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In many countries people with genitourinary symptoms consult pharmacists. García and colleagues studied 227 people with symptoms presenting to 64 pharmacies in Lima, Peru. A significant proportion had an infection; 34% of the men and 12% of the women had gonorrhoea and/or chlamydia. The most common conditions in women were bacterial vaginosis or trichomoniasis (39%) and candidiasis (8%). In men and women a diagnosis of gonorrhoea and/or chlamydia was associated with a relatively short (<5 days) duration of symptoms. The high level of morbidity shows the importance of including pharmacists in STI control programmes in developing countries at least.
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The resurgence of infectious syphilis in Europe has been well documented, with a resulting increase in the risks of congenital syphilis. Tridapalli and colleagues collected data on 19205 women who gave birth to 19548 infants in one city in Italy. The seroprevalence of syphilis in pregnant women was 0.44%, and 85 women were seropositive for syphilis at delivery. Positivity was higher in women from eastern Europe (4.3%) and Central–South America (5.8%). Ten women, including nine from eastern Europe, were only diagnosed at delivery as they had not received antenatal care. All their infants were asymptomatic, but six had both reactive immunoglobulin western blot and rapid plasma reagin tests and were considered prenatally infected. Three of six were preterm (gestational age <37 weeks). The authors advocate better information about antenatal care for migrant women and suggest that women at risk, particularly those from eastern Europe, are offered repeat serological tests in the third trimester.
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There has been a sustained increase in numbers of new cases of HIV in men who have sex with men (MSM) in the UK from 1997 to 2004. This has occurred in all areas and groups except in younger MSM in London, where there was no change. It has been unclear as to whether this is due to increased case ascertainment or increased incidence. Dougan and colleagues produced direct estimates of HIV incidence using Serological Testing Algorithm for Recent HIV Seroconversions (STARHS) and found no evidence of an increase in incidence in MSM over the same time period.
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It is apparent that healthcare providers' access to clinical information about individual HIV‐infected patients' care differs between centres in the UK. Outpatient HIV clinic notes are frequently handled in the same way as genitourinary medicine (GUM) clinic notes, with a separate patient identification number, which is justified by clinicians wishing to preserve ”confidentiality”. This ”firewall” potentially restricts free flow of information about HIV‐infected patients, as they access other in‐ and outpatient services. By contrast, other centres have “normalised” HIV care by allowing free access to case notes within the hospital setting. Rutland et al, on behalf of the British Clinical Co‐operative Group of BASHH, carried out a postal survey of lead clinicians in GUM clinics in the UK. In 88% (114) of centres outpatient HIV notes were separate from hospital inpatient notes. The main findings were that only 12% of 130 treatment centres used combined notes and 42% had encountered difficulties that affected delivery of care for HIV‐infected patients. Centres using combined notes identified a higher frequency of communication with other healthcare professionals and specialities, inferring a higher standard of care. Physicians involved in HIV care should consider combining patients' HIV and hospital notes to improve care.
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Primary HIV infection (PHI), although symptomatic in many patients, is often undiagnosed. Even when suspected clinically the diagnosis may be missed if antibody‐based HIV detection is used. The authors describe a 30‐year‐old MSM with a recent negative HIV antibody test who presented with a rash, neck stiffness and rapid progression to coma. Investigations showed CD4 lymphopenia and a high HIV viral load in the cerebrospinal fluid. With the institution of antiretroviral treatment the patient rapidly recovered. This case is important for clinicians as it underscores the importance of considering PHI in the differential diagnosis of coma and also the importance of nucleic acid amplification techniques for detection of HIV RNA in the diagnosis of PHI.
See p 85