Examining the validity of smart glasses in measuring spatiotemporal parameters of gait among people with Parkinson's disease.

BACKGROUND: Gait impairment is an early marker of Parkinson's disease (PD) and is frequently monitored to evaluate disease progression. Wearable sensors are increasingly being used to quantify gait in the real-world setting among people with PD (pwPD). Particularly, embedding wearables on devices or clothing that are worn daily may represent a useful strategy to improve compliance and regular monitoring of gait. RESEARCH QUESTION: The current investigation examined the validity of innovative smart glasses to measure gait among pwPD. METHODS: Participants wore the smart glasses and 6 APDM gait sensors simultaneously, while performing two walking tasks: the 3-meters Timed Up and Go test (TUG) and the 7-meters Stand and Walk (SAW) test. The following spatiotemporal gait parameters were calculated from the data collected using the two different devices: step time, step length, swing percentage, TUG duration, turn duration, and turn velocity. RESULTS: A total of 31 pwPD (mean age=68.6±8.5 years; 35.48 % female(N=11), mean Unified Parkinson's Disease Rating Scale (UPDRS) total score=32.1±14.7) participated in the study. Smart glasses achieved high validity in measuring step time (ICC=0.92, p=0.01) and TUG duration (ICC=0.96, p=0.03) compared to APDM sensors. On the other hand, the smart glasses did not achieve adequate validity when measuring step length, swing percentage, turn duration or turn velocity. SIGNIFICANCE: The current study suggests that smart glasses has the potential to measure TUG and step time in individuals living with PD. However, further research is needed to improve algorithms for sensors worn on the head.

Effectiveness of Flow Sheet Implementation on Diabetes Progression Screening at a Student-Run Free Clinic.

INTRODUCTION: Diabetes mellitus (DM) disproportionately affects people with low socioeconomic status (SES). Student-run free clinics (SRFC) aim to care for low SES populations and experience high clinician turnover. Flow sheets have been used to improve care for those with diabetes, yet no research has assessed the use of such a flow sheet in a SRFC. The aim of this project was to determine if use of a flow sheet improved care for people with DM in an SRFC. METHODS: Charts from all patients receiving care for DM at one SRFC in the year before (n = 53) and after (n = 56) implementation of the flow sheet were reviewed. Pre- and post-group comparisons and post subgroup comparisons were made for glycosylated-hemoglobin (HgbA1c), microalbumin, and foot and eye exams. RESULTS: During a one-year period, a larger proportion of patients who received care post flow sheet introduction received at least two HgbA1c tests (53%), a microalbumin test (46%), and a foot-exam (46%) compared to those receiving care before the flow sheet (28%, 2%, and 25%, respectively). There was no difference in proportions of patients undergoing eye exams. In post subgroup analysis, flow sheets were used for 50% of patients, and patients who received care with the flow sheet were more likely to receive at least two HgbA1c tests and a foot exam per year. CONCLUSION: Flow sheets may improve the process of care for patients with diabetes in a SRFC, but the effect must be studied further. Regardless, a systematic integration of the flow sheet is being implemented in the SRFC evaluated in this study.

Feasibility of a Memory Clinic-Based Physical Activity Prescription Program.

BACKGROUND: Effective programs for promoting physical activity are needed for those with cognitive impairment. OBJECTIVE: To test the feasibility of mobile Health (mHealth) technology-supported physical activity prescription from a tertiary care memory clinic. METHODS: This feasibility study was designed as a 16-week randomized, crossover trial of a physical activity prescription: 8 weeks of intervention, 8 weeks of baseline or maintenance phase data collection. We recruited 2 cohorts: 21 individuals with Alzheimer-related cognitive impairment (mean age 72.3 (5.2), 9 females), and 9 individuals with normal cognition (mean age 69.6 (5.8), 8 females). We gave each cohort an mHealth accelerometer-based physical activity prescription to double number of steps taken. Our primary outcomes were feasibility and safety. Our secondary outcomes were change in weekly steps taken, Dementia Quality of Life Scale, Self-efficacy Scale, 6-minute Walk, and mini-Physical Performance Test. RESULTS: Set-up and use of the device was not a barrier to participation. However, only 62% of participants with cognitive impairment completed the intervention. The cohort with cognitive impairment did not change their weekly step count above Week 1. All participants in the cohort with normal cognition were able to set up and use their device and increased their weekly step count above Week 1. There were no differences between Week 1 and Week 8 for any secondary measures in either cohort. CONCLUSIONS: Setup and daily use of mHealth technology appears to be feasible for a person with cognitive impairment with the help of a partner, but increasing daily step counts over 8 weeks was not achieved. Future work needs to assess alternative activity prescription goals or additional support for patients and their partners.

Men with sexually transmitted diseases in Bangkok: where do they go for treatment and why?

OBJECTIVES: To describe and identify predictors of health-care seeking behavior among men with sexually transmitted diseases (STDs) in Bangkok, Thailand. DESIGN: Cross-sectional survey. METHODS: Men presenting with STDs were recruited from government clinics (n = 101), private clinics (n = 50) and pharmacies (n = 62). They completed interviewer-administered questionnaires on risk behavior, patterns of treatment-seeking for current and past STDs and attitudes toward health care. RESULTS: Two-thirds of all subjects had had a previous STD. Approximately one-half believed a partner other than a sex worker was the source of their current infection. Of the sample, 39% of men seen initially at drugstores, 29% at private clinics and 19% at government clinics sought subsequent treatment; failure to respond to therapy was the primary reason for seeking additional care. Men attending drugstores were likely to be younger, have less education and income, and to practice riskier sexual behavior. Patients at drugstores and general private clinics received the least amount of counseling or STD testing, while those attending specialized private STD clinics received the most comprehensive services. Attitudes towards government clinics were uniformly positive regardless of the site of enrollment; conversely, about 50% of clients at drugstores felt that the advice and treatment they received were inadequate. Convenience, affordability and lack of embarrassment were associated with choice of treatment site. CONCLUSIONS: STD/HIV control in Thailand must focus on improved treatment and counseling at the point of first encounter in the health-care system, particularly in the private sector. Men may be dissuaded from attending government clinics because of lack of convenience. Syndromic case management, incorporation of STD care at other public clinics and the recognition that more men practice unsafe sex with partners other than sex workers could improve STD control.

PIP: The determinants of treatment-seeking behaviors associated with sexually transmitted diseases (STDs) were investigated in a cross-sectional survey of 213 men recruited from government clinics (n = 101), private clinics (n = 50), and pharmacies (n = 62) in Bangkok, Thailand. 142 of these men had had a prior STD. 34% of men who initially attended pharmacies and 19% of those who first attended a government clinic sought multiple treatments for prior STDs because of an incomplete response to treatment. 50% of STD clients had visited a commercial sex worker in the 3 months preceding the current STD; half believed a casual or new sex partner was the source of infection. 12% of men had sex while they were symptomatic with the current STD. Advice on condom use was conveyed to 88% of government clinic patients, 94% of private clinic patients, and 52% of pharmacy customers; only 72%, 14%, and 22%, respectively, were urged to contact their sexual partner. Men with less education and symptoms of dysuria were more likely to seek care at drugstores. Also associated with seeking care at a pharmacy rather than a government site were waiting less than 7 days to seek treatment, having a travel time less than 20 minutes, and feeling able to pay for treatment. Those seeking care at pharmacies were also more likely to believe that they would recover at least as well as those treated at a government clinic and to believe they were at risk for human immunodeficiency virus infection. Possible strategies for improving STD treatment at the first point of contact within the health care system include promotion of syndromic STD management among pharmacists and general practitioners, integrated STD programs within health care services already providing care to adolescents and other high-risk groups, and strengthening the referral network to government clinics.

Knowledge, attitudes and behaviour among HIV-positive and HIV-negative clients of a confidential HIV counselling and testing centre in Thailand.

OBJECTIVE: To describe the clients, operation and impact of an Asian public HIV counselling and testing centre. DESIGN AND SETTING: Analysis of samples from clients attending the Thai Red Cross Anonymous Clinic (TRC-AC) in Bangkok, Thailand in 1993. SUBJECTS: HIV-positive and HIV-negative consecutive clients (250 of each). MAIN OUTCOME MEASURES: HIV seroprevalence rates, knowledge, attitudes and behaviour. RESULTS: Overall HIV-1 prevalence was 16%; 13% in men and 24% in women. Reasons for requesting an HIV test were high-risk behaviour (21%), feeling unwell (20%), checking a previous HIV test result (18%), a planned marriage or new relationship (10%), and planning a baby (5%). Heterosexual risk behaviour was reported by 85% of clients, while in each case only 1% reported male homosexual or intravenous drug use risk behaviour. Factors associated with HIV infection on univariate analysis included a history of sexually transmitted disease, not using condoms, a low level of education and salary, and being female. Knowledge about HIV transmission risks and AIDS prevention measures was good, and most clients expressed a caring attitude towards people with HIV and AIDS. A former negative HIV test result was associated with higher levels of condom use, and most clients expressed the intention to reduce their HIV risk behaviour in response to a positive or negative HIV test result (more so if positive). CONCLUSIONS: Our study demonstrates the demand for and the feasibility of confidential HIV counseling and testing services in Thailand and illustrates the value of these services in achieving behaviour changes. Such services should be considered as an additional approach for reducing HIV transmission in Asia, especially in areas with high HIV seroprevalence rates.

PIP: Data are presented from HIV serodiagnoses and knowledge, attitude, and behavior questionnaire responses for 250 HIV-positive and 250 HIV-negative consecutive clients attending the Thai Red Cross Anonymous Clinic in Bangkok, Thailand in 1993. The study was conducted to describe the clients, operation, and impact of the public HIV counseling and testing center. The men and women were of mean age 26-29 years in a range of 16-64 years. 16% overall were HIV-1-seropositive; 13% of men and 24% of women. 21% requested the HIV test in response to previous high-risk behavior, 20% felt sick, 18% were checking a previous HIV test result, 10% planned marriage or a new relationship, and 5% planned to have a baby. Heterosexual risk behavior was reported by 85% of clients, but only 1% reported male homosexual or IV drug use risk behavior. These behaviors were reported despite the existence among the sample of ample information about HIV transmission risks and AIDS prevention measures. An history of sexually transmitted disease, not using condoms, low education and salary levels, and being female were associated with HIV infection. Former negative HIV test results were associated with higher levels of condom use, while most clients expressed the intention to reduce their HIV risk behavior in response to either a positive or negative HIV test result. Most clients had caring attitudes toward people with HIV and AIDS. The authors note that sufficient demand exists for confidential HIV counseling and testing services in Thailand. Such services should be considered as a means of reducing HIV transmission in Asia, especially in areas of high HIV seroprevalence.

Patterns and predictors of high-risk sexual behavior in female partners of HIV-infected men with hemophilia.

OBJECTIVE: To characterize and quantify high-risk heterosexual activity in HIV-discordant couples. DESIGN: Analysis of cross-sectional and longitudinal questionnaire data from 217 HIV-negative female sexual partners of HIV-infected hemophilic men. METHODS: Comparison of prevalence rates of anal sex, oral sex, vaginal intercourse with or without condoms, and use of other contraceptives between 1985 and 1991. Logistic regression analysis of demographic, sexual and clinical variables to predict unprotected vaginal sex. Actuarial estimates of semi-annual relapse rates to unsafe sex. RESULTS: The proportion of women at low risk increased from 7 to 69% between 1985 and 1991, mainly because more women were using condoms during all acts of vaginal intercourse. Other contraceptive practices did not change during this time. The proportion engaging in oral or anal sex decreased (from 26 to 13% and 13 to 4%, respectively). Unprotected vaginal sex was more common among women who enrolled earlier, had less education, engaged in oral or anal sex, and among those whose partners had not had AIDS. Unprotected vaginal sex before enrollment was the strongest predictor of this high-risk activity during follow-up. Two-year rates of relapse to high-risk behavior were significantly higher among women who enrolled at high risk compared with those who enrolled at low risk (39 versus 8%, P = 0.005). CONCLUSIONS: Although high-risk sexual behavior became much less prevalent in this population between 1985 and 1991, many continued to have unprotected vaginal sex occasionally. Counseling efforts should target couples who have been the most sexually active or have less education, and should emphasize not only initial risk reduction but also maintenance of low-risk behavior.

PIP: This study sought to characterize and quantify the high-risk heterosexual activity in HIV-discordant couples. An analysis of cross-sectional and longitudinal questionnaire data from 217 HIV-negative female sexual partners of HIV-infected hemophiliac men were included in this study. There was a comparison of prevalence rates of anal sex, oral sex, vaginal intercourse with or without condoms, and use of other contraceptives between 1985-91. Logistic regression analysis of demographic, sexual, and clinical variables was used to predict unprotected vaginal sex. Actuarial estimates of semiannual relapse rates to unsafe sex were used. The proportion of women at low risk increases from 7 to 69% between 1985-91, mainly because more women were using condoms during all acts of vaginal intercourse. Other contraceptive practices did not change during this time. The proportion who engaged in oral or anal sex decreased from 26 to 13% and from 13% to 4%, respectively. Unprotected vaginal sex was more common among women who enrolled earlier, had less education, engaged in oral or anal sex, and among those whose partners had not had AIDS. Unprotected vaginal sex before enrollment was the strongest predictor of this high-risk activity during followup. 2-year rates of relapse to high-risk behavior were significantly higher among women who enrolled at high risk compared with those who enrolled at low risk (39 vs 8%, p=0.005). Although high risk sexual behavior become much less prevalent in this population between 1985-91, many continued to have unprotected vaginal sex occasionally. Counseling efforts should target couples who have been the most sexually active or have less education, and should emphasize not only initial risk reduction but also maintenance of low-risk behavior.

Care of children with HIV infection and AIDS in Africa.

PIP: HIV/AIDS is a major cause of pediatric morbidity and mortality, especially in Africa. The UN Joint Program on HIV/AIDS (UNAIDS) estimates that 85% of the 2.6 million children with HIV infection are from sub-Saharan Africa. About 650,000 children are living with HIV/AIDS and approximately 1000 infected infants are born every day in Africa. Since few of the 7 million infected African women have access to HIV testing and counseling, not to mention interventions such as AZT to reduce the risk of HIV transmission to their infants, the high incidence of HIV-infected children in Africa will likely continue for some time. The countries of east and southern Africa and several countries in west Africa have the highest HIV prevalence rates in the world. The development of cost-effective strategies to provide care and improve the quality of life of HIV-infected infants and children in Africa should be a priority area for increased research and support. The authors describe progress in understanding the natural history of HIV infection in African children, review strategies for managing HIV-infected children in resource-poor settings, and discuss issues of community response and counseling for children.^ieng

Couple communication, sexual coercion and HIV risk reduction in Kigali, Rwanda.

OBJECTIVE: To describe sexual interaction and HIV-related communication in Rwandan couples and to examine their relationship to HIV testing and condom use. STUDY DESIGN: Cross-sectional survey of a longitudinal cohort. METHODS: In 1988, women recruited for an epidemiological study of HIV, and interested male partners, received confidential HIV testing and counseling. Two years after enrollment, 876 women reporting one steady partner in the past year completed a questionnaire addressing sexual and HIV-related communication, sexual motivation and violence in the partnership. RESULTS: Men control sexual decision making, and coercive sex and violence between partners is not uncommon. HIV-positive women were more likely to report coercive sex and less likely to have discussed their test results with their partner. Women with HIV-positive partners were more likely to report being physically abused. Condom use was more common if the man had been previously tested, and if women reported discussing or negotiating condom use. HIV-negative women with untested or seronegative partners were the least likely to use condoms or to discuss or attempt to negotiate condom use. CONCLUSIONS: Participation of the male partner is crucial for successful HIV risk reduction in couples. HIV testing and counseling of couples has beneficial long term effects on condom use and HIV-related communication. Couple communication is associated with condom use, but only when the discussion is specific (sexually transmitted disease risks and using condoms). Seronegative women with untested partners are at increased risk for HIV as they are the least likely to discuss or attempt to negotiate condom use.

PIP: The salience of couple communication to the prevention of human immunodeficiency virus (HIV) was demonstrated in a study of 876 Rwandan women with one steady sexual partner in the preceding year. These women were part of a longitudinal study of the natural history of HIV infection involving 1458 mothers recruited from prenatal and pediatric clinics at a Kigali Hospital in 1988. At study entry, 234 (27%) of the 876 monogamous women were HIV-positive; 45 additional women had seroconverted by the time of the two-year follow-up. Among the 855 sexually active subjects, only 196 (23%) were using condoms. Condom use was substantially higher among HIV-positive women (39%) than their HIV-negative counterparts (17%). In addition, condom use was significantly more likely if the woman had discussed condoms with her partner or if the male partner had agreed to an HIV test. Seronegative women with untested or HIV-negative partners were the least likely to discuss or use condoms. Notable was a pattern of male control of sexual decision making and female responsibility for condom provision, coercive sex, and domestic violence. 33% of women had been forced to have sex with their partner against their will and 21% had been beaten; these rates were even higher among HIV-positive women or HIV-negative women with infected partners. Given the disproportionate power of men in sexual relations in many African societies, efforts to strengthen women's condom negotiation skills may be counterproductive. Recommended, instead, are interventions that increase male involvement in HIV testing and counseling.

The effects of post-test counselling on condom use among prostitutes in The Gambia.

OBJECTIVES: To determine the effect of counselling on condom use by prostitutes. DESIGN: Cohort study. SETTING: Field-based study in The Gambia. PARTICIPANTS: Thirty-one (12 HIV-positive and 19 HIV-negative) prostitutes. INTERVENTIONS: Post-test HIV counselling. MAIN OUTCOME MEASURES: Levels of condom use. RESULTS: Overall, counselling had no effect on condom use. CONCLUSIONS: Scarce resources should be directed towards providing condoms in bars rather than counselling.

PIP: HIV infection is much more prevalent in prostitution than in the general population of the Gambia (26.2 vs. 1.7%, respectively, in 1988). The short-and long-term effects of counseling on condom use by prostitutes was examined by determining condom use in 29 prostitutes, 11 HIV-positive (group 1) and 18 HIV-negative (group 2), before and 1 month after counseling and in 31 prostitutes, 12 HIV-positive group 3) and 19 HIV-negative (group 4), before and 2-5 month after counseling. HIV-positive women were told that reinfection would increase their chances of developing AIDS as well as lead to transmission of the virus. 3515 sexual contacts were recorded before counseling, 1252 after 1 month, and 4949 at 2-5 months later. Group 1 women reported an 89.3% rate of use before counseling; 1 month later, 9 maintained their rate, 1 increased use from 56 to 81%, and 1 decreased use from 31 to 26%. Group 2 women had 88% use before and, in 11 of the 12 women, 90% use after counseling; the 12th woman reduced use to 66% and was observed to increase her alcohol intake significantly. In both groups, 4 increased use and 3 reduced use. In Group 3, condom use declined insignificantly from 89.3 to 83.5%. 4 women maintained 90% use, 6 reduced use, and 2 increased it. Group 4 women decreased use insignificantly from 88% before to 84.4% after counseling. 8 women maintained original levels of use, 4 increased, and 7 decreased (1 from 90% to as low as 17%). In groups 3 and 4, 74% had 90% use precounseling; this fell to 69% at 1 month and 36% at 2-5 months after counseling, a significant decrease in usage. In all of the prostitutes, condom use increased in the first month after counseling and fell 2-5 months later. Counseling, therefore, failed to increase overall condom use. Possible reasons for this failure include the Senegalese backgrounds of many of the women (they were accustomed to health checks and free condoms); the low number of AIDS deaths in the Gambia, which keeps the disease a distant possibility instead of a pressing reality for the prostitutes; and the consideration of condom use as primarily a method to prevent contraction of the traditional sexually transmitted diseases. When resources are scarce, it may be more important to provide free condoms in bars frequented by prostitutes than to provide counseling.

A cohort study of factors associated with failure to return for HIV post-test counselling in pregnant women: Kigali, Rwanda, 1992-1993.

OBJECTIVE: To identify factors associated with failure to return for HIV post-test counselling in pregnant women in Kigali (Rwanda). SUBJECTS AND METHODS: In the context of a study on the impact of HIV infection on pregnancy, HIV-1-antibody testing was offered to all pregnant women attending the antenatal clinic of the Centre Hospitalier de Kigali from July 1992 to August 1993. Pre-test counselling was performed after verbal informed consent was obtained. Two weeks later, we formally enrolled all HIV-positive women and a corresponding number of HIV-negative women in a cohort. At this visit, post-test counselling was given to those wishing to be informed of their HIV serostatus. Level of knowledge about modes of HIV transmission and condom use were recorded. Four months after delivery, another interview was conducted to determine the proportion of women who used condoms regularly. RESULTS: A total of 1233 pregnant women were screened. The HIV seroprevalence was 34.4% [95% confidence interval (CI), 31.7-37.1]; 271 (63.9%) out of 424 HIV-positive and 577 (71.3%) out of 809 HIV-negative women asked for their HIV serostatus (P = 0.008). In multivariate analysis, the only variable significantly associated with failure to return for post-test counselling was a positive HIV test result (odds ratio, 0.7; 95% CI, 0.5-0.9; P = 0.009), independently of obstetrical history and socioeconomic characteristics. Among the 848 women who had post-test counselling, 50.9% of the HIV-positive women and 94.6% of the HIV-negative women stated that they planned to inform their partner of their serostatus (P = 0.0001). More than 95% of the women interviewed knew about sexual and parenteral transmission of HIV, but half were unaware of mother-to-child transmission. More than 80% of the women had seen a condom before, but 14% only had used it at least once. Among women who were sexually active 4 months after delivery, 8.8% of the HIV-positive and 3.9% of the HIV-negative women reported using a condom (P = 0.04). CONCLUSION: Innovative approaches for HIV testing and counselling programs are needed and the importance of psychosocial and cultural factors associated with HIV testing should be emphasized in African populations.

The efficacy of brief group counseling in HIV risk reduction among homosexual Asian and Pacific Islander men.

OBJECTIVES: The incidence of AIDS is increasing at a higher rate among homosexual Asian and Pacific Islanders (API) than white homosexual men in the United States. The number of homosexual API men engaging in unsafe sex is increasing at an alarming rate. HIV risk reduction is urgently needed in this population. SUBJECTS AND METHODS: We developed and evaluated culturally appropriate brief group counseling with 329 self-identified homosexual API recruited in San Francisco between 1992 and 1994. Participants were randomized into a single, 3-h skills training group or a wait-list control group. The intervention consisted of four components: (1) development of positive self-identity and social support, (2) safer sex education, (3) eroticizing safer sex, and (4) negotiating safer sex. Data were collected at baseline and 3 months after the intervention. RESULTS: Significant reductions in number of sexual partners were observed among all treatment subjects, regardless of ethnicity (P = 0.003). Treatment decreased the number of partners reported at 3-month follow-up by 46% [95% confidence interval (CI), 28-77]. Chinese and Filipino men further benefited from the intervention: treatment subjects from these two ethnic groups reduced unprotected anal intercourse at follow-up by more than half when compared to their counterparts (odds ratio = 0.41; 95% CI, 0.19-0.89; P = 0.024). CONCLUSIONS: We demonstrated the efficacy of brief group counseling in reducing HIV risk among homosexual API. Cities with significant API populations should adopt culturally tailored skills training as part of HIV prevention strategies for this group of homosexual men.

Evidence of marked sexual behavior change associated with low HIV-1 seroconversion in 149 married couples with discordant HIV-1 serostatus: experience at an HIV counselling center in Zaire.

To determine the effect of an HIV-1 counselling program on 149 married Zairian couples with discordant HIV-1 serology, the rates of HIV-1 seroconversion and reported condom utilization have been observed during 382.4 person-years of follow-up (minimum follow-up time per couple of 6 months). Before determination of HIV-1 serostatus and counselling, less than 5% of these couples had ever used a condom. One month after notification of HIV-1 serostatus and counselling, 70.7% of couples reported using condoms during all episodes of sexual intercourse. At 18 months follow-up, 77.4% of the 140 couples still being followed reported continued use of condoms during all episodes of sexual intercourse. At the time of notification of HIV-1 serostatus, 18 couples experienced acute psychological distress. Home-based counselling by trained nurses resolved these difficulties in all but three couples who subsequently divorced. Intensive counselling following notification of HIV-1 serostatus led to low rates of HIV-1 seroconversion (3.1% per 100 person-years of observation) in Zairian married couples with discordant HIV-1 serostatus who voluntarily attended an HIV counselling center.

Improving sexually transmitted disease management in the private sector: the Jamaica experience.

OBJECTIVES: To improve the quality of sexually transmitted disease (STD) case management in Jamaica by providing comprehensive continuing medical education to private practitioners who manage 60% of all STDs on the island. METHODS: Six half-day STD seminars were presented at 3-4-month intervals and repeated in three separate geographic locations. All Jamaican practitioners received invitations. The subjects were as follows: urethritis, genital ulcer disease, HIV infection, vaginal discharge syndrome, STDs in children and adolescents, and a review seminar. The program effectiveness was evaluated with a written, self-reported pre-test and a telephone post-test that measured changes in clinical management. RESULTS: Six hundred and twenty eight practitioners attended at least one seminar. Comparing pre- versus post-test scores, there were practitioner improvement trends in all four of the general STD management categories: counseling/education (69.8-73.3%; P > 0.05); diagnostics/screening (57.2-71.0%; P= 0.042); treatment (68.3-74.5%; P> 0.05); and knowledge (66.4-83.2%; P= 0.002). Obtaining syphilis serologies during pregnancy rose from 38.3 to 83.8% (P= 0.001), and providing effective treatment for gonorrhea rose from 57.8 to 81.1 % (P= 0.002), but correct responses on treatment for mucopurulent cervicitis at the post-test was a low 32.4%. CONCLUSION: The introduction of continuing medical education for improved STD care targeting private physicians in Jamaica was successful based on high attendance rates and self-reported STD management practices. However, efforts should continue to address the weaknesses found in STD management and counseling and to reach the providers who did not participate. In the global effort to reduce HIV transmission by improving STD care services, continuing education programs that target the private sector can be successful and should be included as a standard activity to improve care and provide a public/private link to STD/HIV control.

PIP: The Jamaican Ministry of Health has estimated that over 60% of all sexually transmitted diseases (STDs) are managed within the private sector, where 800 (66%) of the country's 1200 registered physicians practice. To improve the quality of STD case management provided by these practitioners, the Medical Association of Jamaica organized a series of 6 half-day seminars repeated at 3-4 month intervals in three geographic locations between December 1993 and July 1995. Topics addressed included urethritis, genital ulcer disease, HIV/AIDS, vaginal discharge, pelvic inflammatory disease, and STDs in children and adolescents. A total of 628 private practitioners attended at least one seminar and almost half the physicians attended two or more. Comparisons of scores on a written pretest completed before the seminar and those from a post-test conducted by telephone after the seminar revealed significant improvements in all four general STD management categories: counseling/education, diagnostics/screening, treatment, and knowledge. The proportion of practitioners who obtained syphilis serologies during pregnancy rose from 38.3% to 83.8% and those providing effective treatment for gonorrhea increased from 57.8% to 81.1%. Overall, 96% of practitioners were providing some level of risk-reduction counseling at the time of the post-test and 74% were prescribing correct treatment regimens. Ongoing education and motivation by the national STD control program or the Medical Association are recommended to improve STD case management even further.

Rapid HIV testing and counseling for voluntary testing centers in Africa.

OBJECTIVE: Voluntary HIV testing and counseling (VTC) has been shown to reduce the incidence of HIV in cohabiting couples who now represent the majority of new infections in many African cities. Community and client perceptions of a 1-day voluntary testing and counseling program in Lusaka, Zambia, were assessed, and a rapid HIV-testing algorithm was evaluated for VTC centers. METHODS AND DESIGN: Between May 1995 and June 1996, outreach workers distributed written invitations door to door. The 1-day program was held 6 days/week including weekends. Transport, child care and lunch were provided. Community and client surveys followed in July 1996. RESULTS: Over 3500 couples married for a median of 4-5 years requested testing: 23% were HIV+/+, 57% were HIV-/- and 20% were discordant with one HIV+ and one HIV- partner. Sixty-eight per cent of couples surveyed had made the decision to be tested before attending the 1-day program and 80% had not previously known where to obtain HIV testing. Knowledge that couples could show discordant results rose from 29 before to 88% after pretest counseling. Clients reported high levels of satisfaction with the services and 90 out of 99 (92%) preferred to receive their results the same day. Clients at another center who waited 10 days for their results reported more fear, and 19 out of 31 (61%) would have preferred to get their results the same day. Over 99% of those who attended the program thought active promotion of voluntary HIV testing in the community was a positive thing, as did 90% of those who were invited but did not attend. Sensitivity and specificity of the rapid test algorithm were both 99.4% in this setting. CONCLUSIONS: Active promotion of voluntary HIV testing and counseling in couples is needed to reduce the spread of HIV in high-prevalence areas. The use of rapid, on-site HIV testing allows clients to receive result-specific counseling in a single visit. Ongoing quality control of a subset of samples at an outside laboratory is essential.

PIP: Voluntary, confidential HIV testing and counseling centers (VTCs) are becoming increasingly popular in African cities with high HIV prevalence. This strategy is especially effective among HIV-discordant couples. During a 12-month period during 1995-96, community outreach workers distributed written invitations to attend a VTC in Lusaka, Zambia, in which couples would receive testing and result-specific counseling in a single visit; transportation, child care, and lunch were offered. Over 3500 couples, one-third of those invited, responded to the invitation and underwent rapid HIV testing. The Dipstick HIV-1 + 2 rapid test was used for screening and the Capillus HIV-1/HIV-2 rapid test was employed for confirmation. Both partners were HIV-positive in 23% of cases and both were HIV-negative in 57%; in the remaining 20% of couples, 1 partner was HIV-positive and the other was uninfected. 68% of participating couples had decided to seek HIV testing before receiving notice of the VTC, but 80% of them did not know where to obtain such services. Couples who attended the VTC that offered same-day test results reported substantially less fear than those who had to wait 10 days for their results. 99% of those who participated in the program thought active community promotion of VTC was desirable, as did 90% of those who were invited but did not attend. The rapid test algorithm had both a sensitivity and specificity of 99.4%. Continued retesting of a subset of samples at an outside laboratory remains essential, however. This intervention is associated with an estimated cost of US $84 per HIV infection prevented.

AIDS and the ethics of public health: challenges posed by a maturing epidemic.

PIP: Ethical issues imposed on the United States by the maturing AIDS epidemic are discussed. In the 2 years since the U.S. Public Health Service predicted that 220,000 new cases of AIDS will appear by 1991, 5 times the number reported in the 1st 7 years, the projections appear to be remarkably on target. The sheer burden of these numbers, and their distribution, will affect the nation's social climate. The "ghettoization" of the disease will subject the voluntary education, counseling and testing policy to elements of coercion. A radical transformation of the culture regarding sexual behavior, childbearing and drug use will be required of the AIDS education campaign. The crippling moralism that inhibits education on sexual matters must be confronted. Efforts to prevent perinatal transmission of HIV will affect women's rights, the nature of counseling, the privacy of the abortion decision, and perhaps elements of coercion. Another serious issue is how to institutionalize and hospitalize poor and minority AIDS victims without turning the wards and hospitals into pariah institutions. Anxiety still persists among health care workers about their risk of contracting AIDS from their patients. A final ethical dilemma is how to allocate research, vaccine and drug testing, and treatment between wealthy and developing nations. The history of earlier epidemics teaches us that an objective, asocial response to disease is impossible: controversies between conflicting values will introduce numerous ethical dilemmas.^ieng

Condom use with primary partners among injecting drug users in Bangkok, Thailand and New York City, United States.

OBJECTIVE: To determine factors associated with likelihood or failure to use condoms with primary sexual partners among injecting drug users (IDU) in two cities. DESIGN AND METHODS: Interviews were conducted with 601 IDU in Bangkok in 1989 and with 957 IDU in New York City in 1990-1991. Subjects were recruited from drug-use treatment programs and a research storefront. Informed consent was obtained and a World Health Organization standardized questionnaire about AIDS risk behaviors administered by a trained interviewer. RESULTS: A substantial minority (37%) of IDU in Bangkok and a majority (55%) of IDU in New York City reported penetrative intercourse (vaginal, anal or oral) with a primary partner in the 6 months before the interview. Of those reporting penetrative intercourse with a primary partner, only 12% in Bangkok and 20% in New York reported that they always used condoms. Parallel bivariate and multiple logistic regression analyses were conducted to distinguish between subjects who reported always using condoms and subjects who reported unsafe sexual activity with primary partners. The same two factor--knowing that one is HIV-seropositive and talking about AIDS with sexual partners--were most strongly associated with always using condoms with primary partners in both cities. CONCLUSIONS: Programs to prevent sexual transmission of HIV among IDU should provide voluntary and confidential/anonymous HIV counseling and testing, and should facilitate discussions of AIDS and sexual transmission of HIV between IDU and their sexual partners. That the same two factors were associated with always using condoms with primary partners among IDU in these two cities suggests that these factors may also be important in other groups at high risk for HIV.

PIP: Trained interviewers spoke to 957 drug users attending a detoxification program, methadone maintenance program, or a research storefront in New York City in 1990-91 and to 601 drug users attending 17 drug use treatment clinics in Bangkok, Thailand, in the autumn of 1989 as part of a study to identify factors linked to the probability or failure of condom use with primary sexual partners among IV drug users. The participants also received HIV counseling and testing. IV drug users in New York City were more likely to be older (36.2 years vs. 30.1 years; p .001), female (25% vs. 5%; p .001), more ethnically diverse (p .001), and inject cocaine more often (33 injections/month vs. 0.5 injections/month) than those in Bangkok. 44% of drug users in New York City and 33% of those in Bangkok engaged in some unprotected penetrative intercourse with a primary heterosexual partner in the previous 6 months. Of drug users having penetrative sexual intercourse with a primary partner in the previous 6 months, 20% in New York City and 12% in Bangkok always used condoms (p .02). The strongest predictors of condom use among IV drug users from both countries were a previous positive HIV test and talking about AIDS with sexual partners (p = .001 for US; p = .0008 for Bangkok and p = .004 for US; p = .0596 for Bangkok, respectively). These findings indicated that unsafe sexual behavior with primary sexual partners among drug users is still a major source of HIV transmission in these 2 cities. Nevertheless, knowledge of HIV positive status and partner communication concerning AIDS are predictors of condom use shared by both groups. Thus, HIV/AIDS prevention programs should provide confidential HIV testing and counseling for drug users and should encourage frank discussions of AIDS between drug users and primary sexual partners. Peer support for risk reduction among drug users has the potential to facilitate such discussions.

Involving traditional healers in AIDS education and counselling in sub-Saharan Africa: a review.

PIP: Traditional healers are the preferred and most accessible care providers in Africa. The AIDS epidemic in sub-Saharan Africa has stimulated interest on the part of modern biomedical health practitioners in collaboration with these traditional healers. The literature includes numerous studies of healers' perceptions of HIV/AIDS and other sexually transmitted diseases. On the basis of study findings, healers have been trained as educators and counselors to disseminate HIV/AIDS information and prevention practices among their peers and communities. This article reviews the initial outcomes and challenges of such new initiatives in Zambia, Uganda, Botswana, Malawi, Mozambique, South Africa, and Central African Republic. None of the projects has completed a comprehensive evaluation of the different approaches used and their real impact on the population served. Overall, however, the case studies indicate that traditional healers are capable of performing at least as well as their biomedical counterparts as AIDS educators and counselors. Of concern is the failure of many projects to provide systematic follow-up to healers after their initial training. Such follow-up is essential to support healers in dealing with unfamiliar issues such as condom use and death and dying.^ieng

Fertility rates in 238 HIV-1-seropositive women in Zaire followed for 3 years post-partum.

Birth-control use and fertility rates were prospectively determined in 238 HIV-1-seropositive and 315 HIV-1-seronegative women in Kinshasa, Zaire, during the 36-month period following the delivery of their last live-born child. No women delivered children during the first follow-up year. Birth-control utilization rates (percentage use during total observation time) and fertility rates (annual number of live births per 1000 women of child-bearing age) in the second year of follow-up were 19% (107.4 per 1000) for HIV-1-seropositive women and 16% (144.7 per 1000) for HIV-1-seronegative women. In the third year of follow-up these rates were 26 (271.0 per 1000) and 16% (38.6 per 1000) for HIV-1-seropositive and HIV-1-seronegative women, respectively (P less than 0.05 for the difference in birth-control utilization and fertility rates between seropositive and seronegative women in the third year of follow-up). Seven (2.9%) of the 238 HIV-1-seropositive women initially included in the study brought their sex partners in for HIV-1 testing; three (43%) of these men were found to be HIV-1-seropositive. New HIV-1 infection did not have a dramatic effect on the fertility of seropositive women. The nearly uniform unwillingness of HIV-1-seropositive women to inform husbands or sexual partners of their HIV-1 serostatus accounted in large part for the disappointingly high fertility rates in seropositive women who had been provided with a comprehensive program of HIV counseling and birth control. Counseling services for seropositive women of child-bearing age which do not also include these women's sexual partners are unlikely to have an important impact on their high fertility rates.

Impact of maternal HIV infection on obstetrical and early neonatal outcome.

In a case-control study of 177 HIV-seropositive and 326 seronegative women and their newborns in Nairobi, Kenya, maternal HIV infection at term was independently associated with travel to other African countries [odds ratio (OR) 4.9, P less than 0.0001], history of a blood transfusion since 1980 (OR 3.5, P = 0.01), history of more than one sexual partner in the previous 5 years (OR 1.8, P = 0.02) and unmarried status (OR 1.8, P = 0.02). Neonates of HIV-positive and HIV-negative women differed little with respect to occurrence of congenital malformations, stillbirths, in-hospital mortality, sex, APGAR score, or gestational age. However, the mean birth weight of singleton neonates of HIV-positive women was significantly lower than that of controls (3090 versus 3220 g, P = 0.005), and birth weight was less than 2500 g in 9% of cases and 3% of controls (OR 3.0, P = 0.007). Among neonates of HIV-seropositive women, birth weight was less than 2500 g in 17% if mothers were symptomatic and 6% if mothers were asymptomatic (OR 3.4, P = 0.08).

The effect of HIV-1 infection during pregnancy and the perinatal period on maternal and child health in Africa.

PIP: In 1989 the Global Program on AIDS (GPA) of the World Health Organization estimated that there were 2.5 million women and half a million children infected with HIV-1 in Africa. A study carried out in two maternities in Kinshasa, Zaire, in 1988 showed higher mortality rates in previously born children of seropositive mothers compared with children of seronegative mothers (43% vs. 32%, p 0.01). A case control study in Nairobi of patients admitted with an acute spontaneous abortion indicated that HIV-1 infection was significantly associated with spontaneous abortion (13.8% vs. 6.2%. p = 0.02). In another study from Nairobi the mean birth weight of infants born to seropositive mothers was slightly but significantly lower than the birth weight of infants with seronegative mothers (3090 vs. 3220 g, p = 0.005). In the Kinshasa study more infants born to HIV-1 seropositive mothers with symptomatic infection were delivered before 38 weeks of gestation compared with neonates of HIV-positive asymptomatic or seronegative women (18%, 12%, and 3%, respectively, p 0.01). In the Nairobi study abnormalities were noted in 115 stillborn neonates, and maternal HIV-1 infection (odds ratio of 2.7) was a contributory factor. Among the 68 live-born infants with HIV-1 seropositive mothers in the Kinshasa study, there were 29 (6.2%) neonatal deaths compared with 8 (1.3%) among infants of seronegative women (p 0.0001). In addition, chorioamnionitis was found significantly more often in the placentas of infants of HIV-1 seropositive mothers with AIDS than among placentas of infants born to asymptomatic seropositive women or seronegative controls (21.4% vs. 1.0% and 2.9%, respectively, p 0.01). In another Nairobi study in 1990 a single session of counseling of HIV-1 seropositive women did not seem to influence their subsequent condom use or reproductive behavior. Pregnancy seemed to accelerate the progression of the disease because of its immunosuppressive effect. The diagnosis of perinatal HIV infection has been difficult and the use of the polymerase chain reaction method has been the most sensitive test.^ieng