[Multicenter study of long-term management of HIV exposed and HIV infected children. Study organization and aims]

In order ot improve and standardize medical and psychosocial care for infants born to HIV-positive mothers, a prospective multicenter study has been initiated at 6 university hospitals in West-Germany in 1987. Aims of the study are: 1) determination of the rate of vertical HIV-transmission, relevant maternal risk factors and the clinical symptomatology of pre-or perinatally acquired HIV-infections, 2) identification of immunological and virological laboratory markers important for the verification and staging of HIV-infections in infants, 3) elaboration of an interdisciplinary approach to the care of HIV-infected children and their families, integrating medical care, social and psychological attendance.

HIV infection in state hospitals: case reports and long-term management strategies

Issues facing state psychiatric hospitals as a result of the epidemic of human immunodeficiency virus (HIV) are illustrated by five cases. These issues include use of universal precautions to prevent transmission of HIV, medical diagnosis and management of HIV-infected patients, management of threatening behavior by infected patients, management of patients' sexual behavior, and discharge planning. The authors suggest that institutions will be required to ensure that sexual behavior between patients does not occur or to offer patients condoms or other means to protect themselves from infection. They recommend upgrading the medical capabilities of state hospitals so that they can competently provide long-term combined medical and psychiatric care to HIV-infected patients.

HIV infection and health policy

The epidemic of human immunodeficiency virus (HIV) infection has given an urgency to health policy dilemmas that have long been brewing. By exacerbating long-standing problems, the epidemic has surpassed what we find tolerable and has pressured politicians and health officials to find solutions. Whether the approaches they take will substantially contribute to solving the underlying problems is unclear. Many persons engaged in health policy believe that in responding to the AIDS crisis we may be defining our society for future historians. Judgement may be passed on how compassionately we care for those who are sick, how effectively we choose our public health measures, and how creatively we apply our scientific knowledge. This paper addresses six challenges that face policymakers: (a) protecting people from discrimination, (b) designing testing and screening programs, (c) developing safe and effective antiviral drugs, (d) planning for future vaccine trials, (e) organizing and delivering health care to sufferers of HIV infection, and (f) financing such health care.

Adolescents & AIDS. Three Michigan physicians reach out to educate youth about AIDS/HIV

Three Michigan doctors are taking promising new approaches to bring home the tough health care issues facing adolescents in the 1990's--most importantly, AIDS. All three approaches, which range from a school-based clinic to a questionnaire, attempt to solve specific, and difficult problems--like HIV infection--by improving the broader health care education and treatment needs of all adolescents. Only one of the approaches singles out HIV infection as its sole target. But all three provide new avenues to deal with this problem--avenues adolescents are willing and capable of traveling.

Strategies in therapy and immunoprophylaxis of human immunodeficiency virus infection

In designing antiviral drugs and therapeutic schemes some basic considerations should be taken into account: 1. RNA viruses and especially HIV (Human Immunodeficiency Virus) respond to environmental changes with evading mutations, hence, the high degree of variability of these viruses. All drugs interfering with viral functions will presumably give rise to resistant variants. 2. Approaches using cytotoxic peptides may induce adverse immune responses. Vaccines may elicit neutralizing antibodies, cellular cytotoxic responses, or both. The limitations of subunit vaccines or oligopeptides in eliciting cell mediated cytotoxicity in all vaccinees are outlined. Recent developments and the suitability of the SIV mac/rhesus monkey model are reviewed. The importance of adjuvants is indicated.

Report of the symposium on the use of intravenous gammaglobulin in adults infected with the human immunodeficiency virus

On July 27, 1989, the International Conference on Molecular Aspects of Immune Response and Infectious Diseases devoted a symposium to the subject of the use of intravenous gamma globulin (IVIG) in acquired immunodeficiency syndrome (AIDS). The information presented confirmed that IVIG benefits human immunodeficiency virus (HIV)-infected children with recurrent infections and that much remains to be learned about the influence of IVIG in adult AIDS. The symposium participants recognized the urgent need to develop randomized clinical trials using a control group to assess the efficacy of a treatment with IVIG in PGL (persistent generalized lymphadenopathy), ARC (AIDS-related complex), and AIDS. To prepare this report, a committee was established, including individuals with expertise in immunology, immunopharmacology, microbiology, virology, infectious diseases, general medicine, and pediatrics and representing research experience in academia and hospitals. After an introduction to the report with a summary of immunotherapeutic agents under evaluation to treat HIV infection, section 1 lays out the present understanding of the disease pathogenesis. Section 2 then outlines the treatment of HIV-seropositive individuals, discussing the uncertainties that any treatment entails. Section 3 discusses the rationale for treating HIV-infected individuals with IVIG, and Section 4 examines the major differences between IVIG and hyperimmunoglobulins for the treatment of HIV infection. Section 5 looks at IVIG as a mean to delay the emergence of opportunistic infections and restore immunocompetence in AIDS and related illnesses, and Sections 6 and 7 suggest a pilot protocol on the use of IVIG in association with low-dose or standard-dose zidovudine (AZT).(ABSTRACT TRUNCATED AT 250 WORDS)

High dose intact-immunoglobulin treatment for an HIV-infected asymptomatic carrier with hemophilia

Intravenous administration of a high dose of intact-immunoglobulin to a human immunodeficiency virus (HIV) infected patient with hemophilia A, whose total lymphocyte and CD4 positive lymphocyte counts showed a decreasing tendency, resulted in a gradual rise in these cell counts. The results were quite reproducible on another occasions. Therefore, intravenous administration of gammaglobulin (IVGG) was thought to be effective for preventing further deterioration of cellular immunity and progression from asymptomatic carrier (AC) to AIDS related complex (ARC)/AIDS in hemophilia patients.

Fewer new cases of HIV infection in Helsinki

The number of new serologically diagnosed HIV infections has decreased in Helsinki since 1986. The clinical search for infections was started in 1983 and the serodiagnostic search in late 1984. The maximum yearly number of new HIV infections was 40 cases in 1986. In 1987 and 1988 the corresponding numbers were 31 and 29, although the number of tests had increased. During the first nine months of 1989 only 16 HIV infections have been diagnosed. The levelling off, and even decrease, in the number of new cases of HIV infection gives cause for optimism about the chances of success of the campaign against AIDS by means of education, information and active screening programmes.

Characteristic immunophenotyping artefact seen in patients with anti-mouse immunoglobulin antibodies

Patients treated with murine monoclonal antibodies develop anti-mouse immunoglobulin antibodies which can interfere with flow cytometry of lymphocytes, giving rise to high levels of nonspecific staining. This artefact can be avoided by using separated, washed lymphocytes for immunophenotyping.

Allogeneic bone marrow transplantation, zidovudine, and human immunodeficiency virus type 1 (HIV-1) infection. Studies in a patient with non-Hodgkin lymphoma

Human immunodeficiency virus type 1 (HIV-1)-infected patients with non-Hodgkin lymphoma are classified as having the acquired immunodeficiency syndrome (AIDS). Allogeneic bone marrow transplantation is a successful therapy for patients with lymphoma who have a poor prognosis. Combined therapy with allogeneic bone marrow transplantation and the antiviral drug zidovudine has the potential advantage of protecting the new donor hematopoietic-lymphoid and monocyte-macrophage cells from HIV-1 infection. A 41-year-old man infected with HIV-1 who had lymphoma was treated with high-dose cyclophosphamide and total body irradiation followed by allogeneic bone marrow transplantation. Before transplantation he received high-dose zidovudine for 2 weeks (5 mg/kg body weight intravenously every 4 hours) and after transplantation he received a lower maintenance dose (1.33 mg/kg body weight intravenously every 4 hours). No untoward toxicities attributable to zidovudine were observed. Bone marrow engraftment occurred on day 17. Chromosome and restriction fragment length polymorphism analyses demonstrated complete chimerism. Peripheral blood mononuclear cells and bone marrow samples were negative for HIV-1 by culture and polymerase chain reaction gene amplification 32 days after transplantation. The patient died 47 days after transplantation because of tumor relapse. Analysis of autopsy tissue showed no evidence of HIV-1 by either culture (brain, bone marrow, lymph node, and tumor specimens) or by polymerase chain reaction gene amplification for HIV-1 RNA and DNA sequences (brain, bone marrow, heart, kidney, liver, lung, rectosigmoid, spleen, and tumor specimens). Immunologic monitoring showed loss of HIV-1 antibody. Adoptive immunologic transfer was shown to be present to both tetanus and diphtheria antigens. Our case suggests that the HIV-1-infected recipient cells may have been eradicated secondary to the bone marrow ablative chemo-radiotherapy and that zidovudine may be able to prevent the establishment of HIV-1 infection in donor hematopoietic-lymphoid cells.

An open study of interferon in HIV-antibody-positive men

Alpha-2a-recombinant interferon (Roferon A) was given subcutaneously in a dose of 3 mega units twice weekly for 15-18 months to 14 HIV-antibody-positive, p24-antigen-negative men with minimal HIV-related disease. Interferon was well-tolerated and safe. Although there was either improvement or lack of deterioration initially in 22 out of 26 HIV disease markers, including lymphadenopathy, thrombocytopenic purpura and nail fungal infection, there were 11 instances of HIV disease indicators appearing during the study. At 15 months, six patients were withdrawn from the study because of clinical and immunological deterioration.

The intrapartum management of the HIV-infected mother and her infant

The number of HIV-infected pregnant women in the United States is steadily increasing. While seroprevalence rates vary widely by geography, as many as 2 to 5 per cent of pregnant women in epicenters are seropositive. Medical management of the HIV-infected woman during labor and delivery depends on the clinical stage of her disease. Many will be asymptomatic or mildly symptomatic and can be managed as usual. For others, delivery may be complicated by concomitant infections and AIDS-related conditions. Between 25 and 40 per cent of infants born to HIV infected mothers will acquire HIV infection. Transmission of HIV from mother to her infant can occur in utero, intrapartum, or postpartum by breastfeeding. Infants who escape intrauterine infection are exposed to HIV-infected maternal blood and secretions at the time of delivery. Precautions should be taken to minimize intrapartum exposure by removing blood and secretions from the surfaces and mucous membranes of the infant as soon as possible after birth. In addition, procedures that involve disruption of the infant's intact skin should be avoided when possible until maternal blood and secretions have been removed. The risk of nosocomial transmission of HIV is low (less than 1 per cent following needlestick exposure). Nevertheless, labor and delivery represent times when exposure to blood and body fluids can be anticipated. Precautions that are designed to prevent parenteral exposure and exposure of mucous membranes and nonintact skin of health care workers to blood and body fluids should be used routinely for all patients.

A protocol for outpatient management of asymptomatic human immunodeficiency infection

The epidemic of HIV infection and its consequences are being increasingly encountered by primary care community physicians. The management of these patients is especially challenging. Presented here is a protocol that utilizes a flow chart for laboratory and treatment decisions and a checklist highlighting signs and symptoms to look for in regular office visits of HIV patients. Matters of legality, physicians' responsibility, insurance, lifestyle management, and prevention of opportunistic infections are discussed. The use of zidovudine (AZT) and alternative drugs is reviewed. More understanding of the special needs of HIV patients will enable the primary care physician to better serve the future needs of his community.

Maintaining health in persons with HIV infection

Despite the inroads that have been made in the treatment and diagnosis of HIV infection, many health care providers have an attitude of hopelessness and pity. Those of us who believe ourselves to be healthy have goals, aspirations, plans, and projects that guide our living. These are our reasons for living: they provide hope, meaning, and substance to our lives. Each of us conducts our life according to individualized personal choices and priorities as do individuals with HIV infection. The patient's autonomy provides a freedom of choice that extends to benign and harmful methods of maintaining health and preventing illness. The individual chooses what will be of most help. The nurse assesses the patient's activities toward health from the patient's perspective. When these activities involve alternative methods, the nurse needs to assess whether or not these are harmful. Providing a nonjudgmental environment for assessment and care will facilitate the patient's providing information about all activities being used to promote or maintain health or prevent illness. Studies have begun to establish that responses to specific stress situations can result in impaired immunity, so the nurse's effort in helping individuals maintain the highest level of health possible has become even more important. The nurse provides a critical link between the individual and the health care complex for optimum communication, comfort, and care in the pursuit of health.

Outcome measurements in decision analysis: life versus quality of life

Life expectancy has been the most popular outcome measurement for decision analyses. The effectiveness, or utility, of a strategy is expressed in years of life gained over a baseline state. This is particularly useful from a public health standpoint when a fixed budget must be used to serve a diverse population. For example, should money be spent on influenza vaccination programs or cholesterol screening? A decision analysis to answer this question might use cost per year of life gained as the primary outcome. Essentially, the public health provider is seeking to minimize cost while maximizing life expectancy. Strategies could be ordered and priority given according to rank.

Substance abuse treatment modalities in the age of HIV spectrum disease

AMSAODD's Third National Forum on AIDS and Chemical Dependency presented a session about the theory and practicality of combining pharmacologic and nonpharmacologic treatment modalities to maximize the social, psychological, and physical health of patients. Synthesizing methadone maintenance for opioid dependence with abstinence modalities for cocaine dependence and alcoholism was discussed. Chronic adequate methadone treatment allows normalization of neuroendocrine function, is associated with normal natural killer-cell activity, and has proven efficacious in retaining patients in chemical dependence treatment, and thus decreasing the risk for transmission of HIV infection. Individualization of treatment is then exemplified by four clinical vignettes that were discussed by a panel of experts.

Thalidomide--a therapy for the immunological consequences of HIV infection?

The beneficial effects of the teratogenic drug thalidomide on a variety of disorders involving the immune system have been established recently. Comparison of symptoms and immunologic abnormalities of such diseases with the acquired immunodeficiency syndrome, as well as experimentally obtained results suggest that thalidomide may be a useful agent suppressing autoaggressive reactions initiated by the human immunodeficiency virus.

HIV infection in women

Acquired immunodeficiency syndrome (AIDS) cripples the immune system, making the patient susceptible to a variety of infections and disorders. AIDS is caused by direct blood contact with a transmissible agent, now known as the human immunodeficiency virus (HIV). The pathophysiology, clinical disease, and treatment of HIV infection in women are discussed.

HIV infection and Scottish general practice: knowledge and attitudes

To assess the knowledge and attitudes of general practitioners about HIV infection, a postal survey was undertaken of one in three of all principals in Scotland; 834 (77.6%) responded. Respondents' knowledge about HIV was often limited, and they found the discussion of sexual behaviour difficult. Most were in favour of routine HIV testing being offered to patients, but against testing without consent. Most general practitioners considered consent unnecessary for the passing of information about HIV status between medical colleagues, but necessary for informing others, in particular the patient's family and sexual partners. Most general practitioners would accept high-risk and HIV-positive patients onto their lists but less than half would accept intravenous drug users. Most respondents did not feel at significant personal risk of HIV infection, but expressed reservations about many other aspects of HIV infection in general practice. If practitioners are to fulfil their potential for tackling the problems of HIV infection, they need increased resources and a policy for education and training that is responsive to local needs.

[Management of patients with HIV infection: utilization of hospital structures and cost]

This pilot survey covers 2,772 stays of AIDS-related patients in 13 French public hospitals over 3 months (August, September and October 1988). The public sector in France accounts for two thirds of all hospital beds but it is likely to be responsible for the hospitalization of nearly all AIDS-related patients. Of these 2,772 stays, 62% last less than 24 hours: indeed, 22% occur in day-care hospitals and about 40% in conventional hospitals (Fig. 3). These percentages evidence the need for steady expansion of the day-care facilities which were created some years ago. Among the patients experiencing a stay of more than 24 hours, the average length of stay varies from 7.5 days (asymptomatic HIV+ patients) to 15.5 days (confirmed AIDS patients). If all stays are taken into account (Fig. 4), the average length decreases, naturally, to lower levels, 2.8 days (HIV+) and 8.1 days (AIDS). Of course, a patient may have several stays during a single year, plus a number of consultations in the out-patient department. Direct medical expenditures per stay, including only diagnostic and care (excluding accommodation, staff wages and other recurrent expenditures of the hospital) increase from 1,960 French Francs for an asymptomatic HIV+ patient to 4,160 French Francs for a confirmed AIDS patient. Average expenditures per day of stay understandably show a reverse trend, from 715 French Francs for HIV+ to 510 French Francs for AIDS patients. Broad deviation from these averages is observed: for a confirmed AIDS patient stay, the extreme values are 580 FF and 38,000 FF (Table VIII). Such a large variation is partially caused by the state of the illness specific to each individual patient. But its main factor is possibly the lack of standardization in diagnostic and therapeutic procedures, accompanied by unawareness of the cost problem among medical doctors.

Objectives for a system of health care delivery for HIV infected people

This paper assumes that the effectiveness and efficiency of an integrated community system of care for HIV infected people may depend to a large extent on common perceptions of the objectives of such a system among three sets of actors--the patient, the professional care manager, and the continual care giver. It discusses a decision analytic inquiry into that concurrence on objectives. The conclusion is that within the community studied there is strong evidence of a significant lack of such common purpose.