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Patterns of HIV incidence in Puerto Rico are very different from those in the 50 states and the District of Columbia, according to the Centers for Disease Control and Prevention.1 In 2006, new infections were diagnosed at a rate of 45 per 100,000 individuals aged 13 and older in Puerto Rico—about twice the overall U.S. rate. Men accounted for two-thirds of new diagnoses in Puerto Rico, and their rate (62 per 100,000) also was roughly twice the comparable rate in the larger population; the rate among women in Puerto Rico (30 per 100,000) was more than double that in the states and the District of Columbia. Overall and gender-specific rates in Puerto Rico are higher than rates among Hispanics nationwide, but the analysts note that differences in the populations may help explain these disparities. Injection-drug use accounted for the greatest proportion of new infections in Puerto Rico; in the states and the District of Columbia, male-to-male sexual activity was the leading route of transmission. Finally, the majority of new infections in Puerto Rico were among people in their 30s, while overall, the majority occurred in individuals aged 13–29. The 30–39-year age-group had the highest rate of new diagnoses both in Puerto Rico and in the nation overall, but again, the rates differed sharply—104 vs. 43 per 100,000.

1. Centers for Disease Control and Prevention, Incidence and diagnoses of HIV infection—Puerto Rico, 2006, Morbidity and Mortality Weekly Report, 2009, 58(21):589–591.


Although a U.S. advisory committee has recommended that health care providers focus on 11–12-year-old girls for vaccination against human papillomavirus (HPV) infection, the message apparently has not made it to all mothers. In a national study of mothers of adolescent and young adult daughters, conducted in 2006–2007 (after the HPV vaccine received federal approval), only 48% of those surveyed said they would have a 9–12-year-old daughter vaccinated; 68% said that they would have a daughter get the injection if she was 13–15 years old, and 86% if she was aged 16–18.1 About half of the women—all of whom were nurses—said that they would have both a preteenage daughter and an older teenager (a 16–18-year-old) vaccinated, four in 10 said only an older teenage daughter, one in 10 said neither a preteenager nor an older teenager, and a negligible proportion said only a preteenager. Mothers' likelihood of intending to have a preteenage daughter vaccinated was positively associated with their beliefs about the necessity of regular Pap tests for their daughter and about the efficacy of the HPV vaccine. The researchers comment that "the development of evidence-based key messages may increase vaccine acceptability among parents and help to maximize vaccine uptake."

1. Kahn JA et al., Mother's intention for their daughters and themselves to receive the human papillomavirus vaccine: a national study of nurses, Pediatrics, 2009, 123(6):1439–1445.


The experiences reported by a sample of 15–21-year-olds who participated in a trial of an HIV prevention program in three cities in 1998–2002 shed light on the predictors of heterosexual anal intercourse among young people.1 All 1,348 participants had had unprotected vaginal or anal intercourse within the 90 days before being screened for the study and completing audio computer-assisted self-interviews. During those interviews, 16% reported having had heterosexual anal sex in the last 90 days. In logistic regression analyses that controlled for social, demographic, attitudinal and behavioral measures, only three characteristics were associated with the likelihood of this behavior among females—having a partner who had ever forced them to have sex (odds ratio, 2.7), living with a partner (1.8) and having had multiple partners (1.7). For males, the only predictor of recent anal intercourse was reporting a sexual orientation other than heterosexual (5.7). Given these findings, the researchers stress the importance of "open dialogue between providers and their young clients about anal intercourse." In particular, they note, "teaching adolescent girls and young women how to be assertive in sexual relationships…is of the utmost importance."

1. Lescano CM et al., Correlates of heterosexual anal intercourse among at-risk adolescents and young adults, American Journal of Public Health, 2009, 99(6):1131–1136.


U.S. women had a record number of births out of wedlock in 2007—1.7 million, or 26% more than the number just five years earlier.1 A report based on national vital statistics reveals that 40% of all births in 2007 were to unmarried women; in 1980, by contrast, the proportion was 18%. Whereas teenagers once accounted for half of nonmarital births, they now account for only 23%; women in their 20s deliver the largest share of infants born out of wedlock (60%). Unmarried teenagers' birthrates have fallen considerably since 1995, although the period from 2002 to 2006 saw a slight rise in the rate for 18–19-year-olds. For unmarried women in their 20s, however, rates have been rising, and much of the increase has occurred in just the last few years. Overall, 51 births occur per 1,000 unmarried women aged 15–44. The rate is dramatically higher among Hispanics (106 per 1,000) and blacks (72 per 1,000). Between 2002 and 2006, the nonmarital birthrate increased by 14% among white women, 9% among blacks, 20% among Hispanics and 24% among Asians and Pacific Islanders (whose overall rate remains fairly low—26 per 1,000). The report notes that "the United States is not unique, [and does not] outpace other countries, in nonmarital childbearing." Two-thirds of births in Iceland in 2007 were to unmarried women, as were 50–55% of those in Sweden, Norway and France.

1. Ventura SJ, Changing patterns of nonmarital childbearing in the United States, NCHS Data Brief, Hyattsville, MD: National Center for Health Statistics, 2009, No. 18.


After New York State introduced a streamlined informed consent procedure for HIV testing in June 2005, the number of people tested grew significantly.1 Under the new procedure, a modified form, which is simpler and easier to read than the old one, allows individuals under-going testing to consent to a number of other HIV-related procedures (including testing for public health monitoring) at the same time. The form also includes an informational section, which is designed to replace face-to-face pretest counseling. The effect of the change on testing rates was measured in a logistic regression analysis of data from New York's Behavioral Risk Factor Surveillance System. Results indicate that in the six months after the new procedure went into effect, 7% of 18–64-year-olds living in the state underwent HIV testing—31%, or 328,000, more than would have done so in the absence of the streamlined procedure. According to the analyst, these findings "provide support for the [Centers for Disease Control and Prevention's] claim that informed consent is a barrier to HIV testing."

1. Wing C, Effects of written informed consent requirements on HIV testing rates: evidence from a natural experiment, American Journal of Public Health, 2009, 99(6):1087–1092.


The younger men are when they become fathers, the more chronic illnesses they have later in life, according to a study based on the National Survey of Midlife Development in the United States.1 The survey, conducted in 1995–1996, sampled English-speaking adults aged 25–74, including twins and other sibling pairs. To study associations between men's age at first birth and subsequent health, researchers analyzed data on 109 pairs of identical twin brothers, 86 pairs of fraternal twins and 75 pairs of brothers who were not twins; the use of twins and nontwin siblings allowed them to conduct analyses both within and between families. Both types of analysis showed a linear relationship between age at first birth and number of chronic illnesses, and both showed that the association is explained by men's educational attainment. "Thus," the researchers remark, "public health campaigns promoting education among men from economically disadvantaged backgrounds…may have long-range implications for men' health."

1. Pudrovska T and Carr D, Age at first birth and fathers' subsequent health: evidence from sibling and twin models, American Journal of Men's Health, 2009, 3(2):104–115.


Should women who have had several consecutive negative Pap tests by age 50 discontinue regular screening? The latest evidence introduced into the ongoing debate suggests not.1 Using a nationwide pathology registry, Dutch researchers selected a sample of women who had had three consecutive negative Pap tests by 1994 and followed them until the end of 2002 or until they received a diagnosis of invasive cervical cancer. The analyses showed similar screening rates for women who were aged 45–54 and those who were 30–44 when they had their third consecutive negative test. Younger women had higher rates of precancerous cervical conditions throughout follow-up, but the two groups had similar rates of invasive cancer: 36–41 per 100,000 women after 10 years, the length of follow-up for most women. By using invasive cancer "as the relevant end point,'' the researchers write, their study "gives a more evidence based answer" to the question of whether women with consecutive negative results by age 50 should continue to undergo screening. The findings, they conclude, support the guidelines in several developed countries, including the United States, that "do not discriminate women by age up to 60–65."

1. Rebolj M et al., Incidence of cervical cancer after several negative smear results by age 50: prospective observational study, BMJ, 2009, 338:b1354, doi: 10.1136/bmj.b1354.


• Health care providers have a new resource to assist them in helping patients choose the most appropriate contraceptive. You Decide: Making Informed Health Choices About Hormonal Contraception includes discussion guides, communication tools, medical history forms and materials for both providers and women on contraceptive efficacy. The free tool kit, a product of the Planned Parenthood Federation of America and the Association of Reproductive Health Professionals, is available at <>.

• A focus group study conducted in five diverse areas of the country suggests that HIV and AIDS are largely "off the radar" for Americans. Although participants were generally sympathetic toward those with HIV or AIDS, they also made it clear that stigma and misperceptions about how the virus is transmitted still abound. The free study report, Impressions of HIV/AIDS in America: A Report on Conversations with People Throughout the Country, may be obtained at <>.

• Pretty much everything you always wanted to know about HIV testing in the United States is now just a few clicks away, courtesy of the Kaiser Family Foundation. A fact sheet on testing includes information on federal recommendations, testing sites and policies, and available types of tests; brief reports based on a 2009 public opinion survey describe the views and experiences of U.S. adults overall and specifically of blacks. For these and related materials, visit Kaiser's Web site at <>.