Seroepidemiological survey of hepatitis C virus among commercial sex workers and pregnant women in Kinshasa, Democratic Republic of Congo.

BACKGROUND: Studies conducted mainly in industrialized countries have shown that the transmission of hepatitis C virus (HCV) is mainly parenteral, and have emphasized the role of nosocomial transmission. In Equatorial Africa, the respective contributions of parenteral and non-parenteral routes of transmission are unknown. The potential role of sexual transmission in this area of high HCV endemicity, where sexually transmitted infections (STI) are frequent, is suggested by the fact that HCV infection is rare in infants and young adolescents, but increases thereafter with age. The present study, conducted in Democratic Republic of Congo, was designed to determine the prevalence of HCV infection and associated sexual risk factors in two female populations with different sexual behaviour. METHODS: Cross-sectional studies conducted among commercial sex workers (CSW; n = 1144) and pregnant women (n = 1092) in the late 1980s in Kinshasa showed a high frequency of at-risk sexual behaviour, STI and human immunodeficiency virus (HIV) infection, particularly among CSW. We screened samples collected during these epidemiological studies for antibodies to HCV using a second-generation ELISA with confirmation by a third-generation LIA. We also assessed sociodemographic variables, medical history, STI markers and sexual behaviour, and their potential association with HCV infection. RESULTS: The overall prevalence of anti-HCV was 6.6% (95% CI : 5.2-8.2) among CSW and 4.3% (95% CI : 3.2-5.7) among pregnant women (age-adjusted OR = 1.5, 95% CI : 1.0-2.1, P = 0.05). Multivariate analysis showed that the presence of anti-HCV among CSW was independently associated with a previous history of blood transfusion (P < 0.001), age >30 years (P < 0.001) and the presence of at least one biological marker of STI (P < 0.03). No such links were found among pregnant women (although the history of blood transfusions was not investigated in this group). Anti-HCV was not associated with sociodemographic variables or sexual behaviour in either group, or with individual markers of STI. Despite the high-risk sexual behaviour and the higher prevalence of STI in CSW, the difference in HCV seroprevalence between CSW and pregnant women (6.6% versus 4.3%) was small, particularly when compared with the difference in the seroprevalence of HIV (34.1% versus 2.8%). CONCLUSION: The role of sexual transmission in the spread of HCV seems to be limited. Parenteral transmission (including blood transfusion and injections), possibly related to the treatment of STI, probably plays a major role.

Prevalence and risk factors of cervicovaginal HIV shedding among HIV-1 and HIV-2 infected women in Dakar, Senegal.

OBJECTIVES: To assess the risk determinants and prevalence of cervicovaginal shedding of HIV-1 and HIV-2 among women in Dakar, Senegal. METHODS: We conducted a cross sectional study of 153 HIV seropositive female sex workers (FSW) and another 142 HIV seropositive women attending an infectious diseases unit, based on an interview, physical examination, and laboratory screening for major sexually transmitted infections (STI). Cervicovaginal lavage fluid was tested for HIV-RNA by means of nested PCR. Links between cervicovaginal shedding of HIV-1 and HIV-2 and sociodemographic, clinical, and laboratory variables were identified by using odd ratios and 95% confidence intervals. Logistic regression analysis was used to identify independent links with HIV shedding. RESULTS: The detection rate of HIV-RNA in cervicovaginal lavage fluid was low among FSW, with no difference between HIV-1 (7/90: 8%) and HIV-2 (3/48: 6%). The rate was far higher among the other women (41%, 48/117; 33%, 7/21 for HIV-1 and HIV-2, respectively). In multivariate analysis, high plasma viral load (>40 000 copies/ml) (AOR = 2.4 (1.0-5.6) p = 0.04) and basic vaginal pH (AOR = 2.2 (1.3-3.7) p = 0.002) were independently associated with HIV-1 shedding. For HIV-2 a CD4 count < 200 cells x 10(6)/l was the only factor associated with the shedding of HIV-2 (AOR = 9.0 (0.9-93)). The genital shedding rate was higher with HIV-1 than with HIV-2 (OR = 2.1 (0.9-4.8), but this difference disappeared after adjustment for the CD4+ cell count (AOR = 1.2 (0.5-2.9)). CONCLUSION: Advanced disease stage and immunosuppression are the major risk determinants for shedding of both HIV-1 and HIV-2. Basic vaginal pH is also a risk determinant for HIV-1 shedding.

Genetic diversity of protease and reverse transcriptase sequences in non-subtype-B human immunodeficiency virus type 1 strains: evidence of many minor drug resistance mutations in treatment-naive patients.

Most human immunodeficiency virus (HIV) drug susceptibility studies have involved subtype B strains. Little information on the impact of viral diversity on natural susceptibility to antiretroviral drugs has been reported. However, the prevalence of non-subtype-B (non-B) HIV type 1 (HIV-1) strains continues to increase in industrialized countries, and antiretroviral treatments have recently become available in certain developing countries where non-B subtypes predominate. We sequenced the protease and reverse transcriptase (RT) genes of 142 HIV-1 isolates from antiretroviral-naive patients: 4 belonged to group O and 138 belonged to group M (9 subtype A, 13 subtype B, 2 subtype C, 5 subtype D, 2 subtype F1, 9 subtype F2, 4 subtype G, 5 subtype J, 2 subtype K, 3 subtype CRF01-AE, 67 subtype CRF02-AG, and 17 unclassified isolates). No major mutations associated with resistance to nucleoside reverse transcriptase inhibitors (NRTIs) or protease inhibitors were detected. Major mutations linked to resistance to non-NRTI agents were detected in all group O isolates (A98G and Y181C) and in one subtype J virus (V108I). In contrast, many accessory mutations were found, especially in the protease gene. Only 5.6% of the 142 strains, all belonging to subtype B or D, had no mutations in the protease gene. Sixty percent had one mutation, 22.5% had two mutations, 9.8% had three mutations, and 2.1% (all group O strains) had four mutations. In order of decreasing frequency, the following mutations were identified in the protease gene: M36I (86.6%), L10I/V (26%), L63P (12.6%), K20M/R (11.2%), V77I (5.6%), A71V (2.8%), L33F (0.7%), and M46I (0.7%). R211K, an accessory mutation associated with NRTI resistance, was also observed in 43.6% of the samples. Phenotypic and clinical studies are now required to determine whether multidrug-resistant viruses emerge more rapidly during antiretroviral therapy when minor resistance-conferring mutations are present before treatment initiation.

Unprecedented degree of human immunodeficiency virus type 1 (HIV-1) group M genetic diversity in the Democratic Republic of Congo suggests that the HIV-1 pandemic originated in Central Africa.

The purpose of this study was to document the genetic diversity of human immunodeficiency virus type 1 (HIV-1) in the Democratic Republic of Congo (DRC; formerly Zaire). A total of 247 HIV-1-positive samples, collected during an epidemiologic survey conducted in 1997 in three regions (Kinshasa [the capital], Bwamanda [in the north], and Mbuyi-Maya [in the south]), were genetically characterized in the env V3-V5 region. All known subtypes were found to cocirculate, and for 6% of the samples the subtype could not be identified. Subtype A is predominant, with prevalences decreasing from north to south (69% in the north, 53% in the capital city, and 46% in the south). Subtype C, D, G, and H prevalences range from 7 to 9%, whereas subtype F, J, K, and CRF01-AE strains represent 2 to 4% of the samples; only one subtype B strain was identified. The highest prevalence (25%) of subtype C was in the south, and CRF01-AE was seen mainly in the north. The high intersubtype variability among the V3-V5 sequences is the most probable reason for the low (45%) efficiency of subtype A-specific PCR and HMA (heteroduplex mobility assay). Eighteen (29%) of 62 samples had discordant subtype designations between env and gag. Sequence analysis of the entire envelope from 13 samples confirmed the high degree of diversity and complexity of HIV-1 strains in the DRC; 9 had a complex recombinant structure in gp160, involving fragments of known and unknown subtypes. Interestingly, the unknown fragments from the different strains did not cluster together. Overall, the high number of HIV-1 subtypes cocirculating, the high intrasubtype diversity, and the high numbers of possible recombinant viruses as well as different unclassified strains are all in agreement with an old and mature epidemic in the DRC, suggesting that this region is the epicenter of HIV-1 group M.

Predominance of subtype A and G HIV type 1 in Nigeria, with geographical differences in their distribution.

The purpose of this study was to generate data on the relative prevalences of the HIV-1 subtypes circulating in Nigeria. A total of 252 HIV-1-positive samples collected during an epidemiologic survey conducted in April 1996 were genetically characterized by HMA (heteroduplex mobility assay) and/or sequencing. Samples were collected in Lagos, Calabar, Kano, and Maiduguri. Overall, the predominant env subtypes were A (61.3%) and G (37.5%). Subtype A is more prevalent in the south (p < 0.001), about 70% in Lagos and Calabar, whereas a quarter of the samples was classified as subtype G in these states. In contrast, subtype G is predominant in the north ( < 0.001), representing 58% of the samples in Kano. In the northeastern region, Maiduguri, almost similar proportions of subtype A and G were seen, 49 and 47.4%, respectively. A total of 37 samples was also sequenced in the p24 region from the gag gene; 13 (35%) had discordant subtype designations between env and gag. The majority of the gag (12 of 17) and env (14 of 22) subtype A sequences clustered with the A/G-IBNG strain. Within subtype G, three different subclusters were seen among the envelope sequences. These different subclusters are observed among samples obtained from asymptomatic individuals and AIDS patients from the four Nigerian states studied. In conclusion, we observed a limited number of HIV-1 subtypes circulating in Nigeria, with subtypes A and G being the major env subtypes responsible for the HIV-1 epidemic. Nevertheless, the high rate of recombinant viruses (A/G) and the different A/G recombinant structures indicate a complex pattern of HIV-1 viruses circulating in this country.

Near-full-length genome sequencing of divergent African HIV type 1 subtype F viruses leads to the identification of a new HIV type 1 subtype designated K.

We recently reported a high divergence among African subtype F strains. Three well-separated groups (F1, F2, and F3) have been shown based on the phylogenetic analysis of the p24 gag and envelope sequences with genetic distances similar to those observed for known subtypes. In this study, we characterized the near-full-length genomes of two strains from epidemiological unlinked individual belonging to each of the subgroups: F1 (96FR-MP411), F2 (95CM-MP255 and 95CM-MP257), and F3 (96CM-MP535 and 97ZR-EQTB11). Phylogenetic analysis of the near-full-length sequences and for each of the genes separately showed the same three groups, supported by high bootstrap values. Diversity plotting, BLAST subtyping, and bootstrap plotting confirmed that the divergent F strains correspond to nonrecombinant viruses. The divergence between F1 and F2 is consistently lower than that seen in any other intersubtype comparison, with the exception of subtypes B and D. Based on all the different analyses, we propose to divide subtype F into two subclades, with F1 gathering the known subtype F strains from Brazil and Finland, and our African strain (96FR-MP411), and F2 containing the 95CM-MP255 and 95CM-MP257 strains from Cameroon. The F3 strains, 97ZR-EQTB11 from the Democratic Republic of Congo and 96CM-MP535 from Cameroon, meet the criteria of a new subtype designated as K. The equidistance of subtype K to the other subtypes of HIV-1 suggests that this subtype existed as long as the others, the lower distance between B and D, and between F1 and F2 suggest a more recent subdivision for these latter strains.

Identification of a complex env subtype E HIV type 1 virus from the democratic republic of congo, recombinant with A, G, H, J, K, and unknown subtypes.

Up to now, all known env subtype E viruses (CRF01-AE) have had the same mosaic structure with subtype A, and no other env subtype E HIV-1 viruses with non-A subtypes in their genomes have been described. In this report we describe the full-length genome sequence of an env subtype E isolate with a recombinant genome different from the prototype CRF01-AE strains. The 97CD-KTB49 strain, obtained from a tuberculosis patient in Kinshasa, has a complex mosaic genome involving subtypes A, E, G, H, J, K, and several unknown fragments. The U sequences formed well-separated clusters together with previously described unknown fragments from CRF04-cpx (subtype I), and from Z321, the oldest intersubtype recombinant isolated in 1976 in the Democratic Republic of Congo. The complex recombinant virus from our study is not an isolated strain; partial sequencing of a second strain, 97CD-KFE45, confirmed the breakpoints observed in the 97CD-KTB49 strain in the regions sequenced. The complexity of these recombinant strains suggests a longstanding presence of subtype E in Central Africa.

Evidence of stable HIV seroprevalences in selected populations in the Democratic Republic of the Congo.

OBJECTIVE: To determine current data on HIV infection and to document changes and trends of HIV seroprevalence in selected populations over time in the Democratic Republic of the Congo (DRC; former Zaïre). METHODS: In February 1997, a large serosurvey was conducted on selected population groups from Kinshasa (capital city), Mbuji-May (southeast) and Bwamanda (northwest). Samples obtained from pregnant women, tuberculosis patients, commercial sex workers, blood donors and sexually transmitted disease patients were screened for the presence of HIV antibodies by a rapid assay and a commercial enzyme-linked immunosorbent assay. All reactive specimens were confirmed and discriminated by a line immunoassay, and were further tested for the presence of HIV-1 group O antibodies. Our results were compared to data reported in previous studies in Kinshasa. RESULTS: Of a total 1970 samples collected, 219 (11.1%) were HIV-1-reactive and seven (0.3%) were dually reactive to HIV-1 and HIV-2. No case of HIV-1 group O or HIV-2 infection was diagnosed. HIV seroprevalence in pregnant women was 3.1% (16 out of 511), 6.3% (19 out of 300) and 1.5% (one out of 65) in Kinshasa, Mbuji-Mayi, and Bwamanda, respectively. HIV seroprevalence in tuberculosis patients was 26% (52 out of 200), 28% (17 out of 60), and 35.3% (29 out of 83), respectively. HIV seroprevalence among blood donors was 3.1% in Kinshasa and 2.8% in Mbuji-Mayi. Compared with data from previous studies performed in Kinshasa, no substantial change in HIV infection rates was observed among the selected population groups. CONCLUSIONS: Our results show that HIV prevalence rates have remained relatively unchanged in selected populations despite the political instability and poor environment observed since 1991 in DRC. It also shows the presence, still at very low rate, of dual HIV-1/HIV-2 seropositivity and a growing problem of HIV infection in rural areas. In contrast to other Central African countries, no HIV-1 group O infections were detected in DRC.

Seroprevalence of HIV-1, HIV-2, and HIV-1 group O in Nigeria: evidence for a growing increase of HIV infection.

To determine current data on HIV infection and to further confirm the presence of HIV-1 group O infection in Nigeria, 2300 samples from five states were tested for the presence of HIV antibody. A convenience sampling was obtained from pregnant women, tuberculosis (TB) patients, commercial sex workers (CSWs), blood donors, patients with sexually transmitted diseases (STDs), patients with skin diseases, male clients of CSWs, outpatients suspected to have AIDS, truck drivers, and community dwellers. With the exception of pregnant women, the HIV prevalences in all these groups were high: 60.6% in CSWs, 16.2% in TB patients, 7.7% in blood donors in some states, and 16% in the rural area of Kano State. Male clients of CSWs, truck drivers, and STD patients had prevalences of 7.8%, 8.6%, and 21.2%, respectively. Regional differences in relation to HIV prevalences were observed; HIV-2 and most of the HIV-1/2 infections were found in the southern states of Nigeria. Higher HIV prevalences were observed in the north-northeast in pregnant women, TB patients, and CSWs, but for blood donors, higher rates were seen in the southeast-southwest. One asymptomatic 50-year-old woman, a community dweller in Kano, was identified to be HIV-1 group O-positive. Compared with data from national surveillance studies in 1991/1992 and 1993/1994, a substantial increase in HIV infection was observed. Our results show a growing incidence of HIV infection in Nigeria and suggest the presence of a rural HIV epidemic. The identification of HIV-1 group O in Kano shows that this virus strain is geographically widespread in Nigeria.

PIP: To obtain current data on HIV infection in Nigeria by population group, a seroanalysis of 2300 samples from 5 states (Lagos, Cross River, Borno, Kano, and Jugawa) was conducted during March-May 1996. The sample included commercial sex workers, pregnant women, tuberculosis patients, blood donors, patients with sexually transmitted diseases (STDs), patients with skin diseases, male clients of commercial sex workers, outpatients suspected to have AIDS, truck drivers, and community residents. Overall HIV prevalence was 40.7%. With the exception of pregnant women (1.7%), HIV prevalence was high in all subgroups: 60.6% in commercial sex workers, 21.2% in STD patients, 16.2% in tuberculosis patients, and 16.0% in rural areas of Kano state. The majority of HIV-positive women were 21-30 years of age, while HIV-infected men were primarily over 40 years of age. Compared with data from national seroprevalence studies conducted during 1991-92 and 1993-94, this study confirms a substantial recent increase in HIV infection in Nigeria. Of the 330 antibody-positive specimens, HIV-1 was the predominant infection in 315; there were 3 cases of HIV-2 and 12 cases involving dual HIV-1/2 infection. Only 1 serum sample was positive for HIV-1 group O antibodies. The high HIV prevalence detected among commercial sex workers indicates the potential for rapid diffusion of HIV to the general population.