Sexual risk behaviors for HIV/AIDS in Chuuk State, Micronesia: the case for HIV prevention in vulnerable remote populations.

BACKGROUND: After the first two cases of locally-acquired HIV infection were recognized in Chuuk State, Federated States of Micronesia (FSM), a public health response was initiated. The purpose of the response was to assess the need for HIV education and prevention services, to develop recommendations for controlling further spread of HIV in Chuuk, and to initiate some of the prevention measures. METHODOLOGY/PRINCIPAL FINDINGS: A public health team conducted a survey and rapid HIV testing among a sample of residents on the outer islands in Chuuk. Local public health officials conducted contact tracing and testing of sex partners of the two locally-acquired cases of HIV infection. A total of 333 persons completed the survey. The majority knew that HIV is transmitted through unprotected sexual contact (81%), injection drug use (61%), or blood transfusion (64%). Sexual activity in the past 12 months was reported among 159 participants, including 90 females and 69 males. Compared to women, men were more likely to have had multiple sex partners, to have been drunk during sex, but less likely to have used a condom in the past 12 months. The two men with locally acquired HIV infection had unprotected anal sex with a third Chuukese man who likely contracted HIV while outside of Chuuk. All 370 persons who received voluntary, confidential HIV counseling and testing had HIV negative test results. CONCLUSIONS/SIGNIFICANCE: Despite the low HIV seroprevalence, risky sexual behaviors in this small isolated population raise concerns about the potential for rapid spread of HIV. The lack of knowledge about risks, along with stigmatizing attitudes towards persons infected with HIV and high risk sexual behaviors indicate the need for resources to be directed toward HIV prevention in Chuuk and on other Pacific Islands.

HIV behavioral surveillance in the U.S.: a conceptual framework.

This article describes a conceptual framework for HIV behavioral surveillance in the United States. The framework includes types of behaviors to monitor, such as risk behaviors, HIV testing behaviors, adherence to HIV treatment, and care-seeking for HIV/AIDS. The framework also describes the population groups in which specific behaviors should be monitored. Because the framework is multifaceted in terms of behaviors and populations, behavioral data from multiple surveillance systems are integrated to achieve HIV behavioral surveillance program objectives. Defining surveillance activities more broadly to include behavioral surveillance in multiple populations will provide more comprehensive data for prevention planning, and lead to a more effective response to HIV/AIDS in the United States.

The epidemiology of HIV/AIDS in women in the southern United States.

OBJECTIVE: We reviewed data from multiple sources to examine distinguishing features of the HIV epidemic among women in the South. GOAL: The goal of this study was to identify HIV and sexually transmitted disease (STD) prevention research priorities in the South. STUDY DESIGN: Cases of HIV/AIDS and STDs were analyzed to compare rates by region and rates in urban versus rural areas. Data from interviews of persons reported with HIV/AIDS from rural areas in 4 southern states compared social and behavioral characteristics of men versus women. RESULTS: The South is characterized by high AIDS and STD rates. The epidemic among southern women is distinguished by the predominance of heterosexually acquired infection, the disproportionate impact on blacks, the high proportion residing in rural areas, and multiple high-risk behaviors. CONCLUSIONS: Research to identify determinants of high-risk sex and drug-using behaviors among poor, minority men and women in less urban and rural southern regions is needed.

A two-stage sampling method for clinical surveillance of individuals in care for HIV infection in the United States.

OBJECTIVES: The goals of this study were two-fold: (1) to describe methods for drawing a population-based sample of individuals in care for HIV infection and (2) to compare data from the sample with data from existing surveillance systems that describe care for HIV. METHODS: The authors implemented a two-stage sampling method, using local HIV/AIDS surveillance data as a sampling frame of HIV care providers in three states. At selected providers, medical records of a random sample of patients were abstracted. RESULTS: The medical records of a number of patients, ranging from 253 to 374 individuals per state, were abstracted. The demographics of sampled individuals and of individuals reported to the local HIV/AIDS surveillance program were similar; however, differences existed in the proportion of individuals receiving HIV care consistent with treatment guidelines between the sample and a contemporary facility-based supplemental surveillance project. The median design effect for outcomes collected in the sample was 1.8 (range=0.5-29.6). CONCLUSIONS: This survey method is feasible for collecting population-based data on patients in care for HIV. Sample size and some design elements should be changed in future studies to increase precision of estimates and usefulness of data for local planning and evaluation.

Epidemiologic profile of HIV and AIDS among American Indians/Alaska Natives in the USA through 2000.

OBJECTIVES: To describe HIV and AIDS among American Indians/Alaska Natives (AI/ AN) in the USA through 2000. DESIGN: An epidemiologic profile was constructed using HIV/AIDS surveillance, sexually transmitted disease (STD), and seroprevalence data. RESULTS: Although AIDS among AI/AN represents < 1% of cumulative AIDS cases in the USA, in 2000 the AIDS incidence rate (cases per 100,000 population) for AI/AN (11.9) was higher than that for whites (7.3). AI/AN had high rates of chlamydia, gonorrhea, and syphilis from 1996 through 2000; among all females, AI/AN females had the second highest rates of chlamydia, gonorrhea, and syphilis reported during this time period. Of all AIDS cases among AI/AN, 70% were reported by 10 states. CONCLUSIONS: These data demonstrate that the impact of STDs and the potential for an impact of HIV/AIDS among AI/AN are greater than indicated by the relatively small number of AIDS cases in this population. Additional mechanisms are needed to fill gaps in the available data. Coordination among the complex network of healthcare providers, tribes, and federal, state, and local health agencies is needed to improve delivery of information about HIV/AIDS to AI/AN and to ensure access to HIV prevention and treatment programs for AI/AN.

Characteristics of adults and adolescents who have migrated from place of AIDS diagnosis to place of death, United States, 1993-2001.

This study compared demographic characteristics of adults and adolescents who received an AIDS diagnosis in one state and died in a different state. We analyzed reports of deaths among persons (> or = 13 years old) with AIDS whose state of residence at diagnosis and state of occurrence of death were different (migrants). Between January 1993 and December 2001, 251,441 deaths of adults and adolescents with AIDS occurred. Of these, 13,860 (5.4%) migrated. Migrants were more likely to be male than female, white than black, and men who have sex with men than persons with heterosexual contact. A small proportion of persons with AIDS migrated between residence at AIDS diagnosis and place of death, suggesting that the effect of migration on destination health care services is likely to be small.

Crack cocaine use and adherence to antiretroviral treatment among HIV-infected black women.

Since the appearance of crack cocaine in the 1980s, unprecedented numbers of women have become addicted. A disproportionate number of female crack users are Black and poor. We analyzed interview data of HIV-infected women > or = 18 years of age reported to 12 health departments between July 1997 and December 2000 to ascertain if Black women reported crack use more than other HIV-infected women and to examine the relationship between crack use and antiretroviral treatment (ART) adherence among Black women. Of 1655 HIV-infected women, 585 (35%) were nonusers of drugs, 694 (42%) were users of other drugs and 376 (23%) were crack users. Of the 1196 (72%) Black women, 306 (26%) were crack users. We used logistic regression to examine the effect of crack use on adherence to ART, controlling for age and education among Black women. In multivariate analysis, crack users and users of other drugs were less likely than non-users to take their ART medicines exactly as prescribed (odds ratio [OR] = 0.37; 95% confidence interval [CI] = 0.24-0.56), OR = 0.47; 95% CI = 0.36-0.68), respectively. HIV-infected Black women substance users, especially crack cocaine users, may require sustained treatment and counseling to help them reduce substance use and adhere to ART.

Estimated number of children left motherless by AIDS in the United States, 1978-1998.

When a mother dies of AIDS, basic needs of her children may be left unmet. To estimate the number and characteristics of maternal AIDS orphans in the United States, demographic techniques were applied to data from several sources. From the national HIV/AIDS surveillance system, reporting delays were adjusted for the number of deaths among women aged 15-44 diagnosed with AIDS through 1998 and reported as deceased by December 1999. No fertility was assumed in the year preceding death. To the adjusted number of deaths the annual age- and race-specific cumulative fertility and infant mortality rates from national vital statistics were applied. A perinatal infection rate of 25% was assumed among children born through 1994, and 10% among children born after 1994. Through 1998, 51,473 women died leaving 97,376 children motherless. Of the estimated 76,661-87,0018 uninfected children, 83% were younger than 21 years when orphaned. After increasing each year, the annual number of orphaned children younger than 21 years peaked in 1995. In 1998, between 4252-4489 uninfected youth were added to 47,863-54,025 existing orphans younger than age 21. Due to declines in AIDS deaths, the annual number of children orphaned by AIDS has declined. Nevertheless, each year thousands of youth are orphaned.

Prevalence of chronic hepatitis B and incidence of acute hepatitis B infection in human immunodeficiency virus-infected subjects.

We determined incidence and risk factors for acute and chronic hepatitis B virus (HBV) infection and HBV vaccination rates among human immunodeficiency virus (HIV)-infected subjects from the Adult/Adolescent Spectrum of HIV Disease Project, during 1998-2001. Among 16,248 HIV-infected patients receiving care, the incidence of acute HBV was 12.2 cases/1000 person-years (316 cases), was higher among black subjects (rate ratio [RR], 1.4; 95% confidence interval [CI], 1.0-2.0), subjects with alcoholism (RR, 1.7; 95% CI, 1.2-2.3), subjects who had recently injected drugs (RR, 1.6; 95% CI, 1.1-2.4), and subjects with a history of AIDS-defining conditions (RR, 1.5; 95% CI, 1.2-1.9) and was lower in those taking either antiretroviral therapy (ART) with lamivudine (RR, 0.5; 95% CI, 0.4-0.6), ART without lamivudine (RR, 0.5; 95% CI, 0.3-0.7), or >/=1 dose of HBV vaccine (14% of subjects) (RR, 0.6; 95% CI, 0.4-0.9). Prevalence of chronic HBV was 7.6% among unvaccinated subjects. HBV rates in this population were much higher than those in the general population, and vaccination levels were low. HBV remains an important cause of comorbidity in HIV-infected persons, but ART and vaccination are associated with decreased disease.

Occupationally acquired human immunodeficiency virus (HIV) infection: national case surveillance data during 20 years of the HIV epidemic in the United States.

OBJECTIVE: To characterize occupationally acquired human immunodeficiency virus (HIV) infection detected through case surveillance efforts in the United States. DESIGN: National surveillance systems, based on voluntary case reporting. SETTING: Healthcare or laboratory (clinical or research) settings. PATIENTS: Healthcare workers, defined as individuals employed in healthcare or laboratory settings (including students and trainees), who are infected with HIV. METHODS: Review of data reported through December 2001 in the HIV/AIDS Reporting System and the National Surveillance for Occupationally Acquired HIV Infection. RESULTS: Of 57 healthcare workers with documented occupationally acquired HIV infection, most (86%) were exposed to blood, and most (88%) had percutaneous injuries. The circumstances varied among 51 percutaneous injuries, with the largest proportion (41%) occurring after a procedure, 35% occurring during a procedure, and 20% occurring during disposal of sharp objects. Unexpected circumstances difficult to anticipate during or after procedures accounted for 20% of all injuries. Of 55 known source patients, most (69%) had acquired immunodeficiency syndrome (AIDS) at the time of occupational exposure, but some (11%) had asymptomatic HIV infection. Eight (14%) of the healthcare workers were infected despite receiving postexposure prophylaxis (PEP). CONCLUSIONS: Prevention strategies for occupationally acquired HIV infection should continue to emphasize avoiding blood exposures. Healthcare workers should be educated about both the benefits and the limitations of PEP, which does not always prevent HIV infection following an exposure. Technologic advances (eg, safety-engineered devices) may further enhance safety in the healthcare workplace.

HIV/AIDS surveillance in the United States, 1981-2001.

We review the HIV/AIDS reporting system, including the legal basis for reporting, the methods and infrastructure for reporting, evaluation of the completeness and quality of the data, and analysis and dissemination of reports. Other information systems (e.g., seroprevalence surveys and behavioral surveys) that collect useful information for HIV prevention and care programs are also described. Multiple data collections systems are needed to monitor the HIV/AIDS epidemic in the United States and to collect the information needed to plan, implement, and evaluate prevention and care programs.

HIV surveillance methods for the incarcerated population.

In the United States, monitoring the HIV/AIDS epidemic among the incarcerated population is done by (a) conducting a census of persons in prisons and jails reported to be infected with HIV or diagnosed with AIDS, (b) seroprevalence surveys in selected correctional facilities, and (c) population-based HIV/AIDS case surveillance by state health departments. We describe methods for HIV/AIDS case surveillance in correctional settings and present data from the HIV/AIDS Reporting System (HARS) and the Supplement to HIV and AIDS Surveillance (SHAS) to describe the demographic, behavioral, and clinical characteristics of HIV-infected persons who were incarcerated at the time of diagnosis. HARS data showed a higher proportion of females and a lower proportion of injection drug users for incarcerated persons diagnosed with HIV (not AIDS) compared to those initially diagnosed with AIDS. The SHAS data showed a high prevalence of injection drug use, crack use, alcohol abuse, and exchanging sex for money or drugs. Together, HARS and SHAS collect fairly comprehensive information of risk behaviors from persons with HIV infection and AIDS. Advances in HIV prevention and care for the incarcerated community will require an accurate and timely description of the magnitude of the HIV epidemic in correctional settings. These data are needed to guide programmatic efforts to reduce HIV transmission in prisons and jails and in the general community upon release and ensure needed risk reduction and health care services for incarcerated persons.

Trends in AIDS incidence and survival among racial/ethnic minority men who have sex with men, United States, 1990-1999.

OBJECTIVES: We describe trends in AIDS incidence, survival, and deaths among racial/ethnic minority men who have sex with men (MSM). METHODS: We examined AIDS surveillance data for men diagnosed with AIDS from 1990 through 1999, survival trends from 1993 through 1997, and trends in AIDS incidence and deaths from 1996 to 1999, when highly active antiretroviral therapy (HAART) was introduced. RESULTS: The percentage of racial/ethnic minority MSM with AIDS increased from 33% of 26,930 men in 1990 to 54% of 17,162 men in 1999. From 1996 through 1998, declines in AIDS incidence were smallest among black MSM (25%, from 66.2 to 49.5 per 100,000) and Hispanic MSM (29%, from 39.3 to 27.8), compared with white MSM (41%, from 17.9 to 10.5). Declines in deaths of MSM with AIDS were also smallest among black MSM (53%, from 39.7 to 18.6 deaths per 100,000) and Hispanic MSM (61%, 21.6 to 8.4), compared with white MSM (63%, 12.3 to 4.5). Survival improved each year for all racial/ethnic groups but was poorest for black MSM in all years. CONCLUSIONS: Since the introduction of HAART, a combination of factors that include relatively higher infection rates in more recent years and differences in survival following AIDS diagnosis contribute to observed differences in trends in AIDS incidence and deaths among racial/ethnic minority MSM. Increased development of culturally sensitive HIV prevention services, and improved access to testing and care early in the course of disease are needed to further reduce HIV-related morbidity in racial/ethnic minority MSM.