RESEARCH AND PRACTICE

Members of the Multistate Evaluation of Surveillance for HIV Study Group are Andrew B. Bindman, MD, Frederick M. Hecht, MD, Dennis Osmond, PhD, Karen Vranizan, MA, Dennis Keane, MPH (University of California San Francisco); John Ward, MD, MPH, Patricia L. Fleming, PhD (Centers for Disease Control and Prevention, Atlanta, Ga); Denise K. Boyd, MS, MPH, Vjollca Berisha, MD, MPH (Arizona Public Health Department); Kenneth Gershman, MD, MPH, Melanie Mattson (Colorado Public Health Department); John Newman, Craig Thompson (Mississippi Public Health Department); Robert Hamm, MD, MPH, Kristen Wendt, MPH, Linda Bell (Missouri Public Health Department); Michael Samuel, DrPH, Mark Stenger, MS (New Mexico Public Health Department); Delbert E. Williams, PhD, Evelyn Foust, MPH, Judy Owen-ODowd (North Carolina Public Health Department); Steven Modesitt, RN, MPH, Roger Wirt, PhD, David Fleming, MD (Oregon Public Health Department); Ann S. Robbins, PhD, Sharon A. King, MA, Douglas Hamaker (Texas Public Health Department).

HIV- and AIDS-Related Knowledge, Awareness, and Practices in Madagascar

| Nicole M. Lanouette, BA, Rivo Noelson, DU,
Andriamahenina Ramamonjisoa, DEM, Sheldon Jacobson, MD, and Jeffrey M. Jacobson, MD

The questionnaire, written in French, was translated for patients who spoke only Malagasy. The same American medical student and at least 1 Malagasy medical student or resident conducted each interview. Patients and visitors were eligible for participation if they were 18 years of age or older and could ambulate to a private room. We performed frequency calculations, t tests, analysis of variance tests, and Spearman rank correlation tests with SPSS, Version 10.0 (SPSS Inc, Chicago, Ill).

RESULTS
The prevalence of HIV in Madagascar has been slowly rising in the past decade but in 1999 was still less than 0.5%.1 Although this rate is low compared with the rates in many other countries, including the United States (0.61%) and especially sub-Saharan African nations such as Zimbabwe (25%) and South Africa (20%),1 the risk factors for an epidemic are present. High rates of syphilis,2 hepatitis B virus,3 and other sexually transmitted diseases, as well as extreme poverty,4 suggest that many of Madagascars 14 million people are at risk for acquiring HIV. The AIDS Impact Model projected that HIV seroprevalence could reach 15% by 2015 if Madagascar follows the epidemic trend of countries like Kenya.5 We sought to determine directly whether high-risk behaviors that might lead to rising infection rates were present in this population. The aims of this study were to (1) determine a baseline level of public awareness and knowledge about HIV and AIDS and (2) ascertain the HIV and AIDS riskrelated behaviors of a segment of the general population in the capital city, Antananarivo.

Demographics
One hundred thirty-six people participated in the informed consent process, after which 2 people declined to participate and 2 other participants completed only the demographics and HIV and AIDS knowledge sections. Of the 134 participants, 71 (53%) were women. The participants median age was 33.5 years; 90 (67%) had completed high school. Ninety (67%) were married, and 32 (24%) lived in rural areas. Every participant had previously received HIV and AIDS information, most commonly from radio (118, 88%), but only 23 (17%) had received it from a health care provider.

Human Participation Protection

This study was approved by the University of California institutional review board and state and local review boards as required.

References
1. Centers for Disease Control and Prevention. Guidelines for national human immunodeficiency virus case surveillance, including monitoring for human immunodeficiency virus infection and acquired immunodeficiency syndrome. MMWR Morbid Mortal Wkly Rep. 1999;48(RR13):131. 2. Klevens RM, Fleming PL, Li J, et al. The completeness, validity, and timeliness of AIDS surveillance data. Ann Epidemiol. 2001;11:443449. 3. Jara MM, Gallagher KM, Schieman S. Estimation of completeness of AIDS case reporting in Massachusetts. Epidemiology. 2000;11:209213. 4. Klevens RM, Fleming PL, Neal JJ, Li J, the Mode of Transmission Validation Study Group. Is there really a heterosexual AIDS epidemic in the United States? Findings from a multisite validation study, 19921995. Am J Epidemiol. 1999;149:7584. 5. Buehler JW, Berkelman RL, Stehr-Green JK. The completeness of AIDS surveillance. J Acquir Immune Defic Syndr. 1992;5:257264. 6. Klungel OH, de Boer A, Paes AH, Seidell JC, Bakker A. Cardiovascular diseases and risk factors in a population-based study in The Netherlands: agreement between questionnaire information and medical records. Netherlands J Med. 1999;55:177183. 7. Bindman AB, Osmond D, Hecht FM, et al. Multistate evaluation of anonymous HIV testing and access to medical care. JAMA. 1998;280:14161420. 8. Kaufman JS. How inconsistencies in racial classification demystify the race construct in public health statistics [editorial]. Epidemiology. 1999;10:101103. 9. Youden WJ. Index for rating diagnostic tests. Cancer. 1950;3235. 10. Cohen J. A coefficient of agreement for nominal scales. Educ Psychol Meas. 1960;20:3746.

HIV and AIDS Knowledge

One hundred twenty-four (93%) participants correctly identified having unprotected vaginal sex with a person who has HIV or AIDS and receiving an unscreened transfusion from someone with HIV or AIDS as high risk (Table 1). However, 91 (68%) did not know that vaginal sex with a properly used condom is low risk. Forty-one (31%) identified kissing someone on the cheek, a common greeting in Madagascars central highlands, as carrying some risk. Most participants believed that intimate kisses, mosquitoes, and sneezes could transmit HIV and AIDS.

METHODS
During July and August 2000, we conducted 134 interviews with patients and visitors in the 2 teaching hospitals of the University of Antananarivo School of Medicine. All interviews used a 3-part, 41-item questionnaire eliciting information about demographics and previous sources of HIV and AIDS knowledge, an assessment of this knowledge, and a detailed personal history of HIV and AIDS riskrelated behaviors.

Personal History
One hundred thirty-two participants completed the personal history section (Table 2). Of the 21 (16%) who had had more than 1 sexual partner in the last 6 months, only 3 (14%) had had more than 2 partners. However, only 2 (10%) reported the consistent

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TABLE 1Responses to HIV and AIDS Risk Assessment Test (N = 134)

Answers, % of Participants Situation Working every day Sharing a drinking glass Having vaginal sexual intercourse without a condom Having vaginal sexual intercourse with a properly used condom Kissing on the cheek Kissing intimately Receiving an (unscreened) transfusion Being bitten by a mosquito Being sneezed on No Risk 65.7 61.2 2.2 34.3 69.4 38.8 3.7 31.3 47.8 Low Risk 16.4 13.4 0.7 32.1 13.4 23.9 1.5 17.2 19.4 Medium Risk 7.5 7.5 4.5 14.2 7.5 12.7 2.2 20.9 20.1 High Risk 9.7 17.2 92.5 17.9 9.7 23.9 92.5 28.4 10.4 Dont Know 0.7 0.7 0 1.5 0 0.7 0 2.2 2.2

Note. Participants were asked to rate each of the hypothetical situations between a person without HIV or AIDS and a person with HIV or AIDS as carrying no risk, low risk, medium risk, or high risk of contracting HIV for the person without HIV or AIDS. (Correct answers are in boldface type.)

TABLE 2Personal Behavior Survey Results (N = 132)

Behavior Sexual activity > 1 sexual partner in last 6 mo Of above, used condoms with every partner Ever had sexual intercourse with someone of same sex Ever received money for sexual activity Ever paid for sexual activity Ever had sexual relations with someone non-Malagasy Blood transfusion or injection drugs Ever received a blood transfusion Ever used injection drugs Travel Ever traveled within Madagascar Ever traveled out of Madagascar Ever traveled to mainland Africa No. Reporting Behavior % Reporting Behavior

21 (19 men, 2 women) 2 2 2 23 (all men) 17 25 0 123 29 0

15.9 (30.2% of men, 2.8% of women) 9.5 1.5 1.5 17.4 (36.5% of men) 12.9 18.9 0 93.2 22.0 0

opportunity for HIV and AIDS prevention counseling.9 The rate of multiple partnering among Malagasy men in this study was similar to World Health Organization reported rates in Uganda, Kenya, and Zimbabwe, whereas reported condom use rates in this study were much lower than the rates in these subSaharan African nations.1 The 2 potential protective factors found in this study were minimal travel to mainland Africa and the lower reported number of sexual partners for persons with multiple partners.

STUDY LIMITATIONS
In this hospital-based survey, sexual activity could have been less than participants would normally report because of personal or family illness. Although every effort was made to make participants feel comfortable, rates of same-sex sexual relations and multiple partnering could have been underreported because of sensitivity and social stigma. Antananarivo is not representative of all of Madagascar, as indicated by higher education levels67% of the study participants had completed high school in a country where 12% start high school6and by higher rural hepatitis B virus prevalence.3

use of condoms. Twenty-three participants, all men (37% of the men), reported having previously paid for sex.

participants who had previously spoken with health care workers about HIV or AIDS (P = .071).

HIV Knowledge and Demographic Correlations

Education level was not associated with the number of questions answered correctly on the risk assessment test (P = .350), but age correlated significantly with test scores, with younger participants performing better (r = 0.264, P = .002). No significant difference was found in the mean test scores of men and women (P = .350) or of participants from rural or urban areas (P = .723). There was a trend toward better scores in

DISCUSSION
The data from the HIV knowledge assessment suggest that HIV and AIDS awareness is high in Antananarivo, but knowledge of how HIV and AIDS cannot be transmitted and the use of condoms in prevention are limited. Understanding how HIV is not transmitted is important for preventing stigma against individuals with HIV and AIDS.6 Fear of stigma is known to deter citizens from being tested for HIV,7,8 an important

CONCLUSIONS
In this initial survey of the HIV and AIDS awareness, knowledge, and related behavior

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in Antananarivo, Madagascar, we observed that HIV and AIDS awareness is high, but knowledge about transmission is incomplete. High rates of multiple partnering and low condom use rates among people with multiple partners suggest that Madagascar is at risk for an epidemic. Intervention by health care workers, the Malagasy government, and nongovernmental organizations is warranted to prevent the disastrously high AIDS rates seen in Madagascars neighbors. A larger study that pairs HIV- and AIDS-related knowledge and behavior surveying with HIV testing and includes participants from other parts of the country is needed to confirm these findings and to develop specific and effective surveillance and prevention programs.

view Board and by the president of CHUA Hopital Joseph Ravoahangy Andrianavalona and the Laboratoire National de Reference VIH/SIDA prior to the start of the study.

References
1. UNAIDS. Report on the global HIV/AIDS epidemic. Available at: http://www.unaids.org/ epidemic_update/report/index.html. Accessed June 2000. 2. Behets FM, Andriamahenina R, Andriamiadana J, May JF, Rasamindrakotroka A. High syphilis and low but rising HIV seroprevalence rates in Madagascar. Lancet. 1996;347(9004):831. 3. Boisier P, Rabarijaona L, Piollet M, Roux JF, Zeller HG. Hepatitis B virus infection in general population in Madagascar: evidence for different epidemiological patterns in urban and in rural areas. Epidemiol Infect. 1996;117:133137. 4. USAID Congressional Presentation, Fiscal Year 1999. USAID; 1999. Available at: http://www.usaid. gov/pubs/cp99. Accessed June 2000. 5. Andriamahenina R, Ravelojaona B, Rarivoharilala E, et al. AIDS in Madagascar, I: epidemiology, projections, socioeconomic impact, interventions. Bull Soc Pathol Exot. 1998;91:6870. 6. Lentine DA, Hersey JC, Iannacchione VG, Laird GH, McClamroch K, Thalji L. HIV-related knowledge and stigma. MMWR Morb Mortal Wkly Rep. 2000; 49(47):10621064. 7. Chesney M, Smith A. Critical delays in HIV testing and care: the potential role of stigma. Am Behav Sci. 1999;42:11621174. 8. Herek G. AIDS and stigma. Am Behav Sci. 1999; 42:11061116. 9. Weinhardt LS, Carey MP, Johnson BT, Bickham NL. Effects of HIV counseling and testing on sexual risk behavior: a meta-analytic review of published research, 19851997. Am J Public Health. 1999;89: 13971405.

risk.911 Although a safe and effective vaccine is available, high vaccine completion rates in IDUs (70%86%) have been achieved primarily in drug treatment settings.1215 Among street-recruited young injectors in San Francisco, Calif, only 13% had serological evidence of prior immunization, and 28% had been infected with HBV.16 We combined cash incentives and street outreach with flexible immunization schedules to improve HBV vaccine completion in young injectors in San Francisco. We examined factors associated with vaccine completion and observed postvaccination antibody responses in completers.

METHODS
Subjects were recruited in a San Francisco study of HIV and viral hepatitis (the UFO Study) described elsewhere.17 Four hundred four IDUs younger than 30 years were interviewed and underwent counseling and serological testing for HIV, HBV, and hepatitis C virus (HCV). Persons without evidence of acute infection, a chronic carrier state, or immunity conferred by antibody to hepatitis B surface antigen (anti-HBs) were recruited. Those declining participation in the study were offered free immunizations. A 20-g intramuscular dose of recombinant DNA hepatitis B vaccine was administered at enrollment. Participants were instructed to return in 1 to 2 months for the second dose and then at 4 to 6 months for the third dose; they received $10 cash each time. Street-based outreach workers began delivering follow-up reminders 3 weeks after the first vaccine dose and again 11 weeks after the second dose. We measured postvaccination anti-HBs seroconversion at 4 weeks after the third dose. We measured vaccine series completion and conducted bivariate analyses of variables associated with vaccine completion. We conducted a multiple logistic regression analysis of significant variables (P < .10) and other variables of interest or potential confounders.

About the Authors

Nicole M. Lanouette is with Mount Sinai School of Medicine, New York, NY. Rivo Noelson is with the University of Antananarivo, Antananarivo, Madagascar. Andriamahenina Ramamonjisoa is with the HIV/AIDS National Reference Laboratory, Ministry of Health, Antananarivo, Madagascar. Jeffrey M. Jacobson is with the Division of Infectious Diseases of the Samuel Bronfman Department of Medicine, Mount Sinai Medical Center, New York, NY. Sheldon Jacobson is with the Department of Emergency Medicine, Mount Sinai Medical Center, New York, NY. Requests for reprints should be sent to Nicole M. Lanouette, BA, 50 E 98th St, No. 14-I, New York, NY 10029 (e-mail: nicole.lanouette@mssm.edu). This brief was accepted March 6, 2002.

Contributors
N. M. Lanouette designed the study, conducted the interviews, analyzed the data, and wrote the brief. R. Noelson assisted with design of the questionnaire, coconducted many of the interviews, and contributed to the writing of the brief. A. Ramamonjisoa assisted with study design, particularly the questionnaire, and with the writing of the brief. J. M. Jacobson and S. Jacobson contributed to and supervised the study design, data analysis, and writing of the brief.

Acknowledgments
This project was solely funded by a Patricia S. Levinson Fellowship through the Mount Sinai School of Medicine. These data were previously presented in a poster presentation at the International Health Medical Education Consortiums February 2001 conference in San Pedro Sula, Honduras. The authors would like to thank the Malagasy medical student association REMEDE for its essential translating aid and Karen Hamilton and Ilene Wilets for their academic support. We also thank the Faculty of Medicine of the University of Antananarivo and Patricia S. Levinson for their support of this project.

Hepatitis B Virus Immunization Among Young Injection Drug Users in San Francisco, Calif: The UFO Study
| Paula J. Lum, MD, MPH, Kristen C. Ochoa,
BA, Judith A. Hahn, PhD, Kimberly Page Shafer, PhD, MPH, Jennifer L. Evans, MS, and Andrew R. Moss, PhD

RESULTS
Hepatitis B virus (HBV) infection is common (44%80%) in injection drug users (IDUs),18 and younger IDUs are at high Of the 404 persons screened, 265 (66%) were eligible for immunization. Of the

Human Participant Protection

This study, questionnaire, and consent forms were approved by the Mount Sinai Hospital Institutional Re-

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