Multiple Victimizations and Overdose Among Women With a History of Illicit Drug Use

The experiences of violence and overdose are highly prevalent among women who use illicit drugs. This study sought to ascertain whether multiple victimizations during adulthood increase the frequency of women's overdose. The sample comprised 218 women recruited at Philadelphia harm reduction sites during 2016-2017. Victimization was assessed as exposure to 16 types of adulthood violence. Three measures were constructed for multiple victimizations: continuous and categorical polyvictimization, and predominant violence domain. Negative binomial regression estimated the incidence rate ratio (IRR) of lifetime overdoses from multiple victimizations. Lifetime history of opioid use (88.6%) and drug injection (79.5%) were common. Among overdose survivors (68.5%), the median of lifetime overdoses was 3. The majority of participants (58.7%) were victims of predominantly sexual violence, 26.1% experienced predominantly physical abuse/assault, and 3.7% were victims of predominantly verbal aggression/coercive control. Participants reported a mean of seven violence types; the higher-score category of polyvictimization (9-16 violence types) comprised 41.7% of the total sample. In multivariable models, one-unit increase in continuous polyvictimization was associated with 4% higher overdose rates (IRR: 1.04, 95% confidence interval [CI]: [1.00, 1.08]). Compared to women who were not victimized (11.5%), those in the higher-score category of polyvictimization (IRR: 2.01; 95% CI: [1.06, 3.80]) and exposed to predominantly sexual violence (IRR: 2.10, 95% CI: [1.13, 3.91]) were expected to have higher overdose rates. Polyvictimization and sexual violence amplified the risk of repeated overdose among drug-involved women. Female overdose survivors need to be screened for exposure to multiple forms of violence, especially sexual violence. Findings underscore the need to scale-up victimization support and overdose prevention services for disenfranchised women.

Health and Health Care Among Transgender Adults in the United States

Transgender (trans) communities in the USA and globally have long organized for health and social equity but have only recently gained increased visibility within public health. In this review, we synthesize evidence demonstrating that trans adults in the USA are affected by disparities in physical and mental health and in access to health care, relative to cisgender (nontrans) persons. We draw on theory and data to situate these disparities in their social contexts, explicating the roles of gender affirmation, multilevel and intersectional stigmas, and public policies in reproducing or ameliorating trans health disparities. Until recently, trans health disparities were largely made invisible by exclusionary data collection practices. We highlight the importance of, and methodological considerations for, collecting inclusive sex and gender data. Moving forward, we recommend routine collection of gender identity data, an emphasis on intervention research to achieve trans health equity, public policy advocacy, and investment in supporting gender-diverse public health leadership. Expected final online publication date for the Annual Review of Public Health, Volume 43 is April 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Structural Transphobia, Homophobia, and Biphobia in Public Health Practice: The Example of COVID-19 Surveillance

Public health surveillance can have profound impacts on the health of populations, with COVID-19 surveillance offering an illuminating example. Surveillance surrounding COVID-19 testing, confirmed cases, and deaths has provided essential information to public health professionals about how to minimize morbidity and mortality. In the United States, surveillance has also pointed out how populations, on the basis of geography, age, and race and ethnicity, are being impacted disproportionately, allowing targeted intervention and evaluation. However, COVID-19 surveillance has also highlighted how the public health surveillance system fails some communities, including sexual and gender minorities. This failure has come about because of the haphazard and disorganized way disease reporting data are collected, analyzed, and reported in the United States, and the structural homophobia, transphobia, and biphobia acting within these systems. We provide recommendations for addressing these concerns after examining experiences collecting race data in COVID-19 surveillance and attempts in Pennsylvania and California to incorporate sexual orientation and gender identity variables into their pandemic surveillance efforts.

Overdose response among trained and untrained women with a history of illicit drug use: a mixed-methods examination

Little is known about differences in bystander behavior among people who use drugs, trained and untrained in opioid overdose prevention. We examined three types of recommended overdose response - a 911 call, rescue breathing/CPR, and naloxone administration-among Philadelphia-based, predominantly street-involved women with a history of illicit drug use. The study utilized a convergent mixed methods approach integrating data from 186 quantitative survey responses and 38 semi-structured qualitative interviews. Quantitative findings revealed that compared to untrained women, trained women were more likely to administer naloxone (32.9% vs. 5.2%) and use two recommended responses (20.0% vs. 9.5%). No significant differences were found between the two groups in calling 911 or using rescue breathing/CPR. Qualitative findings indicated that barriers to enacting recommended overdose response were either structural or situational and included the avoidance of police, inability to carry naloxone or phone due to unstable housing, and perceived lack of safety on the streets and when interacting with strangers. Our study demonstrated that overdose training improved the frequency of naloxone administration among this sample of predominantly street-involved women. Future efforts need to focus on avoiding intrusive policing, scaling-up naloxone refill sites, and providing secondary naloxone distribution via drug user networks.

Mental health disorders mediate association of sexual minority identity with cardiovascular disease

BACKGROUND

Little is known about cardiovascular health disparities for lesbian, gay, or bisexual (LGB) persons and whether these disparities are mediated by mental health disorders due to sexual minority stress. We hypothesize LGB identity is associated with an increased risk of cardiovascular disease (CVD) and that major depressive disorder (MDD) and generalized anxiety disorders (GAD) may mediate this association.

METHODS

The National Epidemiologic Survey on Alcohol and Related Conditions is a longitudinal, nationally-representative study of non-institutionalized U.S. adults. We cross-sectionally analyzed the second wave data (2004-2005) comparing 577 self-identified LGB persons to 33,598 heterosexuals. Multiple logistic regression modeling and mediation analysis (the product of coefficients approach) were performed.

RESULTS

LGB persons had significantly higher CVD prevalence [adjusted odds ratio (AOR): 1.5, 95% CI: 1.2-1.9], and were more likely to be diagnosed with MDD (AOR: 1.9, 1.8-2.1), GAD (AOR: 2.2, 1.9-2.4), or co-occurring MDD and GAD (AOR: 2.2, 2.0-2.5). MDD, GAD, and co-occurrence of MDD and GAD significantly mediated 14.3%, 22.2%, and 33.3% of the association of LGB status with increased CVD prevalence, respectively.

CONCLUSIONS

Our findings identified a 50% increased CVD prevalence among LGB persons and this increased risk was mediated in part by MDD and GAD, both being more prevalent in sexual minority adults.

Transgender Health: New Zealand's Innovative Statistical Standard for Gender Identity

The implementation of the New Zealand government's recently developed statistical standard for gender identity has led to, and will stimulate further, collection of gender identity data in administrative records, population surveys, and perhaps the census. This will provide important information about the demographics, health service use, and health outcomes of transgender populations to allow evidence-based policy development and service planning. However, the standard does not promote the two-question method, risking misclassification and undercounts; does promote the use of the ambiguous response category "gender diverse" in standard questions; and is not intersex inclusive. Nevertheless, the statistical standard provides a first model for other countries and international organizations, including United Nations agencies, interested in policy tools for improving transgender people's health.

Sex and gender in the US health surveillance system: a call to action

Youth Risk Behavior Survey (YRBS) data have exposed significant sexual orientation disparities in health. Interest in examining the health of transgender youths, whose gender identities or expressions are not fully congruent with their assigned sex at birth, highlights limitations of the YRBS and the broader US health surveillance system. In 2009, we conducted the mixed-methods Massachusetts Gender Measures Project to develop and cognitively test measures for adolescent health surveillance surveys. A promising measure of transgender status emerged through this work. Further research is needed to produce accurate measures of assigned sex at birth and several dimensions of gender to further our understanding of determinants of gender disparities in health and enable strategic responses to address them.

Modeling potential effects of reduced calories in kids' meals with toy giveaways

BACKGROUND

Given the large proportion of daily calories attributable to fast food, there is growing interest in considering whether ordinances that restrict calories in kids' meals with toy giveaways could avert weight gain among children.

METHODS

Based upon a literature review and stakeholder feedback, a model was developed to estimate the potential number of children that could be affected by a statewide toy giveaway ordinance and the caloric savings should such a policy effectively reduce the number of calories in kids' meals with toy giveaways. Assumptions included the estimated number of children that eat fast food each day, the proportion that choose a kids' meal with a toy, the caloric savings of a kids' meal that meets nutrition standards, and the degree to which these savings could result in weight gain averted per child per year.

RESULTS

Using New York as a case study, the model estimates that, on a typical day, 5% (163,571) of children 0-12 years of age in New York could be affected by a toy ordinance. A child who typically consumes fast food two times per week could avoid gaining approximately 2 pounds per year with an ordinance requiring kids' meals to be ≤550 calories. The amount of weight gain averted would vary according to the calorie limit set by the law and the frequency of consumption per week.

CONCLUSIONS

Our model indicates that a reduction in calories in kids' meals with toy giveaways has the potential to positively affect weight gain in a considerable percentage of children. Limitations of the model are considered.

Suicide and suicide risk in lesbian, gay, bisexual, and transgender populations: review and recommendations

Despite strong indications of elevated risk of suicidal behavior in lesbian, gay, bisexual, and transgender people, limited attention has been given to research, interventions or suicide prevention programs targeting these populations. This article is a culmination of a three-year effort by an expert panel to address the need for better understanding of suicidal behavior and suicide risk in sexual minority populations, and stimulate the development of needed prevention strategies, interventions and policy changes. This article summarizes existing research findings, and makes recommendations for addressing knowledge gaps and applying current knowledge to relevant areas of suicide prevention practice.

Inclusion of lesbian, gay, bisexual and transgender people in tobacco use-related surveillance and epidemiological research

Researchers and public health advocates have long recognized the importance of demographic characteristics such as sex, race, ethnicity, age, and socioeconomic status in their efforts to understand and control the use of tobacco among population groups. Targeting prevention and cessation efforts based upon such characteristics has consistently been demonstrated to be both efficient and effective. In recent years, attention has modestly turned to how two additional demographic variables, sexual orientation and gender identity, can add to our understanding of how to reduce tobacco use. Research of tobacco industry papers has clearly documented targeted media campaigns to encourage smoking among lesbians and gays in the marketplace. The tobacco industry has long understood the role that sexual orientation can play in the uptake of smoking and the targeted marketing of brands. Those concerned with tobacco use prevention and cessation research have consequently responded to address tobacco use by lesbians and gays, and bisexuals and transgender people as well, but even more can be done. This article reviews what is known about smoking in lesbian, gay, bisexual, and transgender populations and then reviews recommendations from four panels created to examine this topic. In conclusion, we recommend that sexual orientation and gender identity be considered for inclusion as variables in all major research and epidemiological studies of tobacco use. Just as such studies, without hesitation, measure sex, race, ethnicity, age, and socioeconomic status, they need to also include questions assessing sexual orientation and gender identity. Although these new variables need not be the primary focus of these studies, at a minimum, considering their use as controlling variables should be explored. Lesbian, gay, bisexual, and transgender people can benefit from being openly included in the work researchers conduct to inform the design of tobacco control programs and policies.

Epilepsy surgery for pharmacoresistant temporal lobe epilepsy: a decision analysis

CONTEXT

Patients with pharmacoresistant epilepsy have increased mortality compared with the general population, but patients with pharmacoresistant temporal lobe epilepsy who meet criteria for surgery and who become seizure-free after anterior temporal lobe resection have reduced excess mortality vs those with persistent seizures.

OBJECTIVE

To quantify the potential survival benefit of anterior temporal lobe resection for patients with pharmacoresistant temporal lobe epilepsy vs continued medical management.

DESIGN

Monte Carlo simulation model that incorporates possible surgical complications and seizure status, with 10,000 runs. The model was populated with health-related quality-of-life data obtained directly from patients and data from the medical literature. Insufficient data were available to assess gamma-knife radiosurgery or vagal nerve stimulation.

MAIN OUTCOME MEASURES

Life expectancy and quality-adjusted life expectancy.

RESULTS

Compared with medical management, anterior temporal lobe resection for a 35-year-old patient with an epileptogenic zone identified in the anterior temporal lobe would increase survival by 5.0 years (95% CI, 2.1-9.2) with surgery preferred in 100% of the simulations. Anterior temporal lobe resection would increase quality-adjusted life expectancy by 7.5 quality-adjusted life-years (95%, CI, -0.8 to 17.4) with surgery preferred in 96.5% of the simulations, primarily due to increased years spent without disabling seizures, thereby reducing seizure-related excess mortality and improving quality of life. The results were robust to sensitivity analyses.

CONCLUSION

The decision analysis model suggests that on average anterior temporal lobe resection should provide substantial gains in life expectancy and quality-adjusted life expectancy for surgically eligible patients with pharmacoresistant temporal lobe epilepsy compared with medical management.

Use of a telephone screener to identify a probability sample of gays, lesbians, and bisexuals

OBJECTIVES

To examine public response to a telephone screener used to identify a probability sample of lesbians, gays, and bisexuals.

METHODS

A telephone screener was designed to provide a representative sample of self-identified lesbians, gays, and bisexuals (LGB) in the 30 central cities of the 15 largest Consolidated Metropolitan Areas.

RESULTS

Of 14,458 households contacted, 11,612 completed at least part of the survey. Of these, only 2.6% refused or responded "don't know" to the sexual orientation screener question. Respondents from the northeast were more reluctant to answer than respondents from the west.

CONCLUSIONS

The use of a screener on a national telephone survey to screen households for self-identified lesbian, gay, and bisexual adults was a successful way to generate a representative sample.

Health care access among individuals involved in same-sex relationships

OBJECTIVES

We used data from the National Health Interview Survey to compare health care access among individuals involved in same-sex versus opposite-sex relationships.

METHODS

We conducted descriptive and logistic regression analyses from pooled data on 614 individuals in same-sex relationships and 93418 individuals in opposite-sex relationships.

RESULTS

Women in same-sex relationships (adjusted odds ratio [OR]=0.60; 95% confidence interval [CI]=0.39, 0.92) were significantly less likely than women in opposite-sex relationships to have health insurance coverage, to have seen a medical provider in the previous 12 months (OR=0.66; 95% CI=0.46, 0.95), and to have a usual source of health care (OR=0.50; 95% CI=0.35, 0.71); they were more likely to have unmet medical needs as a result of cost issues (OR=1.85; 95% CI=1.16, 2.96). In contrast, health care access among men in same-sex relationships was equivalent to or greater than that among men in opposite-sex relationships.

CONCLUSIONS

In this study involving a nationwide probability sample, we found some important differences in access to health care between individuals in same-sex and opposite-sex relationships, particularly women.

Making waves: systems change on behalf of youth with HIV/AIDS

PURPOSE

To document the effects of five Special Projects of National Significance (SPNS), funded by the Health Resources and Services Administration (HRSA), on HIV care, related service systems, policy, planning, and funding for youth with HIV/AIDS.

METHODS

Literature on services and systems integration and technology transfer is used as a conceptual framework for the examination of HIV-informed, youth-specific changes at the local, state, and national levels. The Principal Investigators for each project and/or the Project Evaluators were interviewed several times to capture "snapshots" of evolving results from the Projects' varied activities in New York City; Newark, New Jersey; Chicago; and Miami. Some changes were consciously targeted, and others occurred serendipitously. This work covers the funding period from 1996 through 2000.

RESULTS AND CONCLUSIONS

There were many "ripple" effects that emanated from these Projects' presence and activities. Important lessons were learned about why systems change is necessary to effectively serve youth with HIV, how to make constructive changes happen, and how to sustain changes once they are achieved. Successful strategies included, but were not limited to, consensus-building among stakeholders, participatory planning and decision-making, collaborative referral and linkage agreements, staff sharing, co-locating services, providing technical assistance, consultation, cross-training, and engaging consumers as partners in communicating new technologies and in advocating for change.

Transitioning youths into care: linking identified HIV-infected youth at outreach sites in the community to hospital-based clinics and or community-based health centers

PURPOSE

To describe and analyze the process of transitioning HIV-infected youths from the point of HIV diagnosis into HIV treatment. Rather than simply offering HIV positive youths a list of referrals, the youth-focused SPNS grantees (AWAC) found it vital that youths were immediately assisted with linkage to a medical provider.

METHODS

From February 1997 to December 2000, 107 identified HIV-infected youths from the five adolescent SPNS projects were surveyed on needs and barriers. The time interval between HIV testing and youth linkage to care was also noted.

RESULTS

Nine percent of youth reported perceived barriers to accessing health care. Perceived needs were identified as Mental Health (44.9%; n = 48); Alcohol and drug treatment (14%; n = 15); transportation to health care settings (40.2%; n = 43); and housing (46.7%; N = 50). At sites tracking linkage to care, the time of being transitioned into a medical setting ranged from 5 to 55 days (average 26 days).

CONCLUSIONS

The period of transitioning identified HIV-infected youths into care can be reduced from 1-5 years to as short as 5-55 days. Success with linking these youth to care involves establishing a series of contacts at outreach sites wherein program staff seeks to build trusting relationships with youths, is able to track these youths and identify and address perceived needs.

The reciprocal effects of program evaluation on service delivery for the SPNS adolescent HIV outreach and treatment programs

PURPOSE

To describe the contexts within which the Special Projects of National Significance (SPNS) Adolescent HIV Outreach and Treatment programs were evaluated, the effects their evaluations had on their respective programs and, in turn, the effects the program delivery had on the evaluations.

METHODS

The full range of process evaluation heuristics were used to analyze the bi-directional effects of conducting field-based, service delivery data collection. Although data collection efforts sometimes interfered with service delivery, and vice versa, several notable positive effects were disclosed.

CONCLUSIONS

Specific guidance and recommendations were provided to program designers, behavioral researchers and institutional funding decision makers. Primary amongst them was a call for research evaluation designs that allow for maximum flexibility.

Case finding for HIV-positive youth: a special type of hidden population

PURPOSE

To describe the HIV case finding strategies used by the Special Projects of National Significance (SPNS), Adolescent HIV Outreach and Treatment programs, the populations of youth they were able to reach, and the populations of HIV-positive youth they were able to identify.

METHODS

Program specifications from five programs located in four major metropolitan centers were contrasted. Four of the programs also provided outcome data for HIV counseling and testing outcome numbers, demographic and risk profile data for youth who underwent HIV testing, and mode of infection of HIV-positive youth.

RESULTS

The program outcomes were discussed in terms of similarities and differences in outreach methods (e.g., peer workers, time of outreach, etc.), geographic settings (i.e., mobile van, institutional settings, community locations), individual characteristics (e.g., pregnant women) and youth subcultures (i.e., gay/transgendered, incarcerated juveniles, homeless).

CONCLUSIONS

Because HIV-positive adolescents will constitutionally remain a "hidden population," a great deal of time and effort will continue to need to go into the front end of outreach, counseling and testing. Specific guidance and recommendations for locating HIV-positive youth were provided to program designers for each type of outreach strategy.

The utilization of treatment and case management services by HIV-infected youth

PURPOSE

This article describes the essential components for effective and comprehensive HIV care for youth who have tested positive and have been linked to HIV treatment. Descriptive profile data are also presented that detail the demographics, risk behaviors and health care barriers of youth served in the five Special Projects of National Significance (SPNS), which focused on adolescents and young adults.

METHODS

Data presented are from the core multi-site data set, which was standardized across the five youth-oriented SPNS projects. Substance use and mental health symptoms were gathered using the Personal Problem Questionnaire (PPQ) screener, which was an adaptation of the PRIME-MD. In-depth qualitative interviews with enrolled HIV-positive youth were also conducted by several Projects.

RESULTS AND CONCLUSIONS

Medical care alone is not enough and cannot be effective without supportive program components such as flexible scheduling, and a multi-disciplinary team approach that includes assertive case management. Case Managers help enrolled youth with concrete service needs such as housing, emergency financial assistance for food/utilities, transportation, child care, coverage for prescriptions, and public entitlements. They also help isolated youth to connect with a personal support system. Addressing those needs helps to facilitate and reinforce treatment adherence and retention. In addition to other identified needs such as stable housing and transportation, a significant number of enrolled youth self-reported having experienced physical, sexual, and/or emotional abuse in their lives and articulated a need for mental health services. Therefore, effective HIV care for youth must be multi-faceted; it must consist of more than a medical component.

Retention, adherence, and compliance: special needs of HIV-infected adolescent girls and young women

PURPOSE

To demonstrate that whereas all HIV-infected youth evidence complex factors that challenge retention in care and adherence to treatment, HIV-infected females have additional issues that are gender-specific.

METHODS

Preliminary data from a subset of 21 adolescent/young women under age 25 from the Whole Life mental health-perinatal HIV care project were analyzed to illustrate the needs of these patients.

RESULTS

Of the 21 young women assessed, all but one was of minority background, and a sizeable majority had limited education (<high school diploma) and were quite poor (incomes <$500/mo.). Nearly 67% first learned of their HIV status between ages 16 and 19 years. More than three-fourths were pregnant and, of these, more than one-third entered prenatal care in the last trimester. More than half had responsibility for one to two other children. Two-thirds reported having unprotected sex in the prior 6 months. Nearly 43% had CD4 counts of 500 or below. About one-third screened positive for a mental health problem, and the majority reported a striking frequency of exposure to abusive events and traumatic losses across their short lifetimes.

CONCLUSIONS

Adolescent girls and young women have unique needs for developmentally appropriate medical and psychosocial approaches to promote retention and adherence.

Sexual orientation data collection and progress toward Healthy People 2010

Without scientifically obtained data and published reports, it is difficult to raise awareness and acquire adequate resources to address the health concerns of lesbian, gay, and bisexual Americans. The Department of Health and Human Services must recognize gaps in its information systems regarding sexual orientation data and take immediate steps to monitor and eliminate health disparities as delineated in Healthy People 2010. A paper supported by funding from the Office of the Assistant Secretary for Planning and Evaluation explores these concerns and suggests that the department (1) create work groups to examine the collection of sexual orientation data; (2) create a set of guiding principles to govern the process of selecting standard definitions and measures; (3) recognize that racial/ethnic, immigrant-status, age, socioeconomic, and geographic differences must be taken into account when standard measures of sexual orientation are selected; (4) select a minimum set of standard sexual orientation measures; and (5) develop a long-range strategic plan for the collection of sexual orientation data.

Cost-effectiveness of elective cesarean delivery in human immunodeficiency virus-infected women(1)

OBJECTIVE

To evaluate the cost-effectiveness of an elective cesarean delivery strategy in human immunodeficiency virus (HIV)-infected women receiving zidovudine therapy to prevent perinatal transmission.

METHODS

A decision-analysis model was constructed to compare two delivery strategies in HIV-infected women: usual care and recommendation for elective cesarean delivery. The model followed a hypothetical cohort of 7000 HIV-infected pregnant women in the United States who were receiving zidovudine therapy for 1 year. The third-party payer perspective was taken. Cost of delivery method with and without complications and lifetime medical care cost for pediatric HIV infection were considered. The main outcome measure was cases of perinatal HIV transmission prevented.

RESULTS

Compared with the usual care strategy, the elective cesarean delivery strategy resulted in an additional 3486 cesarean deliveries each year, prevented 142 cases (52.4%) of perinatal HIV transmission, and resulted in incremental overall cost savings to society of $5.3 million per year ($37,284 saved per case of perinatal transmission prevented). With other estimates held constant, the elective cesarean delivery strategy would not be cost saving when the baseline perinatal HIV transmission rates were all reduced by 43.3%.

CONCLUSIONS

Elective cesarean delivery in HIV-infected women receiving zidovudine is one management strategy for prevention of perinatal HIV transmission and can be cost saving. However, if other strategies, such as use of combination antiretroviral therapy and/or measurement of viral load, result in at least 50% reduction of the baseline perinatal HIV transmission rates, elective cesarean delivery will not be cost saving.

The cost effectiveness of strategies for the treatment of intestinal parasites in immigrants

BACKGROUND

Currently, more than 600,000 immigrants enter the United States each year from countries where intestinal parasites are endemic. At entry persons with parasitic infections may be asymptomatic, and stool examinations are not a sensitive method of screening for parasitosis. Albendazole is a new, broad-spectrum antiparasitic drug, which was approved recently by the Food and Drug Administration. International trials have shown albendazole to be safe and effective in eradicating many parasites. In the United States there is now disagreement about whether to screen all immigrants for parasites, treat all immigrants presumptively, or do nothing unless they have symptoms.

METHODS

We compared the costs and benefits of no preventive intervention (watchful waiting) with those of universal screening or presumptive treatment with 400 mg of albendazole per day for five days. Those at risk were defined as immigrants to the United States from Asia, the Middle East, sub-Saharan Africa, Eastern Europe, and Latin America and the Caribbean. Cost effectiveness was expressed both in terms of the cost of treatment per disability-adjusted life-year (DALY) averted (one DALY is defined as the loss of one year of healthy life to disease) and in terms of the cost per hospitalization averted.

RESULTS

As compared with watchful waiting, presumptive treatment of all immigrants at risk for parasitosis would avert at least 870 DALYs, prevent at least 33 deaths and 374 hospitalizations, and save at least $4.2 million per year. As compared with watchful waiting, screening would cost $159,236 per DALY averted.

CONCLUSIONS

Presumptive administration of albendazole to all immigrants at risk for parasitosis would save lives and money. Universal screening, with treatment of persons with positive stool examinations, would save lives but is less cost effective than presumptive treatment.

Defining and measuring sexual orientation: a review

How to define and identify sexual orientations for the purpose of constructing representative samples of homosexuals, bisexuals, and heterosexuals is unclear and confusing to researchers. Different definitions and measures have been proposed and used to develop samples since the 1860s when sexual orientations first gained widespread research interest. Unfortunately, the definitions and measurement tools used since then result in the selection of divergent and incomparable samples. If advances in the understanding of sexual orientations are to be made, it is critical that definitions and measures of sexual orientation be standardized. This paper reviews and critiques definitions and measures of sexual orientation that have been proposed and used by researchers over the past century. This review is intended to further our understanding of this subject and to encourage researchers to be critical of how they classify subjects based upon sexual orientation.

Sampling homosexuals, bisexuals, gays, and lesbians for public health research: a review of the literature from 1990 to 1992

Our objective was to examine the representativeness of samples of homosexuals, bisexuals, gays, and lesbians obtained for public health research. We identified journal articles cited in Medline and published between 1990 and 1992 that sampled individuals and classified them as homosexual, bisexual, gay, and/or lesbian. Information was abstracted from these articles to evaluate four components of sample selection affecting the representativeness of samples: (1) how the population is conceptually defined, (2) how the sampled population is operationally identified, (3) the setting from which samples are selected, and (4) the use of probability sampling to select subjects. We identified 152 public health articles published between 1990 and 1992 that sampled homosexuals, bisexuals, gays, and/or lesbians. We found articles (1) rarely (4/152) conceptually defined the population they were sampling, (2) used a range of incomparable methods to identify and select subjects, (3) sampled from settings representative of dramatically different populations, and (4) rarely (3/152) used probability sampling. Overall, we find methods used to identify homosexuals, bisexuals, gays, and lesbians for public health research produce samples representative of different and sometimes unidentifiable populations. To understand these populations from a public health perspective, it is imperative that steps be taken by researchers to standardize population definitions and sampling methodologies.

Health values of patients infected with human immunodeficiency virus. Relationship to mental health and physical functioning

To assess the health values of patients infected with human immunodeficiency virus (HIV) and examine the relationships between their health values and health status at two points in time, the authors sought to determine whether patients' physical and mental health statuses were good predictors of how they valued their current state of health. One hundred thirty-nine patients with various stages of HIV infection were interviewed in a prospective cohort study based in a primary care practice of a community-based teaching hospital. Patients were interviewed twice at 6-month intervals using three health value measures--the time trade off, rating scale, and Quality of Well-being Scale--and three health status measures: the 18-item Mental Health Inventory, the Dyspnea-Fatigue Index, and the Medical Outcomes Study SF-36 Health Survey. The health status of HIV-infected patients was compromised and, with the exception of mental health, generally was worse among patients with more advanced HIV-infection. Rating scale and Quality of Well-being Scale scores were related inversely to disease stage, but time-trade off scores generally were higher regardless of disease stage. Health value measures showed moderate relationships with measures of physical functioning (r = 0.34-0.68) but only a fair relationship with mental health (r = 0.00-0.48). The health status of HIV-infected patients who remained asymptomatic or remained symptomatic but without developing acquired immunodeficiency syndrome (AIDS) changed little over 6 months, whereas the health status of patients with AIDS and of patients manifesting progression of HIV-infection deteriorated over time. In contrast, health values, particularly time-tradeoff scores, remained stable even in the face of changes in health status and disease progression. With the exception of mental health, the impact of HIV infection on health status tends to parallel the clinical stage of disease. Health values of HIV-infected patients, however, generally are high and correlate better with physical functioning than with mental health.

Sampling homosexuals, bisexuals, gays, and lesbians for public health research: a review of the literature from 1990 to 1992

Our objective was to examine the representativeness of samples of homosexuals, bisexuals, gays, and lesbians obtained for public health research. We identified journal articles cited in Medline and published between 1990 and 1992 that sampled individuals and classified them as homosexual, bisexual, gay, and/or lesbian. Information was abstracted from these articles to evaluate four components of sample selection affecting the representativeness of samples: (1) how the population is conceptually defined, (2) how the sampled population is operationally identified, (3) the setting from which samples are selected, and (4) the use of probability sampling to select subjects. We identified 152 public health articles published between 1990 and 1992 that sampled homosexuals, bisexuals, gays, and/or lesbians. We found articles (1) rarely (4/152) conceptually defined the population they were sampling, (2) used a range of incomparable methods to identify and select subjects, (3) sampled from settings representative of dramatically different populations, and (4) rarely (3/152) used probability sampling. Overall, we find methods used to identify homosexuals, bisexuals, gays, and lesbians for public health research produce samples representative of different and sometimes unidentifiable populations. To understand these populations from a public health perspective, it is imperative that steps be taken by researchers to standardize population definitions and sampling methodologies.

The prevalence of homosexual behavior and attraction in the United States, the United Kingdom and France: results of national population-based samples

Researchers determining the prevalence of homosexuality in nationally representative samples have focused upon determining the prevalence of homosexual behavior, ignoring those individuals whose sexual attraction to the same sex had not resulted in sexual behavior. We examine the use of sexual attraction as well as sexual behavior to estimate the prevalence of homosexuality in the United States, the United Kingdom, and France using the Project HOPE International Survey of AIDS-Risk Behaviors. We find that 8.7, 7.9, and 8.5% of males and 11.1, 8.6, and 11.7% of females in the United States, the United Kingdom, and France, respectively, report some homosexual attraction but no homosexual behavior since age 15. Further, considering homosexual behavior and homosexual attraction as different but overlapping dimensions of homosexuality, we find 20.8, 16.3, and 18.5% of males, and 17.8, 18.6, and 18.5% of females in the United States, the United Kingdom, and France report either homosexual behavior or homosexual attraction since age 15. Examination of homosexual behavior separately finds that 6.2, 4.5, and 10.7% of males and 3.6, 2.1, and 3.3% of females in the United States, the United Kingdom, and France, respectively, report having had sexual contact with someone of the same sex in the previous 5 years. Our findings highlight the importance of using more than just homosexual behavior to examine the prevalence of homosexuality.

Definition and measurement of sexual orientation

Measurement and definition of sexual orientations have increasingly become a central focus in both research design and public policy debates. This paper reviews major methods, and their theoretical underpinnings, for the definition and measurement of sexual orientation, highlighting their limitations and pitfalls, both practical and conceptual. The increasing politicization of this area is discussed and cautioned against. Recommendations, both general and geared toward measurement concerns with adolescent populations, are made. A specific measurement strategy, which can be utilized at a number of different levels, is detailed.

HIV screening of surgeons and dentists: a cost-effectiveness analysis

OBJECTIVE

To assess the cost-effectiveness of human immunodeficiency virus (HIV) screening strategies of surgeons and dentists.

DESIGN

We constructed a model to project costs and HIV transmissions prevented over 15 years for four screening scenarios: 1) one-time voluntary screening, 2) one-time mandatory screening, 3) annual voluntary screening, and 4) annual mandatory screening. One-time screening occurs only in the first year of the program; annual screening occurs once each year. Under mandatory screening, all practitioners are tested and risks of practitioner-to-patient transmission are eliminated for all practitioners testing positive. Voluntary screening assumes 90% of HIV-positive and 50% of HIV-negative practitioners are tested, and risks of transmission in the clinical setting are eliminated for 90% of HIV-positive surgeons and dentists. All costs and benefits are discounted at 5% per annum over 15 years.

RESULTS

Using "best-case" scenario assumptions, we find for surgeons that a one-time voluntary screening program would be most cost-effective, at $899,336 for every HIV transmission prevented. For dentists, the one-time voluntary program also is the most cost-effective, at $139,571 per transmission prevented. Annual mandatory programs were least cost-effective for both surgeons and dentists, at $63.3 million and $2.2 million per transmission prevented, respectively.

CONCLUSIONS

HIV screening of surgeons and dentists ranks among the more expensive medical lifesaving programs, even using liberal assumptions about program effectiveness. Frequency of screening and whether testing is mandatory or voluntary dramatically affect cost per transmission prevented; these features should be considered carefully in designing specific HIV screening programs.

Alternative techniques of seeding cultured endothelial cells to ePTFE grafts of different diameters, porosities, and surfaces

Attachment of 111Indium-oxine labeled cultured canine venous endothelial cells to expanded polytetrafluorethylene (ePTFE) grafts was evaluated in vitro. Three alternative seeding techniques were studied in grafts having different diameters, porosities, and surfaces, including: (I) manual milking of blood containing endothelial cells within the graft; (II) a two-step procedure of incubating grafts initially with blood and then with an endothelial cell suspension; and (III) mechanical spinning of grafts filled with blood containing endothelium. Method II had significantly higher cell attachment to the graft (11.6%) than did Method I (1.5%) or III (4.7%). A somewhat higher seeding efficiency was noted in 10-mm-I.D. grafts (11.6%) compared to 6-mm-I.D. grafts (6.3%). Different graft porosity, created by altering internodal distances, did not cause significant changes in cell attachment (10 microns, 13.4%; 30 microns, 6.3%; 90 microns, 16.0%). Fibronectin-coated surfaces, which should have enhanced cell adhesion, demonstrated a 6.0% cell attachment, a lower efficiency than the 11.6% observed with a blood coating alone. Acetone-soaked surfaces, which should have predictably exhibited less hydrophobicity, produced quite variable attachments (range 3.4 to 59.7%, mean 23.4%). In the present investigation the best seeding technique was method II, the two-step incubation procedure. Consistent differences were not noted with various ePTFE graft configurations or surfaces.

Enhanced endothelialization of Dacron grafts by external vein wrapping

The efficacy of external vein wrapping of vascular grafts in promoting the development of a luminal endothelial surface was assessed in 12 dogs who underwent thoracoabdominal bypasses with 26-29 cm X 6-mm i.d. double-velour knitted Dacron grafts. In group I (n = 6) 6-cm segments of the grafts were wrapped with autologous jugular vein with its endothelial surface applied against the outside of the graft. In group II (n = 6) the wrap procedure was performed using abdominal wall fascia. The degree and character of graft incorporation was quantitated in all prostheses at 28 days postimplantation. Group I vein wrap prostheses demonstrated uniform endothelial surface coverage in the vein wrap area (means = 88%) that was significantly greater (P less than 0.04) than coverage in adjacent unwrapped segments (means = 48%). Group II fascial wrap grafts demonstrated variable endothelial coverage in the wrapped area (means = 48%) that was consistently less than in adjacent unwrapped portions (means = 62%), and significantly less than vein wrap sections of group I animals (P less than 0.04). No significant differences existed in endothelial coverage of unwrapped regions of group I and II grafts. This investigation documented that wrapping knitted Dacron grafts with vein enhanced endothelialization of their luminal surface.