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Developing appropriate risk messages during challenging situations like public health outbreaks is complicated. The focus of this paper is on how First Nations and Metis people in Manitoba, Canada, responded to the public health management of pandemic H1N1, using a focus group methodology (n = 23 focus groups). Focus group conversations explored participant reactions to messaging regarding the identification of H1N1 virus risk groups, the H1N1 vaccine and how priority groups to receive the vaccine were established. To better contextualize the intentions of public health professionals, key informant interviews (n = 20) were conducted with different health decision makers (e.g., public health officials, people responsible for communications, representatives from some First Nations and Metis self-governing organizations). While risk communication practice has improved, ‘one size’ messaging campaigns do not work effectively, particularly when communicating about who is most ‘at-risk’. Public health agencies need to pay more attention to the specific socio-economic, historical and cultural contexts of First Nations and Metis citizens when planning for, communicating and managing responses associated with pandemic outbreaks to better tailor both the messages and delivery. More attention is needed to directly engage First Nations and Metis communities in the development and dissemination of risk messaging. [ABSTRACT FROM AUTHOR]

The worldwide spread of a novel influenza A (H1N1) virus in 2009 showed that influenza remains a significant health threat, even for individuals in the prime of life. This paper focuses on the unusually high young adult mortality observed during the Spanish flu pandemic of 1918. Using historical records from Canada and the U.S., we report a peak of mortality at the exact age of 28 during the pandemic and argue that this increased mortality resulted from an early life exposure to influenza during the previous Russian flu pandemic of 1889–90. We posit that in specific instances, development of immunological memory to an influenza virus strain in early life may lead to a dysregulated immune response to antigenically novel strains encountered in later life, thereby increasing the risk of death. Exposure during critical periods of development could also create holes in the T cell repertoire and impair fetal maturation in general, thereby increasing mortality from infectious diseases later in life. Knowledge of the age-pattern of susceptibility to mortality from influenza could improve crisis management during future influenza pandemics. [ABSTRACT FROM AUTHOR]

One of network epidemiology's central assumptions is that the contact structure over which infectious diseases propagate can be represented as a static network. However, contacts are highly dynamic, changing at many time scales. In this paper, we investigate conceptually simple methods to construct static graphs for network epidemiology from temporal contact data. We evaluate these methods on empirical and synthetic model data. For almost all our cases, the network representation that captures most relevant information is a so-called exponential-threshold network. In these, each contact contributes with a weight decreasing exponentially with time, and there is an edge between a pair of vertices if the weight between them exceeds a threshold. Networks of aggregated contacts over an optimally chosen time window perform almost as good as the exponential-threshold networks. On the other hand, networks of accumulated contacts over the entire sampling time, and networks of concurrent partnerships, perform worse. We discuss these observations in the context of the temporal and topological structure of the data sets. [ABSTRACT FROM AUTHOR]

Background: Although male circumcision (MC) is recommended as an HIV prevention option, the religious, cultural and biomedical dimensions of its feasibility, acceptability and practice in India have not been explored till date. This study explores beliefs, experiences and understanding of the community and healthcare providers (HCPs) about adult MC as an HIV prevention option in India. Methods: This qualitative study covered 134 in-depth interviews from Belgaum, Kolkata, Meerut and Mumbai cities of India. Of these, 62 respondents were the members of circumcising (CC)/non-circumcising communities (NCC); including medically and traditionally circumcised men, parents of circumcised children, spouses of circumcised men, and religious clerics. Additionally, 58 registered healthcare providers (RHCPs) such as general and pediatric surgeons, pediatricians, skin and venereal disease specialists, general practitioners, and operation theatre nurses were interviewed. Fourteen traditional circumcisers were also interviewed. The data were coded and analyzed in QSR NUD*IST ver. 6.0. The study has not explored the participants' views about neonatal versus adult circumcision. Results: Members of CC/NCC, traditional circumcisers and RCHPs expressed sharp religious sensitivities around the issue of MC. Six themes emerged: Male circumcision as the religious rite; Multiple meanings of MC: MC for ‘religious identity/privilege/sacrifice’ or ‘hygiene’; MC inflicts pain and cost; Medical indications outweigh faith; Hesitation exists in accepting ‘foreign’ evidence supporting MC; and communication is the key for acceptance of MCs. Medical indications could make members of NCC accept MC following appropriate counseling. Majority of the RHCPs demanded local in-country evidence. Conclusion: HCPs must educate high-risk groups regarding the preventive and therapeutic role of MC. Communities need to discuss and create new social norms about male circumcision for better societal acceptance especially among the NCC. Feasibility studies on MC as an individual specific option for the high risk groups in health care setting needs to be explored. [ABSTRACT FROM AUTHOR]

Background: Religion is an important underlying determinant of HIV spread in sub-Saharan Africa. However, little is known about how religion influences changes in HIV prevalence and associated sexual behaviours over time. Objectives: To compare changes in HIV prevalence between major religious groups in eastern Zimbabwe during a period of substantial HIV risk reduction (1998–2005) and to investigate whether variations observed can be explained by differences in behaviour change. Methods: We analysed serial cross-sectional data from two rounds of a longitudinal population survey in eastern Zimbabwe. Univariate and multivariate logistic regression models were developed to compare differences in sexual behaviour and HIV prevalence between religious groups and to investigate changes over time controlling for potential confounders. Results: Christian churches were the most popular religious grouping. Over time, Spiritualist churches increased in popularity and, for men, Traditional religion and no religion became less and more common, respectively. At baseline (1998–2000), HIV prevalence was higher in Traditionalists and in those with no religion than in people in Christian churches (men 26.7% and 23.8% vs. 17.5%, women: 35.4% and 37.5% vs. 24.1%). These effects were explained by differences in socio-demographic characteristics (for Traditional and men with no religion) or sexual behaviour (women with no religion). Spiritualist men (but not women) had lower HIV prevalence than Christians, after adjusting for socio-demographic characteristics (14.4% vs. 17.5%, aOR = 0.8), due to safer behaviour. HIV prevalence had fallen in all religious groups at follow-up (2003–2005). Odds of infection in Christians reduced relative to those in other religious groups for both sexes, effects that were mediated largely by greater reductions in sexual-risk behaviour and, possibly, for women, by patterns of conversion between churches. Conclusion: Variation in behavioural responses to HIV between the major church groupings has contributed to a change in the religious pattern of infection in eastern Zimbabwe. [ABSTRACT FROM AUTHOR]

Setting: Tuberculosis (TB) is highly prevalent in prisons of the former Soviet Union. Objective: To understand the behavioral, demographic and biological factors placing inmates in Tajikistan at risk for active TB. Design: We administered a behavioral and demographic survey to 1317 inmates in two prison facilities in Sughd province, Tajikistan along with radiographic screening for pulmonary TB. Suspected cases were confirmed bacteriologically. Inmates undergoing TB treatment were also surveyed. In-depth interviews were conducted with former prisoners to elicit relevant social and behavioral characteristics. Results: We identified 59 cases of active pulmonary TB (prevalence 4.5%). Factors independently associated with increased prevalence of active TB were: HIV-infection by self-report (PR 7.88; 95%CI 3.40–18.28), history of previous TB (PR 10.21; 95%CI 6.27–16.63) and infrequent supplemental nutrition beyond scheduled meals (PR 3.00; 95%CI 1.67–5.62). Access to supplemental nutrition was associated with frequency of visits from friends and family and ability to rely on other inmates for help. Conclusion: In prison facilities of Tajikistan, HIV-infection, injection drug use and low access to supplemental nutrition were associated with prevalent cases of active pulmonary TB. Policies that reduce HIV transmission among injection drug users and improve the nutritional status of socially isolated inmates may alleviate the TB burden in Tajikistan’s prisons. [ABSTRACT FROM AUTHOR]

The aim of this study is to assess whether the Government of Kenya's Cash Transfer for Orphans and Vulnerable Children (Kenya CT-OVC) can reduce the risk of HIV among young people by postponing sexual debut. The program provides an unconditional transfer of US$20 per month directly to the main caregiver in the household. An evaluation of the program was implemented in 2007–2009 in seven districts. Fourteen Locations were randomly assigned to receive the program and fourteen were assigned to a control arm. A sample of households was enrolled in the evaluation in 2007. We revisited these households in 2011 and collected information on sexual activity among individuals between 15–25 years of age. We used logistic regression, adjusted for the respondent's age, sex and relationship to caregiver, the age, sex and schooling of the caregiver and whether or not the household lived in Nairobi at baseline, to compare rates of sexual debut among young people living in program households with those living in control households who had not yet entered the program. Our results, adjusted for these covariates, show that the program reduced the odds of sexual debut by 31 percent. There were no statistically significant effects on secondary outcomes of behavioral risk such as condom use, number of partners and transactional sex. Since the CT-OVC provides cash to the caregiver and not to the child, and there are no explicit conditions associated with receipt, these impacts are indirect, and may have been achieved by keeping young people in school. Our results suggest that large-scale national social cash transfer programs with poverty alleviation objectives may have potential positive spillover benefits in terms of reducing HIV risk among young people in Eastern and Southern Africa. [ABSTRACT FROM AUTHOR]

In the Susceptible–Infectious–Recovered (SIR) model of disease spreading, the time to extinction of the epidemics happens at an intermediate value of the per-contact transmission probability. Too contagious infections burn out fast in the population. Infections that are not contagious enough die out before they spread to a large fraction of people. We characterize how the maximal extinction time in SIR simulations on networks depend on the network structure. For example we find that the average distances in isolated components, weighted by the component size, is a good predictor of the maximal time to extinction. Furthermore, the transmission probability giving the longest outbreaks is larger than, but otherwise seemingly independent of, the epidemic threshold. [ABSTRACT FROM AUTHOR]

The spread of certain diseases can be promoted, in some cases substantially, by prior infection with another disease. One example is that of HIV, whose immunosuppressant effects significantly increase the chances of infection with other pathogens. Such coinfection processes, when combined with nontrivial structure in the contact networks over which diseases spread, can lead to complex patterns of epidemiological behavior. Here we consider a mathematical model of two diseases spreading through a single population, where infection with one disease is dependent on prior infection with the other. We solve exactly for the sizes of the outbreaks of both diseases in the limit of large population size, along with the complete phase diagram of the system. Among other things, we use our model to demonstrate how diseases can be controlled not only by reducing the rate of their spread, but also by reducing the spread of other infections upon which they depend. [ABSTRACT FROM AUTHOR]

Background: In April 2009, the most recent pandemic of influenza A began. We present the first estimates of pandemic mortality based on the newly-released final data on deaths in 2009 and 2010 in the United States. Methods: We obtained data on influenza and pneumonia deaths from the National Center for Health Statistics (NCHS). Age- and sex-specific death rates, and age-standardized death rates, were calculated. Using negative binomial Serfling-type methods, excess mortality was calculated separately by sex and age groups. Results: In many age groups, observed pneumonia and influenza cause-specific mortality rates in October and November 2009 broke month-specific records since 1959 when the current series of detailed US mortality data began. Compared to the typical pattern of seasonal flu deaths, the 2009 pandemic age-specific mortality, as well as influenza-attributable (excess) mortality, skewed much younger. We estimate 2,634 excess pneumonia and influenza deaths in 2009–10; the excess death rate in 2009 was 0.79 per 100,000. Conclusions: Pandemic influenza mortality skews younger than seasonal influenza. This can be explained by a protective effect due to antigenic cycling. When older cohorts have been previously exposed to a similar antigen, immune memory results in lower death rates at older ages. Age-targeted vaccination of younger people should be considered in future pandemics. [ABSTRACT FROM AUTHOR]

Background: HIV prevalence differs by more than an order of magnitude between South Africa's racial groups. Comparing the sexual behaviors and other risk factors for HIV transmission between the different races may shed light on the determinants of South Africa's generalized HIV epidemic. Methods: Five nationally representative and one city-representative population-based surveys of sexual behavior were used to assess the extent to which various risk factors co-varied with HIV prevalence by race in South Africa. Results: In 2004, the prevalence of HIV was 0.5%, 1%, 3.2% and 19.9% in 15–49 year old whites, Indians, coloureds and blacks respectively. The risk factors which co-varied with HIV prevalence by race in the six surveys were age of sexual debut (in five out of five surveys for men and three out of six surveys for women), age gap (zero surveys in men and three in women), mean number of sex partners in the previous year (five surveys in men and three in women) and concurrent partnerships (five surveys in men and one in women). Condom usage and circumcision were both more prevalent in the high HIV prevalence groups. The reported prevalence of concurrency was 6 to 17 times higher in the black as opposed to the white men in the five surveys. Conclusions: The differences in sexual behavior in general, and the prevalence of concurrency and the number of sexual partners in particular, offer a plausible and parsimonious cause to explain a part of the differing prevalences of HIV between South Africa's racial groups. [ABSTRACT FROM AUTHOR]

Objectives: To investigate the awareness of, and willingness to use, HIV Pre-Exposure Prophylaxis (PrEP), and willingness to take part in a PrEP study among gay and bisexual men in Scotland. Methods: Cross-sectional survey of 17 gay commercial venues in Glasgow and Edinburgh in May 2011 (N = 1515, 65.2% response rate); 1393 are included in the analyses. Results: Just under one-third of participants had heard of PrEP (n = 434; 31.2%), with awareness associated with being aged older than 35 years, talking to UAI partners about HIV, and with having had an HIV or STI test in the previous 12 months. Around half were willing to take part in a PrEP study (n = 695; 49.9%) or to take PrEP on a daily basis (n = 756; 54.3%). In multivariate analysis, willingness to take PrEP was associated with lower levels of education, regular gay scene attendance, ‘high-risk’ unprotected anal intercourse (UAI) and testing for HIV or STI in the previous 12 months. Reasons for not wanting to participate in a PrEP study or take PrEP included perceptions of low personal risk of HIV and concerns with using medication as an HIV prevention method. Conclusions: There is a willingness to engage in new forms of HIV prevention and research amongst a significant number of gay and bisexual men in Scotland. Future biomedical HIV interventions need to consider the links between sexual risk behaviour, testing, and potential PrEP use. [ABSTRACT FROM AUTHOR]

Objectives: To determine the etiology and factors associated with genital ulcer disease (GUD) among patients presenting to a sexually transmitted infections clinic in Manaus, Brazil; and to compare a multiplex polymerase chain reaction (M-PCR) assay for the diagnosis of GUD with standard methods. Methods: Ulcer swabs were collected and used for Tzanck test and processed in an M-PCR to detect herpes simplex virus (HSV-1/2), Treponema pallidum (T. pallidum), and Haemophilus ducreyi (H. ducreyi). Sera were tested for HIV and syphilis antibodies. Multivariable analysis was used to measure the association between clinical aspects and GUD. M-PCR results were compared with syphilis serology and Tzanck tests. Results: Overall, 434 GUD samples were evaluated, 84.8% from men. DNA from HSV-2 was detected in 55.3% of GUD samples, T. pallidum in 8.3%, HSV-1 in 3.2%, and 32.5% of GUD specimens were negative for the DNA of all three pathogens. No cases of H. ducreyi were identified. HIV serology among GUD patients was 3.2%. Treponemal antibodies and Tzanck test positivity for genital herpes was detected in 25 (5.8%) and in 125 (30.3%) of GUD patients, respectively. In multivariable analysis genital herpes etiology by M-PCR was associated with the vesicular, multiple and recurrent lesions whereas T. pallidum with non-vesicular, non-recurrent lesions. Compared to M-PCR, syphilis serology was 27.8% sensitive and 96.2% specific whereas Tzanck test was 43.8% sensitive and 88.9% specific. Conclusions: The predominance of genital herpes etiology suggests a revision of existing national syndromic treatment guidelines in Brazil to include antiherpetic treatment for all GUD patients. The use of M-PCR can significantly improve the diagnosis of GUD and provide a greater sensitivity than standard diagnostics. [ABSTRACT FROM AUTHOR]

Introduction: The objectives of this study are to develop a summary measure of risky sexual practice and examine the factors associated with this among female sex workers (FSWs) in Karnataka, India. Materials and Methods: Data were drawn from special behavioral surveys (SBS) conducted in 2007 among 577 FSWs in two districts of Karnataka, India: Belgaum and Bangalore. FSWs were recruited using the two-stage probability sampling design. FSWs' sexual practice was considered risky if they reported inconsistent condom use with any sexual partner and reported experience of one of the following vulnerabilities to HIV risk: anal sex, alcohol consumption prior to sex and concurrent sexual relationships. Results: About 51% of FSWs had engaged in risky sexual practice. The odds of engaging in risky sex were higher among FSWs who were older (35+ years) than younger (18–25 years) (58% vs. 45%, Adjusted Odds Ratio (AOR): 2.0, 95% confidence interval (CI): 1.2–3.4), who were currently married than never married (61% vs. 51%, AOR: 4.8, 95% CI: 2.5–9.3), who were in sex work for 10+ years than those who were in sex work for less than five years (66% vs. 39%, AOR: 2.6, 95% CI: 1.6–4.2), and who had sex with 3+ clients/day than those who had sex with fewer clients (67% vs. 38%, AOR: 3.7, 95% CI:2.5–5.5). Conclusion: FSWs who are older, currently married, practicing sex work for longer duration and with higher clientele were more likely to engage in risky sexual practices. HIV prevention programs should develop strategies to reach these most-at risk group of FSWs to optimize the effectiveness of such programs. [ABSTRACT FROM AUTHOR]

Introduction: Cryptococcosis is an invasive fungal infection causing substantial morbidity and mortality. Prognostic factors are largely derived from trials conducted prior to the modern era of antifungal and potent combination antiretroviral therapies, immunosuppression, and transplantation. Data describing the clinical features and predictors of mortality in a modern cohort are needed. Methods: We conducted a retrospective cohort study of patients at our institution diagnosed with cryptococcosis from 1996 through 2010. Data included demographics, clinical features, diagnostics, treatment, and outcomes. Results: We identified 302 individuals: 108 (36%) human immunodeficiency virus (HIV)-positive, 84 (28%) organ transplant recipients (OTRs), and 110 (36%) non-HIV, non-transplant (NHNT) patients including 39 with no identifiable immunodeficiency. Mean age was 49 years, 203 (67%) were male and 170 (56%) were white. All-cause mortality at 90 days was 21%. In multivariable logistic regression analyses, cryptococcemia (OR 5.09, 95% CI 2.54–10.22) and baseline opening pressure >25 cmH2O (OR 2.93, 95% CI 1.25–6.88) were associated with increased odds of mortality; HIV-positive patients (OR 0.46, 95% CI 0.19–1.16) and OTRs (OR 0.46, 95% CI 0.21–1.05) had lower odds of death compared to NHNT patients. Conclusions: Predictors of mortality from cryptococcosis in the modern period include cryptococcemia, high intracranial pressure, and NHNT status while drug(s) used for induction and historical prognostic factors including organ failure syndromes and hematologic malignancy were not associated with mortality. [ABSTRACT FROM AUTHOR]

Background: Hepatitis C virus (HCV) emerged as sexually transmitted infection among HIV-infected men who have sex with men (MSM). We studied whether HCV circulated in identifiable high-risk MSM subcultures and performed phylogenetic analysis. Methods: HIV-infected MSM were recruited at the sexually transmitted infections (STI) outpatient clinic and a university HIV clinic in Amsterdam, the Netherlands, 2008–2009. Participants completed a detailed questionnaire and were tested for HCV antibodies and RNA, with NS5B regions sequenced for analysis of clusters. Results: Among 786 participants, the median age was 43 (IQR 37–48) years, and 93 (11.8%) were HCV-positive. Seropositivity was associated with belonging to subcultures identified as leather (aOR 2.60; 95% CI 1.56–4.33), rubber/lycra (aOR 2.15; 95% CI 1.10–4.21), or jeans (aOR 2.23; 95% CI 1.41–3.54). The two largest HCV-RNA monophyletic clusters were compared; MSM in cluster I (genotype 1a, n = 13) reported more partners (P = 0.037) than MSM in cluster II (genotype 4d, n = 14), but demographics, subculture characteristics and other risk behaviors did not differ significantly between the two clusters. Discussion: HCV infection is associated with identifiable groups of leather/rubber/lycra/jeans subcultures among HIV-infected MSM. Separate epidemiological HCV transmission networks were not revealed. Active HCV screening and treatment within specific subcultures may reduce HCV spread among all MSM. [ABSTRACT FROM AUTHOR]

Objective: Determine the acceptability and epidemiological impact of increases in HIV testing in gay men in New South Wales (NSW), Australia– particularly pertinent when considering treatment as prevention and the need to reduce undiagnosed infections. Methods: We conducted an online survey and focus groups to assess whether increases in HIV testing would be acceptable to gay men in NSW. In parallel, we assessed the potential impact of increases in testing coverage and/or frequency using an individual-based model of HIV transmission. Results: If sexual practices and the rate of initiating HIV treatment are unchanged then increasing HIV testing reduces infections. Increasing testing frequency has the largest impact, with a 13.8% reduction in HIV infections over 10 years if the ∼55–75% of men who test at least once per year increased their testing frequency to four times per year. If testing levels decrease from current levels then we expect an increase in HIV infections with a sharply rising trend over time. Increasing HIV testing would be acceptable if testing was more convenient. However, only ∼25% of men surveyed were ‘very likely’ to increase their level of HIV testing. Men delayed or avoided testing due to the slowness in obtaining results and if they believed they had not put themselves at risk. Conclusions: An increase in HIV testing alone is unlikely to reduce HIV incidence substantially in NSW gay men– however, the relatively high testing levels need to continue to prevent an increase in HIV infections. In jurisdictions with lower levels of HIV testing, increases in testing coverage and frequency are likely to have a larger impact. Successful treatment as prevention interventions will require increases in testing rates; such increases would be acceptable to gay men in NSW but only if more convenient testing and rapid communication of results were available. [ABSTRACT FROM AUTHOR]