Little is known about how improved depression care affects HIV-related outcomes in Africa. In a sample of depressed HIV patients in a low income, sub-Saharan country, we explored how implementing measurement-based antidepressant care (MBC) affected HIV outcomes over 4 months of antidepressant treatment.
As part of a project adapting MBC for use in Cameroon, we enrolled 41 depressed HIV patients on antiretroviral therapy in a pilot study in which a depression care manager (DCM) provided an outpatient HIV clinician with evidence-based decision support for antidepressant treatment. Acute depression management was provided for the first 12 weeks, with DCM contact every 2 weeks and HIV clinician appointments every 4 weeks. We measured HIV clinical and psychiatric outcomes at 4 months.
Participants were moderately depressed at baseline (mean Patient Health Questionnaire [PHQ] score = 14.4, range 13.1, 15.6). All HIV clinical outcomes improved by four month follow-up: mean (range) CD4 count improved from 436 (2, 860) to 452 (132, 876), mean (range) log-viral load decreased from 4.02 (3.86, 4.17) to 3.15 (2.81, 3.49), the proportion with virologic suppression improved from 0% to 18%, mean (range) HIV symptoms decreased from 6.4 (5.5, 7.3) to 3.1 (2.5, 3.7), the proportion reporting good or excellent health improved from 18% to 70%, and the proportion reporting any missed ARV doses in the past month decreased from 73% to 55%. Concurrently, psychiatric measures improved. The mean (range) PHQ score decreased from 14.4 (13.1, 15.6) to 1.6 (0.8, 2.4) and 90% achieved depression remission, while mean maladaptive coping style scores decreased and mean adaptive coping scores and self-efficacy scores improved.
In this pilot study of an evidence-based depression treatment intervention for HIV-infected patients in Cameroon, a number of HIV behavioral and non-behavioral health outcomes improved over 4 months of effective depression treatment. These data are consistent with the hypothesis that better depression care can lead to improved HIV outcomes.
Depression affects 18-30% of HIV-infected patients in Africa and is associated with greater stigma, lower antiretroviral adherence, and faster disease progression. However, the region's health system capacity to effectively identify and treat depression is limited. Task-shifting models may help address this large mental health treatment gap.
Measurement-Based Care (MBC) is a task-shifting model in which a Depression Care Manager (DCM) guides a non-psychiatric (e.g., HIV) provider in prescribing and managing antidepressant treatment. We adapted MBC for depressed HIV-infected patients in Cameroon and completed a pilot study to assess feasibility, safety, acceptability, and preliminary efficacy.
We enrolled 55 participants; all started amitriptyline 25-50mg daily at baseline. By 12 weeks, most remained at 50mg daily (range 25-125mg). Median (interquartile range) PHQ-9 depressive severity scores declined from 13 (12-16) (baseline) to 2 (0-3) (week 12); 87% achieved depression remission (PHQ9<5) by 12 weeks. Intervention fidelity was high: HIV providers followed MBC recommendations at 96% of encounters. Most divergences reflected a failure to increase dose when indicated. No serious and few bothersome side effects were reported. Most suicidality (prevalence: 62% at baseline; 8% at 12 weeks) was either passive or low-risk. Participant satisfaction was high (100%), and most participants (89%) indicated willingness to pay for medications if MBC were implemented in routine care.
The adapted MBC intervention demonstrated high feasibility, safety, acceptability, and preliminary efficacy in this uncontrolled pilot study. Further research should assess whether MBC could improve adherence and HIV outcomes in this setting.
HIV; depression; depression treatment; intervention; Measurement-Based Care; Africa
To assess the profile and determinants of health research productivity in Africa since the onset of the new millennium.
Data collection and synthesis
In November 2014, we searched PubMed for articles published between 2000 and 2014 from the WHO African Region, and obtained country-level indicators from World Bank data. We used Poisson regression to examine time trends in research publications and negative binomial regression to explore determinants of research publications.
We identified 107 662 publications, with a median of 727 per country (range 25–31 757). Three countries (South Africa, Nigeria and Kenya) contributed 52% of the publications. The number of publications increased from 3623 in 2000 to 12 709 in 2014 (relative growth 251%). Similarly, the per cent share of worldwide research publications per year increased from 0.7% in 2000 to 1.3% in 2014. The trend analysis was also significant to confirm a continuous increase in health research publications from Africa, with productivity increasing by 10.3% per year (95% CIs +10.1% to +10.5%). The only independent predictor of publication outputs was national gross domestic product. For every one log US$ billion increase in gross domestic product, research publications rose by 105%: incidence rate ratio (IRR=2.05, 95% CI 1.39 to 3.04). The association of private health expenditure with publications was only marginally significant (IRR=1.86, 95% CI 1.00 to 3.47).
There has been a significant improvement in health research in the WHO African Region since 2000, with some individual countries already having strong research profiles. Countries of the region should implement the WHO Strategy on Research for Health: reinforcing the research culture (organisation); focusing research on key health challenges (priorities); strengthening national health research systems (capacity); encouraging good research practice (standards); and consolidating linkages between health research and action (translation).
PUBLIC HEALTH; EPIDEMIOLOGY
Although infection with Hepatitis B Virus (HBV) remains a global public health problem, little is known about its epidemiology in pregnancy in sub-Saharan Africa. This study sought to determine the prevalence of, and identify factors associated with hepatitis B surface antigen (HBsAg) positivity among pregnant women in the Buea Health District (BHD) in rural Cameroon. We also assessed pregnant women’s knowledge about hepatitis B.
A cross-sectional, descriptive study was undertaken. Participants were evaluated using a structured questionnaire with clinical examination and were then screened for HBsAg using a commercial rapid diagnostic test. Assessment of knowledge was done using a hepatitis B basic knowledge summary score.
Of the 176 pregnant women studied, 9.7% (95% CI: 5.7%, 15%) tested positive for HBsAg. None of the risk factors assessed was significantly associated with HBsAg positivity. The hepatitis B knowledge summary score ranged from 0 to 12 with a mean of 1.5 (SD = 3.14, median = 0, IQR = 0 to 0). Only 16% of participants had scores greater than 6/12. The knowledge summary score of the participants was associated with the educational level (p-value = 0.0037).
The high prevalence of HBsAg (9.7%) among women of child bearing age suggests that vertical transmission of HBV may be a public health problem in Buea Health District. Knowledge of HBV among pregnant women was poor. We recommend that all pregnant women ought to be routinely screened for HBV and that health education on HBV should be provided to pregnant women especially during antenatal visits.
Hepatitis B virus; Prevalence; HBsAg; Pregnancy; Cameroon; Knowledge
In high-income countries, depression is prevalent in HIV patients and is associated with lower medication adherence and clinical outcomes. Emerging evidence from low-income countries supports similar relationships. Yet little research has validated rapid depression screening tools integrated into routine HIV clinical care.
Using qualitative methods, we adapted the Patient Health Questionnaire-9 (PHQ-9) depression screening instrument for use with Cameroonian patients. We then conducted a cross-sectional validity study comparing an interviewer-administered PHQ-9 to the reference standard Composite International Diagnostic Interview in 400 patients on antiretroviral therapy attending a regional HIV treatment center in Bamenda, Cameroon.
The prevalence of major depressive disorder (MDD) in the past month was 3% (n=11 cases). Using a standard cutoff score of ≥10 as a positive depression screen, the PHQ-9 had estimated sensitivity of 27% (95% confidence interval: 6–61%) and specificity of 94% (91–96%), corresponding to positive and negative likelihood ratios of 4.5 and 0.8. There was little evidence of variation in specificity by gender, number of HIV symptoms, or result of a dementia screen.
The low prevalence of MDD yielded very imprecise sensitivity estimates. Although the PHQ-9 was developed as a self-administered tool, we assessed an interviewer-administered version due to the literacy level of the target population.
The PHQ-9 demonstrated high specificity but apparently low sensitivity for detecting MDD in this sample of HIV patients in Cameroon. Formative work to define the performance of proven screening tools in new settings remains important as research on mental health expands in low-income countries.
HIV; depression; validation study; screening instruments; Africa
Bacteriuria is associated with significant maternal and foetal risks. However, its prevalence is not known in our community.
This study was carried out to determine the prevalence and predictors of bacteriuria in pregnant women of the Buea Health District (BHD) as well as the antibiotic sensitivity patterns of bacterial isolates. It also sought to determine the diagnostic performance of the nitrite and leucocyte esterase tests in detecting bacteriuria in these women.
An observational analytic cross-sectional study was carried out amongst pregnant women attending selected antenatal care centres in Buea. We recruited 102 consenting pregnant women for the study. Demographic and clinical data were collected using structured questionnaires. Clean catch midstream urine was collected from each participant in sterile leak proof containers. Samples were examined biochemically, microscopically and by culture. Significant bacteriuria was defined as the presence of ≥108 bacteria/L of cultured urine. Identification and susceptibility of isolates was performed using API 20E and ATB UR EU (08) (BioMerieux, Marcy l'Etoile, France).
Significant bacteriuria was found in the urine of 24 of the 102 women tested giving a bacteriuria prevalence of 23.5% in pregnant women of the BHD. Asymptomatic bacteriuria was detected in 8(7.8%) of the women. There was no statistically significant predictor of bacteriuria. Escherichia coli were the most isolated (33%) uropathogens and were 100% sensitive to cefixime, cefoxitin and cephalothin. The nitrite and leucocyte esterase tests for determining bacteriuria had sensitivities of 8%, 20.8% and specificities of 98.7% and 80.8% respectively.
Bacteriuria is frequent in pregnant women in the BHD suggesting the need for routine screening by urine culture. Empiric treatment with cefixime should be instituted until results of urine culture and sensitivity are available. Nitrite and leucocyte esterase tests were not sensitive enough to replace urine culture as screening tests.
In this study we assess the prevalence, characteristics as well as socio-demographic and clinical correlates of a positive screen for HIV-associated dementia in a group of patients on antiretroviral therapy (ART) in Bamenda, Cameroon.
In a cross-sectional study, a structured questionnaire was used to collect data on 400 patients attending the Bamenda Regional Hospital AIDS-treatment Centre. Patients were assessed for neurocognitive function using the International HIV Dementia Scale (IHDS) to assess finger-tapping (FT), alternating hand sequence (AHS) and a 4-word recall (4WR), each scored on a maximum of four.
A total of 297 (74%) participants were females. The total IHDS score ranged from 6–12 with a mean of 9.02 and 85% of subjects screened positive for dementia (≤10 on IHDS). Participants performed worst in the AHS assessment with a mean of 2.25 (IQR: 2–3). In multivariable analyses, screening positive for dementia was significantly associated with having primary education or less (aOR: 8.33, 95%CI: 3.85, 16.67), and having HIV symptoms (aOR: 12.16, 95%CI: 3.08, 48.05).
A very high proportion of patients on ART screened positive for dementia using the IHDS. This could potentially be an indication of a high prevalence of HIV-associated neurocognitive disorders in this population and or a poor performance of the IHDS in patients on ART. Future studies will need to assess the validity of the IHDS in this population of patients on ART and also evaluate long term outcomes in patients with positive dementia screens.
HIV; Dementia; Screen; Cameroon; Antiretroviral therapy
Cervical cancer is the most common cancer in women in low-income countries. Although cervical cancer incidence and mortality is higher in HIV-positive women, resource limitations restrict the implementation of systematic screening programs in these women. We explored the potential for targeted screening by assessing the prevalence, severity and predictors of cervical squamous intra-epithelial lesions (SILs) in HIV-positive women in Cameroon.
Methods and findings
We conducted a cross-sectional study of women on antiretroviral therapy in Cameroon. Socio-demographic, behavioral, and clinical information was obtained from eligible women. Cervical exfoliated cells were then collected, a conventional cytology performed and epithelial lesions classified according to the Bethesda 2001 system.
A total of 282 women, aged 19 to 68 years, were enrolled in this study. The median CD4 count was 179 cells/microliter (interquartile range: 100 to 271). SILs were detected in 43.5% of the 276 women with satisfactory samples: including atypical squamous cells of unknown significance (ASCUS) 0.7%, low-grade SIL (LSIL) 25.0%, atypical squamous cells, cannot exclude high grade lesions (ASC-H) 14.5%, and high-grade SIL (HSIL) 3.3%. None of the demographic or clinical characteristics considered significantly predicted the presence of any SILs or the presence of severe lesions requiring colposcopy.
The prevalence of SIL in women on antiretroviral therapy in Cameroon was high underscoring the need for screening and care in this population. In the absence of any accurate demographic or clinical predictor of SIL, targeted screening does not seem feasible. Alternative affordable screening options need to be explored.
Cervical neoplasm; HIV; Screening; Cameroon; Epidemiology
Rapid scale-up of antiretroviral therapy (ART) and limited access to genotyping assays in low-resource settings (LRS) are inevitably accompanied by an increasing risk of HIV drug resistance (HIVDR). The current study aims to evaluate early warning indicators (EWI) as an efficient strategy to limit the development and spread of preventable HIVDR in these settings, in order to sustain the performance of national antiretroviral therapy (ART) rollout programmes.
Surveys were conducted in 2008, 2009 and 2010 within 10 Cameroonian ART clinics, based on five HIVDR EWIs: (1) Good prescribing practices; (2) Patient lost to follow-up; (3) Patient retention on first line ART; (4) On-time drug pick-up; (5) Continuous drug supply. Analysis was performed as per the World Health Organisation (WHO) protocol.
An overall decreasing performance of the national ART programme was observed from 2008 to 2010: EWI1 (100% to 70%); EWI2 (40% to 20%); EWI3 (70% to 0%); EWI4 (0% throughout); EWI5 (90% to 40%). Thus, prescribing practices (EWI1) were in conformity with national guidelines, while patient adherence (EWI2, EWI3, and EWI4) and drug supply (EWI5) were lower overtime; with a heavy workload (median ratio ≈1/64 staff/patients) and community disengagement observed all over the study sites.
In order to limit risks of HIVDR emergence in poor settings like Cameroon, continuous drug supply, community empowerment to support adherence, and probably a reduction in workload by task shifting, are the potential urgent measures to be undertaken. Such evidence-based interventions, rapidly generated and less costly, would be relevant in limiting the spread of preventable HIVDR and in sustaining the performance of ART programmes in LRS.
Early warning indicator; HIV drug resistance; Surveillance and prevention; Cameroon
The implementation of strategic immunization plans whose development is informed by available locally-relevant research evidence should improve immunization coverage and prevent disease, disability and death in Africa. In general, health research helps to answer questions, generate the evidence required to guide policy and identify new tools. However, factors that influence the publication of immunization research in Africa are not known. We, therefore, undertook this study to fill this research gap by providing insights into factors associated with childhood immunization research productivity on the continent. We postulated that research productivity influences immunization coverage.
We conducted a bibliometric analysis of childhood immunization research output from Africa, using research articles indexed in PubMed as a surrogate for total research productivity. We used zero-truncated negative binomial regression models to explore the factors associated with research productivity.
We identified 1,641 articles on childhood immunization indexed in PubMed between 1974 and 2010 with authors from Africa, which represent only 8.9% of the global output. Five countries (South Africa, Nigeria, The Gambia, Egypt and Kenya) contributed 48% of the articles. After controlling for population and gross domestic product, The Gambia, Guinea-Bissau and Sao Tome and Principe were the most productive countries. In univariable analyses, the country's gross domestic product, total health expenditure, private health expenditure, and research and development expenditure had a significant positive association with increased research productivity. Immunization coverage, adult literacy rate, human development index and physician density had no significant association. In the multivarable model, only private health expenditure maintained significant statistical association with the number of immunization articles.
Immunization research productivity in Africa is highly skewed, with private health expenditure having a significant positive association. However, the current contribution of authors from Africa to global childhood immunization research output is minimal. The lack of association between research productivity and immunization coverage may be an indication of lack of interactive communication between health decision-makers, program managers and researchers; to ensure that immunization policies and plans are always informed by the best available evidence.
Africa; bibliometrics; childhood immunization; Expanded Program on Immunization; low and middle-income counries; research; sub-Saharan Africa
Cervical squamous intra-epithelial lesions (SIL) are more frequent in HIV-positive women overall. However the appropriate age at which to begin and end cervical cancer screening for early detection of lesions in HIV-positive women is not clear. We assessed the age-specific prevalence of any SIL and SIL requiring colposcopy in HIV-positive women in Cameroon.
We enrolled, interviewed and conducted conventional cervical cytology in 282 women, aged 19–68 years, initiating antiretroviral therapy in three clinics in Cameroon. In bivariable analyses, the crude relationship between age and the presence of lesions was assessed using locally weighted regression (LOWESS) methods. In multivariate analyses, generalized linear models with prevalence as the outcome, an identity link and a binomial distribution, were used to estimate prevalence differences. Bias analyses were conducted to assess the potential effect of inaccuracies in cytology.
SIL were detected in 43.5% of the 276 women with satisfactory samples, 17.8% of whom had ASC-H/HSIL. On average, women aged 26 to 59 tended to have a slightly higher prevalence of any SIL than other women (Prevalence difference PD: 6.5%; 95%CI: -11.4, 24.4%). This PD was a function of CD4 count (heterogeneity test p-value =0.09): amongst patients with CD4 counts less than 200cells/uL, the prevalence was higher in patients aged 26–59, while there was essentially no difference amongst women with CD4 counts greater than 200 cells/uL. ASC-H/HSIL were present in women as young as 19 and as old as 62. Overall the prevalence of ASC-H/HSIL increased by 0.7% (95%CI: -3.8%, 5.1%) per decade increase in age.
Both severe and less severe lesions were prevalent at all ages suggesting little utility of age-targeted screening among HIV-positive women. Nevertheless, the long-term evolution of these lesions needs to be assessed in prospective studies.
The objective of this study was to evaluate the use of voluntary counseling and testing (VCT) services for HIV by high school students in the Tiko health district (THD), Cameroon. A cross sectional descriptive, analytical study was conducted using a pre-established questionnaire among high school students in the Tiko health district where a multi stage sampling method was used. A total of 474 students were included in the study. Among them, 350 (73.8%) had heard about VCT, 136 (27.8%) had undergone VCT and 329 (69.4%) were willing to undergo VCT. The use of VCT services was positively associated with age (p<0.001), sex (p<0.001), school (p<0.001), sexual activity (p=0.001), attitude (p=0.001) towards and knowledge of VCT (p<0.001). Knowledge of VCT among the students was high but the use of VCT services was low. We recommend that free screening for HIV should be offered in secondary schools of THD.
HIV; VCT; knowlegde; attitudes; adolescents; youths; students
Recent blue-ribbon panel reports have concluded that HIV treatment programs in less wealthy countries must integrate mental health identification and treatment into normal HIV clinical care and that research on mental health and HIV in these settings should be a high priority. We assessed the epidemiology of depression in HIV patients on antiretroviral therapy in a small urban setting in Cameroon by administering a structured interview for depression to 400 patients consecutively attending the Bamenda Regional Hospital AIDS Treatment Center. One in five participants met lifetime criteria for MDD, and 7% had MDD within the prior year. Only 33% had ever spoken with a health professional about depression, and 12% reported ever having received depression treatment that was helpful or effective. Over 2/3 with past-year MDD had severe or very severe episodes. The number of prior depressive episodes and the number of HIV symptoms were the strongest predictors of past-year MDD. The prevalence of MDD in Cameroon is as high as that of other HIV-associated conditions, such as tuberculosis and Hepatitis B virus, whose care is incorporated into World Health Organization guidelines. The management of depression needs to be incorporated in HIV-care guidelines in Cameroon and other similar settings.
A pool of 38 pan-African Centres of Excellence (CoEs) in health innovation has been selected and recognized by the African Network for Drugs and Diagnostics Innovation (ANDI), through a competitive criteria based process. The process identified a number of opportunities and challenges for health R&D and innovation in the continent: i) it provides a direct evidence for the existence of innovation capability that can be leveraged to fill specific gaps in the continent; ii) it revealed a research and financing pattern that is largely fragmented and uncoordinated, and iii) it highlights the most frequent funders of health research in the continent. The CoEs are envisioned as an innovative network of public and private institutions with a critical mass of expertise and resources to support projects and a variety of activities for capacity building and scientific exchange, including hosting fellows, trainees, scientists on sabbaticals and exchange with other African and non-African institutions.
People living with HIV/AIDS (PLWHA) frequently have abnormal blood counts including anemia, leucopenia and thrombocytopenia. The role of infection with plasmodia on these hematological parameters in PLWHA is not well known. In this study we compared selected hematological parameters between malaria positive and negative PLWHA.
We conducted a cross-sectional study of PLWHA attending the Douala Laquintinie hospital. After obtaining consent, demographic and clinical data were obtained via a standardized questionnaire. Blood samples collected for hematological assays were run using an automated full blood counter. Malaria parasitaemia was determined by blood smear microscopy.
A total of 238 adult PLWHA were enrolled, 48.3% of who were on antiretroviral therapy and 24.8% of whom had malaria parasitaemia. The respective mean (±SD) of hemoglobin level, RBC count, WBC count, platelet count, lymphocyte count and CD4+ T cell counts in malaria co-infected patients versus non-infected patients were: 10.8(±1.9) g/dl versus 11.4(±2.0)g/dl; 3,745,254(±793,353) cells/µl versus 3,888,966(±648,195) cells/µl; 4,403(±1,534) cells/µl versus 4,920(±1,922) cells/µl; 216,051(±93,884) cells/µl versus 226,792(±98,664) cells/µl; 1,846(±711) cells/µl versus 2,052(±845) cells/µl and 245(±195) cells/µl versus 301(±211) cells/µl. All these means were not statistically significantly different from each other.
There was no significant difference in studied hematological parameters between malaria positive and negative PLWHA. These data suggest little or no impact of malaria infection. Hematological anomalies in PLWHA in this area need not be necessarily attributed to malaria. These need to be further investigated to identify and treat other potential causes.
Though documented that HIV infection progresses with the depletion of CD4+ cells, the exact mechanisms by which these cell depletions occur are not clearly understood. This study aimed at evaluating the plasma levels of soluble Fas receptors and ligands in HIV-infected and uninfected patients in Yaounde, Cameroon, a population with a known diversity of HIV in whom this has not been previously assessed.
In a cross-sectional study, 39 antiretroviral naïve HIV-1 positive and negative participants were recruited in Yaounde, Cameroon. CD4+ lymphocyte cell counts were quantified from whole blood using an automated FACScount machine (Becton-Dickinson, Belgium). Plasma samples obtained were analyzed for soluble Fas receptors and Fas ligands in both HIV-1 positive and negative samples using two different quantitative sandwich ELISA kits (Quantikine®, R&D Systems , UK).
Plasma levels of Fas receptors were higher in HIV-1 positive patients (median = 1486pg/ml IQR = 1193, 1830pg/ml) compared to HIV-negative controls (median = 1244pg/ml, IQR = 1109, 1325pg/ml), p-value <0.001. Plasma levels of Fas ligands were also higher in HIV-1 positive patients (median = 154pg/ml, IQR = 111, 203pg/ml) compared to HIV-negative controls (median = 51pg/ml, IQR = 32, 88pg/ml), p-value = 0.005. Plasma concentrations of soluble fas receptors and ligands tended to be negatively correlated with the CD4+ cell counts of HIV-positive patients; the correlation coefficients were -0.34 (value = 0.78) and-0.3 (p-value = 0.51) respectively.
In this population of patients in Cameroon, plasma concentrations of Fas receptors and Fas ligands tend to be higher in HIV-positive patients. The Fas pathway of apoptosis may have a role in the depletion of CD4+ cell counts
Apoptosis; Fas; FasL; Immune activation; HIV; Cameroon
In 2010, more than six million children in sub-Saharan Africa did not receive the full series of three doses of the diphtheria-tetanus-pertussis vaccine by one year of age. An evidence-based approach to addressing this burden of un-immunised children requires accurate knowledge of the underlying factors. We therefore developed and tested a model of childhood immunisation that includes individual, community and country-level characteristics.
Method and Findings
We conducted multilevel logistic regression analysis of Demographic and Health Survey data for 27,094 children aged 12–23 months, nested within 8,546 communities from 24 countries in sub-Saharan Africa. According to the intra-country and intra-community correlation coefficient implied by the estimated intercept component variance, 21% and 32% of the variance in unimmunised children were attributable to country- and community-level factors respectively. Children born to mothers (OR 1.35, 95%CI 1.18 to 1.53) and fathers (OR 1.13, 95%CI 1.12 to 1.40) with no formal education were more likely to be unimmunised than those born to parents with secondary or higher education. Children from the poorest households were 36% more likely to be unimmunised than counterparts from the richest households. Maternal access to media significantly reduced the odds of children being unimmunised (OR 0.94, 95%CI 0.94 to 0.99). Mothers with health seeking behaviours were less likely to have unimmunised children (OR 0.56, 95%CI 0.54 to 0.58). However, children from urban areas (OR 1.12, 95% CI 1.01 to 1.23), communities with high illiteracy rates (OR 1.13, 95% CI 1.05 to 1.23), and countries with high fertility rates (OR 4.43, 95% CI 1.04 to 18.92) were more likely to be unimmunised.
We found that individual and contextual factors were associated with childhood immunisation, suggesting that public health programmes designed to improve coverage of childhood immunisation should address people, and the communities and societies in which they live.
Rapid scale-up of antiretroviral therapy (ART) in resource-limited settings is accompanied with an increasing risk of HIV drug resistance (HIVDR), which in turn could compromise the performance of national ART rollout programme. In order to sustain the effectiveness of ART in a resource-limited country like Cameroon, HIVDR early warning indicators (EWI) may provide relevant corrective measures to support the control and therapeutic management of AIDS.
A retrospective study was conducted in 2010 among 40 ART sites (12 Approved Treatment Centers and 28 Management Units) distributed over the 10 regions of Cameroon. Five standardized EWIs were selected for the evaluation using data from January through December, among which: (1) Good ARV prescribing practices: target = 100%; (2) Patient lost to follow-up: target ≤20%; (3) Patient retention on first line ART: target ≥70%; (4) On-time drug pick-up: target ≥90%; (5) ARV drug supply continuity: target = 100%. Analysis was performed using a Data Quality Assessment tool, following WHO protocol.
The number of sites attaining the required performance are: 90% (36/40) for EWI1, 20% (8/40) for EWI2; 20% (8/40) for EWI3; 0% (0/37) for EWI4; and 45% (17/38) for EWI 5. ARV prescribing practices were in conformity with the national guidelines in almost all the sites, whereas patient adherence to ART (EWI2, EWI3, and EWI4) was very low. A high rate of patients was lost-to-follow-up and others failing first line ART before 12 months of initiation. Discontinuity in drug supply observed in about half of the sites may negatively impact ARV prescription and patient adherence. These poor ART performances may also be due to low number of trained staff and community disengagement.
The poor performance of the national ART programme, due to patient non-adherence and drug stock outs, requires corrective measures to limit risks of HIVDR emergence in Cameroon.
As antiretroviral therapy (ART) is scaled up in resource-limited countries, surveillance for HIV drug resistance (DR) is vital to ensure sustained effectiveness of first-line ART. We have developed and applied a broadly sensitive dried-blood-spot (DBS)-based genotyping assay for surveillance of HIV-1 DR in international settings. In 2005 and 2006, 171 DBS samples were collected under field conditions from newly diagnosed HIV-1-infected individuals from Malawi (n = 58), Tanzania (n = 60), and China (n =53). In addition, 30 DBS and 40 plasma specimens collected from ART patients in China and Cameroon, respectively, were also tested. Of the 171 DBS analyzed at the protease and RT regions, 149 (87.1%) could be genotyped, including 49 (81.7%) from Tanzania, 47 (88.7%) from China, and 53 (91.4%) from Malawi. Among the 70 ART patient samples analyzed, 100% (30/30) of the Chinese DBS and 90% (36/40) of the Cameroonian plasma specimens were genotyped, including 8 samples with a viral load of <400 copies/ml. The results of phylogenetic analyses indicated that the subtype, circulating recombinant form (CRF), and unique recombinant form (URF) distribution was as follows: 73 strains were subtype C (34%), 37 were subtype B (17.2%), 24 each were CRF01_AE or CRF02_AG (11.2% each), 22 were subtype A1 (10.2%), and 9 were unclassifiable (UC) (4.2%). The remaining samples were minor strains comprised of 6 that were CRF07_BC (2.8%), 5 that were CRF10_CD (2.3%), 3 each that were URF_A1C and CRF08_BC (1.4%), 2 each that were G, URF_BC, and URF_D/UC (0.9%), and 1 each that were subtype F1, subtype F2, and URF_A1D (0.5%). Our results indicate that this broadly sensitive genotyping assay can be used to genotype DBS collected from areas with diverse HIV-1 group M subtypes and CRFs. Thus, the assay is likely to become a useful screening tool in the global resistance surveillance and monitoring of HIV-1 where multiple subtypes and CRFs are found.
Anaemia is caused by many factors in developing countries including malaria. We compared anaemia rates in patients with malaria parasitaemia to that of patients without malaria parasitaemia.
A cross-sectional study was carried out from November 2007 to July 2008 in health units in Buea, Cameroon. Adult patients with fever or history of fever were included in the study. Information on socio-demographic variables and other variables was collected using a questionnaire. Malaria parasitaemia status was determined by microscopy using Giemsa stained thick blood smears. Haemoglobin levels were determined by the microhaematocrit technique.
The study population consisted of 250 adult patients with a mean age of 29.31 years (SD = 10.63) and 59.44% were females. 25.60% of the patients had malaria parasitaemia while 14.80% had anaemia (haemoglobin < 11 g/dl). Logistic regression revealed that those with malaria parasitaemia had more anaemia compared to those without malaria parasitaemia(OR = 4.33, 95%CI = 1.21-15.43, p = 0.02) after adjusting for age, sex, rural residence, socioeconomic status, use of antimalarials, use of insecticide treated nets(ITN) and white blood cell count.
In adult patients with fever in this setting, malaria parasitaemia contributes to anaemia and is of public health impact. Our results also provide a baseline prevalence for malaria parasitaemia in febrile adults in health units in this setting.
To assess and summarize the published literature on the extent to which bacterial vaginosis (BV) may increase the risk of HIV acquisition.
Meta-analysis of published studies.
MEDLINE and other electronic databases were systematically searched for eligible publications. The association between BV and incident HIV was separately analyzed from that between BV and prevalent HIV. The latter were further analyzed stratified by BV diagnostic method, HIV risk profile of the study population and whether or not adjusted estimates were presented.
Twenty-three eligible publications were identified, including a total of 30,739 women. BV was associated with an increased risk of HIV acquisition in HIV-incidence studies (relative risk = 1.6, 95% CI: 1.2, 2.1). All but one of 21 HIV-prevalence studies reported estimates above the null. The latter results were heterogeneous and showed some evidence of funnel plot asymmetry, precluding the estimation of a single summary measure. The association between BV and HIV in prevalence studies appeared stronger for women without high-risk sexual behavior.
BV was consistently associated with an increased risk of HIV infection. High BV prevalence may result in a high number of HIV infections being attributable to BV. More prospective studies are needed to accurately evaluate the role of BV in HIV acquisition in low versus high risk women. Furthermore, randomized clinical trials may be worth considering to determine the effect of BV control measures on HIV acquisition.
Bacterial vaginosis; HIV acquisition; meta-analysis
European and Developing Countries Clinical Trials Partnership (EDCTP) was founded in 2003 by the European Parliament and Council. It is a partnership of 14 European Union (EU) member states, Norway, Switzerland, and Developing Countries, formed to fund acceleration of new clinical trial interventions to fight the human immunodeficiency virus and acquired immune deficiency syndrome (HIV/AIDS), malaria and tuberculosis (TB) in the sub-Saharan African region. EDCTP seeks to be synergistic with other funding bodies supporting research on these diseases.
EDCTP promotes collaborative research supported by multiple funding agencies and harnesses networking expertise across different African and European countries. EDCTP is different from other similar initiatives. The organisation of EDCTP blends important aspects of partnership that includes ownership, sustainability and responds to demand-driven research. The Developing Countries Coordinating Committee (DCCC); a team of independent scientists and representatives of regional health bodies from sub-Saharan Africa provides advice to the partnership. Thus EDCTP reflects a true partnership and the active involvement and contribution of these African scientists ensures joint ownership of the EDCTP programme with European counterparts.
The following have been the major achievements of the EDCTP initiative since its formation in 2003; i) increase in the number of participating African countries from two to 26 in 2008 ii) the cumulative amount of funds spent on EDCTP projects has reached € 150 m, iii) the cumulative number of clinical trials approved has reached 40 and iv) there has been a significant increase number and diversity in capacity building activities.
While we recognise that EDCTP faced enormous challenges in its first few years of existence, the strong involvement of African scientists and its new initiatives such as unconditional funding to regional networks of excellence in sub-Saharan Africa is envisaged to lead to a sustainable programme. Current data shows that the number of projects supported by EDCTP is increasing. DCCC proposes that this success story of true partnership should be used as model by partners involved in the fight against other infectious diseases of public health importance in the region.
As programs to prevent and care for HIV-infected persons are scaled-up in Africa, there is the need for continuous evaluation of the performance of test kits that could best support these programs. The present study evaluated the sensitivity, specificity, ease of use, and cost of AWARE ™ Blood Serum Plasma (BSP) and Oral Mucosal Transudate (OMT) Rapid HIV-1/2 test kits using real-time and archived samples of HIV-infected persons from Cameroon. Matched whole blood and OMT specimens were collected prospectively from HIV-positive and HIV-negative persons from different regions of Cameroon and tested using the AWARE ™ BSP and OMT test kits, respectively. These results were compared to the gold standard that included a combination of Determine HIV-1/2 and Enzygnost HIV-1/2. The BSP Rapid test kit was further evaluated using well characterized panels of HIV-2 and HIV-1 group O samples. Cost and end-user analysis of the OMT test kit was done by comparing its actual cost, consumables, safety, bench time and manipulation with other test kits. Of the 732 matched samples, 412 (56.3%) and 320 (43.7%) were from females and males, respectively. Of these samples, 23 (3.1%) gave discordant results between Determine HIV-1/2 and Enzygnost HIV1/2 and were excluded from the analysis. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the AWARE™ BSP were 100%. The AWARE™ OMT had 98.8% sensitivity, 98.9% specificity, 98.0% PPV and 99.4% NPV. The results of a well-characterized archived panel of HIV-2 (n=7) and HIV-1 group O (n=3) samples using the AWARE™ BSP Rapid test kit gave 100% concordance. Total per patient cost of the AWARE OMT rapid test kit was US$4.72 compared to a mean cost of US $7.33 ± 0.11 for the other test kits. Both the AWARE™ BSP and OMT Rapid test kits demonstrated high sensitivities and specificities on all samples tested and were well adapted for use in resource-constrained settings with high HIV heterogeneity such as Cameroon. The AWARE ™ HIV-1/2 OMT Rapid test kit appears to be the cheapest, safest and easiest to use compared with other available test kits.
Cameroon is one of 12 African countries that bear most of the global burden of yellow fever. In 2002 the country developed a five-year strategic plan for yellow fever control, which included strategies for prevention as well as rapid detection and response to outbreaks when they occur. We have used data collected by the national Expanded Programme on Immunisation to assess the progress made and challenges faced during the first four years of implementing the plan.
In January 2003, case-based surveillance of suspected yellow fever cases was instituted in the whole country. A year later, yellow fever immunisation at nine months of age (the same age as routine measles immunisation) was introduced. Supplementary immunisation activities (SIAs), both preventive and in response to outbreaks, also formed an integral part of the yellow fever control plan. Each level of the national health system makes a synthesis of its activities and sends this to the next higher level at defined regular intervals; monthly for routine data and daily for SIAs.
From 2004 to 2006 the national routine yellow fever vaccination coverage rose from 58.7% to 72.2%. In addition, the country achieved parity between yellow fever and measles vaccination coverage in 2005 and has since maintained this performance level. The number of suspected yellow fever cases in the country increased from 156 in 2003 to 859 in 2006, and the proportion of districts that reported at least one suspected yellow fever case per year increased from 31.4% to 68.2%, respectively. Blood specimens were collected from all suspected cases (within 14 days of onset of symptoms) and tested at a central laboratory for yellow fever IgM antibodies; leading to confirmation of yellow fever outbreaks in the health districts of Bafia, Méri and Ntui in 2003, Ngaoundéré Rural in 2004, Yoko in 2005 and Messamena in 2006. Owing to constraints in rapidly mobilising the necessary resources, reactive SIAs were only conducted in Bafia and Méri several months after confirmation of the outbreak. In both districts, a total of 60,083 people (representing 88.2% of the 68,103 targeted) were vaccinated. Owing to the same constraints, SIAs were not conducted promptly in response to the outbreaks in Ntui, Ngaoundéré Rural, Yoko and Messamena. However, these four and two other health districts at high risk of yellow fever outbreaks (i.e. Maroua Urban and Ngaoundéré Urban) conducted preventive SIAs in November 2006, vaccinating a total of 752,195 people (92.8% of target population). In both the reactive and preventive SIAs, the mean wastage rates for vaccines and injection material were less than 5% and there was no report of a serious adverse event following immunisation.
Amidst other competing health priorities, over the past four years Cameroon has successfully planned and implemented evidence-based strategies for preventing yellow fever outbreaks and for detecting and responding to the outbreaks when they occur. In order to sustain these initial successes, the country will have to attain and sustain high routine vaccination coverage in each successive birth cohort in every district. This would require fostering and sustaining high-level political commitment, improving the planning and monitoring of immunisation services at all levels, adequate community mobilisation, and efficient coordination of current and future immunisation partners.