Abstracts

01 Global and Regional Epidemiology of HIV and Its Implications. K. UNGCHUSAK, Bureau of Epidemiology, Department of Disease Control, Ministry of Public Health, Thailand; kum@health.moph.go.th

HIV/AIDS has been an emerging disease since the early 1980s. It became a major pandemic that spread to all regions and countries. Because of the long incubation, which lasts several years, assessing the disease magnitude and trend must be based on available prevalence and incidence data. Estimates and ranges produced by UNAIDS and WHO showed that by December, 2003, the global HIV/AIDS epidemic had killed more than 3 million people, and an estimated 5 million had acquired new HIV infections, bringing the number of people living with the virus around the world to 40 million.

Sub-Saharan Africa, which has less than 2% of the world’s population, is home to about 30% of the people living with HIV/AIDS worldwide. High levels of new HIV infections are continuing and are now matched by high levels of AIDS mortality. The epidemic in Asia and the Pacific is spreading into areas and countries where there was little or no HIV present, including China, Indonesia, and Vietnam. In the older epidemic countries, Cambodia and Thailand, there is a significant spread of HIV from people with higher-risk behavior to their sexual partners.

The AIDS epidemic in Eastern Europe and Central Asia is now showing signs of declining. HIV prevalence continues to rise in the Baltic States, Russian Federation, and Ukraine. In Central Asia, the epidemic is expanding rapidly. In Latin America and the Caribbean, national HIV prevalence has reached or exceeds 1% in 12 countries, all of them in the Caribbean Basin. Sex between men is an important, but neglected, feature of Latin America’s epidemic. HIV prevalence in the Middle East and North Africa region is still very low, with the exception of southern Sudan and recent outbreaks among intravenous drug users in some countries. In the developed countries, the total number of people living with HIV continues to rise, despite access to anti-retroviral treatment. However, there is more evidence of increasing rates of other sexually transmitted infections which reflects the possibility of new increases in HIV incidence, particularly among marginalized groups.

Currently, there is no drug to cure the disease, but new anti-retroviral therapies (ART) are effective in prolonging life and reducing suffering associated with opportunistic infections. Only a small proportion of patients have access to ART. The World Health Organization has aimed to provide ART for 3 million people by 2005. It is still a long while before ART will be accessible to all, or a vaccine becomes available.

The HIV epidemic has caused suffering to individuals, families, societies, and nations. This includes physical illness as well as the discrimination that people living with HIV/AIDS have to face. Although HIV/AIDS has a negative impact on many people, one of the positive effects is that people from different disciplines are working together with strong determination to serve their community, care for their patients, and prevent and control the spread of the disease. With good will and good science, there is no doubt that the pandemic of HIV/AIDS will be brought under control.

02 HIV/AIDS Status and Trends in Asia and the Pacific Region. S. THANPRASERTSUK*, Y.R. LO, Bureau of AIDS, TB and STIS, Department of Disease Control, Ministry of Public Health, Thailand, WHO South East Asia Regional Office, New Delhi, India; sombat@aidsthai.org

The WHO South East Asia and the Western Pacific Region include close to 60% of the total world population. Thus, even low HIV infection rates in this region will contribute to millions of people living with HIV/AIDS and staggering numbers of deaths globally. As of 1 December 2003, 40 million people were living with HIV/AIDS around the world. The sub-Saharan region was accountable for 26.6 million infected people. An estimated 7.4 million people were living with HIV/AIDS in Asia and the Pacific Region. An estimated 5 million people became newly infected globally in 2002. Of them, more than 1 million were in the Asia-Pacific region. In most countries in Asia, the epidemic tends to be concentrated in risk populations, mostly intravenous drug users, with additional spread resulting from sex workers, especially in Indonesia and Nepal, after a prolonged period of low prevalence. Only Cambodia, Myanmar, and Thailand and six states in India have an estimated HIV prevalence of over 1% of the adult population. The course of the epidemics in two of the most populous countries of the world—China and India—will have a decisive influence on the course of the global pandemic. As of 2003, it was estimated that 840,000 people in China were living with HIV infection, corresponding to 0.12% of the total adult population aged between 15 and 49 years. About 70% of these infections were the result of intravenous drug use.

03 Oral Manifestations of HIV in Pregnant Women Attending Ante-natal Clinics in Johannesburg. L.A.O. ADEYEMI¹*, M.J. RUDOLPH¹, A.O. YUSUF², J.A. McINTYRE³, G.E. GRAY³, N. MARTINSON³, ¹School of Public Health, University of the Witwatersrand, ²Department of Community Dentistry, University of Pretoria, ³Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg; benade19@hotmail.com

Introduction: Although several studies have been reported from outside sub-Saharan Africa on the oral manifestations of HIV in women, no such study has yet been undertaken on oral manifestations of HIV in pregnant women in Africa. In some areas of South Africa, one in three pregnant women attending public-sector health facilities is HIV-positive. Oral candidiasis has been shown to be the most common oral lesion associated with HIV infection in women. Objective: To determine the prevalence of oral manifestations in HIV-positive pregnant women attending ante-natal clinics in Johannesburg. Methods: A cross-sectional study was conducted on HIV-positive pregnant women attending ante-natal clinics in three hospitals in Johannesburg, South Africa. A calibrated dentist determined HIV-related oral lesions by doing a clinical examination in 128 HIV-positive pregnant women using the criteria suggested by the EC/WHO. Parity, gravidity, and age of the patients were collected by means of a self-administered structured questionnaire. Results: The age range for the group was 17 to 42 years, with a mean age of 27.9 years. Twenty-eight (22%) of the group was primigravid, while 100 (78%) were multiparous. The majority of the patients, 73 (57%), were in their second trimester. Oral candidiasis and angular cheilitis were the most commonly seen oral lesions in these patients, with a frequency of 78 (61%) and 51 (40%), respectively. Oral ulceration was seen in 35 (27%) of the patients. Thirty-three women (26%) presented with necrotizing ulcerative gingivitis, six (5%) had necrotizing ulcerative periodontitis, and six (5%) had linear gingival erythema. Less than 3% of the patients presented with herpes, which was mainly extra-oral. No other HIV-associated oral lesions were seen in these patients. Conclusion: The prevalence of oral lesions associated with HIV infection for this particular sub-group is similar to results of other prevalence studies conducted elsewhere on women, though the prevalence of oral candidiasis was slightly higher in this group. The confirmation of these findings in pregnant women emphasizes the need for diagnosis of oral lesions by all health care workers and for recommended treatment or referral.

04 Common Oral Lesions Seen among Sero-positive Patients at a Voluntary Confidential Counseling and Testing Center in the Resource-limited Setting of Kaduna, Nigeria. U.E. AMANYEIWE-ADAKA*, C. IGBOKWE, S.O. AJIKE, Maxillofacial Unit, Ahmadu Bello University Teaching Hospital, Kaduna, Nigeria; ugoadaka@yahoo.com

The occurrence of common oral lesions seen among sero-positive patients was investigated in 638 consecutive patients attending the FRC voluntary confidential counseling and testing (VCCT) center from November, 2002, to November, 2003. Different types of oral lesions were observed in 372 (58.3%) of subjects. The most prevalent of these lesions was oral candidiasis, observed in 263 (70.7%) patients. The high prevalence of oral candidiasis is similar to that reported in studies from Jos in Nigeria, Côte D’Ivoire, and South Africa. The prevalence of other oral lesions was much lower, and some patients had more than one type of lesion. They included: aphthous ulcers, 67 (18%); herpes simplex, 47 (12.6%); necrotizing gingivitis, 30 (8.1%); salivary gland enlargement, 19 (5.1%); necrotizing periodontitis, 18 (4.8%); Kaposi’s sarcoma, 12 (3.2%); herpes zoster, seven (1.9%); oropharyngeal carcinoma, five (1.3%); melanotic hyper-pigmentation, three (0.8%); maculopapular lesions, three (0.8%); and necrotizing fascitis, two (0.5%). Similar findings are reported from other studies. Management of these seropositive patients at this VCCT Centre was mainly symptomatic. Patients were given multivitamin supplements and treatment for opportunistic infections. Oral candidiasis was treated with Nystatin pastilles and lozenges, whereas fulminating cases of mycotic infection were given systemic fluconazole. Twelve of the 33 patients who could afford an uninterrupted ARV supply for six months had oral lesions. Conclusion: Oral lesions occurred more frequently in patients who presented with advanced stages of the infection. Seropositive patients on ART presented with fewer oral lesions. In patients with severe opportunistic infections, commencement of ARVs, combined with symptomatic treatment of the opportunistic infections and nutritional support, contributed to recovery. Reduced rates of recurrence of infections, progressive rise in CD4 count, and improvement in the patients’ general status was noted. In resource-limited settings, where facilities are not available, oral lesions may be used as a marker for staging the clinical progress of HIV/AIDS.

05 Gender Differences in Oral Manifestations among South African HIV/AIDS Patients. E. BLIGNAUT, Medical University of Southern Africa; eblignaut@medunsa.ac.za

Objectives: To determine gender differences in numbers, age, and oral manifestations among black HIV/AIDS patients attending three AIDS clinics in the Gauteng province, South Africa. Background: In 2002, it was estimated that 6.5 million South Africans were living with HIV/AIDS, and that women of child-bearing age (15–49 years) constituted half of the infected population. Methods: A retrospective analysis was performed on data obtained over a four-year period, from the primary visit of patients attending outpatient clinics at three hospitals in the Pretoria region. At the time, no patients had access to anti-retroviral therapy. All patients received an oral examination, regardless of any complaints. Surveillance swabbing for Candida was also performed. Results: Of the total patient population, 1031 (67.4%) were female and 498 (32.6%) male. Of the female patients, 78.5% were aged between 20 and 39 years, while 76% of the male patients were 30 years and older. Localized attachment loss was more prevalent in males (p < 0.05), while linear gingival erythema and a pericoronitis around an erupting third molar were observed more frequently in females (p < 0.01 and p < 0.05, respectively). In females, a significant correlation (p < 0.001) between pseudomembranous candidiasis and a CD4 cell count below 200 cells/mm³ was observed. In males, erythematous candidiasis correlated significantly with a CD4 cell count below 200 cells/mm³ (p < 0.01). Conclusion: Twice as many females than males attended the clinics, and they were also younger than the male group. Differences in the prevalence of oral manifestations between males and females were demonstrated, including differences in the correlation of some lesions with a CD4 count below 200 cells/mm³.

06 HIV-related Oral Diseases among Women in Zimbabwe. M.M. CHIDZONGA¹*, M. MWALE¹, L. CHIDZUMO¹, E. MAKURA¹, K. MALVIN², C.H. SHIBOSKI², ¹University of Zimbabwe, ²University of California-San Francisco; mmchidzonga@medsch.uz.ac.zw

Objectives: To estimate oral disease prevalence among women in Harare in relation to HIV serostatus and CD4 count, and to assess sensitivity and specificity of oral soft tissue examinations conducted by nurses compared with those conducted by an oral surgeon. Background: Because biologic assays to measure HIV disease progression are rarely accessible in sub-Saharan African countries, due to prohibitive cost, we sought to investigate the use of HIV-related oral lesions as potential markers for HIV disease progression as an inexpensive alternative. Methods: We recruited HIV+ and HIV- women from 2 prospective cohort studies (HIVNET and WHO) in Harare. HIV serostatus was assessed at baseline. CD4 count was measured and a standardized oral soft tissue examination was performed at six-month intervals by both a nurse examiner trained in the diagnosis of HIV-related oral lesions (using ECC criteria) and an oral surgeon. The examinations were done within 2 weeks of each other when possible. We report preliminary analyses conducted on baseline data, since recruitment is still ongoing. We include only those women who were seen by both nurse and oral surgeon within a two-week window. Results: Of 433 women, 342 (212 HIV+, 130 HIV-) were seen by both nurse and oral surgeon within a two-week period. Mean age was 30.2 years (range, 18–47) among HIV+ women and 27.4 years (range, 19–36 yrs) among HIV- women. Oral candidiasis (OC), predominantly pseudomembranous, was the most common lesion diagnosed by the oral surgeon in both HIV+ and HIV- women (28% vs. 18%; P = 0.03), as well as by nurses (22% vs. 8%; P = 0.001). Hairy leukoplakia and Kaposi’s sarcoma were found in 2% and < 1%, respectively, of HIV+ and in none of the HIV- women (by either nurse or oral surgeon). The prevalence of OC diagnosed by the oral surgeon was significantly higher among women with CD4 count < 200 than in women with CD4 count 200–499 and > 499 (57%, 36%, and 7%, respectively; P = 0.02). The agreement rate between nurse and oral surgeon examinations was high among HIV+ women for the diagnosis of OC (91% agreement on positive diagnoses and 90% agreement on negative diagnoses). However, the agreement rate was lower for examinations done in HIV- women, since the oral surgeon found a higher prevalence of erythematous candidiasis in that group than did the nurses. Conclusion: OC was the most common lesion in HIV-positive Zimbabwean women and was strongly associated with a low CD4 count. The inter-examiner agreement rate was good for diagnoses of OC among HIV-positive women, but erythematous candidiasis remains a diagnostic challenge. These preliminary results suggest that pseudomembranous candidiasis may be used as a surrogate marker of disease progression, and is reliably diagnosed by nurses.

07 Oro-facial Manifestations in Pediatric HIV: a Comparative Study of Institutionalized and Hospital Outpatients. S. NAIDOO*, U. CHIKTE, University of the Western Cape, Cape Town, South Africa; snaidoo@sun.ac.za

The aim of the study was to compare caries status and the numbers and types of oral mucosal lesions in HIV-positive children from a hospital outpatient department and an institutionalized setting. Oral examinations were performed according to presumptive diagnostic criteria. The Fisher’s Exact and the Mann-Whitney tests were used for statistical comparison of the two study groups. In total, 169 children were examined, of whom 42% were institutionalized and 58% were hospital outpatients. One institutionalized child presented with Noma. 21% of the institutionalized population presented with Molluscum contagiosum, while none of the hospital outpatients presented with this condition. Significantly more intra-oral mucosal lesions were observed in the hospital compared with the institutionalized group. The most frequently encountered oral lesion was candidiasis. Twice as many intra-oral ulcers were recorded in the institutionalized group. Thirty-nine percent of the hospitalized patients had multiple lesions, compared with 28% in the institutionalized group. Almost three-quarters of both populations were caries-free. The mean DMFT was higher in the hospital population. For both the permanent and primary teeth, the decayed component made up the major part of the DMFT/dmft, followed by the missing component. No fillings were recorded in either the primary or permanent teeth for both groups. Oral lesions were common in HIV populations and were seen in both the hospital (63%) and institutionalized (45%) groups at high prevalence levels. HIV-infected children should be considered high-risk for caries, due to the use of chronic medication, and should receive appropriate care in terms of both treatment and services.

08 Thalidomide for Palliation of Kaposi’s Sarcoma in Malawian Children. T. HODGSON¹*, W. KONDOWE², E. MOLYNEUX², T. MHANGO², R. SINFIELD², S. PACKER¹, et al. ¹Oral Medicine, Eastman Dental Institute for Oral Health Care Sciences, University College London, UK; ²Department of Paediatrics, College of Medicine, University of Blantyre, Malawi; T.Hodgson@eastman.ucl.ac.uk

Analysis of Malawian National Cancer Registry data suggests an increased incidence of pediatric Kaposi’s sarcoma (PKS) since the start of the HIV pandemic. The presentation and management of PKS in this geographical region are poorly documented. The immunomodulatory, anti-inflammatory, and anti-angiogenic properties of thalidomide, in addition to single daily oral dosing, have potential in the palliation of PKS. Thirty-three children (median age, 9 yrs; range, 2–14 yrs; male:female, 2:1), with histopathologically confirmed PKS, presenting to the Department of Paediatrics, Queen Elizabeth Central Hospital Blantyre, Malawi, over a 14-month period to September, 2003, commenced thalidomide 3 mg/kg/day for 16 wks. Twenty-one children (64%) had oral KS, the lesions being confined to the hard palate. Of this group, 18 (87%) had coincidental cutaneous lesions. Thirty-one of the children proved to be HIV-infected (HIV RNA viral load mean, 58,300; range, 16,400–269,000 copies/mL; CD4 count mean, 290; range, 40–700 x 10³/mm³). The clinical response of mucocutaneous KS to thalidomide therapy plateaued at 8 wks, with a complete response rate of 10%, a partial response rate (> 50% decrease in number and/or size of lesions) of 40%, and 30% had stable disease at 16 wks. While on the study, ten children died of acute bacterial infections, the severity of which cannot be attributed to thalidomide therapy. The most common additional effects of thalidomide reported in this cohort were an improved quality of sleep and an increased appetite. No children reported peripheral neuropathy or cutaneous rash. The mean Lansky performance status improved from 67 (range, 40–100) to 93 (range, 70–100) (p < 0.05) following thalidomide therapy. It is concluded that thalidomide is a potentially efficacious and cheap palliative therapy for mucocutaneous PKS in Malawi.

09 Smoking as a Predictor of Oral Manifestations of HIV Infection. O.A. AYOYUSUF¹*, A.S. BAJOMO², M.J. RUDOLPH¹, ¹Department of Community Dentistry, University of Pretoria; and ²Division of Oral Public Health, University of Witwatersrand, South Africa; lekan.ayoyusuf@up.ac.za

Oral lesions in HIV-infected individuals are potentially useful predictors of disease progression, especially in resource-poor societies. It is therefore important to recognize factors that may have an impact on their presentation and management. This cross-sectional analytical study therefore sought to determine the effect of smoking on oral manifestations (OM) of HIV/AIDS among a South African general hospital outpatient population. Study participants included 175 consenting HIV-infected adults who presented consecutively at the HIV clinic on referral for routine care and support since their diagnosis of HIV seropositivity. Socio-demographic information, drug-treatment status, and smoking history were obtained from the patients by means of a self-administered questionnaire. A systematic oral examination was also conducted on each patient by a trained and calibrated dental clinician, to record the presence of HIV-related oral lesion(s). The examiner was blinded to the completed questionnaire. Cigarette smoking prevalence was 10% (n = 17), with male prevalence of 23%. Only one smoker reported to have reduced consumption since knowing of HIV status, but none had quit. Of the 76% who presented with OM, oral candidiasis was the most common oral lesion (72%). After adjustment for period since visiting (proxy for HIV history) and other variables, logistic regression analysis for presentation with OM indicated that being female (odds ratio [OR], 3.8; 95% confidence interval [CI], 1.1–13.0) and being a regular smoker (OR, 8.6; 95% CI, 1.6–46.4) were significantly associated with higher odds of presenting with OM. The model derived explained 12% of variance in OM. The study findings suggest that smoking is an important predictor of OM in the studied population. However, there is also an indication for further research.

10 The Association of Peripheral Blood Abnormalities and HIV-associated Oral Lesions. D. KERDPON¹*, S. SRETRIRUTCHAI², A. NILMANUT³, A. GEATER², K. WANGRUNGSIMAKUL¹, ¹Faculty of Dentistry, Prince of Songkla University, Thailand; ²Faculty of Medicine, Prince of Songkla University, Thailand; ³Hatyai Regional Hospital, Songkla, Thailand; kduangpo@ratree.psu.ac.th

Few data of peripheral blood abnormalities and their association with HIV-associated oral lesions are available. This study evaluated the prevalence of peripheral blood values less than normal range in HIV-infected patients and their association with numbers and types of HIV-associated oral lesions. One hundred and seventeen HIV-infected patients in a southern Thai hospital were included. Anemia (69.2%), leukopenia (29.1%), and lymphopenia (11.1%) were the most common hematological abnormalities. Lymphopenia was significantly associated with an increased number of HIV-associated oral lesions, the presence of any HIV-associated oral lesions, and oral candidiasis (OC). Lymphopenia was not found in patients without any oral lesions. Low mean corpuscular volume (MCV) was more common among patients without any oral lesions than among those with OC and oral hairy leukoplakia. More studies will help to explain this finding. Lymphopenia might be a practical indicator in the prediction of HIV-associated oral lesions, particularly when CD₄ and viral load are not routinely accessible.

11 Salivary and Oral Findings in HIV-positive and HIV-negative Subjects with Well-controlled Medication. W. NITTAYANANTA¹*, B. NAUNTOFTE², E. DABELSTEEN³, K. STOLTZE⁴, N. CHANOWANNA¹, S. JEALAE⁵, ¹Department of Stomatology, Faculty of Dentistry, and 5Microbiological Unit, Faculty of Medicine, Prince of Songkla University, Thailand; ²Department of Clinical Oral Physiology, ³Department of Oral Diagnostic Sciences, and ⁴Department of Periodontology, School of Dentistry, University of Copenhagen, Denmark; nwipawee@ratree.psu.ac.th

Background: Salivary glands are affected during the course of HIV infection. Many medications may have the potential to impair salivary gland function as well as to induce feelings of oral dryness. In particular, little is known about intake of medication and the presence of hyposalivation and xerostomia among HIV-infected subjects. Objectives: The aims were to assess the prevalence of hyposalivation and xerostomia in HIV and HIV-free subjects with a well-controlled consumption of medications, to study the relationship between unstimulated and stimulated salivary flow rates, to identify factors associated with hyposalivation and xerostomia, and to correlate the presence of hyposalivation and xerostomia with the presence of oral candidiasis, the number of colony-forming units of Candida, the presence of cervical caries, and the number of teeth in the group of HIV-infected subjects. Subjects and methods: A cross-sectional study was performed in the two different regions of Thailand-the north and the south. One hundred and thirty-five subjects were enrolled (56 HIV-seropositive, mean age, 34.5 yrs; and 79 HIV-seronegative individuals, mean age, 29.5 yrs). Measurement of salivary flow rate consisted of both unstimulated and wax-stimulated whole saliva, with the draining method. The effects of HIV serostatus, stage of HIV infection, asymptomatic, symptomatic/AIDS, and medications on the flow rates were analyzed. Results: The unstimulated flow rates in the HIV-positive subjects and HIV-negative controls were 0.19 and 0.33 ml/min (p ~ 0.0024). The stimulated flow rates were 1.45 and 1.62 mL/min (p ~ 0.31). In the HIV-positive group, the unstimulated flow rate was significantly higher in the asymptomatic group (0.17 mL/min), compared with the symptomatic/AIDS group (0.11 mL/min) (p ~ 0.003), whereas the mean stimulated flow rate values were 0.99 and 1.15 mL/min, respectively. No significant difference was found. With respect to medication, unstimulated (or stimulated) flow rates were found to be statistically significantly lower in subjects with xerostomia-inducing drugs compared with those with no medication (p ~ 0.004). The following factors were significantly associated with hyposalivation: sex, stage of HIV infection, risk group, systemic disease, medication, smoking habit, and alcohol consumption. Hyposalivation was found to be significantly associated with the number of colony-forming units of Candida. However, no statistically significant association between hyposalivation and cervical caries (p ~ 0.55) or number of teeth (p ~ 0.13) was observed. Conclusions: Our study indicated that various medications taken among HIV-infected individuals affect their salivary flow rates and feeling of oral dryness. Since saliva plays a key role in maintaining oral functions and protecting the oral hard and soft tissues, xerogenic medications should be prescribed with special caution in this patient group.

12 Quality of Life and Oral Mucosal Lesions among HIV-positive Drug Addicts. S.L. SUJAK*, R.A. KADIR, R. OMAR, University of Malaya, Kuala Lumpur, Malaysia; slsujak@pd.jaring.mv

HIV-infected people are prone to oral mucosal lesions (OML), which can affect the quality of life of this population. The objective of this study was to evaluate the effect of OML on the quality of life among HIV-positive drug addicts. A cross-sectional case-control study involving 917 male drug addicts, 509 HIV-positive (case) and 408 non-HIV (control), was carried out. The mean age of the sample was 31.2 ± 6.5 yrs. A single-item global rating questionnaire was used to measure the quality of life. The prevalence of OML was measured by oral examination. The study showed that HIV-positive patients registered a lower quality-of-life experience (m = 27.3 ± 21.6 points) than did non-HIV subjects (m = 40.8 ± 30.0 points). The difference was statistically significant (p = 0.00). The study also found that 41% of the HIV-positive subjects had OML. Pseudomembranous candidiasis was the most common lesion (21%), followed by hairy leukoplakia (12%) and erythematous candidiasis (12%). These findings suggest that the presence of OML did not affect their quality of life, as shown by the Pearson chi-squared test. Findings from this study concluded that OML had a minor influence on the general quality of life of HIV-positive drug addicts.

13 Oral and Maxillofacial Surgery for the Seropositive Patient in a Resource-limited Setting. U.E. AMANYEIWE-ADAKA*, C. IGBOKWE, S.O. AJIKE, Family Resource Centre ABU, Old Hospital Complex, Kaduna, Nigeria; mfuugo@yahoo.com

Surgical management of HIV sero-positive patients in developing countries such as Nigeria is highly inadequate. This is due to the unavailability of enabling policies and infrastructures that empower both the clinician and the patients. The objective of this paper is to analyze the problems encountered by the average oral/maxillofacial surgeon who has to manage sero-positive patients in an environment with little or no access to sustainable anti-retroviral drug therapies and no access to affordable post-exposure prophylaxis for the surgeon. The need to address these issues cannot be over-emphasized in a country with a sero-prevalence of over 5.8% and having one of the world’s highest incidences of road traffic accidents with associated fractures of the facial skeleton. In conclusion, there is a need for surgeons to empower themselves with scientifically correct knowledge of post-exposure chemoprophylaxis and the strict practice of universal precautions to provide care for HIV+ patients. This should enable patients to regain function of their masticatory apparatus in an environment where nutrition combined with the treatment of opportunistic infections is the cornerstone of management of the HIV infection.

14 Awareness of Occupational Exposure to HIV Infection among Dental Surgeons in Chennai, South India—a KAB Study. S. BALASUNDARAM, Ragas Dental College, Chenai, India; Bbaallaa2002@yahoo.co.in

Issues: HIV infection is a major global health problem. In India, it is estimated that there are four to five million HIV-infected patients (NACO, 2003).(AQ) Increasingly, dental surgeons are treating HIV-infected patients and are exposed to body fluids that are potential sources of HIV infection.The present study was undertaken to ascertain the knowledge, attitude, and behavior of dental surgeons regarding occupational exposure to HIV infection. Description: A pre-tested close-ended questionnaire with 46 items, each having 5 possible response options, was completed by 300 dental professionals from various dental colleges in south India. The questionnaire also had an open-ended segment to enable them to express their opinions. Lessons learned: The study showed that dental surgeons had appropriate understanding of the risk of occupational exposure. Female dental surgeons were less willing to manage HIV-infected patients than their male counterparts. Dental surgeons who graduated after 1986 were more aware of universal precautions to be followed in HIV infection, compared with the pre-’86 graduates. Although knowledge was adequate and appropriate, and infection control procedures were followed, the analysis of attitude and behavior revealed that dental surgeons were not willing to treat HIV-infected patients, if they had a choice. Recommendations: The results of this study emphasize the importance of continuing dental education programs to focus on motivating dental surgeons to provide dental care for HIV-infected patients.

15 Concerns Reported to Dental Protection Limited by Dental Healthcare Workers Treating HIV-positive Patients: 1985–2002. D. CROSER, VM Clinic, Hammersmith and Fulham PCT, UK; david@croser.demon.co.uk

When undertaking clinical procedures, it is possible that either dental healthcare workers (HCW) or patients could experience problems. Good communication between the parties will either eliminate or contain the problem. If the patient is not satisfied with the response, he/she may complain formally through a lawyer or the national registration body. Either way, the HCW is likely to face a situation with significant financial or professional ramifications. The HCW can seek assistance from a defense organization like Dental Protection Limited (DPL), which has 22,500 member dentists, i.e., 70% of the total number of dentists registered in the United Kingdom and 5000 hygienists and therapists. All new potentially litigious cases are recorded under a detailed case headline, facilitating a review of the issues which have concerned HCWs while working with HIV-positive patients over the last 18 years. The data record only situations that either threatened or resulted in legal action. There are no data on unreported problems resolved at the practice level. The trend over the last 18 years has been a fall in the number of cross-infection concerns registered, while the trend has risen for patients refused treatment, when measured over the same time period. Three other significant concerns were also measured: needlestick injuries, HIV testing, and confidentiality. Conclusions: The incidence of concerns about cross-infection has declined. The incidence of problems associated with refused treatment appears to be on the increase. Litigation against healthcare workers in general is on the increase. Financial considerations are a reality for people living with chronic illness, and the difficulty of finding state-funded (NHS) treatment in the UK may be an underlying issue. The three recent cases brought against UK HCWs hinged on poor communication rather than on a refusal to treat. All three HCWs knowingly cared for other HIV patients. Concerns about needlestick transmission are more numerous—possibly due to the availability of effective drug regimens and a reduction in stigma.

16 Formulation of India-specific Protocols for Oral Aspects of HIV Care Research and Education. E. JOSHUA*, T.R. SARASWATHI, M. UMADEVI, S. SOLOMON, N.W. JOHNSON, K. RANGANATHAN, Ragas Dental College & Hospital, Chennai, India; drtroobanmds@redriffmail.com

Acquired Immunodeficiency Syndrome (AIDS)/Human Immunodeficiency Virus (HIV) infection is a global health problem. India has the second highest number of HIV cases in the world. Dentists are encountering and treating more and more HIV patients, and oral lesions are a major finding in these patients. Though there are many health initiatives, the policies pertaining to dentistry are in their early stages, and a definitive framework is needed to tackle the HIV pandemic effectively. A panel of national and international experts, working in the field of HIV, presided over a session consisting of a group of practicing and teaching oral and maxillofacial pathologists and dental surgeons at the national conference of the Indian Academy of Oral and Maxillofacial Patholgists, in New Delhi, India, in December, 2003. Collective experiences were deliberated on, and a 13-point recommendation was framed to be sent to the Dental Council of India for follow-up, modification, and implementation. Recommendation: The guidelines for continuing dental education programs, counseling, oral screening/testing, and relevance of alternative medicine in the screening and treatment of HIV were as follows: (1) Continuing professional education programs for dental surgeons should be made mandatory and should include HIV/AIDS awareness, infection control, and other relevant topics. (2) The undergraduate dental education curriculum must include a strong component on blood-borne viral diseases and their implications for the dental profession, for patients, and for public health. (3) Interdepartmental work in dental colleges should be encouraged for enhanced clinical care of HIV-positive patients and the effective prevention of disease transmission in the community. (4) Close liaison needs to be established between the dental profession and other professional providers of health care and disease prevention. (5) A list of the locations and contact numbers of local HIV counseling and testing services should be available in every dental clinical setting. (6) The use and value of the Complementary and Alternative Medicine (CAM) approach to the management of HIV-positive patients requires well-designed, well-funded research and evaluation. (7) Infection control procedures, using "Universal Precautions", are mandatory in the dental clinical setting. Understanding of these procedures must be part of mandatory CPE/CDE. Consideration should be given by the DCI to means of audit and enforcement, with sanctions. (8) Dental professionals could play a valuable role in public education about HIV risk factors, prevention, and management. (9) Messages relevant to oral health should be integrated into all public health education/health promotion programs. (10) Public health programs should harness the power of "stars" of the media, sports, and fashion to promote key messages about HIV and tobacco risks. There is an important role for faith-based organizations. (11) The Indian Dental Council should take appropriate measures to ensure that dentists do not discriminate or refuse to treat patients on the grounds of their HIV status. (12) Opportunistic screening for oral manifestations of HIV, for oral cancer/pre-cancer, and for manifestations of other oral soft-tissue and systemic diseases is the duty of every dentist every time a patient is seen. (13) HIV testing should be carried out only by laboratories or individuals adequately trained in both technical and counseling aspects. Quality assurance methods should be in place.

17 Association between Self-risk Perception of Occupational HIV Infection and Hollow Needlestick Injuries among Kenyan Oral Health Practitioners. M. D’LIMA¹*, P. WANZALA², M.L. CHINDIA³, ¹Private Dental Practice, Westlands, Nairobi, Kenya; ²Kenya Medical Research Institute, Nairobi, Kenya; ³Department of Oral and Maxillofacial Surgery, Faculty of Dental Sciences, University of Nairobi, Kenya; mdl11261@rediffmail.com

Background: Clinician perception of risk of HIV infection during dental treatment should ensure safe work practices and compliance with universal infection control guidelines. Since accidental exposure still occurs, use of an effective HIV vaccine may provide adjunctive protection. Objective: To investigate the risk of accidental exposures from hollow needlestick injuries (HNI) among dentists who perceive themselves at risk of HIV infection in the workplace. Methods: This was a cross-sectional study conducted among 61 Kenyan participants at a dental conference. A simple standardized semi-structured, self-administered questionnaire was used for the anonymous collection of basic demographic data, HIV infection during practice risk perception, and knowledge about the HIV vaccine and post-exposure prophylaxis. Results: The majority (44.3%) of respondents were aged between 31 and 40 years, and 68.9% were male. Of these, 61.7% engaged in full- or part-time private practice, and 45.6% of them treated between 6 and 10 patients per day. The majority (93.3%) felt that they were at risk of HIV infection during dental practice. Only 21.6% had access to an anti-retroviral starter dose in their dental facility. The questions most infrequently answered were on the mechanism and mode of infection (84%) and the nature of the HIV vaccine (64%). The odds ratio of hollow needlestick injury occurring was highest in the 41- to 50-year-old group [1.5, 95% CI (0.85–2.64)].The Maentel-Haentzel (MH) age-adjusted odds ratio was 2.02, 95% CI (0.2–15.1). The odds ratio in males was 3.75, 95% CI (021–66.7), and in females 1.28, 95% CI (0.07–24.4), with the MH gender-adjusted odds ratio of 2.12 (0.3–16.7). Homogeneity was found between: odds ratios stratified for type of practice; number of patients; injury by non-hollow sharp; knowledge on the mechanism, target, and nature of the Kenyan vaccine; and participation in a clinical vaccine trial. Conclusion: Age was a confounder in the risk odds ratio estimates. Effect modification was observed with gender, and homogeneity was observed on questions about the vaccine. It seems that females are more cautious than males during practice, and information on the HIV vaccine as adjunctive protection during practice may not vary the risk perception and safe practice.

18 Cost of Inpatient Care for HIV-positive Pediatric Patients at Red Cross Children’s Hospital, Cape Town, South Africa. V. YENGOPAL, S. NAIDOO*, University of the Western Cape, Cape Town, South Africa; snaidoo@sun.ac.za

A retrospective study was undertaken to assess the direct treatment costs for pediatric HIV+ inpatients over a one-year period at a large Children’s Hospital in Cape Town, South Africa. Clinical and demographic data for 154 randomly selected patients (25% sample) were obtained from hospital records. Direct costs were calculated for admissions, x-rays, medication, and laboratory and surgical procedures. Of the 16,032 admissions in 2001, 616 (4%) were HIV+. The most common conditions diagnosed clinically on admission were failure to thrive (64%), pneumonia (54%), gastroenteritis (43%), and oral thrush (42%); 54% were found to be underweight for their age, and 87% were malnourished. The average length of stay in hospital was 9 days (vs. 4.03 for others). The average cost for each HIV+ inpatient was R18,765.76. Admission costs formed the bulk of this amount (84%), followed by laboratory costs (9%), medication (3%), surgical (2%), and x-rays (2%). HIV+ patients consumed 26% (R11.56 million) of the total budget (R44.65 million) for direct treatment costs. Current admission policies at the hospital appear unsustainable (4% of the patients consume 26% of the direct treatment costs) in the presence of the ever-increasing demand for care and tough measures by government to force health managers to operate within budget.

19 Assessment of Association between Viral Load CD4 Count and Occurrence of Oropharyngeal Candidiasis in HIV+ Patients. J.E. LEIGH*, D. MERCANTE, E. LILLY, P.L. FIDEL, Louisiana State University Health Sciences Center and Center of Excellence in Oral and Craniofacial Biology, New Orleans, LA 70112, USA; jleigh@lsuhsc.edu

Background: OPC is the most frequently observed oral infection in HIV+ individuals. Historically, lower CD4 counts have been associated with an increased prevalence of OPC in HIV+ patients, but HIV viral load has also recently been recognized as a predictive factor. Objective: The purpose of this study was to examine the impact of viral load vs. blood CD4 cell count on the prevalence of OPC through modern exploratory statistical analyses. Methods: We investigated such associations in 49 HIV+ individuals from an outpatient clinic population in the city of New Orleans. Exploratory descriptive and graphical analyses, as well as inferential methods such as logistic regression and tree classification models, were used to explore and compare the predictive and classification ability of viral load and CD4 cell counts for OPC status. Analyses were adjusted for several potentially confounding variables, such as use of HAART, protease inhibitors, antibiotics, or other medications, and status of patient with respect to IV drug use, smoking, and engagement in a high-risk behavior. Other covariates included age, race, and gender. Results: The cohort consisted of virtually equal numbers of males and females and was 59% African-American and 35% Caucasian, with a mean age of 42 years. Univariate analysis indicated that only viral load and CD4 counts were associated with OPC status. Analyses involving viral load and/or CD4 counts were adjusted only for IV drug use, the only significant covariate. Classification tree and logistic regression models support the finding that higher viral load is more closely associated with occurrence of OPC (OR: 2.2 [1.2, 3.6]), and is 40% less likely to misclassify OPC status as compared with using CD4 counts (OR: 0.61 [0.33, 1.11]). Conclusion: Analysis of these data strongly suggests that viral load may be a better predictor of OPC status than CD4 counts.

20 Chlorhexidine Mouthrinse in the Maintenance of an Oral-candidiasis-free Period among HIV-infected Subjects: an Intervention Study. W. NITTAYANANTA¹*, T.A. DeROUEN², P. AREERATCHAKARAN³, T. LAOTHUMTHUT⁴, K. PANGSOMBOON¹, S. PETSANTAD⁵, et al., ¹Faculties of Dentistry, ⁶Sciences, and ⁷Medicine, Prince of Songkla University, Thailand; ²School of Dentistry, University of Washington, Seattle, USA; ³Faculties of Dentistry, Chulalongkorn University and ⁴Mahidol University and ⁵Bamratnaradoon Hospital, Thailand; nwipawee@ratree.psu.ac.th

Background: Oral candidiasis is the most common oral lesion seen in HIV/AIDS subjects. Due to the underlying immune deficiency, recurrence of the lesion after successful antifungal therapy is frequently observed among the patients. Objective: To determine if chlorhexidine mouthrinse can be used as an intervention after antifungal therapy to prolong the time to relapse of oral candidiasis among HIV/AIDS subjects. Subjects and methods: A double-blind randomized clinical trial was performed in 75 HIV/AIDS subjects with a clinical diagnosis of oral candidiasis confirmed by culture. Oral examination and oral rinse techniques to determine the number of colony-forming units (CFU) of Candida were performed at the first visit. Total lymphocyte cell counts were recorded as the baseline data of the immune status of the subjects. A clotrimazole troche was used to treat oral candidiasis, and the subjects were followed up every two weeks until the lesions were completely eradicated. The subjects were divided randomly into two groups. They received either 0.12% chlorhexidine mouthrinse (n = 37, aged 22–52 yrs, mean 34 yrs) or 0.9% normal saline solution (n = 38, aged 22–55 yrs, mean 38 yrs), and were followed up every two weeks until the next episode of oral candidiasis was observed. Multiple regression analysis and Kaplan-Meier survival estimates were used to analyze the data. Results: Although the recurrence of oral candidiasis was slightly longer in the chlorhexidine than the saline group, the difference between the two groups was not statistically significant (p > 0.05). The following variables were significantly associated with the time of recurrence of the lesion; frequency of antifungal therapy (p ~ 0.011), total lymphocyte cell counts (p ~ 0.017), alcohol consumption (p ~ 0.043), and gingival location of the lesions (p ~ 0.048). The subjects who had low total lymphocyte cell counts (< 1000 cells/mL) showed shorter oral-candidiasis-free periods than those with the higher counts. The number of CFU of Candida at the first visit was not significantly associated with the time to recurrence of oral candidiasis (p ~ 0.669). Conclusions: Chlorhexidine mouthrinse showed a small but not statistically significant effect in maintenance of an oral-candidiasis-free period among HIV/AIDS subjects, compared with normal saline solution. This lack of significance may be due to the small sample size. Further study with a larger number of subjects should be performed to achieve statistical significance for such a small effect, or to confirm our findings.

21 Typing and Clinical Relevance of Candida albicans in HIV-infected Patients. M. NIYOMBANDITH¹*, P. PRIPATANANONT¹, W. SATAYASANSKUL¹, R. TEANPAISAN², ¹Department of Oral and Maxillofacial Surgery, ²Department of Stomatology, Faculty of Dentistry, Prince of Songkla University, Thailand; cmali@ratree.psu.ac.th

Typing of Candida albicans is important in epidemiological studies. However, researchers have investigated the association between genotypes and biotypes of C. albicans and the clinical status of patients. The aim of this study was to investigate the relationship among genotypes, biotypes, and antifungal susceptibility of C. albicans isolated from HIV-infected patients. In total, 189 strains of C. albicans isolated from 41 HIV-infected patients were investigated in the genotypic study, by the randomly amplified polymorphic DNA (RAPD) method. One hundred and six strains were biotyped with the API ZYM system, API AUX 20C system, and boric acid sensitivity. In addition, the minimal inhibitory concentration (MIC) of ketoconazole required to inhibit 94 strains was examined. The relationship was statistically analyzed by the Chi-square test. The results showed that there was no statistically significant relationship among biotypes, genotypes, and antifungal susceptibility. However, the biotype and antifungal susceptibility were associated with the individual host (p = 0.001, p = 0.000, respectively). This study did not find any association among genotyping, biotyping, and antifungal susceptibility. However, it may be useful to test the association between the biotype and antifungal susceptibility in HIV-infected individuals.

22 The Frequencies and Biological Properties of Candida albicans and C. dubliniensis from HIV-positive and -negative Japanese. T. OHSHIMA*, S. NAMIKOSHI, U. YASUNARI, H. WATANABE, N. MAEDA, Tomoko Ohshima Organisation, Tsurumi University, Japan; oshima-t@tsurumi-u.ac.jp

Introduction: Candida dubliniensis, which was originally classified as C. albicans, has been implicated in candidiasis in HIV/AIDS patients. However, there are few data on the prevalence of C. albicans and C. dubliniensis in HIV/AIDS patients in Japan. Objectives: The aims of this study were to investigate the prevalence of C. dubliniensis and C. albicans in the Japanese and to compare the pathogenicity of these species in this population. Methods: In total, 581 strains were isolated from 65 HIV-positive patients and 1438 HIV-negative controls. They appeared as green colonies on CHROM agar and were genotyped as C. albicans A, B, or C, or C. dubliniensis genotype D, by PCR. In addition, growth on Sabouraud’s Dextrose Agar at 30°C and 42°C, carbohydrate assimilation, secreted aspartic proteinases (SAP) production, and antifungal sensitivity of C. albicans and C. dubliniensis was assessed. Results: More than half the isolates typed as genotype A, 10% as B, and 20% as C. Genotype D was found in 10% of HIV-positive and HIV-negative subjects. On Okinawa island, this genotype formed 30~50% of the isolates from HIV-negative subjects. This showed that C. dubliniensis occurred in HIV-positive and -negative patients but varied from region to region. Growth of C. dubliniensis on Sabouraud’s Dextrose Agar at 30°C was lower than that of C. albicans. The carbohydrate assimilation tests showed no difference between the two species, although 75% of strains from HIV-negative subjects showed low levels of xylose assimilation. All strains of C. dubliniensis grew poorly at 42°C, suggesting that growth at this temperature could be used to distinguish between the two species. Secreted aspartic proteinase (SAP) production levels of C. dubliniensis were moderate (relative activity 0.20, n = 40) but lower than those of C. albicans (0.25, n = 117). Most C. albicans strains from HIV-positive patients produced low levels of SAPs (0.21, n = 6). Contrary to our expectation, susceptibility of C. dubliniensis to antifungal agents was higher than that of C. albicans (Fluconazole p < 0.05; Miconazole p, 0.001). C. albicans isolates from HIV-positive patients showed high susceptibility, especially to the azoles (Fluconazole p < 0.0001; Intraconazole p < 0.01; Miconazole p < 0.01), whereas C. dubliniensis susceptibility was low (Miconazole p < 0.01) but not resistant. Conclusion: C. dubliniensis was less pathogenic than C. albicans. However, C. dubliniensis isolated from HIV-positive patients was less susceptible to azoles than isolates from HIV-negative subjects. If strains are isolated from HIV-positive patients with candidiasis, inducible resistance must be considered.

23 In vitro Antifungal Activity of Dodonaea angustifolia, a Traditional South African Medicinal Plant. M. PATEL*, M.M. COOGAN, Oral Microbiology, Oral Health Sciences, University of the Witwatersrand, South Africa; patelms@dentistry.wits.ac.za

Introduction: Oral candidiasis is one of the opportunistic infections most frequently encountered in patients with HIV infection. Antifungal drugs are often prescribed for these patients. However, the long-term use of antimycotic agents leads to the development of resistance. This has led to a search for alternative agents. The leaves of an indigenous South African plant, Dodonaea angustifolia, are used as a traditional remedy for treating oral thrush. Several acids and flavonoids have been isolated from this genus, but no direct link has been established between these compounds and the reported beneficial effects. Objective: This study investigated the antifungal properties of a crude extract of this plant. Methods: Dodonaea angustifolia leaves were collected, dried, milled, and extracted with acetone. The minimal inhibitory concentration (MIC) and percentage kill of the extracts was determined by a microtiter serial dilution technique with C. albicans ATCC 90028 and 20 oral C. albicans strains. Ten strains were isolted from HIV-positive Candida carriers and 10 from HIV-negative Candida carriers. A chlorhexidine gluconate mouthrinse that is recommended for oral candidiasis was used as a positive control. The MIC was performed in triplicate, whereas the percentage kill was tested once on all the strains. Results: Both the plant extract and chlorhexidine inhibited the growth of all the yeast isolates that were tested. The MIC values for the plant extract ranged from 6.25 to 50 mg/mL, whereas the range for chlorhexidine was from 0.008 to 0.016 mg/mL. A concentration of 50 mg/mL of the crude plant extract killed all the isolates within 45 seconds, whereas 2 mg/mL chlorhexidine killed 18 of the 20 isolates within 90 seconds. One of the resistant isolates, from an HIV-positive patient, was killed after 120 seconds, and the other, from an HIV-negative subject, required 180 seconds. There was no significant difference between the results of strains isolated from HIV-positive and -negative patients. Conclusion: These preliminary results indicate that Dodonaea angustifolia has antifungal properties. Further research is required to identify the active ingredient and to test the cytotoxicity of the plant extract.

24 Antifungal Activity of Potassium Lawsone Methyl Ether Mouthwash in Comparison with Chlorhexidine Mouthwash on Oral Candida Isolated from HIV/AIDS Subjects. J. PRASIRST¹, T. LEEWATTHANAKORN¹, U. PIAMSAWAD¹, A. DEJRUDEE¹, P. PANICHAYUPAKARANANT², W. NITTAYANANTA¹*, Faculties of ¹Dentistry and ²Pharmaceutical Sciences, Prince of Songkla University, Thailand; nwipawee@ratree.psu.ac.th

Background: Lawsone methyl ether (2-methoxy-1,4-naphthoquinone) was first isolated from the dried flowers of Impatiens balsamina L and from the Gentianaceae family. It exhibits potent antifungal activity without obvious side-effects. However, the activity of Lawsone methyl ether on Candida albicans isolated from HIV/AIDS subjects has never been studied. Objective: To determine the antifungal activity of 0.5% potassium Lawsone methyl ether mouthwash compared with that of 0.12% and 0.2% chlorhexidine mouthwash on Candida albicans isolated from HIV/AIDS subjects. Methods: An inoculum of Candida albicans isolated from 51 HIV/AIDS subjects was prepared and adjusted with 0.5 McFarland standard. A 0.5-mL quantity of the adjusted inoculum was added in four test tubes with 0.5 mL of each mouthwash, and 0.5 mL RPMI as a control. The tubes were then incubated at 37°C for 48 hrs. The turbidity of each tube was compared with that of the control. The number of Candida albicans colonies was determined by culture with 100 μL of the solution from each tube. Data were analyzed with one-way ANOVA. Results: All of the test tubes with 0.5% potassium Lawsone methyl ether, 0.12%, and 0.2% chlorhexidine mouthwash were clear compared with the controls. Positive culture of Candida albicans was observed in 13 out of 51 plates (25.4%) of 0.12% chlorhexidine mouthwash, in 5 of 51 plates (9.8%) of 0.2% chlorhexidine mouthwash, and in 4 of 51 plates (7.8%) of 0.5% potassium Lawsone methyl ether. The mean number of Candida albicans colonies for each mouthwash were 3.08 (range, 0–40), 0.35 (range, 0–13), and 0.84 (range, 0–24), respectively. Antifungal activity was found to be statistically significantly different between 0.5% potassium Lawsone methyl ether and 0.12% chlorhexidine mouthwash, and between the two concentrations of chlorhexidine mouthwash (P < 0.05). However, no significant difference was observed between the antifungal activity of 0.5% potassium Lawsone methyl ether and 0.2% chlorhexidine mouthwash (P > 0.05). Conclusions: Potassium Lawsone methyl ether showed potent antifungal activity against Candida albicans isolated from HIV/AIDS subjects. Clinical trials of this mouthwash should be conducted to determine if it can be used as an alternative mouthwash in prophylaxis of oral candidiasis among HIV-infected individuals.

25 The Burden of Necrotizing Ulcerative Gingivitis and Periodontitis among Adult Patients Attending a Sexually Transmitted Infection Clinic in Johannesburg. S.R. MTETWA*, J. YENGOPAL, M.J. RUDOLPH, Division of Public Oral Health, University of the Witwatersrand, Johannesburg, South Africa; mtetwas@sph.wits.ac.za

Background: Necrotizing ulcerative gingivitis (NUG) has been identified as the most common oral manifestation of HIV/AIDS seen by public-sector dentists in South Africa (S Afr Dent J 54:594, 1999). Testing for HIV serostatus in adult patients is not undertaken routinely at Public Sector Clinics in Johannesburg. Esselen Street clinic, which is a sexually transmitted infections (STI) clinic based in Hillbrow, Johannesburg, provides an ideal environment to study the prevalence of this condition among HIV-infected adult patients, many of whom do not know their HIV status. The patients were not self-selected for painful oral disease. Objectives: The objectives of the study were (1) to measure the prevalence of NUG and Necrotizing Ulcerative Periodontitis (NUP) in a STI clinic, and (2) to correlate the HIV status with NUG and NUP in patients with a positive diagnosis for NUG and NUP. Methods: One hundred and sixty-five patients whose average age was 28.8 years (range, 19 to 48 yrs) were recruited between 25 November 2003 and 9 March 2004. A questionnaire was administered to obtain demographic details and medical and dental information, and the patients were assessed clinically to establish the absence or presence of NUG and NUP. Patients who were taking antiretrovirals, those with advanced HIV disease, and those who were taking Cotrimoxazole were excluded from the study. Clinic records were checked for information on HIV status. One hundred patients were HIV-negative and 56 were -positive. The diagnostic criteria for HIV-associated periodontal diseases (EC-Clearinghouse, J Oral Pathol Med 22:289, 1993) were used to diagnose NUG and NUP. The diagnostic features of NUG included ulceration, necrosis and sloughing of one or more interdental papillae, and spontaneous bleeding. Tissue destruction was limited to the gingival tissues and did not involve alveolar bone. NUP was characterized by advanced necrotic destruction of the periodontium. There was a rapid loss of the periodontal attachment, destruction or sequestration of bone, and teeth became loose. It was accompanied by severe pain, and halitosis was evident. Results: The prevalence of NUG and NUP at this clinic was 1.8 (3/165). One of the 56 HIV-positive patients had NUG and NUP, and two of the 109 HIV-negative patients had a positive diagnosis for NUG. Conclusion: The correlation of the HIV status with NUG and NUP in patients not self-selected for painful oral disease was weak in this setting.

26 Oral and Periodontal Lesions in 1700 HIV-positive Patients in South India. M. UMADEVI¹*, K. RANGANATHAN¹, T.R. SARASWATHI¹, N. KUMARASWAMY², N.W. JOHNSON³, S. SOLOMON², ¹Department of Oral Pathology, Ragas Dental College and Hospital, ²YRG CARE, VHS Hospital, Chennai, India, and ³Department of Oral and Maxillofacial Medicine and Pathology, Guy’s, King’s & St Thomas Dental Institute, London, UK; uvkrao@vsnl.net

Background: India is estimated to have about 4.5 million people infected with HIV. Oral lesions are common and indicative of HIV infection. Periodontal lesions form an important part of the constellation of oral manifestations in HIV-positive patients. There are very few reports of oral lesions, which describe the periodontal lesions from India. Objectives and setting: This report describes the oral lesions, and periodontal lesions in particular, in 1700 HIV-positive patients presenting to us at RAGAS and YRG CARE, a non-governmental organization in Chennai, South India, since February, 1998. Methods: Clinical diagnosis of oral lesions was based on the criteria of the EC-Clearing House (1993) and the WHO. The simplified Oral Hygiene index (OHI-S) and Community Periodontal Index of Treatment Needs (CPITN) were recorded as described in the WHO reference and reviewed by Page and Morrison (1994). Results: Of the 1700 patients, there were 1251 (74%) males and 449 (26%) females. The age ranged from 7 months to 72 years. 83% of the patients were in the 21- to 40-year age group. 83% of the patients presented with at least one oral lesion. Gingivitis (69%) was the most common lesion, followed by periodontitis (28%) and candidiasis (21%). 44% of patients with periodontitis were smokers. Periodontitis was highly associated with smoking, being 1.6 times more frequent in patients who smoke than in non-smokers (p < 0.01). Patients with candidiasis were 1.7 times more likely to have periodontitis than were patients without candidiasis (p < 0.01). CD4 counts were available for 1070 patients, of whom 454 patients had CD4 counts < 200 and 616 had CD4 counts > 200. There was a statistically significant difference in the occurrence of candidiasis, gingivitis, and periodontitis between these two groups (p < 0.05). Conclusions: Oral lesions are a feature of HIV infection. Gingivitis and periodontitis were the most common oral lesions in our study. Further studies are necessary to understand the importance of periodontitis in HIV patients in our population.

27 Human Papillomavirus (HPV) Type-32-specific Serum IgG Response in HIV-infected Adults. J.E. CAMERON¹*,⁴, J.E. LEIGH^2,4, K. SHETTY^2,4, N. LINDSEY^3,4, E. LILLY^1,4, P.L. FIDEL, Jr.,^1,4, et al., ¹Departments of Microbiology, Immunology & Parasitology, ²General Dentistry, ³Medicine, ⁴Center of Excellence in Oral and Craniofacial Biology, Louisiana State University Health Sciences Center, New Orleans, LA, USA; jcamer@lsuhsc.edu

The incidence of oral warts has reportedly increased in HIV-infected patients during the era of HAART. We have identified HPV-32 as the primary cause of oral warts in the New Orleans HIV cohort. To examine defects in the host response to HPV-32, we cloned and expressed the HPV-32 L1 major capsid gene into the vaccinia virus system to use as antigen in HPV-32-specific immunological assays. Serum from seven case patients (HIV+, with oral warts) and 50 screening patients (HIV+, without oral warts) was tested by enzyme-linked immunosorbent assay (ELISA) for HPV-32-specific IgG antibodies. HPV-32-specific responses were observed in 4/5 cases with HPV-32+ oral warts and in 48% of screening patients, but not in patients with oral warts containing other HPV genotypes. Two out of three screening patients with asymptomatic oral HPV-32 infection seroreacted to HPV-32 capsid antigen. Responses were more frequently detected in men, reflecting the demographics of patients with oral warts in the New Orleans HIV cohort. Future studies will utilize HPV-32 capsids as antigen in ELISA and cellular immune assays to examine peripheral and mucosal responses to HPV-32 infections, to identify markers of susceptibility to HPV-32-associated disease.

28 Local Immune Reactivity in Oral Warts and Oral Hairy Leukoplakia of HIV-infected Persons. E. LILLY, K. SHETTY, K. MCNULTY, J.E. LEIGH, J.E. CAMERON, P.L. FIDEL, Jr.*, et al., Louisiana State University Health Sciences Center and Center of Excellence in Oral and Craniofacial Biology, New Orleans, LA 70112, USA; pfidel@lsuhsc.edu

Background: Oral hairy leukoplakia (OHL) caused by Epstein-Barr virus and oral warts caused by human papillomavirus (HPV) are common infections in HIV-infected persons. Although each pathological condition occurs most often under reduced blood CD4 cell numbers, the lack of concurrent pathologies suggests that each results from unique local immune dysfunction(s). Objective: To evaluate local immune reactivity in oral warts and OHL through salivary cytokines and tissue-associated T-cells and cytokine mRNA. Methods: A cohort of HIV+ persons (n = 48) with and without oral warts and OHL was evaluated. Salivary Th and pro-inflammatory cytokines were quantified in unstimulated saliva by ELISA. CD3, CD4, and CD8 T-cells were identified by immunohistochemical staining of frozen tissue biopsies. Tissue-associated cytokine mRNA was evaluated by real-time PCR. Results: Few differences were detected in any parameter. Compared with matched controls (HIV+ persons without lesions but positive for oral HPV or EBV DNA), those with OHL had increased IL-1, IL-2, and IL-10 in saliva, while those with oral warts had increased IL-1, IL-2, and decreased IL-6. CD8 T-cells predominated in the tissue, but in low numbers. No differences were detected between warts and lesion-negative sites, while CD8 T-cells were greater in lesion-negative sites compared with OHL. Tissue-associated cytokine mRNA between lesion-positive and lesion-negative persons showed decreased IL-2 and increased TNF in those with warts, and decreased IL-1 and increased IL-6 and IL-15 in those with OHL. Conclusion: There is no pattern of changes in local immunity to explain the susceptibility to oral warts and OHL, and overall little evidence for local immune reactivity in either lesion. It is anticipated that while immunosuppression plays an indirect role in susceptibility to infection, virologic factors are most critical to prevalence.

29 Detailed History of HIV+ Individuals with Oral Warts Reveals the Possibility of Two Epidemics. M.E. HAGENSEE*, J.E. CAMERON, J.E. LEIGH, K. SHETTY, N. LINDSEY, P. HICKMAN, et al., Louisiana State University Health Sciences Center, New Orleans, LA, USA; mhagen@lsuhsc.edu

Background: It has been reported that oral warts have increased in prevalence in HIV+ individuals. To understand this better, we performed a detailed chart history of HIV+ individuals from New Orleans and having oral warts. Methods: The medical records of individuals with biopsy-confirmed oral wart were reviewed for the initial date of diagnosis of the oral lesion, any history of anal, hand warts or other HPV-related pathology, detailed history of HAART and its effectiveness, and all CD4 and HIV viral load (VL) measurements. The HPV infection was genotyped by consensus PCR. Results: Charts from 13 patients with oral warts were reviewed, comprising 819 months of care. There were 12 men, of whom nine were Caucasian, with an average CD4 of 256 and HIV VL of 10,683 at the time of oral wart diagnosis. HPV-32 was present in 63%. Ten were on HAART, with only five being effective (HIV VL < 400). There was evidence of 2 distinct groups: chronic—six men with a long history of oral warts (8–37 months) and also having anal or hand warts; and acute—six men with a short history of oral warts (2–15 months) and rare history of other warts. The chronic group had largely uncontrolled HIV infection (5/6 had detectable HIV VL, with frequent therapeutic changes). In contrast, the acute group had largely controlled HIV infection (1/6 had detectable HIV VL with more stable regimens). Both groups had similar average CD4 counts (245 vs. 248). The only woman had an oral wart for a short duration (2 months) but developed invasive cervical cancer 12 months later. Discussion: Detailed histories of HIV+ individuals with oral warts reveal two epidemics in the New Orleans cohort. The chronic cases indicate a generalized susceptibility to HPV infections at any body site. The acute cases may reflect temporary changes in HPV-specific immune function, interactions with HIV medications, or other changes in oral health. Future studies are indicated to improve our understanding of these clinical findings.

30 Site-specific Prevalence of 27 Human Papillomavirus (HPV) Genotypes in the Oral Cavity of HIV+ Individuals. N. LINDSEY*, J.E. CAMERON, A.F. HAMMONS, T.E. BECKEL, K. SHETTY, J.E. LEIGH, et al., Louisiana State University Health Sciences Center, New Orleans, LA, and ⁵Roche Molecular Systems, USA;(AQ) nlinds@lsuhsc.edu

Incidence of oral warts has recently increased in HIV+ individuals. Since little is known about the natural history of oral HPV infection, a comprehensive analysis of the prevalence of all oral HPV genotypes and the infection site was undertaken. We are examining the prevalence of 27 genotypes using sensitive consensus PCR-based detection on DNA obtained from nine oral samples (buccal mucosa, labia, tongue, sublingual mucosa, palate, gingiva, tonsils, saliva, and gargle) in HIV+ subjects who have no oral warts. To date, over 300 people have been enrolled, with 148 subjects having all sites screened for HPV. HPV was most prevalent in gingival (32%) and labial (29%) tissue, though all sites were susceptible. HPV+ subjects (54%) harbored HPV at anywhere from one site to all sites tested. Genotyping by Roche reverse line blot identified HPV-83 and -45 as the most prevalent genotypes. There was no apparent site-predilection associated with any genotype. Subjects with multiple HPV+ sites frequently carried the same genotypes in each site. 27% of HPV infections were untypable. The ongoing development of a rapid screening test for additional oral-specific HPV genotypes will help identify these untypable samples and promote studies of the natural history of oral HPV infection/disease in susceptible hosts.

31 HIV Antibody Screening; Saliva an Alternative to Serum. S. BALASUNDARAM*, Ragas Dental College, Chenai, India; bbaallaa2002@yahoo.co.in

Background: HIV infection is a major health issue in India, with 4–5 million people infected by the end of 2003 (National AIDS Control Organisation). Given the high burden of HIV infection, reliable, rapid screening procedures are needed. Studies have shown that saliva has the potential to be a reliable alternative to blood as a diagnostic fluid. We present here the results, of two serum-based screening tests available in India, for saliva. Methods: A case-control study (25 seropositive and 25 seronegative) was undertaken on patients attending the outpatient unit of Ragas Dental College and Hospital and YRG CARE Chennai, India. Saliva was collected by the ’spit’ method. Salivary antibodies to HIV were investigated by ELISA and the immuno-chromatographic test (IHC). The ELISA values were analyzed with the cut-off prescribed by the manufacturer for the serum test. The IHC was modified to evaluate color change. Results: Our study shows a sensitivity and specificity of 100% for the ELISA method, whereas the IHC procedure demonstrated a sensitivity of 80% and specificity of 100%. Conclusion: The result of this study showed a sensitivity and specificity of 100% for the ELISA method, with the use of a commercially available serum-based kit. If similar results can be obtained with a larger number of patients, this test could be a reliable and easy diagnostic aid in population-based screening procedures.

32 Elevation of Salivary Antimicrobial Protein Concentrations against Increase of Candida Depending on CD4+ Count in HIV-positives. S. NAMIKOSHI¹*, T. OHSHIMA², H. CHIBA¹, N. MAEDA¹, ¹Department of Oral and Maxillofacial Surgery, Tokyo Medical University, AND ²Department of Oral Bacteriology, Tsurumi University School of Dental Medicine, Japan; namilily@hotmail.com

An opportunistic infection, oral candidiasis, frequently occurs among human immunodeficiency virus (HIV)-positive individuals as an initial symptom in the oral cavity, particularly in individuals with less than 200/μL of CD4+ count. However, many antimicrobial proteins—such as secretory leukocyte protease inhibitor (SLPI), lactoferrin, lysozyme, and sIgA—exist in saliva. These proteins play an important role in maintaining oral mucosal integrity. We investigated the relationship between salivary antimicrobial proteins and Candida carriage in both HIV-positive patients and healthy controls. A sample was obtained from the dorsum of the tongue and inoculated onto a selective medium for Candida, CHROMagar^TM Candida (CHROMagar, Paris, France) and incubated at 30°C for 48 hrs. For measurement of antimicrobial proteins, stimulated whole saliva was collected by means of Salivette^® (Sarstedt, Köln, Germany) when the subjects chewed on sterile cotton wool according to the manufacturer’s instructions. The concentrations of SLPI, lactoferrin, and sIgA were determined by enzyme-linked immunosorbent assay with commercially available kits (SLPI, Quantikine^®, R&D Systems, Minneapolis, MN, USA; lactoferrin, Bioxytech^®, OXIS, Portland, OR, USA; sIgA, EIA s-IgA test^®, MBL, Nagoya, Japan). The concentration of lysozyme was determined by a decrease in the turbidity of a Micrococcus lysodeikticus suspension. Candida carriage in the HIV group was significantly higher than in the healthy controls, and increased in inverse proportion to the CD4+ count. When compared with the controls, the level of SLPI in the HIV group was significantly lower, whereas that of sIgA was higher. The levels of lactoferrin and lysozyme in both groups were similar. Contrary to our expectation, most antimicrobial proteins were higher in Candida-positives than in -negatives. All pairs of antimicrobial proteins showed a significantly positive correlation. These results suggested that salivary antimicrobial proteins are elevated in reaction to the increase of Candida. When compared among HIV-positive patients who were divided into three categories based on CDC classification, most antimicrobial proteins were the lowest in category 3, suggesting the suppression of innate immunity in HIV-positive patients whose CD4+ counts were less than 200/μL. These results indicated that the salivary antimicrobial proteins are important factors for protection against several infections, including oral candidiasis. However, their level was suppressed in advanced cases of HIV infection.

33 Identifying Viral Characteristics Responsible for Oral Transmission of SIV through Breast Milk in Rhesus Monkeys. J. RYCHERT¹, L. FRESH², M. RATTERREE², A.M. AMEDEE¹*, ¹Louisiana State University Health Sciences Center, New Orleans, LA, USA, and ²Tulane National Primate Center, Covington, LA, USA; aamede@lsuhsc.edu

Background: Several risk factors have been identified for breast milk transmission of HIV; however, little is known about the specific viral properties responsible. Using SIV-infected lactating rhesus macaques as a model, we have shown that specific viral genotypes are transmitted, and that the level of virus expressed in milk is the most significant correlate of transmission. Objective: The goal of this study was to characterize orally transmitted viral genotypes and evaluate the dynamics of this viral phenotype in naïve lactating macaques. Methods: Viral envelope sequences from ten breast-milk-infected infants were compared with the original virus inoculum and genotypes expressed in milk. For in vivo characterization, virus was amplified from one infected infant (Macaque CK35) and used to inoculate six naïve lactating macaques. Results: SIV envelope sequences from infants infected through breastfeeding only differed from each other and the parental virus stock over the envelope variable regions 1 and 4 (V1 and V4). Using pairwise comparisons, we found that sequences from infants were significantly longer over the V1 sequences found in the parental stock or the milk of non-transmitting mothers, and contained more potential glycosylation sites. Naïve lactating macaques inoculated with SIV/CK35 had peak levels of milk virus similar to those in animals inoculated with the parental strain, but expression was more persistent. Transmission occurred rapidly in 4 of 6 mother-baby pairs infected with SIV-CK35, while rapid transmission was observed in only 2 of 14 mothers infected with the parental virus. Conclusion: These results indicate that specific viral genotypes are more persistently expressed in milk, and are capable of oral transmission through milk. As interventions for breast milk transmission of HIV are designed, the SIV/CK35 isolate provides a valuable tool for targeting and deciphering the specific viral properties responsible for transmission.

34 Immunoglobulin A (IgA) Levels in the Oral Cavities and Respiratory Tracts of HIV+ Individuals Treated with Highly Active Anti-retroviral Therapy (HAART). P. CHAIYARIT¹*, H.L. TWIGG III², R.L. GREGORY², ¹Faculty of Dentistry, Khon Kaen University, Thailand, and ²Indiana University School of Medicine, Indianapolis, USA; pchaiyarit@yahoo.com

In HIV individuals, depletion of CD4+ cells is associated with a loss of immune function, and the mucosa becomes susceptible to various opportunistic infections. Recent studies demonstrated that HAART increased circulating CD4+ T-cells. However, limited data are available on the effect of HAART on mucosal immune responses. Thus, the objective of this study was to measure the mucosal IgA levels in the oral cavities and respiratory tracts of HIV+ individuals treated with HAART, to provide evidence for the effect of HAART on the mucosal humoral responses. Mucosal IgA levels—including IgA, IgA₁, IgA₂, secretory IgA (S-IgA), S-IgA₁, and S-IgA₂ collected from parotid saliva (PS), bronchial fluid (BF), and broncho-alveolar lavage (BAL) of HIV+ individuals—were measured by enzyme-linked immunosorbent assay (ELISA). In total, 36 human subjects were recruited for this research, including 16 HIV- subjects, 12 HIV+ patients with HAART, and eight HIV+ patients without HAART. One-way analysis of variance (ANOVA) was used to compare the mucosal IgA levels among groups. There were significantly lower levels of PS IgA in HIV+ patients with and without HAART than in HIV- subjects (p < 0.05). However, total BF IgA levels from HIV+ patients with and without HAART were significantly increased. BAL IgA₁ and S-IgA₁ levels were significantly increased, whereas BAL IgA and S-IgA₂ levels were decreased in HIV+ subjects. In summary, our findings demonstrated no significant differences of mucosal IgA levels in the oral cavities and respiratory tracts of HIV+ individuals with HAART and without HAART, but there were significant effects between HIV+ and HIV- subjects.

35 HIV-1 and C. albicans Regulate Expression of Calprotectin (S100A8/A9) in Tonsillar Epithelial Cells. A. TANGJATURONRUSAMEE*, M. HERZBERG, K. ROSS, University of Minnesota, Minneapolis, USA; tang0160@umn.edu

Candidiasis is a major problem in HIV-positive patients. This may relate to the increase of Candida virulence or the reduction of host defense to microbial invasion in HIV-positive patients. Calprotectin (S100A8/S100A9;MRP8/14) is an antimicrobial cytosolic protein expressed by gingival keratinocytes and tonsillar epithelial cells. Cytosol from calprotectin-expressing cells contains antifungal activity. We hypothesize that calprotectin is down-regulated during HIV infection, leading to a reduction of the antimicrobial activity of oral epithelial cells. Tonsillar epithelial cells were tested by flow cytometry to demonstrate HIV receptors on the surface. The surfaces were negative for chemokine receptors CXCR4 and CCR5. Heparin sulphate receptors CD3, CD138, LFA-1,CD4, DC-SIGN, CD64, CD89, and CD32 were also negative, but the beta-4 integrin CD104 was found on 91% of cells. Thereafter, primary tonsillar epithelial cells grown in monolayer were incubated with either C. albicans (MOI 100:1) or HIV-1, IIIB, or Ba-L (MOI 1:10) for 2 hrs. Viral uptake in epithelial cells and transfer to peripheral blood mononuclear cells (PBMCs) were observed. Total RNA was extracted with TRIZOL. Expression of mRNA was analyzed by real-time RCP, with TaqMan probes from Applied Biosystems for S100A8, S100A9, and TBP (Tatabox Binding Protein; endogenous control) and compared with expression of S100A8 and A9 in tonsillar epithelial cells alone. S100A8-and S100A9-specific mRNA was up-regulated 8- and 29-fold, respectively, when cells were incubated with C. albicans. Tonsil cells incubated with HIV-1, either IIIB or Ba-L, showed a decrease in S100A8- (IIIB, 0.03-fold; Ba-L, 0.3-fold) and S100A9- (IIIB, 0.08-fold; Ba-L, 0.12-fold). In conclusion, analysis of these data shows that tonsillar epithelial cells respond to HIV-1 and C. albicans by a decrease or increase in S100A8- and A9-specific mRNA. Down-regulation of calprotectin by HIV-1 may play a role in Candida infection of oral epithelial cells.

36 Innate Host Defense in Oral Mucosal Resistance to HIV-1. T. GREENWELL-WILD*, G. MA, W. JIN, K.J. LEI, J. SWISHER, G. PENG, et al., OIIB, NIDCR, NIH, Bethesda, MD 20892-4352, USA; twild@dir.nidcr.nih.gov

Background: Mucosal sites are vulnerable targets for HIV-1 transmission. Nonetheless, in the oral mucosa, transmission is infrequent, and although HIV-1 RNA is detected, identification of infectious virus is rare. Our earlier studies comparing innate and adaptive immune factors that might contribute to resistance revealed that components of the adaptive immune response were not discriminatory between oral and genital mucosa and blood, but differences could be detected in innate host defense molecules. Neither the levels of HIV-1-specific IgA nor IgG correlated with the inhibition of infectious HIV-1, since Ig titers were highest in blood, where infectious virus was highest. Levels of the innate inhibitor, thrombospondin, did not correspond with reductions in infectious virus. By comparison, secretory leukocyte protease inhibitor (SLPI) was highest in the oral cavity, where infectious HIV-1 was undetectable, and lowest in peripheral blood, in which infectious virus was maximal. While SLPI has been shown to inhibit HIV-1 in vitro, and the distribution of SLPI at entry portals portends its involvement in defending the host from pathogens, the mechanism by which it inhibits HIV-1 has remained enigmatic. Objectives: To define the mechanisms by which mucosally derived SLPI influences HIV-1 infection, particularly in macrophages, which are involved in initial viral selection, dissemination, and transmission of virus to CD4+ T-cells and serve as long-term covert reservoirs of HIV-1. Methods: M-tropic HIV-1 was added to macrophage cultures in the presence or absence of SLPI, and infection was monitored by p24 levels. Membrane SLPI binding proteins were isolated by gel electrophoresis, followed by mass spectrometry and sequence analysis. The expression of the membrane-binding proteins was monitored by RNA and protein analysis, including fluorescence microscopy and flow cytometry. Results: SLPI inhibited viral infection by interaction with the host cell, rather than the virus, and blocked infection at an early stage in the viral life cycle. Isolation of membrane SLPI binding proteins revealed several candidates, including a phospholipid-binding protein, characterized by immunological parameters and binding specificity. SLPI did not block HIV-1 binding, but rather inhibited post-binding and pre-reverse transcription, a point in the viral life cycle consistent with a proposed role for SLPI in the inhibition of a fusogenic step. Conclusions: Macrophages represent an important anti-viral target, due to their involvement in viral selection, dissemination, and transmission of HIV-1, and their ability to serve as viral reservoirs. Particularly evident is the enormous viral burden in macrophages in the later-stage HIV-1/AIDS during opportunistic infections. Identification of an SLPI membrane-binding protein provides new insight into its mechanism of action and reveals a new cellular co-factor supporting macrophage HIV-1 infection. Analysis of these data suggests that innate host defense mediators present in the mucosa may influence HIV-1 infection and/or transmission, providing insight into potential interventional approaches.

37 Permissive Factors Underlying HIV-1 Infection in the Tonsil. N.M. MOUTSOPOULOS¹*, T. GREENWELL-WILD², N. VAZQUEZ², J. ORENSTEIN¹, S.M. WAHLM², ¹Oral Infection and Immunity, NIDCR, NIH, Bethesda, MD, and ²Department of Pathology, George Washington University, Washington, DC, USA; niki.moutsopoulos@nih.gov

Background: The tonsils represent secondary lymphoid organs implicated in all stages of HIV-1 pathogenesis. Shortly after HIV-1 infection occurs, the tonsils become heavily infected, both in the germinal center areas and in the region of the lympho-epithelium. Although it is still debated whether the tonsils are a primary, as well as secondary, site of infection, it is clear that they are highly susceptible to infection and viral replication. Objectives: To dissect the cellular and molecular mechanisms underlying the enhanced susceptibility of tonsils to HIV-1 infection in vivo and in vitro. Methods: Tonsil tissues from HIV-1-infected and -uninfected individuals were subjected to cDNA expression array and compared with peripheral blood mononuclear cells (PBMC). Gene expression profiles were confirmed through RNAse protection assays (RPA) and electrophoretic mobility shift assays (EMSA). Immunohistochemical staining of infected and uninfected tissues was performed to identify populations associated with disease pathogenesis. Additionally, in vitro infection of tonsil lymphoid cells was performed in parallel with PBMC, to define mechanisms of susceptibility implicated in the cDNA array analysis. Results: Compared with PBMC, numerous genes were differentially expressed in uninfected tonsils, including genes involved in signal transduction, cell cycle, and transcription. Evidence for increased gene expression of the TH2 cytokines, IL-4, IL-10, and IL-6, and the transcription factor NFATc in the tonsil tissues was consistent with endogenous stimulation. In the tonsils from HIV-1-seropositive patients, an increased expression of genes encoding for antiviral, apoptotic, and extracellular matrix degradation factors was observed. Additionally, immunoregulatory genes, including the cytokines IL-10 and TGF-β, were up-regulated. Analysis of in vitro infection of tonsil lymphoid cells revealed enhanced viral susceptibility consistent with the HIV-1 localization in vivo. Furthermore, altered cytokine profiles in vitro reflected their tissue expression. Conclusions: Persistent underlying immune stimulation in HIV-1-uninfected tonsils is consistent with their enhanced susceptibility to infection and increased viral production. Similarly, the gene profile in HIV-1+ tissues may reflect unsuccessful immune clearance of the virus, which ultimately leads to immune deterioration and local tissue destruction. Furthermore, the presence of immunosuppressive factors may contribute to this ineffective antiviral response, which may suggest potential therapeutic options, as well as furthering our understanding of mechanisms of immune regulation.

38 Oral Epithelial Cell Anti-Candida Activity—Evidence against a Presumptive Role for Carbohydrates. J. YANO*, E. LILLY, P.L. FIDEL, Jr., Louisiana State University Health Sciences Ctr. and Center of Excellence in Oral and Craniofacial Biology, New Orleans, LA, USA; jyano@lsuhsc.edu

Background. Host defense against oropharyngeal candidiasis (OPC) caused by the mucosal commensal organism, Candida albicans, is poorly understood. While cell-mediated immunity (CMI) by Th1-type CD4+ T-cells is considered a critical host defense mechanism against OPC, innate mechanisms are considered to have protective roles as well. Among innate anti-Candida resistance mechanisms, oral epithelial cells inhibit the growth of Candida species in vitro. The mechanism of action includes a strict requirement for cell contact, with no role for soluble factors or epithelial intracellular signaling. Abrogation of activity following treatment of the cells with periodic acid, but not inhibitors of proteins or phospholipids, had suggested a role for a cell-surface carbohydrate. However, studies with several carbohydrate inhibitors have failed to identify any specific effector carbohydrate. Objective: To address further the putative role for carbohydrates in the antifungal activity. Results: Results showed that a putative effector carbohydrate released from epithelial cells by periodic acid treatment could not be regenerated or re-attached. In other studies, the putative carbohydrate(s) released into the supernatant of periodate-treated epithelial cells could not competitively inhibit the antifungal activity by fresh epithelial cells. Additionally, equivalent abrogation of antifungal activity was observed regardless of the amount of carbohydrate released by treated epithelial cells, and abrogation of antifungal activity was similarly observed following treatment with several other acids. Finally, antifungal activity was minimally affected by fixing the cells prior to co-culture, where the majority of cells remained impermeable to trypan blue as a measure of viability. Conclusion: Together, these results suggest that, instead of antifungal activity being mediated by an effector carbohydrate, activity is dependent on contact with intact, but not necessarily live, epithelial cells by an as-yet-unidentified acid-labile mechanism.