[Revival after Ebola: multidisciplinary assessment at 1 year, prospect and follow-up study of surviving patients from Ebola in Guinea (PostEboGui cohort)]. / (Re)vivre après Ebola : bilan à un an et perspectives d'une étude d'évaluation et accompagnement des patients déclarés guéris d'une infection par le virus Ebola en Guinée (cohorte PostEboGui).

Ebola virus disease (EVD) epidemic that spread in West Africa from the end of 2013 to early 2016 has reached more people than all past epidemics. Beyond care management of acute phase ill patients and measures for the control of the epidemic, the outcome of Ebola survivors became an important question as their number increased and raised new issues. A multidisciplinary prospective cohort of survivors in Guinea has been launched by IRD UMI 233 and Donka National Hospital, Conakry, Guinea, to assess the long-term clinical, psychological, sociological, immunological, and viral outcomes potentially related to EVD. This paper describes PostEboGui Programme, constraints and changes to the initial proposal, participants, first results, and new issues, 1 year after its start, in a descriptive and critical view. We started also to work on ethical aspects in the context of epidemics and of mass interventions with a risk of overinvestigation of patients.

[Ebola in Guinea: experience of stigma among health professional survivors]. / Ebola en Guinée : formes de la stigmatisation des acteurs de santé survivants.

This article aims to describe the various forms of stigma faced by Ebola health professional survivors. A study based on in-depth interviews with 20 survivors was conducted in Conakry as part of PostEboGui multidisciplinary cohort research Program (Life after Ebola) in July-August 2015. Participants were health professionals, male and female, mostly with precarious positions in the health system. The results show that stigmatization is mainly expressed through avoidance, rejection, or being refused to be reinstated in the position at work and non-acceptance of the disease by third parties. This stigmatization appears to be rooted in fear of contagion and in diverging conceptions of the disease aetiology that may engender conflict. Being health workers did not protect them against stigma and some of them faced rejection in their own health care facility. This stigmatization was not based on moral grounds, contrary to the one experienced by people living with HIV, and attitudes of solidarity were encountered in family and confessional networks. Responders found support within an association of survivors (Association des personnes guéries et affectées d'Ebola en Guinée, APEGUAEG) that was created in early 2015. Stigmatization was temporary and disappeared for most responders owing to strategies implemented by survivors and because the fear of contagion had vanished: interviews were conducted when the notion of persistence of Ebola virus in the semen was not spread in the population. This research study shows that stigma is perpetuated among health agents, towards workers who were exposed by their professional role. This observation should be considered for specific measures towards behavioural change. Finally, the very notion of "stigmatization", widely used by public health institutions, is challenged by the diversity of individual experiences that are particular to Ebola virus disease regarding their expression and evolution. Studies on stigma related to Ebola should be held in other populations and contexts for comparison.

[Hospital care for a child living with HIV in Dakar. What is the cost for the family?]. / Hospitalisation d'un enfant vivant avec le VIH à Dakar. Quel coût pour la famille ?

In sub-Saharan Africa, hospitalization is one of the main gateway for testing and care of children living with the HIV. The aim of this study is to estimate the direct costs of the hospitalization of children living with the HIV in Dakar (Senegal). The various expenses were collected daily with the medical file and by interview from the accompanying persons in 30 children. Median age was 9 years (1-17) with a sex ratio of 1.3. Siteen children were orphan and 7 died during the sur- vey. The median duration of the hospitaization was 20 days (3-71). Children older than 5 years had longer hospitalization duration than those under 5 years (p = 0.0001). The average full cost was 175,701 FCFA (268 €), distributed as follow: cost in the hospital 36%, cost of drugs 31%, cost of medical care 20% other non-medical expenses 13%. This survey explores an underdocumented aspect of HIV pediatric care : cost of hospitalization. It also addresses the issue of non-medical expenses resulting from the hospitalization, with regards to the families' income.

[Long-term impact of antiretroviral therapy in Africa: current knowledge]. / Impact à long terme des traitements antirétroviraux en Afrique, état des connaissances.

By the end of 2013, 11 million PLHIV were taking ARVs in Africa; application of the WHO recommendation to initiate treatment earlier (at CD4 count of 500 cells/mm3 or less) should further increase this number. Currently, twothirds of patients in Africa have been on treatment for less than five years, and less than 10% have received treatment for eight years or more. Given the historical perspective is in its early stages, the long-term impact of ARV therapy is still unclear. This article reviews the knowledge gained over the period marking the first ten years of implementation of the universal access strategy (2003-2013) in Africa, through a review of the literature documenting the long-term consequence of ARV treatment, focusing on medical care for adults with an emphasis on the patient-centered approach. The goal is to understand the interrelationships between biological and social factors and individual and collective aspects that affect the lives of PLHIV and determine the impacts of ARV treatment over the long term. The biomedical and social factors are addressed successively, based on the most significant results. Key knowledge on the long-term outcomes for PLHIVon ARV treatment offers vital information on the necessary conditions and adaptations for care systems needed to ensure the benefits of treatment endure over time.

[Representations of therapeutic failure of ARV treatment among patients and health care professionals in Dakar]. / Représentations de l'échec thérapeutique des traitements ARV chez les patients et les professionnels de santé à Dakar.

The aim of this qualitative study was to describe and analyze representations of therapeutic failure and the medical and social responses proposed by health care professionals and patients receiving follow-up in the ANRS cohort 1215 in Senegal from 1999 to 2010. Patients' medical histories show that therapeutic failures are related to complex multifactorial situations, resulting from factors attributable to patients (adherence failure related to various psychosocial problems) but also to health care structures (organization of the health system, training for health care professionals and availability of biological exams and appropriate drugs). Both patients and health care staff recognize these causes. The incidence of the onset of therapeutic failures should be regarded as an indicator of the quality of care provided. Further thought should be given to how well health care systems function when changes occur in these rates.

Twelve years of follow-up for patients treated with ARVs in Senegal (ANRS Cohort 1215): description of population and methodology.

The ANRS Cohort 1215 brought together the first 400 patients receiving antiretroviral treatments through the government program for ARV treatment in Senegal. These people, infected with HIV-1, began their treatment between 1998 and 2002; they were treated with 2 NRTI + 1 PI or NNRTI. This prospective observational cohort received follow-up over the course of 12 years, from 1999 to 2010, and was one of the earliest established cohorts in Africa and providing the longest duration of ART follow-up. A series of interdisciplinary studies was conducted among these patients to assess the medical and social as well as the individual and collective impact of these treatments over the long term. This article presents the cohort's key methodological characteristics.

[Assessing the direct cost of medical care for HIV between the third and tenth year of ARV treatment in Dakar]. / Évaluation du coût direct de la prise en charge médicale du VIH entre la troisième et la dixième année de traitement ARV à Dakar.

The direct cost of medical care for HIV infection-excluding ARVs, viral load and CD4 counts-was assessed for patients who received ARV treatment in Senegal within the framework of the ANRS cohort 1215, between the third and tenth year of follow-up. The average annual direct cost was estimated at 120 /patient/year; this amount remained stable over the first ten years of treatment follow-up. Biological assessments for routine follow-up account for the majority of these costs (66%), followed by drugs (26%). Given the level of economic poverty facing by families, patients cannot bear such expenses over several years. However, these costs appear low enough to be covered by HIV-treatment programs or included in Universal Health Coverage systems.

[Sexual complaints and dysfunction among PLHIV receiving ARV treatment for ten years in Senegal]. / Plaintes et dysfonctions sexuelles des personnes vivant avec le VIH (PVVIH), traitées par antirétroviraux (ARV) depuis une dizaine d'année au Sénégal.

The sexual health of people who have been living with HIV (PLHIV) and who have been receiving ARV drug treatment for several years is still a virtually unexplored topic in Africa today. A study was conducted in Senegal on people who have been treated with ARVs for ten years. Half of those interviewed believe that their sexuality has deteriorated. HIV infection has become a chronic disease in which sexual dysfunction related to the disease or age is interpreted in the context of popular representations of HIV infection and those on sexuality defined by social norms.

[The social relegation of widows living with HIV in the time of ART in Senegal]. / La relégation sociale des veuves vivant avec le VIH au temps des antirétroviraux au Sénégal.

While prolonged widowhood is unusual in Senegalese society, some women living with HIV receiving antiretroviral therapy for ten years remained widows. Are they maintained in this situation for refusing or being unable to remarry? To understand the conditions and the reasons for this lack of "matrimonial normalization", a qualitative interview study was conducted in Dakar with 31 widows. Their living conditions are mostly marked by economic difficulties, dependence on host families, and responsibilities visà-vis their children. They refuse to remarry, regret not being able to, or wish to without success, despite the existence locally of social forms of marital union that would respond to their situation. The refusal to disclose their HIV status combined with self-stigma prevent them from improving their condition. This form of social vulnerability that remains beyond the restoration of health is ignored by public policy and HIV/AIDS community based organizations claims. It should be acknowledged and considered for defending PLWAs' rights.

[Late diagnosis of HIV infection in the Fann, Dakar clinic of infectious diseases: testing circumstances, therapeutic course of patients, and determining factors]. / Dépistage tardif de l'infection à VIH à la clinique des maladies infectieuses de Fann, Dakar: circonstances de diagnostic, itinéraire thérapeutique des patients et facteurs déterminants.

BACKGROUND AND METHODOLOGY: The delay in the diagnosis of HIV infection is a major obstacle to optimal care for this disease. To deal with this problem, we conducted this study among newly diagnosed HIV patients hospitalized in the Fann University Hospital Infectious Diseases Clinic in Dakar. The epidemiological, clinical, biological and outcome aspects are described and patient history reviewed. A qualitative socio-anthropological study was made to understand and describe the logic of the decision processes in the patient's search for treatment. RESULTS: One hundred patients were included, with a mean age of 39.5+/-11.1 years and a sex-ratio: 1.08. The transmission was mainly heterosexual (90%), and chronic diarrhea (64%) and/or chronic cough (66%) were the principal symptoms leading to diagnosis. The mean delay before diagnosis was 5+/-4.27 months. The major opportunistic diseases were tuberculosis (44 cases) and infectious diarrhea (23 cases). Most patients were diagnosed at the AIDS stage (97%) and the death rate was 30% among hospitalized patients after admission. Sixty-eight percent of patients had consulted at least three times, generally a "traditional practitioner", at first and 43% had been hospitalized at least once. The qualitative investigation revealed that the "representation" or the "feeling of severity" of the disease were the principal justifications for consulting the "traditional practitioner" or the physician, respectively. CONCLUSION: Better information for health workers and global population is necessary for an earlier diagnosis of HIV infection in Dakar.

[Efavirenz (Sustiva) in pregnancy: a study about 12 HIV patients]. / Grossesse sous efavirenz (Sustiva): à propos de 12 cas de patientes positives pour le VIH.

OBJECTIVE: In developed countries, where the mother-to-child transmission rate of HIV is low (1 to 1,5%), a major medical concern is the safety of new therapies during pregnancy. Teratogenicity has been described with an NNRTI, efavirenz (Sustiva), in animal model, regarding neural tube defects. PATIENTS AND METHODS: We have made a retrospective study of pregnancies starting with efavirenz with a special focus on foetal and infant abnormalities. RESULTS: Three abnormalities were notified no one linked to a neural tube defect. DISCUSSION AND CONCLUSION: In the English literature published, although the prevalence of abnormalities in human is low (1,7%) during pregnancy, due to the potent teratogenicity, efavirenz is contraindicated in the first trimester and should be used with caution in women of childbearing potential.

[Free dispensing of antiretroviral treatments in Africa]. / Pour une délivrance gratuite des traitements antirétroviraux en Afrique.

The bio-clinical efficacy of ART in Africa has now been proven. In 2001, the resolution adopted by the UNGASS meeting confirms that "effective prevention, care and treatment strategies will require [...] a non-discriminatory access to [...] anti-retroviral therapies". Most of the programmes that give access to ART initiated in the sub-Saharan region in 1998 are based on the principle that the patients participate financially to the purchases of ART. Some countries (Côte d'Ivoire, Senegal, and Mali) subsidize ART medications to favour a better access. The financial contribution of patients is supposed to: 1/ translate patient support into government action; 2/ favour a closer therapeutic adherence; 3/ assure the access programmes sustainability. However, despite the subsidies provided by some states, the cost of medical treatment greatly exceeds the resources available to most of the sufferers. The analysis of ART access programmes, specifically in Senegal and Côte d'Ivoire, shows that: 1/ Patient support to government action does not need to be more demonstrated while general access to treatment is officially recognised and recommended by the United Nations. 2/ Patient involvement and better adherence have been noted with patients that receive free ART. 3/ Patient contribution represents less than 10% of the medication's purchasing cost, thus, the cost recovery is marginal and does not allow for sustainable ART access programmes. The cost charged to patients for ARV still represents a major obstacle for proper medical management. Care programmes in African countries should implement free access to ART as a priority.

[Representations of mother to child transmission of AIDS, perception of the risk and health information messages in Burkina Faso]. / Représentations de la transmission mère-enfant du sida, perception du risque et messages d'information sanitaire au Burkina Faso.

In Burkina Faso, in rural Mossi areas, popular contemporary representations of the transmission of HIV from mother to child are based on the idea that "the disease is in the blood" and that the fetus is conceived by "mixing the blood" of its parents. Infection of the child is seen as inevitable and systematic and is believed to occur in utero. Maternal milk is thought to have the same potential for infection because "milk is blood" but its role in transmission is seen as secondary, with transmission occurring before birth. However, breast feeding is believed to be responsible for the transmission of the disease in two ways: 1) by infected women transmitting the illness to healthy children via their milk and 2) by healthy women becoming infected by breast feeding infants born to infected mothers. The belief that transmission is systematic and the fear that the child will contaminate others leads to the widely held view within the population that no care should be taken of children born to women with AIDS and that such children should be abandoned and left to die. These representations have recently developed in the population based on preexisting beliefs relating to the physiology and role of blood in the transmission of diseases and the health information that has been distributed. Health information messages are largely responsible for the representations described above. Indeed, the description of the modes of HIV transmission in such messages has been based on the simplified statement of the triad, sex, blood and mother-child, with no indication of the relative risks of transmission for each. Hence, this incomplete information, interpreted in terms of popular conceptions about contagion, has resulted in maximal probability being attributed to each of the listed modes of transmission. Health information messages are the principal means of communicating scientific information to the general population. The stakes associated with the quality and correctness of the information supplied are therefore very high. The notion of the risk of transmission and statement of the level of risk are essential to any explanation of the modes of transmission of HIV. These ideas cannot be neglected because they are essential to the correct understanding of transmission and to the logical management of individual risk.

[How to manage HIV seropositive or AIDS patients in rural Burkina Faso?]. / Quelle prise en charge pour les malades séropositifs ou sidéens en milieu rural au Burkina Faso?

This article is based on an ethnographical study carried out in 1996. It describes and analyzes the methods of medical and family management of HIV-positive and full-blown AIDS patients in the rural environment of Burkinabé. A number of recommendations are made. Biomedical management of these patients is almost non-existent (currently there is no serology or screening advice available at the dispensary). The patient is never informed of an AIDS diagnosis. The relations between the medical personnel and the patients are dominated by a sense of powerlessness and constant fear of infection. None of the traditional doctors of the region admits to treating AIDS although traditional medicine is used throughout the illness. Family management ranges from complete rejection of the patient to supportive but often misdirected care. It is determined by at least five elements: (1) the composition of the family unit and the nature of relations between the sick individual and the rest of the family, (2) the economic status of the patients, his family group and his parents, (3) the initial uncertainties of the diagnosis of the illness, (4) the fear of contagion and (5) the fear of gossip. Management of these patients would be improved by: (1) real access to counseling and screening, (2) the involvement of health workers in this activity and in the notification of the diagnosis to the peripheral medical organizations, (3) the education of the staff about the risks of contamination and care of the terminally ill, (4) reeducation of the public about the non-contagious nature of the sick by personal counseling given by health care professionals and (5) the material support of families. This is of vital importance but is difficult to achieve in the context of chronic poverty.

PIP: An ethnographic survey of some 10 Mossi villages with a total population of about 13,000 in Oubritenga province carried out between 1993 and 1996 provided information for an analysis of the medical and family management of HIV-seropositive and AIDS patients in rural Burkina Faso. None of the 1000 consultations held annually in the one available dispensary concerned management of seropositive patients. The incurability of AIDS, lack of resources of both the family and the dispensary, feelings of powerlessness of the health workers, and fear of infection discouraged efforts to treat HIV and AIDS patients. Consequently, health workers were unable to provide advice on preventing further spread or on management of the condition, and the opportunity to use statistics from the patient register for epidemiological surveillance was lost. Patients used the services of the 40 or 50 traditional practitioners in the area to obtain treatment for specific symptoms at all stages of HIV infection, although, as in the dispensary, the diagnosis of AIDS was never specified. The daily management of AIDS patients varied from complete rejection to supportive care under the influence of five major elements: 1) the composition of the domestic group and the nature of the relations between the patient and the family; 2) the economic power of the patient, his domestic group, and his extended family; 3) initial uncertainty concerning the diagnosis; 4) increasing fear of contracting AIDS; and 5) fear of disapproval or gossip. Many aspects of the management of AIDS characterize the final stages of any other mortal illness. But shame, fear of infection, and fear of gossip are peculiar to AIDS. Improved patient management is likely to require access to diagnosis and counseling in the dispensaries, training of health workers in the risks of infection and care of the terminally ill, reassurance of the public by health workers that casual contact does not spread AIDS, and material assistance for affected families.