Effectiveness of co-trimoxazole to prevent Plasmodium falciparum malaria in HIV-positive pregnant women in sub-Saharan Africa: an open-label, randomized controlled trial.

BACKGROUND: Human immunodeficiency virus (HIV) and malaria during pregnancy cause substantial perinatal mortality. As co-trimoxazole (CMX) protects children and HIV-positive adults against malaria, we compared the effectiveness of daily CMX with sulfadoxine-pyrimethamine intermittent preventive treatment (IPT-SP) on malaria risk in HIV-positive pregnant women in a Plasmodium falciparum-endemic African area. METHODS: From January 2009 to April 2011, we included in a randomized noninferiority trial all HIV type 1-infected pregnant women (≤28 weeks' gestation, CD4 count ≥200 cells/µL, hemoglobin level ≥7 g/L) in 19 health centers in Togo. Women were randomly assigned to daily 800 mg/160 mg CMX, or IPT-SP. The primary outcome was the proportion of malaria-free pregnancies. Other outcomes included malaria incidence, parasitemia, placental malaria, anemia, and infants' birth weight. RESULTS: Of 264 women randomly assigned to the CMX or IPT-SP group, 126 of 132 and 124 of 132, respectively, were included in the analysis. There were 33 confirmed cases of clinical malaria among 31 women in the CMX group, and 19 among 19 women in the IPT-SP group. Ninety-five of 126 (75.4%) women in the CMX group and 105 of 124 (84.7%) in the IPT-SP group remained malaria-free during their pregnancy (difference, 9.3%; 95% confidence interval [CI], -.53 to 19.1, not meeting the predefined noninferiority criterion). The incidence rate in intention-to-treat analysis was 108.8 malaria episodes per 100 person-years in CMX (95% CI, 105.4-112.2) and 90.1 in IPT-SP (95% CI, 86.8-93.4) (not significant). Prevalence of parasitemia was 16.7% in the CMX group vs 28% in the IPT-SP group (P = .02). Histology revealed 20.3% placental malaria in the CMX group vs. 24.6% in the IPT-SP group (not significant). Grade 3-4 anemia was more frequent in the CMX group (10% vs 4%; P = .008). No pregnant women died. Median birth weight was similar. CONCLUSIONS: Daily CMX was not noninferior to IPT-SP for preventing maternal malaria but safe and at least similar regarding parasitemia or placental malaria and birth outcomes. Clinical Trials Registration ISRCTN98835811.

HIV prevalence and behavioral studies in female sex workers in Togo: a decline in the prevalence between 2005 and 2011.

INTRODUCTION: We determined the sero-prevalence of HIV among female sex workers (FSWs) in Togo identified their sexual risk behaviors. METHODS: We conducted a cross-sectional study from 17 to 27 December, 2011 on 1106 FSWs in Togo. Venous sample were collected to estimate HIV prevalence as per national algorithms. Behavior data were collected by interviewer-administered questionnaires. RESULTS: Of the 1106 FSWs (mean age = 27.6 years) surveyed, 17% and 63% had their first sexual intercourse before the age of 15 and 18 years respectively. Overall, 43.4% of the FSWs had more than seven clients per week. Most FSWs (95%) said they had sex using a condom in their lifetime while 8.8% had used a condom during their last sexual intercourse. About 79% of FSWs used a condom during their sexual encounters the previous week and 11.6% had used a condom during each of their sexual encounters the previous day. Most FSWs (62.2%) reported to have been tested for HIV. Of these, 145 (13.1%) were HIV positive. HIV sero-prevalence decreased from 19.4% in the south to 7.5% in the north of the country. Behaviors associated with FSW being HIV positive included: FSW having more than 7 clients per week (p < 0.001), not using condoms at every intercourse act (p = 0.003) or during the last sexual encounter (p = 0.006) and trading sex in brothels (p < 0.001). CONCLUSION: We estimate HIV sero-prevalence among FSWs in 2011 to be 13.1% in Togo, significantly lower than a prevalence of 29.5% estimated previously in 2005. Inconsistent use of condoms was identified as associated with high risk factor for acquiring HIV.

Loss of HIV-infected patients on potent antiretroviral therapy programs in Togo: risk factors and the fate of these patients.

INTRODUCTION: National programs are facing challenges of loss to follow-up of people living with HIV/AIDS (PLWHA) on antiretroviral therapy (ART). We sought to identify risk factors associated with early loss to follow-up among HIV-infected patients on ART in Togo and the outcome of such patients. METHODS: This was a retrospective cross-sectional study using medical records of all patients older than age 15 years enrolled at 28 treatment centers who were on ART programs and who were lost to follow-up from 2008 to 2011. RESULTS: Of the 16,617 patients on ART, 1,216 (7.3%) were lost to follow-up. Most (94.1%) were infected with HIV-1 and 32.6% were in WHO stage III or IV. The median CD4 count was 118/mm3 (IQR: 58-178 cells/mm3). No telephone number was mentioned in the medical records of 212 patients. Of the 1004 patients whose phone number was listed, 802 patients (79.9%) were not reachable on the recorded number, 114 patients (11.4%) were alive and 88 patients (8.8%) had died. In multivariate analysis, factors associated with loss to follow-up during the first 6 months of ART were: age below 35 years (OR = 1.6; 95%CI: 1.2-2.2), female sex (OR = 1.8; 95%CI: 1.3-2.5), WHO stage III or IV (OR = 1.7; 95%CI: 1.3-2.2), existence of an opportunistic infection (OR = 2.3; 95%CI: 1.5-3.1), and follow-up in a public centre (OR = 1.9; 95%CI: 1.2-3.3). CONCLUSION: This study identified several factors associated with lost to follow-up during the first 6 months of ART, and confirmed high mortality among these patients. The National AIDS Program should strengthen medical support of PLWHA in Togo including active case follow-up.