Factors associated with choosing a primary care career.

The factors influencing the career choices of medical students need to be understood so that the proportion of physicians entering primary care-defined as family practice, general internal medicine, general pediatrics, and general obstetrics and gynecology-can be increased. We sent a questionnaire to 474 University of California, San Diego (UCSD), School of Medicine alumni (classes of 1974, 1978, 1982, 1986, and 1990) inquiring about demographics, personal and medical school factors, and level of debt. A total of 351 alumni responded (74% response rate), and 327 of them were engaged in direct patient care (38% in primary care). Respondents who were older, female, an underrepresented minority, from a rural background, and who chose their specialty before medical school were significantly more likely to enter primary care. The primary care group was influenced by factors unrelated to the medical school environment, such as personal social values, whereas the top 3 factors rated by the non-primary care group were directly related to school environment. Many of the respondents in primary care reported that the environment at UCSD was antagonistic toward primary care. From 1974 to 1990, more students had debt and their total debt increased, although debt had little or no influence on specialty choice.

Estimating the population prevalence of injection drug use and infection with human immunodeficiency virus among injection drug users in Glasgow, Scotland.

Although data on the prevalence of injection drug use are an essential prerequisite for estimating the number of individuals infected with the human immunodeficiency virus (HIV), there have been few attempts to utilize statistical methods of population estimation based on multiple data sources. Data on 3,670 cases (2,866 individuals) were obtained from the HIV test register, drug treatment agencies, police records, and needle and syringe exchanges in Glasgow, Scotland, in 1990. Log-linear analysis was used to model the number of individuals in each of the sources. The model incorporating dependency among the three health care agencies (HIV test, drug treatment, and needle exchange) and independence of the police sample fitted the data well, with a residual chi 2 value of 2.9 (6 df). The expected value of the missing cell corresponding to absence from all four samples was 5,628, yielding an overall estimate of 8,494 injectors (95% confidence interval (CI) 7,491-9,721), for a prevalence rate of 1.35% for people aged 15-55 years in Glasgow during 1990. The high ratio of known to unknown injectors (1:2) resulted from the extensive coverage of known injectors and the relatively high level of overlap between the combined health care agency sample and the police sample. While further analysis demonstrated that the probability of appearing in the four samples varied by age and sex, heterogeneity in the population did not affect the choice of model or substantially alter the estimates for the total number of unknown injectors. A concurrent study of a community-wide sample of 503 injectors resulted in an HIV prevalence rate of 1.1% (95% CI 0.4-2.5%). The results of these studies were combined to produce a further estimate of 93 HIV-infected current injectors in Glasgow (95% CI 33-214).

Prison experience of injecting drug users in Glasgow.

Five hundred three injecting drug users in Glasgow recruited by a multisite and citywide sampling strategy were questioned regarding their drug-taking behaviour during episodes of custody over the six months prior to interview. Fifty-two percent had been in custody during the past 6 months, 16% of these had injected while in custody. Of these 73% borrowed injecting equipment and 78% handed on used equipment to others. All those who shared, cleaned their injecting sets before use. Over half of those who injected had a source of new sets. While the potential exists for spread of HIV among drug users while in custody there is clear understanding among them of the route by which the virus is spread and also the will to prevent it.

HIV testing among injecting drug users in Glasgow.

The use of saliva rather than blood for epidemiological studies of HIV prevalence, especially among injecting drug users, has several practical advantages. In a cross-sectional, behavioural and prevalence study among drug users in Glasgow during 1990, salivary samples were therefore obtained by the use of salivettes. Such samples were requested for anonymous anti-HIV testing from 498 persons in locations varying from residential rehabilitation centres to the open streets. Of this number, 35 refused to give a sample, resulting in a compliance rate of 93%. Of the 463 salivettes received by the laboratory, eight were found to be dry. Of the remaining 455 specimens, eight were found to be positive for HIV-1 antibody by means of an IgG antibody capture ELISA, so giving a prevalence rate of 1.8%. The results of testing saliva and blood spot samples collected at the same time on filter paper from 98 persons for HIV-1 antibody were 100% concordant. The study confirms the experience of others that specimens of saliva are easy to collect under variable conditions by non-medical staff and demonstrates that the salivette can provide an HIV antibody test result the same as that obtained from a blood spot. The prevalence of HIV antibody determined in this study is similar to that of other studies taking place in the city during the same period of time.

Modeling the behavior and attributes of injecting drug users: a new approach to identifying HIV risk practices.

The behaviors and attributes of 503 Scottish injecting drug users were modeled using the linear structural equations program LISREL. Drug use was directly related to prison experience, sexual activity, sharing of injecting equipment, and prostitution. Although the prevalence of HIV among the sample was low (2.0%), the pattern of risk behaviors observed in the data affords potential for future spread of the virus. Harm reduction measures taken by injectors in response to the threat posed by AIDS were inversely related to drug use but, more encouragingly, directly related to awareness of the disease, treatment for drug use, and prostitution.

Estimates of HIV infection among injecting drug users in Glasgow, 1985-1990.

OBJECTIVE: To use research and surveillance studies in Glasgow (Scotland, UK) to estimate the number of current injectors infected with HIV, the total number of injectors infected up to the end of 1990 and the recent incidence of infection. DESIGN: (A) Prevalence of injecting drug use was estimated using log-linear modelling. (B) Prevalence of HIV infection was determined from voluntary testing of a community-wide sample of injectors. (C) The number of infected current injectors was predicted by combining the distributions generated by (A) and (B). (D) Data on known HIV-positive injectors were used in conjunction with (C) to forecast the cumulative number of infected injectors. RESULTS: The number of current injectors was estimated to be 9400; the prevalence of HIV infection among 447 injectors recruited to the HIV prevalence study during 1990 was 1.1%. From these data, the number of HIV-positive current injectors in 1990 was estimated to be between 52 and 138. Between 1985 and 1990, 110 known HIV-positive injectors were registered or received treatment in Glasgow for HIV-related diseases; the total number of cases estimated to have occurred during this period was between 110 and 300. The incidence of infection in Glasgow during 1990 was likely to have been low in light of the finding that only one case in the prevalence study had not previously been diagnosed HIV-positive. CONCLUSIONS: Linkage of datasets from a variety of sources and studies has enabled the substantial refinement of estimates of the number of injectors and the proportion infected with HIV in Glasgow up to 1990.

Reduction in needle sharing among community wide samples of injecting drug users.

Evidence of reduced levels of needle sharing among injecting drug users (IDUs) has largely been confined to IDUs attending needle exchanges or receiving treatment. In this paper we present the results of a serial cross-sectional study of needle sharing conducted in Glasgow using a multisite sampling strategy. Of the estimated 9400 IDUs in the city, 503 were interviewed in 1990 and 535 in 1991. The proportion of IDUs reporting injecting with, or passing on used needles and syringes in the last 6 months fell significantly as did the number of individuals from whom equipment was received or passed on to. The impact of this level of sharing has been limited in terms of HIV transmission; the prevalence of HIV among the 1990 sample was 2.0% and 1.1% for the 1991 sample. However, the fact that third of IDUs in Glasgow continue to inject, even occasionally, with used equipment gives cause for concern in view of the other pathologies known to be associated with poor injecting hygiene.

Prevalence of HIV among childbearing women and women having termination of pregnancy: multidisciplinary steering group study.

OBJECTIVE: To determine the prevalence of HIV among pregnant women, in particular those whose behaviour or that of their partners put them at "low risk" of infection. DESIGN: Voluntary named or anonymous HIV testing of pregnant women during 21 months (November 1988 to July 1990). SUBJECTS AND SETTING: All women who planned to continue their pregnancy and attended clinics serving the antenatal populations of Edinburgh and Dundee. All women admitted for termination of pregnancy to gynaecology wards serving the pregnant populations of Dundee and outlying rural areas. MAIN OUTCOME MEASURES: Period prevalence of HIV antibody positivity. RESULTS: 91% of antenatal clinic attenders and 97% of women having termination of pregnancy agreed to HIV testing on a named or anonymous basis. HIV period prevalences for antenatal clinic attenders and women having termination of pregnancy tested in Dundee were 0.13% and 0.85% respectively, and for antenatal clinic attenders tested in Edinburgh 0.26%. For those at "low risk" rates for antenatal clinic attenders and women having termination of pregnancy in Dundee were 0.11% and 0.13%, and for antenatal clinic attenders in Edinburgh 0.02%. In Dundee HIV prevalence among women having a termination of pregnancy (0.85%) was significantly greater than that among antenatal clinic attenders (0.13%). CONCLUSIONS: HIV infection is undoubtedly occurring among women at "low risk," and it is clear that a policy of selective testing of those at only "high risk" is inadequate for pregnant women living in areas of high prevalence such as Edinburgh and Dundee. Moreover, when studying pregnant populations in such areas there is the need to include those having a termination of pregnancy.

PIP: This study sought to determine the prevalence of HIV among pregnant women, in particular those whose behavior or that of their partners put them at low-risk for infection. This was a voluntary named or anonymous HIV testing of pregnant women between November 1988-July 1990 among all women who planned to continue their pregnancies and attended clinics serving antenatal populations in Edinburgh and Dundee and those women admitted for termination of pregnancy to gynecology wards serving the pregnant populations of Dundee and outlying rural areas. 91% of the antenatal clinic attenders and 97% of women having pregnancy termination agreed to HIV testing on either a named or anonymous basis. HIV period prevalences for antenatal clinic attenders and women having pregnancy termination tested in Dundee were 0.13% and 0.85% respectively, and for antenatal clinic attenders tested in Edinburgh 0.26%. For those at low-risk, the rates for antenatal clinic attenders and women having pregnancy termination in Dundee were 0.11% and 0.13%, and for antenatal clinic attenders in Edinburgh 0.02%. In Dundee, HIV prevalence among women having a termination of pregnancy (0.95%) was significantly greater than that among antenatal clinic attenders (0.13%). HIV infection is undoubtedly occurring among low-risk women and it is clear that a policy of selective testing of those only at high-risk is inadequate for pregnant women living in areas of high prevalence such as Edinburgh and Dundee. Moreover, when studying pregnant populations in such areas, there is a need to include those undergoing pregnancy termination.

What do Scots die of when abroad?

Information was obtained on 952 persons who travelled from Scotland between 1973 and 1988 and who died while abroad. In the older age group cardio-vascular disease was the major cause of death whereas in the younger group traumatic deaths were commonest. Most died in the holiday resorts bordering the Mediterranean and the question is posed on the need for specific advice to those who are most vulnerable before embarking on overseas travel.

Health care needs for children of the recently homeless.

Thirty families were surveyed at a shelter for the homeless in San Diego, California concerning the health care status and needs of their children. 56.7% of the families had no regular source of health care and 46.6% were not covered by any form of health coverage. Children whose families had a regular source of health care were more likely to have reported better health and more frequent checkups. Also, increased duration of homelessness was predictably correlated with poorer reported health of the children. Though the families sampled were representative of those recently made homeless i.e. less than six months, needs were identified that would be applicable to all homeless families. The most frequent needs the families expressed for their children were: general nonemergency clinics (76.7%), emergency services (66.7%), and dental services (66.7%). Nutritional and dietary counseling were chosen by 43.3% and only 6.7% of the parents rated social and psychological services as needed.

Health care usage by Hispanic outpatients as function of primary language.

Three groups of Hispanic patients at five outpatient clinics in San Diego County, California, participated in a survey questionnaire concerning health care usage according to whether they were Spanish-speaking only, bilingual with Spanish as a primary language or primarily English speaking. Although the three groups were similar in age and income distribution, the use of health services (regular source of health care, health insurance, admission to hospital and frequency of general physical, eye and dental examinations) was positively correlated with increased use of English. Likewise, respondents whose primary language was English were more likely to describe their health care as more than adequate and their own health as excellent than were those whose primary language was Spanish.