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OBJECTIVE: To explore the relationship between human immunodeficiency virus (HIV) infection and soft tissue rheumatic lesions in HIV-positive black Zambians. METHODS: We performed a prospective study of all patients over 18 years of age attending a rheumatic clinic in a teaching hospital. All patients underwent routine blood tests, and radiographs were performed when indicated. HIV status was determined by ELISA, and clinical staging was determined by World Health Organization criteria. Patients with isolated sacroiliac pain, enthesitis, or a soft tissue lesion were selected for analysis. For HIV-positive patients, only those in clinical stage 1 (asymptomatic or persistent generalized lymphadenopathy) were selected. RESULTS: Our study cohort comprised 120 patients (41 men, 79 women, age 23-70 yrs). Diagnosis and number (% HIV positive) were distributed as follows: sacroiliitis, 14 (100%); heel pain, 14 (100%); costochondritis, 3 (100%); polyenthesitis (> or = 4 sites), 20 (100%); carpal tunnel syndrome, 8 (63%); rotator cuff syndrome, 18 (30%); tendinitis, 8 (25%); sciatica/cervical spondylosis, 12 (16%); sacroiliac strain, 7 (0%); and de Quervain's tenosynovitis, 16 (0%). HIV seroprevalence was 54% overall, 74% in those under 45 years of age, and 17% in those over 45 years of age. Population prevalence of HIV in Lusaka is about 30% in the 30-40-year age range. Mean erythrocyte sedimentation rate (ESR) in 65 patients positive for HIV was 80 mm/h and in 55 patients negative for HIV, 18 mm/h. Within each subgroup the mean ESR was significantly higher in HIV-positive patients. CONCLUSION: A young age and a raised ESR are both good indications of HIV infection in Zambian patients with soft tissue lesions. Enthesitis is a distinct HIV-related phenomenon, either an early form or a forme fruste of HIV-related spondyloarthropathy.