Norway's policy on targeting AIDS prevention

Norway's policy on targeting AIDS prevention

THE LANCET IOP in normal eyes, because the nitrovasodilators act pharmacologically to mimic the action of NO, which is known to regulate resistance i...

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THE LANCET

IOP in normal eyes, because the nitrovasodilators act pharmacologically to mimic the action of NO, which is known to regulate resistance in systemic blood vessels.5 Thus, NO synthesis might play a part in regulating resistance in the human outflow pathway. The same mechanism as that for nitroglycerine also applies to 17-␤-oestradiol. As a consequence of the action of oestradiol, there is an increase of the endothelium-based constitutive type-3 nitric oxide synthase, also in the regulatory systems of the eye that are responsible for IOP. These findings suggest a physiological role for NO in outflow resistance and that hormonal manipulation of the NO system might influence outflow facility in normal eyes affected by glaucoma.

Our results show that 60% of healthy elderly people are unprotected against tetanus. For two thirds of them, vaccination had not been done at all or not in the past 10 years. Another third were vaccinated according to official vaccination strategies, but were still unprotected. Tetanus immunisation recommendations in many parts of Europe do not guarantee full protection in the elderly. Revaccinations at shorter intervals, possibly combined with antibody determinations, should be considered.

*Michael O Sator, Doris M Gruber, Elmar A Joura

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*Maria M Steger, Christian Maczek, Peter Berger, Beatrix Grubeck-Loebenstein Institute for Biomedical Aging Research of the Austrian Academy of Sciences, Rennweg 10, 6020 Innsbruck, Austria

Department of Obstetrics and Gynecology, Division of Endocrinology and Sterility Treatment, University of Vienna, A-1090 Wien, Austria

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Grierson I. Glaucoma and nitric oxide. Lancet 1996; 347: 1781–82. Imre J. Die regulatorische Wirkung der endokrinen Drüsen auf den intraokulären Druck. Arch Augenheil 1921; 88: 155–57. Ziai N, Ory SJ, Khan AR, Brubaker RF. Beta-human chorionic gonadotropin, progesterone, and aqueous dynamics during pregnancy. Arch Ophthalmol 1994; 112: 801–06. Gharagozloo NZ, Brubaker RF. The correlation between serum progesterone and aqueous dynamics during the menstrual cycle. Acta Ophthalmol Copenh 1991; 69: 791–95. Yasumasa G, Yasuyuki A, Hiromu K. Characterization of ciliary muscle relaxation induced by various agents in cats. Invest Ophthalmol Vis Sci 1993; 36: 1188–91.

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Gergen PJ, McQuillan GM, Kiely M, Ezzati-Rize TM, Sutter RW, Viralla G. A population-based serologic survey of immunity to tetanus in the United States. New Engl J Med 1995; 32: 761–66. Lighthart GJ, Corberand JX, Fournier C, et al. Admission criteria for immunogerontological studies in man: The Senieur protocol. Mech Ageing Dev 1984; 28: 47–55. Reibnegger G, Huber LA, Jürgens G, et al. Approach to define ‘normal aging’ in man. Immune function, serum lipids, lipoproteins and neopterin levels. Mech Ageing Dev 1988; 46: 67–82. Berger P, Panmoung W, Khaschabi D, Mayregger B, Wick G. Antigenic features of human follicle stimulating hormone delineated by monoclonal antibodies and construction of an immunoradiomometric assay. Endocrinology 1988; 123: 2351–59. Grubeck-Loebenstein B, Trieb K, Sztankay A, Holter W, Andrel H, Wick G. Retrobulbar T cells from patients with Graves’ ophthalmopathy are CD8+ and specifically recognize autologous fibroblasts. J Clin Invest 1994; 93: 2738–43.

Vaccination against tetanus in the elderly: do recommended vaccination strategies give sufficient protection?

Norway’s policy on targeting AIDS prevention

SIR—There is little information on immunisation status in the elderly, even against tetanus, against which vaccines have been available for decades. Although a study in the USA suggests that many Americans do not have immunity to tetanus and that rates are lowest among the elderly,1 no similar studies have been done in Europe. As in the UK and in Germany, Austrian health authorities recommend booster injections with tetanus toxoid (TT) every 10 years after initial immunisation in order to assure continuous protection. We recruited two groups, one of young (<30 years; n=25) and one of old (>65 years; n=32) healthy volunteers, selected according to criteria of the SENIEUR protocol for immunogerontological studies of the European Community’s Concerted Action Program on Aging.2,3 Tetanus-specific antibodies were measured in a solid-phase-bound TT (Swiss Serum and Vaccine Institute, Berne, Switzerland) one-site indirect ELISA.4 Antibody titres were given as relative units/mL (U/mL). Values within the triple standard deviation of antibody concentrations in unvaccinated individuals were classified as negative (<10 U/mL). In-vitro proliferation of peripheral blood mononuclear cells (PBMC) after stimulation with TT (1 µg/mL) was assessed by 3H-thymidine incorporation.5 50% of the elderly participants had been vaccinated against tetanus within the past 10 years; 38% of them did not have tetanus-specific antibodies. 28% had been vaccinated against tetanus more than 10 years ago; only three individuals had specific antibodies. PBMC of antibodynegative persons could not be induced to proliferate when stimulated with TT, while proliferation was observed in all antibody-positive participants. 92% of the young participants had tetanus-specific antibodies and their PBMC proliferated on stimulation with TT. Only two in whom vaccination dated back more than 10 years were not protected.

SIR—News reports in The Lancet of July 20 and 27 and Aug 171–3 have covered the debate in Norway on HIV prevention among Africans living in this country. The focus of this discussion is that I, as Director General of Health, have pointed out that HIV is more prevalent in countries in subSaharan Africa than it is in the general population in Norway. Although this was a statement of fact and not an act of discrimination, the ensuing public discussion has tended to focus on potential discrimination rather than on efforts to prevent HIV infection. Norwegian HIV prevention rests on providing factual information to the general public and on interventions targeting vulnerable groups. Messages designed to reach everybody will have a very general character, and those at highest risk stand to lose most if authorities, for fear of being charged with stigmatisation, choose only this strategy. Organisations representing Africans in Norway maintain that one should not talk about “risk groups” but only about “risk behaviour”. There is no disagreement that risk is determined by behaviour. The level of infection in groups where sexual or drug-injecting partners are found will, however, determine the degree of risk attached to unprotected sexual intercourse or needlesharing. Health authorities in Norway, and other countries, cannot avoid the fact that focusing on the vulnerability and level of infection in some groups or communities may lead to increased risk of stigmatisation and discrimination. The Norwegian experience has, however, so far been that the focus on and subsequent collaboration with and activities by other vulnerable groups such as gay men and injecting drug users have led to reduced risk behaviour and increased respect for these groups. In all groups at risk there will be many individuals who never practise the risk behaviour, and this is true for Africans in Norway as elsewhere. Understandably, some people feel

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THE LANCET

strongly that attention is focussed unfairly on their colour and nationality rather than on their actual behaviour. Targeting of messages must, however, build on identification of groups; if a group cannot be defined or described, then targeting is not possible and prevention activities will be less effective. The Board of Health is also, for example, targeting Norwegians who will live for a time in sub-Saharan Africa because members of this group may practise risk behaviour in a risk situation. Your July 20 report1 states that Norway may make HIV antibody testing compulsory for refugees, asylum seekers, and immigrants. We were very surprised to read this, as the Norwegian health authorities have, in national and in international fora, strongly maintained that there is no public health rationale for compulsory testing. We oppose any compulsory testing of migrants, travellers, and other groups. We do, however, maintain that individuals, Norwegians and foreigners alike, can benefit from testing if they have practised risk behaviour in a risk situation. Anne Alvik Norwegian Board of Health, PO Box 8128 DEP, N-0032 Oslo, Norway

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Awounda M. Norwegian health chief angers Africans. Lancet 1996; 348: 190. Awounda M. Norway’s race-relations row simmers on. Lancet 1996; 348: 261. Awounda M. Norway’s racism row simmers on. Lancet 1996; 348: 470.

Red fingers syndrome in HIV patients SIR—Pechère and colleagues (July 20, p 197)1 record erythema of fingers and toes with multiple periungual telangiectasia in nine HIV-infected patients. They report that all the patients had abused intravenous drugs or alcohol and that, importantly, all had antibodies to hepatitis C virus (HCV). The vascular reaction leading to the red fingers might be due to an association of HIV infection with liver disease caused by hepatitis viruses, especially HCV. We, too, have seen nine HIV-positive patients with periungual erythema of the proximal nail fold.2 Redness of the fingers and toes was restricted to the distal parts (figure) and the lesions were painless. Smith and colleagues3 have reported erythematous acral lesions with periungual and palmar affections. Four of our nine patients had antibodies against HCV, and all four positive for HCV were addicted to drugs. Two patients had no antibodies and another was positive for cryoglobulins while HCV antibodies were repeatedly absent.

Figure: Periungual erythema of the proximal nail fold in an HIVinfected patient

Vol 348 • September 14, 1996

Two other patients had normal liver enzymes and no signs of chronic liver disease. Thus, although erythema of the proximal nailfold in HIVpositive patients may be associated with chronic HCV infection, this dermatological condition may occur without underlying chronic disease other than HIV. *Manuel Battegay, Peter H Itin *Outpatient Department of Internal Medicine, and Department of Dermatology, University Hospital, 4031 Basel, Switzerland

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Pechère M, Krischer J, Rosay A, et al. Red fingers syndrome in patients with HIV and hepatitis C infection. Lancet 1996; 348: 196–97. Itin PH, Gilli L, Nüesch R, et al. Erythema of the proximal nailfold in HIV-infected patients. J Am Acad Dermatol (in press). Smith KJ, Skelton HG, Yaeger J, et al. Clinical features of inflammatory dermatoses in human immunodeficiency virus type 1 disease and their relation with Walter Reed stage. J Am Acad Dermatol 1993; 28: 167–73.

Transmission of HIV infection from mother to child SIR—Duke and Kovar (July 27)1 argue for the paediatrician as the child’s advocate. However, in their example of the possible use of compulsory zidovudine in HIV-infected pregnant women they have omitted one important piece of the jigsaw. The use of zidovudine for HIV-infected women and their newborn babies has been shown to reduce the risk of maternal-infant transmission of HIV by 67%.2 Any intervention that can decrease the risks of transmission of HIV infection is an important advance. However, the US trial was not designed to assess fetal toxicity. Short-term toxicity was mild, but only 239 women were randomised to the zidovudine arm of the study, which has as yet been unable to report on long-term toxicity of in-utero exposure to a nucleoside analogue that acts on viral DNA synthesis. In Europe the rate of transmission from HIV-infected mother to child has been estimated at 13–20%.3,4 This is much lower than the rate of 25% found in the placebo arm of the US trial of zidovudine in pregnancy.2 Furthermore, the risk might be substantially lower in HIV-positive women who embark on pregnancy while symptom free, with low plasma viraemia and a high CD4 count.3 Mode and timing of delivery also have an important influence on transmission of HIV infection.3 The use of zidovudine in all pregnancies in women known to be HIV-infected would result in at least four of five fetuses who would not otherwise become infected with HIV being knowingly exposed to a possible teratogen. All these factors rely on the woman’s knowledge of her HIV-antibody status. In 1993/94 only 17% of HIV-infected pregnant women in London and the south east of England and 10% elsewhere in England and Wales had their infection recognised clinically.4 Increasing the uptake of HIV testing before and during pregnancy will have a far greater effect on decreasing vertical transmission than relying solely on treating those pregnant women already known to be HIV positive. Although the evidence is in favour of zidovudine use in pregnancy,5 until more research results are available, the decision is by no means as clear cut as Duke and Kovar suggest. In their argument these authors should balance the rights of the HIV-positive child denied zidovudine prophylaxis in utero with those of the child exposed to zidovudine who may manifest zidovudine-related toxicity in later life. Furthermore, one should consider the potential of a legal action brought by an HIV-infected child whose mother

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