Contact tracing for gonorrhoea in homosexual and heterosexual men

We aimed to determine whether the success of partner notification for gonorrhoea in men was affected by sexual orientation.

Analysis of standard clinic and health adviser records of all male patients found to be infected with gonorrhoea between October 1992 and September 1993 were carried out. Of the 278 cases of gonorrhoea in men, 9% (25) were acquired through homosexual intercourse and 91% (253) by heterosexual contact. Fifteen per cent (24) of Caucasians were homosexual but only 0.9% (1) of Afro-Caribbeans were. The mean number of contacts was 1.36 for homosexuals and 1.38 for heterosexuals. Contact information was given by 55% of heterosexuals and 48% of homosexuals. The proportion of acknowledged contacts attending was 38% for homosexuals and 56% for heterosexuals (P=0.054). Fifty-two per cent of homosexuals and 59% of heterosexuals had at least one contact attend. Data analysis on Caucasians only showed Caucasian gay men had a higher mean number of contacts (1.38) than Caucasian heterosexuals (1.28). Caucasian homosexuals had a lower proportion of contacts attending (40% vs 77%) (P=0.05), 54% of homosexual men and 60% of heterosexual men had at least one contact attending (P=0.74).

There is a trend for partner notification to be less successful in homosexual men when all ethnic groups are considered together. In Caucasian men with gonorrhoea, homosexuals have a greater number of partners than heterosexuals and have a lower proportion of total contacts attending but there is no difference in the proportion having at least one contact attending. Data on sexual orientation and ethnicity should be reported in studies assessing efficacy of contact tracing.

Regression of invasive conjunctival squamous carcinoma in an HIV-positive patient on antiretroviral therapy

Case history of an African woman presenting with advanced HIV and a painful conjunctival lesion is presented. A conjunctival biopsy revealed invasive squamous cell carcinoma, with orbital invasion on computed tomography scan. She was commenced on antiretroviral therapy. She refused surgery to remove the eye and orbital contents (exenteration), and was referred to palliative care. Gradually, her immune status and ocular symptoms improved. At ophthalmic review, the tumour had apparently completely regressed. This unprecedented phenomenon may be due to antiretroviral therapy. Discussion covers conjunctival carcinoma and behaviour of HIV-related tumours with antiretroviral therapy. Antiretroviral drugs may offer a better alternative to disfiguring surgery in the future.

General practitioners and the National Strategy on Sexual Health and HIV

To determine general practitioners' knowledge of, and opinions on, the National Strategy for Sexual Health and HIV and whether they intend to provide Level 1 and 2 HIV/STI services, a self-administered questionnaire was sent to one partner from 155 general practices in Sheffield and North Derbyshire in November 2001. Response rate was 57% (88). Forty-eight (55%) GPs aware of strategy but 53 (60%) had no knowledge of what it involved.

LEVEL 1. Sixty-two (71%) felt confident in providing advice on STI prevention and 46 (52%) on HIV. Nine (10%) GPs provide HIV testing and 29 (33%) anticipate doing so but 24 (83%) require staff training and 20 (70%) increased funding. All Level 1 STI services are provided by 60 (68%) practices and 72 (82%) anticipate providing.

LEVEL 2. Thirty-nine (45%) anticipate testing and treating STIs but only nine (10%) will undertake partner notification. Resources required are training, nine (60%) and funding, nine (60%). The main reasons for not offering in the future were too busy 58 (72%) and lack of demand 25 (31%).

Many GPs are unaware of the strategy but most anticipate providing Level 1 STI services. Less than half anticipate offering HIV testing. Although 45% of GPs may provide Level 2 care, it is unlikely to include partner notification. Many GPs are too busy and require extra training and funding. These needs must be addressed if the Strategy is to be implemented.

Screening, diagnosis and management of early syphilis in genitourinary medicine clinics in the UK

New diagnoses of syphilis in the UK increased eight-fold between 1997 and 2002. This study, conducted in 2002, demonstrated that 31% of clinics were not confident of their expertise to obtain an adequate specimen for dark ground microscopy (DGM), and 35% were not confident of their expertise to detect treponemes on DGM. In all, 64% of clinics had observed adherence problems in HIV-positive patients treated with parenteral regimens, as against 42% with oral regimens. Also, 51% of clinics waited more than a week for the results of initial serological tests for syphilis, and 88% of clinics waited more than a week for confirmatory test results. Other concerns include the failure to perform syphilis serology consistently whenever HIV-positive patients were at risk, and the widespread use of doxycycline as a therapy for syphilis in HIV-positive patients despite concerns that this is not known to be fully treponemicidal in cerebrospinal fluid.

Testing the children of HIV-positive mothers

We aimed to establish current practice regarding the testing of children of HIV-positive women in two centres in the South Yorkshire HIV Network, UK. Notes were reviewed from 59 women who attended clinic over a three-month period from 01 September 2009 to 30 November 2009. In our sample, only 29 of 52 (56%) children living in the UK who required testing had been HIV tested. Testing rates were high in preschool children (15/15) and fell with age to 2/11 (18%) in the 16-20 years age group. Uptake of testing for children of HIV-positive parents could potentially be improved if testing was incorporated into routine clinic practice as part of the package of care offered to a newly diagnosed individual.

Time taken to undetectable viral load, following the initiation of HAART

The notes of all HIV patients in Sheffield, registered at the Department of Genitourinary Medicine at the Royal Hallamshire Hospital, who had initiated HAART in 2005 and 2006, were audited. The aim was to determine what percentage of these patients acquired an undetectable viral load within 24 weeks and whether this was greater than 75% in accordance with the BHIVA guidelines. Twenty-nine (78.4%) of the 37 patients who were initiating treatment for the first time had an undetectable viral load after 24 weeks.

Management of under-16-year olds in UK genitourinary medicine clinics: British Co-operative Clinical Group

Summary:

In 2004, the management of under-16-year olds in UK genitourinary (GU) medicine clinics was surveyed. Questionnaires were sent to 185 lead GU medicine consultants. A total of 111 questionnaires were returned (60%). Ninety-eight percent of respondents managed young people aged 13-16. Fifty percent managed under 13-year-olds. Twenty-nine percent of respondents ran dedicated young people's clinics. Ninety-eight percent were aware of the National Guidelines, and 74%had adopted them. Fifty-seven percent had a named departmental child protection lead. Thirty-seven percent of consultants had received training specific to child protection issues in GU medicine. Improvements had been made since a similar survey published in 2001, but the need for further training was still apparent.

Confidentiality is essential if young people are to access sexual health services

A survey was undertaken to determine the importance of confidentiality of sexual health clinics to young people, and their preferences for service provision. A questionnaire was given to school attenders in year 9 (age 13-14 years) at four comprehensive schools. Class leaders assisted students with literacy or language difficulties. Two hundred and ninety five questionnaires were distributed and all were returned (male 143 (48.5%), female 152 (51.5%). In all 199 (67.5%) had never used sexual health services. The importance of confidentiality (asked in two differently worded questions) was rated as 8.84 and 8.59 (mean) on a scale of 1 (not important) to 10 (very important), 166 (56.3%) rated confidentiality as most important feature of service and 254 (86.1%) were more likely to use a service if it was confidential; 161 (54.6%) would not use service if it were not confidential. Two hundred and sixty-six (90.2%) would give honest answers in a confidential service; 186 (63.1%) would not attend if they thought that child protection services would be informed; 136 (46.1%) would not want general practitioner informed of attendance; 209 (70.8%) would like regular sexual health check ups; 150 (50.8%) would prefer a young people clinic, but only 105 (35.6%) prefer a 'one-stop shop'. This study shows that confidentiality is extremely important to young people considering using a sexual health service. It is the first UK study to show that if confidentiality is lost, young people may not attend, or may not be honest when they utilize a sexual health service. This is particularly relevant at the moment in light of the threat to confidentiality for young people attending sexual health services.

Are women with chlamydia infection who self-refer to genitourinary medicine clinics different?

The objective of this study was to explore whether patients with Chlamydia trachomatis infection who self-refer to genitourinary medicine clinics have different demographic characteristics to those who initially attend other agencies. This study took place in three genitourinary medicine clinics from Birmingham, Nottingham and Sheffield. Demographic and post-code data were collected from female patients diagnosed with genital chlamydia infection in 2000. Townsend scores, as an index of socioeconomic status, were derived from post-codes from a subset of the cohort (from Birmingham). Comparison was made between those who were diagnosed by genitourinary medicine clinics and those diagnosed in the community and referred to genitourinary medicine clinics for further management. Data were collected from 1047 genitourinary medicine and 816 non-genitourinary medicine women, of whom 686 (84.1%) attended genitourinary medicine clinics following referral. After excluding those with incomplete data, 1614 (987 genitourinary medicine and 627 non-genitourinary medicine) patients were included in the study. Using logistic regression analysis, we were unable to demonstrate any significant differences in age or Townsend scores between genitourinary medicine and non-genitourinary medicine patients. However, significantly more Black Caribbean (odds ratio [OR] = 2.72, 95% confidence interval [CI]: 2.22, 3.20) and single women (OR = 1.97, 95% CI: 1.64, 2.29) self-referred to genitourinary medicine clinics compared with other health-care settings. This trend was consistent between Birmingham and Nottingham. In Sheffield, there was no difference in marital status. Ethnicity was not a factor as there were no Black Caribbean patients in the Sheffield cohort. Women who were diagnosed with genital chlamydia infection in genitourinary medicine clinics have some different demographic characteristics to those who were diagnosed in the community.

Trichomonas vaginalis in a Sheffield genitourinary medicine department

The case-notes of all patients who were diagnosed with a first episode of Trichomonas vaginalis (TV) between 1 October 2002 and 30 September 2003 were reviewed. A total of 78 patients were suitable for inclusion in the study. Analysis of their notes revealed that, although the majority of patients presented with symptoms, 15% (n=12) of cases were asymptomatic. A raised vaginal pH was found in 94% (n=47) of the patients in whom it was measured. In all, 97% (n=76) of patients received treatment in accordance with UK national guidelines and, in those tested, initial treatment was found to be 95% (n=57) successful. Treatment of at least one contact could only be confirmed in 27% (n=21) of cases. The implications for future management of TV are discussed.

Introduction of a proforma in the management of under age attendees at a genitourinary clinic

The aim of this review was evaluation of a recently developed proforma for improving assessment and management of patients under the age of 16 in the genitourinary (GU) medicine clinic. A case-note review of all under-16s attending between June 2000 and March 2001 was undertaken (109 patients). Comparison with review from 1998 prior to proforma introduction was carried out. In all, 99 proformas were completed. Fewer young patients were seen solely by junior doctors since proforma introduction (27-45%) (P=0.012), more were referred to health advisors (79% versus 66%) (P = 0.056),but follow-up remains suboptimal (72% versus 78%). Possibility of abuse was assessed in 102 patients (17 cases of non-consensual sex versus six in 1998). In all, 54% were using no contraception and only 21% were consistently using barrier methods; 41% had sexually transmitted infections diagnosed. The proforma is useful for collecting data and directing management when completed fully, and has revealed greater numbers of children involved in risky behaviour and abuse.

The impact of pump-priming funding on genitourinary medicine and modernization of services

Genitourinary (GU) medicine services are under increasing pressure due to increased workload. The Department of Health responded to this crisis by allocating pump-priming funding of ?5 million direct to GU medicine clinics in 2002-03. A survey was performed of all clinics in England to determine if funding was received, its utilization and the extent of modernization of services. Response rate was 71% (147 of 206 clinics), with 95% (140) receiving their allocation. Additional clinics were instated by 54% (74/137) and of these 51% (35/69) had thus reduced their waiting times. Extensive modernization of services was under way, with 89% (130/146) reducing proportion of follow-up attendances, 87% (127/146) extending the nurse role and the majority of clinics looking at developing or extending their clinical networks. This study has shown the direct benefit of increased funding allocated to GU medicine and the extent of modernization under way.

What are the needs of asylum seekers attending an STI clinic and are they significantly different from those of British patients?

To elicit the needs of asylum seekers attending the Royal Hallamshire genitourinary medicine clinic for the first time in 2002 and whether these differed from British patients, a search of patient records for 2002 identified 43 asylum seekers (21 female, 22 male) who were paired with 43 British patients matched by age and sex (mean age 27.9, range 15-56). The needs of the patients were ascertained by retrieving answers to predetermined questions from the paper records. Asylum seekers had 166 appointments while British patients had 113 (P = 0.091) and 21 DNAs (did not attend appointment), compared with seven British DNAs (P = 0.071). Twenty-eight asylum seekers and no British patients needed an interpreter (P < 0.01). Five of the 18 eligible asylum seeker females had an up-to-date smear compared with 13 British females (P = 0.008). Nineteen asylum seekers reported sexual violence compared with none of the British patients (P < 0.011); 15 of these asylum seekers were receiving/had requested counselling. There was no significant difference in the numbers of pregnant women, commercial sex workers and intravenous drug users, and patients reporting a previous history of sexually transmitted infection. There are some differences between the needs of asylum seekers and British patients; the most noticeable are the use of interpreters, the reporting of sexual violence, the need for counselling and the number of women without up-to-date smears. A larger study may highlight more differences.

Medical workforce speciality review for genitourinary medicine 2002/2003: England, Wales, Northern Ireland and Scotland

This document is an updated version of that produced in October 2001 and addresses medical workforce needs for the speciality of genitourinary medicine (GUM) for the next 10 years. Data on current consultant numbers, working patterns and retirement are based on information from the Royal College of Physicians (RCP) Workforce Unit annual census undertaken on 30 September 2001. Information on specialist registrars (SpRs) is from the Joint Committee on Higher Medical Training and the GUM Specialist Registrars Group. Senior house officer data are from the RCP's General Professional Training department. Data on non-consultant career grade doctors is from the Association of Genitourinary Medicine Survey and the GUM Non-Consultants Career Grade Group. Data on incidence of sexually transmitted infections (STIs) are from KC60 returns on STIs collected from GUM clinics by the Communicable Diseases Surveillance Centre. There is considerable movement of doctors in GUM between countries in the UK both during progression from SpR to consultant and at the consultant level. Data are therefore presented as amalgamated UK data and also by country (Table 1). It is essential that workforce planning takes this lateral movement into consideration when undertaking calculations for future workforce requirements. The speciality continues to have inadequate consultant numbers and funding is also required to provide adequate number of non-consultant career grade sessions.

Psychiatric side effects of ofloxacin used in the treatment of pelvic inflammatory disease

The Clinical Effectiveness Group of the Medical Society for the Study of Venereal Diseases and the Association of Genitourinary Medicine published guidelines on the management of pelvic inflammatory disease in 1999. Subsequently, the use of ofloxacin has increased in our department. However, ofloxacin can cause serious psychiatric side effects, particularly in those with a past psychiatric history. This is of relevance to genitourinary medicine (GUM) physicians as there is a high prevalence of psychiatric illness amongst patients attending GUM clinics. We present two cases of ofloxacin causing severe psychiatric symptomatology, in one case causing an acute psychotic reaction. It is recommended a psychiatric history is taken prior to prescribing ofloxacin and that consideration is given to alternative therapy for those with previous psychiatric illness.

Use of a leaflet to replace verbal pretest discussion for HIV: effects and acceptability

OBJECTIVE

To determine the effect of using a leaflet to replace formal verbal pretest discussion and assess its acceptability to patients.

SETTING AND METHODS

A leaflet was developed which gave information on all routine tests undertaken at a genitourinary medicine clinic. Information normally given during verbal pretest discussion for HIV was included. The leaflet was given to all new attenders at routine STI clinics. The proportion of patients accepting tests in the 6 weeks before and 4 weeks after the introduction of the leaflet was elicited by case note review. The acceptability of the leaflet was determined by means of a questionnaire given to patients.

RESULTS

The use of the leaflet increased the number of patients offered an HIV test from 654 of 1004 (65%) patients to 371 of 397 (94%), p<0.001. It also increased the number tested from 325 (32%) of 1004 patients to 210 of 397 (53%, p<0.001). Men were more likely to be offered an HIV test than women at baseline (342 of 500 men, 68%, v 312 of 504 women, 62%, p=0.036) but after the intervention there was no longer a difference (men 217, 93%, female 154, 94%). The number of men accepting a test increased more than the number of women (139 of 233 men, 60%, 71 of 164 women, 43%, p <0.005). The 79 questionnaires suitable for analysis showed patient views on the leaflet were mainly favourable: easy to understand 73 (92%), clear 70 (89%), absence of difficult words 73 (91%), and right balance of information 68 (86%).

CONCLUSIONS

The routine use of a leaflet to replace verbal pretest discussion (PTD) increased the proportion of patients undergoing testing. Part of the increased testing was because physicians were more likely to offer the test, possibly because the time constraints of pretest discussion were removed. This appears to be an acceptable and effective way of increasing HIV testing in GUM clinics but further work is needed to elicit information on non-responders to the questionnaire.

Sexual health needs of the under-16s attending an STI clinic: what are they and are they being addressed?

A retrospective analysis was performed on case notes of patients aged less than 16 years who attended a Department of Genito-Urinary Medicine as a new case in 1998. Seventy-four case notes were reviewed. There was a high rate of sexually transmitted infection (STI) (gonorrhoea six [8%], chlamydia 23 [31%], genital warts nine [12%], trichomonas seven [10%]) and low condom (30, 41%) and other contraceptive use (21 females [35%], six males [60%]). Many female attendees were victims of current or previous sexual abuse (eight, 8%) and/or exploitation, and for a further eight (8%) abuse/exploitation was considered possible; little reference was made to this in the notes. Thirty-three (45%) attendees were seen by junior members of staff, and only 49 (60%) were seen by a health adviser (42 females, seven males [60%]). Young attendees have a high STI rate, low contraceptive use and a significant minority are victims of abuse. Genitourinary medicine clinics need to provide a full sexual health service to this vulnerable group and have guidelines in place to assess for sexual abuse. Recommendations on how to achieve this are given.

Which patients attending genitourinary medicine clinics have HIV tests?

To identify factors associated with uptake of HIV testing a questionnaire was given to patients attending a GUM clinic over a three-week period. One hundred and twenty (69.4%) of 189 patients accepted and 53 (30.6%) refused testing. Variables associated with having a HIV test were: being tested previously (P=0.045), given a leaflet about testing (P=0.001), told about the window period (P=0.006), told about availability of counselling (P=0.030), given insurance advice (P=0.014), and a past history of sexually transmitted infections (P=0.044). Most patients perceived a low risk of being HIV positive (n=143, 75.7%) with no difference between those accepting or declining testing. The principal reason for testing was a check-up, and for refusal was a lack of perceived risk. Patients who are well informed about HIV testing are more likely to accept a test.

Doncaster: the public health response to a local cluster of heterosexually acquired HIV infection

In recent years, clusters of sexually transmitted HIV infection have attracted some media prominence in the UK. We describe our response to a local HIV cluster of five cases that acquired a high media profile. Practical difficulties encountered included: ensuring medical confidentiality in an outbreak control team which included many professional groups; handling a large volume of helpline calls; differing views on how specific health promotion should be; and the impact of summer leave on the control team's continuity. Following publicity, two further cases of HIV infection were found, bringing the total cluster to seven. Both later cases named the man at the centre of the cluster as a sexual partner. Of these two cases, one was local, identified as a direct result of the campaign. The other, living 170 miles distant in London, was identified as a result of increased media awareness. Eventually, the press named the man they thought to be the source case, which the outbreak control team had avoided doing. Good inter-disciplinary working made a co-ordinated public health response possible, and the 1,600 helpline calls dealt with served to reassure the public. Over 1,000 of the callers were advised to contact the Genito Urinary Medicine (GUM) department of their local hospital for counselling and testing of whom 772 took the advice. However, the longer-term effect on sexual behaviour was minimal as evidence by a subsequent survey.

Medical workforce speciality review for genitourinary medicine 2001/2002-England, wales, northern ireland and Scotland

This document addresses medical workforce needs for the speciality of Genitourinary Medicine (GUM) for the next 10 years. Data on current consultant numbers, working patterns and retirement are based on information from the Royal College of Physicians (RCP) Workforce Unit annual census undertaken on 30 September 2000. Information on specialist registrars is from the JCHMT. Senior house officers (SHO) data are from the RCP's General Professional Training department. Data on Non-Consultant Career Grade Doctors is from the Association of Genitourinary Medicine Survey. Data on incidence of Sexually Transmitted Infections (STIs) are from KC60 returns on STIs collected from GUM clinics by CDSC. There is considerable movement of doctors in GUM between countries in the UK both during progression from SpR to consultant and at consultant level. Data are therefore presented as amalgamated UK data and also by country. It is essential that workforce planning takes this lateral movement into consideration when undertaking calculations for future workforce requirements.

Standards for comprehensive sexual health services for young people under 25 years

This document is a first response to the need to develop sexual health services for young people on a single site whilst awaiting research from pilot studies of 'one stop shops' suggested in the Sexual Health and HIV strategy. It is a document which is intended to be a tool to use for those wishing to set up a service providing testing for sexually transmitted infections and provision of contraceptive services for those under 25 years. It is not intended that such a service would replace existing specialist or general practice care but complement it, allowing clients to choose the service most appropriate and acceptable to them, with close links and clear pathways of care for referral between services. This paper should be used as a template when initiating and monitoring a clinic but some of the standards may not be achievable without significant financial input. However, economic limitations should not detract from striving to achieve the best possible care for those most at risk from sexually transmitted infections and unwanted pregnancies. For example, not all clinics will be able to provide the recommended tests for the diagnosis for gonorrhoea and chlamydia immediately, but should work towards achieving them. Although the upper age limit in this document is defined as 25 years, some providers may wish to limit clinics to those under 20 depending on local needs. Detailed information on specific issues such as consent and confidentiality, provision of contraception, investigation of non-sexually transmitted vaginal infections and sexually transmitted infection management and diagnosis are referenced and we recommend these are accessed by the users of this document. Many of the references themselves are live documents available on the worldwide web, and are constantly updated. The Sexual Health and HIV Strategy has now been published and these standards are aimed at those who wish to provide a level 2 sexual health service for young people wherever the setting e.g. genitourinary outreach clinic, contraceptive services, general practice. This document is a starting point to be reviewed and updated as new research becomes available, as the Sexual Health Strategy is implemented and with further input from providers of care (family planning, general practice, genitourinary medicine, gynaecology and paediatrics) and service users. All service providers must maintain a high quality of care and have networks both with those who provide more specialized services (Level 3) and Level 1 services. This document is an initial attempt to ensure that there is equity of clinical provision wherever a Level 2 sexual health service is provided and should be a useful tool for those setting up or monitoring services.

The prevalence of Chlamydia trachomatis infection in male undergraduates: a postal survey

OBJECTIVES

To determine the prevalence of Chlamydia trachomatis infection in male undergraduates and to investigate whether prevalence increases with time spent at university. To investigate the feasibility of screening men for C trachomatis by self sampling and posting of urine specimens.

METHODS

The study design was a postal survey undertaken by the Department of Genito-Urinary Medicine (GUM) and Student University Health Service (SUHS) in SHEFFIELD: 2607 male undergraduates from the SUHS patient list were invited to participate in the study by providing a first void urine specimen and posting it to the laboratory. The main outcome measure was the detection of C trachomatis infection.

RESULTS

758 students participated in the study, a response rate of 29.1%. Nine students (1.2%) tested positive for C trachomatis. The prevalence of infection in the first, second, and third year of study was 0.7%, 1.5%, and 1.6% of participants respectively. There was no statistically significant difference in prevalence of infection between first and third year students (chi(2) test, p = 0.32). However, students with chlamydia had a higher median age (Mann-Whitney U test, p < or = 0.05). Contact tracing identified four further cases of C trachomatis infection.

CONCLUSION

Screening for C trachomatis infection by postal survey is feasible. However, the response rate in this study was poor and the estimated sample size was not reached. Therefore, it has not been possible to determine the true prevalence of infection in this population or to accurately assess changes in prevalence with time spent at university.

Exploring the sexual histories of older GUM clinic attenders

Little is known either of the factors motivating clinic attendance in later life, or the sexual health histories of older clinic attenders. A self-administered questionnaire study linked to patient note data aiming to explore these issues was undertaken within 3 genitourinary medicine (GUM) clinics in the Trent region. Participants comprised 224 individuals aged 50 years and older attending the 3 clinics during the study period. The majority of study participants were attending the clinic with a suspected sexually transmitted infection (STI) (n = 145, 64.7%) and approximately half (n=119, 53.1%) were first-time GUM clinic attenders. Data available for participants recruited from the Sheffield clinic indicated that, although the majority of participants reported having had only one sexual partner during the last 12 months, a significant minority reported considerably higher numbers of partners, including those classed 'higher risk' for STI acquisition. These data indicate that older people engage in behaviours that place them at risk of STI acquisition and many attend GUM clinics for the first time in later life.

Vulvar vestibulitis: aetiology, diagnosis and treatment

Chronic vulval pain can have multi-factorial causes. One of its leading causes, vulvar vestibulitis, is reviewed. A study of vulvar vestibulitis-its epidemiology, aetiology, histopathology, diagnosis and treatment is undertaken. More research is needed on this condition as it is important to make an accurate diagnosis and thus raise awareness before providing proper treatment.

Community control of Chlamydia trachomatis

In order to determine the amount of Chlamydia trachomatis that is diagnosed outside genitourinary medicine (GUM) clinics in a large university city, a review of all positive chlamydial infections diagnosed on specimens received from hospitals (non-GUM) and community sources in 1996 was performed. It was also ascertained whether these patients subsequently attended at GUM. Eight hundred and nine cases of C. trachomatis were diagnosed during the study period. Three hundred and ninety-seven (49%) were initially diagnosed outside GUM of which 264 (66.5%) were referred, giving an overall involvement of GUM in 667 (83.6%) of all cases. The proportion of cases referred varied according to service: Family Planning Clinics 94.5%, Obstetrics and Gynaecology 73%, General Practice 52.5%. Referral rates also showed within service variation, with University Health Services referring 19% vs 73% (P < 0.001). High levels of referral to GUM of patients diagnosed with C. trachomatis are achievable, but referrals show inter- and intra-service variations. Efforts should be made to improve referral rates from those services with the lowest rates.

IN CONCLUSION

(1) The proportion of cases of C. trachomatis diagnosed in the community who are referred to a GUM clinic, varies according to service type. (2) Referral rates vary within services and (3) Distance of services from a GUM clinic does not appear to influence referral rates.

Contact tracing for gonorrhoea in homosexual and heterosexual men

We aimed to determine whether the success of partner notification for gonorrhoea in men was affected by sexual orientation. Analysis of standard clinic and health adviser records of all male patients found to be infected with gonorrhoea between October 1992 and September 1993 were carried out. Of the 278 cases of gonorrhoea in men, 9% (25) were acquired through homosexual intercourse and 91% (253) by heterosexual contact. Fifteen per cent (24) of Caucasians were homosexual but only 0.9% (1) of Afro-Caribbeans were. The mean number of contacts was 1.36 for homosexuals and 1.38 for heterosexuals. Contact information was given by 55% of heterosexuals and 48% of homosexuals. The proportion of acknowledged contacts attending was 38% for homosexuals and 56% for heterosexuals (P = 0.054). Fifty-two per cent of homosexuals and 59% of heterosexuals had at least one contact attend. Data analysis on Caucasians only showed Caucasian gay men had a higher mean number of contacts (1.38) than Caucasian heterosexuals (1.28). Caucasian homosexuals had a lower proportion of contacts attending (40% vs. 77%) (P = 0.05), 54% of homosexual men and 60% of heterosexual men had at least one contact attending (P = 0.74). There is a trend for partner notification to be less successful in homosexual men when all ethnic groups are considered together. In Caucasian men with gonorrhoea, homosexuals have a greater number of partners than heterosexuals and have a lower proportion of total contacts attending but there is no difference in the proportion having at least one contact attending. Data on sexual orientation and ethnicity should be reported in studies assessing efficacy of contact tracing.

Cardiovascular autonomic neuropathy in HIV infected patients

OBJECTIVE

To evaluate the presence and extent of autonomic dysfunction in HIV infected individuals of one ethnic group.

DESIGN

Prospective, age-sex matched study.

METHODS

25 patients (seven asymptomatic (HIV), eight AIDS related complex (ARC), 10 AIDS) and 25 controls were recruited from patients and staff at the Aga Khan Hospital, Nairobi. Autonomic function was assessed by measurement of pulse rate variability on standing, rest, deep breathing, Valsalva manoeuvre, isometric exercise, cold face test, and mental stress. Blood pressure was measured during standing, supine resting, and on Valsalva manoeuvre. CD4 count was correlated with number of abnormal test results.

RESULTS

21 patients had at least one abnormal test of autonomic function compared with one control (p < 0.0001). There were significant differences between AIDS patients and controls for supine heart rate (p < 0.001), Valsalva ratio (p = 0.05), and cold face test (p = 0.05), and almost significant results for mental stress (p = 0.051). Evidence of autonomic hypersensitivity was found in response to exercise and/or mental stress in some patients with HIV or ARC. No difference was found in blood pressure measurements. Abnormalities in autonomic function occurred at all CD4 counts and all patients with four abnormal tests of heart rate variation had a CD4 count less than 300 x 10(6)/l.

CONCLUSIONS

There is evidence of substantial autonomic dysfunction in AIDS patients compared with controls and mild abnormalities in the majority of HIV infected patients studied irrespective of CD4 count. Autonomic hypersensitivity may precede loss of function in some cases.

An audit of diagnostic coding in genitourinary medicine clinics

The KC60 diagnostic code information provides an epidemiological monitor of sexually transmitted infection (STI) and a means of standardizing clinical workload in genitourinary medicine (GUM) departments.

We aimed to assess the coding process and its uniformity within the Trent region by means of a confidential self-administered coding exercise with simulated case presentations.

The correct coding for STIs ranged from 59.4% to 100% in different scenarios. Difficulty was identified in the coding of vulvitis and balanitis where no organism was isolated, as represented by a wide range of codes. HIV pre-test counselling without testing was coded by only 57.8% of respondents. Over 95% indicated correctly the first hepatitis B vaccine dose but 21% failed to code once only for the course.

Coding practice also varied within individual sites with a 21–100% discordance.

In parts diagnostic accuracy was good but there were areas of non-uniformity both within sites and cross-regionally. Regional discussions have resulted in increased training opportunities and guidelines have been developed to increase uniformity and achieve consensus in uncertain areas.

An audit of diagnostic coding in genitourinary medicine clinics. Trent Region Genitourinary Medicine Audit Group

The KC60 diagnostic code information provides an epidemiological monitor of sexually transmitted infection (STI) and a means of standardizing clinical workload in genitourinary medicine (GUM) departments. We aimed to assess the coding process and its uniformity within the Trent region by means of a confidential self-administered coding exercise with simulated case presentations. The correct coding for STIs ranged from 59.4% to 100% in different scenarios. Difficulty was identified in the coding of vulvitis and balanitis where no organism was isolated, as represented by a wide range of codes. HIV pre-test counselling without testing was coded by only 57.8% of respondents. Over 95% indicated correctly the first hepatitis B vaccine dose but 21% failed to code once only for the course. Coding practice also varied within individual sites with a 21-100% discordance. In parts diagnostic accuracy was good but there were areas of non-uniformity both within sites and cross-regionally. Regional discussions have resulted in increased training opportunities and guidelines have been developed to increase uniformity and achieve consensus in uncertain areas.

Knowledge of Chlamydia trachomatis infection in genitourinary medicine clinic attenders

OBJECTIVES

To determine the level of awareness of genital chlamydial infection, and level of knowledge related to this infection, in genitourinary medicine (GUM) clinic attenders.

METHODS

500 consecutive patients attending a GUM clinic for the first time during a 3 month study period were invited to complete an anonymous self administered questionnaire on aspects of chlamydial infection.

RESULTS

482 (96.4%) questionnaires were available for analysis (57% female). 289 (60%) respondents had heard of Chlamydia trachomatis compared with 472 (98%) for thrush, 467 (97%) for HIV/AIDS, and 434 (90%) for gonorrhoea. Subjective knowledge of chlamydia, relative to the other infections, was poor. Overall, the mean chlamydial knowledge score was 0.38 (range 0.0-1.0). Females scored significantly higher than males (0.45 v 0.26; p < 0.00001) and younger females scored significantly higher than older females (p = 0.001). More females had experienced genital chlamydial infection than males (22.4% v 12.1%, p = 0.004). Those with prior exposure to C trachomatis had higher mean knowledge scores than those without (males 0.55 v 0.25, p < 0.00001; females 0.68 v 0.37, p < 0.00001).

CONCLUSION

Even for a population considered as "high risk" by their attendance at a GUM clinic, there was poor awareness of genital chlamydial infection, and mean knowledge scores were low. Whether increased knowledge was due to successful health education at the time of diagnosis in those with previous infection remains to be determined. In the future, one would hope for increased knowledge scores in those at risk before the acquisition of infection, which may be achieved by national health education programmes for C trachomatis.

Delay in symptom presentation among a sample of older GUM clinic attenders

Prior research undertaken with predominantly youthful populations has established that delay between symptom recognition and health-care presentation is a common feature of sexually transmitted infection (STI) related illness behaviour. However, it is not known whether similar behaviours are exhibited by older populations with genitourinary symptoms. The present analyses therefore aim to clarify this issue by focusing upon (1) extent of delay behaviour, (2) reasons for delay behaviour and (3) variables predicting delay behaviour among a sample of genitourinary medicine (GUM) clinic attenders aged over 50 years. A self-administered questionnaire study linked to patient note data was undertaken within 3 GUM clinics in the Trent region between January 1997 and March 1998 (Sheffield, Nottingham and Leicester). Of 121 symptomatic older attenders with suspected STI, 43.8% (n=53) waited over 2 weeks between symptom recognition and clinic attendance. Reasons given for delay included wanting to 'wait and see' if symptoms improved and being embarrassed or afraid to attend clinic. A logistic regression analysis identified that delay behaviour was predicted by history of HIV testing. Comparisons with previous research undertaken in this field indicate that levels of delay behaviour reported by this older sample are higher than those exhibited by youthful populations with genitourinary symptoms. This finding has significant implications for health-care professionals working both within a GUM setting, and with older people, especially when viewed in the context of an ageing population.

Urinary neopterin as a prognostic index of survival time in HIV-1 infection

A prospective semi-longitudinal study was undertaken to determine if urinary neopterin was a predictor for survival in HIV-positive patients. One hundred and one HIV-positive subjects attending a department of genitourinary medicine over a 41-month period were included. Survival data were analysed 6 months after the end of recruitment. Ninety-two subjects were followed up for a minimum of 6 months. Survival figures at 1 and 2 years were 93% (SE 3%) and 79% (SE 5%). There was an inverse relationship between urinary neopterin excretion and 1 and 2-year survival. Two-year survival fell from 70% (SE 6%) for neopterin levels > or = 300 mmol/mol creatinine to 25% (SE 9%) for levels > or = 700 mmol/mol creatinine (P < 0.001). Urinary neopterin may be a useful non-invasive technique in predicting survival in HIV-positive patients.

Attitudes to HIV testing in general practice

Newer therapies for the treatment of HIV infection and the effectiveness of zidovudine in reducing vertical transmission mean that it is becoming increasingly important to diagnose HIV infection earlier. General practitioners (GPs) attending a local study day on sexually transmitted diseases (STDs) were asked about their likelihood of raising the subject of HIV antibody testing, and their anxiety when doing so, for different patient groups. A high level of anxiety was found when raising this topic in certain patient groups, and a proportion of GPs would never discuss HIV testing, even in very high-risk groups. No respondents were aware that vertical transmission could be reduced by antiretroviral drug therapy. These data advocate that the barriers to raising the issue of HIV testing and the methods of reducing GPs' anxiety associated with it, need to be addressed.

Necropsies in HIV medicines

OBJECTIVE

The objective of this study was to determine the availability of necropsy services to departments dealing with HIV positive patients, and to assess their satisfaction with, and utilisation of, these services.

METHOD

Confidential questionnaires were sent to 187 consultants in genitourinary medicine and infectious diseases departments within the United Kingdom and Ireland. One hundred and forty four (77%) replies were suitable for analysis.

RESULTS

Seventy five (52.1%) centres had a routine necropsy service, compared with 59 (41.0%) which did not, including 15 (10.4%) with no service provision. Sixty one (42.4%) centres were satisfied with their current service; however, 31 (21.5%) clinics were not satisfied. The majority of service users considered necropsies to be beneficial in the subsequent management of HIV positive patients.

CONCLUSION

The provision of services for HIV necropsies varies considerably. We advocate that they should be uniformly available, and that the dissatisfaction with current services should be addressed.

Lymphogranuloma venereum: biopsy, serology, and molecular biology

A 21 year old woman presented with painful groin lymphadenopathy and malaise. Lymph node biopsy, to exclude atypical infection and malignancy, suggested the diagnosis of lymphogranuloma venereum. This diagnosis was confirmed by serology and polymerase chain reaction, with the patient subsequently admitting to a casual sexual contact within the United Kingdom. Alternative methods of investigation of this disease are discussed.

When is bacterial vaginosis not bacterial vaginosis?--a case of cervical carcinoma presenting as recurrent vaginal anaerobic infection

Vaginal anaerobic infection is the most common cause of vaginal discharge in women. We present a case of recurrent vaginal anaerobic infection and cervical carcinoma and discuss the association of the two conditions. More frequent cytology/colposcopy may be indicated in women who give a history of recurrent or persistent vaginal anaerobic infection.