Article Text

Download PDFPDF

Clinical round-up
  1. Sophie Herbert1,
  2. Lewis Haddow2
  1. 1Department of GUM/HIV, Derby Hospitals NHS Foundation Trust, Derby, UK
  2. 2Research Department of Infection and Population Health, Centre for Sexual Health & HIV Research, University College London, London, UK
  1. Correspondence to Dr Sophie Herbert, Department of GUM/HIV, Derby Hospitals NHS Foundation Trust, Derby, DE1 2QY UK; sophieherbert{at}nhs.net

Statistics from Altmetric.com

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

HPV vaccination

As we write, the Food and Drug Administration (USA) has approved the use of the 9-valent human papilloma virus (HPV) vaccine. Questions remain, however, about who to vaccinate. Should we be vaccinating boys/men, and how old is too old to be vaccinated? Skinner et al1 go some way to answering the second question with their interim analysis. The VIVIANE study is a multicentre double-blinded randomised controlled trial looking at the efficacy of the bivalent HPV 16/18 vaccine in women >25 years. (The PATRICIA study previously looked at this vaccine in women <25 years).2 In total, 15% of women included in the trial had prior exposure to HPV, and primary endpoints were persistent HPV 16/18 infection at 6 months or CIN1 or greater associated with these subtypes. Vaccine efficacy was 81.1% for the total group and 86.4% for those who were seropositive for HPV but negative for HPV DNA at baseline, after 40.3-month follow-up. The vaccine appears to be more efficacious in the group aged 26–35 years than in the group aged 36–45 years, but the numbers were too small to make any meaningful comment about the vaccine use in women >46 years. They also found some cross-protective benefit for HPV 31 and 45. So where next? If the vaccine works in those with HPV exposure but who are currently DNA negative, how could this be implemented in practice? Should we screen for HPV DNA before vaccination? Should women abstain until they are vaccinated to minimise new HPV exposure? In a separate study on attitudes to HPV vaccination, Harper et al3 asked young women in the USA if they preferred their male partner to be vaccinated against HPV. Not surprisingly, 63% of the women surveyed preferred their partner to be vaccinated, regardless of their own vaccination status.

Rectal chlamydia in women

Juniors new to sexual health often ask about rectal screening in women. Van Liere et al4 from the Netherlands suggest that the current practice of a history-based approach to screening may not be adequate for chlamydia control in women. Their paper demonstrates high prevalence rates (8.4%) of anorectal chlamydia in women routinely screened in a sexual health clinic (n=663) and no correlation to history of anal sex was found. In fact, prevalence rates were higher in women not reporting a history of anal sex 9.2% versus 7.9%. Rates of urogenital chlamydia were also very high (11.2%), so their findings may only be applicable to other high-risk populations. A total of 94.5% (52/55) those with anorectal infections also had urogenital infection, with only three cases of isolated anorectal chlamydia. They conclude that rates of undiagnosed anorectal chlamydia are high when using only a history-based approach to decide who to screen, and they ask what this means for treatment and control of chlamydia in women. Can we rely on azithromycin to adequately treat rectal infections in women or would doxycycline be a better choice? A cost-effectiveness analysis of routine screening would be welcome.

More evidence for prevention during primary HIV infection?

Lastly, we highlight a study by White et al5 looking at how many HIV infections could be averted by targeting primary HIV infection (PHI) in men who have sex with men (MSM). This mathematical modelling study incorporates some assumptions based on empirical data from a previous study by Fox et al6 looking at behaviour change of MSM in the 3 months following receiving an HIV diagnosis. Using these data they propose different models of HIV testing following a potential ‘risk’ (at diagnosis immediately after infection, at fortnightly intervals, monthly, 6 weekly and bimonthly). Combining this with 2 different estimates of HIV transmission risk from studies by Patel et al7 and Scott et al,8 they estimate the number of infections that could be averted. The data are compelling, estimating the number of HIV transmission events from a cohort of 98 MSM experiencing PHI to be 31–48 new infections in the absence of any intervention, with the potential to avert over 50% of these infections if the men tested twice every month. The reduction in transmission declines with less frequent testing and a shorter PHI period. They acknowledge a number of assumptions and identify that 76% of those in the Fox study changed their behaviours to reduce transmission risk in the 3 months after diagnosis, so that the post-diagnosis transmission risk is concentrated in approximately a quarter of individuals. Some of these individuals may increase the numbers of partners they have, but the authors point out that serosorting or condom use may occur in this group, which would contribute to an overestimation of risk. It should be noted that these data are based on idealised conditions and repeated HIV testing after a single isolated risky incident may not be a realistic strategy for many MSM. But clinics might consider adding a repeated serial testing approach to existing strategies offered to high-risk MSM, such as postexposure prophylaxis and risk-reduction counselling.

References

Footnotes

  • Contributors SH and LH decided on the content and wrote the manuscript.

  • Competing interests None.

  • Provenance and peer review Commissioned; internally peer reviewed.