A randomised controlled trial comparing computer-assisted with face-to-face sexual history taking in a clinical setting.

AIM: To compare computer-assisted self-interview (CASI) with routine face-to-face interview (FTFI) for sexual history taking from patients in a clinical setting. METHODS: A randomised controlled trial was undertaken at the Melbourne Sexual Health Centre, Melbourne, Victoria, Australia, in 2005. New, walk-in patients triaged into the centre were eligible for the study. Those who consented to the study were randomly allocated (initially at a ratio of 2:1, then 1:1) to either CASI or FTFI. Those randomised to CASI also subsequently undertook FTFI. RESULTS: During the study period, of 713 patients approached, 611 agreed to participate in the study; 356 were randomised to FTFI and 255 to CASI. Overall, the responses to questioning using CASI and FTFI were similar except that women undertaking the CASI reported a significantly higher median number of male partners for the preceding 12 months (3 v 2, p = 0.05) and the CASI participants reported previous hepatitis B vaccination more often (50% v 37%, p = 0.01). Most participants found the CASI either easy (31; 13%) or very easy (193; 82%) to complete; 83 (35%) were comfortable and 121 (51%) were very comfortable with it. CONCLUSIONS: CASI may be a reliable, efficient and highly acceptable method for the screening of sexual risk in clinical sexual health settings and could be used routinely to improve the efficiency of clinical services.

Sex work practices and condom use in female sex workers in Sydney.

The aim of this study was to determine sex work practices and predictors of condom use among female sex workers (SWs) in Sydney. SWs from two centres completed a self-administered questionnaire covering demographic and sexual characteristics and sex work practices. One hundred and forty-eight international (born in Asia) and 141 local SWs (born in Australia, New Zealand or the UK) were recruited. Local SWs saw more clients per shift than international SWs (P = 0.002), but international SWs worked more shifts per week than local SWs (P = 0.001). International SWs used condoms less consistently at work than local SWs (P = 0.001). About 37% of international SWs never used condoms with non-paying partners, compared with 14% of local SWs (P = 0.01). Speaking Thai (odds ratio [OR] 8.9, 95% confidence interval [CI]; 3.19-24.87) or Chinese (OR 17.4; 95% CI 4.98-60.89) (both P < 0.001) and previous sex work in Thailand (OR 10.0 95% CI 2.31-43.52; P = 0.02) were associated with inconsistent condom use. Strategies to improve condom use need to be evaluated.

Client acceptability of the use of computers in a sexual health clinic.

Computers in sexual health medicine largely remain provider-centred for use in client care, data collection, administration and education. As a formative study for further work we undertook a cross-sectional survey of 679 consecutive new clients attending Melbourne Sexual Health clinic (MSHC) between 9 September 2002 and 15 October 2002 to establish client familiarity and experience with computers and acceptance of computer use in the clinic. A response rate of 616/679 (91%) was achieved. Important findings were: 1. 491/612 (80%) participants reported experience with a personal computer. 2. The majority 488/609 (80%) of clients expected computer technologies to be used in the clinic. 3. The proportion of clients not willing to supply their registration, general health or sexual behaviour details using a computer was 9%, 7% and 21%, respectively. 4. Clients assessed as being at higher risk of acquiring a sexually transmitted infection were no more reluctant than others to provide their details using a computer-assisted self-interview.

Current practice of sexual history taking by sexual health physicians in Australia and New Zealand.

OBJECTIVES: To document the current practice of fellows of the Australasian College of Sexual Health Physicians (ACSHP) when taking a sexual history from a new client. METHOD: A postal questionnaire was sent to all eligible fellows practising sexual health medicine in public sexual health centres in Australia and New Zealand (n = 93). The study period extended from 3 February to 4 April 2003 inclusive. RESULTS: 77 (83%) fellows returned the questionnaire and, of these, 71 (76%) were eligible for inclusion in the analysis. The median number of years of practising sexual health medicine was 16 (range 5-32) with 70% having worked in the field for 10 years or more. The generic questions that fellows asked most often concerned the presenting complaint/reason for attendance, the history of the presenting complaint, current sexual relationship status and last sexual contact, history of sexually transmitted infections (STIs), use of condoms during sexual intercourse in the past 3 months, and pattern (always, usually, sometimes, never) of condom use during that time period. The least frequently asked generic questions concerned age at first sexual activity, the number of sexual contacts, lifetime condom use, and hepatitis A status. CONCLUSION: This study establishes the consistency and variability of sexual health information currently collected by fellows of the ACSHP when taking a history from a new client.

Effects of a change from an appointment service to a walk-in triage service at a sexual health centre.

A walk-in triage system (WITS) was introduced at Melbourne Sexual Health Centre in August 2001 as a result of the perceived need to increase access to the clinic for clients requiring immediate assessment. An audit of this alteration to clinic operation resulted in a significant increase in the number of new clients attending the clinic who were younger and less likely to report using condoms, substantial increases in the number of investigations ordered for bacterial sexually transmitted infections (STIs) and an increase in the detection of genital herpes and chlamydia. There are a number of possible explanations for these changes other than the change to clinic operation but these are less likely causes for the observed changes. Our findings should complement the other reasons to adopt a WITS system, such as improving access for those most in need and vital to reach if STI rates are to fall.

Cervical human papillomavirus infections in commercial sex workers-risk factors and behaviours.

We have investigated the prevalence of, and risk factors for, cervical human papillomavirus (HPV) infection in commercial sex workers (CSWs) and controls attending the same sexual health clinics in Sydney. A self-administered 'risk factor' questionnaire was completed and a Pap smear and a specimen for HPV detection and typing were taken. Results from the 288 CSWs and 266 controls were assessed by univariate and multivariate analyses. No significant difference in the rates of cervical HPV infection in CSWs (31.6%) and controls (24.4%) was found but HPV related cytological abnormalities were more common on the CSWs (P <0.05). In both groups, factors independently associated with HPV infection were the use of non-barrier contraception, cytological abnormalities, age under 36 and the number of non-paying sexual partners. A risk factor for CSWs only was sex-work in Japan. A detailed 'work' history from CSWs may be useful to identify unsafe practices or work in countries where safer sex may be less acceptable.

Is HSV serology useful for the management of first episode genital herpes?

BACKGROUND: First episode genital herpes simplex virus (HSV) infections can be classified into three groups, primary genital herpes (no previous exposure to HSV), non-primary first episode (IgG antibody to HSV of the non-presenting type), and first episode with pre-existing IgG HSV antibodies. The use of IgM to classify first episode genital herpes has not been evaluated. OBJECTIVE: To evaluate the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of HSV-1 and HSV-2 IgM antibodies for the diagnosis of first episode genital herpes, when compared with clinical diagnosis. METHODS: Patients with a first clinical episode of genital herpes were recruited. Sera were tested for IgG antibodies to HSV-2 using an indirect enzyme linked immunosorbent assay (ELISA). Equivocal results were resolved by western blot. HSV-1 IgG and IgM and HSV-2 IgM antibodies were detected using western blot. RESULTS: 157 patients were recruited. 31 were excluded (missing data or no detectable antibodies and negative viral isolation). Therefore, 126 patients were included in the analysis. 23 (18.3%) had primary genital herpes, 34 (27.0%) non-primary first episode, and 69 (54.8%) had pre-existing genital herpes. The specificity and PPV of HSV IgM was 100%; the sensitivity was 79% and the NPV 85%. CONCLUSION: IgM HSV serology may be useful in the management of some patients with first episode genital herpes and provide an indication of the source of infection. Drawbacks include the low sensitivity and NPV, lack of availability, IgM antibodies may occasionally be produced in response to recurrent infection and, finally, IgM antibodies may take up to 10 days to develop and last 7-10 days.

Sexual and demographic risk factors for herpes simplex type 1 and 2 in women attending an antenatal clinic.

OBJECTIVE: To establish risk factors for the presence of HSV-2 and HSV-1 infections in pregnant women. DESIGN, POPULATION, AND SETTING: A prospective study of 3306 women attending the antenatal department Westmead Hospital, Sydney, between June 1995 and April 1998. METHODS: Women completed a self administered questionnaire to establish risk factors for the presence of HSV-2 and HSV-1. Sera were tested for antibodies to HSV-2 and HSV-1. Data were analysed using SPSS and SAS. MAIN OUTCOME MEASURES: Seroprevalence of and risk factors for HSV-2 and HSV-1. RESULTS: 375 (11.3% (95% CI 10.3-12.5)) women were HSV-2 antibody positive. Increasing age, Asian country of birth, lower education level, public hospital status, confirmed genital herpes, a partner with genital herpes, early age of first sex, more than one lifetime sexual partner, and previous chlamydia infection were independently associated with HSV-2 seropositivity. Of 408 women tested for HSV-1 antibodies, 323 (79.2% (95% CI 74.9-83.0)) were positive. Oral herpes, oral blisters or sores, and being HSV-2 seropositive were independently associated with HSV-1 seropositive status. When the logistic regression model was rerun without HSV-2 status, parity of two or more and one or more sexual partners in the past 3 months were significant predictors of HSV-1 seropositivity. CONCLUSIONS: The presence of antibodies to HSV-2 and HSV-1 is related to a number of sexual and demographic risk factors. Public health campaigns directed at encouraging young people to delay the onset of sexual activity and reduce the number of sexual partners need to be evaluated. However, the possible availability of an HSV-2 vaccine that is able to protect over 70% of women offers the best hope for control of genital herpes.

In vitro HIV-specific CTL activity from HIV-seropositive individuals is augmented by interleukin-12 (IL-12).

IL-12 production is reduced in HIV infection, and recombinant human IL-12 (rhIL-12) augments in vitro HIV-specific proliferative responses in PBMC from HIV-seropositive individuals. To determine whether rhIL12 could also augment HIV-specific CTL responses we studied 41 HIV-seropositive individuals. Recombinant hIL-12 increased the detectable in vitro HIV-specific CD8 CTL activity of PBMC taken from HIV-seropositive individuals with CD4 counts >500 cells/microl and from some individuals with lower CD4 counts. IL-12 increased cell recovery in cultures of PBMC from HIV-seropositive individuals with CD4 counts >500 cells/microl and also increased the precursor CTL frequency. However, the increase in HIV-specific CTL activity was not due to IL-2 or IFN-gamma production or an increase in the number of cells with surface markers characteristic of CTL effector cells. This study demonstrates that rhIL-12 augments in vitro HIV-specific CTL activity and provides evidence to justify further investigation within clinical trials of this cytokine in HIV infection.

Opting off the New South Wales Pap Test Register in a sexual health setting.

OBJECTIVES: To determine the proportion of women having a Pap smear at Sydney Sexual Health Centre (SSHC) who opted off the NSW Pap Test Register (PTR) and to establish the characteristics of these women. DESIGN: Retrospective cross sectional study involving three time periods during 1996 and 1997. SETTING: A public sexual health centre in Sydney. PARTICIPANTS: 985 women who had a Pap smear at SSHC. MAIN OUTCOME MEASURES: The participant's decision to opt on or off, and the demographic and behavioural characteristics associated with opting off the PTR. RESULTS: 590 (59.9%) women opted off the PTR. Using logistic regression, young age (p=0.005), birth outside Australia and New Zealand (p=0.0001), not speaking English at home (p=0.005) and being a commercial sex worker (CSW) (p=0.0001) were variables associated with opting off the PTR. Women from countries outside of Australia and New Zealand were more likely to opt off, whether or not they were a CSW and CSWs were more likely to opt off the PTR irrespective of their country of birth (p=0.013). CONCLUSION: The majority of women (60%) attending the SSHC opted off the PTR. Studies to evaluate culturally appropriate health promotion material particularly for CSWs and women with poor English skills living in Australia are needed and if successful may improve uptake on the PTR.

Neonatal herpes prevention: a minor public health problem in some communities.

BACKGROUND: Neonatal herpes is a condition with high morbidity and mortality. The greatest risk occurs when the mother acquires herpes simplex virus (HSV) towards the end of pregnancy. A study from Seattle has suggested that the risk of acquisition of HSV during pregnancy was 3.7%. In Australia, HSV-2 infection is less common in pregnant women than in the United States. Consequently we conducted a study to establish HSV seroprevalence and the rate of HSV seroconversion in this population. METHODS: The study was conducted at Westmead Hospital, Sydney, between June 1995 and April 1998. Women completed a questionnaire covering risk factors for the acquisition of genital herpes. A serum sample during pregnancy and a specimen of cord blood were obtained and tested for antibodies to HSV-2 using a type specific indirect enzyme linked immunosorbent assay (ELISA). Equivocal results were resolved by western blot. A subset of the paired sera was tested for antibodies to HSV-1. The data were analysed using SPSS. RESULTS: 326 of the 2616 (12.5%) women were HSV-2 seropositive. Three women (0.15%) acquired HSV-2 infection during pregnancy. None of the three babies of these mothers developed neonatal herpes. 416 maternal cord pairs were tested for HSV-1 antibodies and 330 (79.3%) were positive. No HSV-1 seroconversions occurred. CONCLUSIONS: In this population, HSV acquisition was uncommon (0.34% per year) and neonatal herpes was rare. A cost effective analysis suggested that type specific serology to screen pregnant women and their partners in low prevalence communities was not cost effective.

Diagnosing PID--getting the balance right.

The objective of the study was to determine the clinical manifestations and diagnostic criteria used to diagnose presumptive pelvic inflammatory disease (PID) at the Sydney Sexual Health Centre (SSHC). The study was a retrospective, case-note review of all women diagnosed with presumptive PID between April 1991 and December 1997. Seven hundred and thirteen women were included. The commonest recorded symptoms were vaginal discharge (68%), lower abdominal pain (65%) and dyspareunia (57%), while adnexal tenderness (83%), cervical motion tenderness (75%) and cervicitis (56%) were the most frequently recorded examination findings. Sixty-two per cent were prescribed doxycycline and metronidazole. The recording of signs and symptoms in women with presumptive PID was poor and only 22% met the current Centers for Disease Control (CDC) diagnostic criteria. It is likely that PID is over diagnosed in this group of women. This may lead to under diagnosis of other conditions causing pelvic pain and may be detrimental to reproductive health.

Assessment of risk for pelvic inflammatory disease in an urban sexual health population.

OBJECTIVES: To determine the sexual and demographic risk factors for the acquisition of presumptive pelvic inflammatory disease (PID). METHODS: A retrospective, case-control study in women, who attended the Sydney Sexual Health Centre (SSHC), between April 1991 and December 1997. Logistic regression analysis was used to adjust for confounding variables. RESULTS: 741 women with PID and an equal number of controls were included. Cases were significantly younger than controls (p < 0.001). 42% of cases were born in north or South East Asia, compared with 12% of the controls (p < 0.001). The adjusted odds ratio for being born in north or South East Asia was 2.8 (95% CI 1.70-4.46), for not speaking English at home was 1.6 (95% CI 1.02-2.55), for having had previous PID was 5.9 (95% CI 3.59-9.73), and for being employed in the commercial sex industry and being born in north or South East Asia was 2.8 (95% CI 1.22-6.22). Women aged 15-19 were at considerable risk of developing PID (OR 5.3 (95% CI 2.76-10.11)). Women with previous human papillomavirus infection were significantly less likely to develop PID (OR 0.6 (95% CI 0.42-0.79)). The use of IUCDs (OR 4.5 (95% CI 2.14-9.39)), condoms (OR 1.4 (95% CI 1.03-1.87)), and not using contraception (OR 1.8 (95% CI 1.20-2.76)) was each associated with an increased risk. CONCLUSIONS: Several measures may help to reduce the burden of PID. Women should be encouraged to delay the onset of sexual activity and IUCDs should not be used in young women. Sexual health services for women whose home language is not English, and for commercial sex workers born in north or South East Asia should be improved.

Evaluation of sexual health services within Australia and New Zealand.

OBJECTIVE: To examine and compare specialised services for patients with sexually transmitted diseases (STDs) in Australia and New Zealand. DESIGN: Postal questionnaire survey. PARTICIPANTS AND SETTING: All STD facilities in Australia and New Zealand in 1993. MAIN OUTCOME MEASURES: Patient numbers and demography; staffing levels; the role of nurses; diagnostic and treatment protocols; contact-tracing policies; and the availability of specialist medical services and community and education programs. RESULTS: 83 of 100 clinics responded; 52 were urban, 21 rural, and nine remote. 95% were open to men and women. Staffing levels were similar in Australia and New Zealand and there was considerable consistency in diagnostic techniques and treatment among clinics. Australian clinics more often used ciprofloxacin or ceftriaxone as the treatment of first choice for gonorrhoea; New Zealand clinics were more likely to test for Chlamydia using direct immunofluorescence; and Australian clinics were more likely to test for hepatitis A and offer hepatitis B vaccination to a broader range of patients. 88% of clinics always traced contacts for gonorrhoea, 86% for syphilis and 77% for Chlamydia. 98% of clinics offered HIV test counselling, and 78% STD health education. CONCLUSIONS: The number of sexual health services has increased over the past decade. Other improvements include most clinics being open to both men and women, and consistency in the diagnosis, treatment and contact tracing of STDs. However, given the lack of adequate comparative data and the variable quality of national surveillance data, it is difficult to determine whether current facilities are meeting service needs.