Gender differences in HIV-1 diversity at time of infection.

To develop an HIV-1 vaccine with global efficacy, it is important to identify and characterize the viruses that are transmitted, particularly to individuals living in areas of high incidence. Several studies have shown that virus from the blood of acutely infected adults was homogeneous, even when the virus population in the index case was genetically diverse. In contrast to those results with mainly male cohorts in America and Europe, in several cases a heterogeneous virus population has been found early in infection in women in Africa. Thus, we more closely compared the diversity of transmitted HIV-1 in men and women who became infected through heterosexual contact. We found that women from Kenya were often infected by multiple virus variants, whereas men from Kenya were not. Moreover, a heterogeneous virus was present in the women before their seroconversion, and in each woman it was derived from a single index case, indicating that diversity was most likely to be the result of transmission of multiple variants. Our data indicate that there are important differences in the transmitted virus populations in women and men, even when cohorts from the same geographic region who are infected with the same subtypes of HIV-1 are compared.

Risk factors for HIV infection among drug users in Yunnan province, China: association with intravenous drug use and protective effect of boiling reusable needles and syringes.

OBJECTIVES: To characterize the prevalence and correlates of HIV infection among drug users in southwestern China. METHODS: Drug users in Longdao village, Yunnan Province underwent standardized interview and voluntary HIV serologic testing in a cross-sectional study. Analyses of potential risk and protective factors were stratified by method of drug use. RESULTS: Of 182 participants, 79 (43%) were HIV-1-seropositive. HIV seropositivity was found in 51 (80%) of the 64 intravenous drug users (IVDU) and 28 (24%) of the 118 who acknowledged use of drugs only by smoking [odds ratio (OR), 12.6; 95% confidence interval (CI), 5.7-28.5]. Among IVDU, reported sterilization of reusable injection equipment by boiling before intravenous drug use was associated with significant protection (adjusted OR, 0.16; 95% CI, 0.03-0.87). This protective association was also significant among the subset of IVDU who shared reusable injection equipment. CONCLUSIONS: HIV infection among drug users in Yunnan Province was highly correlated with intravenous drug use. The protective effect of sterilization of reusable injection equipment by boiling could be easily integrated into health education programs among IVDU in China and other rural Asian settings where reusable injection equipment is used.

HIV infection and vaginal douching in central Africa.

OBJECTIVE: To determine whether vaginal douching is associated with HIV infection. METHODS: A total of 397 female patients who attended the referral clinic for sexually transmitted diseases in Bangui, Central African Republic, from August 1994 to February 1995, were interviewed regarding sexual behavior, sexual history, and vaginal douching during the previous 3 years. Pelvic examinations were conducted and vaginal and cervical fluids evaluated for genital infections. Blood was drawn for HIV and syphilis serologic testing. RESULTS: The seroprevalence of HIV infection in the study population was 34%. Twenty-one per cent of the 115 HIV-seropositive women had a consistent practice of douching with commercial antiseptics versus 35% of the 223 HIV-seronegative women [odds ratio (OR), 0.6; 95% confidence interval (CI), 0.4-0.9; after adjusting for lifetime number of sexual partners, marital status, and condom use]. In contrast, a higher percentage of HIV-seropositive than HIV-seronegative women had a consistent practice of douching with a non-commercial preparation (14.8 versus 6.7%; adjusted OR, 1.7; 95% CI, 1.0-3.0). CONCLUSION: Our results suggest that vaginal douching with non-commercial preparations is associated with an increased prevalence of HIV, whereas douching with commercial antiseptic preparations was associated with a lower prevalence of HIV. The findings from this cross-sectional survey require confirmation in prospective studies.

PIP: Previous research has suggested that frequent vaginal douching modifies vaginal flora and increases the risk of cervical infections -- a probable risk factor for human immunodeficiency virus (HIV). To assess the association between HIV infection and vaginal douching, 397 women attending a sexually transmitted disease clinic in Bangui, Central African Republic, during 1994-95 were interviewed regarding their sexual behavior and vaginal douching practices in the preceding 3 years. The overall HIV prevalence rate was 34%. Douching, primarily for hygiene or treatment of a vaginal discharge, was reported by 195 women (49%); its mean weekly frequency was 7 times. A commercial antiseptic was used by 140 women (72%); 48 (25%) used a noncommercial preparation (largely herbs) and 7 (3%) used water. The analysis was restricted to women who used commercial or noncommercial preparations at least once a week (104 and 32 women, respectively). 25 (21.7%) of the 115 HIV-positive women reported use of commercial antiseptics compared with 79 (35.4%) of seronegative women (odds ratio, 0.6; 95% confidence interval, 0.4-0.9 after adjustment for condom use, lifetime number of sexual partners, and marital status). Use of noncommercial preparations was reported by 17 (14.8%) seropositive and 15 (6.7%) seronegative women (adjusted odds ratio, 1.7; 95% confidence interval, l.0-3.0). Although these findings should be considered preliminary, it is speculated that the antifungal and bacteriostatic properties of commercial antiseptics used after sexual intercourse may reduce the inoculum of HIV through a flushing mechanism or reduce the frequency of sexually transmitted diseases that serve as co-factors for HIV infection. Moreover, the agents used in noncommercial preparations may irritate vaginal mucosa, enhancing HIV transmission.

Acceptability of HIV vaccine trials in high-risk heterosexual cohorts in Mombasa, Kenya.

OBJECTIVES: To ascertain the level of acceptance of a prophylactic HIV vaccine trial in high-risk HIV-seronegative heterosexual cohorts of men and women in Mombasa, Kenya, and to assess the anticipated effects of participation on risk behavior. METHODS: Standardized questionnaire administered to a convenience sample of commercial sex workers and trucking company employees enrolled in prospective cohort studies. RESULTS: Ninety-six per cent of respondents believed that HIV was a major problem in Kenya and 86% of men and 94% of women perceived themselves at risk. One hundred per cent of women and 84% of men expressed interest in participation in an HIV vaccine trial, after explanation of the experimental nature of the vaccine, double-blind placebo-controlled design, prolonged follow-up and potential change in serostatus. Seventeen per cent of men and 9% of women anticipated an increase in risk behavior as a result of participation. CONCLUSION: The majority of individuals in two high-risk cohorts were interested in participating in Phase III efficacy trials of HIV vaccines. A significant minority anticipated an increase in risk behavior, which emphasizes the need for intensive counseling and education throughout a vaccine trial.

PIP: The acceptability of a theoretical human immunodeficiency virus (HIV) vaccine trial was investigated in HIV-negative commercial sex workers and trucking company employees in Mombasa, Kenya. The 206 women and 201 men who completed questionnaires were already enrolled in a prospective cohort study of high-risk heterosexuals. 95% of men and 98% of women surveyed agreed that acquired immunodeficiency syndrome (AIDS) is a major problem in Kenya; however, only 14% and 6%, respectively, considered themselves at personal risk of infection. Only 4% of male and 1% of female respondents stated they would refuse an HIV vaccine of proven safety and efficacy. However, 91% of women but only 67% of men indicated they would participate in a double-blind, placebo-controlled vaccine trial that involved vaccine-induced HIV seropositivity and prolonged follow-up. The main concerns about participation in such a trial were the positive HIV blood test result and fear of acquiring HIV from the vaccine. 9% of men and 6% of women anticipated they would decrease their condom use as a result of participation in such a trial, and 9% of men and 3% of women thought they would increase their number of sexual partners. Anticipated higher risk behavior was significantly associated with male gender, but not with age, education, history of prostitution or of sex with prostitutes, or current condom use. If and when vaccine trials become possible, this high-risk cohort would comprise an ideal target population; however, concurrent counseling about the need to continue preventive behavioral measures would be a necessity.

Effect of intrauterine device use on cervical shedding of HIV-1 DNA.

OBJECTIVE: Hormonal contraception has been associated with an increased prevalence of cervical shedding of HIV-1 DNA among infected women. We conducted this study to evaluate the effect of the use of an intrauterine device (IUD) on the detection of HIV-1 DNA in cervical secretions. DESIGN: A prospective study of HIV-1-seropositive women undergoing IUD insertion at two public family planning clinics in Nairobi, Kenya. METHODS: Cervical swab samples were collected before IUD insertion and approximately 4 months thereafter for the detection of HIV-1-infected cells using polymerase chain reaction (PCR) amplification of HIV-1 gag DNA sequences. RESULTS: Ninety-eight women were enrolled and followed after IUD insertion. The prevalence of HIV-1 DNA cervical shedding was 50% at baseline and 43% at follow-up [odds ratio (OR) 0.8, 95% confidence interval (CI) 0.5-1.2]. There was no statistically significant difference between the baseline and follow-up shedding rates in a multivariate model that controlled for previous hormonal contraceptive use, condom use, cervical ectopy, friable cervix, cervical infections at an interim visit, and CD4 lymphocyte levels (OR 0.6, 95% CI 0.3-1.1). CONCLUSION: The insertion of an IUD did not significantly alter the prevalence of cervical shedding of HIV-1-infected cells. The use of IUDs, in conjunction with condoms, may be an appropriate method of contraception for HIV-1-infected women from the standpoint of potential infectivity to the male partner through exposure to genital HIV-1.

Evaluation of a rapid membrane-based assay (HIV-CHEK) for detection of antibodies to HIV in serum samples from Nairobi.

We evaluated a rapid membrane-based assay (HIV-CHEK) for detection of antibodies to HIV using 737 serum samples in Nairobi, Kenya. The rapid assay had a sensitivity of 96.3% and specificity of 99.8% when compared with enzyme-linked immunosorbent assay (ELISA) and Western blot assay. Results were similar using fresh or previously frozen serum samples, although the latter occasionally left debris on the assay device membrane yielding uninterpretable results. This rapid HIV assay may be of particular use in developing countries where laboratory resources are limited.

Impact of HIV infection on the development, clinical presentation, and outcome of tuberculosis among children in Abidjan, Côte d'Ivoire.

OBJECTIVE: To assess the impact of HIV infection upon the development, clinical presentation, and outcome of tuberculosis (TB) among children. DESIGN: Case-control study and prospective cohort study. METHODS: From March 1994 to November 1995, children aged 0-9 years with newly diagnosed TB were enrolled at the two outpatient TB centers and the two principal university hospitals in Abidjan, Côte d'Ivoire. Children were examined, blood samples were collected for HIV serology and lymphocyte phenotyping, chest radiography was performed, and gastric aspirates and sputum samples were collected for acid-fast bacilli smear and culture. Children were then followed every 2 months during a standard 6-month course of anti-TB therapy. To examine risk factors for TB, age- and sex-matched healthy control children were enrolled from among the siblings of children referred for TB skin testing. RESULTS: Overall, 161 children with TB were enrolled, including 39 (24%) with culture-confirmed pulmonary TB, 80 (50%) with clinically diagnosed pulmonary TB, and 42 (26%) with extrapulmonary TB. Children with TB were significantly more likely than 161 control children to be HIV-seropositive (19 versus 0%), to have a past TB contact (55 versus 16%) and to live in very low socioeconomic status housing (24 versus 6%). No significant differences between HIV-seropositive and seronegative children were found in the distribution of radiologic abnormalities for pulmonary TB or in the site of extrapulmonary TB. The mortality rate in HIV-seropositive children was significantly higher than in seronegative children (23 versus 4%; relative risk, 3.6; 95% confidence interval, 2.0-6.6), and all deaths in HIV-seropositive children with available lymphocyte subtyping results occurred in those with a CD4 percentage of < 10%. CONCLUSIONS: This study documents the importance of HIV infection as an independent risk factor for the development of TB in children, and demonstrates that HIV-related immunosuppression is a critical risk factor for mortality in this population.

Decreased incidence of sexually transmitted diseases among trucking company workers in Kenya: results of a behavioural risk-reduction programme.

OBJECTIVE: To establish a cohort of high-risk individuals suitable for HIV-prevention trials, and to measure changes in sexual behaviour and sexually transmitted disease (STD) incidence after a behavioural intervention. DESIGN: Prospective cohort study in trucking company depots in Mombasa, Kenya. PARTICIPANTS: A total of 556 male HIV-seronegative employees of trucking companies. INTERVENTIONS: HIV serological testing, individual counselling, condom promotion, STD diagnosis and management. MAIN OUTCOME MEASURES: Sexual risk behaviour and symptomatic STD incidence. RESULTS: Using time-trend modelling, significant declines in self-reported high-risk sexual behaviour were demonstrated during a 1-year follow-up. The percentage of men reporting any extramarital sex during the 3-month period prior to a follow-up visit decreased from 49% durig the first quarter of follow-up to 36% during the last quarter (P < 0.001). The decline in reported female sex worker contact was from 12% to 6% (P = 0.001). Approximately 30% of men reported consistent condom use during extramarital sex and this percentage remained unchanged during the study period. The incidence of STD declined from 34 per 100 person years (PY) during the first quarter to 10 per 100 PY during the last quarter (P = 0.001). Significant reductions in gonorrhoea (15 to five cases per 100 PY, P = 0.04), non-gonococcal urethritis (10 to two cases per 100 PY, P = 0.05), and genital ulcer disease (nine to two cases per 100 PY, P = 0.02) were observed. CONCLUSIONS: Among truck company workers who participated in a cohort study in Mombasa, Kenya, there was a significant decrease in sex with high-risk partners, but no change in condom use. The change in heterosexual risk behaviour was accompanied by a significant decrease in incidence of gonorrhoea, non-gonococcal urethritis, and genital ulcer disease.

PIP: 556 male HIV-seronegative male employees of trucking companies in Mombasa, Kenya, were exposed to HIV serological testing, individual counseling, condom promotion, and sexually transmitted disease (STD) diagnosis and management, and returned for at least one follow-up visit in a prospective study to measure changes in sexual behavior and STD incidence after the intervention. There was a significant decrease in sex with high-risk partners over the 1-year period of follow-up, but no change in condom use among study participants; 30% of men reported consistent condom use during extramarital sex throughout the study period. The change in heterosexual risk behavior was accompanied by a significant decrease in the incidence of gonorrhea, nongonococcal urethritis, and genital ulcer disease. The percentage of men reporting extramarital sex decreased from 49% to 36%, while contact with female prostitutes declined from 12% to 6%.

Impact of maternal HIV infection on obstetrical and early neonatal outcome.

In a case-control study of 177 HIV-seropositive and 326 seronegative women and their newborns in Nairobi, Kenya, maternal HIV infection at term was independently associated with travel to other African countries [odds ratio (OR) 4.9, P less than 0.0001], history of a blood transfusion since 1980 (OR 3.5, P = 0.01), history of more than one sexual partner in the previous 5 years (OR 1.8, P = 0.02) and unmarried status (OR 1.8, P = 0.02). Neonates of HIV-positive and HIV-negative women differed little with respect to occurrence of congenital malformations, stillbirths, in-hospital mortality, sex, APGAR score, or gestational age. However, the mean birth weight of singleton neonates of HIV-positive women was significantly lower than that of controls (3090 versus 3220 g, P = 0.005), and birth weight was less than 2500 g in 9% of cases and 3% of controls (OR 3.0, P = 0.007). Among neonates of HIV-seropositive women, birth weight was less than 2500 g in 17% if mothers were symptomatic and 6% if mothers were asymptomatic (OR 3.4, P = 0.08).

HIV infection among lower socioeconomic strata prostitutes in Nairobi.

A cohort of 418 lower socioeconomic strata prostitutes were enrolled in a study of the epidemiology of sexually transmitted diseases (STDs) between January and April 1985. Sixty-two per cent of the women were seropositive for HIV infection at enrollment. Significant associations were found between HIV seropositivity and Tanzanian origin (OR = 2.12, CI 95% = 1.18-3.81, P less than 0.03), younger age, a shorter duration of prostitution, reduced fecundity, use of oral contraceptives (OR = 1.8, CI 95% = 1.1-2.9, P less than 0.05) and genital ulcer disease (OR = 3.32, P less than 0.00001). No associations were noted with other STD. Stepwise logistic regression analysis confirmed independent associations between HIV infection and Tanzanian origin (OR = 2.27, CI 95% = 1.25-4.14, P less than 0.007), reduced fecundity (OR = 0.83, CI 95% = 0.74-0.94, P less than 0.003), oral contraceptive use (OR = 2.02, CI 95% = 1.22-3.35, P less than 0.006) and duration of prostitution (OR = 0.39, CI 95% = 0.23-0.65, P less than 0.004). Oral contraceptives may increase susceptibility to HIV or may be a marker for other factors which increase risk of acquisition. Further studies are necessary to confirm this association.

Treatment of cervicitis is associated with decreased cervical shedding of HIV-1.

OBJECTIVE: To determine whether cervical mucosal shedding of HIV-1 RNA and HIV-1 infected cells decreases following successful treatment of cervicitis. DESIGN: Prospective interventional study. SETTING: Sexually Transmitted Infections Clinic, Coast Provincial General Hospital, Mombasa, Kenya. PARTICIPANTS: Thirty-six HIV-1 seropositive women with cervicitis: 16 with Neisseria gonorrhoeae, seven with Chlamydia trachomatis, and 13 with non-specific cervicitis. INTERVENTIONS: Treatment of cervicitis. MAIN OUTCOME MEASURES: Levels of total (cell-free and cell-associated) HIV-1 RNA and presence of HIV-1 DNA (a marker for infected cells) in cervical secretions before and after resolution of cervicitis. RESULTS: After treatment of cervicitis, the median HIV-1 RNA concentration in cervical secretions was reduced from 4.05 to 3.24 log10 copies/swab (P = 0.001). Significant decreases in cervical HIV-1 RNA occurred in the subgroups with N. gonorrhoeae (3.94 to 3.28 log10 copies/swab; P = 0.02) and C. trachomatis (4.21 to 3.19 log10 copies/swab; P = 0.02). Overall, the prevalence of HIV-1 infected cells in cervical secretions also decreased after treatment, from 67% to 42% (odds ratio, 2.8; 95% confidence interval, 1.3-6.0; P = 0.009). Detection of infected cells was associated with higher mean HIV-1 RNA levels (4.04 versus 2.99 log10 copies/swab; P< 0.0001). CONCLUSIONS: Effective treatment of cervicitis resulted in significant decreases in shedding of HIV-1 virus and infected cells in cervical secretions. Treatment of sexually transmitted diseases may be an important means of decreasing the infectivity of HIV-1 seropositive women by reducing exposure to HIV-1 in genital secretions.

Human T cell leukemia virus type III antibody, lymphadenopathy, and acquired immune deficiency syndrome in hemophiliac subjects. Results of a prospective study.

A cohort of 63 hemophiliac subjects was followed for clinical and immunologic abnormalities related to the acquired immune deficiency syndrome (AIDS). When evaluated in early 1984, antibody to human T cell leukemia virus type III (HTLV-III) was detected in the serum of 59 percent (24 of 41) of factor VIII or IX concentrate recipients, but in none (0 of six) of the cryoprecipitate/fresh frozen plasma recipients. HTLV-III-seropositive hemophiliac subjects, on average, had been exposed to twice as much concentrate during the previous year as seronegative hemophiliac subjects. The seropositive group had a significantly lower mean helper/suppressor T cell ratio and absolute helper T cell level than the seronegative group. By early 1984, 13 hemophiliac subjects in the study population had lymphadenopathy and one had AIDS. Antibody to HTLV-III was detected in the serum of 13 of these 14 hemophiliac subjects with overt clinical disease. The prevalence of lymphadenopathy or AIDS among HTLV-III-seropositive hemophiliac subjects was 54 percent (13 of 24). It is concluded that HTLV-III antibody occurs with high frequency in hemophiliac subjects, and is related to the amount of factor VIII or IX concentrate infused. Over half of HTLV-III-seropositive hemophiliac subjects in this population had overt clinical disease with either lymphadenopathy or AIDS.

Distinct but related human immunodeficiency virus type 1 variant populations in genital secretions and blood.

For a HIV vaccine to be effective, it will be essential that it protect against the virus variants to which individuals are most frequently exposed. HIV-1 is predominantly a sexually acquired virus, thus, variants in genital secretions are a potentially important reservoir of viruses that are transmitted. Because there are no data available on variants in the genital mucosa, we analyzed this provirus population and compared it to the proviruses in the blood of individuals chronically infected with HIV-1. A major genetic difference between variants within a patient were insertions, which were apparently created by duplication of adjacent sequences, that resulted in acquisition of new potential glycosylation sites in V1 and V2. Comparisons of mucosal and PBMC variants suggest that these tissues harbor distinct, but related populations of HIV-1 variants. In two of three patients, the mucosal variants were most closely related to a minor variant genotype in blood. In a third individual, viruses in both tissues were surprisingly homogeneous, but the majority of variants in the cervix encoded a V1 sequence with a predicted glycosylation pattern similar to a minor variant in blood. The V3 sequence patterns of the mucosal isolates indicate they may be predominantly macrophage-tropic viruses.

Phylogenetic evaluation of Kenyan HIV type 1 isolates.

Diversity among global isolates of HIV-1 presents a formidable challenge for vaccine development. As distinct clades of the virus are recognized, it will be important to monitor their geographic distribution and divergence. In this study, we characterized HIV-1 subtypes from 17 seropositive individuals in Nairobi and Mombasa, Kenya. Seventy-one percent of viruses were clade A and 29% were clade D. The most divergent clade A isolate in our survey, Q45-CxA, grouped closely with two other taxa that were previously reported as having no distinct clade affiliation. Thus, these data may suggest the emergence of an outlier group of clade A variants or a new subtype of HIV-1. Phylogenetic relatedness of the 17 Kenyan isolates was determined separately for C2-V3 and V2 sequences of envelope and subtype designation for these isolates was independent of the region analyzed. However, evaluation of transitions, transversions, and specific character state changes indicated that mutations characterizing V2 differed from those in V3 for clade A and clade D isolates. Comparison of secondary structural characteristics of the V1-V3 region between a clade A and a clade D virus revealed conservation of motifs.

PIP: The authors characterized HIV-1 subtypes from 17 seropositive individuals in Nairobi and Mombasa, Kenya. 71% of the viruses were clade A and 29% were clade D. The most divergent clade A isolate identified in the study, Q45-CxA, grouped closely with two other taxa previously reported as having no distinct clade affiliation. These findings may therefore signal the emergence of an outlier group of clade A variants or a new subtype of HIV-1. The evaluation of transitions, transversions, and specific character state changes indicated that mutations characterizing V2 differed from those in V3 for clade A and clade D isolates. Comparison of the secondary structural characteristics of the V1-V3 region between a clade A and a clade D virus revealed conservation of motifs.

Human immunodeficiency virus type 1 IgA antibody in breast milk and serum.

Breast-feeding plays a potentially significant role in mother to child transmission of human immunodeficiency virus type 1 (HIV-1). The additional transmission risk attributable to breast-feeding and the factors that enhance or inhibit transmission are presently unknown. One mechanism by which breast milk might inhibit HIV-1 transmission is the presence of specific antibodies directed against HIV-1 in breast milk of seropositive mothers. In this study serum and breast milk samples from women in Nairobi, Kenya, were tested to determine the prevalence of HIV-1 IgA antibodies. A Western blot test developed in our laboratory was used to detect anti-HIV-1 immunoglobulin A in serum and anti-HIV-1 secretory IgA (sIgA) in breast milk. Ninety-four percent of 63 HIV-1 seropositive women had anti-HIV-1 IgA in serum and 59% had anti-HIV-1 sIgA in their breast milk. No significant associations with maternal characteristics or serum anti-HIV-1 IgA or IgG banding patterns and the presence of anti-HIV-1 sIgA in breast milk were found. No protective effect of anti-HIV-1 sIgA was seen regarding mother to child transmission; however, further studies are necessary to determine the effect of these antibodies in maternal sera or in breast milk on the efficacy of HIV-1 transmission.

Lack of correlation of maternal human immunodeficiency virus infection with neonatal malformations.

A malformation syndrome has been proposed in infants with acquired immunodeficiency syndrome or acquired immunodeficiency syndrome-related complex secondary to congenital infection with human immunodeficiency virus (HIV) in the United States and Europe. To determine whether embryopathy is detectable in HIV-exposed African infants, 85 infants of HIV-seropositive mothers and 98 infants of HIV-seronegative mothers in Nairobi, Kenya, were examined for minor and major anomalous features shortly after birth. No mother used intravenous drugs. With the exception of growth failure no anomalous feature was associated with in utero HIV exposure. No increase in the number of anomalous features per infant was correlated with HIV, nor did any infant have the reported malformation syndrome. Thus in this population of African infants examination for anomalous features during the neonatal period failed to identify those infants with fetal exposure to HIV.

The epidemiology of needlestick and sharp instrument accidents in a Nigerian hospital.

OBJECTIVES: To characterize the epidemiology of percutaneous injuries of healthcare workers (HCWs) in Ile-Ife, Nigeria. DESIGN: A cross-sectional survey of a random sample of HCWs regarding details of needlestick and sharp instrument injuries within the previous year. SETTING: University hospital and clinics in Ile-Ife, Nigeria. PARTICIPANTS: Hospital personnel with potential occupational exposure to patients' blood. RESULTS: Needlestick accidents during the previous year were reported by 27% of 474 HCWs, including 100% of dentists, 81% of surgeons, 32% of nonsurgical physicians, and 31% of nursing staff. The rate of needlestick injuries was 0.6 per person-year overall: 2.3 for dentists, 2.3 for surgeons, 0.4 for nonsurgical physicians, and 0.6 for nursing staff. Circumstances associated with needlestick injuries included unexpected patient movement in 29%, handling or disposal of used needles in 23%, needle recapping in 18%, accidental stick by a colleague in 18%, and needle disassembly in 10%. Sharp instrument injuries were reported by 15% of HCWs and most commonly involved broken glass patient specimen containers (39%). Almost all HCWs were aware of the potential risk of HIV transmission through percutaneous injuries, and 91% considered themselves very concerned about their occupational risk of HIV acquisition. CONCLUSIONS: The high frequency of percutaneous exposure to blood among HCWs in this Nigerian hospital potentially could be reduced by simple interventions at modest cost.

PIP: During the spring of 1991 in Nigeria, 474 health care workers (HCWs) of the Obafemi Awolowo University Teaching Hospital Complex (OAUTHC) in Ile-Ife responded to a questionnaire on needlestick and sharp instrument injuries they had experienced in the last year and on their knowledge of HIV transmission. Current HIV seroprevalence at OAUTHC was less than 2%. 97% knew that an HIV-contaminated needlestick or skin penetration with HIV-infected blood could transmit HIV. 91% were very worried about occupational exposure to HIV. Gloves were always available to only 43%. 34% had experienced at least one accidental percutaneous injury due to a needle stick or sharp instrument during the last 12 months. The rate of percutaneous injuries was 0.8 per person-year. 27% (126) reported at least one needlestick injury. The rate of needlestick injury was 0.6 per person-year. 39 HCWs experienced at least 3 needlestick injuries. Dentists, surgeons, and mortuary attendants experienced the most needlestick injuries (100%, 81%, and 60%, respectively). The most common needlestick injuries occurred during suturing (24%), intramuscular injection (23%), and handling or disposal of used needles (23%). Unexpected patient movement (29%), needle recapping (18%), and accidental stick by colleague accounted for needlestick injuries. 15% (69) of HCWs reported at least one sharp instrument injury. 12 HCWs had at least 3 sharp instrument injuries. HCWs most affected by sharp instrument injuries were dental therapists/assistants (42%), dentists (40%), mortuary attendants (40%), surgeons (35%), and laboratory staff (25%). Broken glass containers containing patient specimens (39%), scalpels (32%), and dental instruments (20%) contributed to most injuries by sharp objects. Some possible cost-effective interventions to prevent occupational exposure to HIV among HCWs include educational seminars, preparation of patients before procedures to reduce unexpected patient movement, and infection control committees.

Evaluation of the MycoDot test for the diagnosis of tuberculosis in HIV seropositive and seronegative patients.

SETTING: Patients were recruited from Siriraj, Bamrasnaradura, and Central Chest Hospitals, the three major hospitals responsible for tuberculosis patients in Bangkok, Thailand, and vicinity. OBJECTIVE: To evaluate a new rapid serologic test, the MycoDot test, for diagnosis of tuberculosis (TB). DESIGN: The study was conducted as a cross-sectional survey. A total of 594 patients were tested with the MycoDot test. This included 142 human immunodeficiency virus (HIV) seropositive patients with active TB, 144 HIV seronegative patients with active TB, 153 HIV seropositive controls, and 155 HIV seronegative controls. RESULTS: The sensitivity of the MycoDot test for detection of TB was 40.1% in HIV seropositive patients, compared with 63.2% in HIV seronegative patients (P < 0.001). If only patients with laboratory proven TB were evaluated, the sensitivity was 40.6% in seropositive and in 70.8% seronegative patients. The sensitivity of the MycoDot test was similar in TB patients with pulmonary and extra-pulmonary disease. The sensitivity of the test in patients with CD4 counts > or = 200 cells/mm3 was significantly higher than in those with CD4 counts < 200 cells/mm3. The specificity of the test was 97.4%, and was identical in HIV seropositive and seronegative individuals. CONCLUSION: The MycoDot test had a higher sensitivity for the diagnosis of TB among HIV seronegative than HIV seropositive patients. Although the MycoDot test has a less than optimal sensitivity, the test specificity approaches 100%. It may be useful in patients with suspected TB and negative smears and in extra-pulmonary TB.

The interrelationship between human immunodeficiency virus infection and other sexually transmitted diseases.

The epidemiology of HIV infection in the United States is changing, with a dramatic reduction in the incidence of new HIV infection in homosexual men over the past decade because of altered sexual practices. In contrast, heterosexual transmission of HIV is increasing and is disproportionately occurring in inner city racial minorities in association with drug use, populations that are currently experiencing epidemics of previously controlled STDs. Sexually transmitted diseases, especially genital ulcerative diseases and perhaps C. trachomatis and T. vaginalis, facilitate sexual transmission of HIV. In addition, HIV infection itself appears to increase the severity of certain STDs once they are acquired. The control of STDs, particularly in those populations that are at high risk for HIV infection, should be of high priority and should be an integral component of AIDS control programs.

Impact of an alarm device on medication compliance in women in Mombasa, Kenya.

A randomized controlled clinical trial was conducted to determine the efficacy and acceptability of an alarm device for improving medication compliance among women in resource poor countries. Study participants were given a one-month supply of daily multi-vitamins in an electronic medication vial. Women randomly received either an alarmed vial or a non-alarmed vial. Sixty per cent of women had good compliance (defined as 95% > or = of pills ingested). Women randomized to use the alarmed vial were significantly more likely to have good compliance than those in the non-alarmed control group (82% vs. 36%, P < 0.001). Vial acceptability was high and 99% of participants said they would choose to use the vial again. In conclusion, the alarm device was found to significantly improve medication adherence rates and may be particularly beneficial for improving adherence to antiretroviral therapy among HIV-1 infected persons in developing countries.