The risk of transfusion‐transmitted infections in sub‐Saharan Africa

BACKGROUND: Blood transfusions carry the risk of transmitting infections. This risk has been studied in detail in high‐income countries but not in sub‐Saharan Africa. This study estimates the risks of acquiring human immunodeficiency virus (HIV), hepatitis B virus (HBV), or hepatitis C virus (HCV) from a single unit of blood in sub‐Saharan Africa. STUDY DESIGN AND METHODS: A mathematical model was constructed to quantify transfusion risks across 45 sub‐Saharan African countries using three components: the risk of a contaminated unit entering the blood supply, the risk that the unit will be given to a susceptible patient, and the risk that receipt of the unit will lead to infection in the recipient. Variables included prevalence of infection in donors, extent of blood testing, test sensitivity, and susceptibility of recipients. Data from the World Health Organization (WHO) African Region and a systematic review of the literature were used to parameterize the model. Uncertainty in the risk estimates was quantified using probabilistic sensitivity analysis. RESULTS: The median overall risks of becoming infected with HIV, HBV, and HCV from a blood transfusion in sub‐Saharan Africa were 1, 4.3, and 2.5 infections per 1000 units, respectively. If annual transfusion requirements projected by the WHO were met, transfusions alone would be responsible for 28,595 HBV infections, 16,625 HCV infections, and 6650 HIV infections every year. Sensitivity analysis suggests that the true risks may be even higher. CONCLUSIONS: This study is the first to systematically quantify the risks of transfusion‐transmitted infections across sub‐Saharan Africa. Although the results are limited by the quality and quantity of available data, these may be the most reliable estimates at this time.     

Dangerous traffic

In the next few years, Africa expects some 75,000 Acquired Immune Deficiency Syndrome (AIDS) related deaths, a human and economic disaster. The transmission of AIDS in Africa largely is through heterosexual contact, which accounts for about 75% of infections. The reasons why transmission is different than in the west are unclear, but 1 theory is that the presence of other sexually transmitted diseases increases the risk of contracting human immunodeficiency virus through sores and inflammation of the genitals. It also has been suggested that susceptibility to HIV is genetically determined by a protein type most commonly found in black Africans. Incidence of HIV is difficult to determine in Africa, but studies of healthy adults suggest that between 1-15% are infected, men and women almost equally affected. Contaminated blood transfusions also are a serious problem. Many African nations lack the facilities or resources to test for HIV. Children are at risk from both maternal transmission and medical injections. The majority of AIDS sufferers are cared for by their own communities, frequently with little or no professional support or guidance.     

Opportunities for treating sexually transmitted infections and reducing HIV risk in rural South Africa

AIM: This paper is a report of a study to determine the aetiological distribution of sexually transmitted infections and prevalence of human immunodeficiency virus infection in selected primary health care clinic attendees. BACKGROUND: South Africa has a high prevalence of human immunodeficiency virus and other sexually transmitted infections. Sexually transmitted infections are managed syndromically in the public sector as part of the essential nurse-driven primary care services provided at no cost to the client. METHOD: This cross-sectional study was conducted in a rural community in South Africa between September and November 2002. A total of 277 consenting women were recruited. Vulvo-vaginal swabs were collected for screening for Neisseriae gonorrheae, Chlamydia trachomatis and Trichomonas vaginalis using DNA amplification methods and Gram stain with Nugent's score for the diagnosis of bacterial vaginosis. Seroprevalence of syphilis and human immunodeficiency virus infection were determined. FINDINGS: The overall prevalence of human immunodeficiency virus in the study was 43.7% (95% confidence interval 37.6-50.0) with the prevalence in family planning clinic attendees 45.5% (95% confidence interval 38.9-52.3) and antenatal clinic attendees 33.3% (95% confidence interval 19.6-50.3). The prevalence of sexually transmitted infections amongst both the antenatal clinic and family planning attendees accounted for at least 70% of cases. Fifty per cent of women had one recognized sexually transmitted infection with 17.9% of the family planning and 14.5% of the antenatal clinic attendees having infections from two recognized pathogens. All infections were asymptomatic. CONCLUSION: Nurse-driven antenatal and family planning services provide a useful opportunity for integrating reproductive health services, human immunodeficiency virus voluntary counselling and testing and treatment of sexually transmitted infections.     

The global distribution of human immunodeficiency virus type 2 (HIV-2) infection

We reviewed published reports of infection with human immunodeficiency virus type 2 (HIV-2) to provide a picture of its geographic distribution, pathogenicity, modes of transmission, and risk to the blood supply. Since the first reports in 1986, 627 HIV-2-seropositive persons have been reported; 604 of these were in natives of West Africa. Acquired immunodeficiency syndrome (AIDS) had developed in 42 patients, while 8 patients had AIDS-related complex. Transmission by sexual intercourse was the usual reported mode of spread. The modes of transmission of HIV-2 are thought to be the same as those for HIV-1, but perinatal transmission and transmission by sharing of needles among intravenous drug abusers have not yet been reported. The virus has not been identified in blood donors in the United States or West Germany, but two HIV-2-infected blood donors were reported in France. Further epidemiologic studies are needed to define the spectrum of disease, modes of transmission, and risk of HIV-2 to the blood supply.     

Factors influencing reduction of sexual risk behaviors for human immunodeficiency virus infection: A review

The past decade witnessed an alarming increase in prevalence of human immunodeficiency virus (HIV) infection. In this paper, we review the literature on factors which influence the reduction of risk behaviors for human immunodeficiency virus among gay and bisexual men, intravenous drug users, and non-intravenous drug using heterosexual adolescents and adults. In this review, specific attention is paid to the reduction of sexual modes of viral transmission. Several risk reduction factors are identified. Methodological limitations are discussed and suggestions for further research are offered.     

The East Africa Consortium for human papillomavirus and cervical cancer in women living with HIV/AIDS

The East Africa Consortium was formed to study the epidemiology of human papillomavirus (HPV) infections and cervical cancer and the influence of human immunodeficiency virus (HIV) infection on HPV and cervical cancer, and to encourage collaborations between researchers in North America and East African countries. To date, studies have led to a better understanding of the influence of HIV infection on the detection and persistence of oncogenic HPV, the effects of dietary aflatoxin on the persistence of HPV, the benefits of antiretroviral therapy on HPV persistence, and the differences in HPV detections among HIV-infected and HIV-uninfected women undergoing treatment for cervical dysplasia by either cryotherapy or LEEP. It will now be determined how HPV testing fits into cervical cancer screening programs in Kenya and Uganda, how aflatoxin influences immunological control of HIV, how HPV alters certain genes involved in the growth of tumours in HIV-infected women. Although there have been challenges in performing this research, with time, this work should help to reduce the burden of cervical cancer and other cancers related to HIV infection in people living in sub-Saharan Africa, as well as optimized processes to better facilitate research as well as patient autonomy and safety.

KEY MESSAGES

• The East Africa Consortium was formed to study the epidemiology of human papillomavirus (HPV) infections and cervical cancer and the influence of human immunodeficiency virus (HIV) infection on HPV and cervical cancer.
• Collaborations have been established between researchers in North America and East African countries for these studies.
• Studies have led to a better understanding of the influence of HIV infection on the detection and persistence of oncogenic HPV, the effects of dietary aflatoxin on HPV detection, the benefits of antiretroviral therapy on HPV persistence, and the differences in HPV detections among HIV-infected and HIV-uninfected women undergoing treatment for cervical dysplasia by either cryotherapy or LEEP.

     

Reducing the rate of mother-to-child HIV transmission in Africa.

Currently there are about twenty four million HIV/AIDS (human immunodeficiency virus and acquired immunodeficiency syndrome) cases on the continent of Africa. Over the past two years, many health care professionals have been in a stage of denial concerning this problem. According to researchers attending the XIII International AIDS Conference held in Durban, South Africa, the world became aware that cost-effective strategies are needed desperately to stop the rapid spread of HIV/AIDS in Africa. Recent studies suggest that modest antiretroviral drug therapies for HIV-positive pregnant women can reduce one-half of the risk of HIV transmission to the unborn child. Challenges to the governments of Africa such as the high cost of drugs, lack of health care infrastructure and cultural barriers, priority to treat only pregnant women has been a difficult decision, while other infected persons with HIV are not treated.     

Human immunodeficiency virus-1 infection correlates strongly with herpes simplex virus-2 (genital herpes) seropositivity in South African and United States blood donations

BACKGROUND: In South Africa, human immunodeficiency virus-1 (HIV-1) infection correlates with herpes simplex virus-2 (HSV-2; genital herpes) seropositivity in genitourinary disease clinic attendees. HSV-2 infection may be a marker for risk behavior and/or directly facilitate HIV-1 transmission. The rate of HSV-2 infection in HIV-infected South African and US blood donations was assessed, and whether the infections were correlated in donors screened and found negative for high-risk behavior by predonation interview was questioned. STUDY DESIGN AND METHODS: A total of 625 South African and 393 US HIV-1-infected repository samples previously characterized for longstanding or recent HIV-1 infection were tested with two commercially available HSV-2-specific assays. The prevalence of HSV-2 antibodies in South Africa was further assessed in 106 HIV-1-infected and 106 HIV-1-negative donors matched for sex, race, and donation history, as well as 200 random HIV-1-negative donors. RESULTS: A total of 52.2 percent of US and 69.3 percent of South African HIV-1-infected donations were HSV-2-seropositive. Age, race, and sex were independent risk factors for HSV-2 antibody prevalence in HIV-1-infected South African donors, who were more likely to be HSV-2 antibody-reactive than random HIV-1-negative donors (72.6% vs. 8.5%: odds ratio [OR], 28.6; 95% confidence interval [CI], 14.5-55) or matched donors (71.6% vs. 19.6%: OR, 10.3; 95% CI, 5.4-19.8). HIV-1 infection and HSV-2 seropositivity correlated in white and black populations when analyzed by age group. CONCLUSIONS: HIV-1 infection correlates strongly with HSV-2 seropositivity in US and South African blood donors. Our data describe the characteristics of HSV-2 antibody testing as a surrogate marker for HIV-1 infection and support a facilitating role for HSV-2 infection in HIV-1 transmission.     

Issues concerning women and AIDS: sexuality.

In the US and globally women are contracting the human immunodeficiency virus (HIV) and developing the acquired immunodeficiency syndrome (AIDS) the fastest. Worldwide, HIV is transmitted primarily through heterosexual intercourse. In the US, the proportion of women who have contracted AIDS by heterosexual transmission has increased from 11% in 1984 to 34% in 1990. Women are at a greater risk than men for transmission by heterosexual intercourse as the ratio of women to men who acquire AIDS by heterosexual transmission is 3 to 1. Furthermore, 25% of AIDS cases caused by heterosexual transmission or iv drug use occurs in women. Although women often develop HIV-related serious gynecologic problems, including cervical cancer and refractory vaginal candidiasis, these conditions do not fall within the Centers for Disease Control definition of AIDS. Women who have gynecologic symptoms are not diagnosed as having AIDS, are not eligible for AIDS benefits, and live half as long as men do once they are diagnosed as being HIV infected. Little is known about the characteristics of HIV infection or AIDS in women. Sexually transmitted diseases (STDs) seem to act as cofactors for HIV infection. The human papilloma virus or genital warts, the herpes simplex virus, syphilis, chancroid, recurrent vaginal candidiasis, abnormal Pap smears, cervical neoplasias, and pelvic inflammatory disease have been associated with HIV infection in women. HIV infection should be considered in all women with symptoms of any of these disorders. Nurses must first become aware of the clinical manifestations of HIV infection specific to women. Nursing interventions should educate about safer-sex including condom use with nonoxynol 9, and the risks of sharing needles. Strategies must be developed that provide empowerment skills and are sensitive to the women's cultural, religious, and ethnic background, beliefs, and values.     

The impact of HIV/AIDS on the African American woman and child: epidemiology, cultural and psychosocial issues and nursing management.

The approach to understanding the human immunodeficiency virus (HIV) and the acquired immunodeficiency syndrome (AIDS) must include the African American woman and children as persons at high risk. This information must be documented in all epidemiology, cultural and psychosocial aspects of care, and nursing management reports. Approximately twenty years after it was first recognized, AIDS is still traveling across the globe at full speed, with very little brake power. In the United States, the African American heterosexual woman continues to be the fastest growing group of persons with the acquired immunodeficiency syndrome. The proportion of cases increased drastically in the period from 1993 to October 1995, with women totaling 18 percent of the total cases (Newman & Wofsy, 1997). The impact that cultural and psychological issues have had on women and children living with HIV or AIDS is immense, involving not only the potential burdens of physical deterioration, but also the stress of accompanying lifestyle and role changes. These issues involve processes in adjusting and adapting to HIV infection that are important not only because of their centrality to the coping individual, but because they directly affect the success of treatment and prevention (Jaccard, Wilson & Radecki, 1995).     

Seroepidemiology of human immunodeficiency viruses in Africa

The first generation of serological tests for anti-HIV-1 gave so many false positives with African sera that it was wrongly postulated that the virus was endemic in Africa. As there is no simian or other virus sufficiently closely related to HIV-1 as to suggest a recent common ancestor, the evolution of HIV-1 is obscure and there is no current evidence to support the hypothesis of an African origin. However, the similarity of HIV-2 to SIV and its geographical distribution do suggest an evolution of this virus in west Africa. The earliest anti-HIV-1 positive serum was from a subject in Kinshasa in 1959. Seroprevalence rose in pregnant women in Kinshasa from 0.25% in 1970, to 3.0% in 1980 and 5.7% in 1986. When two sexually promiscuous groups are compared, seropositivity rose sharply in female prostitutes in Nairobi from 4% in 1981, to 59% in 1984 and 64% in 1986, a curve which is approximately parallel to, but three years later than that of homosexual males in San Francisco. In central and east Africa, HIV-1 is now epidemic from Congo to Kenya and from Uganda to Zimbabwe. In west Africa, both HIV-2 and HIV-1 are epidemic: seroprevalence of HIV-2 is highest in southern Senegal, Guinea-Bissau and C?te d'Ivoire: HIV-1 has the highest frequency in C?te d'Ivoire and Ghana. HIV-2 has not been reported, and HIV-1 is pre-epidemic in Africa north of the Sahara, Nigeria, Angola, Mozambique and southern Africa, being found at significant frequency only in female prostitutes, patients with STD, or, in Morocco and South Africa only, in male homosexuals. Seroprevalence is greatest in female prostitutes and patients with STD: infection is more frequent in urban than in rural populations, except in Uganda. The peak frequency is at 30-34 yr in males and 20-24 yr in females. Other groups at risk are infants born to infected mothers, and those requiring blood transfusions, especially pre-school children, patients with sickle-cell disease and pregnant women. The doubling time for seropositivity is about one year in the sexually active age range in some populations. Even at existing seroprevalence, decimation or worse of the most productive age groups is inevitable during the next few years in certain countries.(ABSTRACT TRUNCATED AT 400 WORDS)     

Human immunodeficiency virus and hepatitis B virus infection in pregnancy: diagnostic potential of viral genome detection

Hepatitis B virus (HBV) and human immunodeficiency virus (HIV) account for millions of cases of vertical infections worldwide. Laboratory diagnosis is essential for the detection of potentially infectious carriers. HBeAg represents the best serological marker for HBV replication. Since 10% of HBeAg-negative carriers transmit the virus to their children, determination of viral DNA is more reliable for the assessment of the risk to vertical infection. Risk assessment of vertical HIV transmission and monitoring AZT therapy during pregnancy are achieved by determination of HIV-1 viral load and CD4+ cell count. HIV-1 RNA or cDNA detection permits a nearly 100% sensitive diagnosis of congenital HIV infection already 2 weeks after birth. While qualitative HBV DNA determination should be limited only to anti-HBe carriers in order to assess infectiosity, HIV-1 RNA measurement represents in combination with the CD4+ cell count the best prognostic marker for vertical HIV infection and for the follow-up of infected children.     

BLOOD DONORS AND BLOOD COLLECTION: Web interface–supported transmission risk assessment and cost‐effectiveness analysis of postdonation screening: a global model applied to Ghana,Thailand, and the Netherlands

BACKGROUND: The goal of our research was to actively involve decision makers in the economic assessment of screening strategies in their region. This study attempted to accomplish this by providing an easy‐to‐use Web interface at http://www.bloodsafety.info that allows decision makers to adapt this model to local conditions. STUDY DESIGN AND METHODS: The cost‐effectiveness was compared of 1) adding antigen screening to antibody screening for hepatitis C virus (HCV) and human immunodeficiency virus (HIV); 2) adding nucleic acid amplification testing (NAT) on hepatitis B virus (HBV), HCV, and HIV in minipool (pool of 6 [MP6] and 24 [MP24]) to antibody screening and hepatitis B surface antigen (HBsAg) screening; and 3) individual‐donation NAT on HBV, HCV, and HIV to antibody screening and HBsAg screening for Ghana, Thailand, and the Netherlands. RESULTS: The combination of HCV antibody‐antigen combination (combo) and HIV combo added to antibody screening in Ghana and Thailand was cost‐effective according to the WHO criteria. MP24‐NAT screening in Ghana was also cost‐effective. MP24‐NAT on HBV, HCV, and HIV was not cost‐effective compared to the other screening strategies evaluated for the Netherlands. Large regional differences in cost‐effectiveness were found for Thailand. CONCLUSION: The young transfusion recipient population of Ghana in combination with a high risk of viral transmission yields better cost‐effectiveness for additional tests. The advanced age of the transfused population of the Netherlands and a small risk of viral transmission gives poor cost‐effectiveness for more sensitive screening techniques. It was demonstrated that a global health economic model combined with a Web interface can provide easy access to risk assessment and cost‐effectiveness analysis.     

Heterosexually acquired human immunodeficiency virus infection and the United States blood supply: considerations for screening of potential blood donors. HIV Blood Donor Study Group

The impact of heterosexual transmission of the human immunodeficiency virus (HIV) on the United States blood supply was assessed, and deferral criteria that may exclude potential donors who are at high risk for heterosexually acquired HIV infection were evaluated. Interviews were conducted with 508 HIV-seropositive blood donors from May 1, 1988, to August 31, 1989 (Phase 1), and with 472 donors from January 1, 1990, to May 31, 1991 (Phase 2), at 20 blood centers. From Phase 1 to Phase 2, the overall HIV prevalence decreased from 0.021 to 0.018 percent (p < 0.001). HIV risk factors among HIV-1-seropositive donors were similar during both study phases. Eleven percent of the men and 56 percent of the women reported as their only risk that they had a heterosexual partner who was at increased risk for HIV or was known to have HIV. These percentages were similar during both study periods. During Phase 2, 13 percent of the men and 17 percent of the women with heterosexual transmission risk had a positive serologic test for syphilis, hepatitis B core antibody, or hepatitis C antibody. Among HIV- 1-seropositive donors reporting heterosexual risk, the median numbers of previous-year and lifetime sex partners for men were 2 and 30, respectively; for women, those numbers were 1 and 7, respectively. Thirty-one percent of the men and 6 percent of the women reporting heterosexual transmission risk also reported having had syphilis or gonorrhea within 3 years of donation. It is concluded that the impact of heterosexual transmission of HIV infection on transfusion safety is not worsening at this time.(ABSTRACT TRUNCATED AT 250 WORDS)     

Elimination of Vertical Transmission of Hepatitis B in Africa: A Review of Available Tools and New Opportunities

Purpose

This review article focuses on preventing vertical transmission of hepatitis B virus (HBV) among pregnant women living in sub-Saharan Africa (SSA), where disease is endemic and the estimated maternal HBV seroprevalence is >8%. Available interventions that have been studied in low- and middle-income countries are compared in terms of efficacy and effectiveness in clinical practice. Global disease-elimination targets, barriers to HBV-prevention efforts, and critical research gaps are discussed.

USPSTF recommendations for STI screening

Since 2000, the U.S. Preventive Services Task Force (USPSTF) has issued eight clinical recommendation statements on screening for sexually transmitted infections. This article, written on behalf of the USPSTF, is an overview of these recommendations. The USPSTF recommends that women at increased risk of infection be screened for chlamydia, gonorrhea, human immunodeficiency virus, and syphilis. Men at increased risk should be screened for human immunodeficiency virus and syphilis. All pregnant women should be screened for hepatitis B, human immunodeficiency virus, and syphilis; pregnant women at increased risk also should be screened for chlamydia and gonorrhea. Nonpregnant women and men not at increased risk do not require routine screening for sexually transmitted infections. Engaging in high-risk sexual behavior places persons at increased risk of sexually transmitted infections. The USPSTF recommends that all sexually active women younger than 25 years be considered at increased risk of chlamydia and gonorrhea. Because not all communities present equal risk of sexually transmitted infections, the USPSTF encourages physicians to consider expanding or limiting the routine sexually transmitted infection screening they provide based on the community and populations they serve.     

Management of newborns exposed to maternal HIV infection

The management of infants whose mothers are infected with the human immunodeficiency virus (HIV) involves minimizing the risk of vertical transmission of HIV, recognizing neonatal HIV infection early, preventing opportunistic infections, and addressing psychosocial issues. Maternal antiretroviral drug therapy during pregnancy and labor, followed by six weeks of neonatal zidovudine therapy, can significantly decrease the risk of vertical transmission. Additional antiretroviral drugs may be needed in some high-risk newborns. Elective cesarean section also may prevent vertical transmission of HIV. Virologic tests allow early diagnosis of HIV infection, facilitating the timely initiation of aggressive treatment and the prevention of opportunistic infections. Even when tests are negative, infants must be closely monitored until age 18 months to completely rule out HIV infection. Prophylaxis for Pneumocystis carinii pneumonia should be initiated when HIV-exposed infants are six weeks old and should be continued for at least four months, regardless of negative virologic tests, because P. carinii pneumonia is often the initial presentation of HIV infection in infants. Laboratory monitoring, screening for perinatal infections, appropriate social support, and other modifications of standard infant care are also necessary.     

Neurological manifestations of acquired immunodeficiency syndrome

This article provides an overview of the range of neurological manifestations that have been described in association with human immunodeficiency virus (HIV) infection. The transmission of acquired immunodeficiency syndrome (AIDS) and the precautions personnel must take when having contact with patients with AIDS are briefly reviewed. The nursing approach to the neurologically impaired victim of HIV infection is discussed.     

Altered small-intestinal permeability associated with diarrhoea in human-immunodeficiency-virus-infected Caucasian and African subjects.

1. Small-intestine integrity in Caucasian and African patients infected with human immunodeficiency virus was determined by measuring the permeation across the mucosa of two sugars, lactulose and mannitol. 2. The sugars were assayed by h.p.l.c. and pulsed amperometric detection in 6 h urine samples. Stool microscopy for enteropathogens was performed in all patients. 3. The ratio of lactulose to mannitol recovered in urine was increased in Caucasian and African patients with advanced human immunodeficiency virus infection. Asymptomatic human-immunodeficiency-virus-infected subjects had a normal lactulose/mannitol ratio. African patients with diarrhoea showed a twofold reduction in mannitol excretion. Such a change in mannitol absorption was not detected in Caucasian patients and occurred regardless of the presence of enteropathogens. 4. Altered small-intestinal permeability is associated with symptomatic diarrhoea in human immunodeficiency virus infection in both Caucasian and African patients.     

Hygiene interventions for prevention of cytomegalovirus infection among childbearing women: systematic review

Title.  Hygiene interventions for prevention of cytomegalovirus infection among childbearing women: systematic review.
Aim.  This paper is a report of a systematic review to examine the effectiveness of preventive interventions to reduce congenital cytomegalovirus transmission and infection among women of childbearing age.
Background.  Congenital cytomegalovirus has been identified as the leading infectious cause of damage to the growing fetus in developed countries, including Down syndrome, fetal alcohol syndrome and spina bifida. Despite the prevalence and consequences of this infection, it has a low profile and pregnant mothers are often unaware of the risks and protective behaviours related to its transmission. Women with children in daycare and nurses working with children are particularly at risk of acquiring the virus.
Data sources.  A computerized literature search for articles up to 1 December 2007 was performed using MEDLINE (from 1950); EMBASE (from 1980) and CINAHL (from 1982).
Review methods.  Both authors independently reviewed studies that met inclusion criteria and assigned a quality rating determined by the number of validity criteria met. Differences were discussed until consensus was reached.
Findings.  Differences in hygiene behaviour changes were most statistically significant for pregnant, seronegative women. Although the methodological quality of the three included studies was not strong, seroconversion rates consistently decreased as cytomegalovirus education and support increased.
Conclusion.  Nurses can act as preventive agents for cytomegalovirus infection through education about hygiene precautions during antenatal care and through preventive measures in the workplace. The review findings suggest educational interventions in hygiene practices have the potential to be a feasible, large-scale, primary prevention strategy.