Lichen sclerosus

Lichen sclerosis is a chronic inflammatory skin disease that causes substantial discomfort and morbidity, most commonly in adult women, but also in men and children. Any skin site may be affected (and, rarely, the oral mucosa) but lichen sclerosus is most common in the anogenital area, where it causes intractable itching and soreness. In children, the disorder may be confused with changes seen in sexual abuse. Progression to destructive scarring is common. There is increased risk of developing vulval cancer, and there are links with penile cancer. Patients should be kept under long-term review. Lichen sclerosus can occur without symptoms, and the exact prevalence is uncertain. It occurs most commonly in women at times of low sex hormone output. The underlying cause is unknown, but there seems to be a genetic susceptibility and a link with autoimmune mechanisms. The wart virus and the spirochaete borrelia have been suggested but not substantiated as infective triggers. The Koebner phenomenon is known to occur (lichen sclerosus occurs in skin already scarred or damaged), so trauma, injury, and sexual abuse have been suggested as possible triggers of symptoms in genetically predisposed people. The treatment of choice for anogenital lichen sclerosus is potent topical corticosteroid ointment for a limited time. Circumcision may be indicated in men, and surgery may be considered in women, to relieve effects of scarring or to treat coexisting carcinoma. Current research aims to identify a treatable cause of lichen sclerosus, to identify patients at risk of scarring and of malignant disorders, and to find target pathways for therapeutic intervention.

The role of partial denervation of the pelvic floor in the aetiology of genitourinary prolapse and stress incontinence of urine. A neurophysiological study

Single-fibre electromyography of the pubococcygeus muscle of the pelvic floor was performed in 69 asymptomatic women and 105 women with stress incontinence of urine or genitourinary prolapse or both. The results suggest that partial denervation of the pelvic floor with subsequent reinnervation is a normal accompaniment of ageing and is increased by childbirth. Women with stress incontinence of urine or genitourinary prolapse or both have a significant increase in denervation of the pelvic floor compared with asymptomatic women.

Non-colonic features of irritable bowel syndrome

In 100 patients with irritable bowel syndrome a wide variety of non-gastrointestinal symptoms were significantly more common than in a group of 100 age, sex, and social class matched controls. Nocturia, frequency and urgency of micturition, incomplete bladder emptying, back pain, an unpleasant taste in the mouth, a constant feeling of tiredness and in women dyspareunia were particularly prominent (p less than 0.001). With reference to non-colonic gastrointestinal symptoms nausea, vomiting, dysphagia and early satiety were very common (p less than 0.0001). This symptom diversity was observed irrespective of whether the patient had a psychiatric disorder or not. Patients smoked more than controls (p = 0.02) drank more caffeine containing drinks (p = 0.03) and 26% had taken at least one week off work in the previous 12 months. Thirty three per cent of patients had a family history of irritable bowel syndrome. Cognisance of these diverse symptoms may prevent referral to the wrong medical specialty and inappropriate investigation. They may also be indicative of a much more diffuse disorder of smooth muscle than has previously been appreciated.

Criteria for diagnosis of Behçet's disease. International Study Group for Behçet's Disease

5 sets of criteria for diagnosis of Behçet's disease are in use--a problem which has hindered interpretation of different studies and collaborative research. An international study group, which included at least one proponent of 4 of the sets, was formed to derive new, internationally agreed diagnostic criteria for Behçet's disease. Data on 914 patients with Behçet's disease, from 12 centres in 7 countries, were compared with controls from the same centres. The new set of diagnostic criteria--which requires the presence of oral ulceration plus any two of genital ulceration, typical defined eye lesions, typical defined skin lesions, or a positive pathergy test--was simpler to use and had an improved discriminatory performance than its predecessors.

A glossary for reporting complications of treatment in gynecological cancers

Reporting and scoring treatment complications in gynecological cancers is difficult because of the variety of normal tissues, anatomical structures and treatment disciplines involved, making it impossible to compare series of patients treated in different institutions even with the same strategy. An international group of experts (gynecologists, radiotherapists and surgeons) developed a multidisciplinary database to identify, score and report early and late normal tissue damage regardless of treatment strategy. The principles involve: (1) The identification of relevant organs and tissues; (2) An accurate definition of the type and score of each complication; (3) Reporting combinations of complications of various degrees; (4) A computerized format for data acquisition, update and retrieval. In the present version, the "Glossary" describes five degrees of increasing severity (0 to 4) in 14 organs and/or normal tissues. The rationale of the glossary leaves it open for as yet undescribed types of complications. This paper contains the definition and scoring for each type of complication, general guidelines for their use.

Sexual behavior and partner characteristics are the predominant risk factors for genital human papillomavirus infection in young women

Risk factors for cervicovaginal human papillomavirus (HPV) infection were investigated in 604 college women. HPV was detected in 168 (27.8%) of the subjects by L1 consensus primer polymerase chain reaction, Southern blot hybridization, or both. Significant independent risk factors for HPV (P < .05) included age (odds ratios [ORs]: 2.6 for 21-23 years old and 1.6 for > 23, vs. < or = 20), ethnicity (ORs: 3.2 for black, 2.2 for Hispanic, vs. white/other), number of lifetime male vaginal sex partners (ORs: 4.5 for 2, 5.8 for 3 or 4, 10.3 for > or = 5, vs. 1), living with smokers (OR: 1.9), male partner's number of lifetime sex partners (ORs: 2.1 for 2 or 3, 3.1 for 4-10, 2.7 for > or = 11, vs. 1), duration of sexual relationship for > 12 months (OR: 0.6), and male partner currently in college (OR: 0.6). These data demonstrate that the predominant risk factors for genital HPV infection in young women are related not only to their own sexual behaviors but also to those of their male partners.

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.

The pathogenesis of genitourinary prolapse and stress incontinence of urine. A histological and histochemical study

Histological and histochemical analysis of biopsy samples of pubococcygeus muscle obtained from asymptomatic women and from women with stress incontinence of urine, with or without genitourinary prolapse, have been compared. In the asymptomatic women both age and parity appeared to be related to the morphological features of the samples and in particular those obtained from the posterior part of the pubococcygeus. In the symptomatic women there was a significant increase in the number of muscle fibres showing pathological damage which were obtained from the posterior part of the pelvic floor. The range of diameters of both Type I and Type II fibres obtained from this region was significantly different between symptomatic and asymptomatic women. These findings may be attributable to partial denervation of the pelvic floor in patients with urinary stress incontinence with or without genital tract prolapse.

The role of pudendal nerve damage in the aetiology of genuine stress incontinence in women

Conduction was studied in the terminal branches of the pudendal nerve in 42 women with normal urinary control and 87 women with stress incontinence of urine, genitourinary prolapse, or both. Women with stress incontinence of urine had delayed conduction to both the striated urethral muscle and the pelvic floor muscle, indicative of denervation injury. Women with normal urinary control and genitourinary prolapse had similar conduction times to the urethral sphincter striated muscle as normal women but clear evidence of denervation damage to the pelvic floor.

Health during prolonged use of levonorgestrel 20 micrograms/d and the copper TCu 380Ag intrauterine contraceptive devices: a multicenter study. International Committee for Contraception Research (ICCR)

OBJECTIVES

To measure and compare the incidence of adverse events during use of two medicated intrauterine devices (IUDs).

DESIGN

A multicenter prospective 7-year randomized study.

SETTING

Family planning clinics, primarily in developing countries.

SUBJECTS

Women age 18 to 38 years at admission, desiring contraception and without contraindications to IUDs.

MAIN OUTCOME MEASURES

Incidence of complaints, conditions, and rates of specific termination for each IUD.

METHODS

Subjects recorded menstrual events, and clinical staff registered all complaints and conditions found on examination at four first-year clinic visits and at semiannual visits thereafter. Difference in rates were analyzed by chi 2 statistics.

RESULTS

Annual pregnancy rates for each IUD averaged 0.2/100 women whereas upper genital tract infection occurred at rates of 0.6 to 0.7 per 100 years of use. The levonorgestrel-releasing IUD significantly decreased bleeding and spotting days in comparison with historical data for noncontraceptors and with the copper-medicated IUD. Dysmenorrhea, vaginitis, and myoma in women with the levonorgestrel IUD were markedly decreased in comparison with the experience of copper IUD users. Significantly higher rates of amenorrhea, delayed ovarian follicular atresia, skin and hair conditions, and headache were observed with the steroid IUD than with the copper-releasing IUD. Rates of reported adverse effects for either IUD were highest in the first 2 years of use and among women under age 25.

CONCLUSIONS

Long-term use of copper or levonorgestrel IUDs is characterized by very low rates of pregnancy and by a low and declining annual incidence of side effects, including pelvic infection and borderline anemia. The levonorgestrel-releasing IUD reduced the incidence of bleeding and, in the long term, of myoma and myoma-related surgery in comparison with the copper T IUD. Both IUDs proved highly acceptable and had few unanticipated side effects.

Polycystic ovary syndrome: syndrome XX?

Polycystic ovary syndrome (PCOS) is now recognized as an important metabolic and reproductive disorder. It is associated with substantial defects in insulin action and secretion that confer a markedly increased risk for type 2 diabetes mellitus. Insulin resistance modifies reproductive function both by the direct actions of insulin on steroidogenesis and by disruption of insulin signaling pathways in the central nervous system. These insights have led to a new therapy for PCOS with insulin-sensitizing agents. Hyperandrogenemia and insulin resistance cluster in PCOS families, consistent with a genetic susceptibility to these abnormalities. There is evidence for both linkage and association of the hyperandrogenemia phenotype with an allele of a marker locus on chromosome 19, in the region of the gene encoding the insulin receptor.

Genital and urinary tract infections in diabetes: impact of pharmacologically-induced glucosuria

Predisposition to genital infections and urinary tract infections (UTIs) in type 2 diabetes mellitus (T2DM) results from several factors such as glucosuria, adherence of bacteria to the uroepithelium and immune dysfunction. The tendency to develop these infections could be even higher in patients with T2DM treated with the emerging class of sodium-glucose cotransporter-2 (SGLT2) inhibitors. Studies have shown that pharmacologically-induced glucosuria with SGLT2 inhibitors raises the risk of developing genital infections and, to a relatively lesser extent, UTIs. However, a definitive dose relationship of the incidence of these infections with the SGLT2 doses is not evident in the existing data. Therefore, the precise role of glucosuria as a causative factor for these infections is yet to be fully elucidated.

Evaluation of clinical findings according to sex in 2313 Turkish patients with Behçet's disease

BACKGROUND

Behçet's disease is a multisystem disease featuring mucocutaneous, ocular, articular, vascular, intestinal, urogenital, and neurologic involvement and occurs with a high prevalence in the Mediterranean including Turkey. Higher incidence of severe clinical course and systemic involvement is observed in male patients.

OBJECTIVE

To determine the influence of sex on the clinical course of Behçet' s disease.

METHODS

We retrospectively evaluated the clinical findings of 2313 Behçet patients followed up at the multidisciplinary Behçet's Disease Center at Ankara University.

RESULTS

The male/female patient ratio was 1.03. Oral aphthae was seen in all patients. In male Behçet patients, the prevalence of mucocutaneous lesions and systemic manifestations was as follows: 85.6% genital aphthae, 45.5% erythema nodosum, 59.5% papulopustular lesions, 17.5% thrombophlebitis, 38.1% ocular involvement, 11.3% articular involvement, 11.7% vascular involvement, 3.3% neurologic involvement, 1.4% gastrointestinal involvement, and 1.8% pulmonary involvement. In female Behçet patients, the prevalence of manifestations were as follows: 91% genital aphthae, 49.8% erythema nodosum, 48.3% papulopustular lesions, 3.5% thrombophlebitis, 19.8% ocular involvement, 11.8% articular involvement, 2.1% vascular involvement, 1.3% neurologic involvement, 1.4% gastrointestinal involvement, and 0.03% pulmonary involvement.

CONCLUSIONS

Only genital aphthae and erythema nodosum were more frequent in females. On the other hand papulopustular eruptions, thrombophlebitis, ocular, neurologic, pulmonary and vascular involvement were more frequent in males. While female patients had the best prognosis, male patients had a worse overall prognosis than females.

Experimental gonococcal genital tract infection and opacity protein expression in estradiol-treated mice

The development of effective prophylactic agents against gonorrhea and the study of adaptation by Neisseria gonorrhoeae to the urogenital mucosa are hindered by the lack of a well-established animal model of gonococcal genital tract infection. Here, a murine model of long-term gonococcal genital tract infection is described. Female BALB/c mice were treated with 17-beta-estradiol and inoculated intravaginally with wild-type gonococcal strain FA1090 or MS11. N. gonorrhoeae was recovered from vaginal swabs for an average of 12 to 13 days following inoculation with 10(6) CFU of either strain. Inflammation occurred in over 80% of infected mice, and diplococci were associated with epithelial cells and neutrophils in stained vaginal smears. Ascended infection occurred in 17 to 20% of mice inoculated with strain FA1090. An outbred mouse strain (SLC:ddY) previously reported to be naturally susceptible to N. gonorrhoeae was also tested; however, as with BALB/c mice, estradiol was required for prolonged infection. Although piliation was not maintained during experimental murine infection, 46 to 100% of vaginal isolates from four of eight BALB/c mice and three of four SLC:ddY mice expressed one or more opacity (Opa) proteins within 4 days after inoculation with an Opa-negative variant of strain FA1090. The observed selection for and/or induction of gonococcal Opa protein expression during murine infection appears to parallel events that occur during experimental urethritis in volunteers.

Intimate Partner Sexual Assault Against Women: Frequency, Health Consequences, and Treatment Outcomes

OBJECTIVE

To describe the characteristics and consequences of sexual assault within intimate relationships specific to racial or ethnic group, compare the findings to a similar group of physically assaulted-only women, and measure the risk of reassault after victim contact with justice and health services.

METHODS

A personal interview survey of 148 African-American, Hispanic, and white English- and Spanish-speaking abused women seeking a protection order. Extent of sexual assault, prevalence of rape-related sexually transmitted diseases and pregnancy, symptoms of posttraumatic stress disorder (PTSD) and depression, and risk of reassault after treatment were measured.

RESULTS

Sixty-eight percent of the physically abused women reported sexual assault. Fifteen percent of the women attributed 1 or more sexually-transmitted diseases to sexual assault, and 20% of the women experienced a rape-related pregnancy. Sexually assaulted women reported significantly (P = .02) more PTSD symptoms compared with nonsexually assaulted women. One significant (P = .003) difference occurred between ethnic groups and PTSD scores. Regardless of sexual assault or no assault, Hispanic women reported significantly higher mean PTSD scores compared with African-American women (P = .005) and White women (P = .012). The risk of sexual reassault was decreased by 59% and 70% for women who contacted the police, or applied for a protection order, after the first sexual assault. Receiving medical care decreased the woman's risk of further sexual assault by 32%.

CONCLUSION

Sexual assault is experienced by most physically abused women and associated with significantly higher levels of PTSD compared with women physically abused only. The risk of reassault is decreased if contact is made with health or justice agencies.

Prevalence and predictors of chronic lower genital tract discomfort

OBJECTIVE

We sought to determine the prevalence of chronic lower genital tract discomfort in the general population and to identify demographic and reproductive characteristics associated with this disorder.

STUDY DESIGN

We surveyed a random sample of 480 women (age range, 20 to 59 years; 60 women for each 5-year age category) from 1 Boston area suburban community. Participants were asked to complete a 1-page self-administered optically scannable questionnaire that pertained to current and previous genital tract discomfort.

RESULTS

After 2 mailings and 1 telephone follow-up, as well as the elimination of 42 ineligible women, 303 (70%) questionnaires were returned. Fifty-six women (18.5%) reported a history of lower genital tract discomfort that persisted for >3 months. Approximately 12% reported a history of chronic knife-like or excessive pain on contact to the genital area, whereas 6.6% experienced persistent lower genital tract itching or burning. Women who reported their age at menarche to be <or=11 years old were more than twice as likely to report a history of chronic lower genital tract discomfort compared with women who began menses at age 12 or later (odds ratio, 2.4; 95% confidence interval, 1.1 to 4.8). Reported pain at the time of first use of tampons was associated with an increased risk of chronic lower genital tract discomfort later in life (odds ratio, 2.4; 95% confidence interval, 1.1 to 4.9).

CONCLUSIONS

We have shown that women from the general population are willing to provide sensitive information on lower genital tract discomfort-a first step toward bringing notice to this understudied disorder. In addition, our data support the theory that vulvar trauma in early life may influence or serve as a marker for risk of subsequent chronic vulvar disorders.

Antiphospholipid syndrome nephropathy in systemic lupus erythematosus

In the course of the antiphospholipid syndrome (APS), the existence of vaso-occlusive lesions capable of affecting numerous organs is now well established. The renal involvement attributable to primary APS, APS nephropathy (APSN), corresponds to vaso-occlusive lesions of the intrarenal vessels, associating side-by-side, acute thromboses with chronic arterial and arteriolar lesions, leading to zones of cortical ischemic atrophy. A retrospective study of 114 lupus patients undergoing renal biopsy was undertaken to determine the following: (1) if APSN can be found in the course of systemic lupus erythematosus (SLE); (2) if certain clinical and biologic factors can permit the prediction of the presence of APSN; and (3) if APSN is a superadded renal morbidity factor in lupus patients. This study shows the following: (1) APSN occurs in SLE (32% of patients with renal biopsies) in addition to, and independently of, lupus nephritis; (2) APSN is statistically associated with lupus anticoagulant but not with anticardiolipin antibodies; (3) APSN is associated with extrarenal APS, mainly arterial thromboses and obstetrical fetal loss, but not with the venous thromboses of APS; (4) APSN is an independent risk factor, over and above lupus nephritis, that contributes to an elevated prevalence of hypertension, elevated serum creatinine, and increased interstitial fibrosis. Thus, it seems likely that, because of its associations with hypertension, elevated serum creatinine, and increased interstitial fibrosis, APSN may worsen the prognosis in these patients. APSN may also have therapeutic significance in that its recognition should permit a better balance between immunosuppressor and antithrombotic and/or vasoprotective therapy. Finally, this study suggests that APSN should be considered as an element to be included in the classification criteria of APS.

Gynaecological and obstetrical morbidity in women with type I von Willebrand disease: results of a patient survey

Type 1 von Willebrand disease (vWD) is generally regarded clinically as 'mild' and the obstetrical-gynaecological features have not been fully described. We administered a patient questionnaire and provider survey of the medical and quality of life aspects of childbirth and menstruation to 99 type 1 vWD patients and compared the patients presently menstruating (n=81) to a cohort of 150 menstruating females in the general population. The following measurements had a statistically higher proportion in the vWD group: number of tampons/towels used for a typical menstrual cycle (P=0. 002); percentage reporting that clothes are stained by menses (P = 0. 001); past or present history of anaemia (P = 0.001); childbirth-related bleeding (P=0.001); and childbirth-related bleeding necessitating RBC transfusion (P=0.002). Quality of life assessment of the impact of menses in both of the above cohorts was measured by a Likert scale using seven quality of life parameters. Compared to the control group, the vWD patients had a significantly higher score, with P-values of < 0.0001 for each parameter. Hormonal interventions for menorrhagia in the vWD patients were < or = 50% effective. Menorrhagia resulted in red blood cell transfusions in 6% of patients, dilatation and curettage in 17% and hysterectomy in 13%. Despite the common connotation of type 1 vWD as clinically 'mild', childbirth and the monthly challenge to haemostasis presented by menstruation result in a substantial degree of morbidity in females with type 1 vWD. These results support the rationale for ongoing international efforts to increase awareness of vWD as a cause for menorrhagia and to improve the quality of life in females with known vWD.

Nontypable Haemophilus influenzae (biotype 4) as a neonatal, maternal, and genital pathogen

Between 1976 and 1981 Haemophilus influenzae was identified in 16 women with postpartum bacteremia and 36 neonates with bacteremia or meningitis. H. influenzae was also recovered from neonatal or genital cultures of 50 additional patients. By counter-immunoelectrophoresis 17% of neonatal isolates from blood or cerebrospinal fluid (CSF) were type b. All remaining strains (94% overall) were nontypable (NT). Of the NT blood or CSF isolates, 38% belonged to biotype 4. Of all the NT biotype 4 isolates referred to the Centers for Disease Control during the study, 82% were of genital, neonatal, or maternal origin, a finding that suggests that this isolate is a genital biotype. Clinical disease was similar to that observed in patients infected with group B Streptococcus except for the infrequent (11%) occurrence of meningitis. Maternal bacteremia resulted in mild febrile illness, while neonatal bacteremia was associated with a high incidence of shock, respiratory distress (50%), and death (30%). H. influenzae bacteremia in these two patient groups was rare in Houston before 1976, but since then it has been responsible for 2.5% of cases of significant bacteremia. NT H. influenzae should be recognized as a definite neonatal, maternal, and genital pathogen.

Urinary incontinence and pelvic organ prolapse in women with Marfan or Ehlers Danlos syndrome

OBJECTIVE

This study was undertaken to determine the prevalence of urinary incontinence and pelvic organ prolapse in a cohort of women with either Marfan syndrome or Ehlers-Danlos syndrome.

STUDY DESIGN

Female patients with either Marfan syndrome or Ehlers-Danlos syndrome were identified through a medical records search at two urban hospitals. Each patient's medical record was reviewed, and the history of pelvic organ prolapse and urinary incontinence was obtained through telephone interview.

RESULTS

Twelve women with Marfan syndrome were identified. Among these women 5 (42%) reported a history of urinary incontinence and 4 (33%) reported a history of pelvic organ prolapse. Eight women with Ehlers-Danlos syndrome were identified. Among these women 4 (50%) reported a history of urinary incontinence and 6 (75%) reported a history of pelvic organ prolapse.

CONCLUSIONS

Women with Marfan or Ehlers-Danlos syndrome have high rates of urinary incontinence and pelvic organ prolapse. This finding supports the hypothesized etiologic role of connective tissue disorders as a factor in the pathogenesis of these conditions.

HIV-1 seroconversion in patients with and without genital ulcer disease. A prospective study

OBJECTIVE

To determine the relative risk for human immunodeficiency virus (HIV-1) seroconversion in patients with and without genital ulcers caused by chancroid, syphilis, and herpes.

DESIGN

A prospective cohort study.

SETTING

An inner-city, sexually transmitted disease clinic.

PATIENTS

Patients seronegative for HIV-1 with and without genital ulcers who were followed for a minimum of 3 months.

INTERVENTIONS

Questionnaire to obtain data on demographics, sexual behavior, and illicit drug use; testing for HIV-1 at entry and at a minimum of 3 months after entry; medical examination for the presence or absence of genital ulcer disease.

RESULTS

Overall, 758 heterosexual men with no history of injection drug use completed the study; HIV-1 seroconversion occurred in 10 of 344 (2.9%; 95% CI, 1.4% to 5.3%) men with a genital ulcer and in 4 of 414 (1%; CI, 0.2% to 2.5%) without a genital ulcer (relative risk, 3.0; P = 0.05). In a multiple logistic regression analysis, those men with chancroid and a new sexually transmitted disease during follow-up each had about three times the risk for HIV-1 seroconversion (P < or = 0.04).

CONCLUSIONS

In this group of heterosexual men, chancroid and repeated acquisition of sexually transmitted diseases appeared to facilitate the sexual transmission of HIV-1.