Showing papers in "Sexually Transmitted Diseases in 1996"

Declining prevalence of cervicovaginal human papillomavirus infection with age is independent of other risk factors.

Abstract: Background and Objectives: Human papillomavirus (HPV) infection of the female genital tract is the most common sexually transmitted disease. Although the prevalence of HPV in women without detectable cervical disease has been shown to decline with increasing age, the relationship to sexual behavior has not been investigated. Goal: To identify risk factors for, and associated with the age-dependent decline in, genital HPV infection in women. Study Design: The prevalence of HPV was determined in a cohort of 439 sexually active inner-city women between the ages of 18 and 50 years recruited in Brooklyn, New York. Cervicovaginal cells were collected by lavage, and HPV was detected by low-stringent Southern blot hybridization. Results: The prevalence of HPV infection ranged from 36% in women younger than 25 years of age to 2.8% in women 45 years or older. Logistic regression analysis identified an increased risk for cervical HPV infection to be independently associated with number of sex partners in the past year (odds ratio [OR], 1.04 per yearly increase in age; 95% confidence interval [CI], 1.00 to 1.08), younger age (OR, 0.92 per year increase in age; 95% CI, 0.88 to 0.95), and not living with partner (OR, 2.28; 95% CI, 1.40 to 4.22). Conclusions: The lower prevalence of HPV infection in older women compared to younger women was found to be independent of sexual behavior. These results suggest that a biologic effect, such as HPV immunity acquired over time and with multiple exposures, may mediate the inverse relationship between age and HPV prevalence.

The causal role for genital ulcer disease as a risk factor for transmission of human immunodeficiency virus. An application of the Bradford Hill criteria.

Abstract: Background and objectives Genital ulcer disease (GUD) has been reported to increase the risk for the acquisition of human immunodeficiency virus (HIV). Although many investigators have reported an increased risk for HIV infection in persons with concurrent or previous GUD, not all studies have been designed to determine whether GUD causes an increased risk for HIV infection or acts only as a risk marker for infection. The evidence from the literature is discussed, and the criteria for causal inference proposed by Sir Austin Bradford Hill are applied. Goal To evaluate the strength of the association between GUD and infection by HIV. Study design Case-control, cross-sectional, and cohort studies that examined the association between HIV seroconversion and GUD were chosen from the literature. Twenty-seven epidemiologic studies were selected for analysis, many of which reported separate analyses of the association between HIV infection and herpes simplex virus infection, syphilis, or nonspecified GUD. The studies were analyzed to investigate the magnitude of association between GUD and HIV, and the evidence evaluated using Hill's criteria. Results Approximately two thirds of the analyses reported a statistically significant association between GUD and HIV infection. Fourteen studies reported 29 separate analyses using a case-control design, 18 of which reported a statistically significant association between GUD (GUD, herpes, and syphilis) and HIV infection, four analyses were of varying significance depending on the analytical technique used, and seven were nonsignificant. Thirteen studies reported 23 separate longitudinal analyses that used a nested case-control or cohort design: 11 reported a significant association, 11 had nonsignificant findings, and results of one study varied. No study reported a statistically significant negative association. When applying the literature to Hill's criteria, all nine criteria for causal inference were met, providing additional evidence that genital ulcers are associated with an increased risk for the development of HIV infection. Conclusions The published evidence suggests that GUD increases the risk for HIV acquisition. Few studies, however, have examined carefully the temporal association between preexisting GUD and subsequent HIV acquisition. The analyses that simultaneously controlled for additional risks for HIV infection, such as lifetime sex partners or history of injection drug use, report a generally lower risk for HIV associated with GUD. It is likely that studies that adequately control for risk factors will find a lower risk associated with GUD than was reported in the literature earlier in the HIV epidemic. Future research needs and the problems associated with conducting these types of studies are discussed.

Sexual mixing patterns of patients attending sexually transmitted diseases clinics.

Abstract: Background: Theoretical studies have highlighted the importance of patterns of choice of sex partner in the transmission and persistence of sexually transmitted diseases (STDs). Goal: To describe reported patterns of sexual mixing according to numbers of sex partners in STD clinics. Study Design: Patients attending public health clinics in Seattle, Washington were interviewed about their own and their partners' behaviors. Results: Throughout, patterns of sexual mixing were weakly assortative. Across activity groups, many respondents believed their partners had no other sexual contacts. Those with three or more partners frequently perceived their partners to have three or more partners as well. Conclusions: Assortatively mixing persons of high sexual activity makes the persistence of STDs within a population likely (i.e., they act as a core group). Additionally, because mixing is not highly assortative (like with like), a steady trickle of infection from members of the core group will pass to other segments of the population.

Risk factors for HPV DNA detection in middle-aged women.

Abstract: Background and objectives Strong epidemiologic evidence indicates that human papillomavirus (HPV) is the main etiologic factor of cervical cancer. A few cohort studies suggest that most HPV infections are transient in young women and that persistent HPV infections are more common in older women. Little is known about the determinants of persistent HPV infections. The present study was aimed at increasing our knowledge about these determinants. Goals To identify risk factors for genital HPV DNA detection among cytologically normal middle-aged women. Study design Eight hundred ten women who participated as control subjects in three case-control studies on cervical cancer in Spain, Colombia, and Brazil were included in this study. After an interview, women underwent a gynecologic examination with collection of exfoliated cells for a Papanicolaou smear and HPV DNA detection. Human papilloma virus DNA was detected by polymerase chain reaction (PCR)-based hybridization techniques. Results The HPV positivity rate was 10.5% in the whole population, but was higher in the areas with high incidence of cervical cancer (17% in Brazil and 13% in Colombia) than in Spain (4.9%), which is a low-risk area for cervical cancer. Age was related to the prevalence of HPV DNA in Brazil, but not in Spain and Colombia. In univariate analyses in all three countries, the prevalence of HPV DNA was positively associated with the number of lifetime sexual partners and inversely associated with the levels of family income and with age at first sexual intercourse. There was four times increase in the odds ratio (OR) of HPV infection in women who had six or more lifetime sexual partners compared with those with one or less. The use of any kind of contraceptive tended to decrease the OR for HPV detection. Their ORs ranged from 0.44 (barrier methods) to 0.48 (oral contraceptives). In Spain and Colombia, antibodies against Chlamydia trachomatis were positively associated with the prevalence of HPV DNA. In a final multivariate model, the positive associations with lifetime number of sexual partners, socioeconomic status, and C. trachomatis persisted. Conclusions These results support the sexual transmission of HPV and suggest that socioeconomic status and antibodies to C. trachomatis are independent predictors of HPV detection in middle-aged cytologically normal women.

Epidemiology of syphilis in the United States, 1941--1993.

Abstract: Background and Objectives : The distribution and trends of syphilis are influenced by biologic factors, sexual behaviors, biomedical technology, availability of and access to health care, public health efforts, changes in population dynamics, and sociocultural factors. The objective of this article is to review the epidemiology of syphilis in the United States during the period 1941-1993 in the context of some of these factors. Study Design : Surveillance data on cases of syphilis and congenital syphilis reported by state and city health departments to the Centers for Disease Control and Prevention were analyzed to show distribution and trends by geographic location, racial and ethnic groups, gender, and age. Results : Historically, syphilis was distributed widely throughout the country and declined rapidly after the introduction of penicillin therapy and broad-based public health programs, attaining its lowest levels in the 1950s. However, in recent years, the disease has returned and become focused in the southern region and in urban areas outside that region. Rates of syphilis have remained highest in black Americans, and the most recent national epidemic of syphilis primarily involved them. Rates in white men were at intermediate levels during the early 1980s but have declined to low rates in the 1990s, possibly because of changes in behavior in response to the AIDS epidemic. Rates in white women and other racial and ethnic groups have remained low throughout the 1980s and 1990s. Conclusions : Syphilis remains a significant problem in the United States, and its epidemiology is influenced by a complex combination of factors. To prevent and control syphilis effectively, public health practitioners must understand these factors and design programs and interventions that address the disease in the context of these factors.

Decreasing incidences of gonorrhea- and chlamydia-associated acute pelvic inflammatory disease. A 25-year study from an urban area of central Sweden.

Abstract: Background and Objectives: Acute pelvic inflammatory disease (PID) affects women in their reproductive years and is often a complication of a sexually transmitted disease (STD), particularly Neisseria gonorrhoeae and Chlamydia trachomatis. Infertility, ectopic pregnancy, and chronic lower abdominal pain are common long-term sequelae to acute PID. Through different preventive measures, endemic N. gonorrhoeae is almost eliminated, and C. trachomatis has been reduced almost fourfold in Sweden. Goals: To investigate variations in STD-associated acute PID and the extent to which this influenced the yearly incidences of patients hospitalized for this complication during a 25-year-period. Study Design: Hospital records of 2499 patients admitted and treated for acute PID from January 1, 1970 to December 31, 1994 were analyzed for infection with N. gonorrhoeae. Routine laboratory diagnosis for C. trachomatis infection started June 1, 1980. Detailed statistical analysis for chlamydial-associated PID in this study, therefore, covers the period January 1, 1981 to December 31, 1994 and includes 1030 patients. Results: Gonorrhea occurred in 42% of patients with acute PID in 1970 and decreased continuously to zero in 1988 and beyond. Concomitant urogenital chlamydial infection reduced almost fourfold from 28.4% in 1985 to 7.7% in 1994. Yearly admissions for acute PID fluctuated slightly (≤16%) in the early 1970s and early 1980s but increased greatly (>60%) in the middle and late 1970s; the highest was 180 per year in 1976. This coincided with high incidence rates of gonorrhea in the general population, and probably of genital C. trachomatis infection as well, coupled with an increased use of intrauterine contraceptive device in nulliparous women. The largest increase in admissions for acute PID was in the 15- to 29-year-old group. A steady decrease started in 1987 and reached the low figure of 26 admissions in 1994. The greatest decrease occurred in the 15- to 19-year-old group, from the relative age distribution of 28.9% in the period 1970 to 1974 to 12.9% in 1990 to 1994. Yearly admissions for the ≥35-year-old group remained almost constant during the study period, but the relative age distribution shifted from second lowest (excluding those 14 years or younger, totaling 15 admissions for the entire study period), 9.1% at at the beginning of the study period, to the second largest, 24.9% at the end of it. The study also showed that the total and relative rates of recurrence decreased. Conclusions: Measures aimed at reducing incidences of gonorrhea and genital chlamydial infection will reduce the incidences of one of the most serious complications of these STDs, acute PID, and, in turn, its long-term sequelae.

Comparison of development of serum antibodies to HPV16 and HPV33 and acquisition of cervical HPV DNA among sexually experienced and virginal young girls. A longitudinal cohort study.

Abstract: Objectives: To study the importance of sexual activity and early coitus debut on the risk for acquiring infection with human papillomavirus (HPV) type 16 or 33. Study Design: Ninety-eight healthy adolescent girls were followed up with consecutive interviews and donations of serum and cervical brush samples during 2 years. Results: Fourteen percent of sexually experienced girls had serum immunoglobulin G to HPV16 and/or HPV33 capsids, and 14% also had cervical HPV16 or HPV33 DNA. Seropositivity for HPV correlated with detection of cervical HPV DNA. None of the 36 girls without coital experience was seropositive or harbored cervical HPV DNA. Seropositivity for HPV was correlated strongly with the number of sexual partners: Odds ratio for >1 sexual partner was 16.3 (P < 0.001), and for early coitus debut (younger than 17 years of age), it was 14.3 (P < 0.002). Conclusions: Both HPV serology and HPV DNA testing indicated that the number of sexual partners and earliness of coitus debut determined the risk for acquiring HPV infection and that nonsexually transmitted infections are rare or nonexistent among adolescent girls.

The relevance of social network concepts to sexually transmitted disease control.

Abstract: Many of the concepts of social network analysis have been tacit assumptions of sexually transmitted disease control efforts for decades. With the advent of AIDS in the 1980s, an overt rapprochement between these two fields--previously separated by culture, context, and language--was made. Social network constructs have immediate appeal to disease control workers, who view many diseases as following the conduits of social interactions. STDs and HIV, in turn, provide network analysts and those who model disease transmission with substantial sets of empirical data that test and illuminate theory. Disease control efforts can be enhanced by incorporating network concepts overtly into current practices. Such concepts offer a path to better delineation of groups at risk, to a better understanding of the interaction of personal risk taking and the social context, and to evaluation of control mechanisms.

Reliability of partner reports of sexual history in a heterosexual population at a sexually transmitted diseases clinic

Abstract: Background: In epidemiologic research, information about sexual frequency and condom use is by necessity based on self-reports. This study investigated the reliability of self-reported sexual behavior in 162 heterosexual partnerships. Methods: Subjects were part of a larger study of condom use and sexually transmitted diseases (STD) conducted in two Baltimore STD clinics from 1990 to 1992. Partners were enrolled on the same day and were interviewed separately. Information about sexual activity and condom use was collected using a retrospective calendar for the 30 days before enrollment. Results: Participants were predominantly young, unmarried African-Americans. Based on Spearman's correlation coefficients and kappa statistics, the authors found only fair agree ment (K = 0.43; r = 0.51) between partner reports of overall condom use for the 30-day period before the interview. Correlation coefficients ranged from 0.43 for frequency of any sexual activity to 0.56 for number of days on which vaginal intercourse occurred. Conclusions: Partner agreement for condom use and frequency of sexual activity decreased as the recall period increased. Higher partner agreement was observed for questions with definite answers compared to the more open-ended sexual behavior questions. These findings indicate potential reporting bias in self-reports of sexual behavior in a population at high risk for STDs.

The social context of syphilis persistence in the Southeastern United States

Abstract: In light of the racial-ethnic and poverty composition of the United States population and the distribution of syphilis morbidity across population subgroups, it is important to determine how race-ethnicity and poverty jointly and independently affect transmission dynamics of syphilis and other sexually transmitted diseases. Populations of minority race ethnicity and populations of poverty are both marked by youthful age composition and relative scarcity of men, and both populations live in areas of high poverty concentration. Sexually transmitted disease morbidity, particularly syphilis morbidity, is concentrated in these populations, which are neither purely racial-ethnic groupings nor purely economic groupings. This social context creates potential sex partner pools of high risk and high sexually transmitted disease prevalence, which carry a higher probability of exposure to infection for each sex act. The combined effects of poverty, minority race-ethnicity, and geographic clustering apparently contribute to persisting syphilis morbidity, particularly in the southeastern United States.

Comparison of DNA amplification methods for the detection of Chlamydia trachomatis in first-void urine from asymptomatic military recruits.

Abstract: Objective To evaluate the performance of DNA amplification-based tests for the diagnosis of urethral chlamydia infection from the urine of asymptomatic young men. Design First-void urine was analyzed by two amplified DNA technologies, the ligase chain reaction (LCR), the polymerase chain reaction (PCR), and enzyme immunoassay (EIA). Specimens yielding discrepant results were subjected to retesting using either the original or a newly processed sample, and for evaluation of truly infected persons they were analyzed by the direct fluorescence antibody assay and by a second LCR directed against a segment of the gene encoding for the major outer membrane protein of Chlamydia trachomatis. Setting The military hospital in which military recruits underwent medical examination before departing for a United Nations mission. Study group Asymptomatic military recruits (705 young men) were screened between January and May 1994. In addition to providing urine specimens, the recruits completed questionnaires concerning previous genital infections and number of sexual partners. Results Overall prevalence of urethral chlamydia infection in the study group was 4.1% (29/705), as determined by confirmed results in all tests collectively. The performance of the DNA amplification methods was markedly better than that of the EIA antigen detection methods. Using an expanded gold standard, the sensitivity of the LCx assay was 93.1% (27/29) compared to 62.1% (18/29) by the PCR assay Amplicor and 37.9% (11/29) by EIA. Repeat testing after freezing and thawing increased the number of positive PCR results to equal the number of positive LCR results. There were three false-positive Amplicor results and no false-positive LCR results. Conclusions The LCx assay performed better than the Amplicor assay and appears reliable for urine testing. The low sensitivity of the Amplicor assay requires further evaluation of possible inhibitors of PCR in fresh specimens. It was found that freezing and thawing the specimens before testing enhanced the performance of PCR.

Sexual intercourse during menstruation and self-reported sexually transmitted disease history among women.

Abstract: Objectives The purpose of this study was to examine the practice of sexual intercourse during menstruation and the relationship of this practice to the experience of sexually transmitted diseases (STD) among women in the United States. Methods Logistic regression technique was used to conduct an analysis of population-based data from a national sample of 1586 sexually active 20- to 37-year-old women to examine the patterns of sexual intercourse during menstruation and its relationship with STD outcome. Results More than one fourth of the women reported that they usually have vaginal intercourse during their menses, and 16% reported that they had had vaginal intercourse during their last menstrual period. Proportions of women engaging in this practice were higher among those who reported greater frequency of intercourse and larger numbers of lifetime sex partners. Almost half the women who had intercourse more than twice a week and more than one third of the women who had more than seven lifetime sex partners reported that they usually have vaginal intercourse during menses. The findings suggest that this practice is relatively more common among the better educated, young, white women and their sex partners. Most interestingly, despite the fact that sex during menses is most common among women in relatively low-risk groups, we were able to observe a strong statistical association between sexual intercourse during menstruation and self-reported STD history. Conclusions Sexual intercourse during menstruation may emerge more consistently as a risk factor for the heterosexual transmission of HIV or other sexually transmitted pathogens in future studies. If future epidemiologic studies continue to bolster this finding, then public health efforts should promote abstinence during the female menstrual period and target those groups of women among whom this practice is prevalent.

Syphilis control. The historic context and epidemiologic basis for interrupting sexual transmission of Treponema pallidum.

Abstract: Syphilis control has been the prototypic sexually transmitted disease (STD) public health program of the 20th century. However, the disease remains nearly as much an epidemiologic enigma as it did in the early 1900s. This article examines the historic and epidemiologic bases for syphilis control, using unpublished data to supplement a recent model of STD transmission. The authors recommend building on such traditional individually oriented strategies as case finding, partner notification, and presumptive treatment as a basis for future community-oriented, population-based strategies including (but not limited to) selective mass treatment in high-prevalence populations. Using epidemiologic information to target population-level interventions will be the paradigm for syphilis control in the 20th century.

Risk factors for pelvic inflammatory disease. A case control study.

Abstract: Background and objectives Pelvic inflammatory disease (PID) is associated with major medical and economic consequences for women of reproductive age. Identification of the risk factors associated with PID is crucial to efforts for prevention of these consequences. Goal To identify risk factors and markers for symptomatic PID. Study design A case-control study of 234 women with PID treated at San Francisco General Hospital between October 1986 and August 1989 and 122 controls attending the Women's Clinic at the same institution. The two groups were comparable in sociodemographic, reproductive, sexual, and medical history. Results Risk factors and markers identified by univariate analysis were 0, parity > 0, spontaneous abortion > 0, lack of a birth control method, > 1 male sexual partner in the previous 30 days, younger than 18 years at age of first sex, history of gonorrhea, sex during the previous menses, douching, exposure to nongonococcal urethritis in the previous 30 days, and history of crack cocaine use. With multivariate analysis to control for confounders the risks still identified were parity > 0, (odds ratio [OR] 4.44; 95% confidence interval [CI] 2.34 to 8.42), > 1 sexual partner in the previous 30 days (OR 11.08; 95% CI 4.31 to 28.5), sex during the previous menses (OR 5.22; 95% CI 1.88 to 14.48), and a lack of contraception (OR 7.6; 95% CI 4.10 to 14.09). Conclusions Findings indicated that certain reproductive behaviors could be targeted for public health attention and risk reduction interventions to reduce the incidence of PID. These include limiting numbers of sexual partners and encouraging the use of barrier methods of contraception for sexually transmitted disease prevention. Another finding was that it is probably best to avoid sexual intercourse during the menses. The question of douching as a risk factor for PID could not be answered by this study.

The vaginal microflora of pig-tailed macaques and the effects of chlorhexidine and benzalkonium on this ecosystem.

Abstract: Background and Objectives: To characterize normal vaginal microflora of pig-tailed macaques and to evaluate two commonly used intravaginal compounds, chlorhexidine (CHG), a vaginal antiseptic (Surgilube, E. Fougera, Melville, NY), and benzalkonium chloride (BZK) (spermicidal contraceptive) in thin monkey model to assess effects on the vagina microflora. Study Design: Vaginal swabs were collected for microbiologic analysis to characterize normal flora. Subsequently, the vagina was exposed to either CHG or BZK twice at 24-hour intervals. Results: The vaginal microflora of 26 pig-tailed macaques was found to be remarkably similar to the vaginal flora of the human with respect to frequency of vaginal colonization by H 2 O 2 -producing lactobacilli, Prevotella species, and several other microorganisms. After two vaginal applications at 24-hour intervals, CHG had only small effects on the vaginal microflora of five animals. By contrast, BZK applied by the same protocol had profound adverse effects on the lactobacilli and Peptostreptococcus and more transient effects on vaginal Prevotella and viridans streptococci of six animals. Conclusions: These observations demonstrate that the vaginal microflora of the pig-tailed macaque is a useful model in which to further evaluate newly developed intravaginal contraceptives that may be microbicidal and/or virucidal before widespread intravaginal use in women.

Human immunodeficiency virus transmission and the role of other sexually transmitted diseases. Measures of association and study design.

Abstract: Background: Studies have reported that infection with certain sexually transmitted diseases (STD), such as chancroid, gonorrhea, and genital herpes, enhances the probability of human immunodeficiency virus (HIV) transmission by sexual contact with an infected partner. Epidemiologic studies vary in design from longitudinal to cross-sectional, with varying periods of follow-up or retrospective history of exposure to STD. The major difficulty in assessing the results of past work centers on the validity and precision of widely used measures of association, such as relative risk (RR) and odds ratio (OR), in situations in which common behavior (e.g., different facets of sexual behavior) underpins the acquisition of both the STD cofactor and HIV. Goal: To evaluate the quality of the cumulative incidence ratio (CIR), the hazard rate ratio (HRR), and the prevalence ratio (PR) as measures of association to estimate and test the increase in HIV transmission probabilities caused by the STD. Study Design: The study is based on a proportional hazard stochastic model of concomitant HIV and STD cofactor transmission. Analysis was performed using Monte-Carlo simulation. Results: Estimates of the HIV-STD association by the CIR, HRR, and PR, adjusted and nonadjusted for sexual activity, are shown to have poor validity and great variability. The adjusted CIR, HRR, and PR tend to underestimate the strength of the true association (specified in the model) in both longitudinal and cross-sectional designs. In the absence an HIV-STD association, the PR tends to overestimate the magnitude, whereas the CIR and HRR may either underestimate or overestimate it in longitudinal studies. These results have direct consequences on the reliability of the test of association showing both a lack of specificity (empirical type I error) and sensitivity (empirical power). Some reasons contributing to the bias in the estimates of the measures of association are the presence of confounding variables, namely the frequency of change of sex partner and the mixing pattern between sexual activity classes, as well as the adopted definition of exposure to the STD cofactor and the prevalence of both HIV and the STD cofactor. Conclusions: The precision of estimates and reliability of the test of HIV-STD association could be improved through longitudinal studies using more careful definition and measurement of exposure to the STD cofactor and larger sample sizes permitting finer stratification of sexual behavior and a sufficient number of persons per stratum.

Status of local cellular immunity in interferon-responsive and -nonresponsive human papillomavirus-associated lesions.

Abstract: Background and Objectives: Anogenital warts are caused by human papillomaviruses (HPVs), which should induce cellular immune responses in immunocompetent patients. However, the natural history of these warts shows considerable variation between persons, ranging from spontaneous regression to prolonged persistence. In addition, the efficiency of immunologically based modalities for the therapy of anogenital warts, such as interferon (IFN) treatment, is highly variable. Methods: Considering that preexisting conditions of the host are important factors in an appropriate immune response, the authors determined the pretreatment status of local cell-mediated immune response to HPV infection by reverse transcription-polymerase chain reaction in patients with condyloma acuminatum, who later received IFN treatment and responded well or poorly to that therapy. Results and Conclusions: The authors found that biopsies from nonresponders were depleted markedly in Langerhans cells, leading to decreases in major histocompatibility complex class II expression and, therefore, to diminished attraction of CD4+ T cells. An inappropriate major histocompatibility complex class I expression also was observed in those nonresponders with decreased CD8+ levels. The mRNA levels of cytokines (interleukin-la, interleukin-lb, granulocyte-macrophage-colony stimulating factor, tumor necrosis factor that participate in immune responses were low in nonresponders. In contrast, responders demonstrated high macrophage-natural killer cell (CD16-positive) and activated CD4 (IL-2, interferon gammapositive, TH1 cells) T-cell recruitment against HPV-infected keratinocytes, which is consistent with a delayed-type hypersensitivity-like cellular immune response. Lack of immune response in nonresponders appeared to correlate with high expression levels of the HPV E7 gene. These differences in local cellular immunity might determine the response rate of HPV-infected cells to immunomodulatory therapies.

Quinolone-resistant Neisseria gonorrhoeae isolated in Sydney, Australia, 1991 to 1995.

Abstract: Background and Objectives: Quinolone antibiotics are used widely for the treatment of gonorrhea, but resistant strains appeared in Sydney in 1984, treatment failure with high-dose regimens in 1991, and isolates with very high minimal inhibitory concentrations (MICs) (16 mg/l) in 1994. Goals: To examine the frequency, source, and characteristics of Quinolone-resistantNeisseria gonorrhoeae(QRNG) in Sydney from 1991 to 1995 and to compare these data with those obtained from 1984 to 1990. Study Design: The antibiotic sensitivity, auxotype-serovar class, and geographic source of QRNG isolated in Sydney from January 1, 1991 to June 30, 1995 were analyzed. Results: One hundred seven QRNG were isolated from 97 patients from 1991 to 1995. The number, proportion, and MICs of QRNG increased slowly in the first 4 years of the study and rapidly in the last 6 months. Most QRNG were isolated from travelers entering Sydney from Asia. Twenty-seven different auxotype-serovar classes were detected including 6 auxotype-serovar classes in 14 isolates with high-level quinolone resistance (MIC, 16 mg/l). Conclusions: QRNG isolated in Sydney during the past decade originated in Asia as multiple gonococcal subtypes and increased substantially in numbers and levels of resistance in 1995.

Sexual adventurism, high-risk behavior, and human immunodeficiency virus-1 seroconversion among the Chicago MACS-CCS cohort, 1984 to 1992. A case-control study.

Abstract: Background and Objectives: To predict incident human immunodeficiency virus (HIV)-1 seroconversions among a cohort of gay and bisexual men based on recalled sexual behavior, drug use, partnership status, and an index of sexual adventurism/risk-seeking attitudes. Study Design: A nested case-control design was used in a retrospective study spanning a 9-year period. Results: Sexual adventurism was an important predictor of HIV-1 infection. The partial risk ratio for our 100-point adventurism scale indicated a marginal rate of increase in seroconversion risk of 4% (odds ratio = 1.04; 95% confidence interval = 1.02 to 1.06), with almost 79% of seroconverters scoring above the median on the index. As expected, partner status, drug use, and unprotected receptive anal (RA) intercourse were associated with seroconversion. However, multivariate results indicated that men using condoms consistently in RA sex were also at higher risk for infection (odds ratio = 2.68; 95% confidence interval = 1.04 to 6.95) than men who abstained from RA intercourse. Conclusions: Results are discussed with respect to their implications for HIV prevention intervention and research. Recommendations include the development of new approaches and the adaptation of existing intervention techniques that recognize and treat persons with strong risk-taking predispositions.

Resolution of Serum and Cerebrospinal Fluid Abnormalities After Treatment of Neurosyphilis. Influence of Concomitant Human Immunodeficiency Virus Infection

Abstract: Background and objectives Little is known about resolution of serum and cerebrospinal fluid abnormalities after neurosyphilis treatment, especially in patients infected with human immunodeficiency virus (HIV). Goal To examine the time course of resolution of these abnormalities. Study design Case series of 22 patients with neurosyphilis (13 infected with HIV) with reactive cerebrospinal fluid Venereal Disease Research Laboratory test who underwent at least one lumbar puncture after treatment. Results Resolution of all serum and cerebrospinal fluid measures was slower in patients infected with HIV. Serum and cerebrospinal fluid abnormalities resolved in most patients not infected with HIV by 30 weeks, and all met Centers for Disease Control and Prevention criteria for cure. One patient infected with HIV failed therapy by Centers for Disease Control and Prevention criteria, and three others had persistent pleocytosis. Conclusions HIV-infected patients with neurosyphilis have slower resolution of serum and cerebrospinal fluid abnormalities after therapy. This observation may suggest impaired clearance of Treponema pallidum from the central nervous system.

A clinical isolate of Neisseria gonorrhoeae with in vitro resistance to erythromycin and decreased susceptibility to azithromycin.

Abstract: BACKGROUND AND OBJECTIVES Erythromycin is a recommended treatment for penicillin-allergic pregnant women with gonorrhea, and azithromycin has been suggested as therapy for coexisting gonococcal and chlamydial infections. Although gonococcal resistance to erythromycin is not uncommon, decreased resistance to azithromycin is rare. A clinical isolate of Neisseria gonorrhoeae with in vitro resistance to erythromycin and decreased susceptibility to azithromycin is reported. STUDY DESIGN This is a case report. RESULTS Antimicrobial susceptibility testing of a clinical isolate of N. gonorrhoeae revealed a minimal inhibitory concentration (MIC) of 2 micrograms/ml to azithromycin and 32 micrograms/ml to erythromycin. Five hundred other urethral isolates were tested, resulting in an MIC for erythromycin ranging from 0.015 to 2 micrograms/ml. The range for azithromycin was 0.015 to 0.5 micrograms/ml. There was a strong correlation between erythromycin and azithromycin MICs (r = 0.73; P < 0.0001). CONCLUSIONS Continued national monitoring is needed to detect the appearance and early dissemination of new types of gonococcal resistance.

Sexual partner networks in the transmission of sexually transmitted diseases. An analysis of gonorrhea cases in Sheffield, UK.

Abstract: Background and objectives Routine contact tracing data on patients with gonorrhea are used to identify sexual partner networks. These are combined with gonococcal typing data to study patterns of transmission. The role of persons in transmission is discussed. Study design Contact tracing data on patients with gonorrhea attending the Royal Hallamshire Hospital in Sheffield in 1988 and 1989 are analyzed. Gonococcal strains identified by auxotype/serovar (A/S) class are combined with these data to identify transmission paths. Results The network contained 1,272 persons, 724 (77%) of whom had gonorrhea during the study period. Four hundred two clusters of linked cases were identified. The largest cluster, containing 35 persons connected over 16 months, is discussed in greater detail to illustrate how these data may help identify patterns of transmission and the role of persons. Conclusion Contact tracing data can be used to identify sexual partner networks and to study transmission patterns. Microbiologic data can aid interpretation. An person's risk of acquiring infection depends on indirect links as well as direct links. To understand patterns of transmission it may be important to distinguish between those involved in transmission and those only acquiring infection. Networks established through gonococcal transmission are also relevant to the transmission of other sexually transmitted diseases.

Comparison of methods for the detection of treponema pallidum in lesions of early syphilis.

Abstract: Background The clinical diagnosis of primary and secondary syphilis can be difficult because of the wide variability of lesions. The available laboratory tests (dark-field microscopy and direct fluorescent antibody) require specialized microscopes and skilled technicians, and serologic tests are insensitive in early infection. Methods Dark-field microscopy and monoclonal antibody staining were compared to a new solid-phase enzyme-linked immunosorbent assay (Visuwell test) for detection of T. pallidum in lesion exudate of 188 patients with genital lesions. Results Sixty-four patients (34%) had lesions of early syphilis diagnosed by either dark-field, monoclonal antibody staining, or both. The Visuwell test and dark-field examination were positive in 52 (81.3%) and 55 (85.9%) of the 64 patients, respectively, whereas the monoclonal antibody staining technique demonstrated the presence of T. pallidum in 59 (92.2%) of the 64 patients. The Visuwell test gave a negative result in 111 of 124 patients who had negative dark-field and direct fluorescent antibody test results (89.5% specificity). Conclusions The Visuwell test is an alternative method for evaluating genital ulcers but is less sensitive and specific than existing tests.

mathematical Modeling of Epidemic Syphilis Transmission : implications for Syphilis Control Programs

Abstract: Background and Objectives: The past 10 years' wave of syphilis epidemics has challenged syphilis control programs. Although apparently connected to drugs-for-sex trading of crack cocaine, the genesis and resolution of these epidemics is poorly understood. Goals of the Study: The goals of this study were to develop a mathematical model of epidemic syphilis transmission based on empiric data, to stimulate and ascertain behavioral and sociologic features necessary to produce epidemic transmission, and to explore mechanisms leading to resolution of epidemic transmission. Study Design: The study used multi-compartment iterative computer simulation using empirically derived input data. Results: Epidemic transmission resulted from adding a small core group of individuals with very high levels of partner exchange (300–400 partners per year) to a population with levels of partner exchange seen in the general population. Epidemic resolution could result from immunity or subtle changes in the size or partner exchange rate of the core group. Conclusions: There is a need for sexually transmitted disease control programs to reevaluate their approach to prevention and control of epidemic syphilis in light of data on transmission dynamics.

History of sexually transmitted diseases infection, drug-sex behaviors, and the use of condoms among midwestern users of injection drugs and crack cocaine

Abstract: During 1992-95 in Ohio outreach workers at various sites in Dayton and Columbus interviewed 749 men and 297 women about their drug use practices sexual behaviors drug-sex behaviors and history of some sexually transmitted diseases (STDs). Researchers aimed to assess baseline behaviors of injection drug users and crack cocaine users. 73.2% of the men and 57.2% of the women used injection drugs. 26.8% of the men and 42.8% of the women used crack cocaine. About 25% of both groups were homeless. 79.7% of men and 68.7% of the women were Black. Among men Blacks were more likely than Whites to have had syphilis and gonorrhea or any STD (6.2% vs. 2% 48.6% vs. 19.1% and 53.6% vs. 29% respectively; p < 0.05). Among women Blacks were more likely to have had trichomonas (40.2% vs. 26.1%; p < 0.05). For men variables associated with not always using condoms in the last 30 days included STD history (odds ratio [OR] = 0.53; p = 0.0069) cohabitation (OR = 0.13; p = 0.00001) and injection drug use (when compared with crack cocaine use) (OR = 0.52; p = 0.0063); for women they were exchanging sex for drugs (OR = 0.31; p = 0.0252) and cohabitation (OR = 0.22; p = 0.0157). Women who traded sex for money were significantly more likely to always use condoms in the last 30 days than those who did not (OR = 4.48; p = 0.0008). These findings show that injection drug users and crack cocaine users face a high risk of acquiring and transmitting STDs. They suggest that intervention efforts to target these two groups need to be sensitive to ethnic and gender differences.

Individual counseling of patients with sexually transmitted diseases. A way to improve partner notification in a Zambian setting

Abstract: In Lusaka Zambia at an urban health center researchers randomly allocated 302 male sexually transmitted disease (STD) patients and 94 female STD patients to receive or not receive individual counseling combined with written information to sex partners (i.e. contact slips). They aimed to determine whether or not this intervention improved partner notification. This study was conducted during October 1992-March 1993. The most common STD for men was chancroid followed by gonorrhea and syphilis. For women it was syphilis followed by gonorrhea. Men and women in the intervention group were more likely to bring at least one sex partner to the clinic than those in the control group (100% vs. 93% and 72% vs. 56% respectively). Men in the intervention group brought more partners from the last three months to the clinic than those in the control group (1.8 vs. 1.2; p < 0.001) while women in both groups brought the same number of partners (0.7). In the intervention group more partners of the men received treatment based on contact slips than partners of the women (1.6 vs. 0.4). For both sexes based on the number of contact slips filed the numbers of partners informed fell gradually with the numbers of partners treated. Men in the intervention group were less likely than those in the control group not to tell all partners from the last three months to come for treatment (19% vs. 48%). Among controls the reasons were health staff failed to tell them to bring more than one partner and the men could not afford the medicines for their partners. Among cases the leading reason was that the partners were unknown or out of town. Quarrels that prevented partners from seeking treatment occurred equally in both groups of women. They occurred more often among male cases than male controls however (p = 0.0008). Yet partners of male controls who had experienced quarrels were less likely to seek treatment than those of male cases (p = 0.0015). The quarrels-related findings suggest the need for counseling to emphasize partners emotional reactions and how to deal with these reactions. Overall findings show that individual counseling of men improved STD partner notification.

Quinolone-resistant Neisseria gonorrhoeae in Hong Kong.

Abstract: This study sought to examine the serologic characters and antibiotic susceptibilities of quinolone-resistant Neisseria gonorrhoeae in Hong Kong. 69 strains of Neisseria gonorrhoea isolated from clinical failure cases after treatment with ofloxacin during the period January 1 1992 to January 1 1995 were studied. A panel of 14 monoclonal antibodies against protein 1 classified these strains into 21 serovars. The pattern of serovar distribution against varying minimum inhibitory concentrations of ofloxacin was compared with 143 strains isolated from a cohort of quinolone-susceptible clinically responsive cases. Antibiotic susceptibility tests were performed on quinolone-resistant strains to penicillin tetracycline ciprofloxacin spectinomycin and ceftriaxone. Epidemiologic information on location of contact was collected. Serologic characterization showed that Bop and Bpy were the dominant serovars among quinolone-resistant strains. Most IA and IB serovars had declined in the selection process for quinolone resistance. Antibiotic susceptibility tests showed that 81.2% 89.9% and 78.3% of quinolone-resistant Neisseria gonorrhoeae strains were resistant to penicillin tetracycline and both respectively whereas 10 of 69 (14.5%) of such strains displayed high-level quinolone resistance (ofloxacin minimum inhibitory concentrations >8 mcg/ml). The quinolone-resistant strains remained fully susceptible to spectinomycin and ceftriaxone. Quinolone-resistant strains have become firmly established in Hong Kong. Serovar determination has documented shifts in the gonococcal population during the selection process for quinolone resistance. Places that use quinolone in the treatment of sexually transmitted diseases should be alert to the emergence of high-level quinolone-resistant Neisseria gonorrhoeae. (authors)

Antibiotic prophylaxis among commercial sex workers in Cebu City, Philippines. Patterns of use and perceptions of efficacy.

Abstract: Some commercial sex workers (CSWs) believe that self-treatment with low-dose prophylactic antibiotics can protect them from contracting sexually transmitted diseases (STDs) including HIV and AIDS. Such practice however provides no protection against STD impedes STD screening efforts and contributes to antibiotic resistance. 200 sexually active female CSWs in Cebu City Philippines were interviewed to determine the extent to which they believe the prophylactic use of antibiotics can protect them from STD. 38% of the 160 CSWs involved in prostitution during the 2 weeks before the interviews reported routine or occasional use of antibiotics and 31% reported use in the past 2 weeks. CSWs not registered with the Cebu City social hygiene clinic were five times more likely to use prophylactic antibiotics than registered CSWs seven times less likely to use condoms with 80% or more of their customers and have sex with three times as many customers.

Human immunodeficiency virus infection and self-treatment for sexually transmitted diseases among northern Thai men.

Abstract: In May 1993 at 11 military camps in the upper northern region of Thailand civilians interviewed 869 men aged 21-29 years (most of whom were 21 years old) so researchers could determine the frequency and variety of self-treatment and self-prophylaxis behaviors for sexually transmitted disease (STD) and the relationship of these behaviors with the prevalence of HIV infection. 12.3% of the men at conscription into the military tested positive for HIV infection. 32.5% had ever had an STD. The leading STDs and syndromes were gonorrhea (16.1%) penile discharge with pus (15.5%) and pain while urinating (11.4%). HIV-positive men were more likely to have had sex with commercial sex workers (CSWs) (odds ratio [OR] = 9.14) to have had an STD (OR = 5.96) and not to use condoms consistently when having sexual intercourse with CSWs (OR = 3.13). 65.2% of men who had ever had an STD self-treated with antibiotics. 8.5% of men who had ever had an STD used antibiotics particularly chloramphenicol before having intercourse with a CSW. Among all the men who had sexual intercourse with CSWs almost all (98.7%) had adopted steps to prevent STDs: increasing urine output (69.2%) washing the genitals with soap and water (28.9%) and using antibiotics (0.9%). Men who self-treated with antibiotics after having intercourse with CSWs were less likely to have HIV infection (OR = 0.53). Antibiotic use before intercourse with CSWs did not have as strong a protective effect as it did after intercourse (OR = 0.74). The protective effect of self-treatment was significant even when controlling for syphilis gonorrhea lymphadenopathy penile discharge with pus and condom use with a CSW. These findings show that some sexually active men in northern Thailand are trying to prevent HIV and other STDs and that self-treatment with antibiotics may reduce the HIV risk associated with bacterial STDs in a high prevalence population.