Journal Reviews
Journal Reviews
Ridzon R, Gallagher K, Ciesielski C, et al. Simultaneous transmission of human immunodeficiency virus and hepatitis C virus from a needle-stick injury. N Engl J Med 1997; 336:919-922.
A Public Health Service interagency working group on the management of occupational exposure to HIV considered this unusual case in reviewing HIV seroconversion guidelines, but decided not to recommend routine HIV serologic follow-up beyond six months after exposure.
The authors documented an infection with both HIV and HCV that a health care worker acquired simultaneously from a single needlestick. The clinical course of the health care worker was remarkable for rapid progression to hepatic failure and death. The time to seroconversion, however, was unusually long for both viruses, thus raising the issue of whether the accepted six-month window for HIV should be extended. Seroconversion to HIV was detected with commercially available assays between 8 and 9.5 months after exposure, and seroconversion to HCV occurred between 9.5 and 13.5 months after exposure.
Because prolonged follow-up would only rarely detect a new infection and would unnecessarily prolong the anxiety of exposed health care workers, the six-month HIV window was left as the standard.
"In the case of simultaneous occupational exposure to HIV and HCV or in the event of clinical symptoms or signs of infection more than six months after exposure, evaluation for late seroconversion may be needed," the authors note.
There is evidence of pathogenic interaction between the two viruses that may help explain the case. The risk of maternal-fetal transmission of HCV, for example, may be increased in women who are also HIV-infected, perhaps because of an increased load of HCV. In HCV-infected patients with hemophilia, progressive liver disease was seen only in those also infected with HIV. In another study, the HCV load was higher in patients with HIV co-infection than in those with HCV infection alone. Another report suggested that HCV transmission may be more likely if the source patient has dual infection, the authors add.
Markowitz N, Hansen NI, Hopewell PC, et al. Incidence of tuberculosis in the United States among HIV-infected persons. Ann Intern Med 1997; 126:123-132.
Some 26% to 38% of the total number of tuberculosis cases in the United States in 1995 were co-infected with HIV, the authors estimate.
Approximately 800,000 to 1.2 million people in the United States are currently infected with HIV. Given the authors’ finding of 0.7 cases of TB per 100 person-years, 5,840 to 8,760 cases of tuberculosis annually would also be infected with HIV, they conclude.
"In addition, our findings suggest that the risk for tuberculosis is 50 to 200 times greater in HIV-infected persons than in the general population, depending on the subgroups examined," they report. "However, because many populations with a high incidence of HIV are independently at increased risk for tuberculosis, the specific contribution of HIV infection to this risk may be considerably lower."
To determine the incidence and predictors of TB in HIV-infected people, the authors conducted a prospective, multicenter cohort study of people with and without HIV infection at centers in the eastern, Midwestern, and western United States. Participants included 1130 HIV-seropositive patients without AIDS who were followed for a median of 53 months. Overall, 31 HIV-seropositive patients developed tuberculosis, allowing the authors to project a ratio of 0.7 cases per 100 person-years. Incidence of tuberculosis was higher in the eastern United States, in patients with CD4 counts of less than 200, and in PPD-positive patients.
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