Syphilis: an important cause of infectious hepatitis.

The UK incidence of infectious syphilis has risen sharply over the last 10 years; however, its diagnosis can be overlooked in patients who fail to disclose risk factors for its acquisition. This patient presented with hepatitis as part of a multisystemic illness and was investigated extensively before being diagnosed with secondary syphilis. The delay to diagnosis and treatment resulted in irreversible disablement. Syphilis should be considered in the differential diagnosis of hepatitis of uncertain aetiology. In addition, due to the similar presentation and risk factors for acquisition, we suggest that syphilis serology should be performed concomitant to all HIV tests, particularly those from outside the genitourinary medicine clinic setting.

An unusual case of vulval lump: tumour of anogenital mammary-like glands.

We describe a 37-year-old woman who presented with a painless vulval lump of eight months duration. Excision biopsy revealed a benign lesion thought to be derived from mammary-like glands, which are well-documented in the anogenital region but under-recognized among genitourinary medicine practitioners. Our case highlights the importance of having a low threshold for biopsy of atypical vulval lesions.

Using chlamydia positivity to estimate prevalence: evidence from the Chlamydia Screening Pilot in England.

Studies have suggested that positivity can be used to estimate the prevalence of Chlamydia trachomatis in large-scale chlamydia screening programmes. A recent pilot of opportunistic screening in England estimated that the prevalence among 16-24-year-old women in Portsmouth and Wirral was 9.8% and 11.2%, respectively. This study assessed the continued validity of positivity as an approximate for prevalence. We re-analysed data from the Chlamydia Screening Pilot to estimate positivity,calculated as total positive tests divided by total tests, and compared these estimates with the previously reported prevalence, measured as the number of women testing positive divided by the total number of women screened. Overall positivity was 9.4% in Portsmouth and 11.0% in the Wirral; these estimates were not statistically different from prevalence, regardless of health-care setting, age group or symptoms. We conclude that positivity can be used as a proxy for prevalence.

Ethnic differences in women with HIV infection in Britain and Ireland. The study group for the mrc collaborative study of HIV infection in women.

OBJECTIVE: To examine ethnic differences in the socio-epidemiological and clinical characteristics of a cohort of women with HIV infection in Britain and Ireland. DESIGN AND METHODS: Analysis of baseline data (ethnic group, sexual history, likely route of HIV infection, reasons for HIV testing and first AIDS-defining disease) from 400 women with HIV infection recruited into a cohort study from 15 genitourinary medicine/HIV clinics in Britain and Ireland. RESULTS: Sixty-five per cent of women were white and 29% black African. Their median number of lifetime sexual partners was seven and three, respectively (P < 0.001). Ninety-three per cent of black African and 43% of white women were probably infected through sexual intercourse. Injecting drug use was the most likely route of infection in 55% of white women, but none of the black African women. Perceived risk (33%) or investigation of symptoms (26%) were the most common reasons for HIV testing. Seven per cent of white women and 16% of black African women (P < 0.001) had AIDS when HIV infection was diagnosed. The distribution of first AIDS-defining diagnoses differed (P = 0.001) by ethnic group. For white women, the most common disease was Pneumocystis carinii pneumonia; for black African women it was pulmonary tuberculosis. CONCLUSION: There are important differences between black African and white women in sexual history and route of transmission, disease stage at diagnosis and pattern of AIDS-defining diseases.

Sustained efficacy of nevirapine in combination with two nucleoside analogues in the treatment of HIV-infected patients: a 48-week retrospective multicenter study.

BACKGROUND: Nevirapine, a nonnucleoside analogue, has demonstrated suppression of human immunodeficiency virus (HIV) replication alone and in combination therapy. However, the durable suppression of HIV with nevirapine when used along with other nucleosides in HIV-infected patients who are treated in clinical practice needs further evaluation. PURPOSE: To evaluate the sustained efficacy of nevirapine in combination with two nucleoside analogues in the treatment of HIV-infected patients in routine clinical practice. DESIGN: A multicenter study from January 1997 to December 2000, with follow-up through 48 weeks, was conducted at four different genitourinary medicine clinics in the United Kingdom. Forty-four HIV-infected patients received nevirapine and two nucleoside analogues. Information from case notes regarding age, sex, side effects, viral load, and CD4 lymphocyte counts at baseline, 24 weeks, and 48 weeks was collected and analyzed. Virologic suppression, defined as HIV RNA concentration of less than 400 copies/mL at Weeks 24 and 48, was considered as the main outcome measure. RESULTS: Out of 44 patients, 41 were men with a mean age of 39.3 years (95% CI 36.7-41.8). The baseline viral load was 2.11 x 10(2) to 9.74 x 10(5) copies/mL (median 7.7 x 10(4) and CD4 counts 6 to 605 cells/dL (M = 247; 95% CI 198-295). Of 39 patients who completed 48 weeks of treatment, viral load suppression was attained in 31 patients (79.4%; 95% CI 66.8-92.0) at 24 weeks and in 27 patients (69.2%; 95% CI 54-83) at 48 weeks. The CD4 lymphocyte count increased in 32 (82%) patients (mean 106 cells/dL, 95% CI 73-139, p =.0001, Wilcoxon signed rank test) after 24 weeks and in 33 (84.6%) patients (mean 160 cells/dL, 95% CI 115-204, p =.0001, Wilcoxon signed rank test) after 48 weeks of treatment. Of 20 patients whose baseline viral load was <100000, 16 had viral load suppressed at 24 weeks and 15 at 48 weeks (p =.6, chi-square test). CONCLUSION: A regime of nevirapine with two nucleoside analogues provided durable suppression of plasma viral load in HIV infected patients, with significant improvement in the CD4 cell count.

Which treatment for genital tract Chlamydia trachomatis infection?

A national opportunistic chlamydia screening programme, mainly targeting young sexually active women, is gradually being introduced across the UK and in future will predominantly occur in primary care sites. The relative efficacy of recommended antibiotic treatments for chlamydia has been poorly studied and especially that of single dose azithromycin. In Portsmouth, 1536 patients treated for chlamydia, with four different antibiotic regimens, during the Department of Health pilot study, were asked to return for test of cure. No difference in treatment outcome was found using doxycycline, oxytetracycline, erythromycin or azithromycin. Directly observed therapy with azithromycin may be especially helpful in treating young chlamydia-positive patients.

Re-infection of Chlamydia trachomatis in patients presenting to the genitourinary medicine clinic in Portsmouth: the chlamydia screening pilot study - three years on.

Chlamydia trachomatis is the most common bacterial sexually transmitted infection (STI) in the UK. The Department of Health set up an opportunistic screening programme for genital chlamydia infection, focusing on sexually active 16-24-year-old women and some men. This study identified those patients re-attending the genitourinary medicine (GUM) clinic and followed them up until September 2002. We examined the reasons for attendance and re-infection with chlamydia. Two hundred and eighty-five patients re-attended the clinic. Two-thirds of these had changed their sexual partners in the follow-up period. Fifty-six patients were diagnosed with genital chlamydia infection in subsequent clinic visits. The majority of them had changed their sexual partners, suggesting new acquisition of infection. This suggests that in this age group re-screening should be offered at a year interval. Patients diagnosed with genital chlamydia infection should be referred to the GUM clinic for further STI screening and partner notification.

Screening for genital chlamydia infection: DNA amplification techniques should be the test of choice.

Our objective was to compare the sensitivities for the detection of Chlamydia trachomatis, of the ligase chain reaction (LCR) on first voided urine (FVU) specimens and enzyme immunoassay (EIA) on pooled endocervical/endourethral swabs from women and endourethral swabs from men. Men and women taking part in the UK chlamydia screening pilot were tested for chlamydia using LCR on a FVU. Patients attending genitourinary medicine clinics also had cervical and/or urethral swabs taken for chlamydia testing by EIA. In women, EIA on pooled swabs detected 575 of the 785 chlamydia positives and in men, EIA detected 209 of 351 positives. The sensitivity of EIA was 73% and 60% in women and men respectively. By using the EIA test, therefore, 27-40% of patients infected with chlamydia will be given a false negative result. We propose that it is unethical to use non-molecular testing in the future.

Opportunistic chlamydia screening; should positive patients be screened for co-infections?

This study examines the requirement for testing patients for other sexually transmitted infections (STIs) and bacterial vaginosis (BV) when diagnosed with genital chlamydia during opportunistic screening. Data were collected on all patients participating in the Department of Health chlamydia screening pilot study in Portsmouth. One thousand two hundred and forty-five women and 490 men with genital chlamydia were seen in Portsmouth genitourinary medicine (GUM) department. Of the women screened in GUM, 28% had coexisting STIs and 21% had BV. The corresponding figures for those initially screened in the community were 4% and 17%. An increased number of female sexual partners of male patients (76%) and male partners of female patients (55%) of the GUM group had co-infections; 58% of male partners from the community group had another STI. The increased morbidity associated with these infections warrants screening of all patients with chlamydia for other STIs and BV.

Triage clinics: a way forward in genitourinary medicine.

Our objective was to evaluate the effectiveness of a nurse-led triage clinic in genitourinary medicine (GUM). A prospective study was made of 200 consecutive patients attending the triage clinic in the GUM Department, Portsmouth. These patients were seen by the triage nurse and treated according to clinic guidelines. The consultants reviewed the case notes to assess the appropriateness of management. During the 6-week study period, 3009 patients were seen in the department. Of the 200 patients seen in the triage clinic, 38 were referred to a doctor during the initial visit. One or more sexually transmitted or associated infections were found in 61 female and 58 male patients. Six female and 4 male patients were not treated according to the clinic guidelines. Given appropriate education and training and working within a supportive framework the nurse undertaking a triage role in GUM can provide a highly effective and high-quality service to patients.

Midwives and HIV antibody testing: identifying the key factors for achieving the targets.

A questionnaire study was designed to assess whether differences in knowledge and attitudes to HIV infection existed between midwives working in areas of higher and lower HIV prevalence, and the extent to which this influenced the uptake of HIV antibody testing by their clients. The response rate was 75% (219/292). Midwives in an area of a higher HIV prevalence had significantly greater experience with HIV-positive mothers, were more confident with HIV-related issues and were less judgemental in their attitudes than midwives in an area of lower HIV prevalence. However, midwives who had been offering HIV testing for more than 2 years were significantly less likely to achieve an HIV antibody test uptake rate of more than 75% than those who had been offering testing for less than 2 years, 35% (95% confidence interval [CI]: 22.2-48.6%) vs 67% (95% CI: 56.3-76.0%), respectively. This demonstrates the need for regular updating of midwives about HIV antibody testing.