A multifaceted intervention to improve syphilis screening and treatment in pregnant women in Kinshasa, Democratic Republic of the Congo and in Lusaka, Zambia: a cluster randomised controlled trial

Background

Despite international recommendations, coverage of syphilis testing in pregnant women and treatment of those found seropositive remains limited in sub-Saharan Africa. We assessed whether combining the provision of supplies with a behavioural intervention was more effective than providing supplies only, to improve syphilis screening and treatment during antenatal care.

Methods

In this 18-month, cluster randomised controlled trial, we randomly assigned (1:1) 26 urban antenatal care clinics in Kinshasa, Democratic Republic of the Congo, and Lusaka, Zambia, to receive a behavioural intervention (opinion leader selection, academic detailing visits, reminders, audits and feedback, and supportive supervision) plus supplies for syphilis testing and treatment (intervention group) or to receive supplies only (control group). The primary outcomes were proportion of pregnant women who had syphilis screening out of the total who attended the clinic; and the proportion of women who had treatment with benzathine benzylpenicillin out of those who tested positive for syphilis at their first antenatal care visit. This trial is registered at ClinicalTrials.gov, number NCT02353117.

Findings

The 18-month study period was Feb 1, 2016, to July 14, 2017. 18 357 women were enrolled at the 13 intervention clinics and 17 679 women were enrolled at the 13 control clinics at their first antenatal care visit. Syphilis screening was done in a median of 99·9% (IQR 99·0–100·0) of women in the intervention clinics and 93·8% (85·0–98·9) in the control clinics (absolute difference 6·1% [95% CI 1·1–14·1]; p=0·00092). Syphilis treatment at the first visit was done in a median of 100% (IQR 99·7–100·0) of seropositive women in intervention clinics and 43·2% (2·6–83·2) of seropositive women in control clinics (absolute difference 56·8% [12·8–99·0]; p=0·0028).

Interpretation

A behavioural intervention, together with the provision of supplies, can lead to more than 95% of women being screened and treated for syphilis. The sole provision of supplies is sufficient to reach such levels of screening coverage but is not sufficient to ensure high levels of treatment.

Funding

Bill & Melinda Gates Foundation.

[Therapeutic outcomes of anti-tuberculosis treatment in the context of HIV-tuberculosis co-infection: Cohort of Kabinda Center in Kinshasa, Democratic Republic of Congo]

BACKGROUND

The study aimed to determine the clinical forms of tuberculosis and therapeutic outcome of anti-tuberculosis treatment in the context of HIV-tuberculosis co-infection.

METHODS

A retrospective cohort of 120 HIV-positive patients with tuberculosis and 297 HIV-negative patients with tuberculosis attending the Kabinda Center was followed from 2010 to June, 30th 2013. The logistic regression model identified the determinants of a defavorable outcome after initiation of tuberculostatics.

RESULTS

The proportion of female patients was higher in the co-infected group compared with the non-co-infected group (60.8% versus 42.7%, P<0.001). HIV-seropositive patients had more forms of pulmonary smear-negative (39.2% versus 25.3%, P<0.002) and extra-pulmonary (38% versus 35%, P<0.002) tuberculosis than HIV-negative patients. HIV-positive serology (OR: 3.13, 95%CI: 1.72-5.69) and age of patients more than 41 years (OR: 3.15, 95%CI: 1.36-7.29) were associated with an unfavorable outcome.

CONCLUSION

This study highlights the usefulness of a systematically determining immunological status in co-infected patients and a timely and systematic ARV treatment, together with early diagnosis of tuberculosis. It also emphasizes the importance of adherence to support measures in order to improve tuberculosis treatment outcomes in co-infected patients.

Comparison of the cytotoxic effect of hormonotoxins prepared with the use of heterobifunctional cross-linking agents N-succinimidyl 3-(2-pyridyldithio)propionate and N-succinimidyl 6-[3-(2-pyridyldithio)propionamido]hexanoate

With the aim of developing cytotoxic hybrid molecules which can be selectively targeted to specific cells in the gonads, a single chain ribosome-inactivating protein, gelonin, was conjugated to ovine luteinizing hormone (oLH) with the use of heterobifunctional cross-linking agents N-succinimidyl3-(2-pyridyldithio)-propionate (SPDP) and long-chain SPDP. Four hormonotoxins were synthesized having a variable spacer arm between oLH and gelonin. The spacer arms in C200A, C210A, C220A, and C230A were 13.6, 22.4, 22.4, and 31.2 A long, respectively. Extensive physiochemical and biochemical analysis revealed a 1:1 molar ratio of the ingredients in its oLH-S-S-gelonin conjugates. The linkage occurred through the epsilon-NH2 group of the alpha-subunit of oLH as judged from RP-HPLC analysis. The hormonotoxins retained substantial receptor binding ability, steriodogenic activity, and immunoreactivity of oLH and gelonin to their respective antibodies. Hormonotoxins bind to Leydig tumor cells via oLH, leaving gelonin free as judged by competitive displacement analysis. The hormonotoxins internalized to a sufficient degree to effectively inhibit protein synthesis. Upon comparison, immunoreactivity, receptor binding steroidogenic activity, and cytotoxicity of oLH-S-S-gelonin conjugates prepared with the use of only LC-SPDP (C230A, 31.2-A spacer arm) and by using both SPDP and LC-SPDP (C210A and C220A, 22.4-A spacer arm) were found to be comparable with that of conjugate prepared with SPDP alone (C200A, 13.6-A spacer arm). Therefore, it may be concluded that the cytotoxicity of oLH-based hormonotoxin remained unaffected with the use of long-chain spacer arms which are believed to be used generally to avoid steric hindrance.

Effect of lysine residue modification of ovine luteinizing hormone by heterobifunctional crosslinking reagent SPDP on subunit-subunit association, receptor binding and biological activity

The increasing use of heterobifunctional crosslinking agent in the design of hormone-carrier conjugates for selective targeting or inducing immune response against the hormone has prompted us to study the effect of epsilon-NH2 group modification of oLH-subunit, their recombination, immunoreactivity, receptor binding and biological activity. The epsilon-NH2 groups of oLH alpha and oLH beta subunits were modified by using SPDP. The SPDP modified oLH alpha derivatives hybridize to native OLH beta as judged by RP-HPLC analysis. The sequential modification of alpha and beta subunits led to progressive reduction in immunoreactivity and receptor binding activities. The steroidogenic potential of oLH beta.SPDP.alpha oLH recombinant was relatively comparable. The modification of six or more epsilon-NH2 groups in oLH alpha although recombine fully with native oLH beta but failed to react to anti-oLH antibody. Moreover, steroidogenic activity was also abolished. Introduction up to four SPDP groups in oLH alpha compromised immunological and biological activities but further addition of two more SPDP groups completely abolished antibody reactivity, receptor binding and steroidogenic activity indicating the importance of later two -NH2 groups in the receptor recognition and steroidogenic potential.

Design of liposome to improve encapsulation efficiency of gelonin and its effect on immunoreactivity and ribosome inactivating property

Gelonin, purified from the seeds of Gelonium multiflorum, using cation-exchange and gel-filtration chromatography was characterised for its purity, homogeneity and molecular weight by reverse-phase HPLC (RP-HPLC) and SDS-PAGE analysis. The HPLC purified gelonin was used for entrapment studies in the liposomes. Liposomes were prepared by reverse phase evaporation (REV) technique using three different types of lipid composition in the same molar ratio. The method resulted in 75-80% entrapment efficiency of gelonin in the liposomes. Entrapped and unentrapped gelonin was characterized for physico-chemical, immunochemical and biological properties. The immunoreactivity of entrapped gelonin was fully preserved but the ribosome-inactivating property was slightly inhibited. The method involved mild conditions, highly reproducible and the liposomes produced appeared to be stable for several months. It has important implications in the development of cell type specific cytotoxic agents where a chemical cross-linking is involved which significantly inhibits both immunoreactivity and ribosome-inactivating ability of the toxin.