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In order to assess attitudes and practices of physicians regarding prescribing syringes to injection drug users (IDUs) to prevent disease transmission, a survey was conducted at the 2000 ASAM Conference. Of 497 physicians, 104 responded, representing 30 states and 3 countries. Seventy-eight percent provided care for IDUs. Only 2% had prescribed syringes to IDUs for safer injection of illegal drugs. Nineteen percent had prescribed syringes to diabetic patients whom they believed would use the syringes for injecting illegal drugs. Overall, 61% of physicians (74% of internists, 37% of psychiatrists) (p = 0.04) would consider prescribing syringes to IDUs. Prescribing syringes to IDUs can be part of a comprehensive approach to preventing spread of HIV and other infections, decreasing complications of syringe reuse, and bringing IDUs into medical and substance abuse treatment. The majority of physicians surveyed expressed interest in prescribing syringes. Psychiatrists may be less willing to do so. [ABSTRACT FROM AUTHOR]

Human immunodeficiency virus (HIV) infection is more prevalent among the incarcerated than the general population. For many offenders, incarceration is the only time that they may access primary care. Project Bridge is a federally funded demonstration project that provides intensive case management for HIV-positive ex-offenders being released from the Rhode Island state prison to the community. The program is based on collaboration between colocated medical and social work staff. The primary goal of the program is to increase continuity of medical care through social stabilization; it follows a harm reduction philosophy in addressing substance use. Program participants are provided with assistance in accessing a variety of medical and social services. The treatment plan may include the following: mental illness triage and referral, substance abuse assessment and treatment, appointments for HIV and other medical conditions, and referral for assistance to community programs that address basic survival needs. In the first 3 years of this program, 97 offenders were enrolled. Injection drug use was reported by 80% of those enrolled. There were 90% followed for 18 months, 7% moved out of state or died, and 3% were lost to follow-up. Reincarceration happened to 48% at least once. Of those expressing a need, 75% were linked with specialty medical care in the community, and 100% received HIV-related medical services. Of those expressing a need for substance abuse treatment, 67% were successful in keeping appointments for substance abuse treatment within the community. Project Bridge has demonstrated that it is possible to maintain HIV-positive ex-offenders in medical care through the provision of ongoing case management services following prison release. Ex-offenders will access HIV-related health care after release when given adequate support. [ABSTRACT FROM AUTHOR]

This study was undertaken to identify factors associated with entry into detoxification among injection drug users (IDUs), and to assess the role of needle-exchange programs (NEPs) as a bridge to treatment. IDUs undergoing semiannual human immunodeficiency virus (HIV) tests and interviews were studied prospectively between 1994 and 1998, during which time an NEP was introduced in Baltimore. Logistic regression was used to identify independent predictors of entry into detoxification, stratifying by HIV serostatus. Of 1,490 IDUs, similar proportions of HIV-infected and uninfected IDUs entered detoxification (25% vs. 23%, respectively). After accounting for recent drug use, hospital admission was associated with four-fold increased odds of entering detoxification for HIV-seronegative subjects. Among HIV-infected subjects, hospital admission, outpatient medical care, and having health insurance independently increased the odds of entering detoxification. After accounting for these and other variables, needle-exchange attendance also was associated independently with entering detoxification for both HIV-infected (adjusted odds ratio [AOR] = 3.2) and uninfected IDUs (AOR = 1.4). However, among HIV-infected subjects, the increased odds of detoxification associated with needle exchange diminished significantly over time, concomitant with statewide reductions in detoxification admissions. These findings indicate that health care providers and NEPs represent an important bridge to drug abuse treatment for HIV-infected and uninfected IDUs. Creating and sustaining these linkages may facilitate entry into drug abuse treatment and serve the important public health goal of increasing the number of drug users in treatment. [ABSTRACT FROM AUTHOR]

Abstract Background Although highly active antiretroviral therapy (HAART) has improved HIV survival, some patients receiving therapy are still dying. This analysis was conducted to identify factors associated with increased risk of post-HAART mortality. Methods We evaluated baseline (prior to HAART initiation) clinical, demographic and laboratory factors (including CD4+ count and HIV RNA level) for associations with subsequent mortality in 1,600 patients who began HAART in a prospective observational cohort of HIV-infected U.S. military personnel. Results Cumulative mortality was 5%, 10% and 18% at 4, 8 and 12 years post-HAART. Mortality was highest (6.23 deaths/100 person-years [PY]) in those with ≤ 50 CD4+ cells/mm3 before HAART initiation, and became progressively lower as CD4+ counts increased (0.70/100 PY with ≥ 500 CD4+ cells/mm3). In multivariate analysis, factors significantly (p < 0.05) associated with post-HAART mortality included: increasing age among those ≥ 40 years (Hazard ratio [HR] = 1.32 per 5 year increase), clinical AIDS events before HAART (HR = 1.93), ≤ 50 CD4+ cells/mm3 (vs. CD4+ ≥ 500, HR = 2.97), greater HIV RNA level (HR = 1.36 per one log10 increase), hepatitis C antibody or chronic hepatitis B (HR = 1.96), and HIV diagnosis before 1996 (HR = 2.44). Baseline CD4+ = 51-200 cells (HR = 1.74, p = 0.06), and hemoglobin < 12 gm/dL for women or < 13.5 for men (HR = 1.36, p = 0.07) were borderline significant. Conclusions Although treatment has improved HIV survival, defining those at greatest risk for death after HAART initiation, including demographic, clinical and laboratory correlates of poorer prognoses, can help identify a subset of patients for whom more intensive monitoring, counseling, and care interventions may improve clinical outcomes and post-HAART survival.

Abstract Background Sterile syringe access is a critical component of HIV prevention programs. Although retail pharmacies provide convenient outlets for syringe access, injection drug users (IDUs) may encounter barriers to syringe purchase even where purchase without a prescription is legal. We sought to obtain an objective measure of syringe access in Tijuana, Mexico, where IDUs report being denied or overcharged for syringes at pharmacies. Methods Trained "mystery shoppers" attempted to buy a 1 cc insulin syringe according to a predetermined script at all retail pharmacies in three Tijuana neighborhoods. The same pharmacies were surveyed by telephone regarding their syringe sales policies. Data on purchase attempts were analyzed using basic statistics to obtain an objective measure of syringe access and compared with data on stated sales policies to ascertain consistency. Results Only 46 (28.4%) of 162 syringe purchase attempts were successful. Leading reasons for unsuccessful attempts were being told that the pharmacy didn't sell syringes (35.3%), there were no syringes in stock (31.0%), or a prescription was required (20.7%). Of 136 pharmacies also surveyed by telephone, a majority (88.2%) reported selling syringes but only one-third (32.5%) had a successful mystery shopper purchase; the majority of unsuccessful purchases were attributed to being told the pharmacy didn't sell syringes. There was similar discordance regarding prescription policies: 74 pharmacies said in the telephone survey that they did not require a prescription for syringes, yet 10 of these pharmacies asked the mystery shopper for a prescription. Conclusions IDUs in Tijuana have limited access to syringes through retail pharmacies and policies and practices regarding syringe sales are inconsistent. Reasons for these restrictive and inconsistent practices must be identified and addressed to expand syringe access, reduce syringe sharing and prevent HIV transmission.

Abstract Background Access to sterile syringes is a proven means of reducing the transmission of human immunodeficiency virus (HIV), viral hepatitis, and bacterial infections among injection drug users. In many U.S. states and territories, drug paraphernalia and syringe prescription laws are barriers to syringe access for injection drug users (IDUs): pharmacists may be reluctant to sell syringes to suspected IDUs, and police may confiscate syringes or arrest IDUs who cannot demonstrate a "legitimate" medical need for the syringes they possess. These barriers can be addressed by physician prescription of syringes. This study evaluates physicians' willingness to prescribe syringes, using the theory of planned behavior to identify key behavioral influences. Methods We mailed a survey to a representative sample of physicians from the American Medical Association physician database. Non-responding physicians were then called, faxed, or re-sent the survey, up to four times. Results Twenty percent responded to the survey. Although less than 1 percent of respondents had ever prescribed syringes to a known injection drug user, more than 60% of respondents reported that they would be willing to do so. Physicians' willingness to prescribe syringes was best predicted by the belief that it was a feasible and effective intervention, but individual and peer attitudes were also significant. Conclusion This was the first nationwide survey of the physician willingness to prescribe syringes to IDUs. While the majority of respondents were willing to consider syringe prescription in their clinical practices, multiple challenges need to be addressed in order to improve physician knowledge and attitudes toward IDUs.

Importance: Post-pandemic, it is essential to understand the epidemiology of pediatric acute respiratory tract infections (ARTIs). Our multi-facility study elucidates the outpatient epidemiology of pediatric ARTI using highly multiplexed PCR testing, providing critical insights into the evolving landscape of the etiological agents with a particular focus on the years following the emergence of SARS-CoV-2. Utilizing data from two different multiplex PCR panels, our research provides a comprehensive analysis of respiratory pathogen positivity from 2018 to 2023. Our findings indicate that over half of the annual test results identified at least one pathogen, primarily of viral origin. Intriguingly, despite the surge in testing during the COVID-19 pandemic, pathogen detection rates remain similar to the pre-pandemic era. These data hold significant implications for directing antimicrobial stewardship strategies, curbing unnecessary antibiotic use in pediatric respiratory diseases, and the value of multiplex PCR testing in the outpatient setting among pediatrics., Competing Interests: T.T.T., B.A.N., Z.H., B.H., M.T., and B.W.G. are employees of bioMérieux, Inc.

Risk behaviors associated with sexually transmitted infections (STIs) among people living with HIV (PLWH) have not been well characterized in the US military. We identified risk behaviors associated with a new STI in this population after the repeal of "Don't Ask, Don't Tell." US Military HIV Natural History Study participants who completed the risk behavior questionnaire (RBQ) between 2014 and 2017 and had at least 1 year of follow-up were included ( n  = 1589). Logistic regression identified behaviors associated with incident STI in the year following RBQ completion. Overall, 18.9% acquired an STI and 52.7% reported condom use at last sexual encounter. Compared with those with no new sex partners, participants with between one and four or five or more new partners were 1.71 [1.25-2.35] and 6.12 [3.47-10.79] times more likely to get an STI, respectively. Individuals reporting low or medium/high perceived risk of STI were 1.83 [1.23-2.72] and 2.65 [1.70-4.15] times more likely to acquire a new STI than those reporting no perceived risk, respectively. Participants who preferred not to answer about sexual preference, number of new partners, or perceived STI risk were also more likely to acquire a new STI. Our study illustrates that despite regular access to health care and accurate perceptions of risk, rates of STI among PLWH remain high in the US military setting, as in others. Given the potential individual and public health consequences of STI coinfection after HIV, more work is needed to assess interventions aimed at sexual behavior change for PLWH.

Objectives: To determine long-term predictors of health-related quality of life (HRQOL) and evaluate the treatment effect of highly active antiretroviral therapy (HAART) on HRQOL in the US Military HIV Natural History Study (NHS) cohort., Methods: Participants were a nested cohort of the NHS who responded to the Rand Short Form 36 questionnaire administered from 2006 to 2010. Physical component summary scores (PCS) and mental component summary scores (MCS) were computed using standard algorithms. HAART-status was categorized as non-protease inhibitor-based (NPI-HAART), protease inhibitor-based (PI-HAART), HAART-naïve, or off-HAART. Mixed linear random effects models were used to estimate changes in PCS and MCS over time for treatment and covariates (including CD4 count, HIV viral load, medical and mental comorbidities)., Results: Eight hundred and twelve participants met the inclusion criteria. There was no difference in PCS or MCS between those on PI-HAART compared to NPI-HAART. Significant predictors of PCS were CD4 count < 200 cells/mm 3 (β = - 2.90), CD4 count 200-499 cells/mm 3 (β = - 0.80), and mental comorbidity (β = - 3.23). Others were medical comorbidity, AIDS-defining illness, being on NPI-HAART, HAART-naïve, age, and rank. Those with medical comorbidities experienced yearly improvement in PCS. Predictors of MCS were CD4 count < 200 cells/mm 3 (β = - 2.53), mental comorbidity (β = - 4.58), and being African American (β = 2.59)., Conclusion: HRQOL was significantly affected by low CD4 count, medical and mental comorbidities. Addressing these modifiable factors would be expected to improve the physical and mental HRQOL of the cohort. Our study did not find any treatment benefit of NPI-HAART over PI-HAART on HRQOL in the long term.

This study evaluated the relationships between depression trajectories, depression diagnosis and sexual risk behaviors in the US Military HIV Natural History Study. Risk behavior survey data, a coded diagnosis of depression, available Center for Epidemiological Studies Depression measures, and self-reported depressive symptoms ( n  = 662) were utilized. Latent class analysis created 3 classes of depression trajectories, namely, low depression (LD, n  = 378), recent-onset depression (ROD, n  = 170), and high depression (HD, n  = 114) trajectories. Overall, participants with clinically diagnosed depression were less likely to report often using condoms with new sexual partners in the past 3 months than those who have never been diagnosed with depression (OR 0.15, 95% CI 0.49-2.53). Participants with ROD (OR 0.52, 95% CI 0.28-0.97) and HD (OR 0.48, 95% CI 0.24-0.96) trajectories were less likely to report often using condoms with new sexual partners in the past 3 months than those with LD trajectories. Moreover, those with either ROD (OR 2.13, 95% CI 1.19-3.80) or HD (OR 2.74, 95% CI 1.43-5.24) trajectories were more likely to have had sex with ≥2 new sexual partners in the last 3 months than those with LD trajectories. Continued efforts targeting HIV-infected persons with mental health disorders are warranted to reduce sexual risk behaviors.

Introduction: There is a high prevalence of at-risk drinking in the U.S. military. Among HIV-infected individuals, alcohol abuse confers additional risk for adverse health outcomes. In the military, however, the characteristics of HIV-infected individuals who engage in high-risk drinking are not well defined. The purpose of this study was to assess risk factors associated with at-risk drinking in an HIV-positive longitudinal cohort of DoD beneficiaries., Materials and Methods: Annual prevalence of at-risk drinking was calculated for members of the U.S. Military HIV Natural History Study who initiated highly active antiretroviral therapy (HAART) during or after January 2006 through May 2014; each participant completed at least one self-reported alcohol survey within a year of HAART initiation. Univariate and multivariable logistic regression was used to analyze factors associated with at-risk drinking., Results: Sixty-six percent of subjects (495/752) reported at-risk drinking on at least one survey after HAART initiation. At-risk drinkers were more likely to be Active Duty compared to Retired (OR 0.65 95% CI [0.46, 0.92]). In multivariate models, Caucasian race (OR 3.30 95% CI [2.31, 4.71]); Hispanic/other race (OR 2.17 95% CI [1.51, 3.14]) and younger age (OR 0.61 per 10 years older, [95%CI 0.49, 0.75]) were significantly associated with at-risk drinking. Single relationship status (OR 1.51 95% CI [1.08, 2.13]) was also associated with at-risk drinking., Conclusions: Consistent with general alcohol consumption patterns in the military, we found a high prevalence of at-risk drinking among individuals with HIV infection, which was associated most closely with young, non-African Americans. Targeting interventions toward this group will be important to reduce at-risk drinking and its potential for HIV-related complications., (Published by Oxford University Press on behalf of Association of Military Surgeons of the United States 2018.)

Background: Pharyngeal and anorectal reservoirs of gonorrhea (GC) and chlamydia (CT) are increasingly recognized among heterosexual women. While a number of studies performed at sexually transmitted disease (STD) clinics have found a high prevalence of extragenital GC/CT infection, such screening is typically not offered during routine primary care visits for women. We sought to define the prevalence of and factors associated with extragenital GC/CT among women in the U.S. Navy., Methods: We recruited servicewomen stationed in San Diego, California, between the ages of 18 and 25 who presented for an annual physical exam between January and September, 2017. Nucleic acid amplification testing was performed on swabs collected at endocervical, oropharyngeal and anorectal sites to assess the presence of GC/CT. An anonymous behavioral questionnaire was also administered to characterize sexual risk. Descriptive statistics were used to compare women with and without a prior history of any sexually transmitted infection (STI) (self-report) along with a current GC/CT diagnosis. This study was approved by the Institutional Review Board of the Uniformed Services University of Health Sciences., Results: Of the 75 patients who were approached, 60 subjects were enrolled in the study, including white 20 (33.3%), black/African American 18 (31.0%), Hispanic/Latina 13 (21.7%) and Asian/Pacific Islander 9 (15.5%) women. Among all the women, six (10.0%) were diagnosed with CT infection, all via endocervical exam. Of these, five (8.3%) had concurrent anorectal infection, including two cases (3.3%) accompanied by pharyngeal infection. Of the subjects, 15 (25.0%) reported anal intercourse in their most recent sexual encounter, most of which was condomless (13/15, 86.7%). A high number of women who reported sex with a casual male partner (19/45, 42.2%) reported rarely or never using condoms; last, 41.7% consuming at least 3 drinks on a typical drinking day, and one-third of the reported drinking more than once per week., Conclusions: We found a high prevalence of anorectal CT infection, although no infections were detected without concurrent endocervical involvement. Nonetheless, the high prevalence of condomless anal intercourse reported by participants argues for further study and ongoing consideration of extragenital screening among high-risk patients. Behavioral interventions are also warranted given the high prevalence of sexual and related risk factors.

Background: Health-related quality of life (HRQOL) is a patient-centered outcome measure used in assessing the individual's overall functional health status but studies looking at HRQOL as a predictive tool are few. This work examines whether summary scores of HRQOL are predictive of all-cause hospitalization in the US Military HIV Natural History Study (NHS) cohort., Methods: The Short Form 36 (SF-36) was administered between 2006 and 2010 to 1711 NHS cohort members whose hospitalization records we had also obtained. Physical component summary scores (PCSS) and mental component summary scores (MCSS) were computed based on standard algorithms. Terciles of PCSS and MCSS were generated with the upper terciles (higher HRQOL) as referent groups. Proportional hazards multivariate regression models were used to estimate the hazard of hospitalization for PCSS and MCSS separately (models 1 and 2, respectively) and combined (model 3)., Results: The hazard ratios (HR) of hospitalization were respectively 2.12 times (95% CI: 1.59-2.84) and 1.59 times (95% CI: 1.19-2.14) higher for the lower and middle terciles compared to the upper PCSS tercile. The HR of hospitalization was 1.33 times (95% CI: 1.02-1.73) higher for the lower compared to the upper MCSS tercile. Other predictors of hospitalization were CD4 count < 200 cells/mm 3 (HR = 2.84, 95% CI: 1.96, 4.12), CD4 count 200-349 cells/mm 3 (HR = 1.67, 95% CI: 1.24, 2.26), CD4 count 350-499 cells/mm 3 (HR = 1.41, 95% CI: 1.09, 1.83), plasma viral load > 50 copies/mL (HR = 1.82, 95% CI: 1.46, 2.26), and yearly increment in duration of HIV infection (HR = 0.94, 95% CI: 0.93, 0.96) (model 3)., Conclusion: After controlling for factors associated with hospitalization among those with HIV, both PCSS and MCSS were predictive of all-cause hospitalization in the NHS cohort. HRQOL assessment using the SF-36 may be useful in stratifying hospitalization risk among HIV-infected populations.

Objective: The aims of this study were: (i) to determine the factors associated with HRQOL at baseline in our cohort, and (ii) to evaluate if there are differences in baseline HRQOL measures by antiretroviral treatment., Methods: The Short Form 36 (SF-36) was administered between 2006 and 2010 among members of the United States HIV Natural History Study cohort (NHS), and participants who completed the SF-36 were included in the study. Physical component summary (PCS) and mental component summary (MCS) scores were computed based on standard algorithms. Multivariate linear regression models were constructed for PCS and MCS to estimate the association between selected variables and HRQOL scores., Results: Antiretroviral therapy (ART) was not independently associated with HRQOL scores. Factors associated with PCS were CD4+ count < 200 cells/mm3 (β = -5.84, 95% CI: -7.63, -4.06), mental comorbidity (β = -2.82, 95% CI: -3.79, -1.85), medical comorbidity (β = -2.51, 95% CI: -3.75, -1.27), AIDS diagnosis (β = -2.38, 95% CI: -3.79, -0.98). Others were gender, military rank, marital status, and age. Factors independently associated with MCS were CD4+ count < 200 cells/mm3 (β = -1.93, 95% CI: -3.85, -0.02), mental comorbidity (β = -6.25, 95% CI: -7.25, -5.25), age (β = 0.37, 95% CI: 0.14, 0.60), and being African American (β = 1.55, 95% CI: 0.63, 2.47)., Conclusion: Among military active duty and beneficiaries with HIV, modifiable factors associated with HRQOL measures included advanced HIV disease, and mental or medical comorbidity. Addressing these factors may improve quality of life of HIV-infected individuals in the NHS cohort.

Background: Treatment guidelines recommend the use of a single dose of benzathine penicillin G (BPG) for treating early syphilis in human immunodeficiency virus (HIV)-infected persons. However, data supporting this recommendation are limited. We examined the efficacy of single-dose BPG in the US Military HIV Natural History Study., Methods: Subjects were included if they met serologic criteria for syphilis (ie, a positive nontreponemal test [NTr] confirmed by treponemal testing). Response to treatment was assessed at 13 months and was defined by a ≥4-fold decline in NTr titer. Multivariate Cox proportional hazard regression models were utilized to examine factors associated with treatment response., Results: Three hundred fifty subjects (99% male) contributed 478 cases. Three hundred ninety-three cases were treated exclusively with BPG (141 with 1 dose of BPG). Treatment response was the same among those receiving 1 or >1 dose of BPG (92%). In a multivariate analysis, older age (hazard ratio [HR], 0.82 per 10-year increase; 95% confidence interval [CI], .73-.93) was associated with delayed response to treatment. Higher pretreatment titers (reference NTr titer <1:64; HR, 1.94 [95% CI, 1.58-2.39]) and CD4 counts (HR, 1.07 for every 100-cell increase [95% CI, 1.01-1.12]) were associated with a faster response to treatment. Response was not affected by the number of BPG doses received (reference, 1 dose of BPG; HR, 1.11 [95% CI, .89-1.4])., Conclusions: In this cohort, additional BPG doses did not affect treatment response. Our data support the current recommendations for the use of a single dose of BPG to treat HIV-infected persons with early syphilis., (© The Author 2014. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.)

Background: Understanding the impact of hepatitis B virus (HBV) coinfection on HIV outcomes in the highly active antiretroviral therapy (HAART) era continues to be a critical priority given the high prevalence of coinfection and the potential for impaired immunologic, virologic, and clinical recovery., Methods: Participants from the US Military HIV Natural History Study with an HIV diagnosis on HAART and serologically confirmed HBV infection status at HAART initiation (HI) were classified into 4 HBV infection (HB) groups. HIV virologic, immunologic, and clinical outcomes were evaluated by HB status., Results: Of 2536 HIV-positive HAART recipients, with HBV testing results available to determine HB status in the HI window, HB status at HI was classified as HB negative (n = 1505; 66%), resolved HB (n = 518; 23%), isolated hepatitis B core antigen (n = 139; 6%), or chronic HB (n = 131; 6%). HIV virologic suppression and failure at 6 months or 1 year were not significantly different by HB status. A significantly faster rate of increase in CD4 cell count during the period between 4 and 12 years was observed for chronic HB relative to HB negative. Chronic and resolved HB were associated with an increased risk of AIDS/death compared with HB-negative individuals (chronic HB-hazard ratio = 1.68, 95% confidence interval: 1.05 to 2.68; resolved HB-hazard ratio = 1.61, 95% confidence interval: 1.15 to 2.25)., Conclusions: HB status did not have a significant impact on HIV virologic outcomes, however, CD4 cell count reconstitution after HI and the risk of an AIDS event or death after HI may be associated with HB status.

Background: Human immunodeficiency virus (HIV)-infected persons are at risk for severe influenza infections. Although vaccination against the H1N1 pandemic influenza strain is recommended, currently there are no data on the durability of post-vaccination antibody responses in this population., Methods: HIV-infected and HIV-uninfected adults (18-50 years old) received a single dose of monovalent 2009 influenza A (H1N1) vaccine (strain A/California/7/2009H1N1). Antibody levels to the 2009 H1N1 pandemic strain were determined at day 0, day 28, and 6 months by hemagglutination-inhibition assay. A seroprotective response was a post-vaccination titer of ≥1:40 among those with a pre-vaccination level of ≤1:10. Geometric mean titers (GMT) and factors associated with higher levels were also evaluated., Results: We studied 127 participants with a median age of 35 (interquartile range (IQR) 28, 42) years. Among the HIV-infected arm (n=63), the median CD4 count was 595 (IQR 476, 819)cells/mm(3) and 83% were receiving HAART. Thirty-five percent of all participants had a pre-vaccination level of >1:10. HIV-infected compared to HIV-uninfected adults were less likely to generate a seroprotective response at day 28 (54% vs. 75%, adjusted OR 0.23, p=0.021) or have a durable response at 6 months post-vaccination (28% vs. 56%, adjusted OR 0.19, p=0.005). Additionally, although pre-vaccination GMT were similar in both arms (median 7 vs. 8, p=0.11), the GMT at 6 months was significantly lower among HIV-infected versus HIV-uninfected adults (median 20 vs. 113, p=0.003). Among HIV-infected persons, younger age (p=0.035) and receipt of HAART (p=0.028) were associated with higher GMTs at 6 months., Conclusions: Despite vaccination, most HIV-infected adults do not generate durable seroprotective antibody responses to the 2009 influenza A (H1N1) virus, and hence may remain vulnerable to infection. In addition to HAART use, more immunogenic vaccines are likely needed for improving protection against influenza in this population., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Background: Limited data exist on the immunogenicity of the 2009 influenza A (H1N1) vaccine among immunocompromised persons, including those with human immunodeficiency virus (HIV) infection., Methods: We compared the immunogenicity and tolerability of a single dose of the monovalent 2009 influenza A (H1N1) vaccine (strain A/California/7/2009H1N1) between HIV-infected and HIV-uninfected adults 18-50 years of age. The primary end point was an antibody titer of ≥ 1:40 at day 28 after vaccination in those with a prevaccination level of ≤ 1:10, as measured by hemagglutination-inhibition assay. Geometric mean titers, influenza-like illnesses, and tolerability were also evaluated., Results: One hundred thirty-one participants were evaluated (65 HIV-infected and 66 HIV-uninfected patients), with a median age of 35 years (interquartile range, 27-42 years). HIV-infected persons had a median CD4 cell count of 581 cells/mm(3) (interquartile range, 476-814 cells/mm(3)) , and 82% were receiving antiretroviral medications. At baseline, 35 patients (27%) had antibody titers of >1:10. HIV-infected patients (29 [56%] of 52), compared with HIV-uninfected persons (35 [80%] of 44), were significantly less likely to develop an antibody response (odds ratio, .20; P = .003). Changes in the median geometric mean titer from baseline to day 28 were also significantly lower in HIV-infected patients than in HIV-uninfected persons (75 vs 153; P = .001). Five influenza-like illnesses occurred (2 cases in HIV-infected persons), but none was attributable to the 2009 influenza H1N1 virus. The vaccine was well tolerated in both groups., Conclusions: Despite high CD4 cell counts and receipt of antiretroviral medications, HIV-infected adults generated significantly poorer antibody responses, compared with HIV-uninfected persons. Future studies evaluating a 2-dose series or more-immunogenic influenza A (H1N1) vaccines among HIV-infected adults are needed (ClinicalTrials.gov NCT00996970).

Purpose: The purpose of this study was to develop and test the efficacy of a prostate health curriculum designed to train African American and Afro Caribbean barbers to deliver prostate cancer control messages to their customers., Procedures: The curriculum was drafted from information obtained from needs assessment surveys administered to barbers and customers from various barbershops in Brooklyn, New York. Focus groups were conducted to further inform the curriculum, which was pilot tested in training sessions., Findings: The high incidence of late-stage diagnosis prostate cancer in African Americans has often been attributed to lack of screening. In surveys administered to 92 customers and 19 barbers, only 26% of customers and 42% of barbers reported having some knowledge of the prostate-specific antigen (PSA) screening test. More than 90% of the barbers expressed a willingness to obtain prostate cancer information to specifically share with their customers, and 83% of customers expressed an interest in obtaining prostate cancer information and willingness to receive that information from their barbers. Following the pilot training, barber knowledge of prostate cancer increased significantly (p < .0001)., Conclusions: This pilot study suggests that there is a need for intervention programs that will raise awareness and increase prostate health knowledge and behavior in communities with elevated incidence of prostate cancer. The study further suggests that barbers are willing to use their leadership skills to educate and encourage their customers to engage in informed decision making.

Unlabelled: Internet-based drug information may be relayed by innovative drug users, a group of individuals who use the web to learn about a new drug, experiment with that substance, and then disseminate their knowledge and experiences to others. We investigated the mechanisms adopted by innovative drug-using adolescents to distribute Internet drug information and experiences to peers, the size and geographic distribution of the receiving group, and the age at which innovative drug users began to disseminate drug information., Method: Cross-sectional survey of adolescents recruited by a respondent-driven sampling method. Of 18 innovative drug users, 17 reported using instant messaging (IM) to disseminate drug information and experiences to peers. The average age at which respondents adopted IM for this purpose was 16 years. Fifteen of 17 described using a distribution list with as many as 200 individuals who received only drug information. Ten respondents instant messaged drug information to online peers greater than 250 miles distant; nine respondents attached links to online drug resources (including www.erowid.org). This study has identified that IM plays an important role in the dissemination of Internet-based drug information by individual innovative drug users into larger social networks. Pediatricians should consider assessing IM use in drug abuse evaluations and recommending that parents of children with drug abuse problems should consider suspending IM services as a means of truncating the delivery of reinforcing drug information.

For correctional HIV testing programs, delivery of HIV test results can be difficult because of short incarceration times for many inmates. Rapid HIV testing enables immediate delivery of test results and can be performed in conjunction with risk reduction counseling. The objective of this study was to determine the feasibility and acceptability of rapid HIV testing within the Rhode Island Department of Corrections jail. Jail detainees were randomly asked to participate in the study. The study included: (1) completing a questionnaire that investigated HIV risk behavior, incarceration history, HIV testing history, and attitudes toward routine HIV testing in jail and toward partner notification services; (2) individualized HIV risk reduction counseling; and (3) the option of rapid HIV testing with delivery of test results. One hundred thirteen inmates were asked to participate and 100 (88%) participated. Among the subjects, there was a high frequency of incarceration and subjects were at significant risk of HIV infection, yet there was low perceived risk. Ninety-five percent of participants underwent rapid HIV testing. Of those, 99% had negative test results and one subject had a preliminary positive result. All subjects received rapid test results and individualized risk reduction counseling. The majority of subjects supported routine HIV testing in jail and the concept of partner notification services. In this population of jail detainees, rapid HIV testing was feasible and highly acceptable. Further studies are needed to successfully incorporate rapid HIV testing into jail HIV screening programs.

Approximately 7 million people in the United States are in jail, in prison, or on probation or parole, many as a result of drug-related offenses. Individuals who use opiates account for a significant minority of this population. Methadone maintenance treatment (MMT) of opiate addiction is highly effective in reducing drug use, drug-related criminal activity, and risk of human immunodeficiency virus transmission. Recently released inmates are at particularly high risk for overdose and disease transmission. Project MOD (Managing Opioid Dependency) provides services to eliminate logistical and financial barriers to MMT entry immediately on release from incarceration. Such programs provide a promising opportunity to facilitate reentry into the community, combat disease transmission, and reduce recidivism.

Many HIV-infected individuals have not reaped the benefits of combination antiretroviral therapy due to inability either to adhere to medications or to access care. It is now recognized that innovative approaches are needed to increase access and adherence to highly active antiretroviral therapy (HAART), especially among these hard-to-reach populations. Due to the success of directly observed therapy (DOT) for the treatment of Mycobacterium tuberculosis (TB), our group and others have questioned whether DOT can be adapted to deliver HAART to hard-to-reach communities. In this review, we discuss the results of pilot programs that have utilized DOT in multiple different settings and use case studies to explore the diverse issues that can arise when implementing these programs. As we continue to gain more experience with observed therapy, we will be able to better identify the key components for a successful intervention.

The high prevalence of infection with HIV and other blood-borne pathogens in injection drug users (IDUs) is directly related to the lack of syringe access. Needle exchange programs (NEPs), syringe prescription, and syringe deregulation are 3 approaches to increasing access to sterile syringes for IDUs. The benefits of NEPs have been repeatedly demonstrated, but the impact of NEPs has been limited by a lack of federal funding. Syringe prescription for IDUs is a promising new strategy supported by many organizations; legalizing syringe purchase and possession has led to a substantial improvement in syringe access in many states. Because each approach has unique advantages, providing IDUs with a variety of options for syringe access is likely to be most beneficial.

It is estimated that up to one-fourth of the people living with human immunodeficiency virus (HIV) infection in the United States pass through a correctional facility each year. The majority of persons who enter a correctional facility today will return home in the near future. Most inmates with HIV infection acquire it in the outside community; prison does not seem to be an amplifying reservoir. How correctional health services deal with the HIV-infected person has important implications to the overall care of HIV-infected people in the community. Routine HIV testing is well accepted. Combination antiretroviral therapy has been associated with a reduction in mortality in prisons. A link between area HIV specialists and correctional health care providers is an important partnership for ensuring that HIV-infected patients have optimal care both inside prison and after release.

The principle of directly observed therapy (DOT) has its roots in the treatment of tuberculosis (TB), for which DOT programs have improved cure rates in hard-to-reach populations. Human immunodeficiency virus (HIV) and TB affect similar populations, and there are concerns about both regarding the development of drug resistance associated with poor adherence to therapy. Accordingly, DOT may benefit certain HIV-infected people who have difficulty adhering to highly active antiretroviral therapy. However, important differences exist in the treatment of these diseases that raise questions about how DOT can be adapted to HIV therapy. DOT for management of HIV infection has been effective among prisoners and in pilot programs in Haiti, Rhode Island, and Florida. Although DOT can successfully treat HIV infection in marginalized populations in the short term, a multitude of questions remain. This review provides an account of the preliminary development of DOT programs for the treatment of HIV-infected individuals.

Injection drug users (IDUs) are a population at high risk for many diseases, including AIDS, and are clearly in need of medical and substance abuse treatment. Access to sterile syringes is critical for lowering the risk of transmission of HIV and other blood-borne pathogens among IDUs. Previously tried strategies include needle exchange programs and changing laws to allow the legal purchase and possession of syringes. An alternative strategy is to have physicians prescribe syringes to IDUs. To the best of our knowledge, this has previously been tried by only a few physicians in rare situations and never on a programmatic basis. This report describes the genesis of physician's syringe prescription in Rhode Island and some of the lessons learned to date. Because of the illicit nature of drug use, a tremendous amount of mistrust and fear on the part of IDUs often leads to poor interaction with the medical establishment. Prescription of syringes by a physician can serve as a tool for reaching out to a high-risk and often out-of-treatment population of drug users. It is a way for the health care community to tap into drug-using networks and bring those populations into a medical care system.

In the United States today, half of all new HIV infections are injection drug use-associated, many of which are a result of the reuse and sharing of contaminated syringes. Thus, providing access to sterile syringes for injection drug users is an important part of preventing HIV transmission. Needle exchange programs (NEPs) have been established as one successful approach to providing sterile injection equipment. The medical literature shows that these programs are effective in decreasing both syringe sharing and HIV incidence in injection drug users. In addition, many NEPs are also beneficial because they provide other injection drug use-relevant services. There are several strategies that can be adopted in order to optimize the impact of needle exchange programs, at both the community and national levels. These include establishing NEPs in communities that need them, expanding and improving those that already exist, and implementing such programs on a larger national scale with the provision of federal funds.

A 37-year-old man coinfected with HIV-1 and human T-lymphotropic virus type II presumably through injection drug use had a high CD4+ count and low HIV viral load without anti-retroviral therapy for over six years. As an HIV long-term non-progressor, his case supports the hypothesis that coinfection with HTLV-II does not adversely affect the course of HIV disease.

This study explores recent temporal trends in HIV prevalence among women entering prison and the incidence and associated risk factors among women reincarcerated in Rhode Island. Results from mandatory HIV testing from 1992 to 1996 for all incarcerated women were examined. In addition, a case control study was conducted on all seroconverters from 1989 to 1997. In all, 5836 HIV tests were performed on incarceration in 3146 women, 105 of whom tested positive (prevalence, 3.3%). Between 1992 and 1996, the annual prevalence of HIV among all women known to be HIV-positive was stable (p = .12). Age >25 years, nonwhite race, and prior incarceration were associated with seropositivity. Of 1081 initially seronegative women who were retested on reincarceration, 12 seroconverted during 1885 person-years (PY) of follow-up (incidence, 0.6/100 PY). Self-reported injection drug use (IDU; odds ratio [OR], 3.7; 95% confidence interval [CI], 1.3-10.1) was significantly associated with seroconversion, but sexual risk was not (OR, 1.1; 95% CI, 0.4-3.5). Incarceration serves as an opportunity for initiation of treatment and linkage to community services for a population that is at high risk for HIV infection.

Objectives: To review issues related to discarded syringes in the community and to describe community-based programs for the safe disposal of used needles and syringes., Methods: We used the medical literature and chain referral to identify community-based syringe disposal programs other than syringe exchange programs (SEPs). We held a workshop in June 1996 involving staff from disposal programs; manufacturers of syringes, sharps containers, and other disposal devices; solid waste companies; public health staff; and researchers., Results: Fifteen programs for the safe disposal of syringes were identified in the United States, Canada, and Australia. Of these, 12 primarily served persons with diabetes who use insulin, and 3 primarily served injection drug users (IDUs). The programs used three major strategies: puncture-resistant containers discarded in trash, community drop boxes, and sharps containers turned in for biohazard disposal at community sites, hospitals, or pharmacies. Participants in the workshop described key points in developing syringe disposal programs. Programs should involve pharmacists, physicians, waste disposal companies, public health departments, hospitals, diabetes educators, persons with diabetes who use insulin, and IDUs. For IDUs, criminal penalties for possession of syringes are a substantial deterrent to participation in community efforts to safely dispose of used syringes. The multiple and sometimes conflicting local, state, and federal laws and regulations concerning medical waste hinder development of multistate or national approaches to the safe disposal of syringes. More information is needed on community-based syringe disposal programs., Conclusion: Communities in the United States, Canada, and Australia have developed different approaches to achieve safe disposal of used syringes.

Before 1982, the authors performed 177 primary total hip arthroplasties using a single-sized, extensively porous-coated cobalt-chrome femoral prosthesis. The current status of 122 of these arthroplasties is known. Two femoral prostheses have been revised for late symptomatic loosening, 2 for stem fracture, and 1 for infection. From 1982 to 1984, 227 primary arthroplasties were performed using the same stem in multiple sizes. Of these cases, 171 are available for followup. One stem (0.6%) has been revised for symptomatic loosening. Large osteolytic femoral lesions (average size, 8.1 cm2) developed in 3 patients, associated with an unusually large amount of polyethylene wear of their acetabular components. These patients have been treated by exchange of the polyethylene liner within the porous-coated acetabular component and allografting of the osteolytic lesions. The femoral components were not exchanged because osteolysis had not eroded the integrity of the supporting bone-implant interface to a point where loosening occurred. Before 1987, 193 patients with loose femoral components were treated with revision total hip arthroplasty, also using an extensively porous-coated cobalt-chrome femoral stem of similar design. Ten (5.7%) patients have required rerevision of the femoral prosthesis. Six of these 10 rerevisions were performed because of symptomatic loosening. Ninety-three percent of the patients in the primary series had relief of their preoperative pain and have improved functional ability; 94.2% are satisfied with their results. In the revision series, 89.1% of the patients are free of pain and function better than preoperatively, and 89.6% are fully satisfied with their results.(ABSTRACT TRUNCATED AT 250 WORDS)

Between 1980 and 1986, ninety-three femoral revision arthroplasties without cement were performed on ninety-one patients who had symptomatic loosening of a stemmed femoral component of a total hip prosthesis. Eighty-one of these patients (eighty-three hips) were followed for at least five years (range, five to thirteen years; mean, nine years). Forty-three hips also had a revision of a cemented acetabular component with use of a hemispherical, porous-coated implant inserted without cement. The results are presented in a traditional manner in terms of implant survivorship, radiographic evaluation for stability of the implant, and standardized hip scores. Changes due to the treatment are presented as outcomes in terms of the physician's criteria for the success of the operation, the patient's criteria for the success of the operation, and the patient's economic status. No hips that needed additional operations were excluded, and we reported the outcome regardless of any interim operative procedures (including re-revisions). At the latest follow-up examination, nineteen (23 per cent) of the eighty-three hips had had an additional operation, including seventeen hips (20 per cent) for which re-revision had been necessary. In ten (12 per cent) of the eighty-three hips, the re-revision had involved an index implant. The rate of re-revision of the index femoral component was 10 per cent and the rate of mechanical loosening of that component was 11 per cent. The rate of re-revision of the index acetabular component was 7 per cent and the rate of mechanical loosening of that component was 11 per cent.(ABSTRACT TRUNCATED AT 250 WORDS)

Fifteen years of clinical experience with porous-coated prostheses demonstrated the durability of this type of fixation. This experience was documented by clinical follow-up study of the 393 cases treated by the senior author before 1985. Only six of these femoral components have been revised: three for loosening, two for stem breakage, and one for infection. Thus, the revision rate for the porous-coated stems was 1.5%. Porous-coated acetabular components were used in 227 of the arthroplasties. Five of these porous-coated cups have been revised: four for malposition leading to dislocation and one for late loosening secondary to osteolysis. Thus, the revision rate for these porous-coated acetabular components was 2.2%. Twenty bipolar and 146 cemented acetabular components were used in the remaining 166 cases treated before 1985. Eleven (7.5%) of the cemented acetabular components were revised. Revisions of the porous-coated components were rare in the first ten postoperative years. The clinical data were supplemented with analysis of postmortem specimens from 15 patients. Mechanical testing of the femoral specimens showed the relative micromotion at the porous surface to be exceptionally small (less than 40 microns). Seven of these postmortem retrievals involved cases with unilateral arthroplasties. In these cases, the contralateral normal femur also was removed, and a prosthesis identical to that in the in vivo implanted side was inserted to simulate the immediate postoperative condition. Dual-energy X-ray absorptiometry (DEXA) of the seven paired femora demonstrated that bone remodeling can be expected to produce a 5%-52% loss of periprosthetic bone mineral content, with the greatest loss occurring in the more osteoporotic patients.(ABSTRACT TRUNCATED AT 250 WORDS)

The authors present their results for cementless femoral revision arthroplasty using extensively porous coated implants. Patients have been prospectively followed for 5 to 11 years (mean 7.4 years). The revision rate was 5.7%, and the radiographic loosening rate was 1.1%, to give a mechanical failure rate of only 6.9%. As a result of the revision procedure, the pain level was improved for 89.1% of the patients, walking status was improved for 82.8% of the patients, and functional level was improved for 88.5% of the patients. These results compare very favorably with any reports on revision arthroplasty using cement with a similar length follow-up.