Cutaneous cryptococcosis: recurrence following oral fluconazole treatment.

A case of recurrent cutaneous cryptococcosis in an immunocompromised patient is described. The patient presented with a non-healing cutaneous ulcer due to infection with Cryptococcus neoformans. Extensive investigation failed to reveal any evidence of associated systemic cryptococcosis. Treatment with oral fluconazole resulted in complete resolution of the ulcer but after several months a second cutaneous cryptococcal lesion appeared, strongly suggesting dissemination from an underlying systemic focus. This case illustrates the hazards associated with making a diagnosis of isolated cutaneous cryptococcosis and the necessity for prolonged follow-up of patients who present in this way.

A survey of female prostitutes at risk of HIV infection and other sexually transmissible diseases.

OBJECTIVE: To determine risk factors for the transmission of human immunodeficiency virus (HIV), including injecting drug use (IDU), sexual behaviour and other sexually transmissible diseases (STDs), in female prostitutes who attended the Sydney Sexual Health (previously STD) Centre. DESIGN: We surveyed by questionnaire 231 (47%) of 491 female prostitutes who visited the Centre over a 19 month period from 1986 to 1988. All were tested for HIV antibody. MAIN OUTCOME: All the women were seronegative for HIV but a number of major risk factors for infection were identified. RESULTS: Seventeen of 26 (65%) current injecting drug users had shared needles in the previous 6 months. Nineteen per cent of those surveyed had bisexual non-paying partners and 21% had partners who injected drugs. Sixty nine per cent always used condoms for vaginal intercourse with paying clients, but they were rarely used with non-paying partners. Condom use was also rare for anal intercourse with clients and/or partners by those (18%) who practised it. Seventeen per cent used condoms alone for contraception and 48% relied on oral contraceptives. We found a reduction in gonorrhoea, herpes and trichomoniasis when compared with a 1985 study conducted at the same Centre. However, there was an increase in reported abnormal cervical cytology. CONCLUSION: In spite of behaviour change by some, there are still many women working as prostitutes in Sydney who remain seriously at risk of HIV infection. We recommend more widespread use of barrier methods of contraception, intensified efforts to prevent the sharing of intravenous needles, closer monitoring of the health of prostitutes, and scientific study of their paying and non-paying sexual partners.

Voluntary HIV antibody testing among STD clinic patients: a pilot study.

A pilot study was conducted with the aim of measuring the acceptability of voluntary testing for human immunodeficiency virus (HIV) antibody among patients attending sexually transmissible disease (STD) clinics. Three STD clinics, two public and one private, participated in the study which was conducted over a three-month period beginning in November 1988. For each patient attending the clinics, sex, date of birth, HIV transmission category and previous HIV test result were recorded. Patients who did not request the HIV antibody test were offered testing. Of the 2356 patients who were included in the analyses, 784 (34%) requested testing. For almost all patients (97%) who requested testing, a serum sample was collected and testing completed. Approximately half (55%) of those patients who were offered the test accepted testing. Overall, 70% of patients completed HIV antibody testing. Of the major transmission categories, the acceptance rate for those offered the test was lowest among homosexual men (45%), who also had the highest rate of HIV antibody seropositivity (11%) among those tested. Of patients who reported themselves to be HIV antibody seronegative prior to the pilot study, 78% were retested during the study and seven had a positive test for HIV antibody. We conclude that voluntary HIV antibody testing is acceptable in both public and private STD clinic settings, although a substantial amount of additional resources would need to be allocated to counselling if voluntary testing is to be introduced on a routine basis.

Drug use by prostitutes in Sydney.

We report a comparative study of drug consumption by 277 female prostitutes and 95 women who had never worked as prostitutes, attending the Sydney STD Centre in 1985 and 1987. Marijuana was the drug most often used by prostitutes and non-prostitutes, followed by sleeping pills, amphetamines, cocaine and heroin. About 12% in both groups used intravenous drugs but prostitutes were significantly more likely to share needles and syringes. Prostitutes were also more likely to smoke cigarettes than non-prostitutes, and young prostitutes smoked significantly more heavily than other women in the study. Although fewer prostitutes than non-prostitutes drank alcohol, those who did drink were more likely to do so at a harmful level. We conclude that where differences in drug consumption exist between prostitutes and non-prostitutes, they are mainly work related.

Human immunodeficiency virus and female prostitutes, Sydney 1985.

One hundred and thirty two female prostitutes and 55 non-prostitutes who were tested for antibodies to human immunodeficiency virus (HIV) were surveyed by questionnaire at this centre. The two groups were well matched for age and were very similar in other except for numbers of their sexual partners. Questions were asked about drug taking, sexual practices, general health, and episodes of sexually transmitted diseases (STDs). None of the women in the survey was found to be seropositive, but both groups were found to be seriously at risk of HIV infection through using intravenous (IV) drugs, having unprotected sexual intercourse with men who used IV drugs, having unprotected sexual intercourse with bisexual men, or exposure to several STDs.

PIP: In 1985, 132 female prostitutes and 55 female nonprostitutes at a sexually transmitted disease (STD) clinic in Sydney, Australia requested to be tested for HIV antibodies and completed a questionnaire covering a wide range of social and medical issues. The 2 groups were matched for age and were similar in other respects, excluding the number of sexual partners. Laboratory personnel tested the serum using the ELISA test and confirmed by the H9 exclusionary ELISA and by immunofluorescence using a T cell line infected with HIV. All the women tested seronegative for HIV antibodies. 19% of the prostitutes and 24% of the nonprostitutes had used IV drugs. A substantial number of women from both groups reported using 1 or more other drugs. 37% of the prostitutes and 45% of nonprostitutes claimed to not have used any of the illegal drugs listed in the questionnaire, during the preceding 6 months. 29% of the prostitutes and 33% of the nonprostitutes recorded partners at risk from IV drug use. The number of sexual partners reported by the 2 groups in the month prior to the survey ranged from 1-250 (median 24.5) for prostitutes and 0-4 (median 1.50) for nonprostitutes. For a 1 year period the corresponding figures included 1-3000 (median 175) for prostitutes and 1-13 (median 3.5) for nonprostitutes. More than 1/3 reported having bisexual partners during the previous 5 years. Prostitutes had significantly more episodes of gonorrhea, chlamydial infection, and pelvic inflammatory disease than the nonprostitute group (p.05). 1/2 of the 8 prostitutes who had hepatitis B were IV drug users. 76% of nonprostitute partners and 49% of prostitute partners did not use condoms. Despite the fact that HIV antibodies were not detected in these women, the researchers concluded that HIV could spread rapidly within the prostitution population and back into the wider community through sexual contacts and IV drug use. Current control measures need to be enhanced and the medical community needs to continue to monitor prostitutes' health.

The Sydney AIDS Project: development of acquired immunodeficiency syndrome in a group of HIV seropositive homosexual men.

The Sydney AIDS Project is a prospective immunoepidemiological study of 996 homosexual/bisexual men enrolled between February 1984 and January 1985. By January 1987, 32 of 386 homosexual men who were seropositive at enrollment in the study had developed AIDS, yielding a crude progression rate of between 2.8% and 4.2% per annum. Of these subjects, 23 (72%) developed AIDS within 12 months of enrollment. In univariate analysis, the only lifestyle differences between seropositive subjects who progressed to AIDS and those that did not progress were less frequent oral sex activity and more use of marijuana in the three months prior to enrollment. In multivariate analysis, seropositive subjects who progressed to AIDS were more likely to have a lower percentage of CD4+ cells, a higher percentage of CD8+ cells and to have used marijuana in the three months prior to enrollment than the seropositive subjects who did not progress. No HIV seropositive subject who was asymptomatic and had normal T-cell subsets at enrollment had developed AIDS by January 1987. Persistent generalised lymphadenopathy was not associated with progression to AIDS. Although there are a number of lifestyle factors that may be associated with HIV infection, this study did not implicate most of these in the progression of HIV seropositive subjects to end-stage AIDS. We conclude that antecedent changes in T-cell subsets are associated with progression to AIDS and we emphasise the prognostic value of enumeration of T-cell subsets in HIV seropositive persons.

Single-dose antibiotic therapy for the treatment of uncomplicated anogenital gonorrhoea.

Appropriate single-dose therapy will cure in excess of 95% of cases of uncomplicated anogenital gonorrhoea. Changes in the susceptibility of local isolates of Neisseria gonorrhoeae, particularly the emergence of beta-lactamase producing (and therefore penicillin-resistant) strains, have necessitated the modification of standard treatment regimens. Different patterns of antibiotic resistance have been documented in different regions of Australia and therapeutic regimens that are appropriate for use in different regions are recommended.

A survey of sexually transmitted disease centres in Australia.

In a nationwide survey carried out in 1981 centres offering free treatment for sexually transmitted diseases (STD) were located and the facilities available to the public were assessed. At least one special centre was located in each of the eight states and territories of Australia, but not in all cases did the clinics meet the basic requirements recommended by the Australian National Health and Medical Research Council. The STD clinics were almost exclusively found in capital cities, leaving large populations with no locally available specialist advice. The major centres, with one or two notable exceptions, were open only during routine office hours. In several centres staffing levels were barely adequate to cope with patient loads let alone deal with other important work required of reference centres--the training of health care workers, education of high risk groups, and institution of STD control programmes. In several respects the sexually transmitted diseases services in Australia were found to be inadequate to meet the needs of the population.