Cohort Profile: The Bissau HIV Cohort-a cohort of HIV-1, HIV-2 and co-infected patients

Monocyte phenotype and extracellular vesicles in HIV-1, HIV-2, and HIV-1/2 dual infection

OBJECTIVE

AIDS-defining illness develops at higher CD4 + T-cell counts in individuals infected with HIV-2 compared with HIV-1-infected, which suggests that the two types of HIV may have different effects on other compartments of the immune system. We here investigate monocyte phenotype, activation and macrophage-derived extracellular vesicles in individuals with different HIV types.

DESIGN

Cross-sectional.

METHODS

ART-naive HIV-1 ( n  = 83), HIV-2 ( n  = 63), and HIV-1/2 dually positive ( n  = 27) participants were recruited in Bissau, Guinea-Bissau, together with HIV-negative controls ( n  = 26). Peripheral blood mononuclear cells (PBMCs) were isolated and analyzed by flow cytometry for monocyte phenotype and activation, and plasma was analyzed for extracellular vesicle forms of CD163 and CD206.

RESULTS

Compared with HIV-negative controls, all groups of HIV-positive participants had a skewed monocyte phenotype with a higher proportion of intermediate monocytes, increased CD163 expression and elevated serum levels of the inflammatory biomarkers soluble (s)CD163 and sCD206. HIV-2-positive participants had lower CD163 monocyte expression than HIV-1-positive participants, regardless of HIV RNA or CD4 + cell count. Levels of sCD206 extracellular vesicles were increased in all HIV groups, and higher in HIV-1 compared with HIV-2-positive participants.

CONCLUSION

The monocyte phenotype of HIV-2-positive participants deviated less from healthy controls than did HIV-1 participants. HIV-2-positive participants also had a lower concentration of extracellular CD206 vesicles compared with HIV-1-positive participants. This does not explain the difference in AIDS development.

The HIV care continuum of Guinea-Bissau; Progress towards the UNAIDS 90-90-90 targets for HIV-1 and HIV-2

OBJECTIVE

In the 2020 UNAIDS HIV treatment goals, 90% of people living with HIV (PLHIV) should be diagnosed, 90% of these should receive antiretroviral treatment (ART) and 90% of these should be virally suppressed. We aimed to evaluate whether Guinea-Bissau fulfills the 2020 treatment goals for both for HIV-1 and HIV-2.

DESIGN

By combining data from a general population survey, treatment records from HIV clinics across Guinea-Bissau and a biobank from patients attending the largest HIV clinics in Bissau, we estimated each column of the 90-90-90 cascade.

METHOD

2601 participated in the survey and were used to estimate the proportion of PLHIV who knew their HIV status and the proportion of PLHIV on ART. Answers given in the survey was verified with treatment records from HIV clinics. We measured viral load from biobank materials from HIV patients and estimated the proportion of virally suppressed PLHIV.

RESULT

19.1% of PLHIV indicated to be aware of their HIV status. Of these, 48.5% received ART, and 76.4% of these were virally suppressed. For HIV-1 and HIV-1/2 the results were 21.2%, 40.9% and 75.1%. For HIV-2 the results were 15.9%, 63.6% and 80.7%. 26.9% of all HIV-1 infected in the survey were virologically suppressed, indicating that a much higher number of HIV-1 infected were aware of their status and on treatment.

CONCLUSION

Guinea-Bissau lags severely behind both the global and regional progress. Improvement in both testing and treating HIV is necessary to improve the quality of care.

Xpert MTB/RIF on urine samples to increase diagnosis of TB in people living with HIV in Guinea-Bissau

OBJECTIVES

We investigated if Xpert MTB/RIF (Xpert) testing on urine samples among newly diagnosed HIV-patients as an adjunctive test to Xpert testing on sputum increases diagnosis. We sought to define subgroups of patients, for whom testing with either test is especially advantageous.

METHODS

We included patients >15 years, newly diagnosed with HIV, that delivered a urine sample on the day of HIV-diagnosis at the biggest HIV-clinic in Guinea-Bissau between September 5, 2016 and October 13, 2017 into a cross-sectional study. Patients were asked for a sputum sample, which was Xpert tested if returned within 30 days. A questionnaire and physical examination were completed on day of inclusion.

RESULTS

We included 390 patients. TB prevalence was 12.6%. Adding Xpert urine test to all newly diagnosed HIV-patients increased diagnostic yield of TB by 58% compared with testing on sputum alone. Patients who tested positive by Xpert on urine samples were clinically similar to those tested with sputum, except that the sputum positives reported more cough (p=0.03).

CONCLUSIONS

Indiscriminate Xpert urine testing in newly diagnosed HIV-patients with advanced disease increased diagnostic yield. Xpert testing for TB on urine and sputum should be offered as screening in Guinea-Bissau and possibly in similar settings.

SARS-CoV-2 seroprevalence among people living with HIV in Guinea-Bissau

Objectives

In low-income countries with poor SARS-CoV-2 monitoring and high HIV burden, the prevalence of SARS-CoV-2 is scarcely studied in people living with HIV (PLWH). We set out to measure SARS-CoV-2 seroprevalence in this group.

Study design

Serosurvey of SARS-CoV-2 in PLWH.

Methods

We measured IgG/IgM antibodies using point-of-care rapid tests in 294 PLWH with HIV-1, HIV-2 or HIV-1/2 dual infection at an HIV clinic in Guinea–Bissau between June 1, 2021, and October 1, 2021.

Results

Unvaccinated PLWH (n = 195), constituting 66% of the total study population, had a seroprevalence of SARS-CoV-2 antibodies of 27.7%. Of SARS-CoV-2 seropositive unvaccinated PLWH, 71.2% reported no symptoms of COVID-19 since the start of the epidemic up to the inclusion date. Among all participants, 90.1% reported never having been tested for SARS-CoV-2 by any test (n = 292). Six participants reported a household death, corresponding to a crude annual death rate of 3.3 per 1000 people.

Conclusions

Despite a low number of officially registered cases of SARS-CoV-2 in Bissau, we found a high seroprevalence of SARS-CoV-2 of 27.7% in unvaccinated PLWH. Coupled with few ever tested for SARS-CoV-2, it indicates that official PCR testing likely underestimates prevalence and that SARS-CoV-2 monitoring is challenged for PLWH. The low number of symptoms from seropositives may stem from survival bias, some effect of herd immunity or, coupled with a low crude annual death rate, that disease symptomatology and severity could be lower than expected.

Life expectancy of HIV-infected patients followed at the largest hospital in Guinea-Bissau is one-fourth of life expectancy of the background population

PURPOSE

To estimate the life expectancy (LE) of HIV-infected patients in the West African country Guinea-Bissau and compare it with the background population.

METHODS

Using data from the largest HIV outpatient clinic at the Hospital Nacional Simão Mendes in the capital Bissau, a retrospective observational cohort study was performed. The study included patients attending the clinic between June 2005 and January 2018. A total of 8958 HIV-infected patients were included. In the analysis of the background population, a total of 109,191 people were included. LE incorporating loss to follow-up (LTFU) was estimated via Kaplan-Meier estimators using observational data on adult HIV-infected patients and background population.

RESULTS

The LE of 20-year-old HIV-infected patients was 9.8 years (95% CI 8.3-11.5), corresponding to 22.3% (95% CI 18.5-26.7%) of the LE of the background population. (LE for 20-year-olds in the background population was 44.0 years [95% CI 43.0-44.9].) Patients diagnosed with CD4 cell counts below 200 cells/µL had a LE of 5.7 years (95% CI 3.6-8.2). No increase in LE with later calendar period of diagnosis was observed.

CONCLUSIONS

LE was shown to be markedly lower among HIV-infected patients compared with the background population. While other settings have shown marked improvements in prognosis of HIV-infected patients in recent years, no improvement in Bissau was observed over time (9.8 years (95% CI 7.6-12.2) and 9.9 years (95% CI 7.6-12.1) for the periods 2005-2010 and 2014-2016, respectively).

CLEC4E (Mincle) genetic variation associates with pulmonary tuberculosis in Guinea-Bissau (West Africa)

Tuberculosis (TB) is the leading cause of death from a single infectious agent. According to the WHO, 85% of cases in 2018 were pulmonary tuberculosis (PTB), making it the most prevalent form of the disease. Although the bacillus responsible for disease, Mycobacterium tuberculosis (MTB), is estimated to infect 1.7 billion people worldwide, only a small portion of those infected (5-10%) will transition into active TB. Because such a small fraction of infected people develop active disease, we hypothesized that underlying host genetic variation associates with developing active pulmonary disease. Variation in CLEC4E has been of interest in previous association studies showing either no effect or protection from PTB. For our study we assessed 60 SNPs in 11 immune genes, including CLEC4E, using a case-control study from Guinea-Bissau. The 289 cases and 322 controls differed in age, sex, and ethnicity all of which were included in adjusted models. Initial association analysis with unadjusted logistic regression revealed putative association with seven SNPs (p < 0.05). All SNPs were then assessed in an adjusted model. Of the six SNPs that remained significant, three of them were assigned to the CLEC4E gene (rs12302046, rs10841847, and rs11046143). Of these, only rs10841847 passed FDR adjustment for multiple testing. Adjusted regression analyses showed that the minor allele at rs10841847 associated with higher risk of developing PTB (OR = 1.55, CI = 1.22-1.96, p-value = 0.00036). Based on these initial association tests, CLEC4E seemed to be the predictor of interest for PTB risk in this population. Haplotype analysis (2-SNP and 3-SNP windows) showed that minor alleles in segments including rs10841847 were the only ones to pass the threshold of global significance, compared to other haplotypes (p-value < 0.05). Linkage disequilibrium patterns showed that rs12302046 is in high LD with rs10841847 (r2 = 0.67), and all other SNPs lost significance when adjusted for rs10841847 effects. These findings indicate that rs10841847 in CLEC4E is the single best predictor of pulmonary tuberculosis risk in our study population. These results provide evidence for the hypothesis that genetic variation of CLEC4E influences risk to TB in Guinea-Bissau.

Effectiveness of four antiretroviral regimens for treating people living with HIV

The aim of this study was to compare 4 different ARV regimens in a clinical cohort in Brazil, with regard to the virologic and immunologic responses, clinical failure and reasons for changing. To compare the virologic response and clinical failure between groups we used the Cox and Kaplan Meier proportional hazard models. To analyze the immunologic outcome, we used multilevel GLLAMM and mixed effect linear regression models. To compare regimen change outcomes we used the Pearson's chi-square test. We included 840 participants distributed across the groups according to the initial ART regimen. The mean follow-up period was 27.8 months. Almost half the sample initiated ART with AIDS-related signs/symptoms. Virologic response was effective in 79.6% of participants within 12 months. The tenofovir/lamivudine/efavirenz group presented a higher proportion of virologic response (VL<50 at 6 months) when compared to the zidovudine/lamivudine/efavirenz group. There was no difference between the regimens regarding the immunologic response. A total of 17.3% of individuals changed regimen because of failure and 46.5% due to adverse events. Changes due to adverse events were more frequent in the group using zidovudine/lamivudine/efavirenz. The proportion of hospitalizations at 1 year was higher in the zidovudine/lamivudine/efavirenz group when compared to the tenofovir/lamivudine/efavirenz group. The effectiveness outcomes between the regimens were similar. Some differences may be due to the individual characteristics of patients, toxicity and acceptability of drugs. Studies are needed that compare similarly effective regimens and their respective treatment costs and financial impacts on SUS (Integrated Healthcare System).

Acceptance and Feasibility of Partner Notification to HIV Infected Individuals in Guinea-Bissau

As partner notification (PN) has shown effective in increasing the number of partners of HIV infected patients being tested we aimed to evaluate the feasibility of implementing PN in the West-African country Guinea-Bissau. Patients enrolled were offered the choice of three different PN methods. Acceptance, successful referrals and HIV status of partners were evaluated. Of 697 patients offered PN, 495 (71.0%) accepted and listed 547 partners. At end of follow-up 118 (21.5%) partners had been tested of which 44 (37.3%) were HIV infected. HIV infected partners had a higher median CD4 count at diagnosis compared with index patients; 401 cells/mm³ versus 240 cells/mm³, p < 0.001. The results indicate that implementation of PN is feasible, effective in identifying HIV infected partners and enables initiation of earlier treatment, yet there are major barriers to bringing partners in for testing which should be addressed in order to exploit the full potential of PN.

A clinical score has utility in tuberculosis case-finding among patients with HIV: A feasibility study from Bissau

BACKGROUND

Clinical scores are promising case-finding tools for tuberculosis (TB) among HIV-infected patients. The Bandim TBscore has been shown to increase the diagnostic yield among patients with presumed TB in general, but has not previously been tested among newly diagnosed HIV patients at high risk of TB.

METHODS

HIV-infected patients were included in this cross-sectional study. A pre-post-intervention study design was used to assess the outcome of a change in practice, i.e. the application of a clinical score (TBscore) consisting of 13 signs and symptoms to assess the need for further TB diagnostics. Patients with a TBscore ≥2 were evaluated using smear microscopy and Xpert MTB/RIF. A TB diagnosis was made based on microbiology or clinical evaluation. The sensitivity and specificity of the TBscore were compared with those of World Health Organization symptoms.

RESULTS

The TB prevalence among newly enrolled HIV-infected patients during the study period was 13.4% (22/164). Using the TBscore and a diagnostic algorithm, it was possible to increase the proportion of patients started on TB treatment from 2.7% (10/367) the year before the study to 10.4% (17/164) during the study period. Five patients diagnosed with TB were not started on TB treatment as they were lost to follow-up or died. With a cut-off value of 2, the TBscore had a sensitivity, specificity, positive predictive value, and negative predictive value of 95.5% (21/22), 36.9% (41/111), 23.1% (22/118), and 97.6% (41/42), respectively.

CONCLUSION

The TBscore is useful for standardized TB screening among HIV-infected individuals and may be a valuable tool to prioritize patients at high risk of TB.

HIV treatment in Guinea-Bissau: room for improvement and time for new treatment options

Despite advances in the treatment quality of HIV throughout the world, several countries are still facing numerous obstacles in delivering HIV treatment at a sufficiently high quality, putting patients' lives in jeopardy. The aim of this status article is to give an overview of HIV treatment outcomes in the West African country, Guinea-Bissau, and to assess how newer treatment strategies such as long-acting injectable drugs or an HIV cure may limit or stop the HIV epidemic in this politically unstable and low-resource setting. Several HIV cohorts in Guinea-Bissau have been established and are used as platforms for epidemiological, virological, immunological and clinical studies often with a special focus on HIV-2, which is prevalent in the country. The Bandim Health Project, a demographic surveillance site, has performed epidemiological HIV surveys since 1987 among an urban population in the capital Bissau. The Police cohort, an occupational cohort of police officers, has enabled analyses of persons seroconverting with estimated times of seroconversion among HIV-1 and HIV-2-infected individuals, allowing incidence measurements while the Bissau HIV Cohort and a newer Nationwide HIV Cohort have provided clinical data on large numbers of HIV-infected patients. The HIV cohorts in Guinea-Bissau are unique platforms for research and represent real life in many African countries. Poor adherence, lack of HIV viral load measurements, inadequate laboratory facilities, high rates of loss to follow-up, mortality, treatment failure and resistance development, are just some of the challenges faced putting the goal of "90-90-90″ for Guinea-Bissau well out of reach by 2020. Maintaining undetectable viral loads on treatment as a prerequisite of a cure strategy seems not possible at the moment. Thinking beyond one-pill-once-a-day, long-acting antiretroviral treatment options such as injectable drugs or implants may be a better treatment option in settings like Guinea-Bissau and may even pave the way for an HIV cure. If the delivery of antiretroviral treatment in sub-Saharan Africa in a sustainable way for the future should be improved by focusing on existing treatment options or through focusing on new treatment options remains to be determined.

HTLV infected individuals have increased B-cell activation and proinflammatory regulatory T-cells

Human T-lymphotropic virus (HTLV) affects the human immune system in many ways, most notably by inducing proliferation of infected CD4 + T cells, but several other cell types are also affected. To characterize the effects of HTLV infection, we analysed blood samples from HTLV-infected individuals by flow cytometry. Samples were collected from visitors at the HIV clinic in Bissau, Guinea-Bissau. These samples were tested for HTLV and HIV, and 199 were analysed by flow cytometry using panels for B cells, T-cell maturation and activation, regulatory T cells (Tregs) and monocytes. CD80+ cell proportions were significantly higher in HTLV infected than in HTLV uninfected in all B cell subsets. Among T cells, there was no change in cell distribution between maturation stages, but a higher CD25+ proportion among Tregs (61.1 % vs 36.3 %, p < 0.001) in HTLV infected than in HTLV uninfected. The level of CD49d on individual cells was also higher (MFI 2734.5 vs 1,041, p < 0.001). In HTLV infected individuals, CD8 + T cells had a lower proportion of CTLA-4+ (2.5 % vs 3.5 %, 0.048) and higher PD1+ proportion on the CD45RO + subset (81.6 % vs 77.1 %, p < 0.001). Together, these findings point toward reduced regulation in HTLV + patients, which leads to immune activation. This study corroborates previous findings and offers new insight into the effects of HTLV by providing a broad flowcytometric analysis of immune cells in HTLV + individuals.

Hepatitis B and C in the adult population of Bissau, Guinea-Bissau: a cross-sectional survey

OBJECTIVE

Hepatitis B virus (HBV) and hepatitis C virus (HCV) are prevalent in West Africa. To address the WHO 2030 goals of a 90% reduction in incidence and a 65% reduction in mortality for both infections, we assessed the prevalence of HBV and HCV from surveys in the general population.

METHODS

Participants in this cross-sectional survey were included from randomly selected houses in a demographic surveillance site in Bissau, Guinea-Bissau. Participants were interviewed and had a blood sample drawn for viral analyses (HBsAg, anti-HBs, anti-HBc, anti-HCV and HCV RNA). Risk factors of HBV and HCV infection were determined by binomial regression adjusted for sex and age.

RESULTS

A total of 2715 participants were included in this study. The overall HBsAg prevalence was 18.7% (95% CI: 17.3-20.2%). HBsAg was associated with male sex (adjusted risk ratio (aRR): 1.64), and prevalence decreased with age >34 years. HBV exposure was found in 91.9% of participants. Although 72.6% of individuals without sexual debut had been exposed to HBV, ever engaging in a sexual relationship was associated with higher risk of HBV exposure (aRR 1.18). The anti-HCV prevalence was 0.5% (95% CI: 0.3-0.9%), and 78.6% of those had detectable HCV RNA. Risk factors for anti-HCV sero-positivity were age above 55 (aRR 10.60), a history of blood transfusion (aRR 5.07) and being in a polygamous marriage (aRR 3.52).

CONCLUSION

In Guinea-Bissau initiatives to implement treatment and widespread testing are needed to reach the WHO 2030 goals.

Protease Inhibitors or NNRTIs as First-Line HIV-1 Treatment in West Africa (PIONA): A Randomized Controlled Trial

BACKGROUND

Nonnucleoside reverse transcriptase inhibitors (NNRTIs) are recommended as part of first-line treatment for HIV-1 in Africa. However, NNRTI-based regimens are more prone to resistance development than protease inhibitors (PIs) in a context in which drug interruptions are frequent. The aim of this study was to compare the efficacy and tolerability of NNRTIs with PIs in HIV-1-infected patients in Guinea-Bissau.

METHODS

This open-label randomized, 2-arm superiority trial compared the use of 2 NRTIs plus either one NNRTI (efavirenz or nevirapine) or one PI (lopinavir/ritonavir) in treatment-naive HIV-1-infected adults in the Bissau HIV Cohort (ClinicalTrials.gov, NCT0019235). The primary endpoint was HIV-1 RNA <400 copies per milliliter after 12 months of treatment.

RESULTS

Between May 5, 2011, and April 26, 2013, 400 patients were included in the study. In an intention-to-treat analysis, the proportions of patients with viral suppression were similar in the NNRTI [65/197 (33.0%)] and PI [68/203 (33.5%)] arms (P = 0.92). No PI resistance was detected, but high-level NNRTI resistance was seen in 17/30 (56.7%) of NNRTI vs. 3/26 (11.5%) of PI-treated patients, P < 0.01. After 1 year of follow-up, 65 patients died (16.3%) and 93 were lost to follow-up (23.3%). There was no difference in mortality (hazard ratio 0.84, 95% confidence interval: 0.51 to 1.36) or frequency of clinical adverse events between treatment arms [NNRTI: 73/197 (37.1%); and PI: 69/203 (34.0%); P = 0.52].

CONCLUSIONS

In patients at an HIV clinic in Guinea-Bissau, treatment with PIs led to less development of resistance compared with NNRTIs but was not superior in terms of viral suppression, CD4 cell increment, mortality, or severe adverse events.

Soluble Macrophage Mannose Receptor (sCD206/sMR) as a Biomarker in Human Immunodeficiency Virus Infection

Macrophages play important roles during human immunodeficiency virus (HIV) infection, reflected by changes in macrophage-activation biomarker soluble CD163 (sCD163). Here, we present data on the novel macrophage-activation biomarker soluble mannose receptor/CD206 (sCD206) in HIV infection. We investigated sCD206 blood levels at baseline and follow-up with/without antiretroviral therapy (ART), in 212 patients with HIV type 1 (HIV-1), HIV type 2 (HIV-2), or dual infection. At baseline, there was no difference in sCD206 level between HIV types, and sCD206 was unchanged at follow-up without ART. However, in contrast to sCD163, sCD206 levels decreased significantly for both HIV-1 and HIV-2, but not for HIV-1/2 patients, during ART. Further investigations are needed to establish sCD206 as a biomarker in HIV infection.

Discriminatory rapid tests cause HIV-type misclassification-evaluation of three rapid tests using clinical samples from Guinea-Bissau

BACKGROUND

Discrimination among HIV types is important because HIV-2 is naturally resistant to some of the first-line drugs used in the treatment of HIV-1. We evaluated three assays for HIV-type discriminatory capacity: SD Bioline HIV 1/2 3.0 (Bioline), First Response HIV 1-2-0 Card Test (First Response) and Genie III HIV-1/HIV-2 (Genie III).

METHODS

Based on results from the Bioline assay, samples from 239 HIV-infected patients from the Bissau HIV cohort in Guinea-Bissau were retrospectively selected for evaluation. Genie III and First Response were scored by three independent readers and compared with a reference test (INNO-LIA HIV I/II Score) confirmed by HIV RNA as well as DNA detection.

RESULTS

The best performing test was Genie III, with an average agreement with the reference test of 93.4%, followed by First Response (86.1%) and Bioline (72.4%). First Response and Bioline were scored with a false high number of HIV-1/2 dual infections. For both First Response and Genie III, there were discrepancies among independent readers, and some tests were scored as HIV non-reactive.

CONCLUSIONS

Using these rapid tests with a suboptimal performance will presumably result in a high rate of false HIV-1/2 dual diagnoses, depriving patients of alternative treatment options in cases of treatment failure.

HIV-2 as a model to identify a functional HIV cure

Two HIV virus types exist: HIV-1 is pandemic and aggressive, whereas HIV-2 is confined mainly to West Africa and less pathogenic. Despite the fact that it has been almost 40 years since the discovery of AIDS, there is still no cure or vaccine against HIV. Consequently, the concepts of functional vaccines and cures that aim to limit HIV disease progression and spread by persistent control of viral replication without life-long treatment have been suggested as more feasible options to control the HIV pandemic. To identify virus-host mechanisms that could be targeted for functional cure development, researchers have focused on a small fraction of HIV-1 infected individuals that control their infection spontaneously, so-called elite controllers. However, these efforts have not been able to unravel the key mechanisms of the infection control. This is partly due to lack in statistical power since only 0.15% of HIV-1 infected individuals are natural elite controllers. The proportion of long-term viral control is larger in HIV-2 infection compared with HIV-1 infection. We therefore present the idea of using HIV-2 as a model for finding a functional cure against HIV. Understanding the key differences between HIV-1 and HIV-2 infections, and the cross-reactive effects in HIV-1/HIV-2 dual-infection could provide novel insights in developing functional HIV cures and vaccines.

Phylogeny of human T-lymphotropic virus-1 subtypes in Guinea-Bissau

Background

Human T-cell leukaemia/lymphoma virus type 1 (HTLV-1) was the first human retrovirus discovered and there is an estimate of 15-20 million infected worldwide. Endemic areas are Japan, West Africa, Central Africa, South America, the Caribbean, Middle East, Australia and the Pacific Islands. In Guinea-Bissau, adult HTLV-1 prevalence is 2-3%, and higher among HIV-infected patients.

Materials and methods

Blood samples were collected in a recent HIV/HTLV survey in Bissau, the capital of Guinea-Bissau. Initially, participants were tested for HTLV serologically. The p24 and LTR regions of the proviral genome were then attempted sequenced. Sequences were analysed phylogenetically and compared with reference sequences for HTLV-1.

Results

A total of 3% (78/2583) participants were positive on chemiluminesent assay, six additional samples came from another study. Of the 84 seropositive participants we successfully performed sequencing on samples, from 66 participants, 17 were positive for LTR only, one for p24 only and 48 for both. Sequences were in subgroup D of HTLV-1a cosmopolitan, while HTLV-1g was present in one participant.

Conclusion

HTLV-1a subgroup D and, to a lesser extent HTLV-1g, is present in Guinea-Bissau and sequences are very similar, especially within households. Presence of HTLV-1g indicates monkey-to-man zoonotic events and at least two circulating HTLV strains in Guinea-Bissau.

New sequences accession numbers

MG387979-MG388043 for LTR and MG388044-MG388092 for p24.

T-cell and B-cell perturbations are similar in ART-naive HIV-1 and HIV-1/2 dually infected patients

BACKGROUND

HIV-2 may slow progression of a subsequently acquired HIV-1 infection through cross-neutralizing antibodies and polyfunctional CD8 T cells. We hypothesized that HIV-1/2 dually infected patients compared with HIV-1-infected patients had more preserved immune maturation subsets and less immune activation of T and B cells.

METHODS

ART-naive patients with HIV-1 (n = 83) or HIV-1/2 dual (n = 27) infections were included in this cross-sectional study at an HIV clinic in Guinea-Bissau. Peripheral blood mononuclear cells (PBMCs) were analyzed by flow cytometry according to T-cell maturation and activation, regulatory T-cell fraction, and B-cell maturation and activation.

RESULTS

HIV-1/2 dually infected patients had lower levels of HIV-1 RNA compared with patients with HIV-1 infection, but the levels of total HIV RNA (HIV-1 and HIV-2) were similar in the two patient groups. T-cell maturation, and proportions of regulatory T cells (FoxP3+) were also similar in the two groups. HIV-1/2 dually infected patients had higher proportions of CD4 and CD8 T cells positive for the activation marker CD38, but there was no difference in other T-cell activation markers (CD28, CTLA-4, PD-1). HIV-1/2 dually infected patients also had higher proportions of IgM-only B cells and plasmablasts.

CONCLUSION

HIV-1/2 was not associated with less immune perturbations than for HIV-1 infection.

T-cell and B-cell perturbations identify distinct differences in HIV-2 compared with HIV-1-induced immunodeficiency

BACKGROUND

For unknown reasons, HIV-2 is less pathogenic than HIV-1, and HIV-2-induced immunodeficiency may be different from that caused by HIV-1. Previous immunological studies have hinted at possible shifts in both T-cell and B-cell subsets, which we aimed to characterize further.

METHODS

From an HIV clinic in Guinea-Bissau, 63 HIV-2, 83 HIV-1, and 26 HIV-negative participants were included. All HIV-infected participants were ART-naive. The following cell subsets were analysed by flow cytometry; T cells (maturation and activation), regulatory T cells, and B cells (maturation and activation).

RESULTS

After standardizing for sex, age, and CD4 T-cell count HIV-2 had 0.938 log10 copies/ml lower HIV RNA levels than the HIV-1-infected patients. Whereas T-cell maturation and regulatory T-cell profiles were similar between patients, HIV-2-infected patients had higher proportions of CD8CD28 and lower proportions of CD8PD-1+ T cells than HIV-1-infected patients. This finding was independent of HIV RNA levels. HIV-2 was also associated with a more preserved proportion of naive B cells.

CONCLUSION

HIV-2 is characterized by lower viral load, and lower T-cell activation, which may account for the slower disease progression.

Performance of Bio-Rad HIV-1/2 Confirmatory Assay in HIV-1, HIV-2 and HIV-1/2 dually reactive patients - comparison with INNO-LIA and immunocomb discriminatory assays

BACKGROUND

Being able to discriminate between HIV-1, HIV-2 and HIV-1/2 dual infection is imperative for the appropriate selection of antiretroviral therapy (ART) in regions with high HIV-2 endemicity.

OBJECTIVES

To evaluate Bio-Rad Geenius HIV-1/2 Confirmatory Assay against INNO-LIA HIV 1/2 Score and ImmunoComb HIV 1/2 BiSpot with an emphasis towards ability to discriminate between HIV-1, HIV-2 and HIV-1/2 dual infection.

MATERIAL AND METHODS

131 samples from ART naïve HIV infected patients in Guinea-Bissau were selected retrospectively and tested with Geenius, INNO-LIA and Immunocomb. HIV-1/2 RNA were measured in all samples and HIV-1/2 DNA in 59 samples.

RESULTS

The Geenius reader typed 62 samples as HIV-1 reactive, 37 samples as HIV-2 reactive and 32 samples as HIV-1/2 dually reactive. Geenius manual reading classified 10% more samples as HIV-1/2 dually reactive (n = 35). INNO-LIA typed 63 samples as HIV-1 reactive, 36 samples as HIV-2 reactive and 32 samples as HIV-1/2 dually reactive while Immunocomb classified a large proportion of samples as HIV-1/2 dually reactive (n = 45). The measurement of agreement of the Geenius reader compared with INNO-LIA and Immunocomb was 92.4% and 84.0% respectively while the measurement of agreement of Geenius manual reading compared with INNO-LIA and Immuncomb was 93.1% and 89.3% respectively.

CONCLUSIONS

Geenius has similar performance characteristics as INNO-LIA, and performs considerably better than Immunocomb, for differentiating between HIV types. This is especially true when using the Geenius reader while manual reading of the Geenius assay seemed to overestimate the numbers of HIV-1/2 dually reactive samples.

HLA-DQB1*06:276, a novel HLA allele fund in a patient from Guinea-Bissau

DQB1*06:276 differs from DQB1*06:03:01:01 by amino acid substitutions p.T71A, p.G74S, and p.L75V in exon 2.

Excessive mortality and loss to follow-up among HIV-infected children in Guinea-Bissau, West Africa: a retrospective follow-up study

OBJECTIVES

To estimate the magnitude of mortality and loss to follow-up and describe predictors of mortality among HIV-infected children in Guinea-Bissau.

METHODS

Retrospective follow-up study among HIV-infected children under 15 years of age at the largest HIV-clinic in Guinea-Bissau from 2006-2016. A multivariate Cox proportional hazards model was used to identify predictors of mortality.

RESULTS

Of 525 children were included in the analysis: 371 (70.7%) with HIV-1, 17 (3.2%) with HIV-2, 25 (4.8%) with HIV-1/2, and 112 (21.3%) with HIV of unknown type. At diagnosis, the median age was 3.5 years, 44.7% met the WHO criteria for severe immunodeficiency by age based on CD4 cell count, and 59.4% were underweight. The median follow-up time was 6 months. Despite the availability of antiretroviral treatment, the mortality rate was 10.4 deaths per 100 person-years of follow-up. Within the first year of follow-up, 11.0% died, 3.1% were transferred and 38.8% were lost to follow-up, leaving 47.1% in follow-up. Severe immunodeficiency (adjusted hazard ratio (aHR) = 2.52, 95% CI: 1.22-5.21) and underweight (aHR = 3.14, 95% CI: 1.40-7.02) were independent predictors of mortality.

CONCLUSIONS

This study reveals a high rate of early mortality and loss to follow-up among HIV-infected children in Guinea-Bissau. Initiatives to improve patient retention are urgently needed.

Prevalence and clinical characteristics of CMV coinfection among HIV infected individuals in Guinea-Bissau: a cross-sectional study

OBJECTIVES

To describe the prevalence of CMV in a cohort of HIV infected individuals in Guinea-Bissau, West Africa and to evaluate differences in patients' clinical characteristics associated with their CMV status.

METHODS

Newly diagnosed HIV infected adults were invited to participate in this cross-sectional study, from May until December 2015. Enrolled patients were interviewed and underwent a full physical examination focusing on CMV disease manifestations. Blood samples were analysed for CMV serology, QuantiFERON-CMV response and CMV DNA. Mortality follow-up were registered for one year after inclusion.

RESULTS

In total, 180 patients were enrolled. Anti-CMV IgG positivity was found in 100% (138/138) and 2.8% (4/138) were anti-CMV IgM positive. A positive QuantiFERON-CMV response was found in 85.7% (60/70) of the patients and 60.6% (83/137) had CMV viraemia. QuantiFERON-CMV response and detectable CMV DNA were associated with lower CD4 cell count, older age and upper gastrointestinal complaints. During one year of follow-up, the IRR for death among CMV DNA positive patients was 1.5 (P = 0.5).

CONCLUSIONS

CMV coinfection was detected among all enrolled patients and CMV viraemia was highly prevalent. Only age and upper gastrointestinal complaints were associated with the patients' CMV status.

HIV-2 continues to decrease, whereas HIV-1 is stabilizing in Guinea-Bissau

OBJECTIVE

Although Guinea-Bissau has the world's highest prevalence of HIV-2, it has been decreasing since 1987. Meanwhile, the prevalence of HIV-1 has been increasing. We describe both the prevalence and changes in incidence of HIV-2 and HIV-1 during the last 30 years of observation in the capital Bissau in Guinea-Bissau.

METHODS

A total of 3125 adults living in 412 houses in Bissau were eligible for inclusion in the present cross-sectional survey conducted from November 2014 to February 2016. All participants had a questionnaire filled out and a blood sample taken. Results were compared with previous surveys.

RESULTS

Of the 3125 eligible adults, 2601 (83.2%) individuals participated. The overall prevalence of HIV decreased from 8.6% (218/2548) in 2006 to 6.7% (173/2601) in 2016 with an age-adjusted and sex-adjusted prevalence ratio (aPR) of 0.71 [95% confidence interval (CI) = 0.59-0.85]. Including HIV-1/2 dual infections, a decrease in the overall prevalence of HIV-2 from 4.4% (112/2548) to 2.8% (72/2601) was observed with an aPR of 0.55 (95% CI = 0.41-0.73). The overall prevalence of HIV-1 decreased from 4.6% (118/2548) to 4% (104/2601) with an aPR of 0.81 (95% CI = 0.63-1.05). Incidence rates for HIV-2 and HIV-1, estimated for 815 individuals, decreased from 0.24 to 0.09 and from 0.50 to 0.40 per 100 person-years of observation, respectively, in the periods between 1996-2006 and 2006-2016.

CONCLUSION

The prevalence of HIV-2 continues to decrease, whereas the prevalence of HIV-1 showed sign of stabilization. The results observed may be explained by a lower pathogenicity of HIV-2 and changes in risk behavior.

The influence of human leukocyte antigen-types on disease progression among HIV-2 infected patients in Guinea-Bissau

OBJECTIVES

HIV-2 is endemic in West Africa and is characterized by lower transmissibility because of lower viral load, and HIV-2-infected persons usually have a slower progression to AIDS. The mechanisms behind the slower disease progression are unknown. The main objective was to identify specific HLA class I and II alleles that may influence the disease progression of HIV-2 infection.

DESIGN

Cohort follow-up study.

METHODS

We used high-resolution HLA typing of DNA from 437 antiretroviral naive HIV-2-infected patients from the Bissau HIV Cohort, Guinea-Bissau, to identify HLA alleles with an influence on HIV-2 disease progression. The effect of HLA-type on viral load and CD4 cell count was assessed initially by ranksum-test and t-test, followed by adjusted logistic regression and multivariable linear regression analysis, respectively.

RESULTS

Three alleles (HLA-B58:01, HLA-DPB110:01 and HLA-DRB111:01) were associated with lower possibility of detectable baseline plasma viral load (P = 0.002, P = 0.044 and P = 0.033, respectively), and no alleles were associated with higher possibility of detectable plasma viral load. HLA-DPB110:01 and HLA-DRB111:01 were in linkage disequilibrium (P = 0.047). Patients with heterozygous HLA types in all their HLA class I loci or in one or two loci were not more likely to have undetectable viral load compared with patients that were homozygous in all their class I loci after adjusting for sex and CD4 cell count (P = 0.93 and P = 0.88, respectively).

CONCLUSION

The three alleles HLA-B58:01, HLA-DPB110:01 and HLA-DRB111:01 may protect against HIV-2 disease progression towards AIDS.

The challenge of discriminating between HIV-1, HIV-2 and HIV-1/2 dual infections

OBJECTIVES

Discrimination between HIV-1 and HIV-2 is important to ensure appropriate antiretroviral treatment (ART) and epidemiological surveillance. However, serological tests have shown frequent mistyping when applied in the field. We evaluated two confirmatory tests, INNO-LIA HIV I/II Score and ImmunoComb HIV 1/2 BiSpot, for HIV type discriminatory capacity.

METHODS

Samples from 239 ART-naïve HIV-infected patients from the Bissau HIV Cohort in Guinea-Bissau were selected retrospectively based on the initial HIV typing performed in Bissau, ensuring a broad representation of HIV types. INNO-LIA results were interpreted by the newest software algorithm, and three independent observers read the ImmunoComb results. HIV-1/HIV-2 RNA and DNA were measured for confirmation.

RESULTS

INNO-LIA results showed 123 HIV-1 positive samples, 69 HIV-2 positive and 47 HIV-1/2 dually reactive. There was agreement between INNO-LIA and HIV-1/HIV-2 RNA and DNA detection, although not all HIV-1/2 dually reactive samples could be confirmed by the nucleic acid results. Overall, the observers found that the ImmunoComb results differed from the INNO-LIA results, with agreements of 90.4, 91.2 and 92.5%, respectively, for HIV-1, HIV-2 and HIV-1/2. The combined kappa-score for agreement between the three observers was 0.955 (z-score 35.1; P < 0.01). Of the HIV-2 mono-reactive samples (INNO-LIA), the three observers interpreted 24.6-31.9% as HIV-1/2 dually infected by ImmunoComb. None of these samples had detectable HIV-1 RNA or DNA.

CONCLUSIONS

There was accordance between INNO-LIA calls and nucleic acid results, whereas ImmunoComb overestimated the number of HIV-1/2 dually infected patients. Confirmatory typing is needed for patients diagnosed with HIV-1/2 dual infection by ImmunoComb.

Increased mortality among HIV infected patients with cryptococcal antigenemia in Guinea-Bissau

Cryptococcal antigenemia may precede development of cryptococcal meningitis and death among patients with advanced HIV infection. Among 200 retrospectively and randomly selected ART-naïve patients with CD4 counts < 100 cells/μl from Guinea-Bissau, 20 (10%) had a positive cryptococcal antigen test. Self-reported headache and fever were predictors of a positive test, while cryptococcal antigenemia was a strong predictor of death within the first year of follow-up, MRR 2.22 (95% CI: 1.15-4.30). Screening for cryptococcal antigenemia should be implemented for patients with advanced HIV in Guinea-Bissau. Pre-emptive anti-fungal therapy should be initiated prior to ART-initiation if the screening is positive.

Awareness, attitudes and perceptions regarding HIV and PMTCT amongst pregnant women in Guinea-Bissau- a qualitative study

BACKGROUND

The human immunodeficiency virus (HIV) continues to be a major cause of maternal and infant mortality and morbidity in sub-Saharan Africa. Prevention of mother-to-child transmission of HIV (PMTCT) strategies have proven effective in decreasing the number of children infected in utero, intrapartum and during the breastfeeding period. This qualitative study explores knowledge and perceptions of HIV amongst pregnant women, healthcare workers' experiences of the national PMTCT services, and barriers to PMTCT, during a period of programme scale-up in urban Guinea-Bissau (2010-11).

METHODS

In-depth interviews were undertaken amongst 27 women and 19 key informants at local antenatal clinics and the national maternity ward in Bissau, Guinea-Bissau.

RESULTS

Amongst women who had been tested for HIV, awareness and knowledge of HIV and PMTCT remained low. Testing without informed consent was reported in some cases, in particular when the test was performed around the time of delivery. Possible drivers of inadequate counselling included lack of confidentiality, suboptimal healthcare worker training, lack of time, and perceived occupational risk. Demand-side barriers to PMTCT included lack of HIV and PMTCT knowledge, customary and cultural beliefs associated with HIV and ill-health, HIV stigma and discrimination, and fear of partnership dissolution.

CONCLUSIONS

Socio-cultural and operational challenges, including HIV testing without informed consent, present significant barriers to the scale-up of PMTCT services in Bissau. Strengthening local capacity for effective counselling and testing in the antenatal setting is paramount. Further research into local customary beliefs relating to HIV is warranted.

Brief Report: Macrophage Activation in HIV-2-Infected Patients Is Less Affected by Antiretroviral Treatment-sCD163 in HIV-1, HIV-2, and HIV-1/2 Dually Infected Patients

The course of disease among HIV-2, HIV-1, and HIV-1/2 dually infected patients is different. We investigated the macrophage activation marker soluble CD163 (sCD163) dynamics in 212 HIV-1, HIV-2, and HIV-1/2 dually infected patients. There were no differences in sCD163 levels at baseline or during follow-up without antiretroviral therapy (ART). At follow-up on ART, median sCD163 levels were decreased for HIV-1-infected patients (P < 0.001), but not among HIV-2 (P = 0.093) or HIV-1/2 dually infected patients (P = 0.145). The larger decrease in sCD163 levels among HIV-1-infected patients during ART may indicate an HIV type-dependent differential effect of ART on macrophage activation during HIV infection.

Noma in an HIV infected patient in Guinea-Bissau: a case report

BACKGROUND

Noma is a multifactorial and multibacterial opportunistic infection that initially causes necrotic gingivitis but rapidly spreads to the nearby orofacial tissue resulting in sloughing and severe deformation of the facial structures. The majority of cases are seen in young children under the age of 6 years. Noma is strongly associated with poverty, malnutrition and immunosuppression, and is often preceded by severe systemic infections such as measles and malaria. Only few cases of noma infection in adults have been described.

CASE REPORT

We present here a case report with a 32-year-old Guinean woman who was diagnosed with noma infection and on that occasion discovered that she was HIV-1 seropositive. After treatment with amoxicillin/clavulanic acid and metronidazole for her noma infection the woman was transferred to the national hospital where antiretroviral treatment was initiated.

CONCLUSION

Noma is an opportunistic infection and immunodeficiencies such as HIV should always be suspected when presenting in an adult patient.

High prevalence and excess mortality of late presenters among HIV-1, HIV-2 and HIV-1/2 dually infected patients in Guinea-Bissau - a cohort study from West Africa

Introduction

HIV infected individuals with late presentation (LP) and advanced disease (AD) have been associated with higher mortality, higher cost of medical management, impaired CD4 cell count increment and potentially ongoing risk of HIV transmission. Here we describe the proportion of patients with LP and AD at an HIV clinic in Guinea-Bissau, identify risk factors and evaluate the outcome of these patients.

Methods

We included all patients >15 years diagnosed with HIV-1 and/or HIV-2 at the outpatient HIV clinic at Hospital National Simão Mendes, during June 2005 - December 2013 in a retrospective cohort study. Patients were followed until December 2014. LP and AD was defined as a baseline CD4 cell count of 200-349 cells/µL and <200 cells/µL, respectively.

Results

A total of 3,720/5,562 (65.7%) patients had a CD4 cell count measured within the first 90 days of HIV diagnosis. Forty-eight percent had AD and 23% had LP. Risk factors for presentation with AD were male sex, age >30 years, Fula and Mandinga ethnicity. HIV-2 and HIV-1/2 dually infected patients had lower risk of AD compared with HIV-1 infected patients. Although antiretroviral therapy (ART) was initiated for 64.4% of patients, those with AD progression had a 3.82 times higher mortality compared to patients with non-LP.

Conclusion

The majority of HIV infected patients presented late. Most of the late-presenters had advanced disease and patients with advanced disease had a very high mortality. Initiatives to enroll patients in care at an earlier point are needed and should focus on risk groups.

Discovery of a novel HLA-B*15 allele, HLA-B*15:379, in a patient from Guinea-Bissau

HLA-B*15:379 differs from HLA-B*15:03:01:01 by a c.T539G substitution in exon 3.

Clinical presentation and opportunistic infections in HIV-1, HIV-2 and HIV-1/2 dual seropositive patients in Guinea-Bissau

BACKGROUND

Better understanding of HIV-2 infection is likely to affect the patient care in areas where HIV-2 is prevalent. In this study, we aimed to characterize the clinical presentations among HIV-1, HIV-2 and HIV-1/2 dual seropositive patients.

METHODS

In a cross-sectional study, newly diagnosed HIV patients attending the HIV outpatient clinic at Hospital Nacional Simão Mendes in Guinea-Bissau were enrolled. Demographical and clinical data were collected and compared between HIV-1, HIV-2 and HIV-1/2 dual seropositive patients.

RESULTS

A total of 169 patients (76% HIV-1, 17% HIV-2 and 6% HIV 1/2) were included in the study between 21 March 2012 and 14 December 2012. HIV-1 seropositive patients were younger than HIV-2 and HIV-1/2 seropositive patients, but no difference in sex was observed. Patients with HIV-1 and HIV-1/2 had a lower baseline CD4 cell count than HIV-2 seropositive patients (median CD4 cell count 185, 198 and 404 cells/μl, respectively (p value 0.001 and 0.05). HIV-1 seropositive patients had a lower BMI and a higher prevalence of weight loss, skin rash and productive cough than HIV-2 seropositive patients (p value 0.03, 0.002, 0.03 and 0.04). Only four cases (2%) of pulmonary tuberculosis (TB) were diagnosed. One patient (1/96, 1%) was tested positive for cryptococcal antigen.

CONCLUSION

HIV-1 and HIV-1/2 seropositive patients have lower CD4 cell counts than HIV-2 seropositive patients when diagnosed with HIV with only minor clinical and demographic differences among groups. Few patients were diagnosed with TB and cryptococcal disease was not found to be a major opportunistic infection among newly diagnosed HIV patients.

Neutralizing Antibody Response and Antibody-Dependent Cellular Cytotoxicity in HIV-1-Infected Individuals from Guinea-Bissau and Denmark

The development of therapeutic and prophylactic HIV vaccines for African countries is urgently needed, but the question of what immunogens to use needs to be answered. One approach is to include HIV envelope immunogens derived from HIV-positive individuals from a geographically concentrated epidemic with more limited viral genetic diversity for a region-based vaccine. To address if there is a basis for a regional selected antibody vaccine, we have screened two regionally separate cohorts from Guinea-Bissau and Denmark for neutralizing antibody activity and antibody-dependent cellular cytotoxicity (ADCC) against local and nonlocal circulating HIV-1 strains. The neutralizing activity did not demonstrate higher potential against local circulating strains according to geography and subtype determination, but the plasma from Danish individuals demonstrated significantly higher inhibitory activity than that from Guinea-Bissau individuals against both local and nonlocal virus strains. Interestingly, an opposite pattern was observed with ADCC activity, where Guinea-Bissau individual plasma demonstrated higher activity than Danish plasma and was specifically against the local circulating subtype. Thus, on basis of samples from these two cohorts, no local-specific neutralizing activity was detected, but a local ADCC response was identified in the Guinea-Bissau samples, suggesting potential use of regional immunogens for an ADCC-inducing vaccine.

Diabetes mellitus and impaired fasting glucose in ART-naïve patients with HIV-1, HIV-2 and HIV-1/2 dual infection in Guinea-Bissau: a cross-sectional study

BACKGROUND

The prevalence of diabetes mellitus (DM) is expected to increase in sub-Saharan Africa. Patients with HIV are at particular risk. We investigated the DM burden among antiretroviral therapy (ART)-naïve patients with HIV in Guinea-Bissau.

METHODS

Patients were consecutively included. Demographic and lifestyle data were collected and one fasting blood glucose (FBG) measurement was used to diagnose DM (FBG≥7.0 mmol/L) and impaired fasting glucose (IFG) (FBG≥6.1 and <7.0 mmol/L).

RESULTS

By June 2015, 953 newly diagnosed ART-naïve patients with HIV had been included in the study of whom 893 (93.7%) were fasting at the time of inclusion. Median age among the fasting patients was 37 years (IQR 30-46 years) and 562 (62.9%) were women. The prevalence of DM was 5.8% (52/893) while 5.6% (50/893) had IFG. DM was associated with family history of DM (OR 3.92, 95% CI 1.78 to 8.63), being 41-50 years (OR 2.98, 95% CI 1.18 to 7.49) or older than 50 years (OR 3.14, 95% CI 1.09 to 9.07) and Fula ethnicity (OR 2.72, 95% CI 1.12 to 6.62).

CONCLUSIONS

DM prevalence was higher among younger patients compared with the background population in Bissau. Traditional risk factors for DM such as advancing age and a family history of DM apply also for ART-naïve patients with HIV.

The when and how of male circumcision and the risk of HIV: a retrospective cross-sectional analysis of two HIV surveys from Guinea-Bissau

Introduction

Male circumcision (MC) reduces the risk of HIV, and this risk reduction may be modified by socio-cultural factors such as the timing and method (medical and traditional) of circumcision. Understanding regional variations in circumcision practices and their relationship to HIV is crucial and can increase insight into the HIV epidemic in Africa.

Methods

We used data from two retrospective HIV surveys conducted in Guinea-Bissau from 1993 to 1996 (1996 cohort) and from 2004 to 2007 (2006 cohort). Multivariate logistical models were used to investigate the relationships between HIV risk and circumcision status, timing, method of circumcision, and socio-demographic factors.

Results

MC was protective against HIV infection in both cohorts, with adjusted odds ratios (AORs) of 0.28 (95% CI 0.12-0.66) and 0.30 (95% CI 0.09-0.93), respectively. We observed that post-pubertal (≥13 years) circumcision provided the highest level of HIV risk reduction in both cohorts compared to non-circumcised. However, the difference between pre-pubertal (≤12 years) and post-pubertal (≥13 years) circumcision was not significant in the multivariate analysis. Seventy-six percent (678/888) of circumcised males in the 2006 cohort were circumcised traditionally, and 7.7% of those males were HIV-infected compared to 1.9% of males circumcised medically, with AOR of 2.7 (95% CI 0.91-8.12).

Conclusion

MC is highly prevalent in Guinea-Bissau, but ethnic variations in method and timing may affect its protection against HIV. Our findings suggest that sexual risk behaviour and traditional circumcision may increases HIV risk. The relationship between circumcision age, sexual behaviour and HIV status remains unclear and warrants further research.

Differential effects of sex in a West African cohort of HIV-1, HIV-2 and HIV-1/2 dually infected patients: men are worse off

OBJECTIVES

Several studies have reported conflicting effects of sex on HIV-1 infection. We describe differences in baseline characteristics and assess the impact of sex on HIV progression among patients at a clinic with many HIV-2 and HIV-1/2 dually infected patients.

METHODS

This study utilised a retrospective cohort of treatment-naïve adults at the largest HIV clinic in Guinea-Bissau from 6 June 2005 to 1 December 2013. Baseline characteristics were assessed and the patients followed until death, transfer, loss to follow-up, or 1 June 2014. We estimated the time from the first clinic visit until initiation of ART, death or loss to follow-up using Cox proportional hazard models.

RESULTS

A total of 5694 patients were included in the study, 3702 women (65%) and 1992 men (35%). Women were more likely than men to be infected with HIV-2 (19% vs. 15%, P < 0.01) or dually infected with HIV-1/2 (11% vs. 9%, P = 0.02). For all HIV types, women were younger (median 35 vs. 40 years), less likely to have schooling (55% vs. 77%) or to be married (46% vs. 67%), and had higher baseline CD4 cell counts (median 214 vs. 178 cells/μl). Men had a higher age-adjusted mortality rate (hazard rate ratio (HRR) 1.29, 95% confidence interval (CI) 1.09-1.52) and were more often lost to follow-up (HRR 1.27, 95% CI 1.17-1.39).

CONCLUSION

Significant differences exist between HIV-infected men and women regardless of HIV type. Men seek treatment at a later stage and, despite better socio-economic status, have higher mortality and loss to follow-up than women.

Lack of awareness of treatment failure among HIV-1-infected patients in Guinea-Bissau - a retrospective cohort study

INTRODUCTION

With more people receiving antiretroviral treatment (ART), the need to detect treatment failure and switch to second-line ART has also increased. We assessed CD4 cell counts (as a marker of treatment failure), determined the rate of switching to second-line treatment and evaluated mortality related to treatment failure among HIV-infected patients in Guinea-Bissau.

METHODS

In this retrospective cohort study, adult patients infected with HIV-1 receiving ≥6 months of ART at an HIV clinic in Bissau were included from June 2005 to July 2014 and followed until January 2015. Treatment failure was defined as 1) a fall in CD4 count to baseline (or below) or 2) CD4 levels persistently below 100 cells/µL after ≥6 months of ART. Cox hazard models, with time since six months of ART as the time-varying coefficient, were used to estimate the hazard ratio for death and loss to follow-up.

RESULTS

We assessed 1,591 HIV-1-infected patients for immunological treatment failure. Treatment failure could not be determined in 594 patients (37.3%) because of missing CD4 cell counts. Among the remaining 997 patients, 393 (39.4%) experienced failure. Only 39 patients (9.9%) with failure were switched from first- to second-line ART. The overall switching rate was 3.1 per 100 person-years. Mortality rate was higher in patients with than without treatment failure, with adjusted hazard rate ratios (HRRs) 10.0 (95% CI: 0.9-107.8), 7.6 (95% CI: 1.6-35.5) and 3.1 (95% CI: 1.5-6.3) in the first, second and following years, respectively. During the first year of follow-up, patients experiencing treatment failure had a higher risk of being lost to follow-up than patients not experiencing treatment failure (adjusted HRR 4.4; 95% CI: 1.7-11.8).

CONCLUSIONS

We found a high rate of treatment failure, an alarmingly high number of patients for whom treatment failure could not be assessed, and a low rate of switching to a second-line therapy. These factors could lead to an increased risk of resistance development and excess mortality.

High level of HIV-1 drug resistance among patients with HIV-1 and HIV-1/2 dual infections in Guinea-Bissau

Background

With the widespread use of antiretroviral treatment (ART) in Africa, the risk of drug resistance has increased. The aim of this study was to evaluate levels of HIV-1 resistance among patients with HIV-1 and HIV-1/2 dual infections, treated with ART, at a large HIV clinic in Guinea-Bissau.

Findings

Patients were selected from the Bissau HIV cohort. All patients had HIV-1 or HIV-1/2 dual infection, a CD4 cell count performed before and 3–12 months after starting ART, and a corresponding available plasma sample. We measured viral load in patients with HIV-1 (n = 63) and HIV-1/2 dual (n = 16) infections a median of 184 days after starting ART (IQR: 126–235 days). In patients with virological failure (defined as viral load >1000 copies/ml) and with sufficient plasma available, we performed an HIV-1 genotypic resistance test. Thirty-six patients (46%) had virological failure. The CD4 cell count did not predict treatment failure. Of the 36 patients with virological failure, we performed a resistance test in 15 patients (42%), and nine patients (9/15; 60%) had resistance mutations. The most common mutation was K103N, which confers high-level resistance to non-nucleoside reverse transcriptase inhibitors (NNRTI). No major mutations against protease inhibitors (PI) were found.

Conclusions

Our results showed that patients with HIV-1 and HIV-1/2 dual infections in Guinea-Bissau had a high rate of virological failure and rapid development of NNRTI resistance. It remains to be determined whether a more robust, PI-based treatment regimen might benefit this population more than NNRTIs.