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Members of the Armed Forces may be exposed to drugs, or combinations of drugs, with the potential to prolong the QRS or QT intervals. The effect of this is to increase the likelihood of developing dangerous ventricular tachyarrhythmias, including ventricular tachycardia, torsades de pointes or ventricular fibrillation. Common examples of the pharmacological agents associated include antibiotics, antiemetics and antimalarials. Genetic predisposition, electrolyte disturbance, anaesthesia and trauma may exacerbate the proarrhythmic effect of these medications. Screening of recruits does not detect all those with a genetic predisposition to drug-associated arrhythmias, so vigilance in preventing this iatrogenic disorder and recognising and appropriately managing it when present is important. This article explains the physiological basis of arrhythmogenesis, outlines the clinical features and provides guidance on investigation and management, with particular reference to military patients.

Objective To investigate factors associated with variations in diagnoses of primary, secondary and early latent syphilis in England and Wales. Methods Data were derived from two sources: diagnoses made in genitourinary medicine clinics reported on form KC60, and information collected through National Enhanced Syphilis Surveillance (NESS). Multinomial regression modelling was used for data analysis. Results Between 1999 and 2008, 12 021 NESS reports were received, 54% of KC60 reports. The dominant profile of the epidemic was one of white men who have sex with men aged 35–44, often co-infected with HIV, centred in larger cities. During this period, the proportion of primary cases increased over time, while the proportion of secondary cases fell. Primary cases exceeded secondary cases by 2004. The proportion of early latent cases remained relatively stable over time and tended to be lower than that of primary and secondary infection. Patients who attended because they had symptoms of infection, had been identified through partner notification, were HIV positive, and were UK born were more likely to present with primary or secondary infection than with early latent infection. A higher proportion of early latent cases were seen among patients who were Asian, had contacted sexual partners through saunas, bars and the internet, had untraceable partners, and had acquired infection in Manchester. Conclusions The continuing syphilis epidemic indicates that control has only been partially effective, with ongoing transmission being sustained. Intensive and targeted efforts delivered locally are required to interrupt further transmission.

To examine the epidemiology of HIV among black and minority ethnic (BME) men who have sex with men (MSM) in England and Wales (EW).Ethnicity data from two national HIV/AIDS surveillance systems were reviewed (1997-2002 inclusive), providing information on new HIV diagnoses and those accessing NHS HIV treatment and care services. In addition, undiagnosed HIV prevalence among MSM attending 14 genitourinary medicine (GUM) clinics participating in the Unlinked Anonymous Prevalence Monitoring Programme and having routine syphilis serology was examined by world region of birth.Between 1997 and 2002, 1040 BME MSM were newly diagnosed with HIV in EW, representing 12% of all new diagnoses reported among MSM. Of the 1040 BME MSM, 27% were black Caribbean, 12% black African, 10% black other, 8% Indian/Pakistani/Bangladeshi, and 44% other/mixed. Where reported (n = 395), 58% of BME MSM were probably infected in the United Kingdom. An estimated 7.4% (approximate 95% CI: 4.4% to 12.5%) of BME MSM aged 16-44 in EW were living with diagnosed HIV in 2002 compared with 3.2% (approximate 95% CI: 2.6% to 3.9%) of white MSM (p0.001). Of Caribbean born MSM attending GUM clinics between 1997 and 2002, the proportion with undiagnosed HIV infection was 15.8% (95% CI: 11.7% to 20.8%), while among MSM born in other regions it remained below 6.0%.Between 1997-2002, BME MSM accounted for just over one in 10 new HIV diagnoses among MSM in EW; more than half probably acquired their infection in the United Kingdom. In 2002, the proportion of BME MSM living with diagnosed HIV in EW was significantly higher than white MSM. Undiagnosed HIV prevalence in Caribbean born MSM was high. These data confirm the need to remain alert to the sexual health needs and evolving epidemiology of HIV among BME MSM in EW.

To examine trends in rates of diagnoses of HIV and other sexually transmitted infections (STIs) in men who have sex with men (MSM) in England and Wales between 1997 and 2002.Estimates of the MSM population living in England and Wales, London and the rest of England and Wales were applied to surveillance data, providing rates of diagnoses of HIV and STIs and age group specific rates for HIV and uncomplicated gonorrhoea.Between 1997 and 2002, rates of diagnoses of HIV and acute STIs in MSM increased substantially. Rates in London were higher than elsewhere. Rises in acute STIs were similar throughout England and Wales, except for uncomplicated gonorrhoea and infectious syphilis, with greater increases outside London. Rates of gonorrhoea diagnoses doubled between 1999 and 2001 (661/100,000, 1271/100,000, p0.001) in England and Wales followed by a slight decline to 1210/100,000 (p=0.03) in 2002-primarily the result of a decline in diagnoses among men aged 25-34 (1340/100,000, 1128/100,000, p0.001) and 35-44 (924/100,000, 863/100,000, p=0.03) in London. HIV was the third most common STI diagnosed in MSM in England and Wales and the second in London, with the highest rate (1286/100,000) found among men aged 35-44 in London in 2002.Rates of diagnosis of HIV and other STIs have increased substantially among MSM in England and Wales. Increases show heterogeneity by infection, geography, and age over time. Rates in London were twice those seen elsewhere, with greatest changes over time. The observed changes reflect concomitant increases in high risk behaviour documented in behavioural surveillance survey programmes.

Background: HIV is now well established in the Caribbean, with prevalence in several countries being surpassed only by those of sub-Saharan Africa. Continuing inward migration from the Caribbean and a high incidence of some bacterial STIs among Britain's black Caribbean communities, suggests a considerable potential for HIV spread. Methods: Data from three national HIV/AIDS surveillance systems were reviewed, providing information on new HIV diagnoses, numbers accessing treatment and care services, and HIV prevalence. Results: Between 1997 and 2001, 528 black Caribbean adults were newly diagnosed with HIV; 62 new diagnoses in 1997, rising to 176 in 2001. Probable heterosexual acquisition accounted for 335 (63%) infections (161 (48%) males, 174 females), and sex between men 171 (32%). Infection was acquired both in the Caribbean and in the United Kingdom. Numbers of black Caribbeans accessing treatment and care services more than doubled between 1997 (294) and 2001 (691). In 2001, 528 (76%) black Caribbeans accessing services were London residents. Among the Caribbean born previously undiagnosed heterosexuals, HIV prevalence was 0.7%; among men who have sex with men (MSM) it was 10.4%. Of those born in the Caribbean, 73% of male heterosexuals, 50% of female heterosexuals, and 65% of MSM who were previously undiagnosed left the clinic unaware of their HIV infection. Conclusions: Numbers of black Caribbean adults newly diagnosed and accessing treatment and care services in England, Wales, and Northern Ireland increased between 1997 and 2001. Despite a high prevalence of diagnosed bacterial STIs, prevalence among Caribbean born heterosexuals remains low, but it is high among MSM. Surveillance data highlight the need for targeted HIV prevention among black Caribbeans.

Behavioural surveillance programmes have enabled the description of population patterns of risk behaviours for STI and HIV transmission and aid in the understanding of how epidemics of STI are generated. They have been instrumental in helping to refine public health interventions and inform the targeting of sexual health promotion and disease control strategies. The formalization and coordination of behavioural surveillance in England and Wales could optimise our ability to measure the impact of interventions and health promotion strategies on behaviour. This will be particularly useful for monitoring the progress towards specific disease control targets set in the Department of Health's new Sexual Health and HIV Strategy.

OBJECTIVE--To identify characteristics of people likely to be unaware of their HIV infection before diagnosis of AIDS defining disease. DESIGN--Survey of continuing surveillance of voluntarily reported AIDS cases. SUBJECTS--4127 adults with AIDS diagnosed during 1989-92 and reported to the Public Health Laboratory Service AIDS Centre. SETTING--England and Wales. MAIN OUTCOME MEASURE--Lack of prolonged awareness of infection before diagnosis of AIDS, defined as an interval of nine months or less between first positive test result and diagnosis of AIDS. RESULTS--Of 3556 adults with known dates of first positive HIV test result and AIDS diagnosis, 1742 (49%) had been unaware of their infection for up to nine months before AIDS was diagnosed. Lack of awareness was independently and positively associated with infection through heterosexual contact (odds ratio 4.46, 95% confidence interval 3.15 to 6.33), AIDS reported outside the Thames regions (1.64, 1.38 to 1.96), and being non-white (1.99, 1.51 to 2.61). Women were less likely to be unaware than men (0.50, 0.33 to 0.76), and people diagnosed in 1992 were least likely to be unaware (0.48, 0.39 to 0.60). Those aged 25-49 years at diagnosis were less likely to be unaware than those aged 15-24 years and those aged 50 and over. CONCLUSIONS--People with certain characteristics are more likely than others to be unaware of their HIV infection before AIDS is diagnosed and are therefore less likely to receive prophylaxis. Methods for educating this heterogeneous group need to be investigated.

OBJECTIVE--To evaluate completeness of reporting of cases of AIDS to the Communicable Disease Surveillance Centre (CDSC) between 1982-1991. SETTING--Southside of the Bloomsbury and Islington District Health Authority. DESIGN--Reconciliation exercise with CDSC of cases reported with those known to have received treatment in the district from 1982 to March 1990. Case note review of unreported cases and follow-up at March 1991. MAIN OUTCOME MEASURES--Delayed and non-reporting of cases. RESULTS--Cumulatively 13% (46/351) of patients whose initial AIDS illness was diagnosed in the District remained unreported by March 1991. Non-reporting increased from 9% (2/23) of cases diagnosed prior to 1985 to 28% (26/92) of cases diagnosed between 1989 and 1990. After September 1987 the proportion of patients with a diagnosis of Pneumocystis carinii pneumonia or Kaposi's sarcoma was significantly higher in the reported group than in the non-reported group: 78% (124/158) v 51% (24/49) p < 0.001. Nine of 19 (47%) cases of AIDS transferring their care into the district had not been reported by their previous District Health Authority. CONCLUSIONS--Within the district non-reporting of cases of AIDS has risen over time as the numbers of patients treated has increased. The physician must be aware of the full AIDS case definition for surveillance purposes and the implications of non-reporting for the allocation of special "ring-fenced" resources for AIDS care. Adequate investment in information and reporting systems would seem essential.

Background Current transmission of HIV within the United Kingdom, especially among men who have sex with men, is unacceptably high. Every potential way of reducing transmission should be explored and, if likely to be eVective, introduced as rapidly as possible. However, we must be reasonably sure of the benefits and risks of any new intervention such as post-exposure prophylaxis (PEP). If there were no side effects from the drugs, if the logistical problems of getting treatment soon enough after exposure could be overcome, if it could be shown that no increase in behavioural risks occurred as a result, if there was no risk of an increase in resistance to the drugs in the population, and if, in these money oriented times, the costs were low we could proceed in spite of a lack of convincing evidence about the eYcacy of the intervention. Unfortunately, none of these criteria are fulfilled for PEP for sexual exposure; indeed, there are no data at all on eYcacy. If, in these circumstances, PEP for sexual exposure is implemented half heartedly this will be the worst possible way of proceeding.

Objective: To identify false negative results arising from the use of a commercial kit to detect antibody to HIV-1 and HIV-2 between July 1995 and March 1996. Design: The 56 laboratories in the United Kingdom that were using the assay were asked to retrieve and retest specimens with an alternative assay for HIV-1 and HIV-2. Details of false negative results were obtained and these serum samples further investigated. Subjects: 24 181 patients tested with the assay who were reported as being negative for HIV antibody. An additional 497 patients were confirmed as HIV positive with the assay. Results: Serum samples of 20 973 of the patients were retested, and four patients were found to have had false negative results with the kit; three further patients were found to have had false negative results in the course of other laboratory testing. The seven patients with false negative results with the kit were of diverse risk group and HIV-1 subtype. Four had evidence of recent HIV infection. Conclusion: The commercial kit had a sensitivity of 99.2% (497/501), or less if the additional three patients with false negative results were taken into account. Key messages Dual screening should be considered for patients known to be at increased risk of HIV infection Although assay kits for HIV antibody generally show high sensitivity, false negative results may still arise during routine use and go undetected Tested serum samples should be stored so that they may, if necessary, be checked. Any kit failures should be reported to the Medical Devices Agency or Adverse Incident Centres, as well as to the manufacturer All laboratories should be informed of test kit failures, whether or not they have used the suspect kit

OBJECTIVE--To examine surveillance data for evidence of changing sexual behaviour and continuing transmission of HIV-1 among men who have sex with men. DESIGN--Analytic study of surveillance data on sexually transmitted diseases. SETTING--England and Wales. MAIN OUTCOME MEASURES--Number of cases of rectal gonorrhoea and newly diagnosed HIV infection in homosexual men. RESULTS--New cases of gonorrhoea among men attending genitourinary medicine clinics increased by 7.7% in 1989 and by 4.2% in 1990. Reports of rectal isolates of Neisseria gonorrhoeae also rose and the male to female ratio for patients with rectal gonorrhoea changed from 0.3:1 during 1988-9 to 2.6:1 in 1990-1. Although the overall number of cases of acute hepatitis B fell during 1988-91, 81 and 82 homosexual men were infected in 1990 and 1991 respectively compared with 50 and 42 in 1988 and 1989. 1526 men had HIV-1 infection diagnosed in 1991, the largest number since 1987. Twenty eight of the 97 (29%) men who seroconverted between January 1989 and December 1991 were aged less than 25. The proportion of men aged 15-19 who were found to be infected with HIV-1 at their first test increased from an average of 2.4% up to 1990 to 4.7% in the first nine months of 1991. The prevalence of HIV infection in men under 25 attending genitourinary medicine clinics in London was 17% compared with 7.8% outside London. CONCLUSION--Unsafe sexual behaviour and HIV transmissions have increased among homosexual men after a period of decline. Recent HIV transmissions may disproportionately affect younger men.

Background Since 2001, rates of congenitally transmissible syphilis have increased amongst reproductive age women. Concerns have been raised about the effectiveness of intervention which has been restricted by an absence of national surveillance data. In 2010, a 3-year study was established to provide an evidence-base for control strategies. Aim To explore the epidemiology of congenital syphilis. Methods The surveillance dataset consisted of returns to the British Paediatric Surveillance Unit, diagnoses made in genitourinary medicine clinics (GUMCAD) and laboratory reports. Infants diagnosed with congenital syphilis under the age of 24 months were included (detailed methodology at: http://www.rcpch.ac.uk/). Results Between 1 February 2010 and 1 November /2011, 11 cases (male=9, female=2) of congenital syphilis were confirmed, all reported from England. Most infants (6/10) were born at over 37 weeks: median birth weight was 2910 g (range: 1340 g to 3690 g). Clinical presentation varied from asymptomatic (1) to acute, including severe anaemia, hepatosplenomegaly, rhinitis, oedema, thrombocytopaenia and skeletal damage. Median maternal age at delivery was 19 (range: 17–28). Many of the infants9 mothers were White and came from the UK and Eastern Europe. Where maternal stage of infection was recorded, 4/7 presented with primary and 3/7 with secondary syphilis. One infection diagnosed late in pregnancy was the result of re-infection acquired after effective screening and management in the first trimester. All diagnoses were managed according to BASHH Guidelines. Conclusions Congenital syphilis presents a complex social, clinical and public health problem. Antenatal screening is largely effective in controlling congenital syphilis but delivering effective health care to women who are marginalised in society and at-risk of acquiring congenitally transmissible syphilis represents an emerging challenge.

The transmission of bloodborne viruses to healthcare workers can have serious consequences not only for clinical practice but also, because of the requirements of health and safety legislation, for their employers.1 In spite of guidance and education,2 however, many healthcare workers continue to be exposed to bloodborne viruses from percutaneous, mucocutaneous, or other injuries. An enhanced system of surveillance of occupational exposure to bloodborne viruses was introduced in mid-1997, developing the passive system that was set up after the first reported case (in 1984) in the United Kingdom of HIV seroconversion associated with needlestick injury.3 Since July 1997 occupational health departments have been requested to complete a brief form outlining the circumstances of any work related exposure to potentially infectious material from patients who are known to be positive for HIV antibodies or hepatitis C antibodies, or for hepatitis B surface antigens. For exposures to HIV or hepatitis C virus, the follow up at six weeks includes more information about the incident, baseline testing of both …

While the risk of transmission through oral sex for men who have sex with men (MSM) is low, discrepancies remain between study findings and there is uncertainty about the exact degree of risk.1 Between July 2001 and September 2003, a total of 4150 MSM were newly diagnosed with HIV infection in England, Wales, and Northern Ireland and reported to the Communicable Disease Surveillance Centre in London. Reports for 1359 cases received during this time included the question “Does the patient believe himself to have been …

Editor—Dodds et al began their paper1 with the statement that the incidence of HIV infection among homosexual men in the United Kingdom is increasing despite efforts to reduce high risk behaviour and supported the statement of increasing incidence by referencing a report from the Public Health Laboratory Service.2 This report, which featured national surveillance data on HIV infection acquired through sex between men, does, however, not suggest that the incidence in homosexual men is rising. Rather, together with the more recent update,3 it highlights the number of new diagnoses of HIV infection acquired through sex between men, which have remained fairly constant at around 1500 a year throughout the 1990s. The published erratum clarifies the situation (16 September, p 675), but the statement caused us to re-examine our data to see what we are able to say about recent trends in HIV among homosexual men. Although trends in the diagnosis of HIV relate more closely to the uptake of HIV testing than to the underlying incidence of infection, the fact that there has been little change in the median age or median CD4 lymphocyte count at diagnosis in this group over the past 10 years suggests that new infections have occurred at similar rates to diagnoses, through most of that period at least.4 At best, however, such indicators provide only a broad measure of past incidence, and more sensitive and timely markers of likely changes in HIV incidence may be found in the surveillance of acute sexually transmitted infections and the type of monitoring of high risk sexual behaviour covered in the paper by Dodds et al. Increases in markers of HIV transmission risk may not, however, be directly translated into increased transmission. The annual survey of prevalent diagnosed HIV infections shows that in 1999 67% of homosexual men with diagnosed HIV infection in England, Wales, and Northern Ireland were receiving multiantiretroviral therapy. Widespread use of treatment that is successfully reducing viral load might well offset any increases in risky behaviour. Although measures of the recent incidence of HIV infection are imprecise, there is clear evidence that the numbers of prevalent HIV infections that are diagnosed are increasing,5 and the messages concerning safer sex practice among men who have sex with men need to be further strengthened. The fact that we have no evidence of a decrease in the incidence of HIV infection is a cause for concern at this stage in the epidemic.

EDITOR—We welcome the article by Gibbon et al drawing attention to an increasing problem of tinea capitis caused by Trichopyton tonsurans .1 In seeking to document the increase the authors cite that the Communicable Disease Surveillance Centre has recorded a 25-fold rise in cases of infection with T tonsurans infection since 1995, and a further doubling of incidence was seen within the first half of 1999. We believe that the magnitude of the rise given by these figures is …