Genitourinary medicine: an opportunity to reduce unwanted pregnancy

We sought to investigate contraceptive use in women attending a genitourinary medicine (GUM) clinic, and to assess the need for a contraceptive service in this setting. Female attendees at Nottingham GUM clinic were invited to complete an anonymous questionnaire regarding past and present contraceptive use and whether a contraceptive service within GUM would be utilized. Four hundred and eighty-nine questionnaires were analysed. The majority had previously used condoms (89.8%) or the combined oral contraceptive pill (COCP) (74.6%), and 46.6% and 37.4%, respectively were currently using these methods. Contraception was frequently used for the dual aims of avoiding both pregnancy and infection (48.5%). General practitioners (GPs) and family planning clinics were most frequently cited as sources of regular contraceptive advice, 58.1% and 47.2% respectively, and emergency contraception 50.8% and 37.3%, respectively. If a contraceptive service was available within GUM 56.9% of respondents indicated they would use it.

Incidence of concurrent sexually transmitted infections in patients with genital warts

A case-note audit of patients presenting to a genitourinary (GU) medicine clinic with external genital warts during a six-month period was conducted. Approximately 40% of patients were referred by a general practitioner or other primary care agency, and >50% were suitable for home-based treatment. Overall incidence of co-existing sexually transmitted infections (STIs) in the study population was 14.0%. Multivariate logistic regression analysis found that age <25 years and presence of other genital symptoms were risk factors for co-existing STIs. All patients with a non-chlamydial STI had genital symptoms. We recommend that patients with uncomplicated genital warts and no additional genital symptoms can be treated in primary care, with chlamydia-screening offered to those aged <25 years.

Does partner notification of men with asymptomatic non-gonococcal non-chlamydial urethritis identify chlamydia-positive women?

The objective of this study was to identify the proportion of female contacts of men diagnosed with non-gonococcal non-chlamydial urethritis (NGNCU) who had chlamydial infection, muco-purulent cervicitis (MPC), pelvic inflammatory disease (PID) or other genital infections, and to determine whether chlamydial rates are higher in women who are contacts of men with NGNCU. A retrospective case-note review of men with NGNCU and their traced female contacts was performed. Seventy-five men were included in the study, of whom 75% were caucasian and 49% were asymptomatic. Twenty-four women were successfully traced equating to 0.32 contacts per index man. In total, 46% of the women were contacts of asymptomatic men. Overall, 26% of women were identified with chlamydial infection, increasing to 36% in the contacts of asymptomatic men. The diagnosis and partner notification of men with asymptomatic NGNCU does identify female contacts with high chlamydial infection rates. However, such targeting is resource-intensive and invasive urethral screening may deter asymptomatic men from attending. It is likely that the needs of the whole health community will be better served by screening a greater number of men and operating an active partner notification system.

HIV in cervical cancer

Women are an increasing proportion of the HIV-infected population. In addition, compared with their HIV-negative counterparts, they have a greater incidence of both cervical intraepithelial neoplasia (CIN) and invasive cervical cancer, which tends to be more progressive and aggressive. The development of invasive cervical carcinoma in an HIV-infected woman is an AIDS-defining diagnosis. However, what is not clear is whether women who are identified with cervical carcinoma should be offered screening for HIV infection. This review addresses these issues and provides a cost-effectiveness assessment.

Pregnancy outcomes of HIV-positive women in a tertiary centre in the UK

With the advent of highly active antiretroviral therapy (HAART), the mother-to-child HIV transmission rate in the UK has reduced to less than 2%. A review of delivery outcomes of 106 HIV-positive pregnant women in a tertiary centre between January 2005 and December 2010 was conducted. A total of 20 women had detectable plasma viral load at 36 weeks, or before in the two women who delivered preterm. Various peripartum management measures were undertaken in women with detectable viral load close to delivery, to accelerate reduction in plasma viral load and to reduce the risk of HIV transmission to the fetus. In our review, the overall mother-to-child transmission rate was less than 1% and in women with undetectable viral load at 36 weeks, it was 0% (zero), which signifies the importance of strict virological control and a multidisciplinary approach, which plays an important role in the successful achievement of this.

Specialty and Associate Specialist doctors: still the dependable backbone of genitourinary medicine

Workforce planning is an inexact science. Specialty and Associate Specialist (SAS) doctors are rarely included in workforce analyses. Past studies have shown that SAS doctors are significant contributors to the work in genitourinary (GU) medicine clinics. This survey confirms the large amount of clinical work undertaken by SAS doctors. It appears that 51% of SAS doctors in GU plan to retire in the next 15 years and it is uncertain what effect the 2008 SAS contract will have on SAS recruitment. This information should be taken into consideration in future GUM workforce planning.

Survey of lactation suppression in HIV-positive pregnant women

The risk of HIV transmission via breastfeeding is well reported. We conducted a national survey in the UK to look at the current knowledge and postpartum practice of HIV physicians caring for HIV-positive pregnant women. In total, 167 questionnaires were distributed, 85 (51%) questionnaires were returned. All the respondents advised their patients against breastfeeding, 17 (23%) respondents routinely prescribed drugs for postpartum lactation suppression and 32 (43%) detailed awareness of interactions between antiretroviral therapy and dopaminergic lactation suppression agents. Thirteen respondents reported awareness of guidance on lactation suppression. The knowledge and use of lactation suppression agents appears to be low. However, its use will not only reduce postnatal mastitis and breast engorgement but will also help women deal with social pressures to breastfeed. Increased use in specific circumstances will improve the postnatal care of HIV-positive pregnant women in the UK.

Uptake of 48-hour access appointments in genitourinary medicine

Summary

Timely access to genitourinary (GU) medicine services is important in the control of sexually transmitted infections (STIs). A target has been set that by March 2008, 100% of patients will be offered a GU medicine appointment within 48 hours. Strategic Health Authorities have also been asked to plan for 95% of patients to be seen within 48 hours. We sought to identify why patients decline appointments offered within 48 hours by collecting prospective data over three months. Additional data was collected over 18 working days to identify if alternative options would be acceptable to decliners. Overall, 1577 patients contacted the clinic, 1524 (96.6%) were offered a 48-hours appointment, 1108 (72.7%) accepted it, 416 (27.3%) declined it and 66.3% citing work commitments as the reason. In 118 patients, who declined the appointment offered; 43.2% indicated no alternative option was acceptable, 23.7% chose a Saturday appointment, which in 78.6% would have exceeded 48 hours. Hence, 73 (61.9%) patients would not have accepted an appointment within 48 hours. The balance of public health control, mixed service provision and informed patient choice is discussed.

Flexible booking systems to improve genitourinary medicine access and increase patient choice

Access to genitourinary (GU) medicine services is crucial for the effective control of infection and it is well recognized that improved access to GU medicine will be required in order to meet a 48-hour access target. The object of this study was to evaluate whether access to our GU medicine service would be improved and the observed default rates decreased by the introduction of a partial closed booking system for new patients. The system was run in parallel to our standard appointment service and triage system. Data were collected for the first six months that the new system was operational, with additional data collection over the corresponding calendar periods of the subsequent two years. Approximately 26% of new patient appointments were booked through the partial closed booking system in the time periods specified. New patient appointment default rates fell from 26.8-30.5% in the standard appointment system to 7.5-9.5% in the partial closed booking system (P < 0.0001). This study supports the importance of clinics adapting and providing a range of appointment system strategies as this may improve their clients' access to GU medicine services.

Pilot study in the development of an interactive multimedia learning environment for sexual health interventions: a focus group approach

In the UK there are high rates of sexually transmitted infections and unintended pregnancies amongst young people. There is limited and contradictory evidence that current sexual health education interventions are effective or that they improve access to appropriate sexual health services. This paper describes the outcome of focus group work with young people that was undertaken to inform the design of an Interactive Multimedia Learning Environment that incorporates message framing, intended for use in sexual health promotion. The focus group work addressed sexual attitudes, behaviour, risk perception, and knowledge of sexual health and sexual health services in Nottingham. The results provided new insights into young peoples' sexual behaviour, and their diversity of knowledge and beliefs. Common themes expressed regarding sexual health services included concerns about confidentiality, lack of confidence to access services and fear of the unknown. The results showed that while the adolescents are reasonably knowledgeable about infection, they do not know as much about the relevant services to treat it. This work emphasizes the need for user involvement throughout the design and development of a sexual health intervention, and will form the basis of the next part of the project.

Quality of working life in genitourinary medicine

Quality issues are becoming increasingly relevant to the working lives of health care staff. We sought to assess the perceived work-related quality of life of staff working in a genitourinary medicine (GUM) department using a self-administered anonymous questionnaire focusing on areas from the Trust's staff charter. Over two-thirds (69%) of the staff members participated. Perceptions of working life were generally good within GUM. In particular staff felt valued as a resource with free expression of ideas, involvement in decision making, fair treatment and respect. Weaker areas were identified enabling a plan to be developed to address these. It is important to address quality in working life in order to achieve improvements.

'Shelf life' of Trichomonas vaginalis

The diagnosis of Trichomonas vaginalis (TV) infection in women may be made by observing motile trichomonads in wet-mount preparations of vaginal discharge. The duration for which these organisms can be identified in such samples is unknown. We sought to assess this by performing wet-mount microscopy on samples from female patients immediately, and then in positive samples, every 10 minutes until motile trichomonads could no longer be identified. Of the 65 wet-mount specimens positive for TV, a cumulative total of 13 (20%) samples had become negative by 10 minutes, 23 (35%) samples by 30 minutes and 51 samples (78%) by two hours, with the remainder exceeding two hours. We conclude that one-fifth of wet-mount vaginal preparations initially positive for motile TV become negative within 10 minutes of the initial, immediate reading. In order to maximize the sensitivity of this widely used test it is recommended that all specimens be examined immediately after they are taken.

Can the Internet be used to improve sexual health awareness in web-wise young people?

OBJECTIVES

To assess Internet use amongst young people to determine whether it would be a practical way to provide sex education and information.

METHODS

Year 10 students (aged 14-15 years) from North Nottinghamshire schools were asked to participate in focus groups to discuss the Internet. A series of predefined questions were directed to the whole group to generate debate. Areas explored included: Internet access and site; frequency and purpose of Internet use; websites visited; ideas for a genitourinary medicine (GUM) website. Responses were recorded by a hand count or as individual verbal responses.

RESULTS

Thirteen focus groups were held involving 287 students of approximately equal sex distribution. All had access to Internet facilities at school and 224 (78.0%) had access elsewhere. Access was at least once a week by 178 (62.0%) mostly for e-mail, games, chatlines and homework. No one accessed for health information. One hundred and seventy-nine (62.4%) participants said they would use a GUM website. A 'question line' where they could e-mail questions to a health care professional was of interest to 202 (70.4%) participants.

CONCLUSIONS

The Internet would be a practical and accessible way of delivering sexual health education to young people, particularly if it is incorporated into activities and websites they enjoy.

Coitarche and care: does experience of the 'looked after' system affect timing of a woman's sexual debut?

Women with an early coitarche may be less connected to home than those with a later coitarche and are more at risk of sexually transmitted infections (STIs). Children in care or the 'looked after' system feel less connected. We investigated whether women ever in care (WEIC) differed from women never in care (WNIC) in terms of coitarche and STIs using self-reported data from women attending Genitourinary Medicine clinics. Of the 336 women participating 17 women had experienced care, of whom 13 (76.5%) had coitarche below 16 years of age; of these five (38.5%) had used a condom at coitarche and three (60%) with genital infections had gonorrhoea, chlamydial infection or pelvic inflammatory disease. This compared with 112 (35.1%), 70 (62.5%) and 29 (40.8%), respectively for WNIC. WEIC are more likely to have early coitarche; if this is below 16 years subsequent genital infections are more likely to be fertility-threatening.

Availability of dental services for patients with blood-borne viruses

Dental practitioners were surveyed, using a self-completed postal questionnaire, to assess their attitudes to managing patients with blood-borne viruses (BBV) and to identify dental services available for such patients in North Nottinghamshire. Questionnaires were completed by 79 (65.3%) of the 121 practitioners from 43 (82.7%) of the 52 study practices. Previous BBV experience was reported by 44 (55.7%), 31 (39.2%), 20 (25.3%) respondents for hepatitis B (HBV), hepatitis C (HCV), HIV, respectively. Over two-thirds would maintain existing patients with subsequently diagnosed BBV on their lists, approximately one-third would accept new BBV patients. Risk factors for BBV of homo/bisexuality and injecting drug use were not asked by 71 (89.9%) and 49 (62.0%) practitioners, respectively. Universal precautions were employed by 67 (84.8%) practitioners regardless of the patient's status and by seven practitioners for known BBV patients. The advice of the General Dental Council, British Dental Association, and the use of universal precautions are discussed.

Contraception and men attending a genitourinary medicine clinic

AIMS

To identify men's knowledge and attitude to contraception and to determine whether there are differences in those men who have previous experience of termination of pregnancy (TOP) compared to those without experience.

METHOD

Cross-sectional survey by written questionnaire of male attenders at a genitourinary medicine (GUM) clinic.

RESULTS

In total 999 men, aged 15 to 70 years, completed questionnaires, 97.2% of those eligible. Over 96% of men wishing to avoid pregnancy with regular sexual partners were using contraception. However, with casual sexual partners 36% of men would not ensure that they were covered for contraception. The majority, 68.8%, of men did not have enough knowledge to access appropriate emergency contraception. Experience of a TOP was reported by 16.5% of men. Compared to men who did not have termination experience there were no differences in contraceptive use or their knowledge of emergency contraception.

CONCLUSION

Use of contraception with regular sexual partners was good, but this was not the case with casual sexual partners or with respect to knowledge of emergency contraception. No significant differences were found in contraceptive use or attitudes between men with or without experience of TOP, but this may be influenced by several factors including the cross-sectional nature of the study. Improved targeting of men at the time of their partner's termination and the development of a National Sexual Health Strategy which takes into account men's needs may address this.

Penile fracture

A wide range of patients present to genitourinary medicine (GUM) clinics with diverse conditions, many of which may not be infective. One such condition, albeit rare, is penile fracture. This is a traumatic rupture of the corpus cavernosum usually associated with blunt trauma to the erect penis. Prognosis and management issues are discussed.

Constitutive promoter modules for PCR-based gene modification in Saccharomyces cerevisiae

Initial steps in investigating gene function often include deleting and overexpressing the gene of interest and identifying the subcellular location of the gene product. To facilitate these procedures, a number of new PCR modules, which contain selectable markers and in some cases other genetic elements (e.g promoter elements, epitope tags, and reporter genes) have been developed. These modules are used as PCR substrates to create products that can be targeted to specified locations in the yeast genome, thus modifying that genomic locus. We describe here a series of plasmids that contain a truncated version of the strong ADH1 promoter with and without amino-terminal 3HA and GST tags. Because these plasmids contain the same vector sequences as the GAL1 promoter plasmids, a constitutive and an inducible promoter can now be integrated with a minimal number of primers.

Genital infection and termination of pregnancy: Are patients still at risk?

OBJECTIVES

To identify the treatment patterns and early complication rates in women identified with a genital infection prior to a termination of pregnancy (TOP) and to re-assess our earlier work on contact attendance and treatment. The aim was to refine current prophylactic measures to provide the most efficient and effective way of reducing post-termination complications.

METHOD

Six-month retrospective analysis of all women with genital Chlamydia trachomatis or Neisseria gonorrhoeae identified prior to TOP. Data on the timing of positive results and treatment in relation to the TOP were recorded. Clinical signs of pelvic infection and the success of contact tracing and treatment were noted.

RESULTS

Forty women were identified with infection, 31 (78%) proceeded to TOP; only five were treated adequately in the peri-TOP period. Twenty-six (84%) of the women undergoing TOP attended the genitourinary medicine (GUM) department after the TOP and received antimicrobial therapy where necessary. In total, four women (10%) were untreated. Approximately two thirds of results were reported prior to, or on the day of, the TOP. The majority of TOPs (71%) were carried out at 5 days or less from the initial assessment. Clinical signs of post-TOP pelvic inflammation developed in seven (28%) women with chlamydial infection. Contact tracing was successful in 24 (69%) of the 35 women who attended the GUM department.

CONCLUSION

The debate about the best option for the most effective management of women undergoing TOP continues. The options with respect to C. trachomatis include universal prophylaxis, screening and treating as necessary, or a 'belt and braces' approach of screening all and treating all. Fundamental is the continuation of active contact tracing and GUM remains integral to this.

An audit of diagnostic coding in genitourinary medicine clinics

The KC60 diagnostic code information provides an epidemiological monitor of sexually transmitted infection (STI) and a means of standardizing clinical workload in genitourinary medicine (GUM) departments.

We aimed to assess the coding process and its uniformity within the Trent region by means of a confidential self-administered coding exercise with simulated case presentations.

The correct coding for STIs ranged from 59.4% to 100% in different scenarios. Difficulty was identified in the coding of vulvitis and balanitis where no organism was isolated, as represented by a wide range of codes. HIV pre-test counselling without testing was coded by only 57.8% of respondents. Over 95% indicated correctly the first hepatitis B vaccine dose but 21% failed to code once only for the course.

Coding practice also varied within individual sites with a 21–100% discordance.

In parts diagnostic accuracy was good but there were areas of non-uniformity both within sites and cross-regionally. Regional discussions have resulted in increased training opportunities and guidelines have been developed to increase uniformity and achieve consensus in uncertain areas.

An audit of diagnostic coding in genitourinary medicine clinics. Trent Region Genitourinary Medicine Audit Group

The KC60 diagnostic code information provides an epidemiological monitor of sexually transmitted infection (STI) and a means of standardizing clinical workload in genitourinary medicine (GUM) departments. We aimed to assess the coding process and its uniformity within the Trent region by means of a confidential self-administered coding exercise with simulated case presentations. The correct coding for STIs ranged from 59.4% to 100% in different scenarios. Difficulty was identified in the coding of vulvitis and balanitis where no organism was isolated, as represented by a wide range of codes. HIV pre-test counselling without testing was coded by only 57.8% of respondents. Over 95% indicated correctly the first hepatitis B vaccine dose but 21% failed to code once only for the course. Coding practice also varied within individual sites with a 21-100% discordance. In parts diagnostic accuracy was good but there were areas of non-uniformity both within sites and cross-regionally. Regional discussions have resulted in increased training opportunities and guidelines have been developed to increase uniformity and achieve consensus in uncertain areas.

Managing STIs identified after testing outside genitourinary medicine departments: one model of care

OBJECTIVES

To develop a local strategy for managing cases of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) which have been identified in the departments of obstetrics and gynaecology (O&G).

METHODS

Weekly notification from the local microbiology laboratory to genitourinary medicine (GUM) departments of all positive CT and GC results generated by tests performed in the two local O&G departments. Direct contact made by GUM departments to index patients identified and "fast track" appointments made. Data recorded for future audit include numbers attending, details of health adviser input, and success of contact tracing.

RESULTS

Over 18 months, 294 women were identified and 231 (78%) attended GUM departments; 142 (48%) had received antibiotics before attending GUM departments and of these, 58 (41%) had risked reinfection by an untreated partner and 48 (20%) were found on screening to have a previously undiagnosed genital infection. Over 90% were interviewed by a health adviser. Appropriate follow up was achieved in 87% of index cases. Of the contacts, 194 were treated--150 in the local GUM department. Of these 150 men, 99 (66%) had an identifiable genital infection and 84% of those with CT/non-gonococcal urethritis were asymptomatic. There have been no complaints either formal or informal, by women managed by this system.

CONCLUSIONS

GUM clinics are the ideal setting to achieve successful treatment of patients with sexually acquired infections, which must include notification and treatment of their partners if reinfection is to be avoided. For patients with infections diagnosed on other settings, such as O&G, a system of direct notification of results to GUM departments by an agreed protocol can be highly successful. For such a system to work, close cooperation and trust between departments is essential.

Nasopharyngeal flora in HIV seropositive men who have sex with men

OBJECTIVES

To assess, in men who were infected with the human immunodeficiency virus (HIV) and who identified themselves as having had sex with men; the nasopharyngeal prevalence of Neisseria gonorrhoeae, N meningitidis, Corynebacterium diphtheriae, and candida species; oral sexual behaviour; the relation between oral flora and oral sexual behavior.

METHOD

Nasopharyngeal swabs were taken from HIV seropositive men for culture. The men were also asked to complete a self administered questionnaire.

RESULTS

390 men were recruited; 286 (73.3%) provided nasopharyngeal samples and questionnaires; 41 (10.5%) provided nasopharyngeal samples only; 63 (16.2%) provided questionnaires only. From the 327 nasopharyngeal samples N meningitidis was cultured in 49 (15%) and candida species in 165 (50.5%). Cultures for N gonorrhoeae and C diphtheriae were all negative. Data from the 349 completed questionnaires indicated that 285 men were practising oro-penile sex, over 90% did not consistently use condoms; 150 men were practising oro-anal sex, one used dental dams. In those providing both nasopharyngeal samples and sexual behaviour data meningococcal carriage was identified in 40 (17.5%) of the 228 men practising receptive oro-penile sex, compared with one (2.3%) of the 43 non-practisers (p < 0.025); in 21 (20%) of the 105 men practising insertive oro-anal sex, compared with 17 (12.5%) of the 136 non-practisers (p = 0.12). No correlation was identified between yeast carriage and oro-genital sex.

CONCLUSION

Oro-genital sex, usually without barrier protection, is common among HIV infected men who have sex with men. It appears to be associated with increased meningococcal carriage but is autonomous to candida species isolation. Routine screening for nasopharyngeal N gonorrhoeae is not deemed necessary.

Inoculation of culture plates: straightforward or is it?

In view of the recent vogue in some genitourinary medicine (GUM) units towards selective microscopy we aimed to assess the adequacy of culture plate inoculation in our own GUM clinic by the visual examination of 350 consecutively inoculated plates. Seventy-five (21%) plates were inoculated so lightly that no indentation in the agar could be seen whilst in 20 (60%) the agar was shredded. Eighty-five per cent of inadequately plated samples were inoculated by the same staff members who were either relatively inexperienced, or well-distanced from their last in-service training. This has many important implications not only in the identification and control of infection but also with respect to staff training. We have now introduced practical plating instruction for all new members of clinical staff and additional in-service training. We plan to repeat the audit in 6 months' time to assess the effect of these changes.

Azithromycin as the first-line treatment of non-gonococcal urethritis (NGU): a study of follow-up rates, contact attendance and patients' treatment preference

AIMS

To identify any differences in follow-up rates or sexual contact attendance rates in men presenting with non-gonococcal urethritis (NGU) after treatment by single dose azithromycin rather than longer standard duration therapies and to identify patients' treatment preferences.

METHODS

A prospective study was performed on 200 consecutive men attending a genito-urinary medicine (GUM) clinic with new episode, microscopically confirmed NGU. The first 100 patients were treated with standard duration therapy (Group S) whilst the second 100 patients received a single 1 g oral dose of azithromycin (Group A). Patient-led contact tracing was arranged and patients were asked to return for review when a test of cure was performed, contact attendance noted and the patient's treatment preference ascertained.

RESULTS

Both groups were predominantly heterosexual and over 60% gave a history of previous sexually transmitted disease (STD). There were no significant differences in efficacy between Groups S and A. However, the index follow-up rate and percentage of traceable sexual contacts attending was higher in Group A. In both groups contacts of homosexual men were more likely to attend the GUM clinic. More additional visits were made by Group S due to mislaid medication or compliance problems. Over 70% of patients questioned expressed a preference for single dose therapy.

CONCLUSION

Single dose therapy with 1 g of azithromycin is as efficacious as longer duration therapies with advantages in patient follow-up rates and contact attendance and for the majority of patients would be their treatment of choice. A cost analysis supports the practical application of this regimen.

How common is self-treatment in non gonococcal urethritis?

OBJECTIVE

To assess the prevalence of self-treatment in men with new episode non gonococcal urethritis (NGU).

METHOD

Three hundred consecutive men with new episode NGU attending an open access genitourinary medicine clinic were interviewed using a semi-structured questionnaire. Details of treatment used before attending the clinic were obtained.

RESULTS

Thirty (10%) men had used treatment, for an average of 7 days, prior to the clinic attendance. Agents used included antibiotics (11), savion or iodine (4), vitamin tablets (4), cisapride (2), local anaesthetic gel (2), antiseptic cream (2), cod liver oil (1), ferrous sulphate (1), naproxen (1), clotrimazole cream (1) and a poultice (1). Over 70% of the men reporting antibiotic use had self-medicated and in one case a fixed drug eruption had ensued.

CONCLUSION

A significant number of men with NGU self-treat. In addition to the adverse effects of such treatment and the potential effect on culture tests, clinic attendance may be postponed, the use of appropriate therapy delayed, and sexual contacts will remain at risk. Early attendance for treatment and contact tracing is essential and should be actively promoted.

Women, contraception and STDs including HIV

It is estimated that eight million women are infected with the human immunodeficiency virus (HIV) worldwide. Heterosexual transmission is the predominant mode of HIV transmission on a global basis and is becoming increasingly important in the Western world. Women have long used contraceptives as a means of protection against an unwanted pregnancy, some of which may also protect against sexually transmitted disease (STD) including HIV. We review the relationship between contraceptive methods and STD acquisition and transmission; HIV acquisition and transmission; and the implications of contraceptive use, particularly regarding disease progression, in those women who are already infected with the virus. It is important for all women that protection against both unwanted pregnancy and HIV acquisition and transmission are considered together and not in isolation as nowhere is the argument for a broad based multi-disciplinary approach more cogent.

Evaluating a designated family planning clinic within a genitourinary medicine clinic

OBJECTIVE

To evaluate an integrated family planning clinic (FPC) established by genitourinary medicine (GUM) staff held within a GUM women-only clinic (WOC).

DESIGN

A retrospective case note review of women attending the FPC during the first year January-December 1992.

RESULTS

One hundred and thirteen women, aged 13-41 years, attended the FPC; 45 were new attenders, six had previously tested antibody positive for the human immunodeficiency virus (HIV), seven were intravenous drug users; 54% had a history of sexually transmitted disease (STD); 17.7% were using no contraception; 32.7% had previous termination of pregnancy (TOP) with 70 TOPs in total. Within three months of FPC attendance 89 (78.8%) women had genital STD screening performed; syphilis, HIV and hepatitis B serology, together with cervical cytology were performed in 77, 18, 13 and 62 women respectively. Infections identified were similar to those identified in the GUM clinic but the prevalence of Chlamydia trachomatis in diagnosed infections was commoner in FPC attenders and epidemiological treatment commoner in GUM attenders. No high grade cytology abnormalities were detected. No positive syphilis or new HIV positive results were identified; five women were found to be hepatitis B surface antibody positive. Contraception was changed in 60.8%. Most frequently supplied was the combined oral contraceptive pill (COCP). At the first FPC attendance six women required post coital contraception (PCC) and five were already pregnant, three suspected it, two were unaware. During the year three women conceived; two used COCP, but were non compliant; one used a diaphragm with unclear compliance. Seven of the eight pregnancies were terminated. Over the following year, 1992-93, contraception was supplied to 42 women; four required PCC; two intentional pregnancies occurred. Only one of the TOP women returned.

CONCLUSION

An integrated FPC provides co-ordinated sexual health care. Pregnancy, TOP and FPC re-attendance rates together with improvement strategies are discussed. Avoiding unwanted pregnancy remains a universal challenge.

Systemic Pneumocystis carinii pneumonia prophylaxis with dapsone and pyrimethamine fails to protect against extrapulmonary pneumocystosis

Extrapulmonary pneumocystosis is a feature of severe immunosuppression which earlier reports have suggested is limited to patients receiving either no prophylaxis or aerosolised pentamidine. We report a case of disseminated pneumocystosis which developed in an HIV positive homosexual man despite systemic primary Pneumocystis carinii pneumonia prophylaxis.