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Members of the Multistate Evaluation of Surveil- lance 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 Depart- ment); John Newman, Craig Thompson (Mississippi Public Health Department); Robert Hamm, MD, MPH, Kristen Wendt, MPH, Linda Bell (Missouri Pub- lic Health Department); Michael Samuel, DrPH, Mark Stenger, MS (New Mexico Public Health Depart- ment); Delbert E. Williams, PhD, Evelyn Foust, MPH, Judy Owen-O’Dowd (North Carolina Public Health Department); Steven Modesitt, RN, MPH, Roger Wirt, PhD, David Fleming, MD (Oregon Public Health De- partment); Ann S. Robbins, PhD, Sharon A. King, MA, Douglas Hamaker (Texas Public Health Department).

Human Participation Protection

This study was approved by the University of Califor- nia institutional review board and state and local re- view boards as required.


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):1–31.

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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 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 epi- demic are present. High rates of syphilis, 2 hepatitis B virus, 3 and other sexually trans- mitted diseases, as well as extreme poverty, 4 suggest that many of Madagascar’s 14 million people are at risk for acquiring HIV. The AIDS Impact Model projected that HIV sero- prevalence 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 popula- tion. The aims of this study were to (1) deter- mine a baseline level of public awareness and knowledge about HIV and AIDS and (2) as- certain the HIV and AIDS risk–related be- haviors of a segment of the general popula- tion in the capital city, Antananarivo.


During July and August 2000, we con- ducted 134 interviews with patients and visi- tors in the 2 teaching hospitals of the Univer- sity of Antananarivo School of Medicine. All interviews used a 3-part, 41-item question- naire eliciting information about demograph- ics and previous sources of HIV and AIDS knowledge, an assessment of this knowledge, and a detailed personal history of HIV and AIDS risk–related behaviors.

The questionnaire, written in French, was translated for patients who spoke only Mala- gasy. 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 vari- ance tests, and Spearman rank correlation tests with SPSS, Version 10.0 (SPSS Inc, Chi- cago, Ill).



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


HIV and AIDS Knowledge

One hundred twenty-four (93%) partici- pants correctly identified having unprotected vaginal sex with a person who has HIV or AIDS and receiving an unscreened transfu- sion 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%) identi- fied kissing someone on the cheek, a common greeting in Madagascar’s central highlands, as carrying some risk. Most participants believed that intimate kisses, mosquitoes, and sneezes could transmit HIV and AIDS.

Personal History

One hundred thirty-two participants com- pleted the personal history section (Table 2). Of the 21 (16%) who had had more than


sexual partner in the last 6 months, only


(14%) had had more than 2 partners. How-

ever, only 2 (10%) reported the consistent

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

Answers, % of Participants


No Risk

Low Risk

Medium Risk

High Risk

Don’t Know

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














































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 2—Personal Behavior Survey Results (N=132)


No. Reporting Behavior

% Reporting 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

21 (19 men, 2 women)

15.9 (30.2% of men, 2.8% of women)







23 (all men)

17.4 (36.5% of men)













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

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 differ- ence was found in the mean test scores of men and women (P = .350) or of partici- pants from rural or urban areas (P = .723). There was a trend toward better scores in

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


The data from the HIV knowledge assess- ment 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 trans- mitted 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

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 re- ported condom use rates in this study were much lower than the rates in these sub- Saharan African nations. 1 The 2 potential protective factors found in this study were minimal travel to mainland Africa and the lower reported number of sex- ual partners for persons with multiple partners.


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 part- nering could have been underreported be- cause of sensitivity and social stigma. Antananarivo is not representative of all of Madagascar, as indicated by higher education levels—67% of the study participants had completed high school in a country where 12% start high school 6 —and by higher rural hepatitis B virus prevalence. 3


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

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| Lanouette et al.

American Journal of Public Health | June 2003, Vol 93, No. 6


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 multi- ple partners suggest that Madagascar is at risk for an epidemic. Intervention by health care workers, the Malagasy government, and non- governmental organizations is warranted to prevent the disastrously high AIDS rates seen in Madagascar’s 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 surveil-

lance and prevention programs.

and effective surveil- lance and prevention programs. About the Authors Nicole M. Lanouette is with Mount

About the Authors

Nicole M. Lanouette is with Mount Sinai School of Medi- cine, New York, NY. Rivo Noelson is with the University of Antananarivo, Antananarivo, Madagascar. Andriamahen- ina Ramamonjisoa is with the HIV/AIDS National Refer- ence Laboratory, Ministry of Health, Antananarivo, Madagascar. Jeffrey M. Jacobson is with the Division of In- fectious 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 1002 9 (e-mail: This brief was accepted March 6, 2002.


N.M. Lanouette designed the study, conducted the in- terviews, 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. Ja- cobson contributed to and supervised the study design, data analysis, and writing of the brief.


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 Educa- tion Consortium’s February 2001 conference in San Pedro Sula, Honduras. The authors would like to thank the Malagasy med- ical student association REMEDE for its essential trans- lating 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.

Human Participant Protection

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

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


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epidemic. Available at:

epidemic_update/report/index.html. Accessed June


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 popu- lation in Madagascar: evidence for different epidemio- logical patterns in urban and in rural areas. Epidemiol Infect. 1996;117:133–137.

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E, et al. AIDS in Madagascar, I: epidemiology, projec- tions, socioeconomic impact, interventions. Bull Soc Pathol Exot. 1998;91:68–70.

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NL. Effects of HIV counseling and testing on sexual risk behavior: a meta-analytic review of published re- search, 1985–1997. Am J Public Health. 1999;89:


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

Hepatitis B virus (HBV) infection is common (44%–80%) in injection drug users (IDUs), 18 and younger IDUs are at high

risk. 911 Although a safe and effective vaccine is available, high vaccine completion rates in IDUs (70%–86%) have been achieved pri- marily in drug treatment settings. 1215 Among street-recruited young injectors in San Fran- cisco, Calif, only 13% had serological evi- dence of prior immunization, and 28% had been infected with HBV. 16 We combined cash incentives and street outreach with flexible immunization sched- ules to improve HBV vaccine completion in young injectors in San Francisco. We exam- ined factors associated with vaccine comple- tion and observed postvaccination antibody responses in completers.


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 inter- viewed and underwent counseling and sero- logical testing for HIV, HBV, and hepatitis C virus (HCV). Persons without evidence of acute infection, a chronic carrier state, or im- munity conferred by antibody to hepatitis B surface antigen (anti-HBs) were recruited. Those declining participation in the study were offered free immunizations. A 20-µg intramuscular dose of recombi- nant DNA hepatitis B vaccine was adminis- tered at enrollment. Participants were in- structed 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 se- roconversion at 4 weeks after the third dose. We measured vaccine series completion and conducted bivariate analyses of variables as- sociated with vaccine completion. We con- ducted a multiple logistic regression analysis of significant variables (P < .10) and other variables of interest or potential confounders.


Of the 404 persons screened, 265 (66%) were eligible for immunization. Of the

June 2003, Vol 93, No. 6 | American Journal of Public Health

Lum et al. | Peer Reviewed | Research and Practice | 919