London Genitourinary Medicine Clinic Research Articles

Poor sensitivity and consistency of microscopy in the diagnosis of low grade non-gonococcal urethritis

Objectives: To determine the reliability of the diagnosis of non-gonococcal urethritis (NGU), and the variation between and within microscopists, from urethral smears at a large London genitourinary medicine clinic. Methods:...

Gonorrhoea in a south London genitourinary medicine department

The management and outcome of all cases of gonorrhoea which presented to a south London genitourinary medicine clinic during 1999 were assessed and compared with published national guidelines. The incidence of penicillin resistance was calculated, as was the rate of co-infection with chlamydia and trichomonas. Information regarding demographic data, microscopy, culture results, test of cure, antibiotic use, sensitivity and health adviser contact was examined. A total of 257 cases of gonorrhoea were diagnosed in 238 patients. Heterosexual men constituted 52.9% of cases, 6.6% were in homosexual men and 40.5% in women. Direct microscopy was positive in 88.8% of men and in 40.5% of women. In women, the rate of gonorrhoea co-infection with chlamydia was 34.7% and with trichomonas was 11.5%. In men the rate of chlamydia co-infection was only 3.3%, however, we do not believe this to be an accurate figure as we are unable to routinely screen all men for chlamydia due to financial restrictions. Amoxicillin with probenecid were the most commonly used antibiotics in line with local guidelines. Penicillin resistance was demonstrated in 4.6% of infected cases. Health advisers saw 73.2% of patients.

An audit to evaluate the accessibility, cost, impact on work place absence and convenience of attending genitourinary medicine clinics in London and Plymouth.

We conducted a survey to assess the accessibility, cost, impact on work place absence and convenience of attending two genitourinary medicine (GUM) clinics, one in London and one in Plymouth. Nine hundred and fifty-eight questionnaires were collected for analysis (448 from London [L] and 510 from Plymouth [P]). The majority in London used public transport whereas the majority in Plymouth used private transport. Journey costs were less than 5 for the majority (75% L and 59% P). Of those in employment 229/678 (44%) had to take time off from work to attend. Women were significantly less likely (13/308, 4%, 95% confidence interval (CI) 2-6.5%) than men (51/370, 14% 95% [CI] 10.317.3%) to give up annual leave to attend. Both clinics were judged accessible, affordable and convenient by the majority of clinic users.

Investigation into the acceptability and effectiveness of a new contact slip in the management of Chlamydia trachomatis at a London genitourinary medicine clinic

Objectives: To improve contact tracing for chlamydia. To determine (i) the acceptability to patients of using a contact slip that named chlamydia as the sexually transmissible infection that the contact...

Ethnic variation in type of genital herpes simplex virus infection in a South London genitourinary medicine clinic.

The aims of this study were to investigate the prevalence of herpes simplex virus (HSV) types 1 and 2 in the study population and correlate the results with clinical and demographic details. Consecutive HSV isolates from 334 clinic attendees were typed by immunofluorescence. Patient information was collected from the case notes. Overall, HSV-1 was isolated from 48 and HSV-2 from 287 samples, respectively. There was no significant difference in isolation rates according to gender. However, 33% of white patients' isolates typed as HSV-1, while only 6% of the isolates from the black population were HSV-1 (P < 0.001). Initial infections were seen in 81% of HSV-1 infections and 48% of HSV-2 infections, respectively. A wide discrepancy was observed in the prevalence of HSV-1 and HSV-2 infections between the ethnic groups in this population, which was not explained in terms of gender or age. This may reflect different exposure to HSV-1 in childhood or different sexual practices. The increased prevalence in genital HSV-1 reported in recent studies was not seen in this population. However, the differing proportions of primary and first episode infections may reflect a changing epidemiology.

Hepatitis B virus infection among Chinese residents in the United Kingdom

Objective: To determine prevalence of hepatitis B virus (HBV) serological markers in Chinese residents in the United Kingdom. Method: Retrospective case-controlled study between January 1997 and June 2000 in two...

Prevalence of sexual dysfunction in new heterosexual attenders at a central London genitourinary medicine clinic in 1998

Objective: To determine the prevalence of sexual dysfunction and dissatisfaction (SD) among new heterosexual attendees at a central London genitourinary medicine (GUM) clinic. Methods: Consecutive new attendees seen by a...

Demographic and socio-economic determinants of community and hospital services costs for people with HIV/AIDS in London

We examined the influence of demographic, social and economic background of people with HIV/AIDS in London on total community and hospital services costs. This was a retrospective study of community and hospital service use, needs and costs based on structured questionnaires administered by trained interviewers and costing information obtained from the service purchasers and providers, based on two Genito-urinary Medicine clinics in London: the Jefferiss Wing at St. Mary's Hospital and Patric Clements at the Central Middlesex Hospital, London, England. The subjects were 225 HIV infected patients (105 asymptomatic, 59 symptomatic non-AIDS and 61 AIDS). We found that over and above well established determinants of health care costs for HIV infected people such as disease stage and transmission category, social and economic factors such as employment and support of a living-in partner significantly reduced community services costs. Private health insurance had a similar effect, though only a small proportion of HIV people had such cover. The cost of community services for HIV infected non-European Union nationals, mainly of African origin, was one quarter that for the European Union nationals. Community services costs were highest for heterosexually infected women and lowest for heterosexually infected men after adjusting for other factors. Hospital services costs were significantly higher for HIV infected people lacking educational qualifications and employment. We conclude that access to community care for HIV infected non-EU nationals appears to be very poor as the cost of their community services was one quarter that for the EU nationals after adjusting for the effects of transmission category, disease stage, living with a partner, employment and having a private health insurance. Additional incentives for informal care for HIV infected people could be a cost-effective way to improve their community health service provisions.

Reasons for HIV antibody testing: plus ca change?

Patient records in a central London genitourinary medicine (GUM) clinic relating to HIV testing were examined and compared for the 3 months immediately before and after World AIDS Day (WAD) in 1994, according to gender and sexual orientation, and the reasons given for testing. Additionally, patient-identified risk was compared with counsellor-identified risk in each case in 1994. Findings were compared with data from the initial HIV awareness campaign in 1986-87. In the 1994 study period, there were no significant differences in overall numbers attending or gender of test-seekers before and after WAD, or proportions of heterosexual, bisexual and gay test-seekers across the time periods. Within each of these groups, gay test seekers were significantly more likely to be HIV positive than heterosexuals, although there were no differences in numbers found positive in each group before and after WAD. Thirty-five per cent (n=268) reported a history of safer sex only, 32% (n=247) said 'sometimes', and 33% (n=249) said 'no'. Overall, the main reasons given for HIV test-seeking included having part of a sexual health screen, having episodes of unprotected sex and/or casual partners, concern over partner's status/monogamy, and intravenous drug user (IDU) contact. Reasons for testing in 1994 reflected greater awareness of HIV transmission compared to 1986-87, although only one-third of those tested reported a history of safer sex.

The psychological impact of sexual assault: A study of female attenders of a sexual health psychology service

Genitourinary clinics are often used as an early point of contact for individuals attending for medical screening following sexual assault. This paper describes the psychological impact of sexual assault in 32 women referred over a one year period to clinical psychology in an East London Genitourinary medicine (GUM) clinic. Women presented with complex histories of sexual abuse and assault and multiple psychological problems. Medical services need to be prepared to deal with the immediate and long-term effects of sexual assault and have access to professional psychological support.

Prevalence of sexual dysfunction in heterosexual patients attending a central London genitourinary medicine clinic.

Our objective was to determine the prevalence of sexual dysfunction among new heterosexual attendees at a central London genitourinary medicine (GUM) clinic. We carried out a cross-sectional study in which patients completed a self-administered questionnaire-the Golombok-Rust Inventory of Sexual Satisfaction (GRISS) and participated in a brief interview during which additional information was sought regarding the patient's sexual history. An overall transformed score of >5 on the GRISS was defined as indicative of overall sexual dysfunction and a score of >5 on any of the subscales as indicative of a specific sexual dysfunction. Twenty-five (24%) men and 10 (9%) women had a GRISS score in keeping with overall sexual dysfunction, the prevalence being significantly lower in women (P=0.01, chi2=6.56, 1df). Sixty-three men (59%) and 63 (60%) women produced scores indicative of significant abnormality on at least one subscale, including, in men: erectile dysfunction 20 (19%), premature ejaculation 23 (22%), and in women: vaginismus 26 (25%) and anorgasmia 23 (22%). Neither an abnormal overall or subscale score on the GRISS was associated with a current STD on KC60 diagnosis or a history of sexual assault for either men or women. There is a substantial prevalence of sexual dysfunction in new heterosexual attendees at our clinic, the service implications of which need to be addressed.

Acceptability and compliance with daily injections of procaine penicillin in the outpatient treatment of syphilis-treponemal infection.

In the United Kingdom, it is recommended that syphilis should be treated with intramuscular daily procaine penicillin with or without oral probenecid for 8 to 21 days. However, it has been argued that this regimen would be unacceptable to patients in terms of daily attendance and volume of drug administered, resulting in poor compliance. To assess the acceptability of and compliance with daily procaine penicillin for 10 to 17 days in patients attending an East London Genito-Urinary Medicine Clinic with a diagnosis of syphilis-treponemal infection. The notes of 210 consecutive patients attending with syphilis-treponemal infection who had been offered treatment with daily procaine penicillin, with or without oral probenecid for 10 to 17 days, were reviewed retrospectively. Of 210 patients who were offered daily procaine penicillin, 42 (20%) declined and were given oral doxycycline, amoxicillin, or depot penicillin injections. Of 168 patients who accepted daily procaine penicillin, depending on the stage of infection, 90 (54%) had 1.8 g of daily procaine penicillin together with oral probenecid 500 mg every 6 hours for 17 days (high-dose regimen), 57 (34%) had 0.6 g of daily procaine penicillin for 10 to 17 days (low-dose regimen), and 21 (12%) had mixed-dose regimens ranging from 0.5 to 2.4 g. Of the 90 who had high-dose regimen, 76 (84%) complied with treatment compared with 50 (88%) of 57 who had low-dose regimen. All 21 patients who had mixed-dose regimens complied fully. Daily procaine penicillin is a well-accepted out-patient regimen with excellent compliance (88% overall) and minimal side effects. Because the high-dose regimen has been shown to achieve treponemicidal levels of penicillin in the cerebrospinal fluid, it is recommended for patients with neurosyphilis or those in whom neurosyphilis cannot be excluded. It also could be considered for patients with concomitant human immunodeficiency virus infection in view of the possible progression to neurosyphilis in those treated with depot penicillin.

To test or not to test, could you repeat the question?

We aimed to investigate clinical practice in the offering of HIV tests and subsequent uptake in a central London genitourinary medicine (GUM) clinic. A random sample (n = 330) of attenders at 3 inner-London GUM departments was surveyed. Reasons for and rates of offering of HIV tests were recorded and analysed in relation to demographic, risk group information and uptake. The results were integrated with the latest unlinked, anonymous seroprevalence data for the clinic. After exclusion of patients known to be HIV-positive or to have recently undergone HIV testing, HIV tests were offered to 96% of homo/bisexual men, 55% of heterosexual men and 60% of heterosexual women. Comparison with anonymous HIV seroprevalence data showed an inverse relationship between seroprevalence rates for heterosexual men/women (2.5% vs 1%) and rates of HIV test offering. A lack of research into the policy of offering HIV tests may have resulted in inconsistencies in practice. An evidence based policy should offer HIV tests in line with seroprevalence.

Emergency hormonal contraception usage in genitourinary medicine clinic attenders.

To assess the indications for usage of emergency hormonal contraception amongst a population of London genitourinary medicine clinic attenders. In a prospective study, 150 consecutive women receiving emergency hormonal contraception (EHC) were enrolled. The attending doctor completed a questionnaire of patient details and prescribed EHC with prophylactic prochlorperazine. Follow-up was arranged three weeks later, at which time outcomes and side-effects of therapy were recorded. For those women who did not reattended as planned case notes were reviewed at three months. Of 150 women surveyed, 100 (66%) reported contraceptive method failure, 48 (32%) had used no contraception at the time of last sexual intercourse and two requested EHC after sexual assault. Ninety three (62%) reported condom failure, 7 (5%) oral contraceptive pill failure. Seventy five (50%) had used EHC before (range 1-10 times). Seventy one (47%) women reattended within three months. Five (3.3%) of the 150 women were pregnant; none of these cases had experienced nausea or vomiting whilst taking EHC. Side-effects were reported by 22 (31%) of the 71 patients who reattended. Nine (6%) women had been followed-up in the family planning advisory clinic. Of the 71 women who reattended, 39 (55%) reported that their preferred future method of contraception would be condoms. Of the 150 women 19 (13%) underwent tests for sexually transmissible infections within one month of presentation. EHC usage in this population was associated with a failure rate of at least 3.3% and an overall side effect rate of 31%. Despite requests for emergency contraception because of condom failure many elected to continue using condoms as their preferred method of contraception. The majority of women (53%) did not return for follow-up or family planning advice, and so we believe that future contraceptive plans must be addressed at the time EHC is prescribed.

Tetracycline-resistant Neisseria gonorrhoeae. Characteristics of patients and isolates at a London Genitourinary Medicine Clinic.

To compare auxotypes, serovars, and antibiograms of tetracycline-resistant Neisseria gonorrhoeae (TRNG) and non-TRNG isolated from patients attending an East London Genitourinary Medicine (GUM) Clinic. To obtain plasmid profiles for penicillinase-producing gonococci (PPNG) as well as presumptive TRNG. To identify differences in patient characteristics for the TRNG and non-TRNG patient groups. Gonococcal isolates were collected from 400 patients attending the GUM clinic at the Royal London Hospital GUM Clinic over a 1-year period. Isolates (378) were tested for susceptibility to various antibiotics, auxotyped, and serotyped. Plasmid profiles were obtained for PPNG and isolates exhibiting high-level tetracycline resistance (TRNG). The presence of the tet M determinant was confirmed using the polymerase chain reaction (PCR). The PCR product was digested with the restriction endonuclease (RE) Hpa II and electrophoresed on a 2.5% agarose gel to determine an "RE pattern." Patient data were collected by retrospective case-note review. TRNG (n = 42) accounted for 11% of the 378 isolates tested, and the remaining 336 (89%) isolates were non-TRNG. Non-requiring auxotrophy and P1B-2 serovar expression occurred more frequently among TRNG. PPNG accounted for 31% of TRNG and 5% of non-TRNG. Chromosomal resistance to penicillin (CMRNG) was absent among TRNG but accounted for 11% of non-TRNG. One TRNG isolate showed decreased susceptibility to ciprofloxacin (MIC 0.25 mg/l). All isolates were sensitive to cefotaxime, cefixime, spectinomycin, and azithromycin. All TRNG possessed the 25.2 MDa plasmid and produced a PCR product of appropriate size after tet M gene sequence amplification. RE digests of the PCR product gave a single pattern. None of the TRNG in contrast to 18% of the non-TRNG were acquired homosexually. Ethnic distribution differed between the patients with TRNG and patients without non-TRNG (Afro-Caribbean 81% versus 58%; white 19% versus 36%). Most TRNG were acquired in the United Kingdom. TRNG differ from the non-TRNG in their auxotype and serovar distribution. PPNG are more common among the TRNG isolates, whereas CMRNG appear absent. TRNG are isolated more commonly from Afro-Caribbean patients and were not represented among homosexually acquired isolates.

HIV media campaigns and HIV-1 testing trends at London genitourinary medicine clinic, 1985-1993.

To describe HIV-related media events in the context of first-time HIV-1-antibody testing trends at a London genitourinary medicine clinic. Demographic and behavioural data were collected prospectively for individuals tested for HIV-1 antibodies between September 1985 and September 1993, at the genitourinary medicine clinic of St Mary's Hospital, London. A total of 19,242 individuals were tested of whom 37% were women. Of the men tested 60% were heterosexual. The women at first time of testing were significantly younger [29.3 years; 95% confidence interval (CI), 28.8-29.7] than the men (32.5 years; 95% CI, 29.2-35.8); mean ages for both sexes did not change significantly over time. Overall, 199 women and 1539 men tested HIV-antibody-positive. The proportions of women testing positive increased significantly over time (chi 2 = 21.7, degrees of freedom = 1; P < 0.001), whereas the proportion of HIV-positive men remained constant for all sexual orientation groups. The proportion of heterosexual women testing positive (2.8%) was similar to the proportion of HIV-positive heterosexual men (2.9%). HIV-positive individuals were significantly older for both sexes. Throughout the study period numerous education campaigns were run using a variety of media complemented by a number of other HIV-related media events. Peak periods of attendance for HIV testing generally corresponded with increased HIV-related media activity and the greatest testing rates were observed when various HIV media events occurred concurrently. The increase in the number of heterosexuals tested suggests that the risk of heterosexual transmission of HIV has been recognized, at least among older individuals. The exact role of HIV-related media events, including celebrities disclosing their HIV-positive status, remains to be elucidated. Whether the relative under-representation of younger people is due to a lack of awareness, increased use of safer sex practices or reluctance to use the service also remains to be addressed. Given the increasing number of HIV-positive women and the relatively constant rate of HIV-positive tests in the male attendees an urgent need exists to assess the impact and effectiveness of specific HIV media campaigns.

Incidence of HIV infection in homosexual men in London, 1988-94.

Measures of the incidence of HIV infection in different groups are essential for targeting and evaluating health education. Incidence measures obtained by the follow up of closed cohorts become biased over time as early infection in those at highest risk results in a subsequent downward trend in incidence.1 2 We describe changes in the age specific incidence of HIV infection in open cohorts of homosexual men continuously recruited from among patients attending genitourinary medicine clinics in London from 1988 to 1994. View this table: Incidence of HIV infection in HIV negative homosexual men by age and over time Homosexual men negative for HIV antibody who had attended genitourinary medicine clinics in London from January 1988 to April 1994 and been voluntarily …

A one-year survey of Neisseria gonorrhoeae isolated from patients attending an east London genitourinary medicine clinic: antibiotic susceptibility patterns and patients' characteristics.

To collect epidemiological data on gonococcal infection in an east London genitourinary medicine (GUM) clinic; to perform antibiotic susceptibility testing on Neisseria gonorrhoeae isolates and relate results to patient data; to assess the efficacy of current first-line antibiotic therapy for treating gonorrhoea. Gonococcal isolates were collected from 113 patients attending the GUM clinic at Newham General Hospital over a one year period. Isolates (104) were tested for susceptibility to various antibiotics. Plasmid profiles were obtained for penicillinase producing gonococci (PPNG) and isolates exhibiting high-level tetracycline resistance (TRNG). Epidemiological information was collected from clinic attenders by routine note-taking. PPNG (16) accounted for 15% of isolates tested, only three being acquired outside the United Kingdom (U.K.). Plasmid typing showed three types of beta-lactamase-encoding plasmids were represented (2.9 MDa, 3.2 MDa and 4.4 MDa). Amongst the non-PPNG isolates, high-level chromosomal resistance to penicillin (CMRNG) was found in 3.5%, intermediate resistance in 57.5% and full susceptibility in 39%. One isolate showed decreased susceptibility to ciprofloxacin (MIC = 0.06 mg/l). Three PPNG isolates also possessed a 25.2 MDa plasmid and expressed high-level tetracycline resistance encoded by tetM. All isolates were susceptible to cefixime, cefotaxime, azithromycin and spectinomycin. Most gonorrhoea (90%) was seen in local residents. The male:female case ratio was 2:1 with homosexually-acquired gonorrhoea accounting for only 3.5% of the total. Most patients (96%) had acquired gonorrhoea in the U.K.. A past history of gonorrhoea was more frequent in male patients. Concurrent chlamydial infection was seen in 31% females and 16% males. The high PPNG rate supports a previous decision to change first-line therapy from amoxycillin with probenecid to ciprofloxacin. There was no evidence of clinical treatment failure with ciprofloxacin. Cefixime, cefotaxime, azithromycin and spectinomycin all appear to be suitable alternative therapies. Acquisition of gonorrhoea abroad was associated with isolates exhibiting penicillin resistance but such isolates were also obtained from patients infected locally and without a history of foreign travel.

Audit of patients' knowledge of their oral contraceptive pill.

Government and media education has promoted the use of condoms in an attempt to reduce the spread of the human immunodeficiency virus (HIV). Condoms have been identified, in vitro, as an effective barrier to HIV and a large heterosexual study has shown there was no transmission of infection in those couples systematically using condoms. Safer sex knowledge and practice and HIV knowledge were assessed in 584 individuals, 16-74 years old, attending a London genitourinary medicine (GUM) clinic via a self-administered, anonymous questionnaire. Over 80% were heterosexual, 64% had attended a GUM clinic before, 60% had a history of sexually transmitted infection. Over 80% were aware of the protective effect of condoms and the risks of intravenous drug use; 66% of geographical risk factors; 49% of the risks of anal sex; and 53% perceived masturbation as safer. Only 10.4% always used condoms; over 50% gave no reason for non-use. Use was not increased in higher risk respondents nor in those with good safer sex/HIV knowledge, nor was there any sex difference. Although knowledge of some aspects of safer sex was good, anal sex risks, geographical sex risks, and alternative safer sexual practices were less well known. In addition, condom use was disappointingly low, even in the presence of good safer sex knowledge, awareness of high risk behavior and despite intense media health education. As a result of this survey educational input was increased, allowing an interaction which is lacking in media campaigns, and a variety of condoms were introduced in an attempt to increase use. Re-audit will be important in assessing the effects of such changes. Pre-adolescent targeting before sexual patterns are learned may be useful. Further research into this difficult area is essential.

Sexual behaviour among London GUM clinic attenders: implications for HIV education.

The aim of this study was to describe the sexual behaviour of a sample of genitourinary medicine (GUM) clinic attenders, 5 years after the launch of the UK government HIV media campaigns. A gender-specific and anonymous cross-sectional self-completion questionnaire was modified from the National Survey of Sexual Attitudes and Lifestyle and completed by 250 men and 250 women. The majority of the respondents were in their twenties, lived in London and were employed or students. Sixty-eight per cent of the men reported that one or more of their last 3 partners was not a regular partner. For those men whose last sexual encounter was with a new partner, 27% of heterosexuals and 33% of homosexuals reported using a condom. Fifty-one per cent of women reported one or more non-regular partners among their last 3 partners. For those women whose last sexual encounter was with a new partner, 43% of heterosexuals and 75% of bisexuals used a condom. Seventy-eight per cent of men and 75% of women had had a previous sexually transmitted disease (STD). These findings highlight the persistence of practices associated with the risk of contracting or transmitting HIV infection and which needs to be addressed in future educational campaigns. The GUM clinic population is an important population to monitor over time, either by longitudinal or serial cross-sectional studies. The results of this study provide a baseline against which to gauge the effects of future educational interventions.