Effects of the COVID-19 Pandemic on ART Initiation and Access to HIV Viral Load Monitoring in Adults Living With HIV in West Africa: A Regression Discontinuity Analysis

OBJECTIVES

Efforts to control the COVID-19 pandemic have potentially compromised the availability and/or quality of HIV services. We aimed to assess the pandemic's impact on antiretroviral therapy (ART) initiation and HIV viral load (VL) monitoring in 3 West African countries.

METHODS

We used routinely collected data from 5 clinics contributing to the International epidemiologic Database to Evaluate AIDS collaboration in Burkina Faso, Côte d'Ivoire, and Nigeria. We included ART-naïve adults living with HIV initiating ART from January 1, 2018. We conducted regression discontinuity analysis to estimate changes in the number of ART initiations and VL measures per week, before and during the pandemic period in each country.

RESULTS

In clinics in Burkina Faso and Côte d'Ivoire, ART initiations per week remained constant throughout the studied periods (-0.24 points (p) of ART initiations/week 95% CI: -5.5 to 5.9, -0.9 p, 95% CI: -8.5 to 8.6, respectively), whereas in Nigeria's clinic, they decreased significantly (-6.3 p, 95% CI: -10.8 to -1.7) after the beginning of the pandemic. The volume of VL tests performed decreased significantly in all 3 countries (-17.0 p, 95% CI: -25.3 to -8.6 in Burkina Faso, -118.4 p, 95% CI: -171.1 to -65.8 in Côte d'Ivoire and -169.1 p, 95% CI: -282.6 to -55.6 in Nigeria).

CONCLUSIONS

HIV clinics in two out of three countries in West Africa demonstrated resilience as they successfully maintained access to ART for ALWH despite the challenges imposed by the pandemic. However, VL monitoring was severely disrupted and did not return to prepandemic levels approximately 1 year after the beginning of the pandemic. Continued monitoring of the HIV care continuum in the postpandemic period is essential to mitigate potential enduring effects on ALWH's virological and clinical outcomes.

Hepatocellular carcinoma surveillance among people living with hepatitis B in Senegal (SEN-B): insights from a prospective cohort study

BACKGROUND

Chronic hepatitis B virus (HBV) infection is the predominant cause of hepatocellular carcinoma in west Africa, yet data on the incidence of HBV-related hepatocellular carcinoma remain scarce. We aimed to describe the uptake and early outcomes of systematic ultrasound-based hepatocellular carcinoma screening in SEN-B, which is a prospective HBV cohort in Senegal.

METHODS

In this prospective cohort study, we included treatment-naive, HBsAg-positive individuals who were referred to the two infectious diseases clinics (the Department of Tropical and Infectious Diseases and Ambulatory Treatment Center) at Fann University Hospital of Dakar, Senegal, between Oct 1, 2019, and Oct 31, 2022. All participants resided within the Dakar region. Participants underwent abdominal ultrasound, transient elastography, and clinical and virological assessments at inclusion and every 6 months. Liver lesions at least 1 cm in diameter on ultrasound were assessed using four-phase CT, MRI, or liver biopsy. Adherence to hepatocellular carcinoma surveillance was measured using the proportion of time covered, calculated by dividing the cumulative months covered by abdominal ultrasound examinations by the overall follow-up time, defined as the number of months from the date of cohort entry until the last recorded visit, hepatocellular carcinoma diagnosis, or death. Optimal adherence was defined as a proportion of time covered of 100%.

FINDINGS

Overall, 755 (99·6%) of 758 participants had at least one abdominal ultrasound performed. The median age of the enrolled participants was 31 years (IQR 25-39), 355 (47·0%) of 755 participants were women, and 82 (10·9%) had a family history of hepatocellular carcinoma. 15 (2·0%) of 755 individuals were HBeAg positive, 206 (27·3%) of 755 individuals had HBV DNA of more than 2000 IU/mL, and 27 (3·6%) of 755 had elastography-defined liver cirrhosis. Of ten (1·3%) participants with a focal lesion at least 1 cm at initial assessment, CT or MRI ruled out hepatocellular carcinoma in nine, whereas imaging and subsequent liver biopsy confirmed one patient with hepatocellular carcinoma. Two further patients with hepatocellular carcinoma were diagnosed at study presentation due to the presence of portal thrombosis on ultrasound. Excluding the three participants with hepatocellular carcinoma identified at baseline, 752 participants were eligible for screening every 6 months. Median follow-up time was 12 months (IQR 6-18) and the median number of ultrasounds per patient was 3 (2-4). During 809·5 person-years of follow-up, one incident hepatocellular carcinoma was reported, resulting in an incidence rate of 1·24 cases per 1000 person-years (95% CI 0·18-8·80). Overall, 702 (93·0%) of 755 participants showed optimal hepatocellular carcinoma surveillance, but this proportion decreased to 77·8% (42 of 54 participants) after 24 months.

INTERPRETATION

Hepatocellular carcinoma screening is feasible in HBV research cohorts in west Africa, but its longer-term acceptability needs to be evaluated. Long-term hepatocellular carcinoma incidence data are crucial for shaping tailored screening recommendations.

FUNDING

Swiss National Science Foundation, the Swiss Cancer Research Foundation, the National Cancer Institute, and Roche Diagnostics.

TRANSLATION

For the French translation of the abstract see Supplementary Materials section.

Sex-Based Disparities in the Transition to Dolutegravir-Based Antiretroviral Therapy in West African HIV Cohorts

Transition to dolutegravir among 21 167 individuals experienced in antiretroviral therapy in West Africa showed heterogeneous timelines and patterns. Initially reported sex disparities tended to catch up over time with persisting disparities, according to contributing HIV clinics. Key factors facilitating dolutegravir switch were male sex, age <50 years, viral suppression, and regimens not based on protease inhibitors.

Metabolic causes of liver disease among adults living with HIV from low- and middle-income countries: a cross-sectional study

INTRODUCTION

Liver disease is a leading cause of morbidity and mortality among persons living with HIV (PLHIV). While chronic viral hepatitis has been extensively studied in low- and middle-income countries (LMICs), there is limited information about the burden of metabolic disorders on liver disease in PLHIV.

METHODS

We conducted a cross-sectional analysis of baseline data collected between October 2020 and July 2022 from the IeDEA-Sentinel Research Network, a prospective cohort enrolling PLHIV ≥40 years on antiretroviral treatment (ART) for ≥6 months from eight clinics in Asia, Americas, and central, East, southern and West Africa. Clinical assessments, laboratory testing on fasting blood samples and liver stiffness measurement (LSM)/controlled attenuation parameter (CAP) by vibration-controlled transient elastography were performed. Multivariable logistic regression models assessed factors associated with liver fibrosis (LSM ≥7.1 kPa) and steatosis (CAP ≥248 dB/m). Population attributable fraction (PAF) of each variable associated with significant liver fibrosis was estimated using Levin's formula.

RESULTS

Overall, 2120 PLHIV (56% female, median age 50 [interquartile range: 45-56] years) were included. The prevalence of obesity was 19%, 12% had type 2 diabetes mellitus (T2DM), 29% had hypertension and 53% had dyslipidaemia. The overall prevalence of liver fibrosis and steatosis was 7.6% (95% confidence interval [CI] 6.1-8.4) and 28.4% (95% CI 26.5-30.7), respectively, with regional variability. Male sex at birth (odds ratio [OR] 1.62, CI 1.10-2.40), overweight/obesity (OR = 2.50, 95% CI 1.69-3.75), T2DM (OR 2.26, 95% CI 1.46-3.47) and prolonged exposure to didanosine (OR 3.13, 95% CI 1.46-6.49) were associated with liver fibrosis. Overweight/obesity and T2DM accounted for 42% and 11% of the PAF for liver fibrosis, while HBsAg and anti-HCV accounted for 3% and 1%, respectively. Factors associated with steatosis included overweight/obesity (OR 4.25, 95% CI 3.29-5.51), T2DM (OR 2.06, 95% CI 1.47-2.88), prolonged exposure to stavudine (OR 1.69, 95% CI 1.27-2.26) and dyslipidaemia (OR 1.68, 95% CI 1.31-2.16).

CONCLUSIONS

Metabolic disorders were significant risk factors for liver disease among PLHIV in LMICs. Early recognition of metabolic disorders risk factors might be helpful to guide clinical and lifestyle interventions. Further prospective studies are needed to determine the causative natures of these findings.

High-risk human papillomavirus distribution according to human immunodeficiency virus status among women with cervical cancer in Abidjan, Côte d'Ivoire, 2018 to 2020

As human papillomavirus (HPV) immunisation and HPV-based cervical cancer (CC) screening programmes expand across sub-Saharan Africa, we investigated the potential impact of human immunodeficiency virus (HIV) status on high-risk (HR)-HPV distribution among women with CC in Côte d'Ivoire. From July 2018 to June 2020, paraffin-embedded CC specimens diagnosed in Abidjan, Côte d'Ivoire were systematically collected and tested for HR-HPV DNA. Type-specific HR-HPV prevalence was compared according to HIV status. Of the 170 CC specimens analysed (median age 52 years, interquartile range: [43.0-60.0]), 43 (25.3%) were from women living with HIV (WLHIV) with a median CD4 count of 526 [373-833] cells/mm3 and 86% were on antiretroviral therapy (ART). The overall HR-HPV prevalence was 89.4% [95% CI: 84.7-94.1]. All were single HR-HPV infections with no differences according to HIV status (P = .8). Among HR-HPV-positive CC specimens, the most prevalent HR-HPV types were HPV16 (57.2%), HPV18 (19.7%), HPV45 (8.6%) and HPV35 (4.6%), with no significant differences according to HIV status. Altogether, infection with HPV16/18 accounted for 71.1% [95% CI: 55.9-86.2] of CC cases in WLHIV vs 78.9% [95% CI: 71.3-86.5] in women without HIV (P = .3). The study confirms the major role of HPV16/18 in CC in Côte d'Ivoire and should support a regional scale-up of HPV16/18 vaccination programmes regardless of HIV status. However, vaccines targeting additional HR-HPV types, including HPV45 and HPV35, could further decrease future CC incidence in Côte d'Ivoire, both for WLHIV and women without HIV.

State of the science and future directions for research on HIV and cancer: Summary of a joint workshop sponsored by IARC and NCI

An estimated 38 million people live with human immunodeficiency virus (HIV) worldwide and are at excess risk for multiple cancer types. Elevated cancer risks in people living with HIV (PLWH) are driven primarily by increased exposure to carcinogens, most notably oncogenic viruses acquired through shared transmission routes, plus acceleration of viral carcinogenesis by HIV-related immunosuppression. In the era of widespread antiretroviral therapy (ART), life expectancy of PLWH has increased, with cancer now a leading cause of co-morbidity and death. Furthermore, the types of cancers occurring among PLWH are shifting over time and vary in their relative burden in different parts of the world. In this context, the International Agency for Research on Cancer (IARC) and the US National Cancer Institute (NCI) convened a meeting in September 2022 of multinational and multidisciplinary experts to focus on cancer in PLWH. This report summarizes the proceedings, including a review of the state of the science of cancer descriptive epidemiology, etiology, molecular tumor characterization, primary and secondary prevention, treatment disparities and survival in PLWH around the world. A consensus of key research priorities and recommendations in these domains is also presented.

Facility-Based Indicators to Manage and Scale Up Cervical Cancer Prevention and Care Services for Women Living With HIV in Sub-Saharan Africa: a Three-Round Online Delphi Consensus Method

BACKGROUND

Of women with cervical cancer (CC) and HIV, 85% live in sub-Saharan Africa, where 21% of all CC cases are attributable to HIV infection. We aimed to generate internationally acceptable facility-based indicators to monitor and guide scale up of CC prevention and care services offered on-site or off-site by HIV clinics.

METHODS

We reviewed the literature and extracted relevant indicators, grouping them into domains along the CC control continuum. From February 2021 to March 2022, we conducted a three-round, online Delphi process to reach consensus on indicators. We invited 106 experts to participate. Through an anonymous, iterative process, participants adapted the indicators to their context (round 1), then rated them for 5 criteria on a 5-point Likert-type scale (rounds 2 and 3) and then ranked their importance (round 3).

RESULTS

We reviewed 39 policies from 21 African countries and 7 from international organizations; 72 experts from 15 sub-Saharan Africa countries or international organizations participated in our Delphi process. Response rates were 34% in round 1, 40% in round 2, and 44% in round 3. Experts reached consensus for 17 indicators in the following domains: primary prevention (human papillomavirus prevention, n = 2), secondary prevention (screening, triage, treatment of precancerous lesions, n = 11), tertiary prevention (CC diagnosis and care, n = 2), and long-term impact of the program and linkage to HIV service (n = 2).

CONCLUSION

We recommend that HIV clinics that offer CC control services in sub-Saharan Africa implement the 17 indicators stepwise and adapt them to context to improve monitoring along the CC control cascade.

Barriers to early diagnosis of cervical cancer: a mixed-method study in Côte d'Ivoire, West Africa

BACKGROUND

Cervical cancer, a major public health problem in many developing countries, is usually associated with a poor survival related to an advanced disease at diagnosis. In Côte d'Ivoire and other developing countries with high cervical cancer prevalence, little is known about factors associated with advanced cervical cancer stages in a context of limited access to screening services.

METHODS

From May to July 2019, we conducted a cross-sectional study using a mixed, quantitative and qualitative method. Information on socio-demographic and history of the disease was extracted from a rapid case ascertainement study performed by the cancer registry of Côte d'Ivoire that enrolled all women diagnosed with cervical cancer between July 2018 and June 2019. In-depth semi-structured interviews were conducted among a subset of these women (12 women) and six healthcare providers to further capture barriers to early cervical cancer diagnosis. Factors associated with an advanced stage III, IV (according to FIGO classification) were estimated by a logistic regression model. Qualitative data were analyzed using a thematic analysis technique guided by the treatment pathway model and triangulated with quantitative data.

RESULTS

In total, 95 women with cervical cancer [median age = 51 (IQR 42-59)] years, were included. Among them, 18.9% were living with HIV and only 9.5% were covered by a health insurance. The majority (71.5%) were diagnosed with advanced cervical cancer. Being HIV-uninfected (aOR = 5.4; [1.6-17.8], p = 0.006) and being uninsured (aOR = 13.1; [2.0-85.5], p = 0.007) were independently associated with advanced cervical cancer in multivariable analysis. Qualitative data raised additional factors potentially related to advanced cervical cancer stages at diagnosis, including the lack of patient information on cervical cancer by healthcare providers and inadequate national awareness and screening campaigns.

CONCLUSION

In a context of challenges in access to systematic cervical cancer screening in Côte d'Ivoire, access to health insurance or integrated healthcare program appear to be key determinants of early diagnosis of cervical cancer.

Same-Day Antiretroviral Therapy Initiation as a Predictor of Loss to Follow-up and Viral Suppression Among People With Human Immunodeficiency Virus in Sub-Saharan Africa

BACKGROUND

Treat-All guidelines recommend initiation of antiretroviral therapy (ART) for all people with HIV (PWH) on the day of diagnosis when possible, yet uncertainty exists about the impact of same-day ART initiation on subsequent care engagement. We examined the association of same-day ART initiation with loss to follow-up and viral suppression among patients in 11 sub-Saharan African countries.

METHODS

We included ART-naive adult PWH from sites participating in the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium who enrolled in care after Treat-All implementation and prior to January 2019. We used multivariable Cox regression to estimate the association between same-day ART initiation and loss to follow-up and Poisson regression to estimate the association between same-day ART initiation and 6-month viral suppression.

RESULTS

Among 29 017 patients from 63 sites, 18 584 (64.0%) initiated ART on the day of enrollment. Same-day ART initiation was less likely among those with advanced HIV disease versus early-stage disease. Loss to follow-up was significantly lower among those initiating ART ≥1 day of enrollment, compared with same-day ART initiators (20.6% vs 27.7%; adjusted hazard ratio: .66; 95% CI .57-.76). No difference in viral suppression was observed by time to ART initiation (adjusted rate ratio: 1.00; 95% CI: .98-1.02).

CONCLUSIONS

Patients initiating ART on the day of enrollment were more frequently lost to follow-up than those initiating later but were equally likely to be virally suppressed. Our findings support recent World Health Organization recommendations for providing tailored counseling and support to patients who accept an offer of same-day ART.

Delayed presentation of HIV among older individuals: a growing problem

Late presentation for care is a major impediment to the prevention and effective treatment of HIV infection. Older individuals are at increased risk of late presentation, represent a growing proportion of people with late presentation, and might require interventions tailored to their age group. We provide a summary of the literature published globally between 2016-21 (reporting data from 1984-2018) and quantify the association of age with delayed presentation. Using the most common definitions of late presentation and older age from these earlier studies, we update this work with data from the International Epidemiology Databases to Evaluate AIDS (IeDEA) consortium, focusing on data from 2000-19, encompassing four continents. Finally, we consider how late presentation among older individuals might be more effectively addressed as electronic medical records become widely adopted.

Age-specific burden of cervical cancer associated with HIV: A global analysis with a focus on sub-Saharan Africa

HIV substantially worsens human papillomavirus (HPV) carcinogenicity and contributes to an important population excess of cervical cancer, particularly in sub-Saharan Africa (SSA). We estimated HIV- and age-stratified cervical cancer burden at a country, regional and global level in 2020. Proportions of cervical cancer (a) diagnosed in women living with HIV (WLHIV), and (b) attributable to HIV, were calculated using age-specific estimates of HIV prevalence (UNAIDS) and relative risk. These proportions were validated against empirical data and applied to age-specific cervical cancer incidence (GLOBOCAN 2020). HIV was most important in SSA, where 24.9% of cervical cancers were diagnosed in WLHIV, and 20.4% were attributable to HIV (vs 1.3% and 1.1%, respectively, in the rest of the world). In all world regions, contribution of HIV to cervical cancer was far higher in younger women (as seen also in empirical series). For example, in Southern Africa, where more than half of cervical cancers were diagnosed in WLHIV, the HIV-attributable fraction decreased from 86% in women ≤34 years to only 12% in women ≥55 years. The absolute burden of HIV-attributable cervical cancer (approximately 28 000 cases globally) also shifted toward younger women: in Southern Africa, 63% of 5341 HIV-attributable cervical cancer occurred in women <45 years old, compared to only 17% of 6901 non-HIV-attributable cervical cancer. Improved quantification of cervical cancer burden by age and HIV status can inform cervical cancer prevention efforts in SSA, including prediction of the impact of WLHIV-targeted vs general population approaches to cervical screening, and impact of HIV prevention.

Global estimates of viral suppression in children and adolescents and adults on antiretroviral therapy adjusted for missing viral load measurements: a multiregional, retrospective cohort study in 31 countries

BACKGROUND

As countries move towards the UNAIDS's 95-95-95 targets and with strong evidence that undetectable equals untransmittable, it is increasingly important to assess whether those with HIV who are receiving antiretroviral therapy (ART) achieve viral suppression. We estimated the proportions of children and adolescents and adults with viral suppression at 1, 2, and 3 years after initiating ART.

METHODS

In this retrospective cohort study, seven regional cohorts from the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium contributed data from individuals initiating ART between Jan 1, 2010, and Dec 31, 2019, at 148 sites in 31 countries with annual viral load monitoring. Only people with HIV who started ART after the time a site started routine viral load monitoring were included. Data up to March 31, 2020, were analysed. We estimated the proportions of children and adolescents (aged <18 years at ART initiation) and adults (aged ≥18 years at ART initiation) with viral suppression (viral load <1000 copies per mL) at 1, 2, and 3 years after ART initiation using an intention-to-treat approach and an adjusted approach that accounted for missing viral load measurements.

FINDINGS

21 594 children and adolescents (11 812 [55%] female, 9782 [45%] male) from 106 sites in 22 countries and 255 662 adults (163 831 [64%] female, 91 831 [36%] male) from 143 sites in 30 countries were included. Using the intention-to-treat approach, the proportion of children and adolescents with viral suppression was 7303 (36%) of 20 478 at 1 year, 5709 (30%) of 19 135 at 2 years, and 4287 (24%) of 17 589 at 3 years after ART initiation; the proportion of adults with viral suppression was 106 541 (44%) of 240 600 at 1 year, 79 141 (36%) of 220 925 at 2 years, and 57 970 (29%) of 201 124 at 3 years after ART initiation. After adjusting for missing viral load measurements among those who transferred, were lost to follow-up, or who were in follow-up without viral load testing, the proportion of children and adolescents with viral suppression was 12 048 (64% [plausible range 43-81]) of 18 835 at 1 year, 10 796 (62% [41-77]) of 17 553 at 2 years, and 9177 (59% [38-91]) of 15 667 at 3 years after ART initiation; the proportion of adults with viral suppression was 176 964 (79% [53-80]) of 225 418 at 1 year, 145 552 (72% [48-79]) of 201 238 at 2 years, and 115 260 (65% [43-69]) of 178 458 at 3 years after ART initiation.

INTERPRETATION

Although adults with HIV are approaching the global target of 95% viral suppression, progress among children and adolescents is much slower. Substantial efforts are still needed to reach the viral suppression target for children and adolescents.

FUNDING

US National Institutes of Health.

Effects of National Adoption of Treat-All Guidelines on Pre-Antiretroviral Therapy (ART) CD4 Testing and Viral Load Monitoring After ART initiation: A Regression Discontinuity Analysis

BACKGROUND

The World Health Organization's Treat-All guidance recommends CD4 testing before initiating antiretroviral therapy (ART), and routine viral load (VL) monitoring (over CD4 monitoring) for patients on ART.

METHODS

We used regression discontinuity analyses to estimate changes in CD4 testing and VL monitoring among 547 837 ART-naive patients enrolling in human immunodeficiency virus (HIV) care during 2006-2018 at 225 clinics in 26 countries where Treat-All policies were adopted. We examined CD4 testing within 12 months before and VL monitoring 6 months after ART initiation among adults (≥20 years), adolescents (10-19 years), and children (0-9 years) in low/lower-middle-income countries (L/LMICs) and high/upper-middle-income countries (H/UMICs).

RESULTS

Treat-All adoption led to an immediate decrease in pre-ART CD4 testing among adults in L/LMICs, from 57.0% to 48.1% (-8.9 percentage points [pp]; 95% CI: -11.0, -6.8), and a small increase in H/UMICs, from 90.1% to 91.7% (+1.6pp; 95% CI: 0.2, 3.0), with no changes among adolescents or children; decreases in pre-ART CD4 testing accelerated after Treat-All adoption in L/LMICs. In L/LMICs, VL monitoring after ART initiation was low among all patients in L/LMICs before Treat-All; while there was no immediate change at Treat-All adoption, VL monitoring trends significantly increased afterwards. VL monitoring increased among adults immediately after Treat-All adoption, from 58.2% to 61.1% (+2.9pp; 95% CI: 0.5, 5.4), with no significant changes among adolescents/children.

CONCLUSIONS

While on-ART VL monitoring has improved in L/LMICs, Treat-All adoption has accelerated and disparately worsened suboptimal pre-ART CD4 monitoring, which may compromise care outcomes for individuals with advanced HIV.

Barriers and facilitators in cervical cancer screening uptake in Abidjan, Côte d'Ivoire in 2018: a cross-sectional study

Backgrounds

Cervical cancer (CC) incidence remains unacceptably high in Côte d’Ivoire. In an effort to prevent this malignant condition, a national CC screening program has been scaled up in the country. This study aimed at assessing CC screening uptake and its associated factors in Abidjan in 2018.

Methods

A cross-sectional survey was conducted from July to September 2018 in the main healthcare facilities of three randomly selected out of the eight health districts of Abidjan. During the study period, a standardized questionnaire was administrated by research assistants to all women aged 25 to 55 years old, attending the three participating facilities. Demographics, knowledge on CC, personal history of CC screening and reasons for not attending CC screening were collected. A logistic regression model was computed to document factors associated with reported CC screening uptake.

Results

A total of 1158 women with a median age of 32 years (IQR [27–36]), including 364 (31.4%) with no formal education were included. Of those participants, 786 (67.9%) had ever heard about CC. CC screening uptake at least once was reported by 7.5% [95% CI: 6.0–9.0] participants. In multivariable analysis, being ≥45 years (aOR: 6.2 [2.3–17.2]), having a university level (aOR: 2.8 [1.2–6.6]) (versus non formal education) and access to mass campaign information (aOR: 18.2 [8.5–39.1]) were associated with a reported CC screening uptake. The main reported barriers to CC screening were unawareness towards CC screening (75.5%), negligence (20.5%), fear of CC detection (3.9%) and fear of additional costs (3.3%).

Conclusion

CC screening uptake remains low despite current initiatives to support awareness and prevention in Abidjan. Awareness campaigns need to be massively increased with the adjunction of tailored messages based on the level of women’s education to enhance the CC screening coverage and reach the WHO goal of CC elimination by 2030.

Chronic viral hepatitis, HIV infection and Non-Hodgkin lymphomas in West Africa, a case-control study

Non-Hodgkin lymphomas (NHL) are underestimated causes of cancer in West Africa where chronic viral hepatitis and HIV are endemic. While the association with HIV infection has already been characterized, limited information is available on the association between chronic viral hepatitis and NHL in sub-Saharan Africa. A case-control study was conducted in referral hospitals of Abidjan (Cote d'Ivoire) and Dakar (Senegal). Cases of NHL were matched with controls on age, gender and participating site. The diagnosis of NHL relied on local pathological examination completed with immunohistochemistry. HIV, HBV and HCV serology tests were systematically performed. A conditional logistic regression model estimated the associations by the Odds Ratio (OR) with their 95% confidence interval (CI). A total of 117 NHL cases (Abidjan n = 97, Dakar n = 20) and their 234 matched controls were enrolled. Cases were predominantly men (68.4%) and had a median age of 50 years (IQR 37-57). While Diffuse Large B-cell lymphoma were the most reported morphological type (n = 35) among mature B-cell NHL, the proportion mature T-cell NHL (30%) was high. The prevalence figures of HBV, HCV and HIV infection were 12.8%, 7.7% and 14.5%, respectively among cases of NHL. In multivariate analysis, HBV, HCV and HIV were independently associated with NHL with OR of 2.23 (CI 1.05-4.75), 4.82 (CI 1.52-15.29) and 3.32 (CI 1.54-7.16), respectively. Chronic viral hepatitis B and C were significantly associated with NHL in West Africa. Timely preventive measures against HBV infection and access to curative anti-HCV treatment might prevent a significant number of NHL.

Geographical Disparities in HIV Seroprevalence Among Men Who Have Sex with Men and People Who Inject Drugs in Nigeria: Exploratory Spatial Data Analysis

BACKGROUND

The assessment of geographical heterogeneity of HIV among men who have sex with men (MSM) and people who inject drugs (PWID) can usefully inform targeted HIV prevention and care strategies.

OBJECTIVE

We aimed to measure HIV seroprevalence and identify hotspots of HIV infection among MSM and PWID in Nigeria.

METHODS

We included all MSM and PWID accessing HIV testing services across 7 prioritized states (Lagos, Nasarawa, Akwa Ibom, Cross Rivers, Rivers, Benue, and the Federal Capital Territory) in 3 geographic regions (North Central, South South, and South West) between October 1, 2016, and September 30, 2017. We extracted data from national testing registers, georeferenced all HIV test results aggregated at the local government area level, and calculated HIV seroprevalence. We calculated and compared HIV seroprevalence from our study to the 2014 integrated biological and behavioural surveillance survey and used global spatial autocorrelation and hotspot analysis to highlight patterns of HIV infection and identify areas of significant clustering of HIV cases.

RESULTS

MSM and PWID had HIV seroprevalence rates of 12.14% (3209/26,423) and 11.88% (1126/9474), respectively. Global spatial autocorrelation Moran I statistics revealed a clustered distribution of HIV infection among MSM and PWID with a <5% and <1% likelihood that this clustered pattern could be due to chance, respectively. Significant clusters of HIV infection (Getis-Ord-Gi* statistics) confined to the North Central and South South regions were identified among MSM and PWID. Compared to the 2014 integrated biological and behavioural surveillance survey, our results suggest an increased HIV seroprevalence among PWID and a substantial decrease among MSM.

CONCLUSIONS

This study identified geographical areas to prioritize for control of HIV infection among MSM and PWID, thus demonstrating that geographical information system technology is a useful tool to inform public health planning for interventions targeting epidemic control of HIV infection.

Ten-year attrition and antiretroviral therapy response among HIV-positive adults: a sex-based cohort analysis from eight West African countries

INTRODUCTION

Sex differences have already been reported in sub-Saharan Africa for attrition and immunological response after antiretroviral therapy (ART) initiation, but follow-up was usually limited to the first two to three years after ART initiation. We evaluated sex differences on the same outcomes in the 10 years following ART initiation in West African adults.

METHODS

We used cohort data of patients included in the IeDEA West Africa collaboration, who initiated ART between 2002 and 2014. We modelled no-follow-up and 10-year attrition risks, and immunological response by sex using logistic regression analysis, survival analysis with random effect and linear mixed models respectively.

RESULTS

A total of 71,283 patients (65.8% women) contributed to 310,007 person-years of follow-up in 16 clinics in eight West African countries. The cumulative attrition incidence at 10-year after ART initiation reached 75% and 68% for men and women respectively. Being male was associated with an increased risk of no follow-up after starting ART (5.1% vs. 4.0%, adjusted Odds Ratio: 1.25 [95% CI: 1.15 to 1.35]) and of 10-year attrition throughout the 10-year period following ART initiation: adjusted Hazard Ratios were 1.22 [95% CI: 1.17 to 1.27], 1.08 [95% CI: 1.04 to 1.12] and 1.04 [95% CI: 1.01 to 1.08] during year 1, years 2 to 4 and 5 to 10 respectively. A better immunological response was achieved by women than men: monthly CD4 gain was 30.2 and 28.3 cells/mL in the first four months and 2.6 and 1.9 cells/μL thereafter. Ultimately, women reached the average threshold of 500 CD4 cells/μL in their sixth year of follow-up, whereas men failed to reach it even at the end of the 10-year follow-up period. The proportion of patients reaching the threshold was much higher in women than in men after 10 years since ART initiation (65% vs. 44%).

CONCLUSIONS

In West Africa, attrition is unacceptably high in both sexes. Men are more vulnerable than women on both attrition and immunological response to ART in the 10 years following ART initiation. Innovative tracing strategies that are sex-adapted are needed for patients in care to monitor attrition, detect early high-risk groups so that they can stay in care with a durably controlled infection.

Changes in HIV-Related Cervical Cancer Over a Decade in Côte d'Ivoire

PURPOSE

Major improvements have occurred in access to invasive cervical cancer (ICC) screening in HIV-infected women over the past decade in sub-Saharan Africa. However, there is limited information on changes in the burden of HIV-related ICC at a population level. Our objective was to compare HIV-related ICC over a decade and document factors associated with HIV infection in women with ICC in Côte d'Ivoire.

METHODS

A repeated cross-sectional study was conducted in referral hospitals of Abidjan, Côte d'Ivoire, through the 2009-2011 and 2018-2020 periods. Women diagnosed with ICC were systematically tested for HIV. Demographics, ICC risk factors, cancer stage (International Federation of Gynecology and Obstetrics), and HIV characteristics were collected through questionnaires. Characteristics of HIV-related ICC were compared between the periods, and factors associated with HIV in women diagnosed with ICC in 2018-2020 were documented through a multivariable logistic model.

RESULTS

During the 2009-2011 and 2018-2020 periods, 147 and 297 women with ICC were diagnosed with estimated HIV prevalence of 24.5% and 21.9% (P = .53), respectively. In HIV-infected women, access to antiretroviral treatment increased from 2.8% to 73.8% (P < 10-4) and median CD4 cell count from 285 (IQR, 250-441) to 492 (IQR, 377-833) cells/mm3 (P = .03). In women diagnosed with ICC during the 2018-2020 period, HIV infection was associated with a less advanced clinical stage (International Federation of Gynecology and Obstetrics I or II stage) (adjusted OR, 2.2 [95% CI, 1.1 to 4.4]) and with ICC diagnosis through a systematic screening (adjusted OR, 10.5 [95% CI, 2.5 to 45.5]).

CONCLUSION

Despite a persistently high proportion of HIV-related ICC over time in Côte d'Ivoire, HIV was associated with less advanced clinical stage at ICC diagnosis. Recent improvements in ICC screening services across HIV clinics might explain this association and support their implementation across non-HIV health facilities.

Alcohol Use Disorder and Hepatitis C Prevention and Care in People Who Inject Drugs: The State of Play

Safe and effective treatment with direct-acting antivirals (DAAs) has ushered in an era in which hepatitis C virus (HCV) elimination, as set out by the World Health Organization, is possible. However, alcohol use disorder (AUD) has the potential to reduce the benefits of prevention interventions and reduce access to and continuity of HCV care in at-risk populations, such as people who inject drugs (PWID). We review the literature on the consequences of AUD on the effectiveness of HCV prevention and the cascade of care in PWID and provide recommendations for future research in the field of alcohol use and HCV.

Validation of the D:A:D chronic kidney disease risk score in people living with HIV: the IeDEA West Africa Cohort Collaboration

OBJECTIVES

A risk score for long-term prediction of chronic kidney disease (CKD) in people living with HIV (PLHIV) has been developed using data from the D:A:D cohort. We assessed the performance of the D:A:D risk score in a cohort of PLHIV in West Africa.

METHODS

Data from PLHIV starting antiretroviral treatment in four clinics in Burkina Faso, Côte d'Ivoire and Togo participating in the IeDEA West Africa collaboration were analysed. CKD was defined as two consecutive estimated glomerular filtration rates (eGFRs) of ≤ 60 mL/min/1.73 m² . The D:A:D score (short version) was calculated using age, gender, nadir CD4 and baseline eGFR and was categorized into low, medium, and high-risk groups.

RESULTS

In 14 930 participants (70% female, median age = 38 years; median nadir CD4 count = 183 cells/µL) followed for a median duration of 5.7 years, 660 (4.4%) progressed to CKD, with an incidence [95% confidence interval (CI)] of 7.8 (7.2-8.4) per 1000 person-years (PY). CKD incidence rates were 2.4 (2.0-2.8), 8.1 (6.8-9.6) and, 30.9 (28.0-34.1) per 1000 PY in the low-, medium- and high-risk groups, respectively. In the high-risk group, 14.7% (95% CI: 13.3; 16.3) had progressed to CKD at 5 years. Discrimination was good [C-statistics = 0.81 (0.79-0.83)]. In all, 79.4% of people who progressed to CKD were classified in the medium- to high-risk group at baseline (sensitivity) and 66.5% of people classified in the low risk group at baseline did not progress to CKD (specificity).

CONCLUSIONS

These findings confirm the validity of the D:A:D score in identifying individuals at risk of developing CKD who could benefit from enhanced kidney monitoring in West African HIV clinics.

Prevalence of Human Papillomavirus, Human Immunodeficiency Virus, and Other Sexually Transmitted Infections Among Men Who Have Sex With Men in Togo: A National Cross-sectional Survey

BACKGROUND

Sub-Saharan Africa is a region of both high human immunodeficiency virus (HIV) and anal cancer incidence. We conducted the first national study in Togo to assess human papillomavirus (HPV), HIV, and other sexually transmitted infection (STI) prevalence among men who have sex with men (MSM).

METHODS

A multicentric cross-sectional study was conducted among MSM recruited in 4 Togolese cities. Anal swabs were collected to test HPV, herpes simplex virus (HSV), and 7 STIs.

RESULTS

Among the 207 MSM, HIV and high-risk HPV (hrHPV) overall prevalence were 26.1% and 44.9%, respectively. The most common hrHPV types were HPV-35 (15.0%) and HPV-16 (13.0%). Prevalence of hrHPV and multiple HPV infections were higher among HIV-infected than among HIV-uninfected MSM (85.2% vs 30.7%, P < 10-5 and 85.2% vs 28.7%, P < 10-5, respectively). Other STIs, except hepatitis B virus, were also more prevalent among HIV-infected MSM (Neisseria gonorrhoeae, P = .03; Mycoplasma genitalium, P = .04; HSV-2, P = .001; and a trend for Chlamydia trachomatis, P = .06). In multivariate analysis (adjusted odds ratio [95% confidence interval]), HIV (10.1 [4.0-25.6]), living in Lomé (2.8 [1.1-7.1]), HSV-2 excretion (26.7 [2.9-244.3]), C. trachomatis (11.7 [2.3-58.9]), and M. genitalium infection (9.6 [3.1-29.9]) were associated with increased risk of hrHPV infection.

CONCLUSIONS

We report a high burden of anal STIs with an unusual hrHPV type distribution among MSM, highlighting the critical need of implementation of a national strategy regarding prevention of STIs and vaccination against HPV.

Human papilloma viruses infection among adolescent females perinatally infected with HIV in Côte d'Ivoire

BACKGROUND

Cervical cancer prevention strategies recommend human papilloma virus (HPV) vaccination for female adolescents prior to their sexual debut. While HIV is a major risk factor for HPV infection in women of childbearing age, its prevalence among HIV-infected adolescent female is mostly unknown. This study aimed to describe the HPV prevalence and correlates among perinatally HIV-infected adolescent females prior to HPV immunisation.

METHODS

A cross-sectional survey was conducted from January to June 2016, in the four major paediatric HIV clinics of Abidjan, Côte d'Ivoire. All HIV-infected females aged 11-16 years were approached to participate in the study. A questionnaire assessing sexual behaviours and genital hygiene practices was administered to participants completed with a systematic vaginal swab collection. HPV genotyping was performed using the Anyplex II HPV28 Detection (Seegene). A logistic regression analysis was performed to identify factors associated with the presence of HPV infection. HPV immunisation was proposed free of charge to all participants.

RESULTS

A total of 250 participants were included, with a median age of 13 years (IQR 11-14). Among them, 237 (94.8%) were on antiretroviral treatment with a median CD4 count of 660 (IQR 439-914) cells/mm³. The overall prevalence of at least one HPV was 3.6% (95% CI 1.6 to 6.7) and the prevalence of at least one carcinogenic HPV was 2.8% (95% CI 0.7 to 4.8). Vaginal cleansing was reported by 75 (30%) of participants, with a median age at initiation of 12 years (IQR 10-13). Sexual activity was self-reported by 12 (4.8%) participants with a median age at sexual debut of 11 years (IQR 10-14). HPV infection was associated with vaginal cleansing (adjusted OR=7.0 (95% CI 1.4 to 31.6)).

CONCLUSION

The reported low prevalence of carcinogenic HPV infections supports the appropriateness of HPV immunisation in this population. The reported association between cleansing practices and HPV infection deserves further prospective longitudinal studies.

International epidemiology databases to evaluate AIDS (IeDEA) in sub-Saharan Africa, 2012-2019

PURPOSE

The objectives of the International epidemiology databases to evaluate AIDS (IeDEA) are to (i) evaluate the delivery of combination antiretroviral therapy (ART) in children, adolescents and adults in sub-Saharan Africa, (ii) to describe ART regimen effectiveness, durability and tolerability, (iii) to examine HIV-related comorbidities and coinfections and (iv) to examine the pregnancy-related and HIV-related outcomes of women on ART and their infants exposed to HIV or ART in utero or via breast milk.

PARTICIPANTS

IeDEA is organised in four regions (Central, East, Southern and West Africa), with 240 treatment and care sites, six data centres at African, European and US universities, and almost 1.4 million children, adolescents and adult people living with HIV (PLWHIV) enrolled.

FINDINGS TO DATE

The data include socio-demographic characteristics, clinical outcomes, opportunistic events, treatment regimens, clinic visits and laboratory measurements. They have been used to analyse outcomes in PLWHIV-1 or PLWHIV-2 who initiate ART, including determinants of mortality, of switching to second-line and third-line ART, drug resistance, loss to follow-up and the immunological and virological response to different ART regimens. Programme-level estimates of mortality have been corrected for loss to follow-up. We examined the impact of coinfection with hepatitis B and C, and the epidemiology of different cancers and of (multidrug resistant) tuberculosis, renal disease and of mental illness. The adoption of 'Treat All', making ART available to all PLWHIV regardless of CD4+ cell count or clinical stage was another important research topic.

FUTURE PLANS

IeDEA has formulated several research priorities for the 'Treat All' era in sub-Saharan Africa. It recently obtained funding to set up sentinel sites where additional data are prospectively collected on cardiometabolic risks factors as well as mental health and liver diseases, and is planning to create a drug resistance database.

Prevalence and correlates of alcohol and tobacco use among key populations in Togo in 2017: a cross-sectional study

OBJECTIVES

The aim of this study was to estimate alcohol and tobacco use prevalence and their correlates among female sex workers (FSW), men who have sex with men (MSM) and drug users (DU) in Togo.

DESIGN, SETTING AND PARTICIPANTS

A cross-sectional bio-behavioural study was conducted among 2115 MSM, FSW and DU in 2017 using a respondent-driven sampling method, in the eight biggest towns of Togo. Selection criteria for the MSM were being male and having had oral or anal intercourse with a man in the previous 12 months; for FSW, being a female and having exchanged sex for money in the previous 12 months; and for DU, consuming heroin, cocaine or hashish for MSM, FSW and DU, respectively. All participants had to be at least 18 years old and residing in the territory for the past 3 months.

RESULTS

The prevalence of alcohol consumption, hazardous/harmful consumption and binge drinking was 64.8%, 38.4% and 45.5%, respectively. Current tobacco use was reported by 30.6% of participants and HIV prevalence was estimated at 12.5%. DU were more likely to engage in binge drinking compared with other key populations (adjusted odds ratio (aOR)=2.0; 95% CI 1.4 to 2.8; p=0.001). Participants who were identified as having hazardous/harmful alcohol consumption had almost three times the odds of tobacco consumption than those with no risky consumption (aOR=2.6; 95% CI 2.0 to 3.4; p=0.001). Hazardous/harmful alcohol consumption was three times more likely among participants with severe psychological distress compared with those with no psychological distress (aOR=3.3, 95% CI 2.2 to 5.1; p=0.001).

CONCLUSION

Findings from this study demonstrate the need for the integration of mental health and substance abuse reduction interventions into HIV prevention programme, particularly those geared towards key populations.

Assessment of the scale-up of cervical cancer screening in Abidjan stratified by HIV status

OBJECTIVE

To report the successes and challenges of scaling up a population-based cervical cancer (CC) screening program from HIV clinics to various healthcare facilities in Abidjan, Côte d'Ivoire.

METHOD

A retrospective analysis of characteristics, outcomes, and follow-up of women attending an initial CC screening visit in Abidjan between January 2010 and December 2014. Data were collected via forms that were systematically completed during CC screening visits. Data from the 2014 population census were used to estimate screening coverage.

RESULTS

Among 16 169 women attending an initial CC screening, 1616 (10.0%) had a positive VIA test. Among 848 women eligible for immediate cryotherapy, 618 (72.9%) underwent the "see-and-treat" approach. The 1-year follow-up rate after cryotherapy was 23.1% (143/618), and was higher among women with HIV (111/362, 30.7%) than among other women (32/256, 12.5%) (P=0.001). The estimated coverage of CC screening in Abidjan was 1.2% (95% confidence interval, 0.6-3.1).

CONCLUSION

Despite successful expansion of CC screening from HIV clinics to other facilities, the estimated screening coverage of the targeted population remained low. Follow-up of positively screened and treated women is a major challenge, especially outside HIV clinics, and would benefit from an innovative information system proving unique identification and tracking systems.

Prevention and care of hepatitis B in the rural region of Fatick in Senegal: a healthcare workers' perspective using a mixed methods approach

Background

In countries where hepatitis B virus (HBV) is endemic, including Senegal, the World Health Organization recommends systematic HBV screening of pregnant women and vaccination at birth to prevent mother-to-child transmission (MTCT). This study investigated healthcare workers’ (HCW) knowledge and practices regarding HBV prevention and care in the rural region of Fatick in Senegal, as well as challenges they faced in implementing prevention activities related to HBV MTCT.

Methods

A mixed-methods survey was conducted between May–July 2017 among 112 HCW working in 15 healthcare facilities in two districts of the Fatick region using face-to-face questionnaires and semi-structured interviews. Descriptive statistics and chi-square/Mann-Whitney tests were used to analyze quantitative data, while qualitative data were analyzed thematically.

Results

The study population included 87 HCW in the quantitative component (83% women, median age [interquartile range, IQR] = 35 [31–40] years) and 11 in the qualitative component. A knowledge gap was observed in key areas of HBV infection: only 24, 51 and 38%, respectively, correctly reported that early HBV acquisition is associated with a high risk of developing chronic infection, that perinatal transmission is one of the main modes of HBV transmission in Senegal, and that three to four doses of HBV vaccine are required to ensure immunization in children. Despite good acceptability of systematic screening of pregnant women and vaccination at birth, only 48% of HCW mainly involved in prenatal care and 71% of those involved exclusively in vaccination routinely performed these two key interventions. HCW reported several structural barriers that may hinder their implementation: a lack of training in HBV and in counseling, poor availability of rapid diagnostic tests (RDT), high costs of both screening and treatment, a lack of adequate information on treatment options and missed opportunities for vaccination at birth.

Conclusions

HCW working in the Fatick region may be insufficiently trained and supported to effectively implement HBV prevention strategies. Our findings suggest an urgent need to strengthen MTCT prevention in this region, by improving HCW knowledge in key areas of HBV infection, providing RDT and antiviral treatment at low cost, and enhancing community-based interventions for the timely vaccination of newborns.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4416-3) contains supplementary material, which is available to authorized users.

Cervical cancer screening uptake and correlates among HIV-infected women: a cross-sectional survey in Côte d'Ivoire, West Africa

OBJECTIVES

Despite the increasing number of interventions aiming to integrate cervical cancer screening into HIV clinics in sub-Saharan Africa, Women living with HIV (WLHIV) still have a high risk of developing cervical cancer. The aim of this study was to estimate the coverage of cervical cancer screening and associated factors among WLHIV in Abidjan, Côte d'Ivoire.

DESIGN

Cross-sectional survey conducted from May to August 2017.

SETTINGS

Outpatient setting in the four highest volume urban HIV clinics of government's or non-governmental organisation's sector in Côte d'Ivoire.

PARTICIPANTS

All WLHIV, aged 25-55 years, followed since at least 1 year, selected through a systematic sampling procedure.

INTERVENTION

A standardised questionnaire administered to each participant by trained healthcare workers.

OUTCOME

Cervical cancer screening uptake.

RESULTS

A total of 1991 WLHIV were included in the study, aged in median 42 years (IQR 37-47), and a median CD4 count (last known) of 563 (378-773) cells/mm³. Among the participants, 1913 (96.1%) had ever heard about cervical cancer, 1444 (72.5%) had been offered cervical cancer screening, mainly in the HIV clinic for 1284 (88.9%), and 1188 reported a personal history of cervical cancer screening for an overall coverage of 59.7% (95% CI 57.6 to 62.0). In multivariable analysis, university level (adjusted OR (aOR) 2.1; 95% CI 1.4 to 3.1, p<0.001), being informed on cervical cancer at the HIV clinic (aOR 1.5; 95% CI 1.1 to 2.0, p=0.017), receiving information self-perceived as 'clear and understood' on cervical cancer (aOR 1.7; 95% CI 1.4 to 2.2, p<0.001), identifying HIV as a risk factor for cervical cancer (aOR 1.4; 95% CI 1.1 to 1.8, p=0.002) and being proposed cervical cancer screening in the HIV clinic (aOR 10.1; 95% CI 7.6 to 13.5, p<0.001), were associated with cervical cancer screening uptake.

CONCLUSION

Initiatives to support cervical cancer screening in HIV care programmes resulted in effective access to more than half of the WLHIV in Abidjan. Efforts are still needed to provide universal access to cervical cancer screening, especially among socioeconomically disadvantaged WLHIV.

Screening and management of mental health and substance use disorders in HIV treatment settings in low- and middle-income countries within the global IeDEA consortium

Introduction

Integration of services to screen and manage mental health and substance use disorders (MSDs) into HIV care settings has been identified as a promising strategy to improve mental health and HIV treatment outcomes among people living with HIV/AIDS (PLWHA) in low‐ and middle‐income countries (LMICs). Data on the extent to which HIV treatment sites in LMICs screen and manage MSDs are limited. The objective of this study was to assess practices for screening and treatment of MSDs at HIV clinics in LMICs participating in the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium.

Methods

We surveyed a stratified random sample of 95 HIV clinics in 29 LMICs in the Caribbean, Central and South America, Asia‐Pacific and sub‐Saharan Africa. The survey captured information onsite characteristics and screening and treatment practices for depression, post‐traumatic stress disorder (PTSD), substance use disorders (SUDs) and other mental health disorders.

Results

Most sites (n = 76, 80%) were in urban areas. Mental health screening varied by disorder: 57% of sites surveyed screened for depression, 19% for PTSD, 55% for SUDs and 29% for other mental health disorders. Depression, PTSD, SUDs and other mental health disorders were reported as managed on site (having services provided at the HIV clinic or same health facility) at 70%, 51%, 41% and 47% of sites respectively. Combined availability of screening and on‐site management of depression, PTSD, and SUDs, and other mental health disorders was reported by 42%, 14%, 26% and 19% of sites, respectively. On‐site management of depression and PTSD was reported significantly less often in rural as compared to urban settings (depression: 33% and 78% respectively; PTSD: 24% and 58% respectively). Screening for depression and SUDs was least commonly reported by HIV programmes that treated only children as compared to HIV programmes that treated only adults or treated both adults and children.

Conclusions

Significant gaps exist in the management of MSDs in HIV care settings in LMICs, particularly in rural settings. Identification and evaluation of optimal implementation strategies to scale and sustain integrated MSDs and HIV care is needed.

High prevalence of binge drinking among people living with HIV in four African countries

INTRODUCTION

Excessive alcohol consumption leads to unfavourable outcomes in people living with HIV (PLHIV), including reduced adherence to antiretroviral therapy (ART) and engagement into care. However, there is limited information on alcohol consumption patterns among PLHIV in sub-Saharan Africa.

METHODS

Using a cross-sectional approach, the Alcohol Use Disorders Identification Test (AUDIT-C) was administered to PLHIV attending HIV clinics in Côte d'Ivoire, Togo, Senegal and Zambia (2013 to 2015). Hazardous drinking was defined as an AUDIT-C score ≥4 for men or ≥3 for women, and binge drinking as ≥6 drinks at least once per month. The prevalence of binge drinking was compared to estimates from the general population using data from the World Health Organization. Factors associated with binge drinking among persons declaring any alcohol use in the past year were assessed using a logistic regression model to estimate odds ratio (OR) and their corresponding 95% confidence intervals (CI).

RESULTS

Among 1824 PLHIV (median age 39 years, 62.8% female), the prevalence of hazardous alcohol use ranged from 0.9% in Senegal to 38.4% in Zambia. The prevalence of binge drinking ranged from 14.3% among drinkers in Senegal to 81.8% in Zambia, with higher estimates among PLHIV than in the general population. Male sex (OR 2.4, 95% CI 1.6 to 3.7), tobacco use (OR 1.7, 95% CI 1.0 to 2.9) and living in Zambia were associated with binge drinking.

CONCLUSIONS

Alcohol consumption patterns varied widely across settings and binge drinking was more frequent in HIV-positive individuals compared to the general population. Interventions to reduce excessive alcohol use are urgently needed to optimize adherence in the era of universal ART.

Substance use and universal access to HIV testing and treatment in sub-Saharan Africa: implications and research priorities

As universal testing and treatment for HIV, or 'treat all', expands across sub-Saharan Africa (SSA), substance use will likely have a negative impact on the success of scale-up efforts for antiretroviral treatment (ART). Overwhelming evidence highlights the negative impact of substance use on HIV care and treatment outcomes. Yet, as many countries in SSA expand ART, evidence of the extent of substance use, and its impact in the region, is more limited. Stigma, and the psychoactive effects of substance use, are barriers to seeking HIV treatment and adhering to ART regimens for persons with heavy alcohol use or substance use. As a result, we identified several implementation and operations research priorities and metrics for monitoring the impact of substance use and Treat All. Identifying barriers and facilitators to the integration of the prevention and treatment of substance use with HIV care, and assessing effects on HIV outcomes, through longitudinal studies are priorities that will determine the impacts of substance use on 'treat all' in SSA. Future research must use existing infrastructure, including large networks of HIV clinics, to enhance our understanding of the implementation and service delivery of substance use screening, referral and treatment. These networks will also inform robust and standardised substance use estimates and interventions within the 'treat all' era in SSA.

Prevalence of hepatitis C among HIV-1, HIV-2 and dually reactive patients: A multi-country cross-sectional survey in West Africa

Little is known on the impact of HIV-2 infection on HCV viral replication. The aim of the study was to compare HCV prevalence and viral replication based on HIV types in West Africa. A cross-sectional survey was conducted within the IeDEA HIV-2 West Africa cohort from March to December 2012. All HIVinfected adult patients who attended participating HIV clinics during the study period were included. Blood samples were collected and re-tested for HIV type discrimination, HCV serology and viral load. A total of 767 patients were enrolled: 186 HIV-1, 431 HIV-2 and 150 HIV-1&2 dually reactive. At time of sampling, 531 (69.2%) were on ART and median CD4+ cell count was 472/mm³. Thirty (3.9%, 95% CI 2.7-5.5) patients were anti-HCV positive (4.3% in HIV-1, 4.0% in HIV-1&2 dually reactive and 3.7% in HIV-2; p=0.91). Detectable HCV RNA was identified in 21 (70.0%) patients (100% in HIV-1 and HIV- 1&2 dually reactive vs. 43.8% in HIV-2; p=0.003). Systematic screening should be promoted and performed in this population, since HCV is now potentially curable in sub- Saharan Africa.

Etiology of hepatocellular carcinoma in West Africa, a case-control study

Hepatocellular carcinoma (HCC) is a leading cause of cancer in West Africa where HBV infection is endemic. However, limited information is available on other risk factors such as alcohol use, HCV and HIV infection. A case-control study was conducted in referral hospitals of Abidjan (Cote d'Ivoire), Bamako (Mali) and Lome (Togo). Cases were matched with controls on age, gender and participating site. The diagnosis of HCC relied on the combination of one or more space-occupying lesions suggestive of an HCC on a standardized abdominal ultrasound and an α-fetoprotein level ≥400 ng/ml. HIV, HBV and HCV serology were performed. Hazardous alcohol use was assessed using the AUDIT questionnaire. A conditional logistic regression model was used to measure odds ratio (OR) with their 95% confidence intervals (CI). A total of 160 cases and 320 controls were included. Cases were predominantly men (80.0%) with a median age of 47 years (IQR 38-57). Hazardous alcohol use (OR = 4.5 [CI 1.1-18.5]), HBV infection (OR = 62.5 [CI 20.5-190.7]) and HCV infection OR = 35.9 [CI 10.0-130.3]) were independently associated with HCC. Combining the effect of HBV infection and alcohol, HBV-infected hazardous drinkers had an OR = 149.8 (CI 13.5-1 667.0), HBV mono-infected had an OR = 57.4 (CI 18.8-175.3) (ref: HBV-negative). Aside the independent association of alcohol use and HBV and HCV infection with HCC, a synergic effect between alcohol use and HBV infection was identified. Timely screening and care of HBV infection and hazardous drinking might prevent a significant number of HCC in West Africa.

Prevention and Care of Hepatitis B in Senegal; Awareness and Attitudes of Medical Practitioners

In highly endemic settings for hepatitis B virus (HBV) infection such as Senegal, access to HBV prevention and care is rapidly evolving. In this context, all medical practitioners should have baseline knowledge on HBV infection and promote access to vaccination, screening, and care. A knowledge and attitudes survey on HBV infection was conducted among a randomly selected sample of medical practitioners in Senegal. Participants were asked to fill-out a questionnaire on the HBV epidemiology, prevention, and treatment. A 60-item knowledge score was computed; the lower quartile of the observed score was used to define poor knowledge. Factors associated with poor knowledge were assessed using a logistic regression model. A total of 127 medical practitioners completed the questionnaire. Only 14 (11.0%) participants knew that HBV vaccine could be safely administered to pregnant women and 65 (51.2%) to newborns. Older practitioners (> 40 years) as well as general practitioners (compared with specialists) were more likely to have a poor knowledge score with odds ratios (ORs) of 3.1 (95% confidence interval [CI] 1.0-9.2) and 2.6 (95% CI 1.0-7.3), respectively. Practitioners who declared not to recommend HBV screening frequently during their consultation were more likely to present a poor knowledge score [OR: 3.0; (95% CI 1.1-8.2)]. As universal HBV screening is being promoted in countries with endemic HBV infection, our finding that poor screening attitudes were associated with a poor knowledge is of concern. There is a need to raise awareness of medical practitioners in Senegal toward universal HBV screening and early vaccination of newborns.

Hepatitis B treatment eligibility in West Africa: Uncertainties and need for prospective cohort studies

BACKGROUND & AIMS

While universal screening of hepatitis B virus (HBV) is recommended in high burden countries, little is known about the proportion of HBV-infected persons in need of antiviral therapy in these settings.

METHODS

Prisoners in Senegal and Togo as well as female sex workers and men who have sex with men in Cote d'Ivoire were screened for HBV infection. All HBsAg-positive participants underwent transient elastography, alanine aminotransferase (ALT) and HBV viral load (VL) quantification. Individuals with cirrhosis or those aged >30 years with an HBV replication ≥20 000 IU/mL and elevated ALT were considered eligible for antiviral therapy.

RESULTS

Of 1256 participants, 110 (8.8%) were HBsAg positive; their median age was 30 years [interquartile range: 25-33] and 96 (86.5%) were men. Three individuals (2.7%) had cirrhosis, while 28 (29.5%) of 94 participants with available measurements had an HBV VL ≥20 000 IU/mL. Overall, 11 (10.0%) subjects were considered eligible for immediate antiviral treatment (2.1% of participants in Dakar, 7.7% in Abidjan and 21.6% in Lome, P=.001) and 59 (53.4%) for close monitoring due to the presence of significant liver fibrosis, elevated ALT or significant HBV replication.

CONCLUSIONS

Among vulnerable populations in West Africa, a minority of HBV-infected individuals were eligible for immediate antiviral therapy. Prospective cohort studies are necessary to evaluate anti-HBV treatment eligibility facing the significant proportion of individuals with active chronic HBV infection.

Incidence of Severe Neutropenia in HIV-Infected People Starting Antiretroviral Therapy in West Africa

BACKGROUND

In sub-Saharan Africa, antiretroviral therapy (ART) including drugs with potential toxicity such as Zidovudine (ZDV) are routinely prescribed. This study aimed at estimating the incidence of severe neutropenia and associated factors after ART initiation in five West African countries.

METHODS

A retrospective cohort analysis was conducted within the international epidemiologic database to evaluate AIDS (IeDEA) collaboration in West Africa. All HIV-infected adults, initiating ART between 2002 and 2014, with a baseline and at least one follow-up absolute neutrophil count (ANC) measurement were eligible. Incidence of severe neutropenia (ANC <750 cells/mm3) was estimated with 95% confidence interval (CI) according to age, gender, HIV clinic, hemoglobin, CD4 count, clinical stage, and ART duration. A Cox proportional hazard model was used to identify factors associated with severe neutropenia, expressed with their adjusted hazard ratios (aHR).

RESULTS

Between 2002 and 2014, 9,426 HIV-infected adults were enrolled. The crude incidence rate of a first severe neutropenia was 9.1 per 100 person-years (95% CI: 8.6-9.8). Factors associated with severe neutropenia were exposure to ZDV <6 months (aHR = 2.2; 95% CI: 1.8-2.6), ≥6-12 months (aHR = 2.1; 95% CI: 1.6-2.8) and ≥12 months (aHR = 1.6; 95% CI: 1.2-2.2) [Ref. no ZDV exposure], CD4 count <350 cells/mm3 (aHR = 1.3; 95% CI: 1.1-1.5) and advanced clinical stage at ART initiation (aHR = 1.2; 95% CI: 1.0-1.4).

CONCLUSION

The incidence of severe neutropenia after ART initiation in West Africa is high and associated with ZDV exposure and advanced HIV disease. In this context, efforts are needed to scale-up access to less toxic first-line ART drugs and to promote early ART initiation.

HIV infection, viral hepatitis and liver fibrosis among prison inmates in West Africa

Background

Prisoners represent a vulnerable population for blood-borne and sexually transmitted infections which can potentially lead to liver fibrosis and ultimately cirrhosis. However, little is known about the prevalence of liver fibrosis and associated risk factors among inmates in sub-Saharan Africa.

Methods

Screening of liver fibrosis was undertaken in a randomly selected sample of male inmates incarcerated in Lome, Togo and in Dakar, Senegal using transient elastography. A liver stiffness measurement ≥9.5 KPa was retained to define the presence of a severe liver fibrosis. All included inmates were also screened for HIV, Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV) infection. Substances abuse including alcohol, tobacco and cannabis use were assessed during face-to-face interviews. Odds Ratio (OR) estimates were computed with their 95 % Confidence Interval (CI) to identify factors associated with severe liver fibrosis.

Results

Overall, 680 inmates were included with a median age of 30 years [interquartile range: 24–35]. The prevalence of severe fibrosis was 3.1 % (4.9 % in Lome and 1.2 % in Dakar). Infections with HIV, HBV and HCV were identified in 2.6 %, 12.5 % and 0.5 % of inmates, respectively. Factors associated with a severe liver fibrosis were HIV infection (OR = 7.6; CI 1.8–32.1), HBV infection (OR = 4.8; CI 1.8–12.8), HCV infection (OR = 52.6; CI 4.1–673.8), use of traditional medicines (OR = 3.7; CI 1.4–10.1) and being incarcerated in Lome (OR = 3.3; CI 1.1–9.8) compared to Dakar.

Conclusions

HIV infection and viral hepatitis infections were identified as important and independent determinants of severe liver fibrosis. While access to active antiviral therapies against HIV and viral hepatitis expands in Africa, adapted strategies for the monitoring of liver disease need to be explored, especially in vulnerable populations such as inmates.

Pitfalls of practicing cancer epidemiology in resource-limited settings: the case of survival and loss to follow-up after a diagnosis of Kaposi's sarcoma in five countries across sub-Saharan Africa

Background

Survival after diagnosis is a fundamental concern in cancer epidemiology. In resource-rich settings, ambient clinical databases, municipal data and cancer registries make survival estimation in real-world populations relatively straightforward. In resource-poor settings, given the deficiencies in a variety of health-related data systems, it is less clear how well we can determine cancer survival from ambient data.

Methods

We addressed this issue in sub-Saharan Africa for Kaposi’s sarcoma (KS), a cancer for which incidence has exploded with the HIV epidemic but for which survival in the region may be changing with the recent advent of antiretroviral therapy (ART). From 33 primary care HIV Clinics in Kenya, Uganda, Malawi, Nigeria and Cameroon participating in the International Epidemiologic Databases to Evaluate AIDS (IeDEA) Consortia in 2009–2012, we identified 1328 adults with newly diagnosed KS. Patients were evaluated from KS diagnosis until death, transfer to another facility or database closure.

Results

Nominally, 22 % of patients were estimated to be dead by 2 years, but this estimate was clouded by 45 % cumulative lost to follow-up with unknown vital status by 2 years. After adjustment for site and CD4 count, age <30 years and male sex were independently associated with becoming lost.

Conclusions

In this community-based sample of patients diagnosed with KS in sub-Saharan Africa, almost half became lost to follow-up by 2 years. This precluded accurate estimation of survival. Until we either generally strengthen data systems or implement cancer-specific enhancements (e.g., tracking of the lost) in the region, insights from cancer epidemiology will be limited.

Oral health and HIV infection among female sex workers in Abidjan, Côte d'Ivoire

BACKGROUND

Worldwide, female sex workers (FSW) represent a vulnerable population for oral diseases due to many risk factors including HIV infection and drug abuse. In sub-Saharan Africa, little is known about the burden of oral diseases and their determinants in vulnerable populations. The aim of the study was to estimate the prevalence and associated factors of oral diseases among FSW.

METHODS

A cross sectional study was conducted among FSW who attended a dedicated non-profit clinic in Abidjan, Côte d'Ivoire from June to August 2013. Data about the presence of dental caries, periodontitis and oral-mucosal lesions were collected by a dentist during an oral examination. Behavioural information related to oral hygiene habits as well as tobacco and alcohol consumption were collected through a standardized questionnaire. Information related to HIV infection including HIV diagnosis, last known CD4 count and antiretroviral therapy were documented through a medical chart review. Logistic regression models were used to identify factors associated with oral diseases.

RESULTS

A total of 249 FSW with a median age of 29 years, [Inter Quartile Range (IQR) = 23-36] and a median duration of sex work of 24 months [IQR 9-60]) were included. Current tobacco use and hazardous alcohol use were reported in 21.7 % and 19.7 % of FSW, respectively. The estimated prevalence of HIV infection was 33.7 % [95 % confidence interval (CI); 27.8 - 39.6]) and 82.1 % of HIV-infected FSW were on antiretroviral therapy . The prevalence of dental caries, periodontitis and oral-mucosal lesions were 62.3 % [95 % CI 55.5 - 67.5], 14.5 % [95 % CI 10.2 - 18.9] and 8.2 % [95 % CI 4.8 - 11.5], respectively. In multivariate analysis, periodontitis, oral-mucosal lesions and HIV infection were associated with odds ratio of 2.6 [95 % CI, 1.2-5.8]) and 50.0 [95 % CI; 6.4-384.6].

CONCLUSIONS

This study showed a high prevalence of oral diseases among FSW in Abidjan. HIV infection was common and significantly associated with periodontal diseases and oral-mucosal lesions. There is a need to integrate regular screening and treatment of oral lesions into the medical follow-up of FSW along with strategies for HIV prevention.

Cancer and HIV infection in referral hospitals from four West African countries

The consequences of the HIV epidemic on cancer epidemiology are sparsely documented in Africa. We aimed to estimate the association between HIV infection and selected types of cancers among patients hospitalized for cancer in four West African countries. A case-referent study was conducted in referral hospitals of Benin, Côte d'Ivoire, Nigeria and Togo. Each participating clinical ward included all adult patients seeking care with a confirmed diagnosis of cancer. All patients were systematically screened for HIV infection. HIV prevalence of AIDS-defining and some non-AIDS defining cancers (Hodgkin lymphoma, leukemia, liver, lung, skin, pharynx, larynx, oral cavity and anogenital cancers) were compared to a referent group of cancers reported in the literature as not associated with HIV. Odds ratios adjusted on age, gender and lifetime number of sexual partners (aOR) and their 95% confidence intervals (CI) were estimated. Among the 1644 cancer patients enrolled, 184 (11.2%) were identified as HIV-infected. The HIV prevalence in the referent group (n=792) was 4.4% [CI 3.0-5.8]. HIV infection was associated with Kaposi sarcoma (aOR 34.6 [CI: 17.3-69.0]), non-Hodgkin lymphoma (aOR 3.6 [CI 1.9-6.8]), cervical cancer (aOR 4.3 [CI 2.2-8.3]), anogenital cancer (aOR 17.7 [CI 6.9-45.2]) and squamous cell skin carcinoma (aOR 5.2 [CI 2.0-14.4]). A strong association is now reported between HIV infection and Human Papillomavirus (HPV)-related cancers including cervical cancer and anogenital cancer. As these cancers are amenable to prevention strategies, screening of HPV-related cancers among HIV-infected persons is of paramount importance in this African context.

Cervical cancer prevention in reproductive health services: knowledge, attitudes and practices of midwives in Côte d'Ivoire, West Africa

Background

Cervical cancer is the most common cancer among women and the leading cause of cancer deaths in women in Côte d’Ivoire. Low resource countries can now prevent this cancer by using HPV vaccine and effective and affordable screening tests. However the implementation of these prevention strategies needs well-trained human resources. Part of the solution could come from midwives by integrating cervical cancer prevention into reproductive health services. The aim of this survey was to assess knowledge, attitudes and practices of midwives towards cervical cancer prevention in Abidjan, Côte d’Ivoire, and to find out factors associated with appropriate knowledge.

Methods

A cross-sectional survey was conducted among midwives in the urban district of Abidjan, using a self-administered questionnaire. Knowledge was assessed by two scores. Factors associated with appropriate knowledge were determined using a logistic regression analysis. Attitudes and practices were described and compare using the Chi² test.

Results

A total of 592 midwives were enrolled, including 24.5% of final-year students. 55.7% of midwives had appropriate knowledge on cervical cancer, and 42.4% of them had appropriate knowledge on cervical cancer prevention strategies. Conferences, courses taken at school of midwifery and special training sessions on cervical cancer (OR = 4.9, 95% CI [1.9 to 12.6], p <0.01) were associated with good knowledge on the management of this disease. Among these midwives, 18.4% had already benefited from a screening test for themselves, 37.7% had already advised screening to patients and 8.4% were able to perform a visual inspection. 50.3% of midwives knew HPV vaccine as a preventive method; among them 70.8% usually recommended it to young girls.

Conclusion

Despite sufficient knowledge about cervical cancer prevention, attitudes and practices of midwives should be improved by organizing capacity building activities. This would ensure the success of integration of cervical cancer prevention into reproductive health services in countries like Côte d’Ivoire.

Risk factors for cervical intraepithelial neoplasia in HIV-infected women on antiretroviral treatment in Côte d'Ivoire, West Africa

Background

Facing the dual burden of invasive cervical cancer and HIV in sub-Saharan Africa, the identification of preventable determinants of Cervical Intraepithelial Neoplasia (CIN) in HIV-infected women is of paramount importance.

Methods

A cervical cancer screening based on visual inspection methods was proposed to HIV-infected women in care in Abidjan, Côte d'Ivoire. Positively screened women were referred for a colposcopy to a gynaecologist who performed directed biopsies.

Results

Of the 2,998 HIV-infected women enrolled, 132 (4.4%) CIN of any grade (CIN+) were identified. Women had been followed-up for a median duration of three years [IQR: 1–5] and 76% were on antiretroviral treatment (ART). Their median most recent CD4 count was 452 [IQR: 301–621] cells/mm³. In multivariate analysis, CIN+ was associated with a most recent CD4 count >350 cells/mm³ (OR: 0.3; 95% CI: 0.2–0.6) or ≥200–350 cells/mm³ (OR 0.6; 95% CI 0.4–1.0) (Ref: <200 cells/mm³ CD4) (p<10⁻⁴).

Conclusions

The presence of CIN+ is less common among HIV-infected women with limited or no immune deficiency. Despite the potential impact of immunological recovery on the reduction of premalignant cervical lesions through the use of ART, cervical cancer prevention, including screening and vaccination remains a priority in West Africa while ART is rolled-out.

Dried cervical spots for human papillomaviruses identification

Financial and operational constraints limit low-resource countries in the screening of high-risk genital human papillomaviruses (HR-HPV), the etiological agents of cervical cancer. With its simple storage, conservation and shipping, dried cervical sample (DCS) could represent an efficient tool. The aim of the study was to evaluate the reliability of HPV genotyping from DCS. Cervical samples were obtained from 50 women infected with HIV-1 in Côte d'Ivoire. After DNA extraction from both DCS and matched liquid cervical samples (LCS), HPV genotyping was performed and the concordance of genotyping results was evaluated. HPV prevalence was 88% in LCS and 78% in DCS. Kappa statistic was 0.51 for the presence of any genotype (95% confidence interval, 0.25-0.77) and 0.73 for HR-HPV (0.45-0.99). Out of 50 samples, 45 were HPV-positive for DCS and/or LCS, and HR-HPV were detected in 37 samples (74%) with 36 HR-HPV multiple infections. Any genotype and HR genotype identification was concordant/compatible in 86% (43/50) and 88% (44/50) of samples, respectively. In most instances, kappa statistics for detection of type-specific HPV was over 0.6 (including HPV-16, -18, -31, -33). An excellent agreement (kappa statistic ≥ 0.81) was found for eight genotypes (HPV-6, -31, -35, -40, -56, -58, -66, and -82). In spite of interfering factors (multiple infections, different HPV loads, amplification competition, different inputs), DCS and LCS led to concordant/compatible results in most cases. DCS could represent an efficient tool for epidemiological field studies in resource-limited settings, and more importantly for improving the screening coverage and care management in women infected with HPV.

The spectrum of cancers in West Africa: associations with human immunodeficiency virus

Background

Cancer is a growing co-morbidity among HIV-infected patients worldwide. With the scale-up of antiretroviral therapy (ART) in developing countries, cancer will contribute more and more to the HIV/AIDS disease burden. Our objective was to estimate the association between HIV infection and selected types of cancers among patients hospitalized for diagnosis or treatment of cancer in West Africa.

Methods

A case-referent study was conducted in referral hospitals in Côte d’Ivoire and Benin. Each participating clinical ward enrolled all adult patients seeking care for a confirmed diagnosis of cancer and clinicians systematically proposed an HIV test. HIV prevalence was compared between AIDS-defining cancers and a subset of selected non-AIDS defining cancers to a referent group of non-AIDS defining cancers not reported in the literature to be positively or inversely associated with HIV. An unconditional logistic model was used to estimate odds ratios (OR) and their 95% confidence intervals (CI) of the risk of being HIV-infected for selected cancers sites compared to a referent group of other cancers.

Results

The HIV overall prevalence was 12.3% (CI 10.3–14.4) among the 1,017 cancer cases included. A total of 442 patients constituted the referent group with an HIV prevalence of 4.7% (CI 2.8–6.7). In multivariate analysis, Kaposi sarcoma (OR 62.2 [CI 22.1–175.5]), non-Hodgkin lymphoma (4.0 [CI 2.0–8.0]), cervical cancer (OR 7.9 [CI 3.8–16.7]), anogenital cancer (OR 11.6 [CI 2.9–46.3]) and liver cancer (OR 2.7 [CI 1.1–7.7]) were all associated with HIV infection.

Conclusions

In a time of expanding access to ART, AIDS-defining cancers remain highly associated with HIV infection. This is to our knowledge, the first study reporting a significant association between HIV infection and liver cancer in sub-Saharan Africa.

Cervical human papillomavirus and HIV infection in women of child-bearing age in Abidjan, Côte d'Ivoire, 2010

Background:

We sought to document the association of Human immunodeficiency Virus (HIV) infection and immunodeficiency with oncogenic Human Papillomavirus (HPV) infection in women with no cervical neoplastic lesions identified through a cervical cancer screening programme in Côte d’Ivoire.

Methods:

A consecutive sample of women stratified on their HIV status and attending the national blood donor clinic or the closest HIV clinic was recruited during a cervical cancer screening programme based on the visual inspection. Diagnosis of HPV infection and genotype identification were based on the Linear Array; HPV test.

Results:

A total of 445 (254 HIV-positive and 191 HIV-negative) women were included. The prevalence of oncogenic HPV infection was 53.9% (95% confidence interval (CI) 47.9–59.9) in HIV-positive women and 33.7% (95% CI 27.1–40.3) in HIV-negative women (odds ratio (OR)=2.3 (95% CI 1.5–3.3)). In multivariate analysis, HIV-positive women with a CD4 count <200 cells mm³ or between 200 and 499 cells mm³ were more likely to harbour an oncogenic HPV compared with women with a CD4 count ⩾500 cells mm³ with OR of 2.8 (95% CI 1.1–8.1) and 1.7 (95% CI 1.0–2.9), respectively.

Conclusion:

A high prevalence of oncogenic HPV was found in women with no cervical neoplastic lesions, especially in HIV-positive women. Despite antiretroviral use, immunodeficiency was a main determinant of the presence of oncogenic HPV.

Cervical cancer screening by visual inspection in Côte d'Ivoire, operational and clinical aspects according to HIV status

Background

Cervical cancer screening is not yet standard of care of women attending HIV care clinics in Africa and presents operational challenges that need to be addressed.

Methods

A cervical cancer screening program based on visual inspection methods was conducted in clinics providing antiretroviral treatment (ART) in Abidjan, Côte d'Ivoire. An itinerant team of midwives was in charge of proposing cervical cancer screening to all HIV-positive women enrolled in ART clinics as well as to HIV-negative women who were attending the Abidjan national blood donor clinic. Positively screened women were systematically referred to a colposcopic examination. A phone-based tracking procedure was implemented to reach positively screened women who did not attend the medical consultation. The association between HIV status and cervical cancer screening outcomes was estimated using a multivariate logistic model.

Results

The frequency of positive visual inspection was 9.0% (95% CI 8.0-10.0) in the 2,998 HIV-positive women and 3.9% (95% CI 2.7-5.1) in the 1,047 HIV-negative ones (p < 10^-4). In multivariate analysis, HIV infection was associated with a higher risk of positive visual inspection [OR = 2.28 (95% CI 1.61-3.23)] as well as more extensive lesions involving the endocervical canal [OR = 2.42 (95% CI 1.15-5.08)]. The use of a phone-based tracking procedure enabled a significant reduction of women not attending medical consultation after initial positive screening from 36.5% to 19.8% (p < 10^-4).

Conclusion

The higher frequency of positive visual inspection among HIV-positive women supports the need to extend cervical cancer screening program to all HIV clinics in West Africa. Women loss to follow-up after being positively screened is a major concern in cervical screening programs but yet, partly amenable to a phone tracking procedure.

Short-term risk of anaemia following initiation of combination antiretroviral treatment in HIV-infected patients in countries in sub-Saharan Africa, Asia-Pacific, and central and South America

Background

The objective was to examine the short-term risk and predictors of anaemia following initiation of combination antiretroviral therapy (cART) in HIV-infected patients from the Western Africa, Eastern Africa, Southern Africa, Central Africa, Asian-Pacific, and Caribbean and Central and South America regions of the International Epidemiologic Databases to Evaluate AIDS (IeDEA) collaboration.

Methods

Anaemia was defined as haemoglobin of < 10 g/dL. Patients were included if they started cART with three or more drugs, had prior haemoglobin of > = 10 g/dL, and had one or more follow-up haemoglobin tests. Factors associated with anaemia up to 12 months were examined using Cox proportional hazards models and stratified by IeDEA region.

Results

Between 1998 and 2008, 19,947 patients initiated cART with baseline and follow-up haemoglobin tests (7358, 7289, 2853, 471, 1550 and 426 in the Western Africa, Eastern Africa, Southern Africa, Central Africa, Asian-Pacific, and Caribbean and Central and South America regions, respectively). At initiation, anaemia was found in 45% of Western Africa patients, 29% of Eastern Africa patients, 21% of Southern Africa patients, 36% of Central Africa patients, 15% of patients in Asian-Pacific and 14% of patients in Caribbean and Central and South America. Among patients with haemoglobin of > = 10 g/dL at baseline (13,445), the risks of anaemia were 18.2, 6.6, 9.7, 22.9, 11.8 and 19.5 per 100 person-years in the Western Africa, Eastern Africa, Southern Africa, Central Africa, Asian, and Caribbean and Central and South America regions, respectively. Factors associated with anaemia were female sex, low baseline haemoglobin level, low baseline CD4 count, more advanced disease stage, and initial cART containing zidovudine.

Conclusions

In data from 34 cohorts of HIV-infected patients from sub-Saharan Africa, Central and South America, and Asia, the risk of anaemia within 12 months of initiating cART was moderate. Routine haemoglobin monitoring was recommended in patients at risk of developing anaemia following cART initiation.