Sexual histories, partnerships and networks associated with the transmission of gonorrhoea.

We aimed to describe and compare sexual links among people with gonorrhoea, by studying patients in 2 UK departments of genitourinary medicine. Interviews were completed for 510 and 235 cases in London and Sheffield respectively. There was a greater proportion of cases in men, homosexual men, non-white and non-British people and fewer female sex workers in London. Total networks of 1738 people in London and 570 people in Sheffield were described. Large linked heterosexual networks identified in Sheffield were associated with local contact, including men with higher numbers of sexual partners. Condom use for vaginal sex was reported for 11% of heterosexual partnerships in Sheffield, and 27% in London, with little difference between regular and casual partners. It was more difficult to define networks in London due to a high proportion of relatively anonymous contacts. These difficulties suggest that research and interventions may profitably focus upon venues for meeting partners as well as partner notification.

Drift in susceptibility of Neisseria gonorrhoeae to ciprofloxacin and emergence of therapeutic failure.

Ciprofloxacin, 500 mg, was introduced as the first-line therapy for gonorrhea at St. Mary's Hospital, London, in 1989, when a surveillance program was initiated to detect the emergence of resistance. Isolates of Neisseria gonorrhoeae from consecutive patients attending the Jefferiss Wing, Genitourinary Medicine Clinic at St. Mary's Hospital, between 1989 and 1997 have been tested for susceptibility to ciprofloxacin by using an agar dilution breakpoint technique. Isolates considered potentially resistant (MIC, >0.12 microg/ml) were further characterized by determination of the MICs of ciprofloxacin, nalidixic acid, and penicillin, auxotyped and serotyped, and screened for mutations in the DNA gyrase gene, gyrA, and the topoisomerase IV gene, parC. A total of 4,875 isolates were tested. While the majority of isolates were highly susceptible (MIC, 0.12 microg/ml); all of these belonged to serogroup B, and NR/IB-1 was the most common auxotype/serovar class. The infections in 14 of the 18 patients were known to be acquired abroad, and 5 were known to result in therapeutic failure. The surveillance program has established that ciprofloxacin is still a highly effective antibiotic against N. gonorrhoeae in this population. However, it has identified a drift in susceptibility which may have resulted from increased usage of ciprofloxacin. High-level resistance has now emerged, although treatment failure is still uncommon.

Partner notification for gonorrhoea: a comparative study with a provincial and a metropolitan UK clinic.

OBJECTIVE: To compare partner notification practice and outcomes at a provincial and a metropolitan clinic. DESIGN: Prospective study, following standardisation of partner notification policy. SETTINGS: Sheffield Department of Genitourinary Medicine, Royal Hallamshire Hospital and Jefferiss Wing Centre for Sexual Health, St Mary's Hospital, London. SUBJECTS: Consecutive patients with culture positive gonorrhoea between October 1994 and March 1996 who were interviewed by a health adviser. RESULTS: In Sheffield, 235 cases reported 659 outstanding contacts, of whom 129 (20%) were subsequently screened, and 65 (50%) had gonorrhoea. At St Mary's 510 cases reported 2176 outstanding contacts, of whom 98 (5%) were known to have been screened, and 53 (54%) had gonorrhoea. Patient or provider referral agreements appeared more productive in Sheffield, where 60% resulted in contact attendance, compared with 13% at St Mary's. Provider referral was used more frequently in Sheffield, for 44% of referrals, compared with 1% at St Mary's. Multivariate analysis showed that partner notification was less effective for casual and short term (< 7 days) partnerships in both centres, and for homosexual men at St Mary's. CONCLUSION: Partner notification outcomes were better in the provincial setting where contact attendance could be recorded more reliably and provider referral was used more extensively. The high proportion of contacts who remained untraced in both settings indicates the need for complementary screening and prevention initiatives.

HIV media campaigns and HIV-1 testing trends at London genitourinary medicine clinic, 1985-1993.

OBJECTIVE: To describe HIV-related media events in the context of first-time HIV-1-antibody testing trends at a London genitourinary medicine clinic. DESIGN: Demographic and behavioural data were collected prospectively for individuals tested for HIV-1 antibodies between September 1985 and September 1993, at the genitourinary medicine clinic of St Mary's Hospital, London. RESULTS: A total of 19,242 individuals were tested of whom 37% were women. Of the men tested 60% were heterosexual. The women at first time of testing were significantly younger [29.3 years; 95% confidence interval (CI), 28.8-29.7] than the men (32.5 years; 95% CI, 29.2-35.8); mean ages for both sexes did not change significantly over time. Overall, 199 women and 1539 men tested HIV-antibody-positive. The proportions of women testing positive increased significantly over time (chi 2 = 21.7, degrees of freedom = 1; P < 0.001), whereas the proportion of HIV-positive men remained constant for all sexual orientation groups. The proportion of heterosexual women testing positive (2.8%) was similar to the proportion of HIV-positive heterosexual men (2.9%). HIV-positive individuals were significantly older for both sexes. Throughout the study period numerous education campaigns were run using a variety of media complemented by a number of other HIV-related media events. CONCLUSIONS: Peak periods of attendance for HIV testing generally corresponded with increased HIV-related media activity and the greatest testing rates were observed when various HIV media events occurred concurrently. The increase in the number of heterosexuals tested suggests that the risk of heterosexual transmission of HIV has been recognized, at least among older individuals. The exact role of HIV-related media events, including celebrities disclosing their HIV-positive status, remains to be elucidated. Whether the relative under-representation of younger people is due to a lack of awareness, increased use of safer sex practices or reluctance to use the service also remains to be addressed. Given the increasing number of HIV-positive women and the relatively constant rate of HIV-positive tests in the male attendees an urgent need exists to assess the impact and effectiveness of specific HIV media campaigns.

Comparative assessment of small intestinal and colonic permeability in HIV-infected homosexual men.

OBJECTIVES: To investigate both small and large intestinal permeability in HIV-positive subjects, and correlate variation in intestinal mucosal abnormality with immunological and nutritional markers of HIV disease. METHODS: Small and large intestinal permeability studies were performed in 14 HIV-seropositive patients and eight healthy men. Eight out of the 14 patients had diarrhoea and all subjects were negative for enteropathogens. Small intestinal permeability was determined using the lactulose-mannitol test and large intestinal permeability using the colonic absorption of 51Cr-EDTA. In addition, CD4 cell count, beta 2-microglobulin, C-reactive protein estimation and anthropometry were carried out in all subjects. RESULTS: HIV-seropositive subjects had higher lactulose-mannitol ratios (LMR; 0.084 +/- 0.007 versus 0.013 +/- 0.0008) and lower 51Cr activity (1.986 +/- 0.066 versus 3.115 +/- 0.560) than controls (P < 0.0004 and P < 0.05, respectively). Colonic uptake of 51Cr-EDTA was no different between subjects with and those without diarrhoea (2.04 +/- 0.124 versus 1.92 +/- 0.143, P > 0.05). A negative correlation was found between LMR and 51Cr-EDTA, but only for patients with diarrhoea (r = -0.81; P = 0.015). CONCLUSION: Regional variation affecting intestinal absorptive function occurs in patients with HIV-related diarrhoea and is characterized by increased LMR and reduced colonic uptake of 51Cr-EDTA. The pathogenesis and clinical significance of such changes are unknown.

The prevalence of sexual assault in a genitourinary medicine clinic: service implications.

OBJECTIVE: To determine the prevalence of sexual assault amongst patients attending a department of genitourinary medicine and to investigate the circumstances of the assault. SETTING AND SUBJECTS: The Department of Genitourinary Medicine (GUM), St. Mary's Hospital, London. All patients attending the walk-in GUM Clinic over a fixed time period were invited to take part in the study. METHODS: Patients were asked to complete an anonymous questionnaire designed by the investigators. RESULTS: 351 (209 women, 142 male) usable questionnaires were returned of 370 distributed. Seventy five persons (21.4%) reported sexual assault: 59 (28.2%) women and 16 (11.3%) men. The incident occurred more than three months before presentation in the majority of persons studied (93%). Twenty one per cent reported the assault to the police, and 34% attended for medical screening. For those who did attend for medical screening, 61% informed their doctor of the assault. The main reason for non-reporting to police and medical staff was "a wish to forget". Counselling was sought by 24% after the sexual assault. CONCLUSIONS: A past history of sexual assault is common amongst GUM clinic attenders, more often disclosed amongst women. Reporting both to police and medical services is low. Clinicians need to be sensitive to the fact that a significant proportion of patients attending GUM services may have been sexually assaulted either in the present or the past and the impact that this may have on health care usage. GUM clinics maybe ideally placed to provide medical and psychological support to these individuals.

Pneumothorax in patients with AIDS.

Eighty-seven inpatients were treated for 93 episodes of Pneumocystis carinii at St Mary's Hospital between January 1989 and December 1990. During this period, 298 patients with the acquired immunodeficiency syndrome (AIDS) were treated at this hospital. Sixteen episodes of pneumothorax occurred and 12 of these, occurring in ten patients, were unrelated to procedure. In six of 12 (50%), the pneumothoraces occurred concurrently with Pneumocystis carinii pneumonia (PCP) and in ten (83%) cases there was a past history of PCP. Bilateral pneumothorax occurred in five cases (42%). In seven (58%) of the cases, patients had been using aerosolized pentamidine as prophylaxis for PCP. This retrospective study confirms the association of pneumothorax with current PCP and also shows an association with previous infection. The use of aerosolized pentamidine was not associated with pneumothorax development. It is important to suspect pneumothorax in a patient with PCP who deteriorates acutely. The high incidence of bilateral pneumothorax means that pleurodesis should be considered early.

Case report: disseminated Pneumocystis carinii infection in a patient with the acquired immune deficiency syndrome causing thyroid gland calcification and hypothyroidism.

We present the case of a homosexual male patient with the acquired immune deficiency syndrome (AIDS) who developed disseminated infection with Pneumocystis carinii. He presented with symptoms and signs of thyroid disease, and developed thyroid gland calcification. This was later histologically proven to be due to P. carinii infection. Disseminated P. carinii infection is rare, and this case represents the first report to our knowledge of thyroid gland involvement causing both hypothyroidism and calcification.

Disseminated pneumocystis carinii infection in AIDS.

Eight patients with AIDS and Pneumocystis carinii infection were studied. Protean manifestations were a feature not untypical of disseminated pneumocystosis. Aerosolised pentamidine as prophylaxis against P carinii pneumonia was ineffective at suppressing dissemination. The knowledge that extrapulmonary infection can occur has implications for the detection and treatment of, and prophylaxis against, P carinii infection. The survival of patients with disseminated pneumocystosis is particularly poor, and may be due to a lack of clinical awareness and consequent delay in diagnosis.

Mycobacterium malmoense infection in HIV positive patients.

Mycobacterium malmoense is a non-tuberculous mycobacterium which has previously been associated with underlying pulmonary pathology and depressed immunity. We describe two patients infected with human immunodeficiency virus from whom M. malmoense was isolated, and discuss its treatment and possible pathogenic role.

Detection of Mycoplasma genitalium in the genitourinary tract of women by the polymerase chain reaction.

A polymerase chain reaction (PCR) was used to demonstrate the presence or absence of Mycoplasma genitalium in the lower genital tract of 57 women who attended a sexually transmitted diseases clinic. The mycoplasma was detected in the cervix of 10 (17.5%) women and also in the vagina of 4 (16%) and the urethra of 6 (24%) of 25 women from whom multiple samples were obtained. Chlamydia trachomatis was detected also by a PCR in 9 (16%) of the women, but only 3 were chlamydia-positive and mycoplasma-positive. M. genitalium was detected occasionally in women with vaginal disease (for example, bacterial vaginosis), whereas C. trachomatis was not, but whether there is any causal relationship between the mycoplasma and vaginal or cervical disease requires further study.

Rape and HIV.

The risk of contracting HIV infection as a result of rape is unknown. We describe 4 female patients who were found to have antibodies to HIV-1 following rape, only one of whom had another recognized risk factor for HIV infection. The need for careful follow-up of rape victims, and the potential for HIV acquisition by the assailant is discussed.