Khady Diouf

Female Genital Cutting and HIV Transmission: Is There an Association?

Female Genital Cutting (FGC) refers to the practice of surgically removing all or part of the female external genitalia for non‐medical purposes. It is a common practice in many countries in Africa, the Middle East, and to a lesser extent, Asia. Over 130 million women worldwide have undergone this procedure, and over 2 million women and girls are subject to it every year. Various complications have been described, including infection, hemorrhage, genitourinary and obstetric complications, as well as psychological sequelae. Since the beginning of the HIV epidemic, a few reports have also described a potentially elevated risk of HIV transmission among women with FGC. In this report, we aim to review the evidence and identify unanswered questions and research gaps regarding a potential association between FGC and HIV transmission.

Mycoplasma genitalium: An Overlooked Sexually Transmitted Pathogen in Women?

Mycoplasma genitalium is a facultative anaerobic organism and a recognized cause of nongonococcal urethritis in men. In women, M. genitalium has been associated with cervicitis, endometritis, pelvic inflammatory disease (PID), infertility, susceptibility to human immunodeficiency virus (HIV), and adverse birth outcomes, indicating a consistent relationship with female genital tract pathology. The global prevalence of M. genitalium among symptomatic and asymptomatic sexually active women ranges between 1 and 6.4%. M. genitalium may play a role in pathogenesis as an independent sexually transmitted pathogen or by facilitating coinfection with another pathogen. The long-term reproductive consequences of M. genitalium infection in asymptomatic individuals need to be investigated further. Though screening for this pathogen is not currently recommended, it should be considered in high-risk populations. Recent guidelines from the Centers for Disease Control regarding first-line treatment for PID do not cover M. genitalium but recommend considering treatment in patients without improvement on standard PID regimens. Prospective studies on the prevalence, pathophysiology, and long-term reproductive consequences of M. genitalium infection in the general population are needed to determine if screening protocols are necessary. New treatment regimens need to be investigated due to increasing drug resistance.

Reproductive biology of the milk shark Rhizoprionodon acutus (Carcharhinidae) off the coast of Senegal

Despite the considerable commercial value of the milk shark Rhizoprionodon acutus (Rüppell 1837) along the Senegal coast, there are few data on its biology. Milk sharks examined in this study were caught by small-scale fisheries on the Senegalese coast from May 2009 to February 2011 at eight landing locations. Landings were higher during the warm season (May–October) (71.5%), and lower during the cold season (November–April) (28.5%). The largest landings were recorded in the central area (36.9%) and the smallest in the coastal area of the Casamance (South-West Senegal) (0.6%). The observed size of individuals ranged from 31 to 113 cm (total length, TL), and the total weight from 150 to 8 500 g. Landings mostly included small individuals with a modal size of 50 cm TL for males and 60 cm TL for females. A reduction in the size range of milk sharks in the study area was consistent with those studied elsewhere. Females were more abundant than males (sex ratio 1.65F:1M). Mature individuals were dominant at the northern landing sites whereas immature individuals were more abundant in the southern regions. Our observations suggest a possible seasonal migration towards the north for reproductive purposes. The size at first sexual maturity was 92 cm TL for females and 82 cm TL for males. The gonadosomatic index, nidosomatic index and hepatosomatic index peaked from May to August, indicating that the reproductive period is during the warm season. Milk sharks off the coast of Senegal appear to have an annual reproductive cycle. Ovarian fecundity varied from 2 to 8 follicles and uterine fecundity from 2 to 7 embryos. Parturition occurred between May and June. Moreover, the presence of mature spermatozoa in the oviducal glands during the warm season supports the notion that mating takes place during that period.

Changes in population structure of the white grouper Epinephelus aeneus as a result of long-term overexploitation in Senegalese waters

In Senegal, a significant decrease in catches indicates that many demersal fish stocks are being overexploited. The white grouper Epinephelus aeneus, locally known as the ‘thiof’, is exploited by both small-scale and industrial fisheries. A 28-year database of E. aeneus catches along the Senegalese coast provided by the Centre for Oceanographic Research of Dakar-Thiaroye, and size at maturity measured in Dakar (Senegal) from monthly samples in 2010, were used to analyse changes in population structure in the area over the past 37 years. Catches from the northern fishing areas were lower than those from the southern fishing areas, and decreased steadily during the period (Kolmogorov–Smirnov test, D = 0.243, p = 0.0002). The individual mean weight of catches decreased from 1974 to 2010 (linear regression, r 2 = 0.40, n = 37) and only 60% of the individuals were mature. The calculated sizes at maturity were 49 cm total length (TL) for females and 55 cm for males, and the optimal length of capture for a sustainable fishery was 96 cm, but only 0.03% of E. aeneus caught reached this length. Most of the catch consisted of juveniles; the larger reproductive individuals had disappeared. The number of individuals caught decreased significantly between 1974 and 2010 (1974–1983, r 2 = 0.98, n = 74 674; 1984–1993, r 2 = 0.95, n = 96 696; 1994–2003, r 2 = 0.93, n = 12 619; 2004–2010, r 2 = 0.91, n = 12 887), whereas the length range remained the same (10–110 cm TL). Biological indicators clearly showed that E. aeneus stocks in Senegal are overexploited and the species is now endangered. Immediate active management of fishing pressure is needed, therefore, to maintain E. aeneus populations in the area. Our results suggest a minimum size of <50 cm should be introduced and that fishing effort should be reduced.

Investigating Potential Associations between Cervical Procedures and HIV Acquisition

Objective. Cervical human papillomavirus (HPV) infection has been associated with human immunodeficiency virus (HIV) acquisition in populations with a high prevalence of both infections. Procedures performed in the management of cervical dysplasia may facilitate HIV entry via mechanical injury. We sought to investigate the association between cervical procedures and incident HIV. Methods. Data on cervical cancer screening and procedures were collected in a cohort study evaluating the diaphragm for HIV prevention in 2040 women. In this secondary analysis, we investigated the association between cervical procedures and HIV acquisition. Results. Out of 2027 HIV-negative women at baseline, 199 underwent cervical procedures. Cumulative risk of HIV was 4.3% over 21 months of median followup (n = 88). Compared with women without cervical procedures, we observed no difference in HIV incidence after a cervical biopsy (RR 0.92, 95% CI 0.39–2.16), endocervical curettage (RR 0.29, 95% CI 0.07–1.22), or loop electrosurgical excision procedure (RR 1.00, 95% CI 0.30–3.30). Conclusions. In this cohort, cervical procedures were not associated with HIV incidence. This lack of association could be due to the small number of events.

Mosquito-borne Diseases as a Global Health Problem: Implications for Pregnancy and Travel

Importance Mosquitoes are the most common disease vectors worldwide. A combination of factors, including changes in public health policy, climate change, and global travel, has led to the resurgence and spread of these diseases in our modern world. Pregnant women are vulnerable to a number of these illnesses, and obstetricians are likely to encounter pregnant travelers who have been exposed. Objective This review was conducted to summarize knowledge of mosquito-borne diseases and their relevance in pregnancy. This will allow obstetricians to provide proper advice regarding travel and prepare providers to recognize manifestations of these illnesses in the pregnant woman. Evidence Acquisition A review of the current literature was performed to summarize the various manifestations of mosquito-borne illnesses in pregnant women and discuss obstetric outcomes and management of disease in pregnancy. Results Mosquito-borne illnesses usually manifest after a period of incubation lasting from days to weeks. Symptoms usually include a febrile illness but may be nonspecific and may masquerade as pregnancy-specific illnesses such as preeclampsia or HELLP (hemolysis, elevated liver enzyme levels, and low platelet levels); a large number of patients remain asymptomatic. Pregnancy-related outcomes include spontaneous abortion, intrauterine fetal demise, intrauterine transmission to the fetus, and congenital anomalies. Management during pregnancy is mainly supportive. Precautions against disease include protective clothing and insect repellents. Vaccines are either available or in development. Conclusions and Relevance Mosquito-borne disease should be considered in pregnant women who present with a febrile illness and a relevant exposure history. Prompt recognition can allow supportive treatment to the mother and fetal resuscitation and surveillance.

Slow growth of the overexploited milk shark Rhizoprionodon acutus affects its sustainability in West Africa.

Age and growth of Rhizoprionodon acutus were estimated from vertebrae age bands. From December 2009 to November 2010, 423 R. acutus between 37 and 112 cm total length (LT ) were sampled along the Senegalese coast. Marginal increment ratio was used to check annual band deposition. Three growth models were adjusted to the length at age and compared using Akaikes information criterion. The Gompertz growth model with estimated size at birth appeared to be the best and resulted in growth parameters of L∞ = 139.55 (LT ) and K = 0.17 year(-1) for females and L∞ = 126.52 (LT ) and K = 0.18 year(-1) for males. The largest female and male examined were 8 and 9 years old, but the majority was between 1 and 3 years old. Ages at maturity estimated were 5.8 and 4.8 years for females and males, respectively. These results suggest that R. acutus is a slow-growing species, which render the species particularly vulnerable to heavy fishery exploitation. The growth parameters estimated in this study are crucial for stock assessments and for demographic analyses to evaluate the sustainability of commercial harvests.

Sexually transmitted infection screening and follow-up in a high-risk urban obstetric clinic

RESULTS: Of 1,785 participants, 58 (3.3%) pregnancies resulted in stillbirth and 198 (11.4%) had a poor birth outcome. In multivariable analysis controlling for age, distance from hospital, referral status, receipt of malaria prophylaxis, report of prior syphilis infection, and parity; attending 4 ANC visits was associated with significantly reduced odds of stillbirth (aOR 0.5, 95% CI 0.3-0.9, P1⁄40.02). Receipt of malaria prophylaxis at ANC was also independently associated with reduced odds of stillbirth (aOR 0.05, 95% CI 0.2-1.0, P1⁄40.04), but report of prior syphilis infection was not associated with stillbirth (aOR 1.0, 95% CI 0.2-1.5, P1⁄40.98). In a multivariable sensitivity analysis of risk factors associated with the composite poor birth outcome, attending 4 ANC visits remained associated with significantly reduced odds of poor birth outcomes when accounting for multiple potential confounders (aOR 0.66, 95% CI 0.4-0.96, P1⁄40.03). CONCLUSIONS: For this cohort of women in rural Uganda, attending 4 ANC visits was associated with reduced odds of stillbirth and poor birth outcomes, which may be related to receipt of antenatal infection screening, treatment, and prevention services.

5. Sexually Transmitted Infections

Objective: To evaluate the human herpesvirus 8 (HHV-8) expression and immune response in cutaneous lesions of classic KS (CKS) and AIDS-associated KS (AIDS-KS). Background and methods: Kaposi sarcoma (KS) is associated with HHV-8. The cutaneous immune response in this tumor is not well established and a better understanding is necessary. A quantitative immunohistochemical study was performed of cells expressing HHV-8 latency-associated nuclear antigen (LANA), CD4, CD8, and interferon (IFN)-γ in skin lesions from patients with CKS and AIDS-KS (with or without highly active antiretroviral therapy [HAART]). Result: CKS showed higher LANA expression than AIDS-KS, regardless of HAART. Higher LANA expression was also found in nodules than patch/plaque lesions. The tissue CD4 + cell proportion was lower in AIDS-KS patients without HAART than in patients with CKS. In CKS lesions, CD4 + and CD8 + cells expressed IFN-γ, as shown by double immunostaining. AIDS-KS presented low numbers of IFN-γ-expressing cells. CD8 + cell numbers were similar in all groups, which appeared unrelated to the clinical or epidemiological type of KS. Conclusion: The quantitative data on the pattern of KS lesions in selected groups of patients, as shown by in situ immune response, demonstrated a CD4 + T-cell involvement associated with IFN-γ, an environment of immune response-modified human immunodeficiency virus (HIV) infection. The promotion of KS in patients without HIV appeared to be related to higher HHV-8 load or virulence than in those with AIDS. This higher resistance may be explained by a sustained immune response against this herpesvirus, that is only partially restored but effective after HAART.

The Role of Minimally Invasive Gynecologic Surgery in Sub Saharan Africa

Purpose of ReviewMinimally invasive gynecologic surgery (MIGS) is now firmly established in developed countries where there has been a trend away from traditional open surgery towards laparoscopy given proven benefits of faster recovery time and better cosmesis for patients. However, this same trend has not been observed in regions like sub Saharan Africa (SSA) where resources are limited. Lack of human and material resources, need for technological support, and challenges with training have been postulated as major limitations for wide spread introduction and expansion of MIGS in SSA. Nonetheless, a few institutions in sub Saharan Africa have been able to surmount these challenges to develop MIGS in SSA. This paper reviews the current state of minimally invasive surgery in sub Saharan Africa. We review the role and benefits of expanding minimally invasive surgery in sub Saharan Africa with a focus on management of gynecologic conditions. Finally, we review the challenges associated with MIGS in SSA and provide recommendations on the way forward.Recent FindingsThere are several published studies on the successful development of minimally invasive surgery in sub -Saharan Africa with similar benefits of shorter hospital stay, quicker recovery, and better cosmesis for patients. These studies also report the challenges with human and material resources and training.SummaryThere is a large role and need for expansion of minimally invasive surgery in sub Saharan Africa. The challenges of lack of resources, personnel, and training can be surmountable through ingenuity, modeling based on experiences from other low to middle income countries and commitment to the advancement of MIGS for the benefit of women’s health globally.