High rates of syphilis among STI patients are contributing to the spread of HIV-1 in India.

BACKGROUND: Recent syphilis outbreaks have raised concern regarding the potential enhancement of HIV transmission. The incidence of syphilis and its association with HIV-1 infection rates among a cohort of sexually transmitted infection (STI) clinic attendees was investigated. METHODS: 2732 HIV-1 seronegative patients attending three STI and one gynaecology clinic, were enrolled from 1993-2000 in an ongoing prospective cohort study of acute HIV-1 infection in Pune, India. At screening and quarterly follow up visits, participants underwent HIV-1 risk reduction counselling, risk behaviour assessment and HIV/STI screening that included testing for serological evidence of syphilis by RPR with TPHA confirmation. Patients with genital ulcers were screened with dark field microscopy. RESULTS: Among 2324 participants who were HIV-1 and RPR seronegative at baseline, 172 participants were found to have clinical or laboratory evidence of syphilis during follow up (5.4 per 100 person years, 95% CI 4.8 to 6.5 per 100 person years). Independent predictors of syphilis acquisition based on a Cox proportional hazards model included age less than 20 years, lack of formal education, earlier calendar year of follow up, and recent HIV-1 infection. Based on a median follow up time of 11 months, the incidence of HIV-1 was 5.8 per 100 person years (95% CI 5.0 to 6.6 per 100 person years). Using a Cox proportional hazards model to adjust for known HIV risk factors, the adjusted hazard ratio of HIV-1 infection associated with incident syphilis was 4.44 (95% CI 2.96 to 6.65; p<0.001). CONCLUSIONS: A high incidence rate of syphilis was observed among STI clinic attendees. The elevated risk of HIV-1 infection that was observed among participants with incident syphilis supports the hypothesis that syphilis enhances the sexual transmission of HIV-1 and highlights the importance of early diagnosis and treatment of syphilis.

Rate of hospitalization and inpatient care costs for HIV-1-infected patients in Pune, India.

BACKGROUND: The transition of human immunodeficiency virus (HIV) infection to acquired immune deficiency syndrome (AIDS) has begun in India, and an increase in AIDS-related hospitalizations and deaths is an anticipated challenge. We estimated the rates of hospitalization and inpatient care costs for HIV-1-infected patients. METHODS: Data were analysed on 381 HIV-1-infected persons enrolled in a HIV-1 discordant couples' cohort between September 2002 and March 2004. Inpatient care costs were extracted from select hospitals where the study patients were hospitalized and the average cost per hospitalization was calculated. RESULTS: A majority of the patients were in an advanced state of HIV-1 disease with the median CD4 counts being 207 cells/cmm (range: 4-1131 cells/cmm). In all, 63 participants who did not receive antiretroviral therapy required hospitalization, 53 due to HIV-1-related illnesses and the remaining 10 due to worsening of pre-existing conditions. The overall HIV-1-related hospitalization rate was 34.2 per 100 person-years (95% CI: 26.94-42.93). The median duration of HIV-1-related hospitalization was 10 days (range 2-48 days) and the median cost was Rs 17,464 (range: Rs 400-63,891). CONCLUSION: It is necessary to strengthen the inpatient care infrastructure and supporting diagnostic set-up, and work out economically optimized treatment algorithms for HIV-1-infected patients. Although this analysis does not cover all costs and may not be generalizable, these baseline data might be a useful reference while planning related studies accompanying the government-sponsored programme to roll out antiretroviral therapy to AIDS patients.

Low HIV-1 incidence among married serodiscordant couples in Pune, India.

Unlike commercial sex workers and patients attending sexually transmitted infection (STI) clinics, married couples are not typically targeted for HIV risk reduction programs in India. Thus, married partners of HIV-infected persons are at particularly high risk for HIV infection. Between September 2002 and November 2004, 457 HIV-1 sero-discordant, married couples were enrolled in a one-year prospective study of HIV transmission in Pune, India. The HIV incidence among uninfected partners was 1.22 per 100 person-years (95% CI 0.45-2.66), which is much lower than what has been previously reported among discordant couples in Africa. This may be due to higher rates of condom use, lower rates of STIs and higher CD4 T lymphocyte counts, among the Indian HIV sero-discordant couples.

High-risk behaviour in young men attending sexually transmitted disease clinics in Pune, India.

The present study reports sexual risk factors associated with HIV infection among men attending two sexually transmitted disease (STD) clinics in Pune, India and compares these behaviours between young and older men. Between April 1998 and May 2000, 1872 STD patients were screened for HIV infection. Data on demographics, medical history and sexual behaviour were collected at baseline. The overall HIV prevalence was 22.2%. HIV risk was associated with being divorced or widowed, less educated, living away from the family, having multiple sexual partners and initiation of sex at an early age. The risk behaviours in younger men were different to older men. Younger men were more likely to report early age of initiation of sex, having friends, acquaintances or commercial sex workers as their regular partners, having premarital sex and bisexual orientation. Young men were more educated and reported condom use more frequently compared with the older men. Similar high HIV prevalence among younger and older men highlights the need for focused targeted interventions aimed at adolescents and young men and also appropriate interventions for older men to reduce the risk of HIV and STD acquisition.

Changing trends in clinical presentations in referred human immunodeficiency virus infected persons in Pune, India.

AIMS: To study profile and trends of clinical presentations among human immunodeficiency virus (HIV) infected individuals seen in a HIV Reference Clinic in Pune. METHODOLOGY: In a cross-sectional study, 3574 subjects were seen at a HIV Clinic in Pune from January 1997 to December 1999. Data on clinical presentation of 2801 (78.4%) HIV seropositive subjects were evaluated. RESULTS: Clinical conditions like oral thrush, tuberculosis, skin rash and sexually transmitted diseases showed decreasing trends during the three years study period (p=0.03, 0.02, < 0.01 and < 0.01, respectively). Conversely a significant increase in the number of asymptomatic HIV positive persons at the time of detection was observed over the same period (p < 0.01). CONCLUSION: Temporal change in the clinical presentations in the HIV positive persons referred to our clinic probably reflects increased awareness and a high index of suspicion among clinicians. Early diagnosis of HIV infection in asymptomatic phase might help the clinicians to make timely decisions on prescribing chemoprophylaxis for prevention of opportunistic infections and to take appropriate measures for prevention of secondary HIV transmission to the uninfected sex partners/spouses.

A serological survey of arboviral diseases among the human population of the Andaman and Nicobar Islands, India.

In an attempt to determine the prevalence of certain arthropod-borne viruses of public health importance amongst the human population of the Andaman and Nicobar Islands of India, 2,401 sera were collected from six major localities. The sera were analysed by the hemagglutination inhibition (HI) and neutralization (N) tests, using Chikungunya (CHIK), Japanese encephalitis (JE), West Nile (WN), dengue (DEN-2), Langat (TP-21) and Kyasanur Forest disease (KFD) viral antigens. The highest prevalence of HI antibodies was detected against KFD virus (22.4%), followed by Langat (20.2%), JE (5.9%), DEN-2 (3.1%), CHIK (2.9%) and WN (0.8%) viruses. Cross-reactions to the viral antigens were also noted. The results of N tests indicated a high prevalence of DEN-2 (25.4%) virus, followed by Langat (17.5%), CHIK (15.3%), KFD (12%), JE (2.19%) and WN (1.8%). These results are discussed in relation to important epidemiological parameters like age, sex and geographical location. To our knowledge, this is the first report of an extensive serosurvey of arthropod-borne viruses on these islands.

Low carotenoid concentration and the risk of HIV seroconversion in Pune, India.

Low vitamin A and carotenoid levels could increase the risk of sexual HIV acquisition by altering the integrity of the genital epithelium or by immunologic dysfunction. We addressed this issue by measuring serum vitamin A and carotenoid levels in patients who were at risk of subsequent HIV infection. In a nested case-control study in individuals attending two sexually transmitted disease (STD) clinics in Pune, India, serum micronutrient levels were measured in 44 cases with documented HIV seroconversion (11 women and 33 men) and in STD patients matched for gender and length of follow-up with no subsequent HIV seroconversion (controls). STD patients in Pune had low vitamin A and carotenoid levels, and low serum beta-carotene levels were independently associated with an increased risk of subsequent HIV seroconversion. STD patients with beta-carotene levels less than 0.075 micromol/L were 21 times more likely to acquire HIV infection than those with higher levels (adjusted odds ratio = 21.1; p =.01). No such association was observed in case of other non-provitamin A carotenoids. This study reports the first evidence of an association between low serum provitamin A carotenoid levels and an increased risk for heterosexual HIV acquisition in STD patients in Pune, India.

Relationship between clinical conditions and CD4 counts in HIV-infected persons in Pune, Maharashtra, India.

BACKGROUND: A decade after the detection of human immunodeficiency virus (HIV) infection in India, a steady increase in the number of patients with acquired immunodeficiency syndrome (AIDS) has been observed. The therapeutic options for patients with AIDS in developing countries include chemoprophylaxis and identifying and treating opportunistic infections. CD4 counts help in clinical monitoring and making decisions about initiating antiretroviral therapy or chemoprophylaxis. Flowcytometry is expensive and available only at specialized laboratories. Therefore, the possibility of using clinical indicators to predict low CD4 counts and disease progression needs to be explored. METHODS: This cross-sectional study was conducted among 137 HIV-infected persons investigated at an HIV reference centre in Pune. The study methods comprised pre-test counselling, informed consent, blood withdrawal and clinical evaluation. Serum samples were tested for HIV and CD4 counts were estimated on FACSort. RESULTS: Study participants commonly reported with oral candidiasis, herpes zoster, pulmonary tuberculosis, lymphadenopathy, weight loss, rash, diarrhoea and fever. CD4 counts were significantly lower among men, symptomatic patients and those with oral candidiasis, weight loss and multiple clinical conditions. The sensitivity of most of the clinical conditions was low, the specificity was high and the positive predictive value of oral candidiasis and weight loss for low CD4 counts was > 75%. CONCLUSION: The presence of oral candidiasis and weight loss were highly predictive of low CD4 counts and these can be considered as markers of HIV disease progression. Absence of clinical conditions was found to be a good predictor of high CD4 counts. Larger systematic natural history studies may help in identifying clinical conditions that could have a prognostic significance among HIV-infected people.

HIV-1 DNA shedding in genital ulcers and its associated risk factors in Pune, India.

HIV infection status was determined in 302 consecutive patients with genital ulcer disease (GUD) presenting to two sexually transmitted disease (STD) clinics in Pune, India. Of the 71 (24%) individuals with HIV infection, 67 (94%) were HIV antibody-positive, and 4 (6%) were HIV antibody-negative but p24 antigen-positive at the time of presentation. HIV-1 DNA was detected in 24 (34%) specimens. The genital ulcers of all four acutely infected p24-antigenemic subjects were HIV-1 DNA-positive by polymerase chain reaction (PCR) assay, compared with 20 of 67 (30%) seropositive patients (p = .01). Presence of chancroid, GUD symptoms for > 10 days, and concurrent diagnosis of cervicitis or urethritis were significantly associated risk factors for HIV-1 DNA shedding in ulcers. Early GUD diagnosis and aggressive treatment of HIV-infected patients may significantly reduce secondary transmission of HIV to other sex partners.

PIP: Genital ulcer disease (GUD) has been associated with an increased risk of HIV infection and transmission. The present study investigated HIV status in 302 consecutive patients with GUD presenting to two sexually transmitted disease (STD) clinics in Pune, India, in a 3-month period in 1994. 71 patients (24%) were HIV-positive; 4 (6%) of these patients were HIV-antibody negative but p24 antigen-positive. HIV-1 DNA was present in 24 specimens (34%). The genital ulcers of all 4 acutely infected p24 antigenemic subjects were HIV-1 DNA-positive by polymerase chain reaction assay compared with 20 (30%) of HIV antibody-positive patients. Significant risk factors for HIV-1 DNA shedding in ulcers were presence of chancroid (adjusted odds ratio (OR), 4.78; 95% confidence interval (CI), 1.15-19.9), GUD symptoms for more than 10 days (adjusted OR, 4.54; 95% CI, 1.19-17.3), and concurrent diagnosis of cervicitis or urethritis (adjusted OR, 9.35; 95% CI, 2.30-38.0). The finding of HIV-1 DNA in all 4 patients with acute primary HIV infection may be related to the high degree of circulating viremia present in acute infection. Early GUD diagnosis and aggressive treatment, especially of chancroid, in HIV-infected patients may significantly reduce secondary transmission of HIV to sexual partners.

Spread of HIV infection in married monogamous women in India.

CONTEXT: A high prevalence of human immunodeficiency virus (HIV) infection in female sex workers (FSWs) and men who attend sexually transmitted disease (STD) clinics poses a risk for spread of infection to other populations. OBJECTIVE: To examine spread of HIV to a low-risk population by comparing prevalence of, and risk factors for, HIV and STDs in FSWs and non-FSWs. METHODS: Women attending STD clinics in Pune, India, were assessed for STDs and HIV from May 13, 1993, to July 11, 1996. Demographic and behavioral information was collected, and clinical and laboratory assessment was performed. MAIN OUTCOME MEASURE: Prevalence and risk determinants of HIV infection. RESULTS: Of 916 women enrolled, 525 were FSWs and 391 were non-FSWs. Prevalence of HIV in FSWs and non-FSWs was 49.9% and 13.6%, respectively (P<.001). In multivariate analysis, inconsistent condom use and genital ulcer disease or genital warts were associated with prevalent HIV in FSWs. History of sexual contact with a partner with an STD was associated with HIV in non-FSWs. CONCLUSIONS: Infection with HIV is increasing in non-FSWs, previously thought to be at low risk in India. Since history of sexual contact with their only sex partner was the only risk factor significantly associated with HIV infection, it is likely that these women are being infected by their spouses. This underscores the need for strengthening partner-notification strategies and counseling facilities in India.

Evidence for high prevalence & rapid transmission of HIV among individuals attending STD clinics in Pune, India.

Prevalence and incidence of HIV-1 infection among persons attending two STD clinics in Pune between May 1993 and October 1995 are reported. On screening 5321 persons, the overall prevalence of HIV-1 infection was found to be 21.2 per cent, being higher in females (32.3%) than in males (19.3%). Analysis of behavioural and biological factors showed that old age, sex work, lifetime number of sexual partners, receptive anal sex, lack of circumcision, genital diseases and lack of formal education were related to a higher HIV-1 seroprevalence. The observed incidence rate of 10.2 per cent per year was very high, much higher in women than in men (14.2% and 9.5% per year respectively) and over three times higher among the sex workers. Females in sex work, males having recent contacts with female sex workers (FSWs) and living away from the family and persons with previous or present genital diseases had a higher risk of seroconversion. Condom usage was shown to have a protective effect in seroprevalence and seroincidence analysis. With limited available resources and lack of a suitable vaccine or a drug, long-term prevention policy of creating awareness in the community must be supplemented by strengthening STD control measures and promotion of condom use and safe sex. Factors related to availability and utilization of condoms must be carefully investigated.

Incidence and predictors of human immunodeficiency virus type 1 seroconversion in patients attending sexually transmitted disease clinics in India.

The first estimates of the seroincidence of human immunodeficiency virus type 1 (HIV-1) and of the risk factors for seroconversion in a cohort of high-risk patients attending sexually transmitted disease (STD) clinics in India are reported. Between 1993 and 1995, 851 HIV-1-seronegative persons were evaluated prospectively every 3 months for HIV infection and biologic and behavioral characteristics. The overall incidence of HIV-1 was 10.2/100 person-years (95% confidence interval, 7.9-13.1). The incidence among commercial sex workers (CSWs) was 26.1/100 person-years, compared with 8.4 among non-CSWs. Recurrent genital ulcer disease and urethritis or cervicitis during the follow-up period were independently associated with a 7- (P < .001) and 3-fold (P = .06) increased risk of HIV-1 seroconversion, respectively. Because of the association of recurrent ulcerative and nonulcerative STDs with HIV-1 seroconversion in this setting, behavioral and biologic measures directed at the prevention and control of STDs would be expected to greatly reduce the transmission of HIV-1 infection in similar high-risk groups.

Risk factors for HIV infection in people attending clinics for sexually transmitted diseases in India.

OBJECTIVE: To investigate the risk factors for HIV infection in patients attending clinics for sexually transmitted diseases in India. DESIGN: Descriptive study of HIV serology, risk behaviour, and findings on physical examination. SUBJECTS: 2800 patients presenting to outpatient clinics between 13 May 1993 and 15 July 1994. SETTING: Two clinics and the National AIDS Research Institute, in Pune, Maharashtra State, India. MAIN OUTCOME MEASURE: HIV status, presence of sexually transmitted diseases, and sexual behaviour. RESULTS: The overall proportion of patients infected with HIV was 23.4% (655/2800); 34% (184) of the women and 21% (459) of the men were positive for HIV infection. Of the 560 women screened, 338 (60%) had a reported history of sex working, of whom 153 (45%) were infected with HIV-1. The prevalence of HIV-1 infection in the 222 women who were not sex workers was 14%. The significant independent characteristics associated with HIV infection based on a logistic regression analysis included being a female sex worker, sexual contact with a sex worker, lack of formal education, receptive anal sex in the previous three months, lack of condom use in the previous three months, current or previous genital ulcer or genital discharge, and a positive result of a Venereal Disease Research Laboratory test. CONCLUSIONS: In India the prevalence of HIV infection is alarmingly high among female sex workers and men attending clinics for sexually transmitted diseases, particularly in those who had recently had contact with sex workers. A high prevalence of HIV infection was also found in monogamous, married women presenting to the clinics who denied any history of sex working. The HIV epidemic in India is primarily due to heterosexual transmission of HIV-1 and, as in other countries, HIV infection is associated with ulcerative and non-ulcerative sexually transmitted diseases.

PIP: During May 1994-July 1995 in India, health workers at two clinics for sexually transmitted diseases (STDs) in Pune provided HIV serological screening and a physical examination to 2800 patients who completed a questionnaire, so that researchers could identify risk factors for HIV-1 infection in this high-risk population. 60% of the female STD patients were sex workers. 90% of the men had contact with a sex worker within the last 3 months. 14% of all STD patients were women who were not sex workers. 82% of these were married and monogamous. 13% of the married and monogamous women tested positive for HIV-1. Overall, 23.4% of all STD patients tested positive for HIV-1. Only 24% of all STD patients had used condoms during the last 3 months. The leading clinical diagnosis was chancroid (33% for men and 20% for women). The logistic regression analysis showed that the risk factors for HIV-1 infection were: being a sex worker (odds ratio [OR] = 3.7; p 0.001), contact with a sex worker (OR = 1.71; p = 0.01), receptive anal sex (OR = 3.52; p 0.001), tattooed after 1985 (OR = 1.31; p = 0.01), current or previous genital ulcer (OR = 1.29; p = 0.01), and a positive result of a Venereal Disease Research Laboratory test (OR = 1.33; p = 0.01). Protective factors were some formal education (OR = 0.76; p = 0.02), and condom use (sometimes/always, OR = 0.75; p = 0.03). These findings indicate a need for comprehensive and national STD services in India to control STDs and a health education campaign on HIV/AIDS to reduce high risk behavior.

Isokinetic measurements of trunk extension and flexion performance collected with the biodex clinical data station.

The purposes of the two experiments presently reported were to determine a) the relationship between subject-dynamometer axis alignment and isokinetic trunk extension-flexion performance and b) the effects of short-term acclimation to the isokinetic dynamometer on the magnitude of isokinetic trunk extension-flexion variables for low back pain and asymptomatic subjects. In the first study, three anatomic landmarks were selected for fixed axis alignment, the anterior superior iliac spine, the femoral greater trochanter, and the posterior superior iliac spine. Ten healthy women performed five reciprocal maximal effort, 100 degrees , concentric contraction trunk extension-flexion cycles at three isokinetic speeds (60, 120, 180 degrees /sec) for each of three subject-dynamometer configurations. Peak torque and the trunk angle at which peak torque occurred for both trunk extension and flexion were analyzed. A 3 x 3 analysis of variance did not provide definitive statistical evidence of the superiority of one alignment over the others. The data generated with the anterior superior iliac spine alignment, however, was more consistent than others relative to expected speed-torque relationships and was associated with the overall smallest variability of the data. In the second study, 8 healthy men and 10 men with a history of low back pain were studied with a within-session, test-retest protocol. The peak torque and total mechanical work for trunk flexion and trunk extension were analyzed. As a group, the low back pain subjects demonstrated universal and, in some cases, large performance improvement (>20%) at the retest. The results of the first study suggest that subject-dynamometer alignment using the anterior superior iliac spine is justifiable. Based upon the results of the second study it was concluded that a clinically relevant measure of sagittal plane isokinetic trunk flexion and extension function for low back pain patients should be collected using a test-retest protocol. J Orthop Sports Phys Ther 1990;11(12):590-598.