Human Papillomavirus: Confronting the Epidemic-A Urologist's Perspective

The human papillomavirus (HPV) has long been associated with the development of penile lesions-condyloma acuminatum and verrucous carcinoma of the penis. More recently, HPV has been implicated as an etiology of more serious neoplasias in men-penile carcinoma and other anogenital squamous-cell carcinomas. HPV is now widely recognized as responsible for more than 95% of cervical cancers in women. HPV seems to have been receiving relatively scant attention to date-from physicians in general, and particularly from urologists-as a venereal disease of significant concern. Yet HPV is recognized to be the most frequently acquired sexually transmitted viral infection worldwide. It is estimated that approximately 6 million new cases of HPV are sexually transmitted annually in the United States. Fortunately, many, if not most, of these HPV infections are transient. However, each newly acquired infection has the potential to persist as an incurable, lifelong affliction, generating a significant increase in the long-term risk of cancer for patients and their sexual partners. Many of these HPV-related cancers will not become manifest until decades later.     

HIV/AIDS epidemic in Eastern Europe: Recent developments in the Russian Federation and Ukraine among women

Background: The Russian Federation and the Ukraine are among the Eastern European countries with the fastest growing number of cases of HIV. According to data from the Joint United Nations Program on HIV/AIDS, nearly 90% of newly reported HIV diagnoses in Eastern Europe in 2006 were from the Russian Federation (66%) and the Ukraine (21%). A growing number of women are infected with HIV. The impact of gender on HIV/AIDS is an important factor in understanding the development and evolution of the HIV/AIDS epidemic in Eastern Europe.Objective: The aim of this study was to assess the importance of integrating gender consideration into the creation of HIV programs and to examine the effect of gender on HIV/AIDS.Methods: Reported HIV/AIDS cases from the official epidemiological register of the Ukrainian Centre for AIDS Prevention alongside data from the Russian Federal AIDS Center were analyzed. Joint United Nations Program on HIV/AIDS country fact sheets were reviewed and analyzed, and this information was supplemented with published HIV prevalence and sexually transmitted disease case reporting information, unpublished reports, and expert evaluations.Results: Of the newly registered cases of HIV, the proportion of women rose from 13.0% in 1995 to 44.0% in 2006 in the Russian Federation, and from 37.2% in 1995 to 41.9% in 2006 in the Ukraine. There has also been a considerable increase in mother-to-child transmission of HIV since 1995. Between 1987 and 1994, the proportion of children among the people newly infected with HIV in the Ukraine was 2.2%; in 2006 it was 17.6%. In 2006, 16,078 new HIV cases were registered in the Ukraine and 39,652 new HIV cases in the Russian Federation. Large increases in the number of HIV-infected women were reported from both countries.Conclusions: The data examined in this study suggest subregional differences in the magnitude of the HIV/AIDS epidemic in the Russian Federation and the Ukraine and the importance of the impact of gender on the rapid spread of the HIV/AIDS epidemic among women and women of child-bearing age. To protect women from HIV infection, it is important to find ways to empower them by implementing policies and specific prevention measures that increase their access to knowledge about HIV/AIDS; the empowerment of women is vital to reversing the HIV/AIDS epidemic.     

Guidelines for the Control of Human Immunodeficiency Virus Infection in Adolescents

Although adolescents account for only 0.4% of reported cases of the acquired immunodeficiency syndrome (AIDS) in the United States, they are sexually active and, therefore, at risk of acquiring human immunodeficiency virus (HIV) infection. To address issues of HIV control in adolescents, we developed guidelines that emphasize education and medical care and deemphasize antibody testing. For adolescents known to be infected with HIV, we recommend no restrictions on access to educational or treatment programs except when their health providers recommend such restrictions to protect them from exposure to opportunistic infections. For adolescents of unknown antibody status with a possible previous exposure to HIV, we recommend that as long as the incidence of HIV infection and clinical AIDS remains low, there should be no restrictions on residential placements and no routine antibody testing.     

Human retroviral infections in The Gambia: prevalence and clinical features

The prevalence of infection with human immunodeficiency virus type 1 (HIV 1) is lower in west Africa than in other parts of Africa. Human immunodeficiency virus type 2 (HIV 2) has been isolated from west African patients and may be transmitted by heterosexual contact. The prevalence of antibodies to HIV 1 and HIV 2 was studied by enzyme linked immunosorbent assay (ELISA) among various groups of subjects in The Gambia, west Africa—namely, prostitutes, blood donors, patients with suspected infection with HIV, patients attending clinics for sexually transmitted diseases, and patients with tuberculosis. Four cases of the acquired immune deficiency syndrome (AIDS) due to infection with HIV 1 were detected, of which three had been acquired abroad. No other subject was found to be positive for antibodies to HIV 1. The prevalence of antibodies to HIV 2 among the patients attending clinics for sexually transmitted diseases was found to have increased from 0/117 in 1984 to 10/185 (5%) in the last six months of 1986. One out of 278 blood donors was positive for antibodies to HIV 2 as were 10 out of 80 patients with suspected AIDS.HIV 2 seems to be transmitted sexually, and, although it has been present for only a short time, it seems to be endemic in The Gambia and is pathogenic.     

Focus: Sex and Gender Health: Beyond the Pap Smear: Gender-responsive HIV Care for Women

Women comprise nearly one-quarter of all people living with human immunodeficiency virus (HIV) in the U.S. and 20 percent of incident annual cases. Though women overall are more likely than men to be diagnosed with HIV and engage in care, they are as unlikely to successfully achieve viral suppression with antiretroviral therapy, suggesting gender-based disparities that should be addressed by gender-responsive policies and programs. Using the socioecological model of health and syndemics theory, we comprehensively reviewed published literature to evaluate reasons for and ways to address gender differences in HIV risk and treatment. We discuss the biologic, sociocultural, interpersonal, and behavioral contexts of HIV risk that affect women, comprehensive healthcare for women with HIV that includes pregnancy planning or prevention, and policy implications.     

Prostitution and risk of HIV: female prostitutes in London.

OBJECTIVE--To measure the prevalence of HIV and to describe established risk factors in female prostitutes. DESIGN--A cross sectional survey. SETTING--A genitourinary medicine clinic, streets, and magistrates'' courts in London. SUBJECTS--280 female prostitutes recruited between April 1989 and August 1991. MAIN OUTCOME MEASURES--Infection with HIV-1, reported risk behaviours, and prevalence of sexually transmitted infections. RESULTS--228 of the women had HIV tests, and two (0.9% (95% confidence interval 0% to 2.1%)) were infected with HIV-1. Reported use of condoms was high for commercial clients and low for non-paying partners: 98% (251/255) of women used condoms with all clients and 12% (25/207) with non-paying partners for vaginal intercourse. Twenty two women were current or past injecting drug users. Of the 193 women examined for sexually transmitted infections, 27 had an acute infection (gonorrhoea, chlamydia, trichomonas, or primary genital herpes) at the time of interview. Infection was associated with younger age and increasing numbers of non-paying sexual partners, but not with duration of prostitution, numbers of clients, or reports of condom failures. When age and numbers of non-paying partners were analysed by logistic regression they remained significantly associated with sexually transmitted infections. CONCLUSIONS--A large and diverse sample of prostitutes had a low prevalence of infection with HIV and high levels of use of condoms in commercial sex. There was a significant risk of other sexually transmitted infections associated with prostitutes'' non-commercial sexual relationships, in which unprotected sex is common. Interventions to reduce the risk of sexually transmitted infections in prostitutes should address both commercial and non-commercial sexual partnerships.     

Risk factors for infection with human immmunodeficiency virus among European expatriates in Africa.

The pattern of cases of AIDS in Belgium suggests that Europeans infected with human immunodeficiency virus (HIV) acquired the infection in Africa. The prevalence of infection was assessed in Belgian advisers and European expatriates and risk factors for infection defined in a case-control study of expatriate men. Fifteen (1.1%) of 1401 Belgian advisers working in Africa and 41 (0.9%) of 4564 European expatriates living in Africa, were positive for antibody to HIV in a voluntary screening programme in Belgium. Among subjects with antibody to HIV the ratio of men to women was 3:1. These subjects did not have a history of intravenous drug abuse or blood transfusion and only one was homosexual. In a case-control study of 33 expatriate men who had antibody to HIV and 119 controls the men with antibody reported significantly more female sexual partners, who were more commonly local; and significantly more sexual contact with prostitutes in Africa. They had a significantly higher prevalence of history of sexually transmitted disease and had received significantly more injections by unqualified staff in Africa during the previous five years. No specific sexual practices were associated with having antibody to HIV. After multivariate analysis sexual contact with local women (adjusted odds ratio 14.7; 95% confidence interval 2.81 to 76.9), sexual contact with prostitutes (adjusted odds ratio 10.8 (1.6 to 71.9), and injections by unqualified staff (adjusted odds ratio 13.5 (3.7 to 49.8) remained independent risk factors for infection. European expatriates in Africa were at increased risk from infection with HIV and were a means of introducing HIV into the heterosexual population in Europe. Transmission from women to men by vaginal intercourse seemed to be the most probable route of infection.     

The epidemiology of human immunodeficiency virus in South Africa

We review the epidemiology of human immunodeficiency virus (HIV) in South Africa where the prevalence of HIV infection is among the highest in the world. The epidemic reached South Africa relatively recently but the prevalence of infection has increased rapidly and there are significant differences among provinces. Although few 15-year-old people are infected the prevalence increases rapidly with age thereafter, especially among women. The prevalence of herpes simplex virus type 2 exceeds that of HIV and curable sexually transmitted infections are common. 'Circular migration' may help to explain the high rates and rapid spread of HIV in the region. The incidence of tuberculosis has increased dramatically as a result of the HIV epidemic. Antiretroviral therapy for the prevention of vertical transmission has been shown to be effective in local conditions but transmission through breast-feeding remains problematical. While some epidemiological models have been developed, much more needs to be done in this regard in order to plan, coordinate and evaluate an effective response to the epidemic. We conclude by discussing some of the research that is needed and steps that could be taken to reduce the continued spread of the infection.     

Drug resistance in the sexually transmitted protozoan Trichomonas vaginalis

Trichomoniasis is the most common, sexually transmitted infection.It is caused by the flagellated protozoan parasite Trichomonas vagina/is. Symptoms include vaginitis and infections have been associatedwith preterm delivery, low birth weight and increased infant mortality, as well as predisposing to HIV/AIDSand cervical cancer. Trichomoniasis has the highest prevalence and incidence of any sexually transmitted infection. The 5-nitroimidazole drugs, of which metronidazole is the most prescribed, are the only approved,effective drugs to treat trichomoniasis. Resistance against metronidazole is frequently reported and cross-resistance among the family of 5-nitroimidazole drugs is common, leaving no alternative for treatment, withsome cases remaining unresolved. The mechanism of metronidazole resistance in T. Vagina/is from treatment failures is not well understood, unlike resistance which is developed in the laboratory under increasingmet ronidazole pressure. In the latter situation, hydrog enosomal function which is involved in activationof the prodrug, metronidazole, is down-regulated. Reversion to sensitivity is incomplete after removal ofdrug pressure in the highly resistant parasites while clinically resistant strains, so far analysed, maintaintheir resistance levels in the absence of drug pressure. Although anaerobic resistance has been regarded asa laboratory induced phenomenon, it clearly has been demonstrated in clinical isolates. Pursuit of both approaches will allow dissection of the underlying mechanisms. Many alternative drugs and treatments have been tested in vivo in cases of refractory trichomoniasis, as well as in vitro with some successes including the broad spectrum anti-parasitic drug nitazoxanide. Drug resistance incidence in T. Vagina/is appears to be on the increase and improved surveillance of treatment failures is urged.     

Mobility,Violence and the Gendering of HIV in Papua New Guinea

The links between gender, sexuality and violence hold serious implications for HIV transmission and its social and economic effects. In Papua New Guinea, enduring and pervasive patterns of male sexual behaviour involving coercion, violence and gang rape are highly conducive to the transmission of HIV and other sexually transmitted infections and have a critical bearing on women's sexual autonomy and health. The realities of violence are intensified by the widespread view that women are responsible for the spread of the virus. This paper engages the theme of mobility to consider the fluid and dynamic character of gender relations and sexuality in contemporary Papua New Guinea, and to gain perspective on constructions of modern masculinity and the discursive representations of gender violence in the context of the escalating HIV epidemic.     

Is Food Insecurity Associated with HIV Risk? Cross-Sectional Evidence from Sexually Active Women in Brazil

Background

Understanding how food insecurity among women gives rise to differential patterning in HIV risks is critical for policy and programming in resource-limited settings. This is particularly the case in Brazil, which has undergone successive changes in the gender and socio-geographic composition of its complex epidemic over the past three decades. We used data from a national survey of Brazilian women to estimate the relationship between food insecurity and HIV risk.

Methods and Findings

We used data on 12,684 sexually active women from a national survey conducted in Brazil in 2006–2007. Self-reported outcomes were (a) consistent condom use, defined as using a condom at each occasion of sexual intercourse in the previous 12 mo; (b) recent condom use, less stringently defined as using a condom with the most recent sexual partner; and (c) itchy vaginal discharge in the previous 30 d, possibly indicating presence of a sexually transmitted infection. The primary explanatory variable of interest was food insecurity, measured using the culturally adapted and validated Escala Brasiliera de Segurança Alimentar. In multivariable logistic regression models, severe food insecurity with hunger was associated with a reduced odds of consistent condom use in the past 12 mo (adjusted odds ratio [AOR] = 0.67; 95% CI, 0.48–0.92) and condom use at last sexual intercourse (AOR = 0.75; 95% CI, 0.57–0.98). Self-reported itchy vaginal discharge was associated with all categories of food insecurity (with AORs ranging from 1.46 to 1.94). In absolute terms, the effect sizes were large in magnitude across all outcomes. Underweight and/or lack of control in sexual relations did not appear to mediate the observed associations.

Conclusions

Severe food insecurity with hunger was associated with reduced odds of condom use and increased odds of itchy vaginal discharge, which is potentially indicative of sexually transmitted infection, among sexually active women in Brazil. Interventions targeting food insecurity may have beneficial implications for HIV prevention in resource-limited settings. Please see later in the article for the Editors'' Summary     

Patterns of sexual behaviour and reported symptoms of STI/RTIs among young people in Croatia--implications for interventions' planning

This paper describes some of the results of the first national-level survey on sexual behaviour and the distribution of risks to sexually transmitted infections (STIs), including human immunodeficiency virus infection (HIV), among youth in Croatia, and the nature and the extent of their vulnerability to these adverse health outcomes. The study was a cross-sectional, probability-based household survey conducted in 2005, and included 1093 respondents aged 18-24. This paper aims to describe the findings related to the knowledge of HIV transmission, key behavioural outcomes relevant for potential transmission of HIV and STIs, and correlates of genital discharge in young men and young women. More than 80% of young people know that the correct use of condoms protects against HIV and that HIV can be transmitted by someone who looks healthy. Fifty-nine percent of young men and 52.4% of young women reported using condoms during the first sexual intercourse, and 59.3% of men and 46.1% of women used condoms during the last sexual intercourse with a casual partner. This points to the gap between knowledge of condom use and the actual use of condoms as a high proportion of risky sexual contact remain unprotected. Having sexual intercourse frequently or regularly while consuming alcohol was reported by 19.2% of men and 7.6% of women. Much lower proportion are using drugs frequently or regularly during sexual intercourse (3.7% of men and 2.1% of women). Among those sexually experienced, 11.8% of men and 44.1% of women reported ever having a genital discharge. Higher presence of genital discharge in women is suggestive of reproductive tract infections that are not necessarily sexually transmitted. In the multivariate analysis, the lack of knowledge of whether chlamydial infections is an STI and having more than five partners in life were correlates of genital discharge in men, while in women the correlates included having more than five partners in life and not using condoms during the first sexual intercourse. Higher burden of STI-related symptoms was found among men who have men as sexual partners, those who paid for sex, and those with concurrent partnerships. These findings point out to the immediate need to strengthen sexual health education among young people and to the necessity for further development of other broad-based interventions to prevent adverse sexual health outcomes among both men and women, as well as those targeted towards more vulnerable subgroups.     

Case-control study of self reported genitourinary infections and risk of gastroschisis: findings from the national birth defects prevention study, 1997-2003

Objective To assess the association between genitourinary infections in the month before conception to the end of the first trimesterand gastroschisis.Design Case-control study with self reported infections from a computer assisted telephone interview.Setting National birth defects prevention study, a multisite, population based study including 10 surveillance systems for birth defects in the United States.Participants Mothers of 505 offspring with gastroschisis and 4924 healthy liveborn infants as controls.Main outcome measure Adjusted odds ratios for gastroschisis with 95% confidence intervals.Results About 16% (n=81) of case mothers and 9% (n=425) of control mothers reported a genitourinary infection in the relevant time period; 4% (n=21) and 2% (n=98) reported a sexually transmitted infection and 13% (n=67) and 7% (n=338) reported a urinary tract infection, respectively. Case mothers aged <25 years reported higher rates of urinary tract infection alone and in combination with a sexually transmitted infection compared with control mothers. In women who reported both types of infection, there was a greater risk of gastroschisis in offspring (adjusted odds ratio 4.0, 95% confidence interval 1.4 to 11.6).Conclusion There is a significant association between self reported urinary tract infection plus sexually transmitted infection just before conception and in early pregnancy and gastroschisis.     

Correlates of HIV Acquisition in a Cohort of Black Men Who Have Sex with Men in the United States: HIV Prevention Trials Network (HPTN) 061

Background

Black men who have sex with men (MSM) in the United States (US) are affected by HIV at disproportionate rates compared to MSM of other race/ethnicities. Current HIV incidence estimates in this group are needed to appropriately target prevention efforts.

Methods

From July 2009 to October 2010, Black MSM reporting unprotected anal intercourse with a man in the past six months were enrolled and followed for one year in six US cities for a feasibility study of a multi-component intervention to reduce HIV infection. HIV incidence based on HIV seroconversion was calculated as number of events/100 person-years. Multivariate proportional hazards modeling with time-dependent covariates was used to identify correlates of HIV acquisition.

Results

Of 1,553 Black MSM enrolled, 1,164 were HIV-uninfected at baseline and included in follow-up. Overall annual HIV incidence was 3.0% (95% confidence interval (CI): 2.0, 4.4%) and 5.9% among men ≤30 years old (95% CI: 3.6, 9.1%). Men ≤30 years old reported significantly higher levels of sexual risk and were more likely to have a sexually transmitted infection diagnosed during follow-up. Younger men also were more likely to not have a usual place for health care, not have visited a health care provider recently, and to have unmet health care needs. In multivariate analysis, age ≤30 years (hazard ratio (HR): 3.4; 95% CI: 1.4, 8.3) and unprotected receptive anal intercourse with HIV-positive or unknown status partners (HR: 4.1; 95% CI: 1.9, 9.1) were significantly associated with HIV acquisition.

Conclusion

In the largest cohort of prospectively-followed Black MSM in the US, HIV incidence was high, particularly among young men. Targeted, tailored and culturally appropriate HIV prevention strategies incorporating behavioral, social and biomedical based interventions are urgently needed to lower these rates.     

Chlamydia heat shock protein 60 induces trophoblast apoptosis through TLR4

Intrauterine infection affects placental development and function, and subsequently may lead to complications such as preterm delivery, intrauterine growth retardation, and preeclampsia; however, the molecular mechanisms are not clearly known. TLRs mediate innate immune responses in placenta, and recently, TLR2-induced trophoblast apoptosis has been suggested to play a role in infection-induced preterm delivery. Chlamydia trachomatis is the etiological agent of the most prevalent sexually transmitted bacterial infection in the United States. In this study, we show that in vitro chlamydial heat shock protein 60 induces apoptosis in primary human trophoblasts, placental fibroblasts, and the JEG3 trophoblast cell line, and that TLR4 mediates this event. We observed a host cell type-dependent apoptotic response. In primary placental fibroblasts, chlamydial heat shock protein 60-induced apoptosis was caspase dependent, whereas in JEG3 trophoblast cell lines it was caspase independent. These data suggest that TLR4 stimulation induces apoptosis in placenta, and this could provide a novel mechanism of pathogenesis for poor fertility and pregnancy outcome in women with persistent chlamydia infection.     

HIV-infection in Estonia

Only a few cases of clinical AIDS have been diagnosed in the Baltic countries that previously were part of the Soviet Union. This suggests that the spread of HIV-infection has been much slower than in several other countries belonging to the previous Eastern Europe. To get a more precise picture of the situation, we have analyzed the data from seroepidemiological screening programs that have been conducted in Estonia since June 1987. Large population groups were tested according to a decree by the former soviet All-Union center on AIDS. On several occasions the tests were mandatory and probably had a coverage close to 100%. After more than a million serum samples were tested, 29 HIV-infected persons, 3 women and 26 men have been identified. One of them was HIV-2 positive. Most of them live in Tallinn, the capital city of Estonia. All cases probably have a sexually transmitted infection. In one the infection has proceeded to clinical AIDS. Analysis of the gene sequences of several strains suggests that the strains are closely related and that the number of sources of infection is quite small. The study suggests that the spread of HIV in Estonia is still quite limited. A contributing factor may be the restricted possibilities for travel to the Western countries during the Soviet era.     

The role of sexually transmitted diseases in HIV transmission

More than 42 million people worldwide are now infected with HIV, in spite of sustained prevention activities. Although the spread of HIV has been primarily sexual, epidemiological studies have indicated that the efficiency of the spread of HIV is poor, perhaps as infrequently as 1 in every 1,000 episodes of sexual intercourse. However, sexually transmitted diseases (STDs) that cause ulcers or inflammation greatly increase the efficiency of HIV transmission--by increasing both the infectiousness of, and the susceptibility to HIV infection. STDs might be particularly important in the early stages of a localized HIV epidemic, when people with risky sexual behaviour are most likely to become infected. In China, eastern Europe and Russia, there has been a remarkable increase in the incidence of STDs in recent years, and this is reflected in the rapid increase in the spread of HIV in these areas. Targeted STD detection and treatment should have a central role in HIV prevention in these emerging epidemics.     

Continuing transmission of sexually transmitted diseases among patients infected with HIV-1 attending genitourinary medicine clinics in England and Wales.

OBJECTIVE--To determine whether those who are aware of being infected with HIV continue to adopt behaviours that place others at risk of HIV infection. DESIGN--Ongoing survey of current diagnosis of sexually transmitted disease and awareness of HIV infection among patients attending genitourinary medicine clinics. SETTING--Six genitourinary medicine clinics in England and Wales (two in London and four outside) participating in unlinked anonymous HIV serosurveillance during 1990-3. SUBJECTS--All attenders having blood drawn for syphilis serology for the first time during the calendar quarter of attendance. MAIN OUTCOME MEASURES--The proportion of syphilis serology specimens with antibody to HIV-1 detected by unlinked anonymous testing of the residue. The proportion of attenders infected with HIV-1 who remained clinically undetected, and the proportion who had another recently acquired sexually transmitted disease. RESULTS--Of 85441 specimens tested, 2328 (2.7%) were positive for antibodies to HIV-1. About 30% of these specimens were from attenders whose HIV-1 infection remained clinically undetected. HIV-1 infection was found to coexist with another recently acquired sexually transmitted disease in 651 attenders, of whom 522 were homosexual or bisexual men. Of these, 245 (47%) already knew themselves to be infected with HIV-1. This proportion increased between 1990 and 1993. CONCLUSIONS--A considerable proportion of patients infected with HIV-1 are not identified by voluntary confidential HIV testing in genitourinary medicine clinics. Substantial numbers of homosexual or bisexual men attending genitourinary medicine clinics continue to practise unsafe sex despite being aware of their infection with HIV-1.     

The prostitution situation in a number of cities of Russia, Ukraine and Byelarus

The analytical study indicating that 25% of prostitutes use drugs by intravenous injection is presented. As determined in this study, prostitutes face the double danger of being infected with HIV (they undergo treatment for drug addiction and sexually transmitted diseases). The conclusion has been made that no educational work on HIV/AIDS is carried out among this group of women, though they run a high risk of infection. According to this study, the requirements which ensure the health of prostitutes may be realized by itinerary educational programs, the publication of information materials, specially intended for distribution among such women. The necessity to supplement information on AIDS with information on STD is noted, alerting the public on the fact that these infections are closely connected. The necessity of educating transport and industrial workers, as well as people working in the system of the Ministry of Defense, with a view to prevent the spread of HIV infection is also considered to be an important factor (on the example of Belarus).