Virologic and immunologic response to antiretroviral therapy and predictors of HIV type 1 drug resistance in children receiving treatment in Abidjan, Côte d'Ivoire

We describe changes in HIV-1 viral load, CD4+ T cell percentage, and incidence of drug resistance and factors associated with drug resistance for 134 children receiving antiretroviral therapy (ART) for approximately 1 year in Abidjan. Between August 1998 and September 2003, ART was initiated for 395 HIV-infected children ages 0-15 years in the C?te d'Ivoire national drug access initiative. All 1-year samples with detectable HIV RNA >1000 copies/ml were tested for HIV-1 drug resistance and changes in viral load and CD4+ T cell counts were also determined. At treatment initiation, 80% of children had CD4+ T cell percentages <15% and a median viral RNA load of 5.6 log copies/ml. The median age at treatment initiation was 7 years with only 25% of patients less than 4 years of age. Of the 134 children receiving therapy, 72 (54%) had undetectable viral load. The estimated 1-year viral load decline was 1.9 log10 copies/ml and the CD4+ T cell percentage increase was 10.9%. The estimated 1-year cumulative probability for developing any class of drug resistance was 0.44 (95% CI, 0.35, 0.53). In a multivariate analysis, the magnitude of virologic response to therapy was inversely associated with development of drug resistance. Children with less CD4+ T cell rise from baseline values and the use of dual therapy were also associated with the development of drug resistance. Guidelines are needed for the treatment of pediatric HIV infection in Africa in order to minimize the occurrence of drug resistance and enhance better virologic, immunologic, and clinical outcomes.     

The impact of war on the evolution of sleeping sickness in west-central Côte d'Ivoire

The impact of war on the evolution of sleeping sickness in west‐central Côte d'Ivoire Objective To evaluate the situation of sleeping sickness in west‐central Côte d'Ivoire from 2000 to 2003, in view of the war which broke out in September 2002. Methods Active surveys by medical teams and passive case detection. Results Between 2000 and 2003, 250 patients were diagnosed with sleeping sickness. At first it appeared that sleeping sickness prevalence had fallen since the beginning of political troubles. But this apparent drop was due to poor population coverage. Participation in medical surveys differed according to ethnic group, reflecting land use conflicts between ethnic communities. Such conflicts are common in this area, but have been exacerbated by the war. Conclusion In war, assessing the importance of sleeping sickness by medical surveys only is very difficult. But detection of sleeping sickness cases by passive surveillance increased.     

Determinants of adherence to highly active antiretroviral therapy among HIV-1-infected patients in Côte d'Ivoire

OBJECTIVE: To assess adherence to HAART and to determine factors associated with poor adherence among HIV-1-infected patients in Abidjan, C?te d'Ivoire. METHODS: A prospective observational study of 614 consecutive patients attending an HIV/AIDS outpatient clinic. Adherence was measured twice at 3-month intervals by self-report of missing doses over 4 days. An adherence level of less than 95% was defined as poor adherence. We used generalized estimating equation models for binomial distribution with repeated measures for data analysis. RESULTS: Of the 591 subjects who completed the study, 74.3% reported adherence levels of 95% or greater. Six factors were independently related to poor adherence: age less than 35 years [relative risk (RR) 1.45; 95% confidence interval (CI) 1.17-1.79], absence of social support (RR 1.66; 95% CI 1.24-2.24), number of daily pills 10 or more (RR 1.47; 95% CI 1.14-1.91), time of adherence assessment (first versus second time assessment RR 1.36; 95% CI 1.12-1.66), CD4 cell count of 250 cells/mul or greater (RR 1.43; 95% CI 1.10-1.88), and not being less worried about HIV infection now that treatments have improved (RR 1.26; 95% CI 1.01-1.58). Drug supply interruptions in the pharmacies were reported by 10.0% of the non-adherent patients as the reason for missing pills. CONCLUSION: Psychosocial factors were found to impact adherence and should be analysed in more detail by further studies. Scaling up antiretroviral therapy in sub-Saharan Africa should be preceded by reliable drug supply and distribution systems.     

Evaluation of HIV serial and parallel serologic testing algorithms in Abidjan, Côte d'Ivoire

OBJECTIVE: To evaluate HIV serologic testing algorithms based on a combination of three enzyme linked immunosorbent assays (ELISA) for the confirmation of HIV infection in Abidjan, C?te d'Ivoire, where HIV-2 and HIV-1 non-B subtypes are prevalent. METHODS: A total of 1069 human sera with known serologic status, in addition to a seroconversion and low titer antibody panel were initially tested by six ELISA to determine the sensitivity, specificity and delta values of the assays. On the basis of the performance of the assays, three ELISA (Enzygnost, ICE 1.0.2, and Vironostika) were selected for use in a parallel and serial testing algorithm in analyzing 8283 consecutively collected sera. In the parallel testing algorithm, sera concordantly reactive or non-reactive by Enzygnost and ICE 1.0.2 were considered as true positive or true negative, respectively. In the serial algorithm, sera reactive by Enzygnost were retested by ICE 1.0.2. Sera with discordant results were tested by Vironostika, and the results was considered definitive. All reactive sera, plus a random sample of negative sera were tested for confirmation by Peptilav. In addition, a random sample of reactive sera was tested by Western blot. RESULTS: All ELISA had 100% sensitivity; specificities ranged from 96.8 to 100%. Positive and negative delta values of the ELISA were high (range, 6.89 to 46.07 and -2.05 to -5.75, respectively). Of the 8283 sera, 2054 were considered true positives and were correctly classified by the parallel testing algorithm (sensitivity, 100%). Of the 6229 true negative sera, 6226 were negative by the parallel testing algorithm (specificity, 99.95%). The sensitivity of the serial algorithm was 99.96%, and specificity was 99.95%. None of the 250 concordant ELISA-negative sera in the algorithm that were randomly tested in Peptilav was positive; similarly, all of the 103 concordant ELISA-positive sera were confirmed by Western blot. The three-ELISA algorithm resulted in reagent cost-savings of at least 50% compared with the Peptilav-based algorithm. CONCLUSION: These results suggest that a combination of ELISA using different principles or antigens in a serial or parallel algorithm is an efficient and cost-effective alternative to the standard algorithm in areas where HIV-1 and HIV-2 are prevalent.     

Clinical impact and cost-effectiveness of co-trimoxazole prophylaxis in patients with HIV/AIDS in Côte d'Ivoire: a trial-based analysis

BACKGROUND: In 2000, WHO/UNAIDS recommended co-trimoxazole prophylaxis for persons at early stages of HIV infection (WHO stage > or = 2) in sub-Saharan Africa. OBJECTIVE: To assess the cost-effectiveness of alternative strategies for initiation of co-trimoxazole in C?te d'Ivoire. DESIGN: Cost-effectiveness analysis with an HIV simulation model using clinical and cost data from a randomized trial of co-trimoxazole in HIV-infected adults. METHODS: The study included HIV-infected patients in C?te d'Ivoire, with median age 33 years. Thirty-four percent were classified as WHO stage 2, 59% as stage 3, and 7% as stage 4. The mean CD4 cell count was 331 x 10(6) cells/l. The interventions were no prophylaxis, clinical criteria-based co-trimoxazole initiation (early: WHO stage > or = 2; late: WHO stage > or = 3), CD4-based co-trimoxazole initiation (< 500, < 200, < 50 x 10(6) CD4 cells/l). The outcome measures were life expectancy, lifetime costs, and incremental cost-effectiveness. RESULTS: The most effective strategy, initiation of co-trimoxazole prophylaxis at WHO stage > or = 2, increased undiscounted life expectancy by 5.2 months, discounted life expectancy by 4.4 months, and lifetime costs by US dollars 60, compared with no prophylaxis. Delaying prophylaxis initiation until WHO stage >or = 3 was less costly and less effective. All CD4-based strategies were dominated. The incremental cost-effectiveness of early versus late co-trimoxazole prophylaxis initiation was US dollars 200/year of life gained. Results were stable despite wide variations in plausible assumptions about bacterial resistance and the prophylaxis efficacy on co-trimoxazole-resistant strains. CONCLUSIONS: For HIV-infected adults in C?te d'Ivoire, co-trimoxazole prophylaxis is reasonably cost-effective and most effective if initiated when WHO stage > or = 2. Early co-trimoxazole prophylaxis will prevent complications prior to antiretroviral therapy initiation and should be considered an essential component of care for early HIV in sub-Saharan Africa.     

Causes and empirical treatment of fever in HIV-infected adult outpatients, Abidjan, Côte d'Ivoire

OBJECTIVES: In Abidjan, HIV prevalence has been estimated at 20% in outpatients attending community clinics. Documenting causes of fever in HIV-infected adult outpatients may help to improve care in these centres with limited facilities. DESIGN: Prospective study. METHODS: We describe all diagnoses and treatments made during febrile episodes in HIV-infected adults participating in the ANRS 059 trial and followed up in a dedicated outpatient centre. RESULTS: Causes of fever could be identified in half of the 269 febrile episodes. Bacterial diseases were the leading identified cause of fever in all CD4 cell count strata (53, 56 and 43% of identified causes in episodes with CD4 count < 200 x 106/l, 200-499 x 106/l, and >or= 500 x 106/l, respectively), followed by malaria (5, 22, and 38%, respectively). Among febrile bacterial diseases, respiratory tract infections and enteritis accounted for 62% of organ involvement, and Streptococcus pneumoniae and non-typhi Salmonella represented 69% of isolated bacterial strains. In these bacterial episodes, an early empirical antibacterial treatment was associated with shorter duration of hospitalization and fever. In the 19 episodes leading to death (7%), the two leading diagnoses were atypical mycobacteriosis (26%) and acute unexplained fever (21%). Death was associated with the absence of antimalarial treatment in the group of acute unexplained fevers. CONCLUSIONS: African HIV treatment guidelines should take into account the predominant role of bacterial infections and malaria in HIV-infected adult outpatients. Reports from other African settings would be useful to compare experiences in algorithms of empirical early antibacterial and antimalarial treatments.     

Rice irrigation and schistosomiasis in savannah and forest areas of Côte d'Ivoire

Prevalence and intensity of infection of Schistosoma haematobium and Schistosoma mansoni were studied in relation to irrigated rice cultivation in C?te d'Ivoire. Urine and stool samples were collected from 4 to 15-year-old children in 24 villages in the savannah zone and 21 villages in the forest zone. Villages were classified according to surrounding inland valleys into three agro-ecosystems: (R2) full or partial water control allowing two rice cycles per year; (R1) no or partial water control allowing one harvest per year and (R0) absence of rice growing. In the savannah zone, S. haematobium prevalence was 4.8%, 2.3% and 0.7% and S. mansoni prevalence was 16.1%, 11.9% and 2.1% in R2, R1 and R0, respectively. In the forest zone, S. haematobium prevalence was 0.9%, 4.4% and 1.7% and S. mansoni prevalence was 61.3%, 46.6% and 17.5% in R2, in R1 and R0, respectively. Prevalences of S. mansoni adjusted for village effects were significantly different between agro-ecosystems in both zones. Significance of differences between agro-ecosystems of S. haematobium infection were strongly influenced by outlying villages. In savannah rice growing villages, negative binomial regression on infection intensity of each species showed significant positive relations to the surface of rice cultivated inland valleys, whereas uncultivated inland valleys showed no significant relation. However, in forest rice growing villages, S. mansoni infection intensity showed significant positive relations to the surface of uncultivated inland valleys, whereas surface water on rice cultivated land showed significant negative relations with infection intensity of each schistosomiasis species.     

Malaria and property accumulation in rice production systems in the savannah zone of Côte d'Ivoire

Irrigation stabilizes agricultural production and hence improves farmers’ living standards and conditions. The permanent presence of water may, however, increase the burden of water‐related parasitic diseases and counter the economic benefits of irrigation by reducing farmers’ health. The purpose of this study was to assess the impact of malaria on farm household property, beyond the health risk (studied elsewhere). The research question was: by weakening individuals, does malaria reduce productive capacities and income workers, and consequently limit their property accumulation? To test this hypothesis, we use data on property (farming equipment, livestock and durable consumer goods) and Plasmodium falciparum indicators generated by a study carried out in 1998 in the Ivorian savannah zone characterized by inland valley rice cultivation, with a sample of nearly 750 farming households. Property is influenced by many factors related to the size of the family, the area under cultivation and high parasite density infection rate of P. falciparum. A significant negative correlation between high‐density infection rate and the property values confirms that by reducing the living standards of households, malaria is a limiting factor for property accumulation.     

Inland valley rice production systems and malaria infection and disease in the savannah of Côte d'Ivoire

In sub-Saharan Africa, lowlands developed for rice cultivation favour the development of Anopheles gambiae s. l. populations. However, the epidemiological impact is not clearly determined. The importance of malaria was compared in terms of prevalence and parasite density of infections as well as in terms of disease incidence between three agroecosystems: (i) uncultivated lowlands, 'R0', (ii) lowlands with one annual rice cultivation in the rainy season, 'R1' and (iii) developed lowlands with two annual rice cultivation cycles, 'R2'. We clinically monitored 2000 people of all age groups, selected randomly in each agroecosystem, for 40 days (in eight periods of five consecutive days scheduled every 6 weeks for 1 year). During each survey, a systematic blood sample was taken from every sick and asymptomatic person. The three agroecosystems presented a high endemic situation with a malaria transmission rate of 139-158 infective bites per person per year. The age-standardized annual malaria incidence reached 0.9 malaria episodes per person in R0, 0.6 in R1 and 0.8 in R2. Children from 0 to 9-year-old in R0 and R2 had two malarial attacks annually, but this was less in R1 (1.4 malaria episodes per child per year). Malaria incidence varied with season and agroecosystem. In parallel with transmission, a high malaria risk occurs temporarily at the beginning of the dry season in R2, but not in R0 and R1. Development of areas for rice cultivation does not modify the annual incidence of malarial attacks despite their seasonal influence on malaria risk. However, the lower malaria morbidity rate in R1 could be explained by socio-economic and cultural factors.     

Assessing the relationship between HIV infection and cervical cancer in Côte d'Ivoire: A case-control study

Background  

The association between HIV infection and invasive cervical cancer that has been reported may reflect differential prevalence of human papillomavirus (HPV) infection or uncontrolled confounding. We conducted a case-control study in a West African population to assess the relationship between HIV infection and invasive cervical cancer, taking into account HPV infection and other potential risk factors for cervical cancer.     

The relationship between Anopheles gambiae density and rice cultivation in the savannah zone and forest zone of Côte d'Ivoire

In 13 villages in the savannah zone and 21 villages in the forest zone of Côte d'Ivoire, the biting density of the principal malaria vector, Anopheles gambiae, was studied as a function of rice cultivation in the inland valleys in a 2‐km radius around each village. In the savannah villages, during the main season cropping period, surface water on rice‐cultivated and to a lesser extent on uncultivated inland valleys seems to contribute strongly to the A. gambiae population density. For the off‐season cropping period (which starts after the first light rains in the savannah zone), correlations were weaker. Breeding sites other than in inland valleys may play an important role in the savannah zone. In the forest zone, however, the A. gambiae population density was strongly correlated with the surface water availability (SWA) in the rice‐cultivated inland valleys, whereas the correlation with the SWA in other (uncultivated) inland valleys was weak. The requirement of sunlit breeding sites for A. gambiae might explain this difference between zones. In the forest zone, only inland valleys cleared for rice cultivation meet this requirement, whereas all other inland valleys are covered with dense vegetation. In the savannah zone, however, most undergrowth is burnt during the dry season, which permits sunlight to reach puddles resulting from the first rains.     

Quality of antenatal and delivery care before and after the implementation of a prevention of mother-to-child HIV transmission programme in Côte d'Ivoire

Objective  To assess whether implementation of a prevention of mother-to-child HIV transmission (PMTCT) programme in Côte d'Ivoire improved the quality of antenatal and delivery care services.
Methods  Quality of antenatal and delivery care services was assessed in five urban health facilities before (2002–2003) and after (2005) the implementation of a PMTCT programme through review of facility data; observation of antenatal consultations ( n  = 606 before; n  = 591 after) and deliveries ( n  = 229 before; n  = 231 after) and exit interviews of women; and interviews of health facility staff.
Results  HIV testing was never proposed at baseline and was proposed to 63% of women at the first ANC visit after PMTCT implementation. The overall testing rate was 42% and 83% of tested HIV-infected pregnant women received nevirapine. In addition, inter-personal communication and confidentiality significantly improved in all health facilities. In the maternity ward, quality of obstetrical care at admission, delivery and post-partum care globally improved in all facilities after the implementation of the programme although some indicators remained poor, such as filling in the partograph directly during labour. Episiotomy rates among primiparous women dropped from 64% to 25% ( P  < 0.001) after PMTCT implementation. Global scores for quality of antenatal and delivery care significantly improved in all facilities after the implementation of the programme.
Conclusions  Introducing comprehensive PMTCT services can improve the quality of antenatal and delivery care in general.