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Objective: To determine the relative risk for human immunodeficiency virus (HIV-1) seroconversion in patients with and without genital ulcers caused by chancroid, syphilis, and herpes.Design: A prospective cohort study.Setting: An inner-city, sexually transmitted disease clinic.Patients: Patients seronegative for HIV-1 with and without genital ulcers who were followed for a minimum of 3 months.Interventions: Questionnaire to obtain data on demographics, sexual behavior, and illicit drug use; testing for HIV-1 at entry and at a minimum of 3 months after entry; medical examination for the presence or absence of genital ulcer disease.Results: Overall, 758 heterosexual men with no history of injection drug use completed the study; HIV-1 seroconversion occurred in 10 of 344 (2.9%; 95% CI, 1.4% to 5.3%) men with a genital ulcer and in 4 of 414 (1%; CI, 0.2% to 2.5%) without a genital ulcer (relative risk, 3.0; P = 0.05). In a multiple logistic regression analysis, those men with chancroid and a new sexually transmitted disease during follow-up each had about three times the risk for HIV-1 seroconversion (P < or = 0.04).Conclusions: In this group of heterosexual men, chancroid and repeated acquisition of sexually transmitted diseases appeared to facilitate the sexual transmission of HIV-1. [ABSTRACT FROM AUTHOR]

Presents a letter to the editor concerning an article entitled, 'Mandatory reporting of HIV testing would deter men from being tested,' published in a 1989 issue of the 'Journal of American Medical Association.'

Introduction: Botswana's AIDS response included free antiretroviral treatment (ART) since 2002, achieving 80% coverage of persons with CD4<350 cells/µl by 2009-10. We explored impact on mortality and HIV prevalence, analyzing surveillance and civil registration data., Methods: Hospital natural cause admissions and deaths from the Health Statistics Unit (HSU) over 1990-2009, all-cause deaths from Midnight Bed Census (MNC) over 1990-2011, institutional and non-institutional deaths recorded in the Registry of Birth and Deaths (RBD) over 2003-2010, and antenatal sentinel surveillance (ANC) over 1992-2011 were compared to numbers of persons receiving ART. Mortality was adjusted for differential coverage and completeness of institutional and non-institutional deaths, and compared to WHO and UNAIDS Spectrum projections., Results: HSU deaths per 1000 admissions declined 49% in adults 15-64 years over 2003-2009. RBD mortality declined 44% (807 to 452/100,000 population in adults 15-64 years) over 2003-2010, similarly in males and females. Generally, death rates were higher in males; declines were greater and earlier in younger adults, and in females. In contrast, death rates in adults 65+, particularly females increased over 2003-2006. MNC all-age post-neonatal mortality declined 46% and 63% in primary and secondary level hospitals, over 2003-2011. We estimated RBD captured 80% of adult deaths over 2006-2011. Comparing empirical, completeness-adjusted deaths to Spectrum estimates, declines over 2003-2009 were similar overall (47% vs. 54%); however, Spectrum projected larger and earlier declines particularly in women. Following stabilization and modest decreases over 1998-2002, HIV prevalence in pregnant women 15-24 and 25-29-years declined by >50% and >30% through 2011, while continuing to increase in older women., Conclusions: Adult mortality in Botswana fell markedly as ART coverage increased. HIV prevalence declines may reflect ART-associated reductions in sexual transmission. Triangulation of surveillance system data offers a reasonable approach to evaluate impact of HIV/AIDS interventions, complementing cohort approaches that monitor individual-level health outcomes.

Introduction: Swaziland's severe HIV epidemic inspired an early national response since the late 1980s, and regular reporting of program outcomes since the onset of a national antiretroviral treatment (ART) program in 2004. We assessed effectiveness outcomes and mortality trends in relation to ART, HIV testing and counseling (HTC), tuberculosis (TB) and prevention of mother to child transmission (PMTCT)., Methods: Data triangulated include intervention coverage and outcomes according to program registries (2001-2010), hospital admissions and deaths disaggregated by age and sex (2001-2010) and population mortality estimates from the 1997 and 2007 censuses and the 2007 demographic and health survey., Results: By 2010, ART reached 70% of the estimated number of people living with HIV/AIDS with CD4<350/mm(3), with progressively improving patient retention and survival. As of 2010, 88% of health facilities providing antenatal care offered comprehensive PMTCT services. The HTC program recorded a halving in the proportion of adults tested who were HIV-infected; similarly HIV infection rates among HIV-exposed babies halved from 2007 to 2010. Case fatality rates among hospital patients diagnosed with HIV/AIDS started to decrease from 2005-6 in adults and especially in children, contrasting with stable case fatality for other causes including TB. All-cause child in-patient case fatality rates started to decrease from 2005-6. TB case notifications as well as rates of HIV/TB co-infection among notified TB patients continued a steady increase through 2010, while coverage of HIV testing and CPT for co-infected patients increased to above 80%., Conclusion: Against a background of high, but stable HIV prevalence and decreasing HIV incidence, we documented early evidence of a mortality decline associated with the expanded national HIV response since 2004. Attribution of impact to specific interventions (versus natural epidemic dynamics) will require additional data from future household surveys, and improved routine (program, surveillance, and hospital) data at district level.

Objective: HIV programs in generalized epidemics have traditionally relied on antenatal clinic (ANC) sentinel surveillance data to guide prevention and to model epidemic trends. ANC data, however, come from a subset of the population, and their representativeness of the population has been debated., Methods: Data from a national population-based Uganda HIV/AIDS Sero-Behavioral Survey (UHSBS) were compared with those from ANC sentinel surveillance. Using geographic information system, UHSBS clusters within a 30 km radius of the ANC sites were mapped. Estimates of HIV prevalence from ANC surveillance were compared with those from UHSBS., Results: The ANC-based HIV prevalence, 6.0% [confidence interval (CI) 5.5% to 6.5%], was similar to that from UHSBS, 5.9% (CI 5.4% to 6.4%). The ANC-based estimate correlated with that of UHSBS catchment area women who were pregnant and those who had given birth in the 2 years preceding the survey. ANC data overestimated prevalence in the 15-year to 19-year age group, were similar to UHSBS for ages 20-29 years, and underestimated prevalence in older respondents. ANC data underestimated HIV prevalence among women (6.0% vs. 7.4%; CI 6.6% to 8.2%) and urban women (7.6% vs. 12.7%) but was similar for rural women (5.3% vs. 4.9%)., Conclusions: ANC-based surveillance remains an important tool for monitoring HIV/AIDS programs. ANC and UHSBS data were similar overall and for 15-year to 29-year olds, women who were pregnant, and women who had a birth in the 2 years before the survey. ANC estimates were lower in those > or = 30 years and in urban areas. Periodic serosurveys to adjust ANC-based estimates are needed.

Despite considerable speculation on the demographic impact of AIDS, there has been, until now, little scientific evidence to establish its existence or scale. Because of the widespread implications of these predictions, methods to combine demography and epidemiology to study empirical situations have been an urgent priority. This study derives the extent and mechanisms of demographic impacts of AIDS from routine data (the 1991 census) in a severely affected country, Uganda. Three characteristics are of particular note: first, the emergence of demographic impacts much earlier than previously estimated; second, their localization with negative population growth at parish but not at district or national scales; third, a greater impact on the number of children than previously predicted, due as much to changes in population fertility as mortality. The emergence of demographic impacts at this stage highlights original aspects of the interdependence of HIV infection and demographic growth not previously recorded and the need to target preventive interventions to youth in developing countries.

An important challenge in modelling the human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) epidemic is to use the increasing quantity of disease surveillance data to validate estimates and forecasts. Presented is a novel model for forecasting HIV incidence by age and sex and among sentinel groups for which data are available. This approach permits a closer relationship between forecasting and surveillance activities, and more accurate estimates validated to data. As inputs the model uses an estimate of the HIV prevalence, country demographic data, and a profile of the sexual risk of HIV infection by age, to project HIV incidence, prevalence, number of AIDS cases and population. The following examples of the use of the model are given: forecasting HIV incidence in East Africa, by age, sex, and among pregnant women; 3-5-year forecasts of HIV incidence; modelling mixed risk behaviour HIV epidemics in South-east Asia; demographic indicators; and targeting a preventive vaccine by age group.

Knowledge of human immunodeficiency virus type 1 (HIV) incidence patterns in East African HIV epidemics like that in Uganda is fundamental for guiding interventions and forecasting the future course of the pandemic, yet they are difficult to determine from surveillance data. The authors deduce hypotheses of HIV incidence dynamics from birth cohort analyses of Ugandan acquired immunodeficiency syndrome (AIDS) incidence from 1987 to 1992 and from the age and sex distribution of sexually transmitted disease: an age dependency for HIV risk; a period effect of varying HIV incidence growth; and a replenishment of HIV-susceptible populations through demographic renewal. The hypotheses are tested by incorporating them into a model that generates patterns of HIV incidence, prevalence, and AIDS cases that are consistent with empiric data. When applied to Uganda, the modeled HIV incidence is characterized by a short temporal concentration of high incidence, followed by a decline, stabilization, and concentration in younger ages. The ensuing HIV dynamics result in a rapid build-up and subsequent stabilization of prevalence and mortality in years 10 and 13, respectively, after epidemic onset. When this model is used to forecast scenarios from 1980 to 2000, HIV prevalence declines in some populations, which is different from earlier scenarios. The techniques presented provide an empiric basis to better direct interventions, forecast epidemic impacts, and evaluate determinants of changing incidence and prevalence patterns.

Objective: To ascertain predictors of survival in HIV-infected tuberculosis (TB) patients., Design: Retrospective cohort study., Setting: New York City public hospital., Patients: Fifty-four consecutive HIV-seropositive patients with newly diagnosed TB and no other AIDS-defining illnesses., Main Outcome Measures: CD4+ T-lymphocyte counts, completion of anti-TB therapy, repeat hospitalizations with TB, and survival., Results: Forty-five (84%) of the 54 patients died a median of 15 months after TB diagnosis (range, 1-80 months), five (9%) were alive after a median of 81 months (range, 75-84 months), and four (7%) were lost to follow-up after a median of 42 months (range, 30-66 months). In univariate analyses, disseminated TB, intrathoracic adenopathy, oral candidiasis and CD4 count depletion were each associated with decreased survival. In a multivariate analysis, CD4 count depletion was the only independent predictor of decreased survival. Repeat hospitalization with TB occurred in 10 out of 15 patients who did not complete anti-TB therapy compared with one out of 21 patients who completed anti-TB therapy (P < 0.001)., Conclusion: The clinical presentation of TB and CD4 count at TB diagnosis are each predictive of survival in HIV-seropositive TB patients. The CD4 count is the only independent predictor of survival.

Objective: Accurate estimates of HIV incidence that reflect the effect of non-vaccine interventions (education, counselling, condom promotion, and possibly sexually transmitted disease treatment) and that may be provided in a Phase III vaccine efficacy trial, are needed so that vaccine trial population sample sizes can be accurately determined. In order to avoid delays in the implementation of efficacy trials, well characterized cohorts must also be developed and available to participate in such trials. We reviewed the potential study populations, the epidemiologic methods for the determination of HIV incidence (using open cohort, closed cohort, and seroprevalence data methods), and the need for the development of population cohorts in preparation for Phase III HIV vaccine efficacy trials., Setting: Phase III trials in developed and developing countries., Methods: Comparison of open and closed cohorts and those using seroprevalence data to estimate HIV incidence., Results: Open and closed cohorts each have disadvantages and advantages. However, the open cohort may be more suitable for determining estimates of HIV incidence that reflect non-vaccine interventions and for the development of a well characterized cohort available to participate in efficacy trials., Conclusion: Careful preparation of research infrastructures and population cohorts will help ensure the successful conduct of scientifically and ethically sound HIV vaccine efficacy trials in the future.

The paper reviews the distribution, transmission patterns, and likely impacts of the HIV pandemic at the beginning of 1993. As of early 1993, a cumulative total of 611,589 cases of AIDS were reported to the World Health Organization (WHO); however, because of less than complete diagnosis and reporting, the WHO estimates that a total of 2.5 million cases of AIDS had actually occurred. As of early 1993, the WHO estimates that there have been approximately 13 million infections, of which about 1 million have been in children. By the year 2000 the WHO predicts that there will be 30-40 million cumulative infections in the world, of which 90% will be in developing countries and almost half will be among women. The epidemic of HIV infection in the decade of the 1980s will result in an epidemic of AIDS in the 1990s, which will place great social and economic strains on many countries, particularly those in many areas of the developing world.

Using lookback procedures and other methods, we identified and then prospectively followed human immunodeficiency virus type 1 (HIV-1)-infected transfusion recipients and their sex partners to determine AIDS incidence and risks of heterosexual transmission of HIV-1. At enrollment, 7 of 32 (21.9%) female partners of male recipients were themselves infected with HIV-1, as compared with none of 14 male partners of female recipients (p = 0.08). No additional episodes of transmission were observed. The prevalence of advanced immunodeficiency at enrollment was similar in male and female recipients. Male recipients with advanced immunodeficiency (CD4+ lymphocyte count < or = 0.20 x 10(9)/L or a history of clinical AIDS) at enrollment were more likely to have infected their female partners (odds ratio = 7.9; p = 0.03) than men with neither condition. Similarly, AIDS-free survival, as estimated by the product-limit method, was lower among male transmitters than among male nontransmitters (p = 0.01). Transmission was not associated with frequency of unprotected vaginal intercourse. Our data suggest that HIV-1-infected men who develop immunodeficiency rapidly are more likely to infect their sex partners and that the greater efficiency of male-to-female HIV-1 transmission is not explained by a greater number of sexual contacts or more advanced immunodeficiency in index subjects.

A study of risk factors for HIV-1 infection was conducted at a sexually transmitted disease clinic in an area of New York City where the cumulative incidence of AIDS in adults through mid-1990 was 9.1 per 1000 of the population and where the use of illicit drugs, including smokable freebase cocaine (crack), is common. The overall seroprevalence among volunteers was 12% (369 out of 3084), with 80% of those who were seropositive reporting risk behavior associated with HIV-1 infection, including male-to-male sexual contact, intravenous drug use and heterosexual contact with an intravenous drug user. The seroprevalence in individuals denying these risks was 3.6% (50 out of 1389) and 4.2% (22 out of 522) in men and women, respectively. Among these individuals, the behaviors significantly associated with infection were use of crack and prostitution in women, and history of syphilis and crack use in men. These results suggest that in areas where the level of HIV-1 infection in heterosexual intravenous drug users is high and the use of crack is common, increased sexual activity (including the exchange of drugs or money for sex) may result in increased heterosexual transmission of HIV-1.

We conducted a telephone survey of a probability sample of 473 internists, family practitioners, general practitioners, and obstetrician-gynecologists in New York City (NY) in 1988 to assess their knowledge, attitudes, and practices with respect to the prevention of the acquired immunodeficiency syndrome (AIDS). Although 71% of the physicians had cared for a patient with AIDS and 90% had been involved in ordering the human immunodeficiency virus antibody test, only about a third of them took appropriate sexual histories of new patients and only about a quarter (28%) counseled new patients about reducing the risk of contracting AIDS. Multivariate analysis revealed that physician knowledge about AIDS prevention was associated with younger age, more positive attitude toward homosexual males and intravenous drug users, confidence that counseling would result in behavioral change among patients, and specialty other than obstetrics-gynecology. Results indicate a need for increased training and education of primary care physicians about AIDS prevention.

The adequacy of treatment for syphilis has routinely been evaluated by the serological response, i.e. the rapid plasma reagin test (RPR). Since the description of AIDS and HIV aspects of both the natural history of syphilis and the response of Treponema pallidum to treatment have come under increased scrutiny. With concurrent epidemics of HIV and syphilis in New York City, a serological case-control study was done to determine whether HIV-infected individuals given treatment for primary or secondary syphilis have a modified serological response. All study participants had primary or secondary syphilis and paired specimens available for testing. Cases were defined as people who were HIV-positive and were compared with controls who were HIV-negative. HIV-infected patients with primary syphilis when compared with HIV-negative controls were less likely to have a fourfold or greater RPR decrease or seroreversion within 6 months of treatment [15 out of 28 versus 153 out of 210; odds ratio = 0.4, P less than 0.05]. Cases and controls with secondary syphilis had similar serological responses after treatment for syphilis. Although this study adds to the growing body of literature which suggests that HIV may alter the RPR response, prospective studies are needed to determine definitively whether HIV alters the serological response to therapy in patients with early syphilis.

Six human immunodeficiency virus type 1 (HIV-1) seropositive semen donors were identified during an antibody screening program initiated at an artificial insemination clinic in New York City in 1985. A total of 176 women underwent artificial insemination with fresh semen from these six donors between 1978 and mid-1985. Of these 176 women, 134 women were HIV-1 antibody tested and 1 was found to be seropositive; she denied all other AIDS-associated risk behavior and her husband was seronegative. The results of this investigation provide additional evidence that HIV-1 transmission can occur through artificial insemination with semen from an infected donor although the risk of HIV-1 transmission appears to be lower than that reported by other investigators. It is clear that HIV-1 screening of all potential semen donors should be routine practice whenever artificial insemination is performed.

By Aug 15, 1985, one hundred ninety-four cases of possible transfusion-associated acquired immunodeficiency syndrome (AIDS) had been reported to the Centers for Disease Control. Cases received their transfusions in 30 states. Infants account for 10% of the cases, suggesting an increased susceptibility to developing AIDS. Investigations one to six years after the transfusions have identified high-risk donors to 47 cases. Of 47 high-risk donors tested, 40 had a reactive serology for human T-cell lymphotropic virus type III/lymphadenopathy-associated virus (HTLV-III/LAV) antibody, including five with no risk for AIDS by history. The HTLV-III/LAV was isolated from 23 of 26 seroreactive high-risk donors, most of whom remained asymptomatic. Blood components that transmitted HTLV-III/LAV included red cells, platelets, plasma, and whole blood. The time from transfusion to diagnosis of AIDS ranged from four to 84 months. The risk of developing AIDS after a blood transfusion has been low and will be lowered further by using both self-deferral and antibody screening.

In a cohort of 5833 subjects in whom the acquired immunodeficiency syndrome (AIDS) was diagnosed in New York City before 1986, the cumulative probability of survival (mean +/- SE) was 48.8 +/- 0.7 percent at one year and 15.2 +/- 1.8 percent at five years. The group with the most favorable survival rate--white homosexual men 30 to 34 years old who presented with Kaposi's sarcoma only--had a one-year cumulative probability of survival of 80.5 percent; that group was used as the reference group in assessing the effect of five variables: sex, race or ethnic background, age, probable route of acquiring AIDS (risk group), and manifestations of AIDS at diagnosis. The range in the mortality rate was greater than threefold, depending on these variables. Black women who acquired the disease through intravenous drug abuse, for example, had a particularly poor prognosis. The manifestations of disease at diagnosis had the most influence on survival, accounting on average for 56.3 percent of the excess risk. This variable was followed in importance by age (12.2 percent), race or ethnicity (10.6 percent), risk group (8.4 percent), and sex (8.0 percent), with 4.5 percent of the risk attributable to interactions between variables. When we compared subcohorts based on the year of diagnosis (1981 through 1985), we found a significant improvement in the one-year cumulative probability of survival among subjects with Pneumocystis carinii pneumonia, but not among subjects without P. carinii pneumonia.

We studied patients with transfusion-associated acquired immunodeficiency syndrome (AIDS) and their blood donors for serologic evidence of infection with human T-cell lymphotropic virus type III/lymphadenopathy-associated virus with two enzyme-linked immunosorbent assays and a Western blot assay. All 19 patients with AIDS were seropositive by at least one test. In all 28 donor sets containing "high-risk" donors, at least one donor was seropositive by one or more tests. Of 255 donors not considered high risk, two (0.8%) were seropositive by all three tests. When 30 seropositive high-risk donors were evaluated a median of 29 months after donation, four (13%) had developed AIDS and eight (27%) had lymphadenopathy. Our findings support the hypothesis that human T-cell lymphotropic virus type III/lymphadenopathy-associated virus causes AIDS and indicate that seropositive high-risk donors may be at relatively high risk for developing AIDS or related conditions themselves.

To investigate whether infection with human T-cell lymphotropic virus/lymphadenopathy-associated virus (HTLV-III/LAV) may be persistent in asymptomatic persons and to correlate infection with seropositivity, we performed virologic and serologic studies in 25 of 30 persons who were identified as being at high risk for the acquired immunodeficiency syndrome (AIDS) and who had donated blood to patients who later contracted transfusion-associated AIDS. High-risk donors were those who belonged to a high-risk population, had AIDS or a closely related condition, or had a low ratio of helper to suppressor T lymphocytes. We performed similar studies in 6 of the 24 patients with AIDS who had received donations from this group. HTLV-III/LAV was isolated from 22 of the 25 donors, between 12 and 52 months (mean, 28) after they had donated blood, and from all 6 recipients, between 14 and 37 months (mean, 26) after they had received blood. Of the 22 virus-positive donors, 2 have contracted AIDS, 5 have generalized lymphadenopathy, and 15 (68 per cent) remain asymptomatic. Antibodies to HTLV-III/LAV were detectable by the enzyme-linked immunosorbent assay in serum samples obtained from each person at the time the virus was isolated. We conclude that infection with HTLV-III/LAV may be persistent and asymptomatic for years. This demonstration that viremic patients may be asymptomatic supports the use of serologic screening of donated blood to supplement current procedures for the prevention of transfusion-associated AIDS.

Increasing mortality in intravenous (IV) drug users not reported to surveillance as acquired immunodeficiency syndrome (AIDS) has occurred in New York City coincident with the AIDS epidemic. From 1981 to 1986, narcotics-related deaths increased on average 32% per year from 492 in 1981 to 1996 in 1986. This increase included deaths from AIDS increasing from 0 to 905 and deaths from other causes, many of which were infectious diseases, increasing from 492 to 1091. Investigations of these deaths suggest a causal association with human immunodeficiency virus (HIV) infection. These deaths may represent a spectrum of HIV-related disease that has not been identified through AIDS surveillance and has resulted in a large underestimation of the impact of AIDS on IV drug users and blacks and Hispanics.