Alfred Spira

Sexual behavior changes and protease inhibitor therapy

ObjectiveTo examine changes in sexual activity and unprotected sexual intercourse among HIV-infected patients before and after the initiation of protease inhibitor therapy. DesignAn analysis of data from the SEROCO Study, a French prospective cohort. MethodsAll 191 patients who initiated protease inhibitor therapy after 1 January 1996, who were interviewed within one year before the initiation of therapy (Time 1), and who had at least 6 months of follow-up after therapy initiation (Time 2) were included. Patients provided information about sex partner characteristics and unprotected sexual intercourse. ResultsEighty-one (42%) were gay or bisexual men, 46 (24%) were heterosexual men, and 64 (34%) were women. No significant increases were found in either the number of patients reporting anal or vaginal sex or the number reporting unprotected sexual intercourse after protease inhibitor initiation. However, in matched pair analysis, gay or bisexual men were three times more likely to report having had unprotected sexual intercourse with partners who were of HIV-negative or unknown serostatus after protease inhibitor initiation [relative risk (RR) = 3.0, 95% confidence interval (CI) = 1.2–7.6]. Non-significant decreases in unprotected sexual intercourse among both heterosexual men and women were also observed. No relationship between plasma viral load after protease inhibitor initiation and unprotected sexual intercourse was found in these data. ConclusionsA relapse in sex risk practices among some HIV-infected gay or bisexual men cannot be ruled out and requires both continued monitoring and immediate secondary preventative intervention.

How would a decline in sperm concentration over time influence the probability of pregnancy

Background: Reports have suggested a decline in sperm concentration during the second half of the 20th century. The effect of this decline on fecundability (the monthly probability of pregnancy) could be detected in principle by a study of time to pregnancy. In practice, the amplitude of this expected effect is not well known and the statistical power of time-to-pregnancy studies to detect it has not been explored. Methods: We developed a nonparametric model to describe a temporal decline in sperm concentration using data on French semen donors. We then applied this model to 419 Danish couples planning a first pregnancy in 1992, to predict their time to pregnancy as if the pregnancy attempt had begun during earlier decades with higher sperm concentrations. Finally, we used bootstrap simulations to estimate the statistical power of prospective or retrospective studies that compared fecundability (estimated from time to pregnancy) across these time periods. We express the change in fecundability over time as a fecundability ratio (FR), with values less than 1 indicating decreased fecundability. Results: We estimate that the median sperm concentration decreased by 21% from 1977 to 1992 and by 47% from 1947 to 1992. The estimated decline in fecundability with those semen changes was 7% from 1977 to 1992 (FR = 0.93, adjusted) and 15% from 1947 to 1992 (FR = 0.85, adjusted). The total numbers of couples that would be needed in prospective studies of time to pregnancy to detect these changes in fecundability (with a power of 80%) were 12,000 when comparing 1977 to 1992, and 2000 when comparing 1947 to 1992. Retrospective studies of the same size that excluded childless couples had much lower statistical power and were biased toward the null. Conclusion: The effect of realistic declines in sperm concentration on time to pregnancy may be observed only with studies that include several thousand couples.

Declining human fertility

n This article comments on the conclusion reached by Akre et al. in their study on human fertility. Akre et al. concluded that subfertility (measured as a waiting time to pregnancy of 1 year) decreased from 1983 to 1993 in Sweden and that the decline followed a birth cohort pattern. In addition, they speculated that the decrease in subfertility during the 1980s is mainly due to the eradication of gonorrhea. However, the data they presented does not seem to justify their conclusion. The researchers did not study the consequences of truncation of the waiting-time distribution in 1993 and 1983, the association between smoking and infertility, and declining semen quality in order to further support their conclusion.n

Analysis of 369 abortions conducted by mifepristone * (RU486) associated with sulprostone † in a French family planning center

Objective To investigate the use of oral mifepristone (RU486; Roussel-Uclaf, Paris, France) associated with IM injection of sulprostone (Schering, Lys-Lez-Lannoy, France) for the induction of legal abortion (7weeks of amenorrhea in France). Design An uncontrolled observational study. Setting A public family planning center in Paris. Patients Three hundred sixty-nine (369) pregnant women with up to 7weeks amenorrhea undergoing legal abortion. Interventions Six hundred milligrams (600mg) of oral mifepristone followed 48hours later by an IM injection of 250 μ g of sulprostone. Main Outcome Measures Frequency of complete abortion and the need for subsequent surgical evacuation, hospitalization, and blood transfusion. Measurement of the β -hCG concentration before and 14days after the oral administration of mifepristone. Results There was complete abortion in 93.2% of the cases. Of the 25 failures, 8 were continued pregnancies, 6 terminated pregnancy but without expulsion of the conceptus, and 11 were placenta retentions. Eight women required short hospitalization, but none needed blood transfusion. Among the 25 failures, 23 had a β -hCG concentration>500IU/mL [sensitivity 92%, specificity 83%]. Conclusion The sequential use of oral mifepristone and IM injection of sulprostone is effective in inducing abortion up to 7weeks of amenorrhea. Nevertheless the risk of maternal morbidity associated with sulprostone and also the risk of fetal malformations in cases of continued pregnancy indicate that this method should only be used in specialist centers.

Sexual behavior and smoking: risk factor for urethritis in men.

Two hundred men who had symptoms of urethritis and 207 controls were interviewed. Because 60% of the men were of foreign nationality, the analysis of risk factors for urethritis was undertaken separately for the French and foreign subpopulations. The risk factors for urethritis were different for the French and foreign men. For the French men who had smoked, the risk of infection was 2.9 times greater than that for men who had never smoked (95% confidence interval, 1.2-7.6), after taking type of sexual behavior into account. There is a significant increase in the risk of urethritis when the amount of tobacco consumed daily increases (P less than 0.02). This finding suggests that smoking is an independent risk factor.

Reproductive life events in the population living in the vicinity of a nuclear waste reprocessing plant

Objective: There is concern about the health of populations living close to nuclear waste reprocessing plants. A comparative study was conducted on reproductive life events in the general population living near the nuclear waste reprocessing plant in Beaumont-Hague, France and a reference area in Brittany. Design, setting and participants: Women were randomly selected and retrospectively questioned on reproductive life events occurring between 1985 and 2000. The monthly probability of pregnancy (assessed by time to pregnancy for pregnancy attempts leading or not to a live birth), occurrence of involuntary infertility, miscarriage and birth weight were compared between both areas using regression models with random effect. Results: Compared with the reference area (326 couples) and after adjustment for sociodemographic and behavioural factors, couples from Beaumont-Hague (857 couples) had an estimated hazard ratio of pregnancy of 1.19 (95% CI 0.89 to 1.58). The prevalence ratio of 12-month involuntary infertility was 0.99 (95% CI 0.64 to 1.55) and the odds ratio of miscarriage was 0.86 (95% CI 0.85 to 1.33) for Beaumont-Hague, compared with the reference area. Mean birth weight was similar in both areas (95% CI of difference −85 g to 53 g). Conclusion: No increased risk of adverse reproductive life events was highlighted in the population living in the vicinity of the French nuclear waste reprocessing plant, compared with the reference area. Reproductive health is unlikely to be strongly altered in the general population of Beaumont-Hague.

Evaluation by women consulting in a family planning centre of their risk of HIV infection.

In order to assess womens self-perception of their risk of infection by HIV, research was performed among 654 women who had consulted in a family planning centre in the Paris region. Of the 452 (69%) women who took part in this research, 77% considered themselves as not at risk of carrying the AIDS virus, 11% as at risk and 12% did not give a specific answer. The most important risk factors noted by the patient and the doctor were found to be the number of partners, the use of syringes and the non-or faulty use of condoms. Estimates of the risk of infection by physicians had a high correlation with those of the women, although there were wide differences between the opinions of the six doctors involved. In one case out of three the doctors were unable to decide whether or not their patient was at risk. The evident difficulties experienced by these physicians show an urgent need for the development of specific medical training programmes. The seroprevalence of 2.4% of HIV infection among the women studied, and 1.1% of those who consulted during the study period, confirm the importance of carrying out specific studies on women consulting in family planning centres.

Les comportements de prévention du Sida : prévalence et facteurs favorisants.

Ducot (Beatrice), Spira (Alfred). - Comportamientos de prevencion del Sida : preva- lencia y factores favorecedores En materia de prevencion de enfermedades sexualmente transmisibles y del Sida se pueden adoptar varias estrategias : seleccion y disminucion del numero de parejas, abando- no de ciertas practicas, utilizacion del preservativo. Entre los individuos heterosexuales en- cuestados para ACSF, el 36 % de los hombres y el 30 % de las mujeres que habian tenido al menos dos parejas distintas durante los ultimos cinco afios declaran haber « cambiado su comportamiento desde que se habla del Sida». Los cambios que se citan con mas frecuencia son una seleccion y una disminucion del numero de parejas. Las personas mas susceptibles de haber cambiado de comportamiento son aquellas que no viven en pareja, con un numero elevado de parejas y las que declaran haber tenido anteriormente una enfermedad sexualmente transmisible. En cuanto al comportamiento durante los doce meses anteriores a la en- cuesta, si se excluyen las personas que declaran haber tenido una sola pareja supuesta о realmente fiel, un 15 % de los hombres y un 8 % de las mujeres con una sola pareja durante el periodo, y un 17 % de los hombres y un 5 % de mujeres con mas de una pareja declaran haber utilizado el preservativo de forma sistematica. Algunos de los factores que favorecen la proteccion son el tipo de pareja, nueva u ocasional, y el caracter reciente de la relacion. Finalmente, el hecho de tener uno o mas confidentes con los cuales se comparten problemas fntimos favorece la concienciacion del riesgo de infeccion y la adopcion de un comportamiento preventivo.

Does male age have an influence on the risk of spontaneous abortion

Couples from Western countries tend to delay their pregnancies, which may affect their ability to obtain a live birth. We assessed the association between male age and the risk of spontaneous abortion taking into account womans age. We performed telephone interviews on a ross-sectional random population sample of 1124 French women who had been pregnant between 1985 and 2000, who described 2281 pregnancies, among which 290 (12.7%) ended by a spontaneous abortion. We used logistic regression and generalised partial linear models, a class of semiparametric regression models. Our final random effect logistic regression model predicted that, among women aged 25 years, the odds-ratio (OR) of spontaneous abortion associated with the male partner being older than 35 years, as compared to men younger than 35 years, was 2.48 (95% Confidence Interval (CI): [1.13-5.41]). No such effect of male age was observed when the woman was 35 years (OR=0.53, CI: [0.27-1.01]). Male age had on the whole no strong influence on the risk of spontaneous abortion, but exhibited an increased risk after 35 years, only among younger women. This possible effect should be further investigated, possibly in studies with assessment of the presence of chromosomal abnormalities in the abortus.

L'enquête ACSF : élaboration d'un projet interdisciplinaire sur la sexualité

Bajos (Nathalie) and Spira (Alfred). - La encuesta ACSF : elaboration de un proyeeto multidisciplinario sobre la sexualidad La Agencia Nacional de Investigaciones sobre el Sida solicite la realizacion de una encuesta sobre los comportamientos sexuales en Francia, como ayuda para elaborar las es- trategias de prevencion de la epidemia. Bajo una perspectiva de salud publica, un proyeeto de este tipo tenia que ser multidisciplinario, combinando un analisis de epidemologia des- criptiva y un analisis psicologico y sociologico de las modalidades y factores ligados a los distintos tipos de actividades sexuales. Para llevar a cabo la encuesta se constituyo un equipo pluridisciplinario compuesto por epidemologos, sociologos, demografos y economistas. La perspectiva multidisciplinaria se tuvo en cuenta en todas las etapas de la investigacion : elaboracion de las problematicas, construccion de la metodologia, recogida de datos, analisis de datos. Es necesario seňalar que los analisis llevados a cabo hasta este momento son basicamente monodisciplinarios, aunque el trabajo realizado por cada miembro del equipo ha estado influido por los numero- sos debates pluridisciplinarios que tuvieron lugar al inicio de la investigacion. Actualmente esta en curso un analisis global y multidisciplinario ; este tiene como objetivo identificar las logicas sociales y psicologicas que generan determinadas situaciones relacionales las cuales comportan ciertas practicas que los epidemiologos definen como practicas de riesgo. Estos analisis deben aportar el material necesario para la comprension de las situaciones bajo riesgo, y permitir con ello una mejor adaptacion de las estrategias de prevencion.