Parenteral transmission of HIV among injection drug users: assessing the frequency of multiperson use of needles, syringes, cookers, cotton, and water

OBJECTIVES

To describe and estimate the frequency of different types of drug preparation and injection practices that could result in the transfer of blood and blood-borne infections among injection drug users (IDUs).

METHODS

We analyzed data from interviews administered to 12,323 active IDUs recruited from 19 sites in the United States. The interviews ascertained drug-related behaviors during the previous 30 days.

RESULTS

31.9% of IDUs reported that they engaged in the use of both needle/syringes and cookers/cotton/water previously used by another IDU; 8.6% engaged only in the use of needle/syringes previously used by another IDU; 17.5% engaged only in the use of cookers/cotton/water previously used by another IDU; and 42.0% reported using neither needle/syringes nor cookers/cotton/water previously used by another IDU. Only 12.6% reported use of new (never-used) needle/syringes. The 3935 IDUs who used both needle/syringes and cookers/cotton/water that had been previously used by another IDU had more than 311.000 potential exposures to blood-borne infections from these high-risk practices in 30 days; about 64% of these exposures were from multiperson use of cookers/cotton/water.

CONCLUSIONS

Programs to limit parenteral transmission of HIV and other blood-borne infections among IDUs must consider all drug preparation and injection practices that could allow transfer of blood and blood-borne infections among IDUs.

The role of the physician as an information source on mammography

PURPOSE

The value of mammography for asymptomatic women younger than 50 years of age has been under debate, and it had been suggested that each woman should decide for herself whether to start having mammograms in her 40s. This decision-making process requires women to have knowledge of screening guidelines. This study reported key determining informational factors that led women age 40 and older to obtain a mammogram.

DESCRIPTION OF STUDY

To examine the relationship between sources of information and utilization of mammography, the authors conducted a communitywide telephone survey, in English and Spanish, of a stratified random sample of 999 white, black, and Hispanic women in Dade County, Florida. The survey was designed to measure knowledge, attitudes, practices, and beliefs about breast cancer, its prevention, and its early detection. Data for 784 women 40 years and older are analyzed and reported here.

RESULTS

The most commonly cited source of information was the media (90.2%). In a logistic regression, having had a checkup in the past year was the strongest predictor of having had a recent mammogram as opposed to a distant one (OR 4.17; 95% CI 2.92-5.95). Women who named their physician as an important source of information about health and prevention were also more likely to have had a recent examination (OR 1.85; 95% CI 1.27-2.69).

CLINICAL IMPLICATIONS

This analysis of the relationship between the source of information and utilization of mammography suggests that physicians, as sources of information, serve to motivate women to obtain a mammogram. This is true even after taking into account the patient's age and utilization of the healthcare system for preventive care in general. For this reason, it is imperative that clinicians be aware of national guidelines for breast cancer screening; of the risks and benefits of screening measures; and of the implications of a positive and negative test result. In addition, clinicians must realize the importance of follow-up to remind the patient to obtain a mammogram or other screening test and should develop strategies to provide this service.

Social influences: living arrangements of drug using women at risk for HIV infection

The purpose of this study was to explore the associations among living arrangements, HIV seroprevalence, and HIV risk and protective factors among 1,322 drug users participating in the University of Miami CARES (Community AIDS Research and Evaluation Studies) HIV intervention program. Living arrangements may be associated with HIV prevention behaviors; however, these influences can be either protective or destructive and therefore merit further examination. Statistical analyses indicated differences in the living arrangements of women compared with men, and significant associations were noted among women's living arrangements, HIV seroprevalence, risk behaviors and protective behaviors. The data from this study suggest that future HIV prevention research should investigate not only high-risk individuals, but persons with whom they interact often, especially those with whom they live or with whom they have sex. The next phase of HIV and drug interventions should be attentive to the incorporation of social context and social influences, paying particular attention to understudied populations such as high-risk women.

Predictors of HIV infection among women drug users in New York and Miami

In the US, the number of women diagnosed with AIDS continues to increase. In this study, women in New York City (East Harlem) and Miami, two sites with high rates of drug use and HIV infection, were first compared on sociodemographic variables and risk behaviors. Logistic regression analyses were used to identify significant, independent predictors of HIV infection in each city. In comparing women from the two cities, several differences in sociodemographic characteristics and drug use were observed. In both cities, ever exchanging sex for drugs and/or money was predictive of HIV infection; and in East Harlem only, other lifetime risk variables independently predicted HIV infection: drug injection, having a sexually transmitted disease, and not having graduated from high school. Results suggest that intervention efforts with women who exchange sex should be intensified in both cities. Also, further comparisons of women drug users in AIDS epicenter cities are necessary to provide information on similarities and differences in sociodemographic characteristics and individual risk behaviors. More research attention should be focused on examining the social context of HIV risk in order to develop innovative intervention strategies which focus on the link between contextual factors and HIV infection.

Effectiveness of HIV interventions among women drug users

A prospective cohort study was conducted among chronic injecting and crack cocaine drug using women. The hypothesis tested was that participation in a standard-plus-innovative intervention was more likely to produce behavior change than participation in a standard intervention. Standardized intervention protocols and corresponding instruments were designed. Data were collected on drug and sex risk behaviors at baseline and six-month follow-up intervals. The level of behavioral change in two intervention arms--standard and a standard-plus-innovative intervention--was measured by composite sex risk and drug risk scores using the generalized estimating equation approach. The results show that on four risk measures the enhanced intervention was significantly associated with positive change in both drug use and sexual behavior: less frequent drug use, less drug use during sex, and more frequent condom use during particular frequencies for specific types of sexual activities. Public health interventions are effective when targeting specific risk behaviors through interventions tailored to prevent HIV and reduce risk behaviors among specific cultural and gender groups.

Cocaine abuse and HIV-1 infection: epidemiology and neuropathogenesis

The epidemiology of cocaine abuse and potential relationships of cocaine withdrawal to human immunodeficiency virus type 1 (HIV-1)-associated dementia (HAD) are discussed. Neuroendocrinological changes in HIV-1 infection of the central nervous system (CNS) are discussed with the relevant impact of cocaine abuse. HIV-1 load in the brain tissue of infected substance users is described along with possible associations with neuropathology and HAD. Finally, the molecular epidemiology and sequence heterogeneity of HIV-1 and their implications for neuropathogenesis are summarized. The complex context of addressing cocaine abuse in the setting of HIV-1 infection appears more tractable when decomposed into its components.

Cost-effectiveness of detecting breast cancer in lower socioeconomic status African American and Hispanic women through mobile mammography services

Lower socioeconomic status African American and Hispanic women suffer from later-stage detection of breast cancer and higher mortality rates than other American women. Low-cost mobile mammography offers one approach to mitigate this problem. This article identifies the economic costs and cost-effectiveness of operating a mobile mammography program targeting indigent populations. Costs are derived from a current mobile mammography service for a range of operating volume conditions and are applied to different detection rates to determine the cost-effectiveness of programs designed to reach different age, racial, and ethnic segments of indigent populations. Results from this work have broad policy implications and form a foundation for future economic and policy analysis in this area.

Injection drug users' practices and attitudes toward intervention and potential for reducing the transmission of HIV

Miami is one of the major centers of illegal drug activity and has a significant proportion of AIDS cases among injection drug users (IDUs). Since Needle Exchange Programs (NEP) are illegal and therefore do not exist in the state of Florida, other strategies must play a large role in reducing the transmission of HIV among IDUs. In order to effectively communicate with IDUs about needle safety, it is necessary to understand the practices and culture of IDUs, including where and how the needle/syringes are obtained and used. Data from recent studies conducted in Miami and other local sites indicate that IDUs inject frequently, averaging more than 1,000 per year, per person. While the vast majority of IDUs feel it is very important to clean needles and to use a needle only one time, these sentiments are not always practiced. Furthermore, data indicate that the context where shooting takes place must be considered in the planning of HIV risk reduction interventions. These findings suggest the importance of understanding patterns of drug use, attitudes toward intervention, and the cultural context where risky behaviors occur. Although Needle Exchange Programs are illegal in Florida, intervention programs must still stress the importance of using only new needles, but since new needles cannot always be obtained, IDUs should be taught and motivated not to use contaminated drug paraphernalia.

Skills for HIV risk reduction: evaluation of recall and performance in injecting drug users

Evaluation of recall and performance skills required to clean needles/ syringes was conducted in Dade County with 393 injecting drugs users (IDUs) in 1988-1989. The study was guided by a question of the extent of correct cleaning of needles/syringes. A free recall procedure which combined cognitive and psychomotor testing provided a means of verifying knowledge and skills. The results show that injecting drug users were able to learn and retain knowledge and skills necessary to prevent risk of HIV infection by use of needles/syringes. Tests of knowledge and performance 6 months after training showed high retention of the material learned. The population at risk is capable of reducing the spread of HIV. The impact would be greater with perfect performance, but even with partial performance, some preventative impact could be assumed provided exposure time to bleach exceeds 30 seconds.

No Pain No Gain, Establishing the Kunming, China, Drug Rehabilitation Center

The Yunnan Province in China may be experiencing the highest incidence of heroin use in China, in part because of its proximity to the Golden Triangle. This high incidence, as elsewhere, threatens to increase associated problems in China, including the spread of HIV. Furthermore, the high purity of heroin used in this Province leads to rapid addiction and increased difficulties in treating the symptoms of withdrawal. One response to this epidemic is the development and implementation of the Kunming Drug Rehabilitation Center. The Center, with a capacity for 620 addicts, is grounded in a recovery-oriented perspective that is based on the Therapeutic Community model and modified for the Yunnan Province and China. It is referred to as the Kunming Model and is known for the development of its own medicine for detoxification and its individualized psychological, psychiatric, medical, and biosocial program. Similarities and differences between the Kunming Center and treatment programs in the United States are discussed and implications for universal approaches to drug treatment are addressed.

Immigration and HIV among Migrant Workers in Rural Southern Florida

We studied HIV seropositivity among a targeted sample of migrant workers who used drugs, primarily crack cocaine, and their sexual partners in rural southern Florida from 1993 to 1995. We enrolled men and women who were born in the United States (n = 369) or in other countries (n = 174). Overall, 11.2% of the sample were HIV positive, including 18% of Blacks from the United States, and about 8% of non-Hispanic whites from the United States, Blacks from the Caribbean, and persons from Central or South America. No Hispanics from the United States or the Caribbean, but 3.4% of Hispanics from Mexico, were HIV positive. In logistic regression analyses, race/ethnicity, gender, and age were most highly associated with HIV seropositivity. Immigration status, current drug use, and current sexual activity were not related to HIV seropositivity. HIV prevention programs must help reduce heterosexual transmission of HIV associated with drug use both locally and where migrants travel and work.

Crack cocaine smoking and oral sores in three inner-city neighborhoods

Crack cocaine causes blisters, sores, and cuts on the lips and in the mouths of persons who smoke it, and such sores may facilitate the oral transmission of HIV. We recruited young adults aged 18-29 years, who either were current regular crack smokers, or who had never smoked crack, from inner city neighborhoods in New York, Miami, and San Francisco. Participants were interviewed for HIV risk behaviors and history of recent oral sores and were tested for HIV, syphilis, and herpes simplex virus (HSV) antibodies. Among the 2,323 participants recruited, 1,404 (60%) were crack smokers. Crack smokers (10.0%) were more likely than nonsmokers (4.5%) to report having had oral sores in the past 30 days [prevalence odds ratio (POR) 2.4, 95% confidence interval (CI) 1.7-3.4]. Sores were also more prevalent among those who had ever injected drugs (14.3%) than among those who had not (6.7%; POR 2.3, 95% CI 1.7-3.4), and among those with HIV infection (14.3%) than among those without it (8.0%; POR 1.9, 95% CI 1.3-2.8). Among the 429 participants who reported receptive oral sex, those who reported oral sores were more likely than those who did not to have HIV infection, after other HIV risk factors were controlled for (adjusted POR 1.9, 95% CI 1.0-3.6). Our results confirm that crack smokers have a high prevalence of oral sores and provides evidence that these sores, although infrequently, may facilitate oral transmission of HIV.

Detection of HIV-1 DNA in needle/syringes, paraphernalia, and washes from shooting galleries in Miami: a preliminary laboratory report

Shared use of injection equipment (needle/syringes), registering, booting, and backloading are practices among injection drug users (IDUs) that increase the risk for transmission of human immunodeficiency virus type 1 (HIV-1). The sharing of injection paraphernalia (including cookers and cottons) and washwater for rinsing used needle/syringes and dissolving drugs could be potential sources for secondary transmission of HIV-1. Laboratory rinses were made from needle/syringes, cottons, and cookers obtained from shooting galleries, and washwaters were obtained from shooting galleries in Miami. Three rinses were analyzed and antibodies to HIV-1 proteins were detected by using Western blot and HIV-1 DNA was detected by using nested polymerase chain reaction (PCR) specific for the gag and envelope genes of HIV-1. Antibodies to HIV-1 proteins were detected in 12 (52%) of 23 rinses from visibly contaminated needle/syringes, in three (18%) of 17 rinses from cottons, in three (14%) of 21 rinses from cookers, and in one (6%) of 17 washwaters. No antibodies were detected in laboratory rinses from visibly clean needles. Using nested PCR followed by Southern blot confirmation of the amplified targets, HIV-1 gag gene DNA was detected in 16 (84%) of 19 and envelope gene DNA in 17 (85%) of 20 laboratory rinses from visibly contaminated needle/syringes. We detected gag and envelope gene DNA, respectively, in three (27%) and four (36%) of 11 cottons, in six (46%) and seven (54%) of 13 cookers, and in five (38%) of 13 and in 10 (67%) of 15 washwaters from shooting galleries. No HIV-1 DNA was detected in laboratory rinses from visibly clean needles. These results indicate that HIV-1 might be present in contaminated cottons, cookers, and washwaters as well as in contaminated needle/syringes at shooting galleries. Reduction of risks of exposure to HIV-1 among IDUs may require modification of behaviors that are ancillary to the act of injection, such as the use of common cookers, cottons, and washwater.

Risk factors for HIV-1 seroconversion among injection drug users: a case-control study

OBJECTIVES

A nested case-control study was conducted in Miami, Fla, to determine risk factors associated with human immunodeficiency virus type 1 (HIV-1) seroconversion among injection drug users.

METHODS

The study identified 21 incident cases of HIV-1 infection and 76 unmatched controls from two longitudinal cohorts of injection drug users. One cohort consisted of individuals who originally had been recruited from treatment centers; a second cohort was recruited from the "street." Logistic regression analyses that adjusted for age, gender, and race were performed.

RESULTS

The final model determined that the primary independent risk factor that best explained the risk for seroconversion was sharing injection equipment in the year prior to conversion; a marginal risk factor was presence of sexually transmitted disease during this same period.

CONCLUSIONS

Both an injection component and a sexual component play a role in seroconversion among injection drug users, although the injection component is much stronger.

HIV-related risk behaviors and seropositivity among homeless drug-abusing women in Miami, Florida

This article examines the multifaceted interactions among homelessness, HIV, substance abuse, and gender. Data were collected on 1,366 chronic drug users using a nationally standardized validated instrument within the Miami CARES project of a multisite federally funded program. HIV testing accompanied by pretest and posttest counseling was conducted on-site by certified phlebotomists and counselors. In addition to descriptive analyses and corresponding tests of significance, logistic regression analyses were used to clarify the complex associations between the outcome variables of homelessness and HIV, recognizing difficulties of determining temporal sequence. HIV infection was found to be 2.35 times more prevalent among homeless women than homeless men and significantly higher for homeless women. The findings indicate that among women, homelessness and HIV have a highly interactive effect increasing the vulnerability of this population and thus rendering them an extremely important priority population on which to focus public health efforts and programs.

Prostate cancer in Florida: knowledge, attitudes, practices, and beliefs

In Florida, prostate cancer continues to be an increasing public health problem, especially among the elderly and medically underserved. Bilingual, random-digit-dialed telephone interviews were conducted with 897 men who were 65 years and older in Dade and Hillsborough counties, with the sample stratified along racial and ethnic lines. The purpose of the survey was to obtain information regarding knowledge, attitudes, practices, and beliefs about prostate cancer, its prevention, and early detection. More than 60% of the 897 respondents believed that a person with prostate cancer had an 80% or greater chance for cure, yet only 67% reported ever having a digital rectal examination. Black (35.7%) and Hispanic respondents (42.5%) were twice as likely to have never had a digital rectal examination than were their white counterparts (19.8%). When asked why they had never had this examination or had not had one in the past 2 years, 38.5% replied that it was "not needed/not necessary" and 27.6% replied they "had not had any problems." When asked their sources for answers to health-related questions, physicians ranked first whereas family and friends ranked near the bottom on a list of some 11 sources. Clearly, efforts need to be increased to identify, reduce, and/or eliminate potential barriers to use of early-detection programs.

Urban rape survivors: characteristics and prevalence of human immunodeficiency virus and other sexually transmitted infections. Multicenter Crack Cocaine and HIV Infection Study Team

OBJECTIVE

To determine the prevalence of recent rape, the characteristics or recent rape survivors, and the seroprevalence of human immunodeficiency virus (HIV), syphilis, and genital herpes (HSV-2) among recent rape survivors.

METHODS

We surveyed women 18-29 years old who were recruited from places unassociated with medical or drug treatment or the criminal justice system in three urban communities where illicit drug use is common. We compared characteristics and HIV, syphilis, and HSV-2 seroprevalence of women who reported recent rape with those of women who denied recent rape.

RESULTS

One hundred fifty-one of 1104 (13.7%) women reported having been raped in the year before our interview. Rape survivors were more likely than women who denied recent rape to smoke crack cocaine (86.8 versus 56.7%; odds ratio [OR] 5.0, 95% confidence interval [CI] 3.2-7.8), to be homeless (17.2 versus 6.1%; OR 3.2, CI 2.0-5.2), to report a recent sexually transmitted disease (38.7 versus 18.7%; OR 2.7, CI 1.9-3.9), and to be infected with syphilis (42.4 versus 28.4%; OR 1.9, CI 1.3-2.6) and HSV-2 (71.9 versus 57.5%; OR 1.9, CI 1.3-2.8). Survivors were more likely to acknowledge any HIV risk behavior (including sex work) (85.4 versus 49.5%; OR 5.9, CI 3.9-9.0) and to be HIV-infected (23.3 versus 13.4%; OR 1.9, CI 1.3-2.9). Rape was not independently associated with HIV (OR 0.8, 95% CI 0.4-1.3), syphilis (OR 0.9, 95% CI 0.6-1.3), or HSV-2 (OR 1.3, 95% CI 0.9-2.0) infections after adjustment for confounding factors.

CONCLUSION

One in seven women reported being raped recently. Rape was most common among sex workers, crack smokers, and the homeless. Most survivors reported HIV risk behaviors, and many were HIV-infected. Programs to prevent repeated rape, voluntary HIV counseling and testing, and other medical and social services may benefit survivors in these and similar communities.

HIV-1 heterogeneity and cytokines. Neuropathogenesis

Mild manifestations (HIV-1 associated minor cognitive/motor disorder), severe manifestations (HIV-1 associated dementia complex and HIV-1 associated myelopathy), and sensory neuropathy are consequences of HIV-1 infection. Our goal is to elucidate the role of HIV-1 in the complications of AIDS including cytokine immunopathology and HIV-1 DNA sequence variants. We have examined the brain and sensory ganglia from 60 AIDS patients and 20 seronegative controls using PCR, DNA sequencing of the HIV-1 envelope protein (env), in situ hybridization (ISH), and immunohistochemistry (IHC). Using our combined ISH-IHC technique, we could identify different types of cells and HIV-1 simultaneously in cryostat and paraffin sections. We found HIV-1 predominantly in macrophage/microglia in brain. In dorsal root ganglia (DRG) we found rare macrophages infected with HIV-1 and neurons and interstitial cells (including macrophages) which were apoptotic. Cytokines were detected in mononuclear and endothelial cells near neurons. We achieved single copy sensitivity detecting HIV-1 in nervous tissue using nested PCR. We sequenced HIV-1, DNA from 3 intravenous drug users (IDUs): from brain, CSF, and blood. PCR amplification was followed by cloning and then sequencing the HIV-1 insert: V1-V5 regions of the envelope (env) gene. We found that the env genes had increased sequence variation compared to the literature, cDNA sequences derived from RNA were less heterogeneous than clones derived from DNA from the same specimens, clones derived from brain are more closely related (show restricted heterogeneity) compared to clones from blood and CSF from the same patients. Patient 149 clones we examined to date did not correspond to any of the designated subtypes (A-F) of HIV-1 based on the DNA sequences of the C2-V3 regions. Finally, the HIV-1 RNA produced in these tissues is derived from a minority of DNA clones. Although HIV-1 infected macrophages are not entirely responsible for pathology in the brain and less so in sensory ganglia, some of the products of infection, cytokines, are more widespread in these tissues. Furthermore, HIV-1 strains infecting the brain appear to exhibit restricted heterogeneity compared to autologous CSF and blood and these strains may be associated with cytokines and pathology. HIV-1 strains that infect nervous tissue and cytokines produced in this tissue may effect neuropathogenesis, in vivo, in spite of low levels of local HIV-1 infection. We attempt to delineate, here, common sequence variations in HIV-1 isolates in the hope of developing future therapeutic strategies.

Implementation of a family-centered treatment program for substance-abusing women and their children: barriers and resolutions

Recent federal health financing and health care delivery programs have increased access to alcohol and other drug abuse treatment programs for low-income women, and have provided intervention and prevention services for their children and families. The Village South Families in Transition (FIT) in Miami, Florida, implemented a residential treatment program for women and their children that aims to decrease alcohol and other drug use, reduce reliance on social and health welfare systems, improve functioning in specific life-skill and vocational areas, improve parenting techniques and maternal/child relations, and provide intervention and prevention services for the clients' children in a safe and supportive environment. Program implementation required resolutions to numerous barriers, including securing a facility for women and children; recruiting, hiring and training of staff; establishing and maintaining community linkages; treatment considerations; balancing treatment versus evaluation/research; and critical decisions faced by treatment staff as they modify client-centered programs to incorporate gender-specific and family-centered programs.

Intersecting epidemics--crack cocaine use and HIV infection among inner-city young adults. Multicenter Crack Cocaine and HIV Infection Study Team

BACKGROUND AND METHODS

The smoking of "crack" cocaine is thought to be associated with high-risk sexual practices that accelerate the spread of infection with the human immunodeficiency virus (HIV). We studied 2323 young adults, 18 to 29 years of age, who smoked crack regularly or who had never smoked crack. The study participants, recruited from the streets of inner-city neighborhoods in New York, Miami, and San Francisco, were interviewed and tested for HIV. This report presents the findings for the 1967 participants (85 percent) who had never injected drugs.

RESULTS

Of the 1137 crack smokers, 15.7 percent were positive for HIV antibody, as compared with 5.2 percent of the 830 nonsmokers (prevalence ratio adjusted for the city, 2.4; 99 percent confidence interval, 1.7 to 3.6). The prevalence of HIV was highest among the crack-smoking women in New York (29.6 percent) and Miami (23.0 percent). Of the 283 women who had sex in exchange for money or drugs, 30.4 percent were infected with HIV as compared with 9.1 percent of the 286 other women (prevalence ratio, 3.1; 99 percent confidence interval, 1.9 to 5.1); of the 91 men who had anal sex with other men, 42.9 percent were infected with HIV as compared with 9.3 percent of the 582 men who did not have anal sex with other men (prevalence ratio, 4.7; 99 percent confidence interval, 3.0 to 7.4). In multivariable analyses, these high-risk sexual practices accounted for the higher prevalence of HIV infection among the crack smokers, as compared with those who did not smoke crack. Women who had recently had unprotected sex in exchange for money or drugs were as likely to be infected as men who had had sex with men (40.9 percent vs. 42.9 percent).

CONCLUSIONS

In poor, inner-city communities young smokers of crack cocaine, particularly women who have sex in exchange for money or drugs, are at high risk for HIV infection. Crack use promotes the heterosexual transmission of HIV.

Breast cancer control program for the socioeconomically disadvantaged. Screening mammography for the poor

A 6-year experience of providing mammograms to the socioeconomically disadvantaged in Dade County, Florida, through Primary Health Care Centers has defined a breast cancer control program that minimizes the barriers to early breast cancer detection for these women. First, an education and recruitment phase that reaches into the community to solicit the target group: Recruitment is needed more than education. Second, a low-cost mammography service that also reaches into the community and makes it available, accessible, and acceptable. Third, a one-stop breast center that minimizes the barriers to diagnostic evaluation. Finally, a multidisciplinary evaluation and treatment planning program offers optimum treatment options to the patient with newly diagnosed breast cancer and an opportunity for bonding between her and the staff. A research overly has allowed data to be collected continuously and provides an evaluation of the effectiveness of the program. This program has saved lives by reducing the projected mortality rate and has saved money by reducing the cost of treatment through earlier diagnosis. All four components are essential to a breast cancer control program for the socioeconomically disadvantaged.