Meeting complex needs: young people with HIV in London.

OBJECTIVES: The aim of the study was to examine the service use and characteristics of young people diagnosed with HIV infection aged under 25 years in order to design appropriate services. METHODS: A retrospective review of medical records of all individuals diagnosed as HIV positive aged under 25 years at Chelsea and Westminster Hospital, London, UK was carried out. The Health Protection Agency traced all individuals who had been lost to follow-up. We collected demographic, clinical, social and behavioural data. RESULTS: Of the 100 individuals diagnosed as HIV positive aged <25 years, 91% acquired HIV sexually; the median age at diagnosis was 21 years. Fifty-nine per cent were born outside the UK. Of 91 individuals diagnosed in the UK, 20% were diagnosed outside genitourinary medicine. Almost half had tested HIV negative a median of 13 months previously. At HIV diagnosis, 26% had a concurrent sexually transmitted infection; thereafter 34% had a documented risk of HIV transmission. The prevalence of psychiatric comorbidity was high (23%). Cervical screening rates were low; of nine women screened, five required treatment for cervical or vulval neoplasia. One fifth of the cohort were lost to follow-up a median 6 months from diagnosis. CONCLUSIONS: Young people with sexually acquired HIV infection have complex medical and psychosocial needs and many disengage from health services. Current services are not meeting the needs of these young people. Specialist young people's clinics may improve standards of care for this vulnerable group.

Outpatient management of severe gonococcal ophthalmia without genital infection.

We report a case of severe gonococcal ophthalmia and peri-orbital cellulitis in an HIV-positive man without genital infection who was treated successfully in the outpatient department. We also highlight the importance of early diagnosis, treatment and liaison with ophthalmology in order to prevent visual complications.

Post-coital bleeding due to penile piercing.

Post-coital bleeding is a common presenting complaint in the genitourinary medicine clinic. We report an unusual case of recurrent post-coital bleeding secondary to urethral trauma during sexual intercourse.

Betadine for herpes simplex infection.

The clinical value of aciclovir, oral or topical, in the episodic treatment of recurrent herpes virus infection is limited. Betadine (povidone-iodine) could provide a cheap, effective alternative for managing symptomatic recurrences. We describe a case where povidone-iodine was used successfully to treat a recurrence of genital herpes simplex and review the literature supporting povidone-iodine in the treatment of genital tract infections.

Ten-year trends in CD4 cell counts at HIV and AIDS diagnosis in a London HIV clinic.

OBJECTIVE: To examine temporal trends (1986-1996) in the CD4 cell count at first HIV-1 positive test and initial AIDS diagnosis, and the influence of selected patient characteristics and treatment factors on these trends. DESIGN: A retrospective clinic-based study. SETTING: Three hospital-based clinics in West London. PATIENTS: A group of 5921 adult HIV-1-seropositive persons and 2835 reported patients with AIDS over a 10-year period from 1 January 1986 to 1 October 1996. METHODS: The CD4 cell count at HIV diagnosis (CD4HIV) was defined as the nearest CD4 cell count to within 2 months of HIV diagnosis; and the CD4 cell count at AIDS diagnosis (CD4AIDS) as the last CD4 cell count in the two months prior to the development of AIDS. Simple and multiple linear regression analysis were used to examine the influence of selected covariates on CD4HIV and CD4AIDS. RESULTS: The percentage of patients with an available CD4HIV and CD4AIDS increased from less than 5% in 1987 to 53% and 40%, respectively, in 1990, and 79% and 48%, respectively, in 1996. Patients with a missing CD4HIV or CD4AIDS were younger and less likely to have received antiretroviral therapy or prophylaxis for Pneumocystis carinii pneumonia (PCP). There was no significant change in CD4HIV over a 10-year period (median 334 x 10(6) cells/l), but a lower CD4HIV was associated with older age at presentation and injecting drug use. There was a delay in the onset of clinical AIDS, with a fall in the median CD4AIDS value from 99 x 10(6) cells/l prior to 1987, to 58 x 10(6) cells/l in 1990, 68 x 10(6) cells/l in 1994 and 60 x 10(6) cells/l in 1996; this decline in onset was seen for PCP as well as for cytomegalovirus and atypical mycobacterial infections. At all time periods, a lower CD4AIDS was associated with combined use of antiretroviral therapy and PCP prophylaxis. After adjustment for use of antiretroviral therapy and PCP prophylaxis prior to AIDS diagnosis, year of diagnosis was no longer associated with CD4AIDS. There was a significant trend towards an improved survival following AIDS diagnosis from 20.1 months prior to 1988, to 20.3 months (1989-1990), 21.0 months (1991-1992) and 22.1 (1993-1994) (P < 0.0005). CONCLUSIONS: The observed decline in CD4AIDS value was related to the introduction of antiretroviral therapy in 1988, and PCP prophylaxis in 1989. Temporal changes in the CD4 cell count at HIV and AIDS diagnosis among different demographic groups can provide insights into the changing natural history of the HIV epidemic and access to medical care. We recommend monitoring of the CD4 cell count at new HIV and AIDS diagnosis and at initiation of antiretroviral therapy as additional measures in national HIV/AIDS surveillance.

Randomized cross-over comparison of liposomal daunorubicin versus observation for early Kaposi's sarcoma.

OBJECTIVES: To evaluate single-agent liposomal daunorubicin chemotherapy in the management of early HIV-related Kaposi's sarcoma (KS). DESIGN: Randomized cross-over comparison of liposomal daunorubicin versus observation. SETTING: Study conducted at single site in tertiary referral HIV unit. PATIENTS: Twenty-nine HIV-seropositive men with < 20 cutaneous KS, no visceral involvement and CD4 cell counts < 400 x 10(6)/I were randomized. Adequate haematological, hepatic and renal function was required for entry. A left ventricular ejection fraction of > 45% was necessary for eligibility. INTERVENTIONS: Patients were randomized to 12 weeks observation or 12 weeks of liposomal daunorubicin 40 mg/m2 every 2 weeks. After 12 weeks, or at disease progression, patients were crossed over to receive the alternative arm. MAIN OUTCOME MEASURES: Disease evaluation was according to AIDS Clinical Trials Group criteria for response assessment and toxicity was recorded using the World Health Organization standardized grading. RESULTS: Response rate to initial liposomal daunorubicin was six out of 15 (40%) and none experienced a spontaneous response during the observation arm. Six patients (40%) randomized to the initial chemotherapy arm progressed during chemotherapy, while 10(72%) in the observation arm progressed. Neutropenia was the main toxicity associated with liposomal daunorubicin and was documented following 20 out of 139(14%) treatment cycles. CONCLUSIONS: Liposomal daunorubicin is a well tolerated and efficacious treatment for early KS; however, the duration of response is brief.

Diminished creatinine clearance in anorexia nervosa: reversal with weight gain.

To assess whether patients with anorexia nervosa have abnormalities in creatinine clearance, we measured plasma creatinine concentration, urinary creatinine excretion, and creatinine clearance in 10 patients with anorexia nervosa before and during treatment. Urinary creatinine excretion and creatinine clearance were diminished in all patients. Nine patients had significant decreases in their plasma creatinine and creatinine clearance was increased even when corrected for body weight and body surface area respectively. The patient who did not show these changes in plasma creatinine concentration and creatinine clearance had gained only 4% in body weight. Body weight and corrected creatinine clearance were significantly correlated, as were percentage increases in body weight and creatinine clearance. Thus anorexia nervosa is associated with a reversible decrease in creatinine clearance. Increase in body weight appears to be cardinal to the recovery of renal function in these patients.

Chronic vaginal candidiasis. Management in the postmenopausal patient.

Vulvovaginal candidiasis (VVC) is a cause of significant morbidity in many women of a childbearing age worldwide. There is a paucity of literature on the prevalence of this condition in postmenopausal women, although it is believed to be uncommon because of the estrogen dependence of VVC. Postmenopausal women who have underlying risk factors for VVC (e.g. hormone replacement therapy, uncontrolled diabetes mellitus, immunosuppression caused by medication or disease) may be at risk of chronic or recurrent VVC. However, as in younger women, it is likely that, even after exhaustive investigations, no cause will be found in a significant number of patients. The investigation and treatment of VVC in older women should be the same as that undertaken in younger women. Both topical and oral preparations are available, but oral regimens are perhaps more acceptable because of the ease of administration and avoidance of potentially messy creams and suppositories. Ketoconazole at a dosage of 400 mg daily for 14 days can be used to achieve clinical remission of symptoms and negative fungal cultures. Induction treatment should be followed by maintenance therapy for 6 months with ketoconazole 100 mg daily, itraconazole 50 to 100 mg daily or fluconazole 100 mg weekly or 150 mg monthly. Short courses of topical therapy, e.g. 500 mg clotrimazole pessaries as a single weekly dose for 6 months or 100mg miconazole pessaries twice weekly for 3 months, followed by once weekly for 3 months may also be used.

HIV-positive women and cervical screening.

To date the management of HIV-positive women regarding the prevention of cervical cancer remains controversial. There are different approaches to cervical screening in different health authorities in the UK and worldwide due to different funding and healthcare provision in general, the official disease prevalence and the attempt to tailor the screening programme according to a perceived risk for the population covered, but most of all in the diverse evidence provided to aid the development of a screening programme. The advent of high active antiretroviral therapy (HAART) may also have altered the natural history of cervical intraepithelial neoplasia (CIN) before it became sufficiently understood and future studies have to take this into account when investigating the impact of human papillomavirus (HPV) and CIN on the risk of developing cervical cancer. This article aims to summarize the available evidence to date and provide a basis on which an effective and acceptable screening programme for HIV-positive women can be developed.

Women, contraception and STDs including HIV.

It is estimated that eight million women are infected with the human immunodeficiency virus (HIV) worldwide. Heterosexual transmission is the predominant mode of HIV transmission on a global basis and is becoming increasingly important in the Western world. Women have long used contraceptives as a means of protection against an unwanted pregnancy, some of which may also protect against sexually transmitted disease (STD) including HIV. We review the relationship between contraceptive methods and STD acquisition and transmission; HIV acquisition and transmission; and the implications of contraceptive use, particularly regarding disease progression, in those women who are already infected with the virus. It is important for all women that protection against both unwanted pregnancy and HIV acquisition and transmission are considered together and not in isolation as nowhere is the argument for a broad based multi-disciplinary approach more cogent.

An audit of emergency contraception: a look at patient characteristics and the effects of a consultation proforma.

The aim of this study was to examine the characteristics of patients requesting emergency postcoital contraception at a genitourinary medicine (GUM) clinic. We also compared the quality of information obtained during the consultation, before and after a proforma was introduced. A retrospective review of all clinical notes of patients who attended for postcoital contraception between January and December 1994 and April to June 1995 was performed. Eighty-three per cent of patients were aged 17-29 years, 68.8% were in relationship, 41.3% were not using regular contraception, 33.8% accepted a sexual health screen and of these, 14.8% had a concurrent sexually transmitted disease (STD). The introduction of a consultation proforma significantly improved certain areas of the consultation. The results suggest that sexual health screens should be encouraged in women attending GUM clinics for postcoital contraception and that the use of a proforma improves the quality of information obtained.

PIP: This study was undertaken to 1) identify the characteristics of emergency postcoital contraception clients, their acceptance of sexual health screening, and the incidence of sexually transmitted diseases in this group and 2) to determine the effect of the introduction of a consultation proforma on the quality of information obtained from the client. Data were gathered from a review of all clinical notes of 80 postcoital patients at a clinic and a hospital in England during 1994 and between April and June 1995, after introduction of the proforma. It was found that 83% of the patients were 17-29 years old, 68.8% were in a relationship, 41.3% were not using regular contraception, 33.8% accepted the offer of a sexual health screening, and 14.8% of these had a sexually transmitted disease. The introduction of the proforma improved the likelihood that vital history information was obtained and that the patient was offered sexual health screening. The results indicate that most of the patients were aware of the importance of timing in obtaining emergency contraception and that they should be more actively encouraged to undergo sexual health screening.

Audit of cervical screening and colposcopy in HIV-positive women at a central London teaching hospital.

The purpose of this audit was to assess the prevalence of cervical pathology and clinical outcome in HIV-infected women as well as adherence to local screening guidelines. As there are no national screening guidelines for HIV-positive patients, recommendations vary widely. At St Stephen's Centre, these included annual cytology and a baseline colposcopy. We audited this recommendation by a clinical notes review using a computer database. Analysis was performed using Statistical Package for Social Sciences (SPSS). Two hundred and twenty-two patients were eligible for analysis, their mean age was 33.6 years, median CD4 count was 239 and median viral load was 7836 RNA copies. Cytology was undocumented in 72 women (32.4%), while overall 42 (28%) smears of the remaining 150 patients were abnormal: borderline 17.3%, mild dyskaryosis 4.6%, moderate dyskaryosis 4%, severe dyskaryosis 2%. The results were normal in 64% and unsatisfactory in 4.6%. Colposcopy was offered to 93 (42%) women who attended at least once in 71 cases (32%). Thirty-one women had biopsies taken (43.6% of all colposcopies). Twenty-four (77.4%) had a histology more severe than HPV and 15 (48.4%) more severe than cervical intraepithelial neoplasia (CIN)-1. Overall, 49.7% had management not complying with the guidelines. This audit led to a critical literature review and of local screening guidelines. A computer aided reminder program has now been installed and re-auditing of the management of HIV-positive women is planned.

Inoculation of culture plates: straightforward or is it?

In view of the recent vogue in some genitourinary medicine (GUM) units towards selective microscopy we aimed to assess the adequacy of culture plate inoculation in our own GUM clinic by the visual examination of 350 consecutively inoculated plates. Seventy-five (21%) plates were inoculated so lightly that no indentation in the agar could be seen whilst in 20 (60%) the agar was shredded. Eighty-five per cent of inadequately plated samples were inoculated by the same staff members who were either relatively inexperienced, or well-distanced from their last in-service training. This has many important implications not only in the identification and control of infection but also with respect to staff training. We have now introduced practical plating instruction for all new members of clinical staff and additional in-service training. We plan to repeat the audit in 6 months' time to assess the effect of these changes.

To test or not to test, could you repeat the question?

We aimed to investigate clinical practice in the offering of HIV tests and subsequent uptake in a central London genitourinary medicine (GUM) clinic. A random sample (n = 330) of attenders at 3 inner-London GUM departments was surveyed. Reasons for and rates of offering of HIV tests were recorded and analysed in relation to demographic, risk group information and uptake. The results were integrated with the latest unlinked, anonymous seroprevalence data for the clinic. After exclusion of patients known to be HIV-positive or to have recently undergone HIV testing, HIV tests were offered to 96% of homo/bisexual men, 55% of heterosexual men and 60% of heterosexual women. Comparison with anonymous HIV seroprevalence data showed an inverse relationship between seroprevalence rates for heterosexual men/women (2.5% vs 1%) and rates of HIV test offering. A lack of research into the policy of offering HIV tests may have resulted in inconsistencies in practice. An evidence based policy should offer HIV tests in line with seroprevalence.

Bronchopulmonary Kaposi's sarcoma in 106 HIV-1 infected patients.

The objectives of this study were to describe the clinical and radiological features at presentation, and the natural history of HIV-related bronchopulmonary Kaposi's sarcoma. A retrospective review of medical records and chest radiographs was performed in 106 HIV-infected homosexual men with bronchopulmonary Kaposi's sarcoma diagnosed at bronchoscopy between September 1988 and November 1994. The majority of patients had evidence of advanced HIV disease at diagnosis (median CD4 cell count was 15 x 10(6)/l, range 0-288), and 93% had had a diagnosis of cutaneous Kaposi's sarcoma for a median duration of 11 months prior to diagnosis of their bronchopulmonary disease. The most frequent symptoms at presentation were cough (92%), dyspnoea (69%), pleuritic pain (20%), haemoptysis (13%) and wheezing (10%). The most common radiological finding in 73% of our series was of poorly defined and confluent opacities, with predominant middle and lower zone involvement. Median survival was 4 months (range 0-37 months) from diagnosis and 9 months (range 1-25) from the onset of symptoms. Treatment with either chemotherapy or radiotherapy was associated with a significantly reduced risk of death (hazards ratio (HR)=0.48, 95% CI=0.26-0.87). Factors associated with a poor survival, after adjustment for treatment effect were older age (HR=1.79, 95% CI=1.22-2.84) for each 10-year increase in age; a history of pleuritic pain (HR=2.97, 95% CI=1.39-6.32); presence of pleural effusion on X-ray (HR=2.01, 95% CI=1.13-3.59) and a prior diagnosis of cutaneous Kaposi's sarcoma (HR=1.8, 95% CI=1.00, 3.24). Bronchopulmonary Kaposi's sarcoma occurs mainly in patients with advanced HIV disease and a prior history of cutaneous disease. Survival is poor, and adverse prognostic factors include older age at diagnosis and the presence of pleural disease.

Liposomal daunorubicin in advanced Kaposi's sarcoma: a phase II study.

We report a non-randomized Phase II clinical trial to assess the efficacy and safety of liposomal daunorubicin (DaunoXome) in the treatment of AIDS related Kaposi's sarcoma. Eleven homosexual men with advanced Kaposi's sarcoma were entered in the trial. Changes in size, colour and associated oedema of selected 'target' lesions were measured. Clinical, biochemical and haematological toxicities were assessed. Ten subjects were evaluated. A partial response was achieved in four, of whom two subsequently relapsed. Stabilization of Kaposi's sarcoma occurred in the remaining six, maintained until the end of the trial period in four. The drug was generally well tolerated, with few mild symptoms of toxicity. The main problem encountered was haematological toxicity, with three subjects experiencing severe neutropenia (neutrophil count < 0.5 x 10(9)/l). There was no evidence of cardiotoxicity. In this small patient sample, liposomal daunorubicin was an effective and well tolerated agent in the treatment of Kaposi's sarcoma.

Platelet function in patients admitted with a diagnosis of myocardial infarction.

Platelet function and thromboxane A2 release were measured in 71 patients admitted to a coronary care unit with a provisional diagnosis of acute myocardial infarction (AMI). All measurements were carried out within twenty-four hours of admission. Of these, 35 patients had the diagnosis of AMI confirmed. The remainder (n = 36), who did not have AMI (NMI), were divided into two groups: those (n = 18) with an unequivocal history of previous vascular disease and those without vascular disease (n = 18). Platelet aggregation and thromboxane A2 (TXA2) release were significantly increased in the AMI group when compared with those in the NMI without vascular disease group or a healthy control group with similar age and sex distribution. Aggregation and TXA2 release in the NMI patients with vascular disease were greater than those in controls and did not differ significantly from those in the AMI group. Patients in the AMI or NMI with vascular disease groups who were taking beta-blockers or calcium channel antagonists at the time of admission showed significantly less platelet aggregation than those who were not taking these drugs. Heparin, added in vitro at therapeutic concentrations, induced significantly more aggregation in patients in the AMI and NMI with vascular disease groups than in the NMI without vascular disease group. We conclude that: platelets obtained from patients with AMI are hyperaggregable and release more TXA2; platelets from patients with significant vascular disease are hyperaggregable, even in the absence of AMI, although they are not as hyperaggregable as those from AMI; treatment with nifedipine and beta-blockers protects these patients from platelet hyperaggregability; heparin induces significant aggregation of platelets from patients with AMI and NMI with vascular disease. These observations are of importance in considering the pathogenesis and treatment of AMI and ischemic heart disease.

Thrombocytopenia and lupus-like anticoagulant in a patient with peripheral vascular disease: response to infusion of prostacyclin.

A 46 year old man with intermittent claudication due to severe peripheral vascular disease had a circulating lupus like anticoagulant (LLAC), thrombocytopenia (79 X 109/1), markedly reduced platelet survival and a normal bone marrow. He was treated with intravenous prostacyclin (PGI2) infusions which resulted in improvement of the patient's exercise tolerance and normalisation of his platelet count (300 X 109/1) and platelet aggregation could then be assessed. The platelets were markedly hyperaggregable and generated supranormal quantities of thromboxane A2. A diagnosis of consumptive thrombocytopenia secondary to peripheral vascular disease and platelet hyperaggregability was made. Despite therapy with aspirin and dipyridamole, gradual and progressive reduction in platelet count followed and his exercise tolerance declined over the next three months. Immunoglobulin prepared from the patient's serum did not inhibit vascular PGI2 synthesis in vitro. To our knowledge this is the first reported case of consumptive thrombocytopenia due to severe peripheral vascular disease and platelet hyperaggregability. PGI2 administration caused a transient resolution of these features which was not sustained by aspirin and dipyridamole.

Primary cervical lymphoma: a rare presentation to a genitourinary medicine clinic.

Primary non-Hodgkin's lymphoma of uterine cervix is a rare diagnosis. We present the case of a 47-year-old woman who presented to our genitourinary (GU) medicine service complaining of a malodorous discharge. Speculum examination revealed a necrotic mass on the cervix. She was referred urgently to gynaecology and subsequent histology revealed a diffuse large B-cell lymphoma. She received six cycles of RCHOP chemotherapy and is now in clinical remission. This case highlights the need for GU medicine physicians to remain vigilant with regard to possible gynaecological malignancies in all of our patients, the need for medical backup within GU medicine clinics and for clear pathways of referral to other specialists to exist.