Human immunodeficiency viruses in patients attending a sexually transmitted disease clinic in London, 1982-7

HIV in gay and bisexual men in the United Kingdom: 25 years of public health surveillance

It is more than 25 years since the first case of AIDS was reported in the United Kingdom. In December 1981 a gay man was referred to a London hospital with opportunistic infections indicative of immunosuppression. National surveillance began the following year, in September 1982, with the notification of deaths and clinical reports of AIDS and Kaposi's sarcoma plus laboratory reports of opportunistic infections. Since then epidemiological surveillance systems have evolved, adapting to, and taking advantage of advances in treatments and laboratory techniques. The introduction of the HIV antibody test in 1984 led to the reporting of HIV-positive tests by laboratories and the establishment of an unlinked anonymous survey in 1990 measuring undiagnosed HIV infection among gay men attending sexual health clinics. The widespread use of highly active antiretroviral therapies (HAART) since 1996 has averted many deaths among HIV-positive gay men and has also resulted in a large reduction in AIDS cases. This led to a need for an enumeration of gay men with HIV accessing NHS treatment and care services (1995 onwards), more clinical information on HIV diagnoses for epidemiological surveillance (2000 onwards) and the routine monitoring of drug resistance (2001 onwards). Twenty-five years after the first case of AIDS was reported, gay and bisexual men remain the group at greatest risk of acquiring HIV in the United Kingdom. Latest estimates suggest that in 2004, 26 500 gay and bisexual men were living with HIV in the United Kingdom, a quarter of whom were undiagnosed. In this review, we examine how national surveillance systems have evolved over the past 25 years in response to the changing epidemiology of HIV/AIDS among gay and bisexual men in the United Kingdom as well as advances in laboratory techniques and medical treatments. We also reflect on how they will need to continue evolving to effectively inform health policy in the future.

Molecular evidence of homosexual transmission of HIV type 2 in Spain

Eight HIV-2-infected Caucasian men living in the same geographical area in Gipuzkoa (northern Spain) have been identified in the last 5 years. HIV-2 infection in this area is uncommon, and no other cases of HIV-2 infection have been found after extensive testing for HIV-1/2 antibodies. Epidemiological data suggested a possible link among the identified subjects, with homosexual contact being the most likely way of transmission. A genetic analysis of four of the subjects, from whom specimens were available, was conducted. Phylogenetic and signature pattern studies of the reverse transcriptase (RT) and env genes supported a single source of infection. Interindividual nucleotide variability ranged from 2.4 to 4.8% in the RT region and from 5.2 to 6.1% in the env gene, whereas the mean divergence between patient and control strains was 9.8 and 18.3%, respectively. The nucleotide and amino acid signature patterns were closely related in viruses from the four examined individuals. This is the first report of a cluster of HIV-2 infections with genetic sequence data support. The singularity of this cluster should alert clinicians on the possibility of HIV-2 outside endemic areas.

Incidence and determinants of hepatitis C virus infection among individuals at risk of sexually transmitted diseases attending a human immunodeficiency virus type 1 testing program

BACKGROUND

The role of sexual transmission of hepatitis C virus (HCV) infection is still not completely understood, partly because of the lack of longitudinal studies among cohorts of HCV-negative individuals who engage in at-risk sexual behavior.

GOALS

To evaluate the incidence of HCV infection in a population at risk for human immunodeficiency virus type 1 (HIV-1) infection and other sexually transmitted diseases (STD) and to identify factors associated with HCV seroconversion.

STUDY DESIGN

A retrospective longitudinal study was carried out on a cohort of consecutive attendees of a voluntary HIV-1 testing and counseling program in a large STD center in Rome. All individuals undergoing at least two consecutive tests for HCV antibodies were enrolled. Clinical data and information on individual behavior were collected for all study participants.

RESULTS

Between June, 1992 and December, 1994, a total of 709 individuals (12 intravenous drug users [IDU], 244 homosexuals, and 453 heterosexual non-IDUs), initially negative for HCV antibody, were tested more than once. Among these individuals, 15 HCV seroconversions occurred. The average follow-up time was 1.25 person/years (p/y) for an incidence rate of 1.69 per 100 p/y. The incidence rates by exposure category were 39.30 per 100 p/y among IDUs, 1.37 per 100 p/y among homosexual men, and 0.97 per 100 p/y among heterosexual non-IDUs. Excluding IDUs, of the 697 STD clinic attendees engaging in at-risk sexual behavior, HIV-1-positive status tended to be associated with HCV seroconversion (relative hazard = 5.48; 95% confidence interval = 0.85-35.40). The HCV crude incidence rates among HIV-1-infected patients at enrollment was 11.5%, 4.2%, and 2.4% in those with severe, moderate, and mild levels of immunosuppression, respectively (chi-square for trend = 2.38, P = 0.1).

CONCLUSIONS

In this cohort, HCV infection was confirmed to be strongly associated with intravenous drug use. Nonetheless, the occurrence of two thirds of the total HCV seroconversions in non-IDU individuals engaging in at-risk behavior suggests a role of sexual practices in the transmission of the infection. Among non-IDU individuals, the risk for development of HCV infection tended to increase in those who were HIV-1 infected.

Interpreting HIV seroprevalence data from pregnant women

HIV prevalence estimates for pregnant women from unlinked anonymous surveys are becoming increasingly available and can be used to determine the prevalence of HIV in women in the same population. The ratio of prevalence in pregnant women to that in all women is influenced by HIV-related risk behaviours that are different for pregnant and nonpregnant women and also by differences in fertility level among infected and uninfected women. This ratio is affected by biases that are likely to be culturally and socially specific. A model is proposed for the qualification and quantification of these biases and hence the estimation of general female population prevalence from serosurveillance data on pregnant women.

Epidemiology of HIV-2 infection in Spain. The HIV-2 Spanish Study Group

Human immunodeficiency virus type 2 (HIV-2) infection is endemic in West Africa, where it is responsible for many cases of AIDS. HIV-2-infected subjects have been described in other countries, mainly African immigrants, although infection in native individuals has been reported as well. The first cases of HIV-2 infection in Spain were identified in 1988. Through December 1995, 56 HIV-2 infected individuals have been diagnosed, primarily in large urban areas (23 cases in Madrid and 18 in Barcelona). All are African immigrants, except for 12 natives (21.4%), six of whom acquired the infection in endemic areas; the remaining six (2 women with numerous sexual partners and 4 homo/bisexual men) acquired the infection in Spain. Heterosexual transmission was probable in all but seven cases: five homo/bisexual males, a subject who likely acquired infection through parenteral exposure, and a child born to an HIV-2-infected mother. Nine patients (all Spanish born) have developed AIDS (16%), six of whom have died. In conclusion, HIV-2 infection is present in Spain at a low rate, and there is little evidence supporting an emerging ongoing transmission outside the population of African immigrants.

Changes in circulating immune complexes during the Jarisch Herxheimer reaction in secondary syphilis

A cohort of 16 patients with early secondary syphilis were recruited to investigate the role of circulating immune complexes in the pathogenesis of the Jarisch Herxheimer reaction. Eleven of 16 patients had a reaction (68.75%) following initial therapy, characterised by rash potentiation, pyrexia, cardiovascular changes and a number of less specific symptoms. Circulating immune complexes were measured by a standard polyethylene glycol precipitation method and a new sensitive conglutinin binding assay that measured the proportion of IgG, IgM and IgA in complexes, in the first 8 hours after initial therapy. In the latter assay, resting levels of IgG (range 46-700 micrograms/ml) and IgM (range 100-410 micrograms/ml) containing complexes were raised in all patients prior to treatment, but levels were not predictive of those who subsequently had a Jarisch Herxheimer reaction. All patients having a reaction demonstrated a mean fourfold or greater rise in IgG (mean rise 712 micrograms/ml; range 180-1506 micrograms/ml) and IgM (mean rise 804 micrograms/ml; range 200-1120 micrograms/ml) containing complexes between two and eight hours after initial therapy. No such effect was seen in the five patients having no reaction or in a control subject. All these results were confirmed using the polyethylene glycol precipitation method for complex detection.

Enzyme-linked immunosorbent assays for the measurement of human immunodeficiency virus, type 1 reverse transcriptase antigen and antibodies

Enzyme-linked immunosorbent assays (ELISA), using recombinant HIV-1 reverse transcriptase (RT; p66), are described for the measurement of RT antigen and serum antibodies to RT (anti-RT). The ELISA for anti-RT was developed in qualitative and quantitative forms, both were highly specific (100%, 0/859; 99.6%, 3/859), the former was sensitive (100%, 364/364) detecting the highest dilution of a standard high titre anti-HIV-1 RT antibody positive control serum. The latter was less sensitive (97.2%, 354/364) detecting lower dilutions of the antibody control, but had the advantage of producing highly reproducible optical density/concentration curves for the quantification of unknown anti-RT samples. In a cross-sectional study of 191 patients with HIV-1 infection, all patients developed anti-RT antibodies in CDC disease group II and III that declined but persisted in all cases into CDC disease group IV. The RT antigen assay was specific (100%, 0/772) and sensitive detecting 6 to 15 pg/ml of recombinant RT antigen diluted in normal human serum. No cross-reactivity using the RT antibody and antigen assays was seen in sera from 85 patients with current or previous hepatitis B infection or 21 sera from patients with HIV-2 infection. Further, no reactivity was demonstrated with the assays in a cohort of 20 seronegative partners (320 samples) exposed to HIV-1 infection over a 4-yr period. In samples from a patient with documented seroconversion, RT antigen was the first detectable marker of HIV-1 infection and was followed by a prompt anti-RT response. Serum RT antigen disappeared or remained low in most patients during CDC disease group II and III and rarely reappeared with progression to CDC disease group IV. In tissue culture studies RT antigen was detected in supernatant within 12 h (75 pg/ml), gave an initial peak at 36 h (300 pg/ml) and then continued to rise up to 5 days (603 pg/ml), offering a simple, cost-effective alternative to existing methods.

The prevalence of human retroviral infections in female patients attending a central London sexually transmitted disease clinic: 1985-1990

OBJECTIVES

To determine the prevalence of infection with HIV-1, HIV2, HTLV-1 and HTLV-2 in female attenders at a central London sexually transmitted disease clinic in an 8 week period in 1989-1990, and compare it with similar samples studied between 1985 and 1987.

DESIGN

Anonymous testing of serum samples from consecutive female patients having routine serological investigation for syphilis. Testing was for clinically important retroviruses, Hepatitis B core antibodies (anti-HBc), and p24 and reverse transcriptase (RT) antigens. Age (in 5 year bands), nationality (in broad geographical zones), diagnosis on the day of presentation, and history of intravenous drug usage were recorded for each patient. Annual gonorrhoea rates were analysed from 1981 to 1990.

SETTING

Outpatients of the department of genitourinary medicine.

PATIENTS

A total of 850 females attending consecutively and having routine syphilis serology.

MAIN RESULTS

The prevalence of anti-HIV-1 in female attenders in 1989-1990 was 0.35% (3/850). Prevalence in the same clinic has remained statistically unchanged since the first female cases were identified in 1986. No cases of HIV-2, HTLV-1 or HTLV-2 were identified, and no early HIV-1 infection evidenced by the presence of p24 or RT antigenaemia was found. Female gonorrhoea rates continued to decline but other STD monthly/annual rates have remained unchanged.

CONCLUSIONS

Over the last 5 years prevalence of HIV-1 infection in females in our clinic has remained unchanged and other retroviral infections have remained absent. However, the unaltered rates of other genital infections, their potential role in the heterosexual spread of HIV-1 infection, and the lack of evidence for any major changes in female sexual behaviour suggests there is a need to remain vigilant. This work complements the MRC multicentre, unlinked, genitourinary medicine clinic, anonymous testing programme, and our group will continue to apply this simple methodology to specimens from female attenders to contribute to the surveillance of the evolving HIV-1 epidemic.

The sexual behaviour of bisexual men in relation to HIV transmission

Relatively little is known about the behaviour of bisexual men which may help in assessing their role in HIV transmission. A sample of 60 behaviourally bisexual men were asked about their sexual behaviour with male and female partners and their perceptions of risk of HIV infection. Only a minority of men engaged in unprotected anal sex with their male partners while two thirds had unprotected vaginal sex with their female partners. This asymmetrical pattern of sexual behaviour reflects a differential perception of risk of HIV infection with male and female partners. A quarter of the men had unprotected penetrative sex with both male and female partners in the previous year. The pattern of risk behaviour varied amongst men living in gay, heterosexual or bisexual contexts.

HIV in the U.K.: problems of prevalence, sociological response and health education

It is argued that the prevalence of AIDS is substantially under-represented in existing national AIDS data. Thus although official statistics demonstrate significant recent shifts in transmission routes for HIV, health educators are faced with a problem because it is difficult to develop preventive strategies against a syndrome whose prevalence can only be estimated. Problems of the true extent of the prevalence of HIV are compounded when there is a lack of knowledge about the specifics of heterosexual behaviour. It is unwise to assume that the protective strategies developed by gay men in the face of HIV are routinely available for adoption by heterosexuals, who are characterised by social divisions of age, gender and relative amounts of social power. These concerns represent a problem for health educators. To date, sociological work may not have made the most effective contribution in its support of intervention strategies against HIV/AIDS. Examination of the empirical literature on lay concepts of health and illness reveals a pessimistic stance on the part of some researchers about the ability of individuals to modify behaviour. More positive readings of their own data are possible. The traditional concerns to emphasise the socio-economic determinants of health and behaviour, now also shared by some health educators, should not obscure a concern for the fate of individuals. The most effective contribution that health promotion may be able to make to the control of HIV in the heterosexual population is to assist in the development of strategies of empowerment and 'horizontal intervention'.

Failure to deliver hepatitis B vaccine: confessions from a genitourinary medicine clinic

OBJECTIVE

To audit hepatitis B immunisation of homosexual or bisexual men in a genitourinary medicine clinic.

DESIGN

Retrospective case note review of all homosexual and bisexual men presenting to a genitourinary clinic as new patients during 12 months in 1988 and follow up review of notes to May 1990.

SETTING

One department of genitourinary medicine, Middlesex Hospital.

PATIENTS

758 homosexual or bisexual men, of whom 207 started a course of hepatitis B vaccine in 1988. Case notes were unavailable for one patient.

MAIN OUTCOME MEASURES

The proportion of patients screened for hepatitis B virus markers, the proportion of susceptible patients immunised, the proportion completing the vaccine course, and the proportion rendered immune.

RESULTS

25 men had been previously tested for hepatitis markers; of the 732 not previously tested, 440 (60.1%) were screened for hepatitis B markers. 207 (69%) of the 300 patients without hepatitis B serological markers started the vaccine course, and 141 (68%) completed it, with 75 (84%) of the 89 tested after immunisation being immune. An estimated 24% of susceptible new patients were rendered immune as a result of the immunisation policy. Patients who presented with a further episode of a sexually transmitted disease were more likely to have been screened (25% v 12%, p less than 0.0001) and immunised (31% v 18% p = 0.02); those known or found to be positive for HIV antibody were more likely to have been screened (23% v 14%, p = 0.047) but less likely to have been immunised (6% v 17%, p = 0.004).

CONCLUSIONS

The major failure was that in not screening; failure to immunise patients found to be susceptible and failure of compliance with the vaccine course contributed. Non-response to the vaccine was of minor importance. Improvements in vaccine delivery are required.

IMPLICATIONS

Other providers should be encouraged to review their performance.

Unlinked surveillance of the prevalence of HIV infection in antenatal patients in the West Midlands, England

In the course of an unlinked, anonymous survey of anti-HIV seroprevalence among antenatal patients in the West Midlands, carried out between November 1986 and March 1990, seven out of 202,012 patient samples were anti-HIV seropositive. Although the numbers of women infected by heterosexual contact are still low in this region, it is likely that HIV infection is no longer limited to well-defined, male risk groups. It is therefore increasingly important to monitor the course of the epidemic through large-scale unbiased surveys of the heterosexual population in order to plan future preventive and health-care strategies.

Hepatitis C virus: evidence for sexual transmission

OBJECTIVE

To determined the prevalence of hepatitis C virus infection and associated risk factors in patients attending a genitourinary medicine clinic, as evidence for sexual transmission.

DESIGN

Seroprevalence estimated by reactivity in an enzyme immunoassay for antibodies to C100 protein with supplementary testing with a recombinant immunoblot assay and an assay for hepatitis C virus RNA.

SETTING

Outpatient genitourinary medicine clinic in central London.

PATIENTS

The panel of 1046 serum samples was from 1074 consecutive patients attending the clinic during November and December 1987 and having blood taken for routine testing for syphilis. Before samples were anonymised demographic and risk factor information was extracted from the clinic notes. Samples had already been tested for antibody to HIV-I and antibody to hepatitis B core antigen.

MAIN RESULTS

Significantly more homosexual subjects than heterosexual subjects were positive for hepatitis C antibody determined by enzyme immunoassay alone (19/275 (6.9%) v 8/771 (1.0%), odds ratio 7.14, p less than 0.0001) and also when reactive serum samples were also tested by recombinant immunoblot assay (6/270) (2.2%) v 3/770 (0.4%), odds ratio 5.88, p less than 0.02). There were also significant associations in patients positive for hepatitis C antibody with positivity for antibodies to HIV and to hepatitis B core antigen, lifetime number of sexually transmitted diseases (homosexual men only), and age (all groups combined). Most patients whose serum samples contained specific antibodies to hepatitis C virus were viraemic.

CONCLUSIONS

The study provides strong evidence for the sexual transmission of hepatitis C virus. Assays derived from other gene products are desirable to investigate the specificity and sensitivity of the enzyme immunoassay for C100 antibody as a marker of hepatitis C virus infection.

Differential regulation of human immunodeficiency viruses (HIVs): a specific regulatory element in HIV-2 responds to stimulation of the T-cell antigen receptor

The human immunodeficiency viruses (HIVs) types 1 and 2 have similar genetic organization but differ significantly in nucleic acid sequence. Although infection by either agent leads to symptoms of immunodeficiency, recent studies suggest potential differences in the time course and severity of these diseases. In this report, the transcriptional regulation and induction of these retroviruses were analyzed. We report that the regulation of HIV-2 differs from that of HIV-1: a distinct T-cell activation pathway, triggering of the CD3 component of the T-cell receptor complex, stimulates HIV-2 but not HIV-1 gene expression. The response to T-cell receptor stimulation in HIV-2 is mediated partly by an upstream regulatory element, termed CD3R, which is recognized by a sequence-specific DNA binding protein, NF-CD3R. Jurkat T leukemia cell lines containing HIV-2 provirus also showed increased viral replication after stimulation of the T-cell receptor complex, in contrast to HIV-1. These findings suggest that transcriptional regulation and induction of HIV-2 differ from HIV-1 and raise the possibility that different cofactors contribute to the activation of HIV-1- and HIV-2-associated AIDS.

Factors influencing condom use in a sample of homosexually active men

A sample of 502 homosexually active men were recruited from genitourinary medicine clinics and non clinic sources and interviewed in relation to their sexual behaviour and factors that might influence their use of condoms. Three hundred and eighty three men (76%) reported penetrative anal sex in the previous year. Ninety four (25%) had not used condoms in penetrative sex. Failure to use condoms was associated with unfavourable attitudes to them, not knowing close friends or partners who had HIV-related health problems, having fewer sexual partners and being in a closed monogamous relationship. On the other hand levels of awareness about the risks of unprotected anal sex and involvement in gay networks and social groups were not predictors of condom use.

The natural history of human immunodeficiency virus infection: a five year study in a London cohort of homosexual men

Progression rates from asymptomatic to symptomatic Human Immunodeficiency Virus (HIV) infection according to the CDC classification were prospectively studied in a cohort of 172 seropositive homosexual and bisexual men. The median follow-up time was 4 years. The progression from data of entry to the study to any group IV disease was 56% (SE 7%) at 5 years. However, the progression from an estimated date of seroconversion to any group IV disease was 36% (SE 4%) at 5 years. This was more than double the progression rate to AIDS-14% (SE 3%) at 5 years calculated in the same way. There were no differences in progression to AIDS from group IV A (systemic symptoms such as unexplained fever, weight loss or persistent diarrhoea) and group IV C-2 (oral candida or oral hairy leukoplakia). Progression rates to AIDS were significantly lower (p = 0.02) in patients who were under 25 years of age at entry than in those over 25. A review of progression rates to AIDS among homosexual cohorts shows that they tend to be higher than in cohorts of haemophiliac patients, in the early stage of infection. However, when Pneumocystis carinii pneumonia is the outcome measure, progression rates in all studies are remarkably similar.

Voluntary HIV antibody testing among STD clinic patients: a pilot study

A pilot study was conducted with the aim of measuring the acceptability of voluntary testing for human immunodeficiency virus (HIV) antibody among patients attending sexually transmissible disease (STD) clinics. Three STD clinics, two public and one private, participated in the study which was conducted over a three-month period beginning in November 1988. For each patient attending the clinics, sex, date of birth, HIV transmission category and previous HIV test result were recorded. Patients who did not request the HIV antibody test were offered testing. Of the 2356 patients who were included in the analyses, 784 (34%) requested testing. For almost all patients (97%) who requested testing, a serum sample was collected and testing completed. Approximately half (55%) of those patients who were offered the test accepted testing. Overall, 70% of patients completed HIV antibody testing. Of the major transmission categories, the acceptance rate for those offered the test was lowest among homosexual men (45%), who also had the highest rate of HIV antibody seropositivity (11%) among those tested. Of patients who reported themselves to be HIV antibody seronegative prior to the pilot study, 78% were retested during the study and seven had a positive test for HIV antibody. We conclude that voluntary HIV antibody testing is acceptable in both public and private STD clinic settings, although a substantial amount of additional resources would need to be allocated to counselling if voluntary testing is to be introduced on a routine basis.

Gay men, social support and HIV disease: a study of social integration in the gay community

As part of a large study of the effects of HIV and AIDS on gay male sexual behaviour, we investigated the extent to which gay men in the UK have access to social support and informal care at times of illness. The study sample (n = 502) demonstrated high levels of willingness to disclose sexuality to others, sociability and social integration. Over 90% reported that they had access to people whom they could turn for practical help at times of temporary incapacity. Between 42% and 46% have known a person, or persons, with HIV symptomatic disease, AIDS or someone who has died of AIDS, although men recruited in larger towns and cities were more likely to know people at every stage of HIV infection and AIDS than those from smaller towns. Twenty-five per cent had provided practical help and support to at least one person with AIDS; men in this situation were more likely to have had a close friend, lover or former lover who had died of AIDS. It is argued that it is not possible to expect the gay community to provide fully for the non-medical care of its members and, whilst some needs can be fulfilled on an informal care basis, the demands of long-term serious illness are such that adequate support services should be available in the community.

Human immunodeficiency virus surveillance at a sexually transmitted disease clinic in Copenhagen

During four study periods, each of 3-4 weeks' duration in 1987 and 1988, all patients attending the Copenhagen outpatient Venereal Disease Clinic were encouraged to have a test for human immunodeficiency virus (HIV) antibody. Anonymous testing or testing for research purposes only without any data was also offered. Patients known to be HIV antibody-positive were not re-tested. A total of 1753 patients (1118 men, 635 women) were counselled and testing recommended. Testing was refused by 255 patients, 57 of whom had been tested (all negative) within the previous 3 months. HIV serology was therefore unknown in 11.7% (198 of 1696 persons), including 120 of 922 heterosexual men (13%), 16 of 159 homo/bisexual men (10%) and 62 of 615 women (10%). There was no substantial difference between the four study periods in the numbers refusing the test. Sixteen of the 1498 patients tested were HIV antibody-positive, including one woman and 3 men with a history of intravenous drug abuse and 11 homo/bisexual men; one heterosexual man with HIV antibodies had no known risk behaviour. It is concluded that HIV testing with informed consent at a sexually transmitted disease clinic will not include all persons, and therefore will not exclude a self-selection bias. Surveillance studies using unlinked HIV testing are therefore necessary and it is recommended that they should be performed in Denmark. In this study, unlinked HIV testing of the serum specimens taken for syphilis serology would have decreased the percentage of 'non-attenders' from 12.4% to 0.8% during the final study period.

HIV infection and community midwives: experience and practice

To assess the effects of HIV infection on the work of community midwives, a postal survey of 1 in 5 in Scotland and England was carried out. The 907 respondents represent an 83% response rate. While only 1% of respondents had experience of patients with AIDS, 8% had been involved with known asymptomatic HIV infection and 32% had encountered those that they considered to be 'at high risk'. While the workload generated by HIV-infected patients for individual midwives at this time was small, almost all midwives themselves considered that they had a role to play in the prevention of HIV infection through health education and in counselling. While less than a quarter of those who had encountered HIV-positive patients had provided health education, more than half had done so to those worried about HIV infection and almost a quarter had counselled them. However, confidence to provide these aspects of practice was low, even among those who had received in-service education, although higher than among those who had not done so. A minority of community midwives had read policies or guidelines about aspects of practice and service provision, except for infection control where two thirds had read what they considered an adequate policy.

The genitourinary physician and AIDS

The arrival of AIDS/HIV infection in the UK has conferred a new significance upon genitourinary medicine which is necessarily involved in all aspects of patient care, surveillance and prevention. HIV should now be considered a relevant issue for discussion with all presenting patients who are at-risk of contracting any sexually transmitted disease. Targetting education at individuals together with the successful implementation of other control strategies through genitourinary medicine clinics provides exceptional opportunities to inhibit the further spread of HIV infection and to reduce morbidity from other STD and related pathology in the wider community.

Fewer new cases of HIV infection in Helsinki

The number of new serologically diagnosed HIV infections has decreased in Helsinki since 1986. The clinical search for infections was started in 1983 and the serodiagnostic search in late 1984. The maximum yearly number of new HIV infections was 40 cases in 1986. In 1987 and 1988 the corresponding numbers were 31 and 29, although the number of tests had increased. During the first nine months of 1989 only 16 HIV infections have been diagnosed. The levelling off, and even decrease, in the number of new cases of HIV infection gives cause for optimism about the chances of success of the campaign against AIDS by means of education, information and active screening programmes.

HIV infection in sexually transmissible disease practice in Sydney: the effects of legislation, public education and changing clinical spectrum

The experience with human immunodeficiency virus (HIV) infection of a private inner-city sexually transmissible diseases (STD) clinic in Sydney was quantified. Between February 1984 and March 1988, 2073 of the Clinic's patients were tested for antibodies to HIV on 5095 occasions. Of those tested, 538 (26%) were positive for antibodies to HIV: 532 (98.9%) of the seropositives had practised male homosexual intercourse. This is the highest reported seroprevalence of HIV for any primary care service in Australia. Those individuals seropositive because of other risk behaviours were detected by voluntary contact tracing rather than by screening. Female prostitution was not found to be a risk factor for HIV. In general, rates of first HIV antibody tests were adversely affected by threatening legislation, and temporarily stimulated (among lower-risk persons) by a national television campaign. These data suggest that much of the counselling, detection and management of HIV infection in Australia is occurring in private practice, and that STD services (private and public) are at the forefront of the HIV epidemic. This has implications for disease surveillance and control, health services planning and medical education.

Sexual attitudes and practices of selected groups in Northern Ireland since the emergence of AIDS

One hundred and seventeen heterosexual males and females attending a sexually transmitted disease clinic and 57 homosexual males from a local "gay" club were asked to complete a questionnaire regarding their attitudes and sexual practices since the emergence of AIDS. The results show a trend towards increasing partner change rate among heterosexual males. There has been an increase in the practice of insertive anal intercourse by homosexual men with Northern Ireland contacts but no corresponding increase with contacts outside Northern Ireland. The practice of receptive anal intercourse has remained constant. Significant differences in attitudes between homosexual and heterosexual males were expressed with regard to testing of 'at risk groups' (p less than 0.001), in the uptake of testing (p less than 0.01), and in attitudes to sexual practices if they themselves became HIV positive. There was a low level of anxiety amongst heterosexuals regarding risk of HIV infection in the future. Less than 50% of the heterosexual patients attending this clinic use condoms, though more claim to intend to use them in future.

Evidence for recent changes in sexual behaviour in homosexual men in England and Wales

Over 80% of cases of Acquired Immune Deficiency Syndrome (AIDS) in England and Wales have occurred in homosexual men. Changes in sexual behaviour in this group may have a substantial influence on the incidence of Human Immunodeficiency Virus (HIV) infection and will therefore be crucial in determining future cases of AIDS. This paper critically weighs the indirect and direct evidence for changes in behaviour in homosexual men since the advent of the AIDS epidemic. The paper reports on falling incidence of gonorrhoea, hepatitis B and syphilis in homosexual men, the changes being most marked from 1985 onwards. Data on temporal trends in HIV prevalence and incidence in homosexual men are reviewed. These suggest that the maximum incidence of HIV infection occurred in 1982-84 and may have fallen since then. Evidence for a concomitant change in sexual behaviour is reported from several sources. This points towards a recent change in sexual behaviour characterized by reduction in the numbers of partners and adoption of safer sexual practices. In some places change may have occurred as early as 1983. A change became apparent generally in 1985 and this appears to have been sustained in 1986-87. Nevertheless, a substantial proportion of homosexual men studied continue to practice high risk sexual practices, such as anal intercourse, including relationships with casual partners.