Abstract

PIP: A landmark paper on autopsies of representative samples of HIV-1 and/or HIV-2-infected patients in Abidjan, Cote d'Ivoire, found disseminated tuberculosis (TB) as the chief cause of morbidity (wasting syndrome) and mortality. Another important finding was the high prevalence of cerebral toxoplasmosis in contrast to somewhat lower figures for East African AIDS patients. The authors argue that few HIV-infected patients in Africa survive long enough to develop the state of immunodeficiency that allows for the development of Pneumocystis carinii pneumonia. This is disputable, since Pneumocystis carinii pneumonia in industrialized countries is an early opportunistic event and was by far the most important AIDS-indicator diagnosis before the introduction of prophylaxis. Moreover, as judged by their CD4+ cell counts, the autopsied patients had a fairly advanced level of immunosuppression. 50% of the patients admitted to the medical wards in Abidjan were HIV-seropositive; in some East-African cities this figure nears 80%, with bed occupancy rates of nearly 200%. The authors point out that over 50% of the deaths were caused by potentially preventable infections. A recent study in Haiti has shown that a 12-month course of daily isoniazid effectively decreases the incidence of TB and delays the onset of HIV-related disease in symptom-free HIV-infected individuals. In another study in Zambia, daily isoniazid treatment of HIV-1-infected individuals without signs of active TB led to reduced mortality rates. Cotrimoxazole (trimethoprim-sulphamethoxazole) has been an effective prophylaxis against cerebral toxoplasmosis. Cotrimoxazole is also active against Pneumocystis carinii. Prophylaxis with a combination of these drugs in African HIV-infected patients may significantly increase survival. Based on the above studies, the Steering Committee on Clinical Research and Drug Development of the Global Programme on AIDS has given priority to studies on combined chemoprophylaxis with isoniazid and cotrimoxazole in African HIV-infected patients.