The early diagnosis of infection with human immunodeficiency virus (HIV) in infants born to infected mothers is essential for early treatment, but current tests cannot detect HIV infection in newborns because of the presence of maternal antibodies. We used the polymerase chain reaction, a new technique that amplifies proviral sequences of HIV within DNA, to detect HIV infection in peripheral-blood mononuclear cells obtained from infants of seropositive women during the neonatal (age less than 28 days) and postneonatal periods. In blood obtained during the neonatal period, the polymerase chain reaction was positive in five of seven infants in whom the acquired immunodeficiency syndrome (AIDS) later developed (a mean of 9.8 months after the test). The test was also positive in one of eight newborns who later had nonspecific signs and symptoms suggestive of HIV infection (mean follow-up, 12 months). No proviral sequences were detected in neonatal samples from nine infants who remained well (mean follow-up, 16 months). HIV proviral sequences were detected in samples obtained during the postneonatal period (median age, five months) in all of 6 infants tested who later had AIDS and in 4 of 14 infants with nonspecific findings suggestive of HIV infection. No proviral sequences were detected in 25 infants who remained well (mean follow-up, 17 months) after being born to HIV-seropositive mothers, or in 15 infants born to HIV-seronegative mothers. We conclude that the polymerase chain reaction will be a useful technique to diagnose HIV infection in newborns and to predict the subsequent development of AIDS. However, larger studies will be required to determine the sensitivity and specificity of the test.

The HIV-infected population in the U.S. is expanding as patients survive longer and new infections are identified. In many areas, particularly rural/medically-underserved regions, there is a growing shortage of providers with sufficient HIV expertise. HIV services incorporated into community-based, primary care settings may therefore improve the distribution and delivery of HIV treatment. Our objective was to describe/compare patients and treatment outcomes in two settings: a community-located, primary care-based HIV program and a hospital-based specialty center. Community-based providers had on-site access to generalist HIV experts. The hospital center was staffed primarily by infectious disease physicians. This was a retrospective cohort study of 854 HIV-positive adults initiating care between 1/2005 and 12/2007 within an academic medical center network in the Bronx, NY. Treatment outcomes were virologic and immunologic response at 16-32 and 48 weeks, respectively, after combination antiretroviral therapy (cART) initiation. We found that hospital-based subjects presented with a higher prevalence of AIDS (59% vs. 46%, p < 0.01) and lower initial CD4 (385 vs. 437, p < 0.05) than community-based subjects. Among 178 community vs. 237 hospital subjects starting cART, 66% vs. 62% achieved virologic suppression ([95% CI difference −0.14-0.06]) and 49% vs. 59% achieved immunologic success, defined as a 100 cell/mm 3 increase in CD4 ([95% CI difference 0.00-0.19]). The multivariateadjusted likelihoods of achieving viral suppression (OR = 1.24 [95% CI 0.69-2.33]) and immunologic success (OR = 0.76 [95% CI 0.47-1.21]) were not statistically significant for community vs. hospital subjects. Because this was an observational study, propensity scores were used to address potential selection bias when subjects presented to a particular setting. In conclusion, HIV-infected patients initiate care at community-based clinics earlier and with less advanced HIV disease. Treatment outcomes are comparable to those at a hospital-based specialty center, suggesting that HIV care can be delivered effectively in community settings.

We studied decisions to continue or terminate pregnancy among human immu-

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