Aedes aegypti, Aedes albopictus, and Dengue virus in Harris county: An estimate of risk

Recent outbreaks of dengue fever (DF) along the United States/Mexico border, coupled with the high number of reported cases in Mexico suggest that there is the possibility for DF emergence in Houston, Texas1,2. To determine the presence of DF, populations of Aedes aegypti and Aedes albopictus were identified and tested for dengue virus. Maps were created to identify "hot spots" (Figure 1) based on historical data on Ae. aegypti and Ae. albopictus, demographic information, and locations of human cases of dengue fever. BG Sentinel Traps®, in conjunction with BG Lure® attractant, octanol and dry ice, were used to collect mosquitoes, which were then tested for presence of dengue virus using ELISA techniques. All samples tested were negative for dengue virus (DV). Survival of DV ultimately comes down to whether or not it will be vectored by a mosquito to a susceptible human host. The presence of infected humans and contact with the mosquito vectors are two critical factors necessary in the establishment of DF. Historical records indicate the presence of Ae. aegypti and Ae. albopictus in Harris County, which would support localized dengue transmission if infected individuals are present.^ (1) Brunkard JM, Robles-Lopez JL, Ramirez J, Cifuentes E, Rothenberg SJ, Hunsperger EA, Moore CG, Brussolo RM, Villarreal NA, Haddad BM, 2007. Dengue fever seroprevalence and risk factors, Texas-Mexico border, 2004. Emerg Infect Dis 13: 1477-1483. (2) Ramos MM, Mohammed H, Zielinski-Gutierrez E, Hayden MH, Lopez JL, Fournier M, Trujillo AR, Burton R, Brunkard JM, Anaya-Lopez L, Banicki AA, Morales PK, Smith B, Munoz JL, Waterman SH, 2008. Epidemic dengue and dengue hemorrhagic fever at the Texas-Mexico Border: results of a household-based seroepidemiologic survey, December 2005. Am J Trop Med Hyg 78: 364-369.^

Dengue risk factor distribution in Harris County, Texas

As an important emerging arboviral disease in Texas and throughout the world, dengue fever has the potential to make a re-emergence in the Harris County/Houston metropolitan area. Harris County has seen dengue epidemics in the past. The area has a competent vector, Aedes aegypti, capable of transmission of the virus should it be introduced. It is important to examine areas of highest risk for dengue emergence and transmission in Harris County so that surveillance and educational programs can be properly implemented. This study uses mapping software to visually represent risk factor information with areas of known Ae. aegypti populations. This study focused on known demographic risk factors such as race/ethnicity, place of birth, gender as well as socioeconomic status represented by educational attainment and income. This study found that there are several areas, particularly in central Harris County that are at particular risk for dengue transmission. The findings support the hypothesis that in areas of lower socioeconomic status there were increased populations of foreign born populations, Hispanic populations, and identified locations of a competent vector present. These findings suggest that more specific surveillance of Ae. aegypti, testing of the mosquitoes for dengue virus, and active surveillance for human cases should be implemented in these areas. ^

Dengue transmission risk maps of the continental United States

Dengue fever is a strictly human and non-human primate disease characterized by a high fever, thrombocytopenia, retro-orbital pain, and severe joint and muscle pain. Over 40% of the world population is at risk. Recent re-emergence of dengue outbreaks in Texas and Florida following the re-introduction of competent Aedes mosquito vectors in the United States have raised growing concerns about the potential for increased occurrences of dengue fever outbreaks throughout the southern United States. Current deficiencies in vector control, active surveillance and awareness among medical practitioners may contribute to a delay in recognizing and controlling a dengue virus outbreak. Previous studies have shown links between low-income census tracts, high population density, and dengue fever within the United States. Areas of low-income and high population density that correlate with the distribution of Aedes mosquitoes result in higher potential for outbreaks. In this retrospective ecologic study, nine maps were generated to model U.S. census tracts’ potential to sustain dengue virus transmission if the virus was introduced into the area. Variables in the model included presence of a competent vector in the county and census tract percent poverty and population density. Thirty states, 1,188 counties, and 34,705 census tracts were included in the analysis. Among counties with Aedes mosquito infestation, the census tracts were ranked high, medium, and low risk potential for sustained transmission of the virus. High risk census tracts were identified as areas having the vector, ≥20% poverty, and ≥500 persons per square mile. Census tracts with either ≥20% poverty or ≥500 persons per square mile and have the vector present are considered moderate risk. Census tracts that have the vector present but have <20% poverty and <500 persons per square mile are considered low risk. Furthermore, counties were characterized as moderate risk if 50% or more of the census tracts in that county were rated high or moderate risk, and high risk if 25% or greater were rated high risk. Extreme risk counties, which were primarily concentrated in Texas and Mississippi, were considered having 50% or greater of the census tracts ranked as high risk. Mapping of geographic areas with potential to sustain dengue virus transmission will support surveillance efforts and assist medical personnel in recognizing potential cases. ^

Evidence of secondary dengue infection and potential for association with clinical depression in a subset of a randomly selected cohort in South Texas

Globally, dengue is an emerging disease resulting in an estimated 50 million new cases and 22, 000 deaths each year. Anecdotally, depression has been reported as a possible sequelae of dengue virus infection. To test the association, we performed a cross-sectional analysis in a selected sub-set of participants from the Cameron County Hispanic Cohort (CCHC) in South Texas. All study subjects in the analysis had Center for Epidemiological Studies Depression scale (CES-D) scores and were tested for dengue antibodies using stored plasma. We found that 5.0% of participants tested either positive or equivocal for anti-dengue IgG antibodies using the capture antibody test, which detects acute secondary infections. Logistic regression identified that evidence of acute secondary dengue infection was not associated with depression (Odds Ratio [OR] = 0.97, 95%Confidence Interval [CI] 0.47-1.98); however, both being female (OR = 1.53, 95%CI 1.09-2.15) and obese body mass index (BMI > 30) (OR = 1.84, 95%CI 1.19-2.84) were associated with depression. ^

Emerging arboviruses in Harris County, Texas

Harris County, which includes Houston, Texas, is an endemic and epidemic area for two viruses transmitted by arthropods (arboviruses). These viruses are maintained in cycles involving mosquitoes and wild birds, and transmission to humans is accidental. The majority of human infections is asymptomatic or may result in a flu-like syndrome. However, some infections can result in meningitis or encephalitis. These neuroinvasive infections may cause death, and those who survive may experience serious neurological complications requiring costly and lengthy medical care. The most important arboviruses in terms of morbidity are St. Louis encephalitis (SLEV) and West Nile (WNV) viruses. In fact, Harris County reports more SLEV encephalitis cases than any other county in the U.S. Most arboviral human cases occur from July through September, when mosquitoes are most active. Those at risk for encephalitis and death are the elderly and those with a history of hypertension or immunosuppresion. There is no specific treatment and no human vaccines are commercially available in the U.S. The approach for control of arboviruses in Harris County during epidemics is multidisciplinary and executed by several agencies. It includes surveillance, vector control, and educational messages for the population. Prevention of outbreaks consists of elimination of the vector and its breeding grounds, and practicing personal protective measures to prevent exposure to mosquitoes. ^ Current findings indicate that mosquito-borne viruses other than SLEV and WNV could pose an additional threat for the population. Eastern equine encephalitis virus (EEEV) activity has been detected in dogs and sentinel chickens in Houston and surrounding areas. Several serotypes of dengue virus have caused recent outbreaks in south Texas, and some locally-acquired cases have been detected in Houston. Since the clinical presentation of all arboviruses that cause encephalitis is very similar, and current surveillance is focused on detecting SLEV and WNV, there is a possibility that other arboviruses could be present in the area but are not being detected. Additionally, Harris County's ample annual rainfall and flooding problems, warm weather, multiple mosquito species, local and migrating birds that are susceptible to arboviral infection, and a constant flow of goods and travelers from many parts of the world could favor the emergence or re-emergence of other arboviruses. ^ The aims of this project were to determine if other arboviruses were circulating in the county, to assess the knowledge and attitudes about mosquito-borne viruses in a sample of the population, and to conduct an analysis of the initial WNV epidemic in Harris County. Through the retrospective analysis of clinical specimens collected during the 2002-2005 epidemic seasons, serologic evidence of dengue infection was detected suggesting the possibility that this virus may be co-circulating with SLEV and WNV. A cross-sectional survey revealed high awareness about arboviruses but not a consistent use of protective measures to avoid mosquitoes. The third component for this project included a retrospective review and geographical analysis of the 2002 WNV epidemic. ^ Overall, this study documented valuable information about the dengue virus, a potentially emerging arbovirus in Texas, revealed the need for more educational preventative programs, reinforced the value of mosquito and avian surveillance, and indicated the importance of continuing to investigate the factors that contribute to the development of outbreaks. ^

Suspected outbreak of dengue fever in Houston: Clinical characteristics and determination of autochthonous transmission between 2003 and 2005

Houston, Texas maintains the appropriate climate and mosquito populations to support the circulation of dengue viruses. The city is susceptible to the introduction and subsequent local transmission of dengue virus with its proximity to dengue-endemic Mexico and the high degree of international travel routed through its airports. In 2008, a study at the University of Texas School of Public Health identified 58 suspected dengue fever cases that presented at hospitals and clinics in the Houston area. Serum or CSF samples of the 58 samples tested positive or equivocal for the presence of anti-dengue IgM antibodies (Rodriguez, 2008). Here, we present the results of an investigation aimed to describe the clinical characteristics of the 58 suspected dengue fever cases and to determine if local transmission had occurred. Data from medical record abstractions and personal telephone interviews were used to describe clinical characteristics and travel history of the suspected cases. Our analysis classified six probable dengue fever cases based on the case definition from the World Health Organization. Three of the probable cases for which we were able to obtain travel history had not recently traveled to an endemic area prior to onset of symptoms suggesting the illnesses were locally acquired in Houston. Further analysis led us to hypothesize that additional cases of dengue fever are present in our study population. Fifty-one percent of the study population was diagnosed with meningitis and/or encephalitis. Sixty percent of the individuals who received a lumbar puncture had abnormal CSF. Together these findings indicate viral infection with neurological involvement, which has been reported to occur with dengue fever. Among the individuals who received liver enzyme analysis, 54% had evidence of abnormal liver enzyme levels, a clinical sign commonly observed with dengue. Our results indicate that a suspected outbreak of dengue fever with autochthonous transmission occurred in the Houston area between 2003 and 2005. ^

A screening for anti-West Nile immunoglobulin-G and immunoglobulin-M in the Cameron County Hispanic cohort

This study is designed to be a cross-sectional, retrospective analysis of the seroprevalence of anti-WNV antibodies in 1,006 plasma samples collected from February 2, 2006 to June 18, 2007 originally for The Cameron County Hispanic Cohort: Extreme obesity and uncontrolled diabetes on the U.S.-Mexico border, major concerns for populations with health disparities. The aim of this thesis research is to give a more up-to-date picture of Flavivirus activity in south Texas, which can potentially contribute to the surveillance objective of arboviral control in this area. A West Nile virus (WNV) seroprevalence study in humans in this particular area has never before been completed. Plasma samples were tested using immunoglobulin-G (IgG) and immunoglobulin-M (IgM) WNV enzyme linked immunosorbent assays (ELISA). Estimated seroprevalence for this particular population was 0.98% or 9.8 cases of West Nile disease per 1,000 citizens. After IgG testing, seroprevalence in the study population was found to be 15.4%. Specimens tested for WNV IgG were compared with a subset of specimens (N=803) tested for history of primary dengue virus (DENV) infection. Of the 803 specimens tested for IgG to DENV, 308 were positive. Of the 132 positive WNV IgG specimens in the subset, 131 (99.2%) tested also tested positive for DENV IgG. It would be helpful to use standard plaque reduction neutralization testing to determine if the seroprevalence is in fact lower because of cross-reaction to DENV on testing. Regardless of the possibility of other Flavivirus activity occurring prior to the introduction of WNV into the United States and the potential for cross-reactivity, Texas has ranked in the top 5 states with the highest, laboratory confirmed incidence of infection with WNV since 2003. Indicating that climate factors and the presence of suitable vectors makes Texas a hotspot for WNV activity. ^ A description of the study population by age, gender, and income was done indicating a statistically significant income difference with a mean household income per year being $13,413.55 for a case and $20,268.80 for non-cases (p=0.001). Lower income neighborhoods should be targeted for education and prevention of vector-borne diseases during the summer months in Cameron County. With respect to gender, being male has been noted in the literature to be a risk factor for infection with WNV (25). In this study, females comprised approximately 68% of the study population, they also made up 66.5% of the positive IgG specimens. An odds ratio of 0.91 indicates that women are less likely to be IgG positive for WNV as compared to men; however, this was not found to be significant based on the 95% confidence interval, but is consistent with the literature. When looking at age difference between positive and negative/equivocal cases, there was no statistical difference found between the two groups. ^ We concluded that this study will enable us to understand the epidemiology of WNV transmission since its introduction into the United States and hopefully to maintain or improve the current measures we have in place to prevent infections that are seen annually with WNV.^

The recombinant adeno-associated virus vector (rAAV2)-mediated apolipoprotein B mRNA-specific hammerhead ribozyme: a self-complementary AAV2 vector improves the gene expression.

BACKGROUND: In humans, overproduction of apolipoprotein B (apoB) is positively associated with premature coronary artery diseases. To reduce the levels of apoB mRNA, we have designed an apoB mRNA-specific hammerhead ribozyme targeted at nucleotide sequences GUA6679 (RB15) mediated by adenovirus, which efficiently cleaves and decreases apoB mRNA by 80% in mouse liver and attenuates the hyperlipidemic condition. In the current study, we used an adeno-associated virus vector, serotype 2 (AAV2) and a self-complementary AAV2 vector (scAAV2) to demonstrate the effect of long-term tissue-specific gene expression of RB15 on the regulation apoB mRNA in vivo. METHODS: We constructed a hammerhead ribozyme RB15 driven by a liver-specific transthyretin (TTR) promoter using an AAV2 vector (rAAV2-TTR-RB15). HepG2 cells and hyperlipidemic mice deficient in both the low density lipoprotein receptor and the apoB mRNA editing enzyme genes (LDLR-/-Apobec1-/-; LDb) were transduced with rAAV2-TTR-RB15 and a control vector rAAV-TTR-RB15-mutant (inactive ribozyme). The effects of ribozyme RB15 on apoB metabolism and atherosclerosis development were determined in LDb mice at 5-month after transduction. A self-complementary AAV2 vector expressing ribozyme RB15 (scAAV2-TTR-RB15) was also engineered and used to transduce HepG2 cells. Studies were designed to compare the gene expression efficiency between rAAV2-TTR-RB15 and scAAV2-TTR-RB15. RESULTS: The effect of ribozyme RB15 RNA on reducing apoB mRNA levels in HepG2 cells was observed only on day-7 after rAAV2-TTR-RB15 transduction. And, at 5-month after rAAV2-TTR-RB15 treatment, the apoB mRNA levels in LDb mice were significantly decreased by 43%, compared to LDb mice treated with control vector rAAV2-TTR-RB15-mutant. Moreover, both the rAAV2-TTR-RB15 viral DNA and ribozyme RB15 RNA were still detectable in mice livers at 5-month after treatment. However, this rAAV2-TTR-RB15 vector mediated a prolonged but low level of ribozyme RB15 gene expression in the mice livers, which did not produce the therapeutic effects on alteration the lipid levels or the inhibition of atherosclerosis development. In contrast, the ribozyme RB15 RNA mediated by scAAV2-TTR-RB15 vector was expressed immediately at day-1 after transduction in HepG2 cells. The apoB mRNA levels were decreased 47% (p = 0.001), compared to the control vector scAAV2-TTR-RB15-mutant. CONCLUSION: This study provided evidence that the rAAV2 single-strand vector mediated a prolonged but not efficient transduction in mouse liver. However, the scAAV2 double-strand vector mediated a rapid and efficient gene expression in liver cells. This strategy using scAAV2 vectors represents a better approach to express small molecules such as ribozyme.

Mutagenicity of herpes simplex virus type 1 in a shuttle vector

The shuttle vector plasmid pZ189 was used to find the kinds of mutations that are induced by herpes simplex virus type-1 (HSV-1). In cells infected by HSV-1 the frequency of mutation in supF gene, the mutagenesis marker, was increased over background by from two- to seven-fold, reaching 0.14-0.45%. No increase was induced by infection by vaccinia virus under the same conditions. Mutagenesis was an early event, showing a four-fold increase in mutation frequency at only two hours after infection, and peaking at a seven-fold increase at four hours after infection. DNA sequencing and gel electrophoresis analysis were performed on 105 HSV-1 induced mutants and 65 spontaneous mutants and provided the following information: (1) A change in plasmid size was seen in 54% of HSV-1 related mutants, compared with only 37% of spontaneous mutants. (2) Among point mutations, the predominant type was G:C to A:T transition, which accounted for 51% of point mutations in mutants isolated from cells infected with HSV-1, and 32% of point mutations in spontaneous mutants. (3) Deletions of DNA were seen in HSV-1 related mutants at a frequency of 40%, compared with 29% in spontaneous mutants. The HSV-1 related deletions were about half the length of spontaneous mutants and three contained short filler sequences. (4) Fifteen (15%) of HSV-1 induced mutants revealed the altered restriction patterns on agarose gel electrophoresis analysis and were due either to rearrangements of plasmid DNA, and/or to insertion of sequences derived from chromosomal DNA (seven plasmids). No insertions of DNA from HSV-1 were detected. Among spontaneous mutants, only 5 (7.7%) were rearrangements and none had inserted chromosomal DNA. (5) DNA sequence analysis of seven plasmids with inserted chromosomal DNA revealed that four cases had repetitive DNA sequences integrated and the other three were unidentified sequences from the GenBank database. Three repetitive DNA included $\alpha$ satellite, Alu and KpnI family sequences. The other sequence was identified as tRNA-like component. The observed mutations have implications for the mechanism of malignant transformation of cells by HSV-1. ^

West Nile virus in the Rio Grande Valley: A seroprevalence study of juvenile dogs

This study used canine sentinel surveillance and collected a sample of adult mosquitoes to investigate the potential impact of West Nile virus (WNV) in human populations in the Rio Grande Valley along the Texas-Mexico border. Samples for this study were collected from juvenile dogs two months to one year of age in animal shelters located in the Rio Grande Valley. The sample was comprised of stray dogs in order to include animals with maximum nighttime exposures to Culex mosquitoes. Serum samples were collected following the 2007 WNV transmission season and were tested for IgG antibodies against WNV. Evidence of antibodies to WNV was found in 35.1% of the sample population consisting of 74 dogs. During this same time period, mosquitoes in Brownsville were trapped and morphologically identified to develop greater understanding of the mosquito populations in the region and to further understand other potential mosquito vectors for disease transmission. The vast majority of mosquitoes living in this area were Aedes albopictus (47.6%), Culex quinquefasciatus (23.7%), and Aedes aegypti (20.1%). This study shows that WNV and the vector responsible for WNV transmission are active in the Rio Grande Valley and pose a threat to the human and animal populations. ^

TRANSOVARIAL TRANSMISSION OF YELLOW FEVER VIRUS BY A SYLVATIC VECTOR, HAEMAGOGUS EQUINUS (THEOBALD)

The potential of a sylvatic vector to act as reservoir of yellow fever virus was assessed in Haemagogus equinus (Theobald). Mosquitoes from the Maje'75 laboratory colony and a Panamanian human isolated strain of yellow fever virus were used. Female mosquitoes infected with yellow fever virus had a minimum transovarial transmission rate of 1:5745. This is the first time transovarial transmission of yellow fever virus has been demonstrated in a New World sylvatic vector. Transovarial transmission of yellow fever virus in this sylvatic mosquito species may be an alternative mechanism for biological survival of the virus during adverse periods or in the absence of susceptible vertebrate hosts. ^

Mapping T-cell epitopes of the rubella virus structural proteins

Rubella virus (RV) typically causes a mild childhood illness, but complications can result from both viral and immune-mediated pathogenesis. RV can persist in the presence of neutralizing antibodies, suggesting that cell-mediated immune responses may be necessary for viral clearance. However, the molecular determinants recognized by RV-specific T-cells have not been identified. Using recombinant proteins which express the entire RV structural open reading frame in proliferation assays with lymphocytes of RV-immune individuals, domains which elicit major histocompatibility complex class II-restricted helper T-cells were identified. Synthetic peptides representing these domains were used to define specific epitopes. Two immunodominant domains were mapped to the capsid protein sequence C$\sb1$-C$\sb{29}$ and the E1 glycoprotein sequence E1$\sb{202}$-E1$\sb{283}.$ RV-specific MHC class I-restricted cytotoxic T lymphocytes (CTLs) were identified using a chromium-release assay with infected fibroblasts as target cells. An infectious Sindbis virus vector expressing each of the RV structural proteins identified the capsid, E2 and E1 proteins as targets of CTLs. Specific CTL epitopes were mapped within the previously identified immunodominant domains. This study identified domains of the RV structural proteins that may be beneficial for development of a synthetic vaccine, and provides normative data on RV-specific T-cell responses that should enhance our ability to understand RV persistence and associated complications. ^

Gene therapy of cancer: Mechanisms of ``bystander effect'' killing in cells expressing the herpes simplex virus-thymidine kinase gene and its potential clinical applications

At the fore-front of cancer research, gene therapy offers the potential to either promote cell death or alter the behavior of tumor-cells. One example makes use of a toxic phenotype generated by the prodrug metabolizing gene, thymidine kinase (HSVtk) from the Herpes Simplex Virus. This gene confers selective toxicity to a relatively nontoxic prodrug, ganciclovir (GCV). Tumor cells transduced with the HSVtk gene are sensitive to 1-50 $\mu$M GCV; normal tissue is insensitive up to 150-250 $\mu$M GCV. Utilizing these different sensitivities, it is possible to selectively ablate tumor cells expressing this gene. Interestingly, if a HSVtk$\sp+$ expressing population is mixed with a HSVtk$\sp-$ population at high density, all the cells are killed after GCV administration. This phenomenon for killing all neighboring cells is termed the "bystander effect", which is well documented in HSVtk$\sp-$ GCV systems, though its exact mechanism of action is unclear.^ Using the mouse colon carcinoma cell line CT26, data are presented supporting possible mechanisms of "bystander effect" killing of neighboring CT26-tk$\sp-$cells. A major requirement for bystander killing is the prodrug GCV: as dead or dying CT26tk$\sp+$ cells have no toxic effect on neighboring cells in its absence. In vitro, it appears the bystander effect is due to transfer of toxic GCV-metabolites, through verapamil sensitive intracellular-junctions. Additionally, possible transfer of the HSVtk enzyme to bystander cells after GCV addition, may play a role in bystander killing. A nude mouse model suggests that in a 50/50 (tk$\sp+$/tk$\sp-$) mixture of CT26 cells the bystander eradication of tumors does not involve an immune component. Additionally in a possible clinical application, the "bystander effect" can be directly exploited to eradicate preexisting CT26 colon carcinomas in mice by intratumoral implantation of viable or lethally irradiated CT26tk$\sp+$ cells and subsequent GCV administration. Lastly, an application of this toxic phenotype gene to a clinical marking protocol utilizing a recombinant adenoviral vector carrying the bifunctional protein GAL-TEK to eradicate spontaneously-arisen or vaccine-induced fibrosarcomas in cats is demonstrated. ^

Spatial analysis of water body distance and West Nile Virus human cases in Houston, TX

West Nile Virus (WNV) is an arboviral disease that has affected hundreds of residents in Harris County, Texas since its introduction in 2002. Persistent infection, lingering sequelae and other long-term symptoms of patients reaffirm the need for prevention of this important vector-borne disease. This study aimed to determine if living within 400m of a water body increases one’s odds of infection with WNV. Additionally, we wanted to determine if one’s proximity to a particular water type or water body source increased one’s odds of infection with WNV.^ 145 cases’ addresses were abstracted from the initial interview and consent records from a cohort of patients (Epidemiology of Arboviral Encephalitis in Houston study, HSC-SPH-03-039). After applying inclusion criteria, 140 cases were identified for analysis. 140 controls were selected for analysis using a population proportionate to size model and US Census Bureau data. MapMarker USA v14 was used to geocode the cases’ addresses. Both cases’ and controls’ coordinates were uploaded onto a Harris County water shapefile in MapInfo Professional v9.5.1. Distance in meters to the closest water source, closest water source type, and closest water source name were recorded.^ Analysis of Variance (p=0.329, R2 = 0.0034) indicated no association between water body distance and risk of WNV disease. Living near a creek (x2 = 11.79, p < 0.001), or the combined group of creek and gully (x 2 = 14.02, p < 0.001) were found to be strongly associated with infection of WNV. Living near Cypress Creek and its feeders (x2 = 15.2, p < 0.001) was found to be strongly associated with WNV infection. We found that creek and gully habitats, particularly Cypress Creek, were preferential for the local disease transmitting Culex quinquefasciatus and reservoir avian population.^

Is family medicine meeting the HIV/AIDS challenge? A national survey of family physicians' beliefs, clinical competence, and experience regarding HIV disease

A national sample of family physicians was surveyed to (1) assess family physicians' beliefs about the human immunodeficiency virus (HIV) and individuals at risk for infection, their clinical competence regarding HIV-related issues, and their experiences with HIV disease; (2) present conclusions to the American Academy of Family Physicians (AAFP) to effect the development of an early clinical care protocol and a continuing medical education curriculum; and (3) collect base-line data for use in the evaluation of an early clinical care protocol and a continuing medical education curriculum, in the case that such programs are developed and disseminated. After considering retired or deceased respondents, of the 2,660 physicians surveyed, 1,678 (63.7%) responded. The resulting sample was representative of the active members of the AAFP. About 77% of the respondents were unable to accurately identify the universal precautions for blood and body fluids to prevent occupational transmission of HIV or hepatitis B virus (HBV). Residency trained and board certified physicians expressed fewer "external constraints," such as fear of losing patients, obviating them from providing treatment to individuals with HIV disease (p =.004 and p $<$.001, respectively). These physicians also manifested fewer "internal constraints" to the provision of HIV treatment, such as fear of becoming infected (p $<$.001 and p =.012, respectively). Residency trained physicians also expressed a greater comfort with discussing sexually-related topics with their patients than did non-residency trained physicians (p $<$.001). There were 67.1% of the physicians surveyed who reported never providing treatment to an individual with HIV disease. Residency trained and board certified physicians expressed a greater likelihood to provide treatment to HIV-infected patients (p $<$.001) than non-residency trained and non-board certified physicians.^ Among the various primary care specialties, family medicine is especially vulnerable to the current challenges of HIV/AIDS. These challenges are augmented by the epidemiologic pattern that characterizes AIDS. For the past several years, we have seen AIDS in this country assume a similar pattern to that seen in most other countries; HIV is becoming increasingly prevalent in the heterosexual population as well as in locations removed from metropolitan centers. This current phase of the epidemic generates greater pressures upon primary care physicians, particularly family physicians, to become better acquainted with the means to provide early care to HIV/AIDS patients and to prevent HIV/AIDS among their patients. Family medicine is especially appropriate for providing care to HIV patients because family medicine involves treatment to all age groups and conditions; other primary care specialties focus on limited patient populations or specific conditions. Family physicians should be armed with the expertise to confront HIV/AIDS. However, family physicians' clinical competence and experience with HIV is not known. The data collected in this survey describes their competencies, attitudes, and experiences. ^