Seropositivity for HIV and the development of AIDS or AIDS related condition: three year follow up of the San Francisco General Hospital cohort

The Italian quality control study for evaluation of CD4 cells in centres involved in the treatment of HIV-1 patients. Italian CD4 Quality Control Group

We report on the experience of establishing a national network for a quality control programme in evaluating CD4 cell counts in most Italian centres involved in the care of patients with HIV disease. The 68 centres were divided according to their geographical location into eight groups, and twice a year (tests A and B) they received three coded whole blood samples (two were replicates of the same sample) obtained from two informed HIV+ patients, one with CD4 counts/mm3 expected to be < 200 and one with values > 300. The medians of the determinations performed by the labs involved in each of the eight areas were taken as the 'true' values for each sample. Unsatisfactory performances for percentage of CD4 cells were identified as a CD4 analysis with residual values > or = +/- 5% and with deviates > or = +/- 2. For absolute numbers of CD4 cells, an unsatisfactory performance was defined as CD4 counts with residual > +/- 100 CD4 cells/mm3 and with deviates > or = +/- 2. The residual value is the CD4 value reported by each lab minus the median value. The deviate is the residual divided by the modified interquartile range (IQR x 0.75). Most of the centres provided reliable results. However, some labs failed to provide satisfactory results for percentages (6.25% of the tested labs for test A and 6.17% for test B) or absolute numbers (16.25% test A and 12.34% test B). Only 3.7% of the labs gave unsatisfactory results in both tests. Four of the unsatisfactory results from the two tests gave an error in absolute numbers > +/- 200 CD4 cells/mm3. Our data suggest that most Italian labs provide reliable results in evaluating the numbers of CD4 cells in HIV-1+ samples, but the importance of running a quality control programme is highlighted by our experience with those centres which provide unsatisfactory data which may lead to incorrect classification of the patients or assessment of treatment.

AIDS prognosis based on HIV-1 RNA, CD4+ T-cell count and function: markers with reciprocal predictive value over time after seroconversion

OBJECTIVE

HIV-1 RNA levels in peripheral blood are strongly associated with progression to AIDS, CD4+ T-cell decline, or death. Their predictive value is reportedly independent of the predictive value of CD4+ T-cell counts. Because the interrelations between these parameters of HIV-1 infection are poorly understood, we studied the kinetics and predictive value of serum HIV-1 RNA levels, CD4+ T-cell counts, and T-cell function.

DESIGN AND METHODS

HIV RNA levels, CD4+ T-cell counts, and T-cell function were measured from seroconversion to AIDS in 123 homosexual men who seroconverted during a prospective study and were followed over 10 years.

RESULTS

Two patterns of median HIV-1 RNA levels were found during infection: a steady-state and a 'U-shaped' curve. Steady-state high RNA levels were related to rapid disease progression. For the U-shaped curve, there were groups with high and low RNA levels related to disease progression. At 1 year after seroconversion, RNA level was the only marker that was strongly predictive. Furthermore, decreasing RNA levels in the first year following seroconversion were related to better prognosis than stable low levels. Low CD4+ T-cell count and T-cell function became predictive of progression to AIDS at 2 and 5 years after seroconversion, respectively.

CONCLUSIONS

With ongoing infection, the predictive value of low CD4+ T-cell count and T-cell function increases, whereas the predictive value of high HIV-1 RNA level decreases. These findings reflect the observation that infection with HIV progressively leads towards immune deficiency, which in later stages is most predictive of disease progression.

Herpes zoster and the stage and prognosis of HIV-1 infection

OBJECTIVES

To examine the incidence of herpes zoster in HIV-1 infection. To assess the prognostic significance of the occurrence of herpes zoster and progression to AIDS or death

DESIGN AND METHODS

146 homosexually active men with known times of HIV-1 seroconversion were identified through the Sydney AIDS Prospective Study and the clinic records of a private medical practice with large caseload of HIV infected homosexual men. Medical records were reviewed for a history of herpes zoster, CD4+ lymphocyte counts, and HIV-1 disease status. Cox's proportional hazards model was used to determine whether herpes zoster predicted progression to AIDS or death.

RESULTS

After a mean follow up of 54 months, 30 men (20%) had an episode of herpes zoster and three of these men had one recurrence. The overall incidence of herpes zoster was 44.4 episodes per 1000 person years (95% CI 30.0-63.5). Herpes zoster was not found to be a marker of deteriorating immune functions as measured by CD4+ lymphocyte counts. CD4+ counts did not differ significantly between those with and without zoster at 1 year (551 v 572.10(6)/1, p = 0.79), 2 years (451 v 557, p = 0.11), and 3 years (424 v 481, p = 0.50) following HIV-1 seroconversion. There was no statistically significant difference in progression to AIDS (RR = 1.89, 95% CI 0.80-4.46, p = 0.15) or death (RR = 0.90, 95% CI 0.31-2.65, p = 0.85) from HIV-1 sero-conversion in those who did and those who did not develop herpes zoster.

CONCLUSION

The incidence of herpes zoster was consistent with the findings of other studies. There was no association between the occurrence of herpes zoster and progression of HIV-1 disease.

Influence of age on rates of new AIDS-defining diseases and survival in 6546 AIDS patients

It has consistently been reported that older AIDS patients have a shortened survival compared with younger patients. The aim of the present study was to investigate whether this difference in survival is caused by differences in the pattern of the complicating diseases. Information on patient follow-up after the AIDS diagnosis was obtained by retrospective case note review. The 6,546 patients were followed from the time of AIDS diagnosis as part of the multicentre AIDS in Europe study, which examined AIDS cases diagnosed at 52 centres in 17 European countries between 1979 and 1989. Occurrence of AIDS-defining events and demographic variables were recorded for all patients, and CD4 lymphocyte count at the time of AIDS diagnosis for approximately half the patients. After adjusting for imbalances in other variables, persons > or = 50 years of age had a significantly higher risk of contracting AIDS wasting syndrome, AIDS dementia complex and oesophageal candidiasis after the initial AIDS diagnosis, compared with age group 30-39 years [relative risk (RR) 95% confidence interval (CI)], 3.23 (2.70-3.75 CI); 2.48 (2.16-2.80 CI); 1.55 (1.26-1.83 CI), respectively]. Shortened survival after the time of AIDS diagnosis was associated with older age. After adjusting for pattern of complicating diseases, the age effect remained unchanged. Older age predisposes to AIDS-related wasting syndrome, AIDS dementia complex and oesophageal candidiasis. Independent of these differences, older age is significantly associated with shortened survival, suggesting that factors such as severity of complicating diseases or the capability of handling serious infections, rather than disease pattern, are responsible for the shortened survival.

Lymphoproliferative immune function in the Sydney Blood Bank Cohort, infected with natural nef/long terminal repeat mutants, and in other long-term survivors of transfusion-acquired HIV-1 infection

OBJECTIVES

To assess T-helper cell immune function (proliferation) in members of the Sydney Blood Bank Cohort (SBBC) compared with other individuals with transfusion- and sexually acquired HIV-1 infection and with matched HIV-negative controls.

DESIGN AND METHODS

Decreasing CD4 counts and T-helper cell function are associated with disease progression. Peripheral blood mononuclear cells (PBMC) from study subjects were assayed for in vitro proliferative responses to HIV-1-derived antigens, recall antigens and alloantigen. T-helper cell function and CD4 counts in members of the SBBC were followed longitudinally.

RESULTS

Proliferative responses and CD4 counts from members of the SBBC were similar to or better than those of other transfusion- or sexually-acquired HIV-1-positive long-term non-progressors (LTNP), including the HIV-negative matched SBBC control groups. However, individuals with disease progression had reduced or undetectable proliferative responses to recall antigens but a conserved response to alloantigen; they also had low CD4 counts and low CD4:CD8 ratios. In the SBBC, these immune parameters were usually stable over time.

CONCLUSIONS

The unique SBBC with natural nef/long terminal repeat deletions in the HIV-1 genome were genuine LTNP without showing signs of disease progression. They appeared to be a group distinct from the tail-end of the normal distribution of disease progression rates, and may remain asymptomatic indefinitely. The SBBC virus may form the basis of a live attenuated immunotherapeutic or immunoprophylactic HIV vaccine.

Projected incidence of AIDS in San Francisco: the peak and decline of the epidemic

To predict the incidence of AIDS from 1978 through 1998 in San Francisco, we developed a model that combined annual HIV seroconversion rates for homosexual and bisexual men and for heterosexual injecting drug users with estimates of the incubation period distribution between HIV seroconversion and AIDS diagnosis and with estimates of the size of the at-risk populations. Our model assumed the availability of antiretroviral therapy at the efficacy level of zidovudine monotherapy. The annual number of new AIDS cases is estimated to have peaked at 3332 in 1992, and is projected to decline to 1196 annually by 1998. Although the projected number of cases decreased steadily during this period for homosexual and bisexual men, the projected number of cases for injection drug users, women, and persons with other risks increased between 1993 and 1998. The decline in the incidence of AIDS in San Francisco reflects the dramatic reductions in new HIV infections that occurred a decade previously and that were achieved as a result of significant changes in high-risk behaviors, primarily among homosexual and bisexual men. Changes in HIV seroincidence must be factored in before attributing the decrease in AIDS incidence to more effective combination antiretroviral treatment.

Elevated CD38 antigen expression on CD8+ T cells is a stronger marker for the risk of chronic HIV disease progression to AIDS and death in the Multicenter AIDS Cohort Study than CD4+ cell count, soluble immune activation markers, or combinations of HLA-DR and CD38 expression

The prognostic value of several immunologic markers were compared in Los Angeles Multicenter AIDS Cohort Study (MACS) participants, most of whom had been infected with HIV for >8 years. Markers studied included CD4+ cell number, flow cytometric measurements of CD8+ cell expression of CD38 and HLA-DR antigens, and serum markers of immune activation including neopterin, beta2-microglobulin, soluble interleukin-2 receptor, soluble CD8, and soluble tumor necrosis factor receptor-alpha (TNF-alpha) type II. Cox proportional hazards models indicated that elevated CD38 on CD8, a flow cytometric measurement of CD8+ T-lymphocyte activation, was the most predictive marker of those studied for development of a clinical AIDS diagnosis and death. As compared with the reference group, who had CD38 on CD8 <2470 molecules per CD8+ cell and in whom 4 of 99 developed clinical AIDS within 3 years, participants with CD38 on CD8 between 2470 and 3899, 3900 and 7250, and >7250 had relative risks (and numbers developing AIDS within 3 years) of 5.0 (15 of 81), 12.3 (24 of 60), and 41.4 (36 of 49), respectively. The strong prognostic value of CD38 on CD8 measurements and the fundamental importance of chronic immune activation in the pathogenesis of HIV disease suggests that this marker might have utility in the clinical management of HIV-infected persons.

A prospective study of oral lesions and their predictive value for progression of HIV disease

OBJECTIVE

This report evaluates and compares individual oral lesions and combinations of lesions in predicting progression-free survival in a seroprevalent cohort of men and women with HIV infection.

DESIGN

This was a prospective study of HIV-infected patients, initially AIDS-free, followed for approximately 30 months.

SETTING

Patients were volunteers examined at an academic medical center and at an inner-city hospital in New York. Participants identified themselves as homosexual men or as injection drug users (IDU).

OUTCOME MEASURES

The primary outcome being assessed is time from a baseline oral examination until the development of an AIDS-defining condition or death from any cause within 12 months of the last study visit. Correlation is measured by relative risk (RR).

RESULTS

While oral lesions were not predictive of progression among subjects with CD4 > or = 200, they were highly predictive of progression among those with CD4 < 200. For subjects with CD4 < 200, the only individual lesion that was significantly associated with progression-free survival was oral candidiasis (RR = 4.12, P = 0.009). Positivity for one or more lesions in a set demonstrated greater prognostic value among those with CD4 < 200, with RR's of 6.03 (P = 0.018) for the set consisting of oral candidiasis, hairy leukoplakia, and necrotizing ulcerative gingivitis (NUG), and 8.77 (P = 0.036) for the set consisting of the above lesions plus linear gingival erythema (LGE). Analysis by cohort suggested that the improvement in correlation was stronger in homosexual men than in IDU, but this question could not be resolved conclusively with these data.

CONCLUSIONS

Lesion sets might be better prognosticators of progression-free survival than individual lesions among HIV-infected subjects with CD4 < 200. Prognostic value of the core lesion set (oral candidiasis and hairy leukoplakia) was enhanced by the addition of other lesions (NUG and LGE) not usually included in HIV staging systems. These results suggest that staging systems for HIV might be improved by the inclusion of other, survival-related oral lesions.

Can repeated plasma donation by asymptomatic HIV-infected individuals delay the onset of AIDS?

Healthy HIV-positive regular donors of plasma in a programme of passive immunotherapy for AIDS patients were studied over a period of about two years. None developed symptoms of clinical progression; most seemed to make substantial gains of CD4 cells by comparison with asymptomatic individuals who were not donating. The effects of donation did not seem to diminish with repetition, and donor CD4 counts tended towards stabilizing within normal limits. Asymptomatic HIV-positive individuals were compared immunologically with 'normals' and people with AIDS, using a battery of 25 measurements on peripheral blood. The immunological profiles of donor and non-donor asymptomatics, indistinguishable at the start, became dissimilar: donors' profiles resembled AIDS less, non-donors became less like 'normal' and a few non-donor results could not be distinguished from AIDS. Improvement in the CD4 counts and amelioration of the immunological profile in donors provide prima facie evidence that plasmapheresis may be therapeutic for asymptomatic HIV-positive people. Further studies are justified.

Markers, cofactors and staging systems in the study of HIV disease progression: a review

This paper is aimed at providing a comprehensive review of markers, cofactors and staging systems used for HIV disease, focusing on some aspects that nowadays could even be considered historical, and advancing in current issues such as the prognostic value of viral load measurements, viral genotypic and phenotypic characterization, and new HIV disease treatment protocols. CD4+ cell values, combined with the new viral markers mentioned are promising as a parsimonious predictor set for defining both severity and progression. An adequate predictor of patient resource use for planning purposes still needs to be defined.

HIV infection and aging: mechanisms to explain the accelerated rate of progression in the older patient

Age is an important predictor of progression in HIV infections. Not only do older individuals' develop AIDS more rapidly than younger persons, they die more quickly after developing an AIDS-defining illness. While the elderly have higher morbidity and mortality rates from viral and bacterial infections, the mechanism(s) responsible for the more rapid progression of HIV infection in older individuals has not been described. Our results demonstrate that the destruction of T cells in both young and old HIV infected patients progresses at the same rate. HIV 1-infected cells from older individuals do not appear more susceptible to immune mediated destruction. The more rapid progression appears due to an inability of older persons to replace functional T cells that are being destroyed. These findings suggest that improved survival in older HIV infected individuals will require more aggressive antiretroviral therapies as well as continued research to identify and preserve immune system elements that control the virus.

Associations of age, immunosuppression, and AIDS among homosexual men in the Tricontinental Seroconverter Study

To characterize the associations of age, immunosuppression, and AIDS outcomes, we evaluated serial measures of CD4+ lymphocytes from 376 homosexual men with documented dates of HIV-1 seroconversion registered in the Tricontinental Seroconverter Study. Using regression models and adjusting for variation within individuals, we found no association between age and the number of CD4+ lymphocytes at seroconversion or with CD4+ lymphocyte decline after seroconversion. Men who developed opportunistic infections had fewer CD4+ lymphocytes at the time of diagnosis compared with men who developed AIDS-defining Kaposi's sarcoma. Older age was significantly associated with higher numbers of CD4+ lymphocytes in individuals diagnosed with AIDS-defining Kaposi's sarcoma but was not significant for individuals with opportunistic infections. Because older age shortens the latency period of Kaposi's sarcoma and does not affect the CD4+ lymphocyte loss, it results in higher CD4+ lymphocytes at the time of diagnosis. These findings suggest distinct biologic mechanisms for various AIDS manifestations, which is important for clinical decision making and health care planning.

Thrombocytopenia in HIV-infected and uninfected hemophiliacs. Multicenter Hemophilia Cohort study

To determine the incidence and prognostic significance of thrombocytopenia among hemophiliacs, we analyzed clinical and hematologic data from the Multicenter Hemophilia Cohort study. Nineteen percent of HIV-infected subjects had thrombocytopenia (platelet count of <100,000/mm3) noted at least once, compared to 3% of HIV-uninfected subjects. For HIV-infected subjects, the prevalence of thrombocytopenia rose in the first 5 years after seroconversion and was twice as common in subjects age >35 years compared to younger subjects. The risk increased after an AIDS-defining illness, particularly among older subjects, nearly one-half of whom had thrombocytopenia within 1 year after AIDS. When adjusted for age and CD4-positive lymphocyte counts, thrombocytopenia was associated with an increased risk of death [relative risk (RR) 1.7, 95%CI = 1.2-2.3] but with little change in the risk of progression to AIDS (RR = 1.2, 95%CI = 0.8-1.7). Treatment with zidovudine was associated with a decreased risk of thrombocytopenia (RR = 0.5, 95%CI = 0.3-0.7). Although 59 HIV-infected subjects died of hemorrhage, only 11 (19%) of the 59 had a reported platelet count of <50,000/mm3, and only 2 (3%) of the deaths were temporally associated with thrombocytopenia. Thus, the risk of death was increased for thrombocytopenic HIV-infected hemophiliacs but this was not explained by an increased risk of developing AIDS and was rarely associated with death from bleeding.

Reductions in HIV-1 disease progression for zidovudine/lamivudine relative to control treatments: a meta-analysis of controlled trials

OBJECTIVES

Four randomized double-blind trials have demonstrated that zidovudine/lamivudine (ZDV/3TC) reduces HIV RNA and raises CD4 counts relative to control treatments (ZDV or ZDV/zalcitabine (ddC)]. A meta-analysis of the clinical events in these trails was conducted to determine whether treatment with ZDV/3TC was also associated with a clinical benefit.

DESIGN

The four trials, ZDV/3TC versus ZDV (NUCA3001, NUCB3001, NUCB3002) or versus ZDV/ddC (NUCA3002), were run concurrently, using the same doses of ZDV and 3TC.

SETTING

Investigational sites in Europe and North America.

PATIENTS

The trials recruited 972 HIV-1-positive, male and female patients aged > or = 18 years, with CD4 counts of 100-500 cells x 10(6)I. Two trials were for ZDV-naive patients and two were for ZDV pre-treated patients.

MAIN OUTCOME MEASURES

Progression to first new Centers for Disease Control and Prevention (CDC) B or C event was compared between all ZDV/3TC arms and all control (ZDV, ZDV/ddC) arms.

RESULTS

A total of 118 patients progressed to a first new CDC B/C event during the four trials, while 28 progressed to a new CDC event. Meta-analysis of the trials showed a 49% reduction in progression to new CDC B/C events (relative risk, 0.509; 95% confidence interval, 0.365-0.710; P < 0.0001) and a 66% reduction in progression to new CDC C events (relative risk, 0.344; 95% confidence interval, 0.169-0.700; P = 0.003) for the ZDV/3TC patients relative to the control patients. Reductions in progression to CDC B/C disease were seen in subgroups of naive and pre-treated patients, those with high and low CD4 counts and symptomatic and asymptomatic patients.

CONCLUSIONS

ZDV/3TC combination treatment delays the progression of CDC B/C disease compared with control treatments. In view of the low incidence of CDC C events, the results for progression to CDC C disease should be interpreted with caution.

Improving the prognostic value of CD4+ count using IgA and clinical signs in HIV-seropositive i.v. drug users

A population of 549 HIV-positive intravenous drug users, 140 of whom were women, recruited between June 1985 and June 1991, were studied to determine the usefulness of minor clinical signs and biological parameters in predicting progression to AIDS at different CD4+ levels. Ninety-eight subjects developed AIDS during a median follow-up of 4 years. Oral thrush was predictive of progression to AIDS independently of the CD4+ level at enrollment; seborrheic dermatitis was predictive of disease progression only in those with CD4+ under 500 cells/mm3. Regarding the predictive value of the biologic parameters examined, similar IgA levels among HIV-seropositive intravenous drug users with CD4+ > 500 cells/mm3 and HIV-negative intravenous drug users were observed, while higher median levels were found among HIV-positive participants with CD4+ level under 500 cells/mm3. Among intravenous drug users with CD4+ < 500 cells/mm3, a level of IgA higher than 200 mg/dl at enrollment was predictive of faster progression to AIDS. Among participants with CD4+ [corrected] over 500 cells/mm3, an IgA level above 400 mg/dl was still predictive of faster progression, but the sensitivity tended to be low. These findings suggest that an elevated level of IgA and presence of oral thrush may be important early markers of disease progression in HIV-infected intravenous drug users. Seborrheic dermatitis is also predictive, but only in later stages.

CD8+,CD38+ lymphocyte percent: a useful immunological marker for monitoring HIV-1-infected patients

We investigated the relationship between three prognostic markers, CD4 lymphocyte count, serum beta2-microglobulin (beta2M) levels, and CD8+,CD38+ lymphocyte percent, and the association with the rate of development of AIDS. The markers were measured regularly throughout follow-up in 224 patients. The risk of developing AIDS during follow-up was investigated using Cox proportional hazards models. Time-updated values of the prognostic markers were used, which modelled the risk of AIDS according to the latest measurement of the marker rather than using a single value of the marker at baseline. During a median follow-up period of 13.6 months (range 0.5-31.9 months), 34 cases of AIDS occurred. In a univariate analysis, all three markers predicted the development of AIDS; a 10% increase in the percentage of CD8+ T cells expressing CD38+ resulted in an 88% increase in the risk of AIDS (95% confidence interval: 53-130%; p < 0.0001). After adjustment for the current CD4 count and beta2M, a 10% increase in the CD8+,CD38+ population was associated with a 37% increase in the risk of AIDS (95% confidence interval: 4-81%; p = 0.02). Thus, the percentage CD8+,CD38+ level predicts the development of AIDS independently of the latest CD4 count and beta2M. This assay is therefore potentially useful in conjunction with blood CD4 counts and serum beta2M levels in patient management and clinical trial design.

Relation of impaired lymphocyte proliferative function to other major human immunodeficiency virus type 1-induced immunological changes

Human immunodeficiency virus (HIV) type 1 (HIV-1) induces impairment of immune function reflected in reduced lymphocyte proliferative responses. Many other immune changes are induced by HIV-1, but their relationship to lymphocyte functional defects is not known. The present study was designed to correlate functional defects with other HIV disease parameters. Cryopreserved samples from 118 HIV-1-positive subjects and 40 seronegative individuals were examined. The main findings were that impaired proliferative responses to mitogens correlated with (i) decreased cell surface expression of the interleukin-2 receptor (CD25), (ii) increased expression of HLA-DR antigens on CD4 cells, (iii) reduced CD4 and increased CD8 cell numbers, and (iv) increased levels of serum immune complex dissociated p24 antigen. However, impaired function was not associated with increased serum neopterin, beta2-microglobulin, or soluble interleukin-2 receptor or with CD38 antigen expression on lymphocytes. In summary, proliferative functional impairment correlated with some, but not all, immunological changes associated with HIV-1 infection. Most of the phenotypic markers that correlated with altered function are cell surface molecules with significant roles in lymphocyte proliferation and were associated primarily with CD4 cells, compatible with the view that dysregulation of CD4 cells is responsible for impaired function.

AIDS epidemic in San Francisco among men who report sex with men: successes and challenges of HIV prevention

San Francisco's gay male community has been hit harder by the HIV/AIDS epidemic than any other community in the world. By 1995, 20,530 of the estimated 58,000 gay men had been diagnosed with AIDS. However, the epidemic has also been more effectively contained within San Francisco than anywhere else, as evidenced by rapidly dropping AIDS incidence and mortality rates. This article reviews the epidemiology of HIV/AIDS among men who report sex with men (MSM) in San Francisco and the successful prevention efforts in this community. Also cited are areas in which the San Francisco prevention model has been less effective, in particular young MSM and gay men of color. San Francisco's experience yields many lessons about the successes and challenges of HIV prevention. Although community mobilization has been effective in reducing infection rates, innovative techniques to address the special needs of young MSM and to prevent the return to unsafe sex among all MSM are needed.

CD8+ lymphocyte responses to antiretroviral therapy of HIV infection

CD8+ T lymphocytes may mediate important host responses to human immunodeficiency virus (HIV) infection by human leukocyte antigen (HLA)-restricted cytotoxicity and production of soluble HIV suppressor factors. CD8+ lymphocytes are also important for the suppression of many latent pathogens responsible for opportunistic disease in HIV-infected patients. There has been no systematic analysis of the responses of CD8+ lymphocyte counts to antiretroviral therapy. We compared CD8+ lymphocyte responses in seven trials of nucleoside or non-nucleoside analog reverse transcriptase inhibitors and in two trials of ritonavir, a HIV protease inhibitor. Nucleoside analog and non-nucleoside analog reverse transcriptase inhibitor monotherapy resulted in no substantial changes in CD8+ counts relative to baseline or placebo. Combination nucleoside analog therapy resulted in variable peak responses (-145 to +240 cells/mm3), which remained significantly above baseline for 0 to 12 weeks. In contrast, ritonavir monotherapy caused a peak increase of 892 CD8+ cells/mm3, which remained significantly above baseline for 32 weeks. There was a significant correlation (Rs 0.61, p = 0.01) between the peak CD4+ cell and CD8+ responses to each therapy, but no significant correlation between the peak viral load responses and peak CD8+ cell responses. These findings suggest that the greater CD8+ response seen with ritonavir may be due to its specific inhibition of HIV protease and also that the CD8+ response is dependent on new CD4+ cell production. The CD8+ lymphocyte proliferation observed with protease inhibitor therapy could result in improved suppression of HIV replication by the immune system and should be confirmed in a prospective trial comparing protease inhibitors with both nucleoside and non-nucleoside analog therapies.

Oral hairy leukoplakia in 71 HIV-seropositive patients: clinical symptoms, relation to immunologic status, and prognostic significance

BACKGROUND

Oral hairy leukoplakia (OHL) is a benign hyperplasia of the oral mucosa that is induced by Epstein-Barr virus. It occurs nearly exclusively in men infected with HIV. OHL is a marker of moderate to advanced immunodeficiency and disease progression in patients with HIV infection.

OBJECTIVE

We attempted to determine the clinical characteristics of OHL in a large group of patients infected with HIV and to analyze its relation to immune status and prognosis.

METHODS

A total of 456 patients with HIV-associated skin disorders were evaluated during the years 1982 through 1992. All patients had an oral examination. CD4+ cell counts were obtained within 3 months of the examination.

RESULTS

OHL was diagnosed in 15.6% of 456 patients. The median age of the patients was 35 years. OHL was found most often on the lateral aspect of the tongue; in one patient the lesion covered the entire dorsal surface of the tongue. Significant immunosuppression was present in the majority of patients at the time of OHL diagnosis (median CD4+ T-lymphocyte count, 235/microliter; median CD4+/CD8+ ratio, 0.3). The median survival time was 20 months in patients with OHL. In patients with a higher CD4 cell count (CD4+ T lymphocyte count, > or = 300/microliter) the diagnosis of OHL was associated with shorter survival times (median survival time, 25 months) compared with other patients with HIV (median survival time, 52 months).

CONCLUSION

OHL is a frequent finding in patients with HIV and indicates advanced immunosuppression. Even in patients with more than 300/microliter CD4+ T lymphocytes, OHL is associated with a poor prognosis.

Serum beta 2-microglobulin at HIV-1 seroconversion as a predictor of severe immunodeficiency during 10 years of followup

In order to examine the relevance of early immune activation to the long-term course of HIV infection, we evaluated the ability of the serum beta 2-microglobulin level measured in 63 haemophiliacs on average 4.9 months from HIV seroconversion to predict the rate of development of server immunodeficiency (CD4) lymphocyte count 50/mm3) or AIDS over the following 10 years. Patients with higher beta 2-microglobulin values tended to develop severe immunodeficiency/AIDS more rapidly than those with lower levels (relative risk 1.68 per 1 mg/L increase; 95% CI 1.26-2.26; p = 0.0004). Older patients also progressed more rapidly, and these two factors acted independently (relative risk 1.65 per 1 mg/L increase; 95% CI 1.21-2.72; p = 0.002 for beta 2-microglobulin and 1.22 per 10 years; 95% CI 1.01-1.48; p = 0.04 for age). These results provide further evidence that the long-term course of HIV infection can, to some extent, be predicted soon after infection. Older patients with high beta 2-microglobulin levels warrant close monitoring and consideration for early antiretroviral therapy.

Lack of predictive value for progression of dissociated circulating P24 antigen in human immunodeficiency virus type 1-infected black patients

In human immunodeficiency virus type 1 (HIV)-1-infected Black people, the circulating p24 antigen is hidden frequently in immune complexes, because of high titers of serum anti-p24 antibodies. In order to evaluate the prognostic values for progression of free and dissociated serum p24 antigen in Black people, sera from 45 HIV-1-infected Black patients, all at non-AIDS stages, were evaluated prospectively for p24 antigen by several assays; circulating free p24 antigen was measured by immunocapture ELISA only (method 1) and with ELAST amplification (method 2), and dissociated p24 antigen determined after glycine-HCl pretreatment of serum, by immunocapture ELISA only (method 3) and with ELAST amplification (method 4). Serum CD4 and CD8 cell counts, beta 2-microglobulin, and total IgA were determined also at least twice a year. Clinical events for AIDS were those included in the 1986 CDC classification for HIV infection. At entry, p24 antigen was found in 3 (6.7%) patients by method 1, in 7 (15.6%) by method 2, in 14 (31.1%) by method 3, and in 22 (48.9%) by method 4. Methods 3 and 4 were more sensitive than method 1 (P < 0.001) and method 2 (P < 0.001). The mean follow-up was 30 months. The free symptom survival times (mean +/- SD months) were significantly lower in patients being p24 antigen positive by method 1 [(+) 33 +/- 27 vs. (-) 61 +/- 15, P = 0.03), but they were similar in patients positive and in those negative for p24 antigen determined by method 2 [(+) 71 +/- 17 vs. (-) 74 +/- 9, P = 0.54], method 3 [(+) 76 +/- 12 vs. (-) 69 +/- 13.2, P = 0.80], and method 4 [(+) 79 +/- 9 vs. (-) 63 +/- 7, P = 0.71]. At 24 months, p24 antigen positivity did not correlate either with CD4 or CD4/CD8 slops, nor with beta 2-microglobulin or IgA variations. By contrast, a CD4 cell count below 200/mm3 at entry was significantly associated with disease progression. In conclusion, dissociated p24 antigenemia does not appear as a useful surrogate marker for progression in HIV-1-infected Black people.

Comorbidity and survival in HIV-infected men in the San Francisco Men's Health Survey

The course of disease associated with infection with the human immunodeficiency virus varies widely. Some patients deteriorate rapidly, while others live for years, even after an illness that defines the acquired immunodeficiency syndrome (AIDS). In this study, comorbidity, or the presence of concurrent health problems, was investigated prospectively as a possible co-factor for different rates of decline in 395 homosexual/bisexual men in the San Francisco Men's Health Study (SFMHS) who were infected with the human immunodeficiency virus (HIV). Comorbidity data obtained from baseline interviews included both chronic and infectious diseases as well as depression. Smoking, alcohol, and drug use were also examined. The most prevalent comorbid conditions were sexually transmitted diseases (90%) and hepatitis B infection (76%). Most chronic and acute concurrent health conditions were not significant discrete predictors of survival to AIDS or death after controlling for immune status and markers of disease progression. Significantly, other risk factors (e.g., depression and smoking) were found to be associated with more rapid progression. Men with symptoms of depression had a higher risk of progression of AIDS diagnosis; the relative hazard (RH) was 1.4 (95% confidence interval [CI], 1.00-2.08); smoking was associated with higher risk of death (RH, 1.6; 95% CI, 1.20-2.17). Older age was marginally associated with poorer survival to death. No associations were found between survival and alcohol and drug use.

Predictive value for survival of soluble tumor necrosis factor receptors p55 and p75 during zidovudine-containing treatment in symptomatic human immunodeficiency virus type 1 infection

Previous studies of asymptomatic human immunodeficiency virus (HIV) infection have shown that serum levels of soluble tumor necrosis factor receptors (sTNFR) are good predictors of disease progression and clinical outcome during zidovudine (ZDV) therapy. The present study of symptomatic HIV infection was designed to evaluate whether sTNFR p55 and p75 at weeks 0 (pretreatment) and 24 and 48 are predictors of death < or = 3 years after the start of ZDV 1,000 mg alone or combined with low-dose interferon-alpha (ZDV 500 mg + IFN-alpha 3 MIU three times weekly). CD4+ T-cell numbers and serum neopterin were analyzed in a similar way. Forty previously untreated symptomatic HIV-infected persons with CD4+ T-cell numbers > or = 150 x 10(6)/L were included. At baseline, in the nonsurvivor group, mean age (42.1 vs. 34.4 years, p = 0.002) and neopterin (24.7 vs. 18.0 nmol/L, p = 0.02) were higher, whereas mean CD4+ T-cell counts (202 vs. 295 x 10(6)/L, p = 0.02) were lower than in the survivors. All analyses were adjusted for age. For the pretreatment marker values, a significant relative risk (RR) for death was noted only in the univariate analysis for sTNFR-p55 > 1.7 ng/ml [RR 3.1; 95% confidence interval (CI) 1.1-8.8; p = 0.04]. During therapy, CD4+ counts < 200 x 10(6)/L at week 24 and 48 and neopterin > 20 nmol/ml at week 48 were independent predictors of survival in the uni- and multivariate analysis. Marker values relative to baseline were not predictive. sTNFR-p55 and p75 were of little use as surrogate markers for clinical efficacy during ZDV-containing drug regimens in symptomatic HIV-infected patients with CD4+ counts 150 x 10(6)/L.

Pilot randomized controlled trial of Chinese herbal treatment for HIV-associated symptoms

We wished to determine the short-term safety and efficacy of a Chinese medicinal herb preparation in treating symptoms of human immunodeficiency virus (HIV) infection in a 12-week randomized, double-blind, placebo-controlled clinical trial in a University-affiliated acquired immunodeficiency syndrome (AIDS) clinic at a public general hospital. Thirty adults with symptomatic HIV infection, no previous AIDS-defining diagnosis, and CD4+ counts of 0.200-0.499 x 10(9)/L (200-499/mm3) received 28 tablets each day of either a standardized oral preparation of 31 Chinese herbs or a cellulose placebo. Primary outcome measures were changes in life satisfaction, perceived health, and number and severity of symptoms. Other outcomes included adherence, and changes in weight, CD4+ count, depression, anxiety, physical and social function, and mental health. Two placebo- and no herb-treated subjects had mild adverse events (AE). Subjects on both arms reported taking 94% of prescribed tablets. No differences between treatment groups reached the p < 0.05 level. Life satisfaction improved in herb-treated [+0.86, 95% confidence interval (CI): +0.29, +1.43] but not in placebo-treated subjects (+0.20, 95% CI -0.35, + 0.75). Number of symptoms was reduced in subjects receiving herbs (-2.2, 95% CI -4.1, -0.3) but not in those receiving placebo (-0.3, 95% CI -3.2, +2.7). There were trends toward greater improvements among herb-treated subjects on all symptom subscales except dermatologic. Believing that one was receiving herbs was strongly associated with reporting that the treatment had helped (p < 0.005), but not with changes in life satisfaction or symptoms. There were improvements in life satisfaction and symptoms among subjects receiving the herbal therapy. Whether Chinese herbs are effective in the management of symptomatic HIV infection can be adequately addressed only by larger trials of longer duration.

Performance of a modified HIV-1 p24 antigen assay for early diagnosis of HIV-1 infection in infants and prediction of mother-to-infant transmission of HIV-1 in Dar es Salaam, Tanzania

The aim of this study was to determine the utility of an amplified human immunodeficiency virus type 1 (HIV-1) p24 antigen (ag) assay using heated plasma or serum samples for the early diagnosis of HIV-1 infection in infants and for the prediction of the risk of mother-to-infant (MTI) transmission of HIV-1 in Dar es Salaam, Tanzania. The study included 125 samples from 76 infants positive for HIV-1 DNA by the polymerase chain reaction (PCR), 106 samples from 101 PCR-negative infants and 116 and 160 samples from seropositive and seronegative mothers, respectively. Samples were boiled to dissociate immune complexes and tested for HIV-1 p24 ag using a p24 ag amplification assay. Reactive samples were confirmed by a neutralization assay. Altogether, 123 of 125 samples from 76 PCR-positive infants were positive for p24 ag (sensitivity = 98.7%). HIV-1 p24 ag was found in all 18 samples collected at 1-8 weeks, in 35 of 36 samples collected at 9-26 weeks, in all 40 samples collected at 27-52 weeks, and in 30 of 31 samples collected > 52 weeks after birth. Detection of HIV-1 p24 ag was significantly more common in transmitting mothers (12 of 29, 41.4%) than in nontransmitting mothers (nine of 87, 10.3%) (p < 0.001). Among mothers with p24 antigenemia, the vertical transmission rate was significantly higher (12 of 21, 57%) than in mothers without p24 antigenemia (17 of 95, 18%) (p < 0.001). All samples from 101 PCR-negative children and 160 seronegative mothers were negative for p24 ag (specificity = 100%). We conclude that using heated plasma or serum increases the sensitivity of the p24 ag assay significantly. This modified simple test may be sufficient for the early diagnosis of HIV-1 infection in infants in settings with limited laboratory facilities. It is also useful for prediction of the risk of MTI transmission of HIV-1.

Neuropathology of human immunodeficiency virus infection at different disease stages

The authors studied the brains of 471 adults infected with human immunodeficiency virus type 1 (HIV-1): 123 asymptomatic carriers, 127 in an early stage of acquired immunodeficiency syndrome (AIDS) with pulmonary tuberculosis or bacterial infections, and 221 in fully developed AIDS with opportunistic infections or neoplasms. Lymphocyte infiltration of the leptomeninges and of perivascular spaces occurred at all stages, but the frequency was significantly higher in asymptomatic carriers. Microglial nodules appeared at all stages of disease; they were not an early indicator of HIV encephalitis (HIVE). The incidence of HIVE was unrelated to the stage of AIDS, suggesting that HIVE occurs before opportunistic infections and neoplasms. Drug abuse, such as cocaine and opiates, may enhance HIV replication and increase the incidence of HIVE in the early stage of AIDS. Opportunistic infections or lymphoma involved only the brain in 31.2% of persons with fully developed AIDS. Conversely, opportunistic infections or neoplasms involved only organs other than the brain in 55.7% of persons with fully developed AIDS. In 13.1% of persons with fully developed AIDS, opportunistic infections or neoplasms involved the brain and other organs. Multiple intracranial opportunistic infections and lymphoma coexisted in 4.1% of persons with fully developed AIDS. The authors identified cerebrovascular disease in 10.6% of asymptomatic carriers, 7.1% of early AIDS, and 5.0% of fully developed AIDS. The observed sequence of abnormalities may be useful in understanding the progression of HIV disease in the brain.

The use of auxiliary events to improve the analysis of survival for HIV-infected patients: application to the French Prospective Multicenter Cohort (SEROCO)

SUMMARY

A multicenter prospective cohort study, including 512 patients for whom date of HIV infection was known, showed that the use of an appropriate auxiliary event can improve the analysis of survival data and lead to an earlier detection of risk factors for HIV patients. Age at seroconversion and primary symptomatic infection were used as risk factors. Two age groups were defined as age at seroconversion >30 years (n = 203) and < or = 30 years (n = 309). Patients with primary symptomatic infection PSI (n = 215) were compared with patients without any clinical manifestation during primary infection (n = 297). Death was considered as the endpoint of primary interest and occurred in 76 patients in the study. Classical non-parametric methods (Kaplan-Meier estimate and long-rank test) and parametric regression model (Weibull model) were used for a standard analysis of survival data. A parametric approach using auxiliary information was used to estimate the survival function and to test the effect of age at seroconversion and PSI. We also applied a recently proposed distribution-free method to produce a non-parametric estimate of the survival function and to test age at seroconversion and PSI with respect to survival estimates. Both methods are compared for two distinct auxiliary events (Karnofsky score below 75 and a first drop of CD4 lymphocyte counts below 200 cells/MM3). The use of CD4 lymphocyte counts below 200 cells/MM3 as an auxiliary event improved the analysis of survival data available in December 1994. For both methods incorporating CD4 counts below 200 cells/mm3 in addition to survival data, the effect of age at seroconversion on survival was significant in April 1992 whereas it was not significant with standard methods. For PSI exposure group, results shown in this work do not indicate any improvement in using auxiliary information. Conditions for using an appropriate auxiliary event as well as advantages and shortcomings of both methods are discussed. Methods used in this work, with appropriate auxiliary information, are promising either through a reduction in the time to follow-up to detect risk factors for cohort studies or the time needed for drug development in clinical trials.

Fluctuations in steady state level of genomic HIV-1 RNA and replication intermediates related to disease progression rate

Steady state levels of HIV-1 genomic RNA and unintegrated circular DNA fluctuate in the course of HIV-1 infection. Genomic RNA in serum was detected using the NASBA technique and the amount of circular DNA was assessed by PCR. Quantification was done by competitive techniques using co-amplification of internal standards. Within the Amsterdam Cohort Studies it was possible to distinguish rapid progressors, intermediate progressors, slow progressors and non-progressors. Rapid progressors show persistently high viral RNA loads from seroconversion on, while all other HIV-1-infected individuals show a steady decline after seroconversion. Subsequent rises in viral RNA levels herald disease progression in later stages of infection. Unintegrated circular DNA shows similar, but somewhat delayed kinetics. These results indicate that the distribution of AIDS and the average length of the symptom-free period in an HIV-1-infected host population is determined by the steady state levels of genomic RNA and of replication intermediates that are produced by a particular HIV-1 virus population in the average seropositive individual.

Prognostic value of oral candidosis and hairy leukoplakia in 111 Mexican HIV-infected patients

A follow-up study was carried out to evaluate the prognostic value of hairy leukoplakia (HL) and oral candidosis (OC) in a cohort of 111 asymptomatic Mexican HIV infected patients. Oral exams were performed at baseline and every 6 months, from September 1989 to March 1994. Chi-square contingency table test, the Kruskall-Wallis one-way analysis of variance, the Kaplan-Meier product-limit method and the log rank test were used for the analysis. Univariate and multivariate Cox's proportional hazards analysis were also performed. Fifty-four patients (51%) progressed to AIDS (initially 36 CDC-II and 18 CDC-III). Individuals with HL and/or OC, showed faster development to AIDS than subjects without lesions or other HIV-related manifestations (P = 0.008). The presence of OC, HL or both always remained significant despite adjustment for total lymphocytes, CDC stage, zidovudine therapy or its combinations. Oral lesions in HIV infection may be regarded with other clinical and laboratory studies as markers of HIV disease progression and as indicators to begin antiretroviral treatment.

Gender and ethnic differences in survival in a cohort of HIV positive clients

OBJECTIVES

The purpose of this study was to examine gender and ethnic differences in survival of persons receiving treatment for HIV infection to determine if differences existed, and if they did, to assess the possibility of explaining these differences by examining other factors, such as age, disease severity when beginning treatment, alcohol, illicit drugs, tobacco, educational level, living arrangements, antiretroviral treatment, PCP prophylaxis, sexually transmitted diseases, mode of transmission and opportunistic infections.

DESIGN

A retrospective cohort study of all clients receiving treatment at an HIV only clinic from its opening in early 1988 until the end of May 1993. Statistical methods used to examine the data included incidence density ratios, Kaplan-Meier survival curves, Breslow (generalized Wilcoxon) tests of equality of survival curves and Cox proportional hazards models both with and without time dependent covariates.

RESULTS

In the cohort (37% African American, 7% Hispanic American and 25% female), 220 deaths occurred during 1223 person years of follow-up. Compared to European American males, the following incidence density ratios were observed: European American females: 0.50, Hispanic American females: 0.70, Hispanic American males: 0.96, African American females: 1.28 and African American males: 2.38. The differences were noted above for gender/ethnicity groups were significant at the p < 0.0001 level. After adjusting for disease stage (as measured by laboratory testing of CD4 positive T-lymphocytes), educational level, and age, no differences in survival by gender or ethnicity remained. Disease stage and educational level had the greatest prognostic significance.

CONCLUSIONS

European Americans entered treatment at a much earlier disease stage (as measured by CD4 positive T-lymphocyte counts) and had higher educational levels (a surrogate for socioeconomic status) than African Americans. These factors may explain the longer survival in European Americans as compared to African Americans in this cohort.

The severity classification system for acquired immunodeficiency syndrome hospitalizations. Association with survival after discharge and inpatient resource use

The Severity Classification for AIDS Hospitalizations (SCAH) was applied to a longitudinal person-based data set of Maryland adult residents diagnosed with acquired immunodeficiency syndrome (AIDS) between 1983 and 1989 to predict long-term survival. In contrast to other AIDS severity measures, SCAH can be applied to administrative data bases for analyses of large populations. Although SCAH was created to predict inpatient mortality using cross-sectional hospital discharge data, the models used in this study show SCAH stage at first AIDS hospitalization to predict long-term survival in persons with AIDS, even after adjusting for sociodemographic and treatment variables. Additional models in the study show SCAH stage at first hospitalization has a strong association with inpatient length of stay and associated charges, making it useful for health care resource planning.

Expression of CD69 after in vitro stimulation: a rapid method for quantitating impaired lymphocyte responses in HIV-infected individuals

A flow cytometric assay based on expression of the activation antigen CD69 was developed to analyze immunological responses of T cells from human immunodeficiency virus (HIV)-infected (HIV+) or HIV-seronegative (HIV-) donors after in vitro simulation by antigens and polyclonal activators. The levels of CD69 on freshly-isolated or unstimulated, cultured CD3+, CD4+, or CD8+ peripheral blood lymphocyte (PBL) subsets were low and did not differ greatly between HIV+ and HIV- donors. The frequencies of CD3+, CD4+, and CD8+ lymphocytes from HIV+ donors that expressed CD69 after culture with antigenic or mitogenic stimuli were significantly lower than in HIV- donors. Comparison of CD69 expression with [3H]thymidine incorporation revealed that both assays could detect lymphocyte responses to antigenic or mitogenic stimuli. The CD3+ PBL from HIV+ or HIV- donors did not show increased CD69 expression after culture with soluble or cross-linked recombinant envelope glycoprotein, gp120. The gp120, however, significantly inhibited CD69 expression in phytohemagglutinin-stimulated T cells in vitro and may also affect T-cell activation in vivo. These studies demonstrate the usefulness of this CD69 expression assay for the rapid assessment of defects in immune responses of phenotypically defined lymphocyte subsets in HIV+ patients and for testing the effects of agents that modulate immune activation.

Immunological and virological markers of HIV-disease progression

This review, based upon scientific literature, evaluates a number of immunological and virological markers for their usefulness as prognostic indicators for progression of HIV disease. The most widely studied marker, the CD4 positive T lymphocyte count, is perhaps the best single indicator of stage of illness. Serum factors such as neopterin and beta-2 microglobulin, alone and in combination with CD4 cell counts, have been shown to have good predictive value. Measurement of viral burden by quantification of viral RNA levels in plasma and immune cells also holds promise for following disease progression. It is recommended that a combination of these factors be monitored in evaluating stage of illness and responses to therapy in HIV-infected persons.

Serum beta 2-microglobulin and prognosis of patients with renal cell carcinoma

Beta 2-Microglobulin (beta 2-M) was analysed in serum of 145 patients with renal cell carcinoma, and serum creatinine < 125 mumol/1 by a radioimmunometric method. Forty-nine (34%) patients had serum beta 2-M level > or = 3.0 mg/l. Of the patients with distal metastases 46% had elevated levels, compared with 19% with stage I disease. Serum beta 2-M correlated with histopathologic grade; 58% of the patients with poorly differentiated (grade 4) tumours had elevated levels compared with 18% in grade 1-2 tumours. Also tumour cell type was associated with serum beta 2-M; 52% of the patients with plasmic tumours had elevated levels compared with 6% in the clear cell type. In a univariate prognostic analysis elevated serum beta 2-M level was inversely correlated with survival time. Using a multivariate analysis the strong prognostic factors were clinical stage and tumour diameter. Weaker factors were age and cell type, whereas the prognostic value of serum beta 2-M disappeared. However, if tumour cell type was excluded from the analysis, serum beta 2-M was identified as a prognostic factor.

Predictive markers of survival in HIV-seropositive and HIV-seronegative Tanzanian patients with extrapulmonary tuberculosis

SETTING

Prediction of survival in Tanzanian patients with extrapulmonary tuberculosis (TB).

OBJECTIVE

To evaluate the prognostic value of clinical and laboratory parameters on survival in human immunodeficiency virus (HIV) seropositive and HIV seronegative patients with extrapulmonary TB.

DESIGN

Over an 8-month period 192 consecutive patients with extrapulmonary TB, admitted to a major referral centre in Tanzania, were enrolled in the study. Their symptoms, signs and PPD skin test were noted. Their sera were tested for HIV and analyzed for beta-2-microglobulin content. Univariate risk factors for 12 months' survival after the start of anti-TB chemotherapy were entered into a stepwise Cox regression model. Survival probabilities were estimated according to the number of risk factors.

RESULTS

Of the 192 patients 126 (65%) were HIV-infected, and 29.7% had disseminated TB. Thirty-five patients, of whom 24 (68.6%) were HIV-positive, withdrew from the study immediately after hospital discharge. For survival analysis 157 patients remained. Within 12 months' follow-up after initiation of anti-TB therapy, the case fatality rate of the 102HHIV-infected patients was 22% and of the 55 HIV seronegative patients 2% (P < 0.001). In the HIV seropositive patients the following independent risk factors were significantly associated with a decreased probability of survival: peripheral lymphadenopathy (Hazard Rate Ratio (HRR) 5.2, 95% Confidence Interval [CI] 1. 7-16.2), a decreased activity score (bedridden > 50%/day (HRR 4.5, 95% CI 1.7-11.7), lymphopenia of < 1000/microL (HRR 4.4, 95% CI 1.7-11.8), and mycobacteraemia (HRR 4.0, 95% CI 1.2-13-.1). An anergic PPD skin test reaction proved to be another independent risk factor when the analysis was performed on 89 patients with available Mantoux test results. In the HIV seropositive patients, the 12 months' survival probabilities were 93%, 86%, 54% and 0% for presence of 0, 1, 2, and > 2 risk factors respectively.

CONCLUSION

Estimation of survival probabilities in patients with extrapulmonary TB may be possible without performing CD4 cell counts.

Prospective cohort study of the effect of pregnancy on the progression of human immunodeficiency virus infection. The Groupe d'Epidémiologie Clinique Du SIDA en Aquitaine

OBJECTIVE

To study the prognostic role of pregnancy on the progression of human immunodeficiency virus (HIV) infection.

METHODS

In a prospective cohort study at the Bordeaux University Hospital, France, 57 women who completed a pregnancy during the course of their HIV infection were compared with 114 HIV-infected women who never conceived. The two groups were matched on CD4 lymphocyte count (CD4), age, and year of HIV diagnosis. The main outcome measures were death, occurrence of a first AIDS-defining event, and drop of the CD4 below 200/mm3.

RESULTS

The mean follow-up period in pregnant women was 61 months from HIV diagnosis (median CD4 at entry 455/mm3) and 54 months from beginning of pregnancy. Nonpregnant women were followed-up for 50 months since HIV diagnosis (median CD4 460/mm3). The proportion of asymptomatic women at entry in the study was 51 of 57 (90%) in pregnant and 87 of 114 (76%) in nonpregnant women. No significant difference was observed between the two groups with regard to the different end points studied, even after adjustment for other prognostic variables. Adjusted hazard ratios (pregnant/nonpregnant) were 0.92 for death (95% confidence interval [CI] 0.40-2.12), 1.02 for occurrence of a first AIDS-defining event (95% CI 0.48-2.18), and 1.20 for drop of the CD4 to less than 200/mm3 (95% CI 0.63-2.27).

CONCLUSION

In a cohort of HIV-infected women with mild to moderate immunosuppression, pregnancy did not accelerate progression to AIDS or death.

Scope of the AIDS epidemic in the United States

Two-dimensional deconvolution techniques are used here to reconstruct age-specific human immunodeficiency virus (HIV) infection rates in the United States from surveillance data on acquired immunodeficiency syndrome (AIDS). This approach suggests that 630,000 to 897,000 adults and adolescents in the United States were living with HIV infection as of January 1993, including 107,000 to 150,000 women. The estimated incidence of HIV infection declined markedly over time among white males, especially those older than 30 years. In contrast, HIV incidence appears to have remained relatively constant among women and minorities. As of January 1993, prevalence was highest among young adults in their late twenties and thirties and among minorities. An estimated 3 percent of black men and 1 percent of black women in their thirties were living with HIV infection as of that date. If infection rates remain at these levels, HIV must be considered as endemic in the United States.

[Effect of primary prevention of Pneumocystis carinii pneumonia on the inaugural clinical and biological presentation of AIDS: 624 cases (Aquitaine Cohort, 1985-1994)]

In a cohort of HIV-infected patients, this study compares the clinical and immunological features at the time of AIDS diagnosis of patients who either received primary Pneumocystis carinii prophylaxis (P+; n = 335) or who did not (P-; n = 289). Frequency of P carinii pneumonia was lower in P+ than in P- patients (14.9% vs 26.0%; p < 0.001). Conversely, toxoplasmic encephalitis, esophageal candidiasis, cytomegalovirus disease and M avium complex disease were more frequent in P+ patients. CD4+ count (median/mm3) at the time of AIDS diagnosis was lower in P+ than in P- patients: 22 vs 97 (p < 0.001); this suggests that early intervention delays the onset of AIDS for about one year. While searching for new prevention strategies against other opportunistic infections, efforts should be expanded to improve prophylaxis of P carinii pneumonia which remains in France the most frequent first AIDS-related illness.

In vitro anti-HIV-1 antibody production in subjects in different stages of HIV-1 infection

We evaluated the in vitro antibody production from peripheral blood mononuclear cells (PBMC) against HIV-1 proteins in infected adults. Fifty-four HIV-1 infected patients (four recent seroconverters, 15 asymptomatics with a CD4 count higher than 500/microliters, 27 asymptomatics with a CD4 count between 200 and 500/microliters and eight symptomatic patients) were tested. PBMC were incubated in the presence or absence of 1% pokeweed mitogen (PWM) at 37 degrees C for 8 days. Western blot assay, p24 antigen ELISA and anti-p24 antibody ELISA were performed on serum and culture supernatants. Spontaneous production of anti-env antibody in culture supernatants was evidenced in all subjects. All the positive supernatants for anti-core antibodies (18/54) were derived from asymptomatic patients. PBMC from recent seroconverters and from symptomatic patients did not produce any anti-core antibody. Antibody production decreased after stimulation with PWM. The concentration of p24 antigen did not significantly increase in p24 positive supernatants following acidification (P = 0.1), suggesting that the inability to detect p24 antibody was not due to the anti-p24 antibody complexed to p24 antigen in culture supernatants. In vitro production of anti-p24 antibodies was significantly more frequent in asymptomatic subjects with high CD4+ cell counts (P = 0.02) and was absent in recent seroconverters. This last finding suggests that during the initial phases of the infection, anti-p24 antibody production may be restricted to cells residing in lymphoid organs. In addition, the lower percentage of anti-core antibody in people with low CD4+ cell counts is not merely a consequence of the binding of the antibody to an increased amount of antigen, but probably reflects an impaired production or a sequestration of producing cells in lymphoid tissue during the late stages of the infection.

CD8+ T lymphocytes and cytomegalovirus retinitis in patients with the acquired immunodeficiency syndrome

PURPOSE

We compared the levels of CD8+ and CD4+ cells in human immunodeficiency virus (HIV)-seropositive patients who had normal eye examinations, microvasculopathy, or ocular infections other than cytomegalovirus retinitis to those of patients with cytomegalovirus retinitis, to determine whether lymphocyte counts other than CD4+ are predictive of cytomegalovirus retinitis.

METHODS

The records of HIV-positive patients who had a lymphocyte subset analysis within three months of a complete eye examination were reviewed for age, gender, mode of HIV transmission, stage of disease, ocular findings, and absolute lymphocyte counts. Data for patients without cytomegalovirus retinitis were compared with those for patients with cytomegalovirus retinitis.

RESULTS

Ninety-three HIV-positive patients had a lymphocyte subset analysis within three months of a complete eye examination; 76 patients had no cytomegalovirus retinitis and 17 had cytomegalovirus retinitis. Patients without cytomegalovirus retinitis and those with cytomegalovirus retinitis had the following median cell counts: CD4+, 76.0 and 15.0 cells/microliters; CD8+, 634.5 and 280.0 cells/microliters, respectively. Patients with cytomegalovirus retinitis had significantly lower CD4+ and CD8+ cell counts than those without cytomegalovirus retinitis (P < .001). CD4+ and CD8+ cells are significantly correlated with each other, and the correlation is much higher in patients with cytomegalovirus retinitis (r = .80, P < .001) than in patients without cytomegalovirus retinitis (r = .57, P < .001). Stepwise logistic regression analysis showed that CD8+ cell counts were also predictive of cytomegalovirus retinitis.

CONCLUSION

Patients with low CD4+ cell counts are known to be at high risk for cytomegalovirus retinitis. We showed that patients with low CD8+ cell counts are also at high risk for cytomegalovirus retinitis.

Gag-specific cytotoxic responses to HIV type 1 are associated with a decreased risk of progression to AIDS-related complex or AIDS

The duration of human immunodeficiency virus (HIV-1) infection prior to the development of AIDS is variable, and for most patients the exact time of infection is not known. A group of 38 HIV-1-infected subjects was tested while asymptomatic for comparative cytotoxic lymphocyte responses to the Gag and envelope antigens of HIV-1. Twenty of the 38 patients had no detectable primary cytotoxic T lymphocyte (CTL) response to Gag, and this was associated with a relative risk of 1.89 for progression to ARC or AIDS during the subsequent 3 to 40 months of observation when compared with patients who had Gag-specific CTL activity at the beginning of the observation period. In contrast, no significant association was observed between envelope-specific cytotoxic activity and disease progression. Other patient characteristics, including CD4+ T lymphocyte counts and antibody levels to the p24gag protein, measured at the start of observation, did not correlate with disease progression during the observation period. This suggests that the anti-Gag CTL response may be protective during HIV-1 infection.