HIV prevention: What have we learned from community experiences in concentrated epidemics?

Drawing on lessons learned from community experiences in concentrated epidemics, this paper explores three imperatives in the effort to reduce the sexual transmission of HIV: combat prevention fatigue, diversify HIV testing and combat stigma and discrimination. The paper argues for a non‐judgmental harm reduction approach to the prevention of sexual transmission of HIV that takes into account the interpretation of risk by diverse individuals and communities in the era of antiretroviral therapy. This approach requires greater attention to increasing access to opportunities to know one's serostatus, especially among key populations at greater risk. Novel approaches to diversifying HIV testing approaches at community level are needed. Finally, the paper makes a plea for bold measures to combat stigma and discrimination, which continues to represent a formidable barrier for access to services for affected populations and may contribute to HIV‐related risk behaviours. A “triple therapy” approach to address stigma and discrimination is discussed, which includes greater acceptance of people living with HIV and AIDS (PLWHA), improving relevant laws and policies, and involving prevention users‐ working with people rather than for people‐. Note: this paper corresponds to the plenary talk of Bruno Spire at the XVIIth World AIDS Conference, August 8th, Mexico city: http://www.kaisernetwork.org/health_cast/player.cfm?id=4383     

Le risque infectieux viral chez le polytransfusé : séroprévalence de sept agents viraux dans le centre tunisien

The aim of this study is to evaluate the prevalence of seven transfusion-transmitted viruses in polytransfused adults and children comparatively with a group of healthy control subjects. We studied 107 polytransfused patients (59 adults and 48 children) and 160 control subjects (100 blood donors and 60 children). Immunoenzymatic tests were used for detection of HBs antigen (HBs Ag), antibodies against hepatitis C Virus (anti-HCV), and human immunodeficiency virus (anti-HIV), and IgG antibodies against human cytomegalovirus (IgG anti-CMV), human parvovirus B19 (IgG anti-PB19), and hepatitis E virus (IgG anti-HEV). An immunofluorescent assay was performed for the detection of human herpesvirus 8 antibodies (anti-HHV8). Prevalence of HBs Ag, anti-HCV, anti-HIV, IgG anti-CMV, IgG anti-PB19, IgG anti-HEV, and anti-HHV8 in polytransfused group was 8.4, 4.7, 0, 86.9, 60.7, 28.9, and 47.6%, respectively, and 1.8, 0.6, 0, 86.2, 53.1, 10, and 12.5%, respectively, in the control group. The difference in prevalence between the two groups was statistically significant for HBs Ag (P = 0.01), anti-HCV (P = 0.03), IgG anti-HEV (P < 10(-4)), and IgG anti-HHV8 (P < 10(-4)). Categorization according to age showed that hepatitis B and C risk was limited in adult polytransfused group. HHV8 infection was higher in polytransfused subjects born before the use of leucocyte-depleted blood components. Our results corroborate literature data on the risk of HEV and HHV8 infection by blood transfusion. Hepatitis B vaccination and improvement in screening tests have an important role in reduction of hepatitis B and C risk in transfusion, especially in young polytransfused persons. However, a residual risk of transmitting viral infections persists, and efforts are needed to improve transfusion safety.     

c.1643_1644delTG XPC mutation is more frequent in Moroccan patients with xeroderma pigmentosum

Xeroderma pigmentosum is a rare autosomal recessive disease characterized by hypersensitivity to UV light which is due to alterations of the nucleotide excision repair pathway. Eight genes (XPA to XPG and XPV) are responsible for the disease. Among them, the XPC gene is known to be the most mutated in Mediterranean patients. The aim of this study was to determine the frequency of the most common XPC mutation and describe the clinical features of Moroccan patients with xeroderma pigmentosum. Twenty four patients belonging to 21 unrelated Moroccan families and 58 healthy subjects were investigated. After clinical examination, the screening for the c.1643_1644delTG (p.Val548AlafsX25) mutation in the XPC gene was performed by PCR and automated sequencing of exon 9 in all patients and controls. The molecular analysis showed that among the 24 patients, 17 were homozygous for the c.1643_1644delTG mutation and all their tested parents were heterozygous, whereas the others (7 patients) did not carry the mutation. The frequency of this mutation was estimated to be 76.19 % (16/21 families). None of the 58 healthy individuals carried this mutation. In addition, clinical investigation showed that the majority of the patients bearing this mutation have the same clinical features. Our results revealed that the p.Val548AlafsX25 mutation is the major cause (76.19 %) of xeroderma pigmentosum in Moroccan families. This would have an important impact on improving management of patients and their relatives.     

Prosthetic valve endocarditis. A survey.

Fifty eight patients (aged 8-59 years, mean 27) treated for prosthetic valve endocarditis from January 1966 to January 1985 were studied retrospectively by review of case notes. There were 12 cases of early and 46 cases of late prosthetic valve endocarditis. These developed in 28 patients with an isolated aortic valve, in 26 with an isolated mitral valve, and in four with both aortic and mitral prosthetic valves. Streptococci were the most commonly isolated microorganisms, followed by staphylococci, Gram negative bacteria, and fungi. A surgical (34 cases) or a necropsy specimen (10 cases) from 44 cases was examined. Eighty two per cent of the patients had congestive heart failure. Twenty four of the 58 patients were medically treated and 17 died (70% mortality). Combined medical and surgical treatment was used in 34 patients; the main indication for surgery was congestive heart failure. Fourteen patients on combined treatment died (40% mortality). Persistent sepsis and prosthetic valve dehiscence were the most common early and late operative complications. The most important influences on outcome were congestive heart failure, the type of micro-organism, the severity and extent of anatomical lesions, the time of onset of prosthetic valve endocarditis, and the type of treatment. This survey indicates that only patients without congestive heart failure or embolic complications and with sensitive micro-organism should be treated medically. In view of the poor prognosis patients with prosthetic valve endocarditis associated with congestive heart failure, persistent sepsis, and repeat arterial emboli should be treated by early surgical intervention.