Survival of European patients with Kaposi's sarcoma as AIDS-defining condition during the first decade of AIDS. AIDS in Europe Study Group

OBJECTIVES

To determine whether the survival of patients with Kaposi's sarcoma as first manifestation of AIDS has changed between 1979 and 1989; and to define whether prognosis factors could be identified.

PATIENTS AND METHODS

This is a multicentric retrospective cohort study from 52 centers in 17 European countries involving adults AIDS patients diagnosed between 1979 and 1989. Variables such as age, sex, geographical regions, transmission groups, date of Kaposi's sarcoma diagnosis, zidovudine use, CD4+ cell count and concomitant opportunistic infections or AIDS-related malignancies were evaluated by using uni- and multivariable proportional hazard models. Log-rank tests were used to determine which variables were associated with survival.

RESULTS

From the 6,546 AIDS patients recruited in the database of the AIDS in Europe Study Group, 1,394 were diagnosed with Kaposi's sarcoma at the time of AIDS diagnosis, from 1979 and 1989. A total of 1,047 Kaposi's sarcoma patients died during the follow-up period. By Kaplan-Meier analyses, the median and mean survival for these Kaposi's sarcoma patients were 17 and 25 months, respectively, with no change over time. However, age, sex (female), geographic region, low CD4+ cell count (< 150 x 10(6)/l) and some opportunistic infections and non-Hodgkin's lymphoma were associated with a poorer prognosis. Zidovudine use, year of diagnosis and risk factor for HIV-1 infection brought no additional information as predictor of mortality.

CONCLUSIONS

This study suggests that the survival of patients with Kaposi's sarcoma as first manifestation of AIDS has remained poor during the last decade in contrast with the overall AIDS survival which had significantly improved from a median of 13-18 months during the same period of observation. There is a need for further prospective information to explain the worse prognosis in women and the geographical variations.

Antenatal serum screening for genital herpes: a study of knowledge and attitudes of women at a central London hospital

OBJECTIVE

To evaluate the knowledge and attitudes of women regarding genital herpes and specifically serum screening for prevention of vertical transmission.

SETTING

Antenatal clinic at the Chelsea and Westminster Hospital, London.

POPULATION

Randomly selected women at their first antenatal visit.

METHODS

A questionnaire focussing on the women's knowledge of, and their attitudes about, genital herpes was completed. The results were analysed using the Statistical Package for Social Sciences (SPSS).

RESULTS

One hundred women were surveyed over six weeks. The majority (80%) were aware that genital herpes was a sexually transmitted disease and 60% were aware that it can be transmitted to the baby in pregnancy. Only 34% thought that genital herpes is always symptomatic and 56% believed that they would know for certain if they had herpes. Sixty percent thought they would know whether their partners had ever been infected. Eighty percent of our sample population were prepared to be screened, and 76% would also encourage their sexual partner to have a blood test.

CONCLUSION

This study shows that the study population had a good knowledge about genital herpes and that there would be acceptance of antenatal testing. Whether serum screening is cost-effective must still be evaluated. The impact of such a screening on a couple's relationship is potentially deleterious and needs to be assessed carefully before a screening programme for genital herpes is actually introduced. The next phase of our study will address this issue.

To test or not to test, could you repeat the question?

We aimed to investigate clinical practice in the offering of HIV tests and subsequent uptake in a central London genitourinary medicine (GUM) clinic. A random sample (n = 330) of attenders at 3 inner-London GUM departments was surveyed. Reasons for and rates of offering of HIV tests were recorded and analysed in relation to demographic, risk group information and uptake. The results were integrated with the latest unlinked, anonymous seroprevalence data for the clinic. After exclusion of patients known to be HIV-positive or to have recently undergone HIV testing, HIV tests were offered to 96% of homo/bisexual men, 55% of heterosexual men and 60% of heterosexual women. Comparison with anonymous HIV seroprevalence data showed an inverse relationship between seroprevalence rates for heterosexual men/women (2.5% vs 1%) and rates of HIV test offering. A lack of research into the policy of offering HIV tests may have resulted in inconsistencies in practice. An evidence based policy should offer HIV tests in line with seroprevalence.

An audit of inadequate cervical cytology in a genitourinary medicine clinic

The taking of inadequate cervical cytological smears leads to patient anxiety, an increased burden on medical and laboratory staff and potentially misses cervical abnormalities. It has been suggested that screening programmes should collect information about the proportion of smears considered unfit for diagnostic purposes. We present an audit of the rate of inadequate smears in our unit and the factors contributing to their taking. The largest single factor in the taking of inadequate smears was the individual performing the test. Measures have been introduced to retrain these staff whilst an ongoing programme of training and evaluation has been implemented for all staff.

Asymptomatic shedding of herpes simplex virus from the genital tract: uncertainty and its consequences for patient management. The Herpes Simplex Virus Advisory Panel

A frequent component of the management of patients with genital herpes concerns the possibility of asymptomatic shedding and potential sexual transmission of the virus. Approaches intended to provide supportive counselling and reassurance of patients about these issues need now to be modified in the light of increasing data of the frequency of asymptomatic detection of virus and the effects of antiviral therapy on this phenomenon. Further studies to delineate the relationship between asymptomatic detection of HSV in the genital tract and the mechanism of sexual transmission of this virus need to be conducted before clinicians instigate antiviral suppressive treatment primarily to prevent sexual transmission of HSV. However, it is important that the new data and our greater understanding of the natural history of genital herpes is translated into accurate and comprehensible information for our patients.

Does HIV disease progression influence epidermal Langerhans cell density?

Langerhans cells (LC) are antigen-presenting CD4+ dendritic cells in the skin which may become infected by the human immunodeficiency virus (HIV). Decreased LC function could account for the cutaneous manifestations seen in HIV disease. Previous studies of epidermal LC density in HIV-infected subjects have produced conflicting results. A definitive, prospective, case-control study was performed to determine whether there is an association between epidermal LC density and HIV clinical disease stage. Skin cryosections were stained with the CD1 monoclonal antibody using a three-step immunoperoxidase method. LC were counted by light microscopy and epidermal dimensions calculated with computer-assisted planimetry. The stage of the HIV clinical disease correlated with epidermal LC densities was quantified by three different methods: mean LC numbers per mm length of basement membrane, mean LC per mm2 of epidermal area, and mean LC population per mm of epidermal surface length. Seventy-one subjects, recruited from a large out-patient HIV clinic in London, comprised 56 HIV-positive men and 15 male HIV-negative controls. Contrary to previous smaller studies, there was no detectable association between epidermal LC density (quantified by any of the three methods) and the stage of the HIV clinical disease. Given that HIV infects large numbers of CD4+ cells, we propose possible hypotheses to account for the apparent preservation of static LC numbers in the skin. Further studies of LC kinetics and function are required to elucidate their role in the natural history of HIV infection.

Azithromycin as the first-line treatment of non-gonococcal urethritis (NGU): a study of follow-up rates, contact attendance and patients' treatment preference

AIMS

To identify any differences in follow-up rates or sexual contact attendance rates in men presenting with non-gonococcal urethritis (NGU) after treatment by single dose azithromycin rather than longer standard duration therapies and to identify patients' treatment preferences.

METHODS

A prospective study was performed on 200 consecutive men attending a genito-urinary medicine (GUM) clinic with new episode, microscopically confirmed NGU. The first 100 patients were treated with standard duration therapy (Group S) whilst the second 100 patients received a single 1 g oral dose of azithromycin (Group A). Patient-led contact tracing was arranged and patients were asked to return for review when a test of cure was performed, contact attendance noted and the patient's treatment preference ascertained.

RESULTS

Both groups were predominantly heterosexual and over 60% gave a history of previous sexually transmitted disease (STD). There were no significant differences in efficacy between Groups S and A. However, the index follow-up rate and percentage of traceable sexual contacts attending was higher in Group A. In both groups contacts of homosexual men were more likely to attend the GUM clinic. More additional visits were made by Group S due to mislaid medication or compliance problems. Over 70% of patients questioned expressed a preference for single dose therapy.

CONCLUSION

Single dose therapy with 1 g of azithromycin is as efficacious as longer duration therapies with advantages in patient follow-up rates and contact attendance and for the majority of patients would be their treatment of choice. A cost analysis supports the practical application of this regimen.

Epidemiology of cryptosporidiosis among European AIDS patients

OBJECTIVE

To study epidemiology and possible risk factors associated with the development of cryptosporidiosis among European patients with AIDS.

METHODS

An inception cohort of 6548 patients with AIDS, consecutively diagnosed from 1979 to 1989, from 52 centres in 17 European countries was studied. Data on all AIDS defining events were collected retrospectively from patients' clinical records. Kaplan-Meier estimates, log rank tests and Cox proportional hazard models were used to examine for possible risk factors associated with cryptosporidiosis.

RESULTS

Cryptosporidiosis was diagnosed in 432 (6.6%) patients, 216 at time of the AIDS diagnosis and 216 during follow-up. The probability of being diagnosed with cryptosporidiosis at AIDS diagnosis was significantly lower for intravenous drug users (1.3%) than for homosexual men (4.1%) and for patients belonging to other transmission categories (4.0%) (p < 0.001). The probability was also higher for patients from Central Europe compared with patients from South Europe (4.1% versus 2.5%, p = 0.005). The rate of developing cryptosporidiosis after the diagnosis of AIDS was 3 per 100 patient years of follow-up. The rate was significantly lower for intravenous drug users than for homosexual men (relative risk 0.34, 95% confidence limits 0.22-0.54) and for women compared with men (RR 0.43 (0.21-0.87)). The risk was higher in North Europe than in South and Central Europe. In a multivariate analysis only transmission category remained a significant predictor for the development of cryptosporidiosis.

CONCLUSION

The development of cryptosporidiosis in AIDS patients may be associated with sexual risk behaviour.

How common is self-treatment in non gonococcal urethritis?

OBJECTIVE

To assess the prevalence of self-treatment in men with new episode non gonococcal urethritis (NGU).

METHOD

Three hundred consecutive men with new episode NGU attending an open access genitourinary medicine clinic were interviewed using a semi-structured questionnaire. Details of treatment used before attending the clinic were obtained.

RESULTS

Thirty (10%) men had used treatment, for an average of 7 days, prior to the clinic attendance. Agents used included antibiotics (11), savion or iodine (4), vitamin tablets (4), cisapride (2), local anaesthetic gel (2), antiseptic cream (2), cod liver oil (1), ferrous sulphate (1), naproxen (1), clotrimazole cream (1) and a poultice (1). Over 70% of the men reporting antibiotic use had self-medicated and in one case a fixed drug eruption had ensued.

CONCLUSION

A significant number of men with NGU self-treat. In addition to the adverse effects of such treatment and the potential effect on culture tests, clinic attendance may be postponed, the use of appropriate therapy delayed, and sexual contacts will remain at risk. Early attendance for treatment and contact tracing is essential and should be actively promoted.

HIV-related non-Hodgkin's lymphoma among European AIDS patients. AIDS in Europe Study Group. AIDS in Europe Study Group

The epidemiology of HIV associated non-Hodgkin's lymphoma (NHL) was investigated in 6550 European patients with AIDS. NHL was diagnosed in 3.5% of all patients at the time of the AIDS diagnosis. Although the probability of being diagnosed with NHL at AIDS diagnosis was significantly higher among intravenous drug users than among homosexual men, and was associated with increasing age, the observed incidences of NHL were more strikingly similar than any differences. The rate of developing NHL after a previous AIDS diagnosis was 2.4 per 100 patient years of follow-up, and remained constant during a 5-year follow-up period. While primary brain lymphomas comprised only 9% of NHL diagnosed at the time of AIDS, they comprised 38% of NHL diagnosed after AIDS (p < 0.001). The prognosis for patients with NHL at AIDS diagnosis was poor with a median survival of 5 months. A diagnosis of primary brain lymphoma was uniformly associated with a poor outcome. It is concluded that the probability of developing NHL in late stage HIV infection is lower than previously anticipated from the results of small studies on patients receiving long-term anti-retroviral therapy.

Intralesional interferon for the treatment of recalcitrant molluscum contagiosum in HIV antibody positive individuals--a preliminary report

Molluscum contagiosum is common in HIV disease and available therapies have a poor success rate and require frequent clinic visits. Interferon alpha has been used to treat recalcitrant condylomata acuminata and this study was undertaken to assess the use of this treatment in unresponsive molluscum contagiosum. A total of 30 molluscum contagiosum were injected with one megaunit of interferon alpha weekly for 4 weeks; 11 molluscum contagiosum completely cleared and 18 reduced in size by over 50%. Molluscum less than 0.5 cm in diameter, and those in patients without AIDS were more likely to respond. No surrounding lesions changed in size.

Multiple pilomatricomas and myotonic dystrophy in a patient with AIDS

We report a 43-year-old man with myotonic dystrophy who developed multiple pilomatricomas 2 years after being diagnosed as having AIDS. This is the first report of pilomatricomas developing in an HIV-1 seropositive patient.

Factors associated with the development of Pneumocystis carinii pneumonia in 5,025 European patients with AIDS. AIDS in Europe Study Group

This study examined the factors associated with the development of a first episode of Pneumocystis carinii pneumonia (PCP) in 5,025 patients with AIDS, including 1,976 patients with primary PCP at the time of AIDS diagnosis and 635 with primary PCP occurring subsequently. Compared with untreated patients, patients treated with zidovudine were at similar risk of developing PCP during the first year of therapy but were at greater risk after longer intervals of treatment. The following factors were associated with an increased risk of PCP (either at the time of AIDS diagnosis or thereafter): lack of primary PCP prophylaxis, male homosexuality/bisexuality, diagnosis of AIDS in northern Europe, and CD4 cell count below 200 x 10(6)/L at the time of AIDS diagnosis. Patients with severe weight loss had a 60% higher risk of developing PCP during follow-up than those without such weight loss. Thus, the occurrence of PCP depended on geographic location, mode of acquisition of human immunodeficiency virus and AIDS, degree of immunodeficiency, and use of various treatment regimens.