Infants of human immunodeficiency virus type 1-infected women in rural south India: feeding patterns and risk of mother-to-child transmission.

BACKGROUND: We assessed the infant feeding choices of HIV-1-infected women in rural Tamil Nadu, India, and risk factors for mother-to-child transmission of HIV-1. METHODS: The study population comprised live born infants of HIV-1-infected women from the antenatal clinics of 2 public hospitals in rural Tamil Nadu, India who were enrolled in a prospective cohort study. All women enrolled in the cohort were offered antiretroviral prophylaxis and infant feeding counseling based on WHO/UNAIDS/UNICEF training materials. Infant study visits were scheduled at birth (within the first 24 hours of life), at 1 week, 1 month, and 2 months after birth, and then every 2 months between 4 and 12 months of age. RESULTS: One-third of women did not breast-feed their infants. Of those who initiated breast-feeding, the median duration of breast-feeding was approximately 3 months. Among those infants who initiated breast-feeding, the proportion exclusively breast-feeding declined from approximately 70% during the first week of life to 0% by the 8 month visit. The observed rate of mother-to-child transmission of HIV-1 in the entire cohort was 6.5% (95% CI: 1.4%-17.9%). The observed HIV-1 incidence among breast-fed infants was 0% (95% CI: 0%-8.9%). CONCLUSION: The overall transmission rate was relatively low, suggesting effectiveness of antiretroviral transmission prophylaxis. The infant feeding choices made may reflect knowledge gained through the educational program and infant feeding counseling provided. Ensuring HIV-1-infected women receive appropriate HIV-1 treatment (for those who meet criteria for treatment) and access to known efficacious interventions to prevent mother-to-child transmission of HIV-1, are essential.

Anemia and growth failure among HIV-infected children in India: a retrospective analysis.

BACKGROUND: Anemia and poor nutrition have been previously described as independent risk factors for death among HIV-infected children. We sought to describe nutritional status, anemia burden and HIV disease correlates among infected children in India. METHODS: We analyzed retrospective data from 248 HIV-infected children aged 1-12 years attending three outpatient clinics in South India (2004-2006). Standard WHO definitions were used for anemia, HIV staging and growth parameters. Statistical analysis included chi square, t tests, univariate and multivariate logistic regression analyses. RESULTS: The overall prevalence of anemia (defined as hemoglobin < 11 gm/dL) was 66%, and 8% had severe anemia (Hb < 7 gm/dL). The proportion of underweight and stunted children in the population was 55% and 46% respectively. Independent risk factors of anemia by multivariate analysis included the pre-school age group (age younger than 6 years) (OR: 2.87; 95% CI: 1.45, 5.70; p < 0.01), rural residence (OR: 12.04; 95% CI: 5.64, 26.00; p < 0.01), advanced HIV disease stage (OR: 6.95; 95% CI: 3.06, 15.79; p < 0.01) and presence of stunting (Height-for-age Z Score < -2) (OR: 3.24; 95% CI: 1.65, 6.35; p < 0.01). Use of iron/multivitamin supplementation was protective against risk of anemia (OR: 0.44; 95% CI: 0.22, 0.90; p = 0.03). Pulmonary tuberculosis was an independent risk factor in multivariate analysis (OR: 3.36; 95% CI: 1.43, 7.89; p < 0.01) when correlated variables such as HIV disease stage and severe immunodeficiency, and nutritional supplement use were not included. Use of antiretroviral therapy (ART) was associated with a reduced risk of anemia (OR: 0.29; 95% CI: 0.16, 0.53; p < 0.01). No significant association was found between anemia and gender, cotrimoxazole, or ART type (zidovudine versus stavudine). CONCLUSION: The high prevalence and strong interrelationship of anemia and poor nutrition among HIV-infected children in India, particularly those living in rural areas underscores the need for incorporating targeted nutritional interventions during national scale up of care, support and treatment among HIV-infected children.

Optimization of the oligonucleotide ligation assay, a rapid and inexpensive test for detection of HIV-1 drug resistance mutations, for non-North American variants.

OBJECTIVE: We evaluated the feasibility of the oligonucleotide ligation assay (OLA), a specific, sensitive, and economical ligase-based point mutation assay designed to detect HIV-1 drug-resistance mutations at 12 codons of HIV-1 subtype B pol, for potential use in resource-poor settings. METHODS: Specimens from HIV-1-infected individuals collected by 7 international laboratories, including subtypes A, B, C, D, F, G, J, and recombinants AE and AG, were tested by the OLA developed for HIV-1 subtype B. Common polymorphisms that interfered with reactivity of the OLA were identified and modified probes designed and evaluated. RESULTS: 92.5% (2,410) of 2,604 codons in specimens from 217 individuals were successfully genotyped by the subtype B OLA. A high rate (range 8.3%-31.2%) of indeterminate results (negative OLA reaction for both mutant and wild type) was observed for 5 codons. Modified probes at reverse transcriptase codons 151 and 184 and protease codon 90 increased the rate of valid OLA to 96.1%. CONCLUSIONS: The OLA designed for HIV-1 subtype B genotyped most pol codons in non-B subtypes from Asia and Africa but was improved by addition of several modified probes. International laboratories experienced in molecular techniques were able to perform the OLA.

The use of dried blood spots on filter paper for the diagnosis of HIV-1 in infants born to HIV seropositive women.

Polymerase chain reaction (PCR) is the most sensitive test to diagnose HIV-1 infection among infants born to HIV seropositive mothers. The purpose of this study was to evaluate the use of dried blood spot (DBS) specimens for PCR and to compare it with whole-blood stored in tubes for HIV-1 DNA PCR. Five hundred and seventy-seven whole-blood infant samples were tested using HIV-1 qualitative in-house nested DNA PCR. Three hundred and fifty-nine samples were from infants at 48 hours of birth and 218 samples at second month. All positive samples tested from whole-blood and every fifth negative sample were coated onto filter paper. DNA was extracted from the filter paper and was amplified using in-house nested PCR. Among the whole-blood samples tested using HIV-1 DNA PCR, 19 of 359 (5.29%) samples were HIV-1 positive and 340 (94.7%) were negative at 48 hours of birth. At second month, 19 (8.7%) of the 218 samples were positive and 199 (91.2%) were negative. Using dried filter paper, 18 samples (95%) tested positive from 19 positive samples (using whole-blood) and 1 tested negative at 48 hours of birth. The 68 negative samples tested using whole-blood were also negative in the DBS test (sensitivity 95% and specificity 100%). At second month, 19 were positive and 40 samples (every fifth sample of 199) were negative (sensitivity and specificity, 100%). PCR performed using DNA extracted from filter paper permits the diagnosis of HIV-1 infection among infants born to HIV-1 seropositive mothers. This assay is simple, rapid, sensitive and specific and can be used in resource limited settings.

Effectiveness of antenatal group HIV voluntary counseling and testing services in rural India.

This study assessed HIV attitudes among pregnant women attending antenatal clinics in the Namakkal district of Tamilnadu, India, as well as HIV knowledge before and after group counseling sessions. Two hundred thirteen women (97%) attending five antenatal clinics in July 2004 accepted HIV counseling and testing and completed precounseling and postcounseling questionnaires. Although the majority of women had heard of HIV, precounseling knowledge was low (mean precounseling score; 6.9/18, SD: 4.53), with scores correlating with the women's educational level and the number of sources from which they had received information about HIV. Posttest scores increased by 21%, however, understanding of modalities to prevent HIV infection remained poor. Group counseling sessions achieve small gains in HIV knowledge, but there is a continued need for ongoing and multifaceted HIV education in rural India.

Safety of HIV-1 Perinatal Transmission Prophylaxis With Zidovudine and Nevirapine in Rural South India.

BACKGROUND: The authors assessed acceptance and safety of, and adherence to, perinatal HIV-1 transmission prophylaxis at 2 public hospitals in rural Tamil Nadu, India. METHODS: Eligible HIV-1-infected women were offered zidovudine (ZDV) beginning at 28-weeks gestation until delivery. Their infants received ZDV for 6 weeks. A subsequent revision to the protocol added 1 dose of nevirapine (NVP) for mother and infant. RESULTS: Sixty of 67 women (90%) met inclusion criteria for the cohort study. Thirty-four of 36 eligible women and all 19 eligible live born infants received prophylaxis on study. Infant, but not maternal, adherence to ZDV varied by antiretroviral prophylaxis group (those receiving combined prophylaxis with ZDV and NVP had lower median adherence) (P = .02). Neutropenia (usually transient) was the most common severe adverse event. Only 1 of 5 women with neutropenia possibly related to ZDV permanently discontinued ZDV. ZDV was not discontinued for any infant. CONCLUSION: With the exception of neutropenia, usually transient and always without clinical consequences, long-term ZDV (with or without NVP prophylaxis) is well tolerated.

Acceptance of HIV-1 education & voluntary counselling/testing by & seroprevalence of HIV-1 among, pregnant women in rural south India.

BACKGROUND & OBJECTIVE: Since the first report of HIV-1 infection in Tamil Nadu, India, HIV-1 seroprevalence in India has increased steadily. Though interventions to prevent mother-to-child transmission (MTCT) are available, their implementation is a significant challenge. Therefore, among pregnant women in rural Tamil Nadu, the acceptance of education regarding HIV-1 infection and transmission and, among a systematic sample, knowledge, attitudes, and beliefs; the acceptance of HIV-1 voluntary counselling and testing (VCT); and the seroprevalence of HIV-1 infection as well as risk factors for seropositivity were assessed. METHODS: Pregnant women registered in the antenatal clinics at Namakkal District Hospital and Rasipuram Government Hospital, Tamil Nadu, India, were offered an educational session regarding HIV-1 infection and transmission. HIV-1 VCT, with informed consent, was offered. Positive results with HIV-1 rapid testing were confirmed with HIV-1 ELISA and Western blot assays. With informed consent, a systematic sample of the study population was asked to participate in pre- and posteducation assessments. Chi-square tests were used to evaluate HIV-1 risk factors. RESULTS: The educational session as well as VCT were well accepted by rural, pregnant, HIV-1- infected women. Of 3722 women registered for antenatal care at the two hospitals over a one year period, 3691 (99.2%) agreed to participate in the educational session and 3715 (99.8%) had VCT [74 had confirmed HIV-1 infection [seroprevalence: 2.0% (95% confidence interval (95%CI): 1.6%, 2.5%)]]. Of 759 eligible women, a systematic sample of 757 (99.7%) women participated in the pre- and post-education assessments. Although baseline knowledge regarding HIV-1 was limited, a highly significant improvement in such knowledge was observed (P<0.0001 for all comparisons of changes in knowledge, attitudes, and beliefs measured before and immediately after the educational session). The median per cent of correct responses increased from 26.4 per cent before the educational session to 93.8 per cent afterwards. Women whose husbands were long distance truck drivers were at increased risk of HIV-1 infection. Other factors associated with HIV-1 infection were clinical site (Namakkal District Hospital), a smaller number of persons in the household, being unmarried, and a history of previous surgeries. INTERPRETATION & CONCLUSION: The acceptability of education and of VCT among antenatal clinic attendees in this study was encouraging. However, the relatively high seroprevalence highlights the spread of HIV-1 from high risk groups to the general population and emphasizes the need for primary prevention of HIV-1 infection among adolescent girls and women of reproductive age in India.

Detection of antibodies to HIV-1 in serum and saliva.

In this study we report the detection of antibodies to HIV-1 in paired serum and saliva collected from 118 HIV-1 infected patients and 80 normal controls in Madras, South India. Saliva was collected using Omnisal (R) collection device. All the reactive samples were confirmed by Western blot test (WB), while all the control serum and saliva were negative for HIV-1 antibodies. 107 (90.6%) HIV individual's serum and saliva contained antibodies to HIV-1. When these reactive samples were tested by WB test for confirmation the following results were obtained; 68% HIV individuals' paired serum and saliva were positive; while 9% of serum samples were positive and the saliva specimens were negative on WB. 3% of paired samples showed indeterminate Western blot pattern in contrast to 10% of serum showed full WB pattern while the saliva result was indeterminate. It is suggested that saliva testing may be appropriate for surveillance and epidemiological studies. However, if used for individual HIV diagnosis it is imperative to use a confirmatory test.

Detection of HIV infection in pulmonary tuberculosis patients.

Well documented 112 pulmonary tuberculosis patients were studied for the prevalence of human immunodeficiency virus (HIV) seropositivity by using two antibody screening tests along with western blot test. Nineteen of the pulmonary tuberculosis patients were HIV seropositive, 12 were acid-fast bacillus smear positive; 12 patients were tuberculin skin test positive and 15 patients were culture positive. As the incidence of HIV infection is increasing in India, it is observed that patients co-infected with HIV and TB are also on the rise. Recognition of the dual infection and taking adequate steps to deal with this epidemic are needed.

PIP: Infection with HIV depresses cell-mediated immunity by selectively depleting the CD4 T cells. That process increases the HIV-infected individual's susceptibility to other infections such as Myco tuberculosis. The World Health Organization estimates that more than 4 million people worldwide have been infected with HIV and Myco tuberculosis. 35 patients newly diagnosed with pulmonary tuberculosis (TB) at the Government Thiruvotteswarar Hospital of Thoracic Medicine in Madras and 77 at the Institute of Thoracic Medicine were tested for infection with HIV using particle agglutination, ELISA, and Western blot. 19 were HIV positive, 12 were acid-fast bacillus smear positive, 12 were tuberculin skin test positive, and 15 were culture positive. As the incidence of HIV infection increases in India, so does the number of patients coinfected with HIV and TB. Health personnel need to recognize such dual infection and take the proper steps to manage the epidemic.

HIV infection among patients attending a sexually transmitted disease clinic in Madras, southern India.

PIP: This paper reports upon the prevalence of HIV infection among 84 men and 36 women who attended a STD clinic operated by the Venerology Department of the Government General Hospital in Madras, India, during July-September 1993. HIV serostatus was determined and confirmed using ELISA and Western blot tests. 99% of the men were VDRL reactive, 74% reported a history of sex with multiple partners, seven men reported being intercourse receptive homosexuals, and only two men were circumcised. All of the women were VDRL reactive, 28% reported having sex with multiple partners, and 14% were prostitutes. HIV antibody was detected in 22.5% of VDRL reactive STD patients. Overall, 55% of the patients had genital ulcer disease and 13% were diagnosed as having syphilis.^ieng

Expression of major histocompatibility complex class I and class II antigens in human Schwann cell cultures and effects of infection with Mycobacterium leprae.

Recent experiments on rats have raised the possibility that Schwann cells can present antigens to T lymphocytes. We have investigated whether this mechanism might be relevant in leprosy by determining under what conditions human Schwann cells express class I and class II antigens, and whether infection with Mycobacterium leprae affects this expression. The distribution of these antigens was examined on human Schwann cells in dissociated cell cultures derived from human fetal peripheral nerves. We find that both Schwann cells and fibroblastic cells in these cultures normally express class I antigens but not class II antigens. When Schwann cells are infected with live Mycobacterium leprae for 48 h, 73% of Schwann cells phagocytose the bacteria. Mycobacterium leprae prevents 3H-thymidine incorporation into cultured human Schwann cells, but does not affect class I expression in these cells. Treatment of normal and Mycobacterium leprae infected cultures with gamma-interferon for 72 h induces class II expression on most Schwann cells but not on the majority of fibroblastic cells. The fact that human Schwann cells infected with Mycobacterium leprae can be induced by gamma-interferon to express class II antigens suggests that they may be able to present Mycobacterium leprae antigens to T lymphocytes and thus initiate immune responses against the bacteria. We suggest that a failure of this response, such as that seen within nerve trunks in lepromatous leprosy, is caused by deficient class II expression on Schwann cells. This deficiency in class II expression, in turn, may be caused by the reduced gamma-interferon production characteristic of lepromatous leprosy.

Gamma interferon, but not Mycobacterium leprae, induces major histocompatibility class II antigens on cultured rat Schwann cells.

In order to investigate the possible role of Schwann cells in immune reactions, and in particular their involvement in the response to infection with Mycobacterium leprae, it was determined under what conditions Schwann cells express major histocompatibility complex class II (MHC class II) antigens, since these molecules are thought to have a key role in antigen presentation during cellular immune responses. In situ and in vitro preparations from newborn and adult rat sciatic nerves were used as a model system to examine this question. Schwann cells in dissociated cell cultures did not express immunohistochemically detectable amounts of MHC class II antigens. Teased nerve preparations from the sciatic nerves of healthy adult rats showed no detectable immunolabelling of either myelin-forming or non-myelin-forming Schwann cells. When dissociated Schwann cell cultures derived from the sciatic nerves of either neonatal or adult rats were treated with 10, 50 or 100 units of gamma interferon, MHC class II antigens were detectable on the surface of some Schwann cells 48 h after addition of the interferon. By 72 h, 32.29 +/- 3.9% of Schwann cells in the cultures from neonatal rats and 53.32 +/- 5.4% of Schwann cells in cultures from adult rats, identified by the presence of intracellular S-100, were clearly MHC class II-positive, especially at doses of 50 and 100 units per ml of gamma interferon. Some, but not all, of the fibroblastic cells were very weakly MHC class II-positive. Infection of the cultures with Mycobacterium leprae did not induce MHC class II antigen expression in either Schwann cells or fibroblasts.(ABSTRACT TRUNCATED AT 250 WORDS)