Behavioral factors affecting HIV prevention for adolescent and young adult IDUs.

Epidemiological and sociobehavioral data regarding HIV-related risk and injection drug use among adolescents and young adults are examined to provide insight and assistance to nurses delivering preventive intervention and community and clinical care. The increase in HIV/AIDS cases among injection drug users (IDUs), adolescents, and African Americans strongly suggests that clinical care providers acquire a better understanding of the sociocultural and behavioral context within which health care is provided. Transition into injection drug use, high-risk injecting and sexual behaviors, sociodemographic differences, and the importance of social networks are discussed. Nurses are encouraged to provide health promotion, disease prevention messages, and health care to IDUs in small nontraditional clinical settings and to seek out the assistance of the IDUs' social network to increase adherence and compliance to complex prevention and therapeutic efforts.

Barriers to school-based health care programs.

Although school-based health care programs (SBHCPs) provide affordable and accessible health care to children and adolescents and are known to improve school attendance, a variety of barriers affect their development. Focus groups were conducted in three schools in Louisiana to demonstrate how barriers can affect the initiation and development of SBHCPs. Each school-based program was in a different stage of development. Identifying potential barriers and developing strategies to overcome them can enhance already existing SBHCPs and make it easier for new programs to begin. The social worker serves as an important ally in the development of SBHCPs and is a necessary part of the school-based health care team.

Community reactions to reproductive health care at three school-based clinics in Louisiana.

Despite the growing success of school-based health care during the past two decades, the issue of providing reproductive health care at school-based health centers remains controversial. In this article, focus group data from three school-based centers in Louisiana, each in different stages of development, demonstrates how the controversies about reproductive health may frame more general concerns about school-based care. In addition, community readiness to address directly problematic sexual behavior relates not only to the specific needs and priorities of the community but to recognition of the negative effect of the consequences of sexual behavior such as pregnancy, high drop out, and absenteeism rates on a community's educational, rather than social, goals and values.

PIP: Under the direction of the Louisiana Office of Public Health, focus groups at three schools were used to conduct a formal evaluation of the school-based health centers (SBHCs). Specifically, researchers aimed to determine the actual educational and health-related benefits of the SBHCs. One high school was in a politically conservative, small city in southern Louisiana. 60% of the students were African-American. More than 50% of girls became pregnant at least once during their high school years. The high pregnancy rate affected school attendance and drop-out rates. The second SBHC served elementary, junior, and senior high school students who lived in a conservative, close-knit community. Most residents were White. 90% of students enrolled for SBHC services. The third SBHC was located in a high school in the inner city of a medium-sized city. Crime, violence, drug dealing, drug use, single-parent families, and poverty were common. Most students were African Americans. Shared commonalities of the three SBHCs included: little controversy existed about provision of pregnancy and STD (sexually transmitted disease) testing or referral about contraceptive counseling, and everyone was aware of the high pregnancy rates in their communities and that adolescent pregnancy is associated with absenteeism and high drop-out rates. Yet, few people were ready to define adolescent pregnancy as a community concern or as a problem appropriately addressed by the SBHC. The willingness of a community to address reproductive health may reflect their concerns about keeping students in school. These findings suggest that SBHCs must develop and maintain strong support and commitment from students, teachers, parents, and the greater community. Once the SBHC has gained their confidence, it is free to develop services that meet the specific needs of the students. Successful launching of SBHCs depends on keeping the health care goals consistent with the community's educational goals rather than social goals.

HIV, TB, and mental illness in a health clinic for the homeless.

The authors reviewed the medical records of both mentally ill and non-mentally ill patients in a clinic for the homeless population of New Orleans. The records of all psychiatric patients (n = 52) and a randomly selected comparison group (n = 236) of clinic patients without mental illness were chosen for review. Five of the 52 homeless mentally ill who were tested for HIV had a positive test (9.6%), as did 7 of the 129 homeless people without mental illness (5.4%). Regarding TB, only 5 of the 29 mentally ill tested for TB were PPD positive (17.2%), as compared to 34 (29.3%) of the non-mentally ill, a strong trend (r = 0.11, p = 0.09). Differing trends were found regarding HIV and TB in the two homeless groups under study. Further work with a larger sample is needed to determine the factors, if any, which facilitate the spread of HIV and inhibit that of TB.

Issues of recruitment, retention, and compliance in community-based clinical trials with traditionally underserved populations.

Site-specific sociodemographic recruitment, retention, and compliance (RRC) data were solicited at two points in time from the 18 National Institutes of Health-funded Community Programs for Clinical Research on AIDS (CPCRA). Based on their experiences delivering primary care to human immunodeficiency virus-infected individuals, nurses at each site identified organizational and client-centered factors functioning as barriers to protocol participation. In addition, the clinicians described the nature, frequency, and relative success of strategies used to enhance recruitment, retention, and protocol compliance. CPCRA units where nurses had clearly identified RRC barriers related to protocol design also were the sites that had accrued the most research participants. This study suggests that as the CPCRA units evolve, the most successful programs will be those in which the clinical and research staff can identify and develop innovative strategies that will successfully overcome RRC barriers.

Relationship between serum cyclo(His-Pro) concentrations and the nutritional status of HIV-infected patients.

Cyclo(His-Pro) (CHP) is a gut-neuropeptide that influences both appetite and carbohydrate metabolism. This study was undertaken to determine whether concentrations of CHP correlated with various clinical markers of nutritional status and progression of HIV infection. Serum concentrations of CHP were analyzed in a clinical sample of 100 HIV-positive patients whose HIV clinical status ranged from asymptomatic to advanced disease with weight loss. We found a relationship between CHP concentrations and serum albumin and hemoglobin levels, markers of chronic nutrition and disease. However, no correlation was seen between CHP and cortisol concentrations, a marker of acute stress. To analyze the relationship of HIV clinical stage and CHP, patients were divided into three subgroups: asymptomatic, mildly symptomatic, and clear-cut AIDS. CHP concentrations were significantly correlated with HIV clinical stage. These data lead to the hypothesis that CHP is a marker of disease progression and that it potentially plays a role in modulating the nutrition of HIV-infected patients.

Training older adults to work as psychiatric case management aides.

Adults who were age 55 and over were trained to work as case management aides for individuals with serious and persistent mental illness. The training program was a cooperative effort of several state, academic, and private agencies in the New Orleans area, including the department of psychiatry at a state university medical center, the State Office of Mental Health, a consortium of colleges and universities providing educational opportunities for older adults, and the American Association of Retired Persons. The program curriculum included ten weeks of classroom instruction and a four-month field practicum. Of the 14 participants in the initial group of trainees, 13 sought and received employment as case aides. At follow-up three months after employment, supervisors of the case aides rated their job performance as excellent.

Using experiential training to enhance health professionals' awareness of patient compliance issues.

PURPOSE: To educate health care practitioners about medication compliance by having them play the role of patients who have been placed on a medication regimen. METHODS: In 1988, ten physicians and ten nurses working in the Acquired Immune Deficiency Syndrome Clinical Trials Unit of Tulane University and Louisiana State University participated in a compliance protocol designed to enable them to better understand the experience of their patients, who were involved in a three-year controlled trial of azidothymidine (zidovudine) for asymptomatic persons infected with the human immunodeficiency virus. Over the three-year trial, the patients were expected to take three pills five times a day at four-hour intervals every day. To gain experiential understanding of this prolonged, intensive medication regimen, the physicians and nurses agreed to follow their patients' pill-taking schedule by using placebos for seven days, and they kept diaries of their reactions to the seven-day experience. Two years later, a follow-up assessment was done to ascertain the participants' opinions about whether the seven-day experience had had a lasting, positive influence on the way they addressed compliance issues with patients. RESULTS: The primary barriers to medication compliance recorded by the participants were time-related difficulties in following such a strict, unvarying schedule (e.g., frustration at having to repeat the pill-taking five times a day at regular intervals). Other frequently recorded difficulties were social barriers to public pill-taking (e.g., being stigmatized as ill or different). The follow-up results indicated that the participants felt that the seven-day experience was a relatively fast, painless, and helpful means of educating themselves about the problems their patients face. CONCLUSION: By playing the role of patients, the physicians and nurses learned to recognize sources of patient noncompliance with medication regimens, and, as the follow-up indicated, they were able to generalize the role-playing experiences to later interactions with patients.

The relationship of serum DHEA-S and cortisol levels to measures of immune function in human immunodeficiency virus-related illness.

Human immunodeficiency virus (HIV) is a major cause of immunoincompetence. Whether the virus, itself, accounts for all the deficiency remains in question. Steroids can also influence immune function; glucocorticoids cause immunoincompetence while dehydroepiandrosterone (DHEA) enhances immune function. Changes in the levels of such hormones during the course of HIV illness might result in significant changes in immune competence. The purpose of this study is to investigate whether dehydroepiandrosterone-sulphate (DHEA-S) or cortisol levels correlate with absolute CD4 lymphocyte levels. Plasma for cortisol and DHEA-S was drawn from 98 adults with HIV. Of these, 67 had simultaneous CD4 levels. Cortisol levels were 12.4 +/- 4.6 micrograms/dl, DHEA-S 262 +/- 142 micrograms/dl, and CD4 levels were 308 +/- 217/mm3 (mean +/- SD). Correlational analysis revealed a significant relationship between DHEA-S and CD4 levels (r = 0.30; p = 0.01) but not between CD4 levels and cortisol (r = 0.11; p = 0.36) or cortisol/DHEA-S ratios (r = 0.17; p = 0.16). When analyzed by clinical subgroups, significant differences were also found with a decrease in DHEA-S levels seen in persons with more advanced illness. The data exhibit a positive relationship between the immune status of patients with HIV-related illness and DHEA, leading to the hypothesis that DHEA deficiency may worsen immune status.

Barriers to human immunodeficiency virus related risk reduction among male street prostitutes.

Two hundred eleven male street prostitutes between the ages of 18 and 51 years were interviewed and tested for antibodies to the human immunodeficiency virus (HIV). Economic, social, and emotional barriers to the reduction of HIV-related risk behavior were examined within the context of several concepts present in the Health Belief Model (HBM). Three lifestyle factors were found to function as barriers to engaging in risk reduction behavior. Subjects who were more economically dependent on prostitution, perceived less control over the hustling encounter, and reported increased pleasure from sexual activity with their customers were more likely to engage in risk-taking behavior. Prostitutes' perception of the severity of HIV infection was not significantly associated with their risk behavior. Unexpected findings indicated that increases in perceived susceptibility to HIV and perceived benefit of condom use for HIV prevention were significantly related to increased risk-taking behavior. Practical applications of findings in the design and implementation of future HIV-related preventive health education programs are discussed.

PIP: A survey of male street prostitutes in New Orleans, Louisiana, on the social, economic, and psychological barriers to human immunodeficiency virus (HIV)-related risk reduction behaviors has significant implications for the design of health education programs. The 211 subjects, ages 18-51 years, were tested for HIV antibodies and interviewed through use of a semi-structured schedule aimed at eliciting data on life-style and based on the Health Belief Model. 37 (17.5%) of study subjects were HIV-positive. HIV risk behavior was measured on the basis of participation in anal-genital and oral-genital sex, sexual orientation, and syphilis serostatus. High-risk behavior was found to be significantly positively associated with economic dependence on hustling, enjoyment of sex with tricks, and perceived control over hustling, negatively with frequency and quantity of substance abuse. These variables accounted for 6%, 3%, 4% and 4%, respectively, of the total variance in risk behavior. 96% of male prostitutes identified HIV as a serious condition; however, risk-taking behavior was found to increase with increased levels of perceived susceptibility to HIV infection. Finally, risk-taking behaviors increased along with increased in perceptions of the availability and efficacy of condoms. These findings suggest that health education efforts based on promoting HIV infection as a serious condition or emphasizing the effectiveness of condom use will be ineffective without attention to the social context of population groups at greatest risk of HIV infection. Measures most likely to reduce HIV-taking behaviors among male prostitutes are, according to these findings, elimination of the economic incentive for engaging in unsafe sex through the provision of alternative income sources, empowering male prostitutes to exert control over the hustling situation, and promotion of achievement of sexual pleasure through safe sex.

Sexual behavior patterns of customers of male street prostitutes.

Information about male customers of male prostitutes, including sociodemographic and life-style characteristics, sexual and drug use behaviors, and knowledge about HIV infection were collected from a convenience sample of 211 male street prostitutes and a convenience sample of 15 male customers as part of a feasibility study. Data from these two groups indicate that despite knowledge of HIV infection and its transmission, customers engage in high-risk sexual and drug use behaviors with prostitutes. Because there is a high HIV infection rate within the male prostitute sample (175/1000) and because these customers for the most part describe themselves as bisexual or heterosexual, it is likely that male customers of male prostitutes serve as a vector of transmission of HIV infection to their other partners including the heterosexual population.

PIP: A sample of 211 adult male street prostitutes and a sample of 15 male customers of male prostitutes were recruited from the Greater New Orleans metropolitan area at the Louisiana State University Medical Center. The prostitutes were tested for HIV using the enzyme-linked immunosorbent assay and the Western Blot. Sociodemographic characteristics, sexual behavior patterns, drug use patterns, knowledge of safer sex, safe drug practices, and HIV transmission data were obtained by interviews. The prostitutes were equally distributed across age 25 and age 25 and IV vs. non-IV drug use. 105 were White, and 196 were Black. Educational level ranged from completion of Grade 1 to college. The customers include 8 Blacks and 7 Whites with an age range of 19-49 years. 7 had never been married, 4 were currently married, and 4 were either separated or divorced. The prostitutes were positive that at least 40% of their customers were married at the time of their encounters. 8 of the customers were bisexual. 6 saw themselves as heterosexual, while 1 identified himself as homosexual. 99% of the prostitutes indicated that they perform oral-genital sex with their customers. When the customer was the insertive partner, the prostitutes states that 46% wore a condom. When the prostitute was the insertive partner in anal sex, 67% of their customers did not request use of a condom. Almost 30% of the prostitutes perceived that customers solicited them for high-risk sexual acts. 8 of the customers reported that they never wore a condom. The other 7 customers said that they never work them with their regular sexual partner(s). 57% of the prostitutes reported using alcohol and drugs with their customer. Among IV drug-using prostitutes, 28% injected drugs and shared needles with their customers. Customers exhibited an accurate knowledge of AIDS, modes of HIV transmission, and safer sex practices, 11 customers said that they had been tested previously for antibodies to HIV. One indicated that he was HIV seropositive, 9 said that they were negative, and 1 subject had not yet received his test results.

Psychological characteristics of a sample of male street prostitutes.

Two hundred and eleven male street prostitutes were interviewed and administered the SCL 90-R psychological symptom checklist. When compared to nonpatient normals, male prostitutes exhibited significantly higher levels of psychopathology. However, when compared to adult psychiatric outpatients, male prostitutes exhibited significantly less psychopathology on all symptom dimensions of the SCL 90-R except paranoid ideation. The male prostitutes' elevated scores on the psychological symptom checklist may reflect their response to an often dangerous and chaotic environment. However, it is as likely that their psychological functioning leads them to this particular milieu.

Relationship of coping style to affective state and perceived social support in asymptomatic and symptomatic HIV-infected persons: implications for clinical management.

The authors describe the relationship of three coping styles to affective state (mood) and perceived social support in 29 human immunodeficiency virus (HIV)-infected homosexual/bisexual men between the ages of 18 and 45 years. Active-behavioral coping was significantly related to enhanced mood and greater perceived social support. Avoidance coping was significantly related to greater mood disturbance and lower social support. No relationships were found for active-cognitive coping. Recommendations for clinical management of HIV-infected persons and their traditional and/or nontraditional family follow from the findings.

The male street prostitute: a vector for transmission of HIV infection into the heterosexual world.

Two hundred and eleven New Orleans male street prostitutes were interviewed and tested for antibodies to the human immunodeficiency virus (HIV). The subjects' lifestyle characteristics and their sex and drug use practices were evaluated to determine the prostitutes' potential to function as a vector for transmission of HIV into populations with currently low infection rates. Information about the customers of the male prostitutes was also obtained from the sample. The period prevalence of HIV in the sample was 175/1000. Many of the male prostitutes reported having wives or girlfriends, some of whom were prostitutes themselves. The prostitutes perceived a majority of their male customers to be heterosexual or bisexual (indicating sexual contact with women as well as men), many (39%) were thought to be married. Results from the study support the argument that male prostitutes serve as a bridge of HIV infection into populations with currently low infection rates through contact with both non-customer sexual partners and customers and thus indirectly to spouses and sexual partners of these individuals.

Determinants of subject compliance within an experimental anti-HIV drug protocol.

A study of subject compliance within an experimental anti-HIV drug protocol was conducted with 40 asymptomatic HIV seropositive persons participating in a double-blind, placebo controlled trial of the effectiveness of ZDV. Subject compliance was assessed through the use of study nurse independent ratings. The 20 most compliant and 20 least compliant subjects were surveyed at a 6-month interval using a self-report instrument designed to assess perceived social support and other psychosocial factors thought to effect compliance. Results indicated that more adherent subjects lived further from their treatment site, did not live alone, saw their study nurse as supportive, and were more likely to depend on a significant other for a wide range of social, economic, and emotional support. Implications for the practical use of these findings are discussed and suggestions for future research are proposed.

A biopsychosocial examination of symptomatic and asymptomatic HIV-infected patients.

This study evaluated twenty-nine symptomatic and asymptomatic HIV-infected homosexual/bisexual men between eighteen and forty-five in the areas of psychiatric/psychosocial, neuropsychological, family, and immunological functioning. The subjects were referred by physicians, nurses, and mental health professionals from the Tulane/Louisiana State University AIDS Clinical Trials Unit and the C-100 outpatient Primary Care Clinic for HIV-infected patients served within the Charity Hospital of Louisiana at New Orleans. All subjects and their significant others were evaluated between November 1987 and October 1988 at the C-100 Clinic. The outcome measures were mood disturbance, psychological distress, and CD4 cell count. The most significant other family member, as selected by each subject, completed family measures. The subjects experienced psychological distress and neuropsychological problems. Active-behavioral coping appeared adaptive (related to enhanced mood) as did perceived social support (related to positive mood and lower psychological distress). Higher levels of neuropsychological functioning (verbal memory, visual memory, motor speed, and visual-motor sequencing) were associated with enhanced psychosocial functioning and/or immunological status. The findings from this study highlight the importance of conducting longitudinal studies using a multidimensional approach in which HIV-infected persons and their most significant other family members are evaluated within a biopsychosocial model.

Effects of infection with Enterobacteriaceae enteropathogens on subsequent infection with Ascaris suum in the laboratory mouse.

Prior to infection with Ascaris suum, ICR strain mice were inoculated with Salmonella typhisuis intraperitoneally or via gastric gavage. Similarly, Salmonella cholerae-suis var. kunzendorf, Salmonella typhimurium and enterotoxigenic Escherichia coli were administered to mice via gastric gavage 2 weeks prior to A. suum inoculation. Previous inoculation with S. typhisuis, via the intraperitoneal or gastric gavage routes and S. cholerae-suis var. kunzendorf decreased recovery of ascarid larvae from mice lungs. This effect appeared to be due to entrapment of migrating larvae by inflammatory reactions in the liver. This reaction was suspected to be due to non-specific resistance stimulated by the prior exposure to the bacterial pathogen. The number of A. suum larvae in the lungs of mice previously inoculated with S. typhimurium or enterotoxigenic E. coli (ETEC) was variable and in some cases greater in mice which had received the bacterial inoculation.

Molecular epidemiology of antibiotic resistance in salmonella from animals and human beings in the United States.

We collected serotyped isolates of salmonella from reference laboratories in the United States, tested their susceptibility to antibiotics, and extracted plasmids from isolates that were resistant to a different combination of antibiotics from each of three serotypes. Restriction-endonuclease digestion showed that within each of the three groups, plasmid molecules from animal and human isolates were often identical or nearly identical. One serotype-plasmid combination appeared to be endemic in cattle in 20 states and infected 26 persons in two states. The human cases, which were not recognizably related except for their common plasmids, appeared to be clustered in time but geographically dispersed, like cases in previous outbreaks spread by food products. These findings suggest that resistance plasmids may be extensively shared between animal and human bacteria, and that spread of multiresistant strains of salmonella among animals and human beings, as observed in Britain, may have been undetected in the United States for lack of comparable surveillance.

Salmonella serotypes isolated from the aquatic environment (Wabash River, Indiana, 1973-1976).

During 1973-1976, 833 isolations of salmonellae were made from the aquatic biosphere of the Wabash River, Lafayette, Ind. Of the isolants, 643 were definitively serotyped. Salmonella typhimurium represented 34.4% of the cultures. Salmonella eimsbuettel previously had not been recognized in Indiana. A total of 35 serotypes and 1 untypable group C1 was obtained from the aquatic samples, ie, river water, river bottom sediment, fish, and mussels. Most of the isolants were presumed to be of human origin, because many samplings were made in close proximity to sewage treatment plant outfalls. During the survey period, epidemic salmonellosis had not been reported for the Lafayette-West Lafayette metropolitan area.