Nsengumuremyi F

Effect of serotesting with counselling on condom use and seroconversion among HIV discordant couples in Africa.

OBJECTIVE--To determine whether HIV testing and counselling increased condom use and decreased heterosexual transmission of HIV in discordant couples. DESIGN--Prospective study. SETTING--Kigali, the capital of Rwanda. SUBJECTS--Cohabiting couples with discordant HIV serology results. MAIN OUTCOME MEASURES--Condom use in the couple and HIV seroconversion in the negative partners. RESULTS--60 HIV discordant couples were identified, of whom 53 were followed for an average of 2.2 years. The proportion of discordant couples using condoms increased from 4% to 57% after one year of follow up. During follow up two of the 23 HIV negative men and six of the 30 HIV negative women seroconverted (seroconversion rates of 4 and 9 per 100 person years). The rate among women was less than half that estimated for similar women in discordant couples whose partners had not been serotested. Condom use was less common among those who seroconverted (100% v 5%, p = 0.01 in men; 67% v 25%, p = 0.14 in women). CONCLUSIONS--Roughly one in seven cohabiting couples in Kigali have discordant HIV serological results. Confidential HIV serotesting with counselling caused a large increase in condom use and was associated with a lower rate of new HIV infections. HIV testing is a promising intervention for preventing the spread of HIV in African cities.

Knowledge Attitudes. and Perceived Risk of AIDS Among Urban Rwandan Women - Relationship to HIV Infection and Behavior Change

We examined factors associated with perceived risk of AIDS, behavior change, and HIV infection in a representative sample of 1458 child-bearing urban women in Rwanda, central Africa. Although 68% of women reported only one lifetime partner, and the majority (87%) lived with a husband or steady partner, the prevalence of HIV antibodies was still high (32%). Before receiving their HIV test results, the women completed a questionnaire about AIDS knowledge, attitudes, and practices. Knowledge about HIV transmission was high, with 96-98% of women correctly identifying the three primary routes of infection. However, only 16% of women reported taking any action to avoid AIDS in the previous year, and most (11%) had done so merely by asking their male partners to change their behavior. Only 7% of women had ever tried condoms, and many (68%) thought they could be dangerous to use. Women who perceived themselves at risk of AIDS (57%) were more likely to report changing behavior; they were also more likely to be infected with HIV. Other factors associated with behavior change included having known someone with AIDS, having discussed AIDS with a male partner, and believing that condoms are not dangerous. Future interventions should enhance perception of risk, encourage male sexual partners to reduce risky behavior, and increase familiarity with condoms.

Postnatal transmission of HIV from mother to child

2 cases of post-partum transmission of human immunodefficiency virus (HIV) from mother to infant from Kigali Rwanda are reported. All results were confirmed by western blot tests. 1) A 23-year-old woman with no history of extramarital sexual contact blood transfusions drug abuse or injections during pregnancy experienced severe bleeding during childbirth and was transfused with 2 units blood one of which had been drawn from a donor who later proved to be seropositive. The child sickened and died at 19 months of chronic diarrhea after having presented with failure to thrive generalized lymphadenopathy oral thrush and hepatomegaly moderate psychomotor delay and lobar pneumonia on chest x-ray. At 15 months post-partum the mother showed mild lymphocytosis and had antibodies to HIV. She had no dermatitis and breast-fed the child without problems until she died. 2) The 2nd case of a boy was quite similar: a postpartum transfusion from a donor who later prove to be seropositive was the most likely source of the mothers HIV infection. The child in question was still being breast fed at 15 months having begun to show symptoms of HIV infection at 5 months of age. A 30-month-old sibling was thriving and seronegative. In both cases the fathers were seronegative. Given the length of time the children had been breast fed and past studies showing the presence of HIV in breast milk as well as colostrum breast milk appears to be the most likely source of the infection in these cases. They were 2 cases out of 107 pediatric cases of AIDS and AIDS-related complex studied over 2 years. The results do not indicate a need to discourage mothers from breastfeeding but do underline the need to enforce measures to avoid contamination of banked breast milk.

Male Circumcision, Sexually Transmitted Disease, and Risk of Hiv

Our objective was to describe associations among male circumcision, behavioral and demographic variables, ulcerative and nonulcerative sexually transmitted disease (STD), and human immunodeficiency virus (HIV) infection via a cross-sectional study in Kigali, the capital of Rwanda. Our subjects were 837 married men who volunteered for HIV testing and counselling. Uncircumcised men had a relatively low-risk profile in that they reported fewer lifetime sexual partners and prostitute contacts than circumcised men and were more likely to live in rural areas with lower HIV prevalence rates. Uncircumcised men were also less likely to report a history of sexually transmitted disease (64% versus 73%, p = 0.01), although they were more likely to report genital ulceration (GUD) (24% versus 17%, p < 0.03) and to have inguinal adenopathy noted on physical exam (42% versus 29%, p = 0.009). Despite the low-risk profile, uncircumcised men had a higher prevalence of HIV infection than circumcised men (29% versus 21% HIV positive, p = 0.02), which was most marked in men reporting five or more lifetime sex partners (36% versus 23% HIV positive, p = 0.005) or contact with prostitutes (35% versus 23% HIV positive, p = 0.009). Circumcision remained a predictor of HIV infection in multivariate analyses (multivariate odds ratio 1.69, 95% confidence interval 1.16-2.47). Lack of circumcision is associated with a higher risk of HIV infection in Rwandan men. Further research is needed to determine whether this higher risk is due in part to poor hygiene or to complex mechanisms operating through the acquisition of other sexually transmitted diseases. Circumcision may be an appropriate risk reduction approach for men with known exposures to the virus when there are constraints to alternatives, such as condom use.

Classification of HIV infection and disease in women from Rwanda. Evaluation of the World Health Organization HIV staging system and recommended modifications.

As the human immunodeficiency virus (HIV) continues to spread globally, increasing attention is being given to the entire spectrum of HIV infection. Although several case definitions for the acquired immunodeficiency syndrome (AIDS) in adults and adolescents have been developed [1-3], these definitions include only the most severe manifestations of HIV-induced immunodeficiency. To describe the full range of HIV-related outcomes, various HIV staging systems have been proposed [3-10]. In one staging system developed by the World Health Organization (WHO), persons are categorized into one of four clinical stages and into one of three laboratory stages; laboratory staging is based on either the total lymphocyte count or the CD4+ lymphocyte count [7, 8]. In another system proposed by the Centers for Disease Control and Prevention (CDC), three clinical stages and three laboratory stages are used; laboratory staging is based entirely on the CD4+ count [3]. A staging system for HIV should ideally have several important characteristics. First, mutually exclusive categories should reflect the entire range of clinical outcomes, from asymptomatic infection to serious illness. Second, the staging system should be clinically relevant and reflect increasing severity of illness. Third, clinicians or researchers for whom the staging system is intended should be able to apply that system under their usual working conditions. A system based on sophisticated immunologic testing might offer good prognostic information but would be impractical for most physicians caring for patients in settings with limited resources. Finally, a staging system should be associated with prognosis. A system reflecting prognosis and severity of illness could provide assistance with counseling and clinical management of patients, including the decision to introduce certain medical interventions. Different stages could be used to provide standardized criteria to evaluate HIV disease progression in efficacy trials of therapeutic drugs or vaccines. Several studies evaluating the WHO staging system have been done, primarily in North America, Europe, and South America [11-15]. A need exists for additional studies evaluating HIV staging systems (including the WHO system) in persons from developing countries, particularly sub-Saharan Africa, where approximately two thirds of the worlds HIV-infected population resides [16]. A need also exists to validate any staging system in women, especially in sub-Saharan Africa, which contains more than 80% of all HIV-infected women [16]. Since 1988, a cohort of urban women recruited from prenatal and pediatric outpatient clinics in Kigali, Rwanda, has been followed with regular clinical and laboratory evaluations [17-21]. We evaluated the proposed WHO HIV-staging system in this cohort. On the basis of this and previous analyses, we propose a series of revisions and a modified staging system that can be used in sub-Saharan Africa and possibly other developing countries. Methods Study Cohort Details of the sampling design and participant recruitment have been published [17-21]. Briefly, during 1986 and 1987, a consecutive sample of 3702 women aged 18 to 35 years was recruited from pediatric and perinatal care outpatient clinics in Kigali, Rwanda, and tested for HIV antibody [17, 18]. From this group, a random sample stratified by HIV status was selected for prospective cohort studies; this sample included 460 HIV-positive and 998 HIV-negative women [19-21]. As in previous studies [19], the follow-up rate after 4 years was approximately 90%. Evaluation Clinical evaluation of these women included a semi-annual medical history and weight measurement and an annual physical examination. Body mass index was evaluated using the Quetelet index (weight in kilograms/height in meters2). Testing for HIV was initially done using an enzyme-linked immunosorbent assay (Wellcome Diagnostics, Research Triangle Park, North Carolina), with confirmation by immunofluorescence (Virion, Lucerne, Switzerland) or Western blot (DuPont, Wilmington, Delaware). Other laboratory testing included an annual complete blood count with differential and a Westergren erythrocyte sedimentation rate. Outpatient medical care was provided at the project site between scheduled visits. Inpatient care was provided at the Kigali Central Hospital, the citys only community hospital, which is located 500 meters from the project site. Information from outpatient and hospital records was incorporated into the clinical data base. For women who died and those for whom these data were not available, family members were interviewed about symptoms before death. Statistical Analysis To evaluate the prognostic significance of a staging system, women were classified at baseline into mutually exclusive stages. We evaluated time to death using the Kaplan-Meier survival analysis. Survival curves were compared using the Wilcoxon test of equality over strata; this test is more sensitive than the log-rank test to losses that occur early in the survival distribution [22]. We defined the second follow-up visit in this cohort study (which occurred 12 months after enrollment) as the baseline date; this allowed us to include in our baseline data all medical conditions that had been diagnosed within the preceding year. Thirty-six months of follow-up were available after this new baseline date. We did four types of analyses. First, we evaluated survival using the current WHO HIV staging system. Second, we did a series of exploratory analyses to evaluate the prognostic significance of various clinical characteristics and laboratory measurements; these were mostly chosen on the basis of previous analyses of morbidity and mortality in this cohort [19]. We also evaluated prognosis associated with chronic or acute oral or genital ulcers, even if the cause was unknown. Third, we evaluated the subset of women who died during the follow-up period and described the time from first report of certain clinical conditions until the date of death. Fourth, we proposed some revisions to the WHO staging system and evaluated the effect of these modifications. For evaluation of hematocrit, women were categorized as having values above or below the lower quartile (the lower 25% of results); for erythrocyte sedimentation rate, women were categorized as having values above or below the upper quartile (the upper 25% of results). We chose three categories for body mass index because the WHO staging system has three weight loss categories; cut-points were selected using whole numbers that would reflect the distribution of body mass index results and allow sufficient numbers in each category for analysis. Operational Modifications in the WHO Staging System For purposes of analysis and because of the methods of data collection, we made several operational adaptations to the WHO clinical staging system. We did not include a formal performance scale, as suggested in the revised WHO staging system [8]. We also did not specifically evaluate women in this cohort for HIV-related encephalopathy. The remaining key features of the WHO system are summarized in the Appendix. The wasting syndrome (for clinical stage IV) was defined as documented weight loss (during any 6- to 12-month interval) of greater than 10% of body weight plus either chronic diarrhea or chronic fever and asthenia. For clinical stage III, pneumonia, meningitis, and pyomyositis were considered severe bacterial infections. Clinical stage II was adapted in four ways: 1) The WHO proposal includes persons with unintentional weight loss less than 10% of body weight. Because this could theoretically include persons with weight loss of 1% to 2% of body weight [within the range of normal weight fluctuations or variability in measurement], we included in stage II persons with weight loss of 5% to 10% of body weight. 2) Minor mucocutaneous manifestations included oral or genital ulcers of any duration and dermatitis [including pruritic dermatitis]. 3) Because of the way questions were asked, we included women who had had herpes zoster within the preceding 6 years [rather than within the preceding 5 years as suggested by WHO]. 4) Recurrent upper respiratory tract infections were defined as recurrent sinusitis noted on two consecutive medical histories that were obtained 6 months apart; we did not include minor illnesses such as colds. In the WHO laboratory axis, stage A includes a CD4+ lymphocyte count greater than 500 106/Lor a total lymphocyte count greater than 2000 106/L. Stage B includes a CD4+ count of 200 to 500 106/L or a lymphocyte count of 1000 to 2000 106/L. Stage C includes a CD4+ count less than 200 106/Lor a lymphocyte count less than 1000 106/L[7]. Because CD4+ counts were not available, we based the laboratory staging solely on the total lymphocyte count. Results Study Population We included in our analysis 412 women who were HIV seropositive at baseline; the median age was 28 years (range, 19 to 38 years). Most were involved in a stable relationship, either a legal (26%) or a common-law marriage (43%). Forty-four percent reported only one lifetime sexual partner, and another 26% reported only two lifetime partners. Ten percent of women were pregnant. Ninety-six women (23%) died after a median of 27 months (range, 3 to 51 months) from baseline evaluation. Among women who did not die, the median length of follow-up was 36 months. Survival Based on the WHO Staging System At the time of baseline evaluation, 35% of women were in WHO clinical stage I, 39% were in clinical stage II, 19% were in stage III, and 8% were in stage IV. Of the stage IV diseases listed in the Appendix, the only conditions diagnosed among women in our analysis were the HIV wasting syndrome, extrapulmonary cryptococcosis, esophageal candidiasis, extrapulmonary tuberculosis, and Kaposi sarcoma. Although stages I and II were associated with the best prognosis, stages III and IV overlapped

Seroincidence of HIV-1 infection in african women of reproductive age: a prospective cohort study in Kigali, Rwanda, 1988-1992

Objective:To estimate the seroincidence of HIV-1 infection among women of reproductive age in Kigali, Rwanda.Design:Fixed prospective cohort followed for 36 months between November 1988 and June 1992, as part of an ongoing study of mother-to-child transmission of HIV-1.Setting:Centre Hospitalier, Kigali, Rwanda.Subjects:A total of 216 HIV-seronegative women were enrolled at delivery between November 1988 and June 1989.Methods:A blood sample was obtained at delivery to test for HIV antibodies (by enzyme-linked immunosorbent assay and Western blot). Serum was tested every 3 months during follow-up. Incidence density rates of HIV seroconversion were estimated.Results:The follow-up rate after 3 years was 89%, assessed by the maximum person-years method. The seroincidence density rate was 3.5 per 100 women-years (95% confidence interval, 1.9–5.0). It decreased linearly from 7.6 during the first 6-months postpartum to 2.5 per 100 women-years during the last 6 months of the third year of follow-up. Maternal age did not affect HIV incidence rates. We examined the role of the cohort, counselling, and the first 6-month postpartum effects on this estimate.Conclusion:This fixed cohort provided an overall estimation of the HIV infection incidence rate and its dynamics. These figures could be used for programming future HIV preventive vaccine efficacy trials in Rwanda.

Bacteraemia as predictor of HIV infection in African children.

ABSTRACT. In Rwanda, both HIV infection and bacteraemia represent major health problems among paediatric populations. We carried out a prospective study to determine if bacteraemia is a marker of HIV infection among ambulatory and hospitalized Rwandese children. All children presenting at the Department of Paediatrics of the Centre Hospitalier de Kigali and who had their blood cultured during a two‐month period were eligible for the study. One hundred and thirty‐five children were included in the study. A pathogen was isolated from 36 children (26.7 %): S. typhimurium (10 cases), S. enteritidis (6), S. typhi (4), Str. pneumoniae (9). H. influenzae (6) and S. aureus (1). No association was found between bacteraemia and HIV seropositivity when all the children were considered. However, among patients less than 2 years old, bacteraemic subjects were more frequently (p≤0.05) HIV seropositive (44 %) than those with negative blood cultures (19 %). Our study shows that in young children in Central Africa, the presence of bacteraemia may be an important marker of HIV seropositivity.

FOOD-BASED ORAL REHYDRATION SALT SOLUTION FOR ACUTE CHILDHOOD DIARRHOEA

Professor Molla and colleagues report improved efficacy in rehydration of children aged 1-5 years with acute diarrhea by use of oral rehydration solutions (ORS) produced from rice maize sorghum millet wheat and potato. Cereal-based carbohydrates in ORS seem to improve clinical and biochemical parameters in children with acute diarrhea (for 48 hours or less) but long-term consequences--especially progression to persistent diarrhea--need to be considered. Protein-containing infant feeds may sensitize intestinal mucosa immunocompetent cells when given during acute diarrhea as shown in infants given feeds based on soy and cows milk. 55.5% of those fed soy protein during an episode of acute diarrhea had histological evidence of soy protein sensitization when challenged 6 weeks after recovery and cows milk protein intolerance was found to delay recovery in 26% of infants fed cows milk during acute diarrhea. The etiology and mechanisms or persistent diarrhea are poorly understood and there is evidence of severe enteropathy in children with persistent diarrhea. Investigators should also consider the risk of sensitization of intestinal mucosa to proteins contained in cereal-based ORS. The risk of sensitization is highest on exposure to protein during an episode of acute diarrhea when the small intestine mucosa is more permeable to macromolecules. Millet sorghum and wheat contain 10-12.5% protein by weight: more than 1/2 of this protein is in the form of prolamines and glutelins which have been shown to be toxic to enterocytes in vitro (maize and rice protein appears to be less noxious.) Long-term follow up will be required to identify whether dietary antigen sensitization occurs in children treated with different types of cereal-based ORS. [full text]

Metastatic focal infections due to multiresistant Salmonella typhimurium in children: A 34 month experience in Rwanda

Nineteen out of 139 children with severe systemic disease due to multiresistant Salmonella typhimurium observed during a 34-month period in an in-patient department in Rwanda had focal metastatic infections. More than 80% of the invasive Salmonella infections were acquired in the hospital. Focal metastatic infections occurred after longer hospital stays than bacteremia (29.1 ± 17.4 days as against 13.5 ± 9.0 days, p < 0.01) and were diagnosed more time after the first sign of infection (3.28 ± 1.41 days as against 1.86 ± 1.10 days, p < 0.01). Bacteremia was documented in 13 of the 17 children with focal infection from whom blood cultures were obtained. Seven of 12 had positive stool cultures. The sites of metastatic focal infection were meninges (7 cases), soft tissue (5 cases), joint or bone (4 cases), pleura, (2 cases), eye (1 case). The clinical course of meningitis was fulminant and 6/7 patients died before receiving adequate antimicrobial therapy. One child with meningitis and 9 patients with focal infections at other sites were treated with cefotaxime and were cured or improved.