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This analysis investigated variability of survival time in a cohort of 553 human immunodeficiency virus type 1 (HIV-1)-infected homosexual or bisexual men with50 CD4+ cells/microL. Median survival after the first CD4+ cell count50/microL was 1.34 years; 25% survivedor = 2 years. Multivariate analysis showed longer survival with concurrent acyclovir and zidovudine use, hemoglobinor = 12 g/dL, and full-time employment (P.0001). Other significant covariates associated with longer survival included African-American race, no prior AIDS illness, weight loss4.5 kg, and zidovudine use (with or without concurrent acyclovir) after CD4+ cells fell to50/microL. An easily derived score identified Multicenter AIDS Cohort Study subjects likely to survive2 years after CD4+ cell count was50/microL. Survival once CD4+ cell count fell below 50/microL may be longer for persons with a good performance status and specific clinical markers. Health care providers should consider these variables in decision-making strategies and design of clinical trials.

PURPOSE To determine if the rates of malignancies other than Kaposi's sarcoma (KS) and non-Hodgkin's lymphoma (NHL) are increased in human immunodeficiency virus (HIV)-infected homosexual men. SUBJECTS AND METHODS From 1984 through 1993, 1,199 homosexual men were studied in the Pittsburgh component of the Multicenter AIDS Cohort Study (MACS), an examination of the natural history of HIV infection. The cohort consisted of 769 HIV-seronegative (SN) participants and 430 seropositive (SP) members who were either seroprevalent at the time of enrollment or who seroconverted during the study. Cancer incidence data were collected through semiannual visits, phone interviews, medical records, and death certificates. Five thousand seven hundred eight person-years and 2,344 person-years were contributed to the study by the SN and SP men, respectively. RESULTS In addition to 44 cases of KS, 13 NHLs, and 3 CNS lymphomas (CNSLs), 27 other malignancies occurred (three nonmelanoma skin cancers and eight other malignancies in the SP group, eight nonmelanoma skin cancers, and eight other malignancies in the SN group). Age-adjusted rates were calculated for both groups and compared with each other and with rates for the general male population in Pennsylvania. There were no differences between the SN group and the general population. Among the SP group, the combined frequency of all cancers other than KS, NHL, CNSL, and nonmelanoma skin cancers was statistically significantly increased in comparison to both the SN group and the general population. This increase was secondary to an unusually increased frequency of both seminoma and Hodgkin's disease. CONCLUSION These findings support the hypothesis that the incidences of cancers other than KS and lymphoma are moderately increased in the setting of HIV infection and immunosuppression.

Human immunodeficiency virus (HIV), the virus that causes acquired immune deficiency syndrome (AIDS), subverts the body's immune system. Infection is usually diagnosed through the enzyme-linked immunosorbent assay (ELISA) and the Western blot tests for antibody to HIV. Seroconversion from negative to positive for HIV antibodies usually occurs within several months after initial infection. However, in very rare cases there may be 12 months or more between infection and the development of antibodies (Wolinsky et al., 1989). HIV antibody testing has been controversial since these tests were developed in 1985. The controversy has centered around a number of issues, including the accuracy of the tests; their usefulness as a prevention tool; the widespread use of the tests with low-risk populations; the psychological impact of testing; use of the tests for insurance screening, employment, and admittance to school; the reporting of test results; and the decision whether to contact partners of people who test positive (Bayer, 1989; Siegel, Levine, Brooks, & Kern, 1989). One result of this controversy has been increased doubt among gay and bisexual men about the usefulness of these tests (Lyter, Valdiserri, Kingsley, Amoroso, & Rinaldo, 1987). Because of psychological problems and possible addiction relapse for intravenous drug users sometimes associated with learning test results, some health care providers have been reluctant to advocate for testing and have supported the decision of asymptomatic patients to not be tested (Cunningham, 1985). As a result, early in the AIDS epidemic many HIV-infected people were not tested for HIV antibodies and may continue to be unaware of their infectious state (Hull et al., 1988). This state of affairs appears to be a continuing problem. In October 1991, the Centers for Disease Control (CDC) found that a large proportion of people at risk for HIV infection had not been tested. The extent of this lack of compliance with public health recommendations is difficult to measure given that the people at highest risk--gay and bisexual men, intravenous drug users, and their sexual partners--cannot easily be counted and surveyed. However, the CDC reported that only about 17,000 HIV-infected gay and bisexual men were tested for HIV in 1990; hundreds of thousands of such men are believed to be infected, and thousands of men are newly infected each year (Staff, 1991). This reluctance to be tested has increasing clinical significance given that treatments to lessen the effects of opportunistic infections or to prevent the development of HIV-related symptoms or disease are being developed at an accelerated rate (Staff, 1987; Volberding et al., 1990). To take advantage of these new developments, people need to be tested, and if they test positive, need to seek treatment, even if they are asymptomatic. Studies on health care utilization, especially those on preventive services, suggest that higher educational levels, greater HIV-related knowledge, and higher socioeconomic status are positively related to the likelihood of seeking out and using preventive interventions (Aday, Anderson, & Fleming, 1980; Becker, 1974; Joseph, Montgomery, Emmons, Kessler, & Ostrow, 1987; Rachlin & Green, 1972, Slovic, Fischhoff, & Lichtenstein, 1987; Winkelstein & Graham, 1959). In a 1986 review of the literature over the previous 20 years, Mueller suggested that cultural factors may also be important in explaining the utilization of health care. Studies about the HIV antibody testing of gay and bisexual men have focused on the decision to be tested and on the decision to return and learn the results (Brendstrup & Schmidt, 1990; Foldspang, Melbye, & the Aarhus Research Group on AIDS, 1990; Kegeles, Catania, Coates, Pollack, & Lo, 1990). The reasons given for being tested and for returning for results reflect peoples' perceptions of the positive and negative implications they associate with HIV testing and results disclosure (Catania, Kegeles, & Coates, 1990; Fox, Odaka, Brookmeyer, & Polk, 1987; Lyter et al. …

Fifty-six gay and bisexual men were tested for antibody to the human immunodeficiency virus. Twenty-two subjects who tested positive, 22 subjects who tested negative, and 12 subjects who chose not to learn the test results were surveyed by questionnaire after one week and after about six months after testing. Subjects who tested positive and those who tested negative were also compared two weeks after learning results. Subjects who tested positive experienced an increase in anxiety, depression, and AIDS anxiety, and subjects who tested negative experienced a decrease in these feelings after learning results. Subjects who did not learn the results of their tests experienced no change in these feelings. All three groups altered their sexual behavior. Subjects were more likely to tell test results to lovers and to regular sexual partners than to casual sexual partners. Implications for social work practice are discussed.

Because of new preventive therapies, HIV-antibody testing of asymptomatic individuals now has clear clinical benefits. Consequently, greater numbers of individuals are expected to seek testing. This article, based on the authors' experiences with disclosing HIV-antibody test results to a high-risk group of men, makes recommendations for how best to present HIV-antibody results. Disclosing HIV-antibody results provides an educational opportunity as well as a psychological challenge for clinicians. Some unusual client reactions are detailed in the case studies.

The relative sexual transmission efficiency of hepatitis B virus (HBV) and human immunodeficiency virus type 1 (HIV-1) was investigated by a prospective study of homosexual men in Pittsburgh, Pa, from the Multicenter AIDS Cohort Study. During the 30-month follow-up, 19.8% and 7.8% of the initially seronegative HBV and HIV-1 groups were estimated to seroconvert to HBV and HIV-1, respectively. The significantly higher cumulative HBV seroconversion rate occurred despite a much lower prevalence of hepatitis B carriers (7% were hepatitis B surface antigen positive) compared with HIV-1 carriers (22% were HIV-1 antibody positive). The sexual exposure profile of HBV and HIV-1 seroconverters was similar during the 6 months prior to seroconversion, supporting the link between anal intercourse and acquisition of either infection. However, insertive, not receptive, anal intercourse was the major risk factor identified for HBV seroconversion, suggesting that transurethral exposure is an important mode of transmission. These data suggest that HBV is transmitted 8.6-fold more efficiently than HIV-1 among homosexual men studied and underscore the benefits of both HBV immunization and use of condoms during intercourse to prevent HBV infection.

Nine hundred fifty-five of 1,384 (69 per cent) gay and bisexual men enrolled in a prospective study of the natural history of human immunodeficiency virus (HIV) infection who reported engaging in anal intercourse in the past six months were surveyed about condom use practices for both insertive (IAI) and receptive anal intercourse (RAI). The following results were obtained: 23 per cent of the men reported that they always used condoms for IAI and 21 per cent for RAI; 32 per cent sometimes used condoms for IAI; 28 per cent sometimes used condoms for RAI; 45 per cent never used condoms for IAI; and 50 per cent never used condoms for RAI. Multiple logistic regression analysis revealed that the following variables were associated with both insertive and receptive condom use: condom acceptability; a history of multiple and/or anonymous partners in the past six months, and the number of partners with whom one is "high" (drugs/alcohol) during sex. Knowledge of positive HIV serostatus was more strongly associated with receptive than with insertive use. Condom use is a relatively complex health-related behavior, and condom promotion programs should not limit themselves to stressing the dangers of unprotected intercourse.

We studied 56 asymptomatic homosexual male volunteers in Pittsburgh for 1 1/2 yr for relationships between cytomegalovirus (CMV) and human T-lymphotropic virus type III (HTLV-III) infections. CMV was most frequently isolated from semen (8%) as compared with throat washings (5.9%) and urine (0%) on initial testing of CMV-seropositive subjects. Other viruses commonly isolated from immunosuppressed patients (herpes simplex virus, adenovirus) were rarely detected in this cohort. Seropositivity to HTLV-III was significantly associated with isolation of CMV from semen in our asymptomatic cohort (odds ratio = 9.5, p = .008). These results suggest that HTLV-III infection is associated with selective, temporal activation of CMV in the genital tract of asymptomatic homosexual men.

Thirteen homosexual men, volunteers in a study of the natural history of HIV, who seroconverted to HIV after participating in an educational program on HIV prevention, were interviewed about the circumstances leading to their seroconversion. Six men had participated in unprotected anal intercourse with at least one partner whom they believed was HIV-negative. Four men attributed their conversion to mental health problems or to drug and alcohol use. Two men's seroconversions could not be ascertained and one man attributed seroconversion to a condom break. Most men who had learned how to avoid infection, and had successfully done so for a time, had knowingly engaged in unsafe behaviors because of strong emotional responses to certain partners or because of mental health or drug and alcohol-related problems. Skills training for dealing with partners who pressure men to behave unsafely is needed, as is mental health and drug and alcohol counseling for men at risk for HIV infection.

Human immunodeficiency virus (HIV) p24 antigenemia was assessed in a longitudinal study of 52 homosexual men who developed serum antibody to HIV. Antibody seroconversion to HIV as defined by a positive HIV enzyme immunoassay (EIA) confirmed by Western (immuno-) blot was associated with three major patterns of HIV antigenemia. In the first pattern, a transient antigenemia was noted 6 (six subjects) and 12 (one subject) months prior to detection of antibody by HIV EIA and Western blot in 7 (13.5%) of the 52 men. Use of an EIA employing a recombinant envelope protein (ENV9) was able to detect antibody in four of these seven men at the time of this early antigenemia. In the second pattern, HIV p24 antigenemia occurred in 8 (15.4%) of the 52 subjects within the first 12 months after HIV antibody seroconversion. No p24 antigen was detected in the 37 (71.1%) remaining subjects. CD4+ cell numbers were lower in antigen-positive men before and after antibody seroconversion. Development of acquired immunodeficiency syndrome (AIDS) or AIDS-related complex was strongly associated with evidence of persistent p24 antigenemia during the early, postseroconversion period. HIV p24 antigenemia may be of value in determining appropriate cohorts for drug therapy trials for subjects with early-phase HIV infection.

Homosexual men were studied for associations among human T-lymphotropic virus type III (HTLV-III) infection, Epstein-Barr virus (EBV) infection, and T cell abnormalities. The presence of IgG antibody to EBV capsid antigen and antibody to EBV early antigen was significantly associated with augmented counts of suppressor T cells in healthy HTLV-III-seronegative men. HTLV-III-seropositive asymptomatic subjects had significantly enhanced titers of antibody to EBV and lower ratios of helper to suppressor T cells compared with HTLV-III-seronegative homosexual men. Of three men who seroconverted to HTLV-III, two had a greater than fourfold increase in titer of IgG antibody to EBV capsid antigen after seroconversion. These results suggest that the interaction of HTLV-III and EBV and their immunologic perturbations are significant in the natural history of this retrovirus infection in homosexual men.

Previously defined "risk factors" in homosexuals with Kaposi's sarcoma may not be causative of AIDS (acquired immune deficiency syndrome) but are an important tool in identifying segments of the homosexual population who are at increased risk for the development of AIDS and who may benefit from health education and surveillance efforts. The epidemiologic characteristics of such a group of homosexuals from a low incidence area (Pittsburgh, PA) are examined and several factors which may account for differences in incidence are briefly discussed.

As a result of the AIDS (Acquired Immune Deficiency Syndrome) epidemic, many community health agencies are faced with the task of planning and implementing programs to prevent or reduce the risks of HIV (Human Immunodeficiency Virus) infection. Furthermore, the urgency of AIDS will force community groups to develop prevention programs prior to an analysis of substantial data relating to intervention efficacy. By using the five criteria for the development of health promotion and education programs enumerated by the American Public Health Association, planners can benefit from the experience of past health promotion initiatives, and insure a comprehensive approach to planning. The authors describe, using specific examples, how these criteria were used to develop and implement an AIDS risk reduction program for gay and bisexual men.

Four hundred sixty-four homosexual and bisexual men, recruited from a cohort of 1,700 men enrolled in a study of the natural history of acquired immunodeficiency syndrome (AIDS), participated in a peer-led, small-group educational session promoting AIDS risk reduction. Although levels of knowledge about AIDS and human Immunodeficiency virus (HIV) transmission were uniformly high prior to intervention, at least 60% of the men reported having engaged in unprotected, receptive anal intercourse with more than one partner in the preceding six months. Prior to intervention, a substantial number of the men had mixed feelings about AIDS risk reduction or endorsed negative attitudes about AIDS risk reduction. After attending the session, attitudes improved significantly in five of the six areas surveyed.

We investigated the association between human immunodeficiency virus (HIV) and Epstein-Barr virus (EBV) infections in 593 homosexual men. The status of EBV infection in this group was evaluated based on serological evidence of EBV-specific antibody responses. The geometric mean titers (GMT) of antibody to EBV capsid antigen (EBV-VCA) (1:154) and EBV early antigen (EA) (1:16) in 141 HIV-seropositive men were significantly higher than respective titers in 452 HIV seronegative men (1:95 and 1:12). Antibody titers to EBV were higher in HIV-infected men with lymphadenopathy than in asymptomatic HIV-seropositive men. However, these correlation were less evident in patients with AIDS-related complex. Elevated antibody titers to EBV were found to be independent of levels of total serum IgG. Cytomegalovirus (CMV) antibody titers were also found to be significantly increased among HIV-seropositive men, independent of total IgG. Antibody titers to EBV were not correlated with those to CMV in either HIV-seronegative or HIV-seropositive men. Subjects without evidence of HIV infection, but who had high antibody titers to EBV-VCA and EBV-EA, had elevated mean numbers of CD3+, CD4+, and CD8+ cells, and lower levels of CD4+/CD8+ cell ratios compared to subjects with low EBV-antibody titers. This study suggests that the elevated levels of circulating antibodies against EBV in homosexual men are associated with loss of control of latent EBV due to HIV infection.

We conducted a study to assess the effect of human immunodeficiency virus (HIV) infection on humoral immunity. Fifty-five homosexual men and 19 heterosexual men had four- to six-week postimmunization antibody responses measured to trivalent influenza vaccine and 23-valent pneumococcal vaccine. The homosexual men were divided into three groups: 20 asymptomatic HIV-seronegative men, 10 asymptomatic HIV-seropositive men, and 25 HIV-seropositive men with persistent generalized lymphadenopathy. Antibody responses to influenza antigens in the subgroups of homosexual men did not significantly differ from those of heterosexual controls. The IgG antibody responses to pneumococcal capsular types 9N and 18C in men with lymphadenopathy, and type 18C in HIV-seronegative homosexual men, were lower than those of heterosexual controls. Otherwise, responses to other ten capsular types showed no significant differences. There was no evidence of an immunosuppressive effect of vaccination on T-cell numbers, or deterioration of clinical status associated with vaccination. This study demonstrates that HIV-infected homosexual men, asymptomatic or with persistent generalized lymphadenopathy, are able to mount appropriate antibody responses to two commonly used vaccines. ( JAMA 1987;257:2047-2050)