Showing papers in "Sexually Transmitted Infections in 1994"

Regional distribution and incidence of human papillomavirus infections among heterosexual men and women with multiple sexual partners: a prospective study.

Abstract: OBJECTIVE--To assess prevalence, incidence and potential risk factors of human papillomavirus (HPV) infection among heterosexual men and women with multiple partners and to identify niches of HPV-infection. DESIGN--A prospective study of heterosexual men and women with multiple partners attending an STD clinic as participants in a study on HIV from May 1988 until January 1991. Routine STD examination and physical examination using colposcopy were performed, interviews with standardised questionnaires were administered. Specimens for HPV DNA detection by polymerase chain reaction were collected from multiple sites of the genital, anorectal and oral regions. In women cervical cytology was performed. SETTING--The STD Clinic of the Municipal Health Service of Amsterdam. PARTICIPANTS--162 women and 85 men entered the study, 110 women and 48 men were followed up. RESULTS--At entry of the study 37 (23%) women and 24 (28%) men were found positive for HPV DNA at any site. Only in one woman was oral presence of HPV DNA found during follow-up. Abnormal cervical cytology was observed in four women. In multivariate analysis, diagnosis of condylomata [odds ratio (OR) 5.61, 95% confidence interval (CI) 1.86 to 16.90)], reporting genital dermatological abnormalities (OR 3.72, 95% CI 1.38 to 9.99) and age (OR per year 0.93, 95% CI 0.88 to 0.99) predicted independently the presence of HPV DNA in women at entry of the study. In women 59 of the 99 (60%) HPV infections were observed in the genital region and 40% in the anorectal region: in men these figures were 65% and 35%, respectively. The incidence of HPV infection was 47.1 and 50.5 per 100 person-years for women and men respectively. At least 20/99 (20%) infections in women were intermediate or long persistent and only 3/48 (6%) HPV infections in men (P = 0.03). No risk factor for persistency could be determined, either in women or in men. CONCLUSIONS--HPV infection was found to be a multicentric genital and/or anorectal event both in women and men. The oral presence of HPV DNA was detected only once in one of the participants. In women persistent HPV infection was more common than in men. Independent predictors for presence of HPV DNA in women were diagnosis of condylomata acuminata, reporting genital dermatologic abnormalities and age. Incidence of HPV infection in women turned out to be 47.1 infections per 100 person-years and for men 50.5 per 100 person-years.

A prospective study of the psychological impact on patients with a first episode of genital herpes.

Abstract: OBJECTIVES--To assess the psychological impact of first episode of genital herpes, and to determine whether this changes over time. SETTING AND SUBJECTS--The Departments of Genitourinary Medicine (GUM), and Dermatology, Middlesex Hospital London. The study group consisted of patients attending the department of GUM with a clinically proven first episode of genital herpes. Two control groups were recruited; firstly patients without herpes attending the GUM Department and secondly patients attending the Dermatology Department out patients with chronic dermatoses. METHODS--Patients and controls completed an 87 item, self-administered psychological questionnaire at 3 monthly intervals for a year. The questionnaire consisted of the General Health Questionnaire (GHQ); the Hospital Anxiety and Depression Questionnaire (HADQ); Illness Attitude Scales and Illness Concern. Patients were also asked questions about their sexual behaviour. RESULTS--Ninety one patients (68 women, 23 men) with genital herpes, 61 GUM controls (42 women, 19 men) and 56 dermatology controls (36 women, 20 men) participated. There were no statistically significant demographic differences between patients and controls. At first visit the proportion of patients classified as "cases" by the GHQ (GHQ cases) were similar for primary herpes patients 62% (56/91) and Dermatology controls 52% (29/56) while a significantly smaller proportion of GUM controls 34% (21/61) were classified as GHQ cases. The primary herpes group were significantly more concerned about their illness than either the GUM controls or the Dermatology controls (p < 0.002). The proportion of primary herpes patients classified as "cases" by the GHQ reduced significantly over the initial three month period with 67% of patients classified as "cases" at their first visit becoming "noncases" after three months (p < 0.0001). Also 50% of those classified as "cases" at first visit by the HADQ become "noncases" after the initial three months (p = 0.007). The illness concern scores also decreased significantly from visit one to visit two (means 14.7 vs. 12.3; p < 0.0001). CONCLUSION--The diagnosis of a first episode of genital herpes has a profound emotional effect on patients. If they do not have recurrent episodes, their emotional state improves. For those who do have recurrences, the level of anxiety and concern remains as high as at the time of their first diagnosis. Clinicians must be sensitive to the emotional impact such a diagnosis may bring.

A comparison between cytology and histology to detect anal intraepithelial neoplasia.

Abstract: INTRODUCTION--Anal intraepithelial neoplasia (AIN), which may be a precursor of anal carcinoma, has been identified on histology following minor anal surgical procedures, in particular the removal of perianal condylomata, in increasing numbers of homosexual and bisexual men. Anal cytology has recently been proposed as a useful method of identifying AIN lesions. OBJECTIVE--To compare anal cytology with histology as a method of detecting AIN. METHODS--215 homosexual and bisexual men attending a central London sexually transmitted diseases clinic had an anal cytological smear performed under standard conditions. The perianal area and anal canal were then examined using a colposcope, and areas macroscopically suggestive of intraepithelial neoplasia were biopsied. RESULTS--176 of the 215 patients were biopsied of whom 76 had AIN on histology. 154 of the 215 patients had an adequate anal smear of whom 46 and 85 had cytological features of both HPV and AIN, or HPV alone respectively. Including features of HPV alone as an abnormal smear, anal cytology, when compared with anoscopy and histology as the gold standard for diagnosing AIN, resulted in a sensitivity of 87.5%, a specificity of 16.3%, a positive predictive value of 37.4% and a negative predictive value of 69.6%. Restricting abnormal smears to those with features of both HPV and AIN resulted in a sensitivity of 33.9%, a specificity of 72.5%, a positive predictive value of 41.3% and a negative predictive value of 65.7%. CONCLUSION--Anal cytology is a sensitive but nonspecific method of identifying patients with biopsy proven AIN if cytological features of HPV alone are included as abnormal smears. Specificity is improved by restricting abnormal smears to those with features of both HPV and AIN but this markedly lowers the sensitivity of the test. At present, anoscopy and histology are required in addition to anal cytology to differentiate between patients who simply have anal condylomata and those who also have AIN.

Expanded gold standard in the diagnosis of Chlamydia trachomatis in a low prevalence population: diagnostic efficacy of tissue culture, direct immunofluorescence, enzyme immunoassay, PCR and serology.

Abstract: OBJECTIVE--To evaluate the diagnostic efficacy of chlamydia culture, direct immunofluorescence (DFA), direct enzyme immunoassay (EIA), polymerase chain reaction (PCR) and serology by defining positive culture or at least two positive non-culture tests as true positive. SETTING--Three gynaecological departments located in separate areas of Sweden. PATIENTS AND DESIGN--All pregnant women requesting abortion during a six month period were included. In cases with unconfirmed non-culture tests, reculture with multiple passage and PCR on the culture transport medium was performed for confirmation. Serum was analysed for chlamydial antibodies type IgG, IgM and IgA using microimmunofluorescence. RESULTS--18 of 419 (4.3%) patients were positive for chlamydia according to the defined criteria. Twelve of 419 (2.9%) were positive in standard culture (primary inoculation). The sensitivity of standard culture, DFA, EIA and PCR were 66.7%, 77.8%, 64.7% and 71.4% respectively. The specificity 100% (by definition), 99.5%, 100%, 100% respectively. The positive predictive value 100% (by definition), 87.5%, 100%, 100% respectively. Negative predictive value 98.5%, 99.0%, 98.5%, 98.9% respectively. Serum IgG titre of > or = 64 and > or = 1024 gave positive predictive values of 10% and 21% respectively. CONCLUSIONS--When an expanded gold standard is used, the specificity and positive predictive value of the non-culture tests used are comparable with that of standard culture even in this low prevalence population. Standard culture underestimated the chlamydia prevalence by 33%. The prevalence found represents a decrease from 10 to 2.9% of culture verified chlamydia during four years in comparable populations. Chlamydial antibodies of certain immunological classes are not necessarily present in cases with chlamydia.

Male circumcision and common sexually transmissible diseases in a developed nation setting.

Abstract: OBJECTIVE--To determine whether the circumcision status of men affected their likelihood of acquiring sexually transmissible diseases (STDs). DESIGN--A cross-sectional study employing an anonymous questionnaire, clinical examination and type specific serology for herpes simplex virus type 2 (HSV-2). SETTING--A public STD clinic in Sydney, Australia. SUBJECTS--300 consecutive heterosexual male patients. MAIN OUTCOME MEASURES--Associations between circumcision status and past or present diagnoses of STDs including HSV-2 serology and clinical pattern of genital herpes. RESULTS--185 (62%) of the men were circumcised and they reported similar ages, education levels and lifetime partner numbers as men who were uncircumcised. There were no significant associations between the presence or absence of the male prepuce and the number diagnosed with genital herpes, genital warts and non-gonococcal urethritis. Men who were uncircumcised were no more likely to be seropositive for HSV-2 and reported symptomatic genital herpes outbreaks of the same frequency and severity as men who were circumcised. Gonorrhoea, syphilis and acute hepatitis B were reported too infrequently to reliably exclude any association with circumcision status. Human immunodeficiency virus infection (rare among heterosexual men in the clinic) was an exclusion criterion. CONCLUSIONS--From the findings of this study, circumcision of men has no significant effect on the incidence of common STDs in this developed nation setting. However, these findings may not necessarily extend to other setting where hygiene is poorer and the spectrum of common STDs is different.

High prevalence of Neisseria gonorrhoeae strains with reduced susceptibility to fluoroquinolones in Japan.

Abstract: OBJECTIVE--To study the antibiotic susceptibility of Neisseria gonorrhoeae strains isolated in Japan and, in particular, to examine the possibility of emerging fluoroquinolone resistance. MATERIALS AND METHODS--Sixty-nine strains of Neisseria gonorrhoeae isolated in 1992 were tested for susceptibility to 15 antibiotics including fluoroquinolones and were seroclassified. Twenty-seven strains isolated from 1981 to 1984 were also evaluated as controls. RESULTS--The MIC90 values of norfloxacin, ofloxacin, and ciprofloxacin against the isolates from 1992 were 2.0, 1.0, and 0.5 microgram/ml, respectively. The MIC90 values of norfloxacin, ofloxacin, and ciprofloxacin against the isolates from 1981-84 (controls) were 0.25, 0.125, and 0.063 microgram/ml, respectively. These results indicate that the MIC90 values of norfloxacin, ofloxacin, and ciprofloxacin against the strains from 1992 were 8-fold higher than those against the strains from 1981-84. However, there were no significant differences in susceptibility to beta-lactams, tetracyclines, macrolides, and spectinomycin between the isolates from 1992 and those from 1981-84. The majority of the isolates belonged to the WII/WIII serogroup. There was no relationship between fluoroquinolone resistance and serogroup. CONCLUSIONS--Fluoroquinolones have been used frequently as first-line therapy and have provided excellent clinical efficacy for gonococcal infections for the last several years in Japan. However, our data indicate that a rapid decrease in the susceptibility of Neisseria gonorrhoeae to fluoroquinolones is occurring in our country.

The Human Herpes Viruses

Abstract: association is influenced by the way in which the control group is selected and in this regard we question the nature of controls studied by Jensen and colleagues. It appears that none of the asymptomatic control subjects was examined microscopically to determine the existence of urethral polymorphonuclear (PMN) leucocytes. Indeed, men with \"asymptomatic\" urethritis may have been included in the control group. Few investigators have compared the prevalence of mycoplasmas in men with microscopic urethritis who have no signs or symptoms with that in men without urethritis. However, Swartz et al6 found that Chlamydia trachomatis was isolated more frequently from men with asymptomatic NGU than from those without objective urethritis, suggesting that urogenital pathogens may be involved in the aetiology of this condition. In addition, it is unclear whether Jensen and colleagues examined the asymptomatic subjects clinically at enrolment. Clearly, asymptomatic men with a discharge on examination and objective urethritis (3 5 PMN leucocytes/high-power microscopic field) have \"clinical urethritis\" and should be excluded from the control group and included in the studygroup. Inclusion of asymptomatic men who have objective urethritis, with or without an observable discharge, in the control group would prevent proper evaluation of negative associations. This may have influenced to some extent the significance given to M genitalium by Jensen and colleagues and biased their results against detecting an association of U urealyticum with NGU. P J HORNER D TAYLOR-ROBINSON The Jefferiss Wing, St. Mary's Hospital, London W2 1NY, UK

Risk factors for hepatitis C virus infection among injecting drug users in Sydney.

Abstract: OBJECTIVE--To study risk factors for hepatitis C virus (HCV) infection in injecting drug users (IDUs) from central Sydney. SETTING AND SUBJECTS--All IDUs attending a primary health care facility in central Sydney between December 1991 and November 1992 who underwent HCV antibody testing. METHODS--Information was obtained retrospectively from client forms routinely completed at the time of medical consultation. Additional information on injecting history and practice was obtained from the registration forms of subjects who also attended the needle syringe exchange programme at the same health care facility. RESULTS--Of the 201 IDUs tested, 118 (59%) had HCV antibodies, which did not differ significantly between males and females. HCV prevalence increased significantly with age, being highest in IDUs who were aged 35 years or more (93%) and lowest in IDUs aged under 20 years (17%). HCV prevalence increased significantly with time since first injecting, from 26% for IDUs who had injected for less than 3 years to 94% for those who had injected for more than 10 years. HCV prevalence was also significantly higher in heterosexual IDUs as compared with homosexual male IDUs, and in opiate users as compared with stimulant users, even after adjustment for age and duration of injecting. HCV prevalence was strongly associated with exposure to hepatitis B virus, but was not associated with exposure to HIV. CONCLUSION--Recent HCV transmission indicates ongoing injecting risk behaviour despite HIV prevention efforts, and underlies the potential for increased transmission of HIV through the sharing of injecting equipment. Within the population of IDUs, those who are heterosexual or inject heroin appear to be at increased risk of HCV infection.

Rectal spirochaetosis in homosexual men: the association with sexual practices, HIV infection and enteric flora.

Abstract: OBJECTIVE--To determine the prevalence of rectal spirochaetosis in homosexual men attending a sexually transmissible diseases clinic and investigate the association between their presence and sexual practices, HIV infection and enteric flora. DESIGN--The study included 144 male homosexual subjects who each completed a questionnaire, underwent physical examination, proctoscopy and investigations for STD and HIV screening, rectal biopsies and collection of faecal samples. SETTING--The Sexual Health Centre, Sydney Hospital, Sydney, Australia. RESULTS--Spirochaetes were detected in 39% of the rectal biopsies, using histological criteria. Logistic regression analysis showed that rectal spirochaetosis was significantly associated with: oral-anal contact. (P

Clinical and microbiological characteristics of symptomatic vulvovaginal candidiasis in HIV-seropositive women

Abstract: OBJECTIVES--To evaluate the clinical and microbiological characteristics of symptomatic vaginal candidiasis in Human Immunodeficiency Virus (HIV)-seropositive women attending a gynaecologic outpatient clinic for sexually transmitted diseases (STDs). DESIGN--Vaginal, rectal and oral specimens from cases and controls were cultured for Candida spp. SUBJECTS--Eighty-four consecutive HIV-seropositive and 384 HIV-seronegative women with clinical signs of vulvovaginitis. SETTING--A gynaecological out-patient clinic in Pavia, Italy. RESULTS--The overall prevalence of vaginal candidiasis was 61.9% (52/84) in the cases and 32.3% (124/384; p < .001) in the controls. After adjustment by logistic regression analysis for confounding factors (age at first intercourse, lifetime sex partners, new partner/s in the last 6 months, type of contraceptive used), HIV-seropositive patients were at higher risk for both Candida albicans (odds ratio = 2.5; 95% confidence interval 1.31-4.69; p = 0.006) and Torulopsis glabrata vaginitis (OR = 3.5; 95% CI = 1.05-11.60; p = 0.04) than controls. HIV-seropositive subjects had also increased rates of oral and rectal colonisation with Candida spp. Finally, the time to recurrence of vaginal infection was significantly shorter in HIV-seropositive patients than controls and was correlated with the severity of HIV-induced immunodepression. CONCLUSIONS--Vulvovaginal candidiasis is very common in HIV-seropositive women and its prevalence is correlated with the immunological status of the host. These patients have higher frequencies of Torulopsis glabrata vaginal infection and are more prone to recurrence than HIV-seronegative controls.

High level ciprofloxacin resistance in Neisseria gonorrhoeae.

Abstract: (71%) of which were diagnosed by Gram stained smear. The findings were presented to the clinic staff and it was recommended that particular care should be taken to clean the cervix prior to sampling and that rectal samples should be taken from \"clear\" areas of mucosa at proctoscopy in order to reduce the proportion of inadequate slides. In addition, nursing staff should practice microscopy with known positive slides and have regular training in Gram stain technique. The audit was then repeated over the next three months. No significant difference was found in the detection rates of gonorrhoea on repeating the audit (see table). The male rectal and female \"specimen\" diagnosis rates had improved but the small numbers of cases means that a statistically significant difference will be difficult to achieve. This study shows that although the detection rate for gonorrhoea in male urethral specimens was satisfactory, the detection rates in female and rectal slides remained poor by comparison with a similar study conducted at this centre in 1973.2 It should be noted, however, that in 1973 there were 441 cases of gonorrhoea in women and in 1991 only 70. Interestingly, comparison of the sensitivity of microscopy performed by MLSOs in a genitourinary service allied to our centre under clinic conditions showed no significant difference from the study presented. Improvement in the diagnosis rate was found in those cases of symptomatic infection, as has been described by previous surveys,3 in those cases known to be contacts of gonorrhoea, and when suspicious pairs seen on microscopy were regarded as positive findings. Finfally, we would re-emphasize the importance of careful specimen taking by the attending physician and of continual in-post training for those performing microscopy, especially where positive findings are few. J K EVANS D E MERCEY P D FRENCH Department of Genitourinary Medicine, Middlesex Hospital M V PRINCE Department ofMicrobiology, University College Hospital, London, UK

Urinary tract infection in men with AIDS.

Abstract: OBJECTIVE--To investigate whether bacteriuria and, specifically, symptomatic urinary tract infection (UTI) occur with increased frequency in men with HIV infection. METHODS--In this cross-sectional study we investigated three groups of men, aged from 18 to 50 years. Group A was composed of patients with a diagnosis of AIDS; Group B, of patients without HIV infection, and group C of patients with asymptomatic HIV infection. Patients with any known predisposing factor for UTI were excluded from the study. A clean-catch midstream urine sample was collected from each patient on the first day of hospital admission (groups A and B) or during a visit to the outpatient clinic (group C). Bacteriuria was diagnosed when > or = 100,000 colony forming units/ml, urine were grown. RESULTS--There were 415 patients, 151 in group A, 170 in group B and 94 in group C. Bacteriuria was significantly more frequently in group A (20 cases, 13.3%) than in groups B (3 cases, 1.8%, p = 0.00007) and C (3 cases, 3.2%, p = 0.009). Ten cases of bacteriuria in group A (6.6%) were symptomatic while no case of symptomatic UTI was seen in groups B (p = 0.0004) and C (p = 0.008). The frequency of UTI in homosexual men with AIDS (7 cases, 6.7%) was not significantly different from that observed in men with AIDS who denied homosexuality (3 cases, 6.5%). E coli was the predominant pathogen associated with UTI. Although adequate response to a two-week course of antibiotics was observed in most cases, an in-hospital mortality rate of 20% was found among AIDS patients with symptomatic UTI. CONCLUSIONS--In the present study, the frequency of bacteriuria and symptomatic UTI was found to be increased in men with AIDS. E coli was the predominant pathogen in these cases. These data suggest that symptomatic UTI may represent a relevant cause of morbidity for men with AIDS.

Contraceptive methods and the transmission of HIV: implications for family planning.

Abstract: Heterosexual transmission is the predominant mode of spread of the Human Immunodeficiency Virus (HIV) in most of the world. Whether the use of hormonal contraceptives, IUDs and spermicides is associated with an increased or decreased risk for HIV acquisition remains controversial. Several mechanisms whereby contraceptive methods may influence the transmission of HIV have been proposed. As contraceptive use increases among women of reproductive age, the group most vulnerable to HIV infection, any associations between contraceptive method and HIV risk become even more important. The available studies of these associations are predominantly cross-sectional and give conflicting results. We review the published evidence for associations between HIV and individual contraceptive methods. At this time no definitive conclusions regarding these associations can be drawn. Further research, especially prospective epidemiological studies and basic biological research on mechanisms of heterosexual transmission and the effect of contraceptives on these mechanisms, is urgently needed.

Risk factors for gonorrhoea, syphilis, and trichomonas infections among women attending family planning clinics in Nairobi, Kenya.

Abstract: OBJECTIVE--To identify the risk factors for gonorrhoea, syphilis, and trichomonas infections among low risk women in Nairobi, Kenya. METHOD--In a cross-sectional study, 4,404 women attending two peri-urban family planning clinics between 1989 and 1991 were interviewed using a structured questionnaire and examined for signs of sexually transmitted disease (STD) infection. Cervical cultures for gonorrhoea, PAP smear (including microscopy for trichomonas), RPR and HIV testing were done. RESULTS--Positive cervical cultures for gonorrhoea were found in 3.2% of women, positive syphilis serology in 1.9%, and positive trichomonas microscopy in 5.2%. Genital ulcers were found in 1.9% of women. Although unmarried status and reporting more than one sex partner in the previous year were both significantly associated with each disease in the crude analysis, these associations were attenuated after controlling for each other and for other risk factors. The population attributable risks (PARs) for these factors were low (7-16%) owing to the high proportion of cases who were married and monogamous. The majority of women with microbiological evidence of infection had normal pelvic examinations. Clinical diagnostic algorithms for STDs in this population had a low sensitivity and positive predictive value. Nevertheless, a strong association between HIV seropositivity and STDs was observed. CONCLUSION--The low population attributable risks found in this study suggest that behaviour change messages directed to women, particularly if they are married have a low potential for preventing STDs. The poor performance of clinical diagnostic algorithms illustrates the desirability of testing these algorithms in a variety of populations and reinforces the need for low-cost methods of microbiologic diagnosis if populations with relatively low prevalences of these infections are to be included in programmes to diagnose and treat STDs.

Self-treatment using 0.25%-0.50% podophyllotoxin-ethanol solutions against penile condylomata acuminata: a placebo-controlled comparative study.

Abstract: OBJECTIVE--To compare the efficacy of 0.50% and 0.25% podophyllotoxin preparations against previously untreated penile warts. DESIGN--The study was performed as a double-blind, placebo-controlled investigation on 57 males randomly allocated to one of three groups of 19 males in each, receiving either the placebo solution (70% ethanolic vehicle) or one of the two podophyllotoxin preparations for 1-2 self-treatment courses b.i.d. for three days, separated by a one-week drug-free interval. SETTING--The STD out-patient clinic of the Department of Dermatovenereology at Southern Hospital of Stockholm, Sweden. RESULT--The placebo solution merely exerted a marginal influence on the warts while a primary cure was documented in 72% (13/18) and 81% (13/16) of altogether 34 evaluable men who treated their warts with 0.25% and 0.50% podophyllotoxin, respectively. Follow-up investigation (range 5-23 weeks) was possible for 24 of 26 podophyllotoxin treated men who were primarily cured. Some degree of relapse occurred in nine of them (38%). Of these relapses, warts occurred on previously untreated sites only in three cases (33%), and in another four (44%) relapse was associated with regrowth on treated sites as well as on new sites. When analysing the debulking potential of podophyllotoxin, it appeared that 0.25% podophyllotoxin eradicated 184 of originally 217 warts (85%); the corresponding figure for 0.50% podophyllotoxin was as high as 130 of 135 lesions (96%). Side effects were generally mild-moderate and well tolerated. CONCLUSION--The results underscore the potential usefulness of low-dose podophyllotoxin preparations as first-line chemotherapy of condylomata acuminata for home-treatment. The efficacy from topical use of 0.25% podophyllotoxin detected in the study is certainly of a magnitude signifying that podophyllotoxin concentrations lower than 0.50% deserve further investigation if the drug may be incorporated into alternative vehicles such as creams or ointments.

Genital ulcer disease: accuracy of clinical diagnosis and strategies to improve control in Durban, South Africa

Abstract: OBJECTIVE--To investigate the accuracy of clinical diagnosis in genital ulcer disease (GUD); to devise management strategies for improving the control of GUD and thereby limit the spread of HIV-1 infection. DESIGN--Clinical and microbiological assessment of GUD in men and women. The index of suspicion, diagnostic accuracy, diagnostic efficiency and positive and negative predictive values of a clinical diagnosis were investigated. SETTING--City Health Sexually Transmitted Diseases Clinic, King Edward VIII Hospital, Durban, South Africa. PARTICIPANTS--100 men and 100 women with genital ulcers. RESULTS--The accuracy of a clinical diagnosis was, in men: lymphogranuloma venereum (LGV) 66%, donovanosis 63%, chancroid 42%, genital herpes 39%, primary syphilis 32%, mixed infections 8%, and in women; secondary syphilis 94%, donovanosis 83%, genital herpes 60%, primary syphilis 58%, chancroid 57%, LGV 40%, mixed infections 14%. Overall, diagnostic efficiency was greater in women than in men. When compared with other causes of GUD, donovanosis ulcers bled to the touch and were larger and not usually associated with inguinal lymphadenopathy. In women, extensive vulval condylomata lata were readily differentiated from all other causes of GUD. CONCLUSION--A clinical diagnosis in genital ulceration was less accurate in men than in women. The diagnostic accuracies for donovanosis and secondary syphilis were relatively high but for most other conditions were low. Differences between clinical and laboratory diagnostic accuracies may reflect similarities between the clinical appearances of the various causes of GUD, the presence of mixed infections, atypical ulceration due to longstanding disease, and insensitive laboratory tests. In this community all large ulcers should be treated empirically for syphilis and donovanosis. Uncircumcised men with GUD are an important HIV core or "superspreader" group locally, and prevention strategies should include counselling and health education in the light of the inaccuracy of clinical diagnosis found in this study. The development of rapid accurate tests for GUD is urgently required.

STD/HIV control in Malawi and the search for affordable and effective urethritis therapy: a first field evaluation.

Abstract: OBJECTIVES--To evaluate gonococcal (GU) and nongonococcal urethritis (NGU), chlamydia antigen, and serostatus for syphilis and human immunodeficiency virus (HIV) among males attending a Malawian STD clinic with complaints of urethral discharge and/or dysuria. To collect demographic and behavioural data and to determine the effectiveness of five treatments for urethritis. METHODS--Urethritis was diagnosed using microscopy and culture for Neisseria gonorrhoeae. Sera were screened with rapid plasma reagin (RPR) and if reactive, with microhaemagglutination for Treponema pallidum (MHA-TP). HIV antibodies and chlamydia antigen were detected using enzyme immunoassay. Patients were randomised for treatment, cure was assessed 8-10 days later. RESULTS--At enrolment, GU was diagnosed in 415 (80.3%) and NGU in 59 (11.2%) of 517 males. Chlamydia antigen was found in 26 (5.2%) of 497 specimens tested. Syphilis seropositivity rate (RPR and MHA-TP reactive) was 10.7%. Overall HIV seroprevalence was 44.2%; 71.7% of men with reactive syphilis serology were HIV(+) compared with 40.9% of syphilis seronegatives (OR: 3.6, p < 0.001). Trimethoprim 320 mg/sulphamethoxazole 1600 mg by mouth for 2 days (TMPSMX), or the combination of amoxicillin 3 gm, probenicid 1 gm, and clavulanate 125 mg by mouth once (APC), failed to cure gonorrhoea effectively. Amoxicillin 3 gm, probenicid 1 gm, and clavulanate 125 mg, by mouth once with doxycycline 100 mg BID for 7 days (APC-D), gentamicin 240 mg IM once (GENT), ciprofloxacin 250 mg by mouth once (CIPRO) cured 92.9% to 95% of gonorrhoea. APC-D treatment did not generate less NGU at follow-up. HIV serostatus did not affect cure of urethritis. CONCLUSION--All patients presenting with urethritis should be treated syndromically using a simple algorithm and screened for syphilis seroreactivity for appropriate treatment and counselling.

Barrier methods of contraception, spermicides, and sexually transmitted diseases: a review.

Abstract: OBJECTIVE--To understand whether barrier methods of contraception (BMC) and/or spermicides lower the risk of acquiring sexually transmitted disease (STD) and to quantify the protection. DESIGN--Review of published experimental studies, in vitro and in vivo evidence on the issue. SUBJECTS--We reviewed 22 papers that examined the impermeability of BMC in vitro against STD agents or the effect of spermicides, and 60 papers reporting results of epidemiological studies on the risk of STD in users of BMC. RESULTS--There was in vitro evidence that both BMC and spermicides were effective against most sexually transmissible agents. Doubts remain on the effectiveness of BMC and spermicides in normal conditions of use, particularly against human papilloma virus. Natural membrane condoms are not impermeable and pores are seen by electron microscopy. Epidemiological studies show a consistent reduction in the risk for use of condoms against gonococcal (most studies giving relative risk, RR, estimates around 0.4 to 0.6) and HIV infection (RRs between 0.3 and 0.6 in most studies). Spermicides protect women against gonorrhoea and trichomoniasis; their role against other STDs is less clear and there is some indication of an irritative effect on the vaginal mucosa that is likely to be dose-dependent. CONCLUSIONS--A large amount of evidence indicates that BMC reduce the risk of gonorrhoea and HIV transmission, but the results are--at least in quantitative terms--less consistent for other diseases. Implications for individual choices and public health approaches should relate to frequency of exposure and severity of the disease too.

Evaluation of the Amplicor Chlamydia trachomatis test versus culture in genital samples in various prevalence populations.

Abstract: OBJECTIVE--To evaluate a newly developed polymerase chain reaction (PCR) assay, Amplicor C trachomatis for the detection of C trachomatis in genital samples using cell culture for comparison. SUBJECTS--501 patients (431 women and 70 men) attending an STD clinic in Hopital Pellegrin (high-risk population) and gynaecological clinics (low-risk population) in Bordeaux, France. METHODS--The genital samples (cervical and urethral) were tested for the presence of C trachomatis using the Amplicor test and using standard cell culture identified by the immunofluorescence test using a monoclonal antibody to C trachomatis. Discrepancies between the results of culture and Amplicor were further analysed by major outer membrane protein gene (omp1)-PCR of the specimens taken in transport media and by direct fluorescent antibody (DFA) staining of elementary bodies in culture transport tubes. RESULTS--After analysis of discrepancies, the revised sensitivity and specificity of PCR were 95.3% and 100% and the positive and negative predictive values were 100% and 99.5%, respectively. CONCLUSION--The present results indicate that the Amplicor assay is rapid, specific and more sensitive than the culture method. This test provides an excellent non-culture method for the detection of C trachomatis in various prevalence populations.

Chlamydia trachomatis in women: the more you look, the more you find

Abstract: OBJECTIVE--To determine the extent to which testing of multiple sites and samples is required to define whether a woman is Chlamydia trachomatis-positive. DESIGN--One-hundred and fifty women attending the Genitourinary Medicine clinic at St Mary's Hospital were enrolled; they had not received antichlamydial antibiotics in the previous three months, were not in a high-risk group for HIV infection, or pregnant, or using an intrauterine contraceptive device. Thirty-two women were re-examined three months after recruitment. METHODS--An urethral specimen was Gram stained (smear) and cultured for gonococci. Another urethral specimen was taken to detect C trachomatis elementary bodies (EBs) by the MicroTrak direct fluorescent antibody (DFA) test (Syva). An endocervical swab specimen was Gram stained (smear) and cultured for gonococci. One of two other endocervical swabs was used for the DFA test and was then placed in medium which was centrifuged in a MicroCentaur at 13,000 rpm for 10 min; the deposit was examined by using the DFA test. The first 15-20 ml of voided urine (first pass urine; FPU) was also centrifuged and the deposit tested similarly. RESULTS--Of 182 cervical smears and/or deposits tested for C trachomatis, 38 were positive; more cervical deposits (37) than smears (26) were positive and, of these, one-fifth of the deposits and one-third of the smears contained fewer than 10 elementary bodies. Of 162 paired urethral smears and FPU deposits available, one or other specimen of 36 pairs was chlamydia-positive, that is 31 smears and 32 deposits; of these, two-fifths of the smears and half of the deposits contained fewer than 10 EBs. Of 150 sets of cervical and urinary tract samples tested, 31 were chlamydia-positive at both sites, six in the cervix alone and four in the urinary tract alone. Of 139 women for whom there were valid first visit sample results, 36 (26%) were chlamydia-positive in the cervix, 34 (25%) in the urinary tract and 41 (29%) had at least one sample from either site positive. Overall, DFA tests of deposits from centrifuged cervical specimens achieved the highest sensitivity (88%) and those of cervical smears the lowest (70%). CONCLUSIONS--Deposits from centrifuged cervical specimens were C trachomatis-positive more often than were cervical smears. Testing deposits from centrifuged urines was as successful as testing urethral smears. One-fifth (cervical deposits) to one-half (urine deposits) of specimens contained fewer than 10 EBs. The urinary tract was chlamydia-positive almost as frequently as the cervix but both sites needed to be tested to define whether a woman was chlamydia-positive.

Casual sexual experience abroad in patients attending an STD clinic and at high risk for HIV infection.

Abstract: OBJECTIVE--To study possible "import" routes of HIV infection to Norway (by obtaining information on casual sexual contacts abroad from patients attending an STD clinic), and to assess their behavioural risk factors (such as alcohol intake, use of condom) for HIV infection. DESIGN AND SETTING--Patients visiting the clinic for sexually transmitted diseases (STD), April-June 1989, received a questionnaire. SUBJECTS--606 consecutive persons of whom 599 agreed (98.8%) to participate. We grouped the patients in four categories. 1: Sex with a prostitute during the last 5 years, 2: Homosexuals/bisexuals, 3: prostitutes/intravenous drug abusers (IVDUs) and 4: Other heterosexuals. RESULTS--245 patients (41%) reported having a casual sex partner abroad (M: 182, F: 63), mainly in Europe, particularly in Spain, Denmark and Greece. Outside Europe such contacts were most frequently reported from USA, Brazil and Thailand. Among men who had had sex with a prostitute, 93.5% reported such sex abroad (homosexuals/bisexuals: 63.6%, prostitutes/IVDUs: 66.7%, "other heterosexuals: 32.1%). Homosexual/bisexual men with casual partner(s) abroad used a condom more frequently than did others. CONCLUSION--245 of 599 persons reported casual sex abroad during 1985-1989, and the different "risk groups" reported countries where most HIV infected persons belonged to their own "risk group". We have reason to believe that alcohol intake increased the likelihood of casual sexual activity and decreased the use of condom. Norwegian travellers need more information on the risks of casual sex abroad, the use of condoms and the combination of alcohol intake and casual sex.

Urethral stricture and urethritis in men in Scotland.

Abstract: OBJECTIVES--To examine the incidence of urethral stricture in men in Scotland during the years 1982-1991 in relation to the changing incidence of gonococcal and non-gonococcal urethritis (NGU) over the past 20 years. DESIGN--Retrospective study of incidence of urethral stricture in Scotland. METHOD--The number of new men in whom a diagnosis of urethral stricture was made for the years 1982-1991 was obtained using the new Scottish Record Linkage system, and the number of cases of gonorrhoea and NGU was obtained from Communicable Diseases (Scotland) Unit. Age-specific rates of urethral stricture were calculated and the Poisson regression model was used to test if there was a trend of rate with age or time change. RESULTS--There was a highly significant increase in the incidence of urethral stricture with age but only a slight increase in incidence over the study period within each age group. CONCLUSION--As the interaction between age and time was not significant, it is concluded that urethritis associated with sexually transmitted organisms is an uncommon cause of urethral stricture in Scotland.

A population based study of syphilis and sexually transmitted diseases in north-western Tanzania.

Abstract: The rationale for improved sexually transmitted disease (STD) facilities in rural Africa as a means of slowing the spread of HIV presupposes that STDs are currently managed poorly and that this is a result of inadequate infrastructure. The finding of Mosha et al' that \"in Mwanza Region [Tanzania], active syphilis seems to be more prevalent than the treated infection\" at first glance provides strong support for the argument that money should be invested urgently in improved facilities for diagnosis and treatment. However, as is common practice (and I have been guilty of this myselfP) active syphilis is defined as being RPR + TPHA + without quoting titres for the nontreponemal test. If such data were presented a different picture might emerge with a large number of individuals with low titre who can not be labelled as having an \"active\" infection with any certainty. A treated individual with a fall in titre from high levels to low levels is regarded as successfully treated unless, on follow up, the titres rise again. Thus a cross-sectional sur-

Unsatisfactory performance of the leukocyte esterase test of first voided urine for rapid diagnosis of urethritis.

Abstract: BACKGROUND AND OBJECTIVES--The objective of this study was to determine the performance characteristics of a dipstick test for leukocyte esterase (LE), (Chemstrip 2LN, Boehringer Mannheim) in predicting the presence of urethritis and urethral pathogens in men presenting to a busy sexually transmitted disease clinic and to street outreach facilities. METHODS--Urethral swabs for polymorphonuclear (pmn) cell count, gonorrhoea culture and chlamydia enzyme immunoassay (EIA) as well as 15 ml of first voided urine (FVU) were collected from 737 symptomatic and 726 asymptomatic men. Gonorrhoea cultures and pmn counts were processed according to standard methods. Either Abbott Chlamydiazyme EIA (confirmed) or Syva Microtrak EIA (confirmed) test was employed to detect C trachomatis. The LE test was immediately dipped in FVU, read after 60-120 seconds by the clinician and considered positive if trace, 1+ or 2+. RESULTS--Microscopic evidence of urethritis (> or = = 4 pmn cells per 1000 x field) was found on urethral smear of 782 (53.5%) patients. Chlamydia, gonorrhoea or both were present in 104 (7.1%) patients. Performance characteristics of the LE test were as follows: (table below) CONCLUSION--The LE test did not have adequate sensitivity to be considered a reliable rapid diagnostic test for urethritis or urethral pathogens, particularly in the asymptomatic portion of this STD clinic population.

Surveillance of sexually transmitted diseases in France: recent trends and incidence.

Abstract: OBJECTIVE--To present recent trends in sexually transmitted diseases (STDs) in France and to estimate the gonorrhoea incidence in 1990. METHODS--Trends were analysed from data of three surveillance systems: (1) STD clinics: number of diagnoses, (2) a sentinel voluntary General Practitioner (GP) network: mean number of acute male urethritis/week/GP, characteristics of the notified urethritis (age, presence of discharge, sexual orientation), (3) a sentinel voluntary laboratory network: mean number of gonorrhoea isolates/month/laboratory, characteristics of patients with positive isolates (sex, age, site of sampling) and of strains (PPNG and TRNG rates). To estimate the gonorrhoea incidence in France in 1990, results of a study held among a national sample of laboratories were used, combined with data from surveillance systems and specific studies. RESULTS--Decreasing trends in gonorrhoea in STD clinics and in the laboratory network as well as in acute male urethritis in the GP network have been observed since implementation of the networks in 1985. The rate of PPNG strains has regularly increased in the laboratory network to reach 14% in 1991. Data suggest that the incidence in some acute non recurrent STDs could have increased among homo/bisexual men since 1988. Chlamydia trachomatis is now the most frequent diagnosis in STD clinics. Estimation of male gonorrhoea incidence rate in France in 1990 of 74/100,000 inhabitants (15-59 years) is consistent with figures observed in England and Wales, where the age distribution is very similar. On the other hand, the estimated female gonorrhoea incidence rate of 14/100,000, which concerns only microbiologically ascertained cases, is one third in France than that observed in England and Wales. CONCLUSION--The consistency of the decreasing trends in gonorrhoea and acute male urethritis observed from the different networks reduces the possibility of a bias due to any change in notification or in prescription. Trends in Chlamydia trachomatis will be better appraised in the near future with the recent implementation of new systems. The French STD surveillance appears quite satisfactory for male infections and has been able to show a marked decrease in the incidence of some STDs in the last years. Surveillance of female STDs is to be improved, in terms of monitored diagnoses and selected health care facilities. Differences between the female gonorrhoea incidence rate observed in England and Wales and the one computed for France could be attributed to differences in contact tracing policies between the two countries or to differences in sexual lifestyles.

Leukocyte esterase urine strips for the screening of men with urethritis--use in developing countries.

Abstract: BACKGROUND AND OBJECTIVES--The leukocyte esterase (LE) strip is a useful tool for the screening of men with urethritis. In developing countries, where laboratory facilities are limited, and sexually transmitted diseases endemic, simple and inexpensive diagnostic tests which perform well, would be of great value. METHODS--Men presenting with urethritis to a referral clinic for sexually transmitted diseases in Nairobi, Kenya participated in this cohort analytical study. First-void urine was collected for LE dipstick testing as part of the diagnostic work-up. The results of the dipstick measurement were compared with the laboratory detection of Chlamydia trachomatis and Neisseria gonorrhoeae. RESULTS--Of 200 men with symptoms of urethritis, 33 (17%) had a pathogen detected from the urethra or the urine. Chlamydia was detected in urine by PCR in 22 (11%), and gonorrhoea was cultured from the urethra in 11 (6%). Esterase activity (trace or greater) had a sensitivity of 76%, a specificity of 80%, a positive predictive value of 42% and a negative predictive value of 94% for the presence of chlamydia or gonorrhoea. CONCLUSIONS--The use of the LE dipstick for the screening of men with symptomatic urethritis can improve diagnostic accuracy and reduce the amount of empiric antimicrobial therapy. The low detection rate of chlamydia in these men with a clinical diagnosis of nongonococcal urethritis needs further study.

Seroprevalence, risk factors and attitude to HIV-1 in a representative sample of lesbians in Turin.

Abstract: OBJECTIVE--To estimate the HIV-1 seroprevalence, behavioural risks and attitude to HIV-1 infection among lesbians. SETTING--Institute of Infectious Diseases, University of Turin, Italy. SUBJECTS--From March 1992 to May 1993, 181 lesbians were tested for HIV-1 and included in the study. METHODS--Sociodemographic details, nonsexual risks for HIV-1, sexual behaviour, STD history and attitude to HIV-1 were obtained from an anonymous, standardised, self-administered, 30-item questionnaire. Snow-ball techniques were used to recruit the largest possible number of participants. RESULTS--11 lesbians (6.1%) were found to be HIV-1 antibody positive. Of them, 10 were intravenous (i.v.) drug users. STD episodes were higher among lesbians with HIV-1 than without (p = 0.04), increasing in both groups over time. Syphilis, genital herpes and viral hepatitis were highly associated with HIV-1 (p = 0.000). In univariate analysis, i.v. drug use, bisexual behaviour, history of STDs, sex during menses and vaginal/anal manipulation were significantly linked to HIV-1 (p = 0.000). In multivariate analysis only history of i.v. drug use (p = 0.04) and bisexual behaviour (p = 0.06) remained independently associated with HIV-1. Seventy-one participants (39.3%) had already undergone AIDS testing. Only 3.5% admitted to be at risk for HIV-1 and 11% changed their sex habits after first hearing of AIDS. No lesbian had ever practised safe-sex. Television was the most important source of information on HIV-1 (84%). CONCLUSION--I.v. drug use was the most likely means of HIV-1 infecting the lesbians of Turin. The high rate of STDs and the low perceived risk to HIV-1 require programmes of STD prevention and AIDS information to be targeted at the lesbian community.

HPV and p53 in cervical cancer.

Abstract: OBJECTIVE--To determine the prevalence of HPV 16 and 18 E6 by DNA detection and p53 abnormal protein expression in cervical cancers in Hong Kong. MATERIALS AND METHODS--Seventy-three squamous cell cervical cancer biopsy were analysed. Detection of HPV DNA was carried out by the polymerase chain reaction and Southern blotting (PCR/SB) technique using primers to the HPV16 & 18 E6 region and consensus primers to the L1 region. Abnormal expression of the p53 protein was detected by immunohistochemical staining (IHS) using the antibody CM1 on frozen sections of 55 cervical cancer samples. Forty-six samples were analysed for both the presence of HPV DNA and abnormal expression of p53. RESULTS--67.2% of the 64 samples showed the presence of HPV 16 E6 DNA and 39.1% showed the presence of HPV 18 E6 DNA. 32.8% showed the presence of both HPV 16 and 18 E6 DNA. No HPV DNA was shown in 10.9% of samples. Only 3.6% (2) of 55 samples showed positive IHS with CM1. One occurred in a HPV negative sample and the other in a HPV positive sample. CONCLUSION--A high prevalence of HPV DNA was detected in cervical cancer in Hong Kong using the PCR/SB technique. However, abnormal expression of p53 was uncommon amongst patients with or without HPV 16 or 18 infection.

Genital ulceration secondary to Epstein Barr virus infection.

Abstract: common techniques for detecting chlamydial antigen are direct immunofluorescence (DIF) and enzyme immuno-assay (EIA). Examination of first void urine (FVU) samples using EIA to detect C trachomatis antigen appears to be as sensitive as taking urethral swabs for diagnosis in men.2 We have studied chlamydia prevalence in males attending their general practitioners from whom a mid stream urine sample (MSU) was submitted for routine bacteriology for suspected urinary tract infection. Direct microscopy and culture were first performed. Samples which had more than 5 pus cells per high power field but no bacterial growth were tested for chlamydia antigen in an EIA (Dako) and all repeatedly reactive samples were confirmed by DIF using fluorescein labelled monoclonal antibody (Syva, Microtrak). The DIF was read by two observers. A preparation showing at least two