Differences between seven measures of self-reported numbers of clients of female sex workers in southern India: implications for individual- and population-level analysis.

Quantifying sexual activity of sub-populations with high-risk sexual behaviour is important in understanding HIV epidemiology. This study examined inconsistency of seven outcomes measuring self-reported clients per month (CPM) of female sex workers (FSWs) in southern India and implications for individual/population-level analysis. Multivariate negative binomial regression was used to compare key social/environmental factors associated with each outcome. A transmission dynamics model was used to assess the impact of differences between outcomes on population-level FSW/client HIV prevalence. Outcomes based on 'clients per last working day' produced lower estimates than those based on 'clients per typical day'. Although the outcomes were strongly correlated, their averages differed by approximately two-fold (range 39.0-79.1 CPM). The CPM measure chosen did not greatly influence standard epidemiological 'risk factor' analysis. Differences across outcomes influenced HIV prevalence predictions. Due to this uncertainty, we recommend basing population-based estimates on the range of outcomes, particularly when assessing the impact of interventions.

Variations in the population size, distribution and client volume among female sex workers in seven cities of Pakistan.

OBJECTIVES: To describe the size and distribution of female sex worker (FSW) populations and the distribution of client-FSW encounters in seven major cities of Pakistan. METHODS: Mapping of FSWs was done using a two-stage process of identifying and validating locations where FSWs solicit and/or meet clients, estimating the size of the FSW population at each location and describing the type of sex work. A sample survey of FSWs was conducted to collect data on sociodemographic and behavioural data. Survey data on client volume were analysed to assess the distributional inequality of client sexual encounters in each of these cities. The overall distributional inequality in client-sex worker encounters across the entire FSW population within a city was assessed by drawing Lorenz curves and computing the Gini coefficient. RESULTS: A total of 34 480 FSWs (40% street-based, 57.5% home-based and 2% brothel-based) were mapped in the seven cities. Of these, 2869 participated in behavioural and biological surveys. The median age of FSWs surveyed was 26 years with sexual debut at 18 years. The contribution of different types of FSWs to the total client volume differed substantially between cities, with the contribution of home-based FSWs ranging from 32% to 75%. The overall distributional inequality in client volume also varied substantially between cities, with the Gini coefficient ranging from 0.22 (low inequality) to 0.50 (high inequality). CONCLUSIONS: The relative size and distribution of sex workers and the sex worker-client patterns differs considerably in cities of Pakistan. Programmes should be planned and implemented accordingly.

Concepts and strategies for scaling up focused prevention for sex workers in India.

OBJECTIVES: To describe the concepts, strategies and field results of a project to scale up prevention programmes and services for female sex workers (FSWs) in Karnataka, India. METHODS: A strategy was developed to scale up urban sex worker interventions in 18 districts in the southern Indian state of Karnataka. Macro-level coverage objectives were defined by mapping the urban locations where FSWs operate and estimating their population size. Prevention programmes were initiated in the urban locations that contained at least 90% of the estimated urban FSW population in each district. Within each location, a micro-planning process was used by FSW peer educators and outreach workers to design local outreach and service delivery plans. RESULTS: An estimated 48 973 FSWs were distributed across 1551 locations and 6232 spots. Outreach was conducted by 1043 peer educators. Services were provided through 170 drop-in centres, 93 programme-run clinics, 110 outreach clinics and 157 referral clinics. Within the first 3 years of the programme the cumulative number of individual FSWs contacted at least once was >78 000, with monthly contact established with 81% of the in situ population; >45 000 FSWs had visited a clinic and >10 000 visited monthly. Direct and indirect condom distribution by the programme amounted to more than 30 per contacted FSW, which is estimated to meet the condom requirement. CONCLUSIONS: A strategy that involves geographically defined coverage and micro-level outreach planning can rapidly and effectively provide outreach and services to large dispersed FSW populations.

Incidence and prevalence of diabetes in children aged 0-14 years in Manitoba, Canada, 1985-1993.

OBJECTIVE: To estimate the incidence and prevalence of type I diabetes among Manitoba children aged 0-14 years from 1985-1993. RESEARCH DESIGN AND METHODS: The Manitoba Diabetes Database (a population-based database of individuals diagnosed with diabetes based on Manitoba's health insurance system) was used to estimate the annual incidence of diabetes for the years 1985-1993 and the point prevalence of diabetes at 31 March 1993 for Manitoba children aged 0-14 years. The Diabetes Education Resource for Children and Adolescents program database was used to correct incidence and prevalence rates for ascertainment using the two-source capture-recapture method. RESULTS: The overall ascertainment rate of the Manitoba Diabetes Database was 95% for incident cases and 93% for prevalent cases. The average annual incidence was 20.4 per 100,000 for children aged 0-14 years. The annual incidence appears to be stable for all age-groups 0-14 years over the past decade. The point prevalence of diabetes among children was 120.4 per 100,000. CONCLUSIONS: The incidence of type I diabetes in children aged 0-14 years in Manitoba is higher than reported previously in other urban regions of Canada, but similar to population-based estimates from Prince Edward Island. The incidence appears stable in Manitoba over the past decade even in the 0-4 year age-group. The Manitoba Diabetes Database appears to be a highly accurate population-based source of data on the epidemiology of diabetes in children.

Incidence and prevalence of diabetes in Manitoba, 1986-1991.

OBJECTIVE: To estimate the incidence and prevalence of diabetes among adults in Manitoba, Canada, from 1986 to 1991. RESEARCH DESIGN AND METHODS: A population-based database of individuals diagnosed with diabetes (Manitoba Diabetes Database) was created using data from Manitoba Health's comprehensive insurance system. Using this database, estimates of the annual incidence and prevalence of diabetes among Manitoba adults aged > or = 25 years were made for the years 1986-1991. Age-specific and age-adjusted rates were calculated separately for men and women. RESULTS: The prevalence of diabetes in 1991 was 66.9/1,000 among adults > or = 25 years. Between 1986 and 1991 the age-adjusted prevalence rose steadily among both men and women. In 1991, the incidence of diabetes was 5.6/1,000. After an observed decline prior to 1989, the annual incidence of diabetes appears to be relatively stable. CONCLUSIONS: The prevalence of diabetes is increasing steadily despite relatively stable incidence rates. Population-based data are required for projecting future trends and are an important tool for planning the required health resources.

Elevated serum levels of neopterin but not beta 2-microglobulin in HIV-1-seronegative injecting drug users.

OBJECTIVE: To determine whether injecting drug use is associated with cellular immune activation in the absence of HIV-1 infection. DESIGN: Serum levels of neopterin and beta 2-microglobulin (beta 2M) were measured cross-sectionally in injecting drug users (IDU) enrolled in a prospective study. SUBJECTS AND METHODS: Two hundred and nineteen HIV-1-seronegative, healthy heterosexual black male IDU aged 21-49 years were selected from the Baltimore-based AIDS Linked to Intravenous Experiences (ALIVE) study. The possibility of including subjects in the process of seroconverting to HIV-1 was minimized by restricting the study to individuals who remained seronegative 6 months after the specimens used for analysis were collected. RESULTS: Mean serum beta 2M levels were not statistically different among groups of IDU whose usual pattern of injection was at least once a day for up to 3 consecutive days (daily users; n = 65), less than once per day (less-than-daily users; n = 75), or not at all for at least 2 weeks (non-recent users; n = 79). In contrast, the mean neopterin level was significantly (P = 0.039) greater in daily users (6.17 nmol/l) than in the other two groups (5.07 and 5.19 nmol/l, respectively, which were not statistically different). These results were not affected, by the frequency of using borrowed non-sterile works or by other demographic and risk factor variables. CONCLUSIONS: Frequent injecting drug use may be independently associated with a small elevation of serum neopterin levels, but not beta 2M levels. Although the occurrence of a type I error in this sample cannot be completely excluded, serum neopterin may be more sensitive than serum beta 2M in detecting activation of immunocompetent cells associated with frequent injecting drug use in this population.

Effects of ticlopidine, a new platelet aggregation inhibitor in man.

Ticlopidine is a new platelet aggregation inhibitor. The effect of this drug was studied on 55 subjects, healthy volunteers and hospitalized patients. The action requires 24 to 48 hr to appear, and lasts more than 3 days. A dose-effect relationship was studied with oral daily doses ranging from 250 to 1,000 mg during 1 wk; it showed a 50% inhibition on adenosine diphosphate (ADP)-induced aggregation at 2 muM concentration on an oral daily dose of 450 mg. No action was found on collagen-induced aggregation, and a mild effect was observed on platelet adhesiveness. Clinical tolerance was assessed in patients given ticlopidine in oral doses up to 500 mg/day during several weeks, showing no overt side effects and no change in the safety parameters.

The incidence of deep venous thrombosis and pulmonary embolism among patients with inflammatory bowel disease: a population-based cohort study.

BACKGROUND: There is an impression mostly from specialty clinics that patients with inflammatory bowel disease (IBD) have an increased risk of venous thromboembolic disorders. Our aim was to determine the incidence of deep venous thrombosis (DVT) and pulmonary embolism (PE) from a population-based database of IBD patients and, to compare the incidence rates to that of an age, gender and geographically matched population control group. METHODS: IBD patients identified from the administrative claims data of the universal provincial insurance plan of Manitoba were matched 1:10 to randomly selected members of the general population without IBD by year, age, gender, and postal area of residence using Manitoba Health's population registry. The incidence of hospitalization for DVT and PE was calculated from hospital discharge abstracts using ICD-9-CM codes 451.1, 453.x for DVT and 415.1x for PE. Rates were calculated based on person-years of follow-up for 1984-1997. Comparisons to the population cohort yielded age-adjusted incidence rate ratios (IRR). Rates were calculated based on person-years of follow-up (Crohn's disease = 21,340, ulcerative colitis = 19,665) for 1984-1997. RESULTS: In Crohn's disease the incidence rate of DVT was 31.4/10,000 person-years and of PE was 10.3/10,000 person-years. In ulcerative colitis the incidence rates were 30.0/10,000 person-years for DVT and 19.8/10,000 person-years for PE. The IRR was 4.7 (95% CI, 3.5-6.3) for DVT and 2.9 (1.8-4.7) for PE in Crohn's disease and 2.8 (2.1-3.7) for DVT and 3.6 (2.5-5.2) for PE, in ulcerative colitis. There were no gender differences for IRR. The highest rates of DVT and PE were seen among patients over 60 years old; however the highest IRR for these events were among patients less than 40 years. CONCLUSION: IBD patients have a threefold increased risk of developing DVT or PE.

Viruses and inflammatory bowel disease: is there evidence for a causal association?

There has been a resurgent interest in potential microbial etiologies of inflammatory bowel disease (IBD). Over the past decade there have been both epidemiological and tissue studies exploring the potential role of paramyxoviruses in IBD, particularly Crohn's disease. This article will review the evidence and hence plausibility of a causal association between these viruses and IBD.

Therapeutic value of a gastroenterology consultation in irritable bowel syndrome.

BACKGROUND: Functional patients comprise the largest group in gastroenterology practice. Pharmacological therapy of irritable bowel syndrome is disappointing. One treatment strategy for irritable bowel syndrome emphasizes the physician's role; the physician is promoted as the therapeutic modality. AIM: To determine the therapeutic value of the contemporary approach to irritable bowel syndrome by examining health care utilization and patient morbidity. METHODS: We performed an observational study over 4 years using an administrative database and morbidity scales. Health care utilization was assessed for 2 years pre- and post-intervention. Patient morbidity was assessed at baseline and 1 and 2 years post-intervention. The participants included 70 irritable bowel syndrome patients referred by primary physicians. A structured consultation was performed, establishing a positive diagnosis of irritable bowel syndrome and providing disease conceptualization. RESULTS: Health care utilization for gastrointestinal diagnoses increased in the year prior to the intervention and declined immediately after to baseline; psychiatric and other visits remained unchanged for 4 years. Pain was reduced but other morbidity persisted. CONCLUSIONS: A consultation itself is a therapeutic intervention in irritable bowel syndrome with regard to its impact on societal economic burden. It is associated with a durable decrease in illness-specific health care utilization. It may not address all aspects of irritable bowel syndrome; multiple domains of morbidity demonstrated persistent distress.

Geographic analysis of diabetes prevalence in an urban area.

The objective of this research is to identify the sociodemographic, environmental, and lifestyle factors associated with the geographic variability of Diabetes Mellitus (DM) prevalence in the City of Winnipeg, Manitoba in Canada. An ecological regression study design was employed for this purpose. The study population included all prevalent cases of DM in 1998 for Winnipeg. Predictor and outcome data were aggregated for analysis using two methods. First, the spatial scan statistic was used to aggregate study data into highly probable diabetes prevalence clusters. Secondly, predictor and outcome data were aggregated to existing administrative health areas. Analysis of variance and spatial and non-spatial linear regression techniques were used to explore the relationship between predictor and outcome variables. The results of the two methods of data aggregation on regression results were compared. Mapping and statistical analysis revealed substantial clustering and small-area variations in the prevalence of DM in the City of Winnipeg. The observed variations were associated with variations in socioeconomic, environmental and lifestyle characteristics of the population. The two methods of data aggregation used in the study generated very similar results in terms of identifying the geographic location of DM clusters and of the population characteristics ecologically correlated to those clusters. High rates of DM prevalence are strongly correlated with indicators of low socioeconomic status, poor environmental quality and poor lifestyles. This analysis further illustrates what a useful tool the spatial scan statistic can be when used in conjunction with ecological regression to explore the etiology of chronic disease.

Development of an assay for antibodies to Saccharomyces cerevisiae: Easy, cheap and specific for Crohn's disease.

OBJECTIVE: To develop a serological test to measure antibodies to Saccharomyces cerevisiae in patients with inflammatory bowel disease. METHODS: An ELISA to the mannan of S cerevisiae that is commercially available was developed. Sera were tested from randomly chosen sera specimens kept frozen at the University of Manitoba Inflammatory Bowel Disease Clinical and Research Centre, Winnipeg, Manitoba. Clinical diagnoses were kept blinded until the assay results were finalized. One hundred thirty-six sera were tested, including 51 with Crohn's disease, 32 with ulcerative colitis, one with indeterminate colitis and 16 other control subjects. Thirty-six samples were duplicates from patients already studied but were either run on separate days or drawn on different days. RESULTS: Using a cutoff of 15 binding units as a positive result, Crohn's disease was found to have a sensitivity of 53% but a specificity of 100% compared with ulcerative colitis. Compared with all other diagnoses (including ulcerative colitis), Crohn's disease had a sensitivity of 53% and a specificity of 96%. For patients with Crohn's disease only, those who were anti-S cerevisiae antibody (ASCA) positive (n=27) were significantly more likely to have proximal gastrointestinal disease and significantly less likely to have colonic or inflammatory type disease than those who were ASCA negative (n=24). The direct cost of this assay was $6.00 per positive test, and the total charge was set at $38.15. CONCLUSIONS: A reasonably inexpensive, easy and reproducible assay to assess for antibodies to S cerevisiae has been developed. Using a cutoff for positivity of 15 binding units, this test had a specificity of 100% for ruling out Crohn's disease and a lower (60%) sensitivity compared with ulcerative colitis. This test could identify a specific phenotype of patients with Crohn's disease as being more likely to have small bowel Crohn's disease and less likely to have colonic (isolated) or inflammatory disease, as opposed to fibrostenotic disease or penetrating disease. The test proved reliable when assaying samples drawn or assayed on different days.

Excess costs of diabetes in the Aboriginal population of Manitoba, Canada.

OBJECTIVE: We developed a measure of the cost of diabetes for general and North American Indian populations of Manitoba and estimated the excess costs of diabetes which are attributable to diabetes prevalence rates and per person utilization of health services. RESEARCH DESIGN AND METHODS: We obtained data from the Manitoba Medicare database and the Manitoba Diabetes Database. We estimated costs for each service and cost per person for four populations: Indian and general population groups with and without diabetes. Excess cost formulas were estimated. RESULTS: Prevalence and utilization were considerably higher for the North American Indian population. As a first approximation, excess costs due to disease prevalence added 15.9% to total costs, while excess costs due to utilization add 14.6%. CONCLUSIONS: Disease prevalence indicates a need to focus on primary preventive measures. High utilization indicates complications, and suggests a need for secondary prevention.

The interactions of ticlopidine and aspirin in normal subjects.

This trial was performed on 24 health volunteers in order to study the possible interactions between aspirin and ticlopidine. The results confirm the inhibitory activity of aspirin on collagen-induced aggregation and that of ticlopidine on ADP-induced aggregation. If aspirin does not modify the inhibitory effect of ticlopidine on ADP-induced aggregation, ticlopidine on the other hand potentiates the effect of aspirin on collagen-induced aggregation.

Rates and determinants of HIV-attributable mortality among rural female sex workers in Northern Karnataka, India.

Female sex workers (FSWs) have among the highest rates of HIV infection in India. However, little is known about their HIV-specific mortality rates. In total, 1561 FSWs participated in a cohort study in Karnataka. Outcome data (mortality) were available on 1559 women after 15 months of follow-up. To gather details on deaths, verbal autopsy (VA) questionnaires were administered to key informants. Two physicians reviewed the VA reports and assigned underlying causes of death. Forty-seven deaths were reported during the follow-up (overall mortality rate was 2.44 per 100 person-years), with VA data available on 45 women. Thirty-five (75.6%) of these women were known to be HIV-positive, but only 42.5% were on antiretroviral therapy (ART). Forty deaths were assessed to be HIV-related, for an HIV-attributable mortality rate of 2.11 deaths per 100 person-years. Absence of a current regular partner (incidence rate ratio: 2.79; 95% confidence interval [CI]: 1.39-5.60) and older age (1.06; 1.01-1.11) were associated with increased HIV-attributable mortality. Reported duration in sex work was not related to HIV-attributable mortality. We found a high HIV-related mortality rate among this cohort of FSWs; nearly 10 times that of national mortality rates among women of a similar age group. Older age, but not reported duration in sex work, was associated with increased mortality, and suggests HIV acquisition prior to self-reported initiation into sex work. Despite significant efforts, there remain considerable gaps in HIV prevention near or before entry into sex work, as well as access and uptake of HIV treatment among FSWs.

Formal and informal sector health providers in southern India: role in the prevention and care of sexually transmitted infections, including HIV/AIDS.

Healthcare providers (HCPs) play a central role in the provision of prevention and care services for people with sexually transmitted infections (STIs), including HIV/AIDS. However, the degree of readiness for this role through appropriate training and experience is not clear. In the case of both the urban and rural areas of the state of Karnataka, India, primary and secondary healthcare is provided by practitioners who can be categorised into three major groups: qualified allopathic physicians, qualified non-allopathic doctors (homeopathic and Ayurvedic) and registered medical practitioners. In 2002, the India-Canada Collaborative HIV/AIDS Project conducted a study in an urban area and a rural district of the state of Karnataka, collecting information from 998 care providers regarding attitudes, knowledge and practices related to STI care and HIV/AIDS care in particular. This paper analyses and compares the three different types of HCPs with respect to these parameters and discusses implications for STI/HIV/AIDS prevention and care programs.

The role of collectives in STI and HIV/AIDS prevention among female sex workers in Karnataka, India.

This paper evaluates the role of female sex worker (FSW) collectives in the state of Karnataka, India, regarding their facilitating effect in increasing knowledge and promoting change towards safer sexual behaviour. In 2002 a state-wide survey of FSWs was administered to a stratified sample of 1,512 women. Following the survey, a collectivization index was developed to measure the degree of involvement of FSWs in collective-related activities. The results indicate that a higher degree of collectivization was associated with increased knowledge and higher reported condom use. Reported condom use was higher with commercial clients than with regular partners or husbands among all women and a gradient was observed in most outcome variables between women with low, medium and high collectivization index scores. Collectivization seems to have a positive impact in increasing knowledge and in empowering FSWs in Karnataka to adopt safer sex practices, particularly with commercial clients. While these results are encouraging, they may be confounded by social desirability, selection and other biases. More longitudinal and qualitative studies are required to better understand the nature of sex worker collectives and the benefits that they can provide.

Populations, pathogens, and epidemic phases: closing the gap between theory and practice in the prevention of sexually transmitted diseases.

The phase specific model for the prevention and control of sexually transmitted infections (STI) offers new insights into the strategic planning of programmes. The model illustrates the importance of modifying the focus of prevention and control activities to different subpopulations as the epidemic evolves over time. However, the practical application of phase specific approaches will depend on an understanding of the variability and determinants in the trajectory by which STI epidemics progress through epidemic phases. This paper draws on empirical observations from diverse populations to explore the influence of sexual behaviour patterns in populations, the biological characteristics of STI pathogens, and the population-pathogen interactions in relation to epidemic trajectories. In addition, various approaches to the determination of epidemic phase are presented.

A double-blind, placebo-controlled multicentre trial of ticlopidine in patients with peripheral arterial disease in Argentina. Design, organization and general characteristics of patients at entry. The EMATAP Group.

Patients with atherosclerotic disease of the lower limbs are at high risk of thrombotic events not only in the peripheral circulation, but also in the coronary and cerebral arteries. Ticlopidine, a potent inhibitor of platelet aggregation, can reduce the incidence of arterial thrombosis in patients suffering from intermittent claudication, as shown by a meta-analysis performed in 1987. In order to confirm these findings, we undertook a randomized, stratified, placebo-controlled, double-blind multicentre trial in Argentina in two parallel groups of patients suffering from intermittent claudication. Twenty-one clinical centres participated in the trial and 615 patients were enrolled. Patients were eligible if they had presented obstructive arterial disease of the upper part of the lower limb (popliteal or above) for at least 12 months, confirmed by either angiography or Doppler studies, and intermittent claudication (stage II) assessed by treadmill testing. Non insulin treated diabetic patients were eligible if they fulfilled the other inclusion criteria and two strata, diabetic and non diabetic, were established. Patients enrolled were treated with either ticlopidine (500 mg/day) or placebo for 24 weeks. In this paper, we report the design and organization of the study and the baseline characteristics of the patient population at inclusion.(ABSTRACT TRUNCATED AT 250 WORDS)

Risk factors for abdominal aortic aneurysm: results of a case-control study.

Abdominal aortic aneurysms (AAAs) have historically been considered to be a manifestation of atherosclerosis. However, there are epidemiologic and biochemical differences between occlusive atherosclerotic disease and aneurysmal disease of the aorta. A case-control study was performed to investigate risk factors for AAA at the two tertiary care hospitals in Winnipeg, Manitoba, Canada, between June 1992 and December 1995 to investigate risk factors for AAA. Newly diagnosed cases of AAA (n = 98) were compared with non-AAA controls (n = 102), who underwent ultrasound for indications similar to those of the cases. Compared with that for never smokers, the adjusted odds ratio (OR) was 2.75 (95% confidence interval (CI): 0.85, 8.91) for 1-19 pack-years, 7.31 (95% CI: 2.44, 21.9) for 20-34 pack-years, 7.35 (95% CI: 2.40, 22.5) for 35-49 pack-years, and 9.55 (95% CI: 2.81, 32.5) for 50 or more pack-years. Other factors significantly associated with AAA were male gender (OR = 2.68, 95% CI: 1.26, 5.73), diastolic blood pressure (OR per 10 mmHg = 1.88, 95% CI: 1.31, 2.69), and family history of AAA (OR = 4.77, 95% CI: 1.26, 18.1). There was an inverse association between diabetes mellitus and AAA (OR = 0.32, 95% CI: 0.12, 0.88). Neither clinical hypercholesterolemia nor serum levels of total cholesterol, low density lipoprotein cholesterol, and high density lipoprotein cholesterol was associated with AAA. The results of this study suggest that the risk factors for AAA differ from those for atherosclerosis and that atherosclerosis per se is not an adequate explanation as the cause of AAAs.