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This year's spring meeting was held in Belfast's Waterfront Hall. We opened with a satellite meeting of the sexual dysfunction special interest group. Frances Keane assured us that assessment of the patient with an ejaculatory disorder started at reception, when their timeliness for appointments could give useful information. Low dose SSRIs or tricyclics have been used effectively for this unlicensed application but can themselves cause erectile dysfunction. Sildenafil (Viagra) may work by reassurance that their erection will last.
We heard a highly entertaining discourse on the determinants of sexual orientation by John Green. He reckoned any genetic determinant for homosexuality should be selected out, since homosexual men have about one fifth as many children as heterosexuals. No hormonal or immunological theories have borne scrutiny. From family studies it would appear that birth order is important: the more older brothers a man has the more likely he is to be homosexual. There is a higher rate of homosexuality in siblings of homosexual men and women.
We heard a lot about the internet and world wide web in the first plenary session, one presentation, and a poster. Three speakers explored the many ways in which the web could be used to our advantage.
We were also reminded of security issues, and the difficulties of typing in key words pertaining to GUM. Just suppose your area of interest is prostitution!
The benefits of collection of information through web based surveys and the dissemination of information to profession and public were discussed. Teaching, through web based lectures or interactive sites, can be accessible at any time and taken at the pace of the student. Sharing of epidemiological data and early warning of outbreaks can make the internet a useful tool for disease control.
Syphilis rates are low but rising, principally among men who have sex with men, and this was illustrated in three papers. Repeatedly, unprotected oral sex between homosexual men with casual partners was a significant risk factor. Oral sex is considered by many to be “safer sex” and condoms are not widely used.
Here for no particular reason, I will mention that that other ex-president, Bill Clinton, was in Belfast at the same time, staying at the Hilton hotel. Many of us managed to catch a glimpse, some even made contact!
The difficulties of providing good GUM services in prisons were explored by Dr Vince Reilly. We know that one in four inmates has injected drugs but we have little idea of the burden of STD in this potentially high risk population.
Dr Cathy Ison presented the results of 4 years of surveillance of gonorrhoea resistance patterns. They have seen a 78% increase in the number of cases of gonorrhoea, with >5% resistance to penicillin. Reduced susceptibility to ciprofloxacin has risen from 0.5% to 2.5%.
Preliminary data from a prospective head to head comparative study of five commonly used clinic based treatment for genital warts were presented by Dr Lynn Riddell. This won the prize for the best presentation. Though no statistics were given because of the small numbers (n=138) at this stage, a trend favouring combination therapy (for example, cryotherapy and podophyllin) was emerging. So, watch this space for evidence for the effectiveness of “real life” wart treatment.
A reception and tour of City Hall followed.
In Friday morning's plenary session, Dr Phil Kell told us “What's new in the management of erectile dysfunction.” On the horizon is sublingual apomorphine, effective in 40 minutes, and with fewer interactions than sildenafil.
There was an entertaining debate of the motion “This house believes that education and counselling cannot produce significant and lasting changes in sexual behaviour.” Dr Oliver Davidson speaking against the motion persuaded the house to change from 72 for and 77 against to 55 for and 92 against, after the debate.
A McOwan and colleagues presented the result of their postal survey of four central London primary care groups. Of the 120 replies received (51% response rate), 85% categorised themselves as currently offering level 1 service in the sexual health strategy. Only 11% wish to offer level 2 service for the future. Interestingly, only 2% of these general practitioners surveyed would currently look to another general practitioner service in their primary care group area for specialist support.
Gill Hennebry presented the results of an excellent peer designed survey of young people in six schools and a pupil exclusion unit. It should come as no surprise that young people have the same priorities as everyone else. They rate good communication skills and sensitivity—“friendliness”—higher than anything else we might think should be on offer. After-school opening times, female staff, and separate “young people friendly” services were also preferred.
Next was a question and answer session on the MSSVD management guidelines. Of particular interest was a very thorough explanation of the guidelines for the management of PID by Jonathan Ross. He highlighted the lack of evidence to support the use of oral doxycycline and metronidazole in outpatient treatment of PID, and thus the recommendation of ofloxacin and metronidazole.
A plenary session took the audience to the dizzy heights of pure science in the form of microbial genomics, the “genetic make-up of bugs.” We learned that sequencing genes of bacteria can aid development of diagnostic tools and vaccines, rational therapy design, and understanding of drug resistance. In addition to discovering the complete genetic sequence of Neisseria gonorrhoeae and serovar D of Chlamydia trachomatis, the humble Candida albicans was found to have genes associated with mating!
In the Harrison Lecture Dr Nicol Thin poignantly reminded the audience that the career of Colonel Harrison had exemplified the principles of clinical audit, research, appraisal, peer review, and lifelong learning, demonstrating that clinical governance is not a 21st century invention.
From Glasgow, Dr Lina Hijazi found that 50% of women, 15% of homosexual men, and 28% of heterosexual men with gonorrhoea were co-infected with chlamydia, with higher rates in younger patients. Screening 14 294 people for chlamydia in Portsmouth revealed that 9% of women and 17.5% of men were infected. A significant number had concurrent STIs—any screening programme should trigger a full screen in positive patients.
Dr Herieka presented a survey of 500 university students in Sudan on female genital mutilation (FGM). There, the practice is (almost) illegal and not a religious requirement. Of the male students, 75% did not prefer a circumcised female. Mothers and grandmothers were mostly held responsible for instigating FGM in the 56.8% of women who said they were circumcised.
A 3M sponsored satellite symposium concentrating on genital warts and herpes was followed by a dinner at Belfast Castle. An auction of rare old medical textbooks including the highly desirable The psychiatric treatment of promiscuous young girls was expertly conducted by Drs Kinghorn and Barton. We were then treated to a fine exhibition of Irish dancing—but not by George and Simon.
On the last day we heard from the Nottingham investigators that 26% of wet preparations of vaginal discharge containing Trichomonas vaginalis can become negative in 10 minutes depending on the conditions. They can also last over 4 hours! Wet slides should be read promptly.
Nick Larbalestier presented 11 years' experience of antenatal care of HIV positive women at Guy's and St Thomas's in London. An increasing number of women conceive while on HAART. Over the years women have been accepting interventions to reduce mother to child transmission from 28% to less than 1%. No transmission has occurred since 1998 in a retrospective review of 147 pregnancies, with no identifiable harm to offspring from ART exposure. While HAART combinations are increasingly prescribed, monotherapy continues to be used in women for whom combinations are not clearly indicated. Denial remains an issue in women who decline intervention.
Dr Kinghorn's presidential address proved that you don't need Charlie Dimmock to make horticulture sexy. His entertaining and thought provoking talk “Passion, stigma, and STIs” was beautifully illustrated with amorous plants. Some practitioners are reluctant to send patients to GUM clinics because of their own prejudice, but for each of their patients referred, four or five have self referred. We should not forget that spending money preventing HIV transmission is a worthwhile investment, considering the high cost of treating one patient with HIV. He contrasted the high cost, low volume care of HIV patients with the high volume day to day care of STD patients and reminded us of the equal value of “sexy” HIV medicine and run of the mill activities. New names for a society taking politics, sexual health, and HIV care under one umbrella were suggested: BASTDs (British Association for STDs) was rejected as questioning our parentage; STIGMA (Sexually Transmitted Infections, Genitourinary Medicine and AIDS) is attractive but could be counterproductive. We like SSSHH—you know who (Society for the Study of Sexual Health and HIV).
Dr Brian Gazzard jetted in for a question and answer session on HIV. He feels that HAART should be started well before the CD4 counts fall to 200, but did not specify a number. He felt that stopping treatment in those with a high CD4 count who started HAART because of a high viral load would result in a rapid fall to previous levels very quickly, but this may not be a problem if the nadir was high. For those on HAART with suppression of viral load with no increase in CD4 he suggested IL-2 though a more functional improvement may be obtained by combining it with GMCSF. The risk of opportunistic infections occurring with undetectable viral load is low.
Mike Brady reviewed the experience of treating primary HIV infection with short course HAART. Of 29 patients with primary HIV, 22 elected to take HAART of combivir plus either nevirapine or nelfinavir. The median plasma viral load pretreatment was 136 000 and post-treatment was 59 618. Early results suggest that preservation of HIV specific responses is possible and that no significant mutations were detected off treatment. This presentation won the Boehringer-Ingelheim prize jointly with Dr Judges's paper on lipodystrophy (qv).
Dr Prasad from Canada described the Merlin immediate test for HIV-1 and HIV-2 antibodies. This is a “point of care” test of fingerprick blood samples, which gives results in 5 minutes. Tests on 3212 subjects demonstrated negative and positive predictive values of 99.96% and 100% respectively.
Professor Jonathan Weber presented a study of the differing resistance mutations in RT or protease found in PBMCs and bronchoalveolar lavage fluid from patients on therapy. He suggested that differences in mutations were most likely to be due to inadequate levels of active drug for various reasons. Professor Weber went on to present two papers looking at the suitability of treating 79 African patients with non-B HIV-1 subtypes with HAART regimens developed in white patients in the West. He found NNRTI and protease containing treatment to be effective in African patients, with baseline polymorphisms in RT and protease not contributing to drug failure. African patients on nelfinavir may show delayed development of D30N mutations in protease.
The natural history of lipodystrophy was investigated by Lucy Judges et al. After 1 year, at least 80% reported stabilisation of fat redistribution of at least one body region without changing HAART.
The MSSVD's secret weapon to hold on to the audience to the end, Dr Colm O'Mahony, had us in stitches as usual talking about private genitourinary medicine.
There were 50 posters. Three outlined recent syphilis outbreaks in Brighton, Peterborough, and north Manchester. Several others devoted to antimicrobial resistance patterns of Neisseria gonorrhoeae, with Ireland reporting low (1%), but Liverpool increasing (6.2%) prevalence of quinolone resistant strains in 2000. Investigators from Hull reconfirmed the old axiom of no sex, in men at least, no urethritis. Dr Keane won the first Maggie Godley Memorial Prize for her poster, “Offering routine antenatal testing for HIV/hepatitis B in a rural county.”
The prize for the best poster went to Dr A Leung for his study of urinary tract infection in patients with acute non-gonococcal urethritis. He reported 6.4% prevalence of urinary tract infection in these patients, and recommends that an MSU should be tested by nitrite and leucocyte esterase dipsticks and cultured accordingly in patients with symptoms.
The Leeds group reported a decrease in waiting time and default rate when a walk-in clinic was introduced to run alongside booked clinics; the Glasgow group reported that more homosexual men accessed dedicated specific sexual health service (61%) than the core GUM service (38%), though the latter group had more STIs; in the Isle of Wight patient, rather than provider, referral for partner notification was preferred by index cases.
A fine dinner in the spectacular setting of Stormont followed a hotly contested one-all draw in the GUM football shield.
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