Mortality associated with HIV infection in rural Rakai District, Uganda.

OBJECTIVE: To assess mortality impact of HIV in rural Uganda. METHODS: An open cohort of 19983 adults aged 15-59 years, in Rakai district was followed at 10 month intervals for four surveys. Sociodemographic characteristics and symptomatology/disease conditions were assessed by interview. Deaths among residents and out-migrants were identified household census. Mortality rates were computed per 1000 person years (py) and the rate ratio (RR) of death in HIV-positive/HIV-negative subjects, and the population attributable fraction (PAF) of death were estimated according to sociodemographic characteristics. Mortality associated with potential AIDS defining symptoms and signs was assessed. RESULTS: HIV prevalence was 16.1%. Mortality was 132.6 per 1000 py in HIV-infected versus 6.7 per 1000 py in uninfected subjects, and 73.5% of adult deaths were attributable to HIV infection. Mortality increased with age, but the highest attributable risk of HIV associated deaths were observed in persons aged 20-39 years (PAF > 80%) and in women. HIV associated mortality was highest in the better educated (PAF > or = 75%) and among government employees (PAF > or = 82%). Of the HIV-positive subjects 40.5% reported no illness < 10 months preceding death, symptoms were poor predictors of death (sensitivity 1.6-38.8%), and only 9.1% met the World Health Organization clinical definition of AIDS. Infant mortality rates in babies of HIV-infected and uninfected mothers were 209.4 and 97.7 per 1000, respectively. CONCLUSION: HIV is taking substantial toll in this population, particularly among the younger better educated adults, and infants. Symptomatology or the World Health Organization definition of AIDS are poor predictors of death.

Relative risks and population attributable fraction of incident HIV associated with symptoms of sexually transmitted diseases and treatable symptomatic sexually transmitted diseases in Rakai District, Uganda. Rakai Project Team.

OBJECTIVES: To assess the linkage of sexually transmitted disease (STD) symptoms and treatable STD to HIV incidence. DESIGN: Analysis of a randomized trial of STD control for HIV prevention, Rakai, Uganda. METHODS: Consenting adults 15-59 years of age were seen at 10-monthly home visits, interviewed regarding STD symptoms, and asked to provide samples for HIV and STD diagnoses. HIV incidence was determined in 8089 HIV-negative subjects over 10 457 person years. Adjusted rate ratios (RR) and 95% confidence intervals (CI) of HIV acquisition associated with genital ulcer disease (GUD) and discharge/dysuria were used to estimate the population attributable fraction (PAF) of HIV acquisition. HIV transmission risks associated with STD symptoms in HIV-positive partners of 167 HIV discordant couples and the numbers of sexual partners reported by HIV-positive subjects were used to estimate the PAF of HIV transmission attributable to STD. RESULTS: HIV prevalence was 16%. The risk of HIV acquisition was increased with GUD (RR 3.14; CI 1.98-4.98) and in males with discharge/dysuria (RR 2.44; CI 1.17-5.12), but not in females with discharge/dysuria. The PAF of HIV acquisition was 9.5% (CI 2.8-15.8%) with any of the three STD symptoms. The PAF for GUD was 8.8% (CI 3.7-13.8), but only 8.2% of reported GUD was caused by treatable syphilis or chancroid . The PAF for discharge/dysuria in males was 6.7% (CI 1.1-13.8), but only 25% of symptomatic males had concurrent gonorrhea or chlamydial infection. No significant differences were seen in PAF between study treatment arms. The PAF of HIV transmission associated with STD symptoms in HIV-positive persons was indirectly estimated to be 10.4%. CONCLUSION: In this mature, generalized HIV epidemic setting, most HIV seroconversion occurs without recognized STD symptoms or curable STD detected by screening. Therefore, syndromic management or other strategies of STD treatment are unlikely to substantially reduce HIV incidence in this population. However, STD is associated with significant HIV risk at the individual level, and STD management is needed to protect individuals.

A comparison of the shear bond strengths of two glass ionomer cements.

The objective of this study was to determine the in vitro shear bond strength (in megapascals) and location of bond failure with two light-cured glass ionomer resin systems. One system was a hybrid glass ionomer cement with resin (GC Orthodontics, Aslip, Ill), and the other system a glass-filled resin system (Reliance Orthodontic Products, Inc, Itasca, Ill). These systems, Fuji Ortho LC (GC Orthodontics) and Ultra Band Lok (Reliance), respectively, were compared to a light-cured composite resin. Maxillary premolar brackets (n = 200) were bonded to the facial surface of human premolar teeth. The two glass ionomer resin systems were each evaluated by two protocols, one according to the manufacturers' direction plus a variation of their respective technique. The five distinct groups (n = 40) were stored in 37 degreesC distilled water for 30 days and subjected to thermocycling before shear bond strength testing. The findings indicated that large variations existed between the bond strengths of the materials tested. The laboratory shear bond strength of the glass-filled resin glass ionomer cement (Reliance), whether tested in a dry or moist field, was similar to the composite control with all of the previous materials being significantly (P <.01) higher than both the hybrid glass ionomer cement groups (Fuji Ortho LC). However, the hybrid glass ionomer cement with enamel conditioner demonstrated a clinically acceptable mean megapascal value. The Adhesive Remnant Index values ranged from 0.53 to 1.62. The hybrid glass ionomer cement without enamel conditioning recorded the lowest mean adhesive remnant index score and the lowest mean megapascal score. Although both products are glass ionomer resin systems, their individual chemistries vary; this affects their clinical performance. Clinically, it may be suggested that glass ionomers used in a dry field may be beneficial for orthodontic bonding, and that glass ionomer resin systems used in a moist environment need an enamel conditioner.

Use of a hybrid capture assay of self-collected vaginal swabs in rural Uganda for detection of human papillomavirus.

A random sample of 960 women aged 15-59 years enrolled in a population-based study in rural Uganda were asked to provide self-collected vaginal swabs for human papillomavirus (HPV) testing by hybrid capture assay. The intensity of HPV infection was assessed by the relative light unit (RLU) ratio in the specimen-to-positive control (PC) ratio. In total, 898 women (93%) provided a swab and 737 provided serum for human immunodeficiency virus type 1 (HIV-1) determination. HPV prevalence was 16.7% and was highest in younger women. HIV-1 prevalence was 17.8%. HPV prevalence was 44.3% in HIV-positive and 10.2% in HIV-negative women (rate ratio, 5.36; 95% confidence interval, 3.81-7.54). The intensity of HPV infection was significantly greater among HIV-positive than HIV-negative women (54. 4 vs. 11.1 RLU/PC; P=.026); intensity of infection was highest in women aged <30 years. The higher prevalence and intensity of HPV infection in HIV-positive women could facilitate HPV transmission in this population. Self-collected vaginal swabs could be used in population-based screening to identify women at high risk of cervical neoplasia.

Sensitivity and specificity of HIV-1 testing of urine compared with serum specimens: Rakai, Uganda. The Rakai Project Team.

BACKGROUND AND OBJECTIVES: To evaluate a urine HIV-1 test. STUDY DESIGN: Paired urine and blood samples from a sample of 222 subjects were assayed for HIV-1 using Calypte HIV-1 Urine enzyme immunoassay (EIA) with Western blot (WB) confirmation, and sera were tested by EIA and WB. Masked assays were done on stored, refrigerated urine at Johns Hopkins University (JH), and on fresh specimens at the Rakai Project, Entebbe (RP). We assessed the sensitivity and specificity of the urine relative to serum assays. RESULTS: Compliance with provision of urine samples (95.0%) was higher than provision of serum (90.5%). Ninety-six sera were HIV-positive; 92 were HIV-positive on stored urine at JH (sensitivity 95.8%, CI 91.8-99.8%); and 94 (100%) were positive on fresh samples at the RP laboratory (sensitivity = 100.0%). Among serum HIV-negative subjects, all frozen urine were negative at JH and 97.7% of fresh samples were negative at RP. CONCLUSIONS: The Calypte urine HIV-1 EIA with WB is sensitive and specific. In this population, provision of urine was more acceptable than provision of blood samples.