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Introduction: Botswana's AIDS response included free antiretroviral treatment (ART) since 2002, achieving 80% coverage of persons with CD4<350 cells/µl by 2009-10. We explored impact on mortality and HIV prevalence, analyzing surveillance and civil registration data., Methods: Hospital natural cause admissions and deaths from the Health Statistics Unit (HSU) over 1990-2009, all-cause deaths from Midnight Bed Census (MNC) over 1990-2011, institutional and non-institutional deaths recorded in the Registry of Birth and Deaths (RBD) over 2003-2010, and antenatal sentinel surveillance (ANC) over 1992-2011 were compared to numbers of persons receiving ART. Mortality was adjusted for differential coverage and completeness of institutional and non-institutional deaths, and compared to WHO and UNAIDS Spectrum projections., Results: HSU deaths per 1000 admissions declined 49% in adults 15-64 years over 2003-2009. RBD mortality declined 44% (807 to 452/100,000 population in adults 15-64 years) over 2003-2010, similarly in males and females. Generally, death rates were higher in males; declines were greater and earlier in younger adults, and in females. In contrast, death rates in adults 65+, particularly females increased over 2003-2006. MNC all-age post-neonatal mortality declined 46% and 63% in primary and secondary level hospitals, over 2003-2011. We estimated RBD captured 80% of adult deaths over 2006-2011. Comparing empirical, completeness-adjusted deaths to Spectrum estimates, declines over 2003-2009 were similar overall (47% vs. 54%); however, Spectrum projected larger and earlier declines particularly in women. Following stabilization and modest decreases over 1998-2002, HIV prevalence in pregnant women 15-24 and 25-29-years declined by >50% and >30% through 2011, while continuing to increase in older women., Conclusions: Adult mortality in Botswana fell markedly as ART coverage increased. HIV prevalence declines may reflect ART-associated reductions in sexual transmission. Triangulation of surveillance system data offers a reasonable approach to evaluate impact of HIV/AIDS interventions, complementing cohort approaches that monitor individual-level health outcomes.

Introduction: Swaziland's severe HIV epidemic inspired an early national response since the late 1980s, and regular reporting of program outcomes since the onset of a national antiretroviral treatment (ART) program in 2004. We assessed effectiveness outcomes and mortality trends in relation to ART, HIV testing and counseling (HTC), tuberculosis (TB) and prevention of mother to child transmission (PMTCT)., Methods: Data triangulated include intervention coverage and outcomes according to program registries (2001-2010), hospital admissions and deaths disaggregated by age and sex (2001-2010) and population mortality estimates from the 1997 and 2007 censuses and the 2007 demographic and health survey., Results: By 2010, ART reached 70% of the estimated number of people living with HIV/AIDS with CD4<350/mm(3), with progressively improving patient retention and survival. As of 2010, 88% of health facilities providing antenatal care offered comprehensive PMTCT services. The HTC program recorded a halving in the proportion of adults tested who were HIV-infected; similarly HIV infection rates among HIV-exposed babies halved from 2007 to 2010. Case fatality rates among hospital patients diagnosed with HIV/AIDS started to decrease from 2005-6 in adults and especially in children, contrasting with stable case fatality for other causes including TB. All-cause child in-patient case fatality rates started to decrease from 2005-6. TB case notifications as well as rates of HIV/TB co-infection among notified TB patients continued a steady increase through 2010, while coverage of HIV testing and CPT for co-infected patients increased to above 80%., Conclusion: Against a background of high, but stable HIV prevalence and decreasing HIV incidence, we documented early evidence of a mortality decline associated with the expanded national HIV response since 2004. Attribution of impact to specific interventions (versus natural epidemic dynamics) will require additional data from future household surveys, and improved routine (program, surveillance, and hospital) data at district level.

Objective: An estimated 4.9 million adults received antiretroviral therapy (ART) in low and middle income countries in 2009. A further estimated 700 000 adults received ART in high-income countries. The impact of providing ART is not often quantifiable due to limited monitoring systems. One measure, life-years gained, provides a standardised measure that shows the survival impact of ART on the population while controlling for variations in underlying survival. Measuring life-years gained allows a comparison of the impact of ART between regions., Methods: Using the Spectrum computer package, two different scenarios were created for 151 countries. One scenario describes the results of providing adults with ART as reported by countries between 1995 and 2009, the second scenario describes a situation in which no ART was provided to adults living with HIV between 1995 and 2009. The difference in the number of life-years accrued among adults in the two scenarios is compared and summarised by geographical region., Results: An estimated 14.4 million life-years have been gained among adults globally between 1995 and 2009 as a result of ART. 54 % of these years were gained in western Europe and North America, where ART has been available for over 10 years. In recent years the growth in life-years has occurred more rapidly in sub-Saharan Africa and Asia., Discussion: The substantial impact of ART described here provides evidence to argue for continued support of sustainable ART programmes in low and middle-income countries. Strengthening ART monitoring systems and mortality surveillance in low and middle-income countries will make this evidence more accessible to programme managers.

Objective: HIV programs in generalized epidemics have traditionally relied on antenatal clinic (ANC) sentinel surveillance data to guide prevention and to model epidemic trends. ANC data, however, come from a subset of the population, and their representativeness of the population has been debated., Methods: Data from a national population-based Uganda HIV/AIDS Sero-Behavioral Survey (UHSBS) were compared with those from ANC sentinel surveillance. Using geographic information system, UHSBS clusters within a 30 km radius of the ANC sites were mapped. Estimates of HIV prevalence from ANC surveillance were compared with those from UHSBS., Results: The ANC-based HIV prevalence, 6.0% [confidence interval (CI) 5.5% to 6.5%], was similar to that from UHSBS, 5.9% (CI 5.4% to 6.4%). The ANC-based estimate correlated with that of UHSBS catchment area women who were pregnant and those who had given birth in the 2 years preceding the survey. ANC data overestimated prevalence in the 15-year to 19-year age group, were similar to UHSBS for ages 20-29 years, and underestimated prevalence in older respondents. ANC data underestimated HIV prevalence among women (6.0% vs. 7.4%; CI 6.6% to 8.2%) and urban women (7.6% vs. 12.7%) but was similar for rural women (5.3% vs. 4.9%)., Conclusions: ANC-based surveillance remains an important tool for monitoring HIV/AIDS programs. ANC and UHSBS data were similar overall and for 15-year to 29-year olds, women who were pregnant, and women who had a birth in the 2 years before the survey. ANC estimates were lower in those > or = 30 years and in urban areas. Periodic serosurveys to adjust ANC-based estimates are needed.

Objective: To ascertain predictors of survival in HIV-infected tuberculosis (TB) patients., Design: Retrospective cohort study., Setting: New York City public hospital., Patients: Fifty-four consecutive HIV-seropositive patients with newly diagnosed TB and no other AIDS-defining illnesses., Main Outcome Measures: CD4+ T-lymphocyte counts, completion of anti-TB therapy, repeat hospitalizations with TB, and survival., Results: Forty-five (84%) of the 54 patients died a median of 15 months after TB diagnosis (range, 1-80 months), five (9%) were alive after a median of 81 months (range, 75-84 months), and four (7%) were lost to follow-up after a median of 42 months (range, 30-66 months). In univariate analyses, disseminated TB, intrathoracic adenopathy, oral candidiasis and CD4 count depletion were each associated with decreased survival. In a multivariate analysis, CD4 count depletion was the only independent predictor of decreased survival. Repeat hospitalization with TB occurred in 10 out of 15 patients who did not complete anti-TB therapy compared with one out of 21 patients who completed anti-TB therapy (P < 0.001)., Conclusion: The clinical presentation of TB and CD4 count at TB diagnosis are each predictive of survival in HIV-seropositive TB patients. The CD4 count is the only independent predictor of survival.

Objective: Accurate estimates of HIV incidence that reflect the effect of non-vaccine interventions (education, counselling, condom promotion, and possibly sexually transmitted disease treatment) and that may be provided in a Phase III vaccine efficacy trial, are needed so that vaccine trial population sample sizes can be accurately determined. In order to avoid delays in the implementation of efficacy trials, well characterized cohorts must also be developed and available to participate in such trials. We reviewed the potential study populations, the epidemiologic methods for the determination of HIV incidence (using open cohort, closed cohort, and seroprevalence data methods), and the need for the development of population cohorts in preparation for Phase III HIV vaccine efficacy trials., Setting: Phase III trials in developed and developing countries., Methods: Comparison of open and closed cohorts and those using seroprevalence data to estimate HIV incidence., Results: Open and closed cohorts each have disadvantages and advantages. However, the open cohort may be more suitable for determining estimates of HIV incidence that reflect non-vaccine interventions and for the development of a well characterized cohort available to participate in efficacy trials., Conclusion: Careful preparation of research infrastructures and population cohorts will help ensure the successful conduct of scientifically and ethically sound HIV vaccine efficacy trials in the future.

Background: The occurrence of pulmonary tuberculosis in human immunodeficiency virus (HIV)-infected persons is believed to represent a less severe stage of HIV-related disease with a more favorable prognosis than other acquired immunodeficiency syndrome (AIDS)-defining conditions; therefore, it has been excluded from the AIDS definition established by the Centers for Disease Control (Atlanta, Ga) criteria., Methods: To determine the prognosis of patients with HIV-related tuberculosis, we assessed the clinical, immunologic, and HIV infection status of a cohort of male subjects aged 20 to 44 years who were hospitalized with tuberculosis but without AIDS in New York City hospitals from 1985 through 1986, and we determined their mortality through May 1991., Results: The 58 patients who agreed to participate were largely (90%) nonwhite and had a high prevalence of pulmonary tuberculosis (90%) and HIV infection (53%). Patients who were HIV seropositive had significantly lower CD4 cell counts (median, 0.136 x 10(9)/L; range, 0.013 x 10(9) to 2.314 x 10(9)/L vs median, 0.765 x 10(9)/L; range, 0.284 x 10(9) to 2.333 x 10(9)/L), and, during the follow-up period, an 83% mortality rate that was 7.5 times higher than the 11% rate in seronegative subjects. Survival analyses revealed that for all HIV-seropositive subjects the probability of death at 30 months was 72% and the median survival was 21 months (95% confidence interval, 15.5 to 26.5 months), while for HIV-seropositive subjects with CD4 cell counts of 0.2 x 10(9)/L or less, the probability of death at 30 months was 92% and the median survival was 15.75 months (95% confidence interval, 14.0 to 17.6 months)., Conclusion: The prognosis for patients with HIV-related pulmonary tuberculosis is poor, and those with CD4 cell counts of 0.2 x 10(9)/L or less have survival patterns similar to that of patients with AIDS. We believe that these data support the expansion of the AIDS case definition to include persons with both pulmonary tuberculosis and severe HIV-related immunosuppression.

We conducted a telephone survey of a probability sample of 473 internists, family practitioners, general practitioners, and obstetrician-gynecologists in New York City (NY) in 1988 to assess their knowledge, attitudes, and practices with respect to the prevention of the acquired immunodeficiency syndrome (AIDS). Although 71% of the physicians had cared for a patient with AIDS and 90% had been involved in ordering the human immunodeficiency virus antibody test, only about a third of them took appropriate sexual histories of new patients and only about a quarter (28%) counseled new patients about reducing the risk of contracting AIDS. Multivariate analysis revealed that physician knowledge about AIDS prevention was associated with younger age, more positive attitude toward homosexual males and intravenous drug users, confidence that counseling would result in behavioral change among patients, and specialty other than obstetrics-gynecology. Results indicate a need for increased training and education of primary care physicians about AIDS prevention.

Six months after receiving 58 units of blood components, a 65-year-old white man from New York City, with no other risk factors for human T-lymphotropic virus type I (HTLV-I) infection, developed HTLV-I-associated myelopathy/tropical spastic paraparesis (HAM/TSP). Investigation of blood donors identified a 25-year-old white Hispanic woman from Florida whose platelets had been given to the patient and who was seropositive for the virus on a serum specimen obtained 2 years after the donation. She was born in Cuba and had had 2 sexual relationships with men who either had been born in or had resided in the Caribbean. Polymerase chain reaction (PCR) studies of peripheral blood mononuclear cells indicated that both donor and recipient were infected with HTLV-I. Molecular studies of a 595-nucleotide sequence in the 5' envelope region of HTLV-I indicated that the viruses from donor and recipient were identical in each of 32 positions in which published HTLV-I sequences demonstrate molecular heterogeneity; the donor and recipient viruses were also identical in 2 additional positions in which they differed from all published sequences. Transfusion-associated HAM/TSP has occurred in the United States, but additional cases should be prevented by screening blood donations for HTLV-I. Molecular studies of HTLV-I may prove useful in defining the genetic heterogeneity of HTLV-I isolates in the United States and in studying transmission of this virus.

In a cohort of 5833 subjects in whom the acquired immunodeficiency syndrome (AIDS) was diagnosed in New York City before 1986, the cumulative probability of survival (mean +/- SE) was 48.8 +/- 0.7 percent at one year and 15.2 +/- 1.8 percent at five years. The group with the most favorable survival rate--white homosexual men 30 to 34 years old who presented with Kaposi's sarcoma only--had a one-year cumulative probability of survival of 80.5 percent; that group was used as the reference group in assessing the effect of five variables: sex, race or ethnic background, age, probable route of acquiring AIDS (risk group), and manifestations of AIDS at diagnosis. The range in the mortality rate was greater than threefold, depending on these variables. Black women who acquired the disease through intravenous drug abuse, for example, had a particularly poor prognosis. The manifestations of disease at diagnosis had the most influence on survival, accounting on average for 56.3 percent of the excess risk. This variable was followed in importance by age (12.2 percent), race or ethnicity (10.6 percent), risk group (8.4 percent), and sex (8.0 percent), with 4.5 percent of the risk attributable to interactions between variables. When we compared subcohorts based on the year of diagnosis (1981 through 1985), we found a significant improvement in the one-year cumulative probability of survival among subjects with Pneumocystis carinii pneumonia, but not among subjects without P. carinii pneumonia.

The autopsy rate was examined for patients dying of acquired immunodeficiency syndrome (AIDS) in New York City from 1982 through 1986 to determine if individuals dying of AIDS had autopsy rates that differed from the general population. Using data from death certificates, verified by hospital records, autopsy rates for various diseases and causes of death were examined in persons aged 25 to 44 years, which represents the age group with the majority of AIDS deaths. The hospital autopsy rate for those patients dying of AIDS dropped from 46% in 1982 to 17% in 1986, while the rate for non-AIDS autopsies went from 23% in 1982 to 15% in 1986. These declines have occurred despite the continued presence of a major epidemic in which the pathophysiology is still under active investigation. The low autopsy rate for patients with AIDS is of concern to both epidemiologists and clinical researchers: the autopsy is vital to a better understanding of the spectrum of human immunodeficiency virus infection.