Nina T. Harawa

The health effects of swimming in ocean water contaminated by storm drain runoff

In a case-control study we assessed whether exposure to high job strain during the first 20 weeks of pregnancy increases the risk of preeclampsia and gestational hypertension. Cases (128 with preeclampsia and 201 with gestational hypertension) and controls (N = 401) were primiparous women who had a paid occupation for at least 1 week during the first 20 weeks of their pregnancy and who delivered between 1984 and 1986 in 10 hospitals of Quebec, Canada. Based on their job title, we assigned women scores of psychological demand and decision latitude derived from the National Population Health Survey and classified these women as exposed to high (high demand, low latitude) versus low (low demand, high latitude) job strain. Women exposed to high job strain were more likely to develop preeclampsia [adjusted odds ratio (aOR) = 2.1; 95% confidence interval (CI) = 1.1-4.1] than women exposed to low job strain. The risk was quite similar for women exposed to a full-time, high strain job (> or =35 hours per week) (aOR = 2.0) than in a part-time, high strain job (aOR = 1.8). High job strain increased the risk of gestational hypertension slightly (aOR = 1.3; 95% CI = 0.8-2.2). These results indicate that women exposed to high job strain are at higher risk of developing preeclampsia and, to a lesser extent, gestational hypertension.

Associations of Race/Ethnicity With HIV Prevalence and HIV-Related Behaviors Among Young Men Who Have Sex With Men in 7 Urban Centers in the United States

Abstract:Using data from a multisite venue-based survey of male subjects aged 15 to 22 years, we examined racial/ethnic differences in demographics, partner type, partner type-specific condom use, drug use, and HIV prevalence in 3316 US black, multiethnic black, Latino, and white men who have sex with men (MSM). We further estimated associations of these factors with HIV infection and their influence on racial/ethnic disparities in HIV prevalence. HIV prevalences were 16% for both black and multiethnic black participants, 6.9% for Latinos, and 3.3% for whites. Paradoxically, potentially risky sex and drug-using behaviors were generally reported most frequently by whites and least frequently by blacks. In a multiple logistic regression analysis, positive associations with HIV included older age, being out of school or work, sex while on crack cocaine, and anal sex with another male regardless of reported condom use level. Differences in these factors did not explain the racial/ethnic disparities in HIV prevalence, with both groups of blacks experiencing more than 9 times and Latinos experiencing approximately twice the fully adjusted odds of infection compared with whites. Understanding racial/ethnic disparities in HIV risk requires information beyond the traditional risk behavior and partnership type distinctions. Prevention programs should address risks in steady partnerships, target young men before sexual initiation with male partners, and tailor interventions to men of color and of lower socioeconomic status.

Diagnosis of Primary HIV-1 Infection

Primary HIV infection is characterized by diverse clinical symptoms (1, 2). Since patients with primary infection are just developing HIV antibodies, recognition of the syndrome in at-risk persons should prompt antibody testing as well as a virologic assay (3, 4). Diagnosing primary infection may decrease HIV transmission (5) and allow consideration of early treatment (2, 6). To date, the optimal patients to screen and the best algorithm for use of diagnostic tests have not been determined. The objectives of this study were to determine the sensitivity and specificity of virologic tests and specific clinical symptoms for diagnosing primary HIV infection. Methods Patients Patients with potential exposure to HIV and compatible symptoms were referred from clinics, testing centers, emergency departments, and community physicians for primary infection screening at Cedars-Sinai Medical Center in Los Angeles, California, and the University of California, San Diego. In Los Angeles, 127 patients were screened between March 1993 and August 1995 (cohort 1) for enrollment in a placebo-controlled trial of zidovudine (7). A similar group of 255 patients was screened in Los Angeles between June 1996 and July 1999 (cohort 2), and 54 patients were screened between June 1996 and March 1999 in San Diego (cohort 3). Patients in cohort 2 received a standardized questionnaire regarding results of past HIV tests, presence of specific symptoms, and potential exposure to HIV during the preceding 2 months. Virologic and Serologic Assays The study was approved by local institutional review boards. All patients provided informed consent and received pre- and post-test counseling. Patients in cohorts 1 and 2 had real-time testing for HIV antibodies and p24 antigen by a polyclonal enzyme immunoassay (Abbott Laboratories, Abbott Park, Illinois); plasma was stored at 70 C. In cohort 2, real-time plasma HIV RNA measurements were performed by branched-chain DNA (bDNA) assay, version 2.0 (lower limit of detection, 500 copies/mL), between June 1996 and July 1998 and by version 3.0 (lower limit of detection, 50 copies/mL) between August 1998 and July 1999 (Chiron Diagnostics, Emeryville, California). Stored samples from cohort 1 were retrospectively tested by bDNA assay, version 3.0. After April 1998, p24 antigen was measured by using the monoclonal HIV AG-1 enzyme immunoassay (Abbott Laboratories), which replaced the previous assay. All samples with detectable p24 antigen were confirmed by neutralization (Abbott Laboratories). Samples positive for HIV antibody were confirmed by Western blot (Cambridge Biotech Corp., Rockville, Maryland). Samples that yielded indeterminate Western blots (<2 envelope bands, core bands, or both) were tested again in approximately 1 month to document seroconversion. Patients in cohort 3 were screened in San Diego by using HIV antibody enzyme immunoassay (Abbott Laboratories). Plasma HIV RNA level was determined by using Amplicor HIV Monitor (Roche Diagnostic Systems, Indianapolis, Indiana), which had a lower limit of detection of 400 copies/mL. Samples that were positive for HIV RNA but negative for HIV antibody were tested for p24 antigen (Beckman Coulter, Fullerton, California). Statistical Analysis Primary infection was defined as a confirmed positive virologic test result with either a negative HIV antibody assay result or an indeterminate Western blot. Because there is no virologic gold standard, we assumed that levels of plasma HIV RNA had a sensitivity of 100% for diagnosing primary infection. False-positive HIV RNA measurements were defined as those that were negative on repeated testing and those obtained in patients who did not undergo seroconversion. In cohort 1, frozen plasma samples that were negative for HIV antibody and p24 antigen were retrospectively tested for HIV RNA. Follow-up was not available for these patients; therefore, before testing any samples, we determined that an HIV RNA level greater than 10 000 copies/mL would be considered a true-positive result. This HIV RNA level, in our experience, has not been seen in false-positive samples. Sensitivity and specificity, along with corresponding 95% confidence intervals, were determined by using tabulated exact binomial limits for sample sizes less than or equal to 100 (8) and by using the normal approximation to the binomial for sample sizes greater than 100. Patients in cohort 2 were analyzed for predictors of primary infection on the basis of uniformly collected demographic characteristics, exposure history, and symptoms. All variables were compared by using a two-sample t-test. To assess the impact of several predictor variables, a stepwise discriminant analysis was performed by using variables that differed significantly between patients with and those without primary infection (significance was indicated by a Pvalue<0.05). Role of the Funding Sources The funding sources had no role in the collection, analysis, or interpretation of the data or in the decision to submit the paper for publication. Results Demographic characteristics were similar across cohorts. Overall, 89% of patients were male, 74% were white, 13% were Hispanic, and 9% were African American. Regarding risk factors, 77% of patients were homosexual men, 18% were heterosexual women, and 4% used intravenous drugs. Patients were categorized as having 1) primary infection with undetectable HIV antibodies or an indeterminate Western blot [12.4%], 2) chronic infection with a positive Western blot [18.1%], or 3) no infection (69.5%). Sensitivity and Specificity of Virologic Assays The results of screening tests are summarized in Table 1. Patients with primary infection had undetectable HIV antibodies or indeterminate Western blot but a confirmed positive virologic test result. Two patients in cohort 1 were negative for HIV antibody and p24 antigen but positive for HIV RNA, with levels greater than 100 000 copies/mL. For the purpose of this analysis, they were considered to be true positive for primary HIV infection. Overall, p24 antigen testing had a sensitivity of 88.7% (95% CI, 77.0% to 95.7%). The mean concentration of HIV RNA in the five patients who had primary infection but undetectable p24 antigen was 251 189 copies/mL (range, 100 000 to 630 957 copies/mL). The overall specificity of tests for HIV RNA and p24 antigen was 97.4% (CI, 94.9% to 98.9%) and 100% (CI, 99.3% to 100%), respectively. Eight of 303 uninfected patients (2.6%) had false-positive results on HIV RNA testing (mean concentration, 269 copies/mL [range, 52 to 1950 copies/mL]). Table 1. Serologic and Virologic Results in Patients Screened for Primary HIV Infection Predictors of Primary HIV Infection Cohort 2 was divided into patients with primary infection and those who were uninfected or had chronic HIV infection (Table 2). The primary infection group involved 25 patients who had a negative antibody test result or indeterminate Western blot and 15 patients who had had a negative antibody test result in the preceding 3 months. Of these 15, 4 had had a negative Western blot in the previous 3 weeks and 11 had had a documented negative antibody test result or evolving Western blot in the previous 3 months. Those with primary infection were more likely to be homosexual; to have been exposed to an HIV-infected person; and to report fever, myalgia, arthralgia, rash, or night sweats (P<0.05 for all comparisons) (Table 2). Combining fever, myalgia, and rash increased the predictive value of symptoms; however, no combination of symptoms identified more than 75% of patients with primary infection. Table 2. Clinical Predictors of Primary HIV Infection in Cohort 2 Discussion Our study shows that no clinical symptoms have sufficient sensitivity or specificity for primary infection to allow targeted screening of at-risk persons. In addition, we show that while both p24 antigen and plasma HIV RNA assays are useful virologic tests for diagnosing primary infection, each has limitations. Assays for HIV RNA are likely to be more sensitive but are associated with lower specificity and can therefore yield more false-positive results. Similar to our study, a study in India that screened patients in sexually transmitted disease clinics showed that certain symptoms occur with increased frequency in patients with primary HIV infection (9). Nevertheless, both this study and our study demonstrate that selective screening would miss a substantial number of patients with primary infection. Thus, to maximize the number of identified infected patients, many seronegative persons must be screened. Several groups have reported that assays for HIV RNA are more sensitive than those for p24 antigen in diagnosing primary infection. However, these studies often screened asymptomatic patients, such as those found to experience seroconversion during cohort studies (10) and those with indeterminate Western blots (11). This makes the findings less relevant for the prospective screening of symptomatic patients. Similar to our study, other studies have shown that the assay for p24 antigen is sensitive in symptomatic antibody-negative patients, in whom virologic testing is necessary for diagnosis (4, 7, 12). Overall, these studies and our own emphasize the importance of analyzing the sensitivity and specificity of virologic assays in the context of the patients clinical and serologic status. When selecting a virologic test, it is important to consider its cost in clinical practice. In our study, it cost approximately

Sexual Behavior, Sexual Identity, and Substance Abuse Among Low-Income Bisexual and Non-Gay-Identifying African American Men Who Have Sex with Men

6000 (

HIV Prevalence Among Foreign- and US-Born Clients of Public STD Clinics

20 per test) to screen all seronegative patients in cohort 2 for p24 antigen. To identify a single patient missed by p24 antigen testing, we were required to perform HIV RNA assays on more than 100 patients at

Perceptions Towards Condom Use, Sexual Activity, and HIV Disclosure among HIV-Positive African American Men Who Have Sex with Men: Implications for Heterosexual Transmission

100 per test, an additional cost of more than

Incarceration, African Americans, and HIV: Advancing a Research Agenda

10 000. Furthermore, false-positive results on HIV RNA assays require follow-up testing and extensive post-test counseling and are associated with substantial psychological distress.

Allostatic Load Burden and Racial Disparities in Mortality

We examined the role of drug use and addiction in same-sex sexuality among non-gay-identifying African American men who have sex with men or with both men and women (MSM/MSMW). Between July 2005 and February 2006, we conducted seven focus groups with 46 predominately low socioeconomic status African American MSM/MSMW. A total of 29 men self-identified as HIV-infected and 17 self-identified as uninfected. Focus group transcripts were analyzed using consensual qualitative research techniques. Alcohol, crack cocaine, and crystal methamphetamine were the primary drugs mentioned by participants. Drug use was identified as playing a central role in same-sex sexuality for many African American MSM/MSMW. Participants described alcohol use and drug transactions, use, and addiction as motivating sex with men, allowing and rationalizing same-sex activity and unprotected sex, and facilitating access to male sex partners. Some of those in treatment for substance abuse indicated that a readiness to admit their same-sex activity and come to terms with their homosexuality/bisexuality was necessary for recovery. Because successful engagement of non-gay-identifying African American MSM/MSMW is essential to the reduction of HIV transmission and substance abuse in Black communities, findings call for drug treatment approaches that acknowledge and accept diverse sexuality in clients. Service providers and policy-makers may be guided by these findings toward building cultural competency among direct service staff. Future research should examine interrelated dynamics of sexual activity, identity, and drug use as they evolve within individual African American MSM/MSMW and compare the frequency with which sex, condom use, and substance use co-occur with male versus female partners.

Learning From Successful Interventions: A Culturally Congruent HIV Risk–Reduction Intervention for African American Men Who Have Sex With Men and Women

OBJECTIVES We examined differences in HIV seroprevalence and the likely timing of HIV infection by birth region. METHODS We analyzed unlinked HIV antibody data on 61 120 specimens from 7 public health centers in Los Angeles County from 1993 to 1999. RESULTS Most (87%) immigrant clients were Central American/Mexican-born. HIV prevalence was similar for US- and foreign-born clients (1.8% [95% confidence interval (CI) = 1.7%, 1.9%] and 1.6% [95% CI = 1.5%, 1.8%], respectively). Seroprevalence was high among sub-Saharan African females and low among Asian/Pacific Islander males and females. For HIV-positive immigrants, the average age at and time since immigration were 20.6 years and 12.3 years, respectively. CONCLUSIONS The relatively young age at arrival and long time since arrival for HIV-positive foreign-born clients suggest that most were infected after immigration.

Immunologic activation during pregnancy: serial measurement of lymphocyte phenotype and serum activation molecules in HIV-infected and uninfected women

Disproportionately high HIV/AIDS rates and frequent non-gay identification (NGI) among African American men who have sex with men or with both men and women (MSM/W) highlight the importance of understanding how HIV-positive African American MSM/W perceive safer sex, experience living with HIV, and decide to disclose their HIV status. Thirty predominately seropositive and non-gay identifying African American MSM/W in Los Angeles participated in three semi-structured focus group interviews, and a constant comparison method was used to analyze responses regarding condom use, sexual activity after an HIV diagnosis, and HIV serostatus disclosure. Condom use themes included its protective role against disease and pregnancy, acceptability concerns pertaining to aesthetic factors and effectiveness, and situational influences such as exchange sex, substance use, and suspicions from female partners. Themes regarding the impact of HIV on sexual activity included rejection, decreased partner seeking, and isolation. Serostatus disclosure themes included disclosure to selective partners and personal responsibility. Comprehensive HIV risk-reduction strategies that build social support networks, condom self-efficacy, communication skills, and a sense of collective responsibility among NGI African American MSM/W while addressing HIV stigma in the African American community as a whole are suggested.