Letters to the Editor
REFERENCES
1. Lee IM, Paffenbarger RS Jr. Re: "Body mass index and lung cancer risk." (Letter). Am J Epidemiol I992;l36:l4l7-l8. 2. Rabat GC, Wynder EL. Body mass index and lung cancer risk. Am J Epidemiol 1992; 135:769-74. 3. Knekt P, Heliovaara M, Rissanen A, et al. Leanness and lung cancer risk. Int J Cancer I99l;49: . 208-13. 4. Noppa H, Bengtsson C. Obesity in relation to smoking: a population study of women in Goteborg, Sweden. Prev Med 1980:9:534-43. 5. Jacobs DR, Gottenberg S. Smoking and weight: the Minnesota Lipid Research Clinic. Am J Public Health 1981 ;71:391-6. 6. Albanes D, Jones DY, Micozzi MS, et al. Associations between smoking and body weight in the US population: analysis of NHANES II. Am J Public Health 1987;77:439-44. 7. Fehily AM, Phillips KM, Yarnell JW. Diet, smok-
1419
ing, social class, and body mass index in the Caerphilly Heart Disease Study. Am J Clin Nutr 1984; 40:827-33. 8. Seidell JC, Cigolini M, Deslypere JP, et al. Body fat distribution in relation to physical activity and smoking habits in 38-year-old European men. The European Fat Distribution Study. Am J Epidemiol lS91;133:257-65. 9. Shimokata H, Muller DC, Andres R. Studies in the distribution of body fat. III. Effects of cigarette smoking. JAMA 1989;261:1169-73. 10. Marti B, Tuomilehto J, Korhonen HJ, et al. Smoking and leanness: evidence for change in Finland. B M J 1989;298:1287-90. Geoffrey C. Kabat
Ernst L. Wynder Division of Epidemiology American Health Foundation New York, NY 10017
RE: "CHLAMYDIA TRACHOMATIS INFECTION IN WOMEN: A NEED FOR UNIVERSAL SCREENING IN HIGH PREVALENCE POPULA T1ONS?" In a recent paper, Weinstock et al. (1) discussed the need for universal screening for Chlamydia trachomatis cervical infections in populations that have a known high prevalence of this infection. We agree with their conclusion and submit data that would suggest an expansion of their recommendations. A rapidly growing population at high risk for having acquired a sexually transmitted cervical infection are women infected with the human immunodeficiency virus (HIV) (2). Although several studies have looked at the epidemiology of pelvic inflammatory disease in HIV-infected women (3-5), there is little information on the prevalence of cervicitis due to Neisseria gonorrhoeae and C. trachomatis in this population. We retrospectively reviewed data regarding cervicitis in HIV-infected women at least 18 years of age who sought treatment at the HIV primary care clinic of the Charity Hospital of New Orleans between January 1988 and December 1991, to evaluate the need for routine universal surveillance screening for cervical infections. Cervical cultures for TV. gonorrhoeae were performed in the routine manner on Thayer-Martin agar plates. C. trachomatis cervical infections were ascertained by C. trachomatis antigen enzymelinked immunosorbent assay. Cultures and C. trachomatis antigen testing within 6 months of previous studies were not included in the analysis. A total of 198 women had at least one comprehensive visit during the specified time period. The median age was 27 years, and 72 percent of the women were African American. The median CD4 cells/mm3 for this cohort in the latter half of 1991 was 457. Although information on marital status was not routinely gathered, the vast
majority of patients were unmarried. Data on sexual activity was unavailable. A total of 161 women, or 81 percent of the total population, had at least one pelvic examination performed in the HIV primary care clinic. Surveillance cervical cultures performed between January 1988 and December 1991 grew N gonorrhoeae in eight of 131 cultures (6 percent), and C. trachomatis was detected in 11 of 102 antigen tests (11 percent). Surveillance screening between January 1991 and December 1991 revealed cervicitis due to N. gonorrhoeae in seven of 92 women (8 percent) and cervicitis due to C. trachomatis in 10 of 80 women (13 percent). No woman had coexistent infections with N. gonorrhoeae and C. trachomatis; that is, 17 of 92 women (18 percent) had cervicitis due either to N. gonorrhoeae or to C. trachomatis during 1991. HIV-infected women are likely to seek medical care more frequently than noninfected women, either because of medical necessity or concern about their own health. Community standards currently recommend pelvic examinations in HIV-infected women at minimum intervals of 6 months because of the high rate of cervical pathology (6). The consequence of these secular trends will be an increasing number of pelvic examinations performed yearly in the United States in the HIV-infected female population. We agree with the conclusion drawn by Weinstock et al. Our data would further suggest that universal surveillance screening for both N. gonorrhoeae and C. trachomatis be considered when performing biannual pelvic examinations in HIV-infected women. Although our numbers were small, a relatively high proportion in our population had cervicitis due to a treatable sex-
1420
Letters to the Editor
ually transmitted disease. It is also likely that the percentage underestimates the true prevalence of cervicitis in our sexually active HIV-infected female population, since our denominator included patients who were sexually active and those who were not. Hopefully, increasing adherence to safe sex precautions and utilization of condoms may lessen the need for increased frequency of universal surveillance screening in the future. However, to monitor potential trends better over time, further studies regarding the prevalence of cervicitis will be warranted in the future. REFERENCES
1. Weinstock HS, Bolan GA, Kohn R, et. al. Chlamydia trachomatis infection in women: a need for universal screening in high prevalence populations? Am J Epidemiol I992;l35:41-7. 2. AIDS in Women: United States. MMWR 1990; 39:845-6. 3. Hoegsberg B, Abulafia O, Sedlis A, et al. Sexually transmitted diseases and human immunodeficiency virus infection among women with pelvic inflammatory disease. Am J Obstet Gynecol 1990; 163:1135-9. 4. Safrin S, Dattel BJ, Hauer L, et al. Seroprevalence and epidemiologic correlates of human immunodeficiency virus infection in women with acute pelvic inflammatory disease. Obstet Gynecol 1990; 75:666-70. 5. Sperling RS, Friedman F, Joyner M, et al. Seroprevalence of human immunodeficiency virus in women admitted to the hospital with pelvic inflammatory disease. J Reprod Med 1991;36:122-4. 6. Minkoff H, Dehovitz JA. HIV infection in women. AIDS d i n Care 1991;3:33-5.
screened. We agree with Clark et al. that women infected with the human immunodeficiency virus (HIV) may be one such population, as might women infected with other sexually transmitted diseases. We found, for example, that 9 of 62 women (14.5 percent) with Trichomonas on wet mount were also positive for chlamydia. We agree that the prevalence of mucopurulent cervicitis and cervical friability in HIV-infected populations needs to be studied. It might also be useful to compare the sensitivity and specificity of these signs as predictors of chlamydial infection in HIV- and non-HIV-infected populations. Clark et al. found that 10-13 percent of their HIV-infected patients had cervicitis due to chlamydia. It is not clear, however, how cervicitis was defined in their population. Among our patients, who were at relatively low risk for HIV infection, 8.4 percent had cervical friability or mucopurulent cervicitis, accounting for 17 percent of chlamydial infections. As we pointed out, these signs, while specific, are not sensitive indicators of chlamydial infection and should not be used as measures of its prevalence. The actual prevalence of both symptomatic and asymptomatic chlamydia in HIV-infected populations warrants future study. The presence of gonorrhea or chlamydia in 18 percent of the HIV-infected women screened by Clark et al. in 1991 suggests that unprotected intercourse is continuing at a high rate in this particular population. In addition to screening these patients for gonorrhea and chlamydia, prevention programs aimed at modifying high-risk behaviors should be made available to these patients and their partners.
Rebecca A. Clark
Infectious Diseases Section Tulane University Medical Center New Orleans, LA 70115 Jeanne Dumestre Carol Pindaro William Brandon Theodore Wisniewsky Department of Medicine Section of HIV Primary Care Louisiana Medical Center New Orleans, LA 70112
THE FIRST TWO AUTHORS REPLY We thank Drs. Clark et al. (1) for their comments on our paper (2). As we showed, known risk factors for chlamydial infections are not sufficiently sensitive and specific, and, therefore, all women in high prevalence populations should be
REFERENCES
1. Clark RA, Dumestre J, Pindaro C, et al. Re: "Chlamydia trachomatis infection in women: a need for universal screening in high prevalence populations?" (Letter). Am J Epidemiol 1992; 136: 1419-20. 2. Weinstock HS, Bolan GA, Kohn R, et al. Chlamydia trachomatis infection in women: a need for universal screening in high prevalence populations? Am J Epidemiol 1992; 135:41-7.
Hillard S. Weinstock Division of Sexually Transmitted Diseases and HIV Prevention Centers for Disease Control and Prevention Atlanta, GA 30333 Gail Bolan San Francisco Department of Public Health San Francisco, CA 94103
REFERENCES
1. Lee IM, Paffenbarger RS Jr. Re: "Body mass index and lung cancer risk." (Letter). Am J Epidemiol I992;l36:l4l7-l8. 2. Rabat GC, Wynder EL. Body mass index and lung cancer risk. Am J Epidemiol 1992; 135:769-74. 3. Knekt P, Heliovaara M, Rissanen A, et al. Leanness and lung cancer risk. Int J Cancer I99l;49: . 208-13. 4. Noppa H, Bengtsson C. Obesity in relation to smoking: a population study of women in Goteborg, Sweden. Prev Med 1980:9:534-43. 5. Jacobs DR, Gottenberg S. Smoking and weight: the Minnesota Lipid Research Clinic. Am J Public Health 1981 ;71:391-6. 6. Albanes D, Jones DY, Micozzi MS, et al. Associations between smoking and body weight in the US population: analysis of NHANES II. Am J Public Health 1987;77:439-44. 7. Fehily AM, Phillips KM, Yarnell JW. Diet, smok-
1419
ing, social class, and body mass index in the Caerphilly Heart Disease Study. Am J Clin Nutr 1984; 40:827-33. 8. Seidell JC, Cigolini M, Deslypere JP, et al. Body fat distribution in relation to physical activity and smoking habits in 38-year-old European men. The European Fat Distribution Study. Am J Epidemiol lS91;133:257-65. 9. Shimokata H, Muller DC, Andres R. Studies in the distribution of body fat. III. Effects of cigarette smoking. JAMA 1989;261:1169-73. 10. Marti B, Tuomilehto J, Korhonen HJ, et al. Smoking and leanness: evidence for change in Finland. B M J 1989;298:1287-90. Geoffrey C. Kabat
Ernst L. Wynder Division of Epidemiology American Health Foundation New York, NY 10017
RE: "CHLAMYDIA TRACHOMATIS INFECTION IN WOMEN: A NEED FOR UNIVERSAL SCREENING IN HIGH PREVALENCE POPULA T1ONS?" In a recent paper, Weinstock et al. (1) discussed the need for universal screening for Chlamydia trachomatis cervical infections in populations that have a known high prevalence of this infection. We agree with their conclusion and submit data that would suggest an expansion of their recommendations. A rapidly growing population at high risk for having acquired a sexually transmitted cervical infection are women infected with the human immunodeficiency virus (HIV) (2). Although several studies have looked at the epidemiology of pelvic inflammatory disease in HIV-infected women (3-5), there is little information on the prevalence of cervicitis due to Neisseria gonorrhoeae and C. trachomatis in this population. We retrospectively reviewed data regarding cervicitis in HIV-infected women at least 18 years of age who sought treatment at the HIV primary care clinic of the Charity Hospital of New Orleans between January 1988 and December 1991, to evaluate the need for routine universal surveillance screening for cervical infections. Cervical cultures for TV. gonorrhoeae were performed in the routine manner on Thayer-Martin agar plates. C. trachomatis cervical infections were ascertained by C. trachomatis antigen enzymelinked immunosorbent assay. Cultures and C. trachomatis antigen testing within 6 months of previous studies were not included in the analysis. A total of 198 women had at least one comprehensive visit during the specified time period. The median age was 27 years, and 72 percent of the women were African American. The median CD4 cells/mm3 for this cohort in the latter half of 1991 was 457. Although information on marital status was not routinely gathered, the vast
majority of patients were unmarried. Data on sexual activity was unavailable. A total of 161 women, or 81 percent of the total population, had at least one pelvic examination performed in the HIV primary care clinic. Surveillance cervical cultures performed between January 1988 and December 1991 grew N gonorrhoeae in eight of 131 cultures (6 percent), and C. trachomatis was detected in 11 of 102 antigen tests (11 percent). Surveillance screening between January 1991 and December 1991 revealed cervicitis due to N. gonorrhoeae in seven of 92 women (8 percent) and cervicitis due to C. trachomatis in 10 of 80 women (13 percent). No woman had coexistent infections with N. gonorrhoeae and C. trachomatis; that is, 17 of 92 women (18 percent) had cervicitis due either to N. gonorrhoeae or to C. trachomatis during 1991. HIV-infected women are likely to seek medical care more frequently than noninfected women, either because of medical necessity or concern about their own health. Community standards currently recommend pelvic examinations in HIV-infected women at minimum intervals of 6 months because of the high rate of cervical pathology (6). The consequence of these secular trends will be an increasing number of pelvic examinations performed yearly in the United States in the HIV-infected female population. We agree with the conclusion drawn by Weinstock et al. Our data would further suggest that universal surveillance screening for both N. gonorrhoeae and C. trachomatis be considered when performing biannual pelvic examinations in HIV-infected women. Although our numbers were small, a relatively high proportion in our population had cervicitis due to a treatable sex-
1420
Letters to the Editor
ually transmitted disease. It is also likely that the percentage underestimates the true prevalence of cervicitis in our sexually active HIV-infected female population, since our denominator included patients who were sexually active and those who were not. Hopefully, increasing adherence to safe sex precautions and utilization of condoms may lessen the need for increased frequency of universal surveillance screening in the future. However, to monitor potential trends better over time, further studies regarding the prevalence of cervicitis will be warranted in the future. REFERENCES
1. Weinstock HS, Bolan GA, Kohn R, et. al. Chlamydia trachomatis infection in women: a need for universal screening in high prevalence populations? Am J Epidemiol I992;l35:41-7. 2. AIDS in Women: United States. MMWR 1990; 39:845-6. 3. Hoegsberg B, Abulafia O, Sedlis A, et al. Sexually transmitted diseases and human immunodeficiency virus infection among women with pelvic inflammatory disease. Am J Obstet Gynecol 1990; 163:1135-9. 4. Safrin S, Dattel BJ, Hauer L, et al. Seroprevalence and epidemiologic correlates of human immunodeficiency virus infection in women with acute pelvic inflammatory disease. Obstet Gynecol 1990; 75:666-70. 5. Sperling RS, Friedman F, Joyner M, et al. Seroprevalence of human immunodeficiency virus in women admitted to the hospital with pelvic inflammatory disease. J Reprod Med 1991;36:122-4. 6. Minkoff H, Dehovitz JA. HIV infection in women. AIDS d i n Care 1991;3:33-5.
screened. We agree with Clark et al. that women infected with the human immunodeficiency virus (HIV) may be one such population, as might women infected with other sexually transmitted diseases. We found, for example, that 9 of 62 women (14.5 percent) with Trichomonas on wet mount were also positive for chlamydia. We agree that the prevalence of mucopurulent cervicitis and cervical friability in HIV-infected populations needs to be studied. It might also be useful to compare the sensitivity and specificity of these signs as predictors of chlamydial infection in HIV- and non-HIV-infected populations. Clark et al. found that 10-13 percent of their HIV-infected patients had cervicitis due to chlamydia. It is not clear, however, how cervicitis was defined in their population. Among our patients, who were at relatively low risk for HIV infection, 8.4 percent had cervical friability or mucopurulent cervicitis, accounting for 17 percent of chlamydial infections. As we pointed out, these signs, while specific, are not sensitive indicators of chlamydial infection and should not be used as measures of its prevalence. The actual prevalence of both symptomatic and asymptomatic chlamydia in HIV-infected populations warrants future study. The presence of gonorrhea or chlamydia in 18 percent of the HIV-infected women screened by Clark et al. in 1991 suggests that unprotected intercourse is continuing at a high rate in this particular population. In addition to screening these patients for gonorrhea and chlamydia, prevention programs aimed at modifying high-risk behaviors should be made available to these patients and their partners.
Rebecca A. Clark
Infectious Diseases Section Tulane University Medical Center New Orleans, LA 70115 Jeanne Dumestre Carol Pindaro William Brandon Theodore Wisniewsky Department of Medicine Section of HIV Primary Care Louisiana Medical Center New Orleans, LA 70112
THE FIRST TWO AUTHORS REPLY We thank Drs. Clark et al. (1) for their comments on our paper (2). As we showed, known risk factors for chlamydial infections are not sufficiently sensitive and specific, and, therefore, all women in high prevalence populations should be
REFERENCES
1. Clark RA, Dumestre J, Pindaro C, et al. Re: "Chlamydia trachomatis infection in women: a need for universal screening in high prevalence populations?" (Letter). Am J Epidemiol 1992; 136: 1419-20. 2. Weinstock HS, Bolan GA, Kohn R, et al. Chlamydia trachomatis infection in women: a need for universal screening in high prevalence populations? Am J Epidemiol 1992; 135:41-7.
Hillard S. Weinstock Division of Sexually Transmitted Diseases and HIV Prevention Centers for Disease Control and Prevention Atlanta, GA 30333 Gail Bolan San Francisco Department of Public Health San Francisco, CA 94103
