The City Clinic Cohort Study: Hepatitis B, HTLV-III/LAV, and CDC AIDS Project 24.

Anticipating the availability of a safe vaccine, scientists at the Center for Disease Control (CDC) planned for a multicenter study of the prevalence, incidence, and efficacy of an experimental vaccine for hepatitis B in 1977, conducted the study among homosexual male volunteers in five collaborating sexually transmitted infection (STI) clinics in the United States from April 1978 through 1980, and concluded that the candidate vaccine was highly efficacious in preventing infections with the hepatitis B virus. Then something completely unexpected and portentous happened. Some successfully vaccinated as well as other homosexual and bisexual men began to show signs and symptoms of a rare cancer, Kaposi's sarcoma, and opportunistic infections typically associated with severe immunodeficiency. As early as October 1983, members of the Hepatitis B study cohort in San Francisco were invited to return to the city STI clinic for further examinations, testing, and confidential interviews about their sexual and other practices. CDC AIDS Project 24 was designed to help describe the natural history of AIDS, define risk factors, and predict future trends. It produced some of the earliest and most convincing scientific evidence about the seriousness and extent of the AIDS epidemic among homosexual and bisexual men in the United States. How the City Clinic Cohort Study came about and evolved is the focus of this commentary.

RESUMEN: Anticipando la disponibilidad de una vacuna segura, los científicos del Centro para el Control de Enfermedades (CDC) planearon un estudio multicéntrico sobre la prevalencia, incidencia y eficacia de una vacuna experimental contra la hepatitis B en 1977; realizaron el estudio entre voluntarios varones homosexuales en cinco colaboraron con clínicas de infecciones de transmisión sexual (ITS) en los Estados Unidos desde abril de 1978 hasta 1980, y concluyeron que la vacuna candidata era muy eficaz para prevenir infecciones por el virus de la hepatitis B. Entonces sucedió algo completamente inesperado y portentoso. Algunos hombres vacunados con éxito, así como otros hombres homosexuales y bisexuales, comenzaron a mostrar signos y síntomas de un cáncer poco común, el sarcoma de Kaposi, e infecciones oportunistas típicamente asociadas con una inmunodeficiencia grave. Ya en octubre de 1983, se invitó a los miembros de la cohorte del estudio de la hepatitis B en San Francisco a regresar a la clínica de ITS de la ciudad para realizar más exámenes, pruebas y entrevistas confidenciales sobre sus prácticas sexuales y de otro tipo. El Proyecto 24 del CDC sobre SIDA fue diseñado para ayudar a describir la historia natural del SIDA, definir factores de riesgo y predecir tendencias futuras. Produjo algunas de las primeras y más convincentes pruebas científicas sobre la gravedad y el alcance de la epidemia de SIDA entre los hombres homosexuales y bisexuales en los Estados Unidos. El tema central de este comentario es cómo surgió y evolucionó el estudio de cohorte de City Clinic.

Confronting AIDS in the Early 1980s: Biomedicine, Public Health, and the Fourth Estate.

Detection of a mysterious and fatal disease among young, previously healthy, homosexual men in spring 1981 warranted a rapid and effective response. An adequate response failed to materialize during the first 5 years of the AIDS pandemic. The failure of biomedicine, public health, and The Press to stop the outbreak was attributed by Randy Shilts to institutional failures. This commentary considers the possibility that organizations, agencies, and authorities failed to safeguard the public's health because they succeeded in carrying out their appropriate tasks of (1) meticulously conducting systematic, scientific, research, (2) cautiously reporting evidence-based observations and alternative interpretations, and (3) carefully exercising rigorous controls over unauthorized and potentially wasteful spending. As practiced in the early 1980s by the National Institutes of Health, Centers for Disease Control and Prevention, and major newspapers and other media outlets, essential features of biomedicine, public health, and The Press inhibited a rapid and effective response.

RESUMEN: La detección de una enfermedad misteriosa y mortal entre hombres homosexuales jóvenes, previamente sanos, en la primavera de 1981 justificó una respuesta rápida y efectiva. Una respuesta adecuada no se materializó durante los primeros cinco años de la pandemia del SIDA. El fracaso de la biomedicina, la salud pública y The Press para detener el brote fue atribuido por Randy Shilts a fallas institucionales. Este comentario considera la posibilidad de que las organizaciones, agencias y autoridades no hayan salvaguardado la salud pública porque lograron llevar a cabo sus tareas apropiadas de (1) realizar meticulosamente investigaciones sistemáticas, científicas, (2) informar cautelosamente observaciones basadas en evidencia e interpretaciones alternativas, y (3) ejercer cuidadosamente controles rigurosos sobre gastos no autorizados y potencialmente derrochadores. Como se practicó a principios de la década de 1980 por los Institutos Nacionales de Salud, los Centros para el Control y la Prevención de Enfermedades y los principales periódicos y otros medios de comunicación, las características esenciales de la biomedicina, la salud pública y la prensa inhibieron una respuesta rápida y efectiva.

Early Detection of Severe Acute Respiratory Syndrome Coronavirus 2 Variants Using Traveler-based Genomic Surveillance at 4 US Airports, September 2021-January 2022.

We enrolled arriving international air travelers in a severe acute respiratory syndrome coronavirus 2 genomic surveillance program. We used molecular testing of pooled nasal swabs and sequenced positive samples for sublineage. Traveler-based surveillance provided early-warning variant detection, reporting the first US Omicron BA.2 and BA.3 in North America.

The First 40 Years of AIDS: Promising Programs, Limited Success.

HIV-prevention program planning, implementation, and evaluation began in the United States shortly after reports of a mysterious, apparently acquired, immune deficiency syndrome appeared in summer 1981. In San Francisco, New York City, and elsewhere, members of LGBT communities responded by providing accurate information, giving support, and raising money. During the first decade of the AIDS pandemic (1981-1990), social and behavioral scientists contributed by designing theory-based and practical interventions, combining interventions into programs, and measuring impact on behavior change and HIV incidence. In the second decade (1991-2000), federal, state, and local agencies and organizations played a more prominent role in establishing policies and procedures, funding research and programs, and determining the direction of intervention efforts. In the third decade (2001-2010), biomedical interventions were prioritized over behavioral interventions and have dominated attempts in the fourth decade (2011-2020) to integrate biomedical, behavioral, and structural interventions into coherent, efficient, and cost-effective programs to end AIDS.

RESUMEN: La planificación, implementación y evaluación de programas de prevención del VIH comenzaron en los Estados Unidos poco después de que aparecieran informes de un misterioso síndrome de inmunodeficiencia aparentemente adquirida en el verano de 1981. En San Francisco, la ciudad de Nueva York y otros lugares, los miembros de las comunidades LGBT respondieron proporcionando información precisa, apoyo y recaudación de fondos. Durante la primera década de la pandemia del SIDA (1981­1990), los científicos sociales y del comportamiento contribuyeron diseñando intervenciones prácticas y basadas en la teoría, combinando intervenciones en programas y midiendo el impacto en el cambio de comportamiento y la incidencia del VIH. En la segunda década (1991­2000), las agencias y organizaciones federales, estatales y locales desempeñaron un papel más destacado en el establecimiento de políticas y procedimientos, la financiación de investigaciones y programas y la determinación de la dirección de los esfuerzos de intervención. En la tercera década (2001­2010), las intervenciones biomédicas se le dieron prioridad sobre las intervenciones conductuales y han dominado los intentos en la cuarta década (2011­2020) de integrar intervenciones biomédicas, bio conductuales y estructurales en programas coherentes, eficientes y económicos para acabar con el SIDA.

Are Men Being Left Behind (Or Catching Up)? Differences in HPV Awareness, Knowledge, and Attitudes Between Diverse College Men and Women.

The aim of this cross-sectional survey was to assess awareness, knowledge, and attitudes in regard to human papillomavirus (HPV) and vaccination against HPV among college students. From 2015 to 2017, 386 diverse undergraduates were recruited from a south Florida university. A survey, part of which was researcher developed, of HPV awareness, knowledge, and attitudes was conducted. The majority (84%) of participants had heard of HPV, and 70% had favorable attitudes toward vaccination. Only 28% of men and 55% of women had received ≥1 dose vaccine (p = .01), and 4% of all participants reported that they had received 3 doses. Those with ≥1 dose (n = 123, 40.1%) were more knowledgeable about HPV (p = .01). High knowledge scores were recorded for 30% of respondents and were strongly associated with HPV vaccine initiation among both men and women (p < .001) and perceived knowledge among women only (p < .001). Negative attitudes toward HPV vaccine acceptance were associated with low knowledge scores (p = .01) and undervaccination (p < .001). Vaccinated women (n = 95) were over seven times more likely than were unvaccinated women (n = 115) to report positive vaccine attitudes (relative risk = 7.1). HPV vaccination status was not associated with vaccine attitudes among men. HPV knowledge and vaccine uptake remain problematic among college students, and deficits in both are associated with negative HPV vaccine attitudes. Although the knowledge gap is narrowing, HPV vaccination efforts should target young men, as HPV-related cancer morbidity continues to rise in men.

Improving Human Papillomavirus-Related Knowledge and Attitudes Among Ethnically Diverse Young Adults.

Purpose: To make baseline comparisons and evaluate the efficacy of an intervention designed to improve human papillomavirus (HPV) and HPV vaccine awareness, knowledge, and attitudes among ethnically diverse participants. Methods: Design: Pre- and post-intervention surveys. Setting: An urban, Hispanic-Serving South Florida university. Subjects: Three hundred eighty-seven diverse college students attending a gender studies course. Intervention: Students received a brief educational message designed to improve HPV-related knowledge and attitudes. Baseline and follow-up survey data were collected. Measures: Outcome measures included baseline and follow-up awareness of HPV, perceived knowledge of HPV and HPV vaccination, measured knowledge score, vaccine attitudes, and doses of HPV vaccine received. Analysis: Chi-square, analysis of covariance (ANCOVA), and Wilcoxon rank-sum tests were used to compare baseline differences and evaluate the efficacy of the intervention. Results: Hispanic participants had more positive attitudes toward HPV vaccination (62% vs. 44%, p=0.009) and were more willing to become vaccinated (66% vs. 46%, p=0.02) than non-Hispanic participants at baseline. Hispanic women (48%) were more likely to have initiated HPV vaccination than Hispanic men (27%, p=0.006). At baseline, only 30% of participants scored ≥4/7 points in knowledge. Participants' HPV knowledge improved by 41% after the intervention, with no difference by ethnicity in the post-intervention score. Conclusion: The intervention was useful in improving HPV-related knowledge and attitudes among diverse college students. Future studies should examine barriers to vaccination among ethnic minorities.

And the Band Played on: Before and After.

In fall 1987, Randy Shilts published his second book, "And the Band Played on: Politics, People, and the AIDS Epidemic." The jacket proclaimed that "the epidemic spread widely because the federal government put budget ahead of the nation's welfare; health authorities placed political expediency before the public health; and scientists were more often more concerned with international prestige than saving lives." In the Prologue Shilts wrote, "The bitter truth was that AIDS did not just happen to America-it was allowed to happen by an array of institutions, all of which failed to perform their appropriate tasks to safeguard the public health." This essay reviews the controversial book published by Randy Shilts 30 years ago in light of some of the events that have followed. First, the context and content of the book-and reactions to its publication-are summarized. Secondly, several major developments after publication of the book are noted. Thirdly, a critical assessment of the author and his work is offered in an era when some politicians and physicians in the United States are imagining "an AIDS-free generation."

A needs assessment of health department employees in Puerto Rico and Florida.

Public health training centers were established to enhance competencies in skills required to meet 21st-century public health challenges. In 2011, the Puerto Rico-Florida Public Health Training Center conducted surveys to assess the training needs of two populations of public health workers serving Hispanic communities: Florida Department of Health employees and workers at the regional and central offices of the Puerto Rico Department of Health. The two surveys were similar, but not identical in content and administration. A 52.6% response rate was achieved in the Commonwealth of Puerto Rico, where limited computer access necessitated use of a pen-and-paper survey. A 20.7% response rate was achieved in Florida, where an online survey was used and incomplete responses were problematic. Puerto Rico respondents (n = 1,414) were similar in age (Mdn age = 48 years) to Hispanic Florida respondents (n = 546, Mdn age =45 years). They also reported higher levels of academic achievement and more years of experience in public health. Nevertheless, self-assessed public health competency scores were in the low- to mid-range for Hispanic respondents in both locales. Although self-assessed training priorities differed, Hispanic employees in both jurisdictions preferred hands-on and face-to-face training to distance learning. Findings indicate a need for training based on adult learning theory, targeted to entry-level employees, and addressing the top five self-assessed training needs, especially health promotion and disease prevention and public health law and policy, which emerged as priority training areas in both survey populations.

Ethnic differences in HIV risk perceptions and behaviors among Black 18-39 year-old residents of Broward County, Florida.

The study assessed ethnic differences in the perceived risks of HIV infection, sexual experiences, and HIV-antibody testing histories among Black populations in Broward County, Florida. Data were analyzed for 2,731 well-characterized survey respondents 18-39 years old who indicated they were African Americans, Caribbean Islanders, English-speaking, or Creole-speaking Haitians. Creole-speaking Haitians were least likely to consider themselves at risk of HIV infection, report using condoms in the last 12 months, and indicate that they had ever been tested for HIV. English-speaking Haitians were more likely than African Americans to report never engaging in sexual intercourse and were less likely to have ever been tested for HIV. English-speaking Caribbean Islanders reported preventive behaviors similar to those of African Americans, but had lower perceptions of HIV risk and were less likely to have ever been tested. Health promotion programs designed to improve HIV prevention practices must appreciate social and cultural differences among Black populations.

Coalition contract management as a systems change strategy for HIV prevention.

Racial and Ethnic Approaches to Community Health (REACH) 2010 provided a unique opportunity for minority community-based organizations (CBOs) to work together to eliminate disparities in HIV disease. A coalition was formed in Broward County to respond to the REACH 2010 program announcement, a university was chosen to coordinate efforts, and contracts were negotiated with CBO partners to develop, implement, and evaluate a community action plan. Contract management provided stability, focus, and a mechanism for coalition partners to measure progress toward achieving project objectives. By emphasizing documentation as well as the delivery of services, however, contract conditions also placed a heavy burden on educational outreach workers, restricted the reimbursable activities of member organizations, and created friction between minority agencies and university staff. Although the coalition met many of its objectives, the introduction and enforcement of a mutually agreed on set of rules and obligations as a way of promoting systems change in Broward County failed to make a lasting impact among community partners. CBOs continued to compete with one another for HIV prevention project funding and stopped collaborating as closely with another when federal support for our REACH 2010 community demonstration project ran out.

AIDS-related stigma among Black and Hispanic young adults.

Telephone surveys with national probability samples of English-speaking adults have suggested that popular support for punitive policies toward people living with HIV/AIDS (PLWHA) declined in the 1990s, but AIDS-related stigma persists in the United States. Our aim was to assess the prevalence and impact of AIDS-related stigma in non-Hispanic Black and Hispanic communities. A cross-sectional computer-assisted telephone-interview survey was conducted in summer 2003 with African-American, Afro-Caribbean, Haitian, and Hispanic 18-39 year-old residents of 12 high AIDS-incidence areas in Broward County, Florida. Stigma items were adopted from national surveys, but interviews were conducted in Spanish and Haitian Creole as well as in English. Stigma scores were higher than those reported for national samples, especially among Haitians interviewed in Creole. AIDS-related stigma was associated with never receiving an HIV-antibody test (adjusted odds ratio [AOR] = 0.78, 95% confidence interval [CI]: 0.62-0.99, P = .046), an elevated perception of HIV risk (AOR = 1.32, 95% CI: 1.01-1.73, P = .045) and a failure to participate in HIV-prevention efforts (AOR = 0.53, 95% CI: 0.34-0.85, P = .008). Interventions are needed to mitigate the pernicious effects of AIDS-related stigma.

Identifying HIV risk-reduction strategies for Hispanic populations in Broward County.

PURPOSE: To improve the effectiveness of behavioral interventions for Hispanic young adults, we studied their perceived risks for HIV infection, lifetime and more recent sexual experiences, use of condoms, and HIV-antibody testing histories. METHODS: Logistic regression was used to analyze computer-assisted telephone-interview surveys of 1,596 randomly selected Hispanic residents of 12 high AIDS-incidence ZIP-code areas. RESULTS: After we controlled for gender, age, marital status, educational attainment, and language of preference, differences were found by country of origin. Those coming from Peru (adjusted odds ratio [AOR]=3.45; 95%CI=1.85-6.43) and Colombia (AOR=1.94; 95%CI=1.12-3.36) were more likely than U.S.-native Hispanics to perceive their risk of acquiring HIV as above average. Sexually active Mexicans (AOR=1.80; 95%CI=1.04-3.10) were significantly more likely than U.S. natives to have used a condom in the past 12 months. Young adults coming from Puerto Rico (AOR=0.55; 95%CI=0.33-0.91) were less likely than U.S.-native Hispanics to have ever been tested for HIV. Virginity and sexual abstinence were unrelated to country of origin, but respondents interviewed in Spanish were more likely than those interviewed in English to be sexually active (AOR=2.57; 95%=1.39-4.75). CONCLUSIONS: To maximize the impact of behavioral interventions, risk-reduction programs must adjust for social and cultural differences within the Hispanic-American population.

Short-term impact evaluation of a social marketing campaign to prevent syphilis among men who have sex with men.

OBJECTIVES: We carried out an independent short-term impact evaluation of a social marketing campaign designed to reduce syphilis infections among men who have sex with men in south Florida in 2004. METHODS: Venue-based surveys were conducted shortly after the campaign began and 6 months later to assess changes in exposure to campaign materials, awareness, knowledge about syphilis, perceptions of risk, sexual behavior, clinic visits, and testing and treatment for syphilis among participants. RESULTS: Exposure to social marketing campaign materials increased from 18.0% at baseline to 36.5% at follow-up (P< .001). Awareness of syphilis and perceptions of risk increased among Broward County residents but not among Miami-Dade County residents. Risky sexual practices and patterns of recreational drug use did not change. No significant increases in knowledge, clinic visits, or testing or treatment for syphilis among participants were detected over the 6-month study period. CONCLUSIONS: None of the campaign objectives were fully met. The interventions were insufficient to produce a significant impact among men who have sex with men in south Florida.

HIV risk reduction among young minority adults in Broward County.

We examined changes in perceptions of HIV risk, abstinence, condom use, and intentions to use condoms for disease protection among African American, Hispanic, Haitian, and Afro-Caribbean unmarried and married men and women living in Broward County, Florida. Data were collected through computer-assisted telephone interview surveys conducted during 2001, 2002, and 2003 with cross-sectional probability samples of 18-39 year old residents of 12 high AIDS incidence ZIP code areas. Perceptions of HIV risk increased over time for men, but not for women. Unmarried Haitian women 18-22 years old were most likely to report abstinence. Condom use during the last 12 months increased among sexually active respondents. Among residents reporting exposure to project interventions, condom use increased from 53.6% in 2001 to 64.7% in 2002 and 71.6% in 2003. HIV-prevention programs should (1) consider locally collected data; (2) take into account cultural, living situation, and other significant differences; and (3) be evaluated to assess differentiated impact.

Risky sexual behaviors associated with recreational drug use among men who have sex with men in an international resort area: challenges and opportunities.

South Florida is home to a highly transient population of approximately 145,000 men who have sex with men (MSM) and annually hosts over 1.8 million gay and bisexual visitors. To develop more effective interventions for HIV/sexually transmitted infections (STI) prevention in this setting, we conducted a cross-sectional study of recreational drug use and risky sexual behaviors among MSM. A standardized, self-administered questionnaire, reviewed and approved by a university Institutional Review Board, was offered to men 18 years of age and older who reported ever having sex with a man. Men were approached on weekends in five diverse locations in Miami-Dade County and five in Broward County in winter 2004. An honorarium of $10 was offered to those who completed and returned a questionnaire. Of 407 participants, 115 men (28%) lived in Miami-Dade, 147 (36%) lived in Broward, 46 (11%) lived in another county in south Florida, and 99 (24%) lived elsewhere. Overall, 32% reported using one or more "club drugs" in the past year. Club drug use was highly associated with unprotected anal intercourse (UAI) (P < .001). MSM residing outside of south Florida were more likely than local residents to report using cocaine and ketamine and engaging in unprotected receptive anal intercourse (URAI) in the past month (P = .03). Tourists may be even more likely than residents to engage in risky sexual behaviors and use certain recreational drugs. Interventions must be developed, implemented, and evaluated that take into account the unique characteristics of international resort areas.

Community planning, HIV prevention, and a needs assessment for men who have sex with men: the South Beach Health Survey.

OBJECTIVE: The objective of this study was to plan for a series of culturally competent and sexually appropriate public health interventions for a highly mobile population of men who have sex with men (MSM). GOAL: The goal of this study was to conduct a comprehensive needs assessment. STUDY: A cross-sectional survey with a multistage probability sample of unmarried adult MSM living in households was conducted. RESULTS: A total of 918 residential units were screened, 154 eligible men were identified, and 140 mostly white (56%) and Hispanic (34%) MSM (median=33.5 years old) were enrolled (90.9% response rate). Almost half (47%) reported engaging in unprotected anal intercourse in the previous 12 months. Drug use was common. Almost one third (31.0%) tested positive for the HIV antibody. Estimated annual incidence of HIV infection was 10.0%. CONCLUSIONS: Population-based HIV antibody testing revealed a remarkably high annual incidence of HIV infection. A community-based organization was transformed to implement a social marketing campaign and provide other disease prevention services for MSM.

HIV testing among men who have sex with men: how often should one test?

HIV counseling and testing has been a cornerstone of AIDS prevention strategies, with men who have sex with men being specifically targeted for the counseling and testing. Unfortunately, it appears that exposure to HIV counseling and testing has little effect on the behaviors of those who test negative. The Centers for Disease Control and Prevention recently altered its recommendations on when and how often men who have sex with men should undergo testing for HIV and other sexually transmitted diseases, now recommending annual testing for sexually active men who have sex with men, with even more frequent testing for men who have sex with men who engage in highest risk behaviors. Using data from our study, we evaluated the new recommendations with respect to HIV testing. Overall, 81% of the men who have sex with men in our sample reported never having tested positive for HIV. Among these men who have sex with men in South Beach nearly 8% tested positive on their current test. Slightly more than half of the men who tested positive on their current test had not been tested in the past 12 months; slightly fewer than half reported they had tested negative within the prior 9 months. Reporting multiple (4 or more) anal sexual partners during the past 12 months was significantly associated with a positive test result. Our results support the new CDC guidelines regarding more frequent testing for sexually active men who have sex with men, with having a high number of anal partners being a significant indicator of need for testing more often than annually in our population.

Eliminating disparities in HIV disease: community mobilization to prevent HIV transmission among Black and Hispanic young adults in Broward County, Florida.

A coalition led by public health professionals adopted the PRECEDE-PROCEED model for community planning and health promotion to eliminate local disparities in HIV disease. Discussion groups and other formative evaluation activities conducted during the first year of the project maximized input from community members and community-based organizations. Twelve of 53 ZIP-code areas, which accounted for 73% of reported AIDS cases among Black and Hispanic young adults (18 to 39 years) from 1994 through 1999, were selected as the primary sites for intervention. Horizontal outreach to residents, vertical outreach to stakeholders and gatekeepers, strategic communications, and capacity building and infrastructure development, were chosen as the most promising activities to promote behavioral and social change. Results from baseline computer-assisted telephone-interview (CATI) surveys completed with 2,011 community residents in 2001, and first-year follow-up interviews with 2,381 in 2002, indicated that: awareness of program efforts had increased from 5.4% in 2001 to 6.7% in 2002; recognition of the extent of the HIV/AIDS problem had increased from 27.5% in 2001 to 35.3% in 2002; and participation in HIV-prevention efforts had increased significantly. Interventions are reaching the target audience, informing young adults of the risks of HIV infection, and encouraging them to take ownership and action.