BEHAVIORAL RISK FACTORS FOR HIV IMPERIL MILLIONS
An estimated 9% of Americans aged 15–44 in 2002 engaged in sexual behavior that put them at risk of acquiring HIV infection, and 2% were at risk because they used injection drugs or crack; together, according to a report based on data from Cycle 6 of the National Survey of Family Growth, unsafe sexual behavior and drug use put 10% of men and women in this age-group at risk of infection.1 When those who had recently been treated for an STD were included, 12% of 15–44-year-olds—14.4 million Americans—were estimated to be at risk of HIV infection because of a behavioral risk factor. The proportion of individuals with behavioral risk factors for HIV was higher among males than among females (13% vs. 11%), and was twice as high among blacks as among whites (20% vs. 10%). The level of risk also differed by education, income, residence and history of incarceration. It was never lower than 8% and reached 16–18% among those living below 150% of the federal poverty level, residents of central cities and individuals who had ever been incarcerated. In almost all demographic categories examined, 6–14% of individuals were at risk because of unsafe sexual behavior, and 2–4% because they had recently had an STD. One-third of men and women at risk of HIV had never been tested for the virus, and six in 10 had not used a condom the last time they had intercourse.
1. Anderson JE, Mosher WD and Chandra A, Measuring HIV risk in the U.S. population aged 15–44: results from Cycle 6 of the National Survey of Family Growth, Advance Data from Vital and Health Statistics, 2006, No. 377.
THE SMOKING GUN?
Concerns about weight control may be a key reason why most women who quit smoking during pregnancy take it up again after giving birth.1 In a study of 119 women who quit while pregnant, 66% were determined to kick the habit for good; compared with women who were less motivated to avoid relapse, this group reported more stress, greater confidence in their ability to control their weight, less reliance on smoking for weight control and less hunger. The highly motivated group also were more likely to intend to breast-feed. When these and other measures related to postpartum smoking were analyzed together, self-efficacy for weight management was the only variable that was significantly associated with motivation to quit for good: For every one-step increase in the weight self-efficacy measure, a woman’s likelihood of intending not to resume smoking after giving birth increased by 40%. The findings, according to the researchers, suggest that “interventions designed to prevent postpartum smoking relapse may need to address women’s concerns about eating and weight.”
1. Levine MD et al., Weight concerns affect motivation to remain abstinent from smoking postpartum, Annals of Behavioral Medicine, 2006, 32(2):147–153.
CUT TO THE CHASTE
Results of a population-based longitudinal study support the view that neonatal male circumcision has long-term benefits.1 In a cohort of Australian males followed from birth through age 25, those who had not been circumcised by age 15 were significantly more likely than their circumcised peers, most of whom had undergone the procedure by four months of age, to report ever having had an STD (odds ratio in an analysis adjusting for potential confounders, 3.2). The researchers estimate that if all of the young men in the cohort had been circumcised as infants, the STD rate through age 25 would have been reduced by 48%. Given the public health benefits, they conclude that the long-term benefits of neonatal circumcision need to be carefully weighed against its perceived costs.
1. Fergusson DM, Boden JM and Horwood J, Circumcision status and risk of sexually transmitted infection in young adult males: an analysis of a longitudinal birth cohort, Pediatrics, 2006, 118(5):1971–1977.
EARLY HPV PREVENTION
The vaccine that prevents infection with four strains of human papillomavirus (HPV), including the ones responsible for the majority of cervical cancers and genital warts, in women aged 16 and older may be effective if administered to girls and boys as young as 10.1 In the first study to examine its effects in preadolescents and young teenagers, sexually inexperienced 10–15-year-olds who received the three-dose vaccination developed sufficient levels of antibodies to ward off infection; moreover, the results “are highly suggestive that long-term protection after vaccination is likely.” As the researchers stress, these findings are important because the risk of HPV infection is greatest in the early years of sexual activity. Finally, the investigators note that although serious adverse consequences of HPV infection are more common among females than among males, infected men are at risk of certain cancers and can spread the infection to their female partners; therefore, they conclude that the findings support “the implementation of gender-neutral immunization.”
1. Block SL et al., Comparison of the immunogenicity and reactogenicity of a prophylactic quadrivalent human papillomavirus (types 6, 11, 16, and 18) L1 virus-like particle vaccine in male and female adolescents and young women, Pediatrics, 2006, 118(5):2135–2145.
THE COST OF SUCCESS
A U.S. adult entering HIV care with a CD4 cell count of less than 350 has a life expectancy of about 24 years, according to an analysis based on data from a consortium of primary care sites with large HIV caseloads.1 The discounted lifetime cost of care is $385,000, and the undiscounted cost is $619,000; antiretroviral drugs account for 73% of the undiscounted cost. By comparison, in the early 1990s, HIV-infected adults with a CD4 cell count of 500 had a life expectancy of about seven years, care over their lifetime cost about $119,000 ($150,000 in discounted dollars) and about half of that cost went to pay for hospitalization stays. Under a range of assumptions about drug costs, the efficacy of therapy and the availability of a fusion inhibitor (a drug that prevents HIV from entering healthy cells), the current estimated life expectancy varied from 21 to 25 years, and discounted lifetime cost varied from about $330,000 to $400,000. Over the long term, the estimated 40,000 HIV infections detected in the United States each year will lead to some $12.1 billion annually in medical costs. The analysts call for “greater investments in evidence-based HIV prevention activities…matched by the commitment of sufficient resources to HIV medical care so that persons living with HIV today can fulfill the expectation that they will live long and healthy lives.”
1. Schackman BR et al., The lifetime cost of current human immunodeficiency virus care in the United States, Medical Care, 2006, 44(11):990–997.
SO MUCH IN COMMON
“Worldwide, not only is sexual behaviour strongly shaped by social forces, but those forces are surprisingly similar in different settings”: Thus conclude a pair of researchers who drew together results of 268 qualitative studies in a way that they consider analogous to techniques of meta-analysis of quantitative data.1 The analysis uncovered seven common themes in the studies, which were published between 1990 and 2004 and focused on populations in both developed and developing countries: Young people estimate a potential partner’s disease risk by how “clean” the individual appears and readily use condoms with partners they deem risky; sexual partners have a strong influence on young people’s general behavior; condoms can be stigmatizing and often are taken as a signal that a person does not trust his or her partner, or thinks that the partner has an STD; gender stereotypes are key determinants of sexual expectations and behavior; society both rewards and penalizes young people for having sex; reputations regarding sexual activity or inactivity are important; and social expectations prevent young people from discussing sex with partners or potential partners. The researchers suggest that these themes “form a useful, evidence-based checklist of social influences that can be a starting point for local needs assessments and developing programmes.”
1. Marston C and King E, Factors that shape young people’s sexual behaviour: a systematic review, Lancet, 2006, 368(9547):1581–1586.
SYPHILIS SCREENING IN PREGNANCY
Consistent with federal guidelines and professional organizations’ recommendations, Florida requires that women be screened for syphilis twice during pregnancy and then at delivery. Prenatal screening and, if necessary, treatment with penicillin can prevent congenital syphilis and its serious health effects. Yet in a Florida county where syphilis rates are high, not all women are adequately screened.1 In a sample of 1,991 women who gave birth in 2001, 83% had had one prenatal screening, 11% had had two, and 9% had been screened twice during pregnancy and then at delivery. In multivariate analyses, the odds of having had no prenatal screening were elevated among blacks and Haitians, women with at most a high school education, those who saw a private provider and those with a public source of insurance. The likelihood of not having had two prenatal screenings was elevated for women who had had more than adequate prenatal care (as measured on a standard index), clients of private clinics and women covered by private insurance. Focusing on the latter set of findings, the analysts suggest that the inadequacy of screening may be due to providers’ unawareness of the county’s syphilis problem or of screening recommendations and requirements. The authors of an editorial accompanying the study add that providers’ noncompliance may be a factor, and stress the need for “enhanced, coordinated efforts by providers and public health professionals to prevent [congenital syphilis].”2
1. Trepka MJ et al., Inadequate syphilis screening among women with prenatal care in a community with a high syphilis incidence, Sexually Transmitted Diseases, 2006, 33(11):670–674.
2. Beltrami J and Berman S, Congenital syphilis: a persisting sentinel public health event, Sexually Transmitted Diseases, 2006, 33(11):675–676.
WHO’S FOR COMPREHENSIVE SEX EDUCATION?
A nationally representative sample of U.S. adults surveyed between July 2005 and January 2006 expressed greater support for comprehensive sex education than for the abstinence-only approach, and results were similar regardless of respondents’ political leanings.1 Overall, 39% of those polled agreed that abstinence-only education is an effective strategy for preventing unintended pregnancies and STDs, whereas 81% agreed that comprehensive sex education is effective; fewer than half felt that instruction on how to use a condom encourages teenagers to have sex. Similarly, 36% of respondents supported abstinence-only education, and 82% supported a comprehensive approach; 68% were in favor of instruction on condom use. Although levels of support varied, a majority of respondents in every political category—70% of those who identified themselves as political conservatives, 86% of moderates and 92% of liberals—favored comprehensive sex education. The same was true for frequency of attendance at religious services: The proportion supporting comprehensive sex education ranged from 60% among respondents who attended services more than once a week to 87% of those who never did. “It appears,” the investigators observe, “that current investments in abstinence-only sex education programs do not correspond with…public opinion…on how sex education should be taught in schools.”
1. Bleakley A, Hennessy M and Fishbein M, Public opinion on sex education in U.S. schools, Archives of Pediatrics & Adolescent Medicine, 2006, 160(11):1151–1156.