Evaluation of a TB infection control implementation initiative in out-patient HIV clinics in Zambia and Botswana.

SETTING: Out-patient human immunodeficiency virus (HIV) care and treatment clinics in Zambia and Botswana, countries with a high burden of HIV and TB infection. OBJECTIVE: To develop a tuberculosis infection control (TB IC) training and implementation package and evaluate the implementation of TB IC activities in facilities implementing the package. DESIGN: Prospective program evaluation of a TB IC training and implementation package using a standardized facility risk assessment tool, qualitative interviews with facility health care workers and measures of pre- and post-test performance. RESULTS: A composite measure of facility performance in TB IC improved from 32% at baseline to 50% at 1 year among eight facilities in Zambia, and from 27% to 80% at 6 months among 10 facilities in Botswana. Although there was marked improvement in indicators of managerial, administrative and environmental controls, key ongoing challenges remained in ensuring access to personal protective equipment and implementing TB screening in health care workers. CONCLUSION: TB IC activities at out-patient HIV clinics in Zambia and Botswana improved after training using the implementation package. Continued infrastructure support, as well as monitoring and evaluation, are needed to support the scale-up and sustainability of TB IC programs in facilities in low-resource countries.

Antiretroviral therapy uptake among adult tuberculosis patients newly diagnosed with HIV in Nyanza Province, Kenya.

SETTING: In 2008, the Kenya tuberculosis (TB) program reported low (31%) antiretroviral therapy (ART) uptake among human immunodeficiency virus (HIV) infected TB patients. OBJECTIVE: To confirm ART coverage and identify factors associated with HIV clinic enrollment and ART initiation among TB patients. DESIGN: Retrospective chart abstraction of adult TB patients newly diagnosed with HIV and eligible for ART at 58 Nyanza Province TB clinics between October 2006 and April 2008. TB data were linked to HIV clinic data at 50 facilities that provided ART. Associations with HIV clinic enrollment and ART were evaluated. RESULTS: Among 1137 ART-eligible TB patient records sampled, 32% documented HIV clinic enrollment and 29% ART. Date fields were largely incomplete; 11% of the patient records included HIV testing dates and ≤1% had dates for cotrimoxazole prophylaxis, HIV clinic enrollment and ART initiation. Adding HIV clinic data increased HIV clinic enrollment and ART documentation to respectively 62% and 44%. Among TB patients in HIV care, female sex, older age group and baseline CD4 documentation were associated with ART initiation. CONCLUSION: Linking data increased documentation of HIV clinic enrollment and ART uptake. Continued efforts are required to improve the documentation of HIV service delivery, especially in TB clinics. Interventions to increase ART uptake are needed for younger patients and men.

Association between crack cocaine use and high-risk sexual behaviors after HIV diagnosis.

OBJECTIVE: To describe the prevalence of crack cocaine use in an HIV-infected population and to examine the association between crack use after HIV diagnosis and high-risk sexual behaviors for heterosexual men, heterosexual women, and men who have sex with men (MSM). METHODS: Analysis of cross-sectional interviews conducted from January 1995 through December 1998 with HIV infected adults in 12 states. RESULTS: Of 10,415 persons with HIV or AIDS, 66.6% never used crack, 10.7% used crack before HIV diagnosis but not after, and 22.7% used crack after diagnosis. High-risk sexual behaviors were more prevalent among those who had ever used crack and were most prevalent among those who used crack after diagnosis. In multivariable analyses, crack use after diagnosis was associated with having multiple sex partners and trading sex for drugs/money in all three groups: heterosexual men, heterosexual women, and MSM. For heterosexual women and MSM, crack use after diagnosis was associated with unprotected sex with a main partner, and among heterosexual men and MSM, with unprotected sex with casual partners. CONCLUSIONS: Crack use after HIV diagnosis was associated with high-risk sexual behaviors. Treatment programs to assist people in quitting crack are needed to help reduce the risk of HIV transmission from this population.

Risk behaviors related to heterosexual transmission from HIV-infected persons. Supplement to HIV/AIDS Surveillance Study Group.

BACKGROUND: To monitor heterosexually acquired HIV infection, it is important to understand transmission from persons infected with HIV to their sex partners. GOAL: To describe sexual behaviors of persons infected with HIV that are related to transmission. STUDY DESIGN: Cross-sectional interviews were conducted from January 1995 to December 1998. RESULTS: Of 4743 heterosexual respondents who had known about their HIV infection for 1 year or longer, 42% were not sexually active and 13% had one sex partner with HIV; the remaining 2099 comprised the sample for analysis. Most respondents were male, black, and of low socioeconomic status. Approximately 60% reported one or more sexual risk behavior. Steady partner's HIV status was the strongest predictor in most models for risk behaviors; those with a partner who was not infected were significantly less likely than those with an infected partner to report any sexual transmission risk behavior (P < 0.05). CONCLUSIONS: The findings point to a continued need to focus on behavioral prevention measures that reduce the heterosexual transmission of HIV.

Human immunodeficiency virus infection in rural areas and small cities of the southeast: contributions of migration and behavior.

The design of education and prevention strategies to stem the spread of human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) in rural areas depends on having accurate patterns of risk behavior and transmission in local areas. Interviews were conducted with people in rural areas and small cities in Delaware, Florida, Georgia and South Carolina who were at least 18 years old and infected with HIV in order to describe demographic characteristics, migration patterns and risk behaviors. Interviews were conducted with 608 people. Most respondents were male (66 percent), black (63 percent of men, 85 percent of women) and had been infected through sexual contact (67 percent of men, 66 percent of women). Most (65 percent) had lived away from a rural area or small city for at least one month; of those, 71 percent had moved from an urban area. Twenty-seven percent of respondents indicated they had been infected locally. People with a history of injection drug use were less likely to have been infected locally than those who had no history of injection drug use (6 percent vs. 26 percent among men, 3 percent vs. 40 percent among women, P < 0.001). Further understanding of the role of socioeconomic factors in HIV transmission in rural areas and small cities is needed. Programs designed to prevent HIV acquisition among people living in rural areas and small cities in the Southeast should focus on sexual behavior.

Effect of HIV reporting by name on use of HIV testing in publicly funded counseling and testing programs.

CONTEXT: Policies requiring confidential reporting by name to state health departments of persons infected with the human immunodeficiency virus (HIV) have potential to cause some of them to avoid HIV testing. OBJECTIVE: To describe trends in use of HIV testing services at publicly funded HIV counseling and testing sites before and after the implementation of HIV reporting policies. DESIGN AND SETTING: Analysis of service provision data from 6 state health departments (Louisiana, Michigan, Nebraska, Nevada, New Jersey, and Tennessee) 12 months before and 12 months after HIV reporting was introduced. MAIN OUTCOME MEASURE: Percent change in numbers of persons tested at publicly funded HIV counseling and testing sites after implementation of confidential HIV reporting by risk group. RESULTS: No significant declines in the total number of HIV tests provided at counseling and testing sites in the months immediately after implementation of HIV reporting occurred in any state, other than those expected from trends present before HIV reporting. Increases occurred in Nebraska (15.8%), Nevada (48.4%), New Jersey (21.3%), and Tennessee (62.8%). Predicted decreases occurred in Louisiana (10.5%) and Michigan (2.0%). In all areas, testing of at-risk heterosexuals increased in the year after HIV reporting was implemented (Louisiana, 10.5%; Michigan, 225.1 %; Nebraska, 5.7%; Nevada, 303.3%; New Jersey, 462.9%; Tennessee, 603.8%). Declines in testing occurred among men who have sex with men in Louisiana (4.3%) and Tennessee (4.1%) after HIV reporting; testing increased for this group in Michigan (5.3%), Nebraska (19.6%), Nevada (12.5%), and New Jersey (22.4%). Among injection drug users, testing declined in Louisiana (15%), Michigan (34.3%), and New Jersey (0.6%) and increased in Nebraska (1.7%), Nevada (18.9%), and Tennessee (16.6%). CONCLUSIONS: Confidential HIV reporting by name did not appear to affect use of HIV testing in publicly funded counseling and testing programs.

Geographic differences in noninjection and injection substance use among HIV-seropositive men who have sex with men: western United States versus other regions. Supplement to HIV/AIDS Surveillance Study Group.

To study the prevalence of and factors associated with the use of alcohol and nonprescription drugs by HIV-seropositive men who have sex with men (MSM) and to describe variations in alcohol and nonprescription drug use by geographic region, we analyzed data from a multistate, population- and facility-based interview study conducted in 12 U.S. states and metropolitan areas. Among 9735 MSM with HIV infection or AIDS who completed a 45-minute interview, nearly one third reported possible alcohol abuse. Large proportions of MSM also reported the use of marijuana (51%), noninjected cocaine (31%), and crack cocaine (16%) in the 5 years before the interview. Smaller proportions of MSM reported ever having injected cocaine (13%), stimulants (8%), and heroin (8%). Results of logistic regression indicated that in the 5 years before interview, white MSM were significantly (p < .01) more likely than referent (mostly Hispanic) MSM to report use of hallucinogens, marijuana, nitrites, noninjected amphetamines, and diazepam; black MSM were significantly more likely than referent MSM to report use of noninjected crack cocaine. Use of injected stimulants was significantly associated with white race versus referent MSM, and residing in the West versus East. The prevalence of alcohol and drug use among HIV-seropositive MSM is high, and prevalences and types of substance use differ by region and racial/ethnic group. To prevent HIV transmission in this population, health departments and community-based organizations must understand the unique local patterns of substance use to develop effective substance abuse prevention and treatment programs.

Gonorrhea in the United States, 1981-1996. Demographic and geographic trends.

OBJECTIVE: To describe demographic and geographic trends in gonorrhea incidence in the United States from 1981 through 1996. STUDY DESIGN: We analyzed aggregate gonorrhea cases reported to the Centers for Disease Control and Prevention by the 50 states, District of Columbia, and 63 large cities. Annual incidence rates (cases/100,000 persons) were calculated. RESULTS: Between 1981 and 1996, the incidence of reported gonorrhea decreased 71.3%, from 431.5 to 124.0 cases/100,000. However, rates among blacks were 35 times higher than rates among whites in 1996 (684.6 versus 19.4) compared with 11 times higher in 1981 (1,894.3 versus 164.3). Among women of all races, 15 to 19 year olds had the highest rates (716.6 in 1996), whereas among men, 20 to 24 year olds had the highest rates (512.9 in 1996). Southern states had higher rates than other regions. CONCLUSIONS: Large segments of the population, including adolescents, young adults, and blacks, continue to have high rates of gonococcal infection; prevention programs and health care providers should address the needs of these groups.

Sociodemographic factors and the variation in syphilis rates among US counties, 1984 through 1993: an ecological analysis.

OBJECTIVES: Syphilis in the United States is focally distributed, with high incidence rates in the South and in metropolitan areas nationwide. In this study an ecological analysis, using the county as the unit of analysis, was performed to generate hypotheses about community-level determinants of syphilis rates. METHODS: Bivariate rank correlations and multivariate, backward stepwise elimination linear regressions were performed. Mean annual incidence of primary- and secondary-stage syphilis in a county was the dependent variable, and county sociodemographic characteristics (from census data) were the independent variables. RESULTS: In the multivariate regression model, sociodemographic characteristics accounted for 71% of the variation in syphilis rates among counties. With other factors accounted for, the most highly correlated characteristics were percentage non-Hispanic Black population, county location in the South, percentage of the population that was urban, percentage Hispanic population, and percentage of births to women younger than 20 years. CONCLUSIONS: Most of the variation in syphilis rates among counties is accounted for by sociodemographic characteristics. Identification and remediation of modifiable health determinants for which these factors are markers are needed to improve the health status of these populations.

Selective screening versus presumptive treatment criteria for identification of women with chlamydial infection in public clinics: New Jersey.

OBJECTIVE: Our goals were to determine the prevalence of chlamydial infection, to identify criteria for selective screening, and to compare the sensitivity of selective screening to presumptive treatment criteria in different clinical settings. STUDY DESIGN: A total of 5128 women enrolled in a cross-sectional study in public clinics in New Jersey. Univariate and multivariate methods of statistical analysis were used. RESULTS: The prevalence of chlamydia varied across type of public clinic and ranged from 8% to 15%. Selective screening criteria were developed for women attending each type of public clinic by use of risk factors significant in the multivariate analyses. A combination of young age and attending an urban clinic was highly predictive of chlamydia infection and identified a minimum of 85% of infected women in all public clinic settings. The use of presumptive treatment criteria identified 78% of infected women in sexually transmitted disease clinics but only 4% to 9% of infected women in other clinical settings. CONCLUSIONS: A chlamydia program that includes presumptive treatment of women attending sexually transmitted disease clinics and selective screening of women in other clinical settings where women are more likely to asymptomatic is a clinically appropriate and economically feasible approach to directing treatment of women with chlamydial infection.

Epidemiology of syphilis in the United States, 1941--1993.

BACKGROUND AND OBJECTIVES: The distribution and trends of syphilis are influenced by biologic factors, sexual behaviors, biomedical technology, availability of and access to health care, public health efforts, changes in population dynamics, and sociocultural factors. The objective of this article is to review the epidemiology of syphilis in the United States during the period 1941-1993 in the context of some of these factors. STUDY DESIGN: Surveillance data on cases of syphilis and congenital syphilis reported by state and city health departments to the Centers for Disease Control and Prevention were analyzed to show distribution and trends by geographic location, racial and ethnic groups, gender, and age. RESULTS: Historically, syphilis was distributed widely throughout the country and declined rapidly after the introduction of penicillin therapy and broad-based public health programs, attaining its lowest levels in the 1950s. However, in recent years, the disease has returned and become focused in the southern region and in urban areas outside that region. Rates of syphilis have remained highest in black Americans, and the most recent national epidemic of syphilis primarily involved them. Rates in white men were at intermediate levels during the early 1980s but have declined to low rates in the 1990s, possibly because of changes in behavior in response to the AIDS epidemic. Rates in white women and other racial and ethnic groups have remained low throughout the 1980s and 1990s. CONCLUSIONS: Syphilis remains a significant problem in the United States, and its epidemiology is influenced by a complex combination of factors. To prevent and control syphilis effectively, public health practitioners must understand these factors and design programs and interventions that address the disease in the context of these factors.

Surveillance for geographic and secular trends in congenital syphilis--United States, 1983-1991.

PROBLEM/CONDITION: CDC monitors trends in the occurrence of congenital syphilis (CS) in the United States by using surveillance data sent from state and local health departments. Comparisons of data from this surveillance system with data from the Division of Sexually Transmitted Diseases/HIV Prevention and the Birth Defects Monitoring Program (BDMP) can be used to assess the potential effects of changes in case finding and reporting practices on these trends. REPORTING PERIOD COVERED: This report covers CS surveillance in the United States for the years 1983-1991. DESCRIPTION OF SYSTEM: Cases of CS among infants < 1 year of age and primary and secondary (P&S) syphilis among women are reported quarterly to CDC. The BDMP is a CDC national surveillance system that samples hospital discharge data on U.S. births. RESULTS: During the period 1983-1991, 12,151 CS cases were reported. Before 1988, regional CS incidence increased 35%-131% annually. Larger increases occurred in the Northeast (578%) in 1989 and in the South (178%), Midwest (244%), and West (777%) in 1990. Within regions, these larger increases were temporally related to increases in P&S syphilis in women and changes to a more sensitive CS case definition. INTERPRETATION: CS incidence has increased since 1983 in all regions of the United States. Increases since 1988 reflect both changes in surveillance reporting practices--the surveillance case definition for CS was changed in 1988 and further revised in 1989--and a true increase in incidence. ACTIONS TAKEN: These data indicate where CS prevention efforts need to be targeted. To facilitate reporting of CS cases, CDC has developed a) a shorter form for reporting cases of CS after 1991 and b) a software package for use by state and local health departments to enter and analyze CS data.

An evaluation of surveillance for Chlamydia trachomatis infections in the United States, 1987-1991.

PROBLEM/CONDITION: Chlamydia is the most common sexually transmitted bacterial pathogen in the United States; however, no precise data on the prevalence and incidence of chlamydia infection are available because currently no comprehensive national surveillance system exists for chlamydia. Despite the absence of such a system, states do report numbers of male and female chlamydia cases to CDC on a quarterly basis. REPORTING PERIOD COVERED: This report summarizes and reviews the chlamydia surveillance data received by CDC from 1987 through 1991. DESCRIPTION OF SYSTEM: Summary data on cases of chlamydia reported to state health departments were sent quarterly to CDC in Atlanta, Georgia. The quarterly data from each state included total number of chlamydia cases by sex and by source of report (public, private). RESULTS: From 1987 through 1991, the number of states with legislation mandating reporting of chlamydia increased twofold. The reported chlamydia rate from those states also doubled during the same time period, from 91.4 cases per 100,000 population in 1987 to 197.5 cases per 100,000 population in 1991. INTERPRETATION: This twofold increase in the rate of chlamydia reported to CDC did not represent a doubling in chlamydia prevalence or incidence during this time period. Instead, the increase resulted from the increase in the number of states with reporting laws and from the initial attempts of those states to identify and report diagnosed chlamydia infections. ACTIONS TAKEN: More accurate measures of the number of chlamydia infections and of trends in the chlamydia infection rate are needed to justify, develop, and evaluate public health programs to control chlamydia infections. An outline of possible surveillance activities for local communities is presented.

Sentinel surveillance for antimicrobial resistance in Neisseria gonorrhoeae--United States, 1988-1991. The Gonococcal Isolate Surveillance Project Study Group.

PROBLEM/CONDITION: The prevalence of antimicrobial resistance in Neisseria gonorrhoeae in the United States has been increasing since the mid-1970s. DESCRIPTION OF SYSTEM: The Gonococcal Isolate Surveillance Project (GISP) was established in 1986 to monitor trends of antimicrobial resistance in N. gonorrhoeae. GISP is a sentinel surveillance system consisting of 26 publicly funded sexually transmitted disease clinics and five regional laboratories. At each clinic, urethral isolates are obtained from the first 20 men diagnosed with gonorrhea each month; these isolates are shipped to one of the regional laboratories, where the susceptibilities of the organisms to a panel of antibiotics are determined. REPORTING PERIOD COVERED: This report describes the results of surveillance for antimicrobial resistance in N. gonorrhoeae from January 1991 through December 1991. These results are compared with data obtained from January 1988 through December 1990. RESULTS AND INTERPRETATION: In the 1991 GISP sample, 32.4% of isolates were resistant to penicillin or tetracycline. The proportions of isolates with high-level, plasmid-mediated resistance to penicillin, tetracycline, or both drugs have increased significantly (p < 0.001) in the GISP sample during 1988-1991. No documented clinical treatment failures have been related to decreased susceptibility of N. gonorrhoeae to either ceftriaxone or ciprofloxacin, which belong to the classes of antibiotics currently recommended for gonococcal therapy. ACTION TAKEN: Because of the demonstrated ability of N. gonorrhoeae to develop resistance to antimicrobial agents, surveillance to guide therapy recommendations will be continued.

Regional and temporal trends in the surveillance of syphilis, United States, 1986-1990.

During the latter half of the 1980s, an epidemic of syphilis occurred throughout the United States. A comparison of regional rates of primary and secondary syphilis in 1990 indicated that the rates were highest in the South, followed by the Northeast, the West, and the Midwest. Primary and secondary syphilis rates from 1986 through 1990 exhibited different regional patterns. Rates of primary and secondary syphilis in the West peaked in 1987 and declined from 1987 to 1990. Rates increased in the Northeast and the South from 1986 to 1990, but the increase reached a plateau in the Northeast in 1990. Rates did not begin to increase in the Midwest until 1988. More detailed analyses of the syphilis epidemics in specific communities in each region are needed to better understand the regional patterns. A comparison of these findings across regions could be helpful in evaluating which sexually transmitted disease intervention and control programs are most effective during epidemic periods.

Epidemiology of primary and secondary syphilis in the United States, 1981 through 1989.

Between 1981 and 1989, the incidence of primary and secondary syphilis in the United States increased 34%, from 13.7 to 18.4 cases per 100,000 persons, the highest since 1949. The populations affected most by syphilis also changed substantially. From a peak of 10.0 cases per 100,000 persons in 1982, the incidence among white men had decreased 69% by 1989 (3.2 cases per 100,000 persons). From 1982 to 1985, the incidence also decreased among black men (30%, 101.9 to 71.5 cases per 100,000) and black women (22%, 45.8 to 35.8 cases per 100,000). However, in 1986 this trend reversed, and the incidence among blacks more than doubled from 1985 to 1989 (52.6 to 121.8 cases per 100,000 persons). Racial differences in syphilis incidence increased (black-to-white incidence rate ratio in 1981 was 14.5 and in 1989 was 47.8), as did regional differences. Trends in syphilis incidence indicate changes in sexual behavior that may determine future sexual transmission of human immunodeficiency virus. Targeting resources at populations most affected by this recent epidemic is an urgent public health priority.

A prevalence survey of behavioural risk factors in Taipei City, Taiwan.

In 1986, we conducted a telephone survey of 2514 residents of Taipei City, Taiwan, to establish baseline prevalence estimates of behavioural risk factors associated with the leading causes of death among adults. Estimates from this survey revealed a high prevalence of sedentary lifestyle (85.6%), seatbelt non-use (67.5%) and motorcycle helmet non-use (31.3%). The smoking rate (26.1%) was similar to that in the US, however, there was almost a tenfold difference between smoking rates in men and women (48.0% versus 5.1%, respectively). Behaviours related to alcohol misuse (binge drinking, chronic heavy drinking and driving and drinking) were also much more prevalent among men than women. This survey demonstrated the feasibility of using the telephone to collect data on the prevalence of behavioural risk factors in a newly industrialized country like Taiwan.

Epidemic septic arthritis caused by Serratia marcescens and associated with a benzalkonium chloride antiseptic.

During a 6-week period, 10 patients were admitted to a hospital for treatment of knee or shoulder joint infections due to Serratia species. Isolates from eight patients were identified as Serratia marcescens with identical biochemical characteristics and antibiotic susceptibility patterns. Before the onset of infections, all patients had been treated by two orthopedic surgeons who shared an office. Studies revealed that infections were associated with previous joint injections (P = 4.44 X 10(-5] of methylprednisolone and lidocaine. Environmental cultures revealed that a canister of cotton balls soaked in aqueous benzalkonium chloride and two multiple-dose vials of methylprednisolone previously used by office personnel were contaminated with the epidemic strain of S. marcescens. The canister may have served as a potential reservoir for contamination of sterile solutions and equipment used for joint injections, of skin at the injection site, and of hands of personnel. No further cases occurred after the use of aqueous benzalkonium chloride was discontinued.

Survival of Serratia marcescens in benzalkonium chloride and in multiple-dose medication vials: relationship to epidemic septic arthritis.

In an epidemic of septic arthritis due to Serratia marcescens, the intra-articular injection of contaminated methylprednisolone may have played a key role. The epidemic strain was found in used multiple-dose vials of methylprednisolone and in a canister of cotton balls soaked in benzalkonium chloride. The cotton balls had been used for antisepsis and disinfection. Growth characteristics of the epidemic strain of S. marcescens were compared with those of control strains of S. marcescens which had been obtained from unrelated nosocomial outbreaks. The epidemic strain was able to survive in 1:100 dilutions of benzalkonium chloride and was able to grow to greater than 10(5) CFU/ml in multiple-dose vials of methylprednisoline; control strains could not be recovered after 24 h in the same solutions. The preservative in methylprednisolone is gamma-myristyl picolinium chloride, a compound chemically related to benzalkonium chloride. We speculate that the epidemic strain of S. marcescens, which was resistant to benzalkonium chloride, had cross-resistance to gamma-myristyl picolinium chloride. If the cotton balls were used to disinfect the tops of the multiple-dose vials of methylprednisolone, small numbers of organisms subsequently introduced into the solution could have grown to high concentrations.