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Objectives: The Saint-Antoine Orchestra Program aims at improving the clinical management of HIV-infected patients through access to care, prevention and early diagnosis of comorbidities., Methods: The program was initiated in December 2004 on the whole database. The following topics were concerned: cardiovascular risk factors, gynecological follow-up, anti-HBV vaccinal coverage, sexuality and prevention of STIs, therapeutic adherence and counsels to travelers. The program included several actions: diffusion of information to patients, development of a computerized chart (alert pop-ups), individualized prescription advice and recommendations for specialist referral., Results: The program was applied to 1959 patients whose initial characteristics were: mean age: 43+/-10 years; ratio M/W: 1466/493; European origin: 69%; sub-Saharan: 19%; mean duration of HIV infection: 9.3+/-6 years; naïve of antiretrovirals: 14%; mean CD4+count: 494+/-277/mm(3); HIV viral load inferior to 50 cp/ml: 62%. Among 1347 patients for whom cardiovascular risk factors were completely informed, 42% had two or more factors. In particular, 31% of them were smokers, 7% had an arterial pressure superior to 140/90 mmHg and 11% had LDL-cholesterolemia superior to 4.1 mmol/l. Among 1448 untreated patients, 70% were initially considered as adherent. Half of the concerned women had neither cervical smear nor mammography up to date. Among 67% patients with an informed complete HBV serology, 27% were seronegative among which 310 (86%) were eligible for the vaccine. Problems of sexual difficulties or prevention were initially discussed for 11% of patients. Among them, 14% had a problem of prevention and 148 (66%) recognized sexual difficulties., Conclusion: The initiation of the Saint-Antoine Orchestra program has provided a unique opportunity to assess and improve the prevention and management of comorbidities in HIV patients. Also, this program aimed to improve professional practices.

Since the Durban conference in 2000, the initiatives of access to antiretroviral therapy (ART) have expanded in sub-Saharan Africa. It is of high interest to monitor observance to HAART, in a context of increasing ART use, a rapid increase of patients under HAART, and the sociocultural specificities in Africa. In sub-Saharan Africa the concept of disease without cure does not exist and a disease always has or is attributed an external cause. Optimizing observance is a key element for the success of implementation programs for which we recommend a light monitoring to follow-up patients and the use of first line and effective antiretroviral drugs, with a low genetic barrier (efavirenz, nevirapine). The consequences of non-adherence are extremely negative for a patient in Africa, for whom we have few assessment tools and a limited number of ART. Improvement of adherence requires the involvement of all health care actors including traditional healers.

Objectives: The authors had for aim to assess incident HIV+ patients in Saint-Antoine hospital, Paris in 2002-2003 (transfers excluded)., Methods: Sociodemographic, clinical, and virological data were collected to compare French and sub-Saharan patients., Results: Three hundred new HIV+ patients were identified: mean age 36.2 year; ratio M/W 65/35; origin: Caucasian 43%, African 44%, Maghrebian 8%, Asian 3%; nationality: French 45%, sub-Saharan African 44%; illegal aliens 65%; employed 51%; transmission: heterosexual 54%, homosexual 39%, intravenous drug user (IVDU) 2%; circumstances for diagnosis: HIV exposure 34%, primary infection 9%, symptoms/AIDS 23%, pregnancy 6%, other 28%; CDC stage: A 77%, B 9%, C 14%; mean T-CD4+ 374/mm3, median HIV-RNA 30780 cp/mL; co-infection HBV 7.3% HCV 5%., Outcome: 88% still followed up in Saint-Antoine, 2% transferred, 9% lost to follow-up, 1% dead. A significant difference was shown: 1) between French (N = 123) and African (N = 46) men for heterosexual transmission (10 vs 91%), working status (85 vs 28%), T-CD4+ (354 vs 251/mm3), outcome (lost to follow-up 5 vs 24%) [P < 0.01]; 2) between French (N=13) and African (N = 85) women for age (41 vs 32 years), working status (38 vs 10%), stage A (54 vs 81%) [P < 0.05]; 3) between African patients according to sex (46M/85W) for age (39 vs 32 years), working status (28 vs 10%; P = 0.01), outcome (lost to follow-up 24 vs 6%) [P < 0.01]., Conclusion: This study highlights the persistence of HIV in native homosexual French men and the increasing prevalence in African migrant with precarious social status.

Objectives: To assess the use of microbiological examinations, notably serology, in the etiological diagnosis of pulmonary diseases in a department of infectious diseases., Methods: A retrospective study assessing the habits of microbiological examination prescriptions in pulmonary infections was carried out from 1/05/2000 to 31/10/2001. All patients admitted during this period for pulmonary infection diagnosis and treatment in the infectious diseases and tropical Unit of Saint Antoine Hospital (Paris), were included. The relevance of use of the following diagnostic procedures was assessed: cytobacteriological examination of sputum, specimens obtained on bronchoscopy, hemoculture, serology and search for Legionella urinary antigens. Factors having influenced the co-prescription of these microbiologic examinations were analysed., Results: The survey concerned 179 patients: 7 acute bronchitis, 25 acute exacerbations of chronic bronchitis and 147 community-acquired pneumonia. Microbiological diagnosis was obtained for 34 patients (17.4%), primarily on respiratory specimens. Serology was prescribed in 61 cases with a second serology in 23% (14/61). The principal factor predictive of bacterial serology prescription was the existence of interstitial opacity on chest radiography. Likewise, the search for Legionella urinary antigens was associated with the presence of interstitial opacity on the X-ray and of hyponatremia. However, it was only carried out in 37% of pneumonia with serious clinical presentation (25/67) and was followed by the prescription of combined antibiotics in 70% of the cases (40/57)., Conclusion: Assessment of the microbiology diagnostic methods of pulmonary infections showed the misuse of serology and insufficient prescription of the search for Legionella urinary antigens, recommended in the case of serious clinical signs.

Remarkable progress has been made in antiretroviral therapeutics, as well as in the prophylaxis and treatment of opportunistic infections, since the beginning of the AIDS epidemic. The patient's life expectancy and quality of life have consequently improved, thanks to better management of opportunistic diseases. The introduction of protease inhibitors-containing regimen (i.e. highly active antiretroviral therapy or HAART), since 1996, has drastically reduced the incidence of opportunistic infections by restoring immunity. The large panel of antiretroviral drugs responsible for frequent sustained viral and immune responses has thus allowed a new definition of guidelines for the prophylaxis and treatment of opportunistic infections. A better use of prophylactic drugs should help to reduce the risk of drug-related toxicity and pharmaceutical interactions. It should also decrease the cost of HIV management and eventually increase compliance to treatment and quality of life.

Remarkable progress has been made in antiretroviral therapeutics, as well as in the prophylaxis and treatment of opportunistic infections, since the beginning of the AIDS epidemic. The patient's life expectancy and quality of life have consequently improved, thanks to better management of opportunistic diseases. The introduction of protease inhibitors-containing regimen (i.e. Highly Active Antiretroviral Therapy or HAART), since 1996, has drastically reduced the incidence of opportunistic infections by restoring immunity. The large panel of antiretroviral drugs responsible for frequent sustained viral and immune responses has thus allowed a new definition of guidelines for the prophylaxis and treatment of opportunistic infections. A better use of prophylactic drugs should help reduce the risk of drug-related toxicity and pharmaceutical interactions. It should also decrease the cost of HIV management and eventually increase compliance to treatment and quality of life.

Unlabelled: The prevalence of squamous-cell carcinoma of the anus seems to be increasing in HIV positive patients. Clinical features and prognosis in this population have not been well evaluated., Aims: To assess the prognosis of anal squamous-cell carcinoma in HIV positive patients as well as clinical features and treatment procedures., Methods: A series of 20 HIV positive patients presenting with invasive anal squamous-cell carcinoma was retrospectively analyzed. Data have been compared to those obtained from 24 randomly selected HIV negative patients who were followed during the same periods in the same centers for anal carcinoma with similar histopathological features., Results: The follow-up ranged from 10 to 172 months. No difference was observed between the two groups concerning the clinical features leading to anal cancer diagnosis, although HIV positive patients were younger. Anal cancer was more frequently associated with lymph node metastasis in HIV positive (60%) than in HIV negative (17%) patients, although its size was similar in both groups. Radiotherapy was similarly performed in both groups, while chemotherapy was administered less frequently in HIV positive than in HIV negative patients (54% vs 25%). Immediate side effects and mortality at 1 year follow-up were similar in both groups, whereas the objective initial response to therapy (50% versus 88%), the remission rate with anal conservation at 1 year follow-up (45% versus 88%), and the mortality at 3 years were better in HIV negative patients., Conclusion: The prognosis of anal squamous-cell carcinoma is poor in HIV positive patients. This correlates with a more advanced tumor stage and an alteration of systemic immunity status at the time of diagnosis and less response rate to treatment. Detection of precancerous lesions and treatment procedures should be evaluated in HIV infected patients.

Objectives: Neurologic infections caused by cytomegalovirus are common in patients with acquired immunodeficiency syndrome (AIDS). The prognosis is particularly severe when the infection is localized in the conus medullaris and/or the cauda equina., Methods: Among the 861 patients with AIDS treated in our unit from 1991 to 1993, 7 cases involving cytomegalovirus infection of the conus medullaris and/or the cauda equina were studied retrospectively. RESULTS OF THE CASE REPORTS: Clinical manifestations were nearly always the same: low back pain, motor deficiency in the lower limbs progressing to flaccid paraplegia and sphincter failure. The cerebrospinal fluid contained a high cell count with unaltered polynuclears and increased protein levels. In 6/7 patients virus cultures and search for the viral genome in the cerebrospinal fluid were positive. The clinical course was favourable in 6 patients after 3 weeks treatment with ganciclovir and/or foscarnet. Virology tests became negative in three-fourths of the patients. Nevertheless, relapse occurred after 4.2 weeks despite long-term therapy., Conclusion: The severe clinical course of this disease and the gravity of constantly fatal relapse requires highly adapted treatment and overall health care.

Clinical management of HIV-infected asymptomatic individuals implies: creating trustful relationship with the practitioner including medical and non medical features such as adequate information and careful attention to emotional and social aspects; integrating, when indicated, the patient in a multidisciplinary approach; establishing a clinical and biological monitoring in order to initiate timely antiretroviral therapy and prophylaxis of opportunistic infections. The occurrence of minor symptoms and the determination of CD4 cell count have a key value in assessing the optimal time to initiate therapy in accordance to current recommendations.

The authors report a case of disseminated pulmonary histoplasmosis in an HIV positive patient who had travelled in countries where the disease was endemic. The principle clinical characteristics of the disease are reviewed including the radiology and the methods of treatment particularly in the forms occurring in this context. Finally the authors underline the difficulty in the differential diagnosis with tuberculosis.

Primary prophylaxis against opportunistic infections is a capital advance in the management of HIV-infected patients. In cases with pneumocystosis prophylaxis is recommended when the number of T4 cells reaches 200/mm3 or 15 to 20% and constitutes a major incitation to apply for detection of seropositivity. It can be predicted that other prophylaxis of this type will be available for other main opportunistic infections whose proportion is increasing due to extension of the patient's life expectation (e.g. toxoplasmosis). Research in this field relies on new drugs, on the use of older drugs, and above all on experimental models providing a good preclinical evaluation. The development of combined prophylactic treatments against several opportunistic infections is a priority target. Maintenance treatments are systematically given after a first opportunistic infection.

The diagnosis of Pneumocystis carinii pneumonia (PCP) rests on the isolation of this micro-organism in patients whose latest blood count, less than 2 months old, shows less than 250 CD4 lymphocytes per cubic mm and who present with signs of impaired lung function. Bronchoalveolar lavage (BAL) is the reference diagnostic method, but induced expectoration may be the initial examination, in which case BAL is performed only when the latter fails or gives negative results. Prognostic factors are those of any interstitial pneumonia plus those specific to PCP and those associated with HIV infection. It is only when no initial severity factor is present that cure can be contemplated, provided the effectiveness of treatment is evaluated daily. Cotrimoxazole is the reference drug for comparisons with all new treatments; the indications of corticosteroid therapy and the necessity of intensive care techniques are now better determined. The frequency of PCP and its mortality rate should be reduced, and one may look forward to a time when this disease will be rare and atypical, thereby raising other diagnostic and therapeutic problems.

There are now three methods to evaluate treatments of pneumocystosis: (1) the animal model, using adult rats under corticosteroids; the intensity of infection is assessed on pulmonary appositions and can then be evaluated after administration of a potential treatment compared with a reference; (2) the in vitro propagation of P. carinii observed from rat lung extracts cultured on cell lines; this method, however, is limited by the difficulties encountered in quantifying the parasitic types; (3) the inhibition by the drugs tested of enzymes involved in folate synthesis is a method that is still under evaluation. The animal model remains the reference method.

Prophylaxis against pneumonia due to Pneumocystis carinii is most often carried out using pentamidine administered as an aerosol. For reasons both of comfort and cost this technique should be developed at home or at least in an extra-hospital environment. Using the Respirgard II as the nebuliser of reference this requires a compressor. We have assessed four different compressors and compared these to pressurised oxygen used in a hospital environment. During the course of nebulisation with a pentamidine aerosol two physical factors may coincide to limit their efficacy. First the deposition of some of the particles on the walls of the apparatus and secondly the production of a particle size which is incompatible with alveolar deposition. This study showed that according to the source of compressed air: 1) the fraction of the pentamidine solution found in an aerosol at the mouthpiece varies from 29 to 62%; 2) the fraction of the aerosol whose particle size is suitable for alveolar deposition (1 to 3 microns) varies from 35 to 48%. The product of these two fractions enables an assessment of the efficiency of each apparatus: 14 to 24% of the pentamidine solution may be deposited at the alveolar level. In addition to this efficiency the duration of the session (from 25 to 50 minutes) for each machine should be taken into consideration when considering the choice of the compressor to be coupled with the Respirgard II in order to improve the comfort and therefore the compliance to the treatment.

In order to determine the extent of liver abnormalities occurring during acquired immunodeficiency syndrome, the available histological analyses of liver samples (32 biopsies, 52 autopsies) from 71 AIDS patients, for the period 1982-1986, were studied retrospectively. Hepatomegaly was the most common clinical symptom (23 patients, 32.4%), while jaundice was rare, being seen in only 5 cases (7%). Progressive anicteric cholestasis was the most frequently observed biological anomaly (29/52, 55.7%). Ten patients had liver infections: 2 Mycobacterium tuberculosis, 8 Mycobacterium avium intracellulare. Cytomegalovirus was present in 3 patients and 1 individual was infected with Cryptococcus neoformans. Granulomatous hepatitis was associated with these infectious agents in 11 patients, but remained unexplained in 11 others. Three patients had cholangitis (2 with CMV inclusions, 1 unexplained). Among the 32 biopsies, 5 elucidated the origin of unexplained fever. Kaposi's sarcoma of the liver was found in 10/52 autopsy samples (19%) and hepatic lymphoma in 2 cases. Non-specific histological lesions were common: inflammation of the portal spaces (48 cases, 67.6%), steatosis (32 patients, 45%), peliosis hepatis (9 cases, 12.6%) and sinusoidal dilations (39 cases, 54.9%).

AIDS-related Kaposi sarcoma is most often multicentric and extensive. Hepatic involvement is unusual and asymptomatic. An anicteric cholestasis may exist. Ultrasonography shows a pedicular echogenic infiltration and a heterogeneous parenchyma with small hyperechoic nodules. On CT, these hypodense lesions are related to the involvement of the hepatic pedicle. This is linked to angiosarcomatous tumorous tissue infiltration of the liver evolving along portal branches. In a patient suffering from cutaneous or digestive Kaposi sarcoma lesions, these radiological aspects are suggestive of hepatic involvement.

A case of AIDS due to HIV/LAV2 is reported. The patient was a 32 year old man from Guinea-Bissau with no known risk factors. He had brain toxoplasmosis, oral thrush and chronic genital herpes. Investigations for IgG anti-HIV/LAV1' (Elisa, Western Blot, Ripa) were negative. Antibodies to HIV/LAV2 were found and cultures of peripheral blood lymphocytes and cerebro-spinal fluid were positive. HIV/LAV2 seems to be similar to STLV-III (mac), STLV-III (agm), and probably HTLV-IV.

A case of P. aeruginosa septicaemia originating from a pace-maker electrode is described. Cure was obtained by surgical ablation of the contaminated electrode by a right thoracotomy and monotherapy with cefsulodin, an antibacterial agent. Nephrotoxicity was observed during treatment and regressed after its withdrawal. No other potentially nephrotoxic drug was used. The therapeutic indications of new beta-lactamase stable cephalosporins are reviewed.

Digestive manifestations of AIDS were studied retrospectively in 87 patients with respect to clinical, microbiological, endoscopic and histological data. Chronic or intermittent diarrhea was observed in 62 p. 100 of patients and frequently associated with major weight loss. The digestive opportunistic infections were: oesophageal candidiasis (42 p. 100), cryptosporidiosis (24 p. 100), cytomegalovirus infections (22 p. 100), isosporiasis (3.4 p. 100), atypical mycobacteriosis (2.2 p. 100), toxoplasmosis (2.2 p. 100). Thirty non-opportunistic agents were detected in 26 patients. Gastrointestinal Kaposi sarcoma occurred in 18 p. 100 of cases. The etiology of diarrhea remained unknown in 16 p. 100 of patients. The value of endoscopy is discussed: esophagogastroduodenal fibroscopy, is usually required to assess oesophageal candidiasis, colonoscopy is required to assess cytomegalovirus colitis on histological data.

The histopathological study of the digestive mucosae has a great diagnostic value. It appreciates lymphoid tissue; it may suggest AIDS when it discloses rare inflammatory or tumoral lesions; it may disclose an infectious and/or Kaposi sarcoma lesion which may be the first manifestation of AIDS in a seropositive LAV patient or may be an additional lesion in a patient known to have AIDS. The autopsies have shown the spread of the extension and the evolution of these lesions. The discussion of the histopathological lesions must always include the extra-digestive localisations as well as the "non opportunistic" associated infections.