HIV-1 subtype E progression among northern Thai couples: traditional and non-traditional predictors of survival.

BACKGROUND: In the continuing effort to introduce antiretroviral therapy in resource-limited settings, there is a need to understand differences between natural history of HIV in different populations and to identify feasible clinical measures predictive of survival. METHODS: We examined predictors of survival among 836 heterosexuals who were infected with HIV subtype CRF01_AE in Thailand. RESULTS: From 1993 to 1999, 269 (49.4%) men and 65 (25.7%) women died. The median time from the estimated seroconversion to death was 7.8 years (95% confidence interval 7.0-9.1). Men and women with enrolment CD4 counts <200 cells/microl had about 2 and 11 times greater risk of death than those with CD4 counts of 200-500 and >500, respectively. Measurements available in resource-limited settings, including total lymphocyte count (TLC), anaemia, and low body mass index (BMI), also predicted survival. Men with two or more of these predictors had a median survival of 0.8 (0.5-1.8) years, compared with 2.7 (1.9-3.3) years for one predictor and 4.9 (4.1-5.2) years for no predictors. CONCLUSIONS: The time from HIV infection to death appears shorter among this Thai population than among antiretroviral naive Western populations. CD4 count and viral load (VL) were strong, independent predictors of survival. When CD4 count and VL are unavailable, individuals at high risk for shortened HIV survival may be identified by a combination of low TLC, anaemia, and low BMI. This combination of accessible clinical measures of the disease stage may be useful for medical management in resource-limited settings.

Protection against sexually transmitted diseases by granting sex workers in Thailand the choice of using the male or female condom: results from a randomized controlled trial.

BACKGROUND: The male condom is the most effective barrier method available for protection against sexually transmitted diseases (STDs), including HIV infection. There is an urgent need to develop and evaluate other prevention methods, such as the female condom. This study estimated the additional protection against STDs offered to sex workers by giving them the option of using the female condom when clients refused to use a male condom. METHODS: Sex establishments in four cities in Thailand were randomized into two study groups: one in which sex workers were instructed to use male condoms consistently (male condom group); and one in which sex workers had the option of using the female condom if clients refused or were not able to use male condoms (male/female condom group). Randomization was done by sex establishments, and not by individuals, to minimize sharing of female condoms across study groups. The proportion of unprotected sexual acts (defined as sexual acts in which condoms were not used, tore, or slipped in or out) and incidence rate of STDs (gonorrhoea, chlamydial infection, trichomoniasis and genital ulcer disease) were measured over a 24-week period and compared between the two study groups. FINDINGS: Results are available from 34 sex establishments (249 women) in the male/female condom group, and 37 sex establishments (255 women) in the male condom group. Condom use was very high in both groups (97.9 and 97.3 % of all sexual acts, respectively, P > 0.05). Male condom use was lower in the male/female condom group when compared with the male condom group (88.2 and 97.5%, respectively, P < 0.001). However, this reduction in male condom use was counterbalanced by the use of female condoms in 12.0% of all sexual acts in the male/female condom group, contributing to a 17% reduction in the proportion of unprotected sexual acts in this group when compared to the male condom group (5.9 versus 7.1%, respectively, P = 0.16). Female condom use was sustained over the entire study period. There was also a 24% reduction in the weighted geometric mean incidence rate of STDs in the sex establishments of the male/female condom group compared to the male condom group (2.81 versus 3.69 per 100 person-weeks, P = 0.18).

Risk factors for HIV-1 transmission from HIV-seropositive male blood donors to their regular female partners in northern Thailand.

OBJECTIVE: To describe risks for HIV transmission from male blood donors to their regular female sex partners in Chiang Mai, Thailand. DESIGN: Cross-sectional study. METHODS: From March 1992 through September 1995, 405 HIV-seropositive male blood donors (index cases) and their regular female partners were enrolled in the study. Women with risk factors for HIV infection other than sexual contact with the index male were excluded. Couples were interviewed and examined; specimens were collected for laboratory analysis. RESULTS: Overall, 46% of the 405 women enrolled were HIV-positive. Ninety-eight per cent of male index cases had a history of sex with a female prostitute; 1.5% reported always using condoms with their regular partner. History of sexually transmitted disease (STD) and swollen inguinal lymph nodes in the female partner were associated with an increased risk of HIV infection in the female. History in the female of genital herpes [odds ratio (OR), 3.46; 95% confidence interval (CI), 1.50-8.78], gonorrhea or chlamydia infection (OR, 2.71; 95% CI, 1.39-5.53), and stable relationship of longer than 24 months (OR, 2.28; 95% CI, 1.02-5.09) were associated with an increased risk of HIV infection in the female. Consistent condom use in the past 2 years (OR, 0.10; 95% CI, 0.01-0.79) was associated with a decreased risk of HIV infection in the female. CONCLUSIONS: Married women in northern Thailand who appear otherwise to be at low risk for HIV infection may be exposed to this virus by their husbands. High rates of sex with commercial sex workers among men and low use of condoms within stable relationships may be important factors promoting the transmission of HIV in married couples. Programs to increase the regular use of condoms among married couples could be an important public health intervention to prevent transmission of HIV and other types of STD in northern Thailand.

PIP: The risk factors for HIV transmission from infected male blood donors to their regular female sex partners were investigated in a cross-sectional study conducted in Chiang Mai, Thailand, in 1992-95. During the 3.5-year study period, 405 couples were recruited. 98% of male blood donors reported a history of sex with female prostitutes. Only 28 men (7%) were aware of their seropositivity prior to notification by the blood bank, and just 1.5% always used condoms with their regular sex partner. 187 (46%) of the 405 female sex partners--none of whom had HIV risk factors other than sexual contact with their husbands--were HIV-positive at baseline. In the multivariate analysis, three variables were associated with a significantly increased risk of HIV in female partners: history of genital herpes (odds ratio (OR), 3.46; 95% confidence interval (CI), 1.50-8.78), history of gonorrhea or chlamydia (OR, 2.71; 95% CI, 1.39-5.53), and a stable relationship of at least 2 years' duration (OR, 2.28; 95% CI, 1.02-5.09); consistent condom use in the past 2 years was significantly associated with a decreased risk of HIV (OR, 0.10; 95% CI, 0.01-0.79). Medroxyprogesterone acetate injection and oral contraceptive use were not associated with HIV risk. These findings confirm a high risk of HIV transmission through monogamous sexual relationships in Thailand. Recommended are campaigns to increase regular condom use among married couples.

Measurement of circulating inhibin forms during the establishment of pregnancy.

This study investigated the forms of inhibin released into the circulation 1) in very early pregnancy, 2) after stimulation of the corpus luteum by exogenous hCG, and 3) in abnormal and failing human pregnancy. Samples were assayed by enzyme-linked immunosorbent assays for inhibin A, inhibin B, and inhibin pro-alphaC-related immunoreactivity (pro-alphaC-RI). The concentration of inhibin A rose steadily during the conception luteal phase to an initial peak 12 days after ovulation (104 +/- 23 pg/mL), then rose rapidly to a further peak 43 days after ovulation 424 +/- 6 pg/mL). The concentration of pro-alphaC-RI exhibited a much larger peak on day 15 after ovulation (1423 +/- 361 pg/mL), but fell thereafter. The concentration of inhibin B was low after ovulation and subsequently barely detectable in pregnancy. hCG treatment resulted in a significant rise in the concentrations of inhibin A and pro-alphaC-RI, but had no effect on the inhibin B concentration. The pro-alphaC-RI concentration was a better indicator of continuing pregnancy viability than either hCG or inhibin A. Early trophoblast secretes proportionately more bioactive inhibin than the corpus luteum. The corpus luteum and trophoblast do not secrete inhibin B into the circulation. These data support the concept of different physiological roles for different inhibin forms.

Condom breakage during commercial sex in Chiang Mai, Thailand.

Used condoms in 30 female brothels in Chiang Mai, Thailand, during the period from August 1992 to October 1992 were examined for breakage. Data were also collected by interviewing 326 prostitutes who accounted for 65 percent of the total prostitutes providing condoms. The prostitutes had a mean age of 20.6 +/- 3.2 years. Sixty-one percent had no formal education. The median duration of prostitution was 13 months. The average number of clients per day in the past 24 hours and in the past 3 months was 4.4 +/- 2.5 and 5.5 +/- 2.2, respectively. Eighty-eight percent charged between $2 and less than $8 for their sexual service. All refused to practice oral or anal sex during the past 24 hours. Of 5,559 condoms, 298 were used two at a time and 15 were used three at a time. The breakage rate per act of intercourse was 5.9 percent (95% CI = 5.3, 6.5). The breakage per total condoms examined was 5.7 percent (95% CI = 5.1, 6.3). Breakage relating to manufacturing defect, i.e., pinholes, and that relating to use was 0.8 percent (95% CI = 0.6, 1.0) and 5.0 percent (95% CI = 4.4, 5.6), respectively. The probability of breakage when using two condoms at the same time was 3.4 percent (95% CI = 0.5, 6.3). Most of the breakage occurred at the distal part of the condom. There was no difference between the breakage rates of condoms provided by the brothels and those brought by the client; nor was there any difference between manufacturing defect or use. The breakage rate per client as estimated by prostitutes in the past 24 hours corroborated with that assessed by examination.

PIP: Brothel-based female prostitution has been the most important source of HIV spread in Thailand, especially in Chiang Mai. Proper and consistent use of condoms during sexual intercourse greatly minimizes the risk of HIV transmission between sex partners. Condoms do, however, occasionally rupture during use. The authors examined used condoms for breakage in thirty female brothels in Chiang Mai, Thailand, over the period August-October 1992, to assess the true level of breakage among users in such a context. 326 prostitutes, or 65% of prostitutes providing condoms, were also interviewed. The women were of mean age 20.6 years and had been working as prostitutes for a median duration of thirteen months. They reported having an average 4.4 clients during the preceding 24 hours, but an average 5.5 clients per day during the preceding three months. All refused to practice oral or anal sex during the preceding 24 hours. Of 5559 condoms, 298 were used two at a time and fifteen were used three at a time. Examination found a 5.9% rate of condom breakage per act of intercourse and a 5.7% rate of breakage per total condoms examined. Most breakage occurred in the distal region of the condom. The breakage rate per client as estimated by prostitutes during the preceding 24 hours corroborated with that assessed by examination. Breakage related to manufacturing defect and use was 0.8% and 5.0%, respectively, with a 3.4% probability of condom breakage when two were used at the same time. No difference was found between the breakage rates of condoms provided by the brothels and those brought by the client, nor was there any difference between manufacturing defect or use.

A study of adrenal corticol function and its reserve activity in long-acting injectable contraceptive users.

Adrenal function and its reserve capacity were studied in eighteen healthy non-lactating women who received depot-medroxyprogesterone acetate (DMPA: 9 subjects) and norethisterone enanthate (NET-EN: 9 subjects) as long-acting injectable contraceptives. Methodological assessments included: (i) morning fasting concentration of serum cortisol; (ii) diurnal variation of adrenal corticol activity as evidenced by cortisol concentration in serum samples taken at 0700 and 1600 hours; (iii) urinary free cortisol excretion; and (iv) cortisol response to insulin-induced hypoglycaemia. None of these assessments was significantly altered by contraceptive administration. This finding indicates that the subject's ability to release cortisol in response to a stressful situation, as well as to normal day-to-day activity, was not impaired by these contraceptive steroids.

PIP: Adrenal cortical function and its reserve capacity were studied in 9 women who received depot medroxyprogesterone acetate (DMPA) and in 9 women who received norethisterone enanthate (NET-EN) as long acting injectable contraceptives. Adrenal function was assessed by means of morning fasting concentration of serum cortisol, diurnal variation of adrenal corticol activity, and measurement of free urinary cortisol, and cortisol release in response to insulin-induced hypoglycemia. These assessments were made both prior to and at intervals after the initiation of contraceptive treatment. Data were combined and presented in 4 blocks: before treatment; 30 days after 1st injection; during treatment (data from 3rd, 4th, and 5th assessments); and after treatment (6th assessment made 6 months after the last injection). Neither the fasting concentration nor the circadian rhythm of cortisol were significantly altered by the use of either form of gestagens, not even when subjects were exposed to a relatively high level of these steroids during the first 30 days of their injection. It seems likely that the slight but insignificant decrease in the mean levels of cortisol following the introduction of gestagen injectable contraceptives is related primarily to reduction of the plasma binding protein. The mean level of free cortisolin 24-hour urine collections remained unchanged in both groups of subjects, confirming that adrenal function remained essentially unchanged in injectable contraceptive users.

Methamphetamine users in northern Thailand: changing demographics and risks for HIV and STD among treatment-seeking substance abusers.

Our objective was to determine sociodemographic, sexual and drug-use-related risk factors among methamphetamine (MA) users presenting for drug treatment in northern Thailand. Patients admitted for drug detoxification for MA and other drugs were studied cross-sectionally for risk factors associated with substance abuse and blood-borne and sexually transmitted pathogens. In all, 1865 (200 women) patients treated for MA, opiate, and mixed substance abuse between 1 February 1999 and 31 January 2000 completed all study procedures. Among 1865 participants, 750 (40.2%) were admitted for MA detoxification and 1115 (59.8%) for opiate (heroin, opium, or both) treatment. MA users were significantly younger, better educated, more likely to be Thai than highland ethnic minorities, and had significantly different sexual risks and sexually transmitted disease rates, including lower syphilis seropositivity and higher chlamydial prevalence, than persons admitted for opiate or mixed drug treatment. For those who reported MA use only, use by injection was rare and HIV infections significantly less common than among all other drug users. Thailand is undergoing an epidemic of MA use. These young users are a strikingly different population from opiate/heroin users in northern Thailand. MA users had higher rates of chlamydia infection than opiate users, reflecting their young age, and HIV rates in this population were lower than injecting drug users, but still elevated. MA use is a serious public health problem in Thailand and both improved prevention and treatment methodologies are urgently needed.

Secondary amenorrhea at Maharaj Nakhon Chiang Mai Hospital.

One hundred and thirty-seven patients attending the gynaecological endocrine clinic at Maharaj Nakhon Chiang Mai hospital between April 1, 1982 and July 31, 1987 were studied. Detailed history, physical and pelvic examination were obtained on all patients, followed by progesterone withdrawal test and other appropriate laboratory studies including thyroid and reproductive hormone profiles. The most common cause of secondary amenorrhea in this study was hypothalamic-pituitary dysfunction (54.7%), not unlike those reports from other foreign series. However, it was notable that nearly 40 per cent of our patients in this group experienced amenorrhea after discontinuation of contraceptive steroids. Premature ovarian failure was the second leading cause of amenorrhea in our patients (13.9%) and, perhaps, deserve future detailed studies. The other causes of amenorrhea in decreasing frequency were: hyperprolactinemia (11.7%), hypothalamic-pituitary failure (8.0%), Asherman's syndrome (5.1%) and androgen excess (2.9%). Primary hypothyroidism was a rare cause of amenorrhea in this study.

Sexually transmitted disease prevalence in brothel-based commercial sex workers in Chiang Mai, Thailand: impact of the condom use campaign.

One hundred and ninety five (195) brothel-based commercial sex workers (CSW) in Chiang Mai, Thailand, were screened for sexually transmitted disease (STD) between October 1994 and April 1995, prior to their enrollment in a multi-center comparative trial of the effectiveness of two strategies using male and female condoms. These CSW had a mean age of 22.2 (SD 4.3) years. Forty-seven per cent were Thai and 57.4 per cent had no formal education. Median duration of prostitution was 16 months and median cost for sexual service was 50 baht (US$ 2) per client. Ninety-four per cent of CSW reported always using condoms with clients. There were 63 (32.3%) CSW infected with at least one type of the STD screened. The prevalence of STD included chlamydial infection (16.9%), gonococcal infection (14.4%), condyloma accuminata (4.6%), moluscum contagiosum (2.6%) and trichomoniasis (1.0%). There was no statistically significant risk factor for STD found in this study. Despite an active programme for prevention of STD in CSW and the provision of free condoms, STD were diagnosed in one-third of the screened CSW in Chiang Mai. The programme needs to be strengthened by more intensive education and practice in the correct and consistent use of condoms and integrated with other STD prevention programmes.

PIP: 195 brothel-based commercial sex workers (CSWs) in Chiang Mai, Thailand, were screened for sexually transmitted diseases (STDs) between October 1994 and April 1995, prior to their enrollment in a multi-center comparative trial of the effectiveness of two strategies using male and female condoms. These CSWs had a mean age of 22.2 (SD 4.3) years. 47% were Thai and 57.4% had no formal education. Median duration of prostitution was 16 months and median cost for sexual service was 50 baht (US$2) per client. 94% of the CSWs reported always using condoms with clients. 63 (32.3%) CSWs were infected with at least one of the screened STDs. The prevalence of STDs was as follows: chlamydial infection (16.9%), gonococcal infection (14.4%), condyloma accuminata (4.6%), moluscum contagiosum (2.6%), and trichomoniasis (1.0%). There was no statistically significant risk factor for STDs found in this study. Despite an active program for prevention of STDs in CSWs and the provision of free condoms, STDs were diagnosed in one-third of the screened CSWs in Chiang Mai. The program needs to be strengthened by means of more intensive education and correct and consistent use of condoms and integrated with other STD prevention programs.

Somatic growth and clinical manifestation in formula fed infants born to HIV--infected mothers during the first year of life.

This was a comparative study of the growth and clinical manifestation between infected and uninfected HIV infants both of whom were fed with a limited quantity of powder milk from birth until one year of age. HIV-infected pregnant women were enrolled from the second trimester or the beginning of the third trimester. After birth, infants had physical examinations, body weight and height were recorded at 2, 4, 6, 9 and 12 month visits. All mothers were given 7 kilograms of infant formula at each infant visit until the infant was one year old. Diagnosis for HIV infection in these infants was made by two positive concordant results of DNA PCR or RNA PCR or HIV RNA. One hundred and two infants were diagnosed for HIV status and 21.5 per cent were infected. The infected infants showed signs of malnutrition. From 2-4 months of age, the averages of their weights and heights were lower than those of non-infected infants. Abnormal clinical signs were found in most infected infants by the time they were 9-12 months old. In conclusion for the infants born to HIV- infected mothers, monitoring signs and symptoms including their weight and height from birth till 9-12 months old, is predictive of the infectious status of most infected infants. The administration and management of infant formula in a limited quantity to HIV infected mothers in upper northern provinces of Thailand is possible without causing abnormal infant growth.

Socio-demographic and drug use factors associated with HIV-1 recombinants and dual infections in Northern Thai drug users: associations of risk with genetic complexity.

BACKGROUND: Dual infection with diverse HIV strains can foster the emergence of recombinants. The resulting increase in viral genetic diversity is a major challenge for vaccine development HIV treatment. In this study we aim to investigate the socio demographic factors associated with an increasing level of genetic diversity among HIV strains in a population of drug-users in Northern Thailand. METHODS: From 1999 through 2000, 2231 volunteers were enrolled in the Opiate-Users Research in Chiang Mai, Thailand. HIV subtype analysis was conducted among those HIV-1 seropositive (n=347) using a multi-region hybridization assay. Social and demographic variables were assessed using a structured questionnaire. RESULTS: Overall, 336/347 (96.8%) of the samples could be typed. 81.8% were CRF01_AE, 3.9% were subtype B, 9.2% were recombinants (mostly between CRF01_AE and B) and 5.1% were dual infections. Dual infections were more frequent among those with a lower education level (AOR: 5.2; 95% CI 1.4-20.3), those who have initiated injecting in the last 3 years (AOR: 3.9; 95% CI 1.1-14.6), and those reporting frequent needle sharing in the last 3 months (AOR: 7.0; 95% CI 1.5-34.1). Both recombinant strains and dual infection were more frequent among those reporting frequent needle sharing in the last 3 months (AOR: 5.3; 95% CI 1.6-17.1). CONCLUSION: To limit the expanding complexity of HIV-1 strains, early intervention should be aimed at reduction in needle sharing, especially among new intravenous drug users.

In-depth, longitudinal analysis of viral quasispecies from an individual triply infected with late-stage human immunodeficiency virus type 1, using a multiple PCR primer approach.

Co-infections with more than one human immunodeficiency virus type 1 (HIV-1) subtype appear to be the source of new recombinant strains and may be commonplace in high-risk cohorts exposed to multiple subtypes. Many potential dual infections have been identified during the HIV Superinfection Study in Mbeya, Tanzania, where 600 female bar workers who are highly exposed to subtypes A, C, and D have been evaluated every 3 months for over 3 years by use of the MHAacd HIV-1 genotyping assay. Here we describe an in-depth, longitudinal analysis of the viral quasispecies in a woman who was triply infected with HIV-1 and who developed AIDS and passed away 15 months after enrollment. The MHA results obtained at 0, 3, 6, 9, and 12 months revealed dual-probe reactivities and shifts in subtype over time, indicating a potential dual infection and prompting further investigation. The multiple infection was confirmed by PCR amplification of three genome regions by a multiple primer approach, followed by molecular cloning and sequencing. A highly complex viral quasispecies was found, including several recombinant forms, with vpu/gp120 being the most diverse region. A significant fluctuation in molecular forms over time was observed, showing that the serial sample format is highly desirable, if not essential, for the identification of multiple infections. In a separate experiment, we confirmed that the detection of co-infections is more efficient with the use of multiple amplification primers to overcome the primer bias that results from the enormous diversity in the HIV-1 genome.

In-depth analysis of a heterosexually acquired human immunodeficiency virus type 1 superinfection: evolution, temporal fluctuation, and intercompartment dynamics from the seronegative window period through 30 months postinfection.

Human immunodeficiency virus type 1 (HIV-1) superinfection refers to the acquisition of another strain by an already infected individual. Here we report a comprehensive genetic analysis of an HIV-1 superinfection acquired heterosexually. The infected individual was in a high-risk cohort in Tanzania, was exposed to multiple subtypes, and was systematically evaluated every 3 months with a fluorescent multi-region genotyping assay. The subject was identified in the window period and was first infected with a complex ACD recombinant strain, became superinfected 6 to 9 months later with an AC recombinant, and was monitored for >2.5 years. The plasma viral load exceeded 400,000 copies/ml during the first 9 months of infection but resolved to the set point of 67,000 copies/ml by 3 months after superinfection; the CD4 cell count was 377 cells/mul at 30 months. Viral diversity was evaluated with techniques designed to fully sample the quasi-species, permitting direct observation of the evolution, temporal fluctuation, and intercompartment dynamics of the initial and superinfecting strains and recombinants derived from them. Within 3 months of superinfection, seven different molecular forms were detected in gag and six were detected in env. The proportions of forms fluctuated widely over time in plasma and peripheral blood mononuclear cells, illustrating how challenging the detection of dually infected individuals can be. Strain-specific nested PCR confirmed that the superinfecting strain was not present until the 9 month follow-up. This study further defines the parameters and dynamics of superinfection and will foster appropriate studies and approaches to gain a more complete understanding of risk factors for superinfection and its impact on clinical progression, epidemiology, and vaccine design.

Effects of the injectable contraceptive depot medroxyprogesterone acetate in Thai women with liver fluke infestation: final results.

PIP: The effect of the 3-monthly injectable contraceptive depot medroxyporgesterone acetate (DMPA) on liver function and lipids was assessed in Thai women both with and without liver fluke (Ophisthorchis viverrini) infestation. DMPA administration was started in the immediate postpartum period and women who accepted immediate postpartum IUD insertion of sterilization were recruited as a control group. Complete 18-month followup results were obtained for 108 DMPA and 106 control fluke-positive subjects and for 89 DMPA and 74 fluke-negative subjects. No woman in any of the groups developed signs or symptoms of hepatic disease and the DMPA users had fewer health-related complaints during followup than the control subjects. Over 80% of both groups of users were amenorrheic 18 months postpartum, compared with about 15% of those in the control group. A large majority of subjects in each group continued to breastfeed for the entire study period without complaint. Weight change was small and similar in both the DMPA and control groups. Total bilirubin, aspartate aminotransferase, alanine aminotransferase, dehydrogenase, and alkaline phosphatase levels at 6, 12, and 18 months in the DMPA groups were generally equivalent to or lower than those in the corresponding control groups. Cholesterol levels were significantly decreased in the fluke-positive DMPA subjects while serum triglycerides were significantly decreased in both DMPA groups compared with their controls throughout the followup period. We conclude that during 18 months of use, DMPA did not cause any deleterious effects on health or on the metabolic factors studied in women with and without liver fluke infestation.^ieng

Serum prolactin and cortisol levels after suckling for varying periods of time and the effect of a nipple shield.

Plasma prolactin and cortisol levels were measured in mothers breast feeding with or without the use of a thin latex nipple shield, and in mothers wearing a nipple shield but who were not nursing. Suckling duration and milk transfer were also recorded. Suckling duration ranged between 6 and 31 min, being significantly correlated with prolactin levels 40 to 120 min after the feed started. At the latter time, baseline prolactin level and time spent nursing accounted together for most of the variance in prolactin levels: R2 was 0.79 and 0.82 at 90 min and 120 min respectively. Prolactin was released as usual when the shield was in place: levels were not significantly different from levels without the shield. Suckling duration was also unaffected by the shield, but milk transfer was significantly reduced. Cortisol was not released by using the shield, and the shield alone (without suckling) did not release prolactin. The thin latex nipple shield has therefore no untoward effect on the release of these hormones during nursing.

The relationship between peripheral immunoactive inhibin, human chorionic gonadotrophin, oestradiol and progesterone during human pregnancy.

OBJECTIVE: The objective of this study was to investigate serial changes in the plasma concentration of inhibin in both the very early days of pregnancy following implantation and in late pregnancy. The timing of the changes in inhibin concentration relative to changes in the concentrations of other hormones of pregnancy was also investigated. DESIGN: Serial observations of the peripheral concentrations of inhibin and other hormones in two groups of healthy volunteers in (a) early pregnancy and (b) late pregnancy. PATIENTS: (a) Four healthy women recruited on cessation of contraception prior to conception. (b) Nine healthy women recruited at the antenatal clinic. MEASUREMENTS: In the early pregnancy subjects, the concentrations of inhibin, progesterone, oestradiol and hCG were measured in plasma samples obtained three times per week from day 8 to day 10 of each menstrual cycle until 11 weeks after the last menstrual period in the conception cycle. In the late pregnancy subjects, plasma samples were obtained at 4-week intervals from 12 weeks until term. RESULTS: The concentration of inhibin, progesterone and oestradiol in conception cycles were similar to those in the preceding cycles until the mid/to late-luteal phase of the cycle when hCG was first measureable. By day 12 of the luteal phase the concentration of inhibin was significantly higher in the pregnancy cycle than in the non-pregnancy cycle (P < 0.05) and progressively increased after the time of the missed menstrual period. The concentration of inhibin reached a peak (513.0 U/l, CI 442.1-595.3) by day 47 when the concentration of hCG was maximal. In early pregnancy the concentration of inhibin was correlated with that of hCG (r = 0.361; P < 0.01) as well as progesterone (r = 0.584, P < 0.001) and oestradiol (r = 0.602, P < 0.001). After 12 weeks there was no significant correlation between hCG and inhibin although significant correlations persisted with progesterone (r = 0.553, P < 0.001) and oestradiol (r = 0.361, P < 0.01). CONCLUSIONS: The corpus luteum makes a significant contribution to the production of inhibin in early pregnancy while after 12 weeks the placenta is the major source.

Multiple condom use and decreased condom breakage and slippage in Thailand.

There is compelling evidence that male condoms effectively prevent transmission of sexual pathogens, including HIV-1. Condom breakage and slippage reduce this effect. We measured rates of condom slippage and breakage during heterosexual commercial sex in northern Thailand. Of 7,594 condoms examined in 4,734 client visits (5,040 sex acts), breakage was noted in 1.8% of single condom use (49.3% of acts), as compared with 0.2% with two condoms (49% of sex acts), and no breaks with more than two condoms (1.2% of sex acts). These breakage rates declined from 5.9% in a similar 1992 study in which 2.8% of sex acts were with more than one condom used at a time. Slippage occurred in only 0.1% of sex acts. Case-control analysis indicated that multiple clients, younger aged clients, sex after midnight, and high intensity (rough) sex were associated with condom breaks. The decline in breakage may be attributable to greater expertise in condom use by sex workers and clients, in response to the successful Thai national "100% Condom Campaign." Use of more than one condom during sex has been initiated by sex workers and their clients, a community response to condom promotion messages and fears of HIV infection. These data demonstrate the potential of condom use for high efficacy in reducing exposure to HIV-1 and other STDs. If condom use in commercial sex remains high, HIV incidence may decline among Thai men.

PIP: During August-October 1995, in northern Thailand, laboratory personnel examined 7594 condoms from 4734 client visits and 5040 sexual acts to evaluate mechanisms of condom breakage and slippage among 68 female commercial sex workers (CSWs) (mean age, 25 years) in 7 brothels in Lamphun City in Lamphun Province in order to verify condom use self-reports among the CSWs and to identify targets for interventions to reduce condom failure. Sexually transmitted disease (STD) episodes in the last year among the CSWs were gonorrhea (45.6%), pelvic inflammatory disease (29.4%), genital ulcer (29.3%), syphilis (13.2%), nongonococcal cervicitis (13.2%), and genital warts (8.8%). A condom was not used during 0.6% (30) of the sexual acts. 99.4% (5010) of the sexual acts involved use of at least one condom. There were only 5 condom slippage events--a condom slippage rate of 0.1%. This rate did not vary with the number of condoms used per sexual act. On the other hand, the condom breakage rate decreased as the number of condoms used per sexual act increased (1 condom = 1.8%; 2 condoms = 0.2%; 3-4 condoms = 0). Single condom use was more likely to yield breakage than multiple condom use (odds ratio [OR] = 11.4). The condom breakage rate 1 year after initiation of the 100% Condom Campaign (1992) was 5.9% compared to 1% in 1995. Condom breaks occurred just below the reservoir (40.2%), at reservoir tips (31.7%), along the shaft (18.3%), and at the base (9.8%). Multiple condom use increased from 2.8% to 50.4% during 1992-95. Factors independently associated with condom breaks included high-intensity (rough) sex (OR = 8.49; p 0.0001), more than one sexual act with the same client on the night of the breakage (OR = 2.72; p = 0.02), and sexual service after midnight (OR = 2.58; p = 0.03). These findings suggest that multiple condom use significantly contributed to the decline in condom breakage among multiple users. Another strong possible factor was greater skill in condom use by CSWs and by clients in response to the 100% Condom Campaign. Multiple condom use may reduce exposure to HIV-1 and other STDs.

Reliability of self-reported sexual behavior in human immunodeficiency virus (HIV) concordant and discordant heterosexual couples in northern Thailand.

A partner study was conducted in northern Thailand between March 1992 and June 1996 which included data that allowed an assessment of the reliability of self-reports of sexual behavior and contraceptive use among heterosexual couples. The authors enrolled 529 couples among whom all male subjects were human immunodeficiency virus (HIV) seropositive voluntary blood donors and their female sexual partners were either HIV infected (n=246) or HIV seronegative (n=283). The levels of agreement within couples were assessed for recency of last sexual intercourse, sexual activity in the prior year, and contraceptive practices. For HIV discordant couples, a prospective study was conducted to examine risk factors for HIV transmission, the primary goal of the study. This allowed assessment of reliability of inter-partner reports over 6-12 months. Overall, agreement among couples was good for common sexual practices, especially vaginal intercourse and time since last intercourse, but was lower for condom use. Anal and oral sex were infrequently reported by these couples and there was greater disagreement for the occurrence of these practices. Partner agreement for contraceptive histories was good to excellent. Prospective data showed less frequent intercourse and more condom use but reliability remained good. Common sexual practices may be reliable for both HIV concordant and discordant couples in studies estimating prevalent infection. Estimates of incident heterosexually transmitted HIV may be made with greater reliability by studies which include assessment of reports of risk behavior by each member of a couple than studies of individuals.

PIP: A study conducted in northern Thailand in 1992-96 enabled assessment of the reliability of self-reports of sexual behavior and contraceptive use among heterosexual couples. Enrolled were 529 HIV-positive male voluntary blood donors and their female partners who were either HIV-infected (n = 246) or seronegative (n = 283). In addition, a prospective analysis was conducted among the HIV discordant couples to examine risk factors for HIV transmission and further assess the reliability of inter-partner reports. Among HIV discordant couples, women reported an average of 185 sexual events in the past 2 years while men reported 165 such events. In discordant couples, these averages were 206 and 186 events, respectively. Agreement of the time since last sex within 3 days was recorded for 63.2% of concordant and 65.0% of discordant couples. Positive agreement on use of any contraceptive method in the past year was 88% for concordant couples and 91% for discordant couples. The prospective analysis demonstrated similar levels of agreement; the frequency of sexual acts decreased by 50% after HIV was diagnosed and condom use increased. The high degree of overall concordance of reports of sexual activity and contraceptive use between partners in this analysis is encouraging in terms of the validity of research studies on HIV transmission. Estimates of incident heterosexually transmitted HIV may be made with greater reliability by studies that include assessment of reports of risk behavior by each member of a couple rather than studies of individuals.

Multiple condom use in commercial sex in Lamphun Province, Thailand: a community-generated STD/HIV prevention strategy.

BACKGROUND AND OBJECTIVE: In an investigation of condom breakage in commercial sex, we found a high proportion of multiple condoms use. This study sought to ascertain the characteristics of brothel-based commercial sex workers (CSWs) and their clients; to identify the decision makers (clients and/or CSWs) active in choosing multiple condom use; and to determine whether there is an implicit hierarchy of condom use negotiation. GOALS: To identify factors associated with multiple condom use in commercial sex and to provide an understanding of how this innovation developed in this setting. STUDY DESIGN: Sixty-seven brothel-based CSWs in Lamphun Province who participated in a study of condom breakage participated in a case-control study of multiple versus single condom use, which determined CSW and client characteristics for evidence of multiple condom use. Interviews and focus groups were used to determine decision making for condom use and the contexts for multiple use. Association between characteristics of CSWs/clients and multiple condom use was analyzed using X2 for trend. RESULTS: No official program encouraged multiple condom use; this appeared to be a community-devised strategy to increase protection from human immunodeficiency virus (HIV) and other sexually transmitted diseases (STDs). CSWs working in daytime brothels had significantly greater multiple condom use than those working in nighttime brothels; mean percentages + SD of multiple simultaneous use were 57.5% + 28.6 and 35.5% + 22.4, respectively (p < 0.001). Day CSWs were older, had more pregnancies, reported higher frequency of STD symptoms and history of pelvic inflammatory disease, and had more clients per day but had a lower number of sex acts per client than night CSWs. Among factors associated with multiple condoms, only age was significant. The decision to use single or multiple condoms for a sex act was primarily (78.2% in single and 79.3% in multiple) made by the CSW herself. The main reason given for multiple condom use was protection from HIV/STD. CONCLUSIONS: There is high compliance between CSWs in Lamphun province and the Ministry of Public Health-sponsored 100% condom use campaign, and CSWs are attempting to further reduce their risks of HIV/STD exposure by using multiple condoms for sex with their clients.