Antenatal screening for HIV in North Trinidad. Demographic characteristics of patients, acceptability of testing and the rising prevalence of infection - Poster abstract

OBJECTIVE: To ascertain the acceptability of HIV screening in pregnancy and the prevalence of HIV in pregnant women in north Trinidad. DESIGN AND METHOD: All women attending an antenatal clinic at the Port of Spain General Hospital were offered HIV testing at booking. Written consent was obtained after testing counselling and blood samples were tested using an ELISA assay with positive results confirmed by western blot. Demographic data were also collected. HIV positive women/infant pairs were tested using a modified CDC - Thailand regime. RESULTS: A total of 338 new patients were seen between March and November 1999 of whom only 8 refused testing. Ten patients tested positive giving a prevalence of 3 percent. All of the HIV positive patients were of African or mixed race descent which reflected the population attending this clinic. CONCLUSION: Our data indicated a slowly rising prevalence of HIV in pregnant women in north Trinidad. The majority of patients (98 percent) easily accept screening.(AU)

Direct and indirect estimates of HIV-1 incidence in a high prevalence population

While the worldwide AIDS epidemic continues to expand, directly measured incidence data are difficult to obtain. Methods to reliably estimate human immunodeficiency virus type 1 (HIV-1) incidence from more easily available data are particularly relevant in those parts of the world where prevalence is rising in heterosexually exposed populations. The authors set out to estimate HIV-1 incidence in a population of heterosexual sexually transmitted disease clinic attended in Trinidad who had a known high prevalence of HIV-1 subtype B. Over the period 1987-1995, HIV-1 incidence estimates from serial cross-sectional studies of HIV-1 prevalence, passive follow-up of clinic recidivists, modeling of early markers of HIV-1 infection (p24 antigen screening), and a cohort study of seronegative genital ulcer disease cases were compared. Measuring incidence density in the genital ulcer disease cases directly gave the highest estimate, 6.9 percent per annum. Screening for the detection of early HIV-1 markers yielded an incidence of 5.0 percent per annum, while estimating incidence from serial cross-sectional prevalence data and clinic recidivists gave estimates of 3.5 percent and 4.5 percent per annum, respectively. These results were found to be internally consistent. Indirect estimates of incidence based on prevalence data can give accurate surrogates of true incidence. Within limitations, even crude measures of incidence are robust enough for health planning and evaluation purposes. For planning vaccine efficacy trails, consistent conservative estimates may be used to evaluate population before targeting them to cohort studies(AU)

Incidence of HTLV-I-associated myelopathy/tropical spastic paraparesis (HAM/TSP) in Jamaica and Trinidad

HTLV-I is sexually transmitted more efficiently from men to women than vice versa, and the majority of HTLV-I endemic areas report a female preponderance of HTLV-I-associated myelopathy/tropical spastic paraparesis (HAM/TSP) cases. The objective of this study was to estimate the gender and age specific incidence rates of HAM/TSP in the general population as well as in the HTLV-I-infected population in Jamaica and Trinidad and Tobago. Incidence rates for HAM/TSP were computed based on all reported incident cases in both countries between 1990 and 1994. Population cenus reports for 1990 were used to calculate the population at risk. The age-standardized HAM/TSP incidence rate (mean +/- standard error of the mean) in Jamaica was 1.8 +/- 0.2/100,000 person years (PY). Among individuals of African descent in Trinidad and Tobago, the rate was 1.7 +/- 0.4/100,000 PY. As in HTLV-I seroprevalence, the incidence rate of HAM/TSP increased with age through the fifth decade of life and was three time as high in women than in men. The HAM/TSP incidence rate, calculated as a function of the number of HTLV-I infection persons in each age stratum, is higher in women (24.7/100,000 PY) than in men 17.3/100,000 PY). With HTLV-I infection, the lifetime risk of developing HAM/TSP was estimated to be 1.9 percent overall and is slightly higher in women (1.8 percent) than in men (1.3 percent). Thus, the higher prevalence of HTLV-I in women in endemic areas does not fully explain the preponderance of female HAM/TSP, suggesting that other cofactors must be present. The higher incidence rate in women between the ages of 40 and 59 years, as well as the increase in HAM/TSP incidence rates with age, are indicative of the importance of adult-acquired HTLV-I infection, presumably through sexual transmission(AU)

Effect of human T-lymphotropic virus type I infection on non-Hodgkin's lymphoma incidence

We previously reported from a case-control analysis that T-cell non-Hodgkin's lymphoma (NHL) was strongly associated with human T-lymphomphotropic virus type I (HTLV-I) infection in Jamaica and Trinidad and that the relative risk for HTLV-I infection was very high in younger patients. Purpose: the objective of this study was to estimate the age-specific incidence rates of NHL among HTLV-I-infected and HTLV-I-uninfected adults in Jamaica and Trinidad. Methods: Population rates of HTLV-I infection were calculated from available census reports and serosurvey data. Incidence rates for NHL were calculated from all incident cases in Jamaica during 1984-1987 (n = 135) and from all incident cases in Trinidad during 1986-1990 (n = 117). Using biopsy material, we determined whether the immunophenotype or the tumor cells was T cell, B cell, or other. NHL incidence rates were computed according to HTLV-I status, age, sex, and tumor phenotype for each country separately and for both countries combined by weighting to the relative population size of each country. Results: The age-standardized NHL incidence rate (mean ñ SE) in Jamaica was 1.9 ñ 0.2 per 100,000 person-years (PY). In Trinidad, the rate was 2.9 ñ 0.4 per 100,000 PY. Overall, the incidence of NHL increased with age and was higher in males than in females. In the HTLV-I-infected population, the incidence of NHL was inversely related to age, and age-specific rates were higher in males than in females. The NHL incidence in those estimated to have acquired HTLV-I infection in childhood, however, showed no sex difference, and one in 1300 such carriers (95 percent confidence interval: one in 1100 to one in 1600) per annum were estimated to be at such risk. For T-cell NHL, as proxy for adult T-cell lymphoma/leukemia, incidence was highest in those patients infected with HTLV-I early in life (perinatally or via breast milk), with high, sustained risk from early adulthood in both sexes. Conclusions: While overall NHL incidence rates reveal that HTLV-I endemicity does not impose an exaggerated lymphoma burden on these populations, the risk for lymphoma among carriers who acquire infection early in life is dramatic and is consistent with the hypothesis that virus exposure early in life is most important for lymphomagenesis. Implications: Studies of HTLV-I carriers known to be infected in childhood may provide insight into markers intermediate in the lymphomagnetic process. Strategies to disrupt early-life transmission of HTLV-I, notably mother-infant transmission, may be critical in reducing the burden of lymphoreticular disease in these populations (AU)

Perinephric abscess mimicking fulminant hepatic failure

We describe a female diabetic patient who presented with features suggestive of hepatobiliary disease and who exhibited clinical signs of fulminant hepatic failure. Identification and drainage of a right perinephric abscess resulted in prompt resolution of both the physical signs and biochemical indices of liver disease. Infection remote from the hepatobiliary tree can mimic fulminant hepatic failure, and recognition of this unusual presentation of infection is important if dangerous delay in diagnosis and treatment is to avioded.

Perinephric abscess mimicking fulminant hepatic failure

We describe a female diabetic patient who presented with features suggestive of hepatobiliary disease and who exhibited clinical signs of fulminant hepatic failure. Identification and drainage of a right perinephric abscess resulted in prompt resolution of both the physical signs and biochemical indices of liver disease. Infection remote from the hepatobiliary tree can mimic fulminant hepatic failure, and recognition of this unusual presentation of infection is important if dangerous delay in diagnosis and treatment is to avioded. (AU)

Role of HTLV-I in development of non-Hodgkin lymphoma in Jamaica and Trinidad and Tobago. The HTLV lymphoma study group

Human T-cell lymphotropic virus type I (HTLV-I) has been implicated in the aetiology of adult T-cell leukaemia/lymphoma in Japan and elsewhere, particularly the Caribbean. We have carried out parallel case-control studies in Jamaica and in Trinidad and Tobago to quantify the role of HTLV-I in the development of non-Hodgkin lymphoma (NHL). 135 cases of NHL were enroled in Jamaica and 104 in Trinidad and Tobago. Controls were selected from patients treated in the same wards or clinics at the same time as the cases. Overall, patients with NHL were 10 times more likely than were controls to be seropositive for HTLV-I (Jamaica odds ratio 10.3 [95 percent CI 6.0-18.0], Trinidad and Tobago 14.4 [7.6-27.2]). In both countries the association between NHL and HTLV-I was greatest for T-cell lymphomas (18.3 [9.5-35.6] and 63.3 [25-267]). Among T-cell lymphomas especially, there was no significant difference between men and women in the association between NHL and HTLV-I, but there was a significant inverse relation between age and likelihood of HTLV-I seropositivity. B-cell lymphomas were predominant in the older age groups and were not associated with HTLV-I seropositivity. These findings are consistent with the hypothesis that early life exposure to HTLV-I is important for risk of subsequent ATL. Prevention of vertical transmission of HTLV-I could reduce by 70-80 percent cases of NHL in people under 60 years in this region (AU)

Cushing's syndrome from tropical glucocorticoids

A case of Cushing's syndrome is described in a woman who self-treated psoriasis with a variety of potent tropical glucocorticoids over 15 years. She was successfully weaned off corticosteroids and was treated with alternative anti-psoriatic drugs. The disappearance, nine months later, of most features of Cushing"s syndrome, and the normal supression of cortisol in response to dexamethasone, excluded endogenous hypercorticolism. The apparent widespread availability across the counter of potent corticosteriods is a cause of concern.

Cushing's syndrome from tropical glucocorticoids

A case of Cushing's syndrome is described in a woman who self-treated psoriasis with a variety of potent tropical glucocorticoids over 15 years. She was successfully weaned off corticosteroids and was treated with alternative anti-psoriatic drugs. The disappearance, nine months later, of most features of Cushing"s syndrome, and the normal supression of cortisol in response to dexamethasone, excluded endogenous hypercorticolism. The apparent widespread availability across the counter of potent corticosteriods is a cause of concern. (AU)

HTLV-1 seroprevalence among blood donors and food handlers in Guyana - a preliminary report - abstract

The aim of this study was to determine the prevalence of HTLV-1 seropositivity in those blood donors, food handlers and patients with symptoms suggestive of HTLV-1 infection who were seen at the Georgetown Hospital from July 15 to September 30, 1992. Sera were tested for HTLV-1 antibodies at the Caribbean Epidemiology Centre. Three hundred and fifty-four subjects were studied of whom 279 (79 per cent) were blood donors and 75 (21 per cent) food handlers; 3.9 per cent of the former (11/279) and 12.0 per cent of the latter (9/75) were seropositive with an overall seropositivity of 5.6 per cent. Although Indo-Guyanese accounted for about 40 per cent of the total sample there was only one Indo-Guyanese who was seropositive for HTLV-1. The presence of signs and symptoms associated with HTLV-1 infection was not a useful predictor of the disease (AU)

SLE or HIV? Dilemma for the Caribbean clinician! - abstract

Systemic lupus erythematosus (SLE) is not an uncommon disease in the Caribbean. The clinical presentation though often characteristic can include a variety of non-specific symptoms. HIV infection, an increasing problem in the region, can mimic rheumatological diseases like SLE. This paper highlights the clinical and serological overlap of these two conditions. A 24-year old female presenting with fever, cough, weight loss, polyarthralgia and alopecia was treated for SLE. The possibility of AIDS was entertained. HIV antibody was positive by ELISA testing. Western Blot analysis was indeterminate with non-viral bands indicating a false positive ELISA test. The eventual outcome supported a final diagnosis of SLE. Four months after presentation, HIV antibody was negative by both ELISA and Western Blot analysis. This case prompted a retrospective analysis of medical records and a further three cases of SLE with false positive HIV tests by ELISA were identified. In a fourth patient with nephritis, the finding of a positive HIV by ELISA pre-empted therapeutic intervention. This patient succumbed. Ante-mortem blood samples were strongly positive for antinuclear factor and double-stranded DNA but negative for HIV by Western Blot. Caribbean clinicians should therefore be made aware of the possibility that HIV can mimic rheumatological disease and that rheumatological disease can result in false positive tests for HIV. The specific immunoblot techniques would be the investigation of choice in suspicious cases (AU)

Tropical spastic paraparesis and HTLV-I: a Caribbean perspective - abstract

Tropical spastic paraparesis (TSP) is a chronic neurological disease which is probably endemic to the Caribbean for at least the last 100 years. Similar syndromes have also been described in other parts of the world including Japan, North and South America, Africa, and South India. Another chronic syndrome known as tropical ataxic neuropathy (TAN), formerly endemic in Jamiaca, shared some clinical features with TSP and has virtually disappeared. These syndromes have been called by various names, including Jamaican neuropathy, tropical myeloneuropathy and strachen disease, and in Japan TSP is known as HTLV-1 associated myelopathy (HAM). Cyanide toxicity is documented as a cause for both endemic TAN and epidemic TSP in Africa. Cyanide toxin found in improperly prepared cassava, vitamin B12 deficiency and syphilis have all been discounted as a cause of TSP in the Caribbean. The association of the human T-cell lymphotrophic virus (HTLV-1) and TSP was discovered through a combination of serendipity, suspicion and science. Exactly one decade ago the first retrovirus, HTLV-1, to be associated with human disease, was isolated from a patient with a cutaneous T-cell lymphoma. HTLV-1 associated with adult T-Cell lymphoma (ATL) and TSP was subsequently reported throughout the Caribbean by various workers. Gessain et al in 1985 found that 10 out of 17 TSP patients in Martinique were HTLV-1 positive. Bartholomew et al in Trinidad and Tobago and Morgan et al in Jamaica confirmed this association. The prevalence of the virus throughout the Caribbean ranges from 2.0 percent in Martinique to 5.6 percent in Grenada. Other neurological syndromes have since been reported to be associated with HTLV-1. These include polymyositis, Guillain-Barre syndrome, facial nerve palsies, anterior horn cell disease and aseptic meningitis/encephalopathy. Non-neurological associations include pulmonary alveolitis, uveitis, Sjorgen's syndrome and inflammatory skin manifestations. In the last decade, 50 cases of TSP have been identified in Trinidad and Tobago with approximately 17 deaths due primarily to infectious complication. No case of TAN was identified. TSP in Trinidad and Tobago appears to be identical with the syndrome as described regionally. Interestingly, all the cases are of African or mixed-African descent although the population proportion of East Indian to African is approximately 1:1. HLA studies in Japan have shown evidence for a genetic role in TSP and ATL (AU)

Retroviruses in the Caribbean

Transmission of HIV in many Caribbean countries has followed the pattern of initial predominance among homosexual and bisexual male, with the infection subsequently spreading into the heterosexual community. However, on Saint Lucia the epidemic began among heterosexual contacts of Saint Lucia labourers from Florida; in Bermuda 58 percent of AIDS cases have been in interavenous drug abusers; and in the infected via the perinanatal route. Seroprevalence of the human T-lymphotropic virus, type 1 (HTLV-), whose modes of transmission resemble those of HIV, has been found to range from 2.3 percent in Trinidad and Tobago to 5.4 percent in Jamaica. In a study of HIV and HTLV-1 infection patterns in homosexuals males in Trinidad and Tobago, the cohort was too small for confirmation that coinfection with these two viruses hastended progression to AIDS, but further investigation is warranted. (AU)