International Journal of STD & AIDS current issue

Denialism undermines AIDS prevention in sub-Saharan Africa

Gisselquist, D — 2008-09-29

Some denialists, widely reviled, contend that HIV does not cause AIDS. Other denialists, widely respected, contend that HIV transmits so poorly through trace blood exposures that iatrogenic infections are rare. This second group of denialists has had a corrosive effect on public health and HIV programmes in sub-Saharan Africa. Guided by this second group of denialists, no African government has investigated unexplained HIV infections. Denialists have withheld and ignored research findings showing that non-sexual risks account for substantial proportions of HIV infections in Africa. Denialists have promoted invasive procedures for HIV prevention in Africa – injections for sexually transmitted infections, and adult male circumcision – without addressing unreliable sterilization of reused instruments. By denying that health care causes more than rare infections, denialists blame (stigmatize) HIV-positive African adults for causing their own infections through sexual behaviour. Denialism must be overcome to ensure safe health care and to combat HIV-related stigma in Africa.

Sexually transmitted infections among brothel-based sex workers in Tel-Aviv area, Israel: high prevalence of pharyngeal gonorrhoea

Linhart, Y, Shohat, T, Amitai, Z, Gefen, D, Srugo, I, Blumstein, G, Dan, M — 2008-09-29

Sex workers play a major role in spreading sexually transmitted infections (STIs). We studied the prevalence rates and risk factors for STIs among 300 brothel-based sex workers in Tel-Aviv. Throat swabs were cultured for Neisseria gonorrhoeae, urine samples were tested by polymerase chain reaction (PCR) for Chlamydia trachomatis and N. gonorrhoeae, and sera were tested for syphilis, human immunodeficiency virus (HIV) and type 2 herpes simplex virus (HSV) antibodies. N. gonorrhoeae was cultured from throat samples of 9.0% of participants; PCR testing of urine was positive for C. trachomatis in 6.3% and for N. gonorrhoeae in 5.0%. Syphilis serology was positive (Venereal Disease Research Laboratory [VDRL] titres >1:8) in 1.3% of women, HSV-2-specific immunoglobulin G was detected in 60% and HIV serology was positive in a single case (0.3%). Having STI was significantly associated with age, number of years in Israel, number of clients a week and condom use for vaginal sex. In a multivariate analysis, having STI was significantly associated with number of clients per week and condom use for vaginal sex. The high prevalence of pharyngeal gonorrhoea reflects most probably the expanding demand of clients for oral sex and the insufficient condom use in this form of sex.

Commercial sex and HIV transmission in mature epidemics: a study of five African countries

Leclerc, P M, Garenne, M — 2008-09-29

The study compares the association between using the services of commercial sex workers and male HIV seroprevalence in five African countries: Ghana, Kenya, Lesotho, Malawi and Rwanda. The HIV seroprevalence among men who ‘ever paid for sex’ was compared with controls who ‘never paid for sex’. Results were based on 12,929 eligible men, aged 15–59 years, interviewed in Demographic and Health Surveys. The odds ratio of HIV seroprevalence associated with ever paying for sex was 1.89 (95% confidence interval = 1.57–2.28), with only minor differences by country. The results were stable in multivariate analysis after controlling for available potential cofactors (data on non-sexual routes of transmission were not available). Given the relatively small proportion of men involved, the risk attributable to ‘ever paying for sex’ remained low: 7.1% in univariate analysis and 4.4% after adjustment, and it varied among countries (range 1.3–9.4%). These results match previous observations that commercial sex seems to play a minor role in the spread of HIV in mature epidemics.

An evaluation of the performance of OraQuick(R) ADVANCE Rapid HIV-1/2 Test in a high-risk population attending genitourinary medicine clinics in East London, UK

2008-09-29

To date, no data have been published on the use of OraQuick^® ADVANCE Rapid HIV-1/2 Test (OraQuick) in the UK. We report preliminary findings of an ongoing evaluation of OraQuick in UK genitourinary (GU) medicine clinics. A total of 820 samples from patients in high-risk groups for HIV were tested with OraQuick and results were compared with standard HIV antibody testing. HIV prevalence (enzyme immunoassay [EIA]) was 5.73%, sensitivity of OraQuick was 93.64% (95% CI 82.46–98.66%), specificity 99.87% (99.28–100%), positive predictive value 97.78% (88.27–99.94%) and negative predictive value 99.61% (98.87–99.92%). This includes three false-negatives considered to be due to observer error and now rectified by further training. This has increased test sensitivity to 100%. Our observed test performance of OraQuick compares well with EIA and with other rapid tests. We believe that simple, non-invasive antibody detection tests such as OraQuick can increase HIV testing and diagnosis in UK GU medicine and community settings.

Cost-effectiveness estimates for antenatal HIV testing in the Netherlands

2008-09-29

This paper provides an estimation of the lifetime health-care cost of HIV-infected children and an update of the cost-effectiveness of universal HIV-screening of pregnant women in Amsterdam (The Netherlands). During 2003–2005, we collected data concerning the prevalence of newly diagnosed HIV-infected pregnant women in Amsterdam. Also, data on resource utilization and HAART regimen for HIV-infected children was gathered from a national registry. Using Kaplan-Meier survival analysis, we estimated the life-expectancy of a vertically HIV-infected child at 19 years, with the corresponding lifetime health-care costs of 179,974. HIV-screening of pregnant women could prevent 2.4 HIV transmissions annually in Amsterdam, based on an estimated prevalence of nine yet undiagnosed HIV-positive pregnant women per 10,000 pregnancies. We show that universal HIV screening during pregnancy generates significant net cost savings and health benefits in most situations. Universal antenatal HIV screening is justified in Amsterdam from a health-economic point of view.

Azithromycin and moxifloxacin for microbiological cure of Mycoplasma genitalium infection: an open study

Jernberg, E, Moghaddam, A, Moi, H — 2008-09-29

There are no evidence-based guidelines for the treatment of Mycoplasma genitalium-positive genital infection. In a retrospective survey, we analysed the treatment results of patients tested for M. genitalium at Olafia, Unit for Sexual Transmitted Diseases in Oslo. Out of 10,109 patients, 452 had a positive polymerase chain reaction. Between 72% and 100% of patients in the different treatment groups returned for test of cure after four to five weeks. First-line treatment with 1 g single dose azithromycin had a recovery rate of 79%. It was as effective as an extended five-days' course of azithromycin. Ofloxacin 200 mg b.i.d for 10 days cured 56% and moxifloxacin 400 mg o.d. for seven days as either second-, third- or fourth-line treatment after azithromycin or ofloxacin failure cured 100%. Azithromycin 1 g as a single dose seems to be the best choice of treatment for M. genitalium, with moxifloxacin 400 mg x 1 for seven days if treatment fails.

Human papillomavirus type-distribution in condylomata acuminata of mainland China: a meta-analysis

Wang, H, Qiao, Y L — 2008-09-29

The aim of this work was to study the human papillomavirus (HPV) type-distribution in condylomata acuminata (CA) of mainland China and to estimate the potential role of HPV prophylactic vaccines for CA in mainland China. Forty-three studies using polymerase chain reaction to detect HPV were included in this meta-analysis, and totally 5247 CA cases and 436 controls were included. The overall and type-specific prevalence of HPV 6, 11, 40, 42, 43, 44 were estimated using non-conditional logistic regression model. Overall HPV prevalence was 84.2% and 4.6% for CA and controls, respectively. Estimated HPV types 6, 11, 40, 42 positive fractions in CA were 54.9%, 41.1%, 2.7% and 2.0%, respectively, and exactly 0% for HPV types 43 and 44. HPV 6 and/or 11-positive fractions were 83.0% in mainland China. Thus, prophylactic HPV vaccine has the potential to protect up to 83% of CA cases in mainland China.

Factors associated with lack of antiretroviral adherence among adolescents in a reference centre in Rio de Janeiro, Brazil

2008-09-29

The objective of this study was to describe the adherence to antiretroviral therapy (ART) among adolescents followed-up in Rio de Janeiro. This cross-sectional study included all adolescents (aged 10–19 years) followed at Instituto de Puericultura e Pediatria Martagão Gesteira and Hospital Universitário Clementino Fraga Filho. Adherence was determined by self-report (number of missed ART doses in three days prior to the interview). Adherence was categorized as taking ≥95% of the ARTs (adherent), or <95% (non-adherent). Variables related to demographics and treatment were evaluated and if P value ≤0.15, they were selected for a logistic regression analysis. One hundred and one adolescents were interviewed. The mean time on ART was 91 months and the mean adherence was 94% of this, 21 were non-adherent, and 80 adherent. The risk factors associated with non-adherence were: if the patient was not concerned about ART, odds ratio (OR) = 3.47 (95% confidence interval [CI] = 1.13–10.68); if they do not carry an extra dose of ART, OR = 6.63 (95% CI = 1.73–25.47); if a health-care worker taught them how to take ART, OR = 0.27 (95% CI = 0.08–0.93). Adherence among adolescents was higher than expected. Factors associated with lack of adherence were: interviewees being unaware of ARTs and lack of commitment to the treatment. Interventions involving these factors must be evaluated.

Reactivity in the Venereal Diseases Research Laboratory test and the Mercia(R) IgM enzyme immunoassay after treatment of early syphilis

McMillan, A, Young, H — 2008-09-29

The aim of the study was to compare reactivity in the Mercia immunoglobulin M enzyme immunoassay (IgM EIA) and the Venereal Disease Research Laboratory (VDRL) after treatment of 229 previously untreated patients with early syphilis. At three months, the VDRL and the IgM EIA were negative in 41 (38%) and 71 (62%) cases, respectively; a four-fold or greater decrease in VDRL titre occurred in 106 (99%). At six months, the VDRL and the IgM EIA were negative in 45 (48%) and 69 (71%) patients, respectively; a four-fold or greater decrease in VDRL titre occurred in 88 (95%) and an eight-fold or greater decrease in 80 (86%). At 12 months, the VDRL and the IgM EIA were negative in 35 (70%) and 55 (92%) patients, respectively; a four-fold or greater decrease in VDRL titre occurred in 49 (98%) and an eight-fold or greater decrease in 47 (94%). The Mercia IgM EIA is as sensitive as the VDRL in monitoring treatment of primary syphilis but not as sensitive as the finding of a four-fold or eight-fold decrease in VDRL titre in patients treated for secondary or early latent infection.

Herpes simplex virus type 2 infection among commercial sex workers in Kunming, Yunnan Province, China

Ngo, T D, Laeyendecker, O, Li, C, Tai, H, Cui, M, Lai, S, Quinn, T C — 2008-09-29

A cross-sectional survey was conducted to determine the sociodemographic correlates of herpes simplex virus type 2 (HSV-2) infection among male and female commercial sex workers in Kunming, Yunnan Province of China. HSV-2 prevalence was 33.0%, human immunodeficiency virus (HIV) infection was 2.4% and hepatitis C virus (HCV) infection was 6.8%. Subjects who were positive for HSV-2 had a significantly higher prevalence of HIV infection (5.5% versus 0.9%, P = 0.002; odds ratio [OR]: 6.4, P = 0.006) and HCV infection (18.7% versus 2.4%, P < 0.001; OR: 7.6, P < 0.001) compared with HSV-2-negative individuals. Risk factors that increased the odds of HSV-2 infection were HIV infection, HCV infection, being female, and having a steady sex partner within the last six months (P ≤ 0.01). In a multivariate analysis, being female (OR: 6.6, P < 0.001), having HCV infection (OR: 5.9, P < 0.001) and having a sex partner within the last six months (OR: 2.2, P < 0.05) showed greater odds of being infected with HSV-2. A strong relationship was found between HSV-2, HIV and HCV infections.

Gay men who engage in substance use and sexual risk behaviour: a dual-risk group with unique characteristics

Mor, Z, Davidovich, U, McFarlane, M, Feldshtein, G, Chemtob, D — 2008-09-29

‘Recreational’ substances used among men having sex with men, and their association with risky unprotected anal intercourse (RUAI) were examined – for the first time in Israel – in an internet-based questionnaire assessing knowledge, practices and motivation. Between March and May 2005, 2873 participants completed the entire questionnaire. Of the total, 669 (23%) reported RUAI during the last six months, and 1319 (46%) used substances during sex. Use of substance was significantly higher among those performing RUAI than those who did not (31.5% versus 26.4%, P = 0.03). Involvement in both substance use and RUAI was reported by 366 participants (13%). HIV rates were higher in this dual-risk group (P < 0.01), and individuals reported more partners in the last six months than those not part of this dual risk (11.6 versus 8.2, P = 0.02). In multivariate analyses, Tel-Aviv residency, lower education, performing receptive RUAI, misperception of HIV transmission and limited negotiation skills were positively associated with this dual-risk behaviour.

Focus-on-Teens, sexual risk-reduction intervention for high-school adolescents: impact on knowledge, change of risk-behaviours, and prevalence of sexually transmitted diseases

Gaydos, C A, Hsieh, Y-H, Galbraith, J S, Barnes, M, Waterfield, G, Stanton, B — 2008-09-29

A community-based intervention, Focus-on-Kids (FOK) has demonstrated risk-behaviour reduction of urban youth. We modified FOK to Focus-on-Teens (FOT) for high schools. High school adolescents (n = 1190) were enrolled over successive school semesters. The small-group sessions were presented during the school-lunch hours. Confidential surveys were conducted at baseline, immediate, six-, and 12-month postintervention for demographics, parental communication/monitoring, sexual risk behaviours and sexually transmitted diseases (STDs)/HIV/condom-usage knowledge. Sexually active participants were encouraged to volunteer for urine-based STDs testing at the School-Based Health Centres. Many (47.4%) students reported having had sexual intercourse at baseline. Overall behaviours changed towards ‘safer’ sex behaviours (intent-to-use and using condoms, communicating with partner/parents about sex/condoms/STDs) with time (P < 0.05). Proportion of students with complete correct knowledge of STDs/HIV increased to 88% at time 4 from 80% at baseline after adjusting for age, gender and sexual activity (P < 0.05). High prevalence of STDs was detected in 875 participants who reported for urine testing at time 1: trichomonas, 11.8%; chlamydia, 10.1% and gonorrhoea, 4.1%. Prevalence decreased significantly for 310 participants who re-tested; chlamydia: 27.4% to 6.1% and gonorrhoea: 11.3% to 3.2%. FOT was successfully implemented as an STDs/HIV risk-reduction intervention. Sustained improvements of knowledge about STDs/HIV/condom usage, decreases in sexual risk behaviours supported the effectiveness of this intervention.

Tackling STI epidemics through the HIV clinic: is sex high enough on the agenda?

Ferrand, R A, de Silva, S, Cartledge, J D — 2008-09-29

Sexually transmitted infection (STI) rates among men having sex with men continue to increase. HIV services may operate independently to genitourinary medicine clinics and the sexual health of HIV-positive patients may be of low priority in the context of medical problems related to HIV. A prospective study of HIV-positive gay men was conducted in a London outpatient clinic over a three-month period. Data were available for 90 men. Forty-five percent had STI screens in the preceding six months. These revealed a high rate of infections; 26 infections diagnosed in 14 men in the study period. Fifty-seven percent of the 90 men in the study had more than one partner in the past three months and approximately one-third had unprotected sexual activity. A significant proportion of men were unaware of recent outbreaks of hepatitis C and lymphogranuloma venereum and of HIV postexposure prophylaxis. We therefore recommend that sexual history-taking, STI screens and health promotion should become a routine feature of HIV outpatient consultations in this group.

Integrated community-based sexual health services for young people in urban areas: are we meeting the needs of the local community?

Forbes, K M, Rahman, N, McCrae, S, Reeves, I — 2008-09-29

Community-based sexual health services (SHS) are intended to improve access for people who may have difficulty attending traditional genitourinary medicine clinics. The objective of this study was to review uptake of sexually transmitted infection (STI) testing in an outreach clinic for those under 25 in an area where Black and minority ethnic groups comprise the majority of the local population. A retrospective case-notes review was undertaken of those attending. Standards were that Fraser guidelines should be completed in all under 16-year-old and all clients should be offered STI testing, HIV testing and contraception (if applicable) in accordance with local standards. One hundred and seventeen clients attended. Ten percent self-reported ethnicity was Asian. Thirty-six (31%) clients tested for chlamydia. Thirty (26%) had an HIV test. Five (14% of those tested) had a positive nucleic acid amplification test for chlamydia. Five (13%) of those requesting long term contraception had STI testing. This service has successfully improved access to STI screening. However, there may have been missed opportunities to offer tests in those requesting contraception. Under-representation of those of non-white ethnicity suggests access to SHS may be a particular problem and further work is required to improve the sexual health of the local community.

Topical cidofovir for severe warts in a patient affected by AIDS and Hodgkin's lymphoma

2008-09-29

We describe a 42-year-old man with AIDS and Hodgkin's lymphoma whose severe and recalcitrant cutaneous warts resolved following treatment with local 1% cidofovir. Clinically significant improvements were observed in a two-week period of therapy. In advanced HIV disease complicated by additional haematological malignancy, cutaneous warts may be difficult to treat and present a challenge for the attending physicians. In similar clinical condition topical anti-human papillomavirus therapy may prove to be safe and curative.

Cholangiocarcinoma presenting in an adolescent with vertically acquired HIV infection

2008-09-29

An adolescent with long-standing HIV infection who was severely immunosuppressed during HIV diagnosis developed cholangiocarcinoma 1.5 years after starting antiretroviral therapy.

Two for the price of one

Samuel, M I, Tenant-Flowers, M, Kumar, U, Taylor, C — 2008-09-29

This case is about an HIV seropositive young woman referred for the treatment of severe menorrhagia causing anaemia due to adenomyosis where the levonorgestrel-releasing intrauterine system (Mirena^®) proved useful in treating her heavy periods and also provided effective contraception without interference from the liver enzyme-inducing effects of antiretroviral medications.

Syphilis causing hearing loss

2008-09-29

An HIV-positive man with hepatitis B co-infection, naïve to highly active antiretroviral therapy, with a CD4 of 594 copies/mL and HIV-1 viral load of 140,070 copies, presented with right-sided facial weakness and hearing loss. He had been treated for secondary syphilis three months earlier when his rapid plasma reagin (RPR) result was 1:16, this had fallen to neat. At presentation, his RPR had risen to 1:16 again. A magnetic resonance imaging scan showed enhancement of the internal auditory canal and right cochlea. His cerebrospinal fluid examination was normal. He was treated with acyclovir and prednisolone before the syphilis serology was known. He was then treated for syphilis with doxycycline. He made an excellent recovery.