Kaveh Khoshnood

Declining Incidence of Invasive Streptococcus pneumoniae Infections among Persons with AIDS in an Era of Highly Active Antiretroviral Therapy, 1995—2000

BACKGROUND Our goal was to describe trends in invasive pneumococcal disease incidence among persons with acquired immunodeficiency syndrome (AIDS) since the introduction of highly active antiretroviral therapy (HAART). METHODS We used time-trend analysis of annual invasive pneumococcal disease incidence rates from a population-based, active surveillance system. Annual incidence rates were calculated for 5 July-June periods by use of data from San Francisco county, the 6-county Baltimore metropolitan area, and Connecticut. The numerators were the numbers of invasive Streptococcus pneumoniae infections among persons 18-64 years of age with AIDS; the denominators were the numbers of persons living with AIDS, estimated on the basis of AIDS surveillance data. RESULTS The annual incidence of invasive pneumococcal disease declined from 1094 cases/100,000 persons with AIDS (July 1995-June 1996) to 467 cases/100,000 persons living with AIDS (July 1999-June 2000). The annual percentage changes in incidence were -34%, -29%, -8%, and -1%. Declines were similar by surveillance area, sex, and race/ethnicity. During the final year of the study, the invasive pneumococcal disease incidence in persons with AIDS was half that of the pre-HAART era but was still 35 times higher than that in similarly aged non-HIV-infected adults. CONCLUSIONS In the United States, invasive pneumococcal disease incidence declined sharply across a range of subgroups living with AIDS during the period after widespread introduction of HAART. Despite these gains, persons with AIDS remain at high risk for invasive pneumococcal disease.

Profiles of risk: a qualitative study of injecting drug users in Tehran, Iran.

BackgroundIn Iran, there are an estimated 200,000 injecting drug users (IDUs). Injecting drug use is a relatively new phenomenon for this country, where opium smoking was the predominant form of drug use for hundreds of years. As in many countries experiencing a rise in injecting drug use, HIV/AIDS in Iran is associated with the injection of drugs, accounting for transmission of more than two-thirds of HIV infections. This study aimed to: describe the range of characteristics of IDUs in Tehran, Irans capital city; 2) examine the injecting-related HIV risk behaviors of IDUs, and 3) suggest necessary interventions to prevent HIV transmission among IDUs and their families and sex partners.MethodsUsing rapid assessment and response methods with a qualitative focus, six districts of Tehran were selected for study. A total of 81 key informants from different sectors and 154 IDUs were selected by purposeful, opportunistic and snowball sampling, then interviewed. Ethnographic observations were done for mapping and studying injecting-related HIV risk settings and behaviors. Modified content analysis methods were used to analyze the data and extract typologies of injecting drug users in Tehran.ResultsEvidence of injecting drug use and drug-related harm was found in 5 of 6 study districts. Several profiles of IDUs were identified: depending on their socioeconomic status and degree of stability, IDUs employed different injecting behaviors and syringe hygiene practices. The prevalence of sharing injection instruments ranged from 30–100%. Varied magnitudes of risk were evident among the identified IDU typologies in terms of syringe disinfection methods, level of HIV awareness, and personal hygiene exhibited. At the time of research, there were no active HIV prevention programs in existence in Tehran.ConclusionThe recent rise of heroin injection in Iran is strongly associated with HIV risk. Sharing injection instruments is a common and complex behavior among Iranian IDUs. For each profile of IDU we identified, diverse and targeted interventions for decreasing sharing behavior and/or its harms are suggested. Some notable efforts to reduce the harm of injecting drug use in Iran have recently been accomplished, but further policies and action-oriented research for identification of effective preventive interventions are urgently needed.

Expanded Access to Naloxone: Options for Critical Response to the Epidemic of Opioid Overdose Mortality

The United States is in the midst of a prolonged and growing epidemic of accidental and preventable deaths associated with overdoses of licit and illicit opioids. For more than 3 decades, naloxone has been used by emergency medical personnel to pharmacologically reverse overdoses. The peers or family members of overdose victims, however, are most often the actual first responders and are best positioned to intervene within an hour of the onset of overdose symptoms. Data from recent pilot programs demonstrate that lay persons are consistently successful in safely administering naloxone and reversing opioid overdose. Current evidence supports the extensive scaleup of access to naloxone. We present advantages and limitations associated with a range of possible policy and program responses.

Syringe use and reuse: effects of syringe exchange programs in four cities.

We determined the effect of syringe exchange programs (SEPs) on syringe reuse patterns. Five methods were employed to estimate injections per syringe made by exchange clients in four cities. In San Francisco, Chicago, and Baltimore, self-reported data on the number of injections per syringe were obtained. In New Haven, self-reported injection frequencies were combined with syringe tracking data to derive two methods for estimating the mean injections per syringe. The average number of injections per syringe declined by at least half after establishment of SEPs in New Haven, Baltimore, and Chicago, all cities where such an analysis could be made. There were significant increases in the percentages of exchangers reporting once-only use of their syringes in San Francisco, Baltimore, and Chicago, all cities where the data were amenable to this form of analysis. Self-report and syringe tracking estimates were in agreement that SEP participation was associated with decreases in syringe reuse by drug injectors. SEP participation was associated with increases in the once-only use of syringes. These findings add to earlier studies supporting the role of SEPs in reducing the transmission of syringe-borne infections such as HIV and hepatitis.

Needle exchange decreases the prevalence of HIV-1 proviral DNA in returned syringes in New Haven, Connecticut

PURPOSE To report on the deployment of the syringe tracking and testing system in the New Haven needle exchange program, which is the first federally funded evaluation of a needle exchange program conducted in the United States. PATIENTS AND METHODS A legal needle exchange for intravenous drug users began in New Haven, Connecticut, in November 1990. All syringes distributed by the program received unique tracking codes. Syringes were tracked and HIV-1 proviral DNA prevalence in returned syringes was assessed using polymerase chain reaction and Southern blotting. RESULTS At the outset of the program, the prevalence of HIV-1 proviral DNA in syringes exceeded two thirds. Prevalence decreased rapidly to less than 45% during the first 3 months of the program and remained at this level for the following 10 months. During the periods of decreasing prevalence and subsequent steady state, no changes in the demographics of program participants or in the drug use habits of newly enrolling clients that could account for the decrease in HIV-1 prevalence in needles were detected. In addition, the program referred almost 20% of its clients to drug treatment programs. CONCLUSION The needle exchange program in New Haven has decreased the percentage of syringes testing positive for HIV-1 proviral DNA among needle exchange clients while simultaneously serving as an entry point for drug treatment.

Correlates of HIV infection among incarcerated women: implications for improving detection of HIV infection.

The prevalence of HIV infection in correctional settings is several-fold higher than found in community settings. New approaches to identifying HIV infection among prisoners are urgently needed. In order to determine the HIV seroprevalence and to identify the correlates of HIV infection among female prisoners, an anonymous, but linked HIV serosurvey was conducted at Connecticut’s sole correctional facility for women (census=1,100). After removing all individual identifiers for inmates’ standardized clinical and risk behavior information, data are linked by a third source to blinded HIV-testing information by a third party. This three-step sequential process allows for anonymous HIV testing that can still be linked with deidentified clinical and behavioral data. Of the 3,315 subjects with complete information, 250 (7,5%) were HIV+. Of these, 157 (63%) selfreported being HIV+. Using multiple logistic regression analysis, having sex with a known HIV+ person [adjusted odds ratio (AOR)=9.1] and injection drug use (AOR=6.1) were the most highly correlated risk factors for HIV, whereas leukopenia (AOR=9.4) and hypoalbuminemia (AOR=7.2) were the most significant laboratory markers. Other independent correlates of HIV included self-report of syphilis (AOR=1.9) or genital herpes infection (AOR=2.7) and being Black (AOR=2.1) or Hispanic (AOR=2.2). The prevalence of HIV and HIV-risk behaviors is high among incarcerated women. Existing voluntary HIV counseling and testing programs do not completely target high-risk groups who remain part of the evolving epidemic. Defined demographic, behavioral, and clinical assessments may provide useful information for encouraging targeted counseling and testing. Newer targeted approaches merit further study to determine the effectiveness of this approach. Alternative methods of facilitating more widespread HIV testing, such as saliva tests, rapid serologic tests, and more routine testing in high HIV-prevalence areas should be considered both for clinical and for public health benefits.

Short-Term Global Health Research Projects by US Medical Students: Ethical Challenges for Partnerships

Recent interest in global health among medical students has grown drastically, and many students now spend time abroad conducting short-term research projects in low-resource settings. These short-term stints in developing countries present important ethical challenges to US-based students and their medical schools as well as the institutions that host such students abroad. This paper outlines some of these ethical issues and puts forth recommendations for ethically mindful short-term student research.

A decline in HIV-infected needles returned to New Haven's needle exchange program: client shift or needle exchange?

The New Haven needle exchange program experienced a significant decline in the fraction of returned needles containing human immunodeficiency virus 1 (HIV-1) proviral DNA. Is this decline due to the operations of the needle exchange or to a shift in clients? Analysis of demographic and behavioral data revealed that only one variable, the race of participating clients, changed significantly over time. However, HIV-1 prevalences in needles given to Whites and to non-Whites were not statistically different. Thus, client shift cannot be responsible for the decline in the observed HIV prevalence in needles. Instead, needle circulation times were a significant predictor of HIV prevalence.

Evaluation of an innovative program to address the health and social service needs of drug-using women with or at risk for HIV infection.

Drug-using women with or at risk for HIV infection have many competing unmet needs, especially for social services, drug treatment, and medical care. High-risk drug-using women were recruited through street outreach, at needle exchange sites, a prison, and local community based organizations in New Haven, Connecticut for a study of the service needs of out-of-treatment drug users and the ability of an interactive case management intervention (ICM) to address those needs. These women were administered baseline and follow-up interviews to identify their health and social service needs and the degree to which these needs were resolved. The women who chose to enroll in the interactive case management intervention (n = 38) did not differ demographically nor in their HIV risk behaviors from those not receiving case management (n = 73). Provision of ICM was most successful in meeting needs for supportive mental health counseling, basic services, and long term housing. The impact of interactive case management was less evident for the acquisition of medical and dental services, which were accessed comparably by women not receiving the intervention. Overall, the women who enrolled in the ICM intervention showed a significant decrease in the number of unmet service needs as compared to those who did not enroll. Multiple contacts were required by the case manager to establish trust and to resolve the unmet service needs of these high-risk women. Women with or at risk for HIV infection can be effectively engaged in an ICM intervention in order to meet their multiple unmet service needs, although such interventions are time-and-labor intensive.

Assessment of Hypertension Control in a District of Mombasa, Kenya

Abstract As populations move to urban centres across East Africa, lifestyle habits that affect cardiovascular disease have changed, affecting non-communicable disease risk. In particular, the prevalence of hypertension, and associated awareness of this life-threatening condition, has not been studied in Mombasa, Kenya. This paper assesses the rates of prevalence, awareness, treatment and control of hypertension in Old Town, an urban district of the coastal city. We surveyed 469 subjects, gathered via a clustered sampling technique. Age-adjusted prevalence of hypertension was measured at 32.6% (±2.2) for adults over 18 and was linearly related to age. Results indicate that hypertension awareness was associated with age and sex, as women were substantially more likely to be aware of and to control their hypertension. Only 23.2% (±2.0) of subjects had knowledge of both the causes of and practical solutions to hypertension, and practical hypertension knowledge was associated with hypertension awareness and gender (women had higher rates of knowledge than men). These results indicate that hypertension is a real public health concern in Old Town, and that younger individuals, particularly males, are least likely to be aware of the dangers of hypertension. Public health measures should focus on this population.