Male circumcision and women's risk of incident chlamydial, gonococcal, and trichomonal infections

BACKGROUND: Male circumcision (MC) decreases the risk of human immunodeficiency virus (HIV) acquisition in men. We explored associations between MC of the primary sex partner and women's risk of acquisition of chlamydial (Ct), gonococcal (GC), or trichomonal (Tv) infections. METHODS: We analyzed data from a prospective study on hormonal contraception and incident human immunodeficiency virus/sexually transmitted infection (STI) among women from Uganda, Zimbabwe, and Thailand. At enrollment and each follow-up visit, we collected endocervical swabs for polymerase chain reaction identification of Ct and GC; Tv was diagnosed by wet mount. Using Cox proportional hazards models, we compared time to STI acquisition for women according to their partner's MC status. RESULTS: Among 5925 women (2180 from Uganda, 2228 from Zimbabwe, and 1517 from Thailand), 18.6% reported a circumcised primary partner at baseline, 70.8% reported an uncircumcised partner, and 9.7% did not know their partner's circumcision status. During follow-up, 408, 305, and 362 participants had a first incident Ct, GC, or Tv infection, respectively. In multivariate analysis, after controlling for contraceptive method, age, age at coital debut, and country, the adjusted hazard ratio (HR) comparing women with circumcised partners with those with uncircumcised partners for Ct was 1.25 [95% confidence interval (CI) 0.96-1.63]; for GC, adjusted HR 0.99 (95% CI 0.74-1.31); for Tv, adjusted HR 1.05 (95% CI 0.80-1.36), and for the 3 STIs combined, adjusted HR 1.02 (95% CI 0.85-1.21). CONCLUSIONS: MC was not associated with women's risk of acquisition of Ct, GC, or Tv infection in this cohort.     

Bacterial vaginosis (BV) and the risk of incident gonococcal or chlamydial genital infection in a predominantly black population

OBJECTIVE: The objective of this study was to assess in prospective data whether bacterial vaginosis (BV) is associated with gonococcal/chlamydial cervicitis. STUDY: A total of 1179 women at high risk for sexually transmitted infections was followed for a median of 3 years. Every 6 to 12 months, vaginal swabs were obtained for Gram stain, culture of microflora, and Neisseria gonorrhoeae and Chlamydia trachomatis. A Gram stain score of 7 to 10 based on the Nugent criteria categorized BV. RESULTS: Baseline BV was associated with concurrent gonococcal/chlamydial infection (adjusted odds ratio, 2.83; 95% confidence interval [CI], 1.81-4.42). However, the association between BV and subsequent, incident gonococcal/chlamydial genital infection was not significant (adjusted relative risk [RR], 1.52; 95% CI, 0.74-3.13). Dense growth of pigmented, anaerobic Gram-negative rods (adjusted RR, 1.93; 95% CI, 0.97-3.83) appeared to elevate the risk for newly acquired gonococcal/chlamydial genital infection. CONCLUSIONS: BV was common among a predominantly black group of women with concurrent gonococcal/chlamydial infection but did not elevate the risk for incident infection.     

Relationship of hormonal contraception and cervical ectopy as measured by computerized planimetry to chlamydial infection in adolescents

BACKGROUND: Adolescents are at increased risk for chlamydial infection and its sequelae. Hormonal contraception and cervical ectopy were previously suggested risk factors for chlamydia. GOAL: To determine if chlamydia is more prevalent in female participants with greater ectopy and in hormonal contraceptive users. STUDY DESIGN: Ninety-seven adolescent females aged 11 to 20 years were recruited from two Baltimore inner-city clinics. After administering a reproductive history questionnaire, endocervical specimens were tested for Chlamydia trachomatis by polymerase chain reaction. After acetic acid application to the cervix, cervical photographs were taken, the area of ectopy was quantified by computerized planimetry, and ectopy was categorized as none (0mm2), mild (< 22mm2), and moderate (> 22mm2). The likelihood of chlamydia by ectopy and type of hormonal contraceptive use was determined by logistic regression adjusted for age and sexual partners. RESULTS: The odds of chlamydial infection was similar in persons with mild ectopy compared with no ectopy (adjusted odds ratio [OR], 0.76; 95% CI, 0.14-4.03), and in persons with moderate ectopy compared with no ectopy (adjusted OR, 1.94; 95% CI, 0.40-9.39). The likelihood of chlamydia was higher in depot-medroxyprogesterone acetate users compared with nonhormone users (adjusted OR, 5.44; 95% CI, 1.25-23.6). Oral contraceptive users did not have an increased likelihood of chlamydia (adjusted OR, 0.92; 95% CI, 0.10-8.78). CONCLUSION: Using a new, reliable, and standardized technique to quantify cervical ectopy, the authors did not find an elevated prevalence of chlamydial infection in adolescents with cervical ectopy. Depot-medroxyprogesterone acetate use may increase the risk of chlamydial infection compared with combined estrogen-progestin oral contraceptives.     

宫颈拭子混合标本PCR法在检测淋球菌和衣原体感染中的应用

背景：多聚酶链反应在衣原体和淋球菌感染的检测中，具有高敏感性和特异性的特点，但价格相对比较昂贵，在检测大宗筛查标本时较为费力；目的：确定混合标本法在对宫颈拭子标本衣原体和淋球菌检测中的可用性。方法：对人工流产妇女宫颈标本采用混合标本PCR法检测衣原体和淋球菌。结果：在2020份宫颈拭子标本中，衣原体检出率4.8%，淋球菌检出率为0.4%，与单个标本检测相比，混合标本法可节约经费62%，且明显减少了工作量。结论：在妇女衣原体和淋球菌筛查中，混合标本PCR法不仅可用于尿液标本，亦可用于宫颈拭子标本。     

Risk factors for bacterial vaginosis incidence in young adult Thai women

OBJECTIVE: To determine risk factors for incident bacterial vaginosis (BV) in young Thai women. STUDY DESIGN: Prospective data from a cohort of 1522 women aged 18 to 35 years, who were enrolled in a study of hormonal contraception and HIV acquisition, were used to evaluate potential risk factors for BV, as diagnosed by Amsel criteria. RESULTS: The median prevalence of BV from 3 to 24 months of follow-up visits was 2.5%. The BV incidence was 10.0 per 100-woman years. Statistically significant factors in multivariable analysis were sex during menstruation [hazard ratio (HR), 1.80; 95% CI, 1.11-2.92], male partners having sex with other women (HR, 2.3; 95% CI, 1.45-2.98), cigarette smoking (HR, 1.79; 95% CI, 1.08-2.98), and trichomoniasis (HR, 15.68; 95% CI, 4.95-49.68). Intravaginal practices were not associated with incident BV in unadjusted or adjusted analysis. CONCLUSIONS: This study supports the association between sexual behaviors and the incident BV. Failure to detect an association between intravaginal practices and incident BV warrants further studies in high-risk populations or in women with a higher prevalence of intravaginal practices.     

Incidence of uncomplicated genital infections in women using oral contraception or an intrauterine device: a prospective study

Over a period of 2 years, the authors prospectively followed a cohort of 123 women using an intrauterine device (IUD) and 108 women using oral contraception (OC) in one family practice. They found nine new episodes of cervical chlamydial infection in OC users (7/100 woman years (WY] as compared to 1 new episode in IUD users (0.8/100 WY), yielding a relative risk (RR) for OC users of 8.8 (95% confidence interval (CI): 1.3-59.0). During the 24 months of observation, 15% of OC and 2% of IUD users acquired at least one episode of Chlamydia trachomatis infection (P = .01). Bacterial vaginosis occurred more frequently in IUD users (25/100 WY) than in OC users (9/100 WY) (RR = 2.8; 95% CI: 1.5-5.1). During the 24-month period, 50% of women using an IUD had at least one episode of bacterial vaginosis, compared with 20% of the OC users (P = .001). Symptomatic bacterial vaginosis was associated with the use of an IUD (RR for IUD users was 7.7; 95% CI: 2.1-28.4), whereas asymptomatic bacterial vaginosis was associated with sexual promiscuity.     

Predicting Neisseria gonorrhoeae and Chlamydia trachomatis infection using risk scores, physical examination, microscopy, and leukocyte esterase urine dipsticks among asymptomatic women attending a family planning clinic in Kenya.

BACKGROUND: Sexually transmitted infections (STIs) continue to exert a tremendous health burden on women in developing countries. Poor socioeconomic status, inadequate knowledge, lack of diagnostic facilities, and shortages of effective treatment all contribute to the high incidence of STIs. The use of clinical algorithms for the detection and management of STIs has gained widespread acceptance in settings where there are limited resources. Evaluation of these algorithms have been few, especially in women who are not recognized as members of high-risk groups. OBJECTIVES: To develop a simple scoring system based on historical and demographic data, physical findings, microscopy, and leukocyte esterase (LE) urine dipsticks to predict cervical gonococcal and chlamydial infection among asymptomatic women. METHODS: One thousand and forty-eight women attending an urban family planning clinic in Nairobi were randomly selected to participate. After the identification of factors that were associated with infection, we assigned one point each for: age 25 or younger, single status, two or more sex partners in the past year, cervical discharge, cervical swab leukocytes, and a positive LE urine dipstick. Identification of any one of these six factors gave a sensitivity of 85% and a specificity of 30% for the detection of cervical infections. A positive LE urine dipstick had a sensitivity of 63 % and a specificity of 47% when used alone and did not contribute to the identification of infection if a physical examination was performed. The application of existing clinical algorithms to this population performed poorly. CONCLUSIONS: The use of risk scores, physical examination, microscopy, and the urine LE dipstick, used alone or in combination, as predictors of gonococcal or chlamydial cervical infection was of limited utility in low-risk, asymptomatic women. Accurate diagnostic testing is necessary to optimize treatment.     

Screening women in jails for chlamydial and gonococcal infection using urine tests: feasibility, acceptability, prevalence, and treatment rates

BACKGROUND: Women entering jails are at high risk for sexually transmitted diseases; however, screening for chlamydial and gonococcal infection is not routinely performed in most jails. New urine tests have made it easier to screen for these infections in nonclinical settings. GOAL: The feasibility and acceptability of urine-based screening for women entering jails and the prevalence of and treatment rates for chlamydial and gonococcal infections were determined. STUDY DESIGN: Women entering jails in Chicago, Illinois; Birmingham, Alabama; and Baltimore, Maryland, who signed consent forms were tested for chlamydial and gonococcal infection by means of the urine ligase chain reaction assay. Those testing positive were treated in jail; health department staff members attempted to contact those already released. RESULTS: Most women who were approached agreed to be tested (range, 87-98%, depending on city), and most of these women provided a specimen (range, 92-100%). Among 5364 women aged 16 to 75 years who were tested, the prevalence of chlamydial and gonococcal infections was high, especially among those <25 years of age (range, 15.3-21.5% for chlamydial infection and 8.2-9.2% for gonorrhea, depending on city). The majority of women testing positive were treated in jail or outside of jail (61-85%). CONCLUSIONS: Screening women in jails for chlamydial and gonococcal infection with urine tests is feasible, is acceptable to most women, and leads to detection and treatment of many infections. Routine screening should reduce medical complications in this population and should prevent transmission in the community, given that many women are soon released.     

男性性工作者尿液筛查沙眼衣原体和淋球菌及危险因素分析

目的:了解男性性工作者沙眼衣原体和淋球菌感染情况,为预防干预提供依据。方法:对男性性工作者采取知情同意进行问卷调查,取尿液进行生殖道沙眼衣原体及淋球菌检测。结果:95例男性性工作者,生殖道沙眼衣原体、淋球菌感染阳性率分别是12.6%、8.4%;两者混合感染2.1%。同性服务时间≤12个月、曾服兴奋剂、性交选择浴池和有固定异性性伴是其危险因素。结论:根据本研究结果有必要对男性性工作者的沙眼衣原体和淋球菌感染进行监测。     

Validity of the vaginal discharge algorithm among pregnant and non-pregnant women in Nairobi, Kenya

OBJECTIVE: To evaluate the validity of different algorithms for the diagnosis of gonococcal and chlamydial infections among pregnant and non-pregnant women consulting health services for vaginal discharge in Nairobi, Kenya. METHODS: Cross sectional study among 621 women with complaints of vaginal discharge in three city council clinics between April and August 1997. Women were interviewed and examined for symptoms and signs of sexually transmitted infections (STIs). Specimens were obtained for laboratory diagnosis of genital infections, HIV, and syphilis. The data were used to evaluate the Kenyan flow chart as well as several other generated algorithms. RESULTS: The mean age was 24 years and 334 (54%) were pregnant. The overall prevalence rates were: 50% candidiasis, 23% trichomoniasis, 9% bacterial vaginosis, 7% gonorrhoea, 9% chlamydia, 7% syphilis, and 22% HIV. In non-pregnant women, gonococcal and chlamydial infection was significantly associated with (1) demographic and behavioural risk markers such as being single, younger than 20 years, multiple sex partners in the previous 3 months; (2) symptom fever; and (3) signs including presence of yellow or bloody vaginal discharge, cervical mucopus, cervical erythema, and friability. Among pregnant women only young age, dysuria, and fever were significantly associated with cervical infection. However, none of these variables was either sensitive or specific enough for the diagnosis of cervical infection. Several algorithms were generated and applied to the study data. The algorithm including risk markers performed slightly better than the current Kenyan algorithm. CONCLUSION: STIs form a major problem in the Nairobi area and should be addressed accordingly. None of the tested algorithms for the treatment of vaginal discharge would constitute a marked improvement of the existing flow chart. Hence, better detection tools for the specific aetiology of vaginal discharge are urgently needed.     

A prospective study of risk factors for bacterial vaginosis in HIV-1-seronegative African women

BACKGROUND: Bacterial vaginosis (BV) is common and has been associated with increased HIV-1 susceptibility. The objective of this study was to identify risk factors for BV in African women at high risk for acquiring HIV-1. METHODS: We conducted a prospective study among 151 HIV-1-seronegative Kenyan female sex workers. Nonpregnant women were eligible if they did not have symptoms of abnormal vaginal itching or discharge at the time of enrollment. At monthly follow-up, a vaginal examination and laboratory testing for genital tract infections were performed. Multivariate Andersen-Gill proportional hazards analysis was used to identify correlates of BV. RESULTS: Participants completed a median of 378 (interquartile range 350-412) days of follow-up. Compared with women reporting no vaginal washing, those who reported vaginal washing 1 to 14 [adjusted hazard ratio (aHR) 1.29, 95% confidence interval (CI) 0.88-1.89], 15 to 28 (aHR 1.60, 95% CI 0.98-2.61), and >28 times/wk (aHR 2.39, 95% CI 1.35-4.23) were at increased risk of BV. Higher BV incidence was also associated with the use of cloth for intravaginal cleansing (aHR 1.48, 95% CI 1.06-2.08) and with recent unprotected intercourse (aHR 1.75, 95% CI 1.47-2.08). Women using depot medroxyprogesterone acetate contraception were at lower risk for BV (aHR 0.59, 95% CI 0.48-0.73). CONCLUSIONS: Vaginal washing and unprotected intercourse were associated with increased risk of BV. These findings could help to inform the development of novel vaginal health approaches for HIV-1 risk reduction in women.     

Identifying cervical infection among pregnant women in Nairobi, Kenya: limitations of risk assessment and symptom-based approaches.

OBJECTIVES: To examine characteristics of pregnant women associated with cervical infection, and to evaluate the accuracy of symptom-based and risk assessment systems which have been developed for identifying cervical infection in antenatal women. METHODS: Interviews were conducted and physical examinations performed on 291 consecutive antenatal clinic attenders in nairobi, Kenya. Vaginal, cervical, urine and blood specimens were also obtained for analysis. RESULTS: The following disease prevalences were observed: candidiasis 26.2%; trichomoniasis 19.9%; bacterial vaginosis 20.6%; any vaginal infection 53.8%; chlamydial cervicitis (CT) 8.8%; gonococcal cervicitis (GC) 2.4%; any cervical infection 10.8%. The only statistically significant association with GC and/or CT cervical infection was the presence of cervical friability (OR = 2.1, P = 0.05). There were trends towards associations with the presence of endocervical mucopus (OR = 2.6, P = 0.06), reporting a new sex partner in the past 3 months (OR = 2.2, P = 0.16) and reporting that a sex partner had an STD-related symptom (OR = 4.4, P = 0.13). There were no associations with other demographic, behavioural or medical characteristics. Risk scores previously developed for detecting GC/CT cervicitis in developing country antenatal populations generally performed poorly. CONCLUSIONS: The prevalences of vaginal and cervical infection observed were extremely high among these "low risk" women. Owing probably to high levels of vaginal infection and to behavioural characteristics of this urban population, factors which elsewhere have been associated with cervical infection were not found to be so in this setting. Further work on symptom-based approaches and risk assessment for STD case detection in pregnant women is required before STD management recommendations can be generalised.     

Epidemiology of gonococcal and chlamydial infections in Harrow and Brent.

OBJECTIVE: To describe the epidemiology and associated clinical features of gonorrhoea and chlamydial infection and to develop a profile of sexually transmitted diseases (STDs) in an outer London health district. DESIGN: Hospital-based retrospective study. SETTING: Genitourinary medicine clinic, Northwick Park Hospital, Harrow and Brent Health Authority. SUBJECTS: 70 male and female individuals with gonorrhoea and 129 with chlamydial infection, diagnosed consecutively over 28 months in 1992-94. RESULTS: More men than women had gonorrhoea (43 versus 27) but more women than men had chlamydial infection (84 versus 45), p < 0.001. There was a clear tendency for cases with either infection to locate along major road and rail transport routes. Foci of gonococcal infection were concentrated mainly in the densely populated areas, whereas chlamydial cases were more evenly spread. There was no significant effect of gender or type of STD on the odds ratio for residence in Harrow, single marital status or attendance for test of cure. However, the odds ratios for women having sexual intercourse with a regular partner only or previous STD were 5 (95% CI 2.4 to 10.2), p < 0.001 and 0.3 (95% CI 0.18 to 0.69), p = 0.002 times the odds for men, respectively. The odds ratios for patients with gonococcal infection being employed or having sex with a regular partner only were 0.5 (95% CI 0.27 to 0.98), p = 0.04 and 0.30 (95% CI 0.15 to 0.60), p < 0.001 times the odds for patients with chlamydial infection, respectively. Of the women with gonorrhoea and previous pregnancy, 68% gave a history of abortion compared with 44% of those with chlamydial infection (p = 0.03). CONCLUSION: The identification of foci gonococcal and chlamydial infection and apparent location of these infections along the major transport routes in our health district require further study. That chlamydial infection, unlike gonorrhoea, is evenly distributed irrespective of population concentration and deprivation, suggests urgent need for a comprehensive local effort to control both STDs.     

阴道镜直视检查在子宫颈上皮内瘤样病变切除手术中的临床意义

目的:本文研究了在子宫颈上皮内瘤样病变切除手术中应用阴道镜直视检查对患者治疗的临床意义。方法:对我院2009年2月至2010年7月期间进行切除治疗的254例子宫颈上皮内瘤样病变患者的临床资料进行了回顾性分析。结果:在子宫颈上皮内瘤样病变切除手术中应用阴道镜直视能够显著降低切除样本的平均高度和直径。患者平均随访时间为(29.2±3.1)月。39例患者最终确认为治疗无效。采用阴道镜直视切除手术的患者相对于手术中不采用阴道镜的患者,其治疗失败风险并无显著差异(HR:0.49;95%CI 0.21~2.33,P=0.468),而相对于阴道镜检查后立即进行切除手术的患者也无显著差异(HR:0.92;95%CI 0.57~1.68,P=0.846)。对治疗失败风险有显著影响的因素是清晰边界的确定(HR:0.35;95%CI 0.20~0.73,P=0.003)和手术切除直径(HR:2.56;95%CI 0.98~5.89,P=0.068)。结论:应用阴道镜直视于子宫颈上皮内瘤样病变切除手术中能够显著降低切除样本的尺寸,但不会导致治疗失败风险的显著变化。     

Treatment of chlamydial infections of the cervix during pregnancy

Chlamydia trachomatis infections in pregnancy are associated with a high rate of transmission to the newborn and may be associated with poor obstetrical outcome including low birth weight, premature delivery, stillbirth and neonatal death. This prospective study of 99 chlamydia infected women assessed the clinical efficacy of treating chlamydial infections diagnosed at the initial obstetrical visit. Twelve women had concomitant gonococcal and/or urinary tract infections. Seven day regimens of erythromycin 1 gm per day and erythromycin 2 gm per day appear to be equally effective (95.1% and 92.3% respectively) in the treatment of chlamydial infections in pregnancy. Successive therapy did not vary with gestational age when treated. Four of 91 erythromycin treated women discontinued therapy due to gastrointestinal distress. Eight women received sulfisoxazole 4 gm per day and all responded to therapy. Additional controlled studies are needed to determine the most efficacious treatment for chlamydial infections in pregnancy.     

Low prevalence of cervical infections in women with vaginal discharge in west Africa: implications for syndromic management

OBJECTIVES: To measure prevalence and risk factors for cervical infections among a large sample of women consulting for vaginal discharge in west Africa and to evaluate its syndromic management through a two visit algorithm. METHODS: In 11 health centres in Bénin, Burkina Faso, Ghana, Guinée, and Mali 726 women who presented with a vaginal discharge without abdominal pain and who denied being a sex worker (SW) were enrolled. Cervical samples were tested for the detection of Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) with polymerase chain reaction (PCR) assays. All participants were treated with single dose (2 g) metronidazole and clotrimazole cream for 3 days. They were randomised to be told either to come back on day 7 only if there was no improvement in the discharge (group A), or to come back on day 7 regardless of response to treatment (group B). RESULTS: Overall, the prevalence of NG and CT was only 1.9% (14/726) and 3.2% (23/726) respectively. Risk factors previously recommended by the WHO were not associated with the presence of cervical infection, with the exception of the number of sex partners in the past 3 months. When taken together, these risk factors had a positive predictive value of only 6.4% to identify cervical infections. Prevalence of cervical infection was not higher in women who came back on day 7, regardless of the strategy used. Prevalence of NG/CT was lower in Ghana and Bénin (5/280, 1.8%), where comprehensive interventions for SW have been ongoing for years, than in the three other countries (27/446, 6.1%, p = 0.01). CONCLUSIONS: NG and CT infections are uncommon in west African women who consult for vaginal discharge and who are not SW. Syndromic management of vaginal discharge should focus on the proper management of vaginitis. The control of gonococcal and chlamydial infection should be redesigned around interventions focusing on sex workers.     

Epidemiology of anorectal chlamydial and gonococcal infections among men having sex with men in Seattle: utilizing serovar and auxotype strain typing

BACKGROUND: Bacterial sexually transmitted diseases (STDs) among men who have sex with men (MSM) have recently increased in Seattle. GOALS: Serovar and auxotype typing of strains was used to assess the epidemiology of anorectal chlamydial and gonococcal infections among MSM attending an STD clinic. STUDY DESIGN: The prevalences of anorectal chlamydial infection and gonorrhea among MSM attending an STD clinic during the period of 1994 to 1996 were compared with prevalences during 1997 to 1999. A retrospective case-control study of MSM attending an STD clinic between 1997 and 1999 was performed. Anorectal chlamydial isolates were characterized by serovar and gonococcal isolates were characterized by serovar and auxotype. Infected MSM were mapped by residence and strain type. RESULTS: Prevalences of anorectal chlamydial and gonococcal infections increased from 4.0% and 6.3%, respectively, during 1994-1996 to 7.6% and 8.7%, respectively, during 1997-1999 (P = 0.004 and P = 0.013 for chlamydial infection and gonorrhea, respectively). Most chlamydial infections were caused by serovars G (47.9%) and D (29.6%), and most gonococcal infections were caused by auxotype/serovar classes Proto/IB-1 (43.3%), Proto/IB-3 (16.5%), and Proto/IB-2 (10.3%). MSM with anorectal chlamydial infection more often had chlamydial urethritis (P = 0.005) and were not white (P = 0.046), in comparison with controls. MSM with anorectal gonorrhea more often had pharyngeal gonorrhea (P < 0.001), had a history of gonorrhea (P = 0.003), and were younger than age 30 years (P = 0.039), in comparison with controls. Residences of MSM with anorectal gonorrhea were clustered in urban areas, whereas those of MSM with anorectal chlamydial infection were more dispersed. CONCLUSION: Prevalences of anorectal chlamydial infection and gonorrhea among MSM in Seattle have increased dramatically over the past 3 years. Serovar and auxotype analyses indicate these increases are not clonal but are due to the spread of unique distributions of strains that differ from those causing urogenital infections in the same community.     

Sexual relationships, risk behaviour, and condom use in the spread of sexually transmitted infections to heterosexual men.

OBJECTIVE: To examine the effect of patient defined non-regular sexual relationships and other risk behaviours on the incidence of sexually transmitted infections in heterosexual men and the role of condom use in the prevention of their spread. DESIGN: A prospective cross sectional study of sexual behaviour reported by a standardised self administered questionnaire in new patients who presented for screening and diagnosis. SETTING: A genitourinary medicine clinic in west London. SUBJECTS: 957 consecutive newly attending heterosexual men who completed a sexual behaviour questionnaire in 1993/94. MAIN OUTCOME MEASURES: Variables relating to sociodemographic status, sexual behaviour, condom use, sexually transmitted infections and testing for HIV infection, stratified by the reporting of non-regular partners. RESULTS: We found that the 65% of men who reported non-regular sexual partners were more likely to be white collar class (d = 7.5%, 95% CI = 1.3, 13.7) and to have had sexual intercourse with non-United Kingdom born women (d = 7.8%, 95% CI = 3.5, 12.2). They also reported coitarche before 16 years of age (d = 13.4%, 95% CI = 8.0, 18.8) and many more sexual partners both in the last year (d = 13.1%, 95% CI = 10.2, 16.0) and in their lifetime (d = 27.9%, 95% CI = 21.6, 34.2). They were significantly more likely to practise anal intercourse (d = 8.7%, 95% CI = 3.3, 14.1), to smoke (d = 16.3%, 95% CI = 9.8, 22.6), to drink alcohol (d = 4.9%, 95% CI = 1.2, 8.6), and to have chlamydial infection (d = 5.7%, 95% CI = 2.2, 9.2), of which 30% was subclinical. Increasing condom use with regular partners correlated with decreasing incidence of urethral infection (gonorrhoeal and/or chlamydial infection) (p < 0.03) and candidal balanitis (p < 0.03) and a greater likelihood of no infection being detected (p = 0.0002). Use of condoms with non-regular partners was much more frequent than with regular partners (d = 21.4%, 95% CI = 16.7, 26.1). However, we found evidence of oral transmission of urethral gonorrhoea and chlamydial infection among men who reported always using condoms. HIV infection was found in only two men (0.2%), both of whom reported intercourse with non-United Kingdom born women. CONCLUSIONS: Heterosexual men who reported non-regular sexual relationships compensated for their increased risk lifestyle by using condoms more frequently and showed only an increased incidence of chlamydial infection. More consistent condom use with regular partners was significantly associated with the absence of sexually transmitted infection. These findings suggest that transmission between regular partners has been underestimated.     

Comparative epidemiology of heterosexual gonococcal and chlamydial networks: implications for transmission patterns

OBJECTIVE: Networks of sex-partner interaction affect differential risk of acquiring sexually transmitted infections. The authors evaluated sociodemographic and behavioral factors that correlated with membership in networks of gonococcal and chlamydial transmission. METHODS: Face-to-face interviews were conducted with 127 patients with gonorrhea and 184 patients with chlamydia (index cases) and their named sex partners, as well as the partners of infected partners. Detailed information was obtained regarding demographic, behavioral, and sexual-history characteristics of all respondents. RESULTS: Gonococcal-network members differed significantly from chlamydial-network members in a number of demographic variables, including race or ethnicity, education, and unemployment status. Gonococcal-network members were more likely to report past history of crack-cocaine use, sexual assault, and having been in jail. Gonococcal-network members also reported having more sex partners during the past 1 year and 3 months than did chlamydial-network members. Gonococcal and chlamydial mixing matrices demonstrated assortativeness for sex partner selection by race or ethnicity but not by sexual activity level, and no systematic differences between networks were noted. Gonococcal networks were larger than chlamydial networks. CONCLUSIONS: Network analyses of gonococcal and chlamydial infections demonstrated significant differences in sociodemographic and behavioral variables. Further research is required to delineate specific predictors of network membership among persons at risk for sexually transmitted infections.     

Clinical utility of measuring white blood cells on vaginal wet mount and endocervical gram stain for the prediction of chlamydial and gonococcal infections

BACKGROUND: White blood cells on endocervical Gram stain and vaginal wet mount are frequently used to predict chlamydial and gonococcal infections. Previous studies provide conflicting evidence for the clinical utility of these tests. GOAL: To evaluate the clinical utility of measuring white blood cells on vaginal wet mount and endocervical Gram stain for the prediction of chlamydial infection and gonorrhea. STUDY DESIGN: Women undergoing pelvic examinations at 10 county health department family planning and sexually transmitted disease clinics were tested for chlamydial infection by ligase chain reaction assay (n = 4550) and for gonorrhea by culture (n = 4402). Vaginal wet mount and endocervical Gram stains were performed in county laboratories at the time of examination. RESULTS: The prevalences of chlamydial infection and gonorrhea were 8.8% and 3.2%, respectively. For detection of chlamydial or gonococcal infection, the likelihood ratio was 2.85 (95% CI, 2.10-3.87) for > 30 white blood cells on vaginal wet mount and 2.91 (95% CI, 2.07-4.09) for > 30 white blood cells on endocervical Gram stain. Similar results were seen for individual diagnoses either of chlamydial infection or of gonorrhea. CONCLUSION: Vaginal wet mount and endocervical Gram stain white blood cells are useful for the presumptive diagnosis of chlamydial infection or gonorrhea only in settings with a relatively high prevalence of infection or when other predictors can increase the likelihood of infection.