Clinical implications of the cervical Papanicolaou test results in the management of anal warts in HIV-infected women.

The Papanicolaou test (or Pap test) has long been used as a screening tool to detect cervical precancerous/cancerous lesions. However, studies on the use of this test to predict both the presence and change in size of genital warts are limited. We examined whether cervical Papanicolaou test results are associated with the size of the largest anal wart over time in HIV-infected women in an on-going cohort study in the US. A sample of 976 HIV-infected women included in a public dataset obtained from the Women's Interagency HIV Study (WIHS) was selected for analysis. A linear mixed model was performed to determine the relationship between the size of anal warts and cervical Pap test results. About 32% of participants had abnormal cervical Pap test results at baseline. In the adjusted model, a woman with a result of Atypia Squamous Cell Undetermined Significance/Low-grade Squamous Intraepithelial Lesion (ASCUS/LSIL) had an anal wart, on average, 12.81 mm(2) larger than a woman with normal cervical cytology. The growth rate of the largest anal wart after each visit in a woman with ASCUS/LSIL was 1.56 mm(2) slower than that of a woman with normal cervical results. However, they were not significant (P = 0.54 and P = 0.82, respectively). This is the first study to examine the relationship between cervical Pap test results and anal wart development in HIV-infected women. Even though no association between the size of anal wart and cervical Pap test results was found, a screening program using anal cytology testing in HIV-infected women should be considered. Further studies in cost-effectiveness and efficacy of an anal cytology test screening program are warranted.

Condom negotiation and use among female sex workers in Phnom Penh, Cambodia.

We examined condom-use negotiation strategies and condom use among 81 female sex workers (FSWs) in Phnom Penh, Cambodia. Percentages of FSWs who did not negotiate condom use or could not describe a negotiation strategy with native clients, foreign clients, and non-paying partners were 15.0, 29.0 and 67.6 %, respectively. The most common negotiation strategy used was "provision of risk information" for native clients (43.8 %) and non-paying partners (26.5 %), and "direct request" for foreign clients (39.5 %). About half could not describe more than one negotiation strategy. Consistent condom use was high with native clients (98.8 %), yet comparatively lower with foreign clients (86.9 %) and non-paying partners (26.5 %). FSWs who did not negotiate or did not know how to negotiate condom use were less likely to report condom use with non-paying regular partners. Future interventions should enhance condom negotiation strategies between FSWs and all partner types.

Performance of Clinical Algorithms for Smear-Negative Tuberculosis in HIV-Infected Persons in Ho Chi Minh City, Vietnam.

Background. Tuberculosis (TB) disease diagnosis in Vietnam relies on symptom screening, chest radiography (CXR), and acid fast bacilli (AFB) sputum smear which have a poor sensitivity in HIV patients. We evaluated the performance of clinical algorithms in screening and diagnosing AFB smear-negative TB in HIV patients. Methods. We enrolled 399 HIV-positive patients seeking care at a HIV clinic in Ho Chi Minh City (HCMC), Vietnam. Participants' demographics, medical history, common TB symptoms, CXR, and laboratory tests were collected. Results. Of 399 HIV patients, 390 had initial AFB-negative smears and 22/390 patients had positive cultures. Symptom screening missed 54% (12/22) of smear-negative pulmonary TB (PTB) cases. Multivariate analysis found CD4+ cell level and CXR were significant PTB predictors. An algorithm combining four TB symptoms and TST presented a high sensitivity (100%), but poorly specific (24%) diagnostic performance for smear-negative PTB. Conclusion. Up to 54% of PTB cases in the HIV-infected population may be missed in the routine screening and diagnostic procedures used in Vietnam. Symptom screening was a poor overall diagnostic measure in detecting smear-negative TB in HIV patients. Our study results suggest that routine sputum cultures should be implemented to achieve a more accurate diagnosis of TB in HIV patients.

Dimensions of gender relations and reproductive health inequity perceived by female undergraduate students in the Mekong Delta of Vietnam: a qualitative exploration.

INTRODUCTION: Increasing evidence indicates that gender equity has a significant influence on women's health; yet few culturally specific indicators of gender relations exist which are applicable to health. This study explores dimensions of gender relations perceived by female undergraduate students in southern Vietnamese culture, and qualitatively examines how this perceived gender inequity may influence females' sexual or reproductive health. METHODS: Sixty-two female undergraduate students from two universities participated in eight focus group discussions to talk about their perspectives regarding national and local gender equity issues. RESULTS: Although overall gender gaps in the Mekong Delta were perceived to have decreased in comparison to previous times, several specific dimensions of gender relations were emergent in students' discussions. Perceived dimensions of gender relations were comparable to theoretical structures of the Theory of Gender and Power, and to findings from several reports describing the actual inferiority of women. Allocation of housework and social paid work represented salient dimensions of labor. The most salient dimension of power related to women in positions of authority. Salient dimensions of cathexis related to son preference, women's vulnerability to blame or criticism, and double standards or expectations. Findings also suggested that gender inequity potentially influenced women's sexual and reproductive health as regards to health information seeking, gynecological care access, contraceptive use responsibility, and child bearing. CONCLUSION: Further investigations of the associations between gender relations and different women's sexual and reproductive health outcomes in this region are needed. It may be important to address gender relations as a distal determinant in health interventions in order to promote gender-based equity in sexual and reproductive health.

Perceived gender inequality, sexual communication self-efficacy, and sexual behaviour among female undergraduate students in the Mekong Delta of Vietnam.

BACKGROUND: Worldwide, the literature on sexual behaviour has documented associations between gender-based relationship inequality and sexual communication ability and the actual use of condoms or other contraceptives among young women. This study aimed to examine these associations among undergraduate female students in the Mekong Delta of Vietnam. METHODS: A cross-sectional survey of 1181 female third-year students from two universities in the Mekong Delta was conducted. Latent variable modelling and logistic regression were employed to examine the hypothesised associations. RESULTS: Among the 72.4% of students who had ever had boyfriends, 44.8% indicated that their boyfriends had asked for sex, 13% had had penile-vaginal sex and 10.3% had had oral sex. For those who had had penile-vaginal sex, 33% did not use any contraceptive method, including condoms, during their first sexual intercourse. The greater a student's perception that women were subordinate to men, the lower her self-efficacy for sexual communication and the lower her actual frequency of discussing safer sex matters and asking her partner to use a condom. Sexual communication self-efficacy was associated with actual contraceptive use (P=0.039) but only marginally with condom use (P=0.092) at first sexual intercourse. CONCLUSION: Sexual health promotion strategies should address the influence of gender relations on young women's sexual communication self-efficacy and the subsequent impact on actual contraceptive and condom use.

CD4+ cell count and HIV load as predictors of size of anal warts over time in HIV-infected women.

BACKGROUND: Little is known about the associations between CD4(+) cell counts, human immunodeficiency virus (HIV) load, and human papillomavirus "low-risk" types in noncancerous clinical outcomes. This study examined whether CD4(+) count and HIV load predict the size of the largest anal warts in 976 HIV-infected women in an ongoing cohort. METHODS: A linear mixed model was used to determine the association between size of anal wart and CD4(+) count and HIV load. RESULTS: The incidence of anal warts was 4.15 cases per 100 person-years (95% confidence interval [CI], 3.83-4.77) and 1.30 cases per 100 person-years (95% CI, 1.00-1.58) in HIV-infected and HIV-uninfected women, respectively. There appeared to be an inverse association between size of the largest anal warts and CD4(+) count at baseline; however, this was not statistically significant. There was no association between size of the largest anal warts and CD4(+) count or HIV load over time. CONCLUSIONS: There was no evidence for an association between size of the largest anal warts and CD4(+) count or HIV load over time. Further exploration on the role of immune response on the development of anal warts is warranted in a larger study.

The evolution of infectious agents in relation to sex in animals and humans: brief discussions of some individual organisms.

The following series of concise summaries addresses the evolution of infectious agents in relation to sex in animals and humans from the perspective of three specific questions: (1) what have we learned about the likely origin and phylogeny, up to the establishment of the infectious agent in the genital econiche, including the relative frequency of its sexual transmission; (2) what further research is needed to provide additional knowledge on some of these evolutionary aspects; and (3) what evolutionary considerations might aid in providing novel approaches to the more practical clinical and public health issues facing us currently and in the future?

Prevalence and outcome of HIV-associated malignancies among children.

OBJECTIVE: To determine the prevalence, associated factors, and outcome of HIV-associated malignancies among children enrolling for care at the Baylor-Uganda pediatric HIV clinic in Mulago Hospital, Kampala, Uganda. STUDY DESIGN: This was a retrospective case series involving records review of all HIV-infected patients who received care at the Baylor-Uganda clinic in Kampala, Uganda between 1 January 2004 and 31 December 2008. METHODS: Medical charts of the clinic patients aged 6 weeks to 18 years were retrieved for data abstraction. Data, including patient's age, sex, diagnosis, type of malignancy, anatomic location of the malignancy, pathology report, baseline laboratory results, and outcome of treatment, were abstracted. Proportions of malignancies among different groups were determined. In addition, Kaplan-Meier survival analysis was conducted. Change in CD4 cell percentages from baseline was assessed with the Wilcoxon signed-rank test. RESULTS: A total of 109 children with malignancies presented to the clinic during the study period, making up 1.67% of the total children visiting the clinic. Only two types of malignancies, Kaposi's sarcoma (90.7%) and non-Hodgkin's lymphoma (9.3%), were found. Deaths during follow-up were seen in the first few weeks to months. Upon starting treatment, the CD4 cell percentage increased significantly from a baseline median of 6-14% at 6 months to 15.8% at 12 months of follow-up. CONCLUSION: HIV-associated malignancies remain an important cause of morbidity and mortality among HIV-infected children in Uganda. Many affected children die in the first weeks of treatment, but those who survive mount good immunologic recovery.

HIV/AIDS testing at ports of entry in China.

In 2007 the Chinese government issued regulations requiring HIV/AIDS testing for Chinese citizens returning at ports of entry if they had resided outside China for 1 year or longer. Three years after publication and partial implementation of the regulations, the Chinese government decided to eliminate compulsory HIV/AIDS testing of returning Chinese. We examine the history of China's HIV/AIDS testing regulations on entry-exit populations, showing how China has gradually altered its policy. As of December 2010, the policy of compulsory HIV/AIDS testing of returning Chinese has been abandoned; however, the regulations still compel HIV/AIDS testing for other groups inside China. Our review sheds new light on the dynamics of regulatory changes in the last 3 years. The Chinese experience that we observed may provide useful insights for policymakers in other parts of the world.

Latent tuberculosis infections in hard-to-reach drug using population-detection, prevention and control.

Interferon-gamma release assays (IGRAs) need be evaluated for effectiveness as screening tests for tuberculosis (TB) infection in drug users. These tests have demonstrated improved sensitivity and specificity, but have not been studied in drug users. These one step blood tests are intended to replace the tuberculin skin test (TST), which is difficult to use and requires 48 hour follow-up, so they are expected to be particularly suitable for risk groups, like drug users, in whom follow-up is problematic. Drug users have traditionally been identified as being at increased risk for acquiring TB disease. The results of our pilot study using the TST and simpler and more sensitive interferon-gamma release assays showed that about 45% of current drug users in Houston tested have at least one test positive for latent tuberculosis infection (LTBI). These preliminary data suggest that there is an important reservoir of LTBI in drug using populations, and the risk of progression to active TB disease with other infections is great. However, LTBI in drug using populations has not been studied in depth and deserves further investigation. We need to evaluate the validity of IGRAs for detection of latent TB infection, the factors associated with LTBI, the incidence and risk for developing active TB disease in drug users and the effectiveness of early treatment of LTBI. We believe that using better tuberculosis screening tools will allow us to more accurately measure the prevalence of latent TB infection and incidence of active TB disease in drug using populations and develop more effective TB prevention and treatment interventions in the community.

Rocks along the road to the control of HBV and HCC.

Hepatitis B vaccine is one of the best human vaccines ever developed; it is safe, cheap, and highly immunogenic, stimulates long lasting protective efficacy, and is the first human cancer vaccine. Remarkably, HBV vaccine works even when administered to newborns, timing which is necessary because of mother to infant transmission. Countrywide HBV immunization programs were initiated in Taiwan and Thailand in the 1980s. HBV vaccine has been part of the WHO global immunization since 199x and with at-birth immunization programs in xxx countries resulting in major declines in acute sequelae of HBV infection. Of far greater significance, HBV vaccination prevents hepatocellular carcinoma (HCC) and its use is reducing mother to infant transmission, the driving force behind the HBV carrier state worldwide. These benefits are just being realized since decades elapse between perinatal transmission at birth and the onset of HCC decades later. Studies in Taiwan and Thailand are showing declines in HCC incidence as a result of country wide at-birth HBV immunization programs initiated in the 1980s. Many investigators from many countries have contributed to the understanding of HBV and its role as the major cause of HCC. This article briefly summarizes the work of my University of Washington laboratory in Taipei, Taiwan where I lived and worked from 1972 and 1986 because of the very high HBV carrier rates of HBV in Taiwan. During those 14 years we discovered vertical transmission, its timing and mechanism, and the predictive value of HBeAg. We went on to establish the efficacy of HBIG for prevention of vertical transmission. In later studies we established the efficacy and timing of HBV vaccine and HBIG and HBV vaccine in combination for optimum preventive efficacy. Of greatest significance, our studies showed that chronic HBV infection is the commonest cause of HCC. Worldwide, mothers are the driving force behind the infections that lead to HCC because the HBV carrier state is inversely proportional to the age of the infant when infected. We were able persuade WHO to adopt HBV as the 7th immunogen in the EPI, its global infant immunization program. In some ways enormous progress has been made but measured against its potential, progress in most countries, including the United States has been far too slow.