Developing standards in behavioral surveillance for HIV/STD prevention.

HIV/STD prevention programs are increasingly guided by behavioral rather than by disease indicators. Relevant HIV/STD-related behavioral information is currently available from a variety of surveys and surveillance systems at three levels: general population, infected populations, and high-risk populations. However, the utility of these systems for local program development is limited due to lack of standardization. In 1997 a Centers for Disease Control and Prevention working group was formed to develop a core set of items for HIV/STD behavioral surveillance for use across surveys. Core items were chosen on the basis of existing surveys and surveillance systems, relevant literature, testing in a cognitive laboratory, and field pilot-testing. A draft of the core set of sexual behavior questions is available on the web at http://www.cdc.gov/nchstp/od/core-workgroup for review and feedback. Questions on drug use, including drug injection practices, as well as questions on HIV testing and sexually transmitted diseases are in preparation and will also be posted on the web site for review.

Missed opportunities for congenital syphilis prevention in an urban southeastern hospital.

BACKGROUND: Despite recent declines in syphilis rates nationally, recent outbreaks suggest that prevention of congenital syphilis remains an ongoing public health problem. GOALS: To identify missed opportunities for congenital syphilis prevention during prenatal care. STUDY DESIGN: Retrospective medical record review of 157 live birth or stillbirth deliveries that involved cases of congenital syphilis from Grady Memorial Hospital (Atlanta, GA). RESULTS: The hospital congenital syphilis prevalence was 8.2 cases per 1,000 live births. Six percent of case patients were HIV positive. Opportunities for earlier maternal screening, treatment, or diagnosis were missed in 60% of case patients who received timely prenatal care. Congenital syphilis cases attributable to preventable missed opportunities were significantly more common among case patients with fewer prenatal visits (66% versus 28%, P = 0.01). CONCLUSION: Provider efforts to reduce congenital syphilis in high-risk populations receiving prenatal care should focus on (1) screening patients at the first opportunity, at both the first prenatal visit and during the third trimester (i.e., 28 weeks); (2) performing on-site testing and same-day treatment; (3) providing appropriate treatment to infected women with penicillin allergy; (4) referring sex partners for treatment to prevent reinfection; and (5) screening all pregnant women attending emergency clinics.

Influence of alcohol and drug use on AIDS risk behavior among youth in dropout prevention.

Youth enrolled in dropout prevention and alternative school programs engage in a number of high risk behaviors in greater numbers than those in traditional school settings [1, 2]. However, data on alcohol and drug use influences and risky sexual behavior are often not collected or reported among these youth due to small enrollments and rapid turnover. In this study alcohol and drug use and sexual behaviors were surveyed among 212 youth in dropout prevention. A risk profile score for HIV/AIDS was developed and the contribution of alcohol and drug use to HIV/AIDS risk was determined. Results showed that use of alcohol and drugs and age of sexual initiation were significantly associated with a high risk profile score. Of sexually active youth, 28 percent reported using alcohol or drugs prior to having sexual intercourse and more than half reported not using condoms during their last sexual experience. Males were more likely than females to use alcohol and drugs before having sex, and were more likely to have had sex with two or more partners. Findings from this study suggest that among youth in dropout prevention, the association of alcohol and drug use to HIV/AIDS risk is significant and that prevention programs need to target alcohol and drug use as important influences on risky sexual behavior.

Factors associated with client-reported HIV infection among clients entering methadone treatment.

To determine demographic and behavioral factors associated with client-reported HIV infection among new enrollees in methadone maintenance treatment programs (MMTPs) in Massachusetts and Connecticut, we examined ethnographic data and interview data from MMTP clients (N = 674). Clients responded to questions about behaviors in the 30 days before drug treatment. ETHNOGRAPH was used to analyze qualitative data, and logistic regression analysis was used to identify variables associated with client-reported HIV infection. Statistical significance was set at p < .05. The client-reported HIV infection rate was 20% (132/674). Odds ratios for factors associated with client-reported HIV infection were being white (0.53), increase in age (1.07), use of non-injected heroin (0.12), use of injected heroin (6.24), cocaine injection (1.78), sharing of "works" with strangers (2.15), and "safer sex" behavior (4.04). Additionally, 35% of those who did not use illicit drugs reported being seropositive. The qualitative data suggested HIV positive clients were concerned about protecting sex partners, and learning of HIV infection motivated some to stop using drugs. Although some clients engaged in low-risk behaviors, others did not, therefore the potential for HIV transmission among injection drug users (IDUs) in Connecticut and Massachusetts exists. HIV prevention and drug treatment program personnel should reinforce and build on the low-risk behaviors that are acceptable and adopted by some in this population.

A community support group for HIV-seropositive drug users: is attendance associated with reductions in risk behaviour?

Although support groups for HIV-seropositive persons are a potential source of emotional support and information, there has been little assessment of such groups as to their role in changing risk behaviour for transmission. The present study combines observations from over 52 group sessions with baseline and follow-up interview data to assess changes in sex and drug behaviour among seropositive drug users participating in an ongoing group for African Americans. The sample of 100 adults was recruited from drug treatment centres and from the community in Atlanta, Georgia. At the 6-month interview, frequency of group attendance was associated mainly with healthier drug behaviour, the topic most frequently discussed by members. Findings suggest that training for support group facilitators needs to target two areas for technology transfer: successful strategies for reducing both high-risk sex and drug behaviour and methods for introducing these behavioural change tools into a setting designed for socio-emotional support. We conclude that community support groups are an untapped opportunity for low-cost prevention services.

A peer-led AIDS prevention program for students in an alternative school.

School-based programs designed to measure health risk behavior and reduce the risk of sexually transmitted diseases (STDs) and human immunodeficiency virus (HIV) infection have not addressed adequately the needs of adolescents outside of main-stream schools. In Florida, these youth represent a sizable proportion of the population and have been shown to be at increased risk for acquiring sexually transmitted diseases and human immunodeficiency virus. This article describes a peer-led STD/HIV intervention for students in a dropout prevention program in Dade Country, Florida. Trained peer counselor/educators (PCEs) led schoolwide activities and classroom sessions covering STD/HIV information, community health resources, communication and negotiation skills, and safer sex strategies. Teachers and students rated the PCEs effective in promoting discussion and serving as sources of information about AIDS and community health resources. Pre/post intervention questionaire results demonstrated an increase in AIDS awareness and discussion among students as well as an increase in condom use. Based on this social influences approach, peer education appears to be a promising health education strategy for students in dropout prevention programs.

HIV prevention in prisons and jails: obstacles and opportunities.

High rates of human immunodeficiency virus (HIV) infection among jail and prison inmates suggest that HIV prevention efforts should focus on incarcerated populations. Overcrowding, the high prevalence of injection drug use, and other high-risk behaviors among inmates create a prime opportunity for public health officials to affect the course of the HIV epidemic if they can remedy these problems. Yet, along with the opportunity, there are certain obstacles that correctional institutions present to public health efforts. The various jurisdictions have differing approaches to HIV prevention and control. Whether testing should be mandatory or voluntary, whether housing should be integrated or segregated by HIV serostatus, and whether condoms, bleach, or clean needles should be made available to the prisoners, are questions hotly debated by public health and correctional officials. Even accurate assessment of risk-taking within the institutions leads to controversy, as asking questions could imply acceptance of the very behaviors correctional officials are trying to prevent. Education and risk-reduction counseling are the least controversial and most widely employed modes of prevention, but the effectiveness of current prevention efforts in reducing HIV transmission in this high-risk population is largely undetermined.

Racial/ethnic differences in smoking, other risk factors, and low birth weight among low-income pregnant women, 1978-1988.

Because of the adverse effects of low birth weight (LBW) on infant morbidity and mortality, one of the 1990 health objectives for the nation has been to reduce the incidence of LBW to 5% among all live births in the United States. Public health surveillance of cigarette smoking during pregnancy has demonstrated an association between smoking and an increased risk of LBW, defined as birth weight of less than 2,500 g. For the period 1978-1988, information on nearly 248,000 women from CDC's Pregnancy Nutrition Surveillance System showed an LBW rate of 6.9%, a high prevalence of smoking during pregnancy (29.7%); and a strong association between smoking during pregnancy and the likelihood of delivering an LBW infant in all age, racial/ethnic, and prepregnancy weight groups. The risk of LBW was greater for smokers than for nonsmokers (9.9% versus 5.7%), creating an excess LBW risk of 4.2% associated with smoking. Overall, the average birth-weight deficit related to smoking was 178 g. Among both smokers and nonsmokers, black women had a higher percentage of LBW infants than did white women, and the risk of LBW related to smoking was greater among black women. That risk tended to increase with age, especially among women with low pregravid weight. Major reductions in LBW might be achieved if smoking were eliminated among pregnant women.

Gonorrhea in the United States: 1967-1979.

Sex-, race-, and age-specific gonorrhea cases and rates reported by public and private sources were studied. The role of the age, sex, and race composition of the population was used to explain changing trends of morbidity due to gonorrhea. Beginning in 1967, reported cases of gonorrhea in the United States increased at an annual rate of 13% through 1975, with increases in women twice those in men. The group aged 20-24 years had the highest age-specific rates of gonorrhea in both men and women, while the highest percentage increases were observed in the 15-19-year-old age group. Since 1975, numbers of reported cases have stabilized. Decreases in rates of gonorrhea were more pronounced in men than in women. Among all ages, the group aged 20-24 showed the largest decrease for race and sex categories, except for nonwhite women.

Syphilis in the United States: 1967-1979.

Reported data on cases of primary and secondary syphilis in the United States during 1967-1979 were analyzed by age, race, sex, and reporting source. Although the incidence of primary and secondary syphilis fluctuated little in the United States between 1967 and 1979, the ratio of male to female cases increased twofold, from 1.5:1 to 3:1. Cases in men, primarily those aged 25-39 years, reported by public clinics increased from 32% to 56% of the total cases reported; in particular, cases among white males reported by public clinics increased by 351%. The percentage of white men with early syphilis who attended public clinics and who reported at least one male sex partner increased from 38% in 1969 to 70% in 1979. These findings suggest that an essential change occurred in the epidemiology of early syphilis in the United States: white gay men became proportionately more burdened by the disease, and increasing transmission of the disease occurred within this segment of the population in the United States.