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Issue #191: August 23, 1998
fastfax is available by fax in the 215 and 610 area codes at no cost, or by mail anywhere for $20.00 per year, by calling 215-545-6868, and by E-mail by contacting and type the message SUBSCRIBE in the message section. Sources for some articles in this issue include AIDS, General Hospital Psychiatry, Philadelphia Gay News, Reuters, Sexually Transmitted Diseases
STDs, risky sex still rising among young people
Testosterone may help with fatigue
Vaginal bacteria increases HIV risk
Oxford pulls out of region - except for HealthChoices
STD rates, risky sex still rising among youth
While the overall US rate of the sexually transmitted disease (STD) gonorrhea has declined since the early 1980s, rates of the disease remain high in adolescents, young adults and blacks, according to a study from the Centers for Disease Control and Prevention (CDC).
"Gonorrhea remains a serious public health problem among minorities and among adolescents of all races," write lead author Dr. Kimberley K. Fox and her colleagues with the CDC in Atlanta, Georgia, and the Center for AIDS and STD at the University of Washington in Seattle.
According to the study, which is published in the August issue of the journal Sexually Transmitted Diseases, reported gonorrhea cases fell 71.3% between 1981 and 1996, from 431.5 to 124 per 100,000 people. However, lower rates among whites and those over age 20 account for the bulk of the overall decline, the authors note.
While the rate of gonorrhea among blacks has also declined, the gap between blacks and whites grew wider. In 1996, the rate of gonorrhea among blacks was 35 times higher than that among whites compared with 11 times higher in 1981, the study found.
Philadelphia saw a 2 percent increase in reported cases of gonorrhea between 1996 and 1997, but its gonorrhea rates are three or more times the national rates in virtually all age categories. In the age group most at risk of HIV infection (15-24), the increase was 8 percent. The Philadelphia rate of gonorrhea incidence among African Americans (who comprised 90 percent of cases) was 949.1, compared to 825.5 nationally.
For 15-19 year old adolescents of all races, the Philadelphia rate was 1865.8, over three times the national rate of 570.8. Frighteningly, Philadelphia saw a rate for boys 10 to 14 years old of 27.6, over three times the national rate (9.1); for girls in the same age range, the rate in Philadelphia in 1997 was 310.0, 5.3 times the national rate of 57.9. Across the board, Philadelphia gonorrhea rates are three or more times the national rates in virtually all age categories.
While Philadelphia continues to make major progress in reducing the incidence of syphilis, the 1997 rate of infection per 100,000 residents (68.8) is still almost 16 times the national rate of 4.3 cases per 100,000 population.
Chlamydia incidence continued to rise as well in Philadelphia between 1996 and 1997, seeing an increase of 23 percent from 1996 to 1997, to 10,480 cases. Philadelphia's rate of incidence of chlamydia per 100,000 population, at 660.0 in 1997, is 3.4 times the national rate of 194.5; similarly, the rate among women in Philadelphia, at 1096.9, is 3.4 times the national rate of 321.5.
Fox points out that riskier sexual behavior among blacks is not to blame for higher STD rates in that community. A recent national survey cited in the article found that "although blacks were more likely to have had more than one sexual partner in the last year, they were also more likely to have used condoms at the last sexual contact and more likely to have changed sexual behaviors in response to the acquired immunodeficiency syndrome epidemic."
Rather, a legacy of poverty, low educational levels and a lack of access to health services may account for the high rates of gonorrhea among minorities, particularly in the rural South, Fox says. According to the report, Southern states had higher rates of gonorrhea than other regions.
The study also found that rates of gonorrhea among black and white adolescent women remain high despite an overall decline within this group, with 15- to 19-year-olds reporting the greatest number of cases. Among men of all races, 20- to 24-year-olds had the highest rates.
The fact that the rates of gonorrhea among adolescents and young adults remain high is disturbing, Fox says, because gonorrhea may facilitate the transmission of human immunodeficiency virus (HIV). "If we are not able to impact the rates of gonorrhea in adolescents, we could see a whole new wave of HIV in the future," she told Reuters Health in an interview.
The authors attribute the overall decline to screening programs, changes in sexual behavior in response to the AIDS epidemic, and a shift in the age structure of the US population. However, rates of gonorrhea in the United States remain the highest of any industrialized country, they add.
Data for the report came from gonorrhea cases reported to the CDC by 50 states, the District of Columbia, and 63 large cities. The study is part of CDC surveillance data to follow long-term trends in STD morbidity.
Meanwhile, significant numbers of U.S. high school students admitted in a nationwide survey that they got drunk, had sex, smoked, carried weapons and practiced other risky behaviors, according to Laura Kann, an epidemiologist with the CDC. Kann's statements are based on the results of the annual Youth Risk Behavior Surveillance Survey (YRBS), which measures the extent of behaviors that put young people at risk of injury, HIV infection and other diseases.
"This report tells us that too many youth practice behaviors that are unnecessarily placing them at risk for serious injury, sexually transmitted diseases and other preventable health problems." The survey found that one-third of high school students had sexual intercourse in the preceding three months, but only 56% used a condom.
According to Kann, high school students are engaging in risky sexual behaviors, even though unintended pregnancies and sexually transmitted diseases, including AIDS, were epidemic among the nation's youth.
The YRBS was based on "national, state, territorial and local school-based surveys of high school students collected from February to May of 1997 by education and health agencies. The report breaks down high-risk youth behavior into categories of gender and race.
Among the other findings:
--With regard to sexual activity, the survey indicated that "nearly half (48.4%) of all students had had sexual intercourse during their lifetime; black students (72.7%) were significantly more likely than Hispanic (52.2%) and white students (43.6%) to have had sexual intercourse."
--Males (9.4%) were nearly twice as likely to have had initial sexual intercourse before age 13 than females (4.5%).
--The percentage of students who had multiple sex partners was 16.0%, and black students (38.5%) had a higher incidence than Hispanic (15.5%) or white (11.6%) students.
--Condom use "during last sexual intercourse" was 56.8%. Males used condoms 62.5% of the time, while 50.8% of females reported use. Black students (64.0%) were significantly more likely than white (55.8%) and Hispanic (48.3%) students to report condom use.
--6.5% of students reported they had been pregnant or had gotten someone else pregnant.
David Harvey, executive director of the AIDS Policy Center for Children, Youth & Families, said, "The youth-risk behavior data released by the CDC should be a wake-up call to policymakers, educators and families across the country that we must take bolder steps to prevent HIV and STD infections among young people." He notes that the report comes at a time when federal funding for HIV prevention is stagnant, and Congress has allocated $50 million per year for "ineffective abstinence only" sexuality education programs. He said, "We must assure that all young people have access to comprehensive youth appropriate HIV/STD prevention and family planning programs that include information about disease and pregnancy prevention methods other than abstinence. We must also increase federal support for programs that target youth at highest risk for HIV infection, including youth of color, young women and young men who have sex with men."
Testosterone may help with fatigue
While powerful drugs have enabled many HIV-positive people to return to work, they are often plagued by fatigue caused by their condition.
But a new study shows that testosterone injections may help relieve the symptoms of fatigue in HIV-positive men, according to New York researchers.
After 66 HIV-positive men received injections of the hormone every two weeks for three months, 79 percent reported a boost in energy levels, said lead author Glenn J. Wagner of the New York State Psychiatric Institute in New York.
At the start of the study, all of the men reported having a diminished sex drive as well as depressed mood, low energy or weight loss.
According to Wagner, testosterone deficiency is the most common hormonal abnormality in men with HIV infection, and often contributes to fatigue.
Fatigue is also a symptom of depression, which often develops in HIV-positive individuals, he noted.
Exactly how testosterone boosted energy levels in the men is unclear, Wagner reported in the August issue of the journal General Hospital Psychiatry. The hormone may have acted directly on the fatigue or may have indirectly reduced fatigue by relieving depression, the New York researcher speculated.
Once their fatigue lifted, the men reported more satisfaction and enjoyment of their lives, Wagner reported.
Some of the men experienced side effects while receiving testosterone, including irritability, acne and hair loss, but the symptoms were mild, according to the study.
Wagner did caution, however, that the long-term effects of testosterone injections are unclear.
While testosterone treatment has side effects, the benefits of the therapy outweigh the drawbacks for many people with HIV, said Dr. Craig Donatucci, an assistant professor of urology at Duke University Medical Center in Durham, N.C. ``The risks are pretty minimal relative to the disease you're treating,'' he said.
Relieving symptoms of testosterone-related fatigue can help a person with HIV resume a more normal life, Donatucci explained.
However, a 12-week regimen of injections is not long enough to sustain results, according to the North Carolina urologist. Most people with testosterone deficiency have to be treated for at least one year, he said.
The National Institute of Allergy and Infectious Diseases plans to collaborate with VaxGen, Inc., developer of the gp120-based AIDSVAX vaccine currently undergoing phase III clinical trials, according to an NIAID press release.
The national AIDSVAX trial began at Philadelphia FIGHT in June.
Along with collaborating with VaxGen in the phase III trials, NIAID will also be working with VaxGen to examine effects of AIDSVAX used in combination with other HIV vaccines also under investigation, the release continued. Other planned joint ventures include HIV vaccine clinical trials with AIDSVAX in developing countries.
The NIAID will help expand "the scientific range of the phase III study and [provide] expertise in certain areas of immunology," the release continued. In addition, the agency also plans to "sponsor the collection of samples from study volunteers, with the subsequent goal of evaluating immune functions in vaccinated volunteers, including infected vaccinees."
The agency previously sponsored VaxGen in phase I and II trials of the first-generation AIDSVAX but withdrew support in 1994. Although the Agency acknowledged that the current AIDSVAX formulation, which uses a bivalent design containing additional gp120 protein, "has a broader representation of HIV strains" compared with the earlier version, NIAID officials do not regret their earlier decision, the release said.
VaxGen announced the start of phase III AIDSVAX trials in June. These trials will include 5,000 volunteers in the US and 2,500 volunteers in Thailand. However, some AIDS researchers have expressed skepticism about the efficacy of the vaccine in preventing AIDS.
"Much of the skepticism comes from the earlier studies of the monovalent vaccine, as well as some doubt about the effectiveness of an antibody-only response," NIAID officials added. "However, only a clinical trial will determine the true activity of the second-generation vaccine."
"The effort to develop a safe and effective vaccine against HIV/AIDS is a global imperative and the highest priority of the HIV/AIDS research program," NIAID Director Dr. Anthony S. Fauci commented. "We expect this collaboration with VaxGen to take us closer to our mutual goal.
"We at VaxGen and NIAID share the goal of finding a vaccine to help bring an end to this epidemic. This collaborative agreement will allow us to leverage our resources and knowledge in the battle against this disease," said Dr. Donald P. Francis, President of VaxGen.
Vaginal bacteria increases HIV risk
Pregnant women in one part of Africa were up to 3.7 times more likely to become infected with HIV if their vaginal bacteria became disrupted by hostile strains, according to researchers at the Johns Hopkins School of Public Health.
The researchers said that the presence of vaginal bacteria as an HIV risk is likely in women in developed nations as well.
The study also established for the first time that a woman's risk of acquiring HIV rose in direct proportion to the severity of bacterial disturbance. The findings appear in the September issue of the journal AIDS.
Previous studies had often suggested an association between HIV and bacterial vaginosis (BV), the most severe disturbance of vaginal flora, but in those studies participants were examined only once and the individual results then pooled and compared. The present study was the first in which all participants were followed over several years so that BV's effect on HIV acquisition could be assessed over time.
"Bacterial vaginosis is common among women of both developed and developing countries," said lead author Taha Taha, PhD, MPH, assistant scientist of epidemiology.
The study recruited 1,196 HIV-negative pregnant women in Malawi, in south-east Africa, and followed them for a median of 3.4 months before their babies were born and then as for a median of 2.5 years after they had given birth. During the study, the women were tested periodically for any disturbance to the vaginal flora and for the presence of HIV.
To measure the severity of the disturbance to vaginal flora, the investigators used four easily detectable symptoms that can be easily detected by healthcare workers to assess the spectrum of vaginal disturbance, from mild to severe, using only routine laboratory tests. The symptoms were elevated vaginal pH, increased vaginal discharge, microscopic detection of clue cells (epithelial cells in the vagina covered with bacteria); and a positive amine test, which detects vaginal malodor.
Women with none of the four clinical criteria were said to have normal vaginal flora. Those with one or two criteria were classified as having a disturbance of vaginal flora and those with three or more were classified as having BV.
As the severity of vaginal disturbance increased, the risk of HIV seroconversion increased among all women in statistically significant steps, both before and after they gave birth. Thus, compared to participants with normal flora, the risk of pregnant women becoming infected with HIV was 50 percent greater for those with one of the criteria, 2.4-fold greater for those with two and 3.7-fold greater for those with BV (three or more criteria).
Similarly, postpartum HIV acquisition was 1.5 times higher among women with a single criterion than among women with normal vaginal flora; 1.7 times higher for women with two; and 3.5 times higher for women with BV.
Bacteria normally present in the vagina produce hydrogen peroxide, creating an acidic (low-pH) environment that is hostile to disease bacteria and HIV. However, if pathogenic bacteria establish a foothold, they can raise vaginal pH, which destroys the normal flora and makes the vaginal environment more friendly to organisms that cause sexually transmitted diseases (STDs) like gonorrhea, syphilis and HIV.
BV has been implicated in several serious obstetric and gynecological problems such as preterm delivery, premature rupture of membranes, amniotic fluid infection and pelvic inflammatory disease. Sexual transmission of BV is unlikely, since several studies have shown that treatment of male partners of women with BV did not reduce the rate of recurrence of BV in the women.
Oxford pulls out of region - except for HealthChoices
Oxford Health Plans, Inc., has informed the Pennsylvania Department of Insurance yesterday that it would no longer actively market its commercial health plans in the state. As a result, Oxford will lay off 16 or 17 people in its commercial sales department in Philadelphia, a company spokeswoman told the Philadelphia Inquirer.
Oxford will continue to participate in Pennsylvania's HealthChoices program, in which it insures 63,810 Medicaid recipients, and will continue to cover 15,000 area commercial subscribers.
In its most recent financial report to the Securities and Exchange Commission, filed on Friday, Oxford said: "The company has also decided to consider strategic alternatives with respect to its Pennsylvania health plan."
Oxford, once considered a model for HMO and other managed-care organizations, saw its fortunes change suddenly in October when the company revealed it would take heavy losses because of billing delays and underestimated costs. Oxford has reported a pretax loss of $508 million for the quarter that ended June 30, including restructuring charges of $174 million and $112 million in charges related to the implementation of its turnaround plan.
Eric Wichner, the director of Philadelphia's annual AIDS Walk, announced on August 12th that he would be resigning after the conclusion of this year's event, scheduled for October 18th.
Wichner took over the struggling fundraising event seven years ago and made it into the area's largest private fundraising effort for AIDS services.
Wichner said he will be taking a position with Green Mountain Energy Resources, a provider of renewable energy sources in Vermont. Wichner said he will be stationed at the organization's Philadelphia offices, however, and will remain active in efforts to support people living with HIV/AIDS. He will also serve as a member of the Walk's Board of Directors.
The Walk changed its name from "From All Walks of Life" to the "AIDS Fund" last year.
"I'm not completely moving on," Wichner told the Philadelphia Gay News. "I'm going to contribute in the fight against AIDS in a different way. I've been involved professionally in AIDS fund-raising for nearly 10 years, and I'm really excited to have completed a decade of service. I'm also excited to be ready to seek out new opportunities and to allow someone to come in with new energy to take AIDS FUND to the next level."
Jim Epstein, president of the AIDS Fund board of directors, said a search firm is likely to be retained to help the organization recruit a new director.
Last year, the annual AIDS Walk attracted more than 25,000 participants and raised over $1.3 million, according to the AIDS Fund. Over 50 organizations in southeastern Pennsylvania and southern New Jersey benefit from the event's proceeds.
To sign up for this year's walk, call 215-731-WALK. To join We The People's Walk Team, register with Team #33 or call 215-545-6868.
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