Clinical spectrum of human immunodeficiency virus disease in children in a west African city. Project RETRO-CI.

OBJECTIVES: To determine the prevalence of HIV infection in children and to compare diagnostic syndromes and outcomes in HIV-positive and HIV-negative children. METHODS: Consecutive children hospitalized in Abidjan's three university hospitals were examined, tested for HIV infection and followed to discharge. Admission or discharge diagnoses and outcome (survived or died) were compared in HIV-positive and HIV-negative children. RESULTS: The prevalence of HIV infection in the 4480 children hospitalized for the first time was 8.2%; the highest age-specific rate (11.2%) was in children ages 15 to 23 months. Six clinical syndromes accounted for more than 80% of admissions in HIV-positive and -negative children (all ages combined): respiratory infection; malnutrition; malaria; anemia; diarrhea; and meningitis. The dominant syndromic diagnoses in HIV-positive children were respiratory infection (26.1%) and malnutrition (25.8%); in HIV-negative children they were malaria (30.4%) and respiratory infection (19.1%). The overall mortality rate in HIV-positive children was 20.8%, compared with 8.7% in HIV-negative children (relative risk, 2.4; 95% confidence interval, 1.9 to 3.1); the highest death rate (28.1%) was in children younger than 15 months. CONCLUSIONS: Clinical syndromes associated with HIV infection in African children are difficult to recognize without access to HIV serology. Respiratory infection and malnutrition were the dominant clinical syndromes in HIV-positive children in Abidjan. Greater overlap exists between the clinical presentations of HIV-associated disease and other common health problems in African children than in adults.

Response to treatment, mortality, and CD4 lymphocyte counts in HIV-infected persons with tuberculosis in Abidjan, Côte d'Ivoire.

We examined the severity of immune deficiency in patients with HIV-associated tuberculosis in Côte d'Ivoire and assessed its effect on mortality and response to treatment. Consecutive patients attending a tuberculosis treatment centre in Abidjan with smear-positive pulmonary or clinically diagnosed extrapulmonary tuberculosis were tested for HIV-1 and HIV-2 infections and had CD4 lymphocyte counts measured. Patients received standard short-course chemotherapy. Analysis of outcome (restricted to smear-positive tuberculosis patients) was done at 6 months. The 247 HIV-positive patients were significantly more likely than the 312 HIV-negative patients to have CD4 lymphocyte counts of less than 200/microL (43% vs 1%; odds ratio 56.9; [95% CI 19.7-185.3]) and 200-499/microL (39% vs 14%, odds ratio 3.8; [2.5-5.9]). Among HIV-positive patients, median CD4 lymphocyte counts in those with extrapulmonary tuberculosis (198/microL; n = 67) was lower, but not significantly so, than among those with pulmonary tuberculosis (257/microL; n = 180). Among 460 patients with pulmonary tuberculosis, the overall mortality rate was significantly higher in HIV-positive than HIV-negative persons (6% vs 0.4%; relative risk 17.1 [2.2-131.4]), and increased with the severity of immune deficiency; mortality rates in HIV-positive patients with CD4 counts of < 200/microL and 200-499/microL were 10% and 4%, relative risk 27.6 (3.5-220.8); and 11.5 (1.2-109), respectively, compared to HIV-negatives. Among patients completing treatment, cure rates were similar in HIV-positive patients (93%) and HIV-negative patients (92%), and were not related to CD4 counts. Severity of immune deficiency was the major determinant of mortality in HIV-associated tuberculosis. Among people completing treatment, microbiological response was satisfactory irrespective of serological or immune status.

Prospective comparison of mother-to-child transmission of HIV-1 and HIV-2 in Abidjan, Ivory Coast.

OBJECTIVE: To compare mother-to-child transmission of human immunodeficiency virus types 1 and 2 (HIV-1 and HIV-2, respectively) and to assess the impact of maternal HIV-1 and HIV-2 infections on child survival. DESIGN: Prospective cohort study. SETTING: Maternal and child health center in a lower socioeconomic class district of Abidjan, Ivory Coast. PARTICIPANTS: A total of 18,099 women delivering between 1990 and 1992 were tested for HIV-1 and HIV-2 antibodies. A cohort of 613 pregnant women and their infants was followed prospectively (138 women reactive to HIV-1, 132 reactive to HIV-2, 69 reactive to both viruses, and 274 HIV-seronegative). MAIN OUTCOME MEASURES: Rates of perinatal transmission for HIV-1, HIV-2, and both viruses, determined from results of serological and polymerase chain reaction tests on children; survival of infants born to HIV-1-positive, HIV-2-positive, dually reactive, and HIV-seronegative women. RESULTS: Of the 18,099 women tested, 9.4% were reactive to HIV-1 alone, 1.6% to HIV-2 alone, and 1.0% to both viruses. The rate of perinatal transmission of HIV-1 was 24.7% (95% confidence interval [CI], 15.8% to 33.7%), compared with 1.2% (95% CI, 0.0% to 3.5%) for HIV-2 (relative risk, 21.3; 95% CI, 2.9 to 154.3). Overall, 19.0% (95% CI, 9.0% to 29.0%) of infants of dually reactive women became infected; of the 11 children concerned, 10 were infected with HIV-1 and one with HIV-1 and HIV-2. Infants of HIV-seropositive mothers had a reduced survival; mortality rates were 15.1, 13.0, 6.5, and 3.4 deaths per 100 child-years, respectively, for children of HIV-1-positive, dually reactive, HIV-2-positive, and HIV-seronegative women. CONCLUSIONS: The rate of perinatal transmission of HIV-2 (1.2%) was much lower than the rate of perinatal transmission of HIV-1 (24.7%), and this was associated with more favorable survival for infants of HIV-2-infected mothers. Dually reactive women could transmit both viruses, although transmission usually involved HIV-1 only. Public health guidelines should incorporate advice that perinatal transmission of HIV-2 is rare.

Tuberculosis and HIV infection in children in Abidjan, Côte d'Ivoire.

Of 5180 consecutive outpatients diagnosed with tuberculosis in Abidjan, Côte d'Ivoire (West Africa), between July 1989 and December 1990, 289 (6%) were children aged less than 15 years. The overall prevalence of human immunodeficiency virus (HIV) 1 and/or HIV-2 infection in children with tuberculosis was 11.8% (HIV-1, 10.0%; HIV-2, 0.7%; reactivity to both viruses, 1%). The highest overall age-specific prevalence was in children aged 1-4 years (23.4%), significantly higher than the rate in attenders at a well child clinic (0.5%) (odds ratio 58.2). Of children with tuberculosis, 26% had sputum smear-positive disease (HIV seroprevalence 2.7%), 20% extrapulmonary disease (HIV seroprevalence 5.2%), and 54% were categorized as having 'clinical tuberculosis' (HIV seroprevalence 18.6%) based on clinical signs and chest X-ray abnormalities with negative sputum smears. Clinical tuberculosis was most frequent in seropositive children, irrespective of age, and in younger seronegative children. Extrapulmonary tuberculosis was equally distributed across age groups, and pulmonary tuberculosis was concentrated in older, seronegative children. HIV-positivity was significantly associated with other features related to the acquired immune deficiency syndrome such as wasting, chronic diarrhoea, oral candidiasis, and negative tuberculin skin tests. Tuberculosis seems to be associated with HIV infection in children in sub-Saharan Africa, but better diagnostic techniques for paediatric tuberculosis are urgently needed.

Epidemiology and transmission of HIV-2. Why there is no HIV-2 pandemic.

Although human immunodeficiency virus type 1 (HIV-1) and HIV-2 share modes of transmission, their epidemiologic characteristics differ and international spread of HIV-2 has been very limited. Recently, the prevalence of infection with HIV-1 but not HIV-2 has increased rapidly in different West African countries, where HIV-2 was probably present earlier. Among 19,701 women of reproductive age tested in Abidjan, Ivory Coast, between 1988 and 1992, the prevalence of HIV-1 infection increased from 5.0% to 9.2%, while that of HIV-2 declined from 2.6% to 1.5%. Differences in viral load may be responsible: reported results of virus culture and polymerase chain reaction assays suggest that at high CD4+ T-lymphocyte counts viral load is lower in HIV-2-infected than in HIV-1-infected persons; the efficacy of heterosexual and perinatal transmission of HIV-2 is less efficient than that of HIV-1 at this stage. At low (< 0.20 x 10(9)/L [< 200/microL]) CD4+ T-lymphocyte counts, virus isolation is equally successful for both viruses, and the efficacy of heterosexual transmission is similar. Differences in HIV-1 and HIV-2 natural history are reflected in differences in viral load, that for HIV-2 being lower until immunodeficiency is severe. Differences in viral load throughout most of the natural history of infection appear to correlate with lower transmissibility of HIV-2 than HIV-1, and are the likeliest explanation for their markedly different global epidemiology.

A population-based serosurveillance of syphilis in Costa Rica.

As part of a case-control study to investigate the high incidence of cervical cancer in Costa Rican women, the seroprevalence of the treponematoses, in particular, syphilis was determined. In each age group, women with a history of two or more sex partners were two to four times more likely to be seroreactive in tests for syphilis than women with zero or one sex partner. The highest percentage of reactive results in the microhemagglutination assay for antibodies to Treponema pallidum (MHA-TP) was seen in samples from women aged 50-59 who had had two or more lifetime partners (23.8%). Three observations from our study support reactivity due to syphilis rather than yaws or pinta: (1) a similar percent of reactive rapid plasma reagin (RPR) card test results among MHA-TP reactors in the two age groups of women who were surveyed (42 vs. 49%) was observed; (2) women who were seroreactive in the MHA-TP had multiple risk factors for STD [low socioeconomic status (9.4%), urban residence (22.8%), first intercourse under 16 years of age (14.1%), and multiple sex partners (26.3%)], and (3) only sexually experienced women had reactive results in the MHA-TP test.

Seroepidemiology of chlamydia in Costa Rica.

A population-based study of the sero-epidemiology of chlamydia was performed among a nationally representative sample of 760 Costa Rican women aged 25 to 59 years. Interviews and sera collection were completed between September 1984 and February 1985. The overall seroprevalence of chlamydial antibodies among these women was 56.1%. Women 25 to 39 years of age had a seroprevalence of 51.1%, while women 40 to 59 years of age had a seroprevalence of 64.2%. Women who reported no prior sexual activity had a seroprevalence rate of 48.6%, compared with a seroprevalence rate of 80.7% among women who reported three or more lifetime sexual partners. The geometric mean titre (GMT) of seropositive women ranged from 34.4 among the women who reported no prior sexual activity to 155.0 among the women with three or more lifetime sexual partners. Sero-positivity was more consistently associated with sexual activity than with age. Women with serological evidence of past Herpes simplex virus type 2 (HSV-2) or syphilis infection were more likely to be seropositive than were women without evidence of exposure to these sexually transmitted diseases, even when controlled for age and the number of lifetime sexual partners. The seropositivity among never sexually active women indicates the probable presence of Chlamydia pneumoniae infections, while the high seroprevalence of chlamydial antibodies among the sexually active women suggests that sexually transmitted Chlamydia trachomatis infections represent a public health problem not previously quantified in Costa Rica. Further seroepidemiological and/or culture studies are warranted to determine the incidence and prevalence of sexually transmitted chlamydial infection among men and younger women.