Individual and poly-substance use and condomless sex among HIV-uninfected adults reporting heterosexual sex in a multi-site cohort.

BACKGROUND: We analyzed the association between substance use (SU) and condomless sex (CS) among HIV-negative adults reporting heterosexual sex in the Seek, Test, Treat, and Retain (STTR) consortium. We describe the impact of SU as well as person/partner and context-related factors on CS, identifying combinations of factors that indicate the highest likelihood of CS. METHODS: We analyzed data from four US-based STTR studies to examine the effect of SU on CS using two SU exposures: 1) recent SU (within 3 months) and 2) SU before/during sex. Behavioral data were collected via 1:1 or self-administered computerized interviews. Adjusted individual-study, multivariable relative risk regression was used to examine the relationship between CS and SU. We also examined interactions with type of sex and partner HIV status. Pooled effect estimates were calculated using traditional fixed-effects meta-analysis. We analyzed data for recent SU (n = 6781; 82% men, median age = 33 years) and SU before/during sex (n = 2915; 69% men, median age = 40 years). RESULTS: For both exposure classifications, any SU other than cannabis increased the likelihood of CS relative to non-SU (8-16%, p-values< 0.001). In the recent SU group, however, polysubstance use did not increase the likelihood of CS compared to single-substance use. Cannabis use did not increase the likelihood of CS, regardless of frequency of use. Type of sex was associated with CS; those reporting vaginal and anal sex had a higher likelihood of CS compared to vaginal sex only for both exposure classifications (18-21%, p < 0.001). Recent SU increased likelihood of CS among those reporting vaginal sex only (9-10%, p < 0.001); results were similar for those reporting vaginal and anal sex (5-8%, p < 0.01). SU before/during sex increased the likelihood of CS among those reporting vaginal sex only (20%; p < 0.001) and among those reporting vaginal and anal sex (7%; p = 0.002). Single- and poly-SU before/during sex increased the likelihood of CS for those with exclusively HIV-negative partners (7-8%, p ≤ 0.02), and for those reporting HIV-negative and HIV-status unknown partners (9-13%, p ≤ 0.03). CONCLUSION: Except for cannabis, any SU increased the likelihood of CS. CS was associated with having perceived HIV-negative partners and with having had both anal/vaginal sex.

An Ad5-vectored HIV-1 vaccine elicits cell-mediated immunity but does not affect disease progression in HIV-1-infected male subjects: results from a randomized placebo-controlled trial (the Step study).

BACKGROUND: The Step study was a randomized trial to determine whether an adenovirus type 5 (Ad5) vector vaccine, which elicits T cell immunity, can lead to control of human immunodeficiency virus (HIV) replication in participants who became HIV-infected after vaccination. METHODS: We evaluated the effect of the vaccine on trends in HIV viral load, CD4+ T cell counts, time to initiation of antiretroviral therapy (ART), and AIDS-free survival in 87 male participants who became infected with HIV during the Step study and who had a median of 24 months of post-infection follow-up. RESULTS: There was no overall effect of vaccine on mean log(10) viral load (estimated difference between groups, -0.11; P = .47). In a subset of subjects with protective HLA types (B27, B57, B58), mean HIV-1 RNA level over time was lower among vaccine recipients. There was no significant difference in CD4+ T cell counts, time to ART initiation, or in AIDS-free survival between HIV-1-infected subjects who received vaccine versus those who received placebo. CONCLUSIONS: HIV RNA levels, CD4+ T cell counts, time to initiation of ART, and AIDS-free survival were similar in vaccine and placebo recipients. There may have been a favorable effect of vaccine on HIV-1 RNA levels in participants with HLA types associated with better control of HIV-1.

Isolation and characterization of a Golgi-rich fraction from the adrenal medulla.

1. A Golgi-rich fraction from bovine adrenal medulla was isolated by centrifugation through discontinuous sucrose density gradients. 2. The specific activity of UDPgalactose-N-acetylglucosamine galactosyl transferase was increased in this fraction. Therefore, this enzyme is a useful marker for Golgi in bovine adrenal medulla. 3. Golgi membranes were reasonably free from mitochondria, lysosomes, endoplasmic reticulum and chromaffin granules as shown by the relatively low activities of marker enzymes. 4. The negative staining techniques of electron microscopy revealed the presence of a system of tubules, vesicles and plate-like center regions which are similar to those structures previously described of the Golgi fraction isolated from the liver. 5. The specific activity of 5'-nucleotidase in the Golgi-rich fraction was 3.5 times greater than that in adrenal homogenates. However, the subcellular distribution patterns of galactosyl transferase and 5'-nucleotidase were similar. The possibility that 5'-nucleotidase might be a conspicious component of the Golgi apparatus is discussed.

HIV-1 subtype E progression among northern Thai couples: traditional and non-traditional predictors of survival.

BACKGROUND: In the continuing effort to introduce antiretroviral therapy in resource-limited settings, there is a need to understand differences between natural history of HIV in different populations and to identify feasible clinical measures predictive of survival. METHODS: We examined predictors of survival among 836 heterosexuals who were infected with HIV subtype CRF01_AE in Thailand. RESULTS: From 1993 to 1999, 269 (49.4%) men and 65 (25.7%) women died. The median time from the estimated seroconversion to death was 7.8 years (95% confidence interval 7.0-9.1). Men and women with enrolment CD4 counts <200 cells/microl had about 2 and 11 times greater risk of death than those with CD4 counts of 200-500 and >500, respectively. Measurements available in resource-limited settings, including total lymphocyte count (TLC), anaemia, and low body mass index (BMI), also predicted survival. Men with two or more of these predictors had a median survival of 0.8 (0.5-1.8) years, compared with 2.7 (1.9-3.3) years for one predictor and 4.9 (4.1-5.2) years for no predictors. CONCLUSIONS: The time from HIV infection to death appears shorter among this Thai population than among antiretroviral naive Western populations. CD4 count and viral load (VL) were strong, independent predictors of survival. When CD4 count and VL are unavailable, individuals at high risk for shortened HIV survival may be identified by a combination of low TLC, anaemia, and low BMI. This combination of accessible clinical measures of the disease stage may be useful for medical management in resource-limited settings.

Strategies for diagnosis of bacterial vaginosis in a resource-poor setting.

This study evaluated Amsel's criteria, the FemExam card and pH plus amine methods for the diagnosis of bacterial vaginosis (BV) in a resource-poor setting. Two hundred Azerbaijani women participated in a study about reproductive health that included a gynaecological examination and an interviewer-administered survey. Using the WHO syndromic diagnosis algorithm, nearly all women (99%) had abnormal vaginal discharge. The prevalence of BV by Gram stain was 35%; using pH plus amine, the FemExam card and Amsel's criteria, prevalence ranged from 29% to 49%. No behavioural or demographic characteristics were associated with BV as diagnosed by Gram stain. The sensitivity ranged from 0.59 to 0.74 and specificity from 0.65 to 0.92 using the three methods. The pH plus amine test is better than syndromic management protocols, and although it is not the most sensitive or specific of the three methods it will be easiest to implement in resource-poor settings.

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.

Bacterial vaginosis and HIV seroprevalence among female commercial sex workers in Chiang Mai, Thailand.

OBJECTIVE: To investigate the relationship between HIV seropositivity and bacterial vaginosis (BV) in a population at high risk for sexual acquisition of HIV. DESIGN: A cross-sectional study was conducted among 144 female commercial sex workers in Chiang Mai, Thailand. METHODS: The participants were tested for cervical gonorrhea and Chlamydia infection, syphilis, Trichomonas vaginitis, Candida vaginitis, BV, and HIV infection. BV was diagnosed by clinical criteria (pH > 4.5, positive amine test, and presence of clue cells) and using Gram stains. RESULTS: Thirty-three per cent of participants had BV, and 43% were HIV-positive. Using clinical criteria, the association of BV and HIV seropositivity was significant [odds ratio (OR), 2.7; 95% confidence interval (CI), 1.3-5.0]. Although the association between BV and HIV prevalence was not significant using Gram stains alone for diagnosis of BV, an association was found between abnormal vaginal flora and HIV (OR, 2.1; 95% CI, 1.0-4.8). In multiple logistic regression analysis, adjusting for age, number of sexual encounters per week, current condom use, and currently having a sexually transmitted disease (STD), both BV and a history of an STD were independently associated with HIV seropositivity (adjusted OR for BV, 4.0 and 95% CI, 1.7-9.4; adjusted OR for history of an STD, 6.9 and 95% CI, 2.1-22.9). CONCLUSIONS: When diagnosed clinically, BV is independently associated with HIV seroprevalence. HIV infection may promote abnormal vaginal flora, or BV may increase susceptibility to sexual transmission of HIV. Alternatively, the association seen here may result from intervening variables; in this case BV may be a marker or a cofactor of HIV transmission.

PIP: To explore a possible association between bacterial vaginosis and human immunodeficiency virus (HIV) infection, 144 consecutively enrolled commercial sex workers from a sexually transmitted disease clinic (STD) in Chiang Mai, Thailand, were interviewed and underwent serologic testing and genital examination. 62 (43%) of sex workers were HIV-positive. A self-reported history of syphilis, chancroid, herpes, gonorrhea, or Chlamydia was significantly associated with HIV infection. Bacterial vaginosis, detected in 49 (34%), was also associated with HIV infection. Sex workers reporting 10-19 and 20 or more sexual encounters per week were 2.2 and 3.5 times, respectively, more likely to be infected with HIV than those reporting under 10 encounters. A clinically established diagnosis of bacterial vaginosis was independently associated with HIV seropositivity even when age, number of sexual encounters per week, current condom use, and past and current STD infection were controlled (odds ratio, 4.0; 95% confidence interval, 1.7-9.4). When the bacterial vaginosis diagnosis was based on Gram stain (score 7-10), however, the association with HIV seropositivity disappeared, but having abnormal vaginal flora (gram stain score 4-10) was related to HIV status. Further epidemiologic studies are recommended to investigate the possibility that bacterial vaginosis--the most prevalent genital infection in Thailand--acts as a cofactor for the heterosexual transmission of HIV.

Risk factors for HIV-1 transmission from HIV-seropositive male blood donors to their regular female partners in northern Thailand.

OBJECTIVE: To describe risks for HIV transmission from male blood donors to their regular female sex partners in Chiang Mai, Thailand. DESIGN: Cross-sectional study. METHODS: From March 1992 through September 1995, 405 HIV-seropositive male blood donors (index cases) and their regular female partners were enrolled in the study. Women with risk factors for HIV infection other than sexual contact with the index male were excluded. Couples were interviewed and examined; specimens were collected for laboratory analysis. RESULTS: Overall, 46% of the 405 women enrolled were HIV-positive. Ninety-eight per cent of male index cases had a history of sex with a female prostitute; 1.5% reported always using condoms with their regular partner. History of sexually transmitted disease (STD) and swollen inguinal lymph nodes in the female partner were associated with an increased risk of HIV infection in the female. History in the female of genital herpes [odds ratio (OR), 3.46; 95% confidence interval (CI), 1.50-8.78], gonorrhea or chlamydia infection (OR, 2.71; 95% CI, 1.39-5.53), and stable relationship of longer than 24 months (OR, 2.28; 95% CI, 1.02-5.09) were associated with an increased risk of HIV infection in the female. Consistent condom use in the past 2 years (OR, 0.10; 95% CI, 0.01-0.79) was associated with a decreased risk of HIV infection in the female. CONCLUSIONS: Married women in northern Thailand who appear otherwise to be at low risk for HIV infection may be exposed to this virus by their husbands. High rates of sex with commercial sex workers among men and low use of condoms within stable relationships may be important factors promoting the transmission of HIV in married couples. Programs to increase the regular use of condoms among married couples could be an important public health intervention to prevent transmission of HIV and other types of STD in northern Thailand.

PIP: The risk factors for HIV transmission from infected male blood donors to their regular female sex partners were investigated in a cross-sectional study conducted in Chiang Mai, Thailand, in 1992-95. During the 3.5-year study period, 405 couples were recruited. 98% of male blood donors reported a history of sex with female prostitutes. Only 28 men (7%) were aware of their seropositivity prior to notification by the blood bank, and just 1.5% always used condoms with their regular sex partner. 187 (46%) of the 405 female sex partners--none of whom had HIV risk factors other than sexual contact with their husbands--were HIV-positive at baseline. In the multivariate analysis, three variables were associated with a significantly increased risk of HIV in female partners: history of genital herpes (odds ratio (OR), 3.46; 95% confidence interval (CI), 1.50-8.78), history of gonorrhea or chlamydia (OR, 2.71; 95% CI, 1.39-5.53), and a stable relationship of at least 2 years' duration (OR, 2.28; 95% CI, 1.02-5.09); consistent condom use in the past 2 years was significantly associated with a decreased risk of HIV (OR, 0.10; 95% CI, 0.01-0.79). Medroxyprogesterone acetate injection and oral contraceptive use were not associated with HIV risk. These findings confirm a high risk of HIV transmission through monogamous sexual relationships in Thailand. Recommended are campaigns to increase regular condom use among married couples.

Toxic epidermal necrolysis: differential diagnosis of an epidermolytic dermopathy in a hematopoietic stem cell transplant recipient.

Toxic epidermal necrolysis (TEN) is an epidermolytic skin disorder associated with drug administration. It is associated with an erythematous rash with full thickness epidermal loss and characteristic histology. A 35-year-old woman underwent allogeneic hematopoietic stem cell transplantation (HSCT) for severe aplastic anemia (SAA). She developed an acute epidermolytic rash and TEN was diagnosed on the basis of skin biopsy. In the HSCT setting, TEN should be thought of as an important differential diagnosis of epidermolytic dermopathies. The most distinctive diagnostic test in the differential diagnosis of these disorders is skin biopsy

Complications of interval laparoscopic tubal sterilization: findings from the United States Collaborative Review of Sterilization.

OBJECTIVE: To estimate the risk of intraoperative or postoperative complications for interval laparoscopic tubal sterilizations. METHODS: We used a prospective, multicenter cohort study of 9475 women who had interval laparoscopic tubal sterilization to calculate the rates of intraoperative or postoperative complications. The relative safety of various methods was assessed by calculating overall complication rates for each major method of tubal occlusion. Method-related complication rates also were calculated and included only complications attributable to a method of occlusion. We used logistic regression to identify independent predictors of one or more complications. RESULTS: When we used a more restrictive definition of unintended major surgery, the overall rate of complications went from 1.6 to 0.9 per 100 procedures. There was one life-threatening event and there were no deaths. Complications rates for each of the four major methods of tubal occlusion ranged from 1.17 to 1.95, with no significant differences between them. When complication rates were calculated, the spring clip method had the lowest method-related complication rate (0.47 per 100 procedures), although it was not significantly different from the others. In adjusted analysis, diabetes mellitus (adjusted odds ratio [OR] 4.5; 95% confidence interval [CI] 2.3, 8.8), general anesthesia (OR 3.2; CI 1.6, 6.6), previous abdominal or pelvic surgery (OR 2.0; CI 1.4, 2.9), and obesity (OR 1.7; CI 1.2, 2.6) were independent predictors of one or more complications. CONCLUSION: Interval laparoscopic sterilization generally is a safe procedure; serious morbidity is rare.

Pelvic inflammatory disease and human immunodeficiency virus infection.

OBJECTIVE: To identify the effect of human immunodeficiency virus (HIV) infection on the clinical course of pelvic inflammatory disease (PID). METHODS: Women hospitalized with PID at an urban hospital serving a population at high risk for HIV were studied cross-sectionally. Data abstracted from medical records of 349 women, admitted between July 1992 and April 1994 were linked anonymously to HIV serology. Main outcome measures were length of hospital stay, prolonged fever, tubo-ovarian abscess, surgery, and change in antibiotics. RESULTS: Among the 349 women with PID, 27 were HIV-positive. These HIV-positive women had lower mean white blood cell counts at admission (7411 versus 11,266, P < .01), lower mean lymphocyte counts (1411 versus 1928, P < .01), greater febrile morbidity (54 versus 28.3%, P < .01), and longer hospital stays (10.5 versus 6.4 days, P < .01) than HIV-negative women. Women who were HIV-positive required more time for defervescence and needed to change their antibiotic regimen more frequently (41 versus 12.7%, P < .01); differences in tubo-ovarian abscesses (19 versus 14%, P = .52) or surgery (15 versus 6.2%, P = .10) were not significant. The differences in hospital course between HIV-positive and HIV-negative women were modest, and they were resolved largely by the fourth or fifth hospital day. All HIV-positive women were treated successfully with first- or second-line antibiotic regimens. CONCLUSION: Despite more severe initial presentation and a prolonged hospital course, HIV-positive women with PID, but without other acute illnesses, were treated successfully with standard therapeutic regimens. These observations support current recommendations for hospitalization of HIV-positive women with PID and treatment according to current standards.

Resurgence of active tuberculosis among pregnant women.

OBJECTIVE: To determine the frequency of active tuberculosis during pregnancy in two hospitals located in an area where tuberculosis is epidemic and to describe its course and association with human immunodeficiency virus (HIV) infection. METHODS: We reviewed and analyzed the medical records of 16 pregnant women diagnosed with tuberculosis between 1985-1992 at Kings County Hospital (n = 12) and Saint Vincent's Hospital (n = 4) in New York City. RESULTS: Ten of the 16 pregnant women with proven active tuberculosis had pulmonary tuberculosis, two had tuberculous meningitis, and one each had mediastinal, renal, gastrointestinal, and pleural tuberculosis. Eleven were tested for HIV, and seven were seropositive. One HIV-infected patient with pulmonary tuberculosis died of respiratory failure. In the 6 years between 1985-1990, five cases of active tuberculosis during pregnancy were identified (12.4 per 100,000 deliveries). During the 2 years of 1991-1992, 11 cases were recorded (94.8 per 100,000 deliveries). CONCLUSION: Cases of active tuberculosis are increasing among pregnant women in epidemic communities and are associated with HIV infection. Early tuberculin skin test screening with appropriate preventive therapy should reduce morbidity due to tuberculosis in HIV-infected women of reproductive age. Identification of pregnant women with tuberculosis requires a high index of suspicion.

Immune compromise and prevalence of Candida vulvovaginitis in human immunodeficiency virus-infected women.

OBJECTIVE: To investigate the effect of human immunodeficiency virus (HIV) infection on vaginal yeast colonization and symptomatic vulvovaginitis and to explore the effects of immune compromise on these conditions in HIV-positive women. METHODS: Between September 1991 and May 1993, 223 HIV-positive women without AIDS-defining conditions were enrolled for prospective follow-up and compared with 289 HIV-negative women enrolled in a concurrent study. Standardized gynecologic assessment was carried out. RESULTS: Cultures from 81 of 223 (36%) HIV-positive women and 72 of 289 (25%) HIV-negative women were positive for any yeast. The most commonly isolated yeasts were Candida albicans and Torulopsis glabrata; the proportion of non-C albicans isolates (26%) did not differ by serostatus. The rates of C albicans colonization and vulvovaginitis among immunocompetent (CD4 count at least 500 cells/mm3) HIV-positive women did not differ from those among HIV-negative women. Among HIV-positive women, risks for colonization and for symptomatic vulvovaginitis were increased approximately threefold and fourfold respectively, in women with CD4 counts below 200 cells/mm3 compared with either immunocompetent HIV-positive women or HIV-negative women. CONCLUSION: The yeast species isolated from HIV-positive and HIV-negative women were similar. Rates of vaginal colonization and vaginitis were similar among nonimmunocompromised HIV-positive women and HIV-negative women. Elevated rates of yeast colonization and vaginitis were not seen among this population of HIV-infected women before immune compromise. Both vaginal colonization and symptomatic vaginitis increased with immune compromise among HIV-positive women, especially at CD4 counts below 200 cells/mm3.

Kaposi sarcoma presenting as a vulvar mass.

BACKGROUND: Kaposi sarcoma has become a common manifestation in people with AIDS, especially men. A few reports of Kaposi sarcoma in women with AIDS have involved nongenital areas. However, of the few patients with genital Kaposi sarcoma reported in the United States, none was believed to be human immunodeficiency virus (HIV)-positive. Genital Kaposi sarcoma associated with HIV has been reported in other parts of the world. CASE: A 29-year-old black woman presented with severe vulvar pain, vaginal discharge, and a vulvar mass. She had been diagnosed with AIDS 25 months earlier. Biopsy of the vulvar mass revealed Kaposi sarcoma; viral analysis of the tumor was positive for herpes simplex virus type 2. Sequencing of polymerase chain reaction product verified the presence of human papillomavirus 26. CONCLUSION: We report an HIV-associated Kaposi sarcoma presenting as a vulvar mass. This report should alert health care providers to include Kaposi sarcoma in the differential diagnosis of vulvar lesions.

Longitudinal analysis of bacterial vaginosis: findings from the HIV epidemiology research study.

OBJECTIVE: To determine the natural history of bacterial vaginosis in women with or at risk for human immunodeficiency virus (HIV). METHODS: A cohort of 854 HIV-infected women and 434 HIV-uninfected women from four US sites was followed prospectively with gynecologic exams every 6 months over a 5-year period. The prevalence, incidence, persistence, and severity of bacterial vaginosis, which was defined using a Gram-staining scoring system, were calculated using generalized estimating equation methods. RESULTS: In adjusted analyses, HIV-infected women had a higher prevalence of bacterial vaginosis than HIV-uninfected women (adjusted odds ratio [OR] 1.29; 95% confidence interval [CI] 1.08, 1.55). Although HIV-infected women were not more likely to have incident infections, they were more likely to have persistence of their infections (adjusted OR 1.49; 95% CI 1.18, 1.89). Similarly, immunocompromised women (CD4+ cell count less than 200 cells/microL) were more likely than HIV-infected women with higher CD4+ cell counts (more than 500 cells/microL) to have prevalent (adjusted OR 1.29; 95% CI 1.03, 1.60) and persistent (adjusted OR 1.38; 95% CI 1.01, 1.91) bacterial vaginosis infections, but not more likely to have incident infections. Immunocompromised women had more severe bacterial vaginosis by both clinical criteria (adjusted OR 1.40; 95% CI 1.08, 1.82) and by Gram-staining criteria (adjusted OR 1.50; 95% CI 1.12, 2.00). CONCLUSIONS: Bacterial vaginosis is more prevalent and persistent among HIV-infected women, particularly among those who are immunocompromised. Immunocompromised women are more likely than HIV-infected women with higher CD4+ cell counts to have severe bacterial vaginosis.

Gynaecological conditions associated with HIV infection in women who are partners of HIV-positive Thai blood donors.

Women who were partners of HIV-positive blood donors were enrolled in a study of heterosexual HIV transmission between March 1992 and December 1996 and were interviewed and examined. Gynaecological conditions, including cervical dysplasia, human papillomavirus (HPV) infection, gonorrhoea, chlamydial infection, trichomoniasis, bacterial vaginosis, vaginal candidiasis and syphilis were assessed in addition to HIV status and CD4 level. Of 481 women enrolled, 224 (46.6%) were HIV seropositive. HIV-infected women were more likely to have abnormal vaginal discharge on physical examination (OR=2.6, P <0.01), HPV infection with a high-risk type (OR=6.9, P <0.01), and cervical dysplasia (OR=5.3, P <0.01). The prevalence of other gynaecological conditions detected at the enrolment visit did not differ by HIV status. History of prior STD (OR=2.0, P <0.01) was more common among HIV-infected women. The median CD4 count was 400 cells/microl among HIV-infected women. The prevalence of abnormal vaginal discharge and bacterial vaginosis increased significantly with decreasing CD4 count. The prevalence of ectopy, vaginal candidiasis, and cervical dysplasia increased with decreasing CD4 count, but these trends were not significant. We conclude that HIV-infected Thai women appear to have increased prevalences of abnormal vaginal discharge, squamous intraepithelial lesions and self-reported history of STD.

PIP: Gynecologic conditions associated with HIV infection were examined in 481 regular female sex partners of HIV-positive male blood donors enrolled in a study of heterosexual HIV transmission conducted at Chiang Mai University Hospital and Lampang Provincial Hospital in Thailand in 1992-96. Of these women, 224 (46.6%) were HIV-infected. HIV-positive and HIV-negative women were similar in terms of age, education, and age at first intercourse; however, a history of sexually transmitted disease was more common among the HIV-infected women (31.7%) than their uninfected counterparts (18.7%). HIV-infected women also were significantly more likely to have abnormal gynecologic conditions, including abnormal vaginal discharge at physical examination (odds ratio (OR), 2.6; 95% confidence interval (CI), 1.6-4.2) and cervical dysplasia (OR, 5.3; 95% CI, 2.0-15.2). Among HIV-positive women, the prevalence of abnormal vaginal discharge and bacterial vaginosis increased significantly with decreasing CD4 count. Syphilis, gonorrhea, chlamydia, and trichomoniasis rates were generally low and did not differ by HIV status. These findings suggest a need for further research on variations in gynecologic conditions associated with HIV infection in different countries.

Comprehensive assessment of HIV target cells in the distal human gut suggests increasing HIV susceptibility toward the anus.

BACKGROUND: Prevention of rectal HIV transmission is a high-priority goal for vaccines and topical microbicides because a large fraction of HIV transmissions occurs rectally. Yet, little is known about the specific target-cell milieu in the human rectum other than inferences made from the colon. METHODS: We conducted a comprehensive comparative in situ fluorescence study of HIV target cells (CCR5-expressing T cells, macrophages, and putative dendritic cells) at 4 and 30 cm proximal of the anal canal in 29 healthy individuals, using computerized analysis of digitized combination stains. RESULTS: Most strikingly, we find that more than 3 times as many CD68 macrophages express the HIV coreceptor CCR5 in the rectum than in the colon (P = 0.0001), and as such rectal macrophages seem biologically closer to the HIV-susceptible CCR5 phenotype in the vagina than the mostly HIV-resistant CCR5 phenotype in the colon. Putative CD209 dendritic cells are generally enriched in the colon compared with the rectum (P = 0.0004), though their CCR5 expression levels are similar in both compartments. CD3 T-cell densities and CCR5 expression levels are comparable in the colon and rectum. CONCLUSIONS: Our study establishes the target-cell environment for HIV infection in the human distal gut and demonstrates in general terms that the colon and rectum are immunologically distinct anatomical compartments. Greater expression of CCR5 on rectal macrophages suggests that the most distal sections of the gut may be especially vulnerable to HIV infection. Our findings also emphasize that caution should be exercised when extrapolating data obtained from colon tissues to the rectum.

Successful thrombolysis and spasmolysis of acute leg ischemia after accidental intra-arterial injection of dissolved flunitrazepam tablets.

A 37-year-old man with known intravenous drug abuse presented in the surgical ambulatory care unit with acute leg ischemia after accidental intra-arterial injection of dissolved flunitrazepam tablets into the right femoral artery. A combination of anticoagulation, vasodilatation, and local selective and superselective thrombolysis with urokinase was performed to salvage the leg. As a result of the severe ischemia-induced pain, the patient had to be monitored over the complete therapy period on the intensive care unit with permanent administration of intravenous fluid and analgetics. We describe the presenting symptoms and the interventional technique, and we discuss the recent literature regarding the management of accidental intra-arterial injection of dissolved flunitrazepam tablets.