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HOME TREATMENT IS BEST
Genital warts are one of the most common conditions seen in sexual health clinics, with up to one million new cases annually in the US and almost 70 000 new cases registered in clinics in the UK each year. There are many ways of managing warts, but treatment failures and recurrence are common, leading to a heavy workload for sexual health services. Lacey and collaborators in 11 UK clinics, carried out a randomised controlled trial and economic evaluation of three treatments in 358 people. Subjects were randomised to self applied podophyllotoxin cream, self applied podophyllotoxin solution, or podophyllin applied in the clinic. The two self treatment groups had significantly better remission at four weeks, although recurrence of warts within 12 weeks was common (43%) and no difference was observed with treatment group. Podophyllotoxin solution was the most cost effective treatment, with the standard clinic based therapy being least. See p 270
PREVENTION IS BETTER THAN HAART
With all the fuss about the effectiveness of antiretroviral therapy (ART) and the obstacles to getting it to the people who really need it, attention has turned away from the simple condom, argue Feldblum et al. The authors trawled through the abstracts from the 2002 International AIDS conference and found that only 3% focussed on condom interventions, compared with 15% on ART. It was not only the scientists who were biased; activists and the media also concentrated on the inequities of treatment. Meanwhile, another 3 to 4 million people were newly infected in 2001, and the condom is still the only way we have of preventing horizontal transmission. The editorial usefully summarises the evidence and the arguments in favour of investment in primary prevention programmes and condom distribution. But we still have a long way to go. If pharmaceutical companies have obstructed distribution of ART and other therapies in pursuit of their profits, then other forces are at work obstructing the condom promotion message, including, not least, the US government. See p 268
IS HSV SEROLOGY USEFUL IN CLINICAL PRACTICE?
The debate over the clinical use of type specific herpes simplex virus (HSV) testing looks set to run for some time yet, with few clear answers and lots of opinion. In a useful contribution to the evidence base, Page and colleagues analysed data from 126 patients with a first clinical episode of genital herpes who had sera tested. They found that only 18% had primary genital herpes, the rest had a non-primary first episode or pre-existing genital herpes. The IgM test had a high specificity and therefore high positive predictive value (100%), but the sensitivity was only 79%. The authors conclude that IgM serology may be useful in managing some patients with first episode genital herpes through indicating the source of infection, but this is limited by the low sensitivity, lack of test availability, and the fact that these antibodies are fleeting. See p 276
STARTING HAART—IS IT ALWAYS GOOD FOR YOU?
Immune reconstitution phenomena are increasingly recognised in HIV infected patients commencing highly active antiretroviral therapy (HAART). Reactions are frequently mild and are often self limiting. Goldsack and colleagues describe a patient in whom adult respiratory distress syndrome developed as an immune reconstitution reaction to Mycobacterium tuberculosis when HAART was started. The case serves to remind clinicians that immune reconstitution phenomena may be severe and are occasionally life threatening. See p 337
LACTIC ACIDOSIS AND NRTIS—BAD LUCK IF YOU ARE FEMALE?
Nucleotide reverse transcriptase inhibitors (NRTIs) remain the backbone of combination antiretroviral therapy. Among their adverse events lactic acidosis is perhaps one of the most severe. Arenas-Pinto and colleagues performed a systematic review of 90 published cases of lactic acidosis. They identified that the risk of lactic acidosis was up to 2.5 times greater in women. Other potential risk factors included the duration of exposure to NRTIs, use of specific drugs, and genetic predisposition. Their study underscores the need for a case control study in order to better define risk factors for lactic acidosis. See p 340