Indinavir did not increase the short-term risk of adverse cardiovascular events relative to nucleoside reverse transcriptase inhibitor therapy in four phase III clinical trials.

A retrospective person-time analysis of the randomized and non-randomized extension phases of four phase III trials was performed to assess the incidence of adverse cardiovascular events in 2680 HIV-infected patients receiving indinavir or nucleoside reverse transcriptase inhibitor therapy, or both. The observed rate of cardiovascular events was not increased in patients receiving indinavir-based regimens compared with therapy without a protease inhibitor. Extrapolation of these findings is limited by the brief length of therapy and the small number of cases.

Strengthening HIV prevention: application of a research-to-practice framework.

As the HIV epidemic continues to affect at-risk and vulnerable populations, providers strive to improve prevention programs, in part by seeking new interventions with greater effects. Although interventions with scientific evidence of effectiveness are vital to this effort, many challenges limit access to research products. We examine key challenges and offer a framework for moving research to practice, one in which research steps are linked to practice steps and all these activities take place in a complex and dynamic environment. The Replicating Effective Programs (REP) project of the Centers for Disease Control and Prevention and other technology transfer activities illustrate the operation of this framework for HIV prevention. Further actions to improve technology transfer are called for. These include reducing time from study design to practice; learning from field-based implementations; providing guidance about fidelity to, and tailoring of, science-based interventions; improving linkages among consumers, providers, and researchers; and seeking additional resources.

Prevalence of sexual and drug-related HIV risk behaviors in the U.S. adult population: results of the 1996 National Household Survey on Drug Abuse.

CONTEXT: Data on the prevalence of HIV risk behavior that are representative of the general population are needed to help evaluate the effectiveness of prevention programs. OBJECTIVE: To use data from a large national interview survey to make estimates of the prevalence of sexual and drug-related HIV risk behaviors in the adult population of the United States. DESIGN: Nationally representative cross-sectional survey with in-person interviews collecting information on drug use and sexual behavior. SETTING AND PARTICIPANTS: 12,381 U.S. adults aged between 18 and 59 who were respondents to the 1996 National Household Survey on Drug Abuse, as part of sample of the noninstitutionalized population. Interviews took place in respondents homes using face-to-face interviewer-administered and self-administered questionnaires. RESULTS: In total, 2.8% of respondents were classified as having increased risk for HIV through sexual behavior; this represents 3.9 million persons. 1.7% reported some degree of risk through drug-related behaviors, representing 1.2 million persons. 3.5% of adults (5 million persons) were found to have some degree of HIV risk from sexual or drug-related behavior. Persons who were at risk through drug behavior were much more likely than others to be at risk through sexual behavior. Condom use was not related to HIV risk, although having a recent HIV test was found to be. Among those who reported some behaviors that placed them at increased risk for HIV infection, only 22% used a condom the last time they had sex with a regular partner. CONCLUSIONS: The high rate of sexual risk behavior on the part of drug users suggests increasing condom use for this group should be a priority goal for programs, especially condom use with main partners. Survey work needs to be continued and improved to make it possible to assess the impact of successful local prevention efforts on national rates of HIV risk behavior.

Condom use and HIV risk behaviors among U.S. adults: data from a national survey.

CONTEXT: How much condom use among U.S. adults varies by type of partner or by risk behavior is unclear. Knowledge of such differentials would aid in evaluating the progress being made toward goals for levels of condom use as part of the Healthy People 2000 initiative. METHODS: Data were analyzed from the 1996 National Household Survey of Drug Abuse, an annual household-based probability sample of the noninstitutionalized population aged 12 and older that measures the use of illicit drugs, alcohol and tobacco. The personal behaviors module included 25 questions covering sexual activity in the past year, frequency of condom use in the past year, circumstances of the last sexual encounter and HIV testing. RESULTS: Sixty-two percent of adults reported using a condom at last intercourse outside of an ongoing relationship, while only 19% reported using condoms when the most recent intercourse occurred within a steady relationship. Within ongoing relationships, condom use was highest among respondents who were younger, black, of lower income and from large metropolitan areas. Forty percent of unmarried adults used a condom at last sex, compared with the health objective of 50% for the year 2000. Forty percent of injecting drug users used condoms at last intercourse, compared with the 60% condom use objective for high-risk individuals. Significantly, persons at increased risk for HIV because of their sexual behavior or drug use were not more likely to use condoms than were persons not at increased risk; only 22% used condoms during last intercourse within an ongoing relationship. CONCLUSIONS: Substantial progress has been made toward national goals for increasing condom use. The rates of condom use by individuals at high risk of HIV need to be increased, however, particularly condom use with a steady partner.

PIP: The 1996 US National Household Survey on Drug Abuse obtained information on a comprehensive set of sex- and drug-related HIV risk behaviors. The sample was comprised of 9270 adults 18-59 years of age. A total of 21% of respondents (12.1% of married and 40.4% of unmarried adults) reported condom use in their most recent sexual encounter. Condoms were used by 19% of those whose last sexual intercourse occurred within a relationship compared with 62% of those whose last intercourse occurred outside of a relationship. Condom use in the context of a committed relationship was highest among respondents who were 18-25 years old (36.3%), Black (29.9%), low-income (24.2%), and from large metropolitan areas (21.2%) and among those with 2 or more sexual partners in the past year (35.3%). In contrast, condom use at last intercourse outside of an ongoing relationship was higher among males (65.3%), college graduates (66.2%), residents of the northeastern US (73.9%), those living in large metropolitan areas (68.9%), and those with two or more partners (65.5%). When the type of relationship was controlled, adults with HIV risk factors (homosexual sex, 6 or more partners, sex with HIV-infected persons, exchange of sex for drugs or money, use of illegal injection drugs in the past 3 years, crack cocaine use during the past year) were not significantly more likely to use condoms than those without these risk factors. Among individuals with one or more sex- or drug-related HIV risk factor, 22% used condoms during last intercourse within an ongoing relationship and 59.5% used condoms at last coitus in a casual relationship. Among adults with no such risk factors, these rates were 18.6% and 62.9%, respectively. Adoption of condom use by high-risk individuals must be increased, particularly with steady partners.

Influence of behavioral and social science on public health policymaking.

Public health policies are important guiding principles that serve to shape the well-being of individuals, groups, and society. Behavioral and social scientists can play key influential roles in public health policymaking. The actors and processes involved in setting public health policy are described, and several substantive examples of public health decision making are discussed, emphasizing HIV prevention policy experiences at the Centers for Disease Control and Prevention. The significant influence of behavioral and social science in each of these examples is identified and critiqued. Challenges to further integration of behavioral science and public health policy are identified, and potential solutions are proposed.

Male bisexual behavior and HIV risk in the United States: synthesis of research with implications for behavioral interventions.

This paper reviews recent literature on male bisexuality and HIV risk and suggests new directions for intervention and research in the United States. AIDS case reports and behavioral studies based on convenience samples suggest that behaviorally bisexual men use condoms inconsistently with male and female partners, seldom disclose their bisexuality to their female partners, and are more likely than exclusively homosexual men to report multiple HIV risk behaviors. Male bisexuality may present greatest HIV risk in the context of (a) male prostitution, (b) injecting drug use, (c) sexual identity exploration, and (d) culturally specific gender roles and norms such as those that may characterize some African American and Hispanic communities in the United States. We review individual and community level interventions to reach men within these four contexts as well as the larger population of bisexual men. We also suggest a heuristic model to encourage additional research examining multiple dimensions of bisexual behavior and HIV risk.

Detection of proviral human T-cell lymphotrophic virus type I DNA in mouthwash samples of HAM/TSP patients and HTLV-I carriers.

Human T-cell lymphotrophic virus type I (HTLV-I), is a member of the oncogenic retroviruses family endemic in several parts of the world and also recently identified in the Jewish Mashhadi population who immigrated from Iran to Israel. The virus is the causative agent of adult T-cell leukemia (ATL) and a chronic myelopathy known both as tropical spastic paraparesis (TSP) or HTLV-I associated myelopathy (HAM). The known modes of HTLV-I transmission are by sexual intercourse, from mother to child in breast milk, via blood transfusion, and by sharing of needles by parenteral drug users. In the present study we examined the presence of HTLV-I provirus genomic DNA by nested polymerase chain reaction (PCR) and by DNA hybridization in mouthwash samples obtained from 13 Mashhadi-born Iranian Jews with spastic paraparesis associated with HTLV-I, 4 Mashhadi-born Iranian Jews asymptomatic carriers for HTLV-I and 21 healthy controls. Proviral HTLV-I DNA was detected by mouthwash PCR in 12 of 17 HTLV-I infected subjects (71%) but in none of 21 controls. Proviral DNA was also detected in mouthwash samples using HTLV-I probe by dot blot hybridization assay. The presence of HTLV-I proviral DNA in whole saliva may suggest a possible transmission of the virus via saliva and explain the increased rate of infection in elderly Mashhadi-Jewish population.

Stress, coping, and attitudes toward HIV treatment in injecting drug users: a qualitative study.

An exploratory study was conducted with 27 injecting drug users (IDUs) on psychosocial factors (stress, coping reactions, and attitudes toward HIV illness and treatment) which are relevant to treatment acceptance and adherence. A semi-structured interview was used to collect qualitative data in a sample of 13 seropositive and 14 seronegative subjects. The results indicated a range of HIV-specific stressors such as social stigma, uncertainty about the future, disclosure of seropositive status, and monitoring of HIV illness. Seeking of social support, relapse to substance abuse, and mental disengagement were the most common coping reactions reported by the sample; there was a lack of behavioral, problem-focused responses. The study also provided descriptive information on attitudes toward HIV treatment, including fatalism, optimism (hope and control), and ambivalence regarding treatment efficacy. Clinical implications and suggestions for future research are discussed.

HIV/AIDS knowledge and high risk sexual practices among southern California Vietnamese.

OBJECTIVES: Vietnamese immigration to the U.S. since the conclusion of the Vietnam war has been substantial and in Orange County, CA, Vietnamese Americans comprise 3% of the population (the largest community in the US). Our objective was to collect data on the HIV/AIDS knowledge, attitudes and self-reported high risk behaviours within this community. METHODS: A survey instrument was administered anonymously in Vietnamese to 532 respondents in their homes. Individuals from three population strata were randomly sampled: men 18 to 35 years old (N = 193); men 36 to 45 years old (N = 137); and women 18 to 35 years old (N = 202). Data were gathered on: (1) degree of acculturation; (2) knowledge and attitudes towards HIV/AIDS; and (3) self-reported sexual and other high risk practices. RESULTS: Survey data indicated that 38% of respondents were very worried about themselves and 83% were worried about a family member getting AIDS. Knowledge about actual modes of HIV transmission was generally accurate, but a substantial minority still believed that HIV can be transmitted through casual contact, and 68% from needles used in hospitals. Women demonstrated less accurate knowledge than men on five key items. Quarantine of the HIV infected was agreed to by 45%. Twenty-nine percent did not believe that the epidemic would affect them personally, and 49% stated that they did not have enough information about AIDS to protect themselves. Regarding sexual practices, 31% reported never having had sex. Of the others, 8% had two or more sexual partners in the prior 12 months. No same sex behaviour was reported. Six percent of men had visited a female prostitute; of these, 24% had visited 2 or more in the prior 12 months; half of encounters in this time period were outside the US. Substantial percentages of sexually active, unmarried respondents indicated that they never use (17-40%) or only sometimes use (10-32%) condoms. Less than 1% had used injection drugs. CONCLUSIONS: Education should be targeted at the Vietnamese community of southern California to improve knowledge that HIV cannot be contracted through casual contact, to convey information about methods for self-protection, and to reduce high risk sexual practices such as unprotected sex, sex with multiple partners and sex with prostitutes.

HIV risk behavior among Peace Corps Volunteers.

OBJECTIVE: To describe HIV risk behaviors among Peace Corps Volunteers (PCV) and to examine correlates of sexual risk behaviors. METHOD: Cross-sectional data were collected from 1242 randomly selected PCV serving in 28 countries in 1991. PCV reported the frequency of specific risk behaviors in self-administered questionnaires, which were completed anonymously and returned to the Centers for Disease Control and Prevention. RESULTS: Non-sexual HIV risk behaviors were rarely reported by PCV. Sixty-one per cent of the 1080 PCV who answered questions about sexual behavior during their Peace Corps service reported having at least one sex partner. Sixty per cent of PCV had another PCV partner, 39% had a host-country national partner, and 29% had a non-PCV expatriate partner. Overall, less than one-third (32%) of unmarried PCV used condoms during every episode of sexual intercourse; more frequent use was reported in relationships with non-steady and (for male PCV) host-country national partners. Among male PCV, condom use was positively related to lower alcohol use and the belief that HIV was a problem in the host country. Female PCV reporting more condom use with male partners were younger and had fewer partners than those reporting less use. CONCLUSION: These data indicate that PCV are at risk for acquiring HIV through unprotected vaginal intercourse. All persons who become sexually active with new partners while travelling or living abroad should be encouraged to use condoms consistently.

PIP: At least 10 former Peace Corps volunteers are believed to have acquired human immunodeficiency virus (HIV) during their time of service. To assess HIV risk behavior among current Peace Corps volunteers, cross-sectional data were collected from 1242 randomly selected volunteers in 28 countries in 1991. 474 (38%) were stationed in sub-Saharan Africa. Non-sexual HIV-related risk activities included injection from local health facilities (209) and ears or body parts pierced (59). Of the 1018 volunteers who were unmarried or not living with a spouse, 61% of men and 60% of women indicated they had at least one sexual partner during their time of service; 30% and 20%, respectively, had three or more partners. Only 17 men and 12 women reported having a same-sex partner. 52% of sexually active Peace Corps volunteers stationed in Eastern Europe, 43% of those in Central or South America, 36% in sub-Saharan Africa, and 32% in Asia and the Pacific had a sexual partner from the host country. 32% of these volunteers used condoms on every occasion with partners from the host country, 49% used condoms some of the time, and 19% never used them. For male volunteers, consistent condom use was negatively associated with alcohol use and positively related to the perception that HIV was a problem in the host country; for female volunteers, younger age and fewer partners were the significant correlates of condom use. The inconsistent use of condoms in countries where HIV is widespread suggests a need for Peace Corps leaders to educate volunteers about local seroprevalence rates, cultural differences in sexual negotiation, and the importance of condom use.

Health insurance and use of medical services by men infected with HIV.

Among 178 HIV-infected men from the San Francisco City Clinic Cohort (SFCCC), we examined the association between health insurance and use of outpatient services and treatment. For men with private insurance, we also assessed the frequency of avoiding the use of health insurance. Men without private insurance reported fewer outpatient visits than men with fee-for-service or managed-care plans. Use of zidovudine for eligible men was similar for those with fee-for-service plans (74%), managed-care plans (77%), or no insurance (61%). Use of Pneumocytstis carinii pneumonia prophylaxis was similar for those with fee-for-service (93%) and managed-care plans (83%) but lower for those with no insurance (63%). Of 149 men with private insurance, 31 (21%) reported that they had avoided using their health insurance for medical expenses in the previous year. In multivariate analysis, the independent predictors of avoiding the use of insurance were working for a small company and living outside the San Francisco Bay Area. Having private insurance resulted in higher use of outpatient services, but the type of private insurance did not appear to affect the use of service or treatment. Fears of loss of coverage and confidentiality may negate some benefits of health insurance for HIV-infected persons.