Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

HLA class II immunogenic mutation burden predicts response to immune checkpoint blockade

BACKGROUND

Whereas human leukocyte antigen (HLA) class I mutation-associated neoantigen burden has been linked with response to immune checkpoint blockade (ICB), the role of HLA class II-restricted neoantigens in clinical responses to ICB is less studied. We used computational approaches to assess HLA class II immunogenic mutation (IMM) burden in patients with melanoma and lung cancer treated with ICB.

PATIENTS AND METHODS

We analyzed whole-exome sequence data from four cohorts of ICB-treated patients with melanoma (n = 110) and non-small-cell lung cancer (NSCLC) (n = 123). MHCnuggets, a neural network-based model, was applied to estimate HLA class II IMM burdens and cellular fractions of IMMs were calculated to assess mutation clonality. We evaluated the combined impact of HLA class II germline genetic variation and class II IMM burden on clinical outcomes. Correlations between HLA class II IMM burden and density of tumor-infiltrating lymphocytes were computed from expression data.

RESULTS

Responding tumors harbored a significantly higher HLA class II IMM burden for both melanoma and NSCLC (P ≤ 9.6e-3). HLA class II IMM burden was correlated with longer survival, particularly in the NSCLC cohort and in the context of low intratumoral IMM heterogeneity (P < 0.001). HLA class I and II IMM landscapes were largely distinct suggesting a complementary role for class II IMMs in tumor rejection. A higher HLA class II IMM burden was associated with CD4+ T-cell infiltration and programmed death-ligand 1 expression. Transcriptomic analyses revealed an inflamed tumor microenvironment for tumors harboring a high HLA class II IMM burden.

CONCLUSIONS

HLA class II IMM burden identified patients with NSCLC and melanoma that attained longer survival after ICB treatment. Our findings suggest that HLA class II IMMs may impact responses to ICB in a manner that is distinct and complementary to HLA class I-mediated responses.

Male polyurethane condoms do not enhance brief HIV-STD risk reduction interventions for heterosexually active men: results from a randomized test of concept

The current study examined the effects of a brief HIV risk reduction intervention for men. Participants were recruited (n=108) from an urban public health clinic and randomly assigned to one of 3 experimental intervention conditions: (1) 3 h HIV-STD risk reduction behavioural skills building latex condom intervention; (2) the same 3 h skills workshop but focused on male polyurethane condoms; or (3) a 3 h HIV education workshop. Results showed all 3 interventions increased AIDS knowledge and positively influenced attitudes, but men who received the polyurethane condom skills intervention were more likely to request condoms at follow ups. In addition, men who received either of the 2 skills interventions evidenced increased condom use at the one-month follow up, with no differences at 3-month follow up. This study is among the first to test a brief HIV risk reduction intervention for men and is the first to test whether polyurethane male condoms enhance HIV risk reduction efforts.

Knowledge and perceived implementation of food safety risk analysis framework in Latin America and the Caribbean region

Risk analysis is increasingly promoted as a tool to support science-based decisions regarding food safety. An online survey comprising 45 questions was used to gather information on the implementation of food safety risk analysis within the Latin American and Caribbean regions. Professionals working in food safety in academia, government, and private sectors in Latin American and Caribbean countries were contacted by email and surveyed to assess their individual knowledge of risk analysis and perceptions of its implementation in the region. From a total of 279 participants, 97% reported a familiarity with risk analysis concepts; however, fewer than 25% were able to correctly identify its key principles. The reported implementation of risk analysis among the different professional sectors was relatively low (46%). Participants from industries in countries with a long history of trade with the United States and the European Union, such as Mexico, Brazil, and Chile, reported perceptions of a higher degree of risk analysis implementation (56, 50, and 20%, respectively) than those from the rest of the countries, suggesting that commerce may be a driver for achieving higher food safety standards. Disagreement among respondents on the extent of the use of risk analysis in national food safety regulations was common, illustrating a systematic lack of understanding of the current regulatory status of the country. The results of this survey can be used to target further risk analysis training on selected sectors and countries.

Assumed infectiousness, treatment adherence and sexual behaviours: applying the Swiss Statement on infectiousness to HIV-positive alcohol drinkers

OBJECTIVES

The success of antiretroviral therapy (ART) for treating HIV infection is now being turned towards HIV prevention. The Swiss Federal Commission for HIV/AIDS has declared that HIV-positive persons who are treated with ART, have an undetectable viral load, and are free of co-occurring sexually transmitted infections (STIs) should be considered noninfectious for sexual transmission of HIV. This study examined the implications of these assumptions in a sample of HIV-positive individuals who drink alcohol.

METHODS

People living with HIV/AIDS (n = 228) were recruited through community sampling. They completed confidential computerized interviews and underwent monthly unannounced pill counts for ART adherence. HIV viral loads were obtained from medical records.

RESULTS

One hundred and eighty-five HIV-positive drinkers were currently receiving ART and 43 were untreated. Among those receiving ART, one in three were not virally suppressed and one in five had recently been diagnosed with an STI. Adherence was generally suboptimal, including among those assumed to be less infectious. As many as one in four participants reported engaging in unprotected intercourse with an HIV-uninfected partner in the past 4 months. There were few associations between assumed infectiousness and sexual practices.

CONCLUSIONS

Less than half of people who drank alcohol and took ART met the Swiss criteria for noninfectiousness. Poor adherence and prevalent STI threaten the long-term potential of using ART for prevention. In the absence of behavioral interventions, the realities of substance use and other barriers call into question the use of ART as prevention among alcohol drinkers.

Falling through the cracks: unmet health service needs among people living with HIV in Atlanta, Georgia

Despite growing numbers of people living with HIV (PLWH), the landscape of related services is shrinking. This study investigated health and social service needs of men (N = 489) and women (N = 165) living with HIV in Atlanta, GA. Participants completed confidential measures asking about the health and social services they needed and accessed. Results showed an array of health and social service needs among PLWH; failure to access services was prevalent. Hunger was among the most common basic needs, reported by greater than 60% of men and women. For men, unmet service needs were associated with fewer years since testing positive for HIV, higher CD4+ T cell values, experiencing more stressors and depression, and greater quantity of alcohol use. For women, failure to access services was associated with experiencing depression and not receiving HIV medications. Providing basic services to PLWH remains a public health priority and a moral imperative.

Sexually transmitted infections and infectiousness beliefs among people living with HIV/AIDS: implications for HIV treatment as prevention

OBJECTIVES

Sexually transmitted infections (STIs) significantly impact the health of people living with HIV/AIDS, increasing HIV infectiousness and therefore transmissibility. The current study examined STIs in a community sample of 490 HIV-positive men and women.

METHODS

Assessments were performed using confidential computerized interviews in a community research setting.

RESULTS

Fourteen per cent of the people living with HIV/AIDS in this study had been diagnosed with a new STI in a 6-month period. Individuals with a new STI had significantly more sexual partners in that time period, including non-HIV-positive partners. Participants who had contracted an STI were significantly more likely to have detectable viral loads and were less likely to know their viral load than participants who did not contract an STI. Multivariate analysis showed that believing an undetectable viral load leads to lower infectiousness was associated with contracting a new STI.

CONCLUSIONS

Individuals who believed that having an undetectable viral load reduces HIV transmission risks were more likely to be infectious because of STI coinfection. Programmes that aim to use HIV treatment for HIV prevention must address infectiousness beliefs and aggressively control STIs among people living with HIV/AIDS.

On holiday: a risk behavior profile for men who have vacationed at gay resorts

Sexual risk behavior is higher when people vacation as compared to when they are at home. The current study uses survey data to compare sexual risk behavior of gay men who vacation at gay resorts to those who do not. Independent predictors of vacationing at gay resorts included income level, relationship status, ever having attended a circuit party, and HIV serostatus. For men who visit resorts to meet sex partners, independent predictors included relationship status, ever having attended a circuit party, HIV serostatus, number of male sex partners in the past six months, and number of anal insertive male partners using a condom. These results show a need for the development of structural interventions in the gay resort and hotel setting.

Perceived prevalence and risks for human papillomavirus (HPV) infection among women who have sex with women

BACKGROUND

Previous research shows that perceptions of disease prevalence, particularly infectious diseases, are also related to health behaviors, but the association between perceived disease prevalence and risk perceptions is unknown. We chose to survey women who have sex with women (WSW) because they are an understudied population who are at risk for human papillomavirus (HPV). Prevalence rate of HPV infection among WSW is around 13%. We sought to test the relationship between having had an abnormal Pap smear and perceived risk for HPV. Perceived prevalence was also hypothesized as being a mediator and moderator of the relationship between abnormal Pap smear and perceived risk of HPV.

METHODS

Participants were approached at a gay pride festival and asked if they would like to complete a survey concerning same-sex relationships. Regression analyses, including moderation and mediation testing, were used to examine women who have and have not had an abnormal Pap smear.

RESULTS

Participants (n = 275) completed anonymous surveys. Eighty-four (27%) women had a history of abnormal Pap smears, and 16 (5%) women had been diagnosed with HPV. Women with a history of abnormal Pap smears perceived themselves at greater risk for and greater prevalence of HPV. The association between history of abnormal Pap smears and risk perceptions was mediated by perceived disease prevalence. The association between perceived disease prevalence and perceived risk was significant only among women with a history of abnormal Pap smears.

CONCLUSIONS

Perceived local disease prevalence is important for understanding risk perceptions in relation to health behaviors and health outcomes. Interventions can use local disease prevalence as a means for motivating behavior change.

Changes in HIV treatment beliefs and sexual risk behaviors among gay and bisexual men, 1997-2005

OBJECTIVE

Beliefs about HIV treatment effectiveness and the impact of HIV treatments on HIV transmission risks were initially related to sexual risk-taking in the late 1990s when multidrug HIV treatments first became available. This study examined changes in beliefs about the effects of HIV treatment for preventing HIV transmission and their association to sexual risk behaviors between the years 1997 and 2005.

DESIGN

Anonymous surveys were administered to a convenience sample of gay and bisexual men attending a large community event in Atlanta, Georgia in 1997 (N = 498) and again at the same community event in 2005 (N = 448). Analyses were performed for men living with HIV/AIDS and for men who have not been diagnosed with HIV/AIDS.

MAIN OUTCOME MEASURES

Rates of unprotected anal intercourse in the previous 3 months.

RESULTS

There were significant increases in high-risk sexual practices that coincided with increased beliefs that HIV treatments can reduce the chance of transmitting HIV. However, optimistic beliefs about the health benefits of HIV treatments decreased over the 8 years and were not related to risk behaviors.

CONCLUSIONS

Beliefs about how HIV treatments impact HIV infectiousness remain associated with HIV transmission risk behavior and interventions targeting at-risk as well as HIV-positive men who have sex with men must directly address these beliefs and perceptions.

Alcohol and risks for HIV/AIDS among sexually transmitted infection clinic patients in Cape Town, South Africa

Alcohol use is prevalent in South Africa and alcohol use may be associated with higher risk for HIV transmission. This paper reports a study of the association between alcohol use and HIV risk-related behavior among 134 men and 92 women receiving sexually transmitted infection (STI) clinic services in Cape Town, South Africa. Participants completed anonymous surveys of demographic information, substance use, and sexual risk behaviors. Results showed that problem drinking was common among STI clinic patients; 58% of men and 28% of women scored above a cut-off of 9 on the Alcohol Use Disorders Identification Test (AUDIT) suggesting possible problem drinking and 46% of men and 19% of women scored above 12 on the AUDIT indicating probable drinking problems. For men, heavier alcohol use was associated with having multiple sex partners in the past month, less condom use, and having a history of sexually assaulting women. Among women, higher scores on the AUDIT were also related to having multiple sex partners as well as a history of exchanging sex for money or materials. The association between alcohol use and sexual risk behaviors in a population at high-risk for HIV transmission demonstrates the need for integrating alcohol risk reduction counseling with HIV prevention counseling among STI clinic patients in South Africa.

Beliefs about treatments for HIV/AIDS and sexual risk behaviors among men who have sex with men, 1997-2006

Beliefs that HIV treatments reduce HIV transmission risks are related to increases in sexual risk behaviors, particularly unprotected anal intercourse among men who have sex with men (MSM). Changes in unprotected anal intercourse and prevention-related treatment beliefs were recently reported for surveys of mostly white gay men collected in 1997 and 2005. The current study extends this previous research by replicating the observed changes in behaviors and beliefs in anonymous community surveys collected in 2006. Results indicated clear and consistent increases in beliefs that HIV treatments reduce HIV transmission risks and increases in unprotected anal intercourse. These changes were observed for both HIV positive and non-HIV positive men. African American men endorsed the belief that HIV treatments protect against HIV transmission to a greater degree than White men. Results show that HIV prevention messages need to be updated to educate MSM about the realities of HIV viral concentrations and HIV transmission risks.

Sexual assault, sexual risks and gender attitudes in a community sample of South African men

Sexual assault against women and HIV infection are both prevalent and related social problems in South Africa. The current study examined hostile attitudes toward women, acceptance of violence against women and masculine ideological beliefs in relation to sexual assault history among men in a Cape Town township in South African. Men (n=435) completed anonymous surveys of sexual assault history, HIV risk history and gender-based attitudes. More than one in five men in this community sample reported that they had either threatened to use force or used force to gain sexual access to a woman in their lifetime. Men with a history of sexual assault were at significantly higher risk for HIV transmission than their non-sexually assaultive counterparts. Men with a history of sexual assault were also more likely to endorse hostile attitudes toward women and were more likely to accept violence against women, although these attitudes and beliefs were prevalent and pervasive across men with and without histories of sexual assault. These findings extend previous research to show that men who have a history of sexual assault also exhibit elevated risks for HIV infection and transmission. Interventions are needed to address hostile attitudes toward women, sexual assault and sexual risks for HIV among South African men.

Altering key characteristics of a disseminated effective behavioral intervention for HIV positive adults: the "healthy relationships" experience

HIV prevention programs targeted to people living with HIV/AIDS are the US national HIV prevention priority. Healthy Relationships is a nationally disseminated HIV prevention program for HIV positive adults. Key characteristics of the intervention package include gender separated groups facilitated by a mental health professional and a HIV positive peer counselor, both of which cause considerable barriers to implementation. We examined an alteration of the original Healthy Relationships intervention (HR-O) that delivered the intervention to mixed gender groups by non-mental health and non-HIV positive facilitators. Process measures from the altered Healthy Relationships intervention (HR-A) were compared to the same measures taken in the HR-O trial. Intervention completion rates were better in the HR-A model (84%) than HR-O (70%). Results showed that HR-A was comparable to HR-O in social support, group cohesion, and group openness. Facilitators in HR-A were viewed somewhat more positive than in HR-O. We found no empirical basis for conducting separate groups by gender or for constraining the facilitators in terms of their professional and HIV statuses. Research is needed to test the assumptions of other evidence-based HIV prevention programs.

Coital bleeding and HIV risks among men and women in Cape Town, South Africa

BACKGROUND

South Africa has one of the world's fastest growing HIV epidemics. Genital bleeding during sexual intercourse may play a role in facilitating HIV transmission in South Africa.

PURPOSE

The purpose of this study was to examine the prevalence and sources of coital bleeding among men and women living in a Cape Town South Africa township.

METHODS

A purposive sample of 464 men and 531 women completed anonymous street intercept surveys of HIV risk history and sexual behaviors.

RESULTS

Thirty-one percent of men and 26% of women had a lifetime history of engaging in sexual intercourse that involved genital bleeding, and 21% of men and 16% of women reported coital bleeding in the previous 3 months. Over 75% of coital bleeding was attributed to menses. Across genders and controlling for demographic, sexual behavior, and life history factors, coital bleeding in the previous 3 months was associated with being an indigenous African, having multiple sexual partners, and higher rates of unprotected intercourse during that time period. People who reported coital bleeding were over 3 times more likely to have been diagnosed with a sexually transmitted infection even after controlling for having had genital ulcers.

CONCLUSIONS

Coital bleeding may be common in South Africa. Prevention messages that promote condom use or refraining from sex when there is genital bleeding are therefore needed.

Sensation seeking, alcohol use, and sexual behaviors among sexually transmitted infection clinic patients in Cape Town, South Africa

Alcohol use is associated with risks for HIV/AIDS. The association between alcohol and sexual risk may be accounted for by sensation seeking personality. However, sensation seeking in relation to substance use and HIV risk has not been examined in Africa. In this study, 292 men and 219 women receiving sexually transmitted infection (STI) diagnostic and treatment services in Cape Town, South Africa, completed anonymous behavioral surveys. Structural modeling was used to test a model of alcohol use and sensation seeking in relation to sexual risk behaviors. Results showed that sensation seeking and alcohol use in sexual contexts were related to HIV risks, controlling for gender and marital status. The association between sensation seeking and HIV risk was partly accounted for by alcohol use in proximity to sex. In contrast to studies conducted in the United States, sensation seeking was not related to alcohol-sex outcome expectancies. These findings suggest that alcohol use is an important HIV transmission risk factor for many STI clinic patients and that interventions for individuals who are characterized as sensation seekers are urgently needed in South Africa.

Internet-based health information consumer skills intervention for people living with HIV/AIDS

Medical information can improve health, and there is an enormous amount of health information available on the Internet. A randomized clinical trial tested the effectiveness of an intervention based on social- cognitive theory to improve information use among people living with HIV/AIDS. Men and women (N = 448) were placed in either (a) an 8-session intervention that focused on Internet information consumer skills or (b) a time-matched support group and were followed to 9 months postintervention. The Internet skills group demonstrated greater Internet use for health, information coping, and social support compared with the control group. The authors conclude that people with HIV infection may benefit from increased access to health information on the Internet and that vulnerability to misinformation and fraud can be reduced through behavioral interventions.

HIV treatment beliefs and sexual transmission risk behaviors among HIV positive men and women

People are living longer and healthier with HIV infection because of successful combination antiretroviral therapies. HIV treatment beliefs are often associated with sexual practices among people living with HIV/AIDS but these associations may depend on the HIV status of sex partners. In a sample of 158 HIV positive men and women who were receiving HIV treatments, we examined the association between HIV treatment beliefs, HIV transmission risk perceptions, medication adherence, viral load and engaging in unprotected intercourse with any sex partners and specifically with sex partners who were not HIV positive (non-concordant). Results showed having missed medications in the past two days and treatment-related beliefs were significantly associated with engaging in unprotected intercourse with all sex partners as well as non-concordant partners. However, multivariate models showed that only treatment beliefs were significantly associated with engaging in unprotected intercourse with non-concordant partners. These results extend past research by demonstrating that the HIV status of sex partners sets the context for whether prevention-related treatment beliefs are associated with HIV transmission risk behaviors among people living with HIV/AIDS.

Generalizing a model of health behaviour change and AIDS stigma for use with sexually transmitted infection clinic patients in Cape Town, South Africa

We tested the Information-Motivation-Behavioural Skills (IMB) model of AIDS preventive behaviour in South Africa. Prospective path analyses were performed on measures collected from 131 men and 60 women with sexually transmitted infections (STI) in Cape Town. Results showed that IMB constructs collected at baseline predicted risk reduction behaviour 3 months later. Risk reduction intentions were positively associated with risk reduction self-efficacy and self-efficacy was in turn positively associated with protective behaviour 3 months later. In a second model, AIDS-related stigmas correlated inversely with AIDS knowledge and there was a trend toward AIDS stigmas correlating inversely with behavioural intentions. Accounting for AIDS-related stigmas did not improve model fit. These findings parallel similar tests of the IMB model in US samples and suggest that the IMB model may generalize to South Africa and may therefore be useful in guiding HIV risk reduction interventions.

HIV/AIDS risks among South African men who report sexually assaulting women

OBJECTIVE

To examine HIV risks among South African men who report having been sexually assaultive.

METHODS

Men (N = 412) in Cape Town completed anonymous surveys.

RESULTS

Twenty-three percent reported a history of sexual assault. Men who had been sexually assaultive were younger, reported more sex partners, were more likely to have a history of genital ulcers, and more likely to have exchanged money for sex. Sexually assaultive men were also more likely to endorse rape myths.

CONCLUSIONS

Interventions that target men as the agents of change in reducing sexual assaults and HIV transmission are urgently needed.

Health information on the Internet and people living with HIV/AIDS: Information evaluation and coping styles

Individuals who seek information on the Internet to cope with chronic illness may be vulnerable to misinformation and unfounded claims. This study examined the association between health-related coping and the evaluation of health information. Men (n = 347) and women (n = 72) who were living with HIV/AIDS and reported currently using the Internet completed measures assessing their Internet use. Health Web sites downloaded from the Internet were also rated for quality of information. HIV-positive adults commonly used the Internet to find health information (66%) and to learn about clinical trials (25%); they also talked to their physicians about information found online (24%). In a multivariate analysis, assigning higher credibility to unfounded Internet information was predicted by lower incomes, less education, and avoidant coping styles. People who cope by avoiding health information may be vulnerable to misinformation and unfounded claims that are commonly encountered on the Internet.

Psychosocial and behavioral correlates of seeking sex partners on the internet among hiv-positive men

BACKGROUND

The Internet is revolutionizing how people access and use information; for some people, the Internet is also redefining interpersonal relationships, including sexual relationships.

PURPOSE

The objective of this study was to extend the understanding of HIV-positive men who use the Internet to meet sex partners.

METHODS

This study examined the use of the Internet for meeting sex partners among 141 sexually active HIV-positive men who completed anonymous surveys.

RESULTS

Results showed that 37% of sexually active HIV-positive men who were using the Internet had gone online to seek potential sex partners in the previous 3 months. Seeking sex partners online was associated with greater likelihood of having HIV-negative sex partners and engaging in unprotected intercourse with HIV-negative or unknown HIV status partners. Multivariate analyses showed that seeking sex partners online was associated with greater education, higher CD4 cell counts, using the Internet for sexual entertainment, and higher Sexual Compulsivity scale scores over and above demographic, health, Internet use, sexual behavior, and other psychosocial characteristics including optimism and depression.

CONCLUSIONS

Results suggest a continued need for interventions targeting HIV transmission risk reduction among HIV-positive men who use the Internet to meet potential sex partners.

Pillboxes and antiretroviral adherence: prevalence of use, perceived benefits, and implications for electronic medication monitoring devices

HIV treatment adherence is improved by behavioral interventions, including medication organizers such as pillboxes, which can also interfere with adherence electronic monitoring devices (EMD). This study examined the characteristics of pillbox users and the implications of pillbox use for research using EMD adherence research. Men and women (n = 160) currently taking antiretroviral medications (ARVs) completed anonymous surveys in a community research setting. Sixty-three (39%) of individuals taking ARVs were currently using a pillbox. Pillbox users were significantly more likely to have an undetectable viral load and less likely to have missed their medications within a day of the assessment. Pillbox users indicated feeling that they benefited from using their pillbox and 76% reported they would likely stop using their pillbox if required to participate in a research study that paid them. Adherence EMD pose methodological limitations to research when pillbox users are excluded and ethical implications when pillbox users stop using their pillbox to participate.

Development of an HIV risk reduction counselling intervention for use in South African sexually transmitted infection clinics

South Africa urgently needs HIV prevention interventions that can be disseminated for use in clinical and community settings. A brief theory-based HIV risk reduction counselling intervention originally developed in the USA has recently been adapted for use in a South African sexually transmitted infection clinic. The 60-minute risk reduction counselling intervention was grounded in the Information-Motivation-Behavioural Skills (IMB) model of HIV preventive behaviour change, adapted through a series of interdisciplinary collaborative workshops. This paper reports the process of developing and culturally adapting the brief risk reduction counselling intervention. The processes used for adapting the HIV risk reduction counselling for South Africa provides a potential model for conducting technology transfer activities with other HIV prevention interventions. Several lessons learned from this process may help guide future efforts to transfer HIV prevention technologies.

Internet use among people living with HIV/AIDS: coping and health-related correlates

People living with HIV/AIDS may experience health benefits from using the Internet for accessing health information as well as potential health hazards, including seeking sex partners online. This study examined how people with HIV/AIDS are using the Internet and how their Internet use may be associated with health behaviors. HIV-positive men (n = 347) and HIV-positive women (n = 72) who reported using the Internet were recruited from community services to complete an anonymous survey of their Internet use and associated factors. HIV-positive Internet users reported using the Internet for a wide range of purposes, with health related searches for information accounting for 1 of 3 Internet activities. People with greater income and more education were more likely to use the Internet for health functions. Health-related Internet use was related to a broader spectrum of health behaviors including HIV treatment adherence and health-related Internet use was associated with active coping strategies and indicators of better health. HIV-positive men and women are frequently using the Internet to access health-related information as well as for other nonhealth-related functions. Searching the Internet for health information can be conceptualized as an active coping strategy, occurring with other health-related behaviors and offering potential health benefits.

Risk factors for HIV-AIDS among youth in Cape Town, South Africa

South Africa is in the midst of a devastating HIV-AIDS epidemic and most new HIV infections occur among young adults and adolescents. The current study examined risk behaviors and HIV risk factors among young people living in a Black South African township. Using community-based outreach methods of street intercept and facility-based surveying, 113 men and 115 women age 25 and younger responded to an anonymous survey. Results showed that men (68%) and women (56%) reported HIV-related high risk sexual behaviors. Although knowledge about HIV transmission was generally high, there was evidence that misconceptions about AIDS persist, particularly myths related to HIV transmission. For young men, HIV risk factors were associated with fewer years of education, lower levels of AIDS-related knowledge, condom attitudes, and Dagga (marijuana) use. Among young women, HIV risk factors were associated with beliefs that condoms get in the way of sex and rates of unprotected vaginal intercourse. Despite adequate general AIDS knowledge and risk sensitization, South African youth demonstrated high rates of sexual practices that place them at risk for HIV infection. There is an urgent need for behavioral interventions targeted to young South Africans living in the most economically disadvantaged areas.

Theory-based HIV risk reduction counseling for sexually transmitted infection clinic patients in Cape Town, South Africa

BACKGROUND

South Africa has the world's fastest growing AIDS epidemic. There is an urgent need for effective HIV risk reduction interventions in South Africa.

OBJECTIVE

The objective of this study was to develop and test the potential efficacy of a brief theory-based HIV prevention counseling intervention for sexually transmitted infection (STI) clinic patients in South Africa.

METHOD

STI clinic patients in Cape Town (N=228) were assessed at baseline and randomized to receive either: 1) a single 60-minute session motivational/skills-building HIV risk reduction counseling intervention or 2) a 20-minute HIV information/education session. Participants completed 1- and 3-month follow ups with 80% retention.

RESULTS

The 60-minute motivational/skills risk reduction counseling demonstrated significantly greater risk reduction practices, lower rates of unprotected intercourse, and greater likelihood of receiving HIV testing after the intervention.

CONCLUSIONS

Brief theory-based HIV prevention counseling may significantly reduce HIV risk behaviors for STI clinic patients in South Africa.

Alcohol use and sexual risks for HIV infection among men and women receiving sexually transmitted infection clinic services in Cape Town, South Africa

OBJECTIVE

To examine the association of alcohol use and sexual risks for HIV infection in South Africa.

METHOD

149 men and 78 women receiving sexually transmitted infection (STI) clinic services in Cape Town, South Africa, completed measures of demographic characteristics, sexual behaviors, HIV risk reduction skills and substance use, including global measures (e.g., Alcohol Use Disorders Identification Test [AUDIT]) and situational measures of alcohol use.

RESULTS

52% of men (n = 72) and 17% of women (n = 13) indicated problem drinking (AUDIT score > or = 9). Problem drinking was associated with greater numbers of sex partners in the past month, history of condom failures and lifetime history of having an STI, as well as lower rates of practicing risk reduction skills. In a separate analysis controlling for global use of alcohol indexed by AUDIT scores, we found that alcohol use in sexual contexts was associated with greater numbers of sex partners, higher rates of unprotected intercourse and condom failures.

CONCLUSIONS

Findings from this initial study of alcohol use and sexual risks in South Africa parallel those from other countries in sub-Saharan Africa. Although limited to STI clinic patients, the results suggest that effective HIV risk reduction interventions will require attention to alcohol use, particularly among South Africans at highest risk for HIV infection.

Closing the digital divide in HIV/AIDS care: development of a theory-based intervention to increase Internet access

Advances in information technology are revolutionizing medical patient education and the Internet is becoming a major source of information for people with chronic medical conditions, including HIV/AIDS. However, many AIDS patients do not have equal access to the Internet and are therefore at an information disadvantage, particularly minorities, persons of low-income levels and individuals with limited education. This paper describes the development and pilot testing of a workshop-style intervention designed to close the digital divide in AIDS care. Grounded in the Information-Motivation-Behavioral Skills (IMB) model of health behaviour change, we developed an intervention for persons with no prior history of using the Internet. The intervention included instruction in using hardware and search engines, motivational enhancement to increase interest and perceived relevance of the Internet, and skills for critically evaluating and using health information accessed via the Internet. Participants were also introduced to communication and support functions of the Internet including e-mail, newsgroups and chat groups. Pilot testing demonstrated feasibility, acceptability and promise for closing the digital divide in HIV/AIDS care using a relatively brief and intensive theory-based intervention that could be implemented in community settings.

Non-tropical thoraco-abdominal pyomyositis caused by group A streptococcus in an immunocompetent adult

We present a case of group A streptococcal pyomyositis of the thoraco-abdominal wall of an immunocompetent adult. This diagnosis was made when soft tissue swelling was seen on chest X-ray. Complete recovery followed drainage of the collection and short-course i.v. penicillin. The importance, diagnosis and treatment of pyomyositis are outlined.

Quitting cigarette smoking produces minimal loss of chronic tolerance to nicotine

RATIONALE

Long-term exposure to nicotine is associated with chronic tolerance to its acute effects, adaptation that may lead to tobacco dependence. The time course for loss of this tolerance after cessation of exposure is not known in humans but could relate to risk of smoking relapse.

OBJECTIVES

We examined changes in responses to nicotine as a function of days, weeks, or years of smoking cessation in formerly dependent smokers to determine at what point sensitivity to nicotine is reinstated (i.e., loss of tolerance).

METHODS

Acute subjective, cardiovascular, performance, and reinforcing (self-administration) effects of nicotine nasal spray (0-20 microg/kg) were assessed prospectively in men and women smokers before and then day-by-day (study 1) or 3 weeks (study 2) after stopping smoking. A smoking resumption period (study 1) and a group of non-quitting smokers (study 2) were included to control for the passage of time. These effects were also compared cross-sectionally between those who had quit for 1-4 years and those who had for 6-19 years in a separate sample of long-time ex-smokers to determine whether lengthier abstinence causes greater loss of tolerance (study 3).

RESULTS

No clear loss of tolerance was observed on any measure in studies 1 or 2, suggesting that chronic tolerance is fully maintained for at least weeks after quitting smoking. Sensitivity to nicotine's effects was also not different as a function of years quit in study 3.

CONCLUSIONS

Chronic tolerance to nicotine is not lost within several weeks of quitting smoking and may not change even after years of abstinence from tobacco use.

Traumatic grief treatment: a pilot study

OBJECTIVE

The effects of a treatment program targeting debilitating grief symptoms were tested in a pilot study.

METHOD

Twenty-one individuals experiencing traumatic grief were recruited for participation, and 13 completed the full 4-month protocol. The treatment protocol used imaginal re-living of the death, in vivo exposure to avoided activities and situations, and interpersonal therapy.

RESULTS

Significant improvement in grief symptoms and associated anxiety and depression was observed for both completer and intent-to-treat groups.

CONCLUSIONS

The traumatic grief treatment protocol appears to be a promising intervention for debilitating grief.

Dissociation of nicotine tolerance from tobacco dependence in humans

Chronic functional tolerance to nicotine generally is believed to be associated with processes responsible for tobacco dependence. The dose-related effects of nicotine (0-20 microg/kg by nasal spray) on subjective, cardiovascular, and performance responses were compared among four groups varying in current or past dependence: dependent smokers (21 cigarettes per day for 20 years; n = 45), nondependent smokers (three cigarettes per day for 14 years; n = 12), former dependent smokers (mean of 7 years quit after smoking 25 cigarettes per day for 19 years; n = 17), and life-long nonsmokers (n = 19). Chronic tolerance was determined by a shift to the right, or flattening, of the dose-response curve relative to the curve for nonsmokers. Responses were corrected for plasma nicotine concentration to rule out dispositional tolerance. Chronic tolerance was observed for most subjective responses, but little or none for cardiovascular and performance effects. Tolerance was substantial and virtually identical between dependent and nondependent smokers, whereas tolerance of former smokers was intermediate between nonsmokers and dependent smokers. Identical chronic tolerance between dependent and nondependent smokers indicates that tolerance is not a linear function of smoking exposure and does not require presence of dependence. Thus, the wide variability in daily smoking rate among smokers cannot be attributed to differences in tolerance and must involve other processes of adaptation to nicotine. The modest reversal of tolerance in long-time former smokers suggests that such tolerance reversal is either limited or extremely slow after extended abstinence, despite loss of dependence. These results suggest there is no close link between nicotine tolerance and dependence and question the utility of tolerance as one of the criteria for defining dependence.

Effectiveness of a video-based motivational skills-building HIV risk-reduction intervention for inner-city African American men

Interventions to reduce HIV risk behavior have shown promise but have demonstrated inconsistent effects with heterosexual men. This article reports a cognitive-behavioral HIV risk reduction intervention designed for heterosexually active African American men. Men (N = 117) recruited from a public clinic were randomly assigned to either (a) a 6-hr video-based small group motivational-skills intervention or (b) a 6-hr video-based contact-matched HIV education comparison group. Results showed men in the motivational-skills intervention reported lower rates of unprotected vaginal intercourse and higher rates of condom use at the 3-month follow-up. However, because of increased condom use in the comparison condition, differences between groups dissipated 6 months following the intervention. These findings are among the first to demonstrate effects from a motivational-skills intervention for reducing HIV risk in men who have sex with women using a model designed to facilitate transferring prevention technology to community settings.

Effectiveness of a video-based motivational skills-building HIV risk-reduction intervention for inner-city African American men

Interventions to reduce HIV risk behavior have shown promise but have demonstrated inconsistent effects with heterosexual men. This article reports a cognitive-behavioral HIV risk reduction intervention designed for heterosexually active African American men. Men (N = 117) recruited from a public clinic were randomly assigned to either (a) a 6-hr video-based small group motivational-skills intervention or (b) a 6-hr video-based contact-matched HIV education comparison group. Results showed men in the motivational-skills intervention reported lower rates of unprotected vaginal intercourse and higher rates of condom use at the 3-month follow-up. However, because of increased condom use in the comparison condition, differences between groups dissipated 6 months following the intervention. These findings are among the first to demonstrate effects from a motivational-skills intervention for reducing HIV risk in men who have sex with women using a model designed to facilitate transferring prevention technology to community settings.

Male polyurethane condoms do not enhance brief HIV-STD risk reduction interventions for heterosexually active men: results from a randomized test of concept

The current study examined the effects of a brief HIV risk reduction intervention for men. Participants were recruited (n = 108) from an urban public health clinic and randomly assigned to one of 3 experimental intervention conditions: (1) 3 h HIV-STD risk reduction behavioural skills building latex condom intervention; (2) the same 3 h skills workshop but focused on male polyurethane condoms; or (3) a 3 h HIV education workshop. Results showed all 3 interventions increased AIDS knowledge and positively influenced attitudes, but men who received the polyurethane condom skills intervention were more likely to request condoms at follow ups. In addition, men who received either of the 2 skills interventions evidenced increased condom use at the one-month follow up, with no differences at 3-month follow up. This study is among the first to test a brief HIV risk reduction intervention for men and is the first to test whether polyurethane male condoms enhance HIV risk reduction efforts.

Effects of prior fluoxetine treatment on EEG sleep in women with recurrent depression

We examined whether fluoxetine treatment has persistent effects on electroencephalographic sleep after drug discontinuation in patients with recurrent major depression. Age-matched groups of 23 women were treated with interpersonal psychotherapy alone (IPT) or fluoxetine plus interpersonal psychotherapy (IPT + FLU). Sleep studies were conducted when patients were depressed, and again at remission, at least four weeks after fluoxetine discontinuation. The groups did not differ in depression ratings pre- to post-treatment. Significant group*time interaction effects were noted for REM sleep (p = .04) and slow wave sleep (p = .02). REM percentage and phasic REM activity increased in the IPT + FLU group but decreased in the IPT group. The effects of fluoxetine treatment on electroencephalographic sleep can be observed for at least four weeks after drug discontinuation and appear to represent both drug discontinuation and neuroadaptation effects.

AIDS treatment advances and behavioral prevention setbacks: preliminary assessment of reduced perceived threat of HIV-AIDS

Recent advances in AIDS treatment have brought renewed optimism for prolonging the lives of those infected with HIV. This article examined beliefs about how new treatments may reduce HIV transmission risk among 298 HIV-negative gay and bisexual men attending a gay pride festival. Results from an anonymous survey showed that men who practiced unprotected anal intercourse as the receptive partner (UAR intercourse) were younger, less well educated, and more likely to believe that it is safe to have UAR intercourse with an HIV-positive man who has an undetectable viral load and that new treatments for HIV relieve their worries about unsafe sex. As HIV treatments continue to advance, new challenges for HIV prevention will likely emerge.

Sexual coercion, domestic violence, and negotiating condom use among low-income African American women

Coercion to engage in unwanted sex places women at risk for human immunodeficiency virus (HIV) infection. A survey of 125 women living in low-income housing developments in Fulton County, Georgia, showed that 53 (42%) women had engaged in unwanted sex because a male partner threatened to use force or used force to obtain sexual access. Women who had been sexually coerced were more likely to have used marijuana and crack cocaine and to have abused alcohol. Coerced women were more likely to have been physically abused by a domestic partner. These women were also more likely to perceive that requesting male partners to use condoms would create a potentially violent situation. These results suggest that women experience an interactive constellation of social problems that create risks for HIV infection and, therefore, that efforts to prevent HIV infection among women will require multifaceted intervention strategies to reach both men and women at risk.

Health care, human worth and the limits of the particular

An ethics concerned with health care developments and systems must be historically continuous, especially as it concerns the application to managed structures of key moral-epistemic concepts such as care, love and empathy. These concepts are traditionally most at home in the personal, individual domain. Human beings have non-instrumental worth just because they are human beings and not by virtue of their capacities. Managed health care systems tend to abstract from this worth in respect of both individuals' distinctness and individual identity. The first, a common feature of quantitative approaches to health care assessment and delivery, is avoidable. The second, by contrast, is necessarily sacrificed in impersonally managed structures. Failure to distinguish the two encourages confusion and distress, and the demand for impossible medico-moral relationships.

It's like a regular part of gay life: repeat HIV antibody testing among gay and bisexual men

HIV antibody testing is a critical facet of national AIDS prevention strategies and increasing numbers of persons are tested each year. Research has shown that a significant number of men who have sex with men are repeatedly tested for HIV antibodies, and many are tested regularly every 6 months. This study investigated the prevalence of repeat testing (having been tested three or more time) and regular testing (having been tested three or more times and getting tested every 6 months), and their association to testing attitudes and sexual behaviors. We found that 66% of 253 HIV seronegative gay and bisexual men surveyed at a large gay pride festival had been repeatedly tested, and 47% were tested regularly. Repeat testing was associated with knowing people with HIV or AIDS, whereas regular testing was associated with younger age and not being in an exclusive sexual relationship. Both repeat and regular testers held more positive health-related attitudes about testing than nonrepeat and nonregularly tested men, respectively. Contrary to previous research, repeat testing was not associated with unprotected anal intercourse or unprotected oral sex. However, both repeat and regular testing were positively related to condom use during anal intercourse as well as having multiple protected anal intercourse partners. We therefore conclude that both repeat testing and higher rates of condom use reflect positive health attitudes and that repeat testing may function to meet the needs of some men who have sex with men.