International Journal of STD & AIDS

Tracing and treating contacts (partner notification, PN) is a crucial part of the control of sexually transmitted infections but few studies have quantified its outcome. A retrospective national study obtained information from 155 clinics on 1308 patients with gonorrhoea, 59% of all UK patients attending in January to March 1995. These gave 1887 contacts (1 : 1.5) of whom 621 attended, 75% being found to be infected. The ratio of contacts attending to index patients was 0.5 (621/ 1260). The ratio was not influenced by gender or ethnicity, but was affected by orientation, being 0.5 for contacts of male heterosexuals, 0.3 for contacts of male < homosexuals (P 0.001). PN outcome was less good in metropolitan (0.3) than provincial clinics (0.5), suggesting that further research is necessary on the reasons for this difference. Reliable ongoing outcome audit will require good communication between clinics to verify that contacts have attended. The contact:index ratio is suitable for evaluation of PN as it relates to actual outcome rather than to the patient's account of contact numbers. Local work can be assessed against these national figures.

Our aim was to determine the number of chlamydial infections detected by Cobas Amplicor CT/NG multiplex polymerase chain reaction (PCR) testing of genital and first-voided urine (FVU) specimens compared with routine culture. Two hundred and eighty-six female and 276 male patients attending the Genito-Urinary Medicine (GUM) Unit at Edinburgh Royal Infirmary were included in the study. Case notes were analysed retrospectively to determine how many infected patients would not have been treated had diagnosis relied on routine culture. Polymerase chain reaction on FVU from women had a sensitivity, specificity, positive and negative predictive value of 91%, 100%, 100% and 99.1%: corresponding values for genital PCR and culture were 96%, 100%, 100%, 99.6% and 65%, 100%, 100%, 96.7% respectively. PCR on FVU from men had a sensitivity, specificity, positive and negative predictive value of 96%, 99.1%, 92.6% and 99.5%: corresponding values for genital PCR and culture were 89%, 99.5%, 95.8%, 98.6% and 48%, 100%, 100%, 94.3% respectively. In both men and women genital PCR and urine PCR were significantly more sensitive than culture. PCR almost doubled the number of patients detected by culture (49 vs 27). Of the 22 cases detected only by PCR 8 would not have received treatment on the basis of clinic treatment policy.

We aimed to describe and compare sexual links among people with gonorrhoea, by studying patients in 2 UK departments of genitourinary medicine. Interviews were completed for 510 and 235 cases in London and Sheffield respectively. There was a greater proportion of cases in men, homosexual men, non-white and non-British people and fewer female sex workers in London. Total networks of 1738 people in London and 570 people in Sheffield were described. Large linked heterosexual networks identified in Sheffield were associated with local contact, including men with higher numbers of sexual partners. Condom use for vaginal sex was reported for 11% of heterosexual partnerships in Sheffield, and 27% in London, with little difference between regular and casual partners. It was more difficult to define networks in London due to a high proportion of relatively anonymous contacts. These difficulties suggest that research and interventions may profitably focus upon venues for meeting partners as well as partner notification.

Sexual functioning is often neglected in the care of HIV-infected patients. Little information exists about the relationship between hormonal factors, psychological factors, medication, HIV disease stage and sexual functioning among persons with HIV disease. In this study, 50 HIV+ men completed the Derogatis Sexual Functioning Inventory (DSFI), and had serum hormonal assays drawn (testosterone, thyroid function test, leuteinizing hormone, prolactin and oestradiol). Although all the subjects reported some degree of sexual dysfunction, persons with symptomatic HIV/AIDS reported more negative mood, lower sexual satisfaction scores and worse body image than persons with asymptomatic HIV. Persons with asymptomatic HIV also tended to have normal testosterone levels compared with persons with symptomatic HIV/AIDS. No relationship was found between medications and low testosterone, although numbers were small. These results suggest that sexual dysfunction is prevalent among persons with HIV disease, is more common as patients become symptomatic and progress to AIDS and that both physiological (low testosterone) and psychological issues play a role.

Women who were partners of HIV-positive blood donors were enrolled in a study of heterosexual HIV transmission between March 1992 and December 1996 and were interviewed and examined. Gynaecological conditions, including cervical dysplasia, human papillomavirus (HPV) infection, gonorrhoea, chlamydial infection, trichomoniasis, bacterial vaginosis, vaginal candidiasis and syphilis were assessed in addition to HIV status and CD4 level. Of 481 women enrolled, 224 (46.6%) were HIV seropositive. HIV-infected women were more likely to have abnormal vaginal discharge on physical examination (OR=2.6, P 0.01), HPV infection with a high-risk type (OR=6.9, P 0.01), and cervical dysplasia (OR=5.3, < P 0.01). The prevalence of other gynaecological conditions detected at the enrolment visit did not differ by HIV status. History of prior STD (OR=2.0, < P 0.01) was more common among HIV-infected women. The median CD4 count mu was 400 cells/ l among HIV-infected women. The prevalence of abnormal vaginal discharge and bacterial vaginosis increased significantly with decreasing CD4 count. The prevalence of ectopy, vaginal candidiasis, and cervical dysplasia increased with decreasing CD4 count, but these trends were not significant. We conclude that HIV-infected Thai women appear to have increased prevalences of abnormal vaginal discharge, squamous intraepithelial lesions and self-reported history of STD. < <

This study set out to investigate whether plasma mannose-binding protein (MBP) deficiency caused by mutations in the MBP gene associates with pyogenic or opportunistic infections in HIV-infected patients. Plasma samples were selected randomly from 131 HIV-infected patients followed prospectively for a period not exceeding 12 months or until death. Plasma MBP concentrations were measured by an ELISA and genotyping was determined by amplification of exon 1 of the MBP gene by polymerase chain reaction (PCR) technology, followed by restriction enzyme analysis and Southern blotting using sequence-specific oligonucleotide probes. Neither MBP concentration nor genotype was found to associate with disease progression or opportunistic infection rate. There was an unexpected increased bacterial infection rate in patients with MBP levels greater than 100 ng/ml and wild type genotype. Thus, MBP does not appear to play a role in HIV infection. MBP is an acute phase reactant and this may explain the higher levels in those with more frequent pyogenic infections.

A study was undertaken in a Cape Town public sector STD clinic to evaluate the content and quality of care provided since it has been recognized that appropriate improvements in the management of conventional sexually transmitted diseases (STDs), including provision of correct therapy, health education, condom promotion and partner notification, could result in a reduced incidence of HIV infection. Our objectives were to assess patients' needs for health education and to assess the quality of STD management in terms of health education, condom promotion, partner notification, the validity of the clinical diagnoses and the adequacy of the treatments prescribed. The study subjects were sampled systematically, according to their gender. Patients included in the study were given a standardized interview and their clinical records reviewed. Specimens were collected for laboratory investigations. For each STD detected, the treatment was defined as adequate if drugs currently known to be active against that infection were prescribed. One hundred and seventy men and 161 women were included in the study (median age: females 22 years, males 26 years). While almost all patients believed their STD may have been caused by unprotected sexual intercourse, many also believed it may have been caused by other factors, such as bewitchment with traditional medicine. Only 21% of male and 37% of female patients received any education about STD transmission during the clinic visit, and only 25% of male and 36% of female patients received education about condom use. As a result of the low sensitivity of the clinicians' diagnoses, 16% of men and 61% of women left the clinic with at least one infection inadequately treated. The majority of patients were not receiving education for the prevention of STDs including HIV. Many were not receiving adequate treatment for their infections. The introduction of a syndromic management protocol in this setting would substantially reduce the proportion of inadequately-treated patients. However, syndromic protocols, and the means by which they are implemented, need to take into account problems with the clinical detection of genital ulcerative disease and candidiasis in women.

Five hundred and twenty female Cameroonian sex workers participating in a clinical trial of the effectiveness of nonoxynol-9 (N-9) contraceptive film to prevent HIV infection were interviewed to determine their experience with this woman-controlled method. The sex workers liked the film, with over 80% stating they would continue to use it if it were shown to be effective against HIV and were to become widely available. However, they were much more likely to use condoms and films simultaneously with their clients (40%) than with their regular partners (16%). The advantages ascribed to the film were that its use was under the woman's control; it could be used without the partner's knowledge; it allowed direct contact between partners; and it provided back-up protection in case of condom breakage. Data from this small study suggest that development of an effective, womancontrolled method of pregnancy and disease protection would be welcomed by these women.

The National Health Service Cervical Screening Programme (NHSCSP) recently published their document Standards and Quality in Colposcopy outlining recommendations for standards in the service provided by colposcopists. In this first audit of colposcopic practice measured against these agreed UK national guidelines, the authors discuss the standards, their attainability, and their relevance to genitourinary medicine (GUM) colposcopy services.

During 1986-88 and 1990-92, 1025 (97%) out of 1057 genital ulcer patients in Kigali, Rwanda, were tested for HIV antibodies and for infection with Treponema pallidum, Haemophilus ducreyi and herpes simplex virus. Overall, 57% of men and 80% of women had antibodies to HIV-1. The most frequent laboratory diagnoses were chancroid (27%), syphilis (19%) and genital herpes (19%) among men and syphilis (35%), genital herpes (23%) and chancroid (20%) among women. HIV-1 seroprevalence increased sharply over time among men but not among women. The clinical presentation of ulcers as well as laboratory diagnoses were similar in the HIV-1 seropositive and seronegative groups. The relative frequency of all laboratory diagnoses remained unchanged over time. HIV-1 seropositivity had no impact on ulcer healing. Advanced immunodeficiency was diagnosed among 12% of the HIV-1 seropositive patients and was significantly associated with increasing age and genital herpes.

Protease inhibitors are increasingly recognized as causing significant metabolic abnormalities including hypertriglyceridaemia, hypercholesterolaemia, insulin resistance, diabetes, and lipodystrophy. Considerable concern has been generated by recent reports of premature coronary artery disease occurring in HIV-1 infected patients on protease inhibitor containing regimens.