STI/HIV Sexual Risk Behavior and Prevalent STI Among Incarcerated African American Men in Committed Partnerships: The Significance of Poverty, Mood Disorders, and Substance Use.

African Americans face disproportionate sexually transmitted infection including HIV (STI/HIV), with those passing through a correctional facility at heightened risk. There is a need to identify modifiable STI/HIV risk factors among incarcerated African Americans. Project DISRUPT is a cohort study of incarcerated African American men recruited from September 2011 through January 2014 from prisons in North Carolina who were in committed partnerships with women at prison entry (N = 207). During the baseline (in-prison) study visit, participants responded to a risk behavior survey and provided a urine specimen, which was tested for STIs. Substantial proportions reported multiple partnerships (42 %), concurrent partnerships (33 %), and buying sex (11 %) in the 6 months before incarceration, and 9 % tested positive for an STI at baseline (chlamydia: 5.3 %, gonorrhea: 0.5 %, trichomoniasis: 4.9 %). Poverty and depression appeared to be strongly associated with sexual risk behaviors. Substance use was linked to prevalent STI, with binge drinking the strongest independent risk factor (adjusted odds ratio: 3.79, 95 % CI 1.19-12.04). There is a continued need for improved prison-based STI testing, treatment, and prevention education as well as mental health and substance use diagnosis.

Sexual Behaviors of US Women at Risk of HIV Acquisition: A Longitudinal Analysis of Findings from HPTN 064.

We describe the sexual behaviors of women at elevated risk of HIV acquisition who reside in areas of high HIV prevalence and poverty in the US. Participants in HPTN 064, a prospective HIV incidence study, provided information about individual sexual behaviors and male sexual partners in the past 6 months at baseline, 6- and 12-months. Independent predictors of consistent or increased temporal patterns for three high-risk sexual behaviors were assessed separately: exchange sex, unprotected anal intercourse (UAI) and concurrent partnerships. The baseline prevalence of each behavior was >30 % among the 2,099 participants, 88 % reported partner(s) with >1 HIV risk characteristic and both individual and partner risk characteristics decreased over time. Less than high school education and food insecurity predicted consistent/increased engagement in exchange sex and UAI, and partner's concurrency predicted participant concurrency. Our results demonstrate how interpersonal and social factors may influence sustained high-risk behavior by individuals and suggest that further study of the economic issues related to HIV risk could inform future prevention interventions.

Recruitment of HIV/AIDS treatment-naïve patients to clinical trials in the highly active antiretroviral therapy era: influence of gender, sexual orientation and race.

BACKGROUND: In the USA, women, racial/ethnic minorities and persons who acquire HIV infection through heterosexual intercourse represent an increasing proportion of HIV-infected persons, and yet are frequently underrepresented in clinical trials. We assessed the demographic predictors of trial participation in antiretroviral-naïve patients. METHODS: Patients were characterized as trial participants if highly active antiretroviral therapy (HAART) was initiated within a clinical trial. Prevalence ratios (PRs) were obtained using binomial regression. RESULTS: Between 1996 and 2006, 30% of 738 treatment-naïve patients initiated HAART in a clinical trial. Trial participation rates for men who have sex with men (MSM), heterosexual men, and women were respectively 36.5, 29.6 and 24.3%. After adjustment for other factors, heterosexual men appeared less likely to participate in trials compared with MSM [PR 0.79, 95% confidence interval (CI) 0.57, 1.11], while women were as likely to participate as MSM (PR 0.97, 95% CI 0.68, 1.39). The participation rate in Black patients (25.9%) was lower compared with non-Black patients (37.5%) (adjusted PR 0.80, 95% CI 0.60, 1.06). CONCLUSIONS: In our clinical setting, gender did not appear to impact participation in HIV treatment trials, but Black patients were slightly less likely to participate in these trials. Considering the substantial proportion of HIV-infected patients who are Black, future trials need to consider strategies to incorporate such underrepresented populations.

Correlates of condom use among sexually experienced secondary-school male students in Nairobi, Kenya.

This study aimed to examine perceptual factors associated with condom use, and the relationship between condom use and the timing of sexual debut among male secondary school students in Nairobi, Kenya. Data are from the TeenWeb study, a school-based project that used the World Wide Web to assess the health needs of secondary school students, and tested the web's utility as a teaching and research modality. Analyses are based on 214 sexually experienced males aged 14 - 20 years who completed web-based questionnaires about their sexual attitudes and behaviour. Results indicate that students did not see themselves as susceptible to HIV/AIDS and believed condom effectiveness in preventing HIV to be low. Consequently, only a marginal association was found between agreeing that buying condoms is embarrassing and condom use at first sexual intercourse. However, contrary to expectation, agreeing that condoms often break (almost half of participants) was associated with a higher likelihood of condom use at first sex. Each year of delay in sexual debut increased the likelihood of using a condom at first sex by 1.44 times. In turn, having used a condom at first sex increased the likelihood of using one at the most recent sex by 4.81 times, and elevated general condom use ('most or all the time') by 8.76 times. Interventions to increase awareness about the role of condoms in preventing HIV, delay sexual initiation, and teach proper condom use among secondary-school students in Nairobi are needed.

Correlates of Condom use among Sexually Experienced Secondary School Male Students in Nairobi; Kenya

This study aimed to examine perceptual factors associated with condom use; and the relationship between condom use and the timing of sexual debut among male secondary school students in Nairobi; Kenya. Data are from the TeenWeb study; a school-based project that used the World Wide Web to assess the health needs of secondary school students; and tested the web's utility as a teaching and research modality. Analyses are based on 214 sexually experienced males aged 14 - 20 years who completed web-based questionnaires about their sexual attitudes and behaviour. Results indicate that students did not see themselves as susceptible to HIV/AIDS and believed condom effectiveness in preventing HIV to be low. Consequently; only a marginal association was found between agreeing that buying condoms is embarrassing and condom use at first sexual intercourse. However; contrary to expectation; agreeing that condoms often break (almost half of participants) was associated with a higher likelihood of condom use at first sex. Each year of delay in sexual debut increased the likelihood of using a condom at first sex by 1.44 times. In turn; having used a condom at first sex increased the likelihood of using one at the most recent sex by 4.81 times; and elevated general condom use (`most or all the time') by 8.76 times. Interventions to increase awareness about the role of condoms in preventing HIV; delay sexual initiation; and teach proper condom use among secondary-school students in Nairobi are needed

Driver's license and voter registration lists as population-based sampling frames for rural African Americans.

PURPOSE: To compare coverage of a state driver's license list and county voter registration lists as frames for sampling rural African Americans. METHODS: Name, birth date, sex, and county were extracted from records for all 18--59 year-old African Americans residing in eight rural North Carolina counties and listed in the North Carolina Driver license file [obtained as a SAS dataset from the University of North Carolina (UNC) Highway Safety Research Center] and in machine-readable text files of registered voters (obtained from county boards of elections). Files were edited, merged, and matched by last name and date of birth to produce three files for each five-year age group, sex, and county: 1) persons listed only in the driver's file; 2) persons listed only in the voter's file; and 3) persons listed in both. RESULTS: The median percentages of unique persons found only on the driver's list, only on the voter's list, and on both lists were 54%, 17%, and 30% men, and 35%, 25%, and 41% women, respectively. CONCLUSIONS: The driver's list provided better coverage than did voter registration lists. Federal legislation that prohibits states from releasing driver's license lists for use in surveys removes a valuable resource for population-based research.

Social context of sexual relationships among rural African Americans.

BACKGROUND: Reasons for the strikingly increased rates of HIV and other sexually transmitted infections (STIs) among African Americans in the rural Southeastern United States remain unclear. Investigators have devoted little attention to the potential influence of the social and economic context on sexual behaviors. GOAL: To examine the potential influence of these contextual factors on behaviors that promote the transmission of STIs. STUDY DESIGN: Focus group interviews in which African Americans from rural North Carolina discussed life in their communities and contextual factors affecting sexual behavior. RESULTS: Respondents reported pervasive economic and racial oppression, lack of community recreation, boredom, and resultant substance abuse. Many perceived a shortage of black men because of their higher mortality and incarceration rates compared with whites, and believed this male shortage to be partly responsible for the concurrent sexual partnerships that they perceived as widespread among unmarried persons. CONCLUSION: Contextual features including racism, discrimination, limited employment opportunity, and resultant economic and social inequity may promote sexual patterns that transmit STIs.

Recombinant glycoprotein vaccine for the prevention of genital HSV-2 infection: two randomized controlled trials. Chiron HSV Vaccine Study Group.

CONTEXT: In the last 3 decades, herpes simplex virus type 2 (HSV-2) infection seroprevalence and neonatal herpes have increased substantially. An effective vaccine for the prevention of genital herpes could help control this epidemic. OBJECTIVE: To evaluate the efficacy of a vaccine for prevention of HSV-2 infection. DESIGN: Two randomized, double-blind, placebo-controlled multicenter trials of a recombinant subunit vaccine containing 30 microg each of 2 major HSV-2 surface glycoproteins (gB2 and gD2) against which neutralizing antibodies are directed, administered at months 0, 1, and 6. Control subjects were given a citrate buffer vehicle. Participants were followed up for 1 year after the third immunization. SETTING AND PARTICIPANTS: We enrolled 2393 persons from December 10, 1993, to April 4, 1995, who were HSV-2 and human immunodeficiency virus seronegative. One trial with 18 centers enrolled 531 HSV-2-seronegative partners of HSV-2-infected persons; the other, with 22 centers, enrolled 1862 persons attending sexually transmitted disease clinics. A total of 2268 (94.8%) met inclusion criteria and were included in the analysis with 1135 randomized to placebo and 2012 to vaccine. MAIN OUTCOME MEASURE: Time to acquisition of HSV-2 infection, defined by seroconversion or isolation of HSV-2 in culture during the study period by randomization group. RESULTS: Time-to-event curves indicated a 50% lower acquisition rate among vaccine vs placebo recipients during the initial 5 months of the trial; however, overall vaccine efficacy was 9% (95% confidence interval, -29% to 36%). Acquisition rates of HSV-2 were 4.6 and 4.2 per 100 patient-years in the placebo and vaccine recipients, respectively (P =.58). Follow-up of vaccine recipients acquiring HSV-2 infection showed vaccination had no significant influence on duration of clinical first genital HSV-2 episodes (vaccine, median of 7.1 days; placebo, 6.5 days; P>.10) or subsequent frequency of reactivation (median monthly recurrence rate with vaccine, 0.2; with placebo, 0.3; P>.10). The vaccine induced high levels of HSV-2-specific neutralizing antibodies in vaccinated persons who did and did not develop genital herpes. CONCLUSIONS: Efficient and sustained protection from sexual acquisition of HSV-2 infection will require more than high titers of specific neutralizing antibodies. Protection against sexually transmitted viruses involving exposure over a prolonged period will require a higher degree of vaccine efficacy than that achieved in this study.

Trends in human immunodeficiency virus (HIV) counseling, testing, and antiretroviral treatment of HIV-infected women and perinatal transmission in North Carolina.

Since 1993, trends in perinatal human immunodeficiency virus (HIV) transmission have been monitored by use of chart review of patients identified at a central diagnostic laboratory. In the population studied, either pre- or postnatal antiretroviral therapy to the infant increased from 21% in 1993 to 95% in 1997. Concurrently, the number of HIV-infected infants declined from 25 in 1993 to 4 in 1997. The complete Pediatric AIDS Clinical Trials Group Protocol 076 regimen was the most effective in reducing transmission (3.1%). Twenty-two of 35 infants who became infected in 1995-1997 had mothers who did not receive antiretroviral therapy, although counseling practices improved with time. In 1995, 87% of the mothers of HIV-seropositive infants were counseled, whereas in 1997, 96% were counseled (P<.005). None of 59 infants tested had high-level phenotypic zidovudine resistance, although 5 (8.8%) of 57 infants had virus isolates with at least one mutation in the reverse transcriptase gene associated with reduced phenotypic susceptibility to zidovudine.

Perinatal HIV infection and the effect of zidovudine therapy on transmission in rural and urban counties.

OBJECTIVES: To assess health care providers' identification of human immunodeficiency virus (HIV)-exposed infants, to ascertain the prevalence of transplacental or oral zidovudine treatment among infants exposed to HIV, and to estimate the impact of zidovudine use on perinatal transmission in rural and urban North Carolina. DESIGN: Survey of North Carolina newborns tested for HIV infection in 1993 and 1994 compared with the number of anonymous HIV-positive childbearing women. SETTING: North Carolina hospitals, public health clinics, and private physicians' offices. MAIN OUTCOME MEASURES: Rates of identification of HIV-exposed infants and of perinatal HIV-1 transmission, determined by HIV culture and polymerase chain reaction testing in the infants. RESULTS: The proportion of HIV-exposed children in North Carolina who were identified and tested increased from 60% in 1993 to 82% for all of 1994, and to more than 90% for the last quarter of 1994. The HIV-exposed infants born in rural counties were more likely to be recognized than those born in urban counties (P<.001). In 1994, most infants were evaluated relatively early in life: 39% by 1 week of age, 63% by 6 weeks, and 76% by 3 months. Among infants with recognized HIV exposure, transmission decreased significantly between 1993 and 1994, from 21% to 8.5%, respectively (P=.009). After the announcement of the results of the AIDS Clinical Trials Group Protocol 076, zidovudine was given to 75% of HIV-positive women who delivered infants in North Carolina. Only 5.7% of infants who received any zidovudine became infected, compared with 18.9% of infants who received no zidovudine (P=.007). CONCLUSIONS: Health care providers in North Carolina are identifying most of the state's HIV-seropositive pregnant women, treating them with zidovudine, and testing their infants soon after birth for HIV infection. The use of zidovudine in pregnant women and their infants has reduced perinatal HIV transmission in the state.

Human papillomavirus infection. Recent findings on progression to cervical cancer.

Substantial evidence indicates a causal role for human papillomavirus (HPV) infection in the development of cervical dysplasia and cancer. However, since recent advances in HPV detection techniques indicate that genital HPV infection among women is common, it is clear that transient HPV infection is not sufficient for development of cervical malignancy. Oncogenesis may require persistent infection as well as the presence of cofactors that are not yet completely understood. The role of HPV detection and typing in clinical management of HPV-associated lesions is currently being investigated.

Vaccines for classic sexually transmitted diseases.

Sexually transmitted diseases (STDs) can substantially increase the morbidity and mortality of exposed adults and children. Despite the advent of new antibiotics and focus on behavioral interventions such as condom use, attempts to limit the spread of STDs have been largely unsuccessful. Vaccines have received increasing attention as a potential strategy for STD control. This article focuses on the current status of vaccine research for five classic STDs: gonorrhea, genital herpes, syphilis, chancroid, and chlamydia.

Outbreak of invasive group A streptococcal infections in a nursing home. Lessons on prevention and control.

OBJECTIVE: Nine outbreaks of group A streptococcal (GAS) infections in nursing homes were reported to the Centers for Disease Control (Atlanta, Ga) during the past two winters. We conducted an intensive epidemiologic and laboratory investigation of one of these outbreaks to determine clinical characteristics, risk factors for transmission and infection, and methods of control and prevention. METHODS: Cases were detected using cultures and serologic tests. Matched case-control and retrospective cohort studies were performed to determine risk factors for infection. RESULTS: Between December 13, 1989, and January 31, 1990, 16 (20%) of 80 residents, and three (7%) of 45 staff, were infected with GAS. Eleven of the residents had invasive disease and four died. Isolates were available from four persons; all were serotype M-1, T-1. There was strong spatial clustering of cases within the nursing home; having a roommate with prior infection was the most important risk factor. Residents with preexisting decubiti had a reduced risk of infection, perhaps because of stricter infection control practices in their care. No evidence was found for common-source transmission of infection. No further cases occurred after improvement of infection control practices and administration of prophylactic antimicrobials to all residents and staff. CONCLUSIONS: Invasive GAS disease is increasing nationwide, and is a potentially serious problem in the growing and high-risk setting of nursing homes. These data suggest that, in this outbreak, a virulent GAS strain was introduced, with subsequent person-to-person transmission. Adherence to infection control practices can prevent or control GAS outbreaks. Prophylactic antimicrobials may be an effective adjunct to control severe or ongoing outbreaks.