[HIV infection in day-care and school centers]

Today it is known in what ways the transmission of HIV may occur in the child population. Most infected children are the offspring of infected mothers; according to the Study of the European Collaborative Community, only 13% of children of HIV infected mothers are infected. Different organizations all over the world have dictated specific regulations and laws to integrate the HIV infected child into groups of other children. In the Basque Country, the Plan of AIDS Prevention and Control was established in January 1988. This is a working plan involving the Departments of Health and Education of the Basque Government with the following objectives: 1) With the authorization of the family, to inform the director of the center where the child is of the child's situation. 2) To maintain the confidentiality. 3) To educate teaching staff in the adoption of measures designed to prevent the theoretical possibility of HIV infection in the school environment. Annually, a meeting of all schools which have enrolled are are to enroll an HIV (+) child is established with the multidisciplinary team. After seven academic years of experience, 53 infected children have been schooled in private and public centers. The periodic meetings between the schools and multidisciplinary team are very useful in developing the plan. The presence of an HIV (+) child in a school does not present special problems for the dynamics of how the school functions. In our opinion, all programmes for the schooling of HIV (+) children should involve coordination between hospital based pediatricians, educators and the Department of Health and Education.

Genetic characterization of human immunodeficiency virus type 1 in blood and genital secretions: evidence for viral compartmentalization and selection during sexual transmission

To explore the mechanism of sexual transmission of human immunodeficiency virus type 1 (HIV-1), we compared HIV-1 gp120 sequences in longitudinal samples from five acute seroconvertors with those from their corresponding sexual partners (transmitters). We used a quantitative homoduplex tracking assay to compare the overall genetic composition of HIV-1 quasispecies in each transmission pair and to track the transmitted viruses during the acute and asymptomatic stages of HIV-1 infection. In the chronically infected transmitters, HIV-1 variants in genital secretions differed from those in blood and variants in cells differed from those in cell-free plasma, indicating remarkable sequence heterogeneity in these subjects as well as compartmentalization of the virus in different bodily sites. Conversely, two of five seroconvertors had only a few related variants and three of five harbored only one viral population, indicating that in these subjects the transmitted viruses were typically homogeneous. Transmitted viruses were evident in the donor's seminal plasma (one of five cases) and even more so in their seminal cells (three of five cases), suggesting that both cell-associated and cell-free viruses can be transmitted. In every pair studied, the transmitted variant(s) represents only a minor population in the semen of the corresponding transmitter, thereby providing evidence that HIV-1 selection indeed occurs during sexual transmission.

[Risk of contamination with blood during obstetric-gynecologic surgery]

To determine the risk of exposure to blood and body fluids potentially contaminated with infectious organisms, we instituted a prospective study of 100 gynecologic procedures performed at Hospital General Regional of Puebla, México. Accidental exposure to blood occurred during 8 procedures (8%). There were 8 glove tears (8%). Needlestick injuries occurred in 6% of the operations. The frequency of blood contamination, glove tears and percutaneous injuries is high; surgical personnel are at risk of contracting a blood-borne disease such as HIV infection or viral hepatitis. Implantation of universal blood and body fluids precautions is useful in preventing HIV exposures of which needlestick precautions are most important.

Longitudinal studies of children born to HIV-1 antibody positive Filipino commercial sex workers (CSW): diagnostic dilemmas

Fifteen term babies born to 12 HIV-1 antibody positive Filipino CSW have been monitored for signs and symptoms of HIV-1 infection. Eleven babies were enrolled in the study within the first 6 months after birth; 4 others were enrolled at 4, 9, 11 and 21 months of age respectively. Every 3 months after enrolment, each baby received a physical examination, serum was tested for HIV-1 antibodies and p24 antigen and peripheral blood mononuclear cells were cultured for isolation of virus. After a mean follow-up period of 39.3 months (range 7-72 months), virus isolation and serum p24 antigen assays confirmed that 2 babies have been infected with HIV-1. If the 4 babies less than 18 months of age were excluded, the vertical transmission rate was 18.2%. Seven babies who have been monitored for a minimum of 25 months (range 31-60 months) lost their maternal antibodies but 6 of them subsequently developed indeterminant Western blots (WB); reactivity to p24 and/or gp120/ 160 but no reactivity to gp41. Of the remaining 6 babies, still less than 25 months of age (range 7-24 months), 2 lost their maternal antibodies within one year. The other 4 continued to recognize either p24 or gp120/160 well after the accepted 15-month period for loss of maternal antibody. Although a diagnosis could not be established upon the basis of these laboratory findings, clinical observations (failure to thrive, anergy, persistent generalized lymphadenopathy and recurrent pneumonias) mimicked HIV-1 infection. However, because these clinical features are common among many babies in the developing world, their usefulness in supporting a diagnosis of perinatal HIV-1 infection is limited.

The health and psychosocial status of HIV-seropositive youth in Minnesota

OBJECTIVE

To describe the health outcomes and health care utilization of nonhemophiliac adolescents diagnosed with human immunodeficiency virus (HIV) infection.

DESIGN

Cross-sectional survey.

SUBJECTS

All state residents without hemophilia, 13-21 years of age at the time of HIV infection diagnosis, reported to the Department of Health through April 1992.

SETTING

A state where HIV and acquired immune deficiency syndrome (AIDS) are reportable conditions.

METHODS

Structured interviews.

RESULTS

The survey response rate was 67%. Most subjects reported preexisting and current psychosocial problems. In 35% of cases, subjects did not recall giving consent for HIV antibody testing; and many reported that seropositive results were delivered inappropriately. Eighty-seven percent of subjects reported recent medical care, without statistically significant differences related to gender, race, or mode of transmission. Within 3.5 years (median) of the diagnosis of HIV infection, 55% of participants reported having physical limitations that were found only to be associated with duration of illness.

CONCLUSIONS

The findings highlight the need for better understanding of the progression and comorbidities of HIV disease during adolescence, counseling and testing practices, and expanded access to supportive services.

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.

[Clinical situation, knowledge and risky behavior of patients with human immunodeficiency virus infection attending a health center]

OBJECTIVE

To establish what information patients diagnosed in our health centre as infected by HIV have about their infection, to evaluate possible changes in their hazardous behaviour and to establish the monitoring level and stage of the condition.

DESIGN

An observational study of a crossover nature. Demographic data and data on patients' understanding of HIV infection, their hazardous behaviour and clinical situation were collected by means of a semistructured survey.

SETTING

Occidente Health Centre, Córdoba.

PATIENTS AND OTHER PARTICIPANTS

35 people with HIV positive serology.

MEASUREMENTS AND MAIN RESULTS

92.6% were or had been users of parenteral drugs. 40.7% believed they had no health problem; 33.4% thought that the fact of having HIV antibodies was reversible; and 22.2% did not think they transmitted the infection. Their understanding of how infection occurred seemed sufficient, but in spite of this 39.1% continued to share syringes and 52.2% did not use condoms habitually. 56% had received what information they had from health staff; and 56.5% of these thought the information was insufficient. 28% did not regularly attend for medical check-ups.

CONCLUSIONS

Knowing you are an HIV carrier and having adequate information on ways of infection appeared to modify hazardous behaviour in our sample, although to a still insufficient extent. The establishment of strategies which not only inform, but also educate, would be of vital importance in slowing down the transmission of the infection.

Neonatal characteristics in rapidly progressive perinatally acquired HIV-1 disease. The French Pediatric HIV Infection Study Group

OBJECTIVE

To identify clinical and laboratory parameters at birth that are associated with the rapidly progressive form of human immunodeficiency virus type 1 (HIV-1) disease in children born to infected mothers.

DESIGN

Multicenter, prospective study of infants born to HIV-seropositive mothers.

SETTING

A total of 62 obstetric and pediatric centers in France.

PARTICIPANTS

Of 1386 children born to HIV-1-seropositive mothers at least 18 months before the cutoff date, 267 were infected. Infection was defined as serological positivity at 18 months or death from HIV disease before the age.

MAIN OUTCOME MEASURE

Category C events (including opportunistic infections, recurrent severe bacterial infections, cancers, specific encephalopathy, and wasting syndrome) in the new pediatric Centers for Disease Control and Prevention classification during the first year of life, according to clinical, immunological, and virological findings at birth.

RESULTS

The risk of category C manifestations at 12 months was significantly higher when an infected newborn had liver and/or spleen enlargement and/or adenopathies (38.1% vs 15.1%; relative risk [RR], 2.5; 95% confidence interval [CI], 1.4 to 6.0; P<.02) or a low proportion (<30%) of CD4+ cells at birth (45.5% vs 15.0%; RR, 3.0; 95% CI, 1.4 to 6.4; P<.005). Similarly, HIV-1 culture and/or polymerase chain reaction positivity during the first week of life was associated with a higher risk of the early, severe form of HIV infection (26.4% vs 9.3%; RR, 2.8; 95% CI, 1.3 to 6.1; P<.006). In case of positive antigenemia at birth, the risk was 50.0% vs 14.4% (RR, 3.5; 95% CI, 1.9 to 6.2; P<.001). These parameters, determined at birth, were strongly interrelated and could reflect active disease onset in utero in some cases of early, severe HIV-1 disease in childhood.

CONCLUSIONS

These prognostic markers, particularly virological parameters, are of value in monitoring children infected by HIV and might serve as a basis for early therapeutic intervention.

Identification of levels of maternal HIV-1 RNA associated with risk of perinatal transmission. Effect of maternal zidovudine treatment on viral load

OBJECTIVE

To determine if there are levels of human immunodeficiency virus type 1 (HIV-1) associated with a high or low risk of perinatal transmission and to ascertain the mechanism by which zidovudine treatment reduces perinatal transmission.

DESIGN

A nonrandomized prospective cohort study.

SETTING

University medical center and two general hospital affiliates from May 1989 to September 1994.

PATIENTS

Ninety-two HIV-1-seropositive women (95 pregnancies) and their 97 infants.

INTERVENTION

Forty-two mothers (43 pregnancies) received zidovudine therapy during pregnancy and/or during labor and delivery. Eleven infants received prophylactic zidovudine for the first 6 weeks after delivery.

MAIN OUTCOME MEASURE

HIV-1 infection status of the infant.

RESULTS

Twenty of the 97 infants were perinatally infected with HIV-1. Transmitting mothers were more likely to have plasma HIV-1 RNA levels higher than 50000 copies per milliliter at delivery than nontransmitting mothers (15 [75.0%] of 20 transmitters vs four [5.3%] of 75 nontransmitters; P < .001). None of the 63 women with less than 20000 HIV-1 RNA copies per milliliter transmitted. Twenty-two women treated with open-label oral zidovudine during gestation showed an eightfold median decrease in plasma RNA levels (median [25th and 75th percentile], 43043 [5699 and 63053] copies per milliliter before zidovudine vs 4238 [603 and 5116] HIV-1 RNA copies per milliliter at delivery; P < .001) and none transmitted. Four zidovudine-treated women with high HIV-1 levels transmitted despite the presence of zidovudine-sensitive virus in vitro in both the mothers and their infants.

CONCLUSIONS

Maternal HIV-1 RNA levels were highly predictive of perinatal transmission risk and suggest that certain levels of virus late in gestation and/or during labor and delivery are associated with both a high risk and a low risk of transmission. Our results also suggest that zidovudine exerts a major protective effect by reducing maternal HIV-1 RNA levels prior to delivery and that further strategies are needed to prevent perinatal transmission in women with high or increasing virus levels and/or zidovudine-resistant virus.

A multicenter proton magnetic resonance spectroscopy study of neurological complications of AIDS

Human immunodeficiency virus (HIV) infection as seen in Europe and the United States has predominantly been contracted through male homosexual sex or intravenous drug abuse. In infected subjects, the brain is frequently affected both clinically and neuropathologically. The aim of this multicenter study has been to evaluate the value of single-voxel proton magnetic resonance spectroscopy (MRS) in the assessment of the neurological complications of acquired immunodeficiency syndrome (AIDS). MRS (voxel size = 8 ml, TR/TE = 1600/135 msec) was performed in 137 HIV-1-seropositive patients and 64 healthy controls without risk factors at three clinical MR sites operating at 1.5 T. The first result of this multicenter trial is that good reproducibility of results among participating sites was found. This demonstrates the reliability and robustness of MRS in the study of in vivo brain metabolism. In HIV patients, there was no significant correlation between metabolite ratios of brain detected by MRS and CDC grouping of patients or CD4 count. In contrast, the variations of brain metabolite ratios (NA/Cr, NA/Cho, and Cho/Cr) were related to the occurrence of encephalopathy, brain atrophy, or diffuse white matter lesions. There was no significant difference in brain metabolites between male homosexual AIDS patients and male intravenous drug user AIDS patients, whatever their neurological status (neurosymptomatic or neuroasymptomatic). Thus, the mode of transmission of HIV infection does not appear to affect the cerebral changes observed in the proton spectra from AIDS patients. Because of its ease of implementation and high information content, single-voxel proton MRS is likely to play a significant role in the evaluation of HIV-related encephalopathies.

Serological investigation of HIV-1 variant subtype strains in transmission in Nairobi

In a bid to determine the HIV-1 subtype variants in transmission in Nairobi and its possible association with clinical status, we screened 207 confirmed HIV-1 positive patients visiting HIV/AIDS laboratory at the Virus Research Centre in Nairobi between January and March 1994. We used a selfmade ELISA obtained from an established panel of HIV-1 V3 loop peptides (ANRS, France) and derived from seven isolates: MN, HXB2, SC, Z6, Z2, ELI and CDC4. Test samples were obtained from 95 blood donors and medical examination attendees, 57 patients with chronic diarrhoea, 31 confirmed pulmonary tuberculosis, 16 with pneumonia and 12 herpes zoster. Out of the total, 21.5% had antibodies against the MN strain, 19.1% had against the Z2 strain while reaction against the HXB2 strain was observed in 17.2%. SC, CDC4, Z6 and ELI had prevalences of 11.5%, 6.2%, 5.3% and 3.8% respectively. Fifteen per cent of the tested sera showed no reaction to any of the used peptides. Strong and significant associations were observed between the total number of strains a sample react to and the clinical state. We infer that both the North American consensus strains (MN and HXB2) and the African isolates (Z2 and Z6) are predominant in Nairobi. The correlation between antibody reactivity and clinical state is an interesting observation that necessitates an expanded study and, the use of strain specific peptides maybe a sensitive and easier method for use for molecular epidemiological purposes.

[The AIDS epidemic in Norway--where did it go?]

The 1986 prognosis for the AIDS-epidemic in Norway has not been fulfilled. The epidemic has been far less extensive than anticipated. In 1986, little knowledge existed about the parameters that influence the spread of the human immunodeficiency virus (HIV): the prevalence of HIV, the HIV transmission rate, the duration of the infectious period and the extent of risk behaviour. The prognosis was therefore not reliable. The causes of the variability in HIV transmission and in the duration of the infectious period are still poorly understood and thus cannot be easily influenced. A reduction of risk behaviour among homosexual men has been observed. In the general population there has been a slight increase in use of condoms. The behavioural changes may express HIV-preventive measures. However, the large discrepancy between the early HIV/AIDS prognosis and the observed epidemic in Norway cannot be explained by behavioural change alone.

Risk factors for HIV-1 seroconversion among young men in northern Thailand

OBJECTIVE

To identify behavioral and sociodemographic risk factors for incident human immunodeficiency virus-1 (HIV-1) infection among healthy young men in northern Thailand.

DESIGN

Men inducted into military service in northern Thailand in May and November 1991 were followed at 6-month intervals until discharge 2 years later. Trained nonmilitary interviewers identified risk factors for HIV-1 infection through interviews with the men.

SETTING

Thirteen military bases in northern Thailand.

PARTICIPANTS

A total of 1932 seronegative men, aged 19 to 23 years (average age, 21 years) at enrollment, conscripted into the Royal Thai Army and Air Force from six upper-northern Thai provinces.

MAIN OUTCOME MEASURES

Human immunodeficiency virus-1 seroincidence as determined through enzyme-linked immunosorbent assay and verified by Western blot, and univariate and multivariate analyses of risk factors related to HIV-1 incidence.

RESULTS

A total of 85 men seroconverted to HIV-1 over the period of observation, giving an incidence rate of 2.43 per 100 person-years. Factors strongly associated with HIV-1 seroconversion were frequency of visits to female commercial sex workers (CSWs), sex with men, and incident sexually transmitted diseases (STDs). High frequency of condom use showed a significant (P < .001) protective effect for HIV-1 incidence among men with a history of recent sex with female CSWs in univariate analysis, but a multivariate model demonstrated no difference in HIV-1 seroconversion rates by consistency of condom use. Multivariate analysis incorporating condom use showed that having sex with men (adjusted relative risk [RR], 2.59; 95% confidence interval [CI], 1.08 to 6.25), having sex with CSWs (adjusted RR ranged from 2.54 [95% CI, 1.81 to 3.58] to 2.74 [95% CI, 1.56 to 4.81]), and incident STDs (adjusted RR, 2.38 [95%, CI, 1.31 to 4.32]) to be predictors of incident HIV-1 infection. Substance use was not associated with HIV-1 seroconversion rates in multivariate analysis.

CONCLUSION

The HIV-1 incidence in this cohort of young men appears to be primarily attributable to having sex with female CSWs. Condom use provided some protection, although not in multivariate analysis; however, condom use has previously been shown likely to be useful in preventing HIV-1 transmission. Thus, programs to increase effective condom use in brothels are essential. Efforts to extend condom use to non-CSW partners are especially needed. More effective prevention and treatment of STDs may also be necessary to decrease HIV-1 infection in this population.

Migrant injecting users: characteristics of Italian drug users living in Amsterdam

The aim of the study was to compare the behavior of Italian injecting drug users (IDUs) in Amsterdam with Italian IDUs who moved abroad but returned with those who never moved. The Italian IDUs in Amsterdam showed a pattern of drug use very similar to the Dutch IDUs. They also reported a high prevalence of needle borrowing, needle lending, and HIV-1 infection. One out of three Italian IDUs in Amsterdam reported nondrug using occasional sexual partners, but condom use was always reported. This study shows that Italian IDUs in Amsterdam are a marginalized population with a high risk of HIV transmission.

Mode of delivery and gestational age influence perinatal HIV-1 transmission. Italian Register for HIV Infection in Children

Some data suggest that cesarean section reduces mother-to-child HIV-1 transmission. To assess the influence of mode of delivery and other maternal and infant factors on the rate of transmission, we analyzed the data of 1,624 children prospectively followed from birth. Of these, at the last visit 1,033 were > 18 months of age or would have been had they not died of HIV-related illness. Among the 975 first singleton children, 180 [18.5%; 95% confidence limits (CL), 16.1-20.9] acquired infection, as did 8 of 56 (14.3%; 95% CL, 5.1-23.5) second-born children. Multivariate stepwise analysis showed that vaginal delivery and development of symptoms in the mother were significantly and independently associated with a higher transmission rate (vaginal delivery; odds ratio, 1.69; 95% CL, 1.14-2.5; symptoms: odds ratio, 1.61; 95% CL, 1.12-2.3). In contrast, a history of maternal drug use, birth weight, breast-feeding (only 37 infants were breast-fed), and child's sex did not have a significant impact on viral transmission. The percentage of infected children was highest (30.7%) among very premature infants (< or = 32 weeks of gestation); this significant trend subsequently decreased to 11.9% at the week 42 (p < 0.001), suggesting a parallel reduction in peripartum transmission. The reduced rate of infection observed in infants born by cesarean section underlines the urgent need for randomized controlled trials to evaluate the protective role of surgical delivery in preventing perinatal HIV-1 transmission.

Case-control study of HIV seroconversion in health-care workers after percutaneous exposure to HIV-infected blood--France, United Kingdom, and United States, January 1988-August 1994

Health-care workers (HCWs) are potentially at risk for human immunodeficiency virus (HIV) infection through occupational exposures to blood. Although prospective studies indicate that the estimated risk for HIV infection after a percutaneous exposure to HIV-infected blood is approximately 0.3% (1,2), factors that influence this risk have not been determined. To assess potential risk factors, CDC, in collaboration with French and British public health authorities, conducted a retrospective case-control study using data reported to national surveillance systems in the United States, France, and the United Kingdom. This report describes the study and summarizes results that suggest that risk factors for HIV transmission include certain characteristics of the exposure and the source patient; in addition, postexposure use of zidovudine (ZDV) by HCWs was associated with a lower risk for HIV transmission.

Sexual sensation seeking and Sexual Compulsivity Scales: reliability, validity, and predicting HIV risk behavior

Two studies are presented that evaluate newly developed scales of sensation seeking and sexual compulsivity. Results showed that the scales were reliable and correlated with convergent and divergent measures in expected directions in samples of both gay men (N = 296) and inner city low-income men and women (N = 158). Consistent with theories of sensation seeking, the scales corresponded to an attraction toward a range of sexual practices, including increased frequencies of unprotected intercourse and a greater number of sexual partners. As expected, sexual compulsivity was not related to variety and novelty in sexual practices, but was associated with lower levels of self-esteem and resistance to adopting sexual risk-reducing strategies. However important differences were observed between the gay men and heterosexual samples; scales correlated with substance use only among gay men, and sexual compulsivity was related to a range of sexual practices only among heterosexuals. The sensation seeking and Sexual Compulsivity Scales were therefore reliable, appeared valid, and useful in predicting sexual risk behaviors.

Comparison of the declines in CD4 counts in HIV-1-seropositive female sex workers and women from the general population in Nairobi, Kenya

Studies from Kenya have reported rapid clinical disease progression among HIV-infected professional sex workers. The reasons for this rapid decline are unknown. To better understand factors influencing the course of disease, HIV-1 disease progression was explored in terms of declines in CD4 counts. Two samples from Nairobi, Kenya, were studied, one from a cohort of female sex workers and another, as a comparison group, from mothers enrolled in an HIV-1 vertical-transmission study. A Markov model was used to analyze transitions between HIV-1 disease stages as defined by CD4 counts. It appears that sex workers experience a rapid decline in CD4 counts, consistent with earlier findings of rapid clinical disease progression among individuals in this group. The rate of decline in CD4 counts among the mothers appears to be lower. It is speculated that either intensive exposure to sexually transmitted pathogens or infection with several strains of HIV-1 may account for the rapid disease progression among female sex workers.