Hormonal contraception, vitamin A deficiency, and other risk factors for shedding of HIV-1 infected cells from the cervix and vagina

BACKGROUND

Factors that influence shedding of HIV-1 infected cells in cervical and vaginal secretions may be important determinants of sexual and vertical transmission of the virus. We investigated whether hormonal contraceptive use, vitamin A deficiency, and other variables were risk factors for cervical and vaginal shedding of HIV-infected cells.

METHODS

Between December, 1994, and April, 1996, women who attended a municipal sexually transmitted diseases (STDs) clinic in Mombasa, Kenya, and had previously tested positive for HIV-1, were invited to take part in our cross-sectional study. Cervical and vaginal secretions from 318 women were evaluated for the presence of HIV-1 infected cells by PCR amplification of gag DNA sequences.

FINDINGS

HIV-1 infected cells were detected in 51% of endocervical and 14% of vaginal-swab specimens. Both cervical and vaginal shedding of HIV-1 infected cells were highly associated with CD4 lymphocyte depletion (p = 0.00001 and p = 0.003, respectively). After adjustment for CD4 count, cervical proviral shedding was significantly associated with use of depot medroxyprogesterone acetate (odds ratio 2.9, 95% CI 1.5-5.7), and with use of low-dose and high-dose oral contraceptive pills (3.8, 1.4-9.9 and 12.3, 1.5-101, respectively). Vitamin A deficiency was highly predictive of vaginal HIV-1 DNA shedding. After adjustment for CD4 count, severe vitamin A deficiency, moderate deficiency, and low normal vitamin A status were associated with 12.9, 8.0, and 4.9-fold increased odds of vaginal shedding, respectively. Gonococcal cervicitis (3.1, 1.1-9.8) and vaginal candidiasis (2.6, 1.2-5.4) were also correlated with significant increases in HIV-1 DNA detection, but Chlamydia trachomatis and Trichomonas vaginalis were not.

INTERPRETATION

Our study documents several novel correlates of HIV-1 shedding in cervical and vaginal secretions, most notably hormonal contraceptive use and vitamin A deficiency. These factors may be important determinants of sexual or vertical transmission of HIV-1 and are of public health importance because they are easily modified by simple interventions.

Impact of HIV infection on the development, clinical presentation, and outcome of tuberculosis among children in Abidjan, Côte d'Ivoire

OBJECTIVE

To assess the impact of HIV infection upon the development, clinical presentation, and outcome of tuberculosis (TB) among children.

DESIGN

Case-control study and prospective cohort study.

METHODS

From March 1994 to November 1995, children aged 0-9 years with newly diagnosed TB were enrolled at the two outpatient TB centers and the two principal university hospitals in Abidjan, Côte d'Ivoire. Children were examined, blood samples were collected for HIV serology and lymphocyte phenotyping, chest radiography was performed, and gastric aspirates and sputum samples were collected for acid-fast bacilli smear and culture. Children were then followed every 2 months during a standard 6-month course of anti-TB therapy. To examine risk factors for TB, age- and sex-matched healthy control children were enrolled from among the siblings of children referred for TB skin testing.

RESULTS

Overall, 161 children with TB were enrolled, including 39 (24%) with culture-confirmed pulmonary TB, 80 (50%) with clinically diagnosed pulmonary TB, and 42 (26%) with extrapulmonary TB. Children with TB were significantly more likely than 161 control children to be HIV-seropositive (19 versus 0%), to have a past TB contact (55 versus 16%) and to live in very low socioeconomic status housing (24 versus 6%). No significant differences between HIV-seropositive and seronegative children were found in the distribution of radiologic abnormalities for pulmonary TB or in the site of extrapulmonary TB. The mortality rate in HIV-seropositive children was significantly higher than in seronegative children (23 versus 4%; relative risk, 3.6; 95% confidence interval, 2.0-6.6), and all deaths in HIV-seropositive children with available lymphocyte subtyping results occurred in those with a CD4 percentage of < 10%.

CONCLUSIONS

This study documents the importance of HIV infection as an independent risk factor for the development of TB in children, and demonstrates that HIV-related immunosuppression is a critical risk factor for mortality in this population.

Decreased incidence of sexually transmitted diseases among trucking company workers in Kenya: results of a behavioural risk-reduction programme

OBJECTIVE

To establish a cohort of high-risk individuals suitable for HIV-prevention trials, and to measure changes in sexual behaviour and sexually transmitted disease (STD) incidence after a behavioural intervention.

DESIGN

Prospective cohort study in trucking company depots in Mombasa, Kenya.

PARTICIPANTS

A total of 556 male HIV-seronegative employees of trucking companies.

INTERVENTIONS

HIV serological testing, individual counselling, condom promotion, STD diagnosis and management.

MAIN OUTCOME MEASURES

Sexual risk behaviour and symptomatic STD incidence.

RESULTS

Using time-trend modelling, significant declines in self-reported high-risk sexual behaviour were demonstrated during a 1-year follow-up. The percentage of men reporting any extramarital sex during the 3-month period prior to a follow-up visit decreased from 49% durig the first quarter of follow-up to 36% during the last quarter (P < 0.001). The decline in reported female sex worker contact was from 12% to 6% (P = 0.001). Approximately 30% of men reported consistent condom use during extramarital sex and this percentage remained unchanged during the study period. The incidence of STD declined from 34 per 100 person years (PY) during the first quarter to 10 per 100 PY during the last quarter (P = 0.001). Significant reductions in gonorrhoea (15 to five cases per 100 PY, P = 0.04), non-gonococcal urethritis (10 to two cases per 100 PY, P = 0.05), and genital ulcer disease (nine to two cases per 100 PY, P = 0.02) were observed.

CONCLUSIONS

Among truck company workers who participated in a cohort study in Mombasa, Kenya, there was a significant decrease in sex with high-risk partners, but no change in condom use. The change in heterosexual risk behaviour was accompanied by a significant decrease in incidence of gonorrhoea, non-gonococcal urethritis, and genital ulcer disease.

Evaluation of the MycoDot test for the diagnosis of tuberculosis in HIV seropositive and seronegative patients

SETTING

Patients were recruited from Siriraj, Bamrasnaradura, and Central Chest Hospitals, the three major hospitals responsible for tuberculosis patients in Bangkok, Thailand, and vicinity.

OBJECTIVE

To evaluate a new rapid serologic test, the MycoDot test, for diagnosis of tuberculosis (TB).

DESIGN

The study was conducted as a cross-sectional survey. A total of 594 patients were tested with the MycoDot test. This included 142 human immunodeficiency virus (HIV) seropositive patients with active TB, 144 HIV seronegative patients with active TB, 153 HIV seropositive controls, and 155 HIV seronegative controls.

RESULTS

The sensitivity of the MycoDot test for detection of TB was 40.1% in HIV seropositive patients, compared with 63.2% in HIV seronegative patients (P < 0.001). If only patients with laboratory proven TB were evaluated, the sensitivity was 40.6% in seropositive and in 70.8% seronegative patients. The sensitivity of the MycoDot test was similar in TB patients with pulmonary and extra-pulmonary disease. The sensitivity of the test in patients with CD4 counts > or = 200 cells/mm3 was significantly higher than in those with CD4 counts < 200 cells/mm3. The specificity of the test was 97.4%, and was identical in HIV seropositive and seronegative individuals.

CONCLUSION

The MycoDot test had a higher sensitivity for the diagnosis of TB among HIV seronegative than HIV seropositive patients. Although the MycoDot test has a less than optimal sensitivity, the test specificity approaches 100%. It may be useful in patients with suspected TB and negative smears and in extra-pulmonary TB.

Antibody to Haemophilus ducreyi among trucking company workers in Kenya

BACKGROUND AND OBJECTIVES

To determine the prevalence, correlates, and incidence of Haemophilus ducreyi antibodies, a cohort of East African trucking company employees was evaluated.

STUDY DESIGN

Human immunodeficiency virus (HIV)-1-seronegative men working in six trucking companies in Mombasa, Kenya, were evaluated with a questionnaire and serologic testing for antibodies to H. ducreyi and other sexually transmitted pathogens. Men who were initially H. ducreyi seronegative were retested at 1 year of follow-up.

RESULTS

The H. ducreyi seroprevalence among 501 men at enrollment was 26.5%. Seropositivity was significantly associated with older age, married status, years of active sex life, number of sex partners in the past year, history of unprotected sex with a prostitute in the past year, and history of alcohol intake (all P values < 0.01). Occupational travel for more than 14 days per month was also significantly associated with H. ducreyi seropositivity (odds ratio [OR] 2.1, 95% confidence interval [CI] 1.3-3.2). Using multivariate analysis, H. ducreyi seropositivity was independently associated with age, married status, history of sex with a prostitute, and history of alcohol intake. Presence of H. ducreyi antibodies was significantly associated with seropositivity to the other major genital ulcerative pathogens, Treponema pallidum (OR 4.3, 95% CI 2.2-8.3), herpes simplex virus type 2 (OR 4.9, 95% CI 2.0-11.5), and Chlamydia trachomatis (OR 3.2, 95% CI 1.5-6.9). These associations remained significant after adjusting for demographic and exposure variables. The incidence of seroconversion to H. ducreyi antibodies was 3.6 per 100 person years.

CONCLUSIONS

Serologic evidence of H. ducreyi infection was common among male trucking company employees. H. ducreyi seropositivity is an objective marker of high-risk behavior and is associated with serologic evidence of other ulcerative sexually transmitted diseases.

Safety of a nonoxynol-9 vaginal gel in Kenyan prostitutes. A randomized clinical trial

OBJECTIVE

To evaluate the safety and toxicity of once-daily administration of Advantage-24 (Columbia Research Laboratories, Inc., Rockville Centre, NY), a vaginal gel containing 52.5 mg of nonoxynol-9 (N-9), including the effects of this gel on the vaginal and cervical epithelium.

STUDY DESIGN

Randomized, placebo-controlled, double-blind crossover trial, with a 2-week product application period and a 2-week washout period.

METHODS

Female sex workers in Mombasa, Kenya were randomized to one of two sequences, N-9 followed by placebo, or vice versa. Women were instructed to apply one applicator of N-9 or placebo gel vaginally once each day. During each of the two product periods, subjects were evaluated by questionnaire and physical examination, including colposcopy, after 7 and 14 days of product use. The primary outcome was genital epithelial disruption.

RESULTS

Sixty subjects were randomized, of whom 52 (87%) had complete follow-up. There were four episodes of epithelial disruption, three of which occurred during the placebo period and one during the N-9 period. The estimated risk of epithelial disruption associated with N-9 use was 0.33 (95% confidence interval, 0.03-3.26). There was no increased frequency of other, nondisruptive epithelial lesions during N-9 use.

CONCLUSIONS

No genital epithelial toxicity of N-9 vaginal gel was observed. This safety profile suggests that this N-9 product is appropriate for evaluation for human immunodeficiency virus type 1 prevention in a phase III efficacy trial.

Phylogenetic evaluation of Kenyan HIV type 1 isolates

Diversity among global isolates of HIV-1 presents a formidable challenge for vaccine development. As distinct clades of the virus are recognized, it will be important to monitor their geographic distribution and divergence. In this study, we characterized HIV-1 subtypes from 17 seropositive individuals in Nairobi and Mombasa, Kenya. Seventy-one percent of viruses were clade A and 29% were clade D. The most divergent clade A isolate in our survey, Q45-CxA, grouped closely with two other taxa that were previously reported as having no distinct clade affiliation. Thus, these data may suggest the emergence of an outlier group of clade A variants or a new subtype of HIV-1. Phylogenetic relatedness of the 17 Kenyan isolates was determined separately for C2-V3 and V2 sequences of envelope and subtype designation for these isolates was independent of the region analyzed. However, evaluation of transitions, transversions, and specific character state changes indicated that mutations characterizing V2 differed from those in V3 for clade A and clade D isolates. Comparison of secondary structural characteristics of the V1-V3 region between a clade A and a clade D virus revealed conservation of motifs.

Urethral infection in a workplace population of East African men: evaluation of strategies for screening and management

Transport workers (n = 504) in Mombasa, Kenya, were screened for urethral infection by history, clinical examination, and laboratory testing of urethral swabs and first-catch urine specimens. The prevalence of Neisseria gonorrhoeae was 3.4%, Chlamydia trachomatis, 3.6%, and Trichomonas vaginalis, 6.0%; more than two-thirds of infections were asymptomatic. A complaint of urethral discharge, dysuria, or both was twice as sensitive as the sign of discharge on physical examination (34.5% vs. 15.5%) in identifying infection. A positive leukocyte esterase dipstick (LED) test on urine predicted infection with a sensitivity of 95.0% and a specificity of 59.3% in symptomatic men and with a sensitivity of 55.3% and a specificity of 82.8% in asymptomatic men. Demographic and behavioral factors were not independent predictors of infection. In resource-poor settings with high prevalences of urethral infection, an effective screening and management strategy would be to treat symptomatic men, as well as asymptomatic men with a positive LED test, for all three infections.

Genital shedding of human immunodeficiency virus type 1 DNA during pregnancy: association with immunosuppression, abnormal cervical or vaginal discharge, and severe vitamin A deficiency

The presence of human immunodeficiency virus type 1 (HIV-1) in genital secretions may be a determinant of vertical HIV-1 transmission. Cervical and vaginal secretions from HIV-1-seropositive pregnant women were evaluated to determine prevalence and correlates of HIV-1-infected cells in the genital tract. HIV-1 DNA was detected by polymerase chain reaction in 32% of 212 cervical and 10% of 215 vaginal specimens. Presence of HIV-1 DNA in the cervix was associated with cervical mucopus and a significantly lower absolute CD4 cell count (354 vs. 469, P < .001). An absolute CD4 cell count <200 was associated with a 9.6-fold increased odds of cervical HIV-1 DNA detection compared with a count > or = 500 (95% confidence interval, 2.8-34.2). Detection of vaginal HIV- 1 DNA was associated with abnormal vaginal discharge, lower absolute CD4 cell count, and severe vitamin A deficiency. Presence of HIV-1-infected cells in genital secretions was associated with immunosuppression and abnormal cervical or vaginal discharge.

HIV infection and vaginal douching in central Africa

OBJECTIVE

To determine whether vaginal douching is associated with HIV infection.

METHODS

A total of 397 female patients who attended the referral clinic for sexually transmitted diseases in Bangui, Central African Republic, from August 1994 to February 1995, were interviewed regarding sexual behavior, sexual history, and vaginal douching during the previous 3 years. Pelvic examinations were conducted and vaginal and cervical fluids evaluated for genital infections. Blood was drawn for HIV and syphilis serologic testing.

RESULTS

The seroprevalence of HIV infection in the study population was 34%. Twenty-one per cent of the 115 HIV-seropositive women had a consistent practice of douching with commercial antiseptics versus 35% of the 223 HIV-seronegative women [odds ratio (OR), 0.6; 95% confidence interval (CI), 0.4-0.9; after adjusting for lifetime number of sexual partners, marital status, and condom use]. In contrast, a higher percentage of HIV-seropositive than HIV-seronegative women had a consistent practice of douching with a non-commercial preparation (14.8 versus 6.7%; adjusted OR, 1.7; 95% CI, 1.0-3.0).

CONCLUSION

Our results suggest that vaginal douching with non-commercial preparations is associated with an increased prevalence of HIV, whereas douching with commercial antiseptic preparations was associated with a lower prevalence of HIV. The findings from this cross-sectional survey require confirmation in prospective studies.

Gender differences in sexual practices and sexually transmitted infections among adults in Lima, Peru

OBJECTIVES

This study examined the prevalences of antibodies to Treponema pallidum, Chlamydia trachomatis, and herpes simplex virus type 2 in a sample of Peruvian adults.

METHODS

Among adults seeking health certification in Lima, Peru, 600 were randomly selected to undergo interviews and serologic testing.

RESULTS

Men's reported mean lifetime number of partners (10.6) far exceeded women's (1.1), yet antibody to sexually transmitted infection pathogens among sexually experienced participants was 2.8 times more prevalent among women than among men. Among men, female sex workers accounted for 37% of recent partners, and only sex with female sex workers while using condoms less than half of the time was independently associated with antibody (odds ratio = 3.6, 95% confidence interval = 1.5, 8.8). among women, number of partners was associated with any sexually transmitted infection antibody, while intercourse before 18 years of age was associated with C trachomatis antibody. At every level of perceived risk, sexually transmitted infection antibody was more frequent among women.

CONCLUSIONS

Men having unprotected sex with female sex workers had the greatest risk of acquiring infections and (by inference) of transmitting them to women.

Frequency and risk of HIV infection among men attending a clinic for STD in Chiang Mai, Thailand

A prospective study was conducted in the Chiang Mai Sexually Transmitted Diseases Clinic to determine the frequency of HIV seroconversion among men following high risk sexual contacts and to establish risk factors for HIV infection. HIV antibodies were detected in 26 out of 150 men on the initial recruitment with a seroprevalence rate of 21%. Among 124 initial HIV negative subjects; 100, 77, 68, and 55 subjects were followed for 2, 4, 12, and 24 weeks, respectively. One subject had HIV seroconversion documented with the rate of 1.0% (1/100, 95% confidence interval [CI] = 0.03-5.4%). Logistic regression analysis found significantly independent associations of HIV prevalence with prostitute visits at least once a month (OR = 3.6, 95% CI = 1.2-10.9), and with cigarette smoking (OR = 3.5, 95% CI = 1.2-10.5). Intensive health education should be elucidated to decrease the high rate of HIV infection among this population.

Distinct but related human immunodeficiency virus type 1 variant populations in genital secretions and blood

For a HIV vaccine to be effective, it will be essential that it protect against the virus variants to which individuals are most frequently exposed. HIV-1 is predominantly a sexually acquired virus, thus, variants in genital secretions are a potentially important reservoir of viruses that are transmitted. Because there are no data available on variants in the genital mucosa, we analyzed this provirus population and compared it to the proviruses in the blood of individuals chronically infected with HIV-1. A major genetic difference between variants within a patient were insertions, which were apparently created by duplication of adjacent sequences, that resulted in acquisition of new potential glycosylation sites in V1 and V2. Comparisons of mucosal and PBMC variants suggest that these tissues harbor distinct, but related populations of HIV-1 variants. In two of three patients, the mucosal variants were most closely related to a minor variant genotype in blood. In a third individual, viruses in both tissues were surprisingly homogeneous, but the majority of variants in the cervix encoded a V1 sequence with a predicted glycosylation pattern similar to a minor variant in blood. The V3 sequence patterns of the mucosal isolates indicate they may be predominantly macrophage-tropic viruses.

Diversity in virus populations from genital secretions and peripheral blood from women recently infected with human immunodeficiency virus type 1

In order to develop a human immunodeficiency virus type 1 vaccine with global efficacy, it is important to evaluate the virus populations that are transmitted to individuals living in high-incidence areas. To determine the nature of the human immunodeficiency virus type 1 population transmitted to women during heterosexual contact, we examined the diversity of the proviral envelope gene in infected cells in both genital secretions and peripheral blood from six recently seroconverted Kenyan women. Heterogeneous virus populations were present in cervical secretions and/or peripheral blood shortly after seroconversion for five of six infected individuals, and tissue-specific variants were identified in several cases.

Human immunodeficiency virus type 1-infected cells in breast milk: association with immunosuppression and vitamin A deficiency

Breast milk samples from human immunodeficiency virus type 1 (HIV-1)-seropositive women were analyzed by polymerase chain reaction to determine the prevalence and determinants of HIV-1-infected cells in breast milk. Breast milk samples (212) were collected from 107 women, and 58% of the samples had detectable HIV-1 DNA. The proportion of HIV-1-infected cells in the milk samples ranged from 1 to 3255/10(4) cells. Breast milk samples with detectable HIV-1 DNA were more likely to be from women with absolute CD4 cell counts of < 400 (odds ratio, 3.1; 95% confidence interval [CI], 1.5-7.0). Severe vitamin A deficiency (< 20 micrograms/dL) was associated with a 20-fold increased risk of having HIV-1 DNA in breast milk among women with < 400 CD4 cells/mm3 (95% CI, 2.1-188.5). Women with CD4 cell depletion, especially those with vitamin A deficiency, may be at increased risk of transmitting HIV-1 to their infants through breast milk.

Human immunodeficiency virus DNA in urethral secretions in men: association with gonococcal urethritis and CD4 cell depletion

To evaluate the prevalence and correlates of human immunodeficiency virus (HIV)-infected cells in urethral secretions, samples were collected from 106 HIV-seropositive men with and without urethritis. HIV DNA was detected by polymerase chain reaction in 27% of 184 urethral specimens and was associated with CD4 cell depletion (P for trend, .03) and with urethritis (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.2-4.6) or gonorrhea (OR, 2.9; 95% CI, 1.5-5.8). Two multivariate models were constructed that included age, CD4 cell count < 200/mm3, and either urethritis or gonococcal infection. Detection of HIV-infected cells in urethral secretions was independently associated with < 200 CD4 cells/mm3 (OR, 2.2; 95% CI, 0.9-5.2; P = .05) and urethritis (OR, 2.7; 95% CI, 1.3-5.3; P = .003) in the first model and with gonococcal infection (OR, 3.2; 95% CI, 1.6-6.4; P < .001) in the second model. Successful treatment of gonococcal urethritis was associated with a 2-fold reduction in urethral HIV DNA (44% vs. 21%; P = .02). Thus, treatment of gonococcal urethritis may be an effective strategy for reducing HIV transmission.

Acceptability of HIV vaccine trials in high-risk heterosexual cohorts in Mombasa, Kenya

OBJECTIVES

To ascertain the level of acceptance of a prophylactic HIV vaccine trial in high-risk HIV-seronegative heterosexual cohorts of men and women in Mombasa, Kenya, and to assess the anticipated effects of participation on risk behavior.

METHODS

Standardized questionnaire administered to a convenience sample of commercial sex workers and trucking company employees enrolled in prospective cohort studies.

RESULTS

Ninety-six per cent of respondents believed that HIV was a major problem in Kenya and 86% of men and 94% of women perceived themselves at risk. One hundred per cent of women and 84% of men expressed interest in participation in an HIV vaccine trial, after explanation of the experimental nature of the vaccine, double-blind placebo-controlled design, prolonged follow-up and potential change in serostatus. Seventeen per cent of men and 9% of women anticipated an increase in risk behavior as a result of participation.

CONCLUSION

The majority of individuals in two high-risk cohorts were interested in participating in Phase III efficacy trials of HIV vaccines. A significant minority anticipated an increase in risk behavior, which emphasizes the need for intensive counseling and education throughout a vaccine trial.

HIV-1 subtypes and male-to-female transmission in Thailand

We examined the risk factors for heterosexual transmission of HIV in a case-control study of couples in Thailand. 90 HIV-positive men and their regular sex partners were enrolled at the immune clinic, Chulalongkorn Hospital, where 92% of male index cases had HIV-1 serotype A (subtype E). Most index cases had acquired HIV through sexual intercourse. 95 couples were enrolled at 15 detoxification clinics, where 79% of them had HIV-1 serotype B (subtype B). Most men had acquired HIV through injecting drug use (IDU).

Risk factors for HIV infection among drug users in Yunnan province, China: association with intravenous drug use and protective effect of boiling reusable needles and syringes

OBJECTIVES

To characterize the prevalence and correlates of HIV infection among drug users in southwestern China.

METHODS

Drug users in Longdao village, Yunnan Province underwent standardized interview and voluntary HIV serologic testing in a cross-sectional study. Analyses of potential risk and protective factors were stratified by method of drug use.

RESULTS

Of 182 participants, 79 (43%) were HIV-1-seropositive. HIV seropositivity was found in 51 (80%) of the 64 intravenous drug users (IVDU) and 28 (24%) of the 118 who acknowledged use of drugs only by smoking [odds ratio (OR), 12.6; 95% confidence interval (CI), 5.7-28.5]. Among IVDU, reported sterilization of reusable injection equipment by boiling before intravenous drug use was associated with significant protection (adjusted OR, 0.16; 95% CI, 0.03-0.87). This protective association was also significant among the subset of IVDU who shared reusable injection equipment.

CONCLUSIONS

HIV infection among drug users in Yunnan Province was highly correlated with intravenous drug use. The protective effect of sterilization of reusable injection equipment by boiling could be easily integrated into health education programs among IVDU in China and other rural Asian settings where reusable injection equipment is used.

Mother-to-child transmission of human immunodeficiency virus type 1: report from the Nairobi Study

Mother-to-child transmission of human immunodeficiency virus type 1 (HIV-1) is a significant problem in countries with endemic HIV-1 infection. Between 1986 and 1991, 365 children of HIV-1-infected mothers and 363 control children were studied in Kenya. The overall risk of transmission from mother to child, determined by serologic evidence of infection by age > or = 12 months and excess mortality in the HIV-1-exposed group, was 42.8% (range, 27.6%-62.2%). Marriage was the only maternal characteristic associated with transmission (odds ratio, 2.2; 95% confidence interval, 1.2-4.2; P < .05). Children who experienced growth failure were more likely to be infected. In 44% of children ultimately infected, the pattern of antibody response implied intrapartum or postnatal exposure to HIV-1. Of potential postnatal exposures examined, duration of breast-feeding beyond age 15 months and the mother being married were independently associated with increased risk of infection and seroconversion of children. The percentage of HIV infection attributable to breast-feeding > or = 15 months was 32%. The frequency of mother-to-child transmission of HIV-1 was high; a substantial proportion of infection occurred postnatally, possibly through breast-feeding.

Human immunodeficiency virus- 1 in leprosy patients attending Kenyatta National Hospital, Nairobi

The purpose of this study was to determine if Mycobacterium leprae is an opportunistic pathogen in immunosuppressed subjects with HIV infection. Ninety six leprosy patients at Infectious Diseases Hospital (IDH), Nairobi were screened for, HIV-1 antibody between January 1991 and June 1992. The patients included 15 who were diagnosed during the study period and 81 who were previously diagnosed and were on anti-leprosy treatment. Blood was screened for HIV antibody by first ELISA and double positive samples were confirmed by a second ELISA. The HIV seronegative patients were re-tested serologically every 3 months. Smears from skin slits were used to determine bacterial index and the patients were classified according to criteria described by Ridley and Jopling. The patients were re-assessed clinically monthly. The mean age of the patients was 40 years and ranged from 13 to 78 years. Forty seven percent had paucibacillary and 53% had multibacillary leprosy. The HIV seroprevalence was 8% in previously diagnosed patients and zero in the newly diagnosed patients. There were no changes in clinical spectrum in HIV seropositive patients during follow up period; neither reversal reactions nor erythema nodosum leprosum were observed. The study suggests that M. leprae may not be an opportunistic pathogen in immunosuppressed subjects with HIV infection.

Human immunodeficiency virus type 1 IgA antibody in breast milk and serum

Breast-feeding plays a potentially significant role in mother to child transmission of human immunodeficiency virus type 1 (HIV-1). The additional transmission risk attributable to breast-feeding and the factors that enhance or inhibit transmission are presently unknown. One mechanism by which breast milk might inhibit HIV-1 transmission is the presence of specific antibodies directed against HIV-1 in breast milk of seropositive mothers. In this study serum and breast milk samples from women in Nairobi, Kenya, were tested to determine the prevalence of HIV-1 IgA antibodies. A Western blot test developed in our laboratory was used to detect anti-HIV-1 immunoglobulin A in serum and anti-HIV-1 secretory IgA (sIgA) in breast milk. Ninety-four percent of 63 HIV-1 seropositive women had anti-HIV-1 IgA in serum and 59% had anti-HIV-1 sIgA in their breast milk. No significant associations with maternal characteristics or serum anti-HIV-1 IgA or IgG banding patterns and the presence of anti-HIV-1 sIgA in breast milk were found. No protective effect of anti-HIV-1 sIgA was seen regarding mother to child transmission; however, further studies are necessary to determine the effect of these antibodies in maternal sera or in breast milk on the efficacy of HIV-1 transmission.

Syphilis and HIV infection among displaced pregnant women in rural Mozambique

A cross-sectional study was conducted among displaced pregnant women in Mozambique to determine the prevalence and correlates of HIV infection and syphilis. Between September 1992 and February 1993, 1728 consecutive antenatal attendees of 14 rural clinics in Zambézia were interviewed, examined, and tested for HIV and syphilis antibodies. The seroprevalence of syphilis and HIV were 12.2% and 2.9%, respectively. Reported sexual abuse was frequent (8.4%) but sex for money was uncommon. A positive MHA-TP result was significantly associated with unmarried status, history of past STD, HIV infection, and current genital ulcers, vaginal discharge, or genital warts. Significant correlates of HIV seropositivity included anal intercourse, history of past STD, and syphilis. In summary, displaced pregnant women had a high prevalence of syphilis but a relatively low HIV seroprevalence suggesting recent introduction of HIV infection in this area or slow spread of the epidemic. A syphilis screening and treatment programme is warranted to prevent perinatal transmission and to reduce the incidence of chancres as a cofactor for HIV transmission.