Clinical audit: adherence to sexually transmitted infection screening guidelines for men who have sex with men.

Australian guidelines recommend regular screening of men who have sex with men (MSM) for sexually transmitted infections (STIs). This audit was performed to determine STI testing rates in Sydney Sexual Health Centre before and after the development of the guidelines, and to describe characteristics of those not tested. The electronic clinic database and a manual file review were used to determine testing rates and reasons for not testing for the years 2000 and 2002. Overall testing rates were high, with 61% of MSM having had all recommended tests within the past year in 2002. There was a significant increase in testing rates for most tests after the development of the guidelines. Asymptomatic men were more likely to be tested than symptomatic men, and HIV-positive men were less likely to be tested for syphilis.

Characteristics of homosexually-active men with gonorrhoea during an epidemic in Sydney, Australia.

Our objective was to investigate an epidemic of gonorrhoea among homosexually-active men in Sydney. Demographic and behavioural data on all homosexually-active men diagnosed with gonorrhoea (any site) at the Sydney Sexual Health Centre (SSHC) from 1992 through 1998 were reviewed. The men diagnosed with anal gonorrhoea were then compared with all homosexually-active men who tested negative for anal gonorrhoea or who were not tested for anal gonorrhoea at the SSHC between 1996 and 1998. Data on HIV status and country of birth of men diagnosed with anal gonorrhoea during 1998 at the Taylor Square Private Clinic were also reviewed. Over the period 1992 to 1998, homosexually-active men diagnosed with gonorrhoea at SSHC tended to become older at the time of diagnosis (median age 26.5 years in 1992 up to 31.0 years in 1998), indicating a cohort effect in the clinic population due to service reductions. When compared with men who tested negative for anal gonorrhoea at SSHC between 1996 and 1998, those with anal gonorrhoea were more likely to have anogenital symptoms (adjusted odds ratio [OR] 2.3), to have had a past history of gonorrhoea (OR 3.1), to present as a contact of gonorrhoea (OR 8.6), to have used condoms less consistently (OR 2.3), to be HIV positive or of unknown HIV status (OR 3.2), and to have been born in an English-speaking country other than Australia (OR 2.9). The last feature was not observed at the private clinic. In conclusion, the gonorrhoea epidemic was linked to public health service reductions, though it seems unlikely to be the only factor. Homosexually-active men with anal gonorrhoea had well established behavioural risk factors while men with concurrent HIV infection were over-represented. Given the role of gonorrhoea in promoting the spread of HIV infection, a National Sexual Health Strategy--closely linked to the National HIV/AIDS Strategy--is due.

HIV, sexually transmitted infections, and risk behaviours in male commercial sex workers in Sydney.

OBJECTIVES: To assess prevalence of HIV and sexually transmitted infections (STIs), risk behaviours, and demographics in male commercial sex workers (CSWs)/prostitutes in Sydney. METHODS: Retrospective, cross sectional study with two comparison groups. Demographic, behavioural, and morbidity data were analysed from standardised medical records of patients attending a public STI and HIV service in Sydney between January 1991 and March 1998. Two comparison groups were used: female CSWs and non-CSW working homosexual men who attended over the same time. RESULTS: 94 male CSWs, 1671 female CSWs, and 3541 non-CSW working homosexual men were included. The prevalence of HIV in male CSWs tested (6.5%) was significantly greater than in female CSWs (0.4%, p = 0.0001), but less than in non-CSW homosexual men (23.9%, p < 0.0001). Genital warts occurred significantly more frequently in male CSWs than in comparison groups. Prevalence of other STIs was similar in all groups. Male CSWs saw significantly fewer clients per week than female CSWs and male and female CSWs used condoms with almost all clients. Male CSWs reported significantly more non-work sexual partners than female CSWs and non-CSW homosexual men and were significantly more likely to have unprotected penetrative sex with their non-work partners than non-CSW homosexual men. Injecting drug use was significantly more frequent in male CSWs than in both comparison groups. CONCLUSIONS: Although male CSWs use condoms with clients, they are more likely to practise unsafe sex with non-work partners (especially women) and inject drugs than female CSWs and non-CSW homosexual men. Some men with HIV are working within the commercial sex industry. Targeted health education to encourage safer drug use and safer sex outside work is needed.

Herpes zoster and the stage and prognosis of HIV-1 infection.

OBJECTIVES: To examine the incidence of herpes zoster in HIV-1 infection. To assess the prognostic significance of the occurrence of herpes zoster and progression to AIDS or death DESIGN AND METHODS: 146 homosexually active men with known times of HIV-1 seroconversion were identified through the Sydney AIDS Prospective Study and the clinic records of a private medical practice with large caseload of HIV infected homosexual men. Medical records were reviewed for a history of herpes zoster, CD4+ lymphocyte counts, and HIV-1 disease status. Cox's proportional hazards model was used to determine whether herpes zoster predicted progression to AIDS or death. RESULTS: After a mean follow up of 54 months, 30 men (20%) had an episode of herpes zoster and three of these men had one recurrence. The overall incidence of herpes zoster was 44.4 episodes per 1000 person years (95% CI 30.0-63.5). Herpes zoster was not found to be a marker of deteriorating immune functions as measured by CD4+ lymphocyte counts. CD4+ counts did not differ significantly between those with and without zoster at 1 year (551 v 572.10(6)/1, p = 0.79), 2 years (451 v 557, p = 0.11), and 3 years (424 v 481, p = 0.50) following HIV-1 seroconversion. There was no statistically significant difference in progression to AIDS (RR = 1.89, 95% CI 0.80-4.46, p = 0.15) or death (RR = 0.90, 95% CI 0.31-2.65, p = 0.85) from HIV-1 sero-conversion in those who did and those who did not develop herpes zoster. CONCLUSION: The incidence of herpes zoster was consistent with the findings of other studies. There was no association between the occurrence of herpes zoster and progression of HIV-1 disease.

Sexual health and use of condoms among local and international sex workers in Sydney.

OBJECTIVES: To compare indicators of sexual health and predictors of condom use for commercial sex among local and international female sex workers first attending an STD clinic. SETTING: A public STD clinic in Sydney, Australia. SUBJECTS: All sex workers first attending between June 1991 and May 1993. METHODS: Cross-sectional analysis of demographic, behavioural and morbidity data from proforma medical records. RESULTS: 91 local sex workers and 123 international sex workers (predominantly from Thailand, Malaysia and China) first presented during the study period. There were significantly higher prevalences of chlamydia (0 v. 15%, p = 0.0002), gonorrhoea (0 v. 14%, p = 0.0006), syphilis (0 v. 10%, p = 0.006) and clinical genital herpes (0 v. 5%, p = 0.04) among international sex workers. The only case of HIV infection was in an international sex worker. Inconsistent condom use for commercial sex was significantly more common among international sex workers (RR = 4.5; 95% CI 3.1-6.5). On multivariate analysis, inconsistent condom use in international sex workers was associated with a recent history of prostitution outside Australia (p = 0.04), while inconsistent condom usage among local sex workers was associated with increasing age (p = 0.003). CONCLUSIONS: These data illustrate the efficacy of condoms and the success of targeted education programmes in local sex workers in Sydney. By contrast, international sex workers continued to be at high risk of STDs. The international sex industry in Sydney requires enhanced culture-specific interventions. Immigration laws as they affect sex workers should also be reviewed.

PIP: This study analyzes data on all female sex workers who attended the Sydney Sexual Health Center for a first visit for a sexually transmitted disease (STD) screening during June 1, 1991, and May 31, 1993. International sex workers were identified as women who do not speak English at home and were born outside Australia. Diseases were confirmed clinically, by specimen or culture or by antibody or serological tests. Results apply to 91 local and 123 international prostitutes. 47% of international prostitutes and 34% of local prostitutes were aged 21-25 years. Most international sex workers spoke Thai or a Chinese dialect. 10% of local prostitutes were born in Asia. 90% of international prostitutes were born in Thailand, Malaysia, or China. Local prostitutes were better educated. 7% of the local prostitutes and none of the international sex workers had a history of injectable drug use. Local prostitutes tended to use condoms for birth control, and international prostitutes tended to use oral contraceptives. One international prostitute tested HIV positive. 1 in 7 international prostitutes had gonorrhea and the same proportion had chlamydia. Viral STDs (chronic hepatitis B, HIV infection, and genital warts) were more prevalent, but uncommon among international prostitutes. More international prostitutes had multiple STDs. 79 international sex workers and only 9 local sex workers had an STD. 47% of international sex workers and only 10% of local sex workers had worked overseas as a prostitute in the preceding 12 months. Over half of local sex workers and only 8% of international sex workers consistently used condoms. Failure to use condoms was associated with being an international sex worker. Inconsistent use of condoms among local prostitutes was related to increased age.

Hepatitis B virus infection and vaccination status of high risk people in Sydney: 1982 and 1991.

OBJECTIVES: To determine the change in prevalence of hepatitis B virus infection among "at risk" patients attending the Sydney Sexual Health Centre between 1982 and 1991 and to determine the hepatitis B vaccination status of the 1991 group. STUDY POPULATION: Consecutive patients attending the Centre between 1 July and 31 December 1991 who belonged to at least one of the following risk groups: men who have sex with men (n = 351); female prostitutes (n = 124); and injecting drug users (n = 153). DESIGN: Hepatitis B infection status was assessed on the basis of patient history and blood testing. All patients without a history of hepatitis B infection or vaccination were offered screening for serum markers of hepatitis B infection. Hepatitis B infection status was correlated with age, sex, country of birth, sexual behaviour and injecting drug use and was analysed separately according to risk category. RESULTS: The prevalences of any hepatitis B marker were: men who have sex with men 38.2% (61.0% in 1982; P < 0.0001); local female prostitutes 14.1% (28.8% in 1982; P = 0.024); international female prostitutes 58.4%; and injecting drug users 42.0%. Of those in the 1991 sample without a history of hepatitis B infection, 27.6% of men who have sex with men, 27.9% of local female prostitutes, 18.2% of international female prostitutes and 7.1% of injecting drug users were vaccinated. CONCLUSIONS: The significantly lower prevalences of serum markers of hepatitis B infection among men who have sex with men and local female prostitutes when compared with 1982 suggest widespread adoption of safer sexual practices. The high prevalence of chronic hepatitis B infection among international female prostitutes indicates a potentially significant source of sexually transmitted hepatitis B infection in Sydney. The low vaccination rates provide an argument for mass vaccination against hepatitis B.

Dominant situational determinants of sexual risk behaviour in gay men.

OBJECTIVE: To examine the interplay between situational, social and psychological factors in gay men's decisions about HIV risk behaviour, using multiple hypothetical situations. METHOD: The sample included 79 gay men from Sydney recruited through flyers, press advertisements or personal contact at gay venues. Subjects were presented with 20 hypothetical situations graphically on a computer, which included different levels of attraction to partner, intoxication, attractiveness to partner, condom availability, desire for anal sex by subject, insistence of partner on using a condom and time constraints in each situation. Subjects used a computerized graphic rating scale to indicate the likelihood of unprotected anal sex in each situation, the frequency with which they had experienced the hypothetical situation in real life and satisfaction with their response. The probability of having unsafe anal sex in any given situation was the dependent variable. All other variables were predictors. RESULTS: A vector of predictors accounted for 30% of the variance (r = 0.54). Ratings of the probability of anal sex increased with the frequency that subjects had experienced hypothetical situations in real life, attraction to partner, attractiveness to partner and time elapsed since real life experience similar to the hypothetical one. Ratings of the probability of anal sex decreased with condom availability. CONCLUSIONS: Our results suggest that interventions must address the way that individuals interact with their partner and their environment in order to be successful.

Why virgins attend sexually transmitted disease clinics.

We sought to ascertain the reasons why virgins might attend sexually transmitted disease (STD) clinics. The medical records of 31 patients (18 males and 13 females) attending a major public STD clinic and who declared no lifetime sexual partners were examined. Nine subjects were concerned about genital anatomical variation while 3 had non-STD genital pathology (urinary tract infection, non-specific genital dermatosis, vaginismus). Six attended for human immunodeficiency virus antibody testing and 3 for hepatitis-related reasons. Of 6 children, 5 were screened for congenital syphilis and the other had genital warts. Three older patients (aged 34-38) presented with genital symptoms as part of a previously diagnosed psychosis. One prostitute who attended for a 'certificate' had never had penetrative sex. Most attendances in this study were appropriate and reflect the increasing recognition of STD clinics as appropriate centres for a wide range of non-STD genital and sexual problems.

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

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

South Australian hypertension survey. General practitioner experiences with drug treatment.

OBJECTIVE: To investigate prescribing habits, educational approaches and perceived needs of general practitioners in the drug treatment of hypertension. DESIGN, SETTING AND PARTICIPANTS: Of 156 randomly selected South Australian general practitioners 132 responded to a questionnaire survey. MAIN FINDINGS: Diuretics are the most commonly chosen drug for the initial management of uncomplicated moderate hypertension. Equivalent patients aged 45, 60 and 75 years would be prescribed a diuretic as drug of first choice in 41%, 55% and 68% of cases respectively. Despite this, there are wide differences in the choice of initial therapy between individual practitioners. These differences can have a substantial cost impact, given that in Australia the cost of diuretic therapy for one month can be as low as $1.97 compared with $34.08 for standard angiotensin converting enzyme inhibitor therapy for one month. There was also a perceived need, and demand, for patient education materials to assist practitioners in the drug treatment of hypertension.

South Australian hypertension survey. General practitioner knowledge and reported management practices--a cause for concern?

OBJECTIVE: To survey South Australian general practitioners to investigate their knowledge and reported management of patients with hypertension. DESIGN, SETTING AND PARTICIPANTS: Of 156 randomly selected SA general practitioners 132 responded to a questionnaire survey. RESULTS: This survey showed substantial differences between general practitioners in their knowledge about hypertension and in their reported practices for diagnostic levels, investigations to be undertaken once diagnosis had been made, levels at which pharmaceutical treatment should be initiated, at which level treatment was regarded as having attained satisfactory control, and length of time for routine review. There was also a demand for materials to be provided to assist in the management of this important condition. CONCLUSIONS: There is a perceived need for better and more appropriate educational materials and a need for a different approach to try and reduce the reported variability in management of patients with hypertension by general practitioners.

"Sick of Smoking": evaluation of a targeted minimal smoking cessation intervention in general practice.

Several smoking intervention studies have been conducted overseas which use a minimal amount of general practitioners' time and are conducted within the constraints of a normal consultation. However, there are no published reports of minimal interventions in Australian general practice. This study reports on 1238 South Australian smokers who were assigned to a non-intervention control group or a group which received firm general practitioner advice to quit smoking plus literature. At one-year follow-up, 7.5% of smokers in the minimal advice group who had quit for six or more months remained non-smokers compared with 3.2% in the control group. If similar analytical procedures had been used in this study as were used in the benchmark study in England in 1979, the quit rate for this study would have been 11.3% in the intervention group, and 4.8% in the control group--a net gain of 6.5%. These results are discussed with regard to widespread implementation in Australian general practice.