Natural history of acquired immunodeficiency syndrome in women in Rhode Island

The relationship between alcohol use and anxiety and retrospective attendance of primary care visits among women with human immunodeficiency virus

In this retrospective study, we sought to determine the associations between alcohol use and anxiety and RIC among WHIV. Alcohol use was assessed using the Timeline Follow-back to measure use over the 90 days preceding the interview. Anxiety symptoms scores, assessed with the Hospital Anxiety and Depression Scale- Anxiety Subscale (HADS-A). Primary care visits over twelve months prior to the interview were collected from clinic registration records. We used three logistic mixed models, adjusting for age, race, education, cocaine use, depression, viral load, and antiretroviral therapy (ART) status. Among 364 WHIV, mean attendance of primary care visits was 63.9%. Every one-day increase in drinking days (OR = 0.99, 95% CI 0.99, 1.00) or heavy drinking days (OR = 0.99, 95% CI 0.90, 1.00) was associated with decreased odds of attending primary care visits (P = 0.02). Moderate/severe anxiety scores, compared to minimal anxiety scores, were associated with decreased odds of attending primary care visits (OR = 0.69, 95% CI 0.50, 0.97). Cocaine use was associated with decreased odds of attending primary care visits (OR 0.56, 0.57). Our findings indicate that identifying and treating WHIV with alcohol use (especially heavy drinking), moderate/severe anxiety symptoms and/or cocaine use could potentially improve their RIC.

Current treatment options for vulvovaginal candidiasis

For practitioners, selecting successful therapy for vulvovaginal candidiasis is anything but trivial. The dominant problem; however, lies not with selecting the correct antimycotic agent, but with making the correct diagnosis and not treating non-yeast infections and noninfections as yeast-induced. Moreover, not all cases of vulvovaginal candidiasis are equal and practitioners owe patients the obligation of selecting appropriate therapy based upon the specific type and severity of vulvovaginal candidiasis. Uncomplicated candidiasis is readily treated with short-term oral or topical therapy, whereas complicated candidiasis needs additional strategies using the plethora of therapies available. Problematic refractory cases still abound and the pipeline for new, more potent antifungal agents is largely empty. Management strategies for complicated Candida vaginitis are discussed.

Vulvovaginal candidosis

Despite therapeutic advances, vulvovaginal candidosis remains a common problem worldwide, affecting all strata of society. Understanding of anti-candida host defence mechanisms in the vagina has developed slowly and, despite a growing list of recognised risk factors, a fundamental grasp of pathogenic mechanisms continues to elude us. The absence of rapid, simple, and inexpensive diagnostic tests continues to result in both overdiagnosis and underdiagnosis of vulvovaginal candidosis. I review the epidemiology and pathogenesis of this infection, and also discuss management strategies.

Correlates of HIV infection among former blood/plasma donors in rural China

BACKGROUND

In 1995, when the first cases of HIV infection were reported among former plasma donors (FPDs), the Chinese government closed all commercial plasma collection stations.

OBJECTIVE

To determine the prevalence of HIV among FPDs and non-donors in affected villages in Anhui, China.

METHODS

A cross-sectional survey was conducted among residents, aged 25-55 years, in 40 villages randomly selected from villages with many former blood/plasma donors, using a two-stage clustered sampling method. A questionnaire was administered face-to-face to 1997 villagers without collecting any identifying information, and venous blood specimens were collected for HIV testing with two enzyme-linked immunosorbent assays and western blotting. EpiData was used for data entry, and STATA was used for data analysis.

RESULTS

Overall HIV prevalence was 10.8%, with values of 15.1% among FPDs and 4.8% among non-donors. Among FPDs, factors associated with HIV infection included: donating plasma more than 10 times [odds ratio (OR) 4.09; P < 0.001] compared with subjects who donated 1-3 times; spouse being HIV-positive (OR, 4.06; P = 0.001); and being male (OR, 2.04; P = 0.011). Condom use was rare, and was not associated with HIV infection (OR, 1.09; P = 0.872). Among non-plasma donors, spouse being HIV-positive (OR, 11.07, P < 0.001) and having multiple sexual partners (OR, 7.04; P = 0.006) were associated with HIV infection.

CONCLUSIONS

The prevalence of HIV infection is high among rural residents in villages with former commercial plasma businesses. Plasma but not blood donations were associated with HIV infection. The HIV/AIDS epidemic has spread to non-donors primarily through sexual transmission. HIV/AIDS education, testing, and condoms should be promoted urgently to prevent further transmission.

Cutaneous markers of HIV infection

Despite the development of laboratory methods, dermatological symptoms are a basic index of the presence and physical course of HIV infection. HIV infection usually undergoes a long latent period, proceeds to a period of immunodeficiency-related symptoms, and ends in an advanced immunodeficiency state characterized by opportunistic infections and neoplasms. Occasionally, dermatological manifestations can be the first signs of asymptomatic disease, indices of advanced immunodeficiency, or symptoms of opportunistic infections or neoplasms. The variety of symptoms and signs for the skin during the course of HIV infection is a consequence of the progressing immunodeficiency and therefore indicates the underlying disorder. The use of these manifestations is a challenge for clinical praxis.

Treatment of vaginal Candida infections

Candida vaginitis is most commonly caused by Candida albicans (> 85%) with little evidence of an increase in vaginitis due to non-C. albicans species. Epidemiological studies are no longer possible in the US in the era of self-diagnosis and -treatment by women empowered by the availability of over-the-counter antimycotics. A new classification of vulvovaginal candidiasis into uncomplicated and complicated vaginitis has simplified choice and duration of antifungal therapy. Vaginitis due to C. albicans responds well to available therapy. In contrast, vaginitis due to Candida glabrata is associated with a high treatment failure rate. Candida vaginitis infection rates in HIV-positive women remain undetermined and reports of refractory fungal vaginitis have not been substantiated. In spite of the wide array of antifungal agents currently available, considerable limitations in available therapy exist in the effective management of complicated vaginitis.

Gynecologic infections in human immunodeficiency virus-infected women

The maturation of the acquired immunodeficiency syndrome epidemic has now claimed more than 12 million women worldwide, the majority in undeveloped countries where human immunodeficiency virus (HIV) and sexually transmitted infections coexist and interact synergistically. Among HIV-infected women, there is excessive morbidity due to sexually transmitted diseases (STDs) and gynecologic disorders. This review summarizes the expanding understanding of vaginal flora, vaginitis, cervicitis, pelvic inflammatory disease, and genital ulcer disease in HIV-infected women. In addition to the altered clinical course, complications, and management difficulties of STDs, some gynecologic infections may influence HIV transmission as well as the vertical transmission of HIV to the newborn. Finally, severe immunodeficiency allows unusual opportunistic pathogens to invade the upper and lower genital tract. Control and prevention of gynecologic infections in HIV-positive and HIV-negative women are key components to preventing further HIV transmission.

Epidemiology of respiratory infectious diseases

Respiratory infections are a frequent burden to health despite the fact that cost-effective methods for their prevention and cure are available. Acute respiratory infections in children under 5 years of age are the most frequent cause of death from lung disease globally, causing more than 4 million deaths annually. Tuberculosis is the most frequent cause of death from a single pathogen in persons aged 15 to 49 years (a total of 2 million to 3 million deaths annually). Respiratory infections are the most frequent complications of immune deficiency (whether due to HIV infection or induced by chemotherapy). Where a "carrier state" occurs (as with many bacterial pathogens), the level of immune function is the key determinant in appearance of disease. Where there is no carrier state (as with many viruses), exposure is the key determinant. Characteristics of the pathogen, including virulence and bacterial load where there is a carrier state, also determine the probability of respiratory infections. Modifiers of these determinants include allergy and toxic exposures including tobacco smoke and ambient pollution.

Prevalence and incidence of gynecologic disorders among women infected with human immunodeficiency virus

OBJECTIVE

Our purpose was to ascertain the prevalence, incidence, and predictors of gynecologic disorders among women infected with human immunodeficiency virus.

STUDY DESIGN

We serially assessed 292 women infected with human immunodeficiency virus and 681 uninfected women. Outcomes were incidence and prevalence of sexually transmitted diseases, viral shedding, findings of Papanicolaou smears, fungal infections, and menstrual disorders.

RESULTS

Women infected with the virus were more likely to have prevalent vulvovaginal candidiasis (odds ratio 1.80, 95% confidence interval 1. 0-3.25, P =.05), oncogenic human papillomavirus (odds ratio 3.79, 95% confidence interval 2.43-5.91, P =.001), abnormal Papanicolaou smears (odds ratio 5.40, 95% confidence interval 3.35-8.78, P =.001), amenorrhea (4.8% vs 0%, P =.05), positive results on Treponema pallidum hemagglutination assay (odds ratio 1.83, 95% confidence interval 1.16-2.88, P =.01), infection with cytomegalovirus (odds ratio 4.2, 95% confidence interval 1.82-10.62, P =.001), and genital warts (odds ratio 6.93, 95% confidence interval 3.16-16.30, P =.001) but were less likely to have Chlamydia trachomatis infection (odds ratio 0.28, 95% confidence interval 0.10-0.66, P =.01). Annual incidence rates among women infected with human immunodeficiency virus were 4.0% for candidiasis, 22.0% for oncogenic human papillomavirus, 11.4% for genital warts, 1.7% for infection with C trachomatis, 1.7% for infection with Neisseria gonorrhoeae, 10.3% for Trichomonas vaginalis, 1.1% for positive results on T pallidum hemagglutination assay, 7.4% for an abnormal Papanicolaou smear, and 10.9% for infection with herpes simplex virus. Overall, 46.9% had at least 1 incident condition. Women infected with human immunodeficiency virus were more likely to have incident oncogenic human papillomavirus infection (odds ratio 2.0, 95% confidence interval 1.01-3.8), abnormal Papanicolaou smears (odds ratio 7.76, 95% confidence interval 2.08-42.8), and genital warts (odds ratio 9. 32, 95% confidence interval 3.04-38.0). Incidence and prevalence of sexually transmitted diseases and oncogenic human papillomavirus infection increased with increased CD4(+) cell counts.

CONCLUSIONS

Women infected with the human immunodeficiency virus are significantly more likely to have prevalent and incident gynecologic disorders but not disorders related to risk taking (eg, incident sexually transmitted diseases). The latter disorders increased in women with CD4(+) cell counts >500 cells/mm3. Clinicians should be aware of these patterns so that they can provide appropriate evaluation and treatment of gynecologic disorders.

Women and HIV. Epidemiology and global overview

The global HIV-1 epidemic in women continues to expand at an alarming rate. More than 11 million women are currently estimated to be HIV-infected, with the majority living in sub-Saharan Africa. The primary risk factor for HIV infection in women is unprotected heterosexual intercourse. Several cofactors may influence a woman's risk for HIV acquisition. These include the presence of other STDs, the prevalence of HIV in the population, engagement in high-risk sexual behaviors at a young age, an increased number of sexual partners, HIV illness severity in an infected partner, host immunogenetic responses, hormonal and other local effects in the female genital tract, and viral characteristics. The general clinical findings in women with HIV disease are similar to those in HIV-infected men. Some studies have noted higher rates of esophageal candidiasis and decreased rates of Kaposi's sarcoma in women when compared with men. Overall disease progression and survival in women and men are similar once an adjustment is made for other important risk factors such as the time of seroconversion, the receipt of antiretrovirals, and baseline CD4 cell counts. Women with HIV have a high frequency of a number of diseases of the reproductive tract, including low-grade cervical dysplasia and vulvovaginal candidiasis. Despite progress in understanding the risk factors for HIV transmission to women and the variables related to disease progression, major research questions remain. These include the role of hormonal contraceptives in the risk for HIV acquisition, the primary mechanism of infection, and host systemic as well as local hormonal and immune responses in the female reproductive tract that may alter the risk of HIV infection. Over the next decade, it is anticipated that the quality of life and length of survival will improve dramatically for both HIV-infected women and men in settings in which new highly active combination antiretroviral therapy is available and affordable. Unfortunately, in most of the world, these antiretroviral drugs are not available for the treatment of the vast numbers of individuals infected by HIV. Therefore, development of successful strategies for primary prevention of HIV infection in women must be a top public health priority.

Natural history of HIV infection in women

Women represent the fastest growing group of adults with AIDS, and poor African-American and Latina women are disproportionately affected. There are differences in the clinical presentation of HIV symptoms in women. Although disease progression seems to be similar for women and men, women with HIV infection seem to have a higher mortality rate than men. Gender, racial, and class differences in access to care may account for this. Phases of the natural history of HIV infection in women are reviewed and include prevention opportunities, acute infection, viral and immunologic parameters of pathogenesis, therapeutic plans, and terminal care.

Molecular epidemiology of mucosal candidiasis in HIV-positive women

Mucosal candidiasis is a common complication of HIV infection and HIV-positive women may develop both oropharyngeal and vaginal disease. Colonization with Candida albicans and related species at either site is a common preceding event in asymptomatic women. To examine the molecular epidemiology of colonizing yeast strains in HIV-positive women, concurrent oropharyngeal and vaginal cultures were obtained from 32 women (mean CD4 count 392 cells/mm3, range 0-1319). Positive oropharyngeal cultures were obtained in 18 (56%) and positive vaginal cultures in 10 (31%). Candida species were isolated from both sites simultaneously in nine (28%) women. All strains were evaluated for restriction fragment length polymorphisms (RFLPs) at the ribosomal DNA locus (using a heterologous 8.4-kb NotI probe from H. capsulatum) and with a C. albicans-specific repetitive DNA probe. Isolates were grouped into three classes by the NotI probe and then members of each class were evaluated with the C. albicans-specific probe. Isolates were subsequently evaluated by random amplified polymorphic DNA (RAPD) PCR with four arbitrary primers to detect strain-specific differences. All isolates tested were unique and could be discriminated by RFLP or RAPD PCR. Vaginal and oropharyngeal isolates from the same individual in all nine cases were dissimilar, suggesting that the dominant strain of Candida colonizing different body sites is different. These findings suggest that the epidemiology of Candida infection in HIV disease is complex, that the development of oropharyngeal and vaginal disease may be disassociated, and that HIV-positive patients are each infected by their own unique strains of Candida.

Health-related quality of life of HIV-infected women: evidence for the reliability, validity and responsiveness of the Medical Outcomes Study Short-Form 20

The purpose of this study was to assess the reliability, validity and responsiveness of a health-related quality of life (HRQOL) instrument, the Medical Outcomes Short-Form 20-Item General Health Survey (MOS SF-20), in a sample of women with the human immunodeficiency virus (HIV). Longitudinal data were collected on 202 HIV-infected women without AIDS who were receiving care at Kings County Hospital or SUNY Health Sciences Center, Brooklyn, New York. Internal consistency results showed acceptable reliability for the four multi-item MOS scales (role function, physical function, general health perceptions and mental health). Symptomatic patients and patients with lower Karnofsky Performance Status (KPS) ratings reported lower HRQOL than those who were asymptomatic or who had higher KPS scores. Patients who were older, unemployed or who had a history of injection drug use (IDU) also reported lower HRQOL than those who were younger, employed or who had no drug use history. Adjusted mean scores on the MOS role and physical functioning scales proved sensitive to differences in clinical status over time. The MOS SF-20 is a reliable and valid instrument of HRQOL for women with HIV infection. Its sensitivity to differences in clinical status over time suggest that it may be useful as an HRQOL indicator for HIV/AIDS clinical trials.

HIV disease progression in 854 women and men infected through injecting drug use and heterosexual sex and followed for up to nine years from seroconversion. Italian Seroconversion Study

OBJECTIVE

To compare the progression of HIV-1 infection in men and women followed up for up to nine years after an accurately estimated date of seroconversion.

DESIGN

Prospective observational study.

SETTING

16 HIV outpatient clinics across Italy.

SUBJECTS

321 women and 533 men infected with HIV through injecting drug use or heterosexual sex and with accurately estimated dates of seroconversion.

MAIN OUTCOME MEASURES

Progression to severe CD4 lymphocytopenia (CD4 lymphocyte count < 200 x 10(6)/l), development of AIDS defining diseases, and death from AIDS.

RESULTS

Thirty two women and 67 men developed AIDS at Kaplan-Meier progression rates of 25% (95% confidence interval 13.8% to 35.5%) and 23% (15.6% to 30.4%), respectively, 7 years after seroconversion. In a Cox proportional hazards model the relative hazard was 0.93 (that is, a slightly lower hazard in women) before and 1.10 (0.70 to 1.72) after adjusting for age, HIV exposure group, and year of seroconversion. When CD4 lymphocytopenia and death from AIDS were used as end points the results were similar, with adjusted relative hazards of 0.95 (0.63 to 1.42) and 0.72 (0.48 to 1.79) respectively. In both women and men the risk of developing AIDS before the CD4 lymphocyte count had declined below 200 x 10(6)/l was small (3% in women, 6% in men). The estimated median count at which AIDS developed in women (34 x 10(6)/l; 10 x 10(6) to 44 x 10(6)) was similar to that for men (44 x 10(6)/l; 22 x 10(6) to 60 x 10(6)).

CONCLUSION

There seems to be little evidence for appreciable differences in the natural course of HIV infection between men and women followed up from the time of seroconversion.

Controversial aspects in the management of vulvovaginal candidiasis

Numerous highly effective topical vaginal antimycotic agents are available that provide high cure rates with a favorable therapeutic side effect ratio. Recently three oral systemic azole agents have been added. Therapeutic options afford the opportunity of customizing therapy to achieve optimal cure rates. At the same time, several new complex issues have appeared that constitute new challenges to successful management, such as women with human immunodeficiency virus infection and infection caused by non-albicans Candida species and resistant strains of Candida albicans.

The AIDS epidemic

The nature of the clinical presentation of HIV infection continues to evolve over time. New cutaneous (e.g., seborrheic dermatitis, onychomycosis, and tinea pedis) and systemic (e.g., Aspergillus fumigatus and Penicillium marneffei) opportunistic fungal infections can now be added to the classic clinical markers for progressive HIV infection, such as Kaposi's sarcoma, Pneumocystis carinii pneumonia, Mycobacterium avium intercellulare infections, and cryptococcal meningitis. The fact that the appearance of many of these fungal diseases is directly correlated with the patient's CD4 cell count is a valuable tool for ongoing clinical evaluation. Although systemic manifestations characterize a progression from asymptomatic HIV infection to AIDS, many of the signs of disease progression are cutaneous. Prophylaxis against many of the potentially life-threatening systemic opportunistic infections associated with HIV positivity has had a positive impact on the life expectancy of patients with AIDS.

Clinical and microbiological characteristics of symptomatic vulvovaginal candidiasis in HIV-seropositive women

OBJECTIVES

To evaluate the clinical and microbiological characteristics of symptomatic vaginal candidiasis in Human Immunodeficiency Virus (HIV)-seropositive women attending a gynaecologic outpatient clinic for sexually transmitted diseases (STDs).

DESIGN

Vaginal, rectal and oral specimens from cases and controls were cultured for Candida spp.

SUBJECTS

Eighty-four consecutive HIV-seropositive and 384 HIV-seronegative women with clinical signs of vulvovaginitis.

SETTING

A gynaecological out-patient clinic in Pavia, Italy.

RESULTS

The overall prevalence of vaginal candidiasis was 61.9% (52/84) in the cases and 32.3% (124/384; p < .001) in the controls. After adjustment by logistic regression analysis for confounding factors (age at first intercourse, lifetime sex partners, new partner/s in the last 6 months, type of contraceptive used), HIV-seropositive patients were at higher risk for both Candida albicans (odds ratio = 2.5; 95% confidence interval 1.31-4.69; p = 0.006) and Torulopsis glabrata vaginitis (OR = 3.5; 95% CI = 1.05-11.60; p = 0.04) than controls. HIV-seropositive subjects had also increased rates of oral and rectal colonisation with Candida spp. Finally, the time to recurrence of vaginal infection was significantly shorter in HIV-seropositive patients than controls and was correlated with the severity of HIV-induced immunodepression.

CONCLUSIONS

Vulvovaginal candidiasis is very common in HIV-seropositive women and its prevalence is correlated with the immunological status of the host. These patients have higher frequencies of Torulopsis glabrata vaginal infection and are more prone to recurrence than HIV-seronegative controls.

Women and AIDS

The number and proportion of women infected with the human immunodeficiency virus (HIV) and with the acquired immunodeficiency syndrome (AIDS) have increased rapidly throughout the last decade. Despite these increases, the scientific community has focused limited research attention on women living with HIV infection. Data from studies of predominantly gay/bisexual men may not reliably be extended to women; studies of the natural history of HIV infection in women are needed. Obstetrician-gynaecologists are increasingly called upon to diagnose HIV infection in women and provide care in both clinical and research settings. In this review we discuss the serodiagnosis of HIV infection in women; the impact of pregnancy on HIV disease progression; transmission of HIV infection from mother to offspring; gynaecological infections and malignancies which may manifest differently in HIV-infected women; and clinical care of women living with HIV.

Psychoneuroimmunological aspects of disease progression among women with human papillomavirus-associated cervical dysplasia and human immunodeficiency virus type 1 co-infection

OBJECTIVE

Psychosocial associations have been observed with level of cervical dysplasia or "pre-cancer" and invasive cervical cancer [related to human papillomavirus (HPV) infection]. Psychoneuroimmunological relationships have been observed in human immunodeficiency virus type 1 (HIV-1) infection, which is being described in an increasing number of women. Our objective was to review these relationships regarding effects that might be expected in HIV-1 and HPV co-infected women.

METHOD

This review was based on a Medline literature search supplemented by a manual search of selected journals unrepresented in that database.

RESULTS

Relationships of psychosocial factors and level of cervical dysplasia were similarly observed with reference to immunological and health status in asymptomatic and early symptomatic HIV-1 infected homosexual men, suggesting that a potentiating effect may occur in HIV-1 and HPV co-infected women. Consistency of relationships across studies appeared to be enhanced by the use of a biopsychosocial model integrating the effects of life stressors, social support and coping style as well as psychiatric disorders.

CONCLUSIONS

Research is indicated on the relationships between psychosocial factors, immunological status and clinical health status in this group of women. Because of the high prevalence of psychosocial risk factors for chronic psychological distress in these women and the known immunological and health status decrements occurring with progression of these two infections, a clinical screening program based on the biopsychosocial model is recommended as a means of secondary prevention. If effective in generating treatment referrals, such a program would likely improve quality of life and could aid in the determination of relationships with immunological and health status as well.

AIDS: Part II

Great strides have been made in the therapy of human immunodeficiency virus (HIV) infection. Currently approved drugs include zidovudine and didanosine. A third drug, dideoxycytidine (zalcitibine), has recently been filed for approval with the Food and Drug Administration. All these drugs work through inhibition of the reverse transcriptase enzyme. Zidovudine is the only drug that has shown clinical efficacy against HIV. Treatment of patients with advanced HIV disease (i.e., acquired immune deficiency syndrome [AIDS] or symptomatic infection with < 200 CD4+ lymphocytes per mm3), results in a prolongation and improved quality of life. Zidovudine is the only antiretroviral agent approved for the treatment of asymptomatic patients. Early intervention with zidovudine has been shown to delay progression to AIDS when patients' CD4+ lymphocyte counts decline to less than 500/mm3, irrespective of clinical signs or symptoms of HIV infection. Didanosine is currently indicated for the treatment of patients with advanced HIV disease who are intolerant to or failing zidovudine therapy. The major toxicity of zidovudine is bone marrow suppression with anemia and granulocytopenia (which occurs in from 1% to 45% of patients, depending on the clinical stage of disease and the dose of the drug). Didanosine and zalcitibine have both been associated with a severe peripheral neuropathy, which is generally reversible on cessation of the drug. In addition, didanosine has been implicated as a cause of pancreatitis that has been fatal in a small percentage of cases. The toxicities of didanosine and zalcitibine range from 1% to 10%, depending on dose, duration of therapy, and the presence of underlying HIV-related peripheral neuropathy or a previous history of pancreatitis. The clinical hallmark of HIV infection is the development of opportunistic infections and malignancies, which are a consequence of the profound immunodeficiency. The risk of an opportunistic infection increases significantly as the T-helper lymphocyte count declines to less than 20%, or 200 to 250/mm3. The spectrum of opportunistic infections ranges from viruses to protozoa. Patients with advanced HIV disease are also at increased risk of infection with nonopportunistic, community-acquired pathogens. Primary and secondary prophylaxis against the most common AIDS-defining opportunistic infection, Pneumocystis carinii pneumonia, is now recommended. Studies are currently underway to determine the efficacy of prophylaxis against other opportunistic pathogens. Treatment of opportunistic infections associated with AIDS has improved significantly over the past 5 years as new drugs and combination regimens of antimicrobials have been developed.(ABSTRACT TRUNCATED AT 400 WORDS)

Survival and disease progression in human immunodeficiency virus-infected women after an index delivery

OBJECTIVE

Our objective was to provide information on survival and disease progression in human immunodeficiency virus antibody-positive pregnant women undergoing prospective evaluation.

STUDY DESIGN

After an index delivery, 103 human immunodeficiency virus antibody-positive pregnant women were identified and underwent follow-up for 3 years. The patients were assessed medically and/or gynecologically when hospitalized for a human immunodeficiency virus-related illness or at each follow-up visit. The life-table method was used to estimate the cumulative probabilities of survival and remaining free of acquired immunodeficiency syndrome. Cox's proportional-hazards analyses were used to identify prognostic factors for survival and progression to acquired immunodeficiency syndrome.

RESULTS

The majority of human immunodeficiency virus-infected pregnant women were alive 3 years later. Lymphadenopathy syndrome or herpes genitalis was significantly associated with a subsequent diagnosis of acquired immunodeficiency syndrome. Of the 103 original patients, six had acquired immunodeficiency syndrome at the index delivery and acquired immunodeficiency syndrome developed in 24. Approximately 94% of evaluable patients with development of acquired immunodeficiency syndrome had CD4-lymphocyte counts < 200/mm3. The most common opportunistic infection was Pneumocystis carinii pneumonia. Acquired immunodeficiency syndrome and postpartum zidovudine therapy were independent prognostic factors affecting survival.

CONCLUSION

Survival was affected by Centers for Disease Control group status of human immunodeficiency virus infection at the index delivery.

HIV-positive women: reasons they are tested for HIV and their clinical characteristics on entry into the health care system

STUDY OBJECTIVE

To describe the reasons for the HIV testing of HIV-positive women and their clinical presentation and to make specific laboratory comparisons between women intravenous drug users (IVDUs) and non-IVDUs who were heterosexually infected (HTs).

DESIGN

Consecutive case series.

SETTING

Four primary care sites associated with the Brown University AIDS Program.

PARTICIPANTS

140 consecutive HIV-seropositive women.

RESULTS

The most common reason for HIV testing in both groups was self-perception of risk. Presenting T-helper lymphocyte counts, leukocyte counts, and hematocrits did not differ significantly between the groups. Intravenous drug users were significantly more likely than HTs to have evidence of hepatitis B virus exposure (p less than 0.0001) and to report the history of a sexually transmitted disease (p = 0.005). Twenty percent of HTs versus 10% of IVDUs were tested only after they had HIV-related symptoms. The most frequent clinical presentation for both groups was Centers for Disease Control Group IV/A constitutional symptoms.

CONCLUSIONS

Many HIV-seropositive women do not enter the health care system until they are symptomatic, but those infected heterosexually and those using parenteral drugs have similar laboratory indices at presentation. AIDS education strategies toward all women at risk must include information about manifestations of HIV disease in women, as well as preventive measures, to ensure early access to the health care system.

Hierarchical pattern of mucosal candida infections in HIV-seropositive women

PURPOSE

Candida is the most common cause of opportunistic mucosal infections in human immunodeficiency virus (HIV)-positive women. We had observed an apparent correlation between the severity of immunodeficiency and the site of mucosal candida infection. The current study was designed to determine whether significant correlations existed between the sites of mucosal candida infection and the degree of immunodeficiency, as determined by subsets of lymphocyte populations.

PATIENTS AND METHODS

The subjects in this study are 66 HIV-seropositive women evaluated by members of the Brown University Acquired Immunodeficiency Syndrome (AIDS) Program during the 3-year period, September 1, 1986, through August 30, 1989. All patients had thorough clinical evaluations and relevant laboratory studies at defined intervals. All patients with CD4 lymphocyte counts below 0.2 X 10(9)/L received zidovudine therapy as soon as it became available. After July 1988, all patients with CD4 counts below 0.2 X 10(9)/L received prophylaxis against Pneumocystis carinii pneumonia. All patients were counseled about HIV infection, its modes of transmission, and the early symptoms of opportunistic infections.

RESULTS

The longitudinal data demonstrated that candida often infected vaginal mucosa when there was no significant reduction in CD4 lymphocyte counts. Candida infection of the oropharyngeal mucosa was associated with highly significant reductions in CD4 lymphocyte counts. Esophageal candidiasis occurred only with advanced immunodeficiency associated with CD4 counts below 0.1 X 10(9)/L.

CONCLUSIONS

Candida mucosal infections occur in a hierarchical pattern in women with HIV infection. Determination of the basis for the differences in susceptibility to candida of the vaginal, oropharyngeal, and esophageal mucosal surfaces will require further studies.

Trends and patterns of opportunistic diseases in Danish AIDS patients 1980-1990

We analysed the AIDS-defining diseases in all 618 notified AIDS patients in Denmark by June 30, 1990, and looked for trends and associations over time. Pneumocystis carinii pneumonia (PCP) was the most commonly reported disease (47%), and showed some but insignificant changes over time. The number of patients reported with Kaposi's sarcoma (KS) declined significantly from 33% in 1980-84 to 12% in 1990. KS was reported 5 times as often in homosexual men as in all other AIDS patients while esophageal candidiasis was reported in one fifth of the patients and were reported twice as often in women as in homosexual men. Wasting and HIV encephalopathy were 2.5 times more often reported in women than in homosexual men. The overall survival rate was 56% (95% confidence interval: 51-61%) at 1 year and 21% (95% confidence interval: 15-28%) at 3 years. Significantly improved survival over time was observed in patients diagnosed with PCP. Patients reported with KS had a significantly better prognosis than those with PCP. Women in general had a bad prognosis.