High rate of HIV seroconversion among patients attending urban sexually transmitted disease clinics.

OBJECTIVE: To study rates of documented HIV seroconversion and syphilis as a cofactor for seroconversion in sexually transmitted disease (STD) clinics. In the main clinic the HIV seroprevalence rate was 12% and most infections had been shown to be acquired by heterosexual contact. METHODS: We analyzed computer records of patients who had at least two HIV-antibody tests between 1 December 1987 and 31 December 1990, at STD clinics in Dade County (Miami), Florida. RESULTS: Of 5164 individuals with two HIV tests, 208 (4.0%) seroconverted. The overall seroconversion rate was 3.1 per 100 person-years. Among blacks, who accounted for 77% of seroconversions, the rate was higher for women (4.8) than for men (2.7). The highest rate was in 15-19-year-old black women (7.1 per 100 person-years). The HIV seroconversion rate was 12.8 for patients with primary or secondary syphilis diagnosed between two HIV tests, 3.1 for patients who acquired syphilis before their first HIV test, and 2.3 for patients who had never had syphilis. Eighteen per cent of all HIV seroconversions were attributable to syphilis acquired in the interval between two HIV tests. CONCLUSIONS: We found high HIV seroconversion rates, especially among black teenagers and black women, in an STD clinic population in which the majority of HIV infections were shown previously to have been acquired heterosexually. Syphilis was a marker for HIV seroconversion and syphilitic ulcers may facilitate HIV transmission. Innovative prevention programs directed towards women and adolescents should be developed and evaluated.

Fertility and use of cigarettes, alcohol, marijuana, and cocaine.

This study demonstrated that cigarette smoking was associated with an increase in both time to conception (among 2817 fertile women) and risk of primary infertility (among 1818 infertile women and their primiparous control subjects). The average time to conception was 4.3 months for women who never smoked, 4.6 months for those who smoked in the past, and 5.1 months for those who currently smoked. The delay in conception for current smokers remained significant after adjusting for confounders (risk ratio of 0.9 (0.8 to 1.0)). Additionally, current smokers were at increased risk of primary infertility (odd ratios of 1.9 (1.5 to 2.3)). For alcohol use, the average time to conception and risk of primary infertility did not vary by level of consumption. The average time to conception was significantly shorter for women who had used marijuana regularly and for women who had ever used cocaine than for women who had never used these drugs. Because of the increased use of marijuana and cocaine among young adults, further investigations of these associations are needed.

Seroepidemiological characterization of a syphilis epidemic in the Republic of the Marshall Islands, formerly a yaws endemic area.

The annual numbers of reported cases of syphilis in the Republic of the Marshall Islands (RMI) increased from none in 1983 to more than 600 in 1989, suggesting a large outbreak of syphilis. Much of the increase resulted from expanded serological screening. The apparent outbreak of syphilis, therefore, may have been partly the result of increased surveillance or, since the RMI was formerly a yaws endemic area, possibly due to a resurgence of yaws. To address this problem and better characterize the epidemic, we analysed results from a 1989/90 Ministry of Health Services mass serological screening on Majuro Atoll, the main population centre. Serum specimens from 9160 people (86% of residents aged 15-44 years) on Majuro were screened with the rapid plasma reagin (RPR) card test; we repeated the RPR and performed a confirmatory microhaemagglutination assay for Treponema pallidum-specific antibodies (MHA-TP) on a sample of serum specimens. To estimate the seroprevalence of syphilis, we also tested a sample of RPR nonreactive specimens by MHA-TP. Among people less than 45 years of age, total (11.5%) and high-titre (5.2%) seropositivity rates were highest in the 20-24 year age group, as was MHA-TP seroprevalence (15.9%). These results suggested that a large outbreak of syphilis was responsible for the observed seroreactivity. Cumulative incidence modelling and comparisons with the results of a previous serosurvey conducted in 1985 suggested that the duration of the syphilis epidemic was approximately 10 years and that incidence had not increased appreciably since 1985.

Primary infertility: characteristics of women in North America according to pathological findings.

STUDY OBJECTIVE: To determine, in women with primary infertility, whether specific characteristics or behavioural factors are associated with the various pathological conditions identified as contributing to the infertility. DESIGN: Case-control study. SETTING: Seven institutions in the USA or Canada. PARTICIPANTS: Study subjects were 1750 women who presented with primary infertility, among whom the main pathological cause of infertility was male factor (417), tubal obstruction (231), endometriosis (194), luteal phase defects (153), other ovulatory problems (193), cervical abnormalities (92), and polycystic ovarian disease (84) and 1765 control women who delivered their first child at the same institution. MAIN RESULTS: Except for tubal obstruction and polycystic ovarian disease, the characteristics and behaviours of the women with infertility did not differ appreciably according to the pathological conditions recorded. Women with tubal obstruction had had more sexual partners, an earlier age at first intercourse, were more likely to have used an intrauterine device but less likely to have used a condom, and were more likely to have smoked cigarettes and to have used various recreational drugs than the other women. Women with polycystic ovarian disease were more obese, had had fewer sexual partners, and were less likely to have used cigarettes, contraceptives, and recreational drugs than the other women. CONCLUSIONS: Sexually transmitted infections seem to increase the risk of tubal obstruction but not other causes of infertility. Obesity is associated with polycystic ovarian disease. These data offer few clues to the aetiology of infertility attributed to endometriosis, cervical abnormalities, luteal phase defects, other ovulatory defects, or to male factors.

A method to describe physician decision thresholds and its application in examining the diagnosis of coronary artery disease based on exercise treadmill testing.

The authors developed a method that utilizes logistic regression analysis to 1) calculate the disease probability with confidence intervals at which any specified proportion of physicians reaches a clinical decision, 2) statistically test whether factors other than disease probability affect this clinical decision, and 3) statistically test whether physician decision making in relation to disease probability varies by other factors. They apply the method to analyze the relationship between disease probability and the proportion of physicians who diagnosed coronary artery disease (CAD) in 127 consecutive subjects who completed the treadmill exercise tolerance test (ETT) at two hospitals. Twenty-five percent of the physicians decided that CAD was possible or definite at a post-ETT disease probability of 0.24 (95% CL= 0.07-0.35); 50% at 0.54 (95% CL = 0.43-0.70); and 75% at 0.82 (95% CL = 0.67-1.0). Multivariate logistic regression analysis revealed three factors significantly and independently related to the diagnosis of CAD: post-ETT disease probability, positive ETT result, and cigarette smoking. The proportion of physicians who reached a diagnosis of CAD did not differ by hospital setting (VA versus university), level of training (attending versus housestaff/fellow), or diagnosing service (cardiology versus other internal medicine). It is concluded that factors other than disease probability may affect physician diagnostic decisions.

Treatment of syphilis, 1993.

Data on treatment of patients with syphilis were reviewed in preparation for revision of the Sexually Transmitted Disease Treatment Guidelines of the Centers for Disease Control and Prevention. Published studies of treatment regimens available and practical for use today were reviewed, particularly in regard to the following issues: treatment for primary, secondary, and latent stages of syphilis; treatment for syphilis during pregnancy; treatment for syphilis in human immunodeficiency virus (HIV)-infected patients; and serological criteria for evaluating response to treatment. The results of treatment and the methodological quality of the studies was considered. Most treatment recommendations must be based on expert judgment and with reliance on the clinical experience over 4 decades. For the treatment of early syphilis in HIV-uninfected patients, this is probably sufficient. Data about HIV-infected patients are insufficient both for determining whether current therapy is adequate and for recommendation of an alternative if a change in therapy is deemed necessary.

Treatment of syphilis, 1989.

With the introduction of penicillin after World War II, the incidence of syphilis in the United States decreased. Because of penicillin's great success, clinical trials stopped after an initial period of intensive investigation. Syphilis is a difficult disease to study; the natural history may span decades in an individual, and diagnosis and outcome are usually defined serologically, not clinically or bacteriologically. Although the recommended penicillin regimens changed, clinical trials were not repeated. Furthermore, because the early studies occurred before modern clinical-trial methodology was developed, interpretation of the results is difficult. As a result, while current regimens for syphilis therapy are effective, they may or may not be optimal. With the accumulation of reports of treatment failures and the recent appearance of human immunodeficiency virus, current regimens for the treatment of syphilis are being questioned. As background for a meeting at which treatment guidelines were reviewed, the available literature on syphilis therapy is summarized herein.

Epidemiology of primary and secondary syphilis in the United States, 1981 through 1989.

Between 1981 and 1989, the incidence of primary and secondary syphilis in the United States increased 34%, from 13.7 to 18.4 cases per 100,000 persons, the highest since 1949. The populations affected most by syphilis also changed substantially. From a peak of 10.0 cases per 100,000 persons in 1982, the incidence among white men had decreased 69% by 1989 (3.2 cases per 100,000 persons). From 1982 to 1985, the incidence also decreased among black men (30%, 101.9 to 71.5 cases per 100,000) and black women (22%, 45.8 to 35.8 cases per 100,000). However, in 1986 this trend reversed, and the incidence among blacks more than doubled from 1985 to 1989 (52.6 to 121.8 cases per 100,000 persons). Racial differences in syphilis incidence increased (black-to-white incidence rate ratio in 1981 was 14.5 and in 1989 was 47.8), as did regional differences. Trends in syphilis incidence indicate changes in sexual behavior that may determine future sexual transmission of human immunodeficiency virus. Targeting resources at populations most affected by this recent epidemic is an urgent public health priority.

Diverging gonorrhea and syphilis trends in the 1980s: are they real?

BACKGROUND: The purpose of this study was to evaluate whether the divergence in national trends of gonorrhea and syphilis from 1986 to 1989 in the United States was real and if overall trends masked a contemporaneous increase in both diseases in a core group. METHODS: We analyzed the following: (1) reported cases of gonorrhea and primary and secondary syphilis in the United States for the years 1981 to 1989, (2) gonorrhea screening results from six states for the years 1985 to 1989, and (3) reported cases of gonorrhea and primary and secondary syphilis by census tract for the years 1986 to 1989 in one city. RESULTS: The incidence of gonorrhea decreased 22% in the United States from 1986 to 1989 while the incidence of primary and secondary syphilis increased 59%. Among Blacks, syphilis incidence increased 100% and gonorrhea incidence decreased 13%; among Whites and Hispanics, the incidence of both diseases decreased. Results from gonorrhea screening among females in six states agree with gonorrhea incidence trends in those areas. Race-specific and census tract analyses of data from a number of metropolitan areas where overall rates diverged did not demonstrate a group in which the incidence of both diseases increased. CONCLUSIONS: We conclude that diverging trends of gonorrhea and syphilis from 1986 to 1989 are real and emphasize differences in the epidemiologic characteristics of these two sexually transmitted diseases.

Surveillance for primary and secondary syphilis--United States, 1991.

PROBLEM/CONDITION: From 1986 through 1990, an epidemic of syphilis occurred throughout the United States. In 1991, the number of reported cases of primary and secondary (P&S) syphilis in the United States declined for the first time since 1985. REPORTING PERIOD COVERED: To examine how this decline reflected sex-specific, race/ethnicity-specific, and regional patterns of syphilis morbidity, we analyzed data for syphilis cases reported to CDC from 1984 through 1991. DESCRIPTION OF SYSTEM: Summary data for cases of syphilis reported to state health departments were sent quarterly and annually to CDC. The quarterly data from each state included total number of syphilis cases by sex, stage of disease (primary, secondary, early latent, and late latent), and source of report (public or private). The annual data from each state included total number of P&S syphilis cases by sex, racial/ethnic group (white, not of Hispanic origin; black, not of Hispanic origin; Hispanic; Asian/Pacific Islander; or American Indian/Alaskan Native), 5-year age group, and source of report. RESULTS: The decline in both the number and rate of reported syphilis cases in 1991 occurred in every racial group in the United States and in both sexes. This decline also occurred in every region of the United States except the Midwest, where the total P&S syphilis rate increased 37.3% from 1990 through 1991. Despite the increase in syphilis rates in the Midwest, the highest rates of P&S syphilis in 1991 were reported from the South. INTERPRETATION: The reasons for the decline in syphilis are unclear. No data exist to conclusively identify which STD control program activities affected the level of syphilis morbidity or to what extent those activities may have contributed to the decline. Changes in drug use and limited immunity to Treponema pallidum may have accounted for some of the decrease in syphilis incidence. Higher levels of poverty in the South and poor access to health-care services associated with poverty probably contributed to continued high levels of disease transmission in the South. ACTIONS TAKEN: Better evaluation of STD control program activities will be necessary to help determine the most effective strategies for preventing and controlling syphilis in different high-risk populations.

Treatment of syphilis, 1998: nonpregnant adults.

Questions regarding the appropriate therapy for syphilis remain, despite the many years during which this infection has been subjected to intense scientific scrutiny. In an effort to provide guidance for the development of the 1998 sexually transmitted disease (STD) treatment guidelines of the Centers for Disease Control and Prevention (CDC), these questions were outlined and an effort to answer them was made. Articles relating to syphilis treatment published after the previous revision of the CDC STD treatment guidelines (in 1993) and by the end of 1996 were identified with use of MEDLINE. Abstracts from relevant scientific meetings held during that time were also examined. Reference was also made to older literature, and expert opinion was sought. Conclusions were reached and recommendations were made on the basis of published evidence wherever possible.

Therapy of uncomplicated gonorrhea due to antibiotic-resistant Neisseria gonorrhoeae.

Antibiotics available to treat uncomplicated anogenital infections due to beta-lactamase-producing Neisseria gonorrhoeae include spectinomycin, ceftriaxone, and clavulanic acid added to aqueous procaine penicillin G or amoxicillin. Important variables in deciding which antibiotic regimen to use include effectiveness against urethral, cervical, pharyngeal, and rectal infections; cost; eradication of coexisting incubating syphilis; adverse effects; efficacy against strains of N. gonorrhoeae with chromosomally mediated resistance to antimicrobial agents; ease of administration; patient acceptance; and the potential for inducing resistance to antimicrobial agents in pathogens other than those causing sexually transmitted diseases. This review outlines the advantages and disadvantages of the various regimens.

Pelvic inflammatory disease: trends in hospitalizations and office visits, 1979 through 1988.

OBJECTIVES: We attempted to assess trends in pelvic inflammatory disease occurrence and to describe current antibiotic treatment and use of surgical procedures for pelvic inflammatory disease in the United States. STUDY DESIGN: Analyses of hospitalizations according to the National Center for Health Statistics, National Hospital Discharge Survey for 1979 to 1988, and of office visits to private physicians from the National Disease and Therapeutic Index for 1979 to 1989 were done. RESULTS: From 1979 to 1988, a mean of 181,700 women aged 15 to 44 years were hospitalized each year for acute pelvic inflammatory disease (3.03/1000 women) and 94,400 for chronic pelvic inflammatory disease (0.90/1000), and nearly 400,000 first visits for pelvic inflammatory disease were made each year to private physicians' offices (7.2/1000 women). Mean visit and hospitalization rates for acute pelvic inflammatory disease were highest for women aged 20 to 24 years and for other-than-white women. By 1987 to 1988, however, pelvic inflammatory disease hospitalization rates were highest for teenagers. Surgery was performed during 42% of hospitalizations for acute pelvic inflammatory disease and 90% of hospitalizations for chronic pelvic inflammatory disease. Over this time period, hospitalization rates for acute pelvic inflammatory disease decreased by 36% while office visit rates remained unchanged. CONCLUSION: This decrease in hospitalizations for pelvic inflammatory disease may indicate a true decrease in its incidence, changes in physician hospitalization practices, or a shift in the spectrum of severity of pelvic inflammatory disease.

Risk factors for syphilis: cocaine use and prostitution.

In Philadelphia, a large increase in syphilis among minority group heterosexuals began in 1986 and preceded similar increases elsewhere in the United States. To determine reasons for this increase, we conducted a case-control study in the metropolitan sexually transmitted diseases clinic during 1987 and 1988. Cocaine use (odds ratio [OR] 3.1; 95% confidence interval [95% CI] = 1.5, 6.5 among men; OR 5.8; 95% CI = 1.5, 33 among women) and exchange of drugs for sex (OR 3.5; 95% CI = 1.4, 8.7 among men) were risk factors for syphilis. Although cocaine users reported more sexual partners and more frequently reported sex with prostitutes, cocaine use remained a risk factor after adjustment for these behaviors. These data suggest that sexual behavior or another factor, such as availability or utilization of health care, among cocaine users leads to increased risk of syphilis in this population. Increases in cocaine use may be partly responsible for recent increases in syphilis incidence in the United States.

Are caffeinated beverages risk factors for delayed conception?

The association between time to conceive reported by 2817 fertile women who had recently had a liveborn child and consumption of coffee, tea, and "cola" drinks has been investigated. No evidence for an adverse effect of caffeine was found. For levels of consumption ranging from less than one cup of coffee per week (501 mg caffeine per month) to more than two cups of coffee per day (7000 mg per month), the average time to conceive was similar. The fecundability ratio adjusted for known risk factors for time to conceive was 1.03 (95% confidence interval 0.92-1.16) between those who consumed more than 7000 mg caffeine per month and those who consumed 500 mg or less per month. Furthermore caffeine consumption was not associated with infertility in 1818 infertile women and their primiparous controls.

Crack, sex, and STD.

Increasing rates of syphilis, gonorrhea, chancroid, and sexually transmitted human immunodeficiency virus infection appear to be related to crack cocaine use. This article critically reviews 16 epidemiologic studies that examine drug use, sexual behavior, and sexually transmitted disease (STD). Eight studies found an association between crack and STD, one study found no association between crack and STD, and seven studies found STD to be related to other drugs or methods of cocaine use. The exchange of sex for money or drugs was associated with STD in seven studies. Publications that were reviewed have numerous methodologic weaknesses: broader sampling, uninfected comparison groups, and greater specification of drug use and sexual risk behaviors are needed. Further research should compare different drugs and associated sexual behavior and STD to assess the unique risk conferred by crack. Designing effective interventions will require investigation of risk behavior determinants and barriers to health care.

Regional and temporal trends in the surveillance of syphilis, United States, 1986-1990.

During the latter half of the 1980s, an epidemic of syphilis occurred throughout the United States. A comparison of regional rates of primary and secondary syphilis in 1990 indicated that the rates were highest in the South, followed by the Northeast, the West, and the Midwest. Primary and secondary syphilis rates from 1986 through 1990 exhibited different regional patterns. Rates of primary and secondary syphilis in the West peaked in 1987 and declined from 1987 to 1990. Rates increased in the Northeast and the South from 1986 to 1990, but the increase reached a plateau in the Northeast in 1990. Rates did not begin to increase in the Midwest until 1988. More detailed analyses of the syphilis epidemics in specific communities in each region are needed to better understand the regional patterns. A comparison of these findings across regions could be helpful in evaluating which sexually transmitted disease intervention and control programs are most effective during epidemic periods.

Treponemal specific tests for the serodiagnosis of syphilis. Syphilis and HIV Study Group.

OBJECTIVES: To determine the rate of concordance of the Microhemagglutination Assay for Antibodies to T. pallidum (MHA-TP) and the Fluorescent Treponemal Antibody-Absorption test (FTA-ABS) prior to therapy in patients with early stage syphilis and to assess the incidence of and associated risk factors for seroreversion of these treponemal specific tests during the first year after therapy for early syphilis. DESIGN: Multicenter, prospective, cohort treatment study of patients with early syphilis. METHODS: Five hundred twenty-five patients were enrolled in a study to evaluate the response of early syphilis to either benzathine penicillin 2.4 million units intramuscularly once or this therapy plus amoxicillin 2 g and probenecid 500 mg orally both three times daily for 10 days. Serologic and clinical follow-up was conducted at intervals over 1 year. MHA-TP and FTA-ABS tests were performed on serologic specimens from each patient visit. RESULTS: Enrollment specimens showed 5% discordant MHA-TP and FTA-ABS results with 85% of these demonstrating a nonreactive MHA-TP. This occurred most commonly in primary syphilis. In patients who had a 1-year serologic follow-up with FTA-ABS or MHA-TP, seroreversion occurred in 9% and 5% of cases, respectively. No association between HIV-seropositivity and TST seroreversion was demonstrated. CONCLUSION: The MHA-TP may be less sensitive than the FTA-ABS for identifying patients with primary syphilis. Treponemal specific tests may become nonreactive during the first year after therapy for early syphilis.

Epidemiology of syphilis in the United States, 1941--1993.

BACKGROUND AND OBJECTIVES: The distribution and trends of syphilis are influenced by biologic factors, sexual behaviors, biomedical technology, availability of and access to health care, public health efforts, changes in population dynamics, and sociocultural factors. The objective of this article is to review the epidemiology of syphilis in the United States during the period 1941-1993 in the context of some of these factors. STUDY DESIGN: Surveillance data on cases of syphilis and congenital syphilis reported by state and city health departments to the Centers for Disease Control and Prevention were analyzed to show distribution and trends by geographic location, racial and ethnic groups, gender, and age. RESULTS: Historically, syphilis was distributed widely throughout the country and declined rapidly after the introduction of penicillin therapy and broad-based public health programs, attaining its lowest levels in the 1950s. However, in recent years, the disease has returned and become focused in the southern region and in urban areas outside that region. Rates of syphilis have remained highest in black Americans, and the most recent national epidemic of syphilis primarily involved them. Rates in white men were at intermediate levels during the early 1980s but have declined to low rates in the 1990s, possibly because of changes in behavior in response to the AIDS epidemic. Rates in white women and other racial and ethnic groups have remained low throughout the 1980s and 1990s. CONCLUSIONS: Syphilis remains a significant problem in the United States, and its epidemiology is influenced by a complex combination of factors. To prevent and control syphilis effectively, public health practitioners must understand these factors and design programs and interventions that address the disease in the context of these factors.