After a period where it was recommended to start antiretroviral therapy (ART) early, the CD4 threshold for treating asymptomatic adults dropped to 200/mm3 at the beginning of the 2000s. This was mostly due to a great prudence with regards to drug toxicity. The ART-start CD4 threshold in most international guidelines was then raised to 350/mm3 in 2006–2009 and to 500/mm3 in 2009–2013. Between 2012 and 2015, international guidelines went the last step further and recommended treating all HIV-infected adults regardless of their CD4 count. This ultimate step was justified by the results of three randomized controlled trials, HPTN 052, Temprano ANRS 12136 and START. These three trials assessed the benefits and risks of starting ART immediately upon inclusion ("early ART") versus deferring ART until the current starting criteria were met ("deferred ART"). Taken together, they recruited 8427 HIV-infected adults in 37 countries. The primary outcome was severe morbidity, a composite outcome that included all-cause deaths, AIDS diseases, and non-AIDS cancers in the three trials. The trial results were mutually consistent and reinforcing. The overall risk of severe morbidity was significantly 44–57 % lower in patients randomized to early ART as compared to deferred ART. Early ART also decreased the risk of AIDS, tuberculosis, invasive bacterial diseases and Kaposi's sarcoma considered separately. The incidence of severe morbidity was 3.2 and 3.5 times as high in HPTN052 and Temprano as in START, respectively. This difference is mostly due to the geographical context of morbidity. The evidence is now strong that initiating ART at high CD4 counts entails individual benefits worldwide, and that this is all the more true in low resource contexts where tuberculosis and other bacterial diseases are highly prevalent. These benefits in addition to population benefits consisting of preventing HIV transmission demonstrated in HPTN052, justify the recommendation that HIV-infected persons should initiate ART regardless of CD4 count. This recommendation faces many challenges, including the fact that switching from "treat at 500 CD4/mm3" to "treat everyone" not only requires more tests and more drugs, but also more people to support patients and help them remain in care.
La tuberculose infantile (TBI) reste largement sous notifiee. La principale raison de la sous-notification est la difficulte diagnostique. Le diagnostic precoce et la prise en charge de la TBI demeurent donc un defi constant a relever. Il s’est agi d’une etude retrospective portant sur les donnees issues des dossiers de 94 enfants de 0 a 14 ans diagnostiques pour une tuberculose du 1er janvier 2015 au 31 decembre 2017 dans deux centres hospitaliers et universitaires d’Abidjan. Ainsi, la tranche d’âge de 0 a 4 ans etait la plus representee. La localisation pulmonaire etait predominante (71 %). Seulement 32 % des enfants ont ete diagnostiques bacteriologiquement en ayant recours a la microscopie (87%) et au tubage gastrique (50 %). Le gene Xpert n’a ete utilise que 11 fois et a decele 2 cas de resistance. La radiographie pulmonaire a ete realisee chez 87 enfants avec 91% d’anomalies observees. La co-infection TB/VIH etait de 24 %. A l’issue de la prise en charge, 71 % ont ete adresses dans un centre specialise pour la poursuite de leur traitement, 16 % sont decedes et 8,5 % etaient perdus de vue. Le diagnostic de la TBI demeure donc complexe. La vulgarisation des techniques moleculaires peut en ameliorer le diagnostic.Mots-cles: Tuberculose, enfant, diagnostic, AfriqueEnglish Title: Diagnostic and clinical aspects of childhood tuberculosis: about 94 cases collected in hospitals in Abidjan, Cote d'Ivoire, from 2015 to 2017English AbstractBackground Childhood TB (CTB) remains massively underreported. The main reason for underreporting is the difficulties with diagnosis. Early diagnosis and management of CTB thus remain a constant challenge to overcome. This was a retrospective chart review study of 94 children aged 0 to 14 diagnosed with Tuberculosis, conducted from 1st January 2015 to 31st December 2017 in 2 university hospitals. For the 94 records collected, the age group from 0 to 4 years was the most represented. The pulmonary localisation was predominant (71%). Only 32% of children were bacteriologically confirmed using microscopy (87%) and gastric aspiration (50%). The GeneXpert was used only 11 times and detected 2 resistance cases. Chest X-ray was performed in 87 children with 91% anomalies observed. The TB/HIV coinfection rate was 24%. At the completion of the treatment and care, 71% were referred to a specialized clinic for the continuation of their treatment and care, 16% died and 8.5% were lost to follow-up. Diagnosis of CTB remains challenging. The popularization of molecular techniques may improve its diagnosis.Keywords: Tuberculosis, child, diagnosis, Africa
Abstract Background HIV-1 DNA persists in infected cells, forming viral reservoirs. Pre-antiretroviral treatment (ART) HIV-1 DNA load was reported to predict ART success in European severely immunocompromised patients. The aim of this study was to determine whether HIV-1 DNA levels are associated with virological success in less severely immunocompromised patients who receive early ART in sub-Saharan Africa. Methods The association between pre-ART HIV-1 DNA and the virological response after 30 months on ART was studied in multivariate logistic regression in patients randomised to immediate ART groups in the Temprano trial, which assessed the benefits of early ART in HIV-infected adults in Côte d’Ivoire. HIV-1 DNA was quantified in peripheral blood mononuclear cell (PBMC) using real-time PCR. Results HIV-1 DNA levels were measured in 1013 patients. Their medians [IQR] of pre-ART CD4 count, HIV-1 RNA and HIV-1 DNA levels were 465 [379–578]/mm 3 , 4.7 [4.0–5.3] log 10 copies/ml and 2.9 [2.5–3.2] log 10 copies/million PBMC, respectively. Pre-ART HIV-1 DNA was significantly correlated with pre-ART HIV-1 RNA (R = 0.59, p < 0.0001). In multivariate analysis, HIV-1 DNA < 3 log 10 copies/million PBMC was significantly associated with virological success at M30 after adjustment for other key variables (ART regimen, IPT, sex, age, WHO clinical stage, CD4 and HIV-1 RNA; aOR 1.57; 95% CI 1.08–2.30; p = 0.02). Conclusion Low HIV-1 DNA was statistically associated with virological success in this population of sub-Saharan African adults who started treatment with a median pre-ART CD4 count at 465/mm 3 . HIV-1 DNA could become a useful tool for guiding some therapeutic decisions in the test-and-treat era. Trial registration TEMPRANO ANRS 12136 ClinicalTrials.gov, number NCT00495651, date of registration 03/07/2007.
SETTING: TEMPRANO was a multicentre, open-label trial in which human immunodeficiency virus (HIV) infected adults with high CD4 counts were randomised into early or deferred antiretroviral therapy (ART) arms with or without 6-month isoniazid preventive therapy (IPT) in a setting where the World Health Organization (WHO) recommends IPT in HIV-infected patients. Despite the WHO recommendation, IPT coverage remains low due to fear of the presence of undiagnosed active TB before prescribing IPT, and the related risk of drug resistance.OBJECTIVE: To report the frequency of undiagnosed TB in patients enrolled for IPT and describe the results of a 1-month buffer period to avoid prescribing IPT for active TB cases.DESIGN: Patients were screened using a clinical algorithm and chest X-ray at Day 0 and started on isoniazid at Month 1 if no sign/symptom suggestive of TB appeared between Day 0 and Month 1.RESULTS: Of 1030 patients randomised into IPT arms. 10% never started IPT at Month 1. Of these, 23 had active TB, including 16 with prevalent TB. Among the 927 patients who started IPT, 6 had active TB, including 1 with prevalent TB. Only 1 patient with active TB received IPT due to the 1-month buffer period between Day 0 and IPT initiation.CONCLUSION: In this study, 1.6% of adults considered free of active TB based on clinical screening at pre-inclusion actually had active TB.
To evaluate the implication of WHO guidelines for serodiscordant couples, we interviewed HIV-infected adults on their partner's serostatus. We found that 12% with more than 500 CD4+ cells/μl should be recommended antiretroviral treatment (ART) because their partner was seronegative; 24% could be recommended not to start ART because their partner was seropositive; and 64% could not be given any recommendation regarding ART early initiation because they had either no stable partnership (30%) or were in a stable partnership with a partner whose status they were not aware of (34%).
We here report the case of a 35-year old man with HIV-1 but with no previous medical-surgical history hospitalized in Abidjan, Côte d'Ivoire, due to fever, cough, dyspnea, chest pain and unfolding of the aortic arch observed on chest x-ray a week after having started antiretroviral therapy (ART). CT angiography of the thoracic aorta showed overall, extended aortic ectasia with mural thrombus. Transesophageal echocardiography objectified type A ascending aortic dissection (Stanford classification). The diagnosis of tuberculosis was confirmed based on Mycobacterium tuberculosis culture isolation. Eight years after, the patient was still alive without surgical treatment and complained of intermittent chest pain. Blood pressure was stable with moderate renal failure. We here report a rare case of aortic aneurism dissection in an adult patient with tuberculosis infected with HIV-1 during immune reconstitution inflammatory syndrome.
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