Two decades after vaccine license: hepatitis B immunization and infection among young men who have sex with men.

OBJECTIVES: This study investigated hepatitis B immunization coverage and the extent of hepatitis B virus (HBV) infection among young men who have sex with men (MSM), a group for whom hepatitis B vaccine has been recommended since 1982. METHODS: We analyzed data from 3432 MSM, aged 15 to 22 years, randomly sampled at 194 gay-identified venues in 7 US metropolitan areas from 1994 through 1998. Participants were interviewed, counseled, and tested for serologic markers of HBV infection. RESULTS: Immunization coverage was 9% and the prevalence of markers of HBV infection was 11%. HBV infection ranged from 2% among 15-year-olds to 17% among 22-year-olds. Among participants susceptible to HBV infection, 96% used a regular source of health care or accessed the health care system for HIV or sexually transmitted disease testing. CONCLUSIONS: Despite the availability of an effective vaccine for nearly 2 decades, our findings suggest that few adolescent and young adult MSM in the United States are vaccinated against hepatitis B. Health care providers should intensify their efforts to identify and vaccinate young MSM who are susceptible to HBV.

Seroepidemiology of human herpesvirus 8 among young men who have sex with men.

BACKGROUND: The modes of transmission of human herpesvirus 8 (HHV-8) remain unclear. GOAL: To study HHV-8 seroprevalence and risk factors among young men. STUDY DESIGN: The Young Men's Survey was a multisite cross-sectional HIV seroprevalence and behavioral risk survey of men aged 15 to 22 years who attended public venues frequented by young men who have sex with men (MSM). Blood specimens were tested for HHV-8 by using an immunofluorescence assay at a 1:40 dilution among 488 participants in Seattle-King County, WA. RESULTS: Total HHV-8 seroprevalence was 6% among MSM and 5% among men who have sex only with women (MSW). In multivariate analysis, unprotected receptive anal sex during the past 6 months, injection drug use, and cytomegalovirus infection were associated with HHV-8 seropositivity in MSM. CONCLUSION: The HHV-8 seroprevalence among these young MSM was similar to the HHV-8 seroprevalence among young MSW, but lower than seroprevalence estimates in earlier studies of older MSM. The association of MSM between HHV-8 infection and unprotected receptive anal sex supports previous findings that HHV-8 is sexually transmitted. Although CMV infection and injection drug use may be markers for unsafe sexual practices, it is also possible that these are independent risk factors for acquiring HHV-8.

High prevalence of HIV infection among young men who have sex with men in New York City.

OBJECTIVE: To determine the prevalence of HIV infection and risk behaviors among young men who have sex with men (MSM) aged 15-22 years in New York City. DESIGN: An anonymous cross-sectional survey. METHODS: The 1998 Young Men's Survey in New York City (YMS-NYC), was a multistage probability survey of 541 MSM aged 15-22 years who attend public venues. After identification of venues and their associated high attendance time periods, random samples of venues and time periods were selected on a monthly basis. At each sampling event, potential participants were approached to determine eligibility. Eligible and willing men were interviewed, counselled and had a blood specimen drawn. RESULTS: Between December 1997 and September 1998, 115 sampling events were conducted. Of 612 men enrolled, 541 reported ever having had sex with a male partner. The HIV seroprevalence among the 541 MSM sampled was 12.1%. The HIV seroprevalence was 18.4% among African-Americans, 16.7% among persons of mixed race, 8.8% among Latino individuals and 3.1% among white men. HIV seroprevalence was 5.0% among 15-18 year olds and 16.4% among 19-22 year olds. A total of 65.5% of MSM were susceptible to hepatitis B virus infection (HBV). Almost half (46.1%) of the men reported unprotected anal sex in the previous 6 months and 16.3% reported ever having had an STD. Multiple regression analyses found that being older, of mixed race, black or ever having had an STD was associated with being HIV antibody positive. CONCLUSION: These data identify a large subgroup of MSM in need of effective HIV and HBV primary and secondary prevention programs.

Very young gay and bisexual men are at risk for HIV infection: the San Francisco Bay Area Young Men's Survey II.

OBJECTIVES: To compare HIV seroprevalence and sexual risk behavior among very young gay and bisexual men (aged 15-17 years) and their older counterparts (aged 18-22 years). To examine drug-use patterns and correlates of sexual risk behavior in both of these age groups. DESIGN AND METHODS: An interviewer-administered cross-sectional survey of 719 gay and bisexual males between 15 and 22 years old was conducted through a venue-based sampling design. Blood specimens were collected and tested for HIV antibodies, hepatitis B, and syphilis. Interviews assessed sexual and drug-use behavior as well as psychosocial variables believed to be related to sexual risk-taking, including self-acceptance of gay or bisexual identity, perceptions of peer norms concerning safer sex, and perceptions of the ability to practice safer sex (safer sex self-efficacy). RESULTS: Of the 719 participants, 100 (16.2%) were aged between 15 and 17 years. HIV seroprevalence was somewhat lower among those aged 15 to 17 years (2.0%) compared with those aged 18 to 22 years (6.8%). Overall, the prevalence of hepatitis-B core antibody was significantly lower in the younger age group (5.0%) than in the older group (14.1%). The men aged 15 to 17 years used alcohol, ecstasy, and heroin less frequently than those aged 18 to 22 years. The age groups did not differ in the proportion of men who reported any unprotected anal intercourse in the previous 6 months (31.2%). In both age groups, use of amphetamines, ecstasy, and amyl nitrate was associated with unprotected anal intercourse. Self-acceptance of gay or bisexual identity was related to less sexual risk for those aged 15 to 17 years. In both age groups, greater safer sex self-efficacy was linked to less HIV sexual risk-taking. In the younger group, perceptions of peer norms that support safer sex were related to less risk behavior. CONCLUSIONS: Very young gay and bisexual men engage in unprotected anal sex at rates comparable with those for their somewhat older counterparts, raising serious concern over their risk of acquiring HIV infection. To prevent seroconversions, interventions must target those <18 years of age, and prevention programs should address the use of certain drugs in relation to sex and sexual risk-taking. To be most effective, programs should develop innovative communication strategies to take into account lack of self-acceptance of gay or bisexual identity and low self-efficacy for practicing safer sex.

HIV prevalence and associated risks in young men who have sex with men. Young Men's Survey Study Group.

CONTEXT: Studies conducted in the late 1980s on human immunodeficiency virus (HIV) infection among older men who have sex with men (MSM) suggested the epidemic had peaked; however, more recent studies in younger MSM have suggested continued high HIV incidence. OBJECTIVE: To investigate the current state of the HIV epidemic among adolescent and young adult MSM in the United States by assessing the prevalence of HIV infection and associated risks in this population in metropolitan areas. DESIGN: The Young Men's Survey, a cross-sectional, multisite, venue-based survey conducted from 1994 through 1998. SETTING: One hundred ninety-four public venues frequented by young MSM in Baltimore, Md; Dallas, Tex; Los Angeles, Calif; Miami, Fla; New York, NY; the San Francisco (Calif) Bay Area; and Seattle, Wash. SUBJECTS: A total of 3492 15- to 22-year-old MSM who consented to an interview and HIV testing. MAIN OUTCOME MEASURES: Prevalence of HIV infection and associated characteristics and risk behaviors. RESULTS: Prevalence of HIV infection was high (overall, 7.2%; range for the 7 areas, 2.2%-12. 1%) and increased with age, from 0% among 15-year-olds to 9.7% among 22-year-olds. Multivariate-adjusted HIV infection prevalence was higher among blacks (odds ratio [OR], 6.3; 95% confidence interval [CI], 4.1-9.8), young men of mixed or other race (OR, 4.8; 95% CI, 3. 0-7.6), and Hispanics (OR, 2.3; 95% CI, 1.5-3.4), compared with whites (referent) and Asian Americans and Pacific Islanders (OR, 1. 1; 95% CI, 0.5-2.8). Factors most strongly associated with HIV infection were being black, mixed, or other race; having ever had anal sex with a man (OR, 5.0; 95% CI, 1.8-13.8); or having had sex with 20 or more men (OR, 3.0; 95% CI, 2.0-4.7). Only 46 (18%) of the 249 HIV-positive men knew they were infected before this testing; 37 (15%) were receiving medical care for HIV, and 19 (8%) were receiving medical drug therapy for HIV. Prevalence of unprotected anal sex during the past 6 months was high (overall, 41%; range, 33%-49%). CONCLUSIONS: Among these young MSM, HIV prevalence was high, underscoring the need to evaluate and intensify prevention efforts for young MSM, particularly blacks, men of mixed race or ethnicity, Hispanics, and adolescents. JAMA. 2000;284:198-204

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.

Continuing high prevalence of HIV and risk behaviors among young men who have sex with men: the young men's survey in the San Francisco Bay Area in 1992 to 1993 and in 1994 to 1995.

Several recent studies have shown high rates of HIV infection and risk behavior among young men who have sex with men (MSM). To assess the direction of the epidemic in this population, we replicated a venue-based study performed in the San Francisco Bay Area during 1992 and 1993. From May 1994 to September 1995, we surveyed 675 MSM aged between 17 and 22. After statistical adjustment for age, ethnicity, residence, and site of recruitment, seroprevalence did not change significantly between the 1992 to 1993 (8.4%) and the 1994 to 1995 (6.7%) surveys. Similarly, no significant changes were found in the rates during the previous 6 months of unprotected receptive anal intercourse (23.4% versus 24.9%), injection drug use (8.0% versus 7.8%), or needle sharing among injection drug users (56.3% versus 64.5%) between the two surveys. Despite the increased attention that the problem of high risk behavior among young MSM has received, effective prevention interventions for MSM are needed as profoundly now as they had been several years ago.

HIV infection in disadvantaged out-of-school youth: prevalence for U.S. Job Corps entrants, 1990 through 1996.

To describe HIV infection prevalence and prevalence trends for disadvantaged out-of-school youth in the United States, we analyzed the HIV prevalence for and demographic characteristics of youth, aged 16 through 21 years, who entered the U.S. Job Corps from January 1990 through December 1996. Job Corps is a federally funded jobs training program for socially and economically disadvantaged out-of-school youth. All 357,443 entrants residing at Job Corps centers during their training were tested for HIV infection; 822 (2.3 per 1000) were HIV-positive. HIV prevalence was higher for women than for men (2.8 per 1000 versus 2.0 per 1000; relative risk [RR]=1.4; 95% confidence interval [CI]=1.2-1.6). Among racial/ethnic groups, prevalence was highest for African Americans (3.8 per 1000). Prevalence was higher for African American women (4.9 per 1000) than for any other gender and racial/ethnic group. From 1990 through 1996, standardized HIV prevalence-stratified by age, race/ethnicity, home region, population of home metropolitan statistical area, and year of entry--declined for women and for men: for women, from 4.1 per 1000 in 1990 to 2.1 per 1000 in 1996 (p=.001); and for men, from 2.8 per 1000 in 1990 to 1.4 per 1000 in 1996 (p=.001). These data suggest that HIV prevalence for disadvantaged out-of-school youth declined from 1990 through 1996. However, considering their youth, prevalence was still high, particularly for women and African Americans, most notably African American women. These data support the need for ongoing HIV prevention programs targeting such youth.

Risk profile of female sex workers who participate in a routine penicillin prophylaxis programme in Surabaya, Indonesia.

We conducted a sexually transmitted disease (STD) prevalence survey of 1867 female sex workers in Surabaya, Indonesia, some of whom reported participation in a routine penicillin prophylaxis programme. In Surabaya, 34% of female sex workers had received a prophylactic penicillin injection programme from the government within 28 days. Sex workers who had received routine prophylaxis injection were more likely to be less educated, to work in brothel complexes, and to have more customers per week than other sex workers. The prevalence rates of syphilis, gonorrhoea, chlamydia, and trichomoniasis were higher among sex workers who received the routine penicillin treatment than among those who had not received antibiotic treatment in the last 28 days. However, after adjustment for age, education, fee per sex act, number of customers, and condom use in the previous 7 days, only trichomoniasis was still significantly different (adjusted odds ratio of 3.2). High-risk women were more likely to participate in the routine penicillin prophylaxis programme. The lack of a demonstrable individual-level protection from this prophylaxis treatment programme in this cross-sectional study appears due to differential uptake of penicillin prophylaxis by women at higher presumptive risk for STD. Randomized clinical trials and mathematical modelling, together with observational data such as presented here, all can contribute to optimal understanding of a complex intervention like mass chemoprophylaxis for STD among female sex workers.

PIP: In Surabaya, Indonesia, routine prophylaxis injection with long-acting penicillin to prevent syphilis has been conducted among female prostitutes since 1957, with the goal of severing the syphilis transmission chain by maintaining a treponemicidal level of penicillin of greater than 0.03 mg/ml of blood in the target population. The program currently provides an intramuscular injection of 1.2 million units of benzathine penicillin once every 2 weeks. Based upon sexually transmitted disease (STD) survey data for 1867 female prostitutes in the city, findings are presented from a study comparing the risk profiles of women who participate in the prophylaxis program with women who do not. 635 (34%) of the prostitutes reported having received a prophylactic penicillin injection from the program within the 28 days preceding the survey. Women who had received an injection were more likely to be less educated, to work in brothel complexes, and to have more customers per week than the other prostitutes. Prevalence rates of syphilis, gonorrhea, chlamydia, and trichomoniasis were higher among prostitutes who received the routine penicillin treatment than among those who had not received antibiotic treatment in the past 28 days. However, after adjusting for age, education, fee per sex act, number of customers, and condom use during the preceding 7 days, only trichomoniasis remained significantly different. High-risk women were more likely to participate in the routine penicillin prophylaxis program. The lack of any demonstrable individual-level protection from this prophylaxis treatment program seems due to the differential uptake of penicillin prophylaxis by women at higher presumptive risk for STD.

Impact of increased legal access to needles and syringes on community pharmacies' needle and syringe sales--Connecticut, 1992-1993.

In May 1992, the Connecticut legislature passed new laws aimed at increasing injecting drug users' (IDUs) access to sterile needles and syringes (syringes); as of July 1992, pharmacists were permitted to sell and individuals were permitted to possess up to 10 syringes without medical prescriptions (nonprescription syringes). We evaluated the impact of the new laws by conducting (1) prospective surveillance of syringe sales and policies at selected community pharmacies (pharmacies) and (2) a telephone survey of pharmacy managers' reports of syringe sales and policies at a statewide stratified random sample of pharmacies. Our data provide direct evidence that most, but not all, Connecticut pharmacies sold nonprescription syringes when permitted to do so by the new laws. For example, using the telephone survey data, we estimate that during November, 1993, 83% [95% CI: 77-89%] of all Connecticut pharmacies sold nonprescription syringes and 56,000 [95% CI: 44,000-68,000] nonprescription syringes were sold, during November 1993. Our data provide indirect evidence that IDUs were purchasing nonprescription syringes at pharmacies. For example, in five Hartford pharmacies located in neighborhoods where injection drug use was prevalent, the total number of nonprescription syringes sold per month increased significantly from 460 in July 1992 to 2,482 in June 1993 (p = 0.0001). The data suggest that the new laws increased IDUs' access to sterile syringes in Connecticut.

Impact of increased legal access to needles and syringes on practices of injecting-drug users and police officers--Connecticut, 1992-1993.

To determine whether the simultaneous, partial repeal of needle prescription and drug paraphernalia laws in Connecticut affected purchasing and usage of needles and syringes (syringes) by injecting-drug users (IDUs) and risk of needlestick injuries to police officers, we conducted two serial cross-sectional surveys with IDUs recruited in drug treatment centers, correctional facilities, and health department settings. Reports of needlestick injuries among Hartford police officers were reviewed before and after the new laws. Among IDUs who reported ever sharing a syringe, syringe-sharing decreased after the new laws (52% before vs. 31% after; p = 0.02). Fewer IDUs reported purchasing syringes on the street after the new laws (74% before vs. 28% after; p < 0.0001). More IDUs reported purchasing syringes from a pharmacy after the new laws (19% before vs. 78% after; p < 0.0001). Eight to eleven months after the new laws were enacted, over two thirds (91 of 134) of active IDUs interviewed were aware of both new laws. Needlestick injury rates among Hartford police officers were lower after the new laws (six injuries in 1,007 drug-related arrests for 6-month period before new laws vs. two in 1,032 arrests for 6-month period after new laws). The changes in Connecticut laws were associated with decreases in self-reported syringe-sharing and increases in purchasing by IDUs of sterile syringes from reliable sources, suggesting that the simultaneous repeal of both prescription and paraphernalia laws is an important HIV prevention strategy.

The impact of HIV-1 infection on child survival in the developing world.

In this study we have used a mathematical projections model and HIV-1 seroprevalence data from samples of pregnant women to estimate infant HIV-1-infection prevalence and HIV-1-attributable mortality among children. This paper presents the results of samples from six developing country capitals and Martinique. The estimated impact of HIV-1 infection on overall infant mortality is low in regions where maternal HIV-1 seroprevalence is low and overall infant mortality is high, but substantial in locations where either maternal HIV-1 seroprevalence is high, or where maternal HIV-1 seroprevalence is moderate and overall infant mortality is low. The estimates for child (ages 1-4 years) and under-5 mortality suggest that the impact of HIV-1 infection on overall mortality in children may exceed the impact on infant mortality. The recent gains made in ensuring child survival are likely to be increasingly reversed in regions where HIV-1 infection is being transmitted in a substantial proportion of pregnancies and births.

PIP: A mathematical projections model was applied to human immunodeficiency virus (HIV)-1 data from samples of pregnant women in 6 capital cities in sub-Saharan Africa and the Caribbean as well as Martinique in order to estimate HIV-1 prevalence and HIV-attributable child mortality. Aside from Martinique, which was selected as a control, the 6 capital city samples were all from developing countries with high overall levels of infant and child mortality and low gross national products. The infant HIV-1 infection prevalence was arrived at by multiplying maternal seroprevalence rates in the capital city sample by current estimates of the vertical transmission rate (currently set at 24-39%). This methodology resulted in the following estimated percentages of infant HIV-1 infection prevalence: Martinique, 0.0.4%; Mozambique, 0.0-0.3%; Ivory Coast, 0.2-2%; Zaire, 1.8-3.5%; Haiti, 1.7-3.8%; Zambia, 2.5-5.0%; and Uganda, 4.5-11.5%. These prevalences were then multiplied by the probability of an HIV-infected liveborn dying at under 1 year and under 5 years of age. The estimates of under-5 years HIV-1-attributable mortality were as follows: Martinique, 1-3/1000 live births; MOZAMBIQUE, 0-2/1000; Ivory Coast, 1-17/1000; Zaire, 7-28/1000; Haiti, 7-30/1000; Zambia, 10-40/1000; and Uganda, 18-89/1000. In developing countries with low HIV-1 seroprevalence, children are at greatest risk of death in the 1st year of life. However, the estimates obtained in this study suggest that the impact of HIV-1 infection on child mortality may exceed the impact on infant mortality in regions with high rates of HIV-1 infection and undermine any gains that have been made in the area of child survival.

Pulse rate, blood pressure and body composition in black adolescents: the Philadelphia Blood Pressure Project.

Patterns of pulse rate, blood pressure (BP), and body size and composition are investigated in a black urban sample of over 600 adolescents (aged 12-17) in Philadelphia as part of the Philadelphia Blood Pressure Project. Supine and seated pulse rates decline after the age of 13 in both males and females, and females have significantly higher pulse rates than males, ranging from 1.6 to 4.7 beats/30 sec higher depending upon chronological age and position. Seated pulse rates are consistently higher than supine in both sexes ranging from 1.3 to 2.9 beats/30 sec depending upon chronological age. Pulse rate and both systolic blood pressure (SBP) and diastolic phase IV blood pressure (DBP) show a positive association throughout adolescence for females (r = 0.16 SBP, r = 0.24 DBP) but not for males (r = -0.06 SBP, r = 0.06 DBP). Females in the highest diastolic IV blood pressure stratum (greater than 85%) maintain higher pulse rates throughout adolescence, while males with the highest DBP have higher pulse rates in early adolescence (ages 12-14) but lower pulse rates in later adolescence (ages 16 and 17). Females with the highest DBP also show consistently higher measures of relative fatness (triceps skinfolds) throughout adolescence. Males with the highest DBP have greater triceps skinfolds in early adolescence and lower triceps in later adolescence, a pattern similar to that shown for pulse rate. For DBP, triceps is significantly and positively associated with pulse rate in the upper DBP percentile group (p less than 0.05). Thus, females with the highest blood pressure during adolescence are characterized by higher pulse rate and greater fatness. Males show this same pattern in early adolescence; whereas, in contrast, the older adolescent males in our sample with the highest DBP are characterized by lower pulse rates, relatively decreased fatness, and increased muscularity. Our findings suggest that, at least in some older black male adolescents, a higher DBP may reflect a decrease in cardiac output as indicated by a lower pulse rate, or an increase in peripheral vascular resistance, possibly associated with relatively decreased fatness and increased muscle mass for size.