Van de erre P

Postnatal transmission of human immunodeficiency virus type 1 from mother to infant -- a prospective cohort study in Kigali Rwanda.

Abstract Background. Although transmission of human immunodeficiency virus type 1 (HIV-1 ) from mother to infant has been well documented during pregnancy and delivery, little is known about the possible transmission of HIV-1 during the postnatal period. Methods. We conducted a prospective cohort study in Kigali, Rwanda, of 212 mother—infant pairs who were seronegative for HIV-1 at delivery. All the infants were breast-fed. The subjects were followed at three-month intervals, with Western blot assays for antibodies to HIV-1 and testing of mononuclear cells by a double polymerase chain reaction (PCR) using three sets of primers. To evaluate potential risk factors, each mother who seroconverted was matched with three seronegative control women. Results. After a mean follow-up of 16.6 months, 16 of the 212 mothers became seropositive for HIV-1. Of their 16 infants, 9 became seropositive. One infant was excluded from the analysis because of a positive test by PCR on the blood sample obtained at birth. Postnat...

Acceptability of voluntary HIV testing by pregnant women in developing countries : an international survey

Objective:To evaluate acceptability of voluntary HIV counselling and testing (VCT) by pregnant women in the context of clinical trials assessing interventions to reduce mother-to-child transmission (MCT) of HIV in developing countries. Methods:During September-October 1997, 13 studies located in West (Abidjan, Bobo Dioulasso), East (Nairobi, Mombasa, Dar Es Salaam, Blantyre, Lusaka, Harare) and South Africa (Soweto, Durban), and Thailand (Bangkok) were included in a cross-sectional mailing survey about the acceptability of VCT in antenatal clinics. Acceptance rate, return rate, overall acceptability of VCT (acceptance of both pre- and post-VCT sessions) were obtained using a standardized questionnaire. Results:The median overall acceptability of VCT was 69% (range, 33–95%). Overall acceptability of VCT most frequently depended on return rates because acceptance rates were generally high. Where several studies were conducted in parallel in the same city or the same country, overall acceptability rates of HIV testing were generally comparable even if the intervention programmes differed. Overall acceptability rates of VCT were high in antenatal clinics where a particular effort in implementing VCT programmes had been made. Conclusions:This international survey shows that despite many obstacles, VCT is feasible and acceptable for pregnant women aiming to reduce their risk of transmitting HIV to their children.

Predictors of Mortality among HIV-infected Women in Kigali, Rwanda

OBJECTIVE To better characterize the natural history of disease due to human immunodeficiency virus (HIV) infection in African women. DESIGN Prospective cohort study over a 2-year follow-up period. PARTICIPANTS A total of 460 HIV-seropositive women and a comparison cohort of HIV-seronegative women recruited from prenatal and pediatric clinics in Kigali, Rwanda in 1988. MEASUREMENTS Clinical signs and symptoms of HIV disease, AIDS, and mortality. MAIN RESULTS Follow-up data at 2 years were available for 93% of women who were still alive. At enrollment, many seropositive women reported symptoms listed in the World Health Organization (WHO) clinical case definition of AIDS, but these were nonspecific and often improved over time. The 2-year mortality among HIV-infected women by Kaplan-Meier survival analysis was 7% (95% CI, 5% to 10%) overall, and 21% (CI, 8% to 34%) for the 40 women who fulfilled the WHO case definition of AIDS at entry. In comparison, the 2-year mortality in women not infected with HIV was only 0.3% (CI, 0% to 7%). Independent baseline predictors of mortality in seropositive women by Cox proportional hazards modeling were, in order of descending risk factor prevalence: a body mass index of 21 kg/m2 or less (relative hazard, 2.3; CI, 1.1 to 4.8), low income (relative hazard, 2.3; CI, 1.1 to 4.5), an erythrocyte sedimentation rate exceeding 60 mm/h (relative hazard, 4.9; CI, 2.2 to 10.9), chronic diarrhea (relative hazard, 2.6; CI, 1.1 to 5.7), a history of herpes zoster (relative hazard 5.3; CI, 2.5 to 11.4), and oral candida (relative hazard, 7.3; CI, 1.6 to 33.3). Human immunodeficiency virus disease was the cause of death in 38 of the 39 HIV-positive women who died, but only 25 met the WHO definition of AIDS before death. CONCLUSIONS Human immunodeficiency virus disease now accounts for 90% of all deaths among child-bearing urban Rwandan women. Many symptomatic seropositive patients may show some clinical improvement and should not be denied routine medical care. Easily diagnosed signs and symptoms and inexpensive laboratory tests can be used in Africa to identify those patients with a particularly good or bad prognosis.

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.

Effect of Hiv-1 infection on pregnancy outcome in women in Kigali, Rwanda, 1992–1994

Objective:To study the effect of HIV-1 infection on pregnancy outcome in women provided with antenatal services including malaria and sexually transmitted disease (STD) treatment in Kigali, Rwanda. Subjects and methods:Pregnant women attending the antenatal clinic ward of the Centre Hospitalier de Kigali in their last 3 months of pregnancy were tested for HIV antibody after consent had been obtained. All HIV-1-infected women were included and compared with HIV-negative women of same age and parity. Until delivery, each woman enrolled had a monthly follow-up including malaria and STD aetiological diagnosis and treatment. At the time of delivery, obstetrical and neonatal characteristics were recorded. Mothers and their children were followed until 6 weeks postpartum. Results:By mid-August 1993, 384 HIV-positive and 381 HIV-negative women had been enrolled and by the end of November 1993, 729 women (95.3%; 364 HIV-positive and 365 HIV-negative) had delivered 725 livebirths, including eight and six twins, respectively; 10 stillbirths were recorded amongst HIV-positive women and eight amongst HIV-negative women (P = 0.60). Excluding twins, premature birth (< 37 completed weeks of gestation) was observed in 22.7% of infants born to HIV-positive women versus 14.1% of those born to HIV-negative women; low birth weight (< 2500 g) was observed in 25.5% of infants born to HIV-positive women versus 14.8% of those born to HIV-negative women. Low birth weight was significantly more frequent in full-term infants born to HIV-positive mothers than to HIV-negative mothers. No significant difference in low birth weight rate was observed in preterm infants. Death occurred in 5.1% of children during the perinatal period without statistically significant difference between the two groups. HIV-positive women were more likely to have a postpartum haemorrhage. Conclusion:In the context of high HIV prevalence, maternal HIV infection is associated with adverse obstetrical and neonatal outcomes even when treating STD and malaria.

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.

Infant feeding policy and practice in the presence of HIV-1 infection.

The finding that HIV-1 is transmissible through breastfeeding has complicated advice for infant feeding in some settings in many countries. Breastmilk, however, is the main source of nutrition for most infants worldwide, and it should continue to be promoted due to its many advantages for both infants and mothers in all environments. In developing countries, breastfeeding promotes child survival and maternal health through child spacing and the prevention of infant mortality from gastrointestinal and respiratory infections. Modeling suggests that a shift to artificial feeding in response to HIV infection in poorer countries would increase child mortality. It is less clear what course should be recommended in intermediate developing countries where the prevalence of HIV-1 is on the rise. Policy based upon local information needs to be developed as soon as possible. It should be understood in the interim that selective advice not to breastfeed should only be given where artificial feeding is affordable, its associated risks can be minimized, and within the context of strong national feeding programs which promote and protect breastfeeding. The authors describe the contribution of breastfeeding to child and maternal health, requirements for minimizing the risks associated with artificial feeding, and recent knowledge relating to the trends and determinants of feeding practices. Evidence for breastfeeding transmission is discussed together with the impact of feeding practices and HIV-1 infection through breastfeeding on child mortality. Current policy on antenatal HIV testing and counseling is considered along with future policy options for feeding and testing. Finally, research needs for public health purposes are suggested.

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.

A Cohort Study of Factors Associated With Failure to Return for HIV Post-Test Counselling in Pregnant Women: Kigali, Rwanda, 1992-1993

ObjectiveTo identify factors associated with failure to return for HIV post-test counselling in pregnant women in Kigali (Rwanda). Subjects and methodsIn the context of a study on the impact of HIV infection on pregnancy, HIV-1 -antibody testing was offered to all pregnant women attending the antenatal clinic of the Centre Hospitalier de Kigali from July 1992 to August 1993. Pre-test counselling was performed after verbal informed consent was obtained. Two weeks later, we formally enrolled all HIV-positive women and a corresponding number of HIV-negative women in a cohort. At this visit, post-test counselling was given to those wishing to be informed of their HIV serostatus. Level of knowledge about modes of HIV transmission and condom use were recorded. Four months after delivery, another interview was conducted to determine the proportion of women who used condoms regularly. ResultsA total of 1233 pregnant women were screened. The HIV seroprevalence was 34.4% [95% confidence interval (CD, 31.7–37.1]; 271 (63.9%) out of 424 HIV-positive and 577 (71.3%) out of 809 HIV-negative women asked for their HIV serostatus (P= 0.008). In multivariate analysis, the only variable significantly associated with failure to return for post-test counselling was a positive HIV test result (odds ratio, 0.7; 95% CI, 0.5–0.9; P= 0.009), independently of obstetrical history and socioeconomic characteristics. Among the 848 women who had post-test counselling, 50.9% of the HIV-positive women and 94.6% of the HIV-negative women stated that they planned to inform their partner of their serostatus (P= 0.0001). More than 95% of the women interviewed knew about sexual and parenteral transmission of HIV, but half were unaware of mother-to-child transmission. More than 80% of the women had seen a condom before, but 14% only had used it at least once. Among women who were sexually active 4 months after delivery, 8.8% of the HIV-positive and 3.9% of the HIV-negative women reported using a condom (P=0.04). ConclusionInnovative approaches for HIV testing and counselling programs are needed and the importance of psychosocial and cultural factors associated with HIV testing should be emphasized in African populations.

Evaluation and simplification of the world health organization clinical case definition for paediatric AIDS

The World Health Organization (WHO) clinical case definition for paediatric AIDS was tested during a 1-month period on 221 consecutive hospitalized children in Kigali, Rwanda. Relevant clinical features not included in the WHO case definition were also evaluated. Thirty-four out of the 221 children (15.4%) were HIV seropositive. Although the specificity of the WHO case definition was high (92%), the sensitivity and the positive predictive value (PPV) were low (41 and 48%, respectively). The following individual signs had a PPV at least equal to the complete WHO case definition: chronic diarrhoea (47%), respiratory distress secondary to lower respiratory tract infection (50%), oral candidiasis (53%), parotitis (67%), generalized lymphadenopathy (88%), and herpes zoster infection (100%). When logistic regression analysis was done on the nine variables included in the WHO case definition, confirmed maternal infection was the best predictive variable for HIV seropositivity in children (P less than 10(-5). We further excluded the serological status of the mother from the analysis and performed a stepwise logistic regression analysis on the 18 clinical signs and symptoms for which information had been collected. Those signs and symptoms contributing the most to the regression were: respiratory distress, chronic diarrhoea and generalized lymphadenopathy. Based on these findings, we propose a simplified clinical case definition for paediatric AIDS in Africa with better sensitivity, specificity and PPV than the WHO case definition. Further work is needed using this approach to develop case definitions useful for epidemiological surveillance and for case management.