- Email: [email protected]
Transmission of HIV-2: another perspective
Reflection & Reaction can be engaged as equal partners in these efforts and build their capacity to develop, apply, and regulate them.6,7 The establishment of a common research and policy formulation network within Africa, through which overseas collaborators can interact as equal partners, would be a first step towards restoring the ideal balance of decision making. We suggest that a pan-African network be established for coordinating and regulating these activities. This network should operate under the auspices of the WHO (African region). Much can be learned from the experiences of the African Malaria Vaccine Testing Network,
now part of the African Malaria Network.8
fax +43 1 2600 28447; email [email protected]
Hassan Mshinda, Gerry F Killeen, Wolfgang R Mukabana, Evan M Mathenge, Leonard EG Mboera, and Bart GJ Knols
References
HM and GFK are at the Ifakara Health Research and Development Centre, Ifakara, Tanzania; WRM and EMM are at the University of Nairobi, Nairobi, Kenya; LEGM is at the National Institute for Medical Research, Dar es Salaam, Tanzania; and BGJK is at the International Atomic Energy Agency, Vienna, Austria. Correspondence: Dr Bart GJ Knols, IAEA, Wagramerstrasse 5, A-1400, Vienna, Austria. Tel +43 1 2600 28426;
1 http://www.grandchallengesgh.org (accessed March 18, 2004). 2 Kilama WL. Equipping Africa’s researchers for global collaboration. http://www.scidev.net/ Opinions/index.cfm?fuseaction=readopinions&itemid= 211&language=1 (accessed Feb 24, 2004). 3 Scott TW, Takken W, Knols BGJ, Boëte C. The ecology of genetically modified mosquitoes. Science 2002; 298: 117–19. 4 Knols BGJ, Scott TW. Ecological challenges concerning the use of genetically-modified mosquitoes for disease control: synthesis and future perspectives. In: Takken W, Scott TW, eds. Ecological aspects for application of genetically modified mosquitoes. Dordrecht: Kluwer Academic Publishers, 2003: 235–42 5 Benedict MQ, Robinson AS. The first releases of transgenic mosquitoes: an argument for the sterile insect technique. Trends Parasitol 2003; 19: 349–55. 6 Harris E, Tanner M. Health technology transfer. BMJ 2000; 321: 817–20. 7 Harris E. Building scientific capacity in developing countries. EMBO Reports 2004; 5: 7–11. 8 http://www.amanet-trust.org (accessed March 18, 2004).
Transmission of HIV-2: another perspective Perpétua Gomes and colleagues’ article on transmission of HIV-2 in Portugal,1 deserves some comments due to features that in our experience could explain the acquisition and dissemination of this virus in our country. The authors report their experience at the Hospital Egas Moniz, Lisboa, in the south of Portugal, where Africans from west Africa were followed. They described 57% of the patients as natives of Guinea-Bissau or Cape Verde; thus 43% were presumably of Portuguese origin. At the Hospital S João and School of Medicine, Porto, located in the north of Portugal, from 1985 to September 2003 we have observed 132 (4%) HIV-2-positive patients among 3251 HIV-infected patients. Diagnosis was based on US Centers for Disease Control and Prevention/WHO criteria, and all the tests for identification of HIV and monitoring of infection were done at the Molecular Biology Centre in our institution, a reference laboratory for Portugal. The first cases of HIV-2 infection in our department were identified in 1985 in two haemophiliac patients with AIDS and in the wife of one of them; she is still symptom-free 19 years after diagnosis. These diagnoses were done retrospectively, because at
that time serologic tests specific for HIV-2 were not available. These three patients were white and had never visited or lived in Africa. 126 of the 132 (95%) of the HIV2-positive patients were white and of Portuguese origin; only six heterosexual patients were Africans— from Guinea-Bissau, Cape Verde, and Angola, all former Portuguese colonies. Their age range was 11–74 years (mean 37·9; SD 14·1) and 76 (60%) were male. From this cohort of 126 white patients, 67 (53%) reported unprotected heterosexual intercourse and in 27 (40%) of these a monogamous relationship was described. One patient had bisexual behaviour. 55 (44%) patients had received transfusions of blood or its derivatives before 1986, and 19 of these patients had haemophilia. In three patients, vertical transmission was documented (in two of them the diagnosis was done only at the ages of 15 and 24 years).2 Risky sexual behaviour and blood transfusions in Africa were reported by 30 (24%) patients: 24 admitted promiscuous heterosexual contact with native Africans, one was a bisexual man who reported sexual intercourse with native Africans, and five received blood transfusions in that continent. Of the patients that have never been in Africa, an indirect relationship could
THE LANCET Infectious Diseases Vol 4 May 2004
be established in 35 (27%): 15 were sexual partners of those who returned from Africa with HIV-2 infection, 17 were transfused in Portugal with blood from three donors infected in Africa, and three reported multiple instances of sexual intercourse with native Africans in Portugal.3,4 Of the remaining 62 (49%) patients, 37 were transfused in Portugal, 13 were promiscuous heterosexuals, nine were sexual partners of these patients, and three acquired the infection by vertical transmission. Most of the patients infected in Africa were in Guinea-Bissau between 1960 and 1974, when it is presumed that the rapid dissemination of HIV-2 occurred.5 During the period of colonial wars, more than one million soldiers stayed in Portugal’s African colonies, and most of them had sexual risk behaviour as was described by our patients. When they returned to Portugal they denied any other risks for HIV infection. The low transmissibility of HIV-2 and the behaviour of these individuals may explain the progression of this epidemic in countries like Portugal, where the infection is controlled. Vertical transmission of HIV-2 is an infrequent event, and we could document it in only three of the 59 children of 27 HIV-2-infected mothers.
http://infection.thelancet.com
For personal use. Only reproduce with permission from The Lancet.
265
Reflection & Reaction The fact that the infection affected a population with low or no risk behaviours, as well as the low transmissibility of the virus, could explain the slow progression of the HIV-2 epidemic in the developed world and could lead to its disappearance outside Africa in the near future if people arriving from these endemic areas can be screened and treated. Our experience supports the opinion that in the developed world early dissemination of the HIV-2 infection was related to the temporary residence of soldiers and dependents in Africa during colonial wars and its connection with sexual behaviour and blood transfusions.4,6 We cannot deny the importance of parenteral transmission of HIV-2 in
native Africans, but it is more relevant to consider sexual behaviour as the important mode of transmission of the virus to Portuguese people in Africa and its dissemination outside this continent. António Mota-Miranda, Helena Gomes, Rosário Serrão, and Fernando Araújo AM-M is head of department, HG is chief of the Infectious Diseases In-patient Clinic, and RS is an infectious diseases assistant, in the Infectious Diseases Department, Hospital S João and School of Medicine, Porto, Portugal; FA is chief of the Molecular Biology Centre, Immunohaemotherapy Service, Hospital S João and School of Medicine, Porto. Correspondence: Dr António MotaMiranda, Infectious Diseases Department, Hospital S João & School
of Medicine, Alameda Professor Hernani Monteiro, 4202–451 Porto, Portugal. Tel/fax +351 22 5512216; email [email protected] or [email protected] References 1 2
3
4
5
6
Gomes P, Abecassis A, Almeida M, Camacho R, Mansinho K. Transmission of HIV-2. Lancet Infect Dis 2003; 3: 683–84. Mota-Miranda A, Gomes H, Lima-Alves C, Araújo F, Cunha-Ribeiro LM, Taveira N. Perinatally acquired HIV-2 infection diagnosed at 15 and 24 years of age. AIDS 2001; 15: 2460–61. Mota-Miranda A, Gomes MH, Serrão MR, et al. HIV-2 infection in blood transfusion patients. 5th European Conference on Clinical Aspects and Treatment of HIV Infection; Copenhagen; September 1995. Abstract 264. Gomes M, Lima-Alves C, Ribeiro N, Serrão R, Marques R, Mota-Miranda A. Epidemiological aspects of HIV-2 infection in Portugal. 41st Interscience Conference on Antimicrobial Agents and Chemotherapy; Chicago; December 2001. Abstract I-236. Lemey P, Pybus OG, Wang B, Saksena NK, Salemi M, Vandamme AM. Tracing the origin and history of the HIV-2 epidemic. Proc Natl Acad Sci USA 2003; 100: 6588–92. Mota-Miranda A, Gomes MH, Sarmento R, et al. HIV-2 infection in the north of Portugal. IXth International Conference on AIDS; Berlin; June 1993. Abstract PO-C09-2798.
Reflection & Reaction is a section for comment on current topics of interest in infectious diseases, in the forms of commissioned writing, and a place for you to share your views. If you would like to respond to an article in The Lancet Infectious Diseases or discuss a topical issue in infection, please send your manuscript, together with full contact details, by email to [email protected], or by fax to +44 (0)20 7424 4557, or post it to The Lancet Infectious Diseases, 32 Jamestown Road, London NW1 7BY, UK.
266
THE LANCET Infectious Diseases Vol 4 May 2004
http://infection.thelancet.com
For personal use. Only reproduce with permission from The Lancet.
now part of the African Malaria Network.8
fax +43 1 2600 28447; email [email protected]
Hassan Mshinda, Gerry F Killeen, Wolfgang R Mukabana, Evan M Mathenge, Leonard EG Mboera, and Bart GJ Knols
References
HM and GFK are at the Ifakara Health Research and Development Centre, Ifakara, Tanzania; WRM and EMM are at the University of Nairobi, Nairobi, Kenya; LEGM is at the National Institute for Medical Research, Dar es Salaam, Tanzania; and BGJK is at the International Atomic Energy Agency, Vienna, Austria. Correspondence: Dr Bart GJ Knols, IAEA, Wagramerstrasse 5, A-1400, Vienna, Austria. Tel +43 1 2600 28426;
1 http://www.grandchallengesgh.org (accessed March 18, 2004). 2 Kilama WL. Equipping Africa’s researchers for global collaboration. http://www.scidev.net/ Opinions/index.cfm?fuseaction=readopinions&itemid= 211&language=1 (accessed Feb 24, 2004). 3 Scott TW, Takken W, Knols BGJ, Boëte C. The ecology of genetically modified mosquitoes. Science 2002; 298: 117–19. 4 Knols BGJ, Scott TW. Ecological challenges concerning the use of genetically-modified mosquitoes for disease control: synthesis and future perspectives. In: Takken W, Scott TW, eds. Ecological aspects for application of genetically modified mosquitoes. Dordrecht: Kluwer Academic Publishers, 2003: 235–42 5 Benedict MQ, Robinson AS. The first releases of transgenic mosquitoes: an argument for the sterile insect technique. Trends Parasitol 2003; 19: 349–55. 6 Harris E, Tanner M. Health technology transfer. BMJ 2000; 321: 817–20. 7 Harris E. Building scientific capacity in developing countries. EMBO Reports 2004; 5: 7–11. 8 http://www.amanet-trust.org (accessed March 18, 2004).
Transmission of HIV-2: another perspective Perpétua Gomes and colleagues’ article on transmission of HIV-2 in Portugal,1 deserves some comments due to features that in our experience could explain the acquisition and dissemination of this virus in our country. The authors report their experience at the Hospital Egas Moniz, Lisboa, in the south of Portugal, where Africans from west Africa were followed. They described 57% of the patients as natives of Guinea-Bissau or Cape Verde; thus 43% were presumably of Portuguese origin. At the Hospital S João and School of Medicine, Porto, located in the north of Portugal, from 1985 to September 2003 we have observed 132 (4%) HIV-2-positive patients among 3251 HIV-infected patients. Diagnosis was based on US Centers for Disease Control and Prevention/WHO criteria, and all the tests for identification of HIV and monitoring of infection were done at the Molecular Biology Centre in our institution, a reference laboratory for Portugal. The first cases of HIV-2 infection in our department were identified in 1985 in two haemophiliac patients with AIDS and in the wife of one of them; she is still symptom-free 19 years after diagnosis. These diagnoses were done retrospectively, because at
that time serologic tests specific for HIV-2 were not available. These three patients were white and had never visited or lived in Africa. 126 of the 132 (95%) of the HIV2-positive patients were white and of Portuguese origin; only six heterosexual patients were Africans— from Guinea-Bissau, Cape Verde, and Angola, all former Portuguese colonies. Their age range was 11–74 years (mean 37·9; SD 14·1) and 76 (60%) were male. From this cohort of 126 white patients, 67 (53%) reported unprotected heterosexual intercourse and in 27 (40%) of these a monogamous relationship was described. One patient had bisexual behaviour. 55 (44%) patients had received transfusions of blood or its derivatives before 1986, and 19 of these patients had haemophilia. In three patients, vertical transmission was documented (in two of them the diagnosis was done only at the ages of 15 and 24 years).2 Risky sexual behaviour and blood transfusions in Africa were reported by 30 (24%) patients: 24 admitted promiscuous heterosexual contact with native Africans, one was a bisexual man who reported sexual intercourse with native Africans, and five received blood transfusions in that continent. Of the patients that have never been in Africa, an indirect relationship could
THE LANCET Infectious Diseases Vol 4 May 2004
be established in 35 (27%): 15 were sexual partners of those who returned from Africa with HIV-2 infection, 17 were transfused in Portugal with blood from three donors infected in Africa, and three reported multiple instances of sexual intercourse with native Africans in Portugal.3,4 Of the remaining 62 (49%) patients, 37 were transfused in Portugal, 13 were promiscuous heterosexuals, nine were sexual partners of these patients, and three acquired the infection by vertical transmission. Most of the patients infected in Africa were in Guinea-Bissau between 1960 and 1974, when it is presumed that the rapid dissemination of HIV-2 occurred.5 During the period of colonial wars, more than one million soldiers stayed in Portugal’s African colonies, and most of them had sexual risk behaviour as was described by our patients. When they returned to Portugal they denied any other risks for HIV infection. The low transmissibility of HIV-2 and the behaviour of these individuals may explain the progression of this epidemic in countries like Portugal, where the infection is controlled. Vertical transmission of HIV-2 is an infrequent event, and we could document it in only three of the 59 children of 27 HIV-2-infected mothers.
http://infection.thelancet.com
For personal use. Only reproduce with permission from The Lancet.
265
Reflection & Reaction The fact that the infection affected a population with low or no risk behaviours, as well as the low transmissibility of the virus, could explain the slow progression of the HIV-2 epidemic in the developed world and could lead to its disappearance outside Africa in the near future if people arriving from these endemic areas can be screened and treated. Our experience supports the opinion that in the developed world early dissemination of the HIV-2 infection was related to the temporary residence of soldiers and dependents in Africa during colonial wars and its connection with sexual behaviour and blood transfusions.4,6 We cannot deny the importance of parenteral transmission of HIV-2 in
native Africans, but it is more relevant to consider sexual behaviour as the important mode of transmission of the virus to Portuguese people in Africa and its dissemination outside this continent. António Mota-Miranda, Helena Gomes, Rosário Serrão, and Fernando Araújo AM-M is head of department, HG is chief of the Infectious Diseases In-patient Clinic, and RS is an infectious diseases assistant, in the Infectious Diseases Department, Hospital S João and School of Medicine, Porto, Portugal; FA is chief of the Molecular Biology Centre, Immunohaemotherapy Service, Hospital S João and School of Medicine, Porto. Correspondence: Dr António MotaMiranda, Infectious Diseases Department, Hospital S João & School
of Medicine, Alameda Professor Hernani Monteiro, 4202–451 Porto, Portugal. Tel/fax +351 22 5512216; email [email protected] or [email protected] References 1 2
3
4
5
6
Gomes P, Abecassis A, Almeida M, Camacho R, Mansinho K. Transmission of HIV-2. Lancet Infect Dis 2003; 3: 683–84. Mota-Miranda A, Gomes H, Lima-Alves C, Araújo F, Cunha-Ribeiro LM, Taveira N. Perinatally acquired HIV-2 infection diagnosed at 15 and 24 years of age. AIDS 2001; 15: 2460–61. Mota-Miranda A, Gomes MH, Serrão MR, et al. HIV-2 infection in blood transfusion patients. 5th European Conference on Clinical Aspects and Treatment of HIV Infection; Copenhagen; September 1995. Abstract 264. Gomes M, Lima-Alves C, Ribeiro N, Serrão R, Marques R, Mota-Miranda A. Epidemiological aspects of HIV-2 infection in Portugal. 41st Interscience Conference on Antimicrobial Agents and Chemotherapy; Chicago; December 2001. Abstract I-236. Lemey P, Pybus OG, Wang B, Saksena NK, Salemi M, Vandamme AM. Tracing the origin and history of the HIV-2 epidemic. Proc Natl Acad Sci USA 2003; 100: 6588–92. Mota-Miranda A, Gomes MH, Sarmento R, et al. HIV-2 infection in the north of Portugal. IXth International Conference on AIDS; Berlin; June 1993. Abstract PO-C09-2798.
Reflection & Reaction is a section for comment on current topics of interest in infectious diseases, in the forms of commissioned writing, and a place for you to share your views. If you would like to respond to an article in The Lancet Infectious Diseases or discuss a topical issue in infection, please send your manuscript, together with full contact details, by email to [email protected], or by fax to +44 (0)20 7424 4557, or post it to The Lancet Infectious Diseases, 32 Jamestown Road, London NW1 7BY, UK.
266
THE LANCET Infectious Diseases Vol 4 May 2004
http://infection.thelancet.com
For personal use. Only reproduce with permission from The Lancet.