Association of sexually transmitted diseases and infection with the human immunodeficiency virus: biological cofactors and markers of behavioural interventions

Genital ulcers caused by sexually transmitted agents

Genital ulcers (GUs) represent a diagnostic challenge and can be secondary to neoplastic and inflammatory processes of different causes. Among those of infectious etiology, there are sexually transmitted infections (STIs), a very frequent reason for seeking the health service. The most common agents are herpes simplex virus and Treponema pallidum and, more rarely, Haemophilus ducreyi, Klebsiella granulomatis and Chlamydia trachomatis. A careful dermatological examination offers important diagnostic elements; however, atypical manifestations are very common. Distinctive characteristics of ulcers to look out for include their margin, edge, bottom, and base. Regional lymph node chain alterations should be evaluated regarding their number, size, mobility, consistency, inflammation, and pain on palpation. Diagnostic tests have variable sensitivity and specificity, and molecular tests are currently considered the reference exams. The rapid immunochromatographic tests represented a significant advance, as they can be performed with blood obtained from the digital pulp, offer results in up to 30 minutes, and do not require a laboratory structure. The treatment of persons affected by GU/STIs must be immediate, as it aims to prevent complications, as well as reduce transmission. It is not always considered that people with GUs/STIs have varying degrees of depression, anxiety, and self-reproach, with an impact on relationships. Establishing a bond and trusting the professional is essential for adherence to treatment and preventive measures that must be discussed individually.

Gaps Along the HIV Care Continuum: Findings Among a Population Seeking Sexual Health Care Services in New York City

BACKGROUND

Linkage/relinkage to HIV care for virally unsuppressed people with new sexually transmitted infections is critical for ending the HIV epidemic. We quantified HIV care continuum gaps and viral suppression among HIV-positive patients attending New York City (NYC) sexual health clinics (SHCs).

METHODS

One thousand six hundred forty-nine HIV-positive patients and a 10% sample of 11,954 patients with unknown HIV status on clinic visit date (DOV) were matched against the NYC HIV registry. Using registry diagnosis dates, we categorized matched HIV-positive patients as "new-positives" (newly diagnosed on DOV), "recent-positives (diagnosed ≤90 days before DOV), "prevalent-positives" (diagnosed >90 days before DOV), and "unknown-positives" (previously diagnosed but status unknown to clinic on DOV). We assessed HIV care continuum outcomes before and after DOV for new-positives, prevalent-positives, and unknown-positives using registry laboratory data.

RESULTS

In addition to 1626 known HIV-positive patients, 5% of the unknown sample (63/1196) matched to the registry, signifying that approximately 630 additional HIV-positive patients attended SHCs. Of new-positives, 65% were linked to care after DOV. Of prevalent-positives, 66% were in care on DOV; 43% of the out-of-care patients were relinked after DOV. Of unknown-positives, 40% were in care on DOV; 21% of the out-of-care patients relinked after DOV. Viral suppression was achieved by 88% of in-care unknown-positives, 76% in-care prevalent-positives, 50% new-positives, 42% out-of-care prevalent-positives, and 16% out-of-care unknown-positives.

CONCLUSIONS

Many HIV-positive people, including those with uncontrolled HIV infection, attend SHCs and potentially contribute to HIV spread. However, HIV status often is not known to staff, resulting in missed linkage/relinkage to care opportunities. Better outcomes could be facilitated by real-time ascertainment of HIV status and HIV care status.

Internet-Based HIV Prevention With At-Home Sexually Transmitted Infection Testing for Young Men Having Sex With Men: Study Protocol of a Randomized Controlled Trial of Keep It Up! 2.0

Background

Human immunodeficiency virus (HIV) infections are increasing among young men who have sex with men (YMSM), yet few HIV prevention programs have studied this population. Keep It Up! (KIU!), an online HIV prevention program tailored to diverse YMSM, was developed to fill this gap. The KIU! 2.0 randomized controlled trial (RCT) was launched to establish intervention efficacy.

Objective

The objective of the KIU! study is to advance scientific knowledge of technology-based behavioral HIV prevention, as well as improve public health by establishing the efficacy of an innovative electronic health (eHealth) prevention program for ethnically and racially diverse YMSM. The intervention is initiated upon receipt of a negative HIV test result, based on the theory that testing negative is a teachable moment for future prevention behaviors.

Methods

This is a two-group, active-control RCT of the online KIU! intervention. The intervention condition includes modules that use videos, animation, games, and interactive exercises to address HIV knowledge, motivation for safer behaviors, self-efficacy, and behavioral skills. The control condition reflects HIV information that is readily available on many websites, with the aim to understand how the KIU! intervention improves upon information that is currently available online. Follow-up assessments are administered at 3, 6, and 12 months for each arm. Testing for urethral and rectal sexually transmitted infections (STIs) is completed at baseline and at 12-month follow-up for all participants, and at 3- and 6-month follow-ups for participants who test positive at baseline. The primary behavioral outcome is unprotected anal sex at all follow-up points, and the primary biomedical outcome is incident STIs at 12-month follow-up.

Results

Consistent with study aims, the KIU! technology has been successfully integrated into a widely-used health technology platform. Baseline enrollment for the RCT was completed on December 30, 2015 (N=901), and assessment of intervention outcomes is ongoing at 3-, 6-, and 12-month time points. Upon collection of all data, and after the efficacy of the intervention has been evaluated, we will explore whether the KIU! intervention has differential efficacy across subgroups of YMSM based on ethnicity/race and relationship status.

Conclusions

Our approach is innovative in linking an eHealth solution to HIV and STI home testing, as well as serving as a model for integrating scalable behavioral prevention into other biomedical prevention strategies.

Trial Registration

Clinicaltrials.gov NCT01836445; https://clinicaltrials.gov/ct2/show/NCT01836445 (Archived by WebCite at http://www.webcitation.org/6myMFlxnC)

HIV, Chlamydia, Gonorrhea, and Primary and Secondary Syphilis among American Indians and Alaska Natives Within Indian Health Service Areas in the United States, 2007-2010

National rates from human immunodeficiency virus (HIV) and sexually transmitted disease (STD) surveillance may not effectively convey the impact of HIV and STDs on American Indian/Alaska Native (AI/AN) communities. Instead, we compared average annual diagnosis rates per 100,000 population of HIV, chlamydia (CT), gonorrhea (GC), and primary and secondary (P&S) syphilis, from 2007 to 2010, among AI/AN aged ≥ 13 years residing in 625 counties in the 12 Indian Health Service Areas, all AI/AN, and all races/ethnicities to address this gap. AI/AN comprised persons reported as AI/AN only, with or without Hispanic ethnicity. Out of 12 IHS Areas, 10 had higher case rates for CT, 3 for GC, and 4 for P&S syphilis compared to rates for all races/ethnicities. Eight Areas had higher HIV diagnosis rates than for all AI/AN, but HIV rates for all IHS Areas were lower than national rates for all races/ethnicities. Two IHS Areas ranking highest in rates of CT and GC and four Areas with highest P&S syphilis also had high HIV rates. STD and HIV rates among AI/AN were greater in certain IHS Areas than expected from observing national rates for AI/AN. Integrated surveillance of overlapping trends in STDs and HIV may be useful in guiding prevention efforts for AI/AN populations.

Elevated sexual risk behaviors among postincarcerated young African American males in the South

The dramatic racial disparities in the rates of HIV/STIs(sexually transmitted infections) among African Americans make understanding broader structural factors that increase the risk for HIV/STIs crucial. The current study of young 564 African American men attending STI clinics investigated whether those who had ever been incarcerated reported recent sexual behaviors relatively more risky than their counterparts who had never been incarcerated. Participants were recruited from clinics treating STIs in three southern U.S. cities. Males 15 to 23 years of age who identified as Black/African American and reported recent (past 2 months) sexual activity were eligible. Linear mixed-effects models and generalized estimating equation models were used to assess associations between baseline incarceration history and sexual risk behavior over a 6-month follow-up period. Mean age was 19.6 years (SD = 1.87). At baseline, 240 (42.6%) men reported history of incarceration. Incarceration history predicted several risk behaviors over a 6-month follow-up period. Compared with those with no incarceration history, men previously incarcerated reported a desire to conceive a pregnancy (β = .40, p = .02), were less likely to have used a condom at last sex act (odds ratio = .91, p = .02) and were more likely to have used drugs and alcohol before sex in the past 2 months (β = .69, p < .001; β = .41, p < .001). A history of incarceration may influence the sexual risk behavior of young African American males. Prevention programs and interventions should intensify support for postincarceration African American males to help mitigate this behavior.

Assessing the impact of a community-wide HIV testing scale-up initiative in a major urban epidemic

BACKGROUND

The Bronx, one of 5 boroughs in New York City (NYC), bears a high burden of HIV. We evaluated the impact of HIV testing initiatives in the Bronx, including the 2008 The Bronx Knows campaign.

METHODS

We used data from an annual telephone survey representative of NYC adults to compare 2005 and 2009 estimates of HIV testing prevalence among Bronx residents and to identify correlates of testing. We used NYC HIV surveillance data to evaluate changes in the percentage of persons concurrently being diagnosed with HIV and AIDS, an indicator of delayed HIV diagnosis.

RESULTS

Between 2005 and 2009, relative increases of 14% and 32% were found in the proportion of Bronx adults who have ever been HIV tested and who have been tested in the past year, respectively (P < 0.001). The largest increases were among those aged 24-44 years, men, non-Hispanic blacks and Hispanics, and those with low income or education, nonheterosexual identity, a personal doctor/provider, or health insurance. Factors independently associated with being recently tested included black or other race, Hispanic ethnicity, and bisexual identity. The proportion concurrently diagnosed with HIV and AIDS fell 22% from 2005 to 2009, and decreases generally occurred among subgroups experiencing increases in testing.

CONCLUSION

Community-wide testing in the Bronx increased the proportion of people with known HIV status and reduced the proportion with delayed diagnoses.

Mutations in the gyrA and parC genes of quinolone-resistant Neisseria gonorrhoeae isolates in India

A dramatic increase in the number of quinolone-resistant Neisseria gonorrhoeae isolates in India and worldwide has been reported recently. This study was undertaken to identify and characterise mutations in the gyrA and parC genes of N. gonorrhoeae resistant to six different quinolone antibiotics. In total, 64 N. gonorrhoeae clinical isolates were obtained during 2007-2009 from patients attending sexually transmitted diseases clinics (New Delhi, 35; Pune, 16; Mumbai, 6; Hyderabad, 6; and Nagpur, 1). Antimicrobial susceptibility was determined by Etest and mutation patterns in gyrA and parC were determined by sequencing analysis. All strains showed varying resistance to different quinolone analogues, ranging from 17.2% (gatifloxacin) to 98.4% (ofloxacin and norfloxacin). Sequencing of gyrA and parC revealed that 100% of strains showed mutations in gyrA and 46.9% showed mutations both in gyrA and parC. All strains showed single or double mutations at Ser-91→Phe, Ser-91→Thr and Asp-95→Gly/Asn in gyrA and at Glu-91→Gly in parC. Asp-95→Asn mutation was the most prevalent in strains isolated from New Delhi, whilst Asp-95→Gly was prevalent in strains isolated from Pune. Strains were categorised into eight different mutation patterns. Resistant strains with high minimum inhibitory concentrations (≥8 μg/mL) showed mutations both in gyrA and parC. The difference in the proportion of strains showing mutations in gyrA and parC was found to be significant (P<0.001). The mutation Asp-95→Asn was restricted to Pune strains only. These results indicate that mutations in quinolone target enzymes may have resulted in the high-level resistance seen in these isolates.

Genital ulcer disease treatment for reducing sexual acquisition of HIV

BACKGROUND

Genital ulcer disease by virtue of disruption of the mucosal surfaces may enhance HIV acquisition. Genital ulcer disease treatment with resolution of the ulcers may therefore contribute in reducing the sexual acquisition of HIV.

OBJECTIVES

To determine the effects of treatment of genital ulcer disease on sexual acquisition of HIV.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, EMBASE, LILACS, NLM Gateway, Web of Science, WHO International Clinical Trials Registry Platform, ClinicalTrials.gov, and reference lists of relevant publications for eligible studies published between 1980 and August 2011.

SELECTION CRITERIA

Randomized controlled trials of any treatment intervention aimed at curing genital ulcer disease compared with an alternative treatment, placebo, or no treatment. We included only trials whose unit of randomization was the individual with confirmed genital ulcer.

DATA COLLECTION AND ANALYSIS

We independently selected studies and extracted data in duplicate; resolving discrepancies by discussion, consensus, and arbitration by third review author. We expressed study results as risk ratios (RR) with 95% confidence intervals (CI).

MAIN RESULTS

There were three randomized controlled trials that met our inclusion criteria recruited HIV-negative participants with chancroid (two trials with 143 participants) and primary syphilis (one trial with 30 participants). The syphilis study, carried out in the US between 1995 and 1997, randomized participants to receive a single 2.0 g oral dose of azithromycin (11 participants); two 2.0 g oral doses of azithromycin administered six to eight days apart (eight participants); or benzathine penicillin G administered as either 2.4 million units intramuscular injection once or twice seven days apart (11 participants). No participant in the trial seroconverted during 12 months of follow-up. The chancroid trials, conducted in Kenya by 1990, found no significant differences in HIV seroconversion rates during four to 12 weeks of follow-up between 400 and 200 mg single oral doses of fleroxacin (one trial, 45 participants; RR 3.00; 95% CI 0.29 to 30.69), or between 400 mg fleroxacin and 800 mg sulfamethoxazole plus 160 mg trimethoprim (one trial, 98 participants; RR 0.33; 95% CI 0.04 to 3.09). Adverse events reported were mild to moderate in severity, and included Jarisch-Herxheimer reactions and gastrointestinal symptoms. The differences between the treatment arms in the incidence of adverse events were not significant. The quality of this evidence on the effectiveness of genital ulcer disease treatment in reducing sexual acquisition of HIV, according to GRADE methodology, is of very low quality.

AUTHORS' CONCLUSIONS

At present, there is insufficient evidence to determine whether curative treatment of genital ulcer disease would reduce the risk of HIV acquisition. The very low quality of the evidence implies that the true effect of genital ulcer disease treatment on sexual acquisition of HIV may be substantially different from the effect estimated from currently available data. However, genital ulcer diseases are public health problems in their own right and patients with these conditions should be treated appropriately; whether the treatment reduces the risk of HIV infection or not.

Application of the attitude-social influence-efficacy model to condom use among African-American STD clinic patients: implications for tailored health communication

The purpose of the current investigation was to apply the attitude-social influence-efficacy (ASE) model to achieve a theory-based understanding of condom use among low income, heterosexually active African-American STD clinic patients. N = 293 participants were recruited from a large, publicly-funded metropolitan STD clinic in the Southeastern United States and surveyed using an ACASI computer program. Results indicated that several ASE variables exhibited meaningful relationships with condom stages of change in univariate analyses, replicating patterns found in previous research. Fewer variables remained significant in multivariate analyses, however. There was also some support for the proposition that early stage movement (e.g., Precontemplation to Contemplation) is based more upon perceptions of condom use (e.g., pros, perceived norms), whereas later stage movement (e.g., Preparation to Action/Maintenance) is based more upon perceived and actual skills acquisition (e.g., condom self-efficacy, negotiation strategies). Results varied with regard to main and casual condom stage of change. Implications for developing tailored HIV prevention interventions with heterosexual African-Americans are discussed.

Using computer technology for HIV prevention among African-Americans: development of a tailored information program for safer sex (TIPSS)

New prevention options are urgently needed for African-Americans in the United States given the disproportionate impact of HIV/AIDS on this group. This combined with recent evidence supporting the efficacy of computer technology-based interventions in HIV prevention led our research group to pursue the development of a computer-delivered individually tailored intervention for heterosexually active African-Americans--the tailored information program for safer sex (TIPSS). In the current article, we discuss the development of the TIPSS program, including (i) the targeted population and behavior, (ii) theoretical basis for the intervention, (iii) design of the intervention, (iv) formative research, (v) technical development and testing and (vi) intervention delivery and ongoing randomized controlled trial. Given the many advantages of computer-based interventions, including low-cost delivery once developed, they offer much promise for the future of HIV prevention among African-Americans and other at-risk groups.

Mycoplasma genitalium as a contributor to the multiple etiologies of cervicitis in women attending sexually transmitted disease clinics

OBJECTIVES

The purpose of this study was to investigate the prevalence of Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, and Mycoplasma genitalium, in women attending a sexually transmitted disease (STD) clinic, as well as the frequency of coinfections, and relationship of each organism to cervicitis.

METHODS

In this cross-sectional study of 324 women attending Baltimore City STD Clinics, C. trachomatis, N. gonorrhoeae, T. vaginalis, and M. genitalium were detected using nucleic acid amplification tests. Demographic characteristics and risk factors were ascertained.

RESULTS

Overall prevalence of infection with C. trachomatis, N. gonorrhoeae, T. vaginalis, and M. genitalium was found to be 11.1%, 4.6%, 15.3%, and 19.2%, respectively. Prevalence in women with cervicitis was 15.8%, 6%, 18.9%, and 28.6% for C. trachomatis, N. gonorrhoeae, T. vaginalis, and M. genitalium, respectively. Percentages of coinfections were high. C. trachomatis and M. genitalium were significantly associated with cervicitis in univariate analysis, but only M. genitalium was significantly associated with cervicitis (AOR: 2.5) in multiple logistic regression models.

CONCLUSION

Knowledge of the statistical association of M. genitalium with cervicitis in this study increases the need for further confirmation of the etiologic significance of this organism with cervicitis in more diverse populations. The high prevalence merits more study and may have implications for diagnosis and treatment of cervicitis.

Structural and social contexts of HIV risk Among African Americans

HIV continues to be transmitted at unacceptably high rates among African Americans, and most HIV-prevention interventions have focused on behavioral change. To theorize additional approaches to HIV prevention among African Americans, we discuss how sexual networks and drug-injection networks are as important as behavior for HIV transmission. We also describe how higher-order social structures and processes, such as residential racial segregation and racialized policing, may help shape risk networks and behaviors. We then discuss 3 themes in African American culture-survival, propriety, and struggle-that also help shape networks and behaviors. Finally, we conclude with a discussion of how these perspectives might help reduce HIV transmission among African Americans.

Polyanionic microbicides modify Toll-like receptor-mediated cervicovaginal immune responses

Topical microbicides are being developed as a preventative approach to reduce the sexual transmission of human immunodeficiency virus type 1 (HIV-1) and other infections. For them to be efficacious, it is believed that they should avoid inducing inflammation while allowing the vaginal epithelium to initiate protective Toll-like receptor (TLR)-mediated innate responses against pathogens. In this study, human cervical and vaginal epithelial cells were exposed to polyanionic HIV entry inhibitors and the following synthetic TLR ligands: (i) the bacterial lipoprotein Pam(3)CSK(4), binding cell surface TLR1/TLR2; (ii) macrophage activating lipopeptide 2 (MALP-2), binding cell surface TLR2/TLR6; and (iii) the viral double-stranded RNA analog poly(I:C), recognized by intracellular TLR3. Cell activation was assessed by nuclear factor kappaB (NF-kappaB) reporter gene transactivation and cytokine production. In spite of enhancing TLR-triggered NF-kappaB activation, the polyanionic microbicide compounds dextran sulfate and polystyrene sulfonate significantly inhibited TLR-mediated cytokine production. They decreased cytokine mRNA and protein levels of proinflammatory (interleukin-8 [IL-8] and IL-1beta) and antiviral (beta interferon) cytokines following epithelial cell stimulation with Pam(3)CSK(4), MALP-2, or poly(I:C). These activities were associated with the sulfate/sulfonate moieties of the polyanionic compounds, since the unsulfated dextran control did not show any effects. Our data demonstrate that these microbicide compounds are capable of selectively interfering with TLR-mediated epithelial responses at different points in their signaling pathways and underscore the importance of expanding the assessment of microbicide compatibility with vaginal innate immune function. Further studies are warranted to determine the impact of this interference on HIV-1 transmission risk.

Biomarkers of leukocyte traffic and activation in the vaginal mucosa

Development of novel vaginal spermicides and anti-human immunodeficiency virus (HIV) microbicides requires careful assessment of their potential to recruit and activate CD4+ HIV-1 host cells in the female genital tract mucosa, two events that facilitate HIV-1 infection. Leukocyte traffic and activation are mediated by proinflammatory cytokines and chemokines, e.g. interleukin (IL)-1, IL-6 and IL-8, which have been detected in vaginal secretions in association with epithelial damage and infections. These proinflammatory mediators, however, have bidirectional, destructive as well as beneficial, effects on the mucosal barrier, and may be counterbalanced by endogenous inhibitors. Here we propose additional biomarkers for the evaluation of compound-induced cervicovaginal mucosal inflammation. Displaying different temporal patterns of detection, the levels of soluble E-selectin, vascular adhesion molecule-1, CD14 and myeloperoxidase in vaginal secretions reflected the mucosal leukocyte reaction to proinflammatory compounds being evaluated for safety in an improved rabbit vaginal irritation model. These biomarkers, which were also detected in human vaginal secretions, may be used to enhance the characterization of mucosal safety of vaginally applied compounds, both in animal as well as clinical studies.

Measure of HIV/STD risk-reduction: strategies for enhancing the utility of behavioral and biological outcome measures for African American couples

OBJECTIVE

Numerous studies have discussed the value of including biological outcome measures as a complement to behavioral outcome measures to assess the efficacy of HIV risk-reduction interventions. This article highlights strategies used to minimize the limitations of including both self-reported sexual behaviors and biologically confirmed sexually transmitted diseases as primary outcome measures in an HIV/sexually transmitted disease (STD) prevention program for African American serodiscordant couples (Eban).

DESIGN

Couples receiving an HIV intervention condition (Eban) were compared with couples receiving a time-equivalent General Health Promotion condition on behavioral and biological outcomes. Both behavioral and biological data were collected at baseline, immediately postintervention, and at 6 and 12 months postintervention.

METHODS

Literature reviews, consulting other researchers who conducted couples studies, our investigative team's experience in previous HIV interventions, and formative work were used to develop procedures to minimize potential limitations associated with the inclusion of behavioral and biological outcome measures for Eban.

RESULTS

Given the strengths of including behavioral and biological outcome measures, the Eban study chose to have both measures serve as primary outcomes. The primary behavioral outcome for the trial is the proportion of protected vaginal and anal intercourse episodes that occurred within the index couple in 90 days before each follow-up assessment and over the 12-month postintervention follow-up period. The primary biological outcome is the proportion of participants (male or female study partners) with an incident STD (Chlamydia, gonorrhea, or trichomoniasis) over the 12-month postintervention follow-up period.

CONCLUSIONS

Employing procedures to minimize limitations of using self-reported sexual behaviors and STDs as complementary primary outcomes enhances their utility as measures of the efficacy of HIV/STD prevention interventions.

[Signs and symptoms associated with sexually transmitted infections in Brazil, 2005]

OBJECTIVE

Sexually transmitted infections (STIs) are a major determinant of population disease burden worldwide. The objective of the study was to assess self-reported morbidity associated to STIs according to gender.

METHODS

The study data were obtained from a 2005 study consisting of a multistage probabilistic sample of 5,040 respondents, aged 16-65 years, living in urban areas in Brazil. These data were compared with those from a previous 1998 study. Bivariate analyses were carried out using Pearson's chi-square test and simple linear regression followed by logistic regression.

RESULTS

In both men and women, the variables: previous HIV testing, personal belief in unfaithful love, and number of sexual partners in a lifetime were significantly associated to STIs. In women only, the covariates: low family income, living in the Center-West, Southeast and South regions, and reporting of physical violence were independently associated to STIs. In men, the variables associated were: age group (35 years or more), living in the South region and in the state of São Paulo, and self-perceived HIV infection risk.

CONCLUSIONS

Signs and symptoms associated to STIs have strong gender differences in the general population and education interventions should be specifically targeted to either men or women.

Incident sexually transmitted infections among persons living with diagnosed HIV/AIDS in New York City, 2001-2002: a population-based assessment

OBJECTIVE/GOAL

To describe the incidence of 3 bacterial sexually transmitted infections (STIs) among persons living with human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) (PLWHA) in New York City (NYC) and to identify predictors for STI acquisition.

STUDY DESIGN

The surveillance registry of PLWHA diagnosed with HIV through December 31, 2000, and reported to the NYC Department of Health and Mental Hygiene was matched with the surveillance registry of persons diagnosed with other STIs during 2001-2002. Incident STIs were defined as cases of gonorrhea, chlamydia, or early syphilis acquired after HIV diagnosis.

RESULTS

Among 62,264 NYC PLWHA, 1466 (2.4%) had an incident STI diagnosed during 2001-2002. Two-year cumulative STI incidence was highest among PLWHA who were men (2.6%), non-Hispanic white (3.2%), aged 13-24 years (8.4%), men who have sex with men (4.5%), and persons living with HIV (non-AIDS) (4.1%). Predictors of STI acquisition among PLWHA varied substantially by STI type.

CONCLUSIONS

This population-based surveillance registry cross-match reveals that high-risk sexual practices occur among specific segments of the NYC PLWHA population. To decrease associated morbidity and prevent the secondary spread of HIV and STIs, prevention efforts should focus on PLWHA who continue to engage in high-risk sexual activity.

Effect of genital ulcer disease on HIV-1 coreceptor expression in the female genital tract

OBJECTIVE

To examine the expression of human immunodeficiency virus type 1 (HIV-1) coreceptors (CCR5 and CXCR4) by monocytic cells within human genital ulcers.

METHODS

Women with primary or secondary syphilis, herpes simplex virus type 1 (HSV-1) or HSV-2 infection, or noninfectious abrasions had a biopsy sample taken from the lesion and contralateral vulva. HIV-1 coreceptor expression on CD3(+) and CD14(+) cells was analyzed by flow cytometry. Real-time reverse-transcriptase polymerase chain reaction was used to assess levels of coreceptor mRNA expression.

RESULTS

Women with primary or secondary syphilis or with HSV-1 or HSV-2 infection had significantly increased numbers of CD14(+) cells expressing CCR5 within the genital ulcer. This increase was also noted in the nonulcerated tissue isolated from women with syphilis and in peripheral blood mononuclear cells from women with secondary syphilis. CCR5 mRNA expression was increased in tissue obtained from syphilis lesions.

CONCLUSIONS

Monocytes recruited to genital ulcer disease (GUD) sites express increased levels of CCR5. This increased expression could account, at least in part, for enhanced HIV-1 transmission in the setting of GUD.

A novel emergency department based prevention intervention program for people living with HIV: evaluation of early experiences

BACKGROUND

HIV prevention is increasingly focused on people living with HIV (PLWH) and the role of healthcare settings in prevention. Emergency Departments (EDs) frequently care for PLWH, but do not typically endorse a prevention mission. We conducted a pilot exploratory evaluation of the first reported ED program to address the prevention needs of PLWH.

METHODS

This retrospective observational cohort evaluation reviewed program records to describe the first six months of participants and programmatic operation. Trained counselors provided a risk assessment and counseling intervention combined with three linkage interventions: i) linkage to health care, ii) linkage to case management, and iii) linkage to partner counseling and referral.

RESULTS

Of 81 self-identified PLWH who were approached, 55 initially agreed to participate. Of those completing risk assessment, 17/53 (32%, 95 CI 20% to 46%) reported unprotected anal/vaginal intercourse or needle sharing in the past six months with a partner presumed to be HIV negative. Counseling was provided to 52/53 (98%). For those requesting services, 11/15 (73%) were linked to healthcare, 4/23 (17%) were coordinated with case management, and 1/4 (25%) completed partner counseling and referral.

CONCLUSION

Given base resources of trained counselors, it was feasible to implement a program to address the prevention needs for persons living with HIV in an urban ED. ED patients with HIV often have unmet needs which might be addressed by improved linkage with existing community resources. Healthcare and prevention barriers for PLWH may be attenuated if EDs were to incorporate CDC recommended prevention measures for healthcare providers.

Biocompatibility of solid-dosage forms of anti-human immunodeficiency virus type 1 microbicides with the human cervicovaginal mucosa modeled ex vivo

Topical anti-human immunodeficiency virus (HIV) microbicides are being sought to reduce the spread of HIV type 1 (HIV-1) during sexual intercourse. The success of this strategy depends upon the selection of formulations compatible with the natural vaginal mucosal barrier. This study applied ex vivo-modeled human cervicovaginal epithelium to evaluate experimental solid-dosage forms of the anti-HIV-1 microbicide cellulose acetate 1,2-benzenedicarboxylate (CAP) and over-the-counter (OTC) vaginal products for their impact on inflammatory mediators regarded as potential HIV-1-enhancing risk factors. We assessed product-induced imbalances between interleukin-1alpha (IL-1alpha) and IL-1beta and the natural IL-1 receptor antagonist (IL-1RA) and changes in levels of IL-6, tumor necrosis factor alpha, IL-8, gamma interferon inducible protein 10 (IP-10), and macrophage inflammatory protein 3alpha (MIP-3alpha), known to recruit and activate monocytes, dendritic cells, and T cells to the inflamed mucosa. CAP film and gel formulation, similarly to the hydroxyethylcellulose universal vaginal placebo gel and the OTC K-Y moisturizing gel, were nontoxic and caused no significant changes in any inflammatory biomarker. In contrast, OTC vaginal cleansing and contraceptive films containing octoxynol-9 or nonoxynol-9 (N-9) demonstrated similar levels of toxicity but distinct immunoinflammatory profiles. IL-1alpha, IL-1beta, IL-8, and IP-10 were increased after treatment with both OTC vaginal cleansing and contraceptive films; however, MIP-3alpha was significantly elevated by the N-9-based film only (P < 0.01). Although both films increased extracellular IL-1RA, the cleansing film only significantly elevated the IL-1RA/IL-1 ratio (P < 0.001). The N-9-based film decreased intracellular IL-1RA (P < 0.05), which has anti-inflammatory intracrine functions. This study identifies immunoinflammatory biomarkers that can discriminate between formulations better than toxicity assays and should be clinically validated in relevance to the risk of HIV-1 acquisition.

Specific and sensitive detection of Neisseria gonorrhoeae in clinical specimens by real-time PCR

Early diagnosis of Neisseria gonorrhoeae infections is important with regard to patients' health and infectivity. We report the development of a specific and sensitive TaqMan assay for the detection of N. gonorrhoeae in clinical samples. The target sequence is a 76-bp fragment of the 5' untranslated region of the opa genes that encode opacity proteins. A panel of 448 well-defined N. gonorrhoeae isolates was used to evaluate and optimize the assay. The method employs two minor-groove binding probes, one of them recognizing a newly identified sequence in the opa genes. Testing a large panel of related and unrelated microorganisms revealed that other Neisseria strains and other microorganisms tested negative in the opa test. With a lower detection limit of one genome per reaction, the opa test appeared more sensitive than both the COBAS AMPLICOR (Roche Diagnostics Nederland BV, Almere, The Netherlands) and a LightCycler 16S rRNA test. Analysis of a panel of 122 COBAS AMPLICOR-positive samples revealed that 68% were negative in both the 16S rRNA test and the opa assay (confirming that the COBAS AMPLICOR test produces false positives), while 30% were positive in both assays. Three samples were opa positive and 16S rRNA negative, which may be due to the higher sensitivity of the opa assay. We conclude that the opa gene-based real-time amplification assay offers a sensitive, specific, semiquantitative, and reliable assay suitable for the detection of N. gonorrhoeae in clinical specimens and/or for confirmation of less specific tests.

The Cost Effectiveness of Gonorrhea Screening in Urban Emergency Departments

BACKGROUND

The prevalence of gonorrhea (GC) among adolescent and young women attending some urban emergency departments (EDs) ranges from 1% to 7%, but historically screening has not been logistically practical.

GOAL

The primary goal of the study was to assess the cost effectiveness of GC screening in women ages 15 to 29, seeking care in urban EDs, using noninvasive or rapid point-of-care tests.

STUDY

We developed a state-transition Markov model to compare the net lifetime health consequences, costs, and cost effectiveness of routine ED care (no screening for women without genitourinary symptoms) to GC screening using 1 of 5 detection methods: Gram-stained smears of endocervical swab specimens, urine-based nucleic acid amplification tests (NAATs), NAATs performed on endocervical swabs, rapid immunochromotographic strip test (RIS) performed on clinician-collected vaginal swabs, and RIS on patient-collected vaginal swabs.

RESULTS

Screening women between 15 and 29 years of age using urine-based NAATs prevented 1247 cases of pelvic inflammatory disease (PID) and saved 177 US dollars per patient compared with no screening. Compared with urine-based NAAT, screening with RIS using clinician-obtained vaginal swabs prevented an additional 220 cases of PID and had an incremental cost effectiveness ratio of 6490 US dollars per quality-adjusted life year (QALY). Results were sensitive to assumptions about loss to follow-up, gonorrhea prevalence, and test costs.

CONCLUSION

Screening females aged 15 to 29 for gonorrhea in some urban EDs will prevent substantial reproductive morbidity. Screening with rapid, point-of-care tests is cost effective compared with other well-accepted preventive interventions.

Anti-human immunodeficiency virus type 1 microbicide cellulose acetate 1,2-benzenedicarboxylate in a human in vitro model of vaginal inflammation

The sexual transmission of human immunodeficiency virus type 1 (HIV-1) is facilitated by inflammation and related epithelial barrier perturbation. Microbicides for vaginal applications are currently being developed to reduce the risk of HIV-1 transmission. However, little is known about their interference with epithelial immune function. In recent clinical trials, nonoxynol-9 (N-9), a virucide with a long history of intravaginal use as a contraceptive, failed to protect against HIV-1 possibly due to mucosal inflammatory damage. Cellulose acetate 1,2-benzenedicarboxylate, also named CAP (for "controls AIDS pandemic"), is an anti-HIV-1 microbicide selected from pharmaceutical excipients that are regarded as safe for oral administration but have not been assessed for potential effects on inflammatory factors in the vaginal environment. Here we use a sensitive human cell culture system to evaluate proinflammatory profiles of soluble CAP in reference to N-9 and known epithelial activators such as tumor necrosis factor alpha (TNF-alpha) and bacterial lysates. Within 6 h of exposure, TNF-alpha and N-9 triggered NF-kappaB and AP-1/cFos activation and upregulated interleukins and an array of chemokines by vaginal and polarized cervical epithelial cells. The induced proinflammatory status continued after removal of stimuli and was confirmed by enhanced transepithelial neutrophil migration. While sustaining stability and anti-HIV-1 activity in the epithelial environment, CAP did not increase the production of proinflammatory mediators during or after exposure, nor did it modify the epithelial resistance to leukocyte traffic. CAP attenuated some TNF-alpha-induced responses but did not interfere with epithelial cytokine responsiveness to gonococcal determinants. The described system may be useful for predicting proinflammatory side effects of other microbicide candidates for vaginal application.

Interleukin (IL)-1, IL-6, and IL-8 predict mucosal toxicity of vaginal microbicidal contraceptives

Inflammation of the female reproductive tract increases susceptibility to HIV-1 and other viral infections and, thus, it becomes a serious liability for vaginal products. Excessive release of proinflammatory cytokines may alter the mucosal balance between tissue destruction and repair and be linked to enhanced penetration and replication of viral pathogens upon chemical insult. The present study evaluates four surface-active microbicide candidates, nonoxynol-9 (N-9), benzalkonium chloride (BZK), sodium dodecyl sulfate, and sodium monolaurate for their activity against human sperm and HIV, and their capacity to induce an inflammatory response on human vaginal epithelial cells and by the rabbit vaginal mucosa. Spermicidal and virucidal evaluations ranked N-9 as the most potent compound but were unable to predict the impact of the compounds on vaginal cell viability. Interleukin (IL)-1 release in vitro reflected their cytotoxicity profiles more accurately. Furthermore, IL-1 concentrations in vaginal washings correlated with cumulative mucosal irritation scores after single and multiple applications (P < 0.01), showing BZK as the most damaging agent for the vaginal mucosa. BZK induced rapid cell death, IL-1 release, and IL-6 secretion. The other compounds required either more prolonged or repeated contact with the vaginal epithelium to induce a significant inflammatory reaction. Increased IL-8 levels after multiple applications in vivo identified compounds with the highest cumulative mucosal toxicity (P < 0.01). In conclusion, IL-1, IL-6, and IL-8 in the vaginal secretions are sensitive indicators of compound-induced mucosal toxicity. The described evaluation system is a valuable tool in identifying novel vaginal contraceptive microbicides, selecting out candidates that may enhance, rather than decrease, HIV transmission.

Recommendations for incorporating human immunodeficiency virus (HIV) prevention into the medical care of persons living with HIV

The estimated number of annual new human immunodeficiency virus (HIV) infections in the United States has remained at 40,000 for >10 years. Reducing the rate of transmission will require new strategies, including emphasis on prevention of transmission by HIV-infected persons. Medical care providers can affect HIV transmission by screening HIV-infected patients for risk behaviors, communicating prevention messages, discussing sexual and drug-use behaviors, reinforcing changes to safer behavior, referring patients for services such as substance abuse treatment, facilitating partner counseling and referral, and identifying and treating other sexually transmitted diseases. The Centers for Disease Control and Prevention (CDC), the Health Resources and Services Administration (HRSA), the National Institutes of Health (NIH), and the HIV Medicine Association (HIVMA) of the Infectious Diseases Society of America (IDSA) have recently collaborated to develop evidence-based recommendations for incorporating HIV prevention into the medical care of persons living with HIV. This article summarizes key aspects of the recommendations.

Transmission of HIV-1 from mother to infant

In the developed world, antiretroviral therapy (ART) administered to the mother during pregnancy and intrapartum and to the infant in the neonatal period has resulted in a reduction of the overall risk of vertical transmission of HIV-1 to approximately 8%. In some settings, ART combined with cesarean section and a reduction in duration of ruptured membranes has resulted in a further lessening of risk to levels < or = 2 percent. A number of less expensive and greatly abbreviated ART regimens, useful for application in resource poor settings, also have resulted in reductions of mother-to-infant transmission of HIV-1 by 33 to 50% compared to baseline. A multitude of studies have shown these drugs to be safe for mothers, fetuses, and newborns. Breastfeeding seems to represent a risk factor that adds to the risk of vertical transmission, especially in infants who are fed a combination of breastmilk and other liquids and solids. Studies designed to assess the possible benefits of treating genital ulcer disease, chorioamnionitis, mastitis, and malnutrition in HIV-infected women, and of applying antiseptic washes to the cervix and vagina during labor, are in progress.

The clinical manifestations and treatment of sexually transmitted diseases in human immunodeficiency virus-positive men

Sexually transmitted diseases (STDs) occur commonly in sexually active human immunodeficiency virus (HIV)-positive men. STDs may have atypical presentations, can cause significant morbidity in persons with HIV infection, and may increase the risk of HIV transmission. Thus, the appropriate diagnosis and treatment of STDs in this population are extremely important. The clinical manifestations and treatment of several common STDs in HIV-positive men are reviewed. Further research is needed to define effective management and screening strategies for STDs in men with HIV infection.

Clinical aspects of diagnosis of gonorrhea and Chlamydia infection in an acute care setting

We found a 10.4% prevalence of unrecognized genital gonorrhea and Chlamydia infection among young adults of an urban emergency department. Intensified detection and treatment policies are needed to prevent continued transmission and complications of sexually transmitted infections.

Unsuspected gonorrhea and chlamydia in patients of an urban adult emergency department: a critical population for STD control intervention

BACKGROUND

Urban emergency departments (EDs) providing services to patients at high risk for sexually transmitted infection may be logical sites for intervention.

GOAL

To determine the prevalence of gonorrhea (GC) and chlamydia (CT) in an adult ED patient population, and to assess risk factors for infection.

STUDY DESIGN

Cross-sectional study of patients aged 18 to 44 in an urban ED, seeking care of any medical nature. Main outcome was positive for GC or CT by urine ligase chain reaction assay.

RESULTS

Test results for GC and/or CT were positive in 13.6% of 434 18 to 31 year-olds and in 1.8% of 221 32 to 44 year-olds. Of 63 infected individuals identified by the study, 15 (23.8%) were treated at the ED visit. Age < or =31 detected 88% of infections. Among 18- to 31-year-old patients, predictive risk factors by multivariate analysis included age <25, >1 sex partner in the past 90 days, and a history of sexually transmitted disease.

CONCLUSION

This study identified a high prevalence of GC and CT in patients seeking ED services. Many of these infections were clinically unsuspected. These data demonstrate that the ED is a high-risk setting and may be an appropriate site for routine GC and CT screening in 18- to 31-year-old patients.

Genital tract infections and perinatal transmission of HIV

In areas of the world where genital tract infections (GTIs) are common, the prevalence of HIV and the rate of mother-to-child transmission (MTCT) of HIV are also high. Although observational studies suggested that GTIs are associated with MTCT of HIV, no controlled clinical trial has confirmed this finding. It is likely that GTIs that cause either discharges or ulcers during pregnancy increase perinatal transmission of HIV. Several potential biological mechanisms might facilitate perinatal transmission. For example, chorioamnionitis, increased viral shedding in cervicovaginal secretions, increased HIV acquisition during pregnancy, inflammatory cytokine production, preterm labor, prolonged rupture of membranes, ascending infection, and increased intrapartum infectious secretions are factors that can be associated with GTIs. Several studies have shown that treating clinical conditions associated with inflammation might alter HIV shedding. It is conceivable that preventing ascending infection or reducing exposure of the infant to infectious material during birth could reduce MTCT. This can possibly be achieved by antimicrobial therapy during pregnancy and intrapartum. Such an approach is practical, is less expensive, and has secondary benefits related to prevention of adverse pregnancy outcomes associated with GTIs. Antibiotics might also complement reductions in MTCT of HIV obtained by antiretrovirals given to the mother around the time of delivery. In addition, antibiotics could reduce infectious causes of morbidity and mortality in infant and mother.

Sexually transmitted diseases and the increased risk for HIV transmission: implications for cost-effectiveness analyses of sexually transmitted disease prevention interventions

We estimated the annual number and cost of new HIV infections in the United States attributable to other sexually transmitted diseases (STDs). We used a mathematical model of HIV transmission to estimate the probability that a given STD infection would facilitate HIV transmission from an HIV-infected person to his or her partner and to calculate the number of HIV infections due to these facilitative effects. In 1996, an estimated 5,052 new HIV cases were attributable to the four STDs considered here: chlamydia (3,249 cases), syphilis (1,002 cases), gonorrhea (430 cases), and genital herpes (371 cases). These new HIV cases account for approximately $985 million U.S. in direct HIV treatment costs. The model suggested that syphilis is far more likely than the other STDs (on a per-case basis) to facilitate HIV transmission. This analysis provides a framework for incorporating STD-attributable HIV treatment costs into cost-effectiveness analyses of STD prevention programs.

Ambulatory STD management in an inner-city emergency department: descriptive epidemiology, care utilization patterns, and patient perceptions of local public STD clinics

BACKGROUND AND OBJECTIVES

In conjunction with a lack of primary and preventive care, many patients are treated in emergency departments (EDs) for sexually transmitted diseases (STDs).

GOAL

To epidemiologically characterize patients accessing an inner-city ED for treatment of STDs.

DESIGN

One hundred patients 17 years or older who were treated for an STD or who had conditions that were given syndromic or presumptive diagnoses of an STD participated in this prospective case series. Cases were identified on the basis of history and physical examination. Patients were interviewed to collect information on demographics, drug and alcohol use, current symptoms, self-medication, and health care access.

RESULTS

A total of 98% of patients who were approached participated. Two thirds of the participants were female. Women were more likely than men to have health insurance, Medical Assistance, and a regular source of health care. Injecting drug use was associated with a 5.3 increase in the odds ratio of delayed treatment seeking (P = 0.038). Effort to self-treat was associated with a 3.2 increase in the odds of delayed treatment seeking (P = 0.015). Being female was associated with a 4.1 increase in the odds of self-treatment (P = 0.009).

CONCLUSION

This study identifies several potential barriers to appropriate health care access and use. The study also identifies the ED as a potential source of intervention for more comprehensive health care and an entry into the health care system for a difficult-to-reach patient population.

A time to be born

OBJECTIVES

This study used a large, population-based data set (n = 619,455) to establish reference standards of the timing of spontaneous vaginal births.

METHODS

Low-risk births in Massachusetts from 1989 to 1995 were studied. This group comprised 242,276 births that met the following criteria: singleton, vertex, vaginal births with a birthweight of between 2500 and 4000 g; gestation between 37 and 42 weeks; a 5-minute Apgar score greater than 6, and no induction or stimulation.

RESULTS

Low-risk births displayed a mild circadian pattern, with a peak between 11:00 AM and 1:00 PM and a trough between 11:00 PM and 1:00 AM. Subgroup analysis showed no clear differences except for parity.

CONCLUSIONS

Reference standards should be developed and used as comparative norms for hospital and practice-based perinatal studies of diurnal patterns of birthing.

Factors predicting completion of a home visitation program by high-risk pregnant women: the North Carolina Maternal Outreach Worker Program

OBJECTIVES

This study sought to identify characteristics of high-risk pregnant women that predicted long-term participation in a home visitation program.

METHODS

Data regarding sociodemographic characteristics, perceived needs, psychological functioning, substance use, and informal social support were collected prospectively from 152 short-term and 221 long-term program participants.

RESULTS

In comparison with short-term participants, long-term participants were more likely to have been African American, married, nonsmokers, and enrolled in the program during their second trimester of pregnancy, and they were more likely to have had emotional and instrumental support needs.

CONCLUSIONS

Women with greater social support needs and healthier behaviors were more receptive to long-term home visitation than other women.

Sources of prenatal care data and their association with birth outcomes of HIV-infected women

OBJECTIVES

Different sources of prenatal care data were used to examine the association between birth outcomes of HIV-infected women and the Adequacy of Prenatal Care Utilization (APNCU) index.

METHODS

Adjusted odds ratios of birth outcomes for 1858 HIV-positive mothers were calculated for APNCU indexes on the basis of birth certificate data or 3 types of physician visits on Medicaid claims.

RESULTS

Claims- and birth certificate-based APNCU indexes agreed poorly (kappa < 0.3). Only the broadest claims-based APNCU index had lower adjusted odds ratios for low birthweight (0.64; 95% confidence interval [CI] = 0.49, 0.84) and preterm birth (0.70; 95% CI = 0.54, 0.91). The birth certificate-based index had a reduced adjusted odds ratio (0.73; 95% CI = 0.56, 0.95) only for preterm birth.

CONCLUSIONS

The association of birth outcomes and adequacy of prenatal care in this HIV-infected cohort differed significantly depending on the source of prenatal care data.

Continued risky behavior in HIV-infected youth

OBJECTIVES

The purpose of this study was to describe and compare risky behaviors in HIV-infected youths and adults.

METHODS

Records of HIV-infected outpatients were reviewed for the period January 1990 to February 1998. Youths (younger than 22 years at HIV diagnosis and younger than 25 years at study entry, n = 139) were compared with adults (22 years or older at HIV diagnosis or 25 years or older at study entry, n = 2880). Risky behaviors occurring after HIV diagnosis included unsafe sex and needle sharing.

RESULTS

Female and male youths were more than twice as likely as adults to engage in risky behavior (adjusted odds ratios of 2.6 and 2.3, respectively).

CONCLUSIONS

Both youths and adults continue to engage in risky behaviors after HIV diagnosis. Prospective studies are needed, along with targeted public health campaigns, for youths with HIV and for those at risk of infection.

Estimates of US children exposed to alcohol abuse and dependence in the family

OBJECTIVES

This study sought to provide direct estimates of the number of US children younger than 18 years who are exposed to alcohol abuse or alcohol dependence in the family.

METHODS

Data were derived from the National Longitudinal Alcohol Epidemiologic Survey.

RESULTS

Approximately 1 in 4 children younger than 18 years in the United States is exposed to alcohol abuse or alcohol dependence in the family.

CONCLUSIONS

There is a need for approaches that integrate systems of services to enhance the lives of these children.

Epidemiology of syphilis and gonorrhoea in eastern Poland in the years 1988-1997

Because of the sexually transmitted diseases (STDs) epidemic in the former Soviet Union and the possibility of a rise in early syphilis and gonorrhoea in the eastern region of Poland it seemed important to calculate the incidence rates for early syphilis and gonorrhoea for 3 border regions (east, west and south) and the central part of the country in the last 10 years. In addition, data were analysed on patients and their sexual partners (from Poland and abroad), and the country where the contact took place obtained from 14 Provincial Skin-VD Out-Patients' Clinics of eastern Poland. The results from 1988/89 and 1996/97 were compared. It was shown that early syphilis morbidity significantly decreased in western and southern Poland, fell in the central part and rose in the east slightly. Gonorrhoea morbidity significantly decreased in all regions. However, the number of provinces with early syphilis and gonorrhoea incidence rates in the 1990s of the same value or higher than in the 1980s, or of the whole of Poland clearly increased in eastern and central regions. The early syphilis and gonorrhoea morbidity in east Poland in the 1990s in relation to 1980s was marked by significant increase in the percentage of the foreigners treated (12.2 vs 1.8, P<0.001 for early syphilis, and 10.0 vs 2.3, P<0.001 for gonorrhoea) and in sexual contacts with foreigners reported by Polish patients (23.7 vs 0.8, P<0.01 for early syphilis and 17.7 vs 4.3, P<0.01 for gonorrhoea). Of the foreign contacts reported in 1996/97 by early syphilis and gonorrhoea patients, 60.4% and 82.2%, respectively, were casual. Contact with foreigners took place, mainly, in the former Soviet Union. The study illustrates that there may be a danger of an increase in the incidence of syphilis and gonorrhoea in Poland due to the epidemics in the neighbouring countries.

The prevalence of sexually transmitted pathogens in patients presenting to a Casablanca STD clinic

The objective of this study conducted at the sexually transmitted diseases (STD) clinic of the Pasteur Institute of Morocco (SCPIM) is to describe clinical complaints and biological findings in patients attending this facility. Two thousand two hundred sixty-four patients had visited the STD clinic from 1992 to 1996. The main reported symptom was genital discharge for men (44.5%) and women (68.6%). Genital eruption and ulcer were more frequent in men. The principal biological result shows a seroprevalence of 0.62% for human immunodeficiency virus (HIV), 3.05% for hepatitis B virus (HBV), 51.5% for chlamydiae and 13.2% for syphilis. Factors associated with clinical findings were age and Gonococcus for men (odds ratio (OR): 1.94 and 5.96, respectively) and Trichomonas and positive TPHA for women (OR: 9.49 and 0.25, respectively). This work describes for the first time the distribution of various germs involved in sexually transmitted diseases in Moroccan population and underlines the importance of studying its sexual behavior as well as determinants of STD incidence.

Relationship between immunoclinical status and prevalence of viral sexually transmitted diseases among human immunodeficiency virus-1 seropositive patients in Ghana

In view of the strong association between the acquired immunodeficiency syndrome (AIDS) and sexually transmitted diseases (STDs), we screened 182 human immunodeficiency virus (HIV)-1 infected patients over a 15-month period for serological markers to previously encountered or current STDs, most of viral etiology. The relationship between their immunological and clinical status and the prevalence of STDs was assessed and compared with that of 88 HIV-seronegative patients. Hepatitis B virus and Treponema pallidum were the most frequently occurring pathogens in both HIV-1-infected and HIV-seronegative patients. Hepatitis C virus (HCV) infection was also observed in both groups, but no HIV-seronegative patient was infected with human T-lymphotropic virus type 1 (HTLV-1). The Centers for Disease Control clinical staging of A1 through C3, representing asymptomatic to severe AIDS conditions, was observed in HIV-1 patients with or without STDs. A mean CD4 count of 288 cells per microliter (95% CI of 237-340 cells per microliter) in HIV-1 patients was significantly lower (P < 0.05) than that in HIV-seronegative individuals with 1019 cells per microliter (95% CI of 924-1115 cells per microliter), irrespective of whether subjects in either group had previous or current STDs. The mean CD4 count of patients with a single infection from HIV-1 was not significantly different (P = 0.36) from that of HIV-1 patients with multiple infections. HIV-1 infection alone appears to be responsible for the marked immunodeficiency status of seropositive patients observed in this study.

Asymptomatic non-ulcerative genital tract infections in a rural Ugandan population

OBJECTIVE

To document the prevalence of asymptomatic non-ulcerative genital tract infections (GTI) in a rural African cohort.

METHODS

The study population consisted of all adults aged 15-59 residing in 56 rural communities of Rakai District, southwest Uganda, enrolled in the Rakai STD Control for AIDS Prevention Study. Participants were interviewed about the occurrence of vaginal or urethral discharge and frequent or painful urination in the previous 6 months. Respondents were asked to provide blood and a first catch urine sample. Serum was tested for HIV-1. Urine was tested with ligase chain reaction (LCR) for N gonorrhoeae and C trachomatis. Women provided two self administered vaginal swabs; one for T vaginalis culture and the other for a Gram stained slide for bacterial vaginosis (BV) diagnosis.

RESULTS

A total of 12,827 men and women were enrolled. Among 5140 men providing specimens, 0.9% had gonorrhoea and 2.1% had chlamydia. Among 6356 women, 1.5% had gonorrhoea, 2.4% had chlamydia, 23.8% were infected with trichomonas and 50.9% had BV.53% of men and 66% of women with gonorrhoea did not report genital discharge or dysuria at anytime within the previous 6 months. 92% of men and 76% of women with chlamydia and over 80% of women with trichomonas or BV were asymptomatic. The sensitivities of dysuria or urethral discharge for detection of infection with either gonorrhoea or chlamydia among men were only 21.4% and 9.8% respectively; similarly, among women the sensitivity of dysuria was 21.0% while that of vaginal discharge was 11.6%. For trichomonas or BV the sensitivity of dysuria was 11.7% and that of vaginal discharge was 10.5%.

CONCLUSION

The prevalence of non-ulcerative GTIs is very high in this rural African population and the majority are asymptomatic. Reliance on reported symptoms alone would have missed 80% of men and 72% of women with either gonorrhoea or chlamydia, and over 80% of women with trichomonas or BV. To achieve STD control in this and similar populations public health programmes must target asymptomatic infections.

Bacterial vaginosis and disturbances of vaginal flora: association with increased acquisition of HIV

BACKGROUND

Cross-sectional studies suggest an association between bacterial vaginosis (BV) and HIV-1 infection. However, an assessment of a temporal effect was not possible.

OBJECTIVES

To determine the association of BV and other disturbances of vaginal flora with HIV seroconversion among pregnant and postnatal women in Malawi, Africa.

DESIGN

Longitudinal follow-up of pregnant and postpartum women.

METHODS

Women attending their first antenatal care visit were screened for HIV after counselling and obtaining informed consent. HIV-seronegative women were enrolled and followed during pregnancy and after delivery. These women were again tested for HIV at delivery and at 6-monthly visits postnatally. Clinical examinations and collection of laboratory specimens (for BV and sexually transmitted diseases) were conducted at screening and at the postnatal 6-monthly visits. The diagnosis of BV was based on clinical criteria. Associations of BV and other risk factors with HIV seroconversion, were examined using contingency tables and multiple logistic regression analyses on antenatal data, and Kaplan-Meier proportional hazards analyses on postnatal data.

RESULTS

Among 1196 HIV-seronegative women who were followed antenatally for a median of 3.4 months, 27 women seroconverted by time of delivery. Postnatally, 97 seroconversions occurred among 1169 seronegative women who were followed for a median of 2.5 years. Bacterial vaginosis was significantly associated with antenatal HIV seroconversion (adjusted odds ratio = 3.7) and postnatal HIV seroconversion (adjusted rate ratio = 2.3). There was a significant trend of increased risk of HIV seroconversion with increasing severity of vaginal disturbance among both antenatal and postnatal women. The approximate attributable risk of BV alone was 23% for antenatal HIV seroconversions and 14% for postnatal seroconversions.

CONCLUSIONS

This prospective study suggests that progressively greater disturbances of vaginal flora, increase HIV acquisition during pregnancy and postnatally. The screening and treating of women with BV could restore normal flora and reduce their susceptibility to HIV.

Screening for gonorrhea and chlamydia by DNA amplification in adolescents attending middle school health centers. Opportunity for early intervention

GOAL

To determine prevalence and incidence of Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) infection and assess risk factors predictive for such infections in a middle school-based clinic sample.

STUDY DESIGN

170 female students and 43 male students making 256 and 47 visits, respectively, > or = 30 days apart, in urban middle school clinics for primary care screening, reproductive health, or illness/injury were routinely asked to provide urine specimens for GC and CT ligase chain reaction testing if sexually active in the preceding 3-month period. Information regarding prior sexually transmitted diseases, reason for visit, and sexual risk behaviors was obtained.

RESULTS

GC: 11.4% of female student and 2.1% of male student tests were positive. Incidence was 34.0 cases/1,000 person months (95% Confidence interval [CI]: 19.5-67.5). Median time to first positive and repeat positive test was 4.6 and 2.6 months, respectively. For CT: 16.4% of female student and 2.1% of male student tests were positive. Incidence was 57.5 cases/1,000 person months (95% CI: 35.2-93.8). Median time to first positive and repeat positive CT test was 6.0 and 4.8 months, respectively. Assessed risk factors failed to specify a candidate screening population.

CONCLUSION

These data suggest that all sexually active adolescent girls in this high risk setting should be offered testing for GC and CT at least twice per year, regardless of age or other sexual risk behaviors and that STD control efforts in high risk middle schools should be encouraged.

Trends of HIV-1 and sexually transmitted diseases among pregnant and postpartum women in urban Malawi

OBJECTIVES

To examine rates of HIV-1 and sexually transmitted disease (STD) among pregnant and postpartum women in urban Malawi, Africa.

DESIGN

Serial cross-sectional surveys and a prospective study.

METHODS

Three major surveys were conducted in 1990, 1993 and 1994/1995. Consecutive first-visit antenatal women and women giving birth at the Queen Elizabeth Central Hospital were tested for HIV and STD after counseling and obtaining informed consent. Unlinked, anonymous HIV testing was also conducted on smaller samples of antenatal women in the same hospital to provide annual prevalence data. HIV-seronegative postpartum women from the 1990 and 1993 surveys were enrolled in a prospective study to determine HIV incidence.

RESULTS

HIV seroprevalence rose from 2.0% in 1985 to 32.8% in 1996, a 16-fold increase. The highest age-specific HIV prevalence was in the following age-groups: 20-24 years during 1990, 25-29 years during 1993, and 30-34 years during 1996. Among 1173 women followed for a median of 30.9 months, HIV incidence was 5.98 per 100 person-years in women aged < 20 years and declined steadily in older women. The prevalence of STD significantly declined among both HIV-positive and negative women. This decline in STD prevalence, however, was not accompanied by increased condom use over time.

CONCLUSIONS

Among urban childbearing women in Malawi, incidence of HIV is highest among young women while, currently, prevalence is highest among older women. Recent declines in STD prevalence suggest that HIV prevention programs are having an impact either through improved STD diagnosis and treatment or reduced risk behaviors. Sequential cross-sectional STD prevalence measures may be useful in monitoring effectiveness of STD and HIV prevention activities.

Chlamydial and gonococcal cervicitis in HIV-seropositive and HIV-seronegative pregnant women in Bangkok: prevalence, risk factors, and relation to perinatal HIV transmission

OBJECTIVES

To determine the prevalence and risk factors associated with cervicitis caused by Chlamydia trachomatis and Neisseria gonorrhoeae in human immunodeficiency virus (HIV) type 1-seropositive and HIV-seronegative pregnant women in Bangkok, and the relation to perinatal HIV transmission.

METHODS

As part of a multicenter perinatal HIV transmission study in an antenatal population with 2% HIV seroprevalence, endocervical swabs obtained at mid-pregnancy from a consecutive sample of 222 HIV-seropositive and 219 HIV-seronegative pregnant women at two large hospitals in Bangkok were tested for the presence of C. trachomatis and N. gonorrhoeae by DNA hybridization probe (Gen-Probe). Clinical risk factors and DNA probe results were analyzed in relation to the women's and newborns' HIV infection status.

RESULTS

The prevalence of C. trachomatis was 16.2% in HIV-seropositive pregnant women and 9.1% in HIV-seronegative pregnant women (P = 0.03). The prevalence of N. gonorrhoeae was 2.7% in HIV-seropositive pregnant women and 1.4% in HIV-seronegative pregnant women (P = 0.5). The overall population prevalence estimate was 9.2% for C. trachomatis and 1.4% for N. gonorrhoeae. Women with gonococcal infection were more likely to be positive for C. trachomatis (RR(MH) = 5.2, P < 0.01). Young age (<21 years) and primigravid status were associated with C. trachomatis infection among HIV-seropositive women; history of multiple sex partners (>1) were associated with C. trachomatis infection among HIV-seronegative women. For HIV-seropositive women, primigravida status also was associated with C. trachomatis infection. The perinatal HIV transmission rates were similar for those with and without C. trachomatis (24.1% and 23.2%, P = 0.9) and among those with and without N. gonorrhoeae (20% and 23.5%, P = 1.0).

CONCLUSIONS

Among pregnant women in Bangkok, C. trachomatis infection was considerably more common than N. gonorrhoeae infection and was associated with HIV infection, young age and first pregnancy (HIV-seropositive women), and multiple partners (HIV-seronegative women). Our data do not suggest an association between perinatal HIV transmission and maternal C. trachomatis or N. gonorrhoeae infection identified and treated during pregnancy. The high prevalence of C. trachomatis found using a test not readily available in Thailand emphasizes the need for improved, inexpensive ways to screen for and diagnose these sexually transmitted infections in developing countries.