Factors associated with sex trade involvement among male participants in a prospective study of injection drug users.

OBJECTIVES: While much research to date has examined female sex trade work, little has been done to evaluate factors associated with male sex trade involvement or to assess their health service needs. This is particularly true for male sex trade workers who are also injection drug users (IDUs). Therefore, the present analyses were undertaken to evaluate factors associated with sex trade work in a prospective cohort study of male IDUs. METHODS: We identified factors associated with sex trade involvement among male participants enrolled in the Vancouver Injection Drug Users Study (VIDUS). Since serial measures for each individual were available at semiannual intervals, variables potentially associated with sex trade involvement were evaluated with adjusted odds ratios (AOR) and 95% confidence intervals (CI) computed using generalised estimating equations (GEE). RESULTS: Between 1996 and 2003, 995 male IDUs were enrolled into the VIDUS cohort among whom 108 (11%) reported being involved in the sex trade at enrolment and 102 (10%) individuals initiated sex trade involvement during the follow up period. In multivariate analyses, factors independently associated with sex trade involvement included HIV positive serostatus (AOR: 1.77 (95% CI: 1.44 to 2.17)), daily cocaine injection (AOR: 1.37 (95% CI: 1.11 to 1.70)), daily crack smoking (AOR: 1.36 (95% CI: 1.07 to 1.72)), borrowing syringes (AOR: 1.73 (95% CI: 1.32 to 2.25)), and inconsistent use of condoms with casual sexual partners (AOR 0.66, CI 0.53 to 0.82). We also found that male sex trade workers were more likely to report having sought but been unable to access substance abuse treatment (AOR: 1.28 (95% CI: 0.98 to 1.67); p=0.076). CONCLUSIONS: Males involved in the sex trade in this setting have higher levels of HIV infection and engage in risky injection behaviours at an elevated rate. Since these behaviours have major implications for HIV acquisition and public health, prevention efforts and targeted provision of addiction treatment to this population should be expanded.

Detection of Kaposi's sarcoma-associated herpesvirus in oral and genital secretions of Zimbabwean women.

Kaposi's sarcoma-associated herpesvirus (KSHV) in oral and genital secretions of women may be involved in horizontal and vertical transmission in endemic regions. Nested polymerase chain reaction assays were used to detect KSHV DNA sequences in one-third of oral, vaginal, and cervical specimens and in 42% of peripheral blood mononuclear cell (PBMC) specimens collected from 41 women infected with human immunodeficiency virus type 1 who had Kaposi's sarcoma (KS). KSHV DNA was not detected in specimens from 100 women without KS, 9 of whom were seropositive for KSHV. A positive association was observed between KSHV DNA detection in oral and genital mucosa, neither of which was associated with KSHV DNA detection in PBMC. These data suggest that KSHV replicates in preferred anatomic sites at levels independent of PBMC viremia. Detection of genital-tract KSHV only among relatively immunosuppressed women may provide an explanation for infrequent perinatal transmission of KSHV.

Association of antiretroviral therapy with detection of HIV-1 RNA and DNA in the anorectal mucosa of homosexual men.

OBJECTIVE: To determine whether combination antiretroviral therapy is associated with reduced detection of HIV-1 RNA and DNA in the anorectal mucosa of men who have sex with men (MSM). DESIGN: Cross-sectional study of 233 MSM recruited from community and clinic sites in Seattle, Washington between July 1996 and December 1997. METHODS: HIV-1 RNA and HIV-1 DNA were detected in anorectal swab specimens by polymerase chain reaction amplification assays. RESULTS: HIV-1 RNA was detected significantly less often in anorectal specimens from users of combination antiretroviral therapies, whether a protease inhibitor was received (15/89; 17%) or not (16/53; 30%), than in men not receiving therapy (43/88; 49%) (P < 0.001, P = 0.03, respectively). In contrast, HIV-1 DNA was detected only slightly less frequently in anorectal specimens obtained from men receiving protease inhibitors (35/81; 43%) or reverse transcriptase inhibitors alone (22/48; 46%) than in specimens from men not receiving therapy (45/78; 58%) (P = 0.07, P = 0.20, respectively). Among men with < 50 copies HIV-1 RNA/ml plasma, detection of HIV-1 RNA in anorectal specimens was rare (1/54; 2%) but detection of HIV-1 DNA was common (14/50; 28%). CONCLUSIONS: Combination antiretroviral therapy is associated with reductions in HIV-1 RNA, but HIV-1 DNA remains detectable in the anorectal canal of almost half of MSM receiving such therapy. Condom use during anal intercourse should be encouraged, regardless of plasma viral load response to potent antiretroviral therapy.

Determinants of human immunodeficiency virus DNA and RNA shedding in the anal-rectal canal of homosexual men.

To define the determinants of anal-rectal shedding of human immunodeficiency virus (HIV) DNA and RNA, 374 HIV-seropositive homosexual men were tested. Factors independently associated with detection of anal-rectal HIV DNA included anal-rectal inflammation and detection of anal human papillomavirus DNA; predictors of HIV RNA included detection of anal-rectal HIV DNA, anal-rectal inflammation, and high plasma HIV RNA levels. The latter (>10,000 copies/mL) was the main determinant of anal-rectal HIV RNA shedding when HIV DNA (e.g., HIV-infected cells) was not detected in the anal-rectal sample. The local presence of HIV-infected cells and local inflammation were the principal determinants of HIV RNA among those with low (<10,000 copies/mL) plasma HIV RNA load. Among those with anal-rectal HIV DNA present, increased HIV RNA plasma load did not increase the risk of shedding of HIV RNA into the anal-rectal canal.

Risk behavior and HIV seroincidence among out-of-treatment injection drug users: a four-year prospective study.

We monitored trends in HIV risk behaviors and seroconversion among out-of-treatment injection drug users (IDUs) receiving street-based outreach intervention. Beginning in 1988, 641 HIV-seronegative IDUs were recruited by targeted sampling methods to reflect broader IDU populations and were followed for 4 years (1988-1992). All were active injectors not in treatment when recruited. Cohort members were targets of HIV-prevention outreach. The intervention was guided by the Indigenous Leader Outreach Model: Exaddicts deliver HIV-prevention services targeting IDU social networks in community settings. Primary outcome measures were HIV seroconversion and HIV risk behaviors. Observed incidence of HIV infection decreased, from 8.4 to 2.4 per 100 person-years. Prevalence of drug risk behaviors also decreased, from 100 to 14%. Seroconversion was associated with injection risk behavior [risk ratio (RR) = 9.8]. Sex risk behavior also decreased, but less dramatically, from 71 to 45%. Out-of-treatment IDUs in Chicago have reduced their rates of new HIV infection by reducing their injection risk behavior. New infections were strongly associated with injection risk behavior but not with sex risk behavior.

HIV seropositivity in community-recruited and drug treatment samples of injecting drug users.

OBJECTIVE: To assess the representativeness of drug use treatment samples for measuring HIV seroprevalence among injecting drug users (IDU) in community settings. DESIGN: Seroprevalence was determined in two cross-sectional, convenience samples including an unlinked survey of IDU entrants to all publicly-funded drug-treatment programs and a survey of community-recruited IDU. METHODS: Unconditional logistic regression [odds ratio (OR)] was used to calculate unadjusted and adjusted OR to measure the association between HIV seropositivity and site of recruitment. RESULTS: Between 1988 and 1989, 25% of 870 community-recruited IDU were seropositive, compared with 13% of 671 entrants to drug-treatment programs. This twofold risk of HIV seropositivity among community-recruited IDU remained after adjustment for sample differences in gender, race-ethnicity, and age group (adjusted OR, 2.09; 95% confidence interval, 1.58-2.78). CONCLUSIONS: These results suggest the importance of extending HIV surveillance outside of drug-treatment facilities. Active serologic surveillance may be feasible by coupling recent saliva and fingerstick sampling techniques with existing community outreach education efforts.

Cost-effectiveness of drug abuse treatment for primary prevention of acquired immunodeficiency syndrome: epidemiologic considerations.

The prevention of AIDS has justified recent increases in drug abuse treatment expenditures. Three of the epidemiologic considerations involved in assessing the cost-effectiveness of drug treatment for primary prevention of AIDS among IV drug users were discussed. First, the considerable geographic variation in the prevalence of the virus that causes AIDS suggests that areas with relatively low infection levels may be more cost-effective targets when allocating limited drug abuse treatment resources. Expansions and modifications in the current national HIV-1 serologic surveillance system will be needed to make informed resource allocation decisions. Second, when comparing the cost-effectiveness of two alternative treatment modalities or programs, the number of new HIV-1 infections does not appear to be an appropriate outcome measure. Serologic testing should be supplemented with self-reported drug use behaviors, with or without drug testing. Finally, significant opportunity costs may be associated with employing drug abuse treatment as the principal approach to primary prevention of HIV-1 infection among IVDUs, when alternative and complementary approaches are also effective. Specifically, treatment expansion is unlikely to be cost-effective when the demand for publicly funded treatment slots exceeds the number available and in communities where only a small minority of IVDUs are enrolled in treatment.

Primary prevention of HIV-1 infection among intravenous drug users.

Recent epidemiologic data underscore the importance of primary prevention programs for promoting behavioral change to reduce the risk of HIV-1 infection among intravenous drug users (IVDUs). Optimal allocation of prevention resources requires expansion of current serologic surveillance with increased attention to areas with relatively low infection levels. Comprehensive AIDS prevention strategies must provide support for abstinence and promote reductions in the sharing of contaminated injection equipment among IVDUs both in and out of drug treatment programs. Preliminary results from outreach programs in multiple sites suggest their efficacy in recruiting drug treatment entrants and promoting risk reduction.

Prevention of human immunodeficiency virus infection: our responsibilities as health care professionals.

The prevention of human immunodeficiency virus (HIV) infection is a major responsibility of health care professionals. This paper deals with the virus itself--its history and prevalent modes of transmission. The low risk of HIV transmission in health care settings and through casual contact is emphasized. A discussion of prevalence rates in the United States is followed by an explanation of methods to prevent HIV infection through testing, counseling, limiting sexual transmission, screening of blood and blood products, reducing risk among intravenous drug users, avoiding perinatal transmission, practicing safety measures in health care settings, and implementing educational goals.