Multi-level Determinants of Clinic Attendance and Antiretroviral Treatment Adherence Among Fishermen Living with HIV/AIDS in Communities on Lake Victoria, Uganda.

This cross-sectional study assessed determinants of HIV clinic appointment attendance and antiretroviral treatment (ART) adherence among 300 male fisherfolk on ART in Wakiso District, Uganda. Multi-level factors associated with missed HIV clinic visits included those at the individual (age, AOR = 0.98, 95% CI 0.97-0.99), interpersonal (being single/separated from partner, AOR: 1.25, 95% CI 1.01-1.54), normative (anticipated HIV stigma, AOR: 1.55, 95% CI 1.05-2.29) and physical/built environment-level (travel time to the HIV clinic, AOR: 1.11, 95% CI 1.02-1.20; structural-barriers to ART adherence, AOR: 1.27, 95% CI 1.04-1.56; accessing care on a landing site vs. an island, AOR: 1.35, 95% CI 1.08-1.67). Factors associated with ART non-adherence included those at the individual (age, ß: - 0.01, η2 = 0.03; monthly income, ß: - 0.01, η2 = 0.02) and normative levels (anticipated HIV stigma, ß: 0.10, η2 = 0.02; enacted HIV stigma, ß: 0.11, η2 = 0.02). Differentiated models of HIV care that integrate stigma reduction and social support, and reduce the number of clinic visits needed, should be explored in this setting to reduce multi-level barriers to accessing HIV care and ART adherence.

One-year follow-up evaluation of the sexually transmitted diseases/human immunodeficiency virus intervention program in a marine corps sample.

Although a substantial number of studies have been conducted to evaluate the impact of various human immunodeficiency virus (HIV) prevention programs, most of them have focused on civilian populations. There is a clear need to develop and evaluate sexually transmitted diseases (STD)/HIV prevention programs designed specifically for U.S. military populations. The objective of the present study was to determine whether a behavioral intervention known as the STD/HIV Intervention Program (SHIP) would have a sustained positive impact on the behavior of a sample of Marines. A 1-year follow-up telephone interview was administered to (1) Marines who participated in the SHIP course (intervention group), and (2) a quasi-control group of Marines who were not exposed to the SHIP course. The intervention and control groups differed significantly in the percentage of the time they had used condoms during the past year. The intervention participants reported using condoms a greater percentage of the time than the nonparticipants.

Prevention of sexually transmitted diseases and HIV in young military men: evaluation of a cognitive-behavioral skills-building intervention.

BACKGROUND: Military personnel deployed to foreign countries with high endemic rates of sexually transmitted diseases (STDs) are at risk. GOAL: To evaluate a cognitive-behavioral, skills-building intervention to prevent STDs in junior, enlisted, male US Marines deployed to the Western Pacific aboard ships with periodic liberty visits to foreign ports. STUDY DESIGN: This study, using a quasi-experimental design, assigned 584 men to a cardiopulmonary resuscitation training (n = 288) or a cognitive-behavioral intervention (n = 296). The intervention aimed to increase prevention knowledge, reduce high-risk psychosocial (motivation) factors, and build decision-making and communication skills to reduce risky sexual behaviors and alcohol consumption. RESULTS: Participation in the intervention was associated with increased knowledge regarding symptoms and treatment of STDs and HIV (P < 0.001), decreased alcohol use (P < 0.01), and sexual risk (P < 0.01) during liberty ports of call. CONCLUSION: A multiple-session, cognitive-behavioral, skills-building intervention can be successfully implemented for deployed military personnel.

Evaluation of a sexually transmitted disease/human immunodeficiency virus prevention train-the-trainer program.

In this study, a behavioral intervention known as the STD/HIV Intervention Program (SHIP) was implemented at the Navy preventive medicine technician (PMT) school as a "train-the-trainer" course. Course evaluation questionnaires were administered to PMT students immediately after the training. Follow-up interviews evaluating the SHIP course were conducted with PMTs (N = 73) 1 year after the training. PMT students were fairly satisfied with SHIP overall, as well as with specific components of the course. As hypothesized, the SHIP train-the-trainer course was considered useful by most PMTs in their first duty assignments after completing PMT school.

Chlamydial infection and unplanned pregnancy in women with ready access to health care.

OBJECTIVE: To apply urine-based ligase chain reaction for Chlamydia trachomatis (C. trachomatis) and Neisseria gonorrhoeae (N. gonorrhoeae) detection and standard urine-based pregnancy testing for Navy-enlisted women, and to compare the prevalence and epidemiologic correlates of these adverse reproductive outcomes. METHODS: Participants were surveyed and urine was collected for pregnancy testing using standard laboratory methods and detection of C. trachomatis and N. gonorrhoeae infection by ligase chain reaction. Self-administered surveys facilitated collection of demographics, sexual behavior, including contraceptive use, sexual partners, sexually transmitted disease, and pregnancy history. RESULTS: Among 299 of 314 participants, the prevalence of chlamydial infection was 4.7% and of pregnancy was 9.7%, with 48.3% of the pregnancies unplanned. Chlamydia trachomatis infection was univariately associated with having a new sex partner within the last 6 months, more sexual partners, single marital status, condom use, drinking until passing out or vomiting in the past 30 days (alcohol misuse), and current pregnancy. Unplanned pregnancy was univariately associated with young age, single marital status, inconsistent condom use, having a new sex partner within the last 6 months, and more recent sexual partners. Among the pregnant women, four (13.8%) were infected with C. trachomatis. CONCLUSION: The high rates of chlamydial infection and unplanned pregnancy found in this population of employed young women with ready access to health care and health education underscore the challenge of enhancing reproductive health via compliance with effective contraceptive and sexually transmitted disease prevention methods. This is a challenge that remains unmet.

Stress fracture in military recruits: gender differences in muscle and bone susceptibility factors.

A total of 693 female U.S. Marine Corps recruits were studied with anthropometry and dual-energy X-ray absorptiometry (DXA) scans of the midthigh and distal third of the lower leg prior to a 12 week physical training program. In this group, 37 incident stress fracture cases were radiologically confirmed. Female data were compared with male data from an earlier study of 626 Marine recruits extended with additional cases for a total of 38 stress fracture cases. Using DXA data, bone structural geometry and cortical dimensions were derived at scan locations and muscle cross-sectional area was computed at the midthigh. Measurements were compared within gender between pooled fracture cases and controls after excluding subjects diagnosed with shin splints. In both genders, fracture cases were less physically fit, and had smaller thigh muscles compared with controls. After correction for height and weight, section moduli (Z) and bone strength indices (Z/bone length) of the femur and tibia were significantly smaller in fracture cases of both genders, but patterns differed. Female cases had thinner cortices and lower areal bone mineral density (BMD), whereas male cases had externally narrower bones but similar cortical thicknesses and areal BMDs compared with controls. In both genders, differences in fitness, muscle, and bone parameters suggest poor skeletal adaptation in fracture cases due to inadequate physical conditioning prior to training. To determine whether bone and muscle strength parameters differed between genders, all data were pooled and adjusted for height and weight. In both the tibia and femur, men had significantly larger section moduli and bone strength indices than women, although women had higher tibia but lower femur areal BMDs. Female bones, on average, were narrower and had thinner cortices (not significant in the femur, p = 0.07). Unlike the bone geometry differences, thigh muscle cross-sectional areas were virtually identical to those of the men, suggesting that the muscles of the women were not relatively weaker.

Streptococcus pneumoniae: bacteremia in an era of penicillin resistance.

BACKGROUND: The proportion of penicillin-resistant Streptococcus pneumoniae isolates and associated risk factors varies by geographic area in the United States. We conducted a retrospective study to determine the extent of penicillin-nonsusceptible S pneumoniae bacteremia and associated risk factors in a tertiary care medical center in San Diego. METHODS: Patients with S pneumoniae bacteremia at the University of California, San Diego Medical Center from September 15, 1991, through July 31, 1998, were identified by hospital-based computerized microbiology records. Hospital records included demographic information, patient data, and antibiotic prescription records for patients with bacteremia as a result of S pneumoniae. Univariate and multivariate analyses were used to determine risk factors for penicillin-nonsusceptible S pneumoniae bacteremia. RESULTS: Of 281 isolates of S pneumoniae identified, 192 (68%) were from hospitalized patients. After controlling for other factors, patients from 1 to 5 years of age (P = .01; odds ratio [OR] = 3.96; 95% CI, 1.50 to 10.44), 6 to 18 years of age (P =.04; OR = 6.42; 95% CI, 1.13 to 36.51), and HIV seropositive patients (P =.002; OR = 5.12; 95% CI, 1.83 to 14.32) were more likely to have penicillin-nonsusceptible S pneumoniae bacteremia. There was a significant increasing trend of penicillin-nonsusceptible S pneumoniae bacteremia from 14% in 1991 to 42% in 1998 (P = .001; OR = 1.42; 95% CI, 1.16 to 1.73); this included only 2 isolates that were highly resistant to penicillin. There was no increase in mortality in patients who had penicillin-nonsusceptible S pneumoniae bacteremia. CONCLUSION: With the increase in S pneumoniae resistance to penicillin, it is important to continue surveillance of infections caused by S pneumoniae. Hospital-based studies are useful for tracking epidemiologically important pathogens.

Prevalence of genotypic and phenotypic resistance to anti-retroviral drugs in a cohort of therapy-naïve HIV-1 infected US military personnel.

OBJECTIVE: While transmission of drug-resistant HIV-1 has been reported, estimates of prevalence of resistance in drug-naïve populations are incomplete. We investigated the prevalence of genotypic mutations and phenotypic antiretroviral resistance in a cohort of HIV-1 infected U.S. military personnel prior to the institution of antiretroviral therapy. DESIGN: Cross-sectional cohort study. METHODS: Plasma was obtained from 114 recently HIV-1 infected subjects enrolled in an epidemiological study. Genotypic resistance was determined by consensus sequencing of a PCR product from the HIV-1 pol gene. Sequences were interpreted by a phenotypic-genotypic correlative database. Resistance phenotypes were determined by a recombinant virus cell culture assay. RESULTS: Genotypic mutations and phenotypic resistance were found at a higher than expected frequency. Resistance to non-nucleoside reverse transcriptase inhibitors was most common, with a prevalence of 15% of 95 subjects by genotype and 26% of 91 subjects by phenotype. Genotypic and phenotypic resistance respectively were found in 4% and 8% of subjects for nucleoside reverse transcriptase inhibitors and in 10% and 1% for protease inhibitors. One subject harbored virus with resistance to all three drug classes. CONCLUSIONS: A substantial frequency of resistance to antiretroviral drugs was identified in a therapy-naïve U.S. cohort. In most cases, the genotypic and phenotypic assays yielded similar results, although the genotypic assay could detect some protease inhibitor resistance-associated mutations in the absence of phenotypic resistance. These data suggest the need for optimization of treatment guidelines based on current estimates of the prevalence of drug resistance in HIV-1 seroconverters.

The association of blisters with musculoskeletal injuries in male marine recruits.

A prospective study examining the epidemiology of blisters and, in particular, the association of blisters with subsequent injuries was conducted involving 2,130 male US Marine Corps recruits participating in initial physical training at the Marine Corps Recruit Depot in San Diego, California. From January 1993 through September 1994, recruits experienced an incidence of 2.05 blisters per 100 recruit-months. Recruits with blisters were 50% more likely to experience an additional training-related injury. Blisters, in combination with other related injuries, resulted in 159 clinic visits, 103 days of assigned light duty, and 177 lost days of training. This loss of time cost a minimum of $29,529. Extrapolating to the annual population of recruits, this represents an approximate annual expense of $690,000. Aggressive blister prevention and management in this setting has the potential to greatly reduce morbidity and fiscal costs.

Drug resistance patterns, genetic subtypes, clinical features, and risk factors in military personnel with HIV-1 seroconversion.

BACKGROUND: Regular testing of military personnel identifies early HIV infection; this identification provides a sentinel cohort in which to describe the evolving molecular epidemiology of HIV-1 transmission. OBJECTIVE: To describe the prevalence and epidemiologic correlates associated with the acquisition of non-subtype B and drug-resistant HIV infections. DESIGN: Cross-sectional study. SETTING: Military referral hospital. PATIENTS: 95 military personnel with HIV-1 seroconversion. MEASUREMENTS: Self-reported questionnaire, CD4 cell counts, plasma HIV-1 RNA levels, and nucleic acid sequence analysis for drug-resistant mutations and HIV-1 genetic subtype. RESULTS: 95 patients were enrolled between February 1997 and February 1998. The likely geographic location of HIV-1 acquisition was overseas in 8% of patients, the United States in 68%, and either overseas or the United States in 24%. Seven patients (7.4%) had subtype E infection; the remainder had subtype B infection. Eight of 31 (26%) treatment-naive patients had mutations in the reverse transcriptase or protease gene associated with drug resistance. CONCLUSIONS: The percentage of HIV-1 non-subtype B infection and antiretroviral drug-resistant mutations was relatively high in U.S. military personnel with recently acquired HIV-1 infection.

The effect of foot structure and range of motion on musculoskeletal overuse injuries.

The purpose of this prospective study was to determine whether an association exists between foot structure and the development of musculoskeletal overuse injuries. The study group was a well-defined cohort of 449 trainees at the Naval Special Warfare Training Center in Coronado, California. Before beginning training, measurements were made of ankle motion, subtalar motion, and the static (standing) and dynamic (walking) characteristics of the foot arch. The subjects were tracked prospectively for injuries throughout training. We identified risk factors that predispose people to lower extremity overuse injuries. These risk factors include dynamic pes planus, pes cavus, restricted ankle dorsiflexion, and increased hindfoot inversion, all of which are subject to intervention and possible correction.

Epidemiological patterns of musculoskeletal injuries and physical training.

PURPOSE: The purpose of this study was to identify rates of diagnosis-specific musculoskeletal injuries in U.S. Marine Corps recruits and to examine the association between patterns of physical training and these injuries. METHODS: Subjects were 1,296 randomly selected male Marine recruits, ages 17 to 28 yr, who reported to Marine Corps Recruit Depot San Diego for boot camp training between January 12 and September 14, 1993. Recruits were followed prospectively through 12 wk of training for injury outcomes. Injury patterns were examined in relation to weekly volumes and types of vigorous physical training. RESULTS: The overall injury rate was 39.6% (number of recruits injured/population at risk), with 82% of injuries occurring in the lower extremities. Overuse injuries accounted for 78% of the diagnoses. The most frequent site of injury was the ankle/foot region (34.3% of injuries), followed by the knee (28.1%). Ankle sprains (6.2%, N = 1,143), iliotibial band syndrome (5.3%, N = 1,143), and stress fractures (4.0%, N = 1,296) were the most common diagnoses. Injury rates were highest during the weeks with high total volumes of vigorous physical training and the most hours of running and marching. Weekly injury rates were significantly correlated with hours of vigorous physical training (overuse injuries r = 0.667, P = 0.018; acute injuries r = 0.633, P = 0.027). CONCLUSIONS: The results of this controlled epidemiological investigation indicate that volume of vigorous physical training may be an etiologic factor for exercise-related injuries. The findings also suggest that type of training, particularly running, and abrupt increases in training volume may further contribute to injury risk.

Use of simple measures of physical activity to predict stress fractures in young men undergoing a rigorous physical training program.

Among a population of randomly selected US Marine Corps recruits at Marine Corps Recruit Depot, San Diego, California, the authors developed a screening tool to identify individuals at high risk for lower extremity stress fracture when beginning a rigorous physical training program. The screening tool was developed among 1,286 recruits, then tested and refined among 1,078 additional recruits. The refined algorithm, consisting of five physical activity questions and a 1.5-mi (2.4-km) run time, revealed that 21.6% of "high risk" subjects suffered more than three times as many stress fractures as "low risk" subjects. These data suggest that risk of stress fracture during rigorous physical training is increased by poor physical fitness and low levels of physical activity prior to their entry into the program.

Epidemiology of illness and injury among U.S. Navy and Marine Corps female training populations.

Evidence suggests that female military populations are at greater risk than their male counterparts for certain training- and combat-related illnesses and injuries. The objective of this prospective, multisite, epidemiological study was to define the patterns of illness and injury in military women during training. We developed a computer-based outpatient tracking system for prospective data collection of all outpatient encounters for use at (1) Officer Candidate School (OCS), Quantico; (2) Marine Corps Recruit Depot (MCRD), Parris Island; and (3) Recruit Training Command (RTC), Great Lakes. During the study period, 85.8% of OCS candidates (260 of 303), 72.4% of MCRD recruits (2,002 of 2,766), and 83.4% of RTC recruits (7,395 of 8,865) had at least one medical encounter during training. The most common category of medical encounters at all three sites was musculoskeletal injury, followed by respiratory and dermatological disorders. This study establishes high morbidity rates and identifies medical priorities for preventive interventions in Marine Corps and Navy female trainees.

Asymptomatic sexually transmitted disease prevalence in four military populations: application of DNA amplification assays for Chlamydia and gonorrhea screening.

The prevalence of asymptomatic chlamydial and gonococcal infections in male and female military populations was determined using urine-based ligase chain reaction DNA amplification assays (DAAs). Cross-sectional surveys in four military settings revealed an overall prevalence of asymptomatic chlamydial infection of 4.2% (56/1338). This included 3.4% (21/618) of Western Pacific shipboard US Marine Corps enlisted men; 5.2% (21/406) of male marines shore-based in Okinawa, Japan; 2.7% (5/183) of female enlisted US Navy subtender personnel in dry dock; and 6.9% (9/131) of shore-based female naval personnel in San Diego. No gonococcal infections were detected. All subjects were treated within 2 weeks of screening; none of them had progressed to symptomatic disease. General population-based screening for asymptomatic sexually transmitted diseases, and in particular chlamydial infection, can be successfully implemented using urine-based DAA tests. Benefits are maximized in a population in which compliance for follow-up therapy is high.

Western blot banding patterns of HIV rapid progressors in the U.S. Navy Seropositive Cohort: implications for vaccine development. Navy Retroviral Working Group.

Although human immunodeficiency virus (HIV) infection is progressive, the rate of decline in CD4+ lymphocyte counts varies. The role of immune system components in limiting HIV infection has yet to be defined, but a previous report on the U.S. Navy HIV Seropositive Cohort reported that strong reactivity in the anti-p55 (core precursor), p24 (core) and p53 (reverse transcriptase) Western blot bands was associated with higher CD4+ lymphocyte counts at the first clinical evaluation for HIV. The previous report examined the cross-sectional association between Western blot banding patterns and initial CD4+ lymphocyte counts. This report examines the association between these banding patterns in individuals who progressed rapidly as compared with patterns of patients who did not, based on their trends in repeated CD4+ lymphocyte counts as a marker of progression. Rapid and slower progressors were identified from a cohort of 3414 Navy and Marine Corps personnel who had a first positive HIV Western blot during 1986-1991. For purposes of this study, rapid progressors were defined as individuals whose CD4+ lymphocyte counts declined to < 500 cells/mm3 within 1 year of seroconversion. A total of 325 individuals met these criteria. A comparison group of 63 slower progressors also was identified; this group consisted of those whose CD4+ lymphocyte counts remained at > or = 500 cells/mm3 for a minimum of 5 years of follow-up after their first positive Western blot. Rapid progressors were slightly younger than slower progressors and were more likely to be never married but did not differ significantly from slower progressors in race or sex. Rapid progressors had weaker reactivity in the anti-p55 core precursor (P < 0.0001), p15 core (P < 0.01), gp41 transmembrane (P < 0.01) and p31 endonuclease (P < 0.05) bands on the Western blot. The odds ratio for rapid progressor status associated with weak or absent reactivity was 7.8 in the anti-p55 band and ranged from 2.0 to 3.2 in the anti-p31, p15, and gp41 bands. These associations remained significant after adjustment for age, race, and sex. The p55 association persisted in repeated Western blots during routine clinical evaluation during a period of 5 years after the first positive Western blot. It was concluded that several possible explanations may account for the weaker reactivity of rapid progressors: (i) weak anti-p55 reactivity might have been a marker of early immune system damage; (ii) high concentrations of p55 or related proteins in the serum may have bound the available anti-p55 antibodies in rapid progressors, making them difficult to identify on the Western blot; or (iii) lack of anti-p55, p15, gp41, or p31 reactivity might have allowed more rapid progression.

Detection of diverse HIV-1 genetic subtypes in the USA.

Of the nine genetic subtypes of HIV-1 that exist world wide, subtype B predominates in North America and Europe. Thus, most knowledge about HIV-1 and most vaccine development efforts are based on subtype B viruses. We document here the detection of HIV-1 subtypes A, D, and E in five US servicemen who acquired these non-subtype-B infections during overseas deployments. The dispersal of diverse HIV-1 subtypes into regions of the world with previously restricted genetic diversity may have important implications for the epidemiology of the epidemic and for the design and implementation of vaccine trials.

Syphilis and neurosyphilis in a human immunodeficiency virus type-1 seropositive population: evidence for frequent serologic relapse after therapy.

OBJECTIVE: To describe clinical and treatment aspects of syphilis infection among patients seropositive for the human immunodeficiency virus (HIV). PATIENTS AND METHODS: Results of serologic tests for syphilis, CD4+ T-lymphocyte counts, and clinical response to therapy were retrospectively monitored in 100 HIV-infected adults with syphilis from a tertiary-care military HIV program. RESULTS: Of the 1,206 HIV-infected patients, 100 (8.3%) in the cohort had syphilis; 61 patients were treated for active syphilis. Serologic or clinical relapse eventually occurred in 10 of the 56 treated patients (17.9%) with follow-up available; 7 of the 10 who relapsed had previously received high-dose intravenous or procaine penicillin therapy. Relapse occurred more than 12 months after initial therapy in 6 of 10 patients (60%) who experienced relapse; 5 patients experienced multiple relapses. The mean CD4+ T-lymphocyte count was not predictive of relapse. Patients with reactive cerebrospinal fluid (CSF) Venereal Disease Research Laboratory (VDRL) test titers (4 of 7 patients [57%]) or the rash of secondary syphilis (4 of 14 patients [29%]) were at highest risk of subsequent relapse or treatment failure when monitored for an average of 2 years. CONCLUSION: Standard penicillin regimens, including high-dose intravenous penicillin, transiently lowered serum VDRL titers in nearly all cases, but were sometimes inadequate in preventing serologic and clinical relapse in patients infected with HIV type-1, especially among those with secondary syphilis and reactive CSF VDRL titers. Careful long-term follow-up is essential, and repeated courses of therapy may be needed for patients infected with HIV type-1 who have syphilis.

The risk of human T cell leukemia virus and viral hepatitis infection among US Marines stationed in Okinawa, Japan.

The prevalence and incidence of human T cell leukemia virus type I/II (HTLV-I/II) and hepatitis A, B, and C virus infection were determined among US Marines stationed in Okinawa, Japan. Of 2875 personnel, 2 (0.07%) had antibody to HTLV-I/II. After 1-3 years, no HTLV seroconversions were observed, although 23% reported sexual contact with Okinawans. Of 1010 hepatitis-tested marines, 121 (12%) had antibody to hepatitis A virus (anti-HAV), 26 (2.6%) had antibody to hepatitis B core antigen (anti-HBc), and 2 (0.2%) had antibody to hepatitis C virus (anti-HCV). On follow-up, 1 subject seroconverted to anti-HAV, 8 to anti-HBc, and none to anti-HCV. Most marines with recent hepatitis B infection were young, single, and enlisted and had been on short deployments to other countries in Southeast Asia. Marines stationed in Okinawa are not at high risk for HTLV infection but are at increased risk for hepatitis B infection and should be considered for vaccination.

Tumor necrosis factor, interleukin-2, and interferon-gamma in adult varicella.

Adult varicella can be a severe illness complicated by pneumonia, encephalitis, or prolonged fever. This study measured levels of tumor necrosis factor (TNF)-alpha, interleukin-2 (IL-2), and interferon gamma (IFN-G) in a consecutive group of 31 adult varicella patients presenting within 24 hours of rash onset. All cytokines were assayed using an ELISA technique. TNF-alpha was detectable in 71% of patients with a mean level of 52 pg/ml. IL-2 was detectable in 29% with a mean level of 1040 pg/ml. IFN-gamma was detectable in only 9%. There was no correlation between TNF, IL-2, or IFN-G level and clinical severity as determined by duration and severity of cutaneous findings, duration of fever, frequency of hepatitis, or thrombocytopenia.