Observational study of anorectal Chlamydia trachomatis infections in France through the lymphogranuloma venereum surveillance network, 2010-2015

The objective of this article is to describe the epidemiology of lymphogranuloma venereum (LGV) and non-LGV Chlamydia trachomatis anorectal infections in France and to examine the characteristics of the affected populations via a voluntary sentinel surveillance system for LGV between 2010 and 2015. Anorectal samples positive for C. trachomatis (CT) were sent by the participating laboratories to the National Reference Center for CT for LGV identification. Biological and clinical data were collected by biologists and clinicians. There were 1740 LGV episodes and 2248 non-LGV episodes. Continuous monitoring highlighted a sharp increase in the number of LGV and non-LGV anorectal infections, which were 2.3-fold and 6.5-fold, respectively. Most of the infections occurred in men who have sex with men. LGV patients were older than non-LGV patients and were more frequently human immunodeficiency virus (HIV)-positive compared to non-LGV patients. Anorectal LGV was significantly associated with residence in Paris, HIV co-infection, concurrent syphilis and bloody anal discharge. Undocumented patient characteristics were strongly associated with anorectal LGV. The anorectal LGV epidemic is poorly controlled in France. Early detection and prompt treatment of patients and their sexual partners are required to prevent transmission in the context of pre-exposure prophylaxis (PrEP) for HIV infection.

Incidence of gonococcal and chlamydial infections and coverage of two laboratory surveillance networks, France, 2012

Surveillance of sexually transmitted diseases in France is based on voluntary networks of laboratories and clinicians. Despite the importance of incidence data in improving knowledge about the national context and in international comparisons, such data were not previously available. During nationwide quality control of laboratories, mandatory for all laboratories, we conducted a survey in June 2013 to estimate the incidence rates of gonococcal and chlamydial infections for 2012 and to estimate the proportion of diagnoses performed (coverage) by the country's two laboratory-based sentinel networks for these diseases. Estimated incidence rates for 2012 were 39 per 100,000 persons aged 15 to 59 years for gonorrhoea and 257 per 100,000 persons aged 15 to 49 years for chlamydia. These rates were consistent with the average levels for a group of other Western countries. However, different estimates between countries may reflect disparate sources of surveillance data and diverse screening strategies. Better comparability between countries requires harmonising data sources and the presentation of results. Estimated coverage rates of the gonococcal and chlamydial infection surveillance networks in France in 2012 were 23% and 18%, respectively, with substantial regional variations. These variations justify improving the representativeness of these networks by adding laboratories in insufficiently covered areas.

Incidence of gonococcal and chlamydial infections and coverage of two laboratory surveillance networks, France, 2012

Binary file ES_Abstracts_Final_ECDC.txt matches

High-level azithromycin-resistant Neisseria gonorrhoeae clinical isolate in France, March 2014

We report the first case in France of a high-level azithromycin-resistant Neisseria gonorrhoeae (minimum inhibitory concentration (MIC) = 96 mg/L) assigned to MLST7363 (NG-MAST ST6360), also resistant to ciprofloxacin and tetracycline but susceptible to ceftriaxone. The patient was a 51 year-old heterosexual man who returned following 1g azithromycin monotherapy. Mechanisms of azithromycin resistance were a C2599T mutation in the four copies of the rrl gene and a novel mutation in the promoter of the mtrR gene.

Self-report of sexually transmitted infections from 1994 to 2010 by adults living in France

BACKGROUND

Since 1994, French population-based knowledge, attitudes, beliefs and practices surveys have enabled researchers to estimate trends in sexual behavioural indicators.

METHODS

We estimated trends and prevalence of self-reported sexually transmitted infections during the previous 5 years among 16,095 sexually active adults aged 18-54 through five cross-sectional telephone surveys between 1994 and 2010. We then studied the factors associated with participants' most recent sexually transmitted infections other than genital candidiasis.

RESULTS

Overall, 2.5% (95% confidence interval: 2.2%-2.9%) of women reported sexually transmitted infections within the previous 5 years, increases being continuously reported between 1998 and 2010. In contrast, men reported lower prevalence of sexually transmitted infections (1.4%; 95% confidence interval: 1.1%-1.7%), which remained stable over time. General practitioners and gynaecologists managed most sexually transmitted infections. Men notified their stable partners about infection less often than women (66% vs. 84%). Self-reported sexually transmitted infections were associated with younger age, multiple sexual partnerships and fear of sexually transmitted infections in both genders, with exclusively homosexual practices in men, and with a high educational level and recent HIV testing in women.

CONCLUSION

Self-reported sexually transmitted infections clearly reflect risky sexual behaviours. The lower prevalence of self-reported sexually transmitted infections among men than among women may reflect less access to screening activities for sexually transmitted infections in men.

Gonococcal infections and emergence of gonococcal decreased susceptibility to cephalosporins in France, 2001 to 2012

Resistance to cephalosporins may lead to untreatable gonococcal infections. We describe the results of the sentinel surveillance of gonococcal infections and the evolution of the resistance of Neisseria gonorrhoeae to antibiotics in France from 2001 to 2012. We also analyse the factors associated with decreased susceptibility to third generation cephalosporins. In France, surveillance of gonococcal infections is conducted through a network of voluntarily participating laboratories. Strains are sent to the national reference laboratory to determine the minimum inhibitory concentration (MIC) for six antibiotics. During the study period, the number of gonococcal infections increased steadily. The susceptibility of 8,649 strains was studied for this period. The proportion of strains with decreased susceptibility to cefixime (MIC>0.125 mg/L) quadrupled between 2011 (0.7%:10/1,521) and 2012 (3.0%: 33/1,093; p<0.001). Between 2001 and 2012, only two of the 8,649 strains, both collected in 2010, had a MIC>0.125 mg/L for ceftriaxone. Decreased susceptibility to cephalosporins increased with older age and was more common in pharyngeal strains. Decreased susceptibility to cefixime may indicate that the national recommendation to use ceftriaxone as a first line treatment for cases of urethritis and cervicitis has not been fully implemented. Enhanced surveillance of pharyngeal strains is strongly suggested.

First cases of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) infections in France, investigations and implications for the prevention of human-to-human transmission, France, May 2013

In May 2013, Middle East Respiratory Syndrome Coronavirus (MERS-CoV) infection was diagnosed in an adult male in France with severe respiratory illness, who had travelled to the United Arab Emirates before symptom onset. Contact tracing identified a secondary case in a patient hospitalised in the same hospital room. No other cases of MERS-CoV infection were identified among the index case’s 123 contacts, nor among 39 contacts of the secondary case, during the 10-day follow-up period.

First two autochthonous dengue virus infections in metropolitan France, September 2010

In September 2010, two cases of autochthonous dengue fever were diagnosed in metropolitan France for the first time. The cases occurring in Nice, southeast France, where Aedes albopictus is established, are evidence of dengue virus circulation in this area. This local transmission of dengue calls for further enhanced surveillance, active case finding and vector control measures to reduce the spread of the virus and the risk of an epidemic.

First two autochthonous dengue virus infections in metropolitan France, September 2010

In September 2010, two cases of autochthonous dengue fever were diagnosed in metropolitan France for the first time. The cases occurring in Nice, south-east France, where Aedes albopictus is established, are evidence of dengue virus circulation in this area. This local transmission of dengue calls for further enhanced surveillance, active case finding and vector control measures to reduce the spread of the virus and the risk of an epidemic.

[Chagas disease in France: estimated number of infected persons and cardiac diseases in 2009, by risk groups]

An estimation of the number of Trypanosoma cruzi infected individuals and expected number of Chagasic cardiomyopathies in France (excluding French Guyana) was conducted in June, 2009 by InVS. Different risk groups were identified: Latino-Americans (LA) from endemic area (naturalized, legal and illegal migrants, adopted children), children born from LA's mother, French Guyanese living in Metropolitan France, expatriated and travellers from endemic countries. Prevalence rates by country of origin were applied to official data on risk populations obtained from the International Adoption Agency, Tourism Direction and French ministries (Finances, Foreign Affairs and Migrations). Around 157,000 individuals were potentially exposed. It is estimated than 1,464 [895-2,619] are infected by T. cruzi, of which 63 to 555 may evolve towards a chronic cardiomyopathy. This figure is within the range of earlier estimations of InVS and Guerri-Guttenberg. Taking into account illegal immigrants, the expected number of infected individuals in France should increase greatly this estimation.

The 2009 pandemic H1N1 influenza and indigenous populations of the Americas and the Pacific

There are few structured data available to assess the risks associated with pandemic influenza A(H1N1)v infection according to ethnic groups. In countries of the Americas and the Pacific where these data are available, the attack rates are higher in indigenous populations, who also appear to be at approximately three to six-fold higher risk of developing severe disease and of dying. These observations may be associated with documented risk factors for severe disease and death associated with pandemic H1N1 influenza infection (especially the generally higher prevalence of diabetes, obesity, asthma, chronic obstructive pulmonary disease and pregnancy in indigenous populations). More speculative factors include those associated with the risk of infection (e.g. family size, crowding and poverty), differences in access to health services and, perhaps, genetic factors. Whatever the causes, this increased vulnerability of indigenous populations justify specific immediate actions in the control of the current pandemic including primary prevention (intensified hygiene promotion, chemoprophylaxis and vaccination) and secondary prevention (improved access to services and early treatment following symptoms onset) of severe pandemic H1N1 influenza infection.

Epidemiology of fatal cases associated with pandemic H1N1 influenza 2009

This article describes the characteristics of 574 deaths associated with pandemic H1N1 influenza up to 16 July 2009. Data (except from Canada and Australia) suggest that the elderly may to some extent be protected from infection. There was underlying disease in at least half of the fatal cases. Two risk factors seem of particular importance: pregnancy and metabolic condition (including obesity which has not been considered as risk factor in previous pandemics or seasonal influenza).

[Evaluation of the pertinence of international courses on human African trypanosomiasis]

The goal of this study was to evaluate the adequacy and relevance of a training course on Human African Trypanosomiasis, targeted to reach support and coordination staff in charge of activities being carried out in related prevention and control programmes. A questionnaire was emailed to the four course organisers and the 65 participants. The response rate among the participants was 41%. The training needs expressed covered issues such as treatment, diagnostic and epidemiological techniques, improved knowledge of the disease, and control planning. The lectures given were adapted for participants' professional activities. At the time of the evaluation (one to three years after the course) 67% of the participants had begun implementing the knowledge they had acquired and applying it to their practice, particularly in the area of programme planning. The analysis of the questionnaire's results pointed to the sections of the course that would benefit from modifications, such as the need for the development of lessons and modules in the areas of patient management and planning for future training sessions.

[Requests for residency permits due to medical reasons from foreigners in the Val-d'Oise county between 1999 and 2003]

The requests for residence permits from foreigners who wish to remain in France for health reasons are submitted for review to the county public health medical officer. This article reports on the quantitative and qualitative evolution and progression of these requests in a county located near Paris. The number of requests has drastically increased, from 152 in 1999 to 1,823 in the year 2003. The majority of the applicants were women and individuals from sub-Saharan Africa. HIV infection was the most frequent reason cited for the submission of requests, but its relative proportion has decreased over time from 25% in 1999 to 15% of overall requests made in the year 2003, which is then followed by diabetes (8% of all requests), hypertension (5%), and tuberculosis (4%). The decision handed down from the authorities was favourable for residence based on the need for healthcare in 74% of the cases. The health status of the illegal immigrants remains difficult to determine and systematically track; therefore, the applications for residency granted on medical grounds serve as a practical and efficient means to assess and map the existing situation.

Autorisation de séjour pour soins des malades étrangers en France : enquête sur les avis des médecins inspecteurs de santé publique

BACKGROUND

Public health medical officers of the different French administrative districts are called in to advise the public authorities (Préfet) on requests for a residence permit from foreigners seeking healthcare asylum in France. Using a medical report chart, the medical officer specifies whether the foreigner requires treatment, whether lack of medical care can have exceptionally serious consequences and whether the patient can obtain a suitable treatment in his/her own country. Considering the marked increase in the number of requests for healthcare asylum and the potential subjective aspect of the medical officer's advice, a survey was conducted to assess medical officers'practices.

METHODS

In March 2002, a questionnaire was addressed by email to the medical officers practising in the 94 administrative districts of metropolitan France. They were to give their advice about two fictional requests for healthcare asylum; the fictional requests closely mimicked real situations which frequently raise difficult issues. The two seekers were a 57-year-old man from Comoros treated for hypertension and noninsulin-dependent diabetes mellitus (case 1) and a 33-year-old woman from the Ivory Coast followed after treatment for tuberculosis (case 2).

RESULTS

Among the 94 district medical officers contacted, 42 (45%) responded. Respectively 88% (case 1) and 67% (case 2) of the medical officers considered that the patient required medical care because lack of care would have serious consequences, but for 26% (cases 1 and 2), treatment could be delivered in the country of origin. Finally, the advise proposed by the different officers varied: for 33% (case 1) and 53% (case 2) of the medical officers, asylum in France for healthcare was unjustified.

CONCLUSIONS

In spite of a low response rate, this survey shows the subjectivity of the advice provided by medical officers, raising the question of its fairness. Our study suggests that this subjectivity is related to the vagueness of the questions asked to the medical officers and the lack of a frame of reference on which to base their advice.

Hepatitis B and C infections, human immunodeficiency virus and other sexually transmitted infections among women of childbearing age in Côte d'Ivoire, West Africa

Few studies have been conducted in developing countries to estimate the prevalence of hepatitis C virus (HCV) infection and its association with human immunodeficiency virus (HIV) and other sexually transmitted diseases (STDs). We have screened for hepatitis B virus (HBV) and HCV markers 200 HIV-1-positive, 23 HIV-2-positive and 206 HIV-negative women attending gynaecology clinics in 1995/96 in Abidjan, Côte d'Ivoire, a sample selected among 2198 consecutive consultants. Taking into account the prevalence of 21.7% for HIV in this population, the overall prevalence of anti-HBV core antibody was 81.6%, that for hepatitis B surface antigen was 9.9% and for HCV antibody was 3.3%. HIV infection and other STDs were not associated with HBV or HCV markers. Moreover, HBV and HCV markers were not statistically associated. Our results confirm the high prevalence of HIV in Abidjan and the endemic situation of HBV infection. Furthermore, HCV infection is not infrequent in this developing country setting, not explained by sexual transmission.

Genital mycoplasmas among pregnant women in Cóte d'Ivoire, West Africa: prevalence and risk factors

A cross-sectional study was conducted among pregnant women in Côte d'Ivoire to assess the prevalence and the factors associated with mycoplasma colonization. A positive culture was found in 400 of 551 women (73%); Ureaplasma urealyticum was identified in 22%, Mycoplasma hominis in 20% and both microorganisms in 31%. Mycoplasma colonization was not associated with genital symptoms or signs. Young age, low educational level, antimicrobial chemotherapy before consultation and presence of bacterial vaginosis were factors independently associated with M. hominis colonization. Among women colonized with M. hominis, HIV seroprevalence was 21% in women with high amounts of M. hominis (> or = 10(4) colour-changing units per ml) versus 7% in women with lower amounts (P=0.01). U. urealyticum was found more often in unmarried women and when pregnancy was less than 20 weeks. Mycoplasma colonization is frequent among pregnant women in Abidjan, but their pathogenicity requires further study.

[The fight against sexually transmitted diseases in Ivory Coast: what strategies can we use in the face of HIV/AIDS?]

In the AIDS era, sexually transmitted diseases (STDs) have become a major health problem in developing countries, particularly in Africa. Delays in the diagnosis and treatment of such infections may result in complications, many of which primarily affect women. Epidemiological studies in Abidjan have shown that more than 10% of the pregnant women attending antenatal clinics present STDs potentially serious for their own health or that of their infants (gonorrhea, chlamydia infection, genital ulcers or active syphilis). There is evidence that STDs increase the transmission of HIV and that improving the syndromic management of STDs reduces the incidence of HIV infection. This provides a strong argument in favor of controlling STDs in areas of high HIV prevalence. In Ivory Coast, as in other African countries, a STD control program has been integrated into the AIDS control program since 1992, as recommended by the World Health Organization. During the first six years of the STD program, considerable progress was made in some areas, but not without difficulty. Simple syndrome-based decision trees have been adopted for the management of STDs in primary health care. Clinical studies have shown these therapeutic algorithms to be effective. At the same time, effective and affordable drugs for treating STDs were added to the list of essential drugs in Ivory Coast, after an international invitation to tender. The entire staff of the public health sector in Abidjan has been trained in syndromic STD management. Training is now being extended to other parts of Ivory Coast, including the private health sector and, in particular, private nurses. The surveillance of syndromic STDs, mainly genital ulcers in both sexes and urethral discharge in men, facilitates monitoring and evaluation of the STD program, following health care activities and adapting orders for drugs for treating STDs to real needs. In the near future, some parts of the STD program will be strengthened, particularly the management of sexual partners of STD patients and reduction of the cost of STD treatment for pregnant women.

Cervical screening in Africa: discordant diagnosis in a double independent reading. DYSCER-CI Group

Interobserver variation in the cytological diagnosis of cervical lesions poses a problem for public health screening programs. This study assessed the frequency of discordant diagnoses between two independent cytopathologists in the screening of African women. In Abidjan, Côte d'Ivoire, 2157 women were recruited from three outpatient gynecology clinics and screened for cervical abnormalities and genital and human immunodeficiency virus (HIV) infections. The degree of agreement between the cytopathologists was assessed by kappa statistics. The overall agreement was poor (kappa = 0.33); however, the degree of agreement increased with the severity of the lesions and was fairly good (kappa = 0.53) for high-grade and invasive lesions requiring curative treatment. Discordance was associated with HIV infection but not with genital infections. For a prevention program of cervical cancer in this African context, strategies must be developed to minimize errors in cervical screening. Particularly, HIV-infected women require a systematic rereading to reduce false-negative results.

Short-term follow up of cervical squamous intraepithelial lesions associated with HIV and human papillomavirus infections in Africa

A prospective study in gynaecology clinics was conducted in Abidjan, Côte d'Ivoire, to assess the short-term evolution of squamous intraepithelial lesions (SILs). Of 94 women with a cytological diagnosis of SIL, 38 were infected with HIV. The average follow-up period after the initial smear was 5 months. Detection of human papillomavirus (HPV) by polymerase chain reaction (PCR) was performed at both the time of enrolment and final follow-up smear. There were 39 cases of persistent SILs. HIV-positive women had a higher percentage of persistent SIL (76%) than HIV-negative women (18%, relative risk (RR)=4.3, 95% confidence interval (CI) = 2.4, 7.7). SILs were more frequent among women infected with HPV at the time of enrolment or with persistent HPV infection, but these associations disappeared after adjusting for HIV serostatus. Spontaneous regression of SILs commonly occurs in HIV-negative African women. HIV-infected women with cervical dyskaryosis require gynaecology follow-up.

Short-term follow up of cervical squamous intraepithelial lesions associated with HIV and human papillomavirus infections in Africa

A prospective study in gynaecology clinics was conducted in Abidjan, Côte d'Ivoire, to assess the short-term evolution of squamous intraepithelial lesions (SILs). Of 94 women with a cytological diagnosis of SIL, 38 were infected with HIV. The average follow-up period after the initial smear was 5 months. Detection of human papillomavirus (HPV) by polymerase chain reaction (PCR) was performed at both the time of enrolment and final follow-up smear. There were 39 cases of persistent SILs. HIV-positive women had a higher percentage of persistent SIL (76%) than HIV-negative women (18%, relative risk (RR)=4.3, 95% confidence interval (CI)=2.4, 7.7). SILs were more frequent among women infected with HPV at the time of enrolment or with persistent HPV infection, but these associations disappeared after adjusting for HIV serostatus. Spontaneous regression of SILs commonly occurs in HIV-negative African women. HIV-infected women with cervical dyskaryosis require gynaecology follow-up.

Vaginal douching: association with lower genital tract infections in African pregnant women

BACKGROUND AND OBJECTIVES

Douching, a common practice, could further increase the risk of genital infections.

GOAL OF THIS STUDY

To describe douching practices in pregnant women and to evaluate associations with lower genital tract infections.

STUDY DESIGN

Cross-sectional study in Abidjan, Côte d'Ivoire.

RESULTS

Among 552 women included, douching before consultation was reported by 97% and was common practice for 98%. Intravaginal drying agents were used by 10%. Genital warts were less frequent for women who usually douched (p = 0.015). U. urealyticum infection was associated with douching and with the use of intravaginal agents. Diagnosis of genital infections was independent of douching with water or soap, but chlamydial infection was associated with douching with antiseptics, used by 14% of the women (p = 0.036). HIV infection was two times more frequent in women using antiseptics (p = 0.17).

CONCLUSION

The study confirms the widespread practice of douching in African pregnant women. The harmful effects of antiseptics need to be substantiated.

Squamous intraepithelial lesions of the cervix, invasive cervical carcinoma, and immunosuppression induced by human immunodeficiency virus in Africa. Dyscer-CI Group

BACKGROUND

Squamous intraepithelial lesions (SILs) of the cervix are associated with human immunodeficiency virus (HIV) infection, but multiple risk factors must be considered in this context. The authors performed a cross-sectional study to assess the prevalence of and the factors associated with SILs and invasive cervical carcinoma (ICC).

METHODS

In Abidjan, Côte d'Ivoire, women were recruited from three outpatient gynecology clinics and screened for both cervical disease and HIV infection. A CD4 cell count was performed for HIV-infected women.

RESULTS

A total of 2198 women were included in the study. The prevalence of HIV infection was 21.7%. Of the 2170 women who underwent a cervical screening, 254 (11.7%) presented with a dysplasia or neoplasia: 7.6% had low grade SILs (LSILs), 3.3% had high grade SILs (HSILs), and 0.8% had ICCs. In multivariate analyses, factors associated with these lesions were as follows: for LSILs, HIV-1 seropositivity, age <24 years, parity >1, consultation for genital infection, and no use of oral contraception in the past; for HSILs, HIV-1 seropositivity, chewing tobacco use, low educational level, and parity >1; and for ICCs, age >33 years, parity >3, and illiteracy. In women infected with HIV-1, the prevalence of LSILs increased with a decrease in CD4 cell count, whereas this relation was not found among patients with HSILs. ICCs were linked to HIV-2 infection, but not to HIV-1 infection, in univariate analysis.

CONCLUSIONS

In Africa, the prevalence of SILs is high. The factors associated with precancerous and cancerous lesions are different. Cancers in women infected with HIV-1 often may not reach the invasive stage. These findings could have implications for cervical screening programs in the future.

Human papillomavirus and human immunodeficiency virus infections: relation with cervical dysplasia-neoplasia in African women

Our study assessed the factors associated with cervical squamous intra-epithelial lesions (SILs) and invasive cervical cancer, with special attention to human immunodeficiency virus (HIV) and human papillomavirus (HPV) infections. Women from 3 outpatient gynecology clinics of Abidjan, Côte d'Ivoire, were screened for cervical abnormalities: 151 women with low-grade SILs and 151 controls, 60 with high-grade SILs and 240 controls, and 13 with invasive cancer and 65 controls were enrolled in 3 case-control studies. Controls were chosen at random among the women without lesions, with a frequency matching for age and center. We used the PCR method for the detection of cervical HPV DNA and the restriction fragment length polymorphism analysis for HPV typing. HIV antibody testing and CD4 cell count were performed. In multivariate analyses, factors associated with cervical lesions were: for low-grade SILs, HPV positivity, HIV-1 seropositivity and parity >3; for high-grade SILs, HPV positivity, chewing tobacco, HIV-1 seropositivity and illiteracy, and for invasive cancer, HPV positivity only. We found a diversity of HPV types associated with SILs. In HIV-1-infected women, SILs occurred at an early stage of HIV disease. Women infected with both HIV-1 and HPV were at much higher risk of SILs than women infected with each of these 2 viruses separately. Invasive cancer was linked to HIV-2 infection in univariate analysis only. Our results suggest that the relation of SILs with HIV-1 infection is mainly explained by HPV infection and that HIV-1-infected African women may not often reach the invasive stage of cervical cancer.

HIV counseling and testing: behavior and practices of women of childbearing age in Abidjan, Côte d'Ivoire. DYSCER-CI Group

We assessed factors associated with women's attitudes toward HIV test results in gynecology clinics in Abidjan, Côte d'Ivoire. HIV testing was systematically offered to nonpregnant women attending two gynecology clinics in Abidjan. Individual pretest counseling was performed by trained midwives. Posttest counseling was given 2 weeks later to women who wished to know their HIV test results. HIV testing was offered to a total of 1482 women, of whom 1401 (94.5%) agreed to be screened. The prevalence of HIV infection was 21.3%. Of the women who participated, 10% failed to return. Youth, low educational level, and absence of genital infection were findings individually associated with failure by participants to return for their test results. Among the 1242 women who returned, 13.7% did not wish to know the results of their HIV test. A positive HIV test result, being native to Côte d'Ivoire, a high educational level, and knowing the existence of the asymptomatic stage of HIV infection were factors independently associated with declining to know the HIV test result. In conclusion, women who declined to know their HIV test results presented a specific profile at the time of HIV testing. This information can be used to improve pretest counseling and the efficacy of future HIV screening programs.

Therapeutic algorithms for the management of sexually transmitted diseases at the peripheral level in Côte d'Ivoire: assessment of efficacy and cost

In the acquired immunodeficiency syndrome (AIDS) era, adequate management of sexually transmitted diseases (STDs) is a primary concern in Africa. Assessed in this study is the clinical efficacy and feasibility of WHO-recommended therapeutic algorithms for genital discharges and ulcers, diagnosed without laboratory tests, for use at the primary health care level. Drugs were sold on a cost-recovery basis and included intramuscular ceftriaxone and oral ciprofloxacin for single-dose therapy of gonorrhoea and chancroid. During April 1993 in 10 peripheral health care centres in Abidjan, Côte d'Ivoire, a total of 207 patients were followed up, including 89 cases of male urethritis, 92 cases of vaginal discharges and 26 cases of genital ulcers; clinical success, assessed 7 days after the onset of therapy, was, respectively, 92%, 87%, and 100%. Less than 10% of the 207 patients were referred to the next care level, an acceptable rate from a public health point of view. Medical adherence to the algorithms was excellent for urethral discharges and genital ulcers but poor for vaginal discharges, partly because of intentional therapeutic modifications, without detriment to success. For drugs, the average cost per cure was 1546 francs CFA (US$ 5.60) (maximum, 2980 francs CFA (US$ 10.70). Effective and affordable treatments for STDs are necessary for their realistic case management in Africa.

Excluding blood donors at high risk of HIV infection in a west African city

OBJECTIVE

To examine the potential impact of deferral of blood donors at high risk of HIV infection in a west African city where blood is screened for HIV antibodies but no other special measures are taken to protect the blood supply.

DESIGN

Cross sectional study.

SETTING

National Blood Transfusion Centre and Project RETRO-CI, an international collaborative AIDS research project, Abidjan, Côte d'Ivoire.

SUBJECTS

1257 male first time blood donors.

INTERVENTIONS

Blood donors were interviewed about demographic and behavioural characteristics and tested for HIV antibodies by enzyme immunoassay and, if positive, synthetic peptide based tests.

MAIN OUTCOME MEASURES

HIV antibody status in relation to presence of behavioural risk factors; calculation of sensitivity, specificity, and predictive values of specific criteria for excluding HIV infected donors.

RESULTS

The overall prevalence of HIV infection was 11.4%. The most important risk factors for HIV positivity were prostitute contact and being aged 30-39 years. For identifying seropositive donors individual criteria had sensitivity, specificity, and positive predictive values ranging from 15% to 98%, 38% to 91%, and 17% to 30% respectively. Prostitute contact in the past five years would have excluded 31% of all donors and 73% of HIV infected donors. 27% of those excluded would have been HIV positive.

CONCLUSIONS

The widespread assumption that donor deferral is not feasible in sub-Saharan Africa needs reassessment. In Abidjan this approach was well accepted and potentially effective. Donor deferral requires evaluation as a strategy for improving blood safety in resource poor areas with high rates of HIV infection.