Off the Wires - May 2000
The majority of patients with serologic evidence of herpes simplex virus type 2 (HSV-2) infection have no symptoms. A prospective study of 53 subjects with antibodies to HSV-2 who reported no history of genital herpes (Wald A, Zeh J, Selke S, et al. N Engl J Med. 2000;342:844. Available at: http://www.nejm.org) attempted to determine whether they have less frequent viral reactivation than those with symptomatic infection. The researchers, led by Dr Wald of the University of Washington at Seattle, evaluated genital shedding of HSV-2 among the 53 subjects and compared it with the shedding patterns of 90 subjects with symptomatic infection. After the individuals with no reported history of herpes received counseling, 26 of the women and 7 of the men reported having ulcers or blisters typical of HSV-2 in the genital areas. The research also showed that the total rate of viral shedding was significantly greater among those with a history of genital herpes than among HSV-2-seropositive patients with no reported history of the disease. According to the authors, it is possible for asymptomatic subjects to transmit the virus to others, especially during an outbreak of shedding. Any patient with a history of HSV-2 or any asymptomatic person with the diagnosis should be aware of the risk of transmitting the virus to sexual partners or neonates. [CDC HIV/STD/TB Prevention News Update, Thursday, March 23, 2000]

HIV patients who experience 1 or more failing antiretroviral regimens are difficult to treat successfully, and physicians often must devise salvage regimens. According to Bruce Soloway and Gerald Friedland (AIDS Clinical Care. 2000;12[3]:23), when switching a patient's failing therapy, physicians should take into account that the success rates of salvage regimens are lower than those of initial therapies and that failure to follow a salvage regimen correctly could lead to additional resistance mutations that make the virus harder to treat. The success of an antiretroviral therapy depends not only on viral loads but also on the interactions of behavioral factors and their effects on adherence. Such viral factors as resistance to 1 or more medications must be treated carefully. It is essential to obtain a complete history of prior antiretroviral therapy from the patient. Adherence failure is the largest factor contributing to treatment failure. The causes of adherence failure, including supply of medications, depression, family crises, and other factors, must be addressed and discussed. The clinician's job is to assess the patient's need for therapy based on CD4 cell count and viral load. The patient's lifestyle, including any substance abuse, privacy needs, and mealtime schedules, must be taken into account. Other factors involved include the patient's commitment to the treatment and his or her relationship with the physician. [CDC HIV/STD/TB Prevention News Update, Monday, March 27, 2000]

An international study (Gordin F, Chaisson RE, Matts JP, et al. JAMA. 2000;283:1445. Available at: http://www. jama.com) compared a 2-month regimen of daily rifampin and pyrazinamide with a 12-month regimen of daily isoniazid to prevent tuberculosis (TB) in HIV-positive patients. Clinics in the United States, Mexico, Haiti, and Brazil recruited a total of 1583 HIV-positive persons aged 13 or older who tested positive for TB. The patients were divided into 2 groups, 1 for each regimen. After a follow-up of 37 months, the results showed that 80% of the rifampin-pyrazinamide group completed the treatment, compared with 69% of the isoniazid treatment group. The rates of TB among the 2 groups were similar, with 2.4% of the rifampin-pyrazinamide group and 3.3% of the isoniazid group developing confirmed disease at rates of 0.8 and 1.1 per 100 person-years, respectively. Overall, the study revealed that a 2-month course of daily rifampin and pyrazinamide is similar -- in terms of safety and efficacy -- to the 12-month isoniazid treatment for preventing TB in HIV patients. In both groups, adherence was high, and toxicity was low. The authors note that the shorter regimen is an effective alternative that has advantages for patients and for TB control efforts, especially in poorer areas with drug-resistant patients. The research was conducted for the Terry Beirn Community Programs for Clinical Research on AIDS, the Adult AIDS Clinical Trials Group, the Pan American Health Organization, and the Centers for Disease Control and Prevention Study Group. [CDC HIV/STD/TB Prevention News Update, Tuesday, March 28, 2000]

A recent study from Ohio State University (Diaz PT, King MA, Pacht ER, et al. Ann Intern Med Online. 2000;132: 369. Available at: http://www.acponline.org/journals/ annals) sought to evaluate the risk of emphysema in a group of HIV-positive patients who did not have AIDS-related pulmonary complications. One hundred fourteen HIV-infected individuals were compared with a group of 44 HIV-negative controls matched for smoking history and age. Previous studies have suggested that HIV-positive persons may develop lung problems more quickly than others, and smoking is a known factor contributing to emphysema. High-resolution CT of the chest was used to determine whether emphysema was present. Emphysema was detected in 17 (15%) of the 114 HIV-positive subjects versus only 1 (2%) of the HIV-negative controls. The researchers suggest that HIV infection directly accelerates the process of smoking-induced parenchymal lung damage. The authors also note that few of the patients received antiretroviral therapy, which was not widely available at the time. [CDC HIV/STD/TB Prevention News Update, Wednesday, March 29, 2000]

To determine the influence of viral load versus that of other risk factors for HIV transmission through heterosexual sex, researchers from the National Institute of Allergy and Infectious Diseases, Johns Hopkins University in Baltimore, Makerere University in Uganda, and Columbia University in New York (Quinn TC, Wawer MJ, Sewankambo N, et al. N Engl J Med. 2000;342:921. Available at: http://www.nejm.org) studied 415 couples in Uganda in whom 1 partner was HIV-1-positive and the other was initially HIV-1-negative. The couples were followed for 30 months, with 90 (22%) of the 415 initially HIV-negative partners seroconverting during the study. The incidence of seroconversion was greatest among partners aged 15 to 19. While the incidence was 16.7 per 100 per year among the 137 uncircumcised male partners, no seroconversions took place among the 50 male partners who were circumcised. The average serum HIV-1 RNA level was higher among the HIV-positive subjects whose partners seroconverted than among those whose partners did not seroconvert. There were no cases of HIV transmission among the 51 individuals with serum HIV-1 RNA levels under 1500 copies/mL. The study found a strong correlation between increased serum HIV-1 RNA levels and a greater risk of transmission of the virus. The researchers concluded that viral load is the primary predictor of the risk of heterosexual transmission of HIV-1 and that transmission is uncommon in individuals who have HIV-1 RNA levels that are below 1500 copies/mL. [CDC HIV/STD/TB Prevention News Update, Thursday, March 30, 2000]

An editorial by Marcia Angell, the editor of The New England Journal of Medicine (2000;342:967), raises the question of ethical research behavior in studies carried out in developing countries. The study in question, published by Thomas C. Quinn et al in the same issue of the journal, investigated HIV transmission, focusing on the relation between viral load and heterosexual transmission of HIV-1 in couples discordant for HIV-1 at baseline. The participants went 30 months without receiving treatment for known HIV infection, and the researchers did not inform the partner of an infected individual that his or her spouse had HIV. Quinn and colleagues said they told the seropositive participants to tell their partners; however, they did not follow up on this. The standards seen here would not take place in the United States or other developed countries. Dr Angell says she approved the study for publication, hoping to raise more discussions concerning ethical issues in HIV research. "I believe . . . that our ethical standards should not depend on where the research is performed," Angell notes. "I also believe that investigators assume broad responsibility for the welfare of the subjects they enroll in their studies." [CDC HIV/STD/ TB Prevention News Update, Thursday, March 30, 2000]

Many young people put their health at risk by getting pierced tongues or faces at the hands of inexperienced clerks (Brody JE. New York Times. Tuesday, April 4, 2000, p D8. Available at: http://www.nytimes. com). According to a recent issue of Emergency Medicine (Stewart C. 2000;32 [2]:92-98), allergic reactions, infection, scars, injury, or jewelry rejection can complicate body piercing. If sterilized instruments are not used, there is a risk of contracting hepatitis B virus or HIV from blood left on the tools. Nose piercing can cause staphylococcal infection, and tetanus is a risk for those not recently immunized. [CDC HIV/STD/ TB Prevention News Update, Tuesday, April 4, 2000]