Three-year incidence of AIDS in five cohorts of HTLV-III-infected risk group members.

The incidence of the acquired immune deficiency syndrome (AIDS) among persons infected with human T-lymphotropic virus type III (HTLV-III) was evaluated prospectively among 725 persons who were at high risk of AIDS and had enrolled before October 1982 in cohort studies of homosexual men, parenteral drug users, and hemophiliacs. A total of 276 (38.1 percent) of the subjects were either HTLV-III seropositive at enrollment or developed HTLV-III antibodies subsequently. AIDS had developed in 28 (10.1 percent) of the seropositive subjects before August 1985. By actuarial survival calculations, the 3-year incidence of AIDS among all HTLV-III seropositive subjects was 34.2 percent in the cohort of homosexual men in Manhattan, New York, and 14.9 percent (range 8.0 to 17.2 percent) in the four other cohorts. Out of 117 subjects followed for a mean of 31 months after documented seroconversion, five (all hemophiliacs) developed AIDS 28 to 62 months after the estimated date of seroconversion, supporting the hypothesis that there is a long latency between acquisition of viral infection and the development of clinical AIDS. This long latency could account for the significantly higher AIDS incidence in the New York cohort compared with other cohorts if the virus entered the New York homosexual population before it entered the populations from which the other cohorts were drawn. However, risk of AIDS development in different populations may also depend on the presence of as yet unidentified cofactors.

HTLV-III exposure among drug users.

The Centers for Disease Control hierarchical classification of those at risk for acquired immunodeficiency syndrome (AIDS) underestimates the number of cases in which illicit drug use may play a role in the exposure to human T-cell leukemia virus type III. The immunosuppressive effects of nitrite inhalants are not sufficiently documented to elucidate their role as a cofactor in the development of AIDS. The currently available data on the immunosuppressive effects of self-administered parenteral drugs and their diluents indicate an associated elevation of immunoglobulin M, depressed helper/suppression T-cell ratios, and even damage to DNA. Illicit psychoactive drugs and their diluents may influence the virulence of the virus among parenteral drug users. An association between parenteral drug use and prostitution is not unexpected. Female prostitutes who use parenteral drugs may be at high risk for exposure to the virus and thus may transmit this infectious agent to their clients and their families.

Selected public health observations derived from Multicenter AIDS Cohort Study.

Selected findings from the Multicenter AIDS Cohort Study (MACS) of homosexual/bisexual men are reviewed. High risk sexual behaviors, the use of drugs/alcohol, condom use, and behavior change are addressed in a public health context. The potential significance of education/behavior modification programs as strategies for public health intervention emerges from these findings. Until there is a realistic timetable for vaccine availability and more effective chemotherapy, the MACS provides the opportunity to continue to study the effects of behavior change on the AIDS epidemic.

Predictors of decline in CD4 lymphocytes in a cohort of homosexual men infected with human immunodeficiency virus.

Longitudinal data on four visits scheduled at 6 month intervals were available on a cohort of 1,827 homosexual men who were human immunodeficiency virus (HIV) seropositive at entry. To identify predictors of the rate of decline of CD4 T-lymphocytes, we used an autoregressive model that relates CD4 counts to predictor variables, while adjusting for previous CD4 counts. Significant predictors of steeper decline of CD4 counts were high CD8 count, low hemoglobin, low platelets, high serum IgA, high cytomegalovirus (CMV) antibody, and low HIV antibody. Using the fitted model, a subject with an initial deficit of 314 CD4 cells (median value of study sample) with respect to seronegative subjects and with average values in all other predictors is estimated to lose approximately 53 cells in a 6 month period (95% C.I. = 45-61 cells). Contrasting this estimate to the one obtained with similar methods in intravenous drug users, it is suggested that a faster rate of decline is present among i.v. drug users. This analysis provides evidence that several covariates in addition to previous number of CD4 counts have significant predictive power for estimating the decline in CD4 counts in HIV seropositive subjects.

Seroconversion, sexual activity, and condom use among 2915 HIV seronegative men followed for up to 2 years.

A cohort of 2915 HIV-1-seronegative men from the four centers of the Multicenter AIDS Cohort Study (MACS) was followed at 6 month intervals for 24 months to identify men who developed antibodies to HIV-1. Two hundred thirty-two men (8%) seroconverted. The highest attack rate was among men who reported practicing both receptive and insertive anal-genital intercourse. The attack rate among men who reported practicing receptive but not insertive intercourse was 3.6 times higher than among men practicing insertive intercourse although those practicing insertive only reported 38% more different partners. Only two men seroconverted who reported not practicing analgenital intercourse in the 12 month prior to the first antibody-positive visit. Because men were followed every 6 months, one of these men could have been infected within 6 months of the actual development of HIV-1 antibodies. The seroconversion rate was significantly lower among men who reported using condoms with all their partners. The results of this study (a) reaffirm that receptive anal-genital intercourse is the major route of infection among homosexual men of HIV-1, (b) suggest that there is a low risk of HIV-1 infection to the insertive partner in anal-genital intercourse, (c) suggest that infection may rarely occur through sexual activities other than anal-genital intercourse, (d) provide evidence that condoms as currently used by men in the MACS provide significant but not complete protection against HIV-1 infection, and (e) suggest that the number of men in the homosexual community engaging in high-risk behavior is declining.

Exposure factors for HIV-1 infection among heterosexual drug abusers in New Jersey treatment programs.

In a cross-sectional study of 926 subjects from 10 drug treatment programs conducted in 1984 in New Jersey, the seroprevalence of human immunodeficiency virus (HIV) was 35% overall; 30% in whites, 33% in hispanics, and 46% in blacks (p = 0.01 for comparison of blacks to non-blacks). Univariate analysis showed the seroprevalence of HIV was not associated with age or gender, but did correlate with frequency of cocaine or heroin injection (p trend less than 0.001); frequency of needle sharing (p trend = 0.007); and inversely with levels of education (p = 0.05). The prevalence of HIV was also inversely related to the distance of the treatment center from lower Manhattan; being highest for distances of less than 5 miles from lower Manhattan and lowest for distances of 80 miles, with intermediate rates for the intervening distances (p trend less than 0.001). In multivariate analyses, HIV seropositivity was consistently associated with the frequency of needle sharing (p = 0.02) and less than 12 years (high school level) of education (p = 0.02), but not with black race. However, blacks who shared needles less than once a month had a relative risk of 3.2 (95% CI 1.2, 7.7) while non-blacks who shared less than once a month had a relative risk of only 0.9 (95% CI 0.3, 2.4). The risk in non-blacks increased to more than twofold with more frequent needle sharing. When the analysis was stratified by gender and adjusted for needle sharing and geography, a significant twofold increased risk was observed for female (but not male) subjects who had two or more heterosexual partners compared with those who had one partner.(ABSTRACT TRUNCATED AT 250 WORDS)

The role of the National Institute on Drug Abuse in the development of naltrexone.

Naltrexone was administered to 114 opiate-addicted business executives and 15 opiate-addicted physicians within a highly structured abstinence-oriented aftercare program following an inpatient detoxification program that used clonidine. The majority of patients successfully completed 6 months of naltrexone treatment without missed visits or drug-positive urines, and were still opiate-free at 12- to 18-months follow-up. The most successful outcomes were achieved by those who had entered treatment with unequivocal job jeopardy. Our findings suggest that naltrexone can be an extremely useful adjunct in the treatment of opiate addiction when administered to employed, motivated patients within a highly structured therapeutic program.

Patterns of alcohol and drug abuse in drug treatment clients from different ethnic backgrounds.

In this paper we have sought to identify differences in alcohol consumption patterns and problems among young adult males from white, black, and Hispanic ethnic groups entering drug treatment programs. In overall consumption patterns we found results similar to those obtained in general population studies. However, about one-third of the clients in all ethnic groups could be classified as heavier drinkers (drinking at least once a week and 4 or more drinks per drinking occasion) in the period immediately prior to treatment. About one-fourth of the clients in each ethnic group consumed a daily average of 2.5 ounces of absolute alcohol. Compared with the other ethnic groups, blacks were the most likely to be abstainers and reported regular alcohol use and drunkenness at later ages. Regardless of the pattern of development, similar proportions of the clients in all ethnic groups reported heavier drinking levels by age 21-30. Consistent with the current hypotheses in the literature, whites reported much higher levels of alcohol-related problems and prior treatment. Despite having similar levels of drinking, black and Hispanic ethnic groups did not appear to recognize alcohol as a problem or to report alcohol-related problems to the extent that whites did. Examination of drug-use patterns showed great variation in the nature and extent of drug use among the three ethnic groups. Whites were distributed among the seven patterns of use. Heroin use with cocaine, marijuana, and alcohol was the predominant pattern for blacks and Hispanics. Although the patterns of drug use differed greatly, these patterns were not differentially related to alcohol consumption or alcohol-related problems within ethnic groups. On the contrary, the drug-use patterns appeared to be a stronger predictor than ethnicity of use and problems. Multiple-nonnarcotic-users reported the highest levels of alcohol consumption and the greatest numbers of alcohol-related problems. This group typically reported the highest number of alcohol-related problems. Expression of a current need for treatment and a history of prior alcohol treatment were highest for black multiple-nonnarcotic-users. Our examination of the influences of family and friends was based on a limited number of questions available in the data. Heavier drinking was reported by clients who lived with friends, had family or friends who drank regularly, or had extensive involvement in the drug-use network, including drug sales. No ethnic differences were found.(ABSTRACT TRUNCATED AT 400 WORDS)

Intravenous drug users and the acquired immune deficiency syndrome.

Acquired immune deficiency syndrome (AIDS), a new epidemic disease characterized by dysfunction of cellular immunity, is most common among homosexual and bisexual males with multiple sexual partners and users of intravenous drugs. AIDS appears to be spread by contact with blood products and body fluids. Not only is the heroin user at increased risk of contracting AIDS, but also the occasional recreational drug user who shares a needle and syringe when he or she self-administers cocaine or amphetamines at a party on a weekend. Although precise figures are not available, there may be as many as several million recreational and regular users of cocaine and heroin. Data from a national sample of drug abuse treatment programs indicates that more than 80 percent of all clients seeking treatment, whatever their primary drug of abuse at the time of admission to treatment, have administered drugs to themselves intravenously during the year before treatment. Several hundred thousand treatment episodes occur each year. Data from surveys indicate that drug users entering treatment are well aware of the increased risks associated with AIDS. It is not surprising that treatment staff, also, have expressed concerns about their own susceptibility to the disease. Special education programs for these health workers have been instituted in New York City and have met with success. These programs have provided information and reassurance to treatment providers. At present, no health worker providing direct treatment service to drug abusers with a history of intravenous drug use has contracted AIDS.

The psychological consequences of the Chernobyl accident--findings from the International Atomic Energy Agency Study.

In October 1989, more than 3 years after the nuclear power plant accident at Chernobyl, in the Ukraine, the Government of the Union of Soviet Socialist Republics requested that the International Atomic Energy Agency (IAEA) evaluate the medical and psychological health of residents living in areas identified as being contaminated with radioactive fallout. The IAEA designed and conducted a collaborative study to examine whether there were any measurable effects of exposure to the low levels of ionizing radiation resulting from the accident. The study, using structured interviews and IAEA laboratory equipment, collected data on more than 1,350 residents of 13 villages. IAEA clinical staff members concluded that they could not identify any health disorders in either the contaminated or nearby (uncontaminated) control villages that could be attributed directly to radiation exposure. The clinical staff, however, did note that the levels of anxiety and stress of the villagers appeared to be disproportionate to the biological significance of the levels of IAEA-measured radio-active contamination. Almost half the adults in all the villages were unsure if they had a radiation-related illness. More than 70 percent of persons in the contaminated villages wanted to move away, and approximately 83 percent believed that the government should relocate them. The IAEA effort indicates that the villagers need to be educated about their actual risks, and they need to understand what types of illnesses are, and are not, associated with exposure to radioactive contamination. Unfortunately, the villagers' needs may exceed the available resources of their local and central governments.

The revitalization of the Public Health Service Commissioned Corps.

The Public Health Service (PHS) is the second oldest uniformed service of the United States; its tradition commenced with the establishment of the Marine Hospital Service in 1798. Congress, in 1889, established the United States Public Health Service Commissioned Corps under the aegis of the Treasury. The Corps was created as a uniformed nonmilitary service with a distinct uniform, insignia, and with titles, pay, and retirement protocols that corresponded to those of the uniformed military services (the Armed Forces). Initially the health care system of the country, and Commissioned Corps members, were concerned with infectious and vitamin-deficiency diseases; more recently the nation's medical community has focused on cardiovascular diseases, cancer, and AIDS. A comprehensive revitalization of the Commissioned Corps began in April 1987. The intent was to restore the Commissioned Corps to its traditional leadership role as a cadre of mobile, compassionate experts ensuring the nation's health. The revitalization activities have been successful. The Commissioned Corps has approximately 5,500 active duty officers. The Surgeon General directed the development of career tracks for 11 categories of commissioned officers to increase the opportunities for professional development within the PHS and thus increase retention and professional growth. The theme for the 1989 celebration of the centennial of the Commissioned Corps is "a century of service with distinction." A hundred years from now, at the bicentennial of the Commissioned Corps, the current Surgeon General would like it to be said that the Public Health Service has had "two centuries of service with distinction."

Consequences of the nuclear power plant accident at Chernobyl.

The Chernobyl Nuclear Power Plant accident, in the Ukrainian Soviet Socialist Republic (SSR), on April 26, 1986, was the first major nuclear power plant accident that resulted in a large-scale fire and subsequent explosions, immediate and delayed deaths of plant operators and emergency service workers, and the radioactive contamination of a significant land area. The release of radioactive material, over a 10-day period, resulted in millions of Soviets, and other Europeans, being exposed to measurable levels of radioactive fallout. Because of the effects of wind and rain, the radioactive nuclide fallout distribution patterns are not well defined, though they appear to be focused in three contiguous Soviet Republics: the Ukrainian SSR, the Byelorussian SSR, and the Russian Soviet Federated Socialist Republic. Further, because of the many radioactive nuclides (krypton, xenon, cesium, iodine, strontium, plutonium) released by the prolonged fires at Chernobyl, the long-term medical, psychological, social, and economic effects will require careful and prolonged study. Specifically, studies on the medical (leukemia, cancers, thyroid disease) and psychological (reactive depressions, post-traumatic stress disorders, family disorganization) consequences of continued low dose radiation exposure in the affected villages and towns need to be conducted so that a coherent, comprehensive, community-oriented plan may evolve that will not cause those already affected any additional harm and confusion.

Use and misuse of epidemiologic data in the courtroom: defining the limits of inferential and particularistic evidence in mass tort litigation.

Medical epidemiology is the cornerstone for understanding the safety and efficacy of drugs and medical devices. Epidemiologic principles provide a statistical basis for determining correlations, and ultimately mathematical causation, between two series of events. Medical epidemiologic evidence and statistical inferences are useful and are now routinely accepted in the courtroom. The complex distribution systems that provide fungible goods throughout the country often preclude the identification of the specific source of an allegedly defective product. An expansion of the principles established in Summers v. Tice and Ybarra v. Spangard provide a logical and rational means for the courts to address products liability issues in cases involving multiple and unnamed defendants. This Article discusses the impact of epidemiology on the judicial process, both in the nature of judicial decision-making and in the nature of the law itself. Part III B discusses the "weak" and "strong" versions of the traditional preponderance of the evidence rule, as recast by recent products liability litigation. The remainder of the Article defines the useful and appropriate scope of epidemiologic evidence, concluding that "intentless" epidemiologic evidence alone cannot support an award of punitive damages.

AIDSphobia litigation.

A significant proportion of adolescent girls engaging in risky behaviors will use confidential HIV counseling and testing services that are linked to primary care. Health-care providers play an important role in helping teens address their risk for and concerns about HIV infection by engaging adolescents in repeated discussions about HIV testing.

Naltrexone: its clinical utility.

Naltrexone is a long-acting orally-administered opioid antagonist that has demonstrated clinical utility as an adjunct in the outpatient treatment of opioid abuse. Naltrexone can be administered on a daily, twice a week or three times a week regimen, based on the clinical needs of the patient, and the therapeutic goals of the patient and therapist. Because naltrexone is unscheduled under the Controlled Substances Act, any licensed physician can prescribe this drug. This decentralized therapeutic approach for the highly motivated patient permits a ready separation between the patient's drug using friends and his or her current activities. The patients most likely to benefit from naltrexone therapy are employed, married, stabilized on low-dose methadone prior to detoxification, or detoxified from their opioid dependency 7 or more days previously, and are highly motivated to be maintained on a nonopioid chemotherapeutic agent. Naltrexone does not cure dependency. It does assist clinicians in dealing with the medical, psychological and economic problems associated with primary opioid abuse. Naltrexone will work well only when it is part of a larger therapeutic regimen which is tailored to the individual needs of the patient.