Offering annual fecal occult blood tests at annual flu shot clinics increases colorectal cancer screening rates

PURPOSE

We wanted to determine whether providing home fecal occult blood test (FOBT) kits to eligible patients during influenza inoculation (flu shot) clinics can contribute to higher colorectal cancer screening (CRCS) rates.

METHODS

The study was time randomized. On 8 dates of an annual flu shot clinic at the San Francisco General Hospital, patients were offered flu shots as usual (control group) and on 9 other dates, patients were offered both flu shots and FOBT kits (intervention group).

RESULTS

The study included 514 patients aged 50 to 79 years, with 246 in the control group and 268 in the intervention group. At the conclusion of flu season, FOBT screening rates increased by 4.4 percentage points from 52.9% at baseline to 57.3% (P = .07) in the control group, and increased by 29.8 percentage points from 54.5% to 84.3% (P <.001) in the intervention group, with the change among intervention participants 25.4 percentage points greater than among control participants (P value for change difference <.001). Among patients initially due for CRCS, 20.7% in the control group and 68.0% in the intervention group were up-to-date at the conclusion of the study (P <.001). In multivariate analyses, the odds ratio for becoming up-to-date with screening in the intervention group (vs the control group) was 11.3 (95% CI, 5.8-22.0).

CONCLUSIONS

Offering FOBT kits during flu shot clinics dramatically increased the CRCS rate for flu shot clinic attendees. Pairing home FOBT kits with annual flu shots may be a useful strategy to improve CRCS rates in other primary care or public health settings.

Five-year neurodevelopmental outcome of neonatal dehydration

OBJECTIVE

To determine the long-term outcome of neonatal dehydration.

STUDY DESIGN

We identified 182 newborns who were rehospitalized with dehydration (weight loss > or =12% of birth weight and/or serum sodium > or =150 mEq/L) and 419 randomly selected controls from a cohort of 106,627 term and near-term infants with birth weight > or =2000 g born between 1995 and 1998 in northern California Kaiser Permanente hospitals. Outcomes data were obtained from electronic records, interviews, questionnaire responses, and neurodevelopmental evaluations performed in a masked fashion.

RESULTS

Follow-up data to age at least 2 years were available for 173 of 182 children with a history of dehydration (95%) and 372 of 419 controls (89%) and included formal evaluation at a mean age (+/-standard deviation) of 5.1 +/- 0.12 years for 106 children (58%) and 168 children (40%), respectively. None of the cases developed shock, gangrene, or respiratory failure. Neither crude nor adjusted scores on cognitive tests differed significantly between groups. There was no significant difference between groups in the proportion of children with abnormal neurologic examinations or neurologic diagnoses. Frequencies of parental concerns and reported behavior problems also were not significantly different in the 2 groups.

CONCLUSIONS

Neonatal dehydration in this managed care setting was not associated with adverse neurodevelopmental outcomes in infants born at or near term.

Estimating HIV incidence in voluntary counseling and testing clients in Uganda (1992-2003)

OBJECTIVES

To estimate HIV incidence from first-time testers among voluntary counseling and testing (VCT) clients in Uganda.

METHODS

Data on 203,000 VCT clients tested from 1992 through 2003 were adjusted for temporal changes in the testing population. Differential mortality rates by HIV status were used to derive expected prevalence at future times from baseline prevalence within 5-year birth cohorts. Incidence was computed as the proportion of HIV-uninfected persons who seroconverted divided by the proportion negative at baseline.

RESULTS

Annual HIV incidence per 100 uninfected persons increased from 0.9 (95% confidence interval [CI]: 0.8 to 1.1) in 1993 to 2.3 (95% CI: 2.2 to 2.5) in 2003 (chi test for trend, P < 0.001). Prevalence decreased from 23% to 13% in 1999 to 2000 and increased to 15% in 2003. Women had a higher incidence. Peak incidence shifted to older age groups over time.

CONCLUSIONS

Estimating incidence from routine data presents a practical way of tracking HIV incidence and is a useful tool in targeting and evaluating the impact of prevention programs. Our analysis reveals a new phase of the HIV epidemic in Uganda: decreasing prevalence and increasing incidence, especially among middle-aged persons. These findings support the need for intensified prevention interventions among middle-aged persons in Uganda.

Working to prevent HIV/STIs among women in the sex industry in a rural town of Hainan, China

We evaluated a two-phase HIV/STIs prevention intervention for female sex workers in a resource-limited rural town in Hainan Province, China. The primary intervention strategy, conducted from 1997 to 2000, was a condom promotion campaign conducted through outreach to sex workers. Four serial cross-sectional surveys were carried out before and after the intervention. Over a period of 2 years, reported condom use during the most recent sexual encounter increased from about 50% to more than 70%; and condom use in more than 50% of sexual acts during the past 6 months increased from less than 40% to near 80% of respondents. Controlling for education, ethnicity and age, reading of educational materials (our intervention variable) was a significant contributor to a higher knowledge score, motivation to use condoms, and reported condom use. This study demonstrates that outreach to female sex workers, if appropriately tailored to local settings, can increase condom use in a resource-limited rural area.

Boyfriends, girlfriends and teenagers' risk of sexual involvement

CONTEXT

Having a boyfriend or girlfriend, especially an older one, is associated with increased sexual risk in early adolescence. The mechanisms underlying this association are unclear.

METHODS

Middle school students in Northern California were surveyed annually from 1997 to 2000. For a sample of 1,214 males and 1,308 females who were sexually inexperienced in seventh grade, logistic and linear regression were used to explore associations between relationship status in seventh grade and sexual activity in ninth grade, controlling for sixth-grade and eighth-grade characteristics.

RESULTS

Males who had had a girlfriend their age by seventh grade were more likely than those who had had no relationship to report sexual activity in ninth grade (odds ratio, 2.1). Similarly, for females, the odds of being sexually active in ninth grade were elevated among those who had had a boyfriend their age (2.9); however, they also were higher among those who had had an older boyfriend than among those who had had one their age (2.1). With sixth-grade risk factors controlled, relationship status in seventh grade remained significant only for females; the association was explained by early menarche and by participation in situations that could lead to sex and riskier peer norms in eighth grade. For males, eighth-grade situations that could lead to sex, Hispanic ethnicity and sixth-grade peer norms explained ninth-grade sexual behavior.

CONCLUSIONS

To reduce the risk of adolescent sexual activity, parents and communities should encourage youth in middle school, especially females who experience early menarche, to delay serious romantic relationships.

Outcomes among newborns with total serum bilirubin levels of 25 mg per deciliter or more

BACKGROUND

The neurodevelopmental risks associated with high total serum bilirubin levels in newborns are not well defined.

METHODS

We identified 140 infants with neonatal total serum bilirubin levels of at least 25 mg per deciliter (428 micromol per liter) and 419 randomly selected controls from a cohort of 106,627 term and near-term infants born from 1995 through 1998 in Kaiser Permanente hospitals in northern California. Data on outcomes were obtained from electronic records, interviews, responses to questionnaires, and neurodevelopmental evaluations that had been performed in a blinded fashion.

RESULTS

Peak bilirubin levels were between 25 and 29.9 mg per deciliter (511 micromol per liter) in 130 of the newborns with hyperbilirubinemia and 30 mg per deciliter (513 micromol per liter) or more in 10 newborns; treatment involved phototherapy in 136 cases and exchange transfusion in 5. Follow-up data to the age of at least two years were available for 132 of 140 children with a history of hyperbilirubinemia (94 percent) and 372 of 419 controls (89 percent) and included formal evaluation at a mean (+/-SD) age of 5.1+/-0.12 years for 82 children (59 percent) and 168 children (40 percent), respectively. There were no cases of kernicterus. Neither crude nor adjusted scores on cognitive tests differed significantly between the two groups; on most tests, 95 percent confidence intervals excluded a 3-point (0.2 SD) decrease in adjusted scores in the hyperbilirubinemia group. There was no significant difference between groups in the proportion of children with abnormal neurologic findings on physical examination or with documented diagnoses of neurologic abnormalities. Fourteen of the children with hyperbilirubinemia (17 percent) had "questionable" or abnormal findings on neurologic examination, as compared with 48 controls (29 percent; P=0.05; adjusted odds ratio, 0.47; 95 percent confidence interval, 0.23 to 0.98; P=0.04). The frequencies of parental concern and reported behavioral problems also were not significantly different between the two groups. Within the hyperbilirubinemia group, those with positive direct antiglobulin tests had lower scores on cognitive testing but not more neurologic or behavioral problems.

CONCLUSIONS

When treated with phototherapy or exchange transfusion, total serum bilirubin levels in the range included in this study were not associated with adverse neurodevelopmental outcomes in infants born at or near term.

Saw palmetto for benign prostatic hyperplasia

BACKGROUND

Saw palmetto is used by over 2 million men in the United States for the treatment of benign prostatic hyperplasia and is commonly recommended as an alternative to drugs approved by the Food and Drug Administration.

METHODS

In this double-blind trial, we randomly assigned 225 men over the age of 49 years who had moderate-to-severe symptoms of benign prostatic hyperplasia to one year of treatment with saw palmetto extract (160 mg twice a day) or placebo. The primary outcome measures were changes in the scores on the American Urological Association Symptom Index (AUASI) and the maximal urinary flow rate. Secondary outcome measures included changes in prostate size, residual urinary volume after voiding, quality of life, laboratory values, and the rate of reported adverse effects.

RESULTS

There was no significant difference between the saw palmetto and placebo groups in the change in AUASI scores (mean difference, 0.04 point; 95 percent confidence interval, -0.93 to 1.01), maximal urinary flow rate (mean difference, 0.43 ml per minute; 95 percent confidence interval, -0.52 to 1.38), prostate size, residual volume after voiding, quality of life, or serum prostate-specific antigen levels during the one-year study. The incidence of side effects was similar in the two groups.

CONCLUSIONS

In this study, saw palmetto did not improve symptoms or objective measures of benign prostatic hyperplasia. (ClinicalTrials.gov number, NCT00037154.).

HIV testing trends and correlates among young Asian and Pacific Islander men who have sex with men in two U.S. cities

We sought to determine the prevalence, trends, and correlates of recent HIV testing (within the past year) among young Asian and Pacific Islander men who have sex with men (API MSM) in two U.S. cities. We conducted serial, cross-sectional, interviewer-administered surveys of 908 API MSM aged 15-25 years, sampled from randomly selected MSM-identified venues annually from 1999 to 2002. The prevalence of recent testing increased from 63% to 71% between the first and fourth year. Recent testing was most significantly associated with ethnicity and with knowledge of testing sites to which respondents felt comfortable going. Other correlates of recent testing included gay identity, comfort with sexual and API identity, having a main partner, social support, and recent unprotected anal intercourse. API MSM who had ever traded sex for material goods or shelter were as likely to have tested recently. HIV prevention campaigns should increase the awareness and availability of culturally appropriate testing sites and urge more frequent testing by young API MSM.

Bupropion for Smoking Cessation

BACKGROUND

Bupropion hydrochloride is recommended for smoking cessation; however, there have been relatively few clinical trials examining its efficacy.

METHODS

A total of 244 current smokers were enrolled in an outpatient randomized blinded smoking cessation trial conducted at the San Francisco Veterans Affairs Medical Center, San Francisco, Calif. Of the 244 participants, 121 received a 7-week course of bupropion and 123 received placebo. All participants received 2 months of transdermal nicotine replacement therapy and 3 months of cognitive-behavioral counseling. We determined on-medication treatment, end-of-medication treatment, 3-month, 6-month, and 1-year quit rates.

RESULTS

During treatment with bupropion vs placebo, there was a trend toward increased quit rates among participants randomized to bupropion; the self-reported end-of-medication treatment quit rates were 64% for the bupropion group vs 57% for the placebo group (P =.23). The trend favoring bupropion persisted at 3 months of follow-up (P =.12) but was not apparent at 6 months and 1 year of follow-up (both P>.78). The 12-month quit rates, validated by either saliva cotinine or spousal proxy, were 22% in the bupropion group and 28% in the placebo group (P =.31). Based on biochemical validation, 19% of the bupropion group vs 24% of the placebo group had quit smoking by 1 year (P =.36).

CONCLUSIONS

In this randomized blinded trial of mostly veteran participants, the addition of a brief 7-week bupropion trial to treatment with nicotine replacement therapy and counseling did not significantly increase smoking cessation rates.

Do required preclinical courses with family physicians encourage interest in family medicine?

BACKGROUND

Many medical schools, including the University of California, San Francisco (UCSF), added required preclinical course work with family physicians in the 1990s. We examined whether current UCSF students interested in family medicine noted more contact with family physicians and more faculty support of their interest than current Stanford students and 1993 UCSF students, neither of whom had required preclinical course work with family physicians.

METHODS

A questionnaire was administered to students interested in family medicine at UCSF and Stanford in February 2001, with response rates of 84% and 90%, respectively. Previously published 1993 data from UCSF were also used for comparison. Data were analyzed using chi-square and t statistics as appropriate.

RESULTS

UCSF students in 2001, despite exposure to required preclinical course work with family physicians, did not perceive greater contact with family physicians than Stanford students. Stanford students perceived greater encouragement from their family medicine faculty but less from faculty overall, compared with 2001 UCSF students. UCSF students in 2001 perceived no more overall faculty encouragement than did UCSF students in 1993.

CONCLUSIONS

Required preclinical course work with family physicians was not consistently associated with greater student perception of faculty support for students' interest in family medicine, nor was it demonstrated to increase the amount or quality of interested students' interaction with family medicine faculty.

Relation of serum ascorbic acid to Helicobacter pylori serology in US adults: the Third National Health and Nutrition Examination Survey

PURPOSE

To examine the relation between serum ascorbic acid and Helicobacter pylori serology from a probability sample of US adults.

SUBJECTS AND METHODS

Data from 6,746 adults (ages 20 to 90 years) enrolled in the Third National Health and Nutrition Examination Survey (NHANES III), 1988-1994 were analyzed. Multiple logistic regression models were examined taking into account sample weights and the complex survey design of NHANES III, and controlling for the effects of potential confounders. Because race appeared to modify the association between serum ascorbic acid and seropositivity to H. pylori, we conducted the analyses stratified by race.

RESULTS

A total of 2,189 adults (32%) had a positive serology for H. pylori, and, of these, 1,175 (54%) were positive for the CagA antigen. Among whites, a 0.50 mg/dL increase in serum ascorbic acid level was associated with decreased seroprevalence of H. pylori (Odds Ratio (OR) = 0.89, 95% confidence interval (CI) CI 0.82-0.96, p < 0.01). In analyses that controlled for seroprevalence of H. pylori, a 0.50 mg/dL increase in serum ascorbic acid level among whites was independently associated with a decreased seroprevalence of the pathogenic cagA-positive strain of H. pylori (OR = 0.31, 95% CI 0.12-0.79, p < 0.05). Serum ascorbic acid levels were not significantly associated with H. pylori serology among non-whites (all p > 0.05).

CONCLUSIONS

Higher serum levels of ascorbic acid were associated with a decreased seroprevalence of H. pylori and of the pathogenic cagA-positive strain of H. pylori among whites. If these associations are related causally and are not the result of residual confounding by factors such as socioeconomic status, ascorbic acid may affect the risk of H. pylori infection and in turn, the risk for peptic ulcer disease and gastric cancer among white Americans.

Dramatic improvement in survival among adult Brazilian AIDS patients

BACKGROUND

Since the last study of survival time among Brazilian AIDS patients, care has improved steadily, culminating in a controversial policy of universal free access to triple antiretroviral treatment since 1996. This large, national study examined how these changes have impacted survival.

METHODS

Using national data for cases diagnosed in 1995 and 1996, we randomly selected 3930 adult AIDS cases from 18 cities in seven states representing all regions of Brazil. Trained abstracters reviewed medical records, determining dates of diagnosis and death or last contact, exposure category, treatment, and demographics. After review, 2821 cases met the inclusion criteria and were available for Kaplan-Meier and proportional hazards analysis. Data from the earlier study were re-analyzed for comparison.

RESULTS

Median survival was 5 months for cases diagnosed in the 1980s, 18 months for those diagnosed in 1995, and 58 months for those diagnosed in 1996. Predictors of longer survival in univariate analysis included antiretroviral treatment, year of diagnosis, higher education, sexual exposure category, female sex, and Pneumocystis carinii pneumonia prophylaxis. In multivariate analysis, the predictive value of most of these was attenuated or disappeared, leaving antiretroviral treatment as the main predictor of survival.

CONCLUSIONS

Survival time has increased substantially for adult Brazilian AIDS patients. The timing of these gains and analysis of the predictors of survival both indicate antiretroviral treatment as the cause. These findings demonstrate that universal access to antiretroviral treatment in a developing country can produce benefits on the same scale as in richer countries.

Intensive smoking cessation counseling versus minimal counseling among hospitalized smokers treated with transdermal nicotine replacement: a randomized trial

PURPOSE

To determine whether an intensive cognitive-behavioral intervention begun during hospitalization when combined with transdermal nicotine replacement therapy is more effective than a minimal counseling intervention combined with transdermal nicotine replacement therapy in helping inpatients to quit smoking.

METHODS

A total of 223 patients who smoked were enrolled in a hospital-based randomized smoking cessation trial at the San Francisco Veterans Affairs Medical Center. One hundred and seven participants (48%) received intensive counseling and outpatient telephone follow-up; 116 participants (52%) received minimal counseling. All study participants received 2 months of transdermal nicotine replacement therapy. We determined 6-month quit rates by self-report and measured saliva cotinine levels or obtained proxy reports to confirm self-reported smoking cessation at 12 months. Analyses adjusted for baseline differences in the distribution of coronary disease.

RESULTS

At 6 months, 35% (36/103) of the intensive intervention group reported quitting, compared with 21% (23/109) of the comparison group (relative risk [RR] = 1.7; 95% confidence interval [CI]: 1.1 to 2.7). At 12 months, the self-reported quit rate was 33% (33/99) in the intensive intervention group versus 20% (21/103) in the comparison group (RR = 1.7; 95% CI: 1.1 to 2.7). Based on biochemical or proxy confirmation, 29% (30/102) in the intensive intervention group versus 20% (21/107) in the comparison group quit smoking at 12 months (RR = 1.6; 95% CI: 0.96 to 2.5).

CONCLUSION

Hospital-initiated smoking cessation interventions that include transdermal nicotine replacement therapy can improve long-term quit rates.

HIV-1 in ethnic Shan migrant workers in northern Thailand

Northern Thailand has one of the highest rates of HIV-1 infection in Southeast Asia. It is also home to a large number of Burmese migrants, believed to be at high risk of HIV. Our 1999 survey of 429 Burmese migrant workers of Shan ethnic origin in Chiang Mai province found a 4.9% rate of HIV-1 prevalence (5.7% men, 3.8% women). This figure is almost double that of comparable population groups in Chiang Mai, e.g. pregnant women and military recruits. HIV prevention programmes are urgently needed for this vulnerable population.

Relation of ascorbic acid to bone mineral density and self-reported fractures among US adults

Ascorbic acid is an essential nutrient involved in collagen formation, and its deficiency is associated with abnormal bone development. To examine the relation of ascorbic acid to bone mineral density and the prevalence of self-reported fractures, the authors analyzed data collected from 13,080 adults enrolled in the Third National Health and Nutrition Examination Survey (NHANES III) during 1988-1994. Because they identified three-way interactions among smoking, history of estrogen use, and dietary and serum ascorbic acid in postmenopausal women, they analyzed these relations stratified by smoking and estrogen use. Dietary ascorbic acid intake was independently associated with bone mineral density among premenopausal women (p = 0.002). Among men, serum ascorbic acid was associated in a nonlinear fashion with bone mineral density (p < 0.05), and dietary ascorbic acid intake was associated in a nonlinear fashion with self-reported fracture (p = 0.05). Among postmenopausal women without a history of smoking or estrogen use, serum ascorbic acid was unexpectedly associated with lower bone mineral density (p = 0.01). However, among postmenopausal women with a history of smoking and estrogen use, a standard deviation increase in serum ascorbic acid was associated with a 49% decrease in fracture prevalence (p = 0.001). Dietary and serum ascorbic acid measures were associated inconsistently with bone mineral density and self-reported fracture among adult participants in NHANES III.

Relation of serum ascorbic acid to mortality among US adults

PURPOSE

To examine the relation between serum ascorbic acid (SAA), a marker of dietary intake (including supplements), and cause-specific mortality.

SUBJECTS AND METHODS

We analyzed data from a probability sample of 8,453 Americans age > or = 30 years at baseline enrolled in the Second National Health and Nutrition Examination Survey (NHANES II), who were followed for mortality endpoints. We calculated relative hazard ratios as measures of disease association comparing the mortality rates in three biologically relevant SAA categories.

RESULTS

Participants with normal to high SAA levels had a marginally significant 21% to 25% decreased risk of fatal cardiovascular disease (CVD) (p for trend = 0.09) and a 25% to 29% decreased risk of all-cause mortality (p for trend <0.001) compared to participants with low levels. Because we determined that gender modified the association between SAA levels and cancer death, we analyzed these associations stratified by gender. Among men, normal to high SAA levels were associated with an approximately 30% decreased risk of cancer deaths, whereas such SAA levels were associated with an approximately two-fold increased risk of cancer deaths among women. This association among women persisted even after adjustment for baseline prevalent cancer and exclusion for early cancer death or exclusion for prevalent cancer.

CONCLUSIONS

Low SAA levels were marginally associated with an increased risk of fatal CVD and significantly associated with an increased risk for all-cause mortality. Low SAA levels were also a risk factor for cancer death in men, but unexpectedly were associated with a decreased risk of cancer death in women. If the association between low SAA levels and all-cause mortality is causal, increasing the consumption of ascorbic acid, and thereby SAA levels, could decrease the risk of death among Americans with low ascorbic acid intakes.

The impact of workplace smoking ordinances in California on smoking cessation

OBJECTIVES

The effect of local workplace smoking laws in California was assessed to determine whether such laws increase smoking cessation.

METHODS

Workplace smoking ordinance data from 1990 were appended to 1990 California Tobacco Survey data from 4680 adult indoor workers who were current cigarette smokers or reported smoking in the 6 months before the survey. Ordinance effects on cigarette smoking and worksite policy were estimated by using multiple logistic regression controlling for sociodemographic variables.

RESULTS

Smokers who worked in localities with a strong workplace ordinance (compared with no workplace ordinance) were more likely to report the existence of a worksite smoking policy (odds ratio [OR] = 1.6; 95% confidence interval [CI] = 1.2, 2.2) and to report quitting smoking in the prior 6 months (OR = 1.5; 95% CI = 1.1, 1.7). In communities with strong ordinances, an estimated 26.4% of smokers quit smoking within 6 months of the survey and were abstinent at the time of the survey, compared with an estimated 19.1% in communities with no ordinance.

CONCLUSIONS

Workplace smoking ordinances increased smoking cessation among employed smokers, indicating that these laws may benefit smokers as well as nonsmokers.

Serum ascorbic acid and gallbladder disease prevalence among US adults: the Third National Health and Nutrition Examination Survey (NHANES III)

BACKGROUND

Ascorbic acid-deficient guinea pigs frequently develop gallstones, and ascorbic acid status may also affect the risk of gallbladder disease in humans. To examine the relationship of ascorbic acid, an antioxidant nutrient involved in cholesterol catabolism, to gallbladder disease, we analyzed data collected from a probability sample of US adults.

METHODS

Analyses of data from 7042 women and 6088 men enrolled in the Third National Health and Nutrition Examination Survey, 1988-1994, were performed. Multiple logistic regression models stratified by sex were examined, controlling for the effects of age, race, diet, body mass index, and other potential confounders.

RESULTS

A total of 761 women (11%) and 235 men (4%) reported a history of clinical gallbladder disease (symptomatic gallstones or cholecystectomy). Of the 9650 participants without a history of clinical gallbladder disease or abdominal pain consistent with gallbladder disease, and with valid abdominal ultrasonography, 408 (8%) of 4863 women and 274 (6%) of 4787 men had asymptomatic gallstones. Serum ascorbic acid level was inversely related to prevalence of clinical and asymptomatic gallbladder disease among women, but not among men. Among women, each SD (27 micromol/L) increase in serum ascorbic acid level was independently associated with a 13% lower prevalence of clinical gallbladder disease (P = .006) and asymptomatic gallstones (P = .048).

CONCLUSION

Ascorbic acid, which affects the catabolism of cholesterol to bile acids and, in turn, the development of gallbladder disease in experimental animals, may affect the risk of gallbladder disease among women.

HIV infection and risk behaviors in two cross-sectional surveys of heterosexuals in alcoholism treatment

OBJECTIVE

To measure the prevalence of human immunodeficiency virus (HIV) infection and high-risk behaviors among heterosexuals in alcoholism treatment, comparing two cross-sectional surveys completed 2 to 3 years apart.

METHOD

Two groups of entrants to alcoholism treatment clinics were recruited, between October 1990 and December 1991 (n = 860; 639 men) and between January 1993 and March 1994 (n = 752; 520 men). Participants underwent a structured interview including an assessment of demographics. substance abuse characteristics and sexual behaviors, as well as serotesting for HIV antibodies. Associations were examined between HIV serostatus and several factors, including demographic variables, substance use and high-risk sexual behaviors.

RESULTS

The overall HIV seroprevalence in the first and second samples was 5% (95% CI: 3-6%) and 5% (95% CI: 3-7%). When the two samples were compared, there were no significant differences in prevalence of HIV infection by categories of gender, race, income and most other demographic characteristics within either sample: history of injection drug use (IDU) was significantly related to HIV serostatus in both samples. Unsafe sexual practices were common in both samples. When samples were combined, those 30 years of age or older were more likely to be HIV infected, and men and women with no reported history of IDU still had an HIV prevalence of 3% and 2%, respectively. More than half of the respondents had two or more partners in the previous 6 months and reported a history of a sexually transmitted disease.

CONCLUSIONS

There was no change in the substantial prevalence of HIV infection and high-risk behavior among heterosexual clients entering alcoholism treatment programs over the 3.5-year study period. The HIV prevalence among non-IDU clients remained several times higher than published estimates from similar community-based heterosexual samples. These data reinforce the concept that heterosexual noninjection drug users are at high risk for HIV and may benefit from intervention programs.

Serum ascorbic acid and other correlates of self-reported cataract among older Americans

The purpose of this study was to examine the correlates of self-reported cataract among older Americans, and specifically, to determine whether serum ascorbic acid levels are associated with a decreased prevalence of cataract. A national probability survey of Americans, the Second National Health and Nutrition Examination Survey (NHANES II), was conducted between 1976 and 1980. A total of 4001 participants were included between the ages of 60 and 74 years with data on serum ascorbic acid level and other variables of interest. A total of 252 women (12%) and 164 men (9%) reported a history of cataract. Serum ascorbic acid level was inversely associated with prevalence of cataract in multiple logistic regression analyses; each 1 mg/dl increase was independently associated with a 26% decrease in cataract (P = 0.03). Other independent correlates of cataract included increasing age, female sex, smoking, and diabetes mellitus (all P<0.01). We identified four correlates of cataract among older Americans: serum ascorbic acid level, increasing age, smoking, and diabetes mellitus. Ascorbic acid, a water-soluble antioxidant found in high concentrations in the lens, may be of importance for the prevention of cataract among older Americans.

Serum ascorbic acid and cardiovascular disease prevalence in U.S. adults: the Third National Health and Nutrition Examination Survey (NHANES III)

PURPOSE

To examine the relation between serum ascorbic acid concentration, which reflects dietary and supplement intake, and the prevalence of cardiovascular disease.

METHODS

We analyzed data from 7658 men and women enrolled in the Third National Health and Nutrition Examination Survey (NHANES III). We calculated odds ratios and 95% confidence intervals (CI) to estimate the relative prevalence of cardiovascular disease, defined as self-reported angina, myocardial infarction, or stroke. Because we detected an interaction between serum ascorbic acid concentration and alcohol intake, we performed analyses stratified by drinking status.

RESULTS

Among participants who reported no alcohol consumption, serum ascorbic acid concentrations were not independently associated with cardiovascular disease prevalence. Among participants who consumed alcohol, serum ascorbic acid concentrations consistent with tissue saturation (1.0-3.0 mg/dl) were associated with a decreased prevalence of angina (multivariate odds ratio (OR): 0.48; 95% CI: 0.23% to 1.03; p for trend = 0.06), but were not significantly associated with myocardial infarction or stroke prevalence.

CONCLUSIONS

These results suggest the possibility of a biologic interaction between ascorbic acid and alcohol and that higher intakes of ascorbic acid may be associated with a decreased risk of angina among drinkers.

Relationship of ascorbic acid to blood lead levels

CONTEXT

Some animal studies suggest that orally administered ascorbic acid may chelate lead and decrease the risk of the toxic effects of lead. However, results from several small studies in humans have yielded inconclusive evidence of a beneficial effect of ascorbic acid on lead toxicity.

OBJECTIVE

To examine the relationship between serum ascorbic acid levels and prevalence of elevated blood lead levels.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional analysis of a probability sample of the US population enrolled in the Third National Health and Nutrition Examination Survey, 1988-1994 (4213 youths aged 6-16 years and 15365 adults aged > or =17 years) without a history of lead poisoning.

MAIN OUTCOME MEASURES

Elevated and log blood lead levels by serum ascorbic acid level.

RESULTS

A total of 22 youths (0.5%) and 57 adults (0.4%) had elevated blood lead levels (defined as > or =0.72 micromol/L [15 microg/dL]) and > or =0.97 micromol/L [20 microg/dL], respectively). After controlling for the effects of age, race, sex, income level, and dietary energy, fat, calcium, iron, and zinc intake, youths in the highest serum ascorbic acid tertile had an 89% decreased prevalence of elevated blood lead levels compared with youths in the lowest serum ascorbic acid tertile (odds ratio, 0.11; 95% confidence interval, 0.04-0.35; P for trend = .002). Adults in the highest 2 serum ascorbic acid tertiles had a 65% to 68% decreased prevalence of elevated blood lead levels compared with adults in the lowest serum ascorbic acid tertile (P for trend = .03). As a continuous predictor, serum ascorbic acid level was independently associated with decreased log blood lead levels among adults (P<.001), but not among youths (P=.14).

CONCLUSIONS

Our data suggest that high serum levels of ascorbic acid are independently associated with a decreased prevalence of elevated blood lead levels. If these associations are related causally, ascorbic acid intake may have public health implications for control of lead toxicity.

The impact of California's smoking ordinances on worksite smoking policy and exposure to environmental tobacco smoke

A subsample of 5776 respondents to the California Tobacco Survey who do not smoke and work indoors outside of their home was analyzed regarding worksite smoking policy and worksite exposure to environmental tobacco smoke. To obtain study results, survey responses were linked to tobacco ordinance data. Nonsmokers who worked in localities with moderate or strong laws were more likely to report worksite smoking policies than nonsmokers in localities without laws. Even in localities with strong laws, 23.5% of respondents reported no worksite policy, and 26.4% reported recent exposure to environmental tobacco smoke at the worksite. Comprehensive laws with minimal exemptions may be necessary to ensure adequate compliance and protection from environmental tobacco smoke.

Relation of serum ascorbic acid to serum vitamin B12, serum ferritin, and kidney stones in US adults

BACKGROUND

Concern has been raised that high levels of ascorbic acid consumption may lead to potential adverse effects, such as vitamin B12 deficiency, iron overload, and kidney stones.

OBJECTIVE

To examine the relation of serum ascorbic acid level, which reflects intake, to serum vitamin B12 level, serum ferritin level, and kidney stones.

METHODS

We analyzed data collected on a random sample of the US population enrolled in the Second National Health and Nutrition Examination Survey, 1976-1980. We analyzed data using linear and logistic regression models. Serum ascorbic acid, serum vitamin B12, hemoglobin, red blood cell mean corpuscular volume (MCV), and serum ferritin levels were measured using standardized protocols. History of kidney stones was determined by self-report.

RESULTS

After multivariate adjustment, serum ascorbic acid level was associated with higher serum vitamin B12 levels among women in regression models that assumed a linear relationship; each 57-pmol/L (1.0-mg/dL) increase in serum ascorbic acid level (range, 6-153 micromol/L [0.1 to 2.7 mg/dL]) was independently associated with a serum vitamin B12 level increase of 60 pmol/L (81 pg/ mL) (P<.001). Among men, serum ascorbic acid level was marginally associated with higher serum vitamin B12 levels: each 57-micromol/L (1.0-mg/dL) increase in serum ascorbic acid level was associated with a serum vitamin B12 level increase of 27 pmol/L (36 pg/mL) (P = .10). In addition, serum ascorbic acid level was not associated with correlates of vitamin B12 deficiency, such as higher MCV levels, macrocytosis (MCV >100), or lower hemoglobin concentrations. Serum ascorbic acid level was not independently associated with serum ferritin levels. However, among women only, serum ascorbic acid levels were associated in a nonlinear fashion with prevalence of elevated serum ferritin levels (P = .02). We found no association between serum ascorbic acid level and prevalence of kidney stones in women or men (both P>.05).

CONCLUSIONS

Serum ascorbic acid levels were not associated with decreased serum vitamin B12 levels (or indicators of vitamin B12 deficiency), prevalence of kidney stones, serum ferritin levels, or-among men-prevalence of elevated serum ferritin levels. Serum ascorbic acid levels were associated with prevalence of elevated serum ferritin levels among women. Although the clinical relevance of these findings is uncertain, it seems prudent to suggest that women with a genetic susceptibility to iron overload should consider moderating their intake of ascorbic acid.

Reducing AIDS risk among port workers in Santos, Brazil

OBJECTIVES

This study examined the impact of worksite-based AIDS prevention program among port workers in Santos, Brazil, on sexual risk behavior for HIV infection.

METHODS

Male port workers (n = 226) were followed in a 3-wave prospective cohort study. A multifaceted intervention costing US $90,000 for 20,000 workers was conducted between waves 2 and 3.

RESULTS

Heterosexual risk behavior showed no decline between waves 1 and 2 (before the intervention) but decreased substantially between waves 2 and 3 (after the intervention). This decrease resulted from both a decrease in nonprimary partners and an increase in condom use.

CONCLUSIONS

This worksite-based AIDS program produced marked behavior change at modest cost.

Effect of evaluator and resident gender on the American Board of Internal Medicine evaluation scores

OBJECTIVE

To examine the effects of resident and attending physician gender on the evaluation of residents in an internal medicine training program.

DESIGN

Cross-sectional study.

SETTING

Large urban academic internal medicine residency program.

PARTICIPANTS

During their first 2 years of training, 132 residents (85 men, 47 women) received a total of 974 evaluations from 255 attending physicians (203 men, 52 women) from 1989 to 1995.

MEASUREMENTS

The primary measurements were the numerical portions of the American Board of Internal Medicine evaluation form. Separate analyses were performed for each of the nine evaluation dimensions graded on a scale of 1 to 9. The primary outcome was the difference in the average scores received by each resident from male versus female attending physicians.

RESULTS

Compared with female trainees, male residents received significantly higher scores from male attending physicians than from female attending physicians in six of the nine dimensions: clinical judgment, history, procedures, relationships, medical care, and overall. Similar trends, not reaching conventional levels of statistical significance, were observed in the other three categories: medical knowledge, physical exam, and attitude. These differences ranged from 0.24 to 0.60 points, and were primarily due to higher grading of male residents by male attending physicians than by female attending physicians.

CONCLUSIONS

In one academic training program, we found a significant interaction in the grading process between the gender of internal medicine residents and the gender of their attending evaluators. This study raises the possibility that subtle aspects of gender bias may exist in medical training programs.

Serum ascorbic acid and other correlates of gallbladder disease among US adults

OBJECTIVES

This study examined the correlates of clinical gallbladder disease among US adults and whether serum ascorbic acid levels are associated with a decreased prevalence of gallbladder disease.

METHODS

Cross-sectional analyses of data from the Second National Health and Nutrition Examination Survey were conducted.

RESULTS

A total of 384 women (8%) and 107 men (3%) reported a history of gallstone disease, and 347 women (7%) and 81 men (2%) reported a history of cholecystectomy. An inverted U-shaped relation was found between serum ascorbic acid level and clinical gallbladder disease among women but not among men.

CONCLUSIONS

Ascorbic acid, which affects the catabolism of cholesterol to bile acids and, in turn, the development of gallbladder disease in experimental animals, may reduce the risk of clinical gallbladder disease in humans.

Relation of serum ascorbic acid to serum lipids and lipoproteins in US adults

OBJECTIVE

To examine the relation of serum ascorbic acid level to serum lipid and lipoprotein levels among a random sample of the US adult population.

METHODS

Using linear regression, the relation of serum ascorbic acid level to serum lipid and lipoprotein levels was examined among 5,412 women and 5,116 men enrolled in the Second National Health and Nutrition Examination Survey (NHANES II), 1976-1980. Age, race, body mass index, level of physical activity, level of education, alcohol intake, and dietary energy, cholesterol, and fat intakes, and other potential confounders were included in the multivariate models.

RESULTS

Serum ascorbic acid level was independently associated with high-density lipoprotein cholesterol (HDL-C) among women; each 1 mg/dl increase in serum ascorbic acid level (range 0.1 to 2.7 mg/dl) was associated with a 2 mg/dl increase in HDL-C level (p = 0.001). Because other investigators have demonstrated an inverse relation between ascorbic acid intake or blood levels and total serum cholesterol in individuals with elevated total serum cholesterol levels, we analyzed four subgroups of NHANES II participants with total serum cholesterol levels > 200 mg/dl. Among women with total serum cholesterol levels > or = 200 mg/dl, each 1 mg/dl increase in serum ascorbic acid level was independently associated with an increase of 2 to 3 mg/dl in HDL-C level (p < or = 0.05). Serum ascorbic acid level was not significantly associated with other serum lipids or lipoproteins.

CONCLUSIONS

If the observed associations are linked causally, they would suggest that ascorbic acid is a factor in cholesterol homeostasis among women and may be particularly important for women at increased risk for coronary heart disease.

Serum ascorbic acid and cardiovascular disease prevalence in U.S. adults

To examine the relation between serum ascorbic acid level and the prevalence of cardiovascular disease, we analyzed data from 6,624 U.S. men and women enrolled in the Second National Health and Nutrition Examination Survey. We calculated odds ratios and 95% confidence intervals to estimate the relative prevalence of cardiovascular disease, defined as self-reported coronary heart disease or stroke, or a diagnosis of peripheral vascular disease based on physical examination. Serum ascorbic acid levels were independently associated with prevalence of coronary heart disease and stroke; a 0.5-mg per dl increase in serum ascorbic acid level was associated with an 11% reduction in coronary heart disease and stroke prevalence. We also analyzed the relation of ascorbic acid, grouped into low to marginal, normal, and saturation serum categories, to cardiovascular disease. Compared with participants with low to marginally low serum ascorbic acid levels, we found a 27% decreased prevalence of coronary heart disease (95% confidence interval = 10-41%) and a 26% decreased prevalence of stroke (95% confidence interval = 3-44%) among participants in the highest serum ascorbic acid category. Serum ascorbic acid levels were not consistently associated with prevalence of peripheral vascular disease. These results are consistent with the hypothesis that increased ascorbic acid intake may decrease the risk of coronary heart disease and stroke.

AIDS and condoms in Brasilia: a telephone survey

A telephone survey was conducted to measure AIDS knowledge, media usage and condom attitudes and behaviors among 500 adults aged 18 to 49 in Brasilia, as well as to evaluate the feasibility of the telephone survey method in a developing country. The response rate was 91.6%. Respondents had good knowledge about correct modes of HIV transmission and prevention but also believed HIV was transmitted through blood donation, public toilets, swimming pools, and mosquito bites. TV and newspapers were the most important sources of information on health matters and AIDS, though health workers were considered the most credible sources of such information. Only 19% of sexual encounters in the 4 weeks prior to the survey included condoms. Single and younger respondents and those with more positive attitudes used condoms more frequently. More work is needed to identify appropriate messages to motivate people to use condoms. Telephone surveys regarding AIDS and sexual attitudes and behaviors are feasible in Brasilia, a planned community with universal telephone coverage.

Traditional Balinese youth groups as a venue for prevention of AIDS and other sexually transmitted diseases

OBJECTIVES

Our aims were to assess the feasibility of conducting peer-led educational interventions against AIDS and other sexually transmitted diseases (STDs) through traditional Balinese youth groups and to gather information on sexual risk-taking and its correlates among Balinese youth.

DESIGN

A cross-sectional survey was conducted, with follow-up questionnaires for pilot intervention participants.

SUBJECTS AND METHODS

A self-administered questionnaire was given to 375 subjects (aged 16-25 years) from 12 youth groups representing four main resort areas in Bali. Post-intervention data were collected from 97 of these subjects who had taken part in pilot educational programs. Focus groups supplemented survey data in evaluating the intervention and understanding risk behaviors.

RESULTS

In a cross-sectional survey, one-quarter of males and few females reported sexual activity; subsequent focus groups suggested under-reporting by females. While knowledge and worries about HIV/AIDS were high, only 10% of sexually active males and no females reported consistent condom use. The mean age of first sexual intercourse was highly correlated with first alcohol consumption (P = 0.0003). Peer educators from selected youth groups planned and implemented interventions for their own groups. Post-intervention data indicated significant increases in communication about sexual issues with friends and parents. Condom attitudes became less negative and efficacy increased. Participants reported this as a first experience with peer-led health education, preferred interactive activities to adult-led lectures and recommended follow-up educational sessions.

CONCLUSIONS

Peer educators from traditional youth groups can plan and conduct prevention programs for HIV/STDs that are well-received by their group memberships. Using such venues may be an efficient way to reach a wide range of pre-sexual Balinese youth, as well as those already at risk for HIV/STD due to unprotected sex, alcohol consumption and multiple sexual partners.

Young people and the structure of sexual risks in Lima

OBJECTIVES

(1) To describe psychosocial variables related to sexual activity and the prevalence of contextual factors (e.g. coercion, paid sex and drug/alcohol use) and various sexual experiences among young men and women in Lima; and (2) to assess the relationship between psychosocial, contextual and behavioral factors on one hand and negative sexual health events such as unplanned pregnancies and sexually transmitted diseases (STDs) on the other hand.

DESIGN

A cross-sectional serosurvey complemented with focus groups and in-depth interviews.

SUBJECTS AND METHODS

A total of 611 adolescents (16-17 years old) and 607 young adults (19-30 years old) were recruited randomly from among those registering for military service (adolescents) or seeking work/study permits (young adults). These subjects were asked to fill out a self-administered questionnaire with detailed information on sexual experiences and psychosocial variables. The response rates were 98% (adolescents) and 82% (young adults). A subsample of 858 subjects provided blood specimens, which were analyzed for antibodies to HIV-1, the hepatitis B virus and syphilis. The relationship between the main study variables and sociodemographic indicators was also assessed, and multivariate analysis was used to identify those variables associated with sexual health problems. A preliminary qualitative phase helped in the questionnaire design and in interpreting survey findings.

RESULTS

Thirty-four percent of adolescents and 75% of young adults were sexually experienced. The prevalence of bisexual behavior was high, particularly among males (12%). The males often reported paid sex (47%) and the females often reported sexual coercion (47%). Among the heterosexually active, only 11% reported consistent use of condoms. While 22% of the heterosexually active reported an unplanned pregnancy in self (females) or partner (males), 18% of the sexually active reported a history of STD symptoms or diagnoses. Among the sexually active who gave a blood sample, 0.2% were positive for HIV, 6.7% for hepatitis B and 1.5% for syphilis. Those who experienced an unplanned pregnancy or STD symptoms or, for the subsample, were seropositive for HIV or other STDs, were more likely to perceive social norms as restricting condom use to casual sex, to be older, to combine sex with alcohol or drugs and to report a history of sexual coercion or of having paid or been paid for sex. For females only, engaging in sex at a younger age was a risk marker, while engaging in any homosexual activity was protective.

CONCLUSIONS

Cultural norms that restrict condoms to casual sex may place many young people in Lima at risk of an unplanned pregnancy or STDs. Sexual behavior may be especially risky in a context of sexual coercion and paid sex, when sex is combined with drugs and alcohol, and when engaged in by younger females. Sexual health education should work to change such cultural norms and these risky contexts.

Condom use with casual partners by men in Kampala, Uganda

OBJECTIVE

To estimate the prevalence and correlates of condom use with casual sex partners by men in urban Uganda and to identify barriers to condom use that are amenable to intervention.

DESIGN

Cross-sectional, door-to-door survey of men residing in a poor area of Kampala, Uganda.

SUBJECTS AND METHODS

A multistage, probability sample was approximated by recruiting participants within randomly selected neighborhoods. A total of 301 men between the ages of 18 and 45 years answered questions about condom knowledge, attitudes, beliefs and practices. The respondents also provided demographic and HIV risk-related information.

RESULTS

Condom use was higher than previously found in studies in Uganda: 46% of men reported using a condom at the last casual sexual encounter; 31% reported always using condoms with casual partners. In multivariate analysis, independent correlates of condom use included higher condom self-efficacy (4-item scale, odds ratio 1.3 per scale point), lower embarrassment around condoms (3-item scale, odds ratio 0.44 per scale point), knowing where to buy a condom (odds ratio 3.9), knowing how to use a condom (8-item scale, odds ratio 1.4 per scale point), and increasing number of casual sex partners (odds ratio 1.4 per partner).

CONCLUSIONS

These data suggest that condom use may be further increased in this population by conducting demonstrations of condom use skills, preparing individuals to anticipate circumstances that make using condoms difficult and using a variety of outlets to dispense condoms.

Changes in HIV-related behaviors among heterosexual alcoholics following addiction treatment

In order to measure changes in HIV-related behaviors among heterosexual alcoholics following treatment, we conducted a prospective cohort study of 700 self-identified alcoholics recruited from five public alcohol treatment centers, all of which included HIV risk-reduction counseling. Respondents underwent an HIV antibody test and interviewer-administered questionnaire at entry to alcohol treatment and after a mean of 13 months later. Compared to baseline, at follow-up there was an overall 26% reduction in having sex with an injection-drug-using partner (23% versus 32%, P < .001) and a 58% reduction in the use of injection drugs (15% versus 37%, P < .001), along with smaller improvements in other behaviors. Respondents also showed a 77% improvement in consistent condom use with multiple sexual partners (35% versus 20%, P < .01) and a 23% improvement in partner screening (71% versus 57%, P < .001). Respondents who remained abstinent showed substantially greater improvement than those who continued to drink.

Predictors of HIV-related risk behaviors among heterosexuals in alcoholism treatment

OBJECTIVE

To determine which measures of alcohol and drug use are associated with HIV-related sexual risk and protective behaviors.

METHOD

Entrants (N = 743, 72% male) to alcoholism treatment clinics underwent a structured interview including an assessment of demographics, substance abuse characteristics and sexual behaviors. Associations were examined between alcohol- and drug-related behaviors, and demographic variables, with the prevalence of high-risk sexual behaviors.

RESULTS

Those more likely to use alcohol or drugs when having sex, and those who expect to have high-risk sex when they drink alcohol, were more likely to engage in high-risk sexual behavior. Measures of severity of alcohol or drug problems alone were not consistently related to high-risk or protective behaviors. Several other concurrently used measures (such as the Addition Severity Index and alcohol expectancies) showed more consistent association with high-risk behaviors. There was no apparent reduction in the likelihood of practicing risk-reducing behaviors among those more severely addicted and those who combined alcohol and/or drugs with sex.

CONCLUSIONS

This study suggests that sexual risk and protective behaviors are not consistently associated with severity of addiction problems. Some measures of alcohol and drug use (i.e., the ASI Drug Composite Score and the Enhanced Risk subscale of the alcohol expectancy measure) were more consistently related to the specific risk behaviors measured than were others (e.g., the ASI Alcohol Composite Score), while most measures showed little or no association with protective behaviors.

HIV infection and risk behaviors among male port workers in Santos, Brazil

OBJECTIVES

This paper measured the extent to which human immunodeficiency virus (HIV) infection has spread among the male working-class population of Santos, Brazil.

METHODS

Questionnaires on risk behaviors and blood tests were administered to a random sample (n = 395) of male port workers employed by the Santos Port Authority.

RESULTS

Although the rate of HIV infection among these men- the working-class male population of Santos-remains low (1.1%), self-reported behavioral risks for HIV infection are common.

CONCLUSIONS

There is still time to prevent a widespread outbreak of HIV infection among the hetero-sexual population of Santos and of the transportation corridors emanating from that city.

Risk factors for HIV and other sexually transmitted diseases and prevention practices among US heterosexual adults: changes from 1990 to 1992

OBJECTIVES

The National AIDS Behavioral Survey (1990-1992) of heterosexual adults (18-49 years) measured human immunodeficiency virus (HIV) risk factors, condom use, and HIV antibody testing, with a focus on major "high-risk" cities.

METHODS

A longitudinal survey was conducted.

RESULTS

There was little reduction in the overall prevalence of HIV risk factors in the national or high-risk cities cohorts over time. Despite this picture of stability, approximately 39% of the population at risk for HIV because of multiple sexual partners turns over annually. There was little change in HIV test-seeking or in consistent condom use with primary sexual partners. Although the majority of at-risk respondents used condoms sporadically or not at all (65%), a significant increase in condom use was found among those reporting multiple sexual partners in both waves, particularly among Black heterosexuals. Data from other surveys and condom sales nationally support the findings.

CONCLUSIONS

There is a need for a series of surveys in this area to assess the reliability of the present findings and to monitor the general US population's response to prevention programs.

Alcohol-related risk factors associated with HIV infection among patients entering alcoholism treatment: implications for prevention

OBJECTIVE

Reports suggest that alcoholics may be at risk for HIV infection. In this article we examine several alcohol-related risk factors for HIV infection among patients entering alcoholism treatment in an AIDS epicenter. Our objective was to identify key factors for HIV prevention and screening among populations receiving treatment for alcohol abuse or alcohol dependence.

METHOD

Clients (N = 921) entering five alcoholism treatment centers in the San Francisco Bay area underwent an interview and blind serotesting for HIV antibodies (76% were male, 16% men who had sex with men, 50% black, 10% Latinos and 6.5% were HIV seropositive). Logistic regression was used to predict HIV serostatus from five possible alcohol-associated risk factors, controlling for demographics and traditional HIV risk factors. These were alcohol impairment, attitudes about socializing in bars, increased sexual risk expectancies when drinking, enhanced sexual expectancies when drinking and decreased nervousness when drinking. Male and female heterosexuals and men with a history of homosexuality were analyzed separately.

RESULTS

Among male and female heterosexuals, HIV infection was positively associated with higher alcohol impairment (OR = 2.69, p = .031) and negatively associated with higher sexual risk expectancies when drinking (OR = 0.24, p = .075). Among men who had sex with men, HIV infection was positively associated with higher bar socializing orientations (OR = 10.06, p = .004). Infection was also negatively associated with higher alcohol impairment (OR = 0.34, p = .052) and higher sexual risk expectancies when drinking (OR = 0.26, p = .024) for these men.

CONCLUSIONS

Since these associations were independent of demographics and traditional HIV risk factors, our research suggests it may be important to also focus HIV screening and prevention on alcohol-related risk factors in AIDS epicenters. For heterosexual alcoholics, the focus should be on those with higher alcohol dependence. For male alcoholics who had sex with men, the focus should be on those who primarily socialize in bars. Further research is needed to determine why higher sexual risk perceptions when drinking were associated with lower rates of HIV infection for both groups, since this discovery may have important prevention implications. The negative association between infection and alcohol impairment among homosexual men also warrants further investigation.

'Dry sex' and HIV infection among women attending a sexually transmitted diseases clinic in Lusaka, Zambia

OBJECTIVES

To describe 'dry sex' practices intended to decrease vaginal secretions and to determine whether these practices are related to HIV infection.

SUBJECTS AND METHODS

A cross-sectional study was conducted in a sexually transmitted diseases clinic in a teaching hospital in Lusaka, Zambia. The subjects comprised 329 women aged 15-50 years presenting consecutively for an initial evaluation of sexually transmitted disease symptoms. Dry sex practices were assessed by questionnaire, and serological testing for HIV antibodies was performed.

RESULTS

Fifty percent of women had engaged in at least one dry sex practice. The most common practices were drinking 'porridge' (a liquid or suspension believed to cause drying of the vagina; 28%), removing vaginal secretions with a cloth (22%) and placing leaves in the vagina (11%). The most frequent reasons given for drinking porridge were to increase the partner's sexual enjoyment and to tighten the vagina, while cleaning the vagina was mentioned often by those using cloth or leaves. Swelling or peeling of the vagina was reported by approximately 10% of women using cloth or leaves. Overall, the HIV seroprevalence in the sample was 58%. In bivariate analysis, no practice was statistically significantly associated with HIV infection. Multiple logistic regression had little impact on these findings.

CONCLUSIONS

Although a variety of practices with potential relevance to HIV transmission were reported, there was no evidence in this study population of a strong relationship between these practices and HIV infection. Women should be counseled about the potential risks of these practices, but prevention efforts should continue to emphasize measures of known effectiveness, particularly limiting the numbers of sexual partners, consistently using condoms and obtaining appropriate treatment for sexually transmitted diseases.

Socioeconomic status and risk of HIV-1, syphilis and hepatitis B infection among sex workers in São Paulo State, Brazil. Instituto Adolfo Lutz Study Group

OBJECTIVES

To determine how HIV risk behavior and the prevalences of sexually transmitted diseases vary according to socioeconomic status and city among sex workers in São Paulo State, Brazil.

SUBJECTS AND METHODS

A cross-sectional study of 600 female sex workers (100 of a higher socioeconomic status and 100 of a lower socioeconomic status in each city) was conducted in the cities of São Paulo, Campinas and Santos. HIV risk behavior was assessed by questionnaire; serological tests were administered to assess prior exposure to HIV-1, syphilis and hepatitis B.

RESULTS

Only statistically significant (P < 0.05) findings are reported here. Compared to those with a higher socioeconomic status, sex workers with a lower socioeconomic status worked longer hours each day (9.6 versus 7.9), had more clients per day (5.4 versus 2.6) and had fewer episodes of intercourse per client per encounter (1.1 versus 1.4). Levels of condom use for vaginal, anal and oral sex were significantly higher in Santos than in São Paulo or Campinas. Twenty-three per cent of the women said they feared violence if they insisted that their clients wear condoms; 74% voiced similar fears regarding their non-client sexual partners. Overall, 11% of sex workers were positive for exposure to HIV-1, 45% for syphilis and 39% for hepatitis B. Those with a lower socioeconomic status were more likely than those with a higher socioeconomic status to be infected with HIV-1 (17 versus 4%), syphilis (66 versus 24%) and hepatitis B (52 versus 26%), but there were no differences in prevalence rates by city.

CONCLUSIONS

These data demonstrate substantial heterogeneity in HIV risk behavior and the prevalence of HIV-1 and other sexually transmitted diseases among sex workers in São Paulo State, many of which were related to differences in socioeconomic status. Interventions to prevent HIV transmission among sex workers must be tailored to the local environment and, in particular, to the socioeconomic status of these workers.

Impact of an intervention on HIV, sexually transmitted diseases, and condom use among sex workers in Bombay, India

OBJECTIVE

To develop and test an HIV intervention targeting sex workers and madams in the brothels of Bombay.

SUBJECTS AND METHODS

In a controlled intervention trial, with measurements before and after the intervention, 334 sex workers and 20 madams were recruited from an intervention site, and 207 and 17, respectively, from a similar control site, both in red-light areas of Bombay. All sex workers were tested for antibodies to HIV and syphilis, and for hepatitis B surface antigen. Information on sexual practices, condom use and knowledge of HIV was collected by interviewer-administered questionnaire. All subjects in the intervention group underwent a 6-month program of educational videos, small group discussions and pictorial educational materials; free condoms were also distributed. The blood tests and the questionnaire were readministered to all subjects at both sites immediately after the intervention. Both groups were followed for approximately 1 year.

RESULTS

The baseline level of knowledge about HIV and experience with condoms was extremely low among both sex workers and madams. The baseline prevalence of HIV antibodies was 47% in the intervention group and 41% in the control group (P = 0.17). The incidence densities for HIV and sexually transmitted diseases were significantly different in the two groups (all P < 0.005): 0.05 and 0.16 per person-year of follow-up for HIV, 0.08 and 0.22 per person-year for antibodies to syphilis, and 0.04 and 0.12 per person-year for hepatitis B surface antigen in the intervention and control women, respectively. Following the intervention, women reported increased levels of condom use, and some (41%) said they were willing to refuse clients who wouldn't use them. However, both the sex workers and the madams were concerned about losing business if condom use was insisted upon.

CONCLUSIONS

Both HIV prevalence and incidence are alarmingly high among female sex workers in Bombay. Successful interventions can be developed for these women, and even a partial increase in condom use may decrease the transmission of HIV and sexually transmitted diseases. Intervention programs of longer duration that target madams and clients and make condoms easily available are urgently needed at multiple sites in red-light areas.

Results of a model AIDS prevention program for high school students in the Philippines

OBJECTIVES

To describe the sexual practices of high school students; to describe the process of development of a school-based AIDS prevention program; and to evaluate the effect of this program on students' AIDS-related knowledge, attitudes and AIDS-preventive behaviors.

SUBJECTS AND METHODS

A cluster-randomized, controlled trial with pretest/post-test evaluation was conducted in four demographically similar public high schools in a semi-urban district of Metro Manila, the Philippines. Of 845 high school students who participated in the baseline survey, 804 (95%) completed a postintervention questionnaire.

INTERVENTION

An AIDS prevention program was developed by public high school teachers together with local AIDS experts, social scientists and health educators. The teacher-led AIDS program was designed to provide students with accurate information about AIDS, particularly in dispelling misconceptions about casual contagion, to foster positive attitudes towards people with AIDS and to develop skills aimed at clarifying values and assessing intended behavior.

RESULTS

At baseline, 11% of students (20% of males and 4% of females) reported ever having had sexual intercourse (mean age 14 years). Among these, condom use was low (24%). After implementation of the AIDS prevention program, statistically significant effects favoring the intervention group were observed in knowledge and attitudes towards people with AIDS. While there was no statistically significant overall effect on intended preventive behavior, the program appeared to delay the students' intended onset of sexual activity.

CONCLUSIONS

A sizable number of Filipino high school students are sexually active but condom use is low. School-based AIDS prevention programs can be developed and implemented in developing countries with the assistance of school personnel to address sexual issues. Our program was successful in increasing AIDS-related knowledge and improving attitudes towards people with AIDS. Supplementation with other preventive activities may be needed to achieve lasting changes in students' risk-taking behavior.

Family practice bashing as perceived by students at a university medical center

BACKGROUND AND OBJECTIVES

Medical schools are being asked to produce more family physicians, but it is not always clear how this can be accomplished. Previous research has focused on students' characteristics and attitudes that predict specialty choice but has paid less attention to feedback they receive in the academic medical center environment.

METHODS

In early 1993, a self-administered questionnaire was mailed to 160 students from all classes of the University of California, San Francisco Medical School who had previously shown interest in family practice. Data are shown for the 138 respondents.

RESULTS

Most students from all years had received positive feedback about their interest in family practice, usually from family physicians. By the fourth year, 95% of students had received negative feedback, usually from physicians in other specialties. Many students gave poignant examples of pejorative comments about family practice by faculty and house staff. Negative feedback seemed strongest at the time students were making decisions about residency. By the fourth year, only 39% of these previously interested students chose family practice.

CONCLUSION

Serious efforts to encourage students to enter family practice must address the problem of negative feedback from other specialties. To promote positive feedback, contact with family physicians should be increased, especially in the third and fourth years.

Classification of HIV infection and disease in women from Rwanda. Evaluation of the World Health Organization HIV staging system and recommended modifications

OBJECTIVE

To develop a human immunodeficiency virus (HIV) staging system for sub-Saharan Africa on the basis of an evaluation of the World Health Organization (WHO) system and predictors of mortality.

DESIGN

Prospective cohort study with 4 years of follow-up.

SETTING

Kigali, Rwanda.

PATIENTS

412 HIV-infected women recruited from prenatal and pediatric clinics.

MEASUREMENTS

Clinical signs and symptoms of HIV disease, laboratory assays (including complete blood count and erythrocyte sedimentation rate), and cumulative mortality.

RESULTS

The WHO staging system includes a clinical and a laboratory axis. The clinical axis was revised by inclusion of oral candidiasis, chronic oral or genital ulcers, and pulmonary tuberculosis as "severe" disease (clinical stage IV); in addition, body mass index was substituted for weight loss in the definition for the wasting syndrome. The 36-month cumulative mortality was 7% for women in modified clinical stage I ("asymptomatic"), 15% for those in stage II, 19% for those in stage III, and 36% for those in stage IV (P < 0.001). The laboratory axis was revised by replacing lymphocyte count with hematocrit and erythrocyte sedimentation rate. The 36-month mortality was 10% for women in modified stage A ("normal" laboratory results) and 33% for those in stage B (erythrocyte sedimentation rate > 65 mm/h or hematocrit < 0.38) (P < 0.001). A single staging system combining clinical and laboratory criteria is proposed, with a 36-month mortality of 7% for women in combined stage I, 10% for those in stage II, 29% for those in stage III, and 62% for those in stage IV (P < 0.001).

CONCLUSIONS

On the basis of this analysis, a staging system relevant for sub-Saharan Africa is proposed that reflects the range of HIV-related outcomes, has strong prognostic significance, includes inexpensive and available laboratory tests, and can be used by both clinicians and researchers.

Levels of HIV testing and low validity of self-reported test results among alcoholics and drug users

OBJECTIVES

To evaluate HIV testing behavior, validity of self-reported serostatus, and intention to test among alcoholics and drug users entering treatment.

DESIGN

Longitudinal cohort study.

METHODS

A total of 952 clients voluntarily entering three outpatient and two inpatient public alcohol treatment centers in San Francisco were enrolled. Seventy-six per cent were men, 50% black, 81% had used both alcohol and drugs during the last year, 43% had injected drugs and 9% of the men were homosexual. Subjects completed an interviewer-administered questionnaire and blindly-linked HIV-antibody test at entry and after 1 year (81% follow-up).

RESULTS

Fifty-seven per cent of subjects reported that they had previously sought HIV testing. Factors associated with HIV testing included homosexual contact, injecting drug use, having a partner who had been tested, and using condoms. Hispanics were the least likely of all ethnic groups to report testing. Of 60 subjects with HIV antibodies, 47 (78%) said they had already been tested; however, 19 (40%) inaccurately reported that their serostatus was negative and another four (9%) had no collected their test results. Blacks were much more likely than other groups to misreport or be unaware of their HIV status. Only half of the 68% who said they planned to be tested during the following year did so. Five (42%) out of 12 HIV-positive individuals who were unaware of, or misreported their serostatus at baseline, and who sought another HIV test during the follow-up year continued to report themselves as uninfected.

CONCLUSIONS

A large proportion of clients attending public alcohol treatment centers report having been HIV tested, much greater than that observed in other populations. However, misreporting of HIV test results was very common among seropositive subjects. Alcohol and drug treatment programs for this high-risk population should include interventions to optimize use of HIV testing for prevention and treatment, and improve understanding of test results.