Female spouses of injection drug users in Pakistan: a bridge population of the HIV epidemic?

An estimated 21% of injection drug users (IDUs) in Pakistan are HIV-positive and data suggest that the spouses of IDUs may be a critical component of the HIV transmission chain. This study interviewed 101 spouses of male IDUs about their sexual practices and drug use. We found that 43% had been sexually active with their partners in the past month but only 4% reported selling sex. Almost a quarter (23%) used drugs and 19% injected drugs, usually a combination of diazepam and pheniramine. Although sex work was infrequent among spouses of IDUs, their risk of contracting HIV and transmitting it to others was high because they received injection drugs, sometimes along with their IDU husbands, from the same health centres that provided therapeutic injections to the rest of the community. IDU spouses may thus serve as a bridge group via therapeutic injections, rather than via sex work.

Female spouses of injection drug users in Pakistan: a bridge population of the HIV epidemic?

An estimated 21% of injection drug users [IDUs] in Pakistan are HIV-positive and data suggest that the spouses of IDUs may be a critical component of the HIV transmission chain. This study interviewed 101 spouses of male IDUs about their sexual practices and drug use. We found that 43% had been sexually active with their partners in the past month but only 4% reported selling sex. Almost a quarter [23%] used drugs and 19% injected drugs, usually a combination of diazepam and pheniramine. Although sex work was infrequent among spouses of IDUs, their risk of contracting HIV and transmitting it to others was high because they received injection drugs, sometimes along with their IDU husbands, from the same health centres that provided therapeutic injections to the rest of the community. IDU spouses may thus serve as a bridge group via therapeutic injections, rather than via sex work

Comparative epidemiology of Chlamydia trachomatis infection among men attending sexually transmitted disease clinics with and without indication for testing.

Understanding the epidemiology of Chlamydia trachomatis infection in men without indication for testing (without symptoms, signs, or a report of sexual contact with an infected partner) is of crucial importance to reduce the heavy burden of this infection, particularly because this group of men is not usually offered testing in different clinical settings. Using electronic medical records of two STD clinics in Connecticut, 2000-02, this study identified the risk factors of C. trachomatis infection in men with and without indication for testing. In both groups, men who were younger than 30, African-American, or had a prior history of C. trachomatis infection were significantly more likely to be infected. Since a system for routine reproductive health care of young men does not currently exist, health-care providers need to promote an increased awareness of C. trachomatis infection among their male patients who are at increased risk of infection.

Barriers to completion of tuberculosis treatment among prisoners and former prisoners in St. Petersburg, Russia.

SETTING: St. Petersburg, Russian Federation. OBJECTIVES: To identify barriers to the completion of tuberculosis (TB) treatment among prisoners and former prisoners in St Petersburg, Russia. DESIGN: Questionnaires were administered to 60 prisoners and 40 former prisoners. Interviews were performed with prison and TB dispensary staff. Treatment follow-up rates were estimated by matching prison release records against attendance records from all 17 St. Petersburg-based TB dispensaries over an 18-month period. RESULTS: Of 80 released prisoners with active TB in 2002, 21 (26.3%) appeared in dispensary attendance records. Barriers to the completion of TB treatment overall were homelessness, unemployment, alcoholism, drug addiction and difficulty tolerating TB medications with co-morbid illnesses such as human immunodeficiency virus and hepatitis. Prisoners and former prisoners ranked help with obtaining an internal passport and money first, followed closely by food and a job, as the most desirable incentives to completing TB treatment. CONCLUSIONS: A future program for soon-to-be released and released prisoners in St. Petersburg that offers an array of desirable flexible social welfare services and incentives has the potential to attract and retain patients within TB treatment, but continued efforts must also be made to include drug treatment, job training and keeping former prisoners out of prison.

Epidemiology of Necator americanus hookworm infections in Xiulongkan Village, Hainan Province, China: high prevalence and intensity among middle-aged and elderly residents.

Hookworm is highly endemic to Hainan Province, an island located in the South China Sea. To investigate the prevalence and intensity of infection in the area, the village of Xiulongkan was surveyed between April and July 1998. A cross-sectional study was conducted in which fecal samples of 80% of the village residents (631 individuals) were tested for the presence of helminth eggs. Hookworm was the predominant intestinal helminth in Xiulongkan, where it was determined that 60% of those tested were infected. Necator americanus was the predominant species of hookworm in this population. The prevalence of hookworm increased with age, and then leveled to a plateau for ages 41 yr and up. This observation was in contrast to infections with Ascaris lumbricoides, where the highest prevalences occurred among school-aged children. Women had a significantly higher prevalence of hookworm than men and this difference emerged in early adulthood. The intensity of hookworm infection also significantly increased with age, with the highest intensity infections occurring among middle-aged and elderly residents. Females were more likely to have moderate or heavy infections, whereas males were more likely to have light infections. The rates of hookworm transmission are particularly high among the middle-aged and elderly residents of Xiulongkan.

Risk of perinatal transmission with treatment combinations of intrapartum and newborn zidovudine monotherapy.

OBJECTIVE: To determine perinatal transmission rates when zidovudine (ZDV) was given either to mothers after labor had begun, to their infants postnatally, or both. METHODS: Woman-infant pairs who received intrapartum and newborn ZDV therapy between January 1, 1992, and July 1, 1998, were considered. A medical record review identified female subjects known to be HIV-infected. All women who were given treatment with any antiretroviral drug before the onset of labor were excluded. All women satisfying eligibility criteria were enrolled. Nonparametric tests were used for analysis. The transmission rate of the study population was compared with rates reported for mother-infant pairs in the United States who did not receive ZDV. RESULTS: Administration of ZDV therapy after onset of labor resulted in a transmission rate of 11.9% (n = 59; 95% confidence interval [CI], 4.9 to 22.9). The overall perinatal transmission rate among women who received ZDV therapy after the onset of labor among sites in New York City was 6.3% (n = 32; CI, 0.8 to 20.8) compared with 18.5% (n = 27; CI, 6.3 to 38.0) among other sites. Administration of intrapartum therapy alone (n = 9), intrapartum plus newborn therapy (n = 37), and newborn therapy alone (n = 13) resulted in transmission rates of 11.1% (CI, 0.3 to 48.2), 13.5% (CI, 4.5 to 28.8), and 7.7% (CI, 0.2 to 36.0), respectively. CONCLUSION: The transmission rates reported here are lower than rates reported when antiretroviral therapy was not administered.

Prevalence of antibodies to human herpesvirus 8 (HHV-8) in Saudi Arabian patients with and without renal failure.

BACKGROUND: Kaposi's sarcoma (KS) is the most common cancer occurring in renal transplant recipients in Saudi Arabia, where the reported incidence of posttransplantation KS is 10 times higher than the incidence in the United States and Western Europe. The reason for the particularly high incidence of posttransplantation KS in this geographic area is unknown. METHODS: To explore the possibility that the high incidence of posttransplantation KS might be the result of widespread infection with human herpesvirus 8 (HHV-8), we determined the prevalence of antibodies to HHV-8 in 201 patients with end-stage renal disease (ESRD) and a comparison group of 358 individuals without renal disease who were similar in age, sex, and area of residence. Antibodies to lytic cycle antigens of HHV-8 were determined by indirect immunofluorescence and confirmed by immunoblots using tetradecanoyl phorbol ester acetate-induced BC-3 cell extracts and recombinant small viral capsid antigen (ORF65). RESULTS: Antibodies to HHV-8 were detected in serum samples from 14 (6.97%) of 201 ESRD patients and from 10 (3.88%) of 258 in the comparison group (P=0.14). HHV-8 seropositive individuals were on average 10 years older than seronegative subjects (55.3 years vs. 46.9 years). Among HHV-8 seropositive subjects, 71% were male and 29% were female. CONCLUSIONS: Serologic evidence of HHV-8 infection was numerically more common in men and in patients with ESRD. However, among patients with and without ESRD, the strongest association was with increasing age.

The social geography of AIDS and hepatitis risk: qualitative approaches for assessing local differences in sterile-syringe access among injection drug users.

While significant gains have been achieved in understanding and reducing AIDS and hepatitis risks among injection drug users (IDUs), it is necessary to move beyond individual-level characteristics to gain a fuller understanding of the impact of social context on risk. In this study, 6 qualitative methods were used in combination with more traditional epidemiologic survey approaches and laboratory bioassay procedures to examine neighborhood differences in access to sterile syringes among IDUs in 3 northeastern cities. These methods consisted of (1) neighborhood-based IDU focus groups to construct social maps of local equipment acquisition and drug use sites; (2) ethnographic descriptions of target neighborhoods; (3) IDU diary keeping on drug use and injection equipment acquisition; (4) ethnographic day visits with IDUs in natural settings; (5) interviews with IDUs about syringe acquisition and collection of syringes for laboratory analysis; and (6) focused field observation and processual interviewing during drug injection. Preliminary findings from each of these methods are reported to illustrate the methods' value in elucidating the impact of local and regional social factors on sterile syringe access.

Syringe source, use, and discard among injection-drug users in New Haven, Connecticut.

We examined syringe source, use, and discard practices of injection-drug users (IDUs) in New Haven, Connecticut, a city with both a legal syringe-exchange program (SEP) and non-prescription availability of syringes through pharmacies. The population demographics, syringe use, and discard practices of IDUs who obtained syringes from various sources were compared using structured interview data. Of the 373 IDUs recruited, 268 (72 percent) resided in the city of New Haven. Among the New Haven IDUs, 111 (41 percent) reported pharmacies, 36 (13 percent) reported the New Haven SEP, 90 (34 percent) reported both, and 27 (10 percent) reported neither as their usual source of syringes in the past six months. No significant differences (p value < 0.05) were observed among New Haven IDUs who relied on pharmacies versus the SEP. However, IDUs who relied on the SEP were significantly less likely to report they threw away used syringes, compared with pharmacy users. Both the pharmacies and the New Haven SEP are important sources of sterile syringes for IDUs in New Haven. The lower frequency of syringe discard by IDUs who obtained their syringes primarily through the SEP indicates another public health benefit of programs such as these.

Health care delivery strategies for criminal offenders.

Men and women under correctional supervision may be the most challenging population of public health concern. Prison inmates, parolees, and probationers experience prevalent infectious disease including HIV and hepatitis C. Many supervised individuals have significant mental or behavioral health problems that require clinical intervention. The U.S. correctional population is also rapidly growing, and now includes more than 5 million men and women. Concerns about quality, accessibility, and cost of correctional care have prompted calls for managed care models in this population. This paper reviews pertinent experiences within Medicaid managed care and suggests four interconnected strategies--outreach, discharge planning, entitlement security, and case management--to improve the quality and efficiency of correctional care.

Evaluation of an innovative program to address the health and social service needs of drug-using women with or at risk for HIV infection.

Drug-using women with or at risk for HIV infection have many competing unmet needs, especially for social services, drug treatment, and medical care. High-risk drug-using women were recruited through street outreach, at needle exchange sites, a prison, and local community based organizations in New Haven, Connecticut for a study of the service needs of out-of-treatment drug users and the ability of an interactive case management intervention (ICM) to address those needs. These women were administered baseline and follow-up interviews to identify their health and social service needs and the degree to which these needs were resolved. The women who chose to enroll in the interactive case management intervention (n = 38) did not differ demographically nor in their HIV risk behaviors from those not receiving case management (n = 73). Provision of ICM was most successful in meeting needs for supportive mental health counseling, basic services, and long term housing. The impact of interactive case management was less evident for the acquisition of medical and dental services, which were accessed comparably by women not receiving the intervention. Overall, the women who enrolled in the ICM intervention showed a significant decrease in the number of unmet service needs as compared to those who did not enroll. Multiple contacts were required by the case manager to establish trust and to resolve the unmet service needs of these high-risk women. Women with or at risk for HIV infection can be effectively engaged in an ICM intervention in order to meet their multiple unmet service needs, although such interventions are time-and-labor intensive.

Syringe use and reuse: effects of syringe exchange programs in four cities.

We determined the effect of syringe exchange programs (SEPs) on syringe reuse patterns. Five methods were employed to estimate injections per syringe made by exchange clients in four cities. In San Francisco, Chicago, and Baltimore, self-reported data on the number of injections per syringe were obtained. In New Haven, self-reported injection frequencies were combined with syringe tracking data to derive two methods for estimating the mean injections per syringe. The average number of injections per syringe declined by at least half after establishment of SEPs in New Haven, Baltimore, and Chicago, all cities where such an analysis could be made. There were significant increases in the percentages of exchangers reporting once-only use of their syringes in San Francisco, Baltimore, and Chicago, all cities where the data were amenable to this form of analysis. Self-report and syringe tracking estimates were in agreement that SEP participation was associated with decreases in syringe reuse by drug injectors. SEP participation was associated with increases in the once-only use of syringes. These findings add to earlier studies supporting the role of SEPs in reducing the transmission of syringe-borne infections such as HIV and hepatitis.

Hepatitis in used syringes: the limits of sensitivity of techniques to detect hepatitis B virus (HBV) DNA, hepatitis C virus (HCV) RNA, and antibodies to HBV core and HCV antigens.

Hepatitis virus infections are common among injecting drug users. Syringes containing hepatitis B virus (HBV) DNA and hepatitis C virus (HCV) RNA were identified by polymerase chain reaction (PCR); syringes containing antibodies to HBV core antigen and HCV were identified by EIA. Syringe use was simulated to determine the sensitivity of these assays. The mean limits for PCR were 0.082 microliter of blood for HBV and 0.185 microliter for HCV; the mean limits for EIA were 0.185 microliter for HBV and 0.023 microliter for HCV. HBV PCR testing of 681 syringes returned to the needle exchange program in New Haven, Connecticut, revealed a decline from 7.8% HBV-positive at the program's outset to 2.6%. HCV antibodies were found in 12.1% of 207 syringes tested. Syringe testing can help estimate the prevalence and incidence of hepatitis virus infections when standard seroepidemiologic analyses cannot be applied.

'Dropouts' or 'drop-ins'? Client retention and participation in New Haven's needle exchange program.

Although evidence is accumulating that needle exchange programs can lower the risk of parenterally transmitted infections, their effectiveness is compromised if they suffer from low client participation. A legal needle exchange in New Haven, CT, has been studied since its inception in November 1990, employing a tracking system to analyze the characteristics of clients participating during the first 20 months of the program. Thirty-four percent of injection drug users who enrolled in the program during the study period made only a single visit. Younger clients were more likely to be in the single visit group. For clients who visited the program more than once, the retention fraction, defined as the ratio of total client-specific observed person-days to full enrollment person-days during the 20-month study period was 67.7 percent, with a median duration of participation of 333 days. Further analysis of the client characteristics, based on surveys completed upon enrollment in the program, revealed several predictors of continuing participation. Most significant were the observations that (a) those injecting for 10 years or longer participated longer than clients who injected drugs for less than 10 years and (b) nonwhite injectors participated longer than whites. The longest duration of participation (median = 501 days) was among nonwhite injectors with 10 years or more of injecting history. There have been limited data on client participation in needle exchange programs. This gap in information must be overcome to allow thorough evaluations of such programs.

A decline in HIV-infected needles returned to New Haven's needle exchange program: client shift or needle exchange?

The New Haven needle exchange program experienced a significant decline in the fraction of returned needles containing human immunodeficiency virus 1 (HIV-1) proviral DNA. Is this decline due to the operations of the needle exchange or to a shift in clients? Analysis of demographic and behavioral data revealed that only one variable, the race of participating clients, changed significantly over time. However, HIV-1 prevalences in needles given to Whites and to non-Whites were not statistically different. Thus, client shift cannot be responsible for the decline in the observed HIV prevalence in needles. Instead, needle circulation times were a significant predictor of HIV prevalence.

Needle exchange decreases the prevalence of HIV-1 proviral DNA in returned syringes in New Haven, Connecticut.

PURPOSE: To report on the deployment of the syringe tracking and testing system in the New Haven needle exchange program, which is the first federally funded evaluation of a needle exchange program conducted in the United States. PATIENTS AND METHODS: A legal needle exchange for intravenous drug users began in New Haven, Connecticut, in November 1990. All syringes distributed by the program received unique tracking codes. Syringes were tracked and HIV-1 proviral DNA prevalence in returned syringes was assessed using polymerase chain reaction and Southern blotting. RESULTS: At the outset of the program, the prevalence of HIV-1 proviral DNA in syringes exceeded two thirds. Prevalence decreased rapidly to less than 45% during the first 3 months of the program and remained at this level for the following 10 months. During the periods of decreasing prevalence and subsequent steady state, no changes in the demographics of program participants or in the drug use habits of newly enrolling clients that could account for the decrease in HIV-1 prevalence in needles were detected. In addition, the program referred almost 20% of its clients to drug treatment programs. CONCLUSION: The needle exchange program in New Haven has decreased the percentage of syringes testing positive for HIV-1 proviral DNA among needle exchange clients while simultaneously serving as an entry point for drug treatment.

Flavivirus type-specific antigens produced from fusions of a portion of the E protein gene with the Escherichia coli trpE gene.

Based on previous data showing that JEV and DEN-1 fusion proteins can be used as antigens, we engineered analogous fusion proteins for the same regions of the E proteins of DEN-2, DEN-3, and DEN-4, using the polymerase chain reaction. The resulting fusion proteins were tested in a modified ELISA for their reactivity with mouse immune ascitic fluids (MIAF) generated against 10 different flaviviruses. The results showed that these recombinant antigens could be used as type-specific immunological reagents, and suggest that these antigens could serve as the basis for rapid, safe, and inexpensive flavivirus serosurveys.