Mary Ann Chiasson

Heterosexual transmission of HIV-1 associated with the use of smokable freebase cocaine (crack)

A study of risk factors for HIV-1 infection was conducted at a sexually transmitted disease clinic in an area of New York City where the cumulative incidence of AIDS in adults through mid-1990 was 9.1 per 1000 of the population and where the use of illicit drugs, including smokable freebase cocaine (crack), is common. The overall seroprevalence among volunteers was 12% (369 out of 3084), with 80% of those who were seropositive reporting risk behavior associated with HIV-1 infection, including male-to-male sexual contact, intravenous drug use and heterosexual contact with an intravenous drug user. The seroprevalence in individuals denying these risks was 3.6% (50 out of 1389) and 4.2% (22 out of 522) in men and women, respectively. Among these individuals, the behaviors significantly associated with infection were use of crack and prostitution in women, and history of syphilis and crack use in men. These results suggest that in areas where the level of HIV-1 infection in heterosexual intravenous drug users is high and the use of crack is common, increased sexual activity (including the exchange of drugs or money for sex) may result in increased heterosexual transmission of HIV-1.

HIV-1 infection and risk of vulvovaginal and perianal condylomata acuminata and intraepithelial neoplasia: a prospective cohort study

BACKGROUNDnInformation about vulvovaginal and perianal condylomata acuminata and intraepithelial neoplasia in women infected with HIV-1 is needed to develop guidelines for clinical care. Our aim was to investigate the incidence of these lesions in HIV-1-positive and HIV-1-negative women and to examine risk factors for disease.nnnMETHODSnIn a prospective cohort study, 925 women had a gynaecological examination twice yearly-including colposcopy and tests for human papillomavirus DNA in cervicovaginal lavage-for a median follow-up of 3.2 years (IQR 0.98-4.87).nnnFINDINGSnVulvovaginal and perianal condylomata acuminata or intraepithelial neoplasia were present in 30 (6%) of 481 HIV-1-positive and four (1%) of 437 HIV-1-negative women (p<0.0001) at enrollment. Women without lesions at enrollment were included in an incidence analysis. 33 (9%) of 385 HIV-1-positive and two (1%) of 341 HIV-1-negative women developed vulvovaginal or perianal lesions, resulting in an incidence of 2.6 and 0.16 cases per 100 person-years, respectively (relative risk 16, 95% CI 12.9-20.5; p < 0.0001). Risk factors for incident lesions included HIV-1 infection (p = 0.013), human papillomavirus infection (p=0.0013), lower CD4 T lymphocyte count (p = 0.0395), and history of frequent injection of drugs (p=0.0199).nnnINTERPRETATIONnOur results suggest that HIV-1-positive women are at increased risk of development of invasive vulvar carcinoma. Thus, we recommend that, as part of every gynaecological examination, HIV-1-positive women should have a thorough inspection of the vulva and perianal region, and women with abnormalities-except for typical, exophytic condylomata acuminata-should undergo colposcopy and biopsy.

HIV-1 Seroconversion in Patients with and without Genital Ulcer Disease: A Prospective Study

Since the beginning of the acquired immunodeficiency syndrome (AIDS) epidemic, two predominant and distinct epidemiologic patterns of human immunodeficiency virus (HIV-1) transmission have been reported. In North America and Western Europe, although heterosexual transmission has been increasing [1], men exposed to HIV-1 through sexual contact with other men and injection drug users (users of illicit drugs) are the predominant groups at risk for development of AIDS [2]. The second pattern, prevalent in Africa and parts of Asia and the Caribbean, is predominantly characterized by heterosexual transmission, with a nearly equal male-to-female ratio of patients [3, 4]. The reasons for these different patterns of transmission have not been fully identified, but studies have addressed the possibility that the presence of genital ulcers, especially chancroid, has enhanced heterosexual transmission [5, 6]. Sexually transmitted diseases that result in a disrupted genital epithelium, such as syphilis, chancroid, and herpes, have been associated with heterosexual transmission of HIV-1 using retrospective studies in the United States [7-10] and both retrospective [11] and prospective studies in sub-Saharan Africa [12, 13]. In New York City, an ongoing epidemic of genital ulcer disease has occurred in communities where HIV-1 infection related to injection drug use is well documented [10, 14]. The number of cases of primary and secondary syphilis reported to the New York City Department of Health increased from 2157 in 1985 to 4231 in 1990. The number of reported cases of chancroid increased from 1323 in 1985 to 2277 in 1989. Consequently, a prospective study of HIV-1 seroconversion was initiated to further characterize the relation between genital ulcer disease and HIV-1 transmission in primarily heterosexual persons in the United States. Methods Study Population This study was done in 1 of the 12 inner-city, sexually transmitted disease clinics operated by the New York City Department of Health. The study site is located in an area of New York City where the cumulative incidence of AIDS in adults through 1990 was 1 per 100 persons (New York City AIDS Case Surveillance data) and illicit drug use, including crack (smokable freebase cocaine) use, is common. In 1990, this clinic provided care to 14 243 persons: 9589 (67%) were men and 4654 were women. Primary or secondary syphilis was diagnosed in 226 patients, and 113 were found to have chancroid. From 1988 to 1989, the HIV-1 prevalence in this clinic was 7.8%, estimated by a serosurvey that was done without using patient identifiers (Weisfuse I. Personal communication). Study Population Recruitment into the study consisted of two phases. In the first phase, all of the approximately 28 000 persons attending the clinic for diagnosis or treatment of a sexually transmitted disease during the study period were asked to participate in a study of the prevalence of HIV-1 infection and associated risk factors. Those who agreed (n = 2893) received HIV-1 pretest counseling and were given a return appointment to receive test results and post-test counseling. Those with a diagnosis of genital ulcer were recruited more intensively. Thus, approximately 700 (24%) of the 2893 participants recruited into phase 1 had genital ulcers. These 700 participants with genital ulcer disease represented more than 80% of all patients seen in the clinic with ulcers during the study period. Study interviewers administered standardized questionnaires in either English or Spanish. Information on demographic characteristics, socioeconomic status, and risk behavior associated with HIV-1 transmission was collected, as previously described [14]. Of the 2543 participants who were HIV negative, 1679 returned for post-test counseling 3 weeks after initial study enrollment and were asked to participate in the prospective component (or phase 2) of the study. For those who agreed, an additional questionnaire was administered to identify potential HIV-1-related high-risk behavior during three periods of interest: the 6 months before the initial clinic visit, the 10 days before the symptom developed that resulted in the clinic visit, and the period while the symptoms were present. The questioning focused on intravenous drug use and the number of sexual contacts and the type of sexual activities with intravenous drug users, homosexual or bisexual men, prostitutes, and others. The regularity of condom use was determined using the following scale: always, usually (>50%), sometimes (approximately 50%), rarely (<50%), and never. Anonymous HIV-1 testing was available for patients who did not want to participate in the study or who did not have a sexually transmitted disease. At the time of enrollment in phase 2, participants were asked to return to the clinic for a third time, approximately 3 months after the initial clinic visit. For the participants who returned for the final follow-up visit, a repeated serum sample for HIV-1 testing was obtained, and a questionnaire similar to that described above was administered to identify high-risk behavior for the period between the two HIV-1 antibody tests. Informed consent was obtained for both phases of the study, and the study was approved by the institutional review boards of the New York City Department of Health and the Centers for Disease Control and Prevention. Laboratory Methods Patients with a genital ulcer had the following diagnostic tests: syphilis serology, dark-field examination of ulcer exudate for Treponema pallidum, Gram stain of ulcer exudate, microbiologic culture for Haemophilus ducreyi using blood and chocolate media, and Tzanck smear for herpes virus. Testing for syphilis was done using the rapid plasma reagin card test (Hynson, Wescott, and Dunning; Baltimore, Maryland) and the microhemagglutination assay for T. pallidum (Fujirebio Inc., Tokyo, Japan, and Ames Division, Miles Laboratory, Elkhart, Indiana). Haemophilus ducreyi was isolated using previously described methods [15]. Antibody testing for HIV-1 was done by an enzyme-linked immunosorbent assay (DuPont, Wilmington, Delaware), followed by a confirmatory Western blot analysis of all reactive samples using reagents prepared by the Laboratory of Retrovirology and Immunobiology of the New York City Department of Health [16]. Diagnosis of Genital Ulcer Disease Primary syphilis was diagnosed when a genital ulcer was present and the ulcer exudate was dark-field positive, the rapid plasma reagin card test was positive, or the patient had recent contact with a person known to have syphilis. A diagnosis of chancroid was made when a positive culture occurred for H. ducreyi, if Gram stain of the ulcer exudate showed pleomorphic gram-negative rods, or if clinical findings suggested chancroid (tender or multiple ulcers, painful inguinal adenitis) with a negative dark-field examination as well as a negative syphilis serologic test result and a negative Tzanck smear. Genital herpes was diagnosed when the lesions were vesicular or recurrent or an ulcer had a positive Tzanck smear. In the absence of, or with negative, microbiologic and serologic data, the clinical diagnosis was made by the supervising physician in the clinic and not by study personnel. Statistical Analysis Analysis was done using the SAS statistical software system, version 6.06 (SAS Institute, Inc., Cary, North Carolina). The strength of the association between individual categorical variables or continuous variables grouped categorically and HIV-1 seroconversion was evaluated by the relative risk, and 95% direct precision-based CIs were obtained. Statistical relations were tested by the chi-square test or the Fisher exact test (two-tailed). Differences between continuous variables were analyzed by the Student t-test (two-tailed), the Wilcoxon rank-sum test, or the median test. The SAS LOGIST procedure was used to fit the multiple logistic regression model to the single binary outcome variable (HIV seroconversion or no seroconversion). The adjusted odds ratios obtained in this model approximated the adjusted relative risk. Measurement of Risk Index For heterosexual men, a summary measure was constructed of the risk for HIV-1 transmission attributable to a combination of the probability of encountering and the frequency of exposure to an HIV-1-infected partner. The sexual risk index was generated for the period from 6 months before the clinic visit through the second HIV test. Indices were computed by taking the sum of the products of the number of sexual contacts with partners in each of four risk groups (prostitutes, female intravenous drug users, women with chancroid, and women with no risk) and the estimated HIV-1 seroprevalence among the members of that group. Prevalence estimates for risk groups were determined from among our own study participants during phase 1, unblinded risk-factor serosurvey because sexual contacts were likely to occur in the local geographic area. The overall seroprevalence for the 644 women with no risk in phase 1 was 6%, for the 88 injection drug users it was 44%, for the 167 female prostitutes it was 29%, and for the 26 women with chancroid it was 19%. Using these values, risk indices were generated for four groups of male study participants: those with chancroid who did and did not seroconvert and those without chancroid who did and did not seroconvert. The risk indices were scaled proportionately from 0 to 100 for graphic presentation. Statistical comparisons were done between the Sexual Risk Index medians of the patients with chancroid and those without chancroid who seroconverted; between those without chancroid who seroconverted and those without chancroid who did not seroconvert; and between patients with chancroid who seroconverted and all patients who did not seroconvert using the median test. Results Of the 2543 seronegative persons identified in the cross-sectional component (phase 1) of the study, 1679 (62%) r

Women at a sexually transmitted disease clinic who reported same-sex contact: their HIV seroprevalence and risk behaviors.

OBJECTIVESnThis study compares characteristics, behaviors, and human immunodeficiency virus (HIV) infection in women who reported same-sex contact and women who had sex only with men.nnnMETHODSnParticipants were patients attending a New York City sexually transmitted disease clinic. Structured questionnaires were administered by interviewers.nnnRESULTSnOverall, 9% (135/1518) of women reported same-sex contact; among these, 93% also reported contact with men. Women reporting same-sex contact were more likely than exclusively heterosexual women to be HIV seropositive (17% vs 11%; odds ratio [OR] = 1.7, 95% confidence interval [CI] = 1.0, 2.6), to exchange sex for money/drugs (48% vs 12%, OR = 6.7, 95% CI = 4.6, 9.8), to inject drugs (31% vs 7%, OR = 6.3, 95% CI = 4.1, 9.5), and to use crack cocaine (37% vs 15%, OR = 3.3, 95% CI = 2.2, 4.8). HIV in women reporting same-sex contact was associated with history of syphilis (OR = 8.8), sex for crack (OR = 5.7), and injection drug use (OR = 4.5).nnnCONCLUSIONSnIn this study, women who reported same-sex contact were predominantly bisexual. They had more HIV risk behaviors and were more often HIV seropositive than women who had sex only with men. Among these bisexual women, heterosexual contact and injection drug use were the most likely sources of HIV. There was no evidence of female-to-female transmission.

Retaining Hard-to-Reach Women in HIV Prevention and Vaccine Trials: Project ACHIEVE

Project ACHIEVE, which conducts HIV prevention research studies, maintains a womens site in the South Bronx in NewYork City. Owing to a focused retention effort at the South Bronx site, high retention rates were achieved in a vaccine preparedness study for women at high risk of HIV infection. Comparable retention rates have been achieved in HIV vaccine trials with similar cohorts of women at this site. These results suggest that concerns about retaining hard-to-reach populations should not cause these populations to be excluded from HIV vaccine and prevention trials.

Possible nosocomial transmission of HIV

Abstract We report an infant with AIDS whose source of HIV is unknown; investigation supported the possibility of patient-to-patient transmission of HIV during medical care.

HIV risk behaviors among adolescents at a sexually transmitted disease clinic in New York City

PURPOSEnThe purpose of this study was to describe human immunodeficiency virus (HIV)-associated risk behaviors among adolescents attending a clinic for the treatment of sexually transmitted disease in New York City.nnnMETHODSnA total of 4,585 volunteers were interviewed and HIV-tested, including 456 adolescents (aged 13-19 years), of whom 220 were women (48%) and 236 men (52%).nnnRESULTSnFewer than 1% of the 456 adolescents said they injected drugs. Unprotected vaginal sex was the most common sexual behavior, with 93% of adolescents reporting always having vaginal sex, and 57% rarely or never using condoms. Anal sex was reported by 18%. Twenty percent of adolescent men had paid for sex, compared to just 1% of women, whereas 3% of men and 4% of women had traded sex for money or drugs. Nine women and three men tested HIV seropositive. All three HIV-positive men reported having had receptive anal sex with men. Among women, HIV seropositivity was most strongly associated with crack cocaine use and trading sex for money or drugs.nnnCONCLUSIONSnHIV prevalence was high, with most infections owing to sexual transmission rather than intravenous drugs. The increased risk of HIV infection in adolescent women was associated with high-risk sex related to crack use and the exchange of sex for money or drugs.

Double Trouble: Violent and Non-Violent Traumas Among Women at Sexual Risk of HIV Infection

ABSTRACT Background: This study examines the association between trauma and HIV risk behaviors among women at sexual risk for HIV infection. Methods: From April to August 1998, high-risk HIV negative women were recruited in the South Bronx into a year-long cohort study. At the 12-month visit, 116 women were interviewed face-to-face about recent and lifetime violent and non-violent traumas. Results: The women reported a substantial prevalence of sexual risk behaviors associated with the acquisition of HIV. At baseline, almost two-thirds (64%) reported unprotected vaginal sex in the previous six months, and in the previous year, 62% had smoked crack, 52% reported sex-for-money-or-drugs exchanges, and 47% had five or more male sex partners. The lifetime prevalence of trauma was high: 81% had experienced one or more violent traumas and 97% had experienced one or more non-violent traumas. Women who had experienced violent trauma-physical assault by a partner (OR = 2.88; 95% CI 1.12; 7.41)-and those who had experienced non-violent trauma-loss of a child to foster care (OR = 3.34; 95% CI 1.04; 10.65)-were more likely to use crack than others. Those who had experienced non-violent trauma, by witnessing a physical assault (OR = 2.31; 95% CI 0.99; 5.40), were also more likely than others to have exchanged sex. Conclusions: Both violent and non-violent traumas appear to play a role in the behaviors that place women at risk of HIV infection, particularly using crack and exchanging sex.

The changing AIDS epidemic in New York City: a descriptive birth cohort analysis of AIDS incidence and age at diagnosis.

ObjectiveTo describe and quantify changing AIDS incidence trends in New York City. MethodsData on 44400 AIDS cases diagnosed and reported between 1981 and 1992 were analyzed among demographic and HIV transmission categories. Data were grouped into 10-year birth cohorts by sex, race/ethnicity, and mode of HIV transmission. AIDS incidence and rates of change, as well as changes in median age at diagnosis, were analyzed for persons born between 1920 and 1969. ResultsDeclining AIDS incidence between 1989 and 1992 was only observed among white men who have sex with men (MSM) born prior to 1960 and among minority MSM born prior to 1940. Between 1989 and 1992 the highest rate of increase in AIDS incidence was observed among female injecting drug users (IDU) and persons born after 1960. Median age at diagnosis increased during the study period by 1 year among white MSM, by 2 years among minority MSM, by 7 and 6 years among male and female IDU, respectively, and by 5 years among women infected through heterosexual contact. ConclusionsThese findings suggest that early HIV infection dynamics of the AIDS epidemic were differentially related to age, sex, and transmission category, which resulted in the diffusion of infection from older to younger cohorts and from men to women. The continuing increase in AIDS incidence among the 1960s cohort suggests that the future growth of the epidemic will be dependent upon infection patterns of younger birth cohorts.