Enhancing adherence to antiretroviral therapy at the HIV clinic in resource constrained countries; the Tanzanian experience.

OBJECTIVE: To evaluate various strategies aimed at improving adherence to antiretroviral therapy (ART). METHODS: Patients initiated on ART at Muhimbili National Hospital HIV clinic were randomly assigned to either regular adherence counseling, regular counseling plus a calendar, or regular counseling and a treatment assistant. Patients were seen monthly; during these meetings self-reported adherence to treatment was recorded. Disease progression was monitored clinically and immunologically. RESULTS: Of the 621 patients randomized, 312 received regular counseling only, 242 regular counseling and calendars, while 67 had treatment assistants in addition to regular counseling. The mean (SD) follow-up time was 14.5 (4.6) months. During follow-up 20 (3.2%) patients died, and 102 (16.4%) were lost to follow-up; this was similar in all groups. In 94.8% of all visits, patients reported to have adhered to treatment. In only 39 (0.7%) visits did patients report a < or = 95% adherence. There were no differences in adherence (P = 0.573) or differences in CD4 count and weight changes over time in the interventions. CONCLUSIONS: Good adherence to ART is possible in resource constrained countries. Persistent adherence counseling in clinic settings by itself may be effective in improving adherence to ART.

Introduction of regular formative assessment to enhance learning for clinical students at Muhimbili University College, Tanzania.

OBJECTIVE: To determine if undertaking regular Formative Assessment (FA) in the setting of our medical school enhanced the students' learning experience. METHODS: An FA intervention was designed and implemented with clinical students during their clerkship in the academic year 2003/04. FA was administered as structured verbal comments on daily clinical case presentations. Evaluation of the intervention included pre- and post-surveys exploring the perceptions of students and teachers on the quality of the learning experience. Focus group discussions with students and with teachers were held at the start and conclusion of the intervention to identify strengths and weaknesses of FA. FINDINGS: All participating teachers perceived that students were interested in learning before the intervention. Teachers who perceived that students achieved the set learning objectives increased from 0% before to 28% after the intervention. Most teachers (71%) and students (86%) perceived FA to enrich students' learning experience. Students appreciated the positive change in teachers' attitudes during the FA intervention. Both students and teachers recommended that FA become a regular and routine activity. CONCLUSIONS: Students and teachers viewed FA as a positive, feasible intervention. They thought it enriched the learning process and recommended it be a routine learning activity.

Tuberculosis among the elderly in Tanzania: disease presentation and initial response to treatment.

BACKGROUND: Reports on tuberculosis (TB) presentation among the elderly in sub-Sahara Africa are scarce at a time when the elderly population is increasing. This dearth of information is likely to lead to an increase in the number of undetected TB cases in the region. OBJECTIVE: To describe TB presentation and response to anti-tuberculosis treatment at 2 months among elderly patients. METHODS: Consecutive patients referred to TB centres in Dar es Salaam, Tanzania, underwent clinical, microbiological and chest X-ray (CXR) evaluations at baseline and after 2 months of anti-tuberculosis treatment. Patients aged 60 years were considered elderly and those aged 18-59 years formed the comparison group. RESULTS: Elderly patients with TB were more likely to have smear-negative TB (76.7% vs. 49.3%, P < 0.0001) and lower-zone lesions on CXR (41% vs. 17%, P < 0.001), but less likely to have cavities on CXR (77.6% vs. 50.4%, P < 0.0001) than the comparison group. Hypertension and diabetes mellitus were more common among the elderly than among controls. Mortality at 2 months was respectively 18.6% and 8.1% among the elderly and among controls. Human immunodeficiency virus infection and smoking increased mortality, while hypertension was associated with reduced mortality. CONCLUSION: TB in the elderly was associated with atypical clinical and radiological presentations. A high index of suspicion could minimise delays in diagnosis and treatment.

High HIV seroprevalence and increased HIV-associated mortality among hospitalized patients with deep bacterial infections in Dar es Salaam, Tanzania.

OBJECTIVES: To correlate deep bacterial infections with HIV infection and evaluate the influence of HIV on clinical picture and outcome in patients with meningitis, pneumonia or pyomyositis. DESIGN: Case-control comparison of HIV seroprevalence between patients and an age- and sex-matched control group in a prospective cross-sectional study of hospitalized patients. PARTICIPANTS: One hundred and sixty-five patients admitted to hospital with either purulent meningitis, pneumonia or pyomyositis and 165 age- and sex-matched controls from orthopaedic/trauma wards. SETTING: University Hospital, Dar es Salaam, Tanzania. OUTCOME MEASURES: Differences in HIV seroprevalence and mortality. RESULTS: Of 78 patients with purulent meningitis, 19 (24%) were HIV-seropositive, compared with 13 (17%) in the control group (P = 0.345). Of 36 patients with meningitis seen before a meningococcal epidemic affected Dar es Salaam, there was a statistically significant association with HIV infection (P = 0.013). Ten out of 19 (53%) HIV-seropositives died, compared with nine out of 59 (15%) seronegatives (P = 0.028). Of patients with pneumococcal meningitis, five out of six (83%) seropositives died, compared with two out of 12 (17%) seronegatives (P = 0.013). Fifteen out of 45 (33%) patients with pneumonia were HIV-seropositive, compared with four (9%) in the control group (P = 0.001). There was no difference in mortality between seropositive and seronegative patients with pneumonia. HIV seroprevalence was 62% among 42 patients with pyomyositis and 12% among 42 controls (P less than 0.0001). Eighteen out of 25 (72%) seropositive patients with pyomyositis fulfilled the World Health Organization (WHO) clinical case definition for AIDS. Response to recommended antibiotic treatment was satisfactory among patients with pneumonia and pyomyositis. CONCLUSIONS: These results show a strong association between pyomyositis, pneumonia and HIV infection. They also indicate an increased mortality associated with HIV infection in patients with pyogenic meningitis, especially pneumococcal meningitis. Pyomyositis should be considered an indicator of stage III HIV disease in the proposed WHO clinical staging system.

PIP: This study sought to correlate deep bacterial infection with HIV infection and evaluate the influence of HIV on clinical practice and outcome in patients with meningitis, pneumonia, or pyomyositis. At University Hospital, Dar es Salaam, Tanzania, 165 patients were admitted to the hospital with purulent meningitis, pneumonia, or pyomyositis and were evaluated in a prospective, cross-sectional study along with 165 age- and sex-matched controls from orthopedic/trauma wards to determine HIV seroprevalence. Of the 78 patients with purulent meningitis, 19 (24%) were HIV-seropositive, as compared with 13 (17%) in the control group (p=0.345). Of 36 patients with meningitis seen before a meningococcal epidemic affected Dar es Salaam, there was a statistically significant association with HIV infection (p=0.013). 10 of 19 (53%) HIV-seropositives died, compared with 9 of 59 (15%) seronegatives (p=0.028). Of patients with pneumococcal meningitis, 5 of 6 (83%) seropositives died, compared with 2 of 12 (17%) seronegatives (p=0.013). 15 of 45 (33%) patients with pneumonia were HIV-seropositive compared with 4 (9%) in the control group (p=0.001). There was no difference in mortality between seropositive and seronegative patients with pneumonia. HIV seroprevalence was 62% among 42 patients with pyomyositis and 12% among 42 controls (p0.0001). 18 of 25 (72%) seropositive patients with pyomyositis fulfilled the WHO clinical case definition of AIDS. Response to recommended antibiotic treatment was satisfactory among patients with pneumonia and pyomyositis. These results show a strong association between pyomyositis, pneumonia, and HIV infection. They also indicate an increased mortality associated with HIV infection in those patients with pyogenic meningitis, especially pneumococcal meningitis. Pyomyositis should be considered an indicator of stage III HIV disease in the proposed WHO clinical staging system.

Prevalence of HIV infection in healthy subjects and groups of patients in Tanzania.

During 1986 sera from 2508 individuals representing various groups of healthy subjects and patients in Dar es Salaam (the capital city of Tanzania), Bukoba (the capital of Kagera region in the northwest corner of Tanzania), Arusha (in the northeast of Tanzania) and Mbeya (in the southwest of Tanzania) were screened for antibodies to HIV by enzyme-linked immunosorbent assay (ELISA). All ELISA-positive sera were also tested by Western blot analysis. In Dar es Salaam HIV antibodies were demonstrated in 3.6% of 192 pregnant women, 5.2% of 784 blood donors, 29.0% of 224 barmaids, 8.0% of 50 male bar workers, 9.25% of 400 male and 12.2% of 90 female patients attending a clinic for sexually transmitted diseases (STDs), 85.7% of 35 patients with herpes zoster and in 97.6% of 84 patients clinically suspected of AIDS. Among the barmaids the seropositivity rate was higher in younger women (45%) than in middle-aged women (11%). Only three (4.6%) out of 65 HIV-seropositive barmaids had HIV-related symptoms. The prevalence of HIV seropositivity among healthy low-risk subjects was highest in Bukoba, namely 16% of 100 pregnant women and 13.9% of 36 blood donors, while in Arusha only one (0.7%) of the 144 pregnant women and none of 41 bar workers, none of 42 blood donors and none of 61 patients with STD were positive. In Mbeya, 3.4% of 118 pregnant women and 11.8% of 34 men with STD were seropositive. Thus the prevalence of HIV infection differs considerably in various population groups and in various parts of Tanzania.

Selection of primers of optimal sensitivity for the detection of HIV-1 from Africa and Europe by polymerase chain reaction.

In order to facilitate the detection of integrated HIV-1 proviral DNA from African as well as European patients, four new primer pairs for use in the polymerase chain reaction (PCR), localised in the gag, pol, vif and env genes of HIV-1, were constructed. The primer pairs were compared to all accessible HIV-1 sequences from African and European isolates and to some of the earlier published and most commonly used primer pairs. HIV-1 DNA was detected in blood drawn from 13 out of 13 individuals infected in Africa, in three out of three Tanzanian HIV-1 isolates and in three out of three asymptomatic Swedes infected in Europe. The new selection of primer pairs can be used as an alternative to enhance the detection of HIV-1 of different origins.

PIP: In order to facilitate the detection of integrated HIV-1 proviral DNA from African as well as European patients, 4 new primer pairs for use in the polymerase chain reaction (PCR), localized in the gag, pool, vif, and env genes of HIV-1, were constructed. The primer pairs were compared to all accessible HIV-1 sequences from African and European isolates and to some of the earlier published and most commonly used primer pairs. HIV-1 DNA was detected in blood drawn from 13 infected individuals in Africa, in 3 Tanzanian HIV-1 isolates, and in the 3 asymptomatic Swedes infected in Europe. The new selection of primer parts can be used as an alternative to enhance the detection of HIV-1 of different origins.

The prevalence and incidence of HIV-1 infection and syphilis in a cohort of police officers in Dar es Salaam, Tanzania: a potential population for HIV vaccine trials.

OBJECTIVES: To assess the suitability of a cohort of police officers in Dar es Salaam for HIV vaccine trials by determining the prevalence and incidence of HIV-1 infection, active syphilis and their associated factors. DESIGN AND SETTING: An open cohort study of police officers in Dar es Salaam, Tanzania. METHODS: Recruitment of police officers began in 1994. A standardized questionnaire was completed at enrolment and subsequent visits. HIV antibodies were determined using two consecutive enzyme-linked immunosorbent assays. Samples repeatedly discordant on the two tests were tested by a Western blot assay. Treponema pallidum antibodies were first determined by Venereal Disease Research Laboratory (VDRL) test and reactive sera were confirmed by Treponema pallidum hemagglutination test. RESULTS: At the end of 1996 a total of 2850 police officers had been recruited of whom 2733 (96%) consented to be tested for HIV. The overall HIV-1 seroprevalence at recruitment was 13.8% (378 of 2733). Females had a significantly higher HIV-1 seroprevalence, 18.0% (55 of 306), as compared to males, 13.3% (323 of 2427), P< 0.05. From a total of 2215 married police officers, 585 (26.4%) responded to a question on extramarital sex within the previous 3 months of whom 36.2% (212 of 585) admitted to have had at least one extramarital sexual intercourse. Condoms were not used during these encounters by 178 of 212 (84.0%). As of 31st December 1998, among the 1524 males observed for 2553 person-years (PYAR), 50 had seroconverted and among 200 females observed for 357 PYAR, eight had seroconverted. The overall crude HIV-1 incidence was thus 19.9/1000 PYAR; 19.6 and 22.4/1000 PYAR for males and females, respectively. The overall prevalence and incidence of active syphilis were 3.1% (88 of 2850) and 8.6/1000 PYAR (26 of 3149), respectively. Males had a higher prevalence of active syphilis, 84 of 2525 (3.3%) than females, five of 325 (1.5%), P = 0.09. CONCLUSIONS: There was high risk sexual practice including low condom use in this cohort of police officers. The incidence and prevalence of HIV infection were high. Police officers in Dar es Salaam are therefore a potential population group for HIV vaccine evaluation.

Alternative confirmatory strategies in HIV-1 antibody testing.

Alternatives to confirmation of human immunodeficiency virus (HIV)-1 seropositivity by Western blot analysis were evaluated retrospectively using combinations of six anti-HIV-1 screening assays, including four enzyme-linked immunosorbent assays (ELISA) and two simple tests (a rapid dot immunoassay and an agglutination assay), according to an algorithm where sera are first screened by one assay and those repeatedly reactive on this assay are tested repeatedly by a second assay. Two panels of sera collected in Dar es Salaam, Tanzania, were used. Panel 1 was composed of 1,465 consecutive blood donor sera of which 99 (6.8%) were confirmed HIV-1 antibody positive, and panel 2 was composed of sera from 396 consecutively admitted patients at two medical wards of which 116 (29.3%) were confirmed HIV-1 antibody positive. Sera reactive on any of the six screening assays were also tested by a confirmatory Western blot assay. The sensitivity of the assays at the initial valid testing were as follows: Abbott 99.5%, Behring 99.5%, Organon 97.7%, Wellcozyme 100%, HIV CHEK-1 95.8%, and Serodia 95.8%. After repeat testing of sera that initially gave false-negative results all assays showed 100% sensitivity except HIV CHEK-1 (98.6%). The specificities after repeat testing were between 99.6 and 99.9% for all assays except for the Behring ELISA (98.1%). Several combinations of screening assays were found to give the same diagnostic accuracy as the screening assay followed by Western blot analysis. We conclude that an alternative confirmatory strategy can be fully satisfactory for some testing purposes.

Evaluation of the FACScount, TRAx CD4 and Dynabeads methods for CD4 lymphocyte determination.

A study to evaluate the performance of the FACScount, TRAx CD4 and Dynabeads methods for the determination of CD4+ T lymphocyte subset levels was conducted in Tanzania as part of a World Health Organization (WHO) collaborative multicenter field evaluation of alternative methodologies for the enumeration of CD4+ T lymphocytes. The objective was to compare the performance of these alternative methods in a developing country setting, against that of flow cytometry as the reference standard. T lymphocyte subset levels were determined in 91 HIV seronegative and 98 HIV-1 seropositive adults using the three alternative methods. CD4+ and CD8+ T lymphocyte counts were determined by all methods except for TRAx CD4 enzyme linked immunosorbent assay (ELISA) which measures CD4+ T lymphocyte levels only. Linear regression analysis was done to correlate the counts obtained by the alternative methods to those obtained by flow cytometry. The overall correlation coefficients of FACScount and Dynabeads CD4+ and CD8+ T lymphocyte counts with those of flow cytometry were high (r > 0.9). A lower correlation (r = 0.631) was obtained when TRAx CD4+ ELISA counts were compared to those of the reference method. These results show that two of these alternative methodologies are suitable for the determination of CD4+ and CD8+ T lymphocyte counts with the use of African blood samples. Since the methods are simpler and cheaper than flow cytometry, they provide an alternative option for the enumeration of T lymphocyte subsets in laboratories with limited facilities.

Estimation of CD4 T-lymphocyte counts from percent CD4 T-lymphocyte determinations in HIV-1-infected subjects in sub-Saharan Africa.

The relationship between CD4 percent and CD4 count has been reported to be different in industrialized countries compared to sub-Saharan Africa, where often only the former is reliable. CD4 determinations from an open cohort of hotel workers in Dar es Salaam followed between 1990 and 1998 were evaluated. T-lymphocyte determinations were offered once a year to 190 HIV-1 seropositive, 80 seroconverters and 495 sex and age matched HIV-seronegative subjects. After log transformation of the CD4 percent and CD4 counts a good fit to a linear regression curve was found, R(2) 0.697. The CD4 percent corresponding to a CD4 count of 200 cells/mm(3) was found to be 9.8%. CD4 percent determination can be useful to estimate CD4 counts, but needs to be locally standardized. The CD4 percent in Africa corresponding to AIDS defining CD4 counts seems to be lower than in the industrialized world.

Response to podophyllotoxin treatment of genital warts in relation to HIV-1 infection among patients in Dar es Salaam, Tanzania.

Forty-two Tanzanian patients with genital warts were treated with 0.5% podophyllotoxin solution (Wartec) for 3 days. Thirteen patients (30.9%) were cured and a further 7 patients (16.7%) had more than 50% of lesions cleared at 6 weeks, while 19 patients were resistant to treatment. Three patients had a recurrence of lesions after an initial response. Thirty-three patients were tested for serological evidence of infection with human immunodeficiency virus (HIV) and 15 (45.5%) patients were shown to be HIV-1 antibody positive. The response to treatment was analysed in relation to HIV antibody status. The cure rate was significantly higher in HIV seronegative patients (8/18 = 44.4%) compared to HIV seropositive patients (1/15 = 6.7%) (P = 0.018). We conclude that podophyllotoxin treatment provides a useful non-hospital based treatment for genital warts, but HIV infection appears to contribute to the failure of treatment for genital warts.

HIV infection in elderly medical patients.

OBJECTIVE: To determine the prevalence and presentation of HIV-infection among medical admissions aged 55 years and above. DESIGN: Prospective cross-sectional study. SETTING: Dar es Salaam, Tanzania. SUBJECTS: Consecutive patients aged 55 years and above hospitalised in the medical wards of the Muhimbili Medical Centre in Dar es Salaam from February to May 1998. RESULTS: The overall HIV-1 seroprevalence was 15.0% (38/253); and by sex it was 18.5 % (28/ 151) among males compared to 9.8% (10/102) amongfemales (p=0.06). The HIV-1 prevalence among those aged 55 to 59 years was 29.7%. There was no association between HIV- 1 serostatus and whether one lived in a rural or urban area, marital status, level of education nor socio-economic status. The main presenting features in patients who were found to be HIV-1 seropositive were wasting 44.7%, fever 39.5%, pallor 34.2% and weight loss 31.6%. Only six (15.8%) of the 38 patients were initially suspected to have been HIV-infected before laboratory results were obtained. CONCLUSIONS: HIV-infection is a notable problem in the population of elderly medical admissions in Dar es Salaam. The possibility of HIV-infection should be considered among elderly patients with clinical features of immunodeficiency. HIV/AIDS prevention programmes directed towards the elderly should be established.

Survival time of patients with acquired immune deficiency syndrome: experience with 274 patients in Dar-es-Salaam.

To determine the survival time once acquired immune deficiency syndrome (AIDS) has developed, we analysed case records of 274 patients confirmed to have died of the disease. Of the 274 patients 193 were males and 81 females (M:F 2:1). The duration of symptoms ranged from a few weeks to two years but over 70% had apparently enjoyed good health until 2-3 months before diagnosis. Weight loss, severe weakness, chronic diarrhoea, prolonged fevers and oro-pharyngeal candidosis were the commonest features. Kaposi's sarcoma (KS) was the presenting feature in 2 (0.7%) patients. Frequent concurrent illnesses included tuberculosis (19%), unspecified (23%) and skin lesions other than KS (24%). In 31 (11.3%) patients no concurrent illness was detected. The survival after one week was 63.5% and 7.5% at the end of three months. These results indicate that due to a combination of factors survival of AIDS patients in developing countries is much shorter than in developed countries.

PIP: To determine the survival time once acquired immune deficiency syndrome (AIDS) has developed, we analyzed case records of 274 patients confirmed to have died of the disease. Of the 274 patients 193 were males and 81 females (M:F 2:1). The duration of symptoms ranged from a few weeks to 2 years but over 70% had apparently enjoyed good health until 2-3 months before diagnosis. Weight loss, severe weakness, chronic diarrhea, prolonged fevers and oro-pharyngeal candidosis were the commonest features. Kaposi's sarcoma (KS) was the presenting feature in 2 (0.7%) patients. Frequent concurrent illness included tuberculosis (19%), unspecified (23%) and skin lesions other than KS (24%). In 31 (11.3%) patients no concurrent illness was detected. The survival after 1 week was 63.5% and 7.5% at the end of 3 months. These results indicate that due to a combination of factors survival of AIDS patients in developing countries is much shorter than in developed countries. (Author's).

Radiological features of pulmonary tuberculosis in patients infected with human immunodeficiency virus.

We tested 120 consecutive admissions with sputum positive pulmonary tuberculosis for antibodies to the human immunodeficiency virus type I (HIV-1). Pre-treatment chest x-ray appearances were recorded. Seventy one patients (59%) were males and 49 (41%) were females. 43 (35.8%) patients were seropositive for HIV, and were all in the age range 16-45 years. The seropositivity for the 56 males and 44 females in the age range 16-45 years were 53 and 26 percent respectively. Atypical x-ray features were found in 21 of 43 cases compared to 15 of 57 referents (p less than 0.025). Radiographic features typical of reactivation pulmonary tuberculosis in the adult were found in 73% and 51% of referents and cases respectively (P less than 0.025). Pulmonary lesions localized to the mid and or lower zones were seen in 20 percent of cases and 3.3% of referents (P = 0.01). Mediastinal and or hilar adenopathy alone or with pulmonary infiltrates occurred more frequently among cases but the results were not significant. Our findings indicate that radiological appearances of pulmonary tuberculosis in patients seropositive for HIV-1 antibodies tend to be atypical in type of lesion and or anatomic distribution, even for patients from communities with high prevalence rates of tuberculosis.

PIP: The authors tested 120 consecutive admissions with sputum positive pulmonary tuberculosis for antibodies to the human immunodeficiency virus type I (HIV-1). Pretreatment chest x-ray appearances were recorded. 71 patients (59%) were males and 49 (41.9%) were females. 43 (35.8%) patients were seropositive for HIV, and were all between the ages of 16-45. The seropositivity for the 56 males and 44 females in this age ranger were 53% and 26%, respectively. Atypical x-ray features were found in 21 of 43 cases compared to 15 of 5 referents (p 0.25). Radiographic features typical of reactivation pulmonary tuberculosis in the adult were found in 73% and 51% of the referents and cases, respectively (p0.025). Pulmonary lesions localized to the middle or lower zones were seen in 20% of cases and 3.3% of the referents (p=0.01). Mediastinal or hilar adenopathy alone or with pulmonary infiltrates occurred more frequently in cases but the results were not significant. These findings indicate that radiological appearances of pulmonary tuberculosis in patients positive for HIV-1 antibodies tend to be atypical in type of lesion and/or anatomic distribution, even for those patients from communities with high prevalence rates of tuberculosis.

Isoniazid prophylaxis for tuberculosis prevention among HIV infected police officers in Dar es Salaam.

OBJECTIVE: To determine the acceptability, compliance and side effects of isoniazid (INH) prophylaxis against tuberculosis among HIV infected police officers (PO) in Dar es Salaam. DESIGN: A nested study from a prospective follow up of a cohort of police officers. SETTING: Dar es Salaam, Tanzania. SUBJECTS: One hundred and forty three HIV-1 infected police officers. MAIN OUTCOME MEASURES: Acceptance and compliance to INH prophylaxis. RESULTS: Of the 400 HIV-1 infected officers, 143 (35.7%) came forward for post-test counselling and HIV test results. Sixty per cent (87/143) of them accepted to be on INH prophylaxis. However only 42.5% (37/87) came forward for evaluation regarding their suitability for INH prophylaxis. During the evaluation, eight (21.6%) of 37 otherwise asymptomatic PO were found to have active pulmonary tuberculosis (TB). Eventually only 29 PO were actually started on INH, and only 16 (55.2%) of them completed the six months course. No serious side effects were observed. One PO developed TB two months after loss to follow up before completing the six months. CONCLUSIONS: There was low acceptability of and poor compliance with INH prophylaxis among the HIV-1 infected PO despite being educated on the benefits of prophylaxis. The prevalence of PTB among asymptomatic HIV-1 infected PO was high, and therefore persons with HIV infection should be examined for TB even in the absence of symptoms.

Immunohaematological findings in healthy and HIV-1 infected adults in Dar es Salaam, Tanzania.

In order to assess the prognostic value of lymphocyte subsets and immune activation markers in HIV-1 infected Tanzanian patients, peripheral white blood cell(WBC) count, total lymphocytes, CD4+ and CD8+ T-lymphocytes and Beta-2 microglobulin (B-2M) concentrations were determined among healthy HIV-1 seronegative Tanzanian blood donors and in infected Tanzania individuals in different clinical stages of HIV-1 infection. CD4+ T-lymphocytes, CD8+ T-lymphocyte percentages, CD4:CD8 lymphocyte ratios and the concentrations of B-2M were strongly correlated with the clinical stages of HIV-1 infection. These results suggest that B-2M could be a useful prognostic marker in HIV-1 infection in settings where T-lymphocyte subset determinations cannot be done.

PIP: Lymphocyte subsets and concentrations of beta-2 microglobulin (B2M) were determined among 119 HIV-1 seronegative and 183 HIV-1 seropositive individuals at Muhimbili Medical Center (MMC) to assess their prognostic value in HIV-1 infected Tanzanian patients. The HIV-negative individuals were blood donors at MMC, while the HIV-positive participants were blood donors, patients admitted to one medical ward, and those seen at MMC's outpatient clinic who were found to be HIV-positive during the study period. HIV-negative blood donors were of mean age 28.8 years and patients were of mean age 33.5. The measurement of peripheral white blood cell (WBC) count, total lymphocytes, CD4 and CD8 T-lymphocytes, and B2M concentrations found CD4 T-lymphocytes, CD8 T-lymphocyte percentages, CD4:CD8 lymphocyte ratios, and the concentrations of B2M to be strongly correlated with the clinical stages of HIV-1 infection. These findings suggest that B2M could be a useful prognostic marker in HIV-1 infection in settings where T-lymphocyte subset determinations cannot be made.

Cutaneous findings associated with HIV disease including AIDS: experience from Sub Saharan Africa.

Cutaneous manifestations are common in patients with HIV infection and tend to be more frequent as immunodeficiency progresses. In the initial stage of HIV infection a transient maculopapular-rash may appear. During the otherwise asymptomatic phase that follows, patients may develop seborrhoeic dermatitis, persistent genital ulcer disease, pruritic papular eruption and/or a variety of scaling dermatoses. The most frequent skin tumour associated with HIV disease is Kaposi's sarcoma. Skin manifestations of adverse reactions to a variety of drugs occur more frequently in patients with HIV disease than in immunocompetent patients. In general most skin diseases that occur in association with HIV disease respond well to standard treatment regimens. However relapses, and/or recurrences are frequent in this group of patients.

PIP: Cutaneous manifestations are common in patients infected with HIV and tend to be more frequent as immunodeficiency progresses. It remains, however, unclear which or how many with HIV-1 infection will develop skin disease. This paper presents and describes the commonly reported skin diseases occurring in people with HIV-1 infection. Observed infections include herpes zoster, herpes simplex, chancroid, syphilis, condylomata acuminata, oral hairy leukoplakia, molluscum contagiosum, candidiasis, bacterial infections, dermatophytosis, and scabies. Noninfective conditions such as pruritic papular eruption, seborrhoeic dermatitis, psoriasis, and others may also present. Regarding disease etiology, a transient maculopapular rash may present in the initial stage of HIV infection. Seborrhoeic dermatitis, persistent genital ulcer disease, pruritic papular eruption, and/or a variety of scaling dermatoses may then be observed during the otherwise asymptomatic phase. Kaposi's sarcoma is the most frequent skin tumor associated with HIV disease. It is also observed that skin manifestations of adverse reactions to drugs occur more frequently in patients with HIV disease than in immunocompetent patients. In closing, most skin diseases associated with HIV disease respond well to standard treatment regimens. Relapses and/or recurrences are, however, frequent among these patients.

The importance of clinical features in differentiating HIV related from non-HIV related Kaposi's sarcoma: experience from Dar es Salaam, Tanzania.

PIP: HIV-associated Kaposi's sarcoma (KS) is reported to be the most common tumor among people infected with HIV and accounts for significant morbidity and mortality. A study was conducted at Muhimbili Medical Center among consecutive patients presenting at the skin clinic or admitted to the surgical or medical wards during April-December 1992 and suspected to have KS. Patients completed a questionnaire, had venous blood samples and biopsies of the suspicion skin lesion taken, and were tested for infection with HIV. 81 adult patients with histologically proven KS were seen during the study period. Epidemic KS (EKS) was diagnosed in 72 patients of whom 49 were male, while African endemic Kaposi's sarcoma (AEKS) was diagnosed in nine patients of whom seven were male. No patient presented with classical KS. Compared to AEKS, EKS was more aggressive and disseminated in patients. The mean duration of illness for patients with AEKS was 37.3 months compared to 8.3 months for those with EKS. The presenting symptoms and past history of HIV-related illness were most pronounced among patients with EKS. Patients with EKS also demonstrated profound T4 lymphopenia and inverted T4:T8 ratio suggestive of advanced HIV infection.^ieng

Treatment of diabetic coma in a tropical environment.

Fourteen patients admitted to Muhimbili Medical Centre, Dar es Salaam in diabetic coma were treated according to a management plan based on the hourly administration of low doses of soluble insulin. The use of this treatment plan resulted in a significant fall in mortality. Three patients died. While these results are still unsatisfactory, the study has shown that combining the treatment plan with enthusiastic and constant medical and nursing care, the results of treatment of diabetic coma in the tropics can approach those of the developed world. The treatment plan is described in detail, since we believe that it can be used in hospitals with only basic facilities.