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It is often uncertain whether deaths that occur during active treatment for complications of AIDS result from diagnostic or therapeutic failure. Accurate diagnosis of infections is particularly important, and has relevance not only for the patient but also to partners, relatives, hospital staff and other patients. In the absence of adequate physical facilities and in view of the lack of success in obtaining formal autopsies in patients dying with AIDS, a limited autopsy protocol was devised for routine application at our hospital, beginning in 1989. The major aim of this protocol was to enable the safe collection of diagnostic material from patients who died despite active therapy, to ascertain unrecognized conditions and confirm existing diagnoses. We present findings from the first 16 limited autopsies which resulted in 12 additional diagnoses and a revision of the principal cause of death in 7 cases.

This study was a cross-sectional study of 122 HIV-positive subjects to determine the prevalence and predictors of weight loss in the era of highly active antiretroviral therapy (HAART). Forty per cent reported lipodystrophy, 40% had documented weight loss (mean 6.6 kg). Mean intake 13400 kJ (118% of estimated requirements calculated using the Harris-Benedict equation). One hundred (82%) were taking antiretroviral therapy. Using forward stepwise logistic regression analysis only viral load (VL) was significantly associated with weight loss when intake, CD4 T-cell count, lipodystrophy, and age were entered into the model with VL (log copies/mL). Every one log increase in HIV VL was associated with an odds of weight loss of 1.58 ( P=0.0008). Weight loss is still common in the HAART era. HIV VL was the most significant predictor of weight loss in this sample. Inadequate dietary intake and self-reported lipodystrophy were not related to weight loss in this population.

1. To determine if resting energy expenditure (REE) adjusted for body composition is elevated in HIV-positive males when compared with healthy controls in the era of highly active antiretroviral therapy. 2. To examine the accuracy of prediction equations for estimating REE in people with HIV. 3. To determine if REE adjusting for body composition is significantly different between those HIV-positive subjects reporting lipodystrophy (LD) or weight loss (or=5%) and those who are weight stable when compared to controls.Cross-sectional study.Tertiary referral hospital HIV unit and an outpatient clinic specializing in HIV care.HIV-positive males (n=70) and healthy male controls (n=16).REE was measured using indirect calorimetry. Body composition was assessed using bioelectrical impedance analysis.1. REE when adjusted for fat-free mass and fat mass using the general linear model (analysis of covariance) was greater in HIV-positive subjects than controls (7258+/-810 kJ, n=70 vs 6615+/-695 kJ, n=16, P0.05). 2. The Harris and Benedict, Schofield, Cunningham and the two equations previously published by Melchior and colleagues in HIV-positive subjects all gave an estimate of REE significantly different from the measured REE in the HIV-positive subjects, therefore a new prediction equation was developed. The inability of the published equations to predict REE in the different HIV-positive subgroups reflected the heterogeneity in body composition. 3. REE adjusted for fat-free and fat mass was significantly greater in the both the HIV patients who were weight stable and those with lipodystrophy compared with the healthy controls.REE is significantly higher in HIV-positive males when compared with healthy controls. Body composition abnormalities common in HIV render the use of standard prediction equations for estimating REE invalid. When measuring REE in HIV-positive males adjustment steps should include fat-free and fat mass.

This randomized, prospective study compared three treatments, nandrolone decanoate (ND), megestrol acetate (MA) or dietary counselling, for managing human immunodeficiency syndrome (HIV) associated weight loss. It was centred on a Tertiary referral hospital, Sydney, Australia. Fifteen patients were randomized to receive ND (100 mg/fortnight), or MA (400 mg/day) or dietary counselling for 12 weeks. Those patients randomized to dietary counselling were further randomized to receive nandrolone or megestrol after completing the dietary counselling arm. Weight, fat free mass (FFM), percentage body fat mass (FM), dietary intake and appetite were assessed before commencing and at the completion of each treatment arm. Weight increased significantly in all treatment arms (dietary counselling 1.13 kg +/- 0.36, nandrolone 4.01 kg +/- 1.68, megestrol 10.20 kg +/- 4.51, p < 0.05 paired t-test). FFM increased significantly in patients receiving ND (3.54 +/- 1.98 kg, p=0.001) and those receiving MA (2.76 +/- 0.55 kg, p=0.002), whereas the change in those receiving dietary counselling alone was not significant. Percentage body fat mass increased significantly only in those receiving MA (7.77 +/- 4.85%, p=0.049). The change in weight and percentage body fat mass was significantly greater in those receiving MA than the other two treatment arms. The increase in FFM was significantly greater in both the nandrolone and megestrol arms than the dietary counselling arm. It was concluded that ND and MA both resulted in an increase in FFM greater than dietary counselling alone. Megestrol produced a significantly greater increase in weight, percentage fat mass, intake and appetite than did the other two treatment arms, suggesting it may be the preferred agent, particularly in a palliative care setting in which weight, appetite and intake increase are desirable without regard to the composition of the body. The long-term use of these agents in people with HIV should be reviewed in the context of improved survival on highly active antiretroviral therapy regimens.

Background: In HIV infection T-cell dysfunction resulting in anergy and hypersensitivity reactions precedes T-cell depletion. A shift in the cytokine profile from a type 1 to a type 2 response has been postulated. Objective: We sought to examine the cytokine expression patterns in HIV infection and the relationship to allergy, stage of HIV disease, and other laboratory parameters. Methods: A cross-sectional analysis of IL-2, IL-4, IL-5, IL-6, IL-10, IL-12p35, IL-13, and IFN-γ mRNA expression in PBMCs by noncompetitive dot-blot PCR was performed on blood obtained from 18 HIV-infected subjects. Delayed-type hypersensitivity multitests to detect anergy, skin prick testing and in vitro assay for specific IgE antibodies, assay for total IgE, and enumeration of eosinophils, CD4 + , and CD8 + T cells were also performed on all subjects. Results: We found evidence of a decline in type 1 cytokines (IL-2, IL-12p35, and IFN-γ) associated with AIDS, CD4 + T cells less than 200/μL, anergy, and atopy, although this only reached statistical significance in anergy. There was no associated significant alteration in type 2 cytokines. Conclusions: This is the first report of an association between low constitutive in vivo expression of IL-12 mRNA and anergy, which supports earlier data from in vitro stimulation studies. The presence of atopy was associated with a more global reduction in cytokine expression. Because the decline in type 1 cytokines was not accompanied by a similar decline in type 2 cytokines, this does suggest a shift in the type 1/type 2 balance. (J Allergy Clin Immunol 1999;103:833-42.)

Background and Aims: Autopsy studies suggest that cardiac inflammation is associated with increased mortality in systemic lupus erythematosus (SLE). Echocardiography has traditionally been the primary cardiac screening modality in SLE; however there are often limitations indetectingmyocardial andpericardial inflammation.We investigate theutilityofdelayed-enhancement cardiac magnetic resonance (CMR) compared to echocardiography in a group of 37 SLE patients – the largest SLE cohort yet investigated with CMR. Methods: Echocardiography and cardiac magnetic resonance (1.5 T) with gadolinium contrast were performed in 37 consecutive SLE patients (mean age 39.9± 12.5 years; 80% female; mean SLEDAI score 3.8± 3.5). Mean exercise capacity was 97.5± 24.5% predicted METS. Results: Of the 37 patients, echocardiography was abnormal in 13 (35%), with 10 cases of valvular incompetence, four of LV wall abnormalities, and three of pericardial pathology. CMR revealed inflammation in 12 patients (32%), of which five had a normal echocardiogram. The presence of CMR-detectable inflammation did not correlate with (i) any immunological markers (dsDNA, C3/C4, CRP, ESR, antibodies to cardiolipin, SSA, SSB or Rho-52), (ii) immunosuppressive regimen, or (iii) exercise tolerance. Conclusions: Echocardiography has a high yield for valvular disease in SLE, whereas CMR detects significant rates of myocardial and pericardial inflammation, often in patients with no detectable echo abnormality. CMR may thus be a worthwhile addition to the cardiac monitoring algorithm in SLE. However, as no immunological or functional correlatesofCMR-detectable inflammationhaveyet been identified, further study is warranted to determine the clinical relevance of this phenomenon.

A diverse range of services were developed in NSW in response to the emerging HIV epidemic. These services included innovative multidisciplinary service models of care most of which have been durable. Allied health teams and ancillary services funded by non-government organisations have played a vital role in delivering care and support in the community. A consistency of approach to treatment across the health sector has been reinforced through continuing education activities and credentialing of antiretroviral-drug prescribers. This investment in care and treatment has resulted in reduced hospital bed use. High levels of treatment uptake over many years are likely to have a favourable impact on transmission rates thus contributing to the stability of the epidemic in NSW.

NSW has been recognised internationally for achieving a sustained, stable rate of HIV infection since 2000. An early mobilisation by communities initially at risk of HIV – gay men, sex workers and injecting drug users – resulted in rapid behaviour change and provided the basis for a continuing cooperative partnership with government, health service providers and researchers. This special issue of the NSW Public Health Bulletin describes the current response to HIV in NSW. Experts from diverse disciplinary and professional fields offer perspectives on the epidemiology, morbidity and impacts of HIV, current prevention challenges including with Aboriginal communities and people from culturally and linguistically diverse backgrounds, models for the diagnosis, care and treatment of HIV, and the legislative protection of public health and those who are living with HIV. The NSW experience demonstrates that the sustained cooperation of those affected, together with the efforts of government, health service providers and researchers, can achieve HIV control.

Australia’s response to HIV/AIDS has contained the local epidemic. Centres of HIV epidemiology, clinical, social and virology research have contributed greatly to the understanding of clinical, pathophysiological, treatment and behavioural aspects of HIV/AIDS in those living with, and at risk for, HIV. Also underpinning the success in fighting HIV/AIDS is a highly regulated, quality assured public/private pathology enterprise interacting with the biomedical industry, pharmaceutical industry innovators and international research groups. Features of the Australian response to HIV have been partnerships of stakeholders, including researchers and pathologists, which have led to a series of formal, bipartisan, National HIV/AIDS Strategy documents and implementation programs operating in a universal access to health care environment. Innovation, such as in politically difficult harm reduction models of prevention, have been adopted and the documented success of the Australian needle and syringe program (NSP), human rights based legislative frameworks and evidenced-based public health policy decision-making has demonstrated that HIV epidemics in intravenous drug use (IVDU) and heterosexual populations can be largely prevented. Recent increases in HIV transmission in gay men reflected in rising rates of new HIV diagnoses, demand innovative approaches in prevention, testing and treatment. Findings from the Australian experience have relevance to other jurisdictions embarking on national strategy development in the HIV/AIDS domain.

The Bug Breakfast topic for October was 'HIV in 2005: The current situation and directions for the future'. The presenters covered the history and epidemiology of HIV, emerging HIV epidemics, clinical aspects of HIV, future treatment options and NSW Health’s NSW HIV/AIDS Strategy 2006–2009.

The variety of problems induced by HIV means that any one of a wide range of investigations may uncover the first clue to unsuspected infection. Some of the more common abnormalities reported on by pathologists and radiologists which should raise the thought of underlying HIV infection are listed in this summary.

One hundred and sixty-one Australian patients with hereditary bleeding disorders comprising hemophilia A (120), hemophilia B (18), von Willebrand's disease (16), and seven symptomatic female hemophilia A or B carriers were screened for clinical and serological evidence of exposure to HTLV-IM/LAV/ARV/HIV infection. During the previous five years (1979–1984) they had been treated almost exclusively with blood products derived from Australian voluntary donors. The prevalence of HTLV-III antibodies in 1985 was 45%, with the highest frequency being in those with severe hemophilia A (78%) and the lowest in patients with hemophilia B (6%). Antibody positivity correlated with a reduced absolute T helper (T4) cell numbers and/or an inverted T4:T8 ratio. Lymphadenopathy was detected in 23 subjects but only 13 had an abnormal T cell ratio. Comparison of seropositivity and T4:T8 ratios in 32 patients studied in 1983 and again in 1985 suggested that T4 cell deficiency reflected HTLV-III exposure rather than being a predisposing factor for infection with the virus. Individual patients showed considerable fluctuation in T cell subsets over a 12 month period of follow-up, but as a population there was a slight trend with time towards diminishing T4:T8 ratio only in the antibody positive hemophilia A patients of mild to moderate severity. Three (2%) of the 161 patients screened to date have developed confirmed AIDS with fatal outcome. Following the introduction of rigid exclusion criteria for donors and heat treatment of Australian lyophilised concentrates in late 1984, no antibody negative subjects have seroconverted. To date none of 15 regular sexual partners of antibody positive patients have been consistently seropositive and four clinically well, antibody negative babies have been born to antibody positive fathers.

Antibodies to the species-specific phenolic glycolipid (PGL-1) of Mycobacterium leprae and a crude M. leprae sonicate were measured by ELISA in sera from newly diagnosed and treated leprosy patients from Sydney and Nepal. IgM anti-PGL-1 antibodies were present in 88-90% of untreated patients at the lepromatous pole of the clinical spectrum and 35-55% of those at the tuberculoid pole. In treated patients with either form of the disease, IgM anti-PGL-1 antibodies were within the normal range or minimally elevated. In contrast, high levels of IgG anti-PGL-1 antibodies were detected in both treated and untreated patients. Neither IgM nor IgG anti-PGL-1 antibodies were elevated in sera from Mantoux negative controls and only one out of 15 sera from patients with untreated tuberculosis contained significant amounts of antibody. Comparison of the data from the anti-PGL-1 assay with the antibody response to a crude M. leprae sonicate revealed that the latter assay yielded more variable results and discriminated less well between lepromatous and tuberculoid subjects and between untreated patients and those on therapy. Thus the IgM anti-PGL-1 response signifies the presence of active disease, particularly in multi-bacillary cases, and has the potential to be used not only to monitor the response of these patients to therapy, but also to detect subclinical leprosy in high-risk groups such as the relatives of patients with lepromatous disease.

Two lambda gt11 recombinant clones, JKL2 and JKL15, each containing an insert coding for part of the highly immunogenic 70-kilodalton (kDa) protein antigen, were isolated from a Mycobacterium leprae genomic library by immunoscreening with the monoclonal antibody L7. Clone JKL2 contained the largest insert, 2.3 kilobase pairs. Nonoverlapping fragments of this insert were used as probes and showed strong hybridization to a number of Mycobacterium tuberculosis-lambda gt11 recombinants producing proteins recognized by an anti-M. tuberculosis 71-kDa monoclonal antibody, IT11. One clone from a recombinant Mycobacterium bovis library was also characterized by using L7, and the insert from this clone, B5bt, hybridized strongly to the M. leprae probes as well. The nucleotide sequence of the 1,037-base-pair coding region of the JKL2 M. leprae clone which encodes the carboxy-terminal half of the 70-kDa protein had extensive homology with genes from a number of species. In all cases, these genes, including the recently described Ag63 and Ag361 of Plasmodium falciparum, were found to be members of the heat shock protein 70 (hsp 70) family of genes. At the amino acid level, homology was maximal between amino acids 83 through 107 and 159 through 184, which showed extreme conservation (92 and 85% identity) with Escherichia coli DnaK amino acids 386 through 409 and 460 through 485, respectively, and was 51% homologous over the entire coding region (amino acids 1 through 344 of JKL2). In contrast, amino acids 129 through 158 had maximal homology with the phylogenetically more distant Xenopus laevis hsp70. Homology declined substantially in the carboxy-terminal 34 amino acids. The predicted ATP-binding functional activity of the 70-kDa antigen from M. bovis was confirmed with affinity purification of the antigen by binding to ATP-agarose and elution with ATP. In view of the conservation of sequences between these mycobacterial antigens and mammalian endogenous cellular enzymes, further evaluation of these molecules in vivo may aid in understanding tolerance to self-antigens as well as provide potentially useful immunodiagnostic reagents.

Background Multicentric Castleman’s disease (MCD) is a pre-malignancy that presents with lymphadenopathy and features of systemic inflammation. Human immunodeficiency virus (HIV)-associated MCD is associated with human herpesvirus-8 (HHV-8) infection. If untreated MCD has a relapsing and remitting course that is eventually fatal. Case presentation A 67-year-old man had six hospital admissions over 20 months characterised by fever, urinary frequency and CRP >100 mg/L. The final admission was complicated by hypotension requiring intensive care unit admission and ionotropic support. His history included HIV and Hepatitis B virus (HBV) co-infection on suppressive therapy. Each presentation was managed as presumed urosepsis with use of empirical antibiotics, however numerous blood and urine cultures failed to identify a pathogen. A bone-marrow aspirate and trephine found no evidence of haematological malignancy. A positron emission tomography scan found active lymph nodes, one of which was biopsied and found to contain the plasma-cell variant of Castleman’s disease. Ultimately the cause for the recurrent presentations was attributed to progressive MCD. The patient received rituximab monotherapy and has had no further related admissions. Conclusions MCD should be considered in patients with chronic HIV infection presenting with recurrent sepsis-like episodes and/or vasodilatory shock, particularly if no pathogen is identified or lymphadenopathy is evident.

BACKGROUND: Global genetic diversity of HIV-1 is a major challenge to the development of HIV vaccines. We aimed to estimate the regional and global distribution of HIV-1 subtypes and recombinants during 1990-2015. METHODS: We searched PubMed, EMBASE (Ovid), CINAHL (Ebscohost), and Global Health (Ovid) for HIV-1 subtyping studies published between Jan 1, 1990, and Dec 31, 2015. We collected additional unpublished HIV-1 subtyping data through a global survey. We included prevalence studies with HIV-1 subtyping data collected during 1990-2015. We grouped countries into 14 regions and analysed data for four time periods (1990-99, 2000-04, 2005-09, and 2010-15). The distribution of HIV-1 subtypes, circulating recombinant forms (CRFs), and unique recombinant forms (URFs) in individual countries was weighted according to the UNAIDS estimates of the number of people living with HIV (PLHIV) in each country to generate regional and global estimates of HIV-1 diversity in each time period. The primary outcome was the number of samples designated as HIV-1 subtypes A, B, C, D, F, G, H, J, K, CRFs, and URFs. The systematic review is registered with PROSPERO, number CRD42017067164. FINDINGS: This systematic review and global survey yielded 2203 datasets with 383 519 samples from 116 countries in 1990-2015. Globally, subtype C accounted for 46·6% (16 280 897/34 921 639 of PLHIV) of all HIV-1 infections in 2010-15. Subtype B was responsible for 12·1% (4 235 299/34 921 639) of infections, followed by subtype A (10·3%; 3 587 003/34 921 639), CRF02_AG (7·7%; 2 705 110/34 921 639), CRF01_AE (5·3%; 1 840 982/34 921 639), subtype G (4·6%; 1 591 276/34 921 639), and subtype D (2·7%; 926 255/34 921 639). Subtypes F, H, J, and K combined accounted for 0·9% (311 332/34 921 639) of infections. Other CRFs accounted for 3·7% (1 309 082/34 921 639), bringing the proportion of all CRFs to 16·7% (5 844 113/34 921 639). URFs constituted 6·1% (2 134 405/34 921 639), resulting in recombinants accounting for 22·8% (7 978 517/34 921 639) of all global HIV-1 infections. The distribution of HIV-1 subtypes and recombinants changed over time in countries, regions, and globally. At a global level during 2005-15, subtype B increased, subtypes A and D were stable, and subtypes C and G and CRF02_AG decreased. CRF01_AE, other CRFs, and URFs increased, leading to a consistent increase in the global proportion of recombinants over time. INTERPRETATION: Global and regional HIV diversity is complex and evolving, and is a major challenge to HIV vaccine development. Surveillance of the global molecular epidemiology of HIV-1 remains crucial for the design, testing, and implementation of HIV vaccines. FUNDING: None. ispartof: LANCET INFECTIOUS DISEASES vol:19 issue:2 pages:143-155 ispartof: location:United States status: published