Differences in participation in experimental drug trials among persons with AIDS

To measure participation in experimental drug trials among persons with acquired immunodeficiency syndrome (AIDS), we interviewed 4,604 persons at least 18 years of age who were reported to have AIDS to 11 state and city health departments in the United States. Ten percent reported that they were currently in a trial. Current enrollment differed significantly (p < 0.05) by race/ethnicity (blacks, 5%; whites, 14%; Hispanics, 15%), gender (women, 7%; men, 11%), exposure mode (injection drug use, 5%, men who have sex with men, 14%), annual household income (< $10,000, 8%, > or = $10,000, 14%), education (< 12 years, 6%; > or = 12 years, 12%), health care (no regular care, 1%, public care, 8%; private care, 17%), and time since AIDS diagnosis (< or = 6 months, 9%; > 6 months, 12%). Adjusting for all factors and time since AIDS diagnosis, blacks (adjusted odds ratio [AOR] = 0.35, 95% confidence interval [CI] 0.26, 0.47), persons with less than 12 years of education (AOR = 0.71, CI 0.53, 0.96), and those without regular health care (AOR = 0.24, CI 0.10, 0.61) remained less likely to be in a trial. Blacks, those with less than 12 years of education, and persons without regular health care were less likely than other persons with AIDS to be currently enrolled in AIDS trials. To increase enrollment of these persons, researchers must address barriers to participation for these groups.

How important is race/ethnicity as an indicator of risk for specific AIDS-defining conditions?

In order to examine differences in the prevalence of AIDS-defining conditions by race/ethnicity, we analyzed U.S. surveillance data for 203,470 adolescents and adults diagnosed with AIDS from 1988 through 1992. A number of AIDS-indicator conditions were more common among certain racial/ethnic groups. The prevalence of extrapulmonary tuberculosis was higher among blacks, Hispanics, Asians/Pacific Islanders, and American Indians/Alaskan Natives than among whites. The prevalence of isosporiasis and toxoplasmosis was higher among Hispanics than among blacks or whites. Furthermore, the likelihood of being diagnosed with extrapulmonary tuberculosis (TB), toxoplasmosis, or isosporiasis was generally higher among foreign-born than among U.S.-born persons of all racial/ethnic groups. The prevalence of all malignancies was higher among whites than among blacks or Hispanics. However, the magnitude of prevalence differences by race/ethnicity was reduced when we controlled for other demographic and exposure risk categories. Although race/ethnicity was significantly associated with the prevalence of a number of conditions, the relative frequency and patterns of AIDS-indicator conditions in different populations are probably most influenced by differences in (1) underlying prevalence or exposure to various etiologic agents causing these conditions, (2) diagnosis and reporting of conditions, and (3) access to care and therapy for HIV-related conditions.

The migration of persons with AIDS: data from 12 states, 1985 to 1992. AIDS Mortality Project Group

This study measured the migration of persons with the acquired immunodeficiency virus (AIDS) between diagnosis and death using AIDS case and death reports from 12 states for 1985 to 1992. Of 49,805 persons with AIDS, 10.6% changed their place of residence, and half of these individuals who moved changed their state of residence. Migration had relatively little impact on the numbers of persons with AIDS in the largest metropolitan areas, which accounted for approximately 90% of AIDS diagnoses. Although only 3% of deaths occurred in residents of nonmetropolitan areas, the net effect of migration was a 24% increase in the number of persons with AIDS residing in such areas.

Relationship between use of condoms and other forms of contraception among human immunodeficiency virus-infected women. Supplement to HIV and AIDS Surveillance Project Group

OBJECTIVE

To describe the relationship between condom use and use of other contraceptives among human immunodeficiency virus (HIV)-infected women.

METHODS

We interviewed 1232 women, 18-50 years of age, who had had sex with a man in the prior 12 months and who were reported with AIDS or HIV to local health departments in 12 states and cities in the United States. These women were asked about condom use and other contraceptive use in the past year.

RESULTS

Forty-seven percent of women reported using condoms as a form of contraception in the past 12 months. Thirty-four percent of the 286 women who had had a tubal ligation and 42% of the 182 women who used oral contraceptives (OC) used condoms. When we controlled for all factors associated with failing to use condoms, women who had had a tubal ligation (adjusted odds ratio [OR] 1.72, 95% confidence interval [CI] 1.28-2.33), women who used OCs (adjusted OR 1.44, CI 1.00-2.08), and women who were unaware of the HIV status of their most recent steady sex partner (adjusted OR 1.72, CI 1.28-2.31) were the least likely to use condoms.

CONCLUSION

Human immunodeficiency virus-infected women who used more effective contraceptive methods were the least likely to have male sex partners who used condoms. In counseling women at high risk of transmitting HIV, health care providers should discuss reasons for using contraceptives (ie, preventing pregnancy versus preventing HIV transmission) and ensure that women understand that different forms of contraceptives may be needed to achieve those different purposes.

Methodological and statistical considerations for exercise-related hormone evaluations

Improvements in laboratory techniques have allowed research related to exercise endocrinology to flourish. The emerging literature, however, is often inconsistent and contradictory. The discrepancies in research findings are possibly the result of poor control of confounding variables and/or inappropriate methodologies or analyses. Environmental and pretesting behavioural conditions must be standardised to minimise the influence of variables not directly related to the investigation. Environmental temperature and relative humidity, alcohol, caffeine and nicotine intake, prandial state, sleep deprivation and previous exercise can each alter hormonal responses to exercise. Both prescription and over-the-counter medications can also modify normal hormonal secretions thereby confusing exercise-induced findings. Specimen collection and analysis procedures must be controlled carefully. Changes in plasma volume related to postural changes or tourniquet-induced stasis can confound attempts to isolate exercise-related endocrine responses. The established circadian and rhythmical variations characteristic of many hormones need to be controlled. The specimen selection (plasma, serum, urine, etc), collection, storage and analysis procedures should be carefully planned and evaluated. The magnitude of haemolysis, analytical and biological variation must also be monitored. Isolating the hormonal perturbations resulting from a particular exercise variable can be very difficult. Exercise intensity, duration, mode, frequency and volume may each have specific effects on the endocrine changes seen with exercise and training. Furthermore, hormonal responses to exercise are dependent upon initial training status and fitness level. The statistical procedures and data presentation options selected to convey experimental findings can bias experimental results. The descriptive and inferential statistics to be used for data analysis should be preplanned and consistent with the underlying assumptions of the analytical procedure. Careful consideration should be given to the biological relevance of statistically significant findings. In some cases, data transformations (e.g. absolute vs relative changes, logarithmic) should be considered for analysis or presentation. Given the individual nature of hormonal responses to exercise, emphasis should be placed presenting individual data. Other considerations, including age, sex, racial origin and disease conditions need to be controlled for when trying to examine exercise-induced hormone changes.

Distribution of CD4+ T lymphocytes at diagnosis of acquired immunodeficiency syndrome-defining and other human immunodeficiency virus-related illnesses. The Adult and Adolescent Spectrum of HIV Disease Project Group

BACKGROUND

Depletion of circulating CD4+ T lymphocytes among persons infected with the human immunodeficiency virus (HIV) is associated with increased risk for development of opportunistic, life-threatening diseases and death.

METHODS

To describe the levels of CD4+ T lymphocytes at which acquired immunodeficiency syndrome (AIDS)-defining and other illnesses initially occur, we analyzed data from an ongoing survey of medical records of 18,062 HIV-infected patients who received medical care between January 1990 and August 1993 in more than 100 clinics, hospitals, and private practices in 10 US cities. We report the median and upper 80th percentile CD4+ T-lymphocyte counts at diagnosis.

RESULTS

We found that AIDS-defining conditions first occurred in HIV-infected patients with CD4+ T-lymphocyte counts below 0.20 x 10(9)/L (200/microL) for 80% of diagnoses. Similarly, AIDS-defining diseases occurred at counts below 0.05 x 10(9)/L for 50% of diagnoses. Exceptions to both criteria were invasive cervical cancer and pulmonary tuberculosis. Non-AIDS-defining illnesses with which 80% of patients were diagnosed at CD4+ T-lymphocyte counts below 0.20 x 10(9)/L were bacterial sepsis and retinopathy (excluding cytomegalovirus).

CONCLUSION

Our observations support the need for continued CD4+ cell count monitoring below a level of 0.20 x 10(9)/L as a guide to diagnosis and medical management of HIV-infected persons.

HIV testing patterns: where, why, and when were persons with AIDS tested for HIV?

OBJECTIVE

To describe the location of, primary reason for, and time between the first positive HIV test and AIDS diagnosis in a sample of persons with newly diagnosed AIDS.

DESIGN

Interviews supplementing information routinely collected through AIDS case reporting.

SETTING

Eleven US states and cities.

PATIENTS

Persons with AIDS (2441) diagnosed between January 1990 and December 1992.

MAIN OUTCOME MEASURES

Location of first positive HIV test, primary reason for testing, and time interval between first positive HIV test and AIDS diagnosis.

RESULTS

Overall, persons were tested late in their course of HIV infection: 36% were tested for HIV within 2 months and 51% within 1 year of their AIDS diagnosis. Sixty-five per cent were HIV-tested in acute health-care settings: 33% in hospitals, 28% in physicians' offices, and 4% in emergency departments. Testing during hospitalization was most common among injecting drug users (43%) and persons infected through heterosexual contact (50%). Persons primarily sought HIV testing because of illness (58%); other reasons included being in a known risk group (13%) and having had a known HIV-infected sex partner (8%). Testing because of being in a known risk group was least common among persons infected through heterosexual contact (1%). Among persons in these exposure categories, testing differed by race/ethnicity.

CONCLUSION

Most persons with AIDS were tested relatively late in their course of HIV infection, in acute health-care settings, and because of illness. Not knowing one's serostatus precludes early medical intervention and may increase transmission.

Assessing HIV risk among women who have sex with women: scientific and communication issues

Data on human immunodeficiency virus (HIV) risk faced by women who have sex with women (WSW) are scarce. The biologic risk of female-to-female transmission is not known. Several surveys have reported that certain groups of WSW engage in behaviors that put them at risk for HIV infection, such as unprotected sex with men, unprotected sex or sharing of sex toys with women, and injection drug use. WSW may also be at risk for HIV through use of unscreened semen from sources other than sperm banks. An evaluation of HIV risk behaviors among WSW has been hampered by methodological issues, such as lack of data about the extent of the population, the use of standard definitions in research, and the design of data collection instruments. HIV prevention efforts have been hampered by communication issues, such as what "safer sex" means to this population and difficulties in interactions with health care providers. Prevention interventions for this population must address behaviors that put WSW at risk for HIV infection, including injection drug use and unprotected penile sex. At the same time, the possibility of sexual transmission of HIV via female-to-female sex should not be discounted. Health providers should understand that sexual identity does not necessarily predict sexual behavior and should not make any assumptions regarding HIV risk based on self-reported or presumed sexual identity.

Who are the primary caretakers of children born to HIV-infected mothers? Results from a multistate surveillance project

OBJECTIVE

To determine the primary caretakers of children born to women with human immunodeficiency virus (HIV) infection.

METHODS

We interviewed women at least 18 years of age who have been reported with HIV infection or acquired immunodeficiency syndrome to local health departments in 10 cities and states regarding the primary caretaker of their children born since 1977.

RESULTS

Of 541 HIV-infected women who had been pregnant since 1977, 88% had living children. These women comprised 478 family units (mother and children); 234 (49%) of these units consisted of two or more children. The most common primary caretakers for all children within a family unit were the mother alone (46%), grandparents (16%), and both mother and father (15%). When the mother used injection drugs or lived alone, in a shelter, or with friends, almost one quarter of all children were cared for by their grandparents. Only 30% of the mothers knew about child care assistance services, and only 8% had contacted or used these services.

CONCLUSIONS

Mothers with HIV, often alone, are the primary caretakers of their children. Increased provisions for child care assistance and planning for future permanent placement of orphaned children are urgently needed.

The effect of mild or moderate hepatic impairment (cirrhosis) on the pharmacokinetics of zileuton

The pharmacokinetics of zileuton and its R(+) and S(-) glucuronide metabolites were determined after single and multiple (400mg every 8 hours) oral dose administration in healthy subjects (n = 5) and patients with mild or moderate hepatic impairment (cirrhosis; n = 8). The clearance of total zileuton (unbound plus bound to plasma proteins) in patients with hepatic impairment (approximately 350 ml/min) was approximately half than in healthy subjects (approximately 670 ml/min), with similar values in patients with mild or moderate cirrhosis. However, the clearance of unbound zileuton in patients with moderate hepatic impairment was nearly half that in patients with mild hepatic impairment, and one quarter that in healthy subjects. On the basis of these findings, it may be necessary to reduce the dose in patients with impaired hepatic function to maintain levels similar to those in healthy subjects.

The types of drugs used by HIV-infected injection drug users in a multistate surveillance project: implications for intervention

OBJECTIVES

This study sought to describe the drugs used by drug injectors infected with human immunodeficiency virus (HIV) and to determine factors associated with the primary injection drug used.

METHODS

A cross-section of persons 18 years of age or older reported with HIV or acquired immunodeficiency syndrome (AIDS) to local health departments in 11 US states and cities was surveyed.

RESULTS

Of 4162 persons interviewed, 1147 (28%) reported ever having injected drugs. Of these 1147 injectors, 72% primarily injected a drug other than heroin. However, the types of drugs injected varied notably by place of residence. Heroin was the most commonly injected drug in Detroit (94%) and Connecticut (48%); cocaine was the most common in South Carolina (64%), Atlanta (56%), Delaware (55%), Denver (46%), and Arizona (44%); speedball was most common in Florida (46%); and amphetamines were most common in Washington (56%). Other determinants of the type of drug primarily injected were often similar by region of residence, except for heroin use. Polysubstance abuse was common; 75% injected more than one type of drug, and 85% reported noninjected drug use.

CONCLUSIONS

Preventing the further spread of HIV will require more drug abuse treatment programs that go beyond methadone, address polysubstance abuse, and adapt to local correlates of the primary drug used.

Sensitive method for the assay of sertindole in plasma by high-performance liquid chromatography and fluorimetric detection

A simple and highly sensitive normal-phase HPLC method is described for determining sertindole concentrations in human plasma using fluorimetric detection. A short C8 column was used to extract sertindole and the internal standard from plasma; the column was rinsed with acetonitrile, and the analytes were recovered by elution with methanol. This uncommon selectivity between the two solvents allowed clean extraction and near- quantitative recovery of the analytes (> 89%). Separation was done on a 5-microns silica-gel column and detection was performed by fluorimetry, with emission at 340 nm and excitation at 260 nm. The detection and lower quantifiable limits were 0.01 and 0.025 ng/ml, respectively, with no interference from plasma or potential metabolites.

Effect of pentoxifylline on intraperitoneal adhesions after intestinal resection in rats

Pentoxifylline, an analogue of the methylxanthine theobromine, inhibits glycosaminoglycan and collagen synthesis by dermal fibroblasts in vitro and also inhibits the proliferation of dermal fibroblasts. It may have the same effect on fibroblasts derived from postoperative adhesion bands, thus preventing postoperative adhesion formation. An animal model was developed to evaluate the effect of pentoxifylline. Twenty-four male Wistar rats were divided into four groups, and all underwent laparotomy with a 15 cm intestinal resection and reanastomosis. The intestinal serosa was scratched to induce adhesion formation. No medication was given in group 1 rats, group 2 rats received 6 mL normal saline by intraoperative peritoneal irrigation, group 3 rats received 6 mL pentoxifylline solution (1 mg/mL) by intraperitoneal irrigation and group 4 rats received both 6 mL intraoperative pentoxifylline solution (1 mg/mL) irrigation and 50 mg/kg pentoxifylline by intramuscular injection, twice a day for 14 days. All rats were sacrificed 2 weeks later. The numbers of fibrous bands at and away from the anastomotic site were recorded and scored. The score for each rat was calculated as the sum of the scores for each band. The strength and the extent of the fibrous bands were also measured and compared. The scores of adhesion bands at the anastomotic site were significantly reduced in group 3 and group 4 rats when compared with group 1 rats. However, there were no significant differences among the 4 groups in the extent and strength of adhesions at sites other than the anastomosis site.

Surveillance of AIDS-defining conditions in the United States. Adult/Adolescent Spectrum of HIV Disease Project Group

OBJECTIVE

To examine the reporting of AIDS-defining illnesses using two national surveillance systems.

METHODS

Comparison of AIDS indicator diseases reported to the national AIDS reporting system (ARS) for AIDS cases diagnosed from January 1990-December 1992 among individuals aged > 13 years in 10 metropolitan areas, with that observed in the Adult/Adolescent Spectrum of HIV Disease (ASD) project, a surveillance project that monitors the clinical diagnoses of HIV-infected individuals receiving medical care.

RESULTS

In the 10 metropolitan areas, 39,265 individuals with AIDS were reported to ARS, and 5969 with AIDS had medical record reviews as part of ASD. At initial AIDS diagnosis, the number of indicator diseases reported to ARS was almost identical to the number observed in ASD (mean number of diagnoses, ARS 1.3; ASD 1.2). However, ASD recorded a greater number of diagnoses over time than ARS (mean number of indicator diagnoses > 12 months after initial diagnosis, ASD 2.3; ARS 1.4). Conditions that typically occur late in the course of AIDS such as Mycobacterium avium infection and cytomegalovirus disease, were more frequently recorded by ASD than by ARS.

CONCLUSION

ARS provides complete, population-based information on the frequency of AIDS-defining conditions at initial diagnosis. However, specialized surveillance projects such as ASD are needed to accurately describe subsequent AIDS-defining conditions.

Risk behaviors of persons with heterosexually acquired HIV infection in the United States: results of a multistate surveillance project

To describe past risk behaviors among persons with heterosexually acquired human immunodeficiency virus (HIV) infection, we interviewed 497 persons > or = 18 years of age with heterosexually acquired HIV infection reported to 11 state and city health departments in the United States. Thirty-nine percent of persons reported using noninjection drugs in the past 5 years; noninjection drug use was highest among men whose sex partners injected drugs (53%). Sixteen percent of all persons used crack, and 17% were classified as potential alcoholics; among men, 29% were classified as potential alcoholics. Of the 49% of men who reported paying a woman for sex, 86% did so multiple times. Most persons had multiple sex partners in the past 5 years; however, 35% of the women had only one sex partner. Thirty-four percent of the women and 50% of the men had been treated for a sexually transmitted disease in the past 10 years. Seventy-four percent of the women and 68% of the men had never used condoms in the 5 years before they knew they were HIV positive. Among these people with heterosexually acquired HIV, noninjection drug use was common, many men have paid someone for sex, and many women have not had multiple sex partners. These findings have important implications for the types of prevention programs that can most successfully lessen the spread of HIV among heterosexuals.

Socioeconomic differences among people with AIDS: results from a Multistate Surveillance Project

To characterize the socioeconomic status of persons with acquired immunodeficiency syndrome (AIDS), 11 U.S. state and city health departments interviewed 2,898 persons > or = 18 years of age reported with AIDS between June 1, 1990, and January 31, 1993. Among men who have sex with men, white men reported the lowest percentage (9%), and Central/South American (50%) and Mexican men (40%) reported the highest percentages not completing 12 years of school. Among intravenous drug users (IDUs), 35% of white men, 64% of black men, 67% of Puerto Rican men, 29% of white women, and 63% of black women had not completed 12 years of school. Overall, 77% of the men and 90% of the women were unemployed; we also found racial/ethnic differences by employment but to a lesser degree than differences in education. Among women, but not among men, differences in household income by race and ethnicity were marked; 76% of white and 91% of black female IDUs reported a household income of $10,000. Human immunodeficiency virus (HIV) prevention programs must be targeted toward the educational level of the populations served, and HIV services must adapt to the financial circumstances of their clientele.

Health insurance coverage among persons with AIDS: results from a multistate surveillance project

To determine factors associated with health insurance coverage among persons with acquired immunodeficiency syndrome (AIDS), we interviewed 1958 persons 18 years of age or older who were reported to have AIDS in 11 states and cities. Overall, 25% had no insurance, 55% had public insurance, and 20% had private insurance. Factors associated with lack of insurance varied by current employment status. Employed persons with an annual household income of less than $10,000 were 3.6 times more likely to lack insurance than employed persons with a higher income. Unemployed persons diagnosed with AIDS for less than 1 year were two times more likely to lack health insurance than unemployed persons diagnosed for a longer time. Making insurance available to persons identified as most likely to lack insurance should improve access to care for persons with AIDS.