Blind spots in the epidemiology of HIV in black Americans.

In the USA, annual rates of new human immunodeficiency virus (HIV)/AIDS diagnoses are seven and 21 times higher in black men and women, respectively, than in whites. Epidemiological inquiry on this disparity has chiefly focused on contextual factors; such emphasis has eclipsed study of direct HIV vectors. The US Centers for Disease Control and Prevention recently announced its intention to curb HIV propagation in black communities, recommending culturally appropriate HIV/AIDS strategies. Contemplated societal interventions should be informed by data evaluating more direct (and under-assessed) HIV transmission vectors, specifically anal intercourse and unsuspected blood exposures. This recommendation involves tracing sexual and non-sexual contacts of recently infected persons and uninfected controls, coupled with DNA sequencing of HIV isolates. Public health authorities do not know the extent to which unmeasured yet plausible HIV transmission vectors can account for ethnic disparities. Appropriate prevention strategies depend critically on direct, rather than ecologic, evidence.

Partner referral tools and techniques for the clinician diagnosing a sexually transmitted infection.

Public health agencies have insufficient resources to trace and refer to medical evaluation the sexual partners of patients with sexually transmitted infections (STI). Only a minority of such patients receives formal sex partner referral services. Hence this responsibility rests, by default, with the diagnosing clinician or with the infected patient. Unfortunately, clinicians do not sufficiently appreciate this public health lacuna, and patients with STI usually perform poorly at notifying partners. Clinician and patient obstacles to successful partner referral are discussed, and brief counselling techniques are suggested. Use of patient-delivered therapy, via medication or prescription (dispensed with appropriate warnings), probably serves to emphasize the urgency and importance of notifying partners. Successful referral to medical attention has been shown to help prevent re-infection of the index patient and to curtail community transmission.

Male and female circumcision associated with prevalent HIV infection in virgins and adolescents in Kenya, Lesotho, and Tanzania.

PURPOSE: Remarkable proportions of self-reported virgins and adolescents in eastern and southern Africa are infected with HIV, yet non-sexual routes of transmission have not been systematically investigated in such persons. Many observers in this region have recognized the potential for HIV transmission through unhygienic circumcision procedures. We assessed the relation between male and female circumcision (genital cutting) and prevalent HIV infection in Kenyan, Lesothoan, and Tanzanian virgins and adolescents. METHODS: We analyzed data from recent cross-sectional national probability sample surveys of adolescents and adults in households, focusing on populations in which circumcision was common and usually occurred in puberty or later. RESULTS: Circumcised male and female virgins were substantially more likely to be HIV infected than uncircumcised virgins (Kenyan females: 3.2% vs. 1.4%, odds ratio [OR] = 2.38; Kenyan males: 1.8% vs. 0%, OR undefined; Lesothoan males: 6.1% vs. 1.9%, OR 3.36; Tanzanian males: 2.9% vs. 1.0%, OR 2.99; weighted mean phi correlation = 0.07, 95% confidence interval, 0.03 to 0.11). Among adolescents, regardless of sexual experience, circumcision was just as strongly associated with prevalent HIV infection. However, uncircumcised adults were more likely to be HIV positive than circumcised adults. Self-reported sexual experience was independently related to HIV infection in adolescent Kenyan females, but was unrelated to HIV infection in adolescent Kenyan, Lesothoan, and Tanzanian males. CONCLUSIONS: HIV transmission may occur through circumcision-related blood exposures in eastern and southern Africa.