Buffering Syndemic Effects in a Sexual Risk-Reduction Intervention for Male Clients of Female Sex Workers: Results From a Randomized Controlled Trial

Objectives. We sought to test the efficacy of a sexual risk intervention for male clients of female sex workers (FSWs) and examine whether efficacy was moderated by syndemic risk.Methods. From 2010 to 2014, we conducted a 2-arm randomized controlled trial (60-minute, theory-based, safer sex intervention versus a didactic time-equivalent attention control) that included 400 male clients of FSWs on the US–Mexico border with follow-up at 4, 8, and 12 months. We measured 5 syndemic risk factors, including substance use and depression. Primary outcomes were sexually transmitted infections incidence and total unprotected sex with FSWs.Results. Although participants in both groups became safer, there was no significant difference in behavior change between groups. However, baseline syndemic risk moderated intervention efficacy. At baseline, there was a positive association between syndemic risk and unprotected sex. Then at 12 months, longitudinal analyses showed the association depended on intervention participation (B = −0.71; 95% confidence interval [CI] = –1.22, –0.20; P = .007). Among control participants there still existed this modest association (B = 0.36; 95% CI = –0.49, 1.22; P = .09); among intervention participants there was a significant negative association (B = −0.35; 95% CI = –0.63, –0.06; P = .02).Conclusion. A brief intervention might attenuate syndemic risks among clients of FSWs. Other populations experiencing syndemic problems may also benefit from such programs.Male clients of female sex workers (FSWs) represent a “bridge population” that has the potential to transmit HIV and sexually transmitted infections (STIs) between higher-risk groups (FSWs) and lower-risk groups (e.g., their wives).1–3 Globally, male clients of FSWs exhibit high-risk sexual behaviors,4–8 as well as higher STI incidence compared with other men.9 Unfortunately, little intervention work has targeted male clients.In 2007, Lowndes et al. implemented a behavioral intervention focusing on condom promotion among male clients of FSWs in Cotonou, Benin.10 Results suggested that male clients of FSWs in a resource-constrained country can reduce their sexual risk behavior through participation in a targeted behavioral intervention. However, this study lacked randomization and a control condition, precluding the ability to evaluate efficacy to reduce sexual risk behavior. A recent review of randomized trials and quasi-randomized trials of behavioral HIV prevention interventions among sex workers and clients did not identify a single randomized controlled trial targeted for male clients.11In Tijuana, Mexico, a border city along San Diego, California, there are an estimated 6000 to 10 000 FSWs offering sexual services to men from both countries.12 Tijuana has an HIV prevalence that is double the national average, and HIV is highest among high-risk groups including FSWs (approximately 6%).12–14In 2008, we conducted pilot research with 400 male clients of FSWs in Tijuana.13 HIV prevalence among clients was similar to that of FSWs (approximately 5%). Clients reported sex with an FSW an average of 26 times in the past year, once every 2 weeks in the past 4 months, and half reported recent unprotected sex with FSWs. Data were used to develop the first sexual risk-reduction intervention for male clients of FSWs. Herein, we aim to first evaluate the efficacy of our brief intervention, using the rigor of a randomized controlled trial. Whereas evaluating an intervention’s efficacy is a necessary step for HIV prevention, scientists must also examine for whom or under what conditions an intervention is efficacious (i.e., test moderators) to best inform prevention strategies both practically and theoretically.In addition to demonstrating risky sexual behavior, our pilot research with male clients in Tijuana showed that history of drug use was prevalent (88% reporting lifetime drug use) and was associated with unprotected sex with FSWs. These data also showed that the clients were more likely to engage in risky sex if they consumed alcohol at hazardous levels.15 Finally, our qualitative data suggested that vulnerability to HIV was associated with mental health problems like depression or loneliness.16,17 These findings are consistent with previous research on syndemic theory.Research has demonstrated the multiple co-occurrence of psychosocial problems (e.g., substance use, violence) and their additive effect on HIV risk behavior, called “syndemics.”18–21 While the specific factors that are included in the operationalization of a syndemic differ and depend on the specific population and region,21,22 studies have essentially found a dose–response relationship such that individuals who report more psychosocial problems are more likely to engage in higher sexual risk behavior or are more likely to be infected with HIV.23 The second aim of the current research was to examine syndemics as a potential moderator of intervention efficacy. In light of the important role that syndemics play in HIV across high-risk populations, and based on our pilot data, we hypothesized that men who experienced more syndemic problems at baseline would be more likely to benefit from the intervention than men who experienced fewer syndemic problems. Although our sexual risk-reduction intervention was not designed to directly address syndemic problems, it was based on cognitive behavioral therapy, social cognitive theory, and the theory of reasoned action, and we included in the intervention theoretical elements and motivational interviewing techniques designed to promote safer sex behavior by addressing perceived barriers to safer sex.     

Practical non-pharmacological intervention approaches for sleep problems among older adults

Poor sleep is common among older adults, often caused by multiple underlying factors such as chronic stress. Poor sleep is subsequently associated with negative health outcomes including higher morbidity and mortality. Our primary purpose is to explore practical non-pharmacological intervention approaches integrating stress management to improve sleep quality among older adults. In doing so, we highlight approaches that appear to hold promise in real-world settings with older individuals. We conducted a tailored literature review specifically on approaches to improve sleep quality among older adults, with emphasis on those integrating stress management. Online search engines were reviewed to identify research in these areas. Various non-pharmacological intervention approaches, such as mindfulness and cognitive behavioral therapy, have shown promise in improving sleep quality and health outcomes within this population. Those integrating chronic stress management appear to be particularly successful. Thus further development of multidimensional sleep interventions integrating stress management with seniors is warranted.     

The impact of mobility limitations on health outcomes among older adults

The purpose of this study was to stratify an older adult population for subsequent interventions based on functional ability, and to estimate prevalence, characteristics and impact of mobility limitations on health outcomes. In 2016, surveys were sent to a stratified random sample of AARP^® Medicare Supplement insureds; mobility limitations were defined using two screening questions. Responses were stratified to three mobility limitation levels. Multivariate regression models determined characteristics and impact on health outcomes. Among weighted survey respondents (N = 15,989), severe, moderate and no limitation levels were 21.4%, 18.4% and 60.3%, respectively. The strongest predictors of increased limitations included pain and poor health. Individuals with more severe limitations had increased falls, decreased preventive services compliance and increased healthcare utilization and expenditures. Utilizing two screening questions stratified this population to three meaningful mobility limitation levels. Higher levels of mobility limitations were strongly associated with negative health outcomes. Mobility-enhancing interventions could promote successful aging.     

Paucity of antigen-specific IgA responses in sera and external secretions of HIV-type 1-infected individuals

This study was undertaken to resolve existing controversies with respect to the detection of IgA HIV-1-specific mucosal antibodies in infected individuals. External secretions, including tears, nasal, rectal, and vaginal washes, saliva, semen, urine, and sera were obtained from 50 HIV-1-infected individuals and 20 controls using collection procedures that minimize the irritation of mucosal surfaces. Levels of total and antigen (gp120 and gp160)-specific antibodies of the IgG and IgA isotypes were measured by assays that proved reliable in a large multicenter study: quantitative ELISA and chemiluminescence-enhanced Western blot analyses. Although the levels of total IgG and IgA were increased or remained unchanged in body fluids of HIV-1-infected individuals as compared to the controls, HIV-1-specific IgA antibodies were either absent or present at low levels even in secretions with characteristically high relative contents of total IgA vs. IgG (saliva, tears, and rectal and nasal washes). In these secretions, HIV-1-specific IgG antibodies dominated. In assessing levels and frequency of detection of IgG antibodies, both female and male genital tract secretions, urine, and nasal wash were preferable to parotid saliva and especially to rectal wash. External secretions contained IgG antibodies to gp160> gp120> gp41 and p24; when present, IgA antibodies were predominantly directed at gp160. Analyses of peripheral blood antibody-secreting cells (ASC) isolated from the same individuals paralleled these serological findings: gp160-specific IgG-secreting ASC were dominant. Therefore, in striking contrast to other mucosally encountered microbial infections, HIV-1 does not induce vigorous specific IgA responses in any body fluid examined or in ASC in peripheral blood.     

The role of hemochromatosis susceptibility gene mutations in protecting against iron deficiency in celiac disease

BACKGROUND & AIMS: Celiac disease and hereditary hemochromatosis are common HLA-defined conditions in northwestern Europe. We sought to determine whether there is a genetic relationship between the 2 diseases and if hemochromatosis susceptibility gene (HFE) mutations are protective against iron deficiency in celiac disease. METHODS: Polymerase chain reaction amplification using sequence-specific primers capable of identifying the 2 HFE gene mutations (H63D and C282Y) and the HLA class I and II alleles was used to type 145 white patients with celiac disease and 187 matched controls. Hemoglobin and fasting serum iron levels in celiac patients were measured at diagnosis. RESULTS: HFE gene mutations, H63D or C282Y, were identified in 70 celiac patients (48.3%) and 61 controls (32.6%) (P = 0.004). The C282Y mutation was associated with HLA-A*03 and B*07 alleles in controls and with A*01, A*03, B*08, and DRB1*0301 alleles in celiac patients; the H63D mutation was associated with HLA-A*25 and DRB1*03 alleles in controls and A*29 and DRB1*03 alleles in celiac patients. At diagnosis, celiac patients with the C282Y mutation had higher mean hemoglobin and fasting serum iron levels compared with the HFE wild type (P = 0.0002 and 0.006, respectively). This was not observed with the H63D mutation. CONCLUSIONS: In celiac disease, HFE gene mutations are common and are in linkage disequilibrium with different HLA alleles compared with controls. A disease-specific haplotype that carries C282Y and DQB1*02 is suggested. We propose that HFE gene mutations provide a survival advantage by ameliorating the iron deficiency seen in celiac patients.     

STUDY OF CARBONIC ANHYDRASE USING PERTURBED ANGULAR CORRELATIONS OF GAMMA RADIATION

The angular correlation of the 150-247 kev gamma-ray cascade of (111m)Cd is strongly perturbed when this nucleus is bound to the enzyme carbonic anhydrase. A comparison of the perturbed angular correlation for the apoenzyme with that for native carbonic anhydrase confirms that the (111m)Cd binds at the active region of the enzyme. These results provide good evidence that the perturbed angular correlation reflects the effective molecular rotational correlation time at the metal binding site, and that this radioactive nucleus can be used as a rotational tracer to label biological macromolecules. The qualitative dependence of the perturbed angular correlation of the (111m)Cd cascade on the molecular rotational correlation time at the metal binding site is illustrated using a cadmium-complex solution at various temperatures.     

Abnormalities of Megakaryocytes in W/Wv Mice

Megakaryocytopoiesis was evaluated ingenetically anemic mice of the W/W^v genotype and was found to be abnormal.Concentration and size of blood plateletswere normal. Megakaryocytes were decreased in number in tibial marrow andspleen, and the size of mature megakaryocytes was increased.

Submitted on April 9, 1973 Revised on May 31, 1973 Accepted on June 12, 1973