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

A Dire Presentation of Carcinoma Cervix in a Human Immunodeficiency Virus-Positive Case: A Salient Display

Despite being one of the commonest malignancies among women worldwide, carcinoma of the cervix, due to its nonspecific symptoms, goes undiagnosed until it reaches advanced stages. This is especially true among women living with human immunodeficiency virus (HIV) as the rate of screening for them is much less as compared to noninfected women. HIV infection greatly impacts the treatment and the prognosis of the diagnosed carcinoma. The existing common linkage between the occurrence of HIV and that of cervical cancer has some significant common elements such as low socio-economic conditions and poor hygiene. The treatment methods in such cases, prove to be of concern, taking into consideration the seropositive status of the case. Here, we discuss one such case of a seropositive patient who presented with complaints of leukorrhea, dysmenorrhea, and dyspareunia. She had stable vitals, with a pulse rate of 86/minute and blood pressure of 100/80 mmHg. On clinical examination, she was diagnosed with stage International Federation of Gynecology and Obstetrics (FIGO) IIIB cervical carcinoma. Under all aseptic precautions, a cervical biopsy was taken and moderately differentiated squamous cell carcinoma of the cervix was diagnosed. A multidisciplinary approach was decided as the course of action, after which she was referred to the department of medical oncology for chemoradiation. Five cycles with a dose of ten Gray (GY) per cycle were planned with concurrent chemotherapy with cisplatin per week. The patient was advised to follow up in the gynecology outpatient department after completion of her chemoradiation cycles for further evaluation and management.

High level of HIV false positives using EIA-based algorithm in survey: Importance of confirmatory testing

The Mozambique Indicators of Immunization, Malaria and HIV/AIDS (IMASIDA) survey was conducted in 2015 and used a two Enzyme Immunoassay (EIA) (Vironostika HIV-1/2 and Murex HIV-1/2) based algorithm to determine the HIV status of the consented participants. The Mozambique Ministry of Health, with support from the US Centers for Disease Control and Prevention (US CDC), added Bio-Rad Geenius™ HIV-1/2 Supplemental Assay to the IMASIDA HIV testing algorithm to confirm all specimens that were found to be reactive on one or both EIAs. In total 11690 specimens were collected to estimate the proportion of HIV positive samples. Results indicate that the proportion of HIV positive samples based on the concordant positive results of two EIA assays was 21.5% (2518/11690). The addition of the Geenius assay to the IMASIDA HIV testing algorithm demonstrated that 792 (31.5%) of 2518 specimens were false-positive and reduced the proportion of HIV positive samples to 14.7% (1722/11690), demonstrating the importance of including a highly specific HIV test to confirm HIV diagnosis. HIV surveys exclusively based on EIA testing algorithm may result in misleading high prevalence results. Our results demonstrate that more specific confirmatory testing should be added to the EIA-based algorithms to ensure accurate HIV diagnosis and correct HIV prevalence estimate in cross-sectional surveys.

HIV serologically indeterminate individuals: Future HIV status and risk factors

BACKGROUND

Indeterminate HIV test results are common, but little is known about the evolution of indeterminate serology and its sociodemographic and behavioral correlates. We assessed future HIV serological outcomes for individuals with indeterminate results and associated factors in Rakai, Uganda.

METHODS

115,944 serological results, defined by two enzyme immunoassay (EIAs), among 39,440 individuals aged 15-49 years in the Rakai Community Cohort Study were assessed. Indeterminate results were defined as contradictory EIAs. Modified Poisson regression models with generalized estimating equations were used to assess prevalence ratios (PRs) of subsequent HIV serological outcomes and factors associated with HIV indeterminate results.

RESULTS

The prevalence of HIV serologically indeterminate results was 4.9%. Indeterminate results were less likely among women than men (adjPR 0.76, 95% CI 0.71,0.81), in unmarried participants than married participants (adjPR 0.92, 95% CI 0.85,99), and in individuals with primary (adjPR 0.90, 95% CI 0.80,1.02), secondary (adjPR 0.83, 95% CI 0.73,0.96) and post-secondary (adjPR 0.75, 95% CI 0.60,0.94) education, relative to no education. The proportions of persons with indeterminate results progressing to HIV positive, negative or indeterminate results in subsequent visits was 5%, 71% and 24%, respectively.

CONCLUSION

HIV serologically indeterminate results were associated with gender and marital status. HIV surveillance programs should develop a protocol for reporting individuals with mixed or persistently indeterminate HIV results on multiple follow-up visits. Most indeterminate results became HIV-negative over time, but follow-up is still needed to detect positive serologies.

Evaluation of nine HIV rapid test kits to develop a national HIV testing algorithm in Nigeria

Background: Non-cold chain-dependent HIV rapid testing has been adopted in many resource-constrained nations as a strategy for reaching out to populations. HIV rapid test kits (RTKs) have the advantage of ease of use, low operational cost and short turnaround times. Before 2005, different RTKs had been used in Nigeria without formal evaluation. Between 2005 and 2007, a study was conducted to formally evaluate a number of RTKs and construct HIV testing algorithms. Objectives: The objectives of this study were to assess and select HIV RTKs and develop national testing algorithms. Method: Nine RTKs were evaluated using 528 well-characterised plasma samples. These comprised 198 HIV-positive specimens (37.5%) and 330 HIV-negative specimens (62.5%), collected nationally. Sensitivity and specificity were calculated with 95% confidence intervals for all nine RTKs singly and for serial and parallel combinations of six RTKs; and relative costs were estimated. Results: Six of the nine RTKs met the selection criteria, including minimum sensitivity and specificity (both ≥ 99.0%) requirements. There were no significant differences in sensitivities or specificities of RTKs in the serial and parallel algorithms, but the cost of RTKs in parallel algorithms was twice that in serial algorithms. Consequently, three serial algorithms, comprising four test kits (BundiTM, DetermineTM, Stat-Pak® and Uni-GoldTM) with 100.0% sensitivity and 99.1% - 100.0% specificity, were recommended and adopted as national interim testing algorithms in 2007. Conclusion: This evaluation provides the first evidence for reliable combinations of RTKs for HIV testing in Nigeria. However, these RTKs need further evaluation in the field (Phase II) to re-validate their performance.

A serial risk score approach to disease classification that accounts for accuracy and cost

The performance of diagnostic tests for disease classification is often measured by accuracy (e.g., sensitivity or specificity); however, costs of the diagnostic test are a concern as well. Combinations of multiple diagnostic tests may improve accuracy, but incur additional costs. Here, we consider serial testing approaches that maintain accuracy while controlling costs of the diagnostic tests. We present a serial risk score classification approach. The basic idea is to sequentially test with additional diagnostic tests just until persons are classified. In this way, it is not necessary to test all persons with all tests. The methods are studied in simulations and compared with logistic regression. We applied the methods to data from HIV cohort studies to identify HIV infected individuals who are recently infected (<1 year) by testing with assays for multiple biomarkers. We find that the serial risk score classification approach can maintain accuracy while achieving a reduction in cost compared to testing all individuals with all assays.

Performance of six commercial enzyme immunoassays and two alternative HIV-testing algorithms for the diagnosis of HIV-1 infection in Kisumu, Western Kenya

Performances of serological parallel and serial testing algorithms were analyzed using a combination of three ELISA and three rapid tests for the confirmation of HIV infection. Each was assessed individually for their sensitivity and specificity on a blinded panel of 769 retrospective sera of known HIV status. Western blot was used as a confirmatory assay for discordant results. Subsequently, one parallel and one serial testing algorithm were assessed on a new panel of 912 HIV-positive and negative samples. Individual evaluation of the ELISAs and rapid tests indicated a sensitivity of 100% for all assays except Uni-Gold with 99.7%. The specificities ranged from 99.1% to 99.4% for rapid assays and from 97.5% to 99.1% for ELISAs. A parallel and serial testing algorithms using Enzygnost and Vironostika, and Determine followed by Uni-Gold respectively, showed 100% sensitivity and specificity. The cost for testing 912 samples was US$4.74 and US$ 1.9 per sample in parallel and serial testing respectively. Parallel or serial testing algorithm yielded a sensitivity and specificity of 100%. This alternative algorithm is reliable and reduces the occurrence of both false negatives and positives. The serial testing algorithm was more cost effective for diagnosing HIV infections in this population.

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

Background

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

Methods

Women with invasive cervical cancer (cases) or normal cervical cytology (controls) were recruited in a hospital-based case-control study in Abidjan, Côte d'Ivoire. Odds ratios and 95% confidence intervals (CI) were estimated in logistic regression analyses controlling for important cofactors.

Results

HIV infection was noted in 22/132 (16.7%) cases and 10/120 (8.3%) controls (p = 0.048). High-risk HPV infection was detected in cervical tumor samples from 89.4% of case-participants and in cervical cytology samples in 31.1% of control-participants. In logistic regression analysis, HIV infection was associated with cervical cancer in women with HPV (OR 3.4; 95% CI 1.1-10.8). Among women aged ≤ 40 years, risk factors for cervical cancer were high-risk HPV infection (OR 49.3; 95% CI 8.2-295.7); parity > 2 (OR 7.0; 95% CI 1.9-25.7) and HIV infection (OR 4.5; 95% CI 1.5-13.6). Among women aged > 40 years, high-risk HPV infection (OR 23.5; 95% CI 9.1-60.6) and parity > 2 (OR 5.5; 95% CI 2.3-13.4), but association with HIV infection was not statistically significant.

Conclusions

These data support the hypothesis that HIV infection is a cofactor for cervical cancer in women with HPV infection, and, as in all populations, the need for promoting cervical screening in populations with high prevalence of HIV infection.

Multiplexed microbead immunoassays by flow cytometry for molecular profiling: Basic concepts and proteomics applications

Flow cytometry was originally established as an automated method for measuring optical or fluorescence characteristics of cells or particles in suspension. With the enormous increase in development of reliable electronics, lasers, micro-fluidics, as well as many advances in immunology and other fields, flow cytometers have become user-friendlier, less-expensive instruments with an increasing importance for both basic research and clinical applications. Conventional uses of flow cytometry include immunophenotyping of blood cells and the analysis of the cell cycle. Importantly, methods for labeling microbeads with unique combinations of fluorescent spectral signatures have made multiplex analysis of soluble analytes (i.e. the ability to detect multiple targets in a single test sample) feasible by flow cytometry. The result is a rapid, high-throughput, sensitive, and reproducible detection technology for a wide range of biomedical applications requiring detection of proteins (in cells and biofluids) and nucleic acids. Thus, novel methods of flow cytometry are becoming important for diagnostic purposes (e.g. identifying multiple clinical biomarkers for a wide range of diseases) as well as for developing novel therapies (e.g. elucidating drug mechanisms and potential toxicities). In addition, flow cytometry for multiplex analysis, coupled with automated sample handling devices, has the potential to significantly enhance proteomics research, particularly analysis of post-translational modifications of proteins, on a large scale. Inherently, flow cytometry methods are strongly rooted in the laws of the physics of optics, fluidics, and electromagnetism. This review article describes principles and early sources of flow cytometry, provides an introduction to the multiplex microbead technology, and discusses its applications and advantages in comparison to other methods. Anticipated future directions, particularly for translational research in medicine, are also discussed.

Viral, HLA and T cell elements in cross-reactive immune responses to HIV-1 subtype A, CRF01_AE and CRF02_AG vaccine sequence in Ivorian blood donors

Comprehensive understanding of the determinants of cross-subtype immune responses in HIV infection is critical to developing efficacious HIV vaccines against multiple viral subtypes. Because HIV-1 subtype A or recombinants comprising subtype A are prevalent in Africa and parts of Asia where HIV is spreading, we assessed the determinants of cross-subtype immune responses in HIV-infected blood donors from Cote d'Ivoire to peptides from a candidate CRF02_AG vaccine sequence, a subtype A sequence from western Kenya and a CRF01_AE sequence from Thailand. We present evidence that immune recognition of multiple viral subtypes is maintained by recognition of multiple epitopes. Our data suggest that complete escape of HIV from immune recognition is uncommon. Evaluation of these frequently generated cross-reactive responses should be included in immunogenicity trials of HIV vaccines.

HIV serological screening in a population of pregnant women in the Republic of Congo: suitability of different assays

Different strategies can be applied for the screening of HIV infection, depending on the local seroprevalence. Within a WHO type III strategy, we compared the results of two different second-line methods for HIV screening of a population of pregnant women in the Republic of Congo. Sera from 3614 consecutive pregnant women were tested for HIV with Genescreen Plus Ag/Ab EIA assay; positive specimens were retested with two different second-line methods. (Determine HIV-1/2 rapid test and Vironostika HIV Ag/Ab specific EIA assay). Discordant samples were tested with HIV-1/2 Western Blot and, if necessary, HIV RNA molecular assay. Of the 3614 sera, 221 were positive with Genscreen. Among them, 21 and 10 tested negative with Vironostika and Determine, respectively. A 100% correspondence with 3rd line confirmation test results was found in Genscreen positive/Vironostika negative samples, whereas a 5.5% overestimation of HIV seroprevalence was observed when Determine, instead of Vironostika, was used as second-line test. The choice of appropriate assays in adequate sequence, within the correct WHO strategy, is pivotal to minimize the risk of overtreatment of HIV infection.

Technological challenges in diagnosis and management of HIV infection in resource limited settings

Relatively quick and cheap tests can work but must be evaluated and monitored properly

Evaluation of the dried blood spot filter paper technology and five testing strategies of HIV-1 and HIV-2 infections in West Africa

Simple robust approaches are needed to monitor the prevalence and incidence of HIV in Africa. The aim of this study was to evaluate the use of dried blood spot (DBS) as an alternative to serum or plasma for sentinel surveillance. Paired DBS and blood samples were obtained from 200 patients attending a genito-urinary medicine clinic in West Africa. The gold standard of diagnosis was based on the combination of 3 enzyme-linked immunosorbent assays (ELISA) using serum. The presence of HIV antibodies in eluates of dried blood spots was detected by ELISA, Gelatin Particle Assay (GPA) and Pepti-Lav 1-2 in 5 different testing strategies. All 200 eluates were tested individually, and in addition pools of 5 eluates each were tested. The sensitivity of the testing strategies ranged from 95.0% (83.1 - 99.4%) to 100% and the specificity from 97.5% (93.7 - 99.3%) to 100%. Testing in pools of 5 did not affect sensitivity. Dried blood spots were easy to work with. Test kit and laboratory consumable costs varied between 492 pounds and 1037 pounds (unpooled strategies) and 163 pounds and 421 pounds (pooled). The monospecific ELISAs used in this study are no longer in production; currently available differentiating assays need to be tested. DBS are recommended for sentinel surveillance in Africa.

Quantification of HIV-1 p24 by a highly improved ELISA: An alternative to HIV-1 RNA based treatment monitoring in patients from Abidjan, Côte d’Ivoire

BACKGROUND

Quantification of HIV-1 RNA remains difficult to implement in Africa. Simple and inexpensive tests for antiretroviral treatment (ART) monitoring are needed.

OBJECTIVE

To evaluate an HIV-1 p24 ELISA, which combines efficient virus disruption, heat-denaturation and signal amplification, in a West African setting.

STUDY DESIGN

Eighty-six HIV-1 infected patients from Abidjan, Côte d'Ivoire, were tested for p24, HIV-1 RNA, and CD4+ count at baseline, and twice within 8 months after ART initiation.

RESULTS

All patients responded to ART with a minimal HIV-1 RNA drop of 0.5 log(10) at first follow-up. Forty-one (47.7%) then rebounded >0.5 log(10) or persisted above 1000 copies/mL by week 24. The predicted baseline concentration of p24 corresponding to 100,000 copies/mL of HIV-1 RNA, above which ART is recommended, was 4546 fg/mL (95% confidence interval 3148-6566). A prediction model of virologic failure, occurring after an initial response to ART, correctly classified 84% of patients using baseline p24, p24 change on therapy, and achievement of undetectable p24 as explanatory variables. The model and further bootstrap evaluation suggested a good ability to discriminate between sustained or failing virologic response to ART.

CONCLUSION

HIV-1 p24 and RNA based-ART monitoring in a low-resource country dominated by HIV-1 CRF02 AG appeared comparable.

Evaluation and diagnostic usefulness of domestic and imported enzyme-linked immunosorbent assays for detection of human immunodeficiency virus type 1 antibody in India

Diagnosis of human immunodeficiency virus (HIV) infection is important for patient management and prevention of new infections. The number of test kits available for the detection of HIV antibodies is unprecedented. In order to identify appropriate test kits, we evaluated a variety of commercial kits manufactured abroad as well as in India. The plasma and serum specimens (n=264) were collected from individuals attending the Voluntary Counseling and Testing Centre at the YRG Centre for AIDS and Education. The specimens were used to evaluate six commercially available HIV test kits: Enzaids HIV 1+2, HIV-CheX, Murex HIV-1.2.0, Genscreen HIV 1/2 version 2, Vironostika HIV Uni-Form II Ag/Ab, and CombAids RS Advantage. High sensitivities and specificities (>or=99%) were observed for the Enzaids, Murex, Vironostika, and CombAids assays. HIV-CheX showed the highest number of false-positive and false-negative results. The Genscreen test also gave many false positives. The study indicated that the Enzaids, Murex, and Vironostika enzyme-linked immunosorbent assay kits and the CombAids RS Advantage rapid assay could be used to achieve acceptable results for the detection of HIV antibodies. A combination of two tests is recommended to optimize the efficiency of HIV antibody testing algorithms, especially when evaluation with an HIV Western blot confirmatory test is not possible.

Evaluation of HIV antibody and antigen/antibody combination ELISAs for use in an alternative confirmatory HIV testing strategy in Dar es Salaam, Tanzania

The aim of this study was to evaluate the performance of two antibody enzyme-linked immunosorbent assays (ELISAs) [Vironostika Uni-Form II plus O and Enzygnost anti-HIV-1/2 Plus], and two antigen/antibody combination ELISAs [Murex and Vironostika HIV Uni-Form II] for use in an alternative confirmatory HIV diagnostic testing strategy in Dar es Salaam, Tanzania. Altogether, 1380 serum samples were included. All ELISA reactive samples were tested using the Inno-Lia antibody assay and discrepant samples were tested on the Innotest p24 antigen assay. Three hundred and one (21.8%) samples were confirmed HIV-1 antibody positive by Inno-Lia including 27/508 (5.3%) from blood donors, 65/511 (12.7%) from pregnant women and 209/361 (57.9%) from hospital patients. The sensitivity at initial testing was 100% (95% CI; 98.8-100%) for all assays except Vironostika Uni-Form II plus O (99.7%; 95% CI; 98.2-99.9%) which showed one false negative sample at initial testing but 100% sensitivity after repeat testing. The final specificity at repeat testing was 100% (95% CI; 99.7-100%) for Enzygnost anti-HIV-1/2 Plus, 99.4% (95% CI; 98.8-99.8%) for each of the antigen/antibody combination ELISAs and 97.9% (95% CI; 96.8-98.6%) for Vironostika plus O ELISA. An alternative confirmatory HIV testing strategy based on initial testing on any of the two antigen/antibody assays followed by testing of reactive samples on the Enzygnost anti-HIV-1/2 Plus assay gave 100% specificity (95% CI; 99.7-100%).

Assessment of CD8 T cell immune activation markers to monitor response to antiretroviral therapy among HIV-1 infected patients in Côte d'Ivoire

Because of the paucity of plasma HIV RNA viral load (VL) tests in resource-poor settings, the CD4(+) T cell count is often used as the sole laboratory marker to evaluate the effectiveness of antiretroviral therapy (ART) in HIV-infected patients. In untreated patients, the level of activated T cells is positively correlated with VL and represents a prognostic marker of HIV infection. However, little is known about its value to predict early drug failure, taking into account the relatively high non-specific immune activation background observed in many resource-limited tropical countries. We assessed the use of immune activation markers (expression of CD38 and/or human leucocyte antigen-DR on CD8(+) lymphocytes) to predict virological response to ART in a cohort of HIV-1 infected patients in Abidjan, Côte d'Ivoire. Correlations between VL, absolute CD4(+) T cell counts and immune activation levels were examined in 111 HIV patient samples at baseline and after 6 and 12 months of therapy. The percentage of CD38(+) CD8(+) T cells appeared to be the best correlate of VL. In contrast, changes in CD4(+) T cell counts provided a poor correlate of virological response to ART. Unfortunately, CD38(+) CD8(+) percentages lacked specificity for the determination of early virological drug failure and did not appear to be reliable surrogates of RNA viral load. CD38(+) CD8(+) T cell percentages may, rather, provide a sensitive estimate of the overall immune recovery, and be a useful extra laboratory parameter to CD4 counts that would contribute to improve the clinical management of HIV-infected people when VL testing facilities are lacking.

Changes in HIV RNA viral load, CD4+ T-cell counts, and levels of immune activation markers associated with anti-tuberculosis therapy and cotrimoxazole prophylaxis among HIV-infected tuberculosis patients in Abidjan, Cote d'Ivoire

We analyzed changes in plasma human immunodeficiency virus (HIV)-1 viral load, CD4+ T-cell count, and markers of immune activation markers at start of treatment of tuberculosis and 12 months after among 44 HIV-1-infected patients with newly diagnosed, sputum-smear positive for Mycobacterium tuberculosis pulmonary infection. All patients received a standard regimen of 6 months of rifampicin and isoniazid with first 2 months of pyrazinamid with or without cotrimoxazole. Compared with values at start of treatment, median viral load increased by a median of 0.64 log10 copies/ml after 12 months of follow-up (P=0.0002). Median CD4+ T-cell counts were 393 cells/L at start of treatment and 370 cells/L after 12 months of follow-up (P=0.61). Levels of serum activation markers decreased significantly at 12 months of follow-up of the patients for both patients on standard and cotrimoxazole treatment. Levels of viral load, CD4+ T-cell counts, and markers of immune activation were not different for patients on standard treatment of tuberculosis compared with those on standard and cotrimoxazole treatment. Levels of serum activation markers decreased significantly at 12 months of follow-up of the patients for both patients on standard and cotrimoxazole treatment. Because viral load is a predictor of disease progression, its persistent elevated levels in blood of HIV-infected patients co-infected with tuberculosis, who successfully complete TB treatment, may account for the high mortality observed in this population.

Performance of drug-resistance genotypic assays among HIV-1 infected patients with predominantly CRF02_AG strains of HIV-1 in Abidjan, Côte d’Ivoire

OBJECTIVE

We evaluated the performance of three genotypic assays to detect resistant mutations among HIV-1 infected patients with known antiretroviral drug resistance profile in Abidjan, Cote d'Ivoire, most of whom had the circulating recombinant form (CRF02_A/G) of HIV-1.

METHODS

The 56 patients analyzed in this study were enrolled in a pilot program to make available antiretroviral therapy (ART) to HIV-infected patients in Abidjan through the UNAIDS Drug Access Initiative (DAI). These patients had failed ART, as demonstrated by rebound in RNA viral load. Their plasma samples had been previously analyzed for ART genotypic drug-resistance by VircoGEN (Mechelen, Belgium) and were known to have primary and secondary resistance mutations, and also had phenotypic drug-resistance by a recombinant virus assay technology (Mechelen, Belgium). The two assays we evaluated were: VircoGEN, TruGene HIV-1, and ViroSEQ HIV-1 assays.

RESULTS

For the reverse transcriptase gene, all 27 samples that had the T215Y/F mutation were detected by VircoGEN , ViroSEQ, and TrueGene. All 19 (100%) samples that had the K70R/E mutation detected by VircoGEN were detected by ViroSEQ, and 18 (94.7%) by TrueGene. All ten samples with the M184V mutation, three with the K65R, two with the G190A mutation, one with the K103N mutation, and one with the V75T mutation were detected similarly by all three assays. For the protease gene, all three assays detected the I84V (n = 1), M46I (n = 1), and L90M (n = 1) mutations.

CONCLUSION

These results suggest that any of these assays should be considered for monitoring the occurrence of drug resistance among HIV-infected patients receiving antiretroviral therapy in West Africa.

Differences in HIV-2 plasma viral load and immune activation in HIV-1 and HIV-2 dually infected persons and those infected with HIV-2 only in Abidjan, Côte D'Ivoire

OBJECTIVE

To determine whether blood plasma levels of HIV-2 RNA viral loads and immune activation markers differ between persons infected with HIV-2 only and those dually infected with HIV-1 and HIV-2.

METHODS

Between September 1996 and February 2000, we collected, analyzed and compared levels of HIV-2 RNA in plasma and immune activation markers among 52 persons infected with HIV-2 alone and 75 with confirmed dual infection. We also compared viral load and immune activation in patients who were infected with HIV-1 only and those who were dually infected.

RESULTS

When we conducted a CD4 T-cell count-stratified multivariate analysis of HIV-2 viral load, controlling for difference in CD4 T-cell counts, age and sex: at < 200 x 10 CD4 T cells/l, HIV-2 viral load was 2.0 log10 copies/ml lower in dually infected patients than in HIV-2 only patients (P < 0.0001). At CD4 T-cell counts between 200 x 10 and 500 x 10/l, HIV-2 viral load was 0.3 log10 copies/ml lower in dually infected patients (P = 0.45). However, at CD4 T-cells counts > 500 x 10/l, HIV-2 viral load was 0.9 log10 copies/ml higher in dually infected patients (P < 0.0001). Dually infected persons with undetectable HIV-2 viral loads had significantly higher median levels of CD8 T cells expressing CD38 (P < 0.001) and HLA-DR (P = 0.01) than HIV-2 only infected patients.

CONCLUSION

These results suggest that in dual infection, the level of HIV-2 replication depends on the immune status of the patients, with HIV-1 out-replicating HIV-2 as disease progress.

Field evaluation of the gag-based heteroduplex mobility assay for genetic subtyping of circulating recombinant forms of human immunodeficiency virus type 1 in Abidjan, Côte d'Ivoire

The gag-based heteroduplex mobility assay (gag-HMA) was evaluated for its ease and reliability in subtyping circulating recombinant forms (CRFs) of human immunodeficiency virus type 1 (HIV-1) in Côte d'Ivoire. One hundred thirty-two plasma samples were analyzed blindly for HIV-1 subtypes by sequencing the pol gene and by gag-HMA. DNA sequencing was used as the "gold standard." Of the 132 samples sequenced, 108 (82%) were CRF02_AG, 14 (11%) were pure subtype A, 5 (4%) were subtype G, 3 (2%) were subtype D, 1 was CRF01_AE, and 1 was subtype H. The gag-HMA correctly classified 126 (95.5%) of the samples. Of the 108 samples that were classified as CRF02_AG by DNA sequencing, 107 (99%) were correctly identified by gag-HMA, resulting in a positive predictive value of 96.4%. The gag-HMA seems to be a valuable tool for understanding the molecular epidemiology of HIV-1 CRF02_AG in Côte d'Ivoire and West Africa, which could be important for developing and evaluating AIDS vaccines, although DNA sequencing remains necessary for accurate molecular epidemiology.

Prevalence of genotypic and phenotypic HIV-1 drug-resistant strains among patients who have rebound in viral load while receiving antiretroviral therapy in the UNAIDS-Drug Access Initiative in Abidjan, Côte d'Ivoire

OBJECTIVE

To determine the prevalence of genotypic and phenotypic antiretroviral (ARV) drug-resistant HIV-1 strains among patients with viral load rebound while receiving ARV therapy in Abidjan, Côte d'Ivoire.

METHODS

Between August 1998 and April 2000, we selected all patients (n = 241) who had received ARV drug therapy for at least 6 months in the UNAIDS-Drug Access Initiative (DAI), in Abidjan. We analyzed for genotypic and phenotypic drug resistance among 97 (40%) of the 241 patients who had a rebound in plasma viral load, defined as an initial decrease of > 0.5 log10 copies/ml followed by a subsequent increase of > 0.25 log10 copies/ml.

RESULTS

Of the viruses isolated from the 97 patients, 86 (88.7%) had usable sequences and 68 (79%) of the 86 patients had genotypic resistance to at least one reverse transcriptase inhibitor (RTI) or protease inhibitor (PI). Resistant mutations were found for zidovudine in 50 (78%) of 64 patients who had received the drug, 11 (68.7%) of 16 patients on lamivudine, for nevirapine in two (2%), for indinavir in one (1%), and for ritonavir in one (1%). Phenotypic resistance to at least one nucleoside RTI was seen in 45 (56%) of the 80 patients tested, to non-nucleoside RTIs in eight (10%), and to PIs in one (1.3%). Multivariate regression analysis showed factors associated with resistance to be initial treatment with dual therapy (P = 0.04) compared with highly active antiretroviral therapy, and maximal initial viral load response (P = 0.006).

CONCLUSION

Our results demonstrate a high prevalence of ARV drug resistance associated with dual ARV therapy. These results indicate the limited role for dual ARV therapy.

Virologic and immunologic outcomes and programmatic challenges of an antiretroviral treatment pilot project in Abidjan, Côte d'Ivoire

BACKGROUND

In Côbte d'Ivoire, a pilot project was developed by UNAIDS and the Ministry of Health to improve access to AIDS care, including antiretroviral therapy, for adults and children infected with HIV. This evaluation of the project is the first to provide results of a large number of HIV-infected patients receiving antiretroviral therapy in West Africa.

METHODS

We evaluated records of persons who presented for care from August 1998 to August 2000 at six accredited centers in Abidjan. Patients were treated with two nucleoside reverse transcriptase inhibitors (2NRTI) or highly active antiretroviral therapy (HAART).

RESULTS

Of 2878 patients who were screened, 2351 (83%) were HIV-infected and eligible (CD4 T lymphocyte count < 500 x 10(6) cells/l or plasma HIV-RNA level > 10 000 copies/ml) for antiretroviral therapy. Of those who were eligible, 81% were symptomatic, 63% had a CD4 cell count < 200 x 10(6) cells/l, 12% had previously taken antiretroviral drugs, and 56% returned to the clinic for follow-up. Of the patients screened, 768 (27%) were started on antiretroviral therapy, including 450 on HAART, 296 on 2NRTI, and 22 on other regimens. We analyzed data from 480 HIV-1-infected adults, who were naive to therapy, were prescribed HAART or 2NRTI, and had at least one clinic visit after starting therapy. In an intent-to-treat analysis of patients who received HAART, the estimated plasma HIV-1 RNA level was approximately 1.9 log10 copies/ml (80-fold) lower, while estimated CD4 cell count was > 100 x 10(6) cells/l higher than baseline values, after 1 year of therapy. Approximately 25% of adults on 2NRTI and 50% of those on HAART had < 200 copies/ml, after 1 year of therapy. The probability of an adverse event occurring within 6 months after starting therapy was 0.20. The probability of survival for at least 1 year was 0.84 (95% confidence interval, 0.80-0.89).

CONCLUSION

After starting antiretroviral therapy, these HIV-1-infected patients in West Africa had similar virologic and immunologic outcomes, probability of an adverse event, and estimated survival, as patients enrolled in clinical trials in the USA and Europe. However, only one-third of eligible patients received therapy, highlighting the importance of providing adequate education and support for initiating and adhering to therapy in this and similar programmes.

Changes in levels of immune activation and reconstitution markers among HIV-1-infected Africans receiving antiretroviral therapy

OBJECTIVE

To describe changes in immune activation and reconstitution markers among HIV-1-infected patients receiving antiretroviral therapy (ART) in Abidjan, Côte d'Ivoire.

METHODS

Between November 1998 and February 2001, we analyzed changes in immune activation and reconstitution markers among 52 patients. Good virologic responders (n = 26) were defined as those who had suppressed and maintained plasma viral load (VL) below the detection limit of the assay for at least 12 months. Poor virologic responders (n = 26) were defined as those with a detectable VL at 6 and 12 months after beginning ART.

RESULTS

Of the 26 good virologic responders, 20 (77%) were on highly active antiretroviral therapy (HAART) compared with one (4%) of the poor responders. Among the 26 good responders, baseline median levels of CD38+CD8+ T cells were elevated, but had decreased significantly at 6 months (P < 0.001) and at 12 months of therapy (P < 0.001). Median levels of HLA-DR+CD8+ T cells also decreased from baseline at 6 months (P < 0.001) and at 12 months of therapy (P < 0.001). Levels of CD62L+CD4+ T cells increased steadily during the 6 and 12 months of therapy and reached levels observed among HIV-negative blood donors (P = 0.07). Among the 26 poor responders, median levels of CD38+CD8+ T cells decreased significantly at 12 months of therapy (P = 0.006), but were higher than levels in blood donors (P = 0.005). Levels of HLA-DR+CD8+ T cells decreased significantly at 12 months of therapy (P < 0.001). Levels of CD62L+CD4+ decreased over time.

CONCLUSION

Our results suggest that HAART can be successfully used in African populations with elevated baseline immune activation markers.

Generation of a consensus sequence from prevalent and incident HIV-1 infections in West Africa to guide AIDS vaccine development

We considered several key issues regarding the development of a DNA-based human immunodeficiency virus type 1 (HIV-1) vaccine: (1) should the candidate vaccine construct be derived from incident or prevalent HIV-1 strains; and (2) should circulating plasma virus, archived HIV-1 provirus recovered from peripheral blood mononuclear cells, or both be included? To address these questions, we collected circulating HIV-1 strains from infected individuals residing in Abidjan, Côte d'Ivoire. From a panel of 23 strains, 22 were HIV-1 subtype A in gag, 19 of which phylogenetically clustered with the recombinant HIV-1, CRF02-AG strains from West Africa. The mosaic genome of CRF02-AG was confirmed by sequencing the protease gene. A consensus gag p24 protein sequence was generated and 147 of 148 codons were identical to CRF02-AG (IbNG). Regardless of the sequence origin (RNA, provirus, incident, or prevalent), the gag p24 consensus sequences were highly representative of these distinct virologic compartments. These data suggest that the consensus sequence generated from incident and prevalent infections may provide an appropriate sequence for a DNA vaccine and is largely representative of the major circulating viral strain.

Multiplexed immunoassays by flow cytometry for diagnosis and surveillance of infectious diseases in resource-poor settings

An accurate, rapid and cost-effective diagnosis is the cornerstone of efficient clinical and epidemiological management of infections. Here we discuss the relevance of an emerging technology, multiplexed immunoassays read by flow cytometry, for the diagnosis of infectious diseases. In these assays, multiple fluorescent microspheres, conjugated to different antigens or antibodies, constitute the solid phase for detecting antibodies or antigens in biological samples. These assays seem to be more sensitive than traditional immunoassays, have a high throughput capacity, and provide a wide analytical dynamic range. Additionally, they have multiplexing ability-ie, they are capable of measuring multiple antibodies or antigens simultaneously. We discuss four different areas where this technology could make an impact in resource-poor settings: (i) infections causing rash and fever in children; (ii) sero-epidemiological studies on vaccine-preventable diseases; (iii) management of genital ulcers and vaginal discharge; and (iv) screening of infections in blood banking. We predict a widespread use for a new breed of small, affordable, practical flow cytometers as field instruments for replacing ELISA and RIA tests, which will also be capable of doing cellular immunological tests such as CD4+ T-cell enumeration and Plasmodium falciparum detection in whole blood.

Changes in plasma HIV-1-RNA viral load and CD4 cell counts, and lack of zidovudine resistance among pregnant women receiving short-course zidovudine

OBJECTIVE

To describe changes in HIV-1 plasma viral load (VL) and CD4 cell counts and to assess zidovudine resistance associated with a short course of oral zidovudine during late pregnancy.

METHODS

From April 1996 to February 1998 in Abidjan, Côte d'Ivoire, 280 HIV-1-seropositive women were randomly assigned at 36 weeks' gestation to receive zidovudine (300 mg) or placebo twice a day, and then one tablet every 3 h from the onset of labor until delivery. Blood samples obtained every 2 weeks until delivery, then at 2 and 4 weeks, and 3 or 6 months after delivery were tested from selected women based on duration of therapy for plasma VL and CD4 cell counts, and samples from 20 women in the zidovudine group were tested by DNA sequencing for the presence of zidovudine resistance mutations.

RESULTS

In the zidovudine group, the median reduction in plasma VL (log(10) copies/ml) was -0.48 after 2 weeks (P = 0.02 versus placebo), -0.48 after 4 weeks (P = 0.06), -0.80 after 6 weeks (P = 0.29) of treatment, -0.12 at delivery (P = 0.11), +0.21 at 2 weeks (P = 0.83), +0.17 at 4 weeks (P = 0.69), and +0.21 at 3 months (P = 0.56) postpartum. Median CD4 cell counts were higher in the zidovudine than in the placebo group after 2, 4, and 6 weeks of treatment (P < 0.05). No mutations associated with zidovudine resistance were identified in any of the samples tested.

CONCLUSION

These findings suggest that a short course of zidovudine has no adverse HIV-1 virological consequences for the mother.

Positive association between beta-chemokine-producing T cells and HIV type 1 viral load in HIV-infected subjects in Abidjan, Côte d'Ivoire

The role of beta-chemokines in controlling HIV replication in vivo is still controversial. Therefore, the association between HIV-1 plasma viral load and the capacity of CD4(+) and CD8(+) T cells to produce beta-chemokines was studied in 28 antiretroviral drug-naïve HIV-1-infected female sex workers in Abidjan, Côte d'Ivoire. Percentages of beta-chemokine-positive T cells were measured in peripheral blood mononuclear cells by flow cytometry after intracellular staining for RANTES (regulated on activation, normal T expressed and secreted), macrophage inflammatory protein (MIP)-1alpha, and MIP-1beta. HIV-1-infected subjects had higher percentages of MIP-1alpha- and MIP-1beta-positive CD4(+) and CD8(+) T cells (p < 0.02) and of RANTES-positive CD8(+) T cells (p = 0.054) than uninfected controls. Percentages of RANTES- and MIP-1beta-positive CD8(+) T cells correlated directly with HIV-1 plasma viral load (p < 0.02). Percentages of beta-chemokine-positive CD4(+) and CD8(+) T cells correlated directly with percentages of HLA-DR-positive T cells (p < 0.02) and inversely (except RANTES in CD4(+) T cells) with absolute numbers of CD4(+) T cells (p < 0.05) in peripheral blood. These data indicate that increased percentages of beta-chemokine-producing T cells in HIV-1-infected subjects correlate with disease progression and are a sign of viremia-driven chronic T cell activation.

Evaluation of an alternative confirmatory strategy for the diagnosis of HIV infection in Dar Es Salaam, Tanzania, based on simple rapid assays

Alternative confirmatory strategies for detection of antibodies to HIV using enzyme-linked immunosorbent assays (ELISAs) have been shown to be useful in laboratories with limited resources. Three simple and rapid HIV antibody detection assays (Capillus, Serocard and Determine) were evaluated using 1412 fresh serum samples in order to formulate an alternative confirmatory strategy for the diagnosis of HIV infection. All sera were also tested by an anti-HIV ELISA and all sera reactive by any of the assays were tested by a second ELISA as well as by Western blot. Three hundred and eighty-three sera were found to be HIV-1 antibody positive, while 1017 sera were HIV antibody negative; 12 sera which were reactive by one or more of the simple assays had indeterminate Western blot results and these were considered HIV seronegative during the analysis. All assays had a sensitivity of 100%. The initial specificity of the assays were 98.7, 98.2 and 97.9% for Capillus, Serocard and Determine, respectively. In an alternative confirmatory strategy the use of Capillus followed by Serocard or Determine gave a specificity of 99.9 and 99.8%, respectively. Serocard followed by Determine gave a specificity of 99.3%. A testing strategy with 100% specificity (95% CI; 99.6-100%) could be achieved by the sequential use of all three simple/rapid assays or by repeat testing by Capillus followed by Serocard.

Lack of effect of chemokine receptor CCR2b gene polymorphism (64I) on HIV-1 plasma RNA viral load and immune activation among HIV-1 seropositive female workers in Abidjan, Côte d'Ivoire

The prevalence of the CCR2b-V64I mutation among human immunodeficiency virus (HIV)-seropositive and -seronegative female workers and the potential effect of heterozygosity of this mutation on HIV-1 plasma RNA viral load and markers of immune activation were assessed. CCR2b-V64I was detected by polymerase chain reaction, followed by restriction enzymes analysis; plasma viral load was measured by the Amplicor HIV-1 monitor assay and CD4(+) T-cell counts and markers of immune activation by standard three-color FACscan flow cytometry. Of the 260 female workers, 56 (21.5%) were heterozygous for CCR2b-V64I, and 8 (3%) were homozygous. Of the 99 HIV-seronegative female workers, 19 (19.2%) were heterozygous for the CCR2b-V64I mutation compared with 37 (23%) of the 161 HIV-seropositive FSW (P = 0.47). In a univariate analysis of viral load among HIV-seropositive FSW, no difference was noted between those heterozygous for or without the mutation; both groups had plasma viral loads of 5.0 log(10) copies/ml. After controlling for the effects of CD4(+) T-cell counts in a multivariate analysis, no significant difference was observed between the groups in viral load or in markers of immune activation. The data suggest that the presence of the CCR2b mutation has no effect on HIV-1 plasma viral load and markers of immune activation in our study population. The finding that the frequency of this mutation is similar in HIV-seropositive and -seronegative female workers suggests that its presence is not associated with increased risk of HIV infection.

Sensitivity and specificity of human immunodeficiency virus rapid serologic assays and testing algorithms in an antenatal clinic in Abidjan, Ivory Coast

To evaluate serologic testing algorithms for human immunodeficiency virus (HIV) based on a combination of rapid assays among persons with HIV-1 (non-B subtypes) infection, HIV-2 infection, and HIV-1-HIV-2 dual infections in Abidjan, Ivory Coast, a total of 1,216 sera with known HIV serologic status were used to evaluate the sensitivity and specificity of four rapid assays: Determine HIV-1/2, Capillus HIV-1/HIV-2, HIV-SPOT, and Genie II HIV-1/HIV-2. Two serum panels obtained from patients recently infected with HIV-1 subtypes B and non-B were also included. Based on sensitivity and specificity, three of the four rapid assays were evaluated prospectively in parallel (serum samples tested by two simultaneous rapid assays) and serial (serum samples tested by two consecutive rapid assays) testing algorithms. All assays were 100% sensitive, and specificities ranged from 99.4 to 100%. In the prospective evaluation, both the parallel and serial algorithms were 100% sensitive and specific. Our results suggest that rapid assays have high sensitivity and specificity and, when used in parallel or serial testing algorithms, yield results similar to those of enzyme-linked immunosorbent assay-based testing strategies. HIV serodiagnosis based on rapid assays may be a valuable alternative in implementing HIV prevention and surveillance programs in areas where sophisticated laboratories are difficult to establish.

High prevalence of genotypic and phenotypic HIV-1 drug-resistant strains among patients receiving antiretroviral therapy in Abidjan, Côte d'Ivoire

To describe prevalence of antiretroviral (ARV) drug-resistant HIV-1 strains among patients with a history of earlier treatment with ARV drugs in Abidjan, Côte d'Ivoire, we determined mutations that confer HIV-1 ARV drug resistance by sequencing the viral reverse-transcriptase and protease genes derived from plasma viral RNA of 68 individuals consecutively enrolled in the Joint United Nations Program on AIDS Drug Access Initiative (UNAIDS-DAI) with a history of earlier ARV drug treatment in Abidjan between August 1998 and April 1999. Phenotypic ARV drug resistance was assessed using a recombinant virus assay. Primary mutations associated with ARV drug resistance to at least one of the reverse-transcriptase inhibitors or protease inhibitors were detected in 39 (57.4%) of the 68 patients. The prevalence of mutations associated with resistance to ARV drugs was: 29 (42.6%) to zidovudine, 10 (14.7%) to lamivudine, one (1.5%) to didanosine, one K103N mutation (associated with resistance to delavirdine, nevirapine, and efavirenz), one Y181C mutation (associated with resistance to delavirdine and nevirapine), two to both indinavir (M46I/L and V82A) and saquinavir (G48V and L90M), and one each to ritonavir (V82A) and nelfinavir (D30N). Phenotypic resistance to at least one nucleoside reverse transcriptase inhibitor (RTI) was seen in 25 (39.7%) patients, to nonnucleoside RTIs in 5 (8%) patients, and to protease inhibitors in 4 (6%) patients. The high prevalence we observed in this study may limit in future the effectiveness of ARV programs in the Côte d'Ivoire.

Dual infection with human immunodeficiency virus type 1 and type 2: impact on HIV type 1 viral load and immune activation markers in HIV-seropositive female sex workers in Abidjan, Ivory Coast

To determine the impact of dual infection with HIV-1 and HIV-2 on HIV-1 viral load and markers of immune activation among HIV-seropositive FSWs in Abidjan, we analyzed blood samples obtained from consenting HIV-seropositive FSWs attending a confidential clinic between September 1996 and June 1997 in Abidjan. Among HIV-1 and HIV-2 dually seropositive FSWs, polymerase chain reaction (PCR) testing with HIV-1 and HIV-2 primers was used to differentiate between FSWs who were PCR positive only for HIV-1 and those positive for both HIV-1 and HIV-2 (dually infected). Of the 203 FSWs, 151 (74%) were HIV-1 seropositive only (median age, 26 years), 4 (2%) were HIV-2 seropositive, and 48 (24%) were dually seropositive (median age, 30 years). Of the 48 dually seropositive FSWs, 33 (69%) were dually infected and 15 (31%) were dually seropositive. Median CD4+ T cell counts per microliter were not significantly different among the three groups (525 for HIV-1 positive only, 502 for dually infected, and 416 for dually seropositive) (p = 0.14). Median viral load (log10 copies/ml) was not significantly different among the HIV-1-only FSWs (4.8 log10 copies/ml) compared with the 32 dually infected FSWs (4.6 log10 copies/ml) and 14 dually seropositive FSWs (4.7 log10 copies/ml; p = 0.95). Median levels of HLA-DR immune activation were increased in both CD4+ and CD8+ T cells for the dually infected (n = 27) FSWs compared with those infected with HIV-1 only (n = 123) (p = 0.019 and p = 0.01, respectively). Dual infection does not appear to influence levels of HIV-1 viral load in vivo. However, levels of HLA-DR are higher among FSWs dually infected with HIV-1 and HIV-2 than among those infected with HIV-1 only.

Distribution of HIV-1 subtypes among HIV-seropositive patients in the interior of Côte d'Ivoire

Limited data exist on the distribution of HIV-1 subtypes in Côte d'Ivoire. The aim of this study is to describe the distribution of genetic subtypes of HIV-1 strains in six regions of Côte d'Ivoire. In 1997, we consecutively collected blood from 172 HIV-1-infected patients from six regional tuberculosis treatment centers. Peripheral blood mononuclear cells (PBMCs) from these people were analyzed by a restriction fragment-length polymorphism (RFLP) assay that involves a sequential endonuclease digestion of a 297-base pair polymerase chain reaction (PCR) fragment; plasma samples were tested by a V3-loop peptide enzyme immunoassay (PEIA). DNA sequencing of the protease or env genes was performed on all samples discordant in the two assays as well as a random sample of the concordant subtyped samples. Of 172 specimens, 3 were PCR-negative, and 169 were putatively classified as subtype A by RFLP. The 3 PCR-negative samples were unequivocally subtyped A by PEIA. Of the 169 RFLP subtype A samples, 159 (94%) were subtyped A by PEIA. Of the 10 discordant samples, PEIA testing classified 3 as subtype C, 2 as D, and 5 as F. Sequencing of the env gene classified these samples as 1 subtype A, 4 Ds, and 5 Gs. Thus, 163 (95%) of the specimens were subtype A, 3 subtype D, 4 subtype G, 1 A/D, and 1 A/G (IbNG) circulating recombinant forms (CRF). In conclusion, most HIV-1-infected tuberculosis patients throughout the interior of Côte d'Ivoire are infected with HIV-1 subtype A, which are very likely the A/G (IbNG) CRF. The uniform distribution of this subtype makes Côte d'Ivoire a potential site for vaccine trials.

Efficacy of trimethoprim-sulphamethoxazole prophylaxis to decrease morbidity and mortality in HIV-1-infected patients with tuberculosis in Abidjan, Côte d'Ivoire: a randomised controlled trial

BACKGROUND

There is a high incidence of opportunistic infection among HIV-1-infected patients with tuberculosis in Africa and, consequently, high mortality. We assessed the safety and efficacy of trimethoprim-sulphamethoxazole 800 mg/160 mg (co-trimoxazole) prophylaxis in prevention of such infections and in decrease of morbidity and mortality.

METHODS

Between October, 1995, and April, 1998, we enrolled 771 HIV-1 seropositive and HIV-1 and HIV-2 dually seroreactive patients who had sputum-smear-positive pulmonary tuberculosis (median age 32 years [range 18-64], median CD4-cell count 317 cells/microL) attending Abidjan's four largest outpatient tuberculosis treatment centres. Patients were randomly assigned one daily tablet of co-trimoxazole (n=386) or placebo (n=385) 1 month after the start of a standard 6-month tuberculosis regimen. We assessed adherence to study drug and tolerance monthly for 5 months and every 3 months thereafter, as well as rates of admission to hospital.

FINDINGS

Rates of laboratory and clinical adverse events were similar in the two groups. 51 patients in the co-trimoxazole group (13.8/100 person-years) and 86 in the placebo group (25.4/100 person-years) died (decrease In risk 46% [95% CI 23-62], p<0.001). 29 patients on co-trimoxazole (8.2/100 person-years) and 47 on placebo (15.0/100 person-years) were admitted to hospital at least once after randomisation (decrease 43% [10-64]), p=0.02). There were significantly fewer admissions for septicaemia and enteritis in the co-trimoxazole group than in the placebo group.

INTERPRETATION

In HIV-1-infected patients with tuberculosis, daily co-trimoxazole prophylaxis was well tolerated and significantly decreased mortality and hospital admission rates. Our findings may have important implications for improvement of clinical care for such patients in Africa.

Short-course oral zidovudine for prevention of mother-to-child transmission of HIV-1 in Abidjan, Côte d'Ivoire: a randomised trial

BACKGROUND

In Africa, the risk of mother-to-child transmission of HIV-1 infection is high. Short-course perinatal oral zidovudine might decrease the rate of transmission. We assessed the safety and efficacy of such a regimen among HIV-1-seropositive breastfeeding women in Abidjan, Côte d'Ivoire.

METHODS

From April, 1996, to February, 1998, all consenting, eligible HIV-1-seropositive pregnant women attending a public antenatal clinic in Abidjan were enrolled at 36 weeks' gestation and randomly assigned placebo or zidovudine (300 mg tablets), one tablet twice daily until the onset of labour, one tablet at onset of labour, and one tablet every 3 h until delivery. We used HIV-1-DNA PCR to test the infection status of babies at birth, 4 weeks, and 3 months. We stopped the study on Feb 18, 1998, when efficacy results were available from a study in Bangkok, Thailand, in which the same regimen was used in a non-breastfeeding population.

FINDINGS

280 women were enrolled (140 in each group). The median duration of the prenatal drug regimen was 27 days (range 1-80) and the median duration of labour was 7.5 h. Treatment was well tolerated with no withdrawals because of adverse events. All babies were breastfed. Among babies with known infection status at age 3 months, 30 (26.1%) of 115 babies in the placebo group and 19 (16.5%) of 115 in the zidovudine group were identified as HIV-1 infected. The estimated risk of HIV-1 transmission in the placebo and zidovudine groups were 21.7% and 12.2% (p=0.05) at 4 weeks, and 24.9% and 15.7% (p=0.07) at 3 months. Efficacy was 44% (95% CI -1 to 69) at age 4 weeks and 37% (-5 to 63) at 3 months.

INTERPRETATION

Short-course oral zidovudine was safe, well tolerated, and decreased mother-to-child transmission of HIV-1 at age 3 months. Substantial efforts will be needed to ensure successful widespread implementation of such a regimen.