Sally Zierler

Adult survivors of childhood sexual abuse and subsequent risk of HIV infection.

BACKGROUND Epidemiologic description of long-term adverse health effects of childhood sexual abuse is lacking, despite estimates that perhaps 30 percent of adults have experienced sexual assault in childhood. METHODS In an adult cohort enrolled to investigate causes of transmission of human immunodeficiency virus, we identified current behaviors affecting risk of infection that were associated with a history of early sexual abuse. One hundred and eighty-six individuals provided information on the occurrence of abuse and subsequent sexual and drug using activities. RESULTS Approximately half of the women and one-fifth of the men reported a history of rape during childhood or adulthood. Twenty-eight percent of the women and 15 percent of the men recalled that they had been sexually assaulted during childhood. People who reported childhood rape compared with people who did not were four times more likely to be working as prostitutes (90 percent confidence interval = 2.0, 8.0). Women were nearly three times more likely to become pregnant before the age of 18 (90% CI = 1.6, 4.1). Men who reported a history of sexual abuse had a twofold increase in prevalence of HIV infection relative to unabused men (90% CI = 1.0, 3.9). CONCLUSIONS The disturbing prevalence of early sexual abuse and its possible health-related consequences call for prompt and routine investigation of sexual abuse histories. Identification of sexual victimization may be an important component for management of risk factors for human immunodeficiency virus.

The Impact of Competing Subsistence Needs and Barriers on Access to Medical Care for Persons with Human Immunodeficiency Virus Receiving Care in the United States

OBJECTIVES To examine whether competing subsistence needs and other barriers are associated with poorer access to medical care among persons infected with human immunodeficiency virus (HIV), using self-reported data. DESIGN Survey of a nationally representative sample of 2,864 adults receiving HIV care. MAIN INDEPENDENT VARIABLES Going without care because of needing the money for food, clothing, or housing; postponing care because of not having transportation; not being able to get out of work; and being too sick. MAIN OUTCOME MEASURES Having fewer than three physician visits in the previous 6 months, visiting an emergency room without being hospitalized; never receiving antiretroviral agents, no prophylaxis for Pneumocystis carinii pneumonia in the previous 6 months for persons at risk, and low overall reported access on a six-item scale. RESULTS More than one third of persons (representing >83,000 persons nationally) went without or postponed care for one of the four reasons we studied. In multiple logistic regression analysis, having any one or more of the four competing needs independent variables was associated with significantly greater odds of visiting an emergency room without hospitalization, never receiving antiretroviral agents, and having low overall reported access. CONCLUSIONS Competing subsistence needs and other barriers are prevalent among persons receiving care for HIV in the United States, and they act as potent constraints to the receipt of needed medical care. For persons infected with HIV to benefit more fully from recent advances in medical therapy, policy makers may need to address nonmedical needs such as food, clothing, and housing as well as transportation, home care, and employment support.

Violence victimization after HIV infection in a US probability sample of adult patients in primary care.

OBJECTIVES This study estimated the proportion of HIV-infected adults who have been assaulted by a partner or someone important to them since their HIV diagnosis and the extent to which they reported HIV-seropositive status as a cause of the violence. METHODS Study participants were from a nationally representative probability sample of 2864 HIV-infected adults who were receiving medical care and were enrolled in the HIV Costs and Service Utilization Study. All interviews (91% in person, 9% by telephone) were conducted with computer-assisted personal interviewing instruments. Interviews began in January 1996 and ended 15 months later. RESULTS Overall, 20.5% of the women, 11.5% of the men who reported having sex with men, and 7.5% of the heterosexual men reported physical harm since diagnosis, of whom nearly half reported HIV-seropositive status as a cause of violent episodes. CONCLUSIONS HIV-related care is an appropriate setting for routine assessment of violence. Programs to cross-train staff in antiviolence agencies and HIV care facilities need to be developed for men and women with HIV infection.

Quality of Community Drinking Water and the Occurrence of Spontaneous Abortion

To investigate the relationship between community drinking water quality and spontaneous abortion, we compared trace element levels in the drinking water of 286 women having a spontaneous abortion through 27 wk gestation with that of 1,391 women having livebirths. Trace element levels were gathered from routine analyses of public tap water supplies from the communities where the women resided during pregnancy. After adjustment for potential confounders, an increase in the frequency of spontaneous abortion was associated with detectable levels of mercury; high levels of arsenic, potassium, and silica; moderately hard water, and surface water. In contrast, a decrease in the frequency of spontaneous abortion was associated with high levels of alkalinity and sulfate, and any detectable level of nitrate. These results require further corroboration because there is a paucity of data investigating this issue.

Adult onset of major depressive disorder in relation to early life violent victimisation: a case-control study

BACKGROUND Major depressive disorder is a significant cause of morbidity among women in the USA. Women are twice as likely as men to be diagnosed with major depressive disorder, yet no known risk factors can account for this sex difference. We aimed to assess violent victimisation as a risk factor for depression in women. METHODS We undertook a case-control study to assess the association between violent victimisation early in life and major depressive disorder in women. We randomly selected a population-based sample of women, aged 36-45 years, from the greater Boston area. In 1999, 236 cases and 496 controls (n=732) completed a self-administered questionnaire designed to ascertain a lifetime history of exposure to violent victimisation. Our main outcome measure was major depressive disorder, assessed by structured clinical interview for Diagnostic Statistical Manual IV (DSM-IV) criteria. FINDINGS 363 (50%) of 732 respondents reported experience or fear of abuse as a child or adolescent. 68 were excluded because they reported violence as an adult only. Compared with women who reported no abuse, risk of depression was increased in women who reported any abuse as a child or adolescent (relative risk 2.5, 95% CI 1.9-3.0), physical abuse only (2.4, 1.8-3.0), sexual abuse only (1.8, 1.2-2.8), and both physical and sexual abuse (3.3, 2.5-4.1). Severity of abuse had a linear dose-response relation with depression. INTERPRETATION Our results suggest a positive association between violent victimisation early in life and major depressive disorder in women.

SKIN CARCINOMA IN PATIENTS WITH PSORIASIS TREATED WITH TOPICAL TAR AND ARTIFICIAL ULTRAVIOLET RADIATION

A case-control study, consisting of 59 skin cancer patients with severe psoriasis, was conducted to evaluate the effect of treatment with tar and/or artificial ultraviolet radiation on the risk of developing cutaneous carcinoma. Using 924 unmatched controls, we estimated that the crude rate of skin cancer was 2.4-fold for patients with high exposure to tar and ultraviolet radiation, compared with those lacking high exposure. Using a control series of 126 patients matched for age, skin type, region of residence, sex, history of exposure to ionising radiation, and number of 8-methoxypsoralen photochemotherapy treatments, we observed a stronger association (relative rate = 4.7, 95% confidence limits = 2.2 to 10.0). The magnitude of the relative rates argues for continued surveillance for tumours among patients with psoriasis who receive long-term tar or artificial ultraviolet radiation therapy.

Perceived Discrimination in Clinical Care in a Nationally Representative Sample of HIV‐Infected Adults Receiving Health Care

BACKGROUND: Perceived discrimination in clinical settings could discourage HIV-infected people from seeking health care, adhering to treatment regimens, or returning for follow-up.OBJECTIVES: This study aims to determine whether HIV-infected people perceive that physicians and other health care providers have discriminated against them.DESIGN, PARTICIPANTS: Cross-sectional data (1996 to 1997) from the HIV Cost and Services Utilization Study (HCSUS), which conducted in-person interviews with a nationally representative probability sample of 2,466 HIV-infected adults receiving health care within the contiguous U.S.MEASUREMENTS: Reports of whether health care providers have been uncomfortable with the respondent, treated the respondent as an inferior, preferred to avoid the respondent, or refused the respondent service. Questions also covered the types of providers who engaged in these behaviors.RESULTS: Twenty-six percent of HIV-infected adults receiving health care reported experiencing at least 1 of 4 types of perceived discrimination by a health care provider since becoming infected with HIV, including 8% who had been refused service. White respondents (32%) were more likely than others (27%) and Latinos (21%) and nearly twice as likely as African Americans (17%) to report perceived discrimination (P<.001). Respondents whose first positive HIV test was longer ago were also more likely to report discrimination (P<.001). Respondents who reported discrimination attributed it to physicians (54%), nurses and other clinical staff (39%), dentists (32%), hospital staff (31%), and case managers or social workers (8%).CONCLUSIONS: Many HIV-infected adults believe that their clinicians have discriminated against them. Clinicians should make efforts to address circumstances that lead patients to perceive discrimination, whether real or imagined.

Use of the ED as a Regular Source of Care: Associated Factors Beyond Lack of Health Insurance

STUDY OBJECTIVE To determine the characteristics and health care experiences of patients who identify the ED as their usual source of care. METHODS We conducted a cross-sectional survey in a Level I trauma center ED at an urban teaching hospital. Our population comprised 892 adults who presented to the ED over the course of 30 days. We asked participants about their regular source of health care, previous health care experiences, and perceptions of the use of the ED. RESULTS Patients who reported the ED as their regular source of care were three times more likely to have used the ED more than once in the preceding year. Among the regular ED users, 68% desired a physician as their regular source of care, and 46% of these subjects said they had tried unsuccessfully to get one in the preceding year. Five variables were associated with self-report of the ED as the regular source of health care: annual income less than

Economic deprivation and AIDS incidence in Massachusetts.

30,000, having been refused care in an office or clinic in the past, perception that an ED visit costs less than an office visit, absence of chronic illness, and unwillingness to use the ED if a

Quality of Community Drinking Water and the Occurrence of Late Adverse Pregnancy Outcomes

25 copayment were in effect. CONCLUSION Low income, perceived mistreatment by health care providers, and misperception about charges contribute to use of the ED as a regular site for health care. These factors suggest the difficulty of altering health care use patterns in this group.