Short-course oral zidovudine for prevention of mother-to-child transmission of HIV-1 in Abidjan, Côte d'Ivoire: a randomised trial

BACKGROUND

In Africa, the risk of mother-to-child transmission of HIV-1 infection is high. Short-course perinatal oral zidovudine might decrease the rate of transmission. We assessed the safety and efficacy of such a regimen among HIV-1-seropositive breastfeeding women in Abidjan, Côte d'Ivoire.

METHODS

From April, 1996, to February, 1998, all consenting, eligible HIV-1-seropositive pregnant women attending a public antenatal clinic in Abidjan were enrolled at 36 weeks' gestation and randomly assigned placebo or zidovudine (300 mg tablets), one tablet twice daily until the onset of labour, one tablet at onset of labour, and one tablet every 3 h until delivery. We used HIV-1-DNA PCR to test the infection status of babies at birth, 4 weeks, and 3 months. We stopped the study on Feb 18, 1998, when efficacy results were available from a study in Bangkok, Thailand, in which the same regimen was used in a non-breastfeeding population.

FINDINGS

280 women were enrolled (140 in each group). The median duration of the prenatal drug regimen was 27 days (range 1-80) and the median duration of labour was 7.5 h. Treatment was well tolerated with no withdrawals because of adverse events. All babies were breastfed. Among babies with known infection status at age 3 months, 30 (26.1%) of 115 babies in the placebo group and 19 (16.5%) of 115 in the zidovudine group were identified as HIV-1 infected. The estimated risk of HIV-1 transmission in the placebo and zidovudine groups were 21.7% and 12.2% (p=0.05) at 4 weeks, and 24.9% and 15.7% (p=0.07) at 3 months. Efficacy was 44% (95% CI -1 to 69) at age 4 weeks and 37% (-5 to 63) at 3 months.

INTERPRETATION

Short-course oral zidovudine was safe, well tolerated, and decreased mother-to-child transmission of HIV-1 at age 3 months. Substantial efforts will be needed to ensure successful widespread implementation of such a regimen.

Evaluation of HIV serial and parallel serologic testing algorithms in Abidjan, Côte d'Ivoire

OBJECTIVE

To evaluate HIV serologic testing algorithms based on a combination of three enzyme linked immunosorbent assays (ELISA) for the confirmation of HIV infection in Abidjan, Côte d'Ivoire, where HIV-2 and HIV-1 non-B subtypes are prevalent.

METHODS

A total of 1069 human sera with known serologic status, in addition to a seroconversion and low titer antibody panel were initially tested by six ELISA to determine the sensitivity, specificity and delta values of the assays. On the basis of the performance of the assays, three ELISA (Enzygnost, ICE 1.0.2, and Vironostika) were selected for use in a parallel and serial testing algorithm in analyzing 8283 consecutively collected sera. In the parallel testing algorithm, sera concordantly reactive or non-reactive by Enzygnost and ICE 1.0.2 were considered as true positive or true negative, respectively. In the serial algorithm, sera reactive by Enzygnost were retested by ICE 1.0.2. Sera with discordant results were tested by Vironostika, and the results was considered definitive. All reactive sera, plus a random sample of negative sera were tested for confirmation by Peptilav. In addition, a random sample of reactive sera was tested by Western blot.

RESULTS

All ELISA had 100% sensitivity; specificities ranged from 96.8 to 100%. Positive and negative delta values of the ELISA were high (range, 6.89 to 46.07 and -2.05 to -5.75, respectively). Of the 8283 sera, 2054 were considered true positives and were correctly classified by the parallel testing algorithm (sensitivity, 100%). Of the 6229 true negative sera, 6226 were negative by the parallel testing algorithm (specificity, 99.95%). The sensitivity of the serial algorithm was 99.96%, and specificity was 99.95%. None of the 250 concordant ELISA-negative sera in the algorithm that were randomly tested in Peptilav was positive; similarly, all of the 103 concordant ELISA-positive sera were confirmed by Western blot. The three-ELISA algorithm resulted in reagent cost-savings of at least 50% compared with the Peptilav-based algorithm.

CONCLUSION

These results suggest that a combination of ELISA using different principles or antigens in a serial or parallel algorithm is an efficient and cost-effective alternative to the standard algorithm in areas where HIV-1 and HIV-2 are prevalent.

Genetic analysis of human immunodeficiency virus in Abidjan, Ivory Coast reveals predominance of HIV type 1 subtype A and introduction of subtype G

To better understand the molecular epidemiology of HIV genetic diversity in Abidjan, Ivory Coast, we performed a genetic analysis of 170 HIV-1-seropositive specimens representing newly diagnosed tuberculosis patients (n = 143) and women monitored in a mother-to-child transmission cohort study (n = 27). Preliminary screening with RFLP presumptively classified 162 (95.3%) of these as subtype A. The envelope region of 108 specimens was subtyped by sequence analysis: 102 (94.4%) were subtype A, 2 (1.9%) were subtype D, and 4 (3.7%) were subtype G. Subtyping gag and env regions of the genome suggested that five of the six nonsubtype A isolates exhibited a potentially mosaic structure. A comparative phylogenetic analysis of HIV-1 subtype A C2V3 from 27 Ivory Coast and 21 Ugandan sequences revealed a striking clustering among Ivory Coast variants, and an independent segregation from Ugandan subtype A. Despite independent clustering with other subtype A specimens, limited variability of the V3 loop apex was observed; the globally predominant V3 motif, GPGQ, represented 90.1% of the HIV-1 strains. This study demonstrates that clade A is the predominant HIV-1 subtype in HIV-seropositive individuals in Abidjan, Ivory Coast and that these strains are phylogenetically distinct from other subtype A strains observed in East Africa.

Spectrum of disease among HIV-infected adults hospitalised in a respiratory medicine unit in Abidjan, Côte d'Ivoire

SETTING

Respiratory medicine wards of the University Teaching Hospital, Abidjan, Côte d'Ivoire.

OBJECTIVES

To describe the spectrum of opportunistic infection among human immunodeficiency virus (HIV) infected adults hospitalised in the respiratory medicine unit in Abidjan, and the level of immunosuppression at which these diseases occur.

DESIGN

Cross-sectional study.

RESULTS

Overall, 75% of patients were HIV-positive: among these patients, the most frequent diagnosis was tuberculosis, in 61%, followed by bacterial pneumonia (15%), Gram-negative septicaemia (particularly non-typhoid Salmonella) (9%) and empyema (5%). Atypical pneumonias appeared to be rare. Most HIV-positive patients had CD4 counts indicative of advanced immunosuppression: 36% had CD4 counts below 100 x 10(6)/l, 19% between 100 and 199 x 10(6)/l, 29% between 200 and 499 x 10(6)/l, and 16% above 500 x 10(6)/l. Overall in-hospital mortality was 27% for HIV-positive patients and 22% for HIV-negative patients (P = 0.5). In a multivariate analysis, the strongest independent risk factors for death were cachexia (odds ratio [OR] 7.4, 95% confidence interval [CI] 2.1-26.3), male sex (OR 4.5, 95% CI 1.2-17.4) and age over 40 (OR 4.1, 95% CI 1.0-17.2).

CONCLUSIONS

Tuberculosis and bacterial infections are the major causes of respiratory morbidity in immunosuppressed HIV-infected adults in this population. Efforts to improve the management of HIV-related disease need to focus on prevention and treatment of these infections.

Comparison of NucliSens and Amplicor monitor assays for quantification of human immunodeficiency virus type 1 (HIV-1) RNA in plasma of persons with HIV-1 subtype A infection in Abidjan, Côte d'Ivoire

We compared the sensitivity and accuracy of the NucliSens assay and those of both the standard and modified (addition of a new primer set, primer mix 1, supplied by Roche) Amplicor HIV Monitor assays to quantify human immunodeficiency virus type 1 (HIV-1) RNA in persons infected with HIV-1 subtype A in Abidjan, Côte d'Ivoire. Seventy-one plasma samples from HIV-1-seropositive persons at different stages of HIV infection and 15 samples from HIV antibody-negative persons were analyzed. The HIV-1 genetic subtype was determined either by DNA sequencing or by a restriction fragment length polymorphism assay. Of the 71 samples, 70 (98%) were subtype A and 1 was subtype G. Of the 70 subtype A samples, the proportion of RNA-positive plasma samples and mean HIV-1 RNA levels were significantly higher by the modified HIV Monitor assay (n = 67 [96%]; mean RNA levels, 5.2 log10 HIV-1 RNA copies/ml) than the NucliSens assay (n = 56 [80%]; 4.3 log10 HIV-1 RNA copies/ml) or the standard HIV Monitor assay (n = 44 [63%]; mean RNA levels, 3.8 log10 HIV-1 RNA copies/ml) (all P values were <0.05). The HIV-1 RNA levels by the modified HIV Monitor assay correlated significantly with those by the NucliSens assay (r = 0.76; P < 0.001) and the standard HIV Monitor assay (r = 0.57; P < 0.001), as did the RNA levels by the NucliSens and the standard HIV Monitor assays (r = 0.60; P < 0. 001). Lower CD4 cell counts were significantly correlated with higher HIV-1 RNA levels by all three assays (r = -0.47 for the NucliSens assay, -0.45 for the standard HIV Monitor assay, and -0.62 for the modified HIV Monitor assay). These results indicate that the modified HIV Monitor assay has the highest sensitivity and efficiency at quantifying the levels of RNA in persons infected with HIV-1 subtype A and thus constitutes a valuable tool for the monitoring of RNA levels in areas of Africa were HIV-1 subtype A is predominant.

The Côte d'Ivoire national HIV counseling and testing program for tuberculosis patients: implementation and analysis of epidemiologic data

OBJECTIVES

To describe the implementation of a free, voluntary and confidential HIV counseling and testing program for patients with newly diagnosed tuberculosis at the eight large outpatient tuberculosis centers in Côte d'Ivoire, and to present epidemiologic findings on participating patients.

DESIGN

HIV counseling and testing program with ongoing HIV serosurveillance.

METHODS

HIV counseling and testing services were established at the two tuberculosis centers in Abidjan in 1989 and were extended to six centers in the Côte d'Ivoire interior in the first half of 1994. Characteristics of counseled patients, acceptance rates of HIV testing, and HIV serologic results were analyzed for all eight centers from 1994 to 1996. Temporal trends in HIV seropositivity rates were examined for the two centers of Abidjan from 1989 to 1996.

RESULTS

From July 1994 through December 1996, 17 946 (91.8%) out of 19 594 patients who were counseled at the eight centers in Côte d'Ivoire consented to HIV testing, of whom 7749 (43.2%) were HIV-seropositive. The highest rates of 47.0 and 45.6% were found in the two centers in Abidjan, with rates ranging from 32.9 to 42.4% in the six centers in the interior. HIV-seropositive tuberculosis patients from each of the 50 districts in Côte d'Ivoire were identified. In Abidjan, the HIV seropositivity rate remained relatively stable among men (46.7% in 1989, 48.5% in 1991, 43.6% in 1996), but rose sharply among women from 32.7% in 1989 to 50.1% in 1996.

CONCLUSIONS

The high HIV seropositivity rates among tuberculosis patients in all geographic regions of Côte d'Ivoire indicate that the HIV epidemic has now spread throughout the country. However, the successful implementation of an extensive HIV counseling and testing program for more than 37000 tuberculosis patients to date demonstrates the commitment of the Côte d'Ivoire Ministry of Health to integrating HIV/AIDS prevention activities with tuberculosis control efforts. When logistically and economically feasible, the extension of HIV-related social and clinical services to HIV-seropositive tuberculosis patients should be considered by other national tuberculosis control programs in Africa.

Field evaluation of a combination of monospecific enzyme-linked immunosorbent assays for type-specific diagnosis of human immunodeficiency virus type 1 (HIV-1) and HIV-2 infections in HIV-seropositive persons in Abidjan, Ivory Coast

Serologic distinction between human immunodeficiency virus type 1 (HIV-1) and HIV-2 infection is made difficult because of the cross-reactivity and high cost of existing differentiation assays. An evaluation of a strategy based on a combination of monospecific enzyme-linked immunosorbent assays (ELISAs) (CME), was carried out in Abidjan, Ivory Coast, where both HIV-1 and HIV-2 are present, to determine its accuracy and cost-effectiveness. A total of 1,608 (428 HIV-1-positive, 361 HIV-2-positive, 371 dually HIV-1 and HIV-2 [HIV-D] reactive, and 448 HIV-negative) sera that had been serotyped by a line immunoassay (Peptilav) were tested retrospectively by an HIV-1-monospecific (Wellcozyme HIV Recombinant ELISA) and an HIV-2-monospecific (ICE*-HIV-2) assay. The CME strategy gave concordant results for all of the 428 sera scored as HIV-1 by Peptilav. Of the 361 sera scored as HIV-2 by Peptilav, 316 (87.5%) were scored as HIV-2 by CME; the remaining 45 sera were positive by both monospecific ELISAs (mean optical density ratios, 1.36 for Wellcozyme and 11.30 for ICE*-HIV-2) and were classified as HIV-D by CME. Of the 371 sera classified as HIV-D by Peptilav, 344 (92.7%), 21, and 6 were scored as HIV-D, HIV-1, and HIV-2, respectively, by CME. Additional testing of the discrepant samples by two HIV differentiation assays (RIBA and INNO-LIA) gave results that agreed with those by CME for most of the sera. In addition, 267 other sera were tested prospectively by both CME and Peptilav. In the prospective evaluation, CME results agreed with those by Peptilav for all 106 HIV-1 sera and 40 of the 41 HIV-2 sera. However, of the 120 sera scored as HIV-D by Peptilav, 69 (57.5%), 47 (39.2%), and 4 (3.3%) were scored as HIV-D, HIV-1 only, and HIV-2 only, respectively, by CME. All 47 samples scored as HIV-1 by CME and two of four HIV-2 sera gave concordant results by RIBA, whereas 29 of 47 sera scored as HIV-1 by CME and all four HIV-2 sera gave concordant results by INNO-LIA. The reagent cost for the CME strategy was 59% lower than the cost of the Peptilav strategy. These results suggest that a combination of highly sensitive and specific commercially available monospecific ELISAs is a reliable and cost-effective strategy for type-specific serodiagnosis of HIV-1 and HIV-2 infections in HIV-seropositive persons and therefore represents a recommended strategy in areas where both HIV-1 and HIV-2 are endemic.

Impact of the 1994 expanded World Health Organization AIDS case definition on AIDS surveillance in university hospitals and tuberculosis centers in Côte d'Ivoire

OBJECTIVE

To assess the impact of the 1994 expanded World Health Organization (WHO) AIDS case definition on AIDS surveillance in Côte d'Ivoire.

DESIGN

Prospective AIDS case surveillance.

METHODS

From March 1994 through December 1996, passive AIDS case surveillance was conducted at the three university hospitals in Abidjan, and active AIDS case surveillance was conducted at the eight tuberculosis (TB) centers in Côte d'Ivoire. Standardized questionnaires were administered and blood samples for HIV serologic testing were collected from the patients evaluated. The numbers of persons who met the modified 1985 WHO clinical AIDS case definition (Bangui definition) and the 1994 expanded WHO AIDS case definition were determined, and the clinical characteristics of these patients were assessed.

RESULTS

Of 8648 university hospital patients, 3658 (42.3%) met the clinical and/or the expanded case definition: 744 (20.3%) HIV-seropositive persons met only the expanded definition, 44 (1.2%) HIV-seropositive persons met only the clinical definition, 2334 (63.8%) HIV-seropositive persons met both definitions, and 536 (14.7%) HIV-seronegative persons met only the clinical definition. Of 18,661 TB center patients, 9664 (51.8%) met the clinical and/or the expanded definition: 5685 (58.8%) HIV-seropositive persons met only the expanded definition, none of the HIV-seropositive persons met only the clinical definition (by definition), 2625 (27.2%) HIV-seropositive persons met both definitions, and 1354 (14.0%) HIV-seronegative persons met only the clinical definition.

CONCLUSIONS

Because of the inclusion of multiple severe HIV-related illnesses into the expanded definition, the number of reportable AIDS cases in HIV-seropositive patients increased 31.3% in the university hospitals, and 217% in the TB centers. The inclusion of HIV seropositivity as a criterion for the expanded definition also enhanced the specificity of AIDS case reporting, eliminating 536 cases in the university hospitals and 1354 cases in the TB centers in HIV-seronegative patients who had clinical signs of AIDS. The use of the 1994 expanded definition for surveillance purposes should be encouraged in areas of the developing world where HIV serologic testing is available.

Mother-to-child transmission of human T-cell lymphotropic virus type I associated with prolonged breast-feeding

OBJECTIVES

We assessed the risk of transmitting human T-cell lymphotropic virus type I (HTLV-I) through breast-feeding.

STUDY DESIGN/METHODS

To assess the risk of mother-to-child transmission of HTLV-I, 212 HTLV-I-seropositive women and 145 HTLV-I-seronegative women were enrolled in a prospective cohort study conducted in Kingston, Jamaica. Their offspring were examined at regular intervals, and HTLV-I serostatus was determined at each visit.

RESULTS

Twenty-eight of the 181 children with at least one postnatal visit born to HTLV-I-seropositive women (and none of the children born to HTLV-I-seronegative women) were persistently seropositive and were considered HTLV-I infected (Kaplan-Meier estimated cumulative incidence, 18%; 95% CI, 12%-24%). Among children observed for at least 24 months, 19 (32%) of 60 children breast fed for 12 months or longer were HTLV-I seropositive, compared with only 8 (9%) of 86 children breast-fed for less than 12 months (relative risk, 3.4; 95% CI, 1.7-6.9). Compared with children weaned at younger ages, transmission of HTLV-I was associated with continued breast-feeding of children who were 12 to 18 months of age (relative hazard, 6.4; 95% CI, 2.1-180.2) and older than 18 months (relative hazard, 18.1; 95% CI, 1.4-29.5). Transmission was also associated with higher maternal antibody titer (a possible marker of virus load), prolonged duration of ruptured membranes during childbirth, and lower maternal income.

CONCLUSIONS

These results suggest that limiting the duration of breast-feeding to less than 12 months for children born to HTLV-I-seropositive mothers may significantly reduce mother-to-child transmission of HTLV-I.

Profound immunosuppression across the spectrum of opportunistic disease among hospitalized HIV-infected adults in Abidjan, Côte d'Ivoire

OBJECTIVES

To describe the spectrum of opportunistic disease in HIV-infected patients admitted to hospital in Abidjan, Côte d'Ivoire, and to describe the level of immunosuppression at which these diseases occur.

DESIGN

Cross-sectional study.

SETTING

In-patient wards of the University Hospital Infectious Diseases Unit.

PATIENTS

A total of 250 adult patients recruited by systematic sampling at the point of hospital admission.

MAIN MEASURES

HIV status; CD4 count; diagnoses, confirmed by microbiological/radiological investigations whenever possible; and outcome of hospitalization (death or discharge).

RESULTS

Overall, 79% patients were HIV-positive. The most frequent diagnoses in HIV-positive patients were septicaemia (20%, with non-typhoid salmonellae, Escherichia coli and Streptococcus pneumoniae the most common organisms), HIV wasting (16%), meningitis (14%), tuberculosis (TB; 13%), isosporiasis (10%), cerebral toxoplasmosis (7%) and bacterial enteritis (7%). Most HIV-positive patients had evidence of severe immunosuppression: 39% had CD4 counts < 50 x 10(6)/l, 17% had 50-99 x 10(6)/l, and 20% had 100-199 x 10(6)/l. In-hospital mortality among HIV-positive patients was 38% compared with 27% among HIV-negative patients [age-adjusted odds ratio (OR), 1.5; 95% confidence interval (CI), 0.7-2.9]. Among HIV-positive patients, the highest case-fatality rates were among patients with meningitis, toxoplasmosis and TB: in a multivariate analysis the strongest independent risk factors for death were an abnormal level of consciousness (OR, 9.3; 95% CI, 3.5-24.6), a haemoglobin concentration below 8 g/dl (OR, 4.2; 95% CI, 1.4-12.8) and age > 40 years (OR, 3.9; 95% CI, 1.5-10.2).

CONCLUSIONS

Our data show that, as in industrialized countries, most HIV-infected individuals admitted to and dying in hospital in Abidjan are profoundly immunosuppressed. Potentially preventable infections are the main causes of in-hospital morbidity and mortality among HIV-infected persons in Abidjan, and the evaluation of appropriate primary prophylactic regimes is a priority.

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.

Late postnatal mother-to-child transmission of HIV-1 in Abidjan, Côte d'Ivoire

BACKGROUND

HIV-1 can be transmitted from an infected mother to her infant through breastfeeding, although the precise risk of transmission by this route is unknown. A long-term follow-up of children born to HIV-infected women in Abidjan, Côte d'Ivoire, has enabled us to estimate this risk.

METHODS

Children born to 138 HIV-1-seropositive women, 132 HIV-2-seropositive women, 69 women seroreactive to both HIV-1 and HIV-2, and 274 HIV-seronegative women were enrolled at birth and followed up for as long as 48 months. All children were breastfed (median duration 20 months). Blood samples for either or both HIV PCR and HIV serology were obtained at 1, 2, and 3 months of age, and every 3 months thereafter. Early HIV infection was defined as a positive HIV-1 PCR result obtained in the first 6 months of life. Late postnatal transmission was diagnosed when a child had a negative PCR at 3 or 6 months of age, followed by either or both a positive HIV-1 PCR at 9 months or older, or persistently positive HIV-1 serology at 15 months or older.

FINDINGS

82 children born to HIV-1-seropositive mothers and 57 children born to mothers seropositive for both HIV-1 and HIV-2 had PCR results for samples taken within the first 6 months. By 6 months of age, 23 (28%; 95% CI 19-39) of the 82 children born to HIV-1-seropositive mothers and ten (18%; 95% CI 9-30) of the 57 children born to dually seropositive mothers were HIV-1 infected. Among children whose PCR results were negative at or before age 6 months, and who were followed up beyond 6 months, an additional four (9%) of the 45 children born to HIV-1-seropositive mothers and two (5%) of the 39 children born to dually seropositive mothers became HIV infected. The estimated rates of late postnatal transmission, with account taken of loss to follow-up and the observed pattern of weaning, were 12% (95% CI 3-23) and 6% (0-14), respectively. One of the five children whose mothers seroconverted from HIV-negative to HIV-1, and one of seven children whose mothers seroconverted from HIV-2 to dual reactivity, became HIV-1 positive. No case of late postnatal transmission occurred in children born to HIV-2-positive or persistently HIV-negative mothers.

INTERPRETATION

Breastfed children born to mothers seropositive for HIV-1 alone or seropositive for HIV-1 and HIV-2 in Abidjan are at substantial risk of late postnatal transmission. Early cessation of breastfeeding at 6 months of age should be assessed as a possible intervention to reduce postnatal transmission of HIV.

High rates of sexual contact with female sex workers, sexually transmitted diseases, and condom neglect among HIV-infected and uninfected men with tuberculosis in Abidjan, Côte d'Ivoire

To characterize human immunodeficiency virus (HIV) risk practices among men with tuberculosis, and to determine what factors are associated with HIV infection in this population, we conducted a case-control analysis of data collected during enrollment in a prospective cohort study in the two large tuberculosis treatment centers of Abidjan, Côte d'Ivoire. Demographic information and data on risk factors for HIV infection, including history of sex with female sex workers (FSWs) and history of sexually transmitted diseases (STDs), were collected on 490 HIV-infected and 239 HIV-uninfected men diagnosed with pulmonary tuberculosis between 1989 and 1992. HIV-infected men were significantly more likely than uninfected men to have had sex with FSWs in their lifetime [83 versus 63%, odds ratio (OR) 2.9, 95% confidence internal (CI) 2.0-4.2], genital ulcer disease in the past 5 years (38 versus 15%, OR 3.4, 95% CI 2.2-5.2), urethritis in the past 5 years (44 versus 23%, OR 2.6, 95% CI 1.8-3.8), and sex with FSWs in the past year (43 versus 25%, OR 2.3, 95% CI 1.6-3.3); no difference was found in the proportion with at least one non-FSW partner in the past year (84 versus 79%, OR 1.3, 95% CI 0.9-2.0). Among all men, 74% never used condoms, and only 1.4% always used condoms. In a multivariate analysis, sex with FSWs, genital ulcer disease, urethritis, and lack of circumcision were all significantly associated with HIV. This study demonstrates the critical roles of commercial sex, STDs, and condom neglect in fueling the HIV/AIDS epidemic in Abidjan, and illustrates the urgent need for widespread HIV education both in the general population and in men with tuberculosis.

Radiologic manifestations of pulmonary tuberculosis in HIV-1 and HIV-2-infected patients in Abidjan, Côte d'Ivoire

OBJECTIVES

To compare the radiologic manifestations of pulmonary tuberculosis in HIV-1-infected, HIV-2-infected, and HIV-negative patients; and to assess the impact of HIV-related immunosuppression on the radiologic manifestations of pulmonary tuberculosis.

METHODS

We compared chest radiographs from consecutive HIV-1-positive, HIV-2-positive and seronegative patients with pulmonary tuberculosis. Differentiation between HIV-1 and HIV-2 antibodies was based on a synthetic peptide-based enzyme immunoassay. A subset of patients had CD4+ lymphocyte levels estimated by flow cytometry; in these patients, abnormalities on chest radiographs were analysed in relation to the severity of CD4+ lymphocyte depletion.

RESULTS

HIV-1-infected patients were significantly more likely to have extrapulmonary tuberculosis than were HIV-2-infected or HIV-negative patients (20% vs 8% and 9%). Among patients with pulmonary tuberculosis, no differences were observed in the rates of specific abnormalities on chest radiographs between HIV-1- and HIV-2-infected patients; both HIV-1- and HIV-2-infected patients had a higher frequency of pleural effusion than did HIV-negative patients (8% and 9% vs 4%). Among HIV-infected patients with CD4+ counts of > or = 400/mm3, 200-399/mm3, and < 200/mm3, respectively, the proportions with non-cavitary infiltrates and hilar adenopathy increased significantly (33% to 44% to 58%, and 0% to 14% to 20%), while the proportion with cavitary lesions decreased significantly (63% to 44% to 29%).

CONCLUSIONS

The radiologic manifestations of pulmonary tuberculosis in HIV-infected patients varied significantly over the spectrum of immune deficiency. HIV-infected patients with tuberculosis and relatively high CD4+ counts showed only slight differences from HIV-negative persons. HIV-1-positive patients had a higher frequency of extrapulmonary tuberculosis at presentation than those infected with HIV-2. Radiographic abnormalities were broadly similar in HIV-2-infected and HIV-1-infected patients. Clinicians and radiologists must be alert to the altered radiologic spectrum of pulmonary tuberculosis in immunosuppressed HIV-infected patients.

The relative distribution of T cell subsets is altered in Jamaican children infected with human T cell lymphotropic virus type I

Early childhood infection with human T cell lymphotropic virus type I (HTLV-I) has been suggested to be involved in the pathogenesis of infective dermatitis and adult T cell leukemia/lymphoma. Since only a very small percentage of HTLV-I-infected children develop disease later in life, identification of early interim markers for persons at risk for developing disease would enable monitoring and might provide insight into the pathophysiology of the various diseases associated with HTLV-I infection. A cross-sectional study analyzed T cell subsets in 35 HTLV-I-seronegative and 16 HTLV-I-seropositive Jamaican children 11-31 months old. HTLV-I seropositivity was associated with an increase in the mean percentage of CD4 cells expressing HLA-DR, a marker for T cell activation (P = .02). This increase was positively correlated with duration of infection (r = .74, P = .009). These data demonstrate perturbation of regulatory cells of the immune system in HTLV-I-infected children.

Demonstration of human T lymphotropic virus type I (HTLV-I)-specific T cell responses from seronegative and polymerase chain reaction-negative persons exposed to HTLV-I

Human T lymphotropic virus type I (HTLV-I) is a human retrovirus etiologically linked to adult T cell leukemia and the progressive chronic neurologic disease HTLV-I-associated myelopathy/tropical spastic paraparesis. Described is a method that measures the production of interleukin-2 from HTLV-I synthetic peptide-stimulated peripheral blood lymphocytes (PBL) of HTLV-I-infected persons. The peptides correspond to immunogenic regions of the HTLV-I Env and Tax proteins. Significantly, this assay demonstrated T cell responses to these HTLV-I peptides from coded PBL samples in 7 of 19 HTLV-I-seronegative polymerase chain reaction-negative persons known to have been exposed to HTLV-I but in none of 16 matched controls without risk factors for exposure (P = .007). The implications of this finding are discussed.

Firearms in New Mexico

To determine the prevalence of firearm ownership and storage practices in New Mexico, we did a random-digit-dialing survey of New Mexico residents in October 1991. Of 200 households surveyed, 79 (40%) had 1 or more firearms in the home. Rural households were more likely than urban households to have firearms (44% versus 30%), and households with annual incomes of greater than $25,000 were more likely to have a firearm than households with incomes of $25,000 or less (41% versus 33%). Household firearm ownership did not vary with the presence of young (< 15 years old) children (38% with children versus 41% without). Handguns were generally owned for self-protection, and rifles were owned for hunting. Of households with firearms, 24% stored them unsafely (unlocked and loaded or unloaded but with ammunition nearby), including 21% of households with young children. Of the households with handguns only, 40% stored these firearms unsafely compared with 13% of those with rifles only. The prevalence of gun ownership in New Mexico is similar to that reported in national surveys; handguns are stored less safely than rifles; and the presence of young children in the home does not appear to improve firearm storage safety.

Mother-to-child transmission of human T-cell lymphotropic virus type I (HTLV-I) in Jamaica: association with antibodies to envelope glycoprotein (gp46) epitopes

To study mother-to-child transmission of HTLV-I in Jamaica, we screened antenatal patients in Kingston, Jamaica, from 1983 to 1985. Of 2,329 women, 81 (3.5%) were HTLV-I seropositive. Two to three years later, 36 seropositive mothers were recontacted, and blood was drawn from them and their children. All sera were tested for HTLV-I antibodies, and mother's sera were additionally tested for HTLV-I whole-virus antibody titer, syncytium-inhibition neutralizing antibody titer, and titers to six synthetic peptides from the HTLV-I envelope glycoprotein gp46. Seventeen of 74 (23%) [95% confidence interval (CI) 15-34%] children were seropositive. HTLV-I transmission was associated with breast-feeding duration > 6 months [relative risk (RR) 3.2; CI 0.4-22.1], maternal age > 30 years (RR 2.8; CI 1.0-7.8), and higher maternal whole-virus antibody titer (RR 3.3; CI 1.3-8.5). After controlling for higher whole-virus antibody titer, transmission remained associated with higher titer of neutralizing antibody and higher titer of antibody to the peptide sp4a1, corresponding to amino acids 196-209 of the gp46 envelope glycoprotein. We conclude that mother-to-child transmission of HTLV-I in Jamaica is associated with longer duration of breast-feeding, older age, and higher HTLV-I antibody titer, in particular to a certain immunogenic portion of the gp46 envelope glycoprotein.

HTLV-I and HTLV-II world-wide distribution: reanalysis of 4,832 immunoblot results

Mapping the geographic distribution of human T-lymphotrophic virus types 1 and 2 (HTLV-I and -II) has been complicated because conventional serologic approaches cannot distinguish between these 2 viruses. To more precisely define the epidemiology of HTLV-I and HTLV-II, we evaluated a convenience sample of 4,832 HTLV-I immunoblot results from over 140,000 samples screened for HTLV-I, collected in 16 countries for 35 separate studies. An algorithm that compares reactivity against p19 and p24, 2 gag (HTLV-I core) proteins, was employed to characterize the immunoblots: type I, p19 stronger than p24 (presumptive HTLV-I), type 2, p24 stronger than p19 (presumptive HTLV-II), or indeterminate (p19 and p24 weakly positive or p19 weakly positive in the presence of p21e). Geographic areas could be grouped into 4 patterns. Patterns A (> 75% type I) and B (> 75% type 2) were usually observed where the specific type of HTLV or its characteristic diseases had been found. Pattern C (mixed type 1 and 2 pattern) was observed predominantly in intravenous-drug-using and other populations in which both virus types have been reported. Pattern D (> 10% indeterminate), suggests the presence of non-specific reactivity, perhaps resulting from exposure to non-virus-related antigens or an HTLV-related virus. HTLV-I predominates in southern Japan, the South Pacific, parts of West Africa, and in Afro-populations of the Western hemisphere. HTLV-II clusters in Native American populations and among intravenous drug users. Pattern-D areas in Africa and Venezuela might prove to be fertile in the search for new and variant HTLV virus types.