International Journal of STD & AIDS recent issues

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

Review of drug treatment for female sexual dysfunction

Wylie, K, Malik, F — Thu, 08 Oct 2009 16:35:25 PDT

Female sexual dysfunction (FSD) incorporates various sexual disorders including hypoactive sexual desire disorder, sexual arousal disorder, orgasmic and sexual pain disorders. Although many strategies have been formulated for the treatment of male sexual problems, FSD remains an area that warrants further research and trial studies to identify the most efficacious treatment options. Research has highlighted numerous pharmacological interventions that have been trialled and found to exhibit positive effects. These include hormonal therapies, prostaglandins, dopaminergic agonists, phosphodiesterase type-5 (PDE-5) inhibitors and melanocortin agonists.

A review of cervical cytology in genitourinary medicine clinics in England between 1997 and 2008

Markos, A R — Thu, 08 Oct 2009 16:35:25 PDT

The current cervical screening guidelines lay the duty of care of women under 25 years of age on genitourinary (GU) medicine clinics. To date there has not been an extensive review of cervical cytology results sourced from GU medicine departments. We reviewed the annual reports of the cervical screening programme, with their extensive and comparative data, including records of cervical cytology from GU medicne. There is a clear and progressive trend of rising percentages of ‘severe dyskaryosis’ in laboratory reported GU medicine cervical smears. The trend and observations indicate that GU medicine physicians should take young women's concern on cervical cancer seriously. The programme of opportunistic cervical screening in GU medicine should not be discouraged.

Concurrent sexual partnerships among individuals in HIV sero-discordant heterosexual couples

Eaton, A, van Der Straten, A — Thu, 08 Oct 2009 16:35:25 PDT

The objective of the study was to assess the level at which individuals in HIV discordant couples engage in concurrent sexual partnerships and factors associated with this risk of transmitting HIV. By using data from a group of HIV discordant heterosexual couples (n = 145), we examined the frequency of concurrent sexual partners and factors associated with such partnerships. The prevalence of concurrent partnerships with heterosexual partners was 16%. Fewer than half of individuals with concurrent partnerships reported that their main study partner knew about these relationships. Of individuals involved in concurrent partnerships, 30% reported inconsistent condom use in these relationships. Unmarried individuals in new HIV sero-discordant relationships were particularly at risk for concurrent partnerships. In conclusion, more frequent HIV testing may complement increased attention to communication, disclosure and condom use in this population that is especially vulnerable to acquiring and transmitting HIV infection.

Cardiovascular risk factors and ultrasound evaluation of carotid atherosclerosis in patients with HIV-1 infection

Thu, 08 Oct 2009 16:35:25 PDT

A cross-sectional study was performed to evaluate classical risk factors for cardiovascular diseases and subclinical atherosclerosis by carotid ultrasonography in HIV-positive subjects, naïve or treated with antiretroviral agents. A total of 66 patients were enrolled into the study: 21 subjects were naïve to all antiretroviral agents (group A) and 45 patients were treated with antiretroviral therapy for greater double equals36 months (group B). The prevalence of carotid plaques was significantly higher in group B than in group A (44.7% versus 0%; P = 0.014). In group B, patients with high 10-year risk of coronary heart disease showed a significantly higher intima-media thickness and prevalence of carotid lesions than those with low risk. Moreover, carotid lesions were structurally comparable to classical atherosclerotique plaques observed in the general population, with iso-hyperechonegic aspects and irregular surfaces. The prevalence of carotid atherosclerosis in experienced patients is higher than in those naïve to highly active antiretroviral therapy and seems mostly associated with a longer duration of HIV infection, more severe lipid metabolism alterations, presence of lipodystrophy syndrome and a more elevated 10-year risk of cardiovascular diseases.

A randomized double-blind comparison of moxifloxacin and doxycycline/metronidazole/ciprofloxacin in the treatment of acute, uncomplicated pelvic inflammatory disease

Heystek, M, Ross, J D C, for the PID Study Group — Thu, 08 Oct 2009 16:35:25 PDT

This multicentre, double-blind study was undertaken to demonstrate non-inferiority of once-daily oral moxifloxacin compared with combination therapy in the management of acute, uncomplicated pelvic inflammatory disease (PID). Women aged ≥18 years with PID were randomized to receive moxifloxacin (400 mg once daily) for 14 days or comparator treatment (doxycycline [100 mg twice daily] plus metronidazole [400 mg three times daily] for 14 days, plus one single 500-mg ciprofloxacin dose). Of the 434 valid per protocol (PP) patients, the overall clinical success rates at 2–14 days post-therapy were 96.6% (moxifloxacin) and 98.0% (comparator); moxifloxacin was non-inferior to the comparator regimen both in the PP (95% confidence interval [CI]: –4.5, 1.6) and intent-to-treat (95% CI: –5.8, 6.9) populations. Clinical success rates at 21–35 days post-therapy were 93.8% (166/177; data missing for 47 patients) for moxifloxacin and 91.3% (147/161; data missing for 37 patients) for the comparator. Bacteriological success rates at 2–14 days post-therapy were 92.5% (moxifloxacin) and 88.2% (comparator). Once-daily dosing and proven efficacy suggest that moxifloxacin may be of value in acute, uncomplicated PID.

The psychological impact caused by genital warts: has the Department of Health's choice of vaccination missed the opportunity to prevent such morbidity?

Lawrence, S, Walzman, M, Sheppard, S, Natin, D — Thu, 08 Oct 2009 16:35:25 PDT

This study evaluated the psychological impact caused by genital warts and whether this altered over time. Eighty-four patients with genital warts and a group of 28 appropriately matched volunteers from the local general population were recruited. The patients were divided into three groups of 28 according to the Health Protection Agency classification codes for genital warts. A comprehensive health questionnaire was completed by all participants. Patients with first attack genital warts experienced significantly more distress, anxiety and depression and were less satisfied with their lives than all the other groups. They also reported less satisfaction with the practical support they received. The recurrent episode genital warts group experienced significantly high levels of emotional distress and the re-registered group reported significantly less emotional and practical support according to their needs. While the first attack genital warts group experienced the most psychological effects, it is clear that those effects did not disappear as an individual came to terms with their diagnosis. The choice of vaccine to prevent cervical cancer will not prevent clinical warts occurring and therefore will not help prevent the psychological morbidity associated with this condition.

What service users want: a new clinic results service. Can we satisfy both patients' needs and wants?

Challenor, R, Deegan, S — Thu, 08 Oct 2009 16:35:25 PDT

Many clinics still have a ‘no news is good news’ (NNIGN) policy for clinic results. We asked our service users their preferences for obtaining results. We also designed a new clinic results service. Patients were invited to complete a service evaluation questionnaire. They were given nine options for obtaining results and asked to rate acceptability on a 1–9 scale (unacceptable to acceptable). Completed questionnaires were compared with the actual method they chose to obtain results for that visit. In all, 1000 questionnaires (561 females, 439 males) were completed. Average acceptability score was highest for mobile phone (7.7), followed by text (5.8) and letter (5.7). NNIGN (3.7) and returning for results (3.6) received the least popular ratings. When compared with the actual method chosen, mobile phone was the most popular (62%) followed by letter (17%). Only 10% of patients found NNIGN acceptable. Following the evaluation we purchased texting software and redesigned our results service. There are now four options for receiving results – texting, letter, patient telephones us and NNIGN. We believe we have been able to satisfy both patients' needs and their wishes by redesigning our service around their views.

Factors associated with unprotected anal intercourse between HIV-positive men and regular male partners in a Sydney cohort

Begley, K, Chan, D J, Jeganathan, S, Batterham, M, Smith, D E — Thu, 08 Oct 2009 16:35:25 PDT

Blood plasma HIV-RNA load (BPVL) is the strongest predictor of HIV-1 transmission during sex. Unprotected anal intercourse (UAI) is the highest risk activity for transmission among men who have sex with men (MSM). Awareness of BPVL may influence rates of UAI. We assessed whether optimism towards antiretroviral therapy (ART) and/or biomedical factors influenced sexual activities with regular partners. Questionnaires were administered to 109 HIV-positive MSM participating in a cross-sectional study of BPVL and seminal viral load. The survey assessed HIV transmission beliefs and sexual practices with regular male partners in the past three months. Sixty-nine of 109 (63.3%) had been in a regular relationship and 42 reported having had anal sex. Unprotected receptive anal intercourse without ejaculation (URAI – e) was associated with awareness that their most recent BPVL was detectable (>50 RNA copies/mL) and not taking ART. Receptive UAI with ejaculation (URAI + e) was associated with not taking ART, having a sexually transmissible infection and having an HIV-positive partner; the latter was also associated with insertive UAI with ejaculation (UIAI + e). Treatment optimism was not associated with UAI. In this cohort, sexual practices were based more upon knowledge of biomedical factors rather than attitudes regarding transmission risks.

Profile of direct walk-in and referred clients attending Integrated Counselling and Testing Centre

Kashyap, B, Bhalla, P, Sharma, A, Saini, S — Thu, 08 Oct 2009 16:35:25 PDT

The HIV pandemic has had a profound impact on the health and economic conditions of individuals, and people living with HIV/AIDS are faced with the task of maintaining optimal health status despite an increasing insult to their immune status. The aim of the present study was to study the profile of direct walk-in and referred patients attending the Integrated Counselling and Testing Centre (ICTC) of a tertiary care hospital, which may provide important clues to understanding the epidemiology of the disease in a particular region. The study included all the attendees of the ICTC referred from the hospital or direct walk-in from January 2007 to December 2007. Three rapid HIV tests were used and the samples showing positive results in all the three tests were declared HIV positive. The results were analysed to correlate between HIV positivity, age, sex, route of transmission and direct walk-in/referred patients. A low proportion of ICTC attendees (27%) in our study were direct walk-ins. As regards HIV positivity, 312 (8.3%) out of 2440 males and 164 (4.3%) out of 1315 females were HIV positive. Among the referred HIV-positive patients 162 were males and 62 females, whereas among the direct walk-in HIV-positive patients, 150 were males and 102 females. Integrated counselling and testing is now seen as a key entry point for HIV prevention. In addition to scaling up ICTC services, it is also important to raise awareness by aggressive health education programmes and integration of ICTC into various community organizations.

Further observations, mainly serological, on a cohort of women with or without pelvic inflammatory disease

Taylor-Robinson, D, Stacey, C M, Jensen, J S, Thomas, B J, Munday, P E — Thu, 08 Oct 2009 16:35:25 PDT

An analysis was undertaken of data pertaining to over 100 women with lower abdominal pain who were laparoscoped. Prior to laparoscopy, 11 of the women were considered to almost certainly have salpingitis, of whom six (55%) had salpingitis at laparoscopy; 17 to probably have salpingitis, of whom six (35%) did; 28 to possibly have salpingitis, of whom five (18%) did; and 56 to be very unlikely to have salpingitis, of whom five (9%) did. Of the 22 women who had salpingitis at laparoscopy, 14 (64%) had a Chlamydia trachomatis IgG antibody titre of ≥1:128 and might reasonably be regarded as having chlamydial disease on this basis; six without such a titre probably did not have chlamydial disease as C. trachomatis could not be detected at any genital site. At laparoscopy, 18 women had adhesions without obvious tubal inflammation; clinically, 15 of them had been regarded as possibly having salpingitis or unlikely to have it, with 12 having chronic pelvic pain. Twelve (67%) of the 18 women had a chlamydial IgG antibody titre of ≥1:128. IgM antibody was also detected most often in the ‘salpingitis’ group. Of 49 women without any abnormality detected at laparoscopy, nine (18%) had a high chlamydial IgG antibody titre. Overall, a woman who had a high titre of chlamydial IgG antibody and acute pelvic pain, together with a clinical picture of pelvic inflammation, was more likely to have salpingitis than adhesions alone. Likewise, a woman who had a high titre of chlamydial IgG antibody and chronic pelvic pain, together with a clinical picture suggesting that salpingitis was unlikely, was more likely to have adhesions alone than acute chlamydial salpingitis. However, while antibody measurement and seeking cervical C. trachomatis may help in formulating a diagnosis, there seems no simple way of detecting the small proportion of women who are infected by C. trachomatis in the upper genital tract but whose laparoscopic findings indicate normality. So far as patient care is concerned, the only way of preventing damage to the upper genital tract is to treat early on the basis of suspicion.

What do patients want most from sexual health services?

Hitchings, S, Allotey, J, Pittrof, R — Thu, 08 Oct 2009 16:35:25 PDT

Changes to sexual health clinics have recently been driven by government waiting time targets. However, patients' needs and expectations should be equally important when making service alterations. This study sought to determine what patients valued most when attending an integrated sexual health clinic. During February 2009, 252 patients attending a sexual health clinic in outer London completed an anonymous questionnaire. The questionnaire asked for their views on different aspects of sexual health care. The results showed that the most highly valued aspects of care were confidentiality (18.47% of points allocated) followed by speed of service (13.1%) and rapid test results (12.12%). These aspects were more important than being seen within 48 hours (7.78%), technical expertise (6.26%) or other patient-centred aspects of care. These findings, which represent patients' views, have important implications for service design.

The evolution of an integrated sexual health service

Creighton, S, Apea, V — Thu, 08 Oct 2009 16:35:25 PDT

The objective of the study was to assess the contributions of different providers across an integrated sexual health-care network to the diagnosis of sexually transmitted infections (STIs). The method employed was retrospective cross-sectional survey of laboratory tests for Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas vaginalis between 01 April 2004 and 31 March 2007. The total number of STI screens in all venues rose from 17,126 to 23,679. The proportion of STI screens occurring in the genitourinary (GU) medicine clinic fell from 75% to 55% (P < 0.0001). There was an 11% increase in male screens performed in the community. The number of STIs diagnosed rose from 2354 in 2004 to 3128 in 2007, with an upward trend of community-diagnosed STIs. In conclusion, the role of community services increased during the evolution of the integrated sexual health network, although the majority of STIs were diagnosed within in the GU medicine clinic. Male screens accounted for one-third of those performed. A gap in male attendances remains despite the plurality of services.

Bronzino's 'Allegory of Venus and Cupid': an exemplary image for contemporary sexual health promotion?

Porter, S, Kelly, C — Thu, 08 Oct 2009 16:35:25 PDT

Recent sexual health promotion strategies have veered between a negative emphasis on the deleterious consequences of sexually transmitted infections, and a more positive, eroticized approach to safer sex. The differences in approach are starkly reflected in the images chosen to illustrate them. We note that there are problems with both approaches. The main purpose of this review is to demonstrate how this dichotomy was transcended by the sixteenth century Florentine Mannerist painter, Agnolo Bronzino, in his allegory on syphilis.

Successful treatment of a large Buschke-Lowenstein tumour with chemo-radiotherapy

Armstrong, N, Foley, G, Wilson, J, Finan, P, Sebag-Montefiore, D — Thu, 08 Oct 2009 16:35:25 PDT

We report the case of a patient with a large Buschke–Lowenstein tumour which had previously recurred following local excision. A preferred treatment modality for this rare variant of human papillomavirus has not been clearly defined. Treatment with chemo-radiotherapy in this case resulted in complete resolution of the disease without the need for further surgical intervention.

Preliminary HIV test result disclosure: lessons we can learn

Tayal, S, Chawla, G — Thu, 08 Oct 2009 16:35:25 PDT

Result disclosure following routine HIV testing can be challenging. We present an interesting real life scenario regarding a young heterosexual Caucasian male patient, who was diagnosed as having a positive HIV antibody result following a routine HIV screening test, his confirmatory test result was HIV negative. This article covers important lessons learnt from the case.

Obstructive endo-bronchial pseudotumour due to herpes simplex type 2 infection in an HIV-infected man

Plowman, G M, Watson, M W, D'Souza, H, Thomas, M G — Thu, 08 Oct 2009 16:35:25 PDT

We report a 31-year-old man with an obstructive bronchial lesion due to herpes simplex type 2 infection, who responded promptly to endoscopic resection and oral treatment with acyclovir. Exophytic lesions of the respiratory tract are rare, potentially life-threatening, but readily treated complication of herpes simplex virus infection in HIV-infected individuals.

Oral-anal intercourse and sexual transmission of Enterobius vermicularis; do we need to screen for other intestinal parasites?

Abdolrasouli, A, Hart, J — Thu, 08 Oct 2009 16:35:25 PDT

Response to Crum-Cianflone et al., Syphilitic hepatitis among HIV-infected patients

Doyle, R J, Desai, M, White, J — Thu, 08 Oct 2009 16:35:25 PDT

Hepatitis B vaccination in HIV-infected adults: current evidence, recommendations and practical considerations

Kim, H N, Harrington, R D, Crane, H M, Dhanireddy, S, Dellit, T H, Spach, D H — Wed, 26 Aug 2009 10:14:22 PDT

Immunization with hepatitis B (HBV) vaccine is recommended for all HIV-infected individuals without immunity to HBV. This patient population, however, has relatively poor HBV vaccine responses. Factors associated with this impaired HBV vaccine response in HIV-infected individuals may include older age, uncontrolled HIV replication, and low nadir CD4 cell count. Postvaccination testing for HBV surface antibody is recommended and vaccine non-responders should undergo repeat immunization with a full series. The benefit of double dosage, the appropriate strategy for HIV-infected patients with isolated HBV core antibody and the timing and number of vaccinations in persons with advanced immunosuppression on highly active antiretroviral therapy remain controversial areas.

Achieving successful partner notification: putting together the pieces of the puzzle

Estcourt, C S, Sutcliffe, L J, Shackleton, T — Wed, 26 Aug 2009 10:14:22 PDT

Partner notification as a public health measure to reduce transmission of sexually transmitted infections (STIs) is a cornerstone of STI control in most countries. The success of any partner notification strategy is conditional on its acceptability and feasibility to both patients and health-care professionals, its compliance with relevant professional and legislative guidance, and its cost-effectiveness.

Is accelerated partner therapy a feasible and acceptable strategy for rapid partner notification in the UK?: a qualitative study of genitourinary medicine clinic attenders

Sutcliffe, L, Brook, M G, Chapman, J L, Cassell, J M, Estcourt, C S — Wed, 26 Aug 2009 10:14:22 PDT

Partner notification (PN) in the UK is of limited effectiveness. Expedited partner therapy improves PN outcomes but does not comply with existing UK professional guidance. We developed two new strategies, known as accelerated partner therapy (APT), based on elements of PN practice for which there is evidence of efficacy, and which conform to UK prescribing guidance. We explored the acceptability and feasibility of these models qualitatively in genitourinary medicine clinic attenders. Both strategies were viewed favourably. Preference was influenced by age, relationship type, whether participants were delivering or receiving APT and whether the sex partner was aware of the participant's clinic visit. APT provides a new approach to PN, which has strong patient support and complies with existing UK regulations. The complex factors that influence patients' choice of PN method suggest that provision of a range of PN options including APT may be central to improving the effectiveness of PN in the UK.

Risk behaviours in HIV-positive men who have sex with men participating in an intervention in a primary care setting

Wed, 26 Aug 2009 10:14:22 PDT

Men who have sex with men receiving HIV care reported their sexual behaviours and their intentions, classified according to the Transtheoretical Model of Change, to modify the following behaviours: (1) condom use by partner type and activity type; (2) reduction of partner number; and (3) disclosure of HIV serostatus to partners. Most participants were white (68.8%) or black (29.5%) and were more likely to report unprotected sex with HIV-positive than with serodiscordant partners for most activities. Whites reported more partners than black patients (mean 4.1 versus 2; P < 0.0001) and black participants reported fewer HIV-negative (P = 0.0084) and -unknown status partners (P = 0.00095) than whites. Cocaine/crack use was associated with more sexual partners (P = 0.001) and more frequent unprotected sex with HIV-negative or -unknown status partners (P = 0.036). Readiness to change risk behaviour varied by partner status and type of sexual activity. Understanding patients' risks and their readiness to change behaviours may help providers to promote sexual health.

HIV seropositive status disclosure to prospective sex partners and criminal laws that require it: perspectives of persons living with HIV

Galletly, C L, Dickson-Gomez, J — Wed, 26 Aug 2009 10:14:22 PDT

Thirty-one HIV-positive persons living in Michigan took part in focus group discussions about Michigan's HIV disclosure law. Discussion themes included perceived responsibility to prevent infection, concern about unwanted secondary disclosure of HIV-positive status, fear of being falsely accused of violating Michigan's HIV disclosure law and perceived vulnerability of HIV-positive persons within the US legal system. Although participants strongly agreed with the ostensible purpose of Michigan's criminal HIV disclosure law, there was considerable concern about the negative impact of the law on persons living with HIV.

Sexual behaviour, drugs and alcohol use of international students at a British university: a cross-sectional survey

Vivancos, R, Abubakar, I, Hunter, P R — Wed, 26 Aug 2009 10:14:22 PDT

The aim of the study was to determine whether international students have greater risk-taking behaviours that could lead to importing novel and resistant strains of sexually transmitted infections (STIs). We conducted a cross-sectional web-based survey of university students' sexual behaviour, alcohol and drug use, and self-reported diagnosis of STIs and compared these between British and international students. In all, 827 students completed the survey, of whom 123 (15%) were international students. International students were less likely to have ever drunk alcohol (95.4% versus 87.8%, P = 0.002) and used drugs (56.4% versus 41.5%, P = 0.002). International students were on average almost two years older at first intercourse (18.7 versus 17 years; P < 0.001). There were no differences in the number of sexual partners between national and international students. On a discriminant analysis model, international students were characterized by being older and from a non-white background, less likely to use cocaine, they drank alcohol less frequently and were more likely to have had unprotected intercourse with two or more partners in the previous year. In conclusion, international students tend to drink more moderately and use fewer recreational drugs than British students. However, they exhibit higher sexual risk behaviours that could lead to importing novel and resistant strains of STIs.

Predictors of mortality among women with AIDS in Illinois, USA

Borchardt, S M, Haufle, V, Whitaker, E E, Dworkin, M S — Wed, 26 Aug 2009 10:14:22 PDT

Population-based surveillance data can help guide research priorities and plan programmes to prevent death among women with AIDS. We describe the predictors of mortality among women diagnosed with AIDS in Illinois, USA. Using the HIV/AIDS Reporting System), we identified 1944 adult women who were diagnosed with AIDS during January 1999–December 2004. The proportion of women who died within one year of diagnosis of AIDS declined from 97% in 1999 to 12% in 2005. Multivariate analysis indicated that age ≥45 years, intravenous drug use, diagnosis of clinical AIDS and hospitalization at the time of AIDS diagnosis were significant predictors of death among women with AIDS. The number of women who died soon after diagnosis with AIDS declined substantially. Nevertheless, prevention programmes designed to improve survival among women with AIDS should emphasize early diagnosis and referral for care in an effort to prevent first diagnosis with clinical AIDS during hospitalization.

Current issues in care and support for HIV-positive gay men in Sydney

Wed, 26 Aug 2009 10:14:22 PDT

We explored current access to care among HIV-positive people in Australia. In 2006, 270 HIV-positive gay men from a community-based Positive Health cohort in Sydney were asked about their health (including medical and social) service needs and, subsequently, about difficulty in accessing services. We report the prevalence of specific needs, barriers and associated factors. Participants most commonly used general practitioners (64%) for HIV management and needed at least one HIV-related medical service (usually several: doctors experienced in HIV management, dentists and hospital pharmacies). Most participants were able to access them. Barriers in accessing services were related to their convenience rather than lack or quality. Cost emerged as a substantial barrier to dental care and psychological counselling (91% and 48% respectively of those in need). Need for an HIV-related social service was reported by 46% of respondents. Difficulties in accessing these related to poor services and staff attitudes. Income was associated with limited access to multiple services. In Australia, HIV-related medical service needs outweigh those for social services. Complex health services remain essential to HIV-positive people, but some services are currently not meeting their needs. To remain adequate, services need to understand and constantly adapt to the changing needs of HIV-positive people.

Herpes simplex virus type 2 and HIV infection among US military personnel: implications for health prevention programmes

Wed, 26 Aug 2009 10:14:22 PDT

US military personnel are routinely screened for HIV infection. Herpes simplex virus type 2 (HSV-2) is a risk factor for HIV acquisition. To determine the association between HSV-2 and HIV, a matched case-control study was conducted among US Army and Air Force servicemembers with incident HIV infections (cases) randomly matched with two HIV-uninfected servicemembers (controls) between 2000 and 2004. HSV-2 prevalence was significantly higher among cases (30.3%, 138/456) than among controls (9.7%, 88/912, P < 0.001). HSV-2 was strongly associated with HIV in univariate (odds ratio [OR] = 4.2, 95% confidence interval [CI] = 3.1–5.8) and multiple analyses (adjusted [OR] = 3.9, 95% CI = 2.8–5.6). The population attributable risk percentage of HIV infection due to HSV-2 was 23%. Identifying HSV-2 infections may afford the opportunity to provide targeted behavioural interventions that could decrease the incidence of HIV infections in the US military population; further studies are needed.

Dysfunctional ideas ('male myths') are a result of, rather than the cause of, psychogenic erectile dysfunction in heterosexual men

Beckwith, A C E, Green, J, Goldmeier, D, Hetherton, J — Wed, 26 Aug 2009 10:14:22 PDT

A variety of aetiological factors have been suggested as predisposing men to psychogenic erectile dysfunction (ED). One issue that has been repeatedly identified is holding dysfunctional beliefs about normal male sexual functioning (‘male myths’ – MMs). Past research found that those with a sexual dysfunction are more likely to believe in MMs. However, there was no distinction between whether these beliefs were the cause or result of having a sexual dysfunction. We sought to establish whether holding dysfunctional beliefs is a psychological predisposing factor for those with psychogenic ED. A total of 91 men (40 – organic ED, 24 – psychogenic ED and 27 controls) completed measures to establish their sexual functioning and beliefs in a number of suggested MM. Individuals with organic and psychogenic ED did not differ in their level of belief in MM but both groups differed significantly from controls. The results suggest that subscribing to MMs is a result, not the cause, of psychogenic ED.

Value of targeting at-risk populations at outreach venues: findings from a local sauna

Wed, 26 Aug 2009 10:14:22 PDT

An assessment of the need to increase access to an outreach venue, the local sauna in Walsall, UK, frequented only by men who have sex with men, was undertaken. A case-notes review of the clients who attended the monthly outreach sessions at the sauna in the year 2007 was performed. Among the 287 men seen at the 12 outreach sessions, 37% had a sexually transmitted infection (STI). Of those tested positive, 88% had never had a previous STI. Twenty-one men had syphilis and a further six tested positive for HIV. Hepatitis B vaccination was completed for 41% of the clients seen. Those who tested positive for an STI said they would not have attended a conventional setting but accepted screening at the sauna. This confirmed the need to increase access at this outreach venue, and further funding has now been provided to have outreach sessions twice a month.

Acceptance of genitourinary medicine clinic appointments within 48 hours is influenced by patient perception of risk but not by symptoms

Steedman, N M, Worsnop, V, Fernie, R — Wed, 26 Aug 2009 10:14:22 PDT

The Department of Health has addressed access to genitourinary medicine services by setting targets that 100% of patients should be offered an appointment within 48 hours of contact and 95% should be seen within 48 hours. Such rapid access appointments are often declined by patients. We wished to ascertain whether patient perception of health risk or the presence of symptoms suggestive of a sexually transmitted infection (STI) might influence how quickly patients accept an appointment. We designed a two-armed study which demonstrated that up to 37% of patients offered an appointment within 48 hours declined it, with work commitments offered by 84% of these patients as the reason for deferring attendance. The presence of symptoms did not influence whether patients accepted an early appointment, however the patient's perception of health risk associated with an untreated STI was statistically significantly associated with earlier attendance (P < 0.0001). Increased public education regarding the consequences of untreated STI may therefore improve the acceptance by patients of appointments within 48 hours.

Audit of early syphilis: Teesside experience 2005-2007

Tayal, S, Ahmed, M S, Hanif, U — Wed, 26 Aug 2009 10:14:22 PDT

A retrospective audit of all cases of early syphilis seen in genitourinary (GU) medicine clinics in Teesside was undertaken between 2005 and 2007. In all 80 patients early syphilis was identified. Data on patient sexuality, treatment, and serological follow-up and partner notification were collected and analysed. There were 48 heterosexual cases. There were 21 heterosexual males, and of the 27 females, 12 (44%) were diagnosed during antenatal care. Intramuscular injections of benzathine penicillin were used to treat 75 out of the 80 patients at the clinics. The remaining five patients received oral therapy for two weeks: four had a course of doxycycline and one received amoxicillin plus probenecid. The treatment rate of the population was 100%. In total, there were 115 contactable partners, of whom 87 (75.7%) were screened and/or treated. Successful treatment was defined as a four-fold or greater titre decrease in the Venereal Disease Reference Laboratory test within 3–6 months after treatment. Twenty-one patients were excluded when assessing this due to incomplete serological follow-up. Satisfactory titre declines occurred in 56 (94.9%) of the 59 patients. Overall, the clinics were shown to have adhered well with national standards. The rise in heterosexual and antenatal incidence is of concern.

Aetiology of genital ulcer disease in female partners of male participants in a circumcision trial in Uganda

Wed, 26 Aug 2009 10:14:22 PDT

HIV acquisition is associated with herpes simplex virus type 2 (HSV-2) infection and genital ulcer disease (GUD). Three randomized control trials demonstrated that male circumcision significantly decreases HIV, HSV-2, human papillomavirus and self-reported GUD among men. GUD is also decreased among female partners of circumcised men, but it is unknown whether male circumcision status affects GUD pathogens in female partners. For the evaluation of GUD aetiology, two separate multiplex assays were performed to detect Haemophilus ducreyi, Treponema pallidum, HSV-1 and HSV-2. Of all the female GUD swabs evaluated, 67.5% had an aetiology identified, and HSV-2 was the primary pathogen detected (96.3%). However, there was no difference in the proportion of ulcers due to HSV-2 or other pathogens between female partners of circumcised men (11/15, 73.3%) compared with uncircumcised men (15/25, 60.0%, P = 0.39). The seroprevalence of HSV-2 is high in this population and therefore most of the detected HSV-2 infections represent reactivation. Since GUD is associated with HIV acquisition and one-third of GUD in this study did not have an aetiological agent identified, further research is needed to better understand the aetiology of GUD in Africa, and its relationship to circumcision and HIV infection.

Outcome from treatment of Pneumocystis jirovecii pneumonia with co-trimoxazole

Fisk, M, Sage, E K, Edwards, S G, Cartledge, J D, Miller, R F — Wed, 26 Aug 2009 10:14:22 PDT

A retrospective case-notes audit of 359 HIV-1-infected adult patients with first-episode laboratory-confirmed Pneumocystis jirovecii pneumonia treated with co-trimoxazole (from 1987 adjuvant steroids were used if PaO₂ <9.3 kPa) showed that only 230/359 (64%) patients completed treatment; 104 (29%) patients had treatment-limiting toxicity; rash occurred in 4/60 (6.7%) patients in 1985–1988 and in 15/47 (31.9%) in 2005–2008. Twenty-five patients (7%) failed co-trimoxazole treatment. Overall mortality was 13.6% (49/359); mortality among patients who failed co-trimoxazole treatment was 48% (12/25) and by contrast mortality was 4.8% (5/104) among patients with treatment-limiting toxicity.

Brain abscess due to viridans streptococci in a severely immunosuppressed HIV-infected patient

Vidal, J E, Tuon, F F — Wed, 26 Aug 2009 10:14:22 PDT

We report a case of viridans streptococcus brain abscess in a severely immunosuppressed HIV-infected patient with a history of chronic sinusitis. A 39-year-old homosexual man showed mental confusion and worsening of a frontal brain lesion after two weeks with antitoxoplasma therapy. Empiric treatment for central nervous system tuberculosis and pyogenic brain abscess was started. He underwent surgical drainage and the diagnosis of brain abscess due to viridans streptococci was confirmed. All empiric treatments were stopped and ceftriaxone was used for eight weeks, showing complete clinical and radiological resolution. Although infrequent, viridans streptococci, a common pyogenic aetiology of brain abscess in immunocompetent patients, should be considered in the differential diagnosis of brain lesions in AIDS patients.

Successful treatment of profuse recalcitrant extra-genital warts in an HIV-positive patient using 5% imiquimod cream

Walzman, M — Wed, 26 Aug 2009 10:14:22 PDT

Common warts, particularly plantar warts, are difficult to treat at the best of times and are likely to be even more difficult to treat when the patient is HIV positive. This case report highlights the successful treatment of profuse common warts of both hands and both feet in an HIV-positive patient using imiquimod 5% cream, following unsuccessful regular cryocautery therapy.

Enterococcus pneumonia complicated with empyema and lung abscess in an HIV-positive patient. Case report and review of the literature

Vanschooneveld, T, Mindru, C, Madariaga, M G, Kalil, A C, Florescu, D F — Wed, 26 Aug 2009 10:14:22 PDT

This report describes the first case of vancomycin-resistant Enterococcus pneumonia complicated with empyema and lung abscess in an HIV patient and reviews previously published cases of Enterococcus pleuro-pulmonary infection. Our case highlights the rarity of this entity and reviews the risk factors for Enterococcus pleuro-pulmonary infections.

Pneumocystis-associated organizing pneumonia as a manifestation of immune reconstitution inflammatory syndrome in an HIV-infected individual with a normal CD4+ T-cell count following antiretroviral therapy

Mori, S, Polatino, S, Estrada-Y-Martin, R M — Wed, 26 Aug 2009 10:14:22 PDT

We describe a rare case of Pneumocystic jirovecii-associated organizing pneumonia (PJP) in an HIV-infected individual on highly active antiretroviral therapy (HAART) with a CD4⁺ T-cell count of 835 x 10³ cells/mL and a low viral load. PJP was confirmed using transbronchial biopsies and bronchoalveolar lavage. The presentation in this patient suggests immune reconstitution inflammatory syndrome (IRIS) after institution of antiretroviral therapy (ART). This case report, however, is the first documented presentation of PJP in a patient with CD4 count greater than 300 prior to the induction of HAART who developed PJP and organizing pneumonia as a manifestation of IRIS. This suggests that there is continuing immune dysfunction in the face of re-expansion of CD4⁺ T-cells and low viral load in HIV patients despite ART.

Is it recurrent cryptococcal meningitis or immune reconstitution inflammatory syndrome?

Lodha, A, Haran, M — Wed, 26 Aug 2009 10:14:22 PDT

We report a case of a 45-year-old patient with a history of cryptococcal meningitis who was started on antiretroviral therapy. The patient presented four months later with complaints of fever and memory loss. Lumbar puncture revealed positive cryptococcal antigen and therefore the patient was treated for recurrent cryptococcal meningitis. Unfortunately, the patient did not improve even after two weeks. The diagnosis of immune reconstitution was made at this time and steroids were started. The patient showed remarkable improvement.

Erratum - Correction of date

Wed, 26 Aug 2009 10:14:22 PDT

Effect of ureaplasmas on male fertility: a continuing enigma

Taylor-Robinson, D — Wed, 26 Aug 2009 10:14:22 PDT

Asymptomatic non-specific urethritis: making observations but drawing the wrong conclusion

Markos, A — Wed, 26 Aug 2009 10:14:22 PDT

Threadworm: an infrequent clinical finding in a genitourinary medicine clinic attendee presenting with ano-genital irritation

Waugh, M A — Wed, 26 Aug 2009 10:14:22 PDT

Feasibility of primary HIV care in a Thai tertiary care centre

Khawcharoenporn, T, Apisarnthanarak, A, Kitkungvan, D, Laowansiri, P, Mundy, L M — Wed, 26 Aug 2009 10:14:22 PDT

Report of spontaneous and persistent genital arousal in women attending a sexual health clinic

Garvey, L J, West, C, Latch, N, Leiblum, S, Goldmeier, D — Wed, 22 Jul 2009 10:59:32 PDT

The frequency of spontaneous genital arousal (GA) and persistent genital arousal disorder (PGAD) in women is unknown. The aim of this study was to conduct an anonymous survey to assess the frequency and nature of spontaneous GA and PGAD in women attending a walk-in sexual health clinic in London. Female patients completed a questionnaire, which included demographic information, medical, psychiatric and gynaecology history, the hospital anxiety and depression scale, and a somatization scale. Patients were then asked to complete three questions regarding spontaneous and persistent GA. Any patient with one or more symptoms then answered questions about the distress, intensity and duration of sensations. Ninety-six subjects participated. The mean age was 28.97 years. Thirty-two women (33.3%) answered ‘yes’ to at least one question regarding spontaneous or persistent GA and six women (6.3%) women answered ‘yes’ to all three questions. Only one subject fulfilled all five diagnostic criteria for PGAD. In conclusion, women report a high rate of spontaneous GA in the absence of desire or excitement. This has not been well described previously. A small proportion of women report multiple features of spontaneous and persistent GA, with chronicity over years, but without distress in most cases. Larger studies are needed.

The frequency of HIV-I drug resistance mutations among treatment-naive individuals at a tertiary care centre in south India

Wed, 22 Jul 2009 10:59:32 PDT

Antiretroviral treatment (ART) use in India requires information on baseline drug resistance mutations and polymorphisms in the protease (Pr) and reverse transcriptase (RT) genes of HIV-1 strains from treatment-naïve individuals. We report resistance predictor mutations and polymorphisms in the Pr and the RT sequence of non-clade B HIV-1 strains from ART naïve individuals. The genotypic resistance assay was done on 93 treatment-naïve individuals. The sequences were analysed by Stanford HIV drug resistance data for genotypic drug resistance analysis and REGA HIV-1 subtyping tool. Phylogenetic tree was generated with MEGA 4 for quality control. Ninety-two strains belonged to clade C and one to clade A (A1). Amino acid substitutions were seen at positions associated with drug resistance in Pr gene – 10, 24, 74 (each 3%) and position 82 (11%). Substitutions were seen at positions 41 (1%), 100 (1%), 101 (6%), 103 (2%), 179 (6%) and 181 (1%) of the RT sequence known to confer drug resistance in clade B.

Polymorphisms in HIV-1 pol gene among treatment-naïve individuals were similar when compared with previous data. One strain each had Y181C substitution, T74S and E35G substitutions in the Pr and one had A98G, K101R and L210FL substitutions in RT.

A randomized trial of computer-based reminders and audit and feedback to improve HIV screening in a primary care setting

Sundaram, V, Lazzeroni, L C, Douglass, L R, Sanders, G D, Tempio, P, Owens, D K — Wed, 22 Jul 2009 10:59:32 PDT

Despite recommendations for voluntary HIV screening, few medical centres have implemented screening programmes. The objective of the study was to determine whether an intervention with computer-based reminders and feedback would increase screening for HIV in a Department of Veterans Affairs (VA) health-care system. The design of the study was a randomized controlled trial at five primary care clinics at the VA Palo Alto Health Care System. All primary care providers were eligible to participate in the study. The study intervention was computer-based reminders to either assess HIV risk behaviours or to offer HIV testing; feedback on adherence to reminders was provided. The main outcome measure was the difference in HIV testing rates between intervention and control group providers. The control group providers tested 1.0% (n = 67) and 1.4% (n = 106) of patients in the preintervention and intervention period, respectively; intervention providers tested 1.8% (n = 98) and 1.9% (n = 114), respectively (P = 0.75). In our random sample of 753 untested patients, 204 (27%) had documented risk behaviours. Providers were more likely to adhere to reminders to test rather than with reminders to perform risk assessment (11% versus 5%, P < 0.01). Sixty-one percent of providers felt that lack of time prevented risk assessment. In conclusion, in primary care clinics in our setting, HIV testing rates were low. Providers were unaware of the high rates of risky behaviour in their patient population and perceived important barriers to testing. Low-intensity clinical reminders and feedback did not increase rates of screening.

Adequacy of testing, empiric treatment, and referral for adult male emergency department patients with possible chlamydia and/or gonorrhoea urethritis

Merchant, R C, DePalo, D M, Stein, M D, Rich, J D — Wed, 22 Jul 2009 10:59:32 PDT

This study evaluated the adequacy of testing, empiric treatment and referral for further evaluation of adult male emergency department (ED) patients with possible chlamydia and/or gonorrhoea urethritis. Of 968 adult male ED patients, 84% were tested for chlamydia and gonorrhoea, 16% for HIV and 27% for syphilis; 92% received empiric treatment for chlamydia and gonorrhoea and 71% were referred for further evaluation; of those tested, 29% were infected with chlamydia, gonorrhoea or both; and 3% of those tested had a positive syphilis test. The results of logistic regression modelling indicated that testing, treatment and referral were not related to a history of sexual contact with someone known to have a sexually transmitted disease or to the patient's ultimate diagnosis of a laboratory-confirmed infection. Compliance with Centers for Disease Control and Prevention (CDC) recommendations for chlamydia and gonorrhoea testing and treatment regimens was high, but was poor for HIV testing. More explicit guidance from CDC regarding syphilis testing and referral for further evaluation is needed.

Unappreciated epidemiology: the churn effect in a regional HIV care programme

Gill, M J, Krentz, H B — Wed, 22 Jul 2009 10:59:32 PDT

High levels of geographic mobility in and out of HIV care centres (i.e. the churn effect) can disrupt the continuity of patient care, misalign prevention services, impact local prevalence data perturbing optimal allocation of resources, and contribute to logical challenges in repeated transfer of health records. We report on the clinical, demographic, and administrative impact of high population turnover within HIV populations.

Anthropometric indices of infants born to HIV-1-infected mothers: a prospective cohort study in Lagos, Nigeria

Ezeaka, V C, Iroha, E O, Akinsulie, A O, Temiye, E O, Adetifa, I M O — Wed, 22 Jul 2009 10:59:32 PDT

Numerous studies have reported that HIV-infected pregnant women are at increased risk of delivery of low birth weight (LBW) infants, of preterm deliveries and of intrauterine growth restriction. The objective of the study was to determine the effect of maternal HIV infection on the anthropometric characteristics of the babies at birth. A prospective study was carried out at the Lagos University Teaching Hospital, Nigeria. There were three times more LBW babies in the HIV-positive group than in the uninfected mothers (odds ratio = 3.47, 95% confidence interval = 1.69, 7.27; ² = 12.99, P = 0.0003).The maternal weight (t = 15.85; P = 0.0001), maternal body mass index (BMI) (t = 15.07; P = 0.0003), birth weight of infants (t = 27.17; P = 0.0001) and birth length (t = 31.20; P = 0.001) were significantly less in HIV-positive mothers than in controls. In conclusion, poor maternal bodyweight and low BMI are significant contributors to LBW in HIV-infected women. Nutritional counselling, dietary intake and weight monitoring during pregnancy should be emphasized to improve pregnancy outcome in HIV-infected women.

HIV/AIDS education effects on behaviour among senior high school students in a medium-sized city in China

Ye, X X, Huang, H, Li, S H, Xu, G, Cai, Y, Chen, T, Shen, L-X, Shi, R — Wed, 22 Jul 2009 10:59:32 PDT

Few studies have examined the long-term effects of peer-led HIV prevention in Chinese adolescents. A two-year follow-up study was conducted among senior high school students in a medium-sized city of Fujian Province, from 1 March 2006 to 30 April 2008. In all, 3068 students from 14 schools were invited in March 2006, and 893 students in five schools were followed up. Data were collected at baseline, right after intervention (one month later) and two years later by a self-administered questionnaire. In the intervention group, the average knowledge score including reproductive health and HIV/AIDS/sexually transmitted diseases rose from 4.30 to 7.06 one month later (P < 0.01) and to 7.08 two years later (P < 0.01). There was no significant difference between the average knowledge score after one month and two years (P > 0.05). Sustained increases were found in the attitude scores towards people living with HIV/AIDS (PLWH) and intention of condom use after intervention. The study indicates that peer-led HIV prevention education succeeds in improving and sustaining HIV/AIDS-related knowledge and some behaviour intentions. Future research should focus on strategies to sustain long-term behaviour change.

Increasing incidence of Kaposi's sarcoma in black South Africans in KwaZulu-Natal, South Africa (1983-2006)

Wed, 22 Jul 2009 10:59:32 PDT

The aim of the study was to describe the temporal trends in the incidence of Kaposi's sarcoma (KS) in black South Africans in KwaZulu-Natal (KZN). The study was designed as a retrospective record review. The incidence of Kaposi's sarcoma was estimated using administrative records for patients receiving care for KS through public sector oncology clinics in KZN, 1983–2006. Annual age-standardized incidence rates were calculated using provincial census data for the denominator. Age-specific rates were calculated for the pre-AIDS (1983–1989) and for the generalized AIDS epidemic eras (2006). Age-standardized incidence of KS increased in KZN from <1:100,000 in 1990 to at least 15:100,000 in 2006; this increase was observed in both men and women. There was a shift in the peak age-specific incidence rates from the sixth decade of life in the pre-AIDS era to the fourth and fifth decades in the AIDS era. In conclusion, KS is a growing public health problem in KZN, South Africa. These data reinforce the need for comprehensive national access to and roll-out of antiretroviral drugs, given their success in prevention and treatment of KS in first-world settings.

'Shame on you' - the psychosocial impact of genital warts

Jeynes, C, Chung, M C, Challenor, R — Wed, 22 Jul 2009 10:59:32 PDT

We aimed to investigate whether patients with genital warts experience greater feelings of shame and lower self-esteem compared with controls. Sixty patients with genital warts were compared with 60 asymptomatic genitourinary (GU) medicine patients and 60 orthopaedic outpatients. The shame scores of those with warts (31.08) were significantly higher (P < 0.0001) than either control group (GU medicine controls 20.77; orthopaedic controls 19.00). The impact on health-related quality of life (HRQoL) by each of the individual emotional parameters of shame, low self-esteem, intrusive thoughts, avoidance behaviour and self-efficacy impact was examined in the wart sample group. Only internalized shame (P = 0.001) and intrusive thoughts (P < 0.0001) were significant in predicting HRQoL scores. There are emotional implications in having genital warts, which can have a profound effect on a patient's quality of life and these need addressing just as much as the physical warts.

HIV/AIDS-related knowledge, sources and perceived need among senior high school students: a cross-sectional study in China

Li, S, Huang, H, Xu, G, Cai, Y, Shi, R, Shen, X — Wed, 22 Jul 2009 10:59:32 PDT

This study aimed to assess HIV/AIDS-related knowledge, sources and perceived need among senior high school students in China. A total of 2668 senior high school students aged 15.17–23.42 years participated in the survey. A self-administered questionnaire was used to collect information on HIV/sexually transmitted infection-related knowledge, sources and perceived information need. The results showed that levels of HIV/AIDS knowledge were distributed as follows: low for 6.8%, moderate for 29.6% and high for 63.7%. The most important information sources were, in rank order, TV/photographic recording (72.1%), school heath education curriculum (51.8%) and reading materials (45.7%). About half of the students, 46.3%, confirmed a need for more information and 87.8% of the sampled senior high school students communicated with others if he/she had problems related to HIV/AIDS. Strengthening and improving information sources, particularly its accuracy and comprehensiveness, would help in ensuring that adolescents obtained the HIV/AIDS health information they needed.

First-line antituberculosis drug resistance prevalence and its pattern among HIV-infected patients in the national referral tuberculosis centre, Iran

Wed, 22 Jul 2009 10:59:32 PDT

The objective of this study was to determine the drug resistance prevalence and its pattern among tuberculosis (TB)–HIV patients in Iran. In this retrospective study, all admitted TB/HIV patients presenting to our tertiary centre during 2005–2007 were considered. After confirmation for TB–HIV, first-line DST was performed for culture-positive patients. The drug resistance patterns and the treatment outcomes were analysed. Of the total 92 TB/HIV patients, 27 were culture negative, and DST were available in 65. Intravenous drug abuse was seen in 59 (90.8%). Thirty-seven (57%) were ‘sensitive’ cases and 28 (43%) were ‘any drug resistance’ cases. Twenty-one (32.3%) were mono-drug, three (4.6%) poly-drug and four (6.1%) were multidrug-resistant TB patients. Previous anti-TB medication was significantly associated with any drug resistance (P = 0.041; 95% confidence interval =0.086–0.984); however, having any drug resistance did not affect the treatment outcome (P = 0.56). Streptomycin showed the highest resistance rate (27%) followed by isoniazid (20%), pyrazinamide (9.8%), rifampin (9.2%) and ethambutol (3%). Drug resistance to antitubercular agents in TB–HIV co-infected patients in Iran is high compared with other reports. Drug resistance is higher among those who have had prior anti-TB medication.

Screening for asymptomatic chlamydia in women - how often would gonorrhoea be missed?

Rosenvinge, M M, Lau, R — Wed, 22 Jul 2009 10:59:32 PDT

Resistance of Neisseria gonorrhoeae (GC) to azithromycin is increasing. The dose of azithromycin used for treating uncomplicated genital chlamydia may be subtherapeutic for GC and contribute to gonococcal resistance. The National Chlamydia Screening Programme (NCSP) does not routinely screen for GC but advises further testing of clients with symptoms. This will miss asymptomatic cases. We conducted a case-note review of 100 women aged 16–24 years diagnosed with chlamydia and women aged 16–24 years co-infected with GC and chlamydia, who attended a London genitourinary clinic from 1 October 2004 to 30 September 2005. There were 559 chlamydia diagnoses; 38 (7%) were co-infected with GC. Those co-infected were younger: mean age 18.9 versus 20.3 (P = 0.005). They were also more likely to have symptoms: 28/38 (74%) versus 50/94 (53%) (P = 0.03). Two of 10 women with asymptomatic GC were contacts; meaning that eight cases of asymptomatic GC would have received subtherapeutic treatment. In conclusion, additional testing for GC should be considered in local NCSP protocols where there is a high prevalence of both infections.

Contraceptive use among women attending an open access genitourinary medicine department

Trewinnard, K, Foley, E — Wed, 22 Jul 2009 10:59:32 PDT

Termination of pregnancy rates among young women are rising in the UK and are associated with poor use of reliable contraceptive methods. Many women attending the genitourinary (GU) department for sexually transmitted infection screening do so because of poor or no condom use and are at ongoing risk of unwanted pregnancy. Few of these women attend a contraception clinic, where a full range of contraceptive methods, including long-acting reversible contraception, are available. In this study of 152 women of reproductive age, half stated that they needed further contraceptive advice. In total four-fifths of the women without a reliable method of contraception wanted contraceptive advice and/or future contraceptive provision in the GU medicine clinic.

Audit of hepatitis B vaccination of men who have sex with men attending Scottish genitourinary medicine clinics

Ramasami, S, Abu-Rajab, K, Sarkar, P, Baguley, S — Wed, 22 Jul 2009 10:59:32 PDT

Practice related to hepatitis B vaccination of men who have sex with men (MSM) in Scottish genitourinary medicine clinics was audited against targets based on the offer and completion of vaccination set by the British Association of Sexual Health and HIV. Of 521cases audited from 11 clinics, 215 (41%) were eligible for vaccination and 175 (81%) of eligible MSM were offered vaccination. Of those, 144 (82%) accepted vaccination. The super-accelerated schedule was most commonly prescribed but only 29% of those starting this schedule completed it, compared with 57% of those receiving the standard course. The overall vaccination completion rate was 31% and 82% of those completing vaccination had antisurface antibodies measured. A more robust recall system and uniformity in vaccination policies addressing the balance of patient compliance and immunogenicity of vaccine schedule are needed to improve completion rates.

Foot ischaemia and toe skin necrosis associated with interleukin-2 infusion in an HIV-infected patient

Wed, 22 Jul 2009 10:59:32 PDT

A 39-year-old white man developed a severe left toe foot ischaemia and toe skin necrosis following his 12 courses of interleukin (IL)-2 (4.5 MIU twice a day, subcutaneously) for five days every two months. He had no known general risk factors for thrombosis other than HIV infection. An arterial Doppler ultrasound examination of the leg confirmed the permeability of the posterior tibial artery and its digital pulse. A diagnosis of foot ischaemia and toe skin necrosis was made. The suspected causative agent was IL-2 since this was the only drug that the patient was taking before the symptoms appeared. The patient was empirically treated with an aspirin and pentoxifylline in order to improve local microcirculation. We observed a satisfactory response with a quick resolve of skin lesions. The most possible cause of foot ischaemia and toe skin necrosis was considered to be IL-2 because of the temporal relationship between the exposure to the drug and onset of symptoms. Based on the Naranjo probability scale, IL-2 could be considered the probable cause of the foot ischaemia and toe skin necrosis. If clinical evaluation leads to the suspicion of ischaemic process, therapy with IL-2 should be discontinued immediately.

Severe HIV-associated hypertriglyceridaemia treated with rosuvastatin plus omega-3 fatty acids

Falasca, K, Ucciferri, C, Mancino, P, Pizzigallo, E, Calza, L, Vecchiet, J — Wed, 22 Jul 2009 10:59:32 PDT

Compared with healthy controls, HIV patients already have abnormal lipoprotein concentrations before the initiation of highly active antiretroviral therapy (HAART), which worsen with the therapy. HAART-associated dyslipidaemia features fundamental proatherogenic changes such as increased plasma triglycerides (TGs), increased total cholesterol and low-density lipoprotein cholesterol as well as decreased high-density lipoprotein cholesterol (HDL-C). The current guidelines for managing HIV-associated dyslipidaemia recommend diet and exercise counselling, alteration of HAART regimen or addition of lipid-lowering medications such as statins, fibrates and omega-3 (OM-3) fatty acids. Given that cardiovascular risk significantly increases with elevated lipid levels, selecting a drug to manage dyslipidaemia is particularly important. A case is described of an HIV patient who had severe hypertriglyceridaemia and bad metabolic parameters treated with rosuvastatin and OM-3 fatty acids. So we obtained a more marked reduction of TG levels than has never been described before in the literature, associated with a significant increase in HDL-C levels.

Laryngeal cancer in acquired immunodeficiency syndrome

Shushan, S, Cinamon, U, Levy, D, Sokolov, M, Roth, Y — Wed, 22 Jul 2009 10:59:32 PDT

With improved survival, more AIDS patients, especially heavy smokers and alcohol abusers, may be confronted with laryngeal squamous cell carcinoma. Since curative treatment may require aggressive combined therapy, these patients, often suffering from immunosupression and poor general condition, present unique therapeutic challenges. The objective of the study was to describe treatment dilemmas. This case report presents a detailed description of an AIDS patient with carcinoma of the larynx. A patient with T3N0M0 laryngeal carcinoma and AIDS underwent tracheotomy and biopsy, followed by severe neck and pulmonary infection. After convalescence, radiotherapy was administered, with no evidence of a disease during a 3.5-year follow-up. During his remaining life, the patient developed severe psychoaffective disorder, his immune state deteriorated until he demised from sepsis. In conclusion, patients with HIV infection, especially having a history of tobacco or alcohol abuse, should be carefully examined for head and neck carcinoma that is likely to be more aggressive. Following surgery, AIDS patients may have worse wound healing and a greater tendency to contract infections. Radiotherapy and especially chemotherapy may cause life-threatening complications. Although early detection may increase survival, curative treatment should involve many disciplines and extra caution.

Cat scratch disease: a diagnostic conundrum

Scott, C, Azwa, A, Cohen, C, McIntyre, M, Desmond, N — Wed, 22 Jul 2009 10:59:32 PDT

We report the case of a patient who presented to a clinic for evaluation of inguinal lymphadenopathy. Histology of the lymph nodes revealed micoabscess formation suggesting infection with Lymphogranuloma venereum (LGV) or Bartonella henselae – the causative agent in cat scratch disease (CSD). The patient recalled no preceding animal exposure. Clinical and serological findings initially suggested early LGV but convalescent serology supported CSD. This serves as an important reminder that B. henselae infection should be considered a cause of regional lymphadenopathy in individuals suspected of having LGV.

The first case of criminalization of transmission of hepatitis B in the UK: defendant sentenced to two years' imprisonment on the grounds of hepatitis B deoxyribonucleic acid sequencing

Mohanty, K — Wed, 22 Jul 2009 10:59:32 PDT

A 29-year-old Turkish man Ercan Yasar, who worked as a restaurant worker in Cheltenham, infected a Cheltenham woman 27 years of age with hepatitis B and chlamydia between 14 and 17 September 2007. He was charged with biological grievous bodily harm, which carries a maximum of five years’ imprisonment if found guilty following a trial. The defendant, Ercan Yasar, pleaded guilty to the charge and was given appropriate credit for entering an early guilty plea and was sentenced to two years’ imprisonment before the Gloucester Crown Court on 14 November 2008.

Conjunctival intraepithelial neoplasia in an HIV-positive patient

Serisha, B, Shenoy, R, Evans, J — Wed, 22 Jul 2009 10:59:32 PDT

We describe the case of a 37-year-old African woman with an asymptomatic lesion on her right conjunctiva; histology of the lesion revealed the presence of conjunctival intraepithelial neoplasia. HIV-positive patients from Africa are at increased risk of developing conjunctival malignancies, and early diagnosis and treatment can prevent serious consequences.

Points to consider: responses to HIV/AIDS in Africa, Asia and the Caribbean

St Lawrence, J S — Wed, 22 Jul 2009 10:59:32 PDT

Erratum

Wed, 22 Jul 2009 10:59:32 PDT

HIV status does not contribute to response to syphilis treatment

Hopkins, S, Bergin, C, Mulcahy, F — Wed, 22 Jul 2009 10:59:32 PDT

Authors' reply to Letter from Hopkins et al. regarding HIV status and response to syphilis treatment

Warwick, Z, Dean, G, Fisher, M — Wed, 22 Jul 2009 10:59:32 PDT

Are there any differences between patients attending walk-in and appointment genitourinary medicine clinics?

Manavi, K — Wed, 22 Jul 2009 10:59:32 PDT

Reply to letter from Dr K Manavi

Elawad, B B — Wed, 22 Jul 2009 10:59:32 PDT