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

Correlation between CD4/CD8 ratio and neurocognitive performance during early HIV infection

INTRODUCTION

CD4/CD8 ratio is a marker of immune activation in HIV infection and has been associated with neurocognitive performance during chronic infection, but little is known about the early phases. The aim of this study was to examine the relationship between blood CD4/CD8 ratio and central nervous system endpoints in primary HIV infection (PHI) before and after antiretroviral treatment (ART).

METHODS

This was a retrospective analysis of the Primary Infection Stage CNS Events Study (PISCES) cohort. We longitudinally assessed blood and cerebrospinal fluid (CSF) markers of inflammation, immune activation and neuronal injury, and neuropsychological testing performance (NPZ4, an average of three motor and one processing speed tests, and a summarized total score, NPZ11, including also executive function, learning and memory) in ART-naïve participants enrolled during PHI. Spearman correlation and linear mixed models assessed the relationships between the trajectory of CD4/CD8 ratio over time and neurocognitive performance, blood and CSF markers of immune activation and neuronal injury.

RESULTS

In all, 109 PHI participants were enrolled. The mean CD4/CD8 ratio decreased with longer time from infection to starting treatment (p < 0.001). Every unit increase in NPZ4 score was independently associated with a 0.15 increase in CD4/CD8 ratio (95% CI: 0.002-0.29; p = 0.047), whereas no correlation was found between CD4/CD8 ratio and NPZ11. Among the cognitive domains, only a change in processing speed was correlated with CD4/CD8 ratio over time (p = 0.03). The trajectory of the CD4/CD8 ratio was negatively correlated with change in CSF neurofilament light chain (p = 0.04).

CONCLUSIONS

The trajectory of CD4/CD8 ratio was independently associated with motor/psychomotor speed performance, suggesting that immune activation is involved in brain injury during the early stages of the infection.

The California HIV/AIDS Research Program: History, Impact, and HIV Cure Initiative

This Special Issue of AIDS Research and Human Retroviruses features results from the HIV Cure Initiative, funded by the California HIV/AIDS Research Program (CHRP). As a publicly funded grant maker, CHRP has served for more than three decades as a unique resource for innovative researchers in California, whose work seeks to address all aspects of the HIV epidemic and the communities affected by it. Early initiatives at CHRP pioneered what would become enduring cornerstones of HIV science: isolation of the virus; efficacy and toxicities of the first HIV treatments; the emergence of drug resistance; the first biospecimen banks for HIV-related research; the first community-based laboratory service for HIV diagnostic serology; and the first longitudinal case-control study of progression from HIV to AIDS-The San Francisco General Hospital Cohort. More recently, CHRP-funded conceptual studies of zinc-finger nuclease-mediated disruption of CCR5 genomic sequences and the safety of solid organ transplantation for HIV-positive patients have progressed from brilliant ideas to clinical realities, and CHRP is currently funding the first multisite trial of HIV preexposure prophylaxis for transgender persons in the United States. The present article outlines the founding of CHRP, our current grantmaking process, and our impact on HIV research over time. In 2013, CHRP launched a new initiative aimed at moving the then nascent frontier of HIV cure science forward: the CHRP HIV Cure Initiative provided over $1.4 million to multiple basic biomedical research projects, and selected results are presented in this Special Issue.

Current Scenario of HIV/AIDS, Treatment Options, and Major Challenges with Compliance to Antiretroviral Therapy

The discovery of the human immunodeficiency virus (HIV) as the causative organism of acquired immunodeficiency syndrome (AIDS) and the inability of modern medicine to find a cure for it has placed HIV as one of the most dreaded pathogens of the 21(st) century. With millions of people infected with HIV, it was once thought to result in "medical apocalypse". However, with the advent of antiretroviral therapy (ART), it is now possible to control HIV. Adherence to ART helps to keep the viral load under control and prolong the time of progression to AIDS, resulting in near normal life expectancy. Even with the introduction of ART, a substantial number of patients fail to adhere due to a variety of reasons, including adverse side effects, drug abuse, mental disorders, socioeconomic status, literacy, and social stigma. With the availability of so many options for HIV treatment at each stage of the disease progression, physicians can switch between the treatment regimens to avoid and/or minimize the adverse effects of drugs. Close monitoring, major social reforms, and adequate counselling should also be implemented to circumvent other challenges.

AIDS, Emergency Operations, and Infection Control

Acquired immunodeficiency syndrome (AIDS) caused by the human immunodeficiency virus (HIV) may turn out to be the largest lethal epidemic of infection ever. The estimated global number of HIV-infected adults in 1993 was 13 million, with projections of up to 40 million by the year 2000. Human immunodeficiency virus infections and AIDS are relevant to surgeons with respect to the surgical management of AIDS patients in general, the treatment of the increasingly long list of surgical complications specific to AIDS patients in particular, and the risks of patient-to-surgeon and surgeon-to-patient HIV transmission. Because of migration of individuals and populations throughout the world, even surgeons practicing in relatively unaffected regions should be familiar with the potential surgical implications of AIDS. Ethical considerations arise, as well. Are surgeons obliged to operate on HIV-positive or AIDS patients? Some surgeons adhere strictly to the Hippocratic Oath, whereas others reserve the right to be selective on whom they operate, except in emergencies. Other common ethical considerations in the AIDS patient are similar to those arising in the terminal cancer case: whether to operate or not; whether to provide advanced support such as total parenteral nutrition or hemodialysis. Answers are not simple and require close collaboration between the surgeon, the AIDS specialist, and involved members of other specialties. Emergency operations become necessary to treat AIDS independent disease such as acute cholecystitis and appendicitis or AIDS-related life-threatening conditions such as gastrointestinal bleeding, obstruction, perforation, or ischemia complicating Kaposi's sarcoma, lymphoma, and cytomegalovirus or disseminated nontuberculous mycobacterial infections. Delays and errors in diagnosis are frequent. Poor nutritional state with weight loss, low serum albumin, and leukocyte count prevails in most patients requiring emergency operations and account for a high mortality. By applying solid judgment and selecting management appropriately, the surgeon has the ability to prolong life and to improve the quality of life for these unfortunate patients, and to do so with extremely minimal risk to himself and his team.

The discovery and development of antiretroviral agents

Since the discovery of HIV as the causative agent of AIDS in 1983/1984, remarkable progress has been made in finding antiretroviral drugs (ARVs) that are effective against it. A major breakthrough occurred in 1996 when it was found that triple drug therapy (HAART) could durably suppress viral replication to minimal levels. It was then widely felt, however, that HAART was too expensive and complex for low- and middle-income countries, and so, with the exception of a few of these countries, such as Brazil, a massive scale-up did not begin until the WHO launched its '3 by 5' initiative and sizeable funding mechanisms, such as the Global Fund to Fight AIDS, TB and Malaria and the US President's Emergency Plan for AIDS Relief (PEPFAR), came into existence. A pivotal enabler of the scale-up was a steady lowering of drug prices through entry of generic antiretrovirals, competition between generic manufacturers and the making of volume commitments. The WHO Prequalification of Medicines Programme and the Expedited Review Provision of the US Food and Drug Administration have been important for the assurance of quality standards. Antiretroviral drug development by research-based pharmaceutical companies continues, with several important innovative products, such as long-acting agents, in the pipeline.

Predictors of CD4:CD8 ratio normalization and its effect on health outcomes in the era of combination antiretroviral therapy

Background

HIV leads to CD4:CD8 ratio inversion as immune dysregulation progresses. We examined the predictors of CD4:CD8 normalization after combination antiretroviral therapy (cART) and determined whether normalization is associated with reduced progression to AIDS-defining illnesses (ADI) and death.

Methods

A Canadian cohort of HIV-positive adults with CD4:CD8<1.2 prior to starting cART from 2000–2010 were analyzed. Predictors of (1) reaching a CD4:CD8 ≥1.2 on two separate follow-up visits >30 days apart, and (2) ADI and death from all causes were assessed using adjusted proportional hazards models.

Results

4206 patients were studied for a median of 2.77 years and 306 (7.2%) normalized their CD4:CD8 ratio. Factors associated with achieving a normal CD4:CD8 ratio were: baseline CD4+ T-cells >350 cells/mm³, baseline CD8+ T-cells <500 cells/mm³, time-updated HIV RNA suppression, and not reporting sex with other men as a risk factor. There were 213 ADIs and 214 deaths in 13476 person-years of follow-up. Achieving a normal CD4:CD8 ratio was not associated with time to ADI/death.

Conclusions

In our study, few individuals normalized their CD4:CD8 ratios within the first few years of initiating modern cART. This large study showed no additional short-term predictive value of the CD4:CD8 ratio for clinical outcomes after accounting for other risk factors including age and HIV RNA.

HIV Drug-Resistant Patient Information Management, Analysis, and Interpretation

Introduction

The science of information systems, management, and interpretation plays an important part in the continuity of care of patients. This is becoming more evident in the treatment of human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS), the leading cause of death in sub-Saharan Africa. The high replication rates, selective pressure, and initial infection by resistant strains of HIV infer that drug resistance will inevitably become an important health care concern. This paper describes proposed research with the aim of developing a physician-administered, artificial intelligence-based decision support system tool to facilitate the management of patients on antiretroviral therapy.

Methods

This tool will consist of (1) an artificial intelligence computer program that will determine HIV drug resistance information from genomic analysis; (2) a machine-learning algorithm that can predict future CD₄ count information given a genomic sequence; and (3) the integration of these tools into an electronic medical record for storage and management.

Conclusion

The aim of the project is to create an electronic tool that assists clinicians in managing and interpreting patient information in order to determine the optimal therapy for drug-resistant HIV patients.

Biomarkers predicting progression of human immunodeficiency virus-related disease

Biomarkers in predicting the progression of HIV infected individuals to a state of HIV disease (AIDS) are studied over more than a decade. Use of surrogate markers in the past for tracking clinical progression of the disease was limited, as little knowledge existed about the disease. The aim of this review was to address various changes in biomarker related studies taking place over the last five years, especially the trend towards use of newer biomarkers and experimentation with novel molecules in a quest for halting HIV disease progression. An open search of PUBMED database was made with search 'key words' such as 'Biomarkers' and 'AIDS (Acquired Immunodeficiency Syndrome)'.The following were the inclusion criteria for articles: a) all articles published in English language, b) years of publication between 2002-2008 and c) articles limited to adult population. This yielded a total of 417 articles. The criteria used for further judging these studies considered a) type of research design, b) number of biomarkers studied, c) validity of the biomarkers, d) techniques to assess the biomarkers and the impact of the studies in furthering biomarker research, e) sample size for the studies and f) article title or abstracts having the following key words 'biomarker' or 'biomarkers' and 'predict progression to AIDS'. A total of 27 abstracts were reviewed and 12 studies met the above criteria. These 12 different studies consisted of three reviews, four cohort designs, three cross-sectional designs, one each of an observational, and an in-vitro design. The various biomarkers emerging as a results were primarily a mix of viral, neural, immunological, HLA (human leukocyte antigen) markers along with lymphocyte counts. Although there have been quite a few advancements in biomarker-related studies, majority of the novel biomarkers discovered need to be further evaluated and replicated in bigger, long-term efficacy trials. Efforts should also be made to discover newer genetic markers of disease progression. Biomarker feedback, a new concept, can be utilized in future studies addressing prevention of HIV infection or halting disease progression.

Development of an HIV Clinical Cohort Database for Enhancing Epidemiologic Surveillance in Hong Kong

The Hong Kong HIV Cohort Database is an observational cohort including all patients enrolled in 2 HIV specialist clinical services in Hong Kong. Basic demographics, HIV transmission category, and the diagnoses of AIDS were captured using a standardized template. As of December 2006, 2132 HIV cases had been registered in the database, representing two thirds of all reports submitted to the government’s surveillance system. Non-Chinese and young females ≤24 years were less represented in the cohort. Description of cohort cases was, however, more complete in terms of transmission category and presentation with AIDS-defining illnesses. Overall, Pneumocystis jirovecci, tuberculosis, and systemic mycosis accounted for a majority of AIDS cases within 3 months of HIV diagnosis. There was a gradual rise of HIV positive men having sex with men in the cohort, notably after 2002, an observation also made in other Asian countries.

Modified Kigali combined staging predicts risk of mortality in HIV-infected adults in Lusaka, Zambia

We assessed the utility of the modified Kigali combined (MKC) staging system for predicting survival in HIV-infected Zambian adults in a prospective, longitudinal, open cohort. From 1995 to 2004, HIV-discordant couples (one HIV-infected partner and one HIV-negative partner) were recruited from couples' voluntary counseling and testing centers in Lusaka, Zambia and followed at 3-month intervals. MKC stage, which incorporates clinical stage with erythrocyte sedimentation rate (ESR), hematocrit, and body mass index (BMI), was determined at enrollment. Kaplan-Meier survival and Cox proportional hazard methods were used to calculate median survival and relative hazards. We enrolled 1479 HIV-discordant couples with a combined 7305 person-years of follow-up. Among HIV-infected participants over the 9-year study period, there were 333 confirmed deaths. The time to 50% mortality was 8.5 years with MKC stage 1 and 2 disease compared to 3.7 years with MKC stage 4 disease at enrollment. Survival rates at 3 years were 85% with MKC stage 1 and 2 disease, 74% with MKC stage 3 disease, and 51% with MKC stage 4 disease. A total of 275 HIV-negative partners seroconverted during follow-up. In comparison, survival rates at 3 years were 94% for HIV-negative participants and 92% for participants who seroconverted during follow-up. In multivariate analysis, MKC stage 4 disease (HR = 3.7, 95% CI = 2.7-5.0) remained a strong predictor of mortality. Incorporating ESR, hematocrit, and BMI with clinical staging is a powerful, low-cost tool to identify HIV-infected adults at high risk for mortality.

Prognostic indicators for the development of AIDS in HIV antibody positive haemophiliac patients: results of a three-year longitudinal study

In February 1986, 40 out of 75 adult patients with haemophilia A attending St. James's University Hospital were human immunodeficiency virus (HIV) antibody positive. Over a three-year period these patients were prospectively studied with regard to possible prognostic indicators for the development of the acquired immune deficiency syndrome (AIDS). Using the Centres for Disease Control (CDC) classification of HIV infection, 17 patients (42.5%) developed group 4 disease during this time, giving an actuarial three-year progression rate of 44%, and 5 patients (12.5%) died. The following parameters measured at recruitment were found independently to predict progression to AIDS: a serum beta 2-m level of greater than 3.5 mg/l, (chi 2 = 15.95, P less than 0.001), a serum IgA level of greater than 4.5 milligram(s) (chi 2 = 6.08, P less than 0.02) and p24 antigenaemia (chi 2 = 5.7, P less than 0.05). The actuarial three-year progression rate in those patients abnormal by two or more of these parameters was 100% (n = 7), compared to only 7% in patients who were normal by all three values (n = 15). CD4+ lymphocyte counts and CD4+:CD8+ ratios were significantly lower in HIV positive compared with HIV negative patients (P less than 0.01), but did not predict the development of AIDS.

Impact of the Menstrual Cycle on Immunologic Markers in HIV-Infected Taiwanese Women

OBJECTIVE

This study tested the relationship between cellular immunity and the menstrual cycle in Taiwanese HIV-infected and normal women.

METHODS

From October 1997 to October 2001, 21 HIV-seropositive women and 30 controls were enrolled in this study. Blood was sampled for hormone profile (estradiol and progesterone) and immunophenotyping with flow cytometry during the follicular and luteal phases. Immunophenotyping included total blood cell count, lymphocyte count, CD4+ cells, CD8+ cells, and their activation markers, including CD25, CD69, HLA-DR, and CD38.

RESULTS

The proportion of CD8+ T cells increased during the follicular phase and activating antigens (HLADR and CD38) were elevated on CD8+ T cells of HIV-seropositive women. All these alterations seemed unrelated to the menstrual cycle.

CONCLUSIONS

The CD8+ T cells were increased and activated in women with HIV infection but these alterations were not affected by the menstrual cycle. Therefore, sex hormones seem not to affect the course of HIV infection.

Oro-facial lesions and CD4 counts associated with HIV/AIDS in an adult population in Oyo State, Nigeria

OBJECTIVE

The objective of this study was to define the oro-facial lesions associated with Human Immunodeficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS) in an adult population in Oyo state, Nigeria and to relate these with the level of immune suppression as measured by the CD4 counts.

MATERIALS AND METHOD

The study population consisted of 679 consecutive subjects who were seen at the state-owned blood bank. Information on demography, medical and medication histories were obtained. Oro-facial examinations were carried out according to Greenspan et al [Oral Surg Oral Med Oral Pathol (1992)73:142-144]. HIV sero-prevalence status was determined for all patients. CD4+ T-lymphocyte count was carried out for those sero-positive for HIV and 31 randomly selected HIV-negative subjects. Data were analyzed using the chi-square test, Fisher's exact test, Student's t-test and odds ratio where appropriate.

RESULTS

Eighty-one (11.9%) of the entire study sample were confirmed HIV positive. The prevalence of specific oral lesions by HIV sero-status revealed that pseudomembranous oral candidiasis and angular cheilitis occurred significantly and more frequently in HIV-positive subjects (33.3 and 21% respectively) than those who were HIV negative (4.3 and 1.8% respectively, P < 0.05). The mean CD4 count of the HIV-positive subjects was 452 cells mm(-3), s.d. 137, while it was 602 cells mm(-3), s.d. 251, for the HIV negatives. The difference was statistically significant (P = 0.000). Forty-four (66.7%) subjects with CD4 counts <500 cells mm(-3) had oro-facial lesions whereas among those with CD4 counts >500 cells mm(-3) only 22 (33.3%) had oro-facial lesions (OR = 4.57).

CONCLUSION

The type of oro-facial lesions most commonly associated with HIV/AIDS in Oyo state, Nigeria, has been shown to be pseudomembranous oral candidiasis. This was followed by angular cheilitis. These lesions, although found in HIV-negative subjects, were in a lower proportion as compared with HIV-positive subjects. Mean CD4 counts were lower in HIV-positive subjects and this was associated with greater prevalence of oro-facial candidiasis and angular cheilitis.

Effect of Plasmodium falciparum malaria on concentration of HIV-1-RNA in the blood of adults in rural Malawi: a prospective cohort study

BACKGROUND

Raised HIV viral load in blood has been associated with accelerated disease progression and increased transmission of infection. To assess the effect of Plasmodium falciparum malaria on concentrations of HIV in blood, we did a prospective cohort study in Malawi.

METHODS

We recruited 367 HIV-1-infected adults. Among 334 people aparasitaemic at baseline, 148 had at least one malaria episode during follow-up and received antimalarial treatment. Of these, 77 had HIV-1-RNA measurements at baseline, during malaria, and post-malaria. We used linear regression with generalised estimating equations to assess effect of four definitions of malaria (any parasitaemia, parasite density > or =2000/microL, febrile parasitaemia, and febrile parasitaemia with parasite density > or =2000/microl) on changes in log HIV-1 RNA, overall and by baseline CD4 count.

FINDINGS

With malaria defined as any parasitaemia, HIV-1-RNA concentration almost doubled between baseline (median 96215 copies per mL) and malaria (168901 copies per mL), a 0.25 (95% CI 0.11-0.39) log increase in mean RNA concentration. HIV-1-RNA concentration fell to median 82058 copies per mL by about 8-9 weeks post-malaria. Increases in HIV-1-RNA were greatest for people with fever, parasite density 2000/microL or greater, and CD4 count more than 300 cells per muL, in whom concentrations rose from median 38483 copies per mL at baseline to 196098 copies per mL during malaria, a mean log increase of 0.82 (95% CI 0.55-1.10, p<0.0001), and fell to median 75331 copies per mL post-malaria. People who remained aparasitaemic showed no changes in HIV-1-RNA concentration.

INTERPRETATION

HIV-infected individuals with malaria have a significantly increased viral load, which might enhance HIV transmission and accelerate disease progression.

Recovery from and consequences of severe iatrogenic lymphopenia (induced to treat autoimmune diseases)

To ascertain the consequences of severe leukopenia and the tempo of recovery, we studied the immunity of 56 adult patients treated for multiple sclerosis or systemic sclerosis with autologous CD34 cell transplantation using extremely lymphoablative conditioning. NK cell, monocyte, and neutrophil counts recovered to normal by 1 month; dendritic cell and B cell counts by 6 months; and T cell counts by 2 years posttransplant, although CD4 T cell counts remained borderline low. Initial peripheral expansion was robust for CD8 T cells but only moderate for CD4 T cells. Subsequent thymopoiesis was slow, especially in older patients. Importantly, levels of antibodies, including autoantibodies, did not drop substantially. Infections were frequent during the first 6 months, when all immune cells were deficient, and surprisingly rare (0.21 per patient year) at 7-24 months posttransplant, when only T cells (particularly CD4 T cells) were deficient. In conclusion, peripheral expansion of CD8 but not CD4 T cells is highly efficient. Prolonged CD4 lymphopenia is associated with relatively few infections, possibly due to antibodies produced by persisting pretransplant plasma cells.

The natural course of disease following HIV-1 infection in dar es salaam, Tanzania: a study among hotel workers relating clinical events to CD4 T-lymphocyte counts

Current HIV management guidelines are based on natural history studies from the developed world. Data on the similarity of the natural course of HIV-1 infection conflict with studies in the developing world. A cohort of 1887 hotel workers with no access to antiretroviral therapy was followed between 1990 and 1998 in Dar es Salaam through annual clinical evaluations and CD4+ T-lymphocyte (CD4 cell) count determinations. 196 (10.4%) were HIV-1 sero-prevalents; 133 (7.9%) were HIV-1 sero-incidents; and 1558 (82.6%) remained HIV seronegative. Follow-up duration was 13,719 and 82,742 months for HIV-1 seropositives and HIV seronegatives respectively. Clinical events occurred at median CD4 cell counts similar to those previously reported from the developed world, but death occurred at higher counts. Off-duty last 6 months, chronic diarrhoea and a faster CD4 cell count decline were associated with faster disease progression and death. In Tanzania HIV natural history is similar to that from the developed world and similar management guidelines could be employed.

Alcohol consumption and HIV disease progression: are they related?

BACKGROUND

The relationship between alcohol consumption and HIV disease progression has received limited attention in the era of highly active antiretroviral therapy (HAART).

METHODS

We assessed CD4 cell count, HIV RNA levels, and alcohol consumption in the past month, defined as none, moderate, and at risk, in 349 HIV-infected people with a history of alcohol problems. We investigated the relationship between alcohol consumption and HIV disease markers CD4 cell count and HIV RNA level, stratified by HAART use, using multivariable regression.

RESULTS

No significant differences in CD4 cell count or HIV RNA level were found across the categories of alcohol consumption for patients who were not receiving HAART. However, among patients who were receiving HAART, log HIV RNA levels were significantly higher in those with moderate (2.17 copies/ml) and at-risk (2.73 copies/ml) alcohol use compared with none (1.73 copies/ml; p = 0.006). CD4 cell counts in those with moderate (368 cells/microl) and at-risk (360 cells/microl) alcohol use were lower than for subjects who reported none (426 cells/microl; p = 0.07).

CONCLUSION

Among patients who have a history of alcohol problems and are receiving antiretroviral treatment, alcohol consumption was associated with higher HIV RNA levels and lower CD4 counts. No comparable association was found for similar patients who were not receiving HAART. Addressing alcohol use in HIV-infected patients, especially those who are receiving HAART, may have a substantial impact on HIV disease progression.

Prevalence of hepatitis C and coinfection with HIV among United States veterans in the New York City metropolitan area

OBJECTIVES

The aims of this study were to determine the prevalence of hepatitis C virus (HCV) infection and its risk factors, as well as the prevalence of coinfection with HIV and its risk factors, among patients with confirmed HCV infection.

METHODS

In a 1-day cross-sectional HCV survey at six Veterans Affairs Medical Centers in the New York City metropolitan area, all 1943 patients undergoing phlebotomy for any reason were asked to be tested for HCV antibody by enzyme immumoassay (EIA). A total of 1098 patients (57%) agreed to HCV testing, 1016 of whom also completed a questionnaire on demographics and HCV risk factors. All HCV EIA(+) samples were confirmed by HCV RNA and HCV recombinant immunoblot assay (RIBA) antibody testing and were also tested for HCV viral load, HCV genotype, and antibodies to HIV in a blinded fashion.

RESULTS

The prevalence of confirmed HCV infection was 10.6% (95% CI = 8.7-12.4%), and the prevalence of HCV viremia was 8.2% (95% CI = 6.6-9.8%). The rate of HCV viremia among anti-HCV(+) patients was 77.6%, and HCV genotype 1 was present in 87.5% of viremic patients. Independent risk factors for HCV infection were injection drug use (OR = 35.6, 95% CI = 16.9-75.2), blood exposure during combat (OR = 2.6, 95% CI = 1.2-5.7), alcohol abuse (OR = 2.4; 95% CI = 1.2-4.8), and service in the Vietnam era (OR = 2.1; 95% CI = 1.0-4.5). Coinfection with HIV was present in 24.8% of anti-HCV(+) patients. The only independent risk factor for coinfection was age <50 yr (OR = 3.7, 95% CI = 1.1-12.1).

CONCLUSIONS

U.S. veterans who are receiving medical care at VA medical centers in the New York City metropolitan area have a much higher rate of chronic hepatitis C than the general population, with a high frequency of genotype 1. Coinfection with HIV is very common in patients with confirmed HCV infection, and these patients should routinely be offered HIV testing.

Posttraumatic stress disorder in women attending human immunodeficiency virus outpatient clinics

This study examined posttraumatic stress disorder (PTSD) in human immunodeficiency virus (HIV)-positive women seeking medical care. Specifically, we examined traumatic life events, psychiatric treatment, social support, and demographic characteristics in relation to level of PTSD symptoms. We recruited and obtained informed consent from 47 ethnically diverse HIV-positive women from two HIV outpatient clinics in a county medical system. Forty-one of these women provided complete data on measures assessing demographics, traumatic life events, PTSD symptoms, social support, and psychotherapy/medical history. Analysis of the data demonstrated that a high percentage (42%) of the HIV-positive women were likely to meet criteria for full current PTSD, and an additional 22% for partial PTSD. Of the women likely with full PTSD, 59% were not receiving any psychiatric treatment, and of those likely with partial PTSD, 78% were not receiving any psychiatric treatment. Also, women reported having experienced a mean of 12 traumatic life events. As hypothesized, the level of PTSD was significantly related to the number of life events experienced (rs = 0.52, p < 0.001), and to perceived social support from friends (rs = - 0.34, p < 0.02) and family (rs = - 0.29, p < 0.05). Given the high percentages of women who were found to have experienced traumatic life events and high levels of PTSD symptoms, it seems important to assess and treat PTSD in women with HIV/acquired immune deficiency syndrome (AIDS).

Cofactors for HIV disease progression in a cohort of homosexual and bisexual men

To evaluate cofactors for progression of HIV infection, the authors identified 370 men with well-defined seroconversion dates and cofactor data among participants in the San Francisco City Clinic Cohort (SFCCC). Postseroconversion substance use, sexual behavior, and sexually transmitted diseases were assessed using multivariate proportional hazards models. Weekly use of hallucinogens strongly and independently predicted death (relative hazard [RH], 2.59; 95% confidence interval [CI], 1.56-4.28), as well as diagnosis of AIDS; weekly cocaine use also predicted mortality. Receptive anal intercourse with ejaculation was independently associated with mortality risk (RH, 1.45; 95% CI, 1.02-2.04) and AIDS. The associations of accelerated progression with weekly use of recreational drugs and unprotected receptive anal intercourse need to be confirmed in other prospective cohorts.

Prognostic Value of Plasma Markers of Immune Activation in Patients with Advanced HIV Disease Treated by Combination Antiretroviral Therapy

We assessed the prognostic role of plasma levels of beta2-microglobulin, TNF-alpha, sTNFR-II, and IFN-gamma on the progression to AIDS in patients mostly treated with combination antiretroviral therapies. HIV-1-infected patients with advanced HIV disease (baseline CD4+ cell count between 50 and 250 x 10(6)/L) were included in a prospective cohort followed up for 36 months. In the 113 patients included, 22 first AIDS-defining events were reported. Cumulative probability of AIDS was 12% at M12, 18% at M24, and 20% at M36. Using a Cox model, the baseline level of sTNFR-II (hazard ratio of 3.75 for sTNFR-II > or =10 ng/ml vs < 10 ng/ml, P = 0.01) was associated with progression to AIDS. sTNFR-II remained a prognostic factor before and after the introduction of combinations of antiretrovirals. Whether or not this marker is of value in patients exclusively treated with highly active antiretroviral therapy needs to be assessed in specific studies.

Asymptomatic HIV patient with cardiomyopathy and nephropathy: case report and literature review

We report a previously asymptomatic HIV patient with high CD4 lymphocyte count and low HIV1 viral load who developed cardiac and renal disease. Management with ACE inhibitor, diuretics and triple antiretroviral combination therapy yielded a rapid clinical response. An understanding of the spectrum of renal and cardiac derangements is essential for clinicians in managing patients with HIV disease.

Prognostic value of single measurements of beta-2-microglobulin, immunoglobulin A in HIV disease after controlling for CD4 lymphocyte counts and plasma HIV RNA levels

The interrelationships between the CD4 lymphocyte count, plasma viral load [human immunodeficiency virus (HIV) RNA], beta-2-microglobulin (beta2-M) and immunoglobulin A (IgA) and the mortality risk was explored in 234 HIV-infected individuals (median CD4 count 230 cells/mm3, range 1-1,247). Product-moment correlation analysis was used to study the association between beta2-M, IgA and HIV RNA. A proportional hazards Cox model was used to estimate the relative hazard (RH) of death. Both beta2-M (r = 0.49, p < 0.0001) and IgA (r = 0.42, p < 0.0001) were positively correlated with HIV RNA. High beta2-M levels were associated with an increased risk of death in both univariate Cox analysis and after adjustment for HIV RNA, CD4 lymphocyte count and age [RH = 1.16 per 100 nmol/l higher beta2-M, 95% confidence interval (CI) 1.05-1.27]. Raised IgA levels were associated with shorter survival in individuals with a CD4 count above 50 cells/mm3 in univariate analysis as well as after adjusting for age and CD4 lymphocyte count (RH = 1.19 per 10 micromol/l higher IgA, 95% CI 1.01-1.39). However, this association was no longer significant after further adjusting for HIV RNA. In conclusion, beta2-M levels provided additional prognostic information for survival to the information obtained by CD4 count and HIV RNA levels, whereas serum IgA only was a weak prognostic marker in this fairly progressed cohort.

Tuberculosis (TB) and HIV infection are independently associated with elevated serum concentrations of tumour necrosis factor receptor type 1 and beta2-microglobulin, respectively

The aim of this study was to identify immune markers that are independently associated with HIV infection or TB in vivo. Using commercially available assays, we measured concentrations of five immune markers in sera from 175 out-patients attending medical clinics in Cote D'Ivoire and Ghana, West Africa. Patients were categorized into groups with TB only (TB+HIV-, n = 55), TB and HIV co-infection (TB+HIV+, n = 50), HIV infection only (TB-HIV+, n = 35), or neither infection (TB-HIV-, n = 35). TB+HIV+ and TB-HIV+ groups were matched for blood CD4+ lymphocyte count. Mean +/- s.d. concentrations of beta2-microglobulin were similarly increased in both the TB-HIV+ (5.3+/-2.1 microg/ml, P<0.0001) and the TB+HIV+ (5.0+/-1.5 microg/ml, P<0.0001) groups compared with the TB-HIV- group (2.2+/-1.8 microg/ml), but were only slightly increased in the TB+HIV- group (3.2+/-1.8 microg/ml, P = 0.01). In contrast, mean serum concentrations of soluble tumour necrosis factor receptor type I (sTNF-RI) were similarly elevated in the TB+HIV- (1873+/-799 pg/ml, P<0.0001) and TB+HIV+ (1797+/-571 pg/ml, P<0.0001) groups compared with uninfected subjects (906+/-613 pg/ml), but there was only a small increase in sTNF-RI in the TB-HIV+ group (1231+/-165 pg/ml, P = 0.03). Both TB and HIV infection were associated with substantial elevation of serum concentrations of soluble CD8, soluble CD54, and sTNF-R type II. Analysis of additional samples from groups of TB+HIV- and TB+HIV+ patients receiving anti-TB treatment showed significant and equal reductions in mean serum sTNF-RI concentrations, but no significant change in mean beta2-microglobulin. Thus, serum beta2-microglobulin and sTNF-RI serve as relatively independent markers of HIV infection and TB, respectively, in studies of co-infected persons.

Human immunodeficiency virus type 1 replication, immune activation, and circulating cytotoxic T cells against uninfected CD4+ T cells

Cytotoxic T lymphocytes (CTL) that kill uninfected activated CD4+ T cells can be induced in vitro by stimulating CD8+ T cells with activated autologous CD4+ T cells. Similar CTL have been detected in circulating T cells from human immunodeficiency virus type I (HIV)-infected individuals. To define the in vivo correlates of this CTL activity, we studied plasma beta-2 microglobulin and HIV RNA levels, T-lymphocyte subset counts, and expression of CD28 on CD8+ T cells concurrently with circulating CTL activity against uninfected CD4+ T cells in 75 HIV-infected individuals at different stages of disease progression. Mean values of each parameter were compared in subsets of this group of 75 segregated on the basis of this CTL activity. The group with CTL against uninfected activated CD4+ T lymphocytes had more CD8+ T cells, a higher percentage of CD28 CD8+ T cells, and higher plasma levels of HIV RNA and beta-2 microglobulin. CTL against uninfected activated CD4+ T cells were predominantly CD28 and in HIV-infected individuals were associated with immunological or virological evidence of progressive disease. In HIV infection, circulating CTL activity against uninfected activated CD4+ T lymphocytes is associated with immune activation, CD8+ T cell expansion, accumulation of CD28 CD8+ T cells, and inadequate suppression of HIV replication.

Stress and coping: the psychoneuroimmunology of HIV/AIDS

A considerable body of evidence, reviewed in this chapter, suggests that psychosocial factors play an important role in progression of HIV infection, its morbidity and mortality. Psychosocial influences relating to faster disease progression include life-event stress, sustained depression, denial/avoidance coping, concealment of gay identity (unless one is rejection-sensitive), and negative expectancies. Conversely, protective psychosocial factors include active coping, finding new meaning, and stress management. In studying long survivors of HIV/AIDS, our group has found protective effects on health of life involvement, collaborative relationship with doctor, emotional expression, depression (conversely), and perceived stress (conversely). Reviewed and discussed are psychoneuroimmunological pathways by which immune and neuroendocrine mechanisms might link psychosocial factors with health and long survival. Finally, biological factors are also a major determinant of disease progression and include genetics and age of the host, viral strain and virulence, medication and several immune response factors on which psychosocial influences could impact.

Beta 2-microglobulin and immunoglobulins are more useful markers of disease progression in HIV than neopterin and adenosine deaminase

Reference change values of six biochemical quantities (beta 2-microglobulin, neopterin, adenosine deaminase and immunoglobulins IgA, IgG and IgM) have been established in asymptomatic human immunodeficiency virus (HIV)-infected patients following the method described by Harris and Yasaka in 1983. Patients included in the evaluation were classified as A1, A2 or A3 according to the classification of the Centers for Disease Control (CDC) (January 1993). All patients were followed-up quarterly, with a minimum of four samples each available for statistical analysis. The main objective of this paper was to study whether differences found to be greater than calculated reference change values could predict clinical or immunological worsening in patients' status. Retrospective analysis was made in asymptomatic patients (n = 256) included in an HIV infection protocol carried out in our hospital. Of these patients, 179 showed clinical or immunological worsening during the study period and 77 maintained their clinical and immunological status. Changes in beta 2-microglobulin showed the greatest sensitivity to detect clinical or immunological worsening (43.0%), whereas changes in adenosine deaminase showed the lowest (21.8%). Clinical or immunological worsening in 169 of the 179 patients was detected by one of the six biochemical quantities evaluated. Ten patients showed clinical or immunological worsening, although differences between measurements were lower than the reference change values calculated. Of 77 patients whose clinical state did not deteriorate, there was a change in biochemical analytes greater than the reference value calculated in 29 patients (a period of 12 months had elapsed since detection). In 48 patients, no increases greater than calculated reference change values were detected. The sensitivity obtained using the six analytes was 94.4% and the specificity was 62.3%.

Comparison of clinical manifestations of HIV infection among women by risk group, CD4+ cell count, and HIV-1 plasma viral load. HER Study Group. HIV Epidemiology Research

OBJECTIVES

To compare the prevalence of HIV-related symptoms, physical examination findings, and hematologic variables among women whose risk for HIV is injection drug use since 1985 as opposed to sexual contact and to evaluate the influence of HIV plasma viral load and CD4+ cell count on clinical manifestations according to risk.

METHODS

Participants of the HIV Epidemiology Research Study (HERS; a multicenter, prospective, controlled study of HIV infection in women) were administered a risk behavior and symptom interview, underwent a physical examination, and received hematologic testing, including CD4+ cell counts done on study entry. Plasma HIV-1 viral loads were performed on stored frozen plasma using an ultrasensitive branched-DNA (b-DNA) signal amplification assay. CD4+ counts were categorized as <200 cells/microl, 200 to 499 cells/microl, or > or =500 cells/microl, and HIV viral loads were characterized in tertiles.

RESULTS

Cross-sectional analysis was conducted on data available for 724 HIV-infected women: 387 had a history of intravenous drug use and 337 were infected through heterosexual contact. The median CD4+ count was 376 cells/microl; the median HIV-1 viral load was 1135 copies/ml; and 281 of 724 HIV-infected women (38.8%) had an undetectable HIV-1 viral load. In analyses adjusting for CD4+ cell level alone and for plasma viral load combined with CD4+ cell level, injection drug users (IDUs) were more likely than those infected through heterosexual contact to report a recent episode of memory loss and weight loss, but less likely to have recent episodes of genital herpes; to have enlarged livers and a body mass index (BMI) <24, and to have hematocrit levels <34% and platelet counts <150,000 cells/ml. After adjustment for CD4+ cell level and risk group, high and medium HIV-1 plasma viral load levels were associated with the presence of oral hairy leukoplakia on examination, and only the highest level of plasma viral load was associated with recent histories of fever and thrush, oral hairy leukoplakia, pseudomembranous candidiasis, and BMI <24 on examination, and hematocrit <34%.

CONCLUSIONS

In this cohort of women, the distribution of HIV-1 plasma viral load was lower than that previously reported in populations of HIV-infected men. This study also shows some differences in frequency of signs, symptoms, and laboratory values between risk groups of HIV-infected women, but these results may be due to effects of injection drug use rather than HIV infection. Signs and symptoms identified as associated with increasing levels of viral load that were not different across risk groups suggest more direct association of these findings with HIV infection.

Human serum beta2-microglobulin levels: correlation with total serum IgG and placental IgG transfer in HIV-infected and non-HIV infected individuals

The acquisition of maternal immunoglobulin G (IgG) is fundamental to the immune defence of the neonate. The receptor responsible for IgG transfer across the human placenta has also been implicated in the maintenance of IgG levels in the circulation. beta2-microglobulin is part of the Fc receptor (FcR) that has recently been purified from the human placenta. In HIV infection, increasing serum levels of total IgG and beta2-microglobulin are observed as the disease progresses. Herein, we have investigated the correlation between beta2-microglobulin and total serum IgG levels in HIV-seropositive mothers and their term neonates (HIV group, n = 37), as well as in HIV-seronegative mothers and their term neonates (control group, n = 50). Serum maternal beta2-microglobulin was directly correlated with total serum IgG levels in HIV-infected mothers (r = 0.58; P = 0.0002), but not in healthy HIV-seronegative mothers (r = -0.20; P = 0.16). Maternal serum beta2-microglobulin was also inversely correlated with placental antibody transfer of total IgG in mother-newborn pairs from the HIV group (r = 0.38; P = 0.02), but not from the control group (r = 0.15. P = 0.31). These results seem to indicate that, in HIV infection, elevated serum beta2-microglobulin levels could be involved in maintenance of abnormally high total serum IgG concentrations; by interfering with the binding of IgG to Fc receptors at the maternal-fetal interface, they might also reduce IgG transfer. By contrast, in normal non-HIV infected individuals, serum beta2-microglobulin levels do not appear implicated in regulation of these two phenomena.

CD4+ and CD8+ lymphocytes and HIV RNA in HIV infection: high baseline counts and in particular rapid decrease of CD8+ lymphocytes predict AIDS

OBJECTIVE

To study the progression of HIV infection in relation to immunological and virological variables with emphasis on the role of CD8+ lymphocytes.

DESIGN

Prospective follow-up from October 1991 of patients observed for at least 18 months allowing nucleoside analogue monotherapy. Peripheral CD4+ and CD8+ lymphocyte counts, HIV RNA, and soluble CD8 were analysed by statistics allowing the evaluation of serial data, avoiding time points with concurrent infections.

SETTING

Tertiary university clinic.

PATIENTS

Forty-nine patients were followed for 52.6 months, baseline CD4+ count of 300 x 10(6)/l, sample interval of 5.9 months (medians).

MAIN OUTCOME MEASURES

AIDS, death, and CDC groups B- or C-related events.

RESULTS

AIDS developed in 28% of patients. Baseline CD8+ counts above the median were significantly associated with AIDS development; the best Cox model included CD8+ cells and the log10RNA/CD4 ratio. A decline in CD8+ counts relative to baseline most significantly predicted AIDS, along with higher baseline RNA and actual CD4+ counts of less than 200 x 10(6)/l. Levels of soluble CD8 in the blood relative to total CD8+ cells significantly increased in patients developing AIDS. Death occurred in 16% of the patients, and was only predicted by high CD8+ cell counts at baseline. CDC B- and C-related events occurred in 35% of the patients and were best predicted by high baseline CD8+ counts and high RNA levels.

CONCLUSIONS

The serial quantitation of CD8+ lymphocytes gave highly significant predictive information on the natural progression of HIV infection in patients with moderate to severe immune deficiency. Our data suggest that the hyperactivation of CD8+ lymphocytes is an important factor leading to a numerical decrease of CD8+ lymphocytes in progressive HIV infection.

The prognostic significance in HIV infection of immune activation represented by cell surface antigen and plasma activation marker changes

One hundred and eighteen HIV-infected homosexual men without AIDS and 40 control seronegative homosexual men were assessed for 23 parameters reflecting immune activation to determine prognostic significance for occurrence of AIDS. Samples cryopreserved in 1987-1989 were analyzed, with AIDS occurrence determined by mid-1992. Cell surface antigens assessed on the major lymphocyte subsets were HLA-DR, CD38, CD71, and CD25. Soluble serum molecules assessed were tumor necrosis factor alpha, soluble TNFalpha receptor II, soluble IL-2 receptor alpha, neopterin, and beta2-microglobulin. Using a proportional hazards model, prognostic markers included decreased CD4 number and percentage; increased sIL-2R, neopterin, and beta2M; increased percentage HLA-DR+ total lymphocytes and CD4+ cells; increased CD38+ total lymphocytes and CD8+ cells; increased CD71+ total lymphocytes and CD4+ cells; and decreased CD25+ total lymphocytes and CD19+ cells. After adjustment for CD4 cell levels, sIL-2R, neopterin, beta2M, and CD25+ CD19 cells remained significant, indicating that additional information about AIDS risk was provided by these markers.

Distribution of CD4+ T-lymphocytes levels in patients with clinical symptoms of AIDS in three west African countries

OBJECTIVES

To study the CD4 T-lymphocyte distribution in patients with clinical signs suggestive of AIDS in West Africa.

DESIGN AND METHODS

Selected patients had clinical AIDS, according to the WHO clinical definition of AIDS in Africa. Serum samples were tested for the presence of HIV antibodies with two different enzyme immunoassays (EIA), and whole blood was used to determine the CD4 lymphocyte levels of each patient, using the TRAx CD4 Test Kit.

RESULTS

In patients with AIDS, the mean CD4+ cell level was 466/microliter; 34% of patients had less than 200/microliter and 62.1% less than 400/microliter. In patients with clinical AIDS but without HIV antibodies, the mean CD4+ cell level was 807/microliter; with 4% below 200/microliter and 14.7% below 400/microliter. The optimal CD4+ cell cut-off between the two groups of patients (with and without antibody to HIV) was 400/microliter.

CONCLUSIONS

The mean CD4 cell levels of AIDS patients was more than twice the 200 CD4+ cells/microliter which, alone or associated with clinical criteria is used to differentiate HIV seropositive patients with and without AIDS. A cut-off of 400 T-lymphocyte equivalents per microlitre (TLE/microliter) will be more appropriate. Only 4% of the anti-HIV negative patients had < 200 CD4 TLE/microliter, and could be infected with unknown immunodeficiency viruses.

Human immunodeficiency virus infection, Part I

Initially recognized in 1982, acquired immunodeficiency syndrome (AIDS) has been the leading cause of death among young adults in the United States for much of this decade, and it has had a devastating impact on people in the developing world. It is estimated that 42 million people worldwide have been infected with human immunodeficiency virus (HIV), the virus that causes AIDS, and that almost 12 million people have died from AIDS-related diseases through 1997. Among these 12 million are 3 million children. Two thirds of the more than 30 million people with HIV or AIDS reside in sub-Saharan Africa. In the United States, 641,086 patients have been diagnosed with AIDS through 1997, and at least 385,000 have died. However, for the first time, new highly active antiretroviral therapies that include multiple drugs that attack the virus at several sites have slowed the progression from HIV to AIDS and from AIDS to death for those infected with HIV. The cumulative effect of these changes has been a reduction in both AIDS incident cases and AIDS deaths. Recent epidemiologic trends indicate that the proportion of AIDS incident cases and new HIV infections are increasing among women, African-Americans, and Hispanics, and the infections are more likely to be acquired through heterosexual transmission. The clinical management of HIV infection and AIDS has become increasingly complex in recent years. In addition to complete medical and social histories and physical examinations, hematologic, biochemical, serologic, and immunologic laboratory tests are required to predict the likelihood that patients will develop opportunistic infections and other complications related to HIV infection. Among the most important laboratory tests are measurements of HIV in plasma (viral load) in conjunction with peripheral blood CD4+ helper T lymphocyte counts. These tests are potent predictors of disease progression and their results have become markers for clinical response to therapy. The development of highly active antiretroviral therapy has had a profound impact on the epidemiology of AIDS and on the lives of individual patients. Through combinations of antiretroviral drugs, especially protease inhibitors, viral suppression can be achieved. However, adherence to these complex medical regimens and drug interactions have been problems for many patients. In addition, numerous questions remain unanswered, most importantly those regarding the timing of the initiation of treatment, the durability of viral suppression and clinical response, and the optimal "salvage" regimens for patients failing therapy either clinically or virologically.

Effects of age at seroconversion and baseline HIV RNA level on the loss of CD4+ cells among persons with hemophilia. Multicenter Hemophilia Cohort Study

OBJECTIVE

To assess the impact of age at seroconversion and HIV RNA level in serum during early chronic infection on the initial values and subsequent trends (slopes) of CD4+ lymphocyte counts.

DESIGN AND METHODS

In a cohort of 137 HIV-1-positive hemophiliacs with well-estimated dates of seroconversion, baseline HIV RNA level was measured by reverse transcription PCR in serum specimens collected 12-36 months after the estimated date of seroconversion. Baseline values, 24 months after seroconversion, and slopes of CD4+ lymphocyte counts by age and HIV RNA quartile were examined by fitting random effects models that allowed for intrasubject variability.

RESULTS

Both age at seroconversion and HIV RNA level were associated with the CD4+ lymphocyte count at baseline and its subsequent slope. The baseline median CD4+ lymphocyte count was 620 x 10(6)/l. Within each HIV RNA quartile, the median CD4+ cell count of the oldest subjects (age 30-58 years) was about 200 x 10(6)/l lower and at least 350 x 10(6)/l lower than the median counts of the younger (age 11-29 years) and youngest (age 2-10 years) subjects, respectively. Within each age-group, the median CD4+ cell count differed by about 200 x 10(6)/l between subjects in the lowest compared with the highest HIV RNA quartiles. The mean slope of the CD4+ lymphocyte count after month 24 was linear on the square-root scale, steeper in children, and did not vary significantly by baseline HIV RNA quartile. There was large variation between subjects that was unexplained by differences in age and HIV RNA level.

CONCLUSIONS

By 24 months after HIV seroconversion, the oldest subjects and those with the highest HIV RNA levels during early chronic infection had experienced the most severe depletion of CD4+ cells. Subsequent declines in CD4+ cells varied little by early chronic HIV RNA level or age.

Determinants of progression of HIV infection in a Greek hemophilia cohort followed for up to 16 years after seroconversion

Our objectives are to describe the progression of HIV disease and to assess the influence of hemophilia-related variables, age at infection, and antibodies to cytomegalovirus infection (anti-CMV) in a Greek cohort of 158 HIV-1-positive hemophilic men, who received prospective follow-up for up to 16 years after infection. A total of 79 patients had died, representing a cumulative progression rate of 72.4% (95% confidence interval [CI], 56.6-83.3). A significant proportion of the mortality (30%) resulted from conditions not formally related to AIDS, with liver failure and cerebral hemorrhage predominant. At 16 years after seroconversion, 66 patients had developed clinical AIDS, a cumulative progression rate of 58.2% (95% CI, 47.1%-86.3%) whereas 15 years after infection 81.5% (95% CI, 74.2%-87.9%) of the patients had AIDS or a CD4 cell count <200 cells/mm3. Hemophilia-related variables or presence of anti-CMV were not significantly associated with disease progression. Age at infection was a strong prognostic factor for all three endpoints. Appropriate modeling showed a nonlinear age effect, with a steeper increase of relative hazard for patients >40 years of age at seroconversion. The age effect remained significant even after controlling for current CD4 cell count. Further investigation is required to elucidate the mechanisms of the age effect and the contribution of HCV coinfection on the disease progression.

CD8+ T-lymphocyte activation in HIV-1 disease reflects an aspect of pathogenesis distinct from viral burden and immunodeficiency

The CD8+ T-cell response is central to control and eventual elimination of persistent viral infections. Although it might be expected that CD8+ T-cell activation would be associated with a better clinical outcome during viral infections, in long-term HIV-1 infection, high levels of CD8+ T-cell activation are instead associated with faster disease progression. In this study, cell surface expression of CD38, a flow cytometric marker of T-cell activation of CD8+ T cells, had predictive value for HIV-1 disease progression that was in part independent of the predictive value of plasma viral burden and CD4+ T-cell number. Measurements of CD38 antigen expression on CD8+ T cells in HIV-1-infected patients may be of value for assessing prognosis and the impact of therapeutic interventions. The pathogenetic reason why CD8+ T-cell activation is associated with poor outcome in HIV-1 disease remains unknown. Possibly CD8+ T-cell activation contributes to immunologic exhaustion, hyporesponsiveness of T cells to their cognate antigens, or perturbations in the T-cell receptor repertoire.

HIV INFECTION IN HERPES ZOSTER

The interaction of Herpes zoster and Human Immunodeficiency Virus (HIV) was evaluated in 120 cases of herpes zoster admitted to our hospital and in 157 HIV positive cases detected in the hospital during the same period. The incidence of HIV seropositivity was 22.5 per cent in cases of herpes zoster without AIDS defining disease conditions. Whereas the incidence of Herpes zoster in cases detected to be HIV positive in the same period was 17.2 per cent. A large number of herpes zoster cases found to be HIV positive were in the sexually active age group viz. 21-30 years. Thoracic dermatomal segments were most frequently involved. None of the cases had severe complications or showed evidence of progression to symptomatic HIV disease.

Comparison of an amplified enzyme-linked immunosorbent assay with procedures based on molecular biology for assessing human immunodeficiency virus type 1 viral load

The sensitivity of the enzyme-linked amplified sorbent test (ELAST) was compared with those of other classic enzyme-linked immunosorbent assays (ELISAs), with or without previous acidic immunocomplex dissociation (ICD), in a series of samples at different stages of human immunodeficiency virus type 1 (HIV-1) infection. The limit of viral detection of ELAST was assessed with fresh HIV-1 preparations quantified by reverse transcription-PCR and with the P24 antigen (Ag) Sanofi Pasteur Calibrator containing lyophilized virus. The P24 Ag detection capacity of ELAST was compared with that of NASBA in samples obtained from infected subjects with less than 250 CD4+ cells. The results of the present study show that ELAST was the most sensitive method for detecting P24 Ag compared to classic ELISA and ICD plus ELISA. ELAST was able to detect 0.5 pg of P24 Ag per ml in a whole virus preparation and the equivalent of 330 to 1,000 RNA copies/ml of HIV. The rate of detection of P24 Ag was always higher in subjects with low levels of anti-P24 antibodies. The number of positive results was dramatically enhanced (from 37% to 94% for subjects with <250 CD4+ cells) when the incubation period was prolonged from 1 to 16 h. In a third series of 84 samples (<250 CD4+ cells) tested in parallel, NASBA yielded 83% of the positive results and ELAST yielded 79%. Considering the high sensitivity, low cost, simplicity of equipment (only a plate reader), and possibility for full automation, ELAST appears to be a promising new tool for measuring viral load, especially in areas with few resources, in which the procedures based on molecular biology techniques may be difficult to install.

Accelerated changes (inflection points) in levels of serum immune activation markers and CD4+ and CD8+ T cells prior to AIDS onset

The trajectories of change in CD4+ and CD8+ lymphocytes and serum neopterin and beta2-microglobulin (beta2M) levels were determined in 158 HIV-seropositive individuals during 5.5 years before a clinical AIDS diagnosis. Each patient was evaluated separately using a two-piece regression model with seven possible change points to identify any adverse change (inflection point) in the slopes of each immunologic marker of HIV infection. Two categories of subjects were distinguished for each marker--those with statistically significant inflection points and those who demonstrated a steady progression of changes to AIDS. Fifty-nine percent had an inflection point for CD4+ T cells. The frequency of inflection points for CD8+ was 49%, for serum neopterin -48% and for beta2M -38%. Inflection points were found over a 4-year span. Three distinctive categories of inflection points were observed on the basis of their independent occurrence: one was in CD4+ T cells, another in CD8+ T cells, and a third in the serum markers of immune activation. The inflection point for CD4+ usually occurred prior to those for CD8+ T cells (p=.0002). The HIV-positive persons with inflection points were diagnosed with AIDS when immunologic parameters were significantly more abnormal than in those with steady progression (p < .0003). Thus, these two groups differed in the course of immune changes and in the levels of immune abnormalities associated with the occurrence of clinical AIDS.

Anal squamous intraepithelial lesions in HIV-positive and HIV-negative homosexual and bisexual men: prevalence and risk factors

Anal cancer is more commonly found in homosexual and bisexual men than cervical cancer is in women. Invasive anal cancer may be preceded by anal squamous intraepithelial lesions (ASIL), and treatment of ASIL may prevent the development of anal cancer. We characterized the prevalence and risk factors for ASIL in 346 HIV-positive and 262 HIV-negative homosexual men. Anal cytology, biopsy of visible anal lesions, and human papillomavirus (HPV) tests were performed, and data on HIV serostatus, CD4 count, and medical and lifestyle history were collected. ASIL was diagnosed in 36% of HIV-positive men and 7% of HIV-negative men (relative risk [RR] = 5.7; 95% confidence interval [CI], 3.6-8.9). Among HIV-positive men, the RR for ASIL increased with lower CD4 levels but was elevated even in men with CD4 levels >500/mm3 (RR = 3.8; 95% CI, 2.1-6.7) when compared with HIV-negative men. High-level HPV infection, as measured by detection of both hybrid capture (HC) group A and group B types, was another significant risk factor for ASIL in both HIV-positive men (RR = 8.8; 95% CI, 2.3-35) and HIV-negative men (RR = 20; 95% CI, 5.5-71) when compared with HC-negative men. HIV-negative men with anal HPV infection and HIV-positive men, regardless of CD4 level, are at high risk for ASIL.

High incidence of anal high-grade squamous intra-epithelial lesions among HIV-positive and HIV-negative homosexual and bisexual men

OBJECTIVE

The incidence of anal cancer among homosexual men exceeds that of cervical cancer in women, and HIV-positive homosexual men may be at even higher risk than HIV-negative men. Cervical cancer is preceded by high-grade squamous intra-epithelial lesions (HSIL) and anal HSIL may similarly be the precursor to anal cancer. In this study, we describe the incidence of and risk factors for HSIL in HIV-positive and HIV-negative homosexual and bisexual men.

DESIGN

Prospective cohort study of HIV-positive and HIV-negative homosexual men.

SETTING

The University of California, San Francisco.

PATIENTS

346 HIV-positive and 262 HIV-negative men enrolled at baseline, 277 HIV-positive and 221 HIV-negative homosexual men followed after baseline.

STUDY DESIGN

A questionnaire was administered detailing lifestyle habits, medical history and sexual practices. Anal swabs for cytology and human papillomavirus studies were obtained, followed by biopsies of visible lesions. Human papillomavirus testing was performed using polymerase chain reaction (PCR) and 'hybrid capture'. Blood was obtained for HIV testing and measurement of CD4 levels.

MAIN OUTCOME MEASURES

Incident HSIL.

RESULTS

HIV-positive men were more likely to develop HSIL than HIV-negative men relative risk (RR), 3.7; 95% confidence interval (CI), 2.6-5.7. Life-table estimates of the 4-year incidence of HSIL was 49% (95% CI, 41-56) among HIV-positive men and 17% (95% CI, 12-23) among HIV-negative men. Among HIV-positive men, those with lower baseline CD4 counts (P = 0.007) and persistent infection with one or more human papillomavirus types, determined using PCR (P = 0.0001), were more likely to develop HSIL.

CONCLUSIONS

HIV infection, lower CD4 levels and human papillomavirus infection were associated with high rates of incident HSIL among homosexual men. However, high rates were found at all CD4 levels among HIV-positive men and among HIV-negative men.

The predictive value of several markers in the progression to acquired immunodeficiency syndrome

Serum beta 2-microglobulin, neopterin, immunoglobulins A, G and M, adenosine deaminase and CD4+ lymphocyte count were evaluated as predictors of progression of HIV-1 infection to AIDS. A population of HIV-1 seropositive, initially asymptomatic men (n = 213) and women (n = 101) was followed up quarterly. We estimated the AIDS-free time using the actuarial method (median survival time 47.2 months). Cox proportional hazard analysis revealed that all markers studied were significant (p < 0.05) in relation to progression to AIDS. The best markers for predicting progression to AIDS were, in descending order, CD4+ lymphocyte count, beta 2-microglobulin, IgA, neopterin, IgG, IgM and adenosine deaminase. On stratifying population into four groups (divided at percentiles 25, 50 and 75--from group 1, with values nearest to reference ranges, to group 4, with most abnormal values) we observed statistically significant differences (p < 0.05) for all markers except for adenosine deaminase. The relative risk from the Cox proportional hazards model were used to quantify the effects of the best markers and compared to the risk obtained in group 1. CD4+ lymphocyte count was the best predictor of progression to AIDS. When considering beta 2-microglobulin and CD4+ together, the relative risk in the group with lowest CD4+ cell count (group 4) ranged from 25.6% (with lower beta 2-microglobulin values) to 41.1% (with higher beta 2-microglobulin values). Similar results were obtained when considering neopterin and CD4+ together. The addition of beta 2-microglobulin or neopterin values to CD4+ lymphocyte count improved the predictive value of CD4+ lymphocyte count.