The natural history of human immunodeficiency virus infection among adults in Mumbai.

BACKGROUND: Natural history studies of untreated HIV infection are useful for clinicians, public health experts and policymakers to improve and monitor care, plan services and control, and to model the epidemic. Several natural history studies on homosexual men and intravenous drug users have been published from developed countries. A few studies have emerged on heterosexual populations from Africa. With an emerging epidemic, a similar study was required in India. This study was designed to determine the progression of HIV disease in a prevalent cohort of adult HIV-seropositive patients. METHODS: A prevalent cohort of 1009 patients comprising 488 asymptomatic HIV-seropositive persons, 259 with AIDS-related complex (ARC), and 262 with acquired immunodeficiency syndrome (AIDS) were recruited for the study at Sir J.J. Hospital, Mumbai. A case-control study was conducted to determine the correlation of clinical features and other factors with disease progression. Disease progression was determined from the asymptomatic stage to that of ARC and AIDS using time series analysis. The incubation period from HIV to AIDS was also determined, using Weibull curves. RESULTS: The median incubation periods for progression were: HIV to AIDS-7.9 years and ARC to AIDS--1.9 years. The median survival after developing AIDS was 19.2 months. A comparison of progressors and non-progressors revealed that disease progression correlated with clinical features such as chronic fever (OR 5.6), persistent generalized lymphadenopathy (OR 4.7), persistent cough for >1 month (OR 3.5), chronic diarrhoea (OR 3.3), oral candidiasis (OR 3.2), >10% loss of body weight within 1 month (OR 2.9), incident tuberculosis (OR 2.8) and herpes zoster (OR 2.5). The annual incidence of active clinical tuberculosis was 86/1503 person-years (5.7/ 100 person-years), the median time to occurrence of active tuberculosis was 21.6 months and the annual incidence of mortality was 96/2009 person-years (4.8/100 person-years, 95% CI 3.4, 6.2). CONCLUSION: Progression to AIDS and death was faster among the heterosexual cohort in Mumbai than that reported for homosexual men and haemophiliacs in the USA and Europe. Strategies need to be developed to prevent the occurrence of tuberculosis among HIV-infected patients because that would help to reduce the morbidity and mortality. This is the first large study from the Indian subcontinent of a longitudinal follow up of HIV-infected persons. The findings will be useful for advocacy and assessing the impact of antiretroviral therapy (ART) in India.

Sociodemographic, environmental and clinical risk factors for developing persistent diarrhoea among infants in a rural community of Egypt.

The study documents the incidence of persistent diarrhoea and its sociodemographic, household, environmental and clinical risk factors. One hundred and fifty-two newborns were followed for the first 12 months of life in Bilbeis, Egypt. The household of each participant was surveyed at baseline and was visited twice a week. The study infants experienced persistent diarrhoea at a rate of 0.51 episode/case per year. Development of persistent diarrhoea was associated with water storage in mud-containers (Odds ratio [OR] = 4.36, confidence interval [CI] 1.4-14.8), pump-water supply (OR = 3.5, CI 1.2-10.2), and absence of a latrine in the household (OR = 2.74, CI 1.01-7.38). Detection of faecal IgE (OR = 3.32, CI 1.0-10.9) and high stool frequency (OR = 2.95, CI 1.1-7.8) appeared as important clinical predictors for the onset of persistent diarrhoea. The incidence of persistent diarrhoea among young infants in Bilbeis, Egypt, was high. Sociodemographic, environmental and clinical parameters were important risk factors for the development of persistent diarrhoea.

Severe weight loss: the predominant clinical presentation of tuberculosis in patients with HIV infection in India.

BACKGROUND: Tuberculosis is endemic in India and its prevalence is reported to be increasing in patients with human immuno-deficiency virus (HIV) infection. Several factors, including the level of immune deficiency, influence the clinical presentation of HIV-associated tuberculosis. METHODS: Between April 1994 and April 1996, 1820 patients with confirmed HIV infection were studied for their clinical, radiological and laboratory parameters. Severe weight loss was observed as a frequent presenting complaint. Hence, a case-control analysis was performed using severe weight loss as the presenting criterion among HIV-seropositive patients. RESULTS: Of the 1820 patients with HIV infection, 410 (23%) presented with severe weight loss of > 10% of body weight within the preceding month. Of these 410 patients, 176 (43%) had tuberculosis, 94 (23%) had chronic diarrhoea, and 89 (22%) had recurrent fever. Among 176 patients with tuberculosis, the following types of HIV-associated tuberculosis were seen: 115/176 (66%) had pulmonary, 49/176 (28%) had extrapulmonary tuberculosis; of these 49 cases with extrapulmonary tuberculosis 33 (18%) had disseminated tuberculosis, and 12/176 (7%) had both pulmonary and extrapulmonary involvement. In the group as a whole, 45/176 (25%) cases had disseminated tuberculosis. Clinical features of HIV-associated tuberculosis in decreasing order of frequency were chronic fever, chronic cough, lymphadenopathy and hepatosplenomegaly. The Mantoux skin test was significantly anergic among patients with extrapulmonary and disseminated tuberculosis (p = 0.001). CONCLUSIONS: There was a significant correlation between severe weight loss and tuberculosis (RR 17.5), chronic diarrhoea (RR 12.8) and recurrent fever (RR 4.5). The diagnostic value of the Mantoux skin test among HIV-associated tuberculosis is reduced, more so among those with extrapulmonary and disseminated forms.

Cryptosporidium, isospora and strongyloides in AIDS.

BACKGROUND: Diarrhoea is a common presentation in patients with AIDS. It occurs due to a number of parasites which are seldom seen in immunocompetent hosts. METHODS: Between January 1993 and July 1994, faecal specimens from 77 patients with AIDS presenting with diarrhoea of more than a month's duration were examined by direct wet mount microscopy of saline and iodine preparations and by the modified Ziehl-Neelsen stain. RESULTS: Cryptosporidium, Isospora and Strongyloides stercoralis alone or in combination were present in 29 of the 77 patients. CONCLUSION: The presence of these parasites highlights their pathogenic potential for immunocompromised patients with AIDS. Diarrhoea due to Isosporais responsive to treatment, hence their identification has therapeutic implications as well.

Association between birth weight and birth arm circumference of neonates in rural Egypt.

In many developing countries including Egypt, the birth weights (BWs) of most babies go unrecorded because they are born at home. Since it is difficult to record BW in the community setting, birth arm circumference (BAC) has been used as a valid proxy for BW to identify at risk babies with low birth weight (LBW). However, the validity of BAC as an indicator of the actual BW has not been assessed fully. We did this study among neonates in rural Bilbeis, Egypt, to examine the association between BW and BAC, to assess whether BAC can serve as an indicator of the actual BW, and to determine the validity indices of 3 different cut-off levels of BAC as indicators of LBW. During 1987-88, the weights and arm circumference of 148 neonates were recorded within 2 weeks of birth. We observed a strong and highly significant positive linear correlation between BW and BAC (r = 0.6188, p = 0.0001). The BAC cut-off value of < 9.5 cm was associated with the optimal combination of sensitivity (50%) and specificity (88.4%) as an indicator of LBW. In linear regression analysis BAC was found to be a significant (p = 0.00001) predictor of BW. The means of the model predicted weights for males, females, and both genders together were identical to the corresponding means of the observed values. In contingency table analysis, for 78 (52.7%) of the 148 neonates studied the observed and predicted BW categories were identical. For another 59 (39.9%) neonates, agreement with the next lower or higher BW category was observed. We feel that BAC can be used as an indicator of the actual BW in settings where routine recording of BW is currently not practicable.