Sexually Transmitted Infections

Etherington, I J; Shafi, M I

doi: 10.1136/sti.72.3.153pmid: 8707314

Edwards, S

doi: 10.1136/sti.72.3.155pmid: 8707315

OBJECTIVES: To give an overview of the literature on balanitis, with a special emphasis on infective causes. METHOD: A data search was performed using the OVID CD plus Medline 1967-1995, using balanitis and balanoposthitis as textword search strategy. Specific subjects such as anaerobic infection, Zoon's balanitis were sought separately and subgroups combined. Original articles and abstracts were referenced to illustrate each condition. These were mainly English language articles, but included appropriate non-English language papers. CONCLUSIONS: Balanitis is a common condition among genitourinary medicine clinic attendees, the cause often remaining undiagnosed. Many cases are caused by infection, with candida being the most frequently diagnosed. However, gardnerella and anaerobic infections are common, and there are a wide variety of other rarer infective causes. In addition irritant balanitis is probably a contributing factor in many cases. Balanitis which persists and in which the cause remains unclear warrants biopsy.

Pham-Kanter, G B; Steinberg, M H; Ballard, R C

doi: 10.1136/sti.72.3.160pmid: 8707316

AIM: To review the epidemiology of and data collection for sexually transmitted diseases (STDs) in South Africa. METHODS: Literature published since 1980 on STDs in South Africa were complied and evaluated. Historical reports and salient unpublished literature were also used in the literature review. Studies were critically reviewed in the light of sample populations and study methods, and a baseline picture of the patterns of STD burden was developed. RESULTS: The STD burden in apparently asymptomatic study populations is significant. Ulcerative infections, primarily caused by syphilis and chancroid, are present in 5-15% of asymptomatic clinic attenders; prevalence rates of gonorrhoea average 8%, with up to 13% of gonococcal isolates resistant to penicillin antibiotics. In addition, on average, chlamydia and vaginal infections are detected in 16% and 20-49%, respectively, of antenatal and family planning clinic attenders. HIV seroprevalence rates have reached 7.6% in antenatal clinic attenders. Most South African STD data are derived from ad hoc surveys which have traditionally focused only on several major infections and particular urban centres. Almost all STD studies have been facility-based, with many studies based at STD clinics, thus reporting only relative frequencies and not population-based prevalences of STDs. With the possible exception of HIV, systematic surveillance data for STDs are conspicuously lacking. CONCLUSION: The disease burden of classic sexually transmitted infections has historically been heavy, and continues to be a serious public health problem in South Africa. Morbidity from both ulcerative and non-ulcerative infections, particularly in women, is significant. The body of STD data, although mostly sound, remains incomplete, and with the rapid emergence of HIV in South Africa, surveillance of STDs and focused STD policies will be critical.

Kelleher, P; Severn, A; Tomson, C; Lucas, S; Parkin, J; Pinching, A; Miller, R

doi: 10.1136/sti.72.3.172pmid: 8707317

OBJECTIVE: Thrombotic microangiopathies have been increasingly recognised in HIV infection. The contribution of haemolytic uraemic syndrome (HUS) has not received as much emphasis as other members of the thrombotic microangiopathies. We describe the clinical features and prognosis of HUS in a group of patients with AIDS. SETTING: St Bartholomew's and The Middlesex Hospitals, London. PATIENTS: Five HIV seropositive individuals with clinical and histological features consistent with HUS. INTERVENTIONS: Blood transfusion, fresh frozen plasma, haemodialysis, renal biopsy, autopsy. CONCLUSIONS: HUS occurs in advanced HIV infection. Hypertension was a prominent clinical feature in HUS in this patient group. Measures to limit renovascular damage were unsuccessful and haemodialysis was usually needed to support renal function. The prognosis is poor, no patient achieved clinical remission and all died.

Schöfer, H; Imhof, M; Thoma-Greber, E; Brockmeyer, N H; Hartmann, M; Gerken, G; Pees, H W; Rasokat, H; Hartmann, H; Sadri, I; Emminger, C; Stellbrink, H J; Baumgarten, R; Plettenberg, A

Tayal, S C; Sankar, K N

doi: 10.1136/sti.72.3.181pmid: 8707319

Ronsmans, C; Bulut, A; Yolsal, N; Agaçfidan, A; Filippi, V

doi: 10.1136/sti.72.3.182pmid: 8707320

OBJECTIVE: To test the diagnostic validity of clinical algorithms for the detection of Chlamydia trachomatis in an urban population of married women in Turkey. DESIGN: Cross-sectional population-based survey. SUBJECTS: A systematic sample of 867 women who reported the use of contraceptive methods. MAIN OUTCOME MEASURES: Sensitivity, specificity and positive predictive value of clinical algorithms for the diagnosis of C trachomatis. RESULTS: C trachomatis was diagnosed in 4.89% of the women. The WHO algorithm for use in settings where no vaginal examination could be performed had a sensitivity of 9% and a specificity of 96%. The corresponding figures for the WHO algorithm incorporating the findings of a speculum examination were 47% and 56% respectively. Algorithms incorporating symptoms or signs other than those suggested by the WHO did not yield satisfactory standards of validity. CONCLUSIONS: The findings of this study do not support the widespread introduction of the use of clinical decision models for screening of women for chlamydia infection in primary health care settings such as family planning or antenatal clinics. The large number of false positive results with the use of the clinical algorithms tested in this study would cause unnecessary costs to the health system and unnecessary interventions to the women treated.

Williams, D I; Stephenson, J M; Hart, G J; Copas, A; Johnson, A M; Williams, I G

doi: 10.1136/sti.72.3.193pmid: 8707322

OBJECTIVE: To investigate current risk factors for HIV seroconversion among homo/bisexual men. DESIGN: Matched case control study in a large STD clinic in central London. Data on risk factors were obtained by case note review. METHODS: Fifty-six cases who had at least one negative HIV test followed by a positive test between June 1988 and July 1993, and two homo/bisexual controls (having two or more negative HIV tests) matched to each case on age, total number of HIV tests and test interval period were identified. Univariate and multivariate odds ratio were calculated for acute STD, ano-genital intercourse, condom use and HIV status of sexual partners. RESULTS: Adjusted odds ratios (95% confidence intervals) for HIV seroconversion were 4.1 (1.3-13.3) for having an acute interval STD and 4.6 (1.4-15.4) for having a known HIV infected sexual partner. Compared with men who always used condoms, odds ratios for men who sometimes or never used condoms were 7.9 (2.2-28.9) and 16.2 (3.0-86.0) respectively. Unprotected ano-genital intercourse was commonly reported by both cases and controls, and reported condom use was no greater with a known HIV infected partner than with a partner of unknown HIV status. CONCLUSION: HIV seroconversion among homo/bisexual men attending STD clinics is strongly related to having an acute STD, a known HIV infected partner and not using condoms. Although consistent use of condoms is highly protective, knowing that a partner is HIV infected does not ensure condom use between serodiscordant men. More effective, well-evaluated interventions are needed to reduce sexual risk-taking in this population.

Johnson, A M; Wadsworth, J; Wellings, K; Field, J

doi: 10.1136/sti.72.3.197pmid: 8707323

OBJECTIVES: To examine the pattern of attendance at sexually transmitted disease (STD) clinics in Britain. To compare the demographic characteristics, behaviours and attitudes of STD clinic attenders with those of non-attenders, and to assess the extent to which STD clinics are used by those with high-risk sexual lifestyles. DESIGN: Random sample general population survey of sexual attitudes and lifestyle. SUBJECTS: 18,876 randomly selected men and women resident in Britain aged 16-59 years. MAIN OUTCOME MEASURES: Demographic characteristics, pattern of homosexual partnerships, heterosexual partnerships, payment for sex, abortion, drug injection in the last five years, and attitudes to sexual behaviours amongst 512 respondents who had attended STD clinic in the last five years compared with those who had not. RESULTS: 8.3% of men and 5.6% of women had attended a clinic in their lifetime and 3.4% and 2.6% respectively in the last five years. Attendance rates varied substantially with area of residence. 11% of Inner London residents had attended in the last five years. In multivariate analysis, STD clinic attendance for men was most strongly associated with increased numbers of heterosexual partners, (OR = 6.01 (4.44-8.15) and homosexual partnerships (OR = 9.59 (5.83-15.8)) and more weakly associated with payment for sex, non-manual social class, age 25-44, unmarried status and smoking. Clinic attendance for women was most strongly associated with numbers of heterosexual partners (OR = 3.74 (2.76-5.08) and injecting drug use (OR = 4.39 (1.73-11.1)). A weaker independent association was found with a history of abortion, anal sex, non-manual social class, non-married status and age 16-24. From the total population, 1 in 6 men and 1 in 7 women in the top 5% of the distribution for numbers of heterosexual partners and 1 in 5 men paying for sex and 1 in 4 of those with a homosexual partner had attended a clinic in the last five years. The probability of attendance increased with multiple risk behaviours. Of women 64.2% and of men 69.7% attending clinics reported major risk markers for STD transmission. CONCLUSIONS: STD clinics in Britain are used by a wide demographic spectrum of the population. The behaviours, but not the attitudes, of attenders differed markedly from those of non-attenders. Clinics are relatively efficient in attracting only those with high-risk lifestyles, but, at a population level, the minority of those reporting risk-markers for STD transmission attend clinics. These findings suggest that STD clinics are an important focus for sexual health promotion, but that community programmes are also important for reaching non-attenders.

Postema, E J; Remeijer, L; van der Meijden, W I

doi: 10.1136/sti.72.3.203pmid: 8707324

OBJECTIVE: To determine how often chlamydial conjunctivitis is accompanied by a genital chlamydial infection and if there is a correlation between the dominant hand and the eye first infected. METHODS: We retrospectively studied the records of 65 patients with chlamydial conjunctivitis who were referred to the Outpatient Department of Sexually Transmitted Diseases (STD) of the University Hospital Rotterdam by ophthalmologists of the Eye Hospital Rotterdam. The patients have recently been asked by letter if they were left- or right-handed. RESULTS: Twenty of the 37 men (54%) had a positive chlamydial urethral culture. Seventy per cent of these men had no genital symptoms. Eight of the 37 men (22%) had a non-specific urethritis (NSU). Twenty of the 27 women examined (74%) had a positive chlamydial cervical culture. Sixty per cent of these women had no genital symptoms. Eight women with a genital chlamydial infection also had another genital infection. Five women without a genital chlamydial infection had another genital infection. Two women had no genital infection at all. A correlation between the eye infected and left- or right-handedness of the patient could not be found. CONCLUSIONS: A considerable percentage of the patients with a chlamydial conjunctivitis had a concomitant genital chlamydial infection. The majority of them had no genital symptoms. Since patients with chlamydial conjunctivitis and/or their partners possibly have a concomitant genital chlamydial infection, we recommend referral of both patients and sexual partners to an STD clinic for routine examination and systemic treatment when indicated.