Martha B. Lee

Reductions in HIV Risk Among Runaway Youth

Runaway youth are 6–12 times more likely to become infected with HIV than other youth. Using a quasi-experimental design, the efficacy of an HIV prevention program was evaluated over 2 years among 2 groups of runaways: (1) those at 2 shelters who received Street Smart, an intensive HIV intervention program, and (2) youth at 2 control shelters. Street Smart provided youth with access to health care and condoms and delivered a 10-session skill-focused prevention program based on social learning theory to youth. Prior to analysis of the interventions outcomes, propensity scores were used to identify comparable subgroups of youth in the intervention (n = 101) and control conditions (n = 86). Compared to females in the control condition, females in the intervention condition significantly reduced their unprotected sexual acts at 2 years and alcohol use, marijuana use, and the number of drugs used over 12 months. Male adolescents in the intervention condition showed significant reductions in marijuana use over 6 months compared to control youth. Adolescent HIV prevention programs must proactively identify mechanisms for maintaining behavior change over the long-term, and innovative research designs are needed to allow examination of agency-level interventions.

Parents'disclosure of HIV to their children

Objective: Parents’ disclosure of their HIV serostatus to all of their children is described over time and the impact of disclosure is examined for their adolescent children. Design: A representative cohort of parents living with HIV (n = 301) and their adolescent children (n = 395) was recruited and assessed repeatedly over 5 years. Methods: Disclosures by parents living with HIV of their HIV status to their children were examined in three ways: (i) trends in disclosure over 5 years to all children; (ii) factors associated with parental disclosure; and (iii) the impact of disclosure on adolescent children (not younger children). Results: Parents were more likely to disclose to older (75%) than to younger children (40%). Mothers were more likely to disclose earlier than fathers and they disclosed more often to their daughters than to their sons. Parents were more likely to disclose over time to children of all ages; disclosure did not vary according to parents’ ethnicity, socio-economic status, self-esteem, or mental health symptoms. Disclosure was significantly more common among parents with poor health, more stressful life events, larger social networks, and those who perceived their children experiencing more HIV-related stigma. Over time, poor health status and a self-destructive coping style were associated with higher rates of disclosure. Parental disclosure was significantly associated with more problem behaviors and negative family life events among their adolescent children. Conclusion: Parental disclosure of HIV status is similar to disclosures by parents with other illnesses. Clinicians must assist patients to make individual decisions regarding disclosure.

Effects of a behavioral intervention to reduce risk of transmission among people living with HIV: The Healthy Living Project randomized controlled study

Context:The US Centers for Disease Control and Prevention (CDC) strongly recommend comprehensive risk counceling and services for people living with HIV (PLH); yet, there are no evidence-based counseling protocols. Objective:To examine the effect of a 15-session, individually delivered, cognitive behavioral intervention on a diverse sample of PLH at risk of transmitting to others. Design:This was a multisite, 2-group, randomized, controlled trial. Participants:Nine hundred thirty-six HIV-infected participants considered to be at risk of transmitting HIV of 3818 persons screened were randomized into the trial. Participants were recruited in Los Angeles, Milwaukee, New York, and San Francisco. Intervention:Fifteen 90-minute individually delivered intervention sessions were divided into 3 modules: stress, coping, and adjustment; safer behaviors; and health behaviors. The control group received no intervention until the trial was completed. Both groups completed follow-up assessments at 5, 10, 15, 20, and 25 months after randomization. Main Outcome Measure:Transmission risk, as measured by the number of unprotected sexual risk acts with persons of HIV-negative or unknown status, was the main outcome measure. Results:Overall, a significance difference in mean transmission risk acts was shown between the intervention and control arms over 5 to 25 months (χ2 = 16.0, degrees of freedom = 5; P = 0.007). The greatest reduction occurred at the 20-month follow-up, with a 36% reduction in the intervention group compared with the control group. Conclusion:Cognitive behavioral intervention programs can effectively reduce the potential of HIV transmission to others among PLH who report significant transmission risk behavior.

Recurrence potential of thin primary melanomas

Between April 1971 and January 1985, the University of California at Los Angeles (UCLA) Division of Surgical Oncology has seen 649 patients diagnosed with thin primary melanomas, as defined by a Clark level less than IV and Breslow depth less than 0.76 mm. Thirty‐six patients, whose primary diagnosis was confirmed by UCLA pathologists, presented with or subsequently developed melanoma metastases. Twenty‐four (67%) had Clark level II lesions, whereas the remaining 12 (33%) had Clark level III lesions. Metastases were noted more frequently in men than in women, with a man‐to‐woman ratio of 3 to 2. The site of the primary lesion in this group was most frequently on the trunk (16 of 36 cases, 44%), followed by the head and neck (9 of 36 cases, 25%) and arm and shoulder (7 of 36 cases, 19%). Metastasizing thin lesions were least likely to occur on the leg and hip (4 of 36 cases, 11%). Twenty of these lesions were recently reexamined, and 17 of 20 cases (85%) demonstrated evidence of regression. Twenty‐eight patients (78%) had their first metastases to regional lymph nodes. Fifteen remained alive with no evidence of disease at a median follow‐up of 99 months. Twenty patients died from systemic metastases, and one patient was alive with brain metastasis at the time of this article. Although infrequent, metastases from thin melanomas do occur, suggesting the need for careful long‐term follow‐up and immediate investigation of adenopathy even in low‐risk patients.

Four-year behavioral outcomes of an intervention for parents living with HIV and their adolescent children.

Objective: The adjustment of parents living with HIV (PLH) and their adolescent children was examined over 4 years in response to an intervention. Outcomes at 2 years had been previously published. Methods: A randomized controlled trial was conducted, with a representative sample from New York City. Results: In the intervention condition, fewer adolescents became teenage parents, and conduct problems tended to be lower over 4 years than in the standard care condition. Fewer parents were drug dependent and tended to relapse into substance use or use passive coping styles compared with the standard care condition over 4 years. The time-trend analysis showed that the significant reductions in problem behaviors and emotional distress previously observed over 15–24 months in the intervention condition, then eroded over time and were non-significant at 48 months. Conclusions: Ongoing support and skills are needed to maintain intervention effects over longer periods.

Challenges Associated With Increased Survival Among Parents Living With HIV

OBJECTIVES This study examined sociodemographic and psychosocial factors that predict survival among parents living with HIV. METHODS Parents with HIV (n = 307) were recruited from 1993 to 1995 in New York City and repeatedly assessed. Survival was monitored among the sample (81% mothers; 45% Latino, 34% African American). RESULTS Over a median period of 28 months (range = 0-53 months), 44% (n = 135) of the parents died. Having an AIDS diagnosis and being African American were associated with earlier death. Sex, age, and financial status were not related to survival. Parents who survived had initially higher levels of anxiety that decreased over time; in contrast, parents who died reported initially lower, but constant, levels of anxiety over time. After HIV diagnostic status was controlled for, it was found that parents who reported having more children, using a coping style of seeking social support, and being sexually active at baseline survived longer. CONCLUSIONS The counterintuitive findings raise hypotheses regarding the role of change and responsibilities in the survival of parents with HIV.

The Relationship between Adjustment of Mothers with HIV and their Adolescent Daughters

The emotional distress, self-esteem and problem behaviors of adolescent daughters aged 11–18 years ( n = 121) and their mothers with HIV were examined and related to reports of parental disclosure of serostatus and adolescents’ perceived bonds with their parents. Most mothers with HIV reported emotional distress in the clinical range (70%). The levels of emotional distress, self-esteem and drug use were significantly correlated between mothers and daughters. Adolescent’s emotional distress was significantly related to maternal disclosure of HIV status. Daughters who perceived their mothers as highly caring also perceived them as low in overprotection. Daughters who perceived their mothers as low in caring were more emotionally distressed and reported more conduct problems and lower self-esteem. Interventions to enhance adjustment of daughters in families coping with HIV must focus on mental health symptoms and mother–daughter bonds.

Sexually Transmitted Disease Prevalence and Characteristics of Market Vendors in Eastern China

Background and Objectives Sexually transmitted diseases (STDs) have soared in China. To address the impact, we studied market stall vendors in eastern China. Goal The goal was to determine STD prevalence and predictors. Study Design A total of 1536 randomly selected market stall vendors were interviewed and tested for STDs. Results The prevalence of any STD was 20.1% among those reporting sexual intercourse and 5.5% among those reporting never having sexual intercourse. Among those reporting sexual intercourse, chlamydia was most common (9.4%), followed by herpes (9.3%). A total of 4.5% of those reporting never having sexual intercourse had herpes infection, but none had chlamydia. Prevalence of all STDs was higher among females, and those with low education and multiple partners. The pharmacy was the major source of health care (48.8%). Conclusion Generalizing from the results, targeting only STD clinic patients and persons reporting multiple partners for intervention will exclude a high proportion of those with STDs. More effective, less stigmatized sources of STD treatment should be developed.

Can the Hypotriglyceridemic Effect of Fish Oil Concentrate Be Sustained

STUDY OBJECTIVE To determine whether high doses of fish oil concentrate followed by low-dose maintenance therapy can sustain the initial plasma triglyceride reductions. DESIGN Before-and-after trial with 3-month treatment periods. SETTING Outpatient lipid clinic at a university medical center. PATIENTS Sixteen patients with hypertriglyceridemia recruited from the General Internal Medicine Clinics. Five had concomitant hypercholesterolemia (type IIb). INTERVENTION Fish oil supplementation at two doses. After basal measurements, 9.8 g/d omega-3 fatty acids were provided for study months 1 to 3, and 3.9 g/d were provided for study months 4 to 6. MEASUREMENTS AND MAIN RESULTS Blood was drawn monthly and plasma was analyzed for levels of triglycerides, low-density-lipoprotein (LDL) cholesterol and apolipoprotein B, high-density-lipoprotein (HDL) cholesterol and apolipoprotein A1, and glucose and glycohemoglobin. During therapy with the higher dose, mean plasma triglyceride levels were reduced from 3.65 +/- 0.35 mmol/L at baseline to 1.85 +/- 0.20 mmol/L at 1 month, but increased by 30% to 2.40 +/- 0.30 mmol/L by the third month of therapy (P less than 0.05): this increase could not be explained by changes in body weight or compliance. Plasma triglyceride levels continued to increase with low-dose therapy and remained only 11% below baseline values by the sixth month of therapy (P = not significant). Although fish oil therapy increased HDL cholesterol levels (+18% at high dose; 99% CI, 5% to 31%), favorable changes were not seen in LDL cholesterol, apolipoprotein B, or apolipoprotein A1 levels. CONCLUSIONS Fish oil concentrate at high doses followed by low-dose maintenance therapy cannot sustain the initial large plasma triglyceride reductions. Moreover, the efficacy of the higher dose becomes less pronounced after the first month of therapy. This reduced efficacy during prolonged therapy, and the lack of beneficial effect on apolipoprotein and LDL cholesterol levels, may limit the practical benefit of fish oil in the treatment of hypertriglyceridemia.

HIV-Related Stigma Among Market Workers in China.

HIV-related stigma was examined among 209 employees and owners of stalls in 5 markets in an eastern coastal city in China. Of the participants 53% were women and 47% were men; 100% were Han. Ages ranged from 18 to 49 years (M=35, SD=8.1). Half of the participants believed that punishment was an appropriate response toward those living with HIV (50%). Over half (56%) were unwilling to be friends with infected individuals. The majority thought that those living with HIV should be isolated (73%). They agreed that persons living with HIV should not take care of other peoples children (85%). Punishing beliefs toward persons living with HIV were related to being male, older, married, less educated, and unwilling to be tested for HIV.