Effects of region of birth, educational level and age on late presentation among men who have sex with men newly diagnosed with HIV in a network of STI/HIV counselling and testing clinics in Spain

This paper analyses late presentation (LP) of HIV infection, and its determinants, among men who have sex with men (MSM) in Spain, newly diagnosed with HIV (2003-2011) in 15 sexually transmitted infection/HIV counselling and testing clinics. LP was defined as <350 CD4 cells/µL or AIDS. In total, 3,081 MSM were included (2,499 having CD4/AIDS); overall LP was 25.3%. LP was higher in men older than 34 years, those not previously HIV-tested (adjusted odds ratio (aOR):3.1; 95% confidence intervals (CI):2.3-4.2) , and those tested > 12 months before diagnosis (12-24 months (aOR:1.4; 95% CI:1.0-2.0); > 24 months (aOR:2.2; 95% CI:1.7-3.0)). LP was less likely in MSM reporting a known HIV-infected partner as infection source or symptoms compatible with acute retroviral syndrome. 'Region of birth' interacted with 'educational level' and 'steady partner as infection source': only African and Latin-American MSM with low educational level were more likely to present late; Latin-American men attributing their infection to steady partner, but no other MSM, had LP more frequently. In Spain, HIV testing among MSM should be promoted, especially those > 34 years old and migrants with low educational level. The current recommendation that MSM be tested at least once a year is appropriate.

HIV/STI co-infection among men who have sex with men in Spain

In Spain, neither the HIV nor the STI national surveillance systems collect information on HIV/STI co-infection. However, there are two networks based on HIV/STI clinics which gather this data. We describe HIV prevalence in men who have sex with men (MSM) diagnosed with infectious syphilis and/or gonorrhoea in 15 STI clinics; and concurrent diagnoses of STI in MSM newly diagnosed with HIV in 19 HIV/STI clinics. In total, 572 MSM were diagnosed with infectious syphilis and 580 with gonorrhoea during 2005-2007. HIV prevalence among syphilis and gonorrhoea cases was 29.8% and 15.2% respectively. In the multivariate analysis, HIV/syphilis co-infection was associated with being Latin American; having a history of STI; reporting exclusively anal intercourse; and having sex with casual or several types of partners. HIV and gonorrhoea co-infection was associated with age older than 45 years; having no education or only primary education completed; and having a history of STI. In total, 1,462 HIV infections were newly diagnosed among MSM during 2003-2007. Of these, 31.0% were diagnosed with other STI at the same time. Factors associated with STI co-infection among new HIV cases in MSM were being Latin American; and having sex with casual partners or with both steady and casual partners. In Spain, a considerable proportion of MSM are co-infected with HIV and STI.

Noninvasive diagnosis of liver fibrosis in patients with HIV infection and HCV/HBV co-infection

The measurement of fibrosis stage critically affects the identification of the progression of liver disease, the establishment of a prognosis and therapeutic decision making. Liver biopsy has been the single, most useful method to determine the degree of liver fibrosis (LF), but with recognized limitations, mainly associated with its invasiveness. In recent years, alternative noninvasive methods have been developed, including imaging methods, such as transient elastometry, and assays based on serum biomarkers. This article reviews the available studies evaluating the value of various noninvasive methods for the assessment of LF in patients with HIV-infection and HBV/HCV co-infection, and makes recommendations on how to best use and combine them in clinical practice.

Oral complication risks after invasive and non-invasive dental procedures in HIV-positive patients

BACKGROUND

Limited published scientific evidence is available to provide guidance to clinicians on possible increased risks of invasive oral procedures associated with the human immunodeficiency virus (HIV) status of the patient. The aim of this study was to assess post-procedural complications in patients infected with HIV.

MATERIAL AND METHODS

This was a retrospective cross-sectional study of the records of 101 consecutive HIV patients treated at the School of Dentistry of Madrid Complutense University and Sandoval STD Clinic in Madrid between January 2003 and February 2005. Data were gathered by an experienced dental practitioner using a structured epidemiological questionnaire for information on gender, age, HIV transmission category, medical history, hepatitis B virus (HBV) or hepatitis C virus (HCV) coinfection and other diseases, TCD4+ and TCD8+ count, HIV viral load (VL), platelet count, neutrophil count, international normalized ratio and haemoglobin level; tobacco and alcohol intake, highly active antiretroviral treatment and presence of oral lesions. Information was also collected on complications related to dental treatment (invasive or non-invasive) during the previous 6 months. Chi-squared test and Fisher's exact test were used to establish statistical significance.

RESULTS

Data were gathered on 314 dental procedures in 101 patients. The overall complication rate was 2.2% (7/314); in 147 invasive procedures, seven complications (4.8%) were documented (one persistent pain, two prolonged bleeding, three infections, one bone sequestrum) including extractions, periodontal scaling, endodontic treatment and biopsy. No differences were found in TCD4+, TCD8+, platelet count, HBV or HCV co-infections or HIV VL between patients with and/or without complications. Patients with complications were mainly in B stage of HIV disease (P=0.020). Oral lesions and smoking habit>20 cig day-1 were documented in 83.3% (P=0.086) and 50% (P=0.060), respectively, of patients with complications.

CONCLUSIONS

The complication rate was 2.2% overall and 4.8% after invasive dental procedures. Presence of oral lesions, smoking habit or HIV clinical stage B may be predictive factors for oral complications in HIV patients. No relationship was found between complications and virological, immunological or other laboratory values. Studies with wider samples and negative control group are warranted to confirm the absence of an association between HIV positivity and higher risk of oral complications.

Oral transmission of HIV, reality or fiction? An update

Human immunodeficiency virus (HIV) and many other viruses can be isolated in blood and body fluids, including saliva, and can be transmitted by genital-genital and especially anal-genital sexual activity. The risk of transmission of HIV via oral sexual practices is very low. Unlike other mucosal areas of the body, the oral cavity appears to be an extremely uncommon transmission route for HIV. We present a review of available evidence on the oral-genital transmission of HIV and analyse the factors that act to protect oral tissues from infection, thereby reducing the risk of HIV transmission by oral sex. Among these factors we highlight the levels of HIV RNA in saliva, presence of fewer CD4+ target cells, presence of IgA antibodies in saliva, presence of other infections in the oral cavity and the endogenous salivary antiviral factors lysozyme, defensins, thrombospondin and secretory leucocyte protease inhibitor (SLPI).

Influence of age and geographical origin in the prevalence of high risk human papillomavirus in migrant female sex workers in Spain

OBJECTIVES

To estimate the prevalence and risk factors of high risk human papillomavirus (HPV) infection in migrant female sex workers (FSW) according to age and geographical origin.

METHODS

Cross sectional study of migrant FSW attending a sexually transmitted infection (STI) clinic in Madrid during 2002. Information on sociodemographic characteristics, reproductive and sexual health, smoking, time in commercial sex work, history of STIs, HIV, hepatitis B, hepatitis C, syphilis, and genitourinary infections was collected. High risk HPV Infection was determined through the Digene HPV Test, Hybrid Capture II. Data were analysed through multiple logistic regression.

RESULTS

734 women were studied. Overall HPV prevalence was 39%; 61% in eastern Europeans, 42% in Ecuadorians, 39% in Colombians, 29% in sub-Saharan Africans, and 24% in Caribbeans (p = 0.057). HPV prevalence showed a decreasing trend by age; 49% under 20 years, 35% in 21-25 years,14% over 36 years% (p<0.005). In multivariate analyses, area of origin (p = 0.07), hormonal contraception in women not using condoms (OR 19.45 95% CI: 2.45 to 154.27), smoking, age, and an interaction between these last two variables (p = 0.039) had statistically significant associations with HPV prevalence. STI prevalence was 11% and was not related to age or geographical origin.

CONCLUSIONS

High risk HPV prevalence in migrant FSW is elevated and related to age, area of origin, and use of oral contraceptives in women not using condoms. These data support the role of acquired immunity in the epidemiology of HPV infection and identifies migrant FSW as a priority group for sexual health promotion.

Plasma RNA viral load is not associated with intrapatient quasispecies heterogeneity in HIV-1 infection

The human immunodeficiency virus type 1 (HIV-1) viral set point has been associated with the rate of, disease progression and with the level of HIV-specific immune response. The analysis of the possible association between viral set point and quasispecies heterogeneity has important consequences in the understanding of HIV-1 in vivo evolution. In this study, we analyzed the association between intrapatient viral diversity and RNA viral load in 16 antiretroviral therapy-naive HIV-1-infected patients at a single time point, during the disease free period. Patients were separated into low and high viral load groups according to plasma RNA values. HIV-1 quasispecies complexity was assessed in the C2-V5 env region. The average intrapatient quasispecies heterogeneity in both groups was not significantly different (t-test, P > 0.05). However, while within the low viral load group both synonymous and non-synonymous mutations contribute to the variation observed, in the heterogeneity observed in the high viral load group there was an increase in the contribution of the non-synonymous mutations. Thus, this study show that although intrapatient quasispecies heterogeneity is not associated with viral set point in HIV-1 infection, some differences exist between the two groups in the pattern of mutation accumulation.

[Women who are partners of a man infected by HIV: description of their characteristics and appraisal of risk]

OBJECTIVE

To describe the situations of risk and the prevalence of HIV in women with a heterosexual partner infected by HIV.

DESIGN

Cross-sectional descriptive study.

SETTING

Out-patient HIV diagnosis centre in Madrid.

PATIENTS

229 women seen for the first time between 1993 and 2002 because they had a stable heterosexual partner diagnosed with HIV, and who were exposed to no other risk.

MAIN MEASUREMENTS

Social and personal details, reproduction history, sexual conduct, clinical, and analytic data of both partners.

RESULTS

66% of couples had maintained sexual relations for over a year. Women were on average younger (29.6 years old) than the men. 29% of the women had children and 5.2% were pregnant. 82% of men had injected drugs, but only 13% still did. 73% had been diagnosed with HIV for over 6 months, 16% had AIDS criteria, and 35% were taking retroviral treatment. 60% of the men who knew of their infection had systematically avoided sex without condoms, against 33% of those who did not know they were infected (P<.001). 19% had had accidents in use of the condom. HIV seroprevalence in the women was 6.1% (95% CI, 3.5%-10.3%).

CONCLUSIONS

Health care of people with HIV must include care of their sexual partner, involving information, psychological support, preventive and reproductive advice, as well as diagnosis of HIV or other sexually transmitted diseases.

[Imputation of the date of HIV seroconversion in cohorts of haemophiliacs]

OBJECTIVES

To describe the methods used to impute HIV seroconversion date in the haemophiliac cohorts from GEMES project and to validate its use.

METHOD

632 haemophiliacs coming from three hemophilia units identified as HIV+ and 1.092 individuals coming from 5 project GEMES cohorts with a seroconversion window (time among test HIV and HIV+) less than 3 years where mid point (PM) was assumed as seroconversion date. For both groups, seroconversion date was imputed after estimating the probability distribution of seroconversion by means of the EM algorithm. Two imputation methods are used: one obtained from the expected value and the other from the geometric mean of 5 random samples. from the estimated distribution. Imputations have been validated in the non haemophiliacs cohorts comparing with the PM seroconversion date. Also AIDS free time and survival from the different seroconversion imputed dates were compared.

RESULTS

Median seroconversion date is located in May of 1993 for the non haemophiliacs and in 1982 for the haemophiliacs. Not big differences are observed among the imputed seroconversion dates and the mid-point seroconversion date in the non-haemophiliac cohorts. Similar results are found for the haemophiliac cohorts. Also no differences are observed in the estimated AIDS-free time for both groups of cohorts.

CONCLUSIONS

Geometric mean imputation from several random samples provides a good estimate of the HIV seroconversion date that can be used to estimate AIDS-free time and survival in haemophiliac cohorts where seroconversion date is ignored.

Sentinel surveillance of HIV infection in HIV test clinics, Spain 1992-2002

HIV infection in Spain was monitored in persons undergoing voluntary HIV testing in ten sentinel clinics between 1992 and 2002. Only patients on their first visit were considered for inclusion, and their numbers rose from 4426 in 1992 to 6649 in 2002. Most of them recognised their risk exposure as heterosexual. The proportion of injecting drug users decreased from 19% to 2% of the study population, and the proportion of female sex workers increased from 6% to 26%. The number of patients diagnosed with HIV infection declined from 604 in 1992 to 153 in 2002, and HIV prevalence fell from 13.6% to 2.3% in the same period. In all risk exposure categories, a decrease in HIV prevalence was observed, more pronounced during the first few years and stabilised in the later years. In 2002, the highest HIV prevalence was found in injecting drug users (IDUs) (14.2%), homo/bisexual men (7.5%) and individuals who had an HIV infected heterosexual partner (10.2%).

Sentinel surveillance of HIV infection in HIV test clinics, Spain 1992-2002

HIV infection in Spain was monitored in persons undergoing voluntary HIV testing in ten sentinel clinics between 1992 and 2002. Only patients on their first visit were considered for inclusion, and their numbers rose from 4426 in 1992 to 6649 in 2002. Most of them recognised their risk exposure as heterosexual. The proportion of injecting drug users decreased from 19% to 2% of the study population, and the proportion of female sex workers increased from 6% to 26%. The number of patients diagnosed with HIV infection declined from 604 in 1992 to 153 in 2002, and HIV prevalence fell from 13.6% to 2.3% in the same period. In all risk exposure categories, a decrease in HIV prevalence was observed, more pronounced during the first few years and stabilised in the later years. In 2002, the highest HIV prevalence was found in injecting drug users (IDUs) (14.2%), homo/bisexual men (7.5%) and individuals who had an HIV infected heterosexual partner (10.2%).

Consensus conference on chronic viral hepatitis and HIV infection: updated Spanish recommendations

Chronic hepatitis B and C represent a leading cause of morbidity and mortality among human immunodeficiency virus (HIV)-infected patients worldwide. New treatment options against both hepatitis B (HBV) and C (HCV) viruses have prompted us to update previous recommendations for the management of coinfected individuals. Fifteen topics (nine related to HCV, five to HBV and one to both viruses) were selected for this purpose. A panel of Spanish experts in the field was invited to review these areas and propose specific recommendations, which were scored according to the Infectious Disease Society of America (IDSA) grading system. These guidelines represent a comprehensive and updated overview on the management of hepatitis B and C in HIV-infected patients.

Absence of hepatitis C virus transmission in a prospective cohort of heterosexual serodiscordant couples

OBJECTIVE

To analyse hepatitis C virus (HCV) transmission in a cohort of heterosexual couples who are discordant both for HIV and for HCV.

METHODS

We followed an open cohort of 171 people, 152 women and 19 men, who were not initially infected by either HIV or HCV, and whose steady heterosexual partner presented antibodies to both viruses (index case). Other risk exposures were excluded. Every 6 months clinical, epidemiological, and risk behaviour information was collected, and antibodies to both viruses were determined.

RESULTS

During 529 person years of follow up more than 40 000 vaginal or anal penetrations were recorded. 74 partners (43.3%) had vaginal and/or anal intercourse without condoms with the index case; another 15.8%, who always used condoms, declared breaking or slipping episodes during intercourse; and another 22.2% had unprotected orogenital exposures. During the follow up, over 5800 unprotected vaginal and anal contacts with the index case were estimated, as well as more than 25 000 unprotected orogenital contacts. 31 women became pregnant (two were index cases), and seroconversion to HIV occurred for one woman (1.7 per 10 000 unprotected contacts; 95% CI, 0 to 9.5), but there was no seroconversion to HCV (95% CI, 0-6.3 per 10 000 unprotected contacts).

CONCLUSION

These results are consistent with a low or null transmissibility of HCV in heterosexual relations, even when the index case is HIV co-infected.

[HIV prevalence among homosexual and bisexual men in Spain, 1992-2000]

BACKGROUND

Our purpose was to describe the time trend in HIV seroprevalence among homo/ bisexual men.

SUBJECTS AND METHOD

We analyzed 9,383 homo/ bisexual men who had a first voluntary test for HIV in 10 Spanish clinics from 1992 to 2000.

RESULTS

HIV prevalence decreased from 20.3% in 1992 to 8.4% in 2000. In the multivariate analysis this decline appeared independently associated with the testing year and the birth cohort.

CONCLUSIONS

New generations of voluntarily tested homo/bisexual men are less infected by HIV, but it is yet necessary to intensify the prevention programs.

Factors influencing HIV progression in a seroconverter cohort in Madrid from 1985 to 1999

OBJECTIVE

To study HIV progression from seroconversion over a 15 year period and measure the population effectiveness of highly active antiretroviral therapy (HAART).

METHODS

A cohort study of people with well documented dates of seroconversion. Cumulative risk of AIDS and death were calculated by extended Kaplan-Meier allowing for late entry. Cox proportional hazards models were used to study variables associated with HIV progression. To assess the impact of HAART, calendar time was divided in three periods; before 1992, 1992-6, and 1997-9.

RESULTS

From January 1985 to May 2000, 226 seroconverters were identified. The median seroconversion interval was 11 months, median seroconversion date was March 1993. 202 (89%) were men, 76% of whom were homo/bisexual. A 66% reduction in progression to AIDS was observed in 1997-9 compared to 1992-96 (HR 0.34 95% CI: 0.16 to 0.70). People with primary education appeared to have faster progression to AIDS compared to those with university studies (HR 2.69 95%CI: 1.17 to 6.16). An 82% reduction in mortality from HIV seroconversion was observed in 1997-9 (HR 0.18 95% CI: 0.05 to 0.68) compared to 1992-6. Progression to death for people with primary education was twice as fast as for those with university education (p 0.0007). People without confirmation of an HIV negative test had faster progression (HR 4.47 95% CI: 1.18 to 16.92).

CONCLUSIONS

The reduction in progression to AIDS and death from seroconversion from 1992-6 to 1997-9 in Madrid is likely to be attributable to HAART. HIV progression was faster in subjects with primary education; better educational level may be associated with better adherence to medication.

Time trend in incidence of HIV seroconversion among homosexual men repeatedly tested in Madrid, 1988--2000

An open cohort of 2670 homosexual men repeatedly tested for HIV at a Madrid clinic has registered 8050 person-years (PY) of follow-up and 157 seroconversions from 1988 to 2000. After declining from 1988 (4.71 per 100 PY), the incidence rate began a significant upward trend, reaching a figure of 2.16 per 100 PY in 2000. These findings ought to alert surveillance systems and prevention programmes.

Prevalence and distribution of HHV-8 in different subpopulations, with and without HIV infection, in Spain

OBJECTIVE

To estimate the seroprevalence of HHV-8 in several Spanish subpopulations with different risk levels of acquiring HIV-1 infection and from different geographical regions.

DESIGN

Cross-sectional seroprevalence study.

METHODS

A total of 1699 serum samples from blood donors (613), children under the age of 12 years (100), injecting drug users (IDU) (382), heterosexuals attending a sexually transmitted disease (STD) clinic (273) and homosexual men attending a STD clinic or a HIV-based hospital unit (331) were analysed for anti-HHV-8 antibodies. The presence of antibodies against HHV-8 was tested with an indirect immunofluorescence assay (IFA). A subsample of HHV-8-positive samples was also tested for antibody titre against HHV-8.

RESULTS

The overall seroprevalence of antibodies against HHV-8 for the blood donor population was 6.5% (7.0% in Andalusia, 8.0% in Catalonia and 4.5% in the Basque Country). None of the children tested positive for HHV-8. The HHV-8 prevalence was 86.7% in HIV-positive homosexual men and 28.0% in HIV-negative homosexual men (P < 0.001). Of heterosexual men attending STD clinics, 17.2% tested positive for HHV-8; 11.5% of IDU tested positive for HHV-8. HHV-8 antibody titres by groups parallel the distribution of HHV-8 prevalence. No association between HHV-8 antibody titres and CD4 cell count or HIV viral load was identified.

CONCLUSIONS

The HHV-8 prevalence among blood donors in Spain is higher than in Northern Europe and the USA, but is similar to that in Northern Italy. The distribution of HHV-8 is compatible with a sexually transmitted agent. The distribution of HHV-8 correlates with that of Kaposi's sarcoma but factors other than HHV-8 seem to explain the Kaposi sarcoma distribution.

[HIV seroprevalence and exposure categories among adolescents tested at a sexually transmitted clinic diseases. Madrid, 1986-2000]

OBJECTIVE

To describe the time-trend in exposure categories and HIV seroprevalence among adolescents who underwent to voluntary testing in the period 1986-2000.

METHODS

This study covered all adolescents, aged 13 to 19 years, at their first test for HIV in a sexually transmitted disease clinic in Madrid. Gender, age and HIV risk behaviours were collected. HIV diagnosis relies on ELISA test and Western blot confirmation. Time trends in HIV seroprevalence and exposure categories were analysed.

RESULTS

A total of 1327 adolescents, 52% women and 22% under 18 years, were studied. The annual number of adolescents remained through the time, but injecting drug users (IDU) and IDU partners declined and female sex workers rose. 108 adolescents were diagnosed with HIV infection -71% were IDU-. HIV seroprevalence was 8.1% -31.3% in IDU-. It declined from 18.2% in 1986 to 1.5% in 1995, and after then it held steady under 4%. This decline involved several risk categories and was statistically significant in homo/bisexual men and female sex workers. The logistic regression analysis, adjusting for changes in exposure categories, showed an annual reduction in HIV seroprevalence (OR = 0.87; 95% CI, 0.81-0.94).

CONCLUSIONS

HIV seroprevalence has decreased due to the fall of new young IDU and the decrease of seroprevalence within several exposure categories. HIV infections and risk behaviours continue happened among adolescents.

Primary genotypic and phenotypic HIV-1 drug resistance in recent seroconverters in Madrid

OBJECTIVE

Transmission of drug-resistant HIV-1 strains is increasing with widespread use of antiretroviral drugs in developed countries. This study examined the prevalence of resistant viruses in recent seroconverters in Madrid, Spain.

DESIGN

HIV isolates from 30 consecutive participants with positive or indeterminate HIV antibody test results and a negative test result at a mean of 6.6 months earlier were examined for HIV drug resistance. All study subjects admitted to having very recently engaged in high-risk practices. All were therapeutically naive and were recruited between 1997 and 1999 in a referring health care facility for sexually transmitted diseases.

METHODS

Population-based sequencing of the viral reverse transcriptase (RT) and protease (PR) regions derived from plasma viral RNA was performed. Phenotypic resistance was assessed by a recombinant virus assay.

RESULTS

Overall prevalence of genotypes associated with reduced susceptibility was 26.7% (8 of 30 participants). Resistance mutations were seen against nucleoside analogues in 7 (23.3%), nonnucleoside reverse transcriptase inhibitors in 1 (3.3%), and protease inhibitors in 2 (6.7%). Zidovudine-resistance mutations M41L and/or T215Y were the commonest, found in 20% (6 of 30 participants). Resistance mutations to at least two antiretroviral families (multidrug-resistance) were detected in 2 (6.7%) study subjects. A median infectious dose (IC50) increase of fourfold for any drug was found in 7 patients, and in 2 was > tenfold for zidovudine (genotype M41L + T215Y) and lamivudine (genotype M184V), respectively.

CONCLUSIONS

Drug-resistant HIV variants were present in over one quarter of individuals recently diagnosed as infected in Madrid, Spain. Therefore, resistance testing at baseline should be considered for the optimal design of first-line antiretroviral combinations.

Genetic analysis of HIV-1 samples from Spain

To characterize the viruses responsible for the HIV-1 epidemic in Spain, we genetically characterized 79 samples obtained from Spanish patients with different risk practices (injecting drug users and male homosexuals) in two regions (Madrid and Navarra). Genetic characterization was carried out by nucleotide sequencing in the C2-V3-C3 region and by phylogenetic analysis. All samples were of subtype B except one that clustered with clade F. Because no segregation of samples was determined according to the risk group of patients nor to their geographic origin, the Spanish samples analyzed constitute a single group of viruses. These data, along with the starlike topology of the phylogenetic tree, support the existence of a single introduction of HIV-1 subtype B in Spain. The mean genetic distance among subtype B sequences was of 13.9%+/-0.06% (range, 5%-25%), suggesting an epidemic of long evolution. Analysis of sequences in relation to isolation dates revealed an increase in the heterogeneity of the nucleotide sequences with time. According to these data, a divergence rate of 0.49%+/-0.11% per year was calculated for the Spanish samples during the period analyzed.

Heterosexual transmission of HIV-1 is associated with high plasma viral load levels and a positive viral isolation in the infected partner

Risk factors for heterosexual HIV transmission are not fully understood. In fact, a proportion of people with sexual exposure to HIV remain uninfected despite multiple and continuous intercourse with HIV-infected partners. In this work, we have analyzed those virologic parameters potentially involved in the transmission of HIV through heterosexual contact. Thirty-eight couples with continuous unprotected sexual intercourse were included. HIV transmission occurred in 10 of 38 couples. No differences in clinical characteristics, exposure time, sexual practices, CD4 counts, or polymorphism in CCR5 were found between transmitter and nontransmitter groups. In contrast, virologic data were different between both groups; median values of viral load were 21.139 and 5.484 RNA copies/ml of plasma in the transmitter and nontransmitter groups, respectively, and a significant difference was found in mean viral load values (p = .03, Mann-Whitney test). Viral isolation was obtained in 90% of transmitters, but in only 44% of nontransmitter subjects (p = .02, Fisher's exact test). These data show that viral load levels and a positive viral isolation in culture must be considered as risk factors for heterosexual transmission of HIV-1.

[Trends in human immunodeficiency virus infection prevalence in homosexual/bisexual men in Madrid (1986-1995)]

BACKGROUND

We analysed the trend in seroprevalence for human immunodeficiency virus (HIV) in homosexual or bisexual men who voluntary requested the test in a sexually transmitted disease/HIV clinic in Madrid.

PATIENTS AND METHODS

We studied 5,424 homo/bisexual non-injecting drug user (non-IDU) men, who came for the first time since 1986 to 1995. We analysed the HIV seroprevalence taken into account the year, age and exchange of sex by money. A hundred and thirty-six IDU homo/bisexual men were also attended during the same period and they were compared with non-IDU.

RESULTS

HIV seroprevalence among the 5,424 non-IDU homo/bisexual men were 20.2%, rising from 19.6% in 1986 to 29.6% in 1990. After then, the trend decreased to 15.3% in 1995 (chi 2 for trend, 66.8; p < 0.0001). Average age was three years higher among seropositives (p < 0.0001), and showed an upward trend from 29.9 in 1986 to 34.6 in 1995 (p = 0.0059). Seroprevalence among homosexuals younger than 25 fell in the last years. One percent of individuals had ever practiced the prostitution. They were younger (average age, 27.6), and their HIV seroprevalence were 25.9%. A hundred and thirty-six IDU homo/bisexual men were also attended for the first time, being 2.4% of overall homo/bisexual men. They had a higher seroprevalence (48.5%) than non-IDU (p < 0.0001), and did not show any significative time-trend.

CONCLUSIONS

A favourable evolution can be observed in HIV seroprevalence among homo/bisexual from Madrid, Spain, men who came to be tested, especially among the youngest. Prevention programs should make an effort to maintain this trend.

[Rapid and slow progression of the infection by the type 1 human immunodeficiency virus in a population of seropositive subjects in Madrid]

BACKGROUND

The rate of progression to AIDS in HIV-1 infected subjects is variable, and circumstances associated with more rapid or slow development of severe immunodeficiency might be grouped in three categories; environmental cofactors, host features, and particular virulence of the virus itself. Currently, it is not yet clear the the relative impact of each one.

PATIENTS AND METHODS

A cross-sectional study was done in a cohort of 1,783 IV-1 infected persons from three centers located in Madrid, mainly devoted to attend persons at risks for HIV infection. Long-term nonprogressors (LTNP) were defined as those with more than 8 years of confirmed HIV seropositivity, and CD4+ T-cell count above 500 x 10(6)/I in the absence of antiretroviral therapy or symptoms suggesting immunodeficiency. Rapid progressors (RP) were those with less than 5 years from seroconversion and repeatedly current CD4+ T-cell count below 200 x 10(6)/I. An analysis of different epidemiological, immunological and virological features was performed comparing LTNP and RP.

RESULTS

Among 1,783 HIV (+) subjects studied, 100 (5.6%) fulfilled criteria for LTNP and 12 (0.7%) for RP. Among LTNP, stabilized CD4 slope was seen in 16 (33%) out of 48 after more than 8 years of infection. Variables statistically associated with LTNP were: past history of intravenous drug addiction (80% of them), male gender (79% of them), high alcohol intake (48% of them), HIV-1 non-syncitium inducing viral phenotype, and very low or undetectable HIV-1 plasma viremia. In contrast, variables associated with RP were: infection by sexual contact (75% of cases), female gender (50% of them), syncitium-inducing viral plenotype, and high titers of plasma viremia. The CD4/CD8 ratio below 1 was seen in all RP and in 88% of LTNP. However, a preferent depletion of CD4+ cell occurred in the first group, instead of an enhancement of the CD8 T-cell count in LTNP. The prevalence of serological markers for hepatotropic viruses and other potential infectious cofactors was not higher in RP.

CONCLUSIONS

Multiple factors seems to account for the different rate of disease progression observed in HIV-1 infected persons. The dynamic equilibrium between the immune system and the virulence of the virus seem to be influenced--but not determined--by environmental infectious or non infectious cofactors.

Epidemiology of human T-lymphotropic virus type II (HTLV-II) infection in Spain. HTLV Spanish Study Group

The human T-lymphotropic virus type II (HTLV-II) has recently been associated with the genesis of some subacute neurological syndromes and, rarely, with atypical T-lymphoid malignancies. The virus is endemic in some Amerindian and African tribes, and among intravenous drug users (IDUs) in North America and Europe. Given that HTLV-II is transmitted by the same routes as other human retroviruses, the screening of antibodies to HTLV-II in blood donors has became a matter of controversy in some countries. Herein, we describe the clinical, epidemiological and virological features of 113 individuals with HTLV-II infection identified in Spain up to September 1995. Most of them (94/113; 83%) were male, and all but seven were natives. Four were African immigrants living in Madrid and 3 had been born in other European countries. All but six subjects were IDUs, and sexual transmission of HTLV-II and transfusion were involved in five and one individual, respectively. Eighty-four percent of the IDUs infected with HTLV-II were co-infected by HIV-I (93/107). Clinical manifestations potentially linked to HTLV-II were absent, although an IDU male co-infected by HIV-1 and HTLV-II developed a severe non-inflammatory proximal myopathy. In conclusion, HTLV-II infection is present in Spain, mainly among IDUs, with a growing incidence and a current overall prevalence of 2.0 percent.

Interferon alpha for the treatment of chronic hepatitis C in patients infected with human immunodeficiency virus. Hepatitis-HIV Spanish Study Group

Liver disease secondary to hepatitis C virus (HCV) infection is a rising cause of morbidity and mortality among individuals who have been infected parenterally with human immunodeficiency virus (HIV) such as injection drug users, hemophiliacs, and transfused patients. We analyzed both the efficacy of interferon (IFN) alpha therapy in these patients and the predictors of response to this agent. A total of 119 patients with chronic hepatitis C (90 of whom were infected with HIV and 29 of whom were not) were included in a multicenter, prospective, open, nonrandomized observational study. IFN-alpha was given subcutaneously in a dosage of 5 million units three times a week during a 3-month period; those patients who responded received a dose of 3 million units given subcutaneously three times a week for an additional 9 months. One hundred seven patients completed the study; the level of aminotransferases returned to normal and sera became negative (complete response) for HCV RNA in 26 (32.5%) of 80 HIV-infected patients and 10 (37.0%) of 27 non-HIV-infected patients (P = .666) after completion of the treatment. Two variables were independently associated with a response in HIV-infected patients: a CD4+ T lymphocyte count of > 500 x 10(6)/L and a baseline HCV viremia level of < 10(7) copies/mL. In the 12 months following treatment, relapses occurred in 30.8% of the HIV-infected patients and 12.5% of non-HIV-infected patients (P = .403).

Are homosexual males a risk group for hepatitis A infection in intermediate endemicity areas?

The purpose of this study was to examine the prevalence of antibody against hepatitis A (anti-HAV) in a population of homosexual men compared with that of heterosexual men in an area of intermediate HAV endemicity (Madrid, Spain). A total of 148 patients were recruited in a Sexually Transmitted Diseases Clinic: 74 homosexuals (mean age of 28 +/- 5 years) and 74 heterosexuals (29 +/- 5 years). The prevalence of anti-HAV antibody was 47% and 43% for homo- and heterosexuals, respectively. Among the factors evaluated (age, sexual orientation and practices, travel to high HAV endemicity areas) oral-anal contact was significantly associated with a higher prevalence of anti-HAV antibody (odds ratio, 2.8; 95% confidence interval, 1.1-7.4; P = 0.03). These results indicated that in an area of intermediate endemicity young homosexual men are not at increased risk of having acquired hepatitis A infection than heterosexuals. Oral-anal contact is an independent risk factor that influences the presence of anti-HAV antibody, regardless of sexual orientation.

[The treatment of chronic hepatitis C with interferon in patients infected with the human immunodeficiency virus. The Spanish Group for the Study of Viral Hepatitis in HIV+ Patients]

BACKGROUND

Alfa-interferon (aIFN) is widely recommended for the treatment of chronic hepatitis C (CHC). Hepatitis C virus (HCV) infection is very common in injecting drug users (IDUs), which in Spain represent the large number of HIV-infected persons. Interaction between human immunodeficiency virus (HIV) and HCV in coinfected patients might accelerate the clinical course of HCV-associated liver disease. The efficacy and safety of aIFN therapy in HIV-infected patients with CHC is not well known.

PATIENTS AND METHODS

In a multicenter, prospective, open, non randomized and partially controlled study, we compared the efficacy and safety of aIFN therapy in 119 patients with CHC, of whom 90 were HIV-positive and 29 HIV-negative. Interferon was started at 5 mega U tiw for 3 months, followed in responders by 3 megaU tiw for additional 9 months.

RESULTS

One hundred seven patients completed the study. A normalization of the aminotransferase values at the end of treatment (complete response, CR) was observed in 26/80 (32.5%) HIV-positive and 10/27 (37.0%) HIV-negative individuals (p = 0.666). Relapses at 12 months of stopping aIFN were seen in 30.8% of HIV-positive subjects and 12.5% of HIV-negatives (p = 0.403). Side effects were uncommon and did not have severity; only one patient required to stop the medication. However, 3 HIV-positive subjects treated with aIFN (3.5% of them) showed an irreversible fall of CD4+ T-cells below half the baseline values.

CONCLUSION

HIV-infected patients with CHC seems to respond to aIFN with a similar rate than HIV-negatives. Moreover, the drug is similarly well tolerated in both groups of patients, although a fall of CD4+ T-cells is an unusual side effect of particular relevance observed in HIV-infected patients.

[The quantification of human immunodeficiency virus viremia in patients with rapid and slow progression of the disease]

BACKGROUND

The natural course of the human immunodeficiency virus type 1 (HIV-1) infection is very variable. The factors which appear to determine the speed of immunodeficiency progression are multiple, although the virulence of the predominant viral strain seems to be one the main factors. The plasmatic viremia in individuals with rapid and slow HIV-1 progression was analyzed in an attempt to establish the degree of correlation between HIV-1 replication and the natural course of the disease.

METHODS

Forty-two samples from 34 seropositive patients, 11 with rapid progression criteria (< 5 years from acute infection and CD4+ lymphocytes < 0.2 x 10(9)/l) and 23 with slow progression (> 7 years from demonstrated infection and > 0.5 x 10(9) CD4+ lymphocytes/l) were studied. The plasmatic viremia was quantified by a new method of plasma DNA genetic amplification, denominated the branched DNA (bDNA) technique. As a reference circulating p24 was determined and the presence of several proviral regions were studied in peripheral blood lymphocytes by polymerase chain reaction (PCR).

RESULTS

The presence of RNA molecules was detected in plasma of 7 (58.3%) out of 12 samples of rapid progression (RP) patients by bDNA. To the contrary, this was negative in 30 samples from slow progression (SP) patients. Four of the 5 negative RP samples corresponded to patients who had taken antiretroviral drugs at the time of the study. The p24 antigenemia was positive in 5 (41.6%) from the RP patients and in none of the SP patients. The presence of gag, pol and env sequences was positive by PCR in all RP patients and in most of the SP patients. However, repeatedly negative results by PCR were observed in 5 SP samples for all or some of the genomic regions studied.

CONCLUSIONS

Patients with rapid progression of HIV-1 have higher plasmatic viremia than subjects with slow disease progression.

Compliance with immunization against hepatitis B. A pragmatic study in sexually transmitted disease clinics

The efficacy of a vaccine is based primarily on the adherence of the subject to the immunization schedule. This paper compares the compliance rates (CR) for the third dose of hepatitis B virus (HBV) vaccine given according to one of two vaccination schedules among subjects attending two sexually transmitted disease (STD) clinics, and the potential influence of place of vaccine administration (STD clinic or at a vaccination centre). Heterosexual, anti-HBc seronegative subjects (n = 331) were randomized to a 0-1-6 month (n = 161) or a 0-1-2-12 month schedule (n = 170) in this prospective, randomized, parallel pragmatic study. Some subjects (n = 50) attended and were vaccinated at one STD clinic (centre A), whereas 281 attended another clinic (centre B) but were referred to a vaccination centre for administration of vaccine. About 31% (103/331) of the subjects received at least three vaccine doses. On assessing the CR at the 3rd dose in all randomized subjects, we observed that administration of the vaccine at the STD clinic attended (A) was associated with a significantly better CR (p < 0.01) than that of the subjects referred to a vaccination centre (B), while the CR is not affected by the schedule. On the other hand, the 0-1-2-12 schedule was associated with a significantly better CR (p = 0.02) at the 3rd dose than the 0-1-6 month schedule among subjects who comply with the first two doses; the actual site of vaccine administration (in situ (A) versus referred (B)) does not affect the CR.(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment with recombinant alpha-interferon of chronic hepatitis C in anti-HIV-positive patients

A pilot study of chronic hepatitis C treatment was conducted in 14 patients (13 had chronic active hepatitis and 1 had liver cirrhosis). All patients were asymptomatic for the human immunodeficiency virus (HIV) type 1 (mean CD4 count of 584 +/- 283 cells/mm3). Patients received 9 MU rIFN-alpha 2A per day for three months. After this, patients received 9 MU three times weekly for three months, 6 MU for another three months on the same protocol, and finally 3 MU again three times weekly for the last three months. After the first month of ALT treatment in 9 patients (64%) returned to normal; a significant decrease in ALT levels was observed with respect to the pretreatment values (mean of 42 IU/l, range 15-75 vs 152 IU/l, range 69-355; P < 0.01). Of the 9 patients who completed the treatment period, 5 had a complete response, and 4 of these 5 continued with normal ALT values during follow-up (sustained response) while the other patient relapsed within one month after cessation of therapy. The remaining 4 patients were non-responders (including one case with a break-through of the response). HCV-RNA was not detectable in 3 of the 5 responders at the end of therapy while during follow-up viral RNA became undetectable in the other 2 patients. 2/4 non-responder patients had detectable HCV-RNA during follow-up. Liver histology improved in all the patients. No changes were observed in the immunological status or HIV infection.

[Heterosexual transmission of HIV infection, Madrid 1987]

Seven males of 132 (5%) and 9 females of 85 (10%) out of 217 heterosexual individuals without addiction to drugs or previous blood transfusion who attended a STD clinic in Madrid because they had high risk sexual partners were found to have antiHIV antibodies by ELISA and immunofluorescence (CNMVIS). However, when variables such as sex, promiscuity and sexual habits were correlated with HIV infection, significant differences were not found between seropositive and seronegative individuals (kappa 2, p greater than 0.05). Among the factors statistically linked with the infection (kappa 2, p less than 0.05) there were the previous STD and the sustained sexual intercourse with proven HIV seropositive individuals: there 8 infected individuals out of 40 with such type of partners (relative risk 4.4). On the other hand, the partners of individuals with unknown serological findings had the following results: 4 seropositive individuals out of 71 partners of parenteral drug abusers, 3 of 82 users of prostitutes, and 1 infected individual out of the 24 remaining ones (partners of bisexual individuals or combinations) (relative risk of each of them less than 1). These results show the importance of heterosexual, not mediated by blood, HIV transmission in couples of high risk persons, and they suggest that the infection is highly likely if sexual intercourse is maintained with infected individuals irrespective of their sex.