International Journal of STD & AIDS

The Caribbean is a multi-ethnic region with many different cultural differences. The majority of the population is of African descent, but there are also other ethnic groups present such as Indians, Chinese, Syrians and Europeans. The Caribbean region is influenced by countries such as the USA, Great Britain, France and Holland. The countries of the Caribbean have a serious problem with HIV infection and AIDS. The epidemiology of HIV infection in this region, is different from most other parts of the world in that the mode of spread does not easily fit into any of the three WHO patterns. This review shows that the infection initially started in the homosexual/bisexual community, but since then, it has moved to the heterosexual population and this form of contact is now the main mode of transmission of the virus. The Governments of the Caribbean countries have realized the extent of the problem and have taken measures to try to control the epidemic.

A prospective STD surveillance system was developed in Italy in 1990. Newly diagnosed cases of sexually transmitted disease (STD) are reported by a network of 45 sentinel STD clinics throughout the country. A total of 10 253 patients were reported between September 1990 and December 1991. The most frequent diagnoses were genital warts (30.8%), non-specific genital infection (male) (12.8%), and non-specific genital infection (female) (11.5%). All patients were asked to undergo an HIV test; 68.4% accepted, of whom 9.3% were seropositive. During the 16–month study period HIV prevalence decreased among IDUs and homo-bisexuals, but increased among non-IDU heterosexuals. These data suggest that STD patients may represent a useful early warning system to detect changes in the epidemic and in the spread of the virus among low-risk heterosexuals. A better counselling programme is needed to improve the acceptance rate of HIV testing among STD patients, and to draw more attention to at-risk sexual behaviours.

The objective was to study the changes in pregnancy HIV prevalence with time. Data were collected from multiple sources to provide a comprehensive record of all HIV seropositive pregnant women identified in the Edinburgh area (Scotland) until December 1992.

There were 177 pregnancies in 108 HIV seropositive identified women. Risk factors were injection drug use (79% of pregnancies) and a known HIV seropositive injection drug-using partner (16%). Prevalence has decreased for Edinburgh City women from 0.5% of all pregnancies in 1986 to 0.1% in 1992; It was higher for induced abortion (0.6%) than for delivery (0.2%). HIV testing in pregnancy has declined. Comparison with unlinked anonymized testing showed that in 1990–1991, 20/22 seropositive women were known. In 1992, only 3 of 10 seropositive pregnancies were identified. The cohort initially infected by exposure to a ‘drug related’ risk factor between 1983 and 1985 may have increasingly finished childbearing, deliberately decided against pregnancy because of HIV status, and declined because of death, illness and emigration from the area, There may not have been major early tertiary heterosexual spread; however, data from 1992 suggest that this could now be impacting on pregnancy prevalence. Local testing policies have not adapted to this possible change.

The first HIV-positive diagnosis among injecting drug users (IDU) in Glasgow was made in 1985. By the end of 1987 prevalence among IDU receiving voluntary attributable tests was 4.8%. Since 1990, an annual cross-sectional survey of HIV prevalence and risk behaviours among 500 current Glasgow IDU has provided a more representative sample. Anonymously-tested saliva samples obtained from respondents revealed prevalence rates of 1.8%, 1.2% and 1.0% in 1990, 1991 and 1992 respectively. Siince 1987 a wide range of measures aimed at reducing HIV-related risk behaviour among IDU has been introduced and maintained in Glasgow. Against this background, there is evidence that IDU in the city have reduced their risk behaviours. The findings reported here suggest that implementing harm-reduction measures when prevalence is low may inhibit the rapid dissemination of HIV.

A retrospective chart review was conducted for one year to determine cervical cytological abnormalities and their distribution among women attending a STD clinic, and to analyse cervical cytologies by STD diagnosis and history or presence of genital warts. Analysis was performed on 790 Pap smears. Most (60%) cytologies were benign. Prevalence of STD among CIN-1 cytologies (78%) was significantly higher (P = 0.02) than among benign cytologies (46%). Commonest cytologies presenting among youngest age groups were CIN-1/condyloma, CIN-1, CIN-2. Women with preceding or concurrent clinical HPV infection had significantly more HPV associated changes on cytology (P < 0.001) than women with no such history. The presentation of cytological abnormalities considered to be precursors to cervical cancer among sexually active young women demonstrates the importance of Pap smear testing of STD clinic populations.

Prevalence of antibody to herpes simplex virus types 1 and 2 was assessed in consecutive serum samples from a total of 3700 women pregnant in 1969, 1983, or 1989 from the same catchment area in Stockholm. There was little change in seroprevalence of antibody to herpes simplex type 1 in the 3 groups, but age-adjusted herpes simplex virus type 2 antibody prevalence was 19, 33, and 33% respectively. Increase in type 2 seropositivity with age was slight and similar in 1969 and 1989, but steep in 1983, indicating a shift in sexual behaviour. However, rising prevalence in women will be mirrored by rising prevalence in their male partners. The increase from 1969 to 1989 will thus partly be due to higher risk of infection per partner, and cannot be taken as direct evidence of increased rate of partner change during this 20-year period.

A cross-sectional study was conducted among displaced pregnant women in Mozambique to determine the prevalence and correlates of HIV infection and syphilis. Between September 1992 and February 1993, 1728 consecutive antenatal attendees of 14 rural clinics in Zambézia were interviewed, examined, and tested for HIV and syphilis antibodies. The seroprevalence of syphilis and HIV were 12.2% and 2.9%, respectively. Reported sexual abuse was frequent (8.4%) but sex for money was uncommon. A positive MHA-TP result was significantly associated with unmarried status, history of past STD, HIV infection, and current genital ulcers, vaginal discharge, or genital warts. Significant correlates of HIV seropositivity included anal intercourse, history of past STD, and syphilis. In summary, displaced pregnant women had a high prevalence of syphilis but a relatively low HIV seroprevalence suggesting recent introduction of HIV infection in this area or slow spread of the epidemic. A syphilils screening and treatment programme is warranted to prevent perinatal transmission and to reduce the incidence of chancres as a cofactor for HIV transmission.

A study was conducted to determine the feasibility of establishing a sentinel human immunodeficiency virus (HIV) surveillance system involving patients with sexually transmitted diseases attending private clinics and a government sexually transmitted disease clinic in Kuala Lumpur, Malaysia. Information on risk behaviours for HIV infection were also collected.

A total of 84 female and 91 male patients were interviewed and tested for HIV infection; 41.7% of the women reported working as prostitutes, other occupations included masseuses, hairdressers, waitresses, salesgirls, receptionists, factory workers, and others. The most common diagnosis was gonorrhoea. Other diagnoses included non-specific genital infection, pelvic inflammatory disease, genital herpes and syphilis. 58.3% of the women had a hundred or more sex partners during the previous month; 99% had 6 or more sex partners.

Only 4.8% of female patients had their male partners using condoms most of the time, 11.9% hardly used condoms at all.

Of the males, 93.3% were heterosexual, while 6.7% were bisexuals, 41.1% had between 6–20 different partners in the previous year. 78.0% of them had prostitutes as their sex partners most of the time. 41.8% had experiences in Thailand and the Philippines. 73.6% never used condoms, while 19.8% only used condoms rarely.

Although all patients were tested negative for HIV antibodies, lot quality assurance sampling methods indicate that the upper limits of prevalences for females and males were 3.5% and 3.3% respectively, at a 5% type I error. The study has shown that it is feasible to carry out a sentinel surveillance programme among STD patients and provided useful baseline data for future comparisons. The high prevalence of risk behaviours among STD patients is alarming and underscores the urgency of multiagency cooperation and aggressive health education and behaviour change programmes to combat the growing problem of HIV infection in the country.

Four cases of male-to-female transsexuals with HIV infection are described, showing that individuals with gender identity disorder are vulnerable to HIV infection through unsafe sexual behaviour and intravenous drug use. The various practical problems associated with carrying out major surgery on this group of individuals are discussed, as well as some of the ethical issues raised by their treatment needs.

A community-derived sample of 392 heroin users and 145 cocaine users were interviewed about their drug use and sexual behaviour, with (optional) collection of saliva specimen for linked anonymous HIV/HBV testing. The heroin sample was stratified (50/50) across current treatment and non-treatment status. For cocaine users 80% were not in current contact with any treatment. Overall levels of sexual activity were several times higher than reported in recent national surveys. Last-year prevalence of heterosexual anal intercourse was 23% and 20% for heroin-using males and females respectively (last-month figures—12% and 10%); and 23% and 15% for cocaine-using males and females respectively (last-month figures—7% and 9%). Two-thirds of subjects rarely or never used condoms during heterosexual anal intercourse. For females, receptive anal intercourse was positively related to a history of sex-for-money activity, high scores of severity of dependence, and injecting as a current route of use.

In this study, a large number of truck drivers were found to be having sex with the prostitutes in rural areas along the highways of India. Some were having sex with men also. HIV/AIDS awareness and condom use was poor among them. Three out of 302 truck drivers were found to be infected with HIV. The truck drivers could play an important role in the spread of the infection in rural India.

The features and clinical course of chronic balanitis in 5 patients are presented. In each case, histological examination of a cutaneous biopsy sample showed pronounced features of human papillomavirus (HPV) infection. In addition, HPV DNA was demonstrated in each biopsy specimen by a polymerase chain reaction and was found to be type 6 by Southern blot hybridization in 4 of the cases.

Although the association of histological features of HPV infection with balanitis does not prove that HPV is causal, the failure to find other causes, the prolonged and distressing symptoms, and the ineffectiveness of topical steroids in improving symptoms, all suggest the importance of HPV infection. While effective treatment needs to be sought and developed, the response of one patient to oral isotretinoin suggests that this agent may be appropriate for a larger trial.