Stigma and behavioral health literacy among individuals with proximity to mental health or substance use conditions.

BACKGROUND: Stigma reduction has been identified as a key public health strategy to increase enrollment in behavioral health services. As our understanding about stigma reduction has become more sophisticated, there has been an increased recognition that efforts to reduce stigma must engage the complex relationships between stigma, literacy, and contact with others who have a behavioral health condition. AIMS: The goal of this project was to improve understanding about the relationships between behavioral health literacy, stigma, and contact to inform efforts to increase public behavioral health literacy and decrease stigma. Specifically, this project explored how the structure of these relationships varied for different substance use and mental health conditions. METHOD: Structural equation modeling was used to depict relationships with data from a nationally-representative survey on behavioral health literacy and stigma. RESULTS: The impact of prior contact and literacy on stigma varied by behavioral health condition. CONCLUSIONS: Stigma reduction efforts will be most successful when they match the level of literacy and prior contact with the condition among the target audience for stigma reduction efforts.

Epidemiology of male same-sex behaviour and associated sexual health indicators in low- and middle-income countries: 2003-2007 estimates.

OBJECTIVES: To conduct a systematic review of published and unpublished data from research and public health information systems on the prevalence of male-to-male sex in the total male population; as well as among men who have sex with men (MSM), data on prevalence of heterosexual activity and heterosexual unions; prevalence of condom use with male and female partners; and prevalence of HIV infection and other sexually transmitted infections (STIs). METHODS: Key indicators were defined (a) among men in the general population: prevalence of sex with a man ever and last year; (b) among MSM: prevalence of heterosexual experiences ever and last year; proportion of male-female transgenders; proportion of sex workers; prevalence of HIV and other STIs, condom use in last sexual encounter; consistent condom use with men last year; never used a condom with a man. With help from key informants, study searches were conducted in Pubmed, LILLACS, institutional databases, conference records and other sources. Methodology and quality of information were assessed, and the best data available for 2003-7 were selected. Indicator estimates from each study were used to propose regional estimate ranges. RESULTS: A total of 83 new entries were entered into the database in addition to the previous 561, totalling 644. Of these, 107 showing 2003-7 data were selected. Many new studies came from sub-Saharan Africa, portraying hidden HIV epidemics among MSM. The most frequently reported estimate was HIV infection, with high estimate ranges in most of the regions, except for Middle East and North Africa and Eastern Europe. The next most frequently reported was lifetime frequency of heterosexual sex, showing that roughly 50% of MSM ever had sex with a woman. The small number of newer studies reporting prevalence of "sex with a man in last 12 months" between 2003 and 2007, did not warrant enough new evidence to revise our 2005 size estimates for MSM populations. CONCLUSIONS: A considerable number of new studies with estimates of relevance to understanding sexual behaviour and HIV among MSM were identified, with an encouraging amount of new data coming from sub-Saharan Africa. However, limitations in the quality, utility and comparability of available information persist. At least three measures could be promoted for use in surveillance and academic studies: standardised indicators for MSM studies; standardised operational definitions of, and instructions to describe, variables; and standardised research designs and data gathering strategies. A prerequisite for this all is intense advocacy to ensure a social climate in which research into such matters is prioritised, resources are made available as needed and the human rights of MSM are respected.

The quality of sero-surveillance in low- and middle-income countries: status and trends through 2007.

OBJECTIVE: To examine the quality of HIV sero-surveillance systems in 127 low-income and middle-income countries by 2007, as well as gaps in data needed for reliable estimates of HIV prevalence and size of populations at risk for infection. METHODS: The quality of countries' surveillance systems was scored using information from 2001 through 2007. Sero-surveillance data were compiled from the US Census Bureau's HIV/AIDS Surveillance Database, from countries' national HIV surveillance reports available to UNAIDS, from demographic and health survey (DHS) data, from the scientific literature and from countries' Estimation and Projection Programme (EPP) data files. The quality of systems was scored according to the classification of the epidemic in each country (generalised, concentrated or low-level). RESULT: The number of countries categorised as fully functioning in 2007 was 40. 43 countries were identified as partially functioning while 44 were categorised as poorly functioning. Low scores were most often attributed to a lack of recent data or data from appropriate risk groups. CONCLUSION: Many countries still have poorly functioning surveillance systems. The inclusion of HIV testing in national population-based surveys in recent years has resulted in some countries with generalised epidemics receiving higher coverage scores, but many countries with concentrated or low-level epidemics continue to lack data on high-risk populations.

Estimates of the number of female sex workers in different regions of the world.

OBJECTIVES: To collect estimated numbers of female sex workers (FSW) and present proportions of FSW in the female population (FSW prevalence) in different regions of the world. METHODS: Subnational and national estimated numbers of FSW reported in published and unpublished literature, as well as from field investigators involved in research or interventions targeted at FSW, were collected. The proportion of FSW in the adult female population was calculated. Subnational estimates were extrapolated to national estimates if appropriate. Population surveys were scanned for proportions of adult women having sex in exchange for money or goods. RESULTS: In sub-Saharan Africa, the FSW prevalence in the capitals ranged between 0.7% and 4.3% and in other urban areas between 0.4% and 4.3%. Population surveys from this same region yielded even higher proportions of women involved in transactional sex. The national FSW prevalence in Asia ranged between 0.2% and 2.6%; in the ex-Russian Federation between 0.1% and 1.5%; in East Europe between 0.4% and 1.4%; in West Europe between 0.1% and 1.4%; and in Latin America between 0.2% and 7.4%. Estimates from rural areas were only available from one country. CONCLUSIONS: Although it is well known and accepted that FSW are a highly vulnerable group in the scope of the HIV epidemic, most countries in the world do not know the size of this population group. The estimates of the prevalence of FSW presented in this paper show how important this hard-to-reach population group is in all parts of the world.

Clients of sex workers in different regions of the world: hard to count.

OBJECTIVES: To estimate the proportion of the male population that reports having paid for sex in different regions. METHODS: Clients of sex workers were identified from representative samples of men asked in face-to-face interviews whether they had had sex in exchange for money or whether they had paid for sex, in the last 12 months. A total of 78 national household surveys and nine city based surveys were selected for inclusion. Where such surveys were not available, results of behavioural surveillance surveys and of research studies were also used. Using national estimates, a median percentage of men who reported paying for sex was calculated for each region. RESULTS: The median percentage of men who exchanged sex for money in the last 12 months in all regions was around 9-10%, with estimates from 13% to 15% in Central African region, 10 to 11% in Eastern and southern Africa, and 5-7% in Asia and Latin America. Estimates for men who paid sex were much lower at around 2-3% with ranges from 7% in the South African region to 1% in Asia and West Africa. CONCLUSIONS: Although errors of measurement and critical issues of definitions and interpretation exist, this compilation represents a first attempt to obtain reasonably coherent estimates of the proportion of men who were clients of sex workers at regional level. Large discrepancies between regions were found. Further improvements in national estimates will be critical to monitor coverage of HIV prevention programmes for sex workers and clients, and to improve estimates of national HIV infection prevalence levels in low and concentrated HIV epidemics.

Estimating the number of men who have sex with men in low and middle income countries.

OBJECTIVES: To collect and analyse published and unpublished surveillance and research data on the prevalence of same sex sexual activity among male adults (including male-to-female transgenders and sex workers) in low and middle income countries. METHODS: Key indicators were operationalised (ever sex with a man, sex with a man last year, high risk sex last year (as defined by unprotected anal sex or commercial sex)) and a database was designed for data collection. Searches were conducted (PubMed, databases (US Census Bureau, World Bank, conferences)) and regional informants helped. Reference reports were used to assess the methodology and quality of information in each record. The best data available per region were identified and indicator estimates were used to propose regional range estimates. RESULTS: Of 561 studies on male sexual behaviour and/or MSM population characteristics, 67 addressed prevalence of sex between men, with diverse numbers per region and virtual unavailability in sub-Saharan Africa, Middle East/North Africa, and the English speaking Caribbean. Overall, data on lifetime prevalence of sex with men (among males) yielded figures of 3-5% for East Asia, 6-12% for South and South East Asia, 6-15% for Eastern Europe, and 6-20% for Latin America. Last year figures were approximately half of lifetime figures, and prevalence of high risk sex among MSM last year was approximately 40-60% in all regions except South Asia, where it is 70-90%. CONCLUSIONS: Data available on the prevalence of male same sex sexual activity across regions are scarce (non-existent in some areas), with validity and comparability problems. In South and South East Asia, Eastern Europe, and Latin America, a lifetime prevalence of 6-20% was estimated, with smaller figures in East Asia. A cross cultural analysis of terminology and practices is needed, as is continued work on epidemiological and social analysis of male-male sexual practices in societies across regions.

The 2005 Workbook: an improved tool for estimating HIV prevalence in countries with low level and concentrated epidemics.

OBJECTIVE: This paper describes improvements and updates to an established approach to making epidemiological estimates of HIV prevalence in countries with low level and concentrated epidemics. METHODS: The structure of the software used to make estimates is briefly described, with particular attention to changes and improvements. DISCUSSION: The approach focuses on identifying populations which, through their behaviour, are at high risk of infection with HIV or who are exposed through the risk behaviour of their sexual partners. Estimates of size and HIV prevalence of these populations allow the total number of HIV infected people in a country or region to be estimated. Major changes in the software focus on the move away from short term projections and towards developing an epidemiological curve that more accurately represents the change in prevalence of HIV over time. The software continues to provide an output file for use in the Spectrum software so as to estimate the demographic impact of HIV infection at country level.

A dengue outbreak among camp participants in a Caribbean island, 1995.

BACKGROUND: Dengue, a mosquito-transmitted viral disease, is a risk for visitors in tropical and subtropical areas. Several participants in a community-assistance program in Tortola, British Virgin Islands, in August, 1995, reported dengue-like symptoms either before or soon after leaving the island. METHODS: We conducted a retrospective cohort study to determine the extent of the outbreak, risk factors for illness, and the proportion of inapparent infections. Program participants were interviewed by telephone or mail, and asked to submit a serum sample for dengue diagnosis. A clinically-diagnosed case of dengue was defined as a person with fever and two or more of the following: headache, retro-orbital pain, myalgia, arthralgia, rash, or hemorrhagic manifestations. Serum specimens were tested for virus isolation, polymerase chain reaction (PCR), plaque-reduction neutralization (PRNT) or anti-dengue IgM and IgG antibody. RESULTS: Thirty-two (97%) of the 33 program participants responded; 21 of the 32 (66%) provided at least one serum sample for study. The median age was 17 years; 20 (62%) were women. Of 32 respondents, 22 (69%) met the clinical case definition for dengue: 15 of them (68%) had a positive IgM antibody response and 7 did not submit a serum sample. Dengue 1 virus (DEN-1) was identified by PCR in one case and all 11 positive PRNT results. No asymptomatic infections were identified. No respondent used effective mosquito repellent, and only 2 (6%) used bednets. CONCLUSIONS: A DEN-1 outbreak with a high attack rate (69%) occurred in a group of young short-term community aid workers. There were no asymptomatic infections documented. Participants' rare use of bednets or effective mosquito repellent highlights the importance of providing travelers to tropical areas with information about dengue fever and the recommended precautions to protect against infection.

Nonmedical doctoral-level scientists in the Centers for Disease Control and Prevention's Epidemic Intelligence Service, 1964-1997.

INTRODUCTION: Although historically a training program in applied epidemiology for physicians, veterinarians, and dentists, CDC's Epidemic Intelligence Service (EIS) has been attracting an increasing number of other doctoral-level scientists with prior experience and training in advanced analytic methods. METHODS: Using data from alumni records, we studied the participation of these nonmedical scientists in the EIS program and their subsequent employment. RESULTS: 160 nonmedical doctoral level scientists enrolled in EIS from 1964 through 1997; 135 had completed EIS as of July 1997. Of 160 enrolled, 94 (59%) had an advanced degree in epidemiology; other degrees included demography, anthropology, behavioral sciences, statistics, and other health areas; 66% were women. Most (112; 70%) were assigned to work in noninfectious disease areas. After completion of EIS, 113 (84%) of 135 officers continued to work in public health activities: 75 (56%) remained employed at CDC; 17 (13%) in academic institutions; 14 (10%) in local or state health departments; 3 (2%) in international health agencies; 2 (1%) in other federal health agencies; and 2 (1%) in public health foundations. Compared with trainees recruited during 1964-1989, greater proportions of those recruited during 1990-1995 remained employed at CDC (44/74 [59%] versus 31/61 [51%]) or at state or local health departments (10 [14%] versus 4 [7%]). Those training during EIS at a state or local health department (15/20, 75%) or in occupational health (17/24, 71%) were more likely than those in other assignments to work outside CDC following EIS. CONCLUSION: There is increasing participation and collaboration of persons trained in nonmedical sciences with those trained in traditional medical areas in the EIS training program and in careers in public health at all levels: local, state, and federal.

Risk and prevention of hepatitis C virus infection. Implications for dentistry.

BACKGROUND: The occupational risk of hepatitis C virus, or HCV, infection in dentistry is very low. Nonetheless, the lack of an effective vaccine, the high rates of chronic infection and the limited effectiveness of treatment may cause concern for dental workers who come into contact with blood in their daily practices. DESCRIPTION OF THE DISORDER: The authors discuss the natural history, diagnosis and treatment, and patterns of transmission of HCV infection, including the Centers for Disease Control and Prevention's recommendations for management and follow-up of health care workers after occupational exposure to HCV. CLINICAL IMPLICATIONS: In the absence of an effective vaccine or postexposure prophylaxis, prevention of occupational transmission of HCV in dental settings continues to rely on the use of universal precautions, including barrier precautions and the safe handling of sharp instruments.

Epidemiology of epidemic diphtheria in three regions, Russia, 1994-1996.

BACKGROUND: A massive diphtheria epidemic which began in the former Soviet Union in 1990 is the first large-scale diphtheria epidemic in developed countries in more than 30 years and has primarily affected adults. In response, health authorities attempted to maximize vaccination for children and conducted an unprecedented campaign to vaccinate adults. METHODS: We analyzed diphtheria surveillance data (case report forms and diphtheria vaccine coverage data) from three Russian regions from January 1994 to December 1996 and estimated vaccine effectiveness by the screening method. RESULTS: We reviewed records from 2243 (97.2%) of 2307 reported cases. The highest cumulative incidence in the period was among children aged 5 to 9 years (106 cases per 100,000 population); adults aged 40-49 years had the highest adult incidence for disease (88 cases per 100,000) and the highest incidence of any age group of clinically severe disease (29 cases per 100,000) and death (5.1 deaths per 100,000). The incidence among women aged 2049 years (82 per 100,000 women) was higher than among men (47 per 100,000, p<0.01). The annual incidence decreased from 25.2 cases per 100,000 population in 1994 to 9.4 cases per 100,000 in 1996. The decrease occurred as adult coverage increased from an estimated 25-30% in December 1992 to 88% in December 1995. Vaccine effectiveness was high among both children and adults. CONCLUSIONS: The Russian diphtheria epidemic primarily affected adults, especially women; this pattern is likely representative of diphtheria epidemics in immunized populations. Raising childhood immunization coverage and mass adult vaccination was effective in controlling the Russian epidemic. An improved understanding of the current epidemiology of diphtheria will be useful to design public health responses to prevent or control modern epidemics.

Beyond performance enhancement: polypharmacy among collegiate users of steroids.

The extremely low prevalence of steroid use among college students makes it virtually impossible to conduct analyses on any single college campus. By studying a cohort of 58,625 college students from 78 institutions that administered the Core Alcohol and Drug Survey in 1990 and 1991, a critical mass of 175 users on which it was possible to conduct statistical analyses was identified. Compared with a randomly selected group of nonusers, the steroid users reported consuming dramatically more alcohol and demonstrated higher rates of binge drinking. In addition, a significantly higher percentage of steroid users reported using tobacco, marijuana, cocaine, amphetamines, sedatives, hallucinogens, opiates, inhalants, and designer drugs. A higher percentage of steroid users than nonusers also reported experiencing negative consequences as a result of substance abuse, and a greater percentage of the steroid users reported family histories of abuse of alcohol and other drugs. Implications from the standpoint of student development are discussed.

Development of the Core Alcohol and Drug Survey: initial findings and future directions.

To assist universities in obtaining accurate information about the effectiveness of their efforts to prevent substance abuse, a committee of grantees of the US Department of Education's Fund for the Improvement of Postsecondary Education (FIPSE) developed an assessment tool known as the Core Alcohol and Drug Survey. This self-report instrument is designed to examine the nature, scope, and consequences of the use of alcohol and other drugs among college students. To date, the survey has been administered to nearly half a million students on 800 campuses, and the findings have been aggregated to create what is presently the largest national database on substance use in the higher education setting. The Core survey has often been used by campus health service personnel in assessment and programming efforts. This article describes the development and administration of the Core Alcohol and Drug Survey and provides a sampling of findings from the 1989-1991 FIPSE drug prevention group. This cohort included 58,625 students who completed the survey. Findings regarding consumption patterns, consequences of use, underage drinking, and regional differences are delineated, along with information regarding the future direction of Core survey projects.