Cost-Effectiveness of Three Alternative Boosted Protease Inhibitor-Based Second-Line Regimens in HIV-Infected Patients in West and Central Africa.

BACKGROUND: While dolutegravir has been added by WHO as a preferred second-line option for the treatment of HIV infection, boosted protease inhibitor (bPI)-based regimens are still needed as alternative second-line options. Identifying optimal bPI-based second-line combinations is essential, given associated high costs and funding constraints in low- and middle-income countries. We assessed the cost-effectiveness of three alternative bPI-based second-line regimens in Burkina Faso, Cameroon and Senegal. METHODS: We used data collected over 2010-2015 in the 2LADY trial/post-trial cohort. Patients with first-line antiretroviral therapy (ART) failure were randomly assigned to tenofovir/emtricitabine + lopinavir/ritonavir (TDF/FTC LPV/r; arm A), abacavir + didanosine + lopinavir/ritonavir (arm B), or tenofovir/emtricitabine + darunavir/ritonavir (arm C). Costs (US dollars, 2016), quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios were computed for each country over 24 months of follow-up and extrapolated to 5 years using a simulated patient-level Markov model. We assessed uncertainty using cost-effectiveness acceptability curves, scenarios and prices threshold analysis. RESULTS: In each country, over 24 months, arm A was significantly less costly than arms B and C (incremental costs ranging from US$410-$US721 and US$468-US$546 for B and C vs A, respectively) and offered similar health benefits (incremental QALY: - 0.138 to 0.023 and - 0.179 to 0.028, respectively). Over 5 years, arm A remained the least costly, health benefits not being significantly different between arms. Compared with arms B and C, in each study country, Arm A had a ≥ 95% probability of being cost-effective for a large range of cost-effectiveness thresholds, irrespective of the scenario considered. CONCLUSIONS: Using TDF/FTC LPV/r as a bPI-based second-line regimen provided the best economic value in the three study countries. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT00928187.

Genotyping and antifungal susceptibility testing of Cryptococcus neoformans isolates from Cameroonian HIV-positive adult patients.

Cryptococcus neoformans is the most common cause of meningitis amongst adult Africans with HIV/AIDS. The widespread use of fluconazole may lead to the emergence of isolates with reduced susceptibility. We studied C. neoformans isolates from HIV-infected patients with cryptococcal meningitis. Genotyping and antifungal testing were performed to assess the genetic diversity, occurrence of mixed infections and in vitro activity of antifungal agents. Isolates were recovered from cerebrospinal fluid prior to systemic antifungal treatment. Six isolates were studied for each sample (a total of 114 isolates from 19 patients). Serotyping was performed via LAC 1 and CAP 64 gene amplification and genotyping was performed using phage M13 core, (GACA)4 and (GTG)5 primers and restriction polymorphism analysis of the URA5 gene. Susceptibilities for amphotericin B, flucytosine, fluconazole, voriconazole and posaconazole were tested by the Sensititre YeastOne® method. All strains were identified as C. neoformans var. grubii serotype A. We identified nine major genotypes. Up to two genotypes were identified in the same sample. None of the isolates were resistant to the studied drugs. However, 13 of 114 strains exhibited a reduced susceptibility to fluconazole and 13 of 114 strains exhibited a reduced susceptibility to flucytosine. No correlation was found between the genotype and susceptibility. This study confirms the prevalence of C. neoformans serotype A in Cameroon. Two genotypes may be responsible for a single episode of cryptococcosis. The possibility of mixed infection and diminished susceptibility to fluconazole or flucytosine must be considered for the management of cryptococcosis.

High rates of active hepatitis B and C co-infections in HIV-1 infected Cameroonian adults initiating antiretroviral therapy.

OBJECTIVES: To investigate the presence of hepatitis B virus (HBV) DNA and hepatitis C virus (HCV) RNA in HIV-infected patients initiating antiretroviral therapy in Cameroon. METHODS: Baseline blood samples from 169 patients were tested retrospectively for hepatitis B surface antigens (HBsAg), anti-hepatitis B core (anti-HBc), anti-HCV and - if HBsAg or anti-HCV result was positive or indeterminate - for HBV DNA or HCV RNA, respectively, using the Cobas Ampliprep/Cobas TaqMan quantitative assay (Roche Diagnostics GmbH, Mannheim, Germany). RESULTS: HBV DNA was detected in 14 of the 18 patients with positive or indeterminate HBsAg results [8.3% of the total study population, 95% confidence interval (CI) 4.6-13.5]. The median HBV viral load was 2.47 x 10(7) IU/mL [interquartile range (IQR) 3680-1.59 x 10(8); range 270 to >2.2 x 10(8)]. Twenty-one patients (12.4%, 95% CI 7.9-18.4) were found with HCV RNA (all with positive HCV serology). The median HCV viral load was 928 000 IU/mL (IQR 178 400-2.06 x 10(6); range 640-5.5 x 10(6)). No patient was co-infected with HBV and HCV. In multivariate analysis, HCV co-infection was associated with greater age [>or=45 years vs. <45 years, odds ratio (OR) 11.89, 95% CI 3.49-40.55, P<0.001] and abnormal serum alanine aminotransferase level [>or=1.25 x upper limit of normal (ULN) vs. <1.25 x ULN, OR 7.81, 95% CI 1.54-39.66, P=0.01]; HBV co-infection was associated with abnormal serum aspartate aminotransferase level (OR 4.33, 95% CI 1.32-14.17, P=0.02). CONCLUSIONS: These high rates of active HBV and HCV co-infections in HIV-positive Cameroonian patients requiring antiretroviral therapy underline the need to promote: (i) screening for HBV and HCV before treatment initiation; (ii) accessibility to tenofovir (especially in HBV-endemic African countries); and (iii) accessibility to treatment for HBV and HCV infections.

Prevalence of methicillin-resistant Staphylococcus aureus in eight African hospitals and Malta.

Methicillin-resistant Staphylococcus aureus (MRSA) poses a serious therapeutic problem worldwide, and its frequency in most African countries has not been reported. This study was aimed at determining the prevalence and antibiotic susceptibility patterns of MRSA in eight large hospitals (>500 beds) in Africa and Malta, from 1996 to 1997. Susceptibility to methicillin (oxacillin) and to other drugs was determined by E test (AB Biodisk, Solna, Sweden) on a total of 1440 clinical isolates of S. aureus. Methicillin resistance was detected in 213 (15%) of the 1440 isolates tested. The rate of MRSA was relatively high in Nigeria, Kenya, and Cameroon (21-30%), and below 10% in Tunisia, Malta, and Algeria. All MRSA isolates were sensitive to vancomycin, with MICs 60%) of MRSA strains were multiresistant. There is a need to maintain surveillance and control of MRSA infections in Africa.

HIV seroprevalence rate and incidence of adverse skin reactions in adults with pulmonary tuberculosis receiving thiacetazone free anti-tuberculosis treatment in Yaounde, Cameroon.

To determine the HIV seroprevalence in adult patients with pulmonary tuberculosis in Yaounde and to compare the incidence of adverse skin reactions in patients with and without HIV infection receiving thiacetazone-free antituberculosis treatment, we studied 235 consecutive patients aged 15 years or more admitted into the Chest Clinic of Hospital Jamot in Yaounde with a diagnosis of pulmonary tuberculosis from July 1 to December 31, 1994. HIV testing was done using two ELISAs and confirmed by Western blot. Each patient was monitored for adverse skin reactions to antituberculosis treatment during the two month initial phase of therapy in hospital. Of the 235 patients studied, 156 (66%) were males (mean age: 33 years) and 79 were females (mean age: 30.3 years). Overall, 16.6% (39 cases) of the 235 patients were HIV seropositive. The prevalence of HIV infection was significantly higher in women (24%) than in men (12.5%) (p = 0.02). Adverse skin reactions to antituberculosis treatment were observed in eleven (4.7%) of the 235 patients. The incidence of the reactions was significantly higher in HIV seropositive (23.1%) than in HIV seronegative patients (1.0%) (p < 10 - 7). Two HIV seropositive patients who developed Stevens-Johnson syndrome died. The drugs incriminated for adverse skin reactions in the nine patients who survived were pyrazinamide (four cases) and rifampicin (five cases).

PIP: A prospective study of 235 consecutive pulmonary tuberculosis (TB) patients admitted to Hospital Jamot in Yaounde, Cameroon, in a 6-month period in 1994 investigated the HIV seroprevalence in these patients and compared the incidence of adverse skin reactions in HIV-positive and HIV-negative patients receiving thiacetazone-free anti-TB treatment. Mean age was 33.0 years in the 158 male and 30.3 years in the 79 female patients. A total of 39 patients (16.6%) were HIV-seropositive; the seroprevalence rate was significantly higher in women (24.0%) than men (12.5%). Adverse skin reactions to anti-TB treatment were noted in 11 patients (4.7%) within 2-8 weeks of onset of treatment. Such reactions occurred in 9 (23.1%) of the HIV-positive patients compared with only 2 (1.0%) seronegative patients. The 2 patients (both HIV-positive) who developed Stevens-Johnson syndrome died. In the remaining 9 cases, reactions were mild to moderate and resolved with discontinuation of treatment (pyrazinamide or rifampicin) with or without the administration of symptomatic treatment. The World Health Organization has warned against use of thiacetazone in the treatment of TB in HIV-infected patients given the high frequency of sometimes fatal cutaneous hypersensitivity reactions. The findings of the present study indicate that, even when thiacetazone-free drugs are used, HIV-infected TB patients should be monitored carefully for adverse skin reactions.

Lower lung field tuberculosis in Yaounde, Cameroon.

Lower lung field tuberculosis was investigated in 273 consecutive adult patients with pulmonary tuberculosis admitted into the Chest Unit of the Jamot Hospital in Yaounde from December 1991 to July 1992. Twenty eight cases were found representing 10.3 pc of the total admissions with pulmonary tuberculosis. Twenty three (82.1 pc) of the patients were under 40 years of age and there were more women than men. Pregnancy, HIV infection and Diabetes mellitus were conditions frequently associated with lower lung field tuberculosis. The clinical symptoms were similar to those found in upper lobe disease. Radiographic changes were found mostly in the right lung and bilateral involvement was infrequent. Extensive homogeneous or patchy consolidation was found in 87.3 pc of the cases. Cavities and pleural effusion were respectively observed in 14 and four of the patients. Tuberculosis should always be considered as a diagnostic possibility in patients with lower lung field lesions.

PIP: Lower lung field tuberculosis (LLFT) was investigated in 273 consecutive adult patients with pulmonary tuberculosis (PT) admitted to the Chest Unit of Jamot Hospital in Yaounde from December 1991 to July 1992. 28 cases were found, 10.3% of total admissions with PT, of mean age 34 years in the range 15-78. There were 12 men and 16 women. 23 of the cases were under age 40 years. Pregnancy, HIV infection, and Diabetes mellitus were frequently associated with LLFT. Clinical symptoms were similar to those found in upper lobe disease. Radiographic changes were found mostly in the right lung and bilateral involvement was infrequent. Extensive homogeneous or patchy consolidation was found in 87.3% of cases. Cavities and pleural effusion were respectively observed in 14 and 4 patients. The authors argue that tuberculosis should always be considered as a diagnostic possibility in patients with LLFT.

Acute community-acquired bacterial pneumonia in Human Immunodeficiency Virus (HIV) infected and non-HIV-infected adult patients in Cameroon: aetiology and outcome.

SETTING: Yaounde Central Hospital, Jamot Hospital, Yaounde, and CEBEC Hospital in Douala. OBJECTIVE: To determine and compare the bacterial aetiology and outcome of acute community-acquired pneumonia in adult patients with and those without the Human Immunodeficiency Virus (HIV) infection. DESIGN: We studied 110 consecutive adult patients admitted for pneumonia into three hospitals in Cameroon, from November 1991 to December 1992. Blood cultures, sputum microscopy and cultures as well as pneumococcal antigen detection in sera and sputum were performed. Serological analysis for HIV, Mycoplasma pneumoniae, Coxiella burnetti and Chlamydia pneumoniae was also done. RESULTS: Twenty-eight (25.5%) of the 110 patients were HIV positive. Streptococcus pneumoniae was the most common single bacterial aetiology in the two groups. Bacteremia was observed in 12 (15.0%) of 80 patients on whom blood cultures were done and was significantly more common in HIV seropositive than seronegative patients. Mortality was the same in the two groups. CONCLUSION: There were no differences in aetiology and outcome between HIV seropositive and seronegative patients. However, bacteremia occurred more significantly in the HIV seropositive group.

PIP: During November 1991 to December 1992, in Cameroon, infectious disease specialists examined blood samples and/or sputum samples of 110 patients aged 15 years or older admitted for acute community-acquired pneumonia to Yaounde Central Hospital and Jamot Hospital in Yaounde and to CEBEC Hospital in Douala. They aimed to determine and compare the etiology and outcome of acute community-acquired pneumonia in HIV-infected and non-HIV-infected adult patients. 28 (25.5%) were HIV-1 positive. 8 HIV-infected patients had AIDS. No patient was HIV-2 positive. The physicians were able to make an etiological diagnosis of pneumonia in 50% of the HIV-infected patients and in 52.4% of HIV-negative patients. Streptococcus pneumoniae was responsible for most acute community-acquired pneumonia cases (29.3% for HIV-negative and 25% for HIV-positive patients; no significant difference). The next most common bacterial agent was Mycoplasma pneumoniae (8.8% and 12%, respectively; no significant difference). HIV-positive pneumonia cases were more likely to have microorganisms isolated from blood cultures than HIV-negative pneumonia cases (30% vs. 10%; p = 0.03). The mortality rate did not differ between HIV-positive and HIV-negative cases (7.1% vs. 7.3%). These findings showed a favorable outcome for both groups. The significant difference between the two groups was a higher frequency of bacteremia in HIV-positive patients.

[Tuberculosis screening of patient contacts in 1993 and 1994 in Yaounde, Cameroon]. / Dépistage de la tuberculose chez les sujets-contacts en 1993 et 1994 à Yaoundé, Cameroun.

To achieve early diagnosis in close contacts of tuberculosis patients and determine the most useful screening procedures for this purpose in Cameroon, 336 tuberculosis patients hospitalized in Unit B of the chest clinic of the Jamot Hospital in Yaounde from September 1993 to September 1994 were asked to bring their close contacts in for screening. Each contact underwent thorough clinical examination, standard postero-anterior chest X-ray, and a tuberculin skin test. If respiratory symptoms and/or chest X-ray lesions were present, acid fast bacilli (AFB) detection testing was performed on bronchial secretions. Only 104 of the 336 tuberculosis patients brought in their close contacts for evaluation. A total of 346 people were examined. Tuberculosis was detected in 50 (14.6%). Half of the new cases were under 14 years old. The most useful screening procedures tuberculosis were clinical examination, chest X-ray, and AFB testing if respiratory symptoms were present. The tuberculin skin test was not helpful.

Seroprevalence of HIV infection among patients with pulmonary tuberculosis in Yaounde-Cameroun.

To determine the seroprevalence of infection with the human immunodeficiency virus (HIV) in pulmonary tuberculosis patients, we conducted an HIV serosurvey in 162 inpatients with pulmonary tuberculosis, in Yaoundé Cameroon. HIV seroprevalence in hospitalized pulmonary tuberculosis patients was found to be 9.9% as compared to the seroprevalence rate of 2.2% for Yaounde, the area from which the patients we studied came. No differences were observed in the clinical, radiological and bacteriological features between HIV seropositive and seronegative patients with pulmonary tuberculosis.

Prevalence of Campylobacter enteritis in children from Yaounde (Cameroon).

A cross sectional study on the prevalence of Campylobacter jejuni/coli and its possible aetiologic role in childhood diarrhoea in Yaounde was undertaken in 272 children presenting with diarrhoea and 157 age matched controls from April 1989 to October 1990. Stool cultures were performed according to standard techniques for Campylobacter jejuni/coli shigella and salmonella species. Rotavirus was detected using a latex agglutination test. Campylobacter jejuni/coli was isolated from 21 (7,7 pc) of 272 patients with diarrhoea and five of 157 (3,2 pc) controls (p > 0.05), all aged zero to four years old. Shigella and salmonella species were cultured from 2,2 pc and 1,1 pc of 272 patients respectively while rotavirus antigen was detected in 19,6 pc of 204 patients. Twenty eight pc of children with Campylobacter enteritis were exposed to chickens while 23,8 regularly drank water from streams which probably were contaminated. Our results indicate a high prevalence of campylobacter enteritis in children living in Yaounde and also suggest that a high rate of carriage of Campylobacter jejuni/coli could exist in children zero to four years without diarrhoeal illness. to four years without diarrhoeal illness.

Radiographic aspects of pulmonary tuberculosis in the adult in Yaounde; Cameroon

Radiographic aspects of newly detected and previously untreated pulmonary tuberculosis in 273 consecutive adult patients admitted into the chest unit of the Jamot Hospital in Yaounde over an 8 month period were reviewed. None of the patients had a normal admission chest X-ray image. Lesions localized only in the upper lung fields were seen in 21.3 percent of the cases. In contrast; 64.1 percent of the patients presented with a far advanced and extensive disease characterized by infiltrates with or without cavities occupying a whole lung field or more. Cavitary disease predominantly made of multiple large cavities was observed in 77.7 percent of the cases. Atypical images including pleural effusion; parenchymal nodules; lymphadenopathy and lower lung field disease were uncommon. Despite recent studies suggesting that pulmonary tuberculosis is presenting with atypical radiographic features more commonly than reported in the past; the chest X-ray manifestations of pulmonary tuberculosis in the series were predominantly characterized by a far advanced disease with multiple large cavities

Depistage de la tuberculose chez les sujets-contacts

De septembre 1993 a septembre 1994; parmi les 336 malades tuberculeux hospitalises a l'Unite B de la Clinique de Pneumophtisiologie de l'Hopital Jamot a Yaounde; seuls 104 ont pu faire examiner les membres de leur entourage pour le depistage systematique de la tuberculose. 346 sujets contacts ont ainsi ete examines. Tout sujet contact a eu un examen clinique complet; une radiographie thoracique standard et une intradermo reaction a 10U.I. de tuberculine. 50 (14;6 pour cent) cas de tuberculose ont ainsi ete depistes parmi les 346 sujets contacts. La moitie des cas depistes avaient un age inferieur ou egal a 14 ans. L'examen clinique; la radiographie thoracique et l'examen bacteriologique des secretions bronchiques en cas de symptome fonctionnel respiratoire constituaient les moyens les plus efficaces pour ce depistage. La pratique de l'IDR n'a par contre aucun interet diagnostique

Pneumopathies communautaires de l'adulte dans un milieu hospitalier a Douala: epidemiologie et clinique

Les caracteristiques epidemiologiques et cliniques de 43 malades ages de 15 a 81 ans (moyenne = 45) admis consecutivement de mars a juin 1992 pour pneumopathie communautaire dans un hopital de 200 lits a Douala sont rapportees par les auteurs. La pneumopathie communautaire de l'adulte represente 4;6 pour cent des admissions dans cet hopital avec un sex-ratio de 2;3 et un taux eleve de population urbaine (70 pour cent). Les facteurs de risque les plus frequents etaient l'alcoolisme (67;4 pour cent); le tabagisme (44;5 pour cent) et l'infection a VIH (20;9 pour cent). [abstract terminated]

Adult response to initial treatment with ampicillin in community acquired pneumonia in Yaoundé, Cameroon.

A prospective study was conducted to evaluate the efficacy of ampicillin as an initial therapy in 60 adult patients with community acquired pneumonia. Bacteriological etiology was obtained only in 24 (40pc) patients by microscopic examination, culture and antigen detection. Streptococcus pneumoniae was the leading causative agent identified in 15 cases. Other etiologies were Klebsiella pneumoniae (3), Streptococcus pyogenes (2) Staphylococcus aureus (2), Haemophilus influenzae (1) and Moraxella catarrhails (1). Patients were started on ampicillin one gram twice daily, empirically, and treated for 10 days. There were 52(86.7pc) patients cured, two(3.3pc) patients improved and six (10pc) were therapeutic failures. The causative agents in patients with failures were: Klebsiella pneumoniae (1), Staphylococcus aureus (1), Streptococcus pneumoniae (1) and unknown in three cases. Only six of 60 patients still febrile after three days were switched to amoxycillin/clavulanic acid or cefaclor according to culture results and susceptibilities or to roxythromycin because no organisms were isolated. Side effects were observed in only one (1.7pc) patient who developed a mild skin rash. Due to its low cost and its high efficacy, ampicillin still appears to be the drug of choice in adult community acquired pneumonia in our region.