Risk of HIV transmission in infected US military personnel

value means that those individuals with higher draw than copy parts of the clock-face test are for the scores likely to be LBD patients.

predictive

*Kanna K Gnanalingham, E Jane Byrne, Andrew Thornton Department of Old Age Psychiatry, Withington Hospital, Manchester M20 8LR, UK 1 Libon DJ, Swenson RA, Barnoski EJ, Sands LP. Clock drawing assessment tool for dementia. Arch Clin

Neuropsychol 1993;

as an

8:

405-15.

2 McKhann G, Drachman D, Folstein M, Katzman R, Price D, Stadlan EM. Clinical diagnosis of Alzheimer’s disease: report of the NINCDS-ADRDA work group under the auspices of Department of Health and Human Services Task Force on Alzheimer’s disease.

Neurology 1984; 34: 939-44. 3 Folstein MF, Folstein SE, McHugh PR. Minimental method for grading the

cognitive

state

state: a

practical

of patients for the clinician.

J Psychiat Res 1975; 12: 189-98. 4 Lang AE, Fahn S. Assessment of Parkinson’s disease. In: Munstat TL, ed. Quantification of neurologic deficit. London: Butterworths, 1989: 285-309. 5 Hansen L, Salmon D, Galsko D, et al. The Lewy body variant of Alzheimer’s disease: a clinical and pathologic entity. Neurology 1990; 40: 1-8.

Risk of HIV transmission in infected US

military personnel SiR-Brodine and colleagues (Nov 4, p 1198)’ document cases of diverse HIV-1 genetic subtypes that had been introduced to the USA through military personnel who had become infected during overseas deployments. They cite accumulating evidence of enhanced transmissibility of subtype E.’- Although subsequent risk of transmission was not the focus of their article, we are concerned that their assertion that HIV transmission by HIV-infected military

personnel "is kept to a minimum by ongoing HIV screening, early detection, and counselling" may be misinterpreted to imply that there is little risk of HIVpositive military personnel transmitting the virus to others. Although it is true that all US military services conduct periodic screening, and counsel personnel who prove HIV positive, the efficacy of this counselling in reducing actual or potential HIV transmission has never been evaluated by the US military. As the scientific director (1990-94) of research in the military’s HIV research programme, I directed a survey of over 1000 HIV-positive military personnel, which documented clinically significant levels of behaviours that could transmit HIV to uninfected sexual partners among the clear majority of those surveyed. Detailed analyses have now been completed (unpublished data); preliminary findings have been presented at several professional meetings,3 as well as at many military briefings and symposia. Our military briefings so thoroughly convinced a triservice HIV/AIDS committee of the gravity of the problem that the committee approved funding, development, and distribution of a series of intensive computer videodisc programs specifically for HIV-positive military personnel. In addition to these videodiscs, our research programme developed several other innovative technologies (including a computerised individual risk appraisal and counselling system, and an audiotape intervention) to reinforce the basic message of sexual responsibility, and to promote positive alternatives to risky sexual behaviours. As far as we are aware, these are the first and only behavioural interventions, in the USA or elsewhere, specifically developed to prevent HIV transmission among infected individuals. These prevention tools were validated and refined in a series of over 50 focus groups conducted with HIV-positive behavioural

across the three services. Groups conducted so far at the University of California San Diego have repeatedly confirmed the same levels of transmissionrisk-relevant behaviours in most HIV-positive personnel as were found in the earlier survey. Qualitative findings further suggest that HIV-positive personnel often have difficulty gauging the riskiness of various sexual behaviours, tend to use sex to cope with the stresses of being infected, and have limited repertoires of non-sexual or low-risk sexual activities. The first clinical trials to evaluate the safety and efficacy of various transmission prevention strategies were approved by all requisite scientific and human use review committees in the military, and implemented in 1994. They were effectively closed down, however, in mid-1995, before any useful results could be obtained. It should be pointed out that the behavioural interventions described by Brodine and colleagues are aimed at reducing HIV exposure in uninfected personnel, not transmission by HIV-positive personnel. Although we agree that it is important to implement effective programmes for military personnel whose behaviours place them at high risk of HIV exposure4 especially during deployments to areas of high HIV-1 prevalence, we feel that it is equally critical to address the generally neglected difficulty of transmission risk by those already infected.

military personnel

*Lydia R Temoshok, Thomas

L Patterson

chemin de l’Avanchet 20, 1216 Cointrin-Geneva, Switzerland

1 2 3

4

Brodine SK, Mascola JR, Weiss PJ, et al. Detection of diverse HIV-1 genetic subtypes in the USA. Lancet 1995; 346: 1198-99. Kunanusont C, Foy HM, Kreiss JK, et al. HIV-1 subtypes and maleto-female transmission in Thailand. Lancet 1995; 345: 1078-83. Temoshok LR. Preventing HIV transmission by HIV infected individuals: the fogotten focus. Plenary address, VIII International Conference on AIDS/III STD World Congress. Amsterdam,

Netherlands, July, 1992. Temoshok LR, Blake SM, Rundell JR, et al. HIV exposure riskrelevant behaviors in the US Army. Oral paper (ThD 1528), VIII International Conference on AIDS/IIISTD World Congress, Amsterdam, Netherlands, July, 1992.

Authors’

reply

SiR-The main objective of our report was to document the detection of non-subtype B HIV-1 in the USA and to discuss the potential implications of this genetic diversity on the epidemiology of the epidemic and the design of vaccine trials. Our comment that "Transmission by deployed US military is minimised by ongoing HIV screening ... HIV seropositive service members do not serve overseas" referred only to US military deployed overseas. US Department of Defense policy requires negative HIV serology in all military personnel before every deployment. Additionally, our data do not address the possibility that HIV-1 subtypes may have different transmission efficiencies. Although limited data that epidemiological suggest subtype E is transmitted more efficiently by heterosexual contact than subtype B, these data need to be confirmed. S K Brodine, J R Mascola, F C Garland Naval Health Research Center, Department of Health Sciences and Epidemiology, Division of Clinical Epidemiology (Code 232), San Diego, CA 92186-5122, USA

SiR-The worldwide HIV-1 epidemic has been complicated the appearance of several HIV-1 subtypes, designated A to I and 0. Brodine and colleagues (Nov 4, p 1198)’ have now documented infections with HIV-1 subtypes A, D, and E in five American servicemen in the USA, in which group, 1 so far, only HIV-1 subtype B was prevalent.’

by

697

MRI abnormalities in tick-borne

SiR-Neurological

encephalitis

manifestations of tick-borne encephalitis

meningoencephalitis, meningitis, encephaloradiculitis. Magnetic encephalomyelitis, resonance imaging (MRI) is usually normal.’ We report on a patient with severe TBE who had pronounced lesions in the thalamus and basal ganglia. A 38-year-old woman was admitted to our hospital with hemiparesis and rigor on the left side and progressive deterioration of mental state. 17 days before admission she had been bitten by a tick near Passau, an endemic area for (TBE)

include

and

IVDU=intravenous

drug user. Table: Serotype and genotype of recent HIV-1 infections in German patients

In 1993, we detected the first HIV-1 subtype E infection in a German with homosexual contacts with a Thai. To further study the spread of HIV subtypes other than B, we analysed sera from randomly selected HIV-positive Germans infected within the past 5-12 months. The samples were first differentiated serologically by a V3-based ELISA.2 Of nine samples, three were serotyped as HIV-IE, one as HIV-1C. Direct sequencing of the V3-region confirmed these subtypes genetically. The seroreactivity of one additional serum (HR007) was misinterpreted as Elike, probably because of a very abnormal subtype B V3sequence. Thus, four of nine newly infected German patients were infected with non-B HIV-1 subtypes (table). All subtype E infections had been acquired through sexual contacts with Thai people. HIV-1 subtypes E and C are prevalent in certain countries of Africa. In Asia, they are responsible for the heterosexual HIV epidemic in Thailand (E) and India (C).3-4 Despite the small number, the high proportion of HIV-1 subtypes E and C among the new infections in Germany, as well as the preferred Langerhans’ cell tropism suggested for these subtypes5 (which could result in a possibly wider spread by the sexual route), may indicate a change of the HIV-epidemic in this country. In a similar study in Spain, we identified nine HIV-1 subtype C infections by our V3-ELISA, three of them in Spanish natives. Thus our studies, together with other reports,5 clearly document that new HIV subtypes have entered the western hemisphere, mostly from Southeast Asia. Differential serodiagnosis of new HIV infections should be taken into account, to follow the HIV epidemic and to implement studies on the natural history of the disease and the effectiveness of antiviral treatment after infection with different subtypes.

TBE; 48 h after the tick bite she had received 5 mL human IgG-immunoglobulin against TBE (FSME-Bulin; 0-1 mL

approximately 10-17 mg), intramuscularly. 12 days developed headache, fever, malaise, nausea, and the next day was admitted to her local hospital. On admission she had a stiff neck, a grade 4/5 hemiparesis on the left side, and tremor and rigor on the left. Lumbar puncture revealed granulocytic pleocytosis (323 cellsx 10’/L). Treatment with ceftriaxone, ampicillin, and acyclovir was initiated. Because of progressive deterioration of her level of consciousness, she was transferred to our department 2 days later. On admission, artificial ventilation was started; the patient had a stiff neck, negative corneal reflex on the left side, left facial palsy, rigor of the extremities (left more than right), left hemiparesis, and bilateral positive Babinski’s sign. Cerebrospinal fluid (CSF) contained 200 cellsX 106/L, predominantly lymphocytes (92%), total protein content (124 mg/dL) was elevated, with a normal CSF/serum glucose ratio. IgM antibodies against TBE virus as determined by ELISA were positive both in serum and in CSF. Antibodies against Borrelia burgdorferi were not detected. Brain oedema demonstrated on CT required administration of hyperosmolar agents and intracranial pressure monitoring by an intraventricular pressure device for 4 days. Cerebral angiography was normal. EEG showed severe generalised slowing activity. MRI 3 days after admission contains later she

This work was supported in part by an AIDS grant from the Bundesministerium fur Bildung, Wissenschaft, Forschung und Technologi to Dietrich (01 KI 9408). Georg-Speyer-Haus is supported by the Bundesministerium fur Gesundheit and the Hessischer Ministerium fur Wissenschaft und Kun.

Horst Ruppach, Heribert Knechten, Hans Jäger, Helga Rübsamen-Waigmann, *Ursula Dietrich *Georg-Speyer-Haus, 60596 Frankfurt, Germany; Praxenzentrum, Aachen; Kuratorium für Immunschwäche, Munchen, and Institut für Virologie, Bayer AG, Wuppertal 1 2

3 4

5

Brodine SK, Mascola JR, Weiss PJ, et al. Detection of diverse HIV-1 genetic subtypes in the USA. Lancet 1995; 346: 1198-99. Dietrich U, Ruppach H, Gehring S, et al. V3-based ELISA for rapid serological typing of HIV infections according to genotype. AIDS Res Hum Retrovir 1995; 11 (suppl 1): S145. Ou CY, Takebe Y, Luo CC, et al. The epidemiology of HIV infection and AIDS in Thailand. AIDS Res Hum Retrovir 1992; 8: 1471-72. Dietrich U, Grez M, von Briesen H, et al. HIV-1 strains from India are highly divergent from prototypic African and US/European strains, but are linked to a South African isolate. AIDS 1993; 7: 23-27. Essex M. HIV Langerhans’ cell tropism: implications for vaccine design. 10th Cent Gardes Meeting, Marne-La-Coquette (Paris), France

1995; abstract, p68.

698

Figure: T2-weighted MRI There

are areas

of mcreased signal Intensity in the thalamus bilaterally head of the caudate nucleus on the left side

(closed arrows) and the (open arrow).