Lyerla et al (August 2008 issue) conclude that there
is a general overall weakness in the surveillance system of most low and middle income countries in their article on the quality of sero-surveillance. This may well be the case. However, the paper has some important inaccuracies and some of their assertions can be challenged.
Their assessment that Jamaica has a poorly functioning surveillance syste...
Lyerla et al (August 2008 issue) conclude that there
is a general overall weakness in the surveillance system of most low and middle income countries in their article on the quality of sero-surveillance. This may well be the case. However, the paper has some important inaccuracies and some of their assertions can be challenged.
Their assessment that Jamaica has a poorly functioning surveillance system is erroneous.
The rating methodology is based on the classification of countries as generalized, concentrated or low-level epidemics. A concentrated epidemic is defined by the authors as having an estimated HIV prevalence consistently over 5% in at least one subpopulation at highest risk of
infection, and a prevalence below 1% in the general adult population (age 15–49 years) in urban areas. Misclassification results in inappropriate
application of the rating tool devised. For example, Jamaica and Guyana are classified as having a concentrated epidemic in the article. Yet the 2007 AIDS epidemic update published by UNAIDS2 reports an estimated HIV
prevalence of 1.6% in Guyana and 1.5% for Jamaica. The classification of these countries as having a concentrated epidemic is not consistent with the UNAIDS own publications on the status of the epidemic. Several other Caribbean countries previously classified as having a generalized epidemic in a similar assessment between 1995 and 2002 by Garcia-Calleja et al,3 are also misclassified here.4 The authors give no justification for classifying only one country in the Caribbean (Haiti) as having a generalized epidemic. Such confusion about the nature of the epidemic will lead to inaccurate assessments of surveillance systems.
The authors assess surveillance of 4 high risk groups (MSM, SW, IDU, and clients of SW) for countries now considered to be having a concentrated epidemic. However, IDU is not an indigenous transmission route of HIV for most Caribbean countries and therefore regular surveillance of this population is not conducted.4 Assuming that all
countries have the same risk groups or risk groups of equal importance in the HIV epidemic is inaccurate. In some countries like Jamaica public STI clinic attendees are included in sentinel surveillance however no provision is made for this in the rating scheme. 4,5
Finally, the authors assess several elements of surveillance systems including consistency of reporting. A maximum score of 7 is assigned to represent the number of times that national surveillance is conducted between 2001 and 2007 suggesting that this activity should optimally be
conducted annually. This is contrary to the 2006 guidance issued for UNGASS reporting, which recommends biennial surveillance for ANC attendees and high risk groups.6 In addition, as surveillance of pregnant women increased to more than 90% in some countries, sentinel surveillance of ANC attendees is increasingly no longer relevant. In countries with limited resources the persons involved in surveillance may be the same staff who are involved in HIV prevention. It can therefore be counterproductive to
conduct annual surveillance because prevention activities will be compromised.
There are other sources of HIV testing that can provide important insights into the HIV epidemic within countries that the rating system does not take into account. These include HIV testing of seasonal migrant
workers, US permanent visa applicants, life insurance medicals, persons being admitted to hospital, blood donors, and outreach testing, all of which Jamaica does. It is difficult to take all of this into account in a broad assessment as conducted by the authors.
However, publications from UN bodies must be accurate and reliable. The use of generic tools to assess country systems emphasize the need for in-depth understanding of country systems in order to produce accurate assessments that can be used for decision-making. It would be far more
meaningful, accurate and constructive to carry out these kinds of assessments on a regional basis in partnership with the countries than trying to make broad generic assessments that frequently miss the mark and contribute little to strengthening the systems being assessed.
References
1. The quality of sero-surveillance in low- and middle incomecountries: status and trends through 2007.
R Lyerla,1 E Gouws,2 J M Garcia-Calleja3,
Sex Transm Infect 2008;84(Suppl I):i85–i91. doi:10.1136/sti.2008.030593
2. UNAIDS (2007). Caribbean AIDS epidemic update Regional Summary: December 2007. UNAIDS, Geneva 2007. Available at http://www.data.unaids.org/pub/Report/2008/jc1528_epibriefs_caribbean_en.pdf
3. Garcia-Calleja JM, EZaniewski E, Ghys PD, et al. A global analysis of trends in the quality of HIV sero-surveillance.
Sex Transm Infect 2004;80(Suppl 1):i25–30.
4. Figueroa JP. The HIV Epidemic in the Caribbean: Meeting the challenges of achieving universal access to prevention, treatment and care.
West Indian Med J 2008; 57(3):195-203.
5. Figueroa JP, Duncan J, Byfield L, Harvey K, Gebre Y, Hylton-Kong T, Hamer F, Williams, Carrington D, Brathwaite AR.
A comprehensive approach to the HIV/AIDS epidemic in Jamaica: a review of the past 20 years. West Indian Med J in press.
6. UNAIDS (2005). Guidelines on construction of core indicators, 2006 reporting. Geneva, UNAIDS.
With regard to your concerns about losing the human touch and confidentiality issues with your patients, our full text article explains the following:
1. All patients are given a preference on how they would like us to communicate results to them, by phone, text or letter. We found the majority preferred text message as the patients believed it led to the
highest degree of confidentiality and ens...
With regard to your concerns about losing the human touch and confidentiality issues with your patients, our full text article explains the following:
1. All patients are given a preference on how they would like us to communicate results to them, by phone, text or letter. We found the majority preferred text message as the patients believed it led to the
highest degree of confidentiality and ensured any messages reached them directly.
2. The text is an initial generic contact message only through which they are asked to contact the clinic at their convenience. On contacting us, their diagnoses are given
and discussed with them by experienced clinic nurses, with an appointment made to deliver treatment or other appropriate follow-up,face-to-face.
There are other practical issues to consider. Your comment that "I still have a doctor who takes the time to call me with my test results" implies you are able to receive calls at any time. For many people at work this is
not so and that receiving phone calls in the work place risks loss of confidentiality. Also,for some, voicemail is perceived as an unnecessary expense whereas receiving a text is free. This is an important distinction when trying to contact someone who is unable to answer their phone. It has been our experience that patients have expressed a high degree of satisfaction with our service. For up to 50% of our population, including vulnerable youth, mobile phones are their only point of contact. Technology is a link that
allows us to effectively communicate and therefore give
individualised care. Don't be afraid to use it to achieve the best outcomes for your patients.
The study reported by Brown et al 1. underscores the urgent need for targeted testing and supportive strategies of opt-out testing and post-exposure prophylaxis. We agree with the editorial review by Steckler & Golden 2., recommending more aggressive analysis of why testing is
accepted/rejected or offered/not pursued by providers; however, we would add a further strategy for the field to consider. Wh...
The study reported by Brown et al 1. underscores the urgent need for targeted testing and supportive strategies of opt-out testing and post-exposure prophylaxis. We agree with the editorial review by Steckler & Golden 2., recommending more aggressive analysis of why testing is
accepted/rejected or offered/not pursued by providers; however, we would add a further strategy for the field to consider. Whether presenting for genitourinary complaints, STI or HIV testing, these clients appear to be
showing up for "germ" testing, in which case it would be difficult to distinguish them from clinic attendees of the prior century who reaped the discoveries of Pasteur, the founder of microbiology, in the 19th century.
But what is most evident from Brown et al 1. is that HIV biomedical science has firmly entered the genomic era and that behavioral HIV prevention must find innovative ways to integrate applicable findings into intervention
content and research.
What would this mean? While personalized genomic medicine may still be premature, to a large degree, knowing about one’s biological vulnerability is not. Cohen et al. (2008)3. have been explicit that the spread of HIV-1 has been heterogeneous and that infectiousness of the
index case and susceptibility of the host determine transmission risk, which largely pivots on exposure to those with acute infection and the total viral load of other pathogens such as STIs, especially HSV-2.
Another recent article by Cohen, Kaleebu, and Coates (2008)4. makes it clear that there are 4 chances to interrupt the trajectory of HIV in each
individual at risk. Brown et al 1. make it clear that the points of missed opportunity can now be easily identified because of the applied science of the genomic revolution. What is not clear, however, is whether the
patients attending this clinic in the UK, or any given clinic in the U.S., know these things, or what they would do if they knew of the possibility of their own missed opportunities or those of their anonymous peers.
A next step for investigators similarly positioned to Brown et al 1. would be to investigate how to effectively interpret and communicate such findings to clients and community stake-holders, and develop a participatory methodology for involving the target audience in the 21st
century science that HIV is a retrovirus, not a germ, and that knowing one’s vulnerability in the time of genomic HIV/AIDS prevention is to know at least as much about the HIV footprint in the human body as carbon footprints and climate change. Most participants in HIV behavioral
prevention programs may still be emerging without knowing that the body is an ecosystem and HIV is a species in it 5. With some shifts of terminology, most HIV prevention programs (including ours until recently)
could easily be about behavioral changes to prevent cold and flu transmission. The biggest behavioral change is still mostly unaddressed: how to be a savvy clinical consumer and sexual partner in the time of ART
and HIV genomics, when HIV has become a strategic target, a more chronic illness, and much more of a normalized topic between patient and doctor.
References
1. Brown AE, Murphy G, Rinck G, et al. Implications for HIV testing policy derived from combining data on voluntary confidential testing with viral sequences and serological analyses. Sex Transm Inf 2009; 85: 4–9.
2. Stekler JD and Golden MR. Learning from the missed opportunities for HIV testing. Sex Transm Inf 2009; 85;2-3.
3. Cohen MS, Hellman N, Levy JA, DeCock K, and Lange J. The spread, treatment, and prevention of HIV-1: evolution of a global pandemic. J Clin Invest 2008; 118:1244–1254.
4. Cohen MS, Kaleebu P, and Coates T. Prevention of the sexual transmission of HIV-1: preparing for success. J Int AIDS Soc. 2008; Oct 1;11(1):4.
5. For reference, see
http://www.virustaxonomyonline.com/virtax/lpext.dll/vtax/agp-0013/rtr03/rtr03-sec1-0007
http://www.ictvonline.org/virusTaxInfo.asp?bhcp=1,
http://www.tolweb.org/treehouses/?treehouse_id=4426
Although the concern to contact patients as soon as possible after the diagnosis is made to initiate treatment and prevent further spread is of great importance, I'm concerned about the possibility of patient confidentiality, and the loss of the human touch.
More and more we are becoming dependant on the latest pieces of technology to transmit information, rather than direct interaction with th...
Although the concern to contact patients as soon as possible after the diagnosis is made to initiate treatment and prevent further spread is of great importance, I'm concerned about the possibility of patient confidentiality, and the loss of the human touch.
More and more we are becoming dependant on the latest pieces of technology to transmit information, rather than direct interaction with the patient. The humanity is leaving the profession. I still have a doctor who takes the time to call me with my test results and know that he
is a rare commodity in his profession, but it was one of the biggest reasons I chose him, the personal care and attention that so many healthcare professionals fail to provide to their patients. Does the text message of results come with a smiley face icon if the test was negative? How about instructions for the teenager who possibly needs some guidance because they contracted it during their first sexual encounter. Is that
covered in a text message?
I find this article just another step toward robotic medicine. Guess I'm just an old fashioned nurse who likes to do things face to face, even if it is giving bad news and dealing with the consequences, rather than a
text reply.
In their letter Aghaizu et al suggest that the differences in the prevalence in their study 1 and our study 2may be attributable to false positive tests using strand displacement assay (ProbeTec, Becton Dickenson). We disagree with these observations. We would like to point out that the populations studied were substantially
different- majority of our subjects attended sexual health and reproduction clinics...
In their letter Aghaizu et al suggest that the differences in the prevalence in their study 1 and our study 2may be attributable to false positive tests using strand displacement assay (ProbeTec, Becton Dickenson). We disagree with these observations. We would like to point out that the populations studied were substantially
different- majority of our subjects attended sexual health and reproduction clinics whereas the population tested in the study by Agaizhu et al was drawn from higher education institutions. Furthermore, in a subsequent study we retested ProbeTec positive specimens from our
laboratory using Gen-Probe APTIMA Combo 2 Assay (Gen-Probe, San Diego, California, USA) at the Health Protection Agency Laboratory, University Hospital Aintree, Liverpool, UK. There was 97.3% concordance between the tests.3 Similarly, in a recent study, Mocanda et al also demonstrated good
concordance between ProbeTec and Gen-Probe APTIMA Combo 2 Assay in a study population that included subjects attending family planning clinic.4
In summary, we are confident that our observations reflect a true prevalence of gonococcal infection in the subjects described in our study.
References
1. A Aghaizu, H Atherton, H Mallinson, I Simms, S Kerry, P E Hay, P Oakeshott. Prevalence of Neisseria gonorrhoeae infection in young women in South London. Sexually Transmitted Infections 2008;84:570
2. Gopal Rao G, Bacon L, Evans J, Dejahang Y, Michalczyk, Donaldson N.
Prevalence of Neisseria gonorrhoeae infection in young subjects attending community clinics in South London. Sex Transm Infect 2007;84:117-121
3. Ruth Hardwick, Guduru Gopal Rao and Harry Mallinson. Confirmation of BD ProbeTec Neisseria gonorrhoea reactive samples by Gen-Probe APTIMA assays
and culture. Sex Transm Inf published online 1 Oct 2008 ;
doi:10.1136/sti.2008.032789
4. Jeanne Moncada, Elizabeth Donegan, and Julius Schachter. Evaluation of CDC
-Recommended Approaches for Confirmatory Testing of Positive Neisseria gonorrhoeae Nucleic Acid Amplification Test Results. J Clin Micro, 2008;46:1614-1619
This report confirms that PID can be often be missed clinically. Other than lowering the threshold for diagnosis, there could be other ways of improving diagnosis of PID. Training background may have contributed to the different rate of diagnosis among doctors. It would be important to review whether high diagnosing doctors were more
likely to have had gynaecology training compared with low diagnosing d...
This report confirms that PID can be often be missed clinically. Other than lowering the threshold for diagnosis, there could be other ways of improving diagnosis of PID. Training background may have contributed to the different rate of diagnosis among doctors. It would be important to review whether high diagnosing doctors were more
likely to have had gynaecology training compared with low diagnosing doctors. Similarly, was there any difference in the gender among high versus low diagnosing doctors?
In response to M O Ramogi on 21st August 2008, it is important to point out that since only patients attending with a new episode were included in the study, those experiencing chronic/recurrent infections or attending solely for treatment were excluded. Therefore the inclusion of patients for who HIV testing is less applicable is unlikely to be the explanation for the association between symptoms of an STI...
In response to M O Ramogi on 21st August 2008, it is important to point out that since only patients attending with a new episode were included in the study, those experiencing chronic/recurrent infections or attending solely for treatment were excluded. Therefore the inclusion of patients for who HIV testing is less applicable is unlikely to be the explanation for the association between symptoms of an STI and a decrease in the likelihood of being offered an HIV test.
With regard to point of care testing (POCT), while anxiety may play a part in the demand from patients for POCT there is evidence that POCT does attract a higher risk population and may lead to an increase in the number
of new HIV diagnoses(1). In a study conducted in Amsterdam average HIV prevalence among MSM receiving one-hour testing with result was 5.2% compared with 3.8% among the control group: those testing with a standard one-week wait. Similar results were found for heterosexuals. In another study among a high risk population utilising a rapid community outreach HIV testing clinic in London, 54% said they would not have tested if a rapid test had not been available(2). Also in London, a recent questionnaire based study found that 51% of high risk patients who declined HIV testing
said they would be more likely to test if POCT was available(3).
In response to M Pammi et al on 16th September 2008, one third of patients reporting a dislike of needles as the reason for declining an HIV test is considerably higher than found in our study. The second most common reason is having “checked recently”. Whether this is truly
reflective of differences in testing among heterosexuals compared with men who have sex with men, or specific to the locality where the study was done, is an interesting point. About two thirds of the patients in the Pammi study gave at least one response that would allow them to be divided
into those who should be tested at the current visit and those who don’t need to be, with those who have recently tested in the latter group. But what to do about those claiming a dislike for needles? Since all respondents in clinics C and D reported one or more reasons for not
testing, is it possible that a dislike of needles is a secondary reason, one not associated with the sensitive issue of actual or perceived risk of HIV exposure? Was there consistency between needle phobia and having
tested before, i.e. none of those reporting needle phobia had tested previously? It would also be interesting to know whether those stating that they have had a recent check have indeed done so within the last 3 months and if they know their status. Of note is the variation even between the two clinics in the proportion who perceived themselves at risk for HIV (the proportion was more than 3-fold higher in clinic U), and in the proportion who were in the window period and who had tested recently (both also higher in clinic U). Does this reflect a difference in the
sexual orientation or the sexual behaviour of the two samples, or merely highlight difficulty in ascertaining valid reasons for not testing? Patients’ reasons for not HIV testing are likely to be an unreliable measure on which to base HIV testing policy recommendations.
With regard to testing within the window period, it is important to note that not testing due to the window in our study was clinician as well as patient driven, which may help explain the higher proportion. In addition, consideration of the window period due to repeat risk may be more relevant to MSM populations than heterosexuals.
References
1. C L J Van Loon, W M E Koevoets. Rapid HIV testing in a one-hour
procedure motivates MSM in the Netherlands to take the test. Oral Abstract
session: The XV International AIDS Conference: Abstract no. TuOrC1197.
2. R Grimes, P Weatherburn, R Mugezi, A Wilkinson, A K Sullivan.
Know4sure: who comes to a rapid HIV testing outreach clinic and why?
Sexually Transmitted Infections 2006;82(Supplement 2 ): P69.
3. S F Forsyth, E A Agogo, L Lau, E Jungmann, S Man, S G Edwards, A J
Robinson. Would offering rapid point-of-care testing or non-invasive
methods improve uptake of HIV testing among high-risk genitourinary
medicine clinic attendees? A patient perspective. Int J STD AIDS 2008;19:
550-552.
Thank you for responding to our manuscript. We have carefully reviewed your comments. Below, please find our responses to the questions raised.
The first comment raised concerns the fact that “sexual factors may have played a lesser role in observed HIV and syphilis prevalence’s than nonsexual factors.”
The sexual transmission of sexually transmitted infections including HI...
Thank you for responding to our manuscript. We have carefully reviewed your comments. Below, please find our responses to the questions raised.
The first comment raised concerns the fact that “sexual factors may have played a lesser role in observed HIV and syphilis prevalence’s than nonsexual factors.”
The sexual transmission of sexually transmitted infections including HIV-1 is a significant risk factor of HIV-1 acquisition in female sex workers and men who have sex with men (MSM), and has been related to HIV-1 acquisition in preliminary analyses from our incidence cohort [1,2]. You
note that the discrepancy between the relationship we found between syphilis and receptive anal intercourse (RAI) and between prevalent HIV-1 and recent RAI among the women is a “red flag.” Please note that our point estimate for the odds of HIV-1 infection among women admitting recent RAI
is 1.2, and has a 95% confidence interval compatible with odds ranging from 0.5 to 2.5. The association between prevalent syphilis on enrolment and recent RAI was based on only 11 cases in women, and the importance of
this finding should not be exaggerated.
Your suggestion that the treponemal disease we have diagnosed in our female sex workers is not syphilis, but rather another treponemal species, is intriguing but very unlikely. Pinta is limited to the Americas, and
endemic syphilis (bejel) is not found in Kenya [3]. Yaws is very uncommon in Kenya [3], and we have seen none of the chronic skin or bone lesions typical of this infection in our clinic population. Other spirochetal illnesses that can lead to positive nontreponemal and treponemal tests
(e.g. relapsing fever, rat-bite fever) are also uncommon and were unsuspected in the clinical context [4]. A non-specific test such as the RPR, followed by a specific treponemal test (TPHA) is the commonly accepted means of diagnosing syphilis [5]. At the same time, syphilis is
the most likely diagnosis in these sexually active young women [6].
Your remark that we did not assess nonsexual (blood) exposures is true, since the focus of this article was on screening for sexually transmitted genital and anorectal infections. While some HIV infections we diagnosed at enrolment into our study population may be due to unsafe
injections, including injection drug use, the prevalence of injection drug use in our population is only 1.4% among MSM [2] and was not reported among women. In a prevalence study, history of any medical injection is not useful because lifetime exposure is very common. Having received a
medical injection in the 3 months preceding enrolment was reported by an equal proportion of HIV negative and positive women (35 vs. 36%). We have included data collection on both injection drug use and a number of other
non-sexual exposures (medical injections, blood transfusion, traditional practices) in our ongoing study of incident HIV-1 infections in this cohort, and hope that your curiosity regarding this factor will be
satisfied in an upcoming publication.
The second remark concerns the fact that “a strong association between anal sex and prostitution might mask the association between anal sex and prevalent HIV-1 in female participants in our cohort”. It is correct that the majority of women (89%) reporting recent RAI,
identified themselves as sex workers. We have also included this in our paper in section ‘results’, in the paragraph on RAI. Please note that table 4 presenting associations between prevalent HIV-1 and RAI are adjusted for age, transactional sex, partner numbers, and unprotected sex.
Finally, a remark was made on the fact that “unprotected receptive anal intercourse is probably not confined to high-risk persons and that broader community prevention messages might more usefully fit overall HIV
prevention objectives.” We agree on the importance of addressing unprotected (receptive) anal
intercourse as a potential risk factor for HIV-1 transmission. We did not mean to imply that this was not important on a population level, but meant
to highlight the urgency of addressing this risk in a targeted setting such as ours.
We trust these answers have addressed the concerns you have raised.
Sincerely,
Marlous Grijsen, MD,
Susan Graham, MD MPH,
Eduard Sanders, MD PhD.
References
1. Grijsen ML, Graham SM, Mwangome M, et al. Screening for genital and anorectal sexually transmitted infections in HIV prevention trials in
Africa. Sex Transm Inf (doi: 10.1136/sti2007.028852)
2. Sanders EJ, Graham SM, Okuku HS, et al. HIV-1 infection in high risk men who have sex with men in Mombasa, Kenya. AIDS 2007;21: 2513-20.
3. Meheus A, Antal GM. The endemic treponematoses: not yet eradicated. World Health Stat Q. 1992;45(2-3): 228-37.
4. Mandell GL, Bennett JE, Dolin R. Principles and practice of infectious diseases. 6th edn. Philadelphia, Pa.: Elsevier Churchill Livingstone; 2005.
5. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2006. MMWR 2006;55(RR-11): 1-94.
6. Holmes KK, Sparling PF, Stamm WE, et al. Sexually transmitted diseases. 4th edn. New York: the McGraw-Hill Companies; 2008.
Although the uptake of the HIV test has increased significantly in recent years, following the introduction of opt-out screening programmes, there is still a substantial number of the HIV population that is still
undiagnosed.1 Therefore, we read with interest the National study of HIV testing in men who have sex with men attending genitourinary clinics in the United Kingdom by H L Munro et el.2 This st...
Although the uptake of the HIV test has increased significantly in recent years, following the introduction of opt-out screening programmes, there is still a substantial number of the HIV population that is still
undiagnosed.1 Therefore, we read with interest the National study of HIV testing in men who have sex with men attending genitourinary clinics in the United Kingdom by H L Munro et el.2 This study focussed on men who have sex with men (MSM) and identified that the most common reason for declining an HIV test was a potential exposure within the three month window period.
We report on a different group of patients, predominantly heterosexual (97%), in whom we conducted a questionnaire survey on the reasons for declining an HIV test. Our study was conducted in two genitourinary medicine clinics over a 10 week period. One clinic was in
based in a University City (Nottingham, Clinic U) and one clinic was based in an urban/semi rural area (Sutton-in-Ashfield, Clinic D). All patients attending the clinics who declined an HIV test were asked to complete a
self-administered questionnaire.
During the study period, 3172 and 1050 new or re-book patients attended Clinic U and Clinic D, respectively, of which 417 (13%) and 211 (20%) declined HIV testing. A total of 231 and 156 questionnaires were filled in by Clinic U and Clinic D respectively. Individuals gave one or
more reasons for declining the test(see Table 1).
In our study the reasons for declining HIV testing in different conurbations and populations appear to be similar in many aspects, for example needle-dislike, regular partner, blood donor. However, variations were seen in relation to result-perception, result-concerns and recent
test history, which indicates the importance of local factors. Unlike Munro et al.2, we identified only 3-6% of individuals who declined an HIV test for reasons related to the window period. This indicates that the reasons for declining an HIV may also differ according to sexual
orientation.
The uptake of HIV testing is a major objective of national strategies across the United Kingdom, with the aim of reducing the undiagnosed disease burden. It would appear that different approaches to encouraging
HIV testing may be required to enable this, taking into account the patient’s sexual orientation and local factors.
References
1. www.hpa.org.uk
2. Munro HL, Lowndes CM, Daniels D et al. National study of HIV testing in men who have sex with men attending genitourinary clinics in the United Kingdom.
Sex Transm Dis 2008; 84: 265-70.
In supporting Colm O’Mahony’s editorial (1), I would like to amplify Karen Rogstad’s concern (2) about the unwitting creation of a two-tier healthcare system for HPV vaccination and the social discord which will inevitably result from the Government’s decision.
Any well-informed parent of sufficient means would want to protect their children against genital warts, so their daughters will necessa...
In supporting Colm O’Mahony’s editorial (1), I would like to amplify Karen Rogstad’s concern (2) about the unwitting creation of a two-tier healthcare system for HPV vaccination and the social discord which will inevitably result from the Government’s decision.
Any well-informed parent of sufficient means would want to protect their children against genital warts, so their daughters will necessarily be involved in the process of obtaining a private prescription for the quadrivalent vaccine: Yet other girls may feel that they have been short-
changed, so this could give rise to a nastier kind of humiliating taunting in the playground, targeted at children of the poor, the ignorant and/or the religiose, thus further exacerbating social class and cultural divisions in schools.
Parents will seek advice, and directly request the vaccine, from their GP. Similar to O’Mahony’s experience, I have yet to meet a GP or other doctor who would chose Cervarix instead of Gardasil for their own children. Thus, on grounds of striving to prevent harm and treating people
with equity, it could be construed as unethical if GPs did not advise parents and their children of the additional benefits of the quadrivalent vaccine.
We must also consider the clinical circumstances where there should be a clear indication for recommending Gardasil instead of Cervarix: Certain children are likely to have a much higher than average risk of suffering from intractable genital warts shortly after sexual debut, as they have conditions where immunity is compromised in a predictably known, therapeutic or idiopathic fashion (categories A-C), and there are others in whom overt genital warts would be especially inconvenient as they have dermatological conditions which may affect genital skin (category D) eg:
A. Type 1 Diabetes, HIV, Primary Immunodeficiency Syndromes (3)
B. Childhood Leukaemias, Juvenile Rheumatoid Arthritis etc
C. History of (or currently extensive) verrucae, hand warts, or recurrent respiratory papillomatosis
D. Psoriasis, Eczema, Lichen Sclerosis etc.
I would be interested to hear from colleagues who have any other conditions or categories to add to the above list.
References
1. O'Mahony C. Government decision on national human papillomavirus vaccine programme is a sad day for sexual health. Sex Transm Infect 2008; 84: 251
2. Rogstad KE. HPV vaccine programme- Increasing inequality in adolescent's sexual health?
STI online (15 August 2008)
Dear Editor,
Lyerla et al (August 2008 issue) conclude that there is a general overall weakness in the surveillance system of most low and middle income countries in their article on the quality of sero-surveillance. This may well be the case. However, the paper has some important inaccuracies and some of their assertions can be challenged. Their assessment that Jamaica has a poorly functioning surveillance syste...
Dear Editor,
With regard to your concerns about losing the human touch and confidentiality issues with your patients, our full text article explains the following:
1. All patients are given a preference on how they would like us to communicate results to them, by phone, text or letter. We found the majority preferred text message as the patients believed it led to the highest degree of confidentiality and ens...
Dear Editor,
The study reported by Brown et al 1. underscores the urgent need for targeted testing and supportive strategies of opt-out testing and post-exposure prophylaxis. We agree with the editorial review by Steckler & Golden 2., recommending more aggressive analysis of why testing is accepted/rejected or offered/not pursued by providers; however, we would add a further strategy for the field to consider. Wh...
Dear Editor,
Although the concern to contact patients as soon as possible after the diagnosis is made to initiate treatment and prevent further spread is of great importance, I'm concerned about the possibility of patient confidentiality, and the loss of the human touch.
More and more we are becoming dependant on the latest pieces of technology to transmit information, rather than direct interaction with th...
Dear Editor
In their letter Aghaizu et al suggest that the differences in the prevalence in their study 1 and our study 2may be attributable to false positive tests using strand displacement assay (ProbeTec, Becton Dickenson). We disagree with these observations. We would like to point out that the populations studied were substantially different- majority of our subjects attended sexual health and reproduction clinics...
Dear Editor,
This report confirms that PID can be often be missed clinically. Other than lowering the threshold for diagnosis, there could be other ways of improving diagnosis of PID. Training background may have contributed to the different rate of diagnosis among doctors. It would be important to review whether high diagnosing doctors were more likely to have had gynaecology training compared with low diagnosing d...
Dear Editor,
In response to M O Ramogi on 21st August 2008, it is important to point out that since only patients attending with a new episode were included in the study, those experiencing chronic/recurrent infections or attending solely for treatment were excluded. Therefore the inclusion of patients for who HIV testing is less applicable is unlikely to be the explanation for the association between symptoms of an STI...
Dear Dr. Potterat and colleagues,
Thank you for responding to our manuscript. We have carefully reviewed your comments. Below, please find our responses to the questions raised.
The first comment raised concerns the fact that “sexual factors may have played a lesser role in observed HIV and syphilis prevalence’s than nonsexual factors.” The sexual transmission of sexually transmitted infections including HI...
Dear Editor,
Although the uptake of the HIV test has increased significantly in recent years, following the introduction of opt-out screening programmes, there is still a substantial number of the HIV population that is still undiagnosed.1 Therefore, we read with interest the National study of HIV testing in men who have sex with men attending genitourinary clinics in the United Kingdom by H L Munro et el.2 This st...
Dear Editor,
In supporting Colm O’Mahony’s editorial (1), I would like to amplify Karen Rogstad’s concern (2) about the unwitting creation of a two-tier healthcare system for HPV vaccination and the social discord which will inevitably result from the Government’s decision.
Any well-informed parent of sufficient means would want to protect their children against genital warts, so their daughters will necessa...
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