The accuracy of anal self- and companion exams among sexual minority men and transgender women: a prospective analysis

Background

Squamous cell carcinoma of the anus (SCCA) annual incidence among sexual minority men with and without HIV is 85/100,000 and 19/100,000 persons, respectively, which is significantly higher than the overall incidence (2/100,000). Incidence may also be higher in transgender women. Since SCCA tumours average ≥30 mm at diagnosis, we assessed the accuracy of individuals to self-detect smaller anal abnormalities.

Methods

Using convenience sampling, the study enrolled sexual minority men and transgender women, aged 25-81 years, in Chicago, Illinois and Houston, Texas, USA, during 2020-2022. Individuals were taught the anal self-examination and anal companion examination (ASE/ACE). Then, a clinician performed a digital anal rectal examination (DARE) before participants conducted the ASE or ACE. The sensitivity, specificity and concordance of the ASE/ACE to detect an abnormality were measured along with factors associated with ASE/ACE and DARE concordance.

Findings

Among 714 enrolled individuals, the median age was 40 years (interquartile range, 32-54), 36.8% (259/703) were living with HIV, and 47.0% (334/710), 23.4% (166/710), and 23.0% (163/710) were non-Hispanic white, non-Hispanic Black, and Hispanic, respectively. A total of 94.1% (671/713) identified as cisgendered men, and 5.9% (42/713) as gender minorities. A total of 658 participants completed an ASE and 28 couples (56 partners) completed an ACE. Clinicians detected abnormalities in 34.3% (245/714) of individuals. The abnormalities were a median of 3 mm in diameter. Sensitivity and specificity of the ASE/ACE was 59.6% (95% CI 53.5-65.7%) and 80.2% (95% CI 76.6-83.8%), respectively. Overall concordance was 0.73 (95% CI 0.70-0.76) between ASE/ACE and DARE and increased with increasing anal canal lesion size (p = 0.02). Concordance was lower when participants were older and received ASE/ACE training from a lay person rather than a clinician.

Interpretation

Sexual minority men/transgender women may self-detect SCCA when malignant lesions are much smaller than the current mean dimension at presentation of ≥30 mm.

Funding

National Cancer Institute.

Genome-wide association study identifies high-impact susceptibility loci for HCC in North America

BACKGROUND AND AIMS

Despite the substantial impact of environmental factors, individuals with a family history of liver cancer have an increased risk for HCC. However, genetic factors have not been studied systematically by genome-wide approaches in large numbers of individuals from European descent populations (EDP).

APPROACH AND RESULTS

We conducted a 2-stage genome-wide association study (GWAS) on HCC not affected by HBV infections. A total of 1872 HCC cases and 2907 controls were included in the discovery stage, and 1200 HCC cases and 1832 controls in the validation. We analyzed the discovery and validation samples separately and then conducted a meta-analysis. All analyses were conducted in the presence and absence of HCV. The liability-scale heritability was 24.4% for overall HCC. Five regions with significant ORs (95% CI) were identified for nonviral HCC: 3p22.1, MOBP , rs9842969, (0.51, [0.40-0.65]); 5p15.33, TERT , rs2242652, (0.70, (0.62-0.79]); 19q13.11, TM6SF2 , rs58542926, (1.49, [1.29-1.72]); 19p13.11 MAU2 , rs58489806, (1.53, (1.33-1.75]); and 22q13.31, PNPLA3 , rs738409, (1.66, [1.51-1.83]). One region was identified for HCV-induced HCC: 6p21.31, human leukocyte antigen DQ beta 1, rs9275224, (0.79, [0.74-0.84]). A combination of homozygous variants of PNPLA3 and TERT showing a 6.5-fold higher risk for nonviral-related HCC compared to individuals lacking these genotypes. This observation suggests that gene-gene interactions may identify individuals at elevated risk for developing HCC.

CONCLUSIONS

Our GWAS highlights novel genetic susceptibility of nonviral HCC among European descent populations from North America with substantial heritability. Selected genetic influences were observed for HCV-positive HCC. Our findings indicate the importance of genetic susceptibility to HCC development.

The accuracy of anal self- and companion exams among sexual minority men and transgender women: The Prevent Anal Cancer Palpation Study

Background

Squamous cell carcinoma of the anus (SCCA) annual incidence among sexual minority men (SMM) with and without HIV is 85/100,000 and 19/100,000 persons, respectively, which is significantly higher than the overall incidence (2/100,000). Since SCCA tumours average ≥30 mm at diagnosis, we assessed the accuracy of individuals to self-detect anal abnormalities.

Methods

The study enrolled 714 SMM and transgender women (SMM/TW), aged 25 to 81 years, in Chicago, Illinois and Houston, Texas during 2020-2022. Individuals were taught the anal self- and companion examinations (ASE/ACE). Then, a clinician performed a digital anal rectal examination (DARE) before participants conducted the ASE or ACE. Accuracy was measured along with factors associated with ASE/ACE and DARE concordance.

Findings

The median age was 40 years (interquartile range, 32-54), 36.8% were living with HIV, and 47.0%, 23.4%, and 23.0% were non-Hispanic white, non-Hispanic Black, and Hispanic. Clinicians detected 245 individuals with abnormalities (median diameter 3 mm). Sensitivity and specificity of the ASE/ACE was 59.6% (95%CI 53.5-65.7%) and 80.2% (95%CI 76.6-83.8%), respectively. Overall concordance was 0.73 (95% CI 0.70-0.76) between ASE/ACE and DARE and increased with increasing anal canal lesion size (p=0.02). However, concordance was lower for participants aged ≥55 years (compared to 25-34 years) and when the ASE/ACE trainer was a lay person rather than a clinician.

Interpretation

SMM/TW who complete an ASE or ACE are likely to detect SCCA at an early stage when malignant lesions are much smaller than the current median dimension at presentation of ≥30 mm.

Funding

National Cancer Institute.

Research in context

Evidence before this study: While squamous cell carcinoma of the anus (SCCA) incidence is substantially elevated in people with HIV, there are currently no consensus recommendations on how to screen for it, nor is there widespread technological infrastructure for one prevailing method, high-resolution anoscopy. In the absence of screening programs, the size of SCCA tumours at diagnosis are > 30 mm. We searched PubMed for articles between January 1, 2000 and June 15, 2023 using the search terms 'anus neoplasm' and 'self-examination'. We found no studies assessing the accuracy of self-examinations to detect anal masses other than our prior feasibility study.Added value of this study: The primary goal of the Prevent Anal Cancer Palpation Study was to assess the accuracy of lay self-examinations and companion examinations to recognise abnormalities in the anal region. Clinicians conducted a digital anal rectal examination and recorded all lesions observed at the perianus or anal canal. The median size of lesions was 3 mm. Participants conducted lay examinations and these results were judged against a clinician's examination. The sensitivity and specificity of the lay examinations, for any lesion at the anal canal or perianal region was 59.6% and 80.1%, respectively. As lesions increased in size, concordance increased between clinician's exam and the lay exam.Implications of all the available evidence: It is now known that high-resolution anoscopy can reduce the risk for SCCA but the infrastructure using this technology is very limited in high-resource settings and almost non-existent in low resource settings, especially where HIV prevalence is highest. The evidence suggests that self- and partner examination of the anal region is feasible and that lay persons can detect lesions that are much smaller than the prevailing size of SCCA tumours.

Prevalence, Incidence, and Predictors of Kaposi Sarcoma-associated Herpesvirus Infection Among Young Men Who Have Sex with Men in the Southern United States

Kaposi Sarcoma (KS) continues to cause substantial morbidity and mortality in populations at risk in the southern US. Utilizing biospecimens from the Houston site of the Young Men's Affiliate Project, 351 men who have sex with men had blood tested for Kaposi Sarcoma-associated herpesvirus (KSHV) IgG. Measuring seroprevalence, seroconversion between timepoints, and demographic and clinical correlates, KSHV prevalence was 36.7% and incidence was 8.9 per 100 person-years, prevalence and incidence were higher among Black individuals, people living with HIV, and those with a history of syphilis. Further research on KSHV risk may improve health disparities in KS diagnosis and outcomes.

Bayesian regularization to predict neuropsychiatric adverse events in smoking cessation with pharmacotherapy

BACKGROUND

Research on risk factors for neuropsychiatric adverse events (NAEs) in smoking cessation with pharmacotherapy is scarce. We aimed to identify predictors and develop a prediction model for risk of NAEs in smoking cessation with medications using Bayesian regularization.

METHODS

Bayesian regularization was implemented by applying two shrinkage priors, Horseshoe and Laplace, to generalized linear mixed models on data from 1203 patients treated with nicotine patch, varenicline or placebo. Two predictor models were considered to separate summary scores and item scores in the psychosocial instruments. The summary score model had 19 predictors or 26 dummy variables and the item score model 51 predictors or 58 dummy variables. A total of 18 models were investigated.

RESULTS

An item score model with Horseshoe prior and 7 degrees of freedom was selected as the final model upon model comparison and assessment. At baseline, smokers reporting more abnormal dreams or nightmares had 16% greater odds of experiencing NAEs during treatment (regularized odds ratio (rOR) = 1.16, 95% credible interval (CrI) = 0.95 - 1.56, posterior probability P(rOR > 1) = 0.90) while those with more severe sleep problems had 9% greater odds (rOR = 1.09, 95% CrI = 0.95 - 1.37, P(rOR > 1) = 0.85). The prouder a person felt one week before baseline resulted in 13% smaller odds of having NAEs (rOR = 0.87, 95% CrI = 0.71 - 1.02, P(rOR < 1) = 0.94). Odds of NAEs were comparable across treatment groups. The final model did not perform well in the test set.

CONCLUSIONS

Worse sleep-related symptoms reported at baseline resulted in 85%-90% probability of being more likely to experience NAEs during smoking cessation with pharmacotherapy. Treatment for sleep disturbance should be incorporated in smoking cessation program for smokers with sleep disturbance at baseline. Bayesian regularization with Horseshoe prior permits including more predictors in a regression model when there is a low number of events per variable.

Are human papillomavirus knowledge and vaccine uptake associated with HIV status and social determinants of health in young sexual minority men?

This brief report examines the relationship, if any, between human immunodeficiency virus (HIV) status, and individual-level and socio-sexual partner-level factors of social determinants of health (SDOH) that are associated with human papillomavirus (HPV) knowledge and vaccine uptake in young sexual minority men (YSMM). We used data from 126 YSMM recruited by network-based sampling during 2015-2016 in Houston, Texas. Descriptive statistics and regression analyses were conducted to test the association between HIV status, SDOH, and HPV knowledge and vaccine uptake. Those living with HIV had lower odds of knowledge of HPV-associated anal cancer (OR: 0.43, 95% CI: 0.18-0.97) and knowledge of HPV spreading via sexual contact (OR: 0.11, 95% CI: 0.01-0.64), and higher odds of HPV vaccine uptake (OR: 2.90, 95% CI: 1.11-8.02). HPV knowledge and vaccine uptake in YSMM was not associated with partner's attributes or individuals' SDOH factors in our study yet was significantly associated with HIV status. Future interventions are needed to increase HPV knowledge among individuals living with HIV and vaccine uptake particularly among YSMM living without HIV that are not engaged in healthcare.

Social networks, high-risk anal HPV and coinfection with HIV in young sexual minority men

OBJECTIVES

Young sexual minority men (SMM) exhibit a high prevalence and incidence of high-risk genotypes of human papillomavirus (hrHPV) anal infections and a confluence of a high prevalence of HIV and rectal STIs. Social determinants of health (SDOHs) are linked to social network contexts that generate and maintain racial disparities in HIV and STIs. A network perspective was provided to advance our knowledge of drivers of genotype-specific hrHPV infection and coinfection with HIV. The study also examined whether socially connected men are infected with the same high-risk HPV genotypes and, if so, whether this tendency is conditioned on coinfection with HIV.

METHODS

Our sample included 136 young SMM of predominantly black race and their network members of other races and ethnicities, aged 18-29 years, who resided in Houston, Texas, USA. These participants were recruited during 2014-2016 at the baseline recruitment period by network-based peer referral, where anal exfoliated cells and named social and sexual partners were collected. Exponential random graph models were estimated to assess similarity in genotype-specific hrHPV anal infection in social connections and coinfection with HIV in consideration of the effects of similarity in sociodemographic, sexual behavioural characteristics, SDOHs and syphilis infection.

RESULTS

Pairs of men socially connected to each other tend to be infected with the same hrHPV genotypes of HPV-16, HPV-45 and HPV-51 or HPV-16 and/or HPV-18. The tendency of social connections between pairs of men who were infected with either HPV-16 or HPV-18 were conditioned on HIV infection.

CONCLUSIONS

Networked patterns of hrHPV infection could be amenable to network-based HPV prevention interventions that engage young SMM of predominantly racial minority groups who are out of HIV care and vulnerable to high-risk HPV acquisition.

Integrated molecular and affiliation network analysis: Core-periphery social clustering is associated with HIV transmission patterns

This study investigates the two-mode core-periphery structures of venue affiliation networks of younger Black men who have sex with men (YBMSM). We examined the association between these structures and HIV phylogenetic clusters, defined as members who share highly similar HIV strains that are regarded as a proxy for sexual affiliation networks. Using data from 114 YBMSM who are living with HIV in two large U.S. cities, we found that HIV phylogenetic clustering patterns were associated with social clustering patterns whose members share affiliation with core venues that overlap with those of YBMSM. Distinct HIV transmission patterns were found in each city, a finding that can help to inform tailored venue-based and network intervention strategies.

Racial/ethnic differences in health-related quality of life among female breast cancer survivors: cross-sectional findings from the Medical Expenditure Panel Survey

OBJECTIVES

Breast cancer survivors have reported worse health-related quality of life (HRQoL) outcomes on some subscales when compared with members of the general population. However, the increased attention to breast cancer survivorship should have improved the HRQoL of these survivors. Our aim was to examine whether physical and mental component scores (PCS-12 and MCS-12) using the Short Form (SF-12) questionnaire were different for racial/ethnic minorities, specifically for Black and Hispanic women relative to White women. Furthermore, we stratified the data by age group to evaluate these racial/ethnic differences in HRQoL of breast cancer survivors.

STUDY DESIGN

Cross-sectional study.

METHODS

Pooled cross-sectional analyses using data from the Medical Expenditure Panel Survey between 2008 and 2016 were conducted. Pooled ordinary least squares (OLS) regression was used to examine the racial/ethnic differences in PCS-12 and MCS-12 scores of breast cancer survivors. Furthermore, stratified analyses by age group were conducted to evaluate racial/ethnic differences in HRQoL by the age of breast cancer survivors.

RESULTS

After adjusting for confounders, there was no association between race/ethnicity and PCS-12 scores. However, Hispanic breast cancer survivors had statistically significantly lower MCS-12 scores (by 1.9 points [95% confidence interval {CI}: -3.53 to -0.37]) when compared with White breast cancer survivors. For PCS-12, after stratifying by age, the adjusted analyses showed no significant differences in PCS-12 scores when White female breast cancer survivors were compared with the other racial/ethnic categories. On the other hand, Black female survivors aged <50 years had 4.3 points (95% CI: 0.46-8.13) higher MCS-12 scores when compared with their White counterparts, while Hispanic breast cancer survivors aged <50 years had 3.1 points (95% CI: -0.40-6.69) higher MCS-12 scores relative to White women. Furthermore, among female breast cancer survivors aged ≥50 years, Hispanic women had 3.2 points (95% CI: -4.98 to -1.40) lower MCS-12 scores than White women.

CONCLUSION

Our study generated findings showing the racial/ethnic differences in HRQoL of breast cancer survivors and presented results stratified by age group. These findings provide the much-needed rationale for targeted and racial/ethnic-specific HRQoL improvement strategies among breast cancer survivors.

Methodological synthesis of Bayesian phylodynamics, HIV-TRACE, and GEE: HIV-1 transmission epidemiology in a racially/ethnically diverse Southern U.S. context

This study introduces an innovative methodological approach to identify potential drivers of structuring HIV-1 transmission clustering patterns between different subpopulations in the culturally and racially/ethnically diverse context of Houston, TX, the largest city in the Southern United States. Using 6332 HIV-1 pol sequences from persons newly diagnosed with HIV during the period 2010–2018, we reconstructed HIV-1 transmission clusters, using the HIV-TRAnsmission Cluster Engine (HIV-TRACE); inferred demographic and risk parameters on HIV-1 transmission dynamics by jointly estimating viral transmission rates across racial/ethnic, age, and transmission risk groups; and modeled the degree of network connectivity by using generalized estimating equations (GEE). Our results indicate that Hispanics/Latinos are most vulnerable to the structure of transmission clusters and serve as a bridge population, acting as recipients of transmissions from Whites (3.0 state changes/year) and from Blacks (2.6 state changes/year) as well as sources of transmissions to Whites (1.8 state changes/year) and to Blacks (1.2 state changes/year). There were high rates of transmission and high network connectivity between younger and older Hispanics/Latinos as well as between younger and older Blacks. Prevention and intervention efforts are needed for transmission clusters that involve younger racial/ethnic minorities, in particular Hispanic/Latino youth, to reduce onward transmission of HIV in Houston.

Factors associated with self-reported anal cancer screening history in men who have sex with men

Background Men who have sex with men (MSM) are at greater risk of developing anal cancer caused by human papillomavirus (HPV) than the rest of the general population. Currently, there are no formal national guidelines in the US advising men how and when to get anal cancer screening. We sought to assess differences in demographics, familiarity and anxiety about anal cancer among men who report having had anal cancer screening (i.e. anal cytology and/or a digital anorectal examination (DARE)).

METHODS

MSM were recruited to participate in a study to assess the feasibility of teaching self and partner anal examinations as a means of screening for anal cancer. Data for this secondary analysis were obtained using a written pre-test and a computer-assisted self-interview. Factors associated with screening were assessed with multivariable logistic regression to allow calculation of adjusted odds ratios (aORs).

RESULTS

Of the 197 participants with data, 145 (73.6%) reported having had anal cancer screening (either anal cytology, DARE or both) during their lifetime. Men who were younger, Black and HIV-negative were associated with decreased odds of reporting any type of anal cancer screening. For example, compared with White men, Black men were 80% less likely to report screening (aOR 0.2; 95% confidence interval (CI) 0.1-0.5). Self-perception of anal cancer knowledge was not associated with screening in multivariable analysis (aOR 1.6; 95% CI 0.6-3.9).

CONCLUSIONS

Age, race and HIV status were independently associated with a history of anal cancer screening.

Prevalence of and Risk Factors for Anal Human Papillomavirus Infection in a Sample of Young, Predominantly Black Men Who Have Sex With Men, Houston, Texas

Background

Young men who have sex with men (MSM) are at increased risk for human papillomavirus (HPV)-associated disease as a result of HPV infection. Our objective was to characterize the prevalence of high-risk anal HPV infection and factors associated with prevalence in a group of young, primarily black MSM in Houston, Texas.

Methods

MSM aged 18-29 years were recruited using a respondent-driven sampling method to study HIV and sexually transmitted disease transmission and risk. All engaged in peer-recruitment chains and self-collected anal exfoliated cells. Prevalence ratios assessed factors associated with high-risk HPV and HPV types in the 9-valent vaccine.

Results

Black race was reported by 87% of men. Slightly over one half (53%) were human immunodeficiency virus (HIV) positive. Approximately 75% of men had at least 1 high-risk HPV type, and 39% of HIV-positive men harbored HPV-16. Analysis that controlled for potential confounders revealed that only HIV infection was associated with high-risk HPV infection.

Conclusion

Black MSM would benefit from increased HPV vaccination efforts, owing to high rates of HPV infection, increased HPV disease, and low vaccination series completion rates in this population.

Acquisition, Persistence, and Clearance of Human Papillomavirus Infection Among Male Virgins Residing in Brazil, Mexico, and the United States

Background

Little is known about the natural history of human papillomavirus (HPV) infection in male virgins. This study estimated the incidence and clearance of genital HPV infection and the factors associated with these measures among men who denied at baseline ever having penetrative sex.

Methods

A cohort of 4123 men residing in Brazil, Mexico, and the United States were followed every 6 months for up to 10 visits. Genital exfoliated cells were collected and genotyped for 36 HPV types. Eighty-seven men were classified as virgins and included for analysis. Cox proportional hazards models identified factors associated with the incidence and clearance of genital HPV infection.

Results

The incidence rates for any HPV infection among virgins who did and those who did not initiate sex during follow-up were 26.2 and 14.6 cases/1000 person-months, respectively. After penetrative sex initiation, 45.5% of men acquired HPV within 24 months. Younger age, current smoking, no recent female sex partners, and prevalent HPV infection were associated with high-risk HPV clearance.

Conclusion

Virgins who did not initiate sex during follow-up still acquired HPV infection, possibly through nonpenetrative sexual contact. Further prospective cohort studies are needed to better understand factors associated with HPV acquisition and clearance in male virgins and recent nonvirgins.

The effect of sustained virological response on the risk of extrahepatic manifestations of hepatitis C virus infection

BACKGROUND AND AIM

Chronic HCV infection is associated with several extrahepatic manifestations (EHMs). Data on the effect of sustained virological response (SVR) on the risk of EHMs are limited.

METHODS

We conducted a retrospective cohort study using data of patients from the US Veterans Affairs HCV Clinical Case Registry who had a positive HCV RNA test (10/1999-08/2009). Patients receiving interferon-based antiviral therapy (AVT) were identified. SVR was defined as negative HCV RNA at least 12 weeks after end of AVT. Risks of eight incident EHMs were evaluated in Cox regression models.

RESULTS

Of the 160 875 HCV-infected veterans, 31 143 (19.4%) received AVT, of whom 10 575 (33.9%) experienced SVR. EHM risk was reduced in the SVR group compared with untreated patients for mixed cryoglobulinaemia (adjusted HR (aHR)=0.61; 95% CI 0.39 to 0.94), glomerulonephritis (aHR=0.62; 95% CI 0.48 to 0.79), porphyria cutanea tarda (PCT) (aHR=0.41; 95% CI 0.20 to 0.83), non-Hodgkin's lymphoma (NHL) (aHR=0.64; 95% CI 0.43 to 0.95), diabetes (aHR=0.82; 95% CI 0.76 to 0.88) and stroke (aHR=0.84; 95% CI 0.74 to 0.94), but not for lichen planus (aHR=1.11; 95% CI 0.78 to 1.56) or coronary heart disease (aHR=1.12; 95% CI 0.81 to 1.56). Risk reductions were also observed when patients with SVR were compared with treated patients without SVR for mixed cryoglobulinaemia, glomerulonephritis, PCT and diabetes. Significant reductions in the magnitude of aHRs towards the null with increasing time to initiation of AVT after HCV diagnosis were observed for glomerulonephritis, NHL and stroke.

CONCLUSIONS

Risks of several EHMs of HCV infection are reduced after AVT with SVR. However, early initiation of AVT may be required to reduce the risk of glomerulonephritis, NHL and stroke.

Short Communication: Lack of Support for Socially Connected HIV-1 Transmission Among Young Adult Black Men Who Have Sex with Men

We explore the phylogenetic relationships among HIV sequences sampled from young adult black men who have sex with men (YAB-MSM), who are connected through peer referral/social ties and who attend common venues. Using 196 viral sequences sampled from the peripheral blood mononuclear cells of 10 individuals, our preliminary phylogenetic results indicate that these socially connected YAB-MSM are infected with distantly related viruses and provide no evidence for viral transmission between network members. Our results suggest that HIV-prevention strategies that target young adult MSM should extend beyond their network members and local community.

A phase II clinical study to assess the feasibility of self and partner anal examinations to detect anal canal abnormalities including anal cancer

OBJECTIVE

Anal cancer is a common cancer among men who have sex with men (MSM); however, there is no standard screening protocol for anal cancer. We conducted a phase II clinical trial to assess the feasibility of teaching MSM to recognise palpable masses in the anal canal which is a common sign of anal cancer in men.

METHODS

A clinician skilled in performing digital anorectal examinations (DARE) used a pelvic manikin to train 200 MSM, aged 27-78 years, how to do a self-anal examination (SAE) for singles or a partner anal examination (PAE) for couples. The clinician then performed a DARE without immediately disclosing results, after which the man or couple performed an SAE or PAE, respectively. Percentage agreement with the clinician DARE in addition to sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated for the SAE, PAE and overall.

RESULTS

Men had a median age of 52 years, 42.5% were African American and 60.5% were HIV positive. DARE detected abnormalities in 12 men while the men's SAE/PAEs detected 9 of these. A total of 93.0% of men classified the health of their anal canal correctly (95% CI 89.5 to 96.5). Overall percentage agreement, sensitivity and specificity were 93.0%, 75.0% and 94.2%, respectively, while PPV and NPV were 45.0% and 98.3%, respectively. The six men who detected the abnormality had nodules/masses ≥3 mm in size. More than half of men (60.5%) reported never checking their anus for an abnormality; however, after performing an SAE/PAE, 93.0% said they would repeat it in the future.

CONCLUSION

These results suggest that tumours of ≥3 mm may be detectable by self or partner palpation among MSM and encourage further investigation given literature suggesting a high cure rate for anal cancer tumours ≤10 mm.

A qualitative investigation among men who have sex with men on the acceptability of performing a self- or partner anal exam to screen for anal cancer

PURPOSE

Persistent infection with oncogenic human papillomavirus (HPV) is the primary cause of anal cancer, a disease that disproportionately affects men who have sex with men (MSM); however, there is no uniform screening protocol to detect anal cancer. This qualitative study explores whether a self-anal exam (SAE) or partner anal exam (PAE), that includes self-palpation or palpation of a partner's anal canal, is an acceptable and self-efficacious screening test, which will cue appropriate follow-up care in MSM.

METHODS

Twenty-four MSM living in Houston took part in four focus group sessions eliciting their responses to a study teaching them to perform an SAE or PAE (SAE/PAE). Participants were asked about the acceptability and feasibility of executing an SAE/PAE routinely. Thematic analysis of session transcripts was used to identify common patterns in participant responses.

RESULTS

Overall, participants expressed self-efficacy for performing an SAE/PAE and voiced a preference for being taught the procedure by a clinician. Participants agreed that they would consult with a clinician if they ever discovered an abnormality while performing an SAE/PAE. A lack of knowledge about anal cancer among MSM may present a barrier to adopting SAE/PAE. In discussing their experience of the exams, some participants suggested that it could become a routine practice for them.

CONCLUSIONS

Our findings suggest that SAE and PAE, as a screen for anal cancer, are acceptable and feasible to MSM. Future research should explore attitudes and beliefs of MSM, with the aim of improving anal cancer education and understanding of pathologic findings.

Hepatitis C virus infection and the risk of cancer among elderly US adults: A registry-based case-control study

BACKGROUND

Hepatitis C virus (HCV) infection causes hepatocellular carcinoma (HCC) and subtypes of non-Hodgkin lymphoma (NHL). Associations with other cancers are not established. The authors systematically assessed associations between HCV infection and cancers in the US elderly population.

METHODS

This was a registry-based case-control study using Surveillance, Epidemiology, and End Results (SEER)-Medicare data in US adults aged ≥66 years. Cases (n = 1,623,538) were patients who had first cancers identified in SEER registries (1993-2011). Controls (n = 200,000) were randomly selected, cancer-free individuals who were frequency-matched to cases on age, sex, race, and calendar year. Associations with HCV (documented by Medicare claims) were determined using logistic regression.

RESULTS

HCV prevalence was higher in cases than in controls (0.7% vs 0.5%). HCV was positively associated with cancers of the liver (adjusted odds ratio [aOR] = 31.5; 95% confidence interval [CI], 29.0-34.3), intrahepatic bile duct (aOR, 3.40; 95% CI, 2.52-4.58), extrahepatic bile duct (aOR, 1.90; 95% CI, 1.41-2.57), pancreas (aOR, 1.23; 95% CI, 1.09-1.40), and anus (aOR, 1.97; 95% CI, 1.42-2.73); nonmelanoma nonepithelial skin cancer (aOR, 1.53; 95% CI, 1.15-2.04); myelodysplastic syndrome (aOR, 1.56; 95% CI, 1.33-1.83); and diffuse large B-cell lymphoma (aOR, 1.57; 95% CI, 1.34-1.84). Specific skin cancers associated with HCV were Merkel cell carcinoma (aOR, 1.92; 95% CI, 1.30-2.85) and appendageal skin cancers (aOR, 2.02; 95% CI, 1.29-3.16). Inverse associations were observed with uterine cancer (aOR, 0.64; 95% CI, 0.51-0.80) and prostate cancer (aOR, 0.73; 95% CI, 0.66-0.82). Associations were maintained in sensitivity analyses conducted among individuals without documented alcohol abuse, cirrhosis, or hepatitis B or human immunodeficiency virus infections and after adjustment for socioeconomic status. Associations of HCV with other cancers were not observed.

CONCLUSIONS

HCV is associated with increased risk of cancers other than HCC in the US elderly population, notably bile duct cancers and diffuse large B-cell lymphoma. These results support a possible etiologic role for HCV in an expanded group of cancers. Cancer 2017;123:1202-1211. © 2016 American Cancer Society.

Human Papillomavirus Prevalence Among 88 Male Virgins Residing in Brazil, Mexico, and the United States

This study determined the prevalence and risk factors for genital human papillomavirus (HPV) detection among men who deny ever engaging in penetrative sex. A questionnaire was administered to 4123 men from a cohort study of HPV natural history. Genital exfoliated cells were collected and genotyped for 36 HPV types. Eighty-eight men were classified as virgins. Log-binomial regression models identified factors associated with genital HPV detection. The prevalence of any and high-risk HPV types among 88 male virgins was 25.0% and 18.2%, respectively. Age and smoking status were associated with HPV detection. Further studies are needed to better understand the risk for HPV infection among male virgins.

Women's communication self-efficacy and expectations of primary male partners' cooperation in sexually transmitted infection treatment in Ho Chi Minh City, Vietnam: a cross-sectional study

Background

Effective control of sexually transmitted infections (STIs) depends on affected patients notifying their sexual partners, and partners following through with screening and treatment. Our study assessed high-risk-STI women’s confidence in STI-diagnosis-related communications with their primary male partners in Ho Chi Minh City, Vietnam, and determined associated characteristics of the women and their partners.

Methods

We employed convenience and snowball sampling in a clinic-based setting to recruit 126 women from August to October 2013. All data were obtained from women’s self-report.

Results

The proportions of participants who were “slightly confident” or “very confident” that they could disclose their STI positivity to partners, ask partners to have an STI examination or treatment, and give partners bacterial-STI medications were 70.3 %, 62.1 %, and 69.0 %, respectively. The proportions who perceived that their partners would be “very likely” to have an STI examination and to take STI medications were 16.2 % and 38.8 %, respectively. Significantly lower self-efficacy was observed in women who had a lower education level, who had ever traded sex, or whose primary partners were not husbands or fiancés.

Conclusions

Our results suggest potential for piloting STI-partner-targeted interventions. To be effective, these programs should improve women’s self-efficacy and primary partners’ cooperation with screening and treatment.

Self-reported oral health, oral hygiene, and oral HPV infection in at-risk women in Ho Chi Minh City, Vietnam

OBJECTIVES

This study aimed to examine the relationships among self-reported oral health, oral hygiene practices, and oral human papillomavirus (HPV) infection in women at risk for sexually transmitted infections (STIs) in Ho Chi Minh City, Vietnam.

STUDY DESIGN

Convenience and referral sampling methods were used in a clinic-based setting to recruit 126 women aged 18-45 years between August and October 2013. Behavioral factors were self-reported. Oral-rinse samples were tested for HPV DNA of 2 low-risk and 13 high-risk genotypes.

RESULTS

A higher unadjusted prevalence of oral HPV infection was associated with poorer self-rated overall oral health (P = .001), reported oral lesions or problems in the past year (P = .001), and reported a tooth loss not because of injury (P = .001). Higher unadjusted prevalence of oral HPV infection was also associated with two measures of oral hygiene: lower frequencies of toothbrushing per day (P = .047) and gargling without toothbrushing (P = .037). After adjusting for other factors in multivariable logistic regression models, poorer self-rated overall oral health remained statistically associated with oral HPV infection (P = .042); yet the frequency of tooth-brushing per day did not (P = .704).

CONCLUSION

Results corroborate the association between self-reported poor oral health and oral HPV infection. The effect of oral hygiene on oral HPV infection remains inconclusive.

Long-term effectiveness of accelerated hepatitis B vaccination schedule in drug users

OBJECTIVES

We demonstrated the effectiveness of an accelerated hepatitis B vaccination schedule in drug users.

METHODS

We compared the long-term effectiveness of accelerated (0-1-2 months) and standard (0-1-6 months) hepatitis B vaccination schedules in preventing hepatitis B virus (HBV) infections and anti-hepatitis B (anti-HBs) antibody loss during 2-year follow-up in 707 drug users (HIV and HBV negative at enrollment and completed 3 vaccine doses) from February 2004 to October 2009.

RESULTS

Drug users in the accelerated schedule group had significantly lower HBV infection rates, but had a similar rate of anti-HBs antibody loss compared with the standard schedule group over 2 years of follow-up. No chronic HBV infections were observed. Hepatitis C positivity at enrollment and age younger than 40 years were independent risk factors for HBV infection and antibody loss, respectively.

CONCLUSIONS

An accelerated vaccination schedule was more preferable than a standard vaccination schedule in preventing HBV infections in drug users. To overcome the disadvantages of a standard vaccination schedule, an accelerated vaccination schedule should be considered in drug users with low adherence. Our study should be repeated in different cohorts to validate our findings and establish the role of an accelerated schedule in hepatitis B vaccination guidelines for drug users.

Risk factors for high-risk and multi-type Human Papillomavirus infections among women in Ho Chi Minh City, Vietnam: a cross-sectional study

Background

Concurrent infection with multiple types of Human Papillomavirus (HPV) is associated with an increased risk of cervical cancer; yet, little is known about risk factors for concurrent HPV infection in Vietnam. This study investigated the prevalence of and risk factors for high-risk-type HPV and multi-type HPV infections among women in Ho Chi Minh City, Vietnam.

Methods

Data were collected from a population-based survey of 1,550 women (mean age = 42.4; SD = 9.5), using a multi-stage sampling process. Socio-demographic and behavioral variables were obtained by self-report. HPV genotypes in cervical specimens were identified using PCR protocols.

Results

The prevalence of any high-risk HPV infection was 9.0%, and of multi-type HPV infection was 1.9%. In the HPV+ subsample, the percentage of high-risk HPV was 84% and of multi-type HPV was 20%. All multi-type HPV infections were high-risk-type. Lifetime smoking and older age of first sex were significantly associated with any high-risk and multi-type HPV infections. Regular condom use was inversely associated with high-risk and multi-type HPV infection.

Conclusions

Risk factors for high-risk and multi-type HPV infections were similar. Further research and intervention are needed to reduce HPV infections in order to prevent HPV-related cancers.

Perception of primary male sexual partners' characteristics and women's history of sexually transmissible infections in Ho Chi Minh City, Vietnam

Background Evidence regarding whether male partners' characteristics can influence women's likelihood of getting sexually transmissible infections (STIs) is insufficient and inconsistent. Our study examined associations between women's perception of primary male partners' demographic and behavioural characteristics and women's history of bacterial STI diagnoses among 126 women at risk for STIs in Ho Chi Minh City, Vietnam.

METHODS

All variables were obtained by women's self-report. Due to the excess zeroes of the number of bacterial STI diagnoses for women, we used Zero-Inflated Poisson regression to examine associations of interest.

RESULTS

Among women who had one lifetime male partner (n=49), the partner's number of female sexual partners [prevalence ratio (PR)=4.63, 95%CI=1.44-14.88] and number of STI diagnoses (PR=27.32, 95%CI=1.56-477.70) were associated with the woman's number of bacterial STI diagnoses, after adjusting for women's education level. For women who had >1 lifetime male partner (n=77), a greater number of women's bacterial STI diagnoses was also associated with their partners' STI history (PR=9.12, 95% CI=2.44-34.11).

CONCLUSIONS

An increased risk for STIs in women was associated with both individual characteristics and their primary male partner's behavioural risk factors. Therefore, primary male partners' risk factors should be included in STI risk assessments, treatment and interventions for women.

Knowledge, Attitude, and Practices Regarding Occupational HIV Exposure and Protection among Health Care Workers in China: Census Survey in a Rural Area

BACKGROUND

Health care workers (HCWs) seek, treat, and care for patients living with HIV/AIDS on a daily basis and thus face a significant risk to work-related infections. To assess the knowledge, attitude, and practices regarding occupational HIV exposure and protection among HCWs in low HIV prevalence areas of rural China.

METHODS

A cross-sectional questionnaire survey was carried out among all medical units in Pucheng County, Shaanxi, China.

RESULTS

Response rate of this study was 94%. The average overall knowledge score of HCWs was 10.9 of 21.0. Deficiencies in general, transmission, exposure, and protection knowledge were identified among HCWs at all levels. A high rate of occupational exposure (85%) and lack of universal precautions practice behavior were recorded. Significant predictors of universal precautions practice behavior were female sex, prior training, and greater knowledge about HIV/AIDS.

CONCLUSION

Health care workers at various levels have inadequate knowledge on HIV/AIDS and do not practice universal precautions. Nurses and medical technicians at the county level faced more occupation risk than other HCWs. The key of AIDS training for different levels of HCWs should be distinguished.

Association of internet use and depression among the spinal cord injury population

OBJECTIVE

To examine the relation between the frequency of Internet use and depression among people with spinal cord injury (SCI).

DESIGN

Cross-sectional survey.

SETTING

SCI Model Systems.

PARTICIPANTS

People with SCI (N=4618) who were interviewed between 2004 and 2010.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The frequency of Internet use and the severity of depressive symptoms were measured simultaneously by interview. Internet use was reported as daily, weekly, monthly, or none. The depressive symptoms were measured by the Patient Health Questionnaire-9 (PHQ-9), with 2 published criteria being used to screen for depressive disorder. The diagnostic method places more weight on nonsomatic items (ie, items 1, 2, and 9), and the cut-off method that determines depression by a (PHQ-9) score ≥10 places more weight on somatic factors. The average scores of somatic and nonsomatic items represented the severity of somatic and nonsomatic symptoms, respectively.

RESULTS

Our multivariate logistic regression model indicated that daily Internet users were less likely to have depressive symptoms (odds ratio=.77; 95% confidence interval, .64-.93), if the diagnostic method was used. The linear multivariate regression analysis indicated that daily and weekly Internet usage were associated with fewer nonsomatic symptoms; no significant association was observed between daily or weekly Internet usage and somatic symptoms.

CONCLUSIONS

People with SCI who used the Internet daily were less likely to have depressive symptoms.

The role of trust in delayed HIV diagnosis in a diverse, urban population

Delayed diagnosis of HIV infection is a common problem. We hypothesized that persons with less trust in physicians and in the healthcare system would be diagnosed with lower CD4 cell counts than persons with more trust because they would delay seeking healthcare. From January 2006 to October 2007, 171 newly diagnosed HIV-infected persons, not yet in HIV primary care, were recruited from HIV testing sites in Houston, Texas, that primarily serve the under- and un-insured. The participants completed instruments measuring trust in physicians and trust in the healthcare system. Initial CD4 cell counts were obtained from medical record review. Mean trust scores for participants with CD4 cell counts ≥200 cells/mm(3) were compared with scores from participants with CD4 cell counts <200 cells/mm(3). We found that 51% of the cohort was diagnosed with a CD4 cell count <200 cells/mm(3). Neither trust in physicians nor trust in the healthcare system was an independent predictor of delayed diagnosis of HIV infection. In multivariate analysis, men who have sex with men and injection drug users were more likely to have early HIV diagnosis. Race/ethnicity was the only variable statistically significantly predictive of trust in physicians and in the healthcare system. Hispanics had the highest trust scores, followed by Blacks and Whites. Low trust is likely not a barrier to timely diagnosis of HIV infection.

Differentially regulated gene expression associated with hepatitis C virus clearance

Human chronic hepatitis C virus (HCV) infections pose a significant public health threat, necessitating the development of novel treatments and vaccines. HCV infections range from spontaneous resolution to end-stage liver disease. Approximately 10-30% of HCV infections undergo spontaneous resolution independent of treatment by yet-to-be-defined mechanisms. These individuals test positive for anti-HCV antibodies in the absence of detectable viral serum RNA. To identify genes associated with HCV clearance, this study compared gene expression profiles between current drug users chronically infected with HCV and drug users who cleared their HCV infection. This analysis identified 91 differentially regulated (up- or downregulated by twofold or more) genes potentially associated with HCV clearance. The majority of genes identified were associated with immune function, with the remaining genes categorized either as cancer related or 'other'. Identification of factors and pathways that may influence virus clearance will be essential to the development of novel treatment strategies.

Demographics, socio-behavioral factors, and drug use patterns: what matters in spontaneous HCV clearance?

Hepatitis C virus (HCV), an emerging bloodborne pathogen, causes chronic liver disease frequently except in about 10-20% of infections which undergo spontaneous resolution. Investigating factors that influence viral clearance is essential to understand the natural history of this infection and establishing novel strategies for prevention and treatment. HCV clearance was estimated in a unique cohort of 1,260 HIV and HBV negative current drug users enrolled for a hepatitis B vaccination study. It was defined as the inability to detect viral RNA using a PCR method in presence of serum anti-HCV antibody EIA. Associated demographic and socio-behavioral factors including drug use patterns were identified from the enrolled subjects using multivariate regression analysis. 33.3% (420/1260) of drug users were found positive for anti-HCV antibodies and 14.8% (62/420) of these individuals achieved viral clearance (negative PCR test). Race or ethnicity of the participants was the only significant factor associated with HCV clearance. Hispanics (OR = 3.4, 95% CI: 1.3-8.5, P = 0.01) and Caucasians (OR = 3.1, 95% CI: 1.5-6.6, P = 0.003) had significantly higher odds of clearing the virus compared to African Americans when adjusted for age and gender. None of the socio-behavioral factors including alcohol intake and drug use patterns were significant determinants of HCV clearance. Racial or ethnic differences in HCV clearance were observed in this study suggesting an important role of host genetic susceptibility factors in determining the clinical course of this disease. Further research is needed to examine these genetic associations of host-virus relationships.

Latent tuberculosis infections in hard-to-reach drug using population-detection, prevention and control

Interferon-gamma release assays (IGRAs) need be evaluated for effectiveness as screening tests for tuberculosis (TB) infection in drug users. These tests have demonstrated improved sensitivity and specificity, but have not been studied in drug users. These one step blood tests are intended to replace the tuberculin skin test (TST), which is difficult to use and requires 48 hour follow-up, so they are expected to be particularly suitable for risk groups, like drug users, in whom follow-up is problematic. Drug users have traditionally been identified as being at increased risk for acquiring TB disease. The results of our pilot study using the TST and simpler and more sensitive interferon-gamma release assays showed that about 45% of current drug users in Houston tested have at least one test positive for latent tuberculosis infection (LTBI). These preliminary data suggest that there is an important reservoir of LTBI in drug using populations, and the risk of progression to active TB disease with other infections is great. However, LTBI in drug using populations has not been studied in depth and deserves further investigation. We need to evaluate the validity of IGRAs for detection of latent TB infection, the factors associated with LTBI, the incidence and risk for developing active TB disease in drug users and the effectiveness of early treatment of LTBI. We believe that using better tuberculosis screening tools will allow us to more accurately measure the prevalence of latent TB infection and incidence of active TB disease in drug using populations and develop more effective TB prevention and treatment interventions in the community.

Influence of trust on HIV diagnosis and care practices: a literature review

Delays in accessing HIV health care and failure to adhere to providers' advice are common. Patient trust is critical to an individual's willingness to seek care and follow the physician's advice. Conversely, patient distrust can diminish the patient's health status. The trust literature is reviewed in an attempt to determine its effect on HIV care. In the HIV literature reviewed, greater trust in health care providers was associated with improved accessing of and remaining in care. Interventions to enhance patient trust have been tested, with no changes in the levels of trust being found. Few studies were rigorous enough to assess causality or temporal relation. It is not clear whether there is a causal association between patient trust and HIV health care outcomes. As these relationships are better understood, interventions can be designed to increase health-promoting behaviors.

Accelerated hepatitis B vaccination schedule among drug users: a randomized controlled trial

BACKGROUND

Hepatitis B vaccine provides a model for improving uptake and completion of multidose vaccinations in the drug-using community.

METHODS

The Drugs, AIDS, STDs, and Hepatitis (DASH) project conducted a randomized controlled trial among not-in-treatment current drug users in 2 urban neighborhoods. Neighborhoods were cluster-randomized to receive a standard behavioral intervention (which provided information on human immunodeficiency virus [HIV]) or an enhanced behavioral intervention (designed to increase acceptance of or adherence to the hepatitis B vaccination protocol). Participants within clusters were randomized to a standard vaccination schedule (vaccines at 0, 1, and 6 months) or an accelerated vaccination schedule (vaccines at 0, 1, and 2 months). The outcomes were completion of the 3-dose vaccine and seroprotection against hepatitis B virus (HBV).

RESULTS

Of participants with negative screening results for HIV and HBV, 77% accepted hepatitis B vaccination, and 75% of vaccinees received all 3 doses. Injection drug users (IDUs) on the accelerated schedule were significantly more likely to receive 3 doses (76%) than those on the standard schedule (66%; P = .04), although for drug users as a whole the corresponding adherence rates were 77% and 73%, respectively. No difference in adherence was observed between the behavioral intervention groups. Predictors of adherence were older age, African American race, stable housing, and alcohol use. Cumulative HBV seroprotection (≥10 mIU/mL) was gained within 12 months by 65% of those completing the schedule. Seroprotection at 6 months was greater for those on the accelerated schedule.

CONCLUSION

The accelerated vaccination schedule improves hepatitis B vaccination adherence among IDUs.

Epidemiologic characterization of culture positive Mycobacterium tuberculosis patients by katG-gyrA principal genetic grouping

Molecular typing techniques make it possible to genetically characterize Mycobacterium tuberculosis isolates. Public health strategies to control the spread of tuberculosis are enhanced by the use of molecular data to study tuberculosis transmission dynamics within populations. This study compared epidemiological and clinical characteristics of three M. tuberculosis groups based on polymorphisms at katG codon 463 and gyrA codon 95 in 1893 culture-positive patients by a retrospective nested case-comparison design. Study participants, diagnosed from 1995 to 2001 in the Houston, Texas metropolitan area, were >/= 18 years old, 70% male, 66% U.S.-born, 40% Black, 29% Hispanic, 19% White, and 12% Asian/Pacific Islander. The prevalence of each principal genetic group (GG) was 30% (GG1), 52% (GG2), and 18% (GG3). Multiple logistic regression analysis showed that GG1 participants were more likely to be Asian, male, and have a history of homelessness, as compared with participants with either GG2 or GG3 isolates. GG2 participants were more likely to be Hispanic, have streptomycin-resistant isolates, and be infected with HIV than either GG1 or GG3 participants. GG3 participants were more likely to be Black or Hispanic, report illicit drug use, and live in a congregative facility at the time of diagnosis, than GG1 or GG2 participants. Ethnicity and sociodemographic findings were significant, prompting additional research into social networks, genetic susceptibility, immunology, and virulence factors.

Relationship of cosmetic procedures and drug use to hepatitis C and hepatitis B virus infections in a low-risk population

We conducted an anonymous cross-sectional seroprevalence study of a population with a low frequency of injection drug use to determine whether persons with a history of cosmetic procedures, such as tattooing and body piercing, or intranasal drug use were at increased risk for hepatitis C virus (HCV) or hepatitis B virus (HBV) infection. Students 18 years and older from eight college campuses in Houston, Texas, were invited to participate in the study. Of the 7,960 who completed a self-administered questionnaire and provided a blood sample, 5,282 U.S.- or Canadian-born participants were analyzed. Their median age was 21, 62% were female, 42% were white, 26% black, 22% Hispanic, and 10% Asian or other. Two percent reported injection drug use, 13.7% intranasal drug use, 21.2% body piercings, and 25.2% tattoos. The overall prevalence of HCV infection was 0.9% and of HBV infection was 5.2%. Higher HCV prevalence was independently associated with increasing age (odds ratio [OR] per year = 1.11; 95% confidence interval [CI] = 1.08-1.14), history of injection drug use (OR = 18.24; 95% CI = 7.74-42.92), blood transfusion before 1991 (OR = 3.21; 95% CI = 1.02-10.12), and incarceration (OR = 3.48; 95% CI = 1.45-8.37). Among 5,066 students who denied injecting drugs, HCV prevalence was 0.8% in those who reported intranasal drug use and 0.6% each in those who reported tattoos and those who reported body piercing. Increased HBV prevalence was associated with high-risk sexual behaviors and black or Asian race. In conclusion, there was no increased risk for HCV or HBV infection in low-risk adults based solely on history of cosmetic procedures or snorting drugs. However, proper infection control practices for cosmetic procedures should be followed, illegal drug use discouraged, and hepatitis B vaccination provided to adolescents and sexually active adults.

Hepatitis B revaccination in healthy non-responder Chinese children: Five-year follow-up of immune response and immunologic memory

To assess persistence of anti-HBs and immunologic memory of non-responders after revaccination, 40 healthy non-responder children were given a three-dose recombinant hepatitis B vaccine revaccination randomly by intramuscular (10 microg per dose) or intradermal (2 microg per dose) route and followed up to five years. All 17 intramuscular and 22 of 23 intradermal children developed a seroprotective antibody response (anti-HBs>or=10 mIU/mL) after revaccination. Children of intramuscular group had significantly higher seroprotection rates and anti-HBs geometric mean titers than the intradermal group. At year 5, 50% of children in intramuscular group, but only 18.2% of intradermal group still maintained seroprotection (P=0.075). By the end of follow-up, a booster dose (5 microg) was given to those who had lost seroprotection. All the eight intramuscular children developed an anamnestic response with increase of anti-HBs level by 215 times, but two of the 18 intradermal children failed to produce seroprotective level. Three-routine-dose intramuscular revaccination was significantly more effective than low-dose intradermal revaccination with the same number of injections. No child seroconverted to HBsAg, and 11 had transient infections indicated by seroconversion to anti-HBc. These results demonstrated that non-responders could benefit from three doses intramuscular revaccination not only in high proportion of anti-HBs conversion but also in long-term persistence of seroprotection, and more importantly in preservation of the immunologic memory years after loss of protective anti-HBs.

Risk factors for perinatal transmission of hepatitis C virus (HCV) and the natural history of HCV infection acquired in infancy

BACKGROUND

The goal of the present study was to assess risk factors for perinatal hepatitis C virus (HCV) transmission and the natural history of infection among HCV-infected infants.

METHODS

In a cohort study, 244 infants born to HCV-positive mothers were followed from birth until age > or =12 months. Maternal serum was collected at enrollment and delivery; infant serum was collected at birth and at 8 well-child visits. Testing included detection of antibody to HCV, detection of HCV RNA (qualitative and quantitative), and genotyping. HCV-infected infants were followed annually until age 5 years.

RESULTS

Overall, 9 of 190 (4.7% [95% confidence interval (CI), 2.3%-9.1%]) infants born to mothers who were HCV RNA positive at delivery became infected, compared with 0 of 54 infants born to HCV RNA-negative mothers (P=.10). Among HCV RNA-positive mothers, the rate of transmission was 3.8% (95% CI, 1.7%-8.1%) from the 182 who were human immunodeficiency virus (HIV) negative, compared with 25.0% (95% CI, 4.5%-64.4%) from the 8 who were HIV positive (P<.05). Three infected infants resolved their infection (i.e., became HCV RNA negative). In multivariate analysis restricted to HCV RNA-positive mothers, membrane rupture > or =6 h (odds ratio [OR], 9.3 [95% CI, 1.5-179.7]) and internal fetal monitoring (OR, 6.7 [95% CI, 1.1-35.9]) were associated with transmission of HCV to infants.

CONCLUSION

If duration of membrane rupture and internal fetal monitoring are confirmed to be associated with transmission, interventions may be possible to decrease the risk of transmission.

Increased plasma levels of angiogenin and the risk of bladder carcinoma: from initiation ot recurrence

BACKGROUND

Angiogenesis is a well known prerequisite for tumor growth and metastasis. It is believed that angiogenin initiates cell migration and aids cell proliferation. Based on this, the authors hypothesized that individuals who had increased plasma levels of angiogenin were at an elevated risk for carcinoma of the urinary bladder.

METHODS

In this ongoing case-control study, the authors used an enzyme-linked immunosorbent assay to compare plasma levels of angiogenin in 209 patients with bladder carcinoma and in 208 healthy control participants who were matched according to age (+/- 5 years), gender, and ethnicity.

RESULTS

The mean plasma angiogenin concentration was significantly higher in patients compared with controls (343.2 ng/mL vs. 308.0 ng/mL, respectively; P < 0.01). High plasma angiogenin levels were associated with a two-fold increased risk for bladder carcinoma. Moreover, in patients who had superficial bladder carcinoma, plasma angiogenin levels were significantly higher among those who had recurrent disease than in those who were without recurrence (P < 0.01). Similarly, patients who had superficial bladder carcinoma with higher angiogenin levels had a shorter recurrence-free survival than patients who had lower angiogenin levels (P < 0.01). Finally, elevated angiogenin levels were associated with an increased recurrence risk, with hazard ratio of 2.85.

CONCLUSIONS

The results of this study demonstrated that the plasma levels of angiogenin were significantly higher in patients who had bladder carcinoma compared with healthy control participants and in patients with superficial bladder carcinoma who had recurrent disease compared with patients who were without recurrence. Therefore, an elevated plasma level of angiogenin may serve as a novel predictor for the risk of bladder carcinoma.

The effect of HIV coinfection on the risk of cirrhosis and hepatocellular carcinoma in U.S. veterans with hepatitis C

OBJECTIVES

This study was conducted to determine whether HIV coinfection increases the risk of cirrhosis in HCV-infected patients in the HAART and pre-HAART eras. Further, the risk of hepatocellular carcinoma was also examined.

METHODS

This retrospective cohort study was conducted among HCV-infected veterans who were seen at one of the 172 Veterans Health Administration hospitals between October 1, 1991 and September 30, 2000. Patients with prerecorded advanced liver disease were excluded. Incidence rates, cumulative incidence, and Cox proportional hazard ratios were calculated.

RESULTS

There were 26,641 patients with HCV-only and 4,761 patients with HCV-HIV coinfection. The unadjusted incidence rate of cirrhosis was lower in patients with coinfection than HCV-only (p < 0.01). After controlling for demographics and confounders (including alcoholism and chronic hepatitis B), coinfection was not significantly associated with cirrhosis. However, there was an increased risk of cirrhosis in patients with coinfection compared to HCV-only during the pre-HAART era (before October 1, 1996) (hazard ratio = 1.48, 1.06-2.07, p= 0.02), but not among patients who entered the cohort during the HAART era. The unadjusted incidence rate of hepatocellular carcinoma in patients with coinfection and HCV-only was 1.3 and 2/1,000 person-years, respectively (p= 0.04). In the multivariate model, coinfection was not associated with hepatocellular carcinoma (hazard ratio = 0.84, p= 0.40).

CONCLUSIONS

Coinfection was a significant risk factor for cirrhosis only during the pre-HAART era and was not associated with hepatocellular carcinoma, irrespective of time period.

Epidemiology and molecular characterization of co-circulating influenza A/H3N2 virus variants in children: Houston, Texas, 1997-8

Co-circulating variants of influenza A/H3N2 viruses in children were studied in Houston, Texas between October 1997 and March 1998 to assess the effects of a new variant strain on the severity of clinical illness. Influenza A virus was isolated from the nasal wash or nasal aspirate specimens collected from children at two tertiary care hospitals, and 271 isolates were available for variant-specific subtyping using RT-PCR and restriction fragment length polymorphism (RFLP) analysis. We classified 124 (46%) influenza viruses as A/H3N2/Wuhan/359/95-like and 137 (50%) as A/H3N2/Sydney/05/97-like. Ten (4%) virus isolates could not be classified. Ill contacts in the household were reported more frequently in patients infected with A/Sydney-like viruses than in those infected with A/Wuhan-like viruses (85% vs. 71%, respectively, P=0.02). There were no differences in other demographic variables among children infected with these strains. This study found no increase in illness severity in children infected with a newly emerging strain.

Prevalence monitoring in syphilis surveillance: results from a multicenter research program

BACKGROUND

Syphilis seroprevalence data can be used as an independent measure of syphilis trends and to augment syphilis case report data for program planning. The prevalence of reactive syphilis serology in jails, delivery rooms, and drug treatment centers was examined from 1995 to 1999. Prevalence was evaluated by age and gender at each site and compared with county primary and secondary syphilis case rates. Annual prevalence of high titer-reactive serology in jails was compared with primary and secondary syphilis case rates.

GOAL

The goal was to examine trends in syphilis seroprevalence and to evaluate the relationship of trends in seroprevalence to reported cases.

STUDY DESIGN

This was a cross-sectional survey.

RESULTS

Prevalence of reactive serology and high titer-reactive serology was lowest among women in delivery rooms (2.9% and 0.4%, respectively) and highest among women in jails (11.1% and 4.1%, respectively), indicating substantial recently treated or active infection among women in jails. Trends in high titer-reactive serology were similar to primary and secondary syphilis case rates.

CONCLUSION

The prevalence of high titer-reactive serology can provide valuable information about community syphilis morbidity for use in prevention and control programs.

Risk factors for hepatocellular carcinoma: synergism of alcohol with viral hepatitis and diabetes mellitus

Risk factors associated with hepatocellular carcinoma (HCC) are well documented, but the synergisms between these risk factors are not well examined. We conducted a hospital-based, case-control study among 115 HCC patients and 230 non-liver cancer controls. Cases and controls were pathologically diagnosed at The University of Texas M. D. Anderson Cancer Center and were matched by 5-year age groups, sex, and year of diagnosis. Information on risk factors was collected by personal interview and medical records review. Blood samples were tested for the presence of antibodies to hepatitis C virus antigen (anti-HCV), hepatitis B surface antigen (HBsAg), and antibodies to hepatitis B core antigen (anti-HBc). Conditional logistic regression was used to determine odds ratios (ORs) by the maximum likelihood method. Multivariate ORs and 95% confidence intervals (CIs) were 15.3 (4.3-54.4), 12.6 (2.5-63.1), 4.5 (1.4-14.8), and 4.3 (1.9-9.9) for anti-HCV, HBsAg, heavy alcohol consumption (>/=80 mL ethanol/d), and diabetes mellitus, respectively. Synergistic interactions on the additive model were observed between heavy alcohol consumption and chronic hepatitis virus infection (OR, 53.9; 95% CI, 7.0-415.7) and diabetes mellitus (OR, 9.9; 95% CI, 2.5-39.3). Independent of the effect of HCV, HBV, and diabetes mellitus, heavy alcohol consumption contributes to the majority of HCC cases (32%), whereas 22%, 16%, and 20% were explained by HCV, HBV, and diabetes mellitus, respectively. In conclusion, the significant synergy between heavy alcohol consumption, hepatitis virus infection, and diabetes mellitus may suggest a common pathway for hepatocarcinogenesis. Exploring the underlying mechanisms for such synergisms may indicate new HCC prevention strategies in high-risk individuals.

Sexual risk behaviours and STIs in drug abuse treatment populations whose drug of choice is crack cocaine

We investigated sexually transmissable infection (STI) prevalence in 407 drug users in three drug treatment programmes in two Texan cities and associated demographic and sexual behaviours. Data analysis focused on differences between those for whom crack cocaine was the drug of preference compared with other drugs, since crack is associated with sexual arousal and a sex for drugs economy. Data indicate that having crack as a drug of preference is significantly associated with increased levels of previous STIs, previous drug treatment, African-American race, selling or buying sex for drugs or money, and increased infection markers for syphilis, chlamydia and herpes simplex-2. Crack preference was also significantly associated with lower rates of injecting drugs or sharing injection equipment and hepatitis C infection markers. Crack preference in heterosexual respondents was significantly associated with increased partner numbers in the past four weeks, more female partners for men and more vaginal sex contacts for men. Analysis of sex differences comparing those for whom crack was the preferred versus nonpreferred drug indicated that female crack users were significantly more likely to engage in oral sex. This supports previous ethnographic data suggesting that oral sex is a common mode of sex for drugs exchange in crack houses. In 7.4% of the total sample (14.4% of the crack-preferring sample), treatable STIs were detected. These data suggest that drug users generally, and crack-using populations in particular, in drug treatment programmes should be routinely screened for STIs as an integral part of drug treatment.

Functional regulation of immunoproteasomes and transporter associated with antigen processing

The central event in the cellular immune response to invading pathogens is the presentation of non-self antigenic peptides by major histocompatibility complex (MHC) class I molecules to cytotoxic T lymphocytes (CTLs). As peptide binding and transport proteins, MHC class I molecules have evolved distinct biochemical and cellular strategies for acquiring antigenic peptides, providing CTLs an extracellular representation of the intracellular antigen content. Whereas efficient generation of MHC class I binding peptides depends on the intracellular, immunoproteasome-mediated proteolysis machinery, translocation of peptides into the lumen of the endoplasmic reticulum requires the endoplasmic reticulum-resident, adenosine 5'-triphosphate (ATP) binding cassette transporter associated with antigen processing (TAP). Here we show, for the first time, that immunoproteasomes, TAP complexes, and MHC class I molecules are physically associated, providing an effective means of transporting MHC class I binding peptides from their sites of generation into the lumen of the endoplasmic reticulum for loading onto MHC class I molecules. In this review, we assess the current understanding of the functional regulation of immunoproteasomes and transporter associated with antigen processing.

Acceptance of syphilis screening among residents of high-STD-risk Houston communities

The purpose of this study was to assess the rate of acceptance of street-intercept syphilis screening and to identify barriers to screening among residents of 2 Houston communities with high rates of syphilis. Each of 691 people who participated in a street-intercept survey about syphilis was offered a free syphilis test immediately after completion of the survey. Acceptors of screening had blood drawn at the site of the interview, and blood samples were tested by rapid plasma reagin (RPR) and a confirmatory microhaemagglutination-Treponema pallidum (MHA-TP) for those with a positive antibody reaction on the RPR. On-street syphilis screening was accepted by 26% of the sample. The most common reason for refusal was not wanting to have blood drawn (19.5%). Among those screened for syphilis (n=148), seroprevalence was 19%, with 33% of women testing positive and 10% of men. The results of this study point to a need for increased case-finding, standard screening recommendations, and interventions targeting specific barriers to syphilis screening.

The role of hepatitis C in hepatocellular carcinoma: a case control study among Egyptian patients

BACKGROUND

Egypt has one of the highest prevalence rates of hepatitis C virus (HCV) infection in the world; however, the risk and attribution related to HCV in Egyptian patients with hepatocellular carcinoma (HCC) remains unknown.

GOALS

The current study was undertaken to estimate the risk of HCC in relation to HCV in Egypt.

STUDY

Thirty-three patients with HCC and 35 healthy controls who had a similar socioeconomic status were prospectively enrolled at the University of Cairo National Cancer Institute.

RESULTS

Anti-HCV antibodies were present in 75.8% of the patients and in 42.9% of the controls (p = 0.01); hepatitis B surface antigen (HBsAg) was present in 15.2% of the patients and in 2.9% of the controls (p = 0.03). In addition, the sex-and age-adjusted odds ratio (OR) for anti-HCV antibodies was 5.1 (95% CI = 1.5-17.4) and for HBsAg was 13.2 (95% CI = 1.2-148.2). Concurrent Schistosoma mansoni and anti-HCV was associated with an OR of 10.3 (95% CI = 1.3-79.8), which was higher than that for anti-HCV (6.5; 95% CI = 1.6-26.6) and S. mansoni infection (0.2; 95% CI = 0.1-6.2) alone. Finally, we estimated the attributable fraction of HCC to HCV to be 64% in this study population and 48% in the general Egyptian population.

CONCLUSIONS

Both HCV and hepatitis B virus infection increase the risk of HCC in Egyptian patients, whereas isolated Schistosoma infection does not. Because of the very high prevalence rate of HCV in the general Egyptian population, it accounts for most HCC cases in Egypt.

Erythema elevatum diutinum mimicking extensive keloids; quiz 386

GOAL

To describe a case of erythema elevatum diutinum (EED) that clinically mimicked extensive keloids.

OBJECTIVES

Upon completion of this activity, dermatologists and general practitioners should be able to: 1. Describe the clinical presentation and lesion appearance in EED. 2. Discuss the electron microscopic and laboratory findings of EED. 3. Outline treatment options for EED. CME: This article has been peer reviewed and approved by Michael Fisher, MD, Professor of Medicine, Albert Einstein College of Medicine.

REVIEW DATE

April 2001. This activity has been planned and implemented in accordance with the Essentials and Standards of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Albert Einstein College of Medicine and Quadrant HealthCom, Inc. The Albert Einstein College of Medicine is accredited by the ACCME to provide continuing medical education for physicians. Albert Einstein College of Medicine designates this educational activity for a maximum of 1.0 hour in category 1 credit toward the AMA Physician's Recognition Award. Each physician should claim only those hours of credit that he/she actually spent in the educational activity. This activity has been planned and produced in accordance with ACCME Essentials.