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Drug use and HIV infection may affect sex hormone levels in women. One hundred and ninety-six women with and without a history of illicit drug use (50 HIV-negative and 148 HIV-infected), with regular menses, who never used antiretrovirals, were evaluated. Luteinizing hormone levels were significantly higher in women with a CD4 cell count

The World Health Organization has estimated that over 60 million incident cases of gonorrhea occur worldwide every year [1]. In the United States 335,104 gonorrhea cases were reported to health departments in 2003 for an annual estimated rate of 116.2 cases per 100,000 personsdone of the highest rates among industrialized countries [2]. As with most other sexually transmitted infections (STIs), these numbers underestimate the true burden of this disease. Many cases of gonorrhea diagnosed by primary care physicians are never reported to local health departments, and others are asymptomatic and are never diagnosed. For example, in a probability sample of adults living in Baltimore, the estimated number of subclinical gonococcal infections was 1.3-fold higher than the number of infections diagnosed and treated in a given year [3]. The sequelae of not treating gonococcal infections can be devastating. These include infertility [4], ectopic pregnancy [5], chronic pelvic pain [6], and increased HIV-1 transmission and acquisition [7]. Diagnostic methods for Neisseria gonorrhoeae have changed dramatically. The Gram stain is still widely used because of its low cost and overall simplicity. In symptomatic men, it is up to 90% sensitive [8]. However, the sensitivity decreases significantly in women and asymptomatic men. The test must also be performed in a laboratory certified according to the Clinical Laboratory Improvement Amendments, which often reduces the cost advantage. Culture remains the gold standard for diagnosing N gonorrhoeae infections, with a reported sensitivity of more than 90% and a specificity of nearly 100% when obtained from the urethra or cervix [9]. Anorectal and

This systematic review addresses 2 questions pertinent to the need for pretreatment liver biopsy in patients with chronic hepatitis C: how well do liver biopsy results predict treatment outcomes for chronic hepatitis C? How well do biochemical blood tests and serologic measures of fibrosis predict the biopsy findings in chronic hepatitis C? Medline and other electronic databases were searched from January 1985 to March 2002. Additional articles were sought in references of pertinent articles and recent journals and by querying experts. Articles were eligible for review if they reported original human data from a study that used virological, histological, pathologic, or clinical outcome measures. Paired reviewers assessed the quality of each eligible study and abstracted data. Studies suggested that advanced fibrosis or cirrhosis on initial liver biopsy is associated with a modestly decreased likelihood of a sustained virological response (SVR) to treatment. Also, studies relatively consistently showed that serum aminotransferases have modest value in predicting fibrosis on biopsy; that extracellular matrix tests hyaluronic acid and laminin may have value in predicting fibrosis, and that panels of tests may have the greatest value in predicting fibrosis or cirrhosis. Biochemical and serologic tests were best at predicting no or minimal fibrosis, or at predicting advanced fibrosis/cirrhosis, and were poor at predicting intermediate levels of fibrosis. Thus, evidence suggests that liver biopsy may have some usefulness in predicting efficacy of treatment in patients with chronic hepatitis C, and biochemical blood tests and serologic tests currently have only modest value in predicting fibrosis on liver biopsy.

This systematic review addresses the following questions: (1) What is the efficacy of using screening tests for hepatocellular carcinoma (HCC) in improving outcomes in chronic hepatitis C, and (2) what are the sensitivity and specificity of screening tests for HCC in chronic hepatitis C? The search strategy involved searching Medline and other electronic databases between January 1985 and March 2002. Additional articles were identified by reviewing pertinent articles and journals and by querying experts. Articles were eligible for review if they reported original human data from studies of screening tests that used virological, histological, pathologic, or clinical outcome measures. Data collection involved paired reviewers who assessed the quality of each study and abstracted data. One nonrandomized prospective cohort study suggested that HCC was detected earlier and was more often resectable in patients who had twice yearly screening with serum alpha-fetoprotein (AFP) and hepatic ultrasound than in patients who had usual care. Twenty-four studies, which included patients with chronic hepatitis C or B or both, addressed the sensitivities and specificities of screening tests. They were relatively consistent in showing that the sensitivity of serum AFP for detecting HCC usually was moderately high at 45% to 100%, with a specificity of 70% to 95%, for a threshold of between 10 and 19 ng/mL. The few studies that evaluated screening with ultrasound reported high specificity, but variable sensitivity. In conclusion, screening of patients with chronic hepatitis C with AFP and ultrasound may improve detection of HCC, but studies are needed to determine whether screening improves clinical outcomes.

We aimed to test the hypothesis that a short anovaginal distance may increase the risk of bacterial vaginosis (BV) due to faecal contamination and disruption of the vaginal microbiota. Women attending two sexually transmitted infection (STI) clinics in Baltimore, Maryland, USA, who complained of a vaginal discharge were asked to participate in a study to measure mucosal immune responses. In this pilot study of all enrolled women, a small plastic ruler was used to measure the anatomic distance from the posterior fourchette to the anus with the participant in the lithotomy position. Cases of BV, defined by Amsel's clinical criteria ( n = 62), were compared with controls ( n = 31) without BV. We used linear and logistic regression models to adjust for potential confounders. A total of 93 women were recruited (median age 28.6 years, 93% black, 4.4% gonorrhoea infection, 7.4% chlamydia infection, 8.6% trichomonas infection, 67% BV diagnosed). Mean anovaginal distance was 3.22 cm (SD: 0.74, range 1.8–5.2) for controls and 3.37 cm (SD: 0.76, range: 1.8–5.7) for cases ( P = 0.38). There was no difference between cases and controls when comparing median values, quartiles and after adjusting for potential confounders. Among high-risk women with multiple co-infections, there was no association between anovaginal distance and clinical diagnosis of BV.

Background. Ceftriaxone is the foundation of currently recommended gonorrhea treatment. There is an urgent need for backup treatment options for patients with cephalosporin allergy or infections due to suspected cephalosporin-resistant Neisseria gonorrhoeae. We evaluated the efficacy and tolerability of 2 combinations of existing noncephalosporin antimicrobials for treatment of patients with urogenital gonorrhea. Methods. We conducted a randomized, multisite, open-label, noncomparative trial in 5 outpatient sexually transmitted disease clinic sites in Alabama, California, Maryland, and Pennsylvania. Patients aged 15–60 years diagnosed with uncomplicated urogenital gonorrhea were randomly assigned to either gentamicin 240 mg intramuscularly plus azithromycin 2 g orally, or gemifloxacin 320 mg orally plus azithromycin 2 g orally. The primary outcome was microbiological cure of urogenital infections (negative follow-up culture) at 10–17 days after treatment among 401 participants in the per protocol population. Results. Microbiological cure was achieved by 100% (lower 1-sided exact 95% confidence interval [CI] bound, 98.5%) of 202 evaluable participants receiving gentamicin/azithromycin, and 99.5% (lower 1-sided exact 95% CI bound, 97.6%) of 199 evaluable participants receiving gemifloxacin/azithromycin. Gentamicin/azithromycin cured 10 of 10 pharyngeal infections and 1 of 1 rectal infection; gemifloxacin/azithromycin cured 15 of 15 pharyngeal and 5 of 5 rectal infections. Gastrointestinal adverse events were common in both arms. Conclusions. Gentamicin/azithromycin and gemifloxacin/azithromycin were highly effective for treatment of urogenital gonorrhea. Gastrointestinal adverse events may limit routine use. These non-cephalosporin-based regimens may be useful alternative options for patients who cannot be treated with cephalosporin antimicrobials. Additional treatment options for gonorrhea are needed. Clinical Trials Registration. {"type":"clinical-trial","attrs":{"text":"NCT00926796","term_id":"NCT00926796"}}NCT00926796.

The term ‘sexually transmitted diseases (STDs)’ refers to a number of distinct infections caused by a variety of organisms, including bacteria, viruses, protozoa, and ectoparasites, which are typically transmitted through sexual contact and result in an array of clinical manifestations. The clinical syndromes associated with infection by one or more of these organisms can range from asymptomatic infection to severe life-threatening disease. The acquisition and transmission of STDs depend primarily on sexual behavior, but some infections, such as hepatitis B and cytomegalovirus, can also be acquired through nonsexual contact in areas with poor living conditions. Some can be transmitted from mother to child during pregnancy and childbirth, and can be sometimes associated with significant infant morbidity and mortality. Others, including syphilis and human immunodeficiency virus (HIV), can be transmitted through blood products and organ transplantation. Over the last two decades, there have been tremendous advances in our understanding of STDs. These include recognition of new pathogens, new clinical syndromes, emerging antimicrobial resistance, the increasing importance of viral pathogens, and a better understanding of the epidemiology of many STDs, and progress has been made in the field of prevention including vaccine development. This article summarizes some important epidemiological trends among the more common STDs, and reviews the clinical syndromes, diagnosis, treatment, and pathogenesis of selected STDs.

Evidence-based guidelines for the management of persons infected with human immunodeficiency virus (HIV) were prepared by an expert panel of the HIV Medicine Association of the Infectious Diseases Society of America. These updated guidelines replace those published in 2009. The guidelines are intended for use by healthcare providers who care for HIV-infected patients. Since 2009, new antiretroviral drugs and classes have become available, and the prognosis of persons with HIV infection continues to improve. However, with fewer complications and increased survival, HIV-infected persons are increasingly developing common health problems that also affect the general population. Some of these conditions may be related to HIV infection itself or its treatment. HIV-infected persons should be managed and monitored for all relevant age- and sex-specific health problems. New information based on publications from the period 2009-2013 has been incorporated into this document.

Certains produits comme le tetrahydrothiophene (THT), dont l'odeur est percue a faible teneur, sont injectes dans le gaz naturel en vue de son odorisation. Cette odorisation artificielle rend toute fuite eventuelle de gaz dans l'atmosphere immediatement detectable. Les auteurs ont mesure les compositions a l'equilibre des phases gaseuses des binaires THT-CH4 , THT-N0 2 et THT-CO2 dans les conditions de transport et de distribution du gaz [ 1 C) < 50] . Dans ce but, un dispositif experimental original base sur un principe de saturation dynamique avec analyse chromatographique en ligne de la phase vapeur a ete realise et mis au point. Des grandeurs thermodynamiques supplementaires sont necessaires pour atteindre les compositions molaires de la phase vapeur. Les auteurs ont mesure les pressions de vapeur du THT et estime les seconds coefficients du viriel. Ces estimations font intervenir les grandeurs critiques et facteurs acentriques qui ont ete calcules par diverses correlations.

The orders of three endocervical specimens of 3,561 women for Chlamydia trachomatis testing were randomized to determine whether test performance measures of two nucleic acid amplification tests and a DNA probe were affected by swab order. Specimen collection order did not appear to affect the diagnostic accuracy of these tests.

BACKGROUND: In an era of constrained resources, new molecular techniques may make it possible to detect common sexually transmitted infections (STIs) without physical examination in selected groups of men. Our objectives were to define the contribution of the physical examination in detecting clinically meaningful diagnoses that may not be identified by current laboratory methods and to identify characteristics that can stratify men into the appropriate risk category. METHODS: A retrospective study from a database of all male visits to 2 urban STI clinics in Baltimore between 1990 and 2001 was conducted. Men were stratified on the basis of reason for visit. Proportions for diagnoses that would have been missed without physical examination were compared using the χ2 test. Logistic regression was used to assess which factors were most predictive of missed diagnoses. RESULTS: A total of 58,073 of 140,052 records were included: 29,172 were asymptomatic, 23,972 were symptomatic, and 4929 were asymptomatic contacts of an infected partner. In addition, 2.7% of ASYM, 10.4% of symptomatic, and 4.5% of contact patients would have had missed diagnoses if no physical examination had been performed. For symptomatic patients, if those reporting rash, lesion, or genital itch were examined, the percent with missed diagnoses would drop to 3.7%. CONCLUSIONS: Asymptomatic men may be candidates for accelerated STI testing, which includes the submission of genital and extragenital swabs as well as blood samples for HIV and syphilis testing without a physical examination. A significant proportion of symptomatic men would miss the opportunity for same-day treatment of gonococcal or nongonococcal urethritis.

Background The current recommended first-line regimen to treat gonorrhea is ceftriaxone in combination with either azithromycin or doxycycline. Azithromycin is the preferred second agent. We retrospectively measured and compared gonorrhea retreatment rates between patients receiving ceftriaxone plus azithromycin and those receiving ceftriaxone plus doxycycline. Methods Using data from public sexually transmitted disease clinics for patients treated for gonorrhea in Baltimore, Maryland, between January 2004 and December 2011, we measured time to retreatment from the date the ceftriaxone regimen was received. Censoring occurred on the earlier of 2 years posttreatment or March 31, 2012. Survival analysis methods were used to compare retreatment rates. Results One tenth (9.9%; n = 4457) of patients were retreated within 2 years. Treatment regimen was not related to time to retreatment (adjusted hazard ratio [aHR], 0.88; 95% confidence interval, 0.69-1.12). Patients receiving expedited partner therapy (EPT) were 45% less likely to be retreated (aHR, 0.55 [0.31-0.96]) compared with patients treated before EPT became available. A subanalysis among patients retested for gonorrhea within 90 and 30 days found retreatment rates of 18.8% (n = 91/485) and 13.5% (n = 19/140), respectively. The 90-day cohort showed no association with treatment regimen (aHR, 0.95 [0.55-1.65]); however, all of the retreated patients in the 30-day cohort had received the doxycycline regimen. Conclusions Gonorrhea retreatment was common, highlighting the need for rescreening and better partner therapies. The protective effect of EPT further underscores the need for effective oral therapies. Azithromycin may be preferable as the second agent to treat gonorrhea, although doxycycline seems to be a reasonable alternative.

Nous reportons les diagrammes d'equilibre liquide-solide des systemes binaires contenant le tetrachlorure de carbone + n-alcanes. Tous les systemes sont a eutectique simple avec presence d'une transition de phase a l'etat solide du tetrachlorure de carbone. L'approximation zero du modele Disquac est appliquee afin de calculer les diagrammes de phase et de les comparer avec les diagrammes experimentaux

Objective We evaluated agreement in diagnoses for bacterial vaginosis (BV), Trichomonas vaginalis (TV) and vulvovaginal candidiasis (VVC) between clinicians examining the patient and performing diagnostic tests versus a clinician with access only to the patient9s history and diagnostic findings from self-obtained vaginal swabs (SOVS). Design Women presenting with vaginal discharge to a sexually transmitted infections clinic provided SOVS for evaluation and completed the study and qualitative questionnaires. A clinician then obtained a history and performed speculum and bimanual examinations. Participants’ history and diagnostic test results from SOVS were provided to a masked non-examining clinician who rendered independent diagnoses. Overall agreement in diagnoses and κ statistics was calculated. Results The prevalence of infections among the 197 participants was 63.4% (BV), 19% (TV) and 14% (VVC). The per cent agreement between the examining and non-examining clinician for the diagnoses of BV was 68.5%, 90.9% for TV and 91.9% for VVC. Of the 105 women diagnosed with BV by the examining clinician, 34 (32%) were missed by the non-examining clinician. The non-examining clinician missed 13 (48%) of 27 women and 12 (34%) of 35 women treated for VVC and TV, respectively. Four women who all presented with abdominal pain were diagnosed with pelvic inflammatory disease. Conclusions Tests from SOVS and history alone cannot be used to adequately diagnose BV, TV and VVC in women presenting with symptomatic vaginal discharge. Cost benefits from eliminating the speculum examination and using only tests from SOVS may be negated by long-term costs of mistreatment.

No single laboratory test is both sensitive and specific to diagnose neurosyphilis. Several major clinical guidelines suggest that negative cerebrospinal fluid (CSF) treponemal-specific antibody tests rule out the diagnosis of neurosyphilis. Our aim was to systematically review the literature and describe the performance of treponemal-specific CSF antibody tests when diagnosing neurosyphilis.Two reviewers independently assessed studies published in electronic databases, trial registries, and bibliographies for content and quality. Entry criteria included the assessment of treponemal-specific CSF tests currently used in clinical practice, and the use of standard criteria for both diagnosis and exclusion of neurosyphilis. The primary outcomes were sensitivity, specificity, and negative predictive values of treponemal-specific CSF antibody tests.Of 141 unique citations, 18 studies were included in the systematic review. Due to significant heterogeneity among studies, we were unable to generate pooled summary statistics. Seven different treponemal-specific tests were assessed. Of those, 13 studies evaluated the CSF FTA-ABS (fluorescent treponemal antibody-absorbed) and 9 evaluated the CSF fluorescent treponemal antibody. The performance estimates of these tests were highly variable and depended on the choice of negative and positive controls. No single test had perfect sensitivity, thus the negative predictive value was dependant on the specificity of the test and the prevalence (i.e., pretest probability) of neurosyphilis: the higher the prevalence, the lower the negative predictive value. Few studies included HIV-infected persons.A negative CSF-treponemal-specific antibody test may not exclude the diagnosis of neurosyphilis when the clinical suspicion for neurosyphilis is high.

Publisher Summary Beyond clinical manifestations and infected anatomic sites, little is known about gender and biologic sex effects for sexually transmitted infections (STIs). This chapter discusses the current state of knowledge of the association of biologic sex with the manifestations, complications, and epidemiology of STIs. Although the response to treatment appears similar in men and women, women are at risk for more severe complications from STIs than are men, which include chronic pelvic pain, ectopic pregnancy, infertility, and neonatal transmission of pathogens. In men, the biological risk factors associated with STIs remain relatively constant throughout life. Early adolescence begins between the ages of 11 and 15 among men, whereas it begins between the ages of 9 and13 for women. Little is known regarding the biological susceptibility of males to STIs over their lifespan with regard to hormonal influences or physiologic immune aging. Male circumcision status is one of the most important characteristics associated with variable risk of STIs. The female reproductive tract (FRT) has evolved to maintain a difficult balance of supporting reproduction and protecting against deleterious pathogen invasion. These roles appear diametrically opposed immunologically. The immune system of the lower genital tract is tasked with maintaining tolerance to commensal organisms, providing at least transient tolerance to allogeneic sperm, and protecting against pathogenic microorganisms.

Sex steroids are central to regulation of the dual roles of the female reproductive tract: support of reproduction and protection against deleterious pathogen invasion. The mechanisms by which sex steroids orchestrate the balance between reproduction and protection against pathogenic microorganisms, however, are complex and poorly understood. Epidemiologic studies have revealed associations between sex steroids and diagnosis, shedding, transmission of sexually transmitted diseases and their clinical sequelae, as well as disruptions to the normal vaginal flora. Experimental approaches, including animal models, have provided some insight into the mechanism of these associations, though often with contradictory results. Inherent limitations in traditional approaches to understanding the physiology of sex steroid regulation of immunity in the female genital tract will require significant interdisciplinary collaboration.

The decision to perform lumbar puncture in patients with asymptomatic human immunodeficiency virus (HIV) infection and syphilis is controversial. The Centers for Disease Control and Prevention recommend certain criteria that warrant lumbar puncture. Here, we assess the performance of these criteria for detecting asymptomatic neurosyphilis (ANS).Eligible subjects consisted of all patients with concurrent HIV infection and syphilis in a prospective clinical cohort who had no neurologic symptoms at the time of lumbar puncture. We retrospectively applied different stratification criteria to calculate the performance of lumbar puncture in detecting ANS: (1) lumbar puncture in patients with late latent syphilis or syphilis of an unknown duration, regardless of the CD4 cell count or rapid plasma reagin titer; (2) lumbar puncture if the CD4 cell count was 350 cells/mL and/or the rapid plasma reagin titer was 1:32, regardless of the syphilis stage; and (3) lumbar puncture in the context of serologic nonresponse to syphilis therapy.Two hundred two of 231 patients with syphilis did not have neurologic symptoms. Immediate lumbar puncture was performed for 46 patients, and 10 cases (22%) of ANS were detected. With use of the first criterion, 2 (14%) of 10 cases of ANS in patients with early-stage syphilis would have been missed (sensitivity, 80% [95% confidence interval [CI], 44%-97%]; specificity, 23% (95% confidence interval [CI], 11.4%-40.2%) [corrected] Criterion 2 would not have missed any cases of ANS (sensitivity, 100% [95% CI, 70%-100%]; specificity, 13.2% (95% CI, 4.4%-29.1%) [corrected] but would have required that a lumbar puncture be performed for 88% of patients. Performance of lumbar puncture performed in 13 cases based on serologic nonresponse to syphilis therapy yielded 4 cases (31%) of ANS.In patients with concurrent HIV infection and syphilis, the use of criteria based on rapid plasma reagin titer and CD4 cell count, instead of stage-based criteria, improved the ability to identify ANS.

Syphilis and human immunodeficiency virus (HIV) frequently coexist in patients, but the effects of immunosuppression on the course of syphilis are unknown. Our goal was to determine whether the degree of HIV-mediated immunosuppression and the use of highly active antiretroviral therapy impact syphilis serologic responses.We assessed all cases of syphilis with positive serologic test results from 1990 through 2006 in a prospective, observational clinical cohort of HIV-infected patients. We defined seroreversion as the loss of reactivity in a patient who previously had a serologic test result positive for syphilis. We defined serologic failure as the lack of a 4-fold decrease in rapid plasma reagin titers 270-365 days after therapy or a 4-fold increase in titersor =30 days after therapy. We used Cox proportional hazards models with statistical adjustments for multiple failure instances.One hundred eighty subjects experienced 231 cases of syphilis. The median follow-up time was 5.3 years. A total of 71 episodes of serologic failure were documented. A CD4 cell count of200 cells/mL at the time of syphilis diagnosis was associated with an increased risk of serologic failure (adjusted hazard ratio, 2.48; 95% confidence interval, 1.26-4.88). The receipt of highly active antiretroviral therapy was associated with a 60% reduction in the rate of serologic failure (adjusted hazard ratio, 0.40; 95% confidence interval, 0.21-0.75), independent of concomitant CD4 cell response. Rapid plasma reagin seroreversion was infrequent (16.1%) and inconsistent, and it was more likely to occur among patients who received macrolides.The use of highly active antiretroviral therapy to reverse immunosuppression and the routine use of macrolides for the prevention of opportunistic infections may reduce syphilis serologic failure rates among HIV-infected patients who have syphilis.

Objective The objective of the study was to evaluate the risk for bacterial vaginosis (BV) in a douching cessation trial. Study Design Thirty-nine reproductive-age women who reported use of douche products were enrolled into a 20-week study consisting of a 4 week douching observation (phase I) followed by 12-weeks of douching cessation (phase II). In phase III, participants then chose to resume douching or continue cessation for the remaining 4 weeks. Self-collected vaginal samples were obtained twice weekly in the first 16 weeks, and 1 sample was collected during week 20 (1107 samples total). BV was diagnosed by Nugent score of 7 or greater. Conditional logistic regression was used to evaluate douching cessation on the risk of BV. Results The adjusted odds ratio (aOR) for BV in the douching cessation phase, as compared with the douching-observation phase was 0.76 (95% confidence interval [CI], 0.33 to 1.76). Among women who reported their primary reason for douching was to cleanse after menstruation, BV was significantly reduced in douching cessation (aOR:0.23; 95% CI, 0.12 to 0.44). Conclusion Vaginal douching cessation may reduce the risk for BV in a subset of women.

Objective: To determine the prevalence of sexually transmitted diseases (STDs) and characterize behavioral correlates among pregnant women attending inner city public STD clinics. Study Design: A retrospective study of 2303 pregnant women frequency matched by clinic and year of visit to 2303 nonpregnant women seeking services during years 1996 to 2002 at public STD clinics in Baltimore, MD. Results: On average, 329 pregnant women attended Baltimore City STD clinics each year during 1996 to 2002. Forty-six and a half percent of pregnant women knew they were pregnant when they presented to the STD clinic. Although pregnant women were younger (23.3 vs. 28.3 years of age, P

Study Objective Bacterial vaginosis (BV) is a common infection and has been associated with adverse health outcomes, including preterm birth, pelvic inflammatory disease (PID), and acquisition of HIV. There are limited data on recurrent BV in adolescents. A relationship between the frequency of BV recurrence and specific risk factors might shed light on the pathophysiology of BV and lead to targeted interventions. Methods Design: Record-based historical clinic study. Setting: Adolescent visits to two sexually transmitted disease (STD) clinics between 1990 and 2002. Participants: 254 girls who had ≥ 2 episodes of BV and at least 3 clinical visits, matched on clinic attendance frequency to 254 girls with only 1 documented BV episode and 254 girls with no history of BV. Main Outcome Measure Risk factor differences between groups. Analysis Multinomial logistic regression with robust estimator of the standard errors, accounting for repeated measures. Results 5,977 adolescent girls visited the clinics. 1509 (25%) had at least one episode of BV; of those, 303 (19.9%) had 2 or more BV episodes. Girls with a history of 1 BV episode and girls with a history of 2 or more BV episodes were more likely to be infected with Trichomonas vaginalis [OR 1.77, 95% CI: 1.17–2.67, OR 1.56, 95% CI: 1.05–2.34] and be diagnosed with PID [OR 1.50, 95% CI: 1.02–2.22, OR 2.05, 95% CI: 1.41–2.98] compared to girls with no BV history, respectively. Girls with a history of BV were also more likely to report active oral sex and lack of contraceptive use. Conclusion Adolescent girls who attend STD clinics have a high prevalence of BV. Although the association between BV and PID is not clearly causal, when one condition is diagnosed, evaluation and counseling for the other may reduce recurrence and sequelae.

Detection of vaginal Y-chromosome sequences (YCS) may be a useful biomarker to validate sexual behavior reporting in women. We describe the effects of condom use on the detection of vaginal YCS. Fifty-six women were asked to abstain from sexual intercourse for 14 days. On day 15 participants were asked to engage in sexual intercourse with their male partners using condoms. Self-collected vaginal swabs were obtained on days 14 16 and 17. YCS were detected using the Roche LightCycler with the use of positive controls. Forty-four of 56 women completed the study. Five women (11.4%) had detectable YCS. The overall specificity of the YCS assay with condom use was 92% (95% CI: 80%-98%). Although women who reported receptive oral sex and digital penetration within 48 hours of swab collection had a higher detection rate of YCS [RR 2.3 (95% CI: 1.1-4.6) and 3.6 (95%CI: 1.6-8.5) respectively] the mean concentration of YCS was much less than that associated with unprotected vaginal intercourse (P

142 Behavior change is an effective strategy in curbing the spread of sexually transmitted infections (STIs). As a first step, we must communicate healthful behaviors to the public. Unfortunately, research has repeatedly shown that knowledge alone is not always enough (1–3): Being aware of a healthful behavior does not necessarily translate into engaging in it. Sexual behavior, in particular, has strong social components that involve a web of social relations, expectations, issues regarding confidence in one’s abilities, beliefs about risk, and the perceived severity of STIs and their sequelae. Therefore, a successful prevention campaign must not only be educational, but also persuasive. The goal of changing sexual behaviors is to ultimately decrease the rate of disease transmission. Transmissibility can be decreased by correct and consistent condom use, delaying the initiation of sexual activity, mutual monogamy, decreasing numbers of sex partners, no concurrency, and promoting use of available vaccines against STIs (e.g., hepatitis B) (4). Duration of infectiousness can be reduced by promoting rapid health evaluations for symptoms of STI and by screening high-risk asymptomatic populations. Therefore, to decrease the rate of spread, we have to target social behaviors explicitly by using persuasive communication to instill behavior change. This approach is at the core of disease prevention—halting the spread of communicable diseases (whether curable, incurable, or chronic) by changing behaviors as a primary prevention strategy, or changing behaviors after infection to prevent further spread. In both instances, social marketing, concretely based on researched theories of behavior change, is a necessary step in order to maximize effectiveness of prevention campaigns. This chapter is not meant to be a systematic or exhaustive review of the literature on mass media campaigns, as those already exist (5). The primary purpose of this chapter is to identify factors, other than knowledge, that influence the adoption of healthful behaviors and to develop social marketing frameworks to help public health officials optimize public health campaigns aimed at preventing STIs, including HIV. We will use social marketing examples and

Background Many older patients remain sexually active well into their eighth decade of life. Surveillance data suggest that rates of sexually transmitted infections (STIs) in this age group may be increasing. We sought to compare demographics, risk behaviours and predictors of acute infections in patients 50 years and older versus younger patients attending STI clinics in Baltimore, Maryland. Methods Retrospective study from a large electronic database of all visits to two urban STI clinics between 2005 and 2010. Proportions were compared using the c2 test. Logistic regression was used to assess predictors of acute STIs in older versus younger groups. Results 4461 first visits for patients over 50 and 4893 visits for patients under 50 were included in the analysis. Patients over 50 frequently reported high-risk behaviours [35.4% (CI 0.34–0.37) vs. 52.7% (CI 0.51–0.54) in those Conclusion Older patients who seek care at STI clinics engage in significant risk behaviours. Race, a factor strongly predictive of acute STIs in young men and women is not a significant predictor of STIs in older persons. Disclosure of interest statement No sources of funding or conflicts of interest to disclose.

Background Suboptimal nutrition has been associated with an increased risk of bacterial vaginosis (BV). In this study, we examined the association between dietary intake and BV-associated vaginal microbiota. Methods We analysed the baseline visit of the Hormonal Contraception Longitudinal Study, a cohort of reproductive-aged women who reported at enrollment intentions to initiate or cease hormonal contraception (HC). Dietary intake was estimated using the Block Brief 2000 Food Frequency Questionnaire. Vaginal microbiota composition was assessed using 16S rRNA gene analysis and categorised based on the types and relative abundance of bacteria (termed community state types (CSTs)). Nutrients were categorised into quartiles and the associations between nutrients and CST-IV, a low- Lactobacillus CST, were evaluated by logistic regression. Separate models were built for each nutrient controlling for demographics, tobacco use, behavioural factors, HC and dietary variables (total energy intake, and where appropriate, percent of calories from fat, protein, carbohydrates). Results A total of 98 women were included in this analysis. The mean age of the women was 25.9, mean body mass index was 27.9, 29.6% were African American and 47.9% were on HC at enrollment. 26.5% of women had a low relative abundance of Lactobacillus spp. (CST-IV). In adjusted multivariate analyses, the highest quartile of vitamin E (OR: 0.01, 95% CI: 0.001–0.26), zinc (OR: 0.03, 95% CI: 0.18–0.03) and magnesium (OR: 0.06, 95% CI: 0.004–0.75) intake were associated with reduced risk of carrying a low- Lactobacillus CST-IV state. Conclusion Higher intakes of vitamin E, zinc, and magnesium were associated with a decreased risk of having a dysbiotic vaginal microbiota. These findings concur with prior studies that have reported magnesium and zinc deficiencies associated with recurrent bacterial infections and inflammation, and vitamin E (an antioxidant) with anti-inflammatory properties. Dietary interventions targeted at improving intake of select micronutrients may decrease the risk of bacterial vaginosis and its sequelae. Disclosure of interest statement Funding for this study was provided by the National Institutes of Allergy and Infectious Diseases. No pharmaceutical grants were received in the development of this study.

Introduction Hormonal contraception (HC) has been associated with a reduced risk of bacterial vaginosis (BV). We conducted a prospective study to evaluate the relationship between vaginal microbiota and several HC methods. Methods During 2-years of follow-up, 108 women provided 2,662 mid-vaginal samples. Participants reported three HC methods [oral contraceptive pill (OCP), vaginal ring, implanon]. Controls not taking HC were also followed. Visits were scheduled at baseline, 2 weeks, 4 weeks, 3 months, 6 months, 12 months, 18 months, and 24 months. Additionally, participants self-collected mid-vaginal swabs twice-weekly in the two weeks before each visit. Vaginal microbiota composition was characterised on all samples by 16S rRNA gene analysis of the V3-V4 hypervariable regions. We identified four community state types (CSTs) which were dominated by Lactobacillus species. CST-IV-B was characterised by a low relative abundance of Lactobacillus spp. and higher proportions of BV-associated bacteria (Gardnerella and Atopobium). A multinomial model for dependence of proportions was used to evaluate the association between CST and HC. Jensen-Shannon distances between all pairs of samples were analysed to assess stability of the microbiota longitudinally. Results Women on OCPs had more stable bacterial communities than controls during the 2-year follow-up (p = 0.04). HC (overall) also tended toward greater stability (p = 0.10). The low- Lactobacillus CST-IV-B had an 83% lower probability among OCP users and a 55% lower probability among implanon users. CST-II (L. gasseri-dominated) was significantly higher in all HC types compared to controls. Additionally, OCP users were more likely to be CST-III-A ( L. iners -dominated) and CST-V (L. jensenni-dominated), while CST-III-A was also high among ring users. CST-I (L. crispatus-dominated) was associated with implanon. All reported findings were statistically significant (p Conclusion Women on HC experienced greater stability of the vaginal microbiota over time compared to controls. OCPs and the vaginal ring were protective against transition to a Lactobacillus -depleted state. Disclosure of interest statement The study was funded by the US National Institute of Allergy and Infectious Diseases (NIAID) R01-AI089878. No pharmaceutical grants were received in the development of this study.

Syphilis rates are increasing in many parts of the world. HIV-infected persons, particularly men who have sex with men (MSM), have been affected disproportionately. In a recent study, 15% of patients attending New York City STD clinics who were diagnosed with syphilis subsequently became HIV-infected. Several questions about the optimal management of syphilis in HIV-infected persons remain unanswered and continue to elicit controversy, yet none of these are responsible for this persistent syndemic. There are, however, many questions whose answers may critically impact the control of these infections: What is the role of novel point-of-care syphilis tests? Is there a role for syphilis pre-exposure prophylaxis and male circumcision? How will PrEP impact the rates of syphilis? Seventy years following the introduction of a cure, and over 30 years after the discovery of HIV, syphilis continues to present formidable challenges to public health.

IMPORTANCE: The incidence of syphilis in the United States is increasing; it is estimated that more than 55 000 new infections will occur in 2014. Treatment regimens are controversial, especially in specific populations, and assessing treatment response based on serology remains a challenge. OBJECTIVE: To review evidence regarding penicillin and nonpenicillin regimens, implications of the “serofast state,” and treatment of specific populations including those with neurosyphilis or human immunodeficiency virus (HIV) infection and pregnant women. EVIDENCE REVIEW: We searched MEDLINE for English-language human treatment studies dating from January 1965 until July 2014. The American Heart Association classification system was used to rate quality of evidence. FINDINGS: We included 102 articles in our review, consisting of randomized trials, meta-analyses, and cohort studies. Case reports and small series were excluded unless they were the only studies providing evidence for a specific treatment strategy. We included 11 randomized trials. Evidence regarding penicillin and nonpenicillin regimens was reviewed from studies involving 11 102 patients. Data on the treatment of early syphilis support the use of a single intramuscular injection of 2.4 million U of benzathine penicillin G, with studies reporting 90% to 100% treatment success rates. The value of multiple-dose treatment of early syphilis is uncertain, especially in HIV-infected individuals. Less evidence is available regarding therapy for late and late latent syphilis. Following treatment, nontreponemal serologic titers should decline in a stable pattern, but a significant proportion of patients may remain seropositive (the “serofast state”). Serologic response to treatment should be evident by 6 months in early syphilis but is generally slower (12-24 months) for latent syphilis. Evidence defining treatment for HIV-infected persons and for pregnant women is limited, but available data support penicillin as first-line therapy. CONCLUSIONS AND RELEVANCE: The mainstay of syphilis treatment is parenteral penicillin G despite the relatively modest clinical trial data that support its use.

Background: With the advent of molecular techniques, self-collected specimens without a clinician’s examination are often adequate to detect common genital infections. Objective: To evaluate the additional information that speculum and bimanual examinations provides clinicians in the routine evaluation of genital infections among attendees of a sexually transmitted disease (STD) clinic. Methods: Cross-sectional study from a database of all visit records to two STD clinics in Baltimore between 1996 and 2002. Women were stratified on the basis of reason for visit. Proportional and likelihood ratio estimates of the speculum examination in detecting clinically relevant cervicovaginal lesions (leading to a diagnosis of other infections or outside referral for further management) and bimanual examination in detecting abnormalities (leading to a diagnosis of pelvic inflammatory disease or referral) are presented. Results: 15 918 of 21 703 records were included: 12 073 were symptomatic (SYM; discharge, rash, abdominal pain, dysuria, genital irritation or odour), 1676 were asymptomatic contacts of an infected partner (CON) and 2169 were asymptomatic and presented for checkup (ASYM). The median age was 26 years; 94% were black. 11.8% of SYM, 4.6% of CON and 3.9% of ASYM patients had clinically meaningful lesions detected on speculum examination. The bimanual examination detected clinically relevant abnormalities in 6.5% of SYM, 0.8% of CON and 0.6% of ASYM patients. Conclusion: Symptomatic women are most likely to benefit from speculum and bimanual examinations. However, their yield in evaluating asymptomatic women is low. Prospective studies are needed to determine whether eliminating speculum and bimanual examinations in a subset of women would offer an operational advantage without compromising patient safety.

A construction project begins with a work plan that includes a budget, a schedule, and an engineered approach designed to complete the project in the most effective manner. Effective project management requires controlling all aspects of a construction project: quality and quantity of work, costs, and schedules to guarantee the success of the project. Performance monitoring of the entire construction project is crucial. One way of measuring overall performance is by using an aggregate performance measure called Earned Value. Earned value is used to measure cost and schedule performance against a baseline plan. All work is planned, budgeted, and scheduled in time phased planned value increments constituting a cost and a schedule measurement baseline. Earned Value is mainly used to monitor the progress of work and compare accomplished work with planned work. A proposed new model based on wireless communications technologies, to track the progress of percentage completed in a construction project is being investigated in this paper. The model is based on Radio Frequency Identification (RFID) system. It will greatly increase productivity and efficiency, reduce labor hours and time required for tracking, and give more accurate result in estimation. This new technology includes an automated system of reading RFID tags placed on items that send out either a tracking number, or other information for that item, directly to the reader. Keeping track of the material used on site, based on the estimated quantity will permit making a better estimate of the amount of work done on a construction site.

Study Objective To evaluate the effect of specimen collection order on the performance of diagnostic tests for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC), and the specimen adequacy of ThinPrep Papanicolaou (Pap) smears. Design Prospective cohort study. Setting Public adolescent clinic. Population 313 women. Interventions The order of five cervical testing specimens was randomized for (1) ligase chain reaction (LCR) and (2) polymerase chain reaction (PCR) for both CT and GC; (3) transcription-mediated amplification (TMA) for CT; (4) culture for CT; and (5) cytology and LCR for GC and CT performed on ThinPrep Pap specimens. For CT and GC, a reference standard was based on three different tests performed on separate specimens. Generalized estimating equations were used to account for repeated measures. Main Outcome Measure Sensitivity and specificity of diagnostic tests. Results The proportion of inadequate Pap smears was independent of specimen order. As a group, nucleic acid amplification test (NAAT) sensitivity and specificity for GC and CT were similar in the first two (early) and last three (late) swabs. Although point estimates for sensitivity were higher in the early swabs compared to the late swabs for GC LCR (13% difference), GC PCR (13%), and CT TMA (10%), these differences were not statistically significant. Their clinical significance warrants further investigation. Conclusions In clinical settings where both Pap smears and STI testing are performed in adolescents, clinical considerations can influence the order of specimen collection, since neither Pap specimen adequacy nor test performance of NAAT for CT and GC were significantly associated with swab order.