Avoiding risky sex partners: perception of partners' risks v partners' self reported risks

BACKGROUND

Key strategies advocated for lowering personal risk of sexual exposure to STD/HIV include having fewer partners and avoiding risky partners. However, few studies have systematically examined how well people can actually discern their sex partners' risk behaviours.

METHODS

We conducted face to face interviews with 151 heterosexual patients with gonorrhoea or chlamydial infection and 189 of their sex partners. Interviews examined the patients' perceptions of their sex partners' sociodemographic characteristics and risk behaviours. Patients' perceptions of partners were then sociometrically compared for agreement with partner self reports, using the kappa statistic for discrete variables and concordance correlation for continuous variables.

RESULTS

Agreement was highest for perceived partner age, race/ethnicity, and duration of sexual partnership; and lowest for knowledge of partner's work in commercial sex, number of other sex partners, and for perceived quality of communication within the partnership. Index patients commonly underestimated or overestimated partners' risk characteristics. Reported condom use was infrequent and inconsistent within partnerships.

CONCLUSION

Among people with gonorrhoea or chlamydial infection, patients' perceptions of partners' risk behaviours often disagreed with the partners' self reports. Formative research should guide development and evaluation of interventions to enhance sexual health communication within partnerships and within social networks, as a potential harm reduction strategy to foster healthier partnerships.

Partner management for gonococcal and chlamydial infection: expansion of public health services to the private sector and expedited sex partner treatment through a partnership with commercial pharmacies

BACKGROUND

Public health partner notification (PN) services currently affect only a small minority of patients with gonorrhea or chlamydial infection and new approaches to PN are needed.

OBJECTIVES

To expand PN for gonorrhea and chlamydial infection to private sector patients and to assess the feasibility of treating sex partners through commercial pharmacies.

METHODS

Selected patients were offered PN assistance and were randomly offered medication to deliver to their partners.

RESULTS

Providers permitted the health department to contact 3613 (91%) of 3972 potentially eligible patients, and 1693 (67%) of 2531 successfully contacted patients consented to interview. Of these, 1095 (65%) reported at least one untreated partner. Most patients (90%) wished to notify partners themselves. Patients were more likely to have partners who had not yet been treated and to request PN assistance if they had more than one sex partner in the preceding 60 days or a partner they did not anticipate having sex with in the future. These two factors characterized 49% of all patients interviewed, 70% of those with a partner that was untreated 7 or more days after index patient treatment, and 83% of those accepting PN assistance. Among 458 randomly selected patients with untreated partners at time of study interview, 346 (76%) agreed to deliver treatment to a partner. Of these, most (266) chose to obtain medication for a partner at a pharmacy, of whom 223 (84%) successfully did so.

CONCLUSION

A substantial minority of private sector patients have untreated partners more than 7 days after their own treatment; some need help with PN, but most will agree to deliver medication to partners themselves.

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.

Determinants of persistent and recurrent Chlamydia trachomatis infection in young women: results of a multicenter cohort study

BACKGROUND

Sequelae of genital Chlamydia trachomatis infection in women are more strongly linked to repeat infections than to initial ones, and persistent or subsequent infections foster continued transmission.

OBJECTIVE

To identify factors associated with persistent and recurrent chlamydial infection in young women that might influence prevention strategies.

METHODS

Teenage and young adult women with uncomplicated C trachomatis infection attending reproductive health, sexually transmitted disease, and adolescent medicine clinics in five US cities were recruited to a cohort study. Persistent or recurrent chlamydial infection was detected by ligase chain reaction (LCR) testing of urine 1 month and 4 months after treatment.

RESULTS

Among 1,194 women treated for chlamydial infection, 792 (66.4%) returned for the first follow-up visit, 50 (6.3 %) of whom had positive LCR results. At that visit, women who resumed sex since treatment were more likely to have chlamydial infection (relative risk [RR], 2.0; 95% CI, 1.03-3.9), as were those who did not complete treatment (RR, 3.4; 95% CI, 1.6-7.3). Among women who tested negative for C trachomatis at the first follow-up visit, 36 (7.1%) of 505 had positive results by LCR at the second follow-up visit. Reinfection at this visit was not clearly associated with having a new sex partner or other sexual behavior risks; new infection was likely due to resumption of sex with untreated partners. Overall, 13.4% of women had persistent infection or became reinfected after a median of 4.3 months, a rate of 33 infections per 1,000 person months.

CONCLUSIONS

Persistent or recurrent infection is very common in young women with chlamydial infection. Improved strategies are needed to assure treatment of women's male sex partners. Rescreening, or retesting of women for chlamydial infection a few months after treatment, also is recommended as a routine chlamydia prevention strategy.

Association of Mycoplasma genitalium with nongonococcal urethritis in heterosexual men

Chlamydia trachomatis and Neisseria gonorrhoeae are universally acknowledged as urethral pathogens, yet the etiology in the majority of cases of urethritis is unclear. Our case-control study assessed the association of Mycoplasma genitalium, Ureaplasma urealyticum, and other potential pathogens with acute nongonococcal urethritis (NGU) in heterosexual men presenting to an urban sexually transmitted diseases clinic. M. genitalium was detected in 27 (22%) of 121 NGU case patients and in 5 (4%) of 117 control subjects (P<.01). Although C. trachomatis was detected in 36 (30%) of 121 NGU case patients and in 4 (3%) of 117 control subjects (P<.01), only 3 men with NGU were infected with both C. trachomatis and M. genitalium. U. urealyticum was not associated with NGU. By multivariate analyses, controlling for age, race, history of prior urethritis, and chlamydial infection, M. genitalium was associated with a 6.5-fold increased risk of urethritis (95% confidence interval, 2.1-19.5), which supports a role of this organism in the etiology of NGU.

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 herpes and public health: addressing a global problem

Genital herpes can be caused by herpes simplex virus 2 (HSV-2) or, less commonly, by herpes simplex virus 1 (HSV-1). With a seroprevalence of antibodies to HSV-2 of 22% in the general population, genital herpes is 1 of the 3 most prevalent sexually transmitted diseases (STDs) in the United States. A central issue in the public health problem of genital herpes is the high proportion of genital HSV infections that are unrecognized by both patients and clinicians. Persons who are HSV-2 seropositive may be symptomatic but nevertheless fail to recognize genital herpes; they serve as reservoirs for transmission. Physicians and patients must be aware of the subclinical presentation of genital herpes and the potential these patients have for transmitting HSV. Serious consequences of HSV infection include neonatal herpes and increased risk of human immunodeficiency virus transmission. Recommendations to physicians for prevention include using type-specific tests for HSV when screening for other STDs and testing for HSV when evaluating patients with genital ulcers. Researchers must evaluate the performance of type-specific tests and strategies to prevent transmission.

Evaluation of office-based intervention to improve prevention counseling for patients at risk for sexually acquired hepatitis B virus infection. Hepatitis B-WARE Study Group

The aim of this study was to determine the effectiveness of tools to identify and counsel patients at risk for sexually transmitted hepatitis B virus infection. Physicians were randomly assigned to either an intervention group or a control group. The intervention group was provided with materials intended to encourage patients to return for counseling and to guide counseling concerning prevention of hepatitis B virus infection. Baseline data on 457 patients at risk for hepatitis B virus infection showed that 7% had received prevention counseling and 2% had begun hepatitis B vaccination. Counseling was least likely to occur in obstetric-gynecologic practices, among uninsured patients, and among patients whose only risk factor was a diagnosis of a sexually transmitted disease. After a 6-month intervention period 26% of the intervention group patients and 7% of the control group patients had been counseled (P <.01). Vaccination was more likely among intervention group patients (8% vs <1%; P <.001). The use of tools to identify and counsel patients at risk for sexually transmitted hepatitis B virus infection resulted in increased office-based prevention activities.

Recombinant glycoprotein vaccine for the prevention of genital HSV-2 infection: two randomized controlled trials. Chiron HSV Vaccine Study Group

CONTEXT

In the last 3 decades, herpes simplex virus type 2 (HSV-2) infection seroprevalence and neonatal herpes have increased substantially. An effective vaccine for the prevention of genital herpes could help control this epidemic.

OBJECTIVE

To evaluate the efficacy of a vaccine for prevention of HSV-2 infection.

DESIGN

Two randomized, double-blind, placebo-controlled multicenter trials of a recombinant subunit vaccine containing 30 microg each of 2 major HSV-2 surface glycoproteins (gB2 and gD2) against which neutralizing antibodies are directed, administered at months 0, 1, and 6. Control subjects were given a citrate buffer vehicle. Participants were followed up for 1 year after the third immunization.

SETTING AND PARTICIPANTS

We enrolled 2393 persons from December 10, 1993, to April 4, 1995, who were HSV-2 and human immunodeficiency virus seronegative. One trial with 18 centers enrolled 531 HSV-2-seronegative partners of HSV-2-infected persons; the other, with 22 centers, enrolled 1862 persons attending sexually transmitted disease clinics. A total of 2268 (94.8%) met inclusion criteria and were included in the analysis with 1135 randomized to placebo and 2012 to vaccine.

MAIN OUTCOME MEASURE

Time to acquisition of HSV-2 infection, defined by seroconversion or isolation of HSV-2 in culture during the study period by randomization group.

RESULTS

Time-to-event curves indicated a 50% lower acquisition rate among vaccine vs placebo recipients during the initial 5 months of the trial; however, overall vaccine efficacy was 9% (95% confidence interval, -29% to 36%). Acquisition rates of HSV-2 were 4.6 and 4.2 per 100 patient-years in the placebo and vaccine recipients, respectively (P =.58). Follow-up of vaccine recipients acquiring HSV-2 infection showed vaccination had no significant influence on duration of clinical first genital HSV-2 episodes (vaccine, median of 7.1 days; placebo, 6.5 days; P>.10) or subsequent frequency of reactivation (median monthly recurrence rate with vaccine, 0.2; with placebo, 0.3; P>.10). The vaccine induced high levels of HSV-2-specific neutralizing antibodies in vaccinated persons who did and did not develop genital herpes.

CONCLUSIONS

Efficient and sustained protection from sexual acquisition of HSV-2 infection will require more than high titers of specific neutralizing antibodies. Protection against sexually transmitted viruses involving exposure over a prolonged period will require a higher degree of vaccine efficacy than that achieved in this study.

Elimination and reintroduction of primary and secondary syphilis

OBJECTIVES

This study was conducted to define factors associated with the epidemic spread, elimination, and reintroduction of primary and secondary syphilis in King County, Washington, from 1987 through 1998.

METHODS

Reports of primary and secondary syphilis in King County from 1987 through 1998 were reviewed retrospectively.

RESULTS

During the epidemic spread of syphilis, only 15.8% of cases were imported. A total of 24.0% of patients reported cocaine use, and 18.3% of female patients reported having commercial sex. During the elimination of syphilis, significantly higher percentages of cases were imported and lower percentages of patients reported cocaine use or female commercial sex. During the reintroduction of syphilis in 1997-1998, 68% of patients were men who reported sex with men; of this 68%, 66% were sero-positive for HIV. Most men reporting sex with men were 30 years or older and recruited many anonymous partners.

CONCLUSIONS

As syphilis wanes, local control must focus on outbreaks following its reintroduction. Resurgence of syphilis among men reporting sex with men recapitulates the epidemiology of syphilis before the historical advent of AIDS, warranting immediate attention to this problem.

Sexual mixing patterns in the spread of gonococcal and chlamydial infections

OBJECTIVES

This study sought to define, among sexually transmitted disease (STD) clinic attendees, (1) patterns of sex partner selection, (2) relative risks for gonococcal or chlamydial infection associated with each mixing pattern, and (3) selected links and potential and actual bridge populations.

METHODS

Mixing matrices were computed based on characteristics of the study participants and their partners. Risk of infection was determined in study participants with various types of partners, and odds ratios were used to estimate relative risk of infection for discordant vs concordant partnerships.

RESULTS

Partnerships discordant in terms of race/ethnicity, age, education, and number of partners were associated with significant risk for gonorrhea and chlamydial infection. In low-prevalence subpopulations, within-subpopulation mixing was associated with chlamydial infection, and direct links with high-prevalence subpopulations were associated with gonorrhea.

CONCLUSIONS

Mixing patterns influence the risk of specific infections, and they should be included in risk assessments for individuals and in the design of screening, health education, and partner notification strategies for populations.

Prevention agenda for genital herpes

Few meeting participants envisioned a prevention and control program on the scale or scope of CDC's programs to prevent HIV infection, syphilis, gonorrhea, and chlamydial infection, but all agreed that the virtual absence of public health interventions to prevent genital herpes is no longer appropriate in light of evolving epidemiologic knowledge and other research advances. The ultimate scope of a national genital herpes prevention effort will depend in part on the results of the recommended research agenda, which probably will evolve over the better part of a decade. Numerous other STD prevention partners will also need to contribute to this effort and help to determine the makeup of future programs. Substantial new fiscal resources will be required both to implement the proposed research agenda and, depending on the results, to undertake the prevention efforts indicated by those studies. Competing STD prevention priorities and other national health needs will influence the availability of those resources. The consultants' meeting and the research and program activities summarized above are described in more detail in the full meeting report, which is posted on the Division's web site (www.cdc.gov/nchstp/dstd/dstdp.html) or may be requested directly from the Division. DSTDP is interested in receiving comments and suggestions about herpes prevention.

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.

Medicaid managed care and STD prevention: opportunities and risks

The shift from fee-for-service reimbursement to Medicaid managed care is intended to expand access to the uninsured and simultaneously control costs. Specific attention must be paid to sexually transmitted disease (STD) prevention because the Medicaid population and STD at-risk groups overlap in their demographic descriptions. Costly, long-term sequelae can be avoided by early treatment of many STDs. Specific agreements between Medicaid and public health agencies may encourage managed care organizations to improve service in the areas that have traditionally been the territory of public health.

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.

Risk factors for urethritis in heterosexual men. The role of fellatio and other sexual practices

BACKGROUND

Nonchlamydial nongonococcal urethritis (NGU) is a common sexually transmitted disease (STD) in heterosexual men. Prior studies have suggested that NGU may be acquired by insertive oral sex.

GOAL

To assess the association of oral sex and other sexual practices with nonchlamydial NGU in heterosexual men in order to better understand this syndrome and to guide its prevention and treatment. Risk factors for urethral gonorrhea and chlamydial infection were explored to contrast with NGU.

STUDY DESIGN

A retrospective case-control study was conducted among heterosexual men attending as STD clinic during 1993 and 1994. The study included 4,848 men who were sexually active within the prior 2 months and had urethral specimens obtained for Gram's stain, culture for Neisseria gonorrhoeae, and culture for Chlamydia trachomatis.

RESULTS

Insertive oral sex was not shown to be an independent risk factor for NGU. Independent predictors of nonchlamydial NGU by multivariate analysis included African-American race (odds ratio [OR] 3.71, 95% confidence interval [95% CI] 3.06 to 4.50) and having > or = two sex partners in the prior 2 months (OR 1.45, 95% CI 1.20 to 1.75). History of using condoms "always" was negatively associated with NGU (OR 0.59, 95% CI 0.43 to 0.79), gonorrhea (OR 0.31, 95% CI 0.17 to 0.56), and chlamydial infection (OR 0.67, 95% CI 0.44 to 1.03).

CONCLUSIONS

This study supports the sexually transmitted nature of nonchlamydial NGU but did not confirm an association with oral sex. However, the analysis was compromised by the rarity of insertive oral sex as patients' only sexual exposure. Consistent condom use protects against all causes of sexually acquired urethritis.

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.

Clinical presentation and natural course of anogenital warts

The natural history of human papillomavirus (HPV) genital tract lesions is complex, partly because infection can appear in several forms and often follows a fluctuating course. The primary mode of transmission of genital strains of HPV is through sexual contact. Most clinically apparent genital warts are caused by HPV type 6 or 11. The main manifestations of anogenital warts are cauliflower-like condylomata acuminata that usually involve moist surfaces; keratotic and smooth papular warts, usually on dry surfaces; and subclinical "flat" warts, which can be found on any mucosal or cutaneous surface. Latent infections that can be detected only by the presence of HPV DNA, with neither macroscopic nor histologic abnormality, are probably the most common form of anogenital HPV infection, regardless of HPV type. Most untreated genital tract lesions eventually resolve spontaneously, but it is likely that latent or subclinical infection persists indefinitely. The natural history of anogenital HPV infection is likely influenced by the cell-mediated immune system.

Sexually transmitted diseases in men who have sex with men. Acquisition of gonorrhea and nongonococcal urethritis by fellatio and implications for STD/HIV prevention

BACKGROUND AND OBJECTIVES

Despite trends toward safer sex practices in homosexually active men, some such people remain at high risk for acquiring sexually transmitted diseases (STD). This study was designed to assess behavioral and demographic determinants of STD acquisition in men who have sex with men (MSM), to guide prevention interventions.

STUDY DESIGN

A cross-sectional medical record review was undertaken of MSM who attended an urban STD clinic from January, 1993 through December, 1994. Gonorrhea, chlamydial infection, Chlamydia-negative nongonococcal urethritis (NGU), and newly documented human immunodeficiency virus (HIV) infection were analyzed in relation to demographic and behavioral variables.

RESULTS

Among 1,253 MSM, 196 (15.6%) had nonchlamydial NGU, 105 (8.4%) had gonorrhea, 31 (2.5%) had chlamydial infection, and 162 (12.9%) had known or newly documented HIV infection. Known HIV infection was an independent predictor of urethral gonorrhea (odds ratio [OR] 2.3, 95% confidence interval [CI95] 1.2-4.8). Oral insertive intercourse was independently associated with urethral gonorrhea (OR 4.4, CI95 1.4-13.4) and nonchlamydial NGU (OR 2.2, CI95 1.3-3.7), and receptive anal intercourse was associated with newly documented HIV infection (OR 2.6, CI95 1.3-4.9). Neither number of sex partners nor condom use was associated with any incident STD outcome, including new HIV infection.

CONCLUSIONS

MSM who attend STD clinics represent a subgroup of homosexually active men who remain at high risk for STDs, including HIV infection. Fellatio, commonly thought to be a "safe" sexual practice, is an independent risk factor for urethral gonorrhea and nonchlamydial NGU. A history of consistent condom use or of few sex partners should not dissuade clinicians from performing screening tests for HIV and other STDs. Repeated STD screening and counseling about safer sex are indicated for many HIV-infected MSM.

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.

Sexual mixing patterns of patients attending sexually transmitted diseases clinics

BACKGROUND

Theorectical studies have highlighted the importance of patterns of choice of sex partner in the transmission and persistence of sexually transmitted diseases (STDs).

GOAL

To describe reported patterns of sexual mixing according to numbers of sex partners in STD clinics.

STUDY DESIGN

Patients attending public health clinics in Seattle, Washington were interviewed about their own and their partners' behaviors.

RESULTS

Throughout, patterns of sexual mixing were weakly assortative. Across activity groups, many respondents believed their partners had no other sexual contacts. Those with three or more partners frequently perceived their partners to have three or more partners as well.

CONCLUSIONS

Assortatively mixing persons of high sexual activity makes the persistence of STDs within a population likely (i.e., they act as a "core group"). Additionally, because mixing is not highly assortative (like with like), a steady trickle of infection from members of the core group will pass to other segments of the population.

Neurologic Manifestations<br />of HIV Infection Without AIDS:Follow-UP of a Cohort<br />of Homosexual and Bisexual Men

To identify neurological abnormalities in HIV infection, 159 HIV-seropositive men without AIDS and 76 seronegative controls underwent standardized general and neurological examinations, lumbar puncture (LP), neuropsychological (NP) assessment, and brain magnetic resonance (MR) imaging. History, physical, and laboratory evaluations were repeated every six months. NP tests (all subjects) and MR imaging (seropositives only) was repeated every 6-12 months; LP (seropositives only) was repeated yearly. Mean follow-up was 24.6 months. Neurological abnormalities, most related to hearing, were seen in 60 (38.2%) of 157 seropositives and 23 (30.3%) of 76 controls at baseline (p = NS). During follow-up, 43 (31.6%) of 136 seropositives had persistent hearing abnormalities compared to 9 (14.1%) of 64 seronegatives (p = 0.008). Seven HIV-seropositives developed peripheral neuropathy; this was more common among those with hearing abnormalities (p = 0.03). HIV-seropositives performed less well on NP tests than controls, but overall performance did not decline. Worsening brain atrophy by MR imaging or cerebrospinal fluid abnormalities are more common in HIV-seropositives than seronegatives and may share a common mechanism with peripheral neuropathy. Further study is needed to determine whether these abnormalities portend more serious neurological disease.

Trends in susceptibility of Neisseria gonorrhoeae to ceftriaxone from 1985 through 1991

The antimicrobial susceptibilities of 16,441 gonococcal isolates from Seattle-King County were determined for ceftriaxone, cefoxitin, penicillin G, and tetracycline. From 1985 to 1989, ceftriaxone, in combination with doxycycline, was increasingly used for treatment of gonorrhea, and by 1989, it was used as therapy for > 80% of cases in Seattle-King County. MICs of ceftriaxone correlated significantly (P < 0.001) with those of the other beta-lactam antibodies included in this study. Geometric mean MICs of penicillin G for isolates that did not produce beta-lactamase increased from 1985 to 1991. The geometric mean MICs of cefoxitin, ceftriaxone, and tetracycline began to decline in 1987 but increased in 1990 and 1991. The percentage of strains with decreased susceptibility to ceftriaxone (MIC, 0.06 to 0.25 microgram/ml) rose from 0.3% in 1985 to 5.3% in 1987 but subsequently declined steadily to 2.6% in 1991, despite increased use of ceftriaxone as routine therapy for gonorrhea. Changes in patterns of antimicrobial susceptibility may be related not only to antimicrobial selection pressures but also to less well understood population shifts among Neisseria gonorrhoeae strains within a community.

Cervical but not urinary excretion of cytomegalovirus is related to sexual activity and contraceptive practices in sexually active women

The relationship between sexual activity and genitourinary excretion of cytomegalovirus (CMV) was evaluated in 1481 women at a sexually transmitted disease (STD) clinic. Among 951 who were CMV-seropositive, 16.6% had CMV isolated, from cervix alone in 9.4%, urine alone in 3.8%, and both sites in 4.2%. Isolation rates were highest in young women (P < .001). Compared with those with only cervical infection, women shedding from both cervix and urine were younger, began sexual activity when younger, had more recent partners, and a higher frequency of CMV-specific IgM, suggesting recent CMV infection. By logistic regression, cervical CMV excretion was associated with concomitant gonococcal infection (P = .008) and was less frequent in those using barrier contraception (P = .036). Isolated urinary excretion of CMV was not associated with sexual activity, concomitant cervical infections, or use of contraception. Cervical CMV infection is related to sexual activity, acquisition of other STDs, or exogenous reinfection, and urinary CMV is not.

Pilot study of azithromycin for treatment of primary and secondary syphilis

Azithromycin has in vitro activity against Treponema pallidum and is effective against experimental syphilis in rabbits. We undertook an open, noncomparative pilot study of oral azithromycin (500 mg once daily for 10 days) to treat 16 patients with primary or secondary syphilis who were seronegative for human immunodeficiency virus. Cure was documented for 11 of 13 patients observed > or = 3 months; three patients were lost to follow-up. The serological response of one patient with secondary syphilis was indeterminate, and one patient with primary syphilis had either relapse or reinfection. Four patients had mild gastrointestinal side effects, and another patient had an episode of nausea and vomiting; all side effects occurred in the first 3 days and resolved spontaneously as treatment continued. Azithromycin shows promise as an alternative agent for treatment of early syphilis; controlled trials and assessment of other dosage regimens are indicated.

Multicenter trial of single-dose azithromycin vs. ceftriaxone in the treatment of uncomplicated gonorrhea. Azithromycin Gonorrhea Study Group

BACKGROUND AND OBJECTIVES

Azithromycin is a new, long-acting azalide antibiotic that is active against Neisseria gonorrhoeae. A single oral dose of 1.0 g is effective against uncomplicated genital infection with Chlamydia trachomatis.

GOAL OF THIS STUDY

To compare the efficacy and tolerance of single-dose treatment of uncomplicated gonorrhea with azithromycin, 2.0 g orally, and ceftriaxone, 250 mg intramuscularly.

STUDY DESIGN

Seven hundred twenty-four men and women with presumptive, uncomplicated gonorrhea were treated with azithromycin 2.0 g orally or ceftriaxone 250 mg intramuscularly in a 2:1 ratio in a multicenter, open, randomized control trial in 10 public sexually transmitted disease clinics in the United States. Patients were followed up in 5 to 9 days and, for a subset of patients, 12 to 18 days after treatment. The main outcome measures were the isolation of N. gonorrhoeae and C. trachomatis and patient-reported side effects.

RESULTS

Among infected patients who returned for follow-up, N. gonorrhoeae was eradicated from all anatomic sites in 370 of 374 (98.9%; 95% confidence interval [95%CI] 97.9%-100%) treated with azithromycin and 171 of 175 (97.7%; 95%CI 95.5%-99.9%) given ceftriaxone. Treatment with either drug was effective in all 73 patients infected with beta-lactamase-producing N. gonorrhoeae. Chlamydial infection was eradicated in all 17 patients given azithromycin who returned and were recultured at follow-up and in two of seven patients given ceftriaxone (P < 0.001). Gastrointestinal side effects occurred in 35.3% (95%CI 30.7%-39.8%) of patients given azithromycin; of those with symptoms, these were moderate in 10.1% and severe in 2.9%.

CONCLUSIONS

Azithromycin 2.0 g and ceftriaxone 250 mg are equally effective in the treatment of uncomplicated gonorrhea. Azithromycin was associated with a relatively high frequency of gastrointestinal side effects and is expensive, but it has the advantages of oral administration and efficacy against concomitant chlamydial infection.

Development of sexually transmitted diseases treatment guidelines, 1993. New methods, recommendations, and research priorities. STD Treatment Guidelines Project Team and Consultants

To develop the 1993 Sexually Transmitted Diseases Treatment Guidelines, experts from the Centers for Disease Control and Prevention reviewed the literature on sexually transmitted disease treatment, assembled tables of evidence, and listed key questions on therapeutic outcome: microbiologic cure, alleviation of symptoms, and prevention of sequelae and transmission. At a meeting with external experts, evidence was systematically assessed and guidelines developed. Quality of evidence for microbiologic cure was generally good for gonorrhea and chlamydia, poor for syphilis, and fair for most other diseases. Evidence on preventing sequelae and transmission was limited. The Guidelines include new recommendations for single-dose oral therapy of gonorrhea (cefixime, ciprofloxacin, and ofloxacin), chlamydia (azithromycin), and chancroid (azithromycin); outpatient therapy of pelvic inflammatory disease (ofloxacin and either clindamycin or metronidazole); and patient-applied therapy of genital warts (podofilox). Syphilis therapy did not change substantially. Several global issues that emerged during the development of the World Health Organization Recommendations for the Management of Sexually Transmitted Diseases also are discussed. This evidence-based approach clarified important treatment issues and the rationale for recommendations, and identified research priorities.

Multicenter, comparative study of cefotaxime and ceftriaxone for treatment of uncomplicated gonorrhea

BACKGROUND AND OBJECTIVES

Cefotaxime is a third-generation cephalosporin that has in vitro activity against Neisseria gonorrhoeae, including beta-lactamase-producing strains. A single 1-g intramuscular dose is effective and is recommended by the Centers for Disease Control and Prevention as an alternative treatment for uncomplicated gonorrhea.

GOAL OF THIS STUDY

This study was conducted to evaluate the efficacy and safety of a lower 500-mg dose of cefotaxime in the treatment of uncomplicated gonococcal infections.

STUDY DESIGN

In a randomized multicenter study, patients who had uncomplicated gonorrhea were treated with 500 mg of cefotaxime or 250 mg of ceftriaxone. Both antibiotics were given intramuscularly. Efficacy and safety were assessed four to seven days following treatment.

RESULTS

Six hundred thirteen patients were enrolled. Bacteriologic eradication rates for anogenital infection were 97.7% of the patients (213/218) in the cefotaxime group and 99.1% of the patients (221/223) in the ceftriaxone group (P = 0.243). Adverse events occurred in 4.2% and 7.5% of patients in the two groups, respectively.

CONCLUSION

Cefotaxime 500 mg appears to be a safe and cost-effective alternative to ceftriaxone 250 mg for the treatment of uncomplicated gonorrhea.

Treatment of uncomplicated gonorrhea with single doses of 200 mg cefixime

BACKGROUND

Single-dose cefixime 400 mg orally is effective in the treatment of uncomplicated gonorrhea. However, lower doses of cefixime have not been studied, and the minimum effective single-dose regimen may risk selecting resistant strains of Neisseria gonorrhoeae. Therefore, we studied the efficacy of a lower dose of cefixime.

OBJECTIVE

To assess the efficacy of 200 mg cefixime in the treatment of uncomplicated gonorrhea.

METHODS

One hundred twenty-five patients (106 men, 19 women) with presumptive gonorrhea were treated with single doses of cefixime 200 mg orally in an open non-comparative study. Follow-up visits were scheduled for four to seven days after treatment.

RESULTS

Genital and rectal gonorrhea were eradicated in 93 (95%, CI95 90.5-99.2%) of 98 patients who were culture-positive at enrollment and returned for follow-up. Treatment was effective in 78 (95%) of 82 men with urethral infection and 15 (94%) of 16 women with anogenital infection. Two of three pharyngeal infections also were eradicated. Persistent infection was not associated with resistance to cefixime, penicillin, or tetracycline.

CONCLUSIONS

Cefixime 200 mg in a single dose has substantial efficacy in the treatment of uncomplicated gonorrhea, enhancing confidence that use of 400 mg cefixime for gonorrhea has a low risk of selecting gonococci with clinically significant antibiotic resistance. However, the 200 mg dose should not be used for routine treatment.

Multicenter trial of fleroxacin versus ceftriaxone in the treatment of uncomplicated gonorrhea

In a multicenter, randomized, open, comparative trial, patients with uncomplicated gonorrhea were treated with 400 mg of oral fleroxacin or 250 mg of intramuscular ceftriaxone. A total of 458 men and 447 women were enrolled. Of these, 312 men (68%) and 245 women (55%) were evaluable for efficacy. The treatment groups were demographically similar. Among evaluable men, fleroxacin eradicated 154 of 155 (99%; 95% confidence interval [CI]: 98.1-100%) urethral and 2 of 2 pharyngeal infections, while ceftriaxone eradicated 156 of 156 (95% CI: 99.4-100%) urethral and 5 of 5 pharyngeal infections. Among evaluable women, fleroxacin eradicated 127 of 128 (99%; 95% CI: 97.7-100%) cervical, 20 of 20 anorectal, 16 of 16 urethral, and 7 of 7 pharyngeal infections, while ceftriaxone eradicated 108 of 108 (95% CI: 99.1-100%) cervical, 24 of 24 anorectal, 25 of 25 urethral, and 9 of 9 pharyngeal infections. Adverse events were reported by 68 (16%) of 426 subjects in the fleroxacin group and 20 (5%) of 380 in the ceftriaxone group (p < 0.0001). The most common adverse events reported by the patients who received fleroxacin were nausea (5%), headache (3%), and vaginitis (3%). One patient had severe vomiting, 19 participants had adverse reactions classified as moderate, and 48 patients had mild adverse reactions. Fleroxacin was highly effective in the treatment of uncomplicated gonorrhea and represents an oral alternative to ceftriaxone. Adverse events were more common with fleroxacin than with ceftriaxone.

Evaluation of new anti-infective drugs for the treatment of vaginal infections. Infectious Diseases Society of America and the Food and Drug Administration

The three major vaginal infections are yeast vulvovaginitis, Trichomonas vaginalis vaginitis, and bacterial vaginosis. In terms of signs and symptoms, these disorders overlap substantially with one another and with other infections. Therefore, the diagnosis of candidiasis and trichomoniasis requires isolation of the responsible pathogen. For the diagnosis of bacterial vaginosis, all other potential causes of vaginal infection must be excluded and specified laboratory criteria must be met. Clinical trials must be carefully designed to control for coexisting pathogens, for potential efficacy of treatment against more than one microbe, and for variable end points used to define clinical response. Prospective, randomized, double-blind, active-control comparative studies are preferred. Follow-up evaluations 5-7 days and 4-6 weeks after the completion of therapy are required for the assessment of outcome. Laboratory studies of vaginal fluid (culture and/or microscopic examination) are paramount in the final appraisal of outcome.

Evaluation of new anti-infective drugs for the treatment of sexually transmitted chlamydial infections and related clinical syndromes. Infectious Diseases Society of America and the Food and Drug Administration

This guideline addresses clinical trials of new antimicrobial agents in the treatment of uncomplicated genital infections caused by Chlamydia trachomatis and of syndromes resembling chlamydial infections. The most common clinical manifestations of chlamydial infection are urethritis in men and mucopurulent cervicitis in women. However, many chlamydial infections are not associated with inflammatory symptoms or signs. Culture is the diagnostic standard for defining the presence of C. trachomatis, although nonculture tests may be used in screening patients for enrollment in clinical trials. Susceptibility testing for C. trachomatis is laborious and difficult to standardize; only a few clinical isolates need to be tested in vitro. Prospective, randomized, double-blind, active-control comparative studies are recommended. Eradication of C. trachomatis defines both microbiological success and overall cure for chlamydial infection, but clinical and nonmicrobiological laboratory criteria are paramount in assessing the therapeutic response in nonchlamydial urethritis or cervicitis.

Evaluation of new anti-infective drugs for the treatment of syphilis. Infectious Diseases Society of America and the Food and Drug Administration

Syphilis is caused by Treponema pallidum, a spirochetal bacterium pathogenic only for humans. The clinical course of disease is divided into three stages interspersed by periods of latency. Penicillin remains the treatment of choice for all stages of infection; tetracycline or erythromycin may be used as therapeutic alternatives in defined circumstances. Patients enrolled in clinical trials should be evaluated clinically, microscopically, and serologically for the presence of the spirochete. All participants, after undergoing counseling and giving informed consent, should be tested for infection with human immunodeficiency virus. Specific criteria exist for diagnosis of syphilis and response to therapy. It may be desirable to perform a small, uncontrolled, open trial of a new anti-infective drug for the collection of preliminary evidence of efficacy. A larger-scale, randomized, active-control comparative clinical trial is necessary to prove efficacy.

Evaluation of new anti-infective drugs for the treatment of uncomplicated gonorrhea in adults and adolescents. Infectious Diseases Society of America and the Food and Drug Administration

Gonorrhea is among the most common sexually transmitted diseases. Treatment for uncomplicated gonorrhea should be efficacious in > or = 95% of cases. Because patients with gonococcal infections often have other sexually transmitted diseases concurrently, individuals enrolled in clinical trials of therapy for gonorrhea should also be evaluated for infection with Chlamydia trachomatis and for syphilis. Testing for other pathogens should be considered in light of the clinical presentation. The presence of gonococcal infection is defined by a positive culture of a specimen obtained from an appropriate mucosal site. Patients enrolled in clinical trials should be otherwise-healthy adults who agree to return for follow-up assessment. These patients should be stratified by gender and anatomic site of infection. The preferred study design is a prospective, randomized, double-blind, active-control comparison. In some circumstances, however, historical controls may suffice. The study drug must have an efficacy rate of > or = 95% in genital and rectal infections. Microbiological eradication, demonstrated by negative cultures of samples from all potentially infected mucosal sites at follow-up, is the sole determinant of efficacy.