Spencer Lieb

Syndromes of Vibrio vulnificus infections. Clinical and epidemiologic features in Florida cases, 1981-1987.

STUDY OBJECTIVE To describe the clinical and epidemiologic features of Vibrio vulnificus infections. DESIGN Case series based on notifiable disease report forms and patient medical records. SETTING Cases reported to the Florida Department of Health and Rehabilitative Services from 1981 to 1987. PATIENTS Sixty-two patients with V. vulnificus infection. MEASUREMENTS AND MAIN RESULTS The three clinical syndromes found were primary septicemia (38 patients), wound infections (17 patients), and gastrointestinal illness without septicemia or wound infections (7 patients). Mortality rate was highest for patients with primary septicemia (55%; 95% CI, 38 to 71) and intermediate for wound infections (24%; 95% CI, 8 to 51): no deaths occurred in those with gastrointestinal illness. Common characteristics and exposures in patients with these syndromes included recent history of raw oyster consumption for primary septicemia and gastrointestinal illness, liver disease for primary septicemia, and either having a preexisting wound or sustaining a wound in contact with seawater for wound infections. CONCLUSIONS Clinicians should ask about marine exposures in patients with underlying medical conditions, especially liver disease, who present with unexplained febrile illness, and should start appropriate therapy promptly.

Statewide Estimation of Racial/Ethnic Populations of Men Who Have Sex with Men in the U.S.

Objectives. Men who have sex with men (MSM) bear the greatest burden of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) in every state in the U.S., but their populations are poorly defined. We estimated and compared populations of MSM in 2007 by region, state, and race/ethnicity. Methods. We averaged findings from two statistical models we had previously developed to estimate the total state-specific percentage and number of males who were MSM. The models were based, respectively, on state-specific rural/suburban/urban characteristics and an index using state-specific household census data on same-sex male unmarried partners. A third model, based on racial/ethnic ratios from a nationally representative behavioral survey, partitioned these statewide numbers by race/ethnicity. Results. Of an estimated 7.1 million MSM residing in the U.S. in 2007, 71.4% (5.1 million) were white, 15.9% (1.1 million) were Hispanic, 8.9% (635,000) were black, 2.7% (191,000) were Asian, 0.4% (26,000) were American Indian/Alaska Native, 0.1% (6,000) were Native Hawaiian/other Pacific Islander, and 0.6% (41,000) were of multiple/unknown race/ethnicity. The overall U.S. percentage of males who were MSM (6.4%) varied from 3.3% in South Dakota to 13.2% in the District of Columbia, which we treated as a state. Estimated numbers of MSM ranged from 9,612 in Wyoming to 1,104,805 in California. Conclusions. Plausible estimates of MSM populations by state and race/ethnicity can inform and guide HIV/AIDS surveillance, allocation of resources, and advocacy. They can help in the planning, implementation, and evaluation of HIV prevention programs and other services. Using MSM numbers as denominators, estimates of population-based MSM HIV incidence, prevalence, and mortality rates could help clarify national and state-level epidemic dynamics. Until corroborated by other modeling and/or empirical research, these estimates should be used with caution.

HIV among injection drug users in large US metropolitan areas, 1998.

This article estimates HIV prevalence rates among injection drug users (IDUs) in 95 large US metropolitan areas to facilitate social and policy analyses of HIV epidemics. HIV prevalence rates among IDUs in these metropolitan areas were calculated by taking the mean of two estimates: (1) estimates based on regression adjustments to Centers for Disease Control and Prevention (CDC) Voluntary HIV Counseling and Testing data and (2) estimates based on the ratio of the number of injectors living with HIV to the number of injectors living in the metropolitan area. The validity of the resulting estimates was assessed. HIV prevalence rates varied from 2 to 28% (median 5.9%; interquartile range 4.0–10.2%). These HIV prevalence rates correlated with similar estimates calculated for 1992 and with two theoretically related phenomena: laws against over-the-counter purchase of syringes and income inequality. Despite limitations in the accuracy of these estimates, they can be used for structural analyses of the correlates, predictors and consequences of HIV prevalence rates among drug injectors in metropolitan areas and for assessing and targeting the service needs for drug injectors.

HIV Prevalence Rates Among Men Who Have Sex with Men in the Southern United States: Population-Based Estimates by Race/Ethnicity

States across the U.S. lack effective ways to quantify HIV prevalence rates among men who have sex with men (MSM). We estimated population-based HIV prevalence rates among MSM in the 17 southern states by race/ethnicity. Through 2007, estimated HIV prevalence rates per 100,000 MSM ranged from 2,607.6 among white (non-Hispanic) MSM in Maryland to 41,512.9 among black (non-Hispanic) MSM in the District of Columbia. Black MSM rates significantly exceeded Hispanic and white MSM rates in each state. Significant racial/ethnic disparities in rates persisted in a sensitivity analysis examining the possibility that minority MSM populations had been underestimated in each state. Compared with black, Hispanic, and white non-MSM males, respectively, rates at the regional level were 25.2 times higher for black MSM, 43.0 times higher for Hispanic MSM, and 106.0 times higher for white MSM. State-level analysis of racial/ethnic-specific MSM HIV prevalence rates can help guide resource allocation and assist advocacy.

Late HIV diagnosis: Differences by rural/urban residence, Florida, 2007-2011.

The purpose of this retrospective cohort study was to identify individual-level demographic and community-level socioeconomic and health care resource factors associated with late diagnosis of HIV in rural and urban areas of Florida. Multilevel modeling was conducted with linked 2007-2011 Florida HIV surveillance, American Community Survey, Area Health Resource File, and state counseling and testing data. Late diagnosis (defined as AIDS diagnosis within 3 months of HIV diagnosis) was more common in rural than urban areas (35.8% vs. 27.4%) (p<0.0001). This difference persisted after controlling for age, sex, race/ethnicity, HIV transmission mode, country of birth, and diagnosis year (adjusted OR 1.39; 95% CI 1.17-1.66). In rural areas, older age and male sex were associated with late HIV diagnosis; zip code-level socioeconomic and county level health care resource variables were not associated with late diagnosis in rural areas. In urban areas only, Hispanic and non-Hispanic black race/ethnicity, foreign birth, and heterosexual mode of transmission were additionally associated with late HIV diagnosis. These findings suggest that, in rural areas, enhanced efforts are needed to target older individuals and men in screening programs and that studies of psychosocial and structural barriers to HIV testing in rural and urban areas be pursued.

Estimating populations of men who have sex with men in the southern United States.

Population estimates of men who have sex with men (MSM) by state and race/ethnicity are lacking, hampering effective HIV epidemic monitoring and targeting of outreach and prevention efforts. We created three models to estimate the proportion and number of adult males who are MSM in 17 southern states. Model A used state-specific census data stratified by rural/suburban/urban area and national estimates of the percentage MSM in corresponding areas. Model B used a national estimate of the percentage MSM and state-specific household census data. Model C partitioned the statewide estimates by race/ethnicity. Statewide Models A and B estimates of the percentages MSM were strongly correlated (r = 0.74; r-squared = 0.55; p < 0.001) and had similar means (5.82% and 5.88%, respectively) and medians (5.5% and 5.2%, respectively). The estimated percentage MSM in the South was 6.0% (range 3.6–13.2%; median, 5.4%). The combined estimated number of MSM was 2.4 million, including 1,656,500 (69%) whites, 339,400 (14%) blacks, 368,800 (15%) Hispanics, 34,600 (1.4%) Asian/Pacific Islanders, 7,700 (0.3%) American Indians/Alaska Natives, and 11,000 (0.5%) others. The estimates showed considerable variability in state-specific racial/ethnic percentages MSM. MSM population estimates enable better assessment of community vulnerability, HIV/AIDS surveillance, and allocation of resources. Data availability and computational ease of our models suggest other states could similarly estimate their MSM populations.

An HIV prevalence-based model for estimating urban risk populations of injection drug users and men who have sex with men

Issues of cost and complexity have limited the study of the population sizes of men who have sex with men (MSM) and injection drug users (IDUs), two groups at clearly increased risk for human immunodeficiency virus (HIV) and other acute and chronic diseases. We developed a prototypical, easily applied estimation model for these populations and applied it to Miami, Florida. This model combined HIV prevalence estimates, HIV seroprevalence rates, and census data to make plausible estimates of the number and proportion of MSM and IDUs under a number of assumptions. Sensitivity analyses were conducted to test the robustness of the model. The model suggests that approximately 9.5% (plausible range 7.7%–11.3%) of Miami males aged 18 years or older are MSM (point estimate, N=76,500), and 1.4% (plausible range 0.9%–1.9%) of the total population aged 18 years or older are IDUs (point estimate, N=23,700). Males may be about 2.5 times more likely than females to be IDUs. The estimates were reasonably robust to biases. The model was used to develop MSM and IDU population estimates in selected urban areas across Florida and should be replicable in other medium-to-large urban areas. Such estimates could be useful for behavioral surveillance and resource allocation, including enhanced targeting of community-based interventions for primary and secondary HIV prevention.

Increasing frequency of heterosexually transmitted AIDS in southern Florida: artifact or reality?

Acquired immunodeficiency syndrome (AIDS) cases reported as the result of heterosexual contact have been increasing in the United States, with Florida reporting a disproportionate number. We investigated 168 such AIDS cases from southern Florida. After follow-up, 50 (30%) patients were reclassified into other transmission categories. The data suggest that the increased rate of heterosexually acquired AIDS cases reported from southern Florida was partially related to misclassification of risk.

Measuring Socioeconomic Inequality in the Incidence of AIDS: Rural–Urban Considerations

Low socioeconomic status (SES) influences the risk of acquiring human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) and thus should be considered when analyzing HIV/AIDS surveillance data. Most surveillance systems do not collect individual level SES data but do collect residential ZIP code. We developed SES deprivation indices at the ZIP code tabulation area and assessed their predictive validity for AIDS incidence relative to individual neighborhood-level indicators in Florida using reliability analysis, factor analysis with principal component factorization, and structural equation modeling. For urban areas an index of poverty performed best, although the single factor poverty also performed well. For rural areas no index performed well, but the individual indicators of no access to a car and crowding performed well. In rural areas poverty was not associated with increased AIDS incidence. Users of HIV/AIDS surveillance data should consider urban and rural areas separately when assessing the impact of SES on AIDS incidence.

Estimated HIV incidence, prevalence, and mortality rates among racial/ethnic populations of men who have sex with men, Florida.

Background:Population-based HIV incidence, prevalence, and mortality rates among men who have sex with men (MSM) have been unavailable, limiting assessment of racial/ethnic disparities and epidemic dynamics. Methods:Using estimated numbers of MSM aged ≥18 years by race/ethnicity as denominators, from models in our prior work, we estimated MSM HIV prevalence and mortality rates for 2006-2007 and HIV incidence rates for 2006 in Florida. Results:Overall, the estimated MSM HIV prevalence rates per 100,000 MSM were 7354.8 (2006), and 7758.3 (2007). With white MSM as the referent, MSM HIV prevalence rate ratios (RRs) equaled 3.7 for blacks in 2006 and 3.6 in 2007 and 1.7 for Hispanics in both years (all P < 0.001). Among all MSM with HIV, the mortality rates were 199.8 (2006) and 188.4 (2007), with RRs of 5.4 for blacks in 2006 and 4.9 in 2007, and 1.6 for Hispanics in 2006 and 1.4 in 2007 (all P < 0.001). In 2006, the estimated HIV incidence rate among all MSM was 656.1 per 100,000 MSM, with RRs of 5.5 (blacks) and 2.0 (Hispanics) (both P < 0.001). A sensitivity analysis indicated that error due to misclassification of minority MSM as males who are not MSM lowered rates and RRs for all the 3 indicators but racial/ethnic disparities persisted (all P < 0.001). Conclusions:The impact of HIV by each measure was greater on black and Hispanic MSM than on white MSM. Quantifying estimates of HIV incidence, HIV prevalence, and mortality rates among MSM with HIV informs HIV surveillance, prevention, treatment, resource allocation, and community mobilization.