For debate. AIDS surveillance in Africa: a reappraisal of case definitions

Statin-use and perceptions of high cholesterol as predictors of healthy lifestyle behaviours in Nigerians

It is unclear how statin-use influences the adoption of healthy lifestyle choices. It is important to understand the nature of this relationship as this could facilitate targeted public health interventions which could help promote a healthy lifestyle, curb the rise of non-communicable diseases, and facilitate overall health. This study aimed to explore whether statin-use influenced the adoption of healthy lifestyle choices by changing the way urban and semi-urban Nigerians thought about their high cholesterol and their future risk of cardiovascular disease. Structured questionnaires were used to compare the lifestyle behaviours, perceptions of high cholesterol and future risk of cardiovascular disease of statin users and non-statin users recruited in urban and a semi-urban Nigeria. In-depth, face-to-face interviews were used to further explore the relationship between statin-use and the adoption of healthy lifestyle choices, and explore the influence of personal and social factors on this relationship. The odds of adopting a low-fat diet increased as perceived statin-effectiveness increased (OR = 2.33, p<0.05), demonstrating a synergistic relationship between statin-use and the adoption of healthy of lifestyle choices. In addition to this synergistic association, at interview, two other relationships were found between statin use and the adoption of healthy lifestyle choices: an antagonistic relationship fuelled by a strong perception of statin effectiveness and a perceived inability to make healthy lifestyle changes, which favoured statin-use, and an antagonistic relationship fuelled by congruous cause-control beliefs and concerns about medication-use which favoured the adoption of healthy lifestyle choices. The odds of adopting a low-fat diet was 5 times greater in urban dwellers than in semi-urban dwellers (p<0.01). Statin-use influenced the adoption of healthy lifestyle choices in three different ways, which require exploration at clinical consultation. Gender, social obligations, and physical environment also influenced statin-use and the adoption of healthy lifestyle choices.

Is HIV-2- induced AIDS different from HIV-1-associated AIDS? Data from a West African clinic

BACKGROUND

Although AIDS is less frequent following HIV-2 than HIV-1 infection, it is unclear whether the clinical picture and clinical course of AIDS are similar in the two infections.

OBJECTIVES

To compare the pattern of AIDS-defining events, CD4 cell count at the time of AIDS diagnosis, survival from time of AIDS, and CD4 cell count near time of death in HIV-1 and HIV-2-infected patients.

METHODS

Adult patients with AIDS who attended the clinics of the MRC in The Gambia were enrolled. AIDS was diagnosed according to the expanded World Health Organization case definition for AIDS surveillance (1994).

RESULTS

Three hundred and forty-one AIDS patients with HIV-1 and 87 with HIV-2 infection were enrolled. The most common AIDS-defining events in both infections were the wasting syndrome and pulmonary tuberculosis. The median CD4 cell count at AIDS was 109 cells/microl in HIV-1 and 176 in HIV-2 (P = 0.01) and remained significantly higher in HIV-2 after adjustment for age and sex (P = 0.03). The median time to death was 6.3 months in HIV-1 and 12.6 months in HIV-2-infected patients (P = 0.03). In a multivariable analysis adjusting for age, sex and CD4 cell count, the mortality rates of HIV-1 and HIV-2-infected patients were similar (P = 0.25). The median CD4 cell count near time of death was 62 and 120 cells/microl in HIV-1 and HIV-2-infected patients, respectively (P = 0.02).

CONCLUSIONS

HIV-2 patients have a higher CD4 cell count at the time of AIDS, and a longer survival after AIDS. The mortality after an AIDS diagnosis is more influenced by CD4 cell count than HIV type.

Role of cerebrospinal fluid shunting for human immunodeficiency virus-positive patients with tuberculous meningitis and hydrocephalus

OBJECTIVE

Tuberculous meningitis (TBM) and its complications continue to have devastating neurological consequences for patients. Budgetary constraints, especially in developing countries, have made it necessary to select patients for shunting who are likely to experience good recoveries. To date, the value of cerebrospinal fluid shunting for human immunodeficiency virus (HIV)-positive patients with TBM has not been clearly established.

METHODS

Thirty patients with TBM and hydrocephalus were prospectively evaluated. Coincidentally, one-half of the patients were HIV-positive. All patients underwent uniform treatment, including ventriculoperitoneal shunt placement and antituberculosis treatment. CD4 counts were measured for all patients. Outcomes were assessed at 1 month.

RESULTS

No complications related to shunt insertion were noted. The HIV-positive group fared poorly (death, 66.7%; poor outcome, 64.7%), compared with the HIV-negative group (death, 26.7%; poor outcome, 30.8%). Despite cerebrospinal fluid shunting, no patient in the HIV-positive group experienced a good recovery (Glasgow Outcome Scale score of 5). This is in contrast to the six patients (40%) in the HIV-negative group who, with the same treatment, experienced good recoveries (Glasgow Outcome Scale scores of 5) at discharge (P<0.14). No patient (either HIV-positive or HIV-negative) who presented in TBM Grade 4 survived, whereas no HIV-positive patient who presented in TBM Grade 3 survived. A significant relationship was noted between CD4 counts and patient outcomes (P<0.031).

CONCLUSION

In the absence of obvious clinical benefit, HIV-positive patients with TBM should undergo a trial of ventricular or lumbar cerebrospinal fluid drainage, and only those who exhibit significant neurological improvement should proceed to shunt surgery.

A new, clinically-based algorithm for the diagnosis of HIV in African tuberculosis patients: cross-sectional analysis from Mzuzu, Malawi

We aimed to create an improved, clinically-based algorithm for the diagnosis of HIV in tuberculosis (TB) patients. Cross-sectional analysis was performed on data from adult TB patients consecutively diagnosed at a Malawian district level hospital. Of 225 patients, 187 with valid HIV results were included in the study. Sixty-seven per cent were HIV seropositive. Urban address, history of skin rash and sexually transmitted diseases (STDs) and, on examination, oral candidiasis and lymphadenopathy, were associated with HIV co-infection. Using these clinical characteristics, a case definition for HIV was constructed. The Mzuzu clinical case definition was highly sensitive (86%). The area under the receiver operating characteristic (ROC) curve was 0.81, significantly larger than existing World Health Organization (WHO) clinical case definitions. The Mzuzu definition is proposed for further evaluation in settings where HIV serological testing is not readily available.

Cell-free human immunodeficiency virus type 1 in breast milk

Breast-feeding may be an important route of human immunodeficiency virus type 1 (HIV-1) vertical transmission in settings where it is routinely practiced. To define the prevalence and quantity of HIV-1 in cell-free breast milk, samples from HIV-1-seropositive women were analyzed by quantitative competitive reverse transcription-polymerase chain reaction (QC-RT-PCR). HIV-1 RNA was detected in 29 (39%) of 75 specimens tested. Of these 29 specimens, 16 (55%) had levels that were near the detection limit of the assay (240 copies/mL), while 6 (21%) had >900 copies/mL. The maximum concentration of HIV-1 RNA detected was 8100 copies/mL. The prevalence of cell-free HIV-1 was higher in mature milk (47%) than in colostrum (27%, P = 0.1). Because mature milk is consumed in large quantities, these data suggest that cell-free HIV-1 in breast milk may contribute to vertical transmission of HIV-1.

Impact of the 1994 expanded World Health Organization AIDS case definition on AIDS surveillance in university hospitals and tuberculosis centers in Côte d'Ivoire

OBJECTIVE

To assess the impact of the 1994 expanded World Health Organization (WHO) AIDS case definition on AIDS surveillance in Côte d'Ivoire.

DESIGN

Prospective AIDS case surveillance.

METHODS

From March 1994 through December 1996, passive AIDS case surveillance was conducted at the three university hospitals in Abidjan, and active AIDS case surveillance was conducted at the eight tuberculosis (TB) centers in Côte d'Ivoire. Standardized questionnaires were administered and blood samples for HIV serologic testing were collected from the patients evaluated. The numbers of persons who met the modified 1985 WHO clinical AIDS case definition (Bangui definition) and the 1994 expanded WHO AIDS case definition were determined, and the clinical characteristics of these patients were assessed.

RESULTS

Of 8648 university hospital patients, 3658 (42.3%) met the clinical and/or the expanded case definition: 744 (20.3%) HIV-seropositive persons met only the expanded definition, 44 (1.2%) HIV-seropositive persons met only the clinical definition, 2334 (63.8%) HIV-seropositive persons met both definitions, and 536 (14.7%) HIV-seronegative persons met only the clinical definition. Of 18,661 TB center patients, 9664 (51.8%) met the clinical and/or the expanded definition: 5685 (58.8%) HIV-seropositive persons met only the expanded definition, none of the HIV-seropositive persons met only the clinical definition (by definition), 2625 (27.2%) HIV-seropositive persons met both definitions, and 1354 (14.0%) HIV-seronegative persons met only the clinical definition.

CONCLUSIONS

Because of the inclusion of multiple severe HIV-related illnesses into the expanded definition, the number of reportable AIDS cases in HIV-seropositive patients increased 31.3% in the university hospitals, and 217% in the TB centers. The inclusion of HIV seropositivity as a criterion for the expanded definition also enhanced the specificity of AIDS case reporting, eliminating 536 cases in the university hospitals and 1354 cases in the TB centers in HIV-seronegative patients who had clinical signs of AIDS. The use of the 1994 expanded definition for surveillance purposes should be encouraged in areas of the developing world where HIV serologic testing is available.

HIV-associated adult mortality in a rural Tanzanian population

OBJECTIVE

To measure HIV-associated adult mortality in a rural population in Tanzania. To record the signs and symptoms associated with deaths of HIV-positive adults.

DESIGN

Prospective cohort study conducted in the context of a randomized controlled trial to evaluate the impact of a sexually transmitted disease treatment programme.

METHODS

A cohort consisting of a random sample of 12501 adults aged 15-54 years was recruited from 12 rural communities in Mwanza region, Tanzania in 1991/1992. Baseline HIV prevalence was 4.0%. The cohort was followed up after 2 years to record mortality according to baseline HIV status. A verbal autopsy questionnaire was administered for each of the deaths reported.

RESULTS

A total of 196 deaths were recorded, of which 73 (37%) occurred in HIV-positive individuals. Mortality rates per 1000 person-years were 6.0 in HIV-negatives and 93.5 in HIV-positives. The age-adjusted mortality rate ratio was 15.68 (95% confidence interval, 11.18-21.03). The proportion of adult deaths attributed to HIV infection was 35% overall and 53% in those aged 20-29 years. Verbal autopsies showed that HIV-positive deaths were significantly associated with fever, rash, weight loss, anaemia, cough, chest pain, abdominal pain and headache, but the specificity of individual symptoms was low. The World Health Organization clinical case definition of AIDS was satisfied for only 13 deaths, of which seven were HIV-positive at baseline. Only seven respondents reported that the death was associated with HIV or AIDS.

CONCLUSIONS

This study confirms the strong association of HIV infection and mortality in rural Africa, with an annual death rate in adult seropositives of over 9%. In this rural population with a relatively low HIV prevalence of 4%, HIV has increased overall adult mortality by more than 50%. Signs and symptoms associated with HIV deaths were non-specific, and the population seemed largely unaware of the contribution of HIV to mortality, an important obstacle to prevention efforts.

Symptomatic human immunodeficiency virus (HIV) infection in Papua New Guinea

BACKGROUND

Human Immunodeficiency Virus (HIV) infection was first detected in Papua New Guinea (PNG) in 1987. By August 1995 a total of 323 persons had been diagnosed as HIV antibody positive nationwide and seroprevalence rates were climbing. This study was prompted by a lack of data on the clinical syndromes associated with HIV infection in Melanesian adults.

AIMS

To describe the clinical and epidemiological features of symptomatic HIV infection in adult Melanesians.

METHODS

A largely retrospective study of patients was admitted to the medical wards of the Port Moresby general hospital between January 1990 and September 1995. Clinical records of patients with antibody to HIV were studied and clinical, laboratory and epidemiological data were recorded.

RESULTS

Seventy patients were studied and the majority were young, urban dwelling adults from a variety of social groups. The sex distribution was even. Common clinical syndromes associated with HIV infection were chronic diarrhoea (47.8%), wasting (94.2%) and oropharyngeal candidiasis (68.7%). Tuberculosis was suspected in 68.6% and cryptococcal meningitis was detected in 8.6% including one patient with Cryptococcus. neoformans var. gattii infection. There was a high mortality (53%) in patients admitted to hospital.

CONCLUSIONS

Patients with HIV infection in PNG present to hospital late in their disease course. Clinical syndromes are similar to those observed in Africa and mortality on first admission is high. The major mode of transmission is heterosexual and sexually transmitted diseases and promiscuity are probably important factors in facilitating spread.

Human immunodeficiency virus type 1-infected cells in breast milk: association with immunosuppression and vitamin A deficiency

Breast milk samples from human immunodeficiency virus type 1 (HIV-1)-seropositive women were analyzed by polymerase chain reaction to determine the prevalence and determinants of HIV-1-infected cells in breast milk. Breast milk samples (212) were collected from 107 women, and 58% of the samples had detectable HIV-1 DNA. The proportion of HIV-1-infected cells in the milk samples ranged from 1 to 3255/10(4) cells. Breast milk samples with detectable HIV-1 DNA were more likely to be from women with absolute CD4 cell counts of < 400 (odds ratio, 3.1; 95% confidence interval [CI], 1.5-7.0). Severe vitamin A deficiency (< 20 micrograms/dL) was associated with a 20-fold increased risk of having HIV-1 DNA in breast milk among women with < 400 CD4 cells/mm3 (95% CI, 2.1-188.5). Women with CD4 cell depletion, especially those with vitamin A deficiency, may be at increased risk of transmitting HIV-1 to their infants through breast milk.

Clinical features and serum beta 2-microglobulin levels in HIV-1 positive and negative Tanzanian patients with tuberculosis

Serum beta 2-microglobulin (beta 2M) rises in the later stages of HIV disease and has therefore been used to monitor progression to AIDS. However, little work has been done on patients co-infected with HIV and tuberculosis. We studied clinical features and serum beta 2-M in 35 Tanzanian patients treated for pulmonary tuberculosis (9 HIV-positive, 26 HIV-negative). The provisional WHO clinical definition of AIDS for use in Africa was fulfilled by 89% of the HIV-positive and 65% of the HIV-negative patients. Median serum beta 2-M on admission was slightly higher in HIV-positive (3.17 mg/l) than in HIV-negative (2.85 mg/l) patients. Serum beta 2-M fell during treatment in 17/24 (71%) of HIV-negative and 3/7 (43%) HIV-positive patients followed up for 6 months. We conclude that serum beta 2-M is frequently raised in active tuberculosis, and is therefore an unreliable indicator of the stage of HIV disease in co-infected patients. The WHO clinical definition of AIDS also proved unreliable in patients with tuberculosis.

AIDS in Namibia

The purpose of this article is to examine the AIDS epidemic in Namibia, a country for which little data currently exists. An examination of published and unpublished literature about the historical, socioeconomic and health factors as well as an analysis of updated data from other sub Saharan countries presented at the IXth International Conference on AIDS in Berlin may shed light on the pandemic as it relates to Namibia. Despite inadequate data, it is clear that the AIDS epidemic has already reached Namibia, though the country has not been afflicted as severely as some of its neighbors. Because of 75 years of apartheid, the new government is faced with a formidable array of problems, both in health care and in the economic domain. The strategies being adopted to confront the AIDS epidemic will take years to evolve, a period of time the nation can ill-afford if it is to wrest control over a virus that is relentlessly spreading into susceptible populations.

Nocardiosis in HIV-positive patients: an autopsy study in West Africa

BACKGROUND

There are many reports of nocardiosis associated with HIV infection in industrialized and developing countries, but its true prevalence is unknown.

MATERIALS AND METHODS

An autopsy study was performed of HIV-positive and HIV-negative patients dying on the general medical wards of a large hospital in Abidjan, Ivory Coast, in 1991.

RESULTS

247 HIV-positive adult cadavers were examined. 10 (4%) had nocardiosis of the lung, of whom 6 showed disseminated disease. 8 patients had one or more AIDS-defining pathologies, and 5 had nocardiosis as the main cause of death. Pulmonary tuberculosis was found in 87 cadavers (35%), giving a ratio of pulmonary nocardial to tuberculous disease of 1:9. No nocardiosis was seen in 42 HIV-negative cadavers.

CONCLUSIONS

This is the highest recorded prevalence of HIV-associated nocardiosis in a representative sample. The prevalence of nocardiosis varies geographically, and in zones where HIV-associated tuberculosis is common, it is possible that some patients diagnosed as smear-negative pulmonary tuberculosis actually have nocardiosis. A revised strategy of sputum examination with gram stain is suggested to detect nocardia.

Two cases of cutaneous leishmaniasis in Malawi

Leishmaniasis is rarely encountered in southern Africa. Two cases were diagnosed by histopathology in northern Malawi in one year. One was an 18 months old child with negative human immunodeficiency virus 1 (HIV-1) serology and widespread skin lesions; the other an HIV-1 positive adult with 2 skin lesions. The Leishmania species responsible could not be identified, but the infection may be more prevalent in this region than previously thought.

Thiacetazone--avoid like poison or use with care?

Recent 5 reports of severe cutaneous hypersensitivity reactions in patients infected with human immunodeficiency virus (HIV) and with tuberculosis treated with thiacetazone have prompted the World Health Organization to advise against the use of thiacetazone in patients known, or suspected, to be infected with HIV. Because the poorest countries will have great difficulty in replacing thiacetazone, the history, metabolism and possible mechanisms underlying the toxicity of this inexpensive, but problematic, drug are reviewed. Guidelines for National Tuberculosis Control Programme policies in response to thiacetazone toxicity are discussed, taking into account the differing levels of resources available to developing countries.

Is a positive western blot proof of HIV infection?

It is currently accepted that a positive Western blot (WB) HIV antibody test is synonymous with HIV infection and the attendant risk of developing AIDS. In this communication we present a critical evaluation of the presently available data on HIV isolation and antibody testing. This evidence indicates that: (1) the antibody tests are not standardized; (2) the antibody tests are not reproducible; (3) the WB proteins (bands) which are considered to be encoded by the HIV genome and to be specific to HIV may not be encoded by the HIV genome and may in fact represent normal cellular proteins; (4) even if the proteins are specific to HIV, because no gold standard has been used to determine specificity, a positive WB may represent nothing more than cross-reactivity with non-HIV antibodies present in AIDS patients and those at risk. We conclude that the use of antibody tests as a diagnostic and epidemiological tool for HIV infection needs to be reappraised.

Case definitions for paediatric AIDS: the Zambian experience

For the purpose of surveillance of the acquired immunodeficiency syndrome (AIDS) in developing countries, the World Health Organization (WHO) has recommended criteria for the clinical case definition of AIDS in adults and children. In a preliminary examination of children in Zambia a number of patients with obvious AIDS did not fit the published WHO case definition for paediatric AIDS. Based on this the Zambia National AIDS Surveillance Committee designed local criteria for the clinical case definition of paediatric AIDS. We compared the Zambian criteria with the WHO criteria for the diagnosis of paediatric AIDS by studying 134 consecutively admitted children to one of the paediatric wards at the University Teaching Hospital in Lusaka. Twenty-nine of the patients were HIV-1 seropositive and 105 were HIV-1 seronegative. Among the 29 HIV-seropositive patients, the Zambian criteria identified 23, and the WHO criteria identified 20 children as having AIDS. The 105 HIV-seronegative children were classified as having AIDS in 9 cases by the Zambian criteria and in 38 cases by the WHO criteria. These results give the Zambian criteria for the diagnosis of AIDS a sensitivity of 79.3%, a specificity of 91.4% and a positive predictive value of 86.8% compared to a sensitivity of 69%, specificity of 64% and a positive predictive value of 38% for the WHO criteria. The current WHO criteria are inadequate for the diagnosis of paediatric AIDS. The need to refine the WHO criteria for the diagnosis of paediatric AIDS is discussed.

A comparison of clinical features in tuberculosis associated with infection with human immunodeficiency viruses 1 and 2

Between July 1989 and December 1990, 4504 new adult patients with tuberculosis were screened for antibodies to human immunodeficiency viruses (HIV) 1 and 2 in Abidjan's 2 tuberculosis treatment centres. The prevalence levels of HIV-1 and HIV-2 infections were 30.2% and 4.2% respectively, a further 9.3% of patients reacting serologically to both viruses. Patients in all 3 seropositive groups differed significantly from seronegatives in having a higher frequency of AIDS-related features such as wasting, chronic diarrhoea, oral candidiasis and generalized lymphadenopathy. These data support earlier work showing an association between HIV-2 infection and similar opportunistic diseases which complicate HIV-1 infection, including tuberculosis. Despite the differences between seropositive and seronegative groups, symptoms and signs of tuberculosis may mimic those of AIDS. HIV testing should be more widely available for the clinical care of tuberculosis patients in Africa, as well as for epidemiological surveillance.

AIDS acquired by drug consumption and other noncontagious risk factors

The hypothesis that human immunodeficiency virus (HIV) is a new, sexually transmitted virus that causes AIDS has been entirely unproductive in terms of public health benefits. Moreover, it fails to predict the epidemiology of AIDS, the annual AIDS risk and the very heterogeneous AIDS diseases of infected persons. The correct hypothesis must explain why: (1) AIDS includes 25 previously known diseases and two clinically and epidemiologically very different epidemics, one in America and Europe, the other in Africa; (2) almost all American (90%) and European (86%) AIDS patients are males over the age of 20, while African AIDS affects both sexes equally; (3) the annual AIDS risks of infected babies, intravenous drug users, homosexuals who use aphrodisiacs, hemophiliacs and Africans vary over 100-fold; (4) many AIDS patients have diseases that do not depend on immunodeficiency, such as Kaposi's sarcoma, lymphoma, dementia and wasting; (5) the AIDS diseases of Americans (97%) and Europeans (87%) are predetermined by prior health risks, including long-term consumption of illicit recreational drugs, the antiviral drug AZT and congenital deficiencies like hemophilia, and those of Africans are Africa-specific. Both negative and positive evidence shows that AIDS is not infectious: (1) the virus hypothesis fails all conventional criteria of causation; (2) over 100-fold different AIDS risks in different risk groups show that HIV is not sufficient for AIDS; (3) AIDS is only 'acquired,' if at all, years after HIV is neutralized by antibodies; (4) AIDS is new but HIV is a long-established, perinatally transmitted retrovirus; (5) alternative explanations disprove all assumptions and anecdotal cases cited in support of the virus hypothesis; (6) all AIDS-defining diseases occur in matched risk groups, at the same rate, in the absence of HIV; (7) there is no common, active microbe in all AIDS patients; (8) AIDS manifests in unpredictable and unrelated diseases; and (9) it does not spread randomly between the sexes in America and Europe. Based on numerous data documenting that drugs are necessary for HIV-positives and sufficient for HIV-negatives to develop AIDS diseases, it is proposed that all American/European AIDS diseases, that exceed their normal background, result from recreational and anti-HIV drugs. African AIDS is proposed to result from protein malnutrition, poor sanitation and subsequent parasitic infections. This hypothesis resolves all paradoxes of the virus-AIDS hypothesis. It is epidemiologically and experimentally testable and provides a rational basis for AIDS control.