Recurrent epidemic cholera with high mortality in Cameroon: persistent challenges 40 years into the seventh pandemic.

Cameroon has experienced recurrent cholera epidemics with high mortality rates. In September 2009, epidemic cholera was detected in the Far North region of Cameroon and the reported case-fatality rate was 12%. We conducted village-, healthcare facility- and community-level surveys to investigate reasons for excess cholera mortality. Results of this investigation suggest that cholera patients who died were less likely to seek care, receive rehydration therapy and antibiotics at a healthcare facility, and tended to live further from healthcare facilities. Furthermore, use of oral rehydration salts at home was very low in both decedents and survivors. Despite the many challenges inherent to delivering care in Cameroon, practical measures could be taken to reduce cholera mortality in this region, including the timely provision of treatment supplies, training of healthcare workers, establishment of rehydration centres, and promotion of household water treatment and enhanced handwashing with soap.

[Professor Jacques Fouad Acar, Africa and the "potluck"]. / Professeur Jacques Fouad Acar, l'Afrique et l'« auberge espagnole ¼.

The biography of Professor Jacques Fouad Acar (1931-2020) shows the exceptional trajectory of an atypical doctor, infectiologist-clinician and microbiologist, propelled by the international dynamics of integration and social progress originating in the Lebanese diaspora with his first founding experiences in Dakar, Senegal, in French West Africa, during the golden age of French colonial medicine. Jacques Acar's imprint will comprise three remarkable dimensions: on the one hand, the promotion of integrated multidisciplinary clinical-biological reasoning in infectious pathology; on the other hand, independence of thought in the field of action, which will become his leitmotiv during his university hospital career, allowing him to integrate "pastoral esprit de corps" into his fundamental research at the Pasteur Institute in Paris on the molecular mechanisms of antibiotic resistance and to participate in the explosion of world medicine; lastly, his unique emotional intelligence potentiated by his instinctive sense of networking, with students of all origins and disciplines.

Gynaecological morbidity among HIV positive pregnant women in Cameroon.

OBJECTIVE: To compare the prevalence of gynaecological conditions among HIV infected and non-infected pregnant women. METHODS: Two thousand and eight (2008) pregnant women were screened for HIV, lower genital tract infections and lower genital tract neoplasia at booking antenatal visit. RESULTS: About 10% (198/2008) were HIV positive. All lower genital tract infections except candidiasis were more prevalent among HIV positive compared to HIV negative women: vaginal candidiasis (36.9% vs 35.4%; p = 0.678), Trichomoniasis (21.2% vs 10.6%; p < 0.001), gonorrhoea (10.1% vs 2.5%; p < 0.001), bacterial vaginosis (21.2% vs 15.2%; p = 0.026), syphilis (35.9% vs 10.6%; p < 0.001), and Chlamydia trachomatis (38.4% vs 7.1%; p < 0.001). Similarly, HIV positive women more likely to have preinvasive cervical lesions: low-grade squamous intraepithelial lesion (SIL) (18.2% vs 4.4%; p < 0.001) and high-grade squamous intraepithelial lesion (12.1% vs 1.5%; p < 0.001). CONCLUSION: We conclude that (i) sexually transmitted infections (STIs) are common in both HIV positive and HIV negative pregnant women in Cameroon, and (ii) STIs and preinvasive cervical lesions are more prevalent in HIV-infected pregnant women compared to their non-infected compatriots. We recommend routine screening and treatment of STIs during antenatal care in Cameroon and other countries with similar social profiles.

Interactions between human immunodeficiency virus and herpes viruses within the oral mucosa.

There is evidence from clinical case reports and epidemiological studies that human immunodeficiency virus (HIV) can be transmitted through oral sex. Herpes viruses that appear in the oral mucosa might influence the oral replication of HIV. A review of data suggesting that interactions occur between HIV and herpes viruses indicates that such interactions might operate in the oral mucosa. Defining the mechanisms by which herpes viruses interact with HIV in the oral mucosa should permit intervention measures to be targeted more precisely.

Serological and virological characterization of HIV-1 group O infection in Cameroon.

OBJECTIVES: To study the presence of HIV-1 group O infection among HIV-infected people in Cameroon and to further characterize the HIV-1 group O infections. DESIGN AND METHODS: During a 2-year survey (1994-1995), all samples tested positive in screening methods in the National Reference and Public Health Laboratory, Centre Pasteur, Yaoundé, Cameroon were identified as HIV-1 group M, HIV-1 group O or HIV-2 by using a serological algorithm. HIV-1 group M and HIV-1 group O were distinguished on the basis of competitive enzyme-linked immunosorbent assay (ELISA) reactivity against gp41 group M recombinant protein. HIV-1 group O infections were confirmed by using group O-specific V3 synthetic peptides. HIV-1 group O strains were isolated by lymphocyte cocultures, proviral DNA was amplified with specific primers, and sequencing was performed on the C2V3 and gag regions. RESULTS: Of the 8,331 screened samples, 3,193 were HIV-reactive, 2,376 (74%) of which were considered to belong to group M. The 817 (26%) that had reacted poorly or not at all against group M gp41 were further characterized: 10 were confirmed as HIV-2 and 82 as HIV-1 group O, the others being indeterminate (n = 285) or negative (n = 440). The frequency of group O relative to group M ranged from 1% in Far North province to 6.3% in the capital. There was no difference in sex, age or frequency of clinical manifestations between group M and group O infections. Group O infection was confirmed in a subset of cases by polymerase chain reaction (n = 14), with perfect concordance. Sequencing and phylogenetic analyses confirmed the high variability inside group O. CONCLUSIONS: Group O and group M epidemiological patterns are known to be similar so the reason for the lower prevalence of group O remains to be found. The wide distribution of group O infection in all Cameroonian provinces underlines the importance of further characterizing the epidemic spread and diffusion of this group.

Herpes simplex virus type 2 and heterosexual spread of human immunodeficiency virus infection in developing countries: hypotheses and research priorities.

Herpes simplex virus type 2 (HSV-2) infection is almost always sexually transmitted, and causes genital ulceration. Significant progress in our understanding of HSV infection has occurred over the last decade, in part related to the development of accurate and sensitive laboratory tests to study HSV-2. The application of PCR and type-specific serology to individual cases and in population-based studies has enabled the identification of a potentially important role for HSV-2 infection as a cofactor in the sexual transmission of HIV. This is a particular issue in developing countries. This review describes the epidemiology of HSV-2 infection in the HIV era, the hypotheses regarding HSV-HIV interactions, and research priorities for the developing world.

Antenatal HIV prevalence in Yaounde, Cameroon.

From June 1994 to July 1996, 4100 pregnant women living in Yaounde, Cameroon, were tested for human immunodeficiency virus type 1 (HIV-1) and syphilis. The HIV seroprevalence was 4.2% (95% confidence interval (CI): 3.6%-4.8%), and that of antibodies to Treponema pallidum was 17.4% (95% CI: 16.3%-18.6%) (HIV infection was twice as common in women with positive syphilis serology) (7.2% vs 3.6%). Over the study period, the antenatal seroprevalence of syphilis remained stable, while there was an increase in the HIV seroprevalence rate. There was an increase in HIV seropositivity in women uninfected with syphilis between 1994/1995 and 1995/1996 from 2.9% to 4.3%. By the end of the study, HIV infection was no commoner in women with negative compared with positive syphilis serology. It is therefore postulated that HIV infection in Yaounde has entered the general, sexually active female population. We suggest that management of pregnant women in Cameroon should include routine screening for both HIV infection and other sexually transmitted diseases (STDs).

[Estimated biological markers of progression in human immunodeficiency virus infection]. / Marqueurs biologiques prévisionnels d'évolution au cours de l'infection par le virus de l'immunodéficience humaine.

The biological markers for determining as early as possible the progression in the infection by the human immunodeficiency virus (HIV) are very important for the health care of patients, and to adapt their anti-retroviral treatment. Among those, four independent biological markers for predicting a pejorative evolution in the following 36 months are used in medical practice: two specific for HIV, p24 antigenemia and serum titre of antibodies to the p24 core antigen, and two non-HIV specific surrogate markers, the beta 2-microglobulinemia and the absolute number of CD4 T cell in blood. P24 antigenemia corresponds to an active retroviral in vivo replication. The cut off for detection is about 10 pg/ml. It is difficult to detect in black people, and in the asymptomatic or pauci-symptomatic stages of the disease. The apparition or the increase of the serum p24 antigen levels suggest the occurrence of opportunistic infections. P24 antigenemia decreases or disappears during the treatment by zidovudine. The diminution or the disappearance of serum antibodies directed to the p24 core protein are secondary to the deficiency of the humoral immunity, and to an increase of the viral replication, which occur at the late stage of the disease. The diminution or the disappearance of serum antibodies to p24 precede the occurrence of AIDS by several months. The increase of the serum beta 2-microglobulin level is associated with the severity of the disease. In the San Francisco prospective cohort, the progression to AIDS in 36 months was 69% when beta 2-microglobulinemia was more than 5 mg/l, 33% when it was between 3.1 to 5 mg/l, and 12% when it was less than 3 mg/l. The beta 2-microglobulin intra-thecal synthesis level could serve as a marker for the specific HIV encephalitis. The CD4 lymphocyte count constitutes an independent provisional marker for progression to AIDS, probably the most important, but mainly of statistical value. A lymphocyte count of 200 CD4/mm3 is considered as the threshold of full blown AIDS. Beside these classic biological markers, numerous other parameters have been evaluated, without knowing their practical interest. Although the predictive markers for AIDS have a real statistical significance, their interpretation could be difficult or hazardous when applied to a sole individual. In a relatively short delay, the actual biological markers will probably be completed or changed, in the routine medical practice, by the use of direct virological markers evaluating the viral load (plasmatic or cellular viremia).

Interactions between herpes simplex virus type 2 and human immunodeficiency virus type 1 infection in African women: opportunities for intervention.

Sexually transmitted diseases (STDs) are cofactors for human immunodeficiency virus (HIV) transmission, but the specific role of herpes simplex virus type 2 (HSV-2) is unclear. This study aimed to examine the in vivo relationships between HSV-2 and HIV-1 in 300 women in Bangui, Central African Republic. Sera were tested for syphilis, HIV-1, HSV-2 antibody, and levels of vitamins A and E. Genital specimens were tested for other STDs. HSV-2 DNA and HIV-1 RNA were quantified in cervicovaginal lavage. The prevalences of HSV-2 antibody (91% vs. 78%, P=.02), HSV-2 shedding (43% vs. 22%, P=. 003), and levels of HSV-2 DNA (P=.01) were all significantly higher among HIV-1-seropositive than among HIV-1-seronegative women. There was a significant correlation between genital HIV-1 RNA and HSV-2 DNA levels (P=.02) among the 23 women who were shedding HSV-2 DNA. If confirmed, such associations highlight the urgent need for HSV-2 control measures in populations at high risk of both infections.

Selection of maternal human immunodeficiency virus type 1 variants in human placenta. European Network for In Utero Transmission of HIV-1.

To determine the mechanisms by which human immunodeficiency virus type 1 (HIV-1) crosses the placenta into the fetal blood, 12 matched samples of serial maternal blood, term placentas, and infant blood obtained from a cohort of pregnant women in Cameroon identified as predominantly infected by subtype A viruses were studied. HIV-1 env sequences were detected by polymerase chain reaction (PCR) in both chorionic villi and enriched trophoblastic cells of all 12 placentas but at variable rates of detection. Heteroduplex mobility assay analysis showed the presence of multiple HIV-1 env quasispecies in sequential maternal peripheral blood mononuclear cell samples, but only a small number of env variants were found in chorionic villi and enriched trophoblastic cells. These data indicate that HIV-1 env sequences are always present in term placentas of seropositive women, contrasting with the low frequency at which infection is diagnosed by PCR in neonates with tat, gag, and env primers. Maternal HIV-1 variants appear to undergo a strong negative selection by different cell populations within the placental villi.

Free and decomplexed human immunodeficiency virus p24 antigenaemia in black patients with AIDS and AIDS-related disorders.

OBJECTIVES: To determine the clinical signification of free and decomplexed p24 antigenaemia in HIV1-infected black individuals. PATIENTS AND METHODS: Sixty African patients with pre-AIDS (n = 12) and AIDS (n = 48), hospitalized in the Centre National Hospitalier Universitaire de Bangui, Central African Republic, were prospectively included. 15 HIV1-seronegative healthy African subjects served as controls. Serum p24 antigenaemia was detected using a polyclonal and a monoclonal sandwich enzyme immunoassay (EIA). All sera were tested again after acid pretreatment (45 mn incubation of serum with a 0.5 N solution of HCl at +37 degrees C). RESULTS: The polyclonal EIA and the monoclonal EIA detected respectively four (7%) to six (10%) free p24 antigen positive samples from the HIV1-infected individuals, with a similar frequency in pre-AIDS and AIDS patients. None of the controls were found p24 antigen positive. After acid pretreatment, the rate of detectable p24 antigenaemia increased significantly, leading with the monoclonal EIA to a 47% positivity rate (p < 0.001), and the patients with AIDS became more frequently p24 antigen positive (54%), than the patients with pre-AIDS (17%) (p = 0.02). CONCLUSION: Detectable p24 antigenaemia in HIV1-infected African subjects could be obtained in nearly half of cases by increasing the sensitivity of the assay using monoclonal EIA and acid hydrolysis of circulating immune complexes. Decomplexed p24 antigenaemia in HIV1-infected Black African patients could have predictive signification similar to free p24 antigenaemia in Caucasians.

Spontaneous peritonitis in cirrhotic hospital in-patients: retrospective analysis of 101 cases.

One hundred and one patients with cirrhosis resulting from alcohol abuse, admitted to Broussais University Hospital, Paris, between January, 1986 and December, 1989 were assessed for infection of the ascitic fluid using clinical and cytobacteriological criteria. All of 46 patients (45.5%) with clinical signs and symptoms of peritonitis had an ascitic fluid polymorphonuclear (PMN) count > 250 cells/mm3. Bacteria could be isolated from the ascitic fluid of 23 patients (50%). Twenty-six bacterial strains were isolated (there was more than one strain in two samples). Escherichia coli was found in 14 cases. It is noteworthy that no anaerobes were grown. Mortality, biochemical parameters and clinical features correlated significantly with an ascitic fluid PMN count > 250 cells/mm3. High mortality correlated with a PMN count > 1000 cells/mm3 (70% vs. 33%).

[Serological confirmation of HIV infections in hospital practice: analysis of indeterminate western blot results]. / Sérologie de confirmation de l'infection par le VIH en pratique hospitalière: analyse des western blots indéterminés.

Among 770 Western blots for HIV-1 confirmation on sera from subjects at high risk for HIV infection, 4.3% (33 cases) were indeterminate. Isolated, stable, reproducible anti-gp 160 reactivity, highly suggestive of a nonspecific reaction, was found in 16% of cases. There were three other probably nonspecific patterns with anti-gp 160 and either anti-gp 41 or anti-gp 120 reactivities and thin, atypical bands. Two patterns with anti-p24 and either anti-gp 160 or anti-gp 120 reactivities were consistent with HIV-1 seroconversion. Reactivity directed solely against gag products was seen in 18% of cases. The repeat test, performed in 16 cases, showed an identical pattern in 3 cases, a modified pattern in 3 cases, negative results in 9 cases, and seroconversion in 1 case. No case of HIV-2 infection was detected. Indeterminate Western blot results reflect nonspecific reactivity in most instances but should nevertheless lead to the exclusion of technical artefacts, seroconversion, and HIV-2 infection.

Insights into the mechanisms of vertical transmission of HIV-1. BIOMED2 Working Group on the in utero transmission of HIV-1.

This paper is a summary of three oral presentations, as well as the ensuing discussion, at the Rijeka/Opatija 3rd Alps Adria Immunology meeting by three members of the European Biomed group on vertical transmission of HIV (G. Chaouat, F. Barre-Sinoussi, G. Scarlatti). This group also involves the laboratories of D. Dormont (CEA, Fontenay aux roses, France), P. Gounon (Electron Microscopy, the Pasteur Institute, France; Irène Athanassakis, University of Crete, Greece; Eva Maria Fenyö, Karolinska Institute, Sweden; and Larry Guilbert, Canada). As such, this paper intends to be neither a review, nor an original article, but rather is an opinion paper discussing the working hypothesis of this network, as well as some of their recent results, which were presented at this meeting. The paper was issued at the request of the organizers of the meeting.