Protease inhibitor combination therapy and decreased condom use among gay men.Background. The objective of the study was to determine whether treatment with protease inhibitors Protease Inhibitors Definition A protease inhibitor is a type of drug that cripples the enzyme protease. An enzyme is a substance that triggers chemical reactions in the body. is associated with unprotected sexual behavior sexual behavior A person's sexual practices–ie, whether he/she engages in heterosexual or homosexual activity. See Sex life, Sexual life. . Methods. A total of 592 HIV-infected persons recruited from statewide public clinics in nonurban Alabama communities completed an assessment that, among other variables, elicited information on demographics, current sexual practices, health status, and medication use. Associations of treatment with protease inhibitors and high-risk sexual behavior were estimated, adjusting for potential confounders. Results. Treatment with protease inhibitors was not associated with whether a person was sexually active or with high-risk practices among sexually active heterosexual men and women. Among men who had sex with men, however, treatment with protease inhibitors was associated with never using condoms and with inconsistent use of condoms. Conclusions. Clinicians treating patients with protease inhibitors should consider providing risk-reduction counseling. ********** THE ADVENT of highly active antiretroviral therapy Noun 1. highly active antiretroviral therapy - a combination of protease inhibitors taken with reverse transcriptase inhibitors; used in treating AIDS and HIV drug cocktail, HAART (HAART HAART highly active antiretroviral therapy. HAART Highly active antiretroviral therapy, triple combination therapy AIDS The concurrent administration of 2 nucleoside reverse transcriptase inhibitors–eg, AZT and 3TC, and a protease ), a protease protease /pro·te·ase/ (pro´te-as) endopeptidase. pro·te·ase n. Any of various enzymes, including the proteinases and peptidases, that catalyze the hydrolytic breakdown of proteins. inhibitor-based combination therapy, has revolutionized the clinical management of HIV HIV (Human Immunodeficiency Virus), either of two closely related retroviruses that invade T-helper lymphocytes and are responsible for AIDS. There are two types of HIV: HIV-1 and HIV-2. HIV-1 is responsible for the vast majority of AIDS in the United States. disease. (1,2) These therapeutic regimens have shown substantial clinical benefits, including the capacity to reduce HIV RNA HIV RNA AIDS RNA of HIV origin, a serum marker of a Pt's 'HIV-ness,' now the standard by which Pt response to antiretovirals is evaluated; HIV RNA levels correlate with CD4+ count, response to antiviral therapy, clinical stage and disease progression. in plasma to undetectable levels, to sustain a reduction in viral load viral load n. The concentration of a virus, such as HIV, in the blood. viral load, n a measure of the number of virus particles present in the bloodstream, expressed as copies per milliliter. , and to increase CD4+ cells over several years. As a consequence of treatment efficacy, marked increases in survival have been observed? In addition to increased survival, HAART has been associated with a declining incidence of opportunistic infections Opportunistic infections Infections that cause a disease only when the host's immune system is impaired. The classic opportunistic infection never leads to disease in the normal host. and a marked reduction in hospital days and use of outpatient services outpatient services Hospital-based services Managed care Medical and other services provided, to a nonadmitted Pt, by a hospital or other qualified facility–eg, mental health clinic, rural health clinic, mobile X-ray unit, free-standing dialysis unit Examples . (4) One unanticipated consequence of treatment advances may be its impact on attitudes toward and practicing safe sex. Relatively little empirical data have examined the impact of protease inhibitor protease inhibitor (prō`tē-ās'), any of a class of drugs that interfere with replication of the AIDS virus (HIV), by blocking an enzyme (protease) necessary in the late stages of its reproduction. combination therapy on individuals' attitudes and sexual behavior. Surveys indicate a diminished concern about acquiring or transmitting HIV because of the advent of effective medical treatment. (5-7) Although the findings from previous surveys are informative, they are limited to relatively homogeneous populations of urban homosexual/bisexual men. Furthermore, none include an assessment of specific sexual risk behavior or actually measure the risk for decreased condom use, an important predictor of HIV transmission. Although informative, the data may be limited, especially for populations other than homosexual/bisexual men and individuals residing in nonurban areas. Our study assessed the impact of protease inhibitor therapy on the sexual risk behavior of persons with HIV. METHODS This cross-sectional study cross-sectional study n. See synchronic study. cross-sectional study, n the scientific method for the analysis of data gathered from two or more samples at one point in time. recruited and interviewed 592 HIV-infected men and women in nonurban Alabama between October 1995 and December 1997. (8) The interview was conducted by trained personnel in private rooms at clinics serving HIV-infected persons. The interview assessed participants' sociodemographics, current sexual behavior, drug history, and currently used medications. Sexual behavior was assessed over a relatively short period, the past 30 days, to minimize inaccurate recall associated with retrospective assessment. (9) Participants reported their number of sex partners, type of sexual intercourse sexual intercourse or coitus or copulation Act in which the male reproductive organ enters the female reproductive tract (see reproductive system). (vaginal or anal), frequency of intercourse, and frequency of condom use during sexual intercourse. Frequency of condom use was measured using a Likert scale Likert scale A subjective scoring system that allows a person being surveyed to quantify likes and preferences on a 5-point scale, with 1 being the least important, relevant, interesting, most ho-hum, or other, and 5 being most excellent, yeehah important, etc with five response options: never, rarely, about half the time, often, always/almost always. Treatment with antiretroviral medications was determined by asking participants to list all current medications. All study protocols were approved by the Ins titutional Review Board of the University of Alabama at Birmingham UAB began in 1936 as the Birmingham Extension Center of the University of Alabama. Because of the rapid growth of the Birmingham area, it was decided that an extension program for students who had difficulties which prevented them from studying in Tuscaloosa was needed. . Data Analysis Participants were categorized according to according to prep. 1. As stated or indicated by; on the authority of: according to historians. 2. In keeping with: according to instructions. 3. whether they had been sexually active (ie, had engaged in anal or vaginal intercourse) within the past 30 days. Differences in selected characteristics (sociodemographics, medication use, and clinical characteristics) between those who were and were not sexually active were assessed using chi-square tests, as were the associations of these characteristics with protease inhibitor use and with high-risk sexual behavior among persons who were sexually active. The high-risk sexual behavior assessed were the following: (1) never using condoms during sexual intercourse within the past 30 days, (2) inconsistent condom use (<50% of the time during the past 30 days), (3) more frequent sexual intercourse (>2 occasions during the past week), (4) having a nonsteady sex partner versus having only a steady partner, and (5) having multiple sexual partners (>1 during the past 30 days). Associations of treatment with protease inhibitors and high-risk sexual behavior were estimated us ing logistic regression In statistics, logistic regression is a regression model for binomially distributed response/dependent variables. It is useful for modeling the probability of an event occurring as a function of other factors. . These associations were first estimated in univariate analysis. Next, they were adjusted for characteristics identified as potential confounders, namely, age, education, whether medically insured, and whether the participant had an AIDS-defining condition. Analyses were conducted for the entire cohort as well as separately for each behaviorally identified sexual preference group: men who have sex with men Men who have sex with men (MSM) is a term used mostly in the United States to classify men who engage in sex with other men, regardless of whether they self-identify as gay, bisexual, or heterosexual. (MSM MSM - Micronetics Standard MUMPS ), heterosexual men (men who had sex only with women), and women. RESULTS The average age of those interviewed was 35.4 [+ or -] 8.0 years (SD); 74% were men and 51% were white. Forty percent had been sexually active within the past 30 days. A higher proportion of the following were sexually active: heterosexuals (men and women) (48% vs 33%, P < .001), persons less than 30 years of age (51% vs 36%, P = .002), those without a high school education (50% vs 36%, P = .002), and those who did not have an AIDS-defining condition (45% vs 32%, P = .002). Current treatment with protease inhibitors was reported by 20.9% of those interviewed. A slightly lower proportion of persons taking protease inhibitors (34% vs 41%, P .17) than those not taking the medications reported being sexually active. The characteristics of the study population who were sexually active are presented in Table 1. Among those sexually active, 17.9% reported being treated with protease inhibitors. At least a marginally significantly higher proportion of the following sexually active persons reported receiving treatment with protease inhibitors: whites (23.3% vs 12.6%, P = .041), persons more than 30 years of age (21.2% vs 10.0%, P = .042), those with above median income of $500/month (22.7% vs 12.9%, P = .061), those who were medically insured (23.8% vs 9.0%, P = .003), and those who had an AIDS-defining condition (25.4% vs 14.7%, P = .064). Only patients' age and whether they were medically insured were associated with protease inhibitor treatment among each sexual preference group, though not all were statistically significant. Of the characteristics assessed (Table 1), none were associated with having nonsteady or multiple partners. None of the high-risk sexual behaviors assessed were associated with race, age, or AZT AZT or zidovudine (zīdō`vy  dēn'), drug used to treat patients infected with the human immunodeficiency virus (HIV), which causes AIDS; also called therapy.
Having a low income (below median of $500/month) was associated with
more frequent sexual activity, whereas being in a research study or
having an AIDS-defining condition was associated with less frequent
sexual activity. Having an AIDS-defining condition, being medically
insured, and being less educated were associated with less frequent
condom use (ie, never or inconsistently). When assessed by sexual
preference group, the associations tended to be present primarily among
MSM.
Treatment with protease inhibitors was not associated with being sexually active during the past month in either univariate analysis (OR = 0.7; 95% CI, 0.5-1.1) or when adjusted for confounders (OR = 0.9; 95% CI, 0.6-1.3). In a multiple regression Multiple regression The estimated relationship between a dependent variable and more than one explanatory variable. analysis among all sexually active patients, no factor was significantly associated with never using condoms, and only lower education was significantly associated with inconsistent use of condoms. Participants treated with protease inhibitors, relative to those not treated with protease inhibitors, were 2.0 times more likely (95% CI, 0.9-4.4, P = .08) to report never using condoms during sexual intercourse and 1.6 times more likely (95% CI, 0.8-3.5, P= .20) to report inconsistent use of condoms (Table 2). More detailed analyses were conducted by stratifying the population according to behaviorally identified sexual preference (Table 2). The association of treatment with protease inhibitors and condom use indicated in the entire study population was present only among MSM, among whom it was strong and significant. Among MSM, those being treated with protease inhibitors were four times more likely (OR = 4.1; 95% CI, 1.4-12.1, P = .009) to report never using condoms during sexual intercourse, and more than three times more likely to report inconsistent condom use (OR = 3.4; 95% CI, 1.2-9.8, P = .021). Treatment with protease inhibitors was the only factor significantly associated with condom use among MSM. Treatment with protease inhibitors was not associated with frequency of intercourse, number of partners, or whether participants reported multiple sex partners, either overall or in any sexual preference group. No factor was significantly associated with condom use among heterosexual men. Among women, lower edu cation cation (kăt'ī`ən), atom or group of atoms carrying a positive charge. The charge results because there are more protons than electrons in the cation. was significantly associated both with never using condoms (OR = 3.9; 95% CI, 1.2-13.3, P = .027) and with inconsistent use (OR = 5.1; 95% CI, 1.6-16.6, P = .006). DISCUSSION We found that treatment with protease inhibitors for HIV infection is not associated with whether a person is sexually active, and among those who are sexually active, treatment with protease inhibitors was not associated with any indicators of high-risk practices among heterosexual men or women. Among MSM, however, treatment with protease inhibitors was strongly associated with failure to use condoms during sexual intercourse. Practitioners and researchers have a perception that each new advance in the diagnosis (from CD4 counts to viral loads) and treatment (from AZT to HAART) of HIV/AIDS HIV/AIDS Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome is accompanied by a recidivism recidivism: see criminology. and unsafe behavior on the part of some HIV-infected persons. The recent surveys of homosexual/bisexual men support this from the perspective of attitudes of these high-risk individuals. (5-7) Our finding that treatment with protease inhibitors was associated with failure to use condoms only among MSM may reflect this. In our study population, MSM were older and more educated than their heterosexual counterparts and were probably more aware of developments in the treatment of HIV. Earlier studies regarding recidivism among MW seropositive seropositive /se·ro·pos·i·tive/ (-poz´i-tiv) showing positive results on serological examination; showing a high level of antibody. se·ro·pos·i·tive adj. or high-risk individuals indicate that the majority of men who purport a desire not to engage in unsafe practices, and report doing so for select periods of time, ultimately revert to former unsafe practices. (10) This is of concern for several reasons. While protease inhibitor com bination therapy can suppress HIV in plasma to undetectable levels, it is uncertain as to what extent reductions in plasma levels correspond to decreased risk of sexual transmission. Recent findings indicate that individuals receiving protease inhibitor combination therapy and having nondetectable HIV levels in plasma may still have the virus present in seminal cells. (11,12) Thus, the potential to sexually transmit HIV may persist despite effective suppression of viral replication Viral replication is the term used by virologists to describe the propagation of biological viruses during the infection process in the target host cells. When used in the strictest sense, the term refers specifically to the amplification of the viral genome . (13) Also, high-risk sexual intercourse may enhance the likelihood of exposure to drug-resistant viral strains. Infection with a drug-resistant strain of HIV may compromise the effectiveness of protease inhibitor combination therapy. (14,15) High-risk sexual intercourse may also result in exposure and acquisition of sexually transmitted diseases Sexually transmitted diseases Infections that are acquired and transmitted by sexual contact. Although virtually any infection may be transmitted during intimate contact, the term sexually transmitted disease is restricted to conditions that are largely . Infection with STDs may facilitate HIV disease progression as well as facilitate transmission of HIV to seronegative seronegative /se·ro·neg·a·tive/ (-neg´ah-tiv) showing negative results on serological examination; showing a lack of antibody. se·ro·neg·a·tive adj. sexual partners. (16-21) The influences that encourage and reinforce high-risk sexual behavior are not well understood among persons treated with protease inhibitors. For instance, in an ongoing study of HIV-infected women, the best predictor of STDs, an objective marker of high-risk sexual intercourse, was the perception that unprotected sexual intercourse did not confer any additional risk for adverse consequences. (22) Thus, inaccurate knowledge, and perceptions of low susceptibility to and severity of adverse outcomes, may militate against mil´i`tate a`gainst´ v. t. 1. To argue against; to cast doubt on; - used in reference to facts which tend to disprove a hypothesis; as, the absence of a correlation of budget deficits with inflation militates against any causal relation the adoption and maintenance of protective behavior such as condom use during sexual intercourse. More indepth studies examining individuals motivations for engaging in high-risk sex high-risk sex Safe sex practices, see there will provide valuable information critical for the design of patient education and sexual risk-reduction interventions. The focus on patients' education and training in sexual risk-reduction skills should not obscure the need to educate clinic staff about potential attitudes or misperceptions that can promote and reinforce sexual risk behavior. Clinic staff need to be alerted to the potential for high-risk sexual behavior as a consequence of protease inhibitor therapy. Moreover, clinic staff need to systematically assess their patients' sexual risk behavior. They also need training to effectively intervene and correct misperceptions, provide accurate information about treatment in a language that is readily understandable, and modify risky attitudes and behavior. Importantly, patient education and risk-reduction interventions need to be integrated into the clinic environment and linked to ongoing clinical activities. The study has limitations. This cross-sectional study required patients to retrospectively recall sexual behavior. For this reason, the period of recall was limited to the past 30 days to minimize inaccurate recall of sexual activity. Likewise, the study relied on patients' recollection of their current medications. Further, although the sample is large, when patients who were not sexually active during the past 30 days are excluded, the sample is reduced. Patients were recruited from the major clinics serving people with HIV in Alabama and a number of smaller clinics, but the sample is not random. The subsample sub·sam·ple n. A sample drawn from a larger sample. tr.v. sub·sam·pled, sub·sam·pling, sub·sam·ples To take a subsample from (a larger sample). of heterosexual men and women was small relative to the sample of MSM, potentially limiting the precision of point estimates. The results reflect a nonurban population, though we believe the findings in other populations suggest that our findings may be generalizable to other regions of the country. Protease inhibitor combination therapy represents one major advance in the clinical management of HIV infection. However, extensive print and electronic media coverage may have inadvertently raised treatment expectations beyond the empirical evidence. Consequently, HIV-infected persons' perceptions of the severity of HIV infection and their susceptibility to other adverse sequelae sequelae Clinical medicine The consequences of a particular condition or therapeutic intervention associated with high-risk sexual intercourse may be diminished and their willingness to engage in high-risk sexual behavior may increase.
TABLE 1
Characteristics of Sexually Active HIV Seropositive Residents of
Nonurban Alabama Attending Clinics Serving HIV-Infected Persons, 1995 to
1997
Sexual Preference (*)
Men-Men Men-Women
(n = 102) (n = 66)
No. (%) No. (%)
White 70 (68.6) 22 (33.3)
Age <30 26 (25.5) 14 (21.2)
Less than high school education 20 (19.6) 32 (48.5)
Income <$500/month 42 (41.2) 35 (53.0)
Medically insured 56 (55.4) 29 (43.9)
Taking protease inhibitors 24 (23.5) 10 (15.2)
Taking AZT 59 (58.4) 34 (52.3)
In a research study 10 (9.8) 1 (1.5)
Have an AIDS-defining condition 33 (32.7) 20 (30.3)
Sexual behavior during past 30 days
Never used condoms 26 (26.0) 7 (10.6)
Inconsistent condom use (<50%) 31 (31.0) 12 (18.2)
Sex [greater than or equal to] 45 (45.0) 29 (43.9)
2 times per week
Only regular partners 71 (71.0) 51 (77.3)
More than 1 partner 24 (24.7) 10 (18.2)
Sexual Preference
(*)
Women All
(n = 67) (n = 235)
No. (%) No. (%)
White 24 (35.8) (P<.001) 116 (49.4)
Age <30 30 (44.8) (P<.01) 70 (29.8)
Less than high school education 31 (46.3) (P<.001) 83 (35.3)
Income <$500/month 39 (58.2) 116 (49.4)
Medically insured 49 (73.1) (P<.01) 134 (57.3)
Taking protease inhibitors 8 (11.9) 42 (17.9)
Taking AZT 33 (50.0) 126 (54.3)
In a research study 76 (10.4) 18 (7.7)
Have an AIDS-defining condition 18 (26.9) 71 (30.3)
Sexual behavior during past 30 days
Never used condoms 18 (26.9) (P<.05) 51 (21.9)
Inconsistent condom use (<50%) 22 (32.8) 65 (27.9)
Sex [greater than or equal to] 38 (56.7) 112 (48.1)
2 times per week
Only regular partners 63 (94.0) (P<.001) 185 (79.4)
More than 1 partner 4 (6.2) (P<.01) 38 (17.5)
(*)Among persons reporting having had anal and/or vaginal intercourse
during the 30 days before interview. Sexual behavior groups are based on
behavior during the past 30 days. Mutually exclusive categories.
Bisexual men are grouped with men who had sex with men (men-men).
Men-women are men who had sex only with women.
TABLE 2
Crude and Adjusted Odds Rations for Protease Inhibitor Therapy and
High-Risk Sexual Behavior Among Sexually Active HIV- Seropositive
Residents of Nonurban Alabama Attending Clinics Serving HIV-Infected
Persons, 1995 to 1997
All (n = 235) Men-Men (n
= 102)
cOR adjOR 95 % CI cOR
Past 30 days
Never used condoms 2.2 2.0 0.9-4.4 4.9
Inconsistent condom use 1.9 1.6 0.8-3.5 4.3
Sex >2 times per week 0.7 0.8 0.4-1.7 1.2
Has nonsteady partners 1.1 1.2 0.5-2.8 0.7
Has >1 partner 1.2 1.4 0.5-3.6 0.6
Men-Men (n = 102) Men-Women (n = 66)
adjOR 95 % CI cOR adjOR
Past 30 days
Never used condoms 4.1 1.4-12.1 0 (*) 0
Inconsistent condom use 3.4 1.2-9.8 0.4 0.4
Sex >2 times per week 1.3 0.5-3.4 0.5 0.5
Has nonsteady partners 0.7 0.2-2.2 1.6 1.8
Has >1 partner 0.7 0.2-2.5 2.6 2.8
Men-Women Women (n = 67)
(n = 66)
95 % CI cOR adjOR 95 % CI
Past 30 days
Never used condoms - 0.9 0.7 0.1-4.7
Inconsistent condom use 0.0-4.0 0.6 0.4 0.1-2.8
Sex >2 times per week 0.1-2.4 0.4 0.4 0.1-2.0
Has nonsteady partners 0.4-9.3 2.7 1.9 0.2-23.3
Has >1 partner 0.3-24.4 2.6 1.8 0.1-22.3
cOR = Crude odds ratios.
adjOR = Odds ratios adjusted for age, education, whether medically
insured, and whether an AIDS-defining condition was present.
CI = Confidence interval.
(*)Ten of the 66 men were taking protease inhibitors; all of the 10 had
used condoms at least occasionally (P = .58).
Number in bold type are statistically significant at P=.05.
References (1.) Hammer SM, Squires KE, Hughes MD, et al: A controlled trial controlled trial Clinical research A clinical study in which one group of participants receives an experimental drug while the other receives either a placebo or an approved–'gold standard' therapy. See Blinding, Double-blinded. of two nucleoside analogues Nucleoside analogues The first group of effective anti-retroviral medications. They work by interfering with the AIDS virus' synthesis of DNA. Mentioned in: AIDS plus indinavir indinavir /in·di·na·vir/ (in-di´nah-vir) an HIV protease inhibitor that causes formation of immature, noninfectious viral particles; used as the sulfate salt in the treatment of HIV infection and AIDS. in persons with human immunodeficiency virus human immunodeficiency virus n. HIV. Human immunodeficiency virus (HIV) A transmissible retrovirus that causes AIDS in humans. infection and CD4 cell CD4 cell CD4+ lymphocyte A circulating T cell with a 'helper' phenotype; in AIDS Pts, the levels of CD4+ cells is a crude indicator of immune status and susceptibility to certain AIDS-related conditions; these Pts may suffer KS as CD4+ cells fall below 0. counts of 200 per cubic millimeter Noun 1. cubic millimeter - a metric measure of volume or capacity equal to a cube 1 millimeter on each edge cubic millimetre metric capacity unit - a capacity unit defined in metric terms or less. N Engl J Med 1997; 337:725-733 (2.) Deeks SG, Smith M, Holodniy M, et al: HIV-1 protease HIV-1 protease is an aspartyl protease that is essential for the life-cycle of HIV. Inhibition of this protease prevents maturation of HIV particles. As such, many drugs have been developed, so-called protease inhibitors, that target this enzyme. inhibitors: a review for clinicians. Jama 1997; 276:146-154 (3.) Palella FJ Jr, Delaney KM, Moorman AC, et al: Declining morbidity and mortality Morbidity and Mortality can refer to:
(4.) Keiser P, Kvanli MB, Turner D, et al: Protease inhibitor-based therapy is associated with decreased HIV-related health care costs in men treated at a Veterans Administration Hospital. J Acquir Immune Defic Syndr Hum Retrovirol 1999; 20:28-33 (5.) Dilley JW, Woods WJ, McFarland W: Are advances in treatment changing views about high-risk sex? N Engl J Med 1997; 337:501-502 (6.) Kelly JA, Hoffman RG, Rompa D, et al: Protease inhibitor combination therapies and perceptions of gay men regarding AIDS severity and the need to maintain safer sex. AIDS 1998; 12:F91-F95 (7.) Kravcik S, Victor G, Houston S, et al: Effect of antiretroviral therapy and viral load on the perceived risk of HIV transmission and the need for safer sexual practices. J Acquir Immune Defic Syndr Hum Retrovirol 1998; 19:124-129 (8.) Beltrami JF, Vermund SH, Fawal HJ, et al: Increasing HIV transmission in the South: AIDS and HIV in nonurban Alabama. South Med J 1999, 92:677-683 (9.) Krauth MR, St. Lawrence JS, Kelly JA: Reliability of retrospective assessments of sexual HIV risk behavior: a comparison of biweekly, three-month, and twelve-month self-reports. AIDS Educ Prev 1991; 3:207-214 (10.) De Wit JBF JBF Just Between Friends (consignment shops) JBF Journal of Banking and Finance , van Griensven GJP GJP Good Job Partner GJP Gemensamma Jordbrukspolitiken (Swedish: Common Agricultural Policy / European Commission, aka: CAP) : Time from safe to unsafe sexual behavior among homosexual men. AIDS 1994; 8:123-126 (11.) Zhang H, Dornadula G, Beumont M, et al: Human immunodeficiency virus type 1 in the semen of men receiving highly active antiretroviral therapy. N Engl J Med 1998; 339:1803-1809 (12.) Albrecht H, del Rio Del Rio (rē`ō), city (1990 pop. 30,705), seat of Val Verde co., W Tex., on the Rio Grande opposite Ciudad Acuña, Mexico; founded 1868, inc. 1911. C, Rimland Rimland is the maritime fringe of a country or continent; in particular, the densely populated western, southern, and eastern edges of the Eurasian continent. According to Nicholas John Spykman, who revisited Halford Mackinder's concepts of geopolitics, the Rimland is that D: Seminal viral loads. AIDS 1998; 12:333-334 (13.) Haase AT, Schacker TW: Potential for the transmission of HIV-1 despite highly active antiretroviral therapy. N Engl J Med 1998; 339:1846-1847 (14.) Hecht FM, Grant RM, Petropoulos CJ, et al: Sexual transmission of an HIV-1 variant resistant to multiple reversetranscriptase and protease inhibitors. N Engl J Med 1998; 339:307-311 (15.) Cohen cohen or kohen (Hebrew: “priest”) Jewish priest descended from Zadok (a descendant of Aaron), priest at the First Temple of Jerusalem. The biblical priesthood was hereditary and male. OJ, Fauci AS: Transmission of multidrug-resistant human immunodeficiency virus, the wake up call. N Engl J Med 1998; 339:341-343 (16.) Cohen MS: Sexually transmitted diseases enhance HIV transmission: no longer a hypothesis. Lancet 1998; 351(suppl 3):5-7 (17.) Kreiss JK, Willerford DM, Hensel M, et al: Association between cervical inflammation and cervical shedding of human immunodeficiency virus DNA DNA: see nucleic acid. DNA or deoxyribonucleic acid One of two types of nucleic acid (the other is RNA); a complex organic compound found in all living cells and many viruses. It is the chemical substance of genes. . J Infect Dis 1994; 170:1597-1601 (18.) Ghys PD, Frasen K, Diallo MO, et al: The associations between cervicovaginal HIV shedding, sexually transmitted diseases and immunosuppression immunosuppression Suppression of immunity with drugs, usually to prevent rejection of an organ transplant. Its aim is to allow the recipient to accept the organ permanently with no unpleasant side effects. in female sex workers in Abidjan, Cote d'Ivoire. AIDS 1997; 11:85-93 (19.) Cohen MS, Hoffman IF, Royce RA, et al: Reduction of concentration of HIV-1 in semen after treatment of urethritis Urethritis Definition Urethritis is an inflammation of the urethra that is usually caused by an infection. Description The urethra is the canal that moves urine from the bladder to the outside of the body. : implications for prevention of sexual transmission of HIV-1. Lancet 1997; 349:1868-1873 (20.) Atkins MC, Carlin car·line or car·lin n. Scots A woman, especially an old one. [Middle English kerling, from Old Norse, from karl, man.] EM, Emery VC, et al: Fluctuations of HIV load in semen of HIV positive patients with newly acquired sexually transmitted diseases. BMJ BMJ n abbr (= British Medical Journal) → vom BMA herausgegebene Zeitschrift 1996; 313:341-342 (21.) Wasserheit JN: Epidemiological synergy: interrelationships between human immunodeficiency virus infection and other sexually transmitted diseases. Sex Transm Dis 1992; 19:61-77 (22.) DiClemente RJ, Wingood GM, MikHail I, et al: Women living with HIV: cognitive, psychosocial, and behaviorally related sexual risk factors. Presented at: Annual Meeting of the American Psychological Association The American Psychological Association (APA) is a professional organization representing psychology in the US. Description and history The association has around 150,000 members and an annual budget of around $70m. , San Francisco San Francisco (săn frănsĭs`kō), city (1990 pop. 723,959), coextensive with San Francisco co., W Calif., on the tip of a peninsula between the Pacific Ocean and San Francisco Bay, which are connected by the strait known as the Golden , Calif, August 14-18, 1998 RELATED ARTICLE: KEY POINTS * Relatively little empirical data has examined the impact of protease inhibitor combination therapy on an individual's attitudes and sexual behavior. * Treatment with protease inhibitors was not associated with being sexually active in the past month in either univariate analysis or when adjusted for confounders. * Treatment with protease inhibitors was not associated with whether a person was sexually active or with high-risk practices among sexually active heterosexual individuals. * Among men having sex with men, those being treated with protease inhibitors were four times more likely to report never using condoms during sexual intercourse, and more than three times more likely to report inconsistent condom use. * Clinicians need to be alerted to the potential for high-risk sexual behavior as a consequence of protease inhibitor therapy, systematically assess their patients' sexual risk behaviors and correct misperceptions, provide accurate information about treatment in a language that is readily understandable, and modify risky attitudes and behaviors. From the Emory University Emory University (ĕm`ərē), near Atlanta, Ga.; coeducational; United Methodist; chartered as Emory College 1836, opened 1837 at Oxford. It became Emory Univ. in 1915 and in 1919 moved to Atlanta. , Rollins School of Public Health The Rollins School of Public Health (RSPH) is the public health school of Emory University. Founded in 1990, RSPH has more than 850 students pursuing master's degrees (MPH/MSPH) and over 100 students pursuing doctorate degrees (PhD). and Emory/Atlanta Center for AIDS Research, Atlanta, Ga; University of Alabama at Birmingham, School of Public Health; and the Division of HIV/AIDS, Centers for Disease Control and Prevention Centers for Disease Control and Prevention (CDC), agency of the U.S. Public Health Service since 1973, with headquarters in Atlanta; it was established in 1946 as the Communicable Disease Center. , Atlanta, Ga. Supported by the Centers for Disease Control and Prevention (grant U64/CCU413433). Reprint requests to Ralph J DiClemente, PhD, Emory University, Rollins School of Public Health, Department of Behavioral Sciences behavioral sciences, n.pl those sciences devoted to the study of human and animal behavior. and Health Education, 1518 Clifton Rd. NE, Suite 520, Atlanta, GA 30322. |
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