Incidence and risk factors for pneumonia in HIV infected and non-infected drug users

OBJECTIVE

To study the incidence and risk factors for pneumonia in a cohort of HIV infected and non-infected drug users (DU).

DESIGN

A prospective epidemiological study.

SETTING AND PATIENTS

Injecting and non-injecting DU who attended the Municipal Health Service in Amsterdam for follow-up visits in the study.

MAIN RESULTS

203 HIV infected and 437 non-infected DU were followed for a total of 1749 person-years. HIV infected DU reported 111 episodes of pneumonia, which required hospitalization in 29 cases, and HIV negative DU reported 55 episodes, which required hospitalization in nine cases. The incidences among HIV positive and HIV negative DU were 0.19 and 0.05 per person-year respectively. With multivariate Poisson regression current injecting (RR 2.13), recent seroconversion (RR 3.92), asthmatic constitution (RR 2.72), CD4+ cell count between 200-500 (RR 1.67 compared to > 500), CD4+ cell count less than 200 (RR 2.23 compared to > 500) and a previous history of pneumonia (RR 2.43) were independently associated with self-reported pneumonia among HIV infected DU. Among HIV negative DU heroin smoking (RR 1.87), asthmatic constitution (RR 3.62) and a previous history of pneumonia (RR 2.84) were independently associated with self-reported pneumonia. Also a higher Quetelet Index (QI) appeared to be protective (QI > or = 21 RR 0.42, QI 19-21 RR 0.82 compared to QI < 19) among HIV negative DU. Risk factors for reported and hospitalized cases of pneumonia were comparable among HIV positive DU.

CONCLUSIONS

HIV infected DU are at increased risk for pneumonia and the rate increases with lower CD4 cell counts. Also behavioural characteristics, such as injecting drug use and smoking heroin, and clinical history variables, such as a history of pneumonia or an asthmatic constitution, are risk factors for pneumonia among DU. Pneumococcal vaccination should not only be focused on HIV positive DU but also on the identified risk groups among HIV negative DU.

[Zidovudine-resistant HIV strains in intravenous drug users and homosexual men in Amsterdam]

OBJECTIVE

To investigate the spread of HIV strains resistant to antiviral drugs prescribed in the Netherlands.

DESIGN

Descriptive.

SETTING

Amsterdam.

METHOD

In several cohorts of homosexual men and intravenous drug users being followed in Amsterdam, in cases of newly acquired HIV infections in the period 1992-1995 HIV RNA was isolated from serum. The nucleic acid sequence encoding the first 250 amino acids of the HIV reverse transcriptase was determined in order to detect mutations conferring resistance to reverse transcriptase inhibitors.

RESULTS

Among participants of the Amsterdam cohort studies, 12 new HIV infections of homosexual men and 23 of IV drug users were observed. In the group of homosexual men the first infection by a zidovudine-resistant HIV was observed in 1995. In the group of IV drug users the first infection by a zidovudine-resistant strain was noticed in 1993 with two more infections in 1995. The mutations regarded positions 41, 67, 70 and 215 of the HIV reverse transcriptase. No HIV strains resistant to didanosine, deoxycytidine, lamuvidine or nevirapine were found in untreated persons with an acute infection.

CONCLUSION

As zidovudine is a vital part of the latest and most efficacious combination therapies of HIV infection, testing for zidovudine-resistance prior to treatment is recommended.

Complications of varicella zoster virus reactivation in HIV-infected homosexual men

OBJECT

To study the complication rate of varicella zoster virus (VZV) reactivation and the relationship between complications, presentation and localization of zoster and immune function in HIV disease.

DESIGN AND METHODS

A total of 142 episodes of VZV reactivation in 113 out of 544 HIV-1-infected participants in the Amsterdam Cohort Study of homosexual men were studied. Persistent hyperkeratotic or necrotic skin lesions, post-herpetic neuralgia, other neurological events, ocular events and pneumonitis occurring within 6 months of the onset of the last episode of VZV reactivation were defined as complications, provided that other possible diagnoses were excluded and the event had been previously described in the literature as related to VZV reactivation.

RESULTS

Twenty-four complications occurred in 15 (11%) of these 142 episodes. Complications occurred exclusively in the 40 episodes with either multidermatomal or disseminated presentation, or a trigeminal localization, or both. In the group of episodes of unidermatomal zoster at a non-trigeminal localization no complications occurred. Twenty-one episodes of herpes zoster were localized in the trigeminal area. Localization was not significantly associated with the level of immune function. Compared to unidermatomal presentation (n = 120), multidermatomal (n = 15) and disseminated presentation (n = 7) occurred at lower median CD4+ cell counts (330, 240 and 50 x 10(6)/l, respectively; P = 0.003) and significantly lower levels of CD3 monoclonal antibodies or phytohaemagglutinin-induced T-cell reactivity in vitro. Complications were related to CD4+ cell counts, but in the cases of disseminated, multidermatomal or trigeminal zoster a CD4+ cell measurement provided no additional information on the risk of complications.

CONCLUSION

In HIV-infected individuals the extent of the clinical presentation and the occurrence of complications of VZV reactivation are related to the degree of immunodeficiency. In episodes of VZV reactivation with either multidermatomal or disseminated presentation or a trigeminal localization, or both the complication rate was high. CD4+ cell counts provided no additional information on the complication risk. Oral acyclovir appears to be sufficient as therapy for unidermatomal zoster at a non-trigeminal localization.

Euthanasia and physician-assisted suicide in homosexual men with AIDS

BACKGROUND

In the Netherlands a nationwide study has shown that, in 38% of deaths, there have been medical decisions concerning the end of life (MDEL); 2.1% of all deaths were brought about by euthanasia or physician- assisted suicide (PAS). We investigated the incidence of MDEL in homosexual men with AIDS, suspecting that it might be higher, and studied the effect of euthanasia/PAS on survival time.

METHODS

The patients were 131 male homosexual participants in a cohort study in Amsterdam, diagnosed between 1985 and 1992 as having AIDS; all had died before Jan 1, 1995. Clinical and laboratory data and information on mode of death were obtained from their physicians and by review of hospital records. Those who died by euthanasia/PAS or in whom there had been other MDEL were then compared with those who died naturally.

FINDINGS

29 men (22%) had died by euthanasia/PAS and in 17 (13%) another MDEL had been made; thus, more than one-third of these men had made medical decisions concerning the end of life. The greatest difference between the groups was in age at time of diagnosis-72% aged 40 or more in the euthanasia/PAS group compared with 38% in the natural death group. The likelihood (relative risk) of euthanasia/PAS increased with duration of survival after AIDS diagnosis. Comparison of the groups in terms of three laboratory markers (CD4+ and CD8+ cells and phytohaemagglutinin responses) in the two years before death, and estimates of these markers at the time of death, did not indicate any substantial shortening of life by euthanasia/PAS; in the judgment of the physicians, most of these patients would have died naturally within one month.

INTERPRETATION

A possible reason for the high incidence of MDEL in this cohort was a good knowledge of the characteristics of AIDS acquired through long-term awareness of HIV infection. The higher rate of euthanasia in those with long survival from AIDS diagnosis could reflect either additional suffering or the greater opportunity to discuss this option with friends and physicians. Our findings indicate that euthanasia and other MDEL did little to shorten life; rather, they were an extreme form of palliation, applied in the terminal phase of a lethal disease.

Predictors of mortality in the Amsterdam cohort of human immunodeficiency virus (HIV)-positive and HIV-negative drug users

The impact of human immunodeficiency virus (HIV) infection and other risk factors on mortality was studied in a cohort of Dutch injection drug users and drug users who did not inject. Participants were recruited between 1985 and 1992 and followed up through 1993. Vital status was ascertained through repeat visit information, supplemented by population register data. A total of 77 deaths were recorded among 632 drug users, for a mortality rate per 1,000 person-years of 7 for HIV-negative noninjection drug users, 18 for HIV-negative injection drug users, and 64 for HIV-positive injection drug users. In multivariate analyses, limited to injection drug users, a positive HIV serostatus, age above 40 years, and using benzodiazepines several times daily were significantly associated with an elevated risk of death, both for death from all causes and for death preceding acquired immunodeficiency syndrome (AIDS) diagnosis (pre-AIDS). For pre-AIDS death, the adjusted relative risk associated with HIV infection was 2.2 (95% confidence interval 1.3-3.7). Only 38% of HIV-infected injection drug users who died were diagnosed with AIDS. However, 76% of HIV-infected injection drug users who died without AIDS diagnosis had evidence of immunosuppression (CD4 count < 500/microliters). Daily use of methadone and participation in needle and syringe exchange schemes were not associated with lower mortality rates. This study illustrates in a group of injection drug users with a 30% HIV seroprevalence and a high background mortality the profound influence on mortality that HIV infection has gained.

Socio-economic and demographic characteristics and HIV-1 infection among female commercial sex workers in Thailand

To identify socio-economic and demographic factors related to prevalent HIV-1 infection among female commercial sex workers (CSW) in Thailand oral interviews and blood samples were taken from 800 female commercial sex workers in northern and southern Thailand during a cross-sectional survey in 1992. The overall HIV-1 prevalence rate was 22% and showed a statistically significant decrease from 36% when the age at start of commercial sex work was between 12 and 15 years old to 11% when the age at start was 21 years or over. Working in direct service, working in the north, not being Thai, lower education, having no children and having a debt to the employer were all related to an elevated risk for HIV-1 infection in univariate analysis. In multivariate analysis younger age at start of commercial sex work, working in direct service, working in the north and having a debt to the employer were independently associated with prevalent HIV-1 infection. Prevention activities are urgently needed to prevent younger girls from entering sexual service business and to protect them from HIV 1 infection once they start working in the commercial sex service.

Validity of self-reported sexually transmitted diseases in a cohort of drug-using prostitutes in Amsterdam: trends from 1986 to 1992

BACKGROUND

Rates of self-reported sexually transmitted diseases (STD) among drug-using prostitutes in Amsterdam have been shown to be declining. However, self reports may provide biased estimates.

METHODS

We determined the prevalence of risk indicators for and time trends in incorrect self-reported STD in a cohort of drug-using prostitutes. Rates of self-reported STD were validated with diagnosed STD from a special STD clinic for drug-using prostitutes.

RESULTS

Between 1986 and 1992, 314 STD were diagnosed in 85 (65%) of 131 studied prostitutes. Overall, 34% of diagnosed STD was not reported in the cohort, referred to as underreporting. For 40% of reported STD, no diagnosis was obtained ('overreporting'). In spite of these misclassifications, absolute numbers of reported and diagnosed STD practically balanced. Underreporting was independently associated with longer residence in Amsterdam (OR = 2.34 per 5 years), more than six clinic visits between two cohort visits (OR = 0.31), daily use of non-parenteral drug (OR = 8.45) and mainly injecting heroin (OR = 6.93); overreporting was independently associated only with a lower frequency of clinic visits. Multivariate analyses showed that trends in underreporting and overreporting were in part explained by a higher number of visits in the cohort and by lower numbers of clinic visits between two cohort visits.

CONCLUSIONS

Self-reporting of STD in our cohort is unreliable and misclassification prevalent; risk factors for and associates of self-reported STD are biased. Inferences drawn from self reports are potentially misleading and therefore such data need to be validated. Trends in misclassification can be interpreted as recall errors and as a study participation effect. For monitoring of STD prevalences in relation to trends in sexual risk behaviours, diagnosed STD should be used in preference to self reports.

Herpes zoster, immunological deterioration and disease progression in HIV-1 infection

OBJECTIVE

To study the incidence of herpes zoster, the relationship between herpes zoster and immunological markers, and the prognostic value of herpes zoster for progression of HIV disease.

DESIGN AND METHODS

A total of 966 homosexual participants in The Amsterdam Cohort Study were studied. Herpes zoster was defined by its characteristic clinical presentation. Incidence was calculated using Poisson regression, cumulative incidence by the Kaplan-Meier product-limit method and the prognostic value was evaluated using Cox proportional hazards model.

RESULTS

The incidence of first episodes of herpes zoster was 3.31 per 1000 person-years (PY) in HIV-seronegatives and 51.51 per 1000 PY in HIV-1-seropositive individuals. Recurrences only occurred in HIV-1-positive patients (25.6%). Cumulative incidences of first episodes increased linearly with the duration of follow-up. In HIV-1-seropositives the incidence was 31.2 per 1000 PY at CD4+ cells > or = 500 x 10(6)/l, 47.2 per 1000 PY [relative risk (RR), 1.51; 95% confidence interval (CI), 0.78-2.94] at CD4+ cells 200-499 x 10(6)/l and 97.5 per 1000 PY (RR, 3.13; 95% CI, 1.54-6.32) at CD4+ cells < 200 x 10(6)/l. Besides CD4+ cell counts, CD3 monoclonal antibodies and phytohaemagglutinin-induced T-cell reactivity were independent predictors for herpes zoster. The hazard ratio for AIDS after herpes zoster was 1.6 (95% CI, 1.1-2.4) and for death 1.7 (95% CI, 1.1-2.5), but these were not independent from CD4+ cell counts.

CONCLUSION

In HIV-1 infection the incidence of herpes zoster increases with the decrease of CD4+ cell counts and T-cell reactivity, but herpes zoster is not an independent predictor for disease progression.

Lower prevalence and incidence of HIV-1 syncytium-inducing phenotype among injecting drug users compared with homosexual men

OBJECTIVE

To study the prevalence, incidence and predictive value for progression to AIDS of the HIV-1 syncytium-inducing (SI) phenotype in HIV-infected injecting drug users (IDU) compared with HIV-infected homosexual men.

DESIGN

Two prospective cohort studies on HIV-1 infection among IDU and homosexual men.

METHODS

HIV-infected IDU (n = 225) and homosexual men (n = 366) without AIDS were studied from March 1989 through December 1993. Data on laboratory markers, including the presence of SI variants, demographics, behavioural characteristics and clinical events were collected at every visit.

RESULTS

At baseline, SI variants were detected in 4% of IDU and 17% of homosexual men. During the study period 18 IDU and 68 homosexual men switched from non-SI to SI phenotype (4-year cumulative incidence, 14.6 and 28.4%, respectively) before AIDS diagnosis. Among participants with a documented date of HIV infection the cumulative incidence of SI was lower among IDU than homosexual men (4-year cumulative incidence, 6.2 and 20.7%, respectively). At AIDS diagnosis, 21% of all AIDS cases among IDU had the SI phenotype compared with 54% among homosexual men. In both risk groups an accelerated CD4 decline was found after the non-SI-to-SI switch. The SI phenotype appeared to be a predictor of AIDS (multivariate relative hazard, 5.33), independent of CD4 cell count and p24 antigen at baseline. In the multivariate time-dependent analysis, the relative hazard of SI phenotype decreased considerably, which is consistent with the hypothesis that the effect of SI phenotype on progression to AIDS is mediated by CD4 cell count.

CONCLUSION

The SI phenotype is associated with accelerated CD4 decline and progression to AIDS in both risk groups. The remarkable lower prevalence and incidence of the SI phenotype among IDU may implicate a difference in pathogenesis and natural history of HIV infection linked to transmission group.

HIV, sexually transmitted diseases and gynaecologic disorders in women: increased risk for genital herpes and warts among HIV-infected prostitutes in Amsterdam

OBJECTIVES

To determine the incidence of sexually transmitted diseases (STD; gonorrhoea, early syphilis, Chlamydia trachomatis infection, trichomoniasis and primary genital herpes) and gynaecologic disorders (vaginal candidiasis, anaerobic vaginosis, genital ulcerations of unknown cause, pelvic inflammatory disease, recurrent genital herpes, recurrent genital warts) in a cohort of HIV-infected and non-infected drug-using prostitutes in Amsterdam between 1986 and 1992.

DESIGN

A subgroup of 212 female drug users with a history of prostitution, who made at least one visit to a special STD clinic for drug-using prostitutes was selected from an ongoing cohort study of drug users in Amsterdam.

METHODS

Using Poisson regression, the relative risk (RR) for each outcome was calculated for HIV-positive women compared with HIV-negative women. To determine potential causal relations with immune suppression, associations between disease incidence and immunologic markers (CD4 cell count and anti-CD3 response) were assessed in HIV-positive women.

RESULTS

Adjusted for number of clients and frequency of condom use, HIV-positive women were at strong and significantly increased risk for primary genital herpes (RR, 7.64), recurrent herpes (RR, 8.33) and recurrent genital warts (RR, 15.93); moderately (significantly) increased risks were found for gonorrhoea (RR, 1.43), trichomoniasis (RR, 1.39), vaginal candidiasis (RR, 2.11) and genital ulcers of unknown aetiology (RR, 2.60). Of these HIV-related outcomes, the risk for recurrent genital herpes and genital warts were strongly associated with decreased CD4 cell counts.

CONCLUSIONS

HIV-infected women experience an excess morbidity of STD and gynaecologic disorders. The strongly increased risk for genital herpes and warts in HIV-seropositive women indicates a causal relation with HIV. This study emphasizes the need for accessible medical care for drug-using prostitutes.

Transmission of zidovudine-resistant human immunodeficiency virus type 1 variants following deliberate injection of blood from a patient with AIDS: characteristics and natural history of the virus

We describe the development and persistence of severe immunodeficiency in a previously healthy young woman shortly after she was deliberately injected with blood that was drawn from a patient with AIDS. The heterogenous populations of human immunodeficiency virus (HIV) in donor and recipient were as closely related as those reported in previous cases of proven transmission. The relatively large proportion of non-syncytium-inducing (NSI) clones in the recipient suggests a selective but not complete suppression of syncytium-inducing (SI) viruses. The continuous presence of SI viruses might explain the severe immunosuppression that persisted once the recipient seroconverted. A codon 215 mutation (indicative of zidovudine resistance) was present in SI and NSI clones of the donor and in NSI clones of the recipient. The relative increase in codon 215 resistance mutation in the absence of zidovudine therapy was secondary to the increase in NSI clones. Findings in this case suggest that qualities of an inoculum and/or the route of transmission are important determinants in the subsequent clinical course of HIV disease.

[HIV surveillance in an outpatient clinic for sexually transmissible diseases in Amsterdam, 1991-1994; low and stable prevalence among heterosexual clients]

OBJECTIVE

To assess the HIV prevalence among heterosexual attenders of a clinic for sexually transmitted diseases (STD) and among subpopulations, including young gay men and ethnic minorities.

SETTING

Outpatient clinic for sexually transmitted diseases (STD) of the Municipal Health Service of Amsterdam, the Netherlands.

METHODS

Semi-annually in the period 1991-1994, blood samples given voluntarily and anonymously were tested for HIV antibodies and some characteristics were collected of approximately 1000 clinic attenders.

RESULTS

Since 1991, 6766 clinic attenders were eligible for participation, of whom 6200 (92%) were actually tested. The overall HIV prevalence decreased from 3.9% in the first half of 1991 to 2.3% in the second half of 1994. Among heterosexual clinic attenders the prevalence remained stable below 1%, due mainly to visitors from abroad rather than to Dutch heterosexuals: 20 of the 23 HIV infected heterosexuals were not Dutch. None of these 23 seropositive persons knew of their HIV infection, mostly because they had not been tested previously. The HIV prevalence among gay men decreased over the years. In addition, the number of gay male attenders younger than 30 years decreased strongly over time.

CONCLUSIONS

HIV infections among heterosexual STD clinic attenders are relatively few and are seen mainly among non-Dutch. We found no indications of an increase of the HIV prevalence among heterosexual clinic attenders. The results among young gay men are suggestive of a shift towards safer sexual behaviour in this group.

Detection of Chlamydia trachomatis infection in urine samples from men and women by ligase chain reaction

The suitability of urine specimens from women and men for the detection of Chlamydia trachomatis infection by a ligase chain reaction (LCR)-based assay with plasmid primers was examined with a group of patients attending a sexually transmitted disease clinic in Amsterdam, The Netherlands. Cervical specimens from 15 of 237 (6.3%) women tested positive for C. trachomatis by cell culture. Of the 25 (10.5%) female urine samples that tested positive by the plasmid-LCR assay, 13 were obtained from cervical culture-positive women. Nine of the 12 plasmid-LCR-positive urine samples from cervical culture-negative women were confirmed to be positive by a second LCR assay with primers based on chromosomal DNA. Urethral specimens from 24 of 258 (9.3%) men were positive for C. trachomatis infection by cell culture. Of the 25 (9.7%) urine samples that tested positive by plasmid-LCR, 20 were from culture-positive men. All five of the LCR-positive urine samples from culture-negative men were confirmed to be positive by the LCR with chromosomal DNA primers. Relative to cell culture, testing by plasmid-LCR analysis of male urine samples had a sensitivity of 83.3% and a specificity of 97.9%; after resolution of discordant samples, these values were 86.2 and 100%, respectively. In the study with women, the sensitivities of plasmid-LCR analysis of cervical and urine specimens in comparison with cervical cell culture were 93.3 and 86.7%, respectively. After resolution of discrepant samples, the sensitivities of the plasmid-LCR test for cervical swabs and female urine samples were 96.3 and 92.6%, respectively. These results indicate that the plasmid-LCR-based assay is a very reliable, sensitive, convenient test for the detection of C. trachomatis infection in female and male urine specimens.

Is the human immunodeficiency virus-related Kaposi's sarcoma epidemic coming to an end? Insights from the Tricontinental Seroconverter Study

A decline in the proportion of Kaposi's sarcoma among AIDS cases since the 1980s has been attributed to changes in sexual behavior among homosexual men and a decreasing exposure to a hypothesized Kaposi's sarcoma cofactor. Recent studies have shown that the incidence rate of Kaposi's sarcoma has remained relatively stable, which seems to argue against the hypothesis of a declining exposure to the putative cofactor. To examine this paradox, we evaluated the incidence of Kaposi's sarcoma, using Cox proportional hazard analyses, and performed a simulation to compare incidences of different AIDS outcomes among 407 homosexual men with documented dates of seroconversion. Our data show that men who seroconverted early in the epidemic did not progress faster to Kaposi's sarcoma than men who seroconverted more recently. A lower incidence rate of Kaposi's sarcoma would be expected among the latter group if exposure to the hypothesized cofactor is decreasing over time. The percentage of Kaposi's sarcoma among incident AIDS cases decreased over the years following seroconversion, but not over calendar time. This study demonstrates that the decline in the proportion of Kaposi's sarcoma among AIDS cases should not be interpreted as a decline in the incidence of Kaposi's sarcoma and that there is no evidence that a hypothesized Kaposi's sarcoma cofactor is declining over calendar time.

The predictive value of T cell function in vitro and pre-AIDS zidovudine use for survival after AIDS diagnosis in a cohort of homosexual men in Amsterdam

The best independent predictors of survival after AIDS diagnosis were determined in 160 homosexual men from the Amsterdam Cohort Study (1987 CDC case definition). In a Cox model, all pre-AIDS laboratory markers gathered during follow-up in the study did not independently predict survival after AIDS. A second analysis, using data available only at AIDS diagnosis, revealed that T cell reactivity after stimulation with phytohemagglutinin and monoclonal CD3 antibodies and the CD4+ cell count at diagnosis were independent predictors of survival. In an interval-based Cox model, the predictive value of pre-AIDS zidovudine use was determined. One year after AIDS diagnosis, participants with pre-AIDS zidovudine use had a worse survival probability (relative hazard = 3.99). In conclusion, the survival probability of homosexual men with AIDS can be estimate adequately using information obtained at clinical AIDS diagnosis. Analysis revealed the important predictive value of T cell function tests in vitro.

Sexual behaviour and sexually transmitted diseases in Dutch marines and naval personnel on a United Nations mission in Cambodia

OBJECTIVES

To determine the sexual risk behaviour and the incidence of sexually transmitted diseases (STD) among Dutch marines and naval personnel during a United Nations (UN) deployment.

METHODS

Surveillance by post deployment questionnaire, administered to 2289 persons in three successive battalions who served for 6 months on a UN deployment in Cambodia during June 1992-November 1993. On site the medical history of all individuals was kept up to date in a database. All personnel received extra education on STD prevention prior to deployment. Condoms were freely obtainable during deployment.

RESULTS

1885 persons (82%) handed in the questionnaire of whom 842 (45%) reported to have had sexual contacts with prostitutes or local population. Being younger and single were independent risk factors for having contact. Out of these 842 persons, 750 (89.1%) reported condom use at all times, while 82 (9.7%) reported inconsistent use and 10 persons (1.2%) reported not to have used condoms. Risk factors for inconsistent and non use were being 40 years or older and a higher number of contacts. From the 832 (750 + 82) condom users, 248 (30%) reported condom failure. Risk factors for failure were: inconsistent condom use, having had more than six contacts and being in the second battalion. The patient recording database showed 43 STD cases registered in the total population of 2289 persons (1.9%).

CONCLUSIONS

A low STD incidence was found despite a considerable number of reported sexual contacts. The reported condom use was high but the failure rate was considerable and needs further attention.

T cell function in vitro is an independent progression marker for AIDS in human immunodeficiency virus-infected asymptomatic subjects

The predictive value of low T cell reactivity to CD3 monoclonal antibodies for development of AIDS was evaluated and compared with low CD4+ cell numbers and the presence of syncytium-inducing human immunodeficiency virus (HIV) variants in 122 seropositive asymptomatic homosexual men for 4.5 years. Low T cell reactivity was a strong predictor for progression to AIDS in a multivariate proportional hazards analysis using these markers as covariates at entry and as time-dependent covariates. The combination of the three markers was associated with development of AIDS in 6 of 7 men within 15 months. In contrast, the group that lacked any of these markers had a very low risk (11%) for developing AIDS. In groups with one or two of these three markers, progression rates were 33% and 66%, respectively. These data demonstrate that measurement of T cell function in vitro is of value for staging of HIV infection and may be useful for monitoring therapy.

An outbreak of hepatitis A among homosexual men in Amsterdam, 1991-1993

BACKGROUND

When in August 1992 it became evident that an outbreak of hepatitis A virus infections (HAV) was taking place in the male homosexual community in Amsterdam a case-control study was conducted to validate the assumption that the outbreak was associated with sexual practices involving oro-anal and digital-anal contact and frequent visits to gay saunas and darkrooms.

METHODS

In all, 37 cases reported to the Amsterdam Municipal Health Service (AMHS) in the period December 1991 to March 1993 and 68 anti-HAV negative controls completed an anonymous questionnaire concerning the practice of different sexual techniques and the number of visits to gay saunas and darkrooms in the 2 months preceding the onset of illness or date of interview. Controls were recruited from healthy homosexual men participating in a prospective study on HIV/AIDS conducted by the AMHS.

RESULTS

In univariate analysis a statistically significant association was found between visits to gay saunas and darkrooms, the number of visits to these locations (OR = 8.2) and HAV infection. In the logistic regression analysis the association for visits to saunas and darkrooms remained significant (OR = 10) whereas high-risk sexual techniques could not be included in the model.

CONCLUSIONS

These results indicate that to prevent future outbreaks of HAV in male homosexuals in Amsterdam there is a need to stress in the 'safe sex' campaigns, directed at the prevention of HIV infection or in additional campaigns, the prevention of other sexually transmitted disease including HAV infection with emphasis on routes associated with certain sexual techniques and on visits to gay saunas and darkrooms.

Death from suicide and overdose among drug injectors after disclosure of first HIV test result

OBJECTIVE

To investigate whether notifying injecting drug users (IDU) of their positive HIV serostatus contributes to suicide and overdose mortality risk.

DESIGN

Members of a cohort of IDU, recruited since December 1985, who first learned their HIV serostatus after study entry but before December 1992, were studied for incidence of deaths due to suicide and overdose.

METHODS

Incidence of mortality due to suicide/overdose was calculated from date of first HIV test result disclosure until the end of follow-up or diagnosis of AIDS.

RESULTS

Eighty-six HIV-positive and 252 HIV-negative IDU were included with median follow-up times of 4.3 and 4.0 years, respectively. Seven suicides and 10 deaths from overdose were recorded. High suicide/overdose risk shortly after test result notification was not found among HIV-positive IDU. Only one out of eight HIV-positive IDU who died of suicide/overdose died within 6 months of first disclosure. The overall suicide/overdose mortality rate was higher for HIV-positive than HIV-negative IDU; the rate ratio being 2.46 [95% confidence interval (CI), 0.95-6.39] or 2.04 (95% CI, 0.77-5.39) after control for confounders.

CONCLUSIONS

Notifying IDU of their positive HIV serostatus does not appear to lead to a sudden and substantial rise in suicide/overdose deaths. Although death from suicide/overdose is more common among HIV-positive than HIV-negative IDU, this difference is likely to result from factors other than test result disclosure. Therefore, provided that appropriate counselling is offered, we see no reason to discourage voluntary HIV test result notification for fear of inducing suicide in HIV-infected IDU.

Predictors of disease progression in HIV-infected homosexual men with CD4+ cells < 200 x 10(6)/l but free of AIDS-defining clinical disease

OBJECTIVE

To study progression of HIV infection in individuals who are free of AIDS-defining clinical disease with CD4+ cell counts < 200 x 10(6)/l.

DESIGN

Prospective and nested case-control study.

SETTING

Amsterdam cohort study on HIV infection, The Netherlands.

PARTICIPANTS

Prospective study: 148 asymptomatic HIV-infected individuals with < 200 x 10(6)/l CD4+ cells. Nested case-control study: 58 men with AIDS-free follow-up more than 2 years after CD4 count < 200 x 10(6)/l, compared with 63 who progressed to AIDS within 2 years.

MAIN OUTCOME MEASURES

Progression to AIDS according to the 1987 Centers for Disease Control and Prevention case definition and death.

RESULTS

Median AIDS-free interval was 22 months, median interval to death 41 months. Presence of syncytium-inducing (SI) HIV variants, HIV p24 antigen, and a low T-cell response after stimulation with phytohaemagglutinin (PHA) were independent predictors of progression to AIDS. Probability of 1 year AIDS-free survival varied between 89 and 38% by the presence or absence of these additional markers. Effect of early treatment could only be detected in men with HIV p24 antigen and SI variants. Case-control analysis showed similar changes over time regarding prognostic markers in both groups although at a lower rate in the AIDS-free men. Eight men remained AIDS-free more than 4 years, SI variants were absent in seven, and all eight were p24-seronegative.

CONCLUSIONS

HIV-infected individuals can remain disease-free for more than 4 years with very low CD4+ cell counts, provided that they lack other progression markers: SI variants, p24 antigen and a low PHA-induced T-cell reactivity. A beneficiary effect of early treatment may be limited to men with SI variants and/or p24 antigen.