Joseph I. Harwell

Association between bacterial vaginosis and expression of human immunodeficiency virus type 1 RNA in the female genital tract.

We assessed the effect of lower genital tract infections on human immunodeficiency virus type 1 (HIV-1) RNA shedding in the female genital tract. Bacterial vaginosis was significantly associated with HIV-1 RNA expression in the female genital tract of HIV-infected women.

Multicenter review of protease inhibitors in 89 pregnancies

Context: Despite the success of highly active antiretroviral therapy, the optimal approach for preventing perinatal HIV‐1 transmission is not known. Objective: A retrospective survey was conducted at six centers in the United States and Puerto Rico from January 1997 to October 1998 to evaluate the effects of protease inhibitor use during pregnancy on maternal and infant safety, prematurity rate, and frequency of perinatal HIV‐1 transmission. Results: In the study, 91 live infants, including 3 sets of twins, and 1 neonate who died shortly after birth were born to 89 women. HIV perinatal transmission rate in this series was 0 (95% confidence interval [CI], 0%‐3%). Prematurity rate was 19.1%, comparable to rates in earlier reports of HIV‐1‐infected women. In multiple regression analysis, only cocaine use and premature rupture of membranes were associated with prematurity (p = .03 and .008, respectively). The gestational week during which the protease inhibitors were initiated was not found to be significantly associated with prematurity. Adverse maternal, obstetric, and infant events possibly related to protease inhibitors were uncommon. Conclusions: Protease inhibitors appeared generally safe in mothers and infants in this series. No perinatal HIV‐1 transmission occurred. Further prospective, controlled studies are needed to define the optimal management of HIV‐1 in pregnancy.

Internet sex-seeking leads to acute HIV infection: a report of two cases

The use of the internet provides a rapid medium for identifying potential sexual partners and arranging in-person meetings that often result in sex. There is growing concern that the internet facilitates the transmission of sexually transmitted diseases and HIV. We report the first two cases of acute HIV infection after internet chat room encounters. Physicians should address the potential risks to sex seekers who use the internet. HIV prevention efforts that target internet sex seekers are needed.

Spectrum of opportunistic infections in hospitalized HIV-infected patients in Phnom Penh, Cambodia

The aim of the study was to provide more comprehensive data on the clinical characteristics of hospitalized AIDS patients in Cambodia. Chart review of 381 HIV-infected patients admitted to a public hospital in Phnom Penh, Cambodia between December 1999 and May 2000 was performed. The in-hospital mortality rate was 43.6%. Approximately 50% of patients had two or more concurrent illnesses. Very advanced HIV disease was common, with CD4 cell counts below 10 cells/mm3 in 43.2%. Only 28.3% of the patients had documentation of their HIV infection prior to hospitalization. Chronic diarrhoea was the most frequent opportunistic illness (41.2%), followed by tuberculosis (26%), cryptococcal meningitis (12.6%), Pneumocystis carinii pneumonia (8.4%), and encephalitis (4.7%). Chronic diarrhoea and tuberculosis were the most important opportunistic infections observed in HIV-infected hospitalized patients in Cambodia. These findings illustrate the need for early diagnosis of HIV-infection, effective prophylaxis for opportunistic infections and improved access to antiretroviral therapy in Cambodia.

Etiology of Chronic Diarrhea in Antiretroviral-Naive Patients with HIV Infection Admitted to Norodom Sihanouk Hospital, Phnom Penh, Cambodia

BACKGROUND Although both human immunodeficiency virus (HIV) infection and diarrhea are considerable problems in Cambodia, there have not been any studies to determine the history, clinical presentation, and etiology of chronic diarrhea in patients with HIV infection in Cambodia. In this article, we present a case-control study involving 40 HIV-infected patients with chronic diarrhea and 40 HIV-infected patients without diarrhea. METHODS Clinical, demographic, and laboratory data were collected. Stool samples were examined for parasites, including Cryptosporidium species (by partial acid-fast stain), bacterial pathogens, and rotavirus. Samples from 10 case patients and 10 control subjects were also analyzed for Cryptosporidium species by polymerase chain reaction-restriction fragment-length polymorphism. RESULTS The median CD4(+) cell count was 11.5 cells/mm(3). A potential pathogen was found in 30 case patients (75%) and 29 control subjects (72.5%). Cryptosporidium was the most common pathogen, present in 16 case patients (40%) and 20 control subjects (53.3%). The presence of Cryptosporidium was confirmed by polymerase chain reaction-restriction fragment-length polymorphism, with a prevalence of 40% in each of the 2 groups of 10 subjects who were enrolled for Cryptosporidium evaluation. CONCLUSIONS Subjects in this cohort had severe immunosuppression. The prevalence of pathogens, including Cryptosporidium, was extremely high but did not differ significantly between the case patients with diarrhea and the control subjects without diarrhea. Further studies are needed to examine factors associated with Cryptosporidium carriage and the natural history of asymptomatic infection.

Directly Observed Highly Active Antiretroviral Therapy for HIV-Infected Children in Cambodia

Antiretroviral medications are becoming available for HIV-infected children in resource-limited settings. Maryknoll, an international Catholic charity, provided directly observed antiretroviral therapy to HIV-infected children in Phnom Penh, Cambodia. Child care workers administered generic antiretroviral drugs twice daily to children, ensuring adherence. Treatment began with 117 late-stage HIV-infected children; 22 died of AIDS during the first 6 months. The rest were treated for at least 6 months and showed CD4 count increases comparable to those achieved in US and European children. Staffing cost for this program was approximately US

Prediction of Treatment Failure Using 2010 World Health Organization Guidelines Is Associated With High Misclassification Rates and Drug Resistance Among HIV-Infected Cambodian Children

5 per child per month, or 15% more than the price of the medications. Drug toxicities were uncommon and easily managed. Directly observed antiretroviral therapy appears to be a promising, low-cost strategy for ensuring adherent treatment for HIV-infected children in a resource-limited setting.

Genital Tract Interleukin-8 but not Interleukin-1 or Interleukin-6 Concentration is Associated with Bacterial Vaginosis and Its Clearance in HIV-Infected and HIV-Uninfected Women

BACKGROUND Antiretroviral therapy (ART) in resource-limited settings (RLSs) is monitored clinically and immunologically, according to World Health Organization (WHO) or national guidelines. Revised WHO pediatric guidelines were published in 2010, but their ability to accurately identify virological failure is unclear. METHODS We evaluated performance of WHO 2010 guidelines and compared them with WHO 2006 and Cambodia 2011 guidelines among children on ≥6 months of first-line ART at Angkor Hospital for Children between January 2005 and September 2010. We determined sensitivity, specificity, positive and negative predictive values, and accuracy using bootstrap resampling to account for multiple tests per child. Human immunodeficiency virus (HIV) resistance was compared between those correctly and incorrectly identified by each guideline. RESULTS Among 457 children with 1079 viral loads (VLs), 20% had >400 copies/mL. For children with WHO stage 1/2 HIV, misclassification as failure (met CD4 failure criteria, but VL undetectable) was 64% for WHO 2006 guidelines, 33% for WHO 2010 guidelines, and 81% for Cambodia 2011 guidelines; misclassification as success (did not meet CD4 failure, but VL detectable) was 11%, 12%, and 12%, respectively. For children with WHO stage 3/4 HIV, misclassification as failure was 35% for WHO 2006 guidelines, 40% for WHO 2010 guidelines, and 43% for Cambodia 2011 guidelines; misclassification as success was 13%, 24%, and 21%, respectively. Compared with WHO 2006 guidelines, WHO 2010 guidelines significantly increased the risk of misclassification as success in stage 3/4 HIV (P < .05). The WHO 2010 guidelines failed to identify 98% of children with extensive reverse-transcriptase resistance. CONCLUSIONS In our cohort, lack of virological monitoring would result in unacceptable treatment failure misclassification, leading to premature ART switch and resistance accumulation. Affordable virological monitoring suitable for use in RLSs is desperately needed.

Acceptability of sexually transmitted infection screening among women in short-term substance abuse treatment.

Genital tract infections and cytokine perturbations are associated with increased HIV acquisition and transmission. We measured the relationship between bacterial vaginosis (BV) and concentrations of Interleukin-8 (IL-8), Interleukin-1β (IL-1β), and Interleukin-6 (IL-6) in cervicovaginal lavage (CVL) specimens collected longitudinally from 16 HIV-infected and 8 HIV-uninfected high-risk women. CVL samples were analyzed when women presented with BV, and at their next visit, after successful treatment, when BV was cleared. A subset of participants had cytokine levels evaluated at three consecutive clinic visits: before developing BV, at the time of BV diagnosis, and after clearing BV. Significantly higher IL-8, but not IL-1β or IL-6 levels were present when women had active BV compared to when BV was absent. Trends in cytokine levels were similar for HIV-infected and HIV-uninfected women. BV in these women was associated with significantly higher concentrations of genital tract IL-8 which decreased 2.4 fold when BV was cleared.

Growth of infants born to HIV-infected women in South Africa according to maternal and infant characteristics

Background Substance abuse treatment centers provide an opportunity to offer sexually transmitted infection (STI) screening to a high-risk and hard-to-reach population. Goal The goal was to assess STI prevalence, risk factors, and acceptability of STI screening among females at substance abuse treatment centers with use of urine testing by ligase chain reaction and self-collected swab specimens. Study Design Adult, female inpatients were offered free testing and treatment for chlamydia infection, gonorrhea, and trichomonas infection. Interviews were conducted to collect risk behavior data. Results Eighty-six percent of inpatients (180/209) accepted testing. Twenty-three percent (41/177) had an STI. Of those with an STI, 90% (37/41) had trichomonas infection. All 41 infected patients received treatment. Drug use before sex, exchange of sex for money/drugs, and any gynecological complaint were significantly associated with infection. Most women were uninsured (76%). Only 45% had undergone a medical examination in the past year. Conclusion STI screening is highly acceptable among women in substance abuse treatment centers. Substance users are at high risk for STIs and may not otherwise receive medical care.