Clinical round-up

Huge burden of undiagnosed gonorrhoea and Chlamydia due to sole testing of urogenital sites

While routine multi-site testing for gonorrhoea and Chlamydia in men who have sex with men (MSM) is increasingly becoming the standard of care, the same is not true for heterosexual women who may also practice oral and anal sexual intercourse. A group of Dutch investigators have reported a study exploring the number of missed infections if only the urogenital site was tested using nucleic acid amplification tests.1 Sampling of the urogenital site was considered to be urine or swabs taken from the urethra, vagina or cervix. A missed infection is considered to be one occurring in the throat or rectum where the urogenital sample is negative.

Between 2006 and 2010, a total of 207 134 new consultations occurred in women. Chlamydia testing was also performed either from the pharynx or rectum in 17.6%. For Chlamydia, the positivity rates were 10.4%, 9.3% and less than 3% for vaginal, anorectal and pharyngeal samples respectively. About 13% of Chlamydia infections would have been missed, as the urogenital test was negative (427 anogenital only, 194 pharyngeal only).

Gonorrhoea testing occurred in 69.8% of women. Another site was samples in 16.7% of women and triple site testing occurred in 13.4%. The gonorrhoea positivity rates were 1.2% urogenital, 1% anorectal and 1.2% pharyngeal. Thirty percent of infections would have been missed if only the urogenital site was sampled (275 pharyngeal only, 115 anorectal only).

This study provides support to change guidelines to increase testing for anorectal and pharyngeal infections in women. The prompt diagnosis and treatment of these infections are likely to have huge public health benefits.

Smoking does not affect the size of anal warts in HIV-infected women

Researchers from the Women's Interagency HIV Study have found that current smoking does not significantly affect the size of anal warts in women living with HIV.2 The population of interest comprised 976 HIV-infected women with anal warts who had not received any specific wart treatment. Women were recruited to the original study between October 1994–November 1995 and October 2001–September 2002.

From baseline, women were followed-up at 6 monthly intervals censored at March 2006. At each visit, data was collected on: demographic and socioeconomic status; medical history (including obstetric and gynaecological); antiretroviral therapy; alcohol and cigarette use; sexual behaviours; abdominal and ano-genital examinations (including per vaginal speculum examination and rectal examination); cervical smear results; and HIV surrogate markers. Anal warts were defined as those located in the right/left and upper and lower anus, and also the perineum. The length and width of the largest wart was measured in millimetres. A linear mixed model approach was used to investigate the relationship between current smoking status and the size of the wart.

About 20% of women had CD4<200 cells/mm³ and 50% had a HIV viral load greater than 100 000 copies/ml. At baseline 65% were current smokers. In both unadjusted and adjusted models, there was no significant association between size of anal wart at baseline and current smoking status over time. However, there was a tendency for smokers to have warts that were 21.79 mm² larger at baseline.

The authors identify that while theirs is the only study to specifically look at this association in this specific way, the findings are not consistent with other studies that have explored the association of smoking with genital warts and other HPV-related diseases. This may in part be explained by the fact that the burden of anal warts was only measured by the size of the largest wart at the time of the examination and does not look at the growth or recrudescence of individual warts, which may be a more relevant clinical indicator.

Is this the end of the confusion about Hepatitis B vaccination strategies in HIV-infected people?

Vaccination against Hepatitis B (HBV) features in the guidelines of many national and international societies for the care of people living with HIV. However, these guidelines have significant differences in their approach and even when in place, are rarely implemented effectively at the clinic level. A group of American researchers have performed a review, which looks at the discrepancies between certain international guidelines and the evidence that actually exists about Hepatitis B vaccination effectiveness.3

The review cites 101 references, which provide data on: the incidence of acute Hepatitis B infection; predictors of anti-Hepatitis B surface antibody (HB-sAb) seroconversion and duration of protection; interpreting effectiveness and longevity of protection against HBV based on the post-vaccination HB-sAb titre; the role of repeat vaccinations and the use of high-dose vaccines; intradermal administration; seroconversion rates depending on dosing frequency/intervals in different vaccine regimens; and the effectiveness of vaccine programmes in implementing guidelines.

The article presents the review of literature in a well structured, easy to read manner with summary tables comparing the relevant studies. A worthwhile read which also highlights the knowledge gaps and potential questions to be answered by future research.