Kaposi's sarcoma in Uganda: risk factors for human herpesvirus 8 infection among blood donors

Improving blood transfusion safety in resource-poor countries: a case study of using leucocyte reduced blood in Uganda

Background:

The majority of blood transfusion safety strategies recommended by the WHO for resource-poor countries focus mainly on reducing the risk of transfusion-transmitted infections (TTIs). Other technologies such as leucocyte reduction may represent complementary strategies for improving transfusion safety.

Objective:

To evaluate the role of using leucocyte reduced blood in a resource-poor country.

Methods:

Pre-storage leucocyte reduced (LR) red blood cells (RBCs) were specially prepared for the Tissue Oxygenation by Transfusion in severe Anaemia and Lactic acidosis (TOTAL) study, at the Uganda Blood Transfusion Services from February 2013 through May 2015. Quality control tests were performed to evaluate the procedure, and the incremental cost of an LR-RBC unit was estimated.

Results:

A total of 608 RBCs units were leucocyte reduced. Quality control tests were performed on 55 random RBCs units. The median (IQR) residual leucocyte count was 4 (0·5–10) WBC/uL, equivalent to 1·8x106 WBC per unit. The estimated incremental unit cost of leucocyte reduction was $37 USD per LR RBC unit.

Conclusion:

Leucocyte reduction of blood in a resource-poor country is doable although relatively costly. As such, its value in resource-poor countries should be weighed against other transfusion safety propositions.

Prevalence and burden of HBV co-infection among people living with HIV: A global systematic review and meta-analysis

Globally, in 2017 35 million people were living with HIV (PLHIV) and 257 million had chronic HBV infection (HBsAg positive). The extent of HIV-HBsAg co-infection is unknown. We undertook a systematic review to estimate the global burden of HBsAg co-infection in PLHIV. We searched MEDLINE, Embase and other databases for published studies (2002-2018) measuring prevalence of HBsAg among PLHIV. The review was registered with PROSPERO (#CRD42019123388). Populations were categorized by HIV-exposure category. The global burden of co-infection was estimated by applying regional co-infection prevalence estimates to UNAIDS estimates of PLHIV. We conducted a meta-analysis to estimate the odds of HBsAg among PLHIV compared to HIV-negative individuals. We identified 506 estimates (475 studies) of HIV-HBsAg co-infection prevalence from 80/195 (41.0%) countries. Globally, the prevalence of HIV-HBsAg co-infection is 7.6% (IQR 5.6%-12.1%) in PLHIV, or 2.7 million HIV-HBsAg co-infections (IQR 2.0-4.2). The greatest burden (69% of cases; 1.9 million) is in sub-Saharan Africa. Globally, there was little difference in prevalence of HIV-HBsAg co-infection by population group (approximately 6%-7%), but it was slightly higher among people who inject drugs (11.8% IQR 6.0%-16.9%). Odds of HBsAg infection were 1.4 times higher among PLHIV compared to HIV-negative individuals. There is therefore, a high global burden of HIV-HBsAg co-infection, especially in sub-Saharan Africa. Key prevention strategies include infant HBV vaccination, including a timely birth-dose. Findings also highlight the importance of targeting PLHIV, especially high-risk groups for testing, catch-up HBV vaccination and other preventative interventions. The global scale-up of antiretroviral therapy (ART) for PLHIV using a tenofovir-based ART regimen provides an opportunity to simultaneously treat those with HBV co-infection, and in pregnant women to also reduce mother-to-child transmission of HBV alongside HIV.

Kaposi Sarcoma-Associated Herpesvirus in a Rural Ugandan Cohort, 1992-2008

Background

The prevalence and titers of antibodies against Kaposi sarcoma-associated herpesvirus (KSHV) in rural Africa are not completely understood, nor are their trends over time in populations in which human immunodeficiency virus (HIV) is also endemic. We examined prevalence, titers, temporal trends, and determinants of anti-KSHV antibodies in each of 3 time periods (1990-1991, 1999-2000, and 2007-2008) within a long-standing, rural population-based cohort in southwestern Uganda.

Methods

For each period, we measured antibodies to the K8.1 and ORF73 KSHV antigens in approximately 3000 people of all ages (1:1 sex ratio).

Results

In all periods, KSHV prevalence increased rapidly through childhood to approximately 90% by age 15 years, plateauing at approximately 95% thereafter. Similarly, antibody titers, particularly against the lytic antigen K8.1, were among the highest seen and increased significantly with age, suggesting sustained viral replication in this population. Male sex was also independently associated with higher prevalence, whereas HIV coinfection was not. A modest reduction in prevalence among children was noted in the most recent period.

Conclusions

KSHV seroprevalence and antibodies titers in this rural Ugandan population are the highest yet reported, perhaps reflecting frequent viral reactivation and persistently elevated transmission.

Beral et al's 1990 paper on Kaposi's sarcoma among persons with AIDS: demonstrating the power of descriptive epidemiology

Here we discuss the impact of Beral et al's 1990 paper "Kaposi's sarcoma among persons with AIDS: a sexually transmitted infection?" Not only did this paper galvanise research into the underlying infectious cause of Kaposi's sarcoma, it also demonstrated the power of observational epidemiology in pointing the way towards major discoveries.

Trends in Kaposi's sarcoma-associated Herpesvirus antibodies prior to the development of HIV-associated Kaposi's sarcoma: a nested case-control study

HIV-associated Kaposi's sarcoma (KS) is a public health challenge in sub-Saharan Africa since both the causative agent, Kaposi's sarcoma associated-herpesvirus (KSHV), and the major risk factor, HIV, are prevalent. In a nested case-control study within a long-standing clinical cohort in rural Uganda, we used stored sera to examine the evolution of antibody titres against the KSHV antigens K8.1 and latency-associated nuclear antigen (LANA) among 30 HIV-infected subjects who subsequently developed HIV-related KS (cases) and among 108 matched HIV/KSHV coinfected controls who did not develop KS. Throughout the 6 years prior to diagnosis, antibody titres to K8.1 and LANA were significantly higher among cases than controls (p < 0.0001), and titres increased prior to diagnosis in the cases. K8.1 titres differed more between KS cases and controls, compared to LANA titres. These differences in titre between cases and controls suggest a role for lytic viral replication in the pathogenesis of HIV-related KS in this setting.

The role of co-infections in mother-to-child transmission of HIV

In HIV-infected women, co-infections that target the placenta, fetal membranes, genital tract, and breast tissue, as well as systemic maternal and infant infections, have been shown to increase the risk for mother-to-child transmission of HIV (MTCT). Active co-infection stimulates the release of cytokines and inflammatory agents that enhance HIV replication locally or systemically and increase tissue permeability, which weakens natural defenses to MTCT. Many maternal or infant co-infections can affect MTCT of HIV, and particular ones, such as genital tract infection with herpes simplex virus, or systemic infections such as hepatitis B, can have substantial epidemiologic impact on MTCT. Screening and treatment for co-infections that can make infants susceptible to MTCT in utero, peripartum, or postpartum can help reduce the incidence of HIV infection among infants and improve the health of mothers and infants worldwide.

Clinical outcomes of HIV-infected patients with Kaposi's sarcoma receiving nonnucleoside reverse transcriptase inhibitor-based antiretroviral therapy in Uganda

BACKGROUND

Clinical outcomes for patients with Kaposi's sarcoma (KS) using nonnucleoside reverse transcriptase inhibitor (NNRTI)-based highly active antiretroviral therapy (HAART) in resource-limited settings have not previously been described.

METHODS

We evaluated HIV-infected patients aged ≥ 18 years, who initiated HAART in the Home-Based AIDS Care (HBAC) project in Tororo, Uganda, between May 2003 and February 2008 and were diagnosed with KS at baseline or during follow-up. We examined independent risk factors for having either prevalent or incident KS and risk factors for death among patients with KS.

RESULTS

Of 1121 study subjects, 17 (1.5%) were diagnosed with prevalent KS and 18 (1.6%) with incident KS over a median of 56.1 months of follow-up. KS was associated with male sex [adjusted odds ratio (AOR) 2.41; 95% confidence interval (CI) 1.20-4.86] and baseline CD4 cell count < 50 cells/μL (AOR 3.25; 95% CI 1.03-10.3). Eleven (65%) of 17 patients with prevalent KS and 13 (72%) of 18 patients with incident KS experienced complete regression (P = 0.137). Eighteen (64%) of 28 patients who remained on NNRTI-based HAART experienced regression of their KS and six (86%) of seven patients who were switched to protease inhibitor-containing HAART regimens had regression of their KS (P = 0.23). Mortality among those with KS was significantly associated with visceral disease (hazard ratio 19.22; 95% CI 2.42-152).

CONCLUSION

Prevalent or incident KS was associated with 30% mortality. The resolution of KS lesions among individuals who initiated HAART with NNRTI-based regimens was similar to that found in studies using only protease inhibitor-based HAART.

Human herpesvirus 8 seropositivity among sexually active adults in Uganda

Introduction

Sexual transmission of human herpesvirus 8 (HHV8) has been implicated among homosexual men, but the evidence for sexual transmission among heterosexual individuals is controversial. We investigated the role of sexual transmission of HHV8 in a nationally representative sample in Uganda, where HHV8 infection is endemic and transmitted mostly during childhood.

Materials and Methods

The study population was a subset of participants (n = 2681) from a population-based HIV/AIDS serobehavioral survey of adults aged 15–59 years conducted in 2004/2005. High risk for sexual transmission was assessed by questionnaire and serological testing for HIV and herpes simplex virus 2. Anti-HHV8 antibodies were measured using two enzyme immunoassays targeting synthetic peptides from the K8.1 and orf65 viral genes. The current study was restricted to 2288 sexually active adults. ORs and 95% CIs for HHV8 seropositivity were estimated by fitting logistic regression models with a random intercept using MPLUS and SAS software.

Results

The weighted prevalence of HHV8 seropositivity was 56.2%, based on 1302 seropositive individuals, and it increased significantly with age (P_trend<0.0001). In analyses adjusting for age, sex, geography, education, and HIV status, HHV8 seropositivity was positively associated with reporting two versus one marital union (OR:1.52, 95% CI: 1.17–1.97) and each unit increase in the number of children born (OR: 1.04, 95% CI: 1.00–1.08), and was inversely associated with ever having used a condom (OR: 0.64, 95% CI: 0.45–0.89). HHV8 seropositivity was not associated with HIV (P = 0.660) or with herpes simplex virus 2 (P = 0.732) seropositivity. Other sexual variables, including lifetime number of sexual partners or having had at least one sexually transmitted disease, and socioeconomic variables were unrelated to HHV8 seropositivity.

Conclusion

Our findings are compatible with the conclusion that sexual transmission of HHV8 in Uganda, if it occurs, is weak.

The T-Cell Immune Response against Kaposi's Sarcoma-Associated Herpesvirus

Kaposi's sarcoma-associated herpesvirus (KSHV) is the aetiological agent of Kaposi's sarcoma (KS), the most frequently arising malignancy in individuals with untreated HIV/AIDS. There are several lines of evidence to indicate that Kaposi's sarcoma oncogenesis is associated with loss of T-cell-mediated control of KSHV-infected cells. KSHV can establish life-long asymptomatic infection in immune-competent individuals. However, when T-cell immune control declines, for example, through AIDS or treatment with immunosuppressive drugs, both the prevalence of KSHV infection and the incidence of KS in KSHV carriers dramatically increase. Moreover, a dramatic and spontaneous improvement in KS is frequently seen when immunity is restored, for example, through antiretroviral therapy or the cessation of iatrogenic drugs. In this paper we describe the current state of knowledge on the T-cell immune responses against KSHV.

Age and HIV sexual risk among women in methadone treatment

This study examines the relationship between age and HIV sexual risk behaviors among a random sample of 372 women in methadone treatment in New York City. Logistic regression results indicate that women of all ages are at risk for HIV through inconsistent condom use. Exposure to intimate partner violence (IPV), alcohol use, and HIV-negative status are associated with inconsistent condom use during vaginal sex. Age (35-44), having a main sexual partner with an HIV risk factor, IPV, and alcohol use are associated with using crack or cocaine during sex. Similarly, age (35-44), having a main sexual partner with an HIV risk factor, IPV, and drug use are associated with consuming four or more drinks prior to sex. The findings highlight the importance of age-appropriate HIV prevention and intervention strategies, as well as the need to address intimate partner violence, mental health, polysubstance use, and relational factors associated with HIV sexual risk behaviors among women in methadone treatment.

Substantial regional differences in human herpesvirus 8 seroprevalence in sub-Saharan Africa: insights on the origin of the "Kaposi's sarcoma belt"

Equatorial Africa has among the highest incidences of Kaposi's sarcoma (KS) in the world, thus earning the name "KS Belt." This was the case even before the HIV epidemic. To date, there is no clear evidence that HHV-8 seroprevalence is higher in this region but interpretation of the available literature is tempered by differences in serologic assays used across studies. We examined representatively sampled ambulatory adults in Uganda, which is in the "KS Belt," and in Zimbabwe and South Africa which are outside the Belt, for HHV-8 antibodies. All serologic assays were uniformly performed in the same reference laboratory by the same personnel. In the base-case serologic algorithm, seropositivity was defined by reactivity in an immunofluorescence assay or in 2 enzyme immunoassays. A total of 2,375 participants were examined. In Uganda, HHV-8 seroprevalence was high early in adulthood (35.5% by age 21) without significant change thereafter. In contrast, HHV-8 seroprevalence early in adulthood was lower in Zimbabwe and South Africa (13.7 and 10.8%, respectively) but increased with age. After age adjustment, Ugandans had 3.24-fold greater odds of being HHV-8 infected than South Africans (p < 0.001) and 2.22-fold greater odds than Zimbabweans (p < 0.001). Inferences were unchanged using all other serologic algorithms evaluated. In conclusion, HHV-8 infection is substantially more common in Uganda than in Zimbabwe and South Africa. These findings help to explain the high KS incidence in the "KS Belt" and underscore the importance of a uniform approach to HHV-8 antibody testing.

Sex and geographic patterns of human herpesvirus 8 infection in a nationally representative population‐based sample in Uganda

BACKGROUND

Human herpesvirus 8 (HHV8), the infectious cause of Kaposi sarcoma, varies dramatically across Africa, suggesting that cofactors correlated with large-area geographic or environmental characteristics may influence risk of infection. Variation in HHV8 seropositivity across small-area regions within countries in Africa is unknown. We investigated this issue in Uganda, where Kaposi sarcoma distribution is uneven and well described.

METHODS

Archival samples from individuals aged 15-59 years randomly selected from a nationally representative 2004-2005 human immunodeficiency virus-AIDS serobehavioral survey were tested for HHV8 seropositivity with use of enzyme immunoassays based on synthetic peptides from the K8.1 and orf65 viral genes. Adjusted odds ratios and 95% confidence intervals (CIs) of association of HHV8 seropositivity with demographic risk factors were estimated.

RESULTS

Among 2681 individuals tested, HHV8 seropositivity was 55.4%. HHV8 seropositivity was lower in female than in male persons (adjusted odds ratio, 0.82 [95% CI, 0.69-0.97]) and increased 2.2% (95% CI, 1.0%-3.6%) in female persons and 1.2% (95% CI, 1.0%-2.3%) in male persons per year of age. HHV8 seropositivity was inversely associated with education ( P = .01, for trend) and was elevated in the West Nile region, compared with the Central region (adjusted odds ratio, 1.49 [95% CI, 1.02-2.18]) but not with other regions.

CONCLUSIONS

Our findings suggest that HHV8 seropositivity in Uganda may be influenced by cofactors correlated with small-area geography, age, sex, and education.

Kaposi's Sarcoma Associated-Herpes Virus (KSHV) Seroprevalence in Pregnant Women in South Africa

Background

Factors previously associated with Kaposi's sarcoma-associated herpesvirus (KSHV) transmission in Africa include sexual, familial, and proximity to river water. We measured the seroprevalence of KSHV in relation to HIV, syphilis, and demographic factors among pregnant women attending public antenatal clinics in the Gauteng province of South Africa.

Methods

We tested for antibodies to KSHV lytic K8.1 and latent Orf73 antigens in 1740 pregnant women attending antenatal clinics who contributed blood to the "National HIV and Syphilis Sero-Prevalence Survey - South Africa, 2001". Information on HIV and syphilis serology, age, education, residential area, gravidity, and parity was anonymously linked to evaluate risk factors for KSHV seropositivity. Clinics were grouped by municipality regions and their proximity to the two main river catchments defined.

Results

KSHV seropositivity (reactive to either lytic K8.1 and latent Orf73) was nearly twice that of HIV (44.6% vs. 23.1%). HIV and syphilis seropositivity was 12.7% and 14.9% in women without KSHV, and 36.1% and 19.9% respectively in those with KSHV. Women who are KSHV seropositive were 4 times more likely to be HIV positive than those who were KSHV seronegative (AOR 4.1 95%CI: 3.4 - 5.7). Although, women with HIV infection were more likely to be syphilis seropositive (AOR 1.8 95%CI: 1.3 - 2.4), no association between KSHV and syphilis seropositivity was observed. Those with higher levels of education had lower levels of KSHV seropositivity compared to those with lower education levels. KSHV seropositivity showed a heterogeneous pattern of prevalence in some localities.

Conclusions

The association between KSHV and HIV seropositivity and a lack of common association with syphilis, suggests that KSHV transmission may involve geographical and cultural factors other than sexual transmission.

Kaposi sarcoma-associated herpesvirus (KSHV) seroprevalence in population-based samples of African children: evidence for at least 2 patterns of KSHV transmission

BACKGROUND

Kaposi sarcoma-associated herpesvirus (KSHV) infection is endemic among adult populations in Africa. A prevailing view is that childhood transmission is primarily responsible for the high seroprevalence of KSHV among adults that is observed throughout the continent. However, few studies have directly examined children, particularly in locations where KS is not commonly endemic.

METHODS

Participants were children aged 1.5-8.9 years, including 427 children from a population-based sample in South Africa, 422 from a population-based sample in Uganda, and 567 from a clinic-based sample in Uganda. All serum specimens were tested by the same laboratory for KSHV antibodies with use of 2 enzyme immunoassays (against K8.1 and ORF65) and 1 immunofluorescence assay.

RESULTS

KSHV seroprevalence was 7.5%-9.0% among South African children and was not associated with age. In contrast, in the Ugandan population-based sample, KSHV seroprevalence increased from 10% among 2-year-old children to 30.6% among 8-year-old children (P(trend) < .001). In the Ugandan clinic-based sample, seroprevalence increased from 9.3% among 2-year-old children to 36.4% among 8-year-old children (P(trend) < .001).

CONCLUSION

Two distinct relationships between age and KSHV infection among children imply that KSHV transmission among children is not uniform throughout Africa and is therefore not always responsible for the high seroprevalence observed in adults. There are at least 2 patterns of KSHV transmission in Africa.

Recombinant ORF66 and ORFK12 antigens for the detection of human herpesvirus 8 antibodies in HIV-positive and -negative patients

Human herpesvirus 8 (HHV-8), also known as Kaposi's sarcoma (KS)-associated herpesvirus (KSHV), is not routinely isolated in cell cultures, and thus detection of HHV-8-specific antibodies is usually performed. In this study, we performed recombinant antigens ORF66- and ORFK12-based Western blot strip assays and ELISA, and surveyed the seroprevalence of HHV-8 antibodies in HIV-positive and -negative patients. In serum samples from patients with positive plasma HHV-8 DNA, the sensitivity of the Western blot strip assay was 100% for the anti-ORF66 antibodies and 83.3% for the anti-ORFK12 antibodies. In addition, ORF66-based ELISA showed higher levels of specificity (87.3%) and sensitivity (84.8%) than ORFK12-based ELISA. Moreover, the area under the receiver-operating characteristics curves (AUROC) was 0.76 for ORF66-based ELISA and 0.66 for ORFK12-based ELISA. The seroprevalence of HHV-8 antibodies to ORF66 and/or ORFK12 in the HIV-infected patients (55%, 97/176) was significantly higher than in the DM patients (45%, 135/301) (P = 0.03) and the HIV-/DM-negative group (11%, 11/100) (P < 0.01). In the HIV-infected patients, the seropositivity of the HHV-8-specific antibody was 30% to both antigens, 19% to ORFK12 and 5.7% to ORF66. Importantly, HHV-8 seropositivity in the HIV-infected patients was significantly associated with the transmission method of intravenous injection and high levels of HIV RNA loading (P < 0.01), but not with gender, CD4 cell numbers or AIDS symptoms. This study assessed the sensitivity and specificity of ORF66 and ORFK12 for the detection of HHV-8 antibodies, providing novel antigens for the diagnosis of HHV-8 infection and epidemiology of HHV-8 seroprevalence.

Kaposi sarcoma: a continuing conundrum

Kaposi sarcoma (KS) remains a challenge. Its classic or Mediterranean form tends to be benign. In transplant recipients it may be less so. As part of the AIDS pandemic, of which it was an original defining component, it may be life-threatening. It is due to human herpesvirus-8, which is necessary but not sufficient to produce the disease. KS has a low prevalence in the general population of the United States and United Kingdom, with an intermediate rate in Italy and Greece, and a high one in parts of Africa. In Italy, hot spots include its southern regions, the Po River Valley, and Sardinia, possibly related to a high density of blood-sucking insects. An important challenge is to treat KS patients without immunocompromising them. The potential of effective anti-herpes virus therapy and the use of sirolimus in transplantation recipients have added new opportunities for KS prevention.

LEARNING OBJECTIVES

At the conclusion of this learning activity, participants should be able to provide the most recent information about Kaposi sarcoma in the context in which it occurs. Its classic or Mediterranean form, its pattern in transplant recipients and others iatrogenically immunosuppressed, and its occurrence as a potentially life-threatening part of the AIDS pandemic will be stressed. Its etiology and transmission will be discussed in detail to facilitate understanding of Kaposi sarcoma and of human herpesvirus-8 infection in the general population of the United States and United Kingdom, in Italy and Greece, and in certain parts of Africa. Its therapy, including the concept of doing it without immunocompromising the patient, will be stressed. New opportunities for Kaposi sarcoma prevention will also be discussed.

No evidence of sexual transmission of Kaposi's sarcoma herpes virus in a heterosexual South African population

BACKGROUND

The transmission of Kaposi's sarcoma herpes virus (KSHV) in men who have sex with men is clearly associated with sexual risk factors, but evidence of heterosexual transmission of KSHV is conflicting.

METHODS

Sera were obtained from 2103 South African individuals (862 miners, 95 sex workers, 731 female and 415 male township residents; mean age 33.2 years; +/- 10.1). All sera were tested for antibodies to KSHV lytic K8.1 and latent Orf73, HIV, gonococcus, herpes simplex virus type 2 (HSV-2), syphilis and chlamydia. Information on social, demographic and high-risk sexual behavior was linked to laboratory data, to evaluate risk factors, expressed as odds ratios (95% confidence interval) for KSHV.

RESULTS

Overall KSHV and HIV prevalences were 47.5 and 40%, respectively (P = 0.43). The risk of HIV infection was highest in sex workers then female residents and miners, compared with male residents (P < 0.001). HSV-2 infection was highly prevalent (66%) and lower, but still substantial, prevalences (6-8%) were observed for other sexually transmitted infections (STI). No significant difference in KSHV infection was observed among the residential groups (P > 0.05). KSHV was not associated with any of the STI or any measures of sexual behavior (P > 0.05).

CONCLUSION

The pattern of HIV and STI in sex workers suggests high rates of high-risk sexual behavior in this population. The lack of association with high-risk sexual behavior, particularly in sex workers, and with any markers of STI strongly suggest that the sexual mode does not play a significant role in KSHV transmission in this South African population.

Human herpesvirus 8 (HHV-8) infection in healthy urban employees from Greece: seroprevalence and associated factors

A cross-sectional study was carried out in healthy company employees from Greece with the aim of assessing the prevalence of human herpesvirus 8 (HHV-8) and identifying risk factors for this herpesviral infection. Serum samples obtained from 955 subjects were tested for antibodies to HHV-8 by the K8.1 enzyme-linked immunosorbent assay (ELISA). Associations between HHV-8 serostatus and potential risk factors were examined using t-test, chi square test, and multivariate logistic regression analysis. HHV-8 prevalence was 7.6% (95% confidence interval (CI): 6.0%, 9.5%) and it increased with age from 6.5% among <30 years old to 13.8% among > or =50 years old subjects (P = 0.006). HHV-8 seropositivity was independently associated with endoscopic examination (odds ratio (OR): 2.01; 95% CI: 1.09, 3.70; P = 0.026), HBsAg positivity (OR: 5.16; 95% CI: 2.02, 13.20; P = 0.001) and age (OR > or =50 years old vs. <50 years old: 2.09; 95% CI: 1.23, 3.52; P = 0.006). No statistically significant associations between HHV-8 positive status and gender, occupational status, surgery, transfusion, tattoos/body piercing, multiple sex partners, weakness/fatigue, HCV status were observed. HHV-8 is prevalent in Greece. The strong association between HBV infection and HHV-8 positive status supports the hypothesis of an association between these two viral infections. The association between HHV-8 seropositivity and endoscopic examination requires further investigation.

Traditional practices and exposure to bodily fluids in Lusaka, Zambia

OBJECTIVES

To ascertain if there are specific sociocultural and behavioural practices associated with the exposure to saliva, semen and vaginal fluids, particularly through child-rearing practices and the use of traditional medicine in Lusaka, Zambia.

METHODS

We conducted 11 focus group discussions with men and women from diverse ethnic and socioeconomic backgrounds (n = 105) in Lusaka, Zambia in March 2004. We also conducted a brief sociodemographic survey of all focus group participants.

RESULTS

Discussions indicated that saliva was used while engaging in home health care practices associated with childcare and the use of traditional medicine. Additionally, semen and vaginal fluids may be used in rituals associated with childcare and health care for children. Our survey indicated that the use of traditional medicine is associated with lower socioeconomic status.

CONCLUSIONS

Population-based studies are needed to evaluate the relationship between traditional behavioural and sociocultural practices, which involve exchange of saliva and other bodily fluids and risk of infectious disease.

Transmission of human herpesvirus 8 by blood transfusion

BACKGROUND

Whether human herpesvirus 8 (HHV-8) is transmissible by blood transfusion remains undetermined. We evaluated the risk of HHV-8 transmission by blood transfusion in Uganda, where HHV-8 is endemic.

METHODS

We enrolled patients in Kampala, Uganda, who had received blood transfusions between December 2000 and October 2001. Pretransfusion and multiple post-transfusion blood specimens from up to nine visits over a 6-month period were tested for HHV-8 antibody. We calculated the excess risk of seroconversion over time among recipients of HHV-8-seropositive blood as compared with recipients of seronegative blood.

RESULTS

Of the 1811 transfusion recipients enrolled, 991 were HHV-8-seronegative before transfusion and completed the requisite follow-up, 43% of whom received HHV-8-seropositive blood and 57% of whom received seronegative blood. HHV-8 seroconversion occurred in 41 of the 991 recipients. The risk of seroconversion was significantly higher among recipients of HHV-8-seropositive blood than among recipients of seronegative blood (excess risk, 2.8%; P<0.05), and the increase in risk was seen mainly among patients in whom seroconversion occurred 3 to 10 weeks after transfusion (excess risk, 2.7%; P=0.005), a result consistent with the transmission of the virus by transfusion. Blood units stored for up to 4 days were more often associated with seroconversion than those stored for more than 4 days (excess risk, 4.2%; P<0.05).

CONCLUSIONS

This study provides strong evidence that HHV-8 is transmitted by blood transfusion. The risk may be diminished as the period of blood storage increases.

Seroprevalence of six different viruses among pregnant women and blood donors in rural and urban Burkina Faso: A comparative analysis

A seroprevalence study was carried out of six different human pathogenic viruses, namely human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), human T-cell leukemia virus (HTLV), human herpesvirus type 8 (HHV-8), and dengue virus among pregnant women and blood donors from rural (Nouna) and urban (Ouagadougou) Burkina Faso, West Africa. A total of 683 samples from blood donors (n = 191) and pregnant women (n = 492) were collected from both sites and screened for the different virus infection markers resulting in the following prevalence values for Nouna or Ouagadougou, respectively: HIV 3.6/4.6, anti-HBV core (anti-HBc) 69.6/76.4, HBV surface antigen (HBsAg)14.3/17.3, HCV 2.2/1.5, HTLV 1.4/0.5, HHV-8 11.5/13.5, dengue virus 26.3/36.5. Individuals aged > or =25 years were more likely to be infected with HIV than those below 24 years (P < 0.05). Infection with HIV increased the likelihood of co-infection with other viruses, such as HHV-8, HBV and HTLV. Co-infection studies involving five viruses (HBV-HBsAg, HHV-8, HIV, HCV, and HTLV) showed that 4.8% (33/683) of the studied population were dually infected, with HBsAg+ HHV-8 (13/33), HBsAg+HIV (8/33) and HIV+HHV-8 (8/33) being the most common co-infections. Of the population studied 0.6% (4/683) was triply infected, the most common infection being with HBV+HIV+HHV-8 (3/4). There was no difference in the prevalence of HIV, anti-HBc, HBsAg, HCV, HTLV, and HHV-8 either among blood donors or pregnant women in urban or rural setting, while dengue virus prevalence was relatively lower in rural (26.3%) than in urban (36.5%) Burkina Faso.

AIDS-associated cancer in developing nations

PURPOSE OF REVIEW

With the emergence of the highly active antiretroviral therapy era, it is apparent that the incidence of Kaposi sarcoma, in particular, and lymphoma in patients with AIDS is declining, especially in regions of the world where these regimens are routinely available. The burden of HIV infection and AIDS is greatest in the developing world, and no doubt neoplastic complications are increasingly encountered. The purpose of this review is to highlight recent developments of this aspect of the AIDS epidemic in the developing world.

RECENT FINDINGS

It was readily apparent that the incidence of Kaposi sarcoma sharply increased after the onset of the AIDS epidemic in developing countries. By the end of the second decade of the epidemic, non-Hodgkin lymphoma is increasing in incidence and the natural history of Burkitt lymphoma is evolving in the backdrop of HIV infection as well. Cervical cancer is the most common cancer in women in many developing countries, yet the true impact of HIV infection on the development of this neoplasm is not fully understood. Squamous cell carcinoma of the conjunctiva appears to be a unique AIDS-associated neoplasm that is encountered in sub-Saharan Africa as well. Finally, although the epidemiologic and clinicopathologic features for many AIDS-associated neoplasms are well characterized in developing regions of the world, there is a paucity of data on the therapeutic approach to these tumors in this setting.

SUMMARY

It is apparent that as the AIDS pandemic proceeds, the burden of neoplastic diseases is increasing in developing nations. Current therapeutic approaches are not well documented. Pragmatic prevention and therapeutic interventions suitable for the resource-constrained setting are clearly needed.

Kaposi's sarcoma: An update

While there have been many important advances in the study of Kaposi's sarcoma (KS), it remains both a challenge and an enigma in many ways. Kaposi's original description of "multiple idiopathic hemorrhagic sarcoma[s]" in patients who died within 2-3 years resembles KS in AIDS more than classic KS in elderly men of Italian, Jewish, or Mediterranean lineage, in whom the disease is usually benign. KS had been evident in about one-third of those with early AIDS, often as its presenting sign, a pattern markedly reduced in recent times since the introduction of highly active anti-retroviral therapy (HAART). The most important advance has been the convincing etiologic linkage of KS with human herpesvirus 8 (HHV-8), which is necessary but not sufficient. It has a low prevalence in the general population of the USA and UK, with an intermediate rate in Italy and Greece, and a high one in Uganda. KS risk may be significantly lower in AIDS patients with a history of anti-herpes therapy. Many aspects of HHV-8, including its transmission pattern and different genospecies, are being scrutinized. The diagnosis of KS may be difficult. One should be aware of KS clinical variants, including telangiectatic, eccymotic, and keloidal KS. One must consider a number of other disorders, including bacillary angiomatosis. HHV-8 DNA sequences in dermatofibromas and other tumors should probably not be viewed as representing a marker for KS. Therapeutic options vary for KS. Intralesional and low-dose outpatient intravenous vinblastine may be valuable, as immunosuppression with KS is not a good idea if it can be avoided. Anti-herpes virus therapy may have potential for wide use, especially in preventing the development of KS in at risk populations, such as HHV-8 seropositive individuals undergoing transplantation surgery.

Epidemiological characteristics of human herpesvirus-8 infection in a large population of antenatal women in Zambia

Comprehensive data describing epidemiological characteristics of the human herpesvirus-8 or Kaposi's sarcoma-associated herpesvirus (HHV-8 or KSHV) infection among pregnant women in a central sub-Saharan Africa are not available. This study determined virus prevalence estimates and the risk factors associated with HHV-8 infection. Cross-sectional, enrollment visit data were analyzed from a prospective cohort study of perinatal transmission of HHV-8 in Lusaka, Zambia. Exposure data were obtained via structured interview, physical examination, medical chart review, and laboratory testing. Among 3,160 antenatal women serologically screened for HHV-8 between September 1998 and October 2000, 40.2% were seropositive. The HHV-8 positive women were more likely to be co-infected with HIV-1 than those who were HHV-8 negative (34% vs. 26%; P < 0.0001). Of 154 variables evaluated by logistic regression analyses, only three risk factors, have emerged as independent predictors of HHV-8 positive serology: diagnosis of genital warts, HIV-1 co-infection and primary education. The association of HHV-8 infection with genital warts and HIV-1 co-infection suggests heterosexual transmission of HHV-8. HIV-1 infection may also act as a marker for particular behaviors, which could be sexual in nature, that are associated with both HIV-1 and HHV-8 transmission. Since HHV-8 facilitates development of AIDS-related Kaposi's sarcoma (KS), the results of this study could be utilized to identify specific population groups of pregnant women who are at increased risk for this disease.

Multicenter comparison of serologic assays and estimation of human herpesvirus 8 seroprevalence among US blood donors

BACKGROUND

As part of assessing the possibility of transfusion transmission of human herpesvirus 8 (HHV-8 or Kaposi's sarcoma-associated herpesvirus), HHV-8 seroprevalence was estimated among US blood donors, the performance of HHV-8 serologic tests was compared, and the presence of HHV-8 DNA was tested for in donated blood.

STUDY DESIGN AND METHODS

Replicate panels of 1040 plasma specimens prepared from 1000 US blood donors (collected in 1994 and 1995) and 21 Kaposi's sarcoma patients were tested for antibodies to HHV-8 in six laboratories. HHV-8 PCR was performed on blood samples from 138 donors, including all 33 who tested seropositive in at least two laboratories and 22 who tested positive in at least one.

RESULTS

The estimated HHV-8 seroprevalence among US blood donors was 3.5 percent (95% CI, 1.2%-9.8%) by a conditional dependence latent-class model, 3.0 percent (95% CI, 2.0%-4.6%) by a conditional independence latent-class model, and 3.3 percent (95% CI, 2.3%-4.6%) by use of a consensus-derived gold standard (specimens positive in two or more laboratories); the conditional dependence model best fit the data. In this model, laboratory specificities ranged from 96.6 to 100 percent. Sensitivities ranged widely, but with overlapping 95 percent CIs. HHV-8 DNA was detected in blood from none of 138 donors evaluated.

CONCLUSIONS

Medical and behavioral screening does not eliminate HHV-8-seropositive persons from the US blood donor pool, but no viral DNA was found in donor blood. Further studies of much larger numbers of seropositive individuals will be required to more completely assess the rate of viremia and possibility of HHV-8 transfusion transmission. Current data do not indicate a need to screen US blood donors for HHV-8.

HIV/AIDS interventions for midlife and older adults: current status and challenges

Drawing on both domestic and global international perspectives, this special issue is devoted to articles that confront the challenges of understanding, preventing, and intervening, with HIV/AIDS as an epidemic that carries increasingly serious consequences for a growing number of adults who are 50 years of age or older. This issue builds on papers first presented at an HIV/AIDS and aging conference sponsored in the fall of 2000 by the National Institute on Aging of the National Institutes of Health. The editors have selected articles that focus dually on what is currently known and what needs to be known to successfully address the needs of persons 50 years of age or older who are vulnerable to the virus's effects. This special issue is organized around a series of subsections representing key issues and research findings related to HIV/AIDS and aging issues, including the epidemiology of HIV/AIDS and aging, HIV/AIDS risk and risk behavior, settings and situations as social contexts of risk, clinical challenges with older populations, living with and managing HIV/AIDS, interventions and research methods, new frontiers and challenges, and strategies for action. Some articles are data driven, whereas others are reflective pieces that recount personal experiences in living with the virus or point to new directions for research and practice. In this introduction, the editors highlight findings and approaches from each article and further add to our knowledge by setting these articles within the context of major themes relevant to the study of HIV/AIDS in an aging population.