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An increase in heterosexual HIV transmission is occurring in Vietnam, where women working in entertainment establishments as well as women in brothels may practice commercial sex. This study surveyed a cross-sectional sample of 500 women in entertainment services in the tourist city of Vung Tau in southern Vietnam in 1996. The mean age of the women was 24 years, 23% were married, and 266 (53%) reported sex during the last 12 months, of whom 70% were having multiple or casual partners (nonregular sex). Twenty-nine percent of married women were having extramarital relations; the mean number of partners during the last year was 22.5 among married women and 18.8 among unmarried women (range 2-360). The HIV prevalence among sexually active women was 0.5%. Factors associated with having more than 5 partners or nonregular sex included working in bars or coffee shops and having a high declared income (>100 USD/month), even though many received no official salary. It is likely that many of these women are practicing commercial sex. Despite the difficulty of access, these women must be targeted for condom promotion and HIV prevention services. [ABSTRACT FROM AUTHOR]

Issue: Several investigators are preparing to conduct efficacy trials of human immunodeficiency virus (HIV) vaccines in the developing world. Failure to adequately address the unique ethical, behavioral, and social issues that surround vaccine testing in that setting will jeopardize the success of these trials and future acquired immunodeficiency syndrome (AIDS) research in the host nation.Description Of the Project: Twelve investigators from Africa, Asia, North America, and South America reviewed previous experience with HIV trials in developing countries and explored potential solutions to these issues.Conclusions: Host country scientists, government officials, and media must be actively involved in all aspects of the trials. Minimum prerequisites for conducting the trial include the following: (1) researching vaccines active against developing world HIV isolates; (2) establishing and maintaining an adequate technological infrastructure; (3) assessing the feasibility of recruitment in countries where the existence of HIV may be denied; (4) designing methods to obtain informed consent from each individual subject, rather than exclusively from family members or community elders; (5) creating locally appropriate instruments to measure risk behavior; (6) identifying a behavioral intervention for placebo and treatment groups; (7) making available laboratory methods to distinguish between natural HIV infection and vaccine-induced seropositivity; and (8) guaranteeing that an effective vaccine is available free of charge to the placebo group and at affordable prices to other host country residents. [ABSTRACT FROM AUTHOR]

Objective: To develop a human immunodeficiency virus (HIV) staging system for sub-Saharan Africa on the basis of an evaluation of the World Health Organization (WHO) system and predictors of mortality.Design: Prospective cohort study with 4 years of follow-up.Setting: Kigali, Rwanda.Patients: 412 HIV-infected women recruited from prenatal and pediatric clinics.Measurements: Clinical signs and symptoms of HIV disease, laboratory assays (including complete blood count and erythrocyte sedimentation rate), and cumulative mortality.Results: The WHO staging system includes a clinical and a laboratory axis. The clinical axis was revised by inclusion of oral candidiasis, chronic oral or genital ulcers, and pulmonary tuberculosis as "severe" disease (clinical stage IV); in addition, body mass index was substituted for weight loss in the definition for the wasting syndrome. The 36-month cumulative mortality was 7% for women in modified clinical stage I ("asymptomatic"), 15% for those in stage II, 19% for those in stage III, and 36% for those in stage IV (P < 0.001). The laboratory axis was revised by replacing lymphocyte count with hematocrit and erythrocyte sedimentation rate. The 36-month mortality was 10% for women in modified stage A ("normal" laboratory results) and 33% for those in stage B (erythrocyte sedimentation rate > 65 mm/h or hematocrit < 0.38) (P < 0.001). A single staging system combining clinical and laboratory criteria is proposed, with a 36-month mortality of 7% for women in combined stage I, 10% for those in stage II, 29% for those in stage III, and 62% for those in stage IV (P < 0.001).Conclusions: On the basis of this analysis, a staging system relevant for sub-Saharan Africa is proposed that reflects the range of HIV-related outcomes, has strong prognostic significance, includes inexpensive and available laboratory tests, and can be used by both clinicians and researchers. [ABSTRACT FROM AUTHOR]

Understanding the incidence of disease is often crucial for public policy decision-making, as observed during the COVID-19 pandemic. Estimating incidence is challenging, however, when the definition of incidence relies on tests that imperfectly measure disease, as in the case when assays with variable performance are used to detect the SARS-CoV-2 virus. To our knowledge, there are no pragmatic methods to address the bias introduced by the performance of labs in testing for the virus. In the setting of a longitudinal study, we developed a maximum likelihood estimation-based approach to estimate laboratory performance-adjusted incidence using the expectation-maximization algorithm. We constructed confidence intervals (CIs) using both bootstrapped-based and large-sample interval estimator approaches. We evaluated our methods through extensive simulation and applied them to a real-world study (TrackCOVID), where the primary goal was to determine the incidence of and risk factors for SARS-CoV-2 infection in the San Francisco Bay Area from July 2020 to March 2021. Our simulations demonstrated that our method converged rapidly with accurate estimates under a variety of scenarios. Bootstrapped-based CIs were comparable to the large-sample estimator CIs with a reasonable number of incident cases, shown via a simulation scenario based on the real TrackCOVID study. In more extreme simulated scenarios, the coverage of large-sample interval estimation outperformed the bootstrapped-based approach. Results from the application to the TrackCOVID study suggested that assuming perfect laboratory test performance can lead to an inaccurate inference of the incidence. Our flexible, pragmatic method can be extended to a variety of disease and study settings., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose: In an effort to decrease transmission during the first years of the COVID-19 pandemic, public health officials encouraged masking, social distancing, and working from home, and restricted travel. However, many studies of the effectiveness of these measures had significant methodologic limitations. In this analysis, we used data from the TrackCOVID study, a longitudinal cohort study of a population-based sample of 3846 adults in the San Francisco Bay Area, to evaluate the association between self-reported protective behaviors and incidence of SARS-CoV-2 infection., Methods: Participants without SARS-CoV2 infection were enrolled from August to December 2020 and followed monthly with testing and surveys (median of four visits)., Results: A total of 118 incident infections occurred (3.0% of participants). At baseline, 80.0% reported always wearing a mask; 56.0% avoided contact with nonhousehold members some/most of the time; 9.6% traveled outside the state; and 16.0% worked 20 or more hours per week outside the home. Factors associated with incident infection included being Black or Latinx, having less than a college education, and having more household residents. The only behavioral factor associated with incident infection was working outside the home (adjusted hazard ratio 1.62, 95% confidence interval 1.02-2.59)., Conclusions: Focusing on protecting people who cannot work from home could help prevent infections during future waves of COVID-19, or future pandemics from respiratory viruses. This focus must be balanced with the known importance of directing resources toward those at risk of severe infections., Competing Interests: Declaration of Competing Interest The authors have no competing interests to disclose., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: There is limited evidence to evaluate screening algorithms with rapid antigen testing and exposure assessments as identification strategies for paucisymptomatic or asymptomatic Ebola virus (EBOV) infection and unrecognized EBOV disease (EVD)., Methods: We used serostatus and self-reported postexposure symptoms from a cohort study to classify contact-participants as having no infection, paucisymptomatic or asymptomatic infection, or unrecognized EVD. Exposure risk was categorized as low, intermediate, or high. We created hypothetical scenarios to evaluate the World Health Organization (WHO) case definition with or without rapid diagnostic testing (RDT) or exposure assessments., Results: This analysis included 990 EVD survivors and 1909 contacts, of whom 115 (6%) had paucisymptomatic or asymptomatic EBOV infection, 107 (6%) had unrecognized EVD, and 1687 (88%) were uninfected. High-risk exposures were drivers of unrecognized EVD (adjusted odds ratio, 3.5 [95% confidence interval, 2.4-4.9]). To identify contacts with unrecognized EVD who test negative by the WHO case definition, the sensitivity was 96% with RDT (95% confidence interval, 91%-99%), 87% with high-risk exposure (82%-92%), and 97% with intermediate- to high-risk exposures (93%-99%). The proportion of false-positives was 2% with RDT and 53%-93% with intermediate- and/or high-risk exposures., Conclusion: We demonstrated the utility and trade-offs of sequential screening algorithms with RDT or exposure risk assessments as identification strategies for contacts with unrecognized EVD., Competing Interests: Potential conflicts of interest. All authors: No reported conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (Published by Oxford University Press on behalf of Infectious Diseases Society of America 2022.)

Purpose: We describe the design of a longitudinal cohort study to determine SARS-CoV-2 incidence and prevalence among a population-based sample of adults living in six San Francisco Bay Area counties., Methods: Using an address-based sample, we stratified households by county and by census-tract risk. Risk strata were determined by using regression models to predict infections by geographic area using census-level sociodemographic and health characteristics. We disproportionately sampled high and medium risk strata, which had smaller population sizes, to improve precision of estimates, and calculated a desired sample size of 3400. Participants were primarily recruited by mail and were followed monthly with PCR testing of nasopharyngeal swabs, testing of venous blood samples for antibodies to SARS-CoV-2 spike and nucleocapsid antigens, and testing of the presence of neutralizing antibodies, with completion of questionnaires about socio-demographics and behavior. Estimates of incidence and prevalence will be weighted by county, risk strata and sociodemographic characteristics of non-responders, and will take into account laboratory test performance., Results: We enrolled 3842 adults from August to December 2020, and completed follow-up March 31, 2021. We reached target sample sizes within most strata., Conclusions: Our stratified random sampling design will allow us to recruit a robust general population cohort of adults to determine the incidence of SARS-CoV-2 infection. Identifying risk strata was unique to the design and will help ensure precise estimates, and high-performance testing for presence of virus and antibodies will enable accurate ascertainment of infections., (Copyright © 2021 The Author(s). Published by Elsevier Inc. All rights reserved.)

We examined associations with HIV recent infection and estimated transmitted drug resistance (TDR) prevalence among 3345 men at sexually transmitted infection clinics in Mumbai (2002-2005). HIV seroincidence was 7.92% by the BED-CEIA and was higher at a clinic located near brothels (12.39%) than at a hospital-based clinic (3.94%). HIV recent infection was associated with a lifetime history of female sex worker (FSW) partners, HSV-2, genital warts, and gonorrhea. TDR prevalence among recent infection cases was 5.7%. HIV testing services near sex venues may enhance case detection among high-risk men who represent a bridging population between FSWs and the men's other sexual partners.

This cross-sectional study investigated the prevalence and correlates of symptoms of depression among 400 people living with HIV/AIDS (PLHIV) from two HIV clinics in Ho Chi Minh City, Vietnam. Based on the Center for Epidemiologic Studies-Depression scale, 36.5% of participants were classified as likely to be clinically depressed. Factors independently associated with symptoms of depression included self-report of poor or fair health (aOR 2.16, 95% CI 1.33-3.51), having a low body mass index (aOR 1.85, 95% CI 1.13-3.04), reporting recent problems with family (aOR 1.97, 95% CI 1.21-3.19), feeling shame about being HIV-infected (aOR 1.90, 95% CI 1.20-3.00), and reporting conflict with a partner (aOR 2.21, 95% CI 1.14-4.26). Participants who lived with family (aOR 0.48, 95% CI 0.25-0.90) or who received emotional support from their families or supportive HIV networks (aOR 0.45, 95% CI 0.25-0.80) were less likely to experience symptoms of depression. Screening for and treatment of depression among Vietnamese PLHIV are needed.

Studies have shown that people suffering from food insecurity are at higher risk for infectious and noncommunicable diseases and have poorer health outcomes. No study, however, has examined the association between food insecurity and outcomes related to Ebola virus disease (EVD). We conducted a cross-sectional study in two Ebola-affected communities in Kono district, Sierra Leone, from November 2015 to September 2016. We enrolled persons who were determined to have been exposed to Ebola virus. We assessed the association of food insecurity, using an adapted version of the Household Food Insecurity Access Scale, a nine-item scale well validated across Africa, with having been diagnosed with EVD and having died of EVD, using logistic regression models with cluster-adjusted standard errors. We interviewed 326 persons who were exposed to Ebola virus; 61 (19%) were diagnosed with EVD and 45/61 (74%) died. We found high levels (87%) of food insecurity, but there was no association between food insecurity and having been diagnosed with EVD. Among EVD cases, those who were food insecure had 18.3 times the adjusted odds of death than those who were food secure ( P = 0.03). This is the first study to demonstrate a potential relationship between food insecurity and having died of EVD, although larger prospective studies are needed to confirm these findings.

Studies have yet to include minimally symptomatic Ebola virus (EBOV) infections and unrecognized Ebola virus disease (EVD) in Ebola-related transmission chains and epidemiologic risk estimates. We conducted a cross-sectional, sero-epidemiological survey from October 2015 to January 2016 among 221 individuals living in quarantined households from November 2014 to February 2015 during the Ebola outbreak in the village of Sukudu, Sierra Leone. Of 48 EBOV-infected persons, 25% (95% confidence interval [CI], 14%-40%) had minimally symptomatic EBOV infections and 4% (95% CI, 1%-14%) were unrecognized EVD cases. The pattern of minimally symptomatic EBOV infections in the transmission chain was nonrandom (P < .001, permutation test). Not having lived in the same house as an EVD case was significantly associated with minimally symptomatic infection. This is the first study to investigate a chain of EBOV transmission inclusive of minimally symptomatic EBOV infections and unrecognized EVD. Our findings provide new insights into Ebola transmission dynamics and quarantine practices.

We evaluated motorcycle taxi ('boda-boda') drivers in Kampala for the prevalence of HIV/sexually transmitted infections. We used respondent-driven sampling to recruit a cross-sectional sample of boda-boda drivers. We collected data through audio computer-assisted self-administered interviews. Men were tested for HIV, syphilis serology using Rapid Plasma Reagin and enzyme immunoassay, and Chlamydia and gonorrhoea using urine polymerase chain reaction. We recruited 683 men. Median age was 26 years; 59.4% were single. The prevalence of HIV was 7.5% (95% CI 5.2-10.0), of positive syphilis serology was 6.1% (95% CI 4.3-8.1), of Chlamydia was 1.1% (95% CI 0.4-2.0), and of gonorrhoea was 1.2% (95% CI 0.1-1.2). Many men (67.8%) had both casual and regular partners, sex with other men (8.7%), and commercial sex (33.1%). Factors associated with having HIV included reporting a genital ulcer (odds ratio [OR] =2.4, 95% CI 1.4-4.4), drinking alcohol during last sex (OR 2.0, 95% CI 1.1-3.7), having 4-6 lifetime partners (OR 2.2, 95% CI 1.0-4.8), and having one's last female partner be >24 years of age (OR 2.8, 95% CI 1.2-6.6). Independent predictors of HIV included age ≥31 (adjusted OR (aOR) 5.8, 95% CI 1.5-48.5), having 4-6 partners (aOR 2.2, 95%CI 1.0-5.1), and self-report of a genital ulcer (OR 2.3, 95% CI 1.2-4.1). Only 39.2% of men were circumcised, and 36.9% had been HIV tested in the past. Male boda-boda drivers have a higher prevalence of HIV than the general population, and low frequency of preventive behaviours, such as circumcision and HIV testing. Targeted and intensified interventions for this group are warranted., (© The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Adolescents and young adults are at high risk of human immunodeficiency virus (HIV) infection in sub-Saharan Africa. Previous reports have found that university students in Africa comprise a sexually active population, although the prevalence of HIV or sexually transmitted infections (STI) has not been measured. We conducted a cross-sectional survey of students from five large universities in Kampala, Uganda, using respondent-driven sampling. We asked students to complete behavioral questionnaires and provide biological samples to test for HIV, Chlamydia trachomatis, Neisseria gonorrhoeae, Treponema pallidum, Trichomonas vaginalis, and bacterial vaginosis. We enrolled 649 students and obtained interpretable data from 640. Around 50% of the respondents were male, and the mean age was 22 years. An estimated 0.8% (95% CI 0.0-2.0) of male students had Chlamydia infection, approximately 4.3% (95% CI 2.0-7.0) had syphilis, 0.4% (95% CI 0.0-0.9) had HIV, and none had gonorrhea. An estimated 32.6% (95% CI 22.4-40.8) of women had bacterial vaginosis, 2.5% (95% CI 0.7-6.3) had Chlamydia infection, 1.7% (95% CI 0.5-3.6) had syphilis, 1.0% (95% CI 0.0-2.4) had gonorrhea, 0.9% (95% CI 0.0-4.2) had trichomoniasis, and 0.9% (95% CI 0.0-1.8) had HIV. We found no significant risk factors for HIV or other STI among males. We also found that not using a condom during the latest sexual intercourse was significantly associated with HIV infection, other STI, or bacterial vaginosis (OR 2.16; 95% 1.26-3.78) among females. We conclude that while university students are sexually active and there is substantial risk for syphilis, there is little evidence of substantially increased HIV risk among them.

Background: The global annual attack rate for influenza is estimated to be 10%-20% in children, although limited information exists for Africa. In 2007, Ghana initiated influenza surveillance by routine monitoring of acute respiratory illness to obtain data on circulating strains. We describe influenza surveillance in children <11 years old who had influenza-like illness (ILI) from January 2008 to December 2010., Methods: Oropharyngeal swabs from pediatric outpatients with ILI attending any of 22 health facilities across the country were submitted. We tested swabs for influenza virus using molecular assays, virus isolation, and hemagglutination assays., Results: Of the 2810 swabs, 636 (23%) were positive for influenza virus. The percentage of positives by gender was similar. The proportion of ILI cases positive for influenza increased with age from 11% (31/275) in infants (aged 0-1 years) to 31% (377/1219) among children aged 5-10 years (P < .001). The majority of cases were influenza A (90%), of which 60% were influenza A(H1N1)pdm09. In all 3 years, influenza activity appeared slightly higher during May through July., Conclusions: During the 3 years of influenza surveillance in Ghana, children aged <11 years bore a high burden of influenza-associated ILI.

No test for assessing cellular immune response in coccidioidomycosis is currently available in the United States. In the present study, we tested 49 healthy subjects living in the coccidioidal endemic region with a 1:55.8 dilution of a single lot of coccidioidin archived since the 1970s. In this group, 23 evaluable subjects demonstrated >/=5 mm of induration at 24, 48 or 72 h, with a mean+/-SEM maximum induration of 18.4+/-4.0 mm. The induration results among 14 subjects reactive at 24 h were compared to those from 179 individuals in an historical cohort studied in the 1980s using a reference lot of coccidioidin. Results were within 5% and not significantly different (P=0.924). The maximum induration response of all evaluable subjects correlated significantly with the results of in vitro tests of coccidioidal cellular immunity using supernatant interferon-gamma concentration and CD69 expression on T cells (Spearman rank correlation coefficients 0.69 and 0.68, respectively; P<0.01 for both). These data suggest that archived coccidioidin retains its potency and specificity and that in vitro test of coccidioidal immunity may have utility in the measurement of coccidioidal cellular immunity.

Objective: We investigated whether men who were under the influence of alcohol when visiting female sex workers (FSW) were at greater risk for sexually transmitted infections (STI) and human immunodeficiency virus (HIV)., Study: A cross-sectional analysis using baseline data from a randomized controlled trial of an HIV prevention intervention for high-risk men in Mumbai, India., Results: The overall HIV prevalence among 1741 men sampled was 14%; 64% had either a confirmed STI or HIV; 92% reported sex with an FSW, of whom 66% reported having sex while under the influence of alcohol (SUI). SUI was associated with unprotected sex (odds ratio [OR]: 3.1; 95% confidence interval [CI], 2.3-4.1), anal sex (OR: 1.5; 1.1-2.0), and more than10 FSW partners (OR: 2.2; 1.8-2.7). SUI was independently associated with having either an STI or HIV (OR: 1.5; 1.2-1.9)., Conclusion: Men who drink alcohol when visiting FSWs engage in riskier behavior and are more likely to have HIV and STIs. Prevention programs in India need to raise awareness of this relationship.

Objective: To determine the incidence of Coccidioides infection among dogs residing in a region in which the organism is endemic (Pima and Maricopa counties, Arizona) and estimate the rate of clinical illness., Design: Community-based longitudinal and cross-sectional studies., Animals: 124 healthy 4- to 6-month-old seronegative puppies (longitudinal study) and 381 4- to 18-month-old dogs with unknown serostatus (cross-sectional study)., Procedure: Dogs in the longitudinal study were tested at 6-month intervals for at least 1 year for anticoccidioidal antibodies. Dogs that became ill were evaluated for coccidioidomycosis. Dogs in the cross-sectional study were tested for anticoccidioidal antibodies once, and clinical abnormalities were recorded., Results: 28 of the 104 (27%) dogs that completed the longitudinal study developed anticoccidioidal antibodies. Thirty-two of the 381 (8%) dogs in the cross-sectional study had anticoccidioidal antibodies. Five seropositive dogs in the longitudinal study and 13 seropositive dogs in the cross-sectional study had clinical signs of disease. The remaining seropositive dogs were otherwise healthy and were classified as subclinically infected. Survival analysis indicated that the cumulative probability of infection by 2 years of age was 28%, and the cumulative probability of clinical infection by 2 years of age was 6%. Titers for clinically and subclinically infected dogs overlapped., Conclusions and Clinical Relevance: Results suggested that young dogs living in the study area had a high likelihood of becoming infected with Coccidioides spp, but few developed clinical illness. Serologic testing alone was insufficient for a diagnosis of clinical disease because of the overlap in titers between clinically and subclinically infected dogs.

Objective: To measure the prevalence of human immunodeficiency virus (HIV) infection and high-risk behaviors among heterosexuals in alcoholism treatment, comparing two cross-sectional surveys completed 2 to 3 years apart., Method: Two groups of entrants to alcoholism treatment clinics were recruited, between October 1990 and December 1991 (n = 860; 639 men) and between January 1993 and March 1994 (n = 752; 520 men). Participants underwent a structured interview including an assessment of demographics. substance abuse characteristics and sexual behaviors, as well as serotesting for HIV antibodies. Associations were examined between HIV serostatus and several factors, including demographic variables, substance use and high-risk sexual behaviors., Results: The overall HIV seroprevalence in the first and second samples was 5% (95% CI: 3-6%) and 5% (95% CI: 3-7%). When the two samples were compared, there were no significant differences in prevalence of HIV infection by categories of gender, race, income and most other demographic characteristics within either sample: history of injection drug use (IDU) was significantly related to HIV serostatus in both samples. Unsafe sexual practices were common in both samples. When samples were combined, those 30 years of age or older were more likely to be HIV infected, and men and women with no reported history of IDU still had an HIV prevalence of 3% and 2%, respectively. More than half of the respondents had two or more partners in the previous 6 months and reported a history of a sexually transmitted disease., Conclusions: There was no change in the substantial prevalence of HIV infection and high-risk behavior among heterosexual clients entering alcoholism treatment programs over the 3.5-year study period. The HIV prevalence among non-IDU clients remained several times higher than published estimates from similar community-based heterosexual samples. These data reinforce the concept that heterosexual noninjection drug users are at high risk for HIV and may benefit from intervention programs.

Objectives: To determine the HIV/sexually transmitted disease (STD) status of male patients at STD clinics and factors associated with frequent visits to commercial sex workers (CSW) in southern Vietnam., Design: Cross-sectional survey., Methods: Confidential interviews and physical and laboratory evaluation of 804 male patients at STD clinics in two semi-rural provinces in the Mekong delta., Results: HIV seroprevalence was 0.5%. The prevalence of urethritis syndrome was 19.3%, gonorrhea 10.2% (Gram-stain positive) and syphilis 2% (reactive rapid plasma reagin test). All the men had visited CSW in the past and 58% had their first sexual experience with a CSW; 73% had visited a CSW in the last 3 years. Married men were equally as likely as single men to have casual partners or to have visited a CSW. The men recruited CSW more from the streets (45%) than from brothels (38%). Factors independently associated with visiting a CSW in the last 3 years included being single [odds ratio (OR), 2.2], age under 20 years (OR, 1.9), having first sexual intercourse with a CSW (OR, 2.1), not having a current girlfriend (OR, 2.1), using alcohol before sex (OR, 2.7) and drug use (OR, 1.8). Only 7% of men used condoms consistently; 70% had never used them. Only 37% had used a condom last time they had intercourse with a CSW., Conclusions: Prevention programs for men in Vietnam, particularly those who are young or single, need to focus on reducing drug and alcohol consumption and improving condom use with CSWs.

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

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

In order to measure changes in HIV-related behaviors among heterosexual alcoholics following treatment, we conducted a prospective cohort study of 700 self-identified alcoholics recruited from five public alcohol treatment centers, all of which included HIV risk-reduction counseling. Respondents underwent an HIV antibody test and interviewer-administered questionnaire at entry to alcohol treatment and after a mean of 13 months later. Compared to baseline, at follow-up there was an overall 26% reduction in having sex with an injection-drug-using partner (23% versus 32%, P < .001) and a 58% reduction in the use of injection drugs (15% versus 37%, P < .001), along with smaller improvements in other behaviors. Respondents also showed a 77% improvement in consistent condom use with multiple sexual partners (35% versus 20%, P < .01) and a 23% improvement in partner screening (71% versus 57%, P < .001). Respondents who remained abstinent showed substantially greater improvement than those who continued to drink.

Objective: To determine which measures of alcohol and drug use are associated with HIV-related sexual risk and protective behaviors., Method: Entrants (N = 743, 72% male) to alcoholism treatment clinics underwent a structured interview including an assessment of demographics, substance abuse characteristics and sexual behaviors. Associations were examined between alcohol- and drug-related behaviors, and demographic variables, with the prevalence of high-risk sexual behaviors., Results: Those more likely to use alcohol or drugs when having sex, and those who expect to have high-risk sex when they drink alcohol, were more likely to engage in high-risk sexual behavior. Measures of severity of alcohol or drug problems alone were not consistently related to high-risk or protective behaviors. Several other concurrently used measures (such as the Addition Severity Index and alcohol expectancies) showed more consistent association with high-risk behaviors. There was no apparent reduction in the likelihood of practicing risk-reducing behaviors among those more severely addicted and those who combined alcohol and/or drugs with sex., Conclusions: This study suggests that sexual risk and protective behaviors are not consistently associated with severity of addiction problems. Some measures of alcohol and drug use (i.e., the ASI Drug Composite Score and the Enhanced Risk subscale of the alcohol expectancy measure) were more consistently related to the specific risk behaviors measured than were others (e.g., the ASI Alcohol Composite Score), while most measures showed little or no association with protective behaviors.

Objective: Reports suggest that alcoholics may be at risk for HIV infection. In this article we examine several alcohol-related risk factors for HIV infection among patients entering alcoholism treatment in an AIDS epicenter. Our objective was to identify key factors for HIV prevention and screening among populations receiving treatment for alcohol abuse or alcohol dependence., Method: Clients (N = 921) entering five alcoholism treatment centers in the San Francisco Bay area underwent an interview and blind serotesting for HIV antibodies (76% were male, 16% men who had sex with men, 50% black, 10% Latinos and 6.5% were HIV seropositive). Logistic regression was used to predict HIV serostatus from five possible alcohol-associated risk factors, controlling for demographics and traditional HIV risk factors. These were alcohol impairment, attitudes about socializing in bars, increased sexual risk expectancies when drinking, enhanced sexual expectancies when drinking and decreased nervousness when drinking. Male and female heterosexuals and men with a history of homosexuality were analyzed separately., Results: Among male and female heterosexuals, HIV infection was positively associated with higher alcohol impairment (OR = 2.69, p = .031) and negatively associated with higher sexual risk expectancies when drinking (OR = 0.24, p = .075). Among men who had sex with men, HIV infection was positively associated with higher bar socializing orientations (OR = 10.06, p = .004). Infection was also negatively associated with higher alcohol impairment (OR = 0.34, p = .052) and higher sexual risk expectancies when drinking (OR = 0.26, p = .024) for these men., Conclusions: Since these associations were independent of demographics and traditional HIV risk factors, our research suggests it may be important to also focus HIV screening and prevention on alcohol-related risk factors in AIDS epicenters. For heterosexual alcoholics, the focus should be on those with higher alcohol dependence. For male alcoholics who had sex with men, the focus should be on those who primarily socialize in bars. Further research is needed to determine why higher sexual risk perceptions when drinking were associated with lower rates of HIV infection for both groups, since this discovery may have important prevention implications. The negative association between infection and alcohol impairment among homosexual men also warrants further investigation.

A total number of two hundred eighty three long distance truck drivers and their assistants (loaders) who ferry goods between Kenya and Zaire were included in a cross-sectional study between September 1991 and April 1992. Twenty six percent of the study subjects were seropositive for HIV-1 and none were HIV-2 seropositive. Countries of birth and residence were significantly associated with HIV infection (X2 = 23.6, P = 0.0006). Significant associations were also found between HIV seropositivity and level of education from secondary school and above (OR = 3.4, 95% C.I. = 1.01-11.55); being circumcised was more protective, (OR = 0.38; 95% C.I. = 0.19-0.76), history of many years of driving (X2 = 9.3, p = 0.0254) and income (OR = 11.13, 95% C.I. = 1.35-91.95). When a stepwise multiple logistic regression model was fitted to all the variables observed to be significant in the univariate analysis, the following risk factors attained statistical significance: lack of circumcision (OR = 3.75); income greater than Ksh. 2000 (OR = 7.24); being employed in long distance driving more than 11 years (OR = 3.98); and secondary school education and above (OR = 4.06, 95% C.I. = 1.18-13.98). Reference for all the above Odds Ratios was 1.

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

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

Objectives: To evaluate HIV testing behavior, validity of self-reported serostatus, and intention to test among alcoholics and drug users entering treatment., Design: Longitudinal cohort study., Methods: A total of 952 clients voluntarily entering three outpatient and two inpatient public alcohol treatment centers in San Francisco were enrolled. Seventy-six per cent were men, 50% black, 81% had used both alcohol and drugs during the last year, 43% had injected drugs and 9% of the men were homosexual. Subjects completed an interviewer-administered questionnaire and blindly-linked HIV-antibody test at entry and after 1 year (81% follow-up)., Results: Fifty-seven per cent of subjects reported that they had previously sought HIV testing. Factors associated with HIV testing included homosexual contact, injecting drug use, having a partner who had been tested, and using condoms. Hispanics were the least likely of all ethnic groups to report testing. Of 60 subjects with HIV antibodies, 47 (78%) said they had already been tested; however, 19 (40%) inaccurately reported that their serostatus was negative and another four (9%) had no collected their test results. Blacks were much more likely than other groups to misreport or be unaware of their HIV status. Only half of the 68% who said they planned to be tested during the following year did so. Five (42%) out of 12 HIV-positive individuals who were unaware of, or misreported their serostatus at baseline, and who sought another HIV test during the follow-up year continued to report themselves as uninfected., Conclusions: A large proportion of clients attending public alcohol treatment centers report having been HIV tested, much greater than that observed in other populations. However, misreporting of HIV test results was very common among seropositive subjects. Alcohol and drug treatment programs for this high-risk population should include interventions to optimize use of HIV testing for prevention and treatment, and improve understanding of test results.

Objective: To measure the prevalence of human immunodeficiency virus (HIV) infection and high-risk behaviors among heterosexuals in alcohol treatment., Design: Cross-sectional survey., Setting: Five public alcohol treatment centers., Subjects: Consecutive sample of 888 heterosexual clients entering treatment between October 1990 and December 1991. Respondents were 51% black, 10% Hispanic, 33% white, and 76% male. The overall response rate was 68%., Measurements: Structured interview and serotesting for HIV antibodies., Results: The overall seroprevalence of HIV infection was 5% (95% confidence interval, 3% to 6%). There were no significant differences in rates of infection by age, gender, or race. The prevalence of infection in heterosexual respondents without a history of injection drug use was 3% in men and 4% in women, several times higher than published estimates from a similar community-based heterosexual sample. Unsafe sexual practices were common: 54% of respondents reported multiple sexual partners in the previous year, 97% of nonmonogamous respondents did not use condoms during all sexual encounters, and few respondents consistently asked new sexual partners about previous high-risk behaviors., Conclusions: There is a substantial prevalence of HIV infection among heterosexual clients in San Francisco (Calif) alcohol treatment programs, much of which is not associated with injection drug use. Because of this and the high prevalence of unsafe sexual behaviors, there is a relatively high likelihood of heterosexual spread of HIV among the large population of clients seeking treatment for alcohol dependency. Interventions to prevent HIV spread should become a standard part of alcohol treatment programs.

Objective: To better characterize the natural history of disease due to human immunodeficiency virus (HIV) infection in African women., Design: Prospective cohort study over a 2-year follow-up period., Participants: A total of 460 HIV-seropositive women and a comparison cohort of HIV-seronegative women recruited from prenatal and pediatric clinics in Kigali, Rwanda in 1988., Measurements: Clinical signs and symptoms of HIV disease, AIDS, and mortality., Main Results: Follow-up data at 2 years were available for 93% of women who were still alive. At enrollment, many seropositive women reported symptoms listed in the World Health Organization (WHO) clinical case definition of AIDS, but these were nonspecific and often improved over time. The 2-year mortality among HIV-infected women by Kaplan-Meier survival analysis was 7% (95% CI, 5% to 10%) overall, and 21% (CI, 8% to 34%) for the 40 women who fulfilled the WHO case definition of AIDS at entry. In comparison, the 2-year mortality in women not infected with HIV was only 0.3% (CI, 0% to 7%). Independent baseline predictors of mortality in seropositive women by Cox proportional hazards modeling were, in order of descending risk factor prevalence: a body mass index of 21 kg/m2 or less (relative hazard, 2.3; CI, 1.1 to 4.8), low income (relative hazard, 2.3; CI, 1.1 to 4.5), an erythrocyte sedimentation rate exceeding 60 mm/h (relative hazard, 4.9; CI, 2.2 to 10.9), chronic diarrhea (relative hazard, 2.6; CI, 1.1 to 5.7), a history of herpes zoster (relative hazard 5.3; CI, 2.5 to 11.4), and oral candida (relative hazard, 7.3; CI, 1.6 to 33.3). Human immunodeficiency virus disease was the cause of death in 38 of the 39 HIV-positive women who died, but only 25 met the WHO definition of AIDS before death., Conclusions: Human immunodeficiency virus disease now accounts for 90% of all deaths among child-bearing urban Rwandan women. Many symptomatic seropositive patients may show some clinical improvement and should not be denied routine medical care. Easily diagnosed signs and symptoms and inexpensive laboratory tests can be used in Africa to identify those patients with a particularly good or bad prognosis.

A disproportionately high number of AIDS cases in the United States involve members of racial minorities. Even so, AIDS deaths of minority members may be undercounted. The completeness of reporting of AIDS deaths to the California AIDS Registry (ARS) among Hispanics, blacks, and whites in 1985 and 1986 from the San Francisco Bay Area was investigated. Death certificates listing AIDS as a cause of death or associated condition were identified and cross-checked with cases reported to ARS, current to December 1988. Death certificates were checked by hand for racial or ethnic classification using a definition of Hispanic based on information available on certificates. Three causes of undercounting in ARS were identified: a death was not reported as an AIDS case at all, an AIDS case was reported to ARS but the person was listed as still living, or an AIDS death was reported to ARS with a different racial or ethnic classification. The proportion of cases not reported at all was similar for all three racial-ethnic groups (5-8 percent). The proportion of deaths reported for persons listed in the registry as still living was 12 percent for Hispanics and 9 percent for blacks, compared with 5 percent for whites. For Hispanics, under-counting was largely due to ethnic misclassification. Twenty percent of Hispanics had been counted as white in the AIDS registry. In comparison, 4 percent of blacks and 1 percent of whites were misclassified by race. AIDS deaths among blacks and Hispanics may be undercounted, even in an area with good AIDS surveillance systems. This suggests that overrepresentation of minorities among AIDS cases in the United States may be even greater than indicated by current reporting data.

Pyrimidine dimer formation in response to UV radiation is governed by the thymine content of the potential dimer and the two flanking nucleotides. An enzymatic activity can be purified from Micrococcus luteus that cleaves the N-glycosyl bond between the 5' pyrimidine of a dimer and the corresponding sugar without rupture of a phosphodiester bond. We propose that strand scission at a dimer site by the M. luteus enzyme requires two activities, a pyrimidine dimer DNA-glycosylase and an apyrimidinic/apurinic endonuclease.