Correspondence
a comparative analysis of HIV service We declare no competing interests.
delivery in the northeast between 2013
and 2016.
We observed that the proportion
of individuals with new HIV infection
decreased by 10%, from 3326 in
2013 to 3007 in 2016. HIV positivity
among people who were tested for
HIV decreased from 898 (9%) of
10 198 individuals in 2013 to 2737 (7%)
of 40 006 in 2016, representing an
annual reduction of 8·4%, the slow­
est improvement in the region.
The facilities providing HIV testing
and prevention of mother-to-child
transmission of (PMTCT) HIV services
decreased by 57%, from 21 facilities
in 2013 to nine facilities in 2016,
whereas the facilities providing anti­
retroviral therapy decreased by 18%,
from 11 treatment centres to nine
centres in 2016. As depicted by the
negative annual change, the state
has a worsening trend for coverage
of PMTCT services and antiretroviral
therapy. Between 2013 and 2016, the
coverage of PMTCT services in Borno
State decreased from 13% to 12%, with
an annual rate of change of –2·7%.
This state had the second highest
antiretroviral therapy coverage after
Adamawa State at the start of the study
period; however, coverage reduced
dramatically to 18% in 2016 (annual
rate of change –41·2%), the worst trend
in northeast Nigeria.
Although we cannot establish
causality and are aware of the
limitations of monitoring HIV services
in armed conflict situations, these data
suggest that between 2013 and 2016
the insurgence might have contributed
to the poor HIV response in Borno State
but has not increased the incidence of
HIV infection. With the concerted effort
by the Nigerian Government, civil
society, and international organisations
to restore peace and stability in Borno
State, improvement of access to HIV
prevention, treatment, and care and
support services is imperative. Such
intervention is crucial since resurgence
of HIV infection could occur in the post-
conflict phase.
1258
disease is on a trajectory to become
*Babayemi O Olakunde,
Daniel A Adeyinka,
Sabastine S Wakdok,
Tolulope T Oladele,
Chamberline E Ozigbu
boolakunde@yahoo.com
National Agency for Control of AIDS (NACA),
Central Business District 900211, Abuja, Nigeria
(BOO, SSW, TTO); National AIDS & STIs Control
Programme, Federal Ministry of Health, Abuja,
Nigeria (DAA, CEO); University of Saskatchewan,
Saskatoon, SK, Canada (DAA); and University of
South Carolina, Columbia, SC, USA (CEO)
1 Mworozi EA. AIDS and civil war: a devil’s
alliance. Dislocation caused by civil strife in
Africa provides fertile ground for the spread
of HIV. AIDS Anal Afr 1993; 3: 8–10.
2 Hankins CA, Friedman SR, Zafar T,
Strathdee SA. Transmission and prevention
of HIV and sexually transmitted infections in
war settings: implications for current and
future armed conflicts. AIDS 2002;
16: 2245–52.
3 Mock NB, Duale S, Brown LF, et al. Conflict
and HIV: a framework for risk assessment to
prevent HIV in conflict-affected settings in
Africa. Emerg Themes Epidemiol 2004; 1: 6.
4 Spiegel PB, Bennedsen AR, Claass J, et al.
Prevalence of HIV infection in conflict-
affected and displaced people in seven
sub-Saharan African countries: a systematic
review. Lancet 2007; 369: 2187–95.
5 Bennett BW, Marshall BDL, Gjelsvik A,
McGarvey ST, Lurie MN. HIV incidence prior
to, during, and after violent conflict in
36 sub-Saharan African nations, 1990–2012:
an ecological study. PLoS One 2015;
10: e0142343.
6 Strand RT, Fernandes Dias L, Bergstrom S,
Andersson S. Unexpected low prevalence of
HIV among fertile women in Luanda, Angola.
Does war prevent the spread of HIV?
Int J STD AIDS 2007; 18: 467–71.
Liver disease mortality
trends: a response to
the editor
We read the Offline Comment by
Richard Horton (Jan 13, p 106) 1
that summarised the evidence and
current policy debate in England
around minimum unit pricing for
alcohol with interest. Unfortunately,
the Comment contained an import­
ant error, which has already been
repeated in UK parliamentary hear­
ings and that we would like to correct
to avoid it being repeated elsewhere.
This error is the statement that “liver
the biggest cause of death in England
and Wales”.
Although the 2017 Liver Disease
Commission2 in The Lancet highlighted
the substantial burden that alcohol
places on the UK National Health
Service and society more broadly,
liver disease was ranked only
tenth among the leading causes
of death in England and Wales in
2016. 3 8220 people died of liver
disease (2% of all deaths) compared
with, for example, 62 948 from
Alzheimer’s dis­ease and dementia
(12% of all deaths).3
The statement comes from the Liver
Disease Commission and originally
asserted that “liver disease surpassed
lung cancer…as the leading cause of
years of working life lost, and is set
to overtake ischaemic heart disease
within 2–3 years.” This statement is
broadly correct, although the precise
timeframe depends on one’s view on
future mortality trends.
We also emphasise that, contrary to
news reports,4 this assertion does not
mean that liver disease is also set to
overtake heart disease as the leading
cause of death in people of working
age. Heart disease kills nearly twice as
many people under 65 every year. Liver
diseases contribute a greater share of
years of working life lost because heart
disease deaths occur, on average, at
older ages.
We declare no competing interests.
*Colin Angus, Petra Meier,
John Holmes
c.r.angus@sheffield.ac.uk
Sheffield Alcohol Research Group, School of Health
and Related Research, University of Sheffield,
Sheffield, S1 4DA, UK
1 Horton R. Offline: Time to act on minimum unit
pricing of alcohol. Lancet 2018; 391: 106.
2 Williams R, Alexander G, Armstrong I, et al.
Disease burden and costs from excess alcohol
consumption, obesity, and viral hepatitis: fourth
report of the Lancet Standing Commission on
Liver Disease in the UK. Lancet 2017; published
online Nov 29. https://doi.org/10.1016/S0140-
6736(17)32866-0.
3 Office for National Statistics. Mortality statistics
- underlying cause, sex and age. https://www.
nomisweb.co.uk/query/select/
getdatasetbytheme.asp?theme=73 (accessed
Jan 26, 2018).
www.thelancet.com Vol 391 March 31, 2018
 Correspondence

4 Young S, for The Independent. Liver disease to
become biggest killer by 2020 with alcohol
and obesity to blame. Dec 1, 2017. http://www.
independent.co.uk/life-style/liver-disease-
premature-death-cause-killer-alcohol-
obesity-a8086441.html (accessed
Jan 26, 2018).
show any anomaly. Although acoustic
neurinomas are more frequent in
neurofibromatosis type 2, they have
also been reported in type 1.9 Cases
of internal auditory meatus enlarge­
ment in neurofibromatosis type 1
have also been described without any
7 Kühnisch J, Set J, Lange C, et al. Multiscale,
converging defects of macro-porosity,
microstructure and matrix mineralization
impact long bone fragility in NF1. PLoS One
2014; 9: e86115.
8 Valvassori GE. The radiological diagnosis of
acoustic neuromas. Arch Otolaryngol 1966;
83: 582–87.
9 Hekmatnia A, Ghazavi A, Marashi Shooshtari

Did Cro-Magnon 1 have associated acoustic nerve tumour,

neurofibromatosis
type 1?
The Cro-Magnon 1 skeleton corres­
ponds to a 28 000 BCE Homo sapiens
male individual that was discovered
in 1868 in a rock shelter in Les Eyzies,
France.1 Since its discovery, various
diagnoses have been proposed with
regards to a round polycyclic osteo­
lytic lesion on the right frontal bone,
measuring 37 mm x 27 mm (appendix):
post-mortem alteration due to the
soil,2 rickets, 3 actinomycosis, 4 and
Langerhans cell histiocytosis.5
Recently, we did a medical CT scan,
followed by a micro CT scan, on the
lesion. The results showed the exact
bone aspect of the pathological zone
and peripheral limits (figure A): a
limited resorption of the external
cortical bone, of granular aspect,
without peripheral sclerosis in the
internal table, which excludes a
malignant transformation. This
aspect agrees with the radio­logical
morphology of a subcutaneous
schwannoma with progressive bone
erosion in the context of neurofibro­
matosis type 1, as confirmed by
bio­­m edical literature 6,7 and direct
comparison with palaeopathological
reference collections (for example,
skull 101 of the Tessier collection, in
Amiens, France).
Additionally, an asymmetry of the
size of the internal auditory meatus
is visible after a micro CT scan exam­
ination and three-dimensional recon­
struct­ion of the Cro-Magnon 1 skull
(appendix), which could be related
to the dev­elopment of an acoustic
neur­inoma (a schwannoma).8 Exam­
ination of other nerve foramina at
the level of the skull base did not
MJ, Hekmatnia F, Basiratnia R. Imaging
review of neurofibromatosis: helpful aspects
with the cause of the enlargement for early detection. Iran J Radiol 2011;
being related to bone dystrophy
8: 63–74.
10 Kitamura K, Senba T, Komatsuzaki A. Bilateral
(bony dysplasia) or dural ectasia.10 internal auditory canal enlargement without
acoustic nerve tumor in von Recklinghausen
According to this retrospective neurofibromatosis. Neurofibromatosis 1989;
diagnosis, a new facial reconstruction 2: 47–52. See Online for appendix
of this individual can be proposed,
featuring the macroscopic aspect
of the disease (figure B). A further A
analysis of the rest of the skeleton
might be of interest to search for
other bone lesions with characteristics
of low growth rate.
We declare no competing interests.
*Philippe Charlier, Nadia Benmoussa,
Philippe Froesch,
Isabelle Huynh-Charlier,
Antoine Balzeau
philippe.charlier@uvsq.fr
Section of Medical Anthropology, University of
Versailles Saint-Quentin-en-Yvelines, 78180
Montigny-Le-Bretonneux, France (PC, NB, PF,
IH-C); Centre d’Accueil et de Soins Hospitaliers and
Institut de la Précarité et de l’Exclusion Sociale,
Nanterre, France (PC); Department of
B
Otolaryngology—Head and Neck Surgery, Rouen
University Hospital, Rouen, France (NB);
Department of Radiology, University Hospital
Pitié-Salpétrière, Paris, France (IH-C); and Section
of Human Paleontology, Department of
Prehistory, National Museum of Natural History,
Musée de l’Homme, Paris, France (AB)
1 Balzeau A, Grimaud-Hervé D, Détroit F,
Holloway RL, Combès B, Prima S. First
description of the Cro-Magnon 1 endocast
and study of brain variation and evolution in
anatomically modern Homo sapiens.
Bull Mem Soc Anthropol Paris 2013; 25: 1–18.
2 Broca P. Sur les crânes et ossements des
Eyzies. Bull Soc Anthropol Paris 1868;
3: 350–92
3 Collective discussion. Sur les crânes et les
ossements des Eyzies. Bull Soc Anthropol Paris
1868; 3: 416–46, 454–514, 554–78.
4 Dastugue J. Pathologie des hommes fossiles
de l’abri de Cro-Magnon. L’Anthropologie
1967; 71: 479–92 (in French).
5 Thillaud PL. L’histiocytose X au Paléolithique
(sujet no 1 de Cro-Magnon): problématique
du diagnostic ostéo-archéologique.
L’Anthropologie (Paris) 1981; 85: 219–39.
6 National Institutes of Health Consensus Figure: Features of the lesion in the Cro-Magnon 1 skull
Development Conference. (A) Detail of the bone erosion at the micro CT examination; bar is 0·5 cm.
Neurofibromatosis: conference statement. (B) Full facial reconstruction with clear visibility of the benign tumour on the
Arch Neurol 1988; 45: 575–78. frontal zone.

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