The Evolution of Candida Species and Fluconazole Susceptibility among Oral and Vaginal Isolates Recovered from Human Immunodeficiency Virus (HIV)-Seropositive and At-Risk HIV-Seronegative Women.

Antifungal agents can effectively treat mucosal candidiasis; however, their use can lead to colonization with less susceptible species and to resistance among normally susceptible strains. Oral and vaginal Candida isolates obtained at 3 points over 2 years from human immunodeficiency virus (HIV)-seropositive and at-risk HIV-seronegative women were identified by species and were evaluated for in vitro fluconazole susceptibility. Prevalence of non-C. albicans strains increased over time, and these strains were more likely among women reporting current antifungal use. Among C. albicans isolates, resistance was rare, with no evidence for progressive reduction in susceptibility over time. Among non-C. albicans isolates, reduced susceptibility occurred frequently and increased with time. HIV-seropositive women were more likely to have non-C. albicans isolates with reduced susceptibility as were women reporting current antifungal use. This evolution and selection of mucosa-colonizing Candida species with reduced susceptibility could play a critical early role in the development of antifungal resistance among C. albicans isolates responsible for refractory candidiasis.

Severe adverse life events and depressive symptoms among women with, or at risk for, HIV infection in four cities in the United States of America.

OBJECTIVE: To examine frequency and predictors of severe adverse life events and depressive symptoms among HIV-infected women and a comparison group of uninfected women. DESIGN: Analysis of baseline data collected from HIV-infected and uninfected women in a prospective cohort study of HIV infection and women, the HIV Epidemiologic Research Study. METHOD: The sample of 871 HIV-infected and 439 demographically and behaviorally similar uninfected women were recruited from four metropolitan areas in the USA. Women provided interview information that included sociodemographic characteristics, sexual and drug-using behaviors, and social and psychological functioning. The outcome measures were number of severe adverse life events (e.g., insufficient money for necessities, physical attack or rape, death of a person close to them) and levels of depressive symptoms. RESULTS: HIV-infected and uninfected women reported numerous adverse life events and high levels of depressive symptoms. The two groups, however, did not differ on either outcome measure. Low socio-economic status, injecting drug and crack cocaine use, and high risk sexual activity were related to reports of more adverse events and depressive symptoms for both groups. CONCLUSIONS: HIV-infected and uninfected women in socially and economically disadvantaged environments experience many adverse events and high levels of depressive symptoms. HIV infection, at least during the early phase, may be less important than socio-environmental factors in predicting negative psychosocial outcomes for women.

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

OBJECTIVE: To determine whether highly active retroviral therapy (HAART) is associated with better neurocognitive outcome over time among HIV-infected women with severely impaired immune function. METHODS: A semiannual neurocognitive examination on four tasks was administered: Color Trail Making, Controlled Oral Word Association, Grooved Pegboard and Four-Word Learning. This protocol was initiated in the HIV Epidemiological Research study (HERS) study when a woman's CD4 cell count fell to < 100 x 10(6) cells/l. Immune function (CD4), viral load status and depression severity (CESD) were also assessed semi-annually, along with an interview to determine medication intake and illicit drug use. RESULTS: HAART was not available to any participant at the time of enrollment (baseline), while 44% reported taking HAART at their most recent visit (mean duration of HAART 36.3 +/- 12.6 months). HAART-treated women had improved neurocognitive performance compared with those not treated with HAART. Women taking HAART for 18 months or more showed the strongest neurocognitive performance with improved verbal fluency, psychomotor and executive functions. These functions worsened among women not taking HAART. Substance abuse status, severity of depressive symptoms, age and educational level did not influence the HAART treatment effects on neurocognitive performance. Neurocognitive improvements were strongly associated with the magnitude of CD4 cell count increases. CONCLUSIONS: HAART appeared to produce beneficial effect on neurocognitive functioning in HIV-infected women with severely impaired immune systems. Benefits were greatest for women who reported receiving HAART for more than 18 months.

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

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

Oral lesions among women living with or at risk for HIV infection. HIV Epidemiology Research Study (HERS) Group.

PURPOSE: Our objectives were to compare the prevalence of oropharyngeal mucosal lesions among human immunodeficiency virus (HIV) seropositive and demographically similar seronegative women, and to determine the association of oral lesions with immunosuppression, substance abuse, use of medications, and utilization of dental services. POPULATION AND METHODS: Participants in a multicenter, longitudinal cohort study of HIV infection in women were evaluated at baseline by interview, physical examination, and laboratory studies. RESULTS: Oropharyngeal pathology was found in 40% of seropositive and 23% of seronegative women. Oral candidiasis was identified in 15% of seropositive and 3% of seronegative women. Among seropositive women, history of previous oral candidiasis, lower CD4 lymphocyte counts, and current antibiotic use were associated with oral candidiasis. Hairy leukoplakia was identified in 5% of seropositive women and was significantly associated with lower CD4 lymphocyte counts. Gingival erythema and ulcerative gingivitis were found in 23% of participants overall, but were unrelated to HIV serostatus or CD4 lymphocyte count. Substance abuse, lack of dental care, and African-American race were associated with gingival pathology. CONCLUSION: The high prevalence of oral lesions among HIV seropositive and at-risk seronegative women underscores the need for routine oral examination and targeted treatment of this population.

Adrenal insufficiency, recurrent bacteremia, and disseminated abscesses caused by Nocardia asteroides in a patient with acquired immunodeficiency syndrome.

Nocardia asteroides is an opportunistic pathogen of increasing incidence in human immunodeficiency virus (HIV)-infected persons. The lungs are the most common site of infection, followed by the brain; involvement of other extrapulmonary sites is less common. We describe a patient with acquired immunodeficiency syndrome who presented with a number of unique manifestations of nocardial infection: the first reported case of bilateral adrenal abscesses with adrenal insufficiency, the first case of a renal abscess due to N. asteroides alone, and the first case of recurrent, symptomatic bacteremia. A review of the literature on nocardial infections in HIV-positive individuals is presented.

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.

Highly active antiretroviral therapy associated with improved anemia among HIV-infected women.

Anemia is common during human immunodeficiency virus (HIV) infection and is associated with increased mortality. We conducted a study to examine the impact of highly active antiretroviral therapy (HAART) on anemia in a multicenter cohort of HIV-positive women, the Human Immunodeficiency Virus Epidemiology Research (HER) Study. Among women receiving HAART (n = 188), non-HAART monotherapy or combination antiretroviral therapy (ART) (n = 111), or who had no reported treatment (n = 62), the prevalence of anemia (hemoglobin, <120 g/L) at baseline was 38.3, 36.9, and 43.6%, respectively (p = 0.58) and at 1-year follow-up was 26.1%, 36.9%, 45.2%, respectively (p = 0.01); mean hemoglobin at baseline was 125 +/- 16, 122 +/- 16, and 122 +/- 18 g/L, respectively (p = 0.29) and at 1-year follow-up was 128 +/- 14, 123 +/- 16, and 119 +/- 20 g/L, respectively (p < 0.0001). Adjusted linear regression models showed that HAART was associated with an increase of hemoglobin of 0.20 g/L per month (p = 0.007). After 1 year of treatment, HAART was associated with a 32% reduction in anemia among HIV-infected women (p = 0.01), whereas there was no significant change in the prevalence of anemia among those on non-HAART ART or those who had no reported treatment. HAART is associated with a large reduction in anemia among HIV-infected women.

Women and AIDS.

The number and proportion of women infected with the human immunodeficiency virus (HIV) and with the acquired immunodeficiency syndrome (AIDS) have increased rapidly throughout the last decade. Despite these increases, the scientific community has focused limited research attention on women living with HIV infection. Data from studies of predominantly gay/bisexual men may not reliably be extended to women; studies of the natural history of HIV infection in women are needed. Obstetrician-gynaecologists are increasingly called upon to diagnose HIV infection in women and provide care in both clinical and research settings. In this review we discuss the serodiagnosis of HIV infection in women; the impact of pregnancy on HIV disease progression; transmission of HIV infection from mother to offspring; gynaecological infections and malignancies which may manifest differently in HIV-infected women; and clinical care of women living with HIV.

PIP: More than 50% of US women with AIDS live in New York City, Newark, Baltimore, and Washington, D.C. Most are of reproductive age. About 75% are Black or Hispanic. Few women are part of AIDS clinical trials. A mix of socioeconomic and demographic factors prevent HIV-positive women from receiving optimal care and being part of research. Researchers has not observed these barriers earlier in the AIDS epidemic. Obstetrician-gynecologists (OB/GYNs) are often the first health providers to diagnose and treat HIV infection since HIV-infected women have a high rate of gynecological infections and malignancies. Many women first learn their HIV status after being treated during pregnancy. Many HIV-infected women have no perceived risk factors and have acquired HIV via heterosexual transmission. HIV infection does not appear to reduce fertility, adversely affect pregnancy outcome, or cause menstrual disturbance. Some physicians suggest that HIV testing should be offered to all pregnant patients, women using IV drugs, women with malignant and premalignant lesions of the genital tract and high-risk behavior, and women with tuberculosis or severe bacterial infections. The risk of sexual transmission of HIV from male to female is 2-16 times greater than it is from female to male. HIV prevalence in postpartum women in some hospitals in some large US cities is as high as that in central Africa. The US vertical transmission rate ranges from 15 to 30%. Essential to improving the situation are: cooperation among researchers to promote studies for and about women, independent of their role in transmitting HIV to partners or children; clinicians mastering their prejudices and abiding by the highest standards of care; and a public policy which upholds reproductive choice for all women regardless of their HIV status. OB/GYNs will be summoned more and more to lead efforts to eliminate barriers to improve care and research.

Adherence discourse among African-American women taking HAART.

Low adherence is the single most important challenge to controlling HIV through the use of high acting anti-retrovirals (HAART). Non-adherence poses an immediate threat to individuals who develop resistant forms of the virus as well as a public health threat if those individuals pass on treatment-resistant forms of the virus. To understand the concerns and perceptions that promote or deter adherence to antiretroviral medication by HIV-positive African-American women, we conducted in-depth interviews with 15 African-American women taking HAART. We focused on the discourse and narratives women use in talking about their adherence practice. Discourse analysis was utilized to identify and explore the sources of influence used by these women in describing their adherence practice. Roughly a third of the sample fell into each of the three self-assessed adherence categories: always adherent, mostly adherent and somewhat adherent. Among the 'always adherent', 80% of the sources of influence cited supported adherence, while only 48% and 47% of the authoritative sources cited by women in the 'mostly' and 'somewhat' categories supported adherence. Each self-assessed adherence group was characterized by its own distinctive discourse style. Findings suggest that adherence to HAART among African-American HIV-positive women would be improved by identifying those influences undermining adherence. Focused study of the 'always adherent' types is recommended.

Qualitative identification of rigid gas permeable contact lens materials by densitometry.

PURPOSE: We describe a practical method to qualitatively identify polymethylmethacrylate (PMMA) and rigid gas permeable (RGP) contact lens materials. METHODS: By progressive dilution of a saturated saline solution made with distilled or tap water and sodium chloride, we recorded comparative densitometry of rigid contact lens materials using a small hydrometer or by liquid displacement. RESULTS: The method was sensitive enough to separate the polymethylmethacrylate, all silicon-methacrylates, and all but two fluorine-containing silicon-methacrylates. The hydrometer had a precision of three decimals rounded to the nearest 0.005. There was only one RGP product that could have been confused with the PMMA material. Most silicon-methacrylates had lower densities than fluorine containing silicon-methacrylates. Only four of 25 products under 1.117 gm/cm3 contained fluorine. CONCLUSIONS: Densitometry with a hydrometer is an effective non-destructive method to identify RGP materials and to verify their quality. The method is easier when lens blanks are tested, but in spite of differences in shape, size, and weight, densitometry may also be used with new or used contact lenses. Its simplicity and low cost makes densitometry feasible for any contact lens laboratory or clinic to use on a routine basis. Only silicon-methacrylates had an inverse relationship between density and oxygen permeability. As the silicon content of the contact lens increases, the Dk increases and the density decreases.

Aphthous vaginal ulceration in two women with acquired immunodeficiency syndrome.

Two women with advanced human immunodeficiency virus infection are described who were seen with painful aphthous vaginal ulceration and CD4+ lymphocyte counts < 50 cells/mm3. A chronic rectovaginal fistula developed in one patient. In spite of extensive investigation no underlying cause of the ulceration was discovered. Clinical therapeutic response suggests that corticosteroid therapy may be of value in healing or stabilizing the destructive process. Clinicians should be aware of this complication in human immunodeficiency virus-infected women with severe vaginal pain and unexplained discharge.

Detection of Pneumocystis carinii in a rat model of infection by polymerase chain reaction.

The polymerase chain reaction (PCR) was employed to detect Pneumocystis carinii in organs of infected rats. Using a pair of oligonucleotides designed to the dihydrofolate reductase (DHFR) gene of rat P. carinii, specific amplification of an expected 415 bp region of P. carinii DHFR DNA of this organism was achieved, while no amplification occurred with the human, Candida albicans, and Mycobacterium avium and tuberculosis DNAs. Using rat P. carinii isolated from in vitro cultures and infected lung homogenates, the minimum detection level by PCR on an ethidium bromide gel was about 200 organisms and by Southern analysis with radiolabelled DHFR probe the detection level improved to 20 organisms. This level of sensitivity is sufficient to detect P. carinii specific band on the gel in infected rat lung and other organs. This PCR technique is potentially useful for detecting P. carinii in bronchoalveolar lavage (BAL) fluids of AIDS patients and for quantifying the organisms in tissues and in in vitro cultures where a high background with conventional stains makes it harder to determine the number of organisms.

Sexual practices in a cohort of US women with and without human immunodeficiency virus. HERS Study. HIV Epidemiology Research Study.

OBJECTIVES: To compare the frequency and pattern of sexual activities of women infected with human immunodeficiency virus (HIV) relative to uninfected women at the time of enrollment into a multisite cohort study. METHODS: The HIV Epidemiology Research Study (HERS) is a prospective study following 873 HIV-infected and 438 HIV-uninfected women. The baseline protocol included interviews about sexual practices, sociodemographic information, and drug and alcohol use, as well as clinical and laboratory studies. Multiple logistic regression models estimated differences between infected and uninfected women in relation to sexual activity and practice. RESULTS: 77% of infected women and 89% of uninfected women reported at least one sexual partner in the six months before study entry. Among sexually active women, specific practices varied little by HIV serostatus, with the exception of oral sex, which was more frequently performed and received by uninfected women. Despite the high prevalence of sexual activity, infected women were 2.5 times as likely not to have had any recent sexual partners as uninfected women (95% CI = 1.77-3.44). CONCLUSIONS: Women who decrease or altogether stop engaging in sexual partnerships may benefit from direct counseling in relation to underlying loss of sexual affection.

Criteria for assessing cutaneous anergy in women with or at risk for HIV infection. HIV Epidemiologic Research Study Group.

BACKGROUND: Controversy exists about both the clinical utility of anergy testing and the optimal criteria for defining anergy. OBJECTIVE: We sought to assess various definitions of cutaneous anergy for ability to distinguish HIV status, level of immunodeficiency, and ability to mount a tuberculin reaction among women with or at risk for HIV infection. METHODS: HIV-seropositive (n = 721) and HIV-seronegative (n = 358) at-risk women at academic medical centers in Baltimore, Detroit, New York, and Providence had cutaneous testing with mumps, Candida, tetanus toxoid, and tuberculin antigens. Associations with HIV status and CD4+ lymphocyte levels were analyzed. RESULTS: Candida, mumps, and tetanus antigens alone or in combination elicited reactions significantly less often in HIV-seropositive than in HIV-seronegative women and less often in seropositive women with lower CD4+ counts, regardless of induration cutpoint chosen to define a positive reaction. The best antigen combinations for distinguishing groups included tetanus and mumps. Some women nonreactive to the 3 antigens ("anergic") had positive tuberculin reactions among both seropositive subjects (range, 1.1% to 2.9% depending on induration cutpoint for defining anergy) and seronegative subjects (range, 8.9% to 14%). CONCLUSION: Absence of reactions to Candida, mumps, and tetanus antigens alone or in combination and at any induration cutpoint is associated with HIV status and with CD4+ level. Combinations, including tetanus and mumps antigens with an induration cutpoint of less than 2 mm, may be the best for defining anergy.

Health services use by urban women with or at risk for HIV-1 infection: the HIV Epidemiology Research Study (HERS).

OBJECTIVE: To characterize health services use by urban women with or at risk for HIV-1 infection enrolled in a prospective multicenter study. METHODS: 1310 women 16 to 55 years of age who were at risk for HIV-1 infection were recruited between April 1993 and January 1995 at four urban centers (Baltimore, Maryland; The Bronx, New York; Detroit, Michigan; and Providence, Rhode Island). HIV-1-seropositive women without AIDS-defining illness were oversampled in a ratio of 2:1 in comparison with HIV-1-seronegative women. At a baseline study visit, the women received physical and laboratory examinations, including CD4+ counts, and were interviewed regarding HIV risk behavior, health services use, and clinical data. RESULTS: 863 women were HIV-1-seropositive and 430 were HIV-1-seronegative. Fifty-two percent of the women reported injection drug use (IDU) since 1985, and 48% acquired HIV through sexual contact. Seventy-seven percent were African American, 23% were white, and 16% were Hispanic. The median age was 35 years. HIV-seronegative women were significantly less likely to have health insurance (19%) than were HIV-seropositive women (30%; p < .001). Among the HIV-seropositive women, 68% had CD4+ cell counts of <500/microl, and 64% were asymptomatic. Sixty-four percent of the HIV-seronegative women had had an outpatient hospital visit in the past 6 months, as had 86% of HIV-seropositive women (p < 0.001). Hospitalization in the past 6 months was also higher in HIV-seropositive women (22% vs. 12%; p < .001). Despite heavy use of health services, only 49% of women with CD4+ counts of <200/microl reported current use of antiretroviral therapy, and only 58% reported current use of Pneumocystis carinii pneumonia (PCP) prophylaxis. Among HIV-seropositive women, and after adjusting for CD4+ count, HIV symptoms, race, and study site, IDUs were significantly less likely to have a regular doctor and a recent outpatient visit and more likely to be hospitalized and use the emergency department (ED) than were non-IDUs. In multivariate analyses of HIV-seropositive persons, African American women had similar access to care and use of antiretroviral therapy and PCP prophylaxis than did white women but were less likely to have an outpatient department visit in the previous 6 months and to be taking PCP and opportunistic infection (OI) prophylaxis. Health services access and use of HIV-related therapies did not significantly differ between Hispanic and white women with HIV infection. CONCLUSION: Although both HIV-seropositive and HIV-seronegative women had high levels of use of medical services, current use of antiretrovirals and OI prophylaxis was low throughout, and IDUs used HIV-related primary health services less and were more likely to receive emergency or episodic care. IDU and African American race were independently associated with decreased use of medical services.

Evolution of vaginal Candida species recovered from human immunodeficiency virus-infected women receiving fluconazole prophylaxis: the emergence of Candida glabrata? Terry Beirn Community Programs for Clinical Research in AIDS (CPCRA).

The effect of fluconazole prophylaxis on the vaginal flora of 323 human immunodeficiency virus-infected women was evaluated in a multicenter, randomized, double-blind, placebo-controlled trial. Women with CD4 cell counts of < or = 300/mm3 received either 200 mg of fluconazole per week or placebo. Vaginal surveillance cultures were performed every 3 months. After a follow-up of 29 months, Candida albicans was recovered from 53% of patients receiving fluconazole and 68% of patients assigned placebo. Fluconazole was associated with a 50% reduction in the odds of being colonized with C. albicans but with higher rates for non-albicans Candida species. Candida glabrata was recovered from 40 women assigned fluconazole and 29 assigned placebo (relative odds, 1.96; 95% confidence interval, 0.98-3.94). Fluconazole had an early and persistent effect on the vaginal mycoflora, with the emergence of C. glabrata vaginal colonization within the first 6 months. The effect of fluconazole prophylaxis can be attributed to the reduction in vaginal C. albicans colonization; however, C. glabrata colonization rapidly supervened.

Self-reported bacterial infections among women with or at risk for human immunodeficiency virus infection.

Bacterial infections are a major cause of morbidity and mortality in persons with human immunodeficiency virus (HIV) infection, particularly women. We performed a cross-sectional analysis of a history of bacterial infections among 1,310 women with or at risk for HIV infection. HIV-seropositive women were significantly more likely than seronegative women to report recent and lifetime histories of bacterial infection, even after history of injection drug use since 1977 was adjusted for; this included recent pneumonia (odds ratio [OR], 3.2; 95% confidence interval [CI], 1.5-6.6), sinusitis (OR, 1.4; 95% CI, 1.0-2.0), and urinary tract infection (OR, 1.5; 95% CI, 1.1-2.1). Compared with HIV-negative women, women with CD4 cell counts of <200 were about eight times more likely to report recent pneumonia (OR, 7.8; 95% CI, 3.4-17.7); those with CD4 cell counts of 200-500 were almost three times more likely to do so (OR, 2.6; CI, 1.2-5.7). Logistic regression analysis revealed that only CD4 cell category and a recent history of smoking had a significant relationship to self-reported pneumonia.

Human papillomavirus-associated cervical cytologic abnormalities among women with or at risk of infection with human immunodeficiency virus.

OBJECTIVE: Correlates of abnormal human immunodeficiency virus cervical cytologic findings were examined among women infected with human immunodeficiency virus and uninfected women. STUDY DESIGN: We performed a cross-sectional analysis of baseline data on demographically similar women with infection or risk factors for it. RESULTS: Among 1050 women without hysterectomy, squamous intraepithelial lesions were more common among women infected with human immunodeficiency virus than among uninfected women (18.8% vs 5.3%; P <.001). In multivariate analysis the association of squamous intraepithelial lesions with human papillomavirus infection was strong; adjusted prevalence ratios were 27 for high-risk, 25 for intermediate-risk, and 10 for low-risk types (95% confidence intervals, 12-58, 12-54, and 4-25, respectively). Much lower adjusted prevalence ratios were seen for the only other factor significantly associated with squamous intraepithelial lesions, namely, infection with human immunodeficiency virus in conjunction with a reduced CD4(+) cell count. Adjusted prevalence ratios were 1.9 for CD4(+) cell counts <200 and 1.6 for CD4(+) cell counts between 200 and 500 (95% confidence intervals, 1.2-3.0 and 1.0-2.5, respectively). Adjusted attributable fractions calculated for this study population indicated that if both human immunodeficiency virus and human papillomavirus were removed, 47.6% of the observed lesions with atypical squamous cells of uncertain significance and 93.4% of the observed squamous intraepithelial lesions would be prevented. CONCLUSION: Squamous intraepithelial lesions are more common among human immunodeficiency virus-infected women and are associated most commonly with high- and intermediate-risk human papillomavirus types and secondarily with human immunodeficiency virus-associated immune compromise.