An Asynchronous, Mobile Text-Based Platform (XatJove Anoia) for Providing Health Services to Teenagers: Protocol for a Quasiexperimental Study

Background

Due to the COVID-19 pandemic, it is more essential than ever to implement protective measures in primary care centers to ensure patients’ safety. This protocol describes a quasiexperimental study on the use of a mobile chat platform as a clinical consultation tool for adolescents and primary health care physicians.

Objective

The purpose of the quasiexperimental study is to demonstrate that the use of mobile phones and messaging apps increases the number of health consultations. The study will be performed as part of the Health and School program in the Anoia region.

Methods

The quasiexperimental study will compare the number of face-to-face consultations to the number of consultations conducted on XatJove Anoia, as part of the Health in Schools program in the Anoia region. The study will involve the use of a new communication platform (ie, XatJove Anoia) for health care professionals and adolescents, and data on the number of face-to-face consultations will be collected as part of the same program in another region. Data will be collected from secondary schools during the academic year 2020-2021. Statistical analyses will be performed on the data that users will enter in the registration form. These data will be collected by means of a questionnaire, which will be submitted once the questionnaire is closed. The questionnaire will consist of multiple-choice questions, which will allow numerical values to be assigned to various responses in order to carry out statistical analyses.

Results

The study is projected to start at the beginning of November 2020 and finish in June 2021, which is when data analysis is expected to start.

Conclusions

The results of the quasiexperimental study may assist in the development and planning of school health programs.

Trial Registration

ClinicalTrials.gov NCT04562350; https://clinicaltrials.gov/ct2/show/NCT04562350.

International Registered Report Identifier (IRRID)

PRR1-10.2196/25062

[Predictive value and sensibility of hospital discharge system (PMSI) compared to cancer registries for thyroïd cancer (1999-2000)]

BACKGROUND

Cancer registries have a complete recording of new cancer cases occurring among residents of a specific geographic area. In France, they cover only 13% of the population. For thyroid cancer, where incidence rate is highly variable according to the district conversely to mortality, national incidence estimates are not accurate. A nationwide database, such as hospital discharge system, could improve this estimate but its positive predictive value and sensibility should be evaluated.

METHODS

The positive predictive value and the sensitivity for thyroid cancer case ascertainment (ICD-10) of the national hospital discharge system in 1999 and 2000 were estimated using the cancer registries database of 10 French districts as gold standard. The linkage of the two databases required transmission of nominative information from the health facilities of the study. From the registries database, a logistic regression analysis was carried out to identify factors related to being missed by the hospital discharge system.

RESULTS

Among the 973 standardized discharge charts selected from the hospital discharge system, 866 were considered as true positive cases, and 107 as false positive. Forty five of the latter group were prevalent cases. The predictive positive value was 89% (95% confidence interval (CI): 87-91%) and did not differ according to the district (p=0,80). According to the cancer registries, 322 thyroid cancer cases diagnosed in 1999 or 2000 were missed by the hospital discharge system. Thus, the sensitivity of this latter system was 73% (70-76%) and varied significantly from 62% to 85% across districts (p<0.001) and according to the type of health facility (p<0.01).

CONCLUSION

Predictive positive value of the French hospital discharge system for ascertainment of thyroid cancer cases is high and stable across districts. Sensitivity is lower and varies significantly according to the type of health facility and across districts, which limits the interest of this database for a national estimate of thyroid cancer incidence rate.

[Iron supplementation associated with malaria prevention among pregnant women in Abidjan]

BACKGROUND

Despite the demonstrated efficacy of iron supplements and malaria prevention, the effectiveness of antenatal care programs for prevention of anaemia (haemoglobin rate<11 g/dL) in pregnant women is low in West Africa. Apart from the issue of availability and despite low cost, the major reason evoked is the lack of motivation of pregnant women and health care professionals. In this study, iron supplements and malaria prophylactics were provided free of charge during pregnancy. The treatment was proposed at the first antenatal visit, with the objective of not interfering with routine practice of birth attendants and women in latter antenatal visits.

METHODS

Haemoglobin rates were measured and Plasmodium falciparum tested for among pregnant women in four maternity units in Abidjan. The tests were carried out at inclusion during the first antenatal visit and during immediate post-partum in 631 pregnant women who delivered in one of the four wards. Considering the objective of the study, compliance was assessed for the month prior to delivery.

RESULTS

Despite an habitual decrease in iron deficiency at the end of pregnancy, haemoglobin rates in the study population increased from 10.4 g/dL at inclusion to 10.9 g/dL during post-partum. Prevalence of anemia consequently decreased from 62.8% to 49.4% (p<0.01). A similar increase of 0.7 g/dL was observed among women stating a regular (57%) or irregular (36.9%) compliance with the protocol. A decrease of 0.4 g/dL (s.t.: 1.8 g/dL) was observed among women stating a lack of compliance with the protocol (5.6%). The prevalence of anaemia according to compliance was consequently 43.1%, 49.7% and 70.1% (p=0.02). Severe anaemia (<8 g/dL) at inclusion was an independent risk factor for post-partum anaemia although a 2.9 g/dL increase (s.t.: 2.0 g/dL) was observed in the latter (p<0.01). However, the 11 g/dL threshold was not reached.

CONCLUSION

It is therefore important to reinforce the availability of treatments to prevent anaemia in pregnant women due to their demonstrated efficiency as a part of routine antenatal activities.

Geographical variation in disease progression in HIV-1 seroconverted injecting drug users in Europe?

BACKGROUND

Human immunodeficiency virus (HIV) disease progression might vary by geographical region due to differences in the spectrum of HIV-related illnesses and (access to) health care. Therefore, the effect of geographical region, next to the effect of other potential cofactors, on disease progression in 664 injecting drug users (IDU) with documented HIV seroconversion from eight cohorts in Europe was studied.

METHODS

Kaplan-Meier methods and Cox proportional hazards analysis were performed to assess the effect of geographical region, other sociodemographics, drug use and repeated HIV exposure on progression from HIV seroconversion to immunosuppression, AIDS and death with AIDS. We considered the confounding effect of study-design related factors (e.g. setting of follow-up), and accounted for pre-AIDS death from natural causes by imputing when each endpoint would have occurred, had they not died without AIDS.

RESULTS

Estimates of progression to AIDS and death with AIDS were substantially faster after taking pre-AIDS mortality into account. Median incubation time from seroconversion to the first CD4 count < 200 cells/microliter was 7.7 years (95% CI: 7.1-8.3) and to AIDS 10.4 years (95% CI: 9.8-infinity). The 10-year survival was 70.3% (95% CI: 62.8-76.6). The relative hazards (RH) of AIDS for IDU from central and southern Europe compared with IDU from northern Europe was 1.9 (95% CI: 1.2-3.0) and 1.2 (95% CI: 0.6-2.3), respectively, before, and 1.5 (95% CI: 0.7-3.2) and 1.1 (95% CI: 0.6-2.3) after taking differences in study-design related factors into account. Accounting for these factors, the RH of death with AIDS was 0.9 (95% CI: 0.3-2.5) for central and 1.2 (95% CI: 0.4-3.4) for southern Europe compared with northern Europe. For the first CD4 count < 200 cells/microliter these figures were 0.8 (95% CI: 0.5-1.4) and 0.8 (95% CI: 0.5-1.4). Age at seroconversion was the strongest predictor of disease progression. No statistically significant differences in disease progression were found by gender, foreign nationality, drug use and potential repeated HIV exposure.

CONCLUSIONS

We found no evidence for regional variability in HIV disease progression among European IDU. Future studies evaluating geographical differences should consider the confounding effect of study-design related factors and differential non-AIDS mortality. As age is an important determinant of disease progression, it should be considered in recommending treatment.

Incidence and sexual risk factors of cytomegalovirus seroconversion in HIV-infected subjects. The SEROCO Study Group

BACKGROUND

Data on incidence of cytomegalovirus (CMV) seroconversion in HIV-infected (HIV(+)) subjects was sparse.

GOAL

To determine the incidence of CMV seroconversion in sexually active HIV(+) subjects and sexual factors associated with CMV seroconversion.

STUDY DESIGN

One hundred eighty four persons not infected by CMV at enrollment in a cohort of HIV(+) persons were studied. A case-control study within the cohort was conducted to determine the effect of sexual behavior in the 6 months prior to CMV seroconversion. Thirty seven cases of CMV seroconversion were compared with 136 controls.

RESULTS

The overall incidence of CMV seroconversion was 9.18 per 100 person-years (95% confidence interval (CI), 6.67-12.28) and was particularly high among homosexual men. After adjustment for age, socio-professional category, sexual orientation, and casual sex, the risk of CMV seroconversion was higher in subjects who never used condoms than in those who used them systematically (adjusted odds ratio (OR) 3.37;95% CI, 1.05-11.00).

CONCLUSIONS

In addition to the need to protect their sexual partners from HIV infection, HIV(+) subjects free of CMV infection should use condoms to avoid CMV infection and its complications.

Predictive value of viral load and other markers for progression to clinical AIDS after CD4+ cell count falls below 200/microL. SEROCO & HEMOCO Study Group

BACKGROUND

To assess the predictive value of biological and clinical events for progression to AIDS (1993 European classification) when the CD4+ cell count falls below 200/microL (CD4 threshold) in different exposure groups. To investigate whether such markers remain predictive independently of the serum HIV-1 RNA level at the CD4 threshold.

METHODS

The predictive value of biological and clinical events occurring during the 24 months prior to the occurrence of CD4 threshold (n = 333) was quantified in a Cox model. Another Cox model was carried out in a subset of 77 patients in whom viral load from stored sera was available. Furthermore, changes in viral load during the 24 months preceding the CD4 threshold were assessed in a mixed model according to subsequent development of AIDS.

RESULTS

Among the 333 patients, the slope of the CD4+ cell counts, the emergence of p24 antigen, persistent thrush, and age at the CD4 threshold were independent predictors of progression to clinical AIDS (44.7%). Among the subset of 77 patients, the HIV-1 RNA level at the CD4 threshold, persistent thrush and age remained independent predictors of progression to AIDS (45.5%). The increase of the HIV-1 RNA level was moderate, both in non-progressors (24.0% per year) and in those who subsequently developed AIDS (27.1% per year), (P = 0.93). Viral load was consistently higher in the latter group (P = 0.002).

CONCLUSION

At a late stage of infection, age and persistent thrush remain predictive of progression to AIDS, independently of viral load.

[Prevalence and incidence of cytomegalovirus infection in patients infected with HIV-1. SEROCO group]

OBJECTIVES

To study prevalence of the cytomegalovirus (CMV) infection as well as incidence of the CMV seroconversions in HIV-infected subjects enrolled in the French multicentric cohort SEROCO.

METHOD

Prevalence of CMV infection at inclusion in the cohort was estimated from 1504 HIV-infected subjects. Incidence of the CMV seroconversion was estimated from 184 subjects CMV seronegative at inclusion. Cox model was used to identify independent factors related to CMV seroconversion.

RESULTS

CMV prevalence was high (87.2%) mainly in homosexual men. The incidence of the CMV seroconversions was also high (9, 18/100 person-years), particularly in homosexual men, in subjects declaring sexual intercourse with occasional partner, and in those declaring a sexually transmitted disease during the follow-up.

CONCLUSION

The risk to develop serious disease related to CMV in subjects with AIDS being particularly high when the CMV primary infection occurs during the course of the HIV infection, the prevention of CMV primary infections is thus a major element in the counselling of HIV-infected subjects.

[Risk reduction and intravenous drug use abstinence in patients with HIV infection. The SEROCO group]

BACKGROUND

Little is known about the complex stepwise process of giving up intravenous (i.v.) drugs. However, HIV risk reduction programs directed towards i.v. drug users have been accused by some opponents to encourage users to continue. In order to better assess the relationships between risk reduction and abstinence, we studied factors associated with abstinence in HIV-infected patients using i.v. drugs at enrollment in the SEROCO cohort (1988-1994).

METHODS

63 HIV-infected patients injecting i.v. drugs at enrollment were followed-up every 6 months with a clinical examination and a questionnaire concerning sexual and drugs practices since last consultation. Abstinence was defined as non injecting for at least 6 months. The 30 patients who became abstinent during a follow-up period of 3 years were compared to the 33 remaining.

RESULTS

Abstinence during follow-up was not related to age at inclusion, duration of i.v. drug use, gender or marital status. However, patients who became abstinent were more likely to have a professional activity at inclusion than the remaining (70% vs 42%, p = 0.03). Before knowledge of HIV infection, frequency of injections, needle sharing and use of condoms did not differ between the 2 groups. During follow-up, behavioural changes occurred in the two groups, but were more marked in those who lately became abstinent. These latter were more likely to always inject with new needles/syringes (57% vs 18%, p = 0.003), and to use condoms with HIV-negative partners or of unknown status (73% vs 39%, p = 0.06). Professional activity and systematic use of new needles/syringes remained independently associated with abstinence in multivariate analysis.

CONCLUSION

In this cohort, abstinence appeared as a stepwise process in which risk reduction preceded abstinence. This confirms that risk reduction programs do not work against those messages aimed at stopping i.v. drug use. Since this analysis selected particular subjects, enrolled in a cohort of HIV-infected patients, results should be confirmed in other samples of i.v. drugs users.

Influence of age at infection on human immunodeficiency virus disease progression to different clinical endpoints: the SEROCO cohort (1988-1994). The Seroco Study Group

METHOD

The influence of age at infection on progression of human immunodeficiency virus (HIV) disease to different clinical endpoints was studied among 393 HIV-seropositive adults selected from the French SEROCO cohort; follow-up lasted from January 1988 to November 1994. Selected patients had a known date of infection and were enrolled shortly after seroconversion. Age-associated risk ratios (RR) were estimated using the Cox model (age fitted as a continuous variable and RR expressed for each 10-year increment after adjustment for symptomatic primary infection and sexual preference).

RESULTS

Age had a weak influence on progression from the date of infection to the first category B event (crude RR = 1.15; adjusted RR = 1.09; 95% confidence interval [CI]: 0.89-1.36) but a marked influence on progression from the first category B to the first category C event (crude RR = 1.95; adjusted RR = 1.97; 95% CI: 1.37-2.79). Similar results were obtained after adjustment for the CD4+ cell count at enrollment. A qualitative CD4+ cell defect could explain the influence of age, but this remains to be confirmed.

CONCLUSION

Age at infection should be included in the definition of CD4+ cell count thresholds for clinical management and treatment initiation. Risk factors for progression should be assessed according to the different clinical endpoints.

Pre-AIDS mortality from natural causes associated with HIV disease progression: evidence from the European Seroconverter Study among injecting drug users

OBJECTIVES

To study differences in pre-AIDS mortality between European cohorts of injecting drug users (IDU) and to evaluate whether pre-AIDS mortality increased with time since HIV seroconversion and decreasing CD4 count.

METHODS

The study population consisted of 664 IDU with documented intervals of HIV seroconversion from eight cohort studies. Differences in pre-AIDS mortality were studied between European sites; an evaluation of whether pre-AIDS mortality increased with time since HIV seroconversion and decreasing CD4 count was carried out using Poisson regression.

RESULTS

One hundred and seven IDU died, of whom 57 did not have AIDS. Pre-AIDS causes of death were overdose/suicide (49%), natural causes such as bacterial infections/cirrhosis (40%), and unintentional injuries/unknown (11%). Considering pre-AIDS death and AIDS as competing risks, 14.7% were expected to have died without AIDS and 17.3% to have developed AIDS at 7 years from seroconversion. No statistically significant differences in pre-AIDS mortality were found between European regions, men and women, age categories and calendar time periods. Overall pre-AIDS mortality did not increase with time since seroconversion, but did increase with decreasing CD4 count. Evaluating cause-specific mortality, only pre-AIDS mortality from natural causes appeared to be associated with time since seroconversion as well as immunosuppression. For natural causes, the death rate per 100 person-years was 0.13 the first 2 years after seroconversion, 0.73 in years 2-4 [risk relative (RR) to years 0-2, 5.6], 1.83 in years 4-6 (RR, 14.0) and 1.54 for > or = 6 years (RR, 11.7). This rate was 0 for a CD4 cell count > or = 500 x 10(6)/l, 1.06 for 200-500 x 10(6)/l and 4.06 for < 200 x 10(6)/l (RR versus > or = 200 x 10(6)/l, 7.0). In multivariate analysis, both CD4 count and time since seroconversion appeared to be independently associated with death from natural causes; CD4 count appeared to be the strongest predictor (adjusted RR, 5.9).

CONCLUSIONS

A high pre-AIDS mortality rate was observed among IDU. No significant differences were observed across European sites. Pre-AIDS mortality from natural causes but not from overdose and suicide was associated with HIV disease progression.

Sexual factors associated with cytomegalovirus seropositivity in human immunodeficiency virus-infected men. The Seroco Study Group

BACKGROUND

Many people infected by human immunodeficiency virus (HIV) acquire severe cytomegalovirus (CMV) diseases. Factors associated with CMV seropositivity are poorly documented in sexually active HIV-infected men.

GOAL

To study CMV seroprevalence in HIV-infected men according to sexual behavior before the diagnosis of HIV seropositivity.

STUDY DESIGN

Cross-sectional study. CMV seroprevalence was studied at enrollment in a prospective cohort of homosexual and heterosexual men infected by HIV through sexual contact.

RESULTS

In the study population (n = 723), age, sexual preference, previous lifetime history of sexually transmitted diseases, and multiple sexual partners were independently related to CMV seropositivity. Furthermore, routine condom use during the 6 months before diagnosis of HIV seropositivity was significantly related to CMV seropositivity (adjusted odds ratio [OR]: 0.4, 95% confidence interval [CI]: 0.1-1.0), occasional condom use being of borderline significance [adjusted OR: 0.5, CI: 0.2-1.3].

CONCLUSIONS

This study confirms the importance of sexual factors in the acquisition of CMV infection by HIV-infected men and suggests a protective effect of condom use.

Has the rate of progression to AIDS changed in recent years?

OBJECTIVES

To investigate whether the rate of progression to AIDS has changed over time by testing an effect of the year of seroconversion on AIDS onset (Centers for Disease Control and Prevention 1987 revised classification), next to an effect of the calendar period of follow-up.

DESIGN

French multicentre prospective study of 385 homosexual and heterosexual subjects and 231 subjects from a multicentre study of European injecting drug users (IDU), all with a documented date of HIV-1 seroconversion.

METHOD

The effect of the year of seroconversion was compared by the log-rank test. Crude and adjusted relative hazard (ARH) were quantified using the Cox model. Calendar period of follow-up was studied separately for sexual exposure group and IDU and treated as a time-dependent variable in a Cox model.

RESULTS

In the 616 study subjects the year of seroconversion was not significantly related to AIDS occurrence (n = 108); the ARH was 0.88 [95% confidence interval (CI), 0.56-1.38] for those who seroconverted in 1988-1989, and 1.17 (95% CI, 0.61-2.25) for those who seroconverted after 1989, compared with those who seroconverted before 1988. In the sexual exposure group, a clear trend towards less rapid progression to AIDS was observed in subjects followed in 1991-1992 (ARH, 0.49; 95% CI, 0.24-0.99) and after 1992 (ARH, 0.54; 95% CI; 0.24-1.21), compared with those followed before 1991. This favorable trend was not observed in IDU despite a significant decrease over time of Pneumocystis carinii pneumonia as AIDS-defining illness. Conversely to sexual exposure groups, the frequency of antiretroviral treatment (mainly zidovudine) prescription was still low during the most recent calendar periods in IDU when the CD4 count threshold of 200 x 10(6)/l was reached.

CONCLUSIONS

No evidence was found of a change in the rate of progression to AIDS in subjects who seroconverted in recent years. Furthermore, conversely to sexual exposure groups, the lack of favorable trends in IDU users followed in recent years suggest that health-care systems are not always adapted to their lifestyles.

The use of auxiliary events to improve the analysis of survival for HIV-infected patients: application to the French Prospective Multicenter Cohort (SEROCO)

SUMMARY

A multicenter prospective cohort study, including 512 patients for whom date of HIV infection was known, showed that the use of an appropriate auxiliary event can improve the analysis of survival data and lead to an earlier detection of risk factors for HIV patients. Age at seroconversion and primary symptomatic infection were used as risk factors. Two age groups were defined as age at seroconversion >30 years (n = 203) and < or = 30 years (n = 309). Patients with primary symptomatic infection PSI (n = 215) were compared with patients without any clinical manifestation during primary infection (n = 297). Death was considered as the endpoint of primary interest and occurred in 76 patients in the study. Classical non-parametric methods (Kaplan-Meier estimate and long-rank test) and parametric regression model (Weibull model) were used for a standard analysis of survival data. A parametric approach using auxiliary information was used to estimate the survival function and to test the effect of age at seroconversion and PSI. We also applied a recently proposed distribution-free method to produce a non-parametric estimate of the survival function and to test age at seroconversion and PSI with respect to survival estimates. Both methods are compared for two distinct auxiliary events (Karnofsky score below 75 and a first drop of CD4 lymphocyte counts below 200 cells/MM3). The use of CD4 lymphocyte counts below 200 cells/MM3 as an auxiliary event improved the analysis of survival data available in December 1994. For both methods incorporating CD4 counts below 200 cells/mm3 in addition to survival data, the effect of age at seroconversion on survival was significant in April 1992 whereas it was not significant with standard methods. For PSI exposure group, results shown in this work do not indicate any improvement in using auxiliary information. Conditions for using an appropriate auxiliary event as well as advantages and shortcomings of both methods are discussed. Methods used in this work, with appropriate auxiliary information, are promising either through a reduction in the time to follow-up to detect risk factors for cohort studies or the time needed for drug development in clinical trials.

HEMOCO: a French prospective study of hemophiliacs infected by human immunodeficiency virus type 1 (HIV-1)

HEMOCO is a multicenter prospective cohort set up in 1989 to monitor 407 French hemophiliacs infected by HIV-1 and recruited in 4 hemophilia treatment centers in the Paris region. As of 15 July 1995, 42% of the patients in the cohort had developed stage B HIV disease and 29% stage C disease (AIDS); 23.1% of the patients had died. The cumulative proportion of patients with AIDS was 4.5% at 5 years and 27.4% at 10 years, while the respective mortality rates were 3.8% and 19.5%. In our study, only age was predictive of AIDS, with an estimated relative risk of 1.2 per 10-year age increment; this factor was also predictive of death. After 10 years of follow-up, 6.1% of the study population had no clinical or laboratory signs of immunodepression. The follow-up protocol in the HEMOCO protocol is the same as that in the French SEROCO study, which includes men infected by HIV-1 through sexual contact. This will allow us to compare the progression of HIV infection between these two exposure groups.

[Cofactors in the course of HIV infection]

Cohorts of patients infected with the human immunodeficiency virus (HIV), and followed-up since their infection, have identified risk factors of progression to acquired immunodeficiency syndrome (AIDS). The risk of progression increases with the subject's age at contamination by 40% for each decade. Other host factors such as certain HLA subtypes would be related to progression. Virus-related factors have also been described. Sexual or transfusional transmission from a highly immunodepressed subject increases the risk of progression in the infected subject. Progression is more rapid in male homosexuals than in heterosexuals, even after exclusion of Kaposi's syndrome. There has been little success in isolating co-infections which might explain this finding. The more rapid progression in homosexuals could be due to infection with particularly virulent strains or particular subtypes. Finally, progresion is more rapid when signs of primary infection are major or prolonged, an observation which probably results from a complex host-virus interaction. Behavioral factors occurring after contamination (pregnancy, continued intravenous drug abuse, tobacco, alcohol) have not been demonstrated until now to play a role in progression.

High risk of HIV disease progression after infection through a sexual partner with AIDS

OBJECTIVE

To investigate whether HIV-1 infection acquired through a severely immunodepressed sexual partner increases the risk of disease progression.

DESIGN

A prospective cohort of patients infected through sexual contact at a known date and enrolled a few months (median, 2 months) after their first HIV-positive test. At enrolment, 12 subjects stated having had unprotected intercourse (anal or vaginal penetration) with a partner with AIDS within the 6 months prior to their first HIV-positive test. For the same period, 60 subjects stated having had unprotected intercourse with a partner, known to be HIV-positive, but who had not developed AIDS.

METHOD

The endpoint was the first occurrence of an HIV-related illness (group IV or AIDS, 1987 Centers for Disease Control and Prevention revised classification). Event-free survival curves since infection were constructed using the Kaplan-Meier method and compared by the log-rank test. The Cox model was used for multivariate analysis.

RESULTS

Disease progression was more rapid among the 12 subjects who stated having sex with a person with AIDS at a time close to infection, than among the other subjects (P = 0.03). Homosexuality and age at infection were also related to HIV disease progression. The adjusted relative risk of developing an HIV-related illness among those 12 subjects was 3.9 (95% confidence interval, 1.5-9.9).

CONCLUSION

Our results confirm the influence of virus-related factors on the onset of immunodepression in subjects infected through sexual contact.

Influence of neurologic manifestations of primary human immunodeficiency virus infection on disease progression. SEROCO Study Group

To determine the influence of neurologic manifestations of primary human immunodeficiency virus (HIV) infection on disease progression, 277 nonhemophiliac adults enrolled < 1 year after HIV infection were studied. Patients with neurologic manifestations during symptomatic primary HIV infection (PSI) (group N+; n = 23), with nonneurologic manifestations (group N-; n = 112) during PSI, and without any clinical manifestation during primary infection (group NPI; n = 142) were compared for disease progression. Age at infection, sex, mode of infection and CD4+ cell count at first visit did not differ between groups. In a Cox model, the relative risk (RR) of developing AIDS was 6.11 (95% confidence interval [CI], 1.94-19.28) in group N+ and 2.32 (95% CI, 0.93-5.83) in group N- compared with group NPI. The RR of AIDS onset after adjustment for treatment and age at infection was, respectively, 4.65 (95% CI, 1.43-15.03) and 2.03 (95% CI, 0.80-5.19) in groups N+ and N-. Neurologic manifestations of primary HIV infection are associated with an accelerated progression of disease.

[Multicenter French cohort of adults with HIV infection. Description and course after 4 years of follow-up. SEROCO]

OBJECTIVES

A prospective multicentric epidemiological study (SEROCO) of subjects with a diagnosis of human immunodeficiency virus (HIV) infection was started on January 1, 1988 in order to better understand the natural history of HIV infection and factors related to outcome. Observations after 4 years of follow-up are reported here.

METHODS

After authorization by the French national ethics committee and the national commission for personal freedom, 18 French centres included non-haemophiliac volunteers who were asymptomatic, had had non anti-HIV treatment and whose HIV positivity had been known less than 1 year at inclusion. These last three criteria were not required for patients whose precise date of contamination was known within a range of +/- 3 months.

RESULTS

On July 15, 1992, there were 1453 infected subjects in the cohort (1063 males, 417 females; age range at inclusion 18-75 years; mean age 31.3 +/- 9.4). Globally, 2.7% of the subjects were symptomatic at inclusion. Mean CD4 lymphocyte count at inclusion was 508/mm3. Clinically, 51.5% of the patients had a history of sexually transmitted disease at inclusion. After 4 years (on July 15, 1992) mean follow-up was 28 +/- 12.9 months for a total of 3428 patient-years. Disease progression to stage IV was observed in 439 patients including 202 who developed the acquired immuno-deficiency syndrome (AIDS). Among these 202 patients, 113 had died at the end-point of this report. The first manifestation of AIDS was Kaposi sarcoma in 44, pulmonary pneumocystosis in 38 and cerebral toxoplasmosis in 27. The probability of developing AIDS was calculated at 13.9% at 5 years, 27.7% at 7 years and 33.7% at 10 years. The probability of a CD4 count below 200/mm3 was 32.7, 55.6 and 67% at 5, 7 and 10 years respectively. For patients with a CD4 count below 200, the probability of developing AIDS was 18% at 1 year, 39% at 2 years and 51% at 3 years.

CONCLUSIONS

SEROCO has been a most useful prospective epidemiological tool due to the diversity of the subjects included. The observed natural history of HIV infection will lead to specific research projects aimed at better understanding the disease process.

Effect of age and exposure group on the onset of AIDS in heterosexual and homosexual HIV-infected patients. SEROCO Study Group

OBJECTIVE

To analyse the influence of age at seroconversion and sexual exposure group on the progression of HIV disease.

DESIGN

This multicentre prospective cohort study involved 443 subjects whose date of HIV infection was known to within +/- 1 year. Individuals whose sexual behaviour was exclusively heterosexual after HIV infection constituted the heterosexual group (n = 131). AIDS-free survival was compared with that of men (n = 312) infected through homosexual sex and who continued homosexual activity after HIV infection. They constituted the homosexual group.

METHODS

The end-point was the onset of an AIDS-defining illness listed in the 1987 revised Centers for Disease Control and Prevention (CDC) criteria. Using the Kaplan-Meier method, AIDS-free survival curves were plotted for three age categories (< 20, 20-39, > or = 40 years). A Cox model was used to quantify the effect of age and to assess the influence of exposure group on AIDS onset after adjustment for age. Because of the high incidence of Kaposi's sarcoma (KS) among homosexual men, a disease that can be an early AIDS-defining illness, multivariate analysis was performed with and without consideration of the occurrence of KS.

RESULTS

Patients aged > or = 40 years at seroconversion progressed more rapidly to AIDS than younger patients (P < 0.006). When age was fitted as a continuous variable and adjusted for exposure group, the relative risk of developing AIDS by any time after seroconversion was 1.34 for a 10-year increase difference [P = 0.03; 95% confidence interval (CI), 1.03-1.77]. After adjustment for age, the relative risk of developing AIDS (CDC criteria) was 2.42 (P = 0.008; 95% CI, 1.18-4.97) among the homosexual men (AIDS cases, n = 56). All cases of KS (n = 19) involved the homosexual group. Excluding KS as a first manifestation of AIDS, homosexual or bisexual subjects had a risk of AIDS of 1.92 (P = 0.07; 95% CI, 0.92-4.03) compared with heterosexual subjects.

CONCLUSIONS

The risk of AIDS increases with age at seroconversion. The more rapid progression towards AIDS in the homosexual group than in the heterosexual group persisted after adjustment for age. Further studies are required to determine the possible role of repeated exposure to HIV or other pathogens acquired sexually.