Thierry H. Roels

Efficacy of trimethoprim-sulphamethoxazole prophylaxis to decrease morbidity and mortality in HIV-1-infected patients with tuberculosis in Abidjan, Côte d'Ivoire: a randomised controlled trial

BACKGROUND There is a high incidence of opportunistic infection among HIV-1-infected patients with tuberculosis in Africa and, consequently, high mortality. We assessed the safety and efficacy of trimethoprim-sulphamethoxazole 800 mg/160 mg (co-trimoxazole) prophylaxis in prevention of such infections and in decrease of morbidity and mortality. METHODS Between October, 1995, and April, 1998, we enrolled 771 HIV-1 seropositive and HIV-1 and HIV-2 dually seroreactive patients who had sputum-smear-positive pulmonary tuberculosis (median age 32 years [range 18-64], median CD4-cell count 317 cells/microL) attending Abidjans four largest outpatient tuberculosis treatment centres. Patients were randomly assigned one daily tablet of co-trimoxazole (n=386) or placebo (n=385) 1 month after the start of a standard 6-month tuberculosis regimen. We assessed adherence to study drug and tolerance monthly for 5 months and every 3 months thereafter, as well as rates of admission to hospital. FINDINGS Rates of laboratory and clinical adverse events were similar in the two groups. 51 patients in the co-trimoxazole group (13.8/100 person-years) and 86 in the placebo group (25.4/100 person-years) died (decrease In risk 46% [95% CI 23-62], p<0.001). 29 patients on co-trimoxazole (8.2/100 person-years) and 47 on placebo (15.0/100 person-years) were admitted to hospital at least once after randomisation (decrease 43% [10-64]), p=0.02). There were significantly fewer admissions for septicaemia and enteritis in the co-trimoxazole group than in the placebo group. INTERPRETATION In HIV-1-infected patients with tuberculosis, daily co-trimoxazole prophylaxis was well tolerated and significantly decreased mortality and hospital admission rates. Our findings may have important implications for improvement of clinical care for such patients in Africa.

The Changing Epidemiology of Salmonella: Trends in Serotypes Isolated from Humans in the United States, 1987–1997

Salmonellosis is a major cause of illness in the United States. To highlight recent trends, data for 1987-1997 from the National Salmonella Surveillance System were analyzed. A total of 441,863 Salmonella isolates were reported, with the highest age-specific rate among infants (159/100,000 infants at 2 months). Annual isolation rates decreased from 19 to 13/100,000 persons; however, trends varied by serotype. The isolation rate of Salmonella serotype Enteritidis increased until 1996, whereas declines were noted in Salmonella serotypes Hadar and Heidelberg. Overall, serotypes that increased in frequency were significantly more likely than those that decreased to be associated with reptiles (P=.008). Salmonella infections continue to be an important cause of illness, especially among infants. Recent declines in food-associated serotypes may reflect changes in the meat, poultry, and egg industries that preceded or anticipated the 1996 implementation of pathogen-reduction programs. Additional educational efforts are needed to control the emergence of reptile-associated salmonellosis.

Early Diagnosis of Human Immunodeficiency Virus in Infants Using Polymerase Chain Reaction on Dried Blood Spots in Botswana's National Program for Prevention of Mother-to-Child Transmission

Background: Botswana has high antenatal human immunodeficiency virus (HIV) prevalence (33.4%). The public health system provides free services for prevention of mother to child transmission of HIV (PMTCT) and antiretroviral therapy, which can reduce vertical HIV transmission from 35% to <5%. Infant HIV diagnosis is challenging in resource-limited settings, and HIV prevalence among HIV-exposed infants in Botswana is unknown. Dried blood spot (DBS) polymerase chain reaction (PCR) provides a feasible method to assess PMTCT programs and identify HIV-infected children. Methods: We trained staff in 15 clinics and a hospital to obtain DBS on HIV-exposed infants age 6 weeks to 17 months receiving routine care. Samples were sent to the national HIV reference laboratory. Roche Amplicor 1.5 DNA PCR testing was performed. Results: Between June–December 2005, 1931 HIV-exposed infants age 6 weeks to 17 months were tested for HIV, of whom 136 (7.0%) were HIV infected. Among infants ≤8 weeks old, 27 of 544 (5.0%) were HIV infected. Among infants tested in clinics (primarily during routine health visits), 65 of 1376 (4.7%) were infected; among infants tested in the hospital, 71 of 555 (12.8%) were infected. Conclusions: Collection and testing of DBS was successfully integrated into routine infant care in the public health system. HIV prevalence among infants in the Botswana PMTCT program is low. National expansion of infant DBS PCR in Botswana is planned.

Sensitivity and Specificity of Human Immunodeficiency Virus Rapid Serologic Assays and Testing Algorithms in an Antenatal Clinic in Abidjan, Ivory Coast

ABSTRACT To evaluate serologic testing algorithms for human immunodeficiency virus (HIV) based on a combination of rapid assays among persons with HIV-1 (non-B subtypes) infection, HIV-2 infection, and HIV-1–HIV-2 dual infections in Abidjan, Ivory Coast, a total of 1,216 sera with known HIV serologic status were used to evaluate the sensitivity and specificity of four rapid assays: Determine HIV-1/2, Capillus HIV-1/HIV-2, HIV-SPOT, and Genie II HIV-1/HIV-2. Two serum panels obtained from patients recently infected with HIV-1 subtypes B and non-B were also included. Based on sensitivity and specificity, three of the four rapid assays were evaluated prospectively in parallel (serum samples tested by two simultaneous rapid assays) and serial (serum samples tested by two consecutive rapid assays) testing algorithms. All assays were 100% sensitive, and specificities ranged from 99.4 to 100%. In the prospective evaluation, both the parallel and serial algorithms were 100% sensitive and specific. Our results suggest that rapid assays have high sensitivity and specificity and, when used in parallel or serial testing algorithms, yield results similar to those of enzyme-linked immunosorbent assay-based testing strategies. HIV serodiagnosis based on rapid assays may be a valuable alternative in implementing HIV prevention and surveillance programs in areas where sophisticated laboratories are difficult to establish.

Prevalence of IgG Antibodies to Ebola Virus in Individuals during an Ebola Outbreak, Democratic Republic of the Congo, 1995

During the 1995 outbreak of Ebola (EBO) hemorrhagic fever in Kikwit, Democratic Republic of Congo, two surveys using a new ELISA for EBO (subtype Zaire) virus antigen were conducted to assess the prevalence of EBO IgG antibodies among residents of Kikwit and the surrounding area. The first study determined the proportion of antibody-positive individuals who were self-identified forest and city workers from the Kikwit area. Serum samples from 9 (2.2%) of 414 workers had IgG EBO antibodies. The second study determined the proportion of EBO antibody-positive individuals who lived in villages surrounding Kikwit. The prevalence of IgG EBO antibodies in this population was 9.3% (151161). The difference in the overall prevalence of EBO antibodies may indicate that villagers have a greater chance of exposure to EBO virus compared with those living in and in close proximity to cities.

Cellular Human Immunodeficiency Virus (HIV)–Protective Factors: A Comparison of HIV-Exposed Seronegative Female Sex Workers and Female Blood Donors in Abidjan, Côte d’Ivoire

Cellular factors that may protect against human immunodeficiency virus (HIV) infection were investigated in 27 HIV-exposed seronegative (ESN) female sex workers (FSWs) and 27 HIV-seronegative female blood donors. Compared with blood donors, ESN FSWs had significantly decreased expression levels of C-X-C chemokine receptor 4 (CXCR4), but not of C-C chemokine receptor 5, on both memory (P<.001) and naive (P=.041) CD4(+) T cells. CXCR4 down-regulation was associated with prolonged duration of commercial sex work by ESN FSWs. CD38 expression on CD8(+) T cells was significantly increased among ESN FSWs, compared with that among blood donors (P=.017). There were no differences in HLA-DR and CD62L expression between blood donors and ESN FSWs. Proportions of T cells producing the beta-chemokines RANTES (regulated on activation, normally T cell-expressed and -secreted), macrophage inflammatory protein (MIP)-1alpha, and MIP-1beta or the cytokines interleukin (IL)-2, IL-4, interferon-gamma, and tumor necrosis factor-alpha, were similar in the 2 groups. These data indicate that ESN FSWs differ from HIV-seronegative female blood donors with respect to immunological factors that have no clear protective potential against HIV transmission.

Prevention of mother-to-child transmission and voluntary counseling and testing programme data: what is their utility for HIV surveillance?

Objective:Antenatal clinic (ANC)-based surveillance through unlinked anonymous testing (UAT) for HIV without informed consent provides solid long-term trend data in resource-constrained countries with generalized epidemics. The rapid expansion of the prevention of mother-to-child transmission (PMTCT) and voluntary counseling and testing (VCT) programmes prompts the question regarding their utility for HIV surveillance and their potential to replace UAT-based ANC surveillance. Methods:Four presentations on the use of PMTCT or VCT data for HIV surveillance were presented at a recent international conference. The main findings are presented in this paper, and the operational and epidemiological aspects of using PMTCT or VCT data for surveillance are considered. Results:VCT data in Uganda confirm the falling trend in HIV prevalence observed in ANC surveillance. Thailand, a country with nationwide PMTCT coverage and a very high acceptance of HIV testing, has replaced UAT data in favor of PMTCT data for surveillance. Studies from Botswana and Kenya showed that PMTCT-based HIV prevalences was similar, but the quality and availability of the PMTCT data varied. Conclusion:The strength of UAT lies in the absence of selection bias and the availability of individual data. Conversely, the quantity of VCT and PMTCT programme testing data often exceed those in UAT, but may be subject to bias due to self-selection or test refusal. When using VCT or PMTCT data for surveillance, investigators must consider these caveats, as well as their varying data quality, accessibility, and availability of individual records.

EntErtainMEnt-Education radio sEriaL draMa and outcoMEs rELatEd to Hiv tEsting in Botswana

Makgabaneng is an entertainment-education radio serial drama written and produced in Botswana to promote prevention of HIV. This effort is part of the national response to HIV/AIDS. Broadcast of the serial drama began in August 2001, and two new 15-minute episodes air each week. We examined associations between exposure to Makgabaneng and outcomes related to HIV testing, including stigmatizing attitudes, intention to be tested, talking with a partner about testing, and testing for HIV, among 555 sexually active respondents. The four measures of exposure to Makgabaneng were frequency of listening, duration of listening, talking about the program, and attentiveness to and identification with relevant characters. Data were collected approximately 18 months after the drama began airing. We found positive associations between exposure to the program and intermediate outcomes, including lower level of stigmatizing attitudes, stronger intention to have HIV testing, and talking to a partner about testing. Although associations were identified with all four measures of exposure, increased duration of listening was associated with more positive outcomes than the other measures. This finding suggests that longer term exposure to entertainment-education programming may be important for behavior change.

Botswana's Tebelopele voluntary HIV counseling and testing network: use and client risk factors for HIV infection, 2000-2004.

Background:HIV services, including voluntary counseling and testing (VCT) and antiretroviral (ARV) therapy, expanded rapidly in Botswana from 2000 through 2004. Methods:Client data from Botswanas Tebelopele VCT network were analyzed to describe clients, factors associated with HIV infection, and trends in VCT use. Results:Tebelopele provided free, anonymous, same-day HIV tests for 117,234 clients from 2000 through 2004. Before ARV therapy was available, 8.3% of clients sought a test because of illness, and 26.3% were HIV-positive. After ARV therapy became available, 20.1% of clients sought a test because of illness, and 38.8% were HIV-positive. Most VCT clients (82.7%) were unmarried; 89.8% reported no or 1 sexual partner in the last 3 months; and 50.2% of unmarried clients reported always using condoms in the last 3 months. In multivariate analysis, higher educational level, marriage, and always using condoms were associated with a lower risk of HIV. Having only 1 recent sexual partner was associated with less condom use and a higher risk of being HIV-positive for men. Conclusions:VCT has been well accepted in Botswana. Analysis of this data set supports efforts to promote 100% condom use and to emphasize that partner reduction must be combined with condom use and HIV testing to protect against HIV.

Epidemic cholera in a crowded urban environment, Port-au-Prince, Haiti.

We conducted a case–control study to investigate factors associated with epidemic cholera. Water treatment and handwashing may have been protective, highlighting the need for personal hygiene for cholera prevention in contaminated urban environments. We also found a diverse diet, a possible proxy for improved nutrition, was protective against cholera.