Human immunodeficiency virus seroprevalence and drug-using behavior in Milwaukee intravenous drug abusers.

We assessed human immunodeficiency virus (HIV) antibody prevalence and drug-using behaviors among intravenous drug abusers (IVDAs) enrolled in Milwaukee drug treatment programs. Six (2.3%) of 266 study participants were positive for HIV antibody by Western blot assay. A history of needlesharing was reported by 91% of participants, injection of drugs within the past 6 months by 76%, visits to a shooting gallery by 34%, and drug injection outside of Wisconsin by 41%. Nonwhite participants were more likely than white participants to share needles greater than 5 times per month (odds ratio of 2.0) and more likely to have visited a shooting gallery greater than 5 times (odds ratio of 2.7). The average frequency of injection did not differ significantly by race or gender. Pharmacies were the most frequently listed source of sterile needles, and the most common reason for sharing needles was convenience. We conclude that as of late 1987, HIV seroprevalence in Milwaukee IVDAs remained relatively low compared to that of IVDAs in the northeastern United States. There may be racial differences in drug-using behaviors that define distinct subpopulations of IVDAs. These differences should be assessed further, since they have important implications for the success of AIDS education efforts.

HIV infection in Wisconsin: an overview of epidemiologic trends, 1983-1999.

A review of HIV case surveillance data shows that the number of persons reported with HIV infection in Wisconsin steadily increased during the 1980s, leveled in the early 1990s and since 1993 has tended to decline. Cases reported in 1999 represented a 44% decrease compared to the 1990-1993 average. The number of deaths among persons with HIV infection declined 64% from 1993 to 1999; as a result, the number of persons living with HIV infection nearly doubled during the 1990s. Comparing cases reported 1995-1999 with cases reported in the 1980s, a higher percentage was attributed to injection drug use and high-risk heterosexual contact. A higher percentage of HIV cases also occurred among females and racial and ethnic minorities.

HIV infection in Wisconsin: state and national resources for clinicians and patients.

The authors review state and national resources for clinicians and patients regarding HIV infection, high-lighting pertinent resources in the Wisconsin AIDS/HIV Program as well as select local and national resources.

Wisconsin statutes regarding HIV testing in primary care: frequent questions and answers.

The authors review Wisconsin statutes related to human immunodeficiency virus (HIV) testing in primary care, including the areas of written informed consent, documentation of consent, testing without consent, testing of minors, disclosure of test results without the consent of the test subject, reporting requirements, discrimination, access by insurance companies and third-party payors to HIV test results, and civil liabilities and criminal penalties associated with violation of HIV-related state statutes. During the course of the HIV epidemic in Wisconsin, many individuals (service providers, legislators, consumers and advocates) supported the enactment of HIV-related legislation. Today, Wisconsin has some of the nation's most comprehensive HIV legislation. These laws have set a legal framework that balances the rights of individuals with protection of public's health. The relatively low seroprevalence of HIV infection in Wisconsin can be attributed, in part, to the state's HIV-related legislation. While Wisconsin HIV legislation is broadly focused, much of it is concerned with HIV testing. This article examines common questions as they pertain to HIV testing in primary care and to the following areas addressed by state statutes: counseling and referral for health and support services [Wisconsin statute s. 252 14(3)] informed consent for testing or disclosure [Wisconsin statute s. 252.15(2)] written consent to disclose [Wisconsin statute s. 252.15(3) & (4)] testing without consent of the test subject [Wisconsin statute s. 252.15(2)] confidentiality of an HIV test [Wisconsin statute s. 252.15(5)] reporting of positive test results [Wisconsin statute s. 252.15(7)] discrimination [Wisconsin statute s. 252.14(2)] civil and criminal liabilities [Wisconsin statute s. 252.14(4); 252.15(8) & (9)].

Meeting the challenge of early identification of HIV infection in primary care.

The authors review the role of human immunodeficiency virus (HIV) testing in primary care, including an overview of epidemiologic trends of the HIV epidemic; avenues for HIV counseling and testing; HIV testing assays; guidelines for HIV test counseling in primary care; special situations involving testing of pregnant women, infants, and young children; post-exposure prophylaxis; and related resources available to Wisconsin primary care clinicians. HIV disease is a major cause of premature death and disability in the United States. Advances in the understanding of the pathogenesis of HIV and developments of newer antiretroviral therapies have resulted in dramatic changes in the management of HIV disease. Combination antiretroviral drug therapy has resulted in prolonged and near complete suppression of detectable HIV replication in many HIV-infected persons. These clinical developments underscore the importance of early identification and intervention in HIV disease. Intervention during primary HIV infection, the time when the viral burden "set point" is achieved, may present a special window of opportunity to effectively intervene in limiting viral replication in an infected individual. This earliest intervention may have major benefits for infected persons and society at large. Decreasing viral load during primary HIV infection may decrease an individual's infectiousness and thereby decrease the overall rate of transmission of infection to others. Primary care clinicians play a critical role in diagnosing, managing, and preventing HIV infection. Because of the ongoing relationship between patient and health care provider, the primary health care clinician is in the best position to provide HIV risk assessment, testing, related prevention education, and coordination of needed health care. This article presents guidelines for conducting HIV counseling and testing in primary care for purposes of furthering the public health objective of early identification of HIV infection. Clinicians can achieve this objective by including HIV risk assessment during the initial history and physical exam of every patient.

HIV seroprevalence among male prison inmates in the Wisconsin Correctional System.

OBJECTIVE: To estimate HIV seroprevalence and the acceptance of voluntary HIV testing among male inmates entering the Wisconsin Correctional System during July 1, 1994-June 30, 1995, and compare these estimates with similar data obtained in 1987-1988. METHODS: A blinded HIV seroprevalence survey concurrent with a review of voluntary HIV antibody testing records. RESULTS: HIV test results were obtained for 3,681 (89%) male prison entrants during the study period; 26 (0.7%) were HIV-1 seropositive. Based on this estimate and the total number of male prison entrants (4,134), an estimated 29 HIV-1 seropositive male inmates entered the Wisconsin Correctional System during the study period. Eighty-four percent of all inmates were tested voluntarily. Among inmates testing HIV-1 seropositive, 69% were tested voluntarily. CONCLUSIONS: These data suggest that HIV-1 seroprevalence among male prison inmates in Wisconsin is low, and is unchanged from the late 1980s; however, a large increase in the prison population has resulted in a substantial increase in the absolute number of HIV-1 seropositive inmates entering the correctional system. Although overall acceptance of voluntary HIV testing is high, nearly one third of HIV-1 seropositive inmates declined voluntary HIV testing.

The effect of publicity on the reporting of toxic-shock syndrome in Wisconsin.

The Wisconsin and Centers for Disease Control (CDC) surveillance for toxic-shock syndrome (TSS) were compared; the distributions of CDC and Wisconsin cases in 1980 by calendar quarter of the initial onset were virtually identical. Among 131 cases in Wisconsin, 33 of 40 self-reported vs. 16 of 91 physician-reported cases were reported during the four-week period (September 18-October 15, 1980) following the CDC announcement of a higher relative risk of TSS among users of Rely tampons (Procter and Gamble, Cincinnati, Ohio) (P less than 0.001). Of cases with onsets during October 1, 1979-June 30, 1980, eight of 31 women with physician-reported cases vs. nine of 15 with self-reported cases used Rely tampons during their TSS-associated menstrual period (P less than 0.05). Multiple interviews of 22 patients with TSS suggested that patient recall of tampon brand may have been influenced by publicity about TSS. Passive as compared with partially active surveillance for TSS significantly favored self-reporting. In Wisconsin, the volume and source of TSS reporting have been greatly influenced by publicity, and selective reporting of TSS has been influenced by the content of news media reports of TSS.

AIDS and HIV in Wisconsin: projections for the decade.

Based on a projection model developed by the Wisconsin AIDS/HIV Program, at the beginning of 1990 there were between 7,143 and 11,957 HIV-infected persons in Wisconsin. During the 1990s the cumulative number of HIV-infected persons in the state may more than double to between 16,471 and 25,932. We project that between 6,329 and 9,489 new cases of acquired immunodeficiency syndrome (AIDS), and between 3,577 and 5,365 AIDS deaths will occur in Wisconsin in next ten years. This is a greater than 13-fold increase in AIDS cases over the 1980s. By the end of the 1990s, the number of persons living with AIDS is projected to be ten-fold greater than the currently estimated number. To make plans for the future, policy makers need to be aware of this expected large increase in HIV-related morbidity and mortality.

Epidemiologic aspects of blastomycosis, the enigmatic systemic mycosis.

A growing body of epidemiologic information derives from the study of sporadic cases and seven epidemics of blastomycosis, although a complete epidemiologic description of the disease is impeded by the absence of a skin test and difficulty isolating the causative fungus, Blastomyces dermatitidis, from nature. Most cases occur sporadically in humans and dogs in a worldwide distribution. Endemic areas in the United States include southeastern, southcentral, and midwestern states, particularly Arkansas, Kentucky, Mississippi, and Wisconsin. Blastomycosis is acquired by inhalation of spores from nature and acute disease occurs 21 to 106 days (median 43 days) after exposure; cutaneous inoculation and sexual and intrauterine transmission are rare. Most human cases are in middle aged men with occupation-, or leisure-related activities involving the soil or wooded areas. Identification of a point source in nature at a beaver pond and lodge was first accomplished during a 1984 Wisconsin epidemic, advancing knowledge of the natural habitat and ecology of the fungus. Blastomcyces alkali- and water-soluble antigen, utilized for in vitro lymphocyte transformation studies during the epidemic, may hold considerable promise for incorporation into a skin test.

HIV seroprevalence among patients attending a Milwaukee clinic for sexually transmitted diseases: findings from four annual surveys, 1988-1991.

Blinded HIV seroprevalence surveys were conducted annually from 1988 through 1991 among patients at a Milwaukee sexually transmitted disease (STD) clinic. Among 5,295 patients tested, 70 (1.3%) were HIV-1 Western blot positive. HIV seroprevalence rates were higher among male patients (1.7%) than among female patients (0.5%). HIV seroprevalence increased progressively with age and the number of prior STD episodes. During the four survey periods, HIV seroprevalence increased among teenage STD patients, patients who reported no prior STD, and patients without determined risk exposures. Selective voluntary HIV testing of patients who reported high risk exposures failed to detect 80% of all HIV seropositive patients. Because STD clinic patients are at high risk of HIV infection, HIV antibody testing, with appropriate referral of patients who test positive, and risk reduction education should be made routinely available to all STD patients with or without HIV-associated risk exposures.

Two outbreaks of blastomycosis along rivers in Wisconsin. Isolation of Blastomyces dermatitidis from riverbank soil and evidence of its transmission along waterways.

Blastomycosis cannot yet be prevented or controlled, in part because the natural habitat of the causative fungus, Blastomyces dermatitidis, remains ill defined. In investigating 2 outbreaks of blastomycosis that occurred in the summer of 1985 among persons engaged in activities along rivers in contiguous central Wisconsin counties, we isolated B. dermatitidis from soil at one of the riverbanks. Blastomycosis developed in 7 (58%) of 12 residents and guests who had gathered at a pheasant farm on the Tomorrow River in early May, and in 7 (88%) of 8 boys and 1 adult who had visited a site on the Crystal River in early June. Of the 14 patients, 13 (93%) were symptomatic. Two patients visiting the sites only once became ill 23 and 78 days after exposure, respectively. We traced one outbreak to fishing from the bank of the Tomorrow River, and the other to climbing into an underground timber fort along the Crystal River. A culture of soil and organic debris from the fishing site yielded B. dermatitidis. From these and other outbreaks, and studies of endemic disease, we conclude that riverbanks can be a natural habitat of B. dermatitidis, and that the environment around waterways represents the most important site yet identified for transmission of B. dermatitidis.

Toxic shock syndrome: a critique of the 1980 Wisconsin case-control study.

Seven cases of toxic shock syndrome has been reported to the Wisconsin Division of Health by 6 January 1980; all seven cases were in female patients, six of whom had onset of illness during active menstruation. Through passive reporting of cases by physicians and patients themselves, a total of 38 patients with confirmed cases of toxic shock syndrome had been identified by the Division of Health by 30 June 1980. Thirty-five patients with menstrual toxic shock syndrome were each age-matched to three menstruating control subjects as part of a case-control study to identify potential risk factors associated with menstrual toxic shock syndrome. Statistically significant findings included increased tampon usage by patients as compared with controls, and fewer patients than controls were using any method of birth control. Numerous other health and hygiene variables were examined and found not to be statistically significant. We critically review the potential biases inherent to the study design. The conclusions and experience gained in this study were crucial to the designing of later case-control studies.

The disease spectrum, epidemiology, and etiology of toxic-shock syndrome.

From this composite picture of the history and recent developments related to TSS, several points are clear. TSS is not a new disease, and TST-producing strains of S. aureus are not new. What is new is the recent dramatic increase of this disease in young women who use tampons during menses and who lack antibody to TST. What is also new is the recognition that the disease commonly recurs but only in menstrually associated cases. What remains to be determined are the precise role of tampons, the factors leading to toxin induction, and the mechanism of action of this potent toxin. In order to better determine what these factors and mechanism of action are, and to determine if the TST marker protein is in fact the critical toxin, a reliable animal model is badly needed. Finally, a reliable laboratory test to confirm the clinical diagnosis is another high-priority need. The further unraveling of the secrets of this complex disease may greatly enhance our understanding of the disease associated with this toxin, of the intricacies of toxin production by other bacteria, and of the role that exogenous cofactors play in disease processes.

Development of long-term specific cellular immunity after acute Blastomyces dermatitidis infection: assessments following a large point-source outbreak in Wisconsin.

Ninety-five persons exposed to a point-source of Blastomyces dermatitidis in Wisconsin in 1984 were evaluated 3 months after exposure for the development of specific cellular immunity, and the 48 infected persons were again evaluated 7 and 21 months after exposure. The immune response was assessed by an assay of [3H]thymidine uptake by lymphocytes proliferating in response to stimulation with Blastomyces alkali- and water-soluble antigen (B-ASWS) or blastomycin and by skin testing with blastomycin. At 3 months, 36 (84%) of 43 patients demonstrated a proliferative response to B-ASWS (mean value of experimental [E]-control [C] counts, 16,852 +/- 2664, and of E/C, 42.2 +/- 5.3). None of the patients demonstrated a proliferative response to blastomycin, and only 19 (41%) of 45 patients tested had a positive blastomycin skin test. By 21 months, 47 (98%) of the 48 patients demonstrated a proliferative response to B-ASWS on at least one testing date. Of those initially positive, 82% had a persistently positive proliferative response at 21 months; mean E-C and E/C values were comparable to those seen at 3 months. None of the 47 uninfected persons demonstrated a proliferative response to B-ASWS: 7 with positive histoplasmin skin tests had a mean E-C value of 1094 +/- 432, and the 40 others, a mean value of 1139 +/- 212. A proliferative response to B-ASWS in exposed individuals is a reliable marker of specific cellular immunity in blastomycosis and the response persists in most patients for up to at least 2 years.

A hospital discharge code review of toxic shock syndrome in Wisconsin.

The Wisconsin Division of Health conducted a review of discharge coding for 142 (97%) of the state's general care hospitals for the period 1980-1983 to evaluate the use of International Classification of Diseases codes for toxic shock syndrome and to estimate completeness of reporting of recognized hospitalized cases of the syndrome to the Division of Health. Hospital use of code 040.89 (other bacterial diseases-other) recommended for toxic shock syndrome by the National Center for Health Statistics in January 1981 increased from 23% of Wisconsin hospitals in 1980 to 92% in 1983. The sensitivity of this code for toxic shock syndrome increased from 54% to 85% from 1981 to 1983; study population specificity was stable at approximately 95%, and the predictive value was 65% in 1981 and 70% in 1983. The use of codes 785.50 (shock, unspecified) and 785.59 (nontraumatic shock-other) frequently assigned to toxic shock syndrome was also assessed; all measures of their utility decreased in proportion to the increasing use of 040.89. The coding review identified 20 previously unreported cases of toxic shock syndrome; the 10 confirmed and 10 probable cases represent 4% and 21% of the state's 223 confirmed and 47 probable cases with onsets in 1980-1983. Results indicate that a National Center for Health Statistics coding recommendation for a disease of emerging significance can result in relatively uniform coding of the illness, which can provide a tool for case finding and surveillance evaluation for hospitalized cases.

Prevalence of serum antibody to staphylococcal enterotoxin F among Wisconsin residents: implications for toxic-shock syndrome.

Staphylococcal enterotoxin F (SEF) has previously been shown to be a marker for toxic-shock syndrome (TSS)-associated strains of Staphylococcus aureus, whereas the serologic absence of antibody to SEF (anti-SEF) has been shown to be a marker for susceptibility of persons to TSS. In this study, anti-SEF was measured by radioimmunoassay in 689 banked sera obtained from Wisconsin residents during 1960, 1970, and 1980. The prevalence of anti-SEF as estimated by logistic regression analysis was 47%, 58%, 70%, 88%, 96%, and 99% at ages one, five, 10, 20, 30, and 50 years, respectively. Evidence for the transplacental transfer of anti-SEF is also presented. Despite the reported increased incidence of TSS occurring during the past five years, with a preponderance of cases occurring among women, no significant differences in the prevalence of anti-SEF were noted between sexes or longitudinally between the years 1960, 1970, and 1980. These data enhance our understanding of the epidemiology of TSS and further identify the population that may be susceptible to TSS.

Toxic shock syndrome: relation to catamenial products, personal health and hygiene, and sexual practices.

In 1980, the discovery of an association between vaginal tampon use and toxic shock syndrome affected the lifestyles of menstruating women and the catamenial products industry. It made both the general public and the medical community more aware of all aspects of menstruation. The relation between developing toxic shock syndrome and tampon use is unclear; tampon fluid capacity (absorbency) remains the best predictive measure of that risk. No unique aspect of tampon use other than absorbency seems to increase the risk of developing toxic shock syndrome, and numerous hygiene and medical history factors do not seem to play a role in the pathogenesis of the disease. Studies in Minnesota, Wisconsin, and Iowa indicate that 70% to 75% of women between the ages of 15 and 24, the group with the highest risk of developing menstrual toxic shock syndrome, continued to use tampons after news media attention in 1980 on the association of the syndrome with tampon use. This rate of use is higher than the rate found for the general population by recent tampon market research.

HIV seroprevalence and the acceptance of voluntary HIV testing among newly incarcerated male prison inmates in Wisconsin.

In 1986-88, voluntary and blinded HIV testing was conducted among Wisconsin male prison entrants. The HIV seroprevalence was 0.30 percent in 1986, 0.53 percent in 1987, and 0.56 percent in 1988. The seroprevalence rates among entrants tested voluntarily did not differ from those tested blindly. Voluntary HIV testing was accepted by 71 percent of male prison entrants in 1988; among entrants reporting intravenous drug use 83 percent consented to voluntary HIV testing. Voluntary HIV testing of entrants appears to be an effective screening strategy in Wisconsin prisons.

HIV-1 among childbearing women and newborns in Wisconsin.

To estimate the prevalence of antibody to human immunodeficiency virus-type 1 (HIV-1) among Wisconsin childbearing women (CBW), a continuous blinded HIV-1 seroprevalence survey is being conducted. This survey uses dried blood specimens obtained from infants as part of the Wisconsin Newborn Screening Program. From February 1989 through March 1990, 79,546 specimens from Wisconsin residents were tested for HIV-1 antibody, 21 (0.026%) were HIV-1 seropositive. Among specimens obtained from Milwaukee County CBW, 15 (0.076%) of 19,781 were HIV-1 seropositive compared to 6 (0.010%) of 59,765 obtained from other Wisconsin counties. After adjusting for maternal residence, Wisconsin minority CBW were six times more likely to be HIV-1 seropositive when compared to white CBW. The survey results underscore the need for strategies to prevent HIV-1 infection that focus on women of childbearing age in Wisconsin.

Cryptosporidiosis-associated mortality following a massive waterborne outbreak in Milwaukee, Wisconsin.

OBJECTIVES: This study estimated the magnitude of cryptosporidiosis-associated mortality in the Milwaukee vicinity for 2 years following a massive waterborne outbreak. METHODS: Death certificates were reviewed. RESULTS: During approximately 2 years before the outbreak, cryptosporidiosis was listed as an underlying or contributing cause of death on the death certificates of four Milwaukee-vicinity residents. In the approximately 2 years after the outbreak, this number was 54, of whom 85% had acquired immunodeficiency syndrome (AIDS) listed as the underlying cause of death. In the first 6 months after the outbreak, the number of death certificates indicating AIDS, but not cryptosporidiosis, as a cause of death was 19 (95% confidence interval = 12.26) higher than preoutbreak trends would have predicted. CONCLUSIONS: Waterborne outbreaks of cryptosporidium infection can result in significant mortality, particularly among immunocompromised populations. Any discussion of policies to ensure safe drinking water must consider the potential fatal consequences of waterborne cryptosporidiosis among immunocompromised populations.