11. SEX AND SPORT: A COMMUNITY BASED PROJECT OF CHLAMYDIA TESTING AND TREATMENT IN RURAL AND REGIONAL VICTORIA

Chlamydia is the most common notifiable infectious disease in Australia with the number of notifications increasing 92% over the past 5 years. The "Sex and Sport" Project is piloting a community based chlamydia testing and treatment program reaching young people in a specific community setting, sporting clubs. This multifaceted approach utilises health education, population screening and collection of data on risk taking behaviour as the first steps in enhancing health and shaping future service provisions. The project's primary aim is to assess the feasibility of an outreach testing and treatment program. Secondary aims are to measure the prevalence of chlamydia and assess sexual risk behaviour in this population. Strong community collaborations and integration into local health services through the Primary Care Partnerships is important in the project's sustainability; in particular key community members respected by sporting clubs needed to be identified, capacity developed to deliver effective health promotion messages and improve young people's access to sexual health services. Additionally, local knowledge has guided overall program implementation and provides opportunities for capacity building to regionally based services. For example, poor access to sexual health services is being addressed by the participants being able to access services via telephone consultation with Melbourne Sexual Health Centre. Approximately 1000 Victorians aged 16-25 years from the Loddon Mallee region of Victoria will be tested between June and September 2007. This paper will report on the feasibility, challenges and possible solutions in establishing a community based outreach testing and treatment program.

56. TAKE THE SEX OUT OF STI SCREENING! VIEWS OF GPS AND YOUNG WOMEN ON IMPLEMENTING CHLAMYDIA SCREENING IN AUSTRALIA

In-depth face to face interviews were carried out with a randomly selected sample of 20 General Practitioners (GPs) and 24 young women from across Victoria. We aimed to determine the attitudes of GPs and young women to chlamydia screening, what systems and education would be required to support chlamydia screening in general practice in Australia and in particular to explore how young women feel about being asked to test for chlamydia when they attend a GP for any reason. Both GPs and young women accept age-based screening for chlamydia and screening during a sexual health related consultation in general practice. Both feel that a large scale public education program, encompassing the high prevalence of chlamydial infection in young people in Australia, the asymptomatic nature of infection and the potential consequences if untreated, will be essential in ensuring the success of a chlamydia screening program in Australia. For the women, trust in their GP, was a major factor in the acceptability of chlamydia screening. They also felt chlamydia screening should be offered to all young women rather than targeted at 'high risk' women based on sexual history and they particularly emphasised the importance of normalising chlamydia screening. Women were clear that they did not want to be asked to provide a sexual history as part of being asked to have a chlamydia test. This finding has not been widely published in the literature and is worthy of comment. There is considerable evidence suggesting that GPs also regard sexual history taking as a barrier to STI testing in general practice. Chlamydia is an STI and notification and treatment of sexual partners is important. Understanding these concepts promotes young women's acceptance of chlamydia screening. However, is a detailed sexual history really an important precursor to a chlamydia test? Our study suggests maybe not.

The incidence of sexually transmitted infections among frequently screened sex workers in a decriminalised and regulated system in Melbourne

OBJECTIVE

To determine the incidence of sexually transmitted infections (STI) among decriminalised and regulated sex workers in Victoria.

METHODS

The incidence of STI was calculated for individuals who attended the Melbourne Sexual Health Centre on more than one occasion. Results of initial screen specimens were not included. Follow up time was calculated in person months and used as the denominator with the number of "specified" STIs diagnosed over the study period as the numerator.

RESULTS

Among 388 sex workers the incidence of chlamydia, Trichomonas vaginalis, genital warts, and herpes was 0.61, 0.11, 0.79, and 0.17, respectively, per 100 person months of follow up. The mean number of sexual non-paying private partners in the past 3 months was significantly greater among those with chlamydia (0.8 v 1.5, p < 0.01) and any STI (0.7 v 1.2, p < 0.05).

CONCLUSION

The incidence of STIs was low among decriminalised and regulated sex work and most infections were related to partners outside of work. Frequent screening of sex workers will reduce the chance of workers passing on an STI but is expensive. However, it may also discourage women from joining the sex work system and push them into an illegal system with a worse outcome.

Risk factors leading to Cryptosporidium infection in men who have sex with men

OBJECTIVES

Cryptosporidiosis is a devastating illness in people with HIV/AIDS yet there have been no analytical epidemiological studies measuring risk factors leading to cryptosporidiosis in men who have sex with men (MSM). The objective of this study was to measure the risk factors for exposure to Cryptosporidium among MSM.

METHODS

The study was a case-control design. It recruited MSM who had laboratory confirmed Cryptosporidium infection between 1997 and 2000. Participants answered a questionnaire about potential risk factors leading to exposure to Cryptosporidium.

RESULTS

10 cases and 24 controls were recruited. Men having more than one sexual partner in the past month were more likely to have had Cryptosporidium diarrhoea p=0.034 (OR 6.67, CI (1.15 to 38.60). Insertive anal sex (p=0.059) and attending a sex venue one or more times (p=0.059) also increased the odds of having cryptosporidiosis.

CONCLUSION

The study results suggest that sexual behaviour is a significant risk factor for cryptosporidial diarrhoea in MSM. The results will be used to inform risk groups about behaviours that may put them at increased risk of cryptosporidial diarrhoea.

Influences on the risk of recurrent high grade cervical abnormality

The objective of this study is to determine the risk of recurrent abnormality after a first episode of high-grade epithelial abnormality and its evolution over time in a population setting. Two cohorts were established from a statewide registry. The cervical intraepithelial neoplasia (CIN) cohort comprised 6849 women with a biopsy of CIN 2, 2/3 or 3 (squamous or glandular) during 1990-92. A cohort of 6857 women with negative cytology during 1990-92 was used for comparison. The CIN cohort had a significantly greater rate of subsequent high-grade epithelial abnormality than the negative cohort. The risk increased with age. For women over 50 years at the incident biopsy, the rate ratio for subsequent high-grade epithelial abnormality was 24.45 (95% CI, 7.2, 84.3). The rate of subsequent high-grade epithelial abnormality was greater if the incident biopsy was CIN 3 (rate 13.50 per 1000 person years [95% CI, 12.5, 14.6]) rather than CIN 2 or 2/3 (rate 7.83 per 1000 person years [95% CI, 7.1, 8.7]). The rate ratio for subsequent invasive cancer was 9.46 (95% CI, 2.5, 35.3) when the CIN cohort was compared with the negative cohort. We conclude the risk of recurrent high-grade epithelial abnormality is related to the age and degree of abnormality on the incident biopsy. Screening policies should acknowledge the risk does not diminish with time.

HIV seroconverters: using surveillance to characterise people with incident HIV infection in Victoria, Australia

This paper describes a cohort of people living in Victoria, Australia, diagnosed with incident HIV infection and identified through routine HIV surveillance. All HIV diagnoses notified to the Victorian HIV Registry between January 1997 and September 1998 were included. Infections were classified as incident if there was a prior negative test and/or seroconversion illness within 12 months of the first positive HIV test. During the study period there were 277 notifications received of which 70 (25%) were incident infections (seroconversions). People with incident infection were aged 36 years (+/- 10), from an Anglo background (76%) and living in Melbourne (91%). Seroconverters were more likely to have acquired their infection in Victoria (76%), through male-to-male sexual contact (86%), and from casual or anonymous partners (67%). Cohorts of individuals with incident HIV infection provide a valuable resource for understanding the dynamics of HIV acquisition and natural history of the infection.

Influences on the risk of recurrent high grade cervical abnormality

The objective of this study is to determine the risk of recurrent abnormality after a first episode of high-grade epithelial abnormality and its evolution over time in a population setting. Two cohorts were established from a statewide registry. The cervical intraepithelial neoplasia (CIN) cohort comprised 6849 women with a biopsy of CIN 2, 2/3 or 3 (squamous or glandular) during 1990–92. A cohort of 6857 women with negative cytology during 1990–92 was used for comparison.

The CIN cohort had a significantly greater rate of subsequent high-grade epithelial abnormality than the negative cohort. The risk increased with age. For women over 50 years at the incident biopsy, the rate ratio for subsequent high-grade epithelial abnormality was 24.45 (95% CI, 7.2, 84.3). The rate of subsequent high-grade epithelial abnormality was greater if the incident biopsy was CIN 3 (rate 13.50 per 1000 person years [95% CI, 12.5, 14.6]) rather than CIN 2 or 2/3 (rate 7.83 per 1000 person years [95% CI, 7.1, 8.7]). The rate ratio for subsequent invasive cancer was 9.46 (95% CI, 2.5, 35.3) when the CIN cohort was compared with the negative cohort. We conclude the risk of recurrent high-grade epithelial abnormality is related to the age and degree of abnormality on the incident biopsy. Screening policies should acknowledge the risk does not diminish with time.

Tracing and recruiting a cohort with community acquired hepatitis 25 years later

OBJECTIVE

We describe the methods used to trace and recruit a cohort (including injecting drug users) 25 years after admission to hospital in Melbourne with hepatitis.

METHODS

Information recorded in the original medical record was used for tracing purposes. Subjects were located using the electoral roll, CD-ROM telephone directory, the Health Insurance Commission database, Hepatitis Foundation newsletters, advertising and features in the press and local radio. Other approaches included contacting local medical officer or next of kin from the original admission, and the National Death Registry.

RESULTS

Tracing was undertaken on all members of the cohort; two-thirds were located. Methods were applied sequentially and 36% were found by CD-ROM telephone directory and the electoral roll, 33% from Health Insurance records, 15% by letter to last known address, 10% from contact of original next of kin, 3% from radio publicity and 1% from media advertisements. Of those who were located, 85% participated in the study.

CONCLUSIONS

Accurate ascertainment of birth date and full name from original case records was essential for tracing purposes. Use of Health Insurance records and CD-ROM telephone directory and the electoral roll were the most successful means of locating subjects while newspaper advertising was non-productive and expensive. History of IDU was the major association with failure to trace and unwillingness to enrol, but despite this tracing and recruitment was high in this group. The high participation rate in those located appears to be due to the experience of the staff member making the initial contact.

Predictors of early rescreening in the National Cervical Screening Program, Australia

OBJECTIVE

To identify variables that predict early rescreening after a negative Pap smear report.

METHODS

Cohort study using the records of a statewide Cervical Cytology Registry in Victoria, Australia. The cohort comprised 31,082 women who had a negative Pap smear report during the first half of 1996 and who were rescreened within the subsequent 36 months. Early rescreening was defined as a further Pap smear within 21 months.

RESULTS

The strongest predictor of early rescreening was a recommendation at the time of issuing the negative Pap smear report by the laboratory for retesting before two years (adjusted odds ratio = 3.81, 95% confidence interval (CI) 3.58-4.05). Mention of reactive or inflammatory change as part of the negative Pap smear report was also a powerful predictor (adjusted odds ratio = 1.67, 95% CI 1.50-1.85). Significant predictors associated with the women were young age, high socio-economic status and residence in the capital city. Significant predictors associated with the practitioner were if either the index or subsequent smear was collected by an obstetrician/ gynaecologist or a hospital-based clinic, or if the practitioner collecting the index smear was a female. The population-attributable risk per cent associated with the laboratory recommendation was 27%.

CONCLUSIONS

This data suggests that a multifaceted strategy targeting pathology laboratories, practitioners and women may be needed to reduce early rescreening.

IMPLICATIONS

Early rescreening is wasteful of health resources. New screening programs should be designed to avoid this problem.

nef-deleted HIV-1 inhibits phagocytosis by monocyte-derived macrophages in vitro but not by peripheral blood monocytes in vivo

OBJECTIVE

HIV-1 infection impairs a number of macrophage effector functions, but the mechanism is unknown. We studied the role of HIV-1 Nef in modulating phagocytosis by human monocytes and monocyte-derived macrophages (MDM).

DESIGN AND METHODS

Using a flow cytometric assay, phagocytosis of Mycobacterium avium complex (MAC) by monocytes in whole blood of Sydney Blood Bank Cohort (SBBC) members infected with a nef-deleted (Delta nef) strain of HIV-1 was compared with that of monocytes from uninfected or wild-type (WT) HIV-infected subjects. The specific impact of Nef on phagocytosis by MDM was determined by either infecting cells in vitro with Delta nef strains of HIV-1 or electroporating Nef into uninfected MDM.

RESULTS

MAC phagocytic capacity of monocytes from SBBC members was equivalent to that of cells from uninfected individuals (P = 0.81); it was greater than that of cells from individuals infected with WT HIV-1 (P < 0.0001), irrespective of CD4 counts and HIV viral load. In contrast, in vitro infection of MDM with either Delta nef or WT strains of HIV-1 resulted in similar levels of HIV replication and equivalent impairment of phagocytosis via Fc gamma and complement receptors. Electroporation of Nef into MDM did not alter phagocytic capacity.

CONCLUSIONS

This study provides evidence demonstrating the complex indirect effect of Nef on phagocytosis by peripheral blood monocytes (infrequently infected with HIV-1) in vivo. Conversely, the fact that MDM infected with either Delta nef or WT HIV-1 in vitro (high multiplicity of infection) show comparably impaired phagocytosis, indicates that HIV-1 infection of macrophages can directly impair function, independent of Nef.

Phosphorylation of Wzc, a tyrosine autokinase, is essential for assembly of group 1 capsular polysaccharides in Escherichia coli

Wzc proteins are tyrosine autokinases. They are found in some important bacterial pathogens of humans and livestock as well as plant-associated bacteria, and are often encoded within gene clusters determining synthesis and assembly of capsular and extracellular polysaccharides. Autophosphorylation of Wzc(cps) is essential for assembly of the serotype K30 group 1 capsule in Escherichia coli O9a:K30, although a genetically unlinked Wzc(cps)-homologue (Etk) can also participate with low efficiency. While autophosphorylation of Wzc(cps) is required for assembly of high molecular weight K30 capsular polysaccharide, it is not essential for either the synthesis of the K30 repeat units or for activity of the K30 polymerase enzyme. Paradoxically, the cognate phosphotyrosine protein phosphatase for Wzc(cps), Wzb(cps), is also required for capsule expression. The tyrosine-rich domain at the C terminus of Wzc(cps) was identified as the site of phosphorylation and autophosphorylation of Wzc requires a functional Walker A motif. Intermolecular transphosphorylation of Wzc(cps) was detected in strains expressing a combination of mutant Wzc(cps) derivatives. The N- and C-terminal domains of Wzc(cps) were expressed independently to mimic the situation found naturally in Gram-positive bacteria. In this format, both domains were required for phosphorylation of the Wzc(cps) C terminus, and for capsule assembly. Regulation by a post-translational phosphorylation event represents a new dimension in the assembly of bacterial cell-surface polysaccharides.

Risk factors for hepatitis C transmission in the Victorian population: a telephone survey

OBJECTIVE

To measure knowledge and prevalences of risk factors for hepatitis C infection in the Victorian community.

METHOD

Telephone survey of 757 Victorian householders aged 15+ years, March 1996.

RESULTS

An estimated 2.2% of Victorians have injected illicit drugs; 4.8% have tattoos and 49.6% have skin piercings; 11.4% received a blood transfusion before screening for HCV was introduced; 10.9% have had a test for HCV antibody. A majority of respondents perceived sexual contact and receipt of a transfusion to be risks for HCV transmission.

CONCLUSIONS

Risk factors associated with the spread of HCV are widespread in the Victorian community; however, the most important risk factor--injecting drug use--has low prevalence. Considerable uncertainty exists about risk factors for hepatitis C.

IMPLICATIONS

A very small percentage of Victorians are injecting drug users and therefore at highest risk of hepatitis C infection, therefore transmission control programs can be efficiently focused on this group. The Victorian community needs to be better educated about risk factors for hepatitis C, in particular that transfusions and blood donations are safe.

Factors affecting men's liking of condoms they have used

The objective of this study was to assess the impact on men's liking for the condoms they use of a range of factors including demographic variables and variables that describe men's experience of using particular condoms. One hundred and ninety-four men used 3765 condoms for which they provided a liking rating. The condoms were manufactured to one of 2 published standards and the study employed a double-blind crossover design. Sixty-one per cent of condoms were rated favourably, 31% were rated neutrally and the remainder (8%) unfavourably. Men rated condoms less favourably if they were experienced as too loose, too tight, too short, if difficulty was experienced applying the condom, if the condom slipped partially or completely down the penis or if the condom broke. Men rated more highly condoms which were experienced as well lubricated throughout use. Men with larger penises rated condoms less favourably and, of all the variables considered, ejaculating in the condom was the variable which had the largest positive impact. Men's liking for the condoms they use is influenced by a range of factors. However, given that most of the factors associated with men liking condoms less are those that can be addressed through better condom design and manufacture, the opportunity exists to enhance men's experience of condom use and hence help reduce resistance to the adoption of consistent condom use.