Comparison of HIV-positive women with children and without children accessing HIV care and treatment in the IeDEA Central Africa cohort.

Globally, women comprise half of all people living with HIV, but in sub-Saharan Africa, women are disproportionately affected. Data were obtained from 8419 HIV-infected women at enrollment into 10 HIV treatment programs in Cameroon, Burundi, and the Democratic Republic of the Congo as part of the Central Africa region of the International Epidemiological Database to Evaluate AIDS. We used chi-squared tests to determine if distributions between women with children differed from those without children, in regards to socio-demographic, behavioral and clinical characteristics. Logistic regression was used to determine if motherhood was associated with medication adherence. Of 8419 women, 81.7% had living children. The majority entered care through voluntary testing, and very few entered care through prevention of mother-to-child transmission programs. Women with children were older and more likely to be widowed, more likely to have no formal education and less likely to have attended university than those without children (p<0.05). Women without children were more likely to live in a home with electricity and potable water (p<0.05). There was no difference in adherence between these groups. However, women older than 50 years, those who reported no drug, tobacco, or alcohol use, and those with higher levels of formal education were more likely to report adherence along with those who had been on treatment for more than two years (p<0.05). As women account for a substantial proportion of HIV cases in sub-Saharan Africa, a broader understanding of their characteristics will inform testing, treatment, and support services. Though we did not find differences in adherence between women with children and those without children, we were able to identify other characteristics that may affect adherence. Further inquiry into the nuances of women living with HIV in sub-Saharan Africa is necessary to further understand their needs.

[HIV, only the tip of the iceberg in Burundi]. / Le Burundi au-delà du VIH.

In Burundi, like in many other resource-limited settings, HIV sector is mainly financed by international funding (IF). Through this way, HIV-infected people may have access to care, antiretroviral therapy and opportunistic infections medications free of charge. In addition, IF can also contribute to major the HIV-health care professionals (HCP) salary. Indeed, because of dramatically low incomes, public sector HCP move frequently through the country or migrate towards foreign countries, attracted by higher salaries and better working environment. To date, relatively large funding became available in some settings for HIV-care. Through illustrative examples from the field in Burundi, we are discussing why consequences are, in many cases, a worsening of inequities and disorganization of the public health sector, instead of leading this latter one towards a global improvement. Furthermore, we are suggesting that HIV-programs per se are not sufficient to provide a proper management of the epidemic at a global scale.

Malnutrition and wasting, immunodepression, and chronic inflammation as independent predictors of survival in HIV-infected patients.

To analyze the long-term survival factors associated with HIV infection, a prospective follow-up study of 165 HIV-infected patients was performed after a clinical, nutritional, and biological evaluation. Survival rate could be determined in 129 patients after a follow-up of 42 mo before the use of protease inhibitors. After univariate analysis, multivariate analysis was performed with the Cox regression proportional-hazard model. Survival curves were calculated and compared with the Kaplan, Meier, and log-rank tests. The study also analyzed the factors associated with impaired nutritional status at the beginning of the study and their effects on the long-term follow-up. Factors that could explain body weight loss before the study were the level of intakes, resting energy expenditure, chronic diarrhea, and the number of previous opportunistic infections. In the long-term follow-up, univariate analysis showed that nutritional status could be separated into four classes of body weight loss (BWL) by degree of loss (BWL < or = 5%, 5% < BWL < or = 10%, 10% < BWL < or = 20%, BWL > 20%); lean body mass (adjusted to height), body cell mass, CD4 count, albumin, prealbumin, and C-reactive protein (CRP) were all significant predictors. Age, stage of disease, number of previous opportunistic infections, and antiviral therapies were not associated with a change in survival. With the multivariate model, only CD4 counts, lean body mass/height squared, and CRP remained significant independent predictors of survival after controlling for other factors.

Comparison of methods for assessing nutritional status in HIV-infected adults.

Malnutrition is a frequent complication of human immunodeficiency virus (HIV) infection and is associated with a poor prognosis. To compare different measures of nutritional status in HIV-infected patients, we prospectively studied 88 outpatients seen at a Paris AIDS outpatient clinic for routine follow-up examinations. Nutritional status was assessed according to body weight loss (BWL, 4 classes), anthropometry, bioelectric impedance analysis (BIA), and subjective global assessment of nutritional status (SGA). Malnutrition was diagnosed in 22.4% of subjects using SGA, and 37.1% by BWL. SGA rapidly detected a worsening of nutritional status, while BWL detected malnutrition at an earlier stage. A good correlation was found between SGA class and body composition assessed by anthropometry and BIA. Deteriorating nutritional status diagnosed by SGA correlated with the CDC HIV disease class. SGA, a simple nutritional assessment, can serve as a basis for prescribing artificial nutrition, while BWL detects malnutrition at an earlier stage.

Nutritional status of adult inpatients in Bujumbura, Burundi (impact of HIV infection).

OBJECTIVE: To determine the prevalence and analyse the characteristics and causes of malnutrition among inpatients in an HIV highly endemic area. DESIGN: Prospective cross-sectional study. SETTING: Department of Internal Medicine, University Hospital, Bujumbura, Burundi. SUBJECTS: 226 adult inpatients. MAIN OUTCOMES MEASURES: Evaluation of nutritional status using anthropometry. Degree of malnutrition defined by the percentage of body weight loss (BWL), calculated by reference to the usual body weight. RESULTS: Among the 226 patients recruited (mean age: 34.4 +/- 11.9 y, M:F sex ratio: 1.72), 102 (45.1%) were HIV seropositive. 62 (60.8%) of these HIV seropositive were AIDS cases. The AIDS defining criterion was 'wasting syndrome' for 25 (40.3%) and opportunistic infection (OI) for 37 (59.7%) including 34 cases of tuberculosis (TB). The nutritional status of 119/226 patients (52.7%) was normal (BWL < or = 10%). Moderate malnutrition (10% < or = BWL < or = 20%) was observed in 47 (20.8%) and severe malnutrition (BWL > 20%) was observed in 60 (26.5%). HIV seroprevalence and, among HIV seropositive subjects, the percentage of AIDS cases increased according to decreasing level of nutrition (Chi2 for trends: P < 0.001 in both instances). The fat free mass mass of malnourished subjects was lower and the fat body mass was higher among HIV seropositive subjects than HIV seronegative subjects. Among HIV seropositive subjects, malnutrition was associated with TB (P < 0.001) and dysphagia (P < 0.05). Among HIV seronegative subjects, malnutrition was associated with decreased food availability (P < 0.003) and TB (P < 0.05). One week after admission, the mortality rate was higher among HIV seropositive subjects (10.8%) than seronegative subjects (2.4%, P=0.009). Other factors associated with death were decreased fat free mass (P < 0.01) and tricipital skinfold thickness (P < 0.04). CONCLUSIONS: The prevalence of malnutrition is high among the inpatients investigated. Main factors are HIV infection and TB. Strategies adapted to the African context should be developed to prevent, detect and treat malnutrition and associated factors, particularly among HIV seropositive subjects.

AIDS related eye disease in Burundi, Africa.

AIMS: To determine the prevalence of ocular manifestations in AIDS patients hospitalised in Bujumbura, Burundi, according to their CD4+ lymphocyte count, serological status for CMV and VZV, and general health status. METHODS: Prospective study of 154 consecutive patients who underwent general and ophthalmological examinations, including dilated fundus examination. AIDS was diagnosed on the basis of Bangui criteria and HIV-1 seropositivity. CD4+ lymphocyte counts were determined by the Capcellia method. CMV and VZV antibodies were detected with ELISA methods. RESULTS: The mean age was 37 (SD 9) years and 65% of the patients were male. Active tuberculosis was the most frequent underlying disease (61%). Almost all the patients (99%) were seropositive for CMV and VZV. Among the 115 patients for whom CD4+ lymphocyte counts were available, 86 (75%) had more than 100 cells x 10(6)/l. Ocular involvement comprised 16 cases of microangiopathy, six of opalescence of the anterior chamber, five of retinal perivasculitis, two of zoster ophthalmicus, two of viral retinitis, and one of opalescence of the vitreous. CONCLUSION: In Africa, the prevalence of ocular involvement in HIV infection is far lower than in Europe and the United States, possibly because most African patients die before ocular opportunistic infections occur.

Tuberculosis, human immunodeficiency virus infection, and malnutrition in Burundi.

In order to compare the nutritional status of tuberculosis (TB) patients who were human immunodeficiency virus (HIV)-seropositive with those who were seronegative, we carried out a cross-sectional anthropometric and biochemical assessment, together with bioelectrical impedance analysis (BIA) of the nutritional status of TB patients hospitalized in the Department of Internal Medicine, Bujumbura University Hospital, Burundi, East Africa. Of the 65 TB patients (33 pulmonary, 6 extrapulmonary, and 26 disseminated TB), 50 (76.9%) were HIV-seropositive (HIV+). When assessed according to anthropometric, BIA, and biochemical variables, HIV+ TB patients had more pronounced malnutrition than HIV- patients. Similar results were obtained when the comparison was restricted to patients with only pulmonary TB: HIV+ patients were more malnourished than HIV- patients. The results according to anthropometric measurements were: weight loss (13.5% of HIV- patients versus 26.4% of HIV+ patients, P = 0.005), body mass index (18.6 versus 15.1, P = 0.003), fat free mass (FFM) (13.9 versus 11.9, P < 0.01), and body fat (BF) (4.55 versus 3.71, P = 0.03) expressed per unit height2. BIA showed that the difference in FFM between HIV- and HIV+ TB pulmonary patients was mostly due to a decrease in body cellular mass. Measurements of albumin, prealbumin, and transferrin showed a marked decrease in all three markers in HIV+ TB pulmonary patients. The nutritional status of HIV+ patients with disseminated versus pulmonary TB was similar. The nutritional status of HIV+ TB patients is far worse than that of HIV- TB patients. In such patients, anthropometry underestimates the degree of malnutrition because it does not account for the water component of FFM. Nutritional status should be assessed and nutritional intervention should be provided in an attempt to improve the prognosis of TB patients, especially those who are infected by HIV.

Nutritional status of HIV-seropositive subjects in an AIDS clinic in Paris.

OBJECTIVE: To measure the prevalence and analyse the characteristics of malnutrition among subjects attending an AIDS outpatient clinic and a day care center, to improve the nutritional management of HIV-infected subjects. DESIGN: Prospective cross-sectional study. SETTING: AIDS clinic in a University Hospital in Paris. SUBJECTS: 124 HIV-seropositive adults attending the clinic. MAIN OUTCOME MEASURES: Evaluation of nutritional status using anthropometry, impedancemetry, plasma albumin and pre-albumin assays. Degree of malnutrition, defined by the percentage of body weight loss (BWL), calculated by reference to the usual body weight. RESULTS: Among the 124 subjects recruited (M:F sex ratio: 3.3, mean age: 36.3 +/- 7.2 y), 77 (62.1%, 95%CI: 53.9-70.3) had normal nutrition status (BWL < or = 5%), 16 (12.9%, 95%CI: 7.0-18.2) moderate malnutrition (5% < BWL < or = 10%), 21 (16.9% 95%CI: 10.3-23.5) intermediate malnutrition (10% < BWL < or = 20%), and 10 (8.1%, 95%CI: 3.3-12.9) severe malnutrition (BWL > 20%). BWL was related to the CDC class (variance analysis, P < 9 x 10(-5)) and CD4 cell count (P < 3 x 10(-5)). Malnutrition was observed even among CDC class A subjects (14.9%). BWL was also related to the body mass index (P < 3 x 10(-6)), lean body mass (P < 3 x 10(-5)), body fat (P < 7 x 10(-6)), and as assessed by impedancemetry, body cell mass (P < 10(-5)) an the extra/intra cellular water ratio (P < 2 x 10(-4)). The decrease in lean body mass was related to the decrease in body cell mass. CONCLUSIONS: Given its high frequency, malnutrition should be prevented, detected, monitored and treated from the early stages of HIV infection among patients attending AIDS clinics in order to improve survival and quality of life.

Seroprevalence of hepatitis E virus in an adult urban population from Burundi.

The prevalence of antibodies to the hepatitis E virus (HEV) was measured in a group of 129 adults from Bujumbura, Burundi, using an ELISA. The prevalence of anti-HEV IgG was 14%, much lower than that of hepatitis A virus (HAV) (97.7%). In addition to the lability of antibodies to HEV, this difference might be explained by the extensive availability of good-quality drinking water in the city. The presence of serologic markers of HBV (77.6%), HCV (27.1%), and human immunodeficiency virus (30.2%) was not associated with that of anti-HEV.

PIP: The seroprevalence of hepatitis E virus (HEV) was measured through use of data from a 1992-93 case-control study of patients with chronic liver diseases conducted at Kamenge University Hospital in Bujumbura, Burundi. 97.7% of subjects were anti-hepatitis A virus (HAV)-positive. In contrast, the seroprevalence of anti-HEV IgG was only 14%. Hepatitis B virus (HBV) markers were as follows: HBV surface antigen, 4.7%; antibody to HBV surface antigen, 55.8%; and antibody to HBV core antigen, 65.1%. The prevalence for all 3 HBV markers combined was 77.6%. No seropositivity was found for anti-hepatitis D virus among subjects positive for HBV surface antigen (4.7%) or for antibody to HBV core antigen (17.1%). 27.1% were anti-hepatitis C virus-positive. The prevalence of HIV was 30.2%. The presence of serologic markers of hepatitis A, B, and C virus was not associated with that of antibody to hepatitis E or HIV. Previous studies have found high rates of HEV in areas that have experienced high rainfall and flooding. The relatively low rate of HEV recorded in this study may reflect the fact that most Bujumbura residents use drinking water pumped from the middle of Lake Tanganyika and piped to taps near homes.

Methods for diagnosing tuberculosis among in-patients in eastern Africa whose sputum smears are negative.

SETTING: Two University hospitals in Eastern African capital cities where large prospective studies had been carried out on hospitalized patients to determine the cause of their respiratory diseases. OBJECTIVE: To identify features that differentiated between tuberculosis (TB) and non-tuberculous respiratory disease (non-TB) in hospitalized patients from Bujumbura, Burundi (n = 111) and Dar es Salaam, Tanzania (n = 71) whose sputum smears were negative on microscopic examination for acid-fast bacilli (AFB). DESIGN: Review of clinical findings, radiologic abnormalities, and laboratory test results from 182 patients, first by univariate and then by multivariate (stepwise logistic regression) analysis to assess the contribution of each factor to the final diagnosis. RESULTS: Of the 182 patients with two or more negative AFB smears, 41 had TB and 141 had non-TB. Stepwise regression analysis revealed four easily ascertained symptoms were associated with TB: 1) cough > 21 days; 2) chest pain > 15 days; 3) absence of expectoration; and 4) absence of shortness of breath. Any two of the four diagnosed TB with 85% sensitivity and 67% specificity; any three of the four with 49% sensitivity and 86% specificity. Multivariate analysis showed that adding lymphadenopathy and hematocrit < 30% improved discrimination. CONCLUSION: This methodological approach provides a means for diagnosing TB among all AFB smear-negative hospitalized patients. In this setting, simple clinical symptoms alone are helpful. Similar studies are needed to develop a system for out-patient TB suspects.

[Markers of hepatitis C and E virus in Burundi (central Africa)]. / Contribution à l'étude des marqueurs des hépatites à virus C et E au Burundi (Afrique centrale).

The prevalence of antibodies to the hepatitis C virus (HCV) and hepatitis E virus (HEV) was measured in a group of 129 adults (mean +/- SD age 44.7 +/- 13.5 years) from Bujumbura, Burundi, Central Africa. Sera were tested using a second generation ELISA and LIA for antibodies to HCV (antiHCV), and ELISA for antibodies to HEV (antiHEV). The prevalence of antiHCV was 27.1%, very high, in agreement which data from other countries of Central Africa, hyperendemic area for HVC. The prevalence of antiHEV was 4%, much lower than that of antiHAV (97.7%). In addition to the lability of antibodies to HEV, this difference might be explained by the extensive availability of good-quality of drinking-water in the city. The presence of serological markers of HBV and HIV was not associated with that of antiHCV or that of antiHEV.

[Extra-pulmonary tuberculosis and dissemination in patients infected by the human immunodeficiency virus in Bujumbura (Burundi)]. / La tuberculose extra-pulmonaire et disséminée chez les patients infectés par le virus de l'immunodéficience humaine à Bujumbura (Burundi).

Scattered and extra pulmonary tuberculosis patients coinfected with HIV represent in Bujumbura (Burundi) more than 56% of tuberculosis cases. The high prevalence of these forms could be explained partly by the hospital recruitment, therefore by patients already strongly immunocompromised. Performing further examinations as abdominal echography, ganglionic biopsy (or firstly a puncture sucking procedure) permit to reveal multifocal affections. These examinations provide valuable diagnostic arguments specially among the negative bacteriological forms.

Soluble intercellular adhesion molecule-1 and E-selectin levels in plasma of falciparum malaria patients and their lack of correlation with levels of tumor necrosis factor alpha, interleukin 1 alpha (IL-1 alpha), and IL-10.

Intercellular adhesion molecule-1 and E-selectin levels were increased in the plasma of 60 falciparum malaria patients and were not related to levels of tumor necrosis factor alpha, interleukin 10, or interleukin 1 alpha. Soluble E-selectin was correlated to disease; its level in plasma was related to levels of both tumor necrosis factor soluble receptors and biological markers of disease severity and returned to baseline after parasite clearance faster than that of soluble intercellular adhesion molecule-1.

Plasma levels of TNF-alpha soluble receptors correlate with outcome in human falciparum malaria.

Plasma from immune (residents of malaria infested areas) and non immune (European travellers) patients suffering from cerebral malaria, severe or mild, was analyzed for the presence of soluble tumor necrosis factor receptors. On admission of the subjects, sTNF-R55 and sTNF-R75 levels were significantly elevated in all groups and correlated with TNF-alpha. Except for sTNF-R55 whose levels were higher in severe than in mild malaria, no correlation was observed between soluble receptors and clinical status. Nevertheless, sTNF-R55 and sTNF-R75 were significantly more elevated in patients who died (10.7 +/- 2.3 ng/ml and 94.9 +/- 31 ng/ml, respectively) than in those surviving (5.5 +/- 0.4 ng/ml and 37.4 +/- 5.4 ng/ml respectively). A marked correlation was observed between soluble receptors levels and some biological markers of gravity like creatinine, urea, and bilirubin. In 13 non immune patients, circulating soluble receptors levels decreased significantly after 7 days when clinical and biological malaria features had disappeared, but TNFsR75 remained above normal levels. After a fortnight of treatment in 17 immune patients, sTNF-R55 and sTNF-R75 remained elevated. However, the ratios of TNF-alpha/s TNF-R55 and 75 were not higher in the cases of cerebral malaria or fatal outcome. Further studies are required to determine if elevated levels of sTNF-R55 and sTNF-R75 are beneficial, due to the inhibition of TNF-alpha or whether they are detrimental since they stabilize this deleterious cytokine.

Prognostic indicators in adult cerebral malaria: a study in Burundi, an area of high prevalence of HIV infection.

We examined the possible risk factors for poor prognostic in cerebral malaria in 31 adults from Burundi, an area of high prevalence rate of HIV-1 infection. Depth of coma, temperature, vomiting, seizures, parasite load, or anaemia did not modify the outcome. High levels of creatinine, bilirubin, and/or lactates were indicators of poor prognostic. HIV-1 infection did not affect the clinical or biological presentation of cerebral malaria, and did not appear to influence the outcome.

PIP: This article reports the findings of a study conducted to identify the relationship between HIV infection and cerebral malaria in Burundi. Study subjects were selected from hospital patients diagnosed with cerebral malaria. The Glasgow scale was used for unconscious patients as a measurement for admission into this study. Parasite density was determined with Giemsa-stained thick blood smears. HIV-1 testing was done by enzyme-linked immunosorbent assay (ELISA) techniques and positives were confirmed by Western blot. All patients received 10 mg of quinine per kg of body weight as an initial dose by intravenous infusion. This regimen was followed by a daily dose of 25 mg/kg body weight via intravenous infusion. If after 2 days the patient could take treatment orally, it was switched. This treatment regimen lasted 5-7 days total. Statistical analysis was performed using the Mann-Whitney U test, the Fisher exact test, and the Chi-square test. Of the 31 study patients, 22 were male and 9 were female. 7 (22.6%) died within the first 96 hours. The surviving 24 patients had a mean coma recovery time of 33.7 +or- 25.8 hours. No neurological damage was noted. The mean Glasgow score was 8.3 +or- 2.7 for the whole group of 31 patients. The mean malaria parasitemia was 11,920 (95% CI: 643-221,018) parasites/mcl of blood. Plasma levels of creatinine were higher in fatal cases than in patients who survived (307.2 +or- 261.8 mcmol/L vs. 135.1 +or- 55.3 mcmol/L). Of the 31 patients, 12 (38.7%) had antibodies to HIV-1. No relationship between positive HIV-1 and cerebral malaria was found, and no patient showed any clinical symptoms of acquired immunodeficiency syndrome.