The authors S Day et al1 should be commended on the performance of their department in the appropriate provision of post-exposure prophylaxis after sexual exposure (PEPSE) in accordance with BASHH
guidelines2.
A co-ordinated post exposure prophylaxis (PEP) policy was introduced at St Mary’s Hospital, London in November 2002, comprising formal links between GUM, A&E and...
The authors S Day et al1 should be commended on the performance of their department in the appropriate provision of post-exposure prophylaxis after sexual exposure (PEPSE) in accordance with BASHH
guidelines2.
A co-ordinated post exposure prophylaxis (PEP) policy was introduced at St Mary’s Hospital, London in November 2002, comprising formal links between GUM, A&E and Occupational Health, and establishing a dedicated PEP
Clinic.
All patients given PEP following sexual or occupational exposures are followed up in this clinic. A retrospective notes audit3 of all clinic attendees was conducted over a 6 month period in 2003, comparing our service with outcome measures highlighted in national guidelines at the time.45
From June to November 2003, 48 patients attended. 54% had occupational exposures. Of the 46% with non-occupational exposures, 27% were sexually exposed (n=13).
Management of our PEPSE recipients has subsequently been compared with BASHH guidelines2.
85% presented for PEPSE via the GUM clinic, 15% via A&E. Demographics, sexual exposures, and attendance for follow up HIV tests, are presented in Table 1.
In 6 of the 13 sexual exposures, the partner was known to be HIV positive, 5 had untraceable partners of unknown serostatus, and in the final case the partner was traced and tested HIV negative on the day of exposure. This patient was not prescribed PEPSE.
PEPSE was in line with ‘recommended’ indications in 11 of the 12 remaining cases. One patient presented after receptive oral sex with a known HIV positive partner, and was concerned that he had bleeding gums. This fell in line with a ‘considered’ indication according to guidelines.
Hence 100% of PEPSE prescriptions fell within recommended guidelines2 (BASHH target 90%).
Time from exposure to first dose was not documented in 1 patient, the remainder received PEPSE within 72 hours (90% target); Range 13-54 hours, mean 28 hours.
100% of PEPSE recipients completed the full 28day course of standard PEP - Combivir, Nelfinavir at the time of audit, (75% target).
Our co-ordinated approach to the provision of PEP has enabled us to provide a successful service. PEPSE is easily accessible, appropriately prescribed, and high completion rates were observed, with no discontinuations related to adverse events. The high adherence rates may have been related to the continuity of seeing the same SpR in clinic
throughout the month of treatment. If appropriate, patients were also referred promptly to clinical psychology services (25% of our cohort) for further adherence support and discussion about sexual risk taking.
At the time of audit we saw comparatively few patients requiring PEPSE. Given recent media coverage, awareness of PEPSE amongst MSM in London has significantly increased – 12 patients requesting PEPSE at St Mary’s in the last 2 weeks alone.
The authors rightly suggest that a PEPSE follow up clinic and dedicated proforma would help ensure appropriate prescription, aid adherence and completion of PEPSE, and improve attendance rates for follow up serology. Certainly the success of our PEP Clinic concurs with this suggestion.
References
1. Post-exposure HIV prophylaxis following sexual exposure:a retrospective adduct against recent draft BASHH guidance. Day S et al. STI 2006;82:236-237
2. BASHH. United Kingdom guideline for the use of post-exposure prophylaxis for HIV following sexual exposure. Fisher M et al. Int J.STD&AIDS 2006;17:81-92
3. A co-ordinated approach to HIV Post Exposure Prophylaxis ensures appropriate and high completion rates. L. Sathia, C Collister, J Walsh. Post Presentation at 7th International Conference on Drug Therapy, Glasgow, Nov '04.
4. HIV Post exposure Prophylaxis - Guidance from the UK chief medical officers expert advisory group on AIDS Revised February 2004 - available at http://www.advisorybodies.doh.gov.uk/eaga/publications.htm
5. Clinical Effectiveness Group (British Association of Sexual Health and HIV) - United Kingdom Guideline for the use of Post-Exposure Prophylaxis for HIV following sexual Exposure available at:
http://www.bashh.org/guidelines/2006/pepse_0206.pdf
In their study Edwards et al. found that the prevalence of sex exchange for money or drugs is approximately 3.5% among the general population of United States adolescents (1). Despite this being a very
worthwhile and understudied area of research, as a researcher and clinician, I have a serious concerns about the data used for this study and the accuracy of the analysis used. Gordis (2) noted that, “...
In their study Edwards et al. found that the prevalence of sex exchange for money or drugs is approximately 3.5% among the general population of United States adolescents (1). Despite this being a very
worthwhile and understudied area of research, as a researcher and clinician, I have a serious concerns about the data used for this study and the accuracy of the analysis used. Gordis (2) noted that, “No
scientific discipline can be better than the quality of its raw data,” and, unfortunately, Edwards, et al. did not take into consideration conditional prevalence in their analysis.
The 3.5% prevalence rate of adolescents who exchange sex for money was derived from self-reports on a single survey item. In other survey questions, the adolescents were asked about engaging in vaginal and anal sex. The adolescents who answered these items in the affirmative do not account for 100% of the adolescents who reported exchanging sex. The authors assumed that the respondents who had exchanged sex, but had not engaged in vaginal and/or anal sex, must have exchanged oral sex. However, there is no evidence to back up this assumption, since the survey did not gather data on oral sex behaviour. Without this information, the possibility that the respondents were confused or simply lied about behaviour is simply too strong, leading to doubts of the accuracy of the results. Therefore, the researchers should have only analyzed the data on survey respondents who answered positively to having vaginal and/or anal sex as well as to having exchanged sex for money or drugs. Although it would have meant a much smaller sample size, the study’s findings would have been more accurate and therefore more helpful to clinicians and researchers alike.
Sincerely,
Karen Matta Oshima, MSW, LICSW
Doctoral Student,
George Warren Brown School of Social Work
References
1. Edwards, JM, Iritani, BJ, and Hallfors, DD. Prevalence and correlates of exchanging sex for drugs or money among adolescents in the United States. STI Published Online First: 10 August 2006.
doi:10.1136/sti.2006.020693.
2. Gordis, L. Assuring the quality of questionnaire data in epidemiological research. American Journal of Epidemiology 1979; 109: 21-24.
Roberts et al (1) have undertaken an ambitious task to critique economic evaluations and mathematical modelling of this topic, and have raised pertinent issues about modelling fidelity. I wish to correct their
reference to my contribution to the field, which has been described as an 'undefined "mathematical model"'. A table in my paper (2) summarised the adapted Markov model with its six inbuilt feedback l...
Roberts et al (1) have undertaken an ambitious task to critique economic evaluations and mathematical modelling of this topic, and have raised pertinent issues about modelling fidelity. I wish to correct their
reference to my contribution to the field, which has been described as an 'undefined "mathematical model"'. A table in my paper (2) summarised the adapted Markov model with its six inbuilt feedback loops allowing estimation of the impact of undetected infection, incomplete treatment,
and partner factors including reinfection. My paper also informed the reader (on page 10) that this was a second order Monte Carlo simulation, running a hypothetical cohort of 100,000 young women through 2,000 iterations. This dynamic population-based model has subsequently been used
to address screening issues: most recently the question of cost saving by pooling urine samples for mass screening in low prevalence situations. A paper on this research will shortly be submitted for publication.
Roberts et al have suggested publication lead time is a reason for the paucity of papers that have described their models in detail. My own experience would indicate that publication bias also operates here: it is much easier to publish an editorial-style paper outlining results obtained
from modelling than to publish the details of the actual mathematical method, especially in journals with clinical readership.
References
(1) Roberts TE, Robinson S, Barton P, Bryan S, Low N. Screening for Chlamydia trachomatis: a systematic review of the economic evaluations and modelling. Sexually Transmitted Infections. 2006; 82: 193-200.
(2) Moriarty HJ. Mathematical modelling: what it can offer to sexual health. Venerology. 2001; 14: 7-13.
In their study, Apoola et al found that patient referral was the most favoured method of partner notification in a large sample of GUM clinics
attendees (1).
Their observations are in line with our findings in a recent (2006) survey in an age- and gender stratified sample of the general population in Flanders, Belgium.
Three hundred patients were questioned regarding acceptability of partn...
In their study, Apoola et al found that patient referral was the most favoured method of partner notification in a large sample of GUM clinics
attendees (1).
Their observations are in line with our findings in a recent (2006) survey in an age- and gender stratified sample of the general population in Flanders, Belgium.
Three hundred patients were questioned regarding acceptability of partner notification strategies in the hypothetical case that they would be diagnosed with an STI.
The large majority of respondents preferred partner
notification (95.8 %). A small minority of respondents indicated that provider referral was acceptable; the provider could be a GP (12.6 %) or another health worker (6.6 %). This pattern was independent of gender,
age, level of education, sexual orientation, number of sexual partners, a history of STIs, and a history of being tested for STIs. In multivariate analysis, older age was slightly associated with the likelihood of accepting provider referral strategies.
Only two respondents stated that they would not inform their partner(s) in case they were diagnosed with an STI.
It remains to be seen to what extent these patients’ preferences in both studies reflect a true believe that being informed directly by a partner is the most optimal strategy for notifying people of a potential STI risk.
It is also conceivable that, by choosing for this strategy, patients try to stay in control over which information on possible STI transmission is disclosed to whom of their regular or occasional sex partners.
A meta-analysis of notification strategies found that patient referral is less effective than provider referral with respect to the number of partners notified and presenting for medical evaluation (2). The reluctance of patients to notify their partners may suggest that they
expect harms from doing so. Potential harms of partner notification, such as the rate of domestic violence, abuse or breaking up of relationships, are poorly understood and need further attention.
References
1. Apoola A, Radcliffe KW, Das S, Robshaw V, Gilleran G, Kumari BS, Boothby M, Rajakumar R. Patient preferences for partner notification. Sex Transm Infect. 2006;82:327-9.
2. Mathews C, Coetzee N, Zwarenstein M, Lombard C, Guttmacher S, Oxman A, Schmid G. Strategies for partner notification for sexually transmitted diseases. Cochrane Database Syst Rev. 2001;4:CD002843.
Low and colleagues used record linkage to identify specific
reproductive health outcomes in women who had or have not had a chlamydia
test. In their paper they refer to "tests done for any purpose as
screening tests". In their analysis they took the "temporal sequence of
chlamydia testing and development of consequences" into account. The most
important finding of this study was the absence of any...
Low and colleagues used record linkage to identify specific
reproductive health outcomes in women who had or have not had a chlamydia
test. In their paper they refer to "tests done for any purpose as
screening tests". In their analysis they took the "temporal sequence of
chlamydia testing and development of consequences" into account. The most
important finding of this study was the absence of any protective effect
of chlamydia testing even for those who tested negative.
Probability of outcome according to chlamydia screen result:
PID: Never tested 2.9%(2.2-2.5%) Negative test 4.0% (3.7-4.4%); Ectopic
pregnancy: Never tested 1.9% (1.7-2.1%) Negative test 2.0% (1.8-2.3%);
Infertility: Never tested 3.1% (2.8-3.3%) Negative test 4.7% (4.4-5.1%).
This is even more surprising as some tests were performed in antenatal
care and thus recruited a population at below average risk for
infertility.
It is of course possible that Low et al did not report the results
chlamydia screening but of chlamydia testing for a variety of indications.
Some patients may have had their tests performed as a part of
investigations for pelvic pain/PID or infertility even if the temporal
sequence was observed as the date of the test (on admission to the
hospital) may have preceded the diagnosis (on discharge from hospital).
Similarly, chlamydia testing may have been performed as a part of an
infertility investigation. Differences in health care seeking behaviour
offer an alternative explanation for the high incidence of PID and
infertility in chlamydia test negative women. To be diagnosed with
infertility or PID a patient has to seek health care. Women who were
tested for chlamydia may be more inclined to use healthcare for other
indications than women who never tested. Interestingly there was no
significant association between the chlamydia testing and ectopic
pregnancy where the diagnosis is unlikely to be affected by health care
seeking behaviour.
It is not inconceivable that chlamydia screening could be seen as
increasing the likelihood of PID or infertility as a negative test could
give false reassurance that risk taking is not harmful. Explaining the
higher incidence of PID and infertility in women who had only negative
chlamydia tests as compared to women who never tested is therefore
essential for the survival of chlamydia screening programmes.
References
(1) Low N, Egger M, Sterne JAC, Harbord RM, Ibrahim F, Lindblom B et al.
Incidence of severe reproductive tract complications associated with
diagnosed genital chlamydial infection: the Uppsala Women's Cohort Study.
Sex Transm Infect 2006;82:212-8.
Chlamydia trachomatis is one of the commonest organisms causing
pelvic inflammatory disease caused by ascending infections to upper female
genital tract from vagina and cervix. It is said to be the most serious
infection encountered by females and about one million teenage girls in
United states suffer from pelvic inflammatory disease caused by ascending
infections including Chlamydia trachomatis.Clini...
Chlamydia trachomatis is one of the commonest organisms causing
pelvic inflammatory disease caused by ascending infections to upper female
genital tract from vagina and cervix. It is said to be the most serious
infection encountered by females and about one million teenage girls in
United states suffer from pelvic inflammatory disease caused by ascending
infections including Chlamydia trachomatis.Clinicians are still kept
handicapped by this bacterium causing severe long term sequale such as
ectopic pregnancy,tubal factor infertility and chronic pelvic pain. It is
the most prevalent and preventable bacterial sexually transmitted
infection recognized through the world(1 ).The asymptomatic nature of more
than 50%of Chlamydial infections which allows a high possibility of
developing silent pelvic inflammatory disease and infertility ,makes the
matters worse(2).
The study(3) had been focused to estimate the cumulative incidence of
severe complications associated with genital Chlamydial infection and the
investigators have been successful in figuring out a lower incidence of
severe complications than expected. This indirectly challenges cost
effectiveness of Chlamydia screening programmes.
But as the authors themselves agree the specificity and sensitivity
of hospital diagnosed pelvic inflammatory disease and infertility should
be incorrect since all the patients presented with features of pelvic
inflammatory disease had not been counted. Some patients may not come out
with classic features of pelvic inflammatory disease such as painful
intercourse, irregular menstrual bleeding, vaginal discharge and cervical
motion tenderness due to social reasons.
Inappropriate and liberal use of antibiotics by the general
practitioners and primary care physicians may well mask the clinical
picture of the disease and can lead to underestimation of the severity of
the problem. Insufficient drug dose, drug resistance, poor tracing and
treating of the partner are major contributors for continued infection and
complications and nothing has been mentioned about these issues. Moreover
nothing is mentioned about pregnant women with Chlamydia infection and
neonatal infection.
Chlamydia is only one of the commonest causes of pelvic inflammatory
diaease.Patients infected with other possible etiological agents such as
Neisseria gonorrhoea,Gardenerella vaginalis,Bacteriodes species, genital
Mycoplasma and Ureaplasma species,Actinomyces species and Mycobacterium
tuberculosis have also to be kept in mind when making the decision. To
make the matters worse only 12% of complications have occurred in patients
with positive Chlamydial test and the remainder were in the other group
who had negative Chlamydial culture report or who had never been tested.
The other shortcoming of the study is that the screening tool which
they have used might well be able to miss some infections. Detection of
specific antibody in patients serum using nucleic acid based tests are
thought to be the best indicators of diagnosing sub clinical and clinical
infection(4) .The authors can not be blamed on this regard since these
diagnostic tools were at a preliminary level when the study was carried
out.
Low educational level has found to be strongly associated with the
development of complications and this seems to be one of the major
achievements of the study. So strategies such as early detection of
infection, risk assessment, and sensitive educational programmes can be
suggested to alert the targeted population.
Health care policy makers in developed and developing countries are
blind about the extent of the Chlamydial infection in the community(2). Unfortunately the results of the study challenges cost effectiveness of
a population based screening programme for Chlamydia trachomatis infection
and the cost might exceed the benefits even in the most optimistic
scenario. But screening programme for Chlamydia infection will be of
paramount importance in the prevention of complications and cost of
screening can be only a fraction of health care cost. So a population
based highly sensitive screening programme is mandatory to prevent
complications.
References
(1) Paavonen J, Eggert-Kruse W. Chlamydia trachomatis: impact on human
reproduction. Hum Reprod Update 1999 Sep-Oct; 5(5)433-47.
(2) Peeling RW et al.The role of the laboratory in a Chlamydia control
programme in a developing country. East Afr Med J.1992 Sep; 69(9):508-14.
(3) Low N,Egger M,Sterne JAC,Hardbord RM,Ibrahim F, Lindblom B,Herrmann
B.Incidence of severe reproductive tract complications associated with
diagnosed genital Chlamydial infection: the Uppsala Women’s Cohort Study.
Sexually Transmitted Infections 2006; 82:212-18.
(4) Chan EL et al.Comparison of effectiveness of polymerase chain
reaction and enzyme immunoassay in detecting Chlamydia trachomatis in
different female genitourinary specimens. Arch Pathol Lab Med 2000 Jun;
124(6):840-3.
We were interested to read Shann and Wilson’s paper: Patients'
attitudes to the presence of medical students in a genitourinary medicine
clinic. [1] They found that younger patients and those attending the
clinic for the first time were less likely to agree to the presence of
medical students in clinic. Additionally young female patients were less
likely to agree to the presence of male students. T...
We were interested to read Shann and Wilson’s paper: Patients'
attitudes to the presence of medical students in a genitourinary medicine
clinic. [1] They found that younger patients and those attending the
clinic for the first time were less likely to agree to the presence of
medical students in clinic. Additionally young female patients were less
likely to agree to the presence of male students. Their findings are not
unexpected and support previous studies. [2] [3] The authors did not
however speculate on the probable causes of these patterns.
A number of psychosocial factors may influence patients’ attitudes to
medical students. One such example might be patient’s perceived stigma of
having a sexually transmitted infection (STI). It has been shown in
females that perceived stigma is associated with increased anticipation of
negative reactions to disclosure of sexual behaviours to a doctor or
nurse. [4] [5]
Consequently, patients’ attitudes to attending genitourinary clinics
might vary according to the reason for attendance. Those patients
attending because they feel they are likely to have an STI may have a high
level of perceived stigma, whereas patients attending for an asymptomatic
screen may view their attendance as a positive health care seeking
activity and not a stigmatising behaviour.
A pilot study carried out in our department in 2006 has shown that
patients attending for asymptomatic screens are more likely to agree to
medical students being present both for their consultation and examination
than those patients who feel they have an infection. This has implications
for training given that the consultation and examination of a symptomatic
patient is more likely to be of educational benefit to medical students.
Following the modernisation of medical careers these clinics may be the
only exposure to genitourinary medicine before specialist training so a
positive experience may be essential to encourage recruitment into the
speciality.
We agree with the authors’ comment that ‘conflict can arise between
the educational requirements of medical students and the needs of
patients’. We feel perceived stigma of having an STI is a major influence
on patients’ acceptance of medical students in genitourinary clinics. This
should be examined further and methods developed to reduce the impact of
perceived stigma within the clinic and in the general population. The use
of alternative teaching models in genitourinary medicine should continue
to be developed so as to enhance student education.
Emma Rutland¹
Hazel Learner²
Elizabeth Foley¹
Raj Patel¹
¹ Department of Genitourinary Medicine, Southampton University
Hospitals Trust
² University of Southampton
References
1. Shann S, Wilson J D. Patients’ attitudes to the presence of
medical students in a genitourinary medicine clinic: a cross sectional
survey. Sex Transm Infect 2006;82:52-54.
2. O’Flynn N, Rymer J. Women’s attitudes to the sex of medical students in
a gynaecology clinic: cross sectional survey. BMJ 2002;325:683-4.
3. Ryder N, Ivens D, Sabin C. The attitude of patients towards medical
students in a sexual health clinic. Sex Transm Infect 2005;81:437-439.
4. Cunningham S D, Tschann J, Gurvey J E, Fortenberry J D, Ellen J M.
Attitudes about sexual disclosure and perceptions of stigma and shame. Sex
Transm Infect 2002;78:334-338.
5. Scoular A, Duncan B, Hart G. “That sort of place…where filthy men go…”:
a qualitative study of women’s perceptions of genitourinary medicine
services. Sex Transm Infect 2001;77:340-343.
We are seriously concerned by the interpretation Low et al.
make from their retrospective cohort study in Uppsala County(1). The
study has many methodological issues which may have influenced the
findings such as: the use of culture which is probably less than 75%
sensitive,(2,3); the exclusion of a fifth (8865) of eligible women in whom
information on chlamydia tests and outcome events were availabl...
We are seriously concerned by the interpretation Low et al.
make from their retrospective cohort study in Uppsala County(1). The
study has many methodological issues which may have influenced the
findings such as: the use of culture which is probably less than 75%
sensitive,(2,3); the exclusion of a fifth (8865) of eligible women in whom
information on chlamydia tests and outcome events were available; and the
measurement of prevalence of complications in a timeframe that coincided
with an extensive chlamydia screening programme. However, our main
concerns are that: the use of the terms "screened" and "screening" is
inaccurate and misleading; and the authors underestimate the incidence of
PID. In addition, there is no explanation of the inconsistencies between
the results presented with data they have previously published from the
same location in which they conclude that "declining rates of genital
chlamydial infections have probably led to a fall in the rate of ectopic
pregnancies"(4).
The study included chlamydia tests undertaken for any reason, which
includes diagnostic testing. Consequently it is not surprising that women
who were never "screened" were at lower risk of complications as it is
likely that the majority of women with complications would have been
tested for chlamydia as part of their routine clinical care. It is likely
that the lower rates observed in those never screened were due to testing
bias.
A diagnosis of PID was used as one of the main outcome measures in
the study. The specificity and sensitivity of PID diagnosis is
notoriously low and there is a high degree of intra and inter-observer
error. Without evidence to show diagnostic accuracy from the group
studied, the authors cannot claim to provide an accurate estimate of
disease burden. The reliance of hospital-based diagnosis is a further
problem as the majority of PID cases do not attend hospital and indeed the
authors point out that this may underestimate the true incidence by a
factor of 10(5). Low et al. suggest that mild cases of PID are less
likely to cause tubal damage but this is not supported by evidence from
the literature. Similar degrees of tubal damage in infertile women with
obstructed fallopian tubes have been seen in women with and without a
history of PID(6-11).
Roberts et al. in a systematic review from the same issue concludes
that two dynamic mathematical modelling studies provide evidence that
screening is cost effective but the authors were concerned about the
accuracy of rates of complication(12,13). Evidence from the evaluation of
outcomes is extremely important in the evolution of screening policies and
practice. It is essential that any estimates must be based on the most
balanced and accurate data available. The estimates of risk of
complications as calculated in this paper are misleading and the
conclusions unjustified.
References
(1) Low N, Egger M, Sterne JAC, Harbord RM, Ibrahim F, Lindblom B et
al. Incidence of severe reproductive tract complications associated with
diagnosed genital chlamydial infection: the Uppsala Women's Cohort Study.
Sex Transm Infect 2006;82:212-8.
(2) Schachter J, McCormack WM, Chernesky MA, Martin DH, Van Der PB,
Rice PA et al. Vaginal swabs are appropriate specimens for diagnosis of
genital tract infection with Chlamydia trachomatis. J Clin Microbiol
2003;41:3784-9.
(3) Burckhardt F, Warner P, Young H. What is the impact of change in
diagnostic test method on surveillance data trends in Chlamydia
trachomatis infection? Sex Transm Infect 2006;82:24-30.
(4) Egger M, Low N, Smith GD, Lindblom B, Herrmann B. Screening for
chlamydial infections and the risk of ectopic pregnancy in a county in
Sweden: ecological analysis. BMJ 1998;316:1776-80.
(5) Simms I, Stephenson JM. Epidemiology of pelvic inflammatory
disease: what do we know and what do we need to know? Sex Transm Inf
2000;76:80-7.
(6) Cates W, Jr., Joesoef MR, Goldman MB. Atypical pelvic
inflammatory disease: can we identify clinical predictors? Am J
ObstetGynecol 1993;169:341-6.
(7) Mueller BA, Luz-Jimenez M, Daling JR, Moore DE, McKnight B, Weiss
NS. Risk factors for tubal infertility. Influence of history of prior
pelvic inflammatory disease. Sex Transm Dis 1992;19:28-34.
(8) Gump DW, Gibson M, Ashikaga T. Evidence of prior pelvic
inflammatory disease and its relationship to Chlamydia trachomatis
antibody and intrauterine contraceptive device use in infertile women. Am
J Obstet Gynecol 1983;146:153-9.
(9) Sellors JW, Mahony JB, Chernesky MA, Rath DJ. Tubal factor
infertility: an association with prior chlamydial infection and
asymptomatic salpingitis. Fertility & Sterility 1988;49:451-7.
(10) Patton DL, Moore DE, Spadoni LR, Soules MR, Halbert SA, Wang SP.
A comparison of the fallopian tube's response to overt and silent
salpingitis. Obstet Gynecol 1989;73:622-30.
(11) Tait IA, Duthie SJ, Taylor-Robinson D. Silent upper genital
tract chlamydial infection and disease in women. Int J STD AIDS 1997;8:329
-31.
(12) Roberts TE, Robinson S, Barton P, Bryan S, Low N, for the
Chlamydia Screening Studies (ClaSS) Group. Screening for Chlamydia
trachomatis: a systematic review of the economic evaluations and
modelling. Sex Transm Infect 2006;82:193-200.
(13) Welte RP. Costs and Effects of Chlamydial Screening: Dynamic
versus Static Modeling. Sex Transm Dis 2005;32:474-83.
The article by Waalboer and colleagues (STI 2006;82:207-211)
precipitated a déjà vu experience for me- albeit along with something new.
They describe a bimodal presentation of chlamydial proctitis in MSM- some
with more severe rectal symptoms caused by LGV serovars and the rest with
much milder rectal disease caused by the D-K serovars.
In 1975 as part of my MD thesis undertaken at The Londo...
The article by Waalboer and colleagues (STI 2006;82:207-211)
precipitated a déjà vu experience for me- albeit along with something new.
They describe a bimodal presentation of chlamydial proctitis in MSM- some
with more severe rectal symptoms caused by LGV serovars and the rest with
much milder rectal disease caused by the D-K serovars.
In 1975 as part of my MD thesis undertaken at The London Hospital I
looked at MSM who had non gonococcal proctitis. I defined this as mucosal
hyperaemia and/ or an excess of polymorphs in rectal exudate. Chlamydial
isolation was by inoculation of irradiated McCoy cells by John Treharne at
London’s Institute of Ophthalmology
Chlamydia was isolated in only 2 of 48 MSM with low grade proctitis
(none had LGV clinically) but in none of 35 control MSM who did not have
proctitis. Another 3 of the men with proctitis had a significant rise in
Micro IF antibody levels (1 in 8 or greater).
All 28 of the 48 men whose Micro IF antibodies were positive showed
serovars in the D-K groups only. No antibodies to LGV were found.
I understand this to mean at least in one large GU clinic in London
in the mid 1970s I saw no MSM who had current or past LGV, in spite of the
fact that unsafe sex was very common in those pre HIV times.
HIV/AIDS is a viral Sexual Transmission Diseases (STDs) which
threatens life expectancy and, with it, development, social cohesion,
political stability and food security. It imposes a devastating economic
burden on countries. Behaviours that bring the highest risk of infection in
Bangladesh are unprotected sex between sex workers and their clients,
needle sharing and unprotected sex between men....
HIV/AIDS is a viral Sexual Transmission Diseases (STDs) which
threatens life expectancy and, with it, development, social cohesion,
political stability and food security. It imposes a devastating economic
burden on countries. Behaviours that bring the highest risk of infection in
Bangladesh are unprotected sex between sex workers and their clients,
needle sharing and unprotected sex between men.
HIV incidence is rising faster in India that is the neighboring
country of Bangladesh. In India rates of sexually transmitted infections
and injecting drug use are also on the rise. Drug trafficking, along with
the economic and psychological consequences of recent conflicts, is
increasing the likelihood that HIV epidemics will emerge in this region.
The Human rights organizations in Bangladesh estimate that more than
20,000 women and children were trafficked annually for the purpose of
prostitution, and more than 50,000 women and children were estimated to
have been trafficked into India annually, most for the sex trade. The
situation of Bangladesh like that trafficking of women or children for
sexual exploiting is a high profitable business. The system of
constitution & low almost every time fever of trafficking criminal as
like Brazil. This criminal group thinks that some time this crime has risk
but less, but it has great profit, no any possible of loss, invest is
nothing size of the profit. Every trafficking event there is several
people work behind the incident. It is group work. They are more
organize and committed. But it is harmful to the thousands of women and
children exploited in slavery-like situation in the global sex industry.
Several social norms and immature behavior fueled of this disease to
scatter rapidly. There are several social components link to develop this
harmful situation. Poverty-behind to force it, gender discrimination plays
a vital role; frustration and risk behaviour help to sink humanity
resulting in infection. The link between poverty and gender discrimination
are help to decline socio economic prosperity. This link creates several
anti social poisonous issues also. Such as trafficking to prostitute, sell
sex for earn or living, break down family norm to create frustration and
driven drug point. We notice easily that Illiteracy is the main watchword
of all circumstance. So it is not easy to remove it from the society,
several programs and strategy are needed to gain sustainable position
Day by day it is mounting evidence that the trafficking of women and
children for sexual exploitation, is a significant problem in every
country. Usually commercially sex trafficking is more than an issue of
crime or migration; it is an issue of gender discrimination and the worse
status of women. Around the world most trafficked people are adolescent
girls, women and children of low socio-economic status, and the primary
trafficking flows are from poor of developing countries to more wealthy
countries.
Rainbow Nari O Shishu Kallyan Foundation found, Trafficking is strong
link HIV pandemic, if we see; globally of those HIV epidemic region,
trafficking & sex exploitation is regular feature of there. Mostly
trafficking victim are used commercial sex industry in other geographical
area, they stay in there, as like in prison, they have no rights of speak
out themselves. They are forced to sexual conduct with multiple partners,
but they have no ability to insist upon condom use or safe sex and are
vulnerable to HIV/STIs transmission. Some time they have to face physical
attack, but they don’t get health care facilities.
Mohammad Khairul Alam
AIDS Researcher
Rainbow Nari O Shishu Kallyan Foundation
rainbowngo@gmail.com
www.plusbangla.com
Reference:
UNICEF, World Bank, Rainbow Nari O Shishu Kallyan
Foundation.
Dear Editor,
The authors S Day et al1 should be commended on the performance of their department in the appropriate provision of post-exposure prophylaxis after sexual exposure (PEPSE) in accordance with BASHH guidelines2.
A co-ordinated post exposure prophylaxis (PEP) policy was introduced at St Mary’s Hospital, London in November 2002, comprising formal links between GUM, A&E and...
Dear Editor,
In their study Edwards et al. found that the prevalence of sex exchange for money or drugs is approximately 3.5% among the general population of United States adolescents (1). Despite this being a very worthwhile and understudied area of research, as a researcher and clinician, I have a serious concerns about the data used for this study and the accuracy of the analysis used. Gordis (2) noted that, “...
Dear Editor
Roberts et al (1) have undertaken an ambitious task to critique economic evaluations and mathematical modelling of this topic, and have raised pertinent issues about modelling fidelity. I wish to correct their reference to my contribution to the field, which has been described as an 'undefined "mathematical model"'. A table in my paper (2) summarised the adapted Markov model with its six inbuilt feedback l...
Dear Editor,
In their study, Apoola et al found that patient referral was the most favoured method of partner notification in a large sample of GUM clinics attendees (1).
Their observations are in line with our findings in a recent (2006) survey in an age- and gender stratified sample of the general population in Flanders, Belgium.
Three hundred patients were questioned regarding acceptability of partn...
Dear Editor,
Low and colleagues used record linkage to identify specific reproductive health outcomes in women who had or have not had a chlamydia test. In their paper they refer to "tests done for any purpose as screening tests". In their analysis they took the "temporal sequence of chlamydia testing and development of consequences" into account. The most important finding of this study was the absence of any...
Dear Editor,
Chlamydia trachomatis is one of the commonest organisms causing pelvic inflammatory disease caused by ascending infections to upper female genital tract from vagina and cervix. It is said to be the most serious infection encountered by females and about one million teenage girls in United states suffer from pelvic inflammatory disease caused by ascending infections including Chlamydia trachomatis.Clini...
Dear Editor,
We were interested to read Shann and Wilson’s paper: Patients' attitudes to the presence of medical students in a genitourinary medicine clinic. [1] They found that younger patients and those attending the clinic for the first time were less likely to agree to the presence of medical students in clinic. Additionally young female patients were less likely to agree to the presence of male students. T...
Dear Editor,
We are seriously concerned by the interpretation Low et al. make from their retrospective cohort study in Uppsala County(1). The study has many methodological issues which may have influenced the findings such as: the use of culture which is probably less than 75% sensitive,(2,3); the exclusion of a fifth (8865) of eligible women in whom information on chlamydia tests and outcome events were availabl...
Dear Editor,
The article by Waalboer and colleagues (STI 2006;82:207-211) precipitated a déjà vu experience for me- albeit along with something new. They describe a bimodal presentation of chlamydial proctitis in MSM- some with more severe rectal symptoms caused by LGV serovars and the rest with much milder rectal disease caused by the D-K serovars.
In 1975 as part of my MD thesis undertaken at The Londo...
Dear Editor,
HIV/AIDS is a viral Sexual Transmission Diseases (STDs) which threatens life expectancy and, with it, development, social cohesion, political stability and food security. It imposes a devastating economic burden on countries. Behaviours that bring the highest risk of infection in Bangladesh are unprotected sex between sex workers and their clients, needle sharing and unprotected sex between men....
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