Routine HIV testing in the context of syndromic management of sexually transmitted infections: outcomes of the first phase of a training programme in Botswana.

OBJECTIVE: In 2004, the Ministry of Health adopted revised protocols for the syndromic management of sexually transmitted infections (STI) that included routine HIV testing. A training programme for providers was developed on the revised protocols that featured interactive case studies and training videos. An objective of the first phase of the training programme was to test its effect on four measures of clinical practice: (1) routine HIV testing; (2) performance of physical examination; (3) risk-reduction counselling and (4) patient education. METHODS: Clinical practice in a district where providers were trained was compared with a district without training. The measures of clinical practice were reported by 185 patients of providers who had been trained and compared with reports by 124 patients at comparison clinics. RESULTS: Relative to patients at comparison clinics, a higher percentage of patients of trainees reported that the provider: (1) offered an HIV test (87% versus 29%; p<0.001); (2) conducted a physical examination (98% versus 64%; p<0.001); (3) helped them to make a plan to avoid future STI acquisition (95% versus 76%; p<0.001) and (4) provided patient-specific information about HIV risk (65% versus 32%; p<0.001). Among patients offered HIV testing, the percentage who accepted did not differ between groups (38% of 161 patients of trainees versus 50% of 36 comparison patients; p = 0.260). Overall, 33% of patients of trainees and 14% of comparison patients were tested (p<0.001). CONCLUSION: A multifaceted training programme was associated with higher rates of HIV testing, physical examination, risk-reduction counselling and better HIV risk education.

Hormonal contraceptive use modulates the local inflammatory response to bacterial vaginosis.

OBJECTIVES: To compare cervical concentrations of numerous cytokines/chemokines in women with bacterial vaginosis (BV) compared with the levels detected after BV resolution and determine if hormonal contraceptive use modulates the local inflammatory response to BV. METHODS: Cervical secretions from 81 women with BV at enrollment and normal flora at one-month follow-up were analysed for 10 different cytokines/chemokines using multiplexed fluorescent bead-based immunoassays. RESULTS: BV was associated with significantly higher concentrations of IL-1 beta, tumour necrosis factor (TNF), interferon-gamma, IL-2, IL-4, and IL-10 compared with the levels detected in the presence of normal vaginal flora. Analysis of results stratified by contraceptive practice demonstrated significantly lower levels of numerous cytokines among women with BV using hormonal contraceptives compared with those women with BV not using hormonal contraceptives. Hormonal contraceptive use was also associated with a statistically significant lesser change in TNF levels between the two study visits compared with the amount of change detected between visits among women who denied their use. CONCLUSIONS: Despite increases in the levels of both pro and anti-inflammatory cytokines in the lower genital tract of women with BV, the overall balance of these two types of molecules was maintained. The character of this local inflammatory response may help explain the typical absence of overt signs of inflammation among women with BV. In addition, hormonal contraceptive use was associated with significantly lower levels of the pro-inflammatory molecules TNF, interferon-gamma, and granulocyte macrophage colony-stimulating factor in women with BV, but did not significantly reduce the levels of IL-10, a key anti-inflammatory cytokine. These results suggest the possibility of an association between hormonal contraceptive use and altered genital tract immunity.

Papanicolaou test screening and prevalence of genital human papillomavirus among women who have sex with women.

OBJECTIVES: The purpose of this study was to examine frequency of and attitudes toward Papanicolaou (Pap) test screening in women who have sex with women (WSW) and to determine prevalence of genital human papillomavirus (HPV). METHODS: Women were eligible if they reported having engaged in sex with another woman in the preceding year Medical and sexual histories were obtained. Cervical specimens for Pap tests and cervical and vaginal specimens for HPV DNA testing were collected. RESULTS: HPV DNA was detected in 31 of 248 WSW (13%). Women who had never had sex with men were less likely to have undergone pelvic examinations and had fewer recent Pap tests. Reasons for not undergoing Pap tests included lack of insurance, previous adverse experiences, and belief that Pap tests were unnecessary. CONCLUSIONS: Despite the occurrence of genital HPV, WSW do not receive adequate Pap test screening. Pap test screening recommendations should not differ for WSW, regardless of sexual history with men.

Urine-based screening for Chlamydia trachomatis in men attending sexually transmitted disease clinics.

BACKGROUND: Nucleic acid-amplified tests for Chlamydia trachomatis are accurate but costly. Screening strategies for asymptomatic men are needed. GOAL: To assess C trachomatis screening strategies for asymptomatic males. STUDY DESIGN: Men attending a sexually transmitted disease clinic were tested for C trachomatis with ligase chain reaction and culture, and for urethral inflammation with urine leukocyte esterase and urethral Gram stain. RESULTS: C trachomatis prevalence was 5.5% among 1,625 asymptomatic men. Ligase chain reaction increased detection by 49% among men without urethral inflammation. An age of younger than 25 years and urethral inflammation were associated with positive ligase chain reaction results. The negative predictive value of urine leukocyte esterase was highest among older men, but urethral Gram stain was equally sensitive in predicting infection regardless of age. An age of younger than 30 years or urethral inflammation identified the highest proportion of infections (92%) and reduced the percentage of men screened by 43%. CONCLUSIONS: Urine ligase chain reaction increased C trachomatis detection, particularly among men without urethral inflammation. Testing all asymptomatic men younger than 30 years is optimal, whereas negative urine leukocyte esterase or urethral Gram stain results in men 30 years or older support no testing.

Characteristics of female sexually transmitted disease clinic clients who report same-sex behaviour.

Female STD clinic clients were categorized by report of sex partners' gender in the preceding 2 months and characterized with respect to HIV risk and STD diagnosis. Among 18,585 visits, 290 women (1.5%) reported sex exclusively with women, and 841 (4.5%) reported sex with both men and women. Relative to women reporting sex only with men, those reporting sex with both men and women reported more recent partners, sex with partners at high risk for HIV, injection drug and crack cocaine use, and exchange of sex for drugs or money. Women reporting sex exclusively with women more frequently reported prior sex with a bisexual man or an HIV-infected partner. Female STD clinic clients who report sex with both men and women may be at increased HIV risk relative to women reporting sex exclusively with men, and women who report sex only with women may be more likely to have had sex with men at high risk for HIV infection.

Genital human papillomavirus infection in women who have sex with women: a review.

Sexual transmission of human papillomavirus between women has been postulated on the basis of reports of abnormal Papanicolaou smears in women who reported no prior sex with men and by studies using amplified deoxyribonucleic acid technology for human papillomavirus detection. To review the current knowledge of the epidemiology of human papillomavirus and the Papanicolaou smear screening practices among women who have sex with women, studies were identified from a search of the MEDLINE database from January 1980-June 1999. Several factors, including prior or concurrent sex with men and sexual behaviors between women, validate the possibility of human papillomavirus infection among women who have sex with women, and data support that human papillomavirus transmission also occurs. Limited data indicate that the frequency of routine Papanicolaou smear screening among women who have sex with women may be suboptimal relative to heterosexual women. Education of women who have sex with women and the providers of their health care should counter any assumptions that sex between women confers no risk of human papillomavirus transmission. Women who have sex with women should receive Papanicolaou smear screening in accord with current guidelines.

Genital human papillomavirus infection in women who have sex with women: a concern for patients and providers.

Certain types of the human papillomavirus (HPV) are sexually transmitted and cause genital warts and cervical neoplasia. Little is known about the epidemiology of HPV among women who have sex with women (WSW), but recent research using amplified techniques for HPV DNA strongly suggests that HPV is sexually transmitted between female sex partners. In a pilot study of 149 WSW in Seattle, Washington, prevalence of HPV as detected by DNA amplification assay was 30%, and was 19% among women reporting no prior sex with men. Although most cervical cancer can be prevented with Pap smear screening by detection of squamous epithelial lesions (SIL), some data suggest that the frequency of Pap smear screening is suboptimal in WSW. Reasons for this are unclear, but may include perceptions by patients and providers that WSW are not at risk for many STD and, by extension, cervical cancer. In our study, WSW who reported no prior sex with men had routine Pap smear screening less frequently than the comparative group, and had a prevalence of SIL of 14%. Combined with the work of other investigators, these data strongly suggest that current recommendations for Pap smear screening among WSW should not differ from those for heterosexual women. WSW and their providers should understand that sex between women may confer a risk of HPV transmission; risk of transmission of other STD, including HIV, deserves further study.

Genital human papillomavirus infection in women who have sex with women.

Genital infection with human papillomavirus (HPV), as determined by polymerase chain reaction detection of HPV DNA and prevalence of HPV-6 and -16 serum antibodies, was investigated in 149 women who were sexually active with women. By use of HPV L1 consensus primers and hybridization to types 6/11, 16, 18, 31/33/35/39, and 45 and a generic probe, HPV DNA was detected in 30% of subjects; of these, 20% had type 31/33/35/39, 18% had type 16, and 2% had type 6/11. Of 21 subjects reporting no prior sex with men, HPV DNA was detected in 19% and squamous intraepithelial lesions in 14%. By capture ELISA with HPV-6 and -16 L1 capsids, 47% of subjects were seropositive for HPV-16 and 62% for HPV-6. Current smoking was associated with detectable HPV DNA. Genital HPV infection and squamous intraepithelial lesions are common among women who are sexually active with women and occur among those who have not had sex with men.

Selective screening for chlamydial infection in women: a comparison of three sets of criteria.

Selective screening has been associated with marked declines in the prevalence of chlamydial infection, the most common bacterial sexually transmitted disease (STD) in the United States. A comparison of the performance of different selective screening criteria in three groups of family planning and STD clinic clients shows that criteria recommended by the Centers for Disease Control and Prevention performed well overall, detecting 88-89% of infections by screening 58-74% of women. Criteria based on age alone performed best among low-risk clients with a low prevalence of chlamydial infection, particularly when all women younger than age 25 were screened (sensitivity, 84-92%); the age-based criteria still required screening only 59-71% of all women. Selective screening criteria should be based on age, risk profile and chlamydia prevalence in specific clinical settings, and should be reevaluated as chlamydia prevalence declines.

Performance and cost-effectiveness of selective screening criteria for Chlamydia trachomatis infection in women. Implications for a national Chlamydia control strategy.

BACKGROUND AND OBJECTIVES: Detection of subclinical Chlamydia trachomatis infection in women is a high but costly public health priority. GOALS: To develop and test simple selective screening criteria for chlamydia in women, to assess the contribution of cervicitis to screening criteria, and to evaluate cost-effectiveness of selective versus universal screening. STUDY DESIGN: Cross-sectional study and cost-effectiveness analysis of 11,141 family planning (FP) and 19,884 sexually transmitted diseases (STD) female clients in Washington, Oregon, Alaska, and Idaho who were universally tested for chlamydia using cell culture, direct fluorescent antibody, enzyme immunoassay, or DNA probe. RESULTS: Prevalence of cervical chlamydial infection was 6.6%. Age younger than 20 years, signs of cervicitis, and report of new sex partner, two or more partners, or symptomatic partner were independent predictors of infection. Selective screening criteria consisting of age 20 years or younger or any partner-related risk detected 74% of infections in FP clients and 94% in STD clients, and required testing 53% of FP and 77% of STD clients. Including cervicitis in the screening criteria did not substantially improve their performance. Universal screening was more cost-effective than selective screening at chlamydia prevalences greater than 3.1% in FP clients and greater than 7% in STD clients. CONCLUSIONS: Age and behavioral history are as sensitive in predicting chlamydial infection as criteria that include cervicitis. Cost-effectiveness of selective screening is strongly influenced by the criteria's sensitivity in predicting infection, which was significantly higher in STD clients. At the chlamydia prevalences in the populations studied, it would be cost saving to screen universally in FP clinics and selectively in STD clinics, the reverse of current practice in many locales.

Cesarean delivery in women with genital herpes in washington state, 1989-1991.

OBJECTIVE: The purpose of this study was to determine whether the proportion of cesarean deliveries in pregnant women with a history of genital herpes and no active lesions at birth is higher than that in women with no history of genital herpes, and to determine whether this risk was modified by birth facilities' underlying prevalence of cesarean delivery. METHODS: This was a retrospective survey. Women who gave birth in Washington state from 1989 to 1991 were identified from the state birth records and were classified as having clinical genital herpes during pregnancy (N = 1,094) or history of genital herpes only (N = 4,163) at delivery. Women without genital herpes (N = 5,257) were randomly selected from remaining births. RESULTS: The main outcome measure was primary cesarean delivery, excluding those performed for indications other than genital herpes. Prevalence of primary cesarean delivery was 59.5% in women with clinical herpes during pregnancy and 12.5% in women with history of herpes, both significantly different from prevalence of 11.2% in unexposed women. Age-adjusted risk for cesarean delivery among women with a history of herpes was 1.13 [95% confidence interval (CI): 0.93, 1.37]. When baseline cesarean delivery prevalence was above 20%, this risk was 1.2 (95% CI: 1.0, 1.4; P = 0.058), compared to 1.1 (95% CI: 0.9, 1.3; P = 0.186) where cesarean delivery prevalence was below 20%. CONCLUSIONS: Women with history of genital herpes appear to have a slightly elevated risk of cesarean delivery, particularly in hospital settings with baseline prevalence of primary cesarean delivery above 20%. This rate is somewhat lower than that noted in a previous survey, suggesting that practitioners are following standard guidelines. Evaluations of cesarean delivery for genital herpes in other states should be performed.

Community-based urine screening for Chlamydia trachomatis with a ligase chain reaction assay.

BACKGROUND: Urine tests for Chlamydia trachomatis permit expansion of screening beyond traditional clinic environments. Prevention of infection in teenagers is a high priority. OBJECTIVE: To define the prevalence of C. trachomatis among teenagers by using the ligase chain reaction assay on urine specimens and to evaluate leukocyte esterase testing of urine specimens as an indicator of infection. DESIGN: Cross-sectional study. SETTING: An adolescent clinic, a juvenile detention facility, seven school-based clinics, and three community-based youth organizations in Seattle, Washington. PARTICIPANTS: 10,118 sexually active teenagers and young adults. MEASUREMENTS: Chlamydia trachomatis infection detected in urine specimens by ligase chain reaction assay and leukocyturia detected by leukocyte esterase testing. RESULTS: The prevalence of chlamydial infection among female participants was 8.6% and declined with increasing age; among male participants, it was 5.4% and increased with increasing age. In female participants, independent predictors of infection were being 17 years of age or younger (odds ratio [OR], 1.49), having had two or more sex partners in the previous 2 months (OR, 1.61), and having genitourinary symptoms (OR, 1.46). In male participants, independent predictors were being of nonwhite race or ethnicity (OR, 2.00 to 3.08), having had two or more sex partners in the previous 2 months (OR, 1.57), and having used a condom during the most recent sexual encounter (OR, 0.67). For identifying infection in male participants, the sensitivity of leukocyte esterase testing was 58.9%, the specificity was 94.9%, the positive predictive value was 38.4%, and the negative predictive value was 97.7%. CONCLUSIONS: Chlamydial infection is common in teenagers and young adults in community settings. The urine ligase chain reaction assay will permit widespread screening for C. trachomatis, but leukocyte esterase testing had low sensitivity for selecting persons for screening with this assay. Indicators of chlamydial infection differed substantially in male and female participants.