The challenge of diagnosis and treatment of neurosyphilis in China: results from a nationwide survey.

Background The uncertainty of how neurosyphilis is diagnosed and treated in clinical settings led us to investigate whether this serious manifestation of syphilis infection is properly managed in China. METHODS: This national cross-sectional study of the diagnosis and treatment of neurosyphilis included 1392 clinicians at 398 hospitals located in 116 cities in China. RESULTS: Of 398 hospitals, 244 (61.3%) failed to perform diagnostic laboratory tests and 181 (45.5%) failed to provide recommended treatment for neurosyphilis. Of 1392 clinicians, 536 (38.5%) had previously diagnosed patients with neurosyphilis, but 419 (78.2%) of the latter provided diagnoses that did not meet the criteria set by national guidelines. Of the 485 clinicians who had previously treated patients with neurosyphilis, 280 (57.7%) failed to follow national guidelines for treatment. Analysis indicated that clinicians working in North China (adjusted odds ratio (aOR), 4.24; 95% confidence interval (CI), 1.65-10.88), tertiary hospitals (aOR, 3.23; 95% CI, 1.63-6.41), and hospitals specialising in sexually transmitted infections (aOR, 2.49; 95% CI, 1.24-4.99) were more likely to follow national guidelines for neurosyphilis treatment. CONCLUSION: Lack of knowledge in disease management poses a great obstacle to prevent the serious consequences of neurosyphilis in Chinese patients. More effective measures are urgently needed to improve this suboptimal situation.

HIV prevalence, incidence and risk behaviours among men who have sex with men in Yangzhou and Guangzhou, China: a cohort study.

INTRODUCTION: In China, the prevalence and incidence of HIV among men who have sex with men (MSM) in large-sized cities have drawn much attention. In contrast, there has been a paucity of research focussing on the sexual health of MSM of medium-sized cities. This study fills this important gap in the knowledge by investigating the sexual health of MSM in a medium-sized city (Yangzhou) and a large-sized city (Guangzhou). METHODS: A baseline survey and a prospective cohort study were conducted among MSM in Yangzhou and Guangzhou from July 2009 to September 2010. A total of 622 MSM (317 from Yangzhou and 305 from Guangzhou) were screened for eligibility. Prevalence and incidence of HIV infection, as well as its risk factors, were investigated. RESULTS: Baseline HIV prevalence was 14.5%, and overall HIV incidence density was 6.78 per 100 person-years (PY) among Yangzhou MSM. Risk factors for HIV prevalence that were significant in multivariate models were older age, married status, unprotected sex with female partners, sexually transmitted disease (STD)-associated symptoms and syphilis positivity. Risk factors for HIV incidence that were significant in multivariate models were STD-associated symptom and syphilis positivity. Compared to Yangzhou MSM, Guangzhou MSM had a lower HIV prevalence (6.2%; p<0.05) and lower overall HIV incidence density (5.77 per 100 PY). Risk factors for HIV prevalence that were significant in multivariate models were married status, unprotected anal sex with men and syphilis positivity. The single risk factor for HIV incidence that was significant in multivariate models was unprotected anal sex with men. CONCLUSIONS: This study showed a high prevalence and incidence of HIV among Yangzhou MSM, which suggest a more serious HIV epidemic than that in large-sized cities. Further investigation targeting MSM in medium-sized cites is urgently needed to prevent the spread of the HIV epidemic in China.

Association of sexually transmitted infections with high-risk human papillomavirus types: a survey with 802 female sex workers in china.

A cross-sectional study that investigated the association between cervical infection of Chlamydia trachomatis, Neisseria gonorrhoeae, or Mycoplasma genitalium and infection with high-risk types of human papillomavirus among female sex workers in China found that the presence of cervical C. trachomatis or M. genitalium infection was independently associated with infection with certain high-risk types of specific high-risk human papillomavirus among this population.

The prevalences of Neisseria gonorrhoeae and Chlamydia trachomatis infections among female sex workers in China.

BACKGROUND: Sexually transmitted infections (STIs) have become a major public health problem among female sex workers (FSWs) in China. There have been many studies on prevalences of HIV and syphilis but the data about Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) infections are limited in this population in China. METHODS: A cross-sectional study was performed among FSWs recruited from different types of venues in 8 cities in China. An interview with questionnaire was conducted, followed by collection of a blood and cervical swab specimens for tests of HIV, syphilis, NG and CT infections. RESULTS: A total of 3,099 FSWs were included in the study. The overall prevalence rates of HIV, syphilis, NG and CT were 0.26%, 6.45%, 5.91% and 17.30%, respectively. Being a FSW from low-tier venue (adjusted odds ratios [AOR]=1.39) had higher risk and being age of ≥ 21 years (AOR=0.60 for 21-25 years; AOR=0.29 for 26-30 years; AOR=0.35 for 31 years or above) had lower risk for CT infection; and having CT infection was significantly associated with NG infection. CONCLUSIONS: The high STI prevalence rates found among FSWs, especially among FSWs in low-tier sex work venues, suggest that the comprehensive prevention and control programs including not only behavioral interventions but also screening and medical care are needed to meet the needs of this population.

HIV prevalence varies between female sex workers from different types of venues in southern China.

We conducted a cross-sectional study on prevalence of human immunodeficiency virus (HIV) and syphilis among female sex workers (FSWs) recruited from different types of venues in 6 cities in China. Among 5322 FSWs (1379 were from high-tier venues, 2482 from middle-tier venues, and 1461 from low-tier venues, respectively), overall HIV prevalence was 0.54% (95% confidence interval [CI], 0.37%- 0.76%). By typology of venues where FSWs solicited clients, the prevalence was 1.37% (95% CI, 0.89%-2.11%) in low-tier venues, 0.28% (95% CI, 0.14%- 0.58%) in middle-tier venues, and 0.07% (95% CI, 0.01%-0.41%) in high-tier venues. The final logistic regression model showed an association of having had HIV infection with working in low-tier venues (adjusted odds ratio 2.73; 95% CI, 1.12-6.67) and coming from Guangxi Province (adjusted odds ratio, 7.89; 95% CI, 1.65-37.64). It can be concluded that FSWs working in low-tier venues (on the streets or public outdoor places) had higher risk of HIV infection than other venues. Such subgroup of FSWs should be efficiently covered by the current HIV/STD surveillance and intervention programs in China.

The effect of a structural intervention for syphilis control among 3597 female sex workers: a demonstration study in South China.

BACKGROUND: Syphilis has made a rapid resurgence in China, especially among high-risk groups including female sex workers (FSWs). METHODS: Two cities in each of 3 provinces in South China were chosen and allocated to intervention or control arms. The intervention consisted of enhancing community-based syphilis screening outreach intervention with comprehensive sexually transmitted infection services at designated clinics while the control maintained routine intervention activities. Generalized linear modeling was used to examine effect of the intervention on incident syphilis infection. RESULTS: A total of 8275 women were eligible, and 3597 women enrolled (n = 2011 in control arm, n = 1586 in intervention arm) in the study. The median follow-up duration was 375 days (interquartile range, 267­475). Syphilis incidence density in the intervention group was reduced by 70% (95% confidence interval, 53%­81%) compared with the incidence in the control arm. The syphilis prevention intervention benefits were robust among FSWs at low-tier venues, individuals with less than high school education, migrants, and women who did not report condom use during the last episode of sex. CONCLUSIONS: Integrated sexually transmitted infection and human immunodeficiency virus prevention strategies substantially reduce syphilis incidence among FSWs, especially among those at low-tier venues. This intervention suggests the need for scaling up comprehensive FSW programs in China.

Risk factors for Mycoplasma genitalium infection among female sex workers: a cross-sectional study in two cities in southwest China.

BACKGROUND: Mycoplasma genitalium (MG) is one of the common causes of non-gonococcal urethritis (NGU) in men and is associated with cervicitis, endometritis, and pelvic inflammatory diseases (PID) in women. The prevalence of MG infection has been reported to be high among female sex workers (FSWs) in many countries, but limited information is known among this population in China. METHODS: From July to September 2009, venue-based FSWs were recruited in two cities (Wuzhou and Hezhou) of Guangxi Autonomous Region in southwest China. Information of socio-demographic and behavioral characteristics was collected by a questionnaire-based interview. Cervical specimens were obtained for detection of MG using a real-time polymerase chain reaction (PCR) assay targeting mgpA gene. RESULTS: The overall prevalence of MG infection among 810 FSWs was 13.2% (95% CI = 10.87%-15.52%). MG infection was significantly associated with less education (adjusted odds ratio (AOR) = 2.36, 95% CI = 1.15-4.87) consisting of junior high school or below, being single (AOR = 2.27, 95% CI = 1.42-3.62), migrant background (AOR = 2.03, 95% CI = 1.29-3.20), and absence of any STI symptoms in the previous year (AOR = 1.66, 95% CI = 1.09-2.52). CONCLUSIONS: MG infection was prevalent among FSWs in the study areas. This pattern of infection suggests that an increasing attention should be paid to MG screening and treatment in this high risk population.

Prevalence of syphilis infection in different tiers of female sex workers in China: implications for surveillance and interventions.

BACKGROUND: Syphilis has made a dramatic resurgence in China during the past two decades and become the third most prevalent notifiable infectious disease in China. Female sex workers (FSWs) have become one of key populations for the epidemic. In order to investigate syphilis infection among different tiers of FSWs, a cross-sectional study was conducted in 8 sites in China. METHODS: Serum specimens (n = 7,118) were collected to test for syphilis and questionnaire interviews were conducted to obtain socio-demographic and behavioral information among FSWs recruited from different types of venues. FSWs were categorized into three tiers (high-, middle- and low-tier FSWs) based on the venues where they solicited clients. Serum specimens were screened with enzyme-linked immunosorbent assay (ELISA) for treponemal antibody followed by confirmation with non-treponemal toluidine red unheated serum test (TRUST) for positive ELISA specimens to determine syphilis infection. A logistic regression model was used to determine factors associated with syphilis infection. RESULTS: Overall syphilis prevalence was 5.0% (95%CI, 4.5-5.5%). Low-tier FSWs had the highest prevalence (9.7%; 95%CI, 8.3-11.1%), followed by middle-tier (4.3%; 95%CI, 3.6-5.0%, P < 0.001) and high-tier FSWs (2.2%; 95%CI, 1.6-2.9%, P < 0.001). Factors independently associated with syphilis infection included older age, lower education level, geographic location, lower tier of typology, and injection drug use. CONCLUSIONS: This multi-site survey showed a high prevalence of syphilis infection among FSWs and substantial disparities in syphilis prevalence by the tier of FSWs. The difference in syphilis prevalence is substantial between different tiers of FSWs, with the highest rate among low-tier FSWs. Thus, current surveillance and intervention activities, which have low coverage in low-tier FSWs in China, should be further examined.

Prevalence and risk factors of HSV-2 infection and HSV-2/HIV coinfection in men who have sex with men in China: a multisite cross-sectional study.

OBJECTIVES: To determine the prevalence and risk factors of herpes simplex virus type 2 (HSV-2) infection and its coinfection with human immunodeficiency virus (HIV) in men who have sex with men (MSM) in China. METHODS: A convenience sample of 1462 MSM were recruited from different settings (an STD clinic, a health center, and MSM venues) in 3 cities in China. Blood specimens were collected for testing for antibodies to HSV-2 and HIV to determinate the seroprevalence of HSV-2 infection and HSV-2/HIV coinfection. Information on sociodemographic and behavioral characteristics was collected to determine the risk factors associated with the infections. RESULTS: The prevalence of HSV-2 infection in 1462 MSM was 16.0% (95% confidence interval [CI], 14.2%-18.0%), the prevalence of HIV infection in this population was 9.5% (95% CI, 8.1%-11.1%), and the rate of coinfection of HSV-2 and HIV was 3.2% (95% CI, 2.4%-4.3%). Multivariate logistic regression analysis showed that risk factors for HSV-2 infection included age older than 30 years, education level lower than senior high school, involvement in commercial sex work, and HIV-positive status. Education level lower than junior high school and history of sexual abuse were associated with HSV-2/HIV coinfection. CONCLUSIONS: The high prevalence of HSV-2 infection and HSV-2/HIV coinfection among MSM in China suggests that an increased focus on HSV control is warranted within China's prevention and intervention programs targeted toward MSM.

Prevalence and genotype distribution of human papillomavirus infection among female sex workers in Guangxi, China: implications for interventions.

Human papillomavirus (HPV) infection is a major public health concern in women, but information on HPV among female sex workers in China is limited. The aim of the study was to estimate the prevalence and genotype distribution of HPV infection among female sex workers in two cities in Guangxi, China. A total of 811 female sex workers were recruited from venues between July and September of 2009. Data on socio-demographic and behavior characteristics were collected, and cervical swabs were collected to determine HPV infection and genotype distribution. The overall prevalence of infection with any HPV type was 38.9%. HPV type 52 was the most prevalent type with prevalence of 11%, followed by HPV types 16, 58, 53, and CP8304, with prevalences of 6.5%, 5.7%, 5.6%, and 4.8%, respectively. HPV 16 or 18 accounted for 23.2% of all HPV positive cases. Age group <20 years was significantly associated with infection of the high-risk and multiple types of HPV infection. A higher prevalence of multiple HPV infection was observed among female sex workers from the outdoor venues (14.0%; 95%CI, 10.6%-17.3%). These findings have important implications for developing HPV prevention programs including HPV vaccination in female sex workers.

HIV/STD pattern and its associated risk factors among male STD clinic attendees in China: a foci for HIV intervention.

BACKGROUND: Previous studies suggested a high prevalence of STDs including HIV among female sex workers and men who have sex with men in China, but little was known about the prevalence in male patients attending public STD clinics. The aim of this study was to investigate STD patterns and HIV prevalence among male STD clinic attendees in different areas in China and the associated risk factors. The feasibility of Provider-initiated HIV testing and counseling (PITC) was evaluated as well. METHODS: A cross-sectional study was conducted at 46 public STD clinics in 4 provinces in China. Between July 2009 and September 2009, a total of 3243 eligible subjects were invited to participate in an interview with a structured-questionnaire for collecting socio-demographic characteristics and sexual behavioral information. They also were asked to provide venous blood samples for serological determinations of HIV and syphilis infection, and first void urine specimens for detecting Chlamydia trachomatis and Neisseria gonorrhoeae infections, RESULTS: Out of the 3243 eligible patients, 2951(91%) men agreed to take part in the HIV and syphilis testing. The overall prevalence rate of HIV infection was 0.7% while the rates of syphilis, N. gonorrhoeae, C. trachomatis infections were 10.7%, 4.3% and 6.9%, respectively, with the highest syphilis and N. gonorrhoeae rates in Jiangsu Province. Patients from Guangxi province, homosexual/bisexual practices and intravenous drug use were significantly associated with HIV infection in multivariate logistic regression analyses. Provider-initiated HIV testing and counseling (PITC) was well accepted by attendees, with 91% of eligible attendees agreeing to undergo HIV testing and counseling. All HIV positive patients were properly managed accordingly. CONCLUSIONS: A modest prevalence of HIV infection and substantial prevalence of other STD infections were found among male patients attending public STD clinics in China. The findings further support the introduction of HIV and syphilis PITC strategy into this important setting.

[Clinical observation on percutaneous autologous bone marrow grafting for treatment of fracture nonunion].

OBJECTIVE: To observe the effectiveness of percutaneous bone marrow grafting for treatment of fractures nonunion. METHODS: From June 2001 to December 2007, 29 consecutive cases of fractures nonunion were treated with percutaneous autologous bone marrow grafting included 20 males and 9 females, ranging in age from 20 to 71 years, with an average of 40 years. All the cases were traumatic fractures involving 13 of tibia, 10 of femur, 3 of humerus, 2 of ulna, 1 of radius, 11 cases of them were open fractures. All the cases were performed internal or external fixation before marrow grafting, intramedullary pin in 15 cases, plate in 12 cases, external fixator in 2 cases. The time from injury to therapy were from 6 to 12 months, with an average of 8.5 months. The type of nonunion included atrophic in 26 cases,hypertrophic in 3 cases. All the cases were performed 3 times injection, the interval was 1 month. According to the different fracture, the amount of bone marrow was from 6 to 15 ml. RESULTS: All the 29 cases were followed-up for from 5 to 22 months with an average of 14 months. Four of them were not observed obvious callus after 3 months from the 3rd injection, judged unsuccessful therapy, changed to perform autologous bone grafting (3 of them re-internal fixation), the follow-up ended. The other 25 cases obtained bone union during 3 to 8 months with an average of 4.5 months, the follow-up ended at the time of internal fixation removal. CONCLUSION: Percutaneous autologous bone marrow grafting is an effective, easy and economic therapy for fracture nonunion. But stable internal or external fixation is the premise. Excessive bone defect, the gap more than 5 mm and mal-align requiring rectification is not appropriate for this therapy.

Syphilis in China: results of a national surveillance programme.

BACKGROUND: After a massive syphilis epidemic in the first half of the 20th century, China was able to eliminate this infection for 20 years (1960-80). However, substantial changes in Chinese society have been followed by a resurgent epidemic of sexually transmitted diseases. Sporadic reports have provided clues to the magnitude of the spread of syphilis, but a national surveillance effort is needed to provide data for planning and intervention. METHODS: We collected and assessed case report data from China's national sexually transmitted disease surveillance system and sentinel site network. FINDINGS: In 1993, the reported total rate of cases of syphilis in China was 0.2 cases per 100,000, whereas primary and secondary syphilis alone represented 5.7 cases per 100,000 persons in 2005. The rate of congenital syphilis increased greatly with an average yearly rise of 71.9%, from 0.01 cases per 100,000 livebirths in 1991 to 19.68 cases per 100 000 livebirths in 2005. INTERPRETATION: The results suggest that a range of unique biological and social forces are driving the spread of syphilis in China. A national campaign for detection and treatment of syphilis, and a credible prevention strategy, are urgently needed.

Prevalence of sexually transmitted infections among long-distance truck drivers in Tongling, China.

Little is known about sexually transmitted infections (STIs), including HIV, among truck drivers in China. A cross-sectional study was conducted among truck drivers in Tongling of Anhui Province. A total of 550 truck drivers were interviewed with a structured questionnaire, and blood samples were collected and tested for HIV, syphilis, and herpes simplex virus 2 (HSV-2), and urine specimens for Neisseria gonorrhoeae and Chlamydia trachomatis. Prevalence was 10.6% for C. trachomatis and 8.1% for N. gonorrhoeae. Antibodies for syphilis were found in 0.7% and for HSV-2 in 4.4%, and none was positive for HIV. About 92 (17.4%) truck drivers had at least one STI. There was no statistically significant association between sociodemographic, occupation or behavioural variables and the presence of a positive test for any STI. Our study suggests a high prevalence of STIs, particularly bacterial infections, among the truck drivers, indicating the need for health education, behavioural change interventions and STI care services in this population.

Co-infection with genital gonorrhoea and genital chlamydia in female sex workers in Yunnan, China.

An observational study on prevalence of co-infection with gonorrhoea and chlamydia was conducted among female sex workers (FSWs) in Kunming, China.A total of 505 FSWs participated in the study. All eligible participants gave informed consent. Demographic, behavioural and clinical information of the participants was gathered by direct structured interviews. Tampon swabs were collected to test for Chlamydia trachomatis and Nesseria gonorrhoeae. One-hundred and twenty-four (24.6%) FSWs were co-infected with these two pathogens. Of the 191 FSWs with gonorrhea, 124 (64.9%, 95% confidence interval [CI] = 57.9-71.3%) were co-infected with chlamydia which was significantly higher than the proportion (41.9%, 95% CI = 36.4-47.6%) co-infected with gonorrhoea among 296 FSWs with chlamydia (P < 0.001). Only 47 of 191 (24.6%) FSWs with gonococcal infection and 28 of 124 (22.6%) with co-infection with gonorrhoea and chlamydia reported vaginal discharge. The results of the study justify the recommendation in the national sexually transmitted disease (STD) guidelines that patients infected with gonorrhoea also be treated routinely with an anti-chlamydial regimen. However, a periodic mass treatment may be considered in some circumstances in STD control programmes to rapidly reduce the infections in this population.

Sexually transmitted infections among female sex workers in Yunnan, China.

A cross-sectional prevalence survey of sexually transmitted infections (STIs) was conducted among female sex workers (FSWs) in Kunming, Yunnan Province, China. A total of 505 FSWs participated in the survey. All eligible participants gave informed consent. Demographic, behavioral, and clinical information of the participants was gathered by direct structured interviews. Tampon swabs were collected to test for Chlamydia trachomatis, Nesseria gonorrhoeae, and Trichomonas vaginalis and serum specimens were collected to test for HIV antibody by enzyme-linked immunosorbent assay (ELISA) screening and Western blot confirmation, syphilis with rapid plasma reagin (RPR) and T. pallidum hemagglutination (TPHA) confirmation, and for HSV-2 antibodies with the HerpeSelect 2 ELISA. The most prevalent bacterial STI was Chlamydia trachomatis (58.6%), followed by Trichomonas vaginalis (43.2%) and Neisseria gonorrhoeae (37.8%). Three hundred twenty-seven (65.1%) sex workers had serologic evidence of exposure to HSV-2 infection. Ten percent were positive for HIV infection, all injecting drug users (IDUs); and 9.5% had infection with syphilis. Comprehensive prevention and effective STI services for sex workers and their clients will be the key strategies to the control of STIs, including HIV. Policies and prevention strategies for STI/HIV need to focus on high-risk subpopulations, such as sex workers (particularly sex workers who inject drugs) and their clients.