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A SOCIAL (GLOBALISED) CONDITION
The globalisation of poverty has driven an increasing number of people to the informal sector of the economy, that zone absent from any official statistics. Part time prostitution is often the sole means women have to feed their children. Temmerman and her colleagues used the technique of snowballing (names dropping) by self identified female sex workers in a largely middle class Mombassa suburb to study this group. Over two thirds of the women had an alternative income in the informal sector. One third did not use a condom in a setting where the antenatal HIV seroprevalence was 14%. Tragically 31% of these part time prostitutes were HIV positive. This is a population both difficult to reach and in dire need of prevention interventions.
See p 271
Marginalised populations are at risk of HIV. A multicentre study of over 8000 voluntary attenders at HIV testing centres in Spain found that Latin American males, half of whom have sex with men, had HIV prevalence rates that were even higher than immigrants from sub-Saharan Africa. Even heterosexual men from Latin America were over nine times more likely to be HIV positive that their Spanish counterparts. HIV infection was rare in Latin American women even though the majority were in the commercial sex trade. More worrying, 5% of women from sub-Sahara Africa and 1.3 % of women from Eastern Europe engaging in commercial sex were HIV positive. Intriguingly, heterosexual women of North African origin not apparently engaged in prostitution had similar rates of HIV to women from sub-Sahara Africa, with an odds ratio of 15 compared to Spanish women attending the same clinics.
See p 250
THE FUTURE IS NAA
Still confused as to the merits of nucleic acid amplification (NAA) tests for the detection of Chlamydia trachomatis? Max Cherensky updates our current knowledge on the commercially available NAA. All four US FDA approved tests seem to have comparable sensitivity, be equally effected by inhibitors and are equally labour intensive. As we move towards self collecting specimens, we need more information on the role of inhibitors since they appear specimen dependent and vary with the amplification technology. We also need tests that can be used in settings with high chlamydia infection rates—the developing world.
See p 232
RPR A COIN
The rapid plasma reagin test is widely used to diagnose syphilis. Even in pristine laboratories and under optimum conditions false positives and negatives are common. Under hot and dusty field conditions the tests behave abysmally. In an antenatal setting with a background syphilis prevalence in the community of 3%, as in rural Gambia, there was a 60% false positive result. Flipping a coin is cheaper.
See p 282
STILL LOOKING FOR A ROLE
Mycoplasma genitalium remains a one parent organism looking for its mother. We know that it is sexually transmitted and is probably associated with non-gonococcal urethritis in men. In animals it causes salpingitis. In a large study reported from Guinea-Bissau, Labbé and colleagues isolated M genitalium from 6.2% of pregnant women but were unable to show any association with adverse pregnancy outcome. Sill looking for a role.
See p 289
TREAT THE FOREST NOT THE TREE
STIs move in packs. Ron Ballard et al proved this truism yet again by showing that over half the men presenting with genital ulcer disease in South Africa had concomitant infection of the urethra by bacterial pathogens. Syndromic management should target the pack and not just its visible leader.
See p 274
TALK ABOUT HIV
Africans living in London are only likely to undergo HIV testing if they have had a history of sexually transmitted infection or think themselves at risk. Only one third of those questioned had been tested for HIV. Presently the majority present to the clinical services with advanced disease. Some imaginative targeting please.
See p 241
If you live in a village which is near a town, has good social and economic activity and a higher bar workers per male population ratio then you are more likely to be HIV positive. These are the not too surprising results of a study performed in rural Tanzania. The authors sensibly, and again not too surprisingly, suggest taking into account community effects in intervention programmes. Why wait 5 years to submit for publication?
See p 261
We are desperate to find a vaginal microbicide to stop vertical transmission of HIV. Access to antiviral drugs is, and will remain, difficult in many resource poor countries. Benzalkonium chloride, has been shown to inactivate HIV in genital secretions and be tolerated well when used intermittently as a spermicide. Sadly, when given to pregnant women in a randomised control trial conducted in a number of West African countries it failed to prevent mother to child transmission of HIV.
See p 267