Allyn K. Nakashima

Epidemiology of Syphilis in the United States, 1941–1993

Background and Objectives: The distribution and trends of syphilis are influenced by biologic factors, sexual behaviors, biomedical technology, availability of and access to health care, public health efforts, changes in population dynamics, and sociocultural factors. The objective of this article is to review the epidemiology of syphilis in the United States during the period 1941–1993 in the context of some of these factors. Study Design: Surveillance data on cases of syphilis and congenital syphilis reported by state and city health departments to the Centers for Disease Control and Prevention were analyzed to show distribution and trends by geographic location, racial and ethnic groups, gender, and age. Results: Historically, syphilis was distributed widely throughout the country and declined rapidly after the introduction of penicillin therapy and broad‐based public health programs, attaining its lowest levels in the 1950s. However, in recent years, the disease has returned and become focused in the southern region and in urban areas outside that region. Rates of syphilis have remained highest in black Americans, and the most recent national epidemic of syphilis primarily involved them. Rates in white men were at intermediate levels during the early 1980s but have declined to low rates in the 1990s, possibly because of changes in behavior in response to the AIDS epidemic. Rates in white women and other racial and ethnic groups have remained low throughout the 1980s and 1990s. Conclusions: Syphilis remains a significant problem in the United States, and its epidemiology is influenced by a complex combination of factors. To prevent and control syphilis effectively, public health practitioners must understand these factors and design programs and interventions that address the disease in the context of these factors.

Self-reported health-related quality of life in persons with HIV infection: results from a multi-site interview project.

BackgroundTo examine demographic and behavioral associations with self-reported health-related quality of life (HRQOL) among persons with HIV infection or AIDS.MethodsAnalysis of interviews with persons ≥ 18 years of age reported through routine disease surveillance with HIV infection or AIDS to nine state and local health departments from January 1995 through December 1996. Scales were constructed from validated measures of HRQOL, and mean scores were calculated (lower scores signified poorer HRQOL). Measures of HRQOL included Overall Health, Pain, Physical Functioning, Role Functioning, Social Functioning, Mental Health, Energy/Fatigue, and Cognitive Functioning. Differences in HRQOL were examined by various demographic and behavioral factors, including taking antiretroviral medication.ResultsHRQOL data were available for 3778 persons. Factors associated with lower HRQOL scores included older age, female sex, black or Hispanic race/ethnicity, injection drug use, lower education and income, no private health insurance, and lower CD4 count. In multivariate analysis, lower CD4 count was the factor most consistently associated with lower HRQOL. Taking antiretroviral medication was not associated with differences in HRQOL regardless of CD4 count.ConclusionsPerception of HRQOL varied in a population with HIV infection or AIDS. On most HRQOL measures, lower CD4 count was associated with lower HRQOL. Measurement of HRQOL can assist in understanding the long-term effects of disease and treatment on persons with HIV.

Sociodemographic factors and the variation in syphilis rates among US counties, 1984 through 1993: an ecological analysis.

OBJECTIVES Syphilis in the United States is focally distributed, with high incidence rates in the South and in metropolitan areas nationwide. In this study an ecological analysis, using the county as the unit of analysis, was performed to generate hypotheses about community-level determinants of syphilis rates. METHODS Bivariate rank correlations and multivariate, backward stepwise elimination linear regressions were performed. Mean annual incidence of primary- and secondary-stage syphilis in a county was the dependent variable, and county sociodemographic characteristics (from census data) were the independent variables. RESULTS In the multivariate regression model, sociodemographic characteristics accounted for 71% of the variation in syphilis rates among counties. With other factors accounted for, the most highly correlated characteristics were percentage non-Hispanic Black population, county location in the South, percentage of the population that was urban, percentage Hispanic population, and percentage of births to women younger than 20 years. CONCLUSIONS Most of the variation in syphilis rates among counties is accounted for by sociodemographic characteristics. Identification and remediation of modifiable health determinants for which these factors are markers are needed to improve the health status of these populations.

CRACK COCAINE USE AND ADHERENCE TO ANTIRETROVIRAL TREATMENT AMONG HIV-INFECTED BLACK WOMEN

Since the appearance of crack cocaine in the 1980s, unprecedented numbers of women have become addicted. A disproportionate number of female crack users are Black and poor. We analyzed interview data of HIV-infected women ≥ 18 years of age reported to 12 health departments between July 1997 and December 2000 to ascertain if Black women reported crack use more than other HIV-infected women and to examine the relationship between crack use and antiretroviral treatment (ART) adherence among Black women. Of 1655 HIV-infected women, 585 (35%) were nonusers of drugs, 694 (42%) were users of other drugs and 376 (23%) were crack users. Of the 1196 (72%) Black women, 306 (26%) were crack users. We used logistic regression to examine the effect of crack use on adherence to ART, controlling for age and education among Black women. In multivariate analysis, crack users and users of other drugs were less likely than non-users to take their ART medicines exactly as prescribed (odds ratio [OR] = 0.37; 95% confidence interval [CI] = 0.24–0.56), OR = 0.47; 95% CI = 0.36–0.68), respectively. HIV-infected Black women substance users, especially crack cocaine users, may require sustained treatment and counseling to help them reduce substance use and adhere to ART.

Patient and Regimen Characteristics Associated with Self-Reported Nonadherence to Antiretroviral Therapy

Background Nonadherence to antiretroviral therapy (ARVT) is an important behavioral determinant of the success of ARVT. Nonadherence may lead to virological failure, and increases the risk of development of drug resistance. Understanding the prevalence of nonadherence and associated factors is important to inform secondary HIV prevention efforts. Methodology/Principal Findings We used data from a cross-sectional interview study of persons with HIV conducted in 18 U.S. states from 2000–2004. We calculated the proportion of nonadherent respondents (took <95% of prescribed doses in the past 48 hours), and the proportion of doses missed. We used multivariate logistic regression to describe factors associated with nonadherence. Nine hundred and fifty-eight (16%) of 5,887 respondents reported nonadherence. Nonadherence was significantly (p<0.05) associated with black race and Hispanic ethnicity; age <40 years; alcohol or crack use in the prior 12 months; being prescribed ≥4 medications; living in a shelter or on the street; and feeling “blue” ≥14 of the past 30 days. We found weaker associations with having both male-male sex and injection drug use risks for HIV acquisition; being prescribed ARVT for ≥21 months; and being prescribed a protease inhibitor (PI)-based regimen not boosted with ritonavir. The median proportion of doses missed was 50%. The most common reasons for missing doses were forgetting and side effects. Conclusions/Significance Self-reported recent nonadherence was high in our study. Our data support increased emphasis on adherence in clinical settings, and additional research on how providers and patients can overcome barriers to adherence.

Improving the Representativeness of Behavioral and Clinical Surveillance for Persons with HIV in the United States: The Rationale for Developing a Population-Based Approach

The need for a new surveillance approach to understand the clinical outcomes and behaviors of people in care for HIV evolved from the new challenges for monitoring clinical outcomes in the HAART era, the impact of the epidemic on an increasing number of areas in the US, and the need for representative data to describe the epidemic and related resource utilization and needs. The Institute of Medicine recommended that the Centers for Disease Control and Prevention and the Heath Resources and Services Administration coordinate efforts to survey a random sample of HIV-infected persons in care, in order to more accurately measure the need for prevention and care services. The Medical Monitoring Project (MMP) was created to meet these needs. This manuscript describes the evolution and design of MMP, a new nationally representative clinical outcomes and behavioral surveillance system, and describes how MMP data will be used locally and nationally to identify care and treatment utilization needs, and to plan for prevention interventions and services.

Gonorrhea in the United States, 1981-1996. Demographic and geographic trends.

Objective: To describe demographic and geographic trends in gonorrhea incidence in the United States from 1981 through 1996. Study Design: We analyzed aggregate gonorrhea cases reported to the Centers for Disease Control and Prevention by the 50 states, District of Columbia, and 63 large cities. Annual incidence rates (cases/100,000 persons) were calculated. Results: Between 1981 and 1996, the incidence of reported gonorrhea decreased 71.3%, from 431.5 to 124.0 cases/100,000. However, rates among blacks were 35 times higher than rates among whites in 1996 (684.6 versus 19.4) compared with 11 times higher in 1981 (1,894.3 versus 164.3). Among women of all races, 15 to 19 year olds had the highest rates (716.6 in 1996), whereas among men, 20 to 24 year olds had the highest rates (512.9 in 1996). Southern states had higher rates than other regions. Conclusions: Large segments of the population, including adolescents, young adults, and blacks, continue to have high rates of gonococcal infection; prevention programs and health care providers should address the needs of these groups.

Association between crack cocaine use and high-risk sexual behaviors after HIV diagnosis.

Objective: To describe the prevalence of crack cocaine use in an HIV‐infected population and to examine the association between crack use after HIV diagnosis and high‐risk sexual behaviors for heterosexual men, heterosexual women, and men who have sex with men (MSM). Methods: Analysis of cross‐sectional interviews conducted from January 1995 through December 1998 with HIV infected adults in 12 states. Results: Of 10,415 persons with HIV or AIDS, 66.6% never used crack, 10.7% used crack before HIV diagnosis but not after, and 22.7% used crack after diagnosis. High‐risk sexual behaviors were more prevalent among those who had ever used crack and were most prevalent among those who used crack after diagnosis. In multivariable analyses, crack use after diagnosis was associated with having multiple sex partners and trading sex for drugs/money in all three groups: heterosexual men, heterosexual women, and MSM. For heterosexual women and MSM, crack use after diagnosis was associated with unprotected sex with a main partner, and among heterosexual men and MSM, with unprotected sex with casual partners. Conclusions: Crack use after HIV diagnosis was associated with high‐risk sexual behaviors. Treatment programs to assist people in quitting crack are needed to help reduce the risk of HIV transmission from this population.

Risk behaviors related to heterosexual transmission from HIV-infected persons

Background: To monitor heterosexually acquired HIV infection, it is important to understand transmission from persons infected with HIV to their sex partners. Goal: To describe sexual behaviors of persons infected with HIV that are related to transmission. Study Design: Cross‐sectional interviews were conducted from January 1995 to December 1998. Results: Of 4743 heterosexual respondents who had known about their HIV infection for 1 year or longer, 42% were not sexually active and 13% had one sex partner with HIV; the remaining 2099 comprised the sample for analysis. Most respondents were male, black, and of low socioeconomic status. Approximately 60% reported one or more sexual risk behavior. Steady partners HIV status was the strongest predictor in most models for risk behaviors; those with a partner who was not infected were significantly less likely than those with an infected partner to report any sexual transmission risk behavior (P < 0.05). Conclusions: The findings point to a continued need to focus on behavioral prevention measures that reduce the heterosexual transmission of HIV.

The epidemiology of HIV/AIDS in women in the southern United States.

Objective: We reviewed data from multiple sources to examine distinguishing features of the HIV epidemic among women in the South. Goal: The goal of this study was to identify HIV and sexually transmitted disease (STD) prevention research priorities in the South. Study Design: Cases of HIV/AIDS and STDs were analyzed to compare rates by region and rates in urban versus rural areas. Data from interviews of persons reported with HIV/AIDS from rural areas in 4 southern states compared social and behavioral characteristics of men versus women. Results: The South is characterized by high AIDS and STD rates. The epidemic among southern women is distinguished by the predominance of heterosexually acquired infection, the disproportionate impact on blacks, the high proportion residing in rural areas, and multiple high-risk behaviors. Conclusions: Research to identify determinants of high-risk sex and drug-using behaviors among poor, minority men and women in less urban and rural southern regions is needed.