Diagnosis of dual human immunodeficiency virus types 1 and 2 infections in a resource-limited setting.

BACKGROUND: The presence of dual HIV-1/HIV-2 infection in Ghana and the different drug requirements for the treatment of HIV-1 and HIV-2 presents difficulties for the treatment of dual infections with both viruses. OBJECTIVES: To determine the prevalence of the dual sero-positive profile in treatment naive patients at a principal ART Clinic in Accra, Ghana and to investigate if rapid screening assays could be useful for diagnosis. DESIGN: A cross-sectional study. SETTING: A principal antiretroviral treatment centre in Accra, Ghana. SUBJECTS: Three hundred and twenty eight antiretroviral treatment naive patients. RESULTS: A total of 12 (3.7%) of patients seen were dual seropositive. There was a slight tendency of dual seropositive females being older than their HIV-1 counterparts (p = 0.088, CI = -10.833 to 0.753). Eight of the 12 of the dual seropositives were reactive for Genie II and were considered as possibly infected with both HIV-I and HIV-2. Seven (87.5%) of Genie II dual seropositives had strong intensities (> 1+) on both HIV-2 specific bands (sgp105 and gp36) on Innolia. CD4 counts were not significantly different in dual seropositives as compared to HIV-1 infected patients. CONCLUSIONS: Dual HIV-1/HIV-2 seropositives (and possibly infections) maybe common especially in older women. The Genie II will be useful as a supplemental rapid test for rapid and accurate differentiation of HIV-1 and HIV-2 antibodies at treatment centres.

Hepatitis E virus infection among pig handlers in Accra, Ghana.

OBJECTIVE: To determine the correlates of hepatitis E virus infection (HEV) in a sample of persons who work with pigs. DESIGN: Cross-sectional study. SETTING: Three pig farms in the Greater Accra Region of Ghana. SUBJECTS: Persons who work with pigs seen at the selected pig farms between the months of January and May 2008. RESULTS: One hundred and five persons who work with pigs voluntarily completed a risk-factor questionnaire and provided blood samples for unlinked anonymous testing for the presence of antibodies to HEV. The median age of participants was 36.5 +/- 15.0 years (range 12-65 years). Of the 105 subjects tested, HEV seroprevelance was 38.1%. On multivariate analysis, the independent determinants of HEV infection were being employed on the farm for less than six months (odds ratio (OR) 9.1; 95% confidence interval (95% CI) 1.0-81.4 and having piped water in the household and/or on the farm (OR 3.9; 95% CI 0.4-90.8). CONCLUSION: Consistent with similar studies worldwide, the results of our studies revealed a high prevalence of HEV infection in persons who work with pigs. Further studies need to be done to isolate, characterise the virus and define the clinical and epidemiological significance of HEV infection in this population.

Differentiation of dual seropositivity to HIV 1 and HIV 2 in Ghanaian sera using line immunoassay (INNOLIA).

Two hundred serum samples from AIDS-like patients, blood donors and miscellaneous patients were screened by ELISA for HIV 1-2. Repeatedly positive samples were confirmed using the Western Blot (WB). Twenty samples that were dual positive were further analysed by Innolia, which contains synthetic or recombinant antigens in HIV-1 and HIV-2. Only 5 of the samples were dual positive. The need for further analysis of dual WB results is re-emphasized.

PIP: A serologic study conducted in Ghana highlighted the importance of differentiating between HIV cross-reactivity and specific reactions directed against the virus itself. 200 serum samples collected from blood donors, patients suspected to have AIDS, and other patients were screened by enzyme-linked immunosorbent assay (ELISA) and, if reactive, confirmed by Western blot. The 20 samples that were dually positive for HIV-1 and HIV-2 according to Western blot were further analyzed by INNOLIA, which contains synthetic or recombinant antigens to HIV-1 and HIV-2. Only 5 of the 20 samples were dually positive. 10 samples were positive for HIV-1 alone, 4 were positive for HIV-2 alone, and 1 was indeterminate. The INNOLIA test offers a more specific test for differentiation than the Western blot, and it is simpler to use since results for both HIV-1 and HIV-2 are recorded on a single test strip.

HIV-1 and HIV-2 in Ghana, west Africa: community surveys compared to surveys of pregnant women.

We conducted a population-based serosurvey of HIV-1/2 in 2,410 residents of two urban and two rural areas of southern Ghana, West Africa and compared the results to serosurveys of 1,417 pregnant women. Using conservative criteria, we found the prevalence of HIV-1/2 in community survey adults (> 15 years old) to be 1.5% in women and 1.0% in men. Among pregnant women, the prevalence was 9.3% in one rural area but only 1.0% in other areas. Many samples, especially among the pregnant women were HIV-1 and -2 dual reactive on serology. We attribute the disparity between prevalence in the community survey participants and pregnant women to local socio-economic factors. Women in this area have a tradition of working throughout West Africa as trader/ commercial sex workers. When pregnant or ill, they return to their home villages to be with their families. HIV surveillance programs which rely on pregnant women need to be sure that sampled populations are truly typical of the communities they are intended to represent.

PIP: HIV prevalence in urban and rural southern Ghana was investigated in a community-based serosurvey of 2410 people conducted in 1989-90 and an analysis of serum samples collected in 1987 from 1330 pregnant women attending antenatal clinics in the Eastern Region. None of the 906 children in the community-based survey was HIV-positive, including 6 born to HIV-infected women. Among the 1329 adults, 5 men (1.0%) and 12 women (1.5%) were infected. Among pregnant women, 100 (7.1%) were HIV-positive. At the four antenatal centers, HIV prevalence ranged from 0.6% to 10.3%. The high HIV prevalence recorded among pregnant women in the Manya-Krobo District (10.3%), a rural area away from major travel routes, likely reflects the tendency for ill women to return home to be cared for by their families. HIV surveillance programs that focus on pregnant women should be aware of this social phenomenon.

Comparison of HHV-6 antibody titers in West Africa and the Caribbean.

Human herpesvirus-6 (HHV-6) infection seems to be ubiquitous early in life, but antibody responses vary by geographic area. We compared HHV-6 antibody titer in 123 West African and 122 Caribbean serum samples. A quantitative immunofluorescence assay (IFA) using antigens derived from an HSB-2 cell line was used to test for IgG HHV-6 (GS strain) antibodies. The prevalence of HHV-6 antibodies was high (98%) in both sites. African samples had a significantly higher geometric mean titer (GMT: 697) than did Caribbean samples (GMT: 99). There was no difference between males (GMT: 260) and females (GMT: 270) overall. Children up to and including 9 years old had significantly higher titers (GMT: 483) than did all others (GMT: 237), and female children tended to have higher titers than did male children. In both areas there was a trend towards highest titer at younger age, followed by a decrease in titer during adulthood and middle age, and a secondary rise in titer in the oldest age group. Environmental and host factors may explain these geographic differences in antibody responses between two groups of African origin.

Comparison of HHV-6 antibody titers in West Africa and the Caribbean

Human herpesvirus-6 (HHV-6) infections seems to be ubiquitous early in life, but antibody responses vary by geographic area. We compared HHV-6 antibody titer in 123 West African and 122 Caribbean serum samples. A quantitative immunofluorescence assay (IFA) using antigens derived from an HSB-2 cell line was used to test for IgG HHV-6 (GS strain) antibodies. The prevalence of HHV-6 antibodies was high (98 percent) in both sites. African samples had a significantly higher geometric mean titer (GMT: 697) than did Caribbean samples (GMT: 99). There was no difference between males (GMT: 260) and females (GMT: 270) overall. Children up to and including 9 years old had significantly higher titers (GMT: 483) than did all others (GMT: 237), and female children tended to have higher titers than did male children. In both areas there was a trend towards highest titer at younger age, followed by a decrease in titer in the oldest age group. Environmental and host factors may explain these geographic differences in antibody responses between two groups of African origin. (AU)

Presence of human T lymphotropic virus types I and II in Ghana, west Africa.

Until recently, HTLV-I was considered to be an Old World virus and HTLV-II was thought to be endemic in the Americas. However, the presence of HTLV-II among Pygmies and other populations of Africa has raised doubts as to whether HTLV-II is primarily a New World virus. The large serosurveys conducted in the urban and rural areas of southern Ghana have identified a 1-2% prevalence for HTLV-I/II. To define the HTLV type, we have used a Western blot assay (HTLV-2.3 blot) that allows simultaneous confirmation and differentiation between HTLVs. Samples (n = 139) were chosen on the basis of previous reactivity with either an enzyme immune assay or r21e-spiked WB results. The WB 2.3 analysis of these specimens identified 55 (40%) to be HTLV positive, 70 (50%) to be HTLV indeterminant, and 14 (10%) to be HTLV negative for HTLV. HTLV seroindeterminant patterns ranged from both gag and env (14 were r21+, p24+, and/or p19+ [all were RIPA negative]) to gag only (21 were p24+/p19+, 16 were p19+, and 7 were p24+), and env only (8 were r21+ and 4 were rgp46+) reactivities. Of the 55 HTLV-positive specimens, 41 were typed as HTLV-I, 9 were HTLV-II, and 5 could not be typed (HTLV-I/II). Of the nine HTLV-II-positive specimens, three were from patients with Burkitt's lymphoma and six were from healthy individuals (two pregnant women) with no obvious risk factors for HTLV-II.(ABSTRACT TRUNCATED AT 250 WORDS)

Hepatitis B viral markers in Ghanaian pregnant women.

Seven hundred pregnant women referred for blood grouping were studied for the presence of some markers of Hepatitis B virus. After collection of personal data including place of permanent residence the sera were tested for the presence of HBs Ag and anti HBs. The sera positive for HBs Ag were tested for the "e" antigen and antibody. The results were analysed according to parity, age and geographical location. Six hundred and ninety-two results were available for analysis showing 464 (67.1%) to have antibodies. 215 (31.1%) had no marker whatsoever. 44 (6.4%) of the women were HBs Ag carriers. Eight of these had the e antigen indicating that 1.16 percent were therefore infective. Calculation was made to determine the extent of vertical transmission using the prevalence of the e antigen. 15% of HBV carrier rate in the population is due to perinatal transmission and this is significant. Parity, age and geographical location did not influence the prevalence of the various markers.

The cost of higher education and its implication for dental education.

In summary, the committee remains convinced that dental education and the dental profession continue to be valuable public resources, greatly respected in the eyes of the public and worthy of the educational investment by students, institutions, federal, and state governments and, ultimately, the public. Among the 54 dental schools, there are 54 different financial situations. It is difficult to generalize about them, but it is not difficult to see, from the information presented, that all are not optimizing their finances and their educational programs. It is the committee's perception that many of the private dental schools and some of the public dental schools are teetering on the verge of extinction. Unless substantial actions are taken, the irretrievable loss of some of these schools is likely to occur. While this committee cannot prescribe actions for all of the schools, it is evident that systematic and sustained effort is needed to prevent these losses. The solution to this complex problem cannot be solely that of dental education. It has to become the concern of all the related constituencies of the profession. Economic factors will continue to increase the cost of education.

The African AIDS case definition and HIV serology in medical in-patients at Komfo Anokye Teaching Hospital, Kumasi, Ghana.

In 914 consecutive medical admissions to Komfo Anokye Teaching Hospital, the prevalence of infection with Human Immunodeficiency Virus type I (HIV-I) and Human Immunodeficiency Virus type 2 (HIV-2) was 12.6%. The prevalence in females was twice that found in males. The infection rate was maximum in the age group 25-29 years for females (45%) and 30-34 years for males (29%). There were 7 cases infected with HIV-2 alone, 55 cases infected with HIV-I alone and 53 cases with dual infection. The cases with HIV-2 infection tended to be older than those with HIV-I infection. For detecting HIV seropositivity in our patients the World Health Organization recommended case definition for AIDS in Africa gave a sensitivity of 32%, a specificity of 93% and a positive predictive value of 42%. The case definition gave the highest specificity and positive predictive values when cases of tuberculosis were not included in the analysis.

PIP: During November 1989-January 1990 in Ghana, medical officers clinically examined and took blood samples from 914 consecutive admissions to Komfo Anokye Teaching Hospital in Kumasi to determine seroprevalence of HIV and different clinical features of HIV infection as well as to assess the value of the World Health Organization (WHO) clinical case definition for AIDS. 12.6% of the admissions were infected with HIV-1 and/or HIV-2. Females were more than two times likely to be infected with HIV than males (17.6% vs. 8.8%). Overall, 25-29 year old women had the highest HIV infection rate (45%). 30-34 year old men had the highest HIV infection rate among males. 56.5% of HIV-infected females and 30.4% of HIV-infected males were infected with both HIV-1 and HIV-2. 7 cases (5 females and 2 males) were infected with just HIV-2. Their ages ranged from 35 to 75 years. When the researchers applied the WHO clinical case definition to all HIV seropositive cases, they found its sensitivity to be 32%, specificity to be 93%, and positive predictive value to be 42%. Sputum-positive tuberculosis (TB) accounted for much of the false positives (28/53). 15% of the 76 sputum positive TB cases were HIV infected. When the researchers excluded all confirmed or suspected TB cases from the analysis, the specificity and positive predictive value increased to a maximum of 97% and 61%, respectively; sensitivity was 28%. Many HIV seropositive cases were not diagnosed with HIV infection either by the case definition or clinically by ward physicians. They probably were asymptomatic. Clinicians should suspect patients diagnosed with pneumonia or meningitis to be HIV infected, as was the case in this study (20% and 17% of HIV seropositive cases who were case definition negative, respectively).

Seasonality of rotavirus infection in Ghana.

Human rotavirus (HRV) infection and its seasonal distribution was studied over a 12-month period in Ghana. A total of 561 stool samples, 447 diarrhoea stools and 114 non-diarrhoea stools (controls), were obtained from children attending three polyclinics in Accra. Rotavirus was detected during 10 of the 12 months and showed a seasonal trend. It was high during the relatively cool dry months and low during the wet season. Peaks of infection were in February (26.2%) and September (24.5%). HRV was detected in 67 of 447 of the diarrhoea stools (15.0%) and in eight of 114 controls (7.0%). The HRV isolation rate was highest (20.2%) in the under-18-months age group. The RNA electropherotype of the HRV isolates was predominantly (83.6%) of the long type. Non-group A HRV was detected in 14.9% of the HRV-positive samples.

HIV seropositive cases presenting as urological patients at the Korle-Bu Teaching Hospital, Accra--a preliminary report.

Thirty-six patients (33 males, 3 females) were screened for HIV antibodies at the Urological clinics, at the Korle Bu Teaching Hospital, Accra because of chronic diarrhoea, unexplained weight loss, multiple sexual partners, recurrent sexually transmitted diseases, non resolution of symptoms or history of possible exposure to HIV. Ten patients (27.8%) were found to be HIV seropositive; 6 were confirmed as HIV-1, one as HIV-2 and 3 as both HIV-1 and HIV-2. The HIV seropositive patients presented as follows: recurrent cystitis and offensive vaginal discharge in 2 females, non-resolution or recurrence of urological symptoms and signs such as warts (genital, meatal and or urethral) in 4 males and recurrent penile ulcers in 4 males. This report indicates that physicians should be alert and screen high risk patients for both HIV-1 and HIV-2 antibodies.

Isolation and characterization of a highly divergent HIV-2[GH-2]: generation of an infectious molecular clone and functional analysis of its rev-responsive element in response to primate retrovirus transactivators (Rev and Rex).

A highly divergent HIV-2 designated as HIV-2[GH-2] was obtained from an AIDS-related complex (ARC) patient in Ghana. A full-length molecular clone of this isolate was obtained and a biologically active clone was constructed. Its restriction pattern differed from that of prototype HIV-2[GH-1] in 25 of 35 restriction sites, but was strikingly similar to a previously characterized HIV-2 isolate from a Ghanaian (HIV-2ALT). The conserved integrase region (288-bp fragment) previously displayed 95% identity with that of ALT but 17-20% divergence from the HIV-2 prototype member, and a new distinct subgroup (HIV-2b) of HIV-2 consisting of GH-2 and ALT was postulated (Miura et al. 1991.) These isolates, however, were biologically distinguishable from each other by its replication capacity in a monocyte line, U937, in which GH-2 could not grow but ALT grew well. In addition, the nucleotide sequence of the LTR of this new isolate displays 21% divergence from that of prototype HIV-2[GH-1], but the core enhancer, Sp1 binding sites and TATA box were conserved. Although the 3' half of the env gene sequence which is deleted in HIV-2ALT clone showed 27% diversity from the prototype, functional differences in the rev-responsive element were not observed.

Field evaluation of alternative HIV testing strategy with a rapid immunobinding assay and an agglutination assay.

A rapid immunobinding assay ('HIVCHEK', Ortho) and an agglutination assay ('Serodia-HIV', Fujirebio) were evaluated as an alternative to enzyme-linked immunosorbent assay (ELISA) and western blot under field conditions in Africa for detection of antibody to human immunodeficiency virus (HIV). 7106 specimens were tested at 25 laboratories in Kenya, Ghana, Senegal, and Zaire. HIVCHEK was used as a screening test, and serodia-HIV as a supplemental test to evaluate these assays in an alternative testing strategy to the standard ELISA/western blot testing procedure. In each country, HIVCHEK was more sensitive and specific than ELISA when compared with western blot. The sensitivity of HIVCHEK ranged from 87.0 to 96.3% and the specificity from 99.0 to 100%. The sensitivity and specificity of serodia-HIV ranged from 85 to 98% and from 88 to 98%, respectively. The sensitivity and specificity were affected by the presence of HIV-2 in Ghana and Senegal. Overall, with an HIV-1 prevalence of 14.8% in Kenya and 22.5% in Zaire, the sensitivities of the alternative strategy were 96.4% and 91.4%, the specificities 99.6% and 100%, the positive predictive values 97.6% and 100%, and the negative predictive values 99.3% and 97.9% for Kenya and Zaire, respectively. With this testing format there was an estimated average cost saving of up to 82% over the conventional strategy with ELISA/western blot. This procedure constitutes a reasonable alternative to the standard ELISA/western blot combination.

A study of the evolution of coxsackievirus A24 variant in Ghana by viral RNA fingerprinting analysis.

An epidemic of acute haemorrhagic conjunctivitis (AHC) caused by coxsackievirus A24 variant (CA24v) was reported in Accra, Ghana in May 1987. We studied 7 of the viral strains collected from May to November, 1987, by RNA genome fingerprinting. Pairwise comparisons of the oligonucleotide maps showed that genetic similarity among them ranged from between 60.0 to 84.7%. Using base sequence variations deduced from genetic similarity among the isolates, isolation time of the strains and the rate of nucleotide substitution (estimated in a previous paper, Miyamura et al., 1990), we calculated divergence times and constructed a phylogenetic tree. This tree indicated that all the 7 strains had diverged from each other from 11 to 26 months before the AHC epidemic in Accra. CA24v may have been introduced into the country or the neighbouring area, at least, more than two years earlier, i.e. in the early half of 1985.

Establishment of a phylogenetic survey system for AIDS-related lentiviruses and demonstration of a new HIV-2 subgroup.

We designed a universal primer (UNIPOL) for DNA amplification of AIDS-related viruses. The phylogenetic tree constructed from the presumed sequences amplified with UNIPOL was representative of the tree calculated from whole pol gene sequences so far reported. UNIPOL was able to amplify the sequences of all four major groups of primate lentiviruses and also that of a distinct virus from a Ghanaian patient with an AIDS-related complex, designated GH-2. This strain scarcely hybridizes with known HIV/simian immunodeficiency virus (SIV) DNA probes. Sequence analysis of the only amplified fragment revealed rapidly that GH-2 was quite similar to the recently reported HIV-2ALT(D205) and that these two viruses form a new subgroup distint from known HIV-2 and SIVmac/SIVsm in the large HIV-2 group. This system will be useful for further phylogenetic study of various primate lentiviruses.

Epidemic acute haemorrhagic conjunctivitis due to Coxsackie virus A24 variant in Ghana.

An outbreak of acute haemorrhagic conjunctivitis (AHC) occurred in Accra, Ghana, reaching a peak in July 1987. Individuals ranging from infants to adults over 50 years were infected, with those between 20 and 30 years being the most affected group. There was a female preponderance. Clinical features included conjunctivitis, subconjunctival haemorrhage and ocular pain. Some patients reported of blurred vision due to mild keratitis. Isolation of virus from clinical specimens of AHC patients was successful only in cells of human origin such as HeLa and FL. Coxsackie virus A24 variant (CA 24v) was identified as the aetiologic agent. This is the first report to associate CA 24v with an epidemic of AHC in Africa, south of the Sahara, which is outside the endemic area of Southeast Asia and the Caribbeans. This finding suggests that earlier outbreaks of AHC in Ghana and Africa may have been due to CA 24v but went undetected. The results of various tests performed during this study suggest that, at least, two antigenically different viruses of CA 24v circulated during the course of this epidemic.

Survey of enteropathogenic agents in children with and without diarrhoea in Ghana.

A survey was carried out over 1 year in a rural area of Ghana on the isolation, detection and/or identification of enteric pathogens from children under 5 years of age with and without diarrhoea. The isolation and detection rate of Shigella flexneri, Shigella dysenteriae, Giardia lamblia and Rotavirus were higher in children with diarrhoea than in controls. Yersinia enterocolitica, Vibrio cholerae and Vibrio parahaemolyticus were not isolated during the period of this survey. The incidence of other enteropathogenic bacteria and parasites identified in the diarrhoeal and non-diarrhoeal children was calculated and is discussed in this study.

Two dose immunization trial with the trivalent oral poliomyelitis vaccine (TOPV) in Ghana

The Virology Unit of Noguchi Memorial Institute for Medical Research in a pilot study has tried by doubling the dose volume; a two dose immunization scheme; which when started at birth; is completed in the sixth week of life