Stand-alone HIV clinic expected to save money, help patients

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Elimination of infectious human immunodeficiency virus from human T-cell cultures by synergistic action of CD4-Pseudomonas exotoxin and reverse transcriptase inhibitors

We have previously described a recombinant protein, designated CD4(178)-PE40, consisting of the human immunodeficiency virus (HIV) envelope glycoprotein-binding region of human CD4 linked to the translocation and ADP-ribosylation domains of Pseudomonas aeruginosa exotoxin A. By virtue of its affinity for gp120 (the external subunit of the HIV envelope glycoprotein), the hybrid toxin selectively binds to and kills HIV-1-infected human T cells expressing surface envelope glycoprotein and also inhibits HIV-1 spread in mixed cultures of infected and uninfected cells. We now report that CD4(178)-PE40 and reverse transcriptase inhibitors exert highly synergistic effects against HIV-1 spread in cultured human primary T cells. Furthermore, combination treatment can completely eliminate infectious HIV-1 from cultures of human T-cell lines. This conclusion is based on protection of a susceptible cell population from HIV-induced killing, complete inhibition of virus protein accumulation, and elimination of HIV DNA (as judged by quantitative polymerase chain reaction analysis). The results highlight the therapeutic potential of treatment regimens involving combination of a virostatic drug that inhibits virus replication plus an agent that selectively kills HIV-infected cells.

Sexually transmitted arthritis syndromes

Sexually transmitted infections may provoke a wide variety of rheumatic lesions. Disseminated N. gonorrhoeae infection leads to septic arthritis, which may be rapidly destructive but which responds promptly to appropriate antibiotic therapy. In contrast, both gonococcal and nongonococcal infections may lead to aseptic "reactive" arthritis or Reiter's syndrome. Inheritance of HLA B27 confers a relative risk of 30 to 50 times for the development of this condition. The demonstration of C. trachomatis antigen in joint material from a minority of patients suggests that direct interaction between microbial components and class I HLA antigens in the joint may be central to the pathogenesis of this disease. Arthralgia and arthritis occur in up to 50% of individuals in the prodrome of hepatitis B infection. Joint symptoms may be accompanied by urticarial or cutaneous vasculitic lesions, especially on the legs; both features resolve with the onset of jaundice. Hepatitis B infection is also a major cause of necrotizing vasculitis, which may or may not be associated with overt hepatitis. Seronegative arthritis, including Reiter's syndrome, psoriatic arthritis, and undifferentiated arthritis, a Sjögren's-like syndrome, vasculitis, and myopathies have been described in association with HIV infection. It is clear that synovitis occurs in those patients despite the fact that HIV is present in immune cells within the joint during inflammatory arthritis and that both antigen presentation and lymphocyte responsiveness within the joint are impaired. Nevertheless, synovitis may occur in the presence of marked CD4-positive lymphocyte depletion. Rheumatic syndromes, including arthralgia, inflammatory arthritis, and neuropathic arthritis, may occur during any stage of congenital or acquired syphilis. Syphilitic synovitis responds well to antibiotic therapy, but neuropathic lesions cannot be treated effectively. Septic arthritis has rarely been described as a complication of disseminated Mycoplasma or Urea-plasma infections, and joint lesions sometimes associated with erythema nodosum have also been reported in lymphogranuloma venereum and granuloma inguinale.

[Methods of hospital management of patients with HIV infection]

Analysis of data on case-management and referral of persons infected by HIV is based upon a cross-sectional study at the national level. The evolution of trends over the last 2 years reveals a rise in the number of AIDS cases undergoing full hospital treatment and a decline in the number of seropositives hospitalised. Irrespective of the clinical presentation, there has been above an increase in hospital care day treatment and consultations. Amongst all AIDS patients there is a growing need for increased treatment and case in the home as well as intermediary length hospital case management--a crucial consideration for the future.

Office management of patients infected with the human immunodeficiency virus (HIV)--1990

Human immunovirus (HIV) infections and related diseases continue to consume a major portion of health care resources nationwide and in the state of Oklahoma. There were 162 new cases of acquired immunodeficiency syndrome (AIDS) diagnosed in Oklahoma in 1989 and an additional 347 cases of other HIV infections were reported. It appears almost certain that few physicians in practice, if any, will escape seeing HIV-related illnesses. It is, therefore, important that all physicians have an adequate understanding of the basic management of these related illnesses. The reader is referred to our original article in the October 1988 issue of the Journal of the Oklahoma State Medical Association, which outlined the office management of HIV-positive patients. The current paper represents an update on this problem. Many of the original tenets and descriptions of management remain the same, and they will not be repeated.

Selective induction of toxicity to human cells expressing human immunodeficiency virus type 1 Tat by a conditionally cytotoxic adenovirus vector

The human immunodeficiency viruses (HIVs) primarily infect CD4+ T lymphocytes, leading eventually to the development of a systemic immune dysfunction termed acquired immunodeficiency syndrome (AIDS). An attractive strategy to combat HIV-mediated pathogenesis would be to eliminate the initial pool of infected cells and thus prevent disease progression. We have engineered a replication-defective, conditionally cytotoxic adenovirus vector, Ad-tk, whose action is dependent on the targeted expression of the herpes simplex virus type 1 thymidine kinase gene (tk), cloned downstream of the HIV-1 long terminal repeat, in human cells expressing the HIV-1 transcriptional activator Tat. Infection of Tat-expressing human HeLa or Jurkat cells with Ad-tk resulted in high-level tk expression, which was not deleterious to the viability of these cells. However, in the presence of the antiherpetic nucleoside analog ganciclovir, Ad-tk infection resulted in a massive reduction in the viability of these Tat-expressing cell lines. As adenoviruses are natural passengers of the human lymphoid system, our results suggest adenovirus vector-based strategies for the targeted expression, under the control of cis-responsive HIV regulatory elements, of cytotoxic agents in HIV-infected cells for the therapy of HIV-mediated pathogenesis.

Immunology of HIV infection, I: Biology of the interferons

Interferons (IFN) are the prototypic biologic response modifiers. They comprise a multigene family of regulatory proteins and glycoproteins that affect a variety of cellular functions, including normal and neoplastic cell growth, immune reactivity, and host-parasite interactions. Their importance to basic cell biology and cellular immune defense, and their interactions with human immunodeficiency viruses (HIV) on the molecular and cellular levels, form the basis for this review.

Search for epitope-specific antibody responses to the human immunodeficiency virus (HIV-1) envelope glycoproteins signifying resistance to disease development

It is essential for the development of strategies for prevention and therapy of human immunodeficiency virus (HIV-1) infections to define host factors playing a dominant role in determining the clinical outcome of infection. Antibodies directed against restricted regions of the HIV-1 glycoproteins gp120 and gp41 are likely to represent important factors involved in host defense against HIV-1. Definition of qualitative and quantitative differences in the spectrum of anti-gp120 and anti-gp41 antibodies between two vastly different groups of HIV-1-infected individuals, long-term asymptomatic carriers, and individuals with acquired immunodeficiency syndrome (AIDS) who died, might reveal the epitope specificity of antibodies contributing to prevention of clinical disease. To accomplish this goal, sera from both groups were assayed for antibodies recognizing synthetic peptides from gp120/gp41 which were shown in earlier experiments to mimic epitopes on the two HIV-1 glycoproteins. None of the sera recognized all of the distinct 27 peptides from gp120 and gp41. The spectrum of antibodies was distinct for each of the sera from both groups of HIV-1-infected individuals. Nevertheless, antibody responses distinguishing the two groups from each other were discerned. In particular, it was possible to predict the unfavorable outcome of disease by comparative measurements of levels of antibodies to a peptide (303-338), corresponding to the entire V3 hypervariable loop of gp120 and/or by providing evidence for declining levels of these antibodies during the course of infection. Antibodies recognizing additional peptides [(219-245), (280-306), (425-452), (658-682), (729-758), (808-845), and (845-862)] were significantly less prevalent in AIDS patients than in asymptomatic carriers. It appears possible that maintenance of high levels of the respective antibodies would contribute to preventing AIDS in HIV-1-infected individuals. Active immunization with antigens containing epitopes defined by the respective peptides and/or administration of the corresponding antibodies may be considered as a modality for therapy of HIV-1 infections.

Human immunodeficiency virus infection, women, and pregnancy. Ethical issues

Should women of childbearing age be screened for the presence of infection with the human immunodeficiency virus? If infected, should they be instructed not to become pregnant or not to bear children? Should pregnant women and their offspring be included in research protocols that explore ways to prevent or treat perinatally acquired HIV disease? This article examines ethical controversies related to HIV screening, counseling, and research and suggests that resolutions may come from achieving greater clarity about the ultimate goals of obstetric and gynecologic care.

Primary care of women infected with the human immunodeficiency virus

AIDS is the leading cause of death among women aged 25 to 34 years in New York City. Gynecologic care should be directed toward early identification and aggressive treatment of infectious and neoplastic processes that may take a more fulminant course in immunosuppressed women. Dealing with women's contraceptive needs highlights the problem of preventing sexually transmitted diseases through contraceptive technology. Public health policies and recommendations will be of no avail without an educated and supportive medical community.

HIV and the obligation to treat

The paper is an attempt to review the basis for the claim that physicians have a professional obligation to treat AIDS patients. Considered are the historical record, two professional codes of ethics, and several recent articles. The paper concludes that the arguments considered, which attempt to support the claim that physicians have an obligation to treat, fail. It is suggested, rather, that common humanity, which physicians share with those who suffer from AIDS, ought to be the basis for engaging in the care of AIDS patients.

Care of the infant born exposed to human immunodeficiency virus

The expanding epidemic of HIV infection in reproductive-age women, the availability of antiretroviral therapy for children, and recommendations for increased case identification activities augur a time when more and more pediatricians are going to be called on to care for HIV-exposed infants. This article outlines a comprehensive medical framework for the care of these children from the labor and delivery setting to the nursery, outpatient clinic, and the emergency room. It includes issues of infection control; medical, developmental, and psychosocial care; and laboratory evaluations. Finally, it address the need for long-term follow-up of all children born exposed to HIV.

[How can we organize the fight against H.I.V.?]

The aim of this article is to highlight the different ways of fighting against H.I.V. With AZT, using peptide T, the author has looked at the latest theories and research being undertaken and their respective successes. He reminds us that the AIDS vaccination is not to be found tomorrow.

The role of liaison psychiatry in an AIDS unit

The experience of a liaison psychiatry team working in the setting of an AIDS unit is described. Several clinical themes are identified which highlight crucial issues with regard to both diagnosis and management. These issues are illustrated by case histories. Discussion draws attention to the value of using a biopsychosocial model in order to understand aetiology and to formulate appropriate management. Issues related to staff involvement provide a further theme for discussion.

A collaborative approach to outpatient care of patients with HIV infection

Patients with human immunodeficiency virus (HIV)-related disease have a host of related medical and other problems that respond to a collaborative model of health care. At the Infectious Disease Clinic at the Department of Veterans Affairs Medical Center, San Francisco, physicians and nurses provide collaborative outpatient health care for more than 500 HIV-infected patients in several specialty clinics.

Human immunodeficiency virus infection in pregnancy

Among an estimated 1 million to 1.5 million Americans infected with HIV, about 10 per cent are women. Moreover, almost 30 per cent of HIV infection among women is acquired through heterosexual activity. Therefore, the average obstetrician/gynecologist is not sheltered from dealing with HIV. This article offers guidelines for caring for HIV-infected pregnant women during antepartum, intepartum, and postpartum phases.

A survey of exposures, practices and recommendations of surgeons in the care of patients with human immunodeficiency virus

Policy makers face a conflict between satisfying concerns of health care workers (HCW) about the occupational risk of human immunodeficiency virus (HIV) infection and ensuring adequate care for patients. This conflict is particularly severe in the field of surgery. We mailed a questionnaire on the surgical care of patients infected with HIV to 1,461 surgeons in New York City and Philadelphia, and 551 (37.7 per cent) responded. Although 1.9 per cent currently were testing all patients for HIV, 42.6 per cent of surgeons believed that all patients in their hospital should be tested. Of the surgeons who responded, 6.3 per cent refused to treat any patient infected with HIV. Less than 50 per cent recommended the use of barrier precautions on all patients in their hospital. Surgeons in New York City were significantly more likely than those in Philadelphia to favor separate facilities for HIV-infected patients. Surgeons considering themselves at higher occupational risk were more likely than those at lower risk to favor widespread testing, separate facilities and use of precautions. Surgeons reported a wide range of opinions. Their approach to the use of barrier precautions differs from the Centers for Disease Control recommendations. The patterns observed suggest that distinct policies may be appropriate for different hospitals.

A putative approach for gene therapy against human immunodeficiency virus (HIV)

It is proposed here that a form of intracellular immunity can be devised which would protect cells from virus infection and, in particular, could be used as a treatment for the human immunodeficiency virus (HIV) infected individual. Following in vitro immunization of naive human B lymphocytes with reverse-transcriptase (RT) or HIV transactivator protein (tat), messenger RNA (mRNA) would be isolated from these cells. Using the mRNA molecules as templates, copy DNA (cDNA) molecules encoding the RT or tat-specific immunoglobulins, are prepared and amplified by the polymerase chain reaction. After engineering of the antibody encoding cDNAs to provide appropriate intracellular addressing information, the cDNAs would be used to transfect stem cells of HIV infected individuals in vitro. The presence, in the cytoplasm and nucleus, of antibodies which had been selected to interfere with the reproduction of the virus, would protect these cells from infection. Autologous transplantation of such cells would confer resistance against HIV replication by these stem cells and their progeny in the treated individual. Such a strategy may also be useful against other retroviruses and could provide resistance against retrovirally triggered leukemia.

Asymptomatic patients with HIV infection. Keeping them well

Primary care physicians need to be prepared to counsel and manage patients with human immunodeficiency virus (HIV) infection. Asymptomatic seropositive patients should be seen quarterly, and T4 lymphocyte counts should be followed. Other serologic markers that may detect disease progression are p24 antigen and beta 2 microglobulin. Abnormalities in the levels of these markers may influence the decision to initiate early antiretroviral therapy. Therapeutic regimens are now available for delaying progression of HIV disease and for preventing Pneumocystis carinii pneumonia, the most common opportunistic infection to develop in patients with HIV infection. Whether antiretroviral therapy should be initiated in all asymptomatic HIV-positive patients remains to be seen. Physicians can do their part by educating themselves about HIV infection so they can provide competent, nonjudgmental care to patients and by supporting legislation to protect the rights of HIV-infected persons.

[Malnutrition--a clinically relevant problem in HIV-1 infection?]

Until now, recommendations for nutrition therapy of HIV-infected subjects can only be regarded as preliminary, because of the lack of scientific results regarding the interactions between HIV-infection and nutrition. HIV-infected patients have a high risk to become malnourished during the course of the disease, as a consequence of multiple pathogenetic factors--similar to the nutritional problems of tumor patients. At the moment, the following procedure is recommended in order to treat or prevent HIV-associated malnutrition: The nutritional status and history should be assessed in each HIV-positive subject as early as possible. Independent of the actual nutritional status, each patient should obtain a nutrition education. A continuous nutrition therapy becomes necessary in the case of evident or imminent malnutrition. Nutrients should be applied by oral access as long as possible. But especially for patients with opportunistic infections of the GI-tract accompanied by malabsorption, total parenteral nutrition may be the only effective way of nutrition.

Proposed guidelines for agencies serving persons with developmental disabilities and HIV infection

The development of procedural guidelines for serving people with developmental disabilities living in the community and infected with HIV was discussed. The need for ethical decision-making and universal infectious disease recommendations that allow for the provision of these services in the "least restrictive" environment was emphasized.

[Symptomatic HIV infection. Approaches to rational therapy]

The symptomatic HIV-infection is characterized by the involvement of multiple organs with a predominance of infectious complications. Treatment of these complications usually follows established therapeutic regimens for the resulting diseases of affected organs. Successful reconstitution of the immunodeficiency resulting from HIV-infection has been unsuccessful so far. Recently, promising results have been obtained by the treatment of patients with antiviral substances which inhibit viral replication. The prototype substance, Zidovudine (AZT) has been proven to be beneficial for patients in advanced stages of the disease and more recently has been shown to delay the occurrence of full-blown AIDS in patients with AIDS-related complex. In consequence, substances with less side effects such as Dideoxycytidine or Dideoxyinosine are currently under investigation.