Pregnancy outcome in HIV-1 positive women in Gandhi Memorial Hospital Addis Ababa, Ethiopia

Between January 1993 and January 1995, a prospective case-control hospital-based study was done in ninety-two HIV seropositive and 173 HIV seronegative mothers for pregnancy outcome and complications associated with the pregnancy in Gandhi Memorial Hospital, Addis Ababa, Ethiopia. The serostatus and seroconversion in the children born to the seropositive women was also assessed. The study showed that there was a significant difference in birthweight (p < 0.001), puerperal infections (p < 0.0001), duration of pregnancy (p < 0.001), and fifth minute APGAR score (p < 0.001) in the two groups of the study population. The study further indicated that the seroprevalence in the pregnant women was 20.4% and vertical transmission rate at 18 months was 68.5%. From the study one can conclude that HIV seropositivity adversely affects pregnancy out come.

A controlled trial of imipramine for the treatment of methamphetamine dependence

At the Drug Detoxification Program of the Haight Ashbury Free Clinics, we conducted a randomized clinical trial of imipramine in the treatment of methamphetamine dependence. The purposes of the trial were to test the efficacy of imipramine as a treatment for methamphetamine dependence and to establish the feasibility of conducting a controlled clinical trial at the Clinic. Thirty-two subjects were randomly assigned to receive either 10 or 150 mg/day of imiprine for 180 days. Imipramine 10 mg/day was the control. Subjects received intensive counseling. Retention in treatment was significantly longer for subjects who were treated with 150 mg of imipramine compared to control (median days: 33.0 vs. 10.5). There were no consistent differences in percent of urine samples positive for methamphetamine, Beck Depression Inventory scores, or craving. Determination of the full extent of imipramine's utility in the treatment of methamphetamine dependence awaits a larger trial.

[The incidence and distribution of accidents with biological fluids among health personnel and the general population]

OBJECTIVES

To assess the informative usefulness of the Registry, to calculate the incidence rates of accident with biological fluids among health care workers and in the community, to know about the postaccident rate of seroconversion to HIV and to identify risk groups.

METHODS

A descriptive study of the HIV records file of the Registry of Accidental Contacts to Biological Fluids in the Clinic Hospital of Zaragoza was conducted, between January 1987 and September 1993. The registry includes the reports of health care workers and the general population of Health Area III in Aragón (Spain), except for the Calatayud's Hospital. Incidence rates, rate ratios and their 95% confidence intervals were calculated.

RESULTS

A total number of 595 accidents were reported, in none of them and HIV infection occurred subsequently. The incidence rate in health care workers was of 1.7 reports per 100 workers per year, while in the community it was of 8.1 per 100,000 people. The housekeeping staff was the group with a higher incidence (rate = 6.7; 95% IC: 3-14.8) and the type of accident more frequently described was needlestick injury.

CONCLUSIONS

The incidence of reported accidents has increased in the community and in health care workers, which may be due to the increase in the reporting. In health care workers, the incidence in 1993 was within the range reported from other countries. The perception of risk is universal after accidents with unknown biological fluids. The correct disposal of material with biological contamination should be the more important preventive action.

Prevalence of markers for hepatitis B virus and HIV-1 among drug injectors in London: injecting careers, positivity and risk behaviour

Concerns about the risks of HIV infection among drug injectors have eclipsed concerns about the prevalence and transmission of hepatitis, and in particular hepatitis B virus infection. Findings are reported from surveys undertaken with two separate community-recruited samples of drug injectors in London collected in 1992 (n = 505) and in 1993 (n = 507). Anonymized confirmed testing of saliva shows 51.5% of drug injectors in 1992 and 47.9% in 1993 to be antibody positive to the core antigen of hepatitis B virus (anti-HBc). Approximately half of the drug injectors confirmed as anti-HBc positive were unaware that they had been infected with hepatitis. Anti-HIV-1 prevalence was considerably lower at 7.0% in 1992 and 6.9% in 1993. Multivariate analyses showed anti-HBc positivity to be most likely among older injectors with longer injecting careers who had a history of having shared used needles and syringes. HIV-1 positivity was also associated with a history of having shared injecting equipment as well as with recent sharing (i.e. in the last 6 months). Unlike anti-HBc positivity, there were no associations between HIV-1 positivity and age or length of injecting career. Younger injectors with shorter injecting careers were more likely to report recent sharing of used injecting equipment than older injectors with longer injecting careers. We note the potential for continued transmission of HBV and HIV-1, particularly among younger injectors. We recommend an integrated strategy to maximize the health of drug injectors, of which HIV and HBV prevention is a part. There is a need to widen the availability of HBV vaccinations for HBV negative drug injectors and their sexual partners and for clear guidelines to drug injectors about the relative efficacy of bleach to disinfect injecting equipment of HBV and HIV.

The UK register of HIV seroconverters: methods and analytical issues. UK register of HIV seroconverters (UKRHS) Steering Committee

A Register of HIV-infected persons who have had a negative antibody test within 3 years of their first antibody positive test (seroconverters) is being set up in the UK to monitor the distribution of times from HIV seroconversion to AIDS (the incubation period) and to death. It will also provide a national resource for use by those designing studies in this group of individuals. Clinicians caring for HIV-positive persons in Genito-Urinary Medicine, Infectious Disease and other departments throughout the UK were asked to participate by providing information on eligible subjects. Most laboratories undertaking HIV antibody testing were also contacted and asked to provide the name of the attending clinician for all seroconverters identified through the HIV laboratory reporting systems of the PHLS Communicable Disease Surveillance Centre (CDSC) and the Scottish Centre for Infection and Environmental Health (SCIEH) and for any other seroconverters known to them but not identified by CDSC or SCIEH. Data items sought for the Register include: sex, ethnic group, probable route of HIV transmission, annual CD4 counts, details of therapy and prophylaxis prescribed, AIDS-defining events and vital status. Follow up information is collected annually. Wherever possible, all seroconverters known to a clinic have been identified, whether currently alive or dead, either from clinic records or laboratory reporting or both. The objective is to establish and update a complete register of seroconverters on a long-term to basis to provide reliable estimates of the incubation period on which future projections of AIDS cases in the UK can be made.

[HIV infection caused by cold preserved bone transplants]

We reporting four cases of HIV infection caused by bone allografts from one donor. All transplantations were performed between November 1984 and January 1985. In all, 12 recipients had bone allografts from the HIV-infected donor, 7 of whom are now HIV-negative and 4, HIV-positive. One of the patients died a natural death in her 10th decade. The donor was not been tested before the grafts were harvested, as HIV-antibody detection was not possible at the time (October 1984); no HIV-antibody kits had yet been developed. Subsequent testing of the asservated serum for HIV antibodies gave a positive result. The chronological course of the case is described and the case is discussed in detail.

Heterosexual transmission of HIV in Haiti

BACKGROUND

Despite the importance of human immunodeficiency virus (HIV) transmission through heterosexual contact, the incidence of HIV infection in heterosexual cohorts has not been well studied, particularly in the developing world.

OBJECTIVE

To 1) determine the incidence of HIV infection in discordant heterosexual couples (couples in which one partner had HIV infection and the other did not) in Haiti and 2) assess risk factors for and methods of preventing HIV infection.

DESIGN

Prospective study.

SETTING

National Institute for Laboratory Research, Portau-Prince, Haiti.

PARTICIPANTS

475 HIV-infected patients and their noninfected regular sex partners.

MEASUREMENTS

Patients and their partners were evaluated at 3- to 6-month intervals for HIV infection, sexually transmitted diseases, and sexual practices. The efficacy of counseling and provision of free condoms was also evaluated.

RESULTS

Among the 177 couples who remained sexually active during the prospective study period, 20 seroconversions to HIV positivity occurred, for an incidence rate of 5.4 per 100 person-years (95% CI, 5.16 to 5.64 per 100 person-years). Thirty-eight couples (21.5%) discontinued sexual activity during the study. Only 1 seroconversion occurred among the 42 sexually active couples (23.7% of the 177 sexually active couples) who always used condoms. In contrast, the incidence in sexually active couples who infrequently used or did not use condoms was 6.8 per 100 person-years (CI, 6.49 to 7.14 per 100 person-years). Transmission of HIV was associated with genital ulcer disease, syphilis, and vaginal or penile discharge in the HIV-negative partner and with syphilis in the HIV-infected partner.

CONCLUSION

Counseling and the provision of free condoms contributed to the institution of safe sex practices or abstinence in 45% of discordant heterosexual couples. However, 55% of couples reported that they continued to have unprotected sex, resulting in an incidence of HIV infection of 6.8 per 100 person-years.

A simulation model of the dynamics of HIV transmission in intravenous drug users

The complex dynamics of HIV transmission and subsequent progression to AIDS make the use of traditional mathematical modeling techniques problematic. In a previous paper for this journal, Leslie and Brunham established the utility of a nonmathematical simulation language in modeling HIV transfer under conditions similar to those found among homosexual males. This study considers the application of such an approach in modeling HIV spread among intravenous drug users (IDUs) injecting within a "shooting gallery," a location providing a common needle supply to a large number of users. Modeling HIV transmission in this population involves not only consideration of heterogeneity in partnership selection, but also of the fact that spread of the virus is not directly from person to person, but via injection equipment. The General Purpose Simulation System was used to create a hypothetical cohort of IDUs, drawing from a common needle supply. Following introduction of an index case, the HIV infection rate in this cohort was followed over 5 simulated years. The model was then used to consider the effects of systematic variation in the frequency of injection and needle-cleaning behavior.

Economic impact of treatment of HIV-positive pregnant women and their newborns with zidovudine. Implications for HIV screening

OBJECTIVES

To estimate the economic impact of (1) treating pregnant women who are human immunodeficiency virus (HIV)-positive with zidovudine and (2) voluntary screening programs for pregnant women for HIV infection and offering treatment with zidovudine to those found to be HIV-positive.

MAIN OUTCOME MEASURES

Number of cases of pediatric HIV infection and costs of screening, zidovudine treatment, and pediatric HIV infection treatment.

DESIGN

Health care costs associated with treatment of HIV-positive pregnant women and their newborns are estimated as the costs of zidovudine and its administration and the reduction in costs of treating pediatric HIV infection. The lifetime costs of pediatric HIV infection are derived from the published literature. Estimates of the reduction in maternal-to-fetal transmission rates are taken from the AIDS [acquired immunodeficiency syndrome] Clinical Trials Group (ACTG) Protocol 076. Costs of a voluntary screening program include costs of screening tests and counseling. Sensitivity and threshold analyses are performed to determine the impact of changes in input parameter values including zidovudine treatment costs, efficacy of treatment, costs of pediatric HIV infection, prevalence of HIV infection in pregnant women, screening test sensitivity and specificity, and pregnancy termination rates on the results.

RESULTS

Assuming transmission rates are reduced from 25.5% to 8.3% as found in the ACTG 076 trial, treatment costs of $104,502 for 100 HIV-positive pregnant women and their newborns are offset by the reduction of $1,701,333 associated with fewer cases of pediatric HIV infection for a net savings of $1,596,831. The sensitivity and threshold analyses show that overall cost savings from treatment of HIV-positive pregnant women and their newborns are achieved for a wide range of possible maternal treatment costs, efficacy rates, and lifetime pediatric HIV treatment costs. In the base-case analysis for the voluntary screening program, overall cost savings are seen when HIV prevalence rate among pregnant women is greater than 4.6 per 1000. However, this threshold prevalence rate is sensitive to changes In parameter value-especially pediatric HIV treatment costs, counselling costs, efficacy of treatment, and years of additional HIV treatment for the pregnant women.

CONCLUSIONS

Offering zidovudine treatment to pregnant women known to be HIV-positive will decrease the number of cases of pediatric HIV infection and reduce health care costs. Voluntary screening programs for pregnant women will further decrease the number of cases of pediatric HIV infection. The effect of a screening program on health care costs varies according to HIV prevalence and the costs associated with the screening program.

Women and HIV infection: investigation of its psychosocial consequences

HIV infection is associated with substantial psychological and social morbidity, although there is a dearth of studies of women with the infection. In recent years, developed countries have reported an increase in the prevalence of HIV infection in women, a fact that makes it all the more important to address the study of their psychological and social status. The study is a controlled investigation of HIV seropositive (n = 49) and seronegative women (n = 43), including study of psychological status and history, social functioning and perceived supports, coping style, life events, and sexual difficulties. The results show that about a third of women were psychiatric cases, regardless of HIV status, although more than half of symptomatic women were psychiatric cases. Seropositive women were less likely to use instrumental social supports and more likely to use mental disengagement as ways of coping. Regarding perceived social supports, positive women had lower scores on social integration and guidance. Positive women were more likely to experience sexual difficulties and not to be in a relationship. Negative women reported more adverse life events in the last 6 months. Psychiatric morbidity was associated with poorer social adjustment and more adverse life events, but not with serostatus. HIV positive women and those at risk of HIV infection have substantial levels of psychological and social morbidity that require recognition by those involved in their care and provision of adequate mental health intervention.

[Problems in and the means for improving the epidemiological surveillance of HIV infection]

The system of the epidemiological surveillance of HIV infection, existing now in Russia and aimed at the detection of sources of the infective agent, is not adapted for territories with a low level of HIV infection among the population. This makes it impossible to evaluate the factors which may contribute to the epidemic spread of the infective agent. A new program of epidemiological surveillance is proposed. This program is based on the complex approach to monitoring infections having epidemiological signs, common with HIV infection; on the organization of serological monitoring for the detection of HIV-seropositive persons on the basis of blind tests and orientation on monitoring the social factors which determine the spread of HIV infection.

Rapid liver failure related to chronic C hepatitis in an HIV seropositive hemophilic patient with severe immunodepression

We report the case of a young HIV seropositive patient with severe hemophilia A who presented rapid liver failure related to his chronic C hepatitis. The patient had been receiving factor VIII:C clotting factor concentrates (mean 60,000 U/year) since 1975. In 1984 alanine aminotransferase presented abnormal levels. The CD4 lymphocyte count in 1991 was normal and ultrasonographic scan showed normal liver morphology. In 1991 the patient were found to be seropositive for HCV antibodies as detected by the ELISA method and confirmed by the RIBA method. One year later, a progressive increase in policlonal gamma-globulin and a decrease in the CD4+ lymphocyte count to below 500/muL were detected in concomitance with ultrasonographic evidence of a progressive increase in the longitudinal diameters of the liver and spleen and signs of liver inhomogeneity. A significant inverse correlation was observed between the increase in the longitudinal diameter of the liver and the decline in albumin levels, and between the increase in the longitudinal diameter of the liver and the drop in platelet count. Elevated levels of ammonemia, gamma-glutamyl transpeptidase, alkaline phosphatase and IgA were detected. Moreover, decreased levels of the C4 and C3 complement fractions were documented. At this time (1994), esophagogram and esophagogastroscopy evidenced varicosities in the lower esophageal section (stage F1). The patient died in 1995 March at the age of 29 years of sudden septic shock related to Pseudomonas aeruginosa infection.

[Maternal-fetal transmission of the acquired immunodeficiency virus. Authors' experience]

The determination of human immunodeficiency virus (HIV) status of the newborn remains a major diagnostic problem as a routine test, which detects antibodies to HIV, is of limited value in evaluating newborns. However, the risk of infection for a baby whose mother is an HIV carrier is not yet clear.

OBJECTIVE

A prospective study to evaluate maternal transmission of HIV in our population. In order to provide a better estimate of the effect of some of the risk factors associated with HIV transmission we present a stratification of the transmission rate by these factors.

STUDY DESIGN

Between January 1990 and December 1994 were examined a total of 10.949 pregnancies. To evaluate maternal HIV transmission to the fetus we considered a positive routine diagnostic test, which detects antibodies to HIV, of definite significance only at the age of 18 months or over.

RESULTS

Our prospective study shows an overall transmission rate in our population of 31.25%. Maternal disease stage, as reflected by CD4+ cell count, prematurity, mode of delivery (episiotomy) was correlated with HIV transmission.

CONCLUSIONS

Although some risk factors have been recognized, our understanding of the various modes of transmission is still limited. We conclude from our experience and previous studies that the risk of maternal to newborn transmission of HIV must be determined according to the specific characteristics of each parturient population.

Detection of human immunodeficiency virus-1 DNA, RNA and antibody, and occult blood in inactivated saliva: availability of the filter paper disk method

Eighty three samples of saliva were collected from 60 subjects who were asymptomatic carriers of AIDS related complex (ARC) and AIDS. They included hemophiliacs, homosexuals and heterosexuals. Occult blood, human immunodeficiency virus-1 (HIV-1) antibody and DNA were assayed after heat treatment at 56 degrees C by strip method, particle agglutination and polymerase chain reaction (PCR), respectively. HIV-1 RNA was assayed by reverse transcription (RT)-PCR after heat treatment at 56 degrees C or 90 degrees C, or after application to filter paper disks with drying and heat treatment at 90 degrees C. Positive results were found in 53% (occult blood), 73% (HIV-1 antibody), 23% (HIV-1 DNA, 56 degrees C), 34% (HIV-1 RNA, 56 degrees C), 33% (HIV-1 RNA, 90 degrees C) and 25% (HIV-1 RNA, 90 degrees C, filter paper disk), respectively. The results did not depend on the stage of the disease or the route of infection. Other studies have reported the use of the filter paper disk method to detect antibodies against HIV and HIV genomes in blood samples. The present study demonstrated that it could also be used for the detection of HIV genomes in saliva samples.

Partner-specific sexual practices among heterosexual men and women with multiple partners: results from the French national survey, ACSF. Analyse des Comportements Sexuel en France

Heterosexual men and women with several partners are at risk of acquiring and transmitting sexually transmitted diseases and HIV. Risk depends on parameters such as the sexual practices themselves which may vary according to the type of partner (regular vs. casual). It is therefore important to describe the sexual practices and identify the correlations between the type of partner and these practices among heterosexuals with multiple partners. A subsample of all subjects having had at least two sexual partners during the previous year (n = 1644) was obtained from the ACSF survey (n = 20,055), the French national telephone survey on sexual behavior conducted between September 1991 and February 1992. Questions concerned in particular sexual practices of the last encounter as well as type of partner. Petting and vaginal penetration were almost systematic, mutual manual stimulation and orogenital sex were common, while self-masturbation and anal sex were infrequent. On average, a condom was seldom used. However, it was used more often when the partner was occasional. Nonpenetrative and oral practices were also more frequent with occasional partners. Women tended to report lower frequencies of practices and of condom use than men. A subset of heterosexuals with multiple partners engaged in safe sex. Practices tend to be partner-specific, with safer sex practices more likely to occur with occasional partners, although the magnitude of the difference is moderate.

HIV risk behaviors among adolescents at a sexually transmitted disease clinic in New York City

PURPOSE

The purpose of this study was to describe human immunodeficiency virus (HIV)-associated risk behaviors among adolescents attending a clinic for the treatment of sexually transmitted disease in New York City.

METHODS

A total of 4,585 volunteers were interviewed and HIV-tested, including 456 adolescents (aged 13-19 years), of whom 220 were women (48%) and 236 men (52%).

RESULTS

Fewer than 1% of the 456 adolescents said they injected drugs. Unprotected vaginal sex was the most common sexual behavior, with 93% of adolescents reporting "always" having vaginal sex, and 57% "rarely or never" using condoms. Anal sex was reported by 18%. Twenty percent of adolescent men had paid for sex, compared to just 1% of women, whereas 3% of men and 4% of women had traded sex for money or drugs. Nine women and three men tested HIV seropositive. All three HIV-positive men reported having had receptive anal sex with men. Among women, HIV seropositivity was most strongly associated with crack cocaine use and trading sex for money or drugs.

CONCLUSIONS

HIV prevalence was high, with most infections owing to sexual transmission rather than intravenous drugs. The increased risk of HIV infection in adolescent women was associated with high-risk sex related to crack use and the exchange of sex for money or drugs.