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Risk Factors for Repeatedly Reactive HIV-1 EIA and Indeterminate Western Blots: A Population-Based Case-Control Study

Risk Factors for Repeatedly Reactive HIV-1 EIA and Indeterminate Western Blots: A... Abstract Objective: Causes of indeterminate results of Western blot testing (IWB) for human immunodeficiency virus (HIV) type 1 include seroconversion, HIV-2 cross-reactivity, and autoimmune disease, but most IWB results remain unexplained. This case-control study assessed risk factors for IWB results, including early HIV infection, other retroviral infection, autoantibodies, and other medical conditions. Design: Prospective study to determine HIV seroconversion rate, with a case-control design to assess other risk factors for IWB. Cases (persons with one or more repeatedly reactive HIV-1 enzyme immunoassay with IWB), their current sexual partners, and controls (persons with negative enzyme immunoassay and Western blot results) were recruited from blood banks, health department and prenatal clinics, and private providers in Washington and Oregon. Results: Of 244 cases enrolled, 206 were followed up for 6 months or longer, and six (3.0%; 95% confidence interval [CI], 0.7% to 5.3%) with recent HIV risk behaviors seroconverted. The Western blot banding patterns differed among groups; cases usually had p17 or p24 bands, while controls and cases' sexual partners usually had polymerase bands. Conditional logistic regression indicated that independent risk factors for IWB among male cases and controls were a tetanus booster in the past 2 years (odds ratio, 3.2; 95% CI, 1.2 to 8.6) and sexual contact with a prostitute (odds ratio, 3.0; 95% CI, 1.0 to 9.5). Independent risk factors for women were parity (odds ratio, 1.2;95%CI, 1.02 to 1.4) and autoantibodies, either rheumatoid factor or antinuclear antibodies (odds ratio, 2.3; 95% CI, 1.03 to 5.6). No cross-reactivity was detected with HIV-2, human T-lymphotrophic virus type 1, feline immunodeficiency or feline leukemia, or bovine immunodeficiency viruses. Conclusions: Evaluation of persons with reactive HIV-1 enzyme immunoassays and IWB should include an assessment of HIV risk and other possible risk factors, such as alloimmunization (ie, parity or recent immunization) or autoantibodies (ie, antinuclear antibodies and rheumatoid factor). The relationship of IWB among men who reported sex with prostitutes is intriguing and warrants further study.(Arch Intern Med. 1994;154:1129-1137) References 1. Reesink HW, Huisman JG, Gonsalves M, et al. Evaluation of six enzyme immunoassays for antibody against human immunodeficiency virus . Lancet. 1986; 2:483-486.Crossref 2. Burke DS, Brundage JF. Redfield RR. et al. Measurement of the false-positive rate in a screening program for human immunodeficiency virus infections . N Engl J Med. 1988;319:961-964.Crossref 3. Weiss SH, Goedert JJ, Serngadharam MG, Bodne AJ, Gallo RC, Blattner WA. Screening tests for HTLV-III (AIDS agent) antibodies . JAMA . 1985;253:221-225.Crossref 4. Ward JW, Grindon AJ, Feorino PM, Schable C, Parvin M, Allen JR. Laboratory and epidemiologic evaluation of an enzyme immunoassay for antibodies to HTLV-III . JAMA. 1986;256:357-361.Crossref 5. Centers for Disease Control. Update: Serologic testing for HIV-1 antibody— United States, 1988 and 1989 . MMWR Morb Mortal Wkly Rep. 1990;39:380-382. 6. Carlson JR, Bryant ML, Hinrich SH, et al. AIDS serology testing in low- and high-risk groups . JAMA. 1988;253:3405-3408.Crossref 7. Schwartz JS, Dans PE, Kinosian BP. Human immunodeficiency virus test evaluation, performance, and use . JAMA. 1988;259:2574-2579.Crossref 8. Centers for Disease Control. Interpretation and use of the Western blot assay for serodiagnosis of human immunodeficiency virus type 1 infections . MMWR Morb Mortal Wkly Rep. 1989;38(No. (S-7) ):1-7. 9. McDonald KL, Jackson JB, Bowman RJ, et al. Performance characteristics of serologic tests of human immunodeficiency virus type 1 (HIV-1) antibody among Minnesota blood donors . Ann Intern Med. 1989;110:617-621.Crossref 10. Midthun K, Garrison L, Clements ML, et al. Frequency of indeterminate Western blot tests in healthy adults at low risk for human immunodeficiency virus infection . J Infect Dis. 1990;162:1379-1382.Crossref 11. Westblom TU, Belshe RB, Gorse GJ, et al. Characteristics of a population volunteering for human immunodeficiency virus immunization . Int J STD AIDS. 1990;1:126-128. 12. Gaines H, Sonnerborg A, Czajkowski J, et al. Antibody response in primary human immunodeficiency virus infection . Lancet. 1987;1:1249-1253.Crossref 13. Ranki A, Krohn M, Allain J-P, et al. Long latency precedes overt seroconversion in sexually transmitted human immunodeficiency virus infection . Lancet. 1987;2:590-593. 14. Wilber JC, Louie B, Soncuya E, et al. Evaluation of indeterminate results in HIV serology: distinguishing seroconversions from false positives . In: Program and abstracts of the 28th Interscience Conference on Antimicrobial Agents and Chemotherapy; October 23-26, 1988; Los Angeles, Calif. 15. Biggar RJ, Melbye M, Ebbesen P, et al. Variation in human T lymphotrophic virus III (HTLV-III) antibodies in homosexual men: decline before onset of illness related to acquired immune deficiency syndrome (AIDS) . BMJ. 1985; 291:997-998.Crossref 16. Farzadegan H, Polis MA, Wolinsky SM, et al. Loss of human immunodeficiency virus type 1 (HIV-1) antibodies with evidence of viral infection in asymptomatic homosexual men . Ann Intern Med. 1988;108:785-790.Crossref 17. O'Brien TR, George JR. Holberg SD. Human immunodeficiency virus type 2 infection in the United States: epidemiology, diagnosis, and public health implications . JAMA. 1992;267:2775-2779.Crossref 18. DeCock KM. Porter A, Kouadio J, et al. Cross-reactivity on Western blots in HIV-1 and HIV-2 infections . AIDS. 1991;5:859-860.Crossref 19. Myers RA, Patel JD, Joseph JM. Identifying HIV-2 seropositive individuals by reevaluating HIV-1 indeterminate sera . J Acquir Immune Defic Syndr. 1992; 5:417-423. 20. George JR, Rayfield MA, Phillips S, et al. Efficacies of U.S. Food and Drug Administration—licensed HIV-1 screening enzyme immunoassays for detecting antibodies to HIV-2 . AIDS. 1990;4:321-326.Crossref 21. Centers for Disease Control. Update: HIV-2 infection—United States . MMWR Morb Mortal Wkly Rep. 1989;33:572-580. 22. Ranki A, Johansson E, Krohn K. Interpretation of antibodies reacting solely with human retroviral core proteins . N Engl J Med. 1988;318:448-449.Crossref 23. Kleinman S, Fitzpatrick L, Secord K, Wilke D. Follow-up testing and notification of anti-HIV Western blot atypical (indeterminant) donors . Transfusion. 1988; 28:280-282.Crossref 24. Dock NL, Lamberson HV, O'Brien TA, et al. Evaluation of atypical human immunodeficiency virus immunoblot reactivity in blood donors . Transfusion. 1988; 28:412-418.Crossref 25. Dock NL, Kleinman SH, Rayfield MA, et al. Human immunodeficiency virus infection and indeterminate Western blot patterns . Arch Intern Med. 1991;151: 525-530.Crossref 26. Moore JD, Cone EJ, Alexander SS. HTLV-III seropositivity in 1971-1972 parenteral drug abusers: a case of false positives or evidence of viral exposure? N Engl J Med. 1986;314:1387-1388. 27. Mendenhall CL, Roelle GA, Grossman CJ, et al. False-positive tests for HTLV-III antibodies in alcoholic patients with hepatitis . N Engl J Med. 1986;314:921-922.Crossref 28. Talal N, Dauphinee MJ, Dang H, et al. Detection of serum antibodies to retroviral proteins in patients with primary Sjogren's syndrome . Arthritis Rheum. 1990;33:774-781.Crossref 29. Courouce AM. Following up indeterminate HIV-1 Western blots . Lancet. 1989; 2:1330-1331.Crossref 30. Celum CL, Coombs RW, Lafferty W, et al. Indeterminate human immunodeficiency virus type 1 Western blots: seroconversion risk, specificity of supplemental tests, and an algorithm for evaluation . J Infect Dis. 1991;164:656-664.Crossref 31. Horsburgh CR, Jason J, Longini IM, et al. Duration of human immunodeficiency virus infection before detection of antibody . Lancet. 1989;2:637-639.Crossref 32. Celum CL, Coombs RW. Indeterminate HIV-1 Western blots: implications and considerations for widespread HIV testing . J Gen Intern Med. 1992;7:640-645.Crossref 33. Ashley RL, Militoni L, Lee F, et al. Comparison of Western blot (immunoblot) and glycoprotein G-specific immunodot enzyme assay for detecting antibodies to herpes simplex virus types 1 and 2 in human sera . J Clin Microbiol. 1988; 26:662-667. 34. Shelton GH, Grant CK, Cotter SM, et al. Feline immunodeficiency virus and feline leukemia virus infections and their relationships to lymphoid malignancies in cats: a retrospective study (1968-1988) . J AIDS. 1990;3:623-630. 35. ASHI Laboratory Manual . 2nd ed. Lenexa, Kan: American Society for Histocompatability and Immunogenetics; 1990. 36. Rhame FS, Maki DG. The case for wider use of testing for HIV infection . N Engl J Med. 1989;320:1248-1251.Crossref 37. Jackson JB, MacDonald KL, Cadwell J, et al. Absence of human immunodeficiency virus infection in blood donors with indeterminate Western blot tests for antibody to HIV-1 . N Engl J Med. 1990;312:217-222.Crossref 38. Sayers MH, Beatty PG, Hansen JA. HLA antibodies as a cause of false-positive reactions in screening enzyme immunoassays for antibodies to human Tlymphotropic virus type III . Transfusion. 1986;26:113-115.Crossref 39. Kunhl P, Seidl S, Holzberger G. HLA DR4 antibodies cause positive HTLV-III antibody ELISA results . Lancet. 1985;1:1222-1223. 40. Golding H, Robdy FA, Gates FT, et al. Identification of homologous regions in human immunodeficiency virus type 1 gp41 and human class II β1 domain . J Exp Med. 1988;167:914-923.Crossref 41. Hawkins BR, O'Connor KJ, Dawkins RL, et al. Autoantibodies in an Australian population: prevalence and persistence . J Clin Lab Immunol. 1979;2:211-215. 42. Garr RF, Fermin CD, Hart DJ, et al. Detection of a human intracisternal A-type retroviral particle antigenically related to HIV . Science. 1990;250:1127-1129.Crossref 43. Talal N, Garry RF, Schur PH, et al. A conserved idiotype and antibodies to retroviral proteins in systemic lupus erythematosus . J Clin Invest. 1990;85: 1866-1871.Crossref 44. Talal N, Dauphinee MJ, Dang H, et al. Detection of serum antibodies to retroviral proteins in patients with primary Sjogren's syndrome (autoimmune exocrinopathy) . Arthritis Rheum. 1990;33:774-781.Crossref 45. Ciampolillo A, Mirakian R, Schulz T, et al. Retrovirus-like sequences in Graves' disease: implications for human autoimmunity . Lancet. 1989;1:1096-1100.Crossref 46. Humphrey M, Baker JR, Carr FE, et al. Absence of retroviral sequences in Graves' disease . Lancet. 1991;337:17-18.Crossref 47. MacKenzie WR, Davis JP, Peterson DE, et al. Multiple false-positive serologic tests for HIV, HTLV-1, and hepatitis C following influenza vaccination, 1991 . JAMA. 1992;268:1015-1017.Crossref 48. Hsia J. False-positive ELISA for human immunodeficiency virus after influenza vaccination . J Infect Dis. 1993;167:989-990.Crossref 49. Koutsky LA, Stevens CE, Holmes KK, et al. Underdiagnosis of genital herpes by current clinical and viral isolation procedures . N Engl J Med. 1992;326:1533-1539.Crossref 50. Siegel D, Golden E, Washington AE, et al. Prevalence and correlates of herpes simplex infections . JAMA. 1992;268:1702-1708.Crossref 51. Johnson RE, Nahmias AJ, Magder LS, et al. A seroepidemiologic survey of the prevalence of herpes simplex virus type 2 infection in the United States . N Engl J Med. 1989;321:7-12.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Risk Factors for Repeatedly Reactive HIV-1 EIA and Indeterminate Western Blots: A Population-Based Case-Control Study

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Publisher
American Medical Association
Copyright
Copyright © 1994 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.1994.00420100115015
Publisher site
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Abstract

Abstract Objective: Causes of indeterminate results of Western blot testing (IWB) for human immunodeficiency virus (HIV) type 1 include seroconversion, HIV-2 cross-reactivity, and autoimmune disease, but most IWB results remain unexplained. This case-control study assessed risk factors for IWB results, including early HIV infection, other retroviral infection, autoantibodies, and other medical conditions. Design: Prospective study to determine HIV seroconversion rate, with a case-control design to assess other risk factors for IWB. Cases (persons with one or more repeatedly reactive HIV-1 enzyme immunoassay with IWB), their current sexual partners, and controls (persons with negative enzyme immunoassay and Western blot results) were recruited from blood banks, health department and prenatal clinics, and private providers in Washington and Oregon. Results: Of 244 cases enrolled, 206 were followed up for 6 months or longer, and six (3.0%; 95% confidence interval [CI], 0.7% to 5.3%) with recent HIV risk behaviors seroconverted. The Western blot banding patterns differed among groups; cases usually had p17 or p24 bands, while controls and cases' sexual partners usually had polymerase bands. Conditional logistic regression indicated that independent risk factors for IWB among male cases and controls were a tetanus booster in the past 2 years (odds ratio, 3.2; 95% CI, 1.2 to 8.6) and sexual contact with a prostitute (odds ratio, 3.0; 95% CI, 1.0 to 9.5). Independent risk factors for women were parity (odds ratio, 1.2;95%CI, 1.02 to 1.4) and autoantibodies, either rheumatoid factor or antinuclear antibodies (odds ratio, 2.3; 95% CI, 1.03 to 5.6). No cross-reactivity was detected with HIV-2, human T-lymphotrophic virus type 1, feline immunodeficiency or feline leukemia, or bovine immunodeficiency viruses. Conclusions: Evaluation of persons with reactive HIV-1 enzyme immunoassays and IWB should include an assessment of HIV risk and other possible risk factors, such as alloimmunization (ie, parity or recent immunization) or autoantibodies (ie, antinuclear antibodies and rheumatoid factor). The relationship of IWB among men who reported sex with prostitutes is intriguing and warrants further study.(Arch Intern Med. 1994;154:1129-1137) References 1. Reesink HW, Huisman JG, Gonsalves M, et al. Evaluation of six enzyme immunoassays for antibody against human immunodeficiency virus . Lancet. 1986; 2:483-486.Crossref 2. Burke DS, Brundage JF. Redfield RR. et al. Measurement of the false-positive rate in a screening program for human immunodeficiency virus infections . N Engl J Med. 1988;319:961-964.Crossref 3. Weiss SH, Goedert JJ, Serngadharam MG, Bodne AJ, Gallo RC, Blattner WA. Screening tests for HTLV-III (AIDS agent) antibodies . JAMA . 1985;253:221-225.Crossref 4. Ward JW, Grindon AJ, Feorino PM, Schable C, Parvin M, Allen JR. Laboratory and epidemiologic evaluation of an enzyme immunoassay for antibodies to HTLV-III . JAMA. 1986;256:357-361.Crossref 5. Centers for Disease Control. Update: Serologic testing for HIV-1 antibody— United States, 1988 and 1989 . MMWR Morb Mortal Wkly Rep. 1990;39:380-382. 6. Carlson JR, Bryant ML, Hinrich SH, et al. AIDS serology testing in low- and high-risk groups . JAMA. 1988;253:3405-3408.Crossref 7. Schwartz JS, Dans PE, Kinosian BP. Human immunodeficiency virus test evaluation, performance, and use . JAMA. 1988;259:2574-2579.Crossref 8. Centers for Disease Control. Interpretation and use of the Western blot assay for serodiagnosis of human immunodeficiency virus type 1 infections . MMWR Morb Mortal Wkly Rep. 1989;38(No. (S-7) ):1-7. 9. McDonald KL, Jackson JB, Bowman RJ, et al. Performance characteristics of serologic tests of human immunodeficiency virus type 1 (HIV-1) antibody among Minnesota blood donors . Ann Intern Med. 1989;110:617-621.Crossref 10. Midthun K, Garrison L, Clements ML, et al. Frequency of indeterminate Western blot tests in healthy adults at low risk for human immunodeficiency virus infection . J Infect Dis. 1990;162:1379-1382.Crossref 11. Westblom TU, Belshe RB, Gorse GJ, et al. Characteristics of a population volunteering for human immunodeficiency virus immunization . Int J STD AIDS. 1990;1:126-128. 12. Gaines H, Sonnerborg A, Czajkowski J, et al. Antibody response in primary human immunodeficiency virus infection . Lancet. 1987;1:1249-1253.Crossref 13. Ranki A, Krohn M, Allain J-P, et al. Long latency precedes overt seroconversion in sexually transmitted human immunodeficiency virus infection . Lancet. 1987;2:590-593. 14. Wilber JC, Louie B, Soncuya E, et al. Evaluation of indeterminate results in HIV serology: distinguishing seroconversions from false positives . In: Program and abstracts of the 28th Interscience Conference on Antimicrobial Agents and Chemotherapy; October 23-26, 1988; Los Angeles, Calif. 15. Biggar RJ, Melbye M, Ebbesen P, et al. Variation in human T lymphotrophic virus III (HTLV-III) antibodies in homosexual men: decline before onset of illness related to acquired immune deficiency syndrome (AIDS) . BMJ. 1985; 291:997-998.Crossref 16. Farzadegan H, Polis MA, Wolinsky SM, et al. Loss of human immunodeficiency virus type 1 (HIV-1) antibodies with evidence of viral infection in asymptomatic homosexual men . Ann Intern Med. 1988;108:785-790.Crossref 17. O'Brien TR, George JR. Holberg SD. Human immunodeficiency virus type 2 infection in the United States: epidemiology, diagnosis, and public health implications . JAMA. 1992;267:2775-2779.Crossref 18. DeCock KM. Porter A, Kouadio J, et al. Cross-reactivity on Western blots in HIV-1 and HIV-2 infections . AIDS. 1991;5:859-860.Crossref 19. Myers RA, Patel JD, Joseph JM. Identifying HIV-2 seropositive individuals by reevaluating HIV-1 indeterminate sera . J Acquir Immune Defic Syndr. 1992; 5:417-423. 20. George JR, Rayfield MA, Phillips S, et al. Efficacies of U.S. Food and Drug Administration—licensed HIV-1 screening enzyme immunoassays for detecting antibodies to HIV-2 . AIDS. 1990;4:321-326.Crossref 21. Centers for Disease Control. Update: HIV-2 infection—United States . MMWR Morb Mortal Wkly Rep. 1989;33:572-580. 22. Ranki A, Johansson E, Krohn K. Interpretation of antibodies reacting solely with human retroviral core proteins . N Engl J Med. 1988;318:448-449.Crossref 23. Kleinman S, Fitzpatrick L, Secord K, Wilke D. Follow-up testing and notification of anti-HIV Western blot atypical (indeterminant) donors . Transfusion. 1988; 28:280-282.Crossref 24. Dock NL, Lamberson HV, O'Brien TA, et al. Evaluation of atypical human immunodeficiency virus immunoblot reactivity in blood donors . Transfusion. 1988; 28:412-418.Crossref 25. Dock NL, Kleinman SH, Rayfield MA, et al. Human immunodeficiency virus infection and indeterminate Western blot patterns . Arch Intern Med. 1991;151: 525-530.Crossref 26. Moore JD, Cone EJ, Alexander SS. HTLV-III seropositivity in 1971-1972 parenteral drug abusers: a case of false positives or evidence of viral exposure? N Engl J Med. 1986;314:1387-1388. 27. Mendenhall CL, Roelle GA, Grossman CJ, et al. False-positive tests for HTLV-III antibodies in alcoholic patients with hepatitis . N Engl J Med. 1986;314:921-922.Crossref 28. Talal N, Dauphinee MJ, Dang H, et al. Detection of serum antibodies to retroviral proteins in patients with primary Sjogren's syndrome . Arthritis Rheum. 1990;33:774-781.Crossref 29. Courouce AM. Following up indeterminate HIV-1 Western blots . Lancet. 1989; 2:1330-1331.Crossref 30. Celum CL, Coombs RW, Lafferty W, et al. Indeterminate human immunodeficiency virus type 1 Western blots: seroconversion risk, specificity of supplemental tests, and an algorithm for evaluation . J Infect Dis. 1991;164:656-664.Crossref 31. Horsburgh CR, Jason J, Longini IM, et al. Duration of human immunodeficiency virus infection before detection of antibody . Lancet. 1989;2:637-639.Crossref 32. Celum CL, Coombs RW. Indeterminate HIV-1 Western blots: implications and considerations for widespread HIV testing . J Gen Intern Med. 1992;7:640-645.Crossref 33. Ashley RL, Militoni L, Lee F, et al. Comparison of Western blot (immunoblot) and glycoprotein G-specific immunodot enzyme assay for detecting antibodies to herpes simplex virus types 1 and 2 in human sera . J Clin Microbiol. 1988; 26:662-667. 34. Shelton GH, Grant CK, Cotter SM, et al. Feline immunodeficiency virus and feline leukemia virus infections and their relationships to lymphoid malignancies in cats: a retrospective study (1968-1988) . J AIDS. 1990;3:623-630. 35. ASHI Laboratory Manual . 2nd ed. Lenexa, Kan: American Society for Histocompatability and Immunogenetics; 1990. 36. Rhame FS, Maki DG. The case for wider use of testing for HIV infection . N Engl J Med. 1989;320:1248-1251.Crossref 37. Jackson JB, MacDonald KL, Cadwell J, et al. Absence of human immunodeficiency virus infection in blood donors with indeterminate Western blot tests for antibody to HIV-1 . N Engl J Med. 1990;312:217-222.Crossref 38. Sayers MH, Beatty PG, Hansen JA. HLA antibodies as a cause of false-positive reactions in screening enzyme immunoassays for antibodies to human Tlymphotropic virus type III . Transfusion. 1986;26:113-115.Crossref 39. Kunhl P, Seidl S, Holzberger G. HLA DR4 antibodies cause positive HTLV-III antibody ELISA results . Lancet. 1985;1:1222-1223. 40. Golding H, Robdy FA, Gates FT, et al. Identification of homologous regions in human immunodeficiency virus type 1 gp41 and human class II β1 domain . J Exp Med. 1988;167:914-923.Crossref 41. Hawkins BR, O'Connor KJ, Dawkins RL, et al. Autoantibodies in an Australian population: prevalence and persistence . J Clin Lab Immunol. 1979;2:211-215. 42. Garr RF, Fermin CD, Hart DJ, et al. Detection of a human intracisternal A-type retroviral particle antigenically related to HIV . Science. 1990;250:1127-1129.Crossref 43. Talal N, Garry RF, Schur PH, et al. A conserved idiotype and antibodies to retroviral proteins in systemic lupus erythematosus . J Clin Invest. 1990;85: 1866-1871.Crossref 44. Talal N, Dauphinee MJ, Dang H, et al. Detection of serum antibodies to retroviral proteins in patients with primary Sjogren's syndrome (autoimmune exocrinopathy) . Arthritis Rheum. 1990;33:774-781.Crossref 45. Ciampolillo A, Mirakian R, Schulz T, et al. Retrovirus-like sequences in Graves' disease: implications for human autoimmunity . Lancet. 1989;1:1096-1100.Crossref 46. Humphrey M, Baker JR, Carr FE, et al. Absence of retroviral sequences in Graves' disease . Lancet. 1991;337:17-18.Crossref 47. MacKenzie WR, Davis JP, Peterson DE, et al. Multiple false-positive serologic tests for HIV, HTLV-1, and hepatitis C following influenza vaccination, 1991 . JAMA. 1992;268:1015-1017.Crossref 48. Hsia J. False-positive ELISA for human immunodeficiency virus after influenza vaccination . J Infect Dis. 1993;167:989-990.Crossref 49. Koutsky LA, Stevens CE, Holmes KK, et al. Underdiagnosis of genital herpes by current clinical and viral isolation procedures . N Engl J Med. 1992;326:1533-1539.Crossref 50. Siegel D, Golden E, Washington AE, et al. Prevalence and correlates of herpes simplex infections . JAMA. 1992;268:1702-1708.Crossref 51. Johnson RE, Nahmias AJ, Magder LS, et al. A seroepidemiologic survey of the prevalence of herpes simplex virus type 2 infection in the United States . N Engl J Med. 1989;321:7-12.Crossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: May 23, 1994

References