Recent eLetters

 

Jacques Pepin addresses the important question of parenteral transmission of HIV-1 in Leopoldville, and criticises aspects of our article (Sousa_et_al,2010,PLoS_ONE 5(4):e9936, http://www.plosone.org/article/info:doi/10.1371/journal.pone.0009936), in which we modelled the initial heterosexual spread of HIV-1 in that city.¹ Here, we respond directly to his criticisms.

He writes that we used a genital ulcer disease(GUD)-related risk ratio of HIV-1 transmission of up to 430. He derives the latter from the measured and published 43% risk incurred by an uncircumcised man exposed to a HIV-1-infected index woman with a genital ulcer, which is 430 times the 0.1% baseline.^2,3 However, it is misleading to represent this parameter as equivalent to a GUD risk ratio of 430, as Pepin does, because the measured 43% risk derived from two concomitant cofactors, GUD and lack of circumcision, the latter increasing the risk from 4% to 43%.³ In addition, for most other situations involving GUD, the cofactor effect was much lower in our simulations, consistent with the studies that estimated them on a per act basis.^3,4

The GUD-related risk ratios of around 3-5 cited by Pepin are based on studies that asked participants whether they had GUD at any time within a long period (e.g., the last 12 months), a procedure that strongly underestimates the per act GUD effect.²

Pepin questions our postulated 10 weeks average ulcer duration. Chancroid's ulcer lasts 10 weeks on average.⁵ On average, syphilis' chancre lasts 12 days, and the secondary stage lasts 3.6 months, often relapsing.⁶ A modelling study postulated 4 weeks of high sexual infectiousness during syphilis secondary stage.⁷ We feel it is reasonable to assume 4-6 weeks high HIV-1 infectiousness due to primary syphilis or mucosal lesions associated with secondary syphilis. Lymphogranulomavenereum (LGV) causes short initial genital ulcers but, in some women, it causes genitoanorectal syndrome, involving years-lasting genital ulceration.^8,9 Given that syphilis, chancroid, and LGV were the most common GUDs in early 20^th century Leopoldville, we consider our choice of ulcers averaging 10 weeks appropriate.

As Pepin acknowledges, we previously reported low GUD prevalence in 1950s Leopoldville/Kinshasa.¹ We agree with him that substantial parenteral transmission of HIV-1 may have occurred in Leopoldville/Kinshasa.

 

1.Sousa_JDd,Müller_V,Lemey_P,Vandamme_A-M,PLoS_ONE(2010);5(4):e9936. http://www.plosone.org/article/info:doi/10.1371/journal.pone.0009936.

2.Powers_KA_et_al,Lancet_Infect_Dis(2008);8:553-563.

3.Cameron_DW_et_al,Lancet(1989);2(8660):403-407.

4.Hayes_et_al,J_Trop_Med_Hyg(1995);98:1-8.

5.Korenromp_EL_et_al,Sex_Transm_Inf(2002);78:55-63.

6.Garnett_GP_et_al,Sex_Transm_Dis(1997);24:185-200.

7.Oxman_GL_et_al,Sex_Transm_Dis(1996);23:30-39.

8.Woodward_JA,In:_Nelson_Al_&_Woodward_JA(Eds.),Current Clinical Practice: Sexually Transmitted Diseases,1997,Totowa,NJ:Humana_Press.

9.Kurz_L,British_J_Obstretics_Gynaecology(1913);23:353-388.

Conflict of Interest:

None declared

The recently published article, Chacko L, Ford N, Sbaiti M, Siddiqui R. Adherence to HIV post-exposure prophylaxis in victims of sexual assault: a systematic review and meta-analysis, Sex Transm Infect doi:10.1136/sextrans-2011-050371, contributes greatly to our understanding of the extent of poor adherence to post-exposure prophylaxis in victims of sexual assault. It also clarifies the percentage of such patients defaulting from care. The article illustrates how victims of sexual assault fail to adhere to guidelines for prevention of HIV infection1.

Sadler AG, Mengeling MA, Syrop CH, Torner JC, Booth BM. Lifetime Sexual Assault and Cervical Cytological Abnormalities Among Military Women. Journal of Women's Health;20(11):1693-1701, revealed that female victims of military sexual trauma have increased risk of cervical cytological abnormalities. This increased gynecological health risk factor requires vigilance in long-term screening to prevent poor future outcomes. The adherence of women Veterans for cervical cancer screening is imperative for their future welfare2,3.

The recent publication, Chacko L, Ford N, Sbaiti M, Siddiqui R. Adherence to HIV post-exposure prophylaxis in victims of sexual assault: a systematic review and meta-analysis, Sex Transm Infect doi:10.1136/sextrans-2011-050371,thus reflects the poor adherence of victims of sexual assault in the prevention of HIV infection1.

Up to 40% of female Veterans may have experienced military sexual trauma, putting them at risk for cervical cytological abnormalities. It is therefore clear that female Veterans, many of whom have experienced sexual assault while in the military,would benefit from preventive care2-4.

Chacko L, et al. reinforce that victims of sexual assault need support and encouragement to seek the medical care they require.

VA applauds such authors in clarifying the needs of those who have experienced sexual assault and make it evident that these victims require much support and help. VA hopes to provide the required support to victims of sexual assault.1,3.

1. Chacko L, Ford N, Sbaiti M, Siddiqui R. Adherence to HIV post -exposure prophylaxis in victims of sexual assault: a systematic review and meta-analysis, Sex Transm Infect doi:10.1136/sextrans-2011-050371. 2. Sadler AG, Mengeling MA, Syrop CH, Torner JC, Booth BM. Lifetime Sexual Assault and Cervical Cytological Abnormalities Among Military Women. Journal of Women's Health;20(11):1693-1701. 3. Lutwak N. The Need for Gynecological Follow-Up Among Women Veterans: The Association of Sexual Assault and Abnormal Cervical Cytology. Journal of Women's Health; 2012;21(3). 4. Kelly UA, Skelton K, Patel M, Bradley B. More Than Military Sexual Trauma: Interpersonal Violence, PTSD, and Mental Health in Women Veterans. Research in Nursing and Health.2011;34(6):457-467.

Conflict of Interest:

None declared

Sinka and colleagues found that using self-taken vaginal swabs for HPV testing was acceptable to young women who had defaulted from their initial HPV screening appointment at age 211. However, the rate of return of postal samples was low (13%, 725/5500). In October 2011 we conducted a feasibility study to evaluate response rates of 16-24yo female GUM clinic attenders to providing two self-taken vaginal swabs for Chlamydia trachomatis and Mycoplasma genitalium testing and allowing access to NHS numbers and medical records for follow up. Women sitting in the female-only waiting area in the Courtyard Clinic at St George’s Hospital were approached by female Foundation Year 2 research doctors or medical students and given a flier about the study. This explained that women aged under 25 were being asked to help in research by providing self-taken samples and completing a questionnaire and that they would be given a lollipop. Those expressing interest were taken to a side room where they were given the full patient information leaflet and taken through the written consent process. They were shown how to take the swabs and asked to provide them in the nearest toilet in addition to any samples taken during their clinic consultation.

Of 154 women approached, 104 (68%) consented to take part. Non responders were similar mean age to responders (19.5 SD 2.5 versus 19.9 SD 2.9 years) but more likely to come from ethnic minority groups: 68% (32/47) versus 50% (50/101) p <_0.05. _="_" p="p">

Among responders, mean age of sexual debut was 15.9 (range 12-21 n=103); 48% (49/102) reported two or more sexual partners in the preceding 12 months; 33% (34/104) said they used condoms; and 51% (53/104) were smokers. There was a high prevalence of reported history of sexually transmitted infections. Of 101 responders, 26% said they had had chlamydia infection, 5% gonorrhoea and 5% pelvic inflammatory disease. Tests showed that 11.5% (12/104) were positive for Chlamydia trachomatis and 1% (1/104) for Neisseria gonorrhoeae.

All but one of the 104 participants gave consent for their NHS number to be obtained and used to access their hospital, general practice and GUM clinic records. This is important for future UK studies investigating long-term sequelae of sexually transmitted infections. All participants agreed their samples could be stored for future research. However, although all but one (103/104) agreed to provide follow up postal samples after three months, the current rate of return is 33% (17/52). As in the study by Sinka and colleagues1 and a postal survey of female students2, it is likely that the rate of return of follow up samples will be less than predicted.

References 1. Sinka K, Lacey M, Robertson C, Kavanagh K, Cushieri K, Nicholson D, Donaghy M, Acceptability and response to a postal survey using self-taken samples for HPV vaccine impact monitoring. STI Online First, published on October 11, 2011 as 10.1136/sextrans-2011-050211 2. Oakeshott P, Aghaizu A, Hay P, Reid F, et al. Is Mycoplasma genitalium in women the ‘new Chlamydia?’ A community-based prospective cohort study. Clinical Infectious Diseases 2010; 51: 1160-6

Ocular syphilis is very rare, equivalent to 1-2% of uveitis, however, is a simulator disease that can be confused, especially in immunocompetent individuals, as HIV-positive patients are more likely to acquire it. HIV co-infection with syphilis increases the risk of central nervous system disease, patients with AIDS who do not receive antiretroviral therapy, have bilateral disease and the posterior segment. There are many ways to manifest eye level, most of the publications mentioned isolated cases of secondary syphilis in stage chronic phase, and the majority in the neurosyphilis. In the cornea is suspected when there is a bilateral stromal keratitis, which may be associated with closed- angle glaucoma. In the iris can be expressed as granulomatous uveitis. In a series of cases of Barile was shown 9% of posterior uveitis and 27 % of panuveitis. Chao JR and colleagues reported four patients with neurosyphilis by positive VDRL and increasing of leukocytes in the cerebrospinal fluid. Two patients had placoid chorioretinitis, a homosexual patient presented bilateral papilledema and a heterosexual man presented anterior uveitis and bilateral papilledema. The condition of the posterior pole can vary as much as vasculitis, macular edema, neuroretinitis and even retinal necrosis. Neuro-ophthalmological manifestations of syphilis include Argyll-Robertson pupil, oculomotor nerve palsy and optic neuritis. Treatment of ocular syphilis should be as neurosyphilis, recommended 12 MU of penicillin G intravenously daily for 10-14 days or 2.4 MU procaine penicillin intramuscularly daily with oral probenecid for two weeks. Penicillin G benzathine can be applied after the treatment of penicillin G or procaine, It should not be applied as a first option, since it does not reach sufficient levels in the cerebrospinal fluid. In case of resistance, can be applied ceftriaxone, 1 g 2 times a day for seven days. We present two cases treated in our services in Cuba. Case 1. This 31 years old male patient referred to the Service of Infectious Diseases for being HIV positive and probable neurosyphilis by bilateral papilledema, was under medical treatment with penicillin G procaine. The reason for the consultation is low vision in Right eye (RE) since two weeks ago. Physical examination: AV 20/80 in RE and 20/25 in LE (Left Eye). IOP of 10 mm Hg in both eyes. RE with fine keratic precipitates, cells in CA 1 +, there are no changes in anterior segment of the LE. In the fundus papilledema is observed in RE and peripheral posterior vitreous detachment in LE. The retinal fluorangiography (FAG) shows active lesions of peripheral vasculitis and bilateral papilledema. Report is sent to the Service of Infectious Diseases where a antiretroviral therapy is indicated, in addition to completing his studies, resulting positive FTA-abs test. Returns three months later his vision improved to 20/25 in both eyes, in the fund of the eye is not observed the edema of the optic nerve previously affected. Case 2. Male patient, 32 years old, referred to the Service of Infectious Diseases for diagnosis of neurosyphilis in HIV-positive FTA-abs test positive. During his hospital stay was diagnosed with bilateral papilledema and paralysis of the fourth right nerve. Admitted by the presence of headache and diplopia of two months before to the first review. Visual acuity is 20/30 right eye and 20/25 left eye. His refraction is -0.75 sphere RE and -0.25 to - 0.75X 0 ° LE, improved to 20/20 RE and 20/15 LE. On examination of ocular motility is observed hiperhipotropia with limitation to the depression of RE and Bielchowski test positive. Conjunctive, cornea and lens of the normal characteristics. Fundus in both eyes and optic disc with excavation 1 / 10, hyperemia and Raised edges, tortuous vessels since the emergency. FAG requested and quoted with results, the patient does not return. The importance of health officials from a country to insist on control of sexually transmitted diseases stems from the increased incidence of these kind of diseases such as syphilis, considered as a "great imitator" of many other infectious diseases and some autoimmune diseases. Dermatological tests are insensitive in the primary or secondary syphilis, because it has reduced levels of normal lymphocyte blastogenesis. In the case of HIV, it can cause a polyclonal expansion of inmunoglobuline IgG, resulting in activation of B cells with a side effect of CD8, complicating HIV infection. Opposite can also happen: there is a decrease of B cells, giving false positive serological tests. T. pallidum increases HIV replication and may also damage the mucosa by increasing the number of cells receptive to HIV. Patients with genital ulcers have an increased excretion of HIV RNA in seminal fluid. In conclusion, ocular syphilis remains a cause of diverse and complex eye conditions. We should suspect this diagnosis in patients without other infectious cause or autoimmune feature. Do not forget the background of sexual transmission risk that patients often deny.

Conflict of Interest:

None declared

Patient Consent - There is no identifiable information presented so patient consent is not needed.

AIDS collects every day more human lives, the sexual irresponsibility, poorness, the economic crises, they have converted in allies of the mortal pandemic. But I wonder: When we find the vaccine to combat this virus, would have we the possibility of putting it at the disposal of the million sick persons around the world and whose economic condition is very bad? The distribution of the antiviral medications at present is limited, the economic restrict the possibilities for poor people, then when we will have the vaccine, the international organizations of health will have to make a great effort to achieve that the vaccine against the HIV is the solution of disease really, and no the agony of other ones that they will not be able to come over the vaccine.

Conflict of Interest:

None declared