Eurosurveillance comes of age and moves to ECDC

Eurosurveillance was created in 1995 to support exchange and dissemination of authoritative scientific information within the part of public health community involved in the field of infectious disease surveillance and control, at a time when European surveillance networks were at an early stage of growth. Now part of a large network, the publication is entering a new stage: the editorial function will now be hosted at the European Centre for Disease Prevention and Control (ECDC) in Stockholm. This will strengthen the platform for the next stage in Eurosurveillance’s development as the major home of peer-reviewed European information on infectious disease surveillance and control.

Cervical squamous intraepithelial lesions in HIV-infected women: prevalence, incidence and regression. European Study Group on Natural History of HIV Infection in Women

OBJECTIVES

To assess the impact of HIV-related immunodeficiency and antiretroviral treatment on the occurrence and evolution of abnormal Papanicolaou tests.

STUDY DESIGN

Cohort of 485 HIV-infected women with a known date of infection, enrolled during May 1993-April 1998 in 23 centres (gynaecology, infectious disease or STD clinics, or drug treatment centres) in 12 European countries; in 21 centres, follow-up was performed every 6 months (median follow-up: 2 years).

METHODS

Human papillomavirus (HPV) was detected at inclusion by Southern blot and PCR. The prevalence of squamous intraepithelial lesions (SIL), the incidence of SIL and regression from low-grade SIL were studied according to CD4 count after controlling for HPV detection results.

RESULTS

Compared with women with CD4 cell counts > 500 x 10(6)/l, women with CD4 cell counts < 200 x 10(6)/l had a twofold increase in both prevalence and incidence of SIL and in non-regression from untreated low-grade SIL; in addition, these women had a lower response rate to treatment of high-grade cervical intraepithelial neoplasia. The increase in SIL incidence associated with a low CD4 cell count was significant in women not receiving antiretroviral treatment (relative risk, CD4 cell count 200-499 x 10(6)/l, 1.9; CD4 cell count < 200 x 10(6)/l, 2.9; CD4 cell count > 500 x 10(6)/l, reference), whereas it was less marked and not statistically significant in treated women.

CONCLUSIONS

Severe HIV-related immunodeficiency strongly increases the risk of occurrence of SIL; antiretroviral treatment may reduce this risk, probably by restoring or at least preserving immune function.

Social change and HIV in the former USSR: the making of a new epidemic

This paper describes the development of the recent HIV epidemic in countries of the former Soviet Union. It explores the socio-political and economic roots of an injection-drug-driven HIV epidemic associated with a drug culture that facilitates HIV transmission. This review, based on many unpublished reports, studies and field notes, discusses the new social and health context in which the epidemic is developing. The evidence of a growing number of drug users in the region is discussed and drug injection behaviour described. The authors present selected data on the heterosexual transmission of HIV and linkages between the drug-linked HIV epidemic and its further spread into the non-injecting population. The potential overlap with the still uncontrolled syphilis epidemic that began in 1990 is probably a key factor in the future of HIV spread in the region. Until now, HIV infection among STD patients has been extremely low. However, rapid changes in sexual norms and behaviours, the growing commercial sex industry, and increased mobility soon may affect the current situation. The huge economic and socio-political crises currently affecting the region have created a "risk situation" for the spread of HIV. Concerns are raised about the appropriateness and the scope of government and non-governmental approaches to the exploding HIV and STD epidemics.

Sexually transmitted infections in European HIV-infected women: incidence in relation to time from infection. European Study on the Natural History of HIV Infection in Women

OBJECTIVES

To investigate the prevalence and incidence of sexually transmitted infections (STI) in HIV-infected women in relation to time from infection and sexual behaviour.

DESIGN

The European study on the natural history of HIV infection in women is a prospective cohort study of 487 HIV-infected women with a known interval of seroconversion from 12 European countries.

METHODS

Incidence was measured with person-time methods. Generalized estimating equations analysis was used to determine risk factors for STI.

RESULTS

At entry, 15% of the women were diagnosed with at least one acute STI (chlamydial infection, trichomoniasis or gonorrhoea), 10% with at least one other STI (genital warts or genital ulcerations) and 13% with vaginal candidiasis. Although frequently diagnosed during follow-up, the occurrence of acute STI and vaginal candidiasis decreased, whereas the occurrence of other STI increased with ongoing time from HIV infection. Furthermore, women with a history of prostitution [relative risk (RR), 2.00; 95% confidence interval (95% CI), 1.20-3.33] and women with irregular condom use (RR, 7.74; 95% CI, 3.52-17.0) were at higher risk for an acute STI.

CONCLUSIONS

Although STI diagnoses were frequent, the occurrence of acute STI declined with time from infection which might be explained by changed sexual behaviour over time. The occurrence of other STI increased with time from HIV infection, presumably due to reactivation as a result of immunosuppression.

HIV-1 diversity in France, 1996-1998. The AC 11 laboratory network

OBJECTIVE

To study the distribution of HIV-1 subtypes in France and to describe the characteristics of patients infected with non-B subtypes.

METHODS

All adults who tested HIV-1 positive on Western blot for the first time in one of the participating laboratories between September 1996 and March 1998 were eligible, whether or not they had been diagnosed previously elsewhere. Data on age, sex, country of birth, HIV-transmission group, dates of the last negative and first positive HIV test and clinical stage were collected. Serotyping was performed with a peptide subtype-specific enzyme immunoassay on each plasma sample and genotyping with heteroduplex mobility assay on each non-B serotype-infected patient. Patients characteristics were compared in B and non-B subtypes.

RESULTS

Of the 2168 HIV-positive patients included by 32 laboratories, subtype,results were available for 2042. Among those, 73.4% were men, 12.2% born in sub-Saharan Africa, 41.5% infected through heterosexual contact and 67.6% in CDC stage A. Among the 2042 patients, 1 725 (84.5%) were infected with B subtype. Among the 317 non-B subtypes, subtype A was predominant (66.9%); all other subtypes (C, D, E, F, G, H, O) were present. Factors independently associated with a non-B subtype were to be included in the Paris area [adjusted odds ratio (aOR), 1.6; 95% confidence interval (CI), 1.1-2.3], to be born in sub-Saharan Africa (aOR, 26.0; 95% CI, 17.5-37.8) and to be infected through heterosexual contact (aOR, 4.2; 95% CI, 2.8-6.4).

CONCLUSIONS

In France, although B subtype is still predominant, all non-B subtypes are now present. The diversity of HIV strains may affect diagnostic tests and clinical practice, especially viral load measurements. Moreover, the decreased susceptibility of non-B subtypes to antiretroviral drugs emphasizes the importance of surveillance of HIV diversity.

[Factors associated with medical management of HIV infected persons in two French districts, 1993-1995]

BACKGROUND

The regularity of medical followup of HIVinfected patients greatly influences the effectiveness of antiretroviral treatments and of prophylaxis of opportunistic infections.

METHODS

To identify potential barriers to a regular followup, a retrospective study was conducted among the adult AIDS patients diagnosed between July 1993 and May 1995 in two French districts (Gironde and HautsdeSeine). Medical followup was described based on the frequency of CD4 counts in the medical file and on a confidential interview among patients whose HIV infection had been diagnosed at least 6 months before AIDS. Irregular followup (less than one CD4 count per year when CD4> 500/ mm(3), and per 6months when CD4< 500/ mm(3)) within the two years preceding AIDS diagnosis was analysed according to socioeconomic status and to social and behavioral factors.

RESULTS

Among 290 patients, followup was irregular in 51% of the patients (injecting drug users: 66%, homo/bisexual men: 41%, patients infected through heterosexual contact: 49%, p<0.01). Factors independently associated with irregular followup were low income level (adjusted odds ratio (aOR)= 2.4; 95% confidence interval (CI), 1.44.1); absence of regular practitioner at HIV diagnosis (aOR= 1.9; 95% CI 1.13.3); imprisonment between HIV diagnosis and AIDS (aOR= 3.8; 95% CI 1.310. 9), and being non homo/bisexual male (aOR= 2.4; 95% CI 1.15.1) versus homo/bisexual male (aOR= 1.3; 95% CI 0.72.7) and female (reference).

CONCLUSIONS

Results of this study show that several socioeconomic, psychological and cultural barriers to a regular preAIDS medical followup still exist. Impact of new antiretroviral therapy may only be optimal if these barriers are overcome.

HIV prevalence in pregnant women in Europe: differences in assessment methods and prevalence levels across countries

OBJECTIVE

To describe methods used to assess HIV prevalence and to assess prevalence levels and time trends among pregnant women in various European countries.

METHODS

We used the European HIV Prevalence Database to examine annual HIV prevalence data in pregnant women for the years 1990 to 1996 (20 countries).

RESULTS

In Western Europe, prevalences were generally obtained through unlinked anonymous surveys, whereas in most Central, and Eastern European countries, they were based on testing programs (voluntary or mandatory). Prevalences (per 10,000) were highest (i.e., 10-30/10,000) in large western urban areas including Amsterdam, Barcelona, London, Milan, Paris, and Rome; between 1 and 2 in Scandinavian countries; and down to 0.5/10,000 in Central and Eastern European countries (except Ukraine, 1996: 5/10,000). Prevalences decreased in Rome, whereas they increased in London, the Czech Republic, and since 1995 in Russia and Ukraine; elsewhere, no time trends were detected.

CONCLUSIONS

Methodologic differences and potential biases should be considered when comparing these data. HIV prevalence in pregnant women is useful for monitoring the AIDS epidemic and for assessing and improving prevention. Efforts should be made to offer voluntary counseling and testing to women at risk for HIV and provide treatment to those who are infected.

Comparative prevalence, incidence and short-term prognosis of cervical squamous intraepithelial lesions amongst HIV-positive and HIV-negative women

OBJECTIVE

To investigate the impact of HIV infection on the prevalence, incidence and short-term prognosis of squamous intraepithelial lesions (SIL), in a prospective study with 1-year follow-up.

METHODS

Between 1993 and 1995, 271 HIV-positive and 171 HIV-negative women at high risk of HIV infection were recruited, 365 (82.6%) of whom completed the 1-year follow-up. The women underwent a Papanicolaou smear test at inclusion and at 6 and 12 months. Human papillomavirus (HPV) was detected at inclusion by Southern blot and PCR.

RESULTS

The SIL prevalence ranged from 7.5% for HIV-negative to 31.3% for HIV-positive women with CD4 cell counts < 500 x 10(6)/l (P < 0.001). Other factors associated independently and significantly with SIL prevalence were HPV-16, 18, 33 and related types, HPV-31, -35, -39 and related types, lifetime number of partners, younger age, past history of SIL and lack of past cervical screening. The SIL incidence ranged from 4.9% in HIV-negative women to 27% in HIV-positive women with CD4 cells < 500 x 10(6)/l (P < 0.001). Progression from low- to high-grade SIL during follow-up was detected in 38.1% of HIV-positive women with CD4 cells < or = 500 x 10(6)/l but in no HIV-negative nor HIV-positive women with CD4 cells > 500 x 10(6)/l. HPV-16, 18, 33 and related types were also associated with higher incidence of SIL and progression from low- to high-grade SIL.

CONCLUSION

HIV-induced immunodeficiency is associated with high prevalence, incidence and persistence/progression of SIL. A pejorative influence of HIV infection without marked immunodeficiency is less clear. HIV-positive women with SIL may thus benefit from early treatment when a useful immune response is still present.

Determinants of delayed diagnosis of HIV infection in France, 1993-1995

OBJECTIVE

To describe the circumstances of the first HIV-positive test and to study the determinants of a delayed diagnosis of HIV infection.

METHODS

In a retrospective study among adult AIDS patients diagnosed between July 1993 and May 1995 in two French districts, data on socioeconomic characteristics, circumstances of first HIV-positive test and attitudes and behaviours regarding medical care were collected in a confidential interview and analysed for potential association with a late test, defined as a first HIV-positive test within 6 months of AIDS diagnosis.

RESULTS

Of the 359 AIDS patients studied, 69 (19.2%) had a late test. Late testers were more likely than other patients to have had an HIV-positive test because of clinical symptoms (89.7 versus 38.9%, P < 0.001) and not to perceive themselves as being at risk of infection with HIV (53.6 versus 39.3%, P < 0.05). The proportion of late testers was 34.6% among heterosexually infected patients, 12.7% among homo-/ bisexual men and 9.6% among injecting drug users. Factors independently associated with a late test were male gender [adjusted odds ratio (aOR), 5.6; 95% confidence interval (CI), 1.7-18.9] and absence of earned income (aOR, 5.2; 95% CI, 1.4-19) among heterosexually infected patients; high education (aOR, 3.1; 95% CI, 1.0-9.6) and having consulted a person practising alternative medicine (aOR, 3.4; 95% CI, 1.2-10) in homo-/bisexual men.

CONCLUSIONS

Despite incentives to be tested for HIV, many individuals in France are still tested too late, even if they are in known high-risk groups. Efforts to test HIV-infected people as early as possible should be made by increasing the perception of HIV risk and decreasing the level of missed opportunities for testing. Current case management approaches make this recommendation critically important from both public health and an individual perspective.

Time trends in HIV infection among pregnant women in Europe

OBJECTIVE

To estimate time trends in HIV prevalence among pregnant women delivering livebirths in 14 European countries using a uniform methodology.

METHODS

A form of back-projection was used to estimate HIV prevalence among pregnant women based on reported cases of AIDS due to perinatally acquired HIV infection. The method used estimates the rate of progression to AIDS in children with HIV, and the rate of transmission of HIV from mother to child, derived from published studies.

RESULTS

The prevalence of HIV among pregnant women delivering livebirths was estimated to be highest in Spain (2.61 per 1000 livebirths in 1992-1993), relatively high (> or = 0.3 per 1000 livebirths) throughout the period 1984-1993 in France, Italy and Switzerland, and low (< 0.2 per 1000 livebirths) in Germany, The Netherlands and Scandinavia. There were large and statistically significant increasing trends in the estimated HIV prevalence among pregnant women in Portugal (an estimated 77% increase per 2-year period), Spain (40% increase) and the United Kingdom (77% increase; all P < 0.001). Statistically significant increasing trends of a smaller magnitude were estimated for France (24% increase) and Italy (23% increase; both P < 0.001).

CONCLUSIONS

Sharp increases in HIV prevalence among pregnant women were estimated for several European countries, whereas in other countries no trends in the estimated prevalence were detected.

The HIV epidemic associated with injecting drug use in Europe: geographic and time trends

OBJECTIVES

To evaluate the magnitude and trends of the HIV epidemic associated with injecting drug use in Europe.

METHODS

AIDS cases associated with injecting drug users (IDU) diagnosed through 1995 were analysed, including IDU, homo-/bisexual IDU, heterosexual partners of IDU and children whose mothers were IDU. HIV seroprevalence studies among IDU were reviewed.

RESULTS

Of the 171,932 cumulative AIDS cases, 73,119 (43%) were IDU-associated (IDU, 89.0%; homo-/bisexual IDU, 3.5%: heterosexual partners of IDU, 6.2%; children with IDU mothers, 1.4%). Over 90% of IDU-associated cases were concentrated in south-western European countries with considerably higher rates in Spain (124 cases per million in 1995) than elsewhere (Italy, 68 per million; Portugal, 42 per million; France, 38 per million). During 1990-1995, incidence increased at an average annual rate of 11% overall and > 23% in central and eastern Europe; overall, incidence increased in older persons (12%) while decreasing in those aged 13-24 years (by 6%). HIV prevalence in IDU showed considerable geographic variation across and within countries. In several countries of western Europe, prevalence decreased. In the former Soviet Union, large HIV outbreaks have recently been detected among IDU through systematic HIV testing (e.g., in Ukraine, 6750 HIV infections were diagnosed in IDU tested during 1995-1996).

CONCLUSIONS

IDU have played a major role in the spread of HIV in Europe. In several western European countries, the incidence of HIV acquired through drug use has declined following high rates in mid-1980s. Studies to assess current transmission are needed and prevention efforts must be maintained. In eastern Europe, emerging epidemics reinforce the urgency for prevention.

Reconstruction and prediction of the HIV/AIDS epidemic among adults in the European Union and in the low prevalence countries of central and eastern Europe

OBJECTIVES

To reconstruct the HIV epidemic and to provide forecasts of AIDS incidence among adults in the European Union (EU) and in a group of low prevalence (LP) countries of central and eastern Europe (including the Asian republics of the former Soviet Union).

METHODS

An empirical Bayesian back-calculation method was applied to AIDS incidence data reported by 31 March 1994. The HIV-infection curve was modelled as a yearly step function and a seven-stage Markov model of disease progression, incorporating effects of pre-AIDS treatment, was used. Estimation was by penalized maximum likelihood with empirical Bayesian smoothing. Data were analysed by transmission group and, within the EU, by country. Predictions of AIDS cases to 1998 were made assuming constant annual HIV incidence from 1993 onwards.

RESULTS

Estimated HIV prevalences per 100,000 population aged 15-59 years were, at 31 December 1993, 198 (n = 447,800) in the EU and 2.7 (n = 6840) in the 22 LP countries, with increases of 41% (EU) and 71% (LP) between 1989 and 1993. Among homo/bisexual men in the EU, prevalence appears to have stabilized since 1989 and AIDS incidence appears to be reaching a peak. Among all prevalent HIV infections in the EU, 42% were estimated to be among injecting drug users, 25% among homo-/bisexual men and 18% among persons infected heterosexually, compared with 29%, 35% and 19%, respectively, in the LP countries. Without allowing for the 1993 revision of the case definition, annual AIDS incidence is predicted to increase, between 1994 and 1998, by 24% in the EU and by 48% in the LP countries, with the largest percentage increases among heterosexually-infected persons.

CONCLUSION

The overall HIV prevalence rate is estimated to have been about 70-fold lower in the LP countries than in the EU in the early 1990s, but to be increasing much more rapidly in the former. Moreover, recent reports of rapidly increasing HIV infection rates suggest that back-calculation may seriously underestimate the size of the epidemic in the LP countries. Implementation of effective preventive measures is urgent if large-scale epidemics are to be avoided in the presently LP countries of the European region.

Pregnancy and contraception in a French cohort of HIV-infected women. SEROCO Study Group

OBJECTIVE

To describe the impact of HIV diagnosis on contraception, incidence of pregnancy and live-births among HIV-infected women in France.

DESIGN

Follow-up of women included in a French cohort of HIV-infected adults (SEROCO).

METHODS

In 17 hospital-based units and one private practitioners' network in the Paris area and south-east region of France, 412 HIV-infected women (volunteers) were enrolled from 1988 to 1993, shortly after HIV diagnosis (median, 3 months), and followed for a median of 3 years. The main outcome measures were incidence and outcome of pregnancy, proportions of women sexually active and methods of contraception.

RESULTS

The incidence of pregnancy decreased significantly from 20.4 per 100 person-years in the year preceding HIV diagnosis to 7.9 per 100 person-years after HIV diagnosis (P < 0.001), whereas the proportion of pregnancies voluntarily interrupted doubled (63 versus 29%). The proportion of women who were sexually inactive increased from 5% before HIV diagnosis to 20% thereafter. During followup, 80% of sexually active women were using contraceptive methods.

CONCLUSIONS

The study supports an association between the discovery of HIV infection and a decrease in the proportion of women who are sexually active, a decrease in the incidence of pregnancy in general and live-births in particular, and an increase in the proportion of pregnancies voluntarily interrupted. Nevertheless, 24% of the women became pregnant and around 20% of sexually active women were not using any contraception. The high rate of voluntary abortion may indicate that many of these pregnancies were unplanned and could have been prevented.

Trends in HIV infection among sexually transmitted disease patients in Paris

OBJECTIVE

To assess trends in HIV infection among sexually transmitted disease (STD) patients.

DESIGN

Repeated unlinked anonymous survey, 1991-1993.

SETTING

STD clinics in Paris, France.

SUBJECTS

Patients (n = 4354) with a new suspected STD.

METHODS

HIV antibody testing, using blood from syphilis samples.

RESULTS

HIV prevalences were stable over time in all transmission groups. One-third of homo-/bisexual men were HIV-positive. Prevalence was 2.5 times higher among heterosexual patients from Africa or the Caribbean than among those from other countries. Among patients under 25 years of age prevalence significantly decreased from 4.3% in 1991 to 0.8% in 1993 (P = 0.01). Among homo-/bisexual men, despite a 50% reduction in the incidence of STD, the absolute number of those newly HIV-infected remained stable; median age increased from 28 years in 1991 to 32 years in 1993 (P = 0.02). Among heterosexuals, trends in HIV incidence were difficult to assess: recently infected patients were more likely to be identified in 1993 than in 1991, since the proportion of patients who reported a recent HIV-negative test increased over time.

CONCLUSION

Prevalence studies contribute to define specific subgroups which should be targeted for prevention (HIV-positive or older homosexuals, heterosexuals from Africa and the Caribbean). Despite a decrease in both overall STD incidence and HIV prevalence among patients aged under 25 years, overall HIV incidence has not decreased, at least among homo-/bisexual men in whom recent HIV infections occurred at a high rate overall, and increased in those aged 35 years or more. Sentinel site-based HIV seroprevalence studies are best interpreted in the light of results obtained from different populations and through routine surveillance of STD.

Factors associated with tuberculosis at AIDS diagnosis in France

OBJECTIVE

To identify factors associated with tuberculosis (TB) at AIDS diagnosis in France.

DESIGN

Analysis of surveillance data.

METHODS

Among all adult AIDS cases diagnosed since January 1988 and reported by December 1993 in France, the proportion diagnosed with AIDS-defining TB (extrapulmonary TB among cases diagnosed between 1988 and 1992, all forms of TB among cases diagnosed in 1993) was analysed by year of diagnosis, sex, age, nationality, profession, HIV transmission group and region of residence by multiple logistic regression.

RESULTS

Between 1988 and 1992, 5.7% (1134 out of 19,968) of AIDS patients were diagnosed with AIDS-defining extrapulmonary TB. Presence of extrapulmonary TB was associated with male sex [adjusted odds ratio (AOR), 1.7], nationality from a sub-Saharan country (AOR, 4.8), heterosexual contact or injecting drug use (AOR, 2.4 and 2.7, respectively), residence in the Paris area (AOR, 1.7), and unemployment or factory work (AOR, 2.5 and 2.4, respectively). In 1993, 10.6% (393 out of 3721) of AIDS patients were diagnosed with TB (all forms). In multivariate analysis, three factors were independently associated with the risk of presenting TB at AIDS diagnosis: transmission category, nationality, and region of residence.

CONCLUSIONS

Some factors associated with TB at AIDS diagnosis in France are known to be related to a high incidence of TB in industrialized countries (nationality, from a developing country, male sex, low socioeconomic status). The independent association with injecting drug use or residence in Paris suggests a contribution of recent TB infection in specific groups of HIV-infected persons. This contribution should be evaluated to implement appropriate preventive measures.

Factors associated with extrapulmonary tuberculosis as an AIDS-defining disease in Europe. The Coordinators of AIDS surveillance in Austria, Belgium, France, Germany, Italy, Portugal, Switzerland, United Kingdom and the city of Amsterdam

SETTING

Western Europe: 8 countries and the city of Amsterdam.

OBJECTIVE

To identify factors associated with extrapulmonary tuberculosis (EPTB) at AIDS diagnosis among adult AIDS patients.

DESIGN

The proportion of AIDS case diagnosed between January 1988 and June 1992 with EPTB was analysed by age, gender, year of diagnosis, country and HIV transmission category. Multiple logistic regression was performed separately for patients infected through heterosexual contact who were likely to originate from Africa or the Caribbean (heterosexual subgroup 1), and for other patients.

RESULTS

The overall proportion with EPTB was 4.6% and remained stable between 1988 and 1992. It differed significantly by country (from 2.4% in the United Kingdom to 24.7% in Portugal) and by transmission category (2.7% among homo/bisexuals, 5.8% among injecting drug users, 13.6% among heterosexual subgroup 1). In multivariate analysis, the risk of EPTB was independently associated with younger age and male gender. Among patients other than from heterosexual subgroup 1, country and transmission category were also independent predictors of EPTB at AIDS diagnosis.

CONCLUSION

The risk of presenting EPTB as an AIDS-defining disease is not homogeneous within Europe. Results suggest an increased risk of tuberculosis in specific groups of HIV-infected persons (persons originating from sub-Saharan Africa, injecting drug users) and a potential role of recent Mycobacterium tuberculosis infection among younger patients.

Recent trends in Pneumocystis carinii pneumonia as AIDS-defining disease in nine European countries. Coordinators for AIDS Surveillance

We analyzed the proportion of AIDS cases with Pneumocystis carinii pneumonia (PCP) at diagnosis among the 43,198 adult AIDS cases diagnosed since January 1988 and reported by June 1992 in Austria, Belgium, France, Germany, Italy, Portugal, Switzerland, United Kingdom, and the city of Amsterdam. In multivariate analysis, the risk of having PCP at AIDS diagnosis decreased slightly with increasing age and was strongly associated with country of diagnosis, transmission category, and year of diagnosis, but not with gender. Since 1989, the proportion of AIDS cases with PCP decreased significantly among homosexual and bisexual men in five of the nine countries examined and among injecting drug users in four of seven countries. In three countries with sufficient data for analysis, no significant decrease was seen among heterosexual patients with a partner originating from a country where heterosexual transmission is common (i.e., Africa/Caribbean). Among other heterosexual patients, a significant decreasing trend was demonstrated in only one of six countries analyzed. For all countries combined, the decrease was significant among hemophiliacs and of borderline significance among transfusion recipients. Results suggest that medical management before AIDS diagnosis is not homogeneous among all human immunodeficiency virus (HIV)-infected persons in Europe. Efforts should be made to provide better information on the potential benefit of early HIV testing and to facilitate the use of preventive treatments.

HIV prenatal screening in south-eastern France: differences in seroprevalence and screening policies by pregnancy outcome

Two complementary surveys were carried out in the 89 hospital units of South-Eastern France which deal with pregnant women. Firstly, in November 1991, medical chiefs of these units were interviewed face-to-face about their current HIV screening policy. Secondly, between Jan 27 and March 22, 1992, all women at the end of their pregnancy attending these units were included in an anonymous unlinked seroprevalence survey, irrespective of pregnancy outcome (n = 11,056). The goal of the research was to compare HIV prenatal screening policies and seroprevalences by pregnancy outcomes in order to contribute to the public debate initiated on that issue by the French health authorities. The seroprevalence survey showed a global prevalence rate of 0.43% (CI 95% = 0.32-0.54) with the prevalence among women who had an elective abortion (0.56%) being more than twice that among women who delivered (0.22%). However, routine HIV screening was more frequent toward women coming for regular prenatal care than for women seeking abortion. A systematic procedure for obtaining women's consent for HIV testing only existed in a minority of units. Only 23 out of the 62 units offering both antenatal and termination services to women had the same screening policy for women attending the different services. The research confirmed that a mandatory requirement would not improve HIV screening policy during prenatal care. However, less emphasis on women who have opted for termination of pregnancy, an absence of appropriate counselling and information procedures, and pressures on HIV-infected women to terminate current pregnancies and discourage future ones strongly suggest that HIV prenatal screening in French hospitals remains mainly focussed on fetal concerns, without sufficient attention towards the needs of women at risk of HIV infection.

Seroepidemiology of HTLV-I/II in universal screening of blood donations in France

OBJECTIVE

To evaluate the serological and epidemiological characteristics of HTLV-I/II-positive blood donors in continental France during the first 6 months of universal screening of blood donations (n = 1,816,927).

METHOD

A collaborative investigation of all confirmed anti-HTLV-I/II-positive samples reported by blood transfusion centres was performed. Seventy-three out of 77 reported samples were retested at two reference laboratories. Epidemiological data on risk factors were compiled.

RESULTS

Of the 73 retested samples, 66 were confirmed to be HTLV-I-positive and one to be HTLV-II-positive; six samples were designated false-positive, mainly because of non-specific reactivity to recombinant gp21 in Western blot. The overall prevalence of HTLV-I/II in continental France is 0.039 per thousand. The main risk factor identified for HTLV-I infection was directly (origin) or indirectly (heterosexual contact) linked to endemicity in the Caribbean. The cost per case of avoided contamination in the 6-month period of this study was 1.36 million French francs.

CONCLUSIONS

Sixty-two per cent of HTLV-I/II-infected blood donations would not have been discarded through the previous targeted HTLV screening or through other mandatory tests, including anti-hepatitis B core. To avoid false-positive results, we propose a new algorithm of diagnosis.

The epidemiology of AIDS-associated non-Hodgkin's lymphoma in the World Health Organization European Region

This paper describes the epidemiology of AIDS-associated non-Hodgkin's lymphoma (NHL) in the World Health Organization (WHO) European Region. Data, collected by the WHO Collaborating Centre on AIDS in Paris, France, were derived from the national AIDS surveillance systems of 21 countries. Among 53,042 cases reported as of the end of June 1991, 1,617 (3.0%) had NHL as the presenting clinical manifestation of AIDS. The proportion of cases presenting with NHL ranged from 1.1% in children infected perinatally to 3.9% among haemophiliacs. In comparison with intravenous drug users (IVDUs) (2.6% of whom had NHL), a moderate excess was found among homosexual or bisexual men (odds ratio - OR -:1.2, 95% confidence interval - CI -:1.0-1.3). Over time, the proportion of NHL was constant, but whereas among homosexual or bisexual men the frequency of NHL as AIDS-indicator disease significantly increased (9.7% per year), among IVDUs a significant downward trend emerged (17.1% per year). In respect to age, two peaks of NHL were seen at the age groups 10-19 (3.8%) and 50-59 (4.3%). The proportion of AIDS-associated NHL significantly increased with increasing age among homosexual and bisexual men and heterosexuals whereas it decreased among IVDUs. All these differences, however, have to be interpreted cautiously on account of the limitations of the reporting systems.

HIV infection at outcome of pregnancy in the Paris area, France

The prevalence of HIV infection in women at end of pregnancy, irrespective of outcome, was determined in a comprehensive survey of both women and medical centres during successive 4-week periods in four areas of the Paris region, France. Blood samples were tested anonymously for antibodies to human immunodeficiency virus (HIV)-1 and HIV-2. Of the 11,593 blood samples 0.40% (95% confidence interval [CI] 0.28-0.51) were positive for HIV-1 and 0.02% (95% binomial interval [BI] 0.002-0.065) for HIV-2. Seroprevalence was higher among women with ectopic pregnancy (2%) (95% BI 0.24-7.04); the rate in women having an elective or therapeutic abortion was more than twice that in those delivering babies (0.70% vs 0.28%, p less than 0.05, relative risk 2.54, 95% CI 1.36-4.75). Studies with neonatal HIV seroprevalence as a surrogate for HIV prevalence in pregnant women would underestimate prevalence in these women.

Surveillance of AIDS in the European Community: recent trends and predictions to 1991

Statistical modelling is applied to routine AIDS surveillance data to assess recent trends and to provide a range of short-term predictions. Several alternative functions have been fitted to half-yearly incidence data reported by the countries of the European Community by 31 December 1989 and adjusted for reporting delays. Among homosexual/bisexual men, recent trends in AIDS incidence are more nearly linear than exponential. Higher though less than exponential rates of growth are observed among intravenous drug users and among those presumed infected by heterosexual contact. Extrapolations to the end of 1991 using each of five functions provide a range of forecasts. Projections of total cumulated cases to the end of 1991 lie in the range 60,000-78,000, with 24,000-30,000 projected cases among homosexual/bisexual men, 23,000-33,000 among intravenous drug users, and 6000-8000 in the heterosexual transmission group. With the possible exception of the latter group, the lower parts of these ranges appear more probable.

Possible correlation between exposure to AIDS risk factors, clinical presentation in AIDS, and subsequent prognosis

AIDS-related Kaposi's sarcoma (KS) has a better prognosis than other presentations of AIDS. It is more frequent among homo-bisexual men than in other risk groups. This has raised the possibility of specific etiological agent(s) or co-factor(s) which induce its development. However, this suggestion is confusing since it implies that exposure to such agent(s) or co-factor(s) would result in an improved prognosis. Recent virological studies indicate that the HIV itself could be responsible for the induction or growth of KS. Since HIV antigenemia and the immunosuppression are lower among KS cases than among those with opportunistic infections (OI), we could expect a lower level of exposure to AIDS-related factors in KS cases as compared to OI cases. To investigate this possibility, we compared 25 cases with Kaposi's sarcoma alone (KS) with 25 cases having OI without KS, among homo-bisexual men. The KS cases were more likely than OI cases to have a higher educational level. They were less likely to have inhaled nitrites, to have had repeated syphilis and repeated gonorrhoea, and to be promiscuous. In the multivariate analysis, the factors which best discriminated the groups were nitrite inhalations, history of repeated syphilis, and anonymous promiscuity ("one-night stands"). Our study does not support the hypothesized association between nitrite inhalations and Kaposi's sarcoma. We found that cases with opportunistic infections - that is, with a poor prognosis - had been exposed to AIDS-related risk factors (e.g. history of venereal diseases, nitrite inhalations, promiscuity) at higher levels than cases with Kaposi's sarcoma alone.(ABSTRACT TRUNCATED AT 250 WORDS)

Misconceptions about transmission of AIDS and attitudes toward prevention in the French general public

A survey of the social perception of AIDS and its prevention was carried out in December 1987 in a representative sample of the adult population of the Paris region (France). A significant part of the general public still holds misconceptions about transmission by casual contact and blood donation. Misbeliefs about modes of transmission clearly encourage individuals' willingness to stigmatize AIDS patients and to support the most coercive measures of prevention (such as quarantine). Advertizing efforts to promote use of condoms, sexual education in schools, and systematic HIV screening for pregnant women are the only measures which create a broad consensus independently of sociocultural differences. Socioeconomic status and even religious or political beliefs strongly influence public opinions toward other preventive measures.

Attitudes towards HIV-antibody testing among general practitioners and their patients

A study was conducted by the French Communicable Diseases Network to evaluate the use of HIV-antibody testing by general practitioners. The study was aimed at determining the type of patient being tested and why. Data from two periods, Nov-Dec 86 and March-April 87, were compared. The percentages of subjects spontaneously asking for the test were about 50% in both studied periods. During the first period, tested patients were mainly male subjects (82%) and belonged to high risk groups (66%), whereas during the second period male subjects represented 47% and subjects belonging to high risk groups 27% of those tested. During the four months between the 2 study periods, an information campaign on AIDS was begun. During the second study period, in fact, the number of women being tested had increased, the number of patients with clinical symptoms had decreased and more patients were tested because of past or present STDs. In addition, fewer seropositive subjects were found during the second period. Only one subject with no known risk factor was found to be seropositive but she did have clinical symptoms of HIV infection.

Risk factors for A.I.D.S. among homosexual men in France

To identify risk factors for A.I.D.S. among homosexual men in France, a high-risk group in a moderate-incidence area, we undertook a case-control study in Paris and its suburbs. Fifty-three cases were compared to 99 controls from a venereal disease clinic and 79 controls from the staff of an amateur gay broadcasting station. In our univariate analysis, cases were more likely than controls to belong to upper socio-economical classes, to have used local corticosteroids, to have regularly inhaled nitrites, to report history of syphilis and of herpes infections, to have higher level of promiscuity with occasional partners ("one night stands"), and to have had sexual encounters in the U.S.A. In the multivariate analysis, history of syphilis and promiscuity with occasional partners appeared to be the main risk factors, as well as the use of local corticosteroids, especially during the prodrome period. The correlation between promiscuity and disease risk was weak in our study when we did not discriminate between occasional and regular sex partners, contrary to that found in epidemiological studies of A.I.D.S. and H.I.V.-seropositivity in high-incidence areas. In association with the history of syphilis, the development of the syndrome in our moderate-incidence country is more correlated to the contact with "one-night-stand" partners rather than to the total number of the sex partners. The public health policies in our area should be adapted to these findings. Otherwise they may be less efficient than hoped.

AIDS in Europe: current trends and short-term predictions estimated from surveillance data, January 1981-June 1986

European AIDS surveillance data, reported to the World Health Organization (WHO) Collaborating Centre on AIDS, Paris by 30 June 1986, have been analysed statistically to assess current trends and to provide short-term predictions. Reported case numbers were first adjusted to allow for the estimated time delays between diagnosis and reporting. The adjusted data (cases per half-year of diagnosis) were then fitted using exponential functions over selected time intervals to monitor and compare the evolution of the epidemic in individual countries and in the European Community (EC) as a whole. Predictions to mid-1988 were made by extrapolation. Results are presented for the EC and for the following individual countries: Belgium, Denmark, France, Federal Republic of Germany, Italy, The Netherlands, Spain, Sweden, Switzerland and the United Kingdom.

The international occurrence of the acquired immunodeficiency syndrome

Through December 1984, 9932 cases of the acquired immunodeficiency syndrome have been reported, mainly from North and South America and Europe; 85% of these cases occurred in the United States. Haiti and the United States have the highest incidence rates, 59 and 36 per million population, respectively. Rates in the United States range from 0.3 (beginning of 1981) to 10.4 (end of 1984). Brazil, Canada, Denmark, Switzerland, France, West Germany, the United Kingdom, and the Netherlands show a slower increase. Homosexual men and intravenous drug users are still the main risk groups in the United States and Europe. The disease is prevalent in heterosexual Haitians and Africans whether they live in their own countries or abroad. Cases of the syndrome have been identified in Zaire, Rwanda, Zambia, and Uganda, but its full extent is not yet known. Consistent with the general history of epidemics, the appearance of geographically separated sites of incidence of the syndrome could be linked to population migrations; however no evidence has been found to identify an index location.

[Acquired immunodeficiency syndrome: epidemiological data in France and throughout the world]

Nearly three years after the first A.I.D.S. cases were detected in the United States, a lot of countries throughout the world have reported varied numbers of such cases. While several U.S. towns have to face up to an epidemic situation, the same phenomenon has not been observed yet in the other areas, including European countries. In those latter countries homosexuals represent the most important group among patients. Two differences have to be noticed with the U.S. situation: numerous cases among patients from Equatorial Africa have been reported, and the disease has not spread over among I.V. drug abusers. Although no specific agent can be identified yet, A.I.D.S. features are characteristic of a transmissible disease.

Adaptation of lymphadenopathy associated virus (LAV) to replication in EBV-transformed B lymphoblastoid cell lines

A strain of lymphadenopathy associated retrovirus ( LAV ) passaged in vitro was used to infect a lymphoblastoid cell line obtained by transformation with Epstein-Barr virus of B lymphocytes from a healthy donor. The virus produced from this line (B- LAV ) was also able to grow at a high rate in some other lymphoblastoid lines and in a Burkitt lymphoma line. This adapted strain retained the biochemical, ultrastructural, and antigenic characteristics of the original strain, as well as its tropism for normal T4+ lymphocytes. It is thus possible to grow LAV in large quantities that can be used for the preparation of diagnostic reagents. The interaction between such a human retrovirus and Epstein-Barr virus, a DNA virus, may have some implication for the pathology of the acquired immunodeficiency syndrome and related diseases.