Twin pregnancies with a 'vanished' embryo: a higher risk multiple gestation group?

BACKGROUND: Prior studies have documented increased risks to the offspring of IVF singletons that result from a vanished twin pregnancy. We aim to investigate the effect on perinatal outcomes of having an early vanished triplet in IVF twins. METHODS: This is a retrospective cohort study of twins from a large academic IVF practice. Multivariate analysis was performed to examine the perinatal risks--including small for gestational age (SGA), low-birthweight (LBW), preterm delivery and early preterm delivery--in twins that resulted from an early vanished triplet compared with twins without a vanished embryo. RESULTS: Of 829 IVF twin deliveries, 59 were a result of vanished triplet pregnancies (7.1%). There was no significant increase in SGA, LBW or delivery <37 weeks in the vanished triplets compared with other twins; however, the risk of early preterm birth (<32 weeks) was significantly higher (OR 3.09, 95% CI 1.63-5.87) and the length of gestation of these pregnancies was on average 1.5 weeks shorter (P < 0.01). In addition, the unadjusted mean birthweight was lower by nearly 200 g in the vanished triplet pregnancies (P < 0.01). CONCLUSIONS: IVF twin pregnancies with a vanished triplet are at an increased risk for early preterm birth compared with other twin pregnancies. These pregnancies should be recognized at higher risk for early preterm birth and considered for increased obstetrical monitoring. A significant limitation of this study is that the cause for preterm birth was unknown.

Interventions to increase access to STI services: a study of England's 'high-impact changes' across three central London clinics.

BACKGROUND: Increasing access to sexual health services is a key objective for the Department of Health in England and Wales. In 2006 it published 10 high-impact changes (HICs) designed to enhance 48 h access to genitourinary medicine services. However, there is limited evidence on the effectiveness of the proposed interventions. OBJECTIVE: To evaluate the implementation of five HICs in three sexual health clinics over 4 years. These HICs included a text message results service, nurse-delivered asymptomatic service, clinic refurbishment, a centralised booking service and an electronic appointment system. METHODS: The effect of HICs was evaluated by measuring clinical activity, number of sexual health screens performed, and patients seen within 48 h. These data were obtained from the clinic database, mandatory reports and Health Protection Agency waiting time surveys, respectively. RESULTS: The median number of new patients seen per month increased from 3635 to 4263 following the implementation of the five HICs. The follow-up/new patient ratio fell from 0.67 to 0.21 during the study. The biggest fall corresponded to a rise in patients receiving results by text message, from 0% to 40%. Only the centralised booking service was associated with a significant increase in the number of new patients seen. DISCUSSION: Providing results by text message was associated with a reduced number of follow-up patients, while implementation of a centralised booking service coincided with a significant increase in patient access. Further research is required to evaluate the relative importance of the other HICs.

The face of HIV and AIDS: can we erase the stigma?

Facial lipoatrophy can be obvious and stigmatising. Poly-L-lactic acid (PLLA) has been used widely for the correction of HIV-associated facial lipoatrophy. Analysis of the PLLA treatment protocols of 441 consecutive patients was undertaken. Product dilution, product volume per session, number of sessions, time between sessions, facial areas treated, plane of injection and incidence of injection-site nodules were recorded. Assessments included the Hospital Anxiety and Depression Scale and the Appearance Satisfaction Questionnaire. During the learning curve 30 patients were treated every 2 weeks for a minimum of three sessions. A 3-ml dilution was used and a total of 5 ml was injected in the deep dermis of the buccal areas. The incidence of nodule formation was 31% and 52% of patients did not achieve resolution of their facial disfigurement. A total of 411 patients were treated every 4 weeks for a minimum of four sessions. A minimum 5-ml dilution was used and a minimum total of 10-ml was injected subcutaneously in the temporal, infraorbital and buccal areas. The incidence of nodule formation was 2.9% and 10% of patients did not achieve resolution of their facial disfigurement. Patient anxiety and depression scores and appearance satisfaction scores improved significantly with treatment.

Chronic genital herpes and disclosure.... The influence of stigma.

The objectives of this study were to assess the nature and effect of stigma on disclosure of diagnosis to sexual partners among those with problematic disease. Data from questionnaires and semistructured interviews were collected and analysed. Data regarding anxiety were also collected using a validated tool. Ethical approval was received from the Chelsea and Westminster Healthcare National Health Service (NHS) Trust. Disclosure of diagnosis tended to occur in the context of established relationships. Herpes-related stigma was associated with non-disclosure of diagnosis to sexual partners. The point prevalence of moderate to severe anxiety in this sample was 32%. The use of suppressive medication did not affect anxiety scores. In conclusion, the reaction to a diagnosis of genital herpes is influenced by a socially constructed understanding and the decision to disclose or not is influenced by this. Stigma is a barrier to disclosure of genital herpes diagnosis. Management strategies aimed at encouraging disclosure to partners must address perceived stigma.

Is it time for the virtual chaperone in genitourinary medicine clinics?

The General Medical Council recommends that chaperones must be offered during intimate examinations. Implementation of these guidelines may serve to protect both patients and staff within the genitourinary (GU) medicine clinic, but is likely to have major ramifications from a practical, financial and staffing perspective. The Virtual Chaperone (VC) is an objective device making audio and visual recordings of patients' consultations and examinations. Information cannot be manipulated and is encrypted for security. It would not replace the human chaperone. This study investigated the attitudes of GU medicine staff and patients to the VC in an inner city sexual health clinic. Voluntary, anonymized questionnaires were distributed to all members of the multidisciplinary team and 200 patients. The patient response rate was 90% (n = 180). Only 40% of respondents felt the VC was acceptable in GU medicine clinics. Two-thirds felt unsure or were against the VC recording during consultations, and fewer wished the examination to be recorded. Most opted to switch off the video entirely. Almost 50% of respondents felt that the VC was designed to protect staff, whereas only 41% thought it would protect patients. The staff response rate was 69% (n = 35). Almost three-quarters of respondents were unsure or felt the device was unacceptable. Less than half would feel comfortable with the VC recording during consults. Overall, three-quarters of respondents were either unsure or did not support the introduction of the VC. There was a clear feeling (>80%) that the VC would protect staff and patients, 71% indicating that the trust would also benefit. Despite its success in other outpatient specialties, GU medicine staff and patients do not favour the introduction of the VC.

Betadine for herpes simplex infection.

The clinical value of aciclovir, oral or topical, in the episodic treatment of recurrent herpes virus infection is limited. Betadine (povidone-iodine) could provide a cheap, effective alternative for managing symptomatic recurrences. We describe a case where povidone-iodine was used successfully to treat a recurrence of genital herpes simplex and review the literature supporting povidone-iodine in the treatment of genital tract infections.

Poly-L-lactic acid for treating HIV-associated facial lipoatrophy: a review of the clinical studies.

Facial lipoatrophy can be associated with human immunodeficiency virus (HIV), impacting severely on quality of life. Various treatments have been investigated, including poly-L-lactic acid (PLLA). Four studies have investigated the efficacy of PLLA in the correction of HIV-associated facial lipoatrophy. The studies: VEGA, Chelsea and Westminster, APEX002 and Blue Pacific involved 50, 30, 99 and 99 patients, respectively, exhibiting HIV-associated facial lipoatrophy. Follow-up ranged from 24-96 weeks. Measures of treatment efficacy included ultrasound and subjective measures. Significant, long-lasting increases in dermal thickness were recorded and in all four studies, a subjective improvement was reported by patients and investigators in facial appearance and quality of life. Treatment was well tolerated. Small, non-bothersome subcutaneous papules were the only device-related adverse events observed. PLLA represents a promising treatment option for HIV-associated facial lipoatrophy. The procedure requires minimal "downtime" and provides long-lasting results without the need for invasive surgery.

Changes in survival over time after a first episode of Pneumocystis carinii pneumonia for European patients with acquired immunodeficiency syndrome. Multicentre Study Group on AIDS in Europe.

BACKGROUND: Factors associated with improved survival over time for patients with the acquired immunodeficiency syndrome (AIDS) who have Pneumocystis carinii pneumonia at diagnosis are not clearly defined. METHODS: An inception cohort of 2533 patients with AIDS, diagnosed from 1979 to 1989, from 52 centers in 17 European countries was studied. Survival 3 months and 3 years after diagnosis was estimated by Kaplan-Meier life tables. Independent predictors of survival were analyzed by construction of Cox proportional hazards models. RESULTS: Patients in whom AIDS and P carinii pneumonia had been diagnosed before 1988 had a poorer 3-month (ie, short-term) survival, whereas the survival 1 and 2 years after P carinii pneumonia was lower only for patients whose disease was diagnosed before 1987 compared with those with more recent diagnoses. Other variables associated with poorer outcome were greater age, infection via blood transfusion, diagnosis made in south Europe, and coexisting illnesses. After controlling for these prognostic markers in multivariate analysis, improvement in survival over time was still evident. For patients who survived the P carinii pneumonia episode, both zidovudine and secondary prophylaxis for P carinii pneumonia initiated around the time of diagnosis were associated with improved survival, and, after controlling for these treatment variables, no statistically significant improvement in survival over time was observed. CONCLUSIONS: Survival after an episode of P carinii pneumonia has improved within recent years. Increased awareness of early symptoms of P carinii pneumonia and better treatment of the pneumonia may have led to improvement in short-term survival over time, whereas the introduction of zidovudine and increased use of secondary P carinii pneumonia prophylaxis may have resulted in the recent increase in survival 1 and 2 years after the diagnosis. However, 3-year survival remained unchanged over time, implying that the underlying human immunodeficiency virus infection and other complications are not effectively controlled.

Predictors of virological success and ensuing failure in HIV-positive patients starting highly active antiretroviral therapy in Europe: results from the EuroSIDA study.

BACKGROUND: Predictors of virological response to highly active antiretroviral therapy (HAART) have never been systematically evaluated in a large continental multicenter cohort of unselected human immunodeficiency virus (HIV)-infected people. OBJECTIVE: To determine the factors related to achieving and maintaining undetectable plasma HIV-1 RNA levels among HIV-1-infected patients first starting protease inhibitor- or nonnucleoside retrotranscriptase inhibitor-containing HAART in Europe. DESIGN: Prospective multicenter cohort study. SETTING: Fifty-two clinical centers in 17 European countries included in the EuroSIDA Study Group, from August 1996 to April 1999. PATIENTS: A total of 1469 HIV-positive patients first starting HAART recruited from an unselected cohort of more than 7300 HIV-positive patients. MAIN OUTCOME MEASURE: Detection of factors related to virological success after first starting HAART (baseline) and ensuing failure by standard survival techniques, including Kaplan-Meier techniques and Cox proportional hazards models. All analyses were intention to treat. RESULTS: Most patients (80%) achieved plasma HIV-1 RNA levels of less than 500 copies/mL during follow-up (60.4% at 6 months from the onset of HAART). Patients with higher baseline HIV-1 RNA levels (relative hazard [RH], 0.76 per log higher; 95% confidence interval [CI], 0.69-0.84; P<.001) and those taking saquinavir mesylate hard gel as a single protease inhibitor (RH, 0.62; 95% CI, 0.47-0.82; P<.001) were less likely to reach undetectable HIV-1 RNA levels. Conversely, higher CD4+ lymphocyte counts (RH per 50% higher, 1.09; 95% CI, 1.02-1.16; P = .008) and the initiation of 3 or more new antiretroviral drugs (RH, 1.29; 95% CI, 1.03-1.61; P = .02) were independent predictors of higher success. Once success was achieved, HIV-1 RNA levels rebounded in more than one third of all patients during follow-up (24% at 6 months). Antiretroviral-naive patients (RH, 0.50; 95% CI, 0.29-0.87; P = .01), older patients (RH, 0.86 per year older; 95% CI, 0.75-0.99; P = .04), and those starting a protease inhibitor other than saquinavir hard gel (RH, 0.66; 95% CI, 0.44-0.98; P = .04) were at decreased hazard for virological failure. Higher baseline HIV-1 RNA level (RH, 1.18 per log higher; 95% CI, 0.99-1.40; P = .06) and a longer time to achieve virological success (RH per 12 months, 1.53; 95% CI, 0.99-2.38; P = .06) were marginally significant predictors of a decreased hazard of ensuing virological failure. CONCLUSIONS: HAART is associated with a favorable virological response if started when the baseline HIV-1 RNA level is low, if at least 2 new nucleoside retrotranscriptase inhibitors are added, and if standard doses of saquinavir hard gel capsule are avoided as a single protease inhibitor. Older patients are more likely to achieve virological success. Thereafter, the higher durability of virological response is predicted by an antiretroviral-naive status and by the use of specific regimens. Lower baseline HIV-1 RNA levels and rapid maximal viral suppression seem to be other important factors in the durability of virological response.

Anaemia is an independent predictive marker for clinical prognosis in HIV-infected patients from across Europe. EuroSIDA study group.

OBJECTIVES: To describe changes in haemoglobin over time and to determine the joint prognostic value of the current haemoglobin, CD4 lymphocyte count and viral load among patients from across Europe. PATIENTS: The analysis included 6725 patients from EuroSIDA, an observational, prospective cohort of patients with HIV from across Europe. METHODS: Normal haemoglobin was defined as haemoglobin greater than 14 g/dl for men and 12 g/dl for women; mild anaemia was 8-14 g/dl for men and 8-12 g/dl for women; severe anaemia was defined as less than 8 g/dl for both males and females. Linear regression techniques were used to estimate the annual change in haemoglobin; standard survival techniques were used to describe disease progression and risk of death. RESULTS: At recruitment to the study, 40.4% had normal levels of haemoglobin, 58.2% had mild anaemia and 1.4% had severe anaemia. At 12 months after recruitment, the proportion of patients estimated to have died was 3.1% [95% confidence interval (CI) 2.3-3.9] for patients without anaemia, 15.9% for patients with mild anaemia (95% CI 14.5-17.2) and 40.8% for patients with severe anaemia (95% CI 27.9-53.6; P < 0.0001). In a multivariate, time-updated Cox proportional hazards model, adjusted for demographic factors, AIDS status and each antiretroviral treatment as time-dependent covariates, a 1 g/dl decrease in the latest haemoglobin level increased the hazard of death by 57% [relative hazard (RH) 1.57; 95% CI 1.41-1.75; P < 0.0001], a 50% drop in the most recent CD4 lymphocyte count increased the hazard by 51% (RH 1.51; 95% CI 1.35-1.70; P < 0.0001) and a log increase in the latest viral load increased the hazard by 37% (RH 1.37; 95% CI 1.15-1.63; P = 0.0005). CONCLUSIONS: Severe anaemia occurred infrequently among these patients but was associated with a much faster rate of disease progression. Among patients with similar CD4 lymphocyte counts and viral load, the latest value of haemoglobin was a strong independent prognostic marker for death.

The significance of the detection of cytomegalovirus in the bronchoalveolar lavage fluid in AIDS patients with pneumonia.

We performed a retrospective study on 112 patients with AIDS-related pneumonias who underwent bronchoscopy and in whom Pneumocystis carinii pneumonia (PCP) and/or cytomegalovirus (CMV) were identified in bronchoalveolar fluid (BAL). CMV was identified by detection of early antigen fluorescent foci (DEAFF) testing in cell cultures of BAL fluid. The short- and long-term survival of all patients was similar regardless of whether PCP, CMV or both were detected at bronchoscopy. Ten out of 14 patients with CMV alone and 13 out of 26 with both CMV and PCP were treated with anti-CMV therapy, but the short- and long-term mortality was similar to that in patients who had no specific antiviral therapy. Extrapulmonary recurrence of CMV (retinitis or gastrointestinal disease) occurred in 22% of patients with evidence of CMV in BAL compared with 16% of those with PCP alone, but this difference was not statistically significant and this recurrence rate was independent of anti-CMV therapy. Detection of CMV shedding from more than one site (BAL, urine, throat or blood) was associated with a worse prognosis at 3 months than in patients in whom CMV was detected in BAL alone. It does not appear that finding CMV shedding is a guide to the cause of pneumonia or an indication for treatment in AIDS patients.

Survival of European patients with Kaposi's sarcoma as AIDS-defining condition during the first decade of AIDS. AIDS in Europe Study Group.

OBJECTIVES: To determine whether the survival of patients with Kaposi's sarcoma as first manifestation of AIDS has changed between 1979 and 1989; and to define whether prognosis factors could be identified. PATIENTS AND METHODS: This is a multicentric retrospective cohort study from 52 centers in 17 European countries involving adults AIDS patients diagnosed between 1979 and 1989. Variables such as age, sex, geographical regions, transmission groups, date of Kaposi's sarcoma diagnosis, zidovudine use, CD4+ cell count and concomitant opportunistic infections or AIDS-related malignancies were evaluated by using uni- and multivariable proportional hazard models. Log-rank tests were used to determine which variables were associated with survival. RESULTS: From the 6,546 AIDS patients recruited in the database of the AIDS in Europe Study Group, 1,394 were diagnosed with Kaposi's sarcoma at the time of AIDS diagnosis, from 1979 and 1989. A total of 1,047 Kaposi's sarcoma patients died during the follow-up period. By Kaplan-Meier analyses, the median and mean survival for these Kaposi's sarcoma patients were 17 and 25 months, respectively, with no change over time. However, age, sex (female), geographic region, low CD4+ cell count (< 150 x 10(6)/l) and some opportunistic infections and non-Hodgkin's lymphoma were associated with a poorer prognosis. Zidovudine use, year of diagnosis and risk factor for HIV-1 infection brought no additional information as predictor of mortality. CONCLUSIONS: This study suggests that the survival of patients with Kaposi's sarcoma as first manifestation of AIDS has remained poor during the last decade in contrast with the overall AIDS survival which had significantly improved from a median of 13-18 months during the same period of observation. There is a need for further prospective information to explain the worse prognosis in women and the geographical variations.

Survival of AIDS patients according to type of AIDS-defining event. The AIDS in Europe Study Group.

BACKGROUND: There are known to be wide differences in the prognosis of patients with a diagnosis of AIDS. In this study of 6578 patients with AIDS form 17 European centres, we develop a ranking of AIDS-defining illnesses, and determine how well this ranking holds after adjustment for potential confounding variables. METHODS: Survival from each AIDS-defining event was calculated and ranked using Kaplan-Meier estimation of median survival. Cox proportional hazards models with each disease modelled as a time dependant covariate were used to determine the risk of death after each diagnosis, before and after adjustment for potential confounders. RESULTS: Median survival after an initial AIDS-defining diagnosis of progressive multifocal leukoencephalopathy and malignant lymphoma was particularly poor (2 and 5 months respectively), while the longest median survival occurred after initial AIDS-defining illnesses of Kaposi's sarcoma and extrapulmonary tuberculosis (17 and 22 months respectively) Patients diagnosed with a primary brain lymphoma had shorter median survival times than patients with a peripheral lymphoma (median survival of 1 month and 4 months respectively P < 0.0001). In general, median survival in patients with cutaneous Kaposi's sarcoma (skin, oral) was between two and four times longer than patients with systemic involvement The ranking of diseases was found to be generally similar after adjustment for all potential confounders. CONCLUSIONS: AIDS-defining events can be grouped into three categories with median survival after diagnosis of < 6 months. 6-12 months and > 12 months. The assigned ranking of disease would not be altered by prognostic factors such as age or CD4 lymphocyte count. These results have important implications in the design of clinical trials and patient management.

Menstrual symptoms in women infected by the human immunodeficiency virus.

OBJECTIVE: To determine whether there is a higher prevalence of menstrual symptoms in women seropositive for the human immunodeficiency virus (HIV) compared to a matched control group and to examine the relation between menstrual symptomatology and immunosuppression. METHODS: In a cross-sectional study, 55 HIV-seropositive women and a matched control group underwent detailed gynecologic assessment. The prevalence of regular cycles, oligomenorrhea, amenorrhea, menorrhagia, dysmenorrhea, and dyspareunia was assessed in the two groups. Any association with clinical disease or CD4 lymphocyte count was sought. RESULTS: There were no significant differences in the prevalence of oligomenorrhea, amenorrhea, menorrhagia, dysmenorrhea, or dyspareunia between the groups. Furthermore, no differences were demonstrated between symptomatic and asymptomatic women infected by HIV, nor was any correlation found between CD4 lymphocyte count and menstrual loss or dysmenorrhea. CONCLUSION: Infection with HIV and related immunosuppression do not seem to have a clinically significant effect on menstruation.

Herpes management and prophylaxis.

In summary, clinical management of HSV infection depends on an individual having an appropriate diagnosis and receiving proper counseling, follow-up of both themselves and their sexual partners, as well as having an opportunity to discuss with more knowledgeable physicians, the options for antiviral management should their individual problems and sequelae of genital HSV infection require it. Although some of the aspects of management such as HSV type 2 serology testing or continuous antiviral therapy will be limited in their availability to individuals worldwide because of cost, it is possible to improve knowledge among physicians about diagnosis. Furthermore, it is necessary to ensure that facilities for patient information and counselling are available. These latter facilities are often provided extremely efficiently by self-help or voluntary groups so it is vital that physicians understand and ensure that they obtain details of such groups to pass on to their patients.

The use of intravenous pentamidine as prophylaxis against Pneumocystis carinii pneumonia in patients with HIV infection.

The purpose of this study is to report on the use of monthly intravenous pentamidine as prophylaxis against Pneumocystis carinii pneumonia (PCP) within a central London HIV unit. A retrospective case note analysis of HIV-seropositive individuals using intravenous pentamidine as PCP prophylaxis was carried out. Aspects examined included reasons for using the regimen, compliance, adverse reactions and episodes of PCP. Eight patients were studied. There was no prophylaxis failure in 5 patients. Three patients developed PCP whilst on the regimen, although their compliance was poor. In patients who are intolerant of established prophylaxis regimens, intravenous pentamidine may be a useful alternative. It is well tolerated, although compliance is the main problem. Further prospective studies are indicated to assess its efficacy.

Azithromycin as the first-line treatment of non-gonococcal urethritis (NGU): a study of follow-up rates, contact attendance and patients' treatment preference.

AIMS: To identify any differences in follow-up rates or sexual contact attendance rates in men presenting with non-gonococcal urethritis (NGU) after treatment by single dose azithromycin rather than longer standard duration therapies and to identify patients' treatment preferences. METHODS: A prospective study was performed on 200 consecutive men attending a genito-urinary medicine (GUM) clinic with new episode, microscopically confirmed NGU. The first 100 patients were treated with standard duration therapy (Group S) whilst the second 100 patients received a single 1 g oral dose of azithromycin (Group A). Patient-led contact tracing was arranged and patients were asked to return for review when a test of cure was performed, contact attendance noted and the patient's treatment preference ascertained. RESULTS: Both groups were predominantly heterosexual and over 60% gave a history of previous sexually transmitted disease (STD). There were no significant differences in efficacy between Groups S and A. However, the index follow-up rate and percentage of traceable sexual contacts attending was higher in Group A. In both groups contacts of homosexual men were more likely to attend the GUM clinic. More additional visits were made by Group S due to mislaid medication or compliance problems. Over 70% of patients questioned expressed a preference for single dose therapy. CONCLUSION: Single dose therapy with 1 g of azithromycin is as efficacious as longer duration therapies with advantages in patient follow-up rates and contact attendance and for the majority of patients would be their treatment of choice. A cost analysis supports the practical application of this regimen.

Audit of patients' knowledge of their oral contraceptive pill.

PIP: Government and media education has promoted the use of condoms in an attempt to reduce the spread of the human immunodeficiency virus (HIV). Condoms have been identified, in vitro, as an effective barrier to HIV and a large heterosexual study has shown there was no transmission of infection in those couples systematically using condoms. Safer sex knowledge and practice and HIV knowledge were assessed in 584 individuals, 16-74 years old, attending a London genitourinary medicine (GUM) clinic via a self-administered, anonymous questionnaire. Over 80% were heterosexual, 64% had attended a GUM clinic before, 60% had a history of sexually transmitted infection. Over 80% were aware of the protective effect of condoms and the risks of intravenous drug use; 66% of geographical risk factors; 49% of the risks of anal sex; and 53% perceived masturbation as safer. Only 10.4% always used condoms; over 50% gave no reason for non-use. Use was not increased in higher risk respondents nor in those with good safer sex/HIV knowledge, nor was there any sex difference. Although knowledge of some aspects of safer sex was good, anal sex risks, geographical sex risks, and alternative safer sexual practices were less well known. In addition, condom use was disappointingly low, even in the presence of good safer sex knowledge, awareness of high risk behavior and despite intense media health education. As a result of this survey educational input was increased, allowing an interaction which is lacking in media campaigns, and a variety of condoms were introduced in an attempt to increase use. Re-audit will be important in assessing the effects of such changes. Pre-adolescent targeting before sexual patterns are learned may be useful. Further research into this difficult area is essential.^ieng

Intralesional interferon for the treatment of recalcitrant molluscum contagiosum in HIV antibody positive individuals--a preliminary report.

Molluscum contagiosum is common in HIV disease and available therapies have a poor success rate and require frequent clinic visits. Interferon alpha has been used to treat recalcitrant condylomata acuminata and this study was undertaken to assess the use of this treatment in unresponsive molluscum contagiosum. A total of 30 molluscum contagiosum were injected with one megaunit of interferon alpha weekly for 4 weeks; 11 molluscum contagiosum completely cleared and 18 reduced in size by over 50%. Molluscum less than 0.5 cm in diameter, and those in patients without AIDS were more likely to respond. No surrounding lesions changed in size.

Audit of cervical screening and colposcopy in HIV-positive women at a central London teaching hospital.

The purpose of this audit was to assess the prevalence of cervical pathology and clinical outcome in HIV-infected women as well as adherence to local screening guidelines. As there are no national screening guidelines for HIV-positive patients, recommendations vary widely. At St Stephen's Centre, these included annual cytology and a baseline colposcopy. We audited this recommendation by a clinical notes review using a computer database. Analysis was performed using Statistical Package for Social Sciences (SPSS). Two hundred and twenty-two patients were eligible for analysis, their mean age was 33.6 years, median CD4 count was 239 and median viral load was 7836 RNA copies. Cytology was undocumented in 72 women (32.4%), while overall 42 (28%) smears of the remaining 150 patients were abnormal: borderline 17.3%, mild dyskaryosis 4.6%, moderate dyskaryosis 4%, severe dyskaryosis 2%. The results were normal in 64% and unsatisfactory in 4.6%. Colposcopy was offered to 93 (42%) women who attended at least once in 71 cases (32%). Thirty-one women had biopsies taken (43.6% of all colposcopies). Twenty-four (77.4%) had a histology more severe than HPV and 15 (48.4%) more severe than cervical intraepithelial neoplasia (CIN)-1. Overall, 49.7% had management not complying with the guidelines. This audit led to a critical literature review and of local screening guidelines. A computer aided reminder program has now been installed and re-auditing of the management of HIV-positive women is planned.