Changing character and waning impact of COVID-19 at a tertiary centre in Cape Town, South Africa

Background

The emergence of genetic variants of SARS-CoV-2 was associated with changing epidemiological characteristics throughout coronavirus disease 2019 (COVID-19) pandemic in population-based studies. Individual-level data on the clinical characteristics of infection with different SARS-CoV-2 variants in African countries is less well documented.

Objectives

To describe the evolving clinical differences observed with the various SARS-CoV-2 variants of concern and compare the Omicron-driven wave in infections to the previous Delta-driven wave.

Method

We performed a retrospective observational cohort study among patients admitted to a South African referral hospital with COVID-19 pneumonia. Patients were stratified by epidemiological wave period, and in a subset, the variants associated with each wave were confirmed by genomic sequencing. Outcomes were analysed by Cox proportional hazard models.

Results

We included 1689 patients were included, representing infection waves driven predominantly by ancestral, Beta, Delta and Omicron BA1/BA2 & BA4/BA5 variants. Crude 28-day mortality was 25.8% (34/133) in the Omicron wave period versus 37.1% (138/374) in the Delta wave period (hazard ratio [HR] 0.68 [95% CI 0.47-1.00] p = 0.049); this effect persisted after adjustment for age, gender, HIV status and presence of cardiovascular disease (adjusted HR [aHR] 0.43 [95% CI 0.28-0.67] p < 0.001). Hospital-wide SARS-CoV-2 admissions and deaths were highest during the Delta wave period, with a decoupling of SARS-CoV-2 deaths and overall deaths thereafter.

Conclusion

There was lower in-hospital mortality during Omicron-driven waves compared with the prior Delta wave, despite patients admitted during the Omicron wave being at higher risk.

Contribution

This study summarises clinical characteristics associated with SARS-CoV-2 variants during the COVID-19 pandemic at a South African tertiary hospital, demonstrating a waning impact of COVID-19 on healthcare services over time despite epidemic waves driven by new variants. Findings suggest the absence of increasing virulence from later variants and protection from population and individual-level immunity.

Quality of life assessment among HIV-positive persons entering the INSIGHT Strategic Timing of AntiRetroviral Treatment (START) trial

OBJECTIVES

With HIV treatment prolonging survival and HIV infection now managed as a chronic illness, quality of life (QOL) is important to evaluate in persons living with HIV (PLWH). We assessed at study entry the QOL of antiretroviral-naïve PLWH with CD4 counts > 500 cells/μL in the Strategic Timing of AntiRetroviral Treatment (START) clinical trial.

METHODS

QOL was assessed with: (1) a visual analogue scale (VAS) for self-assessment of overall current health; (2) the Short-Form 12-Item Version 2 Health Survey(®) (SF-12V2), for which responses are summarized into eight individual QOL domains plus component summary scores for physical health [the Physical Health Component Summary (PCS)] and mental health [the Mental Health Component Summary (MCS)]. The VAS and eight domain scores were scaled from 0 to 100. Mean QOL measures were calculated overall and by demographic, clinical and behavioural factors.

RESULTS

A total of 4631 participants completed the VAS and 4119 the SF-12. The mean VAS score (with standard deviation) was 80.9 ± 15.7. Mean SF-12 domain scores were lowest for vitality (66.3 ± 26.4) and mental health (68.6 ± 21.4), and highest for physical functioning (89.3 ± 23.0) and bodily pain (88.0 ± 21.4). Using multiple linear regression, PCS scores were lower (P < 0.001) for Asians, North Americans, female participants, older participants, and those with less education, longer duration of known HIV infection, alcoholism/substance dependence and body mass index ≥ 30 kg/m(2) . MCS scores were highest (P < 0.001) for Africans, South Americans and older participants, and lowest for female participants, current smokers and those with alcoholism/substance dependence.

CONCLUSIONS

In this primarily healthy population, QOL was mostly favourable, emphasizing that it is important that HIV treatments do not negatively impact QOL. Self-assessed physical health summary scores were higher than mental health scores. Factors such as older age and geographical region had different effects on perceived physical and mental health.

A simple self-reported adherence tool as a predictor of viral rebound in people with viral suppression on antiretroviral therapy

OBJECTIVES

The aim of the study was to investigate the relationship between self-reported antiretroviral therapy (ART) adherence and virological outcomes in the multinational Strategies for Management of Antiretroviral Therapy (SMART) study.

METHODS

Eligible participants were from the continuous ART arm and had at least one viral load (VL) ≤ 50 HIV-1 RNA copies/mL and a subsequent VL value (VL pair). Self-reported adherence was measured at each visit using a five-point Likert scale which employed a 7-day recall. High adherence was defined as taking 'all pills every day' (level 1) for every regimen component; all others had suboptimal adherence (levels 2 - 5). In individuals with VL suppression (≤ 50 copies/mL), the association between adherence (at the time of VL suppression) and VL rebound (> 200 copies/mL at next visit) was assessed using multivariable logistic regression with generalized estimating equations.

RESULTS

A total of 10 761 sets of VL pairs from 1986 participants were included in the study. For 1220 (11%) VL pairs, adherence was suboptimal. For 507 VL pairs (5%), VL rebound occurred. The risk of rebound generally increased as adherence decreased: 4.2% for level 1, 7.7% for level 2, 16.3% for level 3, 9.4% for level 4 and 12.9% for level 5. In multivariable analysis, suboptimal adherence at the time of suppression was associated with a 50% increased odds of experiencing subsequent VL rebound [odds ratio (OR) 1.51; 95% confidence interval (CI) 1.19-1.92; P = 0.0023], compared with high adherence.

CONCLUSIONS

Self-reported suboptimal adherence in people with VL suppression is associated with an increased risk of VL rebound. Our findings highlight the importance of continued adherence counselling, even in people with VL suppression, and to ensure that people with HIV infection maintain excellent adherence in order to minimize the risk of VL rebound.

Lack of immunization documentation in Minnesota refugees: challenges for refugee preventive health care

Children and adults immigrating to the United States without documentation of vaccinations or evidence of immunity should receive age-appropriate immunizations. To learn how often immunization documentation is lacking, we reviewed medical screening records of 1,389 primary refugees over 18 months of age who came Minnesota during 1998. Restricting our analysis to those age groups for whom specific immunizations are recommended, 81.1% of refugees lacked documentation of receiving three doses of diphtheria and tetanus vaccines; 78.8% lacked documentation of one dose of measles vaccine, and 63.8% lacked documentation of three doses of polio vaccine. Of refugees without a known positive test for hepatitis B antigen or antibody, 99.5% lacked documentation of receiving three doses of hepatitis B vaccine. Documentation rates decreased with increasing age, and were lowest for refugees from sub-Saharan Africa (p < 0.001). Refugees and other immigrants may face a number of barriers to receiving necessary immunizations. Health care providers seeing these new arrivals need to ensure that they do fail to receive recommended vaccinations and other preventive health care.

Substance abuse and high-risk needle-related behaviors among homeless youth in Minneapolis: implications for prevention

Homeless and runaway youth face a variety of health risks, including those related to substance abuse and use of unsterile needles. During 1998-1999, we recruited 201 Minneapolis homeless youths aged 15-22 years; these youths were interviewed by experienced street outreach workers from settings where street youth were known to congregate. Respondents spent a median of 6 months in the previous year living on the streets or "couch hopping." There were 37% who reported having 15 or more alcoholic drinks per week, 41% smoked 1 pack or more of cigarettes per day, and 37% used marijuana 3 or more times a week; 15% reported lifetime injection drug use, including 6% who used injection drugs within the previous month. Twenty percent had received a tattoo, and 18% body piercing with a needle that had not been sterilized or had been used by someone else. There were 68% who had been tested for human immunodeficiency virus (HIV), 52% for hepatitis B, and 25% for hepatitis C. There were 44% who said they did not have enough information about hepatitis B and C. Less than half (43%) received hepatitis B vaccine; however, 51% of unvaccinated youths indicated that they would receive vaccination if offered. These Midwestern homeless youths face multiple health risks, including those related to substance use and exposure to unsterile needles. Despite unsafe behaviors, many of these youths were interested in methods to protect their health, including education, knowing their HIV or viral hepatitis serostatus, and obtaining hepatitis B immunization.

Screening for sexually transmitted infections among economically disadvantaged youth in a national job training program

PURPOSE

To evaluate results of screening for syphilis, gonorrhea, and chlamydia among youth in a federally funded job training program.

METHODS

Data were evaluated from medical records of 12,881 randomly selected students in 54 U.S. job training centers during 1996. The intake medical evaluation includes serologic testing for syphilis. The policy was for females to receive a pelvic examination with gonorrhea and chlamydia testing and for males to be first screened with a urine leukocyte esterase (LE) assay, with follow-up gonorrhea and chlamydia testing for those with positive LE results.

RESULTS

Adjusting for our sampling strategy, among females, an estimated 9.2% had a positive chlamydia test, 2.7% a positive gonorrhea test, and 0.4% had a positive syphilis test. Gonorrhea and chlamydia rates among females were highest in African-American followed by Native American students. Chlamydia infection was most common in younger women < or = 17 years of age. An estimated 0.1% of males had a positive syphilis test, and 4.8% of males a positive urine LE test. Of 103 LE-positive males tested for gonorrhea and chlamydia, only 27 (26%) had a positive test for one of these STDs.

CONCLUSIONS

Our study supports routine screening of adolescents for gonorrhea and chlamydia, including those youth from socioeconomically disadvantaged backgrounds. Because individuals from such backgrounds may not regularly interact with traditional clinical health care systems, screening and treatment should be offered in alternative settings, such as the job training program described in this study.

AIDS in Africa. A global responsibility

The global response to the AIDS epidemic has often been marked by ignorance, fear, shame, and complacency, resulting in a spiraling epidemic in Africa and elsewhere. However, when leaders have confronted the realities of HIV with candor and empathized with those stricken with AIDS, the results are encouraging. Because infectious diseases and their consequences do not respect political borders, HIV presents many challenges for both developing and industrialized nations. AIDS in Africa represents a global challenge and requires sustained political and monetary investments. In 1998, only $300 million in international assistance funds were available for combating HIV/AIDS. However, an estimated $1.6 billion to $2.6 billion annually may be needed to mount an effective response in sub-Saharan Africa alone. Those dollars equal less than $3.50 per person in this region, or less than a bottle of cold medicine one of us might purchase at a U.S. pharmacy. Failure to act aggressively now will cost the world economically and socially, and will result in the loss of millions of lives.

The association of poverty and low immunization rates in ZIP code areas. A retrospective survey of Minnesota kindergartners

This study evaluated indicators of poverty in Minnesota ZIP code areas with low childhood immunization rates. During 1996-1997, a retrospective survey of 68,639 Minnesota kindergarten children was conducted; 68% received four doses of diphtheria, tetanus, and pertussis vaccine, three doses of polio vaccine, and one dose of measles, mumps, and rubella vaccine (4:3:1) by 24 months of age. Of 447 ZIP codes further evaluated, 24 (5%; 13 urban and 11 rural) had 4:3:1 immunization rates at 24 months of < or = 50%. None of 159 ZIP codes in which < 5% of residents were below the poverty line had immunization rates < or = 50%, compared with 9 (32%) of 28 ZIP codes with > or = 15% of residents below the poverty line (p < 0.001). Immunization rates were lowest in ZIP codes with a lower median family income and greater proportion of residents below the poverty line. Surveys such as this can help immunization programs target and monitor prevention activities for these pockets of need.

Incentives and accessibility: a pilot study to promote adherence to TB prophylaxis in a high-risk community

SETTING

A community-based directly observed preventive therapy (DOPT) program for treatment of latent tuberculosis infection among injection drug users (IDUs) in an inner-city neighborhood.

OBJECTIVE

To test adherence to a 6-month course of DOPT using cash incentives and an easily accessible neighborhood location.

DESIGN

Street-recruited IDUs (N = 205) were screened for Mycobacterium tuberculosis (TB) infection using the Mantoux test and two controls. Subjects who had a purified protein derivative (PPD) reaction of > or =5 mm, were anergic, or had a history of a positive PPD received clinical evaluation at a community field site, provided in collaboration with the San Francisco Department of Public Health Tuberculosis Clinic. Twenty-eight subjects were considered appropriate candidates for prophylaxis with isoniazid, and 27 enrolled in the pilot study. Participants received twice-weekly DOPT at a community satellite office, with a $10 cash incentive at each visit.

RESULTS

The 6-month (26-week) regimen was completed by 24/27 (89%) participants. The median time to treatment completion was 27 weeks (range 26 to 34 weeks). The median proportion of dosing days attended in 6 months was 96%.

CONCLUSION

Community-based DOPT using cash incentives resulted in high levels of adherence and treatment completion among drug users.

New threats from an old enemy. A physician update on pneumococcus

Pneumonia and influenza together are the sixth-leading cause of death in this country. Physicians have the tools and influence to prevent many of these deaths and significantly improve their patients' health and quality of life. There is no reason for these tools to be underused.

Tuberculin skin testing among economically disadvantaged youth in a federally funded job training program

Low income, medically underserved communities are at increased risk for tuberculosis. Limited population-based national data are available about tuberculous infection in young people from such backgrounds. To determine the prevalence of a positive tuberculin skin test among economically disadvantaged youth in a federally funded job training program during 1995 and 1996, the authors evaluated data from medical records of 22,565 randomly selected students from over 100 job training centers throughout the United States. An estimated 5.6% of students had a documented positive skin test or history of active tuberculosis. Rates were highest among those who were racial/ethnic minorities, foreign born, and (among foreign-born students) older in age (p < 0.001). Weighted rates (adjusting for sampling) were 1.3% for white, 2.2% for Native American, 4.0% for black, 9.6% for Hispanic, and 40.7% for Asian/Pacific Islander students; rates were 2.4% for US-born and 32.7% for foreign-born students. Differences by geographic region of residence were not significant after adjusting for other demographic factors. Tuberculin screening of socioeconomically disadvantaged youth such as evaluated in this study provides important sentinel surveillance data concerning groups at risk for tuberculous infection and allows recommended public health interventions to be offered.

Two-step tuberculin skin testing of injection drug users recruited from community-based settings

SETTING

Cross-sectional study of drug users recruited from street-based settings in four US cities: Denver, Portland, Oakland and San Francisco.

OBJECTIVE

To evaluate responses to two-step tuberculin skin testing among HIV-positive and HIV-negative injection drug users.

DESIGN

Subjects were recruited from existing studies of HIV and risk behaviors for tuberculin skin testing. Those with a negative initial tuberculin test were referred for a second skin test 1-3 weeks later. A positive tuberculin test was defined as > or = 10 mm, or > or = 5 mm if the subject was HIV-positive.

RESULTS

Of 997 persons receiving an initial tuberculin test, 13% had a positive response. Of 644 persons receiving a second tuberculin test, 8% had a positive response, with rates as high as 14% among those from Oakland and 12% among African Americans. HIV-positive subjects were less likely to have skin test responses > or = 10 mm on the initial test (P = 0.03), or increases between the initial and second test of > or = 10 mm (P = 0.06).

CONCLUSION

Boosting occurred in both HIV-positive and HIV-negative injection drug users. Two-step testing should be considered for this population, particularly those on whom repeat tuberculin testing will be performed.

Concordance of PCR and antibody results from HIV testing of injecting drug users

Standard HIV-1 testing relies on the enzyme immunoassay (EIA) for detecting antibodies specific to HIV-1. This technique may misclassify persons as HIV-1-negative in instances where testing follows infection but precedes development of antibody to HIV-1. To evaluate the occurrence of HIV infection in the absence of positive antibody, polymerase chain reaction (PCR) for viral DNA in the blood has been applied. Research comparing these two testing techniques has generally focused on populations of homosexual and bisexual men. This study compares PCR and antibody testing of 337 injecting drug users recruited from street settings in San Francisco. Of 286 HIV-1 antibody-negative samples, 3 (1.0%) were PCR-positive. Of 49 HIV-1 antibody-positive samples, 1 (2.0%) was PCR-negative. Two samples were antibody-indeterminate and PCR-negative. This yielded an overall concordance of 331/335 (98.8%), excluding the indeterminate results. These results suggest that current antibody methodology is adequate. However, misclassification among recently infected individuals may occur, which is of concern in high-incidence groups.

Classification of HIV infection and disease in women from Rwanda. Evaluation of the World Health Organization HIV staging system and recommended modifications

OBJECTIVE

To develop a human immunodeficiency virus (HIV) staging system for sub-Saharan Africa on the basis of an evaluation of the World Health Organization (WHO) system and predictors of mortality.

DESIGN

Prospective cohort study with 4 years of follow-up.

SETTING

Kigali, Rwanda.

PATIENTS

412 HIV-infected women recruited from prenatal and pediatric clinics.

MEASUREMENTS

Clinical signs and symptoms of HIV disease, laboratory assays (including complete blood count and erythrocyte sedimentation rate), and cumulative mortality.

RESULTS

The WHO staging system includes a clinical and a laboratory axis. The clinical axis was revised by inclusion of oral candidiasis, chronic oral or genital ulcers, and pulmonary tuberculosis as "severe" disease (clinical stage IV); in addition, body mass index was substituted for weight loss in the definition for the wasting syndrome. The 36-month cumulative mortality was 7% for women in modified clinical stage I ("asymptomatic"), 15% for those in stage II, 19% for those in stage III, and 36% for those in stage IV (P < 0.001). The laboratory axis was revised by replacing lymphocyte count with hematocrit and erythrocyte sedimentation rate. The 36-month mortality was 10% for women in modified stage A ("normal" laboratory results) and 33% for those in stage B (erythrocyte sedimentation rate > 65 mm/h or hematocrit < 0.38) (P < 0.001). A single staging system combining clinical and laboratory criteria is proposed, with a 36-month mortality of 7% for women in combined stage I, 10% for those in stage II, 29% for those in stage III, and 62% for those in stage IV (P < 0.001).

CONCLUSIONS

On the basis of this analysis, a staging system relevant for sub-Saharan Africa is proposed that reflects the range of HIV-related outcomes, has strong prognostic significance, includes inexpensive and available laboratory tests, and can be used by both clinicians and researchers.

HIV-related oral manifestations in two cohorts of women in San Francisco

The goals of this study were to compare the prevalence of oral lesions in women infected with human immunodeficiency virus (HIV) and HIV-negative women, and to determine the association of oral lesions with route of HIV transmission and with level of immunosuppression in infected women. As part of a prospective 4-year study, oral examinations and blood tests were performed, at 6-month intervals, on 176 HIV-infected women and on 117 HIV-negative women at risk for HIV infection. We evaluated participants for the following oral conditions: hairy leukoplakia, candidiasis, ulcers, warts, non-Hodgkin's lymphoma, Kaposi's sarcoma, and parotid enlargement. As previously reported in men, the prevalence of oral lesions was significantly higher among HIV-infected (22%) than HIV-negative women (3%) [odds ratio (OR) = 8.2; 95% confidence interval (CI) 2.8, 23.5], particularly candidiasis (14%) and hairy leukoplakia (10%). Among HIV-infected women with CD4 cell count nadir > or = 200 cells/microliters, the prevalence of hairy leukoplakia was higher among those infected heterosexually than among injection drug users (OR = 5.5; 95% CI: 1.5; 19). The OR for the association between oral lesions and CD4 cell count nadir (< 200 vs. > 500 cells/microliters) was 8.9 (95% CI: 2.6, 30), indicating a strong positive association with level of immunosuppression.

Severe opportunistic infections in AIDS patients with late-stage disease

BACKGROUND

Clinicians caring for patients who have acquired immunodeficiency syndrome (AIDS) need to be aware of the wide variety of infectious diseases that can occur. Although Pneumocystis carinii pneumonia (PCP) is the most common AIDS-defining infection, other opportunistic infections associated with advanced immunodeficiency can develop after an initial diagnosis.

METHODS

To ascertain AIDS-defining opportunistic infections that developed at the time of or after an AIDS diagnosis, and intensive chart review was conducted for 45 homosexual men with AIDS who died from 1990 through 1992. Time to death after first occurrence of these infections was also determined.

RESULTS

The most common opportunistic infection occurring as the initial AIDS-defining illness was PCP (31 percent). The most common opportunistic infection occurring as a secondary disease was cytomegalovirus (CMV) disease (40 percent), followed by disseminated Mycobacterium avium complex (33 percent) and invasive candidiasis (31 percent). Each of these latter infections was associated with a poor prognosis (median time to death < or = 8 months).

CONCLUSIONS

Diseases caused by CMV, disseminated M. avium complex, and invasive candidiasis were uncommon presenting manifestations of AIDS but were common secondary diseases that tended to be associated with limited survival. With increasing survival and a declining incidence of PCP as a result of medical therapy, other severe opportunistic infections might become increasingly recognized.

Time from HIV seroconversion to oral candidiasis or hairy leukoplakia among homosexual and bisexual men enrolled in three prospective cohorts

OBJECTIVES

We evaluated time from HIV seroconversion to diagnosis of two common oral lesions associated with HIV infection and disease progression.

DESIGN

Oral examinations were performed on homosexual and bisexual men enrolled in prospective cohorts.

SETTING

Homosexual and bisexual men were followed in three epidemiologic cohort studies in San Francisco, California, USA.

PARTICIPANTS

Data were evaluated from 80 men with well-defined dates of HIV seroconversion from 1984 through 1991.

MAIN OUTCOME MEASURES

We determined the cumulative incidence of oral candidiasis and hairy leukoplakia after HIV seroconversion.

RESULTS

Four per cent of men developed oral candidiasis within 1 year after HIV seroconversion, 8% within 2, 15% within 3, 18% within 4, and 26% within 5 years. Nine per cent developed hairy leukoplakia within 1 year, 16% within 2, 25% within 3, 35% within 4, and 42% within 5 years. The median CD4+ count was 391 x 10(6)/l when oral candidiasis was first reported and 468 x 10(6)/l when hairy leukoplakia was first reported.

CONCLUSIONS

Oral candidiasis or hairy leukoplakia appeared in a significant proportion of HIV-infected homosexual and bisexual men. These lesions occurred relatively soon after HIV seroconversion, typically before AIDS. Evaluation of HIV-infected individuals for these lesions has many potential clinical and research benefits, including the possible use of oral lesions as primary end-points in clinical trials.

Discrepancies in tuberculin skin test results with two commercial products in a population of intravenous drug users

Screening for tuberculosis (using the Mantoux test) and human immunodeficiency virus (HIV) was conducted among intravenous drug users (IVDUs) recruited from a San Francisco Bay Area neighborhood. Of 178 IVDUs skin-tested with one commercial purified protein derivative (PPD) preparation, a reaction of > or = 5 mm of induration occurred in 62 (47%) of 133 HIV-negative and 13 (29%) of 45 HIV-positive IVDUs (P = .037). Forty-two IVDUs with an initial PPD reaction > or = 5 mm were retested with a second commercial preparation; 11 (26%) had no reaction (0 mm) on retesting. These 11 were 5 (56%) of 9 HIV-positive and 6 (18%) of 33 HIV-negative persons (P = .038). These discrepancies may be unique to specific lots of product or may reflect more general differences. A degree of caution in evaluating unexpected tuberculin skin test results may be indicated. Response to different tuberculin products by HIV status should be further evaluated.

Two-year incidence of tuberculosis in cohorts of HIV-infected and uninfected urban Rwandan women

To determine the prevalence of Mycobacterium tuberculosis infection and the incidence of tuberculosis in HIV-infected and uninfected urban Rwandan women, 460 HIV-positive and 998 HIV-negative childbearing women were recruited from pediatric and prenatal care clinics and were enrolled in a prospective study in 1988 and followed for 2 yr. Tuberculin testing was administered 12 to 18 months after enrollment. Fifty-three percent of HIV-negative women had positive tuberculin tests (induration > or = 10 mm), with higher rates among older women and among women who had received BCG vaccine. Only 21% of HIV-positive women had positive tuberculin tests, with no relationship to BCG vaccine. Follow-up was available for 93% of subjects. Tuberculosis was diagnosed in 20 HIV-positive women and in two HIV-negative women. Features associated with an increased risk of tuberculosis among HIV-positive women included: age > or = 30, body mass index in the lowest quartile, low income, erythrocyte sedimentation rate > 75, positive tuberculin test, and chronic cough, chronic fever, and weight loss. Among Rwandan women who are infected with HIV, approximately half of those who are infected with M. tuberculosis do not have positive tuberculin tests. The rate ratio for development of tuberculosis among HIV-positive women was 22 (95% CI, 5 to 92). New algorithms are needed to improve the early detection of tuberculosis among HIV-positive patients in Africa.

Serum beta 2-microglobulin and prediction of progression to AIDS in HIV infection

Identification of laboratory tests that can help predict progression to acquired immunodeficiency syndrome (AIDS) in people infected with human immunodeficiency virus (HIV) is important for clinical management and counselling. We have assessed the usefulness of CD4 lymphocyte count, serum beta 2-microglobulin concentration, and the presence of p24 antigen as predictors of AIDS. We studied 214 homosexual and bisexual men with well-defined dates of HIV seroconversion. For each participant, we defined the baseline date as the earliest date before the development of AIDS on which the three laboratory tests were done. beta 2-microglobulin concentration at baseline was in all analyses an independent predictor of AIDS, even after stratification by baseline CD4 count, duration of HIV infection, or use of zidovudine before or at baseline. For example, among men with at least 0.5 x 10(9)/l CD4 cells who were negative for p24 antigen, the risks of AIDS at 12 months and 24 months were 1% and 5%, respectively, for those whose beta 2-microglobulin concentrations were below 4.0 mg/l, compared with 17% and 27%, respectively for those with beta 2-microglobulin concentrations above that cut-off point (p less than 0.001). Among men with an estimated duration of infection of 5 years or less, beta 2-microglobulin concentration was the strongest independent predictor of AIDS. Measurement of serum beta 2-microglobulin adds important prognostic information to CD4 count in determining the risk of progression to AIDS in HIV-infected subjects, including those whose CD4 cell count has not yet fallen.

Progression and clinical outcome of infection due to human immunodeficiency virus

Ten years into the AIDS epidemic, how are we doing? Have we managed to significantly alter the course of infection with human immunodeficiency virus (HIV)? Have we defined factors that accelerate or decelerate the rate of progression of infection to clinical disease? Are we better able to predict who is most likely to develop AIDS, to substantially alter the course of infection, and to prevent or delay HIV-related morbidity and mortality? Advances made during the past decade that have furthered our understanding of the virus itself have been remarkable. We now understand a great deal about how the virus attaches to the CD4 cell receptor; how it is internalized, transcribed onto DNA of the host, and incorporated into the host's genome; and how its expression is latently controlled by a series of regulatory genes. However, translating this basic understanding of the virus into significant clinical advances still seems tediously slow for clinicians caring for HIV-infected individuals. I asked Dr. Alan R. Lifson of the University of California San Francisco School of Medicine and his colleagues from the San Francisco Department of Public Health and the California Department of Health Services to summarize the current status of our attempts to alter the course of HIV infection.

Impact of HIV infection on mortality and accuracy of AIDS reporting on death certificates

To assess the impact of HIV infection on mortality and the accuracy of AIDS reporting on death certificates, we analyzed data from 6704 homosexual and bisexual men in the San Francisco City Clinic cohort. Identification of AIDS cases and deaths in the cohort was determined through multiple sources, including the national AIDS surveillance registry and the National Death Index. Through 1990, 1518 deaths had been reported in the cohort and 1292 death certificates obtained. Of the 1292 death certificates, 1162 were for known AIDS cases, but 9% of the AIDS cases did not have HIV infection or AIDS noted on the death certificate. Only 0.7% of the decedents had AIDS listed as a cause of death and had not been reported to AIDS surveillance. AIDS and HIV infection was the leading cause of death in the cohort, with the highest proportionate mortality ratio (85%) and standardized mortality ratio (153 in 1987), and the largest number of years of potential life lost (32,008 years). The devastating impact of HIV infection on mortality is increasing and will require continued efforts to prevent and treat HIV infection.

Predictors of mortality among HIV-infected women in Kigali, Rwanda

OBJECTIVE

To better characterize the natural history of disease due to human immunodeficiency virus (HIV) infection in African women.

DESIGN

Prospective cohort study over a 2-year follow-up period.

PARTICIPANTS

A total of 460 HIV-seropositive women and a comparison cohort of HIV-seronegative women recruited from prenatal and pediatric clinics in Kigali, Rwanda in 1988.

MEASUREMENTS

Clinical signs and symptoms of HIV disease, AIDS, and mortality.

MAIN RESULTS

Follow-up data at 2 years were available for 93% of women who were still alive. At enrollment, many seropositive women reported symptoms listed in the World Health Organization (WHO) clinical case definition of AIDS, but these were nonspecific and often improved over time. The 2-year mortality among HIV-infected women by Kaplan-Meier survival analysis was 7% (95% CI, 5% to 10%) overall, and 21% (CI, 8% to 34%) for the 40 women who fulfilled the WHO case definition of AIDS at entry. In comparison, the 2-year mortality in women not infected with HIV was only 0.3% (CI, 0% to 7%). Independent baseline predictors of mortality in seropositive women by Cox proportional hazards modeling were, in order of descending risk factor prevalence: a body mass index of 21 kg/m2 or less (relative hazard, 2.3; CI, 1.1 to 4.8), low income (relative hazard, 2.3; CI, 1.1 to 4.5), an erythrocyte sedimentation rate exceeding 60 mm/h (relative hazard, 4.9; CI, 2.2 to 10.9), chronic diarrhea (relative hazard, 2.6; CI, 1.1 to 5.7), a history of herpes zoster (relative hazard 5.3; CI, 2.5 to 11.4), and oral candida (relative hazard, 7.3; CI, 1.6 to 33.3). Human immunodeficiency virus disease was the cause of death in 38 of the 39 HIV-positive women who died, but only 25 met the WHO definition of AIDS before death.

CONCLUSIONS

Human immunodeficiency virus disease now accounts for 90% of all deaths among child-bearing urban Rwandan women. Many symptomatic seropositive patients may show some clinical improvement and should not be denied routine medical care. Easily diagnosed signs and symptoms and inexpensive laboratory tests can be used in Africa to identify those patients with a particularly good or bad prognosis.

Progression to AIDS in HIV-infected homosexual and bisexual men with hairy leukoplakia and oral candidiasis

OBJECTIVE

This study was designed to assess the significance of HIV-related oral lesions in predicting the rate of progression to AIDS.

DESIGN

Cohorts were investigated prospectively, and oral examinations were performed by clinicians trained in the diagnosis of oral lesions.

SETTING

We studied three existing cohorts of homosexual and bisexual men in San Francisco, California, USA.

PARTICIPANTS

Of the HIV-infected men who received standardized oral examinations (n = 791), 603 were eligible for analysis of baseline examinations and 448 for analysis of follow-up examinations.

MAIN OUTCOME MEASURES

We determined time from presence of oral lesion at baseline or follow-up examination, or from participant self-reported history of the lesion, to diagnosis of AIDS.

RESULTS

Using proportional hazard regression and stratifying by CD4 lymphocyte count at the time of baseline oral examination, we found that the rate of development of AIDS was increased among men with hairy leukoplakia [relative hazard, 1.8; 95% confidence interval (CI), 1.2-2.7], oral candidiasis (relative hazard, 7.3; 95% CI, 3.1-17.3), and both lesions (relative hazard, 3.1; 95% CI, 1.6-6.1) compared with men with normal findings. On follow-up examination, stratifying for CD4 count, the rate of progression to AIDS was similar for those with hairy leukoplakia compared with those with oral candidiasis. The progression rate from oral candidiasis to AIDS was faster from presence on baseline examination than from presence on follow-up examination or from self-reported history of the lesion.

CONCLUSION

The presence of oral candidiasis and/or hairy leukoplakia on baseline examination confers independent prognostic information and should be incorporated into HIV-staging schemes.

Current issues concerning the epidemiology of acquired immunodeficiency syndrome and human immunodeficiency virus

This discussion was selected from the weekly staff conferences in the Department of Medicine, University of California, San Francisco. Taken from a transcription, it has been edited by Nathan M. Bass, MD, PhD, Associate Professor of Medicine, under the direction of Lloyd H. Smith Jr, MD, Professor of Medicine and Associate Dean in the School of Medicine.

The association of clinical conditions and serologic tests with CD4+ lymphocyte counts in HIV-infected subjects without AIDS

Early intervention guidelines in HIV infection require knowledge of CD4+ lymphocyte count; however, CD4+ determinations require special laboratory procedures and may not be readily available in all situations. Using data from 207 HIV-seropositive homosexual men without AIDS, we evaluated the association of difference clinical conditions or serologic tests with CD4+ count. Men with conditions including seborrheic dermatitis, hairy leukoplakia, oral candidiasis and chronic diarrhea, and men with beta2-microglobulin levels greater than or equal to 4.0 mg/l had significantly lower CD4+ counts. However, the probability that a subject with such parameters had less than 200 x 10(6)/l CD4+ cells was limited (25-63%). Although the probability that a subject with such parameters had less than 500 x 10(6)/l CD4+ cells was better (76-88%), the probability that a person without these parameters had greater than or equal to 500 x 10(6)/l CD4+ cells was only 45-50%. Clinical and serologic parameters may provide important prognostic information, but cannot be used to reliably determine the level of CD4+ cells.

The prevalence of oral lesions in HIV-infected homosexual and bisexual men: three San Francisco epidemiological cohorts

To establish the prevalence of HIV-related oral lesions, we performed oral examinations of members of three San Francisco epidemiological cohorts of homosexual and bisexual men over a 3-year period. Hairy leukoplakia, pseudomembranous and erythematous candidiasis, angular cheilitis, Kaposi's sarcoma, and oral ulcers were more common in HIV-infected subjects than in HIV-negative subjects. Among HIV-infected individuals, hairy leukoplakia was the most common lesion [20.4%, 95% confidence interval (CI) 17.5-23.3%] and pseudomembranous candidiasis was the next most common (5.8%, 95% CI 4.1-7.5%). Hairy leukoplakia, pseudomembranous candidiasis, angular cheilitis and Kaposi's sarcoma were significantly more common in patients with lower CD4 lymphocyte counts (P less than 0.05). The prevalence of erythematous candidiasis and Kaposi's sarcoma increased during the 3-year period. Careful oral examinations may identify infected patients and provide suggestive information concerning their immune status.

Long-term human immunodeficiency virus infection in asymptomatic homosexual and bisexual men with normal CD4+ lymphocyte counts: immunologic and virologic characteristics

From a prospective cohort study, 24 asymptomatic men were identified who had been antibody positive for human immunodeficiency virus (HIV) for at least 5 years (median = 9.1) with CD4+ lymphocyte counts greater than or equal to 400 cells/mm3. Of these "nonprogressors", 23 (96%) had evidence of HIV infection by either HIV culture or the polymerase chain reaction (PCR) for HIV DNA, although only 1 (4%) had a positive assay for HIV RNA (by PCR) and no one was positive for p24 antigen. Compared with 24 antibody-negative men and 14 men with AIDS, nonprogressors had higher CD8+ counts and lower natural killer cell activity. Nonprogressors had higher beta 2-microglobulin levels than did seronegative controls, suggesting some degree of immune system activation. Compared with men with AIDS, nonprogressors seemed to have a stronger antibody response to six different HIV-related proteins but did not differ significantly in neutralizing antibody or antibody-dependent cellular cytotoxic activity.

HIV seroconversion in two homosexual men after receptive oral intercourse with ejaculation: implications for counseling concerning safe sexual practices

Seroconversion for HIV antibody occurred in two homosexual men who reported no anal intercourse for greater than or equal to 5 years and multiple episodes of receptive oral intercourse with ejaculation. Neither man reported intravenous drug use or receipt of blood products. The last antibody-negative specimen was also negative by the polymerase chain reaction and p24 antigen assays. All sexually active persons should be clearly counselled that receptive oral intercourse with ejaculation carries a potential risk of HIV transmission.

Course of HIV-I infection in a cohort of homosexual and bisexual men: an 11 year follow up study

OBJECTIVE--To characterise the natural history of sexually transmitted HIV-I infection in homosexual and bisexual men. DESIGN--Cohort study. SETTING--San Francisco municipal sexually transmitted disease clinic. PATIENTS--Cohort included 6705 homosexual and bisexual men originally recruited from 1978 to 1980 for studies of sexually transmitted hepatitis B. This analysis is of 489 cohort members who were either HIV-I seropositive on entry into the cohort (n = 312) or seroconverted during the study period and had less than or equal to 24 months between the dates of their last seronegative and first seropositive specimens (n = 177). A subset of 442 of these men was examined in 1988 or 1989 or had been reported to have developed AIDS. MAIN OUTCOME MEASURES--Development of clinical signs and symptoms of HIV-I infection, including AIDS, AIDS related complex, asymptomatic generalised lymphadenopathy, and no signs or symptoms of infection. MEASUREMENTS AND MAIN RESULTS--Of the 422 men examined in 1988 or 1989 or reported as having AIDS, 341 had been infected from 1977 to 1980; 49% (167) of these men had died of AIDS, 10% (34) were alive with AIDS, 19% (65) had AIDS related complex, 3% (10) had asymptomatic generalised lymphadenopathy, and 19% (34) had no clinical signs or symptoms of HIV-I infection. Cumulative risk of AIDS by duration of HIV-I infection was analysed for all 489 men by the Kaplan-Meier method. Of these 489 men, 226 (46%) had been diagnosed as having AIDS. We estimated that 13% of cohort members will have developed AIDS within five years of seroconversion, 51% within 10 years, and 54% within 11.1 years. CONCLUSION--Our analysis confirming the importance of duration of infection to clinical state and the high risk of AIDS after infection underscores the importance of continuing efforts both to prevent transmission of HIV-I and to develop further treatments to slow or stall the progression of HIV-I infection to AIDS.

The role of human immunodeficiency virus infection in pneumococcal bacteremia in San Francisco residents

Human immunodeficiency virus (HIV) is an important risk factor for invasive pneumococcal disease, but information on clinical course and infecting serotypes is limited. To help develop strategies to reduce the morbidity due to invasive pneumococcal disease, episodes of pneumococcal bacteremia were identified by retrospective review of microbiology records (November 1983-November 1987) at 10 San Francisco hospitals and, for patients 20-55 years old living in San Francisco, HIV antibody status was determined by review of medical records. Pneumococcal isolates from one hospital were serotyped. Of 294 patients with pneumococcal bacteremia identified, 32 (11%) had AIDS at the time pneumococcal bacteremia was diagnosed and another 43 (15%) were HIV-infected but did not have AIDS; 12 HIV-infected patients developed AIDS after the episode of pneumococcal bacteremia. The rate of pneumococcal bacteremia in AIDS patients was estimated to be 9.4/1000 patient-years. Serotypes of 27 (82%) of 33 pneumococcal isolates from HIV-infected patients and 107 (90%) from 119 patients without known HIV infection were among the 23 serotypes included in the currently available polysaccharide vaccine. The rate of pneumococcal bacteremia is approximately 100-fold greater in AIDS patients in San Francisco than rates reported before the AIDS epidemic, but more than half the episodes of pneumococcal bacteremia in HIV-infected patients occurred in patients without AIDS. Data on pneumococcal serotypes causing invasive disease in HIV-infected patients suggest that the current pneumococcal vaccine, if effective in this population, could provide significant protection against pneumococcal disease.

Concordance of polymerase chain reaction with human immunodeficiency virus antibody detection

To evaluate the correlation of detection of human immunodeficiency virus (HIV) by polymerase chain reaction (PCR) with detection of HIV antibody, 271 simultaneous serum and peripheral blood mononuclear cell samples were examined from 242 persons whose activities placed them at increased risk for HIV infection: 142 from homosexual men, 86 from hemophilic men, and 43 from heterosexual partners of HIV-infected persons. PCR was performed using the gag region primer pair SK38/39 and the env region primer pairs SK68/69 and CO71/72. Amplified HIV DNA was detected using specific oligomer probes. Of 63 HIV antibody-positive samples, 58 (92%) had HIV DNA by PCR. Of 208 HIV antibody-negative samples, 7 (3.4%) had HIV DNA by PCR. On follow-up, 4 of the latter persons were seropositive when next tested; 2 were well and antibody- and PCR-negative; 1 had died of a stroke before retesting. Thus, PCR detects HIV in most antibody-positive persons; detection is increased by use of multiple primer pairs. PCR-positive antibody-negative specimens may indicate HIV infection in which antibody has not yet developed or may be false-positive PCR results. When PCR is discordant with HIV antibody, testing of additional specimens and clinical follow-up are necessary to assess HIV infection status.

Detection of human immunodeficiency virus DNA using the polymerase chain reaction in a well-characterized group of homosexual and bisexual men

The polymerase chain reaction (PCR) for human immunodeficiency virus type 1 (HIV-1) DNA was performed on specimens from 197 homosexual and bisexual men enrolled in studies of HIV-1 infection. Thirty cycles of amplification were conducted, followed by detection with probes corresponding to two gag primer pairs (SK 38/39 and SK 101/145). Of 107 men who were HIV-1 antibody-negative, 105 (98%) were PCR-negative. Two who were initially PCR-positive antibody-negative were PCR- and antibody-negative on repeat testing of both the same specimen and specimens drawn 8-10 months later; this suggests that the first PCR results were false-positive. Of 90 men who were antibody-positive, PCR was positive in 87 (97%), including all 13 with AIDS, all 22 with AIDS-related conditions, all 11 with generalized lymphadenopathy only, and 41 (93%) of 44 without signs or symptoms of HIV-1 infection. On repeat testing, all 3 PCR-negative, antibody-positive men were PCR-positive. In this population and with this technique, PCR had excellent agreement with the HIV-1 antibody test.

Risk factors for human immunodeficiency virus type 1 (HIV-1) infection in patients at a sexually transmitted disease clinic in New York City

Patients who attended a sexually transmitted disease clinic in New York City in 1987 were offered enrollment in a nonblinded study to estimate human immunodeficiency virus type 1 (HIV-1) seroprevalence in adults with multiple sexual partners and to determine risk factors associated with HIV-1 infection. In addition, a blinded serosurvey of a representative sample of patients was performed to obtain an unbiased estimate of seroprevalence in clinic attendees. The seroprevalence in the blinded serosurvey was 7.5% (26/348), while the seroprevalence of the 1,201 volunteers for the nonblinded study was 11.2%. For men in the nonblinded study, the risk behaviors most strongly associated with HIV-1 infection were intravenous drug use, sexual contact with another man, and sexual contact with a female intravenous drug user. For women, intravenous drug use and sexual contact with a man at risk for HIV-1 infection (an intravenous drug user or a bisexual) were most important. The seroprevalence among persons who denied all high-risk behavior was 1% (7/723). The results of this study, conducted in a city with one of the nation's highest reported cumulative incidences of acquired immunodeficiency syndrome, suggest that HIV-1 infection in clinic attendees was primarily limited to intravenous drug users, homosexual/bisexual men, and the sexual partners of these two groups.

Kaposi's sarcoma in a cohort of homosexual and bisexual men. Epidemiology and analysis for cofactors

Acquired immunodeficiency syndrome (AIDS) surveillance data for both the United States and San Francisco indicate that Kaposi's sarcoma is more common in homosexual and bisexual men with AIDS than in other adults with AIDS, and that the proportion of newly diagnosed AIDS cases presenting with Kaposi's sarcoma has been significantly declining over time. The changing epidemiology of Kaposi's sarcoma was analyzed in a well-characterized cohort of homosexual and bisexual men; laboratory and interview data from a sample of these men were evaluated for determinants of and cofactors associated with Kaposi's sarcoma. Among 1,341 men with AIDS, the proportion presenting with Kaposi's sarcoma declined from 79% in 1981 to 25% in 1989. Compared with other men with AIDS, men with Kaposi's sarcoma had a shorter interval from human immunodeficiency virus (HIV) seroconversion to AIDS diagnosis (median, 77 vs. 86 months). Men with and without Kaposi's sarcoma did not significantly differ with respect to number of sexual partners, history of certain sexually transmitted or enteric diseases, use of certain recreational drugs (including nitrite inhalants), or participation in certain specific sexual practices. The decline in Kaposi's sarcoma may at least partly be due to a shorter latency period from infection to disease. Although cofactors for the development of Kaposi's sarcoma may exist, many previously hypothesized agents were not supported by this analysis.

High-risk sexual behavior and knowledge of HIV antibody status in the San Francisco City Clinic Cohort

To evaluate the effectiveness of human immunodeficiency virus (HIV) testing and counseling among homosexual and bisexual men participating in the San Francisco City Clinic Cohort, compared behavioral data from 181 men who learned their HIV antibody status between 1985 and 1987 with data from 128 men who were tested but declined to receive their results. Overall, significant declines in risk indices for unprotected receptive and insertive anal intercourse occurred between 1983-1984 and 1986-1987, but these declines were independent of both knowledge of HIV status and actual serostatus. Those who chose to learn their HIV status were also no more likely to report depression or to learn their HIV status were also no more likely to report depression or anxiety subsequent to testing. Regression analyses showed no relationship between length of time since learning one's HIV status, mental health symptoms, and the persistence of high-risk behavior in 1986-1987. Although these results do not negate the value of HIV testing and counseling, they suggest that other motivating factors such as frequent access to risk-reduction information may provide sufficient impetus for behavioral change.

Phase I study of low-dose zidovudine and acyclovir in asymptomatic human immunodeficiency virus seropositive individuals

PURPOSE

The combination of zidovudine and acyclovir has shown in vitro antiretroviral activity and led to short-term improvement in patients with symptomatic human immunodeficiency disease (HIV) disease. We performed a phase I study of zidovudine (500 mg/day) plus acyclovir (2 or 4 g/day) in asymptomatic HIV-seropositive men to investigate pharmacokinetics, safety, tolerance, and immunologic effects of the combination.

SUBJECTS AND METHODS

Fifty HIV-seropositive homosexual or bisexual men from the San Francisco City Clinic Cohort Study were recruited for the study; of these, 20 met the eligibility criteria. Treatment with zidovudine and acyclovir was open label. Pharmacokinetic, virologic, immunologic, and clinical data were collected periodically over a 24-week period.

RESULTS

Pharmacokinetic analysis showed no drug interaction. The combination was generally well tolerated, and hematologic parameters remained stable through 24 weeks. There were no significant changes in total lymphocytes, T4 lymphocytes, overall skin test reactivity, or ability to culture virus from peripheral blood.

CONCLUSION

This combination of agents is safe in this population for at least six months. Conclusions about long-term tolerance and efficacy await the results of larger trials with longer follow-up.

Prevalence, incidence, and progression of human immunodeficiency virus infection in homosexual and bisexual men in hepatitis B vaccine trials, 1978-1988

Between 1978 and 1980, 359 hepatitis B seronegative homosexual and bisexual men were recruited from the San Francisco municipal sexually transmitted disease clinic for hepatitis B vaccine trials. Of the 359 participants, 320 (89%) consented to have their stored blood samples tested for human immunodeficiency virus antibodies. The prevalence of human immunodeficiency virus infection in these 320 vaccine trial participants rose from 0.3% in 1978 to 50.9% in 1988. The annual incidence of human immunodeficiency virus infection showed that seroconversion peaked in 1980-1982, dropped significantly in 1983, and has remained low. Men less than 30 years old on entry into the study seroconverted earlier in the epidemic and had higher incidence rates than men 30 years or older (p = 0.07). No statistical difference in seroconversion rates was found for other demographic variables. Using a Kaplan-Meier survival curve of the cumulative proportion of men without acquired immunodeficiency syndrome by duration of human immunodeficiency virus infection, an estimated 39% (95% confidence interval 27%-51%) will develop acquired immunodeficiency syndrome within 9.2 years of infection. Cox proportional hazard stepwise analysis showed no correlation between age at seroconversion, race, or year of seroconversion and progression to acquired immunodeficiency syndrome.

Neurological and neuropsychological manifestations of HIV-1 infection: association with AIDS-related complex but not asymptomatic HIV-1 infection

To determine whether neurological and neuropsychological abnormalities are associated with clinical manifestations of human immunodeficiency virus type 1 (HIV-1) infection in men who do not have acquired immunodeficiency syndrome (AIDS), we performed a historical prospective and cross-sectional study. One hundred HIV-1 seropositive homosexual or bisexual men, of whom 26 had AIDS-related complex, 31 had generalized lymphadenopathy, and 43 had no signs or symptoms of HIV-1 infection, and 157 HIV-1 seronegative men were enrolled from a cohort of 6,701 men who were originally recruited between 1978 and 1980 for studies of hepatitis B virus infection. Evaluation included medical history, physical examination, and neuropsychological tests. Of 26 HIV-1 seropositive subjects with AIDS-related complex, 11 (42%) reported neurological, cognitive, or affective symptoms compared with 30 (19%) of 157 HIV-1 seronegative subjects (relative risk = 2.2, p = 0.02). On neuropsychological testing, subjects with AIDS-related complex performed at a significantly lower level than the HIV-1 seronegative group (p = 0.001). A significantly higher percentage of subjects with AIDS-related complex (8[31%]of 26) than HIV-1 seronegative subjects (19 [12%] of 157) had abnormal results on two or more neuropsychological tests (rate ratio = 2.5, p = 0.03). Symptoms and impairment on neuropsychological tests were correlated only within the group who had AIDS-related complex. Subjects with generalized lymphadenopathy and subjects who had no signs or symptoms of HIV-1 infection were not different from HIV-1 seronegative subjects with respect to symptoms or performance on neuropsychological tests.(ABSTRACT TRUNCATED AT 250 WORDS)