Luke Whitaker

HIV positive patients first presenting with an AIDS defining illness: characteristics and survival.

Abstract Objectives: To study the presentation and survival of patients who present with their first diagnosis of being HIV positive at the same time as their AIDS defining illness. Design: Retrospective study of patients presenting with AIDS between 1991 and 1993. Setting: Department of genitourinary medicine, St Marys Hospital, London. Main outcome measures: AIDS defining illness at presentation and survival after diagnosis of AIDS. Results: Between January 1991 and December 1993, 97 out of 436 patients (22%) presented with their first AIDS defining illness coincident with their first positive result of an HIV test (group B). The remaining 339 patients (78%) had tested positive for HIV-1 infection within the previous eight years and had consequently been followed up in clinics before developing their first AIDS defining illness (group A). The two groups of patients did not differ in age and sex distribution, risk factors for HIV-1 infection, nationality, country of origin, or haematological variables determined at the time of the AIDS defining illness. However, the defining illnesses differed between the two groups. Illnesses associated with severe immunodeficiency (the wasting syndrome, cryptosporidiosis, and cytomegalovirus infection) were seen almost exclusively in group A whereas extrapulmonary tuberculosis and Pneumocystis carinii pneumonia were more common in group B. The survival of patients in group B after the onset of AIDS was significantly longer than that of patients in group A as determined by Kaplan-Meier log rank analysis (P=0.0026). Conclusions: Subjects who are HIV positive and present late are a challenge to the control of the spread of HIV infection because they progress from asymptomatic HIV infection to AIDS without receiving health care. The finding that presentation with an AIDS defining illness coincident with a positive result in an HIV test did not have a detrimental effect on survival gives insights into the effects of medical intervention on disease progression after a diagnosis of AIDS.

Estimating the sexual mixing patterns in the general population from those in people acquiring gonorrhoea infection: theoretical foundation and empirical findings.

STUDY OBJECTIVES--To describe mathematically the relationship between patterns of sexual mixing in the general population and those of people with gonorrhoea infection, and hence to estimate the sexual mixing matrix for the general population. DESIGN--Integration of data describing sexual behaviour in the general population, with data describing sexual behaviour and mixing among individuals infected with gonorrhoea. Use of these data in a simple mathematical model of the transmission dynamics of gonorrhoea infection. SETTING--The general population of London and a genitourinary medicine (GUM) clinic in west London. PARTICIPANT--These comprised 1520 men and women living in London who were randomly selected for the national survey of sexual attitudes and lifestyles and 2414 heterosexual men and women who presented to the GUM clinic with gonorrhoea. MAIN RESULTS--The relationship between sexual mixing among people with gonorrhoea and sexual mixing in the general population is derived mathematically. An empirical estimate of the sexual mixing matrix for the general population is presented. The results provide tentative evidence that individuals with high rates of acquisition of sexual partners preferentially select other individuals with high rates as partners (assortative mixing). CONCLUSIONS--Reliable estimates of sexual mixing have been shown to be important for understanding the evolution of the epidemics of HIV infection and other sexually transmitted diseases. The possibility of estimating patterns of sexual mixing in the general population from information routinely collected in gonorrhoea contact tracing programmes is demonstrated. Furthermore, the approach we describe could, in principle, be used to estimate the same patterns of mixing, using contact tracing data for other sexually transmitted diseases, thus providing a way of validating our results.

Impact of improved treatment of sexually transmitted disease on HIV infection.

Grosskurth and colleagues report the outcomes of a randomized controlled trial to evaluate the impact of improved treatment of sexually transmitted diseases (STD) on HIV infection. The authors congratulate the research team on the high quality of the design and execution of their study. They are amazed by the reported 43% reduction in the incidence of HIV as a result of the medium-strength intervention. The effect upon other STDs is however less apparent. The researchers discussed possible effect modifications of different co-factors but concluded that bias is negligible or very limited. These authors do not however think that the researchers sufficiently consider the implications of the difference in baseline HIV prevalence between intervention and comparison communities. It is important to correct for the initial 14% difference in initial condition since the prevalent cases form the source of subsequent HIV infections. The authors therefore recalculated risk ratios using a correction factor for each of the six matched pair communities. In so doing the overall estimate of HIV reduction as a result of the intervention would be 33% probably a better estimate than the original 43%. The confidence interval for the effect was widened by the correction. A more sophisticated analysis should consider the possibility that frequencies changed during the research period since the HIV epidemic has most likely not yet reached its dynamic equilibrium. The authors stress in closing that a 33% reduction in the frequency of HIV is nonetheless remarkable for this type of intervention.

Demographic and socio-economic determinants of community and hospital services costs for people with HIV/AIDS in London

We examined the influence of demographic, social and economic background of people with HIV/AIDS in London on total community and hospital services costs. This was a retrospective study of community and hospital service use, needs and costs based on structured questionnaires administered by trained interviewers and costing information obtained from the service purchasers and providers, based on two Genito-urinary Medicine clinics in London: the Jefferiss Wing at St. Marys Hospital and Patric Clements at the Central Middlesex Hospital, London, England. The subjects were 225 HIV infected patients (105 asymptomatic, 59 symptomatic non-AIDS and 61 AIDS). We found that over and above well established determinants of health care costs for HIV infected people such as disease stage and transmission category, social and economic factors such as employment and support of a living-in partner significantly reduced community services costs. Private health insurance had a similar effect, though only a small proportion of HIV people had such cover. The cost of community services for HIV infected non-European Union nationals, mainly of African origin, was one quarter that for the European Union nationals. Community services costs were highest for heterosexually infected women and lowest for heterosexually infected men after adjusting for other factors. Hospital services costs were significantly higher for HIV infected people lacking educational qualifications and employment. We conclude that access to community care for HIV infected non-EU nationals appears to be very poor as the cost of their community services was one quarter that for the EU nationals after adjusting for the effects of transmission category, disease stage, living with a partner, employment and having a private health insurance. Additional incentives for informal care for HIV infected people could be a cost-effective way to improve their community health service provisions.

Community service needs of people with HIV infection in London

The objectives of this study were to describe the expressed needs for community services of HIV-infected individuals by disease stage, gender and transmission category and the barriers which prevent the receipt of such services. Structured interviewer-administered questionnaires concerning a 6-month retrospective period were used to obtain information on need for community services and problems which prevented the receipt of services. The study sample included 70 homosexual men with asymptomatic HIV disease, 42 homosexual men with symptomatic non-AIDS, 53 homosexual men with AIDS, 23 heterosexual men, 29 heterosexual women, 9 male and 9 female injecting drug users. The main outcome measures were the extent to which needs for community services were met and person/service combinations for which problems or barriers prevented the receipt of community services. On average, subjects expressed a need for 10 categories of community services over the 6-month period: homosexuals expressed a mean of 10, heterosexuals 10, injecting drug users 11, subjects with asymptomatic HIV infection 9, subjects with symptomatic non-AIDS 11, subjects with AIDS 13, men 9 and women 14. A total of 58% of community service needs were always met, 6% were rarely not met, 16% were sometimes not met, 6% were often not met and 14% were not met at all. The extent to which subjects felt that their needs were met was similar for the different study groups, but the needs of women were met somewhat less frequently than those of men. Similarly, people with AIDS felt that their needs were met slightly less often. Reported levels of unmet need were high for a wide range of services. The most common reason subjects gave for not having received a community service for which they expressed a need was ignorance of where or how to obtain the service. This was mentioned in one-third of all such cases. Anxieties over the competence with which a service would be rendered was mentioned in 13% of cases and long waiting times in 11%. The frequencies of unmet need for many community services were high and often seemed to arise either from a lack of awareness on the part of subjects on how and where services could be obtained or from doubts about the relevance of services offered. Both of these barriers should be surmountable through the provision of better information to patients, extending user involvement in service development and the better co-ordination of service delivery through care management approaches.

Neisseria gonorrhoeae isolated at St. Mary's Hospital London, 1980-91.

OBJECTIVE--To describe and discuss the trends in the isolation of Neisseria gonorrhoeae from patients attending the Genitourinary Medicine Clinic at St. Marys Hospital, Paddington, London between 1980 and 1991. DESIGN--A retrospective study of the total number of gonococci isolated over an eleven year period was performed. In addition, for the years 1988-1991 the number of isolates from homosexual men was analysed by age of the patient, site of infection and HIV antibody status of the patient. RESULTS--The total number of N. gonorrhoeae isolates identified declined markedly between 1980 and 1989 from 3670 to 750 isolates. Over the same time period the number of specimens screened for N. gonorrhoeae fell by 50%. In 1990 there was an increase in N. gonorrhoeae isolates but this was not maintained, and in 1991 the number of N. gonorrhoeae fell to its lowest level of 638 isolates. The decrease since 1980 occurred in both men and women although the number of rectal isolates from men showed a steeper decline reaching its lowest level of 24 isolates in 1988. The number of rectal isolates from homosexual men has since increased with a peak in 1990. Many of the infections among homosexual men occurred in older men and included insignificant number of patients who were HIV positive. CONCLUSION--Gonorrhoea among attenders at St. Marys Hospital has declined dramatically since 1980 following trends reported from much of Europe. The increase in gonococcal isolates since 1989 and the peak in 1990 are unexplained but are coincident with a higher number of isolates from homosexual men.

Clinical features and outcome of first presentation anogenital warts in men and women

Objective Correlation of clinical features of patients on initial presentation of anogenital warts to outcome of treatment.