The Walter Reed staging classification for HTLV-III/LAV infection

Peptides derived from the CDR3-homologous domain of the CD4 molecule are specific inhibitors of HIV-1 and SIV infection, virus-induced cell fusion, and postinfection viral transmission in vitro. Implications for the design of small peptide anti-HIV therapeutic agents

Peptides 12-25 amino acids in length from the V1J1 region of the CD4 molecule (residues 1-120) were synthesized as randomly derivatized, deliberately derivatized, or pure peptide products, and tested for their ability to inhibit HIV-1-induced cell fusion, HIV-1 and SIV infection of CD4-positive human cells, HIV-1 envelope glycoprotein binding to the CD4 molecule, CD4-neutralizing antibody binding to the CD4 holoreceptor, and CD4-dependent cellular immune function in the mixed lymphocyte and cytotoxic T-cell bioassays. Only peptides derived from the complementarity-determining region 3 (CDR3)-homologous domain of CD4, in particular CD4(81-92) and CD4(81-101), were effective antiviral agents. Within the CD4(81-92) series, R-group derivatization of selective amino acid residues was an absolute requirement for biological activity. The prototype compound T1C4E5-tribenzyl-K10-acetyl-TYICEVEDQKEE inhibited HIV-1-induced cell fusion at 32 microM, HIV-1 infection of CEM-SS cells at 10 microM, SIV infection of CEM-174 cells at less than 125 microM, gp120/CD4 binding at 60 microM, and postinfection cell-mediated viral transmission at 10-15 microM. Compounds of identical structure and derivatization, but of altered primary sequence, were substantially less active, or without activity, in these assays. These data indicate that the effect of amino acid derivatization of the CD4(81-92) peptide was most likely restriction of the flexible underivatized peptide backbone to a conformation closely approximating that of the CDR3-homologous gp120 binding site of the native CD4 molecule. Peptide antiviral activity was specific, as judged by lack of cytotoxicity, lack of inhibition of HTLV-1-induced cell fusion, and lack of inhibition of CD4-dependent cellular immune function in vitro. Further derivatization of the prototype compound involving the production of cyclic congeners yielded peptides with submicromolar potency to block HIV-1 infection, strengthening the hypothesis that previous peptide derivations accomplished partial restriction of the conformation of CD4(81-92) to one favorable for interaction with gp120. Concentrations of the original prototype compound T1C4E5-tribenzyl-CD4(81-92) that inhibited infection in vitro more than 50% could be achieved for several hours by intravenous infusion in primates and were well-tolerated at these levels. The peptide was not efficacious to inhibit establishment of viral infection at these doses; however, peptide treatment did lower average viral antigenemia and delay the cumulative time to morbidity relative to the control group.

[Reversible space-occupying lesions of the kidney in HIV infection]

In January 1990 a 32 year old nurse was admitted with fever, weight loss of 9 kilogramms and pain of her right flank. HIV infection due to intravenous drug abuse had been diagnosed in 1986. Ultrasonic imaging revealed a solid tumor of low echogenicity in the cranial part of the right kidney. This finding could be confirmed with computed tomography and magnetic resonance imaging. Angiographic study showed a missing of blood vessels in the same area. A transcutaneous puncture with a thin needle resulted histologically in unspecific findings like detritus, lymphoid cells and neutrophils. Antibiotic treatment with amoxicilline and cefuroxim was without success. Symptoms as well as ultrasonic findings completely disappeared following oral administration of ofloxazine. The clinical course and the successful treatment support the diagnosis of an atypical renal abscess. As a second diagnosis a histologically proven cirrhosis of the liver could be established. Hepatitis C serology proved to be positive.

Cardiac involvement in AIDS

Cardiac involvement in AIDS may occur at any stage of HIV disease and may manifest as congestive cardiomyopathy, potentially lethal arrhythmia, or pericardial effusion and tamponade. The heart may be affected by nearly all of the opportunistic infections and many of the malignancies associated with the syndrome. Although often clinically unobtrusive, cardiac lesions may be important in the pathogenesis of significant clinical symptoms and play an often unrecognized role in the prognosis and natural history of AIDS.

Phagocytic response modifying reactivity of enzymatic cell wall digests of Nocardia opaca

Aqueous extracts (ENOCW) and enzymatic digests of purified Nocardia opaca cell wall fragments, virtually free of muramyl peptides, were monitored for their phagocytic response modifying reactivity on polymorphonuclear leucocytes, separated or unseparated in whole human blood. In the presence of ENOCW a 74% increased production of superoxide during the respiratory burst of TPA-activated polymorphonuclear leukocytes was observed, as compared to the unprimed control. Delipidation of this preparation resulted in a further increase in reactivity (144%). Even in the presence of whole human blood, as a model for competitive binding in biological fluids, an enhanced generation of superoxide by TPA activated blood phagocytes remained detectable. A 37-75% decreased phagocytic reactivity in samples of HIV-seropositive blood was considerably restored in the presence of ENOCW.

[The prognostic significance of lymphocyte subpopulations and macrophages in peripheral blood and in bronchoalveolar lavage in AIDS patients with suspected Pneumocystis carinii pneumonia]

In 36 HIV seropositive patients with the clinical manifestation of AIDS and a suspected Pneumocystis carinii infection, lymphocyte subpopulations were analyzed in the peripheral blood (PBL) and compared with the results of the bronchoalveolar lavage (BAL). Of those 36 patients, 29 showed a highly abnormal CD4/CD8 ratio in both the PBL and the BAL. The clinical course of these 29 patients was unpredictable. In seven patients, however, the CD4/CD8 ratio in the BAL was normal or only slightly altered, despite a highly abnormal CD4/CD8 ratio in the PBL. Five of these seven patients improved greatly during the clinical course. The positive outcome of the clinical course was even more strongly correlated with the number of macrophages in the BAL. Twelve of the 36 patients showed normal or only slightly changed numbers of macrophages in the BAL. Eleven of these twelve patients (92%) improved rapidly during antibiotic therapy, while the clinical course was unpredictable in patients with markedly reduced macrophage counts in the BAL.

[HIV-1 antigenemia and T-cell activation in HIV-1 infected patients]

In order to study a supposed association between T-cell activation in vivo and HIV-1-antigenemia in HIV-1-infected patients, the detection of p24-antigen in sera was correlated to serum levels of beta-2-microglobulin and C1q-binding immune complexes. Anti-p24-antibodies and the urinary excretion of neopterin were also analysed. In 24 of 80 patients (30%) p24-antigen could be detected, and in 15 of 59 (25.4%) there was a loss of anti-p24-antibodies. Tests revealed elevated serum levels of beta-2-microglobulin in 58 of 80 patients (72.5%), elevated levels of C1q-binding immune complexes in 15 of 66 (22.7%), and increased excretion of neopterin in 52 of 60 (86.7%). Detection of p24-antigen, loss of anti-p24-antibodies, serum levels of beta-2-microglobulin, and urinary excretion of neopterin were significantly correlated to advanced stages of HIV-1 infection. Patients with p24-antigen in the serum showed significantly more frequently elevated serum levels of beta-2-microglobulin and no significant association with increased urinary excretion of neopterin. Because of the high proportion of patients with elevated serum levels of beta-2-microglobulin and increased excretion of urinary neopterin in the absence of detectable p24-antigen in serum, we could not correlate HIV-1-antigenemia to T-cell activation in vivo.

Induction of erythrocyte HLA expression during interferon treatment and HIV infection

Although HLA antigens are present on the surface membrane of most cells, erythrocytes express little or no HLA. Occasionally red cells from normal individuals or patients with certain diseases express elevated levels of these molecules. The reasons for such variations are currently not understood. We report here that the expression of very high levels of HLA on erythrocytes occurs in response to interferon alpha given as a therapeutic agent for viral hepatitis. Increased expression became apparent after the second or third week of treatment, peaked at 3-4 months, and decreased at the end of the treatment period. This chronology suggests that elevated HLA expression is originated during erythropoiesis and persists throughout the lifetime of the erythrocyte. Furthermore, erythrocyte HLA expression did not correlate with changes of plasma HLA or beta 2-microglobulin concentrations and was not affected by in vitro chloroquine treatment, ruling out the possibility that HLA was adsorbed from plasma. Increased expression of HLA on erythrocytes was also demonstrated in patients infected with the human immunodeficiency virus, a disease in which increased production of endogenous interferon has been previously documented. We conclude that high HLA expression in red cells occurs in response to persistent interferon stimulation. Further studies will determine if this effect can also be produced by interferon tau or other factors.

HIV infection and AIDS during adolescence

It is clear from the evidence that a growing number of adolescents are acquiring HIV infection and developing AIDS. The impact this epidemic will have on all teenagers is overwhelming. Given the high prevalence of risk-related sexual behaviors, many adolescents are likely to become HIV infected, thus requiring extensive medical and psychosocial services. Other adolescents will lose a parent, relative, or friend to AIDS, and these adolescents will similarly require special services and psychological counseling. Thus, there is an immediate need for the development of methods for (1) providing all adolescents with age-appropriate and culturally relevant interventions for prevention and risk reduction, (2) identifying high-risk adolescents and triaging them to different levels of care and risk reduction counseling, and (3) providing ongoing medical and psychosocial treatments. Accessing adolescents at risk for HIV infection will require networking between the health care system and youth-serving and community-based agencies, particularly agencies servicing high-risk adolescents. We must begin addressing these needs now, in order to prevent further infection and to provide appropriate care for those adolescents who are or will become infected with HIV.

Oral candidosis in HIV-infected patients. Prognostic value and correlation with immunological parameters

In a prospective study, 29 patients were observed over a period of 42 weeks for signs of oral candidosis (OC), immunological parameters and other typical AIDS-related events. Before the study started, no OC was observed in any of the patients. During the observation period, OC was diagnosed in 12 of the 29 patients (41%). 5 of these 12 patients (42%) developed full-blown AIDS during the 42 weeks. In contrast, a progression to AIDS was observed in only 1 of the 17 patients (5.9%) without OC. The laboratory findings for patients with and without OC showed statistically significant differences for neopterin (23.6 against 14.4 nmol l-1), CD4 counts (417 against 763/mm3) and CD4/CD8 ratios (0.45 against 0.85). Based on these results, it seems justifiable to consider prophylactic measures such as pentamidine inhalation and/or treatment with zidovudine in HIV-infected patients with immunodeficiency and occurrence of OC.

Interference with human immunodeficiency virus (HIV) replication by CD8+ T cells in peripheral blood leukocytes of asymptomatic HIV carriers in vitro

A long asymptomatic period is one of the characteristics of human immunodeficiency virus (HIV) infection, despite its fatal consequences. Antiviral defense in HIV-infected individuals controls viral replication during this period. In the present study, we demonstrate that peripheral blood leukocytes (PBL) of asymptomatic HIV-1 carriers, following exogenous HIV-1 infection in vitro, do not support viral replication. These cells do not produce detectable amounts of reverse transcriptase or accumulate unintegrated proviral DNA. This is a striking contrast to the behavior of HIV-1-infected PBL of seronegative individuals, which produce large amounts of RT and unintegrated DNA. Such resistance to HIV-1 replication is not seen in PBL of patients with advanced disease. Since the binding of HIV-1 to CD4 molecule is not impaired in PBL of asymptomatic carriers, the interference with HIV replication must occur after the stage of virus binding. PBL lose their resistance when CD8+ lymphocytes are removed. In addition, these PBL are not resistant to an exogenous infection with HIV-2. These observations suggest that certain populations of CD8+ lymphocytes of asymptomatic HIV-1 carriers operate on the target cells in PBL to block viral replication in an HIV-1-specific manner. Such CD8+ lymphocyte-mediated interference with HIV replication could play an important role in the maintenance of the period of disease latency.

The efficacy of inosine pranobex in preventing the acquired immunodeficiency syndrome in patients with human immunodeficiency virus infection. The Scandinavian Isoprinosine Study Group

We performed a randomized, double-blind, placebo-controlled trial to assess the efficacy and safety of inosine pranobex (Isoprinosine) [corrected] in the treatment of patients with human immunodeficiency virus (HIV) infection but without manifest acquired immunodeficiency syndrome (AIDS). A total of 866 patients were enrolled in 21 centers in Denmark and Sweden. The patients were stratified in three groups according to their CD4+ cell count and randomly assigned to receive either inosine pranobex (1 g three times a day) (n = 429) or matching placebo (n = 437) for 24 weeks. Of the 831 patients who could be evaluated, AIDS developed in 17 in the placebo group as compared with 2 in the inosine pranobex group (P less than 0.001; odds ratio, 8.6 [95 percent confidence limits, 2.2 and 52.6]). There were no significant differences between the groups with respect to changes in CD4+ cell count or the development of other HIV-related conditions, with the exception of thrush, which developed in fewer patients in the inosine pranobex group (P = 0.05). No serious side effects were observed. We conclude that treatment with inosine pranobex delays progression to AIDS in patients with HIV infection. The duration of this beneficial effect, the optimal dose, and the mode of action of inosine pranobex remain to be clarified.

Antigenic characterization of the human immunodeficiency viruses

As more is learned about the human immunodeficiency viruses HIV-1 and HIV-2, increasingly sophisticated methods of acquired immunodeficiency syndrome (AIDS) treatment and prevention may be implemented. Integral to an understanding of these viruses is an analysis of both the viral antigens and the host-immune responses to these antigens, which may differ from HIV-1 to HIV-2. Because levels of both antigen and antibody vary throughout disease development, knowledge of how and why such changes occur will lend insight into viral pathogenic mechanisms and will facilitate the development of differential diagnostic tests for classifying AIDS patients and their disease states. This task becomes very complex when dealing with HIV viruses because they possess an unprecedented number of regulatory genes for members of the retrovirus family.

Ventricle brain ratio in the clinical course of HIV infection

As part of the computerized tomographic assessment of an unselected group of 47 patients in different stages of HIV infection we determined the ventricle brain ratio (VBR) and the width of several cortical sulci. We compared the findings for subgroups of patients defined by their stage in the Walter Reed Staging Classification. There was a significant increase in VBR only in the subgroup of patients with manifest acquired immune deficiency syndrome (AIDS) (WR 6). The findings are discussed in connection with the question of the likelihood that dementia will develop even in stages of HIV-infection preceding AIDS.

Bronchoalveolar lavage findings in patients seropositive for the human immunodeficiency virus (HIV)

To evaluate bronchoalveolar lavage (BAL) findings in patients infected with human immunodeficiency virus (HIV), 39 patients seropositive for the virus but with no history of opportunistic infection were studied. Opportunistic organisms such as Pneumocystis carinii were not found in any of the 35 BAL fluids sent for special stains and cultures. Three of 16 (18 percent) BAL fluids sent for HIV culture were positive compared with a 60.9 percent blood HIV culture positivity in the same group. To evaluate cellular recovery, the patients were divided into Walter Reed (WR) groups 1 and 2 (blood CD4 greater than or equal to 400/cu mm) and WR3 to WR5 (blood CD4 less than 400/cu mm). Compared with ten nonsmoking healthy controls, the WR1 and WR2 group had a greater overall cellular recovery but this was not statistically significant when the smokers were excluded. There was no difference in macrophage or lymphocyte percentages in either patient group compared with controls. T-cell subset analysis of a small group of WR1 to WR5 patient BAL fluids revealed no difference in CD4 numbers or the CD4/CD8 rate between WR1 and WR2 and WR3 to WR5 patients. We conclude that opportunistic pulmonary infection is unlikely in HIV-seropositive patients with normal chest roentgenograms despite symptoms of dyspnea on exertion. Also, HIV can be isolated from BAL fluid from these patients although not as often as from blood. Finally, there appears to be no distinct progression in BAL cellular findings before the onset of acquired immunodeficiency syndrome.

IgG oligoclonal bands in sera of HIV-1 infected patients are mainly directed against HIV-1 determinants

In a series of 60 HIV-1-infected individuals, serum electrofocusing analysis disclosed clonally restricted IgG patterns in 9 patients (15%), most with limited disease progression (stages WR1-WR3). These oligoclonal bands had a very heterogeneous light chain pattern, and most showed specificity for HIV-1 in affinity-driven transfer studies; virus specificity was more clear-cut following adsorption of sera with the relevant antigen. These findings further stress the profound B-cell function derangement in HIV-1 infection; their possible relevance to AIDS-associated lymphoma development is discussed.

Expansion of activated T lymphocytes (CD3 + HLA/DR +) detectable in early stages of HIV-1 infection

The phenotypic characterization of lymphocyte subsets in relation to different clinical stages of HIV infection has mainly focussed on CD4 and CD8 cells. Some reports focus on expansion of activated T lymphocytes in AIDS patients. Yet there is no detailed knowledge whether such changes occur also in earlier stages of HIV infection. In order to describe the kinetics and possible pathogenetic meaning of this subset when related to all distinct chronologic stages, we performed two-color flow cytometric lymphocyte differentiation in 173 HIV-infected patients and 30 healthy controls. All subjects were classified according to the Walter Reed (WR) system. Our results show that a significant increase of activated T lymphocytes (CD3 + HLA/DR +) occurs early, in WR1 and WR2, thus preceding the clinically relevant CD4 depletion. This increase is paralleled by an expansion of CD8 + Leu7 + cytotoxic cells. We conclude, that early changes of lymphocyte subsets are detectable in addition to inversion of the CD4/CD8 ratio. The possible pathogenetic meaning including the question of possible autoimmune mechanisms is discussed.

Increased serum neopterin in patients with HIV-1 infection is correlated with reduced in vitro interleukin-2 production

Recently we have observed that the CD4+ T cell response of peripheral blood mononuclear cells (PBMC) to soluble antigens is the first to be lost in the course of HIV-1 infection followed by the loss of response to HLA alloantigens. In this study we compared serum neopterin concentrations of individuals with early stages of HIV-1 infection (stages WR1 and WR2, Walter Reed staging system) with in vitro interleukin-2 (IL-2) production of PBMC in response to stimulation with soluble antigens (influenza A virus and tetanus toxoid) and alloantigens. Neopterin concentrations were significantly higher in HIV-1-seropositive individuals who showed deficient IL-2 production in response to recall antigens only or to all of the stimuli tested in vitro, compared with HIV-1-seropositive individuals who exhibited no CD4+ T cell defects. No difference in serum neopterin concentrations was observed between the group that was functionally deficient to soluble antigens only versus those who were unresponsive to both types of stimuli. It appears that the selective loss of the MHC self-restricted CD4+ T cell function is associated with an increase in serum neopterin levels. Neopterin concentrations are an estimate of the activation status of macrophages. We conclude that defective in vitro production of lymphokines by T lymphocytes is associated with activated macrophages in vivo.

Mechanisms of infectivity and replication of HIV-1 and implications for therapy

Human immunodeficiency virus type 1 (HIV-1), a retrovirus, is the etiologic agent of AIDS. Like all retroviruses, the viral genes are carried in the viral particle in the form of single-stranded RNA. Once inside a susceptible host cell, this RNA template is reverse-transcribed by virally supplied enzyme functions into a DNA copy, which becomes integrated permanently into the host's own genetic material. The genome of HIV-1, comprising approximately 10,000 bases, is much more complex than those of classic retroviruses, encoding a minimum of six gene products in addition to the gag, pol, and env genes characteristic of all retroviruses. These genes encode regulatory functions that act at diverse points in the virus life cycle. Together, they provide HIV-1 with an exceptional ability to modulate its replication depending on its host environment. This characteristic is reflected in the different stages presented by the disease and the diverse behaviors of the virus in different types of host cells. A greater understanding of the mechanics of this regulation and the factors that influence it may someday permit therapeutic intervention in the disease process that will halt virus replication and the progression of pathology in infected individuals.

Exercise dysfunction in patients seropositive for the human immunodeficiency virus

To confirm the presence of exercise dysfunction in patients seropositive for the human immunodeficiency virus (HIV), 32 such patients without AIDS were evaluated with cardiopulmonary exercise testing, pulmonary function testing, bronchoalveolar lavage, chest roentgenography, and gallium scanning. No evidence of pulmonary opportunistic infection was found. When compared to an otherwise similar group of HIV-seronegative controls, the patients exercised to a significantly lower workload (195 +/- 30 versus 227 +/- 31 W, p less than 0.001). The ventilatory anaerobic threshold (VAT) values were also significantly lower for the patients (49.2 +/- 13.0 versus 61.9 +/- 9.1% of maximum predicted VO2, p less than 0.001). Nine of the patients had VAT values less than the 95% confidence interval for the controls. This subgroup exercised to a significantly lower maximum VO2 (69.9 +/- 11.2 versus 95.9 +/- 17.5% of maximum predicted VO2, p less than 0.001) and workload (165 +/- 21 versus 227 +/- 31 W) when compared to the control group. These patients demonstrated a mild tachypnea throughout exercise relative to the controls and had a significant increase in the slope of the heart rate to VO2 relationship. These findings are most consistent with a limitation of oxygen delivery to exercising muscles, which may represent occult cardiac disease in this group.

Efficacy of intravenous immunoglobulins in patients with advanced HIV-1 infection. A randomized clinical study

40 adults with symptomatic HIV-1 infection (AIDS related complex [ARC] WR 2B-4B or AIDS WR 5-6) were randomized into two groups, receiving either 200 mg of an i.v. immunoglobulin preparation (ivIg)/kg body weight every other week or no such treatment. Medical care and antibiotic therapy were comparable in the two groups. Frequency of opportunistic infections, "B"-symptoms, number of T-helper cells, change of disease stage (Walter Reed Classification, WR), delayed cutaneous hypersensitivity, onset and clinical course of Kaposi's sarcoma, neurological manifestations and proportion of patients alive at the end of the observation period were evaluated. After an average observation period of 13.8 months, decreased mortality was observed in ivIg treated patients of WR 5-6 (p less than 0.004). Frequency and microbial spectrum of opportunistic infections, the most frequent cause of death, were not influenced significantly by ivIg treatment. No statistically relevant differences concerning the other parameters were observed. A similar beneficial effect of ivIg in WR 2B-4 patients has not become apparent so far.

An epitope in human immunodeficiency virus 1 reverse transcriptase recognized by both mouse and human cytotoxic T lymphocytes

T-cell-mediated cytotoxicity may play an important role in control of infection by the human immunodeficiency virus (HIV). In this study, we have identified and characterized a relatively conserved epitope in the HIV-1 reverse transcriptase recognized by murine and human cytotoxic T cells. This epitope was identified using a murine antigen-specific CD8+ class I major histocompatibility complex-restricted cytotoxic T-cell (CTL) line, a transfected fibroblast cell line expressing the HIV-1 pol gene, recombinant vaccinia viruses containing different truncated versions of the pol gene, and overlapping synthetic peptides. The optimal antigenic site was identified as residues 203-219 by synthesizing extended or truncated peptide analogs of the antigenic fragment. The optimal peptide was then tested for sensitization of autologous Epstein-Barr virus-transformed B-cell targets for killing by fresh human peripheral blood mononuclear cells. It was recognized by CTLs from several HIV-seropositive patients but not from any seronegative donor. Therefore, this peptide is a good candidate for inclusion in an AIDS vaccine. This study demonstrates that the same CTL epitope can be seen by murine and human CD8+ CTLs, as previously demonstrated for epitopes recognized by CD4+ helper T cells, and suggests the utility of screening for immunodominant CTL epitopes in mice prior to carrying out studies in humans.

Surgical management of anal condylomata in the HIV-positive patient

A retrospective review of 677 patients who tested positive for the human immunodeficiency virus, evaluated from January 1986 to February 1988, demonstrated 119 patients (18 percent) with anal condylomata. Demographics of these patients were similar to the total human immunodeficiency virus group; ages ranged from 19 to 86 years (mean, 25 years). Ninety-four percent of patients were men, 62 percent were white, 30 percent were black, and 10 percent were other races, primarily Hispanic. Ten percent of the patients admitted to homosexual activity and 2 percent admitted to intravenous drug abuse. Sixty percent of the population had another sexually transmitted illness. The majority of patients were in early Walter Reed Classes (Stage I or II). With follow-up of 4 to 26 months (mean = 12 months), the recurrence rate for anal condylomata was 26 percent after local treatment with podophyllin and 4 percent after fulguration and excision. There were no operative complications. Our study confirmed that anal condylomata and sexually transmitted diseases are common in patients who test positive for the human immunodeficiency virus and that patients who test positive for the human immunodeficiency virus with early Walter Reed stages can be expected to do well with appropriate therapy.

Accessory cell function in asymptomatic human immunodeficiency virus-infected patients

Peripheral blood mononuclear cells from human immunodeficiency virus seropositive (HIV+) individuals who did not exhibit symptoms of acquired immunodeficiency syndrome (AIDS) (Walter Reed Stage 1 patients) were tested for accessory cell function for presentation of recall antigens to autologous T lymphocytes and for presentation of HLA alloantigens to T lymphocytes from healthy, HIV- donors. Neither experimental model indicated a defect in accessory cell function at this early stage after HIV infection, although our study does not exclude the possibility of accessory cell dysfunction at a later stage of AIDS development.

Synthetic peptides define the fine specificity of the human immunodeficiency virus (HIV) gp160 humoral immune response in HIV type 1-infected chimpanzees

The fine specificities of antibodies produced against human immunodeficiency virus type 1 (HIV-1) gp160 were examined in sera from 23 HIV-1-infected chimpanzees. These animals had been infected with one of six isolates of HIV-1. Sera were screened by enzyme-linked immunosorbent assay for reactivity against seven synthetic peptides corresponding to regions of gp160. Chimpanzees appear to remain healthy after infection with HIV-1, suggesting that these animals may prevent extensive spread of the virus in vivo through immunologic mechanisms. Antibody specificity to gp160 epitopes may play a key role in the defense against HIV-1-related disease. Approximately one-half of all chimpanzee sera contained antibodies reactive with peptide 846-860, which corresponds to the carboxyl terminus of gp41. Less than 10% of sera from HIV-1-infected humans that were examined contained antibodies reactive with peptide 846-860, suggesting that this region is not highly immunogenic in humans. Of the human sera containing antibodies reactive with this peptide, all were from individuals classified as Walter Reed stages 1 to 3. No sera from humans with advanced stages of the disease contained antibodies reactive with peptide 846-860. Peptide 600-611, which reportedly reacts with nearly all sera from HIV-infected humans, was reactive with less than one-half of sera from HIV-1-infected chimpanzees. The observed differences in antibody reactivity to gp160 peptides in sera from HIV-1-infected chimpanzees and humans suggest that each may generate antibodies against differing sets of HIV-1 epitopes. These differences may contribute to the lack of disease progression in chimpanzees after infection with HIV-1.

[AIDS-related complex: a superfluous concept?]

The clinical value of different classification systems of HIV-infection has been examined in a cohort of 99 HIV-infected individuals. AIDS-related complex (ARC), Walter-Reed (WR) stage 5 and Centers for Disease Control (CDC) group IV without AIDS cases were equally capable of identifying patients with bad prognosis: Out of 12 patients progressing to AIDS, 9 WR 5, 7 CDC IV and 7 ARC. Prognostic parameters (Erythrocyte sedimentation rate, Haemoglobin, Leucocytes, CD4-lymphocytes and Beta 2-Microglobulin) did not differ in the three groups. However, there were great differences in the frequency of patients infected by homosexual contacts and of intravenous drug-abusers. Drug-abusers were more often seen in the ARC-group, whereas there was a slight dominance of homosexuals in the WR 5-group (and a marked preponderance in the AIDS-group). Using 3 different ARC-definitions we found an ARC-frequency of 10%, 24% and 41% in our cohort. Thus the great variability of the ARC-concept could be demonstrated. In conclusion we believe that for the purpose of clinical documentation and studies the ARC-concept is unnecessary. Further studies have to evaluate other classification systems (Walter-Reed, CDC) or to establish new ones.

Prospective study of psychiatric morbidity in HIV-seropositive women without AIDS

Prospective studies of psychiatric morbidity in HIV-seropositive women without AIDS have not been previously reported. As part of a 5-year longitudinal study, psychiatric diagnoses are described in 20 employed, educated women who are not intravenous drug abusers. This population is markedly different from the urban, minority, intravenous drug dependent groups previously studied and may be more representative of women who acquire the virus through heterosexual contact. Heterosexual transmission was the rule; 20% had HIV-seropositive spouses. All women were largely asymptomatic and in the early stages of infection. Mean length of knowledge of seropositivity was 14.4 months. Fifty percent were found to have an Axis I diagnosis (35% if minor diagnoses are excluded). None developed major depression or became dependent on drugs; 5% abused alcohol. Fifteen percent exhibited subtle signs of cognitive decline. Suicidal behavior and psychiatric hospitalization were absent. Sexual functioning was disrupted in a majority, with 20% meeting criteria for new onset hypoactive sexual desire disorder. Consistently "safe sex" practices were adhered to in 40%; in spite of intensive and repeated HIV education, 60% engaged in unprotected intercourse after knowledge of seropositivity. Progression of HIV infection was found to be three times faster than in a comparable male sample.

Report of the symposium on the use of intravenous gammaglobulin in adults infected with the human immunodeficiency virus

On July 27, 1989, the International Conference on Molecular Aspects of Immune Response and Infectious Diseases devoted a symposium to the subject of the use of intravenous gamma globulin (IVIG) in acquired immunodeficiency syndrome (AIDS). The information presented confirmed that IVIG benefits human immunodeficiency virus (HIV)-infected children with recurrent infections and that much remains to be learned about the influence of IVIG in adult AIDS. The symposium participants recognized the urgent need to develop randomized clinical trials using a control group to assess the efficacy of a treatment with IVIG in PGL (persistent generalized lymphadenopathy), ARC (AIDS-related complex), and AIDS. To prepare this report, a committee was established, including individuals with expertise in immunology, immunopharmacology, microbiology, virology, infectious diseases, general medicine, and pediatrics and representing research experience in academia and hospitals. After an introduction to the report with a summary of immunotherapeutic agents under evaluation to treat HIV infection, section 1 lays out the present understanding of the disease pathogenesis. Section 2 then outlines the treatment of HIV-seropositive individuals, discussing the uncertainties that any treatment entails. Section 3 discusses the rationale for treating HIV-infected individuals with IVIG, and Section 4 examines the major differences between IVIG and hyperimmunoglobulins for the treatment of HIV infection. Section 5 looks at IVIG as a mean to delay the emergence of opportunistic infections and restore immunocompetence in AIDS and related illnesses, and Sections 6 and 7 suggest a pilot protocol on the use of IVIG in association with low-dose or standard-dose zidovudine (AZT).(ABSTRACT TRUNCATED AT 250 WORDS)

HIV-1 infection in haemophilia

Guidelines have been prepared by the National Hemophilia Foundation, USA, for treating patients with haemophilia, these are: 1. General recommendations. The risks of withholding treatment far outweigh risks of treatment. Patients should however be educated to use appropriate clotting factor doses to minimize overuse and contain costs. 2. Factor VIIIC-deficient patients. DDAVP should be used whenever possible by patients with mild or moderate factor VIIIC deficiency. When feasible, an alternative to concentrates may be the use of cryo-precipitate prepared from one well-screened donor or from a small number of such donors. (a) Prevention of hepatitis. Hepatitis B vaccination is essential for uninfected patients. Preliminary data suggest that products that are pasteurized, solvent/detergent-treated or monoclonal antibody-purified are at a reduced risk of transmitting hepatitis viruses. (b) Prevention of HIV-1. Concentrates pasteurized, treated with solvent/detergent, purified with monoclonal antibody, heated in suspension with organic solvents, or dry heat-treated for long periods are preferred. These products carry a substantially reduced risk of transmitting HIV-1. 3. Factor IX deficiency. For patients with severe deficiency the use of virus-inactivated Factor IX concentrate is recommended. For mild to moderate patients when feasible an alternative would be fresh, frozen plasma prepared from one well-screened and repeatedly-tested donor or from a small number of such donors. In the past few years, significant progress has been made in understanding the nature of the defect in haemophilia both at the molecular and structural levels, such a foundation is necessary for definitive treatments in the future. For now, however, the dark side of replacement therapy must be accepted along with its benefits.

Epidemiology and clinical picture of human immunodeficiency virus type 1 infection and the acquired immune deficiency syndrome

Human Immunodeficiency Virus Type 1 (HIV-1) infection which causes the terminal Acquired Immune Deficiency Syndrome (AIDS) is one of the major new pandemics of this millenium. This infection is believed to be a zoonosis which achieved sustained transmission among humans because of recent increases in sexual promiscuity and needle-sharing drug use. Although the HIV-1 epidemic is of relatively recent onset, its modes of transmission have been clearly defined: sexual relations, blood injection, and childbirth. Other possible transmission methods such as non-sexual social interaction and insects have been explicitly excluded. Susceptibility is increased by genital ulcers and lack of male circumcision but probably not by genetic factors or female circumcision. Transmissibility is also increased by genital ulcers and, more importantly, by the stage of disease. Progression by stages to fatal diseases will probably occur in most, if not all, infected individuals, usually within a decade. While HIV-1 has a direct effect on the intestinal track and the central nervous system, its primary effect is suppression of the immune system resulting in overwhelming secondary infections and, less clearly, cancers. Human Immunodeficiency Virus Type 1 infection is incurable and is likely to remain so for the foreseeable future. Although life-prolonging treatments have been developed, a vaccine will likely not be available in the foreseeable future. Like most previous new epidemic diseases, HIV-1 infection is being and will continue to be modified by changing human behavior patterns.

Oral hairy leukoplakia

Oral hairy leukoplakia was first described in homosexual men infected with the human immunodeficiency virus. It is thought to be caused by infection with both the Epstein-Barr virus and human papillomavirus. We report 59 cases of oral hairy leukoplakia. The disease was diagnosed in patients in all risk groups and was categorized in all classes of the Walter Reed classification without significant differences in prevalence. Epstein-Barr virus could be demonstrated in all tissue samples examined; human papillomavirus was found in only a few specimens. In our series oral hairy leukoplakia had a chronic course, although temporary spontaneous healing occurred in some cases. Its appearance was a poor prognostic sign because acquired immunodeficiency syndrome developed in a significant proportion of patients within a few months of onset.

Free and antibody-complexed antigen and antibody profile in apparently healthy HIV seropositive individuals and in AIDS patients

The pattern of free and antibody-complexed HIV antigen and the antibody profile were investigated retrospectively in 305 serum samples taken from 22 AIDS patients before and during the development of AIDS and from 40 apparently healthy seropositive individuals. Most AIDS patients were found positive for both free and complexed antigen and had high gp41 antibody titres but low or undetectable p24 antibody. Four different patterns of HIV antigenaemia were observed: 1) positive for both free and complexed antigen; 2) negative for free HIV antigen at first, but always positive for complexed antigen; 3) positive for free antigen without complexed antigen; and 4) negative for both free and complexed antigen. The development of immune complexes preceded the appearance of free antigen and might reflect the ongoing viral replication with antigen excess and binding of anticore antibodies. No correlation was found between the development of AIDS symptoms and either the duration of free antigen positivity or the level of antigenaemia. A different pattern was observed in apparently healthy seropositive individuals: 90% of whom had high antibody titres to p24 and gp41 and were persistently negative for free and complexed HIV antigen. This study demonstrates that testing HIV markers in sequentially collected serum samples from HIV seropositive individuals is a useful and simple tool for early identification of persons at risk of developing AIDS.

Lymphocyte phenotype does not predict immune function in pediatric patients infected with human immunodeficiency virus type 1

To determine whether assays of lymphocyte phenotype were predictive of antigen-specific immunologic function in children infected with human immunodeficiency virus type 1 (HIV-1), we compared the antigen-specific cellular and humoral functions (tetanus toxoid-induced T lymphocyte blastogenesis and anti-tetanus toxoid antibody) with the patients' T lymphocyte phenotype, determined at the same time. Although both HIV-1-infected patient populations studied (pediatric hemophilia patients and other pediatric patients) had decreases in the values determined by their functional and phenotypic assays, no association between the functional and phenotypic assays was demonstrated. Thus some HIV-1-infected patients with a normal phenotype had no antigen-specific function, whereas other patients with a markedly abnormal T lymphocyte phenotype had normal antigen specific T lymphocyte function. These results indicate that the assessment of HIV-1-infected patients should include assays of antigen-specific immune function in addition to assays of T lymphocyte phenotype.

Detection of three distinct patterns of T helper cell dysfunction in asymptomatic, human immunodeficiency virus-seropositive patients. Independence of CD4+ cell numbers and clinical staging

We have tested the T helper cell (TH) potential of asymptomatic, HIV seropositive (HIV+) patients, using an in vitro assay for IL-2 production. Peripheral blood leukocytes (PBL) from 74 HIV+ patients and 70 HIV- control donors were tested for TH function when stimulated with influenza A virus (FLU), tetanus toxoid (TET), HLA alloantigens (ALLO), or PHA. Of the HIV+ patients, four different response patterns were observed: (a) patients who responded to all four stimuli (16%); (b) patients who were selectively unresponsive to FLU and TET, but responded to ALLO and PHA (54%); (c) patients who were unresponsive to FLU, TET, or ALLO, but responsive to PHA (16%); and (d) patients who failed to respond to any of these stimuli (14%). Our results indicate a time-dependent progression from a stage responsive to all four stimuli to a stage unresponsive to any of the stimuli tested, progressing in the order outlined above. The earliest TH defect is the loss of responses to FLU and TET, indicating a selective defect in CD4+ MHC self-restricted TH function. The later loss of ALLO and PHA IL-2 responses suggests more severe TH dysfunction involving both CD4+ and CD8+ T cells. None of these patterns of TH unresponsiveness in asymptomatic HIV+ individuals were correlated with CD4+ cell numbers nor with Walter Reed staging criteria. This study indicates that the in vitro TH assay used can detect multiple stages of immune dysregulation early in the course of HIV infection and raises the possibility that staging of HIV+ patients should include in vitro TH functional analyses of the type described here.

Plasma glutamate--a prognostic marker of cancer and of other immunodeficiency syndromes?

Elevated plasma levels of glutamate (GLU) have been reported to occur in patients with malignancies and other immunodeficiency syndromes (IDS). To evaluate, whether GLU is useful as prognostic indicator, the plasma concentrations were determined in patients with colorectal carcinoma (CRC), with breast cancer (BRC), and with HIV-infection (HIV). The results were correlated with the disease-stages, and compared with data obtained from patients with benign diseases of the same organ, as well as from sex-matched healthy volunteers. GLU concentrations (volunteers: 27.4 +/- 17.6 mumol/l) were elevated in all BRC patients (range of mean values: 53.5-83.2 mumol/l), in CRC patients with T2-T4-tumours (means: 46.8-85.9), and in HIV+ patients of stage WR 5, 6 (means: 53.9-69.7 mumol/l). All CRC- and BRC-patients with metastases showed highly significant elevations of GLU concentrations (p less than 0.001), but there were no direct correlations between disease stages and GLU levels. Pre-operative patients with benign diseases (diverticulitis, adenoma = GID; and mastopathy = MTP) showed increased GLU levels, which were comparable to those of the tumour patients. The glutamine/GLU ratios (volunteers: 19.3 +/- 15.0) were decreased only in HIV-WR 6 (7.6 +/- 2.1), and BRC-stage 4 (8.0 +/- 1.7). From these results we deduce that the plasma GLU concentrations do not allow a discrimination either between patients with malignancies and without, and between persons of different disease stages.

Levels of soluble CD8 antigen and circulating immune complexes in intravenous drug abusers: relationships to HIV antibody serology

A total of 36 intravenous drug abusers (IVDA) were studied for circulating immune complexes (CIC) and serum soluble CD8 antigen (sCD8). None had symptoms or signs of AIDS-related complex or AIDS. sCD8 levels were significantly higher in 18 patients who had HIV antibody (Ab) compared with 18 patients who were HIV Ab negative (1640 +/- 578 virus 804 +/- 264 U/ml, p less than 0.0001). In HIV Ab+ patients but not in HIV Ab- patients, sCD8 levels significantly correlated with percentages and absolute numbers of activated CD3+DR+ peripheral blood mononuclear cells (p = 0.0024 and 0.0183, respectively). Also in HIV Ab+ patients, CIC levels were significantly greater for both anti-C3 binding (13.1 +/- 11.1 versus 2.9 +/- 3.4 micrograms/ml, p = 0.002) and C1q binding (23.5 +/- 20.2 versus 6.3 +/- 4.3 micrograms/ml, p = 0.001) CIC. Serum C4 concentrations were lower in the HIV Ab+ patient group (33.9 +/- 10.1 versus 41.6 +/- 12.4 mg/dL, p = 0.043). In the seropositive group, IgG levels were higher (2206 +/- 859 versus 1615 +/- 645 mg/dl) and total CD4 cell counts were lower (757 +/- 344 versus 1172 +/- 402 cells per mm3), but at a less significant level (p = 0.024 and 0.005, respectively), than that seen for sCD8 and C1q CIC differences. These results suggest that elevations of both the lymphocyte activation marker sCD8 and antigen nonspecific CIC characterize earlier stages of HIV infection in IVDA.

Treatment of AIDS-associated heart disease

Although the diagnosis of AIDS-associated heart disease is becoming routine, its treatment has not been reported except in anecdote. Also, it has been unclear whether the odds of successful treatment are altered because of the presence of cardiac involvement per se. This communication reports the authors' treatment of 18 patients with AIDS-associated heart disease. Their results are combined with the treatment results of all patients reported in the literature to date with AIDS-associated heart disease. Treatment success, defined as eradication of the organism and no relapse, was achieved in their patients with M. tuberculosis (M. tb), cardiac cryptococcosis, and Salmonella typhimurium. M. tb required emergency pericardiectomy (well tolerated in all patients), then administration of rifampin, isoniazid, and ethambutol. Cryptococcosis was treated acutely with amphotericin B and flucytosine, then with maintenance amphotericin B. The response, which included resolution of congestive heart failure, occurred within a week. Salmonella endocarditis was cured with administration of ampicillin and netilmicin for one month. When the patients' data were combined with those of patients from the literature, the authors found that the odds of successful treatment for tuberculous pericarditis were somewhat lower than if the tuberculosis was extracardiac (50% vs 67%). With cryptococcal heart disease, the odds of successful treatment were actually significantly better than when only extracardiac disease was present. The authors conclude that infectious forms of AIDS-associated heart disease are often treatable. Although some cardiac infections are less likely to respond to treatment if there is cardiac involvement, mostly the response to treatment is similar to the response with only extracardiac involvement.

Prescription drug use patterns of human immunodeficiency virus-infected patients taking zidovudine. Walter Reed Retrovirus Research Group

Prescription drug profiles of 116 human immunodeficiency virus (HIV)-infected patients taking zidovudine in 1988 were surveyed. Patients received the drug an average of 236 days. About one-third (32 percent) required reduced dosage presumably because of hematologic toxicity and this was associated with length of time on the drug. Zidovudine dosage reduction was not associated with concurrent therapy with either acetaminophen or acyclovir. Concomitant drug therapy was common, especially with systemic antifungals (47 percent), antivirals (33 percent), nonsteroidal antiinflammatory drugs (23 percent), and antidepressants (20 percent), as well as topical fungicides (35 percent) and antiinflammatory agents (28 percent). Over three-fourths of patients on zidovudine were on chemoprophylaxis for Pneumocystis carinii pneumonia, most often with pentamidine inhalation therapy. This study showed that the HIV-infected patient population is being treated concomitantly with many pharmacologic agents prescribed by various medical specialties.

Human immunodeficiency virus type 1 (HIV-1) infection of the central nervous system: an evaluation of cytokines in cerebrospinal fluid

Cytokines play an important role not only for initiation of immune reactivity but also for development of tissue injury. Of 38 patients infected with human immunodeficiency virus type 1 (HIV-1) interleukin-1 beta (IL-1 beta) and interleukin-6 (IL-6) were identified in cerebrospinal fluid (CSF) of 22 (58%) and 16 (42%) patients, respectively. Among the IL-1 beta- and IL-6-positive CSF were eight of 15 HIV-1 patients with no clinical signs of central nervous system involvement and four of five patients with acquired immunodeficiency syndrome (AIDS) dementia complex. The presence of IL-6 was often associated with IL-1 beta and soluble interleukin-2 receptor in CSF as well as with intrathecal IgG synthesis. In none of the CSF samples tumor necrosis factor-alpha or interleukin-2 was detected.

Statistical analysis of the stages of HIV infection using a Markov model

We use a staged Markov model to estimate the distribution and mean length of the incubation period for acquired immunodeficiency syndrome (AIDS) from a cohort of 603 human immunodeficiency virus (HIV) infected individuals who have been followed through various stages of infection. The model partitions the infected period into four progressive stages: (1) infected but antibody-negative; (2) antibody-positive but asymptomatic; (3) pre-AIDS symptoms and/or abnormal haematologic indicator; and (4) clinical AIDS. We also model a fifth stage: death due to AIDS. The estimated mean (median) waiting times in each stage of infection are stage 1, 2.2 (1.5) months; stage 2, 52.6 (36.5) months; stage 3, 62.9 (43.6) months; and stage 4, 23.6(16.3) months. We estimate the mean AIDS incubation period (from infection to development of clinical AIDS) as 9.8 years with a 95 per cent confidence interval of [8.4, 11.2] years. The paper also considers the estimated density function of the AIDS incubation period and the estimated survival functions for individuals in each stage of infection. This work represents one of the most complete statistical descriptions to date of the natural history of HIV infection.

Psychiatric response to HIV spectrum disease in children and adolescents

Five clinical situations involving children and adolescents exposed to human immunodeficiency virus illustrate the psychosocial spectrum of the disease. For at-risk gay youth, anxiety and stigma complicate developing sexual practices. Children with perinatal infection may survive for years with a chronic illness, management of which is complicated by parental illness or death. Hemophiliac families must deal with the intrusion of a lethal virus into a long illness course. "Street" adolescents and substance-abusing youth pose particular challenges to public health and education. The range of child psychiatric responses described includes individual and family therapy, neuropsychological assessment, psychopharmacological management, and consultation liaison work.

OKT4/OKT8 ratio in asymptomatic heroin addicts

The OKT4 (helper) and OKT8 (suppressor) lymphocytic subpopulations were enumerated in a sample of 60 asymptomatic drug addicts and in 17 controls. No significant differences in the ratio could be found that could not be explained by the action of HIV. It can be concluded that heroin itself was not responsible for any alteration in the T4/T8 ratio in the population considered.

Department of Army lymphocyte immunophenotyping quality assurance program

With the emergence of the human immunodeficiency virus (HIV) epidemic, lymphocyte immunophenotyping has become the single most important laboratory test for clinical management of HIV-infected subjects. To meet this challenge, the department of Army instituted a multicenter lymphocyte immunophenotyping quality assurance (QA) program in March 1986. An integral part of the QA program has been the development of a monthly proficiency testing program to survey the degree of precision and reproducibility of lymphocyte subset determinations within the Army. After 15 months of proficiency testing, the multicenter cumulative average standard deviation for the percentage of positive CD2 was 3.3, CD3 was 4.4, CD4 was 3.3, CD8 was 3.6, CD8*CD3 was 2.8, CD19/20 was 2.9, and 3.0 for natural killer (NK) cells. The cumulative average coefficient of variation for the percentage of positive CD2 was 3.9%, CD3 was 4.9%, CD4 was 6.6%, CD8 was 11.4%, CD8*CD3 was 9.4%, CD19/20 was 18.8%, and 26.5% for NK. Five survey shipments were also shipped to an additional 49 laboratories outside the Department of Army. The difference of the mean Army percentage positive values from the mean overall percentage positive values ranged from zero to 9.6, with an average difference of 1.6. The interlaboratory variability of flow cytometrically-derived percentage values presented in this report are almost half that cited by other multicenter lymphocyte comparative studies.

Direct measurement of human immunodeficiency virus seroconversions in a serially tested population of young adults in the United States Army, October 1985 to October 1987. Walter Reed Retrovirus Research Group

Direct measurement of the incidence of infection with the human immunodeficiency virus (HIV)--the rate of new HIV infection--is vital if we are to understand better the dynamics of the current epidemic of HIV infection. Because soldiers are periodically and routinely screened for antibody to HIV, it is possible to measure the incidence of HIV infection directly in this large, demographically well-characterized population of young adults. To determine the incidence of HIV infection in this population, we examined test results reported by the U.S. Army's routine antibody-screening programs. During the first two years of the screening programs, the observed incidence of HIV infection was approximately 0.77 per 1000 persons per year. This rate was higher than expected on the basis of previously published estimates of seroprevalence in the Army (approximately 1.50 per 1000). On the basis of this annual incidence, and assuming it to be stable, we estimate that approximately 600 soldiers will become infected with HIV each year. The observed rate in the Army may be lower than the incidence of HIV infection in the corresponding demographic groups within the general U.S. population.