SEXUAL TRANSMISSION OF HEPATITIS B VIRUS, HEPATITIS C VIRUS, AND

HUMAN IMMUNODEFICIENCY VIRUS TYPE 1 INFECTIONS AMONG MALE

TRANSVESTITE COMERCIAL SEX WORKERS IN MONTEVIDEO, URUGUAY
JOSE C. RUSSI, MARGARITA SERRA, JOSE VIOLES, M. T. PREZ, D. RUCHANSKY, G. ALONSO,
JOSE L. SANCHEZ, KEVIN L. RUSSELL, SILVIA M. MONTANO, MONICA NEGRETE, AND
MERCEDES WEISSENBACHER
Department of Laboratories, and AIDS/HIV National Program, Ministry of Heath, Montevideo, Uruguay; Walter Reed Army
Institute of Research, Silver Spring, Maryland; United States Naval Medical Research Center Detachment, Lima, Peru; AIDS National
Reference Center, Buenos Aires, Argentina
Abstract. Prostitution may constitute a risk behavior for infection with hepatitis B virus (HBV), hepatitis C virus
(HCV), and human immunodeficiency virus (HIV). We conducted a seroepidemiologic study among 200 male trans-
vestite commercial sex workers (CSWs) in Montevideo, Uruguay in 1999. Evidence of exposure to HBV, HCV, and HIV
was found in 101 (50.5%), 13 (6.5%), and 43 (21.5%) individuals, respectively. Positivity for HIV was correlated with
both HBV (odds ratio [OR] 2.15, 95% confidence interval [CI] 1.014.67) and HCV (OR 3.47, 95% CI
0.9012.79) infection. Predictors of infection were older age ( 26 years; P < 0.01) for all 3 viruses and time in CSW
(5 years; P < 0.05) for HBV and HIV. Prior history of use of drugs (OR 3.54, 95% CI 1.0911.52) and sexual
contact with foreigners (OR 9.2, 95% CI 1.1673.12) were found to be associated only with HCV infection. Sexual
transmission of these viruses constitutes a significant problem among male transvestite CSWs.
INTRODUCTION
Viral sexually transmitted infections (STIs) constitute an
important cause of morbidity among the sexually active popu-
lation. Human immunodeficiency virus (HIV) and hepatitis B
virus (HBV) are among those viruses that may lead to severe
chronic infections and sequelae. Infection with HBV is known
to be an important sexually transmitted disease;
16
approxi-
mately 50% of infections are thought to be acquired by sexual
contact.
7
Perinatal transmission represents an additional effi-
cient route of infection.
8,9
Hepatitis C virus (HCV) is also
thought to be transmitted sexually, although to a much lesser
extent than HBV.
814
Similar to HBV, HCV can also be
transmitted vertically, especially in women who are co-
infected with HIV.
15,16
In Uruguay, there is a lack of information regarding the
prevalence of HBV, HCV, and HIV viral infections in per-
sons who practice commercial sex work. Seroprevalence sur-
veys conducted among female commercial sex workers
(CSWs) in Uruguay and other countries in South America
seem to indicate a relatively low HIV prevalence of less than
1% (Montano SM and others, unpublished data).
17
In con-
trast, initial estimates of HIV prevalence among male trans-
vestite CSWs in Montevideo have ranged between 19.9% (in
2001) and 21.5% (in 1999), with an observed yearly incidence
of 17.3% (Serra M and others, unpublished data and Russell
K and others, unpublished data).
In the present study, we determined the cross-sectional se-
roprevalence of HBV, HCV, and HIV among a large group of
male transvestite CSWs in Montevideo and sought to identify
potential risk factors predisposing to infection with these
agents.
MATERIALS AND METHODS
Study population. A convenience sample of male transves-
tite CSWs in Montevideo was interviewed during the period
of March through August 1999. Study participants were re-
cruited during the evening hours at working locations such as
streets, discotheques, and nightclubs. Recruitment was car-
ried out by a group of Ministry of Health (MOH) workers
previously trained on counseling for HIV and STI prevention.
In preparation for this study, meetings were held with trans-
vestite organization leaders to solicit support and explore
methods for enhanced participation. Individual interviews
were conducted primarily in the street; study goals were ex-
plained and pretest counseling was offered.
Volunteers were sampled only after initial written informed
consent was obtained. The study protocol was reviewed and
approved by Institutional Review Boards at the Uruguayan
MOH and at the U.S. Naval Medical Research Center (Be-
thesda, MD). Along with counseling, printed and oral infor-
mation on HIV/STI prevention was given, and condoms and
lubricant gel products were provided as requested by study
participants.
Specimen processing. A single blood sample (710 mL)
was obtained, allowed to clot for 12 hours, and centrifuged,
and the serum was separated and frozen at -20C within three
hours of collection for later testing. Individuals were provided
with a coded, preprinted card, devoid of name or other per-
sonal identifiers to ensure anonymity. This preprinted card,
which only contained the subjects study code without any
name or other identifier information, was used by study sub-
jects to obtain results of testing in an anonymous fashion and
only after the person presented himself to request test results.
Serologic testing. Evidence of hepatitis B surface antigen
(HBsAg) carriage was assessed using an immunochromato-
graphic technique (Determine HBsAg; Abbott Laboratories,
Abbott Park, IL) and evidence of past/present HBV infection
was assessed by presence of antibodies to hepatitis B core
antigen (anti-HBc) with a microenzyme immunoassay
(MEIA Corezyme IMx; Abbott Laboratories, Weisbaden-
Delkenheim, Germany). Past exposure to HCV was deter-
mined with an enzyme immunoassay (EIA) (HCV UBI; Or-
ganon-Teknika, Hauppauge, NY); repeatedly reactive
samples on the EIA were confirmed by a line immunoassay
technique (Liatek HCV III; Organon-Teknika, Boxtel, The
Netherlands). Past infection with HIV was determined by
EIA screening (HIV 1/2, MEIA-IMx; Abbott Laboratories,
Abbott Park, IL) with immunoblot confirmation (New LAV
Blot 1; Sanofi-Pasteur, Marnes-La-Coquette, France) of re-
peatedly reactive serum samples.
Am. J. Trop. Med. Hyg., 68(6), 2003, pp. 716720
Copyright 2003 by The American Society of Tropical Medicine and Hygiene
716
Data analysis. Seroprevalence rates were compared by
means of chi-square and Fishers exact tests with 95% confi-
dence intervals (CIs). Stratified analysis for associations of
HIV status and HBV-HCV markers were conducted using
Mantel-Haenszel chi-square tests. Analysis of risk factors was
conducted using univariate, bivariate (adjustment for an age
greater than 26 years versus a younger age), and multivariate
unconditional logistic regression methods.
RESULTS
Of 205 individuals who were approached for participation
in this study, 200 (98%) agreed to participate. Most (92%)
were born in and residents of Uruguay and the remaining 8%
were foreign individuals who came from either bordering
countries (Argentina and Brazil) or other countries such as
Nicaragua or Spain. The sociodemographic characteristics of
study group subjects are shown in Table 1. Approximately
three-fourths were less than 36 years of age (range 1858
years, median 29 years), most (78%) engaged in street-
based commercial sex work, and few (1%) were recognized
being engaged in a marital (i.e., stable monogamous) rela-
tionship.
The extent of sexual contacts varied greatly, with a mean of
approximately 20 partners per week (range 151, median
20). Approximately two-thirds of subjects reported be-
tween 11 and 30 clients per week and 15% reported more
than 30 clients per week. Of the 192 male transvestite CSWs
for whom data was available, 51 (27%) had engaged in pros-
titution for a period of less than five years. Non-injecting drug
consumption was common in 73 (37%) of subjects admitting
inhalational drug use. Of these, 50 (69%) reported cocaine
use and 28 (38%) reported marihuana use. Intravenous drug
use (IDU) was infrequent, reported by only six (3%) of the
subjects.
Overall, anti-HBc positivity was found in 101 (50.5%) of
the study subjects, HBsAg carriage in only six (3%), antibod-
ies to HCV in 13 (6.5%), and HIV positivity in 43 (21.5%).
The distribution of these markers by age group, marital sta-
tus, and workplace location is shown in Table 2. Individuals
more than 25 years of age had significantly higher (P < 0.01)
rates of infection for all three viruses. Higher risks of infection
with HBV were found in older subjects (odds ratio [OR]
2.06, 95% CI 1.083.96), whereas risk of HCV infection
was also found to be higher (OR undefined) when com-
pared with younger subjects. More importantly, the risk of
HIV infection was found to be almost five times higher in
older subjects (OR 4.70, 95% CI 1.7016.05). In addi-
tion, street-based subjects appeared to have sustained a
higher HBV infection rate than others (OR 1.70, 95% CI
0.893.26).
The statistical associations between HIV infection status
and HBV and HCV seroprevalences are shown in Table 3.
The seroprevalences of HBV and HCV were found to be
significantly higher (P < 0.05) among HIV-positive subjects
(OR for HBV 2.15, 95% CI 1.014.67; OR for HCV
3.47, 95% CI 0.9012.79). These positive statistical asso-
ciations between hepatitis B and hepatitis C and past HIV
infection were seen to occur after stratification by age.
Univariate data analysis showed nonsignificant differences
in terms of IDU and HIV, HBV, or HCV serostatus. How-
ever, the study sample was too small to be able to evaluate
IDU as a risk factor since the number of subjects with such a
history was too small (n 6). Likewise, no association was
detected between sexual contact frequency (judged by the
number of weekly clients) and HIV, HBV, or HCV serosta-
tus.
We also found a statistically significant (P < 0.05) direct
correlation between length of time in commercial sex work
and HBV/HIV seroprevalence (Table 4). For HBV, a risk
more than two times higher was documented (OR 2.27,
95% CI 1.1214.64) for those with five or more years as a
CSW, whereas for HIV, a risk almost three times higher was
found (OR 2.57, 95% CI 0.987.96).
Age-adjusted bivariate (Table 5) and multivariate uncon-
ditional logistic regression analysis were performed, taking
into consideration all variables found to be significant on uni-
variate analysis or thought to be of biologic importance in
determining risk for infection with any or all of the three
viruses. Prior use of drugs (adjusted AOR [AOR] 3.54,
95% CI 1.0911.52) was found to be associated with prior
HCV infection, but not HBV infection. Older age (AOR
4.33, 95% CI 1.3913.51) and prior use of intravenous
drugs (AOR 20.98, 95% CI 1.40314.54) were also sig-
nificantly associated with risk of HIV infection.
In addition, a history of sexual contact with foreigners was
also found to be a significant factor only for HCV infection
(AOR 9.22, 95% CI 1.1673.12). It should be noted that
a majority of subjects, approximately two-thirds, had sus-
tained sexual contact with Americans (i.e., from the United
States); contacts with Europeans and Africans occurred in
only approximately one-fourth of the subjects.
DISCUSSION
Commercial sex work is a recognized means of employ-
ment in many parts of the world. Considerable variation ex-
ists in terms of type and distribution of such trade practices
exist. The diversity in the types of commercial sex work prac-
TABLE 1
Sociodemographic characteristics of the study group (n 200)
Characteristic Distribution
Mean age SD (range, median) 30.5 8.2 (1858, 29)
Age group (years) No. (%)
1825 65 (32.5)
2630 43 (21.5)
3135 37 (18.5)
3640 28 (14.0)
>40 27 (13.5)
Marital status, no. (%)
Married 2 (1.0)
Single or widowed 163 (81.5)
Concubinate 33 (16.5)
Divorced 1 (0.5)
Missing 1 (0.5)
Workplace location, no. (%)*
Prostitution house 3 (1.5)
Bar 26 (13.0)
Discotheque 9 (4.5)
Street 155 (77.5)
Home 19 (9.5)
Other 3 (1.5)
No. of sexual partners per week, mean
SD (range, median) 20.5 11.2 (151, 20)
* More than one category per subject is possible.
HBV, HCV, AND HIV IN TRANSVESTITES 717
ticed by heterosexual women, transgendered persons, and
transvestite men reflects, to some extent, the variety of client
demands for sexual services.
18
Unfortunately, such client-
based sexual services are often performed in an unprotected
fashion and invariably result in increased transmission of
sexually transmitted infections
19
with HIV-1, HBV, and pos-
sibly HCV.
In Uruguay, commercial sex work is regulated by law and
CSWs are registered and controlled on a regular basis in ac-
cordance with the policies of the MOH and Department of
Interior, under supervision of government authorities (Law
8080 in 1895, modified by decree number 10, MOH, July 22,
1932). However, it is well recognized that unregistered CSWs
exist, thus, making it difficult for MOH authorities to accu-
rately estimate the population at risk or reliable rates of STIs.
Particularly difficult is estimation of the population of trans-
vestite men at risk. Nevertheless, approximately 2,000 trans-
vestite men are estimated to be engaged in commercial sex in
the city of Montevideo alone (Violes J, unpublished data).
The seroprevalence of HBV in Uruguay is very low and
similar to that estimated from the 1970s to the 1990s for blood
donor populations in the United States.
19,20
Only approxi-
mately 4% of the blood donor population have evidence of
past infection as reflected by the presence of anti-HBc, and
0.2% are considered to be chronic carriers of HBsAg.
21
In
comparison, the seroprevalence of antibodies to HCV in
blood donors in Uruguay is only 0.3%,
24
which approximates
rates of antibodies to HCV in developed countries.
22
Specific
vulnerable populations with high HCV infection rates have
been reported and include patients undergoing renal dialysis,
hemophiliacs, HIV-infected individuals, and intravenous drug
users (Cardozo A and others, unpublished data).
23
Our study illustrates that male transvestite CSWs in Uru-
guay have a high risk of infection with HBV and HIV, and to
a lesser degree with HCV. Infections with both HBV and
HCV were significantly associated with an HIV-positive se-
rostatus. This was most likely due to the fact that these three
viruses share similar routes of transmission. This correlates
well with the published literature, which indicates sexual
transmission as a main factor for HBV infection
19,24,25
and as
a secondary factor in HCV acquisition.
19,26
Evidence of a previous infection with HBV in this group of
transvestites was very high when compared with volunteer
blood donors in Uruguay in 1998, both for anti-HBc (51%
versus 4%) as well as for HBsAg (3% versus 0.2%).
21
This is
most likely due to the presence of sexual risk factors for in-
fection in this group, as suggested by the concomitant high
rate for HIV infection (21.5%) and the demonstrated sexual
promiscuity reported by study subjects.
What is especially interesting in this case, however, is the
association found between HCV and HIV infection in which
the risk of HCV infection was increased almost four-fold in
TABLE 3
Correlation of HIV status and markers for hepatitis B and C*
HIV
status
Number
tested
HCV positive
no. (%)
HBsAg positive
no. (%)
Anti-HBc positive
no. (%)
Positive 43 6 (14.0) 3 (7.0) 28 (65.1)
Negative 157 7 (4.5) 3 (1.9) 73 (46.5)
* For definitions of abbreviations, see Table 2.
P < 0.05, higher prevalence in HIV-positive group; odds ratio (OR) 3.47, 95% con-
fidence interval (CI) 0.9012.79.
P < 0.05, higher prevalence in HIV-positive group; OR 2.15, 95% CI 1.014.67.
TABLE 4
Seropositivity for hepatitis and HIV markers by length of time as a
commercial sex worker (CSW) Montevideo, Uruguay, 1999*
Length of time
as a CSW (years)
Number
tested
HCV
positive
no. (%)
HBsAg
positive
no. (%)
Anti-HBc
positive
no. (%)
HIV
positive
no. (%)
<5 51 2 (3.9) 3 (5.9) 19 (37.3) 6 (11.8)
5 141 11 (7.8) 2 (1.4) 81 (57.4) 36 (25.5)
* Eight subjects had unknown data. For definitions of abbreviations, see Tables 2.
P < 0.05, higher prevalence in group with 5 or more years, odds ratio (OR) 2.27, 95%
confidence interval (CI) 1.1214.64.
P < 0.05, higher prevalence in group with 5 or more years, OR 2.57, 95% CI
0.987.96.
TABLE 2
Distribution of markers for hepatitis B and C and HIV by sociodemographics*
Characteristic Number tested
HCV positive
no. (%)
HBsAg positive
no. (%)
Anti-HBc positive
no. (%)
HIV positive
no. (%)
Age group (years)
1825 65 0 (0) 1 (1.5) 25 (38.5) 5 (7.7)
2635 80 7 (8.8) 4 (5.0) 41 (51.3) 23 (28.8)
>35 55 6 (10.9) 1 (1.8) 35 (63.6) 15 (27.3)
Marital status
Married 2 1 (50.0) 0 (0) 2 (100.0) 2 (100.0)
Single or widowed 163 8 (4.9) 4 (2.5) 86 (52.8) 36 (22.1)
Concubinate 33 3 (9.1) 1 (3.0) 11 (33.3) 3 (9.1)
Divorced 1 1 (100.0) 0 (0) 1 (100) 1 (100)
Workplace location
Prostitution house 3 0 (0) 0 (0) 2 (66.7) 2 (66.7)
Bar 26 2 (7.7) 0 (0) 12 (46.2) 5 (19.2)
Discotheque 9 1 (11.1) 1 (11.1) 3 (33.3) 0 (0)
Street 155 11 (7.1) 5 (3.2) 85 (54.8)# 38 (24.5)
Home 19 1 (5.3) 0 (0) 6 (31.6) 2 (10.5)
Other 3 0 (0) 0 (0) 2 (66.7) 0 (0)
* HIV human immunodeficiency virus; HCV hepatitis C virus; HBsAg hepatitis B surface antigen; Anti-HBc antibodies to hepatitis B core antigen.
P < 0.01, increasing prevalence with age; odds ratio (OR) undefined.
P < 0.01, increasing prevalence with age; OR 2.06, 95% confidence interval (CI) 1.083.96 for subjects more than 25 years of age.
P < 0.01, increasing prevalence with age; OR 4.70, 95% CI 1.7016.05 for subjects more than 25 years of age.
One individual had unknown data on marital status.
# P 0.08, higher prevalence in street-based; OR 1.70, 95% CI 0.893.26 for street-based subjects.
RUSSI AND OTHERS 718
HIV-infected subjects. This association, as in the case of
hepatitis B, potentially reflects similar routes of transmission,
especially the suggestion that hepatitis C may be sexually
transmitted since the frequency of IDU in this population was
very low (only 3% of the study subjects) and a history of
sexual contact with foreigners was found to be a significant
risk factor. In comparison, HCV transmission among other
risk groups such as hemophiliacs and patients on chronic re-
nal dialysis is well documented,
26
and previous studies in
Montevideo have documented very high HCV prevalence
rates among hemophiliacs (91%), in HIV-infected patients
(44%), and in patients undergoing chronic hemodialysis
(10%) (Cardozo A and others, unpublished data).
23
The
overall prevalence of HCV among volunteer blood donors in
Uruguay has been found to be only 0.3%, which is compa-
rable to the general population rates seen in other developed
countries such as the United States.
21
Sexual transmission of HCV has been found to play an
important role in previous studies among homosexu-
als,
12,14,19,20
but has not been previously evaluated among
male transvestite populations. Although the overwhelming
evidence points to sexual transmission playing a secondary
role in transmission of hepatitis C, there is some evidence that
this route may be of greater importance among individuals
with many sexual partners, who sustain frequent STIs and
who practice unprotected sexual (including anal) inter-
course.
12,27
Such activities are commonly seen among male
transvestite CSWs in Uruguay (Serra M and others, unpub-
lished data and Russell K and others, unpublished data).
The prevalence of HIV infection reported in this group of
transvestites (21.5%) is particularly high, especially when
compared with data from other sentinel studies in Uruguay.
Studies performed among female CSWs in Uruguay in
19992001 have documented an HIV seroprevalence rate be-
tween 0.3% and 0.7% (Montano SM and others, unpublished
data). In the general population, as judged by the prevalence
in antenatal patients, a rate of only 0.3% has been docu-
mented (Serra M, unpublished data), whereas among volun-
teer blood donors a rate of only 0.07% has been observed.
21
This definitively supports the notion that these male trans-
vestite CSWs have an increased risk of contracting an HIV
infection.
Few previous studies have examined the risk for infec-
tion with HBV, HCV, or HIV among transgendered individu-
als. One study performed in Amsterdam in 1996 found an
HIV seroprevalence of 24% in transvestite sex workers,
28
whereas in Rome, a high HIV prevalence (74%) was ob-
served among transvestite intravenous drugs users who par-
ticipated in the sex trade.
29
In Karachi, Pakistan, a serologic
study conducted in 1998 among 208 transvestites showed an
HBsAg prevalence of 3.4%; however, no HIV infections were
observed.
30
In Athens, Greece, among 43 male-to-female
transsexual prostitutes, 65.1% were infected with hepatitis B
and 4.7% with hepatitis C.
31
Lastly, a study carried out in
19901991 among 53 transvestite sex workers in Atlanta,
Georgia showed a prevalence of 68.9% for HIV and 80% for
HBV.
32
To diminish the risk of contracting STIs, short-term edu-
cational programs on HBV/HCV and HIV/AIDS prevention
and effective interventions should be implemented. Such pre-
vention activities must then be evaluated. As part of this as-
sessment, it is essential that prevalent STIs and their associ-
ated risk factors be continuously monitored in high-risk
groups of male transvestite and female CSWs. Preventive
measures, such as vaccination for HBV, can thus be appro-
priately tailored to these hard-to-reach high-risk groups, thus
reducing the emerging impact such viral STIs have among
them.
Received October 30, 2002. Accepted for publication March 10,
2003.
Financial support: This work was supported by the U.S. Military HIV
Research Program, Walter Reed Army Institute of Research (Rock-
ville, MD), and by the U.S. Naval Medical Research and Develop-
TABLE 5
Bivariate unconditional logistic regression analysis (adjusted for age)*
HCV HBV HIV
AOR 95% CI AOR 95% CI AOR 95% CI
Marital status
Married/concubine Ref Ref Ref
Single, unmarried, or divorced 0.45 0.131.59 2.01 0.944.30 1.83 0.655.15
Sexual contacts per week
09 Ref Ref Ref
1019 0.54 0.102.96 1.28 0.523.15 1.38 0.454.25
2029 0.45 0.082.45 1.91 0.834.37 1.54 0.534.45
30 1.01 0.205.08 1.12 0.462.76 0.86 0.252.91
Workplace
At home Ref Ref Ref
Bar or Discotheque Undefined Undefined 1.90 0.399.39 2.24 0.2123.63
Street Undefined Undefined 3.15 0.7712.81 3.47 0.4228.78
Time as CSW (5 years) 0.92 0.194.50 1.96 0.964.00 1.62 0.604.39
Sex for money or favor 0.96 0.118.20 2.25 0.816.26 1.25 0.334.69
Condom use 0.67 0.143.22 1.42 0.673.02 0.92 0.382.24
Use of condom-oral sex 1.23 0.393.89 0.69 0.381.23 1.07 0.532.17
Use of condom-anal sex 1.16 0.304.55 1.53 0.713.30 1.39 0.593.25
Use of drugs (any) 3.54 1.0911.52 1.39 0.772.51 1.72 0.853.52
Use of intravenous drugs 5.00 0.4259.26 0.52 0.092.97 6.15 1.0037.91
Sex with foreigner 9.22 1.1673.12 0.79 0.451.40 1.63 0.793.38
* HCV hepatitis C virus; HBV hepatitis B virus; HIV human immunodeficiency virus; AOR, adjusted odds ratio; 95% CI 95% confidence interval on AOR; Ref reference group
for comparison; Undefined AOR not calculated due to lack of observations in reference group; CSW commercial sex worker; Characteristics in bold represent significant values at the P
< 0.05 level.
HBV, HCV, AND HIV IN TRANSVESTITES 719
ment Command (Silver Spring, MD) Work Unit No. 62787 A 873 H
B0002.
Disclaimer: The opinions and assertions made by the authors do not
reflect the official position or opinion of the U.S. Department of the
Navy or Army or the Uruguayan Ministry of Health.
Authors addresses: Jose C. Russi, M. T. Prez, D. Ruchansky, and G.
Alonso, Ministerio de Salud Pblica, Departamento de Laboratorios,
Avenida 8 de Octubre 2720, Montevideo, Uruguay, Telephone: 598-
2-487-2516, Fax: 598-2-480-2014. Margarita Serra and Jose Violes,
Ministerio de Salud Pblica, Programa Nacional de SIDA/VIH, 18 de
Julio 1892, 4to Piso, Montevideo, Uruguay, Telephone: 598-2-408-
8296, Fax: 598-2-408-8399. Jose L. Sanchez, U.S. Military HIV Re-
search Program, Walter Reed Army Institute of Research, 13 Taft
Court, Suite 200, Rockville, MD 20850, Telephone: 301-251-5000,
Fax: 301-762-4177. Silvia Montano, U.S. Naval Medical Research
Center Detachment-Lima, Unit 3800, American Embassy-Lima,
APO AA 34031-3800, Telphone: 51-1-561-2882, Fax: 51-1-561-3042.
Kevin Russell, U.S. Naval Health Research Center, PO Box 85122,
San Diego, CA 92186-5122, Telephone: 619-553-7628, Fax: 619-553-
7601. Monica Negrete, Medecins Sans Frontieres, Apartado No.
5850, Managua, Nicaragua, Telephone: 50-5-222-3532, Fax: 50-5-222-
2482. Mercedes Weissenbacher, Centro Nacional de Referencia para
el SIDA, Departamento de Microbiologia, Facultad de Medicina,
Universidad de Buenos Aires, Paraguay 2155, Piso 11 (1121), Buenos
Aires, Argentina, Telephone: 54-11-4508-3689, Fax: 54-11-4508-3705.
Reprint requests: Jose L. Sanchez, U.S. Military HIV Research Pro-
gram, Walter Reed Army Institute of Research, 13 Taft Court, Suite
200, Rockville, MD 20850, Telephone: 301-251-5000, Fax: 301-762-
4177, E-mail: jsanchez@hivresearch.org.
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