1996 in Abidjan's two largest tuberculosis clinics, knowledge and beliefs about HIV/AIDS were assessed before and immediately after the group pretest sessions, and again 4 months later. RESULTS: Prior to pretest counseling, 68.9% and 68.0% of the 559 enrolled subjects could correctly identify five modes of HIV transmission and five modes of HIV prevention. These proportions increased significantly immediately after pretest counseling (90.0%, 86.6%, respectively), and remained higher 4 months later (83.7%, 87.7%) (all P < 0.01). Among men, consistent condom use during the preceding 4 months with a partner who was not a commercial sex worker increased from 9.9% at enrollment to 23.6% at the 4-month visit (P = 0.001), but not for women (6.3% vs. 9.5%, P = 0.40). CONCLUSIONS: An HIV pretest counseling program conducted in an out-patient tuberculosis clinic was well accepted, and significantly increased the level of HIV/AIDS knowledge and, among men, self-reported condom use.

Cervicovaginal secretory antibodies to human immunodeficiency virus type 1 (HIV-1) that block viral transcytosis through tight epithelial barriers in highly exposed HIV-1-seronegative African women.

Antibodies to human immunodeficiency virus (HIV) of the IgA, IgG, and IgM isotypes and high levels of the HIV suppressive beta-chemokine RANTES (regulated on activation, normally T cell expressed and secreted) were found in the cervicovaginal secretions (CVSs) of 7.5% of 342 multiply and repeatedly exposed African HIV-seronegative female sex workers. The antibodies are part of a local compartmentalized secretory immune response to HIV, since they are present in vaginal fluids that are free of contaminating semen. Cervicovaginal antibodies showed a reproducible pattern of reactivity restricted to gp160 and p24. Locally produced anti-env antibodies exhibit reactivity toward the neutralizing ELDKWA epitope of gp41. Study results show that antibodies purified from CVSs block the transcytosis of cell-associated HIV through a tight epithelial monolayer in vitro. These findings suggest that genital resistance to HIV may involve HIV-specific cervicovaginal antibody responses in a minority of highly exposed HIV-seronegative women in association with other protecting factors, such as local production of HIV-suppressive chemokines.

Effect of interventions to control sexually transmitted disease on the incidence of HIV infection in female sex workers.

OBJECTIVE: To compare the seroincidence of HIV infection among female sex workers in Abidjan, Côte d'Ivoire before and during an intervention study to control sexually transmitted diseases (STD) and to study the effect of two STD diagnosis and treatment strategies on the prevalence of STD and on the seroincidence of HIV infection. METHOD: A screening facility for STD and HIV had been available since October 1992 for female sex workers. From June 1994, women who were HIV seronegative or HIV-2 positive during the screening could enroll in the intervention study in which participants reported once a month to a confidential clinic where they received health education, condoms and STD treatment if indicated. Women in the study were randomized either to a basic STD diagnosis and treatment strategy, which included a gynecologic examination when symptomatic, or to an intensive strategy that included a gynecologic examination regardless of symptoms. An outcome assessment every 6 months included a gynecologic examination, HIV serology and laboratory tests for STD. RESULTS: Of 542 women enrolled in the study, 225 (42%) had at least one outcome assessment. The HIV-1 seroincidence rate during the intervention study was significantly lower than before the study (6.5 versus 16.3 per 100 person-years; P = 0.02). During the study, the HIV-1 seroincidence rate was slightly lower in the intensive than in the basic strategy (5.3 versus 7.6 per 100 person-years; P = 0.5). CONCLUSION: National AIDS control programs should consider adopting as policy the type of integrated approach used in this intervention study for HIV prevention in female sex workers.

Surveillance of STD syndromes: contributing to the STD programme in Côte d'Ivoire.

In Côte d'Ivoire, management of sexually transmitted diseases (STDs) is based on a syndromic approach. The National Health Information System (NHIS), set up in 1995, supervises data drawn monthly on three STD syndromes: genital ulcers, discharges and warts. Information is collected in each community-based public clinic, collated in the 29 districts, then in the 10 regions, and finally centralized. We assessed the relevance of this information and its usefulness for the STD programme. The number of cases notified in adults of 15 years and above was compared in men and women for the years 1995 and 1996. The absolute number of cases was related to the number of consultations to evaluate the relative share of STDs in health care services, and to the population size to estimate STD annual incidence. Between 1995 and 1996, the number of reported STD cases remained steady in men, 32 410 and 31 470 cases, respectively, but increased by 35% in women, from 64 794 to 87 622 cases. As a result, STD annual incidence was unchanging in men (8%), but increased in women from 17 to 23%. However, between these two years, the relative contribution of STDs to all consultations decreased from 4.7 to 3.5% in men, while remaining steady in women, at around 7.0%. In this 2-year period, the ratio of the numbers of ulcers in men and women was about 1:1, and did not vary by district. In contrast, discharges were reported 2.7 times more by women, with a differing sex ratio from district to district. We suggest that vaginal discharges are often physiological, and are poorly instructive for STD surveillance. In contrast, ulcers in both genders, and male discharges, provide relevant information for the STD programme, for example to estimate the volume of STD drugs needed for public health services and to assess the epidemiological trends of STDs.

[The fight against sexually transmitted diseases in Ivory Coast: what strategies can we use in the face of HIV/AIDS?]. / La lutte contre les maladies sexuellement transmissibles en Côte d'Ivoire: quelles stratégies face au VIH/sida?

In the AIDS era, sexually transmitted diseases (STDs) have become a major health problem in developing countries, particularly in Africa. Delays in the diagnosis and treatment of such infections may result in complications, many of which primarily affect women. Epidemiological studies in Abidjan have shown that more than 10% of the pregnant women attending antenatal clinics present STDs potentially serious for their own health or that of their infants (gonorrhea, chlamydia infection, genital ulcers or active syphilis). There is evidence that STDs increase the transmission of HIV and that improving the syndromic management of STDs reduces the incidence of HIV infection. This provides a strong argument in favor of controlling STDs in areas of high HIV prevalence. In Ivory Coast, as in other African countries, a STD control program has been integrated into the AIDS control program since 1992, as recommended by the World Health Organization. During the first six years of the STD program, considerable progress was made in some areas, but not without difficulty. Simple syndrome-based decision trees have been adopted for the management of STDs in primary health care. Clinical studies have shown these therapeutic algorithms to be effective. At the same time, effective and affordable drugs for treating STDs were added to the list of essential drugs in Ivory Coast, after an international invitation to tender. The entire staff of the public health sector in Abidjan has been trained in syndromic STD management. Training is now being extended to other parts of Ivory Coast, including the private health sector and, in particular, private nurses. The surveillance of syndromic STDs, mainly genital ulcers in both sexes and urethral discharge in men, facilitates monitoring and evaluation of the STD program, following health care activities and adapting orders for drugs for treating STDs to real needs. In the near future, some parts of the STD program will be strengthened, particularly the management of sexual partners of STD patients and reduction of the cost of STD treatment for pregnant women.

Distribution of HIV-1 subtypes among HIV-seropositive patients in the interior of Côte d'Ivoire.

Limited data exist on the distribution of HIV-1 subtypes in Côte d'Ivoire. The aim of this study is to describe the distribution of genetic subtypes of HIV-1 strains in six regions of Côte d'Ivoire. In 1997, we consecutively collected blood from 172 HIV-1-infected patients from six regional tuberculosis treatment centers. Peripheral blood mononuclear cells (PBMCs) from these people were analyzed by a restriction fragment-length polymorphism (RFLP) assay that involves a sequential endonuclease digestion of a 297-base pair polymerase chain reaction (PCR) fragment; plasma samples were tested by a V3-loop peptide enzyme immunoassay (PEIA). DNA sequencing of the protease or env genes was performed on all samples discordant in the two assays as well as a random sample of the concordant subtyped samples. Of 172 specimens, 3 were PCR-negative, and 169 were putatively classified as subtype A by RFLP. The 3 PCR-negative samples were unequivocally subtyped A by PEIA. Of the 169 RFLP subtype A samples, 159 (94%) were subtyped A by PEIA. Of the 10 discordant samples, PEIA testing classified 3 as subtype C, 2 as D, and 5 as F. Sequencing of the env gene classified these samples as 1 subtype A, 4 Ds, and 5 Gs. Thus, 163 (95%) of the specimens were subtype A, 3 subtype D, 4 subtype G, 1 A/D, and 1 A/G (IbNG) circulating recombinant forms (CRF). In conclusion, most HIV-1-infected tuberculosis patients throughout the interior of Côte d'Ivoire are infected with HIV-1 subtype A, which are very likely the A/G (IbNG) CRF. The uniform distribution of this subtype makes Côte d'Ivoire a potential site for vaccine trials.

Tuberculin skin testing to assess the occupational risk of Mycobacterium tuberculosis infection among health care workers in Abidjan, Côte d'Ivoire.

SETTING: Tuberculin skin test (TST) survey of health care workers (HCWs) in selected clinical services in Abidjan, Côte d'Ivoire. OBJECTIVE: To assess whether HCWs in Abidjan are at increased risk for occupationally acquired Mycobacterium tuberculosis infection. DESIGN: From October 1996 to January 1997, consenting HCWs from four services where tuberculosis (TB) prevalence among patients was high and two services where it was low were evaluated with a questionnaire, TST (including evaluation of anergy) and chest radiograph. RESULTS: Of the 512 participants, 405 (79%) had a TST reaction of > or =10 mm, eight (2%) were anergic, five (1%) had a radiograph compatible with TB, and two had confirmed TB. Using a cut-off of 10 mm, we found a higher prevalence of TST positivity in services with high TB prevalence than in those with low TB prevalence (92% vs 72%; odds ratio [OR] 4.3; 95% confidence interval [CI] 2.3-8.0]) and among HCWs with direct (87%; OR 2.9; 95%CI 1.6-5.1) and indirect patient contact (80%, OR 1.7; 95%CI 1.0-2.3) than among those with minimal patient contact (69%). CONCLUSION: These findings indicate that TST positivity among HCWs is related to level of exposure to TB patients, and suggest that HCWs in Abidjan are at risk for the nosocomial transmission of TB.

Cervicovaginal anti-HIV antibodies in HIV-seronegative female sex workers in Abidjan, Côte d'Ivoire.

OBJECTIVE: To detect anti-HIV antibodies in cervicovaginal secretions of HIV-seronegative female sex workers and to evaluate whether the presence of these antibodies is associated with increased sexual exposure. METHODS: A cross-sectional study was carried out at a confidential clinic for female sex workers in Abidjan, Côte d'Ivoire. The participants were 342 HIV-seronegative female sex workers in whom a cervicovaginal lavage was collected. The main outcome measures were the detection of antibodies to HIV-1 in cervicovaginal lavages using an in-house and a commercial (Seradyn Sentinel; Calypte Biomedical Corporation, Berkeley, California, USA) enzyme immunoassay; the detection of semen in cervicovaginal lavages; and the assessment of epidemiological and biological markers of sexual exposure to HIV. RESULTS: Cervicovaginal anti-HIV antibodies were detected in 7.3 and 29.8% of women using in-house enzyme-linked immunosorbent assay (ELISA) and Seradyn Sentinel respectively. All cervicovaginal secretions found to be positive by in-house ELISA were also positive by Seradyn Sentinel. In a minority of women, ranging from 2.9% by in-house ELISA to 12.3% by Seradyn Sentinel, the anti-HIV antibodies were present in vaginal fluids that did not contain semen. Sexual exposure to HIV was similar in women with anti-HIV antibodies in their semen-free cervicovaginal secretions compared with women without anti-HIV antibodies in their cervicovaginal secretions. CONCLUSIONS: Cervicovaginal HIV-specific antibodies were detected in a minority of sexually exposed HIV-seronegative female sex workers in Abidjan. The lack of association between increased sexual exposure to HIV and presence of cervicovaginal HIV-specific antibodies suggests that the production of genital HIV-specific antibodies in exposed seronegative women depends on the ability of individual women to mount specific mucosal immunity to HIV antigens, the determinants of which are currently unknown.

What is the meaning of repeated isolation of Mycobacterium africanum?

Mycobacterium africanum is a member of the tuberculosis complex, together with M. tuberculosis and M. bovis. Its morphological growth is quite different from that of M tuberculosis. It is a causative agent of the same tuberculosis disease, and its precise identification seems important only for epidemiological purposes. We report here the repetitive isolation of 17 M. africanum strains (among 321 TB complex strains) during a national primary resistance survey in C te d'Ivoire in 1995. All of the M. africanum strains were isolated in four regions located in the same geographical area. They showed biochemical heterogeneity yielding three patterns, none of which was specific to one region. Molecular analysis by RFLP for 14 strains showed identical patterns for four strains, two by two, and a clustering of 62-77% homology for eight of the 14 strains (57%). This report confirms that M. africanum is less frequent than M. tuberculosis. Its repeated isolation may reflect inter-human transmission. Biochemical similarities between strains may not always be associated with a common geographical origin.

Isoniazid plus sulphadoxine-pyrimethamine can reduce morbidity of HIV-positive patients treated for tuberculosis in Africa: a controlled clinical trial.

An annual 20% excess mortality rate is observed in HIV-seropositive patients after treatment for tuberculosis. An affordable secondary prophylaxis against main opportunistic diseases is needed, i.e. against tuberculosis, toxoplasmosis, pneumocystosis and other infections occurring in this target population. This open prospective randomized study assessed morbidity and mortality in 2 cohorts of HIV-seropositive patients having recently recovered from pulmonary tuberculosis: 134 patients assigned to prophylactic treatment with isoniazid (INH, 300 mg once daily) plus sulphadoxine-pyrimethamine (S, 500 mg/P, 25 mg once weekly), and 129 were controls, comparable for sex, age, weight and HIV-serology. Patients were followed-up for up to 2 years: 192 person-years (PY) in the prophylaxis group and 142 PY in the control group. Four patients developed tuberculosis and 20 patients died in the prophylaxis group, compared to 10 and 23 controls, respectively. Sick days were reported by 22 patients in the prophylaxis group and by 77 patients in the control group. This prophylaxis was associated with a moderate decrease of mortality (log rank test: p = 0.1736), a significant decrease of tuberculosis incidence (log rank test: p = 0. 0234), a highly significant reduction of adverse events and sick days, and a prevention of wasting (p = 0.008) and anaemia (p = 0. 045). No death from toxoplasmosis occurred in the prophylaxis group as compared to 2 possible cases among controls; toxoplasmosis IgG levels declined in treated patients, but increased in controls (p = 0.01). There was no adverse drug reaction due to SP (10,006 doses) or to INH. Compliance with SP intake was good, but moderate as with INH intake. We conclude that a secondary prophylaxis with INH+SP represents a cost-effective measure to improve health conditions of HIV-infected adults in Côte d'Ivoire, following a full treatment course against tuberculosis.

Primary resistance to antituberculosis drugs: a national survey conducted in Côte d'Ivoire in 1995-1996. Ivoirian Study Group on Tuberculosis Resistance.

SETTING: A national survey of resistance to the antituberculosis drugs used in Côte d'Ivoire was conducted in 1995-1996. OBJECTIVE: To determine the rate of primary resistance to antituberculosis drugs. METHODS: Consecutive new tuberculous patients with positive smear were recruited from tuberculosis centres and rural health centres. Drug susceptibility testing was performed according to the proportion method. Positive cultures were tested against streptomycin, isoniazid, rifampicin, and ethambutol. All resistant strains and 10% of all randomly sampled cultures were sent to an external laboratory for quality control. Human immunodeficiency virus (HIV) tests were performed for consenting patients at the tuberculosis centres. RESULTS: Among the 430 samples, 320 were available for analysis. Primary resistance to antituberculosis drugs was observed for 13.4% of the patients (43/320); multidrug resistance (to at least isoniazid and rifampicin) was observed for 5.3% of the patients; 14.2% of HIV-negative and 16.2% of HIV-positive patients were resistant to at least one antituberculosis drug (P = 0.70). CONCLUSION: This study is representative of antituberculosis drug resistance in Côte d'Ivoire. The rate of primary resistance is high and emphasises the need for a sentinel survey of tuberculous resistance. The National Tuberculosis Control Programme needs to make improvements in its management of tuberculosis cases.

Short-course oral zidovudine for prevention of mother-to-child transmission of HIV-1 in Abidjan, Côte d'Ivoire: a randomised trial.

BACKGROUND: In Africa, the risk of mother-to-child transmission of HIV-1 infection is high. Short-course perinatal oral zidovudine might decrease the rate of transmission. We assessed the safety and efficacy of such a regimen among HIV-1-seropositive breastfeeding women in Abidjan, Côte d'Ivoire. METHODS: From April, 1996, to February, 1998, all consenting, eligible HIV-1-seropositive pregnant women attending a public antenatal clinic in Abidjan were enrolled at 36 weeks' gestation and randomly assigned placebo or zidovudine (300 mg tablets), one tablet twice daily until the onset of labour, one tablet at onset of labour, and one tablet every 3 h until delivery. We used HIV-1-DNA PCR to test the infection status of babies at birth, 4 weeks, and 3 months. We stopped the study on Feb 18, 1998, when efficacy results were available from a study in Bangkok, Thailand, in which the same regimen was used in a non-breastfeeding population. FINDINGS: 280 women were enrolled (140 in each group). The median duration of the prenatal drug regimen was 27 days (range 1-80) and the median duration of labour was 7.5 h. Treatment was well tolerated with no withdrawals because of adverse events. All babies were breastfed. Among babies with known infection status at age 3 months, 30 (26.1%) of 115 babies in the placebo group and 19 (16.5%) of 115 in the zidovudine group were identified as HIV-1 infected. The estimated risk of HIV-1 transmission in the placebo and zidovudine groups were 21.7% and 12.2% (p=0.05) at 4 weeks, and 24.9% and 15.7% (p=0.07) at 3 months. Efficacy was 44% (95% CI -1 to 69) at age 4 weeks and 37% (-5 to 63) at 3 months. INTERPRETATION: Short-course oral zidovudine was safe, well tolerated, and decreased mother-to-child transmission of HIV-1 at age 3 months. Substantial efforts will be needed to ensure successful widespread implementation of such a regimen.

Efficacy of trimethoprim-sulphamethoxazole prophylaxis to decrease morbidity and mortality in HIV-1-infected patients with tuberculosis in Abidjan, Côte d'Ivoire: a randomised controlled trial.

BACKGROUND: There is a high incidence of opportunistic infection among HIV-1-infected patients with tuberculosis in Africa and, consequently, high mortality. We assessed the safety and efficacy of trimethoprim-sulphamethoxazole 800 mg/160 mg (co-trimoxazole) prophylaxis in prevention of such infections and in decrease of morbidity and mortality. METHODS: Between October, 1995, and April, 1998, we enrolled 771 HIV-1 seropositive and HIV-1 and HIV-2 dually seroreactive patients who had sputum-smear-positive pulmonary tuberculosis (median age 32 years [range 18-64], median CD4-cell count 317 cells/microL) attending Abidjan's four largest outpatient tuberculosis treatment centres. Patients were randomly assigned one daily tablet of co-trimoxazole (n=386) or placebo (n=385) 1 month after the start of a standard 6-month tuberculosis regimen. We assessed adherence to study drug and tolerance monthly for 5 months and every 3 months thereafter, as well as rates of admission to hospital. FINDINGS: Rates of laboratory and clinical adverse events were similar in the two groups. 51 patients in the co-trimoxazole group (13.8/100 person-years) and 86 in the placebo group (25.4/100 person-years) died (decrease In risk 46% [95% CI 23-62], p<0.001). 29 patients on co-trimoxazole (8.2/100 person-years) and 47 on placebo (15.0/100 person-years) were admitted to hospital at least once after randomisation (decrease 43% [10-64]), p=0.02). There were significantly fewer admissions for septicaemia and enteritis in the co-trimoxazole group than in the placebo group. INTERPRETATION: In HIV-1-infected patients with tuberculosis, daily co-trimoxazole prophylaxis was well tolerated and significantly decreased mortality and hospital admission rates. Our findings may have important implications for improvement of clinical care for such patients in Africa.

Genetic analysis of human immunodeficiency virus in Abidjan, Ivory Coast reveals predominance of HIV type 1 subtype A and introduction of subtype G.

To better understand the molecular epidemiology of HIV genetic diversity in Abidjan, Ivory Coast, we performed a genetic analysis of 170 HIV-1-seropositive specimens representing newly diagnosed tuberculosis patients (n = 143) and women monitored in a mother-to-child transmission cohort study (n = 27). Preliminary screening with RFLP presumptively classified 162 (95.3%) of these as subtype A. The envelope region of 108 specimens was subtyped by sequence analysis: 102 (94.4%) were subtype A, 2 (1.9%) were subtype D, and 4 (3.7%) were subtype G. Subtyping gag and env regions of the genome suggested that five of the six nonsubtype A isolates exhibited a potentially mosaic structure. A comparative phylogenetic analysis of HIV-1 subtype A C2V3 from 27 Ivory Coast and 21 Ugandan sequences revealed a striking clustering among Ivory Coast variants, and an independent segregation from Ugandan subtype A. Despite independent clustering with other subtype A specimens, limited variability of the V3 loop apex was observed; the globally predominant V3 motif, GPGQ, represented 90.1% of the HIV-1 strains. This study demonstrates that clade A is the predominant HIV-1 subtype in HIV-seropositive individuals in Abidjan, Ivory Coast and that these strains are phylogenetically distinct from other subtype A strains observed in East Africa.

[Efficacy of a short 6 month therapeutic coursefor HIV infected tuberculosis patients in Abidjan, Côte d'Ivoire]. / Efficacité du régime thérapeutique court de six mois chez les tuberculeux infectés par le VIH à Abidjan, Côte d'Ivoire.

From December 1992 to February 1993, 104 newly diagnosed pulmonary tuberculosis patients were enrolled in a prospective cohort study to assess the response to the 6 month-short-course regimen implemented in Cote d'Ivoire. This treatment encompassed the daily intake of Rifampicin and Pyrazinamide for 2 months followed by Rifampicin and Isoniazid for the remaining 4 months. All the patients were enrolled at the Treichville Tuberculosis Treatment Centre in Abidjan, and a follow-up of 6 months was observed for each patient. All in all, 41 patients were HIV-positive whereas 63 where HIV-negative. No statistical difference was noted between HIV-positive and HIV-negative patients with regard to the completion of therapy (85% versus 87%). The cure rate after an effective 6 month-therapy was similar among HIV-positive and HIV-negative patients (83% versus 84%) as well as the treatment failure rate which was 2.4% and 3% respectively. The results clearly indicate that the 6 month-short-course regimen policy implemented in Côte d'Ivoire is as effective for the treatment of HIV-associated tuberculosis as for the treatment of tuberculosis.

Improved detection of HIV-2 proviral DNA in dually seroreactive individuals by PCR.

OBJECTIVE: To improve the detection rate of HIV-2 proviral DNA in primary uncultured peripheral blood mononuclear cells (PBMC) of HIV-2-seroreactive and HIV-1-HIV-2 dually seroreactive individuals. MATERIALS AND METHODS: Two newly designed HIV-2 PCR primer pairs in the long terminal repeat (LTR) gag and gag-pol regions and a previously described env and LTR HIV-2 PCR primer pairs were tested on samples from 66 confirmed HIV-2-seropositive individuals (The Gambia, 40; Côte d'Ivoire, 17; Guinea-Bissau, nine), 209 dually seroreactive individuals (The Gambia, 82; Côte d'Ivoire, 127), 24 genetically characterized isolated HIV-1 strains (group M subtypes A-H and group O), one simian immunodeficiency virus (SIV) strain cpz, 10 HIV-2 isolates (subtype A, B and unidentified), two SIVsm isolates, and 10 seronegative samples. RESULTS: All HIV-2 primers evaluated showed 100% specificity since there was no amplification observed with 24 HIV-1, one SIVcpz and 10 seronegative samples. One single copy of the HIV-2 genome could be detected with all outer primer pairs as well as all inner primer pairs on one PCR round used. Sensitivity of primers (at least one of the four primer pairs was positive) to HIV-2-seropositive samples was 100% (all nine) in Guinea-Bissau, 71% (12/17) in Côte d'Ivoire, 100% (all 20) in Gambian AIDS patients, and 85% (17/20) in Gambian pregnant women. Doubling the PBMC of dually seroreactive individuals from 7.5 x 10(4) to 1.5 x 10(5) in the PCR revealed the presence of both HIV-1 and 2 proviral DNA in 72% (92/127) in Côte d'Ivoire and 72% (59/82) in The Gambia. By doubling the number of PBMC, HIV-2 detection in dually seroreactive individuals by PCR was increased from 65 to 77% in Côte d'Ivoire and from 67 to 83% in The Gambia. CONCLUSIONS: The use of 1.5 x 10(5) primary uncultured PBMC and the newly designed HIV-2 primer pairs allowed us to document the highest percentage (72%) ever reported of HIV-1-HIV-2 dual infections amongst HIV-1-HIV-2 dually seroreactive individuals in Côte d'Ivoire and The Gambia. Improved detection of HIV-2 proviral DNA, rather than exposure to both viruses, infection with only one virus, or infection with a unique third virus containing epitopes common to both HIV-1 and HIV-2, contributes to a more accurate monitoring of the prevalence of HIV-1-HIV-2 dual infections.

[Seroprevalence of HIV among pregnant women in the ten regions of the Ivory Coast]. / Séroprévalence du VIH chez les femmes enceintes dans dix régions de Côte d'Ivoire.

UNLABELLED: Ivory Coast, a sub-Saharan African country, has 14 million inhabitants. Two AIDS cases were reported to the WHO in 1985. By December 31st 1996, there were a total of 37,878 AIDS cases in Ivory Coast, 6,727 of which were new cases reported in 1996. Heterosexual transmission is the predominant means of HIV infection in Africa and women of childbearing age account for a substantial proportion of the individuals infected. The aim of this study was to follow the progression of infection in the various regions of the country by comparing data from two time periods: Period I: 1986 to 1989; Period II: 1994 to 1996. LOCATION: Samples were taken in regional maternal and child protection centers. Recruitment method: Women were recruited anonymously, during their antenatal care. BIOLOGICAL ANALYSIS: Period I (1986 to 1989), 2,604 pregnant women. Anti-HIV antibodies were detected with: Abbott HIV-1 EIA Recombinant (Chicago) used initially, for 1,200 sera; Abbott HIV-1/HIV-2 Recombinant (Chicago) used later for the remaining sera. There was no commercially available test for HIV-2 during this first period, so all samples with Rm0.8 (R = optical density/cut-off) were also tested by western blotting. Period II (1994 to 1996), 2,935 pregnant women. All sera were tested with Enzygnost HIV-1-2 and Enzygnost HIV-1-2 Plus, produced by Behring (Germany). All sera testing positive in EIA were also tested by western blotting. RESULTS: The prevalence of HIV infection was 4.23% for Period I and 12.53% for Period II. No region of Ivory Coast was completely free of these 2 viruses after the mid-1980s. Women aged 20 to 29 years of age were the most likely to be infected, for both periods. The highest prevalence of HIV-2 was that for women aged between 20 and 29 years and HIV-2 infection occurred mostly in the South, Southwest and West regions. DISCUSSION: The prevalence of HIV infection is now at least 10% in each region of the country. Abidjan is no longer the city with the highest levels of infection, as shown by the results for Period II. The East and West have the highest levels of HIV infection, and the prevalence of HIV in these areas is significantly higher than that for Abidjan (p = 0.007 for the East and p = 0.009 for the West).

The Côte d'Ivoire national HIV counseling and testing program for tuberculosis patients: implementation and analysis of epidemiologic data.

OBJECTIVES: To describe the implementation of a free, voluntary and confidential HIV counseling and testing program for patients with newly diagnosed tuberculosis at the eight large outpatient tuberculosis centers in Côte d'Ivoire, and to present epidemiologic findings on participating patients. DESIGN: HIV counseling and testing program with ongoing HIV serosurveillance. METHODS: HIV counseling and testing services were established at the two tuberculosis centers in Abidjan in 1989 and were extended to six centers in the Côte d'Ivoire interior in the first half of 1994. Characteristics of counseled patients, acceptance rates of HIV testing, and HIV serologic results were analyzed for all eight centers from 1994 to 1996. Temporal trends in HIV seropositivity rates were examined for the two centers of Abidjan from 1989 to 1996. RESULTS: From July 1994 through December 1996, 17 946 (91.8%) out of 19 594 patients who were counseled at the eight centers in Côte d'Ivoire consented to HIV testing, of whom 7749 (43.2%) were HIV-seropositive. The highest rates of 47.0 and 45.6% were found in the two centers in Abidjan, with rates ranging from 32.9 to 42.4% in the six centers in the interior. HIV-seropositive tuberculosis patients from each of the 50 districts in Côte d'Ivoire were identified. In Abidjan, the HIV seropositivity rate remained relatively stable among men (46.7% in 1989, 48.5% in 1991, 43.6% in 1996), but rose sharply among women from 32.7% in 1989 to 50.1% in 1996. CONCLUSIONS: The high HIV seropositivity rates among tuberculosis patients in all geographic regions of Côte d'Ivoire indicate that the HIV epidemic has now spread throughout the country. However, the successful implementation of an extensive HIV counseling and testing program for more than 37000 tuberculosis patients to date demonstrates the commitment of the Côte d'Ivoire Ministry of Health to integrating HIV/AIDS prevention activities with tuberculosis control efforts. When logistically and economically feasible, the extension of HIV-related social and clinical services to HIV-seropositive tuberculosis patients should be considered by other national tuberculosis control programs in Africa.

HIV counseling and testing: behavior and practices of women of childbearing age in Abidjan, Côte d'Ivoire. DYSCER-CI Group.

We assessed factors associated with women's attitudes toward HIV test results in gynecology clinics in Abidjan, Côte d'Ivoire. HIV testing was systematically offered to nonpregnant women attending two gynecology clinics in Abidjan. Individual pretest counseling was performed by trained midwives. Posttest counseling was given 2 weeks later to women who wished to know their HIV test results. HIV testing was offered to a total of 1482 women, of whom 1401 (94.5%) agreed to be screened. The prevalence of HIV infection was 21.3%. Of the women who participated, 10% failed to return. Youth, low educational level, and absence of genital infection were findings individually associated with failure by participants to return for their test results. Among the 1242 women who returned, 13.7% did not wish to know the results of their HIV test. A positive HIV test result, being native to Côte d'Ivoire, a high educational level, and knowing the existence of the asymptomatic stage of HIV infection were factors independently associated with declining to know the HIV test result. In conclusion, women who declined to know their HIV test results presented a specific profile at the time of HIV testing. This information can be used to improve pretest counseling and the efficacy of future HIV screening programs.