Increased serum lipids are associated with higher CD4 lymphocyte count in HIV-infected women

OBJECTIVE

Highly active antiretroviral therapy (HAART) has been associated with dyslipidaemia; however, the roles of immune status and non-HIV-disease risk factors remain unclear.

METHODS

A cross-sectional analysis of fasting lipids was carried out for 231 women, of whom 132 were HIV-infected and 99 were uninfected. The concentrations of total cholesterol, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), triglycerides, and apolipoprotein B (apo B) were measured. CD4 lymphocyte count, hepatitis C status, demographics, diet, and anthropometrics were also assessed.

RESULTS

A total of 132 women were HIV-infected [30 were antiretroviral-naive, 68 were on protease inhibitors (PIs), and 34 were on non-PI HAART]. HIV infection was associated with higher triglycerides, lower HDL-C, and, among obese women, higher total cholesterol and LDL-C. Non-PI and PI HAART were each independently associated with higher total cholesterol, LDL-C, and apo B, compared with being ART-naive. Among HIV-infected women, after adjustment for HAART use, women with a CD4 lymphocyte count > or =500 cells/microL had total cholesterol 41.8 mg/dL (P = 0.002) and LDL-C 28.8 mg/dL (P = 0.01) higher, on average, than women with a CD4 count <200 cells/microL. Women with a CD4 count of 200-499 cells/microL had total cholesterol 26.31 mg/dL higher, on average, than those with a CD4 count <200 cells/microL (P = 0.04), although differences in LDL-C did not reach significance (15.51 mg/dL; P = 0.12). A higher CD4 count was also associated with higher apo B (P < 0.001). Active hepatitis C infection was associated with lower total cholesterol, LDL-C, triglycerides, and apo B.

CONCLUSIONS

Higher CD4 lymphocyte counts were associated with higher lipid levels, suggesting that immune competence may independently affect the dyslipidaemia seen in the HAART era. In addition, it is important that hepatitis C status be assessed in studies of dyslipidaemia in the HIV-infected population.

Body image in middle-aged HIV-infected and uninfected women

We assessed factors associated with negative body image among 225 HIV-infected and 207 uninfected women. Standardized interviews obtained sociodemographic data and elicited agreement with the statement: 'Overall I am satisfied with my body shape'. Height and weight were measured. Overall, 39% of the women were obese and 47% had a negative body image. Factors independently associated with negative body image were HIV-infection, BMI, and depression. Given the high prevalence of obesity and negative body image, interventions aimed at assisting women with weight loss are warranted.

Body image in older men with or at-risk for HIV infection

We performed a cross-sectional analysis of factors associated with negative body image among 550 older men with or at-risk for HIV infection, including demographics, depression, illicit drug use, and antiretroviral therapy adherence. Overall, 31 per cent of participants reported negative body image, which was independently associated with increased BMI, self-rated fair/poor health, depression, and erectile dysfunction, but not HIV status. Screening for and treating depression, sexual dysfunction, and obesity in older men should be considered.

Shedding of PECAM-1 during HIV infection: a potential role for soluble PECAM-1 in the pathogenesis of NeuroAIDS

Human immunodeficiency virus (HIV) infection is characterized by viral entry into the central nervous system (CNS), which is mediated, in part, by the transmigration of HIV-infected monocytes into the brain. The elaboration of chemokines and other factors by these infected cells contributes to CNS inflammation and cognitive impairment in a significant number of HIV-infected individuals. Recently, we demonstrated that HIV-infected monocyte transmigration into the CNS is enhanced greatly by the chemokine CC chemokine ligand 2 (CCL2)/monocyte chemoattractant protein-1. Platelet endothelial cell adhesion molecule-1 (PECAM-1) plays an important role in leukocyte transmigration across the endothelium of the systemic vasculature by mediating homophilic interactions between endothelial cells (EC)-EC and EC-leukocytes, thus preserving vessel integrity. The role of PECAM-1 in HIV-infected leukocyte transmigration across the blood brain barrier (BBB) and NeuroAIDS has not been characterized. We demonstrate that in brain tissue from individuals with HIV encephalitis, there is an accumulation of cleaved, soluble forms of the extracellular region of PECAM-1 (sPECAM-1). In addition, HIV-infected individuals have elevated levels of sPECAM-1 in their sera. Our in vitro data demonstrate that HIV-infected leukocytes, when treated with CCL2, shed sPECAM-1, suggesting a mechanism of extracellular PECAM-1 cleavage and release dependent on HIV infection and CCL2. We hypothesize that sPECAM-1 production by HIV-infected leukocytes, resulting in the accumulation of sPECAM-1 within the CNS vasculature and the generation of truncated, intracellular forms of PECAM-1 within leukocytes, alters PECAM-1 interactions between EC-EC and EC-leukocytes, thus contributing to enhanced transmigration of HIV-infected leukocytes into the CNS and changes in BBB permeability during the pathogenesis of NeuroAIDS.

A longitudinal analysis of hospitalization and emergency department use among human immunodeficiency virus-infected women reporting protease inhibitor use

The impact of protease inhibitors (PIs) on emergency department (i.e., emergency room [ER]) visits and hospitalizations was examined among a cohort of human immunodeficiency virus (HIV)-infected and high-risk women followed-up in the HIV Epidemiology Research Study (HERS) from 1993 through 1999. The rates of hospitalization and ER visits were measured as a function of recent or current PI use, age, race, transmission risk category, HERS site, baseline CD4 cell count, and baseline virus load; the PI effect was estimated separately by baseline CD4 cell count. In the HERS, PI use was strongly associated with lower rates of ER visits and hospitalizations for patients with baseline CD4 cell counts of <200 cells/mL (for hospitalizations: rate ratio [RR], 0.54; 95% confidence interval [CI], 0.33-0.89; for ER visits: RR, 0.38; 95% CI, 0.24-0.61). Other factors associated with increased hospitalization and ER use included history of injection drug use, low CD4 cell counts, and high virus loads.

Antiretroviral therapy adherence and viral suppression in HIV-infected drug users: comparison of self-report and electronic monitoring

To compare electronically monitored (MEMS) with self-reported adherence in drug users, including the impact of adherence on HIV load, we conducted a 6-month observational study of 67 antiretroviral-experienced current and former drug users. Adherence (percentage of doses taken as prescribed) was calculated for both the day and the week preceding each of 6 research visits. Mean self-reported 1-day adherence was 79% (median, 86%), and mean self-reported 1-week adherence was 78% (median, 85%). Mean MEMS 1-day adherence was 57% (median, 52%), and mean MEMS 1-week adherence was 53% (median, 49%). One-day and 1-week estimates were highly correlated (r>.8 for both measures). Both self-reported and MEMS adherence were correlated with concurrent HIV load (r=.43-.60), but the likelihood of achieving virologic suppression was greater if MEMS adherence was high than if self-reported adherence was high. We conclude that self-reported adherence is higher than MEMS adherence, but a strong relationship exists between both measures and virus load. However, electronic monitoring is more sensitive than self-report for the detection of nonadherence and should be used in adherence intervention studies.

Trends in human immunodeficiency virus among adolescents: implications for the clinician

Human immunodeficiency virus (HIV) is currently a reportable infection in a growing number of states, which makes it possible to track patterns of spread according to demographic characteristics, risk behavior, and geographic region. Lee and Fleming analyzed HIV surveillance results from 1994 to 1998 among women age 15 to 44 from the first 25 states to initiate this program. They found that new diagnoses increased each year among women who were 15 to 19 in 1994, largely in association with heterosexual activity and, to a lesser but increasing extent, with injection drug use. HIV infections in older women declined. HIV increased during this period in the South, in contrast to the West, Central states, and Northeast. This paper suggests that now, even in areas not previously identified as HIV epicenters, discussions about HIV and methods to prevent transmission need to find their way into the routine care we provide.

The incidence of tuberculosis in drug users with small tuberculin reaction sizes

SETTING

In persons infected with the human immunodeficiency virus (HIV), a decreased tuberculin reaction cut-point of > or = 5 mm induration is recommended.

OBJECTIVE

To determine tuberculosis risk in non-anergic HIV-infected persons with 5-9 mm tuberculin reactions.

DESIGN

A prospective study with semi-annual tuberculin and anergy testing, HIV antibody and T cell subset assays, and active surveillance for tuberculosis.

RESULTS

Participants were 572 HIV-seronegative and 241 HIV-seropositive non-anergic drug users. No tuberculosis occurred in HIV-seronegative persons. Tuberculosis incidence among HIV-seropositive drug users was 3.3, 7.7, 0, and 0.34 per 100 person-years in those with tuberculin reaction sizes of > or = 10 mm, 5-9 mm, 1-4 mm, and 0 mm, respectively, and was significantly increased in persons with 5-9 mm induration compared with those with 0-4 mm induration (rate ratio 27.7, 95%CI 2.9-268). Among persons with reaction sizes of 5-9 mm, tuberculosis occurred exclusively in those with CD4+ lymphocyte counts <500/mm3 at the time of their 5-9 mm tuberculin reactions.

CONCLUSION

HIV-infected persons with tuberculin reaction sizes of 5-9 mm are at increased risk for tuberculosis compared to non-anergic persons with smaller (0-4 mm) reaction sizes. However, this increased risk may be limited to those with low CD4+ lymphocyte counts at the time of tuberculin testing.

Tampons as a self-administered collection method for the detection and quantification of genital HIV-1

OBJECTIVE

To assess the detection and quantitation of HIV-1 from tampon eluents in comparison with cervicovaginal lavage (CVL) and plasma specimens from the same women.

METHODS

Ninety-seven tampon, 105 CVL, and 104 plasma specimens from 105 HIV-1 seropositive women were analyzed using Version 3 of the Chiron bDNA assay, with sensitivity of 50 HIV-1 RNA copies/ml. Data analyses used McNemar's test, Wilcoxon signed rank test, and Mantel--Haenszel chi-squared and odds ratios with 95% confidence intervals to assess differences in proportions.

RESULTS

In women for whom both plasma and genital specimens were available, HIV-1 was detected less frequently in genital specimens: [tampons (33/97, 34%) and CVL (48/104, 46%)] than plasma specimens (86/104, 83%) (P < 0.001 for both plasma versus tampon and for plasma versus CVL). However, the proportion of genital specimens with detectable virus did not differ significantly by collection method (P = 0.14). Among women with detectable virus using both collection methods (n = 23), viral load was similar for tampon eluents (median, 355 copies/ml; range, 52--120,898) and CVL specimens (median, 265 copies/ml; range, 61--35,637;P = 0.88).

CONCLUSION

Tampon eluent specimens are slightly less sensitive than CVL specimens in the detection of genital HIV-1, although quantification of viral load, when detectable by both methods, was similar.

Pilot study of expedited HIV-1 testing of women in labor at an inner-city hospital in New York City

To evaluate the feasibility of offering voluntary counseling and expedited human immunodeficiency virus (HIV) testing to women in labor, and to assess the characteristics of two rapid HIV assays compared with results from an expedited standard enzyme immunoassay (EIA), with Western blot confirmation, as indicated, we undertook a pilot study immediately prior to enactment of New York State regulations (August 1999) requiring expedited testing of laboring women (or newborns) with undocumented HIV status. From June 9, 1999 through July 2, 1999, we offered HIV counseling and testing (C&T) to all medically stable women in active labor, 106 of 125 (85%) of whom accepted. One woman was confirmed HIV-1 seropositive. Rapid assay sensitivity and specificity were: SUDS 100 and 98%, and Multispot 100 and 100%, respectively in comparison with 100 and 99% for the standard EIA. The positive predictive values (PPV) were SUDS 33%; Multispot 100%; and EIA 50%. While our sample size was small, it appears that the accuracy of rapid and expedited HIV assays may be improved by requiring two different reactive assays before informing women of HIV-seropositive results or initiating antiretroviral treatment.

Mortality, CD4 cell count decline, and depressive symptoms among HIV-seropositive women: longitudinal analysis from the HIV Epidemiology Research Study

CONTEXT

The impact of depression on morbidity and mortality among women with human immunodeficiency virus (HIV) has not been examined despite the fact that women with HIV have substantially higher rates of depression than their male counterparts.

OBJECTIVE

To determine the association of depressive symptoms with HIV-related mortality and decline in CD4 lymphocyte counts among women with HIV.

DESIGN

The HIV Epidemiologic Research Study, a prospective, longitudinal cohort study conducted from April 1993 through January 1995, with follow-up through March 2000.

SETTING

Four academic medical centers in Baltimore, Md; Bronx, NY; Providence, RI; and Detroit, Mich.

PARTICIPANTS

A total of 765 HIV-seropositive women aged 16 to 55 years.

MAIN OUTCOME MEASURES

HIV-related mortality and CD4 cell count slope decline over a maximum of 7 years, compared among women with limited or no depressive symptoms, intermittent depressive symptoms, or chronic depressive symptoms, as measured using the self-report Center for Epidemiologic Studies Depression Scale.

RESULTS

In multivariate analyses controlling for clinical, treatment, and other factors, women with chronic depressive symptoms were 2 times more likely to die than women with limited or no depressive symptoms (relative risk [RR], 2.0; 95% confidence interval [CI], 1.0-3.8). Among women with CD4 cell counts of less than 200 x 10(6)/L, HIV-related mortality rates were 54% for those with chronic depressive symptoms (RR, 4.3; 95% CI, 1.6-11.6) and 48% for those with intermittent depressive symptoms (RR, 3.5; 95% CI, 1.1-10.5) compared with 21% for those with limited or no depressive symptoms. Chronic depressive symptoms were also associated with significantly greater decline in CD4 cell counts after controlling for other variables in the model, especially among women with baseline CD4 cell counts of less than 500 x 10(6)/L and baseline viral load greater than 10 000 copies/microL.

CONCLUSIONS

Our results indicate that depressive symptoms among women with HIV are associated with HIV disease progression, controlling for clinical, substance use, and sociodemographic characteristics. These results highlight the importance of adequate diagnosis and treatment of depression among women with HIV. Further research is needed to determine if treatment of depression can not only enhance the mental health of women with HIV but also impede disease progression and mortality.

Neurocognitive performance enhanced by highly active antiretroviral therapy in HIV-infected women

OBJECTIVE

To determine whether highly active retroviral therapy (HAART) is associated with better neurocognitive outcome over time among HIV-infected women with severely impaired immune function.

METHODS

A semiannual neurocognitive examination on four tasks was administered: Color Trail Making, Controlled Oral Word Association, Grooved Pegboard and Four-Word Learning. This protocol was initiated in the HIV Epidemiological Research study (HERS) study when a woman's CD4 cell count fell to < 100 x 10(6) cells/l. Immune function (CD4), viral load status and depression severity (CESD) were also assessed semi-annually, along with an interview to determine medication intake and illicit drug use.

RESULTS

HAART was not available to any participant at the time of enrollment (baseline), while 44% reported taking HAART at their most recent visit (mean duration of HAART 36.3 +/- 12.6 months). HAART-treated women had improved neurocognitive performance compared with those not treated with HAART. Women taking HAART for 18 months or more showed the strongest neurocognitive performance with improved verbal fluency, psychomotor and executive functions. These functions worsened among women not taking HAART. Substance abuse status, severity of depressive symptoms, age and educational level did not influence the HAART treatment effects on neurocognitive performance. Neurocognitive improvements were strongly associated with the magnitude of CD4 cell count increases.

CONCLUSIONS

HAART appeared to produce beneficial effect on neurocognitive functioning in HIV-infected women with severely impaired immune systems. Benefits were greatest for women who reported receiving HAART for more than 18 months.

Disease progression and early viral dynamics in human immunodeficiency virus-infected children exposed to zidovudine during prenatal and perinatal periods

Zidovudine (Zdv) is widely used to reduce maternal-infant human immunodeficiency virus transmission (HIV), but its consequences for disease progression among children infected despite Zdv exposure remain unknown. In a multicenter observational cohort study of 325 HIV-infected children born during 1986-1997, clinical progression was compared among infected children exposed or unexposed to Zdv during prenatal and perinatal periods. Zdv exposure was associated with 1.8-fold (95% confidence interval, 1.02-3.11) increased risk of progressing to AIDS or death after adjusting for year of birth, maternal CD4 cell count, maternal AIDS diagnosis, and subsequent antiretroviral therapy of the child. Mean log(10) viral copies at 7-12 weeks were higher among Zdv-exposed children (P=.004). No infected child treated early with multidrug therapy progressed to AIDS or died by 1 year, regardless of early Zdv exposure. More rapid disease progression was observed among infected children exposed during pregnancy or birth to Zdv if effective multidrug therapy was not initiated.

Effectiveness of isoniazid chemoprophylaxis for HIV-infected drug users at high risk for active tuberculosis

OBJECTIVE

To define the effectiveness of chemoprophylaxis, outside of a clinical trial setting, in preventing tuberculosis among tuberculin-reactive and anergic HIV-infected drug users at high risk of developing active tuberculosis.

DESIGN

An observational cohort study.

SETTING

Methadone maintenance treatment program with on-site primary care.

PARTICIPANTS

Current or former drug users enrolled in methadone treatment.

INTERVENTIONS

Annual skin testing for tuberculosis infection and anergy was performed, and eligible patients were offered daily isoniazid for 12 months and followed prospectively.

MAIN OUTCOME MEASURE

The development of active tuberculosis.

RESULTS

A total of 155 persons commenced chemoprophylaxis. Among tuberculin reactors, tuberculosis rates were 0.51 and 2.07/100 person-years in those completing 12 months versus those not taking prophylaxis [rate ratio 0.25, 95% confidence interval (CI) 0.06-1.01]. Among anergic individuals, comparable rates were 0 and 1.44/100 person-years. Lower tuberculosis rates among completers were not attributable to differences in immune status between the treated and untreated groups.

CONCLUSION

The completion of isoniazid chemoprophylaxis was associated with a marked reduction in tuberculosis risk among tuberculin reactors and anergic persons in this high-risk population. These data support aggressive efforts to provide a complete course of preventative therapy to HIV-infected tuberculin reactors, and lend weight to the findings of others that isoniazid can reduce the rate of tuberculosis in high-risk anergic HIV-infected persons.

Allelic variants of human beta-chemokine receptor 5 (CCR5) promoter: evolutionary relationships and predictable associations with HIV-1 disease progression

Variability in the natural history of HIV-1 infection has been repeatedly associated with genetic variants in the beta-chemokine receptor 5 (CCR5) locus. While CCR5 coding sequences have demonstrated relatively limited variation, sequences of its promoter appear polymorphic in all major populations. Our studies revealed five major CCR5 promoter alleles with distributions that differed widely among the four distinct ethnic groups from Kigali, Rwanda and Bronx, New York. In particular, promoter allele P*0103 (G59029-T59353-T59356-A59402-C59653) was largely restricted to black subjects. The promoter allele P*0202 (A59029-C59353-C59356-A59402-T59653) was tightly linked to the slightly less frequent CCR2b-641, a variant of the CCR2b gene, which is about 12.7 kbp upstream from the promoter region. Another closely related promoter allele P*0201 (A59029-C59353-C59356-A59402-C59653) exclusively carried the far less common CCR5-delta 32, a 32-bp deletion in the CCR5 coding sequence 2 kbp downstream from the promoter. The homozygous P*0201/*0201 genotype can be predicted as a risk factor for more rapid disease progression. Among human, chimpanzee, pig-tailed macaque, and sooty mangabey promoter allelic sequences, the apparent ancestral lineage of the promoter sequence (G59029-T59353-C59356-A59402-C59653 = human P*0102) was highly conserved across the primate species analyzed here while P*0201 and P*0202 arose more recently than the other three major alleles. Further effort to establish the mechanism by which CCR chemokine receptor polymorphisms govern the initiation and pathogenesis of primate lentivirus infection apparently requires fully detailed genotypic characterization of the affected populations.

Self-assessment of tuberculin skin test reactions by drug users with or at risk for human immunodeficiency virus infection

SETTING

Self-assessment of tuberculin test results, if accurate, could enhance tuberculosis screening efforts by reducing the need for follow-up visits for skin test reading. We investigated tuberculin test self-assessment in a longitudinal study of tuberculosis infection among drug users.

OBJECTIVE

To determine the accuracy of tuberculin reaction self-assessment by drug users at high risk for tuberculosis infection.

DESIGN

Two readings were compared of the same skin test, performed 48-72 hours after placement: 1) self-assessment using a simple yes-no approach to induration, versus 2) trained examiner reading. Self-assessments were performed immediately prior to trained examiner readings.

RESULTS

Participants were 137 human immunodeficiency virus (HIV) seropositive and 344 HIV-seronegative current and former drug users. Ten per cent (35/344) of reactions read by participants as 'flat' were read by trained examiners as > or =5 mm (54% of which were > or =10 mm). Twenty-three per cent (19/82) of reactions read by trained examiners as > or =10 mm and 32% (35/110) of reactions read by trained examiners as being > or =5 mm were self-read by participants as 'flat'. Sensitivity (0.68) and specificity (0.83) of self-read tuberculin reactions were sub-optimal. Inter-reader reliability was poorer between participants and trained examiners than between trained examiners.

CONCLUSION

Self-assessments of tuberculin skin test responses by drug users with or at risk for HIV infection are not reliable.

A prospective study of HIV disease progression in female and male drug users

OBJECTIVE

To compare HIV disease progression and mortality in a cohort of female and male drug users.

DESIGN

A prospective cohort study of 222 HIV-seropositive women and 302 HIV-seropositive men who attended a hospital-affiliated methadone maintenance program with on-site primary care.

METHODS

Regression slopes of CD4+ cell decline were compared using the two sample t-test, and the distribution of AIDS-defining illnesses evaluated by Mantel-Haenszel chi2 test. Time to AIDS-defining clinical conditions and death were compared using the Kaplan-Meier log-rank test. Multivariate estimates of progression to clinical AIDS or death, for all participants, stratified by sex, were derived from Cox proportional hazards models.

RESULTS

Ninety-five persons (43 women and 52 men) developed AIDS-defining conditions. Analyses of the rates of CD4+ cell decline, the distribution of first AIDS-defining illnesses, and the time to clinical AIDS did not differ by sex. In the multivariate model, sex was not associated with an AIDS outcome, whereas crack-cocaine use [hazards ratio (HR), 1.815; 95% confidence interval (CI), 1.151-2.863], CD4+ cell count (100 x 10(6)/l; HR, 0.589; 95% CI, 0.511-0.679), and two or more HIV-related symptoms (HR, 1.702; 95% CI, 1.125-2.576) were associated. Mortality rates (8.71 per 100 person-years in women and 9.85 per 100 person-years in men) were similar, using univariate or multivariate methods.

CONCLUSIONS

There was little difference in clinical outcomes or mortality between HIV-seropositive female and male drug users with access to primary care. However, crack-cocaine use was independently associated with progression to clinical AIDS.

Temporal trends in the progression of human immunodeficiency virus disease in a cohort of drug users

We evaluated changes over time in rates of progression to AIDS, mortality, and distribution of AIDS-defining illnesses in 524 human immunodeficiency virus (HIV)-seropositive injection drug users enrolled between 1986 and 1995 in a prospective study of HIV infection in the Bronx, NY. At enrollment, participants attended a hospital-affiliated methadone maintenance program with on-site primary care. Using the 1993 clinical definition of AIDS, we found that the hazard ratio (HR) of progression to AIDS declined for enrollees over time in comparison with the referent group of persons enrolled in 1986-1987. For program enrollees in 1988-1989, the HR was 1.0 [95% confidence interval (CI) = 0.6-1.6]; for enrollees in 1990-1991, the HR was 0.3 (95% CI = 0.1-0.9); for enrollees in 1992-1993, the HR was 0.5 (95% CI = 0.3-0.9); and for enrollees in 1994-1995, the HR was 0.2 (95% CI = 0.1-0.7), after controlling on initial CD4+ cell counts and age. Nevertheless, the greater AIDS-free time of later study entrants was not associated with reduced mortality. The study provides evidence that drug users with access to primary care likely benefited from improved management of HIV disease in prolonging AIDS-free time but, through 1996, did not experience greater survival.

Association of human immunodeficiency virus (HIV) load early in life with disease progression among HIV-infected infants. New York City Perinatal HIV Transmission Collaborative Study Group

The utility of RNA virus load to predict progression of human immunodeficiency virus (HIV)-1 disease was assessed in 89 HIV-1-infected children. Of 22 virus load values during week 1 of life, 17 were below the detection threshold. Geometric mean virus load increased to approximately 7 x 10(5) copies/mL by week 4, was sustained throughout the first 6 months of life, and then declined to 1.6 x 10(5) copies/mL during the third year. Samples from week 1 of life had little predictive value, but virus load during days 7-30 strongly predicted progression to CDC-3 classification or death (P = .024; risk ratio = 1.6), and virus load during months 2-3 predicted progression to CDC-C or death within the first 6 months of life (P = .002, risk ratio = 11). Virus load was highly associated with imminent vulnerability to CDC-C or death (P = .002) during the first 18 months of life. Except for values from the first week of life, virus load at any age through 18 months is strongly associated with risk of HIV disease progression.

Methadone treatment protects against HIV infection: two decades of experience in the Bronx, New York City

OBJECTIVE

We undertook a study of the role of methadone maintenance in protecting injecting drug users (IDUs) from human immunodeficiency virus (HIV) infection from the earliest days of the HIV epidemic in New York City to the present. The historical context of the epidemic in the Bronx is discussed.

METHODS

For close to two decades, we have been tracking changes in injecting drug use and HIV infection levels in a Bronx cohort study of IDUs. An initial sample of 622 IDUs was recruited from a methadone treatment program in 1985, with historical data going back to 1978. Behavioral interviews and HIV testing were performed and methadone treatment program records (urine toxicology and methadone dose history) were reviewed. We examined both prevalent and incident HIV infections. The sample included African Americans (24.3%), Latinos (50.3%), and white non-Latinos (24.4%). The average methadone dose was 64 milligrams (mg) per day with an average time in treatment of five and a half years.

RESULTS

We found a very low rate of incident infection of 1.7 per 100 person-years observation since 1986. Because of this low rate of infection, we were unable to determine the association between methadone treatment factors and HIV seroincidence. We found that our prevalence data on the 622 IDUs enrolled from 1985 to 1988 yielded strong findings on the role of methadone maintenance in a period when most infections occurred in this population. HIV seroprevalence was 42.9%. Logistic regression analysis revealed associations of methadone dose > or = 80 mg (adjusted odds ratio = 3.07/yr, 95% confidence interval (CI): 1.23-7.68) and last year entered methadone treatment (adjusted odds ratio = 1.22/yr, 95% CI: 1.06-1.41) to HIV infection, independent of year of last cocaine injection, needle sharing in shooting galleries, number of IDU sex partners, low income, and African American of Latino ethnicity.

CONCLUSIONS

Properly dosed, long-term methadone treatment was found to be a central protective factor in preventing HIV infection from the earliest days of the epidemic in New York City. It is crucial to have high quality drug treatment programs in place before an epidemic draws our attention to the inadequacies through excess and unnecessary morbidity and mortality.

Correlates of voluntary human immunodeficiency virus antibody testing reported by postpartum women

OBJECTIVES

This study examined attitudes, knowledge, and behaviors reported by postpartum women in an AIDS epicenter toward voluntary human immunodeficiency virus (HIV) counseling and testing.

METHODS

From February 1993 to March 1994, a convenience sample of 544 women underwent postpartum interviews at a municipal hospital in the Bronx, New York City. Demographic information and obstetric, sexual, drug use, and HIV testing histories were elicited, and selected variables were abstracted from the medical charts. Univariate and multivariate logistic regression analyses were performed.

RESULTS

Seventy-nine percent of women were voluntarily tested for HIV. In the multivariate model, the strongest individual correlate of HIV testing was a history of drug use. Other independent correlates were being age 25 or younger, having only one child, knowing someone who died of AIDS, and having stigma-related concerns about testing. In univariate analysis, women with a drug risk were more than nine times as likely as others to have delivered without receiving any prenatal care during this pregnancy.

CONCLUSIONS

Voluntary counseling and testing programs can succeed in testing a majority of hospitalized childbearing women. However, women at risk of drug use, who more often reported testing, were probably tested outside of prenatal care settings. Efforts to reduce vertical transmission of HIV infection must focus on bringing more women, especially women who use drugs, into prenatal care.

Vitamin A deficiency and maternal-infant transmissions of HIV in two metropolitan areas in the United States

OBJECTIVE

To determine whether vitamin A deficiency is associated with maternal-infant HIV transmission among HIV-infected pregnant women in two United States cities.

METHODS

Third trimester serum vitamin A levels were evaluated using high-performance liquid chromatography in 133 HIV-infected women who delivered livebirths during May 1986 to May 1994 and whose infants had known HIV infection status.

RESULTS

Sixteen per cent (seven out of 44) of the transmitting mothers and 6% (five out of 89) of the non-transmitting mothers had severe vitamin A deficiency (< 0.70 mumol/l; P = 0.05). Maternal-infant transmission was also associated with prematurity < 37 weeks gestation (P = 0.02), and Cesarean section delivery (P = 0.04), CD4 percentage (P = 0.03) and marginally associated with duration of membrane rupture of > or = 4 h (P = 0.06) by univariate analysis. In a multivariate logistic regression model, severe vitamin A deficiency [adjusted odds ratio (AOR), 5.05; 95% confidence interval (CI), 1.20-21.24], Cesarean section delivery (AOR, 3.75; 95% CI, 1.10-12.87), and prematurity (AOR, 2.25; 95% CI, 1.22-4.13) were associated with transmission after adjusting for CD4+ percentage, and duration of membrane rupture.

CONCLUSION

Increased risk of maternal-infant transmission was associated with severe vitamin A deficiency among non-breastfeeding women in these cohorts from the United States.

Early detection of perinatal human immunodeficiency virus (HIV) type 1 infection using HIV RNA amplification and detection. New York City Perinatal HIV Transmission Collaborative Study

Early diagnosis of perinatally transmitted human immunodeficiency virus type 1 (HIV) infection can guide early interventions. HIV coculture and DNA polymerase chain reaction (DNA-PCR) detect few HIV-infected infants at birth and 90%-100% by age 3 months. Because extracellular HIV RNA may appear soon after infection, a plasma HIV RNA assay was compared with DNA-PCR for early detection of perinatally infected infants. Blood-draw specimens (108) obtained at the same time from 49 HIV-infected infants and 10 specimens from 8 uninfected infants were tested. HIV RNA and DNA-PCR positivity rates were 56% and 33%, respectively, in 36 specimens from 36 infants <28 days of age (binomial test, P = .001). Among 81 specimens obtained after age 14 days, 79 (98%) were positive by HIV RNA testing. No HIV-infected infant specimens were DNA-PCR-positive and HIV RNA-negative. All specimens from 8 uninfected infants were HIV RNA-negative. These results suggest that plasma HIV RNA was detectable earlier and more reliably than HIV DNA in perinatal infection.

Needle exchange use among a cohort of injecting drug users

OBJECTIVE

To study prospectively injection behavior of injecting drug users (IDU) who did and did not utilize a local needle exchange in the Bronx, New York City.

DESIGN

Since 1985, IDU attending a methadone maintenance program have been enrolled in a prospective study of HIV-related risk behaviors. Since 1989, when a needle exchange opened near the methadone program, data have been collected from study participants regarding utilization of the exchange.

PARTICIPANTS

Study participants (n = 904) who injected between 1985 and 1993.

RESULTS

Of 904 IDU, 21.9% used the needle exchange. Male gender [adjusted odds ratio (AOR), 1.57], HIV seropositivity (AOR, 1.39) and younger age (AOR per 10 years of age, 1.66) were independently associated with needle exchange attendance. The percentage injecting declined each year, preceding the opening of the needle exchange and concurrent with its operation (from 64.6% in 1985 to 43.6% in 1993). Among the 329 participants who injected in the year before the exchange opened, 1988, 53 out of 124 (42.7%) needle exchange users and 168 out of 205 (81.9%) non-users reduced or stopped injecting by 1993 (P < 0.001). Exchange users shared needles less than non-users (P < 0.05 in 1993). HIV infection was unrelated to these reductions in injection.

CONCLUSIONS

Methadone-treated IDU with access to a needle exchange reduced injecting and needle-sharing. This pattern of harm reduction, which began at least 4 years before the needle exchange opened, occurred in both those who did and did not utilize the needle exchange. Needle exchange, as a strategy to reduce injection-related harm, should not be viewed as discordant with methadone treatment.

Lack of association of induration size with HIV infection among drug users reacting to tuberculin

Smaller tuberculin test induration sizes suggest eligibility for tuberculosis chemoprophylaxis in HIV-seropositive than in HIV-seronegative persons. To determine whether human immunodeficiency virus (HIV) infection is associated with induration size among tuberculin reactors, a cross-sectional study of HIV-seropositive and -seronegative drug users was performed. Twenty-four of 160 (15%) HIV-seropositive and 68 of 284 (24%) HIV-seronegative patients had reactions to purified protein derivative (PPD) of > or = 2 mm (OR = 0.56, 95% CI 0.32 to 0.96). However, the prevalence of tuberculin reactivity was equal among nonanergic subjects with and without HIV infection. Median induration size was similar among HIV-seropositive (20.5 mm) and -seronegative (17.5 mm) reactors. Thus, although HIV-seropositive patients were less likely, due to cutaneous anergy, to be PPD reactors, induration size was not associated with HIV infection among reactors. Although using a reduced cutpoint to determine suitability of chemoprophylaxis in HIV-seropositive persons may be prudent, the logical assumption that the loss of specificity this entails is accompanied by an increase in sensitivity for detecting Mycobacterium tuberculosis infection remains to be proved.

Behavioral risks for HIV infection associated with HIV-testing decisions

Adolescent and adult women were offered HIV testing as part of a clinic-based research program on HIV/AIDS in New York City. Sixty-four percent consented to testing and 87% of those tested returned to receive their results. This paper uses two-stage regression methods to identify sexual behavioral risk factors for HIV infection associated with the decision to accept the HIV test and subsequently to return for the results. Of the risk factors examined, having more than a single sex partner and never using a condom in the last year were strong predictors of taking the test; three or more sex partners had the strongest effects on the decision to return for the HIV test results. We conclude that voluntary HIV testing in this group can identify women with behavioral risks of HIV infection. Thus, voluntary HIV testing may be effective in targeting persons at high risk because behavioral risks are associated with the decision to take the HIV test.

A prospective study of syphilis and HIV infection among injection drug users receiving methadone in the Bronx, NY

OBJECTIVES

The purpose of this study was to assess the relationship between syphilis and human immunodeficiency virus (HIV) infection in injection drug users.

METHODS

A 6-year prospective study of 790 injection drug users receiving methadone maintenance treatment in the Bronx, NY, was conducted.

RESULTS

Sixteen percent (4/25) of HIV-seroconverting patients, 4.8% (16/335) of prevalent HIV-seropositive patients, and 3.5% (15/430) of persistently HIV-seronegative patients was diagnosed with syphilis. Incidence rates for early syphilis (cases per 1000 person-years) were 15.9 for HIV-seroconverting patients, 8.9 for prevalent HIV-seropositive patients, and 2.9 for persistently HIV-seronegative patients. Early syphilis incidence was higher among women than men (8.4 vs 3.2 cases per 1000 person-years). Independent risks for early syphilis included multiple sex partners, HIV seroconversion, paid sex, and young age. All HIV seroconverters with syphilis were female.

CONCLUSIONS

Diagnosis of syphilis in drug-using women reflects high-risk sexual activity and is associated with acquiring HIV infection. Interventions to reduce the risk of sexually acquired infections are urgently needed among female drug users.

Stress, coping, and attitudes toward HIV treatment in injecting drug users: a qualitative study

An exploratory study was conducted with 27 injecting drug users (IDUs) on psychosocial factors (stress, coping reactions, and attitudes toward HIV illness and treatment) which are relevant to treatment acceptance and adherence. A semi-structured interview was used to collect qualitative data in a sample of 13 seropositive and 14 seronegative subjects. The results indicated a range of HIV-specific stressors such as social stigma, uncertainty about the future, disclosure of seropositive status, and monitoring of HIV illness. Seeking of social support, relapse to substance abuse, and mental disengagement were the most common coping reactions reported by the sample; there was a lack of behavioral, problem-focused responses. The study also provided descriptive information on attitudes toward HIV treatment, including fatalism, optimism (hope and control), and ambivalence regarding treatment efficacy. Clinical implications and suggestions for future research are discussed.

Heroin use during methadone maintenance treatment: the importance of methadone dose and cocaine use

OBJECTIVES

The purpose of this study was to examine factors associated with heroin use during methadone maintenance treatment.

METHODS

Logistic regression statistical models were used to examine data obtained in a cross-sectional sample of 652 methadone patients.

RESULTS

Heroin use during the 3 months prior to interview was shown to be greatest among (1) patients maintained on methadone dosages of less than 70 mg/day (adjusted odds ratio [OR] = 2.1, 95% confidence interval [CI] = 1.3, 3.4) and (2) patients who used cocaine during treatment (adjusted OR = 5.9, 95% CI = 3.8, 9.1). These results were independent of treatment duration, treatment compliance, alcohol use, and socioeconomic factors. Cocaine users were more likely than nonusers of cocaine to use heroin at all methadone dosage levels.

CONCLUSIONS

This study confirms and extends past research showing high-dose methadone maintenance to be important to heroin abstinence. Further investigation of the independent association between heroin use and cocaine use is needed.

Laboratory markers and the risk of developing HIV-1 disease among injecting drug users

OBJECTIVE

To characterize the progression to HIV-1 disease among injecting drug users (IDU) according to laboratory markers.

DESIGN

Prospective study of cohort of HIV-1-seroprevalent IDU, with case-comparison component.

METHODS

Different laboratory markers were examined as predictors of progression to HIV-1-associated diseases including AIDS in a cohort of 318 HIV-1-infected IDU. The cohort was enrolled from a methadone treatment program in the Bronx, New York, USA. The independent utility of non-CD4 cell markers was evaluated after adjustment for the association of low CD4 lymphocyte count with AIDS risk. Clinical events in the natural history of HIV-1 were related to changes in levels of two variables related to duration of infection, CD4 lymphocyte count and serum beta 2-microglobulin (beta 2M) concentration.

RESULTS

On univariate analysis, AIDS incidence measured from baseline increased with declining CD4 lymphocyte number and percentage, increasing serum beta 2M level, low platelet count, low leukocyte count and p24 antigenemia. Among HIV-1-related outcomes prior to any AIDS diagnosis, the relative risk of pyogenic bacterial infections conferred by these markers was similar to the relative risk of AIDS. For all HIV-1 outcomes, the elevated risk encountered at CD4 lymphocyte number < or = 200 x 10(6)/l was entirely due to the high risk at < or = 150 x 10(6)/l. On multivariate analysis, control for CD4 lymphocyte count eliminated the association of any other marker with increased AIDS hazard. HIV-1-related outcomes tended to occur in this order: multiple constitutional symptoms, oral candidiasis, pyogenic bacterial infections and AIDS.

CONCLUSIONS

In HIV-1-infected IDU, several laboratory markers may predict AIDS when analyzed individually. These are not, however, independently related to increased AIDS risk after adjustment for low CD4 lymphocyte count. A CD4 count < or = 150 x 10(6)/l is more strongly related to immediate risk of adverse outcome than a count of 200 x 10(6)/l. A progressive series of clinical events is associated with markers of duration of HIV-1 infection, prior to and including AIDS diagnosis.

Association of baseline neuropsychological function and progression of illness over 4 years in HIV-seropositive individuals

The authors conducted a study to examine the association between neuropsychological markers of central nervous system impairment and systemic human immunodeficiency virus (HIV) disease progression in a sample of 64 HIV-positive asymptomatic patients who were followed for a median of 45.6 months. Patients with poorer baseline scores on the Halstead-Reitan Trail-Making A neuropsychological test developed HIV-related systemic symptoms earlier over the study period than patients with the higher scores on the same test (P < 0.05). Subclinical neuropsychological dysfunction in otherwise asymptomatic HIV-infected individuals may be a harbinger of progressive HIV-related immunologic dysfunction.

A prospective four-year follow-up of neuropsychological function in HIV seropositive and seronegative methadone-maintained patients

The evolution of central nervous system (CNS) impairments associated with human immunodeficiency virus (HIV) infection was assessed by a prospective, longitudinal study of patients in a methadone maintenance clinic. At a mean of 47 months after baseline testing, which included physical exams, HIV antibody testing and a neuropsychological (NP) screening battery, 121 subjects received a second NP assessment. Forty subjects (33%) who were seropositive at baseline showed statistically significant declines in NP function over the 4 years compared with 81 seronegatives, on the Finger Tapping and Trail Making B tests. This relatively long-term follow-up suggests that subtle cognitive deficits develop over time and can be identified early, but their course is slow and appears generally to parallel that of non-CNS symptoms/signs of HIV infection.

Correlates of the rate of decline of CD4+ lymphocytes among injection drug users infected with the human immunodeficiency virus

Changes in the level of CD4-bearing T-lymphocytes in injection drug users infected with the human immunodeficiency virus were evaluated in a sample of 318 subjects enrolled from a methadone program in the Bronx, New York, from 1985 through 1989. Follow-up continued through 1990. The percentage of CD4+ T-lymphocytes (CD4%) was used to maximize the stability of measurements. The rate of decline of the CD4% was determined using a random-effects assumption, and predictors of rate of decline were evaluated using an autoregressive model. The rate of CD4% decline was approximately 1.2 CD4% lost per 6 months, with a higher rate in recent seroconverters (2.2 CD4% lost). The most important predictors of decline of the CD4% in autoregressive models were current pyogenic bacterial infection (CD4% reduced by 2.75, 95% confidence interval (CI) 0.42-5.08), current report of a second constitutional symptom (CD4% reduced by 2.16, 95% CI 0.03-4.29), and history of bacterial infection (CD4% reduced by 1.49, 95% CI 0.09-2.89; proportion of prior CD4% lost increased by 0.14, 95% CI 0.01-0.27). Oral thrush was not related to an accelerated rate of CD4% decline.

CD4+ lymphocyte level and rate of decline as predictors of AIDS in intravenous drug users with HIV infection

OBJECTIVE

To examine the relationship between rate of loss of CD4+ T lymphocytes and risk of AIDS in HIV-infected intravenous drug users (IVDU) enrolled in a methadone program in the Bronx, New York.

DESIGN

Serial CD4 percentages (CD4%) among lymphocytes before AIDS diagnosis were recorded at approximately 6-month intervals for 190 HIV-antibody-positive subjects.

METHODS

A nested case-control study was performed, in which all subjects who developed AIDS were compared with those who remained AIDS-free. The relationship between CD4% decline and AIDS risk was evaluated using proportional-hazards regression.

RESULTS

Analyses that used a single baseline CD4% measurement to adjust for CD4+ lymphocyte count suggested that both low (1-5 CD4% per semester) and high (> 5 CD4% per semester) rates of decline might be related to AIDS risk: relative risks were 1.83 and 1.44, although the 95% confidence intervals (Cl) included 1.0 in each case. Adjustment for current level of CD4% eliminated the association between low rates of CD4% decline and AIDS risk, but not that between high rates of decline and AIDS risk (adjusted relative risk, 1.80; 95% Cl, 0.57-5.70). Serial observations showed that a rate of decline of CD4% > 5 per semester was a significant predictor of AIDS risk after controlling for level of CD4% achieved (adjusted relative risk, 3.58; 95% Cl, 1.07-11.95).

CONCLUSIONS

IVDU who develop AIDS have a greater rate of CD4 cell loss than subjects who remain AIDS-free. A low rate of CD4+ lymphocyte depletion is not an important predictor of the immediate onset of AIDS in HIV-infected IVDU, compared with CD4+ lymphocyte level, but a high rate of CD4+ decline can be.

The underrecognition of HIV infection in women in an inner-city emergency room

OBJECTIVES

This study analyzed the recognition of human immunodeficiency virus (HIV) infection and associated factors in women and men attending an emergency room in the Bronx, New York, NY.

METHODS

From April 16, 1989, to May 5, 1989, the emergency room records of 2102 consecutive patients 13 years of age or older were reviewed and, for 856 patients undergoing venipuncture, linked anonymously to results of HIV antibody tested in excess blood.

RESULTS

HIV seroprevalence was 7.8% in women and 14.6% in men. Among seropositive women, 5.0% had acquired immunodeficiency syndrome (AIDS), compared with 26.0% of men. Excluding patients with AIDS, HIV infection was recognized in 13.2% of women and 27.0% of men. HIV infection was recognized only in women aged 25 through 44 years. In men, recognition occurred in all age groups. Clinical presentation did not distinguish the seropositive from seronegative women. Risk assessments were recorded less frequently for women (11.2%) than men (15.9%). For 92.5% of persons with any behavioral risk assessment, injecting drug use was the only behavior assessed.

CONCLUSIONS

HIV infection is underrecognized in women, in part, because of a lower prevalence of AIDS. Universal HIV risk assessment, which includes heterosexual behaviors, may help increase recognition of HIV in women and opportunities for early intervention.

Effects of HIV infection on the serologic manifestations and response to treatment of syphilis in intravenous drug users

OBJECTIVE

To describe the effects of human immunodeficiency virus (HIV) infection on the serologic manifestations and response to treatment of syphilis in intravenous drug users.

DESIGN

Cohort study of intravenous drug users.

SETTING

Medical clinic in a hospital-based methadone maintenance treatment program in New York City.

PATIENTS

Fifty patients with syphilis, of whom 31 were HIV seropositive and 19 HIV seronegative.

MEASUREMENTS

Serologic tests for syphilis and clinical manifestations.

RESULTS

Stage of syphilis at presentation was not associated with HIV serologic status. No unusual or fulminant manifestations of early syphilis or neurosyphilis were noted among HIV-seropositive cases. Maximum nontreponemal titers were higher among HIV-seropositive (median, 1:128) than among HIV-seronegative (median, 1:32) patients with syphilis (P = 0.05); this difference was present only among patients with first-episode syphilis. All 26 evaluable, HIV-seropositive patients treated for syphilis responded appropriately, including 13 patients given standard or less-than-standard doses of penicillin. Seven of 43 patients (16%) showed reversion to negative treponemal antibody assay results after treatment for syphilis; this finding was not associated with HIV infection, CD4 count, or stage of syphilis. Low nontreponemal titer was weakly associated with treponemal test reversion.

CONCLUSIONS

Infection with HIV did not alter the stage at presentation, clinical course, serologic manifestations, or response to treatment of syphilis in this cohort of intravenous drug users.

Clinical manifestations and predictors of disease progression in drug users with human immunodeficiency virus infection

BACKGROUND AND METHODS

To examine the clinical course of human immunodeficiency virus (HIV) infection in injection-drug users, we conducted a prospective study of a cohort of patients in a methadone-treatment program in New York City from July 1985 through December 1990. The patients underwent standardized evaluations at base line and semiannually thereafter and received on-site primary medical care. Rates of progression to the acquired immunodeficiency syndrome (AIDS) and major outcomes before the development of AIDS were examined by univariate analyses; the risk of AIDS was also assessed by product-limit survival analysis and proportional-hazards regression.

RESULTS

Of 318 HIV-seropositive patients who did not yet have AIDS (171 men and 147 women), 90 were black, 179 were Hispanic, and 49 were white; the median age was 33 years. Over a median of 3.0 years of follow-up, 55 (17 percent) received a diagnosis of AIDS (incidence per 100 person-years, 5.8). Major outcomes before the development of AIDS included oral candidiasis (incidence per 100 person-years, 11.2), pyogenic bacterial infections including pneumonia and sepsis (8.0), pulmonary tuberculosis (1.2), multiple constitutional symptoms (13.6), and herpes zoster (1.3). There were 41 deaths from AIDS, and 13 seropositive patients without AIDS (4.1 percent) died of bacterial infections, as compared with only 1 of 411 seronegative patients studied (P < 0.001). The incidence of AIDS was 62 percent lower among those who took zidovudine than among those who did not (P = 0.02). In the multivariate analysis, progression to AIDS was best predicted by low numbers and percentages of CD4+ lymphocytes, nonuse of zidovudine, and the presence of oral candidiasis, bacterial infections, or tuberculosis. There was no consistent relation between progression to disease and the continued use of injection drugs.

CONCLUSIONS

HIV-infected injection-drug users have progression to AIDS at rates comparable to those of other HIV-infected groups, but they have substantial pre-AIDS morbidity and mortality, particularly from bacterial infections, which also appear to predict disease progression.

High risk of active tuberculosis in HIV-infected drug users with cutaneous anergy

OBJECTIVES

To determine the incidence of active tuberculosis in human immunodeficiency virus (HIV)-seropositive and HIV-seronegative drug injectors with cutaneous anergy and to examine the effectiveness of isoniazid chemoprophylaxis in preventing tuberculosis among drug injectors with positive tuberculin test results.

DESIGN AND SETTING

Prospective observational study linked to an ongoing study of HIV infection within a New York City (NY) methadone program; subjects also underwent routine intradermal tuberculin testing and multiple-antigen delayed-type hypersensitivity skin testing. The 31-month study period ended December 31, 1990.

METHODS

Anergic subjects and tuberculin reactors who were HIV seropositive were compared by HIV disease status and CD4+ T-lymphocyte levels. Tuberculosis incidence was calculated for anergics (none treated with isoniazid) and for treated and untreated tuberculin reactors, by HIV serological status.

RESULTS

Among those seropositive for HIV, anergic subjects had more advanced HIV disease and fewer CD4+ cells (median 0.33 vs 0.56 x 10(9)/L, P less than .01) compared with tuberculin reactors, although neither clinical status nor CD4+ cell counts consistently predicted anergy. Five (7.6%) of 68 anergic subjects who were HIV seropositive and none of 52 anergic subjects who were HIV seronegative (n = 18) or of unknown (n = 34) HIV serological status developed active tuberculosis during the study period (P less than .05). The tuberculosis incidence rate among anergic subjects who were HIV seropositive was 6.6 cases per 100 person-years (95% confidence interval [Cl], 2.1 to 15.3). Of 25 HIV-seropositive tuberculin reactors who did not receive or complete 12 months of isoniazid prophylaxis, tuberculosis incidence was 9.7 cases per 100 person-years (95% Cl, 2.6 to 24.7; P = 0.56, compared with the rate among anergic HIV seropositives); there were no cases of tuberculosis in 53.4 person-years of follow-up for 27 HIV-seropositive tuberculin reactors who received 12 months of prophylaxis (rate difference between treated and untreated groups, 9.7 cases per 100 person-years, 95% Cl, 1.3 to 18.0).

CONCLUSION

Drug injectors with cutaneous anergy who are seropositive for HIV are at high risk of active tuberculosis, similar to that among untreated HIV-seropositive tuberculin reactors. A decreased incidence of active tuberculosis was seen in HIV-seropositive tuberculin reactors receiving 12 months of isoniazid chemoprophylaxis, compared with untreated or partially treated subjects. These results support the routine use of delayed-type hypersensitivity testing to accompany tuberculin testing for drug injectors with known or suspected HIV infection, and consideration of isoniazid prophylaxis for anergic as well as tuberculin-reactive subjects who are HIV seropositive, in populations with a high prevalence of coexisting HIV and Mycobacterium tuberculosis infection.

A prospective study of infants of human immunodeficiency virus seropositive and seronegative women with a history of intravenous drug use or of intravenous drug-using sex partners, in the Bronx, New York City

A prospective study was conducted in the Bronx, New York, of 70 infants of human immunodeficiency virus (HIV)-infected (n = 33) and uninfected (n = 37) mothers who had a history of intravenous drug use or of intravenous drug-using sex partners. Infants were observed from birth to a median age of 23 months (range 3 to 54 months). HIV infection was confirmed in seven infants (21%) of seropositive mothers; six developed HIV disease, with symptoms observed in the first year. Of these, three died (3, 9, and 36 months) of HIV-related causes; 3 of 4 survivors were greater than 25 months of age. HIV symptoms preceded or were concurrent with abnormalities in T-lymphocyte subsets; postneonatal polymerase chain reaction confirmed HIV infection in five infants with symptoms and one without symptoms. Among infants of seropositive mothers, seven without laboratory evidence of HIV (including polymerase chain reaction) had findings suggestive of HIV infection, including persistent generalized lymphadenopathy, hepatosplenomegaly, oral candidiasis, parotitis, and inverted T-lymphocyte ratios. These findings were not observed in infants of seronegative mothers. Although the presence of HIV proviral sequences was associated with HIV disease, the observation of indeterminate symptoms in at-risk infants indicates the importance of long-term clinical follow-up to exclude HIV infection. Disease manifestations in comparable infants of seronegative mothers are important for assessment of the impact of maternal drug use, development of specific clinical criteria for early diagnosis of HIV and eligibility for antiretroviral therapy.

Human T lymphotropic virus type II (HTLV-II) infection in a cohort of New York intravenous drug users: an old infection?

To identify risk factors for human T lymphotropic virus type II (HTLV-II) infection in intravenous drug users (IVDUs), participants in a longitudinal study of human immunodeficiency virus (HIV) infection in a New York methadone maintenance program were studied. Of 270 participants tested for HTLV-I/II, 21 (8%) were seropositive. Of those, 15 (71%) had HTLV-II-specific sequences by polymerase chain reaction (PCR) and 1 (5%) had both HTLV-I- and -II-specific sequences; 3 persons with indeterminate serologic results were also PCR-positive for HTLV-II. HTLV-II infection was significantly associated with older age but was not predicted by sex, race, socioeconomic status, transfusion history, or HIV infection status. Behavioral factors since 1978, such as duration and frequency of intravenous drug use, needle sharing, visits to shooting galleries, or number of sex partners, were also not associated with HTLV-II infection. These findings are in contrast with the association of these risk factors with HIV in this group and suggest that, among IVDUs, HTLV-II is an older endemic infection that is less efficiently transmitted than HIV.

HIV antibody in persons screened for syphilis: prevalence in a New York City emergency room and primary care clinics

An anonymous human immunodeficiency virus (HIV) seroprevalence survey was performed on bloods sent for syphilis serologic testing from the general medical or pediatric clinics or emergency room of a municipal hospital in the Bronx, New York City. From July-December 1987, 549 sera from persons aged 15-54 were collected. HIV antibody was detected in 29/549 (5.3%) sera, increased with age from 0% in the group under 20 to 16.7% in those aged 35-39, and was significantly higher in men (27/230, 11.7%) compared to women (2/319, 0.6%) (P less than .05). Among men aged 35-39, 10/29 (34.5%) were HIV infected. The HIV seroprevalence in emergency room sera was 8/61 (13.1%) versus 21/488 (4.3%) from the out-patient clinics (P less than .05). The presence of a reactive syphilis serology was strongly associated with HIV infection independent of gender (Mantel-Haenszel summary odds ratio (OR) 4.1, 95% CI [1.8, 7.7]) but was stronger for women with reactive syphilis serologies (OR 45.5, 95% CI 5.3, 387.6) than for men (OR 2.6, 95% CI 1.2, 5.8). AIDS prevention strategies may reach at-risk sexually active individuals by focusing on hospital-based emergency rooms and out-patients clinics in areas with high HIV seroprevalence.

A seroprevalence survey for human immunodeficiency virus antibody in mentally retarded adults

The prevalence of human immunodeficiency virus (HIV) infection among adults who are mentally retarded is not known. Policies for those in residential settings are being established despite incomplete information. Knowledge regarding HIV seroprevalence would enable administrators to make more effective policy decisions concerning testing and HIV prevention. Discarded sera from mentally retarded adults were anonymously tested for HIV antibody. Sera were collected from a health facility in Westchester County, NY, that provides care to developmentally disabled adults. After identifications were removed, sera were coded and linked to demographic and clinical variables from hospital and laboratory records. Sera came from individuals living in both institutional and less restrictive community settings in metropolitan New York City and more distant locations in New York State, all of whom were seen by the above facility. No HIV antibody was detected in sera from 241 mentally retarded adults. This study suggests that the prevalence of HIV antibody in mentally retarded adults is not high. Mandatory screening programs may not be appropriate for these individuals. Monies might be better spent on educational programs directed at AIDS prevention, and further development of ethical and safe policies for those who are mentally retarded.

Risk factors for human immunodeficiency virus infection in intravenous drug users

To identify risk factors for human immunodeficiency virus (HIV) infection in intravenous drug users, we undertook a study of the seroprevalence of HIV antibody in 452 persons enrolled in a methadone-treatment program in the Bronx, New York. The seroprevalence of HIV was 39.4 percent overall, 49.1 percent in blacks, 41.8 percent in Hispanics, and 17.2 percent in non-Hispanic whites (P less than 0.001 for all comparisons). The presence of HIV antibody was associated with the number of injections per month (P less than 0.001), the percentage of injections with used needles (P less than 0.001), the average number of injections with cocaine per month (P less than 0.001), and the percentage of injections with needles that were shared with strangers or acquaintances (P less than 0.001), a practice that was more common among blacks and Hispanics than among whites. The number of heterosexual sex partners who used intravenous drugs was associated with HIV infection in women (P less than 0.004) and was the only risk factor found for users who had not injected drugs after 1982 (P less than 0.05). The presence of HIV antibody was independently associated with being black or Hispanic (adjusted odds ratio, 4.56; 95 percent confidence interval, 2.65 to 8.14), a more recent year of the last injection of drugs (adjusted odds ratio, 1.24; 95 percent confidence interval, 1.13 to 1.35), the percentage of injections of drugs that took place in "shooting galleries" (adjusted odds ratio, 1.49; 95 percent confidence interval, 1.19 to 1.88), having sex partners who used intravenous drugs (adjusted odds ratio 1.24; 95 percent confidence interval, 1.06 to 1.45), and low income (adjusted odds ratio, 1.55; 95 percent confidence interval, 1.10 to 2.17). We conclude that differences in both the social setting of drug use and behavior related to injection carry different risks for infection with HIV and may explain, in part, the higher seroprevalence of HIV among blacks and Hispanics. In addition, we found that heterosexual activity was an independent risk factor for drug users.

Knowledge of HIV antibody status and decisions to continue or terminate pregnancy among intravenous drug users

We studied decisions to continue or terminate pregnancy among human immunodeficiency virus (HIV)-seropositive (+) and -seronegative (-) intravenous drug users informed of HIV antibody status before 24 weeks' gestation. Fourteen (50%) of 28 HIV+ vs 16 (44%) of 36 HIV- women chose to terminate their pregnancies. In retrospective interviews, HIV+ women were more likely to have perceived their risk of perinatal HIV transmission to be greater than or equal to 50% and, among those who terminated pregnancy, to cite this concern as an important factor in their decision. However, decisions to terminate pregnancy were predicted more readily by pregnancy-related variables such as prior elective abortion, a negative emotional reaction to pregnancy, and whether the pregnancy had been unplanned. Women who were HIV+ and chose to continue their pregnancies cited the desire for a child, religious beliefs, and family pressure as the most important factors in their decisions. Results indicate that while concerns about perinatal transmission of HIV may lead to decisions to terminate pregnancy in certain cases, there may be other determinants of pregnancy decisions in this population. Counseling of HIV-infected women must address not only perinatal transmission but also the sociocultural and behavioral context in which pregnancy decision making takes place.

Use of the polymerase chain reaction for early detection of the proviral sequences of human immunodeficiency virus in infants born to seropositive mothers. New York City Collaborative Study of Maternal HIV Transmission and Montefiore Medical Center HIV Perinatal Transmission Study Group

The early diagnosis of infection with human immunodeficiency virus (HIV) in infants born to infected mothers is essential for early treatment, but current tests cannot detect HIV infection in newborns because of the presence of maternal antibodies. We used the polymerase chain reaction, a new technique that amplifies proviral sequences of HIV within DNA, to detect HIV infection in peripheral-blood mononuclear cells obtained from infants of seropositive women during the neonatal (age less than 28 days) and postneonatal periods. In blood obtained during the neonatal period, the polymerase chain reaction was positive in five of seven infants in whom the acquired immunodeficiency syndrome (AIDS) later developed (a mean of 9.8 months after the test). The test was also positive in one of eight newborns who later had nonspecific signs and symptoms suggestive of HIV infection (mean follow-up, 12 months). No proviral sequences were detected in neonatal samples from nine infants who remained well (mean follow-up, 16 months). HIV proviral sequences were detected in samples obtained during the postneonatal period (median age, five months) in all of 6 infants tested who later had AIDS and in 4 of 14 infants with nonspecific findings suggestive of HIV infection. No proviral sequences were detected in 25 infants who remained well (mean follow-up, 17 months) after being born to HIV-seropositive mothers, or in 15 infants born to HIV-seronegative mothers. We conclude that the polymerase chain reaction will be a useful technique to diagnose HIV infection in newborns and to predict the subsequent development of AIDS. However, larger studies will be required to determine the sensitivity and specificity of the test.