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McBride et al ( see page 150 ) evaluate instructional and packaging information for patient-delivered partner therapy (PDPT).1 PDPT, also known as expedited partner therapy (EPT), is the practice of providing medication or a prescription to a patient with a treatable sexually transmitted infection (STI) to deliver to their sex partner(s). The authors aptly point out that for the intervention to work at the consumer level, patients must deliver the medicine and partners must take it. These seemingly simple behaviours rely on very complex concepts such as trust and communication. Those who deliver the PDPT must understand the importance of their task, must be good communicators and must abandon their worries of stigma, fear of disclosure and possible rejection by their partner. They must trust that the procedure is safe and legal. Those who receive must trust both the person who delivers the medication package and the persons who prepared it. Trust may be difficult given that the act of delivery itself may be an admission of infidelity and, therefore, a breach of trust. Despite all these apparent obstacles, population-based studies in the USA and UK found that …

OBJECTIVE: To determine if providing Chlamydia trachomatis infected women with medication to deliver to their sex partner(s) could reduce recurrent chlamydia infections compared with the standard partner referral method. STUDY DESIGN: A observational cohort study of 178 women, 14-39 years old attending a family planning clinic, diagnosed and treated for C trachomatis between October 1993 and December 1994 was conducted (43 received patient delivered partner medication (PDPM) and 135 received partner referral cards). Women were retested before or at their annual visit. RESULTS: The mean time of follow up was 17.7 months (SD 7.7). The PDPM group (n = 43) was similar to partner referral group (n = 135) for age, race, contraceptive method, history of an STD, and follow up time. The annual recurrent infection rate was lower among the PDPM group compared with the partner referral group (11.5% v 25.5%, p < 0.05). After adjusting for age in logistic regression, women in the PDPM group were less likely than women in the partner referral group to have an incident C trachomatis infection (OR 0.37, 95% CI 0.15-0.97, p < 0.05). CONCLUSION: These findings suggest that patient delivered partner medication can protect women from recurrent C trachomatis infection compared with the standard partner referral approach. Prospective studies with larger sample sizes are under way.

Drawing on focus group discussions with adolescent and adult HIV-infected women between the ages of 16 and 45, this study explores the barriers to condom use among women infected with HIV. Although most of the participants were comfortable discussing condoms and sexuality, there was little, if any, negotiation of condom use with their male partners. Most of the participants used condoms inconsistently or not at all. Reasons for nonuse included a lack of trust in the reliability of condoms to protect them, a lack of desire for pregnancy prevention, and the male partner's refusal to use condoms. Women in discordant relationships explained their uninfected partner's refusal to use condoms as denial of the risk of contracting HIV or as a way of expressing their love for the infected partner. Women also had great difficulty in disclosing their HIV status to both family and partners. Prevention efforts to increase condom use among HIV-infected women should target both men and women and focus on negotiation and communication skills.While the correct and consistent use of latex condoms is the most effective way of preventing the transmission of HIV and other sexually transmitted diseases (STDs) among sexually active individuals, many women have difficulties using condoms. Focus group discussions were held with 15 African-American, HIV-infected women aged 16-45 years attending a public, state-run HIV ambulatory care clinic in New Orleans in fall 1994, to explore the barriers they face to using condoms. Most study participants were comfortable discussing condoms and sexuality, but there was little, if any, negotiation of condom use with their male sex partners. Most of the women used condoms either inconsistently or not at all. Reasons for nonuse included a lack of trust in the reliability of condoms to protect them, no desire to prevent pregnancy, and the male partner's refusal to use condoms. Women in HIV-discordant relationships explained their uninfected partner's refusal to use condoms as a denial of the risk of contracting HIV or as a way of expressing their love for the infected partner. Women also had considerable difficulty disclosing their HIV serostatus to family and partners. Prevention efforts to increase condom use among HIV-infected women should target men and women, and focus upon negotiation and communication skills.

The objective of this study was to determine whether pregnancy is associated with an acceleration of human immunodeficiency virus (HIV) disease progression in women who have a pregnancy while HIV infected. A retrospective review of all women aged 15-35 years who attended an HIV outpatient program from January 1989 through August 1995, was undertaken. The 192 women who had a term pregnancy after testing positive for HIV were compared with 164 women who were not pregnant during the same period. The main outcome measures were death, the occurrence of a first acquired immunodeficiency syndrome (AIDS)-defining condition, or a condition indicative of symptomatic HIV. Disease progression was assessed using the Kaplan-Meier method and multivariate proportional hazards models. Compared with nonpregnant women, women with a term pregnancy were significantly more likely to be African-American (88% vs. 78%, p < 0.05), younger than 22 years of age (51 % vs. 11%, p < 0.001), and to have entered the clinic with a higher median CD4 count (519 vs. 433 cells/microl, p < 0.001). After adjusting for entry CD4 count and other factors, pregnancy was not associated with progression to any of the study outcomes. Thus, in women attending a publicly funded clinic, pregnancy does not appear to accelerate the progression of HIV disease.

Background The purpose of this study was to examine the origins of repeat infections with Mg among men. High repeat infection rates have been consistently reported and treatment failure secondary to macrolide resistance is thought to be the primary cause. This study adds to the growing literature by describing the possible origins of repeat Mg infections in among men, primarily African American, attending two public STD clinics in southern cities in the U.S. Methods Men diagnosed with NGU at an STD clinic in New Orleans, Louisiana, and Jackson, Mississippi, were tested for Mg using the GenProbe research-use-only assay Mg+ men underwent a 4–10 week test of cure visit (TOC) following treatment with 1 g azithromycin. Detailed sexual behaviour data were collected at baseline and follow-up via ACASI and genotyping was performed. Results Of 205 men with MG, 135 returned for TOC visit and of those, 34.3% were positive. Of the 46 who were positive at TOC, 19.6% reported sexual re-exposure to a baseline partner, 6.5% reported sexual exposure to a new partner, 6.5% reported sexual exposure to both, and 67.4% denied sexual re-exposure. Men who re-tested positive for Mg at TOC (n = 46) were no more likely that those who tested negative (n = 88) to have had sexual exposure to a baseline partner (31.8% vs. 26.1%, P = 0.55) or exposure to a new partner (21.4% vs. 11.3%, P = 0.22). Genotyping on baseline/TOC positive pairs is being performed and will be used in conjunction with behavioural data to more precisely estimate the treatment failure rate. Conclusion The TOC repeat infection rate among men with Mg is high. Our data are consistent with the published literature corroborating that repeat infections in men treated with azithromycin is usually due to treatment failure rather than re-infection. Research is needed to optimise treatment of Mg infections in men.

Background Trichomonas vaginalis (TV) is the most common non-viral STI and has been linked to premature membrane rupture, preterm birth, and low birth weight in pregnant women. TV has also been shown to increase vaginal shedding of HIV and, thus, may influence HIV sexual and perinatal transmission. Repeat infection rates among HIV+ women are high. We have shown that bacterial vaginosis (BV) is associated with single dose metronidazole (MTZ) treatment failure in HIV+ women. A recent study in Africa has found that nevirapine is also associated with a higher rate of repeat infections. The purpose of this study is to determine if other ART interferes with single dose MTZ treatment of TV. Methods A secondary data analysis was performed on a cohort of HIV+/TV+ women who had been randomised to single (2gm) dose or 7 day (500mg BID) dose MTZ. Follow-up visit, including culture, occurred 6–12 days after treatment completion. Data on sexual exposure was collected. Repeat TV infection rates were compared for women on ART at baseline versus not on ART, controlling for BV and treatment arm. Results Of the 230 women included, 65% were receiving ART: NRTI (95%), NNRTI (31%), PI (58%) and other ART (2%). Those on ART had higher repeat infections than women not on ART [25/150 (16.7%) vs. 6/80 (6.3%), p-value = 0.03]. Controlling for BV status and stratifying by treatment arm, the association was found only in the single-dose arm (p-value = 0.05) and not in the multi-dose arm (p-value = 0.39). Only 5% of the women were sexually re-exposed during follow-up. Conclusions ART in general is associated with a higher TV repeat infection rate following single dose MTZ treatment but not for multi-dose. These data further support the recommendation that single dose MTZ not be used in HIV+ women.

Background Recent clinical trials have reported high repeat infection rates (12%–14%) following 1 g azithromycin. These data suggest that single-dose azithromycin may be inadequate, but high repeat infections rates could also be explained by exposure to an original or new partner or retesting before DNA clearance. The purpose of this study was to examine the origins of repeat CT infections among men. Methods Men diagnosed with Ct by Gen-Probe Aptima Combo 2 at STD clinics in New Orleans, and Jackson, Mississippi were re-tested an average of 6 weeks after treatment with single-dose azithromycin. Detailed sexual behaviour histories were collected at baseline and follow-up via computer-assisted/self-administered interview and MLST genotyping was performed. Results Of 367 men with Ct, 222 returned for a f/u visit [mean of 45 days post-baseline (s.d. 13)] and 14/217 (6.5%) were positive. Of the 14, 36% reported sexual re-exposure to a baseline partner, 14% reported sexual exposure to a new partner, 7% reported sexual exposure to both, and 43% denied sexual re-exposure. Thus far MLST genotyping completed for 3 baseline-f/up positive pairs. Two pairs with the same genotype (E/39) reported sexual re-exposure to a baseline partner and the pair with a new genotype reported sexual exposure to a new partner (D/19 to C/15). Conclusion Early repeat infection rate among men with Ct in this study was lower than recently reported and about half could be explained by sexual re-exposure. Rates in the other two studies may have been inflated by high re-exposure rates or premature testing using NAAT since many of the participants were tested before 3 weeks. Studies that examine repeat infections should consider re-exposure/new exposure and retest when DNA clearance is assured. Our data does not support high treatment failure rates for 1 g azithromycin treatment of Ct.

The goal of this study was to describe contraceptive and sexually transmitted disease STD prevention practices in human immunodeficiency virus HIV infected adult and adolescent women, and to determine if hormonal contraception has unique adverse effects in this population. A retrospective review of 241 HIV-infected women age 15-45 years was performed. The associations between contraceptive methods and selected characteristics were determined by chisquare methods and logistic regression modelling. African American race RR 8.6, 95 CI 3.3, 22.5 , injection drug use history RR 5.0, 95 CI 2.2, 11.2 , age 25 years RR 1.9, 95 CI 1.1, 3.5 and progestin only contraceptive use RR 3.0, 95 CI 1.4, 6.6 were significantly associated with incident STDs. The only potential adverse effect of hormonal contraception noted in this retrospective study was the significant association between STDs and progestin-only contraception. Prospective studies to better delineate the true association between STDs and progestin-only agents after adjustment for behaviour patterns are warranted.

To facilitate access to care for HIV-infected women, a maternal-child program was started at an HIV outpatient clinic in New Orleans. The program consisted of free child care and transportation, separate waiting and examination rooms, female care providers, merged visits for mother and child, and on-site colposcopy services. This study evaluates the efficacy of the program on improving attendance at the clinic by follow-up of 143 women and 557 men (serving as controls). Multivariate models were adjusted for history of intravenous drug abuse, race, age, CD4 cell count, staging of disease, and time in the clinic. Half of the clients achieved high attendance rates. Women were as likely as men to achieve high attendance rates before the interventions, but more likely to do so at both 6 months and 1 year postintervention (after adjustment for the other variables). These results suggest that responding to special gender-related needs can improve women's attendance for clinic visits.

Background Partner treatment is an important component of sexually transmitted disease (STD) control. Several randomised controlled trials (RCTs) have compared expedited partner treatment (EPT) to unassisted standard partner referral (SR). All of these trials found that EPT significantly increased partner treatment over SR, and some found that EPT significantly lowered re-infection rates in index patients. Methods We collected cost data to assess the payer-specific, health care system, and societal-level cost of EPT and SR. We used data on partner treatment and index patient re-infection rates from two RCTs examining EPT and SR for patients diagnosed with chlamydia or gonorrhoea. Additional elements were estimated or drawn from the literature, such as the likelihood of progression to and QALY impact of sequelae. We used a Monte Carlo simulation (10 000 iterations) to assess the impact on cost and effectiveness of varying several variables simultaneously, and calculated threshold values for selected variables at which EPT and SR costs per patient were equal. Sensitivity analyses assessed the impact of varying settings in which EPT might be employed, such as one in which no patient counselling or data entry costs were incurred when employing either EPT or SR. Results From a health care system or societal perspective, EPT was less costly and treated more partners than SR. From the perspective of an individual payer, EPT was less costly than SR if ≥ 40%–45% of male index patients’ female partners or ≥38% of female index patients’ male partners received care from the same payer. The Abstract O2-S4.04 figure 1 shows the Monte Carlo results for New Orleans and depicts the relationship between the cost difference between EPT and SR and the proportion of partners of the index patient who receive care from the same payer as the index. Negative values in the figure indicate EPT is less costly per patient. In sensitivity analyses, EPT was less costly than SR from all payer perspectives when counselling and data entry costs were eliminated; when counselling costs were applied to EPT alone, the payer-perspective cost of EPT was greater than SR for index women, but the additional cost was less than $2600 per QALY gained over SR. Conclusions EPT has a lower cost from a societal or health care system perspective than SR and treats more partners. Individual payers may find EPT to be more costly than SR, depending on how many of their patients’ partners receive care from the same payer.

To the Editor: Palella et al. (March 26 issue)1 reported that the use of more intensive antiretroviral therapies is responsible for declines in both morbidity and mortality in patients with AIDS. We conducted a study to evaluate the impact of protease inhibitors on the rates of selected opportunistic processes and mortality and found similar results. Our study population came from a public human immunodeficiency virus (HIV) outpatient clinic in New Orleans. All subjects and data were from the Adult Spectrum of Disease study, a prospective study funded by the Centers for Disease Control and Prevention examining the natural history of . . .

Several studies have found HIV infected adult women particularly those immunosuppressed are at higher risk than non-HIV infected women for cervical dysplasia. Although these results can probably be generalized to adolescent women there are few data pertaining to cervical dysplasia in this age group. To better understand the epidemiology of squamous intraepithelial lesions (SIL) in this population a retrospective study of 62 HIV infected adolescent women from 13-21 years of age enrolled in the HIV Outpatient Program at the Medical Center of Louisiana at New Orleans was undertaken. Demographic and clinical data in this cohort have been previously published. This study is a further analysis of the Papinicoulau (Pap) smear data. Subjects were defined as progressors either if they progressed from a Pap smear not demonstrating SIL to SIL or from low grade SIL to high grade SIL. Rapid CD4 cell count loss was defined as a loss of at least 25% of the baseline CD4 cell count in a period of 6 months. SPSS software was utilized for analyses (SSPS Statistical Software Chicago IL). Significant differences between selected characteristics were determined by Chi-square methods. (excerpt)

Human immunodeficiency virus (HIV)-infected adolescents are faced with serious psychosocial problems. It is vital that clinicians be aware of this aspect of management given the increasing rates of infected youths. To describe these problems a retrospective chart review of all HIV-infected persons 13-21 years of age at entry into a public HIV outpatient clinic in New Orleans Louisiana between November 1 1989 and February 1 1994 was conducted. Psychosocial data were collected retrospectively through medical chart review by trained abstractors. Of the 141 adolescents studied 65% were female and 83% were African-American. Median age and CD4 cell count were 18 (range 14-21 years) and 565 (range 5-1469) respectively. Clinical features of this cohort have been previously described. Fifty-two percent acquired HIV through sex 9% through injection drug use and 2% through infected blood products and 37% were unable to identify their risk factor. The majority of females (44%) were recruited into care from prenatal screening and 13% had a subsequent pregnancy during the follow-up period. Median follow-up time for the cohort was 24 months. Broken appointments were frequent averaging 1.9 missed visits/person-year or 24% of scheduled visits. (excerpt)

Objective. —To determine whether a previously observed association between human immunodeficiency virus type 1 (HIV-1) infection and smoking in Haitian women could be explained by confounding high-risk behaviors. Design and Setting. —A nested case-control study at a primary care health clinic in Cite Soleil, Haiti. Participants. —Women who reported having smoked (n=89) and randomly selected nonsmokers (n = 329) who had participated in a survey 1 to 12 months earlier evaluating risk factors for HIV-1 infection. Main Outcome Measures. —Lifetime sexual practices, smoking, health beliefs and practices, and other factors potentially confounding the relationship between smoking and HIV-1 infection. Results. —Compared with nonsmokers, smokers reported higher rates of high-risk behaviors, including more lifetime sex partners ( P P P Conclusions. —Smoking is a marker for high-risk sexual behavior and is associated with an increased risk of HIV-1 infection in this population. The persistent association between smoking and HIV-1 infection after adjustment for all known risk factors suggests the possibility of a biologic effect of smoking that warrants further evaluation in other populations. ( JAMA . 1992;267:2062-2066)

Of 4588 pregnant women in a high-risk Haitian population, 443 (9.7%) were serologically positive for the human immunodeficiency virus type 1 (HIV-1). Infants born to women who were HIV-1 seropositive were more likely to be premature, of low birth weight, and malnourished at 3 and 6 months of age than were infants born to women who were HIV-1 seronegative. Increased mortality was observed in infants born to women who were HIV-1 seropositive by 3 months of age. At 12 months of age, 23.4% of the infants born to women who were HIV-1 seropositive had died compared with 10.8% of the infants born to women who were HIV-1 seronegative; at 24 months of age, the mortality rates were 31.3% and 14.2%, respectively. Maternal HIV-1 infections resulted in an 11.7% increase in the overall infant mortality rate in this population. The estimated mother-to-infant HIV-1 transmission rate in these breast-fed infants was 25%, similar to the rates reported for non—breast-fed populations in the United States and Europe. (JAMA. 1990;264:2088-2092)

Background: The purpose of this study was to determine the association of serum lactate dehydrogenase (LDH) levels with certain opportunistic infection and to determine an association between LDH levels and CD4+ lymphocyte counts.Methods: We studied 352 patients retrospectively with HIV infection and one of the following infections: histoplasmosis; toxoplasmosis; tuberculosis (pulmonary and disseminated); bacterial pneumonia; Pneumocystis carinii pneumonia. Demographic and clinical data were obtained from the Adult Spectrum of Diseases (ASD) database in New Orleans. Bivariate and multivariate analysis were used to determine the association between LDH levels and opportunistic infections and CD4+ lymphocyte counts.Results: Patients with a serum LDH level

HIV expressed in genital secretions provides the inoculum from which transmitting variants are selected, both in sexual transmission and mother-to-infant transmission during partuition. Characterization of HIV levels and genotypes found in vaginal secretions and the impact of anti-retroviral therapy (ART) on this virus can provide valuable insight for the prevention of HIV transmission. Vaginal HIV was evaluated in a cohort of 43 women attending a New Orleans HIV outpatient clinic. Predominant vaginal genotypes were characterized as R5- or X4-like by heteroduplex tracking analyses of the envelope V3 region. Most women (67.4%) shed R5-like genotypes in vaginal secretions which was associated with elevated plasma HIV levels (≥ 10,000 copies HIV-RNA/mL) and absence of ART. Because R5-like genotypes are more frequently associated with transmission, these observations suggest that the majority of women shedding HIV in genital secretions present a transmission risk. The levels of vaginal virus were similar between both groups, but shedding of X4-like genotypes was associated with lower plasma viral loads and the use of ART, suggesting that ART use may impact the genotypes of virus found in the female genital compartment.