Alcoholism and rapid progression to AIDS after seroconversion

Neutropenia during HIV infection: adverse consequences and remedies

Neutropenia frequently occurs in patients with Human immunodeficiency virus (HIV) infection. Causes for neutropenia during HIV infection are multifactoral, including the viral toxicity to hematopoietic tissue, the use of myelotoxic agents for treatment, complication with secondary infections and malignancies, as well as the patient's association with confounding factors which impair myelopoiesis. An increased prevalence and severity of neutropenia is commonly seen in advanced stages of HIV disease. Decline of neutrophil phagocytic defense in combination with the failure of adaptive immunity renders the host highly susceptible to developing fatal secondary infections. Neutropenia and myelosuppression also restrict the use of many antimicrobial agents for treatment of infections caused by HIV and opportunistic pathogens. In recent years, HIV infection has increasingly become a chronic disease because of progress in antiretroviral therapy (ART). Prevention and treatment of severe neutropenia becomes critical for improving the survival of HIV-infected patients.

Alcohol abuse and HIV infection: role of DRD2

According to a survey from the HIV Cost and Services Utilization Study (HCSUS), approximately 53% of HIV-infected patients reported drinking alcohol and 8% were classified as heavy drinkers. The role of alcohol as a risk factor for HIV infection has been widely studied and recent research has found a significant association between heavy alcohol consumption and lower levels of CD4 T cells among HIV-infected alcoholics. Although there is evidence on the role of alcohol as a risk factor for HIV transmission and disease progression, there is a need for population studies to determine the genetic mechanisms that affect alcohol's role in HIV disease progression. One of the mechanisms of interest is the dopaminergic system. To date, the effects of dopamine on HIV neuroimmune pathogenesis are not well understood; however, dopaminergic neural degeneration due to HIV is known to occur by viral invasion into the brain via immune cells, and modulation of dopamine in the CNS may be a common mechanism by which different types of substances of abuse impact HIV disease progression. Although previous studies have shown an association of D(2) dopamine receptor (DRD2) polymorphisms with severity of alcohol dependence, the expression of this allele risk on HIV patients with alcohol dependence has not been systematically explored. In the current study, DRD2 Taq1A and C957T SNP genotyping analyses were performed in 165 HIV-infected alcohol abusers and the results were examined with immune status and CD4 counts.

Patterns of substance use among a large urban cohort of HIV-infected men who have sex with men in primary care

The present study sought to identify characteristics of HIV-infected MSM that are associated with the use of specific substances and substance abuse in general. Participants were 503 HIV-infected MSM who were receiving primary care. A self-assessment and medical records were used to obtain information about past 3-month alcohol and drug use and abuse, and demographics, HIV-disease stage and treatment, sexual risk, and mental health. Associations of these four domains with substance use and abuse outcomes were examined using hierarchical block-stepwise multivariable logistic regression. Substance use and abuse in the sample was high. Transmission risk behavior was significantly associated with over half of the outcomes. The associations of demographic and HIV-disease stage and treatment variables varied by substance, and mental health problems contributed differentially to almost every outcome. These findings should be considered for designing, implementing, and evaluating substance use programming for HIV-infected MSM.

Litigations for HIV Related Complications

In 1992, a 27-year-old malewith same sex exposure requested human immuno-deficiency virus (HIV) testing anonymously at a walk-in clinic. He was advised that the test (HIV serology) was positive and he requested a repeat test (anonymously) 1 month later, which was also reported as being positive. About 2 years later, he was assessed by a general practitioner for symptoms of depression and continued medical care. At that time, investigations revealed a CD4 T-cell count of about 700 cells/uL. Sometime in 1996 a repeat blood test revealed a CD4 cell count just <500 cells/uL. No consultation to an infectious diseases specialist or HIV clinic was made. The GP(general practitioner) then initiated a regimen consisting of didanosine, lamivudine, and saquinavir for HIV infection. At that time, testing for HIV viral load was not generally available to the medical community, but became procurable in 1997. Initially, the patient tolerated the regimen well and over the next 3 years his CD4 cell count was maintained above 600–700 cells/uL and the HIV viral load remained undetectable (<50 copies). However, the patient started to show morphologic changes of moderate facial and peripheral lipoatrophy, developed mild sensory peripheral neuropathy, and increased liver enzymes attributable to fatty liver, and elevations of the fasting serum glucose. In the summer of 2000, although the CD4 cell count remained stable, the HIV viral load was reported as being over 7,000 copies/uL. At this time, the patient was referred to a university hospital HIV clinic.

A two-sex model for the influence of heavy alcohol consumption on the spread of HIV/AIDS

The HIV/AIDS epidemic, one of the leading public health problems to have affected sub-Sahara Africa, is a multifaceted problem with social, behavioral and biological aspects. In the absence of a cure, behavioral change has been advocated as an intervention strategy for reversing the epidemic. Empirical studies have found heavy alcohol consumption to be a fueling factor for HIV/AIDS infection and progression. Previously [20], we formulated and analyzed a one-sex deterministic model to capture the dynamics of this deadly interaction. But, since alcohol drinking habits, consequent risky sexual practices, alcohol-induced immune suppression, etc., can be different for men and women, the primary objective of our present paper is to construct a two-sex model aimed at shedding light on how both sexes, with varying heavy alcohol consumption trends, contribute differently to the HIV/AIDS spread. Based on numerical simulations, supported by the UNAIDS epidemiological software SPECTRUM and using the available data, our study identifies heavy drinking among men and women to be a major driving force for HIV/AIDS in Botswana and sub-Sahara Africa and quantifies its hazardous outcomes in terms of increased number of active TB cases and economic burden caused by increased need for AntiRetroviral Therapy (ART). Our simulations point to the heavy-drinking habits of men as a major reason for the continuing disproportionate impact of HIV/AIDS on women in sub-Sahara Africa. Our analysis has revealed the possibility of the phenomenon of backward bifurcation. In contrast to the result in some HIV vaccination models [52], backward bifurcation in our model is not removed by replacing the corresponding standard incidence function with a mass action incidence, but is removed by merging the two susceptible classes of the same sex into one, i.e., by ignoring acquisition of, and ongoing recovery from, heavy-drinking habits among the susceptible population.

Causal considerations on alcohol and HIV/AIDS--a systematic review

AIM

The study aimed to explore the possible causal nature of the association between alcohol consumption and HIV/AIDS.

METHODS

A review based on meta-analyses and reviews was conducted according to standard epidemiological criteria to distinguish causality from association, examining (i) the potential impact of alcohol on the incidence of HIV and (ii) alcohol's impact on worsening the disease course.

RESULTS

In terms of incidence of HIV, although we found a consistent and strong association with consumption, there was not enough evidence for a causal connection. In particular, it is not clear whether personality traits such as sensation seeking or sexual compulsivity and psychiatric disorders such as antisocial personality disorder impact both alcohol consumption and risky sex, subsequently creating an association between both behaviors. In terms of worsening the disease course of HIV/AIDS, we found enough evidence for a causal impact of alcohol. Alcohol affects the immune system, thus contributing to a worsened course of HIV/AIDS. In addition, alcohol negatively impacts on behaviors that include support seeking and medication adherence.

CONCLUSIONS

A randomized controlled clinical trial targeted toward at-risk HIV-negative individuals who live in areas with high HIV prevalence is suggested to test the effects of proven effective alcohol interventions on HIV incidence.

Alcohol, signaling, and ECM turnover

Alcohol is recognized as a direct hepatotoxin, but the precise molecular pathways that are important for the initiation and progression of alcohol-induced tissue injury are not completely understood. The current understanding of alcohol toxicity to organs suggests that alcohol initiates injury by generation of oxidative and nonoxidative ethanol metabolites and via translocation of gut-derived endotoxin. These processes lead to cellular injury and stimulation of the inflammatory responses mediated through a variety of molecules. With continuing alcohol abuse, the injury progresses through impairment of tissue regeneration and extracellular matrix (ECM) turnover, leading to fibrogenesis and cirrhosis. Several cell types are involved in this process, the predominant being stellate cells, macrophages, and parenchymal cells. In response to alcohol, growth factors and cytokines activate many signaling cascades that regulate fibrogenesis. This mini-review brings together research focusing on the underlying mechanisms of alcohol-mediated injury in a number of organs. It highlights the various processes and molecules that are likely involved in inflammation, immune modulation, susceptibility to infection, ECM turnover and fibrogenesis in the liver, pancreas, and lung triggered by alcohol abuse.

A recent perspective on alcohol, immunity, and host defense

BACKGROUND

Multiple line of clinical and experimental evidence demonstrates that both acute, moderate, and chronic, excessive alcohol use result in various abnormalities in the functions of the immune system.

METHODS

Medline and PubMed databases were used to identify published reports with particular interest in the period of 2000-2008 in the subject of alcohol use, infection, inflammation, innate, and adaptive immunity.

RESULTS

This review article summarizes recent findings relevant to acute or chronic alcohol use-induced immunomodulation and its consequences on host defense against microbial pathogens and tissue injury. Studies with in vivo and in vitro alcohol administration are both discussed. The effects of alcohol on lung infections, trauma and burn injury, liver, pancreas, and cardiovascular diseases are evaluated with respect to the role of immune cells. Specific changes in innate immune response and abnormalities in adaptive immunity caused by alcohol intake are detailed.

CONCLUSION

Altered inflammatory cell and adaptive immune responses after alcohol consumption result in increased incidence and poor outcome of infections and other organ-specific immune-mediated effects.

The relationship between alcohol consumption and unprotected sex among known HIV-discordant couples in Rwanda and Zambia

Although alcohol abuse is highly prevalent in many countries in sub-Saharan Africa, little is known about the relationship between alcohol consumption and risky sexual behavior in these settings. An understanding of this relationship is particularly important given the high prevalence of HIV that exists in many of these countries. This study analyzes data collected from members of cohabiting HIV-discordant couples regarding alcohol consumption and self-reported condom use. After controlling for demographic and socioeconomic co-factors, alcohol use by male partners of HIV-discordant couples was associated with self-reported unprotected sex at follow-up. Counseling about alcohol use should be part of HIV testing and counseling programs, particularly among those found to be HIV-positive.

Chronic binge ethanol consumption accelerates progression of simian immunodeficiency virus disease

BACKGROUND

While alcohol consumption is known to increase the incidence and severity of infections, the impact of alcohol consumption on human immunodeficiency virus (HIV) disease progression has been difficult to assess. Therefore, we examined the effect of ethanol on simian immunodeficiency virus (SIV) disease progression in a well-defined model utilizing rhesus macaques.

METHODS

Alcohol was administered for 5 hours via an indwelling intragastric catheter to achieve an alcohol concentration of 50 to 60 mM for 4 consecutive days per week for the duration of the study. Control animals received isocaloric sucrose. After 3 months, animals were inoculated intravenously with 10,000 times the ID(50) of SIV(DeltaB670) and followed to end-stage disease.

RESULTS

Plasma SIV ribonucleic acid (RNA) was higher in alcohol-consuming animals compared with sucrose-treated animals during the early asymptomatic stage of disease but not at later time points. This increase in viral set point was associated with more rapid progression to end-stage disease in macaques administered alcohol (median=374 days) compared with sucrose (median=900 days). The decline in blood CD4+ cells was similar in both groups of animals.

CONCLUSIONS

This study indicates that frequent episodes of alcohol intoxication in SIV+ macaques increase viral set point in association with more rapid development of end-stage disease.

Alcohol abuse enhances neuroinflammation and impairs immune responses in an animal model of human immunodeficiency virus-1 encephalitis

Neuroinflammatory disorders (including human immunodeficiency virus-1 encephalitis, HIVE) are associated with oxidative stress and inflammatory brain injury, and excessive alcohol use can exacerbate tissue damage. Using a murine model of HIVE, we investigated the effects of alcohol abuse on the clearance of virus-infected macrophages and neuroinflammation. Severe combined immunodeficient mice were reconstituted with human lymphocytes, and encephalitis was induced by intracranial injection of HIV-1-infected monocyte-derived macrophages (HIV-1(+) MDM). Animals were fed an ethanol-containing diet beginning 2 weeks before lymphocyte engraftment and for the entire duration of the experiment. Lymphocyte engraftment was not altered by ethanol exposure. Alcohol-mediated immunosuppression in ethanol-fed mice was manifested by a significant decrease in CD8(+)/interferon-gamma(+) T lymphocytes, a fivefold increase in viremia, and diminished expression of immunoproteasomes in the spleen. Although both groups showed similar amounts of CD8(+) T-lymphocyte infiltration in brain areas containing HIV-1(+) MDMs, ethanol-fed mice featured double the amounts of HIV-1(+) MDMs in the brain compared to controls. Ethanol-exposed mice demonstrated higher microglial reaction and enhanced oxidative stress. Alcohol exposure impaired immune responses (increased viremia, decreased immunoproteasome levels, and prevented efficient elimination of HIV-1(+) MDMs) and enhanced neuroinflammation in HIVE mice. Thus, alcohol abuse could be a co-factor in progression of HIV-1 infection of the brain.

Expanding research on the role of alcohol consumption and related risks in the prevention and treatment of HIV/AIDS

This article is a review of some of the major epidemiological, behavioral, biological, and integrative prevention research issues and priorities in the area of HIV/AIDS and alcohol consumption. Drinking alcohol increases both the risk for infection with HIV and related illnesses and the morbidity and mortality of patients who progress to AIDS. New and improved measurement procedures have helped in assessment of the complex patterns of alcohol use, identification of intervening explanatory mechanisms for risk behaviors and contexts, and determination of intervention outcomes. Both the direct and indirect effects of alcohol misuse appear to be major contributors to both the risk for infection with HIV and the transmission of HIV/AIDS at the individual and population levels. There is increasing evidence that perhaps no level of alcohol consumption is "safe" for those who are HIV infected and receiving antiretroviral treatment. Interdisciplinary basic behavioral and biomedical research is needed to develop comprehensive culturally appropriate strategies for programs that can be effectively delivered in community contexts in the United States and abroad and that focus on the integration of our understanding of individual behaviors, high-risk group membership, biological mechanisms, and the social and physical environments that place individuals at risk for HIV infection. High-priority topics include improving adherence to antiretroviral medications, prevention of infection in young minority women in the United States, and treatment of HIV+ pregnant women who are alcohol abusers to prevent adverse fetal outcomes, which is an international focus in under-resourced settings in Africa.

Increased viral replication in simian immunodeficiency virus/simian-HIV-infected macaques with self-administering model of chronic alcohol consumption

Alcohol abuse constitutes a major cohort among HIV-infected individuals. The precise effect of alcohol addiction on HIV pathogenesis remains inconclusive, however. This study was designed to determine the effect of alcohol dependence on virus replication and CD4 profiles in simian immunodeficiency virus/simian-HIV-infected rhesus macaques. A group of 3 male Indian rhesus macaques was adapted to a self-drinking model of alcohol consumption, whereas another group of 3 macaques was provided a Nutrasweet solution. After 7 weeks of alcohol consumption, the alcohol-dependent animals along with controls were intravenously inoculated with a mixture of SHIV(KU), SHIV(89.6)P, and SIV/17E-Fr. These animals were followed for a period of 24 weeks for complete blood cell counts, CD4 cell profiles, and viral loads in the blood and cerebral compartments. The alcohol and control groups showed comparable peak viral loads in the blood. The plasma viral load in the alcohol group was 31- to 85-fold higher than that in the control group at weeks 18 through 24 after infection, however. The pattern of cerebrospinal fluid viral replication was also comparable during the acute phase; however, the virus continued to replicate in the brain of alcohol-dependent animals, whereas it became undetectable in the controls. The extent of CD4 cell loss in the alcohol group was significantly higher than that in the control animals at week 1 after infection.

Sexual risk behaviors and substance use among alcohol abusing HIV-positive men who have sex with men

An ethnically diverse sample (79.0% men of color) of HIV seropositive (HIV+) men who have sex with men (MSM) with alcohol use disorders from the New York City metropolitan area was recruited from a variety of settings frequented by such men. Data were collected using quantitative assessments and calendar based techniques at the baseline assessment of a longitudinal study assessing the relationship between alcohol and substance use and sexual risk behaviors as well as alcohol use and HIV disease progression. Data were selected on a sample of 253 HIV+ MSM (mean age = 38.55, SD = 6.73). Of these, the majority of participants (80.2%, n=203) reported engaging in sexual behaviors with casual partners. In terms of sexual behaviors that put partners at greatest risk for HIV transmission, unprotected anal insertive intercourse was most likely to occur with unknown status casual partners (46.8%, n=95) than with either HIV negative casual partners (19.2%, n=39) or with HIV+ casual partners (40.8%, n=83). Further, bivariate analyses indicated significant relationships between the use of several substances and sexual behaviors that put partners at greatest risk for HIV transmission, as well as a significant positive relationship between drinks per drinking day and viral load.

The effect of chronic binge ethanol consumption on the primary stage of SIV infection in rhesus macaques

BACKGROUND

Alcohol abuse and infection with HIV individually compromise immune function, but the consequence of both conditions together is poorly understood owing to the difficulties of performing appropriate studies in human subjects. Simian immunodeficiency virus (SIV) infection of rhesus macaques is considered to closely model HIV disease in that the virus infects CD4+ cells and this infection leads to a similar AIDS state. This study was initiated to study the combined effects of chronic binge alcohol consumption on the primary stage of SIV infection.

METHODS

Rhesus macaques were administered alcohol or isocaloric sucrose via a permanently indwelling intragastric catheter 4 consecutive days per week for the duration of the study. Doses were individualized to achieve plasma alcohol concentrations of 50-60 mM over a 5-hr period. After 3 months, animals were inoculated intravenously with 10,000 times the ID(50) (50% infective dose) of SIV(DeltaB670) at the conclusion of an alcohol session and followed for 2 months postinoculation.

RESULTS

At 1 week, plasma SIV RNA was greater than 60-fold higher in alcohol-consuming animals compared with sucrose controls. Likewise, alcohol consumption enhanced the SIV-induced increase in cell cycling T lymphocytes (i.e., cells expressing Ki67 protein) in blood. These differences between alcohol- and sucrose-treated animals were not sustained during the observation period. Peak viral load occurred 2 weeks post-SIV inoculation at 7.6 +/- 4.2 and 5.2 +/- 3.1 x 106 copies/ml in alcohol- versus sucrose-consuming animals, respectively. Blood CD4+ lymphocyte numbers were decreased 1 and 2 months after SIV inoculation to a similar degree in both sucrose-control and alcohol-treated animals.

CONCLUSIONS

The consequence of the early rise in viral load and increase in lymphocyte turnover seen with excess alcohol consumption is unknown. We hypothesize that alcohol intoxication may increase the susceptibility of the host to HIV/SIV infection. This possibility needs to be explored further.

Alcohol potentiates HIV-1 infection of human blood mononuclear phagocytes

BACKGROUND

Acute and chronic alcohol abuse impairs various functions of the immune system and thus has been implicated as a cofactor in HIV infection. The mechanisms by which alcohol affects the function of human immune cells that are the targets for HIV are unknown.

METHODS

Human blood monocyte-derived macrophages (MDM) were incubated with or without alcohol (10-40 mM) for 24 hr and then infected with HIV for 24 hr. Culture supernatants were harvested for HIV reverse transcription assay. HIV entry receptor (CCR5, CD4, and CXCR4) expression was determined by reverse transcription-polymerase chain reaction and flow cytometry assays. Beta-chemokines were analyzed using enzyme-linked immunosorbent assay. Different HIV strains (Bal, SF-162, 89.6, and UG024) were used for infection experiments. In addition, ADA (macrophage-tropic strain) and murine leukemia virus envelope-pseudotyped HIV infection was carried out.

RESULTS

Although alcohol had little effect on HIV T-lymphocyte-tropic strain infection, it significantly enhanced HIV R5 strain infection in MDM. The enhancing effect of alcohol on the HIV R5 strain was further evidenced by the observation that the R5 (ADA) strain envelope-pseudotyped HIV infection is markedly increased by alcohol, whereas murine leukemia virus envelope-pseudotyped HIV infection was not affected. Alcohol significantly up-regulated CCR5 receptor expression and inhibited the endogenous production of beta-chemokines by MDM.

CONCLUSION

Alcohol, through the down-regulation of beta-chemokine production and the up-regulation of CCR5 receptor expression, enhances HIV R5 strain infection of MDM and may have an important role as a cofactor in the progression of HIV disease.

Immunologic and virologic analyses of an acutely HIV type 1-infected patient with extremely rapid disease progression

The immunologic and virologic factors that impact on the rate of disease progression after acute infection with human immunodeficiency virus (HIV) type 1 are poorly understood. A patient with an extraordinarily rapid disease course leading to AIDS-associated death within 6 months of infection was studied intensively for the presence of anti-HIV immune reactivities as well as changes in the genetic and biologic properties of virus isolates. Although altered humoral responses were evident, the most distinctive immunologic feature was a nearly complete absence of detectable HIV-specific CTL responses. In addition to a rapid decline in CD3+CD4+ cells, elevated percentages of CD8+CD45RA+ and CD8+CD57+ cells and diminished CD8+CD45R0+ and CD8+CD28+ cells were evident. Primary viral isolates recovered throughout the course of infection exhibited limited sequence diversity. Cloned viral envelopes were found to have unusually broad patterns of coreceptor usage for cell-cell fusion, although infectivity studies yielded no evidence of infection via these alternative receptors. The infectivity studies demonstrated that these isolates and their envelopes maintained an R5 phenotype throughout the course of disease. The absence of demonstrable anti-HIV CTL reactivities, coupled with a protracted course of seroconversion, highlights the importance of robust HIV-specific immune responses in the control of disease progression.

Ethanol enhances TNF-alpha-inducible NFkappaB activation and HIV-1-LTR transcription in CD4+ Jurkat T lymphocytes

During the latent phase of human immunodeficiency virus type 1 (HIV-1) infection, CD4+ T cells carrying replication-competent proviral HIV-1 DNA play an important role in persistence of the virus. Several cofactors can induce and or amplify HIV-1 replication and negatively affect disease progression and pathogenesis. Ethanol consumption is an important risk factor for HIV-1 infection, and it has been implicated in increased HIV-1 replication and progression of infection. Because tumor necrosis factor-alpha (TNF-alpha) is an important modulator of HIV-1 replication, in the present study we examined the possible effects of ethanol on TNF-alpha-inducible signaling associated with HIV-1 replication in human CD4+ T cells (Jurkat E6-1). We demonstrate that clinically relevant ethanol concentrations significantly potentiate TNF-alpha-inducible NFkappaB. Although ethanol effectively collaborated with TNF-alpha, by itself it did not have a direct effect on NFkappaB activation. The ethanol-dependent potentiation of TNF-alpha-inducible NFkappaB nuclear translocation was observed to involve the enhanced degradation of IkappaBalpha. Additionally, the ethanol-mediated potentiation of TNF-alpha-inducible NFkappaB activation was abrogated by the known antioxidant pyrrolidinedithiocarbamate, suggesting an important mechanistic role for reactive oxygen species in this process. In correspondence with its effect on NFkappaB, ethanol was also observed to significantly enhance HIV-1 long terminal repeat-dependent transcription induced by TNF-alpha. Overall, the data provide a molecular basis for the possible role of ethanol as a cofactor that can adversely affect HIV-1 infection and pathogenesis.

The integration of medical management with recovery

Patients recovering from alcohol and other drug addiction have unique medical and pharmacological needs. Careful selection of medications call decrease the risk of relapse. Angiotensin-converting enzyme inhibitors and calcium channel-blocking medications are excellent choices to treat hypertension. Most gastrointestinal problems resolve with abstinence and can be treated nonpharmacologically. In managing pain, physicians should avoid narcotics and use nonpharmacological treatment whenever possible. Treating recovering patients with HIV can be challenging because of the side effects of many of the antiviral medications. The newer antiviral agents have fewer side effects and contraindications. Commonly used remedies for colds and cough can cause a relapse to drug use. Patients with diabetes mellitus need to be monitored very closely in early recovery to prevent hypoglycemia. Frequently a team approach is helpful in managing the medication needs of patients in recovery.

Tuberculosis, AIDS, and death among substance abusers on welfare in New York City

BACKGROUND

In New York City, the incidence of tuberculosis has more than doubled during the past decade. We examined the incidence of tuberculosis and the acquired immunodeficiency syndrome (AIDS) and the rate of death from all causes in a very-high-risk group--indigent subjects who abuse drugs, alcohol, or both.

METHODS

In 1984 we began to study prospectively a cohort of welfare applicants and recipients 18 to 64 years of age who abused drugs or alcohol. The incidence rates of tuberculosis, AIDS, and death for this group were ascertained through vital records and New York City's tuberculosis and AIDS registries.

RESULTS

The cohort was followed for eight years. Of the 858 subjects, tuberculosis developed in 47 (5.5 percent), 84 (9.8 percent) were given a diagnosis of AIDS, and 183 (21.3 percent) died. The rates of incidence per 100,000 person-years were 744 for tuberculosis, 1323 for AIDS, and 2842 for death. In this group of welfare clients, the rate of newly diagnosed tuberculosis was 14.8 times that of the age-matched general population of New York City; the rate of AIDS was 10.0 times as high; and the death rate was 5.2 times as high. There was no significant difference in the rate of new cases of tuberculosis between subjects with positive skin tests and those with negative skin tests at examination in 1984.

CONCLUSIONS

Among indigent alcohol and drug abusers in New York City, the rates of tuberculosis, AIDS, and death are extremely high. In this population, a single positive or negative skin test does not predict the development of tuberculosis, probably because both anergy and new infections are common. If programs to control tuberculosis and AIDS are to be effective in groups of indigent substance abusers, health services must be integrated into the welfare delivery system.