Human Immunodeficiency Virus Infection in a Rural Community in the United States

Tedd V. Ellerbrock1 , Sandra Chamblee2, Timothy J. Bush1, Johnny W. Johnson2, Bryan J. Marsh3, Pam Lowell4, Robert J. Trenschel5, C. Fordham von Reyn3, Linda S. Johnson1 and C. Robert Horsburgh, Jr.6

1 Division of HIV/AIDS Prevention, Surveillance, and Epidemiology, National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA.
2 Glades Health Initiative, Inc., Belle Glade, FL.
3 Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
4 Florida Department of Health, Tallahassee, FL.
5 Palm Beach County Health Department, Belle Glade, FL.
6 Department of Epidemiology, School of Public Health, Boston University, Boston, MA.

Received for publication September 23, 2003; accepted for publication April 6, 2004.


    ABSTRACT
 TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
In 1986, a population-based survey of human immunodeficiency virus (HIV) infection in a rural Florida community showed that HIV prevalence was 28/877 (3.2%, 95% confidence interval (CI): 2.0, 4.4). In 1998–2000, the authors performed a second population-based survey in this community and a case-control study to determine whether HIV prevalence and risk factors had changed. After 609 addresses had been randomly selected for the survey, 516 (85%) residents were enrolled, and 447 (73%) were tested for HIV. HIV prevalence was 7/447 (1.6%, 95% CI: 0.4, 2.7) in western Palm Beach County and 5/286 (1.7%, 95% CI: 0.2, 3.3) in Belle Glade (p = 0.2 in comparison with 1986). Independent predictors of HIV infection in both 1986 and 1998–2000 were having a history of sexually transmitted disease, number of sex partners, and exchanging money or drugs for sex. A history of having sex with men was a risk factor among men in 1986 but not in 1998–2000; residence in specific neighborhoods was a risk factor in 1998–2000 but not in 1986. The authors conclude that heterosexually acquired HIV infection did not spread throughout the community between 1986 and 1998 but persisted at a low level in discrete neighborhoods. Interventions targeting HIV-endemic neighborhoods will be needed to further reduce HIV prevalence in this area.

acquired immunodeficiency syndrome; crack cocaine; HIV; HIV infections; risk factors; sexual behavior; sexually transmitted diseases

Abbreviations: Abbreviations: AIDS, acquired immunodeficiency syndrome; CI, confidence interval; HIV, human immunodeficiency virus.


    INTRODUCTION
 TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
An increasing proportion of persons with human immunodeficiency virus (HIV) infection in the United States are residents of the South (1, 2). In addition, the southern region of the United States accounts for most cases of acquired immunodeficiency syndrome (AIDS) among persons residing in rural areas (Centers for Disease Control and Prevention, unpublished data, 2002). In previous reports about AIDS in the rural South, most of those infected were Black, of low socioeconomic status, and at risk of acquiring HIV through sexual contact (37). In women, HIV infection has been associated with use of crack cocaine and the resultant exchange of sex for drugs (8, 9). Moreover, a recent investigation of a cluster of HIV cases in rural Mississippi found that the presence of sexually transmitted diseases and multiple sex partners in small-town sex networks provides a setting for HIV transmission (10).

The economy of western Palm Beach County, Florida, is predominantly agricultural, with sugar cane being the major crop. In 1986, a population-based study in Belle Glade, a rural community in western Palm Beach County, found that the prevalence of HIV infection was 28/877 (3.2 percent, 95 percent confidence interval (CI): 2.0, 4.4) (11). Independent predictors of HIV infection in men included a history of sexually transmitted diseases and sex with men, while independent predictors in women included a positive rapid plasma reagin test and microhemagglutination-Treponema pallidum test and having a male sex partner known to engage in sex with prostitutes. This was the first community in the United States in which heterosexual contact was identified as the predominant route of HIV transmission.

Beginning in 1987, an HIV prevention program was implemented in this community by the Palm Beach County Health Department, the Florida Department of Health, and the Centers for Disease Control and Prevention, in collaboration with local community-based organizations (12). Therefore, in 1998–2000, we performed a second population-based survey and a case-control study to determine HIV prevalence and risk factors and to compare them with the results from the 1986 survey.


    MATERIALS AND METHODS
 TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Population-based survey
During the period January 1, 1998–September 30, 2000, a population-based survey of HIV infection was completed in western Palm Beach County, Florida. Western Palm Beach County was defined as the area included in postal zip codes 33430, 33438, 33476, and 33493. The protocol for the survey and the selection process for participants were essentially the same as those used for the population-based survey of HIV infection in the area during 1986 (11). To recruit participants for the survey, we randomly selected 800 addresses from water meter records by means of a computer program. (Piped water is the only source of water for households in the area, because the high water table makes well water nonpotable.) Of the 800 addresses selected, 81 were the addresses of businesses or vacant lots and 110 had no occupants, leaving 609 that could be used to select participants. The 12 local neighborhoods of Belle Glade were defined in the 1980 US Census and were the same as those used for the 1986 survey (11); the area of western Palm Beach County in the above four zip codes but outside of Belle Glade was designated neighborhood 13.

The protocol was approved by the human subjects committees of the Florida Department of Health, Emory University, Boston University, Dartmouth Medical School, and the Centers for Disease Control and Prevention. At addresses that were households, one person was selected by means of a random selection table. Houses in which no one was found were visited at least six times during the survey period, including at least twice in the evening or on the weekend, before being categorized as unoccupied. After giving informed consent, each participant was administered a questionnaire in English, Spanish, or Haitian Creole by a trained interviewer, received pretest counseling, had blood drawn for HIV and syphilis serologic analysis, and was given a tuberculin skin test. Children aged 12–17 years and their parents or legal guardians were asked to sign consent forms for the survey, and these adolescents were also asked to sign a second consent form for HIV testing and an assent form. Parents of children aged ≤11 years were asked to sign consent forms for a pediatric questionnaire and HIV testing, and children aged 8–11 years were asked to sign consent and assent forms. Children under the age of 1 year were excluded from the survey, as were persons with a history of blistering upon prior tuberculin skin testing.

Blood specimens were tested for HIV by means of enzyme immunoassay, and positive results on enzyme immunoassay were confirmed by Western blot. Serologic testing for syphilis included the rapid plasma reagin test and either the microhemagglutination assay or the fluorescent treponemal antibody-absorption test. HIV test results were given with posttest counseling 2–3 weeks after blood was obtained. Participants who tested positive for HIV or syphilis were referred to the local health clinic or private practitioners for treatment and care.

Case-control study
All HIV-infected residents of the community were also invited to enroll in a case-control study and were evaluated according to the same protocol as that used in the population-based study. These self-identified HIV-infected participants were identified by advertising in local media and by contacting local HIV/AIDS service organizations and care providers. Most of these participants were referred to the study staff from the local health clinic, by private practitioners, or by local HIV service agencies. To examine risk factors for HIV infection, we combined these 210 persons with the seven HIV-infected persons identified in the survey and compared them with the HIV-uninfected persons in the population-based survey. Because there were no cases of HIV infection among children, the case-control analysis was restricted to adults.

Statistical methods
Statistical associations between HIV serostatus and categorical variables were tested by means of the chi-squared test or Fisher’s exact test. Ninety-five percent confidence intervals were calculated using a normal approximation of the binomial distribution. All tests of statistical significance were two-sided. Age and gender adjustment of HIV rates was carried out using the population distribution of the 2000 US Census (13). Associations with continuous variables were analyzed by means of the Wilcoxon rank-sum test. Variables that were associated with HIV infection were then analyzed by stepwise logistic regression using SAS, version 8.0 (SAS Institute, Inc., Cary, North Carolina). Attributable fractions and population attributable fractions were calculated as described by Rothman and Greenland (14), substituting odds ratios for risk ratios.


    RESULTS
 TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Population-based survey
At the 609 usable addresses identified, 92 residents (15 percent) declined to participate and one (0.2 percent) was ineligible because of a history of a blistering reaction to tuberculin skin testing. In addition, 69 residents (11 percent) consented only to being interviewed. As a result, residents at 516 (85 percent) of the 609 addresses were interviewed, and 447 (73 percent) residents were fully enrolled. In the survey, the 69 participants who were only interviewed were similar to the 447 who were fully enrolled in terms of sex, age, current employment, annual income under $10,000, and birth in Haiti, as well as history of transfusion, crack use, any sexually transmitted disease, and exchanging sex for money or drugs. However, the participants who were only interviewed had more lifetime sex partners (5 vs. 3; p = 0.03) and were more likely to be Black but not Haitian (72 percent vs. 59 percent; p = 0.03). The demographic characteristics of participants in the population-based survey and respondents to the 2000 US Census are shown in table 1. Survey participants were less likely than the Census population to be male and less likely to be children under 12 years of age.


View this table:
[in this window]
[in a new window]
 
TABLE 1. Sociodemographic characteristics of participants in the 1998–2000 population-based survey and the 2000 US Census population, western Palm Beach County, Florida
 
HIV prevalence among 1998–2000 survey participants is shown in table 2. The seven HIV-infected residents identified in the population-based survey were aged 28–64 years, with a median age of 46 years; five were men, all were Black, and three were Haitian. HIV prevalence was 7/447 (1.6 percent, 95 percent CI: 0.4, 2.7) in western Palm Beach County and 5/286 (1.7 percent, 95 percent CI: 0.2, 3.3) in the municipality of Belle Glade during 1998–2000 (table 2; p = 0.2 in comparison with the 1986 survey). The decline in prevalence in Belle Glade was more marked among women (12/436 in 1986 vs. 1/161 in 1998–2000; p = 0.11) than among men (16/441 in 1986 vs. 4/124 in 1998–2000; p = 0.81). Age- and gender-adjusted prevalences in western Palm Beach County and Belle Glade were 1.5 (95 percent CI: 0.4, 2.5) and 1.5 (95 percent CI: 0.2, 2.9), respectively.


View this table:
[in this window]
[in a new window]
 
TABLE 2. Prevalence of human immunodeficiency virus among participants in the 1986 and 1998–2000 surveys in western Palm Beach County, Florida, by gender, race, age, and neighborhood
 
Case-control study
Results from univariate analysis of the risk factor distribution in cases and controls are shown in table 3. HIV status was statistically significantly associated with race, birth in the United States, income, education, employment, history of farm work, neighborhood, sexual activity, crack cocaine use, intravenous drug use, and history of blood transfusion prior to 1985 but not with male homosexual activity. Because of significant interaction between gender and infection risk, we constructed separate multivariate models for adult males and females to determine independent predictors of HIV infection. The results are presented in table 4.


View this table:
[in this window]
[in a new window]
 
TABLE 3. Sociodemographic characteristics of human immunodeficiency virus (HIV)-infected adults (cases) and HIV-uninfected adults (controls) in western Palm Beach County, Florida, 1998–2000
 

View this table:
[in this window]
[in a new window]
 
TABLE 4. Independent predictors of human immunodeficiency virus infection in multivariate logistic regression analysis among adults in the 1998–2000 survey, western Palm Beach County, Florida
 

    DISCUSSION
 TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
A population-based survey of HIV infection was performed in 1986 in rural western Palm Beach County to investigate the hypothesis that insects could serve as vectors for HIV transmission. The results of that survey dispelled the notion of vector-borne HIV transmission but confirmed the importance of heterosexual contact in HIV transmission (11). After the 1986 survey revealed an HIV seroprevalence of 3.2 percent, an HIV prevention program was instituted in the area. This program provided community-wide education about HIV infection, and condoms were widely distributed. The present population-based survey revealed an HIV prevalence of 1.6 percent in western Palm Beach County and 1.7 percent in the municipality of Belle Glade during 1998–2000. We conclude that the prevalence of HIV infection did not increase during the interval between the two studies and may have decreased.

Interpreting changes in HIV prevalence over time requires estimation of in- and out-migration of persons with HIV infection, as well as new acquisition of HIV infection and deaths among persons with HIV. When mechanized harvesting of sugar cane was introduced in the late 1980s, a decline in the importation of non-US-born laborers (largely Caribbean) began, and few such workers have come to the area since the early 1990s. Such persons were not likely to have imported HIV infection from outside the area, since they were screened for HIV infection prior to coming to the United States and were denied entry if found to be HIV-infected. In addition, the lack of economic resources in this population makes it unlikely that HIV-infected persons moved away from the area to obtain medical care or social services. Moreover, between 1986 and 1998, the overall number of persons living in the area remained stable (13). Therefore, the observed changes are not likely to have been caused by in- or out-migration.

A persisting cohort of HIV-infected persons from 1986 is suggested by the greater age of HIV-infected persons in 1998–2000 as compared with those studied in 1986. However, it is clear that the HIV epidemic in this area began well before 1986, since a large number of AIDS cases had already appeared by that time. The survival of those persons identified as having HIV in the 1986 survey can be expected to be similar to that of HIV-infected persons from other areas with high AIDS rates in 1986; such persons had only 42–45 percent survival through 1995 (15). Survival to 1998–2000 among persons with HIV infection in 1986 in western Palm Beach County is likely to have been substantially lower than 45 percent, both because 4 additional years had elapsed and because new treatments for HIV and opportunistic infections were not available in that area as early as they were in major urban centers. In addition, the presence of HIV infection among persons as young as age 20 years in our survey suggests that new infections occurred in the intervening period. Therefore, we conclude that HIV transmission also contributed to the observed infection prevalence.

For the results of a population-based survey to be reliable and generalizable, a high participation rate is essential. In this survey, 85 percent of randomly selected residents were interviewed, and 73 percent were tested for HIV. In two previous population-based surveys of HIV infection in the United States, the reported participation rates were 84 percent and 82 percent, while 80 percent and 71 percent of the participants, respectively, were tested for HIV (16, 17). The high participation rate in this survey was attributable to the presence of the Glades Health Initiative, Inc., a community-based organization. Prior to the survey, a pilot study carried out in western Palm Beach County suggested that a high participation rate could not be achieved in the survey without active community involvement (12). Thus, the Glades Health Initiative was created to give the community fiscal and administrative control over the survey and to ensure widespread community acceptance and participation (12).

Despite this high participation rate, participants in the 1998–2000 survey were not similar to residents of western Palm Beach County in the 2000 US Census with respect to age or gender. Fifty-three percent of the population in the Census was male, as compared with 41 percent of those enrolled in the survey, and 23 percent of the Census population was under 12 years of age, as compared with 10 percent of those in the survey (18). The lower proportion of children was an anticipated result of the sampling strategy used, because children are not randomly distributed among households. Underenrollment of children is not likely to have introduced bias, since the reasons for underenrollment were not related to HIV status. Age-adjusted HIV prevalence rates among children were actually slightly lower than the crude values, so the observed prevalence of HIV infection may have been an overestimate.

Underenrollment of men in the population-based survey probably resulted from the absence of male migrant farmworkers from the area for prolonged periods of time, such that, despite our making at least six visits to each household during various seasons and on evenings and weekends, they were less likely to be offered participation in the survey. Western Palm Beach County is at the southern terminus of the East Coast migrant farmworker stream, and most farmworkers in western Palm Beach County have permanent residences in the area, leaving each spring to harvest crops elsewhere and returning to the area after the harvest. In a study of largely male farmworkers in a neighboring community, 5 percent of participants were infected with HIV (19). If men who were not reached by our survey had such a rate of HIV infection, little effect on the estimated prevalence would have been seen. If, on the other hand, men who spend long periods of time away from home have a substantially higher prevalence of HIV infection, the rate we observed may have been an underestimate.

Selection of cases for the case-control study may also have led to bias in that HIV-infected persons who did not know they were infected with HIV could not have been selected as cases. By applying the 1998–2000 HIV prevalence estimate to the population of western Palm Beach County in 2000, we estimated that there were between 140 and 870 HIV-infected persons in the area. If persons who do not know that they are HIV-infected have a different risk profile than those who do, the case-control analysis we performed may have failed to identify those risk factors.

Results from these two cross-sectional surveys covering a 14-year period provide us with a unique opportunity to learn about the natural history of the HIV epidemic in the rural United States. HIV prevalence did not continue to increase during the interval between the two surveys, and it probably decreased. Although the finding was of borderline statistical significance, the relative decline in HIV prevalence was more marked among women than among men. HIV prevention efforts in the area were not specifically targeted towards women, but it was recognized early in the AIDS epidemic that HIV transmission was a particular problem among pregnant women (9). This awareness may have resulted in a greater effect of prevention programs in women than in men. Thus, while the importance of community-wide prevention programs in limiting the spread of the epidemic cannot be conclusively established, it is likely that they contributed to slowing its growth.

In 1998–2000, many HIV risk activities were significantly associated with HIV infection, including heterosexual activity, intravenous drug use, and receipt of blood transfusions between 1977 and 1985. However, intravenous drug use and receipt of transfusions were uncommon, and only activities related to heterosexual HIV transmission were retained in the multivariate model. We conclude that HIV infection has remained a heterosexually transmitted infection in this community, facilitated by other sexually transmitted infections and crack cocaine use. Among men in 1986, a history of having sex with men was significantly associated with HIV infection in multivariate analysis, but by 1998–2000 this association was no longer statistically significant. These results are similar to those from urban areas, where HIV infection is endemic among marginalized populations and is strongly associated with syphilis and other sexually transmitted diseases (18, 2023). In contrast to the situation in urban areas, the contribution of intravenous drug use to HIV transmission in our population was minimal. Thus, essentially all transmission in this community can be attributed to heterosexual activity.

Residence in specific neighborhoods in the community also emerged as an independent predictor of HIV infection in 1998–2000. These high-risk neighborhoods are areas where prostitution and crack cocaine use occur. The persistence of neighborhood as an independent risk factor for HIV infection suggests that this variable may be a surrogate for the risk that an individual’s sex partners are HIV-infected. This result indicates that HIV infection evolves over time into a disease that persists in focal geographic areas without spreading to the community at large.

Analysis of the attributable fractions for HIV infection for factors that were retained in the multivariate model demonstrates that the fraction of the exposed cases that would not have occurred if the exposure had not occurred is high for sexual behaviors. On the other hand, the population attributable fractions are lower for the sexual behaviors, reflecting the smaller fraction of the total number of cases that would not have occurred had the exposure not occurred, since the exposures were infrequent in the population. Nonetheless, a substantial proportion of the risk for HIV can be attributed to modifiable factors such as sexually transmitted diseases other than HIV and number of sex partners. In western Palm Beach County, the Glades Health Initiative has initiated a street outreach campaign in the highest-risk neighborhoods to provide HIV testing and counseling and risk reduction counseling for uninfected persons whose sexual activities place them at high risk for HIV and other sexually transmitted infections. Such programs have been shown to have a high level of acceptability among rural minority populations (24, 25). Further reduction in HIV prevalence may require a better understanding of the social networks that exist in these endemic neighborhoods (26, 27) and ethnographic studies focusing on the identification of factors affecting heterosexual HIV transmission (28).


    ACKNOWLEDGMENTS
 
Support for this investigation was provided by the Centers for Disease Control and Prevention (grants U64/CCU118611 and U64/CCU406791).

The authors acknowledge the staffs of the Glades Health Initiative, Inc., the C. L. Brumback Health Center, and Neighbors Organized for Adequate Housing (all located in Belle Glade, Florida) for their assistance in performing the survey.


    NOTES
 
Reprint requests to Dr. Tedd V. Ellerbrock, Global AIDS Program, Centers for Disease Control and Prevention, 1600 Clifton Road NE, Mailstop E-04, Atlanta, GA 30333 (e-mail: tve1{at}cdc.gov). Back


    REFERENCES
 TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

  1. Karon JM, Fleming PL, Steketee RW, et al. HIV in the United States at the turn of the century: an epidemic in transition. Am J Public Health 2001;91:1060–8.[Abstract]
  2. Update: AIDS—United States, 2000. MMWR Morb Mortal Wkly Rep 2002;51:592–7.[Medline]
  3. Risks of HIV infection among persons residing in rural areas and small cities—selected sites, southern United States, 1995–1996. MMWR Morb Mortal Wkly Rep 1998;47:974–8.[Medline]
  4. Verghese A, Berk SL, Sarubbi F. Urbs in rure: human immunodeficiency virus infection in rural Tennessee. J Infect Dis 1989;160:1051–5.[ISI][Medline]
  5. Rumley RL, Shappley JC, Waivers LE, et al. AIDS in rural eastern North Carolina—patient migration: a rural AIDS burden. AIDS 1991;5:1373–8.[ISI][Medline]
  6. Berry DE. The emerging epidemiology of rural AIDS. J Rural Health 1993;293:293–304.
  7. Roberts NE, Collmer JE, Wispelwey B, et al. Urbs in rure redux: changing risk factors for rural HIV infection. Am J Med Sci 1997;314:3–10.[CrossRef][ISI][Medline]
  8. Whyte BM, Carr JC. Comparison of AIDS in women in rural and urban Georgia. South Med J 1992;85:571–8.[ISI][Medline]
  9. Ellerbrock TV, Harrington PE, Bush TJ, et al. Risk of human immunodeficiency virus infection among pregnant crack cocaine users in a rural community. Obstet Gynecol 1995;86:400–4.[Abstract/Free Full Text]
  10. Cluster of HIV-infected adolescents and young adults—Mississippi, 1999. MMWR Morb Mortal Wkly Rep 2000;49:861–4.[Medline]
  11. Castro KG, Lieb S, Jaffe H, et al. Transmission of HIV in Belle Glade, Florida: lessons for other communities in the United States. Science 1988;239:193–7.[ISI][Medline]
  12. Stratford D, Chamblee S, Ellerbrock TV, et al. Integration of a participatory research strategy into a rural health survey. J Gen Intern Med 2003;18:586–8.[CrossRef][ISI][Medline]
  13. US Census Bureau. American FactFinder. Washington, DC: Bureau of the Census, US Department of Commerce, 2003. (World Wide Web URL: http://factfinder.census.gov/servlet/BasicFactsServlet).
  14. Rothman KR, Greenland S. Modern epidemiology. 2nd ed. Philadelphia, PA: Lippincott, Williams and Wilkins, 1998:295–7.
  15. Koblin BA, van Benthem BH, Buchbinder SP, et al. Long-term survival after infection with human immunodeficiency virus type 1 (HIV-1) among homosexual men in hepatitis B vaccine trial cohorts in Amsterdam, New York City, and San Francisco, 1978–1995. Am J Epidemiol 1999;150:1026–30.[Abstract]
  16. McQuillan GM, Ezzati-Rice TM, Siller AB, et al. Risk behavior and correlates of risk for HIV infection in the Dallas County household HIV survey. Am J Public Health 1994;84:747–53.[Abstract]
  17. McQuillan GM, Khare M, Karon JM, et al. Update on the seroepidemiology of human immunodeficiency virus in the United States household population: NHANES III, 1988–1994. J Acquir Immune Defic Syndr 1997;14:355–60.
  18. Fleming DT, Levine WC, Trees DL, et al. Syphilis in Atlanta during an era of declining incidence. Sex Transm Dis 2000;27:68–73.[ISI][Medline]
  19. Villarino ME, Geiter LJ, Schulte JM, et al. Purified protein derivative tuberculin and delayed-type hypersensitivity skin testing in migrant farm workers at risk for tuberculosis and HIV coinfection. AIDS 1994;8:477–81.[ISI][Medline]
  20. St Louis ME, Farley TA, Aral SO. Untangling the persistence of syphilis in the South. Sex Transm Dis 1996;23:1–4.[ISI][Medline]
  21. Quinn TC, Cannon RO, Glasser D, et al. The association of syphilis with risk of human immunodeficiency virus infection in patients attending sexually transmitted disease clinics. Arch Intern Med 1990;150:1297–302.[Abstract]
  22. Schoenbach VJ, Landis SE, Weber DJ, et al. HIV seroprevalence in sexually transmitted disease clients in a low-prevalence southern state. Ann Epidemiol 1993;3:281–8.[Medline]
  23. Schoenbaum EE, Webber MP, Vermund S, et al. HIV antibody in persons screened for syphilis: prevalence in a New York City emergency room and primary care clinics. Sex Transm Dis 1990;17:190–3.[ISI][Medline]
  24. Brown EJ. Recruitment feasibility and HIV prevention intervention acceptability among rural north Florida blacks. J Community Health Nurs 2002;19:147–60.[Medline]
  25. Brown EJ, Brown JS. HIV prevention outreach in black communities of three rural north Florida counties. Public Health Nurs 2003;20:204–10.[ISI][Medline]
  26. Rothenberg R, Kimbrough L, Lewis-Hardy R, et al. Social network methods for endemic foci of syphilis: a pilot project. Sex Transm Dis 2000;27:12–18.[ISI][Medline]
  27. Rothenberg RB, Wasserheit JN, St Louis ME, et al. The effect of treating sexually transmitted diseases on the transmission of HIV in dually infected persons: a clinic-based estimate. Sex Transm Dis 2000;27:411–16.[ISI][Medline]
  28. Adimora AA, Schoenbach VJ, Martinson FE, et al. Concurrent partnerships among rural African Americans with recently reported heterosexually transmitted HIV infection. J Acquir Immune Defic Syndr 2003;34:423–9.[Medline]




This Article
Abstract
FREE Full Text (PDF)
Alert me when this article is cited
Alert me if a correction is posted
Services
Email this article to a friend
Similar articles in this journal
Similar articles in ISI Web of Science
Similar articles in PubMed
Alert me to new issues of the journal
Add to My Personal Archive
Download to citation manager
Disclaimer
Request Permissions
Google Scholar
Articles by Ellerbrock, T. V.
Articles by Horsburgh, C. R.
PubMed
PubMed Citation
Articles by Ellerbrock, T. V.
Articles by Horsburgh, C. R., Jr.