Rosiglitazone for type 2 diabetes mellitus.

BACKGROUND: Diabetes has long been recognised as a strong, independent risk factor for cardiovascular disease, a problem which accounts for approximately 70% of all mortality in people with diabetes. Prospective studies show that compared to their non-diabetic counterparts, the relative risk of cardiovascular mortality for men with diabetes is two to three and for women with diabetes is three to four. The two biggest trials in type 2 diabetes, the United Kingdom Prospective Diabetes Study (UKPDS) and the University Group Diabetes Program (UGDP) study did not reveal a reduction of cardiovascular endpoints through improved metabolic control. Theoretical benefits of the peroxisome proliferator activated receptor gamma (PPAR-gamma) activator rosiglitazone on endothelial function and cardiovascular risk factors might result in fewer macrovascular disease events in people with type 2 diabetes mellitus. OBJECTIVES: To assess the effects of rosiglitazone in the treatment of type 2 diabetes. SEARCH STRATEGY: Studies were obtained from computerised searches of MEDLINE, EMBASE and The Cochrane Library. SELECTION CRITERIA: Studies were included if they were randomised controlled trials in adult people with type 2 diabetes mellitus and had a trial duration of at least 24 weeks. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial quality and extracted data. Pooling of studies by means of fixed-effects meta-analysis could be performed for adverse events only. MAIN RESULTS: Eighteen trials which randomised 3888 people to rosiglitazone treatment were identified. Longest duration of therapy was four years with a median of 26 weeks. Published studies of at least 24 weeks rosiglitazone treatment in people with type 2 diabetes mellitus did not provide evidence that patient-oriented outcomes like mortality, morbidity, adverse effects, costs and health-related quality of life are positively influenced by this compound. Metabolic control measured by glycosylated haemoglobin A1c (HbA1c) as a surrogate endpoint did not demonstrate clinically relevant differences to other oral antidiabetic drugs. Occurrence of oedema was significantly raised (OR 2.27, 95% confidence interval (CI) 1.83 to 2.81). The single large RCT (ADOPT - A Diabetes Outcomes Progression Trial) indicated increased cardiovascular risk. New data on raised fracture rates in women reveal extensive action of rosiglitazone in various body tissues. AUTHORS' CONCLUSIONS: New studies should focus on patient-oriented outcomes to clarify the benefit-risk ratio of rosiglitazone therapy. Safety data and adverse events of all investigations (published and unpublished) should be made available to the public.

Long-acting insulin analogues versus NPH insulin (human isophane insulin) for type 2 diabetes mellitus.

BACKGROUND: Despite indications from epidemiological trials that higher blood glucose concentrations are associated with a higher risk for developing micro- and macrovascular complications, evidence for a beneficial effect of antihyperglycaemic therapy in patients with type 2 diabetes mellitus is conflicting. Two large studies, the United Kingdom Prospective Diabetes Study (UKPDS) and the University Group Diabetes Program (UGDP), did not find a reduction of cardiovascular endpoints through improvement of metabolic control. The theoretical benefits of newer insulin analogues might result in fewer macrovascular and microvascular events. OBJECTIVES: To assess the effects of long-term treatment with long-acting insulin analogues (insulin glargine and insulin detemir) compared to NPH insulin in patients with type 2 diabetes mellitus. SEARCH STRATEGY: Studies were obtained from computerised searches of MEDLINE, EMBASE, The Cochrane Library and communication with experts in the field as well as insulin producing companies. SELECTION CRITERIA: Studies were included if they were randomised controlled trials in adults with diabetes mellitus type 2 and had a trial duration of at least 24 weeks. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial quality and extracted data. Pooling of studies by means of random-effects meta-analyses was performed. MAIN RESULTS: Six studies comparing insulin glargine to NPH (Neutral Protamine Hagedorn) insulin and two studies comparing insulin detemir to NPH insulin were identified. In these trials, 1715 patients were randomised to insulin glargine and 578 patients to insulin detemir. Duration of the included trials ranged from 24 to 52 weeks. Metabolic control, measured by glycosylated haemoglobin A1c (HbA1c) as a surrogate endpoint, and adverse effects did not differ in a clinical relevant way between treatment groups. While no statistically significant difference for severe hypoglycaemia rates was shown in any of the trials, the rate of symptomatic, overall and nocturnal hypoglycaemia was statistically significantly lower in patients treated with either insulin glargine or detemir. No evidence for a beneficial effect of long-acting analogues on patient-oriented outcomes like mortality, morbidity, quality of life or costs could be obtained. AUTHORS' CONCLUSIONS: Our analysis suggests, if at all only a minor clinical benefit of treatment with long-acting insulin analogues for patients with diabetes mellitus type 2 treated with "basal" insulin regarding symptomatic nocturnal hypoglycaemic events. Until long-term efficacy and safety data are available, we suggest a cautious approach to therapy with insulin glargine or detemir.

Pioglitazone for type 2 diabetes mellitus.

BACKGROUND: Diabetes has long been recognised as a strong, independent risk factor for cardiovascular disease, a problem which accounts for approximately 70% of all mortality in people with diabetes. Prospective studies show that compared to their non-diabetic counterparts, the relative risk of cardiovascular mortality for men with diabetes is two to three and for women with diabetes is three to four. The two biggest trials in type 2 diabetes, the United Kingdom Prospective Diabetes Study (UKPDS) and the University Group Diabetes Program (UGDP) study did not reveal a reduction of cardiovascular endpoints through improved metabolic control. Theoretical benefits of the newer peroxisome proliferator activated receptor gamma (PPAR-gamma) activators like pioglitazone on endothelial function and cardiovascular risk factors might result in fewer macrovascular disease events in people with type 2 diabetes mellitus. OBJECTIVES: To assess the effects of pioglitazone in the treatment of type 2 diabetes. SEARCH STRATEGY: Studies were obtained from computerised searches of MEDLINE, EMBASE and The Cochrane Library. The last search was conducted in August 2006. SELECTION CRITERIA: Studies were included if they were randomised controlled trials in adult people with type 2 diabetes mellitus and had a trial duration of at least 24 weeks. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial quality and extracted data. Pooling of studies by means of random-effects meta-analysis could be performed for adverse events only. MAIN RESULTS: Twenty-two trials which randomised approximately 6200 people to pioglitazone treatment were identified. Longest duration of therapy was 34.5 months. Published studies of at least 24 weeks pioglitazone treatment in people with type 2 diabetes mellitus did not provide convincing evidence that patient-oriented outcomes like mortality, morbidity, adverse effects, costs and health-related quality of life are positively influenced by this compound. Metabolic control measured by glycosylated haemoglobin A1c (HbA1c) as a surrogate endpoint did not demonstrate clinically relevant differences to other oral antidiabetic drugs. Occurrence of oedema was significantly raised. The results of the single trial with relevant clinical endpoints (Prospective Pioglitazone Clinical Trial In Macrovascular Events--PROactive study) have to be regarded as hypothesis-generating and need confirmation. AUTHORS' CONCLUSIONS: Until new evidence becomes available, the benefit-risk ratio of pioglitazone remains unclear. Different therapeutic indications for pioglitazone of the two big U.S. and European drug agencies should be clarified to reduce uncertainties amongst patients and physicians.

Narrowing sexual behavioural differences between Chinese and non-Chinese populations in Hong Kong: implications for sexually transmitted infection (STI) transmission.

Information on sexual networking between different ethnic groups, in particular between Chinese and non-Chinese, is scarce. This study compared patterns of sexual behaviour and determinants of unsafe sexual behaviours amongst the Chinese and non-Chinese residents of Hong Kong. Of the 2,060 respondents (2060/4157; 50% response rate), 73% identified themselves as being ethnic Chinese. Overall, having a non-regular partner was more common amongst the non-Chinese (36%) than the Chinese (17%) respondents. Chinese people who were at increased risk of having had sex with a non-regular partner included social hygiene clinic attendees and airport travellers, males and ever smokers. For non-Chinese this was inconsistent condom use and being aged 18-45. Predictors of inconsistent condom use for Chinese included being aged 18-45, never having been married, and having had sex with non-regular partners; for non-Chinese the predictors were being aged 18-45, having had sex with non-regular partners and being unafraid of AIDS. We conclude that there are similarities and differences in sexual risk-taking behaviours between Chinese and non-Chinese residents in Hong Kong. To maximize potential public health benefits, behavioural interventions should be designed to address the different risk profiles of Chinese and non-Chinese populations separately.

Sexual behaviour: related adverse health burden in the United States.

As part of an analysis of the burden of disease and injury in the United States, we identified and quantified the incidence of adverse health events, deaths, and disability adjusted life years (DALY) attributed to sexual behaviour. In 1998, about 20 million such events (7532/100 000 people) and 29 782 such deaths (1.3% of all US deaths) occurred, contributing to 2 161 417 DALYs (6.2% of all US DALYs). The majority of incident health events (62%) and DALYs (57%) related to sexual behaviour were among females, and curable infections and their sequelae contributed to over half of these. Viral infections and their sequelae accounted for nearly all sexual behaviour related deaths-mostly HIV/AIDS. Sexual behaviour attributed DALYs in the United States are threefold higher than that in overall established market economies.

Reasons for not using condoms among the Hong Kong Chinese population: implications for HIV and STD prevention.

OBJECTIVE: To assess the prevalence and reasons for non-use of condoms among the Hong Kong Chinese population and obtain baseline data to monitor sexual behavioural change. METHODS: Cross sectional self administered questionnaire surveys in convenience sampled groups of Hong Kong Chinese residents were carried out. RESULTS: Of the 1508 respondents, 24% reported consistent condom use and 76% inconsistent use. Overall, 17% of respondents reported having sex with strangers. People who were at increased risk for inconsistent condom use included STD clinics attendees, those who never married, and those reporting low self efficacy for condom use or sex with strangers. Common reasons for not using condoms were trust in partner, use of other contraceptives, and reduced sensation while using condoms. CONCLUSIONS: Given the reported high prevalence of travel and sexual contact with strangers, and misconceptions about condoms among the Hong Kong Chinese population, innovative condom social marketing campaigns are needed. Periodic monitoring of condom use behaviours should be an integral part of HIV/STD surveillance activity.

The relationship of hepatitis B virus infection between adults and their children in Guangxi Province, China.

BACKGROUND/AIM: This study aimed to describe the seroepidemiology of hepatitis B virus (HBV) infection, with emphasis on transmission of HBV infection between adults and their children. METHODS: We analyzed the hepatitis sero-survey data collected from 2132 persons aged 1-59 years (624 families) in Guangxi Province, China, 1992. Blood was tested for the presence of the hepatitis B surface antigen (HBsAg), the antibody to hepatitis B core antigen (anti-HBc), and the antibody to hepatitis B surface antigen (anti-HBs). RESULTS: Of the 2132 persons surveyed, 119 (5.6%) reported receiving HBV vaccination. Among those persons who did not receive HBV vaccination, 19% were HBsAg positive (current HBV infection) and 57% had a past HBV infection (they were HBsAg negative and either anti-HBc positive or anti-HBs positive). Among 519 children aged 1-10 years who did not receive HBV vaccination, 21% had current HBV infection and 37% had past HBV infection. Among 289 children of both parents who were HBsAg negative, 16% had current HBV infection and 36% had past HBV infection. CONCLUSIONS: The high prevalence of community-acquired HBV infection in children and the low HBV vaccination coverage in Guangxi should alert public health agencies to re-examine their current policies for preventing HBV transmission.

Combined tobacco and alcohol use by pregnant and reproductive-aged women in the United States.

OBJECTIVE: To assess trends in the concurrent use of alcohol and tobacco among pregnant women. METHODS: Using behavioral risk factor surveillance system data from 1987 through 1997, we determined the prevalence of concurrent tobacco and alcohol use among women aged 18-44 years by pregnancy status and indirectly estimated pregnancy-related disuse rates. RESULTS: The percentage of women who used alcohol and tobacco decreased significantly from 1987 to 1990 among pregnant (5.4% to 3.0%) and nonpregnant women (17.6% to 14.2%), but thereafter did not change significantly. The estimated pregnancy-related disuse rate of tobacco and alcohol increased insignificantly from 70% in 1987 to 82% in 1997. Among women who used both substances, pregnancy-related disuse was slightly greater for alcohol alone (74%) than for tobacco alone (52%). There was not a significant decline in concurrent use of tobacco and alcohol between 1987 and 1997 among women 18-20 years old (pregnant, 4.4% to 3.6%; nonpregnant, 13.5% to 13.7%). That age group also showed a smaller pregnancy-related disuse rate than older women (1997, 74% versus 83%). CONCLUSION: The steady trend in concurrent use of tobacco and alcohol by young women emphasizes the need for enhanced efforts to reduce the initiation of tobacco and alcohol use by young people. Women who report abuse of tobacco or alcohol should be evaluated for abuse of both substances, and interventions should address abuse of both substances.

A survey of obstetrician-gynecologists on their patients' alcohol use during pregnancy.

OBJECTIVE: To examine knowledge, attitudes, current clinical practices, and educational needs of obstetrician-gynecologists regarding patients' alcohol use during pregnancy. METHODS: A 20-item, self-administered questionnaire on patients' prenatal alcohol use was sent to 1000 active ACOG fellows. Responses were analyzed using univariate and multivariate statistical techniques. RESULTS: Of the 60% of the obstetrician-gynecologists who responded to the survey, 97% reported asking their pregnant patients about alcohol use. When a patient reports alcohol use, most respondents reported that they always discuss adverse effects and always advise abstinence. One fifth of the respondents (20%) reported abstinence to be the safest way to avoid all four of the adverse pregnancy outcomes cited (ie, spontaneous abortion, central nervous system impairment, birth defects, and fetal alcohol syndrome); 13% were unsure about levels associated with all of the adverse outcomes; and 4% reported that consumption of eight or more drinks per week did not pose a risk for any of the four adverse outcomes. The two resources that respondents said they needed most to improve alcohol-use assessment were information on thresholds for adverse reproductive outcomes (83%) and referral resources for patients with alcohol problems (63%). CONCLUSION: Efforts should be made to provide practicing obstetrician-gynecologists with updates on the adverse effects of alcohol use by pregnant women and with effective methods for screening and counseling women who report alcohol use during pregnancy.

Trends in pregnancy-related smoking rates in the United States, 1987-1996.

CONTEXT: Rates of smoking are increasing among adolescents and young adults, but trends in smoking among pregnant women have not been studied. OBJECTIVE: To assess pregnancy-related variations in smoking behaviors and their determinants among women of childbearing age in the United States. DESIGN: Analysis of data collected between 1987-1996 from the Behavioral Risk Factor Surveillance System survey. SETTING AND SUBJECTS: A total of 187302 (178499 nonpregnant and 8803 pregnant) noninstitutionalized women aged 18 to 44 years from 33 states. MAIN OUTCOME MEASURES: Prevalence rates of smoking initiation and current smoking, median number of cigarettes smoked, and adjusted odds ratios for smoking stratified by pregnancy status; prevalence rate ratio for current smoking comparing pregnant with nonpregnant women. RESULTS: The overall percentage of women who had ever initiated smoking decreased significantly from 44.1% in 1987 to 38.2% in 1996. During that 10-year period, the prevalence of current smoking also decreased significantly among both pregnant women (16.3% to 11.8%) and nonpregnant women (26.7% to 23.6%). Overall, pregnant women were about half (54%) as likely as nonpregnant women to be current smokers during 1987-1996. Over time, the median number of cigarettes smoked per day by pregnant smokers remained at 10, whereas among nonpregnant smokers it decreased from 19 to 15 (P<.05 for trend). In the same period, among young women (aged 18-20 years), prevalence rates of smoking initiation and current smoking increased slightly. Sociodemographic subgroups of women at increased risk for current smoking were the same for pregnant and nonpregnant women (ie, those with a completed high school education or less, whites, and those who were unmarried). CONCLUSIONS: In this analysis, the decline in smoking over time among pregnant women was primarily due to the overall decline in smoking initiation rates among women of childbearing age, not to an increased rate of smoking cessation related to pregnancy. To foster effective perinatal tobacco control, efforts are needed to further reduce the number of young women who begin smoking. Clinicians should query all pregnant women and women of childbearing age about smoking and provide cessation and relapse interventions to each smoker.

Comparison of binge drinking among pregnant and nonpregnant women, United States, 1991-1995.

Our goal was to measure the pregnancy-related reduction in the prevalence of reported binge drinking (>/=5 alcoholic drinks per occasion) and to characterize binge drinkers among pregnant and nonpregnant women aged 18-44 years, in the United States, 1991-1995. We used the Behavioral Risk Factor Surveillance System data from 46 states. We used the prevalence rate ratio between pregnant and nonpregnant women to determine the magnitude of the reduction in reported binge drinking and multiple logistic regression models to identify characteristics associated with binge drinking. Between 1991 and 1995, the prevalence of binge drinking among pregnant women increased significantly from 0.7% (95% confidence interval 0.2-0.9) to 2.9% (95% confidence interval 2.2-3.6), whereas among nonpregnant women the prevalence changed little (11.3% vs 11.2%). Over the study period pregnant women were one fifth (prevalence rate ratio 0.2, 95% confidence interval 0.1-0.2) as likely as nonpregnant women to binge drink. Among various population subgroups of women, pregnancy-related reduction in binge drinking was smallest among black women and largest among women aged

Syphilis, gonorrhoea, and drug abuse among pregnant women in Jefferson County, Alabama, US, 1980-94: monitoring trends through systematically collected health services data.

OBJECTIVE: To assess the association between self reported drug abuse and syphilis and gonorrhoea among pregnant women, Jefferson County, Alabama, United States, 1980-94. STUDY DESIGN: We analysed a prenatal care database and assessed the association of self reported drug use with seropositive syphilis and gonorrhoea using prevalence rates, multiple logistic regression models, and the Pearson correlation coefficient (r) for trends. RESULTS: Overall, 5.5% of the women acknowledged drug abuse, 1.4% had seropositive syphilis, and 4.8% had gonorrhoea. In a multivariate analysis, drug abuse was associated with syphilis (odds ratio 2.9, 95% confidence interval 1.6, 5.3) but not with gonorrhoea. Trends in the annual prevalence of drug abuse closely paralleled trends in the annual prevalence of syphilis, including simultaneous peaks in 1992 (drug abuse, 9.1%; syphilis, 3.2%). There was no such parallel trend between drug abuse and gonorrhoea. Annual prevalence of drug abuse correlated with the prevalence of syphilis (r = 0.89, p = 0.001) more than with the prevalence of gonorrhoea (r = 0.45, p = 0.201). CONCLUSION: Among pregnant women, an increase in drug abuse was closely associated with an epidemic of syphilis, but not of gonorrhoea. Systematically collected prenatal care data can usefully supplement surveillance of diseases and behavioural risk factors associated with them.

Alcohol consumption by pregnant women in the United States during 1988-1995.

OBJECTIVE: To examine trends in alcohol use among pregnant women in the United States and to characterize pregnant women who use alcohol, with an emphasis on frequent use (at least five drinks per occasion or at least seven drinks per week). METHODS: We used the Behavioral Risk Factor Surveillance System data from 1988 through 1995 to obtain the percentage of pregnant women who used alcohol. We used multiple logistic models to identify subgroups of pregnant women who are at increased risk for alcohol use. RESULTS: Overall, 14.6% (869 of 5983) of pregnant women consumed alcohol and 2.1% (133 of 5983) consumed alcohol frequently. Among pregnant women, alcohol use decreased from 22.5% (95% confidence interval [CI] 20.8, 23.9) in 1988 to 9.5% (95% CI 7.9, 11.8) in 1992 and then increased to 15.3% (95% CI 13.1, 17.2) by 1995. Among pregnant women, frequent alcohol use decreased from 3.9% (95% CI 2.4, 5.2) in 1988 to 0.9% (95% CI 0.4, 1.6) in 1991 and then increased to 3.5% (95% CI 2.0, 5.1) by 1995. Pregnant women who were at high risk for alcohol use were college educated, unmarried, employed, or students, had annual household incomes of more than $50,000, or were smokers. Pregnant women who were at high risk for frequent alcohol use were more likely to be unmarried, or smokers. CONCLUSION: The increasing prevalence of alcohol use among pregnant women calls for increased ascertainment of alcohol use among preconceptional and pregnant women. Brief interventions by clinicians, increased referral to alcohol treatment programs, and increased use of contraception by women of reproductive age who are problem drinkers should be considered as means of preventing alcohol-exposed pregnancies.

Geography of AIDS-associated Kaposi's sarcoma in Europe.

BACKGROUND: Classical Kaposi's sarcoma (KS) is about four times more common in southern Europeans than in northern Europeans. OBJECTIVE: To describe the epidemiology of AIDS-associated KS (AIDS-KS) in Europe and to determine whether it occurs with increased frequency in southern Europe. METHODS: Analysis of the 'European non-aggregate AIDS data set', as of September 1995. Countries with a cumulative total of > or = 50 KS cases as the presenting manifestation of AIDS were included. Homosexual men were excluded from south versus non-south comparisons because of possible confounding effects due to their route of HIV transmission. RESULTS: KS was the presenting manifestation of AIDS for 13.3% (16,367 out of 122,679) of men and 2% (491 out of 24,826) of women. In all countries, the risk for KS was higher in individuals who acquired HIV infection via sexual rather than parenteral transmission. Among AIDS patients, there is little difference by sex in the risk of KS in injecting drug users (IDU) or transfusion recipients. The percentage with KS increased with age among homosexual and bisexual men, from 10% in the age group 15-19 years to 23% in the age group 30-39 years. In all countries, the percentage with KS declined over time. The risk of KS was not significantly higher in southern Europe. The percentage with KS in southern Europe was slightly lower than in northern Europe (P > 0.1) in male IDU (1.8% versus 2.1%), and only slightly higher (P > 0.1) in female IDU (1.5% versus 1.1%), in male transfusion recipients (3.5% versus 3.0%), in female transfusion recipients (2.4% versus 2.3%), and in both heterosexual men (7.5% versus 6.2%) and women (2.0% versus 1.6%) excluding those originating from countries where heterosexual HIV transmission is frequent. CONCLUSIONS: The strong geographic predilection described for classical KS in southern Europe was not seen for AIDS-KS. If KS is caused by a viral infection in an immunodeficient host, our findings suggest the geographical variations in classical KS are not due to variation in prevalence of the causative virus but may be due to geographical variations in the prevalence of a form of mild immunodeficiency.

Mortality related to sexually transmitted diseases in US women, 1973 through 1992.

OBJECTIVES: This study estimated the trends in mortality related to sexually transmitted diseases (STDs) and their sequelae in US women from 1973 through 1992. METHODS: The total number of deaths was obtained from US national mortality data and from AIDS surveillance data, and current literature was reviewed to estimate proportions of diseases attributable to sexual transmission. RESULTS: From 1973 through 1984, total STD-related deaths decreased 24%. However, from 1985 through 1992, STD-related deaths increased by 31%, primarily because of increasing numbers of deaths from sexually transmitted human immunodeficiency virus (HIV) infection. The most important changes during the 20-year period were the emergence of and continued increase in the number of deaths related to hetero-sexually transmitted HIV. CONCLUSIONS: The leading causes of STD-related mortality in women, viral STDs and their sequelae, are generally not recognized as being sexually transmitted. Increases in STD-related mortality are primarily due to sexually transmitted HIV, which will soon surpass cervical cancer as the leading cause.

Tuberculin sensitivity and HIV-1 status of patients attending a sexually transmitted diseases clinic in Lusaka, Zambia: a cross-sectional study.

A cross-sectional study to estimate the prevalence of latent tuberculosis (TB) in a group of Zambians at high risk of human immunodeficiency virus type 1 (HIV-1) infection and to examine the effect of HIV-1 infection on the tuberculin response was conducted in the University Teaching Hospital in Lusaka, Zambia during July to September 1990. Patients were selected from those presenting to the out-patient clinic for first referral with either sexually transmitted or skin disease. 268 adults were included in the study; 158 (59%; 95% confidence interval [CI] = 53-65%) were HIV-1 antibody positive. Of 82 HIV-1 negative participants who returned for Mantoux skin test reading, 51 (62%; 95% CI = 57-67%) had a positive test reaction (diameter > or = 10 mm) after receiving 2 units of RT-23 tuberculin. Of 106 HIV-1 positive participants who returned, only 32 (30%; 95% CI = 26-34%) had a diameter > or = 10 mm. Nine (28%) of the HIV-1 positive and Mantoux positive participants had large reactions > or = 30 mm, compared to 4 (8%) of the HIV-1 negative, Mantoux positive participants (P = 0.03). Results in the HIV-1 negative group indicated a prevalence of latent TB of 62% in this population. HIV-1 infection was associated with a much higher frequency of negative response to tuberculin and with a few large skin test responses. Thus, in populations where HIV seropositivity is high, Mantoux skin tests cannot be used to assess those with latent TB who might benefit from chemoprophylaxis.

PIP: A cross-sectional study of the Mantoux response and HIV-1 status of a sample of patients with sexually transmitted diseases and skin diseases in Lusaka, Zambia, sought to estimate the prevalence of latent tuberculous infection. The sample was selected from patients attending the sexually transmitted diseases/dermatology section at the University Teaching Hospital, Lusaka, Zambia, between July and September 1990. A questionnaire regarding socioeconomic factors, history of TB, contact with TB, location and documentation of bacillus Calmette-Guerin (BCG) scar(s) and history of BCG vaccination was completed, and a physical examination for acquired immune deficiency syndrome (AIDS) was carried out. The Mantoux result was recorded as the average diameter of induration, measured in 2 perpendicular directions by the pen and palpation method. A total of 158 patients (59%) were HIV-1 positive. Of the 66 women who took part, 46 (70%) were HIV-1 positive; of the 201 men, 112 (56%) were HIV-1 positive (p = 0.06). 232 patients had sexually transmitted diseases, the commonest being genital ulceration; 123/231 (53%) were HIV-1 positive. The remaining 36 patients had skin diseases, the commonest being herpes zoster; 32/36 (89%) were HIV-1 positive. Of the 267 patients remaining in the study, 193 (72%) returned to have their Mantoux test read, 188 within 48-72 h. 106 (67%) HIV-1 positive patients and 82 (75%) HIV-1 negative patients returned. Of the 82 HIV-1 negative patients, 51 (62%) had a Mantoux reaction or= 10 mm; 55 (67%) had a reaction or= 5 mm. Of the 106 HIV-1 positive patients, only 32 (30%) had a Mantoux reaction or= 10 mm; 35 (33%) had a response or= 5 mm. Comparing HIV-1 negative and HIV-1 positive participants gave a significant odds ratio of 3.85 for a Mantoux response or= 10 mm. Among the individuals with a Mantoux reaction or= 10 mm, 9/32 (28%) of HIV-1 positive participants had a megareaction or= 30 mm, while megareactions occurred in 4/51 (8%) of HIV-1 negative participants (odds ratio 4.6).