Satisfaction with health services for STIs, HIV, AIDS among a high-risk population in West Africa.

The goal of this study was to develop an instrument and assess the degree of satisfaction regarding HIV/STIs services for women working in, associated with, or living in or nearby, prostitution environments. This study took place in seven West-African countries (Benin, Burkina Faso, Ghana, Mali, Niger, Senegal, Togo) participating in the West Africa Aids Program (AIDS3). A validated six-dimension questionnaire was used to interview 698 women. The main inclusion criterion was having had recourse to adapted services offered through the AIDS3 program in the last six months. Results showed that women surveyed are satisfied overall. Two dimensions scored low: 'Technical skills perceived' and 'Accessibility'. Regression analyses showed that those most satisfied were women who had used the adapted services many times and women connected with community groups. Although these results are consistent with results published previously in other contexts, they now allow the AIDS3 program to consider the voices of women rarely listened to: West-African women living and working in prostitution environments.

Mycoplasma genitalium: an organism commonly associated with cervicitis among west African sex workers.

OBJECTIVES: To identify the contribution of Mycoplasma genitalium to the aetiology of cervicitis in sub-Saharan Africa and its relative importance in the overall burden of sexually transmitted infections among female sex workers (FSW). METHODS: The study population consisted of FSW recruited in Ghana and Benin during the initial visit of a randomised controlled trial. A questionnaire was administered, a pelvic examination carried out, and cervical samples obtained for detection of M genitalium, Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis. Clinical signs potentially indicating cervicitis were cervical discharge, pus on the cervical swab, bleeding after sampling, and inflammatory cervix. RESULTS: Among 826 FSW, 26.3% were infected with M genitalium. N gonorrhoeae was strongly and independently associated with each of the four signs of cervicitis (adjusted odds ratios (AOR): 4.1 to 6.0). The AOR for C trachomatis were intermediate (1.3-4.1) and the AOR for M genitalium were lower (between 1.6 and 1.8) but statistically significant (p< or =0.05) for each sign. CONCLUSIONS: M genitalium is weakly associated with signs of cervicitis in west African FSW but is highly prevalent.

Low prevalence of cervical infections in women with vaginal discharge in west Africa: implications for syndromic management.

OBJECTIVES: To measure prevalence and risk factors for cervical infections among a large sample of women consulting for vaginal discharge in west Africa and to evaluate its syndromic management through a two visit algorithm. METHODS: In 11 health centres in Bénin, Burkina Faso, Ghana, Guinée, and Mali 726 women who presented with a vaginal discharge without abdominal pain and who denied being a sex worker (SW) were enrolled. Cervical samples were tested for the detection of Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) with polymerase chain reaction (PCR) assays. All participants were treated with single dose (2 g) metronidazole and clotrimazole cream for 3 days. They were randomised to be told either to come back on day 7 only if there was no improvement in the discharge (group A), or to come back on day 7 regardless of response to treatment (group B). RESULTS: Overall, the prevalence of NG and CT was only 1.9% (14/726) and 3.2% (23/726) respectively. Risk factors previously recommended by the WHO were not associated with the presence of cervical infection, with the exception of the number of sex partners in the past 3 months. When taken together, these risk factors had a positive predictive value of only 6.4% to identify cervical infections. Prevalence of cervical infection was not higher in women who came back on day 7, regardless of the strategy used. Prevalence of NG/CT was lower in Ghana and Bénin (5/280, 1.8%), where comprehensive interventions for SW have been ongoing for years, than in the three other countries (27/446, 6.1%, p = 0.01). CONCLUSIONS: NG and CT infections are uncommon in west African women who consult for vaginal discharge and who are not SW. Syndromic management of vaginal discharge should focus on the proper management of vaginitis. The control of gonococcal and chlamydial infection should be redesigned around interventions focusing on sex workers.

HIV infection among sex workers in Accra: need to target new recruits entering the trade.

OBJECTIVE: Description of the epidemiology of HIV infection among sex workers (SW) in Accra, Ghana. METHODS: In all, 1013 SW working out of their homes ( seaters ) or finding customers in bars, hotels, brothels or on the street ( roamers ) were interviewed and tested for HIV. RESULTS: Overall, prevalence of HIV infection was nearly 50% (506 of 1013), varying from 26% (133 of 507) among the roamers to 74% (368 of 496) among the seaters. Profound differences were noted between these two categories of SW with regard to age, number of clients per day, price per instance of intercourse, condom use, and other characteristics. Respectively, 27% and 58% of roamers and seaters were infected with HIV within their first 6 months of sex work, despite a limited number of unprotected sex acts with seropositive clients. Independent risk factors for HIV infection varied between types of SW: age among the roamers; region of origin and duration of sex work among the seaters; number of clients per day, and presence of current or past genital ulcer and gonococcal cervicitis in both groups. CONCLUSION: In Accra, considerable heterogeneity exists in the population of SWs. In both categories of SW, new recruits become rapidly infected with HIV after entering the trade. The 25-fold higher prevalence of HIV among SWs than in the general adult population suggests that in Accra, as in many cities of West Africa, a high fraction of new cases of HIV infection continue to be acquired from SWs. Intervention programs targeting SW should be an essential component of national AIDS control strategies. Special efforts should be made to identify and offer preventive services to new sex workers.

Etiology of urethral discharge in West Africa: the role of Mycoplasma genitalium and Trichomonas vaginalis.

OBJECTIVE: To determine the etiological role of pathogens other than Neisseria gonorrhoeae and Chlamydia trachomatis in urethral discharge in West African men. METHODS: Urethral swabs were obtained from 659 male patients presenting with urethral discharge in 72 primary health care facilities in seven West African countries, and in 339 controls presenting for complaints unrelated to the genitourinary tract. Polymerase chain reaction analysis was used to detect the presence of N. gonorrhoeae, C. trachomatis, Trichomonas vaginalis, Mycoplasma genitalium, and Ureaplasma urealyticum. FINDINGS: N. gonorrhoeae, T. vaginalis, C. trachomatis, and M. genitalium--but not U. urealyticum--were found more frequently in men with urethral discharge than in asymptomatic controls, being present in 61.9%, 13.8%, 13.4% and 10.0%, respectively, of cases of urethral discharge. Multiple infections were common. Among patients with gonococcal infection, T. vaginalis was as frequent a coinfection as C. trachomatis. M. genitalium, T. vaginalis, and C. trachomatis caused a similar clinical syndrome to that associated with gonococcal infection, but with a less severe urethral discharge. CONCLUSIONS: M. genitalium and T. vaginalis are important etiological agents of urethral discharge in West Africa. The frequent occurrence of multiple infections with any combination of four pathogens strongly supports the syndromic approach. The optimal use of metronidazole in flowcharts for the syndromic management of urethral discharge needs to be explored in therapeutic trials.

Improvement of clinical algorithms for the diagnosis of Neisseria gonorrhoeae and Chlamydia trachomatis by the use of Gram-stained smears among female sex workers in Accra, Ghana.

BACKGROUND: Screening for cervical infection is difficult in developing countries. Screening strategies must be improved for high-risk women, such as female sex workers. GOAL: To evaluate the sensitivity and specificity of screening algorithms for cervical infection pathogens among female sex workers in Accra, Ghana. STUDY DESIGN: A cross-sectional study among female sex workers was conducted. Each woman underwent an interview and a clinical examination. Biologic samples were obtained for the diagnosis of HIV, syphilis, bacterial vaginosis, yeast infection, Trichomonas vaginalis, Neisseria gonorrhoeae, and Chlamydia trachomatis infection. Signs and symptoms associated with cervicitis agents were identified. Algorithms for the diagnosis of cervical infection were tested by computer simulations. RESULTS: The following prevalences were observed: HIV, 76.6%; N. gonorrhoeae, 33.7%; C. trachomatis, 10.1%; candidiasis, 24.4%; T. vaginalis, 31.4%; bacterial vaginosis, 2.3%; serologic syphilis, 4.6%; and genital ulcers on clinical examination, 10.6%. The best performance of algorithms were reached when using a combination of clinical signs and a search for gram-negative diplococci on cervical smears (sensitivity, 64.4%; specificity, 80.0%). CONCLUSIONS: In the algorithms, examination of Gram-stained genital smears in female sex workers without clinical signs of cervicitis improved sensitivity without altering specificity for the diagnosis of cervical infection.

Short-course eflornithine in Gambian trypanosomiasis: a multicentre randomized controlled trial.

OBJECTIVE: A randomized controlled trial was conducted to determine whether 7 days of intravenous eflornithine (100 mg/kg every 6 h) was as effective as the standard 14-day regimen in the treatment of late-stage Trypanosoma brucei gambiense trypanosomiasis. METHODS: A total of 321 patients (274 new cases, 47 relapsing cases) were randomized at four participating centres in Congo, Côte d'Ivoire, the Democratic Republic of the Congo, and Uganda to one of these treatment regimens and followed up for 2 years. RESULTS: Six patients died during treatment, one of whom was on the 7-day regimen, whereas the other five had been on the 14-day regimen (P = 0.2). The response to eflornithine differed markedly between Uganda and other countries. Among new cases in Uganda, the 2-year probability of cure was 73% on the 14-day course compared with 62% on the 7-day regimen (hazard ratio (HR) for treatment failure, 7-day versus 14-day regimen: 1.45, 95% CI: 0.7, 3.1, P = 0.3). Among new cases in Côte d'Ivoire, Congo, and the Democratic Republic of the Congo combined, the 2-year probability of cure was 97% on the 14-day course compared with 86.5% on the 7-day regimen (HR for treatment failure, 7-day vs 14-day: 6.72, 95% confidence interval (CI): 1.5, 31.0, P = 0.003). Among relapsing cases in all four countries, the 2-year probability of cure was 94% with 7 days and 100% with 14 days of treatment. Factors associated with a higher risk of treatment failure were: a positive lymph node aspirate (HR 4.1; 95% CI: 1.8-9.4), a cerebrospinal fluid (CSF) white cell count > or = 100/mm3 (HR 3.5; 95% CI: 1.1-10.9), being treated in Uganda (HR 2.9; 95% CI: 1.4-5.9), and CSF trypanosomes (HR 1.9; 95% CI: 0.9-4.1). Being stuporous on admission was associated with a lower risk of treatment failure (HR 0.18; 95% CI: 0.02-1.4) as was increasing age (HR 0.977; 95% CI: 0.95-1.0, for each additional year of age). DISCUSSION: The 7-day course of eflornithine is an effective treatment of relapsing cases of Gambian trypanosomiasis. For new cases, a 7-day course is inferior to the standard 14-day regimen and cannot be recommended.

A seven days course of eflornithine for relapsing Trypanosoma brucei gambiense sleeping sickness.

Forty-seven patients with a relapse following a first treatment of Trypanosoma brucei gambiense trypanosomiasis were treated with a 7 d course of intravenous eflornithine (100 mg/kg every 6 h) and followed for 2 years. Four patients died after treatment, 2 of them possibly due to trypanosomiasis. One patient was completely lost to follow-up, 36 were followed for at least one year, and 25 have completed the 2 years' follow-up. Only one patient, a 5 years old child, subsequently relapsed. Considering this child and 2 of the fatalities as treatment failures, the rate of failure was 6.5%. A 7 d course of intravenous eflornithine is an adequate treatment for cases of Gambian trypanosomiasis relapsing after treatment with another drug.

Familial aggregation of Trypanosoma brucei gambiense trypanosomiasis in a very high incidence community in Zaire.

Familial aggregation of Trypanosoma brucei gambiense human African trypanosomiasis (HAT) was investigated in 3 adjacent villages of central Zaire where 318/1431 inhabitants had previously suffered from HAT. Neither spatial nor familial aggregation was detected when analysing the distribution of cases in the whole community using Poisson, negative binomial and pairwise odds ratio models. However, clustering of cases was observed when specific familial relationships were examined. The risk of HAT for a child was significantly increased if the mother had also had HAT, but it was not influenced by a past history of HAT in the father. Sisters and brothers of cases of HAT had a higher risk of HAT than siblings of individuals who had never had HAT, but no such association was documented for half-sisters and half-brothers. Among married couples, a past history of HAT in one spouse had no impact on the other spouse's risk of HAT. Indirect arguments suggested that familial clustering was a consequence of shared exposure, either sequential or simultaneous, rather than of genetic susceptibility. The existence of familial clustering should be kept in mind when implementing passive or active case-finding activities.

In the heart of darkness: sleeping sickness in Zaire.

PIP: Human African trypanosomiasis (HAT) control programs existed during the colonial era in the Belgian Congo. HAT cases peaked in 1930 at 33,562. They declined gradually to about 1000 cases in 1959. The civil war that erupted after Zaire's independence in 1960 crippled the public health system. During 1960-1967, no active case finding was conducted and notification of HAT cases fell greatly. Mismanagement and corruption maintained a severe social and economic crisis after the civil war. At the end of the 1980s, the number of new HAT cases began to increase from the relatively stable numbers of 4000-6000 during 1969-1981 to almost 10,000. Socioeconomic conditions deteriorated quickly in the 1990s. The withdrawal of foreign aid in 1991 devastated many governmental health facilities that had been dependent on these funds. In much of Zaire, Catholic and Protestant missions were the only health care providers. The breakdown of the health system contributed to epidemics of Ebola fever, dysentery, the plague, and cholera. The specialized mobile teams providing trypanocidal drugs to HAT patients could no longer operate, resulting in drug shortages and thousands of deaths. The teams were somewhat remobilized during 1993-1994, when some foreign aid was again available. A return to neglected areas in 1994 found the HAT prevalence to be 15.4/1000 in the Equator region. In Kimbanzi, Bandundu region, it was 718/1000 among 241 persons examined. Had the teams not arrived when they did, the entire village of Kimbanzi could have disappeared within 1-2 years. The high prevalence rates in neglected areas were the highest rates recorded this century. The neglect brought about an increase in the number of infectious people, an increase in transmission, and a higher cost and toxicity of treatment due to an increase in late-stage HAT cases. The estimated true total incidence of HAT in Zaire in 1994 was about 34,400 new cases. The number of HAT deaths in 1994 was probably at least 80 times higher than that of Ebola deaths in 1995. Proper HAT control methods need to be fully funded and implemented to control this curable disease.^ieng

Relapses following treatment of early-stage Trypanosoma brucei gambiense sleeping sickness with a combination of pentamidine and suramin.

616 patients with early Trypanosoma brucei gambiense trypanosomiasis (no trypanosomes in the cerebrospinal fluid [CSF] and a CSF white cell count [WCC] of 1-5/mm3) were treated with a combination of pentamidine (6 intramuscular [i.m.] injections of 4 mg/kg) and suramin (2 intravenous [i.v.] injections of 20 mg/kg) in Nioki hospital, Zaire, between 1983 and 1992; 46 (7.5%) of them subsequently relapsed. There was no increase in the frequency of treatment failure during this 10 years' period. Relapses were more frequent in children aged 0-17 years (19/163 [11.7%]) than in adults (26/420 [6.2%] (relative risk [RR] = 1.88, 95% confidence interval [CI] 1.07-3.31, P = 0.04). Even within this small range of CSF WCC, the risk of treatment failure increased in parallel with the WCC count and reached 10/36 (27.8%) in patients with a CSF WCC of 5/mm3. Treatment failures were more frequent (5/30 [16.7%]) in a small group of patients treated with a combination of diminazene (3 i.m. injections of 7 mg/kg) and suramin (one i.v. injection of 20 mg/kg) than in the pentamidine/suramin group (RR = 2.23, 95% CI 0.96-5.21, P = 0.08). Our data support the view that central nervous system involvement occurs early in Gambian trypanosomiasis, which in turn raises doubts about the usefulness of adding suramin to pentamidine, as the former drug, which is more expensive than pentamidine and has to be administered intravenously, penetrates poorly into the CSF and may potentially decrease free pentamidine levels in blood and CSF.

Epidemiological evidence for immunity following Trypanosoma brucei gambiense sleeping sickness.

In order to investigate whether protective immunity appears after Trypanosoma brucei gambiense sleeping sickness, we undertook a retrospective cohort study of 3 remote villages in central Zaire (total population 1431), in which 38% of all adults had a past history of human African trypanosomiasis. Among adults previously diagnosed with trypanosomiasis and treated, the risk of a second episode of trypanosomiasis during the 10 years period of observation was only 15% (with a 24 months refractory period) and 30% (without a refractory period) of the risk of a first episode in adults never previously diagnosed. We could not demonstrate a similar difference among children, to some extent because only a few of them were diagnosed for a first time with trypanosomiasis. Our findings suggest that very significant immunity appears after Gambian sleeping sickness, and that developing a vaccine against this subspecies of trypanosomes is biologically plausible.

Natural history of human immunodeficiency virus infection in Zaire.

The natural history of human immunodeficiency virus (HIV) infection in Zaïre was determined by identifying in October, 1984, 125 seropositive hospital personnel without signs or symptoms and 145 age and sex matched seronegative controls from the same population. Between July, 1985, and February, 1986, 67 seropositives, including 38 men and 29 women, and 113 seronegatives were interviewed and examined by an observer who did not know their serological status. The acquired immunodeficiency syndrome (AIDS) had developed in 1 seropositive and no seronegatives (rate difference, 1.3/100 person-years [py]; 95% confidence interval 0-3.3/100 py); AIDS-related complex or generalised lymphadenopathy had developed in 8 seropositives (12%) and 1 seronegative (1%) (rate ratio, 13.2; 95% confidence interval 1.3-134.6); and minimal lymphadenopathy had developed in 19 seropositives (28%) and 8 seronegatives (7%) (rate ratio, 3.9; 95% confidence interval 1.8-8.4). These data provide the first estimates for rates of progression to AIDS or AIDS-related conditions among healthy HIV seropositive heterosexual adults. Rates observed in this study are similar to those reported in US or European homosexual or bisexual men.