Sexually Transmitted Infections

Brew, B J

doi: 10.1136/sti.69.5.333pmid: 8244348

Dikötter, F

doi: 10.1136/sti.69.5.341pmid: 8244349

This paper points to the congruence between political and social variables and the epidemiology of sexually transmitted diseases (STDs) in modern China. STDs became a major health problem after the fall of the empire in 1911 and were only reluctantly addressed by a weak nationalist government during the 1930s. During the 1950s and 60s, the communist regime brought STDs under control, but problems have reappeared since reforms were implemented during the 1980s. Cultural values and social attitudes have also structured medical responses to venereal disease. From the reform movements between the two World Wars to the more recent communist health campaigns, medical theory has often been confused with moral prescription.

Hippeläinen, M I; Syrjänen, S; Hippeläinen, M J; Saarikoski, S; Syrjänen, K

doi: 10.1136/sti.69.5.346pmid: 8244350

OBJECTIVE--To assess the diagnostic criteria of genital HPV lesions in male sexual partners of HPV infected women. METHODS--Peniscopically directed biopsy specimens (from 693 lesions in 300 men) were examined on light microscopy and in situ hybridisation (ISH) for HPV types 6,11,16,18,31,33 and 42. The predictive value of different histological criteria for ISH positivity was also evaluated using stepwise logistic regression analysis. RESULTS--Flat HPV lesions were most accurately predicted by the punctuation pattern on peniscopy, giving the concordance between peniscopy and histology between peniscopy and histology of 79.5% (66/83) and that between peniscopy and ISH of 56.6% (47/83). Diffuse acetowhite pattern disclosed a typical HPV lesion in only 17.8% (13/73), and HPV DNA was found in 11.0% (8/73) of cases. Of the 114 biopsy specimens from peniscopically healthy areas adjacent (0.5-1 cm) to the lesions, 93.0% (106/114) were normal on light microscopy, and HPV DNA was found in only 2.6%. Penile intraepithelial neoplasia (PIN) lesions were most frequently ISH positive, 81.1% (30/37), 50% showing HPV 16 and/or 18 DNA. Lesions classified as HPV-suspicious or nonspecific on light microscopy were HPV DNA-positive in 16.9% (11/65) and 8.1% (13/160), the frequency of high-risk HPV types being 3.1% and 1.3%, respectively. In logistic regression analysis, koilocytosis was the most powerful predictor of ISH-positivity in the flat lesions (without PIN), the risk ratio being 3.7. CONCLUSION--No conclusive peniscopic criteria for male HPV infections could be established, making histological evaluation mandatory. Care should be exercised in interpreting as HPV lesions the cases devoid of koilocytosis, HPV typing being essential in confirming the diagnosis in doubtful cases.

Le Bacq, F; Mason, P R; Gwanzura, L; Robertson, V J; Latif, A S

doi: 10.1136/sti.69.5.352pmid: 8244351

OBJECTIVE--To define the epidemiological characteristics of STD patients attending an outpatient clinic in rural Zimbabwe, to examine the aetiologic agents causing infection and to determine their relationship with HIV infection. SUBJECTS--319 men and 146 women, making a sample of about 7% all patients attending an STD clinic during the 3 month study period. Microbiological data were collected from 104 men and 72 women selected randomly from these. Pregnant women were excluded and patients who had received antibiotics within the previous 14 days were excluded from the microbiology sub-sample. SETTING--An outpatient STD clinic at a District Hospital on a major truck route about 300 km north of the capital, Harare. METHODS--All new patients attending the clinic during a 3 month period were enrolled for clinical and epidemiological investigations using a standard procedure. Specimens for microbiological investigation were taken from every second patient seen on the first three days of each week. RESULTS--The typical patient was male (m:f ratio 2.2) aged 20-29 years (68% patients), not married (56% men) and in paid employment (66% men vs. 27% for the district). In men the most common presenting feature was genital ulceration, while in women, discharges were more common. Genital warts were noted frequently in both sexes. In the sub-sample examined microbiologically, H ducreyi was isolated from 46% ulcers clinically diagnosed as chancroid, and motile spirochaetes were detected in 25% painless ulcers. Neither of these were detected in ulcers in women, but HSV antigen was found as frequently in ulcers from men (19%) as from women (17%). In patients with genital discharges, gonococcal infection occurred in 64% men and 17% women, while T vaginalis was isolated from 39% women and only 8% men. Over 60% gonococcal isolates were PPNG, and 18% showed in vitro resistance to tetracycline. Yeasts, mainly C albicans were isolated from 42% women with a discharge and 25% women with ulcers. In men the presence of yeasts was associated with superficial ulceration and itchiness of the glans. Positive HIV-1 serology was found in 64% patients. There was no statistical association with current genital ulcers, though there was an association with previous STD episodes and particularly with serological evidence of syphilis. Apart from yeasts, there was no association between positive HIV-1 serology and the presence of pathogens in the genital tract. CONCLUSIONS--The high prevalence of HIV-1 antibodies in STD patients in Karoi suggests integration of STD and AIDS control programmes to be a necessity. Since paid employment was a common feature of both STD clinic attendance and HIV-1 seropositivity, these programmes may be effectively directed through the work place.

Kharsany, A B; Hoosen, A A; Moodley, J; Bagaratee, J; Gouws, E

doi: 10.1136/sti.69.5.357pmid: 8244352

OBJECTIVE--To determine the association of sexually transmitted pathogens in women with cervical intra-epithelial neoplasia (CIN). SETTING--An urban tertiary referral hospital serving a large indigent developing community. PARTICIPANTS--48 women attending a colposcopy clinic and 49 women attending a family planning clinic. METHODS--Vaginal, endocervical, rectal swab specimens and sera were collected for the detection of sexually transmitted pathogens. Cervical cytology was performed on all patients. Women attending the colposcopy clinic had confirmation of abnormal cervical cytology by colposcopic directed biopsy. RESULTS--The mean age of women with CIN (33 years) was significantly greater than that of the women without CIN (28 years) and that of the family planning group (26 years). There was a high prevalence of sexually transmitted pathogens in all women. A significantly higher prevalence of bacterial vaginosis was found in women with CIN compared to those without (50% vs 20%; p = 0.034). The human papilloma virus (HPV) was detected in 46% of women with CIN and 65% of those without CIN. Chlamydia trachomatis (21%) and Trichomonas vaginalis (39%) were detected frequently in women with CIN. C. trachomatis (14%-21%) was detected more frequently than Neisseria gonorrhoeae (3-5%) in all asymptomatic women studied. CONCLUSION--This study demonstrates a high prevalence of sexually transmitted pathogens in women with and without CIN as well as family planning clinic attenders. Bacterial vaginosis was a significant finding in women with CIN. C. trachomatis was detected in a high proportion of all women studied and found more commonly than N. gonorrhoeae. We therefore recommend that all women attending gynaecological services in a developing community be investigated and treated for sexually transmitted diseases.

Hoosen, A A; O'Farrell, N; van den Ende, J

doi: 10.1136/sti.69.5.361pmid: 8244353

OBJECTIVE--To investigate the aetiology of acute epididymitis in a developing community with a view of determining appropriate antimicrobial therapy. SETTING--City Health Sexually Transmitted Diseases Clinic, King Edward VIII Hospital, Durban, South Africa. PARTICIPANTS--144 adult men with clinically diagnosed acute epididymitis. METHOD--Endourethral swab and midstream urine (MSU) specimens were processed to detect sexually transmitted pathogens and urinary tract infections. RESULTS--The majority of patients (93%) were less than 35 years of age. Neisseria gonorrhoeae and/or Chlamydia trachomatis were detected in 78% of patients: N gonorrhoeae in 57%, C trachomatis in 34% and both in 13%. Escherichia coli was cultured more frequently from MSU specimens of older patients, 30% versus 3%. In 53% of patients urethritis was diagnosed by the presence of inflammatory cells in endourethral smears in the absence of a visible urethral discharge. CONCLUSION--In our setting of a busy clinic with limited facilities, we recommend the performance of a Gram stain on endourethral specimens from patients with acute epididymitis. If inflammatory cells and Gram negative diplococci are detected, treatment with antimicrobial agents to cover both penicillinase-producing N gonorrhoeae strains and C trachomatis is recommended. If Gram negative diplococci are not detected in the presence of microscopic evidence of urethritis, treatment for chlamydial infection alone is recommended.

doi: 10.1136/sti.69.5.364pmid: 8244354

OBJECTIVE--To review and analyse the changing incidence of gonorrhoea and the increasing antibiotic resistance in gonococci in Australia from 1981 to 1991. DESIGN--Use of data from the sample of gonorrhoea in Australia examined by the Australian Gonococcal Surveillance Programme (AGSP), a continuing long-term multi-centric study of gonococcal disease and gonococcal susceptibility to antibiotics, over the period 1 July, 1981 to 30 June, 1991. RESULTS--Over 32,000 cases and strains from defined sources were examined in the 10 year study period. The number of cases of gonorrhoea in the sample decline from a peak of 6599 in 1982-1983 to 1121 in the final year under review, a reduction of 83%. Periods when greater than average reductions in incidence occurred in different groups were noted. Ano-rectal gonorrhoea in men decreased sharply in 1985 during an overall decline of 92.5% recorded between 1 July, 1981 to 30 June, 1987. However, the incidence of ano-rectal cases in males rose in subsequent years while gonorrhoea, overall, continued to decrease and at a greater rate after 1985. Antibiotic resistance in gonococci in Australia was manifested both as a progressive increase in the levels of intrinsic resistance to the penicillins and through the appearance and spread of penicillinase-producing N gonorrhoeae (PPNG). At the end of the review period in June, 1991, 8.8% of gonococcal isolates in Australia showed high levels of intrinsic resistance to the penicillins and 13% of strains were PPNG. These separate mechanisms of resistance appeared at different times in different parts of Australia, and their importance also varied throughout the country. Most infections with PPNG were acquired by men overseas whereas most women with PPNG were infected locally. Endemic spread of PPNG was a significant problem in Sydney and Melbourne, but decreased in importance in the later years of the study. CONCLUSIONS--In the past decade a large reduction in the incidence of gonorrhoea and, by implication, other STDs has occurred in the past decade in Australia. In some groups of patients the decline in incidence is continuing while in others a slight increase has been noted. Resistance to antibiotics of gonococci in Australia was mainly restricted to the penicillins, but through both chromosomal and plasmid-mediated mechanisms. This resistance was seen particularly in Sydney and Melbourne where endemic cycles of transmission of PPNG were established, and in infected travellers from S-E Asia in other centres. Valid and comparable, and regionally relevant data are a continuing requirement for assessing and modifying antibiotic treatment regimens for gonococcal disease.

Horner, P J; McBride, M; Coker, R J; Crowley, S; Harris, J R; Murphy, S M; Weber, J N; Renton, A M

doi: 10.1136/sti.69.5.370pmid: 8244355

OBJECTIVE--To describe patterns of attendance for follow-up among HIV infected women in Parkside, UK and their correlates. DESIGN--Retrospective cohort study. SUBJECTS--103 HIV infected women. MAIN OUTCOME MEASURES--Whether patients attended for follow-up between three and 18 months. RESULTS--31% of women were married and 46% had children. Women born in sub-Saharan Africa were significantly less likely to attend for follow-up after three months (56%) than women born in other areas who had acquired HIV either heterosexually (82%) or through injecting drug use (81%). This pattern persisted on multivariate analysis controlling for whether women were symptomatic, had had a previous positive test, were married or had children. CONCLUSIONS--HIV positive sub-Saharan African women are less likely to reattend for follow-up than women with heterosexually acquired HIV from other areas or those who acquired infection through intravenous drug use. Further studies are needed to identify barriers to follow-up for women and to shape the development of more appropriate and accessible services for HIV infected women, especially those of sub-Saharan African origin.

Unsworth, D J; Rowen, D; Carne, C; Sonnex, C; Baglin, T; Brown, D L

doi: 10.1136/sti.69.5.373pmid: 8244356

OBJECTIVE--To determine whether HIV (Human Immunodeficiency Virus) antibody positive adults are capable of mounting an effective immune response when immunized with polyvalent pneumococcal vaccine. DESIGN--28 patients (nine homosexual men, one bisexual man, three heterosexual females, 10 injecting drug abusers, five haemophiliacs) and 11 healthy volunteers, were immunised with Pneumovax II and titres of IgG1 and IgG2 specific antibody measured before and 1 month after immunisation. Magnitude of immune response was related to CD4 T-lymphocyte count at time of immunisation to establish whether responses are better in early disease. MAIN OUTCOME MEASURES--Based on our data in healthy volunteers we defined an adequate response to Pneumovax II as a post immunisation IgG2 antibody level at least 50% greater than the pre immunisation level. RESULTS--The magnitude of the response was significantly higher in the normal volunteers (U = 95; p = 0.0328). Adequate IgG2 responses were seen in 11/11 normals but in only 14/28 HIV seropositives (chi 2 = 8.58; p < 0.01). Poor responses were unrelated to the CD4 T-lymphocyte count at immunisation. Absolute IgG2 deficiency accounted for the poor response in only 1 HIV patient. CONCLUSION--50% of HIV antibody seropositive individuals fail to mount adequate immune responses to polyvalent pneumococcal vaccine. Non responders are unlikely to be protected.

Evans, J K; Bingham, J S; Pratt, K; Carne, C A

doi: 10.1136/sti.69.5.377pmid: 8244357

OBJECTIVE--To assess the knowledge and attitudes of medical students to HIV/AIDS and whether attitudes correlate with knowledge and clinical experience. To determine if students felt adequately prepared to deal with medical and psychological aspects of HIV/AIDS. SUBJECTS AND METHODS--The subjects consisted of 190 London and 99 Cambridge medical students at the end of their genitourinary medicine attachment, plus 230 Cambridge medical students at the end of their second pre-clinical year. Between March 1991 and February 1992 all were asked to complete an anonymous questionnaire, covering factual knowledge and attitudes towards HIV/AIDS. MAIN RESULTS--Cambridge genitourinary medicine students, despite spending less time studying HIV infection than their London counterparts gave more correct answers to the factual questions, although this difference did not reach significance (52.4% vs. 47.5%, p = 0.14). One third of students believed that many health care workers were at high risk of acquiring HIV at work and one fifth thought doctors should have the right to refuse to treat people with HIV. Fourteen percent of Cambridge genitourinary medicine students indicated that most British people with HIV have only themselves to blame, by comparison with 4% of London students (p = 0.003). Thirty-nine per cent of Cambridge genitourinary medicine students expressed reluctance to care for someone with AIDS by comparison with 10% of London students (p = 0.0001). CONCLUSIONS--It is important that medical educators convey accurate information about HIV, including the actual risks posed by occupational exposure and try to ensure that medical students spend sufficient time seeing patients with HIV/AIDS during their training.