Where do people go for treatment of sexually transmitted diseases?

CONTEXT: Major public health resources are devoted to the prevention of sexually transmitted diseases (STDs) through public STD clinics. However, little is known about where people actually receive treatment for STDs. METHODS: As part of the National Health and Social Life Survey, household interviews were performed from February to September 1992 with 3,432 persons aged 18-59. Weighted population estimates and multinomial response methods were used to describe the prevalence of self-reported STDs and patterns of treatment utilization by persons who ever had a bacterial or viral STD. RESULTS: An estimated two million STDs were self-reported in the previous year, and 22 million 18-59-year-olds self-reported lifetime STDs. Bacterial STDs (gonorrhea, chlamydia, nongonococcal urethritis, pelvic inflammatory disease and syphilis) were more common than viral STDs (genital herpes, genital warts, hepatitis and HIV). Genital warts were the most commonly reported STD in the past year, while gonorrhea was the most common ever-reported STD. Almost half of all respondents who had ever had an STD had gone to a private practice for treatment (49%); in comparison, only 5% of respondents had sought treatment at an STD clinic. Respondents with a bacterial STD were seven times more likely to report going to an STD clinic than were respondents with a viral STD--except for chlamydia, which was more likely to be treated at family planning clinics. Men were significantly more likely than women to go to an STD clinic. Young, poor or black respondents were all more likely to use a family planning clinic for STD treatment than older, relatively wealthy or white respondents. Age, sexual history and geographic location did not predict particular types of treatment-seeking. CONCLUSIONS: The health care utilization patterns for STD treatment in the United States are complex. Specific disease diagnosis, gender, race and income status all affect where people will seek treatment. These factors need to be taken into account when STD prevention strategies are being developed.

PIP: This article provides population-based estimates of the prevalence of patient-reported sexually transmitted diseases (STDs) and characterizes patterns of treatment utilization according to specific STDs and client characteristics in the US. Using data from the 1992 National Health and Social Life Survey, which included 3432 persons aged 18-59, an estimated 2 million STDs were self-reported in the previous year, and 22 million 18-59 year olds self-reported lifetime STDs. Respondents reported bacterial STDs (gonorrhea, chlamydia, nongonococcal urethritis, pelvic inflammatory disease and syphilis) more than viral STDs (genital herpes, genital warts, hepatitis and HIV). About 49% of the respondents who had an STD mentioned having gone to a private practice for treatment, while only 5% had sought treatment at an STD clinic. Moreover, variations were seen in treatment-seeking for specific bacterial STDs, such as chlamydia and gonorrhea. Other factors that could influence where people go for treatment include gender, race, and income status. Characteristics of providers could also influence patient choice, such as geographic distribution, availability of support services, quality of care, convenience, and privacy.

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.

HIV infection risks, behaviors and methadone treatment: client-reported HIV infection in a follow-up study of injecting drug users in New England.

There is wide variation in reported risk factors for HIV incidence among injecting drug users by community. Available HIV seroprevalence and incidence data indicate that nearly 60% of HIV infection is associated with injecting drug use in Connecticut and 48% in Massachusetts. Using 12-month follow-up data on 354 initially HIV-negative New England (Massachusetts and Connecticut) methadone treatment clients, we assessed the association between baseline drug use practices, sexual behavior, partner behaviors, and client-reported HIV infection during follow-up. Variables that predicted client-reported positive HIV antibody test results were modeled by Cox proportional hazards regression. HIV infection among those tested was 14.2 per 100 person years (PY) [95% Confidence interval (CI) = 9.5 to 21.3]. For each injection the relative risk (RR) was 1.1 (95% CI = 1.1 to 1.2), for males 3.0 (95% CI = 1.2 to 7.3), for blacks 5.0 (95% CI = 1.6 to 15.5), for Hispanics 3.6 (95% CI = 1.2 to 10.5). Men who used more than one unclean needle per day and had an HIV-infected steady partner had an RR of 28.4 (95% CI = 4.4 to 176.4). For women, using speedball (RR = 6.1, 95% CI = 1.2 to 38.8) and being black (RR = 4.4, 95% CI = 1.0 to 19.8) predicted self-reported HIV infection; having a steady partner who ever injected increased this risk substantially (RR = 65.3, 95% CI = 4.0 to 1046.5). These findings for IDUs in Massachusetts and Connecticut indicate that risk factors for HIV infection for men are consistent with expected transmission by unclean needles with an HIV-infected partner, but a preference for using speedball predicted HIV infection among women IDUs.

Sex, drugs and HIV counseling and testing: a prospective study of behavior-change among methadone-maintenance clients in New England.

OBJECTIVES: To determine whether changes in injecting drug use and sexual behavior over a 12-month follow-up are associated with HIV counseling and testing (C and T) of injecting drug users in methadone maintenance treatment programs (MMTP) in Massachusetts and Connecticut. METHODS: Clients were invited to participate in a longitudinal study involving five interviews. Data were also obtained by ethnographers and from clinical records. Behavioral outcomes of interest were number of drug injections, sharing of unclean 'works' (injecting equipment), number of unprotected sex partners, and number of unprotected sexual episodes. Data analyses included multiple regression, odds ratios, and quantitative analysis of text-based data. RESULTS: Subjects reported reductions in both injecting drug use and sexual behavior Primary associations with reduced injecting drug use were remaining in the MMTP and attending HIV-positive support groups. A reduction in high-risk sexual behavior was associated with an HIV-positive test result and duration of HIV counseling in the MMTP. Increase in drug injecting use was associated with an HIV-positive test result. Inconsistent condom use was associated with enrollment in the MMTP where condoms were available only upon request and abstinence and monogamy between uninfected partners were promoted. CONCLUSIONS: Injecting drug users who self-select to participate in MMTP and HIV C and T, two public health HIV-prevention interventions, reduce their HIV-risk behaviors. Clients should be encouraged to remain in MMTP and HIV-infected clients should attend support groups for HIV-positive persons. MMTP staff should promote a variety of safer sex behaviors and provide condoms without request.

Retention in methadone maintenance treatment programs, Connecticut and Massachusetts, 1990-1993.

The goal of this study was to identify factors associated with six- and 12-month retention in methadone maintenance treatment programs (MMTPs) in Massachusetts and Connecticut. Data was obtained from 674 participants, clinic records, and clinic staff. Ethnographic and logistic regression analyses were conducted. Overall, 69% and 48% of the clients remained in treatment at six months and 12 months, respectively. The MMTPs were categorized as either a 12-Step, case management, or primary care model. Factors independently associated with retention in treatment at six months were each one-year increase in age of client (OR 1.05), injecting at three months (OR 0.47), and enrollment in the primary care model (OR 2.10). The same factors were associated with 12-month retention in treatment. To retain clients in MMTPs-which should, in turn, help reduce drug use and prevent HIV transmission among IDUs-younger IDUs and clients still injecting at three months after entering drug treatment may need additional services from the staff, or alternative treatment regimens. MMTP directors should consider differences between these programs and, if appropriate, make changes to increase retention in treatment.

The epidemiology of walking for exercise: implications for promoting activity among sedentary groups.

The relative contribution of walking to overall leisure-time physical activity participation rates was studied among respondents from the 45 states that participated in the 1990 Behavioral Risk Factor Surveillance System (n = 81,557). The percentages of low income, unemployed, and obese persons who engaged in leisure-time physical activity (range = 51.1% to 57.7%) were substantially lower than the percentage among the total adult population (70.3%). In contrast, the prevalence of walking for exercise among these sedentary groups (range = 32.5% to 35.9%) was similar to that among the total population (35.6%). Walking appears to be an acceptable, accessible exercise activity, especially among population subgroups with a low prevalence of leisure-time physical activity.

Prevalence of chronic diseases and impairments among US farmers, 1986-1990.

Farmers in the United States suffer disproportionately from certain chronic diseases and impairments. This analysis estimated the prevalence of selected diseases among farmers and compared these rates with those for other US workers. Five years (1986-1990) of National Health Interview Survey data on white male workers were combined to provide a basis for estimating the prevalence of selected conditions and impairments among this subgroup. Crude prevalence rates were significantly elevated for farmers compared with other workers for cardiovascular diseases, arthritis, skin cancer, hearing loss, and amputations. These elevations persisted when farmers were compared with blue-collar workers. The crude prevalence of orthopedic impairments and chronic respiratory diseases was not elevated among farmers, but the age-adjusted prevalence ratios for cardiovascular diseases, arthritis, and amputations were significantly elevated for farmers as compared with other workers. The prevalence of hearing loss was significantly higher only for farmers older than 65 years. This method of pooling data holds promise for studying disease rates in other small segments of the US population.

Cigarette smoking prevalence by occupation in the United States. A comparison between 1978 to 1980 and 1987 to 1990.

We analyzed data from 1987 to 1990 National Health Interview Surveys and compared them with 1978 to 1980 National Health Interview Surveys data to determine changes in cigarette smoking prevalence by occupation. During this period, cigarette smoking prevalence declined from 31.7% to 24.2% among white-collar workers, from 43.7% to 39.2% among blue-collar workers, and from 37.2% to 34.5% among service workers. For occupational groups, the largest significant declines in smoking prevalence occurred among male sales workers (10.5 percentage points), female and male managers and administrators (9.9 and 8.7 percentage points), female professional and technical workers (8.0 percentage points), and male transportation equipment operatives (7.5 percentage points). Analyses of 1987 to 1990 detailed occupation codes revealed that roofers (57.8%) and crane and tower operators (57.6%) had the highest prevalences of cigarette smoking, whereas physicians (5.4%) and clergy (6.5%) had the lowest smoking prevalences. Since 1978 to 1980, the differences in smoking prevalence by occupation have widened, providing further evidence that smoking has moved from a relatively common behavior practiced by most segment of society to one that has become more concentrated among selected subpopulations. Health professionals need to play an important role in encouraging smoking cessation among workers and in advising management and labor about the benefits of strong work-site smoking policies.

Behavioral Risk Factor Surveillance, 1991: monitoring progress toward the nation's year 2000 health objectives.

PROBLEM/CONDITION: Risk reduction is a major focus of the national health objectives for the year 2000. Progress toward several of these objectives can be evaluated by using data from the Behavioral Risk Factor Surveillance System (BRFSS). Year 2000 objective areas measurable by BRFSS data include those for overweight, lack of physical activity, smoking, safety belt use, and medical screening for breast and cervical cancer and elevated blood cholesterol. BRFSS data have been used to guide health promotion/disease prevention programs. REPORTING PERIOD: 1991. DESCRIPTION OF SYSTEM: BRFSS is a state-based random-digit-dialing telephone survey of noninstitutionalized adults (> or = 18 years of age); 47 states and the District of Columbia participated in BRFSS in 1991. RESULTS: Some year 2000 objectives appear to be readily attainable for many states, whereas others do not. For example, among participating states, a median 57.8% (range = 45.6%-82.8%) of women ages > or = 50 years reported having had both a clinical breast examination and a mammogram in the previous 2 years (year 2000 objective: > or = 60%). In contrast, a median 37.3% (range = 22.1%-52.5%) of persons with annual family income < $20,000 reported that they did not engage in leisure-time physical activity--more than twice the year 2000 objective (> or = 17%). INTERPRETATION: BRFSS data demonstrate substantial state-to-state variation in progress toward year 2000 objectives and highlight areas (e.g., lack of leisure-time physical activity) in which substantial progress remains to be made in most states. Action taken: The BRFSS will continue to report data that relate to year 2000 health objectives. BRFSS data will enable states to monitor progress toward these objectives and develop health policies aimed at achieving them.

Worker awareness of exposure: industries and occupations with low awareness.

A goal of occupational health is to inform workers of hazards on their jobs. This analysis addresses this goal by identifying industries and occupations with low worker awareness of potential exposures. Industries and occupations were ranked by the greatest positive difference between the proportion of workers exposed and proportion perceiving exposure to chemical and physical hazards. Those with low awareness had the greatest difference, i.e., high exposure and low perception. This analysis was performed by adding exposure data from a national exposure survey to a national health survey with perceived exposure data. The hospital and construction industries and occupations in these industries ranked among the top five for all hazards. For example, for hospital workers the difference between proportion exposed and proportion perceiving exposure to chemicals was 62% and to radiation was 42%, and for workers in construction the difference was 54% for exposure to noise and 63% for exposure to vibration.

American adults' knowledge of HIV testing availability.

OBJECTIVES: Understanding client needs, knowledge, and preferences about services is necessary to ensure that human immunodeficiency virus (HIV) counseling and testing programs are accessible. This study addressed knowledge of HIV testing availability. METHODS: To study American adults' knowledge of HIV testing availability, we collected data during 1990 by random digit-dialing telephone surveys of adults residing in 44 states and the District of Columbia. RESULTS: Of the 81,557 persons who responded, almost two thirds identified medical doctors as a source of HIV testing. Fourteen percent identified public sites, and 12% said they didn't know where to go for HIV testing. Persons who were older, less educated, and had lower incomes were less likely to know where they could go for testing. Persons identifying public sites shared some characteristics with others who lacked adequate health care coverage. CONCLUSIONS: Physicians will be increasingly called upon to provide HIV counseling and testing to their patients. This may require additional training to provide effective, individualized, risk-reduction messages about sexual and drug use behaviors. Even when persons have adequate information about availability, sociodemographic characteristics are likely to influence preferences for HIV counseling and testing.

Cancer screening behaviors among U.S. women: breast cancer, 1987-1989, and cervical cancer, 1988-1989.

Data from the Behavioral Risk Factor Surveillance System (BRFSS) were used to examine trends in breast and cervical cancer screening behaviors among U.S. women in selected states. Data reported are from the 1987, 1988, and 1989 BRFSS for breast cancer screening (mammography) and from the 1988 and 1989 BRFSS for cervical cancer screening (Papanicolaou [Pap] smear). Results are presented as either state-specific or state-aggregate data for the years noted above. State-specific analyses indicated that self-reported mammography utilization increased between 1987 and 1989. Although whites and blacks reported similar mammography utilization rates both for screening and for a current or previous breast problem, disparities were evident among women of different ages and incomes. The proportion of women who reported ever having had a Pap smear and having heard of a Pap smear were extremely high and remained fairly consistent across the 2 survey years. State-aggregate analyses, however, showed that the percentage of women who had had a Pap smear within the previous year was negatively associated with age and positively associated with income. A higher proportion of blacks than whites obtained Pap smears. These results indicate that certain segments of the population are not taking full advantage of available breast and cervical cancer screening technologies. Public health strategies, such as those outlined in the Breast and Cervical Cancer Mortality Prevention Act of 1990 (Public Law 101-354), should enhance screening opportunities for these women.

Adjustment for smoking, alcohol consumption, and socioeconomic status in the California Occupational Mortality Study.

This paper presents methods for adjusting for smoking, alcohol, and socioeconomic status in death certificate-based occupational mortality surveillance. The methods were applied in the California Occupational Mortality Study, a statewide study of rates based on 180,000 deaths and census estimates of occupations. For each occupation, levels of smoking, alcohol consumption, and socioeconomic status were estimated using National Health Interview Survey and U.S. Census data, and an empirical Bayes procedure was used to improve the stability of smoking and alcohol estimates for small occupations. Expected death rates for occupations were calculated by modeling rates as a function of age, smoking, alcohol, and socioeconomic status with Poisson regression. The effect of adjustment was usually moderate and in the expected direction, and the adjusted mortality ratios were generally closer to 1.0. Full data on agricultural occupations are presented for illustration.

Behavioral risk factor surveillance, 1986-1990.

Since 1984, an increasing number of states (including the District of Columbia) have participated in the Behavioral Risk Factor Surveillance System (BRFSS). This report provides state-specific estimates of the prevalence of selected health-risk behaviors for the years 1986 through 1990. Apparent trends and progress toward several of the year 2000 national health objectives are discussed, both for the entire adult population (persons ages greater than or equal to 18 years) and selected high-risk demographic subgroups. Now that BRFSS includes 45 states and covers over 90% of the nation's adult population, it can be used both as a measure of state-specific risk factor prevalence and an indicator of national trends.

Risk of neuropsychiatric disability among painters in the United States.

Scandinavian studies have suggested that working with solvents is associated with chronic neuropsychiatric disease. In the United States the Social Security Administration's records of white male recipients of disability compensation were used in a case-referent study on this topic. The cases were defined as men with any one of several neuropsychiatric diseases, and the referents as men with other disabling conditions. The men were considered exposed if they had worked as a painter prior to disability and unexposed if they had worked as a bricklayer. A job-exposure matrix verified the painters' potential exposure to solvents and the bricklayers' lack of potential exposure. The painters had a significant excess of neuropsychiatric disability [adjusted odds ratio (OR) 1.42, 95% confidence interval (95% CI) 1.04-1.94]. Construction painters had an excess of neuropsychiatric disability [OR 1.47 (95% CI 1.07-2.02)] in contrast to spray painters [OR 0.77 (95% CI 0.38-1.54)]. The limitations of the data are discussed, including potential diagnosis bias and exposure misclassification.

Occupational health and safety risks and potential health consequences perceived by U.S. workers, 1985.

Data from the Health Promotion and Disease Prevention Questionnaire, part of the 1985 National Health Interview Survey, were used to report workers' perceptions of occupational risk in their present jobs. This information will be used to monitor progress between 1985 and 1990 toward achieving broad goals in health promotion and disease prevention. The proportions of currently employed persons who perceived exposure to health-endangering substances, work conditions, or risks of injuries were reported for age, race, sex, and occupation groups. Occupational groups were further characterized by the proportion of men and women who reported specific exposures (such as exposure to chemicals or to loud noise) and specific health consequences of exposure (such as risk of developing cancer or hearing impairment). Greater proportions of men than women reported perceived risk from exposure to health-endangering substances, work conditions, and injuries in their present job. Also, a greater proportion of workers perceived risk of injury in their present job than other occupational risk categories. The greatest proportions of perceived exposure to occupational risk were reported by farm operators and managers, police and firefighters, and by workers in forestry and fishing occupations. Among workers reporting perceived exposures, chemicals, noise, and risk of injuries from vehicles were cited by the greatest proportion of workers, as were such health consequences as lung and respiratory problems and hearing impairment. Data from this study may be used to target employment groups for health promotion or education and to develop indepth studies of specific occupational groups to reduce or prevent risk at the worksite.

On the mechanism of the post-asymptotic CR decrement phenomenon.

Three experiments with 49 dogs explored the decrease in CR magnitude that sometimes occurs when CS-US pairings are continued beyond those needed to reach maximum CR magnitude. The first experiment confirmed the existence of the phenomenon, obtaining less conditioned excitation after 300 CS-US trials than after 18 CS-US trials. The second experiment demonstrated that the phenomenon is not dependent upon paired CS-US presentations because 18 CS-US pairings yielded little excitation if preceded by, followed by, or intermixed with 282 US presentations. The third experiment indicated that in contrast to the decremental effects on excitatory conditioning, inhibitory conditioning was faciliated by large numbers of prior US exposures, suggesting explanation of the post-asymptotic decrement phenomenon by opponent-process theory.