title: The early years of the Edinburgh HIV epidemic
Creators: name: Willocks, Lorna Jane
Publisher: name: University of Glasgow
Year: 1994

description: The aim of this thesis is to document the early natural history of HIV infection. A medical clinic for the care of HIV infected patients was established in Edinburgh in October 1985. By November 1989, 409 patients had attended this clinic and most were under regular follow up. Most patients were injection drug users (IDUs) accounting for 78% attenders, 12% were homosexual men, 7% were infected heterosexually, 1% from blood products and in 2% there were no documented risk factors. Most of the IDUs acquired HIV infection between September 1983 and June 1984 and are a unique cohort for prospective natural history studies. The other clinic attenders provide a valuable comparison group. The first four years of the clinic were chosen as the cut off point for early natural history, being six years after the introduction of HIV into the IDU population of Edinburgh. Morbidity was assessed by hospital admissions. All hospital admissions by HIV positive patients in Edinburgh were analysed. These included admissions to the designated HIV unit and to all other general and psychiatric hospitals in Edinburgh. All deaths before November 1989 were analysed, whether they occurred in hospital or at home and all post mortem results were obtained. By November 1989, 910 admissions were recorded. Although 612 of these were to the designated HIV unit, 298 were to other hospitals in Edinburgh. IDUs accounted for 702 (77%) admissions, homosexual men for 136 (15%), patients with heterosexually acquired HIV infection for 62 (7%) and recipients of blood products for 10 (1%). The most frequent admissions were for conditions directly related to drug use. These comprised overdose, trauma, injection injuries and detoxification and accounted for 220 admissions. From comparisons with published data this number is in excess of what would be expected in a historical cohort of HIV negative IDUs. Most days in hospital were used by patients with respiratory conditions (187 admissions). These were the single commonest reason for admission to the designated HIV unit. The majority (97) were for bacterial chest infections (BCIs) and only 48 were with Pneumocystis carinii pneumonia (PCP). Of these 48 admissions, seven had a concomitant BCI. Differentiating BCIs and PCP clinically was difficult, as was the diagnosis of PCP in IDUs. A clinical algorithm was therefore drawn up for the management and investigation of IDUs presenting with respiratory symptoms and a separate study of the use of induced sputum techniques was conducted. This latter study confirmed the value of these techniques, obviating the need for bronchoscopy, the usual "gold standard". Thirty four deaths were recorded before November 1989, of which 19 were due to AIDS, two to liver disease and 13 were ascribed to drug use. Post mortem examination revealed that one of the deaths in the latter category was due to a florid meningoencephalitis. Despite the prevalence of bacterial infections, no deaths were attributable to this. Multiple pathology was detected in all patients dying of AIDS, with unexpected findings in eight of the nine patients who had post mortem examinations. These findings demonstrate a high level of morbidity and mortality even in the early years of HIV infection. Most previously published studies have focused on homosexual men and patients with advanced HIV disease and AIDS. This thesis has the advantage of documenting disease in patients hitherto not the focus of research, namely women, IDUs and patients with early stage HIV infection. It also provides a complete picture of an epidemic in one city, having studied all hospital admissions and deaths. The preponderance of bacterial infections as a cause of morbidity is important for prevention and prophylaxis. The documentation of health care utilisation is vital for planning of future resources. (Abstract shortened by ProQuest.)