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.
Recently, French et al reported the first cases of lymphogranuloma
venereum (LGV) in the United Kingdom.1 One year further, the LGV outbreak
first noticed in 2003 among MSM has spread beyond the first countries
affected (the Netherlands, Belgium, Germany, France, the UK, Sweden and
the United states) to other European countries like Spain, Italy,
Switzerland, Poland, and outside the continent to A...
Recently, French et al reported the first cases of lymphogranuloma
venereum (LGV) in the United Kingdom.1 One year further, the LGV outbreak
first noticed in 2003 among MSM has spread beyond the first countries
affected (the Netherlands, Belgium, Germany, France, the UK, Sweden and
the United states) to other European countries like Spain, Italy,
Switzerland, Poland, and outside the continent to Australia, USA and
Canada. Moreover, some of the questions raised in the publication of
French et al can now been answered partially.
A retrospective study performed on anal swabs from STI clinic
visitors in Amsterdam and San Francisco has learned us that the LGV strain
which seems to be responsible for the current outbreak (L2b) can be traced
back to at least 1981 in the United States and to 2000 in Europe.2,3 So it
seems more appropriate to speak of a slow epidemic rather than an outbreak
of LGV. What has caused LGV to spread unnoticed within the MSM community
worldwide for many years? In part, this can be attributed to the routine
chlamydia test procedures for MSM before 2003. Anal swabs positive for
chlamydia were recorded as chlamydia proctitis. Since the occurrence of
LGV outside the traditionally epidemic countries was unknown additional
testing for LGV was not performed.
Who should be screened for LGV? Most LGV patients reported
unprotective sex and a history of multiple STI’s. In a retrospective study
we have tried to unravel other clinical and epidemiological criteria for
LGV management in MSM.4 HIV status, proctoscopic findings and results of
Gram stained anorectal smears proof helpful in predicting LGV . LGV
specific tests and syndromic treatment are recommended in MSM with
anorectal chlamydia in combination with either clinical signs of
proctitis, HIV seropositivity or an elevated white blood cell count in
Gram stained anorectal smears. Moreover, it appears that part of the LGV
infections do not cause severe clinical symptoms. This may delay the
diagnosis and hamper screening and prevention measures.
Gőtz et al described a group of 15 LGV patients of whom 6
seroconverted for Hepatitis C (HCV) coinciding with the moment they
contracted LGV.5 It was speculated that sexual techniques that lead to
mucosal damage like fisting and use of sex toys, and a concomitant
ulcerative STI like LGV facilitate the sexual transmission of HCV. Raised
diagnostic problems can now be tackled more easily with a recently by our
group developed fast molecular biological diagnostic test (realtime PCR)
designed specifically for LGV Chlamydia trachomatis strains.6 This test
can be performed under routine microbiological laboratory conditions and
will hopefully facilitate the propagation of LGV screening programmes.
During the last International Society for Sexual Transmitted Disease
Research meeting, July 2005 in Amsterdam, The Netherlands a LGV satellite
workshop was organised under the supervision of the European Surveillance
of Sexually Transmitted Infections (ESSTI) network in order to tackle
urgent LGV related research questions in a multilateral joint effort
(www.isstdr.nl/sat_meet.htm). Supranational collaborations will have to
prove their benefit to increase our understanding of this LGV epidemic.
References
1. French P, Ison CA, Macdonald N. Lymphogranuloma venereum in the
United Kingdom. Sex Transm Infect 2005;81:97-8.
2. Spaargaren J, Fennema HS, Morré SA, de Vries HJ, Coutinho RA. New
lymphogranuloma venereum Chlamydia trachomatis variant, Amsterdam. Emerg
Infect Dis 2005;11:1090-2.
3. Spaargaren J, Schachter J, Moncado J, Fennema HS, de Vries HJ,
Coutinho RA, Morré SA. Slow Epidemic of Lymphogranuloma Venereum L2b
Strain. Emerg Infect Dis 2005;11:1787-8
4. van der Bij AK, Spaargaren J, Morré SA, Fennema HS, Mindel A,
Coutinho RA, de Vries HJ. Predictors for lymphogranuloma venereum in men
having sex with men: diagnostic implications. Clin Infect Dis 2006;42:186-
94.
5. Götz HM, van Doornum G, Niesters HG, den Hollander JG, Thio HB, de
Zwart O. A cluster of acute hepatitis C virus infection among men who have
sex with men--results from contact tracing and public health implications.
AIDS 2005;19:969-74.
6. Morré SA, Spaargaren J, Fennema JS, de Vries HJ, Peña AS. Real-
time polymerase chain reaction to diagnose Lymphogranuloma Venereum. Emerg
Infect Dis 2005;11:1311-2
We read with interest the article by Clarke et al1 regarding
assessing demand for access to sexual health services in a community where
a closed appointment system operates1. The genitourinary medicine (GUM)
clinic in North Worcestershire has been operating this closed system for
at least 3 years whereby, patients are offered an appointment either on
the day or the day after and asked to phone back...
We read with interest the article by Clarke et al1 regarding
assessing demand for access to sexual health services in a community where
a closed appointment system operates1. The genitourinary medicine (GUM)
clinic in North Worcestershire has been operating this closed system for
at least 3 years whereby, patients are offered an appointment either on
the day or the day after and asked to phone back if appointments are
unavailable. The BASHH/HPA surveys have demonstrated that the latest
routine waiting times for patients to be seen within 48 hours in this GUM
clinic was 72% (62% unadjusted). Previously figures have varied from 43
to 62%2. However, this figure has not correlated with patient’s
experiences of obtaining an appointment. To analyse this we have
instituted telephone call logging for appointments over a 1 year period
focussing on the availability of routine appointments. Data referring to
emergency appointments or advice calls, although recorded were excluded
from this study. Furthermore call logging was subdivided by sex as in
Clarke’s study and by days of the week to assess areas of maximum demand
for appointments. These measures had fewer implications for workforce
planning than Clarke’s study as this GU clinic sees around 5000 patients a
year with a new and rebook follow up ratio of 2.31:1.
Table 1 shows the average number of routine appointments offered,
appointments requested by patients but not available and appointments
offered to patients but declined as inconvenient. For the purposes of
this correspondence, the logging of calls according to gender has been
grouped together, monthly data aggregated and the mean sum total
represented. Initial data was first presented at the BASHH/BHIVA Spring
meeting of 20053.
Critically, the average data fails to capture the full range recorded
over the last 12 months, for example: appointments unavailable on Monday
varied from 58-127.
As Clarke correctly points out, to avoid incorrect assumptions that
the 48 hour target is being met, the collection of telephone data from
clinics operating closed appointment systems is essential. Furthermore it
remains unclear whether those who are unsuccessful when they first ring
for an appointment are successful thereafter.
In view of the many pressures on “Choosing Health“monies it is
essential that commissioners are presented with an accurate representation
of the demand for GUM services.
References
1) Clarke J, Christodoulides H and Taylor Y. Sexually Transmitted
Infections 2006; 82: 45-48
3) Bhaduri S, Gosling C. Poster 9-Does a closed appointment system
improve access? 11th Annual Conference of BHIVA (British HIV Association)
and BASHH (British Association for Sexual Health and HIV) 2005: 20-23
April
We read Rana et al’s (1) paper entitled “Sexual behaviour and condom
use among individuals with a history of symptomatic genital herpes” with
interest, and find any paper which helps to describe patient’s behaviours
and beliefs useful.
There appears to be one particular flaw in this paper, and that is
the authors’ assumption that people with a history of herpes should use
condoms at all...
We read Rana et al’s (1) paper entitled “Sexual behaviour and condom
use among individuals with a history of symptomatic genital herpes” with
interest, and find any paper which helps to describe patient’s behaviours
and beliefs useful.
There appears to be one particular flaw in this paper, and that is
the authors’ assumption that people with a history of herpes should use
condoms at all times.
The authors justify this statement by referencing three papers. The
first paper (2) highlights that condoms seem to be protective against HSV
transmission in vitro, but is more pessimistic about evidence in vivo, and
limits its recommendations of ‘consistent and correct condom use’ to
pregnant women at risk of HSV-2. The second paper (3) relates to reducing
HIV transmission in developing countries, and makes little mention and no
recommendations about condom use. The third reference (4) does state that
“condom use should be recommended during sexual intercourse when lesions
or symptoms are not present.” But acknowledges “, the data supporting
condom use for the prevention of genital herpes transmission are weak”.
Indeed in the parent paper of this article (5), the same authors,
analysing the same data in the same population demonstrate that increased
risk of transmission of HSV-2 occurred in those who engaged in vaginal sex
during episodes or ‘never’ used condoms, but failed to demonstrate that
condom use between attacks (“always” used condoms) was protective.
As the participants of this study were all in monogamous
relationships, the assertion that they should use condoms at all times
seems unnecessarily punitive. Indeed, 35% of partners were unknowingly
already HSV-2 Positive, a little higher but consistent with international
prevalence estimates (6) and so protected from further infection. As 80%
of HSV-2 infections are asymptomatic or unrecognised (7), and as
transmission rates in discordant couples seem relatively low (2.2% over 8
months for symptomatic infection, 3.6% for serologically proven infection
(8)) then it might be very reasonable for discordant monogamous couples to
choose not to use condoms, reassured in the knowledge that transmission
between attacks can occur but is less likely than transmission during an
attack; that most transmission results in asymptomatic infection; and that
although symptomatic herpes can be troublesome, it is rarely sinister or
dangerous.
In our view, the medicalisation of genital herpes in these
circumstances is overwhelmingly detrimental to sexual health. Advice that
individuals with genital herpes in monogamous relationships should use
condoms regularly and consistently “during both symptomatic and
asymptomatic periods” seems unfounded in the literature, and unnecessarily
stigmatising. The ongoing medicalisation and stigmatisation of herpes will
not, of course, harm sales of Valaciclovir, and we worry about conflicts
of interest in this paper.
Bibliography
______________________
1. Rana RK, Pimenta JM, Rosenberg DM, Warren T, Sekhin S, Cook SF, et
al. Sexual behaviour and condom use among individuals with a history of
symptomatic genital herpes. Sex Transm Infect 2006;82(1):69-74.
2. Casper C, Wald A. Condom use and the prevention of genital herpes
acquisition. Herpes 2002;9(1):10-4.
3. O'Farrell N. Increasing prevalence of genital herpes in developing
countries: implications for heterosexual HIV transmission and STI control
programmes. Sex Transm Infect 1999;75(6):377-84.
4. Stanberry L, Cunningham A, Mertz G, Mindel A, Peters B, Reitano M,
et al. New developments in the epidemiology, natural history and
management of genital herpes. Antiviral Res 1999;42(1):1-14.
5. Rana RK, Pimenta JM, Rosenberg DM, Tyring SK, Paavonen J, Cook SF,
et al. Demographic, behavioral, and knowledge factors associated with
herpes simplex virus type 2 infection among men whose current female
partner has genital herpes. Sex Transm Dis 2005;32(5):308-13.
6. Barton SE. Reducing the transmission of genital herpes. Bmj
2005;330(7484):157-8.
7. Miyai T, Turner KR, Kent CK, Klausner J. The psychosocial impact
of testing individuals with no history of genital herpes for herpes
simplex virus type 2. Sex Transm Dis 2004;31(9):517-21.
8. Corey L, Wald A, Patel R, Sacks SL, Tyring SK, Warren T, et al.
Once-daily valacyclovir to reduce the risk of transmission of genital
herpes. N Engl J Med 2004;350(1):11-20.
Ward and Robinson in their editorial state that the introduction of
restrictive booking systems in which patients can only book appointments
up to 2 days in advance is a response by some clinics to the 48 hour
access target.[1] They quote the Panorama figures that almost one in
five clinics have introduced restrictive booking.
Three day restrictive booking for appointments was introduced...
Ward and Robinson in their editorial state that the introduction of
restrictive booking systems in which patients can only book appointments
up to 2 days in advance is a response by some clinics to the 48 hour
access target.[1] They quote the Panorama figures that almost one in
five clinics have introduced restrictive booking.
Three day restrictive booking for appointments was introduced in the GU
Clinic at St Helier Hospital in October 2004. This was in response to a
25% defaulter rate with a policy of booking appointments up to 7 days in
advance. Sending reminders to patients was considered, but this would
need additional resources. Clarke et al [2] achieved a fall in the
default rate from 22% to 9.9% after introduction of a 48 hours restrictive
booking system. GUM clinic attendees are in the age range which has been
identified as having the highest defaulter rates in general practice.[3]
The introduction of restrictive booking cannot necessarily be
interpreted as a consequence of the 48 hour access target and it may
increase access by reducing the defaulter rate.
Janet Mantell
Consultant in genitourinary medicine
St Helier Hospital
Carshalton, Surrey SM5 1AA
References
1. Ward H, Robinson A. Still waiting: poor access to sexual health
services in the UK. Sex Transm Infect 2006;82:3.
2. Clarke J, Christodoulides H, Taylor Y. Supply and demand: estimating
the real need for care while meeting the 48-hour waiting time target in a
genitourinary medicine clinic by a closed appointment system. Sex Transm
Infect 2006;82:45-48.
3. Sharp DJ, Hamilton W. Non-attendance at general practices and
outpatient clinics. BMJ 2001;323:1081-2.
We were highly interested by the results obtained by Sethi et al. on hepatitis B vaccination for male sex workers.[1] As the authors report, the national strategy for Sexual Health and HIV in England set the target uptake of the third dose of hepatitis B vaccine in susceptible heterosexual and bisexual men attending genitourinary medicine clinics at 50% by the end of 2004 a...
We were highly interested by the results obtained by Sethi et al. on hepatitis B vaccination for male sex workers.[1] As the authors report, the national strategy for Sexual Health and HIV in England set the target uptake of the third dose of hepatitis B vaccine in susceptible heterosexual and bisexual men attending genitourinary medicine clinics at 50% by the end of 2004 and 70% by the end of 2006.[2] In this study 60% of the eligible men received three vaccine doses; this is a stimulating result, obtained by a focused approach of the target group.
However, we cannot agree with the authors’ definition of complete vaccination. Three doses of hepatitis B vaccine were offered according to a 0,1,2 months schedule. According to the literature on hepatitis B vaccination schedules, a full vaccination course against hepatitis B consists of a an initial series of 2 (0,1 months) or 3 doses (0,1,2 months, or 0,7,21 days in an accelerated schedule), followed by a completing dose given several months thereafter. According to the Centers for Disease Control and Prevention, the usual schedule for adolescents and adults is 2 doses separated by no less than 4 weeks, and a third dose 4-6 months after the second dose; the first and third doses should be separated by no less than 16 weeks; doses given at less than these minimum intervals should not be counted as part of the vaccination series.[3]
Such standard 0,1,6 month, or 0,1,4 month or 0,2,4 month schedules have shown to confer very good protection (90-95% >10 IU/L), comparable to that obtained with a 0,1,2,12 month schedule.[4] In addition, lifelong protection is assumed if at least 10 IU/L is obtained, measured 1 to 3 months after a full hepatitis B vaccination course in healthy individuals.[5] Therefore, no conclusions on long term protection can be drawn from anti-HBs values of 10 IU/L or more after 3 doses offered according a 0,1,2 months schedule.
We agree that a 0,1,2,12 month schedule is hard to implement in this mobile at risk population, and many health services have chosen to offer a 0,1,6 months or even the shortest course 0,1,4 months in hard to reach risk groups.[6-8] Therefore we would recommend to implement the shortest possible full vaccination schedules, in particular in this at-risk population. We are convinced that the focused approach presented in this paper could result in a comparably high uptake of a third dose 4 or 6 months after the first one, without jeopardising the long-term benefits of hepatitis B vaccination.
References
1. Sethi G, Holden BM, Greene L, et al. Hepatitis B vaccination for male sex workers: the experience of a specialist GUM service. Sex Transm Infect 2006;82:84-85.
2. Department of Health. National strategy for sexual health and HIV. London, DoH, 2001 (www.dh.gov.uk)
3. Centers for Disease Control and Prevention. Epidemiology & Prevention of Vaccine-Preventable Diseases (The Pink Book) 9th Edition, January 2006. Chapter 15, p.221. Available online from www.cdc.gov/nip/publications/pink/def_pink_full.htm 4. Mast E, Mahoney F, Kane MA, Margolis HS. Hepatitis B vaccine. In: Plotkin SA and Orenstein WA, editors. Vaccines. Elsevier Inc., USA. 4th Edition, 2004:p.299-337.
5. Kane M, Banatvala J, Van Damme P, et al. Are booster immunisations needed for lifelong hepatitis B immunity? European Consensus Group on Hepatitis B Immunity. Lancet 2000;355:561-565.
6. Jilg W. Vaccination against Hepatitis B: Comparison of three different vaccination schedules. Journal of Infectious Diseases 1989;160:766-69.
7. Van Ardenne N, Roelofs I, Leuridan E, et al. Audit on offering and accepting hepatitis B vaccine by sex workers. Intern J STD AIDS 2004;15:493-494.
8. Jaleel H, Allan PS, Huengsberg M, Natin D. Offering the vaccine and accepting it: an audit of hepatitis B vaccination in West Midlands region. Intern J STD AIDS 2003;14:632-635.
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....
Dear Editor,
Recently, French et al reported the first cases of lymphogranuloma venereum (LGV) in the United Kingdom.1 One year further, the LGV outbreak first noticed in 2003 among MSM has spread beyond the first countries affected (the Netherlands, Belgium, Germany, France, the UK, Sweden and the United states) to other European countries like Spain, Italy, Switzerland, Poland, and outside the continent to A...
Dear Editor,
We read with interest the article by Clarke et al1 regarding assessing demand for access to sexual health services in a community where a closed appointment system operates1. The genitourinary medicine (GUM) clinic in North Worcestershire has been operating this closed system for at least 3 years whereby, patients are offered an appointment either on the day or the day after and asked to phone back...
Dear Editor,
We read Rana et al’s (1) paper entitled “Sexual behaviour and condom use among individuals with a history of symptomatic genital herpes” with interest, and find any paper which helps to describe patient’s behaviours and beliefs useful.
There appears to be one particular flaw in this paper, and that is the authors’ assumption that people with a history of herpes should use condoms at all...
Dear Editor,
Ward and Robinson in their editorial state that the introduction of restrictive booking systems in which patients can only book appointments up to 2 days in advance is a response by some clinics to the 48 hour access target.[1] They quote the Panorama figures that almost one in five clinics have introduced restrictive booking.
Three day restrictive booking for appointments was introduced...
Dear Editor,
We were highly interested by the results obtained by Sethi et al. on hepatitis B vaccination for male sex workers.[1] As the authors report, the national strategy for Sexual Health and HIV in England set the target uptake of the third dose of hepatitis B vaccine in susceptible heterosexual and bisexual men attending genitourinary medicine clinics at 50% by the end of 2004 a...
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