B A Evans

NATURAL HISTORY OF LIVER DISEASE IN CHRONIC HEPATITIS B SURFACE ANTIGEN CARRIERS: Survey of 100 Patients from Great Britain

100 consecutive British chronic carriers of hepatitis B surface antigen seen in a London teaching hospital are described. 77 were male homosexuals and only 19 had either symptoms or signs of chronic liver disease. 27 had normal liver function tests and 69 of the remaining patients had minimal changes, chronic persistent hepatitis, chronic active hepatitis, cirrhosis, or hepatocellular carcinoma diagnosed on liver biopsy. The 4 remaining patients did not have a biopsy but did have abnormal liver function tests. Chronic hepatitis B virus infection was an important cause of these conditions. Most patients showed no clinical, biochemical, or histological change during a mean follow-up period of 44 months, and only 9.7% spontaneously seroconverted from hepatitis B antigen positivity to become anti-hepatitis B e antibody carriers. Although the prognosis is good in the medium term, 7 patients died from hepatocellular carcinoma.

Disorders of fat distribution in HIV infection

Alterations in body shape due to fat loss and/or redistribution have been described in HIV-infected individuals and associated with the use of antiretroviral (ARV) combination therapy. Certain of these changes have been referred to as peripheral lipodystrophy (LD) and we describe 12 patients who were recognized with this condition between September 1997 and February 1998. It occurred in 12.5% of patients on ARV combination therapy that included a protease inhibitor (PI). In early descriptions the emphasis was on the abdomen, which may be grossly enlarged. In our patients this feature was much less marked. Patients with LD were significantly older than those on PI therapy who did not develop this condition ( P =0.016). Although all had raised triglyceride (TG) levels, the elevations were not severe (maximum=6.3 mmol/l). CD4 lymphocyte and viral load levels suggested an optimal response to ARV therapy at the time LD developed. Appearances may be disfiguring but no serious systemic consequences of LD have been observed. Most individuals have chosen to remain on their present ARV combinations. When LD occurs, it appears to be a marker of effective response to anti-HIV therapy.

Trends in sexual behaviour and risk factors for HIV infection among homosexual men, 1984-7.

To assess whether the spread of infection with HIV can be reduced by changes in behaviour among groups most at risk because of their sexual practices sexual behaviour was monitored among 1050 homosexual men tested for HIV infection at a genitourinary medicine clinic in west London from November 1984 to September 1987. Four cohorts, defined by date of presentation, were studied by questionnaire at their presentation, and blood samples were analysed. Between the first and last cohorts there was a considerable fall in the proportion reporting casual relationships (291/329 (88%) v 107/213 (50%] and high risk activities, such as anoreceptive intercourse with casual partners (262/291 (90%) v 74/106 (70%], with the greatest changes occurring before the government information campaign began in 1986. Nevertheless, half of the men in the last cohort studied reported having casual partners. Multiple logistic regression showed that behavioural risk factors for HIV infection most closely resembled those for hepatitis B and that previous sexually transmitted diseases (syphilis, hepatitis B, and anogenital herpes) were themselves independent risk factors. A history of syphilis ranked above anoreceptive intercourse as the strongest predictor of HIV infection. Actively bisexual men showed a much lower prevalence of HIV infection (3/57, 5%) than exclusively homosexual men (113/375, 30%). Sexual behaviour among homosexual men changed during the period studied, and the incidence of HIV infection fell, although more education programmes directed at homosexual men are needed to re-emphasise the dangers of infection.

Heterosexual relationships and condom-use in the spread of sexually transmitted diseases to women.

OBJECTIVES--To examine the effect of patient-defined non-regular heterosexual relationships on the incidence of sexually transmitted diseases and other genital infections in women and the role of condom use in the prevention of their spread. DESIGN--A cross-sectional study of sexual behaviour reported by a standardised self-administered questionnaire in new patients who presented for screening and diagnosis. SETTING--A genitourinary medicine clinic in West London. SUBJECTS--938 consecutive newly attending women who completed a sexual behaviour questionnaire in 1992. MAIN OUTCOME MEASURES--Variables relating to socio-demographic status, sexual behaviour, condom use, sexually transmitted diseases and other genital infections stratified by the reporting of non-regular partners. RESULTS--We found that women who reported non-regular sexual partners were more likely to be single (p = 0.0001), white (p < 0.0001), have had coitarche before 17 years of age (p = 0.003) and many more sexual partners both in the last year and in their life-time (p < 0.0001) and were more likely to practise fellatio (p < 0.0001), anal penetration (p = 0.004) and to be smokers (p < 0.0001). Paradoxically, the incidence of sexually transmitted diseases and other genital infections was no higher in this group than in the group of women who did not have non-regular partners. Increasing condom use with regular partners correlated with decreasing incidence of gonorrhoea (p < 0.001), chlamydial infection (p < 0.01) and trichomoniasis (p < 0.02), but increasing condom use with non-regular partners did not show this trend. CONCLUSIONS--Regular heterosexual partners play the major role in transmission of bacterial sexually transmitted diseases to women. This is significantly influenced by use of condoms.

Predictors of seropositivity to herpes simplex virus type 2 in women

Five hundred and twenty consecutive women newly attending a genitourinary medicine clinic who participated in a study of sexual behaviour were also tested for type-specific antibody to herpes simplex virus type 2; 135 (26%) were seropositive, of whom only 29 (21.5%) had had clinical evidence of genital herpes. Seropositive women were much more likely to have a past history of genital herpes (odds ratio [OR] 173). They were also more likely to be black non-UK born (OR 14), aged 30 years or over (OR 6), to have had 6-20 sexual partners (OR 3-4), especially from abroad (OR 12), to be unemployed (OR 6) or blue collar workers (OR 4), to have smoked cigarettes (OR 2) and to have practised peno-anal penetration (OR 5). Disease predictors included a past history of pelvic inflammatory disease (OR 63) and bacterial vaginosis (OR 3). Unexpected predictors were only one sexual partner (OR 5) and no non-regular partners (OR 5). Commencing intercourse before 16 years of age showed a protective effect (OR 0.2) and so did use of oral contraception (OR 0.5). Our findings show that infection with HSV-2 is associated with a wider range of morbidity and also emphasize the role of male sexual partner selection in the transmission of infection.

Sexual relationships, risk behaviour, and condom use in the spread of sexually transmitted infections to heterosexual men.

OBJECTIVE: To examine the effect of patient defined non-regular sexual relationships and other risk behaviours on the incidence of sexually transmitted infections in heterosexual men and the role of condom use in the prevention of their spread. DESIGN: A prospective cross sectional study of sexual behaviour reported by a standardised self administered questionnaire in new patients who presented for screening and diagnosis. SETTING: A genitourinary medicine clinic in west London. SUBJECTS: 957 consecutive newly attending heterosexual men who completed a sexual behaviour questionnaire in 1993/94. MAIN OUTCOME MEASURES: Variables relating to sociodemographic status, sexual behaviour, condom use, sexually transmitted infections and testing for HIV infection, stratified by the reporting of non-regular partners. RESULTS: We found that the 65% of men who reported non-regular sexual partners were more likely to be white collar class (d = 7.5%, 95% CI = 1.3, 13.7) and to have had sexual intercourse with non-United Kingdom born women (d = 7.8%, 95% CI = 3.5, 12.2). They also reported coitarche before 16 years of age (d = 13.4%, 95% CI = 8.0, 18.8) and many more sexual partners both in the last year (d = 13.1%, 95% CI = 10.2, 16.0) and in their lifetime (d = 27.9%, 95% CI = 21.6, 34.2). They were significantly more likely to practise anal intercourse (d = 8.7%, 95% CI = 3.3, 14.1), to smoke (d = 16.3%, 95% CI = 9.8, 22.6), to drink alcohol (d = 4.9%, 95% CI = 1.2, 8.6), and to have chlamydial infection (d = 5.7%, 95% CI = 2.2, 9.2), of which 30% was subclinical. Increasing condom use with regular partners correlated with decreasing incidence of urethral infection (gonorrhoeal and/or chlamydial infection) (p < 0.03) and candidal balanitis (p < 0.03) and a greater likelihood of no infection being detected (p = 0.0002). Use of condoms with non-regular partners was much more frequent than with regular partners (d = 21.4%, 95% CI = 16.7, 26.1). However, we found evidence of oral transmission of urethral gonorrhoea and chlamydial infection among men who reported always using condoms. HIV infection was found in only two men (0.2%), both of whom reported intercourse with non-United Kingdom born women. CONCLUSIONS: Heterosexual men who reported non-regular sexual relationships compensated for their increased risk lifestyle by using condoms more frequently and showed only an increased incidence of chlamydial infection. More consistent condom use with regular partners was significantly associated with the absence of sexually transmitted infection. These findings suggest that transmission between regular partners has been underestimated.

Sexual lifestyle and clinical findings related to HTLV-III/LAV status in homosexual men.

A study of 304 sexually active homosexual men, most of whom had multiple casual partners, showed that receptive anogenital intercourse, independent of anal bleeding, was the only risk factor for HTLV-III/LAV transmission. There was no evidence that HTLV-III/LAV infection, measured by seropositivity, was transmitted by oroanal or orogenital routes, or that insertive penile intercourse constituted a risk. The strongest predictor of seropositivity proved to be homosexual activity for more than five years, which may lead to enhanced susceptibility to infection. Sexual exposure to European men seemed to be even more hazardous than sexual exposure to men from the United States of America, and emphasised the epidemiological importance of the promiscuous homosexual abroad. Skin complaints were the most common presenting symptoms in men with antibody to HTLV-III/LAV. Extrainguinal lymphadenopathy was the commonest sign, which was present in just under half of those who were seropositive. More than one quarter of seropositive patients had had sexual intercourse with a woman in the five years before being tested.

Sexual behaviour and sexually transmitted infection among African and Caribbean men in London

We studied 180 black heterosexual men of whom 133 (74%) were Caribbean and 47 (26%) African. Seventy-three per cent of Caribbeans and 27% of Africans were UK born. We found no difference in age, but more Africans were married (30% cf 10%; P = 0.002) and students (26% cf 10%; P = 0.00008). More Caribbeans smoked 1–10 cigarettes a day (42% cf 22%; P=0.02) and more drank alcohol (89% cf 74%; P = 0.002). Sixty-nine per cent of Caribbeans reported intercourse before the age of 17 compared with 48% of Africans (P=0.004), but there was no difference in the numbers of sexual partners, either in the previous year or in total. Twenty-four (18%) of the 133 Caribbeans had gonorrhoea compared with one (2%) of the 47 Africans (P=0.001). Multivariate analysis showed that coitarche under 16 years of age (odds ratio (OR) 50) and gonococcal and/or chlamydial infection (OR 12.5) were independently associated with Caribbeans. Within this group, gonorrhoea was found more often in teenagers (OR 9.5) who had commenced intercourse before the age of 16 (OR 3.3) and chlamydial infection in those with multiple partners (OR 24). New problem-orientated approaches are needed to eradicate these curable infections which facilitate infection with HIV.

Risk profiles for genital infection in women.

OBJECTIVE--To determine independent risks with predictive value for specific sexually transmitted diseases in women. DESIGN--A prospective study of reported sexual behaviour in patients who presented for screening and diagnosis of sexually transmitted diseases. SETTING--A genitourinary medicine clinic at the West London Hospital. SUBJECTS--1025 consecutive newly attending patients who completed a sexual behaviour questionnaire between February and June 1982. MAIN OUTCOME MEASURES--Sexual behaviour reported by standardised self-administered questionnaire and sexually transmitted diseases diagnosed by routine clinical and laboratory methods. RESULTS--Independent risks for gonorrhoea were teenage (RR 2.0), black race (RR 2.0), more than two partners in the past year (RR 2.2) and previous pregnancy (RR 2.1). Trichomoniasis (RR 2.5), chlamydial infection (RR 1.8) and pelvic inflammatory disease (RR 4.8) also had significant predictive value. Conversely, gonorrhoea proved a risk for chlamydial infection (RR 2.1) together with age under 25 years (RR 2.3) and more than five partners in the previous year (RR 2.2). Ano-genital herpes was predicted by a total of more than 10 sexual partners (RR 2.6) and by both anal (RR 2.2) and oral intercourse (RR 2.9). Age under 25 years was the only independent risk for ano-genital warts (RR 2.0). We found no evidence that either vaginal candidosis or bacterial vaginosis were sexually transmitted. The risk for any genital infection was increased by more than one sexual partner in the preceding year (RR 1.7) and black race (RR 2.0). CONCLUSIONS--Sexually transmitted diseases show both similarities and differences in the risk factors associated with their transmission. These risk profiles facilitate the targeting of health education measures for those sections of the community at greatest risk and form a baseline for the future assessment of the effects of condom protected sexual intercourse and other safer sexual practices.

Fusobacterium nucleatum bacteraemia with multiple liver abscesses in an HIV-1 antibody positive man with IgG2 deficiency

Liver abscess formation due to Fusobacterium nucleatum is rare. We describe an HIV-I antibody positive man, with normal surrogate markers of cell-mediated immunity, who presented with F. nucleatum bacteraemia and liver abscess formation. He was found to have IgG2 subclass deficiency. This case illustrates the clinical importance of altered B-cell function in patients who are at an early stage of HIV disease.