Paraquat and Parkinson's disease: an overview of the epidemiology and a review of two recent studies.

OBJECTIVE: This paper reviews and evaluates two recent epidemiologic studies focused on pesticides, and in particular, paraquat as a cause of PD. Both studies are derived primarily from the Agricultural Health Study (AHS). A review and evaluation is also provided on the AHS and several additional studies of paraquat and PD. METHODS: The methods used to design and conduct the studies and analyze the data are described and evaluated. RESULTS: Studies were inadequately designed and often underpowered with very few exposed individuals. They were not population-based, failed to distinguish incident from prevalent cases, relied on multiple comparisons, and may have reported results selectively. The results across the studies are inconsistent. CONCLUSIONS: The inherent difficulties of studying Parkinson's disease in relation to paraquat or other pesticides are well illustrated by these studies. A conclusion regarding these relationships cannot be reached based on the current literature. Further research with higher methodological standards is needed to reach a definitive conclusion.

Fecal occult blood screening in the Minnesota study: role of chance detection of lesions.

BACKGROUND: In the Minnesota Colon Cancer Control Study, annual fecal occult blood testing reduced mortality from colorectal cancer by at least 33.4%. Some attribute a large part of this reduction to chance detection of cancers by colonoscopies; rehydration of guaiac test slides greatly increased positivity and consequently the number of colonoscopies performed. This study was conducted to determine how much of the reduction resulted from chance detection. METHODS: We used a mathematical model developed by Lang and Ransohoff to estimate the proportion of the 33.4% mortality attainable by chance alone. Applying the model requires the specification of five parameters: duration of follow-up, rate of compliance with fecal occult blood testing, rate of compliance with colonoscopy, positivity rate, and efficacy of colonoscopy in reducing colorectal cancer mortality. We took values for four of the five parameters directly from the Minnesota study. For the fifth parameter, efficacy of colonoscopy, we selected a value of 60%, based on the conclusions of another study. Whereas the Lang-Ransohoff model selects persons for colonoscopy by chance alone, those with bleeding cancers would also be selected by sensitive fecal occult blood testing. We therefore adjusted the result of the Lang-Ransohoff model for this dual detectability. RESULTS: We found that 16%-25% of the reduction in colorectal cancer deaths effected by fecal occult blood testing in the Minnesota study was due to chance detection; the remainder was due to sensitive detection. CONCLUSION: Chance played a minor role in the detection of colorectal cancers by fecal occult blood testing in the Minnesota study.

Fecal occult blood screening in the Minnesota study: sensitivity of the screening test.

BACKGROUND: In the Minnesota Colon Cancer Control Study, which used guaiac slides to annually screen stool samples for blood, mortality from colorectal cancer was reduced by 33.4%. The reported sensitivity of this test for colorectal cancer was about 90%. However, results from another study estimated the sensitivity to be 25%-33%; other investigators have reported intermediate values. Given these contradictions, we examined screening sensitivity for colorectal cancer in the Minnesota study by several direct and indirect methods. METHODS: In this reanalysis of data from the Minnesota study, we distinguished between sensitivity for colorectal cancer of the screening test (composed of six slides) and of the screening program (a series of such tests). We estimated screen sensitivity by adjusting the crude estimate from the final tests in each screening phase for colorectal cancer incidence in 5 years of follow-up, by modeling guaiac slide results at each screen as a function of the presence of occult blood, and by incorporating sensitive detection into a modification of a mathematical model developed by Lang and Ransohoff. Program sensitivity was estimated from the fraction of screen-detected cancers among all cancers diagnosed in screened individuals. RESULTS: The crude estimate of program sensitivity was 89.4%, whereas the modified Lang-Ransohoff model estimates screen sensitivities at 94.1%-96.2%, consistent with the estimates from the other methods. Indirect measures, such as the association between the number of positive slides among the six slides in each set and the positive predictivity for colorectal cancer, are consistent with these estimates. CONCLUSIONS: The Minnesota study reduced mortality from colorectal cancer through use of a screening test with average screen and program sensitivities of about 90%.

Colorectal cancer mortality: effectiveness of biennial screening for fecal occult blood.

BACKGROUND: In 1993, a randomized controlled trial in Minnesota showed, after 13 years of follow-up, that annual fecal occult blood testing was effective in reducing colorectal cancer mortality by at least 33%. Biennial screening (i.e., every 2 years) resulted in only a 6% mortality reduction. Two European trials (in England and in Denmark) subsequently showed statistically significant 15% and 18% mortality reductions with biennial screening. Herein, we provide updated results-through 18 years of follow-up--from the Minnesota trial that address the apparent inconsistent findings among the trials regarding biennial screening. METHODS: From 1976 through 1977, a total of 46551 study subjects, aged 50-80 years, were recruited and randomly assigned to an annual screen, a biennial screen, or a control group. A screen consisted of six guaiac-impregnated fecal occult blood tests (Hemoccult) prepared in pairs from each of three consecutive fecal samples. Participants with at least one of the six tests that were positive were invited for a diagnostic examination that included colonoscopy. All participants were followed annually to ascertain incident colorectal cancers and deaths. RESULTS: The numbers of deaths from all causes were similar among the three study groups. Cumulative 18-year colorectal cancer mortality was 33% lower in the annual group than in the control group (rate ratio, 0.67; 95% confidence interval [CI] = 0.51-0.83). The biennial group had a 21% lower colorectal cancer mortality rate than the control group (rate ratio, 0.79; 95% CI = 0.62-0.97). A marked reduction was also noted in the incidence of Dukes' stage D cancers in both screened groups in comparison with the control group. CONCLUSION: The results from this study, together with the other two published randomized trials of fecal occult blood screening, are consistent in demonstrating a substantial, statistically significant reduction in colorectal cancer mortality from biennial screening.

Reduced risk of large-bowel adenomas among aspirin users. The Polyp Prevention Study Group.

BACKGROUND: Epidemiological studies have indicated that aspirin consumption can lower the risk of large-bowel cancer. These studies are not entirely consistent, however, and their interpretation has been complicated by the possibility that cancer symptoms may have led patients to avoid aspirin or that aspirin may have influenced cancer diagnosis and treatment. PURPOSE: Our purpose was to determine the effect of aspirin on risk of large-bowel neoplasms in a study in which aspirin use would not be expected to affect tumor detection and tumor-related symptoms would not likely influence aspirin use. A less complicated assessment of the relationship between aspirin and large-bowel tumors should thus be possible. METHODS: We studied 793 patients enrolled in a clinical trial of nutrient supplements to prevent large-bowel adenomas. Unlike invasive cancers, adenomas usually do not cause symptoms or detectable gastrointestinal bleeding; thus, adenomas are unlikely to influence aspirin use. Each patient had at least one large-bowel adenoma diagnosed and removed shortly before study entry and had been judged to be free of further tumors by colonoscopy. Use of aspirin was assessed by responses on questionnaires administered 6 and 12 months after enrollment. We performed complete colonoscopies on all patients 1 year after they entered the study and removed all polyps. RESULTS: Patients who reported taking aspirin on both questionnaires (consistent users) had a lower risk of new adenomas at their 1-year follow-up colonoscopy (odds ratio = 0.52; 95% confidence interval = 0.31-0.89) compared with patients who did not report using aspirin on either of the questionnaires. The apparent protective effect of consistent aspirin use was present among both men and women and did not appear to be influenced by the number of prior adenomas. CONCLUSIONS: These data further support the hypothesis that aspirin has an antineoplastic effect in the large bowel. Nevertheless, the question of whether aspirin should be used to prevent large-bowel tumors would be best answered by a randomized controlled clinical trial specifically designed to address this issue.

Protein intake and risk of renal cell cancer.

BACKGROUND: Renal cell cancer, although still relatively uncommon, has been increasing in incidence in the United States and other countries around the world. PURPOSE: Since previous studies have suggested an association with high intake of meat, we sought to further examine the role of diet in renal cell cancer risk. METHODS: Patients with histologically confirmed renal cell cancer that had been diagnosed between July 1, 1988, and December 31, 1990, were identified through the Minnesota Cancer Surveillance System, a statewide cancer registry. The patients eligible for inclusion in this study were white residents of Minnesota between 20 and 79 years of age. Control subjects were selected from the general population of Minnesota residents; subjects under age 65 were selected by use of a random-digit-dialing method and those 65 years or older were sampled from the Health Care Financing Administration files. Population-based control subjects were frequency-matched to cases by sex and 5-year age groups. A total of 690 patients and 707 control subjects were interviewed. Patients and control subjects were similar in distribution by sex, age, and educational level. Usual adult dietary intakes were assessed by questionnaire, and odds ratios were calculated by logistic regression analyses. RESULTS: Significantly increased risks of renal cell cancer were observed with increasing consumption of several food groups, including red meat (P for trend = .05), high-protein foods (P = .01), and staple (grains, breads, and potatoes) foods (P = .009). When examined by macronutrient status, risks increased monotonically with the amount of protein intake, from 1.2 (95% confidence interval [CI] = 0.7-1.9) to 1.4 (95% CI = 0.8-2.5) and 1.9 (95% CI = 1.0-3.6) (P for trend = .03) in the second, third, and fourth quartiles of intake, respectively, after adjustment for age, sex, caloric intake, body mass index, and cigarette smoking. No significant or consistent associations were detected with the intake of other dietary nutrients or beverages. CONCLUSION: Although an independent effect of dietary protein has not been previously associated with renal cell cancer, high protein consumption has been related to development of other chronic renal conditions that may predispose an individual to this cancer. IMPLICATION: These findings should prompt further study of dietary protein and its potential contribution to the origins of renal cell cancer.

Etiology of cancer of the renal pelvis.

A population-based case--control interview study of cancer of the renal pelvis (74 cases and 697 controls) conducted in the Minneapolis--St. Paul metropolitan area showed cigarette smoking to be the major cause of this cancer. The odds ratio (OR) for cigarette smoking was 7.6 among males [95% confidence interval (CI): 2.2-31.5] and 5.8 among females (95% CI: 2.0-17.3), with the OR exceeding 10 for heavy smokers of both sexes. Long-term use of analgesics and several occupational exposures were also found to be risk factors. In addition, there were unexpected positive associations among females for heavy tea consumption and for use of estrogen medications, although the significance of these relationships remains to be clarified.

A population--based case--control study of renal cell carcinoma.

A population-based case-control study of renal cell carcinoma (495 cases and 697 controls) in the Minneapolis-St. Paul seven-county metropolitan area implicated cigarette smoking as a risk factor with an odds ratio (OR) among men of 1.6 (95% confidence intervals: 1.1-2.4) and among women of 1.9 (1.3-3.0). A statistically significant dose response was observed in both sexes for pack-years of cigarette use. On the basis of calculations of attributable risk, it was estimated that 30% of renal cell cancers among men and 24% among women were due to smoking. High relative adult weight as measured by the body mass index (BMI) was found to be a major risk factor among women but not among men, with those in the highest 5% of the BMI having an OR of 5.9 (1.8-20.4) in comparison to the lowest quartile. This association with excess weight was not seen at age 20, but it became more pronounced with increasing age, suggesting that the primary influence of weight gain is during the late stages of renal carcinogenesis. Excess risks were also related to ethnic background (particularly, German), which may account in part for the elevated incidence of renal cancer in the North Central area of the United States. In addition, positive associations were observed for long-term use of phenacetin-containing analgesics, heavy meat consumption, and heavy tea drinking (females only). An occupational clue was provided by an increased risk for exposure to petroleum, tar, and pitch products. Excesses of certain urologic and cardiovascular diseases were also observed among the cases compared to controls.

Folate intake, alcohol consumption, cigarette smoking, and risk of colorectal adenomas.

BACKGROUND: Recent evidence suggests that folic acid (and derivatives) could contribute to the protective effect of fruits and vegetables against the risk of large-bowel cancer. Other evidence indicates that alcohol drinking and cigarette smoking may impair the biologic actions of folate. We used data from an adenoma prevention trial to investigate the occurrence of colorectal adenomas (possible precursors of colorectal cancer) in association with folate intake, alcohol consumption, and cigarette smoking. METHODS: Patients with at least one recent large-bowel adenoma were followed with colonoscopy 1 year and 4 years after their qualifying colon examinations. Adenomas detected after the year 1 examination were used as end points. A food-frequency questionnaire was administered at study entry and at study completion; nutrient intake at study entry was used in this analysis. All statistical tests were two-sided. RESULTS: After adjustment for caloric intake, dietary folate had a significant protective association with the risk of recurrence of large-bowel adenoma (P for trend = .04). However, this inverse association was attenuated by further adjustment for intake of dietary fiber and fat. Use of folate supplements was not associated with a reduction in risk. Alcohol intake (seven or more drinks/week) was associated with increased risk (odds ratio = 2.04; 95% confidence interval = 1.28-3.26). Cigarette smoking, even smoking for long duration, was not related to adenoma recurrence. CONCLUSIONS: These data provide only modest support for previous findings suggesting beneficial effects of folate on colorectal adenoma risk. We find no evidence that cigarette smoking increases risk. These findings do suggest a substantial increase in risk with alcohol consumption.

A research agenda for AIDS prevention in the developing world.

BACKGROUND: In the developing world, HIV is spreading in many epidemiologic patterns, ranging from slow spread in limited segments of the population to exponential growth to mature epidemics. These differences are superimposed on widely varying cultures and patterns of behavior, creating unique challenges for prevention in each setting. Local prevention research is continually necessary to respond appropriately and effectively to local prevention needs and to best use scarce resources. THE RESEARCH AGENDA: We propose a research agenda for AIDS prevention in the developing world, consisting of three main components: epidemiologic and behavioral surveillance; enhancing local understanding of HIV risk behavior; and testing interventions. We review examples of each. This 'bottom-up' research is contrasted with 'top-down' research conducted in the developing world by scientists from developed countries to answer questions of general interest. RESULTS: The articles published in this volume exemplify the scope and importance of AIDS prevention research in the developing world. They also show what can be accomplished through international collaboration directed towards meeting local needs.

PIP: In the developing world, HIV is spreading in many different epidemiologic patterns. The spread may be slow among a few population groups, exponential, or at the level of a mature epidemic. HIV is spreading across a wide range of cultures and behavior patterns. A need therefore exists to tailor prevention measures to conditions and needs at local levels. Research at the local level is needed to guide the development and implementation of appropriate HIV prevention programs. The authors propose a research agenda for AIDS prevention in the developing world which consists of the following central components: epidemiologic and behavioral surveillance, improving the local understanding of HIV risk behavior, and testing interventions. Examples of each component are reviewed. In addition, bottom-up research is contrasted with top-down research conducted in the developing world by scientists from developed countries.

Collaborative AIDS prevention research in the developing world: the CAPS experience.

BACKGROUND: Prevention through behavior change is the only way to control the spread of HIV infection in the developing world. Success in prevention requires consistent and persistent intervention over time, a clear understanding of the realities of target populations and involvement of members of these populations in prevention efforts. Applied local research is urgently needed, especially in the developing world, to design interventions that meet these criteria and to test their effectiveness. CENTER FOR AIDS PREVENTION STUDIES (CAPS) MODEL OF INTERNATIONAL COLLABORATIVE RESEARCH: Each year, eight to 10 scientists from developing countries visit CAPS in San Francisco for 10 weeks of intensive learning and collaboration. The main emphasis is on designing a protocol for a research project related to AIDS prevention in the visiting scientist's home country. CAPS provides pilot study funding and technical assistance to implement the project. RESULTS: The quality of the resulting collaborative research is represented by the articles published in this volume and by the many alumni of the program who have undertaken additional research projects and/or assumed leadership positions in AIDS control efforts in their countries.

PIP: Prevention through behavior change is the only way to control the spread of HIV infection in the developing world. Success in prevention requires consistent and persistent intervention over time, a clear understanding of the realities of target populations, and involvement of members of these populations in prevention efforts. Applied local research is urgently needed, especially in the developing world, to design interventions that meet these criteria and to test their effectiveness. The Center for AIDS Prevention Studies (CAPS) model of international collaborative research has been used at the University of California, San Francisco, for the past eight years. The model involves an intensive period for protocol development and another one for data analysis. Each year, 8-10 scientists from developing countries visit CAPS in San Francisco for 10 weeks of intensive learning and collaboration. They are immersed in HIV epidemiology, research design, computer skills, data management, and psychosocial aspect of the AIDS epidemic. The main emphasis is on designing a protocol for a research project related to AIDS prevention in the visiting scientist's home country. The greatest impediment to intervention trials in developing countries is lack of funding. CAPS provides pilot study funding and technical assistance to implement the project in the home country. In the summer of 1995 eight alumni worked intensively with the CAPS faculty on data analysis and manuscript preparation. The quality of the resulting collaborative research is represented by the articles published and by the many alumni of the program who have undertaken additional research projects and/or assumed leadership positions in AIDS control efforts in their countries. These studies cover a wide range of risk groups, including sexually transmitted disease patients in Zambia; adolescents in the Philippines and Russia; wives of HIV-infected men in Uganda; female sex workers in Brazil, India, and Thailand; and HIV-infected women of childbearing age in Rwanda.

'Superstar' and 'model brothel': developing and evaluating a condom promotion program for sex establishments in Chiang Mai, Thailand.

OBJECTIVES: We developed and evaluated a multifaceted AIDS prevention program to increase condom use among sex workers in the city of Chiang Mai, Northern Thailand. SUBJECTS AND METHODS: A year-long intervention targeted sex workers, brothel owners and clients, promoted cooperation between these groups and the public health office and established a free condom supply for sex establishments. Nearly 500 women from 43 establishments took part in the program, encompassing nearly all direct sex workers in urban Chiang Mai. The intervention included repeated small-group training sessions for sex workers in which experienced women ('superstars') acted as peer educators. The 'model brothel' component encouraged all brothel owners in Chiang Mai to insist on mandatory use of condoms by sex workers and to encourage clients to use condoms. Before and after the intervention, specially trained volunteers posing as clients tested a subsample of sex workers to see whether they insisted on condom use. RESULTS: The intervention was well received by sex workers and obtained strong support and cooperation from brothel owners. Before the intervention, only 42% (10/24) of women surveyed by volunteers posing as clients refused to have sex without a condom, even when the client insisted and offered to pay three times the usual fee. Following the program, 92% (72/78) refused; 1 year later, 78% (69/85) refused during the same scenario. CONCLUSIONS: An innovative program directly involving sex workers as peer educators and enlisting the support of brothel owners and operators can result in improved condom use over time. Lessons learned from this program may be applicable elsewhere.

Traditional Balinese youth groups as a venue for prevention of AIDS and other sexually transmitted diseases.

OBJECTIVES: Our aims were to assess the feasibility of conducting peer-led educational interventions against AIDS and other sexually transmitted diseases (STDs) through traditional Balinese youth groups and to gather information on sexual risk-taking and its correlates among Balinese youth. DESIGN: A cross-sectional survey was conducted, with follow-up questionnaires for pilot intervention participants. SUBJECTS AND METHODS: A self-administered questionnaire was given to 375 subjects (aged 16-25 years) from 12 youth groups representing four main resort areas in Bali. Post-intervention data were collected from 97 of these subjects who had taken part in pilot educational programs. Focus groups supplemented survey data in evaluating the intervention and understanding risk behaviors. RESULTS: In a cross-sectional survey, one-quarter of males and few females reported sexual activity; subsequent focus groups suggested under-reporting by females. While knowledge and worries about HIV/AIDS were high, only 10% of sexually active males and no females reported consistent condom use. The mean age of first sexual intercourse was highly correlated with first alcohol consumption (P = 0.0003). Peer educators from selected youth groups planned and implemented interventions for their own groups. Post-intervention data indicated significant increases in communication about sexual issues with friends and parents. Condom attitudes became less negative and efficacy increased. Participants reported this as a first experience with peer-led health education, preferred interactive activities to adult-led lectures and recommended follow-up educational sessions. CONCLUSIONS: Peer educators from traditional youth groups can plan and conduct prevention programs for HIV/STDs that are well-received by their group memberships. Using such venues may be an efficient way to reach a wide range of pre-sexual Balinese youth, as well as those already at risk for HIV/STD due to unprotected sex, alcohol consumption and multiple sexual partners.

PIP: In a 1995 survey of Balinese youth, 75% expressed a desire to discuss sexual issues and AIDS/sexually transmitted diseases (STDs) with their peers. A cross-sectional survey of 375 young people 16-25 years of age assessed the feasibility of using traditional Balinese youth groups as a vehicle for peer-led AIDS education. In Bali virtually all youth, regardless of educational level or socioeconomic status, join the youth group in their neighborhood at puberty and remain members until they marry. The average age at first intercourse reported in the baseline survey was 18.8 years for males and 20.0 years for females. For 46% of sexually active males, intercourse was accompanied by alcohol consumption. Although youth had adequate knowledge of AIDS before the intervention, only 10% of sexually active males reported consistent condom use. Follow-up interviews with 97 young people from 3 resort areas of Bali who were exposed to the peer-led intervention revealed significant increases in communication about sexual matters with friends and family, more positive attitudes toward condoms, and increased condom use. Exposed youth who participated in focus group discussions expressed a preference for peer-led interactive activities over lectures and indicated they felt more comfortable asking their peers questions about sex. Use of peer educators from Balinese youth groups appears to represent an efficient way to reach young people before the initiation of sexual activity as well as those at high risk of AIDS and other STDs as a result of unprotected sex, alcohol consumption, and multiple sexual partners.

Adolescent sexual behavior along the Trans-Africa Highway in Kenya.

OBJECTIVE: To describe the demographic characteristics and HIV-related risk behaviors of adolescents frequenting truck stops along the Trans-Africa Highway in Kenya. METHODS: A cross-sectional study of 200 adolescents (52% female) aged 15-19 years was conducted at the Malaba, Sachangwan and Mashinari truck stops in Kenya. A standardized questionnaire assessing the adolescents' demographic characteristics and sexual behavior was administered. RESULTS: Most (89%) of the adolescents interviewed were out of school. Their median monthly family income was Ksh1000 (US$25). Most felt that their families provided inadequate access to food (72%), clothing (70%) and pocket money (87%). Ninety-three per cent of girls and 87% of boys had ever had sexual intercourse and of these 54% of girls and 38% of boys had ever used a condom. Fifty-two per cent of the girls and 30% of the boys reported ever having had a sexually transmitted disease. Forty-six percent of girls reported usually having sex with truck drivers, 78% of girls reported usually exchanging sex for gifts or money and 59% of boys reported usually giving gifts or money for sex. Subjects engaging in these three risk behaviors were generally less likely to be in school, less likely to live with relatives and less likely to report getting along well with their parents. CONCLUSION: Adolescents at truck stops along the Trans-African Highway in Kenya appear to be at significant risk for HIV infection. In the absence of an immediate and wide-ranging intervention, these conditions are likely to facilitate the spread of HIV from truck drivers and sex workers to adolescents.

HIV/AIDS-related attitudes and practices of hospital-based health workers in Kampala, Uganda.

OBJECTIVE: To assess HIV/AIDS-related attitudes and practices of hospital-based health workers in Kampala, Uganda. METHODS: A cross-sectional study was conducted in Mulago Hospital, the main national referral hospital in Uganda. A total of 155 physicians and nurses completed a brief questionnaire on HIV risk perception, attitudes and practices regarding AIDS prevention education, HIV counseling and testing and care of patients with HIV disease. RESULTS: Twenty-nine per cent of health workers reported never having discussed AIDS prevention with patients, 26% had never referred patients for HIV counseling and 31% had never advised patients suspected of HIV infection to be tested. Frequent explanations for not providing AIDS prevention education included time constraints and/or lack of related knowledge or skills. While 29% perceived recapping needles as involving no risk, activities involving casual contact with patients and condom use for protection against HIV infection were associated with a high perceived risk of HIV transmission, particularly among nurses. Physicians and nurses differed in their HIV/AIDS-related attitudes and practices. The physicians had a more positive attitude towards the care of patients with HIV disease. In addition, 80% of physicians compared to 59% of nurses referred patients for HIV counseling. A similar trend was found for advising patients to obtain HIV testing. CONCLUSIONS: Hospital-based health workers are missing important opportunities for AIDS prevention education with their patients. There are gaps in their knowledge about HIV and related infection control practices. Interventions should address their concerns and barriers to HIV prevention practices.

Adolescent sexuality in Saint Petersburg, Russia.

OBJECTIVES: To describe adolescent knowledge, attitudes and behavior relevant to sexuality and the prevention of AIDS in Saint Petersburg, Russia. SUBJECTS AND METHODS: A cross-sectional descriptive study was designed, taking a random sample of 10th grade students at 14 Saint Petersburg grade schools, which were stratified by socio-economic district. A total of 185 female and 185 male students completed a self-administered 46-item questionnaire, with a response rate of 94%. RESULTS: From the questionnaires, 20% of females and 31% of males reported having had sexual intercourse and 25% of females and 12% of males reported being sexually abused. These adolescents displayed much misinformation about sexual matters and AIDS prevention. Only 25% of the females and 34% of the males believed that condoms should be used just once, and 38% of each sex believed that if washed, they could be used multiple times. Many respondents, especially males, rated their knowledge about sexual matters as high or adequate. Support for sex education was strong, especially among females, and respondents generally saw sex education as improving sexual pleasure. Most information sources about sexual activity were either not considered very credible, or not adequately accessible. CONCLUSIONS: Substantial reported rates of sexual abuse, sexual experience and much misinformation and unwarranted attitudes toward condoms, safer sexual practices and HIV/AIDS suggest the need for vigorous sex education programs for Russian youth. The early and sustained education of girls is especially important. Sex education should be introduced at an early age so that children can be taught how to reduce the risks of sexual abuse, HIV infection and other sexually transmitted diseases, and to improve their sexual experiences as responsible adults.

HIV risk behavioral surveillance in Bangkok, Thailand: sexual behavior trends among eight population groups.

OBJECTIVE: To assess trends in HIV risk behaviors over a 3-year period in eight population groups in Bangkok, Thailand. DESIGN AND SUBJECTS: Using a repeated cross-sectional survey design with a structured questionnaire, we collected five sets of self-reported sexual behavior data related to HIV risk from the following subject groups at the same sampling sites during 1993-1996: direct and indirect female sex workers, male attenders of sexually transmitted disease (STD) clinics, female attenders of antenatal care clinics, male and female vocational students, and male and female factory workers. RESULTS: Reported patronage of commercial sex by the three male groups declined by an overall average of 48% over the 3-year period. Other non-regular sexual partnerships declined among male STD clinic attenders and vocational students. Condom use during most recent sexual intercourse between sex workers and clients peaked at high levels (>90%) in the early data waves, while among indirect sex workers and their clients, consistent condom usage increased from 56% to 89%. Low condom use persisted among sex workers and their non-paying sex partners. Single women reported low levels of sexual activity and condom use with no signs of an increase. Similarly, married women from antenatal clinics reported low condom use with their husbands, with no change throughout the period of the study. CONCLUSIONS: HIV risk behavioral surveillance is a useful way of determining whether behavior change has occurred in specific population groups. The results here confirm and add to a growing set of evidence of risk behavior reduction in Thailand. The behavioral changes did not occur uniformly but varied depending on the sexual dyad and the population group under study. Behavioral surveillance should be promoted and its methodologies strengthened in attempts to understand the local dynamics of HIV epidemics.

Rising HIV infection rates in Ho Chi Minh City herald emerging AIDS epidemic in Vietnam.

OBJECTIVE: To describe the epidemiology of HIV in Ho Chi Minh City in the context of current surveillance data from Vietnam. METHODS: Since the late 1980s, HIV surveillance data have been collected in Ho Chi Minh City from centers for the treatment of venereal disease and tuberculosis, centers for the rehabilitation of injecting drug users and sex workers, prenatal clinics, blood banks and other sites. RESULTS: The first case of HIV infection in Vietnam was identified in 1990 in Ho Chi Minh City. The cumulative number of reported HIV infections in this city at the end of 1996 was 2774, about half of the number of cases in the country; 86% of infections were among men, 86% among injecting drug users, 2.5% among patients with sexually transmitted diseases and 2.5% among sex workers. The first HIV infection among antenatal women was detected in 1994. The prevalence of HIV among injecting drug users rose dramatically from 1% in 1992 to 39% in 1996, compared with 1.2% among sex workers, 0.3% among blood donors and 1.3% among tuberculosis patients in 1996. The populations of injecting drug users and sex workers in Ho Chi Minh City are estimated to be 30000 and 80000, respectively, and rates of sexually transmitted diseases are 2-3 per 1000 persons per year. By the end of December 1996, 42 out of 53 provinces had reported HIV infections, and border areas near China and Cambodia began identifying large numbers of HIV-seropositive people. CONCLUSIONS: Ho Chi Minh City is at the forefront of a new HIV epidemic in Vietnam. This epidemic shows similarities to that in Thailand nearly a decade ago, with rapidly rising HIV rates among injecting drug users and infection already established among sex workers. Prevention efforts should include the targeting of injecting drug users and sex workers outside rehabilitation centers, the availability of sterile needles and condoms, the establishment of anonymous testing sites, the control of sexually transmitted diseases and the coordination of programs within southeast Asia.

PIP: An analysis of annual sentinel surveillance data from Viet Nam indicates that Ho Chi Minh City is at the forefront of a new HIV epidemic. Since 1990, data on HIV cases have been collected from prenatal clinics, blood banks, centers for the treatment of sexually transmitted diseases (STDs) and tuberculosis, and rehabilitation centers for injecting drug users and commercial sex workers. The first HIV case in Viet Nam was reported in 1990 in Ho Chi Minh City. By the end of 1996, a cumulative total of 4961 HIV cases had been documented in Viet Nam, 2774 of which were in Ho Chi Minh City. In Ho Chi Minh City, 86.5% of cumulative HIV infections involved men. The distribution of total HIV cases by group has been: injecting drug users, 86.0%; tuberculosis patients, 3.3%; sex workers, 2.5%; STD patients, 2.5%; and pregnant women, 0.6%. By 1996, 42 of Viet Nam's 53 provinces had reported HIV cases and infection rates are rising dramatically in border areas near China and Cambodia. The pattern documented in this analysis resembles that observed in Thailand a decade ago: rapidly rising HIV rates among injecting drug users and infection already established among sex workers, without dissemination to the general population. The necessary infrastructure and resources for control of the epidemic are far more limited in Viet Nam than Thailand, however. Recommended, to prevent the further spread of HIV in Viet Nam, are educational activities targeted at injecting drug users and sex workers outside of rehabilitation centers, the availability of condoms and sterile needles, establishment of anonymous testing sites, control of STDs, and the coordination of programs within southeast Asia.

Men with sexually transmitted diseases in Bangkok: where do they go for treatment and why?

OBJECTIVES: To describe and identify predictors of health-care seeking behavior among men with sexually transmitted diseases (STDs) in Bangkok, Thailand. DESIGN: Cross-sectional survey. METHODS: Men presenting with STDs were recruited from government clinics (n = 101), private clinics (n = 50) and pharmacies (n = 62). They completed interviewer-administered questionnaires on risk behavior, patterns of treatment-seeking for current and past STDs and attitudes toward health care. RESULTS: Two-thirds of all subjects had had a previous STD. Approximately one-half believed a partner other than a sex worker was the source of their current infection. Of the sample, 39% of men seen initially at drugstores, 29% at private clinics and 19% at government clinics sought subsequent treatment; failure to respond to therapy was the primary reason for seeking additional care. Men attending drugstores were likely to be younger, have less education and income, and to practice riskier sexual behavior. Patients at drugstores and general private clinics received the least amount of counseling or STD testing, while those attending specialized private STD clinics received the most comprehensive services. Attitudes towards government clinics were uniformly positive regardless of the site of enrollment; conversely, about 50% of clients at drugstores felt that the advice and treatment they received were inadequate. Convenience, affordability and lack of embarrassment were associated with choice of treatment site. CONCLUSIONS: STD/HIV control in Thailand must focus on improved treatment and counseling at the point of first encounter in the health-care system, particularly in the private sector. Men may be dissuaded from attending government clinics because of lack of convenience. Syndromic case management, incorporation of STD care at other public clinics and the recognition that more men practice unsafe sex with partners other than sex workers could improve STD control.

PIP: The determinants of treatment-seeking behaviors associated with sexually transmitted diseases (STDs) were investigated in a cross-sectional survey of 213 men recruited from government clinics (n = 101), private clinics (n = 50), and pharmacies (n = 62) in Bangkok, Thailand. 142 of these men had had a prior STD. 34% of men who initially attended pharmacies and 19% of those who first attended a government clinic sought multiple treatments for prior STDs because of an incomplete response to treatment. 50% of STD clients had visited a commercial sex worker in the 3 months preceding the current STD; half believed a casual or new sex partner was the source of infection. 12% of men had sex while they were symptomatic with the current STD. Advice on condom use was conveyed to 88% of government clinic patients, 94% of private clinic patients, and 52% of pharmacy customers; only 72%, 14%, and 22%, respectively, were urged to contact their sexual partner. Men with less education and symptoms of dysuria were more likely to seek care at drugstores. Also associated with seeking care at a pharmacy rather than a government site were waiting less than 7 days to seek treatment, having a travel time less than 20 minutes, and feeling able to pay for treatment. Those seeking care at pharmacies were also more likely to believe that they would recover at least as well as those treated at a government clinic and to believe they were at risk for human immunodeficiency virus infection. Possible strategies for improving STD treatment at the first point of contact within the health care system include promotion of syndromic STD management among pharmacists and general practitioners, integrated STD programs within health care services already providing care to adolescents and other high-risk groups, and strengthening the referral network to government clinics.

Impact of an intervention on HIV, sexually transmitted diseases, and condom use among sex workers in Bombay, India.

OBJECTIVE: To develop and test an HIV intervention targeting sex workers and madams in the brothels of Bombay. SUBJECTS AND METHODS: In a controlled intervention trial, with measurements before and after the intervention, 334 sex workers and 20 madams were recruited from an intervention site, and 207 and 17, respectively, from a similar control site, both in red-light areas of Bombay. All sex workers were tested for antibodies to HIV and syphilis, and for hepatitis B surface antigen. Information on sexual practices, condom use and knowledge of HIV was collected by interviewer-administered questionnaire. All subjects in the intervention group underwent a 6-month program of educational videos, small group discussions and pictorial educational materials; free condoms were also distributed. The blood tests and the questionnaire were readministered to all subjects at both sites immediately after the intervention. Both groups were followed for approximately 1 year. RESULTS: The baseline level of knowledge about HIV and experience with condoms was extremely low among both sex workers and madams. The baseline prevalence of HIV antibodies was 47% in the intervention group and 41% in the control group (P = 0.17). The incidence densities for HIV and sexually transmitted diseases were significantly different in the two groups (all P < 0.005): 0.05 and 0.16 per person-year of follow-up for HIV, 0.08 and 0.22 per person-year for antibodies to syphilis, and 0.04 and 0.12 per person-year for hepatitis B surface antigen in the intervention and control women, respectively. Following the intervention, women reported increased levels of condom use, and some (41%) said they were willing to refuse clients who wouldn't use them. However, both the sex workers and the madams were concerned about losing business if condom use was insisted upon. CONCLUSIONS: Both HIV prevalence and incidence are alarmingly high among female sex workers in Bombay. Successful interventions can be developed for these women, and even a partial increase in condom use may decrease the transmission of HIV and sexually transmitted diseases. Intervention programs of longer duration that target madams and clients and make condoms easily available are urgently needed at multiple sites in red-light areas.

PIP: The objective was to develop and test an HIV intervention targeting sex workers and madams in the brothels of Bombay. In a controlled intervention trial, with measurements before and after the intervention, 334 sex workers and 20 madams were recruited from an intervention site, and 207 and 17, respectively, from a similar control site, both in red-light areas of Bombay. All sex workers were tested for antibodies to HIV and syphilis, and for hepatitis B surface antigen. Information on sexual practices, condom use, and knowledge of HIV was collected by questionnaires. All subjects in the intervention group underwent a 6-month program of educational videos, small group discussions and pictorial educational materials; free condoms were also distributed. The blood tests and the questionnaire were readministered to all subjects at both sites immediately after the intervention. Both groups were followed for approximately 1 year. The baseline prevalence of HIV antibodies was 47% in the intervention group and 41% in the control group (p = 0.17). The incidence densities for HIV and sexually transmitted diseases were significantly different in the 2 groups (all p 0.005): 0.05 and 0.16 per person-year of follow-up for HIV, 0.08 and 0.22 per person-year for antibodies to syphilis, and 0.04 and 0.12 per person-year for hepatitis B surface antigen in the intervention and control women, respectively. Following the intervention, there was a significant increase in knowledge of modes of HIV transmission in the intervention group (n = 334) compared to the control group (n = 190) (60% vs. 99% compared to 56% vs. 26%, p 0.001). In addition, women reported increased levels of condom use and some (41%) said they were willing to refuse clients who would not use them. However, both the sex workers and 100% of the madams were concerned about losing business if condom use was insisted upon. Intervention programs of longer duration that target madams and clients and make condoms easily available are urgently needed.