Impact of 13-Valent Pneumococcal Conjugate Vaccine on Colonization and Invasive Disease in Cambodian Children.

BACKGROUND: Cambodia introduced the 13-valent pneumococcal conjugate vaccine (PCV13) in January 2015 using a 3 + 0 dosing schedule and no catch-up campaign. We investigated the effects of this introduction on pneumococcal colonization and invasive disease in children aged <5 years. METHODS: There were 6 colonization surveys done between January 2014 and January 2018 in children attending the outpatient department of a nongovernmental pediatric hospital in Siem Reap. Nasopharyngeal swabs were analyzed by phenotypic and genotypic methods to detect pneumococcal serotypes and antimicrobial resistance. Invasive pneumococcal disease (IPD) data for January 2012-December 2018 were retrieved from hospital databases. Pre-PCV IPD data and pre-/post-PCV colonization data were modelled to estimate vaccine effectiveness (VE). RESULTS: Comparing 2014 with 2016-2018, and using adjusted prevalence ratios, VE estimates for colonization were 16.6% (95% confidence interval [CI] 10.6-21.8) for all pneumococci and 39.2% (95% CI 26.7-46.1) for vaccine serotype (VT) pneumococci. There was a 26.0% (95% CI 17.7-33.0) decrease in multidrug-resistant pneumococcal colonization. The IPD incidence was estimated to have declined by 26.4% (95% CI 14.4-35.8) by 2018, with a decrease of 36.3% (95% CI 23.8-46.9) for VT IPD and an increase of 101.4% (95% CI 62.0-145.4) for non-VT IPD. CONCLUSIONS: Following PCV13 introduction into the Cambodian immunization schedule, there have been declines in VT pneumococcal colonization and disease in children aged <5 years. Modelling of dominant serotype colonization data produced plausible VE estimates.

Lessons Learned From the Introduction of Inactivated Poliovirus Vaccine in Bangladesh.

Background: We assessed programmatic adaptations and infants' uptake of inactivated poliovirus vaccine (IPV) after its introduction into the routine immunization schedule in Bangladesh. Methods: Using convenience and probability sampling, we selected 23 health facilities, 36 vaccinators, and 336 caregivers, within 5 districts and 3 city corporations. We collected data during August-October 2015 by conducting interviews, reviewing vaccination records, and observing activities. Results: Knowledge about IPV was high among vaccinators (94%). No problems with IPV storage, transport, or waste disposal were detected, but shortages were reported in 20 health facilities (87%). Wastage per 5-dose vaccine vial was above the recommended 30% in 20 health facilities (87%); all were related to providing <5 doses per open vial. Among eligible infants, 87% and 86% received the third dose of pentavalent and oral poliovirus vaccine, respectively, but only 65% received IPV at the same visit. Among 73 infants not vaccinated with IPV, 58% of caregivers reported that vaccine was unavailable. Conclusions: Bangladesh successfully introduced IPV, but shortages related to insufficient global supply and high vaccine wastage in small outreach immunization sessions might reduce its impact on population immunity. Minimizing wastage and use of a 2-dose fractional-IPV schedule could extend IPV immunization to more children.

Japanese Encephalitis Surveillance and Immunization - Asia and Western Pacific Regions, 2016.

Japanese encephalitis (JE) virus is the most important vaccine-preventable cause of encephalitis in the Asia-Pacific region. The World Health Organization (WHO) recommends integration of JE vaccination into national immunization schedules in all areas where the disease is a public health priority (1). This report updates a previous summary of JE surveillance and immunization programs in Asia and the Western Pacific in 2012 (2). Since 2012, funding for JE immunization has become available through the GAVI Alliance, three JE vaccines have been WHO-prequalified,* and an updated WHO JE vaccine position paper providing guidance on JE vaccines and vaccination strategies has been published (1). Data for this report were obtained from a survey of JE surveillance and immunization practices administered to health officials in countries with JE virus transmission risk, the 2015 WHO/United Nations Children's Fund Joint Reporting Form on Immunization, notes and reports from JE meetings held during 2014-2016, published literature, and websites. In 2016, 22 (92%) of 24 countries with JE virus transmission risk conducted JE surveillance, an increase from 18 (75%) countries in 2012, and 12 (50%) countries had a JE immunization program, compared with 11 (46%) countries in 2012. Strengthened JE surveillance, continued commitment, and adequate resources for JE vaccination should help maintain progress toward prevention and control of JE.

Evaluation of community-based treatment for drug-resistant tuberculosis in Bangladesh.

OBJECTIVE: Drug-resistant tuberculosis (TB) threatens global TB control because it is difficult to diagnose and treat. Community-based programmatic management of drug-resistant TB (cPMDT) has made therapy easier for patients, but data on these models are scarce. Bangladesh initiated cPMDT in 2012, and in 2013, we sought to evaluate programme performance. METHODS: In this retrospective review, we abstracted demographic, clinical, microbiologic and treatment outcome data for all patients enrolled in the cPMDT programme over 6 months in three districts of Bangladesh. We interviewed a convenience sample of patients about their experience in the programme. RESULTS: Chart review was performed on 77 patients. Sputum smears and cultures were performed, on average, once every 1.35 and 1.36 months, respectively. Among 74 initially culture-positive patients, 70 (95%) converted their cultures and 69 (93%) patients converted the cultures before the sixth month. Fifty-two (68%) patients had evidence of screening for adverse events. We found written documentation of musculoskeletal complaints for 16 (21%) patients, gastrointestinal adverse events for 16 (21%), hearing loss for eight (10%) and psychiatric events for four (5%) patients; conversely, on interview of 60 patients, 55 (92%) reported musculoskeletal complaints, 54 (90%) reported nausea, 36 (60%) reported hearing loss, and 36 (60%) reported psychiatric disorders. CONCLUSIONS: The cPMDT programme in Bangladesh appears to be programmatically feasible and clinically effective; however, inadequate monitoring of adverse events raises some concern. As the programme is brought to scale nationwide, renewed efforts at monitoring adverse events should be prioritised.

Bacterial sexually transmitted infections among HIV-infected patients in the United States: estimates from the Medical Monitoring Project.

BACKGROUND: Bacterial sexually transmitted infections may facilitate HIV transmission. Bacterial sexually transmitted infection testing is recommended for sexually active HIV-infected patients annually and more frequently for those at elevated sexual risk. We estimated percentages of HIV-infected patients in the United States receiving at least one syphilis, gonorrhea, or chlamydia test, and repeat (≥2 tests, ≥3 months apart) tests for any of these sexually transmitted infections from mid-2008 through mid-2010. DESIGN: The Medical Monitoring Project collects behavioral and clinical characteristics of HIV-infected adults receiving medical care in the United States using nationally representative sampling. METHODS: Sexual activity included self-reported oral, vaginal, or anal sex in the past 12 months. Participants reporting more than 1 sexual partner or illicit drug use before/during sex in the past year were classified as having elevated sexual risk. Among participants with only 1 sex partner and no drug use before/during sex, those reporting consistent condom use were classified as low risk; those reporting sex without a condom (or for whom this was unknown) were classified as at elevated sexual risk only if they considered their sex partner to be a casual partner, or if their partner was HIV-negative or partner HIV status was unknown. Bacterial sexually transmitted infection testing was ascertained through medical record abstraction. RESULTS: Among sexually active patients, 55% were tested at least once in 12 months for syphilis, whereas 23% and 24% received at least one gonorrhea and chlamydia test, respectively. Syphilis testing did not vary by sex/sexual orientation. Receipt of at least 3 CD4+ T-lymphocyte cell counts and/or HIV viral load tests in 12 months was associated with syphilis testing in men who have sex with men (MSM), men who have sex with women only, and women. Chlamydia testing was significantly higher in sexually active women (30%) compared with men who have sex with women only (19%), but not compared with MSM (22%). Forty-six percent of MSM were at elevated sexual risk; 26% of these MSM received repeat syphilis testing, whereas repeat testing for gonorrhea and chlamydia was only 7% for each infection. CONCLUSIONS: Bacterial sexually transmitted infection testing among sexually active HIV-infected patients was low, particularly for those at elevated sexual risk. Patient encounters in which CD4+ T-lymphocyte cell counts and/or HIV viral load testing occurs present opportunities for increased bacterial sexually transmitted infection testing.

A multisite study of the prevalence of HIV with rapid testing in mental health settings.

OBJECTIVES: We estimated HIV prevalence and risk factors among persons receiving mental health treatment in Philadelphia, Pennsylvania, and Baltimore, Maryland, January 2009 to August 2011. METHODS: We used a multisite, cross-sectional design stratified by clinical setting. We tested 1061 individuals for HIV in university-based inpatient psychiatric units (n = 287), intensive case-management programs (n = 273), and community mental health centers (n = 501). RESULTS: Fifty-one individuals (4.8%) were HIV-infected. Confirmed positive HIV tests were 5.9% (95% confidence interval [CI] = 3.7%, 9.4%) for inpatient units, 5.1% (95% CI = 3.1%, 8.5%) for intensive case-management programs, and 4.0% (95% CI = 2.6%, 6.1%) for community mental health centers. Characteristics associated with HIV included Black race, homosexual or bisexual identity, and HCV infection. CONCLUSIONS: HIV prevalence for individuals receiving mental health services was about 4 times as high as in the general population. We found a positive association between psychiatric symptom severity and HIV infection, indicating that engaging persons with mental illness in appropriate mental health treatment may be important to HIV prevention. These findings reinforce recommendations for routine HIV testing in all clinical settings to ensure that HIV-infected persons receiving mental health services are identified and referred to timely infectious disease care.

Engagement in HIV care among HIV-positive men who have sex with men from 21 cities in the United States.

We assessed factors associated with HIV care among HIV-infected men who have sex with men (MSM). We used 2008 data on MSM from the National HIV Behavioral Surveillance System (NHBS). Venue-based, time-space sampling was used to recruit and interview men in 21 U.S. cities with high AIDS prevalence. Among self-reported HIV-positive MSM, we used generalized estimating equations (clustered on city of interview) to evaluate factors associated with delayed linkage to care (care entry >3 months after diagnosis), not currently receiving care (no visit for HIV care during the 6 months before the study interview), and not being on antiretroviral therapy (ART). Among 8,153 MSM, 882 (11 %) were self-reported HIV-positive. 25 % had delayed linkage, 12 % were not currently receiving care and among those with at least one heath care visit 30 % were not on ART. In multivariate analysis, lower income and testing positive at their first HIV test were associated with delayed linkage. Age 18-29 years, and not having health insurance were associated with not currently receiving care. Among those with at least one health care visit, being age 18-39 years, having private or no health insurance, and stimulant use were associated with not being on ART. These findings can inform efforts to improve engagement in care.

Underdiagnosis in clinical documentation of community-acquired sepsis among children admitted to hospitals in two rural provinces: Thailand, October-December 2017.

Paediatric sepsis prevalence data from low-income and middle-income countries are lacking. In a cross-sectional study, we assessed clinician recognition and documentation of non-neonatal community-acquired paediatric sepsis in two rural border provinces in Thailand among children admitted between October and December 2017. Of the 152 children meeting sepsis criteria (26.9 paediatric sepsis patients per 1000 admissions), 15 (9.9%) had a clinician-documented admission diagnosis of sepsis or septic shock and 18 (11.8%) had a discharge diagnosis with International Classification of Diseases-10 codes related to sepsis. Clinician underdocumentation may cause challenges in global paediatric sepsis surveillance.

Demographic and Clinical Factors Associated with Bacterial or Nonbacterial Etiologies of Acute Undifferentiated Febrile Illness: Findings from a 3-Year Observational Study in Thailand, 2017-2020.

Acute undifferentiated febrile illness (AUFI) is often undiagnosed in Thailand, resulting in delayed or ineffective treatment. We compared the demographic, exposure history, and clinical characteristics of AUFI patients with laboratory evidence of bacterial and nonbacterial pathogens. Patients aged 2-80 years presenting to 12 hospitals in Nakhon Phanom and Tak provinces were enrolled from April 2017 through May 2020. Interviews were conducted and blood, urine, and sputum were collected for culture as well as rapid diagnostic and molecular testing. A total of 1,263 patients tested positive for one or more bacterial, viral, or parasitic pathogens and were included in the analysis. Multivariable logistic regression was performed to compare factors associated with bacterial infections versus nonbacterial infections. Bacterial infections were more commonly identified in participants from Nakhon Phanom than Tak. Bacterial infections were independently associated with several factors including age ≥50 years (adjusted odds ratio [95% CI]): (4.18 [2.85-6.14]), contact with farm animals (1.82 [1.29-2.57]), antibiotic use within 72 hours of hospital presentation (2.37 [1.50-3.74]), jaundice (2.31 [1.15-4.63]), existing comorbidities (2.77 [1.93-3.96]), contact with febrile individuals (0.42 [0.31-0.57]), muscle pain (0.44 [0.31-0.64]), and rash (0.45 [0.29-0.70]). Bacterial infections were also associated with longer hospitalization (2.75 [2.08-3.64]) and lower odds of recovery at the time of discharge (0.14 [0.07-0.31]). Consideration of patient characteristics and signs/symptoms may help to inform targeted laboratory testing for suspected infectious etiologies. Understanding factors associated with bacterial and non-bacterial causes of AUFI may aid diagnosis and judicious use of antibiotics in resource-limited settings.

Network analysis among HIV-infected young black men who have sex with men demonstrates high connectedness around few venues.

BACKGROUND: Network analysis is useful for understanding sexual transmission of HIV and other sexually transmitted infections. We conducted egocentric and affiliation network analysis among HIV-infected young black men who have sex with men (MSM) in the Jackson, Mississippi, area to understand networks and connectedness of this population. METHODS: We interviewed 22 black MSM aged 17 to 25 years diagnosed as having HIV in 2006 to 2008. Participants provided demographic and geographic information about each sex partner during the 12 months before diagnosis and identified venues where they met these partners. We created affiliation network diagrams to understand connectedness of this population and identify venues that linked participants. RESULTS: The median number of partners reported was 4 (range, 1-16); a total of 97 partners (88 of whom were male) were reported. All but 1 participant were connected through a network of venues where they had met partners during the 12 months before diagnosis. Three venues were named as places for meeting partners by 13 of 22 participants. Participants reported having partners from all regions of Mississippi and 5 other states. CONCLUSIONS: HIV-infected young black MSM in this analysis were linked by a small number of venues. These venues should be targeted for testing and prevention interventions. The pattern of meeting sex partners in a small number of venues suggests densely connected networks that propagate infection. This pattern, in combination with sexual partnerships with persons from outside Jackson, may contribute to spread of HIV and other sexually transmitted infections into or out the Jackson area.

Prevalence and incidence of tuberculosis infection among healthcare workers in chest diseases hospitals, Bangladesh: Putting infection control into context.

BACKGROUND: Healthcare workers (HCWs) are at increased risk of tuberculosis infection (TBI). We estimated the prevalence and incidence of TBI and risk factors among HCWs in Bangladeshi hospitals to target TB infection prevention and control (IPC) interventions. METHODS: During 2013-2016, we conducted a longitudinal study among HCWs in four chest disease hospitals. At baseline, we administered a questionnaire on sociodemographic and occupational factors for TB, tuberculin skin tests (TST) in all hospitals, and QuantiFERON ®-TB Gold in-Tube (QFT-GIT) tests in one hospital. We assessed factors associated with baseline TST positivity (induration ≥10mm), TST conversion (induration increase ≥10mm from baseline), baseline QFT-GIT positivity (interferon-gamma ≥0.35 IU/mL), and QFT-GIT conversion (interferon-gamma <0.35 IU/mL to ≥0.35 IU/mL). We included factors with a biologically plausible relationship with TBI identified in prior studies or having an association (p = <0.20) in the bivariate analyses with TST positivity or QFT-GIT positivity in multivariable generalized linear models. The Kaplan-Meier was used to estimate the cumulative TBI incidence rate per 100 person-years. RESULTS: Of the 758 HCWs invited, 732 (97%) consented to participate and 731 completed the one-step TST, 40% had a positive TST result, and 48% had a positive QFT-GIT result. In multivariable models, HCWs years of service 11-20 years had 2.1 (95% CI: 1.5-3.0) times higher odds of being TST-positive and 1.6 (95% CI 1.1-2.5) times higher odds of QFT-GIT-positivity at baseline compared with those working ≤10 years. HCWs working 11-20 years in pulmonary TB ward had 2.0 (95% CI: 1.4-2.9) times higher odds of TST positivity, and those >20 years had 2.5 (95% CI: 1.3-4.9) times higher odds of QFT-GIT-positivity at baseline compared with those working <10 years. TBI incidence was 4.8/100 person-years by TST and 4.2/100 person-years by QFT-GIT. Females had 8.5 (95% CI: 1.5-49.5) times higher odds of TST conversion than males. CONCLUSIONS: Prevalent TST and QFT-GIT positivity was associated with an increased number of years working as a healthcare worker and in pulmonary TB wards. The incidence of TBI among HCWs suggests ongoing TB exposure in these facilities and an urgent need for improved TB IPC in chest disease hospitals in Bangladesh.

Pneumococcal colonization and severity of pneumonia in hospitalized Cambodian children following introduction of the 13-valent pneumococcal conjugate vaccine.

Objectives: This study sought to characterize pneumococcal colonization and clinical/radiological features in Cambodian children admitted to hospital with an illness compatible with pneumonia following national introduction of the 13-valent pneumococcal conjugate vaccine (PCV13). Methods: Children aged 0-59 months admitted to Angkor Hospital for Children who met the World Health Organization (WHO) case definition for clinical pneumonia were enrolled over a 3-year period. Clinical, radiological and vaccination data were collected at enrolment. A nasopharyngeal swab was collected for detection of pneumococcal colonization using the WHO standard culture method. Results: Between 1 September 2015 and 31August 2018, 2209 analysable illness episodes were enrolled. Pneumococci were detected in 943/2209 (42.7%) children. PCV13 serotypes were detected less frequently in children who had been vaccinated appropriately for their age compared with undervaccinated children: 309/567 (53.6%) vs 216/342 (63.2%) (P=0.006). Age-appropriate PCV13 vaccination was negatively associated with hypoxic presentation [adjusted odds ratio (aOR) 0.72, 95% confidence interval (CI) 0.60-0.87; P=0.0006] and primary endpoint pneumonia on chest x ray (aOR 0.69, 95% CI 0.54-0.90; P=0.006). Conclusions: The introduction of PCV13 in Cambodia was associated with a decline in vaccine serotype nasopharyngeal colonization, and clinical and radiological severity in children hospitalized with clinical pneumonia.

Human Exposure to Bats, Rodents and Monkeys in Bangladesh.

Bats, rodents and monkeys are reservoirs for emerging zoonotic infections. We sought to describe the frequency of human exposure to these animals and the seasonal and geographic variation of these exposures in Bangladesh. During 2013-2016, we conducted a cross-sectional survey in a nationally representative sample of 10,002 households from 1001 randomly selected communities. We interviewed household members about exposures to bats, rodents and monkeys, including a key human-bat interface-raw date palm sap consumption. Respondents reported observing rodents (90%), bats (52%) and monkeys (2%) in or around their households, although fewer reported direct contact. The presence of monkeys around the household was reported more often in Sylhet division (7%) compared to other divisions. Households in Khulna (17%) and Rajshahi (13%) were more likely to report drinking date palm sap than in other divisions (1.5-5.6%). Date palm sap was mostly consumed during winter with higher frequencies in January (16%) and February (12%) than in other months (0-5.6%). There was a decreasing trend in drinking sap over the three years. Overall, we observed substantial geographic and seasonal patterns in human exposure to animals that could be sources of zoonotic disease. These findings could facilitate targeting emerging zoonoses surveillance, research and prevention efforts to areas and seasons with the highest levels of exposure.

Occurrence of tuberculosis among people exposed to cattle in Bangladesh.

BACKGROUND: Tuberculosis (TB) has been an important public health concern in Bangladesh. The most common cause of human TB is Mycobacterium tuberculosis, while bovine TB is caused by Mycobacterium bovis. OBJECTIVE: The objective of this study was to determine the frequency of TB in individuals with occupational exposure to cattle and to detect Mycobacterium bovis among cattle in slaughterhouses in Bangladesh. METHODS: Between August 2014 and September 2015, an observational study was conducted in two government chest disease hospitals, one cattle market, and two slaughterhouses. [Correction added on 27 June 2023, after first online publication: In the preceding sentence, the year "2014" has been added after the word "August".] Sputum samples were collected from individuals who met the criteria for suspected TB and had been exposed to cattle. Tissue samples were collected from cattle that had low body condition score(s). Both humans and cattle samples were screened for acid-fast bacilli (AFB) by Ziehl-Neelsen (Z-N) staining and cultured for Mycobacterium tuberculosis complex (MTC). Region of difference (RD) 9-based polymerase chain reaction (PCR) was also performed to identify Mycobacterium spp. We also conducted Spoligotyping to identify the specific strain of Mycobacterium spp. RESULTS: Sputum was collected from a total of 412 humans. The median age of human participants was 35 (IQR: 25-50) years. Twenty-five (6%) human sputum specimens were positive for AFB, and 44 (11%) were positive for MTC by subsequent culture. All (N = 44) culture-positive isolates were confirmed as Mycobacterium tuberculosis by RD9 PCR. Besides, 10% of cattle workers were infected with Mycobacterium tuberculosis in the cattle market. Of all TB (caused by Mycobacterium tuberculosis) infected individuals, 6.8% of individuals were resistant to one or two anti-TB drugs. The majority of the sampled cattle (67%) were indigenous breeds. No Mycobacterium bovis was detected in cattle. CONCLUSIONS: We did not detect any TB cases caused by Mycobacterium bovis in humans during the study. However, we detected TB cases caused by Mycobacterium tuberculosis in all humans, including cattle market workers.

Exposure to Brucella spp. in Humans and Cows in a High Milk-Producing Area of Bangladesh.

Brucellosis is a zoonotic disease, caused by some species within the Brucella genus. The primary and secondary objectives of this cross-sectional study were to determine the seroprevalence of Brucella antibodies in humans and cows and identify risk factors for exposure to Brucella spp. among people in Shahjadpur sub-district, Bangladesh. Twenty-five villages were randomly selected from the 303 milk-producing villages in the sub-district. We randomly selected 5% of the total households from each village. At each household, we collected demographic information and history of potential exposure to Brucella spp. in humans. In addition, we collected serum from household participants and serum and milk from cattle and tested to detect antibodies to Brucella sp. Univariate analysis was performed to detect associations between seropositivity and demographics, risk factors, and behaviors in households. We enrolled 647 households, 1313 humans, and 698 cows. Brucella antibodies were detected in sera from 27 household participants (2.1%, 95% confidence interval [95%CI]: 1.2-2.9%). Eleven (1.6%, 95%CI 0.6-2.4%) cows had detectable Brucella antibodies in either milk or serum. About half (53%) of the 698 cows exhibited more than one reproductive problem within the past year; of these, seven (2%) had Brucella antibodies. Households with seropositive individuals more frequently reported owning cattle (78% vs. 32%, P < 0.001). Despite a low prevalence of Brucella seropositivity in the study, the public health importance of brucellosis cannot be ruled out. Further studies would help define Brucella prevalence and risk factors in this region and nationally.

Assessing perceptions of establishing a vaccine pooled procurement mechanism for the Western Pacific Region.

This study explored the demand and interest among countries in the World Health Organization Western Pacific Region (WPR) to establish and participate in a regional vaccine pooled procurement mechanism. National counterparts affiliated with Ministries of Health that are involved in the national procurement of vaccines within the WPR were identified and invited to complete surveys. Out of 80 counterparts invited, 17 (21%) responded, representing 13 of the 27 WPR countries. Five countries expressed interest in participating in a regional pooled procurement mechanism, 3 expressed lack of interest and 5 did not respond to the question. Preferred characteristics of the procurement mechanism, included flexible participation (i.e. non-compulsory), payment in local currency before receipt of goods and a fixed price for vaccines (i.e. not tiered pricing). Vaccine pricing disparities were noted among upper middle-income and high-income countries for five of the 13 routine vaccines surveyed. Eight countries listed budget planning, quality of vaccines, timely delivery, cost-saving and payment after receipt as potential benefits of pooled procurement.

Acceptability of newborn circumcision to prevent HIV infection in the United States.

BACKGROUND/PURPOSE: To understand whether information from the African clinical trials about the partially protective effect of male circumcision against human immunodeficiency virus (HIV) infection could influence adults to circumcise a newborn son. METHODS: Using the 2008 ConsumerStyles panel survey data, multiple regression analysis was performed to identify correlates of (1) inclination toward circumcising a newborn son and (2) being influenced to have a newborn son circumcised if it would reduce the chance of becoming HIV infected later in life. RESULTS: Response rate was 50.6% (10,108/19,996). Approximately 12% reported not being inclined to circumcise a newborn son. Higher odds of not being inclined to circumcise a newborn son were associated with Hispanic and "other" race/ethnicity, being an uncircumcised man and a man not reporting circumcision status, postgraduate education, region, and negative health-related attitudes. Lower odds were associated with black race and less number of household members. Fifty-three percent of respondents reported that information about the protective effect of circumcision would make them more likely to have a newborn son circumcised. Higher odds of being influenced to have a newborn son circumcised were associated with being ≥45 years of age, black race, living in a household with fewer than 5 members, having high school or some college education, region, and positive health-related attitudes; lower odds were associated with being an uncircumcised man and lower income. CONCLUSIONS: Our findings suggest that providing educational information about the HIV prevention and benefit of circumcision may increase the inclination to circumcise a newborn son for some people.

HIV risk among young African American men who have sex with men: a case-control study in Mississippi.

OBJECTIVES: We conducted a case-control study in the Jackson, Mississippi, area to identify factors associated with HIV infection among young African American men who have sex with men (MSM). METHODS: During February to April 2008, we used surveillance records to identify young (16-25 years old) African American MSM diagnosed with HIV between 2006 and 2008 (case participants) and recruited young African American MSM who did not have HIV (controls). Logistic regression analysis was used to assess factors associated with HIV infection. RESULTS: In a multivariable analysis of 25 case participants and 85 controls, having older male partners (adjusted odds ratio [OR] = 5.5; 95% confidence interval [CI] = 1.8, 17.3), engaging in unprotected anal intercourse with casual male partners (adjusted OR = 6.3; 95% CI = 1.8, 22.3), and being likely to give in to a partner who wanted to have unprotected sex (adjusted OR = 5.0; 95% CI = 1.2, 20.6) were associated with HIV infection. CONCLUSIONS: Given the high prevalence of risk behaviors among the young African American MSM in our study, HIV prevention efforts must begin before or during early adolescence and need to focus on improving negotiation and communication regarding sex.

HIV screening programs in US emergency departments: a cross-site comparison of structure, process, and outcomes.

OBJECTIVE: We present findings from a multisite evaluation that systematically compares HIV screening programs in 6 emergency departments (EDs). METHODS: From 2007 to 2008, we collected previous-year data on structural factors, process attributes, testing outcomes, and cost-effectiveness from 6 ED HIV testing programs operating for 6 months or longer. We administered questionnaires to program directors, conducted site visits, and interviewed key informants. RESULTS: HIV care providers (n=3 sites), emergency physicians (n=2), or health departments (n=1) initiated the testing programs. ED leadership and providers helped design and implement the programs (n=5), and emergency physicians or administrators provided daily oversight (n=5). Testing strategies included targeted (patients selected from at-risk populations; n=2), nontargeted (patients selected without regard to risk or intention of testing all; n=3), and universal (all patients selected; n=1) screening. Testing was conducted by supplemental staff (n=4) and existing hospital staff (n=2). ED testing programs were funded by grants (n=3), city HIV prevention/care budgets (n=2), or the hospital (n=1). The median percentage of census tested was 4.7% (range 2.1% to 8.4%). The median rate of preliminary positive test results was 1.2% (range 1.0% to 7.3%). The median confirmed new HIV diagnosis rate was 0.9% (range 0.8% to 6.4%). The median linkage to care rate was 92.0% (range 50% to 100%). The median cost per patient receiving a new diagnosis and linked to care was $10,200 (range $3,400 to $12,300). CONCLUSION: Although structure and process of screening programs varied across EDs, outcomes were similar, which suggests that with current ED environments, testing methods, and resources available, the capacity and structure to increase testing in EDs has limits. These ED HIV screening programs were cost-effective according to standard thresholds.

HIV screening in an urban emergency department: comparison of screening using an opt-in versus an opt-out approach.

OBJECTIVE: We compare outcomes of opt-in and opt-out HIV screening approaches in an urban emergency department. METHODS: This was a 1-year prospective observational study comparing 2 6-month screening approaches. Eligibility for opt-in and opt-out screening was identical: aged 15 years or older, medically stable, and able to complete general consent. During the opt-in phase, triage nurses referred patients to HIV testers stationed at triage, who obtained separate opt-in written consent and performed rapid oral fluid tests. During the opt-out phase, registration staff conducted integrated opt-out consent and then referred patients to HIV testers. We assessed the proportion of potentially eligible patients who were offered screening (screening offer rate), the proportion offered screening who accepted (screening acceptance rate), the proportion who accepted screening and subsequently completed testing (test completion rate), and the proportion of potentially eligible patients who completed testing (overall screening rate) during each phase. RESULTS: For the opt-in versus the opt-out phases, respectively, there were 23,236 potentially eligible patients versus 26,757, screening offer rate was 27.9% versus 75.8% (P<.001), screening acceptance rate was 62.7% versus 30.9% (P<.001), test completion rate was 99.8% versus 74.6% (P<.001), and overall screening rate was 17.4% versus 17.5% (P = .90). CONCLUSION: A significantly higher proportion of patients were offered HIV screening with an opt-out approach at registration. However, this was offset by much higher screening acceptance and test completion rates with the opt-in approach at triage. Overall screening rates with the 2 approaches were nearly identical.