Antoine Jaquet

The Challenge of AIDS-Related Malignancies in Sub-Saharan Africa

Background With the lengthening of life expectancy among HIV-positive subjects related to the use of highly active antiretroviral treatments, an increased risk of cancer has been described in industrialized countries. The question is to determine what occurs now and will happen in the future in the low income countries and particularly in sub-Saharan Africa where more than two-thirds of all HIV-positive people live in the world. The objective of our paper is to review the link between HIV and cancer in sub-Saharan Africa, putting it in perspective with what is already known in Western countries. Methods and Findings Studies for this review were identified from several bibliographical databases including Pubmed, Scopus, Cochrane, Pascal, Web of Science and using keywords “HIV, neoplasia, epidemiology and Africa” and related MesH terms. A clear association was found between HIV infection and AIDS-classifying cancers. In case-referent studies, odds ratios (OR) were ranging from 21.9 (95% Confidence Interval (CI) 12.5–38.6) to 47.1 (31.9–69.8) for Kaposi sarcoma and from 5.0 (2.7–9.5) to 12.6 (2.2–54.4) for non Hodgkin lymphoma. The association was less strong for invasive cervical cancer with ORs ranging from 1.1 (0.7–1.2) to 1.6 (1.1–2.3), whereas ORs for squamous intraepithelial lesions were higher, from 4.4 (2.3–8.4) to 17.0 (2.2–134.1). For non AIDS-classifying cancers, squamous cell conjunctival carcinoma of the eye was associated with HIV in many case-referent studies with ORs from 2.6 (1.4–4.9) to 13.0 (4.5–39.4). A record-linkage study conducted in Uganda showed an association between Hodgkin lymphoma and HIV infection with a standardized incidence ratio of 5.7 (1.2–17) although OR in case-referent studies ranged from 1.4 (0.7–2.8) to 1.6 (1.0–2.7). Other cancer sites found positively associated with HIV include lung, liver, anus, penis, vulva, kidney, thyroid and uterus and a decreased risk of female breast cancer. These results so far based on a relatively small number of studies warrant further epidemiological investigations, taking into account other known risk factors for these tumors. Conclusion Studies conducted in sub-Saharan Africa show that HIV infection is not only strongly associated with AIDS-classifying cancers but also provided some evidence of association for other neoplasia. African countries need now to implement well designed population-based studies in order to better describe the spectrum of AIDS-associated malignancies and the most effective strategies for their prevention, screening and treatment.

The Spectrum of Cancers in West Africa: Associations with Human Immunodeficiency Virus.

Background Cancer is a growing co-morbidity among HIV-infected patients worldwide. With the scale-up of antiretroviral therapy (ART) in developing countries, cancer will contribute more and more to the HIV/AIDS disease burden. Our objective was to estimate the association between HIV infection and selected types of cancers among patients hospitalized for diagnosis or treatment of cancer in West Africa. Methods A case-referent study was conducted in referral hospitals in Côte d’Ivoire and Benin. Each participating clinical ward enrolled all adult patients seeking care for a confirmed diagnosis of cancer and clinicians systematically proposed an HIV test. HIV prevalence was compared between AIDS-defining cancers and a subset of selected non-AIDS defining cancers to a referent group of non-AIDS defining cancers not reported in the literature to be positively or inversely associated with HIV. An unconditional logistic model was used to estimate odds ratios (OR) and their 95% confidence intervals (CI) of the risk of being HIV-infected for selected cancers sites compared to a referent group of other cancers. Results The HIV overall prevalence was 12.3% (CI 10.3–14.4) among the 1,017 cancer cases included. A total of 442 patients constituted the referent group with an HIV prevalence of 4.7% (CI 2.8–6.7). In multivariate analysis, Kaposi sarcoma (OR 62.2 [CI 22.1–175.5]), non-Hodgkin lymphoma (4.0 [CI 2.0–8.0]), cervical cancer (OR 7.9 [CI 3.8–16.7]), anogenital cancer (OR 11.6 [CI 2.9–46.3]) and liver cancer (OR 2.7 [CI 1.1–7.7]) were all associated with HIV infection. Conclusions In a time of expanding access to ART, AIDS-defining cancers remain highly associated with HIV infection. This is to our knowledge, the first study reporting a significant association between HIV infection and liver cancer in sub-Saharan Africa.

Antiretroviral treatment and quality of life in Africans living with HIV: 12-month follow-up in Burkina Faso.

The scale‐up of highly active antiretroviral therapy (HAART) has led to a significant improvement in survival of the HIV‐positive patient but its effects on health‐related quality of life (HRQOL) are less known and context‐dependent. Our aim was to assess the temporal changes and factors associated with HRQOL among HIV‐positive adults initiating HAART in Burkina Faso.

Short-term risk of anaemia following initiation of combination antiretroviral treatment in HIV-infected patients in countries in sub-Saharan Africa, Asia-Pacific, and central and South America

BackgroundThe objective was to examine the short-term risk and predictors of anaemia following initiation of combination antiretroviral therapy (cART) in HIV-infected patients from the Western Africa, Eastern Africa, Southern Africa, Central Africa, Asian-Pacific, and Caribbean and Central and South America regions of the International Epidemiologic Databases to Evaluate AIDS (IeDEA) collaboration.MethodsAnaemia was defined as haemoglobin of < 10 g/dL. Patients were included if they started cART with three or more drugs, had prior haemoglobin of > = 10 g/dL, and had one or more follow-up haemoglobin tests. Factors associated with anaemia up to 12 months were examined using Cox proportional hazards models and stratified by IeDEA region.ResultsBetween 1998 and 2008, 19,947 patients initiated cART with baseline and follow-up haemoglobin tests (7358, 7289, 2853, 471, 1550 and 426 in the Western Africa, Eastern Africa, Southern Africa, Central Africa, Asian-Pacific, and Caribbean and Central and South America regions, respectively). At initiation, anaemia was found in 45% of Western Africa patients, 29% of Eastern Africa patients, 21% of Southern Africa patients, 36% of Central Africa patients, 15% of patients in Asian-Pacific and 14% of patients in Caribbean and Central and South America. Among patients with haemoglobin of > = 10 g/dL at baseline (13,445), the risks of anaemia were 18.2, 6.6, 9.7, 22.9, 11.8 and 19.5 per 100 person-years in the Western Africa, Eastern Africa, Southern Africa, Central Africa, Asian, and Caribbean and Central and South America regions, respectively. Factors associated with anaemia were female sex, low baseline haemoglobin level, low baseline CD4 count, more advanced disease stage, and initial cART containing zidovudine.ConclusionsIn data from 34 cohorts of HIV-infected patients from sub-Saharan Africa, Central and South America, and Asia, the risk of anaemia within 12 months of initiating cART was moderate. Routine haemoglobin monitoring was recommended in patients at risk of developing anaemia following cART initiation.

Cervical cancer prevention in reproductive health services: knowledge, attitudes and practices of midwives in Côte d’Ivoire, West Africa

BackgroundCervical cancer is the most common cancer among women and the leading cause of cancer deaths in women in Côte d’Ivoire. Low resource countries can now prevent this cancer by using HPV vaccine and effective and affordable screening tests. However the implementation of these prevention strategies needs well-trained human resources. Part of the solution could come from midwives by integrating cervical cancer prevention into reproductive health services. The aim of this survey was to assess knowledge, attitudes and practices of midwives towards cervical cancer prevention in Abidjan, Côte d’Ivoire, and to find out factors associated with appropriate knowledge.MethodsA cross-sectional survey was conducted among midwives in the urban district of Abidjan, using a self-administered questionnaire. Knowledge was assessed by two scores. Factors associated with appropriate knowledge were determined using a logistic regression analysis. Attitudes and practices were described and compare using the Chi2 test.ResultsA total of 592 midwives were enrolled, including 24.5% of final-year students. 55.7% of midwives had appropriate knowledge on cervical cancer, and 42.4% of them had appropriate knowledge on cervical cancer prevention strategies. Conferences, courses taken at school of midwifery and special training sessions on cervical cancer (OR = 4.9, 95% CI [1.9 to 12.6], p <0.01) were associated with good knowledge on the management of this disease. Among these midwives, 18.4% had already benefited from a screening test for themselves, 37.7% had already advised screening to patients and 8.4% were able to perform a visual inspection. 50.3% of midwives knew HPV vaccine as a preventive method; among them 70.8% usually recommended it to young girls.ConclusionDespite sufficient knowledge about cervical cancer prevention, attitudes and practices of midwives should be improved by organizing capacity building activities. This would ensure the success of integration of cervical cancer prevention into reproductive health services in countries like Côte d’Ivoire.

An Insight into Cervical Cancer Screening and Treatment Capacity in Sub Saharan Africa

Objective Approximately 85% of cervical cancer cases and deaths occur in resource-constrained countries where best practices for prevention, particularly for women with HIV infection, still need to be developed. The aim of this study was to assess cervical cancer prevention capacity in select HIV clinics located in resource-constrained countries. Materials and Methods A cross-sectional survey of sub-Saharan African sites of 4 National Institutes of Health–funded HIV/AIDS networks was conducted. Sites were surveyed on the availability of cervical cancer screening and treatment among women with HIV infection and without HIV infection. Descriptive statistics and &khgr;2 or Fisher exact test were used as appropriate. Results Fifty-one (65%) of 78 sites responded. Access to cervical cancer screening was reported by 49 sites (96%). Of these sites, 39 (80%) performed screening on-site. Central African sites were less likely to have screening on-site (p = .02) versus other areas. Visual inspection with acetic acid and Pap testing were the most commonly available on-site screening methods at 31 (79%) and 26 (67%) sites, respectively. High-risk HPV testing was available at 29% of sites with visual inspection with acetic acid and 50% of sites with Pap testing. Cryotherapy and radical hysterectomy were the most commonly available on-site treatment methods for premalignant and malignant lesions at 29 (74%) and 18 (46%) sites, respectively. Conclusions Despite limited resources, most sites surveyed had the capacity to perform cervical cancer screening and treatment. The existing infrastructure of HIV clinical and research sites may provide the ideal framework for scale-up of cervical cancer prevention in resource-constrained countries with a high burden of cervical dysplasia.

Hepatitis B treatment eligibility in West Africa: Uncertainties and need for prospective cohort studies

While universal screening of hepatitis B virus (HBV) is recommended in high burden countries, little is known about the proportion of HBV‐infected persons in need of antiviral therapy in these settings.

Alcohol use, viral hepatitis and liver fibrosis among HIV-positive persons in West Africa: a cross-sectional study

Introduction: Liver fibrosis is often the first stage of liver disease in people living with HIV (PLWHIV) in industrialized countries. However, little is known about liver fibrosis and its correlates among PLWHIV in sub‐Saharan Africa.

Prevention and Care of Hepatitis B in Senegal; Awareness and Attitudes of Medical Practitioners.

In highly endemic settings for hepatitis B virus (HBV) infection such as Senegal, access to HBV prevention and care is rapidly evolving. In this context, all medical practitioners should have baseline knowledge on HBV infection and promote access to vaccination, screening, and care. A knowledge and attitudes survey on HBV infection was conducted among a randomly selected sample of medical practitioners in Senegal. Participants were asked to fill-out a questionnaire on the HBV epidemiology, prevention, and treatment. A 60-item knowledge score was computed; the lower quartile of the observed score was used to define poor knowledge. Factors associated with poor knowledge were assessed using a logistic regression model. A total of 127 medical practitioners completed the questionnaire. Only 14 (11.0%) participants knew that HBV vaccine could be safely administered to pregnant women and 65 (51.2%) to newborns. Older practitioners (> 40 years) as well as general practitioners (compared with specialists) were more likely to have a poor knowledge score with odds ratios (ORs) of 3.1 (95% confidence interval [CI] 1.0-9.2) and 2.6 (95% CI 1.0-7.3), respectively. Practitioners who declared not to recommend HBV screening frequently during their consultation were more likely to present a poor knowledge score [OR: 3.0; (95% CI 1.1-8.2)]. As universal HBV screening is being promoted in countries with endemic HBV infection, our finding that poor screening attitudes were associated with a poor knowledge is of concern. There is a need to raise awareness of medical practitioners in Senegal toward universal HBV screening and early vaccination of newborns.

Determinants of Weight Evolution Among HIV-Positive Patients Initiating Antiretroviral Treatment in Low-Resource Settings.

Background:In resource-limited settings, clinical parameters, including body weight changes, are used to monitor clinical response. Therefore, we studied body weight changes in patients on antiretroviral treatment (ART) in different regions of the world. Methods:Data were extracted from the “International Epidemiologic Databases to Evaluate AIDS,” a network of ART programmes that prospectively collects routine clinical data. Adults on ART from the Southern, East, West, and Central African and the Asia-Pacific regions were selected from the database if baseline data on body weight, gender, ART regimen, and CD4 count were available. Body weight change over the first 2 years and the probability of body weight loss in the second year were modeled using linear mixed models and logistic regression, respectively. Results:Data from 205,571 patients were analyzed. Mean adjusted body weight change in the first 12 months was higher in patients started on tenofovir and/or efavirenz; in patients from Central, West, and East Africa, in men, and in patients with a poorer clinical status. In the second year of ART, it was greater in patients initiated on tenofovir and/or nevirapine, and for patients not on stavudine, in women, in Southern Africa and in patients with a better clinical status at initiation. Stavudine in the initial regimen was associated with a lower mean adjusted body weight change and with weight loss in the second treatment year. Conclusions:Different ART regimens have different effects on body weight change. Body weight loss after 1 year of treatment in patients on stavudine might be associated with lipoatrophy.