AIDS Service Organizations and Their Presence on the Internet

Summary

AIDS service organizations have been the driving forces behind providing HIV/AIDS-positive individuals and the public with up-to-date information about the disease, treatment regimens, and prevention measures. It is critical that these organizations develop and maintain Internet sites for the rapid dissemination of information. The Internet offers the capability of providing a communication and publication means to reach a wider audience, reach greater numbers of HIV/AIDS-positive individuals, and reach even those in the most remote areas. This article discusses six major AIDS service organizations (Gay Men's Health Crisis, San Francisco AIDS Foundation, AIDS Project Los Angeles, AIDS Action Committee of Massachusetts, AID Atlanta, and the Howard Brown Clinic) and their presence on the Internet. All six organizations have made a national impact on the provision of HIV/AIDS services, programs, information, and advocacy efforts.     

Housing Patterns and Correlates of Homelessness Differ by Gender among Individuals Using San Francisco Free Food Programs

Homeless individuals experience high rates of morbidity and mortality, yet many homeless studies include small percentages of female participants. We therefore sought to determine correlates of homelessness separately for men and women in a sample of individuals visiting free food programs. Between August 2003 and April 2004, 324 individuals were recruited from San Francisco free food programs and interviewed regarding housing, sociodemographics, health, drug use, sex trade, and incarceration. Over one-half of women and almost three-fourths of men reported homelessness in the prior year. Among women, white race, younger age, not living with minor children, engaging in sex trade and recent incarceration were strongly associated with homelessness; however, only incarceration maintained the strong association in adjusted analysis (OR = 7.16, CI = 3.83–13.4). Among men, heavy alcohol use, drug use, years spent living in San Francisco and monthly income were strongly associated with homelessness; however, only years living in San Francisco (OR = 0.28, CI = 0.19–0.42) and monthly income maintained strong association in adjusted analysis (OR = 0.27, CI = 0.13–0.57). Housing patterns and the strongest correlates of homelessness among individuals visiting free food programs differ by sex. These results suggest the need to characterize homelessness and develop effective homeless interventions separately for men and women. Riley, Weiser, Dilworth, and Cohen are with the San Francisco General Hospital, Epidemiology and Prevention Interventions Center, University of California, San Francisco, CA, USA; Weiser and Neilands are with the Center for AIDS Prevention Studies, University of California, San Francisco, CA, USA; Sorensen is with the San Francisco General Hospital, Department of Psychiatry, University of California, San Francisco, CA, USA.     

Gender-specific Correlates of Sex Trade among Homeless and Marginally Housed Individuals in San Francisco

Objective: Sex exchange is a well-established risk factor for HIV infection. Little is known about how correlates of sex trade differ by biologic sex and whether length of homelessness is associated with sex trade. We conducted a cross-sectional study among a sample of 1,148 homeless and marginally housed individuals in San Francisco to assess correlates of exchanging sex for money or drugs. Key independent variables included length of homelessness; use of crack, heroin or methamphetamine; HIV status; and sexual orientation. Analyses were restricted by biologic sex. In total, 39% of women and 30% of men reported a lifetime history of sex exchange. Methamphetamine use and greater length of homelessness were positively associated with a history of sex trade among women, while heroin use, recent mental health treatment, and homosexual or bisexual orientation were significantly associated with sex trade for men. Crack use was correlated with sex trade for both genders. Correlates of sex trade differ significantly according to biologic sex, and these differences should be considered in the design of effective HIV prevention programs. Our findings highlight the critical need to develop long-term services to improve housing status for homeless women, mental health services for homeless men, and drug treatment services for homeless adults involved in sex work.Weiser, Dilworth, and Neilands are with the Center for AIDS Prevention Studies, University of California, San Francisco (UCSF), San Francisco, CA, USA. Cohen, Bangsberg, and Riley are with Epidemiology and Prevention Interventions (EPI) Center, Division of Infectious Diseases, San Francisco General Hospital, UCSF; Bangsberg is with the Positive Health Program, San Francisco General Hospital, UCSF.The Epidemiology and Prevention Interventions Center, Positive Health Program and Center for AIDS Prevention Studies are programs of the UCSF AIDS Research Institute.     

The nonprofit sector's response to the AIDS epidemic: community-based services in San Francisco.

Community-based organizations in San Francisco have played a key role in providing social support services and public health information to those affected by acquired immune deficiency syndrome (AIDS). These services have helped minimize the economic impact of the epidemic by reducing the level and expense of hospitalization of AIDS patients. During fiscal year 1984-85, the three largest community-based groups in San Francisco provided more than 80,000 hours of social support and counseling services, responded to over 30,000 telephone inquiries and letters, and distributed nearly 250,000 pieces of literature. Home-based hospice care was provided to 165 AIDS patients at an average cost per day of $94 per patient. Community-based organizations require a significant level of funding from government and private sources. Local government in San Francisco has provided 62 per cent of the revenues for these groups. At the same time, they are not viable without a steady stream of volunteer labor. More than 130,000 hours were donated this past year. There are intrinsic limits to the current dependency on unpaid labor and contributions made by private charity and local government which will eventually require increased support and intervention at the state and federal levels.     

AIDS education and training for health care providers

Many health care providers still harbor fears and misunderstandingsabout AIDS that negatively affect the delivery of patient care.In order to resolve these fears and misunderstandings, fiveregistered nurses representing the California Nurses Association,AIDS Project Los Angeles, the San Francisco AIDS Foundationand the California Statewide Nursing Program developed, implementedand evaluated an innovative AIDS ‘train the trainer’program. The program was designed to replace didactic lectureswith more effective methods to meet the needs of adult learners.Between November 1986 and April 1987, 27 two-day trainings wereconducted throughout California to train 759 key health careprofessionals in both adult learning principles and AIDS content.Creative teaching strategies such as guided fantasy, role playand case studies were utilized to encourage group interactionand the exploration of sensitive issues underlying the fearof AIDS. By June 1, 508 of the 759 Trainers had each conductedinstructional programs for groups of 25 or more health careproviders; a total of 18 879 people were educated in the secondarytrainings. Summative program evaluation showed that the trainingprogram gave participants the knowledge, skills and confidencenecessary to conduct AIDS education for health care providers.     

Tripling of Methamphetamine/Amphetamine Use among Homeless and Marginally Housed Persons, 1996–2003

Methamphetamine/amphetamine (MA)-related morbidity and mortality has been increasing in the United States. MA use is associated with high-risk sexual behavior and syringe-sharing practices. Homeless and marginalized housed persons (H/M) have high rates of substance use and mental health disorders. Little is known about trends of MA use among the H/M. The objective of this study was to quantify increases in MA use among H/M in San Francisco and to determine which demographic and behavioral subgroups have experienced the greatest increases in MA use. We conducted serial cross-sectional population-based studies in three waves: 1996–1997, 1999–2000, and 2003 and studied 2,348 H/M recruited at shelters and lunch lines. The main outcome was self-reported current (30-day) MA use. We found a tripling of current MA use among H/M persons from 1996 to 2003, with a sevenfold increase in smoked MA use. MA use doubled to tripled in most demographic and behavioral subgroups, whereas it quadrupled in those under age 35, and there was a fivefold increase among HIV-infected persons. The increase in MA use among H/M places a vulnerable population at additional increased risk for HIV infection and MA-use related morbidity and mortality. Among HIV-infected H/M, the increase in MA use has important public health implications for the development and secondary transmission of drug-resistant HIV caused by synergistic neurocognitive decline, poor adherence to HIV medications, and increased sexual risk behavior. Clinicians caring for H/M persons should inquire about MA use, refer interested MA users to MA dependence treatment programs and provide targeted HIV sexual risk reduction counseling. For HIV-infected H/M MA users, clinicians should closely monitor adherence to HIV or other chronic medications, to avoid unnecessary morbidity and mortality. Further research is needed to elucidate the most effective prevention and treatment for MA use and dependence among the H/M. Das-Douglas and Bangsberg are with the Department of Medicine, Division of Infectious Diseases, University of California, San Francisco, CA, USA; Das-Douglas, Bangsberg, and Hahn are with the Epidemiology and Prevention Interventions Center, Department of Medicine, San Francisco General Hospital, University of California, San Francisco, CA, USA; Das-Douglas and Bangsberg are with the Center for AIDS Prevention Studies, University of California, San Francisco, CA, USA; Colfax is with the Epidemiology Section, AIDS Office, San Francisco Department of Public Health, San Francisco, CA, USA; Moss is with the Epidemiology and Biostatistics, University of California, San Francisco, USA.     

Focusing on the negative

A San Francisco HIV prevention group has started a series of programs focusing on keeping HIV-negative gay men uninfected. The group, Invention, began the programs in September in response to city-funded studies showing gay men returning to unsafe sexual practices. The San Francisco AIDS Office estimates that 650 gay or bisexual men seroconvert each year, up from 250 in 1987. Infection is sometimes regarded as a rite of passage into the gay community, where half of all gay men are already HIV-positive, and those with HIV are perceived as having a superior social service network for health and counseling needs. The HIV-negative men regard infection as inevitable, and are not as fearful of HIV since those who are positive are living longer. Programs will discuss how to build a meaningful life, help the HIV-negative develop a sense of the gay community apart from AIDS, and encourage dialogue between negative and positive men.     

A thousand points ... needle exchange around the country

Needle exchange in the United States is a part of the AIDS direct action movement. Activists around the country, refusing to wait for health officials to create AIDS interventions for drug users, have taken the task upon themselves. Prevention Point in San Francisco, the National AIDS Brigade in Boston, and ACT UP/New York all run illegal programs in their locales, and member of all three groups have been arrested for their work. Tacoma, Seattle, and New Haven now have authorized programs, but only after Dave Purchase in Tacoma, ACT UP Seattle, and the National AIDS Brigade and ACES in New Haven demonstrated that needle exchange was a viable and necessary public health intervention. Health/PAC here presents some of the stories from this citizen's health action movement.     

Temporal trends in the incidence of non-Hodgkin's lymphoma and selected malignancies in a population with a high incidence of acquired immunodeficiency syndrome (AIDS)

Annual incidence rates for 1975-1985 were derived for Kaposi's sarcoma, non-Hodgkin's lymphomas, and seven other malignancies. Never-married men in the San Francisco Bay area constituted the study population. The pattern of increase in incidence of non-Hodgkin's lymphoma among men aged 25-44 years was similar to that seen for Kaposi's sarcoma; both increased significantly in San Francisco between 1980 and 1985 (p less than 0.001), with an increase among census tracts with high incidence of acquired immunodeficiency syndrome (AIDS) that was greater than the increase seen in other San Francisco census tracts. Among men in tracts with a high incidence of AIDS, non-Hodgkin's lymphoma reached an incidence in 1985 that was five times greater than preepidemic rates. These increased rates support the conclusion of clinical studies that non-Hodgkin's lymphoma is an additional manifestation of AIDS. Similar increases in incidence rates were not observed for other malignancies, suggesting that reports of these malignancies in homosexuals may be isolated incidents. Whether rates of non-Hodgkin's lymphoma will continue to increase and whether rates of other potentially AIDS-associated malignancies will increase in the future may depend on the latency of these malignancies and the survival period of AIDS patients.     

AIDS and Adolescents: School Health Education Must Begin Now

Teenagers must be educated about AIDS. Because thousands of teenagers are at risk because of their behaviors, target groups for special programs should include those who are drug users, gay and bisexual, homeless, or into solicitation and prostitution. Educational material should be developed that includes a culturally sensitive approach for minority teenagers. Certain areas with high prevalence rates of AIDS need special attention because they pose greater risks for teenagers, such as Houston, Los Angeles, Miami, New York City, northern New Jersey, San Francisco, and Washington, DC. Studies show that most teenagers are misinformed or lack of basic knowledge about transmitting or protecting against AIDS. Education should be aimed at countering this misinformation and reducing the panic about the disease. Teenagers need this health-related information for sharing with their siblings and parents as well as for learning for themselves. Most existing school-based education programs are inadequate because few exist, most are only for junior and senior high levels, and may do not focus on prevention information. Ideally, AIDS education should be integrated into existing health or sexuality education programs. The programs should emphasize information on how AIDS is transmitted, how AIDS is not transmitted, and how to protect oneself from HIV.     

Human immunodeficiency virus/acquired immunodeficiency syndrome training from a union perspective.

The authors developed a union sponsored 2-day human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) "train the trainer" program for healthcare workers in the San Francisco Bay Area. The program incorporated the "education for action" approach in an effort to respond to the inadequacies in many traditional, institutional trainings. Service Employees International Union (SEIU) and Labor Occupational Health Program (LOHP) conducted the HIV/AIDS "train the trainer" program for approximately 100 healthcare workers in county public hospitals and community health clinics. After completing the program, these workers went back to their healthcare facilities, or community organizations, and led additional classes on HIV/AIDS transmission and prevention for approximately 600 more people. The goal of the program was to empower healthcare workers to: 1) identify the occupational risks associated with exposure to blood and potentially infectious body fluids at the workplace; 2) develop strategies to reduce those risks; 3) discuss their feelings about caring for an HIV/AIDS patient; and, 4) conduct HIV/AIDS workshops at the workplace.     

Soft tissue infections among injection drug users--San Francisco, California, 1996-2000

Soft tissue infections (STIs), including abscesses and cellulitis, are a common complication of injection drug use. In 1997, 54 (32%) of 169 injection drug users (IDUs) in one San Francisco neighborhood had a drug-injection-related abscess or cellulitis (1). To characterize STIs among IDUs, data from San Francisco General Hospital (SFGH) discharge and billing records were analyzed. This report summarizes the results of that analysis and presents the case report of one IDU with an STI. The findings indicate that STIs are among the most common diagnoses among patients admitted to SFGH. Preventing STIs among IDUs in San Francisco will require coordinated action involving health-care providers, public health agencies, substance abuse treatment, community outreach, syringe exchange programs, IDUs, and community-based organizations.     

The Impact of Legalizing Syringe Exchange Programs on Arrests Among Injection Drug Users in California

Legislation passed in 2000 allowed syringe exchange programs (SEPs) in California to operate legally if local jurisdictions declare a local HIV public health emergency. Nonetheless, even in locales where SEPs are legal, the possession of drug paraphernalia, including syringes, remained illegal. The objective of this paper is to examine the association between the legal status of SEPs and individual arrest or citation for drug paraphernalia among injection drug users (IDUs) in California from 2001 to 2003. Using data from three annual cross-sections (2001-03) of IDUs attending 24 SEPs in 16 California counties (N = 1,578), we found that overall, 14% of IDUs in our sample reported arrest or citation for paraphernalia in the 6 months before the interview. Further analysis found that 17% of IDUs attending a legal SEP (defined at the county level) reported arrest or citation for drug paraphernalia compared to 10% of IDUs attending an illegal SEP (p = 0.001). In multivariate analysis, the adjusted odds ratio of arrest or citation for drug paraphernalia was 1.6 [95% confidence interval (CI) = 1.2, 2.3] for IDUs attending legal SEPs compared to IDUs attending illegal SEPs, after controlling for race/ethnicity, age, homelessness, illegal income, injection of amphetamines, years of injection drug use, frequency of SEP use, and number of needles received at last visit. IDUs attending SEPs with legal status may be more visible to police, and hence, more subject to arrest or citation for paraphernalia. These findings suggest that legislative efforts to decriminalize the operation of SEPs without concurrent decriminalization of syringe possession may result in higher odds of arrest among SEP clients, with potentially deleterious implications for the health and well-being of IDUs. More comprehensive approaches to removing barriers to accessing sterile syringes are needed if our public health goals for reducing new HIV/HCV infections are to be obtained. Martinez is with the Center for AIDS Prevention Studies, University of California, San Francisco, 50 Beale Street, Suite 1300, San Francisco, CA 94105, USA; Bluthenthal is with the Drug Policy Research Center, RAND, Santa Monica, CA, USA and the Urban Community Research Center, Department of Sociology, California State University Dominguez Hills, Carson, CA, USA; Lorvick is with the Urban Health Program, RTI International, San Francisco, CA, USA; Anderson is with the Sacramento Area Needle Exchange, Sacramento, CA, USA; Flynn is with the Department of Internal Medicine, University of California, Davis, CA, USA; Kral is with the Urban Health Program, RTI International, San Francisco, CA, USA and the Department of Family and Community Medicine, University of California, San Francisco, CA, USA.     

Adolescents and AIDS: a survey of knowledge, attitudes and beliefs about AIDS in San Francisco.

To assess adolescents' knowledge, attitudes, and beliefs about AIDS in San Francisco, data were obtained from 1,326 adolescents. There was marked variability in knowledge across informational items, particularly about the precautionary measures to be taken during sexual intercourse which may reduce the risk of infection. We conclude that development and implementation of school health education programs on AIDS and other sexually transmitted diseases are needed in this population.     

Increasing the involvement of national and regional racial and ethnic minority organizations in HIV information and education.

Responding to the facts that (a) the AIDS epidemic is occurring among black and Hispanic populations disproportionately to their percentage of the U.S. population and (b) effective human immunodeficiency virus (HIV) prevention programs are racially, ethnically, and culturally relevant and sensitive, CDC in 1988 initiated a 5-year grant program for HIV prevention efforts by national racial and ethnic minority organizations and regional consortia of racial and ethnic minority organizations. A total of 33 organizations received first-year funds. Of the 32 grants that are ongoing, 15 primarily target blacks, 12 Hispanics, 4 Native Americans and Alaskan Natives, and 1 Asian Americans and Pacific Islanders. Some grants are for more than one racial or ethnic population. Programs may be categorized as (a) education programs within national non-AIDS organizations and their respective affiliate networks to increase their understanding, support, and community out-reach for HIV prevention; for example, National Urban League, Inc.; (b) programs providing specific HIV prevention expertise and technical assistance to community-based and other organizations; for example, National Minority AIDS Council; (c) HIV prevention programs emphasizing communications and media; for example, Hispanic Designers, Inc; and (d) prevention programs targeted to a specific racial or ethnic group within a geographic area; for example, Midwest Hispanic AIDS Coalition. As a result of these grants, substantial resources are being invested in prevention programs developed by and for racial and ethnic minorities. Other overall benefits include an expanded foundation of organizations to address AIDS and other health problems affecting these populations, strengthened interrelationships among HIV-focused and broader-based minority organizations, and extensive collaboration of private sector organizations with Federal and State public health and education agencies.     

Private funders fall short in HIV prevention, study says

A study conducted by the Center for AIDS Prevention Studies at the University of California, San Francisco concluded that private funders are reluctant to support needle-exchange or condom distribution programs. The study found strong funding support for public policy, outreach, and community mobilization, but major gaps remain in terms of harm reduction programs. Most grants were found to be targeted toward the general populations, rather than at-risk groups such as gay men, ethnic minorities, or drug users.     

Do Health Benefits Outweigh the Costs of Mass Recreational Programs? An Economic Analysis of Four Ciclovía Programs

One promising public health intervention for promoting physical activity is the Ciclovía program. The Ciclovía is a regular multisectorial community-based program in which streets are temporarily closed for motorized transport, allowing exclusive access to individuals for recreational activities and physical activity. The objective of this study was to conduct an analysis of the cost-benefit ratios of physical activity of the Ciclovía programs of Bogotá and Medellín in Colombia, Guadalajara in México, and San Francisco in the U.S.A. The data of the four programs were obtained from program directors and local surveys. The annual cost per capita of the programs was: U.S. $6.0 for Bogotá, U.S. $23.4 for Medellín, U.S. $6.5 for Guadalajara, and U.S. $70.5 for San Francisco. The cost-benefit ratio for health benefit from physical activity was 3.23-4.26 for Bogotá, 1.83 for Medellín, 1.02-1.23 for Guadalajara, and 2.32 for San Francisco. For the program of Bogotá, the cost-benefit ratio was more sensitive to the prevalence of physically active bicyclists; for Guadalajara, the cost-benefit ratio was more sensitive to user costs; and for the programs of Medellín and San Francisco, the cost-benefit ratios were more sensitive to operational costs. From a public health perspective for promoting physical activity, these Ciclovía programs are cost beneficial.     

Elevated risk of death for African Americans with AIDS, San Francisco, 1996-2002

Disparities in survival among people with AIDS continue in the treatment era, with a higher rate of death among African Americans than among Whites, Latinos, and Asians/Pacific Islanders (API). Few studies have been able to identify underlying reasons for this disparity. The authors' objectives were to determine the extent of disparities in AIDS-related death by race/ethnicity, and examine factors that may contribute to or explain these differences. Using San Francisco surveillance data, racial/ethnic differences in survival among residents diagnosed with AIDS between 1996 and 2002 were analyzed using Kaplan-Meier survival and Cox proportional hazards regression techniques. The data confirm that a disparity in survival after AIDS persists between African Americans and Whites, Latinos, and APIs in San Francisco. Underlying causes of this disparity are multiple, but many of them are amenable to intervention and should be addressed.     

Collaborative research to prevent HIV among male prison inmates and their female partners.

Despite the need for targeted HIV prevention interventions for prison inmates, institutional and access barriers have impeded development and evaluation of such programs. Over the past 6 years, the authors have developed a unique collaborative relationship to develop and evaluate HIV prevention interventions for prison inmates. The collaboration includes an academic research institution (the Center for AIDS Prevention Studies at the University of California, San Francisco), a community-based organization (Centerforce), and the staff and inmate peer educators inside a state prison. In this ongoing collaboration, the authors have developed and evaluated a series of HIV prevention interventions for prison inmates and for women who visit prison inmates. Results of these studies support the feasibility and effectiveness of HIV prevention programs for inmates and their partners both in prison and in the community. Access and institutional barriers to HIV intervention research in prisons can be overcome through the development of collaborative research partnerships.     

Appeals court says FBI erred in terminating doctor's services. Federal Bureau of Investigations

The late Dr. James Cullen of San Francisco had a four-year contract to perform physical exams on local FBI agents and job applicants. When the FBI learned that Dr. Cullen had AIDS, the San Francisco field office stopped using his services. An initial non-jury trial found that Dr. Cullen did not have private right of action to sue the Federal government, and that his evasive answers as to his state of health and risk of transmission had prevented the FBI from learning the extent of risk. Upon appeal by Dr. Cullen's estate, however, a Federal court determined that the FBI had terminated Dr. Cullen based on his HIV status, not on the quality of his work. The FBI's actions violated the 1973 Rehabilitation Act barring government-funded programs from discrimination based on disability.