Accumulating evidence links intimate partner violence (IPV) victimization with a range of adverse physical and psychologic health outcomes among women, including injury, unwanted pregnancy, sexually transmitted infections (STIs), chronic disease, depression, anxiety, and posttraumatic stress disorder (PTSD).1-5 IPV victimization has a significant impact on women's social lives as well, including quality of life, daily functioning, parenting, community integration, and employment.6-12 Finally, the health care costs associated with IPV have been estimated to exceed 5 billion dollars each year.13
The bulk of research on IPV has been conducted among women and has focused on women's victimization experiences and associated outcomes. Cross-sectional studies of the relations between IPV victimization and sexual HIV risk behaviors among women reveal that IPV is associated with multiple outcomes, including unprotected sex,14-18 sex with multiple or overlapping partners,17 anal sex,19 and sex with a risky partner.17,20,21 In addition, IPV victimization among women has been found to be associated with prevalent STIs19,22 and HIV status23-25 in some studies but in not others.2 Relatively little research has focused on HIV-positive men's perpetration of IPV and its association with drug and alcohol use and HIV transmission risk behaviors, however. This has led for calls to understand men's role in IPV better so as to develop prevention interventions and reduce the associated adverse health outcomes among women.26-28
Lifetime and past 12-month prevalence estimates of men's perpetration of IPV vary widely. For example, Straus and Gelles29 found that approximately 12% of married men reported using physical violence against their female partners in the past year. Among a random sample of military men, Pan et al30 reported a 30% prevalence of physical IPV perpetration. It should be noted that in many studies in which IPV is assessed using behaviorally based measures, men often report experiencing as much violence as do their female partners,29 although whether these men are batterers or victims is the subject of contentious debate within the field of IPV research.31-33 Based on studies of the general population, risk factors for men's perpetration of IPV include young age,30 low socioeconomic status (eg, education, occupational prestige, income),30 childhood physical abuse,30,34 witnessing abuse of mother,35 personality characteristics and psychologic symptoms (eg, authoritarianism, narcissism, anger/hostility, depression, self-esteem),36 and sexist attitudes and sex-role adherence.37 The association between alcohol and drug use and IPV perpetration by men has been the subject of intense research,38 with most research suggesting that heavy alcohol and drug use are important modifiers, if not direct causes, of IPV perpetration.39-42
Data are scant on the prevalence of IPV perpetration among drug-involved and/or HIV-positive men. In one of the few studies on IPV perpetration among drug-involved men, El-Bassel and colleagues43 reported that a third of a random sample of men on methadone in New York City reported perpetrating physical IPV in the past year. More recently, Bogart and colleagues44 reported that among a national sample of HIV-positive men who have received medical care for HIV, 23% reported physical or sexual IPV perpetration within a “close relationship.” IPV perpetration among drug-involved men has also been found to be associated with sexual HIV risk behaviors. For example, El-Bassel and colleagues43 reported that after adjusting for potential confounders, men who perpetrated physical IPV were approximately 3.5 times more likely to have more than 1 intimate partner, 2 times as likely to have multiple sex partners, 2.75 times as likely to have had unprotected anal sex, and 2.5 times more likely to have had sex with an injecting drug user. Using the same data, traditional gender role adherence has been indirectly associated, by means of psychologic domination, with HIV risk behaviors and IPV perpetration.45 In contrast, Bogart and colleagues44 found that HIV-positive men who perpetrated physical or sexual IPV were not more likely to report unprotected sex as compared with men who did not perpetrate IPV. We know of no studies that assess physical or sexual IPV perpetration among men who are HIV-positive and drug involved.
Gaining a better understanding of what factors are associated with IPV perpetration among HIV-positive and drug-involved men is critical to evaluating the need for systematic assessment of IPV in HIV care settings and to designing interventions that focus on HIV-positive men and IPV perpetration. The goals of this study were to assess the prevalence and correlates of the perpetration of physical and/or sexual IPV in current main intimate relationships among HIV-positive men who are current injection drug users (IDUs). We hypothesized that, consistent with previous research, IPV perpetration would be associated with younger age, lower socioeconomic status, history of childhood abuse, higher psychologic distress, heavy and/or binge drinking, and stimulant drug use (eg, crack, cocaine). We further hypothesized that IPV perpetration would be associated with unsafe sexual and unsafe injection drug use risk behaviors among the HIV-positive men in our sample. We should note that we examined only physical and/or sexual violence perpetration in this analysis; thus, as we describe in more detail later, we cannot report the prevalence and/or correlates of partner “abuse,” which may include other forms of violence, is thought to be characterized by controlling behaviors, and is cyclic or patterned.46-48
Baseline data were analyzed from the Intervention for Intervention for Seropositive Injectors-Research and Evaluation (INSPIRE) study, a multisite randomized trial of a 10-session behavioral intervention to reduce risky sexual and injection behaviors and improve health care use and adherence among HIV-positive IDUs. The INSPIRE study, which was coordinated by the Centers for Disease Control and Prevention (CDC) and has been described in detail elsewhere,49 enrolled 1161 men and women in Baltimore, Miami, New York City, and San Francisco. All research activities were approved in advance by institutional review boards at the collaborating sites and the CDC. Individuals were eligible for the study if they were at least 18 years old, able to communicate in English, confirmed to be HIV-positive by means of an oral specimen (OraSUre; OraSUre Technologies, Bethlehem, PA), and reported injection drug use in the past 12 months and having had an opposite-gender partner (defined as any sex with a partner where orgasm occurred) in the 3 months before the baseline survey. Of the 700 men enrolled the in INSPIRE study, 45% (317 of 700) had at least 1 main female partner in the 3 months before baseline and were included in this analysis. Data were collected through self-report using audio computer-assisted structured interviewing (A-CASI) technology (Questionnaire Development System; NOVA Research Company, Bethesda, MD). The recall period for all measures was 3 months before interview unless otherwise noted.
The dependent variable in this analysis was perpetration or threat of physical and/or sexual IPV with a main female partner, hereafter referred to as “IPV perpetration.” Partner violence perpetration was measured using a modified version of the Conflict Tactics Scale50 that has been used in previous research43 and assessed the use and/or threat of physical or sexual IPV with a main female partner in the past 12 months. Eight items assessed various violent acts ranging in severity from threatening to hit or throw something at a partner to using a knife or gun on a partner to using force to make a partner have sex. The 2 items that tapped threats of violence included “threatened to hit or throw something that could hurt” and “threatened with a knife or gun.” Approximately one fifth (21%) of men categorized as perpetrating partner violence only used threats against their main female partners. The internal consistency of the scale with the data obtained was good (α = 0.75). We dichotomized the scale to model any physical and/or sexual IPV perpetration as compared with no physical and/or sexual IPV perpetration in the past year.
To test our hypotheses, we assessed 4 domains for their associations with the perpetration of IPV: sociodemographic, substance use, psychosocial, and HIV risk behaviors. Sociodemographic variables evaluated for their association with the dependent variable included age (continuous), race (white, black, Latino, or other), sexual orientation (self-reported heterosexual vs. bisexual or unknown), income level (more than $5000 per year vs. less than $5000 per year), employment status (full- or part-time paid job vs. no paid job), education level (high school education or more vs. less than high school education), homelessness in the past year (yes/no), lifetime history of incarceration (yes/no) and research site (Baltimore, Miami, New York City, or San Francisco).
Substance use factors assessed included alcohol use (at least daily, at least weekly, at least monthly, or no use) and binge drinking (at least daily, at least weekly, at least monthly, or no use). Drug use was assessed by type of drug (eg, cocaine, heroin, amphetamines, street methadone) and route of administration (eg, injection, inhalation, ingestion). In the present analysis, we categorized drug by type regardless of mode of administration to capture the potential pharmacologic effect on partner violence perpetration. Thus, we recoded variables to capture the following: depressant use only (eg, heroin, acetaminophen/hydrocodone), stimulant use only (eg, crack, cocaine), depressant and stimulant use (eg, “speedball,” “goofball”), or no use of depressants and/or stimulants.
We assessed the association of 5 psychosocial factors with the perpetration of partner violence among HIV-positive male IDUs. We assessed distress experienced in the week before interview using the sum of the anger (6 items), depression (7 items), and hostility (5 items) subscales of the Brief Symptoms Inventory (BSI; higher score indicated greater distress);51 the internal consistency for the entire scale using the data obtained was excellent (α = 0.94). Childhood experience of physical or sexual abuse was assessed with 2 questions asking whether the respondent was ever “beaten, physically attacked or physically abused,” or “sexually attacked, raped or sexually abused,” respectively, as a child. Social support was measured using a modified version the measure of social support in community settings (higher score indicated greater perceived social support) developed by Barrera,52 and the internal consistency of the scale with the data obtained was good (α = 0.89). Domains measured included intimate interaction (ie, emotional support) and directive guidance (ie, listened to personal problems, gave advice), positive social interaction, and instrumental support (ie, would lend money, help out with errands).
A sense of personal responsibility for the spread of HIV was measured with a 7-item scale that tapped perceived responsibility to limit the spread of HIV during a variety of situations involving sex and injection drug use (higher score indicated greater responsibility);53 the internal consistency of the scale with the data obtained was good (α = 0.82). Finally, a sense of empowerment was assessed using a 28-item positively scored scale to measure perceived ability to influence one's environment (higher score indicated greater empowerment);54 the internal consistency of the scale with the data obtained was good (α = 0.85).
In terms of HIV risk behaviors, we assessed sexual and injection drug use risk behaviors. In terms of injection risk, we assessed the presence of recent injection (past 3 months) and whether injection equipment was shared or lent to HIV-negative or unknown status individuals. Sexual HIV risk behaviors, such as unprotected vaginal and/or anal sex, were assessed for main and nonmain sex partners (past 3 months). Participants who had not had vaginal and/or anal sex with a main and/or nonmain partner in the past 3 months were coded as “no” or not having had unprotected vaginal and/or anal sex in the past 3 months with that partner. We examined the following behaviors: unprotected vaginal and/or anal sex with a main partner of any HIV status (yes/no), unprotected vaginal and/or anal sex with a main HIV-negative or unknown status partner (yes/no), unprotected vaginal and/or anal sex with a nonmain HIV-negative or unknown status partner (yes/no), 1 or more nonmain partners (yes/no), status disclosure to main partner (yes/no), and known partner HIV status (known positive/negative or unsure). Finally, we assessed the average number of sexual partners (as a continuous variable), including the main partner.
Descriptive statistics of the sample were generated to describe the sample and assess the extent of IPV perpetration among the sample. Associations between independent variables and the outcome were calculated using χ2 and t tests, as applicable. There were significant differences in the dependent variable (ie, self-reported perpetration of IPV) by recruitment site; however, multivariate modeling revealed that these differences were explained by sociodemographic factors. Logistic regression models were built to examine the outcome. Modeling was performed by adding variables significant at P < 0.10 to the equation in conceptually related sets, starting first with sociodemographic factors and then adding substance use, psychosocial factors, and, finally, HIV risk behaviors. This hierarchic approach was taken to test specific theoretically derived hypotheses. We used the −2-log likelihood value and the Deviance statistic to guide modeling decisions. We obtained the model of best fit by first obtaining a final set of individual-level variables and then considered whether each successive set of variables (eg, substance use) improved the fit.
Sociodemographic Characteristics of the Sample
As Tables 1 and 2 depict, the average age of the men in the sample was 43.3 (SD = 6.3) years, and most of the men in the sample were African American or Latino. The sample was generally poor, with approximately 40% earning less than $5000 per year and approximately a third reporting current homelessness. Almost half possessed a high school degree or the equivalent; yet, <10% of the sample was employed in paid or salaried full-time positions at the time of the interview. Just more than 20% reported a lifetime history of incarceration. Approximately a quarter of the sample reported being homeless in the year before the interview. A small portion of men (16%) reported being bisexual or unsure of their sexual orientation. In terms of alcohol and drug use, most men in the sample used alcohol (78%) and binged on alcohol at least monthly (68%), and few men (8%) reported not using any type of drug in the past 3 months.
Just more than 40% of men reported perpetrating IPV against their main female partner in the past year. Bivariate analyses revealed that perpetration of IPV was positively associated with several sociodemographic factors, including low education (less than a high school degree), current homelessness, and the research study site (see Table 1). In terms of substance use, there was no association between the perpetration of IPV and alcohol use, binge drinking, and drug use, perhaps because such small portions of the sample did not use alcohol or drugs (between 8% and 22% of the sample; see Table 2).
Among the entire sample, the average number of sex partners was 4.5 (SD = 10.6). As shown in Table 2, men who perpetrated IPV had a significantly higher number of sex partners than men who did not perpetrate IPV (6.2 vs. 3.3; P < 0.05). Men who perpetrated IPV against their main female partner were also significantly more likely to have unprotected vaginal and/or anal sex with that partner than were men who did not perpetrate IPV (57% vs. 40%; P < 0.005). The differences between IPV perpetration and unprotected sex with HIV-negative or unknown status main partners (18% vs. 12%; P < 0.18) and nonmain partners of any HIV status (28% vs. 20%; P = 0.11) were not statistically significant, however. Men who perpetrated IPV were significantly more likely to have unprotected vaginal and/or anal sex with HIV-negative or unknown status nonmain partners (16% vs. 6%; P = 0.001). In terms of injection drug use-related HIV risk behaviors, there were no statistically significant differences between men who perpetrated IPV and those who did not in terms of injecting drugs (81% vs. 87%; P = 0.20) or lending used injection equipment to HIV-negative or unknown status fellow injectors (26% vs. 29%; P = 0.24).
Men who perpetrated IPV against their main female partners differed from those who did not in terms of several psychosocial factors as well (see Table 2). Men who perpetrated IPV reported feeling less personally responsible for the spread of HIV, receiving less social support, and feeling more general distress than men who did not perpetrate IPV.
In multivariate analyses, 2 sociodemographic factors, low education and current homelessness, were significantly associated with IPV perpetration (Table 3). Because the subscales of the BSI were highly correlated, we used the summary score for the entire psychologic distress scale and found that of psychologic distress (the BSI), feelings of responsibility for the spread of HIV, and receipt of social support, only psychologic distress was significantly associated with IPV perpetration in the multivariate model. Finally, of the sexual- and drug use-related HIV risk behaviors entered into the model, just 2 factors, unprotected vaginal and/or anal sex with a main female partner and unprotected vaginal and/or anal sex with an HIV-negative or unknown status nonmain partner, were positively associated with the perpetration of IPV against a main female partner. Thus, men who had unprotected sex with their main partners were 1.7 times more likely to perpetrate IPV with those same partners, and men who had unprotected sex with HIV-negative or unknown status nonmain partners were more than 2.6 times more likely to perpetrate IPV.
In this study, we found high rates of IPV perpetration among HIV-positive male IDUs, with more than 40% reporting perpetrating physical and/or sexual IPV with their main female partners in the past 12 months. Of the 317 men included in the analyses, 13 (4%) reported using any sexual IPV and 129 (41%) reported perpetrating physical or sexual IPV; thus, 5 men (0.3%) reported perpetrating only sexual violence against their main female partners. Compared with a sample of methadone-maintained men, 14% of whom were HIV-positive,43 our sample reported a higher overall prevalence of perpetration (41% vs. 23%). Among a national sample of HIV-positive men in medical care but not necessarily drug involved, Bogart et al44 found that 23% of the men in the sample reported perpetrating physical or sexual violence against a woman with whom they were in a “close” primary relationship. Comparability with both studies is limited, however, because the study by Bogart et al44 restricted the time frame to the past 6 months and the study by El-Bassel et al43 did not include sexual violence in their measure of IPV, which may, in small part, account for the larger portion identified in the current study.
The finding that the men in our sample who perpetrated IPV were generally poorer and less well educated than those who did not perpetrate IPV is consistent with previous research among the general population29 and among people with HIV and receiving medical care55 but differs from findings among men on methadone.40 In this sample of HIV-positive men, just 62% were receiving medical care for their HIV and IPV perpetration did not vary by HIV care status. The men who perpetrated IPV in our sample were also psychologically distressed, which is consistent with some research36 and suggests that, in addition to HIV disease treatment, these men may be in need of or presenting for mental health services. Comprehensive HIV care provision, which currently has low rates of assessment of the perpetration or experience of IPV,56 represents an important point of entry into clinical treatment for HIV-positive people who perpetrate or experience IPV. Thus, these settings should strongly consider consistent and systematic assessment of patients' experiences with IPV.
Our results demonstrated that the HIV-positive men in our sample who perpetrated IPV were also more likely to report unprotected sex with their main female partners. The association between unprotected sex and perpetration of IPV was significant among all main partners, however, regardless of the partners' HIV status. Further, neither disclosure of HIV status nor main female partner's known HIV-positive status was independently associated with IPV perpetration by the men in the sample. Thus, men who perpetrated IPV against a main partner tend also to engage in unprotected sex with that partner, regardless of her HIV status. We also found an association between IPV perpetration against a main female partner and unprotected sex with HIV-negative or unknown status nonmain partners. Whether these men also perpetrate violence with these nonmain partners and what type of partners these nonmain partners are (eg, sex workers, men) are unknown. These nonmain partners are clearly at risk of HIV transmission, however, unless already infected with the virus.
This study among HIV-positive men confirms results from studies among women18 and men43 that IPV and sexual HIV risk behaviors are highly correlated. Research based on women's reports suggests that women find it difficult to negotiate condom use in the context of a physically violent relationship14 and that women's condom requests may be met with violence or the threat of violence by their male partners.57 Studies among men have been more equivocal. Bogart et al44 found that compared with women and gay men who perpetrated IPV, heterosexual HIV-positive men who used violence were less likely to engage in unprotected sex. Among drug-involved men, El-Bassel and colleagues58 failed to find a direct path between the perpetration of physical IPV and sexual HIV transmission risk behaviors using structural equation models, although they did find a direct relation between psychologic dominance and sexual HIV risk behavior with main partners of any HIV status. It is possible that among men, some underlying set of factors are causally related to sexual HIV risk behaviors and IPV perpetration. These factors may include social and psychologic factors and may explain why some research has failed to find direct paths between IPV perpetration and sexual HIV risk behavior,58 despite significant evidence that they are highly correlated.
There are several null findings that are important to address here as well. Some research suggests that childhood physical abuse by a parent or parent figure is a risk factor for perpetration of violence and victimization in adulthood.59 Unfortunately, the questions used in this study were not specific to physical abuse perpetrated by a parent or parent figure, which may explain the lack of an association. In addition, we did not have information on witnessing the abuse of a mother or mother figure, which may also be more important to the perpetration of violence by adult men than experiencing abuse by a parent as a child.59 The finding that alcohol and drug use was not associated with the IPV perpetration may be attributable to a “ceiling effect,” whereby drug use was so ubiquitous that finding an association between it and the perpetration of IPV was difficult. Further, drug and alcohol use was not assessed concurrent with the violent episodes captured in the analysis, which may also explain the lack of association. El-Bassel and colleagues43 also failed to find an association between alcohol use and IPV perpetration in their sample of methadone-maintained men. Galvan and colleagues55 did find an association between binge drinking and drug dependence and IPV perpetration among their sample of people with HIV, however.
Before drawing any conclusions from these data, it is important to consider the limitations of the analysis. First, this study can make no claims to establishing causality because of the cross-sectional nature of the analysis. In addition, the time frame used to measure IPV perpetration differed from the correlates we were examining. Thus, the outcome, perpetration of IPV, reflected a 12-month window, whereas the substance use and HIV risk behavior measures captured the past 3 months. The data for this analysis derive from a convenience sample of men recruited from clinic and community sources in 4 US cities; thus, generalizations to other HIV-positive male IDUs cannot be made with certainty. The sample is from multiple sites, however, and included treatment- and community-based recruited individuals. Further, although the accuracy of self-reports from IDUs is a significant concern,60 this study used computerized data collection methods, which have been shown to enhance reporting of sensitive risk behaviors among IDU samples.61 Similarly, there are data to suggest that in face-to-face interviews, men tend to underreport their IPV perpetration against their female partners, resulting in an underestimate of the true prevalence of the perpetration of IPV among male HIV-positive IDUs.29,62 Finally, because this analysis is a post hoc analysis of a data set not designed to identify predictors of IPV perpetration, several important variables were not measured, such as marital status, witnessing abuse of a mother or mother figure in childhood,59 personality characteristics associated with IPV perpetration36 and hostile or sexist attitudes toward women.37,56 In addition, the survey did not evaluate perpetration of IPV with nonmain or same-sex partners, thus potentially underestimating the prevalence of IPV perpetration among HIV-positive male IDUs.
Another important conceptual limitation of this work is that the measure of IPV used here assessed only physical and sexual violence, and thus did not reflect other types of violence, such as emotional/psychologic or financial. As we stated at the outset, the measure used in the present analysis captured what we have chosen to term perpetration of IPV and not partner abuse, which can be understood to reflect a constellation and pattern of behaviors and attitudes that work comprehensively to control the partner.46-48 With that said, research among women has consistently found that physical and/or sexual violence victimization alone has a chilling effect on condom use negotiation, for example, and other adverse health outcomes (for a summary of the literature, see the article by Campbell27). Still, a more comprehensive measure of IPV that included psychologic violence and controlling behaviors would have provided a more in-depth picture, because recent research suggests that psychologically controlling behaviors may differentiate various forms of IPV.46,63,64
Along the same lines, perpetration of IPV captured in this analysis may also reflect being a victim of or experiencing IPV, such that the data reflect retaliatory violence or acts of self-defense. Without additional contextual information (beyond simply assessing perpetration by both partners) and better measures of IPV, however, it is not possible to make a determination as to whether these men are “batterers” or “victims.” We examined whether the respondents only perpetrated, only experienced (ie, were victimized), or perpetrated and experienced physical and/or sexual IPV; we found that only 19 men reported only perpetrating and not experiencing any IPV, whereas 105 men reported perpetrating and experiencing IPV with their main female partners. Research that conceptualizes these 105 men as parties to what has been termed mutual violence ignores the growing understanding within the domestic and family violence literature regarding the need to include such information as the role of controlling behaviors,46 offensive versus defensive assaults, the dynamics of abusive relationships, the greater likelihood that women are injured during physical assaults,65 subjective perceptions of assault, relative interpersonal power within the relationship, the history of violence in the relationship,48 and the larger social context within which women possess less power relative to men,66 among other information (for detailed discussion and review of the empiric literature, see the articles by Kimmel,31 Archer,32 and O'Leary33). Without at least some of this information, it is not possible to determine what portion of the 105 men who perpetrated and experienced IPV are truly in mutually and equally “abusive” relationships. Further, analyses with the 36 men (11%) who reported not using but only experiencing IPV revealed findings generally consistent with findings among women who experience abuse67; thus, bivariate analyses revealed that these men were more highly educated, more likely to use depressant drugs, more likely to inject drugs, and felt significantly less empowered and more depressed than men who used and received, only used, or neither used nor received.
Perpetration of partner violence by HIV-positive male IDUs is a significant public health and social problem. The health effects of experiencing violence for women are multiple and severe. As women continue to make up a growing proportion of new HIV diagnoses68 and research on the role of the experience of violence in susceptibility to HIV and other STIs grows, it is imperative that we develop a better understanding of the men who perpetrate violence, particularly men at risk of transmitting HIV. This article contributes to the small but growing literature on the prevalence and correlates of the perpetration of partner violence by HIV-positive men. These findings suggest that a significant portion of HIV-positive men are perpetrating IPV against their female partners and that important sexual HIV transmission risk behaviors are associated with the perpetration of IPV in this sample of men, many of whom are in medical care for HIV disease. HIV care has begun to integrate the assessment and treatment of violence experience and perpetration, but these efforts are not consistent. There is a need to develop the knowledge base further and to develop and test programs systematically to address the perpetration of IPV in the context of living with HIV and being drug involved. Thus, more sophisticated research is needed that better conceptualizes the construct of IPV, for example, by measuring battering or abuse and various forms of violence, assessing all the risk factors that have been identified for men's perpetration of IPV, and following men over time to understand the natural history of IPV perpetration across the lifespan better and how HIV and drug involvement influence this behavior. From these data, interventions to prevent IPV perpetration may be developed specifically for HIV-positive men and women who experience IPV.
The INSPIRE Study Team includes the following people: Carl Latkin, Amy Knowlton, and Karin Tobin (Baltimore); Lisa Metsch, Eduardo Valverde, James Wilkinson, and Martina DeVarona (Miami); Mary Latka, Dave Vlahov, Phillip Coffin, Marc Gourevitch, Julia Arnsten, and Robert Gern (New York); Cynthia Gomez, Kelly Knight, Carol Dawson Rose, Starley Shade, and Sonja Mackenzie (San Francisco); David Purcell, Yuko Mizuno, Scott Santibanez, Richard Garfein, Ann O'Leary, Ying Chen, and Craig Borkowf (Centers for Disease Control and Prevention); and Lois Eldred and Kathleen Handley (Health Resources and Services Administration).
The authors acknowledge the following people for their contributions to this research: Susan Sherman, Roeina Marvin, Joanne Jenkins, Donny Gann, and Tonya Johnson (Baltimore); Clyde McCoy, Rob Malow, Wei Zhao, Lauren Gooden, Sam Comerford, Virginia Lo Cascio, Curtis Delford, Laurel Hall, Henry Boza, and Cheryl Riles (Miami); George Fesser, Victoria Frye, Carol Gerran, Laxmi Modali, and Diane Thornton (New York); Caryn Pelegrino, Barbara Garcia, Jeff Moore, Erin Rowley, Debra Allen, Dinah Iglesia-Usog, Gilda Mendez, Paula Lum, and Greg Austin (San Francisco); Gladys Ibanez, Hae-Young Kim, Toni McWhorter, Jan Moore, Lynn Paxton, and John Williamson (CDC);and Lee Lam, Jeanne Urban, Stephen Soroka, Zilma Rey, Astrid Ortiz, Sheila Bashirian, Marjorie Hubbard, Karen Tao, Bharat Parekh, and Thomas Spira (CDC Laboratory).
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