Indian-born patients attending a sexual health clinic in Australia have differing characteristics to their Australian-born counterparts.

We report a retrospective cross-sectional study from Western Sydney that assessed the sexual health characteristics of Indian-born patients attending sexual health services compared with Australian-born controls. The sexual health needs of Indian-born patients differed significantly from controls with those born in India reporting more sexual dysfunction and controls having more sexually transmitted infections (STI). These issues should be considered when delivering services to people from culturally and linguistically diverse backgrounds.

The 2010 Royal Australasian College of Physicians' policy statement 'Circumcision of infant males' is not evidence based.

Infant male circumcision (MC) is an important issue guided by Royal Australasian College of Physicians (RACP) policy. Here we analytically review the RACP's 2010 policy statement 'Circumcision of infant males'. Comprehensive evaluation in the context of published research was used. We find that the Statement is not a fair and balanced representation of the literature on MC. It ignores, downplays, obfuscates or misrepresents the considerable evidence attesting to the strong protection MC affords against childhood urinary tract infections, sexually transmitted infections (human immunodeficiency virus, human papilloma virus, herpes simplex virus type 2, trichomonas and genital ulcer disease), thrush, inferior penile hygiene, phimosis, balanoposthitis and penile cancer, and in women protection against human papilloma virus, herpes simplex virus type 2, bacterial vaginosis and cervical cancer. The Statement exaggerates the complication rate. Assertions that 'the foreskin has a functional role' and 'is a primary sensory part of the penis' are not supported by research, including randomised controlled trials. Instead of citing these and meta-analyses, the Statement selectively cites poor quality studies. Its claim, without support from a literature-based risk-benefit analysis, that the currently available evidence does 'not warrant routine infant circumcision in Australia and New Zealand' is misleading. The Statement fails to explain that performing MC in the neonatal period using local anaesthesia maximises benefits, safety, convenience and cost savings. Because the RACP's policy statement is not a fair and balanced representation of the current literature, it should not be used to guide policy. In the interests of public health and individual well-being, an extensive, comprehensive, balanced review of the scientific literature and a risk-benefit analysis should be conducted to formulate policy.

Genital herpes: an Internet-based risk survey.

Genital herpes is one of the most common sexually transmitted infections worldwide. We established a web-based survey to determine risk for genital herpes and encourage people to attend for herpes simplex virus testing. A survey was established on the Australian Herpes Management Forum (AHMF) website, consisting of 16 demographic and sexual health-related questions. Each question carried a numerical risk-weighting based on epidemiological data; the higher the overall score, the greater the risk of herpes. To determine how representative our sample was in relation to age and sex, we compared our survey with Australian Census data. Between October 2006 and August 2007 there were 5572 responses, 4358 (92%) were Australian. Compared with the Australian population, the survey population had a higher proportion of individuals aged less than 34 years, and a lower population over 55. Six hundred and eighty-six (13.8%) were classified as low risk, 2558 (51.6%) as medium risk and 1710 (34.5%) as high risk of having acquired genital herpes. In total, 39% reported four or fewer, and 38% reported 10 or more, sex partners in their lifetime. A large number of individuals participated in this survey, confirming that the Internet is a useful tool for health promotion for genital herpes.

Nurse-led sexually transmitted disease clinics: staff perceptions concerning the quality of the service.

The aim of this study was to evaluate staff perception of a nurse-led sexually transmitted infection (STI) clinical service. The staff at the Amsterdam STI clinic were interviewed using a standardized questionnaire. A series of eight questions was designed to determine the perceived advantages or disadvantages of nurse-led clinics, based on personal experience, using a Likert scale. After completion of the structured interview, the staff were offered the opportunity of providing comments. All 36 members of staff completed the survey. Twenty-seven (75%) agreed or strongly agreed that nurse-led clinics provided more time with patients. Sixty-four percent agreed or strongly agreed that such a service provided greater confidentiality and 94% agreed or strongly agreed that 'nurse-led clinics provided a high level of job satisfaction for nurses.' In contrast, only 64% agreed or strongly agreed that nurse-led clinics provided a high level of job satisfaction for doctors. When staff comments were evaluated, four common themes emerged. First, that this was an efficient way of providing services; second, that the clinic was a pleasant environment, there was excellent teamwork and greater job satisfaction; third, that a good deal of rivalry existed between doctors and nurses and finally, that there was a need for and importance of protocols, rules and staff training and development. In conclusion, there was a high level of staff satisfaction with the service. Nurse-led STI clinics may be a useful adjunct to existing STI facilities.

An open-label phase II pilot study investigating the optimal duration of imiquimod 5% cream for the treatment of external genital warts in women.

Our objective was to determine the optimal duration of treatment with imiquimod for external genital warts over 4, 8, 12 or 16 weeks. A total of 120 women with a history of genital warts for a median of 3-6 months and prior alternative treatments in 73% were evaluated for total clearance rates. There was no statistically significant difference in complete clearance rates after 16-week follow-up across treatment groups: four weeks (40.0%), eight weeks (48.4%), 12 weeks (39.3%) and 16 weeks (51.6%). Imiquimod was well tolerated, and in those treated for four weeks there was a lower incidence of local skin reactions such as erythema and erosion, and no incidences of pain. These preliminary results suggest that a four-week treatment course of imiquimod applied thrice weekly for women with external genital warts may provide a reasonable approach with comparable efficacy and compliance, and minimal adverse events, drug costs and clinic visits.

Increase in rates of herpes simplex virus type 1 as a cause of anogenital herpes in western Sydney, Australia, between 1979 and 2003.

BACKGROUND/OBJECTIVE: Recent studies suggest that herpes simplex virus type 1 (HSV-1) is becoming more common as a cause for genital herpes, relative to HSV-2. We aimed to calculate trends in HSV type from isolates and serology samples sent to a reference virology laboratory in New South Wales (NSW), Australia. METHODS: We compared the proportions of HSV-1 and HSV-2 positive samples, adjusting for age and sex of source patient, in three datasets: anogenital isolates from 1979 to 1988; anogenital isolates from 1989 to 2003; and HSV type specific IgM seropositivity from 1994 to 2003. RESULTS: The number of specimens in each analysis was 17 512, 4359, and 497, respectively. There was a progressive rise in the proportions of typed specimens being HSV-1 in all analyses. The proportion of isolates that were HSV-1 ranged from 3% in 1980 to 41% in 2001. Female sex and age under 25 were associated with a greater proportion of HSV-1 isolates in both time periods. In the period 1979-88, comparing the proportions of HSV-1 and HSV-2 gave an odds ratio (OR) per additional year of 1.24 (95% confidence interval (CI) 1.20 to 1.27; p<0.005) after adjustment for age and sex. In the period 1989-2003 there was a steeper rise in the proportion of isolates that were HSV-1 in samples from younger individuals (OR per year 1.17, 1.12 to 1.22) compared to those over 25 (OR per year 1.06, 1.03 to 1.08). The rise in the proportion of IgM seropositive results reactive for HSV-1 compared to HSV-2 gave an OR of 1.36 per year (1.26 to 1.47; p<0.005). CONCLUSIONS: These data suggest that HSV-1 has become more common as a cause of anogenital herpes in NSW.

Prevalence of infection with herpes simplex virus types 1 and 2 in Australia: a nationwide population based survey.

BACKGROUND: Studies demonstrating previous herpes simplex virus (HSV) type 2 infection as a risk factor for HIV transmission, and the development of a HSV vaccine candidate, have emphasised the need for worldwide population based studies of HSV seroprevalence. The only nationwide seroprevalence studies have been conducted in the United States. METHODS: An Australia-wide, population based study of HSV-1 and HSV-2 seroprevalence was conducted, using serum and sociodemographic data collected between 1999-2000, for a representative study of risk factors for diabetes in over 11 000 adults. A stratified random sample of 4000 was tested for HSV-2 and 1000 for HSV-1, with sampling and weighting for various demographic factors. RESULTS: Seroprevalence of HSV-2 in Australian adults was 12%. Prevalence in women (16%) was twice that in men (8%). Rural populations had a lower prevalence (9%) than metropolitan (13%), and Indigenous had a higher prevalence (18%) than the non-Indigenous populations (12%). The seroprevalence of HSV-1 was 76% with significant differences by age group, sex and Indigenous status. CONCLUSION: These are the first nationwide data to compare with US studies. HSV-2 infection is less common in Australia than the United States, and this will allow planning for combating HIV transmission in high prevalence populations in northern Australia. In addition, the high HSV-1 seroprevalence will be important for future deployment of genital herpes vaccines.

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.

Sexual health problems managed in Australian general practice: a national, cross sectional survey.

OBJECTIVES: To ascertain how frequently Australian general practitioners (GPs) identify sexual health (SH) problems, to gain understanding of how SH problems are managed in general practice and to determine the characteristics of GPs who manage them. METHODS: A secondary analysis of data from the BEACH programme April 2000-March 2003. BEACH is a cross sectional national survey of GP activity: approximately 1000 GPs per year, each records details of 100 consecutive patient encounters. Initially, patient reasons for encounter (RFE), suggestive of a SH problem, were used to derive a list of SH problems (that is, doctor's diagnosis/problem label). Management of these problems was then investigated for all encounters with patients aged 12-49 years. The frequency of SH problems, their management and the characteristics of GPs managing them, were analysed using SAS. RESULTS: During 299,000 encounters with 2990 GPs, 3499 (1.17 per 100 encounters) STI/SH problems were managed, the majority (81.1%) in females. The most common in women were genital candidiasis, vaginal symptoms, urinary symptoms, and intermenstrual bleeding, and in men were testicular symptoms, genital warts, and urethritis. Tests to exclude specific STIs were seldom taken and symptomatic management was common. GPs managing SH problems were younger, more likely to be female, have fewer years in practice, work in larger practices; hold FRACGP status (all p = <0.001) than those GPs who managed none. CONCLUSION: Patients seeking medical attention for SH problems are often managed by GPs. Tests to diagnose or exclude specific sexually transmitted infections are seldom ordered and symptomatic management is common. Strategies to improve management of SH problems in general practice need to be developed and evaluated.

Condom use in multi-partnered males: importance of HIV and hepatitis B status.

The objective of the research was to determine the demographic, sexual and social risk factors associated with condom use in 7,089 multi-partnered men attending the Sydney Sexual Health Centre. A review of computerized medical records from 1991 to 1999 was carried out. Males with two or more partners in the last three months were divided into three condom use groups: consistent, sometimes and never. Men reporting sex with men (MSM) were more likely to use condoms than men having sex with only women (p=0.001). HIV positive men were more likely to use condoms consistently than those who were negative (p=0.001). In HIV negative non-hepatitis-B carriers, factors independently associated with inconsistent condom use included alcohol consumption, intravenous drug use (odds ratio (OR) 0.6 (95% confidence interval (CI) 0.47-0.77)) and being married (OR 0.2 (95% CI 0.21-0.31)). Factors associated with consistent condom use were MSM (OR 1.8 (95% CI 1.26-2.49)) and having three or more partners in the last 3 months (OR 2.4 (95% CI 2.023-2.83)). In the 508 hepatitis B carriers, consistent condom users were less likely to be married or intravenous drug users (OR 0.4 (95% CI 0.23-0.85)). In the 200 HIV antibody positive men, those with three or more partners were less likely to be consistent condom users than those with two (OR 0.3 (95% CI 0.11-0.82)). The conclusions are that a small number of HIV positive men report unsafe sex with multiple partners. Health promotion activities should be directed at this group.

Condom use in multi-partnered females.

Many women attending sexual health clinics have multiple partners, and determining factors associated with condom use may provide useful information for health promotion strategies. Demographic and sexual data were obtained from computerized records at the Sydney Sexual Health Centre from 1991 to 1999. Females with >2 partners were categorized according to their condom use in the last three months and compared using chi-squared (chi2) tests and logistic regression. Of the 2198 women identified, 22% did not use condoms, 28% reported consistent condom use and 50% inconsistent use. Variables independently associated with failure to use condoms included older age and being in a regular relationship. Women with more partners were more likely to use condoms. Students [odds ratio (OR)=0.7 (95% confidence interval (CI) 0.5-0.9)] and those in employment [OR=0.7 (95% CI 0.5-0.9)] were more likely to use condoms than the unemployed. Focusing health promotion on multi-partnered women who fail to use condoms consistently may help in reducing sexually transmitted infections.

The management of sexually transmitted infections by Australian general practitioners.

OBJECTIVES: To ascertain how frequently general practitioners (GPs) in Australia encounter sexually transmitted infections (STIs), how STIs are managed in general practice, and the characteristics of GPs who manage STIs. METHODS: Data were derived from the Bettering the Evaluation and Care of Health (BEACH) database. BEACH is a cross sectional survey of national GP activity. Approximately 1000 GPs per year each record details of 100 consecutive patient encounters. Details from April 1998 to March 2001 about frequency and pattern of STIs managed and the characteristics of GP managing them were analysed using SAS. RESULTS: 3030 GPs provided data on 303000 encounters. Only 521 problems managed were STIs. Viral STIs were most frequently managed including genital herpes (0.08 per 100 encounters), genital warts (0.07 per 100 encounters). Gonorrhoea, syphilis, chlamydia, and trichomoniasis were rarely managed. Medication was prescribed at a rate of 56.1 per 100 STI contacts (95% CI 50.4 to 61.7). Antivirals were the most common followed by topical chemotherapeutics. GPs managing STIs were significantly younger and more likely to be female, urban, have fewer years in practice, work fewer sessions a week, work in a larger practice, have graduated in Australia, and hold the FRACGP (all p<0.005) than those who did not. CONCLUSION: Management of diagnosed STIs forms only a small part of a GP's workload in Australia. Genital herpes and warts are the most commonly managed conditions. GPs managing STIs are different from those who do not. Strategies to improve diagnosis, management, and screening should be evaluated.

Emergency contraception: who are the users?

The objective was to describe the demographic and sexual characteristics of clients attending a Sexual Health Clinic for emergency contraception (EC). Information about women attending the Parramatta Sexual Health Clinic (PSHC) who received EC between January 1999 and July 2002 was derived from the clinic database. Age-matched controls were randomly selected. Univariate and logistic regression analysis was performed to establish which factors were associated with use of EC. Two hundred and sixty-seven women requesting EC, and an equal number of controls, were studied. Factors that were independently associated with EC use were being a student, (OR=1.7 [95% CI 1.02-2.69]) and having a regular sexual partner (OR=2.3 [95% CI 1.14-4.73]). Women requiring EC were significantly less likely to have had a sexually transmitted infection (STI) (OR=0.3 [95% CI 0.16-0.60]) or a previous pregnancy (OR=0.2 [95% CI 0.09-0.67]) than controls. We concluded that users of EC are at low-risk for STIs, but need counselling about safer sex.

HSV type specific serology in sexual health clinics: use, benefits, and who gets tested.

OBJECTIVES: To determine which sexual health clinic clients were tested for herpes simplex virus (HSV) type specific antibodies and whether this test was useful for patient management. METHODS: Demographic, sexual and reproductive history, reasons for performing type specific serology, results, and benefits were derived from patient records from Parramatta Sexual Health Clinic for all patients who were tested between 13 September1993 and 31 December 2001. The value of serology was defined under five categories-diagnostic, counselling, initiating suppressive antiviral therapy, pregnancy counselling, and not useful. To establish whether patients tested for HSV were representative of clinic attendees, a sex matched "control" group was randomly selected. RESULTS: 382/886 (43.1%) were HSV-2 antibody positive and 774/884 (80.8%) were HSV-1 positive. The commonest reasons for requesting serology were having a partner with genital herpes (30%), undiagnosed recurrent genital ulceration (26%), and first episode of genital ulceration (22%). The test was of value in confirming the diagnosis in 57% of men and 60% of women with recurrent genital ulceration and in 28% of men and 40% of women with first episode genital herpes. In patients with a partner with genital herpes the test was of value in making a diagnosis in 27% men and 50% of women and in counselling 50% of women and 73% of men. Patients offered serology were older and more likely to have had genital herpes in the past than controls. CONCLUSION: Type specific serology should be recommended for the management of couples where one has genital herpes and the other apparently does not and in individuals with genital complaints suggestive of herpes.

Social and sexual risk factors for bacterial vaginosis.

BACKGROUND: A number of sexual and social risk factors for bacterial vaginosis (BV) have been identified. However, many previous studies have used small numbers of patients, or highly selected or convenience samples, or poorly defined populations. This study aims to clarify potential sexual and non-sexual risk factors for BV. METHODS: Women attending the Sydney Sexual Health Centre with BV, between March 1991 and July 1999, were included. Controls were randomly selected women without BV. Information on the demographics, clinical findings, and sexual and non-sexual risk behaviours were extracted from the clinic database and analysed using SPSS and SAS. A logistic regression model was used to establish which associations with BV persisted. RESULTS: 890 women with BV and 890 controls were studied. Factors that were independently associated with BV were > or =3 male sexual partners in the past 12 months (OR = 1.60, 95% CI: 1.19 to 2.04), at least one female sexual partner in the past 12 months (OR = 2.1, p = 0.003), a past pregnancy (OR = 1.5, p<0.0006), and smoking. In contrast, women with BV were significantly less likely to have used hormonal contraception (OR = 0.60, 95% CI: 0.51 to 0.81) or to have used condoms consistently (OR = 0.5, 95% CI: 0.31 to 0.71) than controls. CONCLUSION: Our findings may be important for planning a preventive strategy for BV by discouraging smoking and increasing condom use and hormonal contraception among women.

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 behaviour and social class in Australian women.

Sexual behaviour is determined by social, cultural and personal factors. Sexual behaviour studies have been conducted in many countries. However, information from Australia is limited. This study was conducted in Obstetrics Department, Westmead Hospital, Sydney. Questionnaire-derived demographic and behavioural characteristics for public and private patients were compared using bivariate and logistic regression analyses. Of the patients, 3036 were public, and 595 private. On bivariate analysis some significant differences were private patients more likely to be born in Australia and have a higher education level whereas public patients were more likely to have had a greater number of lifetime sexual partners and younger age at first sex. Public patients were more likely to be herpes simplex virus type 2 (HSV-2) antibody positive (12%) than private patients (6%). On logistic regression significant variables included country of birth, being HSV-2 antibody positive, and age at first sex. A number of sexual and social variables were significantly different, comparing patients in the public and private sectors. Evaluation of interventions to reduce the sexual risk to women in the public sector should be considered, including encouraging young women to delay their sexual debut, and reducing the number of sexual partners.

An evidence based approach to testing for antibody to herpes simplex virus type 2.

OBJECTIVES: To establish whether a simple risk scoring system, based on limited information, can reflect the variation in HSV-2 prevalence in a population, and whether a common system can be used across settings. To establish whether knowledge of a patient's score can aid the interpretation of the result from one of the commercial type specific assays. METHODS: Four previous cross sectional studies are considered, with HSV-2 antibody results by western blot or type specific ELISA tests. The clinical settings were a blood donor centre (1359 participants) and STD clinic (808 participants), London, United Kingdom, an antenatal clinic, Sydney, Australia (2317 participants), and a family medical centre, Seattle, United States (478 participants). We determined the factors associated with HSV-2 prevalence, the similarity of associations across settings, and the variation in HSV-2 prevalence by risk score. RESULTS: A simple scoring captured much variation in HSV-2 prevalence in each population-for example, for London blood donors, scoring based on sex, age, and number of lifetime partners, prevalence varied from 0.7% (95% CI 0.1 to 2.0) to 47.3% (37.9 to 56.6) across five risk groups. For number of lifetime partners, and sex, the association with HSV-2 varied significantly across studies. CONCLUSIONS: A scoring system can aid test interpretation-for example, in London blood donors the post-test probability of infection following a positive result varies from around 25% to 98% across risk groups for a typical type specific assay. Further work could address whether this theoretical benefit can be realised in practice. A common risk scoring probably could not be used across settings.

Herpes simplex virus type 1 infection: a sexually transmitted infection of adolescence?

OBJECTIVES: To examine the factors associated with antibodies to herpes simplex virus type 1 (HSV-1). DESIGN: Cross sectional study with HSV-1 antibody testing performed by University of Washington western blot assay. SETTING: Central London STD clinic (1990-1) and central London blood donation centre (1992). PARTICIPANTS: Representative sample of 869 new and rebooked GUM clinic attenders and 1494 consecutive blood donors. RESULTS: The prevalence of HSV-1 antibody among clinic attenders was 60.4% (95% CI 57.0 to 63.7) and among donors was 46.1% (95% CI 43.5 to 48.7). HSV-1 antibody was independently associated with increasing age in both populations (p<0.001). Among clinic attenders, HSV-1 was less common among heterosexual men than women and homosexual men (p<0.005), and was more common among black people (p=0.001) and those of lower socioeconomic status (p=0.05). Among blood donors, being single rather than married was independently associated with HSV-1 infection (p=0.03). Early age at first intercourse was strongly associated with presence of HSV-1 in both populations. The adjusted odds of HSV-1 among GUM clinic attenders was 0.37 (95% CI 0.21 to 0.65) for someone aged 20 at first intercourse compared with someone aged