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1
Challenges in HIV Treatment and Care in a Resource
Constrained Environnement
Serge Paul Eholié
Xavier Anglaret
Affiliation:•ANRS research site in Côte d’Ivoire•Infectious Disease Department, Treichville University Hospital, Abidjan•Inserm U897, ISPED, Bordeaux University
2
INTRODUCTION• In 1998-2001, pilot programs gave evidence that ART could
be feasible and effective in resource limited settings: – UNAIDS Initiative (Uganda, Côte d’Ivoire, Chile, Vietnam)– Countries (Senegal) or NGOS (MSF) initiatives
• From 2000 to 2010, large programs confirmed that ART was feasible and effective in resource limited settings: – As of june 2010, approx 6.6 million people on ART in low- and
middle-income countries (4.5 millions in sub-Saharan Africa); – With success in Scaling program and decentralization, almost
19 000 health facilities implemented;– With extensive evidence that ART reduces morbidity and
mortality in routine conditions.
3
Successes of ART in low and middle income settings
4
SUCCESSES
However, challenges remain!!!!
5
Challenges to ensure the successof ART programs in low- and middle-income countries
* Increase coverage
* Ensure financing sustainability
* Reduce AIDS and HIV non-AIDS morbidity, and mortality
* Implement 2010 WHO guidelines
* Improve assessment of programs efficacy
* Improve prevention, diagnosis, and management of adverse events
* Improve retention
* Ensure comprehensive HIV care
6
CHALLENGE 1
Coverage
7
Number of people receiving ART in december 2009
ART coverage in 2009, based on 2006 guidelines
ART coverage in 2009, based on 2010 guidelines
South Africa 971 556 56% 37%
Kenya 336 980 65% 48%
Nigeria 320 024 31% 21%
Zambia 283 863 85% 64%
Thailand 216 118 76% 67%
Uganda 200 413 57% 39%
Botswana 145 190 >95% 83%
Cameroon 76 228 41% 29%
Côte d’Ivoire 72 011 39% 28%
COVERAGE, December 2009: 36% in LMICIntraregional differences
Towards universal access: Scaling up priority HIV/AIDS interventions in the health sector. Progress report 2010
8
Challenge 2:Financing sustainability
80-95% of funds are from international donors
Achilles’ heel of ART programs
Source Hecht R, Lancet 2010Courtesy of PM Girard
9
CHALLENGE 3
REDUCE MORBIDITY AND MORTALITY
ART Mortality
Countries
* Zambia, Stringer JSA, JAMA 2006
* Senegal, Etard JF, AIDS 2006
* Zimbabwe, Erisktrup C, JAIDS 2007
* Haiti, Tuboi H, JAIDS 2009
* Honduras, Tuboi H, JAIDS 2009
Mortality rate
7%
23.1%
29.5%
12.4%
10.1%
11
Risk factors for mortality
• Male sex• Clinical stage, WHO 3-4, CDC C• Body Mass Index <18-19 Kg/m2
• Haemoglobin<10g/dl• CD4 <200 cells/mm3
• Viral load >5 log10 copies/ml
Stringer JF JAMA 2006, Etard JF AIDS 2006, Erisktrup C JAIDS 2007, Moh R AIDS 2007, Tuboi SH JAIDS 2009, Mills EJ AIDS 2011,
Toure AIDS 2008, Lawn AIDS 2009
12Severe P, N Engl J Med 2010
200-350 CD4/mL
< 200 CD4/mL
Mortality reduction 75%
13
Challenge 3: REDUCE MORBIDITY AND MORTALITY
1) Certainly start ART earlier… but how much earlier ?
< 350 CD4 : minimal threshold worldwide1
< 500 CD4 : minimal threshold in increasing number of rich countries2,3
> 500 CD4 : ongoing randomized trials (START, Temprano4…)
2) Improve access to care, diagnosis and treatment of comon morbity (TB, bacterial diseases…)
1-WHO, Antiretroviral Therapy for HIV infections in adults and adolescents, Recommandations, 2010, h http://www.who.int ttp://www.who.int2- Prise en Charge Me´dicale des Personnes Infecte´es par le VIH Ministry of Health France, 2008. http://www.sante-sports.gouv.fr/3- Panel on Antiretroviral Guidelines for Adults, and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. DHHS, USA,20094- Temprano study ANRS 12 136, clinicaltrials.govNCT00495651
14
Challenges 4
IMPLEMENT 2010 WHO GUIDELINES
15
Main changes in WHO 2010 Guidelines
* Start earlier: CD4 < 350/mm3 or WHO stage 3,4
(vs. 200 CD4 or WHO stage 4 or WHO stage 3 & 200-350)
* First line regimen:
* Include viral load in routine monitoring
* Second line regimen:
WHO, Antiretroviral Therapy for HIV infections in adults and adolescents, Recommandations, 2010, h http://www.who.int ttp://www.who.int
16
Main changes in WHO 2010 Guidelines
1) Start earlier: CD4 < 350/mm3 or WHO stage 3,4
(vs. 200 CD4 or WHO stage 4 or WHO stage 3 & 200-350)
* First line regimen:
* Include viral load in routine monitoring
* Second line regimen:
WHO, Antiretroviral Therapy for HIV infections in adults and adolescents, Recommandations, 2010, h http://www.who.int ttp://www.who.int
17
ART at 350 CD4 vs. 200 CD4
Where to find patients at earlier stage of HIV disease ?
18
ART at 350 CD4 vs. 200 CD4
• Find patients with higher CD4 counts??• Increase Voluntary Counseling and Testing (VCT)• Facilitate or strenghten the link between
VCT centers and ART clinics• Anticipate and face an increase in the number of
patients on ART• Demonstrate cost effectiveness/acceptability to
governments and donors
19Nash D, AIDS 2011
8 countries:3 Eastern Africa, 3 Southern Africa, 1 Western Africa,
1 Central Africa267 sites (ICAP centers)
121 404 patients
Median CD4136 cells/l
20
ART at 350 CD4 vs. 200 CD4
• Find patients wiht higher CD4 counts– Change the paradigm – Target HIV negative patients
• Increase Voluntary Counseling and Testing (VCT)• Facilitate or strenghten the link between
VCT centers and ART clinics• Anticipate and face an increase in the number of patients on
ART• Demonstrate cost effectiveness/acceptability to governments
and donors
21
ART at 350 CD4 vs. 200 CD4
• Find asymptomatic patients– Change the paradigm – Target HIV negative patients
• Increase Voluntary Counseling and Testing (VCT)• Facilitate or strenghten the link between
VCT centers and ART clinics• Anticipate and face an increase in the number of patients on
ART• Demonstrate cost effectiveness/acceptability to governments
and donors
22
Insufficient time
Consent process
Lack of knowledge/training
Language
Lack of patient acceptance
Pre-test counselling requirements
Competing priorities
Inadequate reimbursement
Prenatal
24 barriersOther medical
settings
23 barriers
Why don’t physicians test for HIV? A review of the US littérature. Burke RC, AIDS 2007
Much of the failure to expand HIV Testing guidelines are related to physicians
23
Standard of Care and Intervention periods in a routine HIV Testing Cohort in an out patient department, Durban, SA
Standard of Care(14 weeks)
Intervention(12 weeks)
Patients tested/offered, N (%)
HIV-infected patients, N (%)
HIV infection identified,
average N per week
137/435 (31.5%)
102/137 (74.5%)
8
1414/2912 (48.6%)
463/1414 (32.8%)
39
Bassett IV, JAIDS 2007
We need a pro-active approach!!!!
24
ART at 350 CD4 vs. 200 CD4
• Find asymptomatic patients– Change the paradigm – Target HIV negative patients
• Increase Voluntary Counseling and Testing (VCT)– HIV testing is general medicine (« it’s all HCW business »)– Make rapid tests available
• Facilitate or strenghten the link between
VCT centers and ART clinics• Anticipate and face an increase in the number of patients on
ART• Demonstrate cost effectiveness/acceptability to governments
and donors
25
ART at 350 CD4 vs. 200 CD4
• Find asymptomatic patients– Change the paradigm – Target HIV negative patients
• Increase Voluntary Counseling and Testing (VCT)– HIV testing is general medicine (« it’s all care workers business »)– Make rapid tests available
• Facilitate or strenghten the link between
VCT centers, Ante Natal Clinic and ART clinics• Anticipate and face an increase in the number of patients on
ART• Demonstrate cost effectiveness/acceptability to governments
and donors
26
ART at 350 CD4 vs. 200 CD4
• Find asymptomatic patients– Change the paradigm – Target HIV negative patients
• Increase Voluntary Counseling and Testing (VCT)– HIV testing is general medicine (« it’s all care workers business »)– Make rapid tests available
• Facilitate or strenghten the link between
VCT centers and ART clinics• Anticipate and face an increase in the number of patients
on ART• Demonstrate cost effectiveness/acceptability to governments
and donors
27
<200
% ELIGIBLE<250 (2008 criteria)
%ELIGIBLE<350
%ELIGIBLE
Age 15-24 25+
22.4%41.5%
25.9% (1,15 increase)51.1% (1,24 increase)
41.4% (1,85 increase)63.1% (1,53 increase)
Sex Female Male
35.2%37.5%
43.4% (1,23 increase)40.5% (1,20 increase)
57.2%(1,63 increase)55.0%(1,47 increase)
Overall 35.7% 43.7% (1,23 increase) 56.8% (1.59 increase)
Source: Konde-Lule J, AIDS Care 2010
< 350 vs <200 = 59% increase in demand of services
28
Adjusted HR(95% CI)
p
Patient volume Low (reference) Medium High
-1.40 (1.03-1.92)
1.34 (0.95-1.89) 0.47
Clinical Staff Burden Low (reference) Medium High
-1.01 (0.78-1.32)
1.02 (0.69-1.52) 0.91
Pharmacy Staff Burden Low (reference) Medium High
-1.68 (1.29-2.19)
2.63 (1.70-4.06) < 0.001
Patients Volume, Human Resources Levels and Attrition from HIV Treatment Programs in Central Mozambique
Lambdin BH, JAIDS 2011
Staff burden : do not forget those who deliver the pills !(200-300 patients/day or more !!!!)
29
ART at 350 CD4 vs. 200 CD4
• Find asymptomatic patients– Change the paradigm – Target HIV negative patients
• Increase Voluntary Counseling and Testing (VCT)– HIV testing is general medicine (« it’s all care workers business »)– Make rapid tests available
• Facilitate or strenghten the link between
VCT centers and ART clinics• Anticipate and face an increase in the number of patients
on ART– Set up or strenghten task shifting
• Demonstrate cost effectiveness/acceptability to governments and donors
30
ART at 350 CD4 vs. 200 CD4• Find asymptomatic patients
– Change the paradigm – Target HIV negative patients
• Increase Voluntary Counseling and Testing (VCT)– HIV testing is general medicine (« it’s all care workers business »)– Make rapid tests available
• Facilitate or strenghten the link between
VCT centers and ART clinics• Anticipate and face an increase in the number of patients on
ART– Set up or strenghten task shifting
* Demonstrate benefits and cost effectiveness for acceptability by governments and donors
31
CD4<200 CD4<350 Difference
P-Y of ART 40 752 534 61 292 374 + 20 539 839 (+ 50%)
* AIDS/ deaths
8 180 609 6 501 483 - 1 679 126 (- 21%)
* Life years
162 032 903 163 012 351 + 979 448 (+ 1%)
* New HIV infections
11 198 013 9 946 912 - 1 251 101 (- 11%)
Source: Stover J, AIDS Research and Treatment 2011
Benefits on morbidity, mortality and transmission
Cost effectiveness: Walensky R, Ann Intern Med 2009
32
Main changes in WHO 2010 Guidelines
1) Start earlier : CD4 < 350/mm3 or WHO stage 3,4
(vs. 200 CD4 or WHO stage 4 or WHO stage 3 & 200-350)
2) First line regimen:* Include viral load in routine monitoring* Switch when VL>5,000 copies/ml (vs. >10,000 copies/ml in
2006 guidelines)* Second line
* Stop ABC+ DDI. * AZT/TDF+XTC+ATVr/LPVr
* Start as soon as possible in case of tuberculosis and HVB
33
Challenges for first line regimen
* Costs
* Phase out d4T
* Choice between AZT and TDF- Haematological toxicity, LD (AZT)
- Renal safety, bone mineral toxicity (TDF)
* Choice between efavirenz and nevirapine- Percentage of young women, pregnancy (NVP)
- One pill, once a day, TB co-morbidity (EFV)
* Availabililty of fixed drug combination
* Paediatric formulation
Cost, efficacy, cost-effectiveness and tolerance issues
34
Phase out stavudine : issues* Lingering stocks of d4T
- 30 countries have implemented d4T phase out plan (12/2009)
- 60% first line started with d4T (12/2009)
* Finance constraints – TDF or ZDV first line 2-3 times as high as d4T regimen
– … at a time when we still need to scale up the number of
people initiating ART
Need for :
- Further drug price reductions (AZT and TDF)
- Increase funds for ART programme
Renaud-Thery F, AIDS Res and treatment 2011
35
Bendavid E, AIDS 2011
WHO MEETING REPORT. Short-Term Priorities for Antiretroviral Drug Optimization, London UK, 18-19 avril 2011.
Prevalence of Renal dysfunction in HIV-seropositive untreated patients in Sub saharan Africa
* Nigeria (n=400)
Emen CP, Nephrol Dial Transplant 2008
* South Africa (n= 1322)
Brennan A, AIDS 2011
* Zambia (n=24 596)
Mulenga BL, AIDS 2008
* Msango L (n=335)
AIDS 2011
38%
35.7%
33.7%
63.6%
36HIV is THE kidney killer (not tenofovir)
Incidence of severe renal dysfunction
DART (n=3316) eGFR < 30ml/mn* Median time to severe renal dysfunction14 weeks IQR [4-52]
* TDF 41/2469 (1.7%)
* NVP (Open-label) 4/247 (1.6%)
* ABC (Nora Study) 3/300 (1.0%)
* NVP (Nora Study) 4/300 (1.3%)
Reid A, Clin Infect Dis. 2008
P=0.94
* Zambia, 30/960 (3.2%), M12 (Chi BH, JAIDS 2010)
* Lesotho, 31/566 (5.5%), M12 (Bygrave H, Plos One 2011)
38
Follow WHO guidelines for tenofovir prescription
* Creatinine dosage (creatinine clearance calculation)
* Proteinuria with urines sticks
39
Main changes in WHO 2010 Guidelines
1) Start earlier : CD4 < 350/mm3 or WHO stage 3,4
2)°First line:
3) Include viral load in routine monitoring
* Second line
WHO, Antiretroviral Therapy for HIV infections in adults and adolescents, Recommandations, 2010, h http://www.who.int ttp://www.who.int
40
Case for routine use of viral load
* Best tool to assess adherence
* Maintain first line therapy
* Earlier switch to second line limit NRTI and
NNRTI cumulative resistance;
* Cost effectiveness
41
Status at 12 months of ART :
Messou E, JAIDS 2010
42
Case for routine use of viral load
* Best tool to assess adherence
* Maintain first line therapy
* Earlier switch to second line limit NRTI and
NNRTI cumulative resistance;
* Cost effectiveness
M6N=996
M12N=925
Undectable VL 799 (80.2%) 693 (75%)
Detectable VL
Resistance ≥ 1 mutation
197 (19.8%)
7%
232 (25%)
11%
Messou E, JAIDS 2010
Interest of early viral load (M4-M6) Interventions to reinforce adherence, maintain first line
Half of patients with detectable viral load at 12 months have no resistance mutations
44
Case for routine use of viral load
* Best tool to assess adherence
* Maintain first line therapy
* Earlier switch to second line limit NRTI and
NNRTI cumulative resistance; Keiser et al, AIDS 2011
* Cost effectiveness
45
Case for routine use of viral load
* Best tool to assess adherence
* Maintain first line therapy
* Earlier switch to second line limit NRTI and
NNRTI cumulative resistance;
* Cost effectiveness
46
Relative increase in Life Expectancy (vs. only one line
of ART)
Incremental Cost
Effectiveness Ratio1
($ US/LYS)
Incremental Cost
Effectiveness Ratio2
($ US/LYS)
Switch to 2nd line on :
- WHO stage 3-4 event 24.3 1670 1670
- 50% in peak CD4 46.4 2120 Dominated
- HIV RNA*, 1 log or
return to pretreatment
HIV-RNA
61.3 2280 1990
Source: Kimmel AD,JAIDS 20101 HIV RNA Tests Cost 87 USD2 HIV RNA Tests Cost 25 USD
47
Challenges for use of viral load in RLS
* Affordability (once again… costs…) :
- Advocacy (same as before with ARV drugs)
- Generics tests
* Availability in rural settings:
- Point of care
- Dried Blood Spot
- Power (electricity)
- Maintenance Rouet F and Rouzioux C, Expert Rev Mol Diagn 2007Calmy A, AIDS 2008
48
Main changes in WHO 2010 Guidelines
1)Start earlier : CD4 < 350/mm3 or WHO stage 3,4
2) First line:
«3) Include viral load in routine monitoring
4) Second line
49
Challenges for second line* Costs
* Time to switch to second line in patients failing 1st
line
* Effective NRTI backbone
* Place of drugs already ordered or used (ABC/ddI)
* Fixed Drug Combination or co-blister
* Availability of ritonavir heat stable capsule
* Use in TB co-infected patients
* Forecasting (Renaud-Thery F, AIDS Res and Treatment 2011)
50
Regimen Low incomecountries
Middle IncomeCountries
d4T + 3TC + NVP $ 89 $ 88
AZT + 3TC + NVP $ 149 $ 226
AZT + 3TC + EFV $ 220 $ 281
TDF + 3TC + EFV $ 210 $ 268
TDF + FTC + EFV $ 255 $ 325
TDF + 3TC + NVP $ 190 $ 243
AZT + 3TC + LPV/r $ 585 $ 1150
TDF + 3TC + LPV/r $ 590 $ 1070
TDF/AZT + 3TC + ATV/r $ 395/465
ARV cost per patient per year
Sources: WHO/UNAIDS/UNICEF, Clinton Foundation Health Access Iinitiative, MSF
51
76.5% LPV/r45% suboptimal NRTI regimen??
1.4% of adults receiving ART
Towards universal access: Scaling up priority HIV/AIDS interventions in the health sector Progress report 2010
52
Challenges for second line* Costs
* Time to switch to second line in patients failing 1st
line Keiser et al, AIDS 2011
* Effective NRTI backbone
* Place of drugs already ordered or used (ABC/ddI)
* Fixed Drug Combination or co-blister
* Availability of ritonavir heat stable capsule
* Use in TB co-infected patients
* Forecasting (Renaud-Thery F, AIDS Res and Treatment 2011)
53
Second line efficacy in LMIC* South Africa (n= 1648)*
46% failure > 6 months FU
Factors associated
* Cambodgia** (n=70, all LPV/r)
15% VL failure, FU 24 months
* Thailand (n=95)
2nd line based on genotype
test: VL failure
15% (M24), 10% (M36);
Pujades-rodriguez M,
Jama 2010
Low CD4 cells counts
Suboptimal regimen (NRTI +++)
Ferradini L, J Int Aids Soc 2011
May Myat W, J int Assoc Phys
Aids Care 2011
* MSF programs, ** ESTHER
54
Challenges for second line* Time to switch to second line in patients failing 1st line
* Costs
* Effective NRTI backbone
* Place of ABC and ddI
* Fixed Drug Combination or co-blister
* Availability of ritonavir heat stable capsule
* Paediatric formulation
* Use in TB co-infected patients
* Forecasting
Renaud-Thery F, AIDS Res and Treatment 2011
55
Challenge 5
Third line: Salvage Therapy in LMIC
1-5% or more??
56
Challenges for Third Line
* Cost of darunavir, raltegravir, and etravirine
* Use of genotype test: necessary or essential?
* Assessment of real needs
* Pilot studies assessing : resistance patterns in patients
failing 2nd line, place of adherence reinforcement,
adherence efficacy and tolerance of third line drugs…
(ANRS third line trial in 5 west african countries)
57
Comparaison of prices for ART regimen according to line of treatment
MSF, Antiretroviral Therapy price reductions, 13th edition, July 2010
X 7
58
Challenges for Third Line
* Cost of darunavir, raltegravir, and etravirine
* Place of genotype test: necessary or essential?
* Set up pilot studies assessing resistance patterns
in patients failing 2nd line, place of adherence
reinforcement, efficacy and tolerance of third line
drugs… (ANRS third line trial in 5 West African
countries, 1 South East Asian country)
59
Challenge 6
Long term issues :
• Improve monitoring• Ensure long term adherence• Prevent and take care of long-term toxicity• Diagnose and treat HIV non-AIDS morbidity
60
ART laboratory monitoring (WHO 2010)
Phase of HIV Management
Recommended Test
Desirable Test
At HIV diagnosis CD4 HBs Ag, anti-HCV?Pre ART CD4
At start of ART CD4 Hb for AZT1
Creatinine clearance for TDF2
ALT for NVP3
On ART CD4Hb for AZT1
Creatinine clearance for TDF2
ALT for NVP3 At clinical failure CD4 Viral loadAt immunological failure Viral load
1 Recommended test in patients with high risk of adverse events associated with AZT (low CD4 or low BMI).
2 Recommended test in patients with high risk of adverse events associated with TDF (underlying renal disease, older age group, low BMI, diabetes, hypertension and concomitant use of a boosted PI or nephrotoxic drugs).
3 Recommended test in patients with high risk of adverse events associated with NVP ( ART naive HIV+ women with CD4 > 250 cells/mm3, HCV co-infection)
61
62
Long term monitoring issues We need tests for :
• Metabolic syndrom…
• Renal function …
• Bone Mineral density …
• Cardio-vascular assessment …
• Malignancies diagnosis …
63
Challenges for long term follow-up
• HIV and ageing: 3 millions HIV individuals >50 years in sub-Saharan Africa (14% of overall HIV adults)
• Access to treatment for: malignancies, cardiovascular diseases/neurological diseases, diabetis, dyslipidemia, renal insufficiency …
Mills EJ, Lancet Infect Dis 2010Negin J, JAIDS 2010Nakimuli-Mpungu E, Neurobehavioral HIV Medicine 2011
64
Challenges 7
ENSURE COMPREHENSIVE HIV CARE
Percentage of household expendituresNon ARVs and non CD4 costs among patients receiving ART
Cameroun1 Côte d’Ivoire2
Health expenditures
Medical visits and others
Transportation
20 USD/month
44%
12%
24.3 USD/month
50%
25%
65
1- Boyer S, Bull WHO 2010
2- Beaulière A, PLoS ONE 2010
66
Challenges 8
IMPROVE RETENTION
67
Towards universal access: Scaling up priority HIV/AIDS interventions in the health sector. Progress report 2010
68
* Serious barriers
- Transport costs
- Time needed for treatment
- Logistical challenges
* Less influencal factors
- Stigma around HIV/AIDS
- Side effects
Patients’ perception
69
1) Set up and maintain simple standardized monitoring systems
2) Reliably ascertain true treatments outcomes
3) Reduce death rates
4) Ensure uninterrupted drugs supplies
5) Use simple, non toxic and free ART-regimens
6) Decentralized ART clinics and reduce frequency of visits
7) Reduce indirect patients costs
8) Strenghten ART-links within and between health services and the community
9) Use ART-services to deliver other useful interventions
10) Innovative (tining out of the box intervention)
Harries AD, Trop Med Intern Health 2010
Challenge 9: Human resources
* Motivation: Increase salary
* Struggle the brain draining of health care workers to national
or international NGOs (disparities)
* Cure an emerging disease, « the perdiemitis »
(Ridde V, Trop Med Int Health 2010)
* Set up the task shifting
(monitoring ART: nurses vs doctor, 1.09 (95% CI 0.89–1.33)
(Sanne I, CIPRA Study-South Africa, Lancet 2010)
70
71
Challenges 10
Earthquake (Haiti)Floads
Dryness and Food crisis (eg; East Africa)Socio-political crisis (Eg:Côte d’Ivoire)
Out-of-controlHumanitarian crisis
Jeopardize 10-15 years of successes! !
72
http://www.lemonde.fr/idees/article/2011/04/05/l-attention-aux-malades-du-sida-barometrede-l-humanite_1502634_3232.html
“Justice must prevail against those who exploit patients as political weapons and thereby undermine years of human rights progress. Much has been said and written about the need to treat as war crimes all failures to protect civilians during conflict. Obstructing access to needed medical care should rank high among these.”
73
Conclusion
74
« A perpetual challenge will be living up with the commitment and courage of those who went before- health care workers, scientists, and affected persons- who faced the unknown and took risks. In general 30 years of AIDS confirm that there is indeed « more to admire in men than to despise »
75
Courtesy of S Matheron
76
Acknowledgements* E Bissagnéné
* A Calmy
* JF Delfraissy
* DK Ekouevi
* PM Girard
* C Kouanfack
* PS Sow
* M Vitoria
77
Grazie Merci
ChoukranThank you
Obrigado
Mo
Dieureudieuf Djaraman
Asanti
I ni tché
M"pussda barka
Bondodi
AkpéNgiyabonga
Mo Pi Wo
Amesegnalehu
Gracias
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