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Goals: To describe the interrelationships of douching, sex during menses, dry sex, and anal intercourse and their associations with self-reported history of sexually transmitted diseases (STD). Study Design: The authors interviewed by telephone 422 white Americans (WA) and 44 African Americans (AA) selected using random-digit dialing, and 135 AA selected from a listed sample of census tracks having a population of at least 40% AA. Results: After adjusting for lifetime numbers of vagina] sex partners, sex during menses was associated with self-reported history of chlamydial infection among women (WA: odds ratio [OR] = 3.9; confidence interval [CI]: 1.1, 14.0; AA: OR = 1.6; CI: 0.6, 4.2). Anal sex was associated with self-reported history of genital warts, genital herpes, hepatitis, and gonorrhea; douching with a twofold increase in self-reported pelvic inflammatory disease. Anal sex was most common in women with a history of same- and opposite-sex partners. Conclusions: These data confirm the association of douching and anal sex with various STD and suggest that sex during menses is associated with chlamydial infection., Various sexual habits and sexual hygiene habits seem to be associated with particular sexually transmitted diseases (STDs). In telephone interviews with 581 women some definite relationships were learned. Sex during menstruation seemed to be related to chlamydial infections; anal sex was associated with a history of genital warts, genital herpes, hepatitis, and gonorrhea; and douching was associated with a significantly higher rate of pelvic inflammatory disease.

Background: Epidemiologic studies have demonstrated strong and consistent associations between the detection of human papillomavirus (HPV) type 16 DNA and the risk of cervical intra-epithelial neoplasia (CIN) and cervical cancer. However, HPVI6 is also the most common type of HPV in the normal population, and only a minority of women with HPV16 infection develop cervical cancer. Studies of genomic heterogeneity in HPVI6 have demonstrated the presence of multiple variant forms in all human populations examined to date. It is conceivable that the natural variants of HPVI6 in a given population may not have the same biologic behavior. Purpose: This study was designed to determine the association between natural variants of HPV16 and the risk of biopsy-confirmed CIN 2 or 3, the most important precancerous lesions of the uterine cervix. Methods: Prospective studies were conducted among 1) women attending a university and 2) women presenting to a sexually transmitted disease clinic. Subjects were eligible for inclusion in this investigation if the initial cytologic findings did not reveal CIN 2-3 and HPV16 DNA was detected by means of a polymerase chain reaction (PCR)-based method in one or more cervical or vulvovaginal samples. Eligible subjects were followed every 4 months with cervical Pap smears and colposcopic examinations. Women were referred for biopsy if cytology or colposcopy suggested CIN 2-3. Two groups of HPV16 variants, prototype-like and nonprototype-like, were determined by means of single-strand conformation polymorphism (SSCP) analysis of PCR products from the noncoding region of the viral genome. Representative SSCP patterns from HPV16 variants were further characterized by direct DNA sequencing of the PCR products. Relative risks (RRs) and 95% confidence intervals (CIs) were calculated by Cox regression analysis. Results: Prototype-like variants accounted for 79% of the HPVI6 detected in university students and 86% of the virus detected in patients presenting to the sexually transmitted disease clinic. CIN 2-3 was confirmed by biopsy in nine of 57 HPVI6-positive women attending the university and in 10 of 66 HPV16-positive women presenting to the sexually transmitted disease clinic. Among university students, those with HPVI6 nonprototype-like variants were 6.5 (95% CI = 1.6-27.2) times more likely to develop CIN 2-3 than those with prototype-like variants. A similar association was observed among women presenting to the sexually transmitted disease clinic (RR = 4.5; 95% CI = 0.9-23.8). Conclusions: This study suggests that the risk of developing CIN 2-3 is not the same with all variants of HPVI6 and that nonprototype-like variants confer a greater risk compared with prototype-like variants. The important genomic differences underlying this increased risk of CIN 2-3 remain to be determined.

There appears to be an association between bacterial infections and endometritis. One hundred seventy-eight women with suspected pelvic inflammatory disease were tested for endometritis, salpingitis, Neisseria (N.) gonorrhoeae, and Chlamydia (C.) trachomatis. Tests confirmed endometritis in 65% of the women. Patients with endometritis were 5.7 times more likely to have N. gonorrhoeae and 4.8 times more likely to have C. trachomatis. Of the women with endometritis, 68% also had uterine inflammation while only 23% of the women without endometritis had uterine inflammation.

Certain factors are associated with cervical ectopia and cervicitis. Cervical ectopia is the growth of cells lining the inner cervix over the outer cervix, and cervicitis is inflammation of the cervix. Two groups of women were evaluated to determine what factors are associated with the two conditions: 764 patients at a clinic for sexually transmitted diseases and 819 college students having a regular annual gynecologic examination. Overall, younger age, use of oral contraception, and current infection with Chlamydia trachomatis were associated with cervical ectopia. Among STD patients, cytomegalovirus infection and white race were associated with ectopia. Overall, cervicitis was associated with infection and ectopia. Swelling and redness were associated with contraceptive use. Ectopia may predispose to infection because the cells lining the inner cervix are more vulnerable to injury and infection.

African women who are HIV positive appear to have more severe cases of pelvic inflammatory disease (PID) than comparable women who are HIV negative. A group of 170 adult African women attending five gynecologic clinics in Abidjan, Ivory Coast had HIV testing, a physical examination, and laboratory testing and were diagnosed with PID. Of them, 57 were HIV positive. HIV-positive women were 2.5 times more likely to have a fever, 7.8 times more likely to have a genital ulcer, 2.6 times more likely to have a tubal or ovarian mass as visualized on an ultrasound scan, 6.5 times more likely to require surgery, and 3.5 times more likely to be hospitalized compared with HIV-negative women. However, both groups responded well to antibiotic therapy. Within four days, 95% of HIV-positive patients reported improvement of symptoms as did 93% of HIV-negative patients, and none continued to run a fever.

Objective: Causes of indeterminate results of Western blot testing (IWB) for human immunodeficiency virus (HIV) type 1 include seroconversion, HIV-2 cross-reactivity, and autoimmune disease, but most IWB results remain unexplained. This case-control study assessed risk factors for IWB results, including early HIV infection, other retroviral infection, autoantibodies, and other medical conditions. Design: Prospective study to determine HIV seroconversion rate, with a case-control design to assess other risk factors for IWB. Cases (persons with one or more repeatedly reactive HIV-1 enzyme immunoassay with IWB), their current sexual partners, and controls (persons with negative enzyme immunoassay and Western blot results) were recruited from blood banks, health department and prenatal clinics, and private providers in Washington and Oregon. Results: Of 244 cases enrolled, 206 were followed up for 6 months or longer, and six (3.0%; 95% confidence interval [CI], 0.7% to 5.3%) with recent HIV risk behaviors seroconverted. The Western blot banding patterns differed among groups; cases usually had p17 or p24 bands, while controls and cases' sexual partners usually had polymerase bands. Conditional logistic regression indicated that independent risk factors for IWB among male cases and controls were a tetanus booster in the past 2 years (odds ratio, 3.2; 95% CI, 1.2 to 8.6) and sexual contact with a prostitute (odds ratio, 3.0; 95% CI, 1.0 to 9.5). Independent risk factors for women were parity (odds ratio, 1.2; 95% CI, 1.02 to 1.4) and autoantibodies, either rheumatoid factor or antinuclear antibodies (odds ratio, 2.3; 95% CI, 1.03 to 5.6). No cross-reactivity was detected with HIV-2, human T-lymphotrophic virus type 1, feline immunodeficiency or feline leukemia, or bovine immunodeficiency viruses. Conclusions: Evaluation of persons with reactive HIV-1 enzyme immunoassays and IWB should include an assessment of HIV risk and other possible risk factors, such as alloimmunization (ie, parity or recent immunization) or autoantibodies (ie, antinuclear antibodies and rheumatoid factor). The relationship of IWB among men who reported sex with prostitutes is intriguing and warrants further study. (Arch Intern Med. 1994;154:1129-1137)

To develop the 1993 Sexually Transmitted Diseasas Treatment Guidelines experts from the Centers for Disease Control and Prevention reviewed the literature on sexually transmitted disease treatment, assembled tables of evidence, and listed key questions on therapeutic outcomes: microbiologic cure, alleviation of symptoms, and prevention of sequelae and transmission. At a meeting with external experts, evidence was systematically assessed and guidelines developed. Quality of evidence for microbiologic cure was generally good for gonorrhea and chlamydia, poor for syphilis, and fair for most other diseases. Evidence on preventing sequelae and transmission was limited. The Guidelines include new recommendations for single-dose oral therapy of gonorrhea (cefixime, ciprofloxacin, and ofloxacin), chlamydia (azithromycin), and chancroid (azithromycin); outpatient therapy of pelvic inflammatory disease (ofloxacin and either clindamycin or metronidazole); and patient-applied therapy of genital warts (podofilox). Syphilis therapy did not change substantially. Several global issues that emerged during the development of the World Health Organization Recommendations for the Management of Sexually Transmitted Diseases also are discussed. This evidence-based approach clarified important treatment issues and the rationale for recommendations, and identified research priorities., The Centers for Disease Control and Prevention (CDC) released the 1993 Sexually Transmitted Diseases Treatment Guidelines after reviewing the literature and consulting with a variety of experts. CDC staff also analyzed research results, focusing on prevention of transmission, cure of infection, treatment of symptoms and prevention of complications. They took into account the needs of patients and the costs involved. This process was conducted for each of the major STD: bacterial vaginosis, chancroid, chlamydia, genital herpes, genital warts, gonorrhea, mucopurulent cervicitis, nongonococcal urethritis, pelvic inflammatory disease, syphilis, trichomoniasis and vulvovaginal candidiasis. For some diseases, such as syphilis, the standard treatment was reaffirmed. For others, new treatments were recommended.

Complement independent neutralizing antibody assays (CINA) may not be an effective method for diagnosis of infections caused by herpes simplex virus type 2 (HSV-2). Infections caused by HSV-2 are usually transmitted sexually in genital secretions. A study evaluated blood samples from 521 women using a CINA and a Western blot assay. Seventy-six percent of the women had antibodies to HSV by CINA, compared with 81% by Western blot. Of 220 blood samples with antibodies to HSV-2 by Western blot, only 48% had neutralizing antibodies to HSV-2 by CINA. Evaluation using a CINA may miss a significant number of patients infected with HSV-2.

Background and objectives: The role of spermatozoa in carrying microorganisms from the cervix to the fallopian tubes and promoting infection was examined in eight pig-tailed macaques. Goal of this study: The aim of this study was to determine whether spermatozoa play a role in the transport of Chlamydia trachomatis into the upper reproductive tract and in the pathogenesis of chlamydial salpingitis. Study design: Five monkeys were inoculated with Chlamydia trachomatis in the cervix and mated, and three other monkeys were infected in the cervix but not mated. Results: Culture positive results were obtained for cervical samples from all animals. After cervical inoculation, no mated animals and one unmated animal had positive culture results for samples from the fallopian tubes. After mating, no spermatozoa examined in samples taken from the upper tract or cul de sac had elementary bodies (EBs) on their surfaces, and only one sample obtained from the cervix showed C. trachomatis attached to the spermatozoa, as determined by fluorescent antibody (FA) staining. Two of the mated monkeys became pregnant; one spontaneously aborted late in gestation, and the other delivered a normal female infant. The fallopian tubes of all eight monkeys were challenged directly with serovar D and examined for evidence of salpingitis. Repeat laparoscopy was performed to monitor the inflammatory response. Tubal specimens for isolation and polymerase chain reaction (PCR) were obtained. Hysterectomies were performed between 3 and 4 weeks after tubal inoculation. Histopathologic examination of the fallopian tubes revealed widespread inflammation consisting of focal collections of lymphocytes and plasma cells in the submucosa. Peritubal adhesions were observed in four of five mated monkeys and in two of three unmated monkeys. Conclusion: This study failed to confirm that spermatozoa play a role in the pathogenesis of C. trachomatis infection., Spermatozoa may not play a role in the development of Chlamydial salpingitis. Chlamydial salpingitis is inflammation of the fallopian tubes caused by infection with Chlamydia trachomatis, a pathogenic microorganism that is sexually transmitted. Among eight female monkeys whose cervix was infected with C. trachomatis, five had sexual intercourse with male monkeys and three did not. Of the 16 samples taken of spermatozoa taken from the monkeys, only one contained C. trachomatis. C. trachomatis was not cultured from the fallopian tubes of any of the monkeys who mated. It was cultured from the fallopian tubes of only one monkey who did not mate. None of the monkeys developed salpingitis without direct infection of the fallopian tubes.

Vaginal spermicides have microbicidal properties that suggest their usefulness in helping to protect against human immunodeficiency virus (HIV) and other sexually transmitted infections. Laboratory, animal, and clinical investigations also support this notion. Because of the importance of identifying additional methods to protect against these infections, however, better information is needed on these female-controlled methods. A consistent set of laboratory standards is needed to evaluate the in vitro activity of existing and future virucides. Further evaluation of such areas as the actions of virucides and vehicles on different anatomical sites and safety studies to better judge determinants of toxicity are needed. Clinical studies might compare efficacy of spermicides and condoms in prevention of HIV and other sexually transmitted diseases as well as investigate psychosocial considerations that determine suitable candidates for vaginal virucides, how they are used, and how their use might be improved., Vaginal spermicides may help prevent HIV infection and other types of sexually transmitted diseases in women. These preparations are antiseptics with virucidal properties, or the ability to kill different types of viruses. Vaginal spermicides that are used in different contraceptive products include nonoxynol-9, octoxynol-9, benzalkonium chloride and menfegol. They are used in many different forms including foams, jellies, creams, sponges, suppositories and as a coating for condoms. Research studies have found that spermicides have activity against HIV and herpes simplex virus types 1 and 2. They also have activity against the bacteria that cause gonorrhea and syphilis. Their effectiveness in preventing Chlamydia infections is still questionable. Vaginal spermicides offer women a method of protection from infection that can be used independently of their partner.

* Background.--A previous study of men with proctitis, proctocolitis, or enteritis showed an association of anal human papillomavirus (HPV) infection with human immunodeficiency virus (HIV) infection. Because anorectal abnormalities may confound an observed association between anal HPV DNA and HIV seropositivity, the present study was undertaken among consecutive homosexual men seeking HIV serologic testing who were unselected for anorectal symptoms. Methods.--Consecutive homosexual men underwent a standardized interview, physical examination, and collection of specimens for HIV serologic testing and detection of anal HPV DNA. Results.--Anal HPV DNA was detected in eight (31 %) of 26 HIV-seropositive men and in 10 (8%) of 119 HIV-seronegative men (odds ratio, 5.8; 95 % confidence interval, 1.1 to 30.1, adjusted for history of sexually transmitted disease, current anorectal symptoms, and age). When men with anorectal symptoms were excluded from the analysis, anal HPV DNA was detected in 27% of seropositive men compared with 8% of seronegative men (odds ratio, 4.4; 95 % confidence interval, 1.4 to 13.4). There was no difference between HIV-seropositive and HIV-seronegative men with respect to distribution of type of HPV DNA. Men with group II or III and group IV HIV disease were 4.1 and 10.9 times, respectively, more likely than HIV-seronegative men to have anal HPV DNA detected. Conclusions.--Because HIV-seropositive men appear to be at increased risk for the detection of anal HPV DNA, the natural course of anal HPV infection should be compared among HIV-seropositive and HIV-seronegative homosexual men. (Arch Intern Med. 1992;152:1673-1676)

To evaluate the impact of human immunodeficiency virus (HIV) on human papillomavirus (HPV) and cervical intraepithelial neoplasia (CIN), a study was conducted of 147 HIV-seropositive and 51 HIV-seronegative prostitutes in Nairobi, Kenya. Among the women infected with HIV, 10 (7%) had signs or symptoms of significant HIV-related disease, and the remaining 93% were asymptomatic. The prevalence of cervical HPV DNA was 37% among HIV-seropositive women and 24% in HIV-seronegative women (odds ratio [OR] 1.7, 95% confidence intervals [CI] 0.8, 3.6, after adjusting for potential confounding factors). Genital warts, cervical HPV DNA, and cytologic findings consistent with CIN were all significantly associated with younger age and fewer years of prostitution, but were unrelated or weakly related to number of sexual partners per week or frequency of condom use. In a subset of 63 women with evaluable Papanicolau smears, CIN was found in 50% of the women with HPV but only in 8% of those without HPV (adjusted OR 7.2, 95% CI 1.6, 32.1, P = 0.006). However, CIN was unrelated to HIV seropositivity (prevalence of 26% among HIV-seropositive women and 24% in HIV-seronegative women). Among women with cervical HPV DNA, HIV infection was not associated with an increased prevalence of CIN (47% prevalence among women with HIV versus 57% prevalence among women without HIV). Thus, in this population of HIV-seropositive women, most of whom had CDC Stage II or III infection, there was no demonstration of an adverse impact of HIV on CIN.

The human immunodeficiency virus type 1 (HIV-1) is the virus that causes AIDS. HIV-1 infections are diagnosed by testing a sample of blood to see if it contains HIV-1 antigens (pieces of virus) or HIV-1 antibodies (proteins made by the body to attack the virus). This report describes the laboratory diagnosis of HIV infection and presents an algorithm for evaluating uncertain results. Routine screening of blood samples is performed using a simple test called the enzyme immunoassay (EIA). In this test, HIV-1 antigens are firmly attached to a small plate or a dip stick. The blood sample is added to the plate or stick and after a short incubation period the plate or stick is rinsed with several different solutions. If HIV-1 antibodies were present in the blood, indicating an HIV-1 infection, the plate or dip stick will change color. When a person has a positive EIA test, a second EIA test is performed. If the second test is negative and the person does not engage in high-risk behaviors (intravenous drug use or homosexual relationships), no further testing is conducted. If the second EIA test is positive, then the Western blot test is performed. This test is more difficult to do than the EIA and requires a fully equipped laboratory. Approximately 80 to 90 percent of the blood samples that test positive in the EIA also test positive in the Western blot. The remaining 10 to 20 percent of blood samples with unclear results and are called indeterminate Western blots (IWB). If a person has two positive EIA tests and one positive Western blot, the person is considered to have an HIV-1 infection. If a person has two positive EIA tests and an IWB, then another Western blot test should be performed one month later. If a person who has an IWB engages in high-risk behaviors, repeat testing should be performed at three to six month intervals. In most cases of HIV-1 infection with an initial IWB result, the second Western blot (performed one month after an IWB result) is positive. However, if the second Western blot is negative then the person is not considered to have HIV-1 infection. Risk of HIV infection is an important consideration in monitoring patients who have a second negative EIA or an IWB. (Consumer Summary produced by Reliance Medical Information, Inc.)

Many bacteria can cause pelvic inflammatory disease, and it is possible that multiple species may be responsible for the disease in an individual. In these cases, a single type of antibiotic may not be effective, and combination antimicrobial therapy has been recommended. However, although several regimens have been used, their effectiveness in actual medical practice has not been well-studied. The effectiveness of cefoxitin plus doxycycline was compared with that of clindamycin plus tobramycin in the treatment of pelvic inflammatory disease in 148 women. All antibiotics were administered for a minimum of four days intravenously, and upon discharge from the hospital, a regimen of oral medication was continued for two weeks. An initial satisfactory response to the antibiotics occurred in 97 percent of patients, and response was not different between those with uncomplicated disease and those with abscesses. Neisseria gonorrhoeae and Chlamydia trachomatis (C. trachomatis) were the bacteria most often isolated from patients. C. trachomatis can be especially difficult to remove, and the clindamycin regimen appeared to be more effective in treating this bacterial infection. Mild nausea or diarrhea were the most common side effects of treatment. The results indicate that either regimen is effective and safe in the short-term treatment of pelvic inflammatory disease; the long-term effectiveness of such treatment remains to be determined. (Consumer Summary produced by Reliance Medical Information, Inc.)

The common infection of genital herpes is easy to recognize, and the natural history of this infection has been well-studied. However, many people have become infected with herpes simplex type 2, but do not have symptoms and are often undiagnosed. To estimate the prevalence of unrecognized type 2 herpes, antibody assays were performed on 776 women attending a venereal disease clinic, and 636 college women. Among the women at the sexually transmitted disease clinic, evidence for herpes simplex type 2 infection was found in 46 percent. Among the women attending college, the rate was 8.8 percent. Only a minority of the women testing positive had clinical or historical evidence of a herpes infection; the infection was asymptomatic in 66 percent of the women from the clinic and 71 percent of the college women. The results indicate that a routine medical examination will fail to identify the majority of women with herpes type 2 infection. Therefore, these women are unlikely to receive counseling on preventing the infection in their sexual partners or preventing transmission to an infant during birth. The authors remind the reader that infection with genital herpes is a risk factor for AIDS. This may be due both to the association of herpes infection with higher risk behavior and the possibility that genital sores may promote the transmission of the AIDS virus. (Consumer Summary produced by Reliance Medical Information, Inc.)

Trichomoniasis is a common infection among sexually active women. It can be difficult to diagnose by a physical examination alone; isolation of the organism from tissue samples is needed to confirm its presence. Previous studies of women with genital infections indicated that colpitis macularis ('strawberry cervix') was the best predictive clinical sign for presence of trichomoniasis. In the same study, though, only 50 percent of the women with trichomoniasis had colpitis macularis. These studies were extended to determine if colpitis macularis correlated with some characteristic of trichomoniasis infection, such as type of strain, amount of organism, virulence, or presence of purulent vaginal discharge. Among 12 infected women who had no other genital infections, there was no relationship between presence of colpitis macularis and amount of organism present or virulence as measured by three different techniques. Purulent discharge, which was previously found to be a somewhat predictive sign of trichomoniasis, was confirmed to be associated with presence of colpitis macularis. As colpitis macularis and purulent discharge did not correlate with any of the postulated characteristics, it is suggested that these signs may instead reflect the stage of infection and immune reaction, or they may depend on other organisms to reach full development. Alternatively, the techniques used to measure virulence may not be relevant to the organism's function. Further studies of the biology of trichomoniasis and interaction with human tissue are needed to before the disease can be better diagnosed and understood. (Consumer Summary produced by Reliance Medical Information, Inc.)