Showing papers by "Irving F. Hoffman published in 1998"

Association of CD4 cell depletion and elevated blood and seminal plasma human immunodeficiency virus type 1 (HIV-1) RNA concentrations with genital ulcer disease in HIV-1-infected men in Malawi

Abstract: CD4 cell counts and blood plasma and seminal plasma human immunodeficiency virus type 1 (HIV-1) concentrations were compared in HIV-1 RNA-seropositive men with urethritis and with or without genital ulcer disease (GUD). GUD was associated with lower CD4 cell counts (median, 258 vs. 348/microL) and increased blood plasma HIV-1 RNA (median, 240 x 10[3] vs. 79.4 x 10[3] copies/mL). Men with nongonococcal urethritis and GUD shed significantly greater quantities of HIV-1 in semen (median, 195 x 10[3] vs. 4.0 x 10[3] copies/mL) than men with nongonococcal urethritis without GUD. These levels decreased approximately 4-fold following antibiotic therapy. The results indicate an association between GUD and increased blood HIV-1 RNA levels. Increased HIV-1 in semen was demonstrated in some men with GUD; such an increase could lead to increased transmission, thus complicating interpretation of the role of the genital ulcer itself in the infectiousness of HIV. Reasons for increased HIV RNA in semen in men with GUD remain to be determined.

High Levels of Human Immunodeficiency Virus Type 1 in Blood and Semen of Seropositive Men in Sub-Saharan Africa

Abstract: High levels of human immunodeficiency virus type 1 (HIV-1) replication, as reflected in HIV-1 RNA concentrations in blood and semen, probably contribute to both rapid disease progression and enhanced sexual transmission. Semen and blood were collected from 49 Malawian and 61 US and Swiss (US/Swiss) HIV-1-seropositive men with similar CD4 cell counts and no urethritis or exposure to antiretroviral drugs. Median seminal plasma and blood plasma HIV-1 RNA concentrations were >3-fold (P = .034) and 5-fold (P = .0003) higher, respectively, in the Malawian men. Similar differences were observed in subsets of the Malawian and US/Swiss study groups matched individually for CD4 cell count (P = .035 and P < .002, respectively). These observations may help explain the high rates of HIV-1 sexual transmission and accelerated HIV-1 disease progression in sub-Saharan Africa.

Validation of the WHO diagnostic algorithm and development of an alternative scoring system for the management of women presenting with vaginal discharge in Malawi.

Abstract: Objective To evaluate the performance of the WHO algorithm for the detection of cervical infection in women presenting with vaginal discharge and modify the risk assessment score for optimum effectiveness in Malawi. Methods 550 consecutive women presenting with non-ulcerative genitourinary complaints were interviewed and examined. Cervical infection was defined as presence of Neisseria gonorrhoeae on culture and/or Chlamydia trachomatis by EIA. Other laboratory investigations included wet mount microscopy, serology for syphilis and HIV, LED testing of cervical and vaginal secretions, and pH testing of vaginal fluid. Sensitivity, specificity, and positive predictive values (PPV) of different algorithms were determined in the analysis. Results Cervical infection was identified in 19.5% of women (17.1% gonorrhoea, 3.7% chlamydial infection). The sensitivity/specificity/PPV of the WHO risk assessment were 43%/73%/28%, respectively by history and 62%/61%/27% with the addition of speculum examination. Using Malawi results to modify the risk assessment improved the performance to 61%/68%/31% respectively by history alone, which increased to 73%/64%/33% with bimanual examination and 72%/56%/29% with speculum examination. Conclusion The sensitivity of the WHO risk assessment is low for the detection of cervical infection in Malawi. Although the Malawi risk assessment performed somewhat better on history alone, this study identified external and bimanual examination variables that improved the diagnostic performance of the algorithm in settings where speculum examination is not possible. Although the PPVs of the algorithms are low, country specific risk assessments can provide a framework for management until simple, affordable diagnostic tests for the definitive diagnosis of cervical infection are available.

Improving sexually transmitted disease management in the private sector: the Jamaica experience.

Abstract: The Jamaican Ministry of Health has estimated that over 60% of all sexually transmitted diseases (STDs) are managed within the private sector where 800 (66%) of the countrys 1200 registered physicians practice. To improve the quality of STD case management provided by these practitioners the Medical Association of Jamaica organized a series of 6 half-day seminars repeated at 3-4 month intervals in three geographic locations between December 1993 and July 1995. Topics addressed included urethritis genital ulcer disease HIV/AIDS vaginal discharge pelvic inflammatory disease and STDs in children and adolescents. A total of 628 private practitioners attended at least one seminar and almost half the physicians attended two or more. Comparisons of scores on a written pretest completed before the seminar and those from a post-test conducted by telephone after the seminar revealed significant improvements in all four general STD management categories: counseling/education diagnostics/screening treatment and knowledge. The proportion of practitioners who obtained syphilis serologies during pregnancy rose from 38.3% to 83.8% and those providing effective treatment for gonorrhea increased from 57.8% to 81.1%. Overall 96% of practitioners were providing some level of risk-reduction counseling at the time of the post-test and 74% were prescribing correct treatment regimens. Ongoing education and motivation by the national STD control program or the Medical Association are recommended to improve STD case management even further.

Sexually transmitted diseases are common in women attending Jamaican family planning clinics and appropriate detection tools are lacking.

Abstract: A cross-sectional study was undertaken to assess sexually transmitted diseases (STDs) among 767 women attending Jamaican family planning clinics and to evaluate decision models as alternatives to STD laboratory diagnosis. Study participants were interviewed and tested for syphilis seroactivity using toluidine red unheated serum test and Treponema pallidum hemagglutination; for gonorrhea using a culture; for chlamydial infection using an enzyme-linked immunoassay; and for trichomoniasis using a culture. The women were tested based upon a clinical algorithm. Computer simulations explored the use of risk inclusive decision models for detection of cervical infection and/or trichomoniasis. Results indicated that among the 767 women 26.9% had at least one STD. Prevalence of gonorrhea was 2.7% chlamydial infection 12.2% gonococcal and/or chlamydial cervical infection 14.1% trichomoniasis 11.5% and syphilis seroactivity 5.9%. The clinical algorithm was 3.7% sensitive and 96.7% specific in detecting cervical infection. The positive predictive value of the STD clinic algorithm LED and two developed decision models ranged from 25.0% to 33.4% to detect cervical infection and/or trichomoniasis in the study participants. High STD prevalence was found among these family planning clinic attenders. None of the evaluated decision models was considered a good alternative in case detection using laboratory diagnosis. Thus effective and affordable tools to detect silent genital infections are needed. In the meantime available STD control strategies should be maximized such as condom usage and adequate treatment of STD patients.

Specificity of dysuria and discharge complaints and presence of urethritis in male patients attending an STD clinic in Malawi.

Abstract: The World Health Organization (WHO) has recommended a syndromic approach to the case management of sexually transmitted diseases (STDs) in areas with inadequate laboratories and trained personnel. This study evaluated the specificity of discharge and dysuria for laboratory confirmed urethritis among 517 consecutive symptomatic men presenting to an urban STD clinic in Malawi in 1992-93. Patients were randomized to receive one of five antibiotic regimens with an efficacy range of 33-95% and instructed to return for a follow-up visit in 8-10 days. The present analysis was limited to the 330 men with follow-up data. Overall 257 men (70%) had gonococcal urethritis and 13 (4%) had chlamydia urethritis. Laboratory evidence of urethritis was identified in over 90% of symptomatic patients with discharge or dysuria. Men with complaints of dysuria alone were significantly more likely to have sought treatment elsewhere before presenting to the clinic than men with both discharge and dysuria (72% vs. 48%) and were less likely to have had gonorrhea (64% vs. 83%). 92% of those who returned for the follow-up visit had no symptoms of either discharge or dysuria but 22 of these men (9.2%) had gonorrhea and 52 (21.8%) had nongonococcal urethritis. Among men with symptoms at the time of the follow-up visit 26 (28%) had gonorrhea and 12 (13%) had nongonococcal urethritis. These findings suggest that the symptom of dysuria should be added to discharge as an entry criterion for evaluation for urethritis in WHOs treatment recommendations. Moreover given the high prevalence of asymptomatic infection at follow-up in men who received suboptimal antimicrobial therapy it is recommended that the most effective treatment available should be provided at the first clinic visit.

Indicators and the measurement of STD case management in developing countries

Abstract: The World Health Organizations Global Program on AIDS (WHO/GPA) has developed a protocol for conducting facility-based assessments of sexually transmitted disease (STD) case management strategies. The WHO/GPA methodology measures two composite prevention indicators (PIs): PI16--the proportion of patients presenting with STD symptoms who are diagnosed and treated appropriately and PI17--the proportion who receive basic counseling about condoms and partner notification. The protocol calls for direct observation of provider-client interactions and provider interviews. This article reviews the research literature on the evaluation of STD case management in developing countries. Several studies adapted the WHO/GPA protocol for resource-poor settings and utilized techniques such as record review patient encounter forms patient exit interviews and simulated patients and pharmacy shoppers. Overall experience indicates that it is difficult to implement the protocol as intended in all field situations. Although nonstandardized alternative methods of data collection do not provide a composite PI16 score they do generate rich data for monitoring the quality of STD case management and contribute to managerial and supervisory aspects of intervention programs. A widespread observation was that providers have the knowledge to provide better quality STD care than they do in actual practice.

Indicators and the measurement of STD case management in developing countries. STD PI6&7 Working Group.

Abstract: The paper reviews methodologies for measuring quality of sexually transmitted disease (STD) case management through facility based assessments. These include observations and interviews of providers, as promoted by the World Health Organization's Global Programme on AIDS, and some of the viable alternatives including patient exit interviews, mystery patients, record review and patient encounter forms with supervisory visits. The paper concludes that the alternative approaches are feasible in resource poor settings and that they provide crucial data for evaluation and continued program development.

Choosing an effective and affordable antibiotic regimen for sexually transmitted diseases (STD) patients in Malawi

Abstract: At the STD clinic at Queen Elizabeth Central Hospital, Blantyre, a total of 1295 male patients with complaints of either urethral discharge and/or dysuria (urethritis), or genital ulcer disease (GUD) were enrolled in the study. Gonococcal urethritis was diagnosed in 415 (80.3%) and nongonococcal urethritis (NGU) in 59 (11.2%) of 517 males enrolled with urethritis. Haemophilus ducreyi cultures were positive for 204 (26.2%) of the 778 patients enrolled with GUD. The syphilis seropositivity rate (RPR and MHA-TP reactive) was 10.7% for the urethritis patients and 17.0% of 758 examined sera among the GUD patients. Reactive syphilis serology and/or positive DFA was found for 228 (33.5%) of 681 GUD patients. HIV seroprevalence was 44.2% among the urethritis patients and 58.9% among the GUD patients. For patients with urethritis, trimethoprim 320 mg/sulfamethoxazole 1600 mg PO for 2 days (TMPSMX), or the combination of amoxicillin 3 gm, probenecid 1 gm, and clavulanate 125 mg PO once (APC), failed to cure gonorrhoea effectively. Amoxicillin 3 gm, and clavulanate 125 mg, PO once with doxycycline 100 mg BID for 7 days (APC-D), gentamicin 240 mg 1M once (GENT), and ciprofloxacin 250 mg PO once (CIPRO) cured 92.9% to 95% of gonorrhoea. APC-D treatment did not generate less NGU at follow-up. For the patients with GUD, cotrimoxazole DS (960 mg) PO twice daily for seven days (TMPSMX) was ineffective for the treatment of chancroid-proven GUD. Erythromycin 250 mg three times daily for 7 days (ERY250), erythromycin 500 mg three times dally for seven days (ERY500), ciprofloxacin 250 mg once dally for 5 days (CIP1D) and ciprofloxacin 500 mg (CIP5D) stat dose appear to be equally effective for chancroid proven GUD. Although HIV serostatus did not effect cure of urethritis, HIV. infection clearly impaired healing of GUD. All patients presenting With urethritis or GUD complaints should be treated syndromically, using a simple algorithm, and screened for syphilis seroreactlvlty for appropriate treatment and counselling.