International Journal of STD & AIDS current issue

Questioning the value of screening for gonorrhoea in symptomless heterosexual men

Pittrof, R, Hitchings, S, FitzGerald, M, Pittrof, R, Hitchings, S, FitzGerald, M — Thu, 29 Oct 2009 17:05:24 PDT

These two papers discuss whether gonorrhoea screening of asymptomatic heterosexual men with no contact history should continue in UK genitourinary medicine clinics. Currently, most clinics routinely test all attenders. This requires an estimated 330,000 tests annually to detect 915 positives (1 in 361). The benefits to these patients are uncertain but the costs are huge and could fund currently unprovided services such as oral contraceptive provision or HIV testing before terminations of pregnancy. However stopping testing would deny individuals the reassurance they seek, prevent early detection of outbreaks and fail to detect carriers who go on to cause morbidity in their partners. On this view, the availability of non-invasive tests should be used to widen screening.

Assessing training in sexual dysfunction for genitourinary medicine registrars

Thu, 29 Oct 2009 17:05:24 PDT

The training programme for specialist registrars in genitourinary medicine (GU) lists sexual dysfunction (SD) as ‘beyond essential, core curriculum’ despite many GU medicine clinics offering this service. A cross-sectional study was performed of all trainees on the British Association for Sexual Health and HIV mailing list. Data collected included frequency of clinics attended and involvement, any training and interest in future training. A total of 39/76 (51%) responses were received. In total, 20/39 (51%) work in departments with no SD clinic provision, and 12/39 have had some training in SD. In routine GU medicine consultation, 85% trainees are consulted regarding SD at least monthly. In all, 19/39 (49%) work in areas with weekly SD clinics; however, only three trainees were involved. Thirty-four out of 39 (87%) expressed interest in training and 31/39 (79%) respondents would like to see SD training added to the SpR curriculum. Fifty-one percent of juniors work in units without SD provision. Even when SD clinics occur, only three trainees are routinely involved and a large training opportunity is being missed. Despite this, 12/39 trainees have sought out extra training in the form of seminars, courses and meetings. Eighty-five percent wished to have SD as part of the core curriculum as they may ultimately work in an area where these skills are required.

Destigmatizing genitourinary medicine and sexually transmitted infections in the UK

Sonnex, C — Thu, 29 Oct 2009 17:05:24 PDT

Sexually transmitted infections (STIs) and the clinics patients attend for STI management remain stigmatized. Although emphasizing sexual intercourse rather than sexual behaviour as an important factor in STI acquisition may help to destigmatize STIs, this will require a change in the national mindset. A different approach entails destigmatizing genitourinary (GU) medicine/sexual health thereby normalizing the conditions managed in these settings. This may be helped by emphasizing the non-STI-related aspect of GU medicine and by considering a change in terminology that removes the focus from STIs and attempts to absorb the term into the broader category of genital infection.

Shortening the voiding interval for men having chlamydia nucleic acid amplification tests

Mathew, T, O'Mahony, C, Mallinson, H — Thu, 29 Oct 2009 17:05:24 PDT

Male patients are assessed for a sexually transmitted infection provided a considerable length of time has elapsed since last micturition. The current availability of highly sensitive nucleic acid amplification tests (NAATs) for Chlamydia trachomatis (CT) and Neisseria gonorrhoea such as APTIMA Combo2 (AC2) led us to investigate the impact of voiding interval on the positivity of urine tests for CT. Male patients attending a genitourinary medicine clinic at high clinical risk for CT infection and known CT positives returning for treatment were included. Two first-void urine (FVU) specimens were collected: the first sample in the standard manner and the second sample was collected 20 minutes later or as soon as possible thereafter. Fifty-two CT-positive males were included in the analysis. All of the second samples were also CT positive and none were in the equivocal range. Paired t-test analysis did not show a significant difference between relative light unit readings of the first and second urine samples (P = 0.127). Even in male patients who have recently passed urine, FVU tested by AC2 can still reliably detect CT. This provides us opportunity for more flexible and effective patient management.

Nurse-led sexually transmitted disease clinics: staff perceptions concerning the quality of the service

Mindel, A, Fennema, J S A, Christie, E, van Leent, E — Thu, 29 Oct 2009 17:05:24 PDT

The aim of this study was to evaluate staff perception of a nurse-led sexually transmitted infection (STI) clinical service. The staff at the Amsterdam STI clinic were interviewed using a standardized questionnaire. A series of eight questions was designed to determine the perceived advantages or disadvantages of nurse-led clinics, based on personal experience, using a Likert scale. After completion of the structured interview, the staff were offered the opportunity of providing comments. All 36 members of staff completed the survey. Twenty-seven (75%) agreed or strongly agreed that nurse-led clinics provided more time with patients. Sixty-four percent agreed or strongly agreed that such a service provided greater confidentiality and 94% agreed or strongly agreed that ‘nurse-led clinics provided a high level of job satisfaction for nurses.’ In contrast, only 64% agreed or strongly agreed that nurse-led clinics provided a high level of job satisfaction for doctors. When staff comments were evaluated, four common themes emerged. First, that this was an efficient way of providing services; second, that the clinic was a pleasant environment, there was excellent teamwork and greater job satisfaction; third, that a good deal of rivalry existed between doctors and nurses and finally, that there was a need for and importance of protocols, rules and staff training and development. In conclusion, there was a high level of staff satisfaction with the service. Nurse-led STI clinics may be a useful adjunct to existing STI facilities.

Sexual behaviour, condom use and rates of sexually transmitted infections in HIV clinic attendees in South East London

Hamlyn, E, Welz, T, Rebaudengo, S, Simms, H, Poulton, M — Thu, 29 Oct 2009 17:05:24 PDT

The aim of this study was to examine sexual behaviour, condom use and rates of sexually transmitted infections (STIs) among attendees at a dedicated on-site STI clinic at a South London HIV centre. Data were prospectively collected by using a nurse-completed questionnaire. Ninety-eight percent of women reported one or no sexual partners in the preceding three months, whereas 57% of men who have sex with men (MSM) reported two or more partners. Only 28% of women, 53% of heterosexual men and 29% of MSM always used a condom for vaginal or anal intercourse. Positive STI diagnoses were found in 17.5% of women, 20% of heterosexual men and 49% of MSM. Twenty percent of patients who reported always using a condom and 38% of MSM reporting no sexual activity in the preceding three months had an STI. These results highlight the need for safe sex promotion and STI screening in HIV-infected patients regardless of self-reported sexual activity.

Emotional intimacy predicts condom use: findings in a group at high sexually transmitted disease risk

Damani, R, Ross, M W, Aral, S O, Berman, S, St Lawrence, J, Williams, M L — Thu, 29 Oct 2009 17:05:24 PDT

Previous studies have reported an inverse relationship between condom use and emotional intimacy. The aim of this study was to determine the relationship between condom use and emotional intimacy. The study was a gonorrhoea case-comparison study with the samples being drawn from public health clinics (cases) and select bars/nightclubs (places) of Houston, TX (n = 215). Data were collected by questionnaires administered on a laptop computer. The majority of respondents were African-American (97.7%), women (69.3%) and had either high school or GED education (72.6%). Condom use with the last sexual partner was analysed along with intimacy with that partner assessed on a 3-point scale. Analysis showed that higher intimacy was related to greater condom use which was significant in men but not in women. In conclusion, these data were opposite to those of previous studies, which showed an inverse relationship between condom use and emotional intimacy. We hypothesize that in a high-risk environment, people exert more effort in protecting those they feel closer to. These data suggest a need to further explore the complex relationship between emotional intimacy and condom use.

HIV testing men in the antenatal setting: understanding male non-disclosure

Thu, 29 Oct 2009 17:05:24 PDT

Prevention of infant HIV is a powerful incentive for maternal HIV diagnosis and an opportunity to increase male HIV testing and disclosure of HIV status within couples. We examined male HIV disclosure in couples who attended a Nairobi antenatal clinic (ANC), had individual HIV testing, and were counselled to disclose to their partner. At two-week follow-up, men and women independently reported HIV disclosure. Of 2104 women, 1993 requested partner attendance; 313 male partners came, of whom 183 chose individual HIV testing. Of 106 couples who followed up, 93% of both partners reported disclosure by women versus 71% by men (P < 0.0001); 27% of men reported disclosure while their female partner reported not knowing partner HIV status. In these couples, male ANC HIV testing did not result in shared knowledge of HIV status. Couple counselling models that incorporate disclosure may yield greater HIV prevention benefits than offering individual partner HIV testing services at ANC.

Pearly penile papules regress in older patients and with circumcision

Agha, K, Alderson, S, Samraj, S, Cottam, A, Merry, C, Lee, V, Patel, R — Thu, 29 Oct 2009 17:05:25 PDT

This study assesses the prevalence and correlates of pearly penile papules (PPP) in two non-genitourinary (GU) medicine male cohorts (<25 and >50 years). PPP were categorised in 188 university students (<25 years), based on self-examination, and 70 patients (>50 years), based on clinician examination. PPP were categorised from 1 to 4, based on increasing papule size and distribution. An anonymous questionnaire was used to identify associations with PPP prevalence. The prevalence of PPP was 38.3% in <25 years, and 11.4% in >50 years (P < 0.001). The prevalence of categories 3 and 4 PPP was 8.5% in <25 years, and 1.4% in >50 years (P < 0.05). In the younger age group, the prevalence of PPP was 26.5% in circumcised participants, and 42.4% in uncircumcised participants (P < 0.05), but was unrelated to either frequency of sexual intercourse or time since first sexual intercourse. In conclusion, PPP disappear with age, and any PPP in patients >50 years are less marked than those in patients <25 years. Patients should be advised accordingly. PPP are less prevalent in circumcised men. Patients could be advised to wear the foreskin rolled back – this may maximize exposure of the coronal area to normal abrasion, which may hasten PPP regression.

Mucocutaneous manifestations in 150 HIV-infected Indian patients and their relationship with CD4 lymphocyte counts

Sud, N, Shanker, V, Sharma, A, Sharma, N L, Gupta, M — Thu, 29 Oct 2009 17:05:25 PDT

Mucocutaneous findings in 150 HIV+ve cases (F, 79; M, 71) were evaluated over a one-year period. Mucocutaneous manifestations were seen in 96% with 2.9 mean number of dermatoses and mean cluster of differentiation (CD4) count of 196.33 cells/mm³. The highest number of mean dermatoses, 3.29, was seen in individuals with severe immunosuppression. The most common mucocutaneous manifestation seen was candidiasis (35.33%), followed by seborrhoeic dermatitis (31.33%), oral pigmentation (29.33%), xerosis/ichthyosis (22.67%), pyodermas (22%), periodontitis (17.33%) and nail pigmentation (16.67%). Patient stratification according to the WHO immunological staging, according to CD4 counts, showed a statistically significant association (P < 0.05) for candidiasis, scabies, paronychia, oral pigmentation and diffuse hair loss. Nail and oral pigmentary changes, trichomegaly and subcutaneous fungal infections caused by dermatophytes were highlights of the study. Incidences of xerosis/ichthyosis, pyodermas, scabies and molluscum contagiosum reported in our study were higher and pruritic popular eruptions was lower than those in previous Indian studies. Cutaneous neoplasms were not seen in the present study.

Does the addition of a urine testing kit to use of contact slips increase the partner notification rates for genital chlamydial infection?

Apoola, A, Beardsley, J — Thu, 29 Oct 2009 17:05:25 PDT

This study was designed to determine whether a better partner notification outcome could be achieved by giving female index patients with genital chlamydial infection a home sampling kit instead of contact slips only. Two hundred female patients attending a sexually transmitted infection clinic with a diagnosis of genital chlamydial infection were randomized to either the conventional partner notification arm using contact slips (swab testing arm) or the urine sampling kit for partner notification arm (urine testing arm). There were no differences in the number of partners treated per index case (0.67 in the swab testing group versus 0.62 in the urine testing group, P = 0.46), the median number of traceable partners and the number of index patients with at least one partner treated within 28 days. The addition of a urine testing kit to contact slips for male partners of women with genital chlamydial infection did not increase the partner notification rates for genital chlamydial infection.

Bacterial vaginosis: a cause of infertility?

Mania-Pramanik, J, Kerkar, S C, Salvi, V S — Thu, 29 Oct 2009 17:05:25 PDT

Bacterial vaginosis (BV) is a common disorder of the genital tract in women characterized by an alteration of the normal acidic lactobacilli-predominant vaginal ecosystem to a vaginal environment dominated by Gardnerella vaginalis, mycoplasma species and anaerobes, with an increase in pH. The present study evaluated whether BV is associated with reproductive complications in women. BV was screened with a Gram stain of vaginal smear and interpretation was done using the Nugent score. Wet mount and polymerase chain reaction were used to screen other infections. Among 510 enrolled women, 72 (14.1%) had BV. Statistical analysis between the BV negative and positive population revealed a significant association (P = 0.0001) with infertility. In pregnant women, the infection rate was low (P = 0.01). Multiple infections such as Candida, Chlamydia and human papilloma virus were observed in 4.2%, 15.3% and 8.3% of BV-infected women, respectively. Results suggest that BV infection is associated with infertility and its absence leads to pregnancy, emphasizing its screening and treatment.

Access to dental care for HIV patients: does it matter and does discrimination exist?

Levett, T, Slide, C, Mallick, F, Lau, R — Thu, 29 Oct 2009 17:05:25 PDT

A number of surveys highlight a shortage of dentists in the UK. There is also evidence of discrimination against those with HIV reported within the dental profession and service users. We decided to assess the extent of this problem in our HIV outpatients by conducting a cross-sectional survey, asking them to complete a questionnaire exploring issues related to dental care access, and using clients attending the routine genitourinary (GU) medicine outpatient clinic as controls. A total of 241 outpatients completed the survey, of whom 51 (21%) were HIV patients. Significantly, more HIV patients reported difficulty registering with a dentist than GU patients (58.8% versus 18.2%, ² with Yates correction = 8.76, P = 0.0031). They also report significantly more dental health problems compared with controls (54.9% versus 32.1%, ² with Yates correction = 8.02, P = 0.0046). In total, 34.6% of HIV patients who had declared their status to a dentist thought that it had negatively impacted on their care, with 6.2% being refused treatment. Our small survey confirms that discrimination in relation to access and level of dental care exists, with black African women being at most risk. Efforts are needed to raise professional standards and HIV awareness to prevent continuing inequalities in dental care provision.

Genital herpes: an Internet-based risk survey

Mindel, A, McHugh, L, Christie, E, Chung, C, Berger, T — Thu, 29 Oct 2009 17:05:25 PDT

Genital herpes is one of the most common sexually transmitted infections worldwide. We established a web-based survey to determine risk for genital herpes and encourage people to attend for herpes simplex virus testing. A survey was established on the Australian Herpes Management Forum (AHMF) website, consisting of 16 demographic and sexual health-related questions. Each question carried a numerical risk-weighting based on epidemiological data; the higher the overall score, the greater the risk of herpes. To determine how representative our sample was in relation to age and sex, we compared our survey with Australian Census data. Between October 2006 and August 2007 there were 5572 responses, 4358 (92%) were Australian. Compared with the Australian population, the survey population had a higher proportion of individuals aged less than 34 years, and a lower population over 55. Six hundred and eighty-six (13.8%) were classified as low risk, 2558 (51.6%) as medium risk and 1710 (34.5%) as high risk of having acquired genital herpes. In total, 39% reported four or fewer, and 38% reported 10 or more, sex partners in their lifetime. A large number of individuals participated in this survey, confirming that the Internet is a useful tool for health promotion for genital herpes.

Indeterminate rapid HIV-1 test results among antenatal and postnatal mothers

Thu, 29 Oct 2009 17:05:25 PDT

The sensitivity and specificity of rapid HIV-1 tests may be altered during pregnancy and postpartum. We conducted a study to determine the prevalence and correlates of false-positive Abbott Determine^TM and false-negative Uni-Gold^TM rapid HIV-1 test results among antenatal and postnatal mothers attending a primary care clinic in Nairobi, Kenya. Mothers were tested for HIV-1 using Abbott Determine^TM and non-reactive results were considered HIV-1 antibody negative. Reactive samples by Determine were re-tested by Uni-Gold^TM. Vironostika HIV-1 and Uni-FORM II Enzyme-linked immunosorbent assays were used to confirm samples that had positive Abbott Determine^TM and negative Uni-Gold^TM. Among 2311 women who accepted HIV-1 testing, 1238 (54%) were tested antenatally and 1073 (46%) were tested postnatally. Of tested women, 274 (12%) women were reactive by Abbott Determine^TM and on retesting with Uni-Gold^TM 30 (11%) had indeterminate results. The prevalence of indeterminate results was significantly higher in antenatal women than in postnatal women (2% versus 1%, P = 0.03). In conclusion, indeterminate rapid HIV-1 test results are more common in the antenatal period and appropriate safeguards to confirm HIV-1 infection status should be implemented in antenatal programmes.

Concentrated and linked epidemics of both HSV-2 and HIV-1/HIV-2 infections in Senegal: public health impacts of the spread of HIV

Thu, 29 Oct 2009 17:05:25 PDT

The objective of this article is to report seroprevalences on HIV and herpes simplex virus 2 (HSV-2) in female sex workers (FSW) and in two sentinel populations of pregnant women living in Senegal. Serosurveys of HIV and HSV-2 were conducted in two unselected sentinel populations from Dakar, Senegal, and its provinces, including in 2003 only pregnant women and 2006 pregnant women and FSW. The population study involved 888 pregnant women and 604 FSW.

In pregnant women, HIV and HSV-2 seroprevalences were, respectively, 1.01% and 15.65%. There was no association between HSV-2 and HIV infection, whatever the age. In contrast, the seroprevalence of HIV infection in the group of FSW was high, reaching 22.9% in women over 30 years old. FSW above 20 years of age harboured much higher HSV-2 seroprevalences that those found in pregnant women of similar age groups. In FSW, strong associations between HSV-2 and age, and among HSV-2 and HIV-1 as well HIV-2, were evidenced. In conclusion, HIV epidemic remains concentrated in high-risk groups of the Senegalese population, such as the FSW population in which the seroprevalence of HSV-2 infection is very high. Intervention against STI including HSV-2 is urgently needed to prevent the spreading of HIV epidemic.

Microscopy detection of rectal gonorrhoea in asymptomatic men

Forni, J, Miles, K, Hamill, M — Thu, 29 Oct 2009 17:05:25 PDT

This audit aimed to determine the usefulness of microscopy to detect presumptive rectal gonorrhoea (GC) infection in asymptomatic men. We retrospectively audited more than 400 male patients attending a London genitourinary medicine clinic from January 2005 to March 2007 who tested rectal culture positive for Neisseria gonorrhoeae and compared this with the microscopy detection rate. In total, 123/423 (29%) of culture positive samples were microscopy positive. Of those that tested microscopy negative (300/423), 64 (21%) were symptomatic and 236 (79%) asymptomatic. In addition, a time and motion study examined 81 rectal slides over a two-week period to identify microscopy reading time required to make a presumptive diagnosis of GC. Three slides were positive, resulting in six hours and 45 minutes to detect one positive sample. Given the low sensitivity for rectal microscopy coupled with the length of time required to obtain a presumptive positive rectal GC result, we believe rectal microscopy is no longer a cost-effective tool screening for asymptomatic men, and this report supports the BASHH guideline that it is not recommended in the management of asymptomatic rectal infection.

Chain of evidence in sexual assault cases

Lowe, S M, Rahman, N, Forster, G — Thu, 29 Oct 2009 17:05:25 PDT

Chain of evidence (COE) sampling is a legal concept demonstrating the journey of a sample from origin to court. Positive sexually transmitted infection (STI) results may have importance in criminal proceedings and require a demonstrated COE for them to be used as admissible evidence. A retrospective case-notes review of female sexual assault patients was carried out to review COE sampling in two clinics. Three hundred and eighteen patients underwent sexual health screening and COE sampling was indicated in 58 (18%). COE sampling was carried out in 44 (92%) of 48 indicated cases at the Haven (a dedicated sexual assault centre) and five (50%) of 10 at the Ambrose King Centre (a sexual health clinic). COE protocols should be in place in both sexual assault referral centres and sexual health clinics. In specialist clinics, with well-established guidelines and trained dedicated staff, COE sampling standards can be achieved.

Haemorrhagic transformation of cerebral infarction in an AIDS patient - thrombophaelia screen essential!

Yoganathan, K, Benton, A — Thu, 29 Oct 2009 17:05:25 PDT

Patients with advanced HIV disease with low CD4 count are more prone to thrombo-embolism and various predisposing factors have been identified. These include the presence of anticardiolipin antibodies and the lupus anticoagulant, deficiencies of proteins C and S, heparin co-factor II and antithrombin. Increased levels of Von Willebrand factor and d-dimers have also been linked with thrombo-embolism, as has the presence of concurrent infections and malignancies. We report a case of an AIDS patient who presented with acute hemiparesis. He was severely immunosuppressed. Computed tomography of the head confirmed cerebral infarction with haemorrhagic transformation. He had no known risk factors apart from being severely immunocompromised and had high anticardiolipin antibodies and low free protein S.

Intestinal spirochetosis as a cause of chronic diarrhoea in patients with HIV infection: case report and review of the literature

Ena, J, Simon-Aylon, A, Pasquau, F — Thu, 29 Oct 2009 17:05:25 PDT

We describe a 77-year-old patient with HIV infection suffering from chronic diarrhoea whose colonoscopy findings showed normal appearance mucosa and tissue samples revealed the presence of a dense layer of spirochetes attached to the apical cell membrane. A literature search from 1996 to April 2009 identified 19 additional cases of intestinal spirochetosis in patients with HIV infection. Analysis of cases showed that intestinal spirochetosis causes chronic diarrhoea in men who have sex with men (92% of patients with reported HIV infection risk factors) who are not severely immunosuppressed (70% with CD4 lymphocyte cells >200/µL). Colonoscopy examination often revealed normal appearance mucosa. Haematoxylin and eosin stain of biopsy samples showed the presence of spirochetes, but Warthin–Starry silver staining makes organisms easier to detect. Patients promptly responded to metronidazole or penicillin therapy. In summary, invasive intestinal spirochetosis should be considered in the differential diagnosis of patients with HIV infection and chronic diarrhoea.

Increasing HIV testing in general practice: brief advice seems to work

Phillips, M, Lazaro, N, Sweeney, J, Hesketh, L, Lamden, K — Thu, 29 Oct 2009 17:05:25 PDT

Sex toy hygiene

O'Connor, C, O'Connor, M B, Clancy, J, Ryan, A — Thu, 29 Oct 2009 17:05:25 PDT

Convictions for sexual transmission of diseases do not enhance authority

Phillips, M — Thu, 29 Oct 2009 17:05:25 PDT

Hepatitis C screening in genitourinary clinic attendees

Kerr, R S, Fernando, I, Templeton, K, Flynn, B — Thu, 29 Oct 2009 17:05:25 PDT

Use of two HIV-POCT tests to identify false reactives

Teague, A, Rossi, M, Gilmour, C, Watson, L, Atkins, M, McOwan, A — Thu, 29 Oct 2009 17:05:25 PDT

Condom use and prevalence of sexually transmitted infection among performers in the adult entertainment industry

Hill, S C, King, G, Smith, A — Thu, 29 Oct 2009 17:05:25 PDT

Current management of syphilis infection

Vera, J H, Parkes, R, Goldmeier, D — Thu, 29 Oct 2009 17:05:25 PDT