Cheryl A. Kennedy

Psychological distress, drug and alcohol use as correlates of condom use in HIV-serodiscordant heterosexual couples.

ObjectiveTo investigate the relationship between psychological distress, alcohol, drug and condom use in HIV-serodiscordant heterosexual couples. MethodsStructured interviews were conducted to collect demographic information, detailed data on psychological distress, drug and alcohol use and sexual behavior. ResultsAnalyses were based on 106 pairs of sexually active discordant couples. Significant differences among heterosexual condom users and non-users varied according to gender and HIV serostatus. Affect domains of interpersonal sensitivity and hostility were significant, as were the variables of regular drug or alcohol use and combining sex with drugs or alcohol. Employment was strongly associated with condom use in HIV-negative women whose regular sexual partners were HIV-positive men. ConclusionThe risk of vaginal sex without condoms in HIV-serodiscordant heterosexual couples may be reduced by specific psychological counseling and attention to drug and alcohol use as risk factors. Further research on the effect of employment of HIV-negative women is required.

Herpes simplex type II and Mycoplasma genitalium as risk factors for heterosexual HIV transmission: Report from the heterosexual hiv transmission study

OBJECTIVES Two hundred twenty-four human immunodeficiency virus (HIV) discordant couples (one HIV negative, one HIV positive) were compared with 78 seroconcordant heterosexually infected couples with HIV with regard to sexually transmitted diseases. METHODS Serologic testing and cultures were used to determine exposure of participants to sexually transmitted pathogens. These data were compared with HIV concordance of partners to investigate possible risk factors for HIV transmission. RESULTS Syphilis, chlamydia, and hepatitis B virus (HBV) serologies did not distinguish between concordant and discordant couples nor did cultures for Neisseria gonorrhoeae and Trichomonas or Chlamydia enzyme immunoassay (EIA). Risk of transmission increased with positive serologies for herpes simplex virus (HSV)-2 (P = 0.002), cytomegalovirus (CMV) (P = 0.04), and Mycoplasma genitalium (P = 0.01), but not with Mycoplasma fermentans or Mycoplasma penetrans. Cytomegalovirus was not a significant risk factor when controlled for HSV-2 status. Examination by partner status showed increased risk of concordance with: HSV-2 positive serology in both partners (odds ratio [OR] = 3.14; confidence interval [CI] = 1.62-6.09; P = 0.007); HSV-2 in female secondary partner (OR = 2.10; CI = 1.12-3.93; P = 0.02) or the male primary partner (OR = 2.15; CI = 1.15-4.02; P = 0.017); M. genitalium antibody in both partners (OR = 3.44; CI = 1.68-7.04; P < 0.001); M. genitalium antibody in the primary male partner (OR = 2.51, CI = 1. 27-4.91; P = 0.008) and M. genitalium antibody in the secondary female partner (OR = 2.52; CI = 1.21-5.23; P = 0.01). CONCLUSIONS These data support the role of HSV-2 in transmission of HIV and, for the first time, suggest a role for M. genitalium as an independent risk factor.

Behavioral and Demographic Risk Factors for Transmission of Human Immunodeficiency Virus Type 1 in Heterosexual Couples: Report from the Heterosexual HIV Transmission Study

We compared 224 heterosexual couples who were discordant for human immunodeficiency virus (HIV) type 1 infection (one partner HIV infected) with 78 HIV-concordant couples (both partners HIV infected) to identify demographic and behavioral risk factors for HIV transmission. Among the 229 couples whose male partner was first infected, HIV-concordant couples had engaged in anal sex more frequently before and after knowing that the male was infected than had HIV-discordant couples. Pap smears of grade 2 or higher (inflammation) were more prevalent among the second-infected female partners in HIV-concordant couples than among uninfected women in discordant couples (58% vs. 23%; P < .001). Anal sex and unprotected vaginal sex after knowledge of a male partners infection were significant correlates of concordance in a multivariate logistic model, as were ethnicity, marital status, and antiviral therapy. Ethnicity strongly predicted concordance, even after controlling for sexual risk behaviors and stage of disease.

FAMILY SUPPORT FOR HETEROSEXUAL PARTNERS IN HIV-SERODISCORDANT COUPLES

ObjectiveTo ascertain the extent of family member support to heterosexual HIV-serodiscordant couples, and to identify associated sociodemographic and clinical characteristics. DesignDiscordant couples enrolled in a cohort study of heterosexual HIV transmission were interviewed with structured questionnaires to obtain sociodemographic data, family member awareness of HIV and perceived support from family members. Clinical characteristics were established by medical history, physical examination and laboratory tests. ResultsAwareness and support of family members were associated with sex of family member and HIV seropositivity, sex, education, and race of the partner. HIV-seropositive partners were more likely to have a sister aware than were HIV-negative partners (P =0.01). More educated HIV-positive partners had fewer aware family members than less educated HIV-positive individuals (P = 0.02). Mothers of HIV-positive women were more often aware than mothers of all other partners (P =0.04). Black HIV-negative partners had fewer aware family members than whites or Hispanics (P =0.02). ConclusionThis research shows both encouraging and disturbing patterns of family awareness of HIV and support to serodiscordant partners.

HIV heterosexual transmission : A hypothesis about an additional potential determinant

Transmission rates of human immunodeficiency virus (HIV) during heterosexual intercourse vary dramatically around the world. In Asia and South America, they are extraordinarily high, whereas in the United States and Europe, rates are much lower even after a large number of unprotected contacts. The transmission rates in Africa also probably are high, but the available studies unfortunately are weak. In Thailand, female-to-male transmission rates per contact were estimated at.056 (l in 18) compared to.0002 to.0015 (1/5000-1. 5/1000) for male-to-female transmission in the United States and Europe. Male-to-female transmission in Thailand appears to show, as expected, even greater transmission likelihood compared to female-to-male rates. In general, in the United States and Europe, transmission rates within heterosexual couples range from less than 10% to 22%, whereas in Thailand and Brazil, the rates exceed 40%. The much lower transmission rate per contact in the United States and Europe is based on an assumption that HIV transmitters are a homogeneous group. Wiley and colleagues argue that transmitters are likely to be a heterogeneous group with a large percentage of very low frequency transmitters and a small percentage of high frequency transmitters. That hypothesis is given some support by a cluster of cases in rural New York State in which one man appeared to infect 31% of his many contacts.

CD3+CD8+ cell levels as predictors of transmission in human immunodeficiency virus-infected couples: A report from the heterosexual HIV transmission study

OBJECTIVE The goal of this study was to identify in human immunodeficiency virus (HIV)-infected individuals immunologic markers that correlated with transmission of HIV by heterosexual contact. METHODS In a case-control comparison of couples, immunologic and viral parameters were evaluated in 343 HIV-positive individuals who were members of 67 HIV-seroconcordant couples (both partners HIV positive) and 211 HIV serodiscordant couples (one positive, one negative). RESULTS The most striking immunologic finding was the increased numbers of CD3+CD8+ cells found in the index member of discordant couples as compared to the index member of the concordant couples. Differences in CD3+CD8+ levels persisted after adjustment for stage of disease and CD3+CD4+ count. This increase in the number of CD3+CD8+ cells was accompanied by a concomitant decrease in the amount of viral replication measured by both HIV culture endpoint and quantitative RNA polymerase chain reaction (PCR). CONCLUSION Data presented here further support the role of CD3+CD8+ cells in suppressing or controlling viral activity, although a causal role based on case-control data must be advanced cautiously. This in vivo biologic function may help prevent or lower the risk of HIV transmission.

Cerebellar degeneration associated with HIV infection

To the Editor: HIV type 1 (HIV-1) infection can produce neurologic complications such as dementia, myelopathy, and peripheral neuropathy. Tagliati et al.1 described 10 such patients with symptoms of cerebellar dysfunction that they similarly ascribed to HIV-1 infection. These patients were screened for toxic and neoplastic etiologies of cerebellar degeneration. However, no genetic testing was performed. This sample was quite heterogeneous. Although ataxia was present in all 10 patients, and dysmetria in 9, other cerebellar symptoms including tremor (4 patients), nystagmus (3 patients), and dysdiadochokinesis (6 patients) were less prevalent. Radiologic imaging showed severe cerebellar atrophy in 4 patients, and mild-moderate atrophy in 3 others. Imaging was not performed on 3 patients. Pathologic studies demonstrated cerebellar granular cell loss in only 2 out of 3 autopsied patients. Do such variegated data truly define an HIV-1 related cerebellar disorder? The following report demonstrates that HIV-1–infected individuals may have superimposed genetic disorders that need to be excluded before concluding such a syndrome exists. A 33-year-old man presented in October 1998 with a 1-year history of progressive gait ataxia, dysarthria, and clumsiness. HIV-1 infection had been diagnosed in 1985. He denied any history of alcohol or drug use or opportunistic infections. His viral load was undetectable (less than 50 copies per milliliter) and his CD4 count was 733 cells per mm3. A brain MRI in August 1998 showed …

Terror medicine as part of the medical school curriculum.

Terror medicine, a field related to emergency and disaster medicine, focuses on medical issues ranging from preparedness to psychological manifestations specifically associated with terrorist attacks. Calls to teach aspects of the subject in American medical schools surged after the 2001 jetliner and anthrax attacks. Although the threat of terrorism persists, terror medicine is still addressed erratically if at all in most medical schools. This paper suggests a template for incorporating the subject throughout a 4-year medical curriculum. The instructional framework culminates in a short course for fourth year students, such as one recently introduced at Rutgers New Jersey Medical School, Newark, NJ, USA. The proposed 4-year Rutgers curriculum serves as a model that could assist other medical schools contemplating the inclusion of terror medicine in pre-clerkship and clerkship training.

HIV-Related Neurocognitive Disorders and Drugs of Abuse: Mired in Confound, Surrounded by Risk

It has long been known that human immunodeficiency virus (HIV) uses the central nervous system (CNS) as a reservoir and nursery to replicate; therein, it does damage to cells and creates an inflammation that in turn allows for more virus to pass the blood–brain barrier. The inflammatory process itself can cause considerable damage. Neurocognitive disturbance from HIV infection is also known to occur at any stage of the infection. Likewise, common drugs of abuse also have adverse neurocognitive effects on their own. This review examines the literature available to try to elucidate the mechanisms of neurocognitive disorders in the HIV-infected individuals who have used drugs of abuse. Although the incidence of HIV-associated dementia (HAD) has decreased with the advent of highly active anti-retroviral therapy, less severe forms of neurocognitive impairment persist, even with supported immune systems and undetectable viral loads. Considerations for prevention are discussed.