Objectives: To assess the attitudes and practices of STI care providers towards female sex workers, and the perceptions of FSWs towards STI services, following training.
Methodology: After an intensive physician capacity building programme, 393 exit interviews of FSWs were conducted following clinical encounters, and discussions were held with 131 STI care providers (physicians) across several districts in Karnataka. Focus group discussions were held among FSWs to understand perceptions of non-users of services.
Results: 60% of women reported that the clinics were accessible. 76% of the women who visited clinics for STI consultations were offered a speculum examination. 85% received a condom demonstration, but only 52% were advised for partner treatment. 69% of women were referred for HIV testing. 79% of physicians felt that sex workers were responsible for spreading HIV in the community, and 47% believed that sex work should be banned to control HIV.
Conclusions: Following physician training, quality of care appears to be generally acceptable, but it is important to further improve the attitudes of providers towards sex work, and improve practices such as speculum examination and partner referral that can enhance quality of care.
]]>Methods: Real-time multiplex PCR assays targeting penA, mtrR, penB, ponA, gyrA and parC determinants were applied to 169 NG extracts. Minimum inhibitory concentrations (MICs) for penicillin and ciprofloxacin were determined by E-tests and β-lactamase production was analyzed using nitrocefin discs.
Results: A total of 169 NGs were examined, 110 from New Caledonia, 44 from Madagascar and 15 from Cambodia. Despite the heterogeneity in the number of isolates tested, the susceptibility trends observed in the different geographic areas studied showed a good fit with the multi-gene genotypes. In addition, features related to a specific geographical diversity were found: (i) a high prevalence of strains harbouring the porB1a allele and showing reduced penicillin susceptibility in Madagascar and Cambodia (39 and 40% respectively), (ii) almost all strains from Cambodia were resistant to the drugs tested (11/15 and 14/15 resistant to penicillin and ciprofloxacin respectively) and, (iii) identification of novel penB and mtrR genotypes associated with a moderately decreased penicillin susceptibility in New Caledonia (mtrR novel genotype in 47% of intermediate versus 14% of susceptible isolates).
Conclusions: Showing a good correlation with phenotypic trends of susceptibility, multiplex real-time PCR assays could be used successfully for prospective epidemiological studies notably by characterizing mtrR and penB determinants for their fundamental and complementary roles in increasing the antibiotic resistance. These molecular tools could also provide useful alternative surveillance tools for non-viable strains.
]]>Methods: A cross-sectional study investigating the aetiology of cervicitis in women attending two urban sexual health clinics in Sydney, Australia, enrolled 356 consecutive eligible women from 2006-2008. The diagnostic yield from the standard clinical practice of discretionary high vaginal wet preparation microscopy in women with suspicious vaginal discharge was compared with universal use of nested polymerase chain reaction (PCR) for TV of cervical samples.
Results: TV was detected by PCR in 17/356 women (4.8%, 95% Confidence Interval (CI) 2.8-7.5%), whereas only 4 cases (1.1%, 95% CI 0.3-2.8%) were detected by discretionary wet preparation microscopy. Eleven of the 17 women (p=0.003) were of culturally and linguistically diverse (CALD) background. Additionally, cervicitis was found to be significantly associated with TV, RR 1.66(1.14-2.42), p=0.034
Conclusions: Traditional TV detection methods underestimate TV prevalence in urban Australia. The TV prevalence of 4.8 % by PCR testing in this study exceeds previously reported urban Australian TV rates of <1%. An increase in trichomoniasis-associated adverse reproductive outcomes and enhanced HIV transmission poses a salient public health threat. Accordingly TV warrants a higher profile in urban STI clinic settings in developed countries and we suggest priority be given to development of standardised molecular TV detection techniques and that these become part of routine STI testing.
]]>Methods: Valid specimens for HPV genotyping were obtained from three patient groups consisting of 108 men with anogenital warts (GW), 56 men with urethral discharge syndrome (MUS) and 50 asymptomatic men attending for HIV voluntary counselling and testing (VCT). The Linear Array HPV Genotyping Test was used to determine the HPV genotype distribution among study participants. Sera were tested for HIV antibodies using two commercial rapid tests.
Results: The prevalence of anogenital HPV among study participants was 78% (166). HPV DNA was detected in 100% (108) of GW, 48% (27) of MUS and 62% (31) of VCT participants. HPV types 6, 11, 16 and 18 were prevalent either as single or combined infections in 81% (134) of all HPV-positive study participants. HPV types 6 and/or 11 were significantly higher among GW patients (p<0.001). After adjusting for patient groups, HIV seropositivity was significantly associated with multiple HPV infections (OR=3.98, 95% CI: 1.58, 10.03) but not with presence of a foreskin (OR=0.67, 95% CI: 0.32, 1.40).
Conclusions: Infections with HPV were prevalent among sexually active heterosexual men attending the men’s sexual health clinic. Associations were observed between HIV co-infection and multiple HPV infections. Further population-based studies on the prevalence of HPV genotypes are required to determine if men should be included in any future national HPV vaccination programme in South Africa.
]]>Methods: Prior distributions are specified to represent uncertainty regarding STI parameters. A likelihood function is defined using a hierarchical approach that takes account of variation between study populations, variation in diagnostic accuracy as well as random binomial variation. The method is illustrated using a model of syphilis, gonorrhoea, chlamydial infection and trichomoniasis in South Africa.
Results: Model estimates of STI prevalence are in good agreement with observations. Out-of-sample projections and cross-validations also show that the model is reasonably well calibrated. Model predictions of the impact of interventions are subject to significant uncertainty: the predicted reductions in the prevalence of syphilis by 2020, as a result of doubling the rate of health seeking, increasing the proportion of private practitioners using syndromic management protocols, and screening all pregnant women for syphilis, are 43% (95% CI: 3-77%), 9% (95% CI: 1-19%) and 6% (95% CI: 4-7%) respectively.
Conclusions: This study extends uncertainty analysis techniques for fitted HIV/AIDS models to models that are fitted to other STI prevalence data. There is significant uncertainty regarding the relative effectiveness of different STI control strategies. The proposed technique is reasonable for estimating uncertainty in past STI prevalence levels and for projections of future STI prevalence.
]]>Methods: In a prospective cohort study of 2,296 HIV negative Zimbabwean women aged 18-35 followed for up to two years, we compared four measures of condom use (use since last visit, use at last sex, frequency of use, and count of unprotected acts). We evaluated the performance of each in predicting incidence of pregnancy, cervical STIs (chlamydia/gonorrhea), and HIV.
Results: Over follow-up, 19.3% of women became pregnant; 10.3% acquired a cervical STI; and 6.9% acquired HIV infection. In multivariable analysis, all four condom-use measures were significantly associated with reduced pregnancy incidence; statistical tests-of-fit suggest that the frequency of use measure was most predictive. The time to pregnancy was longer for women who, in a typical month during the previous three months, reported always using condoms as compared with those who never used a condom (HR: 0.19, 95% CI: 0.14, 0.26). Among those women diagnosed with prevalent chlamydia/gonorrhea at study enrollment, three of the four reported condom use measures were associated with a non-significant but decreased risk of incident cervical STI. Reported condom use was associated with an increased risk for cervical STI among women without chlamydia/gonorrhea at enrollment. None of the condom-use measures were associated with HIV infection.
Conclusion: The frequency of reported condom use measure best predicted pregnancy incidence; however, we found no evidence for a clear "best" condom-use measure for use in STI/HIV prevention research in this population of Zimbabwean women.
]]>Data were obtained from the Bayview Network Study (CA), designed to examine the prevalence of STI risk behaviors and transmission patterns among adolescents between July 2000 and October 2001. A total of 782 unique heterosexual relationships were identified. Less than one third were reciprocally nominated heterosexual dyads. A total of first observed 211 reciprocal dyads were reported by 198 females and 179 males. Agreement on partner type between adolescents and their sex partners among reciprocal dyads was poor, although main-main concordant relationships were the most frequent group (66.4%). Multivariate logistic regression analysis showed that male partner’s age and length of relationship significantly increased the odds of a couples’ unprotected sex (adjusted odds ratio (AOR) =1.4, and1.2, p<0.05), and male partner’s frequency of sex significantly decreased the odds of unprotected sex (AOR = 0.69, p<0.05). The concordance of partner type by two sex partners was not significantly related to couples’ unprotected sex when other covariates were taken into account.
This unique study advances knowledge about individuals’ perception of their heterosexual partner types in reported relationships: the majority of adolescent couples were not reciprocally acknowledged, and whether or not two sex partners agreed on partner type did not change the odds of a couples’ unprotected sex even among reciprocal dyads.
]]>To describe testing for hepatitis C virus in sexual health services in England between 2002 and 2007, using data from a sentinel surveillance study of hepatitis testing.
Data on all anti-HCV tests carried out between 2002 and 2007 were collected from 20 participating laboratories. Test requests originating in sexual health services were identified, allowing analysis of the demographic and clinical characteristics of individuals tested in this setting. KC60 statutory returns data were used to estimate the proportion of new GUM clinic attendees tested for hepatitis C each year.
90,424 individuals were tested for anti-HCV in 100 sexual health clinics: 3.2% (n=2,858) were found to be positive. Multivariable analysis showed anti-HCV status to be associated with male sex and reported history of injecting drug use. In those clinics for which data on trends were available, testing for anti-HCV increased over the study period and the percentage testing positive decreased. KC60 data suggested that most clinics tested less than 20% of new patients for anti-HCV, though the proportion of patients tested increased over time.
Sexual health services have become increasingly important locations for hepatitis C testing in England, although the proportion of patients testing positive is low compared to other settings. We suggest that testing in this setting could be better targeted to those most at risk of infection by thorough investigation of risk factors among service users.
HIV transmission among men who have sex with men has become a major concern recently in China. However, little is known about HIV transmission among male sex workers (MSWs). This study aimed to investigate HIV infection prevalence and risk factors among MSWs in Shenzhen, China.
Following formative research, a cross-sectional study was conducted using time-location sampling (TLS) among MSWs in Shenzhen, from April to July, 2008. Behavioral and serologic data on HIV and syphilis were collected. The risk factors for HIV infection were analyzed using a logistic regression model.
In total, 394 male sex workers were recruited for the survey. The prevalence of HIV and syphilis among these workers was 5.3% and 14.3%, respectively. Only a quarter of the MSWs self-identified as homosexual. More than 70% had sex with both men and women. HIV-related knowledge levels were high regardless of HIV sero-status. Consistent condom use was low (37.1%) and varied by type of sexual partner. Factors including more non-commercial male partners, working in small home-based family clubs, being drunk prior to sexual intercourse, having a history of HIV tests, syphilis infection and short period of residence in Shenzhen were associated with an increased risk of HIV infection.
High-risk sexual practices were common among male sex workers regardless of their high level of HIV awareness. The working venues were associated with HIV infection and a recent test for HIV was a potential predictor for HIV infection. The TLS method was found to be an appropriate way of recruiting male sex workers for this study, especially those without fixed working places.
To determine the prevalence and genotypes of Chlamydia trachomatis urogenital infection in Guadeloupe, French West Indies. To compare C. trachomatis direct detection to serological testing.
From March to November 2000, 971 consecutive patients (888 women and 83 men) who had been referred to clinical laboratory of the Institut Pasteur de la Guadeloupe for routine testing for genital infection, were recruited. Samples were subjected to a nucleic acid amplification assay (AMP CT, Gen-Probe). Genotypes were determined by omp1 PCR-RFLP analysis. Serological testing was carried out with the commercially available peptide-based ELISA assay (SERO-CT IgG/IgA, Savyon/BMD).
Positive AMP CT test results were obtained for 102 (10.5%) of the 971 samples. The prevalence of infection was 16.9% in men and 9.8% in women. The most common genotypes were E (34.3%), F (23.9%), Da (13.4%), I (9%), and Ia (7.5%). No relationship was found between genogroups and age, sex or clinical symptoms. With AMP CT used as a reference, the sensitivity, specificity, positive, and negative predictive values of SERO-CT were 81.1%, 56%, 34.5% and 91.2 %, respectively, for IgG and 55.4%, 76.8%, 59.4 %, and 85.8 %, respectively, for IgA. IgG seroprevalence rates were very low (1/5, 20%) in patients infected with genotype Ia strains.
The prevalence found in Guadeloupe did not differ not significantly from that which was found in mainland France. The genotypes Da, F, I , and Ia were more prevalent in Guadeloupe; however, the SERO-CT assay was unable to detect serum antibodies in 80% of the patients infected with genotype Ia strains.
Searching the Internet for information about sexually transmitted infections (STIs) is common. Our goal was to discover which Internet sites offer STI tests and obtain information about the services and their validity.
Using Internet web-based search engines, we collected information from the sites about STI testing services, costs, and types of tests offered, and evaluated tests for accuracy. We investigated "business" functions regarding consent, and return of results. Contact attempts were made by phone, email or "contact us" links, and by mail. Test kits were ordered from six commercial Internet sites and one public health site. Their accuracy was evaluated for chlamydia and gonorrhea.
We identified 27 national/international Internet sites offering STI self-collection kits and services. Tests were available for gonorrhea, syphilis, chlamydia, HIV, herpes, hepatitis viruses, trichomonas, mycoplasma, and "gardnerella." All attempts to administer the survey yielded unsatisfactory results. After sending the survey by mail/email to all of the sites, four responded, two with the survey. Six websites appeared invalid based on non-deliverable emails and returned letters. The remainder did not respond. Test results were obtained from 5/7 ordered kits. Two websites sent mocked urine specimens never provided results. The two "perform-it-yourself" kits yielded false negative results. Two mail-in urine specimens yielded correct positive results. The public health site kit yielded correct positive results.
The Internet STI testing sites were difficult to contact and demonstrated unwillingness to answer consumer-specific questions. Test accuracy varied with home test having poor accuracy and mail-in specimens demonstrating high accuracy.
In settings with poor STI control in high-risk groups, periodic presumptive treatment (PPT) can quickly reduce the prevalence of genital ulcers, Neisseria gonorrhoeae (Ng) and Chlamydia trachomatis (Ct). However, few studies have assessed the impact on HIV. Mathematical modeling is used to quantify the likely HIV-impact of different PPT interventions.
A mathematical model was developed to project the impact of PPT on STI/HIV transmission amongst a homogeneous population of FSWs and clients. Using data from Johannesburg, the impact of PPT interventions with different coverages and PPT frequencies was estimated. A sensitivity analysis explored how the projections were affected by different model parameters, or if the intervention was undertaken elsewhere.
Substantial decreases in Ng/Ct prevalence are achieved amongst FSWs receiving PPT. Although less impact is achieved amongst all FSWs, large decreases in Ng/Ct prevalence (>50%) are possible with >30% coverage and supplying PPT every month. Higher PPT frequencies achieve little additional impact, whereas improving coverage increases impact until Ng/Ct becomes negligible. The impact on HIV incidence is smaller, longer to achieve, and depends heavily on the assumed Ng/Ct cofactors, whether they are additive, the assumed STI/HIV transmission probabilities and STI durations. Greater HIV-impact can be achieved in settings with lower sexual activity (except at high coverage), less STI treatment, or high prevalences of Haemophilus ducreyi.
Despite the model's assumption of homogeneous risk behaviour probably resulting in optimistic projections, and uncertainty in STI cofactors and transmission probabilities, projections suggest PPT interventions with sufficient coverage (≥40%) and follow-up (≥2 years) could noticeably decrease the HIV incidence (>20%) amongst FSW populations with inadequate STI treatment.
Commercial sex is licensed in Victoria, Australia such that sex workers are required to have regular tests for sexually transmitted infections (STIs). However, the incidence and prevalence of STIs in sex workers is very low, especially since there is almost universal condom use at work. We aimed to conduct a cost-effectiveness analysis of the financial cost of the testing policy versus the health benefits of averting the transmission of HIV, syphilis, chlamydia, and gonorrhoea to clients.
We developed a simple mathematical transmission model, informed by conservative parameter estimates from all available data, linked to a cost-effectiveness analysis.
We estimated that under current testing rates it costs over AU$90,000 in screening costs for every chlamydia infection averted (and AU$600,000 in screening costs for each quality adjusted life year (QALY) saved) and over AU$4,000,000 for every HIV infection averted (AU$10,000,000 in screening costs for each QALY saved). At an assumed willingness to pay of AU$50,000 per QALY gained, HIV testing should not be conducted less than approximately every 40 weeks and chlamydia testing approximately once per year; in comparison, current requirements are testing every 12 weeks for HIV and every 4 weeks for chlamydia.
Mandatory screening of female sex workers at current testing frequencies is not cost-effective for the prevention of disease in their male clients. The current testing rate required of sex workers in Victoria is excessive. Screening intervals for sex workers should be based on local STI epidemiology and not locked by legislation.
The N. gonorrhoeae multi-antigen sequence typing (NG-MAST) system, based on PCR amplification and sequence analysis of the gonococcal porB and tbpB genes, is widely used for molecular typing of gonococcal isolates but is not validated for non-cultured clinical samples. We sought to examine the performance on the NG-MAST system on a range of non-cultured samples.
Nucleic acid extracts of 73 N. gonorrhoeae positive samples, comprising 8 cervical swabs, 9 urethral swabs, 35 urine samples, 1 vaginal swab, 13 rectal swabs and 7 throat swabs, were analysed by NG-MAST. For 27 specimens, corresponding gonococcal isolates were also analysed and the results compared. A panel of 44 non-gonococcal Neisseria strains and 100 N. gonorrhoeae negative clinical samples were used to further investigate the specificity of the NG-MAST PCR reactions.
PCR amplification and DNA sequencing of gonococcal porB and tbpB genes was successful for all N. gonorrhoeae positive uro-genital specimens, 11 of 13 rectal swabs and 4 of 7 throat swabs. For the 27 N. gonorrhoeae positive specimens with corresponding gonococcal isolates, the porB and tbpB sequences obtained from the non-cultured specimen were identical to those obtained from the isolate. Cross-reaction with non-gonococcal Neisseria species was observed for both the porB and tbpB PCR reactions, and proved to be problematic for NG-MAST typing of throat swabs specimens.
The NG-MAST system can successfully be applied directly to non-cultured uro-genital samples, however, is less suitable for extra-genital specimens, particularly throat swabs, due to cross-reaction with commensal Neisseria species.
To determine the prevalence of rectal and urethral Mycoplasma genitalium (MG) in men who have sex with men (MSM) attending a genitourinary medicine (GUM) clinic and to measure its associations with symptoms, clinical signs, sexual behaviour and concomitant sexually transmitted infections (STIs).
MSM attending for STI screening were tested for MG using a real-time PCR assay which targets the MgPa gene. Data were collected on demographics, sexual behaviour, past STI history and clinical symptoms and signs.
849 first void urine (FVU) and rectal specimens were collected from 438 MSM. The overall prevalence of MG in MSM was 6.6% with FVU positivity of 2.7% and rectal positivity of 4.4%. MG was significantly associated with HIV positivity (OR 7.6 95% CI 3.2-18.7, p<0.001) in contrast to C. trachomatis (CT) (OR 1.5 95% CI 0.5-4.1, p=0.4) and N. gonorrhoeae (GC) (OR 1.7 95% CI 0.7-3.8, p=0.194). Furthermore, MG was more prevalent than CT (p=0.15) and GC (p=0.02) in this sub-group of HIV-positive MSM. Urethral infection was associated with dysuria (p<0.001) but there was no association between rectal infection and anorectal symptoms or signs.
Rates of MG are much higher in HIV-positive MSM than HIV-negative MSM at both urethral and rectal sites and MG is more prevalent in HIV-positive MSM than other bacterial STIs. Although the subclinical nature of MG in the rectum questions its significance, the high prevalence seen at this site could be a potential source for onward urethral transmission. Future work should assess the need for appropriate screening and treatment of MG infection in MSM, particularly those with HIV infection and high risk sexual behaviour.
An increasing incidence of hepatitis C virus (HCV) infection in HIV positive homosexual men has recently been described, but it is uncertain to what extent this reflects sexual transmission. We report prevalence, incidence and risk factors for HCV infection in community-based cohorts of HIV negative and HIV positive homosexual men in Sydney.
Both cohorts recruited participants using similar community-based strategies. Men underwent annual face-to-face interviews, and reported history of injecting drug use (IDU) and sexual and other behaviours that might lead to blood contact. HCV screening was offered to consenting participants from 2001 to 2007.
At baseline, HCV prevalence was 1.07% in the HIV negative and 9.39% in the HIV positive men. HCV seropositivity was strongly associated with a history of IDU in both cohorts (OR=56.18, 95% CI 12.55-251.5 in HIV negative, and OR=24.46, 95% CI 5.44-110.0 in HIV positive). In the HIV negative cohort, five men seroconverted to HCV over 4412.1 person-years of follow-up, an incidence of 0.11 per 100 person-years (95% CI 0.03-0.26). Only one seroconverter reported IDU. Of the five, four reported sexual contact with HIV positive men (HR=8.23, 95% CI 0.91-74.28) and two had an incident ulcerative sexually transmitted infection. In the HIV positive cohort, none seroconverted over 238.1 person-years of follow-up (97.5% CI 0-1.54, single-sided).
HCV prevalence was almost ten times higher in HIV positive homosexual men. Although incident HCV infection was uncommon in both cohorts, cases of non-IDU related transmission did occur, possibly linked to sexual contact with HIV positive men.
The diagnosis of candida balanitis should be based upon both clinical and mycological data. The procedure of material collection is a critical issue to confirm or rule out the clinical diagnosis of candida balanitis.
To compare direct impression of the glans on the agar surface of solid culture media with the collection of genital exsudate with cotton swab for the diagnosis of candida balanitis.
A prospective cross-sectional study was carried out during a 36-month period. STD clinic attendees with balanitis and asymptomatic men were included. Specimens for yeast culture were collected from the glans penis and inner preputial layer using the direct impression on CHROMagar Candida medium and by swabbing with a sterile cotton swab.
Among 478 men enrolled, 189 suffered from balanitis. The prevalence of candida balanitis was 17.8% (85/478) confirmed after culture by direct impression; the swab method detected only 54/85 (63.5%) of these men. Of the 289 asymptomatic men, 36 (12.5%) yielded Candida spp; the swab method detected only 38.9 % of these men. The risk to have candida balanitis is 8.9 (IC 95% 2.48-32.04) whenever the number of the Candida colonies recovered by direct impression was higher than ten.
Direct impression on CHROMagar Candida medium resulted in the highest Candida spp recovery rate. More than ten colonies yielded by impression culture was statistically associated with candida balanitis. This method shows the ideal profile for sampling the male genital area for yeasts and should be included in the management of balanitis.
Pharyngeal gonorrhoea is common in homosexual men and may be important in maintaining community prevalence of anogenital infections.
From 2003, all participants in the Health in Men cohort of HIV-negative homosexual men in Sydney were offered annual pharyngeal gonorrhoea screening by BD ProbeTec nucleic acid amplification (NAAT) assay with supplementary porA testing. Participants self-reported diagnoses of pharyngeal gonorrhoea made elsewhere between interviews. Detailed sexual behavioural data were collected six-monthly.
Among 1,427 participants enrolled, sixty-five study-visit-diagnosed pharyngeal gonorrhoea infections were identified (incidence 1.51 per 100 person-years, 95% CI 1.19-1.93) of which seven infections were identified on baseline testing (prevalence 0.57%, 95% CI 0.23-1.17%). Almost 85% of study-visit-diagnosed pharyngeal infections occurred without concurrent anogenital gonorrhoea. The combined incidence of study-visit-diagnosed and self-reported pharyngeal gonorrhoea (n=193) was 4.45 per 100 person-years (95% CI 3.86-5.12). On multivariate analysis, incident infection was associated with younger age (p-trend=0.001), higher number of male partners (p-trend=0.002) and reported contact with gonorrhoea (p<0.001). Insertive oro-anal sex ("rimming") was the only sexual behaviour independently associated with incident pharyngeal gonorrhoea (p-trend=0.044).
The majority of pharyngeal gonorrhoea occurred without evidence of concurrent anogenital infection and the high incidence-to-prevalence ratio suggests frequent spontaneous resolution of NAAT-detected infection. The association of pharyngeal gonorrhoea with oro-anal sex indicates a broader range of sexual practices are likely to be involved in transmission of gonorrhoea to the pharynx than previously acknowledged. Screening the pharynx of sexually active homosexual men could play a role in reducing the prevalence of anogenital Neisseria gonorrhoeae.
Few studies have examined factors associated with actual use of the HPV vaccine since licensure in 2006. The aims of this study were to assess HPV vaccination rates and to examine whether knowledge and risk perceptions regarding HPV were associated with reported use of the HPV vaccine among female college students.
Using a cross-sectional design, 406 females ages 18-26 years were recruited at two public universities and completed a self-administered survey. Respondents who reported having received at least one dose of HPV vaccine were classified as "vaccinated" (n=177, 43.6%). Responses, stratified by receipt of HPV vaccine, were compared using descriptive statistics and multivariate models.
Based on multivariate logistic regression modeling, 18 year old females were about four times more likely to report use of the HPV vaccine compared to respondents ages 19-26 years. Respondents who correctly indicated that HPV caused genital warts were 1.85 times more likely (adjusted OR=1.85, 95% CI: 1.20-2.93) to have received at least one HPV vaccine. African American and Asian females were each less likely to be vaccinated compared to white females. Risk perception was not significantly associated with vaccine uptake, however, the majority of respondents failed to accurately recognize their high risk of both acquiring and transmitting HPV.
These findings suggest knowledge deficits and misperceptions about HPV risk as potential themes for educational campaigns encouraging greater use of the preventive HPV vaccine among this subgroup.
To evaluate the usefulness of routine lumbar puncture in non-HIV patients with untreated latent syphilis.
We conducted a prospective study in Seoul National University Bundang Hospital from May 2003 to December 2005. Participants in routine health check-ups of the Healthcare System were screened for serologic evidence of syphilis by the TPPA test. Lumbar puncture was performed, with consent, on untreated latent syphilitic patients. Neurosyphilis was defined as positivity for CSF VDRL, or pleocytosis with a positivity for CSF TPHA, or elevation of CSF protein with IgG index exceeding 0.85.
Of 21,507 participants, 282 (1.4%) had serologic evidence of syphilis. 117 (41%) of these had a history of syphilis treatment, and two were seropositive for HIV. Among the 163 non-HIV patients with untreated latent syphilis, 70 (43%) underwent lumbar puncture. All the patients had VDRL titers less than 1:16. Abnormal neurologic signs or symptoms were present in eight (11%) patients. CSF abnormalities were seen in 57 (81%), but no patient (0%, 95% confidence interval: 0~6.2) was diagnosed with neurosyphilis.
The estimated prevalence of neurosyphilis among non-HIV patients with untreated latent syphilis and serum VDRL < 1:16, was below 6.2%.
In 2006 a new variant of Chlamydia trachomatis (nvCT), with a deletion in the cryptic plasmid, was reported in Sweden. This deletion included the targets for the genetic diagnostic systems used in many clinical laboratories and resulted in thousands of false negative results. The aim of this study was to characterize consecutive Chlamydia tissue culture positive samples from 2006 in Örebro County, after identification of the nvCT, and to compare the results from samples collected in the same county in 1999-2000. The study also aimed to evaluate the discriminatory capacity of multilocus sequence typing (MLST) compared to ompA sequencing.
ompA sequencing and MLST was used to characterize 100 consecutive Chlamydia tissue culture positive samples.
A significant (p<0.001) increase of genotype E, from 47% in 1999-2000 to 69% in 2006, was detected. All 41 nvCT isolates from 2006 displayed an identical ompA genotype E and MLST profile. Excluding the nvCT isolates, the distribution of ompA genotypes is similar to the genotyping results from 1999-2000. Among the wild type genotype E isolates from 2006, 14 unique MLST sequence types were obtained from 26 isolates while they were identical in ompA genotyping. The discriminatory power (D) of C. trachomatis strains in this material was 83.5% using the MLST system compared to 49.5% utilizing ompA sequencing.
In all, MLST enables improved studies of the molecular epidemiology of C. trachomatis. All nvCT isolates from 2006 displayed an identical ompA genotype E and MLST profile, which strongly indicates a clonal spread of the nvCT.
Sero-epidemiological studies of herpes simplex virus type-2 (HSV-2) infection in Africa remain difficult to interpret owing to the high rate of false-positive results observed when using the new recombinant gG2 HSV-2 ELISA tests. We compared the performance of two widely used gG2 ELISAs to derive an appropriate testing algorithm for use in South Africa.
Sera from 210 women attending family planning clinics in Johannesburg were tested using HerpeSelect® and KalonTM HSV-2 gG2 assays. Sera from 19 discordant pairs, 44 concordant positive and 33 concordant negative samples were further tested by HSV Western Blot (WB). Sensitivity and specificity of each test and of combination algorithms compared to WB were calculated.
HerpeSelect® had a sensitivity of 98% (95% confidence interval [CI]: 95-100) and specificity of 61% (95%CI: 48-74). KalonTM was less sensitive (89%, 95%CI: 83-94) but more specific (85%, 95%CI: 61-100). Seroprevalence may have been overestimated by as much as 14% by HerpeSelect®. Specificity was improved by raising the cut-off index for determination of a positive result for HerpeSelect® (to ≥3.5), but not for KalonTM. HIV-1 infection reduced the specificity of HerpeSelect® to 30%. Improved sensitivity and specificity were obtained by a two-test algorithm using HerpeSelect® (≥3.5) as the first test and KalonTM to resolve equivocal results (sensitivity 92%, 95%CI: 82-98; specificity 91%, 95%CI: 79-98).
Newer HSV-2 serological tests have low specificity in this South African population with high HIV-1 prevalence. Two-step testing strategies could provide rational testing alternatives to WB.
Our study aimed at estimating the prevalence of inconsistent condom use and at identifying its determinants in steady partnerships among people living with HIV/AIDS (PLWHA) in Cameroon.
Analyses were based on data collected during the national cross-sectional multicenter survey EVAL (ANRS 12-116), which was conducted in Cameroon between September 2006 and March 2007 among 3,151 adult PLWHA diagnosed HIV-positive for at least 3 months. The study population consisted of the 907 survey participants who reported sexual activity during the previous 3 months, with a steady partner either HIV-negative or of unknown HIV status. Logistic regression was used to identify factors associated with individuals' report of inconsistent condom use during the previous 3 months.
Inconsistent condom use was reported by 35.3% of sexually active PLWHA. In a multivariate analysis adjusted for socio-demographic characteristics, not receiving antiretroviral therapy (ART) (OR[95%CI]: 2.28[1.64-3.18]) was independently associated with inconsistent condom use.
The prevalence of unsafe sex remains high among sexually active PLWHA in Cameroon. Treatment with ART is identified as a factor associated with safer sex, which further encourages the continuation of the national policy for increasing access to HIV treatment and care, and underlines the need to develop counseling strategies for all patients.
Objectives: The primary objective was to determine the prevalence of sexually transmitted infections (STI) in a cohort of HIV-infected men who have sex with men (MSM) in their primary care setting, and to identify the demographic and behavioral characteristics of those infected with STIs and the correlates of sexual transmission risk behavior (TRB).
Methods: At study entry, participants (n=398) were tested for STIs and their medical charts were reviewed for STI results in the previous year. Data on demographics, substance use, sexual behavior, and HIV-disease characteristics were collected through a computer-assisted self-assessment and medical record extraction. Logistic regression analyses assessed characteristics of those with recent STIs and recent TRB.
Results: The sample was predominantly Caucasian (74.6%) and college educated (51.7%). On average, participants were 41.5 (SD=8.4) years old and had been HIV-infected for 8.6 years (SD=6.7). Nine percent of the sample had an STI, with 6.4% testing positive for syphilis, 3.1% for gonorrhea, and 0.25% for Chlamydia. Age (OR=0.63, CI=0.44-0.91) and years since HIV-diagnosis (OR=0.66, CI=0.45-0. 97) were significantly associated with testing positive for an STI, as was engaging in TRB (OR=4.4, CI=1.88-10.36) and using methamphetamine (OR=3.37, CI=1.67-6.81), ketamine (OR: 4.48; CI: 1.83-11.00), and inhalants (OR: 2.60; CI: 1.28-5.30). Substance use, particularly methamphetamine use, and being more recently diagnosed with HIV were each uniquely associated with TRB in a multivariable model.
Conclusions: These results underscore the need to develop more effective secondary prevention-interventions for HIV-infected MSM, tailored to more recently diagnosed patients, particularly those who are younger and substance users.
]]>Introduction: Rapid development of Neisseria gonorrhoeae resistance to several antibiotics in recent years threatens treatment and prevention. Targeted surveillance of new resistance patterns and insight into networks and determinants are essential to control this trend.
Methods: Since the Gonococcal Resistance to Antimicrobials Surveillance project (GRAS) was implemented within the Dutch national STI surveillance network in July 2006, participating STI centres have collected a culture from each gonorrhoea patient. Isolates were tested for susceptibility to penicillin, tetracycline, ciprofloxacin, and cefotaxime using Etest®. Logistic regression was used to determine risk factors for ciprofloxacin resistance.
Results: Between July 2006 and July 2008, prevalence of resistance to penicillin was 10%, to tetracycline 22%, and to ciprofloxacin 42%. Resistance to cefotaxime was not found, although an MIC values of 0.19 mg/L or more drifted upward (p<0.05). Ciprofloxacin resistance rose from 35% in 2006 to 46% in 2008 (p<0.05), despite 2003 guidelines naming cefotaxime as first choice therapy. In men, ciprofloxacin resistance was higher in men having sex with men (MSM) than in heterosexual men (adjusted OR: 2.0, 95%CI: 1.5-2.6). In women, it was higher in commercial sex workers (adjusted OR: 24.5, 95%CI: 7.7-78.2) and women aged over 35 years (adjusted OR: 8.2, 95%CI: 3.0-22.7) than in other women.
Conclusion: Ciprofloxacin resistance in the Netherlands is still increasing, particularly in MSM, older women, and female sexworkers. No resistance to current first choice therapy was found, but alertness to potential clinical failures is essential. By merging epidemiological and microbiological data in GRAS, specific high-risk transmission groups can be identified and policy adjusted when needed.
]]>Objective: Mycoplasma genitalium (Mg) has been identified as a cause of pelvic inflammatory disease (PID), a clinical syndrome associated with the inflammation of the female upper genital tract and serious reproductive sequelae. As the demographic, behavioral and sexual risk profile of women with Mg-associated PID is not well understood, we investigated characteristics of Mg-infected women presenting with clinically suspected PID.
Methods: Data from 586 participants in the PID Evaluation and Clinical Health Study were analyzed. Demographic, sexual history, and behavioral characteristics including age, race, marital status, education level, sexual activity, number of sexual partners, history of sexually transmitted infection (STIs), bacterial vaginosis and PID, contraception use, oral and anal sex, age at sexual debut, douching practices, and drug, alcohol and tobacco use, were compared between 88 women testing positive and 498 women testing negative for Mg by PCR in the cervix and/or endometrium. Twenty-two women with Mg mono-infections were compared to 172 women who tested positive for N. gonorrhoeae by culture and/or C. trachomatis by PCR.
Results: Age <25 years (AOR 2.7, 95% CI 1.5-4.7) and smoking (AOR 2.0, 95% CI 1.3-3.3) were independently associated with Mg. Women with Mg mono-infections were significantly less likely to be African-American (59.1% vs. 86.0%, p=0.001) than women with N. gonorrhoeae and/or C. trachomatis.
Conclusions: Women infected with Mg had some characteristics that are commonly associated with PID and other STIs. The demographic, sexual and behavioral characteristics of Mg-positive women were similar to women with chlamydial and/or gonococcal-PID.
]]>Objectives: Research on men who have sex with men (MSM) in Sub-Saharan Africa was neglected for a long time. The objective of our study was to understand factors associated with unprotected anal intercourse (UAI) with male partners among a group of MSM living in the city of Douala, Cameroon.
Methods: In 2008, a survey on the sexual activity and practices of MSM was set up in Douala in collaboration with a local community-based organization. Data were collected among a convenience sample of 168 MSM during face-to-face interviews with trained interviewers.
Results: A total of 142 individuals reported sexual activity during the previous six months, among whom 80 (57%) reported UAI with male partners. In a multivariate logistic regression model adjusted for the frequency of sexual intercourse, not having had access to prevention interventions and not knowing any HIV-infected person were both independently associated with a higher risk of UAI. Other factors associated with this higher risk included having had a stable male partnership at some point in one’s life and not having been out of Douala for more than four weeks during the previous year.
Conclusions: This community-based research is the first study of MSM in Cameroon and the HIV transmission risks they face. Results show the importance of HIV prevention interventions from peers and underline the need to maintain efforts to develop specific interventions targeting MSM more efficiently in the African context.
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