15 Month follow up of African children following vaginal cleansing with benzalkonium chloride of their HIV infected mothers during late pregnancy and delivery.

OBJECTIVES: To study mother to child HIV-1 transmission (MTCT) and infant mortality following benzalkonium chloride (BC) disinfection. METHODS: A randomised, double blind phase II placebo controlled trial. Women testing positive for HIV-1 infection in prenatal care units in Abidjan, Côte d'Ivoire, and Bobo-Dioulasso, Burkina Faso, from November 1996 to April 1997 were eligible, with their informed consent. Women self administered daily a vaginal suppository of 1% BC (53) or matched placebo (54) from 36 weeks of pregnancy, plus a single dose during labour. The neonate was bathed with 1% BC solution or placebo within 30 minutes after birth. MTCT rate was assessed based on repeated polymerase chain reaction (PCR) and serology results. For the present analysis, children were followed up to 15 months. RESULTS: A total of 107 women were enrolled. Of 103 eligible liveborn children, 23 were HIV infected, 75 uninfected, and five of indeterminate status. MTCT transmission rate was 24.2% overall (95% confidence interval (CI): 14.3% to 30.4%). On an intent to treat basis, the transmission rate did not differ between the two groups (23.5%, CI 13.8 to 38.5, in the BC group and 24.8%, CI 15.0 to 39.6, in the placebo group at 15 months). Similarly, there was no difference in mortality at 15 months (22.9%, CI 13.7 to 36.9, in the BC group and 16.5%, CI 9.0 to 29.4, in the placebo group). CONCLUSION: This analysis failed to suggest any benefit of BC disinfection on mother to child HIV transmission or perinatal and infant mortality.

Hepatitis B and C infections, human immunodeficiency virus and other sexually transmitted infections among women of childbearing age in Côte d'Ivoire, West Africa.

Few studies have been conducted in developing countries to estimate the prevalence of hepatitis C virus (HCV) infection and its association with human immunodeficiency virus (HIV) and other sexually transmitted diseases (STDs). We have screened for hepatitis B virus (HBV) and HCV markers 200 HIV-1-positive, 23 HIV-2-positive and 206 HIV-negative women attending gynaecology clinics in 1995/96 in Abidjan, Côte d'Ivoire, a sample selected among 2198 consecutive consultants. Taking into account the prevalence of 21.7% for HIV in this population, the overall prevalence of anti-HBV core antibody was 81.6%, that for hepatitis B surface antigen was 9.9% and for HCV antibody was 3.3%. HIV infection and other STDs were not associated with HBV or HCV markers. Moreover, HBV and HCV markers were not statistically associated. Our results confirm the high prevalence of HIV in Abidjan and the endemic situation of HBV infection. Furthermore, HCV infection is not infrequent in this developing country setting, not explained by sexual transmission.

[Nutrition problems experienced by adults infected with the human immunodeficiency virus in Abidjan (Ivory Coast)]. / Troubles alimentaires ressentis par des adults infectés par le virus de l'immunodéficience humaine à Abidjan (Côte d'Ivoire).

Denutrition is frequent among HIV-infected (HIV+) adults in sub-Saharan Africa. One of the risk factors for denutrition is a reduction in dietary intake. Eating disorders may be partly responsible for such decreases in food intake. We prospectively analyzed the frequency, associated factors and progression of anorexia, dysphagia and food aversion in a cohort of 330 HIV-infected adults included in a trial of early chemoprophylaxis with cotrimoxazole in Abidjan, Ivory Coast. Patients were followed-up by means of scheduled monthly visits. Eating disorders were assessed using a standardized questionnaire after 6, 12 and 18 months of follow-up. After six months of follow-up, 28% of the patients reported anorexia, 9% dysphagia and 28% food aversion. Multivariate analysis showed that anorexia was significantly more frequent in women than in men (odds ratio (OR) = 2.0 [95% confidence interval: 1.2-3.5]) and in patients with a CD4+ lymphocyte count < 200/mm3 (OR = 1.8 [1.0-3.5]). The risk of dysphagia was also higher for women than for men (OR = 1.8 [1.0-3.5]). The risk of dysphagia was also higher for women than for men (OR = 3.3 [1.3-8.4]). Patients with < 200 CD4+ lymphocytes/mm3 were more likely than those with CD4+ lymphocyte counts of over 200 to suffer food aversion (OR = 1.8 [1.1-3.0]). We analyzed the progression of dietary problems during follow-up and found that anorexia and dysphygia tended to disappear from one evaluation to the next whereas the number of patients reporting food aversion tended to increase. For patients reporting anorexia at the 6-month evaluation, significantly more women than men reported the persistence of anorexia at the 12-month evaluation (16% versus 5%; p = 0.03). Among patients with dysphagia at six months, those with a CD4+ lymphocyte count below 200/mm3 were much more likely than those with a CD4+ count above 200 to report persistent dysphagia at the 12-month evaluation (7% versus 0%; p = 0. 02, Fischer's exact test). For patients with no dietary problems after six months, those taking cotrimoxazole were significantly more likely than those of the placebo group to report food aversion at the 12-month evaluation (21% versus 8%; p = 0.01). We found that dietary problems were associated more with the stage of immunodeficiency that with socioeconomic factors, with the exception of sex, which was associated with several outcomes. These data stress the importance of detecting these frequent dietary problems as part of the overall clinical management of HIV+ adults in Africa, and of providing affected individuals with early nutritional counseling.

Vaginal douching: association with lower genital tract infections in African pregnant women.

BACKGROUND AND OBJECTIVES: Douching, a common practice, could further increase the risk of genital infections. GOAL OF THIS STUDY: To describe douching practices in pregnant women and to evaluate associations with lower genital tract infections. STUDY DESIGN: Cross-sectional study in Abidjan, Côte d'Ivoire. RESULTS: Among 552 women included, douching before consultation was reported by 97% and was common practice for 98%. Intravaginal drying agents were used by 10%. Genital warts were less frequent for women who usually douched (p = 0.015). U. urealyticum infection was associated with douching and with the use of intravaginal agents. Diagnosis of genital infections was independent of douching with water or soap, but chlamydial infection was associated with douching with antiseptics, used by 14% of the women (p = 0.036). HIV infection was two times more frequent in women using antiseptics (p = 0.17). CONCLUSION: The study confirms the widespread practice of douching in African pregnant women. The harmful effects of antiseptics need to be substantiated.

Safety and acceptability of vaginal disinfection with benzalkonium chloride in HIV infected pregnant women in west Africa: ANRS 049b phase II randomized, double blinded placebo controlled trial. DITRAME Study Group.

OBJECTIVES: To study the tolerance and acceptability in Africa of a perinatal intervention to prevent vertical HIV transmission using benzalkonium chloride disinfection. DESIGN: A randomized, double blinded phase II trial. SETTING: Prenatal care units in Abidjan (Côte d'Ivoire) and Bobo-Dioulasso (Burkina Faso). PATIENTS: Women accepting testing and counselling who were seropositive for HIV-1 and under 37 weeks of pregnancy were eligible. A total of 108 women (54 in each group) enrolled from November 1996 to April 1997, with their informed consent. INTERVENTION: Women self administered daily a vaginal suppository of 1% benzalkonium chloride or matched placebo from 36 weeks of pregnancy, and a single intrapartum dose. The neonate was bathed with 1% benzalkonium chloride solution or placebo within 30 minutes after birth. MAIN OUTCOME MEASURES: Adverse events were recorded weekly, with a questionnaire and speculum examination in women through delivery, and examination of the neonate through day 30. The incidence of genital signs and symptoms in the women and cutaneous or ophthalmological events in newborns were compared between groups on an intent to treat basis. RESULTS: The median duration of prepartum treatment was 21 days (range 0-87 days). Compliance was 87% for prepartum and 69% for intrapartum treatment, and 88% for the neonatal bath, without differences between the two groups. In women, the most frequent event was leucorrhoea; the incidence of adverse events did not differ between treatment groups. In children, the incidence of dermatitis and conjunctivitis did not differ between the benzalkonium chloride and placebo groups (p = 0.16 and p = 0.29, respectively). CONCLUSION: Vaginal disinfection with benzalkonium chloride is a feasible and well tolerated intervention in west Africa. Its efficacy in preventing vertical HIV transmission remains to be demonstrated.

Spectrum of disease among HIV-infected adults hospitalised in a respiratory medicine unit in Abidjan, Côte d'Ivoire.

SETTING: Respiratory medicine wards of the University Teaching Hospital, Abidjan, Côte d'Ivoire. OBJECTIVES: To describe the spectrum of opportunistic infection among human immunodeficiency virus (HIV) infected adults hospitalised in the respiratory medicine unit in Abidjan, and the level of immunosuppression at which these diseases occur. DESIGN: Cross-sectional study. RESULTS: Overall, 75% of patients were HIV-positive: among these patients, the most frequent diagnosis was tuberculosis, in 61%, followed by bacterial pneumonia (15%), Gram-negative septicaemia (particularly non-typhoid Salmonella) (9%) and empyema (5%). Atypical pneumonias appeared to be rare. Most HIV-positive patients had CD4 counts indicative of advanced immunosuppression: 36% had CD4 counts below 100 x 10(6)/l, 19% between 100 and 199 x 10(6)/l, 29% between 200 and 499 x 10(6)/l, and 16% above 500 x 10(6)/l. Overall in-hospital mortality was 27% for HIV-positive patients and 22% for HIV-negative patients (P = 0.5). In a multivariate analysis, the strongest independent risk factors for death were cachexia (odds ratio [OR] 7.4, 95% confidence interval [CI] 2.1-26.3), male sex (OR 4.5, 95% CI 1.2-17.4) and age over 40 (OR 4.1, 95% CI 1.0-17.2). CONCLUSIONS: Tuberculosis and bacterial infections are the major causes of respiratory morbidity in immunosuppressed HIV-infected adults in this population. Efforts to improve the management of HIV-related disease need to focus on prevention and treatment of these infections.

Squamous intraepithelial lesions of the cervix, invasive cervical carcinoma, and immunosuppression induced by human immunodeficiency virus in Africa. Dyscer-CI Group.

BACKGROUND: Squamous intraepithelial lesions (SILs) of the cervix are associated with human immunodeficiency virus (HIV) infection, but multiple risk factors must be considered in this context. The authors performed a cross-sectional study to assess the prevalence of and the factors associated with SILs and invasive cervical carcinoma (ICC). METHODS: In Abidjan, Côte d'Ivoire, women were recruited from three outpatient gynecology clinics and screened for both cervical disease and HIV infection. A CD4 cell count was performed for HIV-infected women. RESULTS: A total of 2198 women were included in the study. The prevalence of HIV infection was 21.7%. Of the 2170 women who underwent a cervical screening, 254 (11.7%) presented with a dysplasia or neoplasia: 7.6% had low grade SILs (LSILs), 3.3% had high grade SILs (HSILs), and 0.8% had ICCs. In multivariate analyses, factors associated with these lesions were as follows: for LSILs, HIV-1 seropositivity, age <24 years, parity >1, consultation for genital infection, and no use of oral contraception in the past; for HSILs, HIV-1 seropositivity, chewing tobacco use, low educational level, and parity >1; and for ICCs, age >33 years, parity >3, and illiteracy. In women infected with HIV-1, the prevalence of LSILs increased with a decrease in CD4 cell count, whereas this relation was not found among patients with HSILs. ICCs were linked to HIV-2 infection, but not to HIV-1 infection, in univariate analysis. CONCLUSIONS: In Africa, the prevalence of SILs is high. The factors associated with precancerous and cancerous lesions are different. Cancers in women infected with HIV-1 often may not reach the invasive stage. These findings could have implications for cervical screening programs in the future.

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.

Profound immunosuppression across the spectrum of opportunistic disease among hospitalized HIV-infected adults in Abidjan, Côte d'Ivoire.

OBJECTIVES: To describe the spectrum of opportunistic disease in HIV-infected patients admitted to hospital in Abidjan, Côte d'Ivoire, and to describe the level of immunosuppression at which these diseases occur. DESIGN: Cross-sectional study. SETTING: In-patient wards of the University Hospital Infectious Diseases Unit. PATIENTS: A total of 250 adult patients recruited by systematic sampling at the point of hospital admission. MAIN MEASURES: HIV status; CD4 count; diagnoses, confirmed by microbiological/radiological investigations whenever possible; and outcome of hospitalization (death or discharge). RESULTS: Overall, 79% patients were HIV-positive. The most frequent diagnoses in HIV-positive patients were septicaemia (20%, with non-typhoid salmonellae, Escherichia coli and Streptococcus pneumoniae the most common organisms), HIV wasting (16%), meningitis (14%), tuberculosis (TB; 13%), isosporiasis (10%), cerebral toxoplasmosis (7%) and bacterial enteritis (7%). Most HIV-positive patients had evidence of severe immunosuppression: 39% had CD4 counts < 50 x 10(6)/l, 17% had 50-99 x 10(6)/l, and 20% had 100-199 x 10(6)/l. In-hospital mortality among HIV-positive patients was 38% compared with 27% among HIV-negative patients [age-adjusted odds ratio (OR), 1.5; 95% confidence interval (CI), 0.7-2.9]. Among HIV-positive patients, the highest case-fatality rates were among patients with meningitis, toxoplasmosis and TB: in a multivariate analysis the strongest independent risk factors for death were an abnormal level of consciousness (OR, 9.3; 95% CI, 3.5-24.6), a haemoglobin concentration below 8 g/dl (OR, 4.2; 95% CI, 1.4-12.8) and age > 40 years (OR, 3.9; 95% CI, 1.5-10.2). CONCLUSIONS: Our data show that, as in industrialized countries, most HIV-infected individuals admitted to and dying in hospital in Abidjan are profoundly immunosuppressed. Potentially preventable infections are the main causes of in-hospital morbidity and mortality among HIV-infected persons in Abidjan, and the evaluation of appropriate primary prophylactic regimes is a priority.

CD4+ T-lymphocyte counts in HIV infection: are European standards applicable to African patients?

CD4+ lymphocyte count (CD4+ LC) is a widely used marker of Human Immunodeficiency Virus (HIV) immune impairment. Physiological lymphocytosis is frequently encountered in Africans. Therefore, we tried to determine if given CD4+ LC levels are of similar significance in European versus African HIV-infected individuals. Lymphocyte phenotyping of 750 HIV-infected adults was retrospectively analyzed. Three hundred and seventy patients were consecutively selected in Paris, France; 185 in Abidjan, Côte d'Ivoire; and 195 in Bobo-Dioulasso, Burkina Faso. In the three settings, lymphocyte phenotyping was performed by flow cytometry using similar protocols. Data from Abidjan and Bobo-Dioulasso were combined on the basis of geographic proximity and contrasted with those from Paris. Geometric mean levels of Total Lymphocyte Count (TLC), CD4+ LC, CD8+ lymphocyte count (CD8+ LC), and CD4:CD8 ratio, adjusted for percentage of CD4+ T-cells (%CD4+), were compared between Africans and Europeans. For a given %CD4+, TLC and CD4+ LC but not CD8+ LC tended to be about one third higher in West African than in French adults (p < 0.0001). Approximate equivalencies of absolute CD4+ counts in French and West African HIV-infected adults suggest that where thresholds of 200 and 500 CD4+ cells/microliter are applied in Europe, it might be appropriate to apply a threshold of approximately 250 and 700 CD4+ cells/microliter in West Africa, respectively. Establishing indicators of progression of HIV infection with locally appropriate thresholds may represent important steps toward improvement of HIV disease management in Africa.

PIP: CD4+ T-lymphocyte count (CD4+ LC) is a widely used marker of HIV immune impairment. The authors explored whether given CD4+ LC levels have the same significance in European HIV-infected individuals as they do in similarly infected Africans. 370 HIV-infected adults were consecutively selected in Paris, France, 185 in Abidjan, Cote d'Ivoire, and 195 in Bobo-Dioulasso, Burkina Faso, to undergo retrospective lymphocyte phenotyping using flow cytometry. Data from Abidjan and Bobo-Dioulasso were combined on the basis of geographic proximity and contrasted with those from Paris. Geometric mean levels of total lymphocyte count (TLC), CD4+ LC, CD8+ LC, and CD4:CD8 ratio, adjusted for the percentage of CD4+ T-cells, were compared between Africans and Europeans. For a given percent CD4+, TLC and CD4+ LC, but not CD8+ LC, tended to be about one-third higher in West African than in French adults. Approximate equivalencies of absolute CD4+ counts in French and West African HIV-infected adults suggest that where thresholds of 200 and 500 CD4+ cells/mcl are applied in Europe, thresholds of approximately 250 and 700 CD4+ cells/mcl may be more suitable in West Africa. Establishing indicators of the progression of HIV infection with locally appropriate thresholds may lead to the improved management of HIV disease in Africa.

[Primary chemoprevention of tuberculosis in HIV-infected patients in non-industrialized countries]. / Chimioprophylaxie primaire de la tuberculose chez les personnes infectées par le VIH dans les pays non industrialisés.

In randomized placebo-controlled trials in Haïti, Zambia and Uganda, prophylactic use of isoniazid (INH) for 6 to 12 months reduced the annual incidence of tuberculosis in HIV-infected patients by more than 50 per cent. For several years, WHO, IUTATLD and CDC have recommended that HIV-positive patients testing positive in a PPD test should be treated with INH as a form of anti-tuberculosis chemoprophylaxis (ATC). Whilst these recommendations are easy to follow in industrialized countries, widespread use of ATC in developing countries remains problematic because: (i) It is unknown what proportion of patients are likely to be re-infected at the end of ATC in countries where TB is endemic; (ii) It is possible that resistant bacilli may be selected due to the incomplete exclusion from the ATC program of patients with active TB at enrollment; (iii) It is difficult to identify asymptomatic carriers of M. tuberculosis at enrollment; (iv) It is doubtful that all patients will comply with a treatment regime which lasts several months; (v) The cost of a widespread ATC program, whose full benefit remains to be evaluated, may be difficult to justify. This paper attempts to review these issues and demonstrates the need for more population-based clinical trials in the field.

[Acquired recto-vaginal fistula in children: is HIV infection a cause?]. / La fistule recto-vaginale acquise (FRVA) chez l'enfant: le VIH est-il en cause?

Seven successive cases of acquired rectovaginal fistula have been diagnosed on children of three and half to eighteen months old. These fistula were localised on the fourchette. The seropositivity for HIV of five cases confirmed the results of similar reports found in literature. Surgical treatment of these girls was not done because of their bad presentation. Two of these children died. The other did not come for follow-up. The acquired rectovaginal fistula seems to be a sign of HIV infection. This work is meant to emphasise the relationship between AIDS and acquired rectovaginal fistula for a closer surveillance of future cases.

[The contribution of latex tests for the diagnosis of bacterial infections in Abidjan]. / Apport des tests au latex pour le diagnostic des infections bactériennes a Abidjan.

From 313 samples of CSF, urine, sera and pleural liquid, the authors show how appreciable is the contribution in research of soluble antigens by sensibilized latex particles agglutination method in etiologic diagnosis, especially during meningitis, pulmonary and neonatal infections. Soluble antigens were declared positives in 62.26% of cases against S. pneumoniae, 25.4% of cases against H. influenzae, 6.66% of cases against S. agalactiae, 5.71% of cases against N. meningitidis C, with variable percentages from one biological liquid to another. Compared to classical bacteriologic techniques, this method allows the diagnosis of an infection even when decapitated, and could be used in emergency diagnosis.

[Is cytobacteriological examination of sputum necessary for the diagnosis of bronchopulmonary superinfections in Abidjan?]. / L'examen cytobactériologique des expectorations est-il utile pour le diagnostic des surinfections bronchopulmonaires à Abidjan?

About 276 sputums analysed from 1984 to 1989, 61% of them have been positive. Beside the usual germs of the oropharynged flora, 115 bacteria susceptible of being pathogenic have been isolated. The kinds which are frequently found are Klebsiella = 31 (27%), Escherichia coli = 20 (17%), Enterobacter = 19 (17%), Staphylococcus aureus = 17 (15%) and Pseudomonas aeruginosa = 12 (10%).