Evidence for recent growth of the HIV epidemic among African-American men and younger male cohorts in Los Angeles County

Educational Status and Risk of HIV in Young Gay Men

Lower socioeconomic status (SES) has been associated with higher rates of HIV infection as well as higher rates of unsafe sex. The behavioral determinants that might mediate the effect of SES on risky sex have not been studied thus far. We investigated the involvement of social cognitions in the link between educational status and unprotected anal sex in 292 participants of the Amsterdam Young Gay Men Study. We found that poorly educated men had poorer knowledge about HIV and preventive behavior, perceived social norms to be less favorable towards condom usage with casual partners, and had lower perceived control over that behavior than the better educated men. Poorly educated men were also more likely to have engaged in unprotected anal sex with casual partners in the six-month period that followed the assessment of the social cognitions. However, the education-related behavioral difference could not be explained by social cognitions. We concluded that cognitive models of behavior might not explain all of the risk behavior in gay men with lower SES. These men's risk-taking behavior might result from specific psychological characteristics of men with lower SES that interfere with traditional cognition–behavior correlations as posited in prevailing models of behavior.

HIV seroprevalence among homeless and marginally housed adults in San Francisco

OBJECTIVES

We report HIV seroprevalence and risk factors for urban indigent adults.

METHODS

A total of 2508 adults from shelters, meal programs, and low-cost hotels received interviews, blood tests, and tuberculosis screening.

RESULTS

Seroprevalence was 10.5% overall, 29.6% for men reporting sex with men (MSM), 7.7% for non-MSM injection drug users (IDUs), and 5.0% for residual non-MSM/non-IDUs. Risk factors were identified for MSM (sex trade among Whites, non-White race, recent receptive anal sex, syphilis), non-MSM IDUs (syphilis, lower education, prison, syringe sharing, transfusion), and residual subjects (> or = 5 recent sexual partners, female crack users who gave sex for drugs).

CONCLUSIONS

HIV seroprevalence was 5 times greater for indigent adults than in San Francisco generally. Sexual behavior predicted HIV infection better than drug use, even among IDUs.

Distribuição social da AIDS no Brasil, segundo participação no mercado de trabalho, ocupação e status sócio-econômico dos casos de 1987 a 1998

Estudou-se a evolução temporal da epidemia de AIDS no Brasil, tendo a ocupação como variável identificadora da condição sócio-econômica dos casos. Todos os casos de AIDS de 20 a 49 anos de idade, diagnosticados entre 1987-1998, foram incluídos. Analisou-se a evolução temporal das taxas de incidência de AIDS, por sexo, categoria ocupacional e quintos da Escala de Status Sócio-econômico (ESO), além da proporção de casos segundo os quintos da ESO por categoria de exposição. Entre os homens, as taxas de incidência aumentaram, no 1: período, em praticamente todas as categorias ocupacionais, e reduziram entre aquelas classificadas como "não manuais", no 2: período. Entre as mulheres, observou-se incremento anual em quase todas as categorias ocupacionais, de 1987 a 1998. Os maiores aumentos relativos foram observados nos quintos da ESO de menor status sócio-econômico, para ambos os sexos. A categoria de exposição "UDI" foi a que apresentou o pior status sócio-econômico, em ambos os sexos, e a categoria "homo/bissexual" o status mais elevado, entre os homens. A análise evidenciou a progressiva mudança no gradiente social da epidemia de AIDS, com maior velocidade de disseminação nas populações de menor status sócio-econômico.

Frequent failed early HIV detection in a high prevalence area: implications for prevention

To identify the frequency of and factors associated with early detection of HIV infection in Los Angeles County, data were evaluated from interviews of a population-based sample of adult persons with AIDS. Early detection was defined as greater than 5 years between the first reported positive HIV test and an AIDS diagnosis. The associations between early detection and sociodemographic and behavioral factors were assessed for the period January 1997 through June 2002. Over the study period, only 20% (253/1268) of persons interviewed met the criterion for early detection. Early HIV detection was less likely for women (adjusted odds ratio [AOR] = 0.6, 95% confidence interval [CI]: 0.4, 0.9), blacks (AOR = 0.5, 95% CI: 0.4, 0.8), foreign-born Latinos (AOR = 0.2, 95% CI: 0.1, 0.3), U.S.-born Latinos (AOR = 0.3, 95% CI: 0.2, 0.6, and heterosexuals (AOR = 0.5, 95% CI: 0.3, 0.7). Trends of increasing early detection with older age groups (p < 0.001) and higher educational levels (p < 0.001) were also observed. Our findings indicate an overall low level of early HIV detection and suggest that major sociodemographic and risk group disparities exist in the likelihood of early detection among HIV-infected persons in Los Angeles. These differences have important implications for reducing the level of community HIV transmission and for improving individual health outcomes among people with HIV. Aggressive efforts are needed to expand HIV testing and early detection for women, minorities, heterosexuals, younger age groups, and persons of lower education. Links to treatment and behavioral intervention programs should accompany such expanded testing efforts.

The effect of partner characteristics on HIV infection among African American men who have sex with men in the Young Men's Survey, Los Angeles, 1999-2000

Previous studies have documented disparities in HIV prevalence by race among men who have sex with men (MSM), even after adjusting for traditional risk factors. In this analysis of data collected for the 1999-2000 Los Angeles Young Men's Survey, a cross-sectional venue-based survey of MSM aged 23-29, we investigated whether information on male sex-partner characteristics accounts for some of the racial/ethnic differences in HIV prevalence. In this sample of survey participants, we observed that African American MSM reported similar or lower levels of HIV risk behaviors compared with White MSM but much higher HIV prevalence (26% vs. 7.4%, respectively). In an unadjusted logistic regression model, African American participants had 4.4 times higher odds of HIV infection compared with White participants. In a multiple logistic regression model adjusting for participant behaviors, we observed elevation of the relative odds of HIV infection for African Americans compared with Whites (odds ratio [OR] = 6.9, 95% confidence limits [CL] = 2.5, 19). In a fully adjusted model, controlling for the effects of having older partners and more African American partners, we observed a 20% reduction in the relative odds of HIV for African American participants compared with White participants (OR = 5.5, 95% CL = 1.8, 17). Our findings suggest that differences in male partner types, namely older and African American partners, may account for some of the observed racial disparity in HIV infection, especially for African American MSM compared with White MSM in Los Angeles.

HIV and AIDS risk behaviors among female jail detainees: implications for public health policy

OBJECTIVES

We examined the sexual and injection drug use HIV and AIDS risk behaviors of female jail detainees.

METHODS

The sample (n = 948) was stratified by charge type (felony vs misdemeanor) and race/ethnicity (African American, non-Hispanic White, Hispanic, other).

RESULTS

Non-Hispanic White women, women arrested for less serious charges, women who had prior arrests, women arrested on drug charges, and women with severe mental disorders were at especially high risk for sexual and injection drug transmission of HIV and AIDS.

CONCLUSIONS

Many women at risk for HIV and AIDS--women who use drugs, women who trade sex for money or drugs, homeless women, and women with mental disorders--eventually will cycle through jail. Because most jail detainees return to their communities within days, providing HIV and AIDS education in jail must become a public health priority.

[AIDS epidemic dynamics in the municipality of Rio de Janeiro, Brazil, 1988-1996: Spatial-temporal statistic modeling]

This study uses a spatial-temporal model to analyze the spatial spread of the AIDS epidemic (adult cases) in the municipality of Rio de Janeiro, Brazil, during three periods: 1988-1990, 1991-1993, and 1994-1996. City districts were used as the geographic units of analysis. A spatial analysis was also performed for pediatric AIDS cases due to vertical HIV transmission, according to period of birth, 1985-90 and 1991-96. For total adult AIDS cases, the initial period was characterized by a polygonal cluster located around the harbor area, which expanded from west to east. Among homosexual cases, in situ growth predominated, and a decrease in the intensity of the diffusion process was observed from the second to the final period. Among heterosexual cases, the epidemic displayed a relevant geographic spread, mainly from 1988-1990 to 1991-1993. Among female cases in the final time period, a cluster of high incidence rates was found towards the northwest, including very poor areas. Among pediatric cases in 1991-1996, a significant correlation was found between AIDS incidence rates and poverty levels in the respective municipal districts. The results suggest that a more complete understanding of AIDS spatial-temporal dynamics can make a major contribution to preventive measures.

Increase in the share of steady partners as a source of HIV infection: a 17-year study of seroconversion among gay men

OBJECTIVES

To examine the share of steady versus casual partners as the source of HIV infection in gay male seroconversions between 1984 and 2000 and the effect of age at seroconversion on the source of HIV transmission.

METHODS

The sample consisted of 144 seroconverstors from the Amsterdam Cohort Study among Homosexual Men. Questionnaires and post-seroconversion interviews were used to determine the source of HIV transmission.

RESULTS

Analysis revealed an interaction effect between calendar year and age at seroconversion (P < 0.05). Younger seroconverters had higher odds ratios [odds ratio, 11.33; 95% confidence interval, 1.77--72.13] to be infected by their steady partner late in the AIDS epidemic: 15% (three of 20) between 1984 and 1987 versus 67% (six of nine) between 1994 and 2000. No such time effect was present for older seroconverters who were consistently more likely to be infected by a casual partner: 79% (37 of 47) between 1984 and 1987, and 83% (15 of 18) between 1994 and 2000.

CONCLUSIONS

Young gay seroconverters today are more likely to have contracted HIV from a steady partner than from a casual partner, compared with early in the AIDS epidemic and compared also with older gay seroconverters. There is a pressing need for preventive measures addressing sexual risk behaviour within steady relationships among younger gay men.

The geographic distribution of AIDS in the United States: is there a rural epidemic?

The goal of this study was to examine where people with acquired immune deficiency syndrome (AIDS) in the United States live and the degree to which AIDS is present in rural areas. AIDS cases reported to the Centers for Disease Control and Prevention (CDC) in 1996 were categorized by metropolitan statistical area (MSA) size and compared to the general population. Data were analyzed by region, race/ethnicity and risk exposure; AIDS incidence rates were compared over time by MSA size. Relative to the U.S. population, AIDS cases were disproportionately black (43 percent vs. 11 percent), male (80 percent vs. 48 percent), and from the Northeast (32 percent vs. 20 percent). In all regions, a greater proportion of AIDS cases reside in large MSAs compared with the general population. Risk exposures differ little by MSA size, except in the Northeast. The proportion of people with AIDS who reside in large MSAs exceeds the proportion of the population in those areas, especially when race/ethnicity is considered. AIDS rates have increased in non-MSAs relative to large MSAs, yet do not indicate that the epidemic is increasing rapidly in rural areas. Fewer AIDS cases are reported from smaller communities, yet require medical and social services that may burden the rural health care system.

Comparison of sexual behaviors, unprotected sex, and substance use between two independent cohorts of gay and bisexual men

OBJECTIVE

To compare demographic characteristics, sexual practices, unprotected receptive and insertive anal intercourse, substance use and rates of HIV-1 seroconversion between two prospective cohorts of HIV-negative men who have sex with men.

DESIGN

Comparative analysis of two independent cohorts.

METHODS

Between May 1995 and April 1996, 235 HIV-negative Vanguard Project (VP) participants were enrolled and between January and December 1985, 263 HIV-negative participants in the Vancouver Lymphadenopathy AIDS Study (VLAS) completed a follow-up visit. The VP participants were compared with VLAS participants with respect to self-reported demographic variables, sexual behaviors, unprotected sex, substance use and rates of HIV-1 seroconversion during follow-up.

RESULTS

In comparison with the VLAS participants the VP participants were younger (median age, 26 versus 34 years; P< 0.001), more likely to be non-Caucasian (75 versus 97%; P< 0.001), and were less likely to have attended university/college (35 versus 46%; P = 0.014). The VP participants reported a higher mean number of male sex partners in the previous year (15 versus 12; P= 0.026) and a higher mean number of regular partners (1.7 versus 0.6; P < 0.001). The VP participants were more likely to report engaging in receptive (92 versus 60%; P< 0.001) and insertive (90 versus 69%; P < 0.001) anal intercourse with regular partners and receptive anal intercourse with casual partners (62 versus 38%; P< 0.001). The VLAS participants were more likely to report never using condoms during insertive and receptive anal intercourse with both regular and casual partners. The VP participants were less likely to report using nitrite inhalants (34 versus 43%; P= 0.033), but more likely to report the use of cocaine (30 versus 8%; P< 0.001), LSD (21 versus 3%; P < 0.001), amphetamine (11 versus 1%; P< 0.001), heroin (3 versus 0%; P= 0.010) and methyldiamphetamine (17 versus 10%; P= 0.034). The VLAS participants were nine times more likely to report high-risk sexual behavior, after controlling for differences in age, ethnicity, substance use, and method of recruitment between cohort members. After adjustment for differences in demographics, sexual behaviors, and level of substance use, the risk ratio for seroconversion among VLAS participants remained significantly elevated compared with VP participants.

CONCLUSION

These data provide evidence that men who have sex with men who were enrolled in the VP were more sexually active than their VLAS counterparts were 10 years ago as measured by self-reported numbers of regular and casual partners and frequency of anal intercourse with these partners. However, condom use appears to be significantly higher among VP participants, which has contributed to a lower rate of HIV-1 infection.

AIDS e pauperização: principais conceitos e evidências empíricas

O artigo discute as estratégias metodológicas que vêm sendo usadas na análise das inter-relações entre a vulnerabilidade ao HIV/AIDS e as desigualdades sociais, o preconceito e a marginalização, ressaltando-se as dificuldades metodológicas e as estratégias alternativas de investigação encontradas. Os principais achados da literatura internacional e brasileira foram revistos, enfatizando-se os temas: dimensões econômicas e macropolíticas da difusão do HIV/ AIDS; papel do consumo e da política de drogas; desigualdade e preconceito de gênero; desigualdade e preconceito racial/origem étnica; interação com as demais infecções sexualmente transmissíveis e sua relação com a pobreza; padrões de assistência à saúde e HIV/AIDS, em especial, acesso a anti-retrovirais; e violação dos direitos humanos. Apesar da restrita produção acadêmica brasileira e dos dilemas metodológicos envolvidos no exame das inter-relações entre variáveis psicossociais, culturais, sócio-políticas e vulnerabilidade ao HIV/AIDS, tais temas devem ser investigados em detalhe - considerando especificidades sociais e culturais do Brasil - e beneficiados pelas novas estratégias de pesquisa.

High-risk sexual behavior in Los Angeles: who receives testing for HIV?

No recent population-based data on HIV testing in people with high-risk sexual behavior are available. We sought predictors of testing using data from the 1997 Los Angeles County Health Survey, a random-digit telephone survey of 8004 county households. An estimated 2.3 million (35.5%) adults were tested for HIV in the past 2 years and approximately 370,000 (5.6%) engaged in high-risk sexual behavior (defined as having > or =2 partners in the past 12 months and not always using condoms). Among high-risk persons, an estimated 46% of heterosexual men, 56% of heterosexual women, and 72% of men who had sex with men (MSM) were tested for HIV. In a multivariable model of high-risk people, both heterosexual men (odds ratio [OR], 0.31; 95% confidence interval [CI], 0.16-0.61) and women (OR, 0.41; 95% CI, 0.19-0.87) had significantly lower proportions of testing than MSM. Although African Americans and Hispanics had significantly higher testing proportions than whites overall among all county residents, those reporting high-risk sexual behavior did not test at higher proportions. We conclude that the proportion of adults with high-risk sexual behavior tested for HIV is higher than almost a decade ago. However, testing among this group remains suboptimal. Future public health campaigns should intensify efforts to encourage HIV testing among this population.

Use of protease inhibitors among persons with AIDS in Los Angeles County

We evaluated the access to, and the factors associated with, protease inhibitor use among persons with AIDS in Los Angeles County. A population-based sample of adult persons with AIDS is routinely interviewed in Los Angeles County and includes a 30% random sample of men who have sex with men and all other persons reported with AIDS. Since May of 1996, all participants were asked if their physician had ever prescribed a protease inhibitor for their use. The possible association between protease inhibitor use and sociodemographic, temporal and health care factors was assessed for the 12-month period May 1996 through April 1997. Logistic regression was employed for multivariate analysis. Over the 12-month study period, 61.7% (209/339) persons interviewed reported that their physician had prescribed a protease inhibitor as part of their therapy. In bivariate analysis, treatment with protease inhibitor use was more common for whites (71.4%) and US-born Latinos (68.2%) than blacks (53.4%) and foreign-born Latinos (56.6%), among person of higher income (71.2%) than lower (< $10,000) income (50.3%), in those who reported having insurance (66.7%) than those uninsured (47%) and among persons receiving care at private clinics (86.4%) than at HMOs (63.4%) or public clinics (55.2%). An increasing trend of protease inhibitor use with higher educational level and declining CD4+ count was observed. A temporal increase was noted and this trend was most pronounced for persons receiving care at public clinics. In multivariate analysis, persons receiving care at private facilities (adjusted OR = 2.9, 95% CI 1.0, 8.2) and those with higher incomes (adjusted OR = 2.5, 95% CI 1.5, 4.3), were more likely to report that their physician had prescribed a protease inhibitor. The effect of facility type was modified by time. During the first six months of the study period (May 1996-October 1996) persons with AIDS receiving care at public facilities and HMO sites were substantially less likely to report having been offered a protease inhibitor (adjusted OR = 0.13, 95% CI 0.03, 0.58 and adjusted OR = 0.23, 95% CI 0.05, 1.2, respectively). However, no significant facility-specific differences were observed over the last six-month period (November 1997-April 1997) evaluated. Our findings suggest that substantial differences exist in the prescribing and use of protease inhibitors among persons with AIDS in Los Angeles County. Several factors, including facility of HIV care, calendar time, income, education level and level of immunosuppression were independently associated with protease inhibitor use and suggest the existence of important barriers to access. Efforts should be made to identify and remove barriers that will ensure the widest possible access to protease inhibitors for patients with a clinical indication for their use.

Model for using hip-hop music for small group HIV/AIDS prevention counseling with African American adolescents and young adults

Currently little attention has been directed, with the exception of peer education efforts, to constructively develop new and innovative ways to promote HIV/AIDS primary prevention among African American (AA) adolescents and young adults. With this in mind, the aim of this conceptual effort is to present a HIV/AIDS preventive counseling protocol developed for use with AA young adults that makes use of hip-hop music, a form of music popularized by young AAs. The author contend that an increased understanding of the relationships that many AA young adults have with hip-hop music may be used by disease prevention personnel to educate these populations about protective factors for HIV. Making use of hip-hop music is one strategy for integrating counseling in prevention and health maintenance. The overall implications of using hip-hop music in health promotion are unlimited. First, this method makes use of cultural relevant materials to address the educational and health needs of the target community. Second, it is grounded in an approach that serves to stimulate cooperative learning based on peer developed content. Moreover, the use of this medium can be applied to other health promotion activities such as violence/harm reduction and substance abuse prevention, upon reviews of songs for appropriate content. The authors contend that such an approach holds heuristic value in dealing with HIV/AIDS prevention among AA young adults. Additional testing of the intervention is warranted in the refinement of this innovative intervention.

Determinants of sexual risk-taking among young HIV-negative gay and bisexual men

Data from a cohort of young HIV-negative gay and bisexual men were analyzed to identify determinants of sexual risk-taking at baseline. Gay/bisexual men aged between 18 and 30 completed a self-administered questionnaire including demographics, depression, social support, substance use, and consensual versus nonconsensual sex. Risk-takers were defined as those who had unprotected anal sex with casual male sex partners in the previous year; non-risk-takers were defined as those who reported consistent condom use during anal sex with all male partners in the previous year. Logistic regression was used to identify independent predictors of sexual risk-taking. Of 439 men studied, risk-takers had less education, a higher depression score, less social support, and were more likely to report nonconsensual sex and recreational drug use relative to non-risk-takers. Independent predictors of sexual risk-taking were low education, nitrite use, low social support (adjusted odds ratio [AOR]=1.65; 95% CI, 1.04-2.59), and nonconsensual sex experienced as a youth or adult (AOR=1.85; 95% CI, 1.15-2.96). Young gay/bisexual men reporting nonconsensual sex, low social support, or nitrite use were significantly more likely to have recently had unprotected anal sex with casual partners. HIV prevention programs aimed at young gay/bisexual men should include sexual abuse counselling and foster community norms supporting safer sex practices.

Behavioral factors affecting HIV prevention for adolescent and young adult IDUs

Epidemiological and sociobehavioral data regarding HIV-related risk and injection drug use among adolescents and young adults are examined to provide insight and assistance to nurses delivering preventive intervention and community and clinical care. The increase in HIV/AIDS cases among injection drug users (IDUs), adolescents, and African Americans strongly suggests that clinical care providers acquire a better understanding of the sociocultural and behavioral context within which health care is provided. Transition into injection drug use, high-risk injecting and sexual behaviors, sociodemographic differences, and the importance of social networks are discussed. Nurses are encouraged to provide health promotion, disease prevention messages, and health care to IDUs in small nontraditional clinical settings and to seek out the assistance of the IDUs' social network to increase adherence and compliance to complex prevention and therapeutic efforts.

Risk factors for human immunodeficiency virus infection and unprotected anal intercourse among young men who have sex with men

BACKGROUND AND OBJECTIVES

Few studies concerning human immunodeficiency virus (HIV) and its risk behaviors have been conducted among young men who have sex with men (YMSM). These are important because YMSM will have profound influence on the HIV/acquired immunodeficiency syndrome epidemic.

GOALS

To estimate the prevalence of and risk factors associated with HIV infection and recent unprotected anal intercourse (UAI) among YMSM in California.

METHODS

Between March and October, 1994, 836 men, 17 to 25 years of age, were surveyed at four California sites. The survey consisted of an interview from a standardized questionnaire and a blood draw for HIV antibody testing.

RESULTS

Almost 9.0% tested positive for HIV antibodies, whereas about 36.0% reported recent UAI. Several factors were associated both univariately and multivariately with HIV infection, as well as for recent UAI.

CONCLUSIONS

Young men who have sex with men in California continue to engage in behaviors risky for HIV infection. Efforts helping YMSM reduce them should target subgroups having a high HIV seroprevalence or recent UAI prevalence.

AIDS epidemic in San Francisco among men who report sex with men: successes and challenges of HIV prevention

San Francisco's gay male community has been hit harder by the HIV/AIDS epidemic than any other community in the world. By 1995, 20,530 of the estimated 58,000 gay men had been diagnosed with AIDS. However, the epidemic has also been more effectively contained within San Francisco than anywhere else, as evidenced by rapidly dropping AIDS incidence and mortality rates. This article reviews the epidemiology of HIV/AIDS among men who report sex with men (MSM) in San Francisco and the successful prevention efforts in this community. Also cited are areas in which the San Francisco prevention model has been less effective, in particular young MSM and gay men of color. San Francisco's experience yields many lessons about the successes and challenges of HIV prevention. Although community mobilization has been effective in reducing infection rates, innovative techniques to address the special needs of young MSM and to prevent the return to unsafe sex among all MSM are needed.