Preliminary laboratory studies of inactivation of HIV-1 in needles and syringes containing infected blood using undiluted household bleach.

To evaluate the effectiveness of bleach disinfection of injection equipment, we tested HIV-1 inactivation by household bleach in needles and syringes. We obtained blood from HIV-1 infected injecting drug users (IDUs), placed small aliquots in needles and syringes. Blood with and without anticoagulant was incubated at room temperature for 3, 6, 18, and 24 h, and some needles and syringes from each condition were exposed to undiluted bleach for 15 and 30 s. The needles and syringes were then rinsed and the rinses were used to inoculate peripheral blood mononuclear cells (PBMNCs). HIV-1 replication was monitored using p24 enzyme linked immunosorbent assay (ELISA). We describe results that HIV-1 is inactivated in clotted and unclotted blood allowed to stand at room temperature for 3, 6, 18, and 24 h in needles and syringes using undiluted household bleach at 30 s of exposure time. These results are consistent with earlier findings that micropellets of HIV-1 were inactivated by bleach under similar conditions of exposure to bleach; 10% bleach was not effective at an exposure time of 30 s and undiluted bleach was not effective at an exposure time of 15 s to inactivate HIV-1 in clotted blood. Bleach concentration and exposure time are critical and HIV disinfection may not occur with inadequate exposure to bleach HIV.

Compliance to bleach disinfection protocols among injecting drug users in Miami.

Bleach cleansing of injection equipment has been recommended to reduce the risk of human immunodeficiency virus (HIV) transmission associated with the reuse of injection equipment by injecting drug users (IDUs). We evaluated the recall and performance of the most commonly recommended bleach cleansing procedure of two complete fillings of the syringe with bleach, followed by two complete fillings with rinse water, and not putting used bleach and water back into source containers. IDUs were taught this procedure on enrollment in an HIV prevention demonstration project in Dade County, Florida. During follow-up session 6-12 months after initial training, the knowledge and ability of IDUs to perform bleach cleansing were assessed by trained observers using a standardized method. In 1988-90, we assessed the knowledge and ability of 450 IDUs to perform the bleach cleansing procedure taught at enrollment. More than 90% of IDUs assessed performed the basic steps. However, only 43.1% completely filled the syringe with bleach and only 35.8% completely filled the syringe with bleach at least twice. Substantial proportions of IDUs did not perform all the steps of the previously taught bleach cleansing procedure. Compliance decreased as the number of steps required was increased. This limited compliance may make bleach cleansing less effective and suggests that some IDUs may fail to adequately disinfect injection equipment and therefore sterile needles and syringes are safer than bleach-cleansed ones. Compliance testing can help assess the effectiveness of HIV prevention programs.

Doppler echocardiographic evaluation of pulmonary vascular resistance in children with congenital heart disease.

Noninvasive assessment of pulmonary vascular resistance has not been well defined. Cardiac catheterization findings in 33 patients with congenital heart disease (mean age 1.4 years) were compared with Doppler echocardiographic parameters. The right ventricular pre-ejection period (RVPEP), ejection time (RVET), and the ration RVPEP/RVET correlated better with pulmonary vascular resistance than with pulmonary artery pressure. A highly significant correlation with a small standard error of estimate (SEE) was demonstrated between pulmonary vascular resistance and a newly derived parameter RVPEP/velocity time integral (VTI) [r = 0.87, p < 0.0001, SEE = 2]. An RVPEP/VTI value of < 0.4 seconds/meter (M) was able to select patients with pulmonary vascular resistance < 3 Wood Unit.M2, even in the presence of pulmonary artery hypertension caused by increased pulmonary blood flow, with 97% accuracy (100% sensitivity, and 92% specificity). An RVPEP/VTI value of 0.4 to 0.6 seconds/M identified patients with pulmonary vascular resistance between 3 to 7.5 Wood Unit.M2 with 91% accuracy, and a value of > or = 0.6 seconds/ M selected patients with total pulmonary vascular resistance > or = 7.5 Wood Unit.M2 with 94% accuracy.

HIV-1 RNA load in needles/syringes from shooting galleries in Miami: a preliminary laboratory report.

We quantified HIV-1 RNA load in rinses from needles/syringes (N/S) obtained at shooting galleries in Miami and also analyzed the rinses for antibodies for viral proteins. In rinses from 36 N/S that contained visible blood, 14 (39%) had detectable amounts of HIV-1 RNA. Numbers of copies of HIV-1 RNA ranged from the detection limit (400 copies/ml) to 268,000 copies/ml. We also detected antibodies to HIV-1 polypeptides in 34/36 (94%) of rinses from visibly contaminated N/S using Western blots specific for the HIV-1 proteins. No antibodies were detected in laboratory rinses from six visibly clean needles. The presence of HIV-1 RNA in N/S is an important indication of the risk created by N/S sharing as well as by shared paraphernalia and wash waters by injecting drug users.

HIV-1 prevention: interdisciplinary studies on the efficacy of bleach and development of prevention protocols.

In the United States, a major federally-funded approach to HIV-1 prevention for injecting drug users (IDUs) includes teaching them to always rinse their needles/syringes with household bleach and water before use. This report describes interdisciplinary studies of the extent to which HIV-1 can be found in injection equipment and the efficacy of bleach as a disinfectant, under simulated field conditions. Bloody needle/syringe units collected from Miami, Florida, shooting galleries or from community outreach prevention participants were selected for these studies. Groups of needle/syringe units were cleansed with bleach using a standard technique taught to IDUs in community outreach programs. Cleansed and uncleansed groups of needles/syringe units were then tested for the presence of HIV-1. The data demonstrate the efficacy of bleach rinses in reducing the risks of HIV-1 infection from needle/syringe units and indicate that the teaching of a bleach cleansing method to IDUs should be part of a total AIDS prevention protocol.

Crack cocaine use and sexual activity in Miami, Florida.

Data are analyzed from the Multicenter Study of Crack Cocaine and HIV Infection in Miami, Florida, examining interrelationships among use of crack cocaine, use of other drugs, sexual activity, and exchange of sex for money and drugs. This study was designed to recruit two groups of approximately equal size: persons who reported current use of crack cocaine three or more times per week, and those who had never used crack. Participants (N = 641) were recruited in Miami. Participants' median age for first use of crack cocaine was higher than for use of alcohol, marijuana or powdered cocaine. It was also higher than participants' ages at first sexual activity, and somewhat higher than the median age for reporting initiation of trading sex for money or drugs. The median age of first crack use was lower among younger participants, suggesting that crack use in older participants followed quickly upon availability of the drug. Crack users reported reduced desire for sex and diminished ability to have sex after smoking crack. However, crack use was associated with increased sexual activity, trading sex for money or drugs, and sex with multiple partners. Participants who traded sex for money or drugs (traders) reported higher rates of condom use than nontraders; however, neither traders nor nontraders reported rates of condom use sufficient to substantially reduce the transmission of sexually transmitted diseases and HIV infection.

HIV-related risk behaviors and seropositivity among homeless drug-abusing women in Miami, Florida.

This article examines the multifaceted interactions among homelessness, HIV, substance abuse, and gender. Data were collected on 1,366 chronic drug users using a nationally standardized validated instrument within the Miami CARES project of a multisite federally funded program. HIV testing accompanied by pretest and posttest counseling was conducted on-site by certified phlebotomists and counselors. In addition to descriptive analyses and corresponding tests of significance, logistic regression analyses were used to clarify the complex associations between the outcome variables of homelessness and HIV, recognizing difficulties of determining temporal sequence. HIV infection was found to be 2.35 times more prevalent among homeless women than homeless men and significantly higher for homeless women. The findings indicate that among women, homelessness and HIV have a highly interactive effect increasing the vulnerability of this population and thus rendering them an extremely important priority population on which to focus public health efforts and programs.

The National Birth Center Study. Part II--Intrapartum and immediate postpartum and neonatal care.

Part II of a three-part report of the National Birth Center Study describes care provided to 11,814 women and their newborns during and after labor and delivery until they were transferred or discharged from the birth centers. There were few low birth weight or preterm or postterm births, but more macrosomic babies than among all U.S. births during the same time period. Certified nurse-midwives provided most of the intrapartum care, which is described in the context of medically recommended standards and data that describe care provided to low-risk women giving birth in U.S. hospitals. Birth center care deviated from typical hospital care in several ways. Birth center clients were much less likely to receive central nervous system depressants, anesthesia, continuous electronic fetal monitoring, induction and/or augmentation of labor, intravenous infusions, amniotomies, or episiotomies, and they had relatively few vaginal examinations. They were more likely to eat solid food during labor and to take showers and/or baths. Nulliparity was strongly associated with longer first stage labors and longer labor was associated with more frequent use of many kinds of interventions. Infant birth weight, mother's position during delivery, and forceps- or vacuum-assisted deliveries are examined in relation to episiotomies and lacerations and tears.

The National Birth Center Study. Part I--Methodology and prenatal care and referrals.

This is the first of three articles that will report on the complete findings from the National Birth Center Study (NBCS). This article describes the study methodology, compares the entire group of NBCS subjects with all women who gave birth in the United States in 1986, describes the prenatal care and prenatal referral practices of birth centers in the study, and describes the women who were admitted to the birth centers for intrapartum care with regard to characteristics known or thought to be associated with perinatal risk. Nearly 18,000 women were included in the study; two-thirds of them (n = 11,814) were admitted to the birth centers for intrapartum care. Although medical and obstetric complications were the most common reason for discontinuing birth center care, they accounted for less than half of the women who were not admitted to the birth centers for labor and delivery; many women left for a variety of other reasons. In addition to describing birth center clients, birth center care providers, and birth center care, the NBCS provides detailed information about the characteristics and experiences during pregnancy of a large population of essentially low-risk women receiving a low-intervention style of maternity care.

The National Birth Center Study. Part III--Intrapartum and immediate postpartum and neonatal complications and transfers, postpartum and neonatal care, outcomes, and client satisfaction.

This is the final article of the three-part report of the National Birth Center Study. Eight percent of the mothers or infants had serious complications; 16% were transferred, 12% before and 4% after the deliveries. Fifteen percent of transfers were emergencies. Nulliparous women were much more likely than parous women to experience dystocia, be transferred, or have cesarean sections. Seventy-five percent of the nulliparous women gave birth in the centers, compared with 95% of the parous women. Eighty-four percent of the women had at least one postpartum home or office visit. There were 11,814 mothers, no maternal deaths, and 15 intrapartum/neonatal deaths (1.3/1,000 births, 0.7 excluding congenital anomalies). Postterm deliveries with macrosomic infants, placental abruption, sustained fetal distress, and thick meconium were associated with high mortality. Mortality was very low for those not transferred and much lower for transfers during labor as compared with those after the delivery. Women with no medical/obstetric risk factors had the lowest rates of transfers and serious complications. Except for postterm pregnancies, the intrapartum/neonatal mortality rate for birth center clients was not higher than rates from studies of low-risk hospital births, and the cesarean section rate was lower. There is no evidence that hospitals are a safer place for low-risk births.

Development, inequality, health care, and mortality at the older ages: a cross-national analysis.

We examine mortality at ages 50 and above in female populations of 38 countries and control for variation in quality of the mortality data. We find that economic development, economic distributional inequality, and basic primary health care have independent cross-national effects on cause of death structures and that these effects are not uniform across the age intervals of interest. As improvements occur in level of living and health care, age-specific death rates decline except at the oldest ages, at which point they may increase. Our results are interpreted in terms of their relevance for mortality research, theory, and policy.

The effectiveness of contingency-planning counseling.

A longitudinal study assessed the effectiveness of contingency-planning counselling on contraceptive use and pregnancy outcomes among patients at a family planning clinic. Of 914 women enrolled in the study, 502 received traditional family planning counseling that focused on the provision of information and the selection of a contraceptive method, and 412 received contingency-planning counseling, which provided additional attention to possible problems that might arise with contraceptive use and the particular method selected. Although contingency-planning counseling was favorably received by both patients and staff members, patients in the two groups did not differ significantly on most of the outcomes considered. The two counseling groups had remarkably similar rates of clinic continuation at both the six- and 12-month follow-ups and analogous patterns of contraceptive use. In an exception to this pattern, the six-month pregnancy rate was significantly reduced among contingency-counseled patients who had ever been pregnant. However, the effectiveness of the intervention in reducing the likelihood of unintended pregnancy was short-lived: At 12 months, the pregnancy rate among ever-pregnant women was the same for traditionally counseled patients as for those receiving contingency-planning counseling.

Correlates of participation and willingness to participate in anti-tobacco activities among 4th-7th graders.

The purpose of this study was to identify factors associated with participation and willingness to participate in anti-tobacco community activities in 4-7th grade students. A probability sample was drawn from seven regions in Florida (n = 1219). Telephone interviews assessed socioeconomic status, tobacco use, knowledge, and attitudes, and exposure to anti-tobacco school education and media campaigns. Factors related to both participation and willingness included: parental discussion of tobacco use, exposure to school courses with anti-tobacco curricula and a belief that youth could convince their friends to stop smoking. Additional participation correlates included: parental smoking status and student government activity participation. Additional willingness correlates included: exposure to anti-tobacco television campaigns, liking school, and several tobacco-related knowledge and attitudinal questions. These findings suggest that exposure to community-based tobacco control programs and family discussion of tobacco use is associated with regular participation and/or willingness of youth to participate in anti-tobacco activities.

HIV seroprevalence across the rural/urban continuum.

While the first decade of the AIDS epidemic was characterized by high prevalence rates of AIDS infection in urban areas, there is increasing recognition of the spread of HIV into rural communities in the United States. Data from the Miami CARES cohort collected on 3,555 chronic drug users from 1988 to 1994 provide a unique opportunity to assess sociodemographic characteristics, drug-using behaviors and HIV risk behaviors related to HIV seropositivity in three communities across the rural-urban continuum: Miami, Florida; Belle Glade, Florida and Immokalee, Florida. The three very different communities studied demonstrate that HIV is no respecter of ecological site. The spread of HIV between areas and within areas is specifically correlated with the risk factors including injection drug use, use of crack cocaine, exchange of sex for money, and the rates for sexually transmitted diseases. All of these factors are shown to increase the risk of HIV so that the constellation of these practices helps determine the differential rates and spread of HIV in the three different areas.

AIDS susceptibility in a migrant population: perception and behavior.

Within the framework of the Health Belief Model, this paper examines correlates of perception of AIDS susceptibility among 846 drug-using migrant farm workers and their sex partners. Significant but relatively small differences by ethnicity and gender were found. The data showed a consistent significant statistical relationship between frequency of drug use, high-risk sexual behavior, and perception of AIDS susceptibility. Perception of AIDS susceptibility was significantly related to a subsequent reduction in sexual risk behaviors. Consistent with the Health Belief Model, the data suggest that increasing perception of AIDS susceptibility may be an important motivator in reducing high-risk behaviors.

Behavior changes among crack-using rural and urban women.

This study compared rural and urban crack-using women and examined their responses to two interventions. A prospective cohort study design was employed to assess the effectiveness of standard and innovative HIV prevention interventions on 541 urban and 268 rural women in Florida. Generalized estimating equation analysis, accounting for repeated measures, found that for combined urban and rural samples, the innovative intervention was more effective than the standard for a number of drug and sexual risk behaviors. However, the analysis indicated no significant differences in intervention efficacy between rural and urban women. The results imply that there is a need for similar HIV prevention services in both areas.

Outcomes of care in birth centers. The National Birth Center Study.

We studied 11,814 women admitted for labor and delivery to 84 free-standing birth centers in the United States and followed their course and that of their infants through delivery or transfer to a hospital and for at least four weeks thereafter. The women were at lower-than-average risk of a poor outcome of pregnancy, according to many but not all of the recognized demographic and behavioral risk factors. Among the women, 70.7 percent had only minor complications or none; 7.9 percent had serious emergency complications during labor and delivery or soon thereafter, such as thick meconium or severe shoulder dystocia. One woman in six (15.8 percent) was transferred to a hospital; 2.4 percent had emergency transfers. Twenty-nine percent of nulliparous women and only 7 percent of parous women were transferred, but the frequency of emergency transfers was the same. The rate of cesarean section was 4.4 percent. There were no maternal deaths. The overall intrapartum and neonatal mortality rate was 1.3 per 1000 births. The rates of infant mortality and low Apgar scores were similar to those reported in large studies of low-risk hospital births. We conclude that birth centers offer a safe and acceptable alternative to hospital confinement for selected pregnant women, particularly those who have previously had children, and that such care leads to relatively few cesarean sections.