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Human immunodeficiency virus type 1 (HIV-1) is transmitted mainly by cell-to-cell contact. We postulated that transmission of HIV-1 through breastmilk could be favoured by the presence of infected cells, by deficiency of anti-infective substances in breastmilk, or both factors. 215 HIV-1-infected women were enrolled at delivery in Kigali, Rwanda; milk samples were collected 15 days, 6 months, and 18 months post partum. HIV-1 IgG, secretory IgA, and IgM were assayed by western blot, for the latter two after removal of IgG with protein G. In the 15-day and 6-month samples, we sought viral genome in milk cells by a double polymerase chain reaction with three sets of primers (gag, pol, and env). HIV-1 infection in the offspring was defined according to serological and clinical criteria. At 15 days, 6 months, and 18 months post partum, HIV-1 specific IgG was detected in 95%, 98%, and 97% of breastmilk samples, IgA in 23%, 28%, and 41%, and IgM in 66%, 78%, and 41%. In children who survived longer than 18 months, the probability of infection was associated with lack of persistence of IgM and IgA in their mothers' milk (adjusted chi 2 for trend, p = 0.01 for IgM and p = 0.05 for IgA). The presence of HIV-1-infected cells in the milk 15 days post partum was strongly predictive of HIV-1 infection in the child, by both univariate (p0.05) and multivariate analysis (p = 0.01). The combination of HIV-1-infected cells in breastmilk and a defective IgM response was the strongest predictor of infection. HIV-1 infection in breastfed children born to infected mothers is associated with the presence of integrated viral DNA in the mothers' milk cells. IgM and IgA anti-HIV-1 in breastmilk may protect against postnatal transmission of the virus.

The ability of rural health personnel to recognise AIDS related symptoms and signs according to the WHO clinical case definition (CCD) and its modified Rwandan version was tested in 4141 clinically suspected cases in South-Rwanda. The sensitivities of these CCDs for AIDS in adults were 33% (36%), the specificities 78% (76%), and the positive predictive values (ppv) 46%. For AIDS in children the sensitivities of the CCDs were 13% (16%), the specificities 94% (90%), and the ppv 44% (38%). While the specificities did not differ from those found in studies conducted by trained physicians, the low sensitivities and predictive values demand improvement of the training of the health personnel to diagnose AIDS related symptoms and signs, especially where laboratory tests are not available.In order to test the ability of health care workers in rural Rwanda to recognize the signs and symptoms of AIDS according to the World Health Organization clinical case definition (CCD) and to the slightly modified Rwandan version, serum samples and completed questionnaires were collected from all 4141 clinically-suspected cases of AIDS from 62 rural health centers and hospitals in Butare province during 1991. Of the 3669 patients older than 12 years, 964 met the CCD for adults, and 444 were seropositive. 1040 met the modified Rwandan version of the CCD, and 482 were seropositive. Of the 472 children, 35 met the CCD for children, with 16 seropositive. 53 met the Rwandan CCD, and 20 of these were seropositive. Sensitivities of the CCD and the Rwandan CCD, respectively, were 33 and 36% in adults and 13 and 16% in children. The respective specificities were 78 and 76% in adults and 94 and 90% in children. The positive predictive values were, therefore, 46% in adults and 44 and 38%, respectively, in children. These low sensitivity and positive predictive values will result in many cases of AIDS going undiagnosed. Whereas no single symptom had a sensitivity and specificity high enough to be used for diagnoses, an episode of herpes zoster is highly indicative of AIDS. Since this diagnosis is unequivocal, this strong association may prove useful in the diagnosis of AIDS. Because laboratory tests will remain unavailable in certain settings, health personnel must receive proper training to improve their ability to diagnose AIDS following the clinical case definition.