Susan Y. Chu

HIV testing patterns: where, why, and when were persons with AIDS tested for HIV?

Objective: To describe the location of, primary reason for, and time between the first positive HIV test and AIDS diagnosis in a sample of persons with newly diagnosed AIDS. Design: Interviews supplementing information routinely collected through AIDS case reporting. Setting: Eleven US states and cities. Patients: Persons with AIDS (2441) diagnosed between January 1990 and December 1992. Main outcome measures: Location of first positive HIV test, primary reason for testing, and time interval between first positive HIV test and AIDS diagnosis. Results: Overall, persons were tested late in their course of HIV infection: 36% were tested for HIV within 2 months and 51% within 1 year of their AIDS diagnosis. Sixty‐five per cent were HIV‐tested in acute health‐care settings: 33% in hospitals, 28% in physicians offices, and 4% in emergency departments. Testing during hospitalization was most common among injecting drug users (43%) and persons infected through heterosexual contact (50%). Persons primarily sought HIV testing because of illness (58%); other reasons included being in a known risk group (13%) and having had a known HIV‐infected sex partner (8%). Testing because of being in a known risk group was least common among persons infected through heterosexual contact (1%). Among persons in these exposure categories, testing differed by race/ethnicity. Conclusion: Most persons with AIDS were tested relatively late in their course of HIV infection, in acute health‐care settings, and because of illness. Not knowing ones serostatus precludes early medical intervention and may increase transmission. AIDS 1995, 9:487‐492

Trends in infectious diseases and cancers among persons dying of HIV infection in the United States from 1987 to 1992.

Human immunodeficiency virus (HIV) infection results in various other infectious diseases and cancers. Trends in the proportion of HIV-related deaths caused by these secondary diseases may reflect the efficacy of measures for treating or preventing these diseases and may help identify diseases that need more attention. We used national vital statistics to examine these trends. Methods We obtained data from multiple-cause mortality tapes prepared by the National Center for Health Statistics from death certificates of U.S. residents from 1987 through 1992, which were filed in all 50 U.S. states and the District of Columbia [1]. We identified diseases by their codes in the International Classification of Diseases, Ninth Revision (ICD-9) [2] and identified HIV infection by supplemental codes introduced in 1987 [3]. Among deaths for which HIV infection was recorded as the underlying cause, infectious diseases and cancers that could be secondary to HIV infection were found as nonunderlying (immediate, intermediate, or contributing) causes of death; this classification allowed more than one such disease per death. To determine the percentage of HIV-related deaths caused by a given disease, we excluded from the denominator deaths for which information on secondary diseases was missing: deaths for which no disease but HIV infection was recorded and those for which the only other causes recorded were nonspecific (such as cardiac arrest), not associated with HIV infection (such as trauma), or likely to have preceded HIV infection (such as drug abuse). We examined trends in the annual percentage of deaths associated with each infectious disease or cancer that was reported in at least 1.0% of the denominator in the 6-year period. We used Poisson regression analysis [4] to test the statistical significance (P < 0.05) of the trend for each disease. Results From 1987 to 1992, HIV infection was the underlying cause of 140 461 deaths, of which 104 831 had possible secondary causes of death specified on the death certificates. The proportion represented by the latter (75%) remained stable as the number increased annually from 10 001 deaths in 1987 to 24 230 in 1992. These 104 831 HIV-related deaths provided the denominators for calculating the annual percentage of deaths associated with each disease. Most of these HIV-related deaths (60%) were reported with 1 secondary infectious disease or cancer; 19%, with 2; 6%, with 3 to 8; and 15%, with none (but with other secondary conditions). Twelve infectious diseases and 2 cancers were each reported in at least 1.0% of the HIV-related deaths. The annual number of deaths associated with each disease generally increased as the total number of HIV-related deaths increased, but the relative rates of increase differed among diseases. These varying rates caused distinctly different trends in their percentages (Table 1; Figure 1). The percentages of HIV-related deaths associated with the following three diseases decreased: pneumocystosis, from 32.5% to 13.8%; cryptococcosis, from 7.7% to 5.0%; and candidiasis, from 2.3% to 1.7%. The percentages of deaths associated with eight diseases significantly increased: nontuberculous mycobacteriosis, from 6.7% to 12.2%; cytomegalovirus disease, from 5.2% to 9.9%; bacterial septicemia, from 9.0% to 11.5%; diffuse non-Hodgkin lymphoma, from 3.9% to 5.7%; tuberculosis, from 2.9% to 4.1%; progressive multifocal leukoencephalopathy, from 0.8% to 1.9%; bacterial pneumonia, from 1.2% to 2.1%; and cryptosporidiosis or isosporiasis, from 0.7% to 1.2%. The percentages of HIV-related deaths associated with unspecified pneumonia, Kaposi sarcoma, and toxoplasmosis (ranges from 17.6% to 18.6%, 10.4% to 12.1%, and 4.9% to 5.5%, respectively) had no significant linear trends during the 6-year period. Table 1. Trends in the Percentage of Deaths Associated with Infectious Diseases and Cancers Reported on Death Certificates of Persons Dying of HIV Infection* Figure 1. Trends in the prevalence of infectious diseases and cancers reported among persons dying of human immunodeficiency virus infection in the United States from 1987 to 1992. As a result of these different trends, the ranking of the diseases by the percentage of HIV-related deaths in which they were reported has changed. Pneumocystosis was the most common of these diseases until 1991, when its frequency decreased below that of unspecified pneumonia (Figure 1). The rank of nontuberculous mycobacteriosis increased from sixth place to third during 1987 to 1992, cryptococcosis dropped from sixth to ninth place, and candidiasis dropped from eleventh to thirteenth place. Disease trends among black persons (including Hispanic blacks) were similar to trends among white persons (including Hispanic whites); trends among females were generally similar to those among males. Discussion From 1987 to 1992, the distribution of secondary diseases among persons dying of HIV infection changed markedly. Pneumocystosis, initially the most common of these diseases, accounted for one third of HIV-related deaths in 1987; by 1992, however, it accounted for less than half this proportion. The percentages of cryptococcosis and candidiasis decreased to a lesser extent, those of eight other diseases increased, and those of three others did not change significantly. The dramatic decrease in the percentage of HIV-related deaths associated with pneumocystosis is consistent with results of studies of persons with the acquired immunodeficiency syndrome (AIDS) and of cohorts of HIV-infected persons [5-7]. This decreasing frequency of death associated with pneumocystosis is probably due to two factors: 1) enhanced prevention, attributable to the increasing use of chemoprophylaxis, and 2) increased survival of persons with Pneumocystis carinii pneumonia, attributable to improved methods of diagnosis and treatment [8, 9]. Despite these advances, pneumocystosis continues to cause a relatively large percentage of HIV-related deaths, probably because many HIV-infected persons do not obtain medical care for HIV infection until the infection is in a late stage, when pneumocystosis may have already developed [10]. In addition, P. carinii pneumonia sometimes develops despite prophylaxis, especially as immunodeficiency becomes more severe [11]. The large decrease in the percentage of HIV-related deaths associated with pneumocystosis should be expected to increase the percentages of HIV-related deaths associated with other diseases, in the absence of other influences. However, the percentages of deaths from cryptococcosis and candidiasis also decreased, perhaps because of successful prophylaxis or treatment with new antifungal agents such as fluconazole. This drug was licensed by the U.S. Food and Drug Administration in 1990 and was first used in clinical trials a few years earlier [12, 13]. The percentages of HIV-related deaths associated with toxoplasmosis, Kaposi sarcoma, and pneumonia caused by unspecified organisms did not change despite the decreasing percentages of deaths associated with pneumocystosis, cryptococcosis, and candidiasis. The increasing use of chemoprophylaxis against pneumocystosis with drugs effective against toxoplasmosis could have prevented increases in the percentage of deaths associated with toxoplasmosis and may also have held down the increases in the percentages with bacterial pneumonia and septicemia [14]. The percentage of HIV-related deaths associated with Kaposi sarcoma could have been suppressed by the decreasing percentage of homosexual or bisexual men (who account for most cases of Kaposi sarcoma) among persons with AIDS and the decreasing percentage of homosexual men with Kaposi sarcoma among all homosexual men with AIDS [15, 16]. Unspecified pneumonias are probably a mixture of cases caused by various unidentified pathogens, including P. carinii. Prophylaxis against pneumocystosis would be expected to decrease this component of unspecified pneumonia, whereas other components might be increasing. The net result is an apparently stable trend overall for unspecified pneumonia. Any changes in clinical practice affecting the specificity of the diagnosis of pneumonia could also have influenced these trends. A limitation of our study is the fact that the relative proportions of the components of unspecified pneumonia are unknown. Nonetheless, because of the decreased percentage of HIV-related deaths associated with P. carinii pneumonia, unspecified pneumonia became the leading secondary cause of death among persons dying of HIV infection, accounting for almost one fifth of HIV-related deaths. Some cases of unspecified pneumonia may represent terminal events in patients whose inevitable deaths were caused primarily by other HIV-related diseases. For other cases, determining the causative organisms and the most effective methods for preventing and treating this vaguely described entity may substantially increase the survival of persons with HIV infection. As in our study, studies of persons with AIDS found increasing trends in the percentage of patients with a diagnosis of nontuberculous mycobacteriosis (Mycobacterium avium complex infection) [7]. It is too early to see the effect of newly licensed drugs such as rifabutin in preventing and treating M. avium complex infection [17]. For most of the diseases analyzed in our study, the similarity of trends among whites and blacks and among males and females suggests that advances in treatment and prophylaxis have affected all of these groups. However, racial or sexual inequities in access to such care may still exist [18]. The quality of our data depends on how accurately and thoroughly the causes of death were reported on death certificates. Previous studies suggest that deaths for which the underlying cause was reported as HIV infection represent only 66% to 86% of all deaths attributable to HIV infection among men aged 25 to 44 years and 55% to 80% of such deaths among women

The relationship between body mass and breast cancer among women enrolled in the cancer and steroid hormone study

We examined the relationship between body mass [weight (kg)/height (m)2] and breast cancer using data from the Cancer and Steroid Hormone Study. The study compared 4323 women aged 20-54 years with newly diagnosed breast cancer identified through population-based tumor registries with 4358 women randomly selected from the general population of the same geographic areas. Among naturally menopausal women, risk of breast cancer increased with increasing body mass index (BMI); those severely overweight (BMI greater than or equal to 32.30) had nearly 3-fold higher risk of breast cancer compared with women in the leanest category (BMI less than 20.00). This positive association appeared stronger with increasing years since menopause and in women who had ever used estrogen replacement therapy. A positive association between body mass and breast cancer risk also was observed among premenopausal women; however, risk estimates were substantially lower. Substantial weight gain from adolescence to adulthood was a more important risk factor than lifelong obesity. Prevalence of obesity increases with age; our results suggest that interventions that prevent this trend could have an important effect on breast cancer risk, especially during the menopausal years.

Risk factors for regret after tubal sterilization: 5 years of follow-up in a prospective study *

The Collaborative Review of Sterilization is a prospective, multicenter study that interviewed 7,590 women before they underwent tubal sterilization and then conducted yearly follow-up interviews that included questions on sterilization regret. These women contributed 26,641 observations (for up to 5 years after the procedure, 1978 to 1988) to an analysis of the presterilization characteristics most consistently associated with poststerilization regret. Young age at the time of sterilization was the strongest predictor of regret, regardless of parity or marital status; among women 20 to 24 years of age at sterilization, an average of 4.3% reported regret over the follow-up period. The rate of regret was significantly lower for women 30 to 34 years of age (2.4%).

Sociodemographics and HIV risk behaviors of bisexual men with AIDS : results from a multistate interview project

Objective:To describe the sociodemographic characteristics and sexual and drug use behaviors of men with AIDS who engage in bisexual activity. Methods:We interviewed 2120 men aged ≥ 18 years who were reported with AIDS in 11 states and cities. Men were considered bisexual if they reported having had sex with a man and a woman in the previous 5 years. Results:Of the 2020 men with AIDS who reported being sexually active in the previous 5 years, 1150 (57%) had had male partners only, 522 (26%) had had female partners only and 348 (17%) had had both. White men were least likely to report bisexual behavior (15%; 161 out of 1071). Men of Latin American descent were most likely to report bisexual behavior (24%; 37 out of 155), especially those born outside the United States who had lived there for ≤ 10 years (38%; 11 out of 29). Bisexual Latin American men, regardless of birthplace, were more likely to be currently married than all other bisexual men (22 versus 7%; P< 0.05). HIV risk behaviors differed between men reporting bisexual and those reporting exclusively homosexual or heterosexual activity. Injecting drug use in the previous 5 years was more common among bisexual than homosexual men (12 versus 6%; P< 0.05). Bisexual men were more likely (P< 0.05) to have received money for sex (11%) than homosexual (4%) or heterosexual men (4%). This difference was even greater among injecting drug users receiving money for sex: bisexual (29%), homosexual (13%), heterosexual (3%). Conclusions:Demographics and HIV risk behaviors of bisexual men with AIDS differ from those of homosexual and heterosexual men with AIDS. These findings indicate that special efforts are needed to prevent sexual transmission of HIV among bisexual men.

Relationship between use of condoms and other forms of contraception among human immunodeficiency virus–infected women

OBJECTIVEnTo describe the relationship between condom use and use of other contraceptives among human immunodeficiency virus (HIV)-infected women.nnnMETHODSnWe interviewed 1232 women, 18-50 years of age, who had had sex with a man in the prior 12 months and who were reported with AIDS or HIV to local health departments in 12 states and cities in the United States. These women were asked about condom use and other contraceptive use in the past year.nnnRESULTSnForty-seven percent of women reported using condoms as a form of contraception in the past 12 months. Thirty-four percent of the 286 women who had had a tubal ligation and 42% of the 182 women who used oral contraceptives (OC) used condoms. When we controlled for all factors associated with failing to use condoms, women who had had a tubal ligation (adjusted odds ratio [OR] 1.72, 95% confidence interval [CI] 1.28-2.33), women who used OCs (adjusted OR 1.44, CI 1.00-2.08), and women who were unaware of the HIV status of their most recent steady sex partner (adjusted OR 1.72, CI 1.28-2.31) were the least likely to use condoms.nnnCONCLUSIONnHuman immunodeficiency virus-infected women who used more effective contraceptive methods were the least likely to have male sex partners who used condoms. In counseling women at high risk of transmitting HIV, health care providers should discuss reasons for using contraceptives (ie, preventing pregnancy versus preventing HIV transmission) and ensure that women understand that different forms of contraceptives may be needed to achieve those different purposes.

Differences in Participation in Experimental Drug Trials Among Persons With AIDS

To measure participation in experimental drug trials among persons with acquired immunodeficiency syndrome (AIDS), we interviewed 4,604 persons at least 18 years of age who were reported to have AIDS to 11 state and city health departments in the United States. Ten percent reported that they were currently in a trial. Current enrollment differed significantly (p < 0.05) by race/ethnicity (blacks, 5%; whites, 14%; Hispanics, 15%), gender (women, 7%; men, 11%), exposure mode (injection drug use, 5%, men who have sex with men, 14%), annual household income (<

Toxoplasmic encephalitis in HIV-infected persons : risk factors and trends

10,000, 8%, > or =

How important is race/ethnicity as an indicator of risk for specific AIDS-defining conditions ?

10,000, 14%), education (< 12 years, 6%; > or = 12 years, 12%), health care (no regular care, 1%, public care, 8%; private care, 17%), and time since AIDS diagnosis (< or = 6 months, 9%; > 6 months, 12%). Adjusting for all factors and time since AIDS diagnosis, blacks (adjusted odds ratio [AOR] = 0.35, 95% confidence interval [CI] 0.26, 0.47), persons with less than 12 years of education (AOR = 0.71, CI 0.53, 0.96), and those without regular health care (AOR = 0.24, CI 0.10, 0.61) remained less likely to be in a trial. Blacks, those with less than 12 years of education, and persons without regular health care were less likely than other persons with AIDS to be currently enrolled in AIDS trials. To increase enrollment of these persons, researchers must address barriers to participation for these groups.

Injection and syringe sharing among HIV-infected injection drug users : Implications for prevention of HIV transmission

Objective:To evaluate the incidence of and risk factors for toxoplasmic encephalitis among HIV-infected persons. Design:Medical facility-based prospective medical record reviews of consecutive patients. Methods:We analysed data collected from January 1990 through August 1995 in more than 90 inpatient and outpatient medical facilities in nine US cities. Incidence was calculated as cases per 100 person-years and risk ratios (RR) for annual incidence were calculated using proportional hazards regression while controlling for city, sex, race, age, county of birth, HIV exposure mode, and prior prescription of trimethoprim–sulfamethoxazole (TMP–SMX). Results:The incidence of TE was 4.0 cases per 100 person-years among persons with a CD4+ T-lymphocyte count of < 100×106/l. In multivariate analysis, among the nine cities the annual incidence of toxoplasmosis was significantly lower only in Denver [RR, 0.3; 95% confidence interval (CI), 0.1–0.7; referent city, Seattle]. Persons prescribed TMP–SMX were half as likely to develop toxoplasmic encephalitis as those who were not (RR, 0.5; 95% CI, 0.4–0.7). Of the 4173 persons with AIDS (1987 Centers for Disease Control and Prevention definition) who died during the study period, 267 (6.4%) had toxoplasmic encephalitis in the course of HIV disease. Conclusions:Toxoplasmic encephalitis in HIV-infected persons varies by geographic area in the United States. TMP–SMX reduces the risk for toxoplasmic encephalitis.