The audit by Clarke et al of 106 patients provides a useful estimate
of the percentage of anogenital warts among GUM clinic attenders that the
patient had not noticed (in 2010), at 12.3%[1]. They suggest that failure
to examine these patients may have accounted for a considerable proportion
of the reduction in anogenital warts diagnoses in GUM seen in England
between 2008 and 2012, of 8% among males and females of all age...
The audit by Clarke et al of 106 patients provides a useful estimate
of the percentage of anogenital warts among GUM clinic attenders that the
patient had not noticed (in 2010), at 12.3%[1]. They suggest that failure
to examine these patients may have accounted for a considerable proportion
of the reduction in anogenital warts diagnoses in GUM seen in England
between 2008 and 2012, of 8% among males and females of all ages[2]. In
our detailed ecological analysis of the declines in anogenital warts
diagnoses in GUM clinics[3], we considered changes in diagnosis and
reporting practices as possible explanatory factors. As far as we were
aware, such changes would likely have affected all GUM clinic attenders,
males and females, of all ages. Decreases, however, have not been seen for
all. We have seen declines of over 20% among young women (under 20years),
smaller declines among young men, and level or increasing rates in older
males and females[2-4]. We have also seen similar declines in diagnosis
made by GPs[3]. This pattern is harder to explain by fewer patients being
diagnosed via examination in GUM, but could be explained by cross-
protection from bivalent HPV vaccination. We found a significant
association between observed declines and estimated HPV vaccination
coverage among young women[3,4]. If Clarke et al, or others, have data
showing that the effect of changes in diagnosis and/or reporting practices
in GUM and GP since 2008 differ by sex and age, this could provide an
alternative explanation for the decreases we have seen in anogenital warts
diagnoses in England.
References
1 Clarke E, Board C, Patel N, et al. Why are anogenital warts
diagnoses decreasing in the UK: bivalent human papillomavirus (HPV)
vaccine cross-protection or failure to examine? Sex Transm Infect
2014;90:587.
2 Public Health England. Table 3: Selected STI diagnoses and rates by
gender, sexual risk and age group, 2009 to 2013.
https://www.gov.uk/government/statistics/sexually-transmitted-infections-
stis-annual-data-tables (assessed 28 Nov 2014).
3 Howell-Jones R, Soldan K, Wetten S, et al. Declining genital Warts
in young women in england associated with HPV 16/18 vaccination: an
ecological study. J Infect Dis 2013 Nov 1;208(9):1397-403.
4 Public Health England. Declines in genital warts since start of the
HPV immunisation programme. Health Protection Report 2014;8(24)
The use of recreational drugs used in sexual contexts by MSM
(referred to in many developed countries as "ChemSex") is of increasing
public health concern; it would be helpful if the abstract was ammended to
include which recreational drugs were being used by the cohort in this
study.
Yap and colleagues1 suggest that China's labor camps for drug users
present an opportunity to implement universal 'test and treat' programs.
They contend that such a step would be consistent with 'humanitarian'
principles endorsed by The Global Fund and the World Bank.
Their recommendation is surprising and troubling. The paper cited to
support this position (which we co-authored) is not in fact a call to
scale...
Yap and colleagues1 suggest that China's labor camps for drug users
present an opportunity to implement universal 'test and treat' programs.
They contend that such a step would be consistent with 'humanitarian'
principles endorsed by The Global Fund and the World Bank.
Their recommendation is surprising and troubling. The paper cited to
support this position (which we co-authored) is not in fact a call to
scale up HIV treatment in drug detention centers. Rather, it summarizes
the emerging policy consensus among UN agencies and bilateral and
international aid agencies that drug detention centers undermine the fight
against HIV and should be closed.2
The authors make no mention that The Global Fund board recently
adopted a policy explicitly refusing to fund programs in such facilities
(in China and elsewhere).3 They (and other donors) have taken this
position because they recognize that abuses in such centers are routine
and that donors have little ability to ensure independent oversight of
their funds or programmes.4
Since 2008, Human Rights Watch has conducted research into compulsory
drug detention centers in China and Southeast Asia.5 We have found a wide
range of severe human rights abuses, including, in China, the use of HIV
tests, according to one guard "to know which female inmates they could
sleep with without using a condom."6
Yap and colleagues' recommendations for universal testing and
treatment are intended, no doubt, to protect the health and well-being of
those detained. Yet, their research failed to ask the right questions and
consequently prescribes the wrong medicine. Expanded HIV treatment would
aid some concerns of some detainees. Closing these centers down, in line
with the joint views of 12 UN agencies, would advance both public health
and human rights.7
1. Yap, L., Reekie, J., Liu, W., Chen, Y., Wu, Z., Li, J., ... &
Butler, T. HIV testing in re-education through labour camps in Guangxi
Autonomous Region, China (a cross-sectional survey). Sexually transmitted
infections, 2015: sextrans-2014.
2. Amon JJ, Pearshouse R, Cohen JE, et al. Compulsory drug detention
in East and Southeast Asia: evolving government, UN and donor responses.
Int J Drug Policy 2014;25:13-20
3. The Global Fund, Global Fund Calls for End to Compulsory
Treatment. Announcement, November 26, 2014.
http://www.theglobalfund.org/en/mediacenter/announcements/2014-11-
26_Global_Fund_Calls_for_End_to_Compulsory_Treatment/ (accessed June 2,
2105).
4. Garmaise D. Global Fund to End Funding for HIV Services in Drug
Treatment Centers in Viet Nam. Global Fund Observer Newsletter 2014;234
http://www.aidspan.org/gfo_article/global-fund-end-funding-hiv-services-
drug-treatment-centres-viet-nam (accessed June 2, 2105).
5. Amon J, Pearshouse R, Cohen J, Schleifer R. Compulsory drug
detention centers in China, Cambodia, Vietnam, and Laos: health and human
rights abuses. Health Hum Rights 2013;15(2):124-37.
6. Cohen JE, Amon JJ. Health and human rights concerns of drug users
in detention in Guangxi Province, China. PLoS Med 2008;5:e234.
7. International Labour Organization, Office of the High Commissioner
of Human Rights, World Health Organization, et al. Joint statement:
compulsory drug detention and rehabilitation centres. March 2012.
www.unaids.org/sites/default/files/sub_landing/files/JC2310_Joint%20Statement6March12FINAL_en.pdf
(accessed June 2, 2105).
I read with concern the manuscript by MacLaren DJ et al which
states: "Alternative forms of penile foreskin cutting may be associated
with reduced HIV infection risk in Papua New Guinea." Using data described
in the manuscript, I was able to exactly replicate the authors' primary
numerical finding. However, results of additional analyses not reported in
the manuscript directly conflict with the key message regarding a
po...
I read with concern the manuscript by MacLaren DJ et al which
states: "Alternative forms of penile foreskin cutting may be associated
with reduced HIV infection risk in Papua New Guinea." Using data described
in the manuscript, I was able to exactly replicate the authors' primary
numerical finding. However, results of additional analyses not reported in
the manuscript directly conflict with the key message regarding a
potential association between alternative forms of penile foreskin cutting
and reduced HIV risk.
First, the manuscript does not present individual results according
type of penile foreskin cutting. Neither of the individual associations
between HIV prevalence and prevalence of circumcision or dorsal
longitudinal cut alone reach statistical significance (P=0.1756 and
P=0.1327, respectively).
Second, no results are reported for associations between HIV prevalence and other risk factors for HIV acquisition. Yet, prevalence of condom use
at last sex is significantly associated with HIV prevalence (P=0.0089) and
has a high coefficient of determination (R2=0.9823). Furthermore, the
strength of the association appears to be as strong, or stronger, than
that found for circumcision/dorsal longitudinal cut. The regression
coefficient for condom use at last sex (?=-0.07848) is approximately three
-fold stronger than the coefficient for circumcision/dorsal longitudinal
cut (?=-0.02322).
The manuscript makes bold statements about alternative forms of penile
foreskin cutting and reduced HIV risk. Yet, these claims are not supported
by the individual associations with each type of penile of foreskin
cutting. Additionally, the claims are predicated in part on an apparent
ruling-out of other risk factors for HIV acquisition. Applying the same
analytic approach with prevalence of condom use yields a similar, if not
stronger, association with HIV prevalence. Taken together, I question the
appropriateness of the manuscript's declarative title and the credibility
of its key message regarding alternative forms of penile foreskin cutting
and reduced HIV risk.
1. MacLaren DJ, McBride WJH, Kelly GC, et al. HIV prevalence is
strongly associated with geographical variations in male circumcision and
foreskin cutting in Papua New Guinea: an ecological study. Sexually
Transmitted Infections. Published Online First: 30 June 2015 doi:
10.1136/sextrans-2014-051970.
Dear Editor,
with great interest we read the article by Poynten and collaborators (1),
who investigated the possible relation between recent sexual behaviour and
age-specific prevalence of anal HPV infection in men who have sex with men
(MSM) and cervical HPV infection in women. The authors used the sexual
behavioural data of previously published surveys conducted on these
populations. Their conclusions regarding the assoc...
Dear Editor,
with great interest we read the article by Poynten and collaborators (1),
who investigated the possible relation between recent sexual behaviour and
age-specific prevalence of anal HPV infection in men who have sex with men
(MSM) and cervical HPV infection in women. The authors used the sexual
behavioural data of previously published surveys conducted on these
populations. Their conclusions regarding the association of the age-
specific pattern of sexual behaviour with that of anal HPV prevalence
among MSM are largely consistent with the results of our recent study.
This investigated the association between recent sexual behaviour and anal
HPV infection among 408 HIV-uninfected MSM recruited at a sexual-health
clinic (2). Our results showed an age-independent trend for the prevalence
of any HPV genotype and also for that of high-risk genotypes. Moreover,
the stability of the HPV prevalence trend was supported by a non-
significant change in the median age of sexual partners across different
age groups and by a substantial increase in the median number of recent
sexual partners with age. This indicates that, among MSM, older
individuals still maintain an active sex life, as rightly underlined by
Poynten and collaborators, and that the pattern of mixing-age in sexual
partnership, specific for this population, is an important determinant of
ongoing exposure to HPV throughout life. Thus, as Poynten and
collaborators, we do believe that recent sexual behaviour is the driving
reason for the persistently high prevalence of anal HPV infection in MSM.
However, in addition to the high number of new partners, their age
characteristics are likely to contribute strongly to this phenomenon.
We believe that the study by Poynten and collaborators, together with our
findings, significantly contribute to shedding more light on the reasons
behind the stable prevalence of anal HPV infection among MSM and have
significant implications on the vaccination strategies to be adopted for
these individuals.
1. Poynten IM, Machalek D, Templeton D, et al. Comparison of age-
specific patterns of sexual behavior and anal HPV prevalence in homosexual
men with patterns in women. Sex Trans Infect August 25, 2015:
doi:10.1136/sextrans-2015-052032.
2. Dona' MG, Latini A, Benevolo M, et al. Anal human papillomavirus
infection prevalence in men who have sex with men is age-independent: a
role for recent sexual behavior? Future Microbiol 2014;9:837-44
In the article, the authors' mention this study as being the first to
be carried out on young sexually active women in post-secondary schools in
the UK. They identified pelvic inflammatory disease (PID) in 1.6% of the
individuals recruited for this study which was low because many
individuals were lost during follow-up. However, they mentioned in the
conclusions that medical reports were obtained from clinics for those los...
In the article, the authors' mention this study as being the first to
be carried out on young sexually active women in post-secondary schools in
the UK. They identified pelvic inflammatory disease (PID) in 1.6% of the
individuals recruited for this study which was low because many
individuals were lost during follow-up. However, they mentioned in the
conclusions that medical reports were obtained from clinics for those lost
during follow-up, but made no mention of obtaining individual consents
before accessing their medical information from clinics and doctors. I
identified two sources of error in this study: First, sample collection in
the study was performed by participants and not trained personnel which
will definitely lead to differential bias because the clinical samples
cannot clearly differentiate cases from non-cases. Secondly, potential
confounders were not adjusted which could be a source of bias. A
significant issue in this study was the risk factors proposed for
contracting sexually transmissible disease, hence PIDs among the
participants recruited. Black ethnicity was identified as a risk factor
for this study with no explanation as to why they considered only black
ethnicity (and not ethnicity in general). No information on the diversity
of the population was mentioned which makes their results bias towards a
certain group of individuals. The authors failed to explain why ethnicity
is placed as a risk factor for contracting PIDs in the first place.
Their conclusions for this study could set a damaging public image
for individuals in the specified ethnic group. Questions like, what makes
this ethnic group more susceptible to contracting PID's and why poor
sexual health is associated to blacks in the UK should be thoroughly
explained before conclusions are drawn. To belong to a particular ethnic
group would never place you at risk for developing a particular infection
except for the case of gene involvement in the disease or particular
practices unique to the group which may/or may not predispose you to
developing the disease in question. PIDs are complications of sexually
transmitted diseases which depend on individuals' choices about their
lifestyle and this has nothing to do with your ethnic background, race,
sex or religion. More research on cultural aspects and behaviors in such
groups need to be carried out in order for such conclusions to be made for
any ethnic group studied. Reading this article makes you wonder if the
study was focused only on identifying black women with PIDs in schools or
whether it focused on identifying the prevalence among a diverse group of
young women in the population. It would be best if the authors present
data on the diversity of ethnic groups participating in this study and
then make relative comparisons between the groups in terms of loss to
follow-up and prevalence of PIDs.
While this study contributes greatly in assessing risks for sexually
transmissible diseases and complications among young sexually active
women, it is bias towards a particular group of individuals -black
ethnicity and indirectly places a bad image on this group which could be
detrimental to them if this information is exposed to the public.
By
Akwo Ngwinui Awahsaa
Diploma student Community Health and Humanities
Memorial University of Newfoundland
Canada
We thank the author for her interest in our paper and are happy that
she was able to exactly reproduce our findings.
As explicitly stated - ours was an ecological study, and thus used
aggregate data only. Here we comment on the author's additional
statistical analysis and interpretations:
First, the author of the reply apparently did not test "individual
results" which we assume means the single, diff...
We thank the author for her interest in our paper and are happy that
she was able to exactly reproduce our findings.
As explicitly stated - ours was an ecological study, and thus used
aggregate data only. Here we comment on the author's additional
statistical analysis and interpretations:
First, the author of the reply apparently did not test "individual
results" which we assume means the single, different types of foreskin
cutting. The statistical analysis stated in this context do not test the
"single types of foreskin cuttings" vs no cutting, but rather refer to
"circumcision" vs "dorsal/longitudinal cut or no cut at all" and
"dorsal/longitudinal cut" vs "circumcision or not cut at all". These tests
do not confer any additional information: in contrast, if assume that "any
cut" is associated with HIV prevalence (as our results clearly suggest),
then it should logically not come as a surprise that "one specific type of
cut" vs "another type of cut plus no cut at all' is not significant. This
approach is muddling up the baseline of "no cut" with "another type of
cut" and thus will water down any association of penile cutting with HIV.
Second, we point out that the regression coefficient per se cannot be
used to judge the strength of an association (only its direction / slope
of the resulting regression line). It is consequently a misconception
when the author of the reply states - based on regression coefficients -
that the association between condom use and HIV prevalence is stronger
than that between any cuts and HIV. In fact, the reverse can be seen to be
true when correct correlation coefficients (or their squares, the
coefficients of determination) are used.
Finally, more sophisticated multivariate analyses cannot - and should
not - be applied to this type of ecological data to clarify things
further. In contrast to making "bold" and "declarative" statements, every
effort was made to restrict the interpretation of the results to
"association" as opposed to a causal effect. Please see the paragraph
where we explicitly highlight caution with respect to the interpretation
of results in this study (at the end of the discussion). Our paper also
explicitly stated that the study is of "hypothesis generating" character
rather than of any "confirmative" nature.
The audit by Clarke et al of 106 patients provides a useful estimate of the percentage of anogenital warts among GUM clinic attenders that the patient had not noticed (in 2010), at 12.3%[1]. They suggest that failure to examine these patients may have accounted for a considerable proportion of the reduction in anogenital warts diagnoses in GUM seen in England between 2008 and 2012, of 8% among males and females of all age...
The use of recreational drugs used in sexual contexts by MSM (referred to in many developed countries as "ChemSex") is of increasing public health concern; it would be helpful if the abstract was ammended to include which recreational drugs were being used by the cohort in this study.
Conflict of Interest:
None declared
Yap and colleagues1 suggest that China's labor camps for drug users present an opportunity to implement universal 'test and treat' programs. They contend that such a step would be consistent with 'humanitarian' principles endorsed by The Global Fund and the World Bank.
Their recommendation is surprising and troubling. The paper cited to support this position (which we co-authored) is not in fact a call to scale...
I read with concern the manuscript by MacLaren DJ et al which states: "Alternative forms of penile foreskin cutting may be associated with reduced HIV infection risk in Papua New Guinea." Using data described in the manuscript, I was able to exactly replicate the authors' primary numerical finding. However, results of additional analyses not reported in the manuscript directly conflict with the key message regarding a po...
Dear Editor, with great interest we read the article by Poynten and collaborators (1), who investigated the possible relation between recent sexual behaviour and age-specific prevalence of anal HPV infection in men who have sex with men (MSM) and cervical HPV infection in women. The authors used the sexual behavioural data of previously published surveys conducted on these populations. Their conclusions regarding the assoc...
In the article, the authors' mention this study as being the first to be carried out on young sexually active women in post-secondary schools in the UK. They identified pelvic inflammatory disease (PID) in 1.6% of the individuals recruited for this study which was low because many individuals were lost during follow-up. However, they mentioned in the conclusions that medical reports were obtained from clinics for those los...
We thank the author for her interest in our paper and are happy that she was able to exactly reproduce our findings.
As explicitly stated - ours was an ecological study, and thus used aggregate data only. Here we comment on the author's additional statistical analysis and interpretations:
First, the author of the reply apparently did not test "individual results" which we assume means the single, diff...
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