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High cost and limited availability of the current hepatitis B virus vaccine lead to underutilization. To address this problem, we performed a vaccine trial comparing the currently recommended regimen of 20 μg of hepatitis B surface antigen (HBsAg) intramuscularly on days 0, 30, and 180, with a more economical regimen of 2 μg of HBsAg intradermally on days 0, 30, and 180. This trial was performed in 50 seronegative health care workers to assess the immunogenicity and local reactogenicity of both vaccine regimens. We found no significant difference in seroconversion between the intradermal group (96%) and the intramuscular group (100%). Mean ratios of test sample value to mean negative control value for antibody to HBsAg at 360 days were not significantly different (intradermal group, 84 ±26; intramuscular group, 120 ±22). Reactions in both groups were minor. Although the optimal dose of HBsAg was not investigated, our data demonstrate that 0.1 mL of inactivated hepatitis B virus vaccine (Heptavax-B) intradermally is immunogenic in healthy adults. Vaccination by this regimen can broaden hepatitis B virus disease prevention.(JAMA 1985;254:3203-3206)

Thirty-seven percent (15/41) of patients with human T-cell lymphotropic virus type III (HTLV-III) disease (acquired immunodeficiency syndrome [AIDS] or AIDS-related complex) sequentially evaluated at Walter Reed Army Medical Center, Washington, DC, acquired this infection from a partner(s) of the opposite sex. Demographic features of these 15 patients (ten males and five females) differed substantially from those for patients reported to the Centers for Disease Control. Heterosexual contact with partners who developed AIDS or who were at risk for AIDS was confirmed in six patients. The remaining nine patients had multiple (>50) heterosexual partners and/or sexual contact with prostitutes. The method of sexual activity did not appear to be related to disease acquisition; however, this study clearly demonstrated that receptive anal intercourse was not a requirement. The observations reported herein provide further epidemiologic evidence to support the occurrence of bidirectional heterosexual transmission (both male to female and female to male) of HTLV-III infection and disease.(JAMA 1985;254:2094-2096)

Seven cases of acquired immunodeficiency syndrome (AIDS) and AIDS-related complex (ARC) associated with human T-cell leukemia (lymphotropic) virus (HTLV)-III infection were documented in married males whose family members consented to medical evaluation. Five spouses also had evidence of HTLV-III infection documented by isolation of virus and by detection of serum antibody directed against viral structural proteins. Three of the five HTLV-positive spouses also had clinical evidence of ARC. The remaining four spouses were clinically healthy. Eleven children (between 14 months and 13 years of age) were also evaluated for evidence of disease and exposure to HTLV-III. Only one 14-month-old child was seropositive for antibody to HTLV-III. These data support the opinion that close household contact to patients with ARC or AIDS is not an efficient mechanism for virus transmission, while demonstrating that HTLV-III can be transmitted by repeated heterosexual contact.(JAMA 1985;253:1571-1573)

Twenty-four percent (7/29) of human immunodeficiency virus—infected women seen at Walter Reed Army Medical Center between 1983 and 1986 presented with a history of chronic refractory vaginal candidiasis. In addition to vaginal candidiasis, all patients were found to have oral thrush on physical examination, severe T-helper cell depletion (mean T-helper cell count of 90), and markedly decreased T4/T8 ratios (mean, 0.3); six of seven women were anergic by delayed-type hypersensitivity skin testing. The conditions of six (86%) of these seven women have progressed to acquired immunodeficiency syndrome (WR6 classification). Chronic refractory vaginal candidiasis may be a presenting symptom of human immunodeficiency virus infection. Women with human immunodeficiency virus infection and unexplained oral and vaginal candidiasis are at high risk to develop other opportunistic infections.(JAMA 1987;257:3105-3107)

In Reply.—Because AIDS has been diagnosed almost exclusively in members of "high-risk" groups, physicians often do not consider the diagnosis of HTLV-III infection in individuals who do not belong to these risk groups. We have looked for evidence of HTLV-III infection in all patients (of either sex) presenting to our infectious disease service with the appropriate signs or symptoms and also their sexual partners. This case-finding methodology is etiologically based and epidemiologically sound. Our report documented the occurrence of HTLV-III disease in non-drug-using heterosexual males and females, thus providing scientifically sound evidence for bidirectional heterosexual transmission. Our report did not purport to define the relative risk of infection that is associated with either multiple heterosexual contacts or prostitute contacts. In a heterosexual population, we suggested that the risk of infection with HTLV-III will be more likely in individuals with multiple sexual partners or in individuals whose sexual contacts (eg,

To the Editor.—Although acquired immunodeficiency syndrome has been reported in prisons, the magnitude of human T-cell lymphotropic virus type III (HTLV-III) infection in inmates is not well defined.1 The potential for intraprison transmission clearly exists if a reservoir of infection is present. A history of intravenous drug abuse has been documented by over 30% of inmates at several prisons.2,3 Among a sample of federal penitentiary inmates, 30% admitted to adult homosexual activity in a prison.4 We undertook to document the prevalence and incidence of HTLV-III infection in a maximum-security military prison.

To the Editor.—As part of the US Army quality assurance program for human T-cell lymphotropic virus type III (HTLV-III) testing, we recently sent identical proficiency panels to five large commercial firms that offered HTLV-III Western blot testing on a fee-for-service basis. Each panel consisted of 15 samples from healthy, low-risk adults whose serum was repeatedly negative for HTLV-III antibodies and five samples from HTLVIII-infected (culture-documented) patients. By Western blot analysis, all five positive samples produced definite, but not strong, bands at 41 kilodaltons (kd) and other molecular weights characteristic of HTLV-III proteins.1Scores ranged from 85% to 100% accuracy (Table). Four of the five laboratories reported at least one falsepositive test result. The six falsepositive results were all on different normal specimens, suggesting that the errors were due to technique and not to intrinsic biologic properties of the specimens. There was a substantial range of clarity of the

To the Editor.—Sir William Osler, in an 1897 address to the New York Academy of Medicine, said, "Know syphilis in all its manifestations and relations, and all other things clinical will be added unto you."1 In 1987, clinicians are faced with another sexually transmitted disease with protean clinical manifestations, human immunodeficiency virus (HIV) infection. The HIV epidemic is still in its early stages. Although progressive premature T-cell destruction is the critical pathogenic mechanism by which HIV induces disease,2 the complete clinical spectrum of primary and secondary consequences of HIV infection remains to be elucidated.Study.—We performed a pilot study in an attempt to determine the prevalence of undiagnosed HIV infections among patients presenting for medical care at our institution. During a three-week period in August 1986, all serum specimens sent to the hospital laboratory for a chemical profile (liver function, electrolyte, serum urea nitrogen, glucose, and