Localized Liver Injury During Normothermic Ex Situ Liver Perfusion Has No Impact on Short-term Liver Transplant Outcomes

BACKGROUND

Normothermic ex situ liver perfusion (NESLiP) has the potential to increase organ utilization. Radiological evidence of localized liver injury due to compression at the time of NESLiP, termed cradle compression, is a recognized phenomenon but is poorly characterized.

METHODS

A retrospective analysis of a prospectively collected database was performed of transplanted livers that underwent NESLiP and subsequently had a computed tomography performed within the first 14 d posttransplant. The primary study outcome was 1-y graft survival.

RESULTS

Seventy livers (63%) were included in the analysis. Radiological evidence of cradle compression was observed in 21 of 70 (30%). There was no difference in rate of cradle compression between donor after circulatory death and donated after brain death donors (P = 0.37) or with duration of NESLiP. Univariate analysis demonstrated younger (area under the receiver operating characteristic, 0.68; P = 0.008; 95% confidence interval [CI], 0.55-0.82) and heavier (area under the receiver operating characteristic, 0.80; P < 0.001; 95% CI, 0.69-0.91) livers to be at risk of cradle compression. Only liver weight was associated with cradle compression on multivariate analysis (odds ratio, 1.003; P = 0.005; 95% CI, 1.001-1.005). There was no difference in 1-y graft survival (16/17 [94.1%] versus 44/48 [91.6%]; odds ratio, 0.69; P = 0.75; 95% CI, 0.07-6.62).

CONCLUSIONS

This is the first study assessing the impact of cradle compression on outcome. We have identified increased donor liver weight and younger age as risk factors for the development of this phenomenon. Increasing utilization of NESLiP will result in the increased incidence of cradle compression but the apparent absence of long-term sequelae is reassuring. Routine postoperative axial imaging may be warranted.

Black, White and Gray: Student Perspectives on Medical Humanities and Medical Education

ISSUE

In recent years, the value and relevance of humanities-based teaching in medical education have become more widely acknowledged. In many medical schools this has prompted additions to curricula that allow students to explore the gray-as opposed to the black and white-areas of medicine through arts, humanities, and social sciences. As curricula have expanded and diversified in this way, both medical educators and students have begun to ask: what is the best way to teach medical humanities?

EVIDENCE

In this article, five current medical students reflect on their experiences of medical humanities teaching through intercalated BSc programmes in the UK. What follows is a broad exploration of how the incorporation of medical humanities into students' time at university can improve clinical practice where the more rigid, objective-driven, model of medicine falls short.

IMPLICATIONS

This article reinforces the merit of moving beyond a purely biomedical model of medical education. Using the student voice as a vector for critique and discussion, we provide a starting point for uncovering the path toward true integration of humanities-style teaching into medical school curricula.

The Enhanced Liver Fibrosis test maintains its diagnostic and prognostic performance in alcohol-related liver disease: a cohort study

Background

Alcohol is the main cause of chronic liver disease. The Enhanced Liver Fibrosis (ELF) test is a serological biomarker for fibrosis staging in chronic liver disease, however its utility in alcohol-related liver disease warrants further validation. We assessed the diagnostic and prognostic performance of ELF in alcohol-related liver disease.

Methods

Observational cohort study assessing paired ELF and histology from 786 tertiary care patients with chronic liver disease due to alcohol (n = 81) and non-alcohol aetiologies (n = 705). Prognostic data were available for 64 alcohol patients for a median of 6.4 years. Multiple ELF cut-offs were assessed to determine diagnostic utility in moderate fibrosis and cirrhosis. Survival data were assessed to determine the ability of ELF to predict liver related events and all-cause mortality.

Results

ELF identified cirrhosis and moderate fibrosis in alcohol-related liver disease independently of aminotransferase levels with areas under receiver operating characteristic curves of 0.895 (95% CI 0.823–0.968) and 0.923 (95% CI 0.866–0.981) respectively, which were non-inferior to non-alcohol aetiologies. The overall performance of ELF was assessed using the Obuchowski method: in alcohol = 0.934 (95% CI 0.908–0.960); non-alcohol = 0.907 (95% CI 0.895–0.919). Using ELF < 9.8 to exclude and ≧ 10.5 to diagnose cirrhosis, 87.7% of alcohol cases could have avoided biopsy, with sensitivity of 91% and specificity of 85%. A one-unit increase in ELF was associated with a 2.6 (95% CI 1.55–4.31, p < 0.001) fold greater odds of cirrhosis at baseline and 2.0-fold greater risk of a liver related event within 6 years (95% CI 1.39–2.99, p < 0.001).

Conclusions

ELF accurately stages liver fibrosis independently of transaminase elevations as a marker of inflammation and has superior prognostic performance to biopsy in alcohol-related liver disease.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-021-01795-5.

Decompensated cirrhosis is the commonest presentation for NAFLD patients undergoing liver transplant assessment

Non-alcoholic fatty liver disease (NAFLD) accounts for 10-15% of orthotopic liver transplants (OLTs) in the UK. Index presentations with cirrhotic decompensation represent missed opportunities for preventive treatment leaving OLT or palliation as the only options.We retrospectively reviewed patient records for all NAFLD patients undergoing assessment for OLT between January 2003 and December 2017.Data were available for 81 patients with NAFLD as the primary diagnosis. Fifty-two patients had decompensated cirrhosis at first presentation; 91.7% presented to secondary care compared to 52.7% referred from primary care (p=0.001). Cirrhosis was not suspected at the time of referral to hospital in 24.7% of patients subsequently assessed for OLT. Most patients undergoing assessment for OLT for NAFLD had decompensated cirrhosis at their first diagnosis of chronic liver disease. These data highlight the plight of patients with NAFLD cirrhosis in whom chronic liver disease is diagnosed late.

Uncovering unsuspected advanced liver fibrosis in patients referred to alcohol nurse specialists using the ELF test

BACKGROUND AND AIMS

Alcohol use disorders (AUD) cause 7.2% of UK hospital admissions/year. Most are not managed by hepatologists and liver disease may be missed. We used the Enhanced Liver Fibrosis (ELF) test to investigate prevalence and associations of occult advanced liver fibrosis in AUD patients not known to have liver fibrosis.

METHODS

Liver fibrosis was assessed using ELF in prospective patients referred to the Royal Free Hospital Alcohol Specialist Nurse (November 2018-December 2019). Known cases of liver disease were excluded. Patient demographics, blood tests, imaging data and alcohol histories recorded. Advanced fibrosis was categorised as ELF ≥ 10.5.

RESULTS

The study included 99 patients (69% male, mean age 53.1 ± 14.4) with median alcohol intake 140 units/week (IQR 80.9-280), and a mean duration of harmful drinking of 15 years (IQR 10-27.5). The commonest reason for admission was symptomatic alcohol withdrawal (36%). The median ELF score was 9.62, range 6.87-13.78. An ELF score ≥ 10.5 was recorded in 28/99 (29%) patients, of whom 28.6% had normal liver tests. Within previous 5-years, 76% had attended A&E without assessment of liver disease. The ELF score was not associated with recent alcohol intake (p = 0.081), or inflammation (p = 0.574).

CONCLUSION

Over a quarter of patients with AUD had previously undetected advanced liver fibrosis assessed by ELF testing. ELF was not associated with liver inflammation or recent alcohol intake. The majority had recent missed opportunities for investigating liver disease. We recommend clinicians use non-invasive tests to assess liver fibrosis in patients admitted to hospital with AUD.

Inflammation and fibrosis in chronic liver diseases including non-alcoholic fatty liver disease and hepatitis C

At present chronic liver disease (CLD), the third commonest cause of premature death in the United Kingdom is detected late, when interventions are ineffective, resulting in considerable morbidity and mortality. Injury to the liver, the largest solid organ in the body, leads to a cascade of inflammatory events. Chronic inflammation leads to the activation of hepatic stellate cells that undergo trans-differentiation to become myofibroblasts, the main extra-cellular matrix producing cells in the liver; over time increased extra-cellular matrix production results in the formation of liver fibrosis. Although fibrogenesis may be viewed as having evolved as a “wound healing” process that preserves tissue integrity, sustained chronic fibrosis can become pathogenic culminating in CLD, cirrhosis and its associated complications. As the reference standard for detecting liver fibrosis, liver biopsy, is invasive and has an associated morbidity, the diagnostic assessment of CLD by non-invasive testing is attractive. Accordingly, in this review the mechanisms by which liver inflammation and fibrosis develop in chronic liver diseases are explored to identify appropriate and meaningful diagnostic targets for clinical practice. Due to differing disease prevalence and treatment efficacy, disease specific diagnostic targets are required to optimally manage individual CLDs such as non-alcoholic fatty liver disease and chronic hepatitis C infection. To facilitate this, a review of the pathogenesis of both conditions is also conducted. Finally, the evidence for hepatic fibrosis regression and the mechanisms by which this occurs are discussed, including the current use of antifibrotic therapy.

A review of the clinical utility of the Enhanced Liver Fibrosis test in multiple aetiologies of chronic liver disease

The rising incidence of chronic liver disease continues to be an increasing health burden. The morbidity and mortality associated with chronic liver disease typically occur in patients with advanced fibrosis. Hence, early identification of those at-risk is of vital importance to ensure appropriate ongoing management. Currently, tools for appropriate risk stratification remain limited. Increasing awareness of the limitations of liver biopsy has driven research into alternative non-invasive methods of fibrosis assessment including serological markers assessing functional changes. One such biomarker, the Enhanced Liver Fibrosis test, was initially validated in a cohort of 1021 patients with mixed aetiology chronic liver disease and shown to perform well. Since this pathfinder study, it has been independently validated in cohorts of hepatitis C, non-alcoholic fatty liver disease, alcoholic liver disease, primary biliary cirrhosis and primary sclerosing cholangitis. In addition to performing well as a diagnostic tool, the Enhanced Liver Fibrosis test has been shown to outperform liver biopsy in prognostic studies and is the only non-invasive marker to do so. However, questions remain regarding the use of this test, particularly regarding the possible effect age and alcohol may have on test scores. This review examines the current literature published in relation to the Enhanced Liver Fibrosis test and its clinical utility and highlights areas requiring further study.

Using intervention theory to model factors influencing behavior change. Project RESPECT

Project RESPECT was a multisite randomized trial comparing three clinic-based interventions' ability to increase condom use and prevent infection with HIV and sexually transmitted diseases. Because Project RESPECT had guiding concepts that determined the content of the sessions, the authors investigated how the intervention operated using these theoretical variables. Growth curve analysis and structural equation modeling estimated the correlation between intentions toward condom use and self-reports of condom use and isolated the treatment effects on mediating variables--attitudes, self-efficacy, and social norms--that predict intentions. The correlations between intentions and behavior exceeded .70 for both genders, justifying the emphasis on intentions. Project RESPECT was effective through changing attitudes and self-efficacy for females in both counseling interventions. For males, only enhanced counseling had significant effects on these two mediator variables.

Fleeting foreskins: the misclassification of male circumcision status

BACKGROUND

Errors in the classification of male circumcision status could bias studies linking infection to lack of circumcision.

GOAL

To determine the frequency and factors associated with the reproducibility of reporting circumcision status.

STUDY DESIGN

Secondary analysis of data using logistic regression modeling from a multicenter randomized controlled trial was performed.

RESULTS

At follow-up assessment, 15.6% of clinician reports on circumcision status disagreed with baseline reports. Disagreement was more common if both clinicians were women than if both were men (odds ratio [OR], 2.8; 95% CI, 1.9-4.1). As compared with whites reported as circumcised (4%, 19/532 visits), the highest disagreement involved uncircumcised Hispanic (OR, 3.3; 95% CI, 1.7-6.3), white (OR, 12.2; 95% CI, 5.8-25.6), or black (OR, 17.1; 95% CI, 10.4-27.9) men.

CONCLUSIONS

This is one study among a small number of studies examining the reproducibility of clinician-reported circumcision status by comparing multiple clinical examinations of the same patient. The magnitude of the misclassification discovered could bias results and indicates the need for greater accuracy in reporting circumcision status in future studies.

Structure of outcome beliefs in condom use. The Project RESPECT Study Group

To study the structure of beliefs about condom use outcomes, the authors derived and tested 4 psychosocial hypothetical models: (a) a 2-factor model of the personal and social outcomes of condom use; (b) a 2-factor model of the pros and cons of the behavior; (c) a 3-factor model (i.e., physical, self-evaluative, and social) of outcome expectancies; and (d) a thematic 4-factor model of the protection, self-concept, pleasure, and interaction implications of the behavior. All 4 models were studied with a confirmatory factor analysis approach in a multisite study of 4,638 participants, and the thematic solution was consistently the most plausible. Self-concept and pleasure were most strongly associated with attitudes toward using condoms, intentions to use condoms, and actual condom use, whereas protection and interaction generally had little influence.

Circumcision and STD in the United States: cross sectional and cohort analyses

BACKGROUND

Male circumcision status has been shown to be associated with sexually transmitted disease (STD) acquisition in some, but not all, studies. Most studies have been cross sectional.

OBJECTIVES

We examined the association between circumcision status and the prevalence and incidence of gonorrhoea, chlamydia, and syphilis.

METHODS

We analysed cross sectional and cohort study data from a multicentre controlled trial in the United States. Between July 1993 and September 1996, 2021 men visiting public inner city STD clinics in the United States were examined by a clinician at enrolment and 1456 were examined at follow up visits 6 and 12 months later. At each visit, men had laboratory tests for gonorrhoea, chlamydia, and syphilis and were examined for circumcision status. We used multiple logistic regression to compare STD risk among circumcised and uncircumcised men adjusted for potentially confounding factors.

RESULTS

Uncircumcised men were significantly more likely than circumcised men to have gonorrhoea in the multivariate analyses, adjusted for age, race, and site, in both the cross sectional (odds ratio (OR), 1.3; 95% confidence interval (CI), 0.9 to 1.7) and in the cohort analysis (OR, 1.6; 95% CI, 1.0 to 2.6). There was no association between lack of circumcision and chlamydia in either the cross sectional (OR, 1.0; 95% CI 0.7-1.4) or the cohort analysis (OR, 0.9; 95% CI 0.5-1.5). The magnitude of association between lack of circumcision and syphilis was similar in the cross sectional (OR, 1.4; 95% CI 0.6 to 3.3) and cohort analysis (OR, 1.5; 95% CI 0.4 to 6.1).

CONCLUSION

Uncircumcised men in the United States may be at increased risk for gonorrhoea and syphilis, but chlamydia risk appears similar in circumcised and uncircumcised men. Our results suggest that risk estimates from cross sectional studies would be similar to cohort findings.

Structure of outcome beliefs in condom use. The Project RESPECT Study Group

To study the structure of beliefs about condom use outcomes, the authors derived and tested 4 psychosocial hypothetical models: (a) a 2-factor model of the personal and social outcomes of condom use; (b) a 2-factor model of the pros and cons of the behavior; (c) a 3-factor model (i.e., physical, self-evaluative, and social) of outcome expectancies; and (d) a thematic 4-factor model of the protection, self-concept, pleasure, and interaction implications of the behavior. All 4 models were studied with a confirmatory factor analysis approach in a multisite study of 4,638 participants, and the thematic solution was consistently the most plausible. Self-concept and pleasure were most strongly associated with attitudes toward using condoms, intentions to use condoms, and actual condom use, whereas protection and interaction generally had little influence.

Understanding HIV risks of chronic drug-using men who have sex with men

Focus groups and individual structured interviews were conducted in six cities with 98 predominantly street-recruited men who had a recent history of smoking crack or injecting drugs and who reported having had sex with other men (MSM) in the past year. Twenty-six focus groups explored the cultural and social context of participant's drug use and sexual activity and addressed outreach and HIV prevention issues pertinent to this population. Narrative summaries developed from verbatim focus group transcripts identified seven themes: (a) sexual orientation and gender identity; (b) interactions within and between MSM networks; (c) drug use, sexual activity and personal relationships; (d) HIV transmission bridges; (e) preferred HIV information sources; (f) HIV knowledge, prevention practices and risk behaviours; and (g) availability of HIV and drug-related services. Of the 98 MSM drug users, 42% identified publicly as gay or homosexual; 35% identified publicly, but only 21% privately, as heterosexual. A total of 51% had one or more female sex partners in the past year. There was a high frequency of unprotected sex in conjunction with drug use and a distinct preference for having sex when high. For most participants, drug use rather than sexual orientation formed the core of personal identity. Participants reported associating primarily with other drug users, usually MSM, and had limited contact with people who did not use drugs and the mainstream gay community. Participants' sexual and drug-injecting activities were judged to be a bridge for transmission of HIV to both people who used drugs and those who did not.

Monetary versus nonmonetary incentives for TB skin test reading among drug users

BACKGROUND

In a prior study, we reported that monetary incentives were effective in increasing return for tuberculosis (TB) skin test reading. The purpose of this study was to compare the effects of monetary versus nonmonetary incentives and a theory-based educational intervention on return for TB skin test reading in a sample of newly recruited active injection and crack cocaine users, and to determine the prevalence of TB infection in this sample.

METHODS

Active injection drug and/or crack cocaine users (n = 1,078), recruited using street outreach techniques, were skin tested for TB. They were randomly assigned to 1 of 5 experimental treatment conditions: $10 cash, grocery store coupons, bus tokens/fast-food coupons, motivational education, or usual encouragement to return. Nonmonetary incentives had a $10 value, and all incentives were provided at return for skin test reading.

RESULTS

Ninety-five percent of those who received $10 returned for skin test reading compared to 86% of those who received grocery store coupons and 83% of those who received either bus tokens or fast-food coupons. In contrast, only 47% of those who received the educational session and only 49% of those who received usual encouragement returned for skin test reading. The prevalence of a positive tuberculin test was 21%, and was similar for crack cocaine and injection drug users.

CONCLUSIONS

Nonmonetary and monetary incentives dramatically increased the return rate for TB skin test reading among drug users who are at high risk of TB infection. Nonmonetary incentives were somewhat less effective than monetary incentives.

Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases: a randomized controlled trial. Project RESPECT Study Group

CONTEXT

The efficacy of counseling to prevent infection with the human immunodeficiency virus (HIV) and other sexually transmitted diseases (STDs) has not been definitively shown.

OBJECTIVE

To compare the effects of 2 interactive HIV/STD counseling interventions with didactic prevention messages typical of current practice.

DESIGN

Multicenter randomized controlled trial (Project RESPECT), with participants assigned to 1 of 3 individual face-to-face interventions.

SETTING

Five public STD clinics (Baltimore, Md; Denver, Colo; Long Beach, Calif; Newark, NJ; and San Francisco, Calif) between July 1993 and September 1996.

PARTICIPANTS

A total of 5758 heterosexual, HIV-negative patients aged 14 years or older who came for STD examinations.

INTERVENTIONS

Arm 1 received enhanced counseling, 4 interactive theory-based sessions. Arm 2 received brief counseling, 2 interactive risk-reduction sessions. Arms 3 and 4 each received 2 brief didactic messages typical of current care. Arms 1, 2, and 3 were actively followed up after enrollment with questionnaires at 3, 6, 9, and 12 months and STD tests at 6 and 12 months. An intent-to-treat analysis was used to compare interventions.

MAIN OUTCOME MEASURES

Self-reported condom use and new diagnoses of STDs (gonorrhea, chlamydia, syphilis, HIV) defined by laboratory tests.

RESULTS

At the 3- and 6-month follow-up visits, self-reported 100% condom use was higher (P<.05) in both the enhanced counseling and brief counseling arms compared with participants in the didactic messages arm. Through the 6-month interval, 30% fewer participants had new STDs in both the enhanced counseling (7.2%; P= .002) and brief counseling (7.3%; P= .005) arms compared with those in the didactic messages arm (10.4%). Through the 12-month study, 20% fewer participants in each counseling intervention had new STDs compared with those in the didactic messages arm (P = .008). Consistently at each of the 5 study sites, STD incidence was lower in the counseling intervention arms than in the didactic messages intervention arm. Reduction of STD was similar for men and women and greater for adolescents and persons with an STD diagnosed at enrollment.

CONCLUSIONS

Short counseling interventions using personalized risk reduction plans can increase condom use and prevent new STDs. Effective counseling can be conducted even in busy public clinics.

What about money? Effect of small monetary incentives on enrollment, retention, and motivation to change behaviour in an HIV/STD prevention counselling intervention. The Project RESPECT Study Group

OBJECTIVES

We studied the effect of small monetary incentives and non-monetary incentives of similar value on enrollment and participation in clinic based HIV/STD prevention counselling. We examined incident STDs to try to assess whether participants offered money may be less motivated to change risky behaviours than those offered other incentives.

METHODS

Patients from five US STD clinics were invited to enroll in a multisession risk reduction counselling intervention and, based on their enrollment date, were offered either $15 for each additional session or non-monetary incentives worth $15. The two incentive groups were compared on participants' enrollment, completion of intervention sessions, and new STDs over the 24 months after enrollment.

RESULTS

Of 648 patients offered money, 198 (31%) enrolled compared with 160 (23%) of 696 patients offered other incentives (p = 0.002). Enrollees in the two incentive groups had similar baseline characteristics, including condom use. Of the 198 participants offered money, 109 (55%) completed all sessions compared with 59 (37%) of the participants offered other incentives (p < 0.0001). Comparing those offered money with those offered other incentives STD rates were similar after 6, 12, and 24 months.

CONCLUSIONS

Small monetary incentives enhanced enrollment and participation compared with other incentives of similar value. Regardless of incentive offered, participants had similar post-enrollment STD rates, suggesting that the type of incentive does not adversely affect motivation to change behaviour. Money may be useful in encouraging high risk individuals to participate in and complete counselling or other public health interventions.

Efficacy and effectiveness issues in the NIDA Cooperative Agreement: interventions for out-of-treatment drug users. National Institute on Drug Abuse

This paper examines the Cooperative Agreement (CA) HIV intervention studies for active drug users, sponsored by the National Institute on Drug Abuse, in terms of the constructs of prevention efficacy and effectiveness. A rationale is presented for conservatively interpreting outcome findings of these studies as indicative of intervention efficacy, as opposed to effectiveness. It is argued that the CA studies fall more within the domain of efficacy owing to the high degree of control and optimization that occurred with respect to intervention recruitment, participation, process monitoring, and staff training. Because the interventions were implemented and evaluated in community-based, noninstitutional settings with many real-world constraints, it is suggested that minimal shrinkage of their effects would occur if they were implemented in uncontrolled community settings. The relationship of intervention structure, content, process, dose, and participant characteristics to intervention efficacy is reviewed and discussed, both in general terms and with reference to the CA studies.

Differences in condom behaviors and beliefs among female drug users recruited from two cities

This paper examines predictors of condom cognitions and condom use for vaginal sex within women's main and paying partnerships. The sample consisted of active injection drug and crack-using women recruited from two cities with disparate HIV rates. A total of 338 drug-using women who reported vaginal sex with a main and/or paying partner in the prior 30 days were recruited for this study. Recruitment site was a significant predictor for several of the variables examined, for both main and paying partners. Ethnicity and prior HIV test result were also significant predictors, but only for main sex partners. Findings support previous research and suggest that the factors which predict condom beliefs, intention, and behaviors are different for main versus paying partners. Interventions designed to increase condom use must recognize that cognitive factors associated with condom use may vary by partner type, ethnicity, and recruitment site, particularly when important contextual variables, such as local seroprevalence, vary.

Tuberculosis screening and compliance with return for skin test reading among active drug users

OBJECTIVES

This study assessed the independent and combined effects of different levels of monetary incentives and a theory-based educational intervention on return for tuberculosis (TB) skin test reading in a sample of active injection drug and crack cocaine users. Prevalence of TB infection in this sample was also determined.

METHODS

Active or recent drug users (n = 1004), recruited via street outreach techniques, were skin tested for TB. They were randomly assigned to 1 of 2 levels of monetary incentive ($5 and $10) provided at return for skin test reading, alone or in combination with a brief motivational education session.

RESULTS

More than 90% of those who received $10 returned for skin test reading, in comparison with 85% of those who received $5 and 33% of those who received no monetary incentive. The education session had no impact on return for skin test reading. The prevalence of a positive tuberculin test was 18.3%.

CONCLUSIONS

Monetary incentives dramatically increase the return rate for TB skin test reading among drug users who are at high risk of TB infection.

A cluster analysis of not-in-treatment drug users at risk for HIV infection

The purpose of the analysis described here was to classify not-in-treatment drug users participating in the National Institute on Drug Abuse (NIDA)-sponsored Cooperative Agreement study into several "homogeneous" HIV risk groups using cluster analysis. Data for this analysis (N=17,778) were collected at 19 study sites in the United States and Puerto Rico. Measures selected for the cluster analysis were limited to (a) current drug use and HIV risk behaviors, (b) mutually exclusive behaviors, (c) behaviors directly related to HIV risk, and (d) behaviors that were not statistically rare. Eight homogeneous HIV risk clusters were produced. Crack cocaine use was the most distinguishing feature of three clusters. Another three clusters were distinguishable by drug injection and needle use practices. Two additional clusters could not be grouped with either the crack- or the injection-dominant clusters. Prostitution was the most distinguishing risk behavior of one of these clusters, and extremely high drug injection frequencies and relative rates of risky needle use characterized the other. Composition of the clusters varied significantly by gender, race/ethnicity, educational attainment, and drug use characteristics. In addition, perceptions and behaviors initiated to reduce the chances of becoming infected with HIV varied by cluster. Subjects in the crack-predominant clusters reported low perceptions of the chances of getting AIDS. Perceptions of the chances of becoming infected with HIV among subjects in the injection-predominant clusters were strongly related to injection frequency. Seroprevalence was also related to cluster. Higher rates of HIV infection were evident among the injection-predominant clusters, and higher rates were related to frequency of injection and the rate of risky needle use. Among the crack-predominant clusters, the relationship between drug use and sexual behaviors and HIV infection was less clear.

Using behavioral theory in computer-based health promotion and appraisal

This article explores how behavioral theory can facilitate the development, implementation, and evaluation of health promotion software packages intended to influence personal health practices and/or assess health risks. Current behavioral theories and models are reviewed, and their relevance to developing health promotion software is discussed. A series of six steps is suggested for developing and evaluating health promotion and appraisal software within a behavioral theory framework. These steps should help to facilitate direct application of the theory-based process to health promotion software development.

Assessing reading level of drug users for HIV and AIDS prevention purposes

Using the short form of the Woodcock Reading Mastery Test-Revised and the reading subtest of the Wide Range Achievement Test-Revised, the reading abilities of 284 male and 128 female drug users from five sites across the United States were evaluated. All subjects were participants in a National Institute on Drug Abuse HIV/AIDS prevention project aimed at intravenous drug users and cocaine smokers. Results revealed differences in reading abilities among ethnic groups with Native and white subjects having significantly higher reading levels than Hispanic and black subjects. Significant site differences were revealed, with mean grade equivalent scores ranging from 2.7 to 10.1 grades. Across all subjects, the average grade equivalent reading level was 5.8 to 7.7, indicating that the subjects read below the level of 81.5% to 93% of the general population. We provide implications for development of educational materials that are accessible for this population.

HIV-related training programs for health care professionals: findings from a collaborative assessment

Seeking to avoid duplication of effort, evaluators from twelve separate HIV-related training programs worked together to share information, assessment tools, measurement instruments, and preliminary findings across programs. Each training program focused on preparing health care professionals to meet the growing demands of the AIDS epidemic and specifically address psychosocial issues of care. The collaborative effort of program evaluators included an examination of experiences across programs and yielded recommendations for needs assessments, process evaluation procedures, and outcome measures. This paper focuses on the findings from an analysis of needs assessments and process evaluations across twelve HIV-related training programs in eleven areas of the country.

AIDS and competing health concerns of blacks, Hispanics, and whites

Blacks, Hispanics, and whites were interviewed in a door-to-door survey assessing personal concern about AIDS relative to other health threats and willingness to attend in-home AIDS education programs. The survey consisted of three parts: (1) an open-ended inquiry regarding which health problems individuals wanted to learn more about, (2) ratings of concern about AIDS and nine other common health threats, and (3) assessment of willingness to participate in future neighborhood-based AIDS education programs. Usable data were obtained from 453 respondents. Sixty-seven health threats were mentioned in response to the open-ended inquiry; AIDS was mentioned by 50.7%, followed by cancer (19.9%). AIDS was mentioned more frequently by blacks (63.9%) than by Hispanics (42.5%) or whites (45.7%), X2(3) = 32.07, p less than .002. Participants also reported higher levels of concern about AIDS than any other health problem with the exception of cancer. Concern about AIDS was greater among blacks (M = 2.68) than among Hispanics (M = 2.33) or whites (M = 2.36), F(2,351) = 5.06, p less than .01. Differences as a function of ethnicity, gender, and/or age were observed with respect to concern about heart disease, high blood pressure, diabetes, drug abuse, colds and flu, and herpes. In general, blacks and Hispanics expressed more interest in participating in AIDS education programs than did whites. Concern about AIDS and other health threats was not consistently related to either disease prevalence or severity.

Advances in Tuberculosis Work

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