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

Risk behavior-based model of the cubic growth of acquired immunodeficiency syndrome in the United States

The cumulative number of cases of acquired immunodeficiency syndrome (AIDS) in the United States has grown as the cube of time rather than exponentially. We explain this by interactions involving partner choice and sexual frequency in a risk-behavior model with biased mixing. This leads to a saturation wave of infection moving from high- to low-risk groups. If this description is correct, then the decreasing growth rate of AIDS cases is not due to behavior changes; rather it is due to the intrinsic epidemiology of the disease.

Interleukin-2 production used to detect antigenic peptide recognition by T-helper lymphocytes from asymptomatic HIV-seropositive individuals

T lymphocytes from mice and healthy humans immunized against the human immunodeficiency virus (HIV) envelope have recently been shown to recognize two antigenic regions of the gp160 HIV-envelope protein which have been located on the basis of amphipathicity. In HIV-infected humans, T-cell proliferative responses are lost soon after infection. Here we demonstrate that interleukin-2 production is often retained even when proliferative activity is absent, and that it can be used to monitor T-helper cell responses by HIV-seropositive donors. We use this approach to investigate the T-helper cell response of 42 asymptomatic HIV-seropositive patients to four synthetic gp160 peptides and to influenza A virus, an antigen requiring intact CD4 T-helper cell function. As many as 67% of the HIV-seropositive donors who retain responsiveness to influenza A virus respond to a single peptide, and 85-90% responded to at least one of the peptides.

Tumor necrosis factor alpha (TNF alpha) and neurological diseases. Failure in detecting TNF alpha in the cerebrospinal fluid from patients with multiple sclerosis, AIDS dementia complex, and brain tumours

The presence of tumor necrosis factor alpha (TNF alpha)/cachectin was investigated in 180 paired cerebrospinal fluid (CSF) and serum samples from patients with neurological diseases, and in five paired CSF and serum samples of Macaca cynomolgus monkeys with acute monophasic experimental autoimmune encephalomyelitis (AMEAE). TNF alpha was never detected in human CSF, even when an extensive demyelination was documented (active multiple sclerosis, acquired immunodeficiency syndrome (AIDS) dementia complex). Only one Macaca with AMEAE had detectable levels of TNF alpha in CSF but not in serum, suggesting an intrathecal synthesis of this cytokine in AMEAE.

A new prognostic staging system for the acquired immunodeficiency syndrome

An improved prognostic staging system is needed for patients with the acquired immunodeficiency syndrome (AIDS). To construct such a system, we analyzed the course of 117 consecutive adults who received a diagnosis of AIDS at Yale-New Haven Hospital from 1981 through 1987. The staging system was developed from the data on the first 76 patients, confirmed in the remaining 41 patients, and then applied to the entire cohort. The staging system, which is based on physiologic deficits rather than demographic or diagnostic features, gives one point for each of the following: severe diarrhea or serum albumin level under 2.0 g per deciliter, any neurologic deficit, arterial oxygen tension of 50 mm Hg or less, hematocrit below 30 percent, lymphocyte count below 150 per microliter, white-cell count below 2500, and platelet count below 140,000. The total score determines the presence of Stages I (0 points), II (1 point), or III (2 to 7 points). The three stages had distinctive prognostic gradients in our cohort. For patients in Stages I, II, and III, the median survival times were 11.6, 5.1, and 2.1 months, respectively, with one-year survival rates of 50, 30, and 8 percent. When the staging system was tested with a proportional-hazards model, no other descriptive or laboratory variable added any additional predictive power. Although this new staging system requires further validation in other populations, we believe it will be useful in evaluating new therapies and improving the precision of prognosis in patients with AIDS.

FeLV-FAIDS-induced immunodeficiency syndrome in cats

Findings are reviewed, relevant to elucidation of the pathogenic, genetic and biochemical properties of a single, genetically heterogeneous isolate of feline leukemia virus (FeLV-FAIDS) shown to induce fatal immunodeficiency disease in nearly 100% of inoculated cats. Hypotheses are suggested which pertain to the mechanism of T-cell killing by this virus, and which extrapolate findings in the FeLV-FAIDS animal model to AIDS induced in humans by human immunodeficiency virus (HIV).

beta 2-Microglobulin and antiviral therapy for chronic hepatitis type B

During a randomized controlled trial of interferon and descyclovir therapy, the beta 2-microglobulin and SGOT serum levels in 36 patients with chronic HBe-positive hepatitis B were studied in order to determine whether beta 2-microglobulin has prognostic value for HBe seroconversion. Pretreatment levels of beta 2-microglobulin were elevated in 39% of patients. Significant differences in mean beta 2-microglobulin activity and mean SGOT between treated patients and untreated controls were observed after 4 and 8 weeks of treatment (P less than 0.05). Levels in control patients remained stable. Prior to and during therapy, the mean elevation of beta 2-microglobulin and SGOT levels was similar in responders (N =7) and non-responders (N = 11). The outcome of antiviral therapy in our patients was not dependent on beta 2-microglobulin levels measured before or during interferon therapy.

Monitoring human immunodeficiency virus type 1-infected patients by ratio of antibodies to gp41 and p24

Antibody responses of 85 patients to human immunodeficiency virus type 1 antigens were quantitated by densitometric analysis of Western blot (immunoblot) assays. All patients had been classified into the following three clinical categories: asymptomatic (ASY), acquired immunodeficiency syndrome (AIDS)-related complex (ARC), or AIDS. Fifty of the patients were monitored for 6 to 29 months. The gp41/p24 antibody ratio was examined in three studies. In the first study, initial specimens from each patient were analyzed. The mean gp41/p24 antibody ratios were 1.5 (ASY), 3.2 (ARC), and 5.4 (AIDS). Of ASY patients, 79% had antibody ratios of less than 2.0. In contrast, 72% of patients with AIDS had ratios of greater than or equal to 2.0. In the second study, serially obtained specimens from ASY, ARC, and AIDS patients were analyzed. These patients were further grouped according to progression of their clinical condition. Of ASY patients whose clinical condition progressed to ARC, 80% consistently had ratios of greater than or equal to 2.0. Of ARC patients whose clinical condition progressed to AIDS, 71% consistently had ratios of greater than or equal to 2.0. Of AIDS patients who died during the study, 100% consistently had ratios of greater than or equal to 2.0. No patients were treated with azidothymidine during the first two studies. In the third study, AIDS patients were monitored before and during treatment with azidothymidine. During treatment, ratios stabilized or improved transiently in five of seven patients. In these three studies, a gp41/p24 antibody ratio of less than 2.0 correlated with a benign clinical state and a ratio of greater than or equal to 2.0 correlated with AIDS or progression to AIDS.

Inflammatory myopathy and acquired immunodeficiency syndrome

A 33-year-old black woman with advanced acquired immunodeficiency syndrome (AIDS) presented with rapidly progressive muscle weakness and serologic and radiologic evidence of central nervous system Toxoplasma infection. Muscle biopsy revealed an inflammatory infiltrate predominantly composed of macrophages and T suppressor/cytotoxic cells. Human immunodeficiency virus major core protein (p24) was also detected in macrophages and damaged muscle cells around the inflammatory infiltrates. The patient improved clinically with glucocorticoid therapy for polymyositis and pyrimethamine and clindamycin therapy for toxoplasmosis.

Early lymphocyte transformation abnormalities in human immunodeficiency virus infection

Two hundred twelve patients with enzyme immunoassay and Western blot confirmation of human immunodeficiency virus (HIV) infection were evaluated with anergy panel, lymphocyte cell surface phenotyping, lymphocyte transformation, and serum immunoglobulins. Mitogen responses were used to develop a lymphocyte transformation index (LTI) comparing the summation of each individual's response to its normal control. By multiple regression, anergy panel, absolute CD4 level, and LTI show a progressive decline and IgA shows a progressive increase when correlated with a worsening Walter Reed (WR) classification (R = 0.84). Lymphocyte transformation is first abnormal in WR class 1, absolute CD4 in WR class 3, and anergy and serum IgA in WR class 4. The above markers are useful to assess immunologic function in HIV infection. Lymphocyte transformation abnormalities precede other immunologic deficits in HIV positive patients. Serial evaluation of these markers may help define the immunologic response and natural history of HIV infection.

Patterns of antibody recognition of selected conserved amino acid sequences from the HIV envelope in sera from different stages of HIV infection

A total of six amino acid sequences encoded in conserved regions of the HIV-env (three from gp120 and three from gp41) were selected as potential antigenic domains. These sequences (11-20 amino acids) were fused to the NH2 terminus of beta-galactosidase by recombinant DNA techniques, and the purified chimeric proteins were used to titer (by immunodots) 75 sera from HIV-infected individuals of various stages. All the HIV antigens were recognized by some or all the HIV-seropositive sera but by none of the control sera. Of the three conserved domains in gp41, two are highly immunodominant. All (100%) HIV-seropositive sera reacted with one of these immunodominant domains in titers (approximately 1:100,000) almost two orders of magnitude higher than any other tested domain. This emphasizes the diagnostic value of the epitopes (ERYLKDQLLGIWGCSGKLIC) previously (see Refs. 11 and 12) identified in this domain. A decrease in average antibody titers is observed in late stages of infection for all the antigens tested, yet distribution of antibody reactivity was independent of stage for only three of the six domains. A significantly higher proportion of reactivity of seropositive sera in early stage (62%) compared with late stage (11%) of infection was found for a domain (NVTENFNMWKN) mapped at the NH2 terminus of gp120; serum antibody reactivity with this domain also correlated with a lack of culturable HIV in blood mononuclear cells.

Specificity of polymerase chain amplification reactions for human immunodeficiency virus type 1 DNA sequences

The polymerase chain amplification reaction (PCR) is a sensitive, specific, and quantitative assay of human immunodeficiency virus type 1 (HIV-1). The assay was performed with polymerases from Escherichia coli or Thermus aquaticus (Taq). A single pair of oligonucleotide primers within the long terminal repeat (LTR) sequences were used to detect HIV-1 sequences in infected cell cultures and fresh tissues of the large majority of infected individuals. The amplified product was a faithful copy of this LTR sequence. Utilization of a subsaturating number of cycles of amplification allowed quantitation of HIV-1 DNA sequences.

A model of the spread of HIV infection and the demographic impact of AIDS

The objective of the computer simulation model described here is to project, for periods up to one or more decades, the annual incidence and prevalence of HIV infection and AIDS in a population with given epidemiological, behavioural and demorgraphic characteristics. In addition, the epidemic's impact on a range of demographic variables is calculated. The epidemiological components of the model use a compartmental approach and they are described with sets of linear differential equations. The demographic framework in which the epidemiological components are integrated, is based on a standard cohort component method of population projection. The simulated population is stratified by age, gender, sexual behaviour, marital status and infection/disease status. The concluding section provides an illustrative application of the model to a Central African population. In this hypothetical simulation covering the period from 1975 to 2000, HIV prevalence in the adult population rises from 0 to 21 per cent. By the end of the projection period mortality is about double the level that would have prevailed in the absence of the epidemic, but, owing to the very high birth rates that prevail in most of Africa, the growth rate of the population remains substantially positive.

Neutralizing antibody and clinical status of human immunodeficiency virus (HIV)-infected individuals

An assay based on inhibition of cytopathic effect of human immunodeficiency virus (HIV) strains in Molt 4 cells was developed to quantitate neutralizing antibodies (NA) in sera of HIV-infected individuals. The assay was specific and gave results comparable to those obtained by the inhibition of immunofluorescence (IFI) and reverse transcriptase (RT) activity. Attempts were made to correlate the presence and the antibody titres with the clinical status of HIV-infected individuals classified according to Walter Reed staging classification scheme. NA titres correlated inversely with the stage of HIV infection: Compared with acquired immunodeficiency syndrome (AIDS) patients, HIV-infected subjects at stage WR1 had significantly higher NA titres. Moreover, a decrease in NA titre in relation to clinical deterioration was noted in sequential sera of eight of 11 AIDS patients, retrospectively examined, for NA. The symptomless subjects showed either the same level of NA or a trend towards an increasing antibody titre with time. Different isolates of HIV strains showed a variability in the extent of sensitivity to neutralization by sera obtained from different HIV-infected individuals.

Ultrastructural findings in clinically uninvolved oral mucosa of patients with HIV infection

Twelve biopsies of clinically normal oral mucosa taken from HIV seropositive patients have been investigated by means of light- and electron microscopy. Vascular abnormalities were found in all biopsies, regardless of the clinical stage of the HIV infection. In particular slit-like vascular channels, sparseness of intercellular junctions and swollen, protruded endothelial cells with an increased quantity of Weibel-Palade bodies were noticed. These findings were similar to those described in lesions of early stage Kaposi's sarcoma.

A mathematical simulation of the AIDS patient and extracorporeal detoxification

A simple numerical simulation of AIDS patient detoxification by a hypothetical extracorporeal device for the removal of viruses, infected white cells, and syncytia has been designed. The mathematical model accounts for healthy blood white cells attacking and destroying the viruses, while at the same time the viruses attack and infect certain white cells. The infected white cells serve as a site for viral growth; eventually the cells lyse, releasing a large number of viruses into the blood stream. The healthy white cells and infected white cells combine to form syncytia, where the virus multiplies, and finally the syncytium ruptures releasing all the virus. This model can be used to predict concentrations over a specified period for the patient. This is a mathematical model to be used as a research and design tool only.

EEG discharges in WR 1-5 HIV-seropositive hemophiliacs

Human immunodeficiency virus (HIV)-seropositive patients show involvement of the central and/or peripheral nervous system. We present here the results of electroencephalographic (EEG) findings in stage WR 1-5 HIV-seropositive hemophiliacs from a total of 184 who attended our clinic prior to October 1987.

The relationship of serum IgA concentration to human immunodeficiency virus (HIV) infection: a cross-sectional study of HIV-seropositive individuals detected by screening in the United States Air Force

Serum immunoglobulins were measured in 107 patients with human immunodeficiency virus seropositivity. Each patient was categorized by the Walter Reed staging classification and serum concentrations of immunoglobulins were compared with patient staging. Serum IgM concentrations were normal in all but nine patients. Serum IgG concentrations were elevated in 74 of 107 patients, with no significant differences noted between different stages of disease severity. Serum IgA concentrations were elevated in 38 of 107 patients, with a significant relationship noted between increasing staging category and increasing serum IgA concentration (p = 0.0001). Serum IgA concentrations in patients with human immunodeficiency virus seropositivity may be a useful marker of immunologic progression of disease.

A larger spectrum of severe HIV-1--related disease in intravenous drug users in New York City

Increasing mortality in intravenous (IV) drug users not reported to surveillance as acquired immunodeficiency syndrome (AIDS) has occurred in New York City coincident with the AIDS epidemic. From 1981 to 1986, narcotics-related deaths increased on average 32% per year from 492 in 1981 to 1996 in 1986. This increase included deaths from AIDS increasing from 0 to 905 and deaths from other causes, many of which were infectious diseases, increasing from 492 to 1091. Investigations of these deaths suggest a causal association with human immunodeficiency virus (HIV) infection. These deaths may represent a spectrum of HIV-related disease that has not been identified through AIDS surveillance and has resulted in a large underestimation of the impact of AIDS on IV drug users and blacks and Hispanics.

The clinical prognosis of HIV-1 infection: a review of 32 follow-up studies

Thirty-two follow-up studies of patients with HIV-1 infection, but without AIDS at baseline, were examined for information on the risk of developing AIDS or other conditions. Disease progression in asymptomatic groups was similar to that found in patients with persistent generalized lymphadenopathy (PGL) without other symptoms. Among these asymptomatic and PGL groups, the risk of developing AIDS reached 10% to 15% between 24 and 36 months of follow up. The risk of progression to AIDS continued to increase in the studies with longer follow-up periods, reaching 36% at 88 months. However, more than 40% of "high-risk" groups (characterized by the presence of constitutional symptoms, oral thrush, herpes zoster, and/or low T4 counts) developed AIDS after only 36 months of follow-up. Reliable information about progression to other states (e.g., AIDS-related complex) has not been consistently provided.

Antibody-enhanced infection by HIV-1 via Fc receptor-mediated entry

Monocytes and macrophages, which may play a central role in the pathogenesis of infection with human immunodeficiency virus type 1 (HIV-1), express the CD4 molecule and Fc receptors (FcR) for immunoglobulin G (IgG). To explore the possibility that FcR mediate HIV-1 infection of monocytes, studies were conducted with the human monocytic cell line U937. These cells were exposed to HIV-1 complexed with various concentrations of serum from HIV-1 antibody-positive individuals and monitored for HIV-1 replication. Serum samples from antibody-negative normal individuals did not affect virus yields. High concentrations of antibody-positive sera showed virus-neutralizing activity; however, cells infected with HIV-1 in the presence of antibody-positive sera at subneutralizing concentrations significantly enhanced virus replication. This infection enhancement was blocked by heat-aggregated gamma-globulin. Moreover, the IgG fraction from an HIV-1 antibody-positive serum enhanced HIV-1 infection at the same serum dilution equivalents. In contrast, IgG-F(ab')2 did not enhance HIV-1 infection but showed neutralizing activity with HIV-1. These results are compatible with the concept of FcR-mediated infection enhancement and suggest that this immunological response to HIV-1, instead of protecting the host, potentially facilitates the infection.

The surveillance definition of the acquired immunodeficiency syndrome and the clinical classification of infection with the human immunodeficiency virus type 1

In 1982, one year after the first cases of the acquired immunodeficiency syndrome (AIDS) were reported, a case definition of AIDS was produced by the Centers for Disease Control, Atlanta, Georgia, USA. This definition was implemented world-wide, and it allowed the standardization of the reporting of cases. The identification of the virus that is responsible for AIDS, which subsequently was named the human immunodeficiency virus type 1 (HIV-1), led to the development of laboratory test procedures to detect its presence. The use of these tests confirmed that additional clinical manifestations were associated with severe outcomes of HIV-1 infection, which resulted in an increase in the number of conditions that were encompassed by AIDS. Moreover, the diagnosis of many AIDS-defining conditions could be made presumptively in the presence of proved HIV-1 infection. Thus the case definition required revision in 1985, and again in 1987. In addition, clinical expressions other than AIDS definitively were attributed to infection with HIV-1 after the widespread use of the testing procedures. The case definition of AIDS, as revised by the Centers for Disease Control in 1987, now is the current definition that is used in Australia. The clinical classification of HIV infection, which was produced by the Centers for Disease Control in 1986, was implemented in this country in January 1988.

HBV, HDV and HIV infections in 242 drug addicts: two-year follow-up

Of 242 north Italian heroin addicts, 24 (9.9%) were HBsAg positive. HBeAg was positive in two of them (8.3%), anti-HBe in 16 (66.6%) and anti-HDV in 21 (87.5%). Of the 218 HBsAg negative, 182 (83.5%) had anti-HBc, 72 (33.0%) anti-HBe and 97 (44.5%) anti-HBs. One-hundred-eighty-five drug addicts were anti-HIV positive (76.4%); 77 of these (41.6%) were asymptomatic, 93 (50.3%) had PGL and 15 (8.1%) ARC. T4+ cell count was significantly lower in subjects with ARC as was T4+/T8+ ratio in subjects with PGL and ARC. During a median follow-up of 9.5 months (range 4-25), we observed three new cases of hepatitis (two caused by NANBV and one by HBV with HDV coinfection) and one new HIV infection. Ten anti-HIV positive subjects developed PGL and one AIDS.

Human immunodeficiency virus type 1 has an additional coding sequence in the central region of the genome

Eight coding regions designated gag, pol, env, sor, R, tat, art/trs, and 3' orf have been identified in the genome of the human immunodeficiency virus type 1 (HIV-1). Several other open reading frames have the potential to encode additional viral proteins. In this study, we show that HIV-1 has another coding sequence whose product is expressed during natural infection. Unlike antibody to other HIV-1 proteins, the prevalence of antibody to the product encoded by this region is elevated in patients with acquired immune deficiency syndrome (AIDS). Because no analogous coding region has been identified in HIV-2, the antibody to the product of this coding region may serve as a marker to distinguish infection with HIV-1 from infection with HIV-2.

Mucocutaneous manifestations in patients infected with human immunodeficiency virus

The mucocutaneous manifestations observed in 516 patients infected with human immunodeficiency virus attending an outpatient clinic for acquired immunodeficiency syndrome in Milan, Italy, from July 1985 to March 1987 are listed, and the clinicopathologic aspects of these disorders are reported. The prognostic significance of some human immunodeficiency virus-associated dermatoses is also discussed.

Cutaneous manifestations of early human immunodeficiency virus exposure

After demonstrating antibodies to the human immunodeficiency virus (HIV), two hundred patients were interviewed and given a complete cutaneous and mucous membrane examination. By means of the Walter Reed Staging Classification System for HIV infection, 155 patients were classified as having Walter Reed stage 1A-2A (WR1A-WR2A) infection. The prevalence of seborrheic dermatitis in this group was 36%. There were no other significant cutaneous findings in the WR1A-WR2A patient population.

Immunomodulatory properties of cimetidine in ARC patients

The immunomodulatory potency of cimetidine, a histamine H2 receptor antagonist, was investigated in 33 AIDS-related complex (ARC) patients performing detailed immunological and clinical evaluations. Cimetidine was administered orally in daily doses of 1200 mg for a period of 5 months with an interruption of therapy after the first 3 months for an interval of 3 weeks. Significant (P less than 0.05) elevations of immunoglobulins (IgG, IgA), complement C4, B-lymphocytes, and OKT4+ (helper/inducer) cells were found after cimetidine intake. The in vitro lymphocyte proliferative response to plant mitogens was significantly increased, and the in vivo cell-mediated hypersensitivity reaction assessed by intradermal application of seven recall antigens improved significantly. These effects were both reversible with the discontinuation of cimetidine and reproducible with repeated administration of the drug. Clinical data such as performance status, body weight, and fever were influenced favorably (P less than 0.05) by cimetidine. The frequency of diarrhea and the lymph node size were also diminished significantly. The data suggest that cimetidine may at least partially restore immunofunctions in AIDS-related complex.

Immunocytochemical demonstration of human immunodeficiency virus infected cells in the cerebrospinal fluid

Although involvement of the central nervous system represents one of the most common manifestations of the acquired immunodeficiency syndrome (AIDS), a standard diagnostic test for this condition has not yet been established. At necropsy human immunodeficiency virus (HIV) has been demonstrated in brain macrophages in such patients. HIV antigen was detected in CSF macrophages by immunocytochemistry in six out of 11 HIV infected patients. In addition to the detection of intrathecal synthesis of anti-HIV antibodies this method may be suitable for early diagnosis of CNS involvement in AIDS patients.

Thymostimulin treatment in AIDS-related complex

Thirty-four patients with AIDS-related complex (ARC) were treated for 6 months with thymostimulin, a thymic hormone. Clinical and immunological findings after a 1-year follow-up were compared with those in 24 age- and sex-matched controls receiving no immunotherapy. Statistical evaluation after 6 and 12 months showed significant differences in the two groups. The thymostimulin-treated group had higher leukocyte and lymphocyte counts, more positivity in intradermal tests with multiple recall antigens, and less lymphadenopathy and weight loss. The number of OKT3+ and OKT4+ lymphocytes decreased significantly in the control group, but did not change in the thymostimulin-treated patients. Finally, after 18 months of follow-up, no progression to AIDS was seen among the treated subjects, whereas 3 of the controls developed the disease. We conclude that thymostimulin, alone or in combination with antiviral drugs, may be helpful in the management of ARC patients.

Central nervous system involvement in HIV infection

Central nervous system (CNS) involvement occurs frequently in patients with the acquired immunodeficiency syndrome (AIDS), but at present only a few reports have addressed the analysis of intrathecal IgG synthesis in human immunodeficiency virus (HIV)-seropositive patients with no signs of HIV-related neurologic syndromes. In this study, intrathecal IgG synthesis was investigated using several techniques in patients with different stages of HIV infection and then correlated with the state of the blood-brain barrier. Almost all patients had specific anti-HIV IgG synthesis within the CNS, suggesting the presence of HIV in the brain. These findings further stress that direct CNS infection occurs early in the course of systemic virus spread.

The clinical spectrum of the HIV infection. A working hypothesis

Many clinicians have realised that AIDS is only the most dreadful aspect of HIV infection. Together with the "asymptomatic carrier" condition, other syndromes have been described, including LAS, ARC and Lesser-AIDS. We have developed a working hypothesis to explain the natural history of HIV infection, basing our assumptions on the international literature and our own experience. We have found many analogies and some slight differences between the clinical courses of HIV infection and other chronic infections, especially syphilis. It is possible that, on clinical grounds, the natural histories of both diseases are so similar as to allow us to describe one of them within the scheme of the other. Only careful and prolonged clinical observation will solve the problem of the natural history of HIV infection and solve the problems which are still present in its comprehension.

Transmission of human immunodeficiency virus to sexual partners of hemophiliacs

To examine the variables associated with heterosexual transmission of human immunodeficiency virus (HIV), we studied 32 couples in our hemophilia center who had steady sexual relationships for periods more than 1 year. Of the 32 sexual partners of the hemophiliacs, five (15.6%) were HIV seropositive. All five hemophiliacs with HIV transmission to their sexual partners had measurable immunologic deficiencies, as shown by their lower median T-helper (CD-4+) lymphocyte count of 172 cells/mm3. The hemophiliacs without transmission had a slightly higher median CD-4+ count of 297 cells/mm3 (P = .26). To determine if factors other than the degree of immunologic deficiency in the hemophiliac might contribute to HIV transmission, 18 of the 32 couples were studied more intensively by confidential, coded questionnaires. Regular condom use was reported by nine couples (50%). Two of nine women (22%) without condom usage acquired HIV. One of nine women (11%) using condoms was seropositive; she also reported eight needlestick injuries while assisting her spouse with clotting factor treatments. Intravenous drug abuse was reported in two of the five couples with HIV transmission. Thus, hemophiliacs are at risk for transmitting HIV parenterally as well as venereally. Despite various risk behaviours associated with HIV transmission, the prevalence of infection in our cohort of hemophiliacs' sexual partners is low and within the range (6.8-22%) reported by others. This study underscores the need for comprehensive education and counseling in what previously appeared to be a homogeneous clinic population at risk for transmitting HIV to others.

The prevalence of AIDS-associated oral lesions in a cohort of patients with hemophilia

Oral and perioral lesions have been widely reported in homosexual males and intravenous drug abusers who are seropositive for the human immunodeficiency virus (HIV) or have acquired immunodeficiency syndrome (AIDS). Several case reports have also noted some AIDS-associated lesions among persons with hemophilia, but the prevalence of these lesions in hemophilia populations is not known. This study investigated the prevalence of oral and perioral lesions in a cohort of patients receiving care at a hemophilia treatment center. In a sample of 32 patients with a factor VIII deficiency and 5 patients with a factor IX deficiency who underwent oral examinations, more than 80% were HIV seropositive. Cervical lymphadenopathy was present in more than half of the patients who were HIV seropositive but was absent in those who were HIV seronegative. Intraoral AIDS-associated lesions were present only in patients for whom a diagnosis of AIDS had been made, indicating that oral lesions among persons with hemophilia who are HIV seropositive may be less prevalent than among homosexual males or intravenous drug abusers who are HIV seropositive.

Identification of individuals at increased risk for AIDS among clinically asymptomatic homosexuals and abusers of intravenous drugs

Immunological parameters previously shown to constitute an increased risk for progression towards AIDS have been observed in clinically asymptomatic individuals considered to be at risk for this syndrome. These parameters include severely decreased numbers of T helper cells (count below 400/mm3 blood for CD4+ cells were detected in 7 our of 33 HIV antibody-positive, asymptomatic homosexuals and in 3 out of 29 HIV antibody-positive, asymptomatic drug abusers) and elevated serum IgA and IgM levels (found in 7 to 30 percent of these subjects). Furthermore, up to 60% of risk group members showed a decreased lymphoproliferative response to tetanus toxoid as compared to only 11% of so-called low responders in the simultaneously tested healthy controls. Finally, the capacity to mount an immune response to viral glycoproteins was found to be impaired in individuals at risk for AIDS, as indicated by a low serum level of antibodies to tick-borne meningoencephalitis virus antigen in recently vaccinated subjects.

HIV persistence in monocytes leads to pathogenesis and AIDS

An hypothesis of the pathogenic mechanism leading to acquired immunodeficiency syndrome (AIDS) that places special emphasis on the potential for infected monocytes to act as the reservoir of a persistent human immunodeficiency virus (HIV) infection has been developed. Monocytes may mediate directly the infection and ultimate destruction of helper T cells; this establishes a direct relationship between antigen presentation and HIV dissemination, thus accounting for the cytopathogenic effects and immune system debilitation associated commonly with AIDS. The possibility that this mode of virus dissemination can account for the depletion of helper-T-cell subsets based on their antigen specificity is considered and may explain why the cellular immune response to the virus is ineffective. This concept and may also elucidate the role of intercurrent infections in the development of disease and it suggests mechanistic explanations for the conversion from prodromal to fulminant AIDS.

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

The three year actuarial progression rate to the acquired immune deficiency syndrome (AIDS) in a cohort of men in San Francisco who were seropositive for the human immunodeficiency virus (HIV) was 22%. An additional 26 (19%) developed AIDS related conditions. Beta 2 Microglobulin concentration, packed cell volume, HIV p24 antigenaemia, and the proportion and number of T4 lymphocytes each independently predicted progression to AIDS. Beta 2 Microglobulin was the most powerful predictor. The 111 subjects tested who were normal by all predictors (40%) had a three year progression of 7%, and the 68 subjects who were abnormal by two or more predictors (24%) had a progression rate of 57%. Two thirds of all men who progressed to AIDS were in the last group. The median T4 lymphocyte count in subjects who did not progress to AIDS fell from 626 x 10(6) to 327 x 10(6)/l. HIV p24 antigenaemia developed in 7% of the subjects per year. The proportion who were abnormal by two or more predictive variables rose to 41%. At three years an estimated two thirds of the seropositive subjects showed clinical AIDS, an AIDS related condition, or laboratory results that were highly predictive of AIDS. It is concluded from the observed rates and the distribution of predictive variables at three years that half of the men who were seropositive for HIV will develop AIDS by six years after the start of the study, and three quarters will develop AIDS or an AIDS related condition.

Spontaneous in vitro production of virus-specific antibody by lymphocytes from HIV-infected subjects

In vitro synthesis of IgG directed against HIV components was detected by ELISA and Western blot assay of lymphocyte culture supernatants. Lymphocytes from HIV-infected individuals spontaneously produced antibody against HIV proteins very early in culture, suggesting in vivo activation of HIV-specific antibody-forming cells. The frequency of circulating B cells spontaneously secreting HIV-specific IgG was very high in some cases, but spontaneous HIV-specific antibody synthesis was not accompanied by polyclonal reactivation of B-cell clones of different specificity. The pattern of specificity of the anti-HIV antibody produced in vitro did not reflect the serum pattern consistently. These findings indicate a new approach potentially useful for the study of the immunobiology of HIV infection. The possible implications of the in vitro production of HIV-specific antibody for the diagnosis, prognosis and clinical management of this infection are also discussed.

Peripheral blood mononuclear cell abnormalities and their relationship to clinical course in homosexual men with HIV infection

Quantitative abnormalities of leukocyte subpopulations have been shown to correlate with clinical status in human immunodeficiency virus (HIV) infection. We have performed peripheral blood leukocyte phenotyping in 23 HIV-seropositive homosexual men, and correlated the results with clinical follow-up information. Individuals with CD4+ greater than 400/mm3 (Group 1) had less severe abnormalities in other mononuclear cell subpopulations than patients with CD4+ less than 400/mm3 (Group 2). Group 1 had decreased CD4+CDw29+ (B-cell inducer) cells, compared to HIV-seronegative homosexual controls, with normal CD4+CD45R+ (suppressor-inducer) cells, suggesting that CD4+ subpopulations are reduced at different rates. Group 2 had decreased counts for both CD4+CDw29+ and CD4+CD45R+ cells. Both groups had increased cytotoxic T cells (CD8+CD11b-), with decreased B cells and CD4+/CD8+ ratios, compared to HIV-seronegative homosexual controls. The Group 2 patients with subsequent clinical deterioration had particularly low CD4+ cells, CD4+CD45R+ cells, CD2+Ta1+ cells, and CD4+/CD8+ ratios and high CD8+CD11b- cells, compared to those with clinically stable illness. Our findings suggest that specific leukocyte subpopulations are altered differentially at various stages of HIV infection. However, the study involved only quantitative measurements of specific T- and B-cell subsets with no attempt to measure in vitro function. It is of course possible that normal numbers of cells in these subpopulations might be functionally deficient.

Current problems in the management of AIDS patients

Human immunodeficiency virus infection has numerous clinical manifestations and affects patients from a broad spectrum of social, ethical, cultural and psychological backgrounds. As a result the practising physician has to face multiple, recurrent and complicated problems. This review focuses on the means of early diagnosis, treatment and prevention of opportunistic infections. It also stresses the need for a comprehensive multidisciplinary approach to provide optimal care and to diminish the sense of frustration in treating young patients with an ultimately fatal disease.