International Journal of STD & AIDS recent issues

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.

Travel medicine and HIV infection

Igreja, R. — 2008-08-25

The number of HIV-infected persons who travel is increasing. This increase arises from those who have benefited from advances in antiretroviral therapy. The key to successful travel is careful pre-trip planning although many patients do not obtain advice before travelling. Travel advice for HIV patients is becoming increasingly specialized, and includes travel vaccination and highly active antiretroviral therapy-related issues. A closer collaboration between HIV and travel health clinics could provide better care for HIV-infected individuals.

How men with non-chlamydial, non-gonococcal urethritis are managed in Australasia

2008-08-25

The aim of this study was to ascertain how sexual health physicians in Australia and New Zealand manage men with chlamydia-negative non-gonococcal urethritis (NGU), particularly in relation to the notification of their female sexual partners. In July 2006, a cross-section survey was sent out to all the members of the Australasian Chapter of Sexual Health Medicine. Seventy-three percent of sexual health physicians believed that female partners of men who present with chlamydia-negative NGU were at risk of adverse reproductive health outcomes. At least 62% usually initiated some form of partner notification of female partners of men with chlamydia-negative NGU. However, only 19% (21/111) of sexual health physicians routinely tested for, and only 65% sometimes tested for, pathogens other than Neisseria gonorrhoeae and Chlamydia trachomatis in men presenting with NGU. These included Mycoplasma genitalium, herpes simplex virus, ureaplasma species, Trichomonas vaginalis and adenoviruses.

Measuring the gap: from Home Office to the National Health Service in the provision of a one-stop shop sexual health service in a female prison in the UK

Mahto, M., Zia, S. — 2008-08-25

The Genitourinary (GU) Medicine Service was transferred from the Home Office to the NHS from April 2006 at this female prison to give prisoners access to the same quality of health care as the general public. Medline search showed no published data on the prevalence of sexually transmitted infections (STIs) among female prisoners in the UK. The main aim was to develop a one stop sexual health shop and to determine the prevalence and risk factors for STIs, to determine the uptake rate for HIV testing, hepatitis B vaccination and cervical cytology along with requests for usage of contraceptive services. Challenges were met when introducing change to bring the services in line with the local GU medicine clinic. Review of the service at one year along with retrospective case note review from May 2006 to August 2007 was done. Of the 545 new patients seen, history of substance abuse, IVDU, sexual abuse, sex worker and past history of hepatitis C virus and chlamydia were 86%, 41%,12%, 6%, 17% and 24% respectively.The uptake rate for both STI screen and blood-borne viruses (BBVs) testing was high at 87% and 69.3% respectively. STI was diagnosed in 19.6%. Prevalence rates were: Trichomonas vaginalis (TV) 8.2%, chlamydia 5.3%, gonorrhoea 0.2%, genital warts 5.3%, HIV 0.8%, hepatitis C virus 12% and hepatitis B virus 11%. The uptake rate for 1^st dose hepatitis B vaccination and cervical cytology were 70% and 92% respectively, 36 accessed contraceptive services.

Provision of one stop shop in a female prison is feasible and practical. STIs, particularly TV, and BBVs prevalence is high among the female inmates. Prevention methods targeting this population needs to be intensified.

Condom 'turn offs' among adults: an exploratory study

Crosby, R., Milhausen, R., Yarber, W. L, Sanders, S. A, Graham, C. A — 2008-08-25

An exploratory study compared the prevalence of multiple types of condom-associated ‘turn offs’ in men and women. Nearly 2000 people completed a web-based questionnaire. Data were analysed from 464 men and women who reported that condoms had turned them off the last time they were used. Gender differences were not observed for the majority (9) of 15 turn offs. The most common turn offs related to loss of pleasure. For example, more than three-quarters of the men and nearly 40% of the women reported decreased sexual sensation (P = 0.0001). Putting on condoms was reported by 43.2% of the men versus 30.2% of the women (P = 0.02). Smell was a relatively frequent turn off, with about one-third indicating this issue and no significant gender difference (P = 0.32). Turn offs pertaining to arousal and orgasm were also common. Findings suggest that numerous physical and psychological condom turn offs may be experienced by men and women while using male condoms. Although some turn offs differed as a function of gender, there was remarkable similarity between men and women.

Genotypic distribution of hepatitis C among hepatitis C and HIV co-infected patients in Brazil

Mendes-Correa, M C, Cavalheiro, N P, Mello, C, Barone, A A, Gianini, R J — 2008-08-25

Information on hepatitis C virus (HCV) genotypic distribution among HIV-HCV co-infected patients is lacking in Brazil as well as other Latin American countries. The objective of this study was to evaluate the level of exposure to different risk factors associated with HCV transmission among a group of co-infected patients and to characterize the genotypic distribution of HCV in this cluster. A series of 100 HIV-HCV co-infected patients was analysed. The data to be analysed were collected from specific laboratory tests. Information was collected through a questionnaire. HCV genotyping was carried out by sequencing the 5' non-coding region of HCV. Chi-square and Fischer association tests or Kruskal-Wallis test were used to study the association between HCV transmission-related variables and the established genotypes. In conclusion, exposure to multiple risk factors associated with HCV transmission was common among HIV co-infected patients and an association between HCV genotype 3 and intravenous drug user was observed.

Independent clinical predictors of impaired response to hepatitis B vaccination in HIV-infected persons

Kim, H N., Harrington, R. D, Rompaey, S. E V., Kitahata, M. M — 2008-08-25

Protective response rates to hepatitis B (HB) vaccination have been reported as low as 18–62% in HIV-infected persons. The relative importance of various predictors for this poor response has not been fully characterized. In this retrospective cohort study, we examined the relationship between clinical characteristics and vaccine non-response (HB surface antibody <10 IU/L) among patients attending an urban HIV clinic. Among the 97 patients who met the inclusion criteria, 43 (44%) developed a protective antibody response. In multivariate analyses, age >40 years (odds ratio [OR] 3.03 [95% confidence interval [CI], 1.14–8.06]; P = 0.026) and alcohol abuse (OR 4.92 [95% CI, 1.72–20.89]; P = 0.007) were independent predictors of failure to develop vaccine response. In addition, CD4 nadir <200 (OR 7.24 [95% CI, 1.91–27.41]; P = 0.004), rather than CD4 current to vaccination, remained a strong independent risk factor. Patients with HIV viral suppression on highly active antiretroviral therapy had a significantly lower rate of vaccine failure (OR 0.31 [95% CI, 0.11–0.91]; P = 0.033), after adjusting for these other covariates. Our findings underscore the importance of confirming seroconversion after HB vaccination in HIV-infected patients and initiating vaccination early in the course of HIV infection.

Prevalence and predictors of high-risk human papillomavirus infection in a population-based sample of women in rural Uganda

Asiimwe, S., Whalen, C. C, Tisch, D. J, Tumwesigye, E., Sethi, A. K — 2008-08-25

High-risk genital human papillomavirus (HPV) infection is aetiologically linked to cervical cancer; however, data on the prevalence and determinants of high-risk HPV infection in Uganda are limited. We conducted a population-based cross-sectional survey among 18–49-year-old women in rural Southwest Uganda. The primary outcome was presence or absence of high-risk HPV DNA (for genotypes 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59 or 68) in the genital secretions as determined by HPV DNA Hybrid Capture 2 assay (Digene Corp, Beltsville, MD, USA). In 314 women who participated, the prevalence of high-risk HPV was 17.2% (54/314; 95% confidence interval [CI]: 13–21). Older women had a lower proportion of high-risk HPV infection; with a 9% decrease in the odds ratio (OR) of high-risk HPV infection per year increase in age (OR = 0.91; 95% CI: 0.86, 0.96). The odds of detecting high-risk HPV infection was higher among women who were previously tested positive for HIV (OR = 12.1; 95% CI: 2.8, 52.3). In this population of rural Ugandan women, the prevalence of high-risk cervical HPV infection was high. Information on predictors of high-risk HPV infection and intention to receive a vaccine can guide future immunization initiatives for young sexually active women.

Human papillomavirus detection and typification in cutaneous and mucosal lesions of HIV-seropositive patients

2008-08-25

High-risk human papillomavirus (HPV) in a lesion is related to an increased chance of neoplasic transformation, especially when with immunosuppression, as in HIV infection. We investigated HPV frequency in cutaneous and mucosal lesions of HIV-seropositive male patients. The frequency of malignancy, its association with the HPV type detected and some clinical variables were also assessed. A total of 38 lesions from 27 patients were studied in a period of 18 months. The biopsied fragment was submitted to HPV detection and typification, through polymerase chain reaction with generic (MY09/11) and specific (types 6, 11, 16 and 18) primers. HPV frequency was 63.2%, with detection of HPV types 6, 11 or 16 in 18 lesions and with multi-infection in three. There was low detection of high-risk HPV (type 16, 18.4%) and no HPV type 18. Of the lesions, 36.8% were already premalignant or malignant, and the frequency of moderate or severe dysplasia was higher in the study patients than that described in the HIV-seronegative population. High-risk HPV (type 16) was detected in four benign lesions and low-risk HPV (type 6) in three premalignant genital lesions. There was no significant association between the clinical variables and an increase in the prevalence of premalignant or malignant lesions.

Black and minority ethnic men who have sex with men: a London genitourinary medicine clinic experience

Soni, S, Bond, K, Fox, E, Grieve, A P, Sethi, G — 2008-08-25

The aim was to examine sexual behaviour and rates of sexually transmitted infections (STIs) in black and minority ethnic (BME) men who have sex with men (MSM) attending a London genitourinary medicine clinic. A case-note review of BME MSM (n = 203) attending our service between 1 April 2005 and 31 March 2006 was carried out. BME MSM were those who self-identified as being of Black (Caribbean, African or Other), South Asian (Indian, Pakistani, Bangladeshi or Sri Lankan) and Chinese/South-East Asian (Malaysian, Thai, Filipino, Japanese) ethnicities. Consecutively attending self-identified white British (WB) MSM (n = 203) were used as a comparative group. BME MSM were significantly more likely to report unprotected anal intercourse with casual male partners in the preceding three months (P = 0.0016) and were more likely to report female sexual partners (P = 0.0018). Rectal gonorrhoea was more common in WB MSM (P = 0.02). Numbers of other bacterial STIs and HIV infection were similar in both groups.

The higher reported rates of risk behaviour in BME MSM are of concern and support the need for focussed sexual health promotion.

Qualitative and quantitative aspects of the serological diagnosis of early syphilis

McMillan, A, Young, H — 2008-08-25

The aim of the present study was to evaluate the use of various serological tests in the diagnosis of early syphilis. The Murex enzyme immunoassay (EIA) test was used for screening; the Venereal Diseases Research Laboratory (VDRL) test, the Treponema pallidum particle agglutination assay (TPPA) and the Mercia antitreponemal IgM EIA were used in all the patients with a positive screening test and in those with suspected syphilis or in known contacts. In 89 cases of primary syphilis, the Murex EIA screening test was positive in 67 (75%) patients, the Mercia IgM EIA in 80 (90%) cases, the VDRL in 60 (67%) cases and the TPPA in 85 (96%) cases. All the tests were positive in 68 patients with secondary syphilis. In 72 cases of early latent syphilis, the Murex EIA screening test was positive in 68 (94%) patients, the Mercia IgM EIA in 50 (69%) cases, the VDRL in 61 (85%) cases and the TPPA in 68 (94%) cases. The Mercia IgM EIA was the only test positive in four (6%) of these cases; these four patients were known contacts. Antibody titres in the VDRL and TPPA increased as the infection progressed.

Management of under-16-year olds in UK genitourinary medicine clinics: British Co-operative Clinical Group

2008-08-25

In 2004, the management of under-16-year olds in UK genitourinary (GU) medicine clinics was surveyed. Questionnaires were sent to 185 lead GU medicine consultants. A total of 111 questionnaires were returned (60%). Ninety-eight percent of respondents managed young people aged 13–16. Fifty percent managed under 13-year-olds. Twenty-nine percent of respondents ran dedicated young people's clinics. Ninety-eight percent were aware of the National Guidelines, and 74% had adopted them. Fifty-seven percent had a named departmental child protection lead. Thirty-seven percent of consultants had received training specific to child protection issues in GU medicine. Improvements had been made since a similar survey published in 2001, but the need for further training was still apparent.

Expanding HIV rapid testing via point-of-care paraprofessionals

Knapp, H., Anaya, H. D, Feld, J. E — 2008-08-25

HIV counselling and testing has traditionally been performed by highly trained professionals in clinical settings. With HIV rapid testing, a reliable and easy to use diagnostic tool, paraprofessionals can be trained to administer on-site HIV testing in a variety of non-traditional settings, broadening the HIV detection rates. Our objective was to create a robust and sustainable paraprofessional training module to facilitate off-site HIV rapid testing in non-clinical settings. Trainees attended a series of training sessions involving HIV education, rapid test instructions and communication techniques. After these sessions, trainees competently carried out HIV rapid testing in homeless shelters throughout the Los Angeles county. Agencies motivated to expand HIV screening programmes may use trained paraprofessionals to administer a full range of services (recruitment, pretest counselling, test administration, interpretation of results, post-test counselling and documentation) through this training model and enabling more highly trained healthcare providers to focus efforts on patients identified as HIV-positive.

Attending an STI Foundation course increases chlamydia testing in primary care, but not HIV testing

Bailey, A C, Dean, G, Hankins, M, Fisher, M — 2008-08-25

The Sexually Transmitted Infection Foundation course (STIF) is a recommended training course for UK general practitioners (GPs) and others delivering sexual health services in the community. We assessed the impact of attending the course on testing for HIV and chlamydia. Thirty-one GPs attending Brighton STIF courses were identified and the laboratory database was searched to identify all chlamydia and HIV tests they requested in the three months prior to attending, the first three months after attending and the subsequent three months. Three hundred and eight chlamydia tests were performed precourse, 390 postcourse and 342 in the following three months. This represented a significant increase from baseline to postcourse (P = 0.007), which was lost by three to six months (P = 0.25). The proportion of positives did not change. A total of 98, 111 and 131 HIV tests were performed in the three time periods of which; none were positive. Barriers other than training may need to be overcome to increase HIV testing in primary care.

Prevalence and predictors of herpes simplex virus type 2 infection among female sex workers in Yunnan Province, China

Wang, H., Wang, N., Chen, R. Y, Sharp, G. B, Ma, Y., Wang, G., Ding, G., Wu, Z. — 2008-08-25

The objective of this study was to determine the seroprevalence of herpes simplex virus type 2 (HSV-2), and to evaluate the relationship between HSV-2 infection and sociodemographic factors and the sexual practices of female sex workers (FSWs) in Kaiyuan city, Yunnan Province, China. This cross-sectional study involved 737 FSWs and was carried out from March to May 2006 with confidential interviews and laboratory tests for HSV-2 and other sexually transmitted infections (STI). HSV-2 was the most common STI (68%), followed by Chlamydia trachomatis (26%), Trichomonas vaginalis (11%), Neisseria gonorrhoeae (8%) and syphilis (7%). Prevalence of HIV-1 was 10.3%. Adjusted odds ratios of HSV-2 seroprevalence were 2.6 (95% CI [confidence interval]: 1.30–5.38) for HIV-1 infection, 2.0 (95% CI: 1.33–3.16) for vaginal douching, 2.0 (95% CI: 0.45–0.86) for condom breaking or falling off during sexual intercourse with the client in the previous week, 1.8 (95% CI: 1.07–3.18) for ≥5 years of commercial sex work, 1.6 (95% CI: 1.08–2.33) for ≥5 clients in the previous week, 0.6 (95% CI: 0.45–0.86) for ≥9 years of education. This study identifies a very high prevalence of HSV-2 infections among FSWs in Yunnan Province, with only a few who reported a prior history of genital herpes. HSV-2 serological screening and suppressive therapy should be considered for study populations. Education on the importance of diagnosis, treatment and prevention may help control the spread of HSV-2 infection.

Unilateral penile swelling: an unusual presentation of primary syphilis?

Cheng, S, French, P — 2008-08-25

Primary syphilis is characterized by a solitary, painless, indurated ulcer (chancre) at the site of inoculation, with associated inguinal lymph nodes that are enlarged, rubbery, painless and discrete. We report a case of syphilis that presented with penile swelling associated with tender lymphadenopathy and review the literature concerning this unusual presentation of early syphilis.

Fatal outcome of nevirapine-associated toxic epidermal necrolysis

Leng, K, Lonsdorf, A, Hartmann, M — 2008-08-25

The irregular use of antiretroviral therapy (ART) can result in ART-resistance but can also lead to a sensitization between agents with a cross-sensitivity. We report a case of nevirapine-associated toxic epidermal necrolysis resulting in death in an HIV-infected man.

Successful prevention of multidrug resistant HIV mother-to-child transmission with enfuvirtide use in late pregnancy

2008-08-25

The availability of antiretroviral therapy has dramatically reduced the risk of HIV mother-to-child transmission (MTCT). However, mothers infected with multidrug resistant HIV (MDR-HIV) are at increased risk of MTCT. We report the case of a pregnant patient infected with MDR-HIV in whom MTCT was avoided with enfuvirtide use in late pregnancy and elective caesarean section.

Reassessment of BV causation

Hay, P. E, Taylor-Robinson, D. — 2008-08-25

Patient-delivered partner medication

Coyne, K. M, Cohen, C. E, Smith, N. A, Barton, S. E — 2008-08-25

Achieving 48-hour access targets in genitourinary medicine

Singh, G. — 2008-08-25

Penicillin treatment for early syphilis in the presence of HIV-1 infection: the long or the short of it?

Chan, D. J — 2008-08-25

The epidemiology of Molluscum contagiosum in HIV-seropositive patients: a unique entity or insignificant finding?

Gur, I — 2008-07-28

Molluscum contagiosum (MC) is common in human immunodeficiency virus (HIV) seropositive and immunocompromised patients. This study evaluates the current literature concerning the clinical features of MC in this population, the utility of MC as a predictor of immunocompromised state and the natural history of MC and HIV in patients with these co-morbidities. PubMed database search for English-written original studies found 10 of them, all enrolled for HIV patients. There was no unique feature of MC in adult HIV patients; nevertheless, the appearance of MC lesions in adult men should require evaluation for immunocompromised state. In HIV-positive patients, MC tends to occur during the advanced phase of the disease. MC in children is rarely associated with immunodeficiency and usually no further evaluation is needed. In patients with known HIV infection, the presence of MC may signify advancing immunosuppression.

Acceptability of chlamydia screening using self-taken vaginal swabs

Doshi, J S, Power, J, Allen, E — 2008-07-28

In the first phase of the National Chlamydia Screening Programme (NCSP), the majority of sites involved offered testing with urine sample. Camden & Islington (C&I) were the first site to offer testing with self-taken vaginal swabs (SVS). SVS are appropriate specimens for diagnosing chlamydia by nucleic acid amplification tests. This study aimed to assess the uptake and acceptability of chlamydia screening using SVS within C&I contraceptive clinics. Data collected from women participating in the NCSP between June 2003 and April 2004 were analysed. Of the 3936 women who accepted screening, 90.4% provided a SVS and only 5.8% accepted the offer of providing a urine sample as an alternative to SVS. Women over 19 years and women from Asian ethnic groups were most likely to decline any screening. No woman stated a reluctance to provide a SVS as a reason for declining screening, confirming the acceptability of SVS for chlamydia screening.

Reliability of self-collected versus provider-collected vaginal swabs for the diagnosis of bacterial vaginosis

Kashyap, B., Singh, R., Bhalla, P., Arora, R., Aggarwal, A. — 2008-07-28

Women reluctant to undergo a per-speculum examination consider self-sampling more acceptable. The aim of this study was to compare self-collected vaginal swabs for detection of bacterial vaginosis (BV), candidiasis and trichomoniasis, with vaginal specimens obtained by the gynaecologist at per-speculum examination. Self-collected and provider-collected vaginal swabs were obtained from 50 women attending the gynaecological outpatients department. The Gram-stained smears and saline wet mounts prepared from the provider-collected vaginal swabs were examined by a microbiologist and a gynaecologist. We determined the validity and the inter-rater reliability of the overall BV score and the morphotype specific score using Kappa statistics. When compared with the provider-collected smear, the ability of the self-collected smear to diagnose BV had a sensitivity of 70% and a specificity of 97%. With specific instructions to help assure the depth of sampling, self-collected swabs can reasonably approximate specimens obtained by clinicians during speculum examination for the diagnosis of BV.

Physical activity uptake in patients with HIV: who does how much?

2008-07-28

Regular physical activity is recommended for patients with human immunodeficiency virus (HIV) to help manage their disease. However, to date, little is known about levels of uptake of this advice. This study describes daily physical activity in HIV antibody-positive patients attending a public hospital infectious diseases clinic, compares them with those of patients attending the clinic for general infectious diseases and investigates compliance with the recommendations of the Centres for Disease Control and Prevention and American College of Sports Medicine physical activity guidelines. During April 2006, 261 patients completed the International Physical Activity Questionnaire short form. One hundred and ninety-one reported being HIV antibody-positive. Results showed that 1:4 HIV antibody-positive and 1:3 HIV antibody-negative respondents failed to meet the recommended guidelines. These findings are of concern, given the evidence-based benefits of regular physical activity. Further work is needed to identify barriers to participation and interventions that can improve uptake.

Factors associated with health-related quality-of-life in HIV-infected Brazilians

Razera, F., Ferreira, J., Bonamigo, R. R. — 2008-07-28

Acquired immunodeficiency syndrome HIV/(AIDS) infection has become a chronic disease. This change led to a growing interest in outcomes focusing on the individual, such as health-related quality-of-life (QoL), to assess the impact of treatments. Our study evaluated the impact of the use of antiretroviral drugs, factors related to the infection and socioeconomic factors on the HQoL of HIV-infected patients. A total of 367 patients answered the questionnaire based on the World Health Organization QoL for HIV brief version. According to the modified-Poisson regression approach, the use of antiretroviral drugs was associated with worse QoL in the domain of the level of independence (P = 0.016). Being unemployed was associated with a worse QoL (P < 0.05) in five out of six domains; the only exception was the domain of spirituality (P > 0.05). Among the factors assessed, the socioeconomic aspects were most significant in determining the HQoL of the patients studied.

Chronic colitis associated with HIV infection can be related to intraepithelial infiltration of the colon by CD8+ T lymphocytes

2008-07-28

Gastrointestinal complications in AIDS patients with diarrhoea are common clinical manifestations, frequently diagnosed by colonoscopy as non-specific colitis. We retrospectively study colon biopsies diagnosed as chronic colitis associated with HIV (CCH). Biopsies were sorted as patients with AIDS (serum CD4 <200 cell/mm³) but without any clear infectious process (n = 12) and patients without HIV infection (n = 24). There are low numbers of CD4+ T lymphocytes in lamina propria of AIDS patients, but CD8+ T populations in this area appear to be similar in all studied groups, regardless of HIV infection or laboratory evidence of a specific agent. We found the clear evidence of CD8+ T cells infiltration in colonic mucosa in HIV patients with microscopic colitis. An imbalance of lymphocyte subpopulations in the colon, both in the lamina propria and epithelium, could result in an intraepithelial CD8 infiltration, involved in the pathogenesis of CCH in AIDS patients.

Nadir CD4 count and monthly income predict cervical squamous cell abnormalities in HIV-positive women in a resource-limited setting

2008-07-28

We conducted a cross-sectional study with 385 HIV-positive women in Bangkok to assess the prevalence and predictors of cervical abnormalities on Papanicolaou (Pap) smear. Low-grade squamous intraepithelial lesions (LSIL), high-grade SIL (HSIL) and invasive cervical cell cancer (ICC) were assessed by cytological examination after Pap smear and logistic regression models were used to assess associations with patient characteristics. Overall prevalence of LSIL, HSIL and ICC were 11.2% (95% confidence interval [CI] 8.2–14.7%), 4.7% (95%CI 2.8–7.3%) and 0.5% (95%CI 0.06–1.9%), respectively. In multivariate models, only the nadir CD4 count and income remained significantly associated with cytological abnormalities, whereas smoking, hormonal contraceptive or antiretroviral use, condom use, parity and number of lifetime sexual partners were not associated. The odds ratio for having cytological abnormalities was 2.6 (95% CI 1.24–5.34) in those with a nadir CD4 count <200 cells/mm³ compared with those with a higher nadir CD4 count, and 1.99 (1.11–3.57) in those with an income of <125 US dollars/month compared with those with higher incomes. In settings where access to affordable treatment is improving, this study reinforces the importance of regular Pap smear screening in HIV-positive women, particularly those with low nadir CD4 counts and lower incomes.

Evaluation of a home-delivery service for HIV-infected patients attending an inner London HIV treatment centre

2008-07-28

Home delivery (HD) of medication is a goal of the Department of Health’s Pharmacy in the Future; Implementing the NHS Plan. We evaluated the safety and effectiveness of an HD service for antiretroviral therapy (ART). Patients on ART with stable viral load (VL) <50 were identified. Comparison was made between patients using HD and those using the clinic-based pharmacy (CP). The primary endpoint was HIV virological failure (VF) (HIV VL >400 copies/mL on two consecutive occasions). Secondary endpoints included frequency of outpatient attendances (OPA) and an incidence of adverse events. Cumulative incidences (CulmIn) for each outcome event were calculated. Incidence-rate ratios (IRR) were obtained using Poisson regression. Of 1663 patients identified; 450 received HD and 1213 used CP. CuImIn of VF was =4% in those using HD and =7% in those using CP (IRR [95% confidence intervals, CI] =0.53, 0.32–0.90). HD patients had fewer OPA, less frequent blood test monitoring and less frequent abnormal liver function results (IRR [95% CI]= 0.63 [0.59–0.67] and 0.59 [0.53–0.67], 0.68 [0.65–0.71] and 0.64 [0.53–0.78], respectively). Patients deemed stable enough on social, psychological and medical grounds to receive HD of ART had a lower risk of VF, fewer OPA and no increase in adverse events when compared with patients using CP.

High plasma activity of endogenous antioxidants protect CD4+ T-cells in HIV-serodiscordant heterosexual partners in a Nigerian population

Ibeh, B. O, Obidoa, O., Uzoegwu, P. N — 2008-07-28

Antioxidants significantly inhibit oxidative processes. The study seeks to determine the activity of endogenous antioxidants and CD4+ T-cell expression in HIV-serodiscordant-heterosexual partners. The case-control study had the following groups; A- (13 serodiscordant-seronegative subjects), B- (13 serodiscordant-seropositive subjects) and C/control- (13 healthy volunteers). CD4+ T-cell expression was determined using a FACScan (fluorescent activated cell sorting) flow cytometer. CAT (catalase), superoxide dismutase, glutathione peroxidase (GHPX) and glutathione S-transferase (GST) activities were assayed using spectrophotometer. The activities of SOD, GHPX, GST and CAT were significantly (P < 0.05) increased by 164.7% (0.090 ± 0.032), 126% (662 ± 96), 355.2% (22.023 ± 1.4) and 119.1% (2.76 ± 0.10), respectively, in group A when compared with B. The mean CD4+ T-cell (1348 ± 142) showed a significant (P < 0.05) increase by 237% when compared with group B (400 ± 182). Conversely, group B revealed a significant (P < 0.05) decrease in activity by 86.5% (CAT), 76.5% (SOD), 106.8% (GHPX) and 81.8% (GST) when compared with C. CD4+ T-cells in groups A and C (1390 ± 190) did not show any significant decrease (3.11%). The antioxidant activity showed a positive correlation (P < 0.01, r = 0.89) with their respective CD4+ T-cells in groups A and C. Group B showed same positive correlation (P < 0.01, r = 0.76). These results show that high activity of endogenous antioxidants may have a protective role on CD4+ T-cells, which limits HIV infection.

Efficacy and tolerability of a fosamprenavir-ritonavir-based versus a lopinavir-ritonavir-based antiretroviral treatment in 82 therapy-nayive patients with HIV-1 infection

Calza, L, Manfredi, R, Pocaterra, D, Chiodo, F — 2008-07-28

Recent data indicate that fosamprenavir/ritonavir as part of an initial antiretroviral regimen in HIV-1-infected patients is associated with favourable efficacy and tolerability and in the KLEAN study (kaletra versus lexiva with epivir and abacavir in antiretroviral-naive patients) it was found to be non-inferior to lopinavir/ritonavir in association with abacavir/lamivudine. In our open-label, observational study conducted in 82 therapy-nayive HIV-1-infected patients followed-up for 18 months, virological and immunological efficacy was comparable in subjects receiving a fosamprenavir/ritonavir-based and a lopinavir/ritonavir-based treatment (proportions of patients with HIV RNA <50 copies/mL at month 18 were 76.9% and 74.4%, respectively, when discontinuations were counted as failures). At the same time, frequency of treatment discontinuations and adverse events were similar in both groups, whereas incidence of diarrhoea and hypertriglyceridaemia was significantly higher in lopinavir-treated patients than in fosamprenavir-treated ones (53.5% vs. 25.6% and 69.8% vs. 43.6%, respectively; P < 0.01). In subjects with virological failure, no viral protease resistance mutations were detected by genotype analysis.

The case for social marketing in gonorrhoea prevention: insights from sexual lifestyles in Glasgow genitourinary medicine clinic attendees

Scoular, A., Abu-Rajab, K., Winter, A., Connell, J., Hart, G. — 2008-07-28

We conducted a matched case-control study to investigate social factors associated with gonorrhoea acquisition among genitourinary (GU) medicine clinic attendees, designed to inform appropriate prevention strategies. Detailed social and behavioural data were elicited using a self-completed questionnaire. The effect sizes of these characteristics were quantified using univariate and multivariable conditional logistic regression in 53 cases and 106 matched controls. Homo–bisexual orientation was the strongest independent predictor of gonorrhoea acquisition (Adjusted odds ratio 31.1 (95% confidence intervals, 3.09–312.92). Other independent predictors were not currently being in a relationship and concordant residential characteristics. Three principal implications for sexual health policy were identified; social marketing approaches to gonorrhoea prevention should focus on gay men and individuals not in established relationships; gonorrhoea prevention should be more closely integrated with wider social inclusion policies; finally, more proactive, systematic and theory-based approaches should capitalize on opportunities for sexual health promotion in GU medicine clinic settings.

Would offering rapid point-of-care testing or non-invasive methods improve uptake of HIV testing among high-risk genitourinary medicine clinic attendees? A patient perspective

2008-07-28

While most genitourinary (GU) medicine clinics achieve a high uptake for testing HIV in new patients, they may still miss testing those at highest risk. Point-of-care testing (POCT) and salivary samples are acceptable and feasible but have not yet been shown to increase uptake among high-risk patients (HRP). This study aimed to describe reasons why HRP decline HIV testing and whether offering POCT along with standard testing would increase the uptake of testing HIV in two London GU medicine clinics. Anonymous self-administered questionnaires were offered to all new and rebooked patients. Eight hundred and ninety-nine questionnaires were analysed of which 598 were HRP. Uptake of HIV testing was 77.1% among HRP and 65.8% among the rest. A total of 51.1% of HRP who declined HIV testing said they would be more likely to accept a POCT and 32.8% a salivary test. Introduction of rapid POCT for HIV would increase patient's choice and may increase the likelihood of HRP accepting an HIV test.

Diagnostic yield of fine-needle aspiration cytology in HIV-infected patients with lymphadenopathy in the era of highly active antiretroviral therapy

Lowe, S M, Kocjan, G I, Edwards, S G, Miller, R F — 2008-07-28

Fine-needle aspiration (FNA) cytology has an established role in the investigation of lymphadenopathy in HIV-infected patients. However, changes in the spectrum of disease have been observed since the introduction of highly active antiretroviral therapy (HAART). The aim of the study was to establish whether FNA cytology remains a useful investigative tool in the post-HAART era and to determine whether the cytology results reflect the changing patterns of disease. Retrospective search of the cytopathology database at University College London Hospitals identified 73 FNA cytology procedures performed in 62 patients between January 1998 and December 2006. FNA cytology showed significant disease in 90% of adequate samples. The most common diagnoses were persistent generalized lymphadenopathy (PGL, 50%), infection (22%) and malignancy (18%). Diagnoses could not be made in 31% of patients because of inadequate sampling. An open lymph node biopsy was subsequently performed in 27% of patients. FNA cytology remains an important initial investigation in the post-HAART era, particularly in the diagnosis of PGL, infection and malignancy. Difficulties in diagnosis of Castleman disease and Hodgkin's lymphoma by FNA cytology are recognized.

Referral of young people attending a sexual assault referral centre to mental health services

Sacks, R J, Cybulska, B A, Forster, G E — 2008-07-28

Mental health issues following sexual assault in young people are common but early intervention may improve outcome. A retrospective case-note review of 58 female patients aged between 13 and 18 attending The Haven Whitechapel, a sexual assault referral centre, demonstrated past emotional problems in 72% of those seen, and current emotional problems in 95% of those being followed up. Fifteen percent were already involved with adolescent mental health services (AMHS). All patients requiring and not already receiving input were referred to AMHS or in-house. Of 23 patients referred to AMHS, eight (35%) were accepted and the patients attended, seven (30%) were accepted but did not attend, six (26%) were declined and the outcome of two referrals was unknown. The prevalence of emotional problems and inconsistent referral outcomes demonstrate a need for closer links with AMHS, clearer referral criteria and improved referral pathways.

Contraception and medical gynaecology for HIV-positive women in a one-stop clinic

2008-07-28

HIV-positive women may be reluctant to attend gynaecology or family planning clinics for fear of divulging their condition. Therefore, a referral clinic was opened within the HIV clinic. Retrospective case-note reviews of 197 new patients revealed 109 with a variety of medical gynaecology conditions (menorrhagia being the commonest) and 88 sought contraception. The full range of contraceptives was used, including Mirena for the treatment of menorrhagia as well as contraception and the combined pill adjusted for interaction with liver enzyme-inducing antiretroviral drugs. The acceptance of contraceptive advice and gynaecological evaluation by the patients has resulted in improved reproductive health services for these HIV-positive women. In centres with large cohorts of HIV-positive women, this type of one-stop specialist clinic will be very effective in providing high-quality reproductive health care and hence, this type of clinic is recommended for such centres.

Time to virological failure with atazanavir/ritonavir and lopinavir/ritonavir, with or without an H2-receptor blocker, not significantly different in HIV observational database study

Keiser, P. H, Nassar, N. — 2008-07-28

A retrospective electronic database study was conducted to determine any differences in time to virological failure and percent of virological failure among HIV-infected patients concurrently receiving H₂-blockers versus patients not receiving these agents while receiving atazanavir (ATV)/ritonavir (r) or lopinavir (LPV)/r-containing antiretroviral treatment regimens. Data were culled from October 2003 (when ATV became commercially available) through February 2006. Virological failure was defined as (1) two plasma HIV-1 RNA levels >400 copies/mL after at least one HIV-1 RNA level below the level of detection or (2) failure to achieve an HIV-1 RNA <400 copies/mL within 24 weeks. Data from 267 ATV/r-treated patients who met the case definition were compared with data from 670 LPV/r-treated patients. Approximately 10% of the ATV/r group received concurrent H₂-blockers when compared with 20% of the LPV/r group. Multivariate analysis showed no statistically significant differences regarding time to virological failure between or among the four subgroups, adjusting for differences in baseline characteristics (P = 0.79, log-rank test). At 750 days following treatment initiation, the proportion of patients not experiencing virological failure was 56% in the ATV/r-blocker subgroup, 48% in the ATV/r-alone subgroup, 45% in the LPV/r-alone subgroup and 42% in the LPV/r-blocker subgroup.

Unusual transmission route of Lymphogranuloma venereum; following sexual contact with a female donkey

Khorvash, F., Keshteli, A. H, Salehi, H., Szeredi, L., Morre, S. A — 2008-07-28

Here, we present a 20-year-old man who presented with painful inguinal and femoral masses. He gave a history of sexual contact with a mare 14 days before his recent illness. He was diagnosed with lymphogranuloma venereum based on the histopathological findings and a high titre of IgG (1:1400).

Extensive vulval oedema secondary to severe pelvic infection

O'Mahony, C, Mullin, N, Sissons, G — 2008-07-28

A 17-year-old female developed a complex pelvic abscess a few weeks post-surgical abortion. Despite surgical drainage, a debilitating infection induced a low albumen. The resulting pelvic oedema caused gross vulval oedema that was difficult to manage. She had previously been treated for chlamydia.

Neurosyphilitic gumma in a homosexual man with HIV infection confirmed by polymerase chain reaction

2008-07-28

The brain gumma is a rare manifestation of the tertiary stage of syphilis. A case of neurosyphilitic gumma was confirmed by the Treponema pallidum polymerase chain reaction in a 46-year-old HIV-positive homosexual man. The patient presented with a severe headache and was hospitalized. A computed tomography scan was performed which revealed a left frontal lobe mass. Lymphoma was suspected. However, infectious disease diagnostics were performed on the cerebrospinal fluid that included investigations for syphilis and other microbiological agents such as Toxoplasma gondii. This revealed a reactive venereal disease research laboratory test, a reactive syphilis rapid plasma reagin and a reactive T. pallidum particle agglutination test. The patient was treated for syphilis till complete recovery.

Solid variant of primary effusion lymphoma in successfully treated HIV infection: a case report

2008-07-28

Primary effusion lymphoma (PEL) is a unique form of non-Hodgkin lymphoma, mainly met in severely immunocompromised, HIV-positive patients. PEL is aetiologically related to human herpes virus-8 (HHV-8) and it usually presents as a lymphomatous body cavity effusion in the absence of a solid tumour mass. Recently, cases of HIV-positive patients with HHV-8-positive solid tissue lymphomas, not associated with an effusion, have been reported (solid variant of PEL). The prognosis of PEL is reported to be poor. We report a case of an HIV-positive patient with a typical solid variant of PEL without effusion. Interestingly, his disease developed while being on stable antiretroviral therapy (ART) with high CD4 counts. He had a relatively long survival with chemotherapy and ART.

Outpatient management of severe gonococcal ophthalmia without genital infection

Annan, N T, Boag, F C — 2008-07-28

We report a case of severe gonococcal ophthalmia and peri-orbital cellulitis in an HIV-positive man without genital infection who was treated successfully in the outpatient department. We also highlight the importance of early diagnosis, treatment and liaison with ophthalmology in order to prevent visual complications.

Are they really asymptomatic?

David, N. — 2008-07-28

Bacterial vaginosis: a sexually enhanced disease

Verstraelen, H. — 2008-07-28

Improving genitourinary medicine services in prison

Lau, R. — 2008-06-23

There are many challenges in providing genitourinary medicine services in prison. A review of current service arrangements is overdue. Developing a national standard for sexual health in prison must be a priority. Clinical governance arrangements underpinned by better health informatics and reliable measures of outcomes are key in developing this strategy.

Patient-delivered partner therapy in the UK: what do patients think?

Shivasankar, S., Challenor, R., Ekanayaka, R. — 2008-06-23

The aim of this study was to determine the proportion of genitourinary (GU) medicine patients attending a mixed urban/rural clinic who would welcome patient-delivered partner therapy (PDPT) as a partner management option. Five hundred patients completed the questionnaire. Acceptability of traditional partner referral was 87% (435), partner referral with infection specific guidance was 82% (411) and PDPT was 81% (405). Significantly fewer patients, 71% (354) would find a partner home sampling kit acceptable and provider referral was the least popular option at 23% (117). PDPT is not used in the UK mainly due to concerns of health professionals regarding the legal status of PDPT and the lack of UK evidence. The outcome of the Medical Research Council randomized controlled trial on accelerated partner therapy (which fits in with General Medical Council advice on remote prescribing) is eagerly awaited as professionals would welcome evidence-based guidance and our study suggests that patients are willing to consider this form of partner management as an additional treatment option.