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Brief Encounters
  1. Helen Ward, Editor

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    PARENTS AND ETHICS

    Many people living with HIV want to have children, but would like to reduce the risk of harm to their sexual partners and offspring. Sharma and colleagues on the one side, and Taylor on the other, debate the ethical and practical issues involved. Sharma provides an optimistic view, and argues that it is unethical to deny infertility treatment to HIV couples. Taylor is more guarded, raising concerns about the long term impact on children. Both sides agree that it is possible, and ethical, to provide advice and support to reduce the risk of transmission to partner or child. But, as Taylor points out, there is currently no funding for sperm washing, an intervention that both sides in the debate agree is essential. We should also remember that for millions of people with HIV, effective interventions to reduce vertical transmission are not even available, leading to millions of AIDS orphans. See p 185 and p 189

    POSTCODE LOTTERY?

    The UK is one of the few countries in the world with a substantial network of open access STD clinics and a speciality of genitourinary medicine. But as Carne and colleagues show, this does not lead to uniform standards and a strong evidence base! In a study carried out by the British Cooperative Clinical Group of the MSSVD, wide variation in practice over the most basic protocols was identified. Six per cent of clinics do not offer syphilis screening routinely to heterosexual men, and only 71% meet the national target of offering HIV screening to all. The study highlights some gaps in the evidence base, including: who should be required to attend for a test of cure? What is the additional benefit of cervical microscopy? Why do 79% of clinics culture for candida in asymptomatic women? Sounds like a practical set of research topics for the National Sexual Health Strategy to fund! See p 240


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    See page 179.

    STREAMLINING INFORMED CONSENT

    How can we offer HIV screening to all patients attending for a sexual health check, maintain pretest counselling and consent, and not collapse under the workload? To address this question, Rogstad and colleagues monitored the impact of introducing written pretest information on HIV. A leaflet was prepared and handed to all new patients. The result was an increase in the proportion of patients offered a test and in uptake of the test. This simple change should be widely introduced. See p 243

    ON SITE ANTENATAL TESTING FOR SYPHILIS

    Congenital syphilis is an important global health problem, partly resulting from poor facilities for antenatal testing and treatment in many countries. Delays in treatment while laboratory results are obtained may be a contributory factor. Myer and colleagues carried out a randomised controlled trial of the impact of introducing on site syphilis testing in 14 rural health clinics in South Africa. In contrast to more promising observational studies, they did not find any significant increase in treatment rates or reduction in perinatal mortality. See p 208

    MUTUAL (MIS)TRUST?

    How well do people know their sexual partners? Stoner and colleagues identified 151 heterosexual patients with gonorrhoea or chlamydia, and interviewed them and 189 of their sexual partners to find out what they know about each other. People were pretty good at knowing the age and ethnicity of their partners, but knew far less about their sexual behaviour. There was only 50% agreement on the numbers of sexual partners in the past three months. Women overestimated their partners’ likelihood of paying for sex while men underestimated their partners’ likelihood of selling sex. The authors suggest that prevention programmes should include methods of enhancing communication between partners. See p 197

    THE SICK CAN GET SICKER

    Apoola and colleagues describe an HIV infected patient who presented with widespread lymphadenopathy and pancyopenia that was originally ascribed to tuberculosis. Lymph node biopsy showed both Kaposi’s sarcoma and multicentric Castleman’s disease. Despite both chemotherapy and antiretroviral therapy the patient progressively deteriorated with confusion and dysphasia. Cranial magnetic resonance imaging showed central pontine myelinolysis. This case demonstrates several learning points. Firstly, multicentric Castleman’s disease should be included in the differential diagnosis of diffuse lymphadenopathy and pancytopenia, secondly, more than one disease process may coexist in a biopsy specimen, and thirdly, central pontine myelinolysis may occur in association with a variety of chronic debilitating illnesses. See p 179

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