Problems of providing services to people affected by HIV/AIDS: service providers and recipients perspectives

This qualitative study aimed to identify the health-care problems of people living with HIV (PLHIV) in 2 large cities: Tehran and Kermanshah. Two main groups of stakeholders - service providers (policy-makers, managers, physicians and counsellors) and service recipients (PLHIV and their relatives) - participated in focus group discussions and in-depth interviews. We identified 24 themes covering the major health problems of PLHIV, including: incomplete and inadequate coverage of health-care services; patients' substance abuse; patients' fear of stigma; occupational burnout of certain service providers; patients' dissatisfaction with some of the services provided by counselling centres/clinics; medical staff's failure to observe confidentiality; and patients' lack of access to required specialized services. The problems and needs identified can inform the design and implementation of health programmes in our country and elsewhere in the Eastern Mediterranean Region.

Pulmonary Tuberculosis in Patients with HIV/AIDS in Iran

BACKGROUND

Pulmonary tuberculosis is still the most common form of tuberculosis in HIV infected patients having different presentations according to the degree of immunosuppression. This study appraised the impact of HIV infection on clinical, laboratory and radiological presentations of tuberculosis.

METHODS

The clinical, laboratory and radiological presentations of pulmonary TB in 56 HIV-infected patients were compared with 56 individually sex and age matched HIV-seronegative ones, admitted to Imam Hospital in Tehran (1999-2006) using paired t-test in a case control study.

RESULTS

All cases and the controls were male. Fever was found in 83.9% of the HIV positive patients compared to 80% of the HIV negative ones. Cough was the most common clinical finding in the HIV negative group (89.3% vs. 82.1% in HIV positive group). Among radiological features, cavitary lesions, upper lobe and bilateral pulmonary involvement were observed significantly less often in the HIV-infected group. On the contrary, lymphadenopathy was just present in the HIV positive group in this series of patients (12%) and primary pattern tuberculosis was more common, as well (71% vs. 39%, P= 0.02). The Tuberculin test was reactive in 29% of the HIV/TB patients.

CONCLUSION

The coexistence of both infections alters the picture of tuberculosis in many aspects and should be taken into account when considering a diagnosis of HIV infection and its potential for TB co-infection, and vice-versa.

Frequency of isolated hepatitis B core antibody in HIV-hepatitis C virus co-infected individuals

Association between isolated hepatitis B core antibody (anti-HBc) and hepatitis C virus (HCV) infection has been noted in HIV-infected individuals. This study describes the frequency of isolated anti-HBc and its possible value for the detection of HBV-DNA in HIV-infected patients with or without HCV co-infection. Ninety-two HIV-infected patients were enrolled in the study. Hepatitis B surface antigen (HBs Ag), anti-HBs, anti-HBc, anti-HCV, HIV viral load and CD4 count were tested in all subjects. Then we compared 63 subjects with HIV-HCV co-infection with 29 subjects with HIV infection alone regarding isolated anti-HBc (HBs Ag negative, anti-HBs negative and anti-HBc positive). The presence of HBV-DNA was determined by real-time polymerase chain reaction in serum samples of patients with isolated anti-HBc. Of 63 anti-HCV-positive patients, 18 subjects (28.6%, 95% [confidence interval] CI: 22.6-34.6%), and of 29 anti-HCV-negative patients, five subjects (17.2%, 95% CI: 11.5-22.9%) had isolated anti-HBc. HBV-DNA was detectable in three of 18 anti-HCV-positive patients (16.7%, 95% CI: 9.7-23.7%) and none of the anti-HCV-negative patients with isolated anti-HBc. Our study showed that individuals co-infected with HIV and HCV were more likely to have isolated anti-HBc than subjects with HIV alone. This investigation also demonstrates that the presence of isolated anti-HBc in HIV-HCV-infected individuals may reflect occult HBV infection in these patients.

Clinical profile and management of brucellosis in Tehran - Iran

BACKGROUND

Brucellosis is one of the most frequent infectious diseases in many regions of Iran. The purpose of this study was to evaluate different clinical, laboratory and therapeutic aspects of this disease.

METHOD

This retrospective descriptive study was performed on patients referred to two teaching hospitals in Tehran/Iran with brucellosis diagnosis during the years 1998 - 2005. Patients' signs and symptoms, laboratory findings and clinical responses were evaluated during the study period.

RESULTS

More than half of the 415 patients enrolled in this study were female. The duration of the symptoms was reported to be less than 2 months in 83.85% of the patients prior to being examined in our centre. While sweating and fever were the most common symptoms, peripheral arthritis, sacroiliitis and splenomegaly were the most frequently reported signs. Rifampin plus cotrimoxazole was the most common regimen administered in these cases (32%) and relapse was also more frequently seen in this group of patients (13.8%), whilst doxycycline and cotrimoxazole led to the least number of relapses (2.5%).

CONCLUSIONS

Brucellosis is known to have various manifestations, so it should be considered as one of the differential diagnoses of any patient referred with different organs involvement accompanied with or without fever. Relapse is one of the complications reported even following an appropriate treatment.

Assessment of the factors involving in the development of hypothyroidism in HIV-infected patients: a case-control study

OBJECTIVES

Increased prevalence of thyroid dysfunction has been reported in HIV-infected patients, and recent studies have shown hypothyroidism as the most common thyroid function abnormality in this population, especially after treatment with antiretroviral drugs (HAART). The aim of this study is to assess risk factors of hypothyroidism in HIV-infected patients in Iran.

DESIGN

This case-control study was conducted among 15 hypothyroid (cases) and 70 euthyroid (control group) HIV-infected outpatients. Serum Free T4, Free T3, and TSH levels were measured, and data on age, sex, body mass index, opium addiction or injection of illicit drugs, duration of HIV infection and HAART, disease stage, CD4-cell count, opportunistic infection (OI) or malignancy, HCV co-infection, and drug use were collected.

RESULTS

We found no association between hypothyroidism in HIV-infected patients and any parameters measured, and P value was not significant for receipt of HAART (0.141), CD4-cell count (0.094), duration of HIV infection (0.474), duration of HAART (0.418), HCV co-infection (0.146), OI (0.566), or receipt of rifampin (0.816).

CONCLUSION

In this study, age, sex, HAART, mean CD4- cell count, duration of HIV infection, HCV co-infection, and OI were not significant risk factors of hypothyroidism in HIV-infected patients. The occurrence of hypothyroidism may be related to other factors or HIV infection itself. Therefore, hypothyroidism should be considered in all HIV-infected patients.

Strongyloides stercoralis hyper-infection syndrome in HIV+/AIDS patients in Iran

Strongyloides stercoralis is an intestinal nematode in humans, distributed through tropical and subtropical regions of the world. In most individuals, the infection has a chronic nature due to auto-infection at the low level. Accelerated auto-infection, mainly after an alteration in immune status, can cause a syndrome of severe hyper-infection or potentially fatal disseminated strongyloidiasis. Due to the increasing numbers of immunocompromised patients in Iran, strongyloidiasis is an emerging public health concern in the country. In the current study, which was carried out between 2003 and 2005, for the investigation on strongyloidiasis in HIV(+)/AIDS patients, a total of 781 patients were examined by agar plate culture, formalin ether concentration, and direct smear preparation of stool samples. According to the results, 2 out of 781 HIV( + )/AIDS patients were found infected with S. stercoralis, but both patients were at the progressive stage of AIDS and showing severe hyper-infection syndrome. In both cases, numerous rhabditiform and filariform larvae were found in fresh stool direct smears, and rapid and intensive development of parasite in agar plate cultures. In conclusion, in the progressive stages of AIDS, as a result of immunosuppression conditions or in the context of chemotherapy, S. stercoralis is capable of inducing overwhelming infection.

Molecular characterization of Cryptosporidium isolates from humans and animals in Iran

Isolates of Cryptosporidium spp. from human and animal hosts in Iran were characterized on the basis of both the 18S rRNA gene and the Laxer locus. Three Cryptosporidium species, C. hominis, C. parvum, and C. meleagridis, were recognized, and zoonotically transmitted C. parvum was the predominant species found in humans.

Efficacy of cotrimoxazole and rifampin for 6 or 8 weeks of therapy in childhood brucellosis

From March 1998 to September 2001, 64 children and from October 2001 to December 2004, 66 children < or = 15 years with brucellosis in Babol, Iran, were treated with cotrimoxazole and rifampin for 6 or 8 weeks, respectively. Cure rate for 6 weeks was 89.1% and for 8 weeks it was 95.5%. Six weeks of therapy with cotrimoxazole plus rifampin is sufficient for treatment of childhood brucellosis.

Dominant Th1 cytokine production in early onset of human brucellosis followed by switching towards Th2 along prolongation of disease

Human brucellosis is a worldwide zoonotic infectious disease which is caused by intracellular bacteria belonging to the genus Brucella. Based on murine studies it has been shown that host resistance to Brucella depends on Th1 response, whereas Th2 response is involved in the severity of the disease. Since the immune response during human brucellosis has not been profoundly studied we have tried to evaluate cytokine production in patients suffering from brucellosis. Diluted whole blood samples were cultured in the presence of the mitogen, heat inactivated bacteria or medium alone. IL-12, IFN-gamma and IL-10 were measured by specific sandwich ELISA. In addition, the percentage of CD3(+) T cells producing either IL-13 or IFN-gamma was determined by flow cytometry. It was found that not only IFN-gamma production but also the number of CD3(+) IFN-gamma-producing cells decreased with prolongation of the disease but the percentage of CD3(+) IL-13(+) T cells were significantly increased. No correlation between duration of disease and IL-10 or IL-12 production was found. In conclusion, it is proposed that at the onset of brucellosis, Th1 response dominates while diminishing with prolongation of the disease.

Reconstitution of detergent-solubilized Na,K-ATPase and formation of two-dimensional crystals

Very pure, detergent-solubilized Na,K-ATPase from dog or lamb kidneys has been successfully reconstituted at high protein-to-lipid weight ratios. Studies have been conducted to establish the orientation of the Na,K-ATPase molecules in the reconstituted membranes and to assess the functional activity and the conformational state of the reconstituted enzyme. Results indicate that reincorporation of the Na,K-ATPase molecules in the lipid bilayer is unidirectional and that the reconstituted enzyme retains its functional and structural integrity. Two-dimensional crystals have been induced in these preparations by vanadate ions. The arrays, with a dimeric structure in the unit cell, have a morphology similar to that of the crystals that had previously formed in the native membranes. Filtered images show that in projection, the molecule had an asymmetrical mass distribution, which at the resolution of 2.5 nm is identical to that of the earlier crystals. These sheets, although small, represent the first crystals of Na, K-ATPase to be formed by reconstitution. We expect that optimization of the reconstitution and crystallization parameters will lead to larger and better-ordered sheets, suitable for electron crystallography.

Immunoelectron microscopy of epitopes on Na,K-ATPase catalytic subunit. Implications for the transmembrane organization of the C-terminal domain

The transmembrane folding of the alpha subunit of Na,K-ATPase was studied by using immunoelectron microscopy to determine whether monoclonal antibodies with defined epitopes bind to the extracellular or cytoplasmic surface. In double labeling experiments, an antibody and a reference marker were bound to purified membrane-associated Na,K-ATPase and were visualized by employing colloidal gold particles of two different sizes. Wheat germ agglutinin and a previously characterized monoclonal antibody were used as control markers for the exoplasmic and cytoplasmic surfaces, respectively. Three antibodies, VG4, VG2, and IIC9, unambiguously bound to the extracellular surface. Previously IIC9 had been assigned to the cytoplasmic surface because, in immunofluorescence studies, it stained intact cells only when they were detergent-permeabilized. To investigate the basis for this contradiction, a third assay for sidedness was used: competition binding in solution to right-side-out renal medullary vesicles. IIC9 was found to bind to the extracellular surface of sealed vesicles, but only in certain experimental conditions. It was concluded that IIC9 has an epitope that is not always accessible and that in this instance, studies of binding to intact and detergent-treated cells had given misleading results. An extracellular disposition for all three antibodies is not compatible with existing folding models, and new models are presented.

The structure of the adenovirus capsid. III. Hexon packing determined from electron micrographs of capsid fragments

The orientation and relative positions of all 240 hexons in the icosahedral outer capsid of adenovirus have been determined. Two types of capsid fragments, obtained after selective disruption of the virion, were analyzed using electron microscopy and image-processing techniques. Planar inverted groups-of-nine, arising from the central region of the capsid facet, were minimally stained to reveal the morphology of restricted regions of their component hexons. Images shown to be related by correspondence analysis were averaged and features of the individual hexon molecule, known from an X-ray crystallographic investigation, were used in their interpretation. The study confirms earlier observations that the hexons in the group-of-nine are distributed on a p3 net, shows that the hexons form a close-packed array using the pseudo-hexagonal shape of the hexon base, and provides their relative positions. Twenty interlocking groups-of-nine account for 180 of the 240 hexons present in the viral capsid. The orientation of the remaining 60 peripentonal hexons was obtained from a rotationally averaged image of a quarter-capsid, a novel viral fragment comprising five complete facets. Each peripentonal hexon forms planar asymmetric interactions with two neighbors in an adjacent group-of-nine so that it lies on an extension of the p3 net. The complete facet thus consists of 12 hexons arranged on a planar p3 net, with a shape that permits interlocking of hexons at the capsid edge. The relative positions of the hexons have been determined to within 5 A using the molecular model, and indicate that the pseudo-hexagonal basal regions are close-packed in a manner that maximizes the hexon-hexon contacts. The results confirm the model proposed earlier for the arrangement of hexons within the adenovirus capsid (Burnett, 1985), and show the power of the inter-disciplinary approach.

The three-dimensional structure of the Na,K-ATPase from electron microscopy

The structure of Na,K-ATPase has been studied by electron microscopy and image reconstruction. A three-dimensional structure of this enzyme has been obtained to an overall resolution of 2.5 nm using data from specimens of negatively stained dimer sheets tilted through a range of angles +/- 60 degrees. The reconstruction shows a complex mass distribution consisting of ribbons of paired molecules extending approximately 6.0 nm from the cytoplasmic side of the membrane. The molecular envelope consists of a massive "body" with "lobe" and "arm" structures projecting from it. The body has a columnar shape and is tilted with respect to the plane of the membrane. The region of interaction responsible for dimer formation is located between two bodies and is clearly visible in the reconstruction. It has been identified as a segment in the amino-terminal portion of the alpha subunit. The arms that interconnect the ribbons are located close to the membrane and are most probably formed by the beta subunits.

Interpretation of electron micrographs of adenovirus hexon arrays using a crystallographic molecular model

Two types of two-dimensional arrays of purified adenovirus type 2 hexon have been obtained and analyzed by Fourier filtration of their electron micrographs. One array contained continuously close-packed hexons, distributed on a hexagonal p3 lattice, with a unit cell dimension of 94 +/- 2 A. The other array contained close-packed hexons with a regular absence, so that rings of six hexons related by sixfold symmetry formed a p6 unit cell. The cell dimension of the hexagonal array was 153 +/- 3 A, with neighboring hexons separated by 88 +/- 2 A. Smaller p6 arrays were also formed by hexons freed from complete virions on the microscope grid by treatment with distilled water. A molecular model of hexon, known from the X-ray crystallographic structure, was used to interpret Fourier-filtered images of the arrays, and to determine the relative orientations of the hexon molecules. The hexon-hexon interaction in the p3 array is that found in the virion facet, whereas that in the p6 array is a planar form of the interaction between peripentonal hexons around the vertex.

Novel crystalline sheets of Na,K-ATPase induced by phospholipase A2

Treatment of purified preparations of Na,K-ATPase by phospholipase A2 has led to the formation of two-dimensional crystals of the protein. Control tests with another phospholipase and two detergents have shown that crystallization occurs as the result of hydrolysis and/or solubilization of the phospholipids in the enzyme vesicles. Experimentation with various buffer systems has indicated that reduction in the amount of phospholipids alone is sufficient for inducing the formation of crystalline sheets. Inclusion of crystal inducing ions in the buffer facilitates the crystallization process, resulting in more extensive arrays. The new crystalline sheets are exclusively dimeric with average unit cell dimensions: a = 15.8 +/- 0.4 nm, b = 4.9 +/- 0.2 nm, and gamma = 64 +/- 3 degrees. Examination of the micrographs shows that the initial intermolecular interaction leading to the formation of sheets is between the alpha subunits. Results from this study suggest that removal and/or modification of phospholipids by phospholipases could prove successful in crystallizing those membrane proteins in which excess lipid is the main barrier to the formation of two-dimensional arrays.

Structure of (Na+,K+)-ATPase as revealed by electron microscopy and image processing

(Na+,K+)-ATPase was studied by electron microscopy and image processing of negatively stained and freeze-dried and shadowed crystalline sheets induced by a number of inorganic salts. Extensive experiments have identified new conditions for optimum crystal formation. Two crystal forms have been observed, one with a monomer and the other with a dimer, in the unit cell. Both show the same structure for the enzyme monomer. The enzyme can also be crystallized after partial proteolysis of its alpha subunit by trypsin. The proteolysed enzyme crystallizes under the same conditions as the whole enzyme. Comparison of the mass distributions in the images of the intact and proteolysed enzyme has allowed the tentative identification of the location of the alpha subunit within the monomer. The relationship between the structure of the crystallized enzyme and that of the enzyme in its native form is discussed, as is its apparent close structural relationship to the calcium-ATPase.