The Urban Environment and Sexual Risk Behavior among Men who have Sex with Men

Increasingly, studies show that characteristics of the urban environment influence a wide variety of health behaviors and disease outcomes, yet few studies have focused on the sexual risk behaviors of men who have sex with men (MSM). This focus is important as many gay men reside in or move to urban areas, and sexual risk behaviors and associated outcomes have increased among some urban MSM in recent years. As interventions aimed at changing individual-level risk behaviors have shown mainly short-term effects, consideration of broader environmental influences is needed. Previous efforts to assess the influence of environmental characteristics on sexual behaviors and related health outcomes among the general population have generally applied three theories as explanatory models: physical disorder, social disorganization and social norms theories. In these models, the intervening mechanisms specified to link environmental characteristics to individual-level outcomes include stress, collective efficacy, and social influence processes, respectively. Whether these models can be empirically supported in generating inferences about the sexual behavior of urban MSM is underdeveloped. Conceptualizing sexual risk among MSM to include social and physical environmental characteristics provides a basis for generating novel and holistic disease prevention and health promotion interventions. Frye, Latka, Putnam, Galea, and Vlahov are with the Center for Urban Epidemiologic Studies, New York Academy of Medicine, 1216 Fifth Avenue, New York, NY 10029, USA; Koblin is with the New York Blood Center, New York, NY, USA; Halkitis is with the Department of Applied Psychology, New York University, New York, NY, USA; Vlahov is with the Department of Epidemiology, Columbia University, New York, NY, USA; Galea is with the Department of Epidemiology, University of Michigan, Ann Arbor, MI, USA.     

Integrating HIV Prevention Activities into the HIV Medical Care Setting: A Report from the NYC HIV Centers Consortium

With the maturing of the HIV epidemic and availability of potent antiretroviral therapies in the US, priorities for HIV prevention have shifted from general population approaches to case finding, treatment, risk reduction and relapse prevention activities among those at greatest risk for acquiring or transmitting HIV infection. The challenges of this approach include ensuring access and adherence to HIV care and treatment and appropriate prevention activities to ensure adequate and sustained sexual and drug use risk reduction across diverse populations. Experience with approaches to address these issues, particularly in the context of primary care, has been limited. An agenda for future research and practice includes continued development and evaluation of interventions that can address this next generation of health care issues. Vlahov is with the Center for Urban Epidemiologic Studies, New York Academy of Medicine, USA; Crystal is with the AIDS Research Group, Rutgers the State University of New Jersey, USA; Absalon is with the Center for Infectious Disease Epidemiologic Research, Mailman School of Public Health, Columbia University, USA; Klein and Agins are with the New York State Department of Health, AIDS Institute, USA; Remien is with the HIV Center for Clinical and Behavioral Studies, Columbia University and the NY State Psychiatric Institute, USA. An erratum to this article can be found at     

Men, Multiple Sexual Partners, and Young Adults’ Sexual Relationships: Understanding the Role of Gender in the Study of Risk

Heterosexual transmission of HIV and other sexually transmitted infections has become a primary health concern worldwide. Gender roles for heterosexual interactions appear to sanction men’s sexual risk-taking, especially the pursuit of multiple sexual partners. Using measures developed in this study, the current study assessed the associations between men’s and women’s relationship attitudes and experiences and their sexual risk encounters. Participants were 104 men and 103 women (18–24 years) from a large, urban college located in a high HIV risk neighborhood of New York City. All completed a survey assessing HIV risk and the battery of relationship measures assessing traditional sexual roles, sexual conflicts, significance of sex, relationship investment, need for relationship, and unwanted sex. For men, greater sexual conflict in their primary relationships was associated with more sexual partners and fewer unprotected vaginal intercourse encounters with a primary partner and across sex partners overall. In addition, men’s endorsement of more traditional sexual roles and lower relationship investment were associated with higher numbers of sexual partners. Among women, compliance with men to engage in unwanted sex was associated with higher levels of participation in unprotected sex. For both men and women, greater significance given to sex in a relationship was associated with fewer extradyadic partners. This study demonstrates the utility of measures of relationship attitudes and experiences to characterize sexual risk, especially among men. Findings are discussed in terms of implications for prevention program targeting young urban adults.O’Sullivan is with the Department of Family & Social Medicine, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Mazer 100, Bronx, NY 10461, USA; O’Sullivan, Hoffman, and Dolezal are with the HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York, NY, USA; Hoffman is with the Department of Epidemiology, Joseph L. Mailman School of Public Health, Columbia University, New York, NY, USA; Harrison is with the Department of Medicine, Division of Infectious Diseases and Population Studies and Training Center, Brown University, Providence, RI 02912, USA.     

Aging and HIV Infection

With the advent of highly active antiretroviral therapy (HAART) in mid-1995, the prognosis for HIV-infected individuals has brightened dramatically. However, the conjunction of potent antiviral therapy and longer life expectancy may engender a variety of health risks that, heretofore, HIV specialists have not had to confront. The long-term effects of HIV infection itself and exposure to antiretroviral agents is unknown. Several aspects of aging, including psychiatric disease, neurocognitive impairment, and metabolic and hormonal disorders, may be influenced by chronic exposure to HIV and/or HIV therapeutics. In this paper, we discuss the health issues confronting HIV-infected older adults and areas for future research. Dr. Klein and Dr. Schoenbaun are with the Division of Infectious Diseases, Department of Medicine and The AIDS Research Program, Department of Epidemiology and Population Health, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY; Dr. Anastos is with the Division of Infectious Diseases, Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY; Dr. Minkoff is with the Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, NY; Dr. Sacks is with the Department of Community and Preventive Medicine, Mount Sinai School of Medicine, New York, NY.     

Suicide Tourism in Manhattan,New York City, 1990–2004

Suicide accounts for over 30,000 deaths per year in the United States and is associated with psychiatric illness and substance abuse. Research suggests a strong relationship between method of suicide and the lethal means that are readily available in one’s community of residence. However, certain individuals may also seek the opportunity for suicide outside their proximal environment, often in well-known places. Whereas prevention efforts have been aimed at certain repeatedly used sites for suicide (i.e., Golden Gate Bridge), little research has studied “suicide tourism,” the phenomenon of out of town accompanied by suicide. We collected data on all suicide deaths in New York City (NYC) between 1990 and 2004 from the Office of the Chief Medical Examiner of NYC. We examined trends and correlates of out-of-town residents who committed suicide in NYC. Manhattan accounted for 274 of the 407 nonresident suicides in NYC, which represented over 10% of all suicides committed in Manhattan. The most common methods of suicide for the Manhattan nonresidents were long fall, hanging, overdose, drowning, and firearms; the most common locations included hotels and commercial buildings, followed by outside locations such as bridges, parks, and streets. Nonresident victims tended to be younger, more often white and Asian and less often black and Hispanic than their residential counterparts. An analysis of nonresident suicides in Manhattan revealed that it is a location where individuals travel and take their lives, often by similar means and in similar locations. A comparison with residential suicide implied that a different type of individual is at risk for nonresidential suicide, and further research and prevention efforts should be considered. Gross and Tardiff are with the Department of Psychiatry, Weill Cornell Medical College, Cornell University, New York, NY, USA; Gross is with the Subprogram in Clinical Psychology, The Graduate Center, City University of New York, New York, NY, USA; Markham Piper, Bucciarelli, Vlahov and Galea are with the Center of Urban Epidemiologic Studies, New York Academy of Medicine, New York, NY, USA; Galea is with the Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA; Galea is with the Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA.     

Challenges and Facilitating Factors in Sustaining Community-Based Participatory Research Partnerships: Lessons Learned from the Detroit, New York City and Seattle Urban Research Centers

In order to address the social, physical and economic determinants of urban health, researchers, public health practitioners, and community members have turned to more comprehensive and participatory approaches to research and interventions. One such approach, community-based participatory research (CBPR) in public health, has received considerable attention over the past decade, and numerous publications have described theoretical underpinnings, values, principles and practice. Issues related to the long-term sustainability of partnerships and activities have received limited attention. The purpose of this article is to examine the experiences and lessons learned from three Urban Research Centers (URCs) in Detroit, New York City, and Seattle, which were initially established in 1995 with core support from the Centers for Disease Control and Prevention (CDC). The experience of these Centers after core funding ceased in 2003 provides a case study to identify the challenges and facilitating factors for sustaining partnerships. We examine three broad dimensions of CBPR partnerships that we consider important for sustainability: (1) sustaining relationships and commitments among the partners involved; (2) sustaining the knowledge, capacity and values generated from the partnership; and (3) sustaining funding, staff, programs, policy changes and the partnership itself. We discuss the challenges faced by the URCs in sustaining these dimensions and the strategies used to overcome these challenges. Based on these experiences, we offer recommendations for: strategies that partnerships may find useful in sustaining their CBPR efforts; ways in which a Center mechanism can be useful for promoting sustainability; and considerations for funders of CBPR to increase sustainability. Israel, Lichtenstein, and McGranaghan are with the University of Michigan, School of Public Health, Ann Arbor, MI, USA; Krieger and Ciske are with the Epidemiology, Planning and Evaluation Unit, Public Health—Seattle & King Country, Seattle, WA, USA; Vlahov is with the Center for Urban Epidemiologic Studies, New York Academy of Medicine, New York, NY, USA; Foley is with the Department of Community and Preventive Medicine, Mt. Sinai Medical School, New York, NY, USA; Fortin is City Research Scientist, New York City Department of Health, New York, NY, USA; Guzman is with the Community Health and Social Services, Inc., Detroit, MI, USA; Palerno is with the Center for Multicultural and Community Affairs, Mount Sinai School of Medicine, New York, NY, USA; Tang is with the Aging and Adult Services Company, Asian Counseling and Referral Services, Seattle, WA, USA. The first three authors are the Principal Investigators of the three Urban Research Centers. The other coauthors from the three Centers are listed in alphabetical order. See the acknowledgements at the end for a list of all of the partner organizations involved.     

Sampling and Recruitment in Multilevel Studies among Marginalized Urban Populations: The IMPACT Studies

Illicit drug use in urban settings is a major public health problem. A range of individual level factors are known to influence drug use and its consequences, and a number of recent studies have suggested that the neighborhood in which an individual lives may also play a role. However, studies seeking to identify neighborhood-level determinants of drug use, particularly among marginalized urban populations, need to overcome significant challenges, particularly in the area of sampling and recruitment. One key issue is defining functional neighborhoods that are relevant to local residents. Another arises from the need to sample a representative or even a diverse population when studying marginalized groups such as illicit drug users. These are common problems that raise particular challenges when both need to be addressed in the same study. For example, many sampling approaches for neighborhood-level studies have included some form of random sample of households, but this may systematically overlook marginalized populations. On the other hand, the sampling approaches commonly used in studies of hidden populations such as chain referral, snow ball, and more recently, respondent-driven sampling, typically expand beyond a geographic “neighborhood.” We describe the organization and rationale for the IMPACT Studies in New York City as a case illustration on how such issues may be addressed. Ompad, Galea, Fuller, Weiss, Beard, Chan, Edwards, and Vlahov are with the Center for Urban Epidemiologic Studies, New York Academy of Medicine, New York, NY, USA; Galea is with the Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA; Marshall is with the RAND Corporation, Santa Monica, CA, USA; Fuller and Vlahov are with the Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.     

A medical school's involvement in the development of a community-based health center

This paper presents a planning model developed by the Department of Community Medicine of the Mount Sinai School of Medicine to facilitate the interactions between the medical school and the community. The planning process involved application of the model, exemplified through the growth and development of a neighborhood health center governed by a community agency. The main characteristics of the medical school, of the community, and of the community agency are presented briefly and the seven-year history of the development of the neighborhood health center is summarized. In recapitulating that history three distinct phases are identified in the planning process: how the planning was planned, how the plan was prepared, and how the services program was implemented. The role of the Department of Community Medicine in each phase is analyzed.Dr. Merino is Assistant Professor, Department of Community Medicine, Mount Sinai School of Medicine, New York, NY 10029. Dr. Rose is Instructor, Departments of Medicine and Community Medicine, Mount Sinai School of Medicine, New York, NY 10029. Dr. Bosch is Professor and Deputy Chairman, Department of Community Medicine, Mount Sinai School of Medicine, New York, NY 10029.     

Symptoms of Posttraumatic Stress Disorder in a New Orleans Workforce Following Hurricane Katrina

On August 29, 2005, Hurricane Katrina made landfall resulting in catastrophic damage and flooding to New Orleans, LA, and the Gulf Coast, which may have had significant mental health effects on the population. To determine rates and predictors of symptoms consistent with a diagnosis of posttraumatic stress disorder (PTSD) in New Orleans residents following Hurricane Katrina, we conducted a web-based survey 6 months after Hurricane Katrina made landfall. Participants included 1,542 employees from the largest employer in New Orleans. The prevalence of PTSD symptoms was 19.2%. Predictors of PTSD symptoms in a multivariate-adjusted regression model included female sex, non-black race, knowing someone who died in the storm, not having property insurance, having had a longer evacuation, a much longer work commute compared to before Hurricane Katrina, and currently living in a newly purchased or rented house or in a temporary trailer. Despite universal health coverage and the benefits of an employee assistance program for all employees, only 28.5% of those with PTSD symptoms had talked to a health professional about the events of Hurricane Katrina or issues encountered since the storm. A significant burden of PTSD symptoms was present 6 months following Hurricane Katrina among a large group of adults who had returned to work in New Orleans. Given their key role in the economic redevelopment of the region, there is a tremendous need to identify those in the workforce with symptoms consistent with PTSD and to enhance treatment options. The strong relationship between displacement from ones’ pre-Katrina residence and symptoms of PTSD suggests a need to focus resource utilization and interventions on individuals living in temporary housing. DeSalvo, Tynes, and Muntner are with the Section of General Internal Medicine and Geriatrics, Tulane University School of Medicine, New Orleans, LA, USA; DeSalvo, Hyre, Menke, and Muntner are with the Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA; Ompad is with the Center of Urban Epidemiologic Studies, New York Academy of Medicine, New York, NY, USA; Tynes is with the Department of Psychiatry, Tulane University School of Medicine, New Orleans, LA, USA; Tynes is with the Jefferson Parish Human Services Authority, Metairie, LA, USA.     

Predictors of Partner Notification for C. trachomatis and N. gonorrhoeae: An Examination of Social Cognitive and Psychological Factors

Efforts to control chlamydial and gonococcal infections include notifying eligible sexual partners of possible infection, primarily by asking the diagnosed patient to notify their partners. This approach, known as patient referral, is widely used but poorly understood. The current study examined psychosocial and cognitive factors associated with patient referral among an urban, minority sample of 168 participants recently diagnosed with Chlamydia trachomatis or Neisseria gonorrhoeae. At a follow-up interview 1-month from diagnosis, participants were more likely to have notified all eligible partners if they had greater intention to notify at baseline (OR = 3.72; 95% CI = 1.34, 10.30) and if they had only one partner at baseline (OR = 4.08; 95% CI = 1.61, 10.31). There were also gender differences as well as differences based on type of partner (i.e., regular, casual, one-time). The implications of these findings for the design of programs to promote patient referral for sexually transmitted infections are discussed. Schwartz, Malka, Augenbraun, McCormack, and Wilson are with the State University of New York, Downstate Medical Center, Brooklyn, NY, USA; Rubin is with the New York City Department of Health, Bureau of STD Control, New York, NY, USA; Rubin, Hogben, and Liddon are with the Centers for Disease Control and Prevention, Atlanta, GA, USA; Schwartz is with the Department of Preventive Medicine and Community Health, SUNY Downstate Medical Center, Box 1240, 450 Clarkson Avenue, Brooklyn, NY 11203, USA.     

Pilot Survey of Subway and Bus Stop Noise Levels

Excessive noise exposure is a serious global urban health problem, adversely affecting millions of people. One often cited source of urban noise is mass transit, particularly subway systems. As a first step in determining risk within this context, we recently conducted an environmental survey of noise levels of the New York City transit system. Over 90 noise measurements were made using a sound level meter. Average and maximum noise levels were measured on subway platforms, and maximum levels were measured inside subway cars and at several bus stops for comparison purposes. The average noise level measured on the subway platforms was 86 ± 4 dBA (decibel-A weighting). Maximum levels of 106, 112, and 89 dBA were measured on subway platforms, inside subway cars, and at bus stops, respectively. These results indicate that noise levels in subway and bus stop environments have the potential to exceed recommended exposure guidelines from the World Health Organization (WHO) and U.S. Environmental Protection Agency (EPA), given sufficient exposure duration. Risk reduction strategies following the standard hierarchy of control measures should be applied, where feasible, to reduce subway noise exposure.Gershon and Barrera are with the Department of Sociomedical Sciences, Columbia University, Mailman School of Public Health, 600 West 168th Street, 4th Floor, New York, NY 10032, USA; Neitzel is with the Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, WA 98105, USA; Akram is with the Department of Environmental Health Sciences, Columbia University, Mailman School of Public Health, New York, NY 10032, USA.     

Evaluation of an Intervention to Increase Screening Colonoscopy in an Urban Public Hospital Setting

Only 50% of New Yorkers aged 50 and over reported ever being screened for colorectal cancer by any modality according to a recent household survey. The objective of this investigation was to assess the impact of a hospital-based intervention aimed at eliminating health care system barriers to timely colorectal cancer screening at Lincoln Medical Center, a large, urban public hospital in one of the nation's poorest census tracts. We conducted a retrospective analysis of all colonoscopies performed over an 11-month period, during which a multi-pronged intervention to increase the number of screening colonoscopies took place. Two “patient navigators” were hired during the study period to provide continuity for colonoscopy patients. A Direct Endoscopic Referral System (DERS) was also implemented. Enhancements to the gastrointestinal (GI) suite were also made to improve operational efficiency. Immediately following the introduction of the patient navigators, there was a dramatic and sustained decline in the broken appointment rates for both screening and diagnostic colonoscopy (from 67% in May of 2003 to 5% in June of 2003). The likelihood of keeping the appointment for colonoscopy after the patient navigator intervention increased by nearly 3-fold (relative risk = 2.6, 95% CI 2.2–3.0). The rate of screening colonoscopies increased from 56.8 per month to 119 per month. The screening colonoscopy coverage provided by this facility among persons aged 50 and over in surrounding Zip codes increased from 5.2 to 15.6% (RR 3.0, 95% CI 1.9–4.7). Efforts to increase the number of screening colonoscopies were highly successful, due in large part to the influence of patient navigators, a streamlined referral system, and GI suite enhancements. These findings suggest that there are significant health-care system barriers to colonoscopy that, when addressed, could have a significant impact on screening colonoscopy rates in the general population. Nash is with the Center for Urban Epidemiologic Studies, The New York Academy of Medicine, New York, NY, USA, the Department of Epidemology, International Center for AIDS Care and Treatment Programs, Columbia University, Mailman School of Public Health, New York, NY, USA; Azeez is with the Department of Gastroenterology, Lincoln Medical Center, Bronx, NY, USA; Vlahov is the Director of the Center for Urban Epidemiologic Studies at the New York Academy of Medicine, New York, NY, USA; Schori is with the Office of the Medical Director, Lincoln Medical Center, Bronx, NY, USA. An erratum to this article can be found at     

Co-located Substance Use Treatment and HIV Prevention and Primary Care Services,New York State, 1990–2002: A Model for Effective Service Delivery to a High-Risk Population

The New York State Department of Health (NYSDOH) AIDS Institute (AI) began an initiative in 1990 in collaboration with the Office of Alcoholism and Substance Abuse Services (OASAS) to colocate HIV prevention and clinical services at drug treatment clinics. In 1990, the initiative began funding drug treatment programs to provide HIV counseling, testing, and prevention services. HIV primary care was added the following year. Program implementation and development are described. An analysis is included of HIV counseling and testing data for the period 1990–2002 and quality of care data for five standardized quality measures with comparisons to data from other clinical settings. In the first 13 years of the initiative 168,340 HIV-antibody tests were conducted including 52,562 tests of injection drug users (IDUs) identifying 14,612 HIV-infected persons; the seroprevalence was 8.68%. By the end of 2000, the HIV primary care caseload peaked at 3,815 patients. Quality of primary medical care services among participating drug treatment programs has consistently matched or exceeded that provided in more conventional health care settings such as the hospitals and community health centers that were used as a basis for comparison. Colocating HIV primary care within substance use treatment is an effective strategy for providing accessible high-quality HIV prevention and primary care services. Rothman is with the Bureau of HIV Ambulatory Care, AIDS Institute, New York State Department of Health, Albany, New York, USA; Rudnick and Slifer are with the Substance Abuse Unit, AIDS Institute, New York, NY, USA; Agins is with the Office of the Medical Director, AIDS Institute, New York, NY, USA; Heiner is with the Karl Heiner Statistical Consulting, Ltd., Schenectady, New York, USA; Birkhead is with the AIDS Institute, Albany, New York, USA.     

Pathways to Health Risk Exposure in Adult Film Performers

Despite being part of a large and legal industry in Los Angeles, little is known about adult film performers’ exposure to health risks and when and how these risks might occur. The objective was to identify exposure to physical, mental, and social health risks and the pathways to such risks among adult film performers and to determine how risks differ between different types of performers, such as men and women. Semi-structured in-depth interviews were conducted with 18 female and ten male performers as well as two key informants from the industry. Performers and key informants were recruited through Protecting Adult Welfare, adult film venues, and snowball sampling. Performers engaged in risky health behaviors that included high-risk sexual acts that are unprotected, substance abuse, and body enhancement. They are exposed to physical trauma on the film set. Many entered and left the industry with financial insecurity and suffered from mental health problems. Women were more likely than men to be exposed to health risks. Adult film performers, especially women, are exposed to health risks that accumulate over time and that are not limited to sexually transmitted diseases. At the time of the study, Grudzen was with the Robert Wood Johnson Clinical Scholars Program at the University of California, Los Angeles, Los Angeles, CA, USA; Grudzen is now with the Department of Emergency Medicine, Mt. Sinai School of Medicine, New York, NY, USA; Ryan is with the RAND Corporation, Santa Monica, CA, USA: Margold is with Protecting Adult Welfare, Sherman Oaks, CA, USA; Torres is with the School of Public Health, University of California, Los Angeles, Los Angeles, CA, USA; Gelberg is with the Department of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA     

Greater Drug Injecting Risk for HIV, HBV, and HCV Infection in a City Where Syringe Exchange and Pharmacy Syringe Distribution are Illegal

Comparing drug-injecting risk between cities that differ in the legality of sterile syringe distribution for injection drug use provides a natural experiment to assess the efficacy of legalizing sterile syringe distribution as a structural intervention to prevent human immunodeficiency virus (HIV) and other parenterally transmitted infections among injection drug users (IDUs). This study compares the parenteral risk for HIV and hepatitis B (HBV) and C (HCV) infection among IDUs in Newark, NJ, USA, where syringe distribution programs were illegal during the period when data were collected, and New York City (NYC) where they were legal. IDUs were nontreatment recruited, 2004–2006, serotested, and interviewed about syringe sources and injecting risk behaviors (prior 30 days). In multivariate logistic regression, adjusted odds ratios (AOR) and 95% confidence intervals (95% CI) for city differences are estimated controlling for potential city confounders. IDUs in Newark (n = 214) vs. NYC (n = 312) were more likely to test seropositive for HIV (26% vs. 5%; AOR = 3.2; 95% CI = 1.6, 6.1), antibody to the HBV core antigen (70% vs. 27%; AOR = 4.4; 95% CI = 2.8, 6.9), and antibody to HCV (82% vs. 53%; AOR = 3.0; 95% CI = 1.8, 4.9), were less likely to obtain syringes from syringe exchange programs or pharmacies (AOR = 0.004; 95% CI = 0.001, 0.01), and were more likely to obtain syringes from street sellers (AOR = 74.0; 95% CI = 29.9, 183.2), to inject with another IDU’s used syringe (AOR = 2.3; 95% CI = 1.1, 5.0), to reuse syringes (AOR = 2.99; 95% CI = 1.63, 5.50), and to not always inject once only with a new, sterile syringe that had been sealed in a wrapper (AOR = 5.4; 95% CI = 2.9, 10.3). In localities where sterile syringe distribution is illegal, IDUs are more likely to obtain syringes from unsafe sources and to engage in injecting risk behaviors. Legalizing and rapidly implementing sterile syringe distribution programs are critical for reducing parenterally transmitted HIV, HBV, and HCV among IDUs. Neaigus, Zhao, Gyarmathy, and Cisek are with the Institute for International Research on Youth at Risk, National Development and Research Institutes, New York, NY, USA; Neaigus is with the Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA; Gyarmathy is with the Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA; Friedman is with the Institute for AIDS Research, National Development and Research Institutes, New York, NY, USA; Friedman is with the Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA; Baxter is with the North Jersey Community Research Initiative, Newark, NJ, USA.     

An Analysis of Respondent Driven Sampling with Injection Drug Users (IDU) in Albania and the Russian Federation

Internet access has caused a global revolution in the way people of all ages and genders interact. Many have turned to the Internet to seek love, companionship, and sex, prompting researchers to move behavioral studies online. The sexual behavior of men who have sex with men (MSM) has been more closely studied than that of any other group online given the abundance of gay-oriented websites and concerns about increasing transmission of HIV and other sexually transmitted infections. Not only does the Internet provide a new medium for the conduct of behavioral research and for participant recruitment into an array of research studies, it has the as yet unrealized potential to reach huge numbers of MSM with innovative harm reduction and prevention messages tailored to individualized needs, interests, and risk behavior. Internet-based research on sexual behavior has many advantages in rapidity of recruitment of diverse samples which include individuals unreachable through conventional methods (i.e., non-gay identified and geographically and socially isolated MSM, etc.). Internet-based research also presents some new methodologic challenges in study design, participant recruitment, survey implementation, and interpretation of results. In addition, there are ethical issues unique to online research including difficulties in verifying informed consent, obstacles to surveying minors, and the ability to assure anonymity. This paper presents a review of Internet-based research on sexual behavior in MSM, a general discussion of the methodologic and ethical challenges of Internet-based research, and recommendations for future interdisciplinary research. Dr. Parsons is with the Center for HIV/AIDS Educational Studies and Training (CHEST), Hunter College and the Graduate Center of the City University of New York, NY; Dr. Tesoriero is with the Office of Program Evaluation and Research, New York State Department of Health AIDS Institute, Menands, NY; Dr. Carballo-Dieguez is with the HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York, NY; Dr. Remien is with the HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York, NY.     

Implementing a Routine, Voluntary HIV Testing Program in a Massachusetts County Prison

Although U.S. prison inmates have higher rates of HIV infection than the general population, most inmates are not routinely tested for HIV infection at prison entry. The study objective was to implement a routine, voluntary HIV testing program in a Massachusetts county prison. During admission, inmates were given group HIV pre-test counseling and were subsequently offered private HIV testing. This intervention was compared to a control period during which HIV testing was provided only upon inmate or physician request. Between November 2004 and April 2005, 1,004 inmates met inclusion criteria and were offered routine, voluntary HIV testing. Of these, 734 (73.1%) accepted, 2 (0.3%) were HIV-infected, and 457 (45.5%) had been tested for HIV in the previous year. The testing rate of 73.1% was significantly increased from the rate of 18.0% (318 of 1,723) during the control period (p<0.001). Among the inmates tested for HIV in the prior year, 78.2% had received their last HIV test in the prison setting. Careful attention should be paid to prevent redundancy of testing efforts in the prison population. Implementing a routine HIV testing program among prison inmates greatly increased testing rates compared to on-request testing. Liddicoat is with the Department of Medicine, Greater Los Angeles Veterans Administration, Mail 111G, 11301 Wilshire Boulevard, Los Angeles, CA 90073, USA; Zheng, Freedberg, and Walensky are with the Division of General Medicine, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Freedberg and Walensky are with the Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Zheng, Freedberg, and Walensky are with the Partners AIDS Research Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Internicola and Golan are with the Suffolk County House of Corrections, Boston, MA, USA; Golan is with the Department of Infectious Disease, Tufts University Medical School, Boston, MA, USA; Rubinstein is with the HIV/AIDS Bureau, Massachusetts Department of Public Health, Boston, MA, USA; Werner and Kazianis are with the Massachusetts State Laboratory Institute, Boston, MA, USA.     

Community-oriented health services education: A strategy for international cooperation

This paper describes the approach of the Department of Community Medicine of the Mount Sinai School of Medicine in the education of local and foreign physicians and their participation in the development of community oriented health care systems. It also presents the first steps taken by this medical school to create an international program whose aims are to develop long-term partnership agreements with foreign universities by bringing together and integrating medical education with the development of community-oriented health care services.Samuel J. Bosch, M.D., is Charles G. Bluhdorn Professor of International Community Medicine, Department of Community Medicine, The Mount Sinai School of Medicine of the City University of New York. One Gustave L. Levy Place, New York, N.Y. 10029.Alan Silver, M.D. is Assistant Professor and Director of the Education Unit, Department of Community Medicine, The Mount Sinai School of Medicine of the City University of New York. One Gustave L. Levy Place, New York, N.Y. 10029     

Estimation of HIV Prevalence,Risk Factors,and Testing Frequency among Sexually Active Men Who Have Sex with Men,Aged 18–64 Years—New York City, 2002

Population-based estimates of human immunodeficiency virus (HIV) prevalence and risk behaviors among men who have sex with men (MSM) are valuable for HIV prevention planning but not widely available, especially at the local level. We combined two population-based data sources to estimate prevalence of diagnosed HIV infection, HIV-associated risk-behaviors, and HIV testing patterns among sexually active MSM in New York City (NYC). HIV/AIDS surveillance data were used to determine the number of living males reporting a history of sex with men who had been diagnosed in NYC with HIV infection through 2002 (23% of HIV-infected males did not have HIV transmission risk information available). Sexual behavior data from a cross-sectional telephone survey were used to estimate the number of sexually active MSM in NYC in 2002. Prevalence of diagnosed HIV infection was estimated using the ratio of HIV-infected MSM to sexually active MSM. The estimated base prevalence of diagnosed HIV infection was 8.4% overall (95% confidence interval [CI] = 7.5–9.6). Diagnosed HIV prevalence was highest among MSM who were non-Hispanic black (12.6%, 95% CI = 9.8–17.6), aged 35–44 (12.6%, 95% CI = 10.4–15.9), or 45–54 years (13.1%, 95% CI = 10.2–18.3), and residents of Manhattan (17.7%, 95% CI = 14.5–22.8). Overall, 37% (95% CI = 32–43%) of MSM reported using a condom at last sex, and 34% (95% CI = 28–39%) reported being tested for HIV in the past year. Estimates derived through sensitivity analyses (assigning a range of HIV-infected males with no reported risk information as MSM) yielded higher diagnosed HIV prevalence estimates (11.0–13.2%). Accounting for additional undiagnosed HIV-infected MSM yielded even higher prevalence estimates. The high prevalence of diagnosed HIV among sexually active MSM in NYC is likely due to a combination of high incidence over the course of the epidemic and prolonged survival in the era of highly active antiretroviral therapy. Despite high HIV prevalence in this population, condom use and HIV testing are low. Combining complementary population-based data sources can provide critical HIV-related information to guide prevention efforts. Individual counseling and education interventions should focus on increasing condom use and encouraging safer sex practices among all sexually active MSM, particularly those groups with low levels of condom use and multiple sex partners At the time this work was conducted, Manning and Marx were with the Epidemic Intelligence Service, Office of Workforce and Career Development, Centers for Disease Control and Prevention, Atlanta, GA, USA; Thorpe, Ramaswamy, Hajat, Marx, Karpati, Mostashari, and Pfeiffer are with the New York City Department of Health and Mental Hygiene, New York, NY, USA; Nash is with the Department of Epidemiology and International Center for AIDS Care and Treatment Programs, Columbia Mailman School of Public Health, New York, NY, USA; Manning is with the Massachusetts Department of Public Health, Bureau of Family and Community Health, Boston, MA, USA.     

Understanding Immigrant Chinese Americans’ Participation in Cancer Screening and Clinical Trials

The purpose of this study was to identify potential barriers and facilitators to Chinese immigrant participation in cancer screening and clinical trials. A series of focus groups, in English, Cantonese, and Mandarin, were conducted with physicians, community leaders, and first generation members of the Manhattan Chinatown community. Participants were asked to discuss their beliefs about cancer, cancer screening, clinical trials, and cancer health education materials. Focus group data were stratified by respondent group and analyzed for thematic content. Eleven physicians, 15 community leaders, and 38 community members participated. Some community members were not familiar with cancer screening as a preventive measure and had not received common screens such as PAP smears or mammograms. They described widespread misconceptions about cancer that act as screening deterrents, e.g. testing for cancer can cause cancer. Community members were unfamiliar with clinical trials and would not participate in a clinical trial unless “sick,” and only on the recommendation of their physicians. Physicians did not see the relevance or value of clinical trials for their patients. Among first generation Chinese immigrants, there are many perceptual barriers to cancer screening and clinical trials recruitment. There is a need for effective culturally tailored health education on these health topics to address persistent misconceptions about cancer and to increase knowledge about cancer screening and clinical trials. Health education efforts and clinical trial recruitment in this community must involve community physicians. Jennifer S. Lin, MD was Senior Chief Resident at New York University School of Medicine, Department of Medicine and is currently a Bowen-Brooks Fellow, New York Academy of Medicine; Alyssa Finlay, MD was a General Internal Medicine Fellow at New York University School of Medicine, Department of Medicine, Primary Care and is currently an Epidemic Intelligence Service Officer, Center for Disease Control; Angela Tu, MD is a Resident at New York University School of Medicine, Department of Medicine, Primary Care; Francesca M. Gany, MD, MS is Director at the Center for Immigrant Health and Assistant Professor at New York University School of Medicine, Division of General Internal Medicine, Primary Care.