Confidentiality, privacy, and respect: experiences of female sex workers participating in HIV research in Andhra Pradesh, India

Female sex workers (FSWs) from Andhra Pradesh, India, who had participated in HIV research were interviewed to examine participant perspectives on research ethics. Content analysis indicated that aspects of the consent process, staff gender and demeanor, study environment, survey content, time requirements for study participation, and perceived FSW community support for research were key factors influencing whether FSWs perceived their confidentiality and privacy had been maintained, and whether they felt the study was conducted respectfully. Findings suggest that partnership with community-based organizations and investigation of participant's experiences in HIV prevention research can provide critical information to best inform research ethics protocols, a particular priority among research studies with highly stigmatized populations, such as FSWs.

HIV and syphilis prevalence trends among men who have sex with men in Guangxi, China: yearly cross-sectional surveys, 2008-2012

Background

Men who have sex with men (MSM) represent the fastest growing key population for incident HIV cases in China. We examined five consecutive years of HIV and syphilis prevalence and risk factors data among MSM in Guangxi Province with the second highest estimated number of people living with HIV/AIDS (PLWHAs) in China in 2011.

Methods

We collected demographic and behavioral data from national sentinel surveillance and HIV/syphilis blood samples in five annual cross-sectional surveys from 2008 to 2012. We analyzed HIV and syphilis prevalence trends stratified by social/behavioral characteristics.

Results

HIV prevalence climbed steadily from 1.7% (95% confidence interval [CI]: 1.0 to 3.0) in 2008 to 3.7% (95% CI: 3.0 to 5.0) in 2012. Syphilis prevalence increased steadily from 5.1% (95% CI: 4.0 to 6.0) in 2008 to 8.4% (95% CI: 7.0 to 10.0) in 2012. HIV prevalence rose notably among MSM who were ≤25 years of age, never married, did not engage in sexual intercourse with women in the past six months, and had not been tested for HIV in the past year. Syphilis prevalence rose notably among MSM who were >25 years of age, ever married or living with a partner, and engaged in sexual intercourse with women in the past six months. HIV prevalence was much higher in MSM with current syphilis than without. Finally, current syphilis was the most significant predictor of HIV infection, and age was the most significant predictor of syphilis infection.

Conclusions

HIV and the syphilis prevalence expansion among MSM suggest an urgent public health prevention challenge for Guangxi provincial health officials. Risk factors for each infection differed such that all MSM, each of whom might be at risk of HIV, syphilis or both, should be targets for heavy intervention.

Drug users in Hanoi, Vietnam: factors associated with membership in community-based drug user groups

Background

A syndemic conjoins injection drug use, incarceration, and HIV in Vietnam, where there is a need for programs that empower people who use drugs to minimize the harms thereby produced. Here we present a post-hoc evaluation of the organizing efforts of the Centre for Supporting Community Development Initiatives (SCDI) with two community-based drug user groups (CBGs) in Hanoi.

Methods

Members (n = 188) of the CBGs were compared to non-member peers (n = 184) on demographic, psychosocial, behavioral and knowledge variables using a face-to-face structured interview that focused on issues of quality of life and harm reduction. Bivariate analyses were conducted, and variables significantly associated with membership at p < 0.10 were included in a multivariate model.

Results

Variables associated with membership in the CBGs in the multivariate model included increased self-efficacy to get drug-related health care (OR 1.59, 1.24-2.04), increased quality of life in the psychological (OR 2.04, 1.07-3.93) and environmental (OR 2.54, 1.31-4.93) domains, and greater history of interactions with police about drugs (OR 3.15, 1.79-5.52). There was little difference between members and non-members on injection-related harms except in the domain of knowledge about opioid overdose. Among the 114 current injectors (30.6% of the sample), low rates of unsafe injection practices were reported, and low statistical power limited the ability to conclusively assess association with membership.

Conclusions

Although the CBG members displayed higher levels of well-being and access to healthcare than non-members, further longitudinal study is required to determine if these are a result of membership. The CBGs should pay more attention towards meeting challenges in responding to specific health issues of those who continue to use drugs including HIV, hepatitis, and drug overdose.

Violent conflict and opiate use in low and middle-income countries: a systematic review

BACKGROUND

Violent conflicts disproportionately affect populations in low and middle-income countries, and exposure to conflict is a known risk factor for mental disorders and substance use, including use of illicit opiates. Opiate use can be particularly problematic in resource-limited settings because few treatment options are available and dependence can impede economic development. In this systematic review, we explore the relationship between violent conflict and opiate use in conflict-affected populations in low and middle-income countries.

METHODS

We searched MEDLINE, PsychINFO, SCOPUS, PILOTS, and select grey literature databases using a defined list of key terms related to conflict and opiate use, screened the results for relevant and methodologically rigorous studies, and conducted a forward search of the bibliographies of selected results to identify additional studies.

RESULTS

We screened 707 articles, selecting 6 articles for inclusion: 4 quantitative studies and 2 qualitative studies that examined populations in 9 different countries. All study participants were adults (aged 15-65) living in or displaced from a conflict-affected country. Data sources included death records, hospital records, and interviews with refugees, internally displaced persons, and others affected by conflict. Overall, we found a positive, but ambiguous, association between violent conflict and opiate use, with five of six studies suggesting that opiate use increases with violent conflict. Five key factors mediate the conceptual relationship between opiate use and violent conflict: (1) pre-conflict opiate presence, (2) mental disorders, (3) lack of economic opportunity, (4) changes in social norms or structure, and (5) changes in drug availability.

CONCLUSIONS

The strength and direction of the association between opiate use and violent conflict and the proposed mediating factors may differ between contexts, necessitating country and population-specific research and interventions. Prevalence of opiate use prior to the start of conflict was common to all populations in which conflict induced a change in opiate use, suggesting that interventions to reduce opiate use and future research should focus on such populations. Population-based, longitudinal studies that use systematic measures of exposure to conflict and opiate use are needed to further explore this association and its mediating factors.

The impact of comprehensive prevention of mother-to-child HIV transmission in Dehong prefecture, Yunnan province, 2005-2010: a hard-hit area by HIV in Southern China

The burden of HIV/AIDS in China has been disproportionately concentrated in Yunnan Province, where in Dehong prefecture, the HIV prevalence rate among pregnant women reached 1.3% in 2003, a rate that is indicative of a generalized epidemic. Since then, there have been extensive efforts to expand prevention to reduce mother-to-child transmission (MTCT) in this high-prevalence region. These intensified MTCT reduction efforts and their impact on MTCT are yet to be examined. We described the changes in access to HIV screening and antiretroviral therapy (ART) among pregnant women from 2005 to 2010 in this region and the corresponding reduction in MTCT over this period. Between 2005 and 2010, the annual number of pregnant women screened for HIV in Dehong Prefecture more than doubled. The proportion of pregnant women screened for HIV rose from an estimated 15-20% to 99.8%, and the proportion of HIV-infected pregnant women receiving ART increased from 63% to 99%. We estimate that the proportion of children born with HIV to HIV-infected mothers decreased from 15.4% to 7.2% over this period. Sustained low-level MTCT following comprehensive interventions in this region is encouraging. Over the last decade, comprehensive PMTCT efforts, coupled with national and local government policy support in this area appear to be effective.

Total HIV/AIDS expenditures in Dehong Prefecture, Yunnan province in 2010: the first systematic evaluation of both health and non-health related HIV/AIDS expenditures in China

OBJECTIVE

We assessed HIV/AIDS expenditures in Dehong Prefecture, Yunnan Province, one of the highest prevalence regions in China, and describe funding sources and spending for different categories of HIV-related interventions and at-risk populations.

METHODS

2010 HIV/AIDS expenditures in Dehong Prefecture were evaluated based on UNAIDS' National AIDS Spending Assessment methodology.

RESULTS

Nearly 93% of total expenditures for HIV/AIDS was contributed by public sources. Of total expenditures, 52.7% was allocated to treatment and care, 24.5% to program management and administration and 19.8% to prevention. Spending on treatment and care was primarily allocated to the treatment of opportunistic infections. Most (40.4%) prevention spending was concentrated on most-at-risk populations, injection drug users (IDUs), sex workers, and men who have sex with men (MSM), with 5.5% allocated to voluntary counseling and testing. Prevention funding allocated for MSM, partners of people living with HIV and prisoners and other confined populations was low compared to the disproportionate burden of HIV/AIDS in these populations. Overall, people living with HIV accounted for 57.57% of total expenditures, while most-at-risk populations accounted for only 7.99%.

CONCLUSIONS

Our study demonstrated the applicability of NASA for tracking and assessing HIV expenditure in the context of China, it proved to be a useful tool in understanding national HIV/AIDS response from financial aspect, and to assess the extent to which HIV expenditure matches epidemic patterns. Limited funding for primary prevention and prevention for MSM, prisoners and partners of people living with HIV, signal that resource allocation to these key areas must be strengthened. Comprehensive analyses of regional and national funding strategies are needed to inform more equitable, effective and cost-effective HIV/AIDS resource allocation.

Externalities of prevention of mother-to-child transmission programs: a systematic review

There has been considerable debate about the effects of targeted global health assistance in low- and middle-income countries on health systems, specifically HIV/AIDS funding. Recently, a handful of studies have emerged that describe the implementation of PMTCT programs, which have many theoretical links to maternal and child health. Through a systematic review of research published between January 2000 and March 2011, this paper synthesizes evidence evaluating the impact of these programs. We assessed 5,855 papers, reviewed 154, and included 21 articles. They offer evidence of beneficial synergies between PMTCT programs and both STI prevention and early childhood immunization. Other data, including information about antenatal and delivery care, family planning, and nutrition supplementation varied considerably across studies demonstrating both positive and negative effects of PMTCT. More research is needed to allow countries and funders to make informed decisions regarding allocation of limited funds to targeted versus broad categories of health care.

Opiate use, treatment, and harm reduction in Afghanistan: recent changes and future directions

Afghanistan leads global opium and cannabis production, amidst concerted efforts to improve the country's infrastructure. In this commentary, the evidence base for drivers of increased drug use in the context of deteriorating security is presented, government, donor, and civil society responses to date are described, and key areas for health policy response are summarized. Opiate use in Afghanistan shows disturbing trends: multiple substances are accessible at low cost and frequently used in combination, and injecting use has become more common. Pressures from both donor and governmental sectors have compromised innovations in programming. Further, civil unrest and resultant displacement have created challenges for programme implementation. Afghanistan urgently needs a well-funded, sustainable, comprehensive, and inclusive programme of drug dependency treatment, aftercare, and harm reduction services, as well as realistic, effective, and culturally salient primary prevention programmes. To date, drug dependence is not a prioritised issue, current programmes are under-resourced, and the continuum of care has a narrow scope generally limited to treatment. Unless this issue is addressed, the next generation of Afghans is poised to become a casualty of the opiate industry.

Exploring the Ethics of Observational Research: The Case of an HIV Study in Tanzania

BACKGROUND

Observational studies have generally been viewed as incurring minimal risk to participants, resulting in fewer ethical obligations for investigators than intervention studies. In 2004, the lead author (AN) carried out an observational study measuring sexual behavior and the prevalence of HIV, syphilis, and herpes simplex virus type 2 (HSV-2), among Tanzanian agricultural plantation residents (results reported elsewhere). This article uses an ethical lens to consider the consequences of the observational study and explore what, if any, effects it had on participants and their community.

METHODS

Using a case study approach, we critically examine three core principles of research ethics-respect for persons/autonomy; beneficence/nonmaleficence; and distributive justice-as manifested in the 2004 observational study. We base our findings on three sources: discussions with plantation residents following presentations of observational research findings; in-depth interviews with key informants; and researcher observations.

RESULTS

The observational research team was found to have ensured confidentiality and noncoercive recruitment. Ironically, maintenance of confidentiality and voluntary participation led some participants to doubt study results. Receiving HIV test results was important for participants and contributed to changing community norms about HIV testing.

CONCLUSIONS

Observational studies may act like de facto intervention studies and thus incur obligations similar to those of intervention studies. We found that ensuring respect for persons may have compromised the principles of beneficence and distributive justice. While in theory these three ethical principles have equal moral force, in practice, researchers may have to prioritize one over the others. Careful community engagement is necessary to promote well-considered ethical decisions.

HIV/AIDS-Related Knowledge and Its Association With Socioeconomic Status Among Women

This article assesses the association of women’s HIV/AIDS knowledge of transmission and prevention with socioeconomic status (SES). Data from the 2004 Lebanese PAPFAM (Pan-Arab Project for Family Health) survey were used. The survey was based on a representative household sample (n = 5532 households; n = 3315 women) of ever-married women aged 15 to 55 years. Adjusted analysis revolved around multivariate logistic regression models. 18% of women were knowledgeable of HIV/AIDS transmission methods and 21% of prevention methods. Income and education were significantly related to women’s transmission and prevention knowledge. Significant differences were also found by region and media exposure. Women in the richest income quintile were 4 times (95% confidence interval [CI] = 2.43-6.42) more likely to be knowledgeable than those in the poorest. Women with the highest education were 2.57 times more likely (95% CI = 1.98-3.34) to be knowledgeable than those with elementary education or less. These results suggest the need for incorporating contextual regional and population differences for more effective HIV/AIDS awareness campaigns in Lebanon.

Assessment of hypertension control in a district of Mombasa, Kenya

As populations move to urban centres across East Africa, lifestyle habits that affect cardiovascular disease have changed, affecting non-communicable disease risk. In particular, the prevalence of hypertension, and associated awareness of this life-threatening condition, has not been studied in Mombasa, Kenya. This paper assesses the rates of prevalence, awareness, treatment and control of hypertension in Old Town, an urban district of the coastal city. We surveyed 469 subjects, gathered via a clustered sampling technique. Age-adjusted prevalence of hypertension was measured at 32.6% (± 2.2) for adults over 18 and was linearly related to age. Results indicate that hypertension awareness was associated with age and sex, as women were substantially more likely to be aware of and to control their hypertension. Only 23.2% (± 2.0) of subjects had knowledge of both the causes of and practical solutions to hypertension, and practical hypertension knowledge was associated with hypertension awareness and gender (women had higher rates of knowledge than men). These results indicate that hypertension is a real public health concern in Old Town, and that younger individuals, particularly males, are least likely to be aware of the dangers of hypertension. Public health measures should focus on this population.

Barriers to antiretroviral adherence in HIV-positive patients receiving free medication in Kayunga, Uganda

Global and local efforts have been devoted to increase the supply of antiretroviral therapy (ART) in sub-Saharan Africa. Recent qualitative studies suggest that even with free ART, patients may fail to adhere to medication because of socioeconomic barriers such as transportation costs to clinics. The aim of this study was to measure adherence in a population of patients receiving free ART and to examine barriers to adherence. Adherence was measured using the pill count and self-report methods among 140 HIV-positive patients at four PEPFAR-facilitated ART clinics in Kayunga, a rural district in Uganda. Self-report was also used to examine reasons for non-adherence. Pill count adherence estimates revealed that 86.4% of the patients were adherent (≥95%) in the past six months. Self-report estimates showed that all the patients were adherent in the past six months with average adherence of 99.7%±0.6. The main reasons for non-adherence were being away from medication at dose time (29.4%) and forgetting to take pills (27.5%). Lack of access to food and transportation costs accounted for 11.7% and 7.8% of non-adherence, respectively. Patients with 100% adherence reported lack of access to food as the main challenge they had to overcome to stay adherent. Patients attending the rural clinic were significantly less adherent to ART than patients at the Kayunga district capital [OR 0.046 (0.008-0.269)]. The study revealed that the greatest patient-perceived challenge to adherence in this population is the lack of access to food; however, the immediate reasons for non-adherence were found to be forgetfulness and being away from medication at dose's time. These results suggest that interventions tackling lack of access to food are necessary, but interventions addressing forgetfulness and being away from medication at dose's time would be the most effective in enhancing adherence inpatients receiving free ART.

Lost in translation: reproductive health care experiences of Somali Bantu women in Hartford, Connecticut

INTRODUCTION

Reproductive health problems are the leading cause of women's morbidity and mortality worldwide. In the United States, officially sponsored refugee women continue to face challenges in accessing reproductive health programs despite having access to health insurance.

METHODS

The objective of this study was to explore the reproductive health experiences of 1 such population--Somali Bantu women in Connecticut--to identify potential barriers to care experienced by marginalized populations. The study was qualitative, consisting of key informant interviews, a focus group session, and a semistructured survey.

RESULTS

Although all the women in the study reported having access to reproductive health care services, they also reported having unmet health needs resulting from barriers to care that included ethnic distinction/language barriers, passive acceptance of incorrect care, cultural discordance in family planning services, patient-provider sex discordance, and desire but limited scope for ownership in health care outcomes. The root cause of the various types of patient-provider discordance was the lack of recognition that the Somali Bantu are distinct in culture, language, and solidarity from ethnic Somalis, resulting in Language Line translation services being conducted in a Somali language that the Somali Bantu women did not understand.

DISCUSSION

The results of the study primarily highlight the larger issue of information asymmetry within the health care system that, if left unaddressed, will persist as new vulnerable populations of refugees arrive in the United States.

Female spouses of injection drug users in Pakistan: a bridge population of the HIV epidemic?

An estimated 21% of injection drug users (IDUs) in Pakistan are HIV-positive and data suggest that the spouses of IDUs may be a critical component of the HIV transmission chain. This study interviewed 101 spouses of male IDUs about their sexual practices and drug use. We found that 43% had been sexually active with their partners in the past month but only 4% reported selling sex. Almost a quarter (23%) used drugs and 19% injected drugs, usually a combination of diazepam and pheniramine. Although sex work was infrequent among spouses of IDUs, their risk of contracting HIV and transmitting it to others was high because they received injection drugs, sometimes along with their IDU husbands, from the same health centres that provided therapeutic injections to the rest of the community. IDU spouses may thus serve as a bridge group via therapeutic injections, rather than via sex work.

Opium trade, insurgency, and HIV/AIDS in Afghanistan: relationships and regional consequences

Global health and conflict studies share key linkages that have important research and policy implications but for which data are currently lacking. This analytical review examines the ongoing conflict in Afghanistan, using it as a basis to develop a conceptual framework that integrates security and public health concepts. The analysis draws on recent peer-reviewed and gray literature to assess the interrelationship among 3 variable clusters and their impact on the emergence of the HIV epidemic in Afghanistan. The evidence suggests that there is a complex indirect relationship linking illicit opium trade, the ongoing insurgency, and forced and spontaneous migration to the emergence of an injection drug use-driven HIV epidemic in Afghanistan. These findings demonstrate a clear need for an integrated cross-disciplinary and regional approach to the emerging threat of HIV/AIDS in Afghanistan, to inform more balanced and effective policy making in this and other regions of strategic global import.

Short-term global health research projects by US medical students: ethical challenges for partnerships

Recent interest in global health among medical students has grown drastically, and many students now spend time abroad conducting short-term research projects in low-resource settings. These short-term stints in developing countries present important ethical challenges to US-based students and their medical schools as well as the institutions that host such students abroad. This paper outlines some of these ethical issues and puts forth recommendations for ethically mindful short-term student research.

Expanded access to naloxone: options for critical response to the epidemic of opioid overdose mortality

The United States is in the midst of a prolonged and growing epidemic of accidental and preventable deaths associated with overdoses of licit and illicit opioids. For more than 3 decades, naloxone has been used by emergency medical personnel to pharmacologically reverse overdoses. The peers or family members of overdose victims, however, are most often the actual first responders and are best positioned to intervene within an hour of the onset of overdose symptoms. Data from recent pilot programs demonstrate that lay persons are consistently successful in safely administering naloxone and reversing opioid overdose. Current evidence supports the extensive scaleup of access to naloxone. We present advantages and limitations associated with a range of possible policy and program responses.

Assessment of HIV testing of urban injection drug users: implications for expansion of HIV testing and prevention efforts

OBJECTIVES

We sought to determine the extent of HIV testing among urban injection drug users (IDUs) to assess whether an expansion of targeted testing programs would be consistent with national goals to identify previously undetected infections.

METHODS

IDUs in 5 US cities (Oakland, Calif; Chicago, Ill; Hartford and New Haven, Conn; and Springfield, Mass) were recruited either by chain referral or time-location sampling. The IDUs were questioned about HIV testing, and factors associated with HIV testing were analyzed.

RESULTS

Ninety-three percent of 1543 IDUs had been tested. Among those tested but who did not report having been told that they were HIV seropositive, 90% had been tested within the past 3 years. Women and syringe-exchange customers were more likely to have been tested ever and in the recent past. We estimated the number of undetected infections among urban IDUs in the United States to be less than 40000.

CONCLUSIONS

Testing for HIV has reached the vast majority of IDUs through the current options. Expending scarce prevention money to expand testing of IDUs is unlikely to be productive. Instead, resources should be used for proven HIV-prevention strategies including syringe exchange, drug treatment, and secondary prevention for those who are HIV positive.

Assessing the efficacy of a voluntary HIV counseling and testing intervention for pregnant women and male partners in Urumqi City, China

This study investigated the efficacy of voluntary counseling and testing (VCT) in an educated cohort of pregnant women attending antenatal clinics in Urumqi, China. VCT was given to women and their partners (experimental group) or women alone (control group). Both groups were given pre- and post-intervention questionnaires to assess HIV knowledge and willingness to get HIV testing. Multivariate analysis showed that all women improved significantly in HIV knowledge between baseline and follow-up. Moreover, HIV knowledge was significantly associated with HIV testing willingness. At follow-up, women in the control and experimental groups were 6.8 and 7.9 times more willing to receive HIV testing than at baseline, respectively. VCT seems effective in this cohort of educated pregnant women.

Anxiety, depression, and posttraumatic stress in Iranian survivors of chemical warfare

CONTEXT

In the 1980-1988 Iran-Iraq War, extensive use of chemical weapons resulted in high rates of morbidity and mortality. While much is known about the physical consequences of chemical warfare, there is a paucity of information about the long-term effects of chemical attacks on mental health.

OBJECTIVE

To assess the long-term psychological impact of chemical warfare on a civilian population.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional randomized survey conducted in July 2004 of 153 civilians in 3 towns exposed to warfare in northwestern Iran: Oshnaviyeh (low-intensity conventional warfare), Rabat (high-intensity conventional warfare), and Sardasht (both high-intensity conventional warfare and chemical weapons).

MAIN OUTCOME MEASURES

Full or partial posttraumatic stress disorder (PTSD) diagnosis, anxiety symptoms, and depressive symptoms were assessed using Farsi versions of the Clinician-Administered PTSD Scale, Hamilton Scale for Anxiety, and Beck Depression Inventory, respectively.

RESULTS

Overall participation rate was 93%. Respondents had a mean age of 45 years and were all of Kurdish ethnicity. Among individuals exposed to both high-intensity warfare and chemical weapons, prevalence rates for lifetime PTSD, current PTSD, major anxiety symptoms, and severe depressive symptoms were 59%, 33%, 65%, and 41%, respectively. Among the low-intensity warfare group, the corresponding rates were 8%, 2%, 18%, and 6%, respectively, while intermediate rates were found among those exposed to high-intensity warfare but not to chemical weapons (31%, 8%, 26%, and 12%, respectively). Compared with individuals exposed to low-intensity warfare, those exposed to both high-intensity warfare and chemical weapons were at higher risk for lifetime PTSD (odds ratio [OR], 18.6; 95% confidence interval [CI], 5.8-59.4), current PTSD (OR, 27.4; 95% CI, 3.4-218.2), increased anxiety symptoms (OR, 14.6; 95% CI, 6.0-35.6), and increased depressive symptoms (OR, 7.2; 95% CI, 3.3-15.9). Exposure to high-intensity warfare but not to chemical weapons was also significantly associated with lifetime PTSD (OR, 5.4; 95% CI, 1.7-17.6), compared with those in the low-intensity warfare group. Further, compared with individuals exposed to high-intensity warfare alone, those exposed to both high-intensity warfare and chemical weapons were at higher risk for lifetime PTSD (OR, 3.4; 95% CI, 1.5-7.4), current PTSD (OR, 6.2; 95% CI, 2.0-20.1), increased anxiety symptoms (OR, 5.6; 95% CI, 2.5-12.6), and increased depressive symptoms (OR, 3.7; 95% CI, 1.8-7.2).

CONCLUSION

Exposure to chemical warfare is an extreme traumatic event that has long-lasting adverse consequences on mental health.

HIV prevalence, sociodemographic, and behavioral correlates and recruitment methods among injection drug users in St. Petersburg, Russia

OBJECTIVE

In St. Petersburg, Russia, we sought to describe the characteristics of active high-risk injection drug users (IDUs) to evaluate the associations between behavioral and demographic characteristics and HIV-1 infection and to describe 3 discrete recruitment methods.

METHODS

Active high-risk IDUs were recruited in 3 ways: through street outreach, at facilities serving IDUs, and by network-based chain referral. Recruits were screened, counseled, and tested for HIV-1. Sociodemographic and behavioral data were collected. HIV-1 prevalence was analyzed as a function of sociodemographic and behavioral variables.

RESULTS

During the 10-month recruitment period, data from 900 participants were collected: median age was 24 years, and in the previous month, 96% used heroin and 75% shared needles with others. The baseline HIV prevalence was 30% (95% confidence interval [CI]: 27 to 33). Recruitment through social networks was the most productive strategy. HIV-positive individuals were younger, but none of the other sociodemographic or behavioral characteristics differed significantly by HIV status.

CONCLUSIONS

The estimated HIV prevalence of 30% places St. Petersburg among the worst IDU-concentrated epidemics in Europe. Recruitment through network-based chain referral is a useful method for recruiting active IDUs. Sociodemographic and behavioral links to prevalent HIV infection remain to be elucidated.

Profiles of risk: a qualitative study of injecting drug users in Tehran, Iran

Background

In Iran, there are an estimated 200,000 injecting drug users (IDUs). Injecting drug use is a relatively new phenomenon for this country, where opium smoking was the predominant form of drug use for hundreds of years. As in many countries experiencing a rise in injecting drug use, HIV/AIDS in Iran is associated with the injection of drugs, accounting for transmission of more than two-thirds of HIV infections. This study aimed to: describe the range of characteristics of IDUs in Tehran, Iran's capital city; 2) examine the injecting-related HIV risk behaviors of IDUs, and 3) suggest necessary interventions to prevent HIV transmission among IDUs and their families and sex partners.

Methods

Using rapid assessment and response methods with a qualitative focus, six districts of Tehran were selected for study. A total of 81 key informants from different sectors and 154 IDUs were selected by purposeful, opportunistic and snowball sampling, then interviewed. Ethnographic observations were done for mapping and studying injecting-related HIV risk settings and behaviors. Modified content analysis methods were used to analyze the data and extract typologies of injecting drug users in Tehran.

Results

Evidence of injecting drug use and drug-related harm was found in 5 of 6 study districts. Several profiles of IDUs were identified: depending on their socioeconomic status and degree of stability, IDUs employed different injecting behaviors and syringe hygiene practices. The prevalence of sharing injection instruments ranged from 30–100%. Varied magnitudes of risk were evident among the identified IDU typologies in terms of syringe disinfection methods, level of HIV awareness, and personal hygiene exhibited. At the time of research, there were no active HIV prevention programs in existence in Tehran.

Conclusion

The recent rise of heroin injection in Iran is strongly associated with HIV risk. Sharing injection instruments is a common and complex behavior among Iranian IDUs. For each profile of IDU we identified, diverse and targeted interventions for decreasing sharing behavior and/or its harms are suggested. Some notable efforts to reduce the harm of injecting drug use in Iran have recently been accomplished, but further policies and action-oriented research for identification of effective preventive interventions are urgently needed.

Treatment of multiple drug-resistant tuberculosis (MDR-TB) in Iran

SETTING

Masih Daneshvari Hospital, Tehran, Iran, 2000-2002.

OBJECTIVE

To evaluate the effectiveness of multiple drug-resistant tuberculosis (MDR-TB) treatment for the first time in Iran.

DESIGN

All cases of MDR-TB with complete follow-up data were recruited and results of their treatments were evaluated.

RESULTS

MDR-TB treatment was initiated with 5.23 drugs, on average. Isoniazid, amikacin, and ofloxacin were present in the drug regimen of all patients. Average duration of the treatment was 18.5 months (range, 7-36). Over 76% of the patients responded to the treatment (negative smear and culture). Cure and probable cure were documented in seven (41.2%) and four (23.5%) of the patients, respectively. No failure in the treatment occurred when cycloserine was present in the treatment regimen.

CONCLUSION

A majority of the MDR-TB patients in Iran can be cured with the use of appropriate treatment regimens. An even greater success could be achieved by providing more second-line drugs.

Barriers to completion of tuberculosis treatment among prisoners and former prisoners in St. Petersburg, Russia

SETTING

St. Petersburg, Russian Federation.

OBJECTIVES

To identify barriers to the completion of tuberculosis (TB) treatment among prisoners and former prisoners in St Petersburg, Russia.

DESIGN

Questionnaires were administered to 60 prisoners and 40 former prisoners. Interviews were performed with prison and TB dispensary staff. Treatment follow-up rates were estimated by matching prison release records against attendance records from all 17 St. Petersburg-based TB dispensaries over an 18-month period.

RESULTS

Of 80 released prisoners with active TB in 2002, 21 (26.3%) appeared in dispensary attendance records. Barriers to the completion of TB treatment overall were homelessness, unemployment, alcoholism, drug addiction and difficulty tolerating TB medications with co-morbid illnesses such as human immunodeficiency virus and hepatitis. Prisoners and former prisoners ranked help with obtaining an internal passport and money first, followed closely by food and a job, as the most desirable incentives to completing TB treatment.

CONCLUSIONS

A future program for soon-to-be released and released prisoners in St. Petersburg that offers an array of desirable flexible social welfare services and incentives has the potential to attract and retain patients within TB treatment, but continued efforts must also be made to include drug treatment, job training and keeping former prisoners out of prison.

Correlates of HIV infection among incarcerated women: implications for improving detection of HIV infection

The prevalence of HIV infection in correctional settings is several-fold higher than found in community settings. New approaches to identifying HIV infection among prisoners are urgently needed. In order to determine the HIV seroprevalence and to identify the correlates of HIV infection among female prisoners, an anonymous, but linked HIV serosurvey was conducted at Connecticut's sole correctional facility for women (census=1,100). After removing all individual identifiers for inmates' standardized clinical and risk behavior information, data are linked by a third source to blinded HIV-testing information by a third party. This three-step sequential process allows for anonymous HIV testing that can still be linked with deidentified clinical and behavioral data. Of the 3,315 subjects with complete information, 250 (7.5%) were HIV+. Of these, 157 (63%) self-reported being HIV+. Using multiple logistic regression analysis, having sex with a known HIV+ person [adjusted odds ratio (AOR)=9.1] and injection drug use (AOR=6.1) were the most highly correlated risk factors for HIV, whereas leukopenia (AOR=9.4) and hypoalbuminemia (AOR=7.2) were the most significant laboratory markers. Other independent correlates of HIV included self-report of syphilis (AOR=1.9) or genital herpes infection (AOR=2.7) and being Black (AOR=2.1) or Hispanic (AOR=2.2). The prevalence of HIV and HIV-risk behaviors is high among incarcerated women. Existing voluntary HIV counseling and testing programs do not completely target high-risk groups who remain part of the evolving epidemic. Defined demographic, behavioral, and clinical assessments may provide useful information for encouraging targeted counseling and testing. Newer targeted approaches merit further study to determine the effectiveness of this approach. Alternative methods of facilitating more widespread HIV testing, such as saliva tests, rapid serologic tests, and more routine testing in high HIV-prevalence areas should be considered both for clinical and for public health benefits.

Declining incidence of invasive Streptococcus pneumoniae infections among persons with AIDS in an era of highly active antiretroviral therapy, 1995-2000

BACKGROUND

Our goal was to describe trends in invasive pneumococcal disease incidence among persons with acquired immunodeficiency syndrome (AIDS) since the introduction of highly active antiretroviral therapy (HAART).

METHODS

We used time-trend analysis of annual invasive pneumococcal disease incidence rates from a population-based, active surveillance system. Annual incidence rates were calculated for 5 July-June periods by use of data from San Francisco county, the 6-county Baltimore metropolitan area, and Connecticut. The numerators were the numbers of invasive Streptococcus pneumoniae infections among persons 18-64 years of age with AIDS; the denominators were the numbers of persons living with AIDS, estimated on the basis of AIDS surveillance data.

RESULTS

The annual incidence of invasive pneumococcal disease declined from 1094 cases/100,000 persons with AIDS (July 1995-June 1996) to 467 cases/100,000 persons living with AIDS (July 1999-June 2000). The annual percentage changes in incidence were -34%, -29%, -8%, and -1%. Declines were similar by surveillance area, sex, and race/ethnicity. During the final year of the study, the invasive pneumococcal disease incidence in persons with AIDS was half that of the pre-HAART era but was still 35 times higher than that in similarly aged non-HIV-infected adults.

CONCLUSIONS

In the United States, invasive pneumococcal disease incidence declined sharply across a range of subgroups living with AIDS during the period after widespread introduction of HAART. Despite these gains, persons with AIDS remain at high risk for invasive pneumococcal disease.

Writing about risk: use of daily diaries in understanding drug-user risk behaviors

As part of a larger syringe access and HIV risk study, a subsample of 23 current injection drug users completed daily diaries, highlighting activities related to syringe acquisition, use, and discard. Diaries have been previously utilized in a variety of psychological, public health, and nutrition studies to assess risk as well as correlated behaviors. We piloted the diary methodology in three northeastern U.S. cities (Hartford and New Haven, CT, and Springfield, MA) to learn about correlates of HIV risk. We discovered that the method provided advantages over several other qualitative and ethnographic methods. Results indicate that daily diaries elucidated (1) patterns of injection drug use, (2) sporadic and high-risk events, (3) HIV and hepatitis risk related to the syringe life cycle, and (4) emotional correlates of drug use. Furthermore, we witnessed an unexpected intervention effect that the diary may have in the lives of drug users.

Incidence of anal cytological abnormalities in a cohort of human immunodeficiency virus-infected women

Little is known about the natural history of anal human papillomavirus (HPV) infection in HIV-infected women because, to date, no longitudinal studies have been reported in the scientific literature. This article estimates the incidence of anal cytological abnormalities in a cohort of HIV-infected women. It also examines potential risk factors for the development of an anal cytological abnormality. A cohort of HIV-infected women underwent interview, anal cytology, and anogenital HPV DNA testing. Women with a normal baseline anal cytology were followed for the development of an anal cytological abnormality. The incidence of an abnormality was calculated. Survival analyses were performed to examine risk factors for the development of an abnormality. Fourteen of 100 HIV-infected women had an abnormal anal cytology at baseline. Among the 86 women with a normal baseline cytology, the incidence of an abnormality was 22 [95% confidence interval (CI), 14-33] per 100 person-years. In a multivariate analysis, women were at increased risk if, at baseline, they had a CD4+ T-cell count of <500 cells/mm(3) [relative hazard (RH) = 4.11; 95% CI, 1.18-14.25], high-risk type anal HPV infection (RH = 2.54; 95% CI, 0.91-7.14) or were cigarette smokers (RH = 3.88; 95% CI, 1.12-13.42). The incidence of anal cytological abnormalities was high among this cohort of HIV-infected women, indicating that they are at high risk of anal squamous intraepithelial lesions. HIV-infected women are likely to be at higher risk than their HIV-uninfected counterparts because immune suppression conferred substantially increased risk. Continued research on the association between smoking and the development of squamous intraepithelial lesions in HIV-infected women is warranted.

Syringe source, use, and discard among injection-drug users in New Haven, Connecticut

We examined syringe source, use, and discard practices of injection-drug users (IDUs) in New Haven, Connecticut, a city with both a legal syringe-exchange program (SEP) and non-prescription availability of syringes through pharmacies. The population demographics, syringe use, and discard practices of IDUs who obtained syringes from various sources were compared using structured interview data. Of the 373 IDUs recruited, 268 (72 percent) resided in the city of New Haven. Among the New Haven IDUs, 111 (41 percent) reported pharmacies, 36 (13 percent) reported the New Haven SEP, 90 (34 percent) reported both, and 27 (10 percent) reported neither as their usual source of syringes in the past six months. No significant differences (p value < 0.05) were observed among New Haven IDUs who relied on pharmacies versus the SEP. However, IDUs who relied on the SEP were significantly less likely to report they threw away used syringes, compared with pharmacy users. Both the pharmacies and the New Haven SEP are important sources of sterile syringes for IDUs in New Haven. The lower frequency of syringe discard by IDUs who obtained their syringes primarily through the SEP indicates another public health benefit of programs such as these.

Effects of increasing syringe availability on syringe-exchange use and HIV risk: Connecticut, 1990-2001

Syringe-exchange programs (SEPs) in Connecticut operate with caps on the number of syringes exchanged per visit. We investigated the effects of legislation increasing the cap on drug injectors' access to clean syringes through the SEPs in New Haven and Hartford. The mixed design of this study included longitudinal and cross-sectional data from individuals and ecological data from program operations. Five parameters-syringe return rate, syringes per visit to the SEP, syringe reuse rate, syringe human immunodeficiency virus (HIV) prevalence, and syringe sharing-were monitored through syringe tracking and testing of SEP syringes and by interviewing injectors. Two increases in the cap-from 5 to 10 and then from 10 to 30-had little effect on the five parameters that measured injectors' access to clean syringes. In contrast, access to clean syringes increased when the New Haven SEP first began operations, when syringes first became available at pharmacies in Hartford, and when the agency running the Hartford SEP changed. Legislation providing piecemeal increases in the cap may not, by themselves, be sufficient to increase injectors' access to clean syringes and decrease the risk of human immunodeficiency virus transmission in this population.

The impact of needle exchange-based health services on emergency department use

OBJECTIVE

To examine the impact of the New Haven Community Health Care Van (CHCV), a mobile needle exchange-based health care delivery system, in reducing emergency department (ED) use among out-of-treatment injection drug users (IDUs) between January 1, 1996 and December 31, 1998.

DESIGN

A pre-post comparison of ED utilization was performed using linked medical records from New Haven's only two emergency departments. Fixed-effect negative binomial regression analysis was used to explore the impact of the CHCV on ED use within a longitudinal cohort.

SETTING

Mobile health clinic in New Haven, Conn.

PARTICIPANTS

Out-of-treatment IDUs.

INTERVENTION

Acute care, linkages to medical, drug treatment, and social services.

MEASUREMENTS AND MAIN RESULTS

Among 373 IDUs, 117 (31%) were CHCV clients, and 256 had not used CHCV services. At baseline, CHCV users were more frequent users of ED services (P <.001). After full-scale implementation, mean ED utilization declined among CHCV clients and increased within the non-CHCV group. CHCV use is associated with statistically significant reductions in ED use, with an incidence rate ratio (IRR) of 0.79 (95% confidence interval [95% CI], 0.66 to 0.95). Subgroup analyses demonstrated significant IRR reductions, notably among Hispanics (0.65; 95% CI, 0.47 to 0.90), men (0.79; 95% CI, 0.64 to 0.98], HIV-negative IDUs (0.79; 95% CI, 0.63 to 0.98), and those with mental illness (0.75; 95% CI, 0.60 to 0.94).

CONCLUSION

Needle exchange-based health care services can reduce ED utilization among high-risk injection drug users. Such services may have an important role within communities with high rates of drug use and HIV/AIDS.

Ethical dilemmas created by the criminalization of status behaviors: case examples from ethnographic field research with injection drug users

The criminalization of behaviors such as the ingestion of certain mood-altering drugs creates ethical dilemmas for researchers studying those behaviors. The Syringe Access, Use, and Discard (SAUD) project is designed to uncover microcontextual factors that influence HIV and hepatitis risk behaviors of injection drug users. The article presents seven ethical dilemmas encountered using ethnographic methods: issues involving syringe replacement at injection locales, risks of participants' arrest, potential disruptions in participants' supply routes, risks of research staff arrest, threats to the protection of confidentiality, issues surrounding informed consent in working with addicts, and the confiscation of potentially incriminating information by police. The article concludes with a discussion of the limitations of traditional ethical frameworks, such as utilitarianism, for resolving these dilemmas and recommends instead improving public health professionals' capacity for practical reasoning (phronesis) through the greater use of case studies in public health curricula.

Epidemiology of Necator americanus hookworm infections in Xiulongkan Village, Hainan Province, China: high prevalence and intensity among middle-aged and elderly residents

Hookworm is highly endemic to Hainan Province, an island located in the South China Sea. To investigate the prevalence and intensity of infection in the area, the village of Xiulongkan was surveyed between April and July 1998. A cross-sectional study was conducted in which fecal samples of 80% of the village residents (631 individuals) were tested for the presence of helminth eggs. Hookworm was the predominant intestinal helminth in Xiulongkan, where it was determined that 60% of those tested were infected. Necator americanus was the predominant species of hookworm in this population. The prevalence of hookworm increased with age, and then leveled to a plateau for ages 41 yr and up. This observation was in contrast to infections with Ascaris lumbricoides, where the highest prevalences occurred among school-aged children. Women had a significantly higher prevalence of hookworm than men and this difference emerged in early adulthood. The intensity of hookworm infection also significantly increased with age, with the highest intensity infections occurring among middle-aged and elderly residents. Females were more likely to have moderate or heavy infections, whereas males were more likely to have light infections. The rates of hookworm transmission are particularly high among the middle-aged and elderly residents of Xiulongkan.

Prevalence of antibodies to human herpesvirus 8 (HHV-8) in Saudi Arabian patients with and without renal failure

BACKGROUND

Kaposi's sarcoma (KS) is the most common cancer occurring in renal transplant recipients in Saudi Arabia, where the reported incidence of posttransplantation KS is 10 times higher than the incidence in the United States and Western Europe. The reason for the particularly high incidence of posttransplantation KS in this geographic area is unknown.

METHODS

To explore the possibility that the high incidence of posttransplantation KS might be the result of widespread infection with human herpesvirus 8 (HHV-8), we determined the prevalence of antibodies to HHV-8 in 201 patients with end-stage renal disease (ESRD) and a comparison group of 358 individuals without renal disease who were similar in age, sex, and area of residence. Antibodies to lytic cycle antigens of HHV-8 were determined by indirect immunofluorescence and confirmed by immunoblots using tetradecanoyl phorbol ester acetate-induced BC-3 cell extracts and recombinant small viral capsid antigen (ORF65).

RESULTS

Antibodies to HHV-8 were detected in serum samples from 14 (6.97%) of 201 ESRD patients and from 10 (3.88%) of 258 in the comparison group (P=0.14). HHV-8 seropositive individuals were on average 10 years older than seronegative subjects (55.3 years vs. 46.9 years). Among HHV-8 seropositive subjects, 71% were male and 29% were female.

CONCLUSIONS

Serologic evidence of HHV-8 infection was numerically more common in men and in patients with ESRD. However, among patients with and without ESRD, the strongest association was with increasing age.

Risk of perinatal transmission with treatment combinations of intrapartum and newborn zidovudine monotherapy

OBJECTIVE

To determine perinatal transmission rates when zidovudine (ZDV) was given either to mothers after labor had begun, to their infants postnatally, or both.

METHODS

Woman-infant pairs who received intrapartum and newborn ZDV therapy between January 1, 1992, and July 1, 1998, were considered. A medical record review identified female subjects known to be HIV-infected. All women who were given treatment with any antiretroviral drug before the onset of labor were excluded. All women satisfying eligibility criteria were enrolled. Nonparametric tests were used for analysis. The transmission rate of the study population was compared with rates reported for mother-infant pairs in the United States who did not receive ZDV.

RESULTS

Administration of ZDV therapy after onset of labor resulted in a transmission rate of 11.9% (n = 59; 95% confidence interval [CI], 4.9 to 22.9). The overall perinatal transmission rate among women who received ZDV therapy after the onset of labor among sites in New York City was 6.3% (n = 32; CI, 0.8 to 20.8) compared with 18.5% (n = 27; CI, 6.3 to 38.0) among other sites. Administration of intrapartum therapy alone (n = 9), intrapartum plus newborn therapy (n = 37), and newborn therapy alone (n = 13) resulted in transmission rates of 11.1% (CI, 0.3 to 48.2), 13.5% (CI, 4.5 to 28.8), and 7.7% (CI, 0.2 to 36.0), respectively.

CONCLUSION

The transmission rates reported here are lower than rates reported when antiretroviral therapy was not administered.

The social geography of AIDS and hepatitis risk: qualitative approaches for assessing local differences in sterile-syringe access among injection drug users

While significant gains have been achieved in understanding and reducing AIDS and hepatitis risks among injection drug users (IDUs), it is necessary to move beyond individual-level characteristics to gain a fuller understanding of the impact of social context on risk. In this study, 6 qualitative methods were used in combination with more traditional epidemiologic survey approaches and laboratory bioassay procedures to examine neighborhood differences in access to sterile syringes among IDUs in 3 northeastern cities. These methods consisted of (1) neighborhood-based IDU focus groups to construct social maps of local equipment acquisition and drug use sites; (2) ethnographic descriptions of target neighborhoods; (3) IDU diary keeping on drug use and injection equipment acquisition; (4) ethnographic day visits with IDUs in natural settings; (5) interviews with IDUs about syringe acquisition and collection of syringes for laboratory analysis; and (6) focused field observation and processual interviewing during drug injection. Preliminary findings from each of these methods are reported to illustrate the methods' value in elucidating the impact of local and regional social factors on sterile syringe access.

Health care delivery strategies for criminal offenders

Men and women under correctional supervision may be the most challenging population of public health concern. Prison inmates, parolees, and probationers experience prevalent infectious disease including HIV and hepatitis C. Many supervised individuals have significant mental or behavioral health problems that require clinical intervention. The U.S. correctional population is also rapidly growing, and now includes more than 5 million men and women. Concerns about quality, accessibility, and cost of correctional care have prompted calls for managed care models in this population. This paper reviews pertinent experiences within Medicaid managed care and suggests four interconnected strategies--outreach, discharge planning, entitlement security, and case management--to improve the quality and efficiency of correctional care.

Evaluation of an innovative program to address the health and social service needs of drug-using women with or at risk for HIV infection

Drug-using women with or at risk for HIV infection have many competing unmet needs, especially for social services, drug treatment, and medical care. High-risk drug-using women were recruited through street outreach, at needle exchange sites, a prison, and local community based organizations in New Haven, Connecticut for a study of the service needs of out-of-treatment drug users and the ability of an interactive case management intervention (ICM) to address those needs. These women were administered baseline and follow-up interviews to identify their health and social service needs and the degree to which these needs were resolved. The women who chose to enroll in the interactive case management intervention (n = 38) did not differ demographically nor in their HIV risk behaviors from those not receiving case management (n = 73). Provision of ICM was most successful in meeting needs for supportive mental health counseling, basic services, and long term housing. The impact of interactive case management was less evident for the acquisition of medical and dental services, which were accessed comparably by women not receiving the intervention. Overall, the women who enrolled in the ICM intervention showed a significant decrease in the number of unmet service needs as compared to those who did not enroll. Multiple contacts were required by the case manager to establish trust and to resolve the unmet service needs of these high-risk women. Women with or at risk for HIV infection can be effectively engaged in an ICM intervention in order to meet their multiple unmet service needs, although such interventions are time-and-labor intensive.