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The purpose of this study was to determine the prevalence and to assess the efficacy of a single one gram oral dose of azithromycin under direct observed therapy of genital discharge due to Neisseria gonorrhoeae and Chlamydia trachomatis infections in STD clinic attenders in Trinidad and Tobago. All patients with genital discharge and their contacts were given one gram oral dose of azithromycin under direct supervision after collection of urethral and cervical swabs for N gonorrhoeae culture and smear and for C trachomatis antigen detection by ELISA. Clinical and microbiological evaluation was done on those who returned after 7 to 10 days for follow up. Of the 735 patients who were enrolled in the study, 319 (43.4 percent) had N gonorrhoeae and 100 (13.6 percent) had C trachomatis. Only 151 (36 percent) of the 419 patients with a pathogeneic isolate returned for clinical and microbiological assessment. The remaining 268 (64 percent) of the 419 patients were lost to follow up. One hundred and forty three patients (94.7 percent) had total abatement of signs and symptoms after taking azithromycin. One patient (0.65 percent), who had both N gonorrhoeae and C trachomatis, improved clinically with the drug. Seven patients (six with N gonorrhoeae and one with C trachomatis) failed to respond clinically to azithromycin. Microbiological eradication was achieved in 115 (100 percent) patients who had single infection with N gonorrhoeae and in 23 patients (96 percent) with C trachomatis infections, N gonorrhoeae and C trachomatis were eradicated in 10 and 12 patients, respectively, after initial treatment. In two patients with combined infection, N gonorrhoeae continued to be isolated after treatment with azithromycin. A single one gram oral dose of azithromycin under direct supervision is useful in the treatment of uncomplicated genital infection with N gonorrhoeae and C trachomatis in STD clinic attenders in Trinidad. (AU)

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While the worldwide AIDS epidemic continues to expand, directly measured incidence data are difficult to obtain. Methods to reliably estimate human immunodeficiency virus type 1 (HIV-1) incidence from more easily available data are particularly relevant in those parts of the world where prevalence is rising in heterosexually exposed populations. The authors set out to estimate HIV-1 incidence in a population of heterosexual sexually transmitted disease clinic attended in Trinidad who had a known high prevalence of HIV-1 subtype B. Over the period 1987-1995, HIV-1 incidence estimates from serial cross-sectional studies of HIV-1 prevalence, passive follow-up of clinic recidivists, modeling of early markers of HIV-1 infection (p24 antigen screening), and a cohort study of seronegative genital ulcer disease cases were compared. Measuring incidence density in the genital ulcer disease cases directly gave the highest estimate, 6.9 percent per annum. Screening for the detection of early HIV-1 markers yielded an incidence of 5.0 percent per annum, while estimating incidence from serial cross-sectional prevalence data and clinic recidivists gave estimates of 3.5 percent and 4.5 percent per annum, respectively. These results were found to be internally consistent. Indirect estimates of incidence based on prevalence data can give accurate surrogates of true incidence. Within limitations, even crude measures of incidence are robust enough for health planning and evaluation purposes. For planning vaccine efficacy trails, consistent conservative estimates may be used to evaluate population before targeting them to cohort studies(AU)

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Treatment failures with standard doses of penicillin have been observed in the Sexually Transmitted Diseases (STD) clinics in Trindad and Tobago. In the absence of an ongoing surveillance system, the antimicrobial susceptibility of 518 Neisseria gonorrhoeae strains was determined in order to guide treatment. 39 (7.6 percent) strains were resistant to penicillin, including 27 (5.2 percent) positive for beta-lactamase; that is penicillinase-producing Neisseria gonorrhoeae (PPNG). 51 (10 percent) strains were resistant to tetracycline, with 26 (5.0 percent) of these exhibiting high levels of resistance compatible with tetracycline resistant Neisseria gonorrhoeae (TRNG). Six strains showed evidence of having both PPNG and TRNG plasmids, and five strains showed chromosomally-mediated resistance to both penicillin and tetracycline. The overall resistance rate to penicillin and tetracycline was 17.7 percent. There was no resistance to spectinomycin, cefuroxine, ceftriaxone and norfloxacin. The resistance rates demonstrated in this study are sufficently significant to preclude the use of penicillin and tetracycline in the STD clinics and to justify the use of newer antimicrobials. It is essential that resistance patterns be monitored by continued surveillance.(AU)

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An open, non-randomized and non-comparative clinical study was undertaken to assess the efficacy of a single gram dose of azithromycin under supervision in patients with uncomplicated genital discharge and contacts of known STD cases. 151/435 patients (36 percent) with +ve culture for N. gonorrhoeae and antigen +ve for C. trachomatis by ELISA were available for evaluation of azithromycin. There were 119 males (median age 28 years) and 32 females (median age 23 years). Clinical cure was achieved in 95 percent of patients. Bacteriological eradication of N. gonorrhoeae was achieved in all patients with a single infection (115) and in 5/12 with dual infection with C. trachomatis 7 patients had persistence N. gonorrhoeae (5 smear positive and two culture positive) and were subsequently treated with spectinomycin C. trachomatis was eradicated in 23/24 (96 percent) patients with single, and 100 percent patients with mixed, infection during a follow-up assessment with repeat ELISA tests. No patients receiving oral azithromycin reported side effects. This study showed that a single one gram oral dose of azithromycin under supervision is effective in the syndromic management of genital discharge due to N. gonorrhoeae and C. trachomatsis. (AU)

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Treatment failures of 20 percent with standard doses of penicillin have been observed in our sexually transmitted disease (STD) clinics in the treatment of gonorrhoea. A large number of Neisseria gonorrhoeae strains (547) from various STD clinics were tested against selected antimicrobials in order to determine the most appropriate alternative treatment regimen. Using an agar dilution technique and testing for the presence of beta-lactamase production, it was determined that less than 1 percent of Neisseria gonorrhoeae strains were sensitive to penicillin, 85 percent were moderately sensitive and 15 percent were completely resistant to penicillin. More than 5 percent of the strains produced beta-lactamase. Tetracycline resistance was seen in 57 percent of the strains, and 7.3 percent of the strains were resistant to cefuroxime. There was no resistance to spectinomycin, ceftriaxone or norfloxacin. STD clinics in Trinidad and Tobago can no longer rely on penicillin and tetracycline in the treatment gonorrhoea. Protocols will have to include spectinomycin, ceftriaxone or norfloxacin (AU)

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This study is an ongoing cross sectional survey aimed at determining factors associated with HIV infection in HIV-infected heterosexuals and bisexuals and their heterosexual partners. HIV-positive patients (index cases) were recruited when they attended the Queen's Park Counselling Centre and Clinic, the main clinic for sexually transmitted diseases in Trinidad. All subjects were required to give signed consent to participate in the study and respond to a questionnaire administered by an interviewer. Both partner notification (index cases refer partners) and provider notification (contact tracers locate partners) were used. A partner was defined as one who had had sexual intercourse with the index case up to 5 years preceding the interview. On enrolment, partners were counselled and offered an HIV test and a medical examination. Samples were screened by ELISA for HIV antibody and repeatedly reactive samples were confirmed, using immunofluorescence assay or Western Blot. Between September 14, 1992 and October 8, 1993, 192 index cases and 50 partners had been enrolled. Recruitment of partners was a challenge as the prospect of notification caused anxiety for many patients. Overall, HIV seroprevalence of sexual partners was 54 percent (27/50) and HIV seropositivity was significantly (p<0.05) associated with history of STDs and prostitution within the last 2 years. Genital ulcer diseases may be another risk factor (p<0.10). Cocaine use, though not itself associated with HIV seropositivity, was significantly associated with 2 of the 3 proposed risk factors, and may play an indirect role in HIV transmission (AU)

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This manual is intended as a guide for a systematic approach to STD management, and as an easy reference for the busy clinician.

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