Recent eLetters

Displaying 1-10 letters out of 173 published

  1. Alternative forms of penile foreskin cutting and HIV infection in Papua New Guinea

    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.

    Conflict of Interest:

    None declared

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  2. Human Rights and HIV Interventions in Chinese Labor Camps

    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. 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 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. (accessed June 2, 2105).

    Conflict of Interest:

    None declared

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  3. Recreational Drugs used

    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.

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  4. Why are anogenital warts diagnoses decreasing: Can we explain sex- and age-specific decreases?

    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.


    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. 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)

    Conflict of Interest:

    None declared

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  5. STIs and HIV in South Africa

    Dear Editor,

    In South Africa, a country that has battled with the HIV and TB co- epidemic for more than two decades, STI management has received little attention. We were delighted to read the article by Lurie et al, which highlights the high burden of STI syndromes in people living with HIV, in particular, in the period before ART initiation. While we concur with the authors' conclusions that systematic STI testing and treatment is warranted in HIV care programmes, the epidemiological data presented leave several unanswered questions.

    There are major problems with reliance on syndromic management, particularly with the syndrome of vaginal discharge. STI symptoms poorly correlate with laboratory diagnoses, illustrated by gonorrhoea and chlamydia, which are mostly asymptomatic in women. Studies at the Centre for the AIDS Programme of Research in South Africa (CAPRISA) have shown a high prevalence of laboratory-diagnosed STIs in women at the time of acute HIV infection. Further analysis showed that clinical assessment alone missed 88% of laboratory-diagnosed STIs and 66% received unnecessary treatment [1].

    Furthermore, the commonest cause of vaginal discharge is bacterial vaginosis (BV), an infection that is associated with sex, but does not appear to be sexually transmitted. We have found that over 50% of women had BV at HIV diagnosis which is often persistent [1]. Lurie et al omit mentioning BV, perhaps misclassifying some of their findings.

    While the authors' results are intriguing, a potential mechanism for the reduction of syndromic STIs on ART is missing. One could hypothesize that immunosuppression may increase the susceptibility and ability to clear STIs and BV. However, in this study the reduction in incidence was independent of CD4 count, in fact, the opposite was true, that a higher CD4 count was associated with more syndromic STI diagnoses. Alternative mechanisms namely behavioural change and length of clinical follow-up may have had a greater impact on the reduction of syndromic STI incidence than improvement in CD4 count in response to ART.

    We hope, that the findings by Lurie et al and the following debate will contribute to the long overdue implementation of STI testing and treatment policies in South Africa.

    Yours sincerely,

    Nigel Garrett and Adrian Mindel Centre for the AIDS Programme of Research in South Africa (CAPRISA)

    1.Mlisana K, Naicker N, Werner L, Roberts L, van Loggerenberg F, Baxter C, et al. Symptomatic vaginal discharge is a poor predictor of sexually transmitted infections and genital tract inflammation in high- risk women in South Africa. J Infect Dis 2012,206:6-14.

    Conflict of Interest:

    None declared

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  6. Missing the path: time to reconceptualise STD prevention

    The highlights of a strategy endorsed by the World Health Organization (WHO) in 2010 for Sexually Transmitted Infections (STI) screening, testing and early initiating into treatment (TnT) to Men that have Sex with Men (MSM) and transgender people are discussed by Cohen et al. in their editorial letter entitled "WHO guidelines for HIV/STI prevention and care among MSM and transgender people: implications for policy and practice" (1,2). In the same line as WHO, the authors call for improved access to STI screening services for people in low and middle- income settings regardless of their sexual identity, sexual orientation or their cultural and socioeconomic characteristics (1,2) Due to the higher prevalence of STI among these vulnerable groups, compared to the general population, the uptake of this guideline is recommended to prevent the transmission of STI and ensure that sexual minorities enjoy their right to access quality provision of STI healthcare (1,2).

    The advantages of this strategy are understandable. This, regardless of the scarcity of data on the cost-effectiveness, cost-benefit and impact on community incidence of STI of routine TnT to asymptomatic MSM and transgender people that the WHO recommends (1). As the raison d'etre of a public health approach being informed by the evidence seems disregarded, in this letter we intend to highlight some gendered aspects that also derive from the WHO guideline and that, in our opinion, Cohen et al. may have given the same relevance as they had given to the WHO-endorsed TnT strategy.

    STI screening is a secondary prevention strategy. In the scenario we are discussing, it may be assumed that all MSM and transgender people may eventually engage in sexual risky behaviours and, as consequence, be infected with an STI. Hence, the recommendation to screen those targets populations for STI even if asymptomatic. The pitfall of this recommendation is that these vulnerable groups may end up dealing with healthcare providers with prejudices towards them. The first assumption healthcare providers should have in mind is that these groups adhere to key messages on how to lead a healthy sexual life. Hence, Routine STI screening should not be the first step in the cascade to prevent, detect and treat STI. It can be ventured that STI TnT approach might result being less cost-effective, potentially more stigmatizing, and, more distanct from the goal of equity that the traditional primary prevention strategies hold (2,4).

    On the other hand, women are not listed among the beneficiaries of this prevention strategy. The significance of understanding the motivations and other factors contributing to sexual risk taking among MSM that also have sexual intercourse with Women (MSMW) have been highlighted elsewhere (5,6,7). It must be acknowledged that in many low and middle- income countries, in order to fulfil with social expectations, many MSM may also engage, in an casual or in a permanent manner, in heterosexual relationships (7). To effectively reduce the community-level prevalence of STI, all asymptomatic women should also be targeted as beneficiaries of this TnT. In a context where cultural taboos and social stigma, judgemental attitudes from health workers towards sexual minorities, repressive policies, and anti-gay legislation, it is very unlikely that their MSMW might disclose to their female partners or their healthcare providers that they occasionally engage in unprotected same-sex sexual intercourse.

    Fear to being stigmatized acts as a driving force that leads MSM to becoming MSMW, keeping their sexual orientation hidden, and hindering them from accessing and demanding STI healthcare. Acknowledging this leads us to another worrisome issue that should not be neglected from the umbrella of responsibilities that lie within the scope of the public health arena; how many countries with pandemic HIV/AIDS infection figures have actually decriminalized homosexuality in the last decade? According to the International Lesbian and Gay Association Report, there were 76 countries prosecuting people because of their sexual orientation as recent as in 2010. Eleven countries still include death penalty for homosexuals in their penal code (8). To effectively inform and carry out any health promotion campaign targeting MSM and transgender people, beyond advocating for the implementation of massive TnT strategies that capitalize the potential of new nucleid acid amplification testing technologies, the international community should move the focus to advocate for low and middle-income countries? governments to abolish their pre-colonial 'anti- sodomy laws', build the capacity of their healthcare providers to better address the health needs of MSM and transgender people, and raise awareness among the general population to respect the sexual rights of the most vulnerable ones (9,10).

    A behavioural change approach, with the aim to promote adoption of safer sexual practices and an active demand of HIV/STI healthcare services, needs to be effectively integrated with any proposed TnT strategy. Health promotion is a basic public health tool that we find that it is not referred to in Cohen et al. missive. There is scientific evidence that behavioural change-based education, community awareness and advocacy approaches targeting sexual minorities may have a positive impact -even in budget-constrained settings- in terms of adoption of safer sexual practices with the ultimate goal to reduce incidence of HIV/STI (11). Why for Cohen et al. the cornerstone of the cascade of "solutions" to the high prevalence of STI may lie in targeted routine TnT when there is evidence on the benefits primary prevention strategies?.

    From a primary prevention point of view, other approaches should be recommended. A public health approach to tackle HIV/STI is necessarily gendered. The structural gender system has to be taken into account, including in low and middle-income countries, when designing and endorsing these types of prevention strategies. It is crucial to understand how gender constructions are determinant in populations adopting sexual risk practices, in impeding or facilitating their access to HIV/STI diagnostic and treatment services, and in influencing government and institutional policy and decision making processes (12). To have a more comprehensive picture to inform approaches such as the STI TnT discussed in this letter, it can be suggested that other subjects such as "masculinities, transactional sex, infrastructural deficits in health and education (at all levels), fragile states and global governance" (13) should be studied and that sexual risk practices should be tackled in a broader context in which gender equity is pursued and stigma and discrimination are combatted.


    1. Cohen J, Lo Y, Caceres CF, Klausner JD, for the WHO guideline working group. WHO guidelines for HIV/STI prevention and care among MSM and transgender people: implications for policy and practice. Sex Transm Infect 2013;89:536-538. 2. Gerbase A. Prevention and treatment of HIV and other sexually transmitted infections among men who have sex with men and transgender People: Recommendations for a public health approach. Geneva, Switzerland: WHO, Programme HIV/AIDS, 2011. Report No.: ISBN 978 92 4 150175 0. 3. Starfield B, Hyde J, Gerv?s J, Heath J. The concept of prevention: a good idea gone astray? J Epidemiol Community Health 2008;62:580-583. 4. Starfield B, Shi L, Macinko J. Contribution of Primary Care to Health Systems and Health. Milbank Quaterly 2005;83:457-502. 5. Maulsby C, Sifakis F, German D, et al. HIV risk among men who have sex with men only (MSMO) and men who have sex with men and women (MSMW) in Baltimore. J Homosex 2013;60:51-68. 6. Harawa NT, McCuller WJ, Chavers C, et al. HIV risk behaviours among Black/African American and Hispanic/Latina Female partners of men who have sex with men and women. AIDS Behav 2013;17:848-55. 7. Eaton LA, Pitpitan EV, Kalichman SC, et al. Men who report recent male and female sex partners in Cape Town, South Africa: an understudied and underserved population. Arch Sex Behav 2013;42:1299-308. 8. Ottoson D. State-Sponsored Homophobia. A world survey of laws prohibiting same sex activity between consenting adults. ILGA (International Lesbian, Gay, Bisexual, Trans and Intersex Association). 2010. 9. Joint United Nations Programme on HIV/AIDS (UNAIDS). UNAIDS Action Framework: Universal Access for Men who have Sex with Men and Transgender People. WHO Library Cataloguing-in-Publication Data. 2009. 10. Ripley J, Lauer K, Hebert P, et al. Speaking Out: A Toolkit for MSM- led HIV/AIDS Advocacy. Levi Strauss Foundation. The Global Forum on MSM and HIV (MSMGF). 2010. 11. McDaid LM, Hart GJ. Sexual risk behaviour for transmission of HIV in men who have sex with men: recent findings and potential interventions. Curr Opin HIV AIDS 2010;5:311-5. 12. Connell R. Gender, health and theory: Conceptualizing the issue, in local and world perspective. Social Science and Medicine 2012;74:1675- 1683. 13. Phillips AF, Pirkle CM. Moving beyond behaviour: advancing HIV risk prevention epistemologies and interventions (A report on the state of the literature). Glob Public Health 2011;6:577-92.

    Conflict of Interest:

    None declared

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  7. Response to 'Relative or Absolute? - Miller'

    Dear editor,

    Responding to the editorial by Miller et al regarding the methodology of our study , we would challenge the assessment of the Zelen design as representing a form of 'deception'. Zelen design is employed to generate real life responses to help understand the translation challenges of introducing any similar or modified intervention across a whole area.

    When general practices involved in our study were later informed of their participation none expressed concern. Qualitative work undertaken with these practices since the study has further confirmed they were supportive of the study design selected, and stated it reduced bias. Chlamydia data from general practice are routinely collected and published in England.

    The editorial correctly identifies that levels of chlamydia screening within general practices in England is currently low. Viewed in this context, the 60% uptake generated by this intervention is significant. In terms of the increases in testing observed during and after the intervention period, our results were reported without inflation. Further, while the results from the intervention may be modest, repeated on a national scale a substantial increase in overall testing rates would be observed.

    The National Chlamydia Screening Programme identifies general practice as an important venue through which opportunistic screening can be offered to young adults. We also know the most common form of contact young people have with medical services is with their GP. The results generated through our intervention represent a positive development in our understanding of how to increase screening in this setting. By engaging GPs in chlamydia screening, opportunities are created to discuss wider sexual health issues with young people, in a familiar and trusted surrounding.

    We concur with Miller et al that changing practitioner behaviour is challenging. General practice is a complex environment where practitioner behaviour is subject to the influence of previous education and training, practice managers and partners, competing targets, and other priorities determined by the NHS. Other further research has shown that sustained support is important to maintain the impact of any multifaceted intervention, , and therefore Public Health England is continuing to provide such support. However, further research into how to sustain and maximise the impact of interventions to improve the sexual health service delivered in primary care would also be beneficial.

    AUTHOR NAMES; Cliodna A M McNulty 1, Angela H Hogan 2, Ellie J Ricketts 3, Louise Wallace 5, Isabel Oliver 6, Rona Campbell 7, Sebastian Kalwij 8, Elaine O'Connell 4, Andre Charlett 9

    Author affiliations

    1 Public Health England Primary Care Unit, Microbiology Department, Gloucestershire Royal Hospital, and Cardiff University, Cardiff, UK

    2 (Previously) Public Health England Primary Care Unit, (Currently) Integrated Biobank of Luxembourg, Luxembourg, Luxembourg

    3 Public Health England Primary Care Unit, Microbiology Department, Gloucestershire Royal Hospital

    4 (Previously) Public Health England Primary Care Unit, (Currently) University of Bristol, Bristol, UK

    5 Applied Research Centre Health & Lifestyle Interventions, Coventry University, Coventry, UK

    6 Field Epidemiology Service, Public Health England, and University of Bristol, Bristol, UK

    7 School of Social and Community Medicine, University of Bristol, Bristol, UK

    8 Amersham Vale Training Practice, London, UK

    9 Statistics, Modelling and Economics Department, Public Health England, 61 Colindale Avenue, London, UK


    Miller W, Nguyen N. Relative or Absolute? A significant intervention for chlamydia screening with small absolute benefit. Sex Transm Infec [Editorial -in print] 2014

    McNulty C a M, Hogan AH, Ricketts EJ, Wallace L, Oliver I, Campbell R, et al. Increasing chlamydia screening tests in general practice: a modified Zelen prospective Cluster Randomised Controlled Trial evaluating a complex intervention based on the Theory of Planned Behaviour. Sex Transm Infec [Internet]. 2013 Sep 4 [cited 2013 Oct 23];1-7. Available from:

    Shafer M-AB, Tebb KP, Pantell RH, Wibbelsman CJ, Neuhaus JM, Tipton AC, et al. Effect of a clinical practice improvement intervention on Chlamydial screening among adolescent girls. JAMA?: J. Amer Med Assoc. 2002 p. 2846-52.

    Kalwij S, French S, Mugezi R, Baraitser P. Using educational outreach and a financial incentive to increase general practices' contribution to chlamydia screening in South-East London 2003-2011. BMC public health [Internet]; 2012 Jan [cited 2013 Oct 23];12(1):802. Available from:

    PHE National Chlamydia Screening Programme (NCSP) website; accessed on 8th April 2014

    Conflict of Interest:

    All authors have completed the Unified Competing Interest form at (available on request from the corresponding author) and declare that '(1) CM, ER, AH, LW, RC, IS, EO, SK, AC have support from the Public Health England for the submitted work. Dr Cliodna McNulty leads the Public Health England Primary Care Unit that has an ongoing programme of work aimed at improving the management of infectious disease in primary care. Public Health England leads the National Chlamydia Screening Programme in England.

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  8. Promoting HIV testing, chlamydia testing and long acting reversible contraception.

    Phillips and colleagues found a third of in-patients had HIV tests following implementation of a routine HIV testing policy at Croydon University Hospital1. We recently found similar rates of HIV testing in young women in the community in our medical student research projects. In line with the 2013 Framework for Sexual Health Improvement's "three specific indicators for sexual health" 2, we investigated reported uptake of HIV testing, chlamydia testing and long acting reversible contraception (LARC) in young women attending a further education college and a university in London.

    In September 2013 consecutive women in common room areas were invited to complete a confidential questionnaire on sexual health. The response rate among women at Lambeth College was 78% (77/99). The mean age of responders was 18 years (range 16-24), and 43% described themselves as being of black ethnicity, 19% white, and 38% of other ethnicity. Of the 39 (51%) women who said they were sexually active, 51% (20/39) had been tested for HIV in the past year and 78% (28/36) for chlamydia. A third (13/39) were currently using LARC (implant n=10, injection n=3).

    The response rate among women at London Southbank University was 92% (79/86). The mean age of responders was 21 years (range 18-25) and 38% were from ethnic minorities. In the past year, 32% (25/79) had been tested for HIV and 34% (26/77) for chlamydia. Only 5% (4/79) reported the use of LARC in the past year, all of these being the implant. We agree with Phillips and colleagues that late diagnosis of HIV is a major public health problem. The recent Natsal report found that 29% of women but only 14% of men aged 16-24 years reported being tested for HIV in the past 5 years 3. Although rates of HIV testing in sexually active, multiethnic young women in our study were encouraging, it is also crucial to promote HIV testing in young men.

    Anne Tear and Jessica Herbert 3rd year Medical Students Pippa Oakeshott Reader in General Practice Population Health Sciences and Education, St George's, University of London Correspondence:, Acknowledgement We thank students and staff at Lambeth College and London Southbank University.

    Reference List (1) Philips. D, Barbour. A, et al, Implementation of a routine HIV testing policy in an acute medical setting in a UK general hospital: a cross sectional study, STI 2013, doi: 10.1136/sextrans-2013-051302 (2) Department of Health, Improving outcomes and supporting transparency, November 2013, pg 53, 91,99 [Acessed 13th December 2013] (3) Sonnenberg P, Clifton S, Beddows S, et al, Prevalence, risk factors, and uptake of interventions for sexually transmitted infections in Britain: findings from the National Surveys of Sexual Attitudes and Lifestyles (Natsal), The Lancet, Volume 382, Issue 9907, Pages 1795 - 1806, 30 November 2013 doi:10.1016/S0140-6736(13)61947-9

    Conflict of Interest:

    None declared

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  9. Dear Editor

    Trichomonas Vaginalis (TV) is frequently described as being associated with pre-term delivery and low birth weight - and was again by Professor Hillier in her editorial in her (unreferenced) introductory paragraph. As far as I can ascertain, this association appears to be based on published evidence from the 80s and 90s.

    Is it possible, given the more recent understanding of a link between TV and poverty, that these 20 year old studies were confounded?

    There is conflicting evidence as to whether the use of metronidazole is itself associated with worse birth outcomes1,2 and so it is important to have a full understanding of the role of TV.

    In global terms I work and teach in a setting with a low prevalence of HIV. Can anyone help me find reasonably strong evidence that TV is other than a harmless commensal for those of my patients who are asymptomatic?

    1.What have we learned about vaginal infections and preterm birth? Carey JC et al Semin Perinatol 2003 27(3):212-6 2. Investigation of metronidazole use during pregnancy and adverse outcomes Catherine A Coss et al Antimicrobial Agents and Chemotherapy 2012 56(9) 4800-5

    Conflict of Interest:

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  10. Response to a letter Recent Advances of the HIV Surveillance System in Iran: Current Situation and Ways Forward

    We very much appreciate the letter that Dr Haghdoost and colleagues wrote in relation to some of the issues outlined in our paper HIV surveillance in MENA: recent developments and results and, in addition, described some more recent developments in HIV surveillance in Iran.

    We would like to reflect on several issues that they raised.

    Our paper states that Djibouti, Iran, Morocco and Pakistan can be classified as having fully functioning HIV surveillance systems as trends in HIV prevalence in these countries can be assessed over time for certain population sub-groups. Surveillance systems in these countries have a sufficient quantity and quality of the data that can be used to guide the programmatic responses. We also mentioned other nine countries that have partially functioning HIV surveillance systems.

    As described in the Methods section of our paper, the assessment of the quality of HIV surveillance systems was based on the questionnaire sent to National AIDS Programmes (NAPs) of the countries of the WHO Eastern Mediterranean Region (EMR) in 2009, 2010 and 2011, and not on the data presented in the paper by Garcia Calleja et al published in Sexually Transmitted Infections in 2010. As described in our paper, to assess the quality of HIV surveillance systems we adapted a method developed by WHO and UNAIDS.123

    As one of the limitations, we outlined that data were provided by the NAPs, which might have missed data sources collected by other agencies that Haghodoost et al. mention, such as surveys in partners of IDUs. However, as planning of surveillance and programmatic responses is lead by the NAPs, we think that collecting data from NAPs gives an appropriate insight into the type and quality of data that the countries use for planning and evaluating the national HIV response. We are aware that many studies might be undertaken in the EMR, but their results are not disseminated, and this is particularly the case with studies done in groups at higher risk of HIV that are heavily stigmatized.

    In relation to some other issues that the colleagues raised, surveys using respondent-driven sampling were done in many other countries in the Region (some of these are referenced in the paper) as well as Mode of Transmission studies.4

    We have not reflected on the reasons for the improvements in HIV surveillance in North Africa and the Middle East, but we believe this has been due to greater availability of funding provided by the Global Fund to Fight AIDS, Tuberculosis and Malaria and capacity building efforts of numerous international and national agencies.

    We agree with Dr Haghdoost and the colleagues that there are substantial improvements in HIV surveillance in Iran though significant challenges remain in bridging the gaps that the system still has. One of them is certainly in conducting studies on HIV and sexually transmitted infections in MSM and transgendered individuals, which due to prevailing stigmatization are still lacking throughout the Region.


    1. Garcia Calleja JM, Jacobson J, Garg R, et al. Has the quality of serosurveillance in low- and middle-income countries improved since the last HIV estimates round in 2007? Status and trends through 2009. Sex Transm Infect 2010;86(Suppl 2):ii35-42

    2. Walker N, Garcia-Calleja JM, Heaton L, et al. Epidemiological analysis of the quality of HIV sero-surveillance in the world: how well do we track the epidemic? AIDS 2001;15:1545-54

    3. Lyerla R, Gouws E, Garcia-Calleja JM. The quality of sero- surveillance in low- and middle-income countries: status and trends through 2007. Sex Transm Inf 2008;84: i85-91.

    4. Mumtaz G, Hilmi N, Zidouh A, El Rhilani H, Alami K, Bennani A, Gouws E, Ghys P, Abu- Raddad L. HIV Mode of Transmission Analysis. Rabat: Kingdom of Morocco. Ministry of Health, Department of Epidemiology and Disease Control, 2010.

    Conflict of Interest:

    None declared

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