The clinical prognosis of HIV-1 infection: a review of 32 follow-up studies

Weight loss might be an early clinical feature of undiagnosed human immunodeficiency virus infection in Taiwan

BACKGROUND/OBJECTIVE

Little research is available on the relationship between weight loss and human immunodeficiency virus (HIV) infection in Taiwan. We hope to evaluate whether weight loss could be an early clinical feature of undiagnosed HIV infection in Taiwan.

METHODS

We conducted a retrospective population-based cohort study using the database of the Taiwan National Health Insurance (NHI) Program. There were 4748 male subjects aged 1-84 with newly diagnosed weight loss as the weight loss group from 1998-2012 and 18982 age-matched male subjects without weight loss as the non-weight loss group. The incidence of HIV infection at the end of 2013 was measured in both groups. The multivariable Cox proportional hazards regression model was used to measure the hazard ratio (HR) and 95% confidence interval (CI) for HIV risk associated with weight loss.

RESULTS

The overall incidence of HIV infection was 3.79-fold higher in the weight loss group than in the non-weight loss group (6.83 vs. 1.80 per 10000 person-years, 95% CI 3.41, 4.21). The incidence was the highest during the first 6 months of follow-up in the weight loss group (39.0 per 10000 person-years). After adjusting for confounding factors, the adjusted HR of HIV infection was 3.63 (95% CI 1.77, 7.44) for the weight loss group, compared with the non-weight loss group.

CONCLUSION

Weight loss might be an early clinical feature of undiagnosed HIV infection in Taiwan. Male patients with weight loss who have risk factors for HIV infection should be recommended to regularly be tested for HIV infection.

Symptomatology of HIV-related illness and community-acquired illness in an HIV-infected emergency department population

STUDY HYPOTHESIS

Community-acquired infections and non-AIDS-related illnesses are a significant proportion of the final diagnoses in HIV-infected patients presenting to an emergency department. We hypothesized that emergency physicians over-diagnose opportunistic infections in the HIV-infected patient. We also hypothesized that the absolute CD4 lymphocyte level could be used to stratify patients by likelihood of HIV related disease.

METHODS

We retrospectively reviewed ED logbooks and medical records to find all ED patients with self-reported HIV seropositivity during a 19-month period. Age, sex, insurance status, chief complaint(s), ED assessment, and disposition were recorded from the ED logs; absolute CD4 lymphocyte counts, risk factors, and final diagnoses were recorded from the medical records. HIV-related disease was evaluated with the use of established Centers for Disease Control and Prevention criteria. Data were evaluated with the use of the chi 2 test, the chi 2 test for trend, and kappa-proportions.

RESULTS

Analysis of 344 ED visits demonstrated that decreasing absolute CD4 lymphocyte counts were associated with increasing incidence of HIV-related disease (P < .001), even when noninfectious causes were excluded. Only 34% of visits were related to HIV-associated illness. Emergency physicians exhibited high sensitivity (72.9%) and specificity (95.5%) in diagnosing HIV-related disease and conducted appropriate visit disposition.

CONCLUSION

ED visits by HIV-infected individuals are often not made for reasons of opportunistic infection, and the absolute CD4 lymphocyte count is inversely related to HIV-related disease.

An eleven year follow-up of delayed-type hypersensitivity testing for the identification of HIV-1 infected patients at increased risk of developing AIDS

The objective of this study was to investigate whether testing of delayed-type hypersensitivity (DTH) to recall antigens could be used to identify HIV-1 infected patients at increased risk of death or developing AIDS. Eighty-five HIV-1 infected Swedish homosexual men were tested for DTH using a commercially available kit with 7 recall antigens (Multitest, Mérieux). The patients were followed prospectively for 11 years or until death. The 11-year actuarial progression rate to AIDS was 69% and to death 60%. Older age was identified as a factor predisposing to rapid progression independent of cell-mediated immunity measured by DTH. Patients with a subnormal DTH had a significantly more rapid progression to AIDS and death than did patients with normal DTH, and the time between AIDS diagnosis and death was shorter. For patients with a multiscore (MS) < 10 mm, the median time to AIDS was 59 months, the median time to death 88 months, and the median time from AIDS diagnosis to death 11 months, compared to 106, 139, and 25 months, respectively, for patients with MS > or = 10 mm. Of the individual antigens, only a negative reaction to tuberculin was independently predictive of progression to all 3 endpoints, while a negative reaction to tetanus was independently predictive of progression to death. Thus, determination of DTH improves the early recognition of patients at increased risk of progressive disease.

Brain, blood, and cerebrospinal fluid distribution of a zidovudine chemical delivery system in rabbits

Improved brain delivery of zidovudine (AZT) was shown to occur after iv dosing of a chemical delivery system (CDS) for the modified deoxynucleoside. Specifically, administration of a 25-mg/kg dose of 5'-[(1-methyl-1,4-dihydropyridin-3-yl)carbonyl]-3'-azido-3'-deoxyt hymidine (AZT-CDS) generated higher and more sustained levels of AZT in brain tissue of rabbits than did dosing with AZT itself. The significant increase in the area under the AZT brain concentration-time curve occurred with lower AZT present in the systemic circulation and with similar AZT levels in cerebrospinal fluid. These results, as well as previously published reports examining AZT-CDS in mice, rats, and dogs, indicate that this delivery system may be beneficial in the treatment of AIDS-related encephalopathy.

A prospective study of 115 initially asymptomatic HIV infected gay men in Stockholm, Sweden

A cohort of 115 asymptomatic gay men, all seropositive for HIV, was recruited in a health screening project in Stockholm, Sweden, between Nov. 1982 and Dec. 1983 and subsequently followed and clinically evaluated after a mean observation time of 63 months. AIDS in accordance with the surveillance definition (CDC group IV C-1 and D) developed in 34 (29.6%) of the men, while 1 (0.9%) additional man died of multiple myeloma classified as CDC group IV E. Constitutional symptoms (CDC group IV A) developed in 13 (11.3%) men, while symptoms from the central nervous system classified as CDC group IV B occurred in 1 (0.9%) additional man. Minor opportunistic infections included in the definition for CDC group IV C-2 developed in 12 (10.4%) men, while 48 (41.7%) men remained asymptomatic, with or without persistent generalized lymphadenopathy (PGL). One man who died of AIDS had been treated for malignant melanoma (MM) and one who did not fulfill the criteria for CDC group IV died of MM during the observation period. The 5-year actuarial progression rate to surveillance defined AIDS was 31.5% and to CDC group IV 53.6%. No statistically significant association was found between disease progression and a number of recorded epidemiological variables, most previous and present sexually transmitted diseases (STD) (except gonorrhoea) and the presence of PGL at entry. On the other hand, reduced delayed cutaneous hypersensitivity, in particular to tuberculin, as well as the presence of a high IgG titer against cytomegalovirus (CMV), were correlated to disease progression.

Development of AIDS in a cohort of HIV-seropositive homosexual men in Australia

The Sydney AIDS Prospective Study is a cohort study of 1057 homosexual men enrolled between February 1984 and January 1985. By June 30, 1989, 111 (26.8%) of the 414 men who were seropositive for antibodies to human immunodeficiency virus (HIV) at enrollment had developed the acquired immunodeficiency syndrome (AIDS). On univariate analysis the following baseline factors were significantly associated with subsequent development of AIDS: splenomegaly; a lymphocyte count less than 1500 x 10(6)/L; a percentage of CD4+ cells less than 20% of the total lymphocyte count; an absolute number of CD4+ cells less than 200 x 10(6)/L; and a CD4+: CD8+ ratio less than 1.00. In a proportional hazards model the following factors retained significance: a lymphocyte count less than 1500 x 10(6)/L; an absolute number of CD4+ cells less than 200 x 10(6)/L; and a CD4+: CD8+ ratio less than 1.00. A CD4+ cell count less than 200 x 10(6)/L carried the greatest relative risk (3.99) for the development of AIDS. This study has confirmed that the appreciable rates of progression to AIDS demonstrated in overseas cohorts of HIV-infected persons also apply in the Australian context. A number of laboratory variables was found to be predictive for the subsequent development of AIDS. As we were not able to determine accurately whether subjects were receiving antiretroviral treatment or prophylaxis for opportunistic infections the observed rates in this study should be seen as minimum estimates. These findings have important implications for HIV-infected persons and for public health planning, and emphasise the need for regular clinical monitoring and T-cell subset enumeration in HIV-infected persons.

Profile of patients with human immunodeficiency virus infection presenting to an inner-city emergency department: preliminary report

Increasing numbers of patients with diagnosed HIV infection are presenting to inner-city emergency departments. Unfortunately, there is little information available on the characteristics and emergency clinical problems of HIV-infected patients to guide physicians in patient care and strategies for resource use. Preliminary data from an on-going investigation revealed that there were 254 emergency visits (1.8% of total) by 164 patients with known HIV infection during the four-month period of March to June 1988. Only 171 visits (62%) were likely related to patients' underlying HIV infection. Nine percent of IV drug users (IVDUs) carried a diagnosis of AIDS before presentation compared with 68% of patients who were homosexual or bisexual. Fifty-five patients (21.7%) presented with their first known complication of HIV. Among the 140 risks from patients previously considered asymptomatic, those with homosexual or bisexual risk were 3.6-fold more likely to present with a first-time complication of HIV than were IVDUs. HIV-infected patients were twice as likely to have inadequate insurance compared with a sample of ED seronegative controls. Of the 130 risks by IVDUs, 85% were without adequate insurance coverage compared with 56% of the 91 patient risks from homosexual or bisexuals (P less than .05). Generally, patient presentations did not imply an obvious diagnosis; vague constitutional complaints were the most common (42%). Preliminary interpretation of the data is that IVDUs use emergency services as a routine source of care. Because IVDUs probably represent those with more recent infection and HIV infection continues to spread unabated in this risk group, we can expect increasing numbers of patients to present to EDs with symptomatic HIV infection in the future.(ABSTRACT TRUNCATED AT 250 WORDS)

Zidovudine prophylaxis for needlestick exposure to human immunodeficiency virus: a decision analysis

OBJECTIVE

To perform a decision analysis to determine the thresholds of safety and effectiveness that would justify short-term zidovudine (AZT) administration for persons with accidental percutaneous exposure to HIV-positive blood.

DESIGN

Published data were used to estimate the seroconversion rate (0.42%), rate of developing AIDS if HIV-infected (5%/year), and survival with AIDS (50%/year). No information is available on zidovudine effectiveness and little is known about fatal toxicity of zidovudine. Death from AIDS or from zidovudine toxicity was used as the endpoint.

RESULTS

For those with exposure to blood known to be HIV-seropositive, the benefits of zidovudine outweight the risks if efficacy is above approximately 3% to 8%. Wide variations in the assumptions have little effect on the thresholds.

CONCLUSIONS

Since clinical trials to determine zidovudine effectiveness in this setting will probably never be done, decision analysis offers the only quantitative method for addressing this question. Unless future studies show zidovudine to be both ineffective and toxic, the benefits of short-term administration of zidovudine outweigh the risks immediately after exposure to HIV-positive blood. Zidovudine benefits do not clearly outweigh the risks after exposure to blood of unknown serologic status, or if there is a delay in starting therapy.

Management of early HIV-1 infection in adults

A person who fears that he or she may be infected with the human immunodeficiency virus (HIV-1) is likely to seek help from a primary care physician, so preparation is vital. The authors discuss how to differentiate HIV-1 infection from disorders that may have a similar presentation, the importance of referring the patient to available community resources, and the best ways to accomplish long-term suppression of infection.