Monitoring HPV type-specific prevalence over time through clinic-based surveillance: a perspective on vaccine effectiveness

We investigated the feasibility of monitoring trends in prevalence of vaccine-preventable human papillomavirus (HPV) types in different clinic populations. We collected cervical specimens from women presenting to family planning, primary care, and sexually transmitted disease (STD) clinics for routine pap smears in five US cities during 2003-2005. We performed HPV genotyping and calculated annual type-specific prevalences; pre-vaccine era prevalence was highest for HPV 16 (6.0; 95% confidence interval [CI] 5.5-6.6%) and annual prevalences for vaccine-preventable types were stable, with few exceptions, after controlling for clinic type, age group, and city. With sufficient sample size and stable population characteristics, clinic-based surveillance systems can contribute to monitoring HPV vaccine impact in the cervical screening population.

HLA class II DR-DQ and increased risk of cervical cancer among Senegalese women

To examine Senegalese women to confirm and extend associations between HLA class II types and cervical cancer previously observed among African-American, Caucasian, Hispanic, and Japanese ethnic populations, 55 Senegalese women with invasive cervical carcinoma were compared with age-matched (human papillomavirus) HPV-positive (n = 83) and HPV-negative (n = 107) control women. PCR-based HPV and HLA typing methods were used. Data were analyzed using a global randomization test and conditional logistic regression. Although this study failed to confirm a previously reported association between cervical cancer and DQB1*03 alleles, the DRB1*1101-DQB1*0301 haplotype was detected more frequently among cervical carcinoma cases than among controls (adjusted odds ratio, 2.6; 95% confidence interval, 1.0-7.1). Furthermore, as reported by others, we observed a negative association of borderline statistical significance between DRB1*13 and cervical carcinoma (adjusted odds ratio, 0.5; 95% confidence interval, 0.2-1.1). Observations from this study confirm earlier findings of a negative association between DRB1*13 and cervical cancer and suggest that specific DRB1-DQB1 haplotype combinations, rather than individual DQB1*03 alleles, increase the risk for cervical cancer.

Papanicolaou test screening and prevalence of genital human papillomavirus among women who have sex with women

OBJECTIVES

The purpose of this study was to examine frequency of and attitudes toward Papanicolaou (Pap) test screening in women who have sex with women (WSW) and to determine prevalence of genital human papillomavirus (HPV).

METHODS

Women were eligible if they reported having engaged in sex with another woman in the preceding year Medical and sexual histories were obtained. Cervical specimens for Pap tests and cervical and vaginal specimens for HPV DNA testing were collected.

RESULTS

HPV DNA was detected in 31 of 248 WSW (13%). Women who had never had sex with men were less likely to have undergone pelvic examinations and had fewer recent Pap tests. Reasons for not undergoing Pap tests included lack of insurance, previous adverse experiences, and belief that Pap tests were unnecessary.

CONCLUSIONS

Despite the occurrence of genital HPV, WSW do not receive adequate Pap test screening. Pap test screening recommendations should not differ for WSW, regardless of sexual history with men.

Multiple conformational epitopes are recognized by natural and induced immunity to the E7 protein of human papilloma virus type 16 in man

The reactivity of sera from patients with cervical cancer with the E7 protein of human papilloma virus type 16 (HPV16) was estimated using a novel non-radioactive immunoprecipitation assay and four established protein- and peptide-based immunoassays. Six of 14 sera from patients with cervical cancer and 1 of 10 sera from healthy laboratory staff showed repeated reactivity with E7 in at least one assay. Four of the 7 reactive sera were consistently reactive in more than one assay, but only one was reactive in all four assays. Following immunization with E7, 2 of 5 patients with cervical cancer had increased E7-specific reactivity, measurable in one or more assays. No single assay was particularly sensitive for E7 reactivity, or predictive of cervical cancer. Mapping of E7 reactivity to specific E7 peptides was unsuccessful, suggesting that natural or induced E7 reactivity in human serum is commonly directed to conformational epitopes of E7. These results suggest that each assay employed in this study measures a different aspect of E7 reactivity, and that various reactivities to E7 may manifest following HPV infection or immunization. This finding is of significance for monitoring of E7 immunotherapy and for serological screening for cervical cancer.

Characteristics of female sexually transmitted disease clinic clients who report same-sex behaviour

Female STD clinic clients were categorized by report of sex partners' gender in the preceding 2 months and characterized with respect to HIV risk and STD diagnosis. Among 18,585 visits, 290 women (1.5%) reported sex exclusively with women, and 841 (4.5%) reported sex with both men and women. Relative to women reporting sex only with men, those reporting sex with both men and women reported more recent partners, sex with partners at high risk for HIV, injection drug and crack cocaine use, and exchange of sex for drugs or money. Women reporting sex exclusively with women more frequently reported prior sex with a bisexual man or an HIV-infected partner. Female STD clinic clients who report sex with both men and women may be at increased HIV risk relative to women reporting sex exclusively with men, and women who report sex only with women may be more likely to have had sex with men at high risk for HIV infection.

Concurrent and sequential acquisition of different genital human papillomavirus types

Coinfection with multiple types of genital human papillomavirus (HPV) has been reported, but how frequently it occurs and whether prior infection with specific HPV types inhibits subsequent infection by related types are not known. To address this, 518 women were followed for an average of 2.9 years, and behavioral information and cervical and vulvovaginal swabs for HPV DNA assay were obtained at 4-month intervals. A polymerase chain reaction-based method was used to detect types frequently found in cervical cancers (HPV 16, 18, 31, and 45) and in genital warts (HPV 6 and 11). Concurrent acquisition of multiple types occurred more often than expected by chance. However, no 2 types were more or less likely to be acquired concurrently than any other 2 types. When considering sequential acquisition of HPV types, we found that risk of acquiring a new HPV type was not decreased among those with prior infection by a phylogenetically related or unrelated type (hazard ratio [95% confidence interval], 1.0 [0.4-3.0] and 1.3 [0.8-2.1], respectively).

Genital human papillomavirus infection in women who have sex with women: a review

Sexual transmission of human papillomavirus between women has been postulated on the basis of reports of abnormal Papanicolaou smears in women who reported no prior sex with men and by studies using amplified deoxyribonucleic acid technology for human papillomavirus detection. To review the current knowledge of the epidemiology of human papillomavirus and the Papanicolaou smear screening practices among women who have sex with women, studies were identified from a search of the MEDLINE database from January 1980-June 1999. Several factors, including prior or concurrent sex with men and sexual behaviors between women, validate the possibility of human papillomavirus infection among women who have sex with women, and data support that human papillomavirus transmission also occurs. Limited data indicate that the frequency of routine Papanicolaou smear screening among women who have sex with women may be suboptimal relative to heterosexual women. Education of women who have sex with women and the providers of their health care should counter any assumptions that sex between women confers no risk of human papillomavirus transmission. Women who have sex with women should receive Papanicolaou smear screening in accord with current guidelines.

Comparison of human papillomavirus types 16, 18, and 6 capsid antibody responses following incident infection

The relationship between human papillomavirus (HPV) DNA in the genital mucosa and serum IgG to HPV-16, -18, and -6 was studied in a cohort of 588 college women. Among women with incident HPV infections, 59.5%, 54.1%, and 68.8% seroconverted for HPV-16, -18, or -6, respectively, within 18 months of detecting the corresponding HPV DNA. Transient HPV DNA was associated with a failure to seroconvert following incident HPV infection; however, some women with persistent HPV DNA never seroconverted. Antibody responses to each type were heterogeneous, but several type-specific differences were found: seroconversion for HPV-16 occurred most frequently between 6 and 12 months of DNA detection, but seroconversion for HPV-6 coincided with DNA detection. Additionally, antibody responses to HPV-16 and -18 were significantly more likely to persist during follow-up than were antibodies to HPV-6.

Detection of cervical antibodies to human papillomavirus type 16 (HPV-16) capsid antigens in relation to detection of HPV-16 DNA and cervical lesions

A more sensitive luminescence immunoassay (LIA) for human papillomavirus type 16 (HPV-16) was developed and used to measure HPV-16 antibodies in cervical samples from 292 college-aged women who were examined at 4-month intervals. Of the 609 collected samples, IgG, IgA, and secretory piece-associated antibodies to HPV-16 were detected in 12%, 6%, and 8%, respectively, of samples tested. Cervical IgG antibodies were most strongly associated with HPV-16 DNA detected within the previous 12 months (odds ratio, 3.3; 95% confidence interval, 1.4-7.8). Secretory IgA (cervical IgA- and secretory piece-positive) was most strongly associated with detection of a squamous intraepithelial lesions 4-8 months earlier (odds ratio, 6.4; 95% confidence interval, 1.9-21.8). As with serum HPV-16 antibodies, there appears to be a several-month delay between cervical HPV infection and detection of cervical antibodies.

Comparison of variant-specific hybridization and single-strand conformational polymorphism methods for detection of mixed human papillomavirus type 16 variant infections

PCR-based variant-specific hybridization (VSH) and single-strand conformational polymorphism (SSCP) analyses were compared for their capacities to detect mixed human papillomavirus type 16 (HPV-16) variant infections within clinical specimens. The SSCP assay used in this comparison targets a 682-bp fragment that spans nucleotides 7445 to 222 within the HPV-16 genome. This fragment includes portions of the HPV-16 long control region and the E6 open reading frame and identifies three categories of SSCP patterns: those identical to the patterns of prototype HPV-16 (P), those identical to the patterns of Caski-derived HPV-16 (C), or those that are different from the P and C HPV-16 patterns and that are therefore classified as belonging to novel (N) HPV-16 variants. VSH targets the entire HPV-16 E6-coding region (nucleotides 56 to 640) and distinguishes previously described variant nucleotides at positions 109, 131, 132, 143, 145, 178, 286, 289, 350, 403, and 532. Clinical samples used in VSH and SSCP analyses were subjected to multiple independent amplification reactions. The resultant amplicons were cloned, and 14 to 78 clones per clinical specimen were evaluated by VSH. VSH detected an HPV-16 variant that represented at least 20% of the amplified HPV-16 variant population. In contrast, SSCP analysis detected HPV-16 variants that represented 36% of the amplified HPV-16 population. Comparison studies were conducted with mixed HPV-16 variant laboratory constructs. Again, VSH had a higher sensitivity than SSCP analysis in detecting mixed HPV-16 variant infections in these constructed amplicon targets. Accurate detection of HPV-16 variants may enhance our understanding of the natural history of HPV-16 infections.

Risk factors for HIV-1 shedding in semen

Semen is the body fluid most commonly associated with sexual transmission of human immunodeficiency virus type-1 (HIV-1). Because the male genitourinary tract is distinct immunologically from blood, compartment-dependent factors may determine HIV-1 shedding in semen. To identify these factors, the authors obtained 411 semen and blood specimens from 149 men seen up to three times. Seminal plasma was assayed for HIV-1 RNA and semen was cocultured for HIV-1 and cytomegalovirus (CMV), which may up-regulate HIV-1 replication. The best multivariate model for predicting a positive semen HIV-1 coculture included two local urogenital factors, increased seminal polymorphonuclear cell count (odds ratio (OR) = 12.6 for each log10 increase/mL, 95% confidence interval (CI) 12.2, 134.5) and a positive CMV coculture (OR = 3.0, 95% CI 1.2, 7.7). The best multivariate model for predicting semen HIV-1 RNA included two systemic host factors, CD4+ cell counts <200/microliter (OR = 3.0, 95 percent CI 1.3, 6.9) and nucleoside antiretroviral therapy (monotherapy: OR = 0.5, 95% CI 0.3, 1.0; combination therapy: OR = 0.4, 95% CI 0.2, 0.9), and a positive CMV coculture (OR = 1.7, 95% CI 1.0, 3.0). Thus, both systemic and local genitourinary tract factors influence the risk of semen HIV-1 shedding. These findings suggest that measures of systemic virus burden alone may not predict semen infectivity reliably.

Clinical features of Chlamydia trachomatis rectal infection by serovar among homosexually active men

BACKGROUND AND OBJECTIVES

Because C. trachomatis serovars correlate with the clinical manifestations of cervical infection, we undertook this study to determine whether clinical, behavioral, and laboratory findings correlate with C. trachomatis serovars isolated from rectal infections.

GOAL OF THIS STUDY

To correlate C. trachomatis serovar with signs and symptoms of rectal infection.

STUDY DESIGN

A cross-sectional study of 454 men with rectal C. trachomatis infection attending an urban sexually transmitted disease (STD) clinic was undertaken. Isolates were thawed, passaged to high titer, and typed using a panel of monoclonal antibodies. Compared to men infected with B complex isolates (164), men with C complex isolates (55) were less likely to report symptoms (OR: 0.4; 95% CI: 0.1-0.8), or to have erythema, bleeding, or mucopus (OR: 0.3; 95% CI: 0.1-0.8). Among men with inclusion counts of more than 100, those infected with FG group versus B complex isolates were more likely to present with mucopus (OR: 10.5; 95% CI: 1.2-95.5), more than 15 polymorphonuclear leukocytes (OR: 19.2; 95% CI: 1.7-219.8), and proctitis (OR: 4.2; 95% CI: 1.1-16.7).

CONCLUSION

Signs and symptoms of rectal infection correlate with the serovar of C. trachomatis isolates.

A case-control study of necrotizing fasciitis during primary varicella

OBJECTIVE

An increase in the incidence of necrotizing fasciitis (NF) occurring in previously healthy children with primary varicella was noted in the Washington State area between December 1993 and June 1995. Our objective was to investigate ibuprofen use and other risk factors for NF in the setting of primary varicella.

METHODS

Case-control study. Demographic information, clinical parameters, and potential risk factors for NF were compared for cases and controls. Cases of NF were analyzed to identify potential determinants of NF complicated by renal insufficiency and/or streptococcal toxic shock syndrome. Multivariate logistic regression was used to evaluate the association between ibuprofen use and NF. A case was defined as a child with NF hospitalized within 3 weeks of primary varicella (n = 19). Controls were children hospitalized with a soft tissue infection other than NF within 3 weeks of primary varicella (n = 29). Odds ratios (ORs) of ibuprofen, as well as other potential risk factors were evaluated. In addition, demographic and clinical data as well as other potential risk factors were compared between cases and controls.

RESULTS

After controlling for gender, age, and group A streptococcus isolation, cases were more likely than controls to have used ibuprofen before hospitalization (OR, 11. 5; 95% confidence interval, 1.4 to 96.9). In most children, ibuprofen was initiated after the onset of symptoms of secondary infection. Children with NF complicated by renal insufficiency and/or streptococcal toxic shock syndrome were more likely than children with uncomplicated NF to have used ibuprofen (OR, 16.0; 95% confidence interval, 1.0 to 825.0). Children with complicated NF also had a higher mean maximum temperature (40.9 degrees C vs 39.3 degrees C), and a longer mean duration of secondary symptoms (1.7 days vs 0.6 days) before admission than children with uncomplicated NF.

CONCLUSION

Ibuprofen use was associated with NF in the setting of primary varicella. Additional studies are needed to establish whether ibuprofen use has a causal role in the development of NF and its complications during varicella.

Effect of trimethoprim-sulfamethoxazole as Pneumocystis carinii pneumonia prophylaxis on bacterial illness, Pneumocystis carinii pneumonia, and death in persons with AIDS

To measure the effect of trimethoprim-sulfamethoxazole (TMP-SMX) in preventing bacterial illness, Pneumocystis carinii pneumonia (PCP), and death in people with AIDS, we conducted a retrospective medical record review of 1078 persons who were observed for 3 years on average who attended nine outpatient facilities in Seattle, Washington between January 1990 and April 1996. We calculated relative risk estimates to measure the protective effect of TMP-SMX on the development of major bacterial illnesses, PCP, and death. Use of TMP-SMX decreased the risk of PCP (relative risk [RR] = 0.23; 95% confidence interval [CI], 0.14-0.36) and deaths not attributable to PCP (RR = 0.59; 95% CI, 0.47-0.73). Prevention of major bacterial illnesses of known etiology was of borderline significance (RR = 0.77; 95% CI, 0.57-1.05) and became statistically significant with the addition of patients with infections of unknown etiology (RR = 0.77; 95% CI 0.61-0.97). Use of TMP-SMX PCP prophylaxis significantly reduced the risks of death and of PCP and was associated with a trend toward reduced risk of major bacterial infections.

A matched prospective study of human immunodeficiency virus serostatus, human papillomavirus DNA, and cervical lesions detected by cytology and colposcopy

OBJECTIVE

To compare the prevalence and type of human papillomavirus (HPV) infections in the genital tract of human-immunodeficiency-virus- (HIV) seropositive and -seronegative women matched for cytology and to examine prospectively the relationship of HPV DNA, colposcopic findings and cervical squamous intraepithelial lesions (SIL) in these matched seropositive and seronegative cohorts.

METHODS

A matched prospective study of HIV-seropositive and -seronegative women undergoing cytologic screening, colposcopy, and testing for HPV DNA and other infections at each visit.

RESULTS

Twenty-three HIV-seropositive women were matched with 23 seronegative women by cervical cytology reading, lifetime number of sexual partners, age, and follow-up length. Fourteen pairs of these women had follow-up visits every 4 months, for 56 and 53 total visits in seropositive and seronegative women, respectively. After matching, the groups had a similar overall prevalence of HPV DNA and of HPV oncogenic (high risk) types at baseline. On follow up, HIV-seropositive women were more likely than seronegative women to develop SIL (38% vs. 10%), less likely to have negative cytology (34% vs. 60%, overall P = 0.03), more visits with HPV DNA detected (68% vs. 40% P = 0.04), and more visits with multiple HPV DNA types detected (18% vs. 0%, P = 0.02). Colposcopic lesions in the seropositive women were more likely to have sharp borders or mosaicism or to be thick white (P = 0.009).

CONCLUSIONS

After matching for baseline Papanicolaou smear readings, these data suggest that over time seropositive women have more visits that yield abnormal cytology, more persistent HPV DNA detection, and more colposcopic abnormalities than seronegative women.

A matched prospective study of human immunodeficiency virus serostatus, human papillomavirus DNA, and cervical lesions detected by cytology and colposcopy

OBJECTIVE

To compare the prevalence and type of human papillomavirus (HPV) infections in the genital tract of human-immunodeficiency-virus- (HIV) seropositive and -seronegative women matched for cytology and to examine prospectively the relationship of HPV DNA, colposcopic findings and cervical squamous intraepithelial lesions (SIL) in these matched seropositive and seronegative cohorts.

METHODS

A matched prospective study of HIV-seropositive and -seronegative women undergoing cytologic screening, colposcopy, and testing for HPV DNA and other infections at each visit.

RESULTS

Twenty-three HIV-seropositive women were matched with 23 seronegative women by cervical cytology reading, lifetime number of sexual partners, age, and follow-up length. Fourteen pairs of these women had follow-up visits every 4 months, for 56 and 53 total visits in seropositive and seronegative women, respectively. After matching, the groups had a similar overall prevalence of HPV DNA and of HPV oncogenic (high risk) types at baseline. On follow up, HIV-seropositive women were more likely than seronegative women to develop SIL (38% vs. 10%), less likely to have negative cytology (34% vs. 60%, overall P = 0.03), more visits with HPV DNA detected (68% vs. 40% P = 0.04), and more visits with multiple HPV DNA types detected (18% vs. 0%, P = 0.02). Colposcopic lesions in the seropositive women were more likely to have sharp borders or mosaicism or to be thick white (P = 0.009).

CONCLUSIONS

After matching for baseline Papanicolaou smear readings, these data suggest that over time seropositive women have more visits that yield abnormal cytology, more persistent HPV DNA detection, and more colposcopic abnormalities than seronegative women.

Genital human papillomavirus infection in women who have sex with women

Genital infection with human papillomavirus (HPV), as determined by polymerase chain reaction detection of HPV DNA and prevalence of HPV-6 and -16 serum antibodies, was investigated in 149 women who were sexually active with women. By use of HPV L1 consensus primers and hybridization to types 6/11, 16, 18, 31/33/35/39, and 45 and a generic probe, HPV DNA was detected in 30% of subjects; of these, 20% had type 31/33/35/39, 18% had type 16, and 2% had type 6/11. Of 21 subjects reporting no prior sex with men, HPV DNA was detected in 19% and squamous intraepithelial lesions in 14%. By capture ELISA with HPV-6 and -16 L1 capsids, 47% of subjects were seropositive for HPV-16 and 62% for HPV-6. Current smoking was associated with detectable HPV DNA. Genital HPV infection and squamous intraepithelial lesions are common among women who are sexually active with women and occur among those who have not had sex with men.

Diagnostic accuracy of HIV-associated central nervous system toxoplasmosis

Our objective was to examine the accuracy of diagnosis of HIV-associated central nervous system (CNS) toxoplasmosis. Individuals diagnosed with HIV-associated CNS toxoplasmosis and controls were ascertained from a population-based database. Diagnosis was confirmed by response to therapy or by histology. Symptoms, results of anti-Toxoplasma serology and use of Pneumocystis carinii pneumonia (PCP) prophylaxis were recorded. Central nervous system toxoplasmosis was confirmed in 54 (76%) of 75 patients. Reactive anti-Toxoplasma serology was associated with CNS toxoplasmosis (OR=20.4, 95% CI 3.1-175.8). Adjusting for CD4 and use of dapsone or aerosolized pentamidine, trimethoprim-sulphamethoxazole (TMP-SMX) for PCP prophylaxis was associated with lower likelihood of CNS toxoplasmosis (OR 0.3, 95% CI 0.1-0.7). Diagnosis of CNS toxoplasmosis is often incorrect. Another diagnosis is most likely in patients who are anti-Toxoplasma seronegative or who are receiving prophylactic TMP-SMX.

Vulvovaginal candidiasis: clinical manifestations, risk factors, management algorithm

OBJECTIVE

To correlate symptoms, signs, and risk factors with positive wet mounts or cultures for Candida albicans and to develop an algorithm to diagnose vulvovaginal candidiasis.

METHODS

This cross-sectional study of 774 randomly selected women from an urban sexually transmitted disease (STD) clinic evaluated symptoms, signs, and risk factors associated with C albicans, detected by wet mount and culture, and constructed an algorithm.

RESULTS

C albicans, recovered from 186 (24%) of the 774 women, was associated with chief complaints of vulvar pruritus or burning. Elicited symptoms were vulvar pruritus, pain or burning, and external dysuria; signs were vulvar erythema, edema, fissures, vaginal erythema, and thick, curdy vaginal discharge. Among 545 women with symptoms of either increased vaginal discharge or vulvar pruritus or burning, only 155 (28%) had positive C albicans cultures, whereas bacterial vaginosis or other sexually transmitted infections were found in 288 (53%). In multivariate analysis, risk factors for positive C albicans culture included condom use, presentation after the 14th menstrual cycle day, sexual intercourse more than four times per month, recent antibiotic use, young age, past gonococcal infection, and absence of current gonorrhea or bacterial vaginosis. A clinical algorithm based on symptoms, signs, and selective use of wet mounts and cultures would have provided prompt treatment to 150 of 167 (90%) women with vulvovaginal candidiasis while minimizing the number of cultures performed.

CONCLUSION

A simple algorithm using symptoms, signs, wet mounts, and selective cultures can identify 90% of women with vulvovaginal candidiasis. In this STD clinic, vulvovaginal symptoms also require assessment for bacterial vaginosis, trichomoniasis, and cervical infection.

Risk of anal carcinoma in situ in relation to human papillomavirus type 16 variants

Infection with human papillomavirus (HPV), especially HPV16, is central to the development of squamous anogenital cancers and their precursor lesions, termed "squamous intraepithelial neoplasias." Men who have sex with men, particularly those who are infected with HIV, are at a high risk for anal infection with HPV16 and for low-grade anal neoplasia; however, only a subset of these men develop anal invasive cancer or its immediate precursor lesion, anal carcinoma in situ (CIS). To examine the hypothesis that certain variants of HPV16 are most strongly associated with development of anal CIS, we followed 589 men who have sex with men whose initial anal cytological smears did not show anal CIS. Anoscopy, anal cytology, and PCR-based assays for detection and classification of HPV types were performed every 4-6 months, with HPV16 further classified by single-stranded conformation polymorphism analysis as being a prototype-like (PL) or non-prototype-like (NPL) variant. Anal CIS was histologically confirmed in 6 of 384 (1.6%) consistently HPV16-negative men, in 12 of 183 (6.6%) men with HPV16 PL variants, and in 4 of 22 (18.2%) men with HPV16 NPL variants. After adjustment for anal cytological diagnoses at study entry, HIV status and CD4 count, and detection of HPV types other than type 16, men with HPV16 NPL variants were 3.2 times (95% confidence interval, 1.0-10.3) more likely to develop anal CIS than were those with PL variants. Neither detection of HPV16 DNA at high levels nor detection of HPV16 DNA for a prolonged period, factors that we previously demonstrated to be associated with risk of high-grade anal squamous intraepithelial neoplasia, was significantly associated with HPV16 NPL variants. The biological mechanism relating to Ihis excess risk remains undetermined.

Use of hospital services by AIDS patients with psychiatric illness

The purpose of this study was to assess the effect of psychiatric illness on length of stay and patterns of admission among AIDS patients hospitalized for medical illnesses. Medical records were abstracted for AIDS patients admitted to hospitals in Washington State from 1990 through 1992. Psychiatric comorbidity was defined by the presence of an International Classification of Disease-9 code reflecting psychiatric illness. Medical morbidity was addressed using CD4 count and AIDS-defining illnesses as markers of disease severity. Of 2834 admissions, 15% included one or more psychiatric diagnoses. Psychiatric illness (F 39.1; df 1,2830; p < 0.001) and discharge disposition (F 81.2; df 2,2830; p < 0.001) contributed significantly to the model, explaining increased length of stay (F 67.2; df 3,2830; p < 0.001). Future research needs to address the possible etiology of psychiatric comorbidity's contribution to length of stay and the effect on quality and cost of care.

Rapid and inexpensive approaches to managing abnormal vaginal discharge or lower abdominal pain: an evaluation in women attending gynaecology and family planning clinics in Peru

OBJECTIVES

To assess low abdominal pain, yellow vaginal discharge, other symptoms and signs, and demographic and behavioural variables as predictors for cervical or vaginal infection.

METHODS

A cross sectional study of women attending gynaecology and family planning clinics in Lima, Peru was undertaken. 630 consecutive eligible female patients with chief or elicited complaints of yellow vaginal discharge, low abdominal pain, or both were interviewed and examined, together with a comparable reference group without these complaints. Vaginal specimens were tested for trichomoniasis and bacterial vaginosis. Endocervical specimens were tested for Neisseria gonorrhoeae and Chlamydia trachomatis using the ligase chain reaction.

RESULTS

Infections found included chlamydial infection in 69 women (10.9%), gonorrhoea in 10 (1.6%), and either infection in 77 (12.2%); trichomoniasis in 46 (7.3%), bacterial vaginosis in 189 (30%), and either infection in 209 (33.2%). Cervical infection with C trachomatis and/or N gonorrhoeae was independently associated with history of a new sex partner within the last 3 months, more than one sex partner within the last year, use of condoms never or in less than 50% of sex acts, history of sex partner with STD within the last year; with symptoms of persistent low abdominal pain and of yellow vaginal discharge; and with signs of profuse and yellow vaginal discharge, cervical ectopy, easily induced endocervical bleeding, or brown cervical secretion. Using these findings, an algorithm was created that had a positive predictive value (PPV) of 36% for cervical infection among women reporting chief or elicited complaint of this abnormal vaginal discharge and a PPV of 25% among those without a complaint. A chief complaint of yellow vaginal discharge had a PPV of 50% for trichomoniasis or bacterial vaginosis. Among women without a chief complaint of yellow vaginal discharge, clinical findings of yellow vaginal discharge had a PPV of 55%.

CONCLUSIONS

Where economic and technical constraints preclude testing, clinical findings and risk assessment are helpful in detecting vaginal and cervical infections. Several demographic, behavioural, clinical, and laboratory variables were predictive of infection in this population.

Low risk of perinatal transmission of human papillomavirus: results from a prospective cohort study

OBJECTIVE

Our purpose was to evaluate the risk of perinatal transmission of human papillomavirus.

STUDY DESIGN

Pregnant women were evaluated at <20 weeks' and between 34 and 36 weeks' gestation for genital human papillomavirus by clinical and colposcopic examination and by polymerase chain reaction. Their 151 infants were evaluated at birth, 6 weeks, and 6, 12, 18, 24, and 36 months of age for detection of human papillomavirus deoxyribonucleic acid by polymerase chain reaction on samples from the mouth, external genitalia, and anus. Polymerase chain reaction was performed with human papillomavirus L1 consensus primers and hybridization to human papillomavirus types 6, 11, 16, 18, 31, 33, 35, 39, and 45 and to a generic probe.

RESULTS

During pregnancy 112 (74%) of 151 women had historic, clinical, or deoxyribonucleic acid evidence of genital human papillomavirus infection. At 479 infant visits, human papillomavirus deoxyribonucleic acid was detected from only five (1.5%) of the 335 genital, four (1.2%) of the 324 anal, and none of the 372 oral or nasopharyngeal specimens. A positively reacting specimen was obtained from three (4%) of 80 infants born to women with human papillomavirus deoxyribonucleic acid detected at 34 weeks' gestation and from five (8%) of 63 born to women without human papillomavirus deoxyribonucleic acid (p = 0.47). All positive results in the infants were positive only with the generic probe and were preceded or followed by negatively reacting specimens. No clinical manifestations of human papillomavirus infection were detected in any infant.

CONCLUSIONS

The isolated detection of unclassified human papillomavirus types from infants at only single visits may represent low-level genital or nongenital human papillomavirus or may represent contamination. Although perinatal transmission of human papillomavirus is not ruled out by these data, the upper 95% confidence interval for detection of perinatal transmission from women with any evidence of genital human papillomavirus was only 2.8%.

Bacterial infections in adult patients hospitalized with AIDS: case-control study of prophylactic efficacy of trimethoprim-sulfamethoxazole versus aerosolized pentamidine

To determine the association between trimethoprim-sulfamethoxazole (TMP-SMX) prophylaxis for Pneumocystis carinii pneumonia and risk of bacterial infections in persons with AIDS, we abstracted hospital records from 6496 adult admissions to 42 hospitals in western Washington state. Of these admissions, 570 involved 637 bacterial infections diagnosed among patients who had been prescribed prophylactic TMP-SMX or aerosolized pentamidine. Cases [admissions with bacteraemia, bacterial pneumonia, acute or chronic sinusitis, or urinary tract infection (UTI)] were compared to controls (admissions not associated with any of the 5 bacterial infections). After adjusting for CD4 lymphocyte count and presence of P. carinii pneumonia, TMP-SMX prophylaxis, relative to aerosolized pentamidine prophylaxis, was associated with a reduced risk of bacteraemia (adjusted OR = 0.5; 95% CI, 0.2-1.0; P = 0.04), bacterial pneumonia (adjusted OR = 0.5; 95% CI, 0.3-0.8; P = 0.01), acute sinusitis (adjusted OR = 0.5; 95% CI, 0.2-1.3; P = 0.2), chronic sinusitis (adjusted OR = 0.3; 95% CI, 0.1-0.7; P = 0.01), and UTI (adjusted OR = 0.5; 95% CI, 0.2-1.2; P = 0.1), and all 5 bacterial infections combined (adjusted OR = 0.6; 95% CI, 0.5-0.8; P < 0.001).

Genomic variation of human papillomavirus type 16 and risk for high grade cervical intraepithelial neoplasia

BACKGROUND

Epidemiologic studies have demonstrated strong and consistent associations between the detection of human papillomavirus (HPV) type 16 DNA and the risk of cervical intraepithelial neoplasia (CIN) and cervical cancer. However, HPV16 is also the most common type of HPV in the normal population, and only a minority of women with HPV16 infection develop cervical cancer. Studies of genomic heterogeneity in HPV16 have demonstrated the presence of multiple variant forms in all human populations examined to date. It is conceivable that the natural variants of HPV16 in a given population may not have the same biologic behavior.

PURPOSE

This study was designed to determine the association between natural variants of HPV16 and the risk of biopsy-confirmed CIN 2 or 3, the most important precancerous lesions of the uterine cervix.

METHODS

Prospective studies were conducted among 1) women attending a university and 2) women presenting to a sexually transmitted disease clinic. Subjects were eligible for inclusion in this investigation if the initial cytologic findings did not reveal CIN 2-3 and HPV16 DNA was detected by means of a polymerase chain reaction (PCR)-based method in one or more cervical or vulvovaginal samples. Eligible subjects were followed every 4 months with cervical Pap smears and colposcopic examinations. Women were referred for biopsy if cytology or colposcopy suggested CIN 2-3. Two groups of HPV16 variants, prototype-like and nonprototype-like, were determined by means of single-strand conformation polymorphism (SSCP) analysis of PCR products from the noncoding region of the viral genome. Representative SSCP patterns from HPV16 variants were further characterized by direct DNA sequencing of the PCR products. Relative risks (RRs) and 95% confidence intervals (CIs) were calculated by Cox regression analysis.

RESULTS

Prototype-like variants accounted for 79% of the HPV16 detected in university students and 86% of the virus detected in patients presenting to the sexually transmitted disease clinic. CIN 2-3 was confirmed by biopsy in nine of 57 HPV16-positive women attending the university and in 10 of 66 HPV16-positive women presenting to the sexually transmitted disease clinic. Among university students, those with HPV16 nonprototype-like variants were 6.5 (95% CI = 1.6-27.2) times more likely to develop CIN 2-3 than those with prototype-like variants. A similar association was observed among women presenting to the sexually transmitted disease clinic (RR = 4.5; 95% CI = 0.9-23.8).

CONCLUSIONS

This study suggests that the risk of developing CIN 2-3 is not the same with all variants of HPV16 and that nonprototype-like variants confer a greater risk compared with prototype-like variants. The important genomic differences underlying this increased risk of CIN 2-3 remain to be determined.

The natural history of human papillomavirus type 16 capsid antibodies among a cohort of university women

To study the temporal relationship between serum antibody response and human papillomavirus type 16 (HPV-16) infection, a cohort of 325 university women were scheduled for examinations at 4-month intervals. At every examination, interviews were completed, cells were obtained for polymerase chain reaction-based testing and for Pap screening, and serum was obtained for testing with a HPV-16 capsid-capture ELISA. Seroreactivity was associated with detection of HPV-16 DNA and with increased numbers of sex partners. The median time to seroconversion was 8.3 months among women with incident HPV-16 infections. Within 16 months following HPV-16 DNA detection, 93.7% of women with prevalent and 67.1% of women with incident infections seroconverted. After seroconversion, antibody responses were maintained during follow-up among HPV-16 DNA-positive women. Women who seroconverted were 5.7 times (95% confidence interval = 2.4-13.4) more likely to have squamous intraepithelial lesions associated with the detection of HPV-16 DNA than were women who did not seroconvert.

Hydrogen peroxide-producing lactobacilli and acquisition of vaginal infections

This cohort study of 182 women attending a sexually transmitted disease clinic evaluated the hypothesis that women colonized by lactobacilli have decreased acquisition of vaginal infections. During a 2-year follow-up, 50 women acquired bacterial vaginosis (BV), 25 acquired symptomatic vulvovaginal candidiasis (VVC), and 7 acquired vaginal trichomoniasis. By multivariate analysis, utilizing Cox proportional hazards modeling with time-dependent covariates, acquisition of BV was independently associated with lack of vaginal H2O2-producing lactobacilli (hazard ratio [HR] = 4.0, P < .001) or presence of only non-H2O2-producing lactobacilli (HR = 2.2, P = .02). Acquisition of BV was associated with having a new sex partner (HR = 2.5, P = .004) and with douching for hygiene (HR = 2.1, P = .05). Absence of lactobacilli did not increase acquisition of VVC. Trichomoniasis was associated only with having a new sex partner (HR = 4.7, P = .05). These results support the hypothesis that H2O2-producing vaginal lactobacilli protect against acquisition of BV but do not protect against VVC or vaginal trichomoniasis.

The inflammatory Papanicolaou smear: what does it mean?

OBJECTIVE

To determine the correlation between inflammation detected on Papanicolaou smear and specific lower genital tract agents, and, based on these findings, to develop recommendations for follow-up tests and treatment of young women with inflammation on smears.

METHODS

A high-risk population of 779 randomly selected women attending a sexually transmitted disease (STD) clinic and a low-risk population of 1050 consecutive women presenting for annual examination at a university student health center underwent a standardized history and gynecologic examination. Univariate and multivariate analyses, focusing on the association between dense inflammation on Papanicolaou smear and specific lower genital tract pathogens or findings on cervical examination, were done for each population.

RESULTS

Dense inflammation was present on the Papanicolaou smear of 256 (33%) of the 779 women in the STD clinic and 200 (19%) of 1050 students. Dense inflammation on Papanicolaou smear was independently associated with mucopus, cervical ectopy, cervical infection with Neisseria gonorrhoeae, Chlamydia trachomatis, herpes simplex virus (HSV), and vaginal infection by Trichomonas vaginalis in the STD population; in the student population, it was associated with cervical ectopy, C trachomatis, and mucopus.

CONCLUSION

Although dense inflammation on Papanicolaou smear was a common finding in both the high- and low-risk populations, about half of the inflammation detected in the high-risk setting was associated with a specific microbial organism (C trachomatis, N gonorrhoeae, HSV, or T vaginalis), whereas less than 10% of the dense inflammation detected in the low-risk setting was linked with a specific pathogen (C trachomatis). In both settings, a substantial population of sexually active women had dense inflammation associated with cervical ectopy but none of the specific organisms evaluated in this study.

Analysis of human papillomavirus type 16 variants indicates establishment of persistent infection

Sequence differences in the noncoding region of the human papillomavirus type 16 (HPV-16) genome were displayed using single-stranded conformational polymorphism (SSCP) analysis of polymerase chain reaction (PCR)-amplified material. Two variants accounted for 50%-70% of all HPV-16 variants from 3 cohorts in Seattle. Seventy subjects who were repeatedly HPV-16 DNA-positive over 2-8 4-monthly visits showed an identical SSCP pattern at every visit. Only 10%-20% of the specimens showed evidence of infection by multiple variants when assessed by SSCP. However, cloning and sequencing of the PCR products revealed a substantially higher proportion of specimens with > 1 variant. Sequencing many clones from each specimen confirmed that 1 major variant seemed to predominate over time, whereas minor variants appeared more transient. These results suggest that HPV-16 establishes a persistent infection in which a single variant predominates: coinfection with addition HPV-16 variants results in a minor population of HPV-16 genomes.

Determinants of cervical ectopia and of cervicitis: age, oral contraception, specific cervical infection, smoking, and douching

OBJECTIVE

Our purpose was to assess determinants of cervical ectopia and cervicitis, specifically after adjustment for cervical infection.

STUDY DESIGN

A cross-sectional study was conducted with colposcopic, cytologic, and microbiologic examination of 764 randomly selected women attending a sexually transmitted disease clinic and 819 consecutive college students undergoing routine annual examination.

RESULTS

After we controlled for potential confounders, cervical ectopia was positively associated with oral contraception and Chlamydia trachomatis infection and negatively associated with aging in both populations, with recent vaginal douching in patients with sexually transmitted diseases, and with current smoking in college students. Oral contraception wa also associated with the radius of ectopia, and among users of oral contraception ectopia was associated with duration of oral contraception. Cervicitis (evaluated by Gram stain, Papanicoloau smear, and colposcopy) was associated with cervical infection by C. trachomatis and cytomegalovirus (both populations) and with gonorrhea and cervical herpes simplex virus infection (patients with sexually transmitted diseases). Cervicitis was independently associated with ectopia but not with oral contraception after we adjusted for these four cervical infections. However, oral contraception was associated with edema and erythema of the zone of ectopia among women without cervical infection.

CONCLUSIONS

Oral contraception, aging, cervical infection, smoking, and douching have effects on cervical ectopia that may influence the acquisition, transmission, or effects of sexually transmitted agents. Ectopia is associated with young age, oral contraception, and cervical infection; cervicitis is associated with ectopia and cervical infection by C. trachomatis, Neisseria gonorrhoeae, herpes simplex virus, and cytomegalovirus. In women without cervical infection, edema and erythema of the zone of ectopia are associated with oral contraception.

Use of human papillomavirus type 6 capsids to detect antibodies in people with genital warts

Human papillomavirus (HPV) type 6 capsids were produced by recombinant vaccinia viruses and used in a capture ELISA to screen 901 human sera from three studies of genital HPVs. The highest seroprevalence was observed among subjects with recurrent genital warts. In a population-based case-control study of genital warts, 26 (58%) of 45 women with recurrent genital warts were seropositive compared with 19 (19%) of 101 control women with no history of genital warts (odds ratio, 6.5; 95% confidence interval, 3.0, 14.1). Among a cohort of pregnant women, 7 (88%) of 8 with recurrent warts were seropositive compared with 24 (30%) of 79 pregnant women with no such history. A significant association between seropositivity to HPV-6 capsids and the detection of HPV-6/11 DNA from genital specimens by polymerase chain reaction was also observed. Men with genital warts were less likely to be seropositive than were women with genital warts, and a positive association between the number of sex partners and seropositivity was observed among only the female university students.

Genital human papillomavirus infection among male and female sex partners: prevalence and type-specific concordance

Penile, cervical, and vulvovaginal samples from 50 couples attending a sexually transmitted disease clinic and perianal samples from women only were tested for human papillomavirus (HPV) DNA by dot filter hybridization (DFH) and polymerase chain reaction (PCR). Only 18% of women and 4% of men were HPV-positive by DFH, but 72% of women and 63% of men were HPV-positive by PCR. HPV type-specific concordance between partners was more common than predicted by chance (P = .01) and was associated with detection of HPV DNA by DFH in either partner. Thus, genital HPV infection in this population is common in both men and women, and the HPV type-specific concordance in sex partners is consistent with sexual transmission. Higher levels of genital or perianal HPV, as reflected by detection of HPV DNA with the less-sensitive DFH method, may promote sexual transmission.

Psychiatric comorbidity and length of stay in hospitalized AIDS patients

OBJECTIVE

The purpose of this study was to assess the effect of psychiatric comorbidity on specific measures of hospital utilization, including length of stay, among hospitalized AIDS patients.

METHOD

Data collection involved medical record abstraction for AIDS patients admitted to any one of 19 hospitals in Washington State during 1990. Psychiatric comorbidity was defined by the presence of an ICD-9 code reflecting psychiatric illness. Medical/surgical admissions of AIDS patients with psychiatric diagnoses were compared to those of AIDS patients without psychiatric diagnoses on measures of mean length of stay for the first admission in 1990, total number of hospitalizations in 1990, and total number of hospital days in 1990. Medical morbidity was addressed using CD4+ cell count and current and previous AIDS-defining illnesses as markers of disease severity.

RESULTS

Of 357 patients hospitalized with AIDS, 49 (14%) had at least one psychiatric diagnosis. Patients with psychiatric illness were hospitalized an average of 6.6 days longer than AIDS patients without such illnesses. Differences in medical morbidity did not account for the longer length of stay.

CONCLUSIONS

Psychiatric comorbidity increased the average length of stay among hospitalized AIDS patients. Future research needs to address the possible effects of this phenomenon on quality and cost of care received by AIDS patients.

Use of HPV 1 capsids produced by recombinant vaccinia viruses in an ELISA to detect serum antibodies in people with foot warts

A sandwich ELISA was developed to detect HPV antibodies using HPV 1 capsids that were purified from recombinant vaccinia virus-infected cells and a monoclonal antibody to the HPV 1 L1 protein. Sera from 91 college-aged women who had been previously screened for HPV 1 antibodies by immune precipitation of capsid proteins were tested by ELISA. A cutoff point was established independently of other criteria based on the assumption that the ELISA values came from a mixture of two Normal distributions representing seropositive and seronegative individuals. It was found that the data fit this model best when the natural log of the ELISA (+0.5 to make all of the values positive) was used. Positive sera were shown to react with a conformational epitope(s) on the L1 protein. In the population reporting foot warts, 16 of 18 (89%) had ELISA values above the cutoff. This compared to 38 of 73 (53%) positives in the population reporting no history of foot warts. The odds ratio for the association of the ELISA reactivity with foot warts was 7.23 (95% CI 1.53, 69.4; P < 0.01). There was no significant association between the ELISA reactivity and wart infections reported at other sites. The average of the log ELISA values for individuals never reporting foot warts was -0.223 (SD 0.468), whereas the average value for individuals reporting foot warts within 10 years was 0.191 (SD 0.450) (P = 0.001). There was a negative correlation between the magnitude of ELISA reactivity and the time elapsed since the last appearance of foot warts. This apparent loss of seroreactivity over time may indicate that HPV 1 is usually eliminated from the host after infection or that inadequate levels of HPV 1 capsid antigen are produced during latent foot warts to maintain antibody levels.

Circumcision and sexually transmitted diseases

OBJECTIVES

New evidence linking lack of circumcision with sexually transmitted human immunodeficiency virus revives concerns about circumcision and other sexually transmitted diseases. This study was undertaken to assess the relationship between circumcision and syphilis, gonorrhea, chlamydial infection, genital herpes, nongonococcal urethritis, and exophytic genital warts.

METHODS

A cross-sectional study of 2776 heterosexual men attending a sexually transmitted disease clinic in 1988 was used to investigate the relationship between circumcision and sexually transmitted diseases. Subjects with specific sexually transmitted diseases and those without such diseases were compared after adjustment for age, race, zip code of residence, other sexually transmitted diseases, and number of sexual partners.

RESULTS

A positive relationship was observed between uncircumcised status and both syphilis and gonorrhea. A negative relationship was found between warts and lack of circumcision. No apparent relationship was noted between uncircumcised status and genital herpes, chlamydial infection, or nongonococcal urethritis.

CONCLUSIONS

Uncircumcised men were more likely than circumcised men to have syphilis and gonorrhea and were less likely to have visible warts.

HPV-1 capsids expressed in vitro detect human serum antibodies associated with foot warts

Seventy-eight human serum samples were screened for their ability to immunoprecipitate the major (L1) and minor (L2) capsid proteins of HPV1. The L1 and L2 proteins expressed from a recombinant vaccinia virus were able to self assemble into capsids in the nuclei of infected cells. Twenty-eight of the sera precipitated the L1 protein. The L1 protein was only precipitated when the protein was native, denatured protein was not precipitated by the human sera. None of the sera precipitated the L2 protein. The assay demonstrated a significant association between the ability of sera to precipitate the L1 protein and a clinical history of foot warts (P = 0.001). The same serum samples were tested by immunoblots using L1 and L2-trpE bacterial fusion proteins. It was found that almost half of the sera reacted with the L2 fusion protein and few reacted with the L1 protein. Immunoblot results did not correlate well with a clinical history of foot warts (P = 0.7), suggesting that immune precipitation of capsid proteins may be superior to immunoblotting for serodiagnosis of HPV infections.

Clinical presentation of genital warts among circumcised and uncircumcised heterosexual men attending an urban STD clinic

INTRODUCTION

A recent study comparing heterosexual men with and without confirmed sexually transmitted diseases (STDs) in an urban STD clinic showed that uncircumcised men were less likely than circumcised men to have genital warts detectable by clinical examination (adjusted odds ratio 0.7, 95% confidence interval 0.4, 0.9). Based on these initial findings we hypothesised that the appearance and anatomic distribution of genital warts, and possibly treatment response, may be different for circumcised and uncircumcised men.

METHODS

The anatomic location, appearance, number of warts, and response to treatment was investigated through review of medical records of 459 heterosexual men with genital warts detected in 1988.

RESULTS

Age- and race-adjusted estimates indicated that among men with genital warts, warts were detected much more commonly on the distal penis--that is, the corona, frenulum, glans or urethral meatus-, among uncircumcised men (26%) than among circumcised men (3%) (OR 10.0, 95% CI 3.9, 25.7). Where the appearance was specified, warts were more often described as condylomatous in uncircumcised men and slightly more often as papular in circumcised men. No significant difference between circumcised and uncircumcised men was seen in the number of return visits to the clinic for persistent warts after treatment with liquid nitrogen: 2.2 visits for 19 uncircumcised men and 2.3 visits for 149 circumcised men.

CONCLUSION

Circumcised men were more likely than uncircumcised men to have genital warts, but when present, warts were more often located on the distal portion of the penis among uncircumcised men. This paradox is not understood, but could reflect either nonspecific resistance to proximal penile warts conferred by the foreskin, or heightened susceptibility to various HPV types in uncircumcised men, some of which may confer subsequent immunity to genital warts.

Underestimation of HSV-2 seroprevalence in a high-risk population by microneutralization assay

BACKGROUND

Complement independent neutralizing antibody assays (CINA) have been used in seroepidemiologic studies and in diagnostic laboratories to distinguish between antibodies to herpes simplex virus types 1 (HSV-1) and 2 (HSV-2). The accuracy of CINA has not been rigorously tested against protein-specific typing assays, such as Western blot.

GOAL OF THIS STUDY

To determine the ability of CINA to identify HSV-2 antibodies alone or in the presence of HSV-1 antibodies.

STUDY DESIGN

Sera from randomly selected women at the Seattle King County Sexually Transmitted Disease Clinic were tested by CINA and Western blot.

RESULTS

Of 521 women tested, 81% had HSV antibodies by Western blot and 76% had neutralizing antibodies. Of 220 sera with HSV-2 antibodies by Western blot, 106 (48%) were serotyped correctly by CINA. Of the women studied, 140 (27%) had type-indeterminate neutralizing antibodies; 55 of these sera (39%) had antibody only to HSV-1 by Western blot.

CONCLUSION

The seroprevalence of HSV-2 in an STD clinic population was seriously underestimated by CINA.

A cohort study of the risk of cervical intraepithelial neoplasia grade 2 or 3 in relation to papillomavirus infection

BACKGROUND

Human papillomavirus (HPV) has been associated with cervical intraepithelial neoplasia, but the temporal relation between the infection and the neoplasia remains unclear, as does the relative importance of the specific type of HPV, other sexually transmitted diseases, and other risk factors.

METHODS

We studied prospectively a cohort of 241 women who presented for evaluation of sexually transmitted disease and had negative cervical cytologic tests. The women were followed every four months with cytologic and colposcopic examinations of the uterine cervix and tests for HPV DNA and other sexually transmitted diseases.

RESULTS

Cervical intraepithelial neoplasia grade 2 or 3 was confirmed by biopsy in 28 women. On the basis of survival analysis, the cumulative incidence of cervical intraepithelial neoplasia at two years was 28 percent among women with a positive test for HPV and 3 percent among those without detectable HPV DNA: The risk was highest among those with HPV type 16 or 18 infection (adjusted relative risk as compared with that in women without HPV infection, 11; 95 percent confidence interval, 4.6 to 26; attributable risk, 52 percent). All 24 cases of cervical intraepithelial neoplasia grade 2 or 3 among HPV-positive women were detected within 24 months after the first positive test for HPV. After adjustment for the presence of HPV infection, the development of cervical intraepithelial neoplasia was also associated with younger age at first intercourse, the presence of serum antibodies to Chlamydia trachomatis, the presence of serum antibodies to cytomegalovirus, and cervical infection with Neisseria gonorrhoeae.

CONCLUSIONS

Cervical intraepithelial neoplasia is a common and apparently early manifestation of cervical infection by HPV, particularly types 16 and 18.

Prevalence and cytologic manifestations of human papilloma virus (HPV) types 6, 11, 16, 18, 31, 33, 35, 42, 43, 44, 45, 51, 52, and 56 among 500 consecutive women

The prevalence and associated cytologic manifestations of cervical infection with human papillomavirus (HPV) types 6, 11, 16, 18, 31, 33, 35, 42, 43, 44, 45, 51, 52, and 56 were studied among 500 consecutive women attending the Harborview Medical Center Sexually Transmitted Diseases (STD) Clinic in Seattle, WA. Using radiolabeled-probes without prior amplification of DNA, HPV DNA was detected in cervical specimens from 120 (24%) of the women and was found to be more prevalent than Chlamydia trachomatis (13%), Neisseria gonorrhoeae (12%), or mucopurulent cervicitis (20%). High-risk HPV types 16 or 18 were present alone in 5% of the women; intermediate-risk types 31, 33, 35, 45, 51, 52, or 56 in 3%; and low-risk types 6, 11, 42, 43, and 44 in 5%. In an additional 8% HPV DNA was detected but could be characterized only as being type 6, 11, 16, 18, 31, 33, or 35. Each grouping of HPV types was equally associated with squamous intraepithelial lesions (SILs) of the cervix. In the absence of SIL and koilocytosis, the cytologic changes associated with HPV infection included frequent binucleation and variation in nuclear size and chromatin distribution. Parakeratosis and hyperkeratosis without nuclear atypia were not associated with HPV DNA. The natural history and clinical significance of these HPV-associated lesions remain to be defined.

Underdiagnosis of genital herpes by current clinical and viral-isolation procedures

BACKGROUND

The current clinical strategy for diagnosing genital herpes simplex virus (HSV) infection in women relies on clinical findings plus the selective use of viral culture. The effectiveness of this approach for identifying women with genital herpes is unknown.

METHODS

We performed physical examinations, colposcopy, Pap smears, viral cultures, and HSV type-specific serologic assays of 779 randomly selected women attending a sexually transmitted disease clinic.

RESULTS

Evidence of HSV type 2 infection was detected in 363 women (47 percent), and 9 others (1 percent) had positive cultures indicative of urogenital or anal infection with HSV type 1. Of these 372 women, only 82 (22 percent) had symptoms. Fourteen women (4 percent) had viral shedding without symptoms, 60 (16 percent) had formerly had symptomatic episodes, and 216 (58 percent) had antibodies to HSV-2 with neither viral shedding nor a history of clinical episodes. Characteristic ulcerations of the external genitalia were present in only two thirds of the 66 women with positive HSV cultures; the others had atypical genital lesions or asymptomatic viral shedding. Isolation of HSV from a genitourinary tract specimen was the most sensitive (77 percent) test for confirming a first episode of infection. The detection of HSV-2-specific antibodies was the most sensitive (97 percent) way to confirm symptomatic reactivations of HSV-2 infection. HSV-2 serologic testing also identified the 290 women with asymptomatic HSV-2 infections (37 percent), including 14 (5 percent) who were shedding virus asymptomatically on the day of the examination.

CONCLUSIONS

The current strategy for diagnosing genital HSV infection in women misses many cases. Newly developed type-specific serologic methods can identify women with recurrent genital HSV-2 infection, as well as those with unrecognized or subclinical infection.

Comparison of Southern transfer hybridization and dot filter hybridization for detection of cervical human papillomavirus infection with types 6, 11, 16, 18, 31, 33, and 35

A commercial dot filter hybridization kit (Virapap Kit) was compared with Southern transfer hybridization for the detection of seven types of human papillomavirus (HPV) in cervical specimens from 450 consecutive females attending a sexually transmitted diseases clinic. In comparison with Southern transfer hybridization, performed with the same probes used in the dot filter kit, the sensitivity, specificity, and positive and negative predictive values of dot filter hybridization were 90%, 94%, 74%, and 98%, respectively. Among patients with cervical cytologic dysplasia, HPV DNA was detected in 44% by dot filter hybridization and in 35% by Southern transfer hybridization. Although 26% of specimens positive by dot filter hybridization were not confirmed by Southern transfer hybridization, cervical dysplasia was detected in 5 (25%) of 20 with HPV DNA detected by dot filter hybridization alone, compared with 25 (8%) of those with no definitive evidence of HPV by either method (P = 0.009) and with 16 (30%) of 53 with HPV DNA detected by both methods (P = 0.7). The kappa statistic for interobserver and intraobserver reproducibility for interpretation of blots was similar for the two methods. The dot filter hybridization method evaluated appears to be a satisfactory alternative to Southern transfer hybridization for detection of HPV DNA.