Lack of induction of interleukin-2-receptor-alpha in patients with tuberculosis and human immunodeficiency virus co-infection: implications for pathogenesis.

Since expression of both interleukin-2 (IL-2) and IL-2-receptor-alpha (IL-2R-alpha) by lymphocytes is inhibited by human immunodeficiency virus (HIV) in vitro, we hypothesized that HIV-co-infection among persons with tuberculosis (TB) might impair T-lymphocyte responses to TB via this mechanism. We measured soluble IL-2R-alpha (sIL-2R-alpha), a surrogate marker of T-lymphocyte activation and proliferation, and soluble tumour necrosis factor receptor I (sTNF-RI) in sera from West African patients categorized into 4 groups: those with TB alone (TB+ HIV-, n = 55), CD4-matched groups with TB and HIV co-infection (TB+ HIV+, n = 50) or HIV infection alone (TB- HIV+, n = 35), and patients with neither disease (TB- HIV-, n = 35). The median level of sIL-2R-alpha was markedly greater in the TB+ HIV- group (1580 U/mL) compared to the TB- HIV- (670 U/mL; P < 0.001) and TB- HIV+ (880 U/mL; P < 0.01) groups. More importantly, the median concentration of sIL-2R-alpha was much lower in the TB+ HIV+ group (855 U/mL) compared to the TB+ HIV- group (1580 U/mL; P < 0.01) despite similar levels of sTNF-RI. These results suggest that T-lymphocyte activation in TB patients is impaired by HIV co-infection and, furthermore, this suppressive effect was independent of numerical depletion of CD4 lymphocytes. Impairment to IL-2-signalling might contribute to the profound impact that HIV has had on both the incidence and the clinicopathological manifestations of TB.

Tuberculosis (TB) and HIV infection are independently associated with elevated serum concentrations of tumour necrosis factor receptor type 1 and beta2-microglobulin, respectively.

The aim of this study was to identify immune markers that are independently associated with HIV infection or TB in vivo. Using commercially available assays, we measured concentrations of five immune markers in sera from 175 out-patients attending medical clinics in Cote D'Ivoire and Ghana, West Africa. Patients were categorized into groups with TB only (TB+HIV-, n = 55), TB and HIV co-infection (TB+HIV+, n = 50), HIV infection only (TB-HIV+, n = 35), or neither infection (TB-HIV-, n = 35). TB+HIV+ and TB-HIV+ groups were matched for blood CD4+ lymphocyte count. Mean +/- s.d. concentrations of beta2-microglobulin were similarly increased in both the TB-HIV+ (5.3+/-2.1 microg/ml, P<0.0001) and the TB+HIV+ (5.0+/-1.5 microg/ml, P<0.0001) groups compared with the TB-HIV- group (2.2+/-1.8 microg/ml), but were only slightly increased in the TB+HIV- group (3.2+/-1.8 microg/ml, P = 0.01). In contrast, mean serum concentrations of soluble tumour necrosis factor receptor type I (sTNF-RI) were similarly elevated in the TB+HIV- (1873+/-799 pg/ml, P<0.0001) and TB+HIV+ (1797+/-571 pg/ml, P<0.0001) groups compared with uninfected subjects (906+/-613 pg/ml), but there was only a small increase in sTNF-RI in the TB-HIV+ group (1231+/-165 pg/ml, P = 0.03). Both TB and HIV infection were associated with substantial elevation of serum concentrations of soluble CD8, soluble CD54, and sTNF-R type II. Analysis of additional samples from groups of TB+HIV- and TB+HIV+ patients receiving anti-TB treatment showed significant and equal reductions in mean serum sTNF-RI concentrations, but no significant change in mean beta2-microglobulin. Thus, serum beta2-microglobulin and sTNF-RI serve as relatively independent markers of HIV infection and TB, respectively, in studies of co-infected persons.

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

BACKGROUND: There is a high incidence of opportunistic infection among HIV-1-infected patients with tuberculosis in Africa and, consequently, high mortality. We assessed the safety and efficacy of trimethoprim-sulphamethoxazole 800 mg/160 mg (co-trimoxazole) prophylaxis in prevention of such infections and in decrease of morbidity and mortality. METHODS: Between October, 1995, and April, 1998, we enrolled 771 HIV-1 seropositive and HIV-1 and HIV-2 dually seroreactive patients who had sputum-smear-positive pulmonary tuberculosis (median age 32 years [range 18-64], median CD4-cell count 317 cells/microL) attending Abidjan's four largest outpatient tuberculosis treatment centres. Patients were randomly assigned one daily tablet of co-trimoxazole (n=386) or placebo (n=385) 1 month after the start of a standard 6-month tuberculosis regimen. We assessed adherence to study drug and tolerance monthly for 5 months and every 3 months thereafter, as well as rates of admission to hospital. FINDINGS: Rates of laboratory and clinical adverse events were similar in the two groups. 51 patients in the co-trimoxazole group (13.8/100 person-years) and 86 in the placebo group (25.4/100 person-years) died (decrease In risk 46% [95% CI 23-62], p<0.001). 29 patients on co-trimoxazole (8.2/100 person-years) and 47 on placebo (15.0/100 person-years) were admitted to hospital at least once after randomisation (decrease 43% [10-64]), p=0.02). There were significantly fewer admissions for septicaemia and enteritis in the co-trimoxazole group than in the placebo group. INTERPRETATION: In HIV-1-infected patients with tuberculosis, daily co-trimoxazole prophylaxis was well tolerated and significantly decreased mortality and hospital admission rates. Our findings may have important implications for improvement of clinical care for such patients in Africa.

The Côte d'Ivoire national HIV counseling and testing program for tuberculosis patients: implementation and analysis of epidemiologic data.

OBJECTIVES: To describe the implementation of a free, voluntary and confidential HIV counseling and testing program for patients with newly diagnosed tuberculosis at the eight large outpatient tuberculosis centers in Côte d'Ivoire, and to present epidemiologic findings on participating patients. DESIGN: HIV counseling and testing program with ongoing HIV serosurveillance. METHODS: HIV counseling and testing services were established at the two tuberculosis centers in Abidjan in 1989 and were extended to six centers in the Côte d'Ivoire interior in the first half of 1994. Characteristics of counseled patients, acceptance rates of HIV testing, and HIV serologic results were analyzed for all eight centers from 1994 to 1996. Temporal trends in HIV seropositivity rates were examined for the two centers of Abidjan from 1989 to 1996. RESULTS: From July 1994 through December 1996, 17 946 (91.8%) out of 19 594 patients who were counseled at the eight centers in Côte d'Ivoire consented to HIV testing, of whom 7749 (43.2%) were HIV-seropositive. The highest rates of 47.0 and 45.6% were found in the two centers in Abidjan, with rates ranging from 32.9 to 42.4% in the six centers in the interior. HIV-seropositive tuberculosis patients from each of the 50 districts in Côte d'Ivoire were identified. In Abidjan, the HIV seropositivity rate remained relatively stable among men (46.7% in 1989, 48.5% in 1991, 43.6% in 1996), but rose sharply among women from 32.7% in 1989 to 50.1% in 1996. CONCLUSIONS: The high HIV seropositivity rates among tuberculosis patients in all geographic regions of Côte d'Ivoire indicate that the HIV epidemic has now spread throughout the country. However, the successful implementation of an extensive HIV counseling and testing program for more than 37000 tuberculosis patients to date demonstrates the commitment of the Côte d'Ivoire Ministry of Health to integrating HIV/AIDS prevention activities with tuberculosis control efforts. When logistically and economically feasible, the extension of HIV-related social and clinical services to HIV-seropositive tuberculosis patients should be considered by other national tuberculosis control programs in Africa.

Impact of HIV infection on the development, clinical presentation, and outcome of tuberculosis among children in Abidjan, Côte d'Ivoire.

OBJECTIVE: To assess the impact of HIV infection upon the development, clinical presentation, and outcome of tuberculosis (TB) among children. DESIGN: Case-control study and prospective cohort study. METHODS: From March 1994 to November 1995, children aged 0-9 years with newly diagnosed TB were enrolled at the two outpatient TB centers and the two principal university hospitals in Abidjan, Côte d'Ivoire. Children were examined, blood samples were collected for HIV serology and lymphocyte phenotyping, chest radiography was performed, and gastric aspirates and sputum samples were collected for acid-fast bacilli smear and culture. Children were then followed every 2 months during a standard 6-month course of anti-TB therapy. To examine risk factors for TB, age- and sex-matched healthy control children were enrolled from among the siblings of children referred for TB skin testing. RESULTS: Overall, 161 children with TB were enrolled, including 39 (24%) with culture-confirmed pulmonary TB, 80 (50%) with clinically diagnosed pulmonary TB, and 42 (26%) with extrapulmonary TB. Children with TB were significantly more likely than 161 control children to be HIV-seropositive (19 versus 0%), to have a past TB contact (55 versus 16%) and to live in very low socioeconomic status housing (24 versus 6%). No significant differences between HIV-seropositive and seronegative children were found in the distribution of radiologic abnormalities for pulmonary TB or in the site of extrapulmonary TB. The mortality rate in HIV-seropositive children was significantly higher than in seronegative children (23 versus 4%; relative risk, 3.6; 95% confidence interval, 2.0-6.6), and all deaths in HIV-seropositive children with available lymphocyte subtyping results occurred in those with a CD4 percentage of < 10%. CONCLUSIONS: This study documents the importance of HIV infection as an independent risk factor for the development of TB in children, and demonstrates that HIV-related immunosuppression is a critical risk factor for mortality in this population.

High rates of sexual contact with female sex workers, sexually transmitted diseases, and condom neglect among HIV-infected and uninfected men with tuberculosis in Abidjan, Côte d'Ivoire.

To characterize human immunodeficiency virus (HIV) risk practices among men with tuberculosis, and to determine what factors are associated with HIV infection in this population, we conducted a case-control analysis of data collected during enrollment in a prospective cohort study in the two large tuberculosis treatment centers of Abidjan, Côte d'Ivoire. Demographic information and data on risk factors for HIV infection, including history of sex with female sex workers (FSWs) and history of sexually transmitted diseases (STDs), were collected on 490 HIV-infected and 239 HIV-uninfected men diagnosed with pulmonary tuberculosis between 1989 and 1992. HIV-infected men were significantly more likely than uninfected men to have had sex with FSWs in their lifetime [83 versus 63%, odds ratio (OR) 2.9, 95% confidence internal (CI) 2.0-4.2], genital ulcer disease in the past 5 years (38 versus 15%, OR 3.4, 95% CI 2.2-5.2), urethritis in the past 5 years (44 versus 23%, OR 2.6, 95% CI 1.8-3.8), and sex with FSWs in the past year (43 versus 25%, OR 2.3, 95% CI 1.6-3.3); no difference was found in the proportion with at least one non-FSW partner in the past year (84 versus 79%, OR 1.3, 95% CI 0.9-2.0). Among all men, 74% never used condoms, and only 1.4% always used condoms. In a multivariate analysis, sex with FSWs, genital ulcer disease, urethritis, and lack of circumcision were all significantly associated with HIV. This study demonstrates the critical roles of commercial sex, STDs, and condom neglect in fueling the HIV/AIDS epidemic in Abidjan, and illustrates the urgent need for widespread HIV education both in the general population and in men with tuberculosis.

Autopsy-proven causes of death in HIV-infected patients treated for tuberculosis in Abidjan, Côte d'Ivoire.

OBJECTIVE: To determine autopsy-proven causes of death in HIV-infected patients treated for tuberculosis in Abidjan, Côte d'Ivoire. METHODS: A computerized listing of 9523 patients diagnosed with tuberculosis and tested for HIV infection at Abidjan's two large tuberculosis treatment centers from July 1989 to December 1991 was matched against a listing of 496 patients who were autopsied in Abidjan's largest public hospital in 1991-1992. RESULTS: Fifteen matching patients were identified including 11 adults with smear-positive pulmonary tuberculosis, three adults with extrapulmonary tuberculosis, and one child with smear-negative pulmonary tuberculosis. The autopsy-proven causes of death among the adults were tuberculosis (n = 4), bacterial infections (n = 3), cerebral toxoplasmosis (n = 2), pulmonary nocardiosis (n = 2), Pneumocystis carinii pneumonia (n = 1), atypical mycobacteriosis (n = 1), and wasting syndrome (n = 1). Tuberculosis was the primary cause of death in two of five smear-positive patients who had not completed therapy, in none of the six patients with smear-positive disease who had completed therapy, and in two of the three patients with extrapulmonary tuberculosis. CONCLUSIONS: Chemoprophylaxis with trimethoprim-sulfamethoxazole (TMP-SMX) might have provided benefit to eight (57%) of the 14 adults in this series who died either of bacterial infections, toxoplasmosis, nocardiosis, or pneumocystosis. Prospective studies are required to elucidate further the causes of increased mortality, and to evaluate the benefits of TMP-SMX prophylaxis in HIV-infected African patients with tuberculosis.

Two-year follow-up of persons with HIV-1- and HIV-2-associated pulmonary tuberculosis treated with short-course chemotherapy in West Africa.

OBJECTIVE: To assess the response to therapy for tuberculosis using rifampicin-containing short-course chemotherapy, and to compare recurrence and mortality rates in seronegative persons and those with HIV-1, HIV-2, and dual serologic reactivity in West Africa. METHODS: A cohort of 835 adult patients (167 HIV-1-positive, 143 HIV-2-positive, 243 dual-reactive, 282 HIV-negative) with smear-positive pulmonary tuberculosis was followed for 2 years under programme conditions. Standard self-administered treatment was daily rifampicin and isoniazid for 6 months, and in addition pyrazinamide during the first 2 months. Outcomes evaluated were rates of completion of therapy, cure, failure of treatment, recurrence after cure, and mortality. RESULTS: HIV-positive patients had lower rates of completion of therapy (65-73%) than seronegative patients (79%), mainly because of increased mortality. Among patients completing therapy, failure of treatment was similarly low in HIV-positive (2%) and seronegative patients (1%). Recurrence rates after cure did not differ significantly in the 18 months of follow-up in the four serologic groups (3-7%). The respective mortality rates for HIV-1-positive, HIV-2-positive, and dually reactive patients were 20.3, 8.3, and 25.5 per 100 person-years (PY), compared with 2.2 per 100 PY among seronegatives. CONCLUSIONS: Rifampicin-containing short-course chemotherapy for pulmonary tuberculosis is associated with similar cure and recurrence rates in HIV-positive and HIV-negative persons completing 6 months of therapy. HIV-2 infection is associated with more favourable survival than HIV-1 infection or dual reactivity, even when AIDS-defining illness is already present. However, mortality is significantly increased in all seropositive groups compared with HIV-negative tuberculosis patients; thus, establishing the causes of this increased mortality is a priority.

Radiologic manifestations of pulmonary tuberculosis in HIV-1 and HIV-2-infected patients in Abidjan, Côte d'Ivoire.

OBJECTIVES: To compare the radiologic manifestations of pulmonary tuberculosis in HIV-1-infected, HIV-2-infected, and HIV-negative patients; and to assess the impact of HIV-related immunosuppression on the radiologic manifestations of pulmonary tuberculosis. METHODS: We compared chest radiographs from consecutive HIV-1-positive, HIV-2-positive and seronegative patients with pulmonary tuberculosis. Differentiation between HIV-1 and HIV-2 antibodies was based on a synthetic peptide-based enzyme immunoassay. A subset of patients had CD4+ lymphocyte levels estimated by flow cytometry; in these patients, abnormalities on chest radiographs were analysed in relation to the severity of CD4+ lymphocyte depletion. RESULTS: HIV-1-infected patients were significantly more likely to have extrapulmonary tuberculosis than were HIV-2-infected or HIV-negative patients (20% vs 8% and 9%). Among patients with pulmonary tuberculosis, no differences were observed in the rates of specific abnormalities on chest radiographs between HIV-1- and HIV-2-infected patients; both HIV-1- and HIV-2-infected patients had a higher frequency of pleural effusion than did HIV-negative patients (8% and 9% vs 4%). Among HIV-infected patients with CD4+ counts of > or = 400/mm3, 200-399/mm3, and < 200/mm3, respectively, the proportions with non-cavitary infiltrates and hilar adenopathy increased significantly (33% to 44% to 58%, and 0% to 14% to 20%), while the proportion with cavitary lesions decreased significantly (63% to 44% to 29%). CONCLUSIONS: The radiologic manifestations of pulmonary tuberculosis in HIV-infected patients varied significantly over the spectrum of immune deficiency. HIV-infected patients with tuberculosis and relatively high CD4+ counts showed only slight differences from HIV-negative persons. HIV-1-positive patients had a higher frequency of extrapulmonary tuberculosis at presentation than those infected with HIV-2. Radiographic abnormalities were broadly similar in HIV-2-infected and HIV-1-infected patients. Clinicians and radiologists must be alert to the altered radiologic spectrum of pulmonary tuberculosis in immunosuppressed HIV-infected patients.

HIV status of female sex partners of men reactive to HIV-1, HIV-2 or both viruses in Abidjan, Côte d'Ivoire.

OBJECTIVES: To compare rates of serologic concordance in the female sex partners of men with HIV-1 and HIV-2 infections, and to determine the serologic status of sex partners of men who reacted serologically to both viruses. DESIGN: Cross-sectional study. SETTING: Infectious diseases service in a University Hospital in Abidjan, Côte d'Ivoire (West Africa). PARTICIPANTS: Hospitalized men reactive on synthetic peptide-based tests to HIV-1, HIV-2 or both viruses (dually reactive), and their spouses visiting them in hospital. OUTCOME MEASURES: Serologic status of female spouses of seropositive men. RESULTS: The serologic status of 540 spouses of 490 HIV-1- and/or HIV-2-positive, hospitalized men was studied. Similar proportions of spouses of HIV-1-infected men (49%) and HIV-2-infected men (44%) were concordantly seropositive. The overall prevalence of infection in spouses of dually reactive men (72%) was significantly higher than in spouses of other men; 44% of these spouses were infected with HIV-1, 8% with HIV-2, and 20% were themselves dually reactive. Considering only the seropositive female spouses of men monotypically reactive to HIV-1 or HIV-2, and the male spouses of women monotypically infected, rates of serologic discordance were significantly greater in men (24%) than women (7%). CONCLUSIONS: Men were likely to have been infected earlier than women because of their HIV-associated illness; also, men more frequently had serologic profiles indicative of infection outside of the union. Rates of serologic concordance in spouses of men with advanced HIV-1 or HIV-2 infection were similar (44-49%). Dually reactive hospitalized men frequently (72%) had seropositive sex partners, most of whom were HIV-1-positive. Dual reactivity was also frequent in these spouses, suggesting transmission of both HIV-1 and HIV-2, or of a cross-reactive strain, and a minority of partners were infected with HIV-2 alone. Prospective studies of discordant couples using quantitative molecular diagnostic techniques are required for better understanding of dual reactivity and transmission of HIV-1 and HIV-2.

Response to treatment, mortality, and CD4 lymphocyte counts in HIV-infected persons with tuberculosis in Abidjan, Côte d'Ivoire.

We examined the severity of immune deficiency in patients with HIV-associated tuberculosis in Côte d'Ivoire and assessed its effect on mortality and response to treatment. Consecutive patients attending a tuberculosis treatment centre in Abidjan with smear-positive pulmonary or clinically diagnosed extrapulmonary tuberculosis were tested for HIV-1 and HIV-2 infections and had CD4 lymphocyte counts measured. Patients received standard short-course chemotherapy. Analysis of outcome (restricted to smear-positive tuberculosis patients) was done at 6 months. The 247 HIV-positive patients were significantly more likely than the 312 HIV-negative patients to have CD4 lymphocyte counts of less than 200/microL (43% vs 1%; odds ratio 56.9; [95% CI 19.7-185.3]) and 200-499/microL (39% vs 14%, odds ratio 3.8; [2.5-5.9]). Among HIV-positive patients, median CD4 lymphocyte counts in those with extrapulmonary tuberculosis (198/microL; n = 67) was lower, but not significantly so, than among those with pulmonary tuberculosis (257/microL; n = 180). Among 460 patients with pulmonary tuberculosis, the overall mortality rate was significantly higher in HIV-positive than HIV-negative persons (6% vs 0.4%; relative risk 17.1 [2.2-131.4]), and increased with the severity of immune deficiency; mortality rates in HIV-positive patients with CD4 counts of < 200/microL and 200-499/microL were 10% and 4%, relative risk 27.6 (3.5-220.8); and 11.5 (1.2-109), respectively, compared to HIV-negatives. Among patients completing treatment, cure rates were similar in HIV-positive patients (93%) and HIV-negative patients (92%), and were not related to CD4 counts. Severity of immune deficiency was the major determinant of mortality in HIV-associated tuberculosis. Among people completing treatment, microbiological response was satisfactory irrespective of serological or immune status.

Tuberculosis and HIV infection in children in Abidjan, Côte d'Ivoire.

Of 5180 consecutive outpatients diagnosed with tuberculosis in Abidjan, Côte d'Ivoire (West Africa), between July 1989 and December 1990, 289 (6%) were children aged less than 15 years. The overall prevalence of human immunodeficiency virus (HIV) 1 and/or HIV-2 infection in children with tuberculosis was 11.8% (HIV-1, 10.0%; HIV-2, 0.7%; reactivity to both viruses, 1%). The highest overall age-specific prevalence was in children aged 1-4 years (23.4%), significantly higher than the rate in attenders at a well child clinic (0.5%) (odds ratio 58.2). Of children with tuberculosis, 26% had sputum smear-positive disease (HIV seroprevalence 2.7%), 20% extrapulmonary disease (HIV seroprevalence 5.2%), and 54% were categorized as having 'clinical tuberculosis' (HIV seroprevalence 18.6%) based on clinical signs and chest X-ray abnormalities with negative sputum smears. Clinical tuberculosis was most frequent in seropositive children, irrespective of age, and in younger seronegative children. Extrapulmonary tuberculosis was equally distributed across age groups, and pulmonary tuberculosis was concentrated in older, seronegative children. HIV-positivity was significantly associated with other features related to the acquired immune deficiency syndrome such as wasting, chronic diarrhoea, oral candidiasis, and negative tuberculin skin tests. Tuberculosis seems to be associated with HIV infection in children in sub-Saharan Africa, but better diagnostic techniques for paediatric tuberculosis are urgently needed.

A comparison of clinical features in tuberculosis associated with infection with human immunodeficiency viruses 1 and 2.

Between July 1989 and December 1990, 4504 new adult patients with tuberculosis were screened for antibodies to human immunodeficiency viruses (HIV) 1 and 2 in Abidjan's 2 tuberculosis treatment centres. The prevalence levels of HIV-1 and HIV-2 infections were 30.2% and 4.2% respectively, a further 9.3% of patients reacting serologically to both viruses. Patients in all 3 seropositive groups differed significantly from seronegatives in having a higher frequency of AIDS-related features such as wasting, chronic diarrhoea, oral candidiasis and generalized lymphadenopathy. These data support earlier work showing an association between HIV-2 infection and similar opportunistic diseases which complicate HIV-1 infection, including tuberculosis. Despite the differences between seropositive and seronegative groups, symptoms and signs of tuberculosis may mimic those of AIDS. HIV testing should be more widely available for the clinical care of tuberculosis patients in Africa, as well as for epidemiological surveillance.

PIP: Tuberculosis (TB) is the most important opportunistic disease complicating HIV-1 infection in sub-Saharan Africa. Since the discovery of HIV-2, speculation has existed over how aggressively it leads to debilitating illness and the nature of its association with TB. If HIV-2 is associated with AIDS, one could expect TB to be a consequence of HIV-2 infection. Work in Cote d'Ivoire has shown an increased prevalence of HIV-2 infection in ambulatory TB patients. To gain insight into this potential association, the clinical, features of TB patients infected with HIV-1, HIV-2, and both are compared with those of seronegative persons. A total of 4504 new adult patients with tuberculosis were screened during 1989-90 for antibodies to HIV-1 and HIV-2 in Abidjan's tuberculosis treatment centers. 30.2% of the sample tested seropositive for HIV-1, 4.2% for HIV-2, and 9.3% to both. Individuals testing seropositive to either or both viruses had a significantly higher frequency compared with seronegatives of AIDS - related features like wasting, chronic diarrhea, oral candidiasis, and generalized lymphadenopathy. These findings definitely support earlier work demonstrating an association between HIV-2 infection and tuberculosis. It should be noted, however, that since the wasting and fever signs and symptoms of TB may mimic those of AIDS and that it is extremely difficult to distinguish between HIV+ and HIV- TB in Africa, blood testing for HIV is ultimately needed. Accordingly, HIV testing should be made widely available for the clinical care of TB patients in Africa as well as for epidemiological surveillance.

HIV-1 and HIV-2 infections in men attending sexually transmitted disease clinics in Abidjan, Côte d'Ivoire.

OBJECTIVE: (1) To determine the prevalence of HIV-1 and HIV-2 infections and associated risk factors in men attending Abidjan's three sexually transmitted disease (STD) clinics; (2) to examine the use of such sites for epidemiological surveillance. DESIGN: Cross-sectional study. SETTING: Abidjan's two main STD clinics (Clinics A and T), and the University Hospital Dermatology outpatients clinic. PATIENTS: Consecutive patients with genitourinary symptoms. MAIN OUTCOME MEASURES: Prevalence of reactivity to HIV-1, HIV-2, and both viruses; descriptive characteristics of clinic attenders; clinical diagnoses of STD; risk factors associated with HIV-1 and HIV-2 positivity. RESULTS: The overall prevalence of HIV (HIV-1 and/or HIV-2) infection was 21% (250 out of 1169; 16% HIV-1, 2% HIV-2, 3% dual reactivity). Overall prevalence varied by clinic: University Hospital Dermatology outpatients clinic, 39%; Clinic T, 19%; Clinic A, 10%. Men with STD had an overall prevalence of 31% (155 out of 506), compared with 14% in men without physical signs of STD (odds ratio 2.6, 95% confidence interval 2.0-3.6). The highest prevalence, 46%, was in men with genital ulcer disease. Risk factors associated with HIV-1 as well as with HIV-2 infection after multivariate analysis were a history of sex with prostitutes, lack of circumcision, being unskilled, and a history of prior genital ulcer. Current genital ulcer, current STD and positive Treponema pallidum haemagluttination assay were associated with HIV-1 and dual reactivity. CONCLUSIONS: Risk factors for HIV-2 infection in men attending Abidjan STD clinics were broadly similar to those for HIV-1 infection. HIV-1 infection was more strongly associated with current STD. Important differences between the three clinics were observed in STD prevalence and type, and HIV seroprevalence. Such differences should be taken into account in the planning of HIV serosurveillance in STD clinics.