HIV serostatus disclosure among gay and bisexual men in four American cities: general patterns and relation to sexual practices.

The present study examined patterns of serostatus disclosure among previously untested HIV-seropositive and HIV-seronegative gay and bisexual men recruited from four American cities (n = 701). Six months after learning their HIV serostatus, 97% of study participants had disclosed their test results to at least one other individual. Consistent with earlier studies, test results were most frequently shared with friends and the respondent's primary partner. HIV serostatus was disclosed less frequently to family members, co-workers, and non-primary sex partners. Compared with HIV-seronegative men, HIV-seropositive men were more likely to have disclosed their status to a health care provider and less likely to have shared this information with family members. Of seropositive men, 11% did not disclose their serostatus to their primary partner and 66% did not disclose to a non-primary sex partner. Of HIV-seropositive men with one or more non-primary partners, 16% of those who did not disclose their serostatus reported inconsistent condom use during anal intercourse with these partners. No significant differences in self-reported sexual practices were observed for HIV-seropositive disclosers versus non-disclosers. Compared with HIV-seronegative men who did not disclose, seronegative men who shared information about their serostatus were more likely to have had receptive anal intercourse with their primary partner (p < 0.05) and to have engaged in mutual masturbation (p < 0.005), receptive oral sex (p < 0.005) and insertive anal intercourse (p < 0.05) with non-primary partners. No significant differences were observed between disclosers and non-disclosers with regard to condom use. Implications of the findings for future research and HIV prevention programmes are discussed.

Effect of HIV infection on the natural history of anal human papillomavirus infection.

OBJECTIVE: To identify risk factors for the detection of prevalent and incident anal human papillomavirus (HPV) infection, and HPV persistence among HIV-seropositive and seronegative homosexual men. DESIGN: Longitudinal study of 287 HIV-seronegative and 322 HIV-seropositive men attending a community-based clinic. METHODS: Subjects underwent an interview and examination; specimens were collected for HIV serology and assessment of anal HPV and HIV DNA. RESULTS: Anal HPV DNA was detected at study entry in 91.6% of HIV-infected men, and 65.9% of men not infected with HIV. HPV detection was associated with lifetime number of sexual partners and recent receptive anal intercourse (HIV-seronegative men), decreased CD4+ lymphocyte count (HIV-seropositive men), and anal warts (all men). Among men negative for HPV at study entry, subsequent detection of HPV was associated with HIV, unprotected receptive anal intercourse, and any sexual contact since the last visit. Among men positive for HPV at study entry, subsequent detection of additional HPV types was more common among HIV-seropositive men. Becoming HPV negative during follow-up was less common among men with HIV or high HPV levels at study entry. Among those with HIV, HPV persistence was associated with presence of anal HIV DNA, but not with CD4+ lymphocyte count. CONCLUSIONS: Risk of anal HPV infection appears to increase with sexual exposure, epithelial trauma, HIV infection and immune deficiency. Incident infection may result from recent sexual exposure or reactivation of latent infection. Further studies are needed to elucidate the mechanism by which HIV DNA in the anal canal increases the risk of HPV persistence.

HIV testing among men who have sex with men--results of a telephone survey.

BACKGROUND: This article describes the testing behavior for human immunodeficiency virus (HIV) antibody among an urban population of men who have sex with men (MSM) and the reasons given for not being tested for HIV. METHODS: A random digit dialing telephone survey of men living in selected neighborhoods of Seattle, Washington, was conducted from June through August 1992. RESULTS: Of 603 MSM interviewed, 82% had ever been tested for HIV; 19% of tested men were seropositive. MSM who were older, nonwhite, with lower income, or not currently sexually active were less likely to have been tested. Among nontesters, 57% believed their risk of infection was too low to justify testing; 52% said they had not tested due to fear of learning the result. Testers and nontesters had similar rates of unprotected sexual behavior. CONCLUSIONS: Most MSM who had not been tested for HIV believed they were not at risk of infection and/or were fearful of learning the result. To increase the proportion of MSM who test, public health agencies may need to emphasize that unexpected infection does occur and that new therapies are available for those testing positive. Innovative programs may be necessary to reach those who have not yet decided to be tested.

Changes at a human immunodeficiency virus testing clinic in the prevalence of unsafe sexual behavior among men who have sex with men.

GOAL: Given reductions in risky sexual behavior reportedly occurring during the 1980s among men who have sex with men, the authors sought to assess if such trends are continuing. STUDY DESIGN: The authors analyzed initial visit data for 4,880 men who presented at a human immunodeficiency virus testing clinic from 1988 through 1993 and who reported any male partners during the preceding 12 months. RESULTS: From 1988 to 1993, the percent of men who have sex with men reporting any oral sex (virtually all of which was unprotected) or any anal sex (more than two-thirds of which was unprotected) during the previous 6 months increased from 78% to 90% (P < 0.001) and from 47% to 55% (P = 0.6), respectively. Adjusting for demographics and numbers of partners did not change results. CONCLUSIONS: Unprotected anal sex persists, whereas unprotected oral sex is increasing among men who have sex with men and who present for human immunodeficiency virus testing. New strategies are needed to reduce human immunodeficiency virus risk among men who have sex with men.

Prospective study of high grade anal squamous intraepithelial neoplasia in a cohort of homosexual men: influence of HIV infection, immunosuppression and human papillomavirus infection.

OBJECTIVE: To determine the risk of developing high grade anal squamous intraepithelial neoplasia (HG-AIN) in relation to HIV infection and immunosuppression, after controlling for the effects of human papillomavirus (HPV) infection. DESIGN: Prospective cohort study of 158 HIV-seropositive and 147 HIV-seronegative homosexual men presenting to a community-based clinic with initially negative anal cytologic and colposcopic findings. METHODS: Subjects completed self-administered questionnaires, underwent cytologic screening, and standardized unaided and colposcopic examination of the proximal anal canal for presence of abnormalities suggestive of AIN. Anal specimens were screened for HPV DNA. RESULTS: HG-AIN developed in eight (5.4%) and 24 (15.2%) HIV-seronegative and -seropositive men, respectively. Risk of HG-AIN among HIV-seronegative men was associated with detection of anal HPV types 16 or 18 by Southern transfer hybridization (STH), detection of HPV 16 or 18 at the lower levels by polymerase chain reaction but not by STH, and with number of positive HPV tests; HG-AIN risk among HIV-seropositive men was associated with detection of HPV 16 or 18 only by STH, detection of HPV types other than 16 or 18, CD4 count < or = 500 x 10(6)/l, and number of positive HPV tests. HIV-induced immunosuppression remained an independent predictor of HG-AIN after adjusting for type and level of detection of HPV; HIV infection predicted HG-AIN risk after adjustment for number of positive HPV tests. CONCLUSIONS: The association of HG-AIN with HIV, independent of HPV type, level of HPV detection and number of positive HPV tests, suggests that this increased risk cannot be entirely explained by an effect of HIV on HPV detection. Future studies focusing on factors more specific to the local microenvironment in the anal canal should help clarify these issues.

Demographic and behavioral differences among participants, nonparticipants, and dropouts in a cohort study of men who have sex with men.

BACKGROUND AND OBJECTIVES: Results of prospective cohort studies can be biased when subjects selectively refuse to participate or be included in follow-up. GOAL OF THIS STUDY: To assess the potential for bias in a longitudinal study of sexual risk behavior among men who have sex with men. STUDY DESIGN: This was a cross-sectional comparison of clinical data regarding men who have sex with men attending an urban human immunodeficiency virus testing clinic. RESULTS: Of 3,390 men who have sex with men invited to participate, 2,063 refused, 589 dropped out after completing an initial study questionnaire, and 738 participated in follow-up at 6 months. There were no significant differences in the same-gender sexual behaviors of participants, dropouts, and nonparticipants, with one exception: Nonparticipants were more likely to abstain from receptive oral sex (27%) compared with participants (18%) or dropouts (21%). CONCLUSION: The similarities in reported activities among participants, dropouts, and nonparticipants suggest that selection bias may have limited impact on cohort studies of sexual behavior.

Restriction fragment length polymorphism analysis detecting a community-based tuberculosis outbreak among persons infected with human immunodeficiency virus.

Analysis of restriction fragment length polymorphisms (RFLP) was used to investigate an increase in tuberculosis (TB) among noninstitutionalized human immunodeficiency virus (HIV)-infected persons in King County, Washington. Using the IS6110 insertion sequence, RFLP analysis was done on Mycobacterium tuberculosis isolates from 18 HIV-infected patients and 10 randomly selected patients without HIV risk factors. Six HIV-infected patients with the same M. tuberculosis strain had contact at one or more of three bars as their only common exposure. Two other HIV-infected persons, a patient and a health care worker who had close contact, had matching strains. Isolates from the 10 remaining HIV-infected patients and the 10 patients without HIV risk factors had different DNA patterns. Analysis of RFLP patterns revealed a community outbreak of TB among HIV-infected persons who had not been previously linked following conventional investigation by the health department. This technique deserves further evaluation as an epidemiologic tool in the investigation of TB.

An explosive point-source measles outbreak in a highly vaccinated population. Modes of transmission and risk factors for disease.

In 1985, 69 secondary cases, all in one generation, occurred in an Illinois high school after exposure to a vigorously coughing index case. The school's 1,873 students had a pre-outbreak vaccination level of 99.7% by school records. The authors studied the mode of transmission and the risk factors for disease in this unusual outbreak. There were no school assemblies and little or no air recirculation during the schooldays that exposure occurred. Contact interviews were completed with 58 secondary cases (84%); only 11 secondary cases (19%) of these may have had exposure to the index case in the classrooms, buses, or out of school. With the use of the Reed-Frost epidemic model, only 22-65% of the secondary cases were likely to have had at least one person-to-person contact with the index case during class exchanges, suggesting that this mode of transmission alone could not explain this outbreak. A comparison of the first 45 cases and 90 matched controls suggested that cases were less likely than controls to have provider-verifiable school vaccination records (odds ratio (OR) = 8.1) and more likely to have been vaccinated at less than age 12 months (OR = 8.6) or at age 12-14 months (OR = 7.0). Despite high vaccination levels, explosive measles outbreaks may occur in secondary schools due to 1) airborne measles transmission, 2) high contact rates, 3) inaccurate school vaccination records, or 4) inadequate immunity from vaccinations at younger ages.

The relative impact of smoking and oral contraceptive use on women in the United States.

Women who smoke and use oral contraceptives (OCs) are at increased risk for cardiovascular and cerebrovascular disease. To study the prevalence of smoking and OC use and other behaviors affecting health, 28 states and the District of Columbia conducted telephone surveys during 1981 through 1983. More than 22,000 US adults were interviewed, of whom 5779 women aged 18 to 44 years were studied. Data were weighted to represent the US population. Overall, 7.4% of US women aged 18 to 44 years reported smoking and using OCs; 1.1% reported smoking 25 or more cigarettes per day while using OCs. Although women aged 18 to 24 years were most likely to smoke and use OCs, combined smoking and OC use contributed substantially to the number of excess cases of myocardial infarctions occurring among US women aged 35 to 44 years. However, regardless of OC use, smoking accounted for most of the excess cases. Therefore, health care providers need to intensify their efforts to reduce smoking among their patients.

Failure to use seat belts in the United States. The 1981-1983 Behavioral Risk Factor Surveys.

Although seat belt use could prevent thousands of highway deaths and save billions of dollars annually, most Americans do not routinely buckle up. To understand better this phenomenon and other health-related behaviors, 28 states, the District of Columbia, and the Centers for Disease Control, Atlanta, surveyed over 22,000 US adults from 1981 through 1983. Overall, 76% of US adults reported not using seat belts. Blacks, 18- to 24-year-olds, persons with no more than a high school education, and persons with other risk behaviors (especially drunk driving) were least likely to use seat belts. Legislation by the states and education by physicians can increase seat belt use and reduce morbidity and mortality due to motor vehicle collisions.

The risks of exercise: a public health view of injuries and hazards.

Relatively little is known about the incidence of the risks facing those who exercise regularly. Clinical reports suggest a variety of musculoskeletal ailments, and several pathophysiologic conditions may result from the various aerobic activities most likely to be pursued by large parts of the U.S. population. But adequate epidemiologic data are scarce. Careful epidemiologic studies are needed to develop incidence information.