Declining HIV/AIDS mortality in New York City

BACKGROUND: New York City has only 3% of the U.S. population but has reported nearly 16% of all AIDS cases. METHODS: This is an observational study using the New York City vital events and AIDS case surveillance registries to describe trends in HIV/AIDS mortality from 1983 through June 30, 1998. RESULTS: Annual HIV/AIDS deaths increased steadily until stabilizing at 7046 in 1995, declined 29% to 4998 in 1996, and declined 47% to 2625 in 1997. Comparing data from 1997 with those from 1995, declines occurred in all demographic groups and in all major HIV transmission categories: 74% in men who have sex with men, 68% in injecting drug users, and 64% in heterosexuals. In the first 6 months of 1998, declines were smaller than they had been in previous 6-month intervals in all demographic groups except Hispanic males and those between 35 and 44 years of age. From 1995 to the first 6 months of 1998, the number of people living with AIDS in New York City increased 22% (from 32,692 to 39,976). CONCLUSIONS: The precipitous 63% decline in HIV/AIDS deaths from 1995 to 1997 occurred at the same time that more effective antiretroviral therapies became widely available. The slowing in the mortality decline observed in 1998, however, suggests that although these new therapies may have a profound effect at the population level, deaths due to AIDS will continue.     

Seroepidemiology of HIV infection in two cohorts of intravenous drug users in New York City

Few issues have been able to capture the attention of the scientific community and the lay public in the manner that the acquired immunodeficiency syndrome (AIDS) has. Despite significant advances in many areas, the morbidity and mortality statistics remain as somber reminders of the devastation attributed to this epidemic. This devastation appears particularly acute among those portions of the population already subject to the least desirable health status indicators. Efforts directed at known methods of disease acquisition and populations with a disproportionately greater susceptibility may serve as important foci of health prevention. To this end, intravenous drug users and minority group members present some interesting interrelationships.     

Similarities and differences by race/ethnicity in changes of HIV seroprevalence and related behaviors among drug injectors in New York City, 1991-1996.

OBJECTIVE: To measure differences and similarities in the prevalence of HIV infection and of related risk and protective behaviors among New York City black, white, and Hispanic drug injectors during a period of decreasing HIV prevalence. METHODS: Drug injectors were interviewed at a drug detoxification clinic and a research storefront in New York City from 1990 to 1996. All subjects had injected drugs within the last six months. Phlebotomy for HIV testing was conducted after pretest counseling. Analysis compares the first half (period) of this recruitment interval with the second half. RESULTS: HIV seroprevalence declined among each racial/ethnic group. In each period, white drug injectors were significantly less likely to be infected than either blacks or Hispanics. Similar declines were found in separate analyses by gender, length of time since first injection, and by recruitment site. After adjustment for changes in sample composition over time, blacks and Hispanics remained significantly more likely to be infected than whites. Interactions indicate that the decline may be greatest among Hispanics and slowest among blacks. A wide variety of risk behaviors declined in each racial/ethnic group; and syringe exchange use increased in each group. Few respondents reported injecting with members of a different racial group at their last injection event. CONCLUSIONS: HIV prevalence and risk behaviors seem to be falling among each racial/ethnic group of drug injectors. Black and Hispanic injectors continue to be more likely to be infected. Declining prevalence among whites poses some risk of politically based decisions to reduce prevention efforts. Overall, these results show that risk reduction can be successful among all racial/ethnic groups of drug injectors and suggest that continued risk reduction programs may be able to attain further declines in infection rates in each group.     

HIV infection in intravenous drug abusers in Berlin: Risk factors and time trends

Summary To investigate the epidemiology of HIV infection among intravenous drug abusers (IVDA) in Berlin (West), from October 1984 to October 1988, 741 heterosexual IVDA were recruited from facilities for drug treatment and counseling. In this group 22.8% were seropositive for antibodies against HIV, representing 21.1% of the females and 23.5% of the males. Seroprevalences of hepatitis B, hepatitis A, and lues were 67.7%, 40.1%, and 4.0%, respectively. Seropositivity for HIV antibodies correlated with positive seromarkers for hepatitis B and A, and with certain behavioral and social features such as sharing of injection equipment, imprisonment, and intravenous drug use in prison. The crude time trend of HIV seroprevalence shows an increase from 17.1% in those subjects who discontinued i.v. drug abuse in 1983 or earlier to 31.5% in 1985, and a decrease over the past 3 years to 14.1% in 1988. After adjusting for temporary changes in the study group, the estimated HIV seroprevalence odds show an almost steady increase and were significantly higher for those who were injecting drugs in 1987 and 1988 compared with those who stopped i.v. drug use before 1984. Thus IVDA with a persistent risk profile are at a still-increasing risk of acquiring HIV infection.Abbreviations AIDS acquired immunodeficiency syndrome - CDC centers for disease control - HIV human immunodeficiency virus - IVDA intravenous drug abusers - PGL persistent generalized lymphadenopathy     

Medical students' attitudes toward AIDS, homosexual, and intravenous drug-abusing patients: a re-evaluation in New York City

After completing their clinical rotations, 69% of the third-year medical school class at Columbia University responded to a survey based on one originally used by Kelly et al. at the University of Mississippi, to determine their attitudes toward acquired immunodeficiency syndrome (AIDS) patients, homosexual men, and intravenous drug abusers (IVDAs). Results of this study were compared to the findings of Kelly et al. to determine how, if at all, geographic and environmental exposures affected student attitudes. Unlike the University of Mississippi students, who exhibited a highly negative and prejudiced view of homosexuals and patients with AIDS, Columbia students displayed no evidence of negative attitude toward homosexuals and a much less harsh judgment of AIDS patients. They, however, did have dramatically negative attitudes toward IVDAs; 78.4% stated that they strongly disliked and would avoid this group of patients. There is a complex multi-variable environmental effect on students' attitudes during medical school. It is not possible to generalize attitudes from one medical school to another. The necessity of incorporating activities into student education to evaluate and to reduce prejudice is discussed.     

Nutritional assessment in intravenous drug users with HIV/AIDS

Studying metabolic, endocrine, and gastrointestinal (MEG) disorders in drug abuse and HIV infection is important. Equally important, however, are the tools we use to assess these disorders. Assessment of nutritional status may include any combination of biochemical and body composition measurements, dietary intake assessment, and metabolic studies. Each method has its strengths and weaknesses and there is no perfect tool. When assessing nutritional status in injection drug users (IDU) and in HIV-infected people, the decision on which method or methods to use becomes even more complex. A review of studies reported during the XII World Conference on AIDS reveals that of 64 abstracts on the topic of nutrition in HIV-infected adults, only 11 assessed diet, 41 assessed anthropometry, and 24 assessed some form of biochemical measure. The most commonly reported methods for dietary intake included 24-hour recalls, food records, and food frequencies. The commonest methods used for measuring body composition included height, weight, bioimpedance, and dual-energy x-ray absorptiometry (DEXA). Biochemical measurements included various blood nutrients, lipids, and albumin. Methods varied greatly between studies, and caution should be taken when trying to compare results across studies, especially among those using different methods. Currently, few studies deal with the development of methods that can be used for research in HIV-infected and IDU populations. We need to work toward better tools in dietary intake assessment, body composition, and biochemical measurements, especially methods that will allow us to track changes in nutritional status over time.     

Trends in HIV seroprevalence and needle sharing among Puerto Rican drug injectors in Puerto Rico and New York: 1992-1999

This study assessed trends in HIV seroprevalence and needle-sharing behaviors among Puerto Rican injection drug users (IDUs) in Puerto Rico and New York. Data from two studies of IDUs conducted from 1992 through 1995 and 1998 through 1999 in Bayamón, Puerto Rico, and East Harlem, New York, were examined to assess trends over this period. Separate analyses were conducted for IDUs who were current crack smokers. Significant decreasing trends in seroprevalence were found among IDUs in the New York and Puerto Rico samples (p <.001). Significant decreasing trends in receptive and distributive needle sharing were found in the New York sample, and a significant decline in receptive sharing was found in the Puerto Rico sample. Overall, higher levels of needle-sharing behaviors were reported in Puerto Rico compared with New York. Decreasing trends in needle sharing and seroprevalence in both communities are an encouraging finding. Ongoing epidemiologic studies to monitor the epidemic and continued prevention efforts to help maintain or further these declines are needed, particularly to address the higher rates of needle sharing in Puerto Rico.     

Estimated HIV incidence among high-risk heterosexuals in New York City, 2007

We sought to describe virologic and clinical retention outcomes among a group of HIV-infected adolescents and young adults (AYA) newly established in an adult HIV clinic compared with matched HIV-infected adults. AYA demonstrated lower rates of HIV-1 virologic suppression and higher rates of HIV-1 viral rebound and loss to follow-up compared with adults. African American AYA had the lowest rates of virologic suppression and the highest rates of viral rebound. Adult providers should consider HIV-infected AYA, particularly African American HIV-infected AYA, to potentially be at high risk for poor clinical outcomes in adult care.     

Infective endocarditis in intravenous drug abusers: an update

Infective endocarditis despite advances in diagnosis remains a common cause of hospitalization, with high morbidity and mortality rates. Through literature review it is possible to conclude that polymicrobial endocarditis occurs mainly in intravenous drug abusers with predominance in the right side of the heart, often with tricuspid valve involvement. This fact can be associated with the type of drug used by the patients; therefore, knowledge of the patient's history is critical for adjustment of the therapy. It is also important to emphasize that the most common combinations of organisms in polymicrobial infective endocarditis are: Staphylococcus aureus, Streptococcus pneumonia and Pseudomonas aeruginosa, as well as mixed cultures of Candida spp. and bacteria. A better understanding of the epidemiology and associated risk factors are required in order to develop an efficient therapy, although PE studies are difficult to perform due to the rarity of cases and lack of prospective cohorts.     

Sexual contacts of intravenous drug abusers: implications for the next spread of the AIDS epidemic

A scarcity of knowledge exists regarding the sexual behavior of intravenous drug abusers (IVDAs) despite their potential role in the heterosexual transmission of acquired immunodeficiency syndrome (AIDS). Using a standardized questionnaire of drug and sexual practices, 96 patients enrolled in methadone maintenance treatment in New York City were interviewed anonymously.     

Decreased natural and antibody-dependent cellular cytotoxic activities in intravenous drug abusers

Peripheral blood lymphocytes from 14 adult male patients admitted to the hospital with complications of intravenous drug abuse (IDA) were examined for natural killer (NK) and antibody-dependent cellular cytotoxic (ADCC) activities, lectin-dependent cellular cytotoxicity, and interferon (IFN)- and interleukin 2 (IL-2)-induced NK activity. Serum was also assayed for circulating interferon levels and soluble factor(s) capable of suppressing the cytotoxic potential of allogeneic lymphocytes from healthy donors. IDA patients demonstrated significantly decreased levels of NK and ADCC activities compared to age- and sex-matched healthy controls. The lectin, phytohemagglutinin, could significantly enhance the cytotoxicity of IDA lymphocytes; however, activity was not completely restored to normal levels. IDA sera demonstrated a significant inhibitory effect on the NK and ADCC activities of normal allogeneic lymphocytes, and these sera contained negligible levels of circulating IFN. Although the NK activity of IDA lymphocytes could not be restored completely to normal levels by either IFN-alpha or IL-2, the percentage enhancement of cytotoxicity was remarkably higher in IDA patients with significantly reduced NK activity than that observed using PBL from patients with near normal NK activity. The ability of IFN or IL-2 to enhance the decreased cytotoxicity of PBL from drug abusers suggests a novel therapeutic approach to the management of the complications of IDA.     

The association of hepatitis C prevalence,activity, and genotype with HIV infection in a cohort of New York City drug users

Factors associated with serum HCV antibody, HCV RNA level, and HCV genotype were assessed in 557 current and former drug users. Additional assays included HIV antibody, CD4+ lymphocyte counts, HIV viral loads, and hepatitis B markers. Seventy-five percent of subjects were anti-HCV positive, of whom 75% had detectable HCV RNA (median, 5.04 x 10(5) IU/mL; range, 1020-15.7 x 10(6)). On multivariate analysis HCV seropositivity was associated with history of drug injection, HIV seropositivity, and increased age and inversely with drug snorting. Among anti-HCV-positive persons, detectable HCV RNA was independently associated with HIV seropositivity, male gender, and history of injection and inversely associated with hepatitis B surface antigen positivity. Among persons with detectable HCV RNA, higher levels were independently associated with higher HIV viral load, increased age, and genotypes 2a and 2b. These findings demonstrate an association of HCV RNA level with HIV viral load, independent of the level of immunosuppression. However, a substantial degree of the person-to-person variability in the prevalence and level of detectable HCV RNA remains unexplained.     

Hematological indices in a cohort of HTLV-I/II and HIV-1 infected intravenous drug users in New York City

The prevalence and clinical consequences of human T-cell lymphotropic viruses types I and II (HTLV-I/II) infection in human immunodeficiency virus-1 (HIV-1) infected persons are areas of continuing interest. This article reports the preliminary findings of the hematological indices in 454 patients infected with HIV-1 and HTLV-I/HTLV-II. Based on serology, 46.2% of the patients had evidence of HIV-1 infection only, 4.6% had evidence of HTLV-I/II only, 14.3% had evidence of both HIV-1 and HTLV-I/II, and 34.8% had evidence of neither HIV-1 or HTLV-I/II. The patient group with both HTLV-I/II and HIV-1 infection had lower total white blood cell, platelet, and serum hematocrits than patients with either HIV-1 or HTLV-I/II infection. While these differences were insignificant, they do not suggest any HTLV-I/II-induced protective effect against HIV-1 related hematological consequences.     

A histopathologic study of persistent generalized lymphadenopathy in intravenous drug abusers

Persistent generalized lymphadenopathy (PGL) has been reported in groups at risk for the acquired immunodeficiency syndrome including intravenous (iv) drug abusers. We investigated the histology of the lymph node biopsies obtained from 18 iv heroin abusers. All the patients (13 males and 5 females; median age 23.5) had generalized lymphadenopathy. This was associated with one or more systemic symptoms in 72% of the cases. Immunologic abnormalities were present in most of the patients. The overall histological picture consisted of a fairly repetitive pattern dominated by an exuberant and diffuse hyperplasia of frequently misshapen and poorly outlined follicles, associated with a striking proliferation of capillary vessels and a very consistent amount of plasma cells both extending in the follicular and interfollicular areas. Multinucleated giant cells of the Warthin-Finkeldey type ("mulberry cells") were encountered in 22% of the cases. It would appear that in the follicular district the most indicative diagnostic clues of PGL can be obtained if one considers the abnormal morphology of the follicles associated with a consistent presence of plasma cells and a scattered fine network of proliferating capillary vessels.     

Natural killer cells in intravenous drug abusers with lymphadenopathy syndrome.

We have investigated 25 intravenous drug abusers with the clinical and laboratory features of lymphadenopathy syndrome (LAS) and 10 AIDS patients for the expression of NK activity. LAS and AIDS patients had low NK cytotoxicity compared to normal donors. The defective NK cytotoxicity was analysed in the eight LAS subjects with most marked depression. NK effectors were identified by morphology (large granular lymphocytes, LGL) and monoclonal antibody-defined surface markers (B73.1, N901, HNK1). LAS patients had normal percentages of LGL and B73.1+ and N901+ cells. with the exception of two subjects with very low frequency of B73.1+ and N901+ cells. The percentage of HNK1+ cells was increased in LAS, probably because of the reactivity of this reagent with a subset of conventional OKT8+ cells, relatively augmented in LAS subjects. Depletion of monocytes did not enhance NK activity consistently. LAS patients had a normal frequency of cells capable of binding K562. In-vitro exposure to interferon beta (natural) or gamma (recombinant) augmented the defective NK activity of LAS subjects. Thus, patients with LAS have defective NK activity that cannot be accounted for by a low frequency of the relevant effector cells or by monocytic suppressors. These observations suggest a functional defect of NK cells at one or more of the post-binding steps required for the completion of killing.     

Lymph node immunohistology in intravenous drug abusers with persistent generalized lymphadenopathy

Lymph node biopsy specimens from 16 intravenous drug abusers with persistent generalized lymphadenopathy were evaluated by immunohistochemical methods using a panel of antisera to detect different cell populations. The 11 cases that we tested on cryostat sections showed an increased number of Leu-2a-positive cells (cytotoxic-suppressor phenotype) in the follicular centers and a significantly reduced helper-to-suppressor T-cell mean ratio when compared with control tissues. In these 11 patients the peripheral helper-suppressor ratio was at the lower normal limit or inverted. Ten cases tested for anti-human T-cell lymphotropic virus type III antibodies were positive. In all 16 cases, immunohistology of paraffin-embedded sections demonstrated a polyclonal B population; 12 of 15 patients tested had polyclonal hypergammaglobulinemia, mostly IgG. The mixed-cell population of the lymph node sinuses was composed mostly of Leu-M1-positive and lysozyme-positive cells and, to a lesser extent, by alpha 1-antichymotrypsin-positive and S100 protein-positive cells. It seems that many of the immunologic dysfunctions found in these patients appear to be reflected in a fairly repetitive immunohistologic pattern.     

Close relationships between neopterin and beta-2-microglobulin levels in intravenous drug abusers

Serum from 36 intravenous drug abusers without acquired immunodeficiency syndrome (AIDS) or AIDS-related complex were tested for concentrations of neopterin and beta 2-microglobulin. The seroprevalence of human immunodeficiency virus (HIV) antibody in this group was 50%. Previous studies of this group showed that the HIV antibody positive patients had significant increases in HLA-DR expression on peripheral blood lymphocytes and increases in serum soluble CD8 antigen. Both neopterin and beta 2-microglobulin concentrations were significantly higher in the HIV antibody seropositive patients compared to the seronegative patients (p = 0.001 and p = 0.005, respectively). A highly significant positive correlation between neopterin and beta 2-microglobulin was found for the seropositive patients (r = 0.8879, p less than 0.0001) as well as for the entire group (r = 0.6054, p = 0.0002). Significant positive correlations were also found between neopterin or beta 2-microglobulin and the percent DR + T cells and CD8 antigen levels, although these correlations were not as significant as that observed between neopterin and beta 2-microglobulin. No relationships were found between neopterin or beta 2-microglobulin and total CD4 cell concentrations or CD4/CD8 ratios. These data demonstrate the significant interrelationships between various immune activation markers in a population at risk for developing AIDS.     

Hepatitis C virus infection among noninjecting drug users in New York City

The prevalence of hepatitis C virus (HCV) infection among noninjecting drug users has been reported to be higher than in the general population, but the reasons for this observation remain unclear. Noninjecting drug users aged 15-40 years and who used drugs for no longer than 10 years were enrolled in the study. The participants were interviewed about risk behaviors and had specimens drawn for serological testing. Of 276 enrolled, 4.7% were infected with HCV. Drug users who had ever sniffed or snorted heroin in combination with cocaine were significantly more likely to be infected with HCV compared with those who never sniffed or snorted heroin with cocaine. No other drug use or sexual risk behaviors were found to be associated with HCV infection. These findings suggest that sniffing or snorting heroin with cocaine may explain the increase frequently found in HCV infection among noninjectors, but further studies are necessary.