HIV incidence among injection drug users in New York City, 1992-1997: evidence for a declining epidemic.

OBJECTIVES: We assessed recent (1992-1997) HIV incidence in the large HIV epidemic among injection drug users in New York City. METHODS: Data were compiled from 10 separate studies (N = 4979), including 6 cohort studies, 2 "repeat service user" studies, and 2 analyses of voluntary HIV testing and counseling services within drug treatment programs. RESULTS: In the 10 studies, 52 seroconversions were found in 6344 person-years at risk. The observed incidence rates among the 10 studies were all within a narrow range, from 0 per 100 person-years at risk to 2.96 per 100 person-years at risk. In 9 of the 10 studies, the observed incidence rate was less than 2 per 100 person-years at risk. The weighted average incidence rate was 0.7 per 100 person-years at risk. CONCLUSIONS: The recent incidence rate in New York City is quite low for a high-seroprevalence population of injection drug users. The very large HIV epidemic among injection drug users in New York City appears to have entered a "declining phase," characterized by low incidence and declining prevalence. The data suggest that very large high-seroprevalence HIV epidemics may be "reversed."

Gender differences in sexual behaviors and factors associated with nonuse of condoms among homeless and runaway youths.

Few studies have examined gender-specific factors associated with the nonuse of condoms among homeless and runaway youths (HRYs)-a population at high risk for HIV infection. In this article, we evaluate these factors and explore gender differences in background experiences, psychosocial functioning, and risk behaviors among HRYs from four U.S. metropolitan areas. Of 879 sexually active HRYs sampled, approximately 70% reported unprotected sexual intercourse during a 6-month period, and nearly a quarter reported never using condoms in the same period. Among males and females, having only one sex partner in the previous 6 months had the strongest association with nonuse of condoms. Among males, nonuse was also associated with having ever caused pregnancy, frequent marijuana use, prior physical victimization, and low self-control and sociability. Among females, nonuse was associated with knowledge of HIV status, prior sexual victimization, low social support, and infrequent marijuana use. These findings highlight the ongoing need for HIV prevention services for HRYs. Implications for the scope and content of these services are discussed.

Newborn seroprevalence study: methods and results.

For the 28-month period, November 30, 1987 through March 31, 1990, 653,117 blood specimens obtained on all newborn infants in New York State for detection of metabolic disorders were also analyzed for HIV serologic status. The overall seroprevalence rate was 0.66 percent: 1.24 percent in New York City and 0.17 percent in New York State exclusive of New York City. Rates of seropositivity were highest in the Bronx (1.72 percent) and Manhattan (1.59 percent). Outside of New York City, HIV seropositivity was concentrated in certain areas. Sixty-four zip codes with two or more seropositives and an HIV seroprevalence rate twice the average outside of New York City contained 65 percent of the HIV seropositives but only 16 percent of the newborns tested. Newborn seropositivity increased with maternal age. In New York City, the seroprevalence rates increased from 0.16 percent (1 in 624) for 14-year-olds to 1.41 percent (1 in 71) for 24-year-olds, a ninefold rise. This survey has provided the impetus for a number of preventive initiatives.

Comparison of newborn screening records and birth certificates to estimate bias in newborn HIV serosurveys.

Implicit in the New York State Newborn HIV Seroprevalence Study is the assumption that newborns of all New York State residents are tested for human immunodeficiency virus (HIV) antibodies. We examined this assumption by describing that part of the 1988 New York newborn population not tested in the HIV seroprevalence study and assessing any bias contributed by this group. Of the expected total HIV specimens 1.5 percent were never received by the Newborn Screening Program, 0.5 percent were invalid specimens for which no repeat specimen could be obtained, and 1.7 percent were unsuitable or of insufficient quantity to be tested for HIV antibody. Thus 96.3 percent of all 1988 New York newborns were tested for HIV antibody. Black infants from New York City and low-birthweight infants were represented disproportionately among those not tested. Assignment of all untested newborn to HIV-positive status increased the seroprevalence rate 17 percent (0.64 percent to 0.75 percent).

Geographic distribution of newborn HIV seroprevalence in relation to four sociodemographic variables.

The geographic distribution of newborn human immunodeficiency virus seroprevalence at zip code level was compared with the distribution of four sociodemographic variables. For New York City significant univariate correlations were found between HIV and low birthweight, drug use (as measured by hospital discharges), maternal education less than 12 years, and race/ethnicity. Less significant correlations were found for New York State exclusive of New York City. For New York City a model comprising low birthweight and all drug discharges was shown by multiple regression analysis to be most strongly associated with HIV status (r2 = .77). Elsewhere a model comprising race/ethnicity (percent Black, percent Hispanic) and cocaine drug discharges had the best, but less strong association (r2 = .39). However, because of intercorrelations, race/ethnicity added little when the other variables were included first. Knowledge of the geographic association between HIV seroprevalence and sociodemographic status can be useful in designing and focusing prevention efforts in areas at highest risk for future HIV/AIDS activity.

Hospitalization of HIV-seropositive newborns with AIDS-related disease within the first year of life.

The purpose of this study was to estimate the proportion of HIV-seropositive newborns hospitalized for an AIDS-related diagnosis within 12 months of birth and to characterize these hospitalizations. The number of HIV-seropositive infants born December 1987 through June 1988 was derived from the blinded New York State Newborn HIV Seroprevalence Study. The number of infants who were born in these same months and hospitalized with an ARD within 12 months of birth was obtained from a data base containing information on all hospital discharges in New York State. Comparisons were made on the basis of month of birth. Of infants born during the study period, 995 tested positive for HIV antibody, and 151 infants (15 percent) were hospitalized with an ARD within 12 months of birth. The 151 ARD cases had a total of 240 hospitalizations, accounting for 5,772 patient days. Fifty-six percent of the ARD cases were diagnosed within six months of birth.

Ectopic pregnancies in upstate New York.

Data on ectopic pregnancies reported to the New York State Department of Health for upstate residents for the years 1971 through 1979 were analyzed by maternal age, race, and gravidity. Trends in the rate of ectopic pregnancies were also examined for this time period. The rate of ectopic pregnancies per 1,000 conceptions increased with increasing maternal age and was higher for nonwhite women compared with white women. There was a slight increase in the rate of ectopic pregnancies with increasing gravidity, but this was due in part to the interaction of age with gravidity. The rate of ectopic pregnancies per 1,000 conceptions increased by 217% from 1971 to 1979. This trend differed within subgroups of maternal age, race, and gravidity. The percentage of increase was greater for women 30 years of age or older compared with women 30 years of age or younger, greater for white women compared with nonwhite women, and greater for women with three or more previous pregnancies compared with women with fewer previous pregnancies.

Maternal exposure to exogenous sex hormones in relation to birth weight of offspring.

Birth weight was analyzed among singleton live births (N = 665) in Upstate New York in 1974 to women who used oral contraceptives (OC) in comparison to live births to women who used no contraceptives (N = 716), within 11 months prior to last menstrual period (LMP). In addition, birth weight was examined among live births to women who received hormone support therapy (N = 97) and hormone pregnancy tests (N = 75) during pregnancy. There was no evidence for a reduction in mean birth weight, or an increase in frequency of lower weights, among births to OC users, including those who stopped using OC within 2 months of LMP. Generally similar findings held within three maternal age groups (less than 25, 25-29, and 30-39 years). There was no evidence for a reduction in birth weight among offspring of women who received hormone pregnancy tests. Mean birth weight was relatively low among male and female births to women who received hormone therapy for "threatened abortion," but this may reflect the selection of women for such treatment rather than an effect of exogenous hormones on fetal growth.

PIP: Birth weight was analyzed among singleton live births (N=665) in upstate New York in 1974 to women who had used no contraceptives (N=716) within 11 months prior to the last menstrual period (LMP). In addition, birth weight was examined among live births to women who received hormone support therapy (N=97) and hormone pregnancy tests (N=75) during pregnancy. There was no evidence for a reduction in mean birth weight, or an increase in frequency of lower weights among births to OC users, including those who stopped using OCs within 2 months of LMP. Generally similar findings held within 3 maternal age groups (25, 25-29, 30-39 years). There was no evidence for a reduction in birth weight among offspring of women who received hormone pregnancy tests. Mean birthweight was relatively low among male and female births to women who did receive hormone therapy for threatened abortion but this may reflect the selection of women for such treatment rather than an effect of exogenous hormones on fetal growth.

Breast cancer and oral contraceptive use: a case-control study.

The effect of oral contraceptive (OC) use was examined among parous breast cancer cases diagnosed at less than or equal to 45 years of age, and in two different general population control groups of parous women. The primary analysis compared 278 cases with 520 controls. In the secondary analysis, a subgroup of 190 cases were compared with 190 controls from another reference group. In both analyses, ever use of OC, duration of OC use, and OC use prior to first pregnancy showed no significant association with breast cancer risk. Also in both analyses, in women with prior benign breast disease OC use increased the risk of breast cancer, although this finding was statistically significant only in the larger group used in the primary analysis.

Birth weight and birth defects in relation to maternal spermicide use.

The possible effects of maternal spermicide use on birth characteristics of offspring were examined in two studies. First, birth weight of offspring was examined in a cohort study of 302 women who reported using spermicides and 716 women who used no contraceptive methods in the year prior to pregnancy resulting in a 1974 live birth (without a malformation) in Upstate New York. There was no evidence that spermicide use prior to the last menstrual period (LMP) had an effect on mean birth weight or on the proportion of lower weights. Mean birth weight of female births was significantly lower in post-LMP spermicide users than in pre-LMP-only spermicide users and no-contraceptive users. In multiple linear regression analyses of birth weight among births to spermicide users, including maternal smoking during pregnancy and other variables, time of discontinuation of spermicide use was an important predictor of female (but not male) birth weight. In the second (case-control) study of 715 Upstate New York births with selected birth defects and 715 control births (matched on maternal age and race), no significantly increased relative risks were associated with maternal spermicide use prior to LMP or after LMP. Based on small numbers, relative risks for post-LMP spermicide use were greater than 1.00 for hypospadias (8/2 or 4.00, not significant) and for limb reduction defects (6/3 or 2.00, not significant).

"Risk factors for benign breast disease".

PIP: Brinton et al. report an inverse relationship between oral contraceptive (OC) use and benign breast disease. Their contention that the association is real and not due to selective bias, as has been suggested by Janerich et al., is difficult to accept from the data that are reported. Adequate control for both selection bias and confounding factors influenced by physicians' prescribing practices and the benign breast disease patients' choice of contraception has not been carried out in the majority of studies reported. In the study conducted by Brinton et al., careful control of influencing factors such as reason for discontinuing OC use, prior breast disease and social class was carried out, but there is a strong possibility of a selection bias affecting the results. Cases and controls were selected from participants in the Oxford-FPA study who were restricted to married women 25-39 years of age and who were currently using OCs, an IUD, or a diaphragm without previous OC use. Thus, women who, prior to 25 years of age, elected to discontinue OC use because of breast discomfort related to benign breast disease, or women whose physician discontinued prescribing OCs because of benign breast disease, would have been entirely selected out of the Oxford-FPA study. Such women would have no opportunity of being included in Brinton's study, reducing the overall likelihood that OC ever users and longterm users would be found among the women with benign breast disease. This could account for some or all of the deficit of OC ever users and longterm users among the benign breast disease cases found in Brinton's study. Brinton's thorough analysis has contributed to the understanding of several factors related to the risk of benign breast disease such as obesity and fertility factors. The association between parity and late age at 1st birth and benign breast disease must be sorted out before the interpretation of a "protective effect" of OCs on benign breast disease can be accepted.^ieng

Oral contraceptives and birth defects.

This report compares the history of oral contraceptive (OC) use for 715 New York state women who gave birth to malformed infants with the history for a group of 715 matched controls who gave birth to normal children. The case mothers were found to have used the OC after last menstrual period (LMP), or just before conception, slightly more often than the controls. Confidence intervals for the relative risk estimates were wide, and were significantly higher than 1.0 only among the group of women whose children had one or more major structural or anatomical malformations. Cytogenetic abnormalities and hypospadias were not associated with OC use around or after the time of conception. For women who had children with major anatomical or structural malformations, the association with OCs was stronger among the older age group. The authors found no evidence of an increased risk among women who had conveived their child after one or more pill-free menstrual cycles. Several reported studies, including this one, show a predominance of males among malformed offspring whose mothers used OCs during pregnancy. These findings indicate that the association between birth defects and OC use around the time of conception is not large, but the association is not easily reconciled with a non-causal explanation.

PIP: This report compares the history of (OC) oral contraceptive use for 715 New York State women who gave birth to malformed infants with the history for a group of 715 matched controls who gave birth to normal children. The case mothers were found to have used OCs after their last menstrual period or just before conceptions slightly more often than the controls. Confidence intervals for the relative risk estimates were wide, and were significantly higher than 1.0 only among the group of women whose children had 1 or more major structural or anatomical malformations. Cytogenetic abnormalities and hypospadias were not associated with OC use around or after the time of conception. For women who had children with major anatomical or structural malformations, the association with OCs was stronger among the older age group. The authors found no evidence of an increased risk among women who had conceived their child after 1 or more pill-free menstrual cycles. Several reported studies, including this 1, show a predominance of males among malformed offspring whose mothers used OCs during pregnancy. These findings indicate that the association between birth defects and OC use around the time of conception is not large, but the association is not easily reconciled with a noncausal explanation.

Sex of first child as a prognostic factor for breast cancer in young women.

In a study in upstate New York, incidence and survival rates of 317 young women (less than 45 years), diagnosed with breast cancer, were examined in relation to the sex of each woman's first offspring. While incidence of breast cancer was not found to be affected by the sex of the first child, prognosis was poorer when the first child was made (p less than 0.05). The authors examined the effect of stage at diagnosis, interval between first pregnancy and diagnosis and concurrent pregnancy at the time of diagnosis as factors other than sex of first offspring that might have an additional influence on survival. Among these, only interval had an effect, and it was of weak statistical significance (0.05 less than p less than 0.1). These findings regarding survival in relation to the sex of the offspring are opposite to those reported recently in France by Juret et al. (Lancet 1:415-416, 1978). Possible differences between the two studies which may account for the opposite findings are discussed.

Benign breast disease and oral contraceptive use.

A random selection of 1,230 upstate New York childbearing women was used to examine the history of oral contraceptive use in women with a clinical diagnosis of benign breast disease. We found that 73 women who had benign breast disease had a reduced duration of pill use. When determining the reason for this reduction, we found that in a significant portion (P less than .05) of our benign breast disease cases, the women had been advised by their physicians to discontinue pill use for breast-related reasons. We then surveyed a large group of upstate New York physicians. One third of them considered benign breast disease a potential contraindication for starting oral contraceptive use. Nearly one half throught the development of benign breast disease to be a potential contraindication for continuing oral contraceptive use. It is premature to conclude that oral contraceptive usage protects against benign breast disease.