A Petruckevitch

Disease progression and survival in HIV-1-infected Africans in London

Objective:To examine differences in progression to AIDS and death between HIV-1-positive Africans (most infected in sub-Saharan Africa and therefore with non-B subtypes) and HIV-1-positive non-Africans in London. Design:Retrospective cohort study of 2048 HIV-1-positive individuals. Setting:HIV-1-infected individuals attending 11 of the largest HIV/AIDS units in London. Patients:Subjects were 1056 Africans and 992 non-Africans seen between 1982–1995. Results:There were no differences in crude survival from presentation to death between Africans and non-Africans (median 82 and 78 months, respectively; P = 0.22). Africans progressed more rapidly to AIDS [hazard ratio (HR), 1.21; 95% confidence interval (CI), 1.02–1.45] but after adjustment for age, sex, Centers for Disease Control and Prevention category B symptoms and CD4+ lymphocyte count at presentation, year of HIV diagnosis and hospital attended, this difference was no longer significant (adjusted HR, 1.15; 95% CI, 0.93–1.43). Africans with AIDS had a reduced risk of death compared with non-Africans (HR, 0.78; 95% CI, 0.63–0.96) but not after adjustment for age, CD4+ lymphocyte count at AIDS, initial AIDS-defining conditions (ADC) and hospital attended (HR, 0.98; 95% CI, 0.76–1.27). Tuberculosis as the first ADC was associated with a 64% reduction in the risk of death. CD4+ lymphocyte decline was not significantly different between Africans and non-Africans (P = 0.18). Conclusions:Differences in progression to AIDS and death and CD4+ lymphocyte decline between HIV-1-infected Africans and non-Africans in London could not be attributed to ethnicity or different viral subtypes. Age and the clinical and immunological stage at presentation, or AIDS, were the major determinants of outcome. Compared with other diagnoses, tuberculosis as the initial ADC was associated with increased survival. Lack of access to health care and exposure to environmental pathogens are the most likely causes of reduced survival with AIDS in Africa, rather than inherently different rates of progression of immune deficiency due to racial differences or viral subtypes.

Disease progression and survival following specific AIDS-defining conditions: a retrospective cohort study of 2048 HIV-infected persons in London.

Objective: To assess the impact of specific AIDS‐defining conditions on survival in HIV‐infected persons, with emphasis on the effect of tuberculosis. Methods: A retrospective cohort analysis of HIV‐infected Africans and non‐Africans attending 11 specialist HIV/AIDS units in London enrolled for a comparison of the natural history of HIV/AIDS in different ethnic groups. Results: A total of 2048 patients were studied of whom 627 (31%) developed 1306 different AIDS indicator diseases. Pneumocystis carinii pneumonia accounted for 159 (25%) of initial AIDS episodes and tuberculosis for 103 (16%). In patients with HIV disease, tuberculosis had the lowest risk [relative risk (RR), 1.11; 95% confidence interval (CI), 0.75–1.63], and high‐grade lymphoma had the highest risk (RR, 20.56; 95% CI, 2.70–156.54) for death. For patients with a prior AIDS‐defining illness, the development of subsequent AIDS indicator diseases such as Pneumocystis carinii pneumonia (RR, 1.18; 95% CI, 0.77–1.83) and tuberculosis (RR, 1.36; 95% CI, 0.76–2.47) had the best survival, and non‐Hodgkins lymphoma had the worst survival (RR, 9.67; 95% CI, 1.26–74.33). Patients with tuberculosis had a lower incidence of subsequent AIDS‐defining conditions than persons with other initial AIDS diagnoses (rate ratio, 0.47; 95% CI, 0.37–0.59). Conclusions: Considerable variation exists in the relative risk of death following different AIDS‐defining conditions. The development of any subsequent AIDS‐defining condition is associated with an increased risk of death that differs between diseases, and this risk should be considered when evaluating the impact of specific conditions. Like other AIDS‐defining conditions, incident tuberculosis was associated with adverse outcome compared with the absence of an AIDS‐defining event, but we found no evidence of major acceleration of HIV disease attributable to tuberculosis.

Spectrum of disease in Africans with AIDS in London

Objective: To compare the spectrum of disease, severity of immune deficiency and chemoprophylaxis prescribed in HIV‐infected African and non‐African patients in London. Design: Retrospective review of case notes of all HIV‐infected Africans and a comparison group of non‐Africans attending 11 specialist HIV/AIDS Units in London. Main outcome measures: Comparison of demographic information, first and subsequent AIDS‐defining conditions, levels of immune deficiency, and chemoprophylactic practices between the African and non‐African groups. Results: A total of 1056 Africans (313 developing AIDS) and 992 non‐Africans (314 developing AIDS) were studied. Africans presented later than non‐Africans (median CD4+ lymphocyte counts at diagnosis 238 and 371 × 106/l, respectively). Tuberculosis accounted for 27% of initial episodes of AIDS in Africans and 5% in non‐Africans; Pneumocystis carinii pneumonia (PCP) was the initial AIDS‐defining condition in 34% of non‐Africans and 17% of Africans. The incidence of tuberculosis in Africans with another AIDS‐indicator disease was 16 per 100 person‐years. PCP prophylaxis was prescribed for 40% Africans and 32% non‐Africans; only 8% of Africans received tuberculosis preventive therapy. Conclusions: HIV‐infected African patients presented at lower levels of CD4+ lymphocyte count, at a more advanced clinical stage, and with different AIDS‐indicator diseases as compared with non‐Africans. Prophylaxis against tuberculosis should be considered for all HIV‐infected African patients in industrialized countries. The high incidence of diseases that are indicative of advanced immunodeficiency (e.g., cytomegalovirus disease) in African patients contrasts with data from Africa, suggesting better survival chances in the UK.

Risk of cancer in patients with HIV disease

The aim of this study was to compare cancer incidence in a cohort of HIV-infected patients with the incidence rates in the population of South East England. Data collected for a retrospective cohort study of 2048 HIV-infected patients were analysed to examine the incidence of cancer. Cases of cancer occurring in South East England from 1985-1995 were obtained from the Thames Cancer Registry. Standardized incidence ratios were calculated by comparison of the observed number of cases for each cancer type in HIV-infected non-Africans with the numbers expected, calculated from the age and sex specific registration rates for the South East England population using person-years of observation. The crude incidence rates of cancer were calculated for HIV-infected Africans. The incidence of non-AIDS defining cancers such as Hodgkins disease (standardized incidence ratio 22; 95% CI: 3-80) and anal cancer (standardized incidence ratio 125; 95% CI: 3-697) were significantly increased for non-African males with HIV disease. Anal cancer was also significantly increased for non-African females (standardized incidence ratio 1667; 95% CI: 43-9287). Kaposis sarcoma (KS) was the commonest cancer among HIV-infected Africans and males had an incidence which was nearly 3 times that of females. There is evidence to suggest that the risks for other non-AIDS defining cancers were significantly increased in persons with HIV disease which may have implications for HIV/AIDS surveillance.

A school-based randomized controlled trial of peer-led sex education in England

This article discusses the design of an ongoing cluster-randomized trial comparing two forms of school-based sex education in terms of educational process and sexual health outcomes. Twenty-nine schools in southern England have been randomized to either peer-led sex education or to continue with their traditional teacher-led sex education. The primary objective is to determine which form of sex education is more effective in promoting young peoples sexual health. The trial includes an unusually detailed evaluation of the process of sex education as well as the outcomes. The sex education programs were delivered in school to pupils ages 13-14 years who are being followed until ages 19-20. Major trial outcomes are unprotected sexual intercourse and regretted intercourse by age 16 and cumulative incidence of abortion by ages 19-20. We discuss the rationale behind various aspects of the design, including ethical issues and practical challenges of conducting a randomized trial in schools, data linkage for key outcomes to reduce bias, and integrating process and outcome measures to improve the interpretation of findings.

Voluntary universal antenatal HIV testing

Objectives To assess the uptake of universal voluntary named HIV testing of hospital booked antenatal women and to identify behavioural and demographic factors associated with testing. To identify the number of previously undiagnosed women detected by the new policy and to compare prevalence among those testing with that measured by unlinked anonymous monitoring.