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doi: 10.1136/sti.75.1.3pmid: 10448335
OBJECTIVES: To review the scientific data on the role of sexually transmitted diseases (STDs) in sexual transmission of HIV infection and discuss the implications of these findings for HIV and STD prevention policy and practice. METHODS: Articles were selected from a review of Medline, accessed with the OVID search engine. The search covered articles from January 1987 to September 1998 and yielded 2101 articles. Methods used to uncover articles which might have been missed included searching for related articles by author, and combing literature reviews. In addition, all abstracts under the category "sexually transmitted diseases" from the XI and XII International Conferences on AIDS (Vancouver 1996 and Geneva 1998) and other relevant scientific meetings were reviewed. Efforts were made to locate journal articles which resulted from the research reported in the identified abstracts. All original journal articles and abstracts which met one of the following criteria were included: (1) studies of the biological plausibility or mechanism of facilitation of HIV infectiousness or susceptibility by STDs, (2) prospective cohort studies (longitudinal or nested case-control) which estimate the risk of HIV infection associated with specific STDs or STD syndromes, or (3) intervention studies which quantitate the effect which STD treatment can have on HIV incidence. RESULTS: Strong evidence indicates that both ulcerative and non-ulcerative STDs promote HIV transmission by augmenting HIV infectiousness and HIV susceptibility via a variety of biological mechanisms. These effects are reflected in the risk estimates found in numerous prospective studies from four continents which range from 2.0 to 23.5, with most clustering between 2 and 5. The relative importance of ulcerative and non-ulcerative STDs appears to be complex. Owing to the greater frequency of non-ulcerative STDs in many populations, these infections may be responsible for more HIV transmission than genital ulcers. However, the limited reciprocal impact of HIV infection on non-ulcerative STDs and the evidence that non-ulcerative STDs may increase risk primarily for the receptive partner (rather than bidirectionally) may modulate the impact of these diseases. The results of two community level randomised, controlled intervention trials conducted in Africa suggest that timely provision of STD services can substantially reduce HIV incidence, but raise additional questions about the optimal way to target and implement these services to achieve the greatest effect on HIV transmission. CONCLUSIONS: Available data leave little doubt that other STDs facilitate HIV transmission through direct, biological mechanisms and that early STD treatment should be part of a high quality, comprehensive HIV prevention strategy. Policy makers, HIV prevention programme managers, and providers should focus initial implementation efforts on three key areas: (i) improving access to and quality of STD clinical services; (ii) promoting early and effective STD related healthcare behaviours; and (iii) establishing surveillance systems to monitor STD and HIV trends and their interrelations.
doi: 10.1136/sti.75.1.18pmid: 10448336
Cytomegalovirus (CMV) retinitis is the commonest ocular complication of AIDS and the prevention of recurrence has been dependent on lifelong maintenance treatment. Recently there has been a dramatic downturn in the number of new cases of CMV retinitis, which has been attributed to the introduction of highly active antiretroviral therapy (HAART) and subsequent improved survival. Whereas paucity of inflammation has been considered to be the hallmark of the ophthalmic manifestations of AIDS, with immune recovery, a new pattern of ophthalmic AIDS has emerged. This is characterised by a heightened inflammatory response and more frequent complications associated with this response--for example, vitritis, cystoid macular oedema. In spite of this, regression of CMV retinitis has been reported, as well as absence of reactivation or progression after withdrawal of anti-CMV maintenance treatment. How long this situation will continue is not known and we remain cautious about the future of CMV retinitis and other opportunistic ocular infections.
doi: 10.1136/sti.75.1.21pmid: 10448337
Further research is necessary to elucidate the pathogenesis of chlamydial PID. It is hoped that these endeavours will eventually lead to a vaccine to prevent not only chlamydia infection, but also chlamydia associated infertility, ectopic pregnancy, and chronic pelvic pain. In the meantime we need to develop strategies to prevent primary and secondary chlamydia infection and its sequelae. Recently, Scholes et. al demonstrated that a population based approach to identify and test women at high risk for cervical C trachomatis infection effectively reduced risk of PID. Hopefully, through the use of public health measures, we can see similar decreases of chlamydia associated genital tract disease worldwide.
Howling, S J; Shaw, P J; Miller, R F
doi: 10.1136/sti.75.1.25pmid: 10448338
OBJECTIVES: To determine the incidence, mode of presentation, and outcome of pulmonary embolism (PE) in patients with HIV infection. METHODS: Retrospective review of clinical case records, imaging department database, and necropsy reports of patients admitted to the specialist HIV/AIDS unit at UCL hospitals from April 1993 to August 1997 in order to identify those with a diagnosis of PE. RESULTS: During the study period there were 3792 admissions of whom 10 (0.26%) had PE. All patients with PE presented with fever, seven were dyspnoeic, and seven had cough: all were thought initially to have respiratory infection. Only five patients had pleural pain. All 10 patients had abnormal baseline chest radiographs. The diagnosis in six was made by computed tomograph (CT) pulmonary angiography, in two was made by ventilation perfusion (V/Q) scanning, in one by both techniques, and in one at necropsy. CT angiography in addition to identifying thrombus also showed concomitant lung parenchymal abnormalities in all but one patient. Nine patients with PE had one or more risk factors for venous thromboembolism as did 34/40 case matched controls (odds ratio = 1.67; 95% confidence interval = 0.18-15.5). All patients diagnosed in life were anticoagulated and five survived. CONCLUSIONS: PE was uncommon in this HIV infected population. The diagnosis should be considered in patients with respiratory infection which does not respond to antibiotics. Identifiable risk factors for venous thromboembolism appear to be unhelpful in increasing clinical index of suspicion for PE. As baseline chest radiographs are frequently abnormal, the diagnostic utility of V/Q scanning may be reduced and CT pulmonary angiography is the imaging modality of first choice.
Limpakarnjanarat, K; Mastro, T D; Saisorn, S; Uthaivoravit, W; Kaewkungwal, J; Korattana, S; Young, N L; Morse, S A; Schmid, D S; Weniger, B G; Nieburg, P
doi: 10.1136/sti.75.1.30pmid: 10448339
OBJECTIVES: To determine demographic and behavioural factors and sexually transmitted infections (STIs) associated with prevalent HIV-1 infection among brothel based and other female sex workers (FSWs) in Chiang Rai, northern Thailand. METHODS: Data were collected from questionnaires, physical examinations, and laboratory evaluations on Thai FSWs enrolled in a prospective cohort study in Chiang Rai, Thailand, from 1991 to the end of 1994. RESULTS: HIV-1 seroprevalence was 32% among 500 women: 47% for 280 brothel workers and 13% for 220 other FSWs (p < 0.001); 96% of infections were due to HIV-1 subtype E. At enrolment, other STIs were common: chlamydia, 20%; gonorrhoea, 15%; active syphilis (serological diagnosis), 9%; genital ulcer, 12%; seroreactivity to Haemophilus ducreyi, 21%, and herpes simplex virus type 2 (HSV-2), 76%. On multiple logistic regression analysis, HIV-1 was associated with brothel work, birth in upper northern Thailand, initiation of commercial sex at < 15 years of age, syphilis, HSV-2 seropositivity, and genital ulcer. CONCLUSIONS: Young Thai FSWs working in brothels in northern Thailand in the early phase of the HIV epidemic have been at very high risk for HIV-1 infection and several other STIs. Programmes are needed to prevent girls and young women from entering the sex industry and to reduce the risk of infection with HIV-1 and other STIs.
Kellock, D J; Piercy, H; Rogstad, K E
doi: 10.1136/sti.75.1.36pmid: 10448340
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.
Temple-Smith, M J; Mulvey, G; Keogh, L
doi: 10.1136/sti.75.1.41pmid: 10448341
OBJECTIVE: To examine general practitioners' (GPs') attitudes towards taking a sexual history. METHODS: Questions on sexual history taking were included in a random survey on the STD knowledge, attitudes, and practices of 600 GPs practising in Victoria, Australia. RESULTS: Most GPs commonly asked patients about safe sex (79%), number of sex partners (63%), and injecting drug use (60%) while fewer asked about recent overseas travel (50%) and sex with sex workers (31%). GPs who performed sexual health consultations daily or weekly identified barriers to sexual history taking to be of less concern than those who performed such consultations infrequently. Most GPs (92%) would take a sexual history from a man presenting as the sexual contact of an infected partner, but less than a third would do so for a patient routinely requesting the contraceptive pill (28%), a Papanicolaou (Pap) smear (30%), or advice about immunisation before overseas travel (30%). Female GPs were significantly more likely than male GPs to take a sexual history in those clinical situations involving a female patient and also to perceive these patients as experiencing less embarrassment. CONCLUSIONS: This study highlights both the lack of opportunistic sexual history taking and the main barriers to sexual history taking in general practice in Victoria, Australia. The importance of educating both patients and GPs about sexual history taking are discussed.
Winceslaus, J; Blount, J; Cryer, C
doi: 10.1136/sti.75.1.45pmid: 10448342
OBJECTIVES: To devise a method of communicating with the general practitioners (GPs), overcoming the constraints imposed by patient confidentiality and the low levels of staffing in genitourinary medicine (GUM) clinics. To assess the GPs' responses to this method of communication. SETTING: GUM clinics at two centres in Kent-Maidstone and Tunbridge Wells. METHODS: Patients were recruited if they attended the clinic of their own accord without a letter of referral from their GPs; a definitive or provisional diagnosis was made and the patient was managed in the clinic; the patient's GP had received a conventional reply from the GUM clinic for other patients referred in the past. Separate GP letters were developed for male and female patients. These handwritten study letters were read by the patients who took the responsibility to deliver them to their GPs. This was followed by a questionnaire to the GPs. RESULTS: 75 patients were eligible. Seven patients refused to participate. All questionnaires were returned by the GPs for the 68 participating patients (100%). Seven GPs failed to receive the study letter. For these unreferred patients, this was an improvement in communication level from 0% to 80%. 79% (95% confidence interval: 67%-87%) preferred the study letter, 97% (89%-99%) would like to receive a similar letter for future patients. All GPs thought that the study letter was at least as good as the standard letter 52% (40%-64%) thought it was better. For 82% (70%-90%) it was the preferred format for future communication. CONCLUSION: The study has shown a way of establishing communication with GPs for patients who do not object to this. The results also suggest that in the study districts neither the GPs nor the majority of study patients had any objection to the sharing of information between the GUM clinics and GPs.
doi: 10.1136/sti.75.1.49pmid: 10448343
BACKGROUND: Genital infection with herpes simplex virus (HSV) is common and can cause severe morbidity, over many years in some cases. Aciclovir provides suppressive therapy but there is debate over the effects of its use on the spread of infection. OBJECTIVES: To explore the influence of the natural history of genital HSV and the impact of antiviral therapy. METHODS: A simple mathematical model of HSV-2 transmission dynamics was developed, and parameter values estimated from published data. RESULTS: The relative durations of the risk of transmitting HSV-2 and the duration of therapy generate a non-linear relation between the duration of antiviral therapy and the reduction in prevalence infection. If there is a wide distribution of risk of HSV-2 transmission over the course of an infection then practicable aciclovir use is unlikely to have any great impact on disease transmission dynamics. CONCLUSIONS: There are still many uncertainties in the transmission dynamics of HSV-2. In particular, infectiousness over the course of an infection requires more detailed exploration. To have a significant impact on the prevalence of HSV-2 aciclovir use would have to be widespread and for a long duration.
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