Pulmonary tuberculosis in Kigali, Rwanda. Impact of human immunodeficiency virus infection on clinical and radiographic presentation.

The aim of the present study was to compare the clinical and radiographic presentation as well as the therapeutic outcome of pulmonary tuberculosis (PT) in adult patients with and without human immunodeficiency virus type 1 (HIV-1) infection in Kigali, Rwanda. Over a 17-month period 59 consecutive patients with bacteriologically and/or histopathologically documented PT were enrolled. Of these, 48 (81%) patients were HIV seropositive. Among these, 35 fit the WHO clinical criteria for AIDS (WHOCCA) at the time of admission. Significant differences were found between the HIV-seropositive and HIV-seronegative groups of patients: fever (85 versus 36%; p less than 0.001), tuberculin skin test anergy (69 versus 0%; p less than 0.01), mediastinal and/or hilar adenopathies (31 versus 0%; p = 0.05), and pleural effusion (43 versus 9%; p less than 0.05) were more frequently encountered in the HIV-seropositive group, and upper lobe infiltrates (55 versus 16%; p less than 0.02) and cavitation (91 versus 39%; p less than 0.003) were more often seen in the HIV-seronegative group. However, HIV-seropositive patients not meeting WHOCCA were less frequently anergic (0 versus 100%; p less than 0.001) and feverish (53 versus 97%; p less than 0.01) and more often had cavitation (69 versus 28%; p less than 0.02) and less often mediastinal and/or hilar adenopathies (7 versus 40%; p less than 0.04) compared with HIV-seropositive patients meeting WHOCCA. Under antituberculosis treatment, clearance of fever was slower in HIV-seropositive compared with HIV-seronegative patients, and among the HIV-seropositive group it was slower in those fitting WHOCCA.(ABSTRACT TRUNCATED AT 250 WORDS)     

Longitudinal study of cervical squamous intraepithelial lesions in human immunodeficiency virus (HIV)-seropositive and at-risk HIV-seronegative women

We examined incidence and correlates of progression and regression of abnormal cervical cytologic test results, defined as at least low-grade squamous intraepithelial lesions (SILs), in 774 human immunodeficiency virus (HIV)-seropositive and 391 HIV-seronegative women monitored semiannually for up to 5.5 years. During follow-up, 224 (35%) HIV-seropositive women and 34 (9%) HIV-seronegative women had incident SILs detected by Pap test; 47 (7%) HIV-seropositive women developed high-grade lesions. The incidence of SILs was 11.5 cases among HIV-seropositive and 2.6 cases among HIV-seronegative women per 100 person-years of observation (rate ratio, 4.5; 95% confidence interval, 3.1-6.4; P<.001). Risk of incident SILs and likelihood of Pap test progression were increased among HIV-seropositive women with CD4(+) lymphocyte counts <500 cells/mm(3) and among women with human papillomavirus (HPV) infection, with risk-ordering from low- to high-risk HPV type. SIL regression was less likely among HIV-seropositive women with higher HIV loads. No beneficial effect of highly active antiretroviral therapy was demonstrated.     

A retrospective cohort study of the risk of tuberculosis among women of childbearing age with HIV infection in Zaire

To determine the risk of active tuberculosis associated with HIV infection, we retrospectively studied a cohort of HIV-seropositive and HIV-seronegative women participating in an HIV perinatal transmission study in Kinshasa, Zaire. After a median follow-up of 32 months, new cases of proven pulmonary or clinically diagnosed tuberculosis occurred in 19 of the 249 HIV-seropositive women (7.6%, 3.1 cases per 100 person-years) compared with 1 of the 310 HIV-seronegative women (0.3%, 0.12 cases per 100 person-years), for a relative risk of 26 (95% confidence interval, 5 to 125). Proven pulmonary tuberculosis was diagnosed in 7 HIV-seropositive women (2.8%, 1.2 cases per 100 person-years) and 1 HIV-seronegative woman (0.3%, 0.12 cases per 100 person-years), for a relative risk of 10 (95% confidence interval, 1.5 to 47). We estimated that 66 cases of proven pulmonary tuberculosis in 100,000 person-years of follow-up in women of childbearing age could be attributed to HIV; this is 35% of their estimated total incidence of proven pulmonary tuberculosis. Among those followed for 2 yr, 27 (11%) of 243 HIV-seropositive women died during 2 yr of follow-up compared with none of 296 HIV-seronegative women (p less than 0.001). In HIV-seropositive women with proven or clinically diagnosed tuberculosis mortality was even higher: 5 (26%) of the 19 HIV-seropositive women with proven pulmonary or clinically diagnosed tuberculosis died during follow-up compared with 22 (10%) of the 224 HIV-seropositive women not diagnosed as having tuberculosis (relative risk 2.7; 95% confidence interval, 1.1 to 6.3).(ABSTRACT TRUNCATED AT 250 WORDS)     

Relapse rates after short-course (6-month) treatment of tuberculosis in HIV-infected and uninfected persons.

OBJECTIVE: To determine the rate of tuberculosis relapse among HIV-seropositive and -seronegative persons treated for active tuberculosis with short-course (6-month) therapy. DESIGN: Consecutive cohort study. SETTING: City of Baltimore tuberculosis clinic. PATIENTS: Tuberculosis patients treated between 1 January 1993 and 31 December 1996. INTERVENTION: Patients received 2 months of isoniazid, rifampin, pyrazinamide and ethambutol followed by 4 months of isoniazid and rifampin. MAIN OUTCOME MEASURE: Passive follow-up for tuberculosis relapse was performed through September 30, 1998. RESULTS: There were 423 cases of tuberculosis during the study period; 280 patients completed a 6-month course of therapy. Therapy was directly-observed for 94% of patients. Of those who completed therapy, 47 (17%) were HIV-seropositive, 127 (45%) were HIV-seronegative, and 106 (38%) had unknown HIV status. HIV-infected patients required more time to complete therapy (median 225 versus 205 days; P = 0.04) but converted sputum culture to negative within the same time period (median 77 versus 72 days; P = 0.43) as HIV-seronegative or unknown patients. Relapse occurred in three out of 47 (6.4%) HIV-infected patients compared to seven out of 127 (5.5%) HIV-seronegative patients (P = 1.0). Relapse rates also did not differ when HIV-seropositive patients were compared with HIV-seronegative and patients with unknown HIV status (6.4% versus 3.0%; P = 0.38). Of the 10 patients with tuberculosis relapse, restriction fragment length polymorphism data were available for five; all five relapse isolates matched the initial isolate. CONCLUSIONS: These results support current recommendations to treat tuberculosis in HIV-infected patients with short-course (6-month) therapy.     

HIV infection in patients with tuberculosis in Kinshasa, Zaire

To better define the interrelationship of infection with human immunodeficiency virus (HIV) and tuberculosis (TB), we conducted three HIV serosurveys of inpatients and outpatients with confirmed or suspected TB in Kinshasa, Zaire. HIV seroprevalence in hospitalized sanatorium patients did not change significantly in serosurveys conducted in 1985 and 1987 (92/231 [40%] versus 85/234 [36%]). These proportions were significantly higher than the 17% HIV seroprevalence observed in a 1987 serosurvey of 509 consecutive patients with an initial diagnosis of pulmonary TB seen at an outpatient TB diagnostic center in Kinshasa (p less than 0.001). HIV seroprevalence was higher in sanatorium patients with extrapulmonary TB (22/46 [48%]) and suspected pulmonary TB (60/132 [45%]) than in patients with bacteriologically confirmed pulmonary TB (94/287 [33%]) (p less than 0.02). Mycobacterium sputum isolation rates were similar in HIV-seropositive (28/34 [82%]) and HIV-seronegative patients (135/159 [85%]). All isolates were Mycobacterium tuberculosis. Eighteen (21%) of 84 HIV-seropositive sanatorium patients in 1987, who were followed for two months after admission, had died, compared with 11 (9%) of 128 HIV-seronegative patients (p less than 0.01). However, clearance rates of acid-fast bacilli from sputum after standard therapy were equally good in HIV-seropositive and HIV-seronegative survivors. With the growing AIDS problem, the serious TB burden in sub-Saharan Africa may become even more onerous and may critically overload the stressed African health care systems.     

Does infection with Human Immunodeficiency Virus affect the antibody responses to Plasmodium falciparum antigenic determinants in asymptomatic pregnant women?

OBJECTIVES: HIV-seropositive pregnant women are more susceptible to malaria than HIV-seronegative women. We assessed whether HIV infection alters maternal and cord plasma malarial antibody responses and the mother-to-infant transfer of malaria antibodies. METHODS: We determined plasma levels of maternal and cord antibodies [Immunoglobulin (IgG)] to recombinant malarial proteins [merozoite surface protein 1 (MSP-1(19kD)), the erythrocyte binding antigen (EBA-175)], the synthetic peptides [MSP-2, MSP-3, rhoptry associated protein 1 (RAP-1), and the pre-erythrocytic stage, circumsporozoite protein (NANP)(5)] antigenic determinants of Plasmodium falciparum; and tetanus toxoid (TT) by ELISA among samples of 99 HIV-seropositive mothers, 69 of their infants, 102 HIV-seronegative mothers and 62 of their infants. RESULTS: The prevalence of maternal antibodies to the malarial antigenic determinants ranged from 18% on MSP3 to 91% on EBA-175; in cord plasma it ranged from 13% to 91%, respectively. More than 97% of maternal and cord samples had antibodies to TT. In multivariate analysis, HIV infection was only associated with reduced antibodies to (NANP)(5) in maternal (P=0.001) and cord plasma (P=0.001); and reduced mother-to-infant antibody transfer to (NANP)(5) (P=0.012). This effect of HIV was independent of maternal age, gravidity and placental malaria. No consistent HIV-associated differences were observed for other antigenic determinants. CONCLUSION: An effect of HIV infection was only observed on one malarial antigenic determinant, suggesting that the increased susceptibility to malaria among HIV-infected pregnant women may not be explained on the basis of their reduced antibody response to malaria antigens.     

Pneumococcal bacteremia in adults in Soweto, South Africa, during the course of a decade.

We retrospectively reviewed 414 episodes of pneumococcal bacteremia that occurred in adults from July 1986 through June 1987 (1986/1987) and from July 1996 through June 1997 (1996/1997) to monitor the incidence and clinical and laboratory characteristics and to assess the influence of human immunodeficiency virus (HIV) infection on any changes. The incidence increased from 26 per 100,000 persons in 1986/1987 to 36 per 100,000 persons in 1996/1997; the increase was most marked among patients who were aged 25-44 years (24 cases per 100,000 persons to 45 per cases 100,000 persons) and > or =65 years (43 cases per 100,000 persons to 50 cases per 100,000 persons). Of 161 patients who were tested for HIV in 1996/1997, 108 (67%) were HIV seropositive. Among the general population, the prevalence of other underlying diseases and smoking decreased from 45% and 67%, respectively, in 1986/1987 to 23% (P<.0001) and 35% (P<.0001) in 1996/1997. Strains of pneumococci that were not susceptible to penicillin were found in 4% patients in 1986/1987 and 12% in 1996/1997 (P=.005). This increase occurred exclusively among the HIV-infected patients (22% of the HIV-seropositive patients versus 4% of HIV-seronegative patients; P=.008), and there was a parallel increase for childhood serotypes (51% of HIV-seropositive patients versus 17% of HIV-seronegative patients; P<.0001).     

Bacteremic pneumococcal pneumonia in HIV-seropositive and HIV-seronegative adults.

STUDY OBJECTIVES: To compare the demographic, clinical, laboratory, and microbiological data, and the hospital course and outcome of HIV-seropositive and HIV-seronegative adults with bacteremic pneumococcal pneumonia. DESIGN: Retrospective observation study conducted over a 2-year period. SETTING: Academic teaching hospital attached to the University of the Witwatersrand, Johannesburg, South Africa. PATIENTS: Consecutive patients with bacteremic pneumococcal pneumonia were identified on the basis of positive blood culture results. INTERVENTIONS: All available demographic, clinical, routine laboratory, radiographic, and microbiological data were recorded retrospectively for each of the patients, and the combined data for the HIV-seropositive patients were compared with those of the HIV-seronegative patients. MEASUREMENT AND RESULTS: A total of 112 patients (31 HIV-seropositive and 81 HIV-seronegative patients) were entered into the study. The HIV-seropositive patients were significantly younger than the HIV-seronegative patients (32.8 vs 39.6 years old) and had lower admission hemoglobin (11.8 vs 13.4 g/dL), WBC count (10.3 vs 14.3 x 10(9)/L), serum albumin (31 vs 36 g/L), sodium (129 vs 132 mmol/L), and potassium (3.0 vs 3.5 mmol/L), respectively. Although the HIV-seropositive patients appeared to have more multilobar pulmonary consolidation on the chest radiograph than the HIV-seronegative patients (60% vs 34%), this did not quite reach statistical significance. In addition, the HIV-seropositive patients had significantly more infections (48.4% vs 20.8%) with pneumococcal serogroups/serotypes (serogroups 6, 19, 23, and serotype 14) that are found more commonly in children, and they also had more penicillin-resistant isolates (13% vs 2.5%) than the HIV-seronegative patients, respectively. Similarly, it was noted that when these data were analyzed according to gender (irrespective of HIV status), women had significantly more infections than men (47% vs 21%) with serogroups/serotypes that are usually found in children, more penicillin-resistant isolates (15% vs 1%), and more co-trimoxazole-resistant isolates (21% vs 5%), respectively. There were no differences noted in any of the other parameters, including initial APACHE (acute physiology and chronic health evaluation) II score, PaO2/fraction of inspired oxygen ratio, duration of temperature, duration of IV therapy, duration of hospitalization, complications, and outcome, when comparing HIV-seropositive and HIV-seronegative patients. Two patients in each group died. CONCLUSIONS: The clinical features of bacteremic pneumococcal pneumonia are similar in HIV-seropositive and HIV-seronegative patients. Although differences are noted in various laboratory and microbiological parameters, they do not appear to have an impact on outcome.     

The effect of immunodeficiency on cutaneous delayed-type hypersensitivity testing in HIV-infected women without anergy: implications for tuberculin testing. HER Study Group. HIV Epidemiology Research.

SETTING: A collaborative study in four urban medical centers in the United States. OBJECTIVE: To determine the effect of human immunodeficiency virus (HIV) infection and immunodeficiency on delayed type hypersensitivity (DTH) responses and the implications for interpretation of tuberculin reactions in non-anergic women with or at risk for HIV infection. DESIGN: Demographic and behavioral information, HIV antibody testing, CD4+ lymphocyte counts, and cutaneous responses to DTH testing with mumps, Candida, tetanus toxoid, and tuberculin (purified protein derivative-PPD) antigens were obtained in 1184 women. RESULTS: Reactions to one or more of the four antigens occurred in 436 HIV-seropositive and 356 high-risk seronegative women. Among non-anergic women, HIV-seropositives were less likely (P < or = 0.05) to react to mumps (62% vs 81%), tetanus (72% vs 84%), and PPD (13% vs 19%). Induration in HIV-seropositive reactors was associated with CD4+ cell level for mumps (P = 0.004) and tetanus (P < 0.001), but not for Candida or PPD. HIV-seropositive reactors with CD4+ cell counts >500/mm3 did not have significantly smaller reactions than HIV-seronegatives for any antigen tested. PPD sizes were similar among HIV-seropositive reactors with CD4+ cell counts >500/mm3 (12.4 +/- 7.4 mm) and HIV-seronegative reactors (12.0 +/- 8.3 mm); induration > or =10 mm was seen in 16/173 (9.2%) seropositive women with CD4+ cell counts >500/mm3 and 41/356 (11.5%) seronegative women, respectively (P = 0.5). CONCLUSION: Among HIV-infected women able to react to a DTH antigen, induration in response to that antigen was relatively intact at CD4+ counts >500/mm3. This suggests that degree of immunodeficiency should be considered when interpreting PPD reactions in HIV-infected persons.     

Human immunodeficiency virus infection in tuberculosis patients

Human immunodeficiency virus (HIV) serology was performed in non-Asian-born patients 18-65 years old with newly diagnosed tuberculosis at a county tuberculosis clinic, and demographic and clinical features of HIV-seropositive and HIV-seronegative patients were compared. Sixty of 128 eligible patients agreed to participate, of whom 17 (28%) were seropositive. Risk of HIV was associated with homosexual contact, intravenous drug use, or both; however, 4 (24%) of the 17 seropositives denied risk behaviors. Significantly more blacks (48%) than whites (10%) or Latinos (20%) were HIV-seropositive (P less than .01). Site of disease, tuberculin reactivity, response to therapy, drug toxicity, and relapse did not differ significantly between groups. HIV-seropositive patients had significantly lower median CD4+ cell counts (326/mm3, range 23-742/mm3, vs. 929/mm3, range 145-2962/mm3, P less than .0005) and median CD4+:CD8+ ratios (0.50, range 0.14-1.07 vs. 1.54, range 0.35-4.36, P less than .0001). HIV infection is associated with clinically typical tuberculosis and HIV screening of tuberculosis patients is recommended in areas where HIV is endemic.     

HIV infection and primary resistance to antituberculosis drugs in Abidjan, C?te d'Ivoire.

OBJECTIVE: To determine the prevalence of Mycobacterium tuberculosis resistance to antituberculosis drugs, and to relate this resistance to HIV serologic status. DESIGN: Cross-sectional prevalence study. SETTING: The two major outpatient tuberculosis clinics in Abidjan, C?te d'Ivoire, West Africa. PATIENTS: Sixty individuals with newly diagnosed pulmonary tuberculosis and sputum smears positive for acid-fast bacilli. MAIN OUTCOME MEASURES: HIV serologic status and in vitro testing for susceptibility of M. tuberculosis isolates to antituberculosis drugs. RESULTS: M. tuberculosis was isolated from 82% (49 out of 60) of sputum specimens. Thirty-five per cent (17 out of 49) were obtained from HIV-seropositive and 65% (32 out of 49) from HIV-seronegative patients. There was no statistically significant difference in the proportion of resistant isolates from HIV-seropositive versus HIV-seronegative patients, although the relatively small sample size limited power. Of the total number of isolates, 17% were resistant to isoniazid; resistance was less to streptomycin (7%), rifampin (2%), pyrazinamide (0%), and ethambutol (0%). Eighteen and 21% of mycobacterial isolates from HIV-seropositive and HIV-seronegative individuals, respectively, were resistant to one or more of these drugs. CONCLUSIONS: Surveys of this type are useful in planning and evaluating tuberculosis preventive therapy in individuals with dual infection.     

Class-specific antibody response to pneumococcal capsular polysaccharides in men infected with human immunodeficiency virus type 1

We characterized the effect of infection with human immunodeficiency virus type 1 (HIV) on levels of total immunoglobulins and pneumococcal vaccine-specific immunoglobulins in 28 heterosexual and 25 homosexual men seronegative for HIV; 27 asymptomatic, seropositive homosexual men; and 21 patients with AIDS. Total serum IgG levels were increased in both HIV-seropositive groups compared with the HIV-seronegative men (P less than .001). Total IgM levels, however, were elevated only in the asymptomatic, HIV-seropositive men (P less than .08); total IgA levels were elevated only in the patients with AIDS (P less than .05). Vaccine-specific serum IgG, IgM, and IgA significantly increased over baseline three and six weeks after immunization in all groups (P less than .05). Responses to vaccine among the HIV-seronegative groups were similar but were greater for all antibody classes than were responses among the HIV-seropositive groups (P less than .05).     

Helicobacter pylori infection in symptomatic HIV-seropositive and -seronegative patients: a case-control study

We conducted a case-control study in a Greek hospital to evaluate the prevalence and morbidity of Helicobacter pylori in HIV-infected patients. HIV-seropositive patients were infected by H. pylori less often than HIV-seronegative controls [12/58 (20.7%) versus 38/58 (65.5%),p < 0.001]. The mean CD4 count was lower for H. pylori-negative than H. pylori-positive HIV-infected patients (p < 0.007). Also, among HIV patients, prior use of antibiotics or proton pump inhibitors was more common in those without H. pylori infection, however, this difference was not statistically significant (p = 0.06). The grading of the density of H. pylori infection and the grading of the histomorphological findings according to the Sydney classification were similar between HIV-seropositive and -seronegative patients with H. pylori infection.     

Population-based study of malignancies and HIV infection among injecting drug users in a New York City methadone treatment program, 1985-1991.

OBJECTIVE: To study the incidence of AIDS-defining and non-AIDS-defining malignancies in injecting drug users with and without HIV infection in a methadone maintenance treatment program (MMTP). DESIGN: Prospective study within a hospital-affiliated MMTP with on-site primary medical services. The MMTP has been the site of a voluntary longitudinal cohort study of HIV infection since 1985. METHODS: Active surveillance for all new cancer cases occurring among patients in the MMTP between July 1985 and August 1991. Cancer cases were identified by review of clinic and hospital records, hospital-based tumor registries, and New York City vital records. Cancer incidence was determined for the overall MMTP population and for HIV-seropositive and HIV-seronegative cohort study subgroups. RESULTS: During the study period the MMTP population comprised 2174 patients followed for 5491 person-years; 844 patients (380 HIV-seropositive, 464 HIV-seronegative) also participated in the cohort study. Fifteen non-AIDS-defining malignancies occurred among all MMTP patients (2.73 cases per 1000 person-years); the most frequent sites were lung, larynx, and cervix (n = 6, 2 and 2, respectively). Eighty per cent of patients with these cancer diagnoses and known HIV serologic status were seropositive. Within the cohort study group, six out of 380 HIV-seropositives developed non-AIDS-defining cancers versus one out of 464 HIV-seronegatives (P = 0.05, Fisher's exact test). Lung cancer cases in HIV-seropositive patients tended to occur at an earlier age and was more aggressive than in patients with HIV-seronegative or unknown status. During the same period, two cases of AIDS-defining lymphoma and one case of Kaposi's sarcoma were diagnosed in the MMTP population (0.5 cases per 1000 person-years). CONCLUSION: Solid neoplasms, while infrequent, were associated with HIV infection and were more common than AIDS-defining cancers in this population of drug injectors. Further study is needed to explore the relationship between HIV, behavioral factors, and cancer risk in injecting drug users.     

HIV prevalence, immunosuppression, and drug resistance in patients with tuberculosis in an area endemic for AIDS.

From October 1987 to June 1988, we attempted to determine the prevalence of HIV infection among patients hospitalized with tuberculosis and the extent of immunosuppression among those tuberculosis patients infected with HIV. Of 178 consecutive patients, 18-65 years of age, who were hospitalized with newly diagnosed, previously untreated tuberculosis, 46% (82 out of 178) had clinical or serological evidence of HIV infection, 30% (54 out of 178) were HIV-seronegative, and 24% (42 out of 178) could not be assessed for the presence of HIV infection. Among the HIV-seropositive patients without an AIDS-defining diagnosis by non-tuberculous criteria, the median CD4 lymphocyte (CD4) count was 133 x 10(6) cells/l (range: 11-677 x 10(6]; among the HIV-seronegative patients, the median CD4 count was 613 x 10(6) cells/l (range: 238-1614 x 10(6); P less than 0.001). Among the HIV-seropositive patients, those with disseminated tuberculosis (median CD4 = 79 x 10(6) cells/l) and those with pulmonary tuberculosis who had radiographic evidence of mediastinal or hilar adenopathy (median CD4 = 45 x 10(6) cells/l) had the most severe CD4 depletion, whereas those with localized extrapulmonary tuberculosis (median CD4 = 242 x 10(6) cells/l) and those with pulmonary tuberculosis without adenopathy (median CD4 = 299 x 10(6) cells/l) were less severely immunosuppressed. Of the 178 patients, 6% (11 out of 178) were infected with strains of Mycobacterium tuberculosis resistant to both isoniazid and rifampin.     

Violence Among Women with or at Risk for HIV Infection

To estimate the prevalence and to identify correlates of physical and sexual assaults or abuse among women with or at risk for HIV infection, a cross-sectional survey was conducted within a longitudinal cohort study. A total of 765 HIV-seropositive and 367 HIV-seronegative women with a history of injection drug use (51%) or high-risk sex (49%) completed the interview. Both physical abuse and sexual abuse as a child were common for both HIV-seropositive (41.3%, 41.0%) and uninfected women (43.3%, 45.8%), respectively. Both physical abuse and sexual abuse as adults were even more common in both HIV-seropositive (66.4%, 45.7%) and HIV-seronegative women (69.2%, 48.8%), respectively. In the 6 months prior to interview, the most important predictors for being the victim of violence was age <30 years old, use of crack, use of marijuana, having multiple sex partners, and not having a steady sex partner. However, even after accounting for these other factors, HIV-infected women with low CD4 cell counts (<350/l) were less likely than the other women to experience recent violence. While the lower rate of recent violence among those with low CD4 cell count probably represents effects of HIV-related disability, women at high risk for HIV remain at high risk for violence. Both HIV prevention and treatment services need to recognize the background level of violence and incorporate appropriate counseling services.     

Impact of human immunodeficiency virus type 1 on tuberculosis in rural Haiti

We conducted a case-control study to determine the relative and attributable risk of HIV seropositivity for bacillary-positive (smear and/or culture) pulmonary tuberculosis in Haiti. There were 274 patients with tuberculosis and an equal number of control subjects. Antibodies to HIV were present in 67 (24%) patients and eight (3%) control subjects. Odds ratios suggested that the risk of pulmonary tuberculosis was 15.7 times as great (95% confidence interval, 4.8 to 5.0; p less than 0.05) in patients 20 to 39 yr of age who were HIV-seropositive than in HIV-seronegative patients. In contrast, the relative risk in those 40 to 59 yr of age was elevated (3.0 times), though not significantly (lower 95% confidence interval, 0.8). In the 20- to 39-yr age group, 31% of tuberculosis was attributable to HIV infection (95% confidence interval between 23 and 39%). HIV-seropositive and HIV-seronegative patients did not differ with respect to sputum smear positivity. HIV-seronegative patients were twice as likely to be infected with resistant organisms, though this was not significant. We conclude that HIV infection is a major risk factor for pulmonary tuberculosis in young adult residents of Haiti. This, together with the fact that similar proportions of HIV-seropositive and HIV-seronegative patients were potentially infectious, suggests that without vigorous counteraction tuberculosis will become a greater problem for Haiti.     

Cryptogenic liver disease in HIV-seropositive men

Objectives In the era of highly active antiretroviral therapy (HAART), liver disease has become a leading cause of morbidity and mortality in HIV-seropositive individuals. Although liver disease is commonly caused by viral co-infection, it has also been described in patients without viral hepatitis. In this study, we determined clinical factors associated with the development of cryptogenic liver disease in HIV-infected individuals.
Methods HIV-seropositive and -seronegative patients undergoing evaluation for liver transplantation were selected if they met clinical criteria for cryptogenic liver disease. Clinical data were collected retrospectively, and radiological and histological data were reviewed separately.
Results Nine HIV-seropositive individuals were compared with 41 HIV-seronegative patients with cryptogenic liver disease. Only one HIV-seropositive patient (11%) had cirrhosis, compared to 39 HIV-seronegative patients (93%) ( P <0.001). Three HIV-infected patients (33%) had histological evidence of nodular regenerative hyperplasia. HIV-seropositive patients had significantly lower body mass indices, and lower Child–Pugh–Turcotte and Model for Endstage Liver Disease scores than HIV-seronegative patients ( P <0.05).
Conclusions Advanced cryptogenic liver disease in HIV-infected patients is infrequently caused by cirrhosis, and more frequently by nodular regenerative hyperplasia. This disease entity may become more common in the HAART era, and may contribute to an increased morbidity in HIV-infected individuals.     

Immunological investigation in hemophiliacs with and without human immunodeficiency virus (HIV) infection]

Immunological studies were carried out in three HIV-seropositive hemophiliacs and the results were compared with those of 26 HIV-seronegative hemophiliacs 18 normal controls. In the three HIV-seropositive hemophiliacs it was demonstrated that there was a decrease in peripheral helper T cells, a fact significantly different from normal controls (P less than 0.05); there was an increase in peripheral suppressor T cells and a decrease in helper to suppressor T cell ratio, another fact significantly different from normal controls (P less than 0.005, P less than 0.002 respectively) as well as HIV-seronegative hemophiliacs (P less than 0.02). In addition, all three HIV-seropositive hemophiliacs had anergy for 1:2000 OT test. It appeared that these immunological abnormalities are the results of HIV infection. The number of peripheral helper T cell and suppressor T cells and the ratio of helper to suppressor cells in the HIV-seronegative hemophiliacs did not differ from those in normal controls. Among 15 HIV-seronegative hemophiliacs tested with 1:2000 OT, only two showed anergy. The findings in our study differed somewhat from those reported abroad. This difference may be due to the fact that our hemophilic patients had been treated with much smaller doses of blood products for alleviating coagulation defects.     

HIV increases the risk of malaria in women of all gravidities in Kisumu,Kenya

OBJECTIVE: To study the importance of HIV infection for malaria in pregnancy in Kisumu, Kenya. SUBJECTS AND METHODS: Healthy women with an uncomplicated pregnancy of 32 weeks or more attending the prenatal clinic in the Provincial Hospital between June 1996 and March 1999 were tested for HIV and malaria after consent had been obtained. For participating women who delivered in the same hospital, a blood smear of the mother and the placenta were obtained. RESULTS: In the third trimester, 5093 women consented to testing: the prevalence of malaria and HIV was 20.1 and 24.9%, respectively. Among the 2502 screened women who delivered in the hospital, the prevalence of HIV, peripheral parasitaemia and placental malaria was 24.5, 15.2, and 19.0%, respectively. Compared with HIV-seronegative women, HIV-seropositive women were more likely to be parasitaemic, to have higher parasite densities, and to be febrile when parasitaemic. Placental infections in HIV-seropositive women were more likely to be chronic, as indicated by the presence of moderate to heavy pigment depositions. When adjusted by age, the typical gravidity-specific pattern of malaria in pregnancy disappeared in HIV-seropositive women; HIV-seropositive primigravidae had a similar risk of malaria as HIV-seropositive multigravidae. The excess malaria attributable to HIV in the third trimester increased from 34.6% among HIV-seropositive primigravidae, to 41.5% among HIV-seropositive secundigravidae, and 50.7% among HIV-seropositive gravidae with three or more pregnancies. CONCLUSION: HIV infection alters patterns of malaria in pregnant women; in areas with both infections, all pregnant women should use malaria prevention.