Social and psychosocial factors associated with high-risk sexual behaviour among university students in the United Kingdom: a web-survey.

In the UK there are limited data about university students' risky sexual behaviour. A cross-sectional web-survey was conducted to investigate factors associated with high-risk sex among students at two UK universities. High-risk sex was reported by 25% of 1108. High personal sexually transmitted infection (STI) risk perception and permissive attitudes towards casual sex were associated with high-risk sex for both men (odds ratio [OR]: 12.12; 95% confidence interval [CI]: 4.10-35.81; OR: 2.49; 95%CI: 1.11-5.56, respectively) and women (OR: 22.31; 95% CI: 9.34-53.26; OR: 3.02; 95% CI: 1.82-5.01, respectively). For men, drinking alcohol (OR: 17.67; 95% CI: 1.90-164.23) and for women age and frequent drinking (OR: 2.02; 95% CI: 1.05-3.89; OR: 1.89; 95% CI: 1.08-3.31, respectively) were associated with high-risk sex. However, perceiving an average student as more likely to contract STIs (men, OR: 0.34; 95% CI: 0.16-0.75) or HIV (men, OR: 0.44; 95% CI: 0.20-0.96; women, OR: 0.42; 95% CI: 0.28-0.63) and finding it difficult to discuss sexual matters (women, OR: 0.60; 95% CI: 0.39-0.91) were negatively associated with high-risk sex. Most of the factors found were similar to other populations, but some psychosocial factors showed complex patterns of association that require further investigation.

The impact of genital warts: loss of quality of life and cost of treatment in eight sexual health clinics in the UK.

OBJECTIVES: To estimate the loss of quality of life and cost of treatment associated with genital warts seen in sexual health clinics. METHODS: A cross-sectional questionnaire study and case note review of individuals with genital warts, carried out in eight sexual health clinics in England and Northern Ireland. Individuals with genital warts attending the participating clinics were invited to take part in the questionnaire study. 895 participants were recruited. A separate sample of 370 participants who had attended a participating clinic with a first visit for a first or recurrent episode of genital warts between April and June 2007 was included in the case note review. Quality of life was measured using the EQ-5D questionnaire and the cost of an episode of care was derived from the case note review. RESULTS: The weighted mean EQ-5D index score was 0.87 (95% CI 0.85 to 0.89). The weighted mean disutility was 0.056 (95% CI 0.038 to 0.074). The estimated mean loss of quality-adjusted life-years associated with an episode of genital warts was 0.018 (95% CI 0.0079 to 0.031), equivalent to 6.6 days of healthy life lost per episode. The weighted mean cost per episode of care was £94 (95% CI £84 to £104), not including the cost of a sexually transmitted infection screen. CONCLUSIONS: Genital warts have a substantial impact on the health service and the individual. This information can be utilised for economic evaluation of human papillomavirus vaccination.

Mollaret's meningitis and herpes simplex virus type 2 infections.

Benign recurrent aseptic meningitis is a rare disorder described by Mollaret in 1944. When initially described, this form of aseptic meningitis had no identifiable infecting agent. New sophisticated diagnostic tools have now identified herpes simplex type 2 virus as the most commonly isolated agent. Antiviral treatment has been used successfully for prophylaxis and treatment.

Cost-effectiveness of screening high-risk HIV-positive men who have sex with men (MSM) and HIV-positive women for anal cancer.

BACKGROUND: Anal cancer is uncommon and predominantly a disease of the elderly. The human papillomavirus (HPV) has been implicated as a causal agent, and HPV infection is usually transmitted sexually. Individuals who are human immunodeficiency virus (HIV)-positive are particularly vulnerable to HPV infections, and increasing numbers from this population present with anal cancer. OBJECTIVE: To estimate the cost-effectiveness of screening for anal cancer in the high-risk HIV-positive population [in particular, men who have sex with men (MSM), who have been identified as being at greater risk of the disease] by developing a model that incorporates the national screening guidelines criteria. DATA SOURCES: A comprehensive literature search was undertaken in January 2006 (updated in November 2006). The following electronic bibliographic databases were searched: Applied Social Sciences Index and Abstracts (ASSIA), BIOSIS previews (Biological Abstracts), British Nursing Index (BNI), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, NHS Database of Abstracts of Reviews of Effects (DARE), NHS Health Technology Assessment (HTA) Database, PsycINFO, Science Citation Index (SCI), and Social Sciences Citation Index (SSCI). STUDY SELECTION: Published literature identified by the search strategy was assessed by four reviewers. Papers that met the inclusion criteria contained the following: data on population incidence, effectiveness of screening, health outcomes or screening and/or treatment costs; defined suitable screening technologies; prospectively evaluated tests to detect anal cancer. Foreign-language papers were excluded. Searches identified 2102 potential papers; 1403 were rejected at title and a further 493 at abstract. From 206 papers retrieved, 81 met the inclusion criteria. A further treatment paper was added, giving a total of 82 papers included. DATA EXTRACTION: Data from included studies were extracted into data extraction forms by the clinical effectiveness reviewer. To analyse the cost-effectiveness of screening, two decision-analytical models were developed and populated. RESULTS: The reference case cost-effectiveness model for MSM found that screening for anal cancer is very unlikely to be cost-effective. The negative aspects of screening included utility decrements associated with false-positive results and with treatment for high-grade anal intraepithelial neoplasia (HG-AIN). Sensitivity analyses showed that removing these utility decrements improved the cost-effectiveness of screening. However, combined with higher regression rates from low-grade anal intraepithelial neoplasia (LG-AIN), the lowest expected incremental cost-effectiveness ratio remained at over 44,000 pounds per quality-adjusted life-year (QALY) gained. Probabilistic sensitivity analysis showed that no screening retained over 50% probability of cost-effectiveness to a QALY value of 50,000 pounds. The screening model for HIV-positive women showed an even lower likelihood of cost-effectiveness, with the most favourable sensitivity analyses reporting an incremental cost per QALY of 88,000 pounds. LIMITATIONS: Limited knowledge is available about the epidemiology and natural history of anal cancer, along with a paucity of good-quality evidence concerning the effectiveness of screening. CONCLUSIONS: Many of the criteria for assessing the need for a screening programme were not met and the cost-effectiveness analyses showed little likelihood that screening any of the identified high-risk groups would generate health improvements at a reasonable cost. Further studies could assess whether the screening model has underestimated the impact of anal cancer, the results of which may justify an evaluative study of the effects of treatment for HG-AIN.

Nodular herpes simplex virus-1-positive oral lesions as a manifestation of immune reconstitution inflammatory syndrome.

We describe a case of nodular oral herpes simplex virus-1-positive lesions consistent with immune reconstitution inflammatory syndrome in a patient recently commenced on treatment for tuberculosis and HIV co-infection.

Mannose-binding lectin is present in human semen and modulates cellular adhesion of Neisseria gonorrhoeae in vitro.

Mannose-binding lectin (MBL) is an innate immune molecule present in blood and some mucosal tissues, which can influence microbial attachment and inflammatory responses of host cells during infection. In this study MBL was found to be present at a low concentration in semen samples in the range 1.2-24.9 ng/ml. Co-incubation of bacteria with semen resulted in the binding of MBL to the bacterial surface. Neisseria gonorrhoeae is a common cause of genitourinary infection. MBL bound to N. gonorrhoeae with strain-to-strain variation in the intensity of binding and nature of the bacterial receptor. Pretreatment with MBL concentrations similar to those found in human serum modulated the adhesion of N. gonorrhoeae strain FA1090 but not strain MS11 to epithelial cells. This effect was dose-dependent. This work demonstrates that MBL is present in human semen and modifies cellular responses to N. gonorrhoeae in a concentration-dependent manner.

A retrospective study of recurrent chlamydia infection in men and women: is there a role for targeted screening for those at risk?

Chalmydia trachomatis remains the commonest sexually transmitted infection (STI) in the UK. This study identifies those at risk of recurrent infection (RI) attending a central genitourinary clinic, time to subsequent reinfection and duration of at-risk behaviour for the consideration of targeted chlamydia screening. From 1995 to 2005, a total of 14,011 patients' were diagnosed with chlamydia and 1743 (12.4%) had RI, classified as a repeat infection greater than three months after initial diagnosis. Individual risk factors for both sexes include young age <25, two or more partners and failure to attend for test of cure (TOC) and previous STI. Men of non-White ethnicity, symptoms and those self-referred were also at risk. Combined risk factors for both sexes were non-White ethnicity, symptoms, young age, previous STI and two or more partners. Attendance for TOC considerably reduced RI rates in men (odds ratio [OR] = 0.549; 95% confidence interval [CI] 0.359-0.840). Mean time to first and last reinfection in men was 1.91 and 2.49 years, in women 1.76 and 1.92 years. One in eight individuals with chlamydia infection are at risk of RI, the majority of which will occur within two years of initial presentation. These individuals have identifiable risk factors facilitating targeted re-screening, enhanced follow-up and support for behavioural change.

Treatment outcome and cost-effectiveness of different highly active antiretroviral therapy regimens in the UK (1996-2002).

The aim of this study was to estimate the outcome and cost-effectiveness per life-year-gained (LYG) of first-, second- and third-line non-nucleoside reverse transcriptase inhibitors (NNRTI) versus protease inhibitor (PI) containing highly active antiretroviral therapy regimens. Hospital care costs (2002 US dollars discounted 3.5% per annum) were linked to treatment failure times. Results show that the median time-to-treatment failure for first-line (nucleoside reverse transcriptase inhibitors) 2NRTIs + NNRTI was substantially longer than that for 2NRTIs + PI(boosted), 2NRTIs + PI and 2NRTIs + 2PIs, whereas for second- and third-line they were similar. Comparing first-line 2NRTIs + NNRTI with 2NRTIs + PI(boosted) cost per LYG was US$ 12,375; US$ 12,139 per LYG when compared with 2NRTIs + PI and US$ 2948 per LYG when compared with 2NRTIs + 2PIs. For second-line cost per LYG comparing 2NRTIs + NNRTI with 2NRTIs + PI(boosted) was US$ 19,501; US$ 18,364 per LYG when compared with 2NRTIs + PI and cost-saving when compared with 2NRTIs + 2PIs. For third-line cost per LYG comparing 2NRTIs + NNRTI with 2NRTIs + PI(boosted) was US$ 2708; US$ 11,559 per LYG when compared with 2NRTIs + PI and cost-saving when compared with 2NRTIs + 2PIs. In conclusion, first-line 2NRTIs + NNRTI was cost-effective or cost-saving when compared with PI-containing regimens for all lines of therapy. Such information is required by clinicians and managers of HIV services to make appropriate treatment decisions based on clinical and financial grounds, and given the increasing number of people living with HIV, such information will become more important over time.

BASHH survey of additional genitourinary medicine-targeted allocations in 2003 and 2004.

In response to the increasing waiting times for appointments at genitourinary (GU) medicine clinics, the Department of Health has made three targeted funding allocations to improve access consisting of a non-recurrent allocation of 5 million pounds in 2002-03, followed by an 8 million pounds recurrent and a further 5 million pounds non-recurrent allocation in 2003-04. The British Association for Sexual Health and HIV (BASHH) conducted a survey of lead consultants for GU medicine clinics in March 2004 to determine if they could confirm whether all of the targeted funding had been allocated to their budgets. A total of 122 individuals representing 132 (65%) clinics in England, responded to the questionnaire for either calendar year. Of the first 5 million pounds non-recurrent allocation, made in January 2003, the number and percentage of the 117 respondents who had received their full allocation was 96 (82%) compared to 13 (11%) who received less than the allocated amount and 8 (7%) who were uncertain. These individuals were able to confirm that 3,155,000 pounds (92%) of the 3,424,500 pounds allocation to their clinics had reached its intended target. Of the second 8 million pounds recurrent allocation in financial year 2003-04, 76 (64%) of 119 respondents received their full allocation, 30 (25%) respondents received less than the allocated amount, and 13 (11%) respondents were uncertain. The total amount of the allocation for the clinics represented by these 106 recipients was 4,566,500 pounds of which 3,619,663 pounds (79%) had reached their clinic budgets. Of the final non-recurrent 5 million pounds allocation in financial year 2003-04, 61 (51%) respondents received their full allocation, 49 (41%) respondents received less than their allocated amount, and nine (8%) respondents remained uncertain. The total amount of the allocation for the clinics represented by these 110 recipients was 3,258,000 pounds of which 1,638,000 pounds (50%) had reached their clinic budgets. Thus, of the total 7,824,500 pounds allocation to the Primary Care Trusts (PCTs) with lead sexual health responsibilities for the GU medicine clinics of recipients in 2003-04, only 5,257,663 pounds (67%) was confirmed to have reached clinic budgets. Overall, only 51 (43%) of 119 respondents could confirm having received all of their recurrent and non-recurrent allocations, 58 (49%) had received either a reduced allocation or none at all and 10 (8%) were uncertain. This survey suggests that a significant proportion of the additional funding to improve access to GU medicine clinics failed to reach its intended target. The deficit between the amounts allocated and received by clinics was larger in financial year 2003-04, when the funding was given to PCTs with lead roles for sexual health, as compared with the preceding year when it was allocated directly to clinics. Moreover, the late allocation of non-recurrent funding and the inability of many clinics to arrange for this funding to be carried forward at year-end may have further prevented its intended use to increase service capacity and reduce waiting times.

Persistence of two genotypes of Neisseria gonorrhoeae during transmission.

Isolates of Neisseria gonorrhoeae were tested using a highly discriminatory typing method, opa typing, to examine the genetic diversity over a 2-year study period of isolates from all consecutive patients with gonorrhea attending the Genitourinary Medicine clinic in Sheffield, United Kingdom. Two opa genotypes were detected throughout the 2-year time period and comprised 41% of all strains tested. The persistence of two opa types was investigated further to determine the apparent genetic stability, by examining the ability of isolates to undergo intragenic and intergenic recombination and mutation in vitro. Intragenic recombination or mutation involving the opa genes of N. gonorrhoeae in the selected isolates was not detected, but intergenic recombination did occur. opa genes of N. gonorrhoeae in vivo appear to diversify primarily through intergenic recombination. Intergenic recombination in vivo would require the presence of a mixed gonococcal infection, in which an individual is concurrently colonized with more than one strain of N. gonorrhoeae. We propose that the level of diversity of opa genotypes in a population is linked to the degree of sexual mixing of individuals and the incidence of mixed infections of N. gonorrhoeae.

Randomised controlled trial and economic evaluation of podophyllotoxin solution, podophyllotoxin cream, and podophyllin in the treatment of genital warts.

OBJECTIVES: To evaluate the efficacy and cost effectiveness of self applied podophyllotoxin 0.5% solution and podophyllotoxin 0.15% cream, compared to clinic applied 25% podophyllin in the treatment of genital warts over 4 weeks. METHODS: We conducted a randomised controlled trial in 358 immunocompetent men and women with genital warts of 3 months' duration or less. RESULTS: In the principal analysis both podophyllotoxin solution (OR 2.93, 95% CI 1.56 to 5.50) and podophyllotoxin cream (OR 1.97, 95% CI 1.04 to 3.70) were associated with significantly increased odds of remission of all warts compared to podophyllin. We performed two further analyses. When subjects defaulting from follow up were assumed to have been cured odds of remission of all warts were also significantly increased both for podophyllotoxin solution (OR 3.04, 95% CI 1.68 to 5.49) and for podophyllotoxin cream (OR 2.46, 95% CI 1.38 to 4.40). When subjects defaulting from follow up were assumed not to have been cured odds of remission of all warts were significantly increased for podophyllotoxin solution (OR 1.92, 95% CI 1.13 to 3.27), but not for podophyllotoxin cream (OR 1.17, 95% CI 0.69 to 2.00). Local side effects were seen in 24% of subjects, and recurrence of warts within 12 weeks of study entry in 43% of all initially cleared subjects, without statistically significant differences between the treatment groups. Direct, indirect, and total costs were similar across the three treatment groups. Podophyllotoxin solution was the most cost effective treatment, followed by podophyllotoxin cream, with podophyllin treatment being the least cost effective. CONCLUSIONS: Self treatment of anogenital warts with podophyllotoxin showed greater efficacy and cost effectiveness than clinic based treatment with podophyllin.

Use of a leaflet to replace verbal pretest discussion for HIV: effects and acceptability.

OBJECTIVE: To determine the effect of using a leaflet to replace formal verbal pretest discussion and assess its acceptability to patients. SETTING AND METHODS: A leaflet was developed which gave information on all routine tests undertaken at a genitourinary medicine clinic. Information normally given during verbal pretest discussion for HIV was included. The leaflet was given to all new attenders at routine STI clinics. The proportion of patients accepting tests in the 6 weeks before and 4 weeks after the introduction of the leaflet was elicited by case note review. The acceptability of the leaflet was determined by means of a questionnaire given to patients. RESULTS: The use of the leaflet increased the number of patients offered an HIV test from 654 of 1004 (65%) patients to 371 of 397 (94%), p<0.001. It also increased the number tested from 325 (32%) of 1004 patients to 210 of 397 (53%, p<0.001). Men were more likely to be offered an HIV test than women at baseline (342 of 500 men, 68%, v 312 of 504 women, 62%, p=0.036) but after the intervention there was no longer a difference (men 217, 93%, female 154, 94%). The number of men accepting a test increased more than the number of women (139 of 233 men, 60%, 71 of 164 women, 43%, p <0.005). The 79 questionnaires suitable for analysis showed patient views on the leaflet were mainly favourable: easy to understand 73 (92%), clear 70 (89%), absence of difficult words 73 (91%), and right balance of information 68 (86%). CONCLUSIONS: The routine use of a leaflet to replace verbal pretest discussion (PTD) increased the proportion of patients undergoing testing. Part of the increased testing was because physicians were more likely to offer the test, possibly because the time constraints of pretest discussion were removed. This appears to be an acceptable and effective way of increasing HIV testing in GUM clinics but further work is needed to elicit information on non-responders to the questionnaire.

Imiquimod 5% cream is an acceptable treatment option for external anogenital warts in uncircumcised males.

OBJECTIVES: To determine the safety and efficacy of imiquimod (Aldara) 5% cream in the treatment of prepuce-associated warts in uncircumcised males. METHODS: An open-label study in six UK medical centres with 35 uncircumcised males with prepuce-associated warts treated with imiquimod 5% cream three times per week for up to 16 weeks. Other anogenital warts were also treated. RESULTS: Three times weekly application of imiquimod was found to be safe, with erythema as the most commonly reported local skin reaction. Forty per cent of patients had complete clearance of anogenital warts within 16 weeks. CONCLUSIONS: Imiquimod cream at a dosing regimen of three times per week, is effective and has an acceptable safety profile in the treatment of prepuce associated warts and other external anogenital warts in uncircumcised males.

Imiquimod and resiquimod as novel immunomodulators.

Augmenting the host's natural immune response to viruses by the administration of exogenous cytokines such as interferon-alpha (IFN-alpha) is a strategy increasingly employed in antiviral therapeutics. Enhancing the release of endogenous cytokines is, however, an alternative approach. The imidazoquinolinamines imiquimod and resiquimod have demonstrated potency as inducers of IFN-alpha and other cytokines both in vitro and in vivo. Cytokine gene activation is mediated via the signal transducer and activator of transcription 1 (STAT-1) and involves the transcription factors NFkappaB and alpha4F1. Antiviral activity has been demonstrated against a variety of viruses, and clinical efficacy has been demonstrated against genital warts, herpes genitalis and molluscum contagiosum. Imiquimod is administered as a 5% cream (Aldara) and has been licensed for the treatment of anogenital warts in immunocompetent patients. Complete clearance of warts has been observed in up to half of treated patients with only local side effects reported. Resiquimod can be administered topically but also exists as an oral formulation. The range of potential infections for which these agents may have clinical utility includes chronic hepatitis C virus infection and Kaposi's sarcoma. In addition, the imidazoquinolinamines may find roles in the therapy of cancers and as vaccine adjuvants.

Genitourinary medicine services in the United Kingdom are failing to meet current demand.

Recent increases in the incidence of sexually transmitted disease (STD) in the UK have given rise to concerns over the ability of genitourinary medicine (GUM) services to cope with increased demands. We conducted a postal survey to assess the capacity of GUM clinics to meet patient demand for both routine and emergency consultations. A questionnaire was sent to all lead GUM physicians in the UK. The response rate was 80%. In some clinics, patients had to wait for up to 28 days for routine appointments. Urgent appointment patients were seen within 24 h by only 54% of clinics and some had to wait for at least one week (5% of clinics). Prolonged waiting times were reported nationwide in addition to widely expressed concerns about the increasing workload. Additional resources should be made available to GUM services if the population's sexual health is to be improved.