Rate of hospitalization and inpatient care costs for HIV-1-infected patients in Pune, India.

BACKGROUND: The transition of human immunodeficiency virus (HIV) infection to acquired immune deficiency syndrome (AIDS) has begun in India, and an increase in AIDS-related hospitalizations and deaths is an anticipated challenge. We estimated the rates of hospitalization and inpatient care costs for HIV-1-infected patients. METHODS: Data were analysed on 381 HIV-1-infected persons enrolled in a HIV-1 discordant couples' cohort between September 2002 and March 2004. Inpatient care costs were extracted from select hospitals where the study patients were hospitalized and the average cost per hospitalization was calculated. RESULTS: A majority of the patients were in an advanced state of HIV-1 disease with the median CD4 counts being 207 cells/cmm (range: 4-1131 cells/cmm). In all, 63 participants who did not receive antiretroviral therapy required hospitalization, 53 due to HIV-1-related illnesses and the remaining 10 due to worsening of pre-existing conditions. The overall HIV-1-related hospitalization rate was 34.2 per 100 person-years (95% CI: 26.94-42.93). The median duration of HIV-1-related hospitalization was 10 days (range 2-48 days) and the median cost was Rs 17,464 (range: Rs 400-63,891). CONCLUSION: It is necessary to strengthen the inpatient care infrastructure and supporting diagnostic set-up, and work out economically optimized treatment algorithms for HIV-1-infected patients. Although this analysis does not cover all costs and may not be generalizable, these baseline data might be a useful reference while planning related studies accompanying the government-sponsored programme to roll out antiretroviral therapy to AIDS patients.

Profile of bone marrow examination in HIV/AIDS patients to detect opportunistic infections, especially tuberculosis.

Morphological evaluation of 140 bone marrow aspirations received in haematopathology laboratory with serologically established HIV infection, along with other relevant special haematological tests, was done during 1st Jan 1999 - 31st Dec 2002 at state government run tertiary care General Hospital in Maharashtra state, India. Out of 140 cases: 118 (84.28%) patients had anaemia, 25 (17.86%) had leukopenia, while 13 (9.28%) were thrombocytopenic. Dyserythropoiesis was present in 18 (12.86%) cases, dysmyelopoiesis 37 (26.43%) and micromegakaryocytes were noted in 44 (31.43%) cases. Haemophagocytosis was evident in 8 (5.71%) cases. Plasmacytosis encountered in 120 (85.71%) cases was a common feature. Based on clinical profile and results of other investigations 56 (40%) patients were clinically diagnosed to be of Mycobacterium tuberculosis (TB). Of these, 18 (12.86%) bone marrow aspirates were positive for AFB, Mycobacterium tuberculosis. In 4 cases cryptococci were demonstrated (Mucicarmine stain). There was one case each of Histoplasma capsulatum and leishmaniasis. One patient showed dense parasitemia with Plasmodium falciparum. One patient had immunoblastic lymphoma and showed bone marrow infiltration. Findings in this study strongly indicate that in HIV/AIDS, AFB stain should be done on each marrow aspirate to rule out tuberculosis in countries like India; where TB and AIDS are marching together.

Phase I safety & preliminary acceptability of nonoxynol-9 vaginal pessary as a vaginal microbicide in low risk women in Pune, India.

BACKGROUND & OBJECTIVES: Though nonoxynol-9 (N-9) is available in India as a spermicidal pessary, data on its safety as a potential microbicide among Indian women are not available. Nonoxynol-9 containing compounds have shown anti-HIV activity in in vitro studies and protection against cervical infections. Nonoxynol-9 is being extensively evaluated as a vaginal microbicide world-wide. We assessed the safety and preliminary acceptability of nonoxynol-9 pessary as a vaginal microbicide in women at low risk for human immunodeficiency virus (HIV) infection and sexually transmitted diseases (STDs). METHODS: Twenty three HIV seronegative women enrolled in the study were given Today pessarys containing 5 per cent of nonoxynol-9 for vaginal use at bedtime for 14 days. Colposcopy was done at enrollment and on day 14 and speculum examination on day 7 to assess the local toxicity. RESULTS: Most of the women (16/23, 69.6%) did not experience any symptoms of genital irritation. The remaining 7 (30.4%, 95% CI 11.6-49.2) women reported 11 episodes of mild irritative symptoms of short duration. On clinical examination, three adverse events were reported of which one could have been product related. Eight (34.8%) women showed willingness to use the product for protection against HIV transmission if it was approved. INTERPRETATION & CONCLUSION: Nonoxynol-9 vaginal pessary was found to be safe and acceptable in once daily dose in low risk women after consecutive use for 14 days. Willingness for future use, if found safe and effective for HIV prevention was shown by 8 (34.8%) women.

Cervical intraepithelial changes & HIV infection in women attending sexually transmitted disease clinics in Pune, India.

BACKGROUND & OBJECTIVES: Cervical cancer is the most important cause of malignancy associated deaths among women in India. Western studies have reported higher risk of abnormal Pap smears in HIV infected women. A large burden of HIV infection and increasing HIV epidemic in India threatens to exacerbate incidence of cervical cancer. The objective of this study was to assess the frequency of Pap smear abnormalities and its association with HIV infection in women attending sexually transmitted disease (STD) clinics and to identify associated risk factors. METHODS: Between June 1996 and September 1999, women attending two STD clinics in Pune were screened for HIV infection, offered STD laboratory diagnosis and treatment and their Pap smears were evaluated. RESULTS: Squamous cell abnormality was detected in 10 per cent of HIV sero negative women attending STD clinics. This proportion was nearly double (19.2%) (Odds ratio = 2.14, 95% C.I. 1.03-4.48, P = 0.04) in HIV seropositive women. Having more than one life time partners and presence of STDs were also significantly associated with Pap smear abnormality in univariate analysis. In multivariate analysis, women presenting with STD and HIV infection both, were 2.8 times more likely to have inflammatory Pap smear and 3.5 times more likely to have abnormal Pap smear compared to HIV seronegative women presenting without STDs. INTERPRETATION & CONCLUSION: Pap smear abnormalities were common in women attending STD clinics in Pune. Presence of HIV infection further increased the risk two-folds. Therefore, women suffering from STDs should undergo periodic Pap smear screening for early detection of cervical abnormalities and should receive appropriate management to reduce morbidity and mortality.

Cross-reactive HIV-1-specific CTL in recent seroconverters from Pune, India.

In the light of the diversity of HIV, matching the genotype of candidate HIV vaccines with the transmitted genotype may be required. Alternatively, matching the immunotype of HIV vaccines and transmitted subtypes may be the best option. Since studies of cross-subtype HIV-1 immunity are limited, subtype B specific cytolytic T lymphocyte (CTL) responses were measured in subtype C infected individuals. HIV-1 subtype B-specific CTLs, plasma viral load and absolute CD4 and CD8 lymphocyte numbers were measured in six HIV-1 subtype C infected individuals within a year of seroconversion. HIV-1 subtype B env. gag and nef-specific CTL precursor frequencies were measured by limiting dilution analysis. Three of the six subjects had demonstrable CTL directed at more than one HIV-1 subtype B antigens. One individual demonstrated CTL directed against all three HIV-1 subtype B antigens, while two individuals did not demonstrate CTL against HIV-1 subtype B antigens. The frequencies of CTL precursor were not associated with plasma viral load or absolute CD4 cell counts in peripheral blood. These findings suggest that some individuals recently infected with subtype C HIV-1 generate cross-reactive CTL that are directed against HIV-1 subtype B.

Transmission of genetically diverse strains of HIV-1 in Pune, India.

Surveillance of the different HIV-1 subtypes has important implications for developing candidate vaccines and understanding the dynamics of HIV transmission in various populations. In this study, HIV-1 viral subtypes were determined for homologies in the V3-V5 region by heteroduplex mobility assay (HMA) in 46 patients with sexually transmitted diseases (STD) in Pune, India. Proviral DNA from peripheral blood mononuclear cells (PBMCs) from 20 recent sero-coverters and 26 HIV seropositive individuals were analyzed. Of the 46 samples analyzed, 44 (96%) were HIV-1 subtype C and one each of subtypes A and B. Further analyses revealed that 29 (66%) of the C subtype samples had maximum homology to the C3-Indian reference strain, while 15 (34%) were most homologous to the C2-Zambian strain. The C3 genotype prevailed in the majority (80%) of the seropositive individuals. Most of the C3 (Indian) strains were closely homologous to each other, while more nucleotide sequence divergence was seen in C2 samples. A higher quasispecies complexity was observed in the samples collected from seropositive individuals. These findings may have important implications for the design and testing of effective candidate HIV-1 vaccines for India.

Awareness & knowledge of AIDS & HIV risk among women attending STD clinics in Pune, India.

The present study attempts to understand the awareness, knowledge and risk to HIV/AIDS among two groups of women: one reporting sex-work (FSW) and second reporting other work (FOW) from two clinics in Pune. The patients are screened for HIV and enrolled in the study. This paper includes 711 women covered between May 1993 and April 1995, 409 FSW and 302 FOW women, who differed by several characteristics. The FSW are older, less educated, unmarried, staying away from home, speak Kannada with 60 per cent using condoms for preventing pregnancy. FOW are ever-married women and among Family Planning method users only 7 per cent used condoms and 84 per cent had tubal ligation. At enrollment 47 per cent FSW and 14 per cent FOW were HIV positive with less than one third of all the women reporting AIDS knowledge. Among the knowledgeable women, 82 per cent understood the sexual route, half knew of transmission by blood and a third understood the vertical route of transmission; 77 per cent FSW and 48 per cent FOW knew that condom was protective. FSW reporting consistent condom use in past three months had greater knowledge of AIDS transmission, were more likely to have used condoms as contraceptive or had tubal ligation and less likely to have history of STD. This suggests the HIV/AIDS awareness and educational programs are having a limited effect specially among the married women who do not perceive of the risk of STD/HIV from their spouses and requires urgent preventive measures through innovative approaches that focus on female controlled methods. It is of critical importance that family planning and STD/HIV programs be integrated.

Evidence for high prevalence & rapid transmission of HIV among individuals attending STD clinics in Pune, India.

Prevalence and incidence of HIV-1 infection among persons attending two STD clinics in Pune between May 1993 and October 1995 are reported. On screening 5321 persons, the overall prevalence of HIV-1 infection was found to be 21.2 per cent, being higher in females (32.3%) than in males (19.3%). Analysis of behavioural and biological factors showed that old age, sex work, lifetime number of sexual partners, receptive anal sex, lack of circumcision, genital diseases and lack of formal education were related to a higher HIV-1 seroprevalence. The observed incidence rate of 10.2 per cent per year was very high, much higher in women than in men (14.2% and 9.5% per year respectively) and over three times higher among the sex workers. Females in sex work, males having recent contacts with female sex workers (FSWs) and living away from the family and persons with previous or present genital diseases had a higher risk of seroconversion. Condom usage was shown to have a protective effect in seroprevalence and seroincidence analysis. With limited available resources and lack of a suitable vaccine or a drug, long-term prevention policy of creating awareness in the community must be supplemented by strengthening STD control measures and promotion of condom use and safe sex. Factors related to availability and utilization of condoms must be carefully investigated.