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Do men and women differ in their HIV outcomes?
Numerous studies have explored gender-related differences in HIV outcomes, and a meta-analysis of heroic scale (over 100 studies in the final evidence synthesis) recently combined these results.1 Their main finding was that men with HIV experience greater mortality (risk ratio (RR) for all-cause mortality 1.23, 95% CI 1.17 to 1.29) and faster disease progression (RR 1.11, 95% CI 1.02 to 1.21) compared to women. The large number of studies in the analysis allowed detailed exploration of factors that may explain the heterogeneity between cohorts. This can explain why a higher mortality in men is not familiar to many clinicians from their daily practice. It appeared that the gender-related difference in risk of death was largely confined to low-income and middle-income countries, patients on antiretroviral therapy (ART), and those younger than 50 years old. In high-income countries, patients older than 50 years and untreated patients, there was no difference in mortality between men and women.
Not when to stop, but where to stop co-trimoxazole prophylaxis
The need to decide to start or stop prophylaxis for opportunistic infections in HIV-positive patients is infrequent in current practice in the West, because of diagnosis and treatment earlier in the time course of the infection. However, in resource-limited settings, these issues have certainly not gone away. An interesting randomised trial from Kenya compared cessation with continuation of co-trimoxazole in 500 ART-treated patients with CD4 counts of >350 cells/µL.2 The combined rate of mortality and morbidity in those discontinuing co-trimoxazole was more than twice that of those continuing the drugs (rate ratio 2.27, 95% CI 1.52 to 3.38), an effect that was almost entirely driven by malaria incidence: 33 out of 34 cases of malaria during the study were in the co-trimoxazole cessation arm. While the findings have clear relevance in sub-Saharan Africa where advanced HIV is most prevalent, one strength of this important trial is the potential to translate its results to both malaria-endemic and non-endemic regions.
Patient-reported problems with sleep and cognitive function in HIV
Neurocognitive complaints are common in people living with HIV (PLWH), but the predictive value of perceived symptoms among PLWH as an indication of true functional impairment is fairly weak (as it is in the general population). Eliciting symptoms of memory loss or concentration difficulties should lead clinicians to consider problems with low mood, stressful life events, anxiety, pain and substance use. According to results from a recent questionnaire study of 268 adults with HIV in California, self-reported sleep quality and objectively-measured sleep quantity are associated with symptoms of cognitive difficulties.3 Using a device worn on the wrist, the mean sleep time was estimated at 6.2 hours/day, and using an established scale there was a 63% prevalence of poor sleep quality. The study focussed on patient experiences, hence it leaves many unanswered questions about true associations between sleep patterns and objective measures of neurocognitive function. The results imply that sleep symptoms should be explored in patients who report cognitive impairment symptoms, and that they should be counselled about this relationship.
Ejaculatory frequency and risk of prostate cancer
The idea that a higher lifelong frequency of ejaculation is preventive for prostate cancer is one of those ‘read it in the paper’ sexual health facts that has entered public awareness.4 The Clinical Round-Up authors were pleased to read an update on this cohort of more than 30 000 men who have now been followed up for 18 years.5 The results showed that men ejaculating at least 21 times per month had around 20% reduction in incidence of prostate cancer compared to men ejaculating 4–7 times per month, based on their reported ejaculatory frequency both in their 20s (HR 0.81, 95% CI 0.72 to 0.92) and in their 40s (HR 0.78, 95% CI 0.69 to 0.89). There were limitations to the interpretation of the original results due to potential bias in the observational cohort design, hence the need to publish an updated analysis. The finding is important for a disease accounting for 15% of all male cancer diagnoses with no other modifiable risk factors, little in the way of effective prevention strategies, and much still to be understood about its early aetiology.
Contributors Both authors contributed to the identification of studies and writing of the manuscript. LH wrote the first draft.
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.
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