tag:blogger.com,1999:blog-49878033749898656012024-02-19T23:40:28.920-08:00Health Research Journals - Jurnal Penelitian KesehatanJurnal Hasil Penelitian Kesehatan,Jurnal,Kesehatan,Penelitian,Journals,Health,Research,Health Research,Research JournalsAll About Bloggerhttp://www.blogger.com/profile/17282736671555579827noreply@blogger.comBlogger18125tag:blogger.com,1999:blog-4987803374989865601.post-3534387657932353322010-06-04T02:06:00.001-07:002010-06-04T02:06:47.766-07:00Sexually Transmitted Diseases Screening; Scientists at School of Public Health target sexually transmitted diseases screening<strong>Sexually Transmitted Diseases Screening; Scientists at School of Public Health target sexually transmitted diseases screening<br /><br /></strong><em>Anonymous</em>. <!--End AUTHORS--><!--Start PUB_TITLE--><b><a href="http://proquest.umi.com/pqdweb?RQT=318&pmid=51275&TS=1275642334&clientId=45625&VInst=PROD&VName=PQD&VType=PQD">Medical Letter on the CDC & FDA</a></b><!--End PUB_TITLE-->. <!--Start PM_QUAL-->Atlanta: <!--End PM_QUAL--><!--Start ISSUE_URL--><a href="http://proquest.umi.com/pqdweb?RQT=572&VType=PQD&VName=PQD&VInst=PROD&pmid=51275&pcid=51783431&SrchMode=3">May 2, 2010</a>. <!--End ISSUE_URL--> pg. 88<!--End CITATION--> <div style="width: 12px; height: 12px;"><!-- --></div> <a name="summary"></a><!--Start ABSTRACT--><a name="abstract"></a><div class="docSection" style="padding-top: 4px; padding-left: 4px;"><span class="textSmall"><h2 class="docview inline">Abstract (Summary)</h2></span><div class="textMedium"><p style="margin-top: 0px;">United States, Sexually Transmitted Diseases Screening, Chlamydia Trachomatis, Gonorrhea, Gynecology, AIDS/HIV, Infectious Disease, Opportunistic Infections, Public Health, Regulatory Actions, Sexually Transmitted Diseases, Syphilis, Trichomonas Vaginitis, <em class="keywordhit">Trichomoniasis</em>, Women's Health's. </p></div></div><!--End ABSTRACT--><div style="padding-bottom: 15px;" class="textSmall"> <span style="font-family:Verdana,Geneva,Arial,Helvetica,sans-serif;font-size:85%;color:#cc0000;"><strong>»</strong></span> <a href="http://proquest.umi.com/pqdweb?index=2&did=2014712101&SrchMode=1&sid=2&Fmt=3&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1275641944&clientId=45625#indexing">Jump to indexing (document details)</a></div> <a name="fulltext"></a><!--Start FULL TEXT--><div style="margin-top: 5px;" class="docSection"><div class="textSmall docBar"><table><tbody><tr><td class="langDir" nowrap="nowrap"><span class="left"><h2 class="docview inline">Full Text</h2> </span><span class="right">(430 words)</span></td></tr></tbody></table></div><div class="textMedium"><span class="italic">(c)Copyright 2010, Medical Letter on the CDC & FDA via NewsRx.com</span><br /><br /><p style="margin-top: 0px;">2010 MAY 2 - (<http://www.newsrx.com> NewsRx.com) -- A report, 'Establishment of an HIV/sexually transmitted disease programme and prevalence of infection among incarcerated men in Jamaica,' is newly published data in International Journal of STD & AIDS (see also <http://www.newsrx.com/library/topics/sexually-transmitted-diseases-screening.html> Sexually Transmitted Diseases Screening). "The goal of this study is to describe the establishment of an HIV testing and treatment programme in the Jamaican correctional system and to estimate the prevalence of HIV/sexually transmitted disease (STD) among adult incarcerated men in this country. A demonstration project was implemented by the Jamaican Department of Correctional Services and Ministry of Health in the nation's largest correctional centre," scientists writing in the International Journal of STD & AIDS report.</p><p style="margin-top: 0px;">"All inmates were offered HIV and syphilis testing, and a subset was offered chlamydia, gonorrhoea and trichomoniasis testing. Cross-sectional data from the project were reviewed to determine the prevalence and correlates of HIV/STD. HIV test acceptance was 63% for voluntary testers (n=1200). The prevalence of HIV was 3.3% (95% confidence interval [CI] 2.33-4.64) (n=1017) and the prevalence syphilis was 0.7% (95% CI 0.29-1.49) (n=967). Among the subset tested (n=396) the prevalence of chlamydia was 2.5% (95% CI 1.22-4.49) and for trichomoniasis it was 1.8% (95% CI 0.01-3.60), but no cases of gonorrhoea were detected (n=396). The prevalence of HIV was significantly higher at 25% (95% CI 13.64-39.60) for persons located in a separate section where individuals labelled as men who have sex with men (MSM) are separated. HIV/STD testing is important and feasible in Jamaica. A special focus should be placed on providing services to inmates labelled as MSM," wrote K. Andrinopoulos and colleagues, School of Public Health.</p><p style="margin-top: 0px;">The researchers concluded: "Other Caribbean nations may also benefit from similar programmes."</p><p style="margin-top: 0px;">Andrinopoulos and colleagues published their study in International Journal of STD & AIDS (Establishment of an HIV/sexually transmitted disease programme and prevalence of infection among incarcerated men in Jamaica. International Journal of STD & AIDS, 2010;21(2):114-9).</p><p style="margin-top: 0px;">Additional information can be obtained by contacting K. Andrinopoulos, Tulane School of Public Health and Tropical Medicine, New Orleans, LA USA.</p><p style="margin-top: 0px;">The publisher of the International Journal of STD & AIDS can be contacted at: Royal Society Medicine Press Ltd., 1 Wimpole Street, London W1G 0AE, England.</p><p style="margin-top: 0px;">Keywords: City:New Orleans, State:LA, Country:United States, Sexually Transmitted Diseases Screening, Chlamydia Trachomatis, Gonorrhea, Gynecology, AIDS/HIV, Infectious Disease, Opportunistic Infections, Public Health, Regulatory Actions, Sexually Transmitted Diseases, Syphilis, Trichomonas Vaginitis, Trichomoniasis, Women's Health's.</p><p style="margin-top: 0px;">This article was prepared by Medical Letter on the CDC & FDA editors from staff and other reports. Copyright 2010, Medical Letter on the CDC & FDA via <http://www.newsrx.com> NewsRx.com.</p></div></div><!--End FULL TEXT--><!--APGIndexTermNormal--><input str="http://exslt.org/strings" value="305" name="RQT" type="hidden"><input str="http://exslt.org/strings" name="SQ" type="hidden"><input str="http://exslt.org/strings" value="PQ" name="querySyntax" type="hidden"> <input str="http://exslt.org/strings" value="REVERSE_CHRON" name="sortby" type="hidden"> <input str="http://exslt.org/strings" value="1275642334" name="TS" type="hidden"><div str="http://exslt.org/strings" class="docBlock docBar textSmall langDir"><a name="indexing"></a><h2 class="docview inline">Indexing (document details)</h2></div><!--Indexing of New York Time Index Start--><!--Indexing of New York Time Index End--><!--Start INDEX TERMS--><table str="http://exslt.org/strings" id="tableIndexTerms" border="0" cellpadding="4" cellspacing="1"><tbody><tr><td class="textSmall" valign="top" nowrap="nowrap"><strong>Subjects:</strong></td><td class="textSmall engContent" valign="top" align="left"><a href="javascript:searchSideWays(%22SUB%22,%22Sexually%20transmitted%20diseases--STD%22)">Sexually transmitted diseases--STD</a>, <a href="javascript:searchSideWays(%22SUB%22,%22Acquired%20immune%20deficiency%20syndrome--AIDS%22)">Acquired immune deficiency syndrome--AIDS</a>, <a href="javascript:searchSideWays(%22SUB%22,%22Studies%22)">Studies</a>, <a href="javascript:searchSideWays(%22SUB%22,%22Gonorrhea%22)">Gonorrhea</a>, <a href="javascript:searchSideWays(%22SUB%22,%22Confidence%20intervals%22)">Confidence intervals</a>, <a href="javascript:searchSideWays(%22SUB%22,%22Mens%20health%22)">Mens health</a>, <a href="javascript:searchSideWays(%22SUB%22,%22Womens%20health%22)">Womens health</a></td></tr><!--End INDEX TERMS--><!--Start SPEAKER BIO--> <!--Start AUTHORS--><tr><td class="textSmall" valign="top" nowrap="nowrap"><strong>Author(s):</strong></td><td class="textSmall engContent" valign="top" align="left">Anonymous</td></tr><!--End AUTHORS--><!--Start ARTICLE TYPE--><tr><td class="textSmall" valign="top" nowrap="nowrap"><strong>Document types:</strong></td><td class="textSmall engContent" valign="top" align="left">Expanded Reporting</td></tr><!--End ARTICLE TYPE--><!--Start DOCUMENT LANGUAGE--><!--End DOCUMENT LANGUAGE--><!--Start PUB TITLE--><tr><td class="textSmall" valign="top" nowrap="nowrap"><strong>Publication title:</strong></td><td class="textSmall engContent" valign="top" align="left"><a href="http://proquest.umi.com/pqdweb?RQT=318&pmid=51275&TS=1275642334&clientId=45625&VInst=PROD&VName=PQD&VType=PQD">Medical Letter on the CDC & FDA</a>. Atlanta: <a href="http://proquest.umi.com/pqdweb?RQT=572&VType=PQD&VName=PQD&VInst=PROD&pmid=51275&pcid=51783431&SrchMode=3">May 2, 2010</a>. pg. 88</td></tr><!--End PUB TITLE--><!--place of publication begins--><!--place of publication ends--><!--Source Type--><tr><td class="textSmall" valign="top" nowrap="nowrap"><strong>Source type:</strong></td><td class="textSmall" valign="top">Periodical</td></tr><!--Source Type--><!--Start ISSN--><tr><td class="textSmall" valign="top" nowrap="nowrap"><strong>ISSN:</strong></td><td class="textSmall" valign="top">10782907</td></tr><!--End ISSN--><!--Start DOCID--><tr><td class="textSmall" valign="top" nowrap="nowrap"><strong>ProQuest document ID:</strong></td><td class="textSmall" valign="top">2014712101</td></tr><!--End DOCID--><!--Start WORD COUNT--><tr><td class="textSmall" valign="top" nowrap="nowrap"><strong>Text Word Count</strong></td><td class="textSmall" valign="top">430</td></tr><!--End WORD COUNT--><!--Start ARTICLE URL--><tr><td class="textSmall" valign="top" nowrap="nowrap"><strong>Document URL:</strong></td><td class="textSmall" valign="top"><span id="wrapURL7">http://proquest<wbr>.umi<wbr>.com/pqdweb<wbr>?did=2014712101<wbr>&sid=2<wbr>&Fmt=3<wbr>&clientId=45625<wbr>&RQT=309<wbr>&VName=PQD</span></td></tr></tbody></table>All About Bloggerhttp://www.blogger.com/profile/17282736671555579827noreply@blogger.com0tag:blogger.com,1999:blog-4987803374989865601.post-37251139727271556162010-06-04T02:04:00.001-07:002010-06-04T02:04:39.854-07:00Trichomoniasis; New findings from University of Alabama in the area of trichomoniasis described<span class="italic">c)Copyright 2010, AIDS Weekly via NewsRx.com</span><br /><br /><p style="margin-top: 0px;">2010 MAY 17 - (<http://www.newsrx.com> NewsRx.com) -- Current study results from the report, 'Treatment of trichomoniasis in pregnancy in sub-Saharan Africa does not appear to be associated with low birth weight or preterm birth,' have been published (see also <http://www.newsrx.com/library/topics/trichomoniasis.html> Trichomoniasis). In this recent article published in the South African Medical Journal Suid-afrikaanse Tydskrif Vir Geneeskunde, scientists in the United States conducted a study "To determine whether treatment of trichomoniasis increases the risk of prematurity. Sub-analysis of a randomised trial."</p><p style="margin-top: 0px;">"We analysed data from HPTN trial of antenatal and intrapartum antibiotics to reduce chorioamnionitis-related perinatal HIV transmission. Pregnant women from four sites in Africa. Gestational age at the time of delivery or mean birth weight. Of 2,428 women-infant pairs included, 428 (18%) had trichomoniasis at enrolment. There were no differences in infant age or birth weight between women with or without trichomoniasis. By randomisation group, there were no differences in gestational age at birth or birth weight. Of the 428 women diagnosed with trichomoniasis, 365 (83%) received antibiotics and 63 (15%) did not. In analysis of actual use of antibiotics, women with trichomoniasis who received no treatment were more likely to deliver a preterm infant when the symphysis-fundal height was used to estimate gestational age (36% v. 23%; p=0.03), but not when the Ballard score was used (16% v. 21%; p=0.41). There were no differences in mean birth weight between groups," wrote E. Stringer and colleagues, University of Alabama.</p><p style="margin-top: 0px;">The researchers concluded: "In pregnant women in sub-Saharan Africa, most of whom were HIV-infected, neither trichomoniasis nor its treatment appears to influence the risk of preterm birth or a low-birth-weight infant."</p><p style="margin-top: 0px;">Stringer and colleagues published their study in South African Medical Journal Suid-afrikaanse Tydskrif Vir Geneeskunde (Treatment of trichomoniasis in pregnancy in sub-Saharan Africa does not appear to be associated with low birth weight or preterm birth. South African Medical Journal Suid-afrikaanse Tydskrif Vir Geneeskunde, 2010;100(1):58-64).</p><p style="margin-top: 0px;">Additional information can be obtained by contacting E. Stringer, University of Alabama at Birmingham, Dept. of Obstetrics and Gynecology, Birmingham, Alabama USA.</p><p style="margin-top: 0px;">The publisher of the South African Medical Journal Suid-afrikaanse Tydskrif Vir Geneeskunde can be contacted at: Med Association S Africa, Med House Central Sq 7430 Pinelands Priv Bag X1, Johannesburg, South Africa.</p><p style="margin-top: 0px;">Keywords: City:Birmingham, State:Alabama, Country:United States, Antibacterial, Antibiotics, Antimicrobial, HIV Infections, HIV/AIDS, Infectious Disease, Primate Lentiviruses, RNA Viruses, Retroviridae, Therapy, Treatment, Trichomonas Vaginitis, Trichomoniasis, Vertebrate Viruses, Viral Sexually Transmitted Diseases.</p><p style="margin-top: 0px;">This article was prepared by AIDS Weekly editors from staff and other reports. Copyright 2010, AIDS Weekly via <http://www.newsrx.com> NewsRx.com.</p><h2 class="docview inline">Indexing (document details)</h2><!--Indexing of New York Time Index Start--><!--Indexing of New York Time Index End--><!--Start SPEAKER BIO--> <!--Start AUTHORS--><table str="http://exslt.org/strings" id="tableIndexTerms" border="0" cellpadding="4" cellspacing="1"><tbody><tr><td class="textSmall" valign="top" nowrap="nowrap"><strong>Author(s):</strong></td><td class="textSmall engContent" valign="top" align="left">Anonymous</td></tr><!--End AUTHORS--><!--Start ARTICLE TYPE--><tr><td class="textSmall" valign="top" nowrap="nowrap"><strong>Document types:</strong></td><td class="textSmall engContent" valign="top" align="left">Expanded Reporting</td></tr><!--End ARTICLE TYPE--><!--Start DOCUMENT LANGUAGE--><!--End DOCUMENT LANGUAGE--><!--Start PUB TITLE--><tr><td class="textSmall" valign="top" nowrap="nowrap"><strong>Publication title:</strong></td><td class="textSmall engContent" valign="top" align="left"><a href="http://proquest.umi.com/pqdweb?RQT=318&pmid=51278&TS=1275642187&clientId=45625&VInst=PROD&VName=PQD&VType=PQD">AIDS Weekly</a>. Atlanta: <a href="http://proquest.umi.com/pqdweb?RQT=572&VType=PQD&VName=PQD&VInst=PROD&pmid=51278&pcid=52100681&SrchMode=3">May 17, 2010</a>. pg. 88</td></tr><!--End PUB TITLE--><!--place of publication begins--><!--place of publication ends--><!--Source Type--><tr><td class="textSmall" valign="top" nowrap="nowrap"><strong>Source type:</strong></td><td class="textSmall" valign="top">Periodical</td></tr><!--Source Type--><!--Start ISSN--><tr><td class="textSmall" valign="top" nowrap="nowrap"><strong>ISSN:</strong></td><td class="textSmall" valign="top">10691456</td></tr><!--End ISSN--><!--Start DOCID--><tr><td class="textSmall" valign="top" nowrap="nowrap"><strong>ProQuest document ID:</strong></td><td class="textSmall" valign="top">2031280491</td></tr><!--End DOCID--><!--Start WORD COUNT--><tr><td class="textSmall" valign="top" nowrap="nowrap"><strong>Text Word Count</strong></td><td class="textSmall" valign="top">418</td></tr><!--End WORD COUNT--><!--Start ARTICLE URL--><tr><td class="textSmall" valign="top" nowrap="nowrap"><strong>Document URL:</strong></td><td class="textSmall" valign="top"><span id="wrapURL7">http://proquest<wbr>.umi<wbr>.com/pqdweb<wbr>?did=2031280491<wbr>&sid=2<wbr>&Fmt=3<wbr>&clientId=45625<wbr>&RQT=309<wbr>&VName=PQD</span></td></tr></tbody></table>All About Bloggerhttp://www.blogger.com/profile/17282736671555579827noreply@blogger.com0tag:blogger.com,1999:blog-4987803374989865601.post-32804542035294535022009-11-16T00:41:00.000-08:002009-11-16T00:45:08.472-08:00Risk Assessment and Screening for Sexually Transmitted Infections, HIV, and Hepatitis Virus Among Long-Distance Truck Drivers in New Mexico, 2004-2006<div class="docCitationContainer"><div class="textMedium"><a onclick="return searchSideWays("AU","Sarah Valway");" href="javascript:void(0);"><em>Sarah Valway</em></a>, <a onclick="return searchSideWays("AU","Steven Jenison");" href="javascript:void(0);"><em>Steven Jenison</em></a>, <a onclick="return searchSideWays("AU","Nick Keller");" href="javascript:void(0);"><em>Nick Keller</em></a>, <a onclick="return searchSideWays("AU","Jaime Vega-Hernandez");" href="javascript:void(0);"><em>Jaime Vega-Hernandez</em></a>, <a onclick="return searchSideWays("AU","Donna Hubbard McCree");" href="javascript:void(0);"><em>Donna Hubbard McCree</em></a>. <!--End AUTHORS--><!--Start PUB_TITLE--><b><a href="http://proquest.umi.com/pqdweb?RQT=318&pmid=8&TS=1258360991&clientId=45625&VInst=PROD&VName=PQD&VType=PQD">American Journal of Public Health</a></b><!--End PUB_TITLE-->. <!--Start PM_QUAL-->Washington: <!--End PM_QUAL--><!--Start ISSUE_URL--><a href="http://proquest.umi.com/pqdweb?RQT=572&VType=PQD&VName=PQD&VInst=PROD&pmid=8&pcid=49407841&SrchMode=3">Nov 2009</a>. <!--End ISSUE_URL--><!--Start PCVOLUME-->Vol. 99<!--End PCVOLUME--><!--Start PCISSUE-->, Iss. 11;<!--End PCISSUE--> pg. 2063, 6 pgs</div><!--End CITATION--></div> <div style="width: 12px; height: 12px;"><!-- --></div> <a name="summary"></a><!--Start ABSTRACT--><a name="abstract"></a><div class="docSection" style="padding-top: 4px; padding-left: 4px;"><span class="textSmall"><h2 class="docview inline">Abstract (Summary)</h2></span><div class="textMedium"><p style="margin-top: 0px;">We examined sexually transmitted infection (STI), HIV, and hepatitis virus prevalence and risk behaviors among truck drivers. We asked participants about their risk behaviors, and we screened them for STIs, HIV, and hepatitis infections. We used logistic regression to identify factors associated with outcomes. Of the 652 enrolled participants, 21% reported sex with sex workers or casual partners in the prior year. Driving solo (odds ratio [OR]=15.04; 95% confidence interval [CI]=1.92, 117.53; P=.01), history of injection drug use (IDU; OR=2.69; 95% CI=1.19, 6.12; P=.02), and history of an STI (OR=2.47; 95% CI=1.19, 5.09; P=.01) were independently associated with high-risk sexual behaviors. Fourteen percent of participants reported drug use in the previous year, and 11% reported having ever injected drugs. Participants tested positive as follows: 54 for HCV antibodies (8.5%), 66 for hepatitis B anticore (anti-HBc) antibodies (10.4%), 8 for chlamydia (1.3%), 1 for <em class="keywordhit">gonorrhea</em> (0.2%), 1 for syphilis (0.2%), and 1 for HIV (0.2%). History of injecting drugs (OR=26.91; 95% CI=11.61, 62.39; P<.01) and history of anti-HBc antibodies (OR=7.89; 95% CI=3.16, 19.68; P<.01) were associated with HCV infection. Our results suggest a need for hepatitis C screening and STI risk-reduction interventions in this population.</p><p style="margin-top: 0px;"></p><div style="margin-top: 5px;" class="docSection"><div class="textMedium"><span class="italic">Copyright American Public Health Association Nov 2009</span><br /><br /><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td class="textSmall" nowrap="nowrap"><b>[Headnote]</b></td></tr><tr><td class="textSmall">Objectives. We examined sexually transmitted infection (STI), HIV, and hepatitis virus prevalence and risk behaviors among truck drivers.</td></tr><tr><td class="textSmall">Methods. We asked participants about their risk behaviors, and we screened them for STIs, HIV, and hepatitis infections. We used logistic regression to identify factors associated with outcomes.</td></tr><tr><td class="textSmall">Results. Of the 652 enrolled participants, 21% reported sex with sex workers or casual partners in the prior year. Driving solo (odds ratio [OR]=15.04; 95% confidence interval [CI]=1.92, 117.53; P=.01), history of injection drug use (IDU; OR=2.69; 95% CI=1.19, 6.12; P=.02), and history of an STI (OR=2.47; 95% CI=1.19, 5.09; P=.01) were independently associated with high-risk sexual behaviors. Fourteen percent of participants reported drug use in the previous year, and 11% reported having ever injected drugs. Participants tested positive as follows: 54 for HCV antibodies (8.5%), 66 for hepatitis B anticore (anti-HBc) antibodies (10.4%), 8 for chlamydia (1.3%), 1 for gonorrhea (0.2%), 1 for syphilis (0.2%), and 1 for HIV (0.2%). History of injecting drugs (OR=26.91; 95% CI=11.61, 62.39; P<.01) and history of anti-HBc antibodies (OR=7.89; 95% CI=3.16, 19.68; P<.01) were associated with HCV infection.</td></tr><tr><td class="textSmall">Conclusions. Our results suggest a need for hepatitis C screening and STI risk-reduction interventions in this population. (Am J Public Health. 2009;99: 2063-2068. doi:10.2105/AJPH.2008.145383)</td></tr></tbody></table></span><table border="0" cellpadding="0" cellspacing="0"><tbody></tbody></table><br /><p style="margin-top: 0px;">Studies in Africa, Southeast Asia, Eastern Europe, and South America have linked long-distance truck drivers and commercial sex workers with the dissemination of sexually transmitted infections (STIs), including human immunodeficiency virus (HIV) infection. 1-15 Evidence suggests that the spread of HIV throughout central Africa was facilitated by truck traffic along the Kinshasa-Mombasa highway. 1,2 High rates of STIs and HIV have been observed among long-distance truck drivers in India and Bangladesh, where truck drivers are implicated in the spread of STIs and HIV into rural areas and areas surrounding international border crossings.7-11 Results from studies in Eastern Europe suggest risky behavior and increased syphilis rates among truck drivers.12,13 Additionally, studies among truck drivers in Brazil show low levels of perceived risk of infection despite high rates of syphilis and high levels of risky behaviors, e.g., unprotected sex with multiple partners, including commercial sex workers, and high levels of drug use.14,15</p><p style="margin-top: 0px;">Little is known about the roles that longdistance truck drivers and sex workers at truck stops might play in spreading STIs or HIV in the United States. An ecological study in North Carolina examining reported syphilis cases during an outbreak found that the counties along interstate highways had higher syphilis rates than other counties in the state.16 The authors theorized that truck drivers and sex workers might have played a role in this finding, but there were no data to support this. A 1995 ethnographic study in Florida examining STI risk behaviors of truck drivers found low levels of perceived STI or HIV risk but high levels of risky behaviors.17 However, no laboratory studies were conducted; therefore, there are no data estimating the prevalence of STIs among long-distance truck drivers in the United States.</p><p style="margin-top: 0px;">To examine the environments in which STIs, HIV, and hepatitis virus are transmitted, and to assess the prevalence of STIs, HIV infection, and hepatitis virus infection and risk behaviors among truck drivers, we conducted a risk assessment and screening for STIs, HIV, and hepatitis among truck drivers traveling through New Mexico.</p><p style="margin-top: 0px;">METHODS</p><p style="margin-top: 0px;">From December 2004 through March 2006, we used mobile clinic vans to conduct this study at a large trucking terminal in Albuquerque, New Mexico, and at 10 truck stops on interstate highways elsewhere in the state. The 10 truck stops ranged in size from small (parking capacity approximately 50) to very large (more than 400 parking places). Nine truck stops had 24-hour restaurants, 4 had private security patrolling the lots, and 2 were located on Indian reservations and associated with casinos. Seven truck stops were on Interstate 40, running east-west through New Mexico; the rest were located in the southern part of the state on Interstate 25, Interstate 10, and at the intersection of interstates 285 and 360.</p><p style="margin-top: 0px;">Truck driverswere recruited via citizens' band radio and leaflets distributed at trucking venues. Any long-distance truck driver aged 21 years or older who had a valid commercial driver's license, who traveled interstate, and who did not return home nightly was eligible for the study. Participants provided verbal informed consent and completed a face-to-face interview conducted by a study team member. STI and hepatitis screening was conducted after the interview. Interviews lasted 15 to 30 minutes, and each participant was reimbursed $35 cash.</p><p style="margin-top: 0px;">The structured interview form collected demographics, driving history (e.g., years working as a driver), sexual behavior (e.g., condom use, STI history), and drug and alcohol use. All interviews were conducted anonymously, with no identifying or locating information collected, and all interview forms were coded with unique numbers.</p><p style="margin-top: 0px;">STI, HIV, and Hepatitis Screening</p><p style="margin-top: 0px;">Blood and urine samples were collected from study participants at the conclusion of the interview. We used a nucleic acid amplification test (Aptima Combo 2, Gen-Probe Inc, San Diego, CA) to test urine samples for chlamydia and gonorrhea. Blood serum samples were tested for syphilis,HIV, hepatitis B virusmarkers, andHCV markers. Syphilis antibodieswere assayed using a rapid plasma reagin (RPR) assay (Wampole Impact Syphilis RPR Card Test, Inverness Medical ProfessionalDiagnostics,Waltham,MA); positive RPR tests were confirmed using a Treponema pallidum particle agglutination (TPPA) assay (Serodia-TP-PA, Fujirebio Diagnostics, Malvern, PA). HIV antibodies were assayed using an HIV enzyme immunoassay (EIA) (Vironostika HIV- 1Microelisa System, bioMe'rieux, Marcy l'Etoile, France); positive EIA results were confirmed using an HIV-1Western blot assay (Genetic Systems HIV-1Western Blot, Bio-Rad Laboratories, Hercules, CA). Hepatitis B surface antigen (HBsAg) was assayed using the Genetic Systems HBsAg 3.0 test (Bio-Rad Laboratories), and total antihepatitis B core antibodies (anti-HBc) were assayed using the ETI-AB-COREK PLUS assay (DiaSorin, Saluggia, Italy). HCV antibodies were assayed using the ORTHO HCV version 3.0 ELISA test (Ortho Clinical Diagnostics, Rochester, NY). Positive test results for total HCV antibody were reported with a signal-to-cutoff ratio. A signal-to-cutoff ratio of at least 3.8 is predictive of a true positive test result more than 95% of the time.18</p><p style="margin-top: 0px;">All laboratory testing was performed by the Scientific Laboratory Division of the New Mexico Department of Health. No specimens were tested for drugs or alcohol.</p><p style="margin-top: 0px;">Data Analysis</p><p style="margin-top: 0px;">No identifying information was collected; thus, it was possible that drivers volunteered more than once. To identify potential duplicates, data were examined to identify drivers reporting the same response for age, gender, race, ethnicity, marital status, number of years driving, and home state. No potential duplicates were identified in this manner.</p><p style="margin-top: 0px;">Truck drivers were classified by type of driver: company drivers (union and nonunion), lease drivers, and owners/operators. Company drivers are employees of union and nonunion shops; all loads, driving schedules, and routes are arranged for them by the company. For union employees, the driving schedule is usually a set route. For nonunion employees, the driving schedules and routes are highly variable and often are modified while the driver is on the road. Lease drivers own their own truck and lease it to 1 or more companies. These drivers have some flexibility in their driving schedules and routes, and they usually have their loads arranged for them by the company to which they lease their truck. Owner/operator drivers are completely independent; these drivers own their own trucks, arrange their own loads, and determine their own driving schedule and routes.</p><p style="margin-top: 0px;">We used EpiInfo version 6 (Centers for Disease Control and Prevention, Atlanta, GA) and Intercooled Stata version 9 (StataCorp LP, College Station, TX) to conduct data analyses and all logistic regressions (descriptive, univariate, stratified, and multivariate). Numeric variables were analyzed as continuous variables. Age and number of years driving were also examined as categorical variables: age was divided into10- year age groups, and years driving was divided into groups of less than1year,1to5 years,6to10 years, and more than 10 years. For multivariate logistic regression analyses examining risk factors independently associated with having sex with a sex worker, drug use, and positive laboratory test results, all variables found by univariate analyses to be significantly associated with the outcomeat P£.05were included in analyses.</p><p style="margin-top: 0px;">RESULTS</p><p style="margin-top: 0px;">This study was conducted 2 to 3 times per month from December 2004 through March 2006 at the trucking terminal or a truck stop. A total of 652 drivers enrolled. Demographic characteristics are shown in Table 1. Most drivers resided in 44 of the contiguous 48 US states, with a few living in Canada. Thirty-nine (6%) had been driving for less than 1 year, and half of the drivers had been driving for more than 10 years (mean=13 years; range=1-48 years). Drivers reported being away from home a mean of 288 nights per year (range=60- 365 nights). However, the time away from home was not evenly distributed throughout the year. Some drivers (<10%)><p style="margin-top: 0px;">A number of differences were found when driver characteristics were examined by gender. Female drivers were significantly more likely than male drivers to have attended or completed college (odds ratio [OR]=2.79; 95% confidence interval [CI]=1.58, 4.93; P<.01) and to always drive as part of a team (OR=5.76; 95% CI=10.55, 19.45; P<.01). Of drivers always driving as part of a team, female drivers were significantly more likely to drive with their spouse or steady partner than male drivers were (OR=8.99; 95% CI=3.43, 24.16; P<.01). Female drivers also reported significantly fewer years driving than male drivers (mean 7.4 years for women vs 14.0 years for men; P<.01) and a lower mean annual income than men ($50000 vs $61000).</p><p style="margin-top: 0px;">Of the 652 drivers in this study, 5% were union employees, 71% were nonunion employees, 19% were lease drivers, and 5% were owner/operators. Union drivers reported almost always being home on weekends and spent significantly less time away from home than any of the other 3 types of drivers (mean=219 nights away from home per year vs 291, 296, and 278 nights away from home per year for nonunion drivers, lease drivers, and owner/operators, respectively; P<.01). Union drivers were also significantly more likely to always drive as part of a team (45% vs 20%, 14%, and 3% respectively), to have health insurance (100% vs 73%, 51%, and 57% respectively), and to have paid sick leave (100%vs 21%, 5%, and 0%; P<.01 for all analyses).</p><p style="margin-top: 0px;">Regarding health status, 31% of drivers reported their current health as fair or poor, with obesity, poor diet, and lack of exercise being common concerns. Health insurance coverage was reported by 67% of drivers, but only 19% had paid sick leave. For unionized drivers, health insurance was a benefit provided with employment. Most nonunion company drivers could purchase insurance through the company for which they worked; however, many said the cost was prohibitive. The high cost of insurance was also the main reason given by lease drivers and owner/operators for not purchasing health insurance coverage. Even though two thirds of the drivers had health insurance, they reported great difficulty accessing care and locating providers. As a result, drivers reported continuing to drive when ill (unless extremely ill) and using overthe- counter medications to alleviate symptoms</p><p style="margin-top: 0px;">Alcohol Use, Drug Use, and Sexual Risk Behaviors</p><p style="margin-top: 0px;">Twenty-five percent of drivers reported no alcohol consumption in the previous year, and 33% reported rarely drinking alcohol. Only 270 (41.4%) reported drinking 1 or more drinks per week (range=1-60 drinks/week). Binge drinking ([double dagger]5 drinks at 1 sitting) in the previous year was reported by 47% of drivers. Among these, 21% reported binge drinking at least 10 times in the previous year (mean=10; range=1-360).</p><p style="margin-top: 0px;">The mean number of reported lifetime sexual partners was 48 (median=15; range=1 to>1000), and 3% of male drivers reported ever having sex with a man. Previous STI treatment was reported by 132 drivers (gonorrhea 12%, chlamydia 5%, herpes 2%, syphilis 1%, and human papillomavirus 1%).</p><p style="margin-top: 0px;">Having sex with a sex worker in the previous 5 years was reported by 74 male drivers (13% of male drivers) and ranged from 1 time to more than 100 times. Forty-eight male drivers also reported having sex with a sex worker in the previous year (range=1-30 times). Sex with a casual partner (e.g., pick-up at bars, Internet contacts, another driver, truck stop employees) was reported by10 female and126 male drivers (21% of all drivers) for the previous 5 years and by 7 female and 73 male drivers (12% of all drivers) for the previous year. Among drivers reporting sex with a sex worker, 46% stated they used condoms less than half of the time, and 32% reported never having used condoms. Similar levels of condom use was reported for sex with a casual partner. Half the drivers reported that they had not used a condom the last time they had sex with a sex worker or casual partner. There were no statistically significant differences in reported condom use for drivers who reported having a spouse or steady partner.</p><p style="margin-top: 0px;">In multivariate logistic regression, only being a solo driver (OR=15.04; 95% CI=1.92, 117.53; P=.01), having a history of current or prior injection drug use (IDU; OR=2.69; 95% CI=1.19, 6.12; P=.02), and having a history of an STI (OR=2.47: 95% CI=1.19, 5.09; P=.01) remained independently associated with having sex with a sex worker in the previous year (Table 2). Having a current partner (OR=0.44; 95% CI=0.22, 0.89; P=.02) and increasing number of years driving (OR=0.95; 95% CI=0.92, 0.99; P=.01) remained independently associated with a decreased likelihood of having sex with a sex worker in the previous year.</p><p style="margin-top: 0px;">Drivers were asked about their use of ecstasy, heroin, crack cocaine, powder cocaine, methamphetamines, and marijuana in the previous 1 and 5 years. Overall, 195 (30%) reported any drug use in the previous 5 years and 93 (14%) in the previous year. However, 25% of the 652 drivers had been driving less than 5 years and 6% for less than 1 year. Thus, analysis of reported drug use among working drivers included only those working during the entire time period being analyzed, i.e., 486 drivers working at least 5 years and 613 drivers working at least 1 year.</p><p style="margin-top: 0px;">For the 486 drivers working at least 5 years, 126 (26%) reported any drug use during those 5 years, and 65 (14%) reported drug use in the previous 1 year. This significant decrease in reported drug use (P<.01 for marijuana and methamphetamine; P=.03 for powder cocaine) was reported to be a direct result of required random drug testing20 and the consequences of a positive test result, i.e., loss of job. For the 613 drivers working at least 1 year, 85 (14%) reported any drug use during that year (Table 3). Of drivers reporting any drug use in the previous year, 34 reported using marijuana at least monthly and 19 weekly, 17 used methamphetamines at least monthly and14 weekly, 7 used cocaine at least monthly, and 7 used crack at least monthly. A history of IDU was reported by 70 (11%) of all 652 drivers, and IDU in the previous year was reported by 9 (1%) drivers. Of the 9 drivers reporting recent IDU, 3 reported usingmultiple drugs, 4 injected heroin, 4 injected cocaine, and 4 injected methamphetamines.</p><p style="margin-top: 0px;">Univariate and multivariate logistic regression analyses were used to identify risk factors associated with reported drug use in the previous year. Only consuming at least 1 drink per week in the previous year (OR=2.44; 95% CI=1.26, 4.71; P=.01) remained independently associated with increased likelihood of using drugs, and only having health insurance (OR=0.59; 95% CI=0.35, 0.99; P=.05) remained independently associated with a decreased risk of drug use (Table 2).</p><p style="margin-top: 0px;">STI and Hepatitis Screening Test Results</p><p style="margin-top: 0px;">Urine specimens were obtained from 631 (96.8%) drivers and were tested for chlamydia and gonorrhea. Blood specimens were obtained from 636 (97.5%) drivers and were tested for HIV, syphilis, and hepatitis B and C. One male driver had a positive test for gonorrhea, and 8 drivers (4 men, 4 women) had positive test results for chlamydia (Table 4). One man with a history of IDU had positive test results for HIV (ELISA and Western blot). One man with a history of prior treatment of syphilis had a reactive test for syphilis (RPR 1:4 and TPPA positive). Three male drivers were HBsAg positive, and 66 others (10.4%; 5 women and 61 men) had remote resolved hepatitis B virus infection, i.e., a positive serum anti- HBc antibody test with a negative HBsAg test.</p><p style="margin-top: 0px;">A total of 54 drivers (8.5%; 4 women and 50 men) had a positive test result for HCV antibodies by EIA. The anti-HCV signal-tocutoff ratio for all but 1 of these drivers was greater than 4.2, indicating a high likelihood that the EIA results were true positive results.18 Of these 54 drivers, 36 (66.7%) reported prior or current IDU (2 of these 36 drivers also reported receiving blood transfusions prior to 1990, and 1 other had worked as an emergency medical technician); 2 reported blood transfusions prior to 1990; 1 worked as a dialysis nurse; 1 had a spouse with HCV; and for 14 there was no risk identified in the interview. Five already knew they had HCV, and 1 had undergone treatment for HCV. Of the 54 drivers positive for HCV, 28 (52%) reported having health insurance, 43 (80%) reported drinking alcohol in the previous year, 27 (50%) reported at least 1 episode of binge drinking in the previous year, and 11 (20%) reported binge drinking more than 10 times in the previous year. In multivariate analyses comparing drivers with positive HCV test results to those with negative results, history of IDU (OR=26.91; 95% CI=11.61, 62.39; P<.01) and having a positive anti-HBc antibody test (OR=7.89; 95% CI=3.16, 19.68; P<.01) were highly associated with positive HCV test results (Table 2).</p><p style="margin-top: 0px;">DISCUSSION</p><p style="margin-top: 0px;">Similar to results from studies of truck drivers in developing countries and in Florida, drivers in this study reported engaging in risky behaviors associated with STIs.1-15,17 However, STI prevalence was low. Multiple factors may contribute to this finding. First, rates of STIs in the United States among the general population are lower than in developing countries, particularly for countries with high rates of HIV infection. Second, sexual contact with commercial sex workers was reported by a small minority of study participants. Additionally, half of the study participants reported using a condom during their last sexual encounter. Finally, the sample was a voluntary, convenience sample; it is possible that those with STIs choose not to volunteer.</p><p style="margin-top: 0px;">An interesting finding was the high prevalence of HCV infection. The rate in this sample, 8.5%, was higher than the highest rate (4.3% in people aged 40-49 years) reported in the third National Health and Nutrition Examination Survey (1988-1994).21Two thirds of the HCVantibody- positive truck drivers reported previous or current IDU as a risk behavior likely related to HCV infection. Most participants who were HCV positive were unaware of their infection. This finding is significant because drivers also reported ongoing alcohol consumption, including binge drinking. Alcohol consumption is a strong independent risk factor for the progression of HCV-associated liver disease that potentially can be modified through patient education and behavior change.22,23</p><p style="margin-top: 0px;">We found that14%of drivers reported using an illicit drug during the previous year, with marijuana use reported more than twice as often as methamphetamine or cocaine use. Although no drug or alcohol testing was included in this study, the self-reported drug use among study participants was similar to the results of voluntary drug testing in Oregon in April 2007, when 10% of drivers tested positive for controlled substances.24 The Oregon study lent some validity to the self-reported drug use of drivers in the current study. Although most drivers in the current study reported occasional drug use, some reported regular use, including IDU. This presents a potentially grave safety issue if any drivers are under the influence while driving.</p><p style="margin-top: 0px;">Access to health care was repeatedly cited as a major concern for the truck drivers, a finding that has been previously documented.25 Even though most drivers had health insurance, they reported barriers to use. Their jobs necessitate mobility and routines that impede scheduling medical or dental appointments. Efforts such as establishing networks of medical or dental facilities with flexible hours at locations near trucking venues may provide improved access to health services for this population.</p><p style="margin-top: 0px;">This study has several limitations. The sample was a convenience sample of drivers traveling across New Mexico who volunteered to participate. Therefore, the results may not be representative of all US truck drivers. No information was available for drivers who did not volunteer. Behaviors of these drivers may be different from those who volunteered; drivers engaging in risky behaviors may have chosen not to participate. The demographic breakdown of drivers in this study was very similar to that estimated by the Department of Labor and the American Trucking Association. In 2000, the American Trucking Association estimated that 80% of truckers were White, 9.7% Hispanic, 11.7% African American, 25.7% did not complete high school, 59% were aged 35 to 54 years, and 4.6% were women.26 The Department of Labor estimates that up to 12% of drivers are women.27 However, there may be significant differences in risk factors or STI prevalence between drivers traveling through New Mexico and those traveling the East Coast or between cities with high rates of STIs or HIV.</p><p style="margin-top: 0px;">Additionally, the study design included a face-to-face interview, and data were selfreported. Therefore, social desirability may have caused under- or overreporting of risky behaviors, and drivers may have been reluctant to report use of alcohol or illegal drugs.</p><p style="margin-top: 0px;">Despite these limitations, this study contributes to the literature on STIs and HIV among US truck drivers by providing information on drivers' current health needs and opportunities for intervention among them. Prevalence of STIs and HIV was low, but drivers reported risky behaviors. Our results suggest that drivers may benefit from HIV, STI, and hepatitis prevention interventions embedded within comprehensive wellness programs that are convenient and easily integrated into the mobile environment of the trucking industry. Additional studies including different US trucker populations and more rigorous study designs should be conducted to confirm these results and provide more data to inform the development of STI and HIV intervention and wellness programs for the study population.</p><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td nowrap="nowrap"> <span class="bold textSmall">[Reference]</span> <span class="raquo">» </span> <a title="View a list of references included in this document" href="http://proquest.umi.com/pqdweb?VInst=PROD&VName=PQD&VType=PQD&RQT=594&did=1897707891&Fmt=3&refType=CITEDIN&b2=d&SrchMode=1&sid=1&index=10&TS=1258360991" class="textSmall">View reference page with links</a></td></tr><tr><td class="textSmall">References</td></tr><tr><td class="textSmall">1. Bwayo J, Plummer F, Omari M, et al. Human immunodeficiency virus infection in long-distance truck drivers in East Africa. Arch Intern Med. 1994;154:1391-1396.</td></tr><tr><td class="textSmall">2. Nzyuko S, Lurie P, McFarland W, Leyden W, Nyamwaya D, Mandel JS. Adolescent sexual behavior along the Trans-Africa Highway in Kenya. AIDS. 1997; 11(suppl 1):S21-S26.</td></tr><tr><td class="textSmall">3. Carswell JW, Lloyd G, Howells J. Prevalence of HIV- 1 in east African lorry drivers. AIDS. 1989;3:759-761.</td></tr><tr><td class="textSmall">4. Karim QS, Karim SS, Soldan K, Zondi Ml. Reducing the risk of HIV infection among South African sex workers: socioeconomic and gender barriers. Am J Public Health. 1995;85:1521-1525.</td></tr><tr><td class="textSmall">5. Ramjee G, Gouws E. Prevalence of HIV among truck drivers visiting sex workers in KwaZulu-Natal, South Africa. Sex Transm Dis. 2002;29:44-49.</td></tr><tr><td class="textSmall">6. Morris M, Podhisita C, Wawer MJ, Handcock MS. Bridge populations in the spread of HIV/AIDS in Thailand. AIDS. 1996;10:1265-1271.</td></tr><tr><td class="textSmall">7. Singh YN, Malaviya AN. Long distance truck drivers in India: HIV infection and their possible role in disseminating HIV into rural areas. Int J STD AIDS. 1994;5:137-138.</td></tr><tr><td class="textSmall">8. Manjunath JV, Thappa DM, Jaisankar TJ. Sexually transmitted diseases and sexual lifestyles of long-distance truck drivers: a clinico-epidemiologic study in south India. Int J STD AIDS. 2002;13:612-617.</td></tr><tr><td class="textSmall">9. Gibney L, Saquib N, Metzger J, Choudhury P, Siddiqui M, Hassan M. Human immunodeficiency virus, hepatitis B, C and D in Bangladesh's trucking industry: prevalence and risk factors. Int J Epidemiol. 2001;30:878-884.</td></tr><tr><td class="textSmall">10. Gibney L, Macaluso M, Kirk K, et al. Prevalence of infectious diseases in Bangladeshi women living adjacent to a truck stand: HIV/STD/hepatitis/genital tract infections. Sex Transm Infect. 2001;77:344-350.</td></tr><tr><td class="textSmall">11. Gibney L, Saquib N, Macaluso M, et al. STD in Bangladesh's trucking industry: prevalence and risk factors. Sex Transm Infect. 2002;78:31-36.</td></tr><tr><td class="textSmall">12. Grgic-Vitek M, Klavs I, Potocnik M, Rogl-Butina M. Syphilis epidemic in Slovenia influenced by syphilis epidemic in the Russian Federation and other newly independent states. Int J STD AIDS. 2002;13(suppl 1): 2-4.</td></tr><tr><td class="textSmall">13. Kulis M, Chawla M, Kozierkiewicz A, SubataTruck Drivers E, Sex Casual: An Inquiry Into the Potential Spread of HIV/AIDS in the Baltic Region. Washington, DC: World Bank; 2004.</td></tr><tr><td class="textSmall">14. Lacerda R, Gravato N, McFarland W, et al. Truck drivers in Brazil: prevalence of HIV and other sexually transmitted diseases, risk behavior and potential for spread of infection. AIDS. 1997;11(suppl 1):S15-S19.</td></tr><tr><td class="textSmall">15. Malta M, Bastos FI, Pereira-Koller EM, Cunja MD, Marques C, Strathdee SA. A qualitative assessment of long distance truck drivers' vulnerability to HIV/AIDS in Itajai, southern Brazil. AIDS Care. 2006;18:489-496.</td></tr><tr><td class="textSmall">16. Cook RL, Royce RA, Thomas JC, Hanusa BH. What's driving an epidemic? The spread of syphilis along an interstate highway in rural North Carolina. Am J Public Health. 1999;89:369-373.</td></tr><tr><td class="textSmall">17. Stratford D, Ellerbrock TV, Akens JK, Hall HL. Highway cowboys, old hands, and Christian truckers: risk behavior for human immunodeficiency virus infection among long haul truckers in Florida. Soc Sci Med. 2000;50:737-749.</td></tr><tr><td class="textSmall">18. Alter MJ, Kuhnert WL, Finelli L, Centers for Disease Control and Prevention. Guidelines for laboratory testing and result reporting of antibody to Hepatitis C virus. MMWR Recomm Rep. 2003;52(RR03):1-16.</td></tr><tr><td class="textSmall">19. Federal Motor Carrier Safety Administration. Hours-of-Service Regulations. Available at: http:// www.fmcsa.dot.gov/rules-regulations/topics/hos/hos- 2005.htm. Accessed June 15, 2008.</td></tr><tr><td class="textSmall">20. Federal Motor Carrier Safety Administration. Alcohol and Drug Rules. Available at: http://www.fmcsa. dot.gov/rules-regulations/topics/drug/engtesting.htm. Accessed June 15, 2008.</td></tr><tr><td class="textSmall">21. Armstrong GL, Wasley A, Simard EP, McQuillan GM, Kuhnert WL, Alter MJ. The prevalence of Hepatitis C virus infection in the United States, 1999 through 2002. Ann Intern Med. 2006;144:705-714.</td></tr><tr><td class="textSmall">22. Bell BP, Manos MM, Zaman A, et al. The epidemiology of newly diagnosed chronic liver disease in gastroenterology practices in the United States: results from population-based surveillance. Am J Gastroenterol. 2008;103:2727-2736.</td></tr><tr><td class="textSmall">23. Bedogni G, Miglioli L, Masutti F, et al. Natural course of chronic HCV and HBV infection and role of alcohol in the general population: the Dionysos Study. Am J Gastroenterol. 2008;103:2248-2253.</td></tr><tr><td class="textSmall">24. Oregon State Police. After Action Report: Operation Trucker Check-12, Woodburn Port of Entry, April 10- 12, 2007. Available at: www.oregon.gov/OSP/PATROL/ docs/trucker_check_after_action_report.pdf. Accesed June 15, 2008.</td></tr><tr><td class="textSmall">25. Solomon AJ, Doucette JT, Garland E, McGinn T. Health care and the long haul: long distance truck drivers-a medically underserved population. Am J Ind Med. 2004;46:463-471.</td></tr><tr><td class="textSmall">26. American Trucking Associations. The US Truck Driver Shortage: Analysis and Forecast. Available at: http://www.thetruckersreport.com/truckernews/ATADriverShortageStudy05[ 1].pdf. Accessed June 15, 2008.</td></tr><tr><td class="textSmall">27. Bureau of Labor Statistics, US Department of Labor. Occupational Employment Statistics. Available at: http:// www.bls.gov/cps/wlf-table14-2007.pdf. Accessed June 15, 2008.</td></tr></tbody></table></span><table border="0" cellpadding="0" cellspacing="0"><tbody></tbody></table><br /><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td class="textSmall" nowrap="nowrap"><b>[Author Affiliation]</b></td></tr><tr><td class="textSmall">Sarah Valway, DMD, MPH, Steven Jenison, MD, Nick Keller, BS, Jaime Vega-Hernandez, and Donna Hubbard McCree, PhD, MPH, RPh</td></tr></tbody></table></span><table border="0" cellpadding="0" cellspacing="0"><tbody></tbody></table><br /><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td class="textSmall" nowrap="nowrap"><b>[Author Affiliation]</b></td></tr><tr><td class="textSmall">About the Authors</td></tr><tr><td class="textSmall">Sarah Valway, Steven Jenison, Nick Keller, and Jaime Vega-Hernandez are with the Public Health Division, New Mexico Department of Health, Santa Fe. Donna Hubbard- McCree is with the National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA.</td></tr><tr><td class="textSmall">Correspondence should be sent to Sarah Valway, DMD, MPH, New Mexico Department of Health, Infectious Diseases Bureau, 1190 South Saint Francis Drive, Santa Fe, NM 87502 (e-mail: s.valway@att.net). Reprints can be ordered at http://www.ajph.org by clicking the ''Reprints/ Eprints'' link.</td></tr><tr><td class="textSmall">This article was accepted February 17, 2009.</td></tr><tr><td class="textSmall">Contributors</td></tr><tr><td class="textSmall">All the authors conceptualized the study design and developed and tested questionnaires prior to implementation. N. Keller led the recruitment of truck drivers. S. Valway, S. Jenison, N. Keller, and J. Vega-Hernandez conducted interviews with study participants and oversaw specimen collection. S. Valway led data management, article writing, and analyses. S. Jenison, N. Keller, J. Vega-Hernandez, and D. Hubbard McCree made significant contributions to data management, article writing, and analyses. S. Jenison and D. Hubbard McCree provided overall supervision of the study.</td></tr><tr><td class="textSmall">Acknowledgments</td></tr><tr><td class="textSmall">This research was funded by cooperative agreement from the Centers for Disease Control and Prevention through the Association for Prevention Teaching and Research (U36/CCU300860).</td></tr><tr><td class="textSmall">The authors appreciate the assistance of the truck drivers who participated in this study. Without their assistance, the study could not have been completed.We also acknowledge the many staff of the New Mexico STD Program, whose assistance with this study was vital to its success.</td></tr><tr><td class="textSmall">Human Participant Protection</td></tr><tr><td class="textSmall">The study was approved by the institutional review boards of the Centers for Disease Control and Prevention and the New Mexico Department of Health.</td></tr></tbody></table></span><table border="0" cellpadding="0" cellspacing="0"><tbody></tbody></table><br /></div></div><!--End FULL TEXT--> <!--Start References--><a name="references"></a><div id="refListContainer"><div class="docBlock docBar textSmall langDir"><h2 class="docview inline">References</h2></div><div class="textMedium" id="refListULContainer"> <ul class="refListBox"> <li class="first"> <a href="http://proquest.umi.com/pqdweb?VInst=PROD&VName=PQD&VType=PQD&RQT=594&did=1897707891&Fmt=3&refType=CITEDIN&b2=d&SrchMode=1&sid=1&index=10&TS=1258360991" title="View a list of references included in this document">References (27)</a></li> </ul> </div></div><!--End References--> <!--APGIndexTermNormal--><input str="http://exslt.org/strings" value="305" name="RQT" type="hidden"><input str="http://exslt.org/strings" name="SQ" type="hidden"><input str="http://exslt.org/strings" value="PQ" name="querySyntax" type="hidden"> <input str="http://exslt.org/strings" value="REVERSE_CHRON" name="sortby" type="hidden"> <input str="http://exslt.org/strings" value="1258360991" name="TS" type="hidden"><div str="http://exslt.org/strings" class="docBlock docBar textSmall langDir"><a name="indexing"></a><h2 class="docview inline">Indexing (document details)</h2></div><table str="http://exslt.org/strings" id="tableIndexTerms" border="0" cellpadding="4" cellspacing="1"><!--Indexing of New York Time Index Start--><!--Indexing of New York Time Index End--><!--Start INDEX TERMS--><tbody><tr><td class="textSmall" nowrap="nowrap" valign="top"><strong>Subjects:</strong></td><td class="textSmall engContent" align="left" valign="top"><a href="javascript:searchSideWays(%22SUB%22,%22Human immunodeficiency virus--HIV%22)">Human immunodeficiency virus--HIV</a>, <a href="javascript:searchSideWays(%22SUB%22,%22Trucking industry%22)">Trucking industry</a>, <a href="javascript:searchSideWays(%22SUB%22,%22Truck drivers%22)">Truck drivers</a>, <a href="javascript:searchSideWays(%22SUB%22,%22Wellness programs%22)">Wellness programs</a>, <a href="javascript:searchSideWays(%22SUB%22,%22Studies%22)">Studies</a>, <a href="javascript:searchSideWays(%22SUB%22,%22Risk factors%22)">Risk factors</a>, <a href="javascript:searchSideWays(%22SUB%22,%22Hepatitis%22)">Hepatitis</a>, <a href="javascript:searchSideWays(%22SUB%22,%22Health services%22)">Health services</a>, <a href="javascript:searchSideWays(%22SUB%22,%22Health care access%22)">Health care access</a>, <a href="javascript:searchSideWays(%22SUB%22,%22Flexible hours%22)">Flexible hours</a>, <a href="javascript:searchSideWays(%22SUB%22,%22Ethnicity%22)">Ethnicity</a>, <a href="javascript:searchSideWays(%22SUB%22,%22Drug testing%22)">Drug testing</a>, <a href="javascript:searchSideWays(%22SUB%22,%22Data analysis%22)">Data analysis</a>, <a href="javascript:searchSideWays(%22SUB%22,%22Alcohol use%22)">Alcohol use</a></td></tr><!--End INDEX TERMS--><!--Start SPEAKER BIO--> <!--Start AUTHORS--><tr><td class="textSmall" nowrap="nowrap" valign="top"><strong>Author(s):</strong></td><td class="textSmall engContent" align="left" valign="top"><a onclick="return searchSideWays("AU","Sarah Valway");" href="javascript:void(0);">Sarah Valway</a>, <a onclick="return searchSideWays("AU","Steven Jenison");" href="javascript:void(0);">Steven Jenison</a>, <a onclick="return searchSideWays("AU","Nick Keller");" href="javascript:void(0);">Nick Keller</a>, <a onclick="return searchSideWays("AU","Jaime Vega-Hernandez");" href="javascript:void(0);">Jaime Vega-Hernandez</a>, <a onclick="return searchSideWays("AU","Donna Hubbard McCree");" href="javascript:void(0);">Donna Hubbard McCree</a></td></tr><!--End AUTHORS--><!--Start Author Affiliations--><tr><td class="textSmall" nowrap="nowrap" valign="top"><strong>Author Affiliation:</strong></td><td class="textSmall engContent" align="left" valign="top">Sarah Valway, DMD, MPH, Steven Jenison, MD, Nick Keller, BS, Jaime Vega-Hernandez, and Donna Hubbard McCree, PhD, MPH, RPh<br /><br />About the Authors<br />Sarah Valway, Steven Jenison, Nick Keller, and Jaime Vega-Hernandez are with the Public Health Division, New Mexico Department of Health, Santa Fe. Donna Hubbard- McCree is with the National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA.<br />Correspondence should be sent to Sarah Valway, DMD, MPH, New Mexico Department of Health, Infectious Diseases Bureau, 1190 South Saint Francis Drive, Santa Fe, NM 87502 (e-mail: s.valway@att.net). Reprints can be ordered at http://www.ajph.org by clicking the ''Reprints/ Eprints'' link.<br />This article was accepted February 17, 2009.<br />Contributors<br />All the authors conceptualized the study design and developed and tested questionnaires prior to implementation. N. Keller led the recruitment of truck drivers. S. Valway, S. Jenison, N. Keller, and J. Vega-Hernandez conducted interviews with study participants and oversaw specimen collection. S. Valway led data management, article writing, and analyses. S. Jenison, N. Keller, J. Vega-Hernandez, and D. Hubbard McCree made significant contributions to data management, article writing, and analyses. S. Jenison and D. Hubbard McCree provided overall supervision of the study.<br />Acknowledgments<br />This research was funded by cooperative agreement from the Centers for Disease Control and Prevention through the Association for Prevention Teaching and Research (U36/CCU300860).<br />The authors appreciate the assistance of the truck drivers who participated in this study. Without their assistance, the study could not have been completed.We also acknowledge the many staff of the New Mexico STD Program, whose assistance with this study was vital to its success.<br />Human Participant Protection<br />The study was approved by the institutional review boards of the Centers for Disease Control and Prevention and the New Mexico Department of Health.</td></tr><!--End Author Affiliations--><!--Start ARTICLE TYPE--><tr><td class="textSmall" nowrap="nowrap" valign="top"><strong>Document types:</strong></td><td class="textSmall engContent" align="left" valign="top">Feature</td></tr><!--End ARTICLE TYPE--><!--Start Doc Features--><tr><td class="textSmall" nowrap="nowrap" valign="top"><strong>Document features:</strong></td><td class="textSmall engContent" align="left" valign="top">Tables, References</td></tr><!--End Doc Features--><!--Start SECTION--><tr><td class="textSmall" nowrap="nowrap" valign="top"><strong>Section:</strong></td><td class="textSmall engContent" align="left" valign="top"><span class="italic">RESEARCH AND PRACTICE</span></td></tr><!--End SECTION--><!--Start DOCUMENT LANGUAGE--><!--End DOCUMENT LANGUAGE--><!--Start PUB TITLE--><tr><td class="textSmall" nowrap="nowrap" valign="top"><strong>Publication title:</strong></td><td class="textSmall engContent" align="left" valign="top"><a href="http://proquest.umi.com/pqdweb?RQT=318&pmid=8&TS=1258360991&clientId=45625&VInst=PROD&VName=PQD&VType=PQD">American Journal of Public Health</a>. Washington: <a href="http://proquest.umi.com/pqdweb?RQT=572&VType=PQD&VName=PQD&VInst=PROD&pmid=8&pcid=49407841&SrchMode=3">Nov 2009</a>. Vol. 99, Iss. 11; pg. 2063, 6 pgs</td></tr><!--End PUB TITLE--><!--place of publication begins--><!--place of publication ends--><!--Source Type--><tr><td class="textSmall" nowrap="nowrap" valign="top"><strong>Source type:</strong></td><td class="textSmall" valign="top">Periodical</td></tr><!--Source Type--><!--Start ISSN--><tr><td class="textSmall" nowrap="nowrap" valign="top"><strong>ISSN:</strong></td><td class="textSmall" valign="top">00900036</td></tr><!--End ISSN--><!--Start DOCID--><tr><td class="textSmall" nowrap="nowrap" valign="top"><strong>ProQuest document ID:</strong></td><td class="textSmall" valign="top">1897707891</td></tr><!--End DOCID--><!--Start WORD COUNT--><tr><td class="textSmall" nowrap="nowrap" valign="top"><strong>Text Word Count</strong></td><td class="textSmall" valign="top">4757</td></tr><!--End WORD COUNT--><!--Start ARTICLE URL--><tr><td class="textSmall" nowrap="nowrap" valign="top"><strong>Document URL:</strong></td><td class="textSmall" valign="top"><span id="wrapURL7">http://proquest<wbr>.umi<wbr>.com/pqdweb<wbr>?did=1897707891<wbr>&sid=1<wbr>&Fmt=3<wbr>&clientId=45625<wbr>&RQT=309<wbr>&VName=PQD</span></td></tr></tbody></table><p></p></div></div>All About Bloggerhttp://www.blogger.com/profile/17282736671555579827noreply@blogger.com0tag:blogger.com,1999:blog-4987803374989865601.post-7832820012706870742009-11-16T00:34:00.000-08:002009-11-16T00:40:06.079-08:00Candidiasis Genetics; Researchers at University of Kansas<div align="left"><strong><em class="keywordhit">Candidiasis</em> Genetics; Researchers at University of Kansas have published new data on <em class="keywordhit">candidiasi</em> genetics</strong></div><div align="left"><div class="docSection" style="padding-top: 4px; padding-left: 4px;"><span class="textSmall"><h2 class="docview inline">Abstract (Summary)</h2></span><div class="textMedium"><p style="margin-top: 0px;">Drosophila cuticular hydrocarbons (CHCs) can function as pheromones and consequently affect mate recognition. In a previous study of the two major CHCs in females that affect mating discrimination between Drosophila simulans and D. sechellia, quantitative trait loci (QTL) were identified on the X and third chromosome, and a few candidate genes were potentially implicated. Here we specifically test candidate genes for CHC biosynthesis and determine the genetic architecture of four additional CHCs that differ in abundance between D. simulans and D. sechellia females. The same QTL, and new ones, were found for additional CHCs. By examining all these CHCs and exploring their covariance, we were able to ascribe putative function to the major QTL. Although desaturases have received considerable attention for their role in CHC biosynthesis, evidence here implies that elongases may be just as important.</p><div class="textMedium"><span class="italic">(c)Copyright 2009, Health & Medicine Week via NewsRx.com</span><br /><br /><p style="margin-top: 0px;">2009 NOV 9 - (<http://www.newsrx.com> NewsRx.com) -- A new study, 'Identification of quantitative trait loci function through analysis of multiple cuticular hydrocarbons differing between Drosophila simulans and Drosophila sechellia females,' is now available (see also <http://www.newsrx.com/library/topics/candidiasis-genetics.html> Candidiasis Genetics). "The genetics of sexual isolation, behavioral differences between species that prevent mating, is understood poorly. Pheromonal differences between species can influence sexual isolation in many animals and in some cases a single locus can cause large functional changes in pheromonal mating signals," investigators in the United States report.</p><p style="margin-top: 0px;">"Drosophila cuticular hydrocarbons (CHCs) can function as pheromones and consequently affect mate recognition. In a previous study of the two major CHCs in females that affect mating discrimination between Drosophila simulans and D. sechellia, quantitative trait loci (QTL) were identified on the X and third chromosome, and a few candidate genes were potentially implicated. Here we specifically test candidate genes for CHC biosynthesis and determine the genetic architecture of four additional CHCs that differ in abundance between D. simulans and D. sechellia females. The same QTL, and new ones, were found for additional CHCs. By examining all these CHCs and exploring their covariance, we were able to ascribe putative function to the major QTL. Although desaturases have received considerable attention for their role in CHC biosynthesis, evidence here implies that elongases may be just as important. Sex determination genes do not seem to have a role in this species difference although D. sechellia is sexually dimorphic in CHCs, whereas D. simulans is not," wrote J.M. Gleason and colleagues, University of Kansas.</p><p style="margin-top: 0px;">The researchers concluded: "Epistatic interactions, only detected for CHCs limited to D. sechellia, imply that complex interactions among loci may also be having a role in these compounds that affect mating isolation."</p><p style="margin-top: 0px;">Gleason and colleagues published their study in Heredity (Identification of quantitative trait loci function through analysis of multiple cuticular hydrocarbons differing between Drosophila simulans and Drosophila sechellia females. Heredity, 2009;103(5):416-24).</p><p style="margin-top: 0px;">For additional information, contact J.M. Gleason, University of Kansas, Dept. of Ecology and Evolutionary Biology, Lawrence, KS USA..</p><p style="margin-top: 0px;">The publisher of the journal Heredity can be contacted at: Nature Publishing Group, 345 Park Avenue South, New York, NY 10010-1707, USA.</p><p style="margin-top: 0px;">Keywords: United States, Lawrence, Candidiasis Genetics, Behavior, Vaginal Candidiasis.</p><p style="margin-top: 0px;">This article was prepared by Health & Medicine Week editors from staff and other reports. Copyright 2009, Health & Medicine Week via <http://www.newsrx.com> NewsRx.com.</p></div><!--End FULL TEXT--><!--APGIndexTermNormal--> <div class="docBlock docBar textSmall langDir"><a name="indexing"></a><h2 class="docview inline">Indexing (document details)</h2></div><!--Indexing of New York Time Index Start--><!--Indexing of New York Time Index End--><!--Start SPEAKER BIO--> <!--Start AUTHORS--><table id="tableIndexTerms" border="0" cellpadding="4" cellspacing="1"><tbody><tr><td class="textSmall" valign="top"><strong>Author(s):</strong></td><td class="textSmall engContent" align="left" valign="top">Anonymous</td></tr><!--End AUTHORS--><!--Start ARTICLE TYPE--><tr><td class="textSmall" valign="top"><strong>Document types:</strong></td><td class="textSmall engContent" align="left" valign="top">Expanded Reporting</td></tr><!--End ARTICLE TYPE--><!--Start DOCUMENT LANGUAGE--><!--End DOCUMENT LANGUAGE--><!--Start PUB TITLE--><tr><td class="textSmall" valign="top"><strong>Publication title:</strong></td><td class="textSmall engContent" align="left" valign="top"><a href="http://proquest.umi.com/pqdweb?RQT=318&pmid=51262&TS=1258188638&clientId=45625&VInst=PROD&VName=PQD&VType=PQD">Health & Medicine Week</a>. Atlanta: <a href="http://proquest.umi.com/pqdweb?RQT=572&VType=PQD&VName=PQD&VInst=PROD&pmid=51262&pcid=49283191&SrchMode=3">Nov 9, 2009</a>. pg. 837</td></tr><!--End PUB TITLE--><!--place of publication begins--><!--place of publication ends--><!--Source Type--><tr><td class="textSmall" valign="top"><strong>Source type:</strong></td><td class="textSmall" valign="top">Periodical</td></tr><!--Source Type--><!--Start ISSN--><tr><td class="textSmall" valign="top"><strong>ISSN:</strong></td><td class="textSmall" valign="top">15316459</td></tr><!--End ISSN--><!--Start DOCID--><tr><td class="textSmall" valign="top"><strong>ProQuest document ID:</strong></td><td class="textSmall" valign="top">1892898141</td></tr><!--End DOCID--><!--Start WORD COUNT--><tr><td class="textSmall" valign="top"><strong>Text Word Count</strong></td><td class="textSmall" valign="top">392</td></tr><!--End WORD COUNT--><!--Start ARTICLE URL--><tr><td class="textSmall" valign="top"><strong>Document URL:</strong></td><td class="textSmall" valign="top"><span>http://proquest.umi.com/pqdweb?did=1892898141&sid=2&Fmt=3&clientId=45625&RQT=309&VName=PQD</span></td></tr></tbody></table></div></div></div>All About Bloggerhttp://www.blogger.com/profile/17282736671555579827noreply@blogger.com0tag:blogger.com,1999:blog-4987803374989865601.post-89146474492013804912009-11-08T03:58:00.000-08:002009-11-08T04:15:25.520-08:00Data mining of tuberculosis patient data using multiple correspondence analysis<div class="textMedium"><strong>Data mining of tuberculosis patient data using multiple correspondence analysis<br /></strong><a onclick="'return" href="javascript:void(0);"><em>T W RENNIE</em></a>, <a onclick="'return" href="javascript:void(0);"><em>W ROBERTS</em></a>. <!--End AUTHORS--><!--Start PUB_TITLE--><b><a href="http://proquest.umi.com/pqdweb?RQT=318&pmid=79022&TS=1257682105&clientId=45625&VInst=PROD&VName=PQD&VType=PQD">Epidemiology and Infection</a></b><!--End PUB_TITLE-->. <!--Start PM_QUAL-->Cambridge: <!--End PM_QUAL--><!--Start ISSUE_URL--><a href="http://proquest.umi.com/pqdweb?RQT=572&VType=PQD&VName=PQD&VInst=PROD&pmid=79022&pcid=49318231&SrchMode=3">Dec 2009</a>. <!--End ISSUE_URL--><!--Start PCVOLUME-->Vol. 137<!--End PCVOLUME--><!--Start PCISSUE-->, Iss. 12;<!--End PCISSUE--> pg. 1699, 6 pgs<br /><span class="italic">Copyright © Cambridge University Press 2009</span><br /><br /><p style="margin-top: 0px;">(ProQuest: ... denotes non-US-ASCII text omitted.)</p><p style="margin-top: 0px;">Tuberculosis</p><p style="margin-top: 0px;">INTRODUCTION</p><p style="margin-top: 0px;">There has been a rise in tuberculosis (TB) notifications in the UK since 1987 [1]. However, excluding TB in London, rates of TB in the UK are relatively low and stable. In the context of North East (NE) London, high rates of TB are observed in some primary care trust areas (PCTs) whilst in others rates are relatively low [2]. This demonstrates the complexity of TB epidemiology in the UK and London and is suggestive of a range of factors that give rise to high rates of TB in specific geographical areas.</p><p style="margin-top: 0px;">As TB is a notifiable disease specialist TB healthcare professionals report demographic and clinical variables of patients who are notified to public health authorities. The Enhanced Tuberculosis Surveillance (ETS) system was introduced in 1999 to aid notification [3]. These collected data show the different demographic and clinical profiles of patients observed in NE London and may account for variations in TB rates. This is a valuable health information source, for example, in identifying commissioning priorities for different PCTs. This requires appropriate statistical support and effective communication to decision makers [4, 5]. However, analysis of large amounts of data with a large proportion of categorical/nominal data (e.g. gender, ethnicity, etc.) that can display multiple associations may prove to be difficult to interpret if bivariate comparisons are made. Factor analysis and principal components analysis (PCA) are inappropriate methods of analysis for these data which include a mix of continuous and categorical data. Multiple correspondence analysis (MCA) is an analytical method that allows analysis of multiple categorical variables [6]. The usefulness of this method lies in its reduction of large quantities of data and inclusion of any number of categorical variables although it does not provide a statistical assessment of association. We demonstrate the use of MCA as a tool for performing epidemiological 'mapping' of TB patient variables. This may prove to be useful in identifying commissioning priorities in NE London.</p><p style="margin-top: 0px;">METHOD</p><p style="margin-top: 0px;">MCA</p><p style="margin-top: 0px;">Greenacre [7] describes correspondence analysis (CA) in its simplest form as a two-way cross-tabulation summarizing the distribution of frequencies to display a data 'map' in two-dimensional space. MCA is the multivariable extension of CA that allows explanation of relationships between two or more variables [8]. By including more than two variables in this type of analysis the complexity is increased; relationships between variables are described in terms of the variance of data. As this technique involves categorical variables the variance of the data, specific to each variable category, can be plotted in dimensional space; the variance for each category can be 'averaged' to one point in space (the centroid). This results in two graphical outputs - object plots which show the spread of category data variance, and variable plots which can display joint category plots. The latter is useful in that entered variables may then be described by the proximity of variable categories to other categories' points, their inertia (degree of variance), and whether they lie along particular dimensions in common with other category points. This technique differs from PCA in that it permits analysis of multiple categorical variables [9]. However, continuous data, such as age, may be categorized and entered for analysis. For a full description of the use of MCA see Greenacre [6].</p><p style="margin-top: 0px;">Analytical strategy</p><p style="margin-top: 0px;">Data from the ETS dataset for NE London between the years 2002 and 2007 were selected and entered for analysis; this included data for seven PCTs. Denotified TB cases, where initial TB diagnosis was later changed, were excluded ( <i>n </i>=441). Data were entered into a data-frame in SPSS (version 14.0; SPSS Inc., USA) for analyses. After categorizing continuous data (patient age), data were entered for MCA using the 'optimal scaling' option in SPSS. A two-dimensional graphical output plot of data displaying variable categories was selected (variable plot - joint category plot function in SPSS).</p><p style="margin-top: 0px;">RESULTS</p><p style="margin-top: 0px;">Data for 4947 TB patients between the years 2002 and 2007 were entered for analysis. In this cohort of patients, male gender was slightly more common and the three most common ethnicities were Black African, Indian Asian, and Pakistani Asian; only 18·3% of patients were born in the UK (Table 1). A minority of patients (11·7%) had their consumption of treatment supervised by directly observed treatment (DOT) and over a third of patients were hospitalized. For three variables in particular (Table 1: employment, sputum smear test, bacterial resistance) there were large amounts of missing data. However, for data available, 46·4% of patients tested had a positive sputum smear result ( <i>n </i>=2269) and 18·3% of patients exhibited TB strains of any bacterial resistance to first-line TB medicines ( <i>n </i>=1673).</p><p style="margin-top: 0px;">Table 1. </p><p style="margin-top: 0px;">Demographic and clinical TB patient data, 2002-2006</p><p style="margin-top: 0px;">DOT, Directly observed treatment.</p><p style="margin-top: 0px;">Percentages calculated from <i>n </i>=4947 unless other sample size quoted due to missing data.</p><p style="margin-top: 0px;">* Employment excluding children, retired, housewives, asylum seekers or any ambiguity regarding current employment.</p><p style="margin-top: 0px;">[dagger] </p><p style="margin-top: 0px;">'Any resistance' refers to resistance to any of isoniazid, rifampicin, streptomycin, ethambutol, pyrazinamide.</p><p style="margin-top: 0px;">MCA was used to analyse these data in three ways: data were entered for analysis in their entirety, data were analysed by PCT, and data were analysed by year.</p><p style="margin-top: 0px;">Complete dataset analysis</p><p style="margin-top: 0px;">When all of the data were analysed together the joint category plot was complex and difficult to interpret reliably (Fig. 1 <i>a </i>). However, PCT6 associated with 'Bangladeshi' ethnicity as an outlying group. This finding demonstrated the known higher prevalence of Bangladeshi TB patients in this PCT [10]. However, this strong association dominated the output. Therefore, to investigate associations between other variables without the dominating effect of ethnicity on PCT6, ethnicity was excluded and the analysis repeated (Fig. 1 <i>b </i>). This suggested that both PCT6 and DOT ('Yes') categories were outliers from the dataset.</p><p style="margin-top: 0px;">Fig. 1. </p><p style="margin-top: 0px;">Multiple correspondence analysis graphical output of TB variable categories. ( <i>a </i>) All variables, all years. ( <i>b </i>) All variables, all years except ethnicity.</p><p style="margin-top: 0px;">Analysis by PCT</p><p style="margin-top: 0px;">MCA was repeated by analysing by each separate PCT. Figure 2 <i>a </i> displays an example of the output for PCT2 and is suggestive of an association between two groups of variable categories: Group 1: DOT ('Yes'), previous diagnosis ('Yes'), UK born ('Yes') and age >75 years. Group 2: hospital admission ('Yes'), positive sputum smear result ('Pos'), drug resistance ('Res') and pulmonary TB ('Yes'). The output for PCT7 is suggestive of a division between recent and earlier years of notification (Fig. 2 <i>b </i>). More recent years (2004-2007) appear to group with more positive variable categories such as patients not being admitted to hospital ('No'), no previous diagnosis ('No') and no DOT ('No'). Earlier years (2002-2003) appear to associate with less positive variable categories such as previous TB diagnosis ('Yes'), DOT ('Yes'), and positive sputum smear result ('Pos').</p><p style="margin-top: 0px;">Fig. 2. </p><p style="margin-top: 0px;">Multiple correspondence analysis graphical output of TB variable categories by primary care trust (PCT). ( <i>a </i>) PCT2; ( <i>b </i>) PCT7.</p><p style="margin-top: 0px;">Analysis by year</p><p style="margin-top: 0px;">Finally, MCA was repeated by analysing by year. For example, Figure 3 <i>a </i> displays data from 2002 with a possible association between PCT2 and PCT3 with the variable categories DOT ('Yes') and UK born ('Yes'). However, in 2007 this specific grouping was not observed although PCT2 appeared to associate with DOT ('Yes'), previous TB diagnosis ('Yes'), UK born ('Yes') and resistance ('Res') suggesting a complex case-load for this PCT (Fig. 3 <i>b </i>).</p><p style="margin-top: 0px;">Fig. 3. </p><p style="margin-top: 0px;">Multiple correspondence analysis graphical output of TB variable categories by year. ( <i>a </i>) 2002; ( <i>b </i>) 2007.</p><p style="margin-top: 0px;">DISCUSSION</p><p style="margin-top: 0px;">A commissioning framework report published by the Department of Health and informed by the governmental White Paper 'Our health, our care, our say: a new direction for community services' [4] highlighted the need for understanding the requirements of both populations and individuals as well as more effective sharing and use of information [5]. Data reported by healthcare systems is used to inform decisions concerning the commissioning of health services. Although these processes tend to be quite blunt, nevertheless, health commissioning would be ill-informed without the use of such data sources. It is pertinent to identify local trends in data to best focus healthcare resources and commission services appropriately. MCA is a well reported technique for the reduction of data and has previously been utilized in a wide range of different disciplines, e.g. analysis of wealth indices [9], more informative analyses of data for cardiac implantable devices [11], and investigations into subjective well-being, poverty and ethnicity [12]. This technique has previously been advocated for its use in the analysis of large datasets of categorical data, identifying themes according to data variance, and for scaling methods.</p><p style="margin-top: 0px;">The current study used MCA to epidemiologically 'map' data that related to TB patients in NE London between 2002 and 2007. This identified a number of trends between data variables, differences between PCTs, and changes over time. For example, there appeared to be an association between patients that were born in the UK, patients that received DOT, and patients that were admitted to hospital. There may also be links between these variable categories and resistance to anti-tuberculous drugs and higher age group (>75 years). These associations are rational in that, within the TB population in London where most patients were born outside the UK, UK-born patients who contract TB are more likely to be older due to reactivation of disease rather than primary infection, and older patients are more likely to be admitted to hospital. MCA output for one PCT (PCT7) appeared to suggest recent improvement in that more positive variable categories, such as no hospital admission, associated closer to recent year categories (2004-2007) whereas less positive categories, such as previous TB diagnosis, associated closer to earlier year categories (2002-2003).</p><p style="margin-top: 0px;">When analysed by year a similar grouping of more negative variable categories with two PCTs in particular (PCT2 and PCT3) was observed in 2002, and a similar grouping again observed for one of these PCTs (PCT2) in 2007. This suggests that cohorts of patients located within these PCTs had a greater burden of patients with complex needs in terms of provision of DOT and managing drug resistance, and that this issue had probably been resolved over time for PCT3. This clearly has resource implications. Treating patients with drug resistance, for example, has been estimated to be ten times the cost of treating a patient with drug-sensitive forms of TB [13]. Therefore, year-by-year analyses of this kind may inform where priorities lie. The various associations can be validated with further investigation to identify whether there are indeed greater priorities for certain PCTs in relation to specific patient groups and this, in turn, can inform commissioning priorities.</p><p style="margin-top: 0px;">With such a large dataset where small associations are more likely to achieve statistical significance, MCA provides meaningful analyses that account for interactions between variables in the dataset as a whole. Another benefit of MCA is that it allows analysis of numerous variables of a categorical nature - the only continuous variable in the current study was patient age which was categorized for analysis. Analysis of a wider set of more descriptive variables in the current study, focusing on other aspects of patient complexity, for example, would better inform TB priorities for each PCT. However, to our knowledge, this is the first instance of an analysis of this type being performed with the explicit aim of identifying commissioning priorities. In addition, we believe this to be the first reporting of a TB dataset in this way.</p><p style="margin-top: 0px;">A number of variables had large amounts of missing data. For example, sputum smear results and results for drug sensitivities were available for less than half of the cohort. This may relate to such results only having been recorded by TB services when they were deemed of clinical importance, such as resistance to a particular drug (recording only where tests had been performed and results obtained). However, it implies that these variables, in particular, were not reliably reported. Better recording of data would help to ensure that analyses were more reliable. Interestingly, MCA is a method used to explore patterns of missing data by categorizing missing data and including it in analyses, e.g. see Greenacre [7]. This technique could have been applied for the current dataset to assess whether missing data for specific variables differed from data that were better reported. Although this was beyond the aim of our study we are currently assessing data from the ETS dataset to better understand what the missing data might represent and, therefore, clarify reasons for non-reporting of data. In the current study only two-dimensional analyses were carried out to simplify the interpretation of results. In reality, the association between variables may be multidimensional and reveal further relationships between variable categories. However, for the purposes of using MCA as a commissioning tool multidimensional analyses are unlikely to be of significant added benefit.</p><p style="margin-top: 0px;">In conclusion, we present an analytical technique that allows analysis of multiple datasets that can contain different data types. This tool can be used as an epidemiological method to inform commissioning priorities in healthcare such as TB service provision. Whilst users should be aware of the limitations, MCA is an efficient technique that effectively produces a data map displaying association. This may be of particular use where large amounts of heterogenous data are available.</p><p style="margin-top: 0px;">ACKNOWLEDGMENTS</p><p style="margin-top: 0px;">Our thanks to the continued efforts of TB Services in North East London without whose help this work could not have been conducted.</p><p style="margin-top: 0px;">DECLARATION OF INTEREST</p><p style="margin-top: 0px;">T.W.R. and W.R. are both employed on a full-time basis by the National Health Service.</p><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td nowrap="nowrap"> <span class="bold textSmall">[Reference]</span> </td></tr><tr><td class="textSmall">REFERENCES</td></tr><tr><td class="textSmall">1. Health Protection Agency. (www.hpa.org.uk). Accessed 19 January 2009.</td></tr><tr><td class="textSmall">2. North East London TB Network. Annual report of demographic and epidemiological trends of TB in North East London. London, 2007.</td></tr><tr><td class="textSmall">3. BP Van. Data mining of tuberculosis patient data using multiple correspondence analysis Communicable Disease and Public Health 1998; 1: 219-220.</td></tr><tr><td class="textSmall">4. Department of Health. Our health, our care, our say: a new direction for community services. London: Department of Health, 2006.</td></tr><tr><td class="textSmall">5. Department of Health. Commissioning framework for health and well-being. London: Department of Health, 2007.</td></tr><tr><td class="textSmall">6. M Greenacre. Correspondence Analysis in Practice, 2nd edn. London: Taylor and Francis, 2007.</td></tr><tr><td class="textSmall">7. M Greenacre. Data mining of tuberculosis patient data using multiple correspondence analysis. Gaceta Sanitaria 2002; 16: 160-170.</td></tr><tr><td class="textSmall">8. E Kaciak, J Louviere. Data mining of tuberculosis patient data using multiple correspondence analysis. Journal of Marketing Research 1990; 27: 455-465.</td></tr><tr><td class="textSmall">9. LD Howe, JR Hargreaves, SR Huttly. Data mining of tuberculosis patient data using multiple correspondence analysis. Emerging Themes in Epidemiology 2008; 5: 3.</td></tr><tr><td class="textSmall">10. Directorate of Public Health. Tower Hamlets Public Health Report. Tower Hamlets Primary Care Trust, 2007.</td></tr><tr><td class="textSmall">11. M Guéguin, Data mining of tuberculosis patient data using multiple correspondence analysis. Conference Proceedings of the Annual International Conference of the IEEE Engineering in Medicine and Biology Society 2007; 1: 3848-3851.</td></tr><tr><td class="textSmall">12. DF Neff. Data mining of tuberculosis patient data using multiple correspondence analysis. Social Indicators Research 2007; 80: 313-341.</td></tr><tr><td class="textSmall">13. VL White, J Moore-Gillon. Data mining of tuberculosis patient data using multiple correspondence analysis. Thorax 2000; 55: 962-963.</td></tr></tbody></table></span><table border="0" cellpadding="0" cellspacing="0"><tbody></tbody></table><br /><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td class="textSmall" nowrap="nowrap"><b>[Author Affiliation]</b></td></tr><tr><td class="textSmall">North East London Tuberculosis Commissioning Unit, Newham Primary Care Trust, London, UK</td></tr></tbody></table></span><table border="0" cellpadding="0" cellspacing="0"><tbody></tbody></table><br /></div><!--End FULL TEXT--><!--APGIndexTermNormal--><input str="http://exslt.org/strings" value="305" name="RQT" type="hidden"><input str="http://exslt.org/strings" name="SQ" type="hidden"><input str="http://exslt.org/strings" value="PQ" name="querySyntax" type="hidden"> <input str="http://exslt.org/strings" value="REVERSE_CHRON" name="sortby" type="hidden"> <input str="http://exslt.org/strings" value="1257682105" name="TS" type="hidden"><div str="http://exslt.org/strings" class="docBlock docBar textSmall langDir"><a name="indexing"></a><h2 class="docview inline">Indexing (document details)</h2></div><!--Indexing of New York Time Index Start--><!--Indexing of New York Time Index End--><!--Start SPEAKER BIO--> <!--Start AUTHORS--><table str="http://exslt.org/strings" id="tableIndexTerms" border="0" cellpadding="4" cellspacing="1"><tbody><tr><td class="textSmall" valign="top" nowrap="nowrap"><strong>Author(s):</strong></td><td class="textSmall engContent" valign="top" align="left"><a onclick="'return" href="javascript:void(0);">T W RENNIE</a>, <a onclick="'return" href="javascript:void(0);">W ROBERTS</a></td></tr><!--End AUTHORS--><!--Start Author Affiliations--><tr><td class="textSmall" valign="top" nowrap="nowrap"><strong>Author Affiliation:</strong></td><td class="textSmall engContent" valign="top" align="left">North East London Tuberculosis Commissioning Unit, Newham Primary Care Trust, London, UK</td></tr><!--End Author Affiliations--><!--Start ARTICLE TYPE--><tr><td class="textSmall" valign="top" nowrap="nowrap"><strong>Document types:</strong></td><td class="textSmall engContent" valign="top" align="left">Feature</td></tr><!--End ARTICLE TYPE--><!--Start DOCUMENT LANGUAGE--><!--End DOCUMENT LANGUAGE--><!--Start PUB TITLE--><tr><td class="textSmall" valign="top" nowrap="nowrap"><strong>Publication title:</strong></td><td class="textSmall engContent" valign="top" align="left"><a href="http://proquest.umi.com/pqdweb?RQT=318&pmid=79022&TS=1257682105&clientId=45625&VInst=PROD&VName=PQD&VType=PQD">Epidemiology and Infection</a>. Cambridge: <a href="http://proquest.umi.com/pqdweb?RQT=572&VType=PQD&VName=PQD&VInst=PROD&pmid=79022&pcid=49318231&SrchMode=3">Dec 2009</a>. Vol. 137, Iss. 12; pg. 1699, 6 pgs</td></tr><!--End PUB TITLE--><!--place of publication begins--><!--place of publication ends--><!--Source Type--><tr><td class="textSmall" valign="top" nowrap="nowrap"><strong>Source type:</strong></td><td class="textSmall" valign="top">Periodical</td></tr><!--Source Type--><!--Start ISSN--><tr><td class="textSmall" valign="top" nowrap="nowrap"><strong>ISSN:</strong></td><td class="textSmall" valign="top">09502688</td></tr><!--End ISSN--><!--Start DOCID--><tr><td class="textSmall" valign="top" nowrap="nowrap"><strong>ProQuest document ID:</strong></td><td class="textSmall" valign="top">1894220731</td></tr><!--End DOCID--><!--Start WORD COUNT--><tr><td class="textSmall" valign="top" nowrap="nowrap"><strong>Text Word Count</strong></td><td class="textSmall" valign="top">2479</td></tr><!--End WORD COUNT--><!--Start DOI--><tr><td class="textSmall" valign="top" nowrap="nowrap"><strong>DOI:</strong></td><td class="textSmall" valign="top">10.1017/S0950268809002787</td></tr><!--End DOI--><!--Start ARTICLE URL--><tr><td class="textSmall" valign="top" nowrap="nowrap"><strong>Document URL:</strong></td><td class="textSmall" valign="top"><span id="wrapURL7">http://proquest<wbr>.umi<wbr>.com/pqdweb<wbr>?did=1894220731<wbr>&sid=2<wbr>&Fmt=3<wbr>&clientId=45625<wbr>&RQT=309<wbr>&VName=PQD</span></td></tr></tbody></table>All About Bloggerhttp://www.blogger.com/profile/17282736671555579827noreply@blogger.com0tag:blogger.com,1999:blog-4987803374989865601.post-45241989610292228382009-01-26T19:47:00.000-08:002009-01-26T19:51:20.512-08:00Influence of Life Course Socioeconomic Position on Older Women's Health Behaviors: Findings From the British Women's Heart and Health Study<div class="headerBlack"><strong>Influence of Life Course Socioeconomic Position on Older Women's Health Behaviors: Findings From the British Women's Heart and Health Study</strong></div><div class="textMedium"><!--Start AUTHORS--> <a onclick="'return" href="javascript:void(0);"><em>Hilary C Watt</em></a>, <a onclick="'return" href="javascript:void(0);"><em>Claire Carson</em></a>, <a onclick="'return" href="javascript:void(0);"><em>Debbie A Lawlor</em></a>, <a onclick="'return" href="javascript:void(0);"><em>Rita Patel</em></a>, <a onclick="'return" href="javascript:void(0);"><em>Shah Ebrahim</em></a>. <!--End AUTHORS--><!--Start PUB_TITLE--><b><a href="http://proquest.umi.com/pqdweb?RQT=318&pmid=8&TS=1233028224&clientId=45625&VInst=PROD&VName=PQD&VType=PQD">American Journal of Public Health</a></b><!--End PUB_TITLE-->. <!--Start PM_QUAL-->Washington: <!--End PM_QUAL--><!--Start ISSUE_URL--><a href="http://proquest.umi.com/pqdweb?RQT=572&VType=PQD&VName=PQD&VInst=PROD&pmid=8&pcid=41675711&SrchMode=3">Feb 2009</a>. <!--End ISSUE_URL--><!--Start PCVOLUME-->Vol. 99<!--End PCVOLUME--><!--Start PCISSUE-->, Iss. 2;<!--End PCISSUE--> pg. 320, 8 pgs</div><table border="0" cellpadding="2" cellspacing="0"></table><!--End CITATION--> <div style="width: 12px; height: 12px;"><!-- --></div> <a name="summary"></a><!--Start ABSTRACT--><a name="abstract"></a><div class="docSection" style="padding-top: 4px; padding-left: 4px;"><span class="textSmall"><strong>Abstract (Summary)</strong></span><div class="textMedium"><p style="margin-top: 0px;">We examined the association between health behaviors and socioeconomic status (SES) in childhood and adult life. Self-reported diet, smoking, and physical activity were determined among 3523 women aged 60 to 79 years recruited from general practices in 23 British towns from 1999 through 2001. The most affluent women reported eating more fruit, vegetables, chicken, and fish and less red or processed meat than did less affluent women. Affluent women were less likely to smoke and more likely to exercise. Life course SES did not influence the types of fat, bread, and milk consumed. Adult SES predicted consumption of all foods considered and predicted smoking and physical activity habits independently of childhood SES. Childhood SES predicted fruit and vegetable consumption independently of adult SES and, to a lesser extent, predicted physical activity. Downward social mobility over the life course was associated with poorer diets and reduced physical activity. Among older women, healthful eating and physical activity were associated with both current and childhood SES. Interventions designed to improve social inequalities in health behaviors should be applied during both childhood and adult life.</p><p style="margin-top: 0px;"><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td class="textSmall" nowrap="nowrap"><b>[Headnote]</b></td></tr><tr><td class="textSmall">Objectives. We examined the association between health behaviors and socioeconomic status (SES) in childhood and adult life.</td></tr><tr><td class="textSmall">Methods. Self-reported diet, smoking, and physical activity were determined among 3523 women aged 60 to 79 years recruited from general practices in 23 British towns from 1999 through 2001.</td></tr><tr><td class="textSmall">Results. The most affluent women reported eating more fruit, vegetables, chicken, and fish and less red or processed meat than did less affluent women. Affluent women were less likely to smoke and more likely to exercise. Life course SES did not influence the types of fat, bread, and milk consumed. Adult SES predicted consumption of all foods considered and predicted smoking and physical activity habits independently of childhood SES. Childhood SES predicted fruit and vegetable consumption independently of adult SES and, to a lesser extent, predicted physical activity. Downward social mobility over the life course was associated with poorer diets and reduced physical activity.</td></tr><tr><td class="textSmall">Conclusions. Among older women, healthful eating and physical activity were associated with both current and childhood SES. Interventions designed to improve social inequalities in health behaviors should be applied during both childhood and adult life. (Am J Public Health. 2009;99:320-327. doi:10.2105/AJPH.2007.129288)</td></tr></tbody></table></span></p><table border="0" cellpadding="0" cellspacing="0"><tbody></tbody></table><br /><p style="margin-top: 0px;">In 1977, the United Kingdom Department of Health commissioned an inquiry focusing on health inequalities in the country's population. The resulting report-the Black Report, published in 1980-highlighted the marked association between adult socioeconomic status (SES) and mortality rates.1 Such socioeconomic gradients inmortality rates persist today, tracking into old age.2</p><p style="margin-top: 0px;">Inequalities in health are a result of clearly identifiable social and economic factors that could potentially be modified to improve people's quality and length of life. Employment, education, housing, transportation, environment, health care, and "lifestyle" (in particular smoking, exercise, and diet) all affect health and tend to be favorably distributed in advantaged groups.</p><p style="margin-top: 0px;">In the United Kingdom, the introduction of the National Service Framework for Coronary Heart Disease in 2000 was intended to reduce the prevalence of and social inequalities in coronary risk factors in the country's population. 3 Achieving these aims requires equitable access to and use of preventive care irrespective of SES, age, and gender. Health promotion initiatives such the "5-a-day" fruit and vegetable diet plan,4 smoking cessation clinics, and structured exercise plans have all been part of the drive to reduce the prevalence of coronary risk factors.</p><p style="margin-top: 0px;">Recent years have seen increased recognition of the potential implications of life course SES and a deeper understanding of the conceptual framework on which it is based.5,6 There is growing evidence that coronary heart disease (CHD) risk is associated with life course SES,7-10 with those in the most disadvantaged SES groups throughout life showing nearly 3 times greater risk than those in more advantaged groups.8 This raises the question of the extent to which behavioral CHD risk factors are similarly dependent on life course SES. We examined the effects of childhood and adulthood SES on various health behaviors (diet, smoking, and physical activity) of older British women.</p><p style="margin-top: 0px;">METHODS</p><p style="margin-top: 0px;">Study Design and Data Collection</p><p style="margin-top: 0px;">We conducted a cross-sectional analysis of baseline data from participants in the British Women's Heart and Health Study. The methodology of that study has been fully reported elsewhere.11 Briefly, from 1999 through 2001, 4286 women aged 60 to 79 years were recruited from general practice lists in 23 representative British towns. Participants completed a questionnaire including items focusing on diet, smoking,12 and physical activity. As a means of gathering dietary data, women were asked how often (more than once a day, daily, most days, once or twice a week, less than weekly, or never) they ate fresh fruit, green vegetables, meat, and other foods.</p><p style="margin-top: 0px;">Behavioral Data</p><p style="margin-top: 0px;">Principal-component analyses were used to identify various food groups. Fruits, salads, green vegetables, fish, and poultry formed the first component; however, given the public health focus on fruits and vegetables, these foods were examined separately. Red and processed meat formed the second component; healthful bread (e.g., whole-meal bread), milk (e.g., skim milk), and fat (e.g., vegetable oil rather than animal fats, and low-fat margarine rather than butter) formed the third.</p><p style="margin-top: 0px;">Participants were asked to indicate the number of hours each week during the winter and summer they engaged in a specified range of physical activities; they were also asked to rate their walking speeds.13 These measurements were used to calculate their weekly number of hours of moderate or vigorous physical activity. Activities considered moderate or vigorous included walking at a relatively brisk or fast pace, cycling, heavy gardening, and other physical exercise (e.g., aerobics, swimming).</p><p style="margin-top: 0px;">Socioeconomic Status Data</p><p style="margin-top: 0px;">Ten SES indicators8 were used to construct a life course SES score and childhood and adult subscores: longest-held occupation of the participant's father during her childhood; whether the participant's childhood home had a bathroom and a hot water supply; whether the participant had shared a bedroom as a child; whether, during the participant's childhood, her family had access to a car; the age at which the participant completed full-time education; the longest-held occupation of the participant and her spouse; the participant's current housing status (whether she lived in rented social housing or owner-occupied and private rented properties); and the participant's current automobile access and pension arrangements (state only or state in combination with other arrangements).</p><p style="margin-top: 0px;">Participants' childhood social class was based on their fathers' longest-held occupation, and their adult social class was based on their husbands' longest-held occupation (or, in the case of single women, their own longest-held occupation). Adult and childhood social class categories, defined according to the UK registrar general's classification, ranged from I (nonmanual, professional occupations) to V (manual, unskilled occupations). Given that the life-course SES score denoted the number of socioeconomic hardships experienced by women, a score of 10 indicated the greatest level of hardship.</p><p style="margin-top: 0px;">We assessed the effects of changes in SES over the life course on health behaviors by classifying upward social mobility as change from manual social class in childhood (defined according to father's occupation) to nonmanual social class in adulthood (defined according to husband's occupation or, among unmarried women, their own occupation); downward social mobility was classified as the reverse circumstance. All analyses were restricted to women without any evidence of CHD or stroke at baseline (n=3523; 83% of the cohort); 595 women (13%) were excluded from the analyses (with the exception of those involving multiple imputations) because they also had missing data on 1 or more SES indicator.</p><p style="margin-top: 0px;">Statistical Analyses</p><p style="margin-top: 0px;">Women were grouped according to SES score, and the percentage of women reporting adverse health behaviors in each SES group was calculated. We assessed differences in the percentages of women reporting high-risk behaviors by individual SES indicator variables. In addition, stratifying by town of recruitment, we conducted logistic regression analyses examining the relative importance of childhood SES and adult SES scores as predictors of health behaviors and the effects of upward and downward social mobility on health behaviors.</p><p style="margin-top: 0px;">We used conditional logistic regression in most of our analyses because the sampling strategy produced data clustered according to town of residence. We used ordinal logistic regression, clustered by town, in analyses of smoking and diet because the behavioral data were collected in 3 ordered categories. This technique allowed us to avoid using multiple significance tests, which would have been required to compare each pair of categories in turn.</p><p style="margin-top: 0px;">Our analyses were based on the assumption that missing data were missing completely at random; that is, women included in the analyses could be regarded as a random sample of the women who took part in the study. If this assumption proved to be false, our results could be biased.</p><p style="margin-top: 0px;">We assessed the sensitivity of the results by examining the effects of missing data. We assumed that data were missing at random (rather than missing completely at random, where the probability of data being missing does not depend on observed or unobserved values) and in this situation the missing values depend on the values of variables measured in the study. The missing values can then be imparted from knowledge of other measured values. Multiple imputation allowed our analysis to be conducted under the missing-atrandom assumption; we used the multivariate chained equation method,14,15 including all of the health habit variables and childhood and adulthood SES scores in the imputation model.</p><p style="margin-top: 0px;">Ten regression switching cycles were used with 20 imputed data sets. Use of Rubin's formulas for combining results from the separate imputed data sets ensured that any incomplete data were properly accommodated in the inferences. The results of these alternative analyses were very similar to the results of the analyses conducted with women who had complete data (i.e., the analyses described here). Stata version 9 (StataCorp, College Station, TX) was used in conducting all analyses.</p><p style="margin-top: 0px;">RESULTS</p><p style="margin-top: 0px;">Table 1 presents health behavior data by SES score, and Table 2 shows differences in the percentages of women reporting unhealthful behaviors according to individual SES indicator variables. Table 3 shows odds of unhealthful behaviors for each 1-unit increase in childhood and adulthood SES score (i.e., increasing deprivation), with adjustment of childhood associations for adult SES (and vice versa).</p><p style="margin-top: 0px;">Diet</p><p style="margin-top: 0px;">Only 10% of women reported eating 4 or 5 portions of fruits and vegetables daily (the UK government recommendation); half reported consuming less than 2 portions (Table 1). A majority of the women (55%) selected mostly healthful fat, milk, and bread options; 30% ate red or processed meat on most days.</p><p style="margin-top: 0px;">Women in the most deprived groups (those with an SES score of 9 or 10) had poorer diets than did women in the less deprived groups, consuming fewer fruits and vegetables (61% consumed less than 2 portions per day) and more red or processed meats (41% ate these meats on most days; Table 1). Both childhood and adult indicators of low SES were associated with unhealthful diets (Table 2). Eleven percent (P<.001) more women raised in manual social class families than in nonmanual social class families ate fruits and vegetables less than twice a day. Similar differences of between 5% and11%in consumption of fruit and vegetables were seen for other childhood deprivation indicators (e.g., no hot water in the family home, no family access to a car).</p><p style="margin-top: 0px;">Adult indicators of deprivation showed similar levels of strength; the strongest predictor was current residence in local authority (i.e., social) housing (13% more women living in local authority housing than women not living in such housing reported eating fruit and vegetables less than twice a day; P<.001). Both childhood (for each 1-unit increase in childhood SES score, odds ratio [OR]=1.13; 95% confidence interval [CI]=1.07, 1.19) and adult (for each 1-unit increase in adult SES score, OR=1.16; 95% CI=1.07, 1.25) SES scores were independent predictors of fruit and vegetable intake (Table 3).</p><p style="margin-top: 0px;">Associations with the other dietary variables were less strong. Consumption of red or processed meat on most days was independently associated with adult SES (adjusted OR=1.15; 95% CI=1.06, 1.25) but not childhood SES (adjusted OR=1.03; 95% CI=0.97, 1.09) after mutual adjustment. Poultry and fish consumption showed a similar pattern of stronger association with adult SES (adjusted OR=1.17; 95% CI=1.08, 1.26) than childhood SES (adjusted OR=1.06; 95% CI=1.00, 1.12). Selection of mostly healthful fat, milk, and bread options was not significantly related to SES or any SES subcomponents.</p><p style="margin-top: 0px;">Smoking</p><p style="margin-top: 0px;">Most women (57%) had never smoked tobacco regularly, and only 11% currently smoked (Table 1). However, 62% of women in the lowest SES group had smoked regularly at some point in their life (and 18% of them continued to smoke), as compared with less than 50% of the women in all other SES groups. The median age of smoking initiation was 18 years (5th percentile=15 years, 95th percentile=35 years), and there were minimal differences according to SES. Among quitters, women in higher SES groups quit at a younger median age (45 years [5th percentile=24 years, 95th percentile=65 years] among women with SES scores of 0-3 and 51 years [5th percentile=22 years, 95th percentile=70 years] among women with SES scores of 7-10).</p><p style="margin-top: 0px;">Smoking was associated with having grown up in a manual social class family but was not related to other childhood SES indicators (Table 2). All adverse adult SES indicators were associated with smoking. The strongest predictor was local authority housing tenancy; women living in such housing were 18% more likely to smoke. As can be seen in Table 3, adult SES, but not childhood SES, was independently associated with smoking (for each 1-unit increase in adult SES, adjusted OR=1.18; 95% CI=1.09, 1.27).</p><p style="margin-top: 0px;">Physical Activity</p><p style="margin-top: 0px;">Most women were inactive. Sixty-one percent reported less than 2 hours per week of moderate or vigorous exercise; however, more than one quarter (28%) engaged in more than the recommended minimum of 3 hours per week. Generally, more women in the most disadvantaged SES groups than in the less disadvantaged groups reported a sedentary lifestyle (P<.001).</p><p style="margin-top: 0px;">Adverse individual childhood and adult SES indicators were each associated with an increase in physical inactivity of at least 5% (Table 2). The strongest association was with local authority housing tenancy in adulthood; 16% more women living in this type of housing than in other types of housing engaged in less than 2 hours of moderate or vigorous activity each day. Adult SES and childhood SES were both independently associated with physical activity, but the association with adult SES was stronger (for each 1-unit increase in childhood SES, adjusted OR=1.06; 95% CI=1.01, 1.12; for each 1-unit increase in adult SES, adjusted OR=1.22; 95% CI=1.13, 1.32).</p><p style="margin-top: 0px;">Social Mobility</p><p style="margin-top: 0px;">Table 4 shows the effects of social mobility, classified according to father's and husband's social class (or, in the case of unmarried women, their own social class), on women's health behaviors. Upwardly mobile women were less likely to report unhealthful behaviors than were women who remained in the manual group. For example, they were 37% less likely to consume small amounts of fruits and vegetables (OR= 0.73; 95% CI=0.61, 0.88) and 21% less likely to be inactive (OR=0.79; 95% CI=0.66, 0.94).</p><p style="margin-top: 0px;">Downwardly mobile women adopted worse health behaviors than women remaining in the nonmanual social class. For example, they were 51% more likely to eat red or processed meat on most days (OR=1.51; 95% CI=1.04, 2.18) and 47% more likely to engage in less than 2 hours of exercise per week (OR=1.47; 95% CI=1.05, 2.06); surprisingly, however, they were 45% more likely to select mostly healthful fat, milk, and bread options (OR=1.45; 95% CI=1.03, 2.06). We found no effects of social mobility on smoking. Although downward social mobility adversely affected women's diet and physical activity behaviors, the effect was not as marked as that observed when women who had remained in the manual social class throughout their life were compared with those who had always been in the nonmanual class.</p><p style="margin-top: 0px;">DISCUSSION</p><p style="margin-top: 0px;">Women who had experienced socioeconomic adversity throughout their lives were less likely than women who had not to eat healthily and were more likely to have smoked regularly at some point in their lives, to currently smoke, and to be inactive. Our data suggest that both childhood and adult SES affect fruit and vegetable consumption in old age, with roughly an equal strength of association. However, it was primarily adult SES that influenced whether these women were more likely to eat meat or fish. Adult SES appeared to determine quantity and duration of smoking through the age of smoking cessation. Although exercise behaviors in old age were influenced by childhood SES, the effect of adult SES was greater. Upward social mobility and downward social mobility were, respectively, beneficial and detrimental with respect to health behaviors.</p><p style="margin-top: 0px;">Diet</p><p style="margin-top: 0px;">Elderly people come from a generation in which childhood diets were generally healthier in terms of lower saturated fat and calorie content than today. Indeed, it has been reported that older people continue to have better diets; however, deprivation, which may particularly affect elderly people, may partially counteract this trend.16 Other studies have shown that elderly people often have a poor diet that is low in energy and in the amounts of vitamins and minerals consumed. 17-19</p><p style="margin-top: 0px;">Given that few people do so, it is not surprising that small numbers of women in this cohort reported eating the recommended 5 portions of fruits and vegetables per day. Our findings with respect to deprivation are consistent with those of other research.20 People in lower SES groups are more likely to live in areas lacking access to high-quality produce, especially if they do not have access to a car or suffer from poor personal mobility.21Access to social support (e.g., "meals on wheels" programs) may provide a partial solution for the most vulnerable groups.</p><p style="margin-top: 0px;">Childhood SES indicator variables were associated with diet quality in adulthood; however, after adjustment for adult SES, the associations were weaker than the associations of adult SES variables adjusted for childhood SES. This finding suggests that some of the childhood risk factors assessed were mediated through adult SES. The direct effect of childhood SES on diet in old age may result from the tastes developed and the cooking skills and practices learned in childhood.22 This might explain some of the observed effect of childhood SES on adult CHD risk.</p><p style="margin-top: 0px;">Childhood diet may also have a more direct effect on adult health, in that growth affects later disease risk. Leg length (indicative of prepubertal nutritional status) is positively associated with a reduced risk of cardiovascular disease in later life.23,24 Similarly, reduced energy intake in childhood is associated with reduced adult cancer risk.25,26 This direct effect on health may have unforeseen consequences for the increasing number of overweight children in our population.</p><p style="margin-top: 0px;">Smoking</p><p style="margin-top: 0px;">Women who experienced lifelong deprivation were more likely to have smoked in the past and to currently smoke. Among those who had quit, more deprived women generally had smoked for longer periods. These findings are consistent with those of other research on SES and smoking habits.27-29</p><p style="margin-top: 0px;">Our analysis of individual SES indicators suggested that, consistent with other research, adult SES had a strong influence on smoking habits.30 If women perceive more immediate threats to their health (e.g., occupational hazards, street crime), they may downplay the health dangers of smoking and place less priority on stopping smoking.31,32 There is little evidence in our data that childhood SES was related to smoking. This may reflect the attitude toward smoking in the 1940s and 1950s; when these women were young, smoking was more acceptable.</p><p style="margin-top: 0px;">Physical Activity</p><p style="margin-top: 0px;">Most participants were inactive, which is a concern given the strong evidence linking activity with healthy survival in old age.33,34 However, the percentage of women who did exercise for more than 3 hours per week (28%) was higher than the percentages reported among other UK cohorts (e.g., 13% in the English Longitudinal Study of Ageing35). According to the Allied Dunbar National Fitness Survey, conducted in1990, 40%of women aged 65 to 74 years (comparable to the age range in our cohort) reported no physical activity in the previous 4 weeks, and the average was less than 3.5 hours during a 4-week period.36 However, that survey showed that neither education nor social class had an effect on women's exercise behavior.</p><p style="margin-top: 0px;">Our data show that both adult SES and childhood SES were associated with exercise patterns. Few studies have examined the relationship between SES and physical activity across the life span.37 Participation in sports in adolescence is reportedly a predictor of adult physical activity,38 and teenagers in low-SES groups have been shown to be less likely to participate than teenagers in high-SES groups. Other studies have revealed little association between childhood SES and adult physical activity.39 In a separate study involving the present cohort,40 we also found an independent effect of area-level deprivation over and above individual SES, and this is a further and important dimension for consideration in developing health and social policy.</p><p style="margin-top: 0px;">Adult SES affects exercise behavior both directly, as a result of factors such as financial costs (e.g., gym memberships), and indirectly, given that deprivation is associated with increased disability.41 Women without access to a car reported less physical activity than those who had a vehicle, suggesting that walking does not fully compensate for structured exercise opportunities.</p><p style="margin-top: 0px;">Social Mobility</p><p style="margin-top: 0px;">Our data suggest that socially mobile individuals adopt the eating and exercising habits of their new social group. Women whose SES improved over the course of their lives (i.e., women who became more affluent) were more likely than were women whose SES did not improve to eat fruit and vegetables and to exercise; however, they were not as likely to do so as those who had always been members of the nonmanual social class. Conversely, those who moved down the social scale were likely to adopt detrimental health behaviors, but these behaviors were not as harmful, in general, as those engaged in by women who had always been members of the manual social class.</p><p style="margin-top: 0px;">Motivation for some of these behavioral changes may be financial; for example, processed meats are cheaper, and gym admissions and structured exercise programs are expensive. Moreover, many downwardly mobile women married men from poorer backgrounds who then influenced the family's health behaviors.</p><p style="margin-top: 0px;">Strengths and Limitations</p><p style="margin-top: 0px;">Previous studies have highlighted how the use of separate indicators for education, occupation, and family income during childhood adds uniquely to our understanding of how SES is related to behavior.5,6,8 Our work, which extends earlier findings in that we used a much wider range of SES indicators, demonstrates the various ways in which cumulative disadvantage influences health behaviors. Our use of several childhood and adult SES indicators is a strength of this study; it is common practice to use only 1 measure for each, often occupational social class. Adjusting for an individual's socioeconomic position either by conditional logistic regression adjusted for the10-point socioeconomic score, or by using each of the 10 socioeconomic variables as a binary indicator variable did not make any difference to the findings.</p><p style="margin-top: 0px;">We acknowledge that SES measurement error may have influenced the accuracy of our results regarding the independent predictive effects of adulthood and childhood SES on women's health behaviors. However, the modest correlation of 0.33 between SES scores in childhood and adulthood, the differences in the independent predictive power of childhood and adult SES with respect to different health behaviors, and the use of multiple SES indicators at each study time point all suggest that our results are likely to have captured meaningful differences in the predictive power of childhood and adult SES.</p><p style="margin-top: 0px;">Our results were derived from women who were all aged 60 to 79 years at the time of data collection. Without evidence to the contrary, it seems likely that today's children will also retain some of their dietary and exercise habits into adulthood, implying that our findings may have some relevance to the current population of children.</p><p style="margin-top: 0px;">Some women without cardiovascular disease at baseline were excluded from the study because they had missing SES data; however, it is unlikely that exclusion of these women resulted in substantial bias in our analyses, as indicated by the very similar findings obtained in multivariate multiple imputation analyses (data available on request). Dietary data were derived from a simple selfreported food frequency questionnaire that allowed participants to answer questions relatively quickly and easily. The resulting food groups used to indicate a healthful diet were simple but were based on a principalcomponents analysis that produced interpretable groupings. However, our categories did not capture detailed differences in types of food; for example, fish and chicken can include very healthful oily fish and unhealthful fried chicken and fish.</p><p style="margin-top: 0px;">Physical activity as assessed here was not purely a measure of exercise or sporting activities, but rather, included day-to-day activities such as walking and gardening, which are recommended as part of adult activity programs. These forms of physical activity were appropriate for women of the age of our study population and captured the activity level currently recommended by the UK government (30 minutes of moderate activity at least 5 days a week).42</p><p style="margin-top: 0px;">Social desirability bias is a potential issue in all observational studies that collect selfreported behavioral data. However, such bias would tend to attenuate any associations and was unlikely to be sufficiently powerful to remove the widely reported differences in cardiovascular disease outcomes either between socioeconomic groups or by selfreported diet, exercise, or smoking behaviors. Whenever possible, we attempted to validate our risk factor data; for example, we found, in a repeated measures analysis of variance, a significant association between quantity of fruits and vegetables consumed and serum vitamin C levels (P<.001), suggesting that reported intake was a valid indicator (data available on request).</p><p style="margin-top: 0px;">Implications</p><p style="margin-top: 0px;">We have demonstrated that childhood SES, independently of adult SES, is associated with aspects of a healthful diet and physical activity. Our results emphasize the importance of establishing good habits during childhood. School meals in England, after strong criticism, 43 are currently being reformed through government programs. These reform efforts may improve the diets of today's generation of children as they mature.</p><p style="margin-top: 0px;">Home economics classes in which children are taught about food preparation and healthful eating may also be helpful. Successfully educating adults to improve their diets will reduce not only their own CHD risk but that of their children. Targeted programs aimed at increasing physical activity in the poorest communities (where activity levels are lowest), through better provision of opportunities for activity in schools, may also help to increase adult activity levels in years to come.</p><p style="margin-top: 0px;">A focus on the individuals who are currently at highest cardiovascular risk is also warranted. Seemingly the most direct way to improve older people's health behaviors would be to tackle their underlying deprivation. According to recent estimates, the minimum income for pensioners in the United Kingdom to maintain a healthful lifestyle is £122.70 ($236.00) per person per week, somewhat more than the minimum pension credit of £109.45 ($210.50) (including additional benefits such as winter fuel).44 One of the consequences of poverty is that dietary decisions are often financial,45 and members of low-SES groups typically choose unhealthful, cheaper foods. A healthful diet for a moderately active couple in which each partner is older than 65 years costs approximately £63.70 ($122.50) per week, yet average spending in the poorest 40% of couples in this age group is just £44.50 ($85.60) per week.44</p><p style="margin-top: 0px;">The small increases in the UK basic pension instituted in the past 2 years have not been adequate to close these gaps. Older widowed women, previously dependent on their partner's income to raise their family, are particularly affected by today's inadequate pension provisions. Additional financial support for our growing elderly population is needed to ensure people's health in old age.</p><p style="margin-top: 0px;">Conclusions</p><p style="margin-top: 0px;">Our findings highlight the adverse effects of socioeconomic inequalities throughout life on behaviors that are known risk factors for cardiovascular disease and other life-threatening conditions. Improving socioeconomic inequalities in health behaviors and, ultimately, in disease outcomes will require development of better interventions, and these interventions will need to be applied across the life course and will need to focus on disadvantaged groups to provide the greatest benefit.</p><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td nowrap="nowrap"> <span class="bold textSmall">[Reference]</span> <span class="raquo">» </span> <a title="View a list of references included in this document" href="http://proquest.umi.com/pqdweb?VInst=PROD&VName=PQD&VType=PQD&RQT=594&did=1630875651&Fmt=3&refType=CITEDIN&b2=d&SrchMode=1&sid=1&index=1&TS=1233028224" class="textSmall">View reference page with links</a></td></tr><tr><td class="textSmall">References</td></tr><tr><td class="textSmall">1. Black D, Morris J, Smith C, Townsend P, eds. The Black Report. 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Am J Public Health. 2003;93: 266-270.</td></tr><tr><td class="textSmall">32. Stewart MJ, Gillis A, Brosky G, et al. Smoking among disadvantaged women: causes and cessation. Can J Nurs Res. 1996;28:41-60.</td></tr><tr><td class="textSmall">33. Schnohr P, Lange P, Scharling H, Jensen JS. Longterm physical activity in leisure time and mortality from coronary heart disease, stroke, respiratory diseases, and cancer: the Copenhagen City Heart Study. Eur J Cardiovasc Prev Rehabil. 2006;13:173-179.</td></tr><tr><td class="textSmall">34. Manini TM, Everhart JE, Patel KV, et al. Daily activity energy expenditure and mortality among older adults. JAMA. 2006;296:171-179.</td></tr><tr><td class="textSmall">35. Marmot M, Banks J, Blundell R, Lessof C, Nazaroo J. Health, Wealth and Lifestyles of the Older Population in England: The 2002 English Longitudinal Study of Ageing. London, England: Institute for Fiscal Studies; 2003.</td></tr><tr><td class="textSmall">36. Allied Dunbar National Fitness Survey: A Report on Activity Patterns and Fitness at All Levels. London, England: London Sports Council and Health Education Authority; 1992.</td></tr><tr><td class="textSmall">37. Malina RM. Tracking of physical activity and physical fitness across the lifespan. Res Q Exerc Sport. 1996; 67(suppl 3):S48-S57.</td></tr><tr><td class="textSmall">38. Tammelin T, Nayha S, Laitinen J, Rintamaki H, Jarvelin MR. Physical activity and social status in adolescence as predictors of physical inactivity in adulthood. Prev Med. 2003;37:375-381.</td></tr><tr><td class="textSmall">39. Parsons TJ, Power C, Manor O. Longitudinal physical activity and diet patterns in the 1958 British Birth Cohort. Med Sci Sports Exerc. 2006;38:547-554.</td></tr><tr><td class="textSmall">40. Hillsdon M, Lawlor DA, Ebrahim S, Morris JN. Physical activity in older women: associations with area deprivation and with socioeconomic position over the life course: observations in the British Women's Heart and Health Study. J Epidemiol Community Health. 2008;62: 344-350.</td></tr><tr><td class="textSmall">41. Ebrahim S, Papacosta O, Wannamethee G, Adamson J. Social inequalities and disability in older men: prospective findings from the British Regional Heart Study. Soc Sci Med. 2004;59:2109-2120.</td></tr><tr><td class="textSmall">42. The National Service Framework for Older People. London, England: Dept of Health Publications; 2004.</td></tr><tr><td class="textSmall">43. Gould R, Russell J, Barker ME. School lunch menus and 11 to 12 year old children's food choice in three secondary schools in England-are the nutritional standards being met? Appetite. 2006;46:86-92.</td></tr><tr><td class="textSmall">44. Morris J, Dangour A, Deeming C, Fletcher A, Wilkinson P. Minimum Income for Healthy Living: Older People. London, England: Age Concern Reports; 2005.</td></tr><tr><td class="textSmall">45. Giskes K, Lenthe F, Brug HJ, Mackenbach J. Dietary intakes of adults in the Netherlands by childhood and adulthood socioeconomic position. Eur J Clin Nutr. 2004;58:871-880.</td></tr></tbody></table></span><table border="0" cellpadding="0" cellspacing="0"><tbody></tbody></table><br /><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td class="textSmall" nowrap="nowrap"><b>[Author Affiliation]</b></td></tr><tr><td class="textSmall">Hilary C. Watt, MSc, MA, Claire Carson, PhD, Debbie A. Lawlor, PhD, MBChB, MPH, FFPH, Rita Patel, MSc, and Shah Ebrahim, DM, MSc, BMedSci, FRCP, FFPHM</td></tr></tbody></table></span><table border="0" cellpadding="0" cellspacing="0"><tbody></tbody></table><br /><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td class="textSmall" nowrap="nowrap"><b>[Author Affiliation]</b></td></tr><tr><td class="textSmall">About the Authors</td></tr><tr><td class="textSmall">Hilary C. Watt, Claire Carson, and Shah Ebrahim are with the Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, England. Debbie A. Lawlor and Rita Patel are with the Department of Social Medicine, University of Bristol, Bristol, England.</td></tr><tr><td class="textSmall">Requests for reprints should be sent to Shah Ebrahim, BMedSci, MSc, DM, FRCP, FFPHM, Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, England (e-mail: shah.ebrahim@lshtm.ac.uk).</td></tr><tr><td class="textSmall">This article was accepted May 1, 2008.</td></tr><tr><td class="textSmall">Contributors</td></tr><tr><td class="textSmall">H. C. Watt contributed to developing the study aims and writing the article and undertook and interpreted the statistical analysis. C. Carson contributed to developing the study aims, undertook the literature review, and made major contributions to the drafting of the article. D. A. Lawlor contributed to developing the study aims and design and contributed to the writing of the article. R. Patel contributed to the drafting of the article. S. Ebrahim supervised the writing of the article and contributed to developing the study aims.</td></tr><tr><td class="textSmall">Acknowledgments</td></tr><tr><td class="textSmall">The British Women's Heart and Health Study was funded by the Department of Health Policy Research Programme and the British Heart Foundation. Debbie A. Lawlor is funded by a UK Department of Health Career Scientist Award.</td></tr><tr><td class="textSmall">We thank Carol Bedford, Alison Emerton, Nicola Frecknall, Karen Jones, Mark Taylor, and Katherine Wornell for collecting and entering British Women's Heart and Health Study data.Wethank all of the general practitioners and their staff who supported collection of data for this study and the women who took part in the study.</td></tr><tr><td class="textSmall">Note. The views expressed in this article are those of the authors and not necessarily those of any funding agency. No funding agency influenced data analysis or interpretation.</td></tr><tr><td class="textSmall">Human Participant Protection</td></tr><tr><td class="textSmall">The British Women's Heart and Health Study received local research ethics committee approval from each of the 23 towns in the study and multicenter approval from the London Multi Region Ethics Committee. All participants provided informed consent.</td></tr></tbody></table></span><table border="0" cellpadding="0" cellspacing="0"><tbody></tbody></table><br /><!--End FULL TEXT--><!--Start References--><a name="references"></a><div id="refListContainer"><div class="docBlock docBar textSmall langDir"><span class="bold">References</span></div><div class="textMedium" id="refListULContainer"> <ul class="refListBox"><li class="first"> <a href="http://proquest.umi.com/pqdweb?VInst=PROD&VName=PQD&VType=PQD&RQT=594&did=1630875651&Fmt=3&refType=CITEDIN&b2=d&SrchMode=1&sid=1&index=1&TS=1233028224" title="View a list of references included in this document">References (44)</a></li></ul> </div></div><!--End References--><!--APGIndexTermNormal--><input str="http://exslt.org/strings" value="305" name="RQT" type="hidden"><input str="http://exslt.org/strings" name="SQ" type="hidden"><input str="http://exslt.org/strings" value="PQ" name="querySyntax" type="hidden"> <input str="http://exslt.org/strings" value="REVERSE_CHRON" name="sortby" type="hidden"> <input str="http://exslt.org/strings" value="1233028224" name="TS" type="hidden"><div str="http://exslt.org/strings" class="docBlock docBar textSmall langDir"><a name="indexing"></a><strong>Indexing (document details)</strong></div><table str="http://exslt.org/strings" id="tableIndexTerms" border="0" cellpadding="4" cellspacing="1"><!--Indexing of New York Time Index Start--><!--Indexing of New York Time Index End--><!--Start INDEX TERMS--><tbody><tr><td class="textSmall" valign="top" nowrap="nowrap"><strong>Subjects:</strong></td><td class="textSmall engContent" align="left" valign="top"><a href="">Cardiovascular%20disease</hhl>%22)"><span style="color:red;"><b>Cardiovascular disease</b></span></a>, <a href="javascript:searchSideWays(%22SUB%22,%22Womens%20health%22)">Womens health</a>, <a href="javascript:searchSideWays(%22SUB%22,%22Older%20people%22)">Older people</a>, <a href="javascript:searchSideWays(%22SUB%22,%22Health%20behavior%22)">Health behavior</a>, <a href="javascript:searchSideWays(%22SUB%22,%22Diet%22)">Diet</a></td></tr><!--End INDEX TERMS--><!--Start SPEAKER BIO--> <!--Start AUTHORS--><tr><td class="textSmall" valign="top" nowrap="nowrap"><strong>Author(s):</strong></td><td class="textSmall engContent" align="left" valign="top"><a onclick="'return" href="javascript:void(0);">Hilary C Watt</a>, <a onclick="'return" href="javascript:void(0);">Claire Carson</a>, <a onclick="'return" href="javascript:void(0);">Debbie A Lawlor</a>, <a onclick="'return" href="javascript:void(0);">Rita Patel</a>, <a onclick="'return" href="javascript:void(0);">Shah Ebrahim</a></td></tr><!--End AUTHORS--><!--Start Author Affiliations--><tr><td class="textSmall" valign="top" nowrap="nowrap"><strong>Author Affiliation:</strong></td><td class="textSmall engContent" align="left" valign="top">Hilary C. Watt, MSc, MA, Claire Carson, PhD, Debbie A. Lawlor, PhD, MBChB, MPH, FFPH, Rita Patel, MSc, and Shah Ebrahim, DM, MSc, BMedSci, FRCP, FFPHM<br /><br />About the Authors<br />Hilary C. Watt, Claire Carson, and Shah Ebrahim are with the Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, England. Debbie A. Lawlor and Rita Patel are with the Department of Social Medicine, University of Bristol, Bristol, England.<br />Requests for reprints should be sent to Shah Ebrahim, BMedSci, MSc, DM, FRCP, FFPHM, Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, England (e-mail: shah.ebrahim@lshtm.ac.uk).<br />This article was accepted May 1, 2008.<br />Contributors<br />H. C. Watt contributed to developing the study aims and writing the article and undertook and interpreted the statistical analysis. C. Carson contributed to developing the study aims, undertook the literature review, and made major contributions to the drafting of the article. D. A. Lawlor contributed to developing the study aims and design and contributed to the writing of the article. R. Patel contributed to the drafting of the article. S. Ebrahim supervised the writing of the article and contributed to developing the study aims.<br />Acknowledgments<br />The British Women's Heart and Health Study was funded by the Department of Health Policy Research Programme and the British Heart Foundation. Debbie A. Lawlor is funded by a UK Department of Health Career Scientist Award.<br />We thank Carol Bedford, Alison Emerton, Nicola Frecknall, Karen Jones, Mark Taylor, and Katherine Wornell for collecting and entering British Women's Heart and Health Study data.Wethank all of the general practitioners and their staff who supported collection of data for this study and the women who took part in the study.<br />Note. The views expressed in this article are those of the authors and not necessarily those of any funding agency. No funding agency influenced data analysis or interpretation.<br />Human Participant Protection<br />The British Women's Heart and Health Study received local research ethics committee approval from each of the 23 towns in the study and multicenter approval from the London Multi Region Ethics Committee. All participants provided informed consent.</td></tr><!--End Author Affiliations--><!--Start ARTICLE TYPE--><tr><td class="textSmall" valign="top" nowrap="nowrap"><strong>Document types:</strong></td><td class="textSmall engContent" align="left" valign="top">Feature</td></tr><!--End ARTICLE TYPE--><!--Start Doc Features--><tr><td class="textSmall" valign="top" nowrap="nowrap"><strong>Document features:</strong></td><td class="textSmall engContent" align="left" valign="top">Tables, References</td></tr><!--End Doc Features--><!--Start SECTION--><tr><td class="textSmall" valign="top" nowrap="nowrap"><strong>Section:</strong></td><td class="textSmall engContent" align="left" valign="top"><span class="italic">RESEARCH AND PRACTICE</span></td></tr><!--End SECTION--><!--Start DOCUMENT LANGUAGE--><!--End DOCUMENT LANGUAGE--><!--Start PUB TITLE--><tr><td class="textSmall" valign="top" nowrap="nowrap"><strong>Publication title:</strong></td><td class="textSmall engContent" align="left" valign="top"><a href="http://proquest.umi.com/pqdweb?RQT=318&pmid=8&TS=1233028224&clientId=45625&VInst=PROD&VName=PQD&VType=PQD">American Journal of Public Health</a>. Washington: <a href="http://proquest.umi.com/pqdweb?RQT=572&VType=PQD&VName=PQD&VInst=PROD&pmid=8&pcid=41675711&SrchMode=3">Feb 2009</a>. Vol. 99, Iss. 2; pg. 320, 8 pgs</td></tr><!--End PUB TITLE--><!--place of publication begins--><!--place of publication ends--><!--Source Type--><tr><td class="textSmall" valign="top" nowrap="nowrap"><strong>Source type:</strong></td><td class="textSmall" valign="top">Periodical</td></tr><!--Source Type--><!--Start ISSN--><tr><td class="textSmall" valign="top" nowrap="nowrap"><strong>ISSN:</strong></td><td class="textSmall" valign="top">00900036</td></tr><!--End ISSN--><!--Start DOCID--><tr><td class="textSmall" valign="top" nowrap="nowrap"><strong>ProQuest document ID:</strong></td><td class="textSmall" valign="top">1630875651</td></tr><!--End DOCID--><!--Start WORD COUNT--><tr><td class="textSmall" valign="top" nowrap="nowrap"><strong>Text Word Count</strong></td><td class="textSmall" valign="top">6054</td></tr><!--End WORD COUNT--><!--Start ARTICLE URL--><tr><td class="textSmall" valign="top" nowrap="nowrap"><strong>Document URL:</strong></td><td class="textSmall" valign="top"><span id="wrapURL7">http://proquest<wbr>.umi<wbr>.com/pqdweb<wbr>?did=1630875651<wbr>&sid=1<wbr>&Fmt=3<wbr>&clientId=45625<wbr>&RQT=309<wbr>&VName=PQD</span></td></tr></tbody></table><p style="margin-top: 0px;"><br /></p></div></div>All About Bloggerhttp://www.blogger.com/profile/17282736671555579827noreply@blogger.com0tag:blogger.com,1999:blog-4987803374989865601.post-91946724582467939292009-01-15T22:28:00.000-08:002009-01-15T22:30:38.442-08:00Acute infections, vaccination and prevention of cardiovascular disease<div class="headerBlack"><strong>Acute <span style="color:red;"><b>infections</b></span>, vaccination and prevention of cardiovascular disease</strong></div><div class="textMedium"><!--Start AUTHORS--> <a onclick="'return" href="javascript:void(0);"><em>Mohammad Madjid</em></a>. <!--End AUTHORS--><!--Start PUB_TITLE--><b><a href="http://proquest.umi.com/pqdweb?RQT=318&pmid=33824&TS=1232087315&clientId=45625&VInst=PROD&VName=PQD&VType=PQD">Canadian Medical Association. Journal</a></b><!--End PUB_TITLE-->. <!--Start PM_QUAL-->Ottawa: <!--End PM_QUAL--><!--Start ISSUE_URL--><a href="http://proquest.umi.com/pqdweb?RQT=572&VType=PQD&VName=PQD&VInst=PROD&pmid=33824&pcid=40555031&SrchMode=3">Oct 7, 2008</a>. <!--End ISSUE_URL--><!--Start PCVOLUME-->Vol. 179<!--End PCVOLUME--><!--Start PCISSUE-->, Iss. 8;<!--End PCISSUE--> pg. 749, 2 pgs</div><table border="0" cellpadding="2" cellspacing="0"></table><!--End CITATION--> <div style="width: 12px; height: 12px;"><!-- --></div> <a name="summary"></a><!--Start ABSTRACT--><a name="abstract"></a><div class="docSection" style="padding-top: 4px; padding-left: 4px;"><span class="textSmall"><strong>Abstract (Summary)</strong></span><div class="textMedium"><p style="margin-top: 0px;">The study by [Lamontagne] and colleagues does not include data on the incidence of pneumonia and its relation to myocardial infarction in cases and controls. However, it is reasonable to hypothesize that pneumococcal vaccination may protect against cardiovascular events by preventing pneumonia, as the latter has been shown to trigger myocardial infarction. Musher and colleagues4 reviewed a series of 170 patients admitted to hospital with pneumococcal pneumonia over a 5- year period and found that about 7% of patients had a myocardial infarction while in hospital. They also report that about 20% of patients had either a myocardial infarction, atrial fibrillation, or new or worsening congestive heart failure while in hospital.4 Other studies have suggested that <span style="color:red;"><b>infections</b></span> in the upper respiratory <span style="color:red;"><b>tract</b></span> and urinary <span style="color:red;"><b>tract</b></span> can trigger myocardial infarctions.5 Spodick and colleagues reported that, in the 2-week period before being admitted to hospital for a myocardial infarction, 28% of patients had acute respiratory symptoms.6 In an autopsy-based study, my group observed that influenza epidemics are associated with a sharp rise in the number of deaths caused by myocardial infarction and ischemic heart disease.7 In fact, during almost all influenza epidemics and pandemics (except for the 1918 Spanish influenza pandemic), about twice as many people die of cardiac causes as die of pneumonia.8 Myocardial infarction was also reported to be the cause of death in 2 of 5 fatal cases among 75 patients with severe acute respiratory syndrome.9</p><p style="margin-top: 0px;">Multiple mechanisms could contribute to the cardioprotective effect of pneumococcal vaccination. A study in mice lacking the low-density lipoprotein (LDL) receptor suggested that the molecular mimicry between epitopes of Streptococcus pneumoniae and oxidized LDL may lead to increased anti-oxidized LDL immunoglobins following pneumococcal vaccination, which may lead to a decreased extent of atherosclerosis.10 However, production of such antibodies following pneumococcal vaccination in humans has not been confirmed.11 This interesting pathway requires further research. In addition, S. pneumoniae and other respiratory <span style="color:red;"><b>infections</b></span> may exert many acute effects directly relevant to acute <span style="color:red;"><b>coronary</b></span> syndromes. My colleagues and I have previously shown that influenza <span style="color:red;"><b>infection</b></span> leads to excessive recruitment of inflammatory cells to atherosclerotic aortic plaques in mice lacking apolipoprotein E receptor.12 Similarly, compared with controls, the <span style="color:red;"><b>coronary</b></span> arteries of patients who died of acute systemic <span style="color:red;"><b>infections</b></span> show a higher number of macrophages and T cells in their adventitia and periadventitial fat, and more dendritic cells in the intima and media.13 In synergy with local cellular inflammation, there is an extensive systemic inflammation heralded by acute increase in systemic markers of inflammation.2 These acute inflammatory changes are paralleled by activation of the coagulation cascade and increased levels of coagulation factors. Finally, such acute <span style="color:red;"><b>infections</b></span> are also associated with tachycardia, hemodynamic stress, fever, dehydration, increased plasma viscosity, release of endogenous cathecholamines, possible demand ischemia, severe endothelial dysfunction and qualitative pro-oxidant changes in high-density lipoprotein. Each of these can play an important role in acute <span style="color:red;"><b>coronary</b></span> syndromes.2,14</p><p style="margin-top: 0px;"><span class="italic">Copyright Canadian Medical Association Oct 7, 2008</span><br /><br /></p><p style="margin-top: 0px;">Extensive research in recent decades has established a critical role for cellular and humoral inflammation in the initiation and progression of atherosclerosis and its acute clinical presentations.1 Although atherosclerotic disease has a slow progression over many years, several intrinsic and extrinsic factors may trigger latent stable atherosclerotic plaques to become inflamed, unstable plaques that often rupture and start a cascade leading to thrombus formation and acute coronary syndromes or sudden cardiac death. Respiratory infections are among the known triggers for such acute cardiovascular events.</p><p style="margin-top: 0px;">In the past 2 decades, many basic and epidemiologic studies have suggested a role for chronic indolent infections, such as Chlamydia pneumoniae, in the chronic progression of atherosclerotic lesions over years. Failure of clinical trials using antibiotics against C. pneumoniae to prevent cardiovascular events has led to a decreased interest in the role of infections in cardiovascular disease. However, in contrast to chronic infections, acute infections may cause acute coronary syndromes by triggering severe and abrupt inflammatory changes in high-risk coronary plaques over a few days or weeks. Prevention or treatment of these infections may offer new targets for coronary prevention.2</p><p style="margin-top: 0px;">In this issue of CMAJ, Lamontagne and colleagues3 present their findings from a large hospital-based database study. The authors studied the incidence of myocardial infarctions among those who had or had not received a pneumococcal vaccine before admission to hospital. They include patients who were free of known atherosclerotic disease but who were at risk of myocardial infarction based on age (men aged 45 years or older, women aged 50 years or older) and who had at least 1 cardiovascular disease risk factor (hypertension, diabetes or hyperlipidemia). The authors report that people who had a myocardial infarction were less likely than those who did not have a myocardial infarction to have received a pneumococcal polysaccharide vaccine (7.1% v. 11.6%; adjusted odds ratio 0.53, 95% confidence interval 0.40-0.70).</p><p style="margin-top: 0px;">The study by Lamontagne and colleagues does not include data on the incidence of pneumonia and its relation to myocardial infarction in cases and controls. However, it is reasonable to hypothesize that pneumococcal vaccination may protect against cardiovascular events by preventing pneumonia, as the latter has been shown to trigger myocardial infarction. Musher and colleagues4 reviewed a series of 170 patients admitted to hospital with pneumococcal pneumonia over a 5- year period and found that about 7% of patients had a myocardial infarction while in hospital. They also report that about 20% of patients had either a myocardial infarction, atrial fibrillation, or new or worsening congestive heart failure while in hospital.4 Other studies have suggested that infections in the upper respiratory tract and urinary tract can trigger myocardial infarctions.5 Spodick and colleagues reported that, in the 2-week period before being admitted to hospital for a myocardial infarction, 28% of patients had acute respiratory symptoms.6 In an autopsy-based study, my group observed that influenza epidemics are associated with a sharp rise in the number of deaths caused by myocardial infarction and ischemic heart disease.7 In fact, during almost all influenza epidemics and pandemics (except for the 1918 Spanish influenza pandemic), about twice as many people die of cardiac causes as die of pneumonia.8 Myocardial infarction was also reported to be the cause of death in 2 of 5 fatal cases among 75 patients with severe acute respiratory syndrome.9</p><p style="margin-top: 0px;">Multiple mechanisms could contribute to the cardioprotective effect of pneumococcal vaccination. A study in mice lacking the low-density lipoprotein (LDL) receptor suggested that the molecular mimicry between epitopes of Streptococcus pneumoniae and oxidized LDL may lead to increased anti-oxidized LDL immunoglobins following pneumococcal vaccination, which may lead to a decreased extent of atherosclerosis.10 However, production of such antibodies following pneumococcal vaccination in humans has not been confirmed.11 This interesting pathway requires further research. In addition, S. pneumoniae and other respiratory infections may exert many acute effects directly relevant to acute coronary syndromes. My colleagues and I have previously shown that influenza infection leads to excessive recruitment of inflammatory cells to atherosclerotic aortic plaques in mice lacking apolipoprotein E receptor.12 Similarly, compared with controls, the coronary arteries of patients who died of acute systemic infections show a higher number of macrophages and T cells in their adventitia and periadventitial fat, and more dendritic cells in the intima and media.13 In synergy with local cellular inflammation, there is an extensive systemic inflammation heralded by acute increase in systemic markers of inflammation.2 These acute inflammatory changes are paralleled by activation of the coagulation cascade and increased levels of coagulation factors. Finally, such acute infections are also associated with tachycardia, hemodynamic stress, fever, dehydration, increased plasma viscosity, release of endogenous cathecholamines, possible demand ischemia, severe endothelial dysfunction and qualitative pro-oxidant changes in high-density lipoprotein. Each of these can play an important role in acute coronary syndromes.2,14</p><p style="margin-top: 0px;">Given the pivotal role of inflammation and its relation to infection in the development of acute coronary syndromes, it would be prudent to test drugs that affect inflammatory mechanisms in clinical scenarios involving atherosclerosis. Statins are known to have such anti-inflammatory effects.1 There have been conflicting conclusions from studies examining the effect of statins on mortality of people admitted to hospital with community-acquired pneumonia. New well-designed studies of statins in the context of acute infection focused on cardiovascular outcomes are needed. Preliminary reports from my laboratory suggest that statins have a direct antiinfluenza effect,15 and they could be tested for similar effects against S. pneumoniae and other microbial agents. Hypothetically, in adults with respiratory infections, acetylsalicylic acid (ASA) could be useful not only for relief of respiratory symptoms but also for preventing coronary events, because ASA may help to reduce inflammation and inhibit platelet function during high-risk periods.2 Finally, further research is needed to assess whether the use of antimicrobials can prevent cardiovascular events if used in a timely manner when infections occur without or despite vaccination.</p><p style="margin-top: 0px;">Multiple case-control, cohort and randomized clinical trials in different settings have shown that preventing influenza by vaccination can reduce the risk of recurrent myocardial infarction, sudden cardiac death, cardiac hospital admissions, need for revascularization and stroke.2,14 The current study by Lamontagne and colleagues suggests that pneumococcal vaccination could similarly be a safe and inexpensive tool to prevent cardiovascular events. However, results of case-control studies should be interpreted with caution. "Healthy user" bias is a possibility in case-control studies. Receipt of pneumococcal vaccine may be an indicator of better access to health care, healthier life style and better control of risk factors. The study findings were significant after adjustment for several confounders; however, statistical models may not completely overcome the complex interactions between confounders. Further prospective and randomized studies are needed to confirm these findings.</p><p style="margin-top: 0px;">Until confirmatory studies are available, clinicians should comply with available guidelines by increasing current vaccination rates among patients at high risk. In the United States, rates of pneumococcal and influenza vaccination are well below the established goals, and the situation is worse in many other countries. In addition, clinicians should reduce the baseline risk of cardiovascular events in vulnerable patients by judicious use of antihypertensive, lipid-lowering drugs (preferably statins) and ASA.</p><p style="margin-top: 0px;">Competing interests: Mohammad Madjid received an honorarium from Pfizer for participation in an advisory board meeting in 2007.</p><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td class="textSmall" nowrap="nowrap"><b>[Sidebar]</b></td></tr><tr><td class="textSmall">Key points</td></tr><tr><td class="textSmall">* Infections of the upper respiratory tract, including pneumonia and influenza, can trigger acute coronary syndromes.</td></tr><tr><td class="textSmall">* Prevention of these infections by vaccination may prevent cardiovascular events in people at high risk.</td></tr><tr><td class="textSmall">* Rates of pneumococcal and influenza vaccination are below the optimal level in most countries.</td></tr><tr><td class="textSmall">* Physicians need to improve vaccination rates by actively advocating vaccination following established guidelines.</td></tr><tr><td class="textSmall">* Special attention should be paid to symptoms and signs of cardiac events in patients at high risk for cardiovascular disease who have an upper respiratory tract infection.</td></tr><tr><td class="textSmall">From the Texas Heart Institute and the Baylor College of Medicine, Houston, USA</td></tr></tbody></table></span><table border="0" cellpadding="0" cellspacing="0"><tbody></tbody></table><br /><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td nowrap="nowrap"> <span class="bold textSmall">[Reference]</span> <span class="raquo">» </span> <a title="View a list of references included in this document" href="http://proquest.umi.com/pqdweb?VInst=PROD&VName=PQD&VType=PQD&RQT=594&did=1566223051&Fmt=3&refType=CITEDIN&b2=d&SrchMode=1&sid=1&index=1&TS=1232087315" class="textSmall">View reference page with links</a></td></tr><tr><td class="textSmall">REFERENCES</td></tr><tr><td class="textSmall">1. Willerson JT, Ridker PM. Inflammation as a cardiovascular risk factor. Circulation 2004;109(Suppl 1):II2-10.</td></tr><tr><td class="textSmall">2. Madjid M, Naghavi M, Litovsky S, et al. Influenza and cardiovascular disease: a new opportunity for prevention and the need for further studies. Circulation 2003;108:2730-6.</td></tr><tr><td class="textSmall">3. Lamontagne F, Garant MP, Carvalho JC, et al. Pneumococcal vaccination and risk of myocardial infarction. CMAJ 2008;179:773-7.</td></tr><tr><td class="textSmall">4. Musher DM, Rueda AM, Kaka AS, et al. The association between pneumococcal pneumonia and acute cardiac events. Clin Infect Dis 2007;45:158-65.</td></tr><tr><td class="textSmall">5. Smeeth L, Thomas SL, Hall AJ, et al. Risk of myocardial infarction and stroke after acute infection or vaccination. N Engl J Med 2004;351:2611-8.</td></tr><tr><td class="textSmall">6. Spodick DH, Flessas AP, Johnson MM. Association of acute respiratory symptoms with onset of acute myocardial infarction: prospective investigation of 150 consecutive patients and matched control patients. Am J Cardiol 1984;53:481-2.</td></tr><tr><td class="textSmall">7. Madjid M, Miller CC, Zarubaev VV, et al. Influenza epidemics and acute respiratory disease activity are associated with a surge in autopsy-confirmed coronary heart disease death: results from 8 years of autopsies in 34,892 subjects. Eur Heart J 2007;28:1205-10.</td></tr><tr><td class="textSmall">8. Madjid M, Casscells SW. Of birds and men: cardiologists' role in influenza pandemics. Lancet 2004;364:1309.</td></tr><tr><td class="textSmall">9. Peiris JS, Chu CM, Cheng VC, et al. Clinical progression and viral load in a community outbreak of coronavirus-associated SARS pneumonia: a prospective study. Lancet 2003;361:1767-72.</td></tr><tr><td class="textSmall">10. Binder CJ, Horkko S, Dewan A, et al. Pneumococcal vaccination decreases atherosclerotic lesion formation: molecular mimicry between streptococcus pneumoniae and oxidized LDL. Nat Med 2003;9:736-43.</td></tr><tr><td class="textSmall">11. Nguyen JT, Myers N, Palaia J, et al. Humoral responses to oxidized low-density lipoprotein and related bacterial antigens after pneumococcal vaccine. Transl Res 2007;150:172-9.</td></tr><tr><td class="textSmall">12. Naghavi M, Wyde P, Litovsky S, et al. Influenza infection exerts prominent inflammatory and thrombotic effects on the atherosclerotic plaques of apolipoprotein e-deficient mice. Circulation 2003;107:762-8.</td></tr><tr><td class="textSmall">13. Madjid M, Vela D, Khalili-Tabrizi H, et al. Systemic infections cause exaggerated local inflammation in atherosclerotic coronary arteries: clues to the triggering effect of acute infections on acute coronary syndromes. Tex Heart Inst J 2007;34:11-8.</td></tr><tr><td class="textSmall">14. Madjid M, Aboshady I, Awan I, et al. Influenza and cardiovascular disease: Is there a causal relationship? Tex Heart Inst J 2004;31:4-13.</td></tr><tr><td class="textSmall">15. Haidari M, Ali M, Casscells W, et al. Statins block influenza infection by downregulating Rho/rho kinase pathway [abstract]. Circulation 2007;116:II_7.</td></tr></tbody></table></span><table border="0" cellpadding="0" cellspacing="0"><tbody></tbody></table><br /><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td class="textSmall" nowrap="nowrap"><b>[Author Affiliation]</b></td></tr><tr><td class="textSmall">Mohammad Madjid MD</td></tr></tbody></table></span><table border="0" cellpadding="0" cellspacing="0"><tbody></tbody></table><br /><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td class="textSmall" nowrap="nowrap"><b>[Author Affiliation]</b></td></tr><tr><td class="textSmall">Correspondence to: Dr. Mohammad Madjid, Texas Heart Institute, 6770 Bertner Ave., MC 2-255, Houston TX 77030, USA; fax 832 355-9595; mmadjid@gmail.com</td></tr></tbody></table></span><table border="0" cellpadding="0" cellspacing="0"><tbody></tbody></table></div></div>All About Bloggerhttp://www.blogger.com/profile/17282736671555579827noreply@blogger.com0tag:blogger.com,1999:blog-4987803374989865601.post-64412667255891739752009-01-11T15:33:00.000-08:002009-01-11T15:59:03.785-08:00Impact of type 2 diabetes on manifestations and treatment outcome of pulmonary tuberculosisImpact of type 2 diabetes on manifestations and treatment outcome of pulmonary tuberculosis<br />C S WANG, C J YANG, H C CHEN, S H CHUANG, et al. Epidemiology and Infection. Cambridge: Feb 2009. Vol. 137, Iss. 2; pg. 203, 8 pgs<br />Abstract (Summary)<br /><br />SUMMARY<br /><br />Diabetes mellitus (DM) is a known risk factor for pulmonary tuberculosis (PTB). This study aimed to determine if type 2 DM alters manifestations and treatment outcome of PTB. Records of 217 consecutive culture-proven PTB patients were analysed retrospectively. The manifestations and treatment outcomes of 74 patients with type 2 DM (PTB-DM group) were compared to 143 patients without DM (PTB group). PTB-DM patients showed higher frequencies of fever, haemoptysis, positive acid-fast bacilli sputum smears, and consolidation, cavity, and lower lung field lesions on chest radiographs, and higher mortality rate. Furthermore, type 2 DM, age [= or >, slanted]65 years, and extensive radiographic disease were factors independently associated with an unfavorable outcome. This study confirmed that clinical manifestations and chest radiographs of PTB patients associated with type 2 DM significantly depart from the typical presentation. Type 2 DM seems to have a negative effect on treatment outcome of PTB. [PUBLICATION ABSTRACT]<br />» Jump to indexing (document details)<br />Full Text (2829 words)<br />Copyright © 2008 Cambridge University Press<br /><br />(ProQuest: ... denotes non-US-ASCII text omitted.)<br /><br /><br />INTRODUCTION<br /><br />Although the prevalence rate of pulmonary tuberculosis (PTB) has declined significantly in western countries in the past few decades, PTB remains one of the most common infectious diseases in developing countries [1]. Diabetic patients are considered a high-risk population [2] and many studies have shown a 1·5-7·8 times higher prevalence of PTB among diabetics than non-diabetics [3-6]. With increasing life expectancy, there is also a current global increase in diabetic patients [7]. Thus, PTB in diabetic patients will become an increasingly important problem.<br /><br />A high index of suspicion and prompt investigation of diabetic patients with clinical presentation of PTB may allow earlier diagnosis and treatment. Nonetheless, some previous reports have described an atypical presentation of PTB in diabetic patients [8-10]. When these differences are ignored, establishing a diagnosis may be delayed, leading to increased morbidity and mortality.<br /><br />On the other hand, there is scarce information about the influence of type 2 diabetes mellitus (DM) on the treatment outcome of culture-proven PTB patients. The present study aimed to determine, in a developed Asian city with a sizable study sample and a high prevalence of PTB, if type 2 DM alters manifestations and treatment outcome of PTB.<br /><br />METHODS<br /><br />Subjects and study design<br /><br />This study was conducted at the Kaohsiung Municipal Hsiao-Kang Hospital, a 500-bed, university-affiliated teaching hospital that serves as a tertiary referral centre and primary-care facility in southern Taiwan. From the retrospective review, 217 consecutive adult patients with PTB from 1 January 2003 to 31 December 2006 were selected and 21 patients were excluded because either the chest radiograph (CXR) done at the first presentation was missing or there was no clear data on bacteriology and history of DM, as radiographic and bacteriological findings were the main parameters that this study investigated in patients with and without DM. The study protocol was reviewed and approved by the hospital's human experiment and ethics committee.<br /><br />Cases were identified from the hospital coding system and microbiology department records, and included both outpatients and in-patients. In this institution, the main criteria for hospital admission of tuberculous patients included sepsis, haemoptysis, respiratory failure, advanced malnutrition, and pleural effusion. However, about two-thirds of hospitalized tuberculous patients were admitted for treatment or diagnosis confirmation even in the absence of the above-mentioned criteria. Patients were excluded if one of the following was present: aged <18>126 mg/dl on a different day in an outpatient setting. Patients who did not have DM in the same period were chosen as the control group (PTB group). The characteristics of the 74 type 2 DM patients (PTB-DM group) were compared to those of the 143 non-diabetic patients (PTB group).<br /><br />Clinical data collection<br /><br />All of the patients had a medical chart, microbiology results, and standard posterior-anterior CXR. Although this was a retrospective study, the patients were interviewed by the same trained nurse-case manager using a structured questionnaire and the completed questionnaires were then reviewed by the physician investigator. Demographic information included age and sex. Risk factors for PTB infection were recorded, including previous TB disease, infectious TB contact history, alcoholism, illegal drug use, long-term glucosteroid use, immunosuppressive drug use, and other comorbidities associated with TB, such as DM, end-stage renal disease, cancer, human immunodeficiency virus infection, silicosis, and gastrectomy history.<br /><br />Initial presenting symptoms prior to hospital consultation included the presence of cough, expectoration, fever, weight loss, dyspnoea, anorexia, haemoptysis, chest pain, fatigue, and night sweats, which were considered positive if these symptoms were present for [= or >, slanted]2 weeks. Less than this was coded as negative for the analysis. Weight loss was defined as positive if it was >10% of body weight within the last 6 months. Fever was defined as a body axillary temperature above 37·5°C. Haemoptysis was recorded as positive even if it occurred only once.<br /><br />All of the sputum smears were concentrated and stained with Ziehl-Neelsen stain by trained technicians. Each sputum sample was prepared in Löwenstein-Jensen culture medium and Middlebrook 7H11 selective agar, and maintained for at least 8 weeks to detect the presence of growth.<br /><br />Initial standard posterior-anterior CXR taken at the time of the patient's first hospital visit was independently reviewed by two external chest physicians, both of whom were unaware of the patient's clinical data. Differences were then resolved by consensus. CXR results were categorized by the involved field and pattern. An upper lung field lesion was defined as the presence of any lesion above an imaginary line across the hilum. Radiographic presentation was categorized as normal, consolidation, cavity, or pleural effusion [12]. 'Normal' pattern was defined as the absence of any abnormal lesion on CXR. 'Consolidation' pattern was defined as an essentially homogenous opacity in the lung characterized by little or no loss of volume, effacement of blood vessel shadows, and sometimes by the presence of an air bronchogram. 'Cavitary' pattern was defined as a lucent area within the lung that may or may not contain a fluid level and that is surrounded by a wall, usually of varied thickness. 'Pleural effusion' was defined as a uniform opacity extending upwards from the costophrenic angle in an erect film. Ultrasound was later used to confirm pleural effusion.<br /><br />TB treatment consisted of a standard regimen of daily rifampicin, isoniazid, pyrazinamid, and ethambutol for 2 months and rifampicin, isoniazid, and ethambutol for another 4 months or daily rifampicin, isoniazid, and ethambutol for 9 months. Treatment outcomes after 1 year from the initiation of anti-TB treatment were extracted from the records. They were analysed and defined according to World Health Organization recommendations [13]. 'Cure' was defined as a patient who was sputum smear-negative in the last month of treatment and on at least one previous occasion. 'Treatment completed' was defined as a patient who had completed treatment but who did not meet the criteria to be classified as a cure or a failure. 'Treatment failure' was defined as a patient who was sputum smear-positive at 5 months or later during treatment. 'Died' was defined as a patient who died for any reason during the treatment course. 'Default' was a patient whose treatment was interrupted for two consecutive months or more, and 'Transfer out' was a patient who was transferred to another recording and reporting unit, with unknown outcome. A favourable outcome was defined as including cure and treatment completed. Any other outcome was classified as unfavourable. In subgroup analysis, 'PTB-related death' was defined as a patient who died due to PTB during the treatment course.<br /><br />Statistical analysis<br /><br />Univariate comparisons between the PTB-DM and PTB groups were performed using the [chi] 2 test except when expected values of <5>, slanted]0·10. All of the analyses were performed using a statistical software program (version 12.0, SPSS Inc., Chicago, IL, USA).<br /><br />RESULTS<br /><br />Demographic characteristics and sputum acid-fast bacilli (AFB) stain results<br /><br />A total of 217 culture-positive PTB patients were enrolled in the study. There were no type 1 DM patients in this study. The demographic characteristics and sputum AFB stain results of the PTB-DM and PTB groups are presented in Table 1. There was no statistically significant difference between the two groups regarding age, sex, previous TB disease, infectious TB contact history, alcoholism, end-stage renal disease, and cancer. No patient had the following risk factors: illegal drug use, long-term glucosteroid or immunosuppressive drug use, human immunodeficiency virus infection, silicosis, and gastrectomy history. In the PTB-DM group, 68·9% of patients were AFB positive on sputum smear compared to 53·8% of the PTB group (OR 1·90, 95% CI 1·051-3·435).<br /><br /><br />Initial presenting symptoms<br /><br />The initial presenting symptoms of the PTB-DM and PTB groups are described in Table 2. The PTB-DM group had higher frequencies of fever (OR 2·2, 95% CI 1·233-4·011) and haemoptysis (OR 2·6, 95% CI 1·238-5·297) than the PTB group. There were no statistically significant differences in terms of cough, expectoration, weight loss, dyspnoea, anorexia, chest pain, fatigue, and night sweats.<br /><br /><br />Initial presenting CXR findings<br /><br />Initial presenting CXR findings of the PTB-DM and PTB groups are shown in Table 3. Isolated lower lung field lesions were significantly more common in the PTB-DM group than the PTB group (OR 2·04, 95% CI 1·027-4·042). The PTB-DM group also had significantly higher frequencies of consolidation (OR 2·23, 95% CI 1·040-4·798) and cavity (OR 1·91, 95% CI 1·072-3·412) in terms of lung lesions. There were no statistically significant differences between the two groups regarding radiographic features, including the prevalence of normal and pleural effusion.<br /><br /><br />Treatment outcome after 1 year from the initiation of anti-TB treatment<br /><br />Treatment outcome after 1 year from the initiation of anti-TB treatment is shown in Table 4. Mortality for PTB-DM patients was 17·6%, in sharp contrast to 7·7% for PTB patients (OR 2·56, 95% CI 1·084-6·034). Univariate analysis shows that type 2 DM (OR 2·9, 95% CI 1·456-5·928), age [= or >, slanted]65 years (OR 8·5, 95% CI 3·970-18·352), and extensive radiographic disease that was defined as radiographic lesions involving both upper and lower lung field (OR 3·2, 95% CI 1·551-6·802) were all associated with an unfavourable outcome. On multiple logistic regression analysis after adjusting for age and sex, type 2 DM (OR 5·5, 95% CI 2·273-13·452), age [= or >, slanted]65 years (OR 10·8, 95% CI 4·402-26·251), and extensive radiographic disease (OR 2·40, 95% CI 1·027-5·617) remained as independent and significant risk factors (Table 5). In subgroup analysis, PTB-related death was significantly more common in the PTB-DM group than the PTB group (12·2% vs . 4·2%; OR 3·16, 95% CI 1·080-9·257). On multiple logistic regression analysis after adjusting for age and sex, type 2 DM (OR 7·6, 95% CI 1·976-29·083) still remained as an independent and significant risk factor for PTB-related death.<br /><br /><br /><br />DISCUSSION<br /><br />The increased incidence of DM among PTB patients is well known [3-6], but less is known about its possible effects on the manifestations and treatment outcome of PTB. Recent studies show that 10-30% of patients with PTB may also have DM [2-4, 14-18]. In this study, 34% of the total PTB patients had co-existing type 2 DM.<br /><br />Recently, a number of studies compared disease presentation between diabetic and non-diabetic PTB patients. Studies in Saudi Arabia [16], Malaysia [19], and Turkey [20] did not find major differences in presenting symptoms. Similar to our findings, a recent large retrospective study involving the Texas-Mexico border region revealed a higher rate of fever and haemoptysis among diabetic PTB patients [14]. Whether the symptomatic differences of PTB patients with DM in the present study represent physiological or cultural differences (or both) remains unclear.<br /><br />Comparative studies of PTB images in diabetics have yielded conflicting results. The impact of DM on the radiological presentation of PTB is important because misinterpretations may delay appropriate diagnostic tests and treatment, thus risking dissemination of M. tuberculosis to others. Some studies on the radiographic findings of PTB patients with DM report atypical localization patterns, namely an increased incidence of lower lung field involvement [8-10], which is confirmed in the present study. Other reports do not confirm these observations and find no difference in terms of the radiographic involvement of the lung fields [20, 21]. Possible explanations for these discrepancies are demographic characteristics and patient selection process.<br /><br />Our study shows a significantly higher frequency of consolidation and cavitary lung lesions on CXR in the PTB-DM group. Some previous studies have also reported cavitary lesions as more common among diabetic patients [8-10, 14, 22]. Moreover, our sputum bacteriology results reveal that diabetics have a higher prevalence of AFB smear-positive cases compared to non-diabetic PTB patients. Our study also shows an interesting finding - increasing cavitation together with increased smear positivity in the diabetic group - which is the same as a previous study [23]. Cavitary disease is associated with a larger population of bacilli.<br /><br />Immunosuppression induced by DM may be responsible for the atypical images and higher bacillary load in PTB patients with DM [24]. It is known that DM causes a decrement in lymphocyte activity and a diminution in the number of monocytes and macrophages, with abnormalities in their chemotactic and phagocytic activities [25, 26]. Moreover, DM also causes dysfunction of polymorphonuclear leukocytes, with a reduction in their bactericidal activity [27].<br /><br />There are conflicting reports regarding the influence of associated DM on the treatment outcome of TB patients. One study has reported no effect of DM on the treatment outcome of TB patients [16], while another has reported a negative effect [18]. In the present study, the mortality rate for all patients at 12 months was 11·0%, accounting for 60% (24/40) of the patients with unfavourable outcome. There was also a sharp contrast in mortality rates (17·6% vs . 7·7%; OR 2·56, 95% CI 1·084-6·034) and PTB-related death (12·2% vs . 4·2%; OR 3·16, 95% CI 1·080-9·257) between PTB-DM and PTB patients. As more than one third of patients were diabetics with PTB, the higher mortality rate may have contributed to the overall low treatment completion rate.<br /><br />Altered pharmacokinetics of anti-TB drugs may explain the adverse effect of DM on the treatment outcome of TB patients. One recent study has reported low plasma concentrations of rifampicin in diabetic patients with TB [28]. Several mechanisms have been postulated to explain the altered pharmacokinetics of anti-TB drugs in TB patients with DM. The absorption, distribution, metabolism, and excretion of drugs could all be changed in TB patients with DM [29]. Lower plasma concentrations of anti-TB drugs have been associated with clinical failure and acquired drug resistance [30]. If these findings are confirmed, higher fixed dosages of rifampicin may be warranted for TB patients with DM. If available, physicians may consider the assessment of plasma concentrations of rifampicin in patients with DM in order to individualize dosing.<br /><br />The present study reveals on univariate analysis that type 2 DM, age [= or >, slanted]65 years, and extensive radiographic disease were all associated with an unfavourable outcome. Moreover, even after adjustment for age and sex, logistic regression analysis also showed that type 2 DM was an independent and significant risk factor associated with an unfavourable outcome. This suggests that clinicians must pay more attention to PTB patients with associated DM. A previous study has shown that the advent of effective anti-TB and anti-diabetic treatments has led to a decrease in the death rate of TB in patients with DM [31].<br /><br />Our study had some methodological limitations. Twenty-one patients were excluded in the retrospective study because either the CXR that was done at the first presentation was missing or there was no clear data on bacteriology and history of DM. Part of the findings might result from missing patient records unrelated to DM status. Therefore, future prospective studies should formally evaluate the differences.<br /><br />In summary, this study has shown that PTB patients with associated type 2 DM had higher frequencies of fever, haemoptysis, positive AFB sputum smears, and consolidation, cavity, and lower lung field lesions on CXR, and mortality rate. Furthermore, PTB-DM patients also have higher frequencies of unfavourable outcome. PTB should be included in the differential diagnosis when diabetic patients present with unusual findings, thus avoiding postponing the diagnosis and the start of treatment, and reducing the dissemination of M. tuberculosis to others and the mortality rate for PTB-DM patients.<br /><br />DECLARATION OF INTEREST<br /><br />None.<br />[Reference]<br />REFERENCES<br /> <br />[Author Affiliation]<br />1 Department of Internal Medicine, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan<br />2 Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan<br /><br />Indexing (document details)<br />Subjects: Diabetes, Tuberculosis, Epidemiology<br />Author(s): C S WANG, C J YANG, H C CHEN, S H CHUANG, I W CHONG, J J HWANG, M S HUANG<br />Author Affiliation: 1 Department of Internal Medicine, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan<br />2 Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan<br />Document types: Feature<br />Publication title: Epidemiology and Infection. Cambridge: Feb 2009. Vol. 137, Iss. 2; pg. 203, 8 pgs<br />Source type: Periodical<br />ISSN: 09502688<br />ProQuest document ID: 1621810791<br />Text Word Count 2829<br />DOI: 10.1017/S0950268808000782<br />Document URL: http://proquest.umi.com/pqdweb?did=1621810791&sid=1&Fmt=3&clientId=45625&RQT=309&VName=PQDAll About Bloggerhttp://www.blogger.com/profile/17282736671555579827noreply@blogger.com0tag:blogger.com,1999:blog-4987803374989865601.post-31439775594604602532008-12-30T01:03:00.000-08:002008-12-30T01:05:21.248-08:00The Interaction of Sexual Identity With Sexual Behavior and Its Influence on HIV Risk Among Latino Men: Results of a Community Survey<strong>The Interaction of Sexual Identity With Sexual Behavior and Its Influence on <span style="color:red;"><b>HIV</b></span> Risk Among Latino Men: Results of a Community Survey in Northern San Diego County, California<br /><br /></strong><div class="docSection" style="padding-top: 4px; padding-left: 4px;"><span class="textSmall"><strong>Abstract (Summary)</strong></span><div class="textMedium"><p style="margin-top: 0px;">We examined the sexual behavior, sexual identities, and <span style="color:red;"><b>HIV</b></span> risk factors of a community sample of Latino men to inform efforts to reduce Latinos' <span style="color:red;"><b>HIV</b></span> risk. In 2005 and 2006, 680 Latino men in San Diego County, California, in randomly selected, targeted community venues, completed an anonymous, self-administered survey. Most (92.3%) respondents self-identified as heterosexual, with 2.2%, 4.9%, and 0.6% self-identifying as bisexual, gay, or other orientation, respectively. Overall, 4.8% of heterosexually identified men had a lifetime history of anal intercourse with other men. Compared with behaviorally heterosexual men, heterosexually identified men who had sex with both men and women were more likely to have had a sexually transmitted infection, to have unprotected sexual intercourse with female partners, and to report having sex while under the influence of alcohol or other drugs. Bisexually identified men who had sex with men and women did not differ from behaviorally heterosexual men in these risk factors. Latino men who have a heterosexual identity and bisexual practices are at greater risk of <span style="color:red;"><b>HIV</b></span> infection, and efforts to reduce <span style="color:red;"><b>HIV</b></span> risk among Latinos should target this group.</p><p style="margin-top: 0px;"><br /></p></div></div><span class="italic">Copyright American Public Health Association Jan 2009</span><br /><br /><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td class="textSmall" nowrap="nowrap"><b>[Headnote]</b></td></tr><tr><td class="textSmall">Objectives. We examined the sexual behavior, sexual identities, and HIV risk factors of a community sample of Latino men to inform efforts to reduce Latinos' HIV risk.</td></tr><tr><td class="textSmall">Methods. In 2005 and 2006, 680 Latino men in San Diego County, California, in randomly selected, targeted community venues, completed an anonymous, self-administered survey.</td></tr><tr><td class="textSmall">Results. Most (92.3%) respondents self-identified as heterosexual, with 2.2%, 4.9%, and 0.6% self-identifying as bisexual, gay, or other orientation, respectively. Overall, 4.8% of heterosexually identified men had a lifetime history of anal intercourse with other men. Compared with behaviorally heterosexual men, heterosexually identified men who had sex with both men and women were more likely to have had a sexually transmitted infection, to have unprotected sexual intercourse with female partners, and to report having sex while under the influence of alcohol or other drugs. Bisexually identified men who had sex with men and women did not differ from behaviorally heterosexual men in these risk factors.</td></tr><tr><td class="textSmall">Conclusions. Latino men who have a heterosexual identity and bisexual practices are at greater risk of HIV infection, and efforts to reduce HIV risk among Latinos should target this group. (Am J Public Health. 2009;99:125-132. doi:10.2105/AJPH.2007.129809)</td></tr></tbody></table></span><table border="0" cellpadding="0" cellspacing="0"><tbody></tbody></table><br /><p style="margin-top: 0px;">Latinos and sexual minorities are disproportionately affected by HIV/AIDS. Latinos represented 14% of the US population in 2005,1 but they accounted for18%ofHIV/AIDS cases diagnosed in 2006.2 Although an estimated6%to9%of the US population has a lifetime history of homosexual sex,3,4 menwho have sexwithmen accounted for 49% of all HIV/AIDS cases diagnosed in the United States in 2006.2 Sexual risk for HIV varies considerably by sexual orientation, with gay-identified and bisexually identified men generally at greater risk.5,6 However, a person's selfidentified sexual orientation frequently does not correspond to his or her sexual behavior.7-9</p><p style="margin-top: 0px;">Within Latino culture, it is possible for a man to have sex with men while maintaining a heterosexual identity and protecting his sense of masculinity.10-13 For Latino men, sexual identity appears to be contingent upon certain behavioral and contextual factors, such as whether they have female sexual partners, are primarily attracted to women, adopt an insertive role in sexual practices, have sex with effeminate men, or have sex with men when under the influence of alcohol or drugs. Homophobia, social stigma attached to same-sex practices, and sexual conservatism are commonly found throughout Latino culture andmay inhibit Latino men who have sex withmen fromself-identifying as gay or bisexual.9,10,14-16 Research suggests that Latino men are more likely than are White men to engage in bisexual behavior (i.e., to have sex with both men and women)8,17,18 but are less likely than are White men to disclose a nonheterosexual orientation.16,19,20</p><p style="margin-top: 0px;">Among men, bisexual behavior appears to be more prevalent than bisexual identity. Although approximately1%to 2% of the US male population identifies as bisexual,3,4 rates of male bisexual behavior in national samples have ranged from 1% to 5%.4,21,22 However, these estimates are questionable because of differences in sampling methods and varying definitions of bisexuality.23 Recent research conducted in the United States suggests that men who have sex with men and women (MSMW) are at greater risk of HIV infection than men who have sex with men (MSM) exclusively and men who have sex with women (MSW) exclusively.24-26 By contrast, investigators in Mexico have found that MSMW who self-identify as bisexual practice less risky sexual behaviors with their male partners than do exclusively gay men.6</p><p style="margin-top: 0px;">It has been difficult to quantify the population of heterosexually identified Latino MSMWbecause of the secretive nature of their sexual practices. In a homophobic cultural context, the fear of social rejection encourages people to hide their same-sex sexual behavior and lead a double life.10Astudy involving a large population ofHIVpositive MSM found that 15% of the Latino sample identified as heterosexual had a history of same-sex intercourse,27 whereas a survey of 455 men recruited from gay-oriented publications and venues in 12 US cities found that17% (n=26) of Hispanic respondents (as per terminology used in the original survey) reported being "on the down low".9 Although these results may not generalize to community-based US samples of Latino men, they suggest that a substantial proportion of heterosexually identified Latino men have a history of sex with men. Similarly, a household probability survey in Mexico City found that 73% of men with a lifetime history of bisexual practices identified as heterosexual, as did 29%of those with a lifetime history of having sex only with men.6</p><p style="margin-top: 0px;">Men's nondisclosure of sexual practices with men has implications for the health of their female sexual partners.8,17 In the United States in 2006, Latinas accounted for 23.7% of HIV infections among Hispanics; of these, an estimated 51.7% were infected through heterosexual contact.2 Although most cases of heterosexual transmission to Latinas are related to sex with injection drug users,28 women who have unprotected sex with heterosexually identified MSMWare also at risk and are likely a subset of this population.</p><p style="margin-top: 0px;">Although there is some evidence of greater HIV risk among MSMW than among MSM or MSW,24-26 previous research has not examined the roles that both sexual behavior and sexual identity play in HIV risk among Latino men in particular. Sexual identitymay influenceHIV risk among Latino MSMW because a man who identifies as heterosexual may perceive that he is at lower risk of sexually transmitted infections (STIs) than are gay or bisexual men and may thus take fewer measures to protect himself or his partner. MSMW who identify as heterosexual may also be more likely to resort to substance use to reduce sexual inhibition, thus increasing the likelihood that they will engage in unsafe sex.29</p><p style="margin-top: 0px;">Our goal was to learn more about the sexual practices of Latino men and to better understand the interactions among sexual behaviors and sexual identities in this population so as to inform efforts to reduce HIV risk among Latinos. Using survey data, we examined the sexual behavior of a community sample of Latino men; determined the proportions of MSM, MSW, and MSMW among them; elicited any discrepancies between their sexual behavior and their sexual identity; and searched for differences in HIV risk by sexual orientation.</p><p style="margin-top: 0px;">METHODS</p><p style="margin-top: 0px;">Design and Procedures</p><p style="margin-top: 0px;">We used baseline data collected as part of a larger study that evaluated a social marketing campaign to reduce HIV risk among heterosexually identified Latino MSMW in northern San Diego County, California. From December 2005 through April 2006, a cross-sectional community-based survey was conducted with Latino men recruited from 12 local venues. Using formative research, venues were selected to represent both high-risk and low-risk locations, with risk level determined by the extent to which sexual risk practices were likely to occur at or in proximity to the venue. Twelve sites covering the geographic region of northern San Diego County were identified, including 7 low-risk venues (i.e., a workplace, a migrant camp, a labor pickup site, 2 shopping centers, a center for the teaching of English as a second language, and a men's shelter) and 5 high-risk venues (i.e., an adult bookstore and 4 bars or clubs).</p><p style="margin-top: 0px;">Sampling shifts at each venue were selected based on days and times when sampling venues were operating (e.g., bars and clubs were only open in the evening) and when access to Latino men could be ensured (e.g., men congregated at labor pickup sites only in the morning). During every sampling period, random selection procedures were used to screen and recruit eligible participants. Eligibility included self-reported Latino ethnicity, being 18 years or older, and being alone or in the company of other men. Venue-specific recruitment goals were established based on the results of previous enumeration activities, to ensure that the number of completed surveys for each venue was proportional to the size of the target population visiting each site. The survey design included 3 sampling periods (December 2005, February 2006, and April 2006) and was based on the aims of the larger intervention study for which these data served as baseline. The response rate across all venues was 63% (70% for low-risk venues and 53% for high-risk venues).</p><p style="margin-top: 0px;">Measures</p><p style="margin-top: 0px;">Participants completed a self-administered intercept survey on a handheld computer using Questionnaire Development Software's HAPI data-collection module (NOVA Research Company, Bethesda, MD). The survey was anonymous and was available in either Spanish or English. Survey topics included demographic information; lifetime history of HIV and STI testing; lifetime and recent (previous 60 days) sexual behavior with both female and male partners, including vaginal intercourse, insertive anal intercourse, and receptive anal intercourse; and recent (previous 60 days) substance use.</p><p style="margin-top: 0px;">Statistical Analysis</p><p style="margin-top: 0px;">We defined sexual orientation according to 2 dimensions: gender of lifetime sexual partners and self-identified sexual orientation. We defined men as behaviorally heterosexual if they self-identified as heterosexual and reported no history of sexual activity with men (heterosexually identified MSW). We defined men as gay if they self-identified as gay or homosexual (gay-identified MSM). We defined men as bisexual if they self-identified as bisexual (bisexually identified MSMW). We defined men as heterosexually identified MSMW if they identified as heterosexual but had a history of having sex with men. All other men were classified as having an orientation of "other."</p><p style="margin-top: 0px;">Descriptive statistics and frequencies were computed for demographics, sexual behavior, substance use, and HIV and STI testing history. Bivariate (likelihood ratio) analyses explored differences in sexual behavior, substance use, and HIV and STI testing history by sexual orientation. Logistic regression models were estimated with each of the HIV risk variables as dependent variables, with sexual orientation as the main predictor variable, and with age, marital status, education, acculturation, and survey venue as covariates. Because of the small sample size and heterogeneity of the "other" sexual orientation category, this subgroup was included in descriptive analyses for the whole sample but was excluded from subsequent bivariate and multivariate analyses comparing HIV risk among sexual orientation categories. All analyses were computed using SPSS version 14.0 (SPSS Inc, Chicago, IL).</p><p style="margin-top: 0px;">RESULTS</p><p style="margin-top: 0px;">Sample Characteristics</p><p style="margin-top: 0px;">A total of 781 Latino men completed the survey. After excluding repeat survey participants, we included 680 participants (mean age=28.4 years; SD=9.1; range=18-65 years) in descriptive analyses. More than half (53%) were single or never married. Only 21.8% had completed a high school education or higher. The vast majority (92%) were born in Mexico, with an additional 5% born in the United States and 3% in another country. Among foreignborn participants (n=647), more than two thirds had been in the United States for 5 or fewer years , with 30% reporting US residency of less than1year. The percentage in our sample who reported being of Mexican origin matched US Census data for San Diego County, as did the percentage of foreign-born respondents who reported Mexico as their place of birth.30,31 Almost all respondents were primarily employed in 1 of 4 occupations: agriculture (29%), manufacturing (21%), service industry (24%), and construction (20%).</p><p style="margin-top: 0px;">The majority (92.3%) of participants selfidentified as heterosexual, with 2.2%, 4.9%, and 0.6% self-identifying as bisexual, gay, or other orientation, respectively. However, a smaller percentage (86.2%) reported a lifetime history of sexual practices with female partners exclusively. About 6% of men reported having a history of having sex with both men and women, 5.4% reported a history of sex with men only, and 2.4% reported no previous sexual practices with males or females. In all, 4.8% of heterosexually identified men had a lifetime history of anal intercourse with other men. According to our criteria, 87.6% of respondents were classified as heterosexually identified MSW; 4.4% as heterosexually identified MSMW; 2.4% as bisexually identified MSMW; and 4.7% as gay-identified MSM. The following percentages of respondents were recruited from high-risk recruitment venues: 46% of heterosexually identified MSW, 66.7% of heterosexually identified MSMW, 71.9% of gay-identified MSM, and 75% of bisexually identified MSMW.</p><p style="margin-top: 0px;">Sexual Risk Practices</p><p style="margin-top: 0px;">Most (56.5%) of the total sample of men reported sex with a female partner during the previous 60 days; of these, 58.2% reported not using a condom during 1 or more of these encounters, with percentages ranging from 25% among bisexually identified MSMW to 77.5% among heterosexually identified MSMW (Table 1). A minority of respondents (6.8%) reported engaging in anal intercourse with a male partner during the previous 60 days, with 57.8% of these reporting 1 or more unprotected encounters. The percentage of insertive anal intercourse equaled that of receptive anal intercourse (3.97%). By sexual orientation, percentages of insertive anal intercourse during the previous 60 days ranged from 31.2% among gay-identified MSM and bisexually identified MSMW to 36.7% among heterosexually identified MSMW. Percentages of receptive anal intercourse during the previous 60 days ranged from 10% among heterosexually identified MSMW to 50% among gayidentified MSM (P=.002). A majority (53.8%) of those who had insertive anal intercourse did so without using a condom, as did almost half (48.1%) of those who had receptive anal intercourse (Table 1).</p><p style="margin-top: 0px;">Out of 30 heterosexually identified MSMW, 40% (n=12) were estimated to have engaged in sex with both female and male partners during the previous 60 days. Among this subset, 91.7% (n=11) reported engaging in unprotected sex with both female and male partners. By contrast, 25% of 16 bisexually identified MSMW (n=4) reported sexual intercourse with both men and women during the previous 60 days; among them, only 1 reported unprotected sex with both genders.</p><p style="margin-top: 0px;">After adjusting for covariates, we found that heterosexually identified MSMW were 3.5 times more likely than were heterosexually identified MSW to report not using a condom with a female partner during the previous 60 days (95% confidence interval [CI]=1.15, 10.81; Table 2). Given the small size of the subsamples that reported recent anal intercourse with male partners, we performed no multivariate tests for significant differences in unprotected insertive and receptive anal intercourse with males by sexual orientation.</p><p style="margin-top: 0px;">Other HIV-Risk-Related Practices</p><p style="margin-top: 0px;">Condom carrying and risk perception. Overall, 23.1% of participants were carrying condoms at the time of the survey, with percentages ranging from 21% among heterosexually identified MSMW to 53.1% among gay-identified MSM (Table 3). With regard to perceived risk for HIV infection, 26.9% of participants considered themselves at medium or high risk, with percentages of risk perception being lowest among heterosexually identified MSW (23.4%) and highest among bisexually identified MSMW (68.8%; P<.001).</p><p style="margin-top: 0px;">After adjusting for covariates, we observed significant differences in the distribution of condom carrying and risk perception. Gayidentified MSM were 3.3 times more likely than were heterosexually identified MSW to report current condom carrying (95% CI=1.5, 7.2; Table 4). Gay-identified MSM were 4.8 times more likely than were heterosexually identified MSW to perceive themselves as being at risk of HIV infection (95% CI=2.2, 10.4), and bisexually identified MSMW were 7.4 times more likely than were heterosexually identified MSW to perceive themselves as being at risk of HIV infection (95% CI=2.5, 22.1). A trend was observed suggesting that heterosexually identified MSMW were more likely to perceive themselves as being at risk of HIV infection than were heterosexually identified MSW; however, this result did not reach statistical significance (P =.07). No significant differences were found between heterosexually identified MSMW and heterosexually identified MSW for condom carrying.</p><p style="margin-top: 0px;">Substance use. Almost one quarter of participants (23.4%) reported having sex while under the influence of alcohol during the previous 60 days, with percentages varying from18.8% among bisexually identified MSMW to 50% among heterosexually identified MSMW. In addition, 11.5% reported using illegal drugs, 6.1% reported having sex under the influence of illegal drugs, and 14.9% reported injection of a substance (e.g., medication, vitamins, illegal drugs). Heterosexually identified MSMWtended to report the highest percentages of illegal drug use (43.3%), drug use during sex (30%), and substance injection (26.7%). Bivariate statistical tests indicated significant differences in alcohol use before or during sex (P=.004), illegal drug use (P<.001), and drug use during sex (P<.001), by sexual orientation (Table 3).</p><p style="margin-top: 0px;">After adjusting for covariates, we found that heterosexually identified MSMW were 3.3 times more likely to report sex under the influence of alcohol (95% CI=1.5, 7.1), 6 times more likely to report illegal drug use (95% CI=2.7, 13.5), and 6.2 times more likely to report sex under the influence of illicit drugs (95% CI=2.4, 16.1) than were heterosexually identified MSW (Table 4). Bisexually identified MSMW were also significantly more likely than were heterosexually identified MSW to report use of illegal substances (odds ratio [OR]=3.8; 95% CI=1.2, 11.8). Sexual orientation was not predictive of substance injection.</p><p style="margin-top: 0px;">HIV and STI testing. Only 38.2% of the sample reported having been tested for HIV. Of these, 3.5% (n=9) reported that they were HIV positive. Among those who were HIV negative or whose HIV status was unknown, 46.5% did not know where they could get tested, and 43.4% had no intention of being tested in the next 6 months. Only 23% of men reported having been tested for STIs. Of these, 11% reported having had an STI in their lifetime (Table 3). Results from multivariate analysis indicated that, compared with heterosexually identified MSW, heterosexually identified MSMW and gay-identified MSM were significantly more likely to have been tested for HIV (heterosexually identified MSMW: OR=4.5; 95% CI=2.0, 10.2; gay-identified MSM: OR=11.3; 95% CI=3.8, 33.6). Gay-identified MSM were more likely than were heterosexually identifiedMSWto intend to be tested in the next 6 months (OR=2.7; 95% CI=1.2, 6.4). Heterosexually identified MSMW (OR=4.1; 95% CI=1.9, 9.0), bisexually identified MSMW (OR=3.1; 95% CI=1.1, 8.8), and gay-identified MSM (OR=3.7; 95% CI=1.7, 8.1) were more likely than were heterosexually identified MSW to have been tested for other STIs (Table 4). Heterosexually identified MSMW were more than 4.3 times more likely than were heterosexually identified MSW to report having had a STI (OR=4.3; 95% CI: 1.8, 9.9).</p><p style="margin-top: 0px;">DISCUSSION</p><p style="margin-top: 0px;">The estimate of behavioral bisexuality found among the present sample of Latino men (6%) was slightly larger than those previously reported in Mexico6 (2.1% for lifetime bisexual practices) and national US samples (1%-4.9% for various time frames).4,21,22 This may reflect our definition of behavioral bisexuality, which was based on lifetime sexual practices instead of recent sexual practices, and the fact that some of our venues had a significant proportion of gay-identified patrons. It may also be indicative of the higher rates of behavioral bisexuality among men of color reported in previous research. 8,9,17,18,26,29 However, we obtained a smaller percentage of heterosexually identified MSMW in our sample than those obtained in previous studies that included Latinos in the United States.8,9 This difference could be explained by an underreporting of sexual practices, particularly those that are stigmatized; a lack of measures on oral sex in our study; sampling biases in our study and in previous research; or the paucity of research that has simultaneously examined sexual identity and sexual behaviors with both women and men. Regardless, these results indicate that a significant proportion of heterosexually identified Latino men in our sample have engaged in sexual intercourse with men.</p><p style="margin-top: 0px;">HIV testing rates for our sample (38.2%) were lower than those estimated for Latino males in the United States (45%)32 and may be explained by the fact that most of the respondents in our sample were foreign born or recent immigrants. However, our HIV and STI testing rates were higher than were those estimated for migrants returning to Mexico from the United States (HIV testing: 22%-29%; STI testing: 10%-13%).33 A surprisingly high proportion of men reported being HIV positive; in the context of limited HIV testing, this finding may actually reflect underestimated rates of infection. However, these data must be interpreted cautiously, because the inclusion of high-risk venues may have caused us to find higher HIV rates than would be seen in the general population and because our data on HIV status are based solely on self-reports. Still, these findings call attention to the need to promote HIV and STI testing for low-acculturated Latinos.</p><p style="margin-top: 0px;">Compared to heterosexually identified MSW, heterosexually identified MSMW were more likely to report a history of STIs and recent unprotected sexual intercourse with a female partner. Moreover, half of heterosexually identified MSMW reported recent anal intercourse with a male partner; among them, 3 out of 4 reported inconsistent condom use during same-sex encounters. These findings add to previous research on behavioral bisexuality24-26,34 and have significant implications for the health of our respondents' sexual partners. Previous studies have suggested that risky bisexual behavior among men may serve as a bridge for HIV transmission from high-prevalence groups to the general population. 6,25,35 Research suggests that a relatively small proportion of HIV infections in the United States are attributable to bisexual behavior.35 However, these estimates rely on openly reported bisexual behavior. Because of stigma associated with homosexual practices,19,36 many behaviorally bisexual men may underreport or deny same-sex practices. Underreporting of same-sex practices among heterosexually identified MSMW may lead to an underestimation of the contribution that this transmission avenue makes to the HIV epidemic in the United States.</p><p style="margin-top: 0px;">Heterosexually identified MSMW were also more likely to report recent drug use and sexual intercourse while under the influence of alcohol or other drugs. This finding is consistent with previous research suggesting that substance use is frequently a contextual factor in same-sex intercourse among heterosexually identified MSMW14,16,37 and may contribute to increased risk for HIV infection among these men and their sexual partners.37 With less than 50% of men in our sample reporting using a condom during every recent sexual encounter, additional efforts clearly must be taken to encourage heterosexually identified MSMW to consistently use condoms with both male and female partners.</p><p style="margin-top: 0px;">Despite their same-sex sexual practices and substance-influenced encounters, heterosexually identified MSMW did not perceive their risk for HIV to differ significantly from that of heterosexually identified MSW. A considerable proportion of heterosexually identified MSMW in our sample (27%; data not shown) only adopted an insertive role in anal intercourse with men, reducing to some extent their risk of acquiring HIV. However, HIV and STI prevention interventions clearly should be targeted toward this population, including efforts to raise risk awareness.</p><p style="margin-top: 0px;">Implications</p><p style="margin-top: 0px;">These findings have important implications for future HIV prevention research and practice. First, more research is warranted to elucidate the relative contributions of male sexual identity and bisexual behavior to the increasing proportion of Latinas among new HIV cases. Previous studies have suggested that Latino MSM and MSMW are more likely to maintain a heterosexual identity than are Whites.16,19 However, more comparative studies are needed because little research has been conducted with White men on this issue. Additional research is also required to identify factors associated with the adoption of a heterosexual identity among MSMW. Because the only thing that differentiates bisexually identified MSMW from heterosexually identified MSMW is sexual identity, a comparison between these 2 groups would be particularly interesting.</p><p style="margin-top: 0px;">Second, these findings underscore the need for HIV prevention efforts targeting heterosexually identified Latino MSMW and their male and female sexual partners, such as efforts to reduce social stigma attached to same-sex intercourse and campaigns to raise HIV awareness regardless of sexual identity. Other interventions may include (but are not limited to) those promoting routine HIV and STI screening as a standard part of well-adult care38 and those attempting to normalize condom use regardless of sexual identity or the gender of one's sexual partners. Programs need to be consistent with and respectful of these men's sexual identities; they also must reduce the stigma associated with HIV testing and condom use, which are often perceived among Latinos as practices associated with homosexuality and signs of distrust or infidelity within relationships.39,40 Finally, interventions targeting Latinas as the sexual partners of MSMW are needed, especially in light of recent findings that sex within marriage may be the single greatest risk for HIV among Mexican women.34,41These interventions should be gender sensitive, taking into account potential constraints upon women's abilities to respond to their partners' risk, and routine opt-out HIV testing should be promoted.38</p><p style="margin-top: 0px;">Our findings offer additional evidence that both behavior and identity are important dimensions of sexual orientation that need to be contemplated when assessing HIV risk and evaluating prevention interventions. Our results point to the need for future research that will help investigators develop a better understanding of how heterosexual identity might increase HIV risk among behaviorally bisexual Latino men. There is also a need for research examining whether the differences among various sexual orientation groups observed here extend to Latino men in general or to other racial/ethnic male populations. Research on these topics should be carefully framed to avoid adding stigma and generating sensationalist discourses regarding heterosexually identified MSMW of color, or the so-called "down low" phenomenon.</p><p style="margin-top: 0px;">Limitations</p><p style="margin-top: 0px;">Our sampling procedures were part of a larger intervention study and included targeted sampling at venues in which heterosexually identified MSMW were likely to be found. Thus, the results may not reflect the risk dynamics of Latinos outside northern San Diego County and may be limited to the population of Latino men who frequent these types of venues. In addition, the inclusion of lifetime versus recent sexual practices in our definition of behavioral bisexuality may have overestimated the proportion of behaviorally bisexual men among our sample. Estimates of bisexuality have been found to vary substantially depending on the time frame of sexual behavior selected.6 Our use of lifetime sexual practices may have captured early same-sex experiences (e.g., single-incident youthful experimentation or instances of childhood sexual abuse) that are not indicative of recent sexual practices. The use of alternate time frames to differentiate past sexual experimentation from current behavioral practices should be explored, and clear distinction should be made between consensual sexual experiences versus those that were forced or coerced. Future research should also examine the number of male partners and sexual encounters, because these factors would affect the probability of viral exposure and thus the risk for HIV infection.</p><p style="margin-top: 0px;">More than 90% of our sample was born in Mexico, limiting our ability to generalize these results to other foreign-born Latino men. Future research should include larger subsamples of Latino males from countries other than Mexico to allow analysis of possible differences by country of origin. Because of survey space and time limitations, we were also unable to directly assess contextual and sociodemographic factors that might be associated with sexual risk, such as housing type and urban versus rural place of residence. Future research should include measures of these factors and assess the extent to which they may confound the observed association between sexual identity and HIV risk.</p><p style="margin-top: 0px;">Participants in our survey were only asked about anal intercourse with other men, because these present the highest risk for HIV infection or transmission. However, oral sex with male partners may be a more common sexual practice for behaviorally defined bisexual Latino men.6 Although oral sex may represent a low-risk behavior from an HIV-transmission perspective, if the experience is perceived favorably, it may serve as a gateway to riskier same-sex practices. Oral sex also has significant implications for STI transmission. Future research should therefore estimate the prevalence of oral sex with male partners among heterosexually identified MSMW and explore the relationship of these practices to subsequent sexual risk behavior.</p><p style="margin-top: 0px;">Finally, because of the small number of men reporting recent anal intercourse with another man, we were unable to explore the relationship between sexual identity and condom use with male partners. Because unprotected anal intercourse represents the greatest risk for HIV and STI transmission between male partners, further research is needed to examine the extent to which heterosexually identified MSMWmay differ from men of other sexual orientations in their same-sex sexual practices.</p><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td nowrap="nowrap"> <span class="bold textSmall">[Reference]</span> <span class="raquo">» </span> <a title="View a list of references included in this document" href="http://proquest.umi.com/pqdweb?VInst=PROD&VName=PQD&VType=PQD&RQT=594&did=1613679071&Fmt=3&refType=CITEDIN&b2=d&SrchMode=1&sid=2&index=18&TS=1230627727" class="textSmall">View reference page with links</a></td></tr><tr><td class="textSmall">References</td></tr><tr><td class="textSmall">1. US Census Bureau. American Community Survey: United States, 2006. Table generated using American FactFinder (http://factfinder.census.gov). Accessed October 30, 2007.</td></tr><tr><td class="textSmall">2. Centers for Disease Control and Prevention. HIV/ AIDS Surveillance Report, 2006. Atlanta, GA: US Dept of Health and Human Services; 2008.</td></tr><tr><td class="textSmall">3. Laumann E, Gagnon J, Michael R, et al. The Social Organization of Sexuality: Sexual Practices in the United States. Chicago, IL: University of Chicago Press; 1994.</td></tr><tr><td class="textSmall">4. Mosher WD, Chandra A, Jones J. Sexual behavior and selected health measures: men and women 15-44 years of age, United States, 2002. Adv Data Vital Health Stat. September 15, 2005;362.</td></tr><tr><td class="textSmall">5. Gayle H. An overview of the global HIV/AIDS epidemic, with a focus on the United States. AIDS. 2000;14:S8-S17.</td></tr><tr><td class="textSmall">6. Izazola-Licea JA, Gortmaker SL, de Gruttola V, Tolbert K, Mann J. Sexual behavior patterns and HIV risks in bisexual men compared to exclusively heterosexual and homosexual men. Salud Pu blica Me x. 2003;45 (suppl 5):S662-S671.</td></tr><tr><td class="textSmall">7. Millett G, Malebranche D, Mason B, Spikes P. Focusing "down low": bisexual black men, HIV risk and heterosexual transmission. J Natl Med Assoc. 2005; 97(7 suppl):52S-59S.</td></tr><tr><td class="textSmall">8. Montgomery J, Mokotoff E, Gentry A, Blair J. The extent of bisexual behaviour in HIV-infected men and implications for transmission to their female sex partners. AIDS Care. 2003;15:829-837.</td></tr><tr><td class="textSmall">9. Wolitski R, Jones K, Wasserman J, Smith J. Selfidentification as "down low" among men who have sex with men (MSM) from 12 US cities. AIDS Behav. 2006;10:519-529.</td></tr><tr><td class="textSmall">10. Carrillo H. The Night is Young: Sexuality in Mexico in the Time of AIDS. Chicago, IL: University of Chicago Press; 2002.</td></tr><tr><td class="textSmall">11. Prieur A. Mema's House, Mexico City: On Transvestites, Queens, and Machos. Chicago, IL: University of Chicago Press; 1998.</td></tr><tr><td class="textSmall">12. Magaña JR, Carrier JM. Mexican and Mexican American male sexual behavior and spread of AIDS in California. J Sex Res. 1991;28(3):425-441.</td></tr><tr><td class="textSmall">13. Nuñez Noriega J. Reconociendo los placeres, desconstruyendo las identidades: antropologia, patriarcado, y homoerotismo en Mexico [Acknowledging pleasure, deconstructing identities: anthropology, patriarchy, and homoerotism in Mexico]. Desacatos. 2001;6:15-34.</td></tr><tr><td class="textSmall">14. Diaz RM. Latino Gay Men and HIV: Culture, Sexuality, and Risk Behavior. New York, NY: Routledge; 1998.</td></tr><tr><td class="textSmall">15. Doll LS, Beeker C. Male bisexual behavior and HIV risk in the United States: synthesis of research with implications for behavioral interventions. AIDS Educ Prev. 1996;8:205-225.</td></tr><tr><td class="textSmall">16. Zea M, Reisen C, Diaz R. Methodological issues in research on sexual behavior with Latino gay and bisexual men. Am J Community Psychol. 2003;31(3-4):281-291.</td></tr><tr><td class="textSmall">17. Chu SY, Peterman TA, Doll LS, Buehler JW, Curran JW. AIDS in bisexual men in the United States: epidemiology and transmission to women. Am J Public Health. 1992;82:220-224.</td></tr><tr><td class="textSmall">18. Doll L, Petersen L, White C, et al. Homosexually and nonhomosexually identified men who have sex with men: a behavioral comparison. J Sex Res. 1992;29:1-14.</td></tr><tr><td class="textSmall">19. Mason H, Marks G, Simoni J, Ruiz M, Richardson J. Culturally sanctioned secrets? Latino men's nondisclosure of HIV infection to family, friends, and lovers. Health Psychol. 1995;14:6-12.</td></tr><tr><td class="textSmall">20. Zea MC. Latino HIV-positive gay men's narratives on disclosure of serostatus. Paper presented at: American Public Health Association 1999 Annual Meeting; November 7-11, 1999; Chicago, IL.</td></tr><tr><td class="textSmall">21. Smith TW. Adult sexual behavior in 1989: number of partners, frequency of intercourse and risk of AIDS. Fam Plann Perspect. 1991;23:102-107.</td></tr><tr><td class="textSmall">22. Jeffries WL, Dodge B. Male bisexuality and condom use at last sexual encounter: results from a national survey. J Sex Res. 2007;44:278-289.</td></tr><tr><td class="textSmall">23. Adimora AA, Fullilove RE. Men who have sex with men and women: pieces of the US HIV epidemic puzzle. Sex Transm Dis. 2006;33:596-598.</td></tr><tr><td class="textSmall">24. Brooks R, Rotheram-Borus MJ, Bing EG, Ayala G, Henry CL. HIV and AIDS among men of color who have sex with men and men of color who have sex with men and women: an epidemiological profile. AIDS Educ Prev. 2003;15(1 suppl A):1-6.</td></tr><tr><td class="textSmall">25. Prabhu R, Owen C, Folger K, McFarland W. The bisexual bridge revisited: sexual risk behavior among men who have sex with men and women, San Francisco, 1998-2003. AIDS. 2004;18:1604-1606.</td></tr><tr><td class="textSmall">26. Munoz-Laboy M, Dodge B. Bisexual Latino men and HIV and sexually transmitted infections risk: an exploratory analysis. Am J Public Health. 2007;97:1102-1106.</td></tr><tr><td class="textSmall">27. Centers for Disease Control and Prevention. Unpublished data. 1999. Cited by: Centers for Disease Control and Prevention. HIV/AIDS among racial/ethnic minority men who have sex with men-United States, 1989-1998. MMWR Morb Mortal Wkly Rep. 2000;49(1):4-11.</td></tr><tr><td class="textSmall">28. The HIV/AIDS Epidemic in the Latino Community. Atlanta, GA: Centers for Disease Control and Prevention. Available at: http://www.cdc.gov/hiv/resources/ reports/slcp/epidemic.htm. Accessed September 20, 2007.</td></tr><tr><td class="textSmall">29. Diaz R. Trips to fantasy island: contexts of risky sex for San Francisco gay men. Sexualities. 1999;2:89-112.</td></tr><tr><td class="textSmall">30. US Census Bureau. Census 2000 Summary File 1 (SF-1) 100-Percent Data. San Diego County, California: Hispanic or Latino by Specific Origin: Mexican. Table generated using American FactFinder (http://factfinder. census.gov). Accessed February 15, 2008.</td></tr><tr><td class="textSmall">31. US Census Bureau. Census 2000 Summary File 3 (SF-3) Sample Data. San Diego County, California: Hispanic or Latino by Specific Origin: Mexican. Table generated using American FactFinder (http://factfinder. census.gov). Accessed February 15, 2008.</td></tr><tr><td class="textSmall">32. Anderson JE, Chandra A, Mosher WD. HIV testing in the United States, 2002. Adv Data. 2005; 363:1-32.</td></tr><tr><td class="textSmall">33. Rangel M, Martínez-Donate A, Hovell M, Santibanez J, Sipan C, Izazola-Licea J. Prevalence of risk factors for HIV infection among Mexican migrants and immigrants: probability survey in the north border of Mexico. Salud Pública Méx. 2006;48:3-12.</td></tr><tr><td class="textSmall">34. Pulerwitz J, Izazola-Licea JA, Gortmaker SL. Extrarelational sex among Mexican men and their partners' risk of HIV and other sexually transmitted diseases. Am J Public Health. 2001;91:1650-1652.</td></tr><tr><td class="textSmall">35. Kahn JG, Gurvey J, Pollack LM, Binson D, Catania JA. How many HIV infections cross the bisexual bridge? An estimate from the United States. AIDS. 1997;11:1031-1037.</td></tr><tr><td class="textSmall">36. Rosario M, Schrimshaw EW, Hunter J. Ethnic/racial differences in the coming-out process of lesbian, gay, and bisexual youths: a comparison of sexual identity development over time. Cultur Divers Ethnic Minor Psychol. 2004;10:215-228.</td></tr><tr><td class="textSmall">37. Dolezal C, Carballo-Dieguez A, Nieves-Rosa L, Diaz F. Substance use and sexual risk behavior: understanding their association among four ethnic groups of Latino men who have sex with men. J Subst Abuse. 2000;11:323-336.</td></tr><tr><td class="textSmall">38. Centers for Disease Control and Prevention. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006; 55(RR-14):1-17.</td></tr><tr><td class="textSmall">39. Hirsch JS, Higgins J, Bentley ME, Nathanson CA. The social constructions of sexuality: marital infidelity and sexually transmitted disease-HIV risk in a Mexican migrant community. Am J Public Health. 2002;92:1227-1237.</td></tr><tr><td class="textSmall">40. McQuiston C, Gordon A. The timing is never right: Mexican views of condom use. Health Care Women Int. 2000;21:277-290.</td></tr><tr><td class="textSmall">41. Hirsch JS, Meneses S, Thompson B, Negroni M, Pelcastre B, del Rio C. The inevitability of infidelity: sexual reputation, social geographies, and marital HIV risk in rural Mexico. Am J Public Health. 2007;97(6): 986-996.</td></tr></tbody></table></span><table border="0" cellpadding="0" cellspacing="0"><tbody></tbody></table><br /><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td class="textSmall" nowrap="nowrap"><b>[Author Affiliation]</b></td></tr><tr><td class="textSmall">Jennifer A. Zellner, PhD, Ana P. Martínez-Donate, PhD, Fernando Sañudo, MPH, Araceli Fernández-Cerdeño, MA, Carol L. Sipan, MPH, RN, Melbourne F. Hovell, PhD, MPH, and Héctor Carrillo, DrPH</td></tr><tr><td class="textSmall">About the Authors</td></tr><tr><td class="textSmall">At the time of the study, Jennifer A. Zellner, Ana P. Martínez-Donate, Araceli Fernández-Cerdeño, Carol L. Sipan, and Melbourne F. Hovell were with the Center of Behavioral Epidemiology and Community Health, Graduate School of Public Health, San Diego State University, San Diego, CA. Ana P. Martínez-Donate was also with the Department of Population Health Sciences, University of Wisconsin, Madison. Fernando Sañudo was with Vista Community Clinic, Vista, CA. Héctor Carrillo was with the Department of Human Sexuality Studies, San Francisco State University, San Francisco, CA.</td></tr><tr><td class="textSmall">Requests for reprints should be sent to Ana P. Martínez-Donate, Department of Population Health Sciences, University of Wisconsin-Madison, 610 Walnut St, WARF 605, Madison, WI 53726-2397 (e-mail: martinezdona@ wisc.edu).</td></tr><tr><td class="textSmall">This article was accepted May 6, 2008.</td></tr><tr><td class="textSmall">Contributors</td></tr><tr><td class="textSmall">J. A. Zellner supervised the study, assisted with analyses, and led the writing of the article. A. P. Martínez-Donate originated and directed the study, performed the data analyses, and contributed substantially to the writing of the article. F. Sañudo was the co-principal investigator of the study. A. Fernández-Cerdeño, C. L. Sipan, M. F. Hovell, and H. Carrillo assisted with the design and implementation of the study. All authors helped interpret findings and reviewed drafts of the article.</td></tr><tr><td class="textSmall">Acknowledgments</td></tr><tr><td class="textSmall">This research was supported by the California HIV/AIDS Research Program of the University of California, Office of the President (grants AL04-SDSUF-804 and AL04-VCC-805), and by intramural support from the Center of Behavioral Epidemiology and Community Health at San Diego State University.</td></tr><tr><td class="textSmall">Human Participant Protection</td></tr><tr><td class="textSmall">All study procedures were reviewed and approved by the San Diego State University institutional review board and by the social and behavioral sciences institutional review board at the University of Wisconsin-Madison.</td></tr></tbody></table></span>All About Bloggerhttp://www.blogger.com/profile/17282736671555579827noreply@blogger.com0tag:blogger.com,1999:blog-4987803374989865601.post-52446691150587832662008-12-30T00:47:00.000-08:002008-12-30T00:48:34.747-08:00Influence of Coping, Social Support, and Depression on Subjective Health Status Among HIV-Positive Adults With Different Sexual Identities<div class="docSection" style="padding-top: 4px; padding-left: 4px;"><span class="textSmall"><strong>Abstract (Summary)</strong></span><div class="textMedium"><p style="margin-top: 0px;">The authors examined associations between psychosocial variables (coping self-efficacy, social support, and cognitive depression) and subjective health status among a large national sample (N = 3,670) of human immunodeficiency virus (<span style="color:red;"><b>HIV</b></span>)-positive persons with different sexual identities. After controlling for ethnicity, heterosexual men reported fewer symptoms than did either bisexual or gay men and heterosexual women reported fewer symptoms than did bisexual women. Heterosexual and bisexual women reported greater symptom intrusiveness than did heterosexual or gay men. Coping self-efficacy and cognitive depression independently explained symptom reports and symptom intrusiveness for heterosexual, gay, and bisexual men. Coping self-efficacy and cognitive depression explained symptom intrusiveness among heterosexual women. Cognitive depression significantly contributed to the number of symptom reports for heterosexual and bisexual women and to symptom intrusiveness for lesbian and bisexual women. Individuals likely experience <span style="color:red;"><b>HIV</b></span> differently on the basis of sociocultural realities associated with sexual identity. Further, symptom intrusiveness may be a more sensitive measure of subjective health status for these groups. [PUBLICATION ABSTRACT]</p><p style="margin-top: 0px;"><span style="font-weight: bold;" class="italic">Copyright Heldref Publications Winter 2009</span><br /><br /><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td class="textSmall" nowrap="nowrap"><b>[Headnote]</b></td></tr><tr><td class="textSmall">The authors examined associations between psychosocial variables (coping self-efficacy, social support, and cognitive depression) and subjective health status among a large national sample (N = 3,670) of human immunodeficiency virus (HIV)-positive persons with different sexual identities. After controlling for ethnicity, heterosexual men reported fewer symptoms than did either bisexual or gay men and heterosexual women reported fewer symptoms than did bisexual women. Heterosexual and bisexual women reported greater symptom intrusiveness than did heterosexual or gay men. Coping self-efficacy and cognitive depression independently explained symptom reports and symptom intrusiveness for heterosexual, gay, and bisexual men. Coping self-efficacy and cognitive depression explained symptom intrusiveness among heterosexual women. Cognitive depression significantly contributed to the number of symptom reports for heterosexual and bisexual women and to symptom intrusiveness for lesbian and bisexual women. Individuals likely experience HIV differently on the basis of sociocultural realities associated with sexual identity. Further, symptom intrusiveness may be a more sensitive measure of subjective health status for these groups.</td></tr><tr><td class="textSmall">Index Terms: coping, depression, HIV, sexual identity, symptoms, social support</td></tr></tbody></table></span></p><table border="0" cellpadding="0" cellspacing="0"><tbody></tbody></table><br /><p style="margin-top: 0px;">Human immunodeficiency virus (HIV) is increasingly considered a chronic disease. For a person living with HIV, this means having to cope with a range of HIV-related symptoms for extended periods. Symptoms may be related to the infection itself, comorbid illnesses, or iatrogenic effects from HIV-related medications.1,2 Commonly experienced symptoms include fatigue, stiff or painful joints, muscle aches, diarrhea, depression, and neuropathy.3,4 Side effects from certain antiretroviral therapies used to treat HIV include gastrointestinal distress, hyperlipidemia, and nephrolithiasis.2 These illness-related experiences can negatively influence one's quality of life by impairing social functioning and physical health.3,5-9 Although the vast majority of people living with HIV experience HIV-related symptoms,2 the degree to which the symptoms affect them varies.10 This variation raises questions about potential contributors to symptom experience,9 including psychosocial factors. Longitudinal studies involving diverse samples of HIV-positive people indicate that mental health variables, such as depression, hopelessness, and social support, can impact HIV-related biological markers11 and symptom reports.12 We designed this study to further understand the role psychosocial factors may play in the experience of physical symptoms.</p><p style="margin-top: 0px;">Psychosocial functioning among HIV-positive persons likely varies as a function of sexual identity.13-17 For example, among men who have sex with men (MSM), a gay sexual identity has been associated with less loneliness and isolation,18 less depression, and better social support.19 Similarly, higher levels of distress and depression have been associated with not identifying as gay, queer, or homosexual among MSM in the Urban Men's Health Study.20 Heterosexual men and women tend to have different social support experiences, coping mechanisms, and stressors than do gay men or women.21 Familial social support is more readily available and satisfactory for HIV-positive heterosexual women than for HIV-positive heterosexual men22 or gay men.17 Further, HIV is considered to be a more stigmatizing condition for non-gay-identifying men23 and heterosexual women24 than for gay men. Coping strategies and depression also vary by gender and sexual identity.14,17</p><p style="margin-top: 0px;">Less is known about the association between sexual identity and health or whether psychological differences among individuals with diverse sexual identities influence their particular illness experiences. Differences with regard to the role of psychological predictors of physiological functioning could have very real implications for disease morbidity and mortality among individuals of diverse sexual identities. For example, some analyses have indicated that a heterosexual identity is associated with poorer functional health status.13 Others found that a concealed minority sexual identity was associated with faster disease progression, at least in the pre-HAART (highly active antiretroviral therapy) era.25 This association was significant, even after controlling for age, health practices (such as substance use, exercise, and sleep), psychosocial characteristics (including anxiety, depression, coping, and social support), sexual behavior, and the use of azidothymidine (AZT). More recent research has found similar associations between immune system suppression and concealed homosexual identity.19 Our study extends research on the association between psychosocial and physical functioning among HIV-positive persons by examining these relationships in a large sample of individuals of diverse sexual identities. This study also offers insight into the functioning of individuals in the era of HAART, which has been shown to lower disease morbidity and mortality rates.26-28</p><p style="margin-top: 0px;">In addition to physiological markers, such as CD4 count and viral load, it is useful to examine subjective indicators of health status, including symptom reports,29,30 which can provide information about how individuals perceive illness and the effects of illness on other aspects of their functioning.31 Investigating symptom reports affords researchers the unique opportunity to understand the physiological markers of illness and the perceptions of illness impact.9 In fact, physical symptoms, rather than physiological markers, are more closely related to psychological distress.32</p><p style="margin-top: 0px;">First, we examine whether individuals with diverse sexual identities differ with regard to either their physical or psychosocial functioning and, second, the degree to which psychosocial indicators are associated with subjective health status. The results of this study could have important implications for the delivery of more tailored mental health interventions for HIV-positive persons. For example, if we find that a minority sexual identity is associated with poorer physical or psychological functioning, health care providers and researchers would need to make a more concerted effort to address factors that may contribute to lowered resilience among such groups. Likewise, identifying differences in the degree to which psychosocial indicators are associated with illness experiences will help those developing targeted interventions focus their resources on the most relevant factors, contributing to better health outcomes among these groups.</p><p style="margin-top: 0px;">METHODS</p><p style="margin-top: 0px;">Procedure</p><p style="margin-top: 0px;">The data reported in this article are from screening/baseline interviews from a multisite, randomized, controlled trial of a behavioral intervention designed to decrease transmission risk for HIV-infected persons.32-34 The Institutional Review Board from each participating institution approved the study's procedures. Eligibility criteria included being at least 18 years old and providing medical documentation of HIV-positive status. Interviews were conducted between May 2000 and February 2002 using computer-assisted personal interview technology. Participants were paid $50 for their time.</p><p style="margin-top: 0px;">Measures</p><p style="margin-top: 0px;">Demographic Characteristics</p><p style="margin-top: 0px;">Demographic characteristics assessed included participant gender, sexual identity, race/ethnicity, age, relationship status, educational level, and employment status. All items were self-reported. Sexual identity was assessed by asking participants whether they currently identify as heterosexual/ straight, homosexual/gay, or bisexual.</p><p style="margin-top: 0px;">Coping Self-Efficacy</p><p style="margin-top: 0px;">We measured coping self-efficacy using a 15-item version of Chesney, Folkman, and Chambers'35 measure of self-efficacy for coping with challenges and threats. Participants rated items on a Likert scale from 0 (cannot do at all) to 10 (certain can do) according to their level of confidence in their ability to perform particular coping strategies. Examples of items included "Break an upsetting problem down into smaller parts." The mean item score was computed for use in the analysis. For the present study, internal consistency reliability was good (α = .92).</p><p style="margin-top: 0px;">Social Support</p><p style="margin-top: 0px;">We measured social support by the 24-item Social Provisions Scale,36 which includes types of support, such as guidance, reliable alliance, attachment, social integration, reassurance of worth, and the opportunity to provide support to others. Respondents consider their entire support network in assessing the extent to which they believe such provisions are available to them, and they respond on a 4- point Likert scale from 1 (strongly disagree) to 4 (strongly agree), such that higher scores reflected greater provisions of social support. A mean scale score was computed. This scale has demonstrated adequate validity and reliability in other samples.36 In this sample, the Social Provisions Scale was highly internally consistent (α = .92).</p><p style="margin-top: 0px;">Cognitive Depression</p><p style="margin-top: 0px;">The Beck Depression Inventory37 (BDI) is a 21-item measure assessing cognitive, affective, behavioral, and somatic symptoms of depression. Although we administered the full inventory, on the basis of the concerns raised by Kalichman et al38 regarding the confounding of HIV symptoms with BDI items reflecting somatic symptoms of depression, we restricted our data analysis to the 12-item cognitive subscale. The items included in this subscale include sadness, pessimism, failure, dissatisfaction, guilt, punishment, disappointment, weakness, suicide, crying, irritation, and social withdrawal. Summing the item ratings creates a score of cognitive depression. Items are rated on a 4-point scale from 0 (representing the absence of the symptom) to 3 (representing greatest symptom intrusiveness), such that higher scores reflected greater levels of cognitive depression. Following the recommendations of Kalichman et al,37-38 we considered a score of 10 or higher to indicate clinical depression. For the present study, α =. 85.</p><p style="margin-top: 0px;">Health Status and Medication Use</p><p style="margin-top: 0px;">We defined subjective health status as (1) the total number of HIV-related symptoms and (2) symptom intrusiveness. We measured total number of symptoms using the HIV Symptom Index.39 Examples of symptoms included dizziness, nausea, nervousness, and muscle aches. (Because of confounding with the BDI, we did not include the sadness/ depression item in the index.) We first asked participants to indicate which of 25 HIV-related symptoms they had experienced in the past 3 months. The number of symptoms was summed to create a total symptom report score. Participants then indicated the degree to which those symptoms bothered them (ie, symptom intrusiveness) using a 4-point scale (1 [It doesn't bother me at all], 2 [It bothers me a little], 3 [It bothers me quite a bit], 4 [It bothers me a great deal]). For the multiple regression analyses, we calculated the symptom intrusiveness score by summing the number of symptoms for which each participant indicated being bothered quite a bit or a great deal. Thus, if a particular symptom did not bother the person or bothered them only a little, it was not included in the total score. We used this method to diminish the relative influence any particular reported symptom may have on the overall intrusiveness score when it does not, in fact, disrupt one's quality of life. We conducted separate multivariate analyses using the symptom report and symptom intrusiveness scores as outcome variables. Other indicators of health status included date of diagnosis, CD4 count, and antiretroviral use. These items were selfreported. We measured CD4 count by a single, self-reported item of participants' most recent clinical measurement. A single dichotomous item measured current (in the past 3 months) antiretroviral use.</p><p style="margin-top: 0px;">Data Analysis</p><p style="margin-top: 0px;">We used SPSS (Version 12.0) for data analysis. Prior to multivariate analysis, we screened data for accuracy of data entry, missing values, and concordance between their distributions and the assumptions of the multivariate analyses. Descriptive statistics were computed for demographics, psychosocial scale scores, CD4 count, HIV symptom report, and antiretroviral use for each group. Tests of differences were conducted to examine differences by sexual orientation groups for the demographic variables. Bivariate correlation coefficients were computed to examine multicollinearity among the predictors. We conducted 2 separate univariate analysis of variances (ANOVAs) to test whether the number of symptoms reported or symptom intrusiveness differed by sexual identity. Ethnicity has been associated with biological markers and subjective health status among HIV-positive persons.3,40-43 In addition, an earlier analysis using this same sample revealed ethnic differences with regard to perceived effects of antiretroviral therapy.3 Therefore, ethnicity was entered as a covariate. Hierarchical regression analyses predicting the number of symptoms reported and symptom intrusiveness were performed (controlling for ethnicity, age, and CD4 counts) for each sexual identity group to examine the relationships with coping self-efficacy, social support, and cognitive depression.</p><p style="margin-top: 0px;">RESULTS</p><p style="margin-top: 0px;">Sample Description</p><p style="margin-top: 0px;">We interviewed 3,819 participants for this project (see Weinhardt, Kelly, Brondino, et al34 for a more detailed description of the sample). To examine differences on the basis of sexual identity, only men and women who identified as being heterosexual, bisexual, or gay were included in this study. Individuals who did not identify as being heterosexual, bisexual, or gay (n = 89) were excluded from these analyses. Likewise, because individuals who identified as being transgender or other (n = 68) do not represent a monolithic group with regard to either gender or sexual identity, we excluded these data from the analyses. (We excluded 13 individuals for reasons pertaining to gender and sexual identity criteria.) The participants for this study (N = 3,670) included 1,505 (41.0%) gay men, 840 (22.9%) heterosexual men, 365 (9.9%) bisexual men, 808 (22.0%) heterosexual women, 61 (1.7%) lesbian women, and 91 (2.5%) bisexual women.</p><p style="margin-top: 0px;">Sexual Identity, Sociodemographics, and Health Status</p><p style="margin-top: 0px;">Sociodemographic characteristics of participants by sexual identity groups are shown in Table 1. Preliminary analyses indicated differences by groups in terms of data collection site, ethnicity, educational level, employment status, the number of years they had been HIV-positive, and age. The presence of specific symptoms in the past 3 months and symptom intrusiveness are presented in Table 2. The 11 most frequently occurring symptoms were reported by more than half the sample. The most intrusive symptoms were fatigue, sleep disruptions, muscle/joint and nonspecific pain, and diarrhea. Eighty percent of the sample had been diagnosed with HIV prior to 1995. CD4 counts ranged widely from 0-2,675 (M = 440.5; SD = 298.6). Twenty-one percent of participants had CD4 counts lower than 200 copies, the clinical cutoff for an acquired immune deficiency syndrome (AIDS) diagnosis. Less than 9% of the study participants had never received antiretroviral therapies.</p><p style="margin-top: 0px;">Sexual Identity and Psychosocial Indicators</p><p style="margin-top: 0px;">Nearly one-quarter (24.8%) of the participants met the criteria for cognitive depression. Descriptive statistics for social support, coping self-efficacy, and cognitive depression are reported in Table 3 for each of the sexual identity groups. The groups differed on social support (F[5, 3,660] = 5.8, p < .001) and coping (F[5, 3,664] = 2.4, p = .03), but not on cognitive depression (ns, p = .69). Post hoc analyses indicate that heterosexual men reported less social support than either heterosexual women or gay men did and bisexual men reported less social support than heterosexual women did. However, heterosexual men reported greater coping self-efficacy than either gay or bisexual men did and heterosexual women reported greater coping self-efficacy than gay men did.</p><p style="margin-top: 0px;">To test the hypothesis that sexual identity group membership was predictive of subjective health status, we performed two separate univariate ANOVAs. The results indicated that after partialing out the effects of ethnicity, the number of symptoms differed across sexual identity groups (F[5, 3,657] = 4.14, p <.01). Post hoc analyses revealed that heterosexual men reported fewer symptoms (M = 10.9, SD = 5.7) than either bisexual (M = 12.0, SD = 5.5) or gay (M = 12.0, SD = 5.1) men did. In addition, heterosexual women reported fewer symptoms on average (M = 11.7, SD = 5.6) than bisexual women (M = 12.8, SD = 5.0). Symptom intrusiveness also differed across sexual identity groups after controlling for the effects of ethnicity (F[5, 3,643] = 7.31, p < .01). Post hoc analyses revealed that heterosexual women and bisexual women reported greater symptom intrusiveness (M = 8.5, SD = 5.8 and M = 9.7, SD = 5.3, respectively) than either heterosexual men (M = 7.3, SD = 5.6) or gay men (M = 7.7, SD = 5.4) did.</p><p style="margin-top: 0px;">Hierarchical multiple regression analyses were then conducted to examine the relative influence of coping self-efficacy, social support, and cognitive depression on symptom reports and intrusiveness scores in the subsamples of heterosexual, gay, and bisexual men; and heterosexual, lesbian, and bisexual women. The results for the number of symptom reports (provided in Table 4) indicate that after controlling for ethnicity, age, and most-recent CD4 counts, coping self-efficacy and cognitive depression independently explained symptom reports for heterosexual, gay, and bisexual men. Cognitive depression significantly contributed to the number of symptom reports for heterosexual and bisexual women. None of the independent variables significantly predicted symptom reports for lesbians. When taken together, the predictors accounted for 14-23% of the adjusted variance in symptom reports for the other 5 sexual orientation groups.</p><p style="margin-top: 0px;">Results from the examination of the relative influence of coping self-efficacy, social support, and cognitive depression on symptom intrusiveness (provided in Table 5) indicate that after controlling for ethnicity, age, and most-recent CD4 count, coping self-efficacy and cognitive depression independently explain symptom intrusiveness for heterosexual, gay, and bisexual men and heterosexual women. Cognitive depression significantly contributed to symptom intrusiveness for lesbian and bisexual women. When taken together, the predictors accounted for 10-29% of the variance in symptom intrusiveness for the 6 sexual identity groups.</p><p style="margin-top: 0px;">COMMENT</p><p style="margin-top: 0px;">We examined the relative contribution that social support, coping self-efficacy, and cognitive depression made on illness symptom reports among a US national sample of HIV-positive persons. In a much smaller sample, other researchers found that depression was more comprehensively related to HIV-related quality of life than either coping or social support was.44 However, this is the first time these relationships have been examined for their association with subjective health status using a large, diverse national sample. We conducted the analyses across different sexual identity groups, controlling for the effects of ethnicity, age, and CD4 counts on subjective health status.</p><p style="margin-top: 0px;">Our analyses indicated that heterosexual and bisexual women, in particular, experience more symptom intrusiveness than either heterosexual men or gay men do. This gender difference is consistent with research that has found that HIV-positive women have lower health-related quality of life, particularly with regard to pain and physical functioning.45 Cultural factors may be related to the perception of pain or discomfort as well.42 Further, socioeconomic status, life stressors associated with poverty, racial discrimination, and single parenthood likely affect certain groups more than others, particularly HIV-positive ethnic minority women.46-47 Future research needs to be conducted to better understand the interaction between illness experiences and related cultural norms or life stressors for women in particular.</p><p style="margin-top: 0px;">Cognitive depression was evident in a quarter of the sample, and there were no significant differences between groups on depressive symptoms. Depression independently explained symptom reports and intrusiveness for nearly all groups (although it did not explain symptom reports for lesbians). Further, cognitive depression independently accounted for the largest percentage of the variance for the number of symptoms reported and symptom intrusiveness in all groups. Consistent with other research,48-51 our results demonstrate the presence of a relationship between psychological symptoms and physiological disease. When taken together, the results suggest that the most salient point of intervention with regard to illness adjustment or health-related quality of life is the alleviation of cognitive depression, regardless of sexual identity status. Therefore, identifying and treating psychological distress is likely to decrease physiological morbidity among a substantial proportion of HIV-positive persons. This has important implications for structural change with regard to standard-of-care medical practice in the treatment of HIV disease such that HIV-positive patients may experience significant improvement in overall health outcomes if infectious disease practitioners regularly assess depression and provide appropriate referrals to mental health services.</p><p style="margin-top: 0px;">Lower coping self-efficacy also independently predicted more symptom reports and greater symptom intrusiveness for all 3 groups of men. These results suggest that a strength-based approach may assist HIV-positive men, in particular, to achieve a sense of competence in adjusting to their illness. Cognitive-behavioral interventions can promote the identification of personal strengths and facilitate the development of skills to cope with particularly difficult or stressful life events. Individuals can then learn how to reframe life stressors as manageable challenges and develop strategies to effectively deal with them, which reduces psychological stress by improving not only their overall mental health, but also their symptom experiences.</p><p style="margin-top: 0px;">Last, although statistically significant differences were found among the groups on a measure of social support, the degree of difference may not be clinically significant. Furthermore, social support did not independently explain symptom reports or intrusiveness as cognitive depression or coping self-efficacy did. Although social support likely plays an important role in disease management and quality of life, subjective health status may be better reflected in measures of cognitive depression and coping self-efficacy.</p><p style="margin-top: 0px;">A paucity of quantitative research exists related to the experience of HIV-positive sexual minority women. Although we were able to recruit a small sample of lesbian (n = 61) and bisexual (n = 91) women for our study, the small sample sizes limited statistical power. For example, we failed to find differences with regard to psychosocial variables for lesbian and bisexual women, although our data suggest that lesbians may actually experience more social support and less cognitive depression than the other groups. The hierarchical regression results indicate that cognitive depression accounts for a significant amount of the variance in symptom intrusiveness for this group. Yet, limited power may have resulted in nonsignificant relationships between the psychosocial variables and symptoms reports. For example, the standardized beta indicating the relationship between cognitive depression and symptom reports was identical to that for heterosexual men (.27), although these results were not significant in the former sample. Researchers must use targeted sampling plans to further quantitative research agendas related to the experience of living with HIV among lesbians in particular. We know little about the psychosocial stressors that may influence physical symptoms in this population, and such nescience likely results in inadequate approaches to addressing sexual minority women's specific illness adjustment needs.</p><p style="margin-top: 0px;">We used 2 measures of subjective health status for this study. The results indicate that measures of symptom intrusiveness, particularly questions about how much the symptoms bother people, may be a better indicator of subjective health status than the total number of symptoms experienced. The symptom intrusiveness model accounted for a larger portion of the variance for each subsample, and the individual predictors appear to be more strongly associated with symptom intrusiveness than the number of symptoms experienced. For these reasons, symptom intrusiveness may be a more salient measure of subjective health status, a contradiction of others' findings.30 The results also suggest that it may be beneficial for health care providers to evaluate the degree to which particular symptoms influence an individual's quality of life or daily functioning. Moreover, self-report symptom checklists should be used to facilitate a discussion about symptom intrusiveness and not as the sole indicator of functional status.</p><p style="margin-top: 0px;">There are 2 significant limitations to this study. First, this is a cross-sectional analysis. Therefore, we cannot determine causality. In this article, we chose to examine the influence of psychosocial factors on symptom reporting to test the hypothesis that poorer psychosocial functioning manifests in relation to greater experience of negative symptoms. This perspective is consistent with results from longitudinal studies that have demonstrated the influence of psychosocial factors on salient health outcomes.11,12,52 For example, depression and coping style could influence not only the perception of symptoms, but also important physiological processes, such as immunological functioning.11,49,50,53 However, illness experiences, such as a greater number of or more intrusive symptoms, could lead to clinical depression,54,55 although this relationship has received less research attention. Ultimately, we are able to examine 1 piece of the puzzle with these data; longitudinal studies, ideally with more frequent assessments, are needed to provide a thorough analysis of the nature of the association between psychological and physiological symptoms and their recursive influence.</p><p style="margin-top: 0px;">The second limitation of this study is related to the demographics and health status of the samples. There were substantial differences among the groups in terms of key demographic variables. On the basis of these differences and those that appear to be most salient in the literature in terms of illness experiences, we controlled for ethnicity, CD4 counts, and age in the hierarchical regression analyses. Beyond variability among the groups, the mean age was approximately early 40s in each group, and 80% of the participants learned of their HIV status prior to 1995. Therefore, this sample is overrepresented by those who are somewhat older and have been living with HIV for many years. In addition, more than one-fifth of the sample had an AIDS diagnosis at the time of the interview, and nearly the entire sample had taken antiretroviral therapies. Thus, these results may be more generalizable to those who have lived with HIV for a number of years compared with those who have been recently diagnosed or those who are significantly younger. Although this study contributes to a better understanding of the mental and physical health correlates of long-term survivors in the contemporary HAART era, understanding the needs of younger and newly diagnosed individuals is also necessary to address mental health, HIV-related risk behavior, and treatment adherence factors that may have serious and long-term effects on illness adjustment and disease progression.</p><p style="margin-top: 0px;">ACKNOWLEDGMENTS</p><p style="margin-top: 0px;">The Healthy Living Project was funded by cooperative agreements between the National Institute of Mental Health (NIMH) and Columbia University (U10MH057636); the Medical College of Wisconsin (U10MH057631); University of California, Los Angeles (U10MH057615); and the University of California, San Francisco (U10MH057616). The NIMH Healthy Living Trial Group includes members of the research steering committee (site principal investigators and NIMH staff collaborator): Margaret A. Chesney, PhD; Anke A. Ehrhardt, PhD; Jeffrey A. Kelly, PhD; Willo Pequegnat, PhD; and Mary Jane Rotheram-Borus, PhD. Collaborating scientists, coprincipal investigators, and investigators were Eric G. Benotsch, PhD; Michael J. Brondino, PhD; Sheryl L. Catz, PhD; Edwin D. Charlebois, PhD, MPH; Don C. Des- Jarlais, PhD; Naihua Duan, PhD; Theresa M. Exner, PhD; Rise B. Goldstein, PhD, MPH; Cheryl Gore-Felton, PhD; A. Elizabeth Hirky, PhD; Mallory O. Johnson, PhD; Robert M. Kertzner, MD; Sheri B. Kirshenbaum, PhD; Lauren E. Kittel, PsyD; Robert Klitzman, MD; Martha Lee, PhD; Bruce Levin, PhD; Marguerita Lightfoot, PhD; Stephen F. Morin, PhD; Steven D. Pinkerton, PhD; Robert H. Remien, PhD; Fen Rhodes, PhD; Wayne T. Steward, PhD, MPH; Susan Tross, PhD; Lance S. Weinhardt, PhD; Robert Weiss, PhD; Hannah Wolfe, PhD; Rachel Wolfe, PhD; and F. Lennie Wong, PhD. Data management and analytic support were provided by Philip Batterham, MA; W. Scott Comulada, MS; Tyson Rogers, MA; and Yu Zhao, MS. Site project coordinators were Kristin Hackl, MSW; Daniel Hong, MA; Karen Huchting, BA; Joanne D. Mickalian, MA; and Margaret Peterson, MSW. NIMH staff include Christopher M. Gordon, PhD; Dianne Rausch, PhD; and Ellen Stover, PhD.</p><p style="margin-top: 0px;">NOTE</p><p style="margin-top: 0px;">For comments and further information, address correspondence to Dr Katie E. 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Predicting HIV transmission risk among HIV-infected men who have sex with men: Findings from the Healthy Living Project. JAIDS 2005;40:226-235.</td></tr><tr><td class="textSmall">34. Weinhardt LS, Kelly JA, Brondino MJ, et al. HIV transmission risk behavior among men and women living with HIV in 4 cities in the United States. J AIDS. 2004;36:1057-1066.</td></tr><tr><td class="textSmall">35. Chesney MA, Folkman S, Chambers D. Coping effectiveness training for men living with HIV: preliminary findings. Int J STD AIDS. 1996;7:75-82.</td></tr><tr><td class="textSmall">36. Cutrona CE, Russell D. The provisions of social relationships and adaptation to stress. In: Jones WH, Perlman D, eds. Advances in Personal Relationships, Volume 1. Greenwich, CT: JAI Press; 1987:37-68.</td></tr><tr><td class="textSmall">37. Beck AT, Steer RA. BDI: Beck Depression Inventory Manual. New York, NY: Psychological Corporation; 1993.</td></tr><tr><td class="textSmall">38. Kalichman SC, Sikkema KJ, Somlai A. Assessing persons with human immunodeficiency virus (HIV) infection using the Beck Depression Inventory: disease processes and other potential confounds. J Pers Assess. 1995;64:86-100.</td></tr><tr><td class="textSmall">39. Justice AC, Holmes W, Gifford AL, et al; for the Adult AIDS Clinical Trials Unit Outcomes Committee. Development and validation of a self-completed HIV symptom index. J Clin Epidemiol. 2001;54(suppl):77-90.</td></tr><tr><td class="textSmall">40. Dobalian A, Tsao JC, Duncan RP. Pain and the use of outpatient services among persons with HIV: results from a nationally representative survey. Med Care. 2004;42:129-138.</td></tr><tr><td class="textSmall">41. Heckman BD. Psychosocial differences between whites and African Americans living with HIV/AIDS in rural areas of 13 US States. J Rural Health. 2006;22:131-139.</td></tr><tr><td class="textSmall">42. Rotheram-Borus MJ. Variations in perceived pain associated with emotional distress and social identity in AIDS. AIDS Patient Care STDS. 2000;14:659-665.</td></tr><tr><td class="textSmall">43. Vidrine DJ, Amick BC III, Gritz ER, Arduino RC. Functional status and overall quality of life in a multiethnic HIV-positive population. AIDS Patient Care STDS. 2003;17:187-197.</td></tr><tr><td class="textSmall">44. Jia H, Uphold CR, Wu S, Reid K, Findley K, Duncan PW. Health-related quality of life among men with HIV infection: effects of social support, coping, and depression. AIDS Patient Care STDS. 2004;18:594-603.</td></tr><tr><td class="textSmall">45. Mrus JM, Williams PL, Tsevat J, Cohn SE, Wu AW. Gender differences in health-related quality of life in patients with HIV/AIDS. Qual Life Res. 2005;14:479-491.</td></tr><tr><td class="textSmall">46. Arend ED. The politics of invisibility: homophobia and lowincome HIV-positive women who have sex with women. J Homosex. 2005;49:97-122.</td></tr><tr><td class="textSmall">47. Springer E. Reflections on women and HIV/AIDS in New York City and the United States. In: Bury J, Morrison V, McLachlan S, eds. Working with Women with AIDS: Medical, Social, and Counseling Issues. New York, NY: Tavistock/ Routledge; 1992:32-40</td></tr><tr><td class="textSmall">48. Antoni MH, Baggett L, Ironson G, et al. Cognitivebehavioral stress management intervention buffers distress responses and immunologic changes following notification of HIV-1 seropositivity. J Consult Clin Psychol. 1991;59:906-915.</td></tr><tr><td class="textSmall">49. Leserman J, Petitto JM, Perkins DO, Folds JD, Golden RN, Evans DL. Severe stress, depressive symptoms, and changes in lymphocyte subsets in human immunodeficiency virusinfected men: a 2-year follow-up study. Arch Gen Psychiatry. 1997;54:279-285.</td></tr><tr><td class="textSmall">50. Leserman J, Petitto JM, Golden RN, et al. Impact of stressful life events, depression, social support, coping self-efficacy, and cortisol on progression to AIDS. Am J Psychiatry. 2000;157:1221-1228.</td></tr><tr><td class="textSmall">51. Simoni JM, Ng MT. Abuse, health locus of control, and perceived health among HIV-positive women. Health Psychol. 2002;21:89-93.</td></tr><tr><td class="textSmall">52. Cruess DG, Douglas SD, Petitto JM, et al. Association of resolution of major depression with increased natural killer cell activity among HIV-seropositive women. Am J Psychiatry. 2005;162:2125-2130.</td></tr><tr><td class="textSmall">53. Villes V, Spire B, Lewden C, et al and ANRS CO-8 APROCOCOPILOTE Study Group. The effect of depressive symptoms at ART initiation on HIV clinical progression and mortality: implications in clinical practice. Antiviral Ther. 2007;12:1067-1074.</td></tr><tr><td class="textSmall">54. Davis S. Clinical sequelae affecting quality of life in the HIVinfected patient. J Assoc Nurses AIDS Care. 2004;15(suppl):28- 33.</td></tr><tr><td class="textSmall">55. Moneyham L, Sowell R, Seals B, Demi A. Depressive symptoms among African American women with HIV disease. Sch Inq Nurs Pract. 2000;14:9-39.</td></tr></tbody></table></span><table border="0" cellpadding="0" cellspacing="0"><tbody></tbody></table><br /><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td class="textSmall" nowrap="nowrap"><b>[Author Affiliation]</b></td></tr><tr><td class="textSmall">Katie E. Mosack, PhD; Lance S. Weinhardt, PhD; Jeffrey A. Kelly, PhD; Cheryl Gore-Felton, PhD; Timothy L. McAuliffe, PhD; Mallory O. Johnson, PhD; Robert H. Remien, PhD; Mary Jane Rotheram- Borus, PhD; Anke A. Ehrhardt, PhD; Margaret A. Chesney, PhD; Stephen F. Morin, PhD</td></tr><tr><td class="textSmall">Dr Mosack is with the Department of Psychology at the University of Wisconsin in Milwaukee. Drs Weinhardt, Kelly, and McAuliffe are with the Department of Psychiatry and Behavioral Medicine at the Medical College of Wisconsin in Milwaukee. Dr Gore-Felton is with the Department of Psychiatry and Behavioral Sciences at Stanford University School of Medicine. Drs Johnson and Morin are with the Center for AIDS Prevention Studies at the University of California in San Francisco. Dr Remien is with the HIV Center for Clinical and Behavioral Studies in New York, NY. Dr Rotheram- Borus is with the Center for HIV Identification, Prevention, and Treatment Services at the University of California in Los Angeles. Dr Ehrhardt is with the HIV Center for Clinical and Behavioral Studies at New York State Psychiatric Institute and Columbia University in New York, NY. Dr Chesney is with the National Center for Complementary and Alternative Medicine in Bethesda, MD.</td></tr><tr><td class="textSmall">Copyright © 2008 Heldref Publications</td></tr></tbody></table></span></div></div>All About Bloggerhttp://www.blogger.com/profile/17282736671555579827noreply@blogger.com0tag:blogger.com,1999:blog-4987803374989865601.post-73936585143422529532008-12-30T00:43:00.000-08:002008-12-30T00:45:16.693-08:00The Interaction of Sexual Identity With Sexual Behavior and Its Influence on HIV Risk Among Latino Men<strong>The Interaction of Sexual Identity With Sexual Behavior and Its Influence on <span style="color:red;"><b>HIV</b></span> Risk Among Latino Men: Results of a Community Survey in Northern San Diego County, California<br /><br /></strong><div class="docSection" style="padding-top: 4px; padding-left: 4px;"><span class="textSmall"><strong>Abstract (Summary)</strong></span><div class="textMedium"><p style="margin-top: 0px;">We examined the sexual behavior, sexual identities, and <span style="color:red;"><b>HIV</b></span> risk factors of a community sample of Latino men to inform efforts to reduce Latinos' <span style="color:red;"><b>HIV</b></span> risk. In 2005 and 2006, 680 Latino men in San Diego County, California, in randomly selected, targeted community venues, completed an anonymous, self-administered survey. Most (92.3%) respondents self-identified as heterosexual, with 2.2%, 4.9%, and 0.6% self-identifying as bisexual, gay, or other orientation, respectively. Overall, 4.8% of heterosexually identified men had a lifetime history of anal intercourse with other men. Compared with behaviorally heterosexual men, heterosexually identified men who had sex with both men and women were more likely to have had a sexually transmitted infection, to have unprotected sexual intercourse with female partners, and to report having sex while under the influence of alcohol or other drugs. Bisexually identified men who had sex with men and women did not differ from behaviorally heterosexual men in these risk factors. Latino men who have a heterosexual identity and bisexual practices are at greater risk of <span style="color:red;"><b>HIV</b></span> infection, and efforts to reduce <span style="color:red;"><b>HIV</b></span> risk among Latinos should target this group.</p><p style="margin-top: 0px;"><br /></p><p style="margin-top: 0px;"><span class="italic">Copyright American Public Health Association Jan 2009</span><br /><br /><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td class="textSmall" nowrap="nowrap"><b>[Headnote]</b></td></tr><tr><td class="textSmall">Objectives. We examined the sexual behavior, sexual identities, and HIV risk factors of a community sample of Latino men to inform efforts to reduce Latinos' HIV risk.</td></tr><tr><td class="textSmall">Methods. In 2005 and 2006, 680 Latino men in San Diego County, California, in randomly selected, targeted community venues, completed an anonymous, self-administered survey.</td></tr><tr><td class="textSmall">Results. Most (92.3%) respondents self-identified as heterosexual, with 2.2%, 4.9%, and 0.6% self-identifying as bisexual, gay, or other orientation, respectively. Overall, 4.8% of heterosexually identified men had a lifetime history of anal intercourse with other men. Compared with behaviorally heterosexual men, heterosexually identified men who had sex with both men and women were more likely to have had a sexually transmitted infection, to have unprotected sexual intercourse with female partners, and to report having sex while under the influence of alcohol or other drugs. Bisexually identified men who had sex with men and women did not differ from behaviorally heterosexual men in these risk factors.</td></tr><tr><td class="textSmall">Conclusions. Latino men who have a heterosexual identity and bisexual practices are at greater risk of HIV infection, and efforts to reduce HIV risk among Latinos should target this group. (Am J Public Health. 2009;99:125-132. doi:10.2105/AJPH.2007.129809)</td></tr></tbody></table></span></p><table border="0" cellpadding="0" cellspacing="0"><tbody></tbody></table><br /><p style="margin-top: 0px;">Latinos and sexual minorities are disproportionately affected by HIV/AIDS. Latinos represented 14% of the US population in 2005,1 but they accounted for18%ofHIV/AIDS cases diagnosed in 2006.2 Although an estimated6%to9%of the US population has a lifetime history of homosexual sex,3,4 menwho have sexwithmen accounted for 49% of all HIV/AIDS cases diagnosed in the United States in 2006.2 Sexual risk for HIV varies considerably by sexual orientation, with gay-identified and bisexually identified men generally at greater risk.5,6 However, a person's selfidentified sexual orientation frequently does not correspond to his or her sexual behavior.7-9</p><p style="margin-top: 0px;">Within Latino culture, it is possible for a man to have sex with men while maintaining a heterosexual identity and protecting his sense of masculinity.10-13 For Latino men, sexual identity appears to be contingent upon certain behavioral and contextual factors, such as whether they have female sexual partners, are primarily attracted to women, adopt an insertive role in sexual practices, have sex with effeminate men, or have sex with men when under the influence of alcohol or drugs. Homophobia, social stigma attached to same-sex practices, and sexual conservatism are commonly found throughout Latino culture andmay inhibit Latino men who have sex withmen fromself-identifying as gay or bisexual.9,10,14-16 Research suggests that Latino men are more likely than are White men to engage in bisexual behavior (i.e., to have sex with both men and women)8,17,18 but are less likely than are White men to disclose a nonheterosexual orientation.16,19,20</p><p style="margin-top: 0px;">Among men, bisexual behavior appears to be more prevalent than bisexual identity. Although approximately1%to 2% of the US male population identifies as bisexual,3,4 rates of male bisexual behavior in national samples have ranged from 1% to 5%.4,21,22 However, these estimates are questionable because of differences in sampling methods and varying definitions of bisexuality.23 Recent research conducted in the United States suggests that men who have sex with men and women (MSMW) are at greater risk of HIV infection than men who have sex with men (MSM) exclusively and men who have sex with women (MSW) exclusively.24-26 By contrast, investigators in Mexico have found that MSMW who self-identify as bisexual practice less risky sexual behaviors with their male partners than do exclusively gay men.6</p><p style="margin-top: 0px;">It has been difficult to quantify the population of heterosexually identified Latino MSMWbecause of the secretive nature of their sexual practices. In a homophobic cultural context, the fear of social rejection encourages people to hide their same-sex sexual behavior and lead a double life.10Astudy involving a large population ofHIVpositive MSM found that 15% of the Latino sample identified as heterosexual had a history of same-sex intercourse,27 whereas a survey of 455 men recruited from gay-oriented publications and venues in 12 US cities found that17% (n=26) of Hispanic respondents (as per terminology used in the original survey) reported being "on the down low".9 Although these results may not generalize to community-based US samples of Latino men, they suggest that a substantial proportion of heterosexually identified Latino men have a history of sex with men. Similarly, a household probability survey in Mexico City found that 73% of men with a lifetime history of bisexual practices identified as heterosexual, as did 29%of those with a lifetime history of having sex only with men.6</p><p style="margin-top: 0px;">Men's nondisclosure of sexual practices with men has implications for the health of their female sexual partners.8,17 In the United States in 2006, Latinas accounted for 23.7% of HIV infections among Hispanics; of these, an estimated 51.7% were infected through heterosexual contact.2 Although most cases of heterosexual transmission to Latinas are related to sex with injection drug users,28 women who have unprotected sex with heterosexually identified MSMWare also at risk and are likely a subset of this population.</p><p style="margin-top: 0px;">Although there is some evidence of greater HIV risk among MSMW than among MSM or MSW,24-26 previous research has not examined the roles that both sexual behavior and sexual identity play in HIV risk among Latino men in particular. Sexual identitymay influenceHIV risk among Latino MSMW because a man who identifies as heterosexual may perceive that he is at lower risk of sexually transmitted infections (STIs) than are gay or bisexual men and may thus take fewer measures to protect himself or his partner. MSMW who identify as heterosexual may also be more likely to resort to substance use to reduce sexual inhibition, thus increasing the likelihood that they will engage in unsafe sex.29</p><p style="margin-top: 0px;">Our goal was to learn more about the sexual practices of Latino men and to better understand the interactions among sexual behaviors and sexual identities in this population so as to inform efforts to reduce HIV risk among Latinos. Using survey data, we examined the sexual behavior of a community sample of Latino men; determined the proportions of MSM, MSW, and MSMW among them; elicited any discrepancies between their sexual behavior and their sexual identity; and searched for differences in HIV risk by sexual orientation.</p><p style="margin-top: 0px;">METHODS</p><p style="margin-top: 0px;">Design and Procedures</p><p style="margin-top: 0px;">We used baseline data collected as part of a larger study that evaluated a social marketing campaign to reduce HIV risk among heterosexually identified Latino MSMW in northern San Diego County, California. From December 2005 through April 2006, a cross-sectional community-based survey was conducted with Latino men recruited from 12 local venues. Using formative research, venues were selected to represent both high-risk and low-risk locations, with risk level determined by the extent to which sexual risk practices were likely to occur at or in proximity to the venue. Twelve sites covering the geographic region of northern San Diego County were identified, including 7 low-risk venues (i.e., a workplace, a migrant camp, a labor pickup site, 2 shopping centers, a center for the teaching of English as a second language, and a men's shelter) and 5 high-risk venues (i.e., an adult bookstore and 4 bars or clubs).</p><p style="margin-top: 0px;">Sampling shifts at each venue were selected based on days and times when sampling venues were operating (e.g., bars and clubs were only open in the evening) and when access to Latino men could be ensured (e.g., men congregated at labor pickup sites only in the morning). During every sampling period, random selection procedures were used to screen and recruit eligible participants. Eligibility included self-reported Latino ethnicity, being 18 years or older, and being alone or in the company of other men. Venue-specific recruitment goals were established based on the results of previous enumeration activities, to ensure that the number of completed surveys for each venue was proportional to the size of the target population visiting each site. The survey design included 3 sampling periods (December 2005, February 2006, and April 2006) and was based on the aims of the larger intervention study for which these data served as baseline. The response rate across all venues was 63% (70% for low-risk venues and 53% for high-risk venues).</p><p style="margin-top: 0px;">Measures</p><p style="margin-top: 0px;">Participants completed a self-administered intercept survey on a handheld computer using Questionnaire Development Software's HAPI data-collection module (NOVA Research Company, Bethesda, MD). The survey was anonymous and was available in either Spanish or English. Survey topics included demographic information; lifetime history of HIV and STI testing; lifetime and recent (previous 60 days) sexual behavior with both female and male partners, including vaginal intercourse, insertive anal intercourse, and receptive anal intercourse; and recent (previous 60 days) substance use.</p><p style="margin-top: 0px;">Statistical Analysis</p><p style="margin-top: 0px;">We defined sexual orientation according to 2 dimensions: gender of lifetime sexual partners and self-identified sexual orientation. We defined men as behaviorally heterosexual if they self-identified as heterosexual and reported no history of sexual activity with men (heterosexually identified MSW). We defined men as gay if they self-identified as gay or homosexual (gay-identified MSM). We defined men as bisexual if they self-identified as bisexual (bisexually identified MSMW). We defined men as heterosexually identified MSMW if they identified as heterosexual but had a history of having sex with men. All other men were classified as having an orientation of "other."</p><p style="margin-top: 0px;">Descriptive statistics and frequencies were computed for demographics, sexual behavior, substance use, and HIV and STI testing history. Bivariate (likelihood ratio) analyses explored differences in sexual behavior, substance use, and HIV and STI testing history by sexual orientation. Logistic regression models were estimated with each of the HIV risk variables as dependent variables, with sexual orientation as the main predictor variable, and with age, marital status, education, acculturation, and survey venue as covariates. Because of the small sample size and heterogeneity of the "other" sexual orientation category, this subgroup was included in descriptive analyses for the whole sample but was excluded from subsequent bivariate and multivariate analyses comparing HIV risk among sexual orientation categories. All analyses were computed using SPSS version 14.0 (SPSS Inc, Chicago, IL).</p><p style="margin-top: 0px;">RESULTS</p><p style="margin-top: 0px;">Sample Characteristics</p><p style="margin-top: 0px;">A total of 781 Latino men completed the survey. After excluding repeat survey participants, we included 680 participants (mean age=28.4 years; SD=9.1; range=18-65 years) in descriptive analyses. More than half (53%) were single or never married. Only 21.8% had completed a high school education or higher. The vast majority (92%) were born in Mexico, with an additional 5% born in the United States and 3% in another country. Among foreignborn participants (n=647), more than two thirds had been in the United States for 5 or fewer years , with 30% reporting US residency of less than1year. The percentage in our sample who reported being of Mexican origin matched US Census data for San Diego County, as did the percentage of foreign-born respondents who reported Mexico as their place of birth.30,31 Almost all respondents were primarily employed in 1 of 4 occupations: agriculture (29%), manufacturing (21%), service industry (24%), and construction (20%).</p><p style="margin-top: 0px;">The majority (92.3%) of participants selfidentified as heterosexual, with 2.2%, 4.9%, and 0.6% self-identifying as bisexual, gay, or other orientation, respectively. However, a smaller percentage (86.2%) reported a lifetime history of sexual practices with female partners exclusively. About 6% of men reported having a history of having sex with both men and women, 5.4% reported a history of sex with men only, and 2.4% reported no previous sexual practices with males or females. In all, 4.8% of heterosexually identified men had a lifetime history of anal intercourse with other men. According to our criteria, 87.6% of respondents were classified as heterosexually identified MSW; 4.4% as heterosexually identified MSMW; 2.4% as bisexually identified MSMW; and 4.7% as gay-identified MSM. The following percentages of respondents were recruited from high-risk recruitment venues: 46% of heterosexually identified MSW, 66.7% of heterosexually identified MSMW, 71.9% of gay-identified MSM, and 75% of bisexually identified MSMW.</p><p style="margin-top: 0px;">Sexual Risk Practices</p><p style="margin-top: 0px;">Most (56.5%) of the total sample of men reported sex with a female partner during the previous 60 days; of these, 58.2% reported not using a condom during 1 or more of these encounters, with percentages ranging from 25% among bisexually identified MSMW to 77.5% among heterosexually identified MSMW (Table 1). A minority of respondents (6.8%) reported engaging in anal intercourse with a male partner during the previous 60 days, with 57.8% of these reporting 1 or more unprotected encounters. The percentage of insertive anal intercourse equaled that of receptive anal intercourse (3.97%). By sexual orientation, percentages of insertive anal intercourse during the previous 60 days ranged from 31.2% among gay-identified MSM and bisexually identified MSMW to 36.7% among heterosexually identified MSMW. Percentages of receptive anal intercourse during the previous 60 days ranged from 10% among heterosexually identified MSMW to 50% among gayidentified MSM (P=.002). A majority (53.8%) of those who had insertive anal intercourse did so without using a condom, as did almost half (48.1%) of those who had receptive anal intercourse (Table 1).</p><p style="margin-top: 0px;">Out of 30 heterosexually identified MSMW, 40% (n=12) were estimated to have engaged in sex with both female and male partners during the previous 60 days. Among this subset, 91.7% (n=11) reported engaging in unprotected sex with both female and male partners. By contrast, 25% of 16 bisexually identified MSMW (n=4) reported sexual intercourse with both men and women during the previous 60 days; among them, only 1 reported unprotected sex with both genders.</p><p style="margin-top: 0px;">After adjusting for covariates, we found that heterosexually identified MSMW were 3.5 times more likely than were heterosexually identified MSW to report not using a condom with a female partner during the previous 60 days (95% confidence interval [CI]=1.15, 10.81; Table 2). Given the small size of the subsamples that reported recent anal intercourse with male partners, we performed no multivariate tests for significant differences in unprotected insertive and receptive anal intercourse with males by sexual orientation.</p><p style="margin-top: 0px;">Other HIV-Risk-Related Practices</p><p style="margin-top: 0px;">Condom carrying and risk perception. Overall, 23.1% of participants were carrying condoms at the time of the survey, with percentages ranging from 21% among heterosexually identified MSMW to 53.1% among gay-identified MSM (Table 3). With regard to perceived risk for HIV infection, 26.9% of participants considered themselves at medium or high risk, with percentages of risk perception being lowest among heterosexually identified MSW (23.4%) and highest among bisexually identified MSMW (68.8%; P<.001).</p><p style="margin-top: 0px;">After adjusting for covariates, we observed significant differences in the distribution of condom carrying and risk perception. Gayidentified MSM were 3.3 times more likely than were heterosexually identified MSW to report current condom carrying (95% CI=1.5, 7.2; Table 4). Gay-identified MSM were 4.8 times more likely than were heterosexually identified MSW to perceive themselves as being at risk of HIV infection (95% CI=2.2, 10.4), and bisexually identified MSMW were 7.4 times more likely than were heterosexually identified MSW to perceive themselves as being at risk of HIV infection (95% CI=2.5, 22.1). A trend was observed suggesting that heterosexually identified MSMW were more likely to perceive themselves as being at risk of HIV infection than were heterosexually identified MSW; however, this result did not reach statistical significance (P =.07). No significant differences were found between heterosexually identified MSMW and heterosexually identified MSW for condom carrying.</p><p style="margin-top: 0px;">Substance use. Almost one quarter of participants (23.4%) reported having sex while under the influence of alcohol during the previous 60 days, with percentages varying from18.8% among bisexually identified MSMW to 50% among heterosexually identified MSMW. In addition, 11.5% reported using illegal drugs, 6.1% reported having sex under the influence of illegal drugs, and 14.9% reported injection of a substance (e.g., medication, vitamins, illegal drugs). Heterosexually identified MSMWtended to report the highest percentages of illegal drug use (43.3%), drug use during sex (30%), and substance injection (26.7%). Bivariate statistical tests indicated significant differences in alcohol use before or during sex (P=.004), illegal drug use (P<.001), and drug use during sex (P<.001), by sexual orientation (Table 3).</p><p style="margin-top: 0px;">After adjusting for covariates, we found that heterosexually identified MSMW were 3.3 times more likely to report sex under the influence of alcohol (95% CI=1.5, 7.1), 6 times more likely to report illegal drug use (95% CI=2.7, 13.5), and 6.2 times more likely to report sex under the influence of illicit drugs (95% CI=2.4, 16.1) than were heterosexually identified MSW (Table 4). Bisexually identified MSMW were also significantly more likely than were heterosexually identified MSW to report use of illegal substances (odds ratio [OR]=3.8; 95% CI=1.2, 11.8). Sexual orientation was not predictive of substance injection.</p><p style="margin-top: 0px;">HIV and STI testing. Only 38.2% of the sample reported having been tested for HIV. Of these, 3.5% (n=9) reported that they were HIV positive. Among those who were HIV negative or whose HIV status was unknown, 46.5% did not know where they could get tested, and 43.4% had no intention of being tested in the next 6 months. Only 23% of men reported having been tested for STIs. Of these, 11% reported having had an STI in their lifetime (Table 3). Results from multivariate analysis indicated that, compared with heterosexually identified MSW, heterosexually identified MSMW and gay-identified MSM were significantly more likely to have been tested for HIV (heterosexually identified MSMW: OR=4.5; 95% CI=2.0, 10.2; gay-identified MSM: OR=11.3; 95% CI=3.8, 33.6). Gay-identified MSM were more likely than were heterosexually identifiedMSWto intend to be tested in the next 6 months (OR=2.7; 95% CI=1.2, 6.4). Heterosexually identified MSMW (OR=4.1; 95% CI=1.9, 9.0), bisexually identified MSMW (OR=3.1; 95% CI=1.1, 8.8), and gay-identified MSM (OR=3.7; 95% CI=1.7, 8.1) were more likely than were heterosexually identified MSW to have been tested for other STIs (Table 4). Heterosexually identified MSMW were more than 4.3 times more likely than were heterosexually identified MSW to report having had a STI (OR=4.3; 95% CI: 1.8, 9.9).</p><p style="margin-top: 0px;">DISCUSSION</p><p style="margin-top: 0px;">The estimate of behavioral bisexuality found among the present sample of Latino men (6%) was slightly larger than those previously reported in Mexico6 (2.1% for lifetime bisexual practices) and national US samples (1%-4.9% for various time frames).4,21,22 This may reflect our definition of behavioral bisexuality, which was based on lifetime sexual practices instead of recent sexual practices, and the fact that some of our venues had a significant proportion of gay-identified patrons. It may also be indicative of the higher rates of behavioral bisexuality among men of color reported in previous research. 8,9,17,18,26,29 However, we obtained a smaller percentage of heterosexually identified MSMW in our sample than those obtained in previous studies that included Latinos in the United States.8,9 This difference could be explained by an underreporting of sexual practices, particularly those that are stigmatized; a lack of measures on oral sex in our study; sampling biases in our study and in previous research; or the paucity of research that has simultaneously examined sexual identity and sexual behaviors with both women and men. Regardless, these results indicate that a significant proportion of heterosexually identified Latino men in our sample have engaged in sexual intercourse with men.</p><p style="margin-top: 0px;">HIV testing rates for our sample (38.2%) were lower than those estimated for Latino males in the United States (45%)32 and may be explained by the fact that most of the respondents in our sample were foreign born or recent immigrants. However, our HIV and STI testing rates were higher than were those estimated for migrants returning to Mexico from the United States (HIV testing: 22%-29%; STI testing: 10%-13%).33 A surprisingly high proportion of men reported being HIV positive; in the context of limited HIV testing, this finding may actually reflect underestimated rates of infection. However, these data must be interpreted cautiously, because the inclusion of high-risk venues may have caused us to find higher HIV rates than would be seen in the general population and because our data on HIV status are based solely on self-reports. Still, these findings call attention to the need to promote HIV and STI testing for low-acculturated Latinos.</p><p style="margin-top: 0px;">Compared to heterosexually identified MSW, heterosexually identified MSMW were more likely to report a history of STIs and recent unprotected sexual intercourse with a female partner. Moreover, half of heterosexually identified MSMW reported recent anal intercourse with a male partner; among them, 3 out of 4 reported inconsistent condom use during same-sex encounters. These findings add to previous research on behavioral bisexuality24-26,34 and have significant implications for the health of our respondents' sexual partners. Previous studies have suggested that risky bisexual behavior among men may serve as a bridge for HIV transmission from high-prevalence groups to the general population. 6,25,35 Research suggests that a relatively small proportion of HIV infections in the United States are attributable to bisexual behavior.35 However, these estimates rely on openly reported bisexual behavior. Because of stigma associated with homosexual practices,19,36 many behaviorally bisexual men may underreport or deny same-sex practices. Underreporting of same-sex practices among heterosexually identified MSMW may lead to an underestimation of the contribution that this transmission avenue makes to the HIV epidemic in the United States.</p><p style="margin-top: 0px;">Heterosexually identified MSMW were also more likely to report recent drug use and sexual intercourse while under the influence of alcohol or other drugs. This finding is consistent with previous research suggesting that substance use is frequently a contextual factor in same-sex intercourse among heterosexually identified MSMW14,16,37 and may contribute to increased risk for HIV infection among these men and their sexual partners.37 With less than 50% of men in our sample reporting using a condom during every recent sexual encounter, additional efforts clearly must be taken to encourage heterosexually identified MSMW to consistently use condoms with both male and female partners.</p><p style="margin-top: 0px;">Despite their same-sex sexual practices and substance-influenced encounters, heterosexually identified MSMW did not perceive their risk for HIV to differ significantly from that of heterosexually identified MSW. A considerable proportion of heterosexually identified MSMW in our sample (27%; data not shown) only adopted an insertive role in anal intercourse with men, reducing to some extent their risk of acquiring HIV. However, HIV and STI prevention interventions clearly should be targeted toward this population, including efforts to raise risk awareness.</p><p style="margin-top: 0px;">Implications</p><p style="margin-top: 0px;">These findings have important implications for future HIV prevention research and practice. First, more research is warranted to elucidate the relative contributions of male sexual identity and bisexual behavior to the increasing proportion of Latinas among new HIV cases. Previous studies have suggested that Latino MSM and MSMW are more likely to maintain a heterosexual identity than are Whites.16,19 However, more comparative studies are needed because little research has been conducted with White men on this issue. Additional research is also required to identify factors associated with the adoption of a heterosexual identity among MSMW. Because the only thing that differentiates bisexually identified MSMW from heterosexually identified MSMW is sexual identity, a comparison between these 2 groups would be particularly interesting.</p><p style="margin-top: 0px;">Second, these findings underscore the need for HIV prevention efforts targeting heterosexually identified Latino MSMW and their male and female sexual partners, such as efforts to reduce social stigma attached to same-sex intercourse and campaigns to raise HIV awareness regardless of sexual identity. Other interventions may include (but are not limited to) those promoting routine HIV and STI screening as a standard part of well-adult care38 and those attempting to normalize condom use regardless of sexual identity or the gender of one's sexual partners. Programs need to be consistent with and respectful of these men's sexual identities; they also must reduce the stigma associated with HIV testing and condom use, which are often perceived among Latinos as practices associated with homosexuality and signs of distrust or infidelity within relationships.39,40 Finally, interventions targeting Latinas as the sexual partners of MSMW are needed, especially in light of recent findings that sex within marriage may be the single greatest risk for HIV among Mexican women.34,41These interventions should be gender sensitive, taking into account potential constraints upon women's abilities to respond to their partners' risk, and routine opt-out HIV testing should be promoted.38</p><p style="margin-top: 0px;">Our findings offer additional evidence that both behavior and identity are important dimensions of sexual orientation that need to be contemplated when assessing HIV risk and evaluating prevention interventions. Our results point to the need for future research that will help investigators develop a better understanding of how heterosexual identity might increase HIV risk among behaviorally bisexual Latino men. There is also a need for research examining whether the differences among various sexual orientation groups observed here extend to Latino men in general or to other racial/ethnic male populations. Research on these topics should be carefully framed to avoid adding stigma and generating sensationalist discourses regarding heterosexually identified MSMW of color, or the so-called "down low" phenomenon.</p><p style="margin-top: 0px;">Limitations</p><p style="margin-top: 0px;">Our sampling procedures were part of a larger intervention study and included targeted sampling at venues in which heterosexually identified MSMW were likely to be found. Thus, the results may not reflect the risk dynamics of Latinos outside northern San Diego County and may be limited to the population of Latino men who frequent these types of venues. In addition, the inclusion of lifetime versus recent sexual practices in our definition of behavioral bisexuality may have overestimated the proportion of behaviorally bisexual men among our sample. Estimates of bisexuality have been found to vary substantially depending on the time frame of sexual behavior selected.6 Our use of lifetime sexual practices may have captured early same-sex experiences (e.g., single-incident youthful experimentation or instances of childhood sexual abuse) that are not indicative of recent sexual practices. The use of alternate time frames to differentiate past sexual experimentation from current behavioral practices should be explored, and clear distinction should be made between consensual sexual experiences versus those that were forced or coerced. Future research should also examine the number of male partners and sexual encounters, because these factors would affect the probability of viral exposure and thus the risk for HIV infection.</p><p style="margin-top: 0px;">More than 90% of our sample was born in Mexico, limiting our ability to generalize these results to other foreign-born Latino men. Future research should include larger subsamples of Latino males from countries other than Mexico to allow analysis of possible differences by country of origin. Because of survey space and time limitations, we were also unable to directly assess contextual and sociodemographic factors that might be associated with sexual risk, such as housing type and urban versus rural place of residence. Future research should include measures of these factors and assess the extent to which they may confound the observed association between sexual identity and HIV risk.</p><p style="margin-top: 0px;">Participants in our survey were only asked about anal intercourse with other men, because these present the highest risk for HIV infection or transmission. However, oral sex with male partners may be a more common sexual practice for behaviorally defined bisexual Latino men.6 Although oral sex may represent a low-risk behavior from an HIV-transmission perspective, if the experience is perceived favorably, it may serve as a gateway to riskier same-sex practices. Oral sex also has significant implications for STI transmission. Future research should therefore estimate the prevalence of oral sex with male partners among heterosexually identified MSMW and explore the relationship of these practices to subsequent sexual risk behavior.</p><p style="margin-top: 0px;">Finally, because of the small number of men reporting recent anal intercourse with another man, we were unable to explore the relationship between sexual identity and condom use with male partners. Because unprotected anal intercourse represents the greatest risk for HIV and STI transmission between male partners, further research is needed to examine the extent to which heterosexually identified MSMWmay differ from men of other sexual orientations in their same-sex sexual practices.</p><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td nowrap="nowrap"> <span class="bold textSmall">[Reference]</span> <span class="raquo">» </span> <a title="View a list of references included in this document" href="http://proquest.umi.com/pqdweb?VInst=PROD&VName=PQD&VType=PQD&RQT=594&did=1613679071&Fmt=3&refType=CITEDIN&b2=d&SrchMode=1&sid=2&index=18&TS=1230626613" class="textSmall">View reference page with links</a></td></tr><tr><td class="textSmall">References</td></tr><tr><td class="textSmall">1. US Census Bureau. American Community Survey: United States, 2006. Table generated using American FactFinder (http://factfinder.census.gov). Accessed October 30, 2007.</td></tr><tr><td class="textSmall">2. Centers for Disease Control and Prevention. HIV/ AIDS Surveillance Report, 2006. Atlanta, GA: US Dept of Health and Human Services; 2008.</td></tr><tr><td class="textSmall">3. Laumann E, Gagnon J, Michael R, et al. The Social Organization of Sexuality: Sexual Practices in the United States. Chicago, IL: University of Chicago Press; 1994.</td></tr><tr><td class="textSmall">4. Mosher WD, Chandra A, Jones J. Sexual behavior and selected health measures: men and women 15-44 years of age, United States, 2002. Adv Data Vital Health Stat. September 15, 2005;362.</td></tr><tr><td class="textSmall">5. Gayle H. An overview of the global HIV/AIDS epidemic, with a focus on the United States. AIDS. 2000;14:S8-S17.</td></tr><tr><td class="textSmall">6. Izazola-Licea JA, Gortmaker SL, de Gruttola V, Tolbert K, Mann J. Sexual behavior patterns and HIV risks in bisexual men compared to exclusively heterosexual and homosexual men. Salud Pu blica Me x. 2003;45 (suppl 5):S662-S671.</td></tr><tr><td class="textSmall">7. Millett G, Malebranche D, Mason B, Spikes P. Focusing "down low": bisexual black men, HIV risk and heterosexual transmission. J Natl Med Assoc. 2005; 97(7 suppl):52S-59S.</td></tr><tr><td class="textSmall">8. Montgomery J, Mokotoff E, Gentry A, Blair J. The extent of bisexual behaviour in HIV-infected men and implications for transmission to their female sex partners. AIDS Care. 2003;15:829-837.</td></tr><tr><td class="textSmall">9. Wolitski R, Jones K, Wasserman J, Smith J. Selfidentification as "down low" among men who have sex with men (MSM) from 12 US cities. AIDS Behav. 2006;10:519-529.</td></tr><tr><td class="textSmall">10. Carrillo H. The Night is Young: Sexuality in Mexico in the Time of AIDS. Chicago, IL: University of Chicago Press; 2002.</td></tr><tr><td class="textSmall">11. Prieur A. Mema's House, Mexico City: On Transvestites, Queens, and Machos. Chicago, IL: University of Chicago Press; 1998.</td></tr><tr><td class="textSmall">12. Magaña JR, Carrier JM. Mexican and Mexican American male sexual behavior and spread of AIDS in California. J Sex Res. 1991;28(3):425-441.</td></tr><tr><td class="textSmall">13. Nuñez Noriega J. Reconociendo los placeres, desconstruyendo las identidades: antropologia, patriarcado, y homoerotismo en Mexico [Acknowledging pleasure, deconstructing identities: anthropology, patriarchy, and homoerotism in Mexico]. Desacatos. 2001;6:15-34.</td></tr><tr><td class="textSmall">14. Diaz RM. Latino Gay Men and HIV: Culture, Sexuality, and Risk Behavior. New York, NY: Routledge; 1998.</td></tr><tr><td class="textSmall">15. Doll LS, Beeker C. Male bisexual behavior and HIV risk in the United States: synthesis of research with implications for behavioral interventions. AIDS Educ Prev. 1996;8:205-225.</td></tr><tr><td class="textSmall">16. Zea M, Reisen C, Diaz R. Methodological issues in research on sexual behavior with Latino gay and bisexual men. Am J Community Psychol. 2003;31(3-4):281-291.</td></tr><tr><td class="textSmall">17. Chu SY, Peterman TA, Doll LS, Buehler JW, Curran JW. AIDS in bisexual men in the United States: epidemiology and transmission to women. Am J Public Health. 1992;82:220-224.</td></tr><tr><td class="textSmall">18. Doll L, Petersen L, White C, et al. Homosexually and nonhomosexually identified men who have sex with men: a behavioral comparison. J Sex Res. 1992;29:1-14.</td></tr><tr><td class="textSmall">19. Mason H, Marks G, Simoni J, Ruiz M, Richardson J. Culturally sanctioned secrets? Latino men's nondisclosure of HIV infection to family, friends, and lovers. Health Psychol. 1995;14:6-12.</td></tr><tr><td class="textSmall">20. Zea MC. Latino HIV-positive gay men's narratives on disclosure of serostatus. Paper presented at: American Public Health Association 1999 Annual Meeting; November 7-11, 1999; Chicago, IL.</td></tr><tr><td class="textSmall">21. Smith TW. Adult sexual behavior in 1989: number of partners, frequency of intercourse and risk of AIDS. Fam Plann Perspect. 1991;23:102-107.</td></tr><tr><td class="textSmall">22. Jeffries WL, Dodge B. Male bisexuality and condom use at last sexual encounter: results from a national survey. J Sex Res. 2007;44:278-289.</td></tr><tr><td class="textSmall">23. Adimora AA, Fullilove RE. Men who have sex with men and women: pieces of the US HIV epidemic puzzle. Sex Transm Dis. 2006;33:596-598.</td></tr><tr><td class="textSmall">24. Brooks R, Rotheram-Borus MJ, Bing EG, Ayala G, Henry CL. HIV and AIDS among men of color who have sex with men and men of color who have sex with men and women: an epidemiological profile. AIDS Educ Prev. 2003;15(1 suppl A):1-6.</td></tr><tr><td class="textSmall">25. Prabhu R, Owen C, Folger K, McFarland W. The bisexual bridge revisited: sexual risk behavior among men who have sex with men and women, San Francisco, 1998-2003. AIDS. 2004;18:1604-1606.</td></tr><tr><td class="textSmall">26. Munoz-Laboy M, Dodge B. Bisexual Latino men and HIV and sexually transmitted infections risk: an exploratory analysis. Am J Public Health. 2007;97:1102-1106.</td></tr><tr><td class="textSmall">27. Centers for Disease Control and Prevention. Unpublished data. 1999. Cited by: Centers for Disease Control and Prevention. HIV/AIDS among racial/ethnic minority men who have sex with men-United States, 1989-1998. MMWR Morb Mortal Wkly Rep. 2000;49(1):4-11.</td></tr><tr><td class="textSmall">28. The HIV/AIDS Epidemic in the Latino Community. Atlanta, GA: Centers for Disease Control and Prevention. Available at: http://www.cdc.gov/hiv/resources/ reports/slcp/epidemic.htm. Accessed September 20, 2007.</td></tr><tr><td class="textSmall">29. Diaz R. Trips to fantasy island: contexts of risky sex for San Francisco gay men. Sexualities. 1999;2:89-112.</td></tr><tr><td class="textSmall">30. US Census Bureau. Census 2000 Summary File 1 (SF-1) 100-Percent Data. San Diego County, California: Hispanic or Latino by Specific Origin: Mexican. Table generated using American FactFinder (http://factfinder. census.gov). Accessed February 15, 2008.</td></tr><tr><td class="textSmall">31. US Census Bureau. Census 2000 Summary File 3 (SF-3) Sample Data. San Diego County, California: Hispanic or Latino by Specific Origin: Mexican. Table generated using American FactFinder (http://factfinder. census.gov). Accessed February 15, 2008.</td></tr><tr><td class="textSmall">32. Anderson JE, Chandra A, Mosher WD. HIV testing in the United States, 2002. Adv Data. 2005; 363:1-32.</td></tr><tr><td class="textSmall">33. Rangel M, Martínez-Donate A, Hovell M, Santibanez J, Sipan C, Izazola-Licea J. Prevalence of risk factors for HIV infection among Mexican migrants and immigrants: probability survey in the north border of Mexico. Salud Pública Méx. 2006;48:3-12.</td></tr><tr><td class="textSmall">34. Pulerwitz J, Izazola-Licea JA, Gortmaker SL. Extrarelational sex among Mexican men and their partners' risk of HIV and other sexually transmitted diseases. Am J Public Health. 2001;91:1650-1652.</td></tr><tr><td class="textSmall">35. Kahn JG, Gurvey J, Pollack LM, Binson D, Catania JA. How many HIV infections cross the bisexual bridge? An estimate from the United States. AIDS. 1997;11:1031-1037.</td></tr><tr><td class="textSmall">36. Rosario M, Schrimshaw EW, Hunter J. Ethnic/racial differences in the coming-out process of lesbian, gay, and bisexual youths: a comparison of sexual identity development over time. Cultur Divers Ethnic Minor Psychol. 2004;10:215-228.</td></tr><tr><td class="textSmall">37. Dolezal C, Carballo-Dieguez A, Nieves-Rosa L, Diaz F. Substance use and sexual risk behavior: understanding their association among four ethnic groups of Latino men who have sex with men. J Subst Abuse. 2000;11:323-336.</td></tr><tr><td class="textSmall">38. Centers for Disease Control and Prevention. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006; 55(RR-14):1-17.</td></tr><tr><td class="textSmall">39. Hirsch JS, Higgins J, Bentley ME, Nathanson CA. The social constructions of sexuality: marital infidelity and sexually transmitted disease-HIV risk in a Mexican migrant community. Am J Public Health. 2002;92:1227-1237.</td></tr><tr><td class="textSmall">40. McQuiston C, Gordon A. The timing is never right: Mexican views of condom use. Health Care Women Int. 2000;21:277-290.</td></tr><tr><td class="textSmall">41. Hirsch JS, Meneses S, Thompson B, Negroni M, Pelcastre B, del Rio C. The inevitability of infidelity: sexual reputation, social geographies, and marital HIV risk in rural Mexico. Am J Public Health. 2007;97(6): 986-996.</td></tr></tbody></table></span><table border="0" cellpadding="0" cellspacing="0"><tbody></tbody></table><br /><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td class="textSmall" nowrap="nowrap"><b>[Author Affiliation]</b></td></tr><tr><td class="textSmall">Jennifer A. Zellner, PhD, Ana P. Martínez-Donate, PhD, Fernando Sañudo, MPH, Araceli Fernández-Cerdeño, MA, Carol L. Sipan, MPH, RN, Melbourne F. Hovell, PhD, MPH, and Héctor Carrillo, DrPH</td></tr><tr><td class="textSmall">About the Authors</td></tr><tr><td class="textSmall">At the time of the study, Jennifer A. Zellner, Ana P. Martínez-Donate, Araceli Fernández-Cerdeño, Carol L. Sipan, and Melbourne F. Hovell were with the Center of Behavioral Epidemiology and Community Health, Graduate School of Public Health, San Diego State University, San Diego, CA. Ana P. Martínez-Donate was also with the Department of Population Health Sciences, University of Wisconsin, Madison. Fernando Sañudo was with Vista Community Clinic, Vista, CA. Héctor Carrillo was with the Department of Human Sexuality Studies, San Francisco State University, San Francisco, CA.</td></tr><tr><td class="textSmall">Requests for reprints should be sent to Ana P. Martínez-Donate, Department of Population Health Sciences, University of Wisconsin-Madison, 610 Walnut St, WARF 605, Madison, WI 53726-2397 (e-mail: martinezdona@ wisc.edu).</td></tr><tr><td class="textSmall">This article was accepted May 6, 2008.</td></tr><tr><td class="textSmall">Contributors</td></tr><tr><td class="textSmall">J. A. Zellner supervised the study, assisted with analyses, and led the writing of the article. A. P. Martínez-Donate originated and directed the study, performed the data analyses, and contributed substantially to the writing of the article. F. Sañudo was the co-principal investigator of the study. A. Fernández-Cerdeño, C. L. Sipan, M. F. Hovell, and H. Carrillo assisted with the design and implementation of the study. All authors helped interpret findings and reviewed drafts of the article.</td></tr><tr><td class="textSmall">Acknowledgments</td></tr><tr><td class="textSmall">This research was supported by the California HIV/AIDS Research Program of the University of California, Office of the President (grants AL04-SDSUF-804 and AL04-VCC-805), and by intramural support from the Center of Behavioral Epidemiology and Community Health at San Diego State University.</td></tr><tr><td class="textSmall">Human Participant Protection</td></tr><tr><td class="textSmall">All study procedures were reviewed and approved by the San Diego State University institutional review board and by the social and behavioral sciences institutional review board at the University of Wisconsin-Madison.</td></tr></tbody></table></span><table border="0" cellpadding="0" cellspacing="0"><tbody></tbody></table></div></div>All About Bloggerhttp://www.blogger.com/profile/17282736671555579827noreply@blogger.com0tag:blogger.com,1999:blog-4987803374989865601.post-4780971427871913082008-12-30T00:38:00.000-08:002008-12-30T00:39:29.800-08:00Mortality Among Men and Women in Same-Sex Marriage: A National Cohort Study of 8333 Danes<div class="docSection" style="padding-top: 4px; padding-left: 4px;"><span class="textSmall"><strong>Abstract (Summary)</strong></span><div class="textMedium"><p style="margin-top: 0px;">We studied overall mortality in a demographically defined, complete cohort of gay men and lesbians to address recent claims of markedly shorter life spans among homosexual persons. We calculated standardized mortality ratios (SMRs) starting 1 year after the date of same-sex marriage for 4914 men and 3419 women in Denmark who married a same-sex partner between 1989 and 2004. Mortality was markedly increased in the first decade after same-sex marriage for men who married between 1989 and 1995 (SMR=2.25; 95% confidence interval [CI]=2.01, 2.50), but much less so for men who married after 1995, when efficient <span style="color:red;"><b>HIV</b></span>/AIDS therapies were available (SMR=1.33; 95% CI=1.04, 1.68). For women who married their same-sex partner between 1989 and 2004, mortality was 34% higher than was mortality in the general female population (SMR=1.34; 95% CI=1.09, 1.63). For women, and for men marrying after 1995, the significant excess mortality was limited to the period 1 to 3 years after the marriage. Despite recent marked reduction in mortality among gay men, Danish men and women in same-sex marriages still have mortality rates that exceed those of the general population. The excess mortality is restricted to the first few years after a marriage, presumably reflecting preexisting illness at the time of marriage. Although further study is needed, the claims of drastically increased overall mortality in gay men and lesbians appear unjustified.</p><p style="margin-top: 0px;"><span class="italic">Copyright American Public Health Association Jan 2009</span><br /><br /><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td class="textSmall" nowrap="nowrap"><b>[Headnote]</b></td></tr><tr><td class="textSmall">Objectives. We studied overall mortality in a demographically defined, complete cohort of gay men and lesbians to address recent claims of markedly shorter life spans among homosexual persons.</td></tr><tr><td class="textSmall">Methods. We calculated standardized mortality ratios (SMRs) starting 1 year after the date of same-sex marriage for 4914 men and 3419 women in Denmark who married a same-sex partner between 1989 and 2004.</td></tr><tr><td class="textSmall">Results. Mortality was markedly increased in the first decade after same-sex marriage for men who married between 1989 and 1995 (SMR=2.25; 95% confidence interval [CI]=2.01, 2.50), but much less so for men who married after 1995, when efficient HIV/AIDS therapies were available (SMR=1.33; 95% CI=1.04, 1.68). For women who married their same-sex partner between 1989 and 2004, mortality was 34% higher than was mortality in the general female population (SMR=1.34; 95% CI=1.09, 1.63). For women, and for men marrying after 1995, the significant excess mortality was limited to the period 1 to 3 years after the marriage.</td></tr><tr><td class="textSmall">Conclusions. Despite recent marked reduction in mortality among gay men, Danish men and women in same-sex marriages still have mortality rates that exceed those of the general population. The excess mortality is restricted to the first few years after a marriage, presumably reflecting preexisting illness at the time of marriage. Although further study is needed, the claims of drastically increased overall mortality in gay men and lesbians appear unjustified. (Am J Public Health. 2009;99:133-137. doi:10.2105/AJPH.2008.133801)</td></tr></tbody></table></span></p><table border="0" cellpadding="0" cellspacing="0"><tbody></tbody></table><br /><p style="margin-top: 0px;">Numerous reports have addressed the excess mortality among gay men who are HIV infected or who have AIDS.1 The remarkable decline in mortality following the introduction of highly active antiretroviral treatment (HAART) regimens since 1996 has also been well documented. 2,3 However, there is a lack of methodologically sound studies on whether mortality among gaymen who are not directly affected by the HIV/AIDS epidemic (the majority of gay men) is any different from that of the general male population. Likewise, despite recent calls for increased attention to the health needs of sexual minority groups,4,5 no population-based study has provided data on the overall mortality among lesbians. One major practical reason that mortality has not been studied in these groups, whose basic human rights remain controversial in many countries, is the difficulty identifying large and unbiased groups of gay men and lesbians. Further stressing the need for a thorough investigation, a recent Internet-based publication used flawed methodology to arrive at the conclusion that life expectancies for gay men and lesbians are, on average, shorter than those of heterosexual men and women by more than 20 years.6</p><p style="margin-top: 0px;">Our goal was to provide a population-based estimate of the overall mortality in a welldefined, complete cohort of gay and lesbian persons without obvious health-related characteristics that would lead to biased mortality estimates. We utilized favorable opportunities for conducting nationwide epidemiologic studies in Denmark to identify a cohort of more than 8000 persons whose only eligibility criterion was that they had formalized their partnership in same-sex marriage.</p><p style="margin-top: 0px;">METHODS</p><p style="margin-top: 0px;">In 1989, the Danish parliament was the first in the world to pass a law allowing registered homosexual partnerships, i.e., same-sex marriages, that provided same-sex couples with legal rights resembling those of people in heterosexual marriages.7 We used the Civil Registration System, a centralized and continuously updated electronic database that keeps track of demographic changes (including marital status) in the entire Danish population8 to identify 8667 persons who married a same-sex partner between October 1, 1989, and July 15, 2004. Because of insufficient follow-up data, we excluded 31 persons who had emigrated from Denmark at the time of their marriage. Furthermore, 303 persons with less than 1 year of follow-up were excluded because we disregarded the first year after marriage from all mortality calculations to reduce the influence of deaths from severe diseases that were present at the time of marriage and that may have contributed to the decision to marry. Thus, the study cohort consisted of 8333 persons (4914 men, 3419 women) who were followed after 1 year of their first same-sex marriage until death, emigration, or end of follow-up (July 15, 2005).</p><p style="margin-top: 0px;">We used measures of relative and excess mortality to compare overall mortality rates among persons in same-sex marriages with those of the general Danish population. The standardized mortality ratio (SMR), defined as the ratio of observed to expected numbers of deaths, is a frequently used summary measure of relative mortality. The excess death rate (EDR), defined as the observed minus the expected number of deaths per1000 person-years of observation, is useful when comparing groups with different baseline mortality rates. We calculated overall, marital age-specific (£35 or >35 years at first same-sex marriage), and period-specific (first same-sex marriage in 1989-1995 or1996-2004;1996 was the year HAART regimens dramatically improved survival of patients with HIV/AIDS) SMRs and EDRs with accompanying 95% confidence intervals (CIs), thus comparing mortality rates among persons in same-sex marriages with those of the general Danish population. Expected numbers of deaths in the cohort (denominators of the SMRs) were estimated by adding the gender-, age-and time period-specific contributions (1-year age and 5-year time period-specific stratifications) of person-years of observation multiplied by corresponding gender-, age-and time period-specific death rates in the general population. SMRs whose 95% CIs excluded unity (i.e.,1.00) were considered to be statistically significant.</p><p style="margin-top: 0px;">RESULTS</p><p style="margin-top: 0px;">Overall Mortality, 1990-2005</p><p style="margin-top: 0px;">During 60316 person-years of observation starting 1 year after a same-sex marriage, 618 deaths (518 in men, 100 in women) occurred in the cohort, yielding crude mortality rates of 13.5 and 4.6 per 1000 person-years among men and women, respectively. These mortality rates were significantly higher than corresponding rates in the general Danish population (for men: SMR=1.78; 95% CI=1.63,1.94; for women: SMR=1.34; 95% CI=1.09, 1.63; Table 1). In terms of excess deaths, persons in same-sex marriages experienced 5.92 and 1.15 extra deaths per 1000 person-years among men and women, respectively, compared with death rates in the general Danish population. Among both men and women, there was a pattern of declining SMRs and EDRs over time after the first same-sex marriage. For men, mortality was 165% higher than in the general male population during the 1-to 3-year period after the marriage (SMR=2.65; 95% CI=2.28, 3.06; n=187 deaths) but gradually diminished to general population levels in the 13 to 14 years after the marriage (SMR=1.02; 95% CI=0.70, 1.42; n=34 deaths). For women, mortality was 91% higher in the period 1 to 3 years after the marriage (SMR=1.91; 95% CI=1.36, 2.60: n=40 deaths), but mortality rates did not deviate significantly from those of the general female population in subsequent periods 4 or more years after the marriage (n=60 deaths).</p><p style="margin-top: 0px;">Mortality by Age at First Same-Sex Marriage</p><p style="margin-top: 0px;">As shown in Table 1, EDRs were quite similar among men who were 35 years or younger or were older than 35 years at their first samesex marriage (EDR=6.27 vs 5.64 excess deaths per 1000 person-years, respectively). However, because of lower background mortality rates in the younger category, SMRs were markedly different (5.15 for the younger group [95% CI=4.30, 6.11; n=131 deaths] vs 1.46 for the older group [95% CI=1.32, 1.61; n=387 deaths]). Among women, differences between those who were 35 years or younger and those who were older than 35 years at their first same-sex marriage were smaller, with SMRs of 2.04 (95% CI=1.21, 3.22; n=18 deaths) and 1.24 (95% CI=0.99, 1.54; n=82 deaths), respectively.</p><p style="margin-top: 0px;">Mortality by Period of Same-Sex Marriage</p><p style="margin-top: 0px;">To evaluate the impact of HIV/AIDSassociated mortality on overall mortality among men, we subsequently calculated SMRs and EDRs for the first decade (1-9 years) after same-sex marriage in 2 calendar periods (Table 2). The first period covered men who married during the pre-HAART period of1989 to 1995. The second period covered men who married between 1996 and 2004, when HAART was available to treat patients with HIV/AIDS. For those who entered same-sex marriage in the pre-HAART period, the overall SMR 1 to 9 years later was 2.25 (95% CI=2.01, 2.50; n=338 deaths). For those who married after the introduction of HAART, the SMR was 1.33 (95% CI=1.04, 1.68; n=70 deaths) and only significantly elevated above unity 1 to 3 years after marriage. Corresponding EDRs declined dramatically from 9.63 excess deaths per1000 person-years among men who married their same-sex partner between 1989 and 1995 to 1.53 excess deaths per 1000 person-years among those who did so between 1996 and 2004.</p><p style="margin-top: 0px;">DISCUSSION</p><p style="margin-top: 0px;">Strengths and Limitations</p><p style="margin-top: 0px;">To the best of our knowledge this is the first population-based assessment of mortality in a demographically defined, complete group of gay and lesbian persons. Despite dramatic reductions in AIDS-associated mortality over the past decade, our study shows that same-sex-marrying Danish men and women have overall mortality rates that are currently 33% to 34% higher than those of the general population. Among women, the increased mortality was limited to the first 1 to 3 years of marriage, which is likely explained by deaths caused by severe diseases that were already present at the time of their marriage. Among men who married their partner during recent years when HAART was available to reduce the impact of AIDS deaths, SMRs were greater than 1.00 up to 6 years after the marriage, although only significantly so in the first1to 3 years. Since the introduction of HAART in 1996, AIDS-related deaths have contributed successively less to overall mortality among gay men, the population at highest risk of HIV/AIDS in Denmark.9 Accordingly, among the men in our study, we observed a drastic reduction from 9.63 excess deaths per 1000 person-years among those who married their partner in the pre-HAART period to 1.53 excess deaths per 1000 person-years for those who married during the HAART period.</p><p style="margin-top: 0px;">Mortality in industrialized countries like Denmark is largely determined by deaths from cardiovascular diseases and cancers. We are aware of no studies on the burden of cardiovascular diseases among gay and lesbian persons, but a previous study reported no evidence to suggest major differences in cancer morbidity between same-sex married persons and the general Danish population.10 Causes other than cancer deaths are therefore likely to account for the observed excess mortality in our cohort of same-sex marrying persons.</p><p style="margin-top: 0px;">As with heterosexual couples, same-sex couples' decisions to marry rather than to stay together, unmarried, are determined by a variety of factors that, apart from romantic, emotional, sexual, moral, and religious arguments, may include financial, children-related, or other practical factors. The significant excess mortality in the first1to 3 years of samesex marriage among women and men who married their partner after the introduction of HAART is likely, at least in part, to reflect preexisting severe illness. Some same-sex couples may have decided to marry to ensure that the surviving partner would have housing, inheritance, pension, and other financial advantages that would not otherwise be available to them.</p><p style="margin-top: 0px;">Official estimates of the proportion of Danes who are gay or lesbian do not exist, so we cannot know how representative persons in same-sex marriages are of all gay and lesbian persons in Denmark. In a previous study, people in same-sex marriages were estimated to constitute somewhere between 1% and 6% of all gay or lesbian persons in Denmark.10 Our mortality findings are not necessarily representative of all Danish gay men or lesbians. Although our findings are likely to apply to other same-sex-partnered persons who live in steady relationships without formal registration,11 it is more questionable to what extent our findings will also apply to unmarried gay or lesbian persons with continuously shifting partners, those who have both male and female partners, and those self-identified gay men and lesbians who do not have a partner at all. Lifestyles may differ considerably between subgroups, and it is likely that some subgroups have lower mortality rates than do others, depending on individual risk-taking behaviors, such as smoking, alcohol consumption, recreational drug use, and casual sexual relations.</p><p style="margin-top: 0px;">Because same-sex marriage is a rather new institution, there is no empirical evidence available to suggest major systematic differences in known determinants of mortality between same-sex married persons and other gay or lesbian persons. In other settings in which homosexuality is not broadly accepted, same-sex marriage might serve as an indicator of "outness" that could be associated with other risk-taking behaviors. The situation is likely to be different in Denmark, which is more liberal on individual sexual rights than some other countries. It is plausible that men and women in same-sex marriages may have systematically fewer exposures to known health hazards than do other gay men and lesbians, a situation parallel to that of married versus unmarried heterosexuals.12,13 If this is true, our current findings should raise cautious concern over what may be potentially higher mortality rates among the majority of gay and lesbian persons who do not opt for same-sex marriage.</p><p style="margin-top: 0px;">The available literature contained no population-based data on mortality among gay and lesbian persons free of sexually transmitted infections. We had therefore anticipated that, at the group level, gay men might have somewhat higher mortality than do heterosexual men, because of the impact of AIDS deaths, notably before the introduction of HAART in 1996. Additionally, suicides and accidents-which according to some studies may be more common among gay men and lesbians than among heterosexuals14-16-lifestyles that include higher levels of tobacco and alcohol consumption17-21 and, among women, overweight17,21,22 would further contribute to the expected higher mortality among gay men and lesbians. Our findings are compatible with these expectations, but additional study is required to identify the underlying specific causes of death contributing to the observed excess mortality overall.</p><p style="margin-top: 0px;">Flawed Claims of Major Excess Mortality</p><p style="margin-top: 0px;">Authors from the Family Research Institute, a US-based institution fighting to "restore a world . . . where homosexuality is not taught and accepted, but instead is discouraged and rejected at every level,"23 have produced a series of reports24-27 in which they claim homosexuality is incompatible with full health25 and as dangerous to public health as drug abuse, prostitution, and smoking.27 In a recent report, the authors obtained data from Statistics Denmark and Statistics Norway and compared the average age at death amongmen and women who had ever been in a same-sex marriage with the average age at death among people who had ever been heterosexually married.6 Because the age distribution among persons in same-sex marriages was considerably younger than that of people who had ever been heterosexually married, the average age at death among those who actually died during the observation period was, not surprisingly, considerably younger in the population of samesex married persons. The Family Research Institute presented the lower mean age at death (by 22-25 years) for persons in same-sex versus heterosexual marriages as evidence that persons who married heterosexually "outlived gays and lesbians by more than 20 years on average." 6(p13) Elementary textbooks in epidemiology warn against such undue comparisons between group averages because they lead to seemingly common-sense yet seriously flawed conclusions.28</p><p style="margin-top: 0px;">Constructive Concern Required</p><p style="margin-top: 0px;">Conventional statistical analysis of Danish data provides a much less dramatic picture than the one drawn by the Family Research Institute. Nevertheless, our observations deserve careful consideration and constructive concern. We have documented the existence of moderately increased mortality among samesex married Danish gay men and lesbians during the first few years of their marriages, even in recent years when AIDS deaths have declined markedly among gay men.9 By excluding the first year of marriage from our mortality calculations, we aimed to avoid serious overestimation of mortality because of preexisting illnesses at the time of marriage. However, our mortality rates may still be too high in the first1to 3 years because of chronic diseases with slow progression to death. Our findings are compatible with such an extended period during which preexisting illnesses may have inflated the mortality rates. Reassuringly, there was no significant excess mortality 4 or more years after same-sex marriage for women or men who married during the HAART period. As the cohort grows and matures, we hope to get a clearer picture of mortality differences between persons in same-sex marriages and other persons in Denmark.</p><p style="margin-top: 0px;">Future Directions</p><p style="margin-top: 0px;">To our knowledge, we have presented the first population-based assessment of mortality in a demographically defined, complete group of gay and lesbian persons. Our results showed markedly increased SMRs among same-sex married men in the pre-HAART era, when AIDS deaths contributed importantly to high mortality among Danish gay men. Since the introduction of HAART in 1996, this pattern has changed dramatically, but overall mortality remains elevated in the first few years after entry into same-sex marriage. Similarly, mortality rates among women in the first few years of a same-sex marriage are about 34% higher than those of other women in Denmark. Although preexisting illness provides a plausible explanation for the excess mortality in the first years of same-sex marriage, additional followup of the cohort is required to provide estimates of long-term mortality, and studies of underlying cause-specific mortality are clearly warranted to identify the causes of death that prevail among gay and lesbian persons. Finally, studies in other settings are warranted to judge how generalizable our findings are to other groups of gay men and lesbians and to those in other countries. It may very well be that differentials in mortality between homosexual and heterosexual persons are more pronounced in other countries in which gay and lesbian persons are subject to stigmatization, indirect or overt discrimination, or even criminal prosecution.</p><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td nowrap="nowrap"> <span class="bold textSmall">[Reference]</span> <span class="raquo">» </span> <a title="View a list of references included in this document" href="http://proquest.umi.com/pqdweb?VInst=PROD&VName=PQD&VType=PQD&RQT=594&did=1613679081&Fmt=3&refType=CITEDIN&b2=d&SrchMode=1&sid=2&index=16&TS=1230626274" class="textSmall">View reference page with links</a></td></tr><tr><td class="textSmall">References</td></tr><tr><td class="textSmall">1. Hogg RS, Strathdee SA, Craib KJ, O'Shaughnessy MV, Montaner JS, Schechter MT. Modelling the impact of HIV disease on mortality in gay and bisexual men. Int J Epidemiol. 1997;26:657-661.</td></tr><tr><td class="textSmall">2. Schneider MF, Gange SJ, Williams CM, et al. Patterns of the hazard of death after AIDS through the evolution of antiretroviral therapy: 1984-2004. AIDS. 2005; 19:2009-2018.</td></tr><tr><td class="textSmall">3. Louie JK, Hsu LC, Osmond DH, Katz MH, Schwarcz SK. Trends in causes of death among persons with acquired immunodeficiency syndrome in the era of highly active antiretroviral therapy, San Francisco, 1994-1998. J Infect Dis. 2002;186:1023-1027.</td></tr><tr><td class="textSmall">4. Hughes C, Evans A. Health needs of women who have sex with women. BMJ. 2003;327:939-940.</td></tr><tr><td class="textSmall">5. Makadon HJ. Improving health care for the lesbian and gay communities. N Engl J Med. 2006;354:895-897.</td></tr><tr><td class="textSmall">6. Cameron P, Cameron K. Federal distortion of homosexual footprint (ignoring early gay death?). Available at: http://www.lifesite.net/ldn/2007_docs/ CameronHomosexualFootprint.pdf. Accessed April 14, 2008.</td></tr><tr><td class="textSmall">7. Act No. 372 of 7 June 1989 on registered partnerships. Annu Rev Popul Law. 1989;16:56.</td></tr><tr><td class="textSmall">8. Pedersen CB, Gøtzsche H, Møller JØ, Mortensen PB. The Danish Civil Registration System: a cohort of eight million persons. Dan Med Bull. 2006;53:441-449.</td></tr><tr><td class="textSmall">9. Cowan SA, Smith E. Forekomsten af HIV/AIDS i Danmark i perioden 1990-2005 [Incidence of HIV/ AIDS in Denmark, 1990-2005]. Ugeskr Laeger. 2006;168:2247-2252.</td></tr><tr><td class="textSmall">10. Frisch M, Smith E, Grulich A, Johansen C. Cancer in a population-based cohort of men and women in registered homosexual partnerships. Am J Epidemiol. 2003;157:966-972.</td></tr><tr><td class="textSmall">11. Balsam KF, Beauchaine TP, Rohtblum ED, Solomon SE. Three-year follow-up of same-sex couples who had civil unions in Vermont, same-sex couples not in civil unions, and heterosexual married couples. Dev Psychol. 2008;44:102-116.</td></tr><tr><td class="textSmall">12. Duncan GJ, Wilkerson B, England P. Cleaning up their act: the effects of marriage and cohabitation on licit and illicit drug use. Demography. 2006;43:691-710.</td></tr><tr><td class="textSmall">13. Nystedt P. Marital life course events and smoking behaviour in Sweden 1980-2000. Soc Sci Med. 2006;62:1427-1442.</td></tr><tr><td class="textSmall">14. Friedman RC, Downey JI. Homosexuality. N Engl J Med. 1994;331:923-930.</td></tr><tr><td class="textSmall">15. Garofalo R, Wolf RC, Wissow LS, Woods ER, Goodman E. Sexual orientation and risk of suicide attempts among a representative sample of youth. Arch Pediatr Adolesc Med. 1999;153:487-493.</td></tr><tr><td class="textSmall">16. Remafedi G, French S, Story M, Resnick MD, Blum R. The relationship between suicide risk and sexual orientation: results of a population-based study. Am J Public Health. 1998;88:57-60.</td></tr><tr><td class="textSmall">17. Case P, Austin SB, Hunter DJ, et al. Sexual orientation, health risk factors, and physical functioning in the Nurses' Health Study II. J Womens Health. 2004;13: 1033-1047.</td></tr><tr><td class="textSmall">18. Gruskin EP, Gordon N. Gay/Lesbian sexual orientation increases risk for cigarette smoking and heavy drinking among members of a large northern California health plan. BMC Public Health. 2006;6:241.</td></tr><tr><td class="textSmall">19. Lewis CE, Saghir MT, Robins E. Drinking patterns in homosexual and heterosexual women. J Clin Psychiatry. 1982;43:277-279.</td></tr><tr><td class="textSmall">20. Ryan H, Wortley PM, Easton A, Pederson L, Greenwood G. Smoking among lesbians, gays, and bisexuals: a review of the literature. Am J Prev Med. 2001;21:142-149.</td></tr><tr><td class="textSmall">21. Valanis BG, Bowen DJ, Bassford T, Whitlock E, Charney P, Carter RA. Sexual orientation and health: comparisons in the women's health initiative sample. Arch Fam Med. 2000;9:843-853.</td></tr><tr><td class="textSmall">22. Boehmer U, Bowen DJ, Bauer GR. Overweight and obesity in sexual-minority women: evidence from population-based data. Am J Public Health. 2007;97:1134-1140.</td></tr><tr><td class="textSmall">23. Mission statement of the Family Research Institute. Available at: http://www.familyresearchinst.org. Accessed April 14, 2008.</td></tr><tr><td class="textSmall">24. Cameron P, Cameron K, Playfair WL. Does homosexual activity shorten life? Psychol Rep. 1998;83:847-866.</td></tr><tr><td class="textSmall">25. Cameron P, Cameron K, Proctor K. Effect of homosexuality upon public health and social order. Psychol Rep. 1989;64:1167-1179.</td></tr><tr><td class="textSmall">26. Cameron P, Cameron K. Gay obituaries closely track officially reported deaths from AIDS. Psychol Rep. 2005;96:693-697.</td></tr><tr><td class="textSmall">27. Cameron P, Landess T, Cameron K. Homosexual sex as harmful as drug abuse, prostitution, or smoking. Psychol Rep. 2005;96:915-961.</td></tr><tr><td class="textSmall">28. Rothman KJ. Introduction to epidemiologic thinking. In: Rothman KJ, ed. Epidemiology: An Introduction. New York, NY: Oxford University Press; 2002:1-7.</td></tr></tbody></table></span><table border="0" cellpadding="0" cellspacing="0"><tbody></tbody></table><br /><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td class="textSmall" nowrap="nowrap"><b>[Author Affiliation]</b></td></tr><tr><td class="textSmall">Morten Frisch, MD, PhD, DSc(Med), and Henrik Brønnum-Hansen, MSc</td></tr><tr><td class="textSmall">About the Authors</td></tr><tr><td class="textSmall">Morten Frisch is with the Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark. Henrik Brønnum-Hansen is with the National Institute of Public Health, University of Southern Denmark, Copenhagen.</td></tr><tr><td class="textSmall">Reprint requests should be sent to Morten Frisch, MD, PhD, DSc(Med), Department of Epidemiology Research, Statens Serum Institut, 5 Artillerivej, DK-2300 Copenhagen S, Denmark (e-mail: mfr@ssi.dk).</td></tr><tr><td class="textSmall">This article was accepted April 16, 2008.</td></tr><tr><td class="textSmall">Contributors</td></tr><tr><td class="textSmall">M. Frisch originated and designed the study and drafted the article. H. Brønnum-Hansen conducted the statistical analyses and helped revise the article.</td></tr><tr><td class="textSmall">Human Participant Protection</td></tr><tr><td class="textSmall">This register-based study was approved by the Danish Data Protection Board (approval no. 2003-41-3329).</td></tr></tbody></table></span><table border="0" cellpadding="0" cellspacing="0"><tbody></tbody></table></div></div>All About Bloggerhttp://www.blogger.com/profile/17282736671555579827noreply@blogger.com0tag:blogger.com,1999:blog-4987803374989865601.post-6643492671655626092008-12-30T00:34:00.000-08:002008-12-30T00:36:27.697-08:00THE POLITICS OF AIDS IN AFRICA<a target="_blank" href="http://iupjournals.org/africatoday"><img alt="Publication Image" src="http://proquest.umi.com/i/pub/38820.gif" border="0" /></a><br /><span class="italic">Copyright Indiana University Press Spring 2009</span><br /><br /><p style="margin-top: 0px;">Patterson, Amy S. 2006. THE POLITICS OF AIDS IN AFRICA. Boulder, Colo.: Lynne Rienner. 226 pp. $52.00 (cloth); $19.95 (paper).</p><p style="margin-top: 0px;">Patterson's book is published in the series "Challenge and Change in African Politics." Patterson claims that the fight against HIV/AIDS has not received the attention it deserves in African politics. Political centralization, neopatrimonialism, low capacity, and instability have slowed down the fight. Central to the study, which analyzes AIDS and politics in South Africa, Swaziland, Uganda, and Zimbabwe, is the idea that the magnitude of the problem, the growing inequality on the continent, and cultivation of open responsible institutions by African states and all groups in the international community, would go a long way toward implementing a solution. Patterson structures the first two chapters on discourses on the decline of the African state and unsuccessful democratic transitions and analyzes approaches to combating HIV/AIDS-approaches that include an open dialogue and campaign against the disease by President Museveni of Uganda; centralization in the case of Zimbabwe; the right discourse, but contradictory actions by the King of Swaziland; and Thabo Mbeki's pronouncements that have questioned whether HIV causes AIDS and have raised doubts about generic drugs. Despite the fact that South Africa is an open society, in which activists have taken up the cause, South Africa has achieved little because the ruling party, the African National Congress, has centralized the fight against the disease. Patterson uses the available literature on political thought and HIV/AIDS to provide insights into the political behavior and operations in the selected countries, and the result is an insightful book, which demonstrates that the fight against AIDS ought to involve all sectors of the political community, and political leaders at the highest level ought to take charge in creating and implementing policies that would strengthen the fight.</p><p style="margin-top: 0px;">In chapter 3, Patterson works with the postulate that democratic states promote health. She examines this idea through several themes, namely that citizens in African countries want their governments to prioritize AIDS and have organized through civil society to have governments take action in fighting it. It is thought that governments often to respond to such demands because they fear that if they do not respond, they would see an adverse effect during elections. Furthermore, democratic institutions are avenues for promoting the fight against AIDS, and democratic governments respond to citizens' views. The critical analysis of political action in the four countries demonstrates that contrary to these political assumptions, AIDS has not been a major issue in elections, and governments have not taken the risk of budgeting money to fight the disease. Most of the money actually used to fight the disease has come from outside donors. Patterson argues, "with the exception of South Africa, democratic institutions such as legislators, judiciaries, and local governments have played a minor role in AIDS policy development" (p. 91).</p><p style="margin-top: 0px;">In chapter 4, Patterson analyzes the role played by civil society groups in the fight against AIDS, and highlights why some AIDS organizations are strong and some influence policy. What emerges in this chapter is careful description and analysis of well-known AIDS organizations, like the Treatment Action Campaign (TAC) in South Africa, and other organizations in Ghana and Zimbabwe. The strength of an organization depends on adequate financial resources, the capacity of its members, its leaders, and its internal structures. By all four of these criteria, TAC in South Africa is probably a strong AIDS organization, one of the few on the continent. The influence an organization can have in the fight against AIDS depends on several factors, including the political system, which is democratic in the organizations studied, except the Zimbabwean AIDS organization, which is autocratic because of Robert Mugabe's domination. The other factors are the political culture in the country that supports AIDS activism, the building of national and international coalitions, and the relationship the organization has with the state. Here, some organizations, like the AIDS organization in Zimbabwe, have been captured by the state, while some cooperate with and confront the state.</p><p style="margin-top: 0px;">In chapter 5, Patterson analyzes the work of donor agents by focusing on two major programs, the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM), formed in 2001, initially the brainchild of Jeffrey Sachs and Kofi Annan, Secretary General of the United Nations. The other program is the President's Emergency Plan for AIDS Relief (PEPFAR), announced by President Bush in his State of the Union Address to Congress. The U.S. Congress approved PEPFAR in 2003. This move by the White House came after criticism that the United States was not doing enough in the fight against the disease. Patterson argues that the two programs and agencies have approached AIDS in different ways. PEPFAR has approached HIV/AIDS as an emergency, giving the impression that something can be done to "fix" it quickly. GFATM does not see HIV/AIDS as an emergency, but neither approaches the fight against HIV/AIDS in a way that would provide resources for dealing with broader issues of AIDS, such as poverty, conflicts, human rights, gender inequalities, and governance. Structurally, PEPFAR has a complicated setup, which follows mandates laid down by the Congress when it appropriated the necessary funds. For example, PEPFAR works largely through U.S. faith-based organizations, the United States Agency for International Development (USAID), the United States Centers for Disease Control (CDC), and other agencies approved by the United States through embassies in recipient countries. PEPFAR requires that participants in the program use drugs approved by the U.S. Food and Drug Administration (FDA), and use those funds mostly on abstinence programs. This approach has been criticized because it ignores national plans, and many FBOs do not have the capacity to absorb large amounts of money. Additionally, PEPFAR does not give African governments much say in the structure and operation of PEPFAR. The GFATM has a more flexible structure, requires that recipients create national committees, and makes its grant to governments. Patterson argues that donors have to make a long-term commitment to fighting AIDS, and African governments must demonstrate a long-term commitment and be accountable to those affected by the disease.</p><p style="margin-top: 0px;">In the final chapter, Patterson argues that institutions are crucial in the fight against AIDS. The establishment of those institutions is the responsibility of the political leaders who must assume leadership in the fight against AIDS. "AIDS is a public policy problem; how we address the disease is the outcome of political decision making. Politics is about some people convincing others that one policy idea or resource allocation should be accepted over another" (p. 178). Therefore, the state and public organizations must work together with political actors taking an active role in the fight against HIV/AIDS.</p><p style="margin-top: 0px;">Patterson's book is well documented, with several graphs, and she demonstrates an exemplary mastery of the political issues. It is unclear whether, for this book, Patterson (who has lived in Senegal, but does not mention it here) was in Africa, but she indicates that her students gathered most of the material in the United States, and they have not studied the fight against AIDS on the ground in Africa. Regardless of that, in reading the book, one has the impression that one is following things as they happen, especially in chapter 5, where a large number of Patterson's sources are U.S. newspapers. That aside, Patterson not only reports what newspapers publish, but offers critical perspectives on the issues she discusses. All involved in the fight against AIDS will find Patterson's analysis of PEPFAR and its limitations helpful because the control of PEPFAR lies very much with the U.S. government, U.S. embassies, agencies with strong U.S. connections, and FBOs. Scholars and politicians weary of international relations cannot miss the fact that even with amounts that are quite generous, PEPFAR promotes U.S. products and personnel, and for that reason it has not departed from prevailing practices in the foreign-aid industry. Though Patterson does not speculate on how long the fight against AIDS would take, her criticism of treating the pandemic as an emergency demonstrates that African government and their leaders ought to engage in long-term planning if they want to make gains against the pandemic. Patterson's book is very accessible, and it will be useful to all involved in the fight against the HIV/AIDS.</p><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td class="textSmall" nowrap="nowrap"><b>[Author Affiliation]</b></td></tr><tr><td class="textSmall">Elias K. Bongmba</td></tr><tr><td class="textSmall">Rice University</td></tr></tbody></table></span><table border="0" cellpadding="0" cellspacing="0"><tbody></tbody></table>All About Bloggerhttp://www.blogger.com/profile/17282736671555579827noreply@blogger.com0tag:blogger.com,1999:blog-4987803374989865601.post-43057137715578160362008-12-30T00:06:00.000-08:002008-12-30T00:09:24.155-08:00Prevalence of RTI/STI agents and HIV infection in symptomatic and asymptomatic women attending peripheral health set-ups in Delhi, India<span class="italic">Copyright © 2007 Cambridge University Press</span>
<br />
<br /><p style="margin-top: 0px;">INTRODUCTION</p><p style="margin-top: 0px;">Incidence/prevalence data have a key role in control strategies for HIV and sexually transmitted infections (STIs). Moreover, comprehensive baseline information on the epidemiology of STIs, the proportion of symptomatic and asymptomatic infections and other associated factors are essential for the design, implementation and monitoring of successful targeted interventions [1], which are important in reducing the incidence of HIV infection [2].</p><p style="margin-top: 0px;">In India, routine surveillance of these infections is not carried out and estimation of the total incidence/prevalence is quite difficult. Lack of laboratory diagnostic facilities, limited resources, poor recognition of reproductive tract infections (RTIs)/STIs by the medical profession as a major public health problem, stigma and discrimination associated with STIs and poor attendance of STI patients, especially women, in sexually transmitted disease (STD) clinics, are some of the main reasons for lack of RTI/STI data. Taking the above factors into consideration, it is meaningful to have comprehensive and reliable laboratory-based data on the incidence/prevalence of RTIs/STIs.</p><p style="margin-top: 0px;">Studies on STI prevalence in India have so far focused on patients attending STD clinics in hospitals in big cities [3-6], whereas, the infection rate in women attending the small primary health centres, situated in the peripheral areas, away from big cities and catering to the community, has not received the same attention. A few community-level studies have been undertaken [7-10], but the data are relatively patchy and incomplete [11]. Studies on STIs in asymptomatic women are almost non-existent.</p><p style="margin-top: 0px;">The current study in rural and urban women was carried out with the following objectives: to determine (i) the socio-demographic profile of the study population as a whole, (ii) their STI burden by eliciting their past gynaecological and obstetric history and treatment-seeking behaviour, (iii) the proportion of women, rural and urban, with RTI/STI morbidity and (iv) laboratory-based prevalence of total RTI/STI and HIV infection in these women.</p><p style="margin-top: 0px;">METHODS</p><p style="margin-top: 0px;">The study was carried out in one urban and one rural government peripheral health centre in each of four zones of Delhi, during the period March 2002 to April 2004. Approval of the ethical committee of each hospital was obtained.</p><p style="margin-top: 0px;">Selection of study area and population groups</p><p style="margin-top: 0px;">Table 1 shows the different study groups and their sample size from rural and urban centres. A total of 2011 consecutive women from rural areas and 2079 from urban areas were included in the study and assigned into four study groups (groups I-IV) according to their history and clinical status. Group IV served as the control group.</p><p style="margin-top: 0px;">Table 1. </p><p style="margin-top: 0px;">Study groups with sample size</p><p style="margin-top: 0px;">ANC, Antenatal clinic; STI, sexually transmitted infection; RTI, reproductive tract infection.</p><p style="margin-top: 0px;">Interview and counselling</p><p style="margin-top: 0px;">A trained female social worker interacted with consecutive patients in the above groups, attending each of the above-mentioned centres, to collect the data regarding the patients' sociodemographics and risk behaviour in a questionnaire schedule. Gynaecological and obstetric history was also collected. All the women were informed of the symptoms of STI and questioned about any similar experience in the past and also about their treatment-seeking behaviour. Pre-test counselling for HIV testing was imparted using conventional techniques and informed consent in writing was obtained from all for participation in the study for clinical examination, HIV and other laboratory testing. The study subjects were assured of anonymity.</p><p style="margin-top: 0px;">Gynaecological examination</p><p style="margin-top: 0px;">Detailed general, physical and internal examination including speculum examination of all the study subjects was carried out by the female medical officer, accompanying the team and the data were recorded in predesigned proformae. RTIs/STIs were diagnosed by clinical features. (The detailed data have been submitted for separate publication.)</p><p style="margin-top: 0px;">Collection of specimens and their transport and laboratory techniques</p><p style="margin-top: 0px;">Appropriate specimens such as cervical, vaginal and urethral swabs and blood samples (Table 2) were collected in transport media (wherever applicable) or directly inoculated on chocolate agar and saponin lysed blood agar with vancomycin, colistin, nystatin, and trimethoprim (VCNT) inhibitors and placed in a candle jar in a moist atmosphere immediately in the field for isolation of <i>Neisseria gonorrhoeae </i> and transported to the Regional STD Reference Laboratory under the Regional STD Teaching, Training and Research Centre, Vardhaman Mahaveer Medical College and Safdarjung Hospital, New Delhi and processed on the same/next day. Tests were carried out (Table 2) by standard laboratory techniques [12] for detection of classical and other agents of STIs, and also the agents of RTIs, e.g. <i>Candida albicans </i> and species, and bacterial vaginosis (BV).</p><p style="margin-top: 0px;">Table 2. </p><p style="margin-top: 0px;">Laboratory diagnostic methodology and criteria for diagnosis of STI/RTI</p><p style="margin-top: 0px;">STI, sexually transmitted infection; RTI, reproductive tract infection.</p><p style="margin-top: 0px;">Statistical analysis</p><p style="margin-top: 0px;">Epi-Info version 6.04d software (CDC, Atlanta, GA, USA) was used for data entry and analysis. The [chi] <sup>2 </sup> test was applied to compare proportions and <i>P </i> values were calculated.</p><p style="margin-top: 0px;">RESULTS</p><p style="margin-top: 0px;">Sociodemographic profile of the study population</p><p style="margin-top: 0px;">Table 3 shows the sociodemographic parameters and contraceptive use in rural and urban women in the study population.</p><p style="margin-top: 0px;">Table 3. </p><p style="margin-top: 0px;">Sociodemographic profile and contraceptive use of the study population</p><p style="margin-top: 0px;">SC/ST, Schedule caste/schedule tribe.</p><p style="margin-top: 0px;">Age group</p><p style="margin-top: 0px;">Most of the women, in all the areas, belonged to the reproductive age group, the most predominant age group being 14-25 years.</p><p style="margin-top: 0px;"> Occupation of the women</p><p style="margin-top: 0px;">A total of 93% of the women in the study groups were housewives, although a few women employed as labourers (3·4%), in service (2·6%) and in business (1·3%) were seen. No difference was noted between women from urban (U) and rural (R) areas.</p><p style="margin-top: 0px;"> Occupation of the spouses</p><p style="margin-top: 0px;">The occupation of the spouses of the women varied considerably in the different zones, although no significant difference was noted between overall figures from urban and rural areas. Service-employed individuals, labourers and businessmen were commonly seen.</p><p style="margin-top: 0px;"> Socioeconomic status</p><p style="margin-top: 0px;">About half of the study subjects were of low socioeconomic status, i.e. income level below Rs. 2500.</p><p style="margin-top: 0px;"> Literacy status</p><p style="margin-top: 0px;">A total of 35% of the study population were illiterate. The different literacy status is shown in the Table 3.</p><p style="margin-top: 0px;"> Religion and caste</p><p style="margin-top: 0px;">Most of the women (77·4%) belonged to Hindu upper caste. However, Hindu schedule caste (SC)/schedule tribe (ST) and Muslim women were also observed in small proportions.</p><p style="margin-top: 0px;"> Marital status</p><p style="margin-top: 0px;">A total of 99·6% were married and the rest were either 'single' or 'married, not living with spouse'. A total of 92·4% (95% U, 90% R) women were married for >1 year. About 31·4% (36·9% U, 25·2% R) women were married for >10 years.</p><p style="margin-top: 0px;">Use of contraceptives</p><p style="margin-top: 0px;">Overall, 61·6% of the women in the study groups did not use contraceptives (Table 3). There was no significant association between literacy status and use of contraceptives as a similar proportion of the illiterate women, as well as those with literacy status 'just literate', up to graduation, used some contraceptive.</p><p style="margin-top: 0px;">Obstetric history</p><p style="margin-top: 0px;">A total of 15·8% (14·3% U, 17·4% R) were without any children. Most of the women, i.e. 54·9% (52·8% U, 57·0% R) had 1-2 live births, whereas, 25·9% (28·9% U, 22·9% R) had 3-4 live births. A total of 32·5% of women (33·3% U, 31·5% R) gave a history of abortion and the type of abortion in 76·4% was spontaneous (79·2% U, 75% R), followed by medical termination of pregnancy in 18·8% cases (13·5% U, 21·5% R). The majority of the women had the last delivery within the past 5 years.</p><p style="margin-top: 0px;">Past history of STI-related illness</p><p style="margin-top: 0px;">Following an explanation of the symptoms, a total of 58·9% of the women (63·4% U and 54·4% R) confirmed that they had STI-like symptoms in the past. A major proportion (43·5% U, 52·1% R, respectively), suffered from STI for >1 year, whereas, the rest suffered for 15 days (11·3% U, 9·4% R), 6 months (23·1% U, 23·3% R), and 1 year (22·0% U, 14·5% R). The main complaints were white vaginal discharge and abdominal pain/low backache (35% U, 33·2% R). In both areas, the next two important combination of symptoms were abdominal pain and curd-like discharge (5·8% U, 8·7% R). About 5% of urban women also complained of redness and itching of the genital area, along with abdominal pain and curd-like discharge.</p><p style="margin-top: 0px;">Treatment-seeking behaviour</p><p style="margin-top: 0px;">The majority (65·0%) of the women who had some past experience of STIs (71·7% U, 56·9% R) first consulted their husband when the symptoms occurred. The mother-in-law was consulted by 25·3%, (20·2% U, 31·4% R). Relatives, friends, doctors, health workers, etc. were consulted first only by a small group of women in both the areas.</p><p style="margin-top: 0px;">Overall, 54·5% (50·5% U, 59·3% R) women did not take any sort of treatment for their 'illness'. A total of 33·9% (37·4% U, 29·7% R) attended government dispensaries and 11·6% (12·2% U, 11·0% R) attended private facilities. The majority (94·6%) consulted doctors in both areas. However, negligible numbers went to registered medical practitioners (1·4%), chemists (2·0%), health workers (0·2%) and traditional midwives ( <i>dais </i>) (0·1%). An allopathic system of medicine was preferred by 94·5% (93·8% U, 95·4% R) women. Very few consulted Ayruvedic physicians (2·0%) and homeopaths (1·9%). Most of the women (>86%) took a complete course of treatment.</p><p style="margin-top: 0px;">A total of 52·2% women, who received treatment, were completely relieved with treatment and 34·6% were partially relieved. The cost of private treatment was Rs. 250, as stated by 89·7% (83·9% U, 93·9% R). However, 5·4%, 2·9% and 1·8% spent Rs. 251-500, Rs. 501-1000 and Rs. >1000, respectively.</p><p style="margin-top: 0px;">Self-reporting of symptoms</p><p style="margin-top: 0px;">Overall, 65% of the subjects (65·5% U, 64·3% R) complained of some RTI/STI symptom, although none complained of genital ulcers or genital warts. Most of the women complained of vaginal discharge, either singly (11·2%) or in combination with other symptoms, e.g. abdominal pain, low backache, redness and itching of the vulva, dyspareunia, etc. (49·0%). Abdominal pain/low backache was sometimes the only symptom (3·7%). There was no difference in complaints for women from rural and urban areas. A total of 79·1% women, out of those with a history of STI in the past, compared to 44·2% with no past history of STI had complained of some STI-related illness during the study. The difference was statistically highly significant ( <i>P </i><0·001).</p><p style="margin-top: 0px;">Clinical examination</p><p style="margin-top: 0px;">Eighteen (0·9%) of the women were observed to have genital ulcers and were clinically diagnosed as chancroid (5) and herpes genitalis (13). Similarly, genital warty growths were present only in 18 (0·9%) women (7 U, 11 R). Vaginal discharge was mostly prevalent in the study subjects (66·7%). Women from rural areas were more affected (63·6% U <i>vs </i>. 69·9% R). On pelvic examination, lower abdominal tenderness was observed in 13·5% of women (8·1% U, 19·1% R). Cervical discharge, either singly (52·4% overall, 46·1% U, 58·9% R) or in combination with cervical growth/erosion/other findings (3·1% overall, 1·2% U, 5·1% R) was observed on speculum examination.</p><p style="margin-top: 0px;">Laboratory studies</p><p style="margin-top: 0px;">Prevalence of RTI/STI/HIV in women from rural and urban areas</p><p style="margin-top: 0px;">Overall, the proportion of women infected was 32·1% (single 27·9%, multiple 4·2%). The difference observed in the infection rate in the women from urban (33·4%) and rural (30·9%) areas was found to be insignificant. However, in different groups, laboratory prevalence of RTI/STI varied (Table 4). Urban women in group I had highest prevalence, significantly higher than women in the other groups whereas, prevalence was highest in group II in rural women.</p><p style="margin-top: 0px;">Prevalence of aetiological agents of RTI/STI in different study groups</p><p style="margin-top: 0px;">Table 4 shows the prevalence of various aetiological agents in women belonging to the four study groups. Total prevalence of RTIs (24·3%) was higher ( <i>P </i><0·001)>Candida infection ( <i>C. albicans </i> and other species together) was predominant, followed by HSV-2 IgM, BV and trichomoniasis. Low rates of other STIs were also observed. Pregnant women were harbouring RTI/STI agents almost at the same level as the first two groups. The prevalence of both STI (9·9%) and RTI (15·2%) agents in the asymptomatic women in group IV, although lower than that observed in the other groups, was quite high.</p><p style="margin-top: 0px;">Table 4. </p><p style="margin-top: 0px;">Group-wise break up of prevalence of RTI/STI in study subjects</p><p style="margin-top: 0px;">STI, sexually transmitted infection; RTI, reproductive tract infection; BV, bacterial vaginosis; TV, <i>Trichomonas vaginalis </i>; GC, <i>Neisseria gonorrhoeae </i>; VDRL/TPHA, Venereal Disease Research Laboratory <i>/Treponema Pallidum </i> haemagglutination test; CT, <i>Chlamydia trachomatis </i>; EIA, enzyme-linked immunosorbent assay.</p><p style="margin-top: 0px;">Seroprevalence of HIV infection</p><p style="margin-top: 0px;">Both the rural and urban women included in the study had low HIV prevalence (0·1%). Seroprevalence was 0·3% in groups I and III (Table 4).</p><p style="margin-top: 0px;">Prevalence of multiple infections</p><p style="margin-top: 0px;">Multiple infections were seen in a variety of combinations (Table 5). The highest combinations were observed with <i>Candida </i> infection, followed by that with BV. Multiple STIs were also observed. Multiple infections were more common in urban areas.</p><p style="margin-top: 0px;">Table 5. </p><p style="margin-top: 0px;">Varieties of multiple infections in rural and urban areas</p><p style="margin-top: 0px;">TV, <i>Trichomonas vaginalis </i>; BV, bacterial vaginosis; CT, <i>Chlamydia trachomatis </i>.</p><p style="margin-top: 0px;">DISCUSSION</p><p style="margin-top: 0px;">The World Health Organisation [13] estimates that about 340 million new cases of the four main curable STIs (gonorrhoea, chlamydial infection, syphilis and trichomoniasis) occur every year, the majority of them in developing countries. In a few countries, most of the epidemiological data have been obtained from prevalence studies carried out in selected populations [14, 15].</p><p style="margin-top: 0px;">In India, STIs and RTIs are important public health problems. However, systematic and comprehensive STI surveillance is almost non-existent. A nationwide community-based study performed by the National AIDS Control Organization (NACO) in 2001 to estimate the STD prevalence in urban and rural areas of India showed a prevalence of 5-6% STI/RTI in the adult population (A. Pandey, unpublished report of NACO, India). Based on this, it is estimated that 30 million people are infected with STI/RTI in India and half of them are likely to be symptomatic.</p><p style="margin-top: 0px;">The high prevalence of RTI/STIs in women, mostly in the 14-25 years age group, in the present study, supports the current consensus that young adults should constitute a priority target group in the STI Control Programme. The physiological risk of increased susceptibility to infection among adolescent girls is due to the presence of greater cervical ectopy, making the cervix more susceptible to gonorrhoea, chlamydia and HPV. The present study population consisted mostly of illiterate women, of low socioeconomic status, with a history of low use of contraceptives and poor treatment-seeking behaviour. All these factors might have contributed to the high RTI/STI endemicity in the study areas. Moreover, concurrent treatment of the spouse is almost non-existent in the programme because of the gap in knowledge and also the lack of cooperation from husbands in Indian communities. Efforts need to be stepped up to target these groups under the Control Programme to decrease the STI burden in order to create a dent in the HIV epidemic. Fortunately, in spite of the high RTI/STI prevalence, HIV seroprevalence was very low in these women, providing a window of opportunity for the programme managers.</p><p style="margin-top: 0px;">The present study offers an important insight into the burden and pattern of RTIs and STIs in women in the community in the capital city of India. The majority of women reported with vaginal discharge, the most perceivable symptom, confirming earlier studies [10] and other STI symptoms as well as syndromes, especially genital ulcers, were almost non-existent. On the other hand, laboratory prevalence of RTI/STIs was 36·8%, much lower than the self-reporting of morbidity, confirming a recent study in India [16], indicating either the non-specific nature of the latter or inappropriate, inadequate and indiscriminate antimicrobial use, rampant in the community, because of 'over-the-counter' availability of antimicrobials. Predominantly <i>Candida </i> infection (20·2%), followed by herpes (5·7%), BV (4·1%), <i>Trichomonas vaginalis </i> (TV) (2·1%), chlamydia (1·5%), HBsAg (1·3%), syphilis (1·1%), gonorrhoea (0·7%) and HIV infection (0·1%), were observed, the total STI prevalence being 12·5%. The data compare well with a previous study under AIDS Prevention and Control Project [7], jointly undertaken by Voluntary Health Services (VHS) and US Agency for International Development (USAID), in a community of urban and rural adult population of Tamilnadu, a HIV high prevalence state. The study revealed that the STI prevalence was 15·8% with the classical STDs being 9·7%. Genital discharge was most common (41·5%) in women, with TV, 5·1%, <i>Chlamydia trachomatis </i> (CT) 3·9% and <i>N. gonorrhoeae </i> (GC), 3·7%. In another study [10], 41·5% of the women had BV, 18·6% candidiasis, 4·3% TV and 28·7% CT. The high prevalence of BV in women reported from different parts of the country [16-18] including the present study, should be noted with concern as the presence of BV has a role in acquisition of HIV and thus requires prompt treatment [19]. An earlier report [11], summarizing the results of different surveys and studies of STI/HIV prevalence in India, observed that the prevalence of STIs in women in the community varied between 0·0% and 4·2% for GC, 0·5-28·7% for CT, 0·2-8·8% seropositivity for syphilis and 4·3-27·4% for TV.</p><p style="margin-top: 0px;">Multiple infections were observed to be common in the study groups in all combinations, predominantly with candidiasis, highlighting the importance of laboratory studies for the undertaking of appropriate therapeutic strategy for individual cure and thereby the control of these infections.</p><p style="margin-top: 0px;">The aetiological pattern of genital ulcer diseases (GUD) is changing [20] and HSV-2 is emerging as an important aetiological agent [3]. HSV-2 infection has been shown to increase the rate of HIV transmission [21, 22] There are no community-based studies on prevalence of HSV-2 infection. In the present study, although genital ulcers were observed in negligible numbers, 5·7% seroprevalence of HSV-2 IgM antibodies (the commonest STI), indicates that the presence of this infection in these women may be as an unapparent infection. A recent community study in India [23] found that women had a higher prevalence of HSV-2 than men, but were more likely than men to be asymptomatic. The present data suggest that it may be relevant to start interventions targeting HSV-2 transmission.</p><p style="margin-top: 0px;">High STI/RTI prevalence in pregnant women (38·7%), reported in the present study, indicates their vulnerability and the risk of adverse consequences of STIs, e.g. syphilis, gonococcal and chlamydial infections to the unborn foetus. A review of several studies on prevalence of STIs [24] has revealed the variation in prevalence of these infections and the adverse outcomes of individual STIs. These authors recommended mandatory screening of syphilis and HIV infection for antenatal women in developing countries and management of the syndromes, if present. The only screening facilities available in the RCH programme in India, so far, is syphilis screening, which is also not always followed everywhere. HIV screening under the parent-to-child transmission programme of NACO, India has been initiated in Goverment set-ups. The present study highlights the importance of routine RTI/STI screening of antenatal mothers, especially those with symptoms, when they report to the clinic during this period.</p><p style="margin-top: 0px;">The asymptomatic nature of STIs is well known [10, 15] and aetiological agents of RTI/STIs were also found in healthy women in the present study with chances of future morbidity and transmission to their spouses. This was emphasized in a study in the red-light area in Surat, India [25], when the prevalence of laboratory-confirmed syphilis was 22·7%, GC 16·9%, genital CT 8·5%, TV 14·4%, and HIV 43·2%. However, it is not feasible to screen all asymptomatic women with the present infrastructure and facilities available in India, as it would not be cost-effective. Screening could probably be done after risk assessment of the women, targetting these subgroups for education and regular provision of STI diagnosis and treatment services. In addition, efforts should be made to develop an affordable, rapid, and effective diagnostic technique that will improve STD detection in resource-poor settings.</p><p style="margin-top: 0px;">ACKNOWLEDGEMENTS</p><p style="margin-top: 0px;">The authors are indebted to the Indian Council of Medical Research, New Delhi, for financial assistance in the form of a Project and to the Additional DG & Medical Superintendent, Safdarjung Hospital, for permission to carry out this study. The technical assistance provided by the staff of the Regional STD Teaching, Training and Research Centre is acknowledged. Thanks are due to Mr S. M. Gupta for statistical analysis.</p><p style="margin-top: 0px;">DECLARATION OF INTEREST</p><p style="margin-top: 0px;">None.</p><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td nowrap="nowrap"> <span class="bold textSmall">[Reference]</span> </td></tr><tr><td class="textSmall">REFERENCES</td></tr><tr><td class="textSmall">1. </td></tr><tr><td class="textSmall"> World Health Organisation. Prevalence of RTI/STI agents and HIV infection in symptomatic and asymptomatic women attending peripheral health set-ups in Delhi, India. Gobal AIDS News 1994; 4: 13-15.</td></tr><tr><td class="textSmall">2. </td></tr><tr><td class="textSmall"> JN Wasserheit, SO Aral. Prevalence of RTI/STI agents and HIV infection in symptomatic and asymptomatic women attending peripheral health set-ups in Delhi, India. Journal of Infectious Diseases 1996; 174 (Suppl. 2): S201-213.</td></tr><tr><td class="textSmall">3. </td></tr><tr><td class="textSmall"> K Ray, Prevalence of RTI/STI agents and HIV infection in symptomatic and asymptomatic women attending peripheral health set-ups in Delhi, India. Indian Journal of Medical Research 2006; 124: 559-568.</td></tr><tr><td class="textSmall">4. </td></tr><tr><td class="textSmall"> N Khanna. Prevalence of RTI/STI agents and HIV infection in symptomatic and asymptomatic women attending peripheral health set-ups in Delhi, India. Indian Journal of Sexually Transmitted Diseases 2002; 232: 58-66.</td></tr><tr><td class="textSmall">5. </td></tr><tr><td class="textSmall"> SB Murgesh, Sugareddy, S Raghunath. Prevalence of RTI/STI agents and HIV infection in symptomatic and asymptomatic women attending peripheral health set-ups in Delhi, India. Indian Journal of Sexually Transmitted Diseases 2004; 25: 9-12.</td></tr><tr><td class="textSmall">6. </td></tr><tr><td class="textSmall"> M Chatterjee, P Ramadasan. Prevalence of RTI/STI agents and HIV infection in symptomatic and asymptomatic women attending peripheral health set-ups in Delhi, India. Indian Journal of Sexually Transmitted Diseases 2004; 25: 13-17.</td></tr><tr><td class="textSmall">7. </td></tr><tr><td class="textSmall"> AIDS Prevention and Control Project (APAC). Community prevalence of sexually transmitted diseases in Tamil Nadu 1998 - a report. Voluntary Health Services, Chennai, India: APAC, 1998.</td></tr><tr><td class="textSmall">8. </td></tr><tr><td class="textSmall"> M Koenig, Prevalence of RTI/STI agents and HIV infection in symptomatic and asymptomatic women attending peripheral health set-ups in Delhi, India. Reproductive Health Matters 1998; 6: 84-96.</td></tr><tr><td class="textSmall">9. </td></tr><tr><td class="textSmall"> J Bhatia, J Cleland. Prevalence of RTI/STI agents and HIV infection in symptomatic and asymptomatic women attending peripheral health set-ups in Delhi, India. Studies in Family Planning 2000; 31: 267-273.</td></tr><tr><td class="textSmall">10. </td></tr><tr><td class="textSmall"> S Garg, Prevalence of RTI/STI agents and HIV infection in symptomatic and asymptomatic women attending peripheral health set-ups in Delhi, India. Asia-Pacific Population Journal 2001; 16: 75-92.</td></tr><tr><td class="textSmall">11. </td></tr><tr><td class="textSmall"> S Hawkes, KG Santhya. Prevalence of RTI/STI agents and HIV infection in symptomatic and asymptomatic women attending peripheral health set-ups in Delhi, India Sexually Transmitted Infections 2002; 78 (Suppl. 1): i31-i39.</td></tr><tr><td class="textSmall">12. </td></tr><tr><td class="textSmall"> E Van Dyck, AZ Meheus, P Piot. Laboratory Diagnosis of Sexually Transmitted Diseases. Geneva: World Health Organisation, 1999.</td></tr><tr><td class="textSmall">13. </td></tr><tr><td class="textSmall"> WHO. Global prevalence and incidence of selected curable sexually transmitted infections: overviews and estimates. WHO/HIV_AIDS/2001-02. Geneva: World Health Organisation, 2001.</td></tr><tr><td class="textSmall">14. </td></tr><tr><td class="textSmall"> LF Johnson, DJ Coetzee, RE Dorrington. Prevalence of RTI/STI agents and HIV infection in symptomatic and asymptomatic women attending peripheral health set-ups in Delhi, India. Sexually Transmitted Infection 2005; 81: 287-293.</td></tr><tr><td class="textSmall">15. </td></tr><tr><td class="textSmall"> K Nessa, Prevalence of RTI/STI agents and HIV infection in symptomatic and asymptomatic women attending peripheral health set-ups in Delhi, India. Sexually Transmitted Diseases 2005; 32: 13-19.</td></tr><tr><td class="textSmall">16. </td></tr><tr><td class="textSmall"> S Agarwal, V Sharma, R Sarin. Prevalence of RTI/STI agents and HIV infection in symptomatic and asymptomatic women attending peripheral health set-ups in Delhi, India. Indian Journal of Sexually Transmitted Diseases 2005; 26: 72-77.</td></tr><tr><td class="textSmall">17. </td></tr><tr><td class="textSmall"> J Joshi, Prevalence of RTI/STI agents and HIV infection in symptomatic and asymptomatic women attending peripheral health set-ups in Delhi, India. Indian Journal of Sexually Transmitted Diseases 1996; 17: 66-70.</td></tr><tr><td class="textSmall">18. </td></tr><tr><td class="textSmall"> NS Tankhivale, AA Pathak, S Mundhda. Prevalence of RTI/STI agents and HIV infection in symptomatic and asymptomatic women attending peripheral health set-ups in Delhi, India. Indian Journal of Sexually Transmitted Diseases 2000; 221: 25-29.</td></tr><tr><td class="textSmall">19. </td></tr><tr><td class="textSmall"> G Schmid, Prevalence of RTI/STI agents and HIV infection in symptomatic and asymptomatic women attending peripheral health set-ups in Delhi, India. Sexually Transmitted Infection 2000; 76: 3-4.</td></tr><tr><td class="textSmall">20. </td></tr><tr><td class="textSmall"> N O'Farrell. Prevalence of RTI/STI agents and HIV infection in symptomatic and asymptomatic women attending peripheral health set-ups in Delhi, India. Sexually Transmitted Infection 1999; 75: 377-384.</td></tr><tr><td class="textSmall">21. </td></tr><tr><td class="textSmall"> RM Mar Pujades, Prevalence of RTI/STI agents and HIV infection in symptomatic and asymptomatic women attending peripheral health set-ups in Delhi, India. Acquired Immuno Deficiency Syndrome 2002; 16: 451-462.</td></tr><tr><td class="textSmall">22. </td></tr><tr><td class="textSmall"> SJ Reynolds, Prevalence of RTI/STI agents and HIV infection in symptomatic and asymptomatic women attending peripheral health set-ups in Delhi, India. Journal of Infectious Diseases 2003; 187: 1513-2125.</td></tr><tr><td class="textSmall">23. </td></tr><tr><td class="textSmall"> S Panchanadeswaran, Prevalence of RTI/STI agents and HIV infection in symptomatic and asymptomatic women attending peripheral health set-ups in Delhi, India. Sexually Transmitted Infection 2006; 82: 491-495.</td></tr><tr><td class="textSmall">24. </td></tr><tr><td class="textSmall"> S Mullick, Prevalence of RTI/STI agents and HIV infection in symptomatic and asymptomatic women attending peripheral health set-ups in Delhi, India. Sexually Transmitted Infection 2005; 81: 284-302.</td></tr><tr><td class="textSmall">25. </td></tr><tr><td class="textSmall"> VK Desai, Prevalence of RTI/STI agents and HIV infection in symptomatic and asymptomatic women attending peripheral health set-ups in Delhi, India. Sexually Transmitted Infection 2003; 79: 111-115.</td></tr></tbody></table></span><table border="0" cellpadding="0" cellspacing="0"><tbody></tbody></table>
<br /><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td class="textSmall" nowrap="nowrap"><b>[Author Affiliation]</b></td></tr><tr><td class="textSmall">1 Regional STD Teaching, Training & Research Centre, VMMC & Safdarjung Hospital, New Delhi, India</td></tr><tr><td class="textSmall">2 Department of Community Health Administration, NIHFW, New Delhi, India</td></tr><tr><td class="textSmall">3 Department of Obstetrics & Gynaecology, VMMC & Safdarjung Hospital, New Delhi, India</td></tr></tbody></table></span>All About Bloggerhttp://www.blogger.com/profile/17282736671555579827noreply@blogger.com0tag:blogger.com,1999:blog-4987803374989865601.post-84435069853717723992008-12-30T00:05:00.000-08:002008-12-30T00:06:35.060-08:00A gendered look at Mexico's health-sector reform<span class="italic">Copyright Lancet Ltd. Nov 18-Nov 24, 2006</span><br /><br /><p style="margin-top: 0px;">The strong links between health and development have been increasingly articulated by leaders in health policy and economic development: investments in health systems help to reduce poverty and promote sustainable development, while national development contributes to improved public health.1 The connection between health and development is clearly articulated in the Millennium Development Goals, which provide a global framework for current development efforts.</p><p style="margin-top: 0px;">Gender-the social, cultural, and political constructs that prescribe feminine and masculine roles and which often lead to power imbalances between women and men2-also strongly affects health and development. Gender-related disadvantages, in addition to undermining human rights and social justice, contribute to poverty and poor health. Health policies and social systems that ensure women's equal access to information and services not only contribute to their wellbeing, but also affect economic growth and reduction of poverty by raising productivity, improving efficiency, and enabling the female half of the population to reach its full potential.3</p><p style="margin-top: 0px;">Most developing countries are currently implementing complex processes to improve the efficiency, equity, and effectiveness of the health sector. Central elements of these reform programmes in the health sector include ensuring fairness, access, quality, and the social right to health protection.4 There is much debate, however, over the effect of health-sector reform on the most vulnerable segments of the population, particularly women.5</p><p style="margin-top: 0px;">Gender imbalances contribute to women's and men's different positions as users and providers of health care.4 Women's needs as consumers of health care are often neglected. As providers of health care, women have a vital but often understated role in both the private and professional spheres. A disproportionate burden of informal health care in households and communities is provided by women. The hierarchical health workforce is also predominantly female, yet men continue to dominate positions of influence and power.4 Given the profoundly important roles of women as consumers and providers of health care in all developing countries, health-sector reform cannot succeed if it is gender blind.</p><p style="margin-top: 0px;">Mexico is engaged in a dynamic process of health-system reform. The Seguro Popular health-insurance scheme addresses women's health problems, such as maternal mortality, HIV/AIDS, cervical and breast cancer, and gender violence.6 The programme has also responded to the problem of gender inequality by: increasing health-care coverage for poor women (especially female heads of households, who are enrolling at an accelerated rate); expanding the range of services offered; broadening the definition of family so that more female family members are eligible; and increasing attention to community health promotion and disease prevention (Aurora del Rio Zolezzi, National Program for Women and Health, Mexico City, personal communication).</p><p style="margin-top: 0px;">Along with Seguro Popular, the current administration in Mexico also started the innovative National Program on Women and Health (PROMSA), which is implemented by the National Center for Gender Equity and Reproductive Health and aims to integrate a gender perspective in all national policies and programmes across the health sector. PROMSA focuses on three main areas: meeting women's health-care needs throughout life, addressing the challenges women face as health-care professionals, and as caregivers in the family and community. This pioneering programme seeks to redress gender exclusion and discrimination in the health sector by making the invisible visible. PROMSA works in close collaboration with those engaged in the process of health-sector reform, and although improvements are evident, the integration of a gender perspective is a challenging and slow process. Its success, however, is essential if Mexico is to break down conditions of gender inequality, poverty, and poor health.</p> <table border="0" cellpadding="0" cellspacing="0" width="200"><tbody><tr><td><a href="http://proquest.umi.com/pqdweb?vinst=PROD&fmt=4&filenumber=1&clientid=45625&vname=PQD&RQT=309&did=1169834151&scaling=HALF&ts=1230623477&vtype=PQD&rqt=309"><img src="http://proquest.umi.com/pqdweb?vinst=PROD&fmt=4&filenumber=1&clientid=45625&vname=PQD&RQT=309&did=1169834151&scaling=THUMBNAIL&ts=1230623477&vtype=PQD&rqt=309" alt="Photograph" /></a></td><td><table border="1" cellpadding="0" cellspacing="0"><tbody><tr><td nowrap="nowrap"><a href="http://proquest.umi.com/pqdweb?vinst=PROD&fmt=4&filenumber=1&clientid=45625&vname=PQD&RQT=309&did=1169834151&scaling=HALF&ts=1230623477&vtype=PQD&rqt=309">Enlarge 200%</a></td></tr><tr><td nowrap="nowrap"><a href="http://proquest.umi.com/pqdweb?vinst=PROD&fmt=4&filenumber=1&clientid=45625&vname=PQD&RQT=309&did=1169834151&scaling=FULL&ts=1230623477&vtype=PQD&rqt=309">Enlarge 400%</a></td></tr></tbody></table></td></tr></tbody></table><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td class="textSmall" nowrap="nowrap"><b>[Photograph]</b></td></tr></tbody></table></span><table border="0" cellpadding="0" cellspacing="0"><tbody></tbody></table><br /><p style="margin-top: 0px;">Mexico's health-sector advances, including Seguro Popular, show critical initial stops toward gender equality in health care. But much remains to be done to achieve the ambitious goals set by this administration-ie, that by 2015, all Mexican health programmes and services will be designed, budgeted, and evaluated with a gender perspective. Continued progress will require strong leadership and support at the highest levels. Without the vision, political will, and accompanying resource allocation of the current administration, gender mainstreaming will not be possible. The foundation has been laid, but only with sustained efforts will gender equality in Mexico's health sector be attained.</p> <table border="0" cellpadding="0" cellspacing="0" width="200"><tbody><tr><td><a href="http://proquest.umi.com/pqdweb?vinst=PROD&fmt=4&filenumber=2&clientid=45625&vname=PQD&RQT=309&did=1169834151&scaling=HALF&ts=1230623477&vtype=PQD&rqt=309"><img src="http://proquest.umi.com/pqdweb?vinst=PROD&fmt=4&filenumber=2&clientid=45625&vname=PQD&RQT=309&did=1169834151&scaling=THUMBNAIL&ts=1230623477&vtype=PQD&rqt=309" alt="Illustration" /></a></td><td><table border="1" cellpadding="0" cellspacing="0"><tbody><tr><td nowrap="nowrap"><a href="http://proquest.umi.com/pqdweb?vinst=PROD&fmt=4&filenumber=2&clientid=45625&vname=PQD&RQT=309&did=1169834151&scaling=HALF&ts=1230623477&vtype=PQD&rqt=309">Enlarge 200%</a></td></tr><tr><td nowrap="nowrap"><a href="http://proquest.umi.com/pqdweb?vinst=PROD&fmt=4&filenumber=2&clientid=45625&vname=PQD&RQT=309&did=1169834151&scaling=FULL&ts=1230623477&vtype=PQD&rqt=309">Enlarge 400%</a></td></tr></tbody></table></td></tr></tbody></table><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"></table></span><table border="0" cellpadding="0" cellspacing="0"><tbody></tbody></table><br /><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td class="textSmall" nowrap="nowrap"><b>[Sidebar]</b></td></tr><tr><td class="textSmall">Published Online</td></tr><tr><td class="textSmall">October 25, 2006</td></tr><tr><td class="textSmall">DOI:10.1016/S0140-6736(06)69527-5</td></tr></tbody></table></span><table border="0" cellpadding="0" cellspacing="0"><tbody></tbody></table><br /><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td nowrap="nowrap"> <span class="bold textSmall">[Reference]</span> </td></tr><tr><td class="textSmall">We declare that we have no conflict of interest.</td></tr><tr><td class="textSmall">1 Sachs J. Macroeconomics and health investing in health for economic development. Report of the commission on macro economics and health Geneva: World Health Organization, 2001.</td></tr><tr><td class="textSmall">2 Gomez E. Equity, gender, and health policy reform in Latin America and the Caribbean. Washington, DC: Pan American Health Organization, 2000.</td></tr><tr><td class="textSmall">3 Freedman LP, Waldman RJ, de Pinho H, et al. Who's got the power? Transforming health systems for women and children. Task Force on Child Health and Maternal Health. New York: Millennium Development Project, 2005.</td></tr><tr><td class="textSmall">4 Standing H. Gender and equity in health sector reform programs: a review. Health Policy Plan 1997; 12: 1-18.</td></tr><tr><td class="textSmall">5 Doyal L. Gender and health sector reform a literature review and report from a workshop at Forum 7. Geneva: Global Forum for Health Research, 2003.</td></tr><tr><td class="textSmall">6 Frenk J. Bridging the divide, global lessons from evidence-based health policy in Mexico Lancet 2006: 368: 9640 -71</td></tr><tr><td class="textSmall">7 Programa Mujer y Salud. Vision statement 2006. http://www.mujerysalud.gob. mx/contenido/vision.html (accessed Oct 9, 2006)</td></tr></tbody></table></span><table border="0" cellpadding="0" cellspacing="0"><tbody></tbody></table><br /><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td class="textSmall" nowrap="nowrap"><b>[Author Affiliation]</b></td></tr><tr><td class="textSmall">*Ana Langer, Jennifer Catino</td></tr><tr><td class="textSmall">EngenderHealth, NewYork, NY 10001, USA</td></tr><tr><td class="textSmall">alanger@engenderhealth.org</td></tr></tbody></table></span>All About Bloggerhttp://www.blogger.com/profile/17282736671555579827noreply@blogger.com0tag:blogger.com,1999:blog-4987803374989865601.post-21400405134263631002008-12-29T23:52:00.000-08:002008-12-29T23:53:04.803-08:00A prescription for AIDS 2006-10<span class="italic">Copyright Lancet Ltd. Aug 26-Sep 1, 2006</span><br /><br /><p style="margin-top: 0px;">In June, 2006, UN member states at the General Assembly High Level Meeting on AIDS ambitiously committed themselves to provide "universal access to comprehensive prevention programmes, treatment, care, and support by 2010". The XVI International AIDS Conference, held last week in Toronto, provided the first opportunity to draft a strategy to meet that goal.</p><p style="margin-top: 0px;">What werethe highlightsof this meeting? Fresh science brought attention to a new class of antiviral agent, the integrase inbibitors. An extremely drug-resistant (XDR) strain of tuberculosis (TB) was described. A visible shift took place in the terms of engagement with HIV-from treatment to prevention.1 Male circumcision, preexposure prophylaxis with antiretrovirals, microbicides, and vaccines were all discussed vigorously. Women were centre stage. Routine testing for HIV provoked furious debate, with proponents arguing that it was one of the few practicable ways to expand treatment. Opponents said it would undermine essential liberties. In sum, there was much to reflect on: narrowly defined, a success.</p> <table border="0" cellpadding="0" cellspacing="0" width="200"><tbody><tr><td><a href="http://proquest.umi.com/pqdweb?vinst=PROD&fmt=4&filenumber=1&clientid=45625&vname=PQD&RQT=309&did=1123409131&scaling=HALF&ts=1230623477&vtype=PQD&rqt=309"><img src="http://proquest.umi.com/pqdweb?vinst=PROD&fmt=4&filenumber=1&clientid=45625&vname=PQD&RQT=309&did=1123409131&scaling=THUMBNAIL&ts=1230623477&vtype=PQD&rqt=309" alt="Photograph" /></a></td><td><table border="1" cellpadding="0" cellspacing="0"><tbody><tr><td nowrap="nowrap"><a href="http://proquest.umi.com/pqdweb?vinst=PROD&fmt=4&filenumber=1&clientid=45625&vname=PQD&RQT=309&did=1123409131&scaling=HALF&ts=1230623477&vtype=PQD&rqt=309">Enlarge 200%</a></td></tr><tr><td nowrap="nowrap"><a href="http://proquest.umi.com/pqdweb?vinst=PROD&fmt=4&filenumber=1&clientid=45625&vname=PQD&RQT=309&did=1123409131&scaling=FULL&ts=1230623477&vtype=PQD&rqt=309">Enlarge 400%</a></td></tr></tbody></table></td></tr></tbody></table><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td class="textSmall" nowrap="nowrap"><b>[Photograph]</b></td></tr></tbody></table></span><table border="0" cellpadding="0" cellspacing="0"><tbody></tbody></table><br /><p style="margin-top: 0px;">But the opportunity to produce a roadmap to reach the 2010 target of universal access was squandered. Rarely has there been a meeting that felt so disengaged from a global predicament of such historic proportions. The agenda in Toronto was unfocused, giving prime air time to celebrities, such as Bill Gates and Bill Clinton, while largely ignoring Africa. Africa bears the greatest burden of AIDS today-24-5 million of 38-6 million people with HIV. Yet no African representative spoke at the opening of this meeting. Instead, non-Africans were nominated to speak on behalf of Africa. This surprising marginalisation sent an incredibly negative signal to the conference's 30 000 attendees. It suggested that Africa lacked leadership on HIV-AIDS and that its peoples paid the disease far too little attention. A leadership vacuum does exist in one country-South Africa. But in its anger over South Africa's shameful handling of the AIDS epidemic, the International AIDS Society inadvertently silenced the voice of a great continent.</p><p style="margin-top: 0px;">Away from the star-studded plenaries, Africans and many others from countries most affected by AIDS had a troubling message. Global action to defeat this pandemic has stalled. A veneer of achievement-1-6 million people taking antiretroviral drugs, together with the existence of powerful financing mechanisms, such as the Global Fund, the President's Emergency Plan for AIDS Relief (PEPFAR), and the Gates Foundation-has bred complacency. Those who lead the AIDS community should be asking difficult questions if they wish to turn back the tide of HIV. Here are ten questions that failed to get the answers they deserved last week.</p><p style="margin-top: 0px;">1 Why do we refuse to admit that there is still no genuine global commitment to scale up our response to AIDSP There remains a massive funding gap in the effort to control HIV. 2005 saw the world's AIDS budget reach USS8-3 billion. But $30 billion will be needed by 2010 to achieve the goal of universal access. The Global Fund is already several billion dollars short of what it needs for 2006-0/ And G8 countries continue to renege on their past financial pledges.</p><p style="margin-top: 0px;">2 Why are the wider health, economic, social, and cultural contexts of AIDS still being ignored? There are catastrophic weaknesses in health systems and human resources for health. But AIDS is a human crisis, as well as a health crisis. In particular, AIDS is a crisis for women, driven as it is by vast gender inequalities that stubbornly persist in the world today. Somehow, the international commitments made in Cairo in 1994 to the rights of women to reproductive health services have been forgotten. Reproductive health has become divorced from the response to AIDS, a mistake of impossibly large proportions.</p><p style="margin-top: 0px;">3 Why does our definition of science still seem to include only the laboratory experiment and the clinical trial? Social and ethnographic approaches to HIV treatment and prevention research are yielding important warnings about current AIDS strategies. HIV programmes can foster conflict and resentment,3 they often ignore sensitive cultural dynamics,4 and they can marginalise the influence of violence, crime, and alcohol on the way public health messages are transmitted and received.5 Unless we broaden the meaning of HIV science, AIDS campaigns will fail.</p><p style="margin-top: 0px;">4 Why do we see biology, medicine, epidemiology, social science, and policy making as parallel, mutually exclusive "tracks" at the International AIDS Conference? Why do we reinforce these disciplinary divisions, instead of creating new alliances between them? The International AIDS Society would likely plead that rigid separation of communities is the only way to handle the huge number of submitted abstracts. But if the Society truly wants to foster science and social change, it should not buckle in the face of scholarly boundaries. It has to devise and promote different ways of working.</p><p style="margin-top: 0px;">5 After 25years of AIDS, why are children still largely ignored? 2-3 million children under 15-2 million in sub-Saharan Africa alone-live with HIV. Yet fewer than 5% of these children receive the treatment they need. The worst shortfalls are in paediatric care, prevention of motherto-child-transmission, primary prevention, and the protection and support of children affected by AIDS, notably the 12 million children in Africa who have lost one or both parents to AIDS." HIV is an exquisitely acute child killer, yet children are barely mentioned in our strategies to defeat this disease.</p><p style="margin-top: 0px;">6 Why do health agencies and programmes still base their prevention messages on the outdated and scientifically corrupt idea of abstinence? As studies in Africa show all too clearly, abstinence programmes do not and will not work. Abstinence alone is simply incompatible with most African cultures. Sex is bound up with traditions and practices that cannot be terminated by the moralistic injunction of one donor government. As the AIDS activist, Beatrice Were, argued in Toronto, abstinence is not only not protecting women, it is also hastening stigma and fuelling the African epidemic by making it harder to talk about sex, rape, and intimate partner violence.</p><p style="margin-top: 0px;">7 Why are civil society and NGOs still not being given the credit they deserve as vital levers in the global AIDS response? Why do we still not see the community as a means for societal change? The focus of action on AIDS ranges from international instruments (eg, the Global Fund) to individual risk interventions. Intermediatelevel mechanisms to mobilise and engage communities are rarely discussed. Yet it is these community-based responses that will have the greatest impact on the epidemic, as evidenced from work in other fields, such as maternal and child health.</p><p style="margin-top: 0px;">8 Why is stigma-of gay men and women, indigenous peoples, migrants, refugees, internally displaced persons, drug users, sex workers, and prisoners-still not the concerted focus of the AIDS response? The greatest impediment to AIDS prevention today is the invisibilisation of large social groupings by mainstream society. Communities are erased, phobias are fermented, and human vulnerabilities are criminalised. AIDS exposes the profoundest prejudices in our society, and wo do too little to reverse their pernicious effect.</p><p style="margin-top: 0px;">9 Why do so many of those committed to defeating AIDS prefer to lecture one another about what each is doing wrong, instead of working harder to find meeting points of dialogue and partnership? Part of the answer is that there are few places where such constructive collaborations can be formed and nurtured. This is perhaps the chief challenge facing the global AIDS architecture.</p><p style="margin-top: 0px;">10 All of which leads, finally, to the most damning question of all: why is the world's response to AIDS failing?</p> <table border="0" cellpadding="0" cellspacing="0" width="200"><tbody><tr><td><a href="http://proquest.umi.com/pqdweb?vinst=PROD&fmt=4&filenumber=2&clientid=45625&vname=PQD&RQT=309&did=1123409131&scaling=HALF&ts=1230623477&vtype=PQD&rqt=309"><img src="http://proquest.umi.com/pqdweb?vinst=PROD&fmt=4&filenumber=2&clientid=45625&vname=PQD&RQT=309&did=1123409131&scaling=THUMBNAIL&ts=1230623477&vtype=PQD&rqt=309" alt="Photograph" /></a></td><td><table border="1" cellpadding="0" cellspacing="0"><tbody><tr><td nowrap="nowrap"><a href="http://proquest.umi.com/pqdweb?vinst=PROD&fmt=4&filenumber=2&clientid=45625&vname=PQD&RQT=309&did=1123409131&scaling=HALF&ts=1230623477&vtype=PQD&rqt=309">Enlarge 200%</a></td></tr><tr><td nowrap="nowrap"><a href="http://proquest.umi.com/pqdweb?vinst=PROD&fmt=4&filenumber=2&clientid=45625&vname=PQD&RQT=309&did=1123409131&scaling=FULL&ts=1230623477&vtype=PQD&rqt=309">Enlarge 400%</a></td></tr></tbody></table></td></tr></tbody></table><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td class="textSmall" nowrap="nowrap"><b>[Photograph]</b></td></tr></tbody></table></span><table border="0" cellpadding="0" cellspacing="0"><tbody></tbody></table><br /><p style="margin-top: 0px;">The grip of AIDS will only be broken by effective programmes at country level. The difficulty is that agencies and funders-WHO and UNAIDS; PEPFAR, the Global Fund, and World Bank-operate quasiindependently of one another. They each have their own separate missions, governance structures, staff, and comparative advantages. What never happens is an event or process to develop integrated country strategies that focus only on the country-not on the interests of the agency, funder, or constituency (academic, policy, or activist). This exclusive country focus should be the purpose of the International AIDS Society's conference-a global accountability mechanism to monitor country progress, to hold all parties responsible for the part they play in defeating AIDS, and to set specific, measurable objectives for the succeeding 2 years.</p><p style="margin-top: 0px;">A partnership between scientists and people living with AIDS could develop a set of indicators to track HIV prevention, treatment, and care, much as has been done for child survival.8 The International AIDS Conference should identify priority countries and devote specific sessions to each country-South Africa, Botswana, China, Russia, and so on-inviting ministers, policymakers, scientists, and civil society to join together in mapping, evaluating, and planning that country's response to AIDS. This biennial gathering would then provide the necessary accountability instrument, a tool to chart success and to identify catalysts of change or obstacles underlying failure.</p><p style="margin-top: 0px;">In Toronto, Julio Montaner, president-elect of the International AIDS Society, blamed political leaders for permitting the "genocide" that is the AIDS pandemic.9 This rhetoric attracts headlines and gives welcome publicity to a still neglected disease. But such extreme language fails to point out the responsibility of the AIDS community itself, and specifically the International AIDS Society, for providing a neutral forum for scientists, policymakers, and others to work collectively against AIDS. The International AIDS Conference is a unique event in medicine. Its remarkable and inspiring diversity provides the foundation for a step change in its purpose. The power to cause a necessary schism between future and past responses to HIV lies not in the hands of political leaders, but within the AIDS community.</p><p style="margin-top: 0px;">The Russian writer, Aleksander Herzen, once wrote that "Man and science are two concave mirrors continually reflecting each other." In Mexico in 2008, the international AIDS community will reconvene to take stock of this unprecedented pandemic and to review progress towards the 2010 goal of universal access. The litmus test for Mexico's success will be the degree to which the conference can be transformed from a scientific meeting and global beacon for AIDS, to a coordinating mechanism to drive advances in prevention, treatment, and care at country level. Talking is easy. Doing will demand a revolution. Historically and programmatically, Mexico is a perfect place to begin.</p><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td nowrap="nowrap"> <span class="bold textSmall">[Reference]</span> </td></tr><tr><td class="textSmall">1 Picard A. Gathering opens with focus on AIDS prevention. The Globe and Mail, August 14, 2001: A1.</td></tr><tr><td class="textSmall">2 Editorial. To empower women in the war on AtDS. The Globe and Mail, August 17, 2006: A14.</td></tr><tr><td class="textSmall">3 Gruber J, Caffrey M. HIV/AIDS and community conflict in Nigeria: implications and challenges. Soc Sci Med 2005; 60:1209-18.</td></tr><tr><td class="textSmall">4 Morrow OI, Sweat MD, Morrow RH. The Mafalisi: pathway to early sexual initiation among the youth of Mpigi, Uganda. AIDS Behav 2004; 8: 365-78.</td></tr><tr><td class="textSmall">5 Muturi NW. Communication for HIV/AIDS prevention in Kenya: social-cultural considerations. J Health Commun 2005; 10: 77-98.</td></tr><tr><td class="textSmall">6 UNICEF, UNAIDS, PEPFAR. Africa's orphaned and vulnerable generations. New York: UNICEF, 2006.</td></tr><tr><td class="textSmall">7 Manandhar DS, Osrin D, Shrestha BP, et al. Effect of a participatory intervention with women's groups on birth outcomes in Nepal: cluster-randomised controlled trial. Lancet 2004; 364: 970-79.</td></tr><tr><td class="textSmall">8 Horton. R. The coming decade for global action on child heath. Lancet 2006; 367:3-5</td></tr><tr><td class="textSmall">9 Picard A. Political leaders accused of AIDS genocide. The Globe and Mail, August 18, 2006: A7.</td></tr></tbody></table></span><table border="0" cellpadding="0" cellspacing="0"><tbody></tbody></table><br /><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td class="textSmall" nowrap="nowrap"><b>[Author Affiliation]</b></td></tr><tr><td class="textSmall">Richard Horton</td></tr><tr><td class="textSmall">The Lancet, London, NW1 7BY, UK</td></tr></tbody></table></span>All About Bloggerhttp://www.blogger.com/profile/17282736671555579827noreply@blogger.com0tag:blogger.com,1999:blog-4987803374989865601.post-55192081347796754732008-12-29T23:49:00.000-08:002008-12-29T23:50:33.802-08:00Women Who Report Having Sex With Women: British National Probability Data on Prevalence, Sexual Behaviors, and Health Outcomes<span class="italic">Copyright American Public Health Association Jun 2007</span><br /><br /><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td class="textSmall" nowrap="nowrap"><b>[Headnote]</b></td></tr><tr><td class="textSmall">Objectives. We estimated the prevalence of same-sex experience among women and compared women reporting sex with women and men and women reporting sex exclusively with women with women reporting sex exclusively with men, in terms of sociodemographics and sexual, reproductive, and general health risk behaviors and outcomes.</td></tr><tr><td class="textSmall">Methods. We used a British probability survey (n = 6399 women, aged 16 to 44 years) conducted from 1999 to 2001 with face-to-face interviewing and computer-assisted self-interviewing.</td></tr><tr><td class="textSmall">Results. We found that 4.9% of the women reported same-sex partner(s) ever; 2.8% reported sex with women in the past 5 years (n = 178); 85.0% of these women also reported male partner(s) in this time. Compared with women who reported sex exclusively with men, women who reported sex with women and men reported significantly greater male partner numbers, unsafe sex, smoking, alcohol consumption, and intravenous drug use and had an increased likelihood of induced abortion and sexually transmitted infection diagnoses (age-adjusted odds ratios = 3.07 and 4.41, respectively).</td></tr><tr><td class="textSmall">Conclusions. For women, a history of sex with women may be a marker for increased risk of adverse sexual, reproductive, and general health outcomes compared with women who reported sex exclusively with men. A nonjudgmental review of female patients' sexual history should help practitioners discuss risks that women may face.</td></tr><tr><td class="textSmall">(Am J Public Health. 2007;97:1126-1133. doi:10.2105/AJPH.2006.086439)</td></tr></tbody></table></span><table border="0" cellpadding="0" cellspacing="0"><tbody></tbody></table><br /><p style="margin-top: 0px;">Sex between women is thought to be low risk for transmission of sexually transmitted infections (STI) such as chlamydia, gonorrhea, or HFV.1"3 However, studies from several countries indicate that women who have sex with women (WSW) may in fact be at greater risk than women with exclusively male partners, through behaviors such as risky sex with male sexual partners and activities such as injection drug use (IDU).4"7</p><p style="margin-top: 0px;">Most studies of WSW use convenience sampling in clinic or community settings because WSW are a hard-to-reach, "hidden" population.8 Convenience samples drawn from selected populations are not generalizable to all WSW, and there are few robust data internationally that measure prevalence, characteristics, and health outcomes in WSW from representative, general population samples. We noted a marked increase in the reported prevalence of sexual intercourse between women in Britain in the 10 years between the 2 National Surveys of Sexual Attitudes and Lifestyles (Natsal).9 The most recent survey, Natsal 2000, provides contemporary data to explore the prevalence of reported same-sex sexual experience and to make comparisons between women who reported sex exclusively with men, women who reported sex with women and men, and women who reported sex exclusively with women in the past 5 years in terms of sociodemographics and sexual, reproductive, and general health risk behaviors and outcomes.</p><p style="margin-top: 0px;">METHODS</p><p style="margin-top: 0px;">Data and Measures</p><p style="margin-top: 0px;">Natsal 2000 is a stratified probability sample survey of the general population aged 16 to 44 years who reside in Great Britain. A total of 11 161 people, of whom 6399 were women, were interviewed between May 1999 and February 2001. Details of the methodology and question wording are published elsewhere.9·10 Briefly, a sample of 40 523 addresses were selected from the small-user Postcode Address File for Great Britain with a multistage probability cluster design, with oversampling in greater London. Interviewers visited all selected addresses and recorded the number of residents aged 16 to 44 years. One resident from every household was invited by random selection to participate in the study.</p><p style="margin-top: 0px;">Natsal 2000 achieved a response rate of 65.4%, which is in line with other major surveys conducted in Great Britain." Trained interviewers conducted face-to-face interviews in respondents' homes, followed by computer-assisted self-interview. The face-to-face interview included questions on sociodemographics, health, alcohol consumption, smoking, attitudes (including perceived HIV risk), sexual attraction, and sexual experience. Respondents who reported no sexual experience of any kind in the face-to-face interview and those aged 16 and 17 years with some heterosexual experience but no heterosexual intercourse or same-sex experience reported in screening questions were not given the computer-assisted self-interview.</p><p style="margin-top: 0px;">In the computer-assisted self-interview, eligible women were asked the following question about same-sex sexual experience: "Have you ever had ANY kind of sexual experience or sexual contact with a female? Please say 'yes' here, even if it was a long time ago or did not involve contact with the genital area or vagina. This can include kissing or cuddling, not necessarily leading to genital contact" Women were then asked the following about same-sex genital contact: "Have you had sex with a woman involving genital/ vaginal contact? (That is, oral sex or any other contact involving the genital area)" The computer-assisted self-interview also asked about sexual practices with women and men, number of partners, sexually transmitted infection clinic attendance, STI diagnosis, HIV testing, abortion, and IDU.</p><p style="margin-top: 0px;">Statistical Analysis</p><p style="margin-top: 0px;">All analyses were performed with the survey analysis functions of Stata version 7.0 (Stata Corp, College Station, Tex) to account for stratification, clustering, and weighting of the data. The data were weighted to correct for unequal selection probabilities, including oversampling in greater London, and to match Great Britain's age and gender population profile.9·10</p><p style="margin-top: 0px;">We used survival analysis to estimate the median age at first same-sex experience and first same-sex genital contact. This method allows for the fact that younger respondents may not have yet experienced these events, so figures were derived from the estimated cumulative incidence at 44 years, assuming that age of first occasion stays constant across generations.12·13 Therefore, our estimates were for all women, not just those reporting these events.</p><p style="margin-top: 0px;">We used binary logistic regression to obtain odds ratios (ORs)9·12·13 to compare estimates for women who reported sex with women and men and women who reported sex exclusively with women relative to women who reported sex exclusively with men. We adjusted for age to control for variation in the age distribution among the 3 groups of women (Table 1 ). We used linear regression to compare the mean numbers of sexual partners among these groups of interest (Table 2). Tables 3 and 4 show ageadjusted ORs for risk factors and sexual and reproductive outcomes; we discuss additionally adjusting for reported numbers of male partners to control for confounding by this variable. Statistical significance was considered as P<.05 for all analyses.</p> <table border="0" cellpadding="0" cellspacing="0" width="200"><tbody><tr><td><a href="http://proquest.umi.com/pqdweb?vinst=PROD&fmt=4&filenumber=1&clientid=45625&vname=PQD&RQT=309&did=1286896911&scaling=HALF&ts=1230623341&vtype=PQD&rqt=309"><img src="http://proquest.umi.com/pqdweb?vinst=PROD&fmt=4&filenumber=1&clientid=45625&vname=PQD&RQT=309&did=1286896911&scaling=THUMBNAIL&ts=1230623341&vtype=PQD&rqt=309" alt="Table" /></a></td><td><table border="1" cellpadding="0" cellspacing="0"><tbody><tr><td nowrap="nowrap"><a href="http://proquest.umi.com/pqdweb?vinst=PROD&fmt=4&filenumber=1&clientid=45625&vname=PQD&RQT=309&did=1286896911&scaling=HALF&ts=1230623341&vtype=PQD&rqt=309">Enlarge 200%</a></td></tr><tr><td nowrap="nowrap"><a href="http://proquest.umi.com/pqdweb?vinst=PROD&fmt=4&filenumber=1&clientid=45625&vname=PQD&RQT=309&did=1286896911&scaling=FULL&ts=1230623341&vtype=PQD&rqt=309">Enlarge 400%</a></td></tr></tbody></table></td></tr></tbody></table><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td class="textSmall">TABLE 1-Soclodemographlc Characteristics of Women Who Reported Sex Exclusively With Men (WSEM), Women Who Reported Sex With Women and Men (WSWM), and Women Who Reported Sex Exclusively With Women (WSEW) In Natsal 2000: Great Britain</td></tr></tbody></table></span><table border="0" cellpadding="0" cellspacing="0"><tbody></tbody></table><br /><p style="margin-top: 0px;">RESULTS</p><p style="margin-top: 0px;">Prevalence of Same-Sex Attraction, Sexual Experience, and Genital Contact</p><p style="margin-top: 0px;">We found that 0.6% of women reported that they "never felt sexually attracted to anyone at all" (95% confidence interval [CI]=0.4%, 0.9%). Approximately 1 in 10 women reported sexual attraction, at least in part, to women (11.2%; 95% CI= 10.3%, 12.1%). And 0.2% of women reported they had only ever felt sexually attracted to women (95% CI=0.1%, 0.4%).</p><p style="margin-top: 0px;">Same-sex sexual experiences were reported by 9.7% of the women (95% CI=8.9%, 10.5%). Using survival analysis, we estimated the median age at first same-sex sexual experience to be 19 years (lower and upper quartiles: 14 and 27 years, respectively). As previously reported, 4.9% of all women reported same-sex genital contact (95% CI=4.3%, 5.5%).9 We estimated the median age at first same-sex genital contact as 22 years (lower and upper quartiles: 16 and 32 years, respectively). Same-sex genital contact before age 16 years was reported by 1.3% of all women (95% CI= 1.1%, 1.7%). Of women reporting same-sex genital contact, 42.9% reported heterosexual intercourse before age 16 (95% CI=37.2%, 48.9%). This is a significantly larger proportion than observed among women who did not report same-sex genital contact (21.2%; 95% CI= 19.9%, 22.5%; P<.001).</p> <table border="0" cellpadding="0" cellspacing="0" width="200"><tbody><tr><td><a href="http://proquest.umi.com/pqdweb?vinst=PROD&fmt=4&filenumber=2&clientid=45625&vname=PQD&RQT=309&did=1286896911&scaling=HALF&ts=1230623341&vtype=PQD&rqt=309"><img src="http://proquest.umi.com/pqdweb?vinst=PROD&fmt=4&filenumber=2&clientid=45625&vname=PQD&RQT=309&did=1286896911&scaling=THUMBNAIL&ts=1230623341&vtype=PQD&rqt=309" alt="Table" /></a></td><td><table border="1" cellpadding="0" cellspacing="0"><tbody><tr><td nowrap="nowrap"><a href="http://proquest.umi.com/pqdweb?vinst=PROD&fmt=4&filenumber=2&clientid=45625&vname=PQD&RQT=309&did=1286896911&scaling=HALF&ts=1230623341&vtype=PQD&rqt=309">Enlarge 200%</a></td></tr><tr><td nowrap="nowrap"><a href="http://proquest.umi.com/pqdweb?vinst=PROD&fmt=4&filenumber=2&clientid=45625&vname=PQD&RQT=309&did=1286896911&scaling=FULL&ts=1230623341&vtype=PQD&rqt=309">Enlarge 400%</a></td></tr></tbody></table></td></tr></tbody></table><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td class="textSmall">TABLE 2-Numbers of Male Sexual Partners Reported by Women Who Reported Sex Exclusively With Men (WSEM), Women Who Reported Sex With Women and Men (WSWM), and Women Who Reported Sex Exclusively With Women (WSEW) In Natsal 2000: Great Britain</td></tr></tbody></table></span><table border="0" cellpadding="0" cellspacing="0"><tbody></tbody></table><br /><p style="margin-top: 0px;">Comparisons</p><p style="margin-top: 0px;">When we focused on women who reported at least 1 sexual partner in the 5 years prior to interview for Natsal 2000, we found that 2.8% of these women reported sex with women in the past 5 years (n= 178; 95% CI=2.4%, 3.3%). (This prevalence estimate is slightly higher than the estimate previously reported, 9 because here the numerator includes women [n=7] who reported any female partner in the 5 years prior to interview but did not give a precise number [e.g., "at least one"], rather than just women reporting a specific number of partners [n= 171].) A large proportion of these women also reported sex with men (85.0%; 95% CI=78.7%, 89.6%) and were labeled as women who reported sex with women and men, and so we consider these women separately from women who reported sex exclusively with women. Given the relatively small number of women who reported sex exclusively with women (n=31), our main focus is on women who reported sex with women and men compared with women who reported sex exclusively with men in terms of sododemographics and sexual, reproductive, and general health risk behaviors and outcomes.</p><p style="margin-top: 0px;">Sociodemographlc Characteristics</p><p style="margin-top: 0px;">Table 1 shows that women who reported sex with women and men were significantly younger than were women who reported sex exclusively with men (mean ages=27.3 years and 31.7 years, respectively; standard deviations [SD]=7.2 and 7.7, respectively; P<.001). However, women who reported sex exclusively with women were significantly older than were women who reported sex exclusively with men (mean age=3 3.9 years; SD=6.2 years; /K.001). Of the women who reported sex with women and men, 47.8% reported opposite-sex cohabitation or marriage and 4.2% reported living with a woman. In contrast, 67.0% of women who reported sex exclusively with men reported opposite-sex cohabitation or marriage, and 64.4% of women who reported sex exclusively with women reported same-sex cohabitation. The women who reported sex with women and men were significantly less likely to have any natural children than were women who reported sex exclusively with men, even after control for age (age-adjusted OR=0.63; 95% CI=0.40, 0.97; P= .038). There were no statistically significant ethnic or social class differences among the 3 groups of women, but women who reported sex exclusively with women were significantly more likely to be educated at least to university level than were women who reported sex exclusively with men and women who reported sex with women and men. A significantly larger proportion of women who reported sex with women and men and women who reported sex exclusively with men resided in the greater London area than did women who reported sex exclusively with men.</p><p style="margin-top: 0px;">Sexual Partners</p><p style="margin-top: 0px;">Approximately half of women who reported sex with women and men (48%; 95% CI=38.8%, 57.3%) reported no female partners in the past year in contrast with 4.8% of women who reported sex exclusively with women (95% CI= 1.4%, 15.6%; P<.001). A greater proportion of women who reported sex with women and men than women who reported sex exclusively with women reported 1 female partner only in the past 5 years: 70.7% (95% CI=61.9%, 78.2%) versus 50.8% (95% CI=32.0%, 69.3%; P= .060). A small proportion of both groups reported 5 or more female partners in the past 5 years: 6.0% (95% CI=3.1%, 11.5%) and 3.5% (95% CI=0.8%, 14.6%), respectively.</p> <table border="0" cellpadding="0" cellspacing="0" width="200"><tbody><tr><td><a href="http://proquest.umi.com/pqdweb?vinst=PROD&fmt=4&filenumber=3&clientid=45625&vname=PQD&RQT=309&did=1286896911&scaling=HALF&ts=1230623341&vtype=PQD&rqt=309"><img src="http://proquest.umi.com/pqdweb?vinst=PROD&fmt=4&filenumber=3&clientid=45625&vname=PQD&RQT=309&did=1286896911&scaling=THUMBNAIL&ts=1230623341&vtype=PQD&rqt=309" alt="Table" /></a></td><td><table border="1" cellpadding="0" cellspacing="0"><tbody><tr><td nowrap="nowrap"><a href="http://proquest.umi.com/pqdweb?vinst=PROD&fmt=4&filenumber=3&clientid=45625&vname=PQD&RQT=309&did=1286896911&scaling=HALF&ts=1230623341&vtype=PQD&rqt=309">Enlarge 200%</a></td></tr><tr><td nowrap="nowrap"><a href="http://proquest.umi.com/pqdweb?vinst=PROD&fmt=4&filenumber=3&clientid=45625&vname=PQD&RQT=309&did=1286896911&scaling=FULL&ts=1230623341&vtype=PQD&rqt=309">Enlarge 400%</a></td></tr></tbody></table></td></tr></tbody></table><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td class="textSmall">TABLE 3-Provalence of Selected Sexual Practices and Sexual Risk Behaviors In Women Who Reported Sex Exclusively With Men (WSEM), Women Who Reported Sex With Women and Men (WSWM), and Women Who Reported Sex Exclusively With Women (WSEW), In Natsal 2000: Great Britain</td></tr></tbody></table></span><table border="0" cellpadding="0" cellspacing="0"><tbody></tbody></table><br /><p style="margin-top: 0px;">In terms of male partners, women who reported sex with women and men reported significantly higher male partner numbers than did women who reported sex exclusively with men over all time frames (Table 2). For example, the median number of male partners ever was 4 for women who reported sex exclusively with men and 15 for women who reported sex with women and men, and in the past 5 years, 1 and 5 male partners, respectively. Of women who reported sex with women and men, 49.4% reported multiple male partners in the past year compared with 13.4% of women who reported sex exclusively with men. Three in 5 women who reported sex with women and men reported a new male partner in the past year in contrast to approximately 1 in 5 women who reported sex exclusively with men.</p><p style="margin-top: 0px;">Sexual Practices</p><p style="margin-top: 0px;">The women who reported sex with women and men who reported male partnerfs) in the past year were as likely to report vaginal intercourse as women who reported sex exclusively with men, but significantly more likely to report anal intercourse, oral sex, or other genital contact not leading to intercourse with men than were women reporting exclusively male partners (age-adjusted ORs=2.89, 2.41, and 3.80, respectively; Table 3). When women who reported sex with women and men were compared with women who reported sex exclusively with women, there were no differences in the reporting of sexual practices with female partners asked about in Natsal 2000, after control for age. Relative to women who reported sex exclusively with men, women who reported sex with women and men and women who reported sex exclusively with women were significantly more likely to report masturbation in the past 4 weeks (age-adjusted ORs=3.91 and 2.50, respectively).</p><p style="margin-top: 0px;">Relative to women who reported sex exclusively with men, women who reported sex with women and men were significantly more likely to report first sexual intercourse with their most recent partner within 24 hours of meeting and to describe this partner as "not regular" (age-adjusted ORs=2.44 and 1.76, respectively; no significant differences were detected for women who reported sex exclusively with women). However, after additionally adjusting for partner numbers in the past year, these ORs were no longer statistically significant (1.56 [95% CI = 0.79, 3.08; P= .201] and 0.86 [95% CI=0.45, 1.63; P=.637], respectively). Among women reporting male partners in the past 4 weeks, women who reported sex with women and men were significantly more likely to have had unsafe heterosexual sex (defined as reporting 2 or more male partners and inconsistent condom use in this time frame)9 than women who reported sex exclusively with men (age-adjusted OR=7.17). This association remained highly significant after additionally adjusting for numbers of male partners in the past 4 weeks (adjusted OR=6.97; 95% CI=3.12, 15.6; P<.00l).</p><p style="margin-top: 0px;">Sexual, Reproductive, and General Health Risks and Outcomes</p><p style="margin-top: 0px;">Relative to women who reported sex exclusively with men, women who reported sex with women and men were significantly less likely to describe their health as "good" or "very good," were more likely to report illnesses lasting at least 3 months in the past 5 years, and to have been to the hospital as an outpatient in the past year (excluding for ante- or postnatal reasons; Table 4). The women who reported sex with women and men were more likely to have ever smoked, to smoke heavily, to drink more than recommended alcohol limits per week,w and to have injected nonprescribed drugs than were women who reported sex exclusively with men. There were no statistically significant differences between women who reported sex exclusively with men and women who reported sex exclusively with women, but numbers of the latter were small.</p><p style="margin-top: 0px;">The women who reported sex with women and men were significantly more likely to perceive themselves as "greatly" or "quite a lot" at risk of HIV relative to women who reported sex exclusively with men and women who reported sex exclusively with women (11.1%, 2.4%, and 0.0%, respectively; P<.001). In contrast, women who reported sex with women and men were significantly less likely to perceive female homosexuals as "greatly" or "quite a lot" at risk of HIV than were women who reported sex exclusively with men (26.6% vs 50.9%, respectively; P<.00\). Table 4 may reflect the greater self-perceived HIV risk reported by women who reported sex with women and men, because these women were significantly more likely than were women who reported sex exclusively with men to report visiting an STI clinic and testing for HIV in the past 5 years.</p><p style="margin-top: 0px;">The women who reported sex with women and men were also significantly more likely to report STI diagnoses, specifically diagnoses of chlamydia, pelvic inflammatory disease, or genital warts, as well as induced abortion, in this time frame. These associations remain after additionally adjusting for the reported number of male partners in the past 5 years. Although relatively small in number, none of the women who reported sex exclusively with women reported any STI diagnoses in the past 5 years.</p><p style="margin-top: 0px;">DISCUSSION</p><p style="margin-top: 0px;">Principal Findings</p><p style="margin-top: 0px;">Data from this large national probability sample show that women who reported sex with women and men were significantly more likely to report adverse sexual, reproductive, and general health risk behaviors and outcomes than were women who reported sex exclusively with men. Among all WSW, few female partners were reported on average, but the majority reported male partners. The women who reported sex with women and men reported significantly larger average numbers of male partners than women who reported sex exclusively with men and were significantly more likely to report HIV risk behaviors including IDU, unsafe sex,9 describing their most recent partner as "not regular," and reporting first sexual intercourse with this partner within 24 hours of meeting. The women who reported sex with women and men reported poorer general health and significantly greater smoking and alcohol consumption, induced abortion, and STI diagnoses than women who reported sex exclusively with men.</p><p style="margin-top: 0px;">Around 10% of women in Natsal 2000 reported sexual attraction to women, with a much smaller percentage reporting same-sex genital contact within the past 5 years (2.8%). However, first same-sex sexual experience tends to occur at older ages than first heterosexual experience, and these unadjusted prevalences do not take into account the cumulative increase in same-sex sexual experience with age. Only 4 of the 178 WSW in Natsal 2000 reported no male sexual partners ever.</p><p style="margin-top: 0px;">Comparison With Other Studies</p><p style="margin-top: 0px;">Studies of WSW have generally used convenience samples and study designs that differ in sampling strategies, inclusion criteria and place of recruitment, which makes comparison difficult. Sexual attraction, sexual behavior, and sexual identity are not equivalent;15 convenience samples tend to capture those who identify as lesbian or bisexual.16 Our results included a large proportion of women who reported sex with women and men who reported current heterosexual cohabitation or marriage and those who had felt sexually attracted only to males, never to females. Therefore, an important strength of our study is that it utilizes probability survey data that samples all WSW, not just visible communities. '7</p><p style="margin-top: 0px;">The majority of WSW in Natsal 2000 reported fewer than 5 female partners ever, similar to findings in an Australian probability sample.5 The majority of WSW in Natsal 2000 also reported male partners within the past year. These findings are in marked contrast to the findings in some UK studies that used convenience sampling, in which most WSW reported sexual activity only with women in the past year,18 and fewer lifetime male partners but more female partners ever18 and in the past year,19 than in this probability survey.</p><p style="margin-top: 0px;">In comparisons with women who reported sex exclusively with men, others have also found that women who reported sex with women and men report greater numbers of male partners ever6 and in the past year.20 The women who reported sex with women and men also appear more likely to choose sexual partners who are at a higher risk of STI and blood-borne infection such as bisexual men or injection drug users.6'7'20"22 Natsal 2000 did not include questions about the risk behaviors of respondents' partners because of the potential inaccuracy of responses. The women who reported sex with women and men in our data reported earlier onset of heterosexual activity, more unsafe sex, sex with a partner described as not regular, and greater sexual repertoire (i.e. a larger range of sexual practices experienced) compared with women who reported sex exclusively with men. Consistent with these sexual health risks, 19% of women who reported sex with women and men in Natsal 2000 reported termination of pregnancy, and 18% reported a history of STI, predominantly chlamydia These findings highlight the need for access to contraceptive advice and STI screening and treatment among women who reported sex with women and men. In contrast, there were no STIs reported by the small number of women who reported sex exclusively with women in the study.</p> <table border="0" cellpadding="0" cellspacing="0" width="200"><tbody><tr><td><a href="http://proquest.umi.com/pqdweb?vinst=PROD&fmt=4&filenumber=4&clientid=45625&vname=PQD&RQT=309&did=1286896911&scaling=HALF&ts=1230623341&vtype=PQD&rqt=309"><img src="http://proquest.umi.com/pqdweb?vinst=PROD&fmt=4&filenumber=4&clientid=45625&vname=PQD&RQT=309&did=1286896911&scaling=THUMBNAIL&ts=1230623341&vtype=PQD&rqt=309" alt="Table" /></a></td><td><table border="1" cellpadding="0" cellspacing="0"><tbody><tr><td nowrap="nowrap"><a href="http://proquest.umi.com/pqdweb?vinst=PROD&fmt=4&filenumber=4&clientid=45625&vname=PQD&RQT=309&did=1286896911&scaling=HALF&ts=1230623341&vtype=PQD&rqt=309">Enlarge 200%</a></td></tr><tr><td nowrap="nowrap"><a href="http://proquest.umi.com/pqdweb?vinst=PROD&fmt=4&filenumber=4&clientid=45625&vname=PQD&RQT=309&did=1286896911&scaling=FULL&ts=1230623341&vtype=PQD&rqt=309">Enlarge 400%</a></td></tr></tbody></table></td></tr></tbody></table><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td class="textSmall">TABLE 4-Prevalence of Health-Related Factors and Sexual and Reproductive Health Care Experiences of Women Who Reported Sex Exclusively With Men (WSEM), Women Who Reported Sex With Women and Men (WSWM), and Women Who Reported Sex Exclusively With Women (WSEW), In Natsal 2000: Great Britain</td></tr></tbody></table></span><table border="0" cellpadding="0" cellspacing="0"><tbody></tbody></table><br /><p style="margin-top: 0px;">Population-based studies from the United States concur with our findings that women who reported sex with women and men smoke more frequently,23'24 drink more alcohol,24·25 and report IDU21 and dependency upon illicit drugs26 more frequently compared with women who reported sex exclusively with men. Other studies describe high proportions of women who reported sex with women and men engaged in sex work,67·21 associations between IDU and sex work in women who reported sex with women and men,27 and greater prevalence of hepatitis B and C (but not HIV) in women who reported sex with women and men.21 Natsal 2000 did not include questions about sex work.</p><p style="margin-top: 0px;">Half of women who reported sex with women and men in Natsal 2000 reported current heterosexual cohabitation or marriage. More than two thirds of women who reported sex with women and men reported only 1 female partner in the past 5 years, in contrast to a median of 5 male sexual partners in the same time frame. A third of women who reported sex with women and men who reported only 1 female partner said that they had felt sexually attracted only to males, never to females. These proportions were surprising; Natsal 2000 used random sampling techniques and behavioral inclusion criteria and therefore included WSW who did not identify as lesbians or bisexual women. Qualitative investigation would help to explore the relationships among sexual attraction, sexual behavior, and sexual identity16 and help in understanding the sexual networks of WSW.</p><p style="margin-top: 0px;">Limitations</p><p style="margin-top: 0px;">Sensitive sexual behavior such as homosexuality may be underreported in sexual health surveys.28 However, the CASI that was developed for Natsal 2000 was more reliable than face-to-face data collection techniques or pen-and-paper methods.29"31</p><p style="margin-top: 0px;">Although Natsal 2000 was a large national survey, the sample included relatively few WSW (178 women) because of the low reported prevalence of same-sex sexual behavior. Although convenience samples may include larger numbers of WSW, this national probability sample allowed for the estimation of the size of the population of WSW. Census data estimated the number of women aged 16 to 44 years resident in Great Britain in mid-1999 as 11.5 million," so using our prevalence estimate, that suggests that approximately 322000 of these women are WSW Our data also allowed for the quantification of risks and outcomes that are generalizable to the British population. Inclusion of data about sexual behavior and partnerships in national statistics such as STI diagnoses and cancer incidence data would help to address gaps in knowledge about health outcomes in WSW.32,33</p><p style="margin-top: 0px;">Natsal 2000 surveyed those aged 16 to 44 years, so findings are not generalizable to other age groups, although other studies indicate that health risks may also be prevalent in WSW (specifically women who reported sex with women and men) at older and younger ages.4,34'35 As a general survey of sexual behavior, Natsal 2000 did not have the scope to ask women detailed questions about specific sexual practices with women.18 However this study and others show that the greatest sexual and reproductive health risks for WSW (again, specifically women who reported sex with women and men) seem to be from heterosexual sexual activity6·7·21 and behaviors such as smoking,23'24 alcohol use,24'25and IDU.21</p><p style="margin-top: 0px;">Possible Explanations and Implications for Clinicians and Policymakers</p><p style="margin-top: 0px;">In these data, a history of sex with a woman is, for a woman, a marker for increased risk of adverse sexual, reproductive, and general health outcomes, in particular more risky heterosexual practice and greater substance misuse than women who reported sex exclusively with men. Many WSW fear disclosing sexual identity to health professionals36,37 and may avoid seeking medical care.19,38 Nearly one third of women who reported sex with women and men in this survey had utilized sexual health services in the past 5 years, but only 11.1% perceived their own HIV risk as "great" or "quite a lot" despite reporting a range of risk behaviors. In addition to health promotion among WSW, there is a need for practitioners to develop skills and attitudes that allow nonjudgmental sexual history-taking from female patients, without making assumptions about sexuality or sexual behavior, to facilitate discussion of risks that WSW may face.36,39,41</p><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td nowrap="nowrap"> <span class="bold textSmall">[Reference]</span> <span class="raquo">» </span> <a title="View a list of references included in this document" href="http://proquest.umi.com/pqdweb?VInst=PROD&VName=PQD&VType=PQD&RQT=594&did=1286896911&Fmt=4&refType=CITEDIN&b2=d&SrchMode=1&sid=5&index=9&TS=1230623360" class="textSmall">View reference page with links</a></td></tr><tr><td class="textSmall">References</td></tr><tr><td class="textSmall">1. Petersen LR, Doll L, White C, Chu S. No evidence for female-to-female HIV transmission among 960,000 female blood donors. The HIV Blood Donor Study Group. J Acquir Immune Defic Syndr. 1992;5:853-855.</td></tr><tr><td class="textSmall">2. Bailey JV, Farquhar C, Owen C, Mangtani P. Sexually transmitted infections in women who have sex with women. Se* Transm Infect. 2004;80:244-246.</td></tr><tr><td class="textSmall">3. Skinner CJ, Stokes J, Kirlew Y, Kavanagh J, Forster GE. A case-controlled study of the sexual health needs of lesbians. Genitourin Med. 1996;72:277-280.</td></tr><tr><td class="textSmall">4. van Griensven F, Kilmarx PH, Jeeyapant S, et al. The prevalence of bisexual and homosexual orientation and related health risks among adolescents in northern Thailand. Arch Sex Behav. 2004;33:137-147.</td></tr><tr><td class="textSmall">5. Grulich AE, de Visser RO, Smith AM, Rissel CE, Richters J. Sex in Australia: homosexual experience and recent homosexual encounters. Aust NZJ Public Health. 2003:27:155-163.</td></tr><tr><td class="textSmall">6. Fethers K, Marks C, Mindel A, Estcourt CS. Sexually transmitted infections and risk behaviours in women who have sex with women. Sex Transm Infect. 2000;76:345-349.</td></tr><tr><td class="textSmall">7. Marrazzo JM, Koutsky LA, Handsfield HH. Characteristics of female sexually transmitted disease clinic clients who report same-sex behaviour. IntJ STD AIDS. 2001;12:41-46.</td></tr><tr><td class="textSmall">8. Aaron DJ, Chang YF, Markovic N, LaPorte RE. Estimating the lesbian population: a capture-recapture approach. JEpidemiol Community Health. 2003;57: 207-209.</td></tr><tr><td class="textSmall">9. Johnson AM, Mercer CH, Erens B, et al. Sexual behaviour in Britain: partnerships, practices, and HIV risk behaviours. Lancet. 2001;358:1835-1842.</td></tr><tr><td class="textSmall">10. Erens B, McManus S, Field J, et al. National Survey of Sexual Attitudes and Lifestyles II: Technical Report. London, England: National Centre for Social Research; 2001.</td></tr><tr><td class="textSmall">11. Walker A, O'Brien M, Traynor J, Fox K, Goddard E, Foster K. National Statistics. Living in Britain. Results From the 2001 General Household Survey. London, England: Her Majesty's Stationery Office; 2002. Available at: http://www.statistics.gov.uk/lib2001/resources/ fileAttachments/GHS2001.pdf. Accessed February 7, 2007.</td></tr><tr><td class="textSmall">12. Weffings K, Nanchahal K, Macdowall W, et al. Sexual behaviour in Britain: early heterosexual experience. Lancet. 2001;358:1843-1850.</td></tr><tr><td class="textSmall">13. Fenton KA, Mercer CH, McManus S, et al. Ethnic variations in sexual behaviour in Great Britain and risk of sexually transmitted infections: a probability survey. Lancet. 2005;365:1246-1255.</td></tr><tr><td class="textSmall">14. Alcohol and the Heart in Perspectiue: Sensible Limits Reaffirmed. London, England: Royal College of Physicians, Psychiatrists and General Practitioners; 1995.</td></tr><tr><td class="textSmall">15. Smith AM, Rissel CE, Richters J, Grulich AE, de Visser RO. Sex in Australia: sexual identity, sexual attraction and sexual experience among a representative sample of adults. Aust N ZJPublic Health. 2003;27: 138-145.</td></tr><tr><td class="textSmall">16. Brogan D, Frank E, Eton L, O'Hanlan KA. Méthodologie concerns in defining lesbian for health research. Epidemiology. 2001;12:109-113.</td></tr><tr><td class="textSmall">17. Malterud K. Health needs of women who have sex with women: methodological assumptions underlying conclusions should have been questioned. BM]. 2004:328:463-464.</td></tr><tr><td class="textSmall">18. Bailey JV, Farquhar C, Owen C, Whittaker D. Sexual behaviour of lesbians and bisexual women. Set Transm Infect. 2003;79:147-150.</td></tr><tr><td class="textSmall">19. Henderson L, Reid D, Hickson F, McLean S, Cross J, Weatherburn P. First, Service. Relationships. Sex and Health Among Lesbian and Bisexual Women. London, England: Sigma Research; 2002.</td></tr><tr><td class="textSmall">20. Koh AS, Gomez CA, Shade S, Rowley E. Sexual risk factors among self-identified lesbians, bisexual women, and heterosexual women accessing primary care settings. sec Transm Dis. 2005;32:563-569.</td></tr><tr><td class="textSmall">21. Scheer S, Peterson I, Page-Shafer K, et al. Sexual and drug use behavior among women who have sex with both women and men: results of a populationbased survey. Am] Public Health. 2002;92:1110-1112.</td></tr><tr><td class="textSmall">22. Lemp GF, Jones M, Kellogg TA, et al. HIV seroprevalence and risk behaviors among lesbians and bisexual women in San Francisco and Berkeley, California Am J Public Health. 1995:85:1549-1552.</td></tr><tr><td class="textSmall">23. Tang H, Greenwood GL, Cowling DW, Lloyd JC, Roeseler AG, BaI DG. Cigarette smoking among lesbians, gays, and biscxuals: how serious a problem? (United States). Cancer Causes Control. 2004;15: 797-803.</td></tr><tr><td class="textSmall">24. case P, Austin SB, Hunter DJ, et al. Sexual orientation, health risk factors, and physical functioning in the Nurses' Health Study H./ Womens Health (Larchmt). 2004;13:1033-1047.</td></tr><tr><td class="textSmall">25. Cochran SD, Keenan C, Schober C, Mays VM. Estimates of alcohol use and clinical treatment needs among homosexually active men and women in the US population./Consult CHn Psychol. 2000;68: 1062-1071.</td></tr><tr><td class="textSmall">26. Cochran SD, Mays VM. Relation between psychiatric syndromes and behaviorally denned sexual orientation in a sample of the US population. Am J Epidemiology. 2000:151:516-523.</td></tr><tr><td class="textSmall">27. Richters J, Bergin S, Lubowitz S, Prestage G. Women in contact with Sydney's gay and lesbian community: sexual identity, practice and HFV risks. AIDS Care. 2002:14:193-202.</td></tr><tr><td class="textSmall">28. Copas AJ, Wellings K, Erens B, et al. The accuracy of reported sensitive sexual behaviour in Britain: exploring the extent of change 1990-2000. Sex Transm Infect. 2002:78:26-30.</td></tr><tr><td class="textSmall">29. Johnson AM, Wadsworth J, Wellings K, Bradshaw S, Field J. Sexual lifestyles and HIV risk. Nature. 1992; 360:410-412.</td></tr><tr><td class="textSmall">30. Johnson AM, Wadsworth J, Wellings K, Field J. Sexual Attitudes and Lifestyles. Oxford, England: Blackwell Scientific Press; 1994.</td></tr><tr><td class="textSmall">31. Johnson AM, Copas AJ, Erens B, et al. Effect of computer-assisted self-interviews on reporting of sexual HIV risk behaviours in a general population sample: a methodological experiment AIDS. 2001:15:111-115.</td></tr><tr><td class="textSmall">32. Ford C, Clarke K. Sexually transmitted infections in women who have sex with women. Surveillance data should include this category of women. BM]. 1998:316:556-557.</td></tr><tr><td class="textSmall">33. Frisch M, Smith E, Grulich A, Johansen C. Cancer in a population-based cohort of men and women in registered homosexual partnerships. Am ] Epidemiol. 2003:157:966-972.</td></tr><tr><td class="textSmall">34. Valanis BG, Bowen D], Bassford T, Whitlock E, Charney P, Carter RA. Sexual orientation and health: comparisons in the women's health initiative sample. Arch Fam Med. 2000:9:843-853.</td></tr><tr><td class="textSmall">35. Smith AM, Lindsay J, Rosenthal DA. Same-sex attraction, drug injection and binge drinking among Australian adolescents. Aust NZJ Public Health. 1999;23: 643-646.</td></tr><tr><td class="textSmall">36. Mathieson CM. Lesbian and bisexual health care. Straight talk about experiences with physicians. Can Fam Physician. 1998:44:1634-1640.</td></tr><tr><td class="textSmall">37. Wilton T, Kaufmann T. Lesbian mothers' experiences of maternity care in the UK. Midwifery. 2001 ;17: 203-211.</td></tr><tr><td class="textSmall">38. Marrazzo JM, Stine K, Koutsky LA. Genital human papillomavirus infection in women who have sex with women: a review. AmJ Obstet Gynecol. 2000:183: 770-774.</td></tr><tr><td class="textSmall">39. McNair R. Lesbian sexuality. Do GPs contribute to lesbian invisibility and ill health? Aust Fam Physician. 2000:29:514-516.</td></tr><tr><td class="textSmall">40. O'Hanlan KA, Crum C. Lesbian health and homophobia: perspectives for the treating obstetrician/ gynecologist Curr Probl Obstet Gynecol Fertil. 1995;18: 94-133.</td></tr><tr><td class="textSmall">41. Diamant AL, Schuster MA, McGuigan K, Lever J. Lesbians' sexual history with men: implications for taking a sexual history. Arch Intern Med. 1999;159: 2730-2736.</td></tr><tr><td class="textSmall">42. The National Statistics Socio-economic Classification. Available at: http://www.tatistics.gov.uk/methods_ quality/ns_sec/continuity.asp. Accessed February 7, 2007.</td></tr></tbody></table></span><table border="0" cellpadding="0" cellspacing="0"><tbody></tbody></table><br /><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td class="textSmall" nowrap="nowrap"><b>[Author Affiliation]</b></td></tr><tr><td class="textSmall">Catherine H. Mercer, PhD, Julia V. Bailey, MD, Anne M. Johnson, MD, Bob Erens, MA, Kaye Wellings, MSc, Kevin A. Fenton, PhD, and Andrew J. Copas, PhD</td></tr></tbody></table></span><table border="0" cellpadding="0" cellspacing="0"><tbody></tbody></table><br /><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td class="textSmall" nowrap="nowrap"><b>[Author Affiliation]</b></td></tr><tr><td class="textSmall">About the Authors</td></tr><tr><td class="textSmall">Catherine H. Mercer and Andrew]. Copas are with the Centre for Sexual Health and HlV Research at University College London, London, England. At the time of the study, Julia V. Bailey was with Kings College London, London. Anne M.Johnson is with the Department of Primary Care and Population Sciences at University College London, London. Bob Erens is with the National Centre for Social Research, London. Kaye Wellings is with the London School of Hygiene and Tropical Medicine, London. Kevin A. Fenton is with the Division of STD Prevention, National Centers for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Ga.</td></tr><tr><td class="textSmall">Requests for reprints should be sent to Catherine Mercer, Centre for Sexual Health and HIV Research, University College London, Mortimer Market Centre, off Capper Street, London, WClE 6JB, England (e-mail: cmercer@gum.ucl.ac.uk).</td></tr><tr><td class="textSmall">Contributors</td></tr><tr><td class="textSmall">C.H. Mercer and A.M. Johnson originated the study. C. H. Mercer led the writing of the article and carried out all analyses with assistance from A. J. Copas. J. V. Bailey led the literature review and contributed extensively to the interpretation of the data and the article's writing. A. M. Johnson, B. Erens, K. Wellings, and K. A. Fenton were co-investigators and participated in the design and management of the main study. All authors contributed to the preparation of the article.</td></tr><tr><td class="textSmall">Acknowledgments</td></tr><tr><td class="textSmall">The study was supported by a grant from the United Kingdom Medical Research Council with funds from the Department of Health, the Scottish Executive, and the National Assembly for Wales.</td></tr><tr><td class="textSmall">We thank the study participants, the team of interviewers and operations, and computing staff from the National Centre for Social Research who carried out the interviews.</td></tr><tr><td class="textSmall">Note. The views expressed in this article are that of the authors and do not necessarily reflect the views of the funding institutions.</td></tr><tr><td class="textSmall">Human Participant Protection</td></tr><tr><td class="textSmall">The study was approved by the University College Hospital and North Thames Multi-Centre Research Ethics Committee and all the Local Research Ethics Committees in Britain.</td></tr></tbody></table></span><table border="0" cellpadding="0" cellspacing="0"><tbody></tbody></table>All About Bloggerhttp://www.blogger.com/profile/17282736671555579827noreply@blogger.com0tag:blogger.com,1999:blog-4987803374989865601.post-67513005420375605592008-12-29T23:38:00.000-08:002008-12-29T23:47:26.633-08:00Acute infections, vaccination and prevention of cardiovascular disease<p style="margin-top: 0px;">Extensive research in recent decades has established a critical role for cellular and humoral inflammation in the initiation and progression of atherosclerosis and its acute clinical presentations.1 Although atherosclerotic disease has a slow progression over many years, several intrinsic and extrinsic factors may trigger latent stable atherosclerotic plaques to become inflamed, unstable plaques that often rupture and start a cascade leading to thrombus formation and acute coronary syndromes or sudden cardiac death. Respiratory infections are among the known triggers for such acute cardiovascular events.</p><p style="margin-top: 0px;">In the past 2 decades, many basic and epidemiologic studies have suggested a role for chronic indolent infections, such as Chlamydia pneumoniae, in the chronic progression of atherosclerotic lesions over years. Failure of clinical trials using antibiotics against C. pneumoniae to prevent cardiovascular events has led to a decreased interest in the role of infections in cardiovascular disease. However, in contrast to chronic infections, acute infections may cause acute coronary syndromes by triggering severe and abrupt inflammatory changes in high-risk coronary plaques over a few days or weeks. Prevention or treatment of these infections may offer new targets for coronary prevention.2</p><p style="margin-top: 0px;">In this issue of CMAJ, Lamontagne and colleagues3 present their findings from a large hospital-based database study. The authors studied the incidence of myocardial infarctions among those who had or had not received a pneumococcal vaccine before admission to hospital. They include patients who were free of known atherosclerotic disease but who were at risk of myocardial infarction based on age (men aged 45 years or older, women aged 50 years or older) and who had at least 1 cardiovascular disease risk factor (hypertension, diabetes or hyperlipidemia). The authors report that people who had a myocardial infarction were less likely than those who did not have a myocardial infarction to have received a pneumococcal polysaccharide vaccine (7.1% v. 11.6%; adjusted odds ratio 0.53, 95% confidence interval 0.40-0.70).</p><p style="margin-top: 0px;">The study by Lamontagne and colleagues does not include data on the incidence of pneumonia and its relation to myocardial infarction in cases and controls. However, it is reasonable to hypothesize that pneumococcal vaccination may protect against cardiovascular events by preventing pneumonia, as the latter has been shown to trigger myocardial infarction. Musher and colleagues4 reviewed a series of 170 patients admitted to hospital with pneumococcal pneumonia over a 5- year period and found that about 7% of patients had a myocardial infarction while in hospital. They also report that about 20% of patients had either a myocardial infarction, atrial fibrillation, or new or worsening congestive heart failure while in hospital.4 Other studies have suggested that infections in the upper respiratory tract and urinary tract can trigger myocardial infarctions.5 Spodick and colleagues reported that, in the 2-week period before being admitted to hospital for a myocardial infarction, 28% of patients had acute respiratory symptoms.6 In an autopsy-based study, my group observed that influenza epidemics are associated with a sharp rise in the number of deaths caused by myocardial infarction and ischemic heart disease.7 In fact, during almost all influenza epidemics and pandemics (except for the 1918 Spanish influenza pandemic), about twice as many people die of cardiac causes as die of pneumonia.8 Myocardial infarction was also reported to be the cause of death in 2 of 5 fatal cases among 75 patients with severe acute respiratory syndrome.9</p><p style="margin-top: 0px;">Multiple mechanisms could contribute to the cardioprotective effect of pneumococcal vaccination. A study in mice lacking the low-density lipoprotein (LDL) receptor suggested that the molecular mimicry between epitopes of Streptococcus pneumoniae and oxidized LDL may lead to increased anti-oxidized LDL immunoglobins following pneumococcal vaccination, which may lead to a decreased extent of atherosclerosis.10 However, production of such antibodies following pneumococcal vaccination in humans has not been confirmed.11 This interesting pathway requires further research. In addition, S. pneumoniae and other respiratory infections may exert many acute effects directly relevant to acute coronary syndromes. My colleagues and I have previously shown that influenza infection leads to excessive recruitment of inflammatory cells to atherosclerotic aortic plaques in mice lacking apolipoprotein E receptor.12 Similarly, compared with controls, the coronary arteries of patients who died of acute systemic infections show a higher number of macrophages and T cells in their adventitia and periadventitial fat, and more dendritic cells in the intima and media.13 In synergy with local cellular inflammation, there is an extensive systemic inflammation heralded by acute increase in systemic markers of inflammation.2 These acute inflammatory changes are paralleled by activation of the coagulation cascade and increased levels of coagulation factors. Finally, such acute infections are also associated with tachycardia, hemodynamic stress, fever, dehydration, increased plasma viscosity, release of endogenous cathecholamines, possible demand ischemia, severe endothelial dysfunction and qualitative pro-oxidant changes in high-density lipoprotein. Each of these can play an important role in acute coronary syndromes.2,14</p><p style="margin-top: 0px;">Given the pivotal role of inflammation and its relation to infection in the development of acute coronary syndromes, it would be prudent to test drugs that affect inflammatory mechanisms in clinical scenarios involving atherosclerosis. Statins are known to have such anti-inflammatory effects.1 There have been conflicting conclusions from studies examining the effect of statins on mortality of people admitted to hospital with community-acquired pneumonia. New well-designed studies of statins in the context of acute infection focused on cardiovascular outcomes are needed. Preliminary reports from my laboratory suggest that statins have a direct antiinfluenza effect,15 and they could be tested for similar effects against S. pneumoniae and other microbial agents. Hypothetically, in adults with respiratory infections, acetylsalicylic acid (ASA) could be useful not only for relief of respiratory symptoms but also for preventing coronary events, because ASA may help to reduce inflammation and inhibit platelet function during high-risk periods.2 Finally, further research is needed to assess whether the use of antimicrobials can prevent cardiovascular events if used in a timely manner when infections occur without or despite vaccination.</p><p style="margin-top: 0px;">Multiple case-control, cohort and randomized clinical trials in different settings have shown that preventing influenza by vaccination can reduce the risk of recurrent myocardial infarction, sudden cardiac death, cardiac hospital admissions, need for revascularization and stroke.2,14 The current study by Lamontagne and colleagues suggests that pneumococcal vaccination could similarly be a safe and inexpensive tool to prevent cardiovascular events. However, results of case-control studies should be interpreted with caution. "Healthy user" bias is a possibility in case-control studies. Receipt of pneumococcal vaccine may be an indicator of better access to health care, healthier life style and better control of risk factors. The study findings were significant after adjustment for several confounders; however, statistical models may not completely overcome the complex interactions between confounders. Further prospective and randomized studies are needed to confirm these findings.</p><p style="margin-top: 0px;">Until confirmatory studies are available, clinicians should comply with available guidelines by increasing current vaccination rates among patients at high risk. In the United States, rates of pneumococcal and influenza vaccination are well below the established goals, and the situation is worse in many other countries. In addition, clinicians should reduce the baseline risk of cardiovascular events in vulnerable patients by judicious use of antihypertensive, lipid-lowering drugs (preferably statins) and ASA.</p><p style="margin-top: 0px;">Competing interests: Mohammad Madjid received an honorarium from Pfizer for participation in an advisory board meeting in 2007.</p><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td class="textSmall" nowrap="nowrap"><b>[Sidebar]</b></td></tr><tr><td class="textSmall">Key points</td></tr><tr><td class="textSmall">* Infections of the upper respiratory tract, including pneumonia and influenza, can trigger acute coronary syndromes.</td></tr><tr><td class="textSmall">* Prevention of these infections by vaccination may prevent cardiovascular events in people at high risk.</td></tr><tr><td class="textSmall">* Rates of pneumococcal and influenza vaccination are below the optimal level in most countries.</td></tr><tr><td class="textSmall">* Physicians need to improve vaccination rates by actively advocating vaccination following established guidelines.</td></tr><tr><td class="textSmall">* Special attention should be paid to symptoms and signs of cardiac events in patients at high risk for cardiovascular disease who have an upper respiratory tract infection.</td></tr><tr><td class="textSmall">From the Texas Heart Institute and the Baylor College of Medicine, Houston, USA</td></tr></tbody></table></span><table border="0" cellpadding="0" cellspacing="0"><tbody></tbody></table><br /><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td nowrap="nowrap"> <span class="bold textSmall">[Reference]</span> <span class="raquo">» </span> <a title="View a list of references included in this document" href="http://proquest.umi.com/pqdweb?VInst=PROD&VName=PQD&VType=PQD&RQT=594&did=1566223051&Fmt=3&refType=CITEDIN&b2=d&SrchMode=1&sid=1&index=0&TS=1230622793" class="textSmall">View reference page with links</a></td></tr><tr><td class="textSmall">REFERENCES</td></tr><tr><td class="textSmall">1. Willerson JT, Ridker PM. Inflammation as a cardiovascular risk factor. Circulation 2004;109(Suppl 1):II2-10.</td></tr><tr><td class="textSmall">2. Madjid M, Naghavi M, Litovsky S, et al. Influenza and cardiovascular disease: a new opportunity for prevention and the need for further studies. Circulation 2003;108:2730-6.</td></tr><tr><td class="textSmall">3. Lamontagne F, Garant MP, Carvalho JC, et al. Pneumococcal vaccination and risk of myocardial infarction. CMAJ 2008;179:773-7.</td></tr><tr><td class="textSmall">4. Musher DM, Rueda AM, Kaka AS, et al. The association between pneumococcal pneumonia and acute cardiac events. Clin Infect Dis 2007;45:158-65.</td></tr><tr><td class="textSmall">5. Smeeth L, Thomas SL, Hall AJ, et al. Risk of myocardial infarction and stroke after acute infection or vaccination. N Engl J Med 2004;351:2611-8.</td></tr><tr><td class="textSmall">6. Spodick DH, Flessas AP, Johnson MM. Association of acute respiratory symptoms with onset of acute myocardial infarction: prospective investigation of 150 consecutive patients and matched control patients. Am J Cardiol 1984;53:481-2.</td></tr><tr><td class="textSmall">7. Madjid M, Miller CC, Zarubaev VV, et al. Influenza epidemics and acute respiratory disease activity are associated with a surge in autopsy-confirmed coronary heart disease death: results from 8 years of autopsies in 34,892 subjects. Eur Heart J 2007;28:1205-10.</td></tr><tr><td class="textSmall">8. Madjid M, Casscells SW. Of birds and men: cardiologists' role in influenza pandemics. Lancet 2004;364:1309.</td></tr><tr><td class="textSmall">9. Peiris JS, Chu CM, Cheng VC, et al. Clinical progression and viral load in a community outbreak of coronavirus-associated SARS pneumonia: a prospective study. Lancet 2003;361:1767-72.</td></tr><tr><td class="textSmall">10. Binder CJ, Horkko S, Dewan A, et al. Pneumococcal vaccination decreases atherosclerotic lesion formation: molecular mimicry between streptococcus pneumoniae and oxidized LDL. Nat Med 2003;9:736-43.</td></tr><tr><td class="textSmall">11. Nguyen JT, Myers N, Palaia J, et al. Humoral responses to oxidized low-density lipoprotein and related bacterial antigens after pneumococcal vaccine. Transl Res 2007;150:172-9.</td></tr><tr><td class="textSmall">12. Naghavi M, Wyde P, Litovsky S, et al. Influenza infection exerts prominent inflammatory and thrombotic effects on the atherosclerotic plaques of apolipoprotein e-deficient mice. Circulation 2003;107:762-8.</td></tr><tr><td class="textSmall">13. Madjid M, Vela D, Khalili-Tabrizi H, et al. Systemic infections cause exaggerated local inflammation in atherosclerotic coronary arteries: clues to the triggering effect of acute infections on acute coronary syndromes. Tex Heart Inst J 2007;34:11-8.</td></tr><tr><td class="textSmall">14. Madjid M, Aboshady I, Awan I, et al. Influenza and cardiovascular disease: Is there a causal relationship? Tex Heart Inst J 2004;31:4-13.</td></tr><tr><td class="textSmall">15. Haidari M, Ali M, Casscells W, et al. Statins block influenza infection by downregulating Rho/rho kinase pathway [abstract]. Circulation 2007;116:II_7.</td></tr></tbody></table></span><table border="0" cellpadding="0" cellspacing="0"><tbody></tbody></table><br /><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td class="textSmall" nowrap="nowrap"><b>[Author Affiliation]</b></td></tr><tr><td class="textSmall">Mohammad Madjid MD</td></tr></tbody></table></span><table border="0" cellpadding="0" cellspacing="0"><tbody></tbody></table><br /><span style="font-size:100%;"><table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td class="textSmall" nowrap="nowrap"><b>[Author Affiliation]</b></td></tr><tr><td class="textSmall">Correspondence to: Dr. Mohammad Madjid, Texas Heart Institute, 6770 Bertner Ave., MC 2-255, Houston TX 77030, USA; fax 832 355-9595; mmadjid@gmail.com</td></tr></tbody></table></span>All About Bloggerhttp://www.blogger.com/profile/17282736671555579827noreply@blogger.com0