Prostitution, Condom Use, and Invasive Squamous Cell Cervical Cancer in Thailand

Cervical cancer is probably caused by a sexually transmitted agent. A case-control study was conducted in three hospitals in Thailand to investigate further the role of male sexual behavior, particularly regarding sexual contacts with prostitutes, in the development of this disease. Data were obtained from interviews with 225 married women with invasive squamous cell cervical carcinoma and 791 hospitalized controls, all of whom reported having only one sexual partner, and from interviews with their husbands. Risk of cervical cancer was strongly related to the women's husbands having visited prostitutes without using a condom when the husbands were less than 30 years old. A strong increasing trend in risk in relation to decreasing frequency of the husbands' condom use with prostitutes was observed, and a weaker increasing trend in risk with husbands' estimated lifetime total number of visits to prostitutes was found. The average latent period between the women's likely initial exposure to a sexually transmitted oncogenic agent and her diagnosis of invasive cervical cancer was about a quarter of a century. Regular use of condoms by customers of prostitutes could reduce the number of invasive cervical cancer cases in the general population of Thailand by at least one fourth. Am J Epidemiol 1996; 143: 779-8

The socio-cultural context of the transmission of HIV in Thailand

At a global level there are considerable differences between regions in the levels of prevalence, and rate of transmission, of the Human Immunodeficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS). Furthermore there are differences between regions in the social and demographic characteristics of HIV carriers/AIDS sufferers (e.g. heterosexuals, homosexuals, injecting drug users, infants). It is notable that Asia has generally lagged behind other regions in the spread of HIV. However recently Thailand has acknowledged rapidly increasing levels of infection. This paper is structured in terms of three broad sections. (1) An outline of some basic epidemiological principles concerning the transmission of HIV which help account for the regional variations in prevalence; (2) a description of the emerging awareness of HIV as a public health problem within Thailand; (3) a review of the social characteristics of HIV carriers in Thailand, interpreted by reference to the wider social context, chiefly in terms of; the commercial sex industry/sexual lifestyles, international tourism, and injecting drug dependency. Reference is also made to impressions of the personal response of individuals learning of their HIV seropositive status. A brief comment compares the sexual culture and sex industry in Thailand to that of other South East Asian countries (most notably the Philippines). The paper highlights the importance of considering the particular social and historical factors which shape and sustain the transmission of HIV within a particular country.HIV AIDS Thailand social context commercial sex industry injecting drug dependency

Efficacy and safety of 1-month postpartum zidovudine-didanosine to prevent HIV-resistance mutations after intrapartum single-dose nevirapine.

BACKGROUND: Intrapartum single-dose nevirapine plus third trimester maternal and infant zidovudine are essential components of programs to prevent mother-to-child transmission of human immunodeficiency virus (HIV) in resource-limited settings. The persistence of nevirapine in the plasma for 3 weeks postpartum risks selection of resistance mutations to nonnucleoside reverse-transcriptase inhibitors (NNRTIs). We hypothesized that a 1-month zidovudine-didanosine course initiated at the same time as single-dose nevirapine (sdNVP) would prevent the selection of nevirapine-resistance mutations. METHODS: HIV-infected pregnant women in the PHPT-4 cohort with CD4 cell counts >250 cells/mm3 received antepartum zidovudine from the third trimester until delivery, sdNVP during labor, and a 1-month zidovudine-didanosine course after delivery. These women were matched on the basis of baseline HIV load, CD4 cell count, and duration of antepartum zidovudine to women who received sdNVP in the PHPT-2 trial (control subjects). Consensus sequencing and the more sensitive oligonucleotide ligation assay were performed on samples obtained on postpartum days 7-10, 37-45, and 120 (if the HIV load was >500 copies/mL) to detect K103N/Y181C/G190A mutations. RESULTS: The 222 PHPT-4 subjects did not differ from matched control subjects in baseline characteristics except for age. The combined group median CD4 cell count was 421 cells/mm3 (interquartile range [IQR], 322-549 cells/mm3), the median HIV load was 3.45 log10 copies/mL (IQR, 2.79-4.00 log10 copies/mL), and the median duration of zidovudine prophylaxis was 10.4 weeks (IQR, 9.1-11.4 weeks). Using consensus sequencing, major NNRTI resistance mutations were detected after delivery in 0% of PHPT-4 subjects and 10.4% of PHPT-2 controls. The oligonucleotide ligation assay detected resistance in 1.8% of PHPT-4 subjects and 18.9% of controls. Major NNRTI resistance mutations were detected by either method in 1.8% of PHPT-4 subjects and 20.7% of controls (P < .001). CONCLUSIONS: A 1-month postpartum course of zidovudine plus didanosine prevented the selection of the vast majority of NNRTI resistance mutations

Switching HIV treatment in adults based on CD4 count versus viral load monitoring: a randomized, non-inferiority trial in Thailand.

BACKGROUND: Viral load (VL) is recommended for monitoring the response to highly active antiretroviral therapy (HAART) but is not routinely available in most low- and middle-income countries. The purpose of the study was to determine whether a CD4-based monitoring and switching strategy would provide a similar clinical outcome compared to the standard VL-based strategy in Thailand. METHODS AND FINDINGS: The Programs for HIV Prevention and Treatment (PHPT-3) non-inferiority randomized clinical trial compared a treatment switching strategy based on CD4-only (CD4) monitoring versus viral-load (VL). Consenting participants were antiretroviral-naïve HIV-infected adults (CD4 count 50-250/mm(3)) initiating non-nucleotide reverse transcriptase inhibitor (NNRTI)-based therapy. Randomization, stratified by site (21 public hospitals), was performed centrally after enrollment. Clinicians were unaware of the VL values of patients randomized to the CD4 arm. Participants switched to second-line combination with confirmed CD4 decline >30% from peak (within 200 cells from baseline) in the CD4 arm, or confirmed VL >400 copies/ml in the VL arm. Primary endpoint was clinical failure at 3 years, defined as death, new AIDS-defining event, or CD4 400 copies/ml at switch was 7.2 months (5.8-8.0) in VL versus 15.8 months (8.5-20.4) in CD4 (p=0.002). FDO scores were not significantly different at time of switch. No adverse events related to the monitoring strategy were reported. CONCLUSIONS: The 3-year rates of clinical failure and loss of treatment options did not differ between strategies although the longer-term consequences of CD4 monitoring would need to be investigated. These results provide reassurance to treatment programs currently based on CD4 monitoring as VL measurement becomes more affordable and feasible in resource-limited settings. TRIAL REGISTRATION: ClinicalTrials.govNCT00162682 Please see later in the article for the Editors' Summary

Venous thromboembolic disease and combined oral contraceptives: results of international multicentre case-control study

The composition and use of oral contraceptives (OCs) have changed since their cardiovascular side-effects were established 20 years ago. This report describes the risk of idiopathic venous thromboembolic (VTE) events (deep vein thrombosis [DVT] and/or pulmonary embolism [PEI]) in association with current use of combined OCs among 1143 cases aged 20-44 and 2998 age-matched controls, as evaluated in a hospital-based, case-control study in 21 centres in Africa, Asia, Europe, and Latin America.OC use was associated with an increased risk of VTE in Europe (odds ratio 4.15 [95% CI 3.09-5.57]) and in non-European (''developing'') countries (3.25 [2.59-4.08]). Risk estimates were generally higher for DVT than for PE but no consistent trend by certainty of diagnosis (definite, probable, possible) was found. Increased risk was apparent within 4 months of starting OCs, was unaffected by duration of current episode of OC use, and had disappeared within 3 months of stopping OCs. Relative risk estimates of VTE associated with OC use were unaffected by age of user, by history of hypertension (excluding hypertension in pregnancy), or in any consistent way by smoking. However, in both groups of countries increased body mass index (BMI) was an independent risk factor for VTE, and OC-associated odds ratios were higher among those with a BMI above 25 kg/m(2) than among those with smaller BMIs. OC-associated risk estimates were high among women in Europe with a history of hypertension in pregnancy.Odds ratios associated with the use of OCs containing a third-generation progestagen observed with progestagens type) and second (norgestrel group) generation. Odds ratios associated with first and second generation progestagens tended to be lower, though not significantly, when used in combination with low (<50 mu g oestrogen) rather than higher oestrogen doses. This study confirms an association between OC use and VTE in Europe and the developing countries, although overall risk estimates associated with use were lower than demonstrated in most previous studies of non-fatal idiopathic VTE.ESCOLA PAULISTA MED,SAO PAULO,BRAZILESCUELA MED,VALPARAISO,CHILESHANGHAI INST PLANNED PARENTHOOD RES,SHANGHAI,PEOPLES R CHINAUNIV VALLE,FAC SALUD,CALI,COLOMBIAUNIV OXFORD,OXFORD,ENGLANDZENTRUM EPIDEMIOL & GESUNDHEITFORSCH,BERLIN,GERMANYCHINESE UNIV HONG KONG,HONG KONG,HONG KONGALBERT SZENT GYORGYI MED UNIV,H-6701 SZEGED,HUNGARYUNIV INDONESIA,FAC MED,JAKARTA,INDONESIAUNIV W INDIES,TROP METAB RES UNIT,KINGSTON 7,JAMAICAKENYA GOVT MED RES CTR,NAIROBI,KENYAGRP INTERUNIV MEXICANO INVEST EPIDEMIOL SALUD REP,DURANGO,MEXICOUNIV LJUBLJANA,INST PUBL HLTH,LJUBLJANA,SLOVENIACHULALONGKORN HOSP,BANGKOK,THAILANDSIRIRAJ HOSP,SIRIRAJ FAMILY HLTH RES CTR,BANGKOK,THAILANDUNIV BELGRADE,SCH MED,BELGRADE,YUGOSLAVIAUNIV LUSAKA,TEACHING HOSP,LUSAKA,ZAMBIAUNIV ZIMBABWE,HARARE,ZIMBABWEESCOLA PAULISTA MED,SAO PAULO,BRAZILWeb of Scienc

Acute myocardial infarction and combined oral contraceptives: Results of an international multicentre case-control study

Background The association between oral contraceptive (OC) use and acute myocardial infarction (AMI) was established in studies from northern Europe and the USA, which took place during the 1960s and 1970s. Few data are available to quantify the risk worldwide of AMI associated with use of OCs introduced since those early studies. This hospital-based case-control study examined the association between a first AMI and current OC use in women from Africa, Asia, Europe, and Latin America (21 centres).Methods Cases were women aged 20-44 years who had definite or possible AMI (classified by history, electrocardiographic, and cardiac-enzyme criteria), who were admitted to hospital, and who survived for at least 24 h. Up to three hospital controls matched by 5-year age-band were recruited for each of the 368 cases (941 controls). All participants were interviewed while in hospital with the same questionnaire, which included information on medical and personal history, lifetime contraceptive use, and blood-pressure screening before the most recent episode of OC use. Odds ratios compared the risk of AMI in current OC users and in non-users (past users and never-users combined).Findings The overall odds ratio for AMI was 5.01 (95% CI 2.54-9.90) in Europe and 4.78 (2.52-9.07) in the non-European (developing) countries; however, these risk estimates reflect the frequent coexistence of other risk factors among OC users who have AMI. Very few AMIs were identified among women who had no cardiovascular risk factors and who reported that their blood pressure had been checked before OC use; odds ratios associated with OC use in such women were not increased in either Europe or the developing countries. Among OC users who smoked ten or more cigarettes per day, the odds ratios in Europe and in the developing countries were over 20. Similarly, among OC users with a history of hypertension (during pregnancy or at any other time), odds ratios were at least ten in both groups of countries, No consistent association between odds ratios for AMI and age of OC users or oestrogen dose was apparent in either group of countries, No significant increase in odds ratios was apparent with increasing duration of OC use among current users, and odds ratios were not significantly increased in women who had stopped using OCs, even after long exposure. The study had insufficient power to examine whether progestagen dose or type had any effect on AMI risk.Interpretation Current use of combined OCs is associated with an increased risk of AMI among women with known cardiovascular risk factors and among those who have not been effectively screened, particularly for blood pressure, AMI is extremely rare in younger (<35 years) non-smoking women who use OCs, and the estimated excess risk of AMI in such women in the European centres is about 3 per 10(6) woman-years. The risk is likely to be even lower if blood pressure is screened before, and presumably during, OC use. Only among older women who smoke is the degree of excess risk associated with OCs substantial (about 400 per 10(6) woman-years).ESCOLA PAULISTA MED,BR-04023 SAO PAULO,BRAZILUNIV CHILE,ESCUELA SALUD PUBL,SANTIAGO,CHILENATL RES INST FAMILY PLANNING,BEIJING,PEOPLES R CHINASICHUAN FAMILY PLANNING RES INST,CHENGDU,PEOPLES R CHINASHANGHAI INST PLANNED PARENTHOOD RES,SHANGHAI,PEOPLES R CHINAUNIV VALLE,FAC SALUD,CALI,COLOMBIAZENTRUM EPIDEMIOL & GESUNDHEITSFORSCH,BERLIN,GERMANYCHINESE UNIV HONG KONG,SHATIN 100083,HONG KONGALBERT SZENT GYORGYI MED UNIV,H-6701 SZEGED,HUNGARYUNIV INDONESIA,FAC MED,JAKARTA,INDONESIAKENYA GOVT MED RES CTR,NAIROBI,KENYAINTERUNIV MEXICANO INVEST EPIDEMIOL SALUD REPROD,DURANGO,MEXICOUNIV W INDIES,TROP METAB RES UNIT,KINGSTON 7,JAMAICAESCUELA MED,VALPARAISO,CHILEUNIV LJUBLJANA,INST PUBL HLTH,LJUBLJANA,SLOVENIACHULALONGKORN HOSP,BANGKOK,THAILANDSIRIRAJ HOSP,BANGKOK,THAILANDUNIV OXFORD,OXFORD,ENGLANDUNIV BELGRADE,SCH MED,YU-11001 BELGRADE,YUGOSLAVIAUNIV TEACHING HOSP,LUSAKA,ZAMBIAUNIV ZIMBABWE,HARARE,ZIMBABWEUNIV OXFORD,OXFORD OX1 2JD,ENGLANDKAISER PERMANENTE,PASADENA,CANICHHD,BETHESDA,MDAARHUS UNIV,DANISH EPIDMEIOL SCI CTR,DK-8000 AARHUS C,DENMARKLONDON SCH HYG & TROP MED,LONDON WC1,ENGLANDESCOLA PAULISTA MED,BR-04023 SAO PAULO,BRAZILWeb of Scienc