Common AIDS-defining Illness Research Articles

Initial diagnosis of HIV/AIDS in patients presenting to the emergency department: Imaging and clinical findings at a single institution

PurposeTo evaluate the clinical, laboratory, and imaging findings along with treatment and outcomes associated with patients presenting to the emergency department (ED) who were subsequently diagnosed with HIV/AIDS. Methods591 patients with HIV and available imaging studies presenting to our hospital's ED between 2004 and 2019 were identified in the medical record. Following initial review, we identified 19 patients who were diagnosed with HIV within one week after an initial ED visit and also had received CT imaging during the ED visit. Demographic, clinical, treatment, imaging, and outcome data were reviewed and recorded for each patient. ResultsAmong this 19-patient cohort, the most common indication for HIV testing was oral/esophageal candidiasis (n = 8, 42%). 12 patients presented with an AIDS-defining illness upon initial diagnosis; the most common were esophageal candidiasis (4) and Pneumocystis jiroveci pneumonia (PJP) (3). 10 patients (59%) presented with CD4+ counts <200 cells/L. The most common imaging findings were liver abnormalities (n = 9, 47%). Five of the 19 patients were confirmed deceased at the time of this study, with the median time from diagnosis to death of 5.6 months (range 8 days-14 months). ConclusionOur series demonstrates the breadth of potential imaging findings and clinical presentations of late-stage HIV in the emergency setting, including common AIDS-defining illnesses such as PJP and PML. Although the incidence of these conditions is decreasing, maintaining awareness of their clinical and imaging findings, as well as the potential for multi-organ involvement, is essential due to the possibility of rapid decline in these patients.

AIDS-Defining Illnesses at Initial Diagnosis of HIV in a Large Guatemalan Cohort

BackgroundAnecdotal evidence suggests that a high proportion of patients diagnosed with HIV in Guatemala present with AIDS. There remain limited data on the epidemiology of AIDS-defining illnesses (ADIs) in Central America.MethodsWe conducted a retrospective cohort study of all patients living with HIV at the largest HIV clinic in Guatemala. Charts were analyzed for clinical and demographic data. Presence of an ADI was assessed by US Centers for Disease Control definitions; patients who presented with an ADI were compared with those without ADI using descriptive statistics.ResultsOf 3686 patients living with HIV, 931 (25.3%) had an ADI at HIV diagnosis, 748 (80.3%) of whom had CD4 counts lower than 200 cells/mm3. Those with ADIs were more likely to be male (67.5% vs 54.6%; P < .0001) and heterosexual (89.4% vs 85.0%; P = .005). The most common ADIs were Mycobacterium tuberculosis (55.0%), Pneumocystis jirovecii pneumonia (13.7%), esophageal candidiasis (13.4%), and histoplasmosis (11.4%). Histoplasmosis and HIV wasting syndrome were both more common among rural patients.ConclusionsIn this large Guatemalan cohort of patients currently living with HIV, a significant portion presented with an ADI. These data inform the most common ADIs diagnosed among survivors, show that histoplasmosis is more commonly diagnosed in rural patients, and suggest that HIV wasting syndrome may reflect missed histoplasmosis diagnoses.

Design and structure of the Estonian HIV Cohort Study (E-HIV)

Background: Estonia is experiencing the new Eastern Europe human immunodeficiency virus (HIV) epidemic, with the highest incidence of new infections in the EU. We describe demographic changes, HIV-related laboratory parameters and co-infections during the concentrated HIV epidemic using the Estonian HIV Cohort Study (E-HIV) database, founded in 2009. Methods: All 3750 subjects in the E-HIV database on December 31, 2013 were included. Subjects were divided into risk groups: people who inject drugs (PWIDs), sexual transmission (heterosexual/homosexual), and other (perinatal) or unknown risk group. Subjects diagnosed before 2009 (first period) and after (second period) were analyzed separately. Results: The mean age at diagnosis has increased from 22.8 years (interquartile range (IQR) = 19.5–27.2) to 29.7 years (IQR = 25.3–36.2) (p < 0.001) between the first and second periods. PWIDs were younger than other transmission groups (23.2 vs 27.1; p < 0.001). There is a statistical difference in the route of transmission among genders, with overall increasing sexual transmission. The most common AIDS-defining illness was tuberculosis (0.5%). HIV/hepatitis C (HCV) co-infection was diagnosed in 42% of cases. The population median CD4 + cell count at diagnosis has declined over the years; in total 53% have been late presenters. Half of the patients are receiving antiretroviral treatment (cART). The most common combinations are nucleoside reverse transcriptase inhibitor (NRTI) backbone plus protease inhibitors (PIs) (57%) or NRTI backbone + non-NRTIs (42%). Conclusion: The E-HIV enables us to fill the gap in the lack of data on the course of the new Eastern European HIV epidemic. These data demonstrate that the HIV epidemic in Estonia is moving from PWIDs to the general population, suggesting that prevention measures and testing guidelines should be revised.

Risk factors for AIDS-defining illnesses among a population of poorly adherent people living with HIV/AIDS in Atlanta, Georgia

In order to achieve the programmatic goals established in the National HIV/AIDS Strategy, virologic suppression remains the most important outcome within the HIV care continuum for individuals receiving antiretroviral therapy (ART). Therefore, clinicians have dedicated substantial resources to improve adherence and clinic retention for individuals on ART; however, these efforts should be focused first on those most at risk of morbidity and mortality related to AIDS. Our study aimed to characterize the factors that are associated with AIDS-defining illnesses (ADIs) amongst people living with HIV (PLHIV) who are poorly adherent or retained in care in order to identify those at highest risk of poor clinical outcomes. We recruited 99 adult PLHIV with a history of poor adherence to ART, poor clinic attendance, or unsuppressed viral load (VL) from the Infectious Disease Program (IDP) of the Grady Health System in Atlanta, Georgia between January and May 2011 to participate in a survey investigating the acceptability of a financial incentive for improving adherence. Clinical outcomes including the number of ADI episodes in the last five years, VLs, and CD4 counts were abstracted from medical records. Associations between survey items and number of ADIs were performed using chi-square analysis. In our study, 36.4% of participants had ≥1 ADI in the last five years. The most common ADIs were Pneumocystis jirovecii pneumonia, recurrent bacterial pneumonia, and esophageal candidiasis. Age <42.5 years (OR 2.52, 95% CI = 1.08–5.86), male gender (OR 3.51, 95% CI = 1.08–11.34), CD4 nadir <200 cells/µL (OR 11.92, 95% CI = 1.51–94.15), unemployment (OR 3.54, 95% CI = 1.20–10.40), and travel time to clinic <30 minutes (OR 2.80, 95% CI = 1.20–6.52) were all significantly associated with a history of ≥1 ADI in the last five years. Awareness of factors associated with ADIs may help clinicians identify which poorly adherent PLHIV are at highest risk of HIV-related morbidity.

HIV-associated histoplasmosis early mortality and incidence trends: from neglect to priority.

BackgroundHistoplasmosis is an endemic fungal infection in French Guiana. It is the most common AIDS-defining illness and the leading cause of AIDS-related deaths. Diagnosis is difficult, but in the past 2 decades, it has improved in this French overseas territory which offers an interesting model of Amazonian pathogen ecology. The objectives of the present study were to describe the temporal trends of incidence and mortality indicators for HIV-associated histoplasmosis in French Guiana.MethodsA retrospective study was conducted to describe early mortality rates observed in persons diagnosed with incident cases of HIV-associated Histoplasma capsulatum var. capsulatum histoplasmosis admitted in one of the three main hospitals in French Guiana between 1992 and 2011. Early mortality was defined by death occurring within 30 days after antifungal treatment initiation. Data were collected on standardized case report forms and analysed using standard statistical methods.ResultsThere were 124 deaths (45.3%) and 46 early deaths (16.8%) among 274 patients. Three time periods of particular interest were identified: 1992–1997, 1998–2004 and 2005–2011. The two main temporal trends were: the proportion of early deaths among annual incident histoplasmosis cases significantly declined four fold (χ2, p<0.0001) and the number of annual incident histoplasmosis cases increased three fold between 1992–1997 and 1998–2004, and subsequently stabilized.ConclusionFrom an occasional exotic diagnosis, AIDS-related histoplasmosis became the top AIDS-defining event in French Guiana. This was accompanied by a spectacular decrease of early mortality related to histoplasmosis, consistent with North American reference center mortality rates. The present example testifies that rapid progress could be at reach if awareness increases and leads to clinical and laboratory capacity building in order to diagnose and treat this curable disease.

Liver Space Occupying Lesion in a Patient with Secondary Immunodeficiency

A 46-year-old female presented with significant weight loss and low grade fever of 2 months duration. She had cholecystectomy one year back. Ultrasonography abdomen revealed large mass in right lobe of liver. Complete blood count was and peripheral smear were normal. Her hepatitis B virus antigen (HBsAg) and antibody to hepatitis C virus (anti-HCV) were non-reactive. Human immunodeficiency virus (HIV) serology was positive. Subsequently, CT angiography of abdomen was done which revealed a large heterogenous mass of 7 cm × 5.8 cm in segment 4 and 5 of liver infiltrating gall-bladder fossa (Figure 1A & B). CA 19.9 and AFP were normal. Her CD 4 + counts was 43/μl and HIV RNA was 1,90,000/μl. Figure 1 A: Arterial phase of triphasic CT showing infiltrating lesion in segment 4 & 5. There is no enhancement in arterial phase. B: Venous phase of Triphasic CT showing infiltrating lesion in segment 4 & 5. There is no contrast uptake in venous ... Ultrasound guided biopsy from liver mass revealed non-Hodgkin’s Lymphoma (NHL), diffuse large B cell (Figure 2) and positive CD 20 staining (Figure 3). CT chest and bone marrow aspirate was done; both were normal. She was started on highly activated anti-retroviral therapy (HAART) i.e. tenofovir, emtricitabine and efavirenz along with R–CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone). Figure 2 Liver biopsy showing infiltration by atypical lymphoid cells (arrow). Figure 3 Strong immunopositivity of atypical lymphoid cells for B cell marker CD 20. (IHC × 400). NHL in acquired immunodeficiency syndrome (AIDS) is a late manifestation of disease, most often associated with CD4+ < 100, though can occur at any CD4+ count.1 Whereas secondary involvement of the liver by NHL is relatively common, involving liver in as many as 21% of advanced NHL cases, primary hepatic lymphoma is extremely rare. NHL associated with AIDS involves primarily extranodal sites, especially the digestive tract and the central nervous system. Primary hepatic lymphoma is an uncommon neoplasm among these patients.2 Lei et al proposed diagnostic criteria for PHL3 (i) the symptoms are mainly caused by liver involvement at presentation, (ii) distant lymphadenopathy is neither palpable clinically at presentation or detected during radiological staging studies and (iii) no leukemic blood picture is observed on the peripheral blood film. Diffuse large B cell lymphoma is the commonest histological type of PHL as was seen in this patient. Incidence of all AIDS-related lymphomas has declined since the use of HAART. Still with better control of opportunistic infections, PHL is a common AIDS-defining illness. There are many histologic types of primary hepatic lymphoma however diffuse large B cell lymphoma is most common type. Chemotherapy with RCHOP regimen is treatment of choice.4 PHL is an aggressive disease with poor response to therapy and survival.

Rupioid histoplasmosis: first case reported in an AIDS patient in Argentina

Disseminated histoplasmosis is a relatively common AIDS-defining illness, occurring in almost 4% of patients living in endemic areas and it may be the first clinical expression of the HIV infection. A broad spectrum of clinical skin lesions associated with Histoplasma capsulatum infection have been described in AIDS patients, such as erythematous macules, papules, nodules, and pustules. Herpetic, acneiform, erythema multiforme-like, molluscum contagiosum-like, vasculitic, and exfoliative forms have also been reported. To our knowledge, this is the first case of disseminated histoplasmosis in an AIDS patient presented as a rupioid eruption.

Cost‐Effectiveness of Serum Cryptococcal Antigen Screening to Prevent Deaths among HIV‐Infected Persons with a CD4+Cell Count ⩽100 Cells/μL Who Start HIV Therapy in Resource‐Limited Settings

Cryptococcal meningitis (CM) remains a common AIDS-defining illness in Africa and Asia. Subclinical cryptococcal antigenemia is frequently unmasked with antiretroviral therapy (ART). We sought to define the cost-effectiveness of serum cryptococcal antigen (CRAG) screening to identify persons with subclinical cryptococcosis and the efficacy of preemptive fluconazole therapy. There were 609 ART-naive adults with AIDS who started ART in Kampala, Uganda, and who had a serum CRAG prospectively measured during 2004-2006. The number needed to test and treat with a positive CRAG was assessed for > or = 30-month outcomes. In the overall cohort, 50 persons (8.2%) were serum CRAG positive when starting ART. Of 295 people with a CD4(+) cell count < or = 100 cells/microL and without prior CM, 26 (8.8%; 95% confidence interval [CI], 5.8%-12.6%) were CRAG positive, of whom 21 were promptly treated with fluconazole (200-400 mg) for 2-4 weeks. Clinical CM developed in 3 fluconazole-treated persons, and 30-month survival was 71% (95% CI, 48%-89%). In the 5 CRAG-positive persons with a CD4(+) cell count < or = 100 cells/microL treated with ART but not fluconazole, all died within 2 months of ART initiation. The number needed to test and treat with CRAG screening and fluconazole to prevent 1 CM case is 11.3 (95% CI, 7.9-17.1) at costs of $190 (95% CI, $132-$287). The number needed to test and treat to save 1 life is 15.9 (95% CI, 11.1-24.0) at costs of $266 (95% CI, $185-$402). The cost per disability-adjusted life year saved is $21 (95% CI, $15-$32). Integrating CRAG screening into HIV care, specifically targeting people with severe immunosuppression (CD4(+) cell count < or = 100 cells/microL) should be implemented in treatment programs in resource-limited settings. ART alone is insufficient treatment for CRAG-positive persons.

5. HIV AND WOMEN: THE AFRICAN EXPERIENCE

Africa as a continent has been devastated by the acquired immunodeficiency syndrome epidemic caused by the human immunodeficiency virus (HIV). Women are more likely to acquire HIV/AIDS for a number of reasons and incidence studies show that younger women are particularly at risk of HIV acquisition. Biologically, they are more vulnerable and the acquisition of HIV can be influenced by hormonal contraceptives as well as sexually transmitted infections, which are often more asymptomatic than is the case for men. Women in Africa are also more vulnerable because of cultural issues; in some countries polygamy is accepted practice. Women are often economically disadvantaged and disempowered. It is often hard for them to insist on the use of condoms with husbands and regular partners. Physical and sexual abuse of women, including rape, remains a major problem on the continent, particularly in times of civil war. Many women are forced to work as sex workers or be involved in transactional sex in order to survive. Most countries rely on anonymous antenatal surveys to generate HIV seroprevalence data for women of reproductive age. These data is often used as surrogate markers for HIV prevalence rates in men of a similar age. The seroprevalence of HIV among pregnant women differs remarkably around the continent, with the highest rates being seen in Southern Africa, as high as 30%, and much lower rates being seen in West Africa. These reasons underlying these differences are complex and not completely understood. UNAIDS estimated in 2005 that 470�000 (87%) of the world's 540�000 newly infected children (&lt;15 years old) reside in Sub-Saharan Africa. Prevention of mother to child transmission (PMTCT) of HIV is thus a national priority in many Sub-Saharan African countries. Despite policies, treatment is sometimes not given at the clinic level for several reasons, and when it is, most commonly it is with single dose Nevirapine. Data from South Africa has shown that both mothers and infected babies rapidly acquire nevirapine resistance. It is likely that this will lead to early failure of first line antiretroviral (ARV) therapy among these mothers once they start their ARVs. In South Africa, for example, either efavirenz or nevirapine form the backbone of the first-line ARV regimens. AIDS defining illnesses (ADIs) in women living in Africa are similar to those observed in men. Tuberculosis is the most common ADI but other life-threatening illnesses such as cryptococcal meningitis are relatively common compared to other parts of the world. Cervical cancer and cervical intra-epithelial neoplasia (CIN) lesions are more common in HIV-infected than in non-infected women. Most countries in Africa do not have cervical screening programmes and, even in richer countries such as South Africa, the national policy is to screen women three times in their life at 30, 40 and 50 years of age. Many HIV specialist centres, with additional donor funds, are now attempting to perform annual cervical screening, at least in South Africa.

Opportunistic Infections and Other AIDS-defining Illnesses in Poland in 2000–2002

The introduction of highly active antiretroviral therapy (HAART) led to a decreased incidence of the most severe opportunistic infections (OIs) in HIV-infected patients. In Poland, HAART became widely used in 1998. This study was based on data from medical records data collected in the years 2000-2002 from medical centers for HIV-infected patients in Poland. The aim of the study was to determine the incidence of opportunistic infections (OIs) and other AIDS defining illnesses (ADIs). The chi(2) test was used to determine any significant trends. The incidence of ADIs was 6.8, 6.5 and 4.8/100 persons/year in 2000-2002, respectively. The most common diagnosed OIs were: fungal infections, tuberculosis, recurrent pneumonia, PCP and toxoplasmosis. In patients receiving HAART (HAART+) the incidence of ADIs was significantly lower than in non-ARV-treated as well as in all HIV+ (p < 0.02, p < 0.001, p < 0.001, respectively). A significant decrease in the incidence of ADIs in HAART+ patients between 2000 and 2002 (p < 0.0001) was observed. From 25% to 30% of ADIs among HAART+ patients were diagnosed within the first 3 months of antiretroviral therapy. In HAART+ patients the most common ADIs were fungal infections and tuberculosis. The diagnosis of ADIs resulted in the recognition of HIV status in 8.7-8.9% of patients. Five years after the introduction of HAART the incidence of ADIs had declined. Fungal infections and tuberculosis were the most common OIs in HIV+ patients in Poland.

Changing spectrum of HIV infection and its associated conditions in Spain: the end of the beginning?

To evaluate the natural history and the impact that different strategies have had on HIV infection and its associated conditions, a cohort of 970 patients (432 had AIDS) who had been seen over a period of 13 years were studied. The incidence of new HIV-infected patients had increased steadily since 1985, peaking in 1993 (52.9 cases/100,000 population), to significantly decrease in the subsequent years. The most common AIDS-defining illnesses (ADIs) were tuberculosis (52.3% of the patients), Pneumocystis carinii pneumonia (30%), and candidal esophagitis (28.6%). The frequency of new cases of tuberculosis per patient with ADI clearly decreased over this period (p < 0.0001), whereas that of P. carinii pneumonia decreased slowly until 1994, to fall thereafter to about half the previous levels (p = 0.005). Candidal esophagitis showed a biphasic pattern, the second peak probably due to the emergence of fluconazole resistance. The number of ADIs per patient increased from the beginning of the observation period, peaking in 1995 (1.67 ADI/patient), followed by a statistically significant decrease that, in 1997, reached the 1987 levels (1.22 ADI/patient). We conclude that the clinical spectrum of HIV infection is improving in the last years. Except for tuberculosis, prophylaxis for other ADIs, although effective, does not seem to have had a dramatic impact on occurrence. The most impressive reductions have been observed only after the introduction of antiretroviral combination therapy.

AIDS in pregnancy among Indian tribal women

In February 1992 71 tribal women from Manipur India with AIDS matched for age parity CD4 lymphocyte counts and demographic characteristics were recruited into a prospective study. 32 women were 8-10 weeks pregnant while the remainder were not pregnant. Both groups were closely studied until February 1996. Pneumocystis carinii pneumonia followed by miliary tuberculosis and wasting disease were the most common AIDS-defining illnesses and causes of maternal death in both groups. 28 women died as a direct result of AIDS-defining illness 18 of whom were pregnant. Three of these 18 deaths occurred within 14 weeks of an uneventful first trimester medical termination of pregnancy; 13 died undelivered at 30-34 weeks gestation and two died within 3 weeks of delivery. 14 women delivered vaginally 14 preterm infants at 28-35 weeks gestation. 11 of these infants died within 6 weeks of which nine deaths were a direct result of prematurity and clinical diagnosis of AIDS-defining illness. The mean survival time was 9.72 months for the pregnant and 22.6 months for the nonpregnant mothers respectively. These study outcomes indicate that in AIDS-infected pregnant women pregnancy had a significantly adverse effect upon both maternal and obstetrical outcome. Also there was clinical and immunological deterioration with acceleration of material disease process resulting in a very high rate of prematurity maternal mortality and a significant decrease in survival time compared to nonpregnant women.

Epidemiology of pediatric Human Immunodeficiency Virus infection in the United States

Human Immunodeficiency Virus (HIV) infection is a growing problem for children worldwide. As of 31 December 1992, 4249 children with Acquired Immunodeficiency Syndrome (AIDS) under 13 years of age had been reported to the US Centers for Disease Control and Prevention (CDC). HIV is transmitted to children predominantly from their mothers. Nearly all cases of HIV infection acquired from blood transfusions in the United States occurred before donor-screening practices were implemented in March 1985. In 1991, approximately 7000 HIV-infected women gave birth to a liveborn infant in the United States, for a prevalence of 1.7 per 1000 women. Despite recent advances in prophylactic therapy for opportunistic infections, Pneumocystis carinii pneumonia remains the most common AIDS-defining illness in children in the United States. If these cases are to be prevented, children born to HIV-infected mothers will need to be identified early and monitored appropriately for CD4+ cell counts to determine the need for prophylaxis.