You'll see that this is a very special issue. We have brought together two mini-themed issues, both reflecting on social, legal and ethical issues of wide interest. David Gurnham of the University of Southampton is leading a series of seminars, funded by the UK's Economic and Social Research Council on ‘Criminalising Contagion’ which some of our readers may have attended. We are delighted that he is Guest Editing a series on this topic. We present some research papers which will encourage deeper understanding and wider discussion of emerging political and legal debates about criminalisation. Gurnham's introductory editorial
I am also grateful to Nicola Low, Deputy Editor, for commissioning a collection which reflects on the lessons of the Guatemala syphilis...]]>
Something that the articles collected here may be taken to suggest is that, while the...]]>
Sexually transmitted infections (STIs) are an important cause of morbidity among incarcerated women and female sex workers (FSW). Little is known about FSW incarcerated in New York City (NYC) jails. We reviewed jail health records to identify the STI and HIV prevalence among newly incarcerated FSW in NYC jails. We also examined the relationship of demographics and self-reported clinical and risk behaviour history with FSW status and compared FSW with non-FSW incarcerated women to identify FSW predictors and, guide NYC jail programme planning and policy.
We retrospectively reviewed routinely collected jail health record data to identify the prevalence of chlamydia (Ct), gonorrhoea (Ng) and HIV infection among women newly incarcerated in NYC jails in 2009–2010 (study period) and studied the relationship of STIs, demographics and self-reported clinical and risk behaviour history with FSW status.
During the study period, 10 828 women were newly incarcerated in NYC jails. Of these, 10 115 (93%) women were tested for Ct and Ng; positivity was 6.2% (95% CI 5.7% to 6.7%) and 1.7% (95% CI 1.4% to 1.9%), respectively. Nine percent had HIV infection. Seven hundred (6.5%) were defined as FSW. FSW were more likely to have Ct (adjusted OR (AOR): 1.55; 95% CI 1.17 to 2.05; p<0.0001) but not Ng or HIV. FSW were more likely to report age 20–24 years, reside in boroughs other than Manhattan, ≥6 prior incarcerations, ≥2 incarcerations during the study period, condom use with current sex partners, multiple sex partners and current drug use.
Women incarcerated in NYC jails had high rates of Ct, Ng, and HIV infection. FSW were at higher risk for Ct than non-FSW incarcerated women. These findings are being used to design targeted interventions to identify FSW, provide clinical and preventive services in jail and coordinate care with community partners.
The law in relation to HIV has prominence in the formation and regulation of moral norms—in regard to human rights, and in regard to criminalisation, the policing of sexuality and intimate behaviours, and the production of stigma. The research focuses on the potential and impotence of the law to govern for, and enable, the human right to health in the context of HIV in Malawi.
This one-country qualitative case study (Malawi) action research involved data collection during a 6-month period (October 2010–March 2011). Datasets include interviews with law commissioners (n=10), opinion leaders (n=22), life story participants who were people living with and closely affected by HIV (n=20), reflections of the action research team (n=6), and a review of the proposed HIV and AIDS (Prevention and Management) Bill, legal and policy documents.
The analysis of the perspectives of the law commissioners, who formed the Special Law Commission and drafted the Bill, revealed that stigma was consciously invoked to delineate social norms and guide governance of notions of personal responsibility. The analysis of the perspectives of the life story participants, whose lives would be most directly impacted if these provisions came into force, reveals the extent to which the stigma associating criminality and HIV is falling on fertile ground through its engagement and generation of internalised stigma; unearthing an uneasy link between stigma and the law in response to HIV in Malawi.
The results indicated that the proposed HIV Bill in Malawi manifests a tension between intention and impact. By incorporating criminal sanctions as part of the proposed HIV Bill, the lawmakers actively seek to use stigma to shape social attitudes and attempt to guide normative behaviour.
To examine the views of educated people in Togo on the acceptability of criminal prosecution of a male partner for sexual transmission of infectious diseases (STIDs) to his female partner.
199 adults living in Kara, Togo judged acceptability of criminal prosecution for STID in 45 scenarios composed of combinations of five factors: (a) severity of disease; (b) awareness and communication of one's serological status; (c) partners’ marital status; (d) number of sexual partners the female partner has and (e) male partner's subsequent attitude (supportive or not).
Acceptability was lower (a) when the male partner decided to take care of his female partner he had infected than when he decided to leave, (b) when both partners were informed but decided not to take precautions than when none of them was informed or when only the male partner was informed and (c) when the female partner has had several male sexual partners than when she has had only one. Two qualitatively different views were identified. For 66% of participants, when the male partner accepts to take care of his partner, he should not be sued, except when he did not disclose his serological status. For 34%, when both partners were informed, the male partner should not be sued, irrespective of other circumstances.
Regarding criminal prosecution for STID, most people in the sample endorsed the position of the Joint United Nations Programme on HIV/AIDS that urges governments not to apply criminal law to cases where sexual partners disclosed their status or were not informed of it.
The archival materials for the Guatemala studies were discovered inadvertently by Dr Susan Reverby, a historian at Wellesley College, whose work has focused on the infamous Tuskegee studies of untreated syphilis, which occurred from the late 1930s through 1972. Reverby's work focused primarily on experiential history, from the view point of the research subjects, of the health professionals who...]]>
Second, the papers provide an opportunity to reflect on current...]]>
Self-obtained penile-meatal swabs and urine specimens have been used for Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) and Trichomonas vaginalis (TV) for outreach screening in men.
To compare the sensitivity of self-collected male penile-meatal swabs and urine for the detection of CT, NG and TV.
Matching penile-meatal swabs and urines were collected at home after recruitment to the study; via the internet programme, http://www.iwantthekit.org. The instructions directed the participant to place the tip of a Copan flocked swab at the meatal opening of the urethra to collect the penile-meatal sample. Two ml of urine was collected after the swab onto a Copan sponge-on-a-shaft collection device. Both swab and urine were placed into individual Aptima transport media tubes and mailed to the laboratory for testing. All specimens were tested for CT and NG using the GenProbe Aptima Combo2 Assay and for TV using GenProbe Aptima Analyte Specific Reagents with TV oligonucleotides.
Of 634 men, 86 (13.6%) were positive for CT, 9 (1.4%) were positive for NG and 56 (9.3%) positive for TV. For CT, swab sensitivity was 81/86 (94.2%), and urine sensitivity was 66/86 (76.7%). For NG, swab sensitivity was 9/9 (100%) and urine sensitivity was 8/9 (88.9%). For TV, swab sensitivity was 45/56 (80.4%) and urine sensitivity was 22/56 (39.3%).
Self-obtained penile-meatal swabs provided for the detection of more CT, NG and TV, than urine specimens.
Bacterial vaginosis (BV) is one of the most common infections in women of reproductive age. Clinical studies have shown an association among BV and abnormal pregnancy, pelvic inflammatory disease and an increased risk of sexually transmitted infections, including HIV.
The development of molecular techniques such as Denaturing Gradient Gel Electrophoresis (DGGE) and DNA sequencing produced a clearer picture of the complexities of the vaginal microbiota.
The 2008 UK National Guidelines for HIV testing recommended HIV testing should be offered to all general medical admissions aged 16–60 years in high prevalence areas, and that this should be evaluated to ensure this was effective in diagnosing previously undiagnosed HIV.
HIV testing was introduced as a routine test for all patients admitted to the acute medical admissions unit, comparisons were made between the testing rates before, during and after this intervention.
The pilot was initiated in August 2009. Prior to the pilot the unit was carrying out 15 tests per month. However, when the pilot was introduced 82 tests were being carried out per month with a total of 10 new diagnoses since the start of the pilot. The proportion of patients tested versus those eligible for testing remained low varying between 6% and 22% month by month. 10 patients we found to be HIV positive with a prevalence of approximately 1%, 10 fold higher than the cut off for cost effectiveness used in the guidelines.
Overall the pilot showed that HIV testing could be delivered without the use of extra resources and is acceptable to patients.
Butler et al
Recommendations by the authors about breaking down the last barriers to condom availability in prisons are particularly significant and timely for several reasons. First, condoms are not always available in prisons and, paradoxically, this is particularly true in countries...]]>
To assess the evidence of differences in the risk of HIV, sexually transmitted infections (STI) and health-related behaviours between migrant and non-migrant female sex workers (FSWs).
Systematic review of published peer-reviewed articles that reported data on HIV, STIs or health-related harms among migrant compared with non-migrant FSWs. Studies were mapped to describe their methods and focus, with a narrative synthesis undertaken to describe the differences in outcomes by migration status overall and stratified by country of origin. Unadjusted ORs are presented graphically to describe differences in HIV and acute STIs among FSWs by migration and income of destination country.
In general, migrant FSWs working in lower-income countries are more at risk of HIV than non-migrants, but migrants working in higher-income countries are at less risk. HIV prevalence was higher among migrant FSWs from Africa in high-income countries. Migrant FSWs in all countries are at an increased risk of acute STIs. Study designs, definitions of FSWs and recruitment methods are diverse. Behavioural data focussed on sexual risks.
The lack of consistent differences in risk between migrants and non-migrants highlights the importance of the local context in mediating risk among migrant FSWs. The higher prevalence of HIV among some FSWs originating from African countries is likely to be due to infection at home where HIV prevalence is high. There is a need for ongoing monitoring and research to understand the nature of risk among migrants, how it differs from that of local FSWs and changes over time to inform the delivery of services.
Systematic review of the performance and operational characteristics of point-of-care (POC) tests for the diagnosis of Neisseria gonorrhoeae.
We searched PubMed and Embase until August 2010 using variations of the terms: ‘rapid test’, ‘Neisseria gonorrhoeae’ and ‘evaluation’.
We identified 100 papers, 14 studies were included; nine evaluated leucocyte esterase (LE) dipsticks and three immunochromatographic strips, and two clinical audits of microscopy were identified. Of the field evaluations the gold standard was nucleic acid amplification technology in six studies and bacterial culture in the other six. In four studies, 50% or more of the patients were symptomatic. The median sensitivity of LE dipsticks was 71% (range 23–85%), median specificity was 70% (33–99%), median positive predictive value (PPV) was 19% (5–40%) and median negative predictive value (NPV) was 95% (56–99%). One LE study found a sensitivity of 23% overall, increasing to 75% in symptomatic women. LE dipsticks mostly involved three steps and took under 2 min. The median sensitivity of immunochromatographic tests (ICT) was 70% (60–94%), median specificity was 96% (89–97%), median PPV was 56% (55–97%) and median NPV was 93% (92–99%). Immunochromatic strips involved five to seven steps and took 15–30 min. Specificity of microscopy ranged from 38% to 89%.
ICT and LE tests had similar sensitivities, but sensitivity results may be overestimated as largely symptomatic patients were included in some studies. ICT had a higher specificity in women than LE tests. The findings highlight the need for improved POC tests for diagnosis of N gonorrhoeae and more standardised evaluations.
Human papillomavirus (HPV) is the commonest sexually transmitted infection. Despite the significant morbidity and mortality associated with HPV-related diseases, previous studies have demonstrated low HPV knowledge in the general population. The objectives of this study were to assess knowledge of cervical cancer and HPV among young women and investigate predictors of high knowledge.
Female subjects, aged 16–25 years living in Victoria, Australia, were recruited using targeted advertising on Facebook from May to September 2010. A web-based questionnaire was used in a cross-sectional pilot study for a large longitudinal study on women's health, The Young Female Health Initiative.
A total of 278 women completed the questionnaire. The geographic region, indigenous status and socio-economic status of participants were representative of the target population. Overall, 63% knew what HPV was, but only 48% knew it was a common virus. Predictors of high HPV knowledge on multivariate analyses were older age (adjusted OR (aOR) 2.78, 95% CI 0.77 to 10.04), higher socio-economic status (aOR 1.39, 95% CI 0.66 to 2.95), being Australian-born (aOR 3.10, 95% CI 1.15 to 8.36), older age at first vaginal intercourse (aOR 1.84, 95% CI 0.66 to 5.14), awareness of HPV vaccines (aOR 2.16, 95% CI 0.68 to 6.85) and chlamydia (aOR 2.57, 95% CI 1.11 to 5.94), and self-reported HPV vaccination status (aOR 1.83, 95% CI 0.76 to 4.41).
HPV and cervical cancer knowledge among participants were relatively high compared with other studies conducted both worldwide and in Australia. However, deficits in knowledge exist and warrant address in educational initiatives.
To investigate the prevalence and correlates of concurrent (overlapping) sexual partnerships among female sex workers (FSWs) and their non-commercial male partners in two Mexico–US border cities.
A cross-sectional survey of FSWs and their non-commercial male partners was conducted in Tijuana and Ciudad Juárez, Mexico (2010–2011). Eligible FSWs and verified non-commercial partners were aged ≥18 years; FSWs had ever used hard drugs (lifetime) and recently exchanged sex for money, drugs or other goods (past month). Participants underwent baseline questionnaires obtaining dates of sex and condom use with ≤5 other recurring partners, including FSWs’ regular clients. These dates were compared with dates of sex with enrolled study partners to determine overlap (ie, ‘recurring’ concurrency). Bivariate probit regression identified recurring concurrency correlates.
Among 428 individuals (214 couples), past-year recurring concurrency prevalence was 16% and was higher among women than their non-commercial male partners (26% vs 6%). In 10 couples (5%), both partners reported recurring concurrency. The majority of couples (64%) always had unprotected sex, and most of the individuals (70%) with recurring concurrency ‘sometimes’ or ‘never’ used condoms with their concurrent partners. Recurring concurrency was positively associated with FSWs’ income, men's caballerismo (a form of traditional masculinity) and men's belief that their FSW partners had sexually transmitted infections (STIs).
Recurring concurrency, representing sustained periods of overlapping partnerships in which unprotected sex was common, should be addressed by couple-based STI prevention interventions.
The objective of this study was to estimate the prevalence of human T cell lymphotropic virus (HTLV)-1/2, HIV-1, hepatitis B virus (HBV), Trypanosoma cruzi, Treponema pallidum and Toxoplasma gondii infections and to identify the subtypes/subgroups of HTLV-1/2 among pregnant women (PW) from non-endemic provinces of Argentina.
Methods A total of 2403 samples were screened for HTLV-1/2 and confirmed by western blot and PCR. The long terminal repeat (LTR) of HTLV-1 and HTLV-2 were amplified. Phylogenetic analysis was performed by Neighbour Joining by using molecular evolutionary genetics analysis (MEGA) 4.0.
Among a total of 2403 PW studied, 6 (0.25%) tested positive for HTLV-1/2 (3 HTLV-1 (0.12%) and 3 HTLV-2 (0.12%)). The total prevalence when distributed by province was 0.3% (3/804) for Buenos Aires (BA), 0.4% (1/241) for BA surroundings, 0.1% (1/707) for Neuquen and 1.0% (1/95) for Ushuaia. In San Juan, no PW were HTLV-1/2 positive. The prevalence was similar when compared with rates among blood donors of the same areas and years. The phylogenetic analysis classified one sequence as HTLV-1 aA and one as HTLV-2b. The prevalence of HIV-1, HBV, T cruzi, T pallidum and T gondii was 0.6%, 0.2%, 1.4%, 1.2% and 20.9%, respectively. One case of HTLV-1/HIV-1 and one of HTLV-2/HIV-1 co-infection were detected.
HTLV-1/2, which have been associated with different diseases, are circulating among PW of Argentina, even in non-endemic areas. Therefore, testing should be recommended in women who have risk factors for these infections given that the majority of HTLV-1/2 mother to child transmission can be prevented by the avoidance of breast feeding.
The authors adopt a social constructionist perspective on sexual behaviour, highlighting the importance of considering the social determinants of sexual behaviour, and the impact social and historical contexts have on public health efforts to improve sexual health.
Chapters 2–5 discuss a comprehensive set of sexual health outcomes of sexual activity, including STIs, unplanned pregnancies, sexual violence, sexual function, sexual pleasure and sexual satisfaction.
Chapters 6–10 look at high-risk populations (ie, young people, men who have sex with men,...]]>