A New Specific Method for Measuring S-100B in Serum

The S-100 family of proteins are acidic calcium and zinc binding low molecular weight proteins mainly present in astrocytes and in a population of oligodendrocytes of the CNS. S100b, an acidic low weight and zinc binding protein, has attracted considerable interest due to its release into the cerebrospinal fluid and blood from brain tissue following brain damage and from malignant melanomas. A new simple two-step incubation assay has now been elaborated in which two catcher and one tracer monoclonal antibodies are used. The specificity of this assay is high because all the MAbs used bind exclusively to S-100B, as shown by real-time biospecific interaction analyses. Moreover, the working range of the assay is 0.2–60 μg/L with a CV of less than 10%; the resulting high sensitivity has been confirmed by clinical studies. Time dependence, shaking conditions, lower limit of detection limits, effects of dilution, hook effect, recovery, impression as intra- and interassay variations, and crossreactivities with S-100A1 were tested in order to obtain a highly reproducible assay. Sera from healthy blood donors and patients undergoing cardiopulmonary bypass operations were tested with the assay. Several of the patients undergoing open heart surgery presented measurable values in this IRMA S-100 assay, indicating cerebral effects of open heart surgery. The test may be used for postoperative monitoring of these patients.

HIVIS-DNA or HIVISopt-DNA priming followed by CMDR vaccinia-based boosts induce both humoral and cellular murine immune responses to HIV

Background

In order to develop a more effective prophylactic HIV-1 vaccine it is important optimize the components, improve Envelope glycoprotein immunogenicity as well as to explore prime-boost immunization schedules. It is also valuable to include several HIV-1 subtype antigens representing the world-wide epidemic.

Methods

HIVIS-DNA plasmids which include Env genes of subtypes A, B and C together with Gag subtypes A and B and RTmut/Rev of subtype B were modified as follows: the Envelope sequences were shortened, codon optimized, provided with an FT4 sequence and an immunodominant region mutated. The reverse transcriptase (RT) gene was shortened to contain the most immunogenic N-terminal fragment and fused with an inactivated viral protease vPR gene. HIVISopt-DNA thus contains fewer plasmids but additional PR epitopes compared to the native HIVIS-DNA. DNA components were delivered intradermally to young Balb/c mice once, using a needle-free Biojector® immediately followed by dermal electroporation. Vaccinia-based MVA-CMDR boosts including Env gene E and Gag-RT genes A were delivered intramuscularly by needle, once or twice.

Results

Both HIVIS-DNA and HIVISopt-DNA primed humoral and cell mediated responses well. When boosted with heterologous MVA-CMDR (subtypes A and E) virus inhibitory neutralizing antibodies were obtained to HIV-1 subtypes A, B, C and AE. Both plasmid compositions boosted with MVA-CMDR generated HIV-1 specific cellular responses directed against HIV-1 Env, Gag and Pol, as measured by IFNγ ELISpot. It was shown that DNA priming augmented the vector MVA immunological boosting effects, the HIVISopt-DNA with a trend to improved (Env) neutralization, the HIVIS-DNA with a trend to better (Gag) cell mediated immune reponses.

Conclusions

HIVIS-DNA was modified to obtain HIVISopt-DNA that had fewer plasmids, and additional epitopes. Even with one DNA prime followed by two MVA-CMDR boosts, humoral and cell-mediated immune responses were readily induced by priming with either DNA construct composition. Priming by HIV-DNA augmented neutralizing antibody responses revealed by boosting with the vaccinia-based heterologous sequences. Cellular and antibody responses covered selected strains representing HIV-1 subtypes A, B, C and CRF01_AE. We assume this is related to the inclusion of heterologous full genes in the vaccine schedule.

Cross-Resistance between AZT, ddl and other Antiretroviral Drugs in Primary Isolates of HIV-1

Primary isolates of human immunodeficiency virus type 1 (HIV-1) were tested for sensitivity to 3′-azido-3′-deoxythymidine (AZT), 3′-fluoro-3′-deoxythymidine (FLT), 2′,3′-dideoxyinosine (ddl), 2′,3′-dideoxycytidine (ddC), and phosphonoformate (PFA) in peripheral blood mononuclear cells (PBMC). Forty-eight isolates from HIV-1-infected patients treated with AZT for various lengths of time were investigated. More than half of the patients harboured virus resistant to AZT after treatment. There was no correlation between resistance and length of therapy. A significant correlation between resistance to AZT and reduced susceptibility to ddl and ddC was apparent. These results indicate that development of resistance to AZT is common in patients treated with AZT and may be associated with reduced sensitivity to ddl and ddC.

Impairment of short-term memory and Korsakoff syndrome are common in AIDS patients with cytomegalovirus encephalitis

BACKGROUND AND PURPOSE

The diagnosis of cytomegalovirus encephalitis (CMV-E) in AIDS patients is challenging as other illnesses may obscure the symptoms. Here, we characterize the clinical symptoms of CMV-E and link them to post-mortem findings. Patients and methods In 254 homosexual men with AIDS, followed from HIV diagnosis to death before the antiretroviral combination therapy era, CMV-E was suspected in 93 cases. All were CMV-positive in blood. Neurological examination, including cognitive testing was performed in 34 of them within 6 months before death. CMV-E was diagnosed by CMV-PCR in cerebrospinal fluid (n = 24) or by post-mortem (n = 24).

RESULTS

The majority complained of forgetfulness (91%), balance difficulties (85%) and impotence (85%). Impaired short-term memory was present in 29 patients. It was extreme in 17, justifying the diagnosis of Korsakoff's syndrome. This was often associated with infectious CMV in blood (P = 0.01). Brainstem symptoms were found in 19 patients. Post-mortem examination often revealed ventriculoencephalitis. CMV was found primarily around the ventricles and in other structures, described in Korsakoff's syndrome.

CONCLUSION

The location of CMV in the brain corresponded well to the clinical findings, demonstrating the close relationship between the neurological symptoms and the neuroanatomical lesions.

Transoesophageal echocardiography for the detection and quantification of pleural fluid in cardiac surgical patients

BACKGROUND

Transoesophageal echocardiography (TOE) can image pleural fluid. Left pleural collections may be easier to detect than right, as the thoracic aorta serves as an acoustic window. Attempts to quantify pleural fluid using TOE are restricted to a case report in which volume was predicted by multiplying maximal cross-sectional area (CSA(max)) by axial length (AL). A computed tomography (CT) derived formula for quantifying pleural effusions is maximal effusion depth squared (d2) multiplied by maximal effusion length.

METHODS

Eight patients were studied before chest closure following coronary bypass surgery. Fifty millilitre saline aliquots were instilled into the pleural space until detected by TOE. Saline was then instilled up to the next 200 ml increment and further 200 ml aliquots added until it spilled from the pleural space. CSA(max), d and AL were measured for each stage and used to calculate pleural fluid volume.

RESULTS

Median detection volume (range) was 125 ml (50-200) on the left and 225 ml (150-300) on the right (P = 0.016). Volume calculated by CSA(max) x AL correlated strongly with actual volume (r2 = 0.93 left and 0.92 right) as did volume calculated by d2 x AL (r2 = 0.86 left and 0.89 right). Mean difference between volume calculated by CSA(max) x AL and actual volume was - 51 ml on the left and 45 ml on the right vs - 253 ml on the left and - 212 ml on the right for volume calculated by d2 x AL.

CONCLUSIONS

TOE detects small volumes of pleural fluid on both sides of the chest. CSA(max) x AL provides a reasonably accurate measure of pleural fluid volume.

The rationale behind a vaccine based on multiple HIV antigens

The viral diversity of HIV-1 is likely to require a vaccine strategy that induces broad cellular and humoral anti-HIV-1 immunity. Our strategy is based on multiple HIV-1 DNA immunogens together with adjuvant recombinant granulocyte-macrophage stimulating factor. This article describes pre-clinical and clinical work preceding the initiation of clinical HIV-1 phase I/II trials.

DNA immunization with HIV early genes in HIV type 1-infected patients on highly active antiretroviral therapy

The aim of this study was to evaluate the immunological responses induced by DNA plasmids containing HIV regulatory genes administered in combination in HIV-1-infected patients with pretreatment with highly active antiretroviral treatment (HAART). The study is a double-blind, randomized, and placebo-controlled study, including 15 asymptomatic HIV-1-infected patients on stable HAART for at least 6 months and with plasma HIV RNA levels below 50 copies/ml. Ten patients received a combination of rev, tat, and nef intramuscularly (im) at weeks 0, 4, and 16 at increasing doses giving totals of 300 (100 x 3), 900 (300 x 3), and 1800 (600 x 3) micrograms DNA. Five patients received saline in the same amounts im. Antigen-specific cytotoxic T lymphocyte (CTL) levels were preserved or increased and new T lymphocyte proliferative responses were induced in the group immunized with the HIV DNA genes. No increase in antibody levels was noted. Despite a 10-fold higher vaccine dose, patients on HAART did not respond better to vaccination compared to non-HAART patients included in a previous study where the genes were administered separately. Combining the regulatory genes rev, tat, and nef in increasing doses may reduce the anticipated augmentation of HIV-specific T cell proliferative and CTL responses. Viral suppression did not seem to further improve the initial vaccine responses of patients with comparable CD4 levels.

Estimation of CD4 T-lymphocyte counts from percent CD4 T-lymphocyte determinations in HIV-1-infected subjects in sub-Saharan Africa

The relationship between CD4 percent and CD4 count has been reported to be different in industrialized countries compared to sub-Saharan Africa, where often only the former is reliable. CD4 determinations from an open cohort of hotel workers in Dar es Salaam followed between 1990 and 1998 were evaluated. T-lymphocyte determinations were offered once a year to 190 HIV-1 seropositive, 80 seroconverters and 495 sex and age matched HIV-seronegative subjects. After log transformation of the CD4 percent and CD4 counts a good fit to a linear regression curve was found, R(2) 0.697. The CD4 percent corresponding to a CD4 count of 200 cells/mm(3) was found to be 9.8%. CD4 percent determination can be useful to estimate CD4 counts, but needs to be locally standardized. The CD4 percent in Africa corresponding to AIDS defining CD4 counts seems to be lower than in the industrialized world.

Better preserved immune responses after immunization with rgp 160 in HIV-1 infected patients treated with highly active antiretroviral therapy than in untreated patients with similar CD4 levels during at 2 years' follow-up

OBJECTIVE

To study the impact of effective highly active antiretroviral therapy (HAART) on the preservation of long-term CD4 memory cells induced by vaccines in HIV-1-infected patients.

METHODS

Thirty HIV-1-positive patients on HAART with undetectable viral load were randomized into three groups: 10 received HIV-1 rgp160 vaccine, 10 received tetanus vaccine and 10 patients were not immunized. As controls, 10 HIV-negative volunteers were immunized with tetanus vaccine. The results were compared with an rgp160 vaccine study performed before the era of HAART on patients with comparable CD4 levels. All patients were monitored for 2 years for T-cell proliferative responses, T-cell subset levels, serum IgG and viral load.

RESULTS

After 1 year all patients immunized with rgp160 had strong T-cell responses to the rgp160 antigen. After 2 years this response was preserved in the HAART-treated group, but not in the rgp160 immunized non-HAART group, despite comparable CD4 levels. Recall effects of the CD4-specific responses towards other antigens were seen in the rgp160-immunized HAART group.

CONCLUSION

Immunization with rpg 160 leads to positive effects on HIV-specific T-cell proliferative responses in patients both with and without HAART. Immune responses after immunization is better preserved in HAART-treated patients who have low viral amounts than in individuals with high viral load and no HAART despite comparable CD4 levels during 2 years' follow-up. Interruption of HAART with return of a high viral load might thus have negative effects on T-cell functions in the long term, even if CD4 levels are kept at clinically acceptable levels.

Use of heparin-bonded circuits in cardiopulmonary bypass improves clinical outcome

OBJECTIVE

The use of heparin-coated surfaces in cardiopulmonary bypass has been shown to decrease the inflammatory response imposed by the contact between blood and artificial surfaces. One would expect this reaction to improve clinical outcome. However, this has been difficult to verify. This investigation is based on an aggregation of two randomized studies from our institution and highlights possible effects of heparin coating on a number of clinically oriented parameters.

DESIGN

Departmental analysis of patients subjected to coronary artery bypass surgery using heparin-coated circuits. Cardiopulmonary bypass was employed using either the Carmeda or Duraflo heparin coatings compared with a control. The systemic heparin dose was reduced in the heparin-coated groups (ACT > 250 s) vs control group patients (ACT > 480 s). The effects of heparin coating related to clinical outcome were studied.

RESULTS

The use of heparin-coated circuits reduced the mean length of stay in hospital from 7.8 +/- 2.5 to 7.3 +/- 1.8 days (p = 0.040) and postoperative ventilation time from 9.7 +/- 9.2 to 8.2 +/- 8.5 h (p = 0.018), blood loss 8 h post surgery from 676 +/- 385 to 540 +/- 245 ml (p = 0.001), individual perioperative change of haemoglobin loss (p = 0.001), leukocyte count (p = 0.000) and creatinine elevation (p = 0.000), proportion of patients exposed to allogenous blood transfusions 39.2 vs 23.9% (p = 0.001), postoperative coagulation disturbances 4.4 vs 0.4% (p = 0.006), postoperative deviations from the normal postoperative course 47.2 vs 36.7% (p = 0.035), neurological deviations 9.4 vs 3.9% (p = 0.021) and atrial fibrillation 26.4 vs 18.0% (p = 0.041). No effects were found with respect to perioperative platelet count, postoperative fever reaction and 5-year survival.

CONCLUSION

Based on several indicators, the use of heparin coating in cardiopulmonary bypass is associated with improved clinical results.

HIV subtypes and recombination strains--strategies for induction of immune responses in man

Clinical and experimental studies of HIV-1 subcomponents were made in order to increase their immunogenicity. HIV subtype envelopes A, B and C have been compared and a detailed analysis made by peptides of the coreceptor-ligand interactions. We identified a direct interaction between HIV-1 envelope and a cellular receptor at the amino acid level. Both the viral subtype and its tropism appeared to influence inhibition of infection. Genetic immunization induced new cytotoxic responses while proteins appeared to efficiently boost previous responses. One HIV-1 subtype B antigen was strongly immunogenic in a human immunotherapeutic trial and permitted better survival at 2 years of the study in patients with poor prognosis.

Sexual behaviour among youths at high risk for HIV-1 infection in Dar es Salaam, Tanzania

OBJECTIVES

To investigate sex specific sexual behaviour in youths visiting a youth clinic for sexual and reproductive health in Dar es Saalam.

METHODS

A questionnaire was administered to a random sample of youths between 10 and 24 years of age attending the youth health clinic in Dar es Saalam. The clinical investigation included testing for syphilis and HIV-1 antibodies

RESULTS

1423 youths attended the clinic between September 1997 and August 1998. The study population comprised 213 (53.5%) males and 185 (46.5%) females. 97 (24.4%) were below 20 years. The mean age at coitarche was 16.5 and 17.0 years of age for males and females, respectively. The coitarche was involuntary in 15 females (8.6%). 49.5% males reported more than five lifetime partners compared with 14.1% for females (p<0.0001). Males reported recent partners to be 2.5 years younger, while females reported them to be 5.0 years older. No contraceptive use was reported by 29.7% of the males and 40.3% of females. 52.7% females had been pregnant and 26 (14.1%) reported induced abortions. Genital discharge was found in 69.5% and 73.9% and GUD in 36.6% and 27.1% of males and females respectively. 12 males (5.9%) and 43 females (24.6%) were found to be HIV-1 infected. 13.8% of the females with only one lifetime partner were HIV-1 infected compared with 40.9% with more than five partners (p = 0.028).

CONCLUSIONS

Many youths in Dar es Salaam engage in sexual behaviours that put them at risk of unwanted pregnancies and STIs including HIV infection. Female youths were more likely to contract HIV infection than males. In African urban areas youth oriented clinics can have a pivotal role in HIV/STI prevention and control

[HIV, gonorrhea, chlamydia and syphilis are increasing among homosexual men]

The incidence of gonorrhoea, chlamydia, syphilis and HIV infection is increasing among homosexual men in Stockholm, Sweden. This indicates that the frequency of unsafe sex is on the increase while the use of condoms is decreasing.

Clinical and immunological benefits from highly active antiretroviral therapy in spite of limited viral load reduction in HIV type 1 infection

Both naive and memory T lymphocyte responses are lost during advanced HIV infection. Treatment with highly active antiretroviral therapy (HAART) is associated with an increase in T lymphocytes and a reduction in viral load. However, the viral response to HAART in patients with low levels of helper T lymphocytes and a high viral load is often not satisfactory. We investigated the capacity of long-term HAART to reconstitute the immune system in severely ill patients. A nonselected longitudinal patient population with high baseline viral levels and CD4(+) cells below 100 x 10(6)/liter were monitored for 2 years during HAART. Markers to estimate the therapeutic effects included viral levels and cell surface markers representing naive and memory T lymphocytes as well as activation markers, B cells, NK cells, and clinical events. After 2 years of treatment, viral load was reduced to undetectable levels in 55% (viral responders, vRs) and less than 1 log (median value) from baseline in 45% (viral low responders, vLRs). Elevated numbers of memory and naive CD4(+) and CD8(+) cells as well as a decrease in activation markers were seen in both vRs and vLRs. However, the magnitude was greater in vRs. No differences in the clinical outcome were observed between vRs and vLRs. We conclude that most patients, even in advanced stages of HIV disease, benefited from HAART. The magnitude of the response was related to good viral reduction, but even patients with poor viral reduction had a recovery of naive and memory CD4(+) and CD8(+) cells. Even a small reduction in viral load is thus of importance for health and potentially also for years of survival.

Neurological and general outcome in low-risk coronary artery bypass patients using heparin coated circuits

OBJECTIVE

The clinical significance of heparin coating in cardiopulmonary bypass has previously been investigated. However, few studies have addressed the possible influence on brain function and memory disturbances.

METHODS

Three hundred low-risk patients exposed to coronary bypass surgery were randomised into three groups according to type of heparin coating: Carmeda Bioactive Surface, Baxter Duraflo II and a control group. Outcome was determined from a number of clinically oriented parameters, including a detailed registry of postoperative deviations from the normal postoperative course. Brain damage was assessed through S100 release and memory tests, including a questionnaire follow-up.

RESULTS

Clinical outcome was similar for all groups. Blood loss (Duraflo only), transfusion requirements and postoperative creatinine elevation were reduced in the heparin-coated groups. A lower incidence of atrial fibrillation was noted in the Duraflo group. Heparin coating did not uniformly attenuate the release of S100 or the degree of memory impairment.

CONCLUSIONS

Cardiopulmonary bypass (CPB) with heparin coating and a reduced dose of heparin seems to be safe. Clinical outcome and neurological injury seem not to be associated with type of heparin coating used for CPB. However, blood loss and transfusion requirements may be reduced.

The health-related quality of life in a Swedish sample of HIV-infected persons

The purposes of the present study are (1) to assess the health-related quality of life (HRQOL) and the subjective health status in a sample of human immunodeficiency virus (HIV)-infected persons (2) to relate the results to different population groups and (3) to investigate the relationship of medical and demographic variables with HRQOL. A total of 72 HIV-infected men were included. They answered the Swedish health-related quality of life questionnaire and the health index. Demographic and medical data were obtained from the medical records. The data collection took place before entering a therapeutic HIV vaccine trial. The results showed a more negative impact on the HRQOL and subjective health status in the HIV-positive subjects, compared with male population groups. The dimensions of emotional well-being were most affected. When comparisons were made according to the medical and demographic variables for different subgroups within the HIV sample, differences in the physical-dimension scales were most prominent. Symptomatic HIV infection or acquired immunodeficiency syndrome (AIDS), anti-retroviral treatment, sick leave or disability pension, low income and basic education were associated with worse HRQOL and health status. In conclusion, it is of utmost importance to take into account, aspects of the patients' emotional well-being in nursing, as well as in medical care and interventions. Moreover, individualized caring programs are needed because the disruptions in HRQOL fluctuated within the HIV sample.

Isoniazid prophylaxis for tuberculosis prevention among HIV infected police officers in Dar es Salaam

OBJECTIVE

To determine the acceptability, compliance and side effects of isoniazid (INH) prophylaxis against tuberculosis among HIV infected police officers (PO) in Dar es Salaam.

DESIGN

A nested study from a prospective follow up of a cohort of police officers.

SETTING

Dar es Salaam, Tanzania.

SUBJECTS

One hundred and forty three HIV-1 infected police officers.

MAIN OUTCOME MEASURES

Acceptance and compliance to INH prophylaxis.

RESULTS

Of the 400 HIV-1 infected officers, 143 (35.7%) came forward for post-test counselling and HIV test results. Sixty per cent (87/143) of them accepted to be on INH prophylaxis. However only 42.5% (37/87) came forward for evaluation regarding their suitability for INH prophylaxis. During the evaluation, eight (21.6%) of 37 otherwise asymptomatic PO were found to have active pulmonary tuberculosis (TB). Eventually only 29 PO were actually started on INH, and only 16 (55.2%) of them completed the six months course. No serious side effects were observed. One PO developed TB two months after loss to follow up before completing the six months.

CONCLUSIONS

There was low acceptability of and poor compliance with INH prophylaxis among the HIV-1 infected PO despite being educated on the benefits of prophylaxis. The prevalence of PTB among asymptomatic HIV-1 infected PO was high, and therefore persons with HIV infection should be examined for TB even in the absence of symptoms.

Serum lipid levels associated with increased risk for cardiovascular disease is associated with highly active antiretroviral therapy (HAART) in HIV-1 infection

The long-term effects of fat metabolism, storage and utilization in HIV-1 infected patients on highly active antiretroviral therapy (HAART) including a protease inhibitor are profound and cause increasing concern. The main importance of these lipid/metabolic disorders lies in their assumed contribution to an increased risk of coronary heart disease (CHD). In the general population increased levels of lipoprotein(a) [Lp(a)] constitute an independent risk factor for CHD by itself as well as in combination with increased levels of cholesterol and low density lipoprotein (LDL)-cholesterol, respectively. Two hundred and fifty-six patients with 27 +/- 7 months HAART and 84 treatment-naive HIV-1 positive patients were screened for cardiovascular risk factors. The subjective perception of fat wasting and/or accumulation in different sites of the body, which was possible to evaluate in 235 patients on HAART and 73 treatment-naive patients, the levels of plasma triglycerides (TG), cholesterol, LDL and high-density lipoproteins (HDL)-cholesterol, LDL/HDL ratio and Lp(a) were measured. Of the patients on HAART, 42% (98/235) reported abnormal fat distribution as compared with 4% (3/73) of the treatment-naive patients (P<0.0001). The levels of TG, cholesterol and LDL-cholesterol, but not HDL-cholesterol or Lp(a) were higher (P<0.0001) in the HAART group as compared with the naive group. Very high Lp(a) levels (> 700 mg/l) were more common among HAART patients as compared with naive, 14% (36/256) vs 2% (2/83); P=0.0022. The Lp(a) levels correlated to the levels of LDL-cholesterol, but not to total cholesterol, HDL-cholesterol or TG, and did not differ between patients with and without subjective perception of abnormal fat distribution. A significant number of the HAART patients had very high levels of Lp(a) and various combinations of increased lipid values associated with considerably increased risk for CHD. The elevation of Lp(a) did not relate to any other clinical or laboratory parameter than to LDL-cholesterol.

Cross-reactive T-helper responses in patients infected with different subtypes of human immunodeficiency virus type 1

Immunization with a recombinant glycoprotein 160 envelope immunogen derived from a virus of genetic subtype B induced strong specific T-helper cell responses in asymptomatic human immunodeficiency virus (HIV) carriers infected with subtypes B to G. This indicates that the HIV-specific T-helper immunity, which is the basis for development of antibodies and cytotoxic T lymphocytes, can be improved by both homologous and heterologous antigens. It also suggests that a particular immunogen can be effective against many different HIV strains.

The prevalence and incidence of HIV-1 infection and syphilis in a cohort of police officers in Dar es Salaam, Tanzania: a potential population for HIV vaccine trials

OBJECTIVES

To assess the suitability of a cohort of police officers in Dar es Salaam for HIV vaccine trials by determining the prevalence and incidence of HIV-1 infection, active syphilis and their associated factors.

DESIGN AND SETTING

An open cohort study of police officers in Dar es Salaam, Tanzania.

METHODS

Recruitment of police officers began in 1994. A standardized questionnaire was completed at enrolment and subsequent visits. HIV antibodies were determined using two consecutive enzyme-linked immunosorbent assays. Samples repeatedly discordant on the two tests were tested by a Western blot assay. Treponema pallidum antibodies were first determined by Venereal Disease Research Laboratory (VDRL) test and reactive sera were confirmed by Treponema pallidum hemagglutination test.

RESULTS

At the end of 1996 a total of 2850 police officers had been recruited of whom 2733 (96%) consented to be tested for HIV. The overall HIV-1 seroprevalence at recruitment was 13.8% (378 of 2733). Females had a significantly higher HIV-1 seroprevalence, 18.0% (55 of 306), as compared to males, 13.3% (323 of 2427), P< 0.05. From a total of 2215 married police officers, 585 (26.4%) responded to a question on extramarital sex within the previous 3 months of whom 36.2% (212 of 585) admitted to have had at least one extramarital sexual intercourse. Condoms were not used during these encounters by 178 of 212 (84.0%). As of 31st December 1998, among the 1524 males observed for 2553 person-years (PYAR), 50 had seroconverted and among 200 females observed for 357 PYAR, eight had seroconverted. The overall crude HIV-1 incidence was thus 19.9/1000 PYAR; 19.6 and 22.4/1000 PYAR for males and females, respectively. The overall prevalence and incidence of active syphilis were 3.1% (88 of 2850) and 8.6/1000 PYAR (26 of 3149), respectively. Males had a higher prevalence of active syphilis, 84 of 2525 (3.3%) than females, five of 325 (1.5%), P = 0.09.

CONCLUSIONS

There was high risk sexual practice including low condom use in this cohort of police officers. The incidence and prevalence of HIV infection were high. Police officers in Dar es Salaam are therefore a potential population group for HIV vaccine evaluation.

C-reactive protein levels in HIV complicated by opportunistic infections and infections with common bacterial pathogens

In order to determine the pattern of C-reactive protein (CRP) concentrations in HIV-infected patients with various other infections, we conducted a prospective study (for the period 1990-91) of all HIV-seropositive patients hospitalized with fever and a retrospective study (for the period 1990-95) of all patients infected with Mycobacterium avium complex (MAC) and Pneumocystis carinii pneumonia (PCP). Samples from blood, cerebrospinal fluid and sites with clinical signs of infection were obtained for bacteriological culture. Polymerase chain reaction (PCR) determination was performed for cytomegalovirus in blood and CSF. Patients with opportunistic infections had a significantly lower increase in CRP concentration than patients infected with common bacterial pathogens. Patients with PCP and mycobacterial infections had a distinct CRP response after the onset of therapy. Lack of CRP increase at diagnosis of MAC infection was associated with a shorter survival and normalization of CRP after MAC therapy with a significantly longer survival.

Immune responses in asymptomatic HIV-1-infected patients after HIV-DNA immunization followed by highly active antiretroviral treatment

Intensive chemotherapy is capable of reducing the viral load in HIV-1-infected individuals while infected cells are still present. A special property of DNA immunization is to induce both new CTL and Ab responses. We evaluated the possibility of inducing new immune responses in already infected individuals by means of DNA constructs encoding the nef, rev, or tat regulatory HIV-1 genes. Significant changes in viral loads and CD4+ counts were observed in four patients who started highly active antiretroviral treatment (HAART) during the immunization study. The DNA immunization induced Ag-specific T cell proliferation, which persisted up to 9 mo after the last DNA injection, and cytolytic activities but did not, by itself, reduce viral load. Increased levels of CTL precursor cells were induced in all nine DNA-immunized patients. The profile of IFN-gamma secretion observed when human PBMC were transfected with the nef, rev, and tat DNA resembled that found in the CTL activity (nef > tat > rev). Ab responses that occurred after immunizations were of a low magnitude. In accordance with the high IL-6 production induced by the nef DNA plasmid, IgG titers were highest in patients immunized with nef DNA. The initiation of HAART appears to contribute to the induction of new HIV-specific CTL responses, but by itself did not cause obvious re-induction of these activities.

Long-term immunotherapy in HIV infection, combined with short-term antiretroviral treatment

Forty asymptomatic HIV-infected individuals with CD4+ lymphocyte levels above 400x10(6)/l were immunized over 5 years with recombinant envelope glycoprotein gp160 (rgp160). After 5 years there was a trend towards more non-progressors in the immunized group as compared to the matched controls. Since immunizations could activate HIV, the first 6 immunizations were followed by 2 weeks of zidovudine or placebo, double-blind. The viral load did not change during the first 6 months and was not different from that of the matched controls after 5 years. The best effect on CD4+ lymphocyte development was seen in individuals with a high viral load randomized to rgp160+zidovudine and in individuals with a low viral load randomized to rgp160+placebo. We conclude that rgp160 is safe and results in temporarily improved CD4+ development. Concomitant antiviral treatment might be of benefit, especially in patients with a more advanced disease and can today be given with more effective combinations.

Therapeutic immunisation with recombinant gp160 in HIV-1 infection: a randomised double-blind placebo-controlled trial. Nordic VAC-04 Study Group

BACKGROUND

The immune system's ability to scavenge and destroy detrimental HIV-1 products has an important effect on virion production and the course of infection. In earlier trials of therapeutic immunisation with envelope protein recombinant gp160 (rgp160) we observed a transient positive effect on CD4-lymphocyte counts. This randomised placebo-controlled study investigated whether our preliminary findings represented a potential for a more benign clinical course.

METHODS

835 HIV-seropositive patients from 20 centres in Sweden, Norway, and Finland with CD4-cell counts above 200/microL were randomly assigned to receive 160 microg rgp160 or placebo (alum adjuvant alone) every 3 months for 3 years after an induction period, as well as optimum available treatment. Analyses were by intention to treat.

FINDINGS

63 of 416 vaccine-group patients and 61 of 419 placebo-group patients reached a primary clinical endpoint (AIDS-defining event or death); the time to first clinical endpoint did not differ between the groups (p=0.864). Significantly fewer vaccine-group patients than placebo-group patients reached the primary immunological endpoint of a decrease of more than 30% from baseline CD4-cell count (157 vs 189, p=0.03). A higher proportion of the vaccine group had CD4-cell counts higher than baseline at 6 months (167 vs 133, p=0.014). HIV-1-specific T-cell immune reactivity was induced in all vaccine recipients studied. No severe adverse events associated with the vaccine were noted during the study. There were significantly fewer deaths among the vaccine recipients than among the placebo-group patients at 2 years, but not at the end of the study.

INTERPRETATION

Therapeutic immunisations with rgp160 have a modest effect on CD4-cell counts, but this treatment alone did not lead to clinical benefit when given in addition to best clinical practice at the time of the trial. Immunisation in conjunction with antiretroviral therapy was also effective, which strongly suggests that a combination with highly active therapy would improve the total effect.

Treatment history and baseline viral load, but not viral tropism or CCR-5 genotype, influence prolonged antiviral efficacy of highly active antiretroviral treatment

BACKGROUND

The efficacy of highly active antiretroviral treatment (HAART) in HIV-1 disease may vary between nucleoside-naive and experienced patients as well as between patients with different viral phenotypes and in different stages of disease.

OBJECTIVE

To investigate variables of importance for successful long-term viral suppression by analysing virological, clinical and immunological characteristics at initiation of protease inhibitor treatment on suppression of HIV RNA over 1 year.

DESIGN

An open, non-randomized, observational clinical study.

SETTING

Venhälsan, Department of Dermatovenereology, Söder Hospital, Stockholm, Sweden.

PATIENTS

A total of 147 unselected advanced patients with known HIV-1 infection for a mean of 7 years, of whom 37% had AIDS and who started treatment with a protease inhibitor during 1996.

INTERVENTIONS

All patients received HAART with at least two nucleoside analogues in combination with either indinavir (81%) or ritonavir (19%). The majority (77%) had been previously treated with nucleoside analogues for a mean of 39 months.

MEASUREMENTS

CD4+ lymphocyte count, plasma HIV-1 RNA, viral phenotype and HIV-1 coreceptor CCR-5 genotype at baseline. Viral load and CD4+ lymphocyte count were determined every 3 months.

RESULTS

Patients were analysed on an intention-to-treat basis. The mean CD4+ lymphocyte count at baseline was 170 x 10(6)/l and the median viral load was 68 600 copies/ml. Heterozygosity for the delta32 deletion of the CCR-5 gene (delta32/wt) was found in 27%. MT-2 positive virus (syncytium-inducing) was isolated in 46%. Logistic regression revealed that nucleoside analogue experience and baseline log10 HIV-1 RNA were the only factors independently related to plasma HIV-1 RNA levels below 500 copies/ml after 1 year of treatment, which was found in 69%.

CONCLUSION

The virological outcome after 1 year of HAART was strongly correlated to prior treatment history and baseline viral load, whereas CD4+ lymphocyte count, CCR-5 genotype and viral biological phenotype had less influence. The long-term antiviral efficacy of HAART was lowest in individuals with previous nucleoside analogue treatment and a high baseline viral load. In these individuals an even more aggressive treatment should be considered.

Indicators of T-cell activation: correlation between quantitative CD38 expression and soluble CD8 levels in asymptomatic HIV+ individuals and healthy controls

Increased activation of CD8+ T cells, particularly increased expression of CD38 antigen, has been shown to strongly correlate with progression of human immunodeficiency virus-positive (HIV+) individuals to acquired immunodeficiency syndrome (AIDS) and death. As part of a study evaluating responses to a recombinant gp160 vaccine, we have used quantitative three-color flow cytometry (QFCM) to further investigate the relationships among several measures of lymphocyte activation/immunological status. Parameters evaluated included 1) absolute circulating counts for the major lymphocyte phenotypes (T, B, NK) and selected activated/regulatory subsets believed to have clinical value in the monitoring of patients with HIV infection; 2) level of CD38 expression (antibody-binding capacity [ABC]) on the lymphocyte subsets defined by CD8, CD38, and HLA-DR; and 3) serum levels of soluble CD8. CD8+DR+CD38+ counts were found to be markedly increased (approximately 10-fold) in HIV+ individuals, whereas CD4+CD45RA+ counts were markedly decreased (approximately 5-fold). We confirmed previous reports that CD38 expression on CD8 T cells (here reported as CD38 ABC) are increased in asymptomatic HIV+ individuals as compared with healthy controls, and further found that CD38 ABC was elevated approximately 2-fold on CD8+DR+ cells as compared with CD8+DR- cells in healthy controls, and almost 2-fold further elevated on CD8+DR+ cells in HIV+ individuals compared with CD8+DR+ cells in healthy controls. In agreement with previous studies, we found increased serum CD8 levels (sCD8) and increased CD8+DR+ counts in asymptomatic HIV+ individuals. However, when sCD8 was expressed relative to CD8+DR+ cell counts (RsCD8), this index was found to be significantly decreased in HIV+ individuals. Although CD38 ABC on CD8+DR+ cells showed no correlation with sCD8, it was significantly correlated with RsCD8 in both HIV+ and HIV- individuals. Absolute lymphocyte counts were strongly correlated with both CD38 ABC and RsCD8 in HIV+ individuals. However, CD4 counts were correlated with CD38 ABC (but not RsCD8) in HIV+ patients and with RsCD8 (but not CD38 ABC) in HIV-controls. Our results suggest that QFCM is significant in understanding the role of CD8+DR+CD38+ cells in processes such as lymphocyte homeostasis and HIV-induced CD4-cell depletion.

HIV testing in Swedish STD clinics 1986-1994

In 1986 Swedish STD clinicians decided on a national policy of offering HIV tests routinely to all their patients. During the period July 1986 through December 1994, 224,722 tests were performed. HIV tests for one or more specific reasons were carried out on 7% of the patients, and 20% requested the test solely because of anxiety. The remaining 73%, accepted the test as part of the clinical routine without giving any specific reason. Of those offered a test, 54% had been tested at least once before. Twenty-three per cent did not accept the test. Among those tested, 373 persons (0.2%) were found to have a newly detected HIV infection. Contact tracing was the reason for testing in 11%, whilst 32% were tested for other specific reasons, 29% requested testing for no stated specific reason and 28% had been tested as a routine. Of all the tested men who reported sex with men, 7% proved to be HIV positive. The 373 persons with newly detected HIV infection constituted 14% of the total newly detected cases in Sweden during the period in question.

MT-2 tropism and CCR-5 genotype strongly influence disease progression in HIV-1-infected individuals

BACKGROUND

The beta-chemokine receptor CCR-5 is the coreceptor for cellular entry by non-syncytium-inducing (NSI) HIV-1 strains that dominate early in infection. A 32 base-pair deletion (delta32) in the CCR-5 gene renders this coreceptor non-functional. Heterozygosity for this deletion [delta32/wild-type (wt)] is associated with slow disease progression. The purpose of this study was to document the combined impact on HIV-1 disease progression of the CCR-5 genotype and the biological phenotype of HIV-1.

METHODS

In a cross-sectional study of 258 HIV-1-infected Swedish individuals, the CCR-5 genotype (wt/wt or delta32/wt) was determined by polymerase chain reaction and the biological phenotype [NSI or syncytium-inducing (SI)] of virus isolates was determined in the MT-2 cell assay. Clinical status, HIV-1 RNA levels in plasma, CD4+ lymphocyte counts, and rate of CD4+ lymphocyte decline, based on retrospective analysis of CD4+ lymphocyte counts, were also recorded. None of the individuals were treated with protease inhibitors.

RESULTS

The prevalence of the delta32/wt genotype was 23%. Subjects with the delta32/wt CCR-5 genotype more often carried SI virus than subjects with the wt/wt genotype (49 versus 35%; P=0.067), but there were no differences between the two groups in prevalence of AIDS, viral load, CD4+ lymphocyte count or CD4+ slope. NSI virus isolates were found in 159 (62%) out of 258 individuals. Individuals with NSI had lower prevalence of AIDS (39 versus 19%; P < 0.01), higher CD4+ lymphocyte counts (289+/-188 x 10(6)/l versus 153+/-162 x 10(6)/l; P=0.001), lower viral loads (median, 4.45 log10 versus 4.91 log10 copies/ml; P < 0.01) and a lower prevalence of the delta32/wt genotype (19 versus 29%; P=0.067) compared with individuals with SI virus. When the material was further subdivided, subjects with the delta32/wt genotype and SI virus had the highest prevalence of AIDS (P < 0.001), lowest CD4+ lymphocyte count (P=0.0001) and highest viral load (P=0.023) whereas the opposite was true for subjects with the delta32/wt genotype and NSI virus. A significantly higher proportion of subjects with NSI virus with delta32/wt and wt/wt CCR-5 genotype had been immunized with recombinant gp160.

CONCLUSION

In summary, the delta32/wt CCR-5 genotype has a protective effect against HIV-1 disease progression that appears to be limited to individuals carrying HIV-1 variants with NSI phenotype. Immunization with recombinant gp160 tended to reduce the frequency of SI phenotypes.

Cellular cytotoxic response induced by DNA vaccination in HIV-1-infected patients

BACKGROUND

DNA vaccination is known to generate immune responses against HIV-1 in animal models. We aimed to assess the efficacy of DNA vaccination in induction of immune responses in HIV-1-infected human beings.

METHODS

Nine symptom-free HIV-1-infected patients were immunised with DNA constructs encoding the nef, rev, or tat regulatory genes of HIV-1. The patients were selected for having no or low antibody reactivities to these antigens. HIV-1-specific cytotoxic T-lymphocytes (CTLs), precursor frequencies, and antigen-specific proliferative responses were measured before, during, and after three immunisations over 6 months.

FINDINGS

Cellular immune reactivities against the HIV-1 regulatory proteins were absent or low before DNA immunisation. DNA vaccination induced detectable memory cells in all patients and specific cytotoxicity in eight patients. CTLs were MHC-class-I restricted and mainly of CD8+ origin. In three patients the cellular activity was transient, decreasing after an initial response.

INTERPRETATION

DNA immunisation with HIV-1 genes can induce specific cellular responses in human beings with no apparent side-effects. It is theoretically possible that HIV-1-specific cytotoxic responses to regulatory proteins could lead to infected cells being eliminated before they have released new viral particles. However, it is possible that the patients we selected responded less than would non-selected or non-infected individuals. The small number of patients presented here does not allow generalisation of our findings.

Induction of specific T-cell responses in HIV infection

OBJECTIVES

To induce recovery of HIV-1-specific immune responses by combining immunization with antiviral chemotherapy.

DESIGN

Forty HIV-infected patients entered a double-blind study with recombinant gp160 in combination with zidovudine or placebo. The pretreatment observation period was around 2 years and the treatment period 5 years. Eighty matched HIV-infected patients served as controls.

METHODS

Immune status was monitored by proliferation assays with HIV-specific antigens, mitogens and recall antigens. Viral load, CD4 cell counts, apoptosis, T-cell clonal analysis and CC-chemokine receptor (CCR)-5 status were determined.

RESULTS

All immunized patients showed a strong and HIV-specific T-cell proliferative response. This response was related to the immunizations, and was not enhanced by the zidovudine monochemotherapy given during the first 6 months of the immunizations. The treatments did not significantly alter viral load. Potent antiviral combination therapy given to non-immunized individuals reduced their viral load but did not influence HIV-specific immune responses. There was a trend for an increased frequency of non-progression in the immunized group compared with controls. These individuals had both wild-type and mutant CCR-5 genes.

CONCLUSION

The results clearly show that restoration of HIV-specific T-cell immunity occurs after immunization with the HIV gp160 antigen and is not influenced by the addition of antiviral monochemotherapy. Even intensive chemotherapy alone did not restore HIV-specific immunity and immunization alone did not influence viral load. This suggests that combinations of intensive chemotherapy with specific HIV immunization would result both in viral load reduction and improved immune responses to HIV.

[Report on the history of condoms]

Is there any other positive reason for using a condom, from a man's point of view, than contraception and prophylaxy? There are no studies on the effects of using a condom on the sensation. The writer started a study on the topic.

The influence of MT-2 tropism on the prognostic implications of the delta32 deletion in the CCR-5 gene

BACKGROUND

Long-term non-progression in HIV-1-infected patients has been reported to be associated with a 32 base-pair deletion (delta32) in one CCR-5 allele. The normal gene product acts as a coreceptor for HIV cell entry and is essential for infection of cells by non-syncytium-inducing and MT-2-negative HIV-1 strains.

METHODS

Forty individuals were studied, all of whom had been HIV-1-seropositive for a mean of 8 years.

RESULTS

Eight (20%) were heterozygous for the CCR-5 allele delta32 deletion. Six of these eight patients harboured MT-2-negative HIV-1 strains. Of these six, three were long-term non-progressors with a positive CD4 cell slope, not receiving antiretroviral treatment, whereas the other three were progressors (mean CD4 cell decline, 3.8 x 10(6)/l per month) receiving antiretroviral combination therapy. Two of the eight patients with the delta32 deletion had MT-2-positive HIV-1 strains. Both had very rapid CD4 cell decline (6.7 and 7.6 x 10(6)/l per month, respectively), despite triple antiretroviral therapy including a protease inhibitor. One of the patients with an MT-2-positive virus strain has suffered from Pneumocystis carinii bronchitis and the other from cytomegalovirus colitis.

CONCLUSIONS

Disease progression may also occur in individuals with the coreceptor deficiency, especially in association with MT-2-positive HIV-1 strains. It is suggested that MT-2-positive HIV-1 enters cells through the CXC chemokine receptor-4 fusin coreceptor, thus circumventing the defective CC chemokine receptor-5 coreceptor. Various levels of expression of the wild-type CCR-5 gene and the gene with the delta32 deletion might explain variations in the disease progression in heterozygous patients with MT-2-negative HIV-1 strains.

Hemodynamics, cerebral circulation, and oxygen saturation in Cheyne-Stokes respiration

Because cardiovascular disorders and stroke may induce Cheyne-Stokes respiration, our purpose was to study the interaction among cerebral activity, cerebral circulation, blood pressure, and blood gases during Cheyne-Stokes respiration. Ten patients with heart failure or a previous stroke were investigated during Cheyne-Stokes respiration with recordings of daytime polysomnography, cerebral blood flow velocity, intra-arterial blood pressure, and intra-arterial oxygen saturation with and without oxygen administration. There were simultaneous changes in wakefulness, cerebral blood flow velocity, and respiration with accompanying changes in blood pressure and heart rate approximately 10 s later. Cerebral blood flow velocity, blood pressure, and heart rate had a minimum occurrence in apnea and a maximum occurrence during hyperpnea. The apnea-induced oxygen desaturations were diminished during oxygen administration, but the hemodynamic alterations persisted. Oxygen desaturations were more severe and occurred earlier according to intra-arterial measurements than with finger oximetry. It is not possible to explain Cheyne-Stokes respiration by alterations in blood gases and circulatory time alone. Cheyne-Stokes respiration may be characterized as a state of phase-linked cyclic changes in cerebral, respiratory, and cardiovascular functions probably generated by variations in central nervous activity.