Risk factors associated with incident sexually transmitted infections in HIV-positive patients in the Australian HIV Observational Database: a prospective cohort study.

OBJECTIVES: We established a subcohort of HIV-positive individuals from 10 sexual health clinics within the Australian HIV Observational Database (AHOD). The aim of this study was to assess demographic and other factors that might be associated with an incident sexually transmitted infection (STI). METHODS: The cohort follow-up was from March 2010 to March 2013, and included patients screened at least once for an STI. We used survival methods to determine time to first new and confirmed incident STI infection (chlamydia, gonorrhoea, syphilis or genital warts). Factors evaluated included sex, age, mode of HIV exposure, year of AHOD enrolment, hepatitis B or C coinfection, time-updated CD4 cell count, time-updated HIV RNA viral load, and prior STI diagnosis. RESULTS: There were 110 first incident STI diagnoses observed over 1015 person-years of follow-up, a crude rate of 10.8 [95% confidence interval (CI) 9.0-13.0] per 100 person-years. Factors independently associated with increased risk of incident STI included younger age [≥ 50 vs. 30-39 years old, adjusted hazards ratio (aHR) 0.4; 95% CI 0.2-0.8; P < 0.0001]; prior STI infection (aHR 2.5; 95% CI 1.6-3.8; P < 0.001), and heterosexual vs. men who have sex with men (MSM) as the likely route of exposure (aHR 0.2; 95% CI 0.1-0.6; P < 0.001). CONCLUSIONS: In this cohort of individualsbeing treated with antiretroviral drugs, those who were MSM, who were 30-39 years old, and who had a prior history of STI, were at highest risk of a further STI diagnosis.

Does use of antiretroviral therapy regimens with high central nervous system penetration improve survival in HIV-infected adults?

OBJECTIVES: The aim of the study was to determine whether combination antiretroviral therapy (cART) with high central nervous system penetration-effectiveness (CPE) rank (neurocART) is associated with increased survival benefit compared with non-neurocART. METHODS: Prospective data were examined for HIV-positive patients in the Asia Pacific HIV Observational Database who had commenced cART. CPE rank was calculated using the 2010 rankings process. NeurocART status was assigned to regimens with a CPE rank of 8 or more. Survival was analysed using Cox proportional hazards models with covariates updated at changes in cART regimen and with deaths up to 90 days after regimen cessation attributed to that regimen. Sensitivity analyses were conducted to examine the robustness of analysis assumptions. RESULTS: Among 5882 patients, 308 deaths occurred. The hazard ratio (HR) for neurocART use was 0.89 (P=0.35) when data were stratified by cohort and adjusted for age, mode of HIV exposure, hepatitis B virus coinfection, AIDS-defining illness, CD4 count (cells/µL) and regimen count. Sensitivity analyses showed similar nonsignificant results. We also examined a composite endpoint of AIDS-defining illness or death (HR=0.93; P=0.61), baseline regimen as neurocART (HR=0.95; P=0.69), CPE category (P=0.71) and prior neurocART duration (P=0.16). No association between CD4 cell count and neurocART use was observed (P=0.52). CONCLUSIONS: Our findings do not show a significant overall survival benefit associated with neurocART compared with cART. The potential benefit associated with neurocART in terms of prevention of neurocognitive impairment did not translate into an improvement in overall survival in this population. These findings were limited by the low incidence of associated mortality. Further studies and more extensive data are needed to address these limitations.

Risk factors for HIV transmission in Asia and the Pacific.

PIP: One may be at risk of contracting HIV in Asia and the Pacific through unprotected heterosexual or homosexual intercourse, receiving infected blood in a transfusion, and/or the use HIV-contaminated injection equipment. The initial spread of HIV may be more rapid among IV drug users and men who have sex with men, but heterosexual infections will eventually dominate in the region. That will be so due to the large male segments of populations in the region which engage in casual and commercial sex without condom use. Many man become infected by prostitutes during sexual intercourse and then infect their steady female partners and wives. When heterosexual transmission of HIV becomes the dominant mode of infection throughout Asia and the Pacific, the second highest level of risk behavior in the region may well be blood transfusion unless the largest countries of the region expand coverage of their screening practices. Risk behaviors for HIV infection exist to some extent in every country of the region, but in most countries that extent is largely unknown. Solid behavioral research is therefore urgently needed to determine national levels of risk behaviors and their distribution throughout the Asia-Pacific region. Complacency among policymakers will only benefit the epidemic, for it would be a mistake to assume that the epidemic will remain small in a country simply because data are not available on risk behaviors or the extent of HIV spread. This paper presents data on sexual risk behaviors; IV drug use; blood transfusions, medical injections, and traditional practices; special populations; AIDS/HIV knowledge; and other STDs.^ieng

Neuropsychological characterization of the AIDS dementia complex and rationalization of a test battery.

OBJECTIVE: To define the neuropsychological deficits present in mild human immunodeficiency virus type 1 (HIV-1) associated with the acquired immunodeficiency syndrome (AIDS) dementia complex (ADC) and to develop a rational neuropsychological test battery for its diagnosis. DESIGN: Survey. SETTING: Subjects were recruited from large metropolitan hospital outpatient clinics and were all living independently in the general community. PATIENTS: Three volunteer samples of homosexual-bisexual men: (1) 15 patients who met clinical and research criteria for mild ADC; (2) 27 HIV-seronegative (HIV-) controls; and (3) 17 patients with AIDS who were neurologically intact (NI-AIDS) who were matched with the ADC subjects by CD4 lymphocyte counts for severity of systemic HIV disease. MAIN OUTCOME MEASURES: Neuropsychological test performance; z score comparisons were made with the HIV-control group using 2.25-SD cutoffs for abnormality. RESULTS: Compared with NI-AIDS subjects, performance of patients with mild ADC was markedly worse in the cognitive areas of executive function, memory, and complex attention but not in affect or the cognitive areas of simple motor function, orientation, language, or visuospatial construction. Within the areas of executive function, memory, and complex attention, all of the HIV-controls and 95% of the NI-AIDS subjects had impaired test performance in a maximum of one area only. In marked contrast, 14 (93%) of the 15 patients with mild ADC had abnormal test performances in all three of these cognitive areas. Using a criterion of abnormal performance in at least two of the cognitive areas of executive function, memory, and complex attention, all patients with mild ADC could be differentiated from HIV-controls with 100% sensitivity and specificity and from NI-AIDS subjects matched for disease severity by CD4 lymphocyte count with 100% sensitivity and 94% specificity, which increased to 100% with the requirement of impairment in all three cognitive areas. CONCLUSIONS: If time constraints or patient compliance limit neuropsychometric testing, examination to detect mild ADC first should be directed to the areas of executive function, memory, and complex attention. This pattern of neuropsychological deficits in patients with mild ADC is suggestive of subcortical dementia.

Thymoma-associated autoimmune enteropathy. A report of two cases.

Autoimmune enteropathy is an increasingly recognized cause of severe protracted diarrhea, usually affecting infants and children predisposed to autoimmune phenomena. Although this may be a common cause of diarrheal illness, it is scarcely recognized in the American literature. In association with thymoma, a case of so-called graft-vs-host-like colitis and 2 cases of chronic diarrhea associated with thymoma were reported, but, to our knowledge, no cases of autoimmune enteropathy have been reported as such. We describe 2 adults with autoimmune enteropathy found in association with a thymoma.

Alpha 1-antitrypsin phenotypes in homosexual men.

The alpha 1-antitrypsin (AAT) phenotype was determined by isoelectric focusing in 215 male homosexuals and compared with those in 208 male heterosexuals. The incidence of abnormal phenotypes was 16.3% in the homosexual group which was significantly different (p less than 0.03) than the 8.7% in the heterosexual group. There was no difference in the phenotype distribution between homosexuals who were anti-human immunodeficiency virus reactive and those who were non-reactive. It suggests that investigation into the interplay of factors associated with homosexuality could include genetic as well as psychological and social factors.

Sex and travel: studies of sexual behaviour, disease and health promotion in international travellers--a global review.

Sexually transmitted diseases (STDs) continue to be the most common notifiable infectious conditions worldwide. Their unacceptably high incidence is underlined by the recent emergence of a (presently) incurable and lethal STD--human immunodeficiency virus (HIV) infection--which merits its description as a pandemic, and with which other STDs interact in an epidemiological synergy. Data that quantify the association between STDs/HIV infection with travel and difficult to obtain; nevertheless figures are presented that reveal the lower limit to be large enough to be of considerable concern. Studies from around the world show, overall, although knowledge of STDs is increasing amongst travellers, the level of knowledge has little to do with actual behaviour, with a modest increase in the use of condoms, but abundant evidence that a wide variety of sexual behaviours take place among travellers and with local inhabitants. Certain travellers, by virtue of their behavioural interactions with 'core-groups' of efficient transmitters, may have a high risk of acquisition of an STD/HIV. Worldwide, sexual health promotion for travellers is in its infancy; indeed, it could more accurately be merely described as 'sexual education'. A fresh approach is recommended, which includes comprehensive programme planning and outcome, impact, and process evaluations.

Response to hepatitis B vaccination in a primary care setting: influence of HIV infection, CD4+ lymphocyte count and vaccination schedule.

Factors affecting the response to hepatitis B vaccination in a primary care setting were examined by means of a review of case notes of patients attending 22 sexually transmissible disease services. Where not available from the notes, presence of antibody to hepatitis B surface antigen (anti-HBs) was determined by testing available stored serum. One hundred and ninety-five patients completed a course of 3 injections and had an anti-HBs assay performed. The highest response rate (anti-HBs > or = 10 IU/L) was found in human immunodeficiency virus (HIV)-negative heterosexual women (16 of 17, 94.1%) followed by HIV-negative heterosexual men (11 of 12, 91.7%); HIV-negative homosexual men (105 of 120, 87.5%); and HIV-positive homosexual men (6 of 14, 42.9%). (For HIV-positive vs HIV-negative homosexual men, P = 0.0003). Eleven of 14 (78.6%) homosexual men of unknown HIV status responded to vaccination. There was a trend to lower CD4+ lymphocyte counts among HIV-infected patients who responded to hepatitis B vaccination (mean 482 cells/cm2) when compared to those that did not respond (632 cells) but this difference was not statistically significant (P = 0.330). Neither the type of vaccine (recombinant, plasma-derived or mixed) nor the length of vaccination course (mean 6.2 months; range 2 to 18) affected response. This study confirmed that vaccination against hepatitis B is much less effective in HIV-infected homosexual men and marginally less effective for HIV-negative homosexual men, though the mechanism for this reduced response is uncertain. Reassuringly vaccine response was not affected by common variables in primary care settings such as vaccine type or delays in the vaccine schedule.

Sexually transmitted diseases in Australia: a decade of change. Epidemiology and surveillance.

Survival data in the last decade for sexually transmitted diseases (STDs) other than human immunodeficiency virus (HIV) are uneven across the states/territories. The incidence of gonorrhoea decreased by more than 80%, but at different times in different patient groups, different states, and different anatomical sites. There was a resurgence of rectal gonorrhoea in homosexual men in 1989-1991. Resistance to penicillin steadily increased, and partial resistance to quinolones has emerged. There was a marked decline in syphilis in most states. Lymphogranuloma venereum is rare, and chancroid seen mostly in returning travellers from Southeast Asia; however, hundreds of cases of donovanosis are seen annually among rural Aborigines. The prevalence of genital infections with Chlamydia trachomatis remained stable at 2.5%-14% in STD clinics, and 5% in family planning clinics. The numbers of cases of clinical genital herpes and warts are mostly unavailable. However, specific serology for herpes simplex virus type 2 (HSV-2) indicates that 14% of antenatal clinic patients, and 40%-60% of STD patients have been exposed. Pap smears have detected the presence of human papilloma virus (HPV) in 14%-40% of various clinic populations. Exposure to hepatitis B in the non-Aboriginal population decreased markedly. Hepatitis C infection occurred in a high percentage of injecting drug users; the evidence for sexual transmission is not strong. An epidemic of hepatitis A infection occurred in male homosexuals in 1989-1991. Changes in the Australian sex industry resulted in marked improvements in the sexual health of local (but not international) sex workers. The high levels of STDs in Aboriginal communities continues to cause concern.

Venereology as a specialty in Australia.

The development of venereology as a medical specialty began in 1979-1981 with the formation of multidisciplinary venereology societies in each state, followed by annual convention of an advocacy body, the National Venereology Council of Australia, which also included governmental representatives. In 1988 the Australian College of Venereologists was incorporated as a professional training body, and in 1992, the first Chair in Sexual Medicine was established by the Universities of Sydney and New South Wales. In parallel, the role of the nursing profession as active participants evolved dramatically: nurses work within the context of the health care team, with clinical, teaching, and outreach responsibilities, and by collaborating or initiating research. Sexual and Reproductive Health nursing is recognised as a specialist area, and the Australian Sexual Health Nurses Association (ASHNA) was inaugurated in 1991. Sexual Health Counselors come from a range of disciplines which represent the shift in focus from disease control to education and prevention, and which encompass sexual dysfunction, gender identity issues, sexual assault, and the empowerment of clients. Within the repertoire of many health care workers in sexually transmissable disease services are skills in the ¿new¿ public health (particularly health promotion), and an understanding of cultural influences on sexuality. ¿Sexual Health¿ has become the preferred name for such services.

Sexually transmissible diseases and travel.

Sexually transmissible diseases (STDs) continue to be the most common notifiable infectious conditions worldwide. Their unacceptably high incidence is underlined by the recent emergence of a (presently) incurable and lethal STD, human immunodeficiency virus (HIV) infection, which merits its description as a pandemic, and with which other STDs interact in an epidemiological synergy. Certain travellers, by virtue of their behavioural interactions with 'core-groups' of efficient transmitters, may have a high relative risk of acquisition of an STD. This risk can be virtually eliminated by avoiding penetrative sexual intercourse with casual partners, especially injecting drug users and persons who have had multiple sexual partners (particularly prostitutes), or reduced by the use of condoms. The risk of parenteral exposure can be reduced by avoiding parenteral drug use and behaviour that is likely to lead to injury and by seeking facilities with adequate capabilities to screen blood donors and to sterilize instruments.

Diabetic gastroparesis. Case report and review of the literature.

A case report is presented of a diabetic patient who vomited unsuspected stomach contents peri-operatively due to gastroparesis. A short review of this condition is presented, together with suggestions for pre-operative management.

Anticardiolipin antibodies in homosexual men: prevalence and lack of association with human immunodeficiency virus (HIV) infection.

Tests for anticardiolipin antibodies (ACL) on sera from 100 male homosexuals and 60 male heterosexuals showed that 57% of the homosexuals, in contrast to none of the heterosexuals, were ACL positive. The ACL were predominantly of the immunoglobulin G isotype and, in a high proportion of cases tested (82%), were reactive with other phospholipids, especially those with a negative charge. ACL were not related to the clinical status of the homosexuals, being evenly distributed among 40 with acquired immunodeficiency syndrome (AIDS), 20 with AIDS-related complex (ARC), 20 with asymptomatic infection with human immunodeficiency virus (HIV) and/or lymphadenopathy syndrome, and 20 who were HIV-antibody negative. Nor were they associated with thrombocytopenia, thrombosis, neurologic disease, a biological false-positive test for syphilis (BFP), or antibodies to DNA. It is concluded that factors other than infection with HIV are responsible for ACL positivity in homosexual males and that the epitopes recognized by ACL in this group are distinct from those associated with thromboembolism or the BFP reaction or cross-reactive with DNA.

Bullous impetigo in homosexual men--a risk marker for HIV-1 infection?

OBJECTIVE: To determine the incidence of bullous impetigo in a group of homosexual men at high risk of HIV-1 infection. DESIGN: A longitudinal descriptive study (1984-9). SETTING: A private primary care and STD clinic in Sydney, Australia. SUBJECTS: 88 homosexual men documented to seroconvert to HIV-1, and 37 homosexual controls who had practised unprotected anal intercourse with another man known to be HIV-1 positive but who remained HIV-1 negative. MAIN OUTCOME MEASURE: Incidence of bullous impetigo. RESULTS: The crude annual incidence of bullous impetigo was 0.015 in subjects while they remained HIV-1 negative (10 cases) and 0.045 in early HIV-1 positive subjects (2 cases). Overall, 9% of the HIV-1 seroconverters and 9% of the HIV-1 negative controls were documented as suffering bullous impetigo over a mean of 29.2 and 39.3 months, respectively. CONCLUSIONS: Bullous impetigo in an adult could prove to be a clinical indication that a person is either infected with HIV-1 or is in close (possibly sexual) contact with a person with HIV-1 infection. If true, the recognition of bullous impetigo could provide an opportunity for behavioural intervention to limit the spread of HIV-1.

Abnormalities of visual spatial attention in HIV infection and the HIV-associated dementia complex.

Covert orienting of visuospatial attention (COVAT) was examined in 88 homosexual or bisexual men: 12 with mild HIV-associated dementia complex (ADC), 30 neurologically intact with AIDS (NI-AIDS), 23 asymptomatic HIV+ (HIV+ASX), and 23 HIV-negative control subjects. In mild ADC, COVAT was normal for spatial but impaired for nonspatial cues; 17% of NI-AIDS and HIV+ASX subjects had similar COVAT impairment patterns and also showed cognitive deficits. HIV+ subjects with normal COVAT showed normal cognitive performance. Impairment of nonspatial attentional processing in the ADC subjects and subgroups of the neurologically intact HIV+ subjects may reflect early subcortical dysfunction caused by HIV infection. COVAT assessment may be sensitive for detection of early subclinical neurological impairment in HIV infection.

Early HIV-related neuropsychological impairment: relationship to stage of viral infection.

Sixty male outpatients with no past neuropsychiatric history were examined for evidence of early HIV-related neuropsychological impairment. Significant cognitive deficit, as measured by the RAVLT and WAIS-R Digit Symbol Substitution tests, and moderate correlation with indices of immune function, were observed in a group of patients with AIDS-Related Complex [ARC]. Patients with asymptomatic HIV-infection demonstrated no significant differences in performance compared to a group of HIV-seronegative controls. No significant group differences in age, education, predicted-IQ or self-rated depression and anxiety were observed. These results support the hypothesis that HIV-related cognitive disturbance occurs within the context of immunosuppression.

Nonspecific proctitis: association with human immunodeficiency virus infection in homosexual men.

In a cross-sectional study of 140 homosexual men attending a sexually transmissible diseases clinic, the association between the presence of antibody to the human immunodeficiency virus (HIV) and the presence of proctitis, as determined by histologic examination, as well as part or present exposure to other pathogens and details of sexual practices was analyzed. Significant associations with HIV seropositivity were found with the number of lifetime partners, positive treponemal serology, and evidence of previous infection with herpes simplex virus. However the major and unique finding was the strong and independent association between proctitis diagnosed by histologic criteria and seropositivity for HIV. Whether this is cause or effect awaits further elucidation.

Failure of azithromycin therapy in gonorrhea and discorrelation with laboratory test parameters.

BACKGROUND: Azithromycin is efficacious in the treatment of chlamydial genital tract infection but less so in gonorrhea. However, MICs of azithromycin for gonococci from previously reported azithromycin treatment failures were consistently below the 'susceptible' MIC level of 2 mg/L. GOAL OF THIS STUDY: To examine gonococci not eliminated with 1 g azithromycin therapy to establish treatment outcome/MIC correlates in gonorrhea. STUDY DESIGN: The MICs and phenotypes of gonococci isolated from five cases of treatment failure after 1 g azithromycin therapy were determined and compared with the MICs of a systematic sample of routine isolates. RESULTS: Azithromycin MICs of gonococci from five cases of failed 1 g azithromycin treatment were 0.125 or 0.25 mg/L, well within the current 'susceptible' MIC range. None of the isolates were of the mtr phenotype. The MIC90 of a systematic sample of 219 gonococcal isolates was 0.25 mg/L. CONCLUSION: The antibiotic MIC/treatment outcome correlates that are usually found in gonorrhea do not apply for azithromycin. Current MIC criteria do not accurately define susceptibility or resistance of gonococci to azithromycin and by themselves do not predict the likely outcome of therapy. Pharmacokinetic factors may decrease the predictive value of MIC data.

Anti-sperm antibodies in homosexual men: prevalence and correlation with sexual behaviour.

The sera of 60 homosexual males were examined for the presence of antibodies to sperm using an indirect immunobead test (IBT). Six of 60 (10%) had antibodies of IgG isotype; in addition two of the six had antibodies of IgA isotype. The presence of antibodies was associated with the practice of unprotected receptive anal intercourse in the previous six months. Antibodies were not found in homosexual men who were celibate, or who practised only oral intercourse during the same period. There was no correlation between the presence of anti-sperm antibodies and antibodies to human immunodeficiency virus (HIV), or numbers of T lymphocytes. These preliminary results lend support to the hypothesis that antigen presentation in the lower gut may be a source of sensitisation against sperm. The possibility that anti-sperm antibodies may be a marker of receptive anal intercourse merits further investigation.

PIP: It has been suggested that the introduction of spermatozoa to the rectum leads to the development of a humoral immune response. The immunobead method was used to investigate antisperm antibody titre and prevalence and their relation to HIV status in 60 homosexual men attending the Royal Melbourne Hospital (Australia) HIV/AIDS clinic as part of an ongoing epidemiologic study. On the basis of their sexual practices in the preceding 6 months, the men were categorized into four groups: Group 1--unprotected oral intercourse only (n = 13), Group 2--unprotected oral and anal intercourse (n = 39), Group 3--unprotected anal intercourse only (n = 2), and Group 4--celibate (n = 6). Antibodies to sperm were found in the sera of 6 men (10%), all of whom were from Groups 2 and 3. Thus, the prevalence of antisperm antibodies in men who had practiced unprotected anal receptive intercourse in the preceding 6 months was 17%. Antibodies were of the IgG and IgA isotypes. There was no correlation between the presence of antisperm antibodies and antibodies to HIV or numbers of T lymphocytes. 30 men, including 2 of the 6 men with antisperm antibodies, were HIV-positive. These preliminary findings lend support to the hypothesis that antigen presentation in the lower gut may be a source of sensitization against sperm. They further suggest a possible role for antisperm antibodies as a marker of receptive anal intercourse.