Approaches to control sexually transmitted diseases in Haiti, 1992-95.

Despite major obstacles, activities to control sexually transmitted diseases (STDs) were initiated in Haiti in 1992 in collaboration with local nongovernmental organizations. The approaches included review of available local data, assessment of STD case management practices and constraints, and development of specific STD control activities at the primary health care level, such as systematic screening of all pregnant women for syphilis and improved comprehensive syndrome-based STD case management. The activities included conduct of local studies, presentation and dissemination of results to key audiences, training of health care providers, improvement of local capacities, and consensus-building on implementation of STD control approaches. STD awareness and case management improved considerably; for example, 69% of the clinicians interviewed reported correct STD treatments in the north-eastern primary health care centres in 1995, compared with < 10% in 1992. At the end of the project, national STD case management guidelines were developed by consensus between the various organizations and the Ministry of Health. Lessons learned included the importance of local data generation and of communication and collaboration with various institutions for consensus-building, the need for continued training, and field supervision to ensure behaviour change among STD care providers. A national STD control programme should be implemented as soon as possible in both the public and private sector. External funding will remain critical to control this important public health problem in Haiti.

PIP: Mid-1992 was a time of considerable political and socioeconomic instability in Haiti. Haiti's first democratically elected president had been ousted by a military junta and both political crimes and human rights abuses abounded. No national sexually transmitted disease (STD) control program was in place and almost no data were available on the magnitude and scope of STDs in the country. In this context, and despite many obstacles, STD control activities were planned with the hope of eventually developing a national STD control program. US Agency for International Development-funded AIDSCAP HIV/AIDS/STD prevention initiatives were first launched in Haiti in mid-1992 in collaboration with local nongovernmental organizations (NGOs). Direct collaboration with the de facto government was not allowed until democracy was restored in October 1994. The authors describe the STD control approaches and interventions initiated under these circumstances, with lessons learned for potential application outside of Haiti. Approaches included a review of available local data, an assessment of STD case management practices and constraints, and the development of specific STD control activities at the primary health care level, such as the systematic screening of all pregnant women for syphilis and improved comprehensive syndrome-based STD case management. Local studies were conducted, with the salient results presented to key audiences; health care providers were trained; local capacities improved; and consensus built upon the implementation of STD control approaches. STD awareness and case management improved considerably, with national STD case management guidelines developed at the end of the project through consensus between various organizations and the Ministry of Health.

Prevalence of HIV infection and high-risk activities in Haiti.

The prevalence of antibodies to human immunodeficiency virus (HIV) was determined in the relatives, friends, and sex partners of AIDS patients in Haiti and in other unrelated Haitian population groups. Among contacts of AIDS patients, HIV seroprevalence was highest among sex partners of the opposite sex (55%) and lowest among female relatives and friends (9%) of female AIDS patients. Male relatives and friends of male AIDS patients had a seroprevalence rate of 19% and also had a history of multiple heterosexual partners and frequent contact with prostitutes. The HIV seroprevalence rate among unrelated groups of Haitian adults ranged from 2% in rural healthy adults to 22% among tuberculosis patients to a high of 49% among Haitian prostitutes. This seroprevalence pattern suggests that HIV infection is widespread in Haiti and that heterosexual activity plays a major role in transmission.

Pruritic skin lesions. A common initial presentation of acquired immunodeficiency syndrome.

During July 1983 to December 1984, we observed that 62 (46%) of 134 Haitian patients with acquired immunodeficiency syndrome had intensely pruritic eruptions for which neither specific causative nor categoric diagnoses could be established. These lesions were a presenting manifestation of acquired immunodeficiency syndrome in 79% of the patients and appeared a mean of 8 months before the diagnosis of either Kaposi's sarcoma or opportunistic infection. Lesions included erythematous round macules, papules, or nodules that first appeared on the extensor surface of the arms, but subsequently involved the legs, trunk, and face. Histologically, the lesions were characterized by varying degrees of mixed (predominantly eosinophilic) perivascular and perifollicular inflammatory cell infiltrates of the dermis. The lesions did not respond to any therapeutic regimens used and usually persisted throughout the acquired immunodeficiency syndrome illness. Demographic and laboratory data did not distinguish these patients from those without pruritic skin lesions.

[Problems posed by HIV infection in women in tropical zones]. / Les problèmes posés par l'infection à virus HIV chez les femmes en zone tropicale.

Retroviruses (mainly H.I.V. 1 and H.I.V. 2) are now largely spread over in Central Africa and Caribbean Islands, particularly in large cities. Their transmission is essentially horizontal and mainly sexual. As a matter of fact, sexual transmission is responsible in about 80% of the cases, leaving only a small percentage to transmission by needle (or by any aggressive material), blood or blood by-products. As far as sexual transmission is concerned, it is essentially heterosexual, in spite of the primary epidemic outbreak in the occidental world that focused interest toward male homosexual group, the first exposed to A.I.D.S. Nowadays we know that heterosexual transmission is important and bi-directionnal, even if transmission female to male has seemed to be more difficult to enlight, as it is common in sexually transmitted diseases. Transmission risk to an heterosexual partner is between 20 and 70%. Virus is present in semen, and in cervico-vaginalis secretions during all menstruation cycle. Vertical transmission, mother to child, through placenta or during delivery is frequent, and is of about 50%. First data on heterosexual transmission have been found in Central Africa, indicating high rates for prostitutes, their "customers", unmarried women with numerous partners, women with an other S.T.D. A.I.D.S. in child has been first described in Haïti and in Zaïre. The very important role played by heterosexual transmission imposed sanitary education and usage of contraceptives which are efficient but difficult to firmly recommended for social and cultural considerations.

PIP: The retrovirus responsible for AIDS began circulating in Africa during the 1970s. Seroepidemiologic studies in Zaire and elsewhere in Central Africa show infection rates of 6-10%, with urban rates even higher and most rural rates close to zero. The modes of transmission are analogous to those of hepatitis B. Homosexual transmission has probably played a small role in Africa. Most epidemiological studies in Central Africa show that almost all seropositive persons are young sexually active adults, with the most affected age groups 20-30 for women and 30-40 for men. The risk of male to female sexual transmission appears to be about 20%, but increases with prolonged relationships. Sperm is able to induce a chronic immunological stimulation and immune perturbations favoring clinical expression of the infection, especially if the sperm comes in contact with the partner's blood because of erosion of the vaginal or anal mucus. Infection of men by women is harder to demonstrate but it cannot yet be confirmed that there are significant differences related to sex. The virus is present in cervicovaginal secretions during the entire menstrual cycle. Seroprevalence rates among prostitutes in Central Africa have increased steadily and are correlated to the time spent as a prostitute and the annual number of clients. Sexually transmitted diseases that disturb the genital mucus appear to favor infection during heterosexual intercourse. In Zaire, 61% of women and 36% of men with AIDS are unmarried. For both sexes, numerous partners appear to increase the risk of infection. Frequent use of prostitutes increases the risk for men. Transmission from mothers to infants can occur during delivery or transplacentally during any trimester of pregnancy. The risk of transmission from an infected mother appears to be about 50%. HIV infection does not appear to have any specific clinical manifestation in the female genital tract. Some studies suggest that the likelihood of 1st trimester spontaneous abortion or of postnatal mortality is increased in infants of seropositive mothers. The clinical characteristics of AIDS in children are not specific and a positive serological test in necessary to confirm the diagnosis. Prevention of HIV infection in the foreseeable future will require health education and the use of condoms, which gained little acceptance in most of Africa.

Risk factors associated with AIDS in Haiti.

A total of 121 acquired immunodeficiency syndrome (AIDS) patients diagnosed in Haiti were studied between June 1979 and December 1983. Risk factors were identified in 65% of 34 patients evaluated in a standardized manner since July 1983 and included: bisexuality, 38%; blood transfusion, 21%; and intravenous drug abuse or a spouse with AIDS, 6%. These risk factors were reported by only 20% of the 85 patients studied between June 1979 and June 1983. AIDS patients also reported more frequent parenteral injections prior to the onset of their illness than control subjects (e.g., siblings, friends, sexual partners). Heterosexual activity among female AIDS patients was also greater than in their female controls. It was concluded that, in contrast to the experience reported among Haitians with AIDS in the USA, risk factors are present among most patients with AIDS in Haiti.

The acquired immunodeficiency syndrome in Haiti.

Two hundred twenty-nine patients in Haiti with the acquired immunodeficiency syndrome were studied between 1979 and 1984. The clinical spectrum of the syndrome in Haitians was similar in most aspects to that in patients with the disease in the United States. However, in contrast to findings in the United States, accepted risk factors (bisexuality, blood transfusions, intravenous drug abuse) were identified in only 43% of Haitian patients. Patients in Haiti with and without these risk factors were similar to each other but differed from age- and sex-matched siblings and friends in the number of heterosexual contacts and receipt of intramuscular injections. These latter activities were commoner in patients than in their siblings and friends, and represent potential modes of transmission of infection with the human T-lymphotropic virus type III.

[Dermatophytic disease. Recent Algerian observations]. / La maladie dermatophytique. Observations algériennes récentes.

We have reported 5 cases of dermatophytic disease observed in Algiers. We insist on three characteristics of the disease: 1. - the familial predisposition; 2. - the deficiency of the cell-mediated immunity while humoral immunity remains apparently intact with high levels of IgE; 3. - the seriousness of the disease: one of our patients has a cerebral abscess, while another died despite the grisefulin therapy.

Characteristics of the acquired immunodeficiency syndrome (AIDS) in Haiti.

To identify the characteristics of the acquired immunodeficiency syndrome (AIDS) as it occurs in Haiti, we studied 61 previously healthy Haitians who had diagnoses of either Kaposi's sarcoma (15), opportunistic infections (45), or both (1) established in Haiti between June 1979 and October 1982. The first cases of Kaposi's sarcoma and opportunistic infections in Haiti were recognized in 1978-1979, a period that coincides with the earliest reports of AIDS in the United States. We do not believe that AIDS existed in Haiti before this period. The types of opportunistic infections and the clinical course in Haitians with Kaposi's sarcoma and opportunistic infections were similar in most aspects to those in patients with AIDS in the United States. The median age of Haitians with Kaposi's sarcoma and opportunistic infections was 32 years, and 85 per cent were men. The interval between diagnosis and death was six months in 80 per cent of the patients. Diarrhea was the most common reason for seeking medical attention in patients with opportunistic infections. Lymphopenia and skin-test anergy were observed in 86 and 100 per cent of patients, respectively. Potential risk factors (bisexual activity or blood transfusions) were identified in 17 per cent of male and 22 per cent of female patients. Demographic information suggests that patients belonged to all socioeconomic strata of Haitian society.

[Kaposi's sarcoma in Haiti: unknown reservoir or a recent appearance?]. / Le sarcome de Kaposi en Haiti: foyer méconnu ou récemment apparu?

For a 29 months period, from June 1979 to November 1981. 11 cases of Kaposi Sarcoma (3 women and 8 men) have been diagnosed in Port-au-Prince. Two more cases (men) were seen in haitian refugees in Miami (C. D. C. report). Only one case of K. S. had been diagnosed in Haïti previously in 1972. The mean age was 37. Involvement of lymph nodes and viscera were frequent and the patients died within 24 months (the mean survival time after diagnosis was 5 months). This apparent outbreak probably has no relation with that one in U. S. homosexuals which appeared simultaneously. Drugs and homosexuality have no importance in haitian cases. K. S. in U. S. homosexuals and in heterosexual haitians has a bad prognosis as in Africans: they all differ from the classical european and north american forms by the age of onset, the frequent visceral involvement and the early death. The review of histological data and different etiological factors lead to think that it is the same disease everywhere in spite of those marked differences.

Depressed cell-mediated immunity in chronic dermatophytic infections.

The immune response was studied in 10 patients with benign dermatophytosis and in 5 patients with a severe affection. At the humoral level no deficiencies were observed in both groups. However, all patients showed a marked and constant increase in IgE level. Skin test response in various concentrations of antigens as well as studies of activation of lymphocytes by specific and non-specific mitogens in vitro have demonstrated a depressed cell-mediated immunity. This anergy, however, is not an "all-or-one" phenomenon; it varies, and there seems to be a direct relationship between the state of anergy and the severity of the cases. Furthermore, certain discrepancies were observed between the in vivo and in vitro responses suggesting that defective cellular immune reactions in dermatophytosis may be symptomatic of a lack of some humoral factor and do not necessarily reflect an intrinsic cellular defect. Finally, among these 15 patients, 7 were brothers and sisters from 3 separate and unrelated families, suggesting an autosomal hereditary influence.

[Hendersonula toruloidea, causative agent of a fungal verrucous dermatitis observed in Algeria]. / Hendersonula toruloidea, agent d'une dermatite verruqueuse mycosique observée en Algérie.

A verrucose dermatitis of the face, accompanied by onychomycosis was observed in a 30 years old male living in Algeria. He was born there and 15 years previously he had been treated successfully for "Dermatophytic disease" due to Trichophyton verrucosum. A deficiency in his cellular immune mechanism was noted at that time. On this occasion Hendersonula toruloidea was isolated from facial lesions and affected nails. The infection of the face, but not the nails, responded to treatment with amphotericin B. In the facial lesions, the fungus was present as single cell units sometimes with a false bud or a short hyphal extension. Cross walls were occasionally present but the cell walls were not pigmented. Intratesticular inoculation of the isolates to guinea pigs resulted in an infection in which the morphology of the fungus conformed to that found in the facial lesions. In cultures, the isolates of H. toruloidea conformed to the descriptions in literature, although pycnidia were not formed.

Depressed cell-mediated immunity in chronic dermatophytic infections.

The immune response was studied in ten patients with benign dermatophytosis, and in five patients with a severe affection. At the humoral level no deficiencies were observed in both groups. However, all patients showed a marked and constant increase in IgE level. Skin test response in various concentrations of antigens as well as studies of activation of lymphocytes by specific and non-specific mitogens in vitro have demonstrated a depressed cell-mediated immunity. This anergy, however, is not an "all-or-none" phenomenon; it varies and there seems to be a direct relationship between the state of anergy and the severity of the cases. Furthermore, certain discrepancies were observed between the in vivo and in vitro responses suggesting that defective cellular immune reactions in dermatophytosis may be symptomatic of a lack of some humoral factor and do not necessarily reflect an intrinsic cellular defect. Finally, among these 15 patients, 7 were brothers and sisters from 3 separate and unrelated families, suggesting an autosomal hereditary influence.

[Blastomyces dermatitidis blastomycosis in Africa. First Algerian case]. / La blastomycose à Blastomyces dermatitidis en Afrique. A propos du premier cas Algérien

A case of fatal generalized Blastomycosis is reported. It was the first case of that mycosis observed in Algeria. The parasitic yeast-like cells of the fungus were seen in pus and tissue sections and Blastomyces dermatitidis cultured from pathological specimens. Yeast-like form was obtained in vitro on Kurung's agar at 37 degrees C. Male hamsters infected with this strain failed to develop an experimental disease. The occurrence and distribution of Blastomycosis in Africa are discussed.

[Histopathological study on the course of a dermatophytic disease]. / Etude histo-pathologique du déroulement d'une maladie dermatophytique

Histological study of cutaneous biopsies of an algerian girl with a "dermatophytic disease" (cf. supra Marill and al.). During the six first years of evolution diagnosis of mycosis had not been made for no specific fungus staining was done, but the fungus was present in the tissues. Vesicular forms and few filaments were seen in the first biopsies but polymorphism increased with the time and filaments became predominant and very abundant at the end of the disease.