Mullick, Watson-Jones, Beksinska and Mabey1 have done a great job in
summarising the approaches for treatment and control as well as the
prevalence and impact of STIs in pregnancy in developing countries. Among
the approaches cited is the contact tracing or partner notification as an
integral part of STIs control.
Coincidentally we read this article after we discussed cultural
sexual prac...
Mullick, Watson-Jones, Beksinska and Mabey1 have done a great job in
summarising the approaches for treatment and control as well as the
prevalence and impact of STIs in pregnancy in developing countries. Among
the approaches cited is the contact tracing or partner notification as an
integral part of STIs control.
Coincidentally we read this article after we discussed cultural
sexual practices that fuel the epidemic of STIs particularly HIV as part
of a multidisciplinary course on “Integration of HIV/AIDS into the
curriculum for institutions of Higher Learning”, held in Pretoria, South
Africa. As the issue of contact tracing is considered in light of cultural
practices, it seems that the approach would be difficult to enforce in
some African countries where multi-sexual partnerships are expected and
accepted
In a focus group discussion facilitated by the authors, 31
participants whose characteristics are described in Table 1, were asked to
comment on the following statement: “Using examples, describe cultural
sexual practices that increase the spread of sexually transmitted
infections (STIs) particularly HIV in your country, province, or tribe”.
Their responses are summarized in Tables 1 and 2. The practice of
“dry sex”, rites of passage into adulthood, sexual cleansing of widows and
widowers, widow inheritance, wife-sharing, and couple-deceit prostitution
are some of the sexual practices that were mentioned as having the
potential to increase the spread of HIV and other STIs. As pointed out by
Gausset2, these practices cannot be solely held responsible for the spread
of STIs because they are not incompatible with safer sex practices. For
instance, Okeyo and Allen3 reported that lack of condom use among African
widows is related to their lack of knowledge about its ability to prevent
STIs.
Although some of the African cultural sexual practices may seem
strange for other people, their philosophical basis and metaphysical
significance are part of a broader concept of the universe by the people
who practise them. For instance the practice of widow inheritance, or
levirate, is founded on the concept that the dead brother can continue to
live through his living brother who continue to fulfill his duties and
responsibilities towards his wife, children and society at large. This
practice ensures a safety net for children and the widow by guarantying
their economic and social benefits. 4 Similarly, rites of passages and
widow cleansing are milestones in life progression among the living as
also practised in non-African cultures. 5-6
But some of the African cultural sexual practices do not lend
themselves to the idea of contact tracing: How would a 12-year old girl or
boy who contracted an STI from the rite of passage ceremony bring a
partner? The age gap between herself and the man who performed the ritual,
the enforced secrecy, the hurt or shame experienced, and even the fact
that the man (woman) may not be easily identifiable given the
circumstances of the ritual which is generally conducted in the dark. Or
in the case of wife-sharing practice, which partner should a Ankole,
Masai, or Yao woman bring if requested to do so? How would one diffuse the
potential conflict emanating from publicizing what is normally a private
affair?
While we concur with Mullick et al.(2005) that more information is
needed on the acceptability and effectiveness of contact tracing in
Africa, we also add that studies and interventions that seek deeper
understanding of cultural sexual practices need to be undertaken. These
studies should assist in finding ways to accommodate these practices as
they transform in the face of the devastating effects of HIV/AIDS. 7
Table: Participants’ characteristics (n=31)
Age Value (years)
Mean 40.9
Median 39.0
Mode 39.0
Minimum 28.0
Maximum 55.0
Gender Percent
Male 45.2
Female 54.8
Marital status
Married 74.2
Not married 25.8
Level of education
Higher diplomas 22.6
Degrees 77.4
Country of origin
Ethiopia 6.5
Kenya 12.9
Lesotho 12.9
Malawi 16.1
Swaziland 6.5
Tanzania 12.9
Uganda 3.2
Zambia 12.9
Zimbabwe 16.1
Table 2: Cultural sexual practices (n=31)
Men’s demand for “dry sex” : To ensure that there is less lubrification,
and render the vagina as small as possible (Leosotho) Lesotho, Swaziland,
Zimbabwe, Malawi, Zambia, Tanzania
Rites of passage called “washing” in which boys and girls aged 11-15 are
required to sleep either with an old lady (boys) or a old man (girls)
chosen by the community for the purpose ; or pick up any woman during the
closing moments of the ceremony (Luhya tribe-Kenya) Lesotho, Malawi,
Kenya,
Wife’s inheritance (levirate): A brother of the deceased man inherit the
wife and all other family responsibilities Ethiopia, Kenya, Lesotho,
Malawi, Swaziland, Tanzania, Uganda, Zambia, Zimbabwe
The practice of women-sharing based on the concept that it is the “Woman’s
duty” to accept sexual intercourse with any man from the community who
request it – A Yao woman should never say no to a request for sexual
intercourse because sex is a free gift from God! Yao tribes of Malawi and
Tanzania
The practice of giving a sister, cousin or niece to help the breastfeeding
mother and her husband. Once the husband sleeps with sister, … she becomes
automatically his second wife; the man cannot be given another sister or
cousin. Swaziland
The acceptance that a woman must always have 3 stones (men) to sustain
her. The woman must ensure that the three men never know each other.
Zaramo tribes in Tanzania
The practice of sharing wives among all men of the same generation in
Masai tribes (Kenya, Tanzania); or of a wife among sibling men (Ankole
tribe-Uganda) Kenya , Tanzania, Uganda
Couple-deceit prostitution where a man and his wife agree that the wife
must seduce a rich man (who has more cattle) so that the husband can catch
them during the intercourse and oblige the rich man to pay fines (1-5
cows) Zambia, Kenya (Tribes: Wajibana, Nduruma, Ndjibe, ..etc)
Widows’ cleansing ceremony in which a widow is expected to sleep with a
man chosen by the community (Lesotho) or herself (Zimbabwe) to mark the
end of her mourning period. The man chosen for the purpose is somewhat the
one who is known not to mind about doing it. Ethiopia, Kenya, Lesotho,
Malawi, Swaziland, Tanzania, Uganda, Zambia
Table 3: Methods and items used for dry sex (n=31)
Methods and Items used for dry sex and enhance pleasure Country
Douching is done with Coca-Cola, Soda water, snuff, magnesium salts in
solution (from chemists), some mines’residues stones; herbal mixtures
(such as “Mutiburo” means heighten libido; “Chiswabunga” means sexual
prowess or strength for the man; and “Mugondorosi” meaning extend duration
of man’s stay) Lesotho, Zimbabwe, Malawi, Zambia
Insertion into the vagina prior to sexual intercourse of blue soap;
cataplasms made of some herbal mixture made into small balls that are sold
as such and referred to as “baboon urine” in Zimbabwe Lesotho, Zimbabwe,
Malawi, Zambia
References
1. Mullick S, Watson-Jones D, Beksinska M, and MabeyD. Sexuallly
transmitted infections in pregnancy: prevalence, impact on pregnancy
outcomes, and approach to treatment in developing countries. Sex Transm.
Inf. 2005;81;294-302.
2. Gausset Q. AIDS and cultural practices in Africa: the case of the
Tonga (Zambia). Social Science and Medicine 2001;52:509-18
3. Okeyo TM, Allen AK.Influence of widow inheritance on the
epidemiology of AIDS in Africa. Afr J Med Pract. 1994 Mar-Apr;1(1):20-5.
4. Phiri, Z.(2002). Inculturating African widowhood rites. Available
at: http://www.jctr.org.zm/bulletins/incult-widows.htm {Retrieved 21
September 2005)
5. Goseyun, A. E. (2001). Sunrise Ceremonial: An Apache Girl's Coming
of Age White Mountain Apache Reservation, Whiteriver, Arizona, 1990.
Balch Institute. Available at:
http://www.balchinstitute.org/rites/apache.html. [Retrieved on September
21, 2005]
6. Holland, E. (2001). Quinceanera: Latino Sweet Sixteen. Balch
Institute. Available at : http://www.balchinstitute.org/rites/latino.html.
[Retrieved on September 21 , 2005]
7. Malungo J. Sexual cleansing (Kusalazya) and levirate marriage
(Kunjilila mung’anda) in the era of AIDS: changes in perceptions and
practices in Zambia. Social Science and Medicine 2001;53:371-82.
We read with interest the paper by Brown and Peerapatanapokin
regarding estimated condom use rate required to control the HIV epidemic
in Thailand.[1] Their Asian Epidemic Model predicts that a sustained
high condom use rate (85% or more) among sexual workers is required to
control the HIV epidemic. If the condom use rate drops to 60%, their
model predicts a resurgence of the HIV epidemic.[1] We reac...
We read with interest the paper by Brown and Peerapatanapokin
regarding estimated condom use rate required to control the HIV epidemic
in Thailand.[1] Their Asian Epidemic Model predicts that a sustained
high condom use rate (85% or more) among sexual workers is required to
control the HIV epidemic. If the condom use rate drops to 60%, their
model predicts a resurgence of the HIV epidemic.[1] We reached a similar
conclusion using a different model developed for a different situation in
Taiwan[2], where prevalence of HIV infection is as low as 0.019% (end of
2002) and highly active antiretroviral therapy has been freely provided by
the government since 1997.
Sexual contact (96.4%, n=4,390 at the end of 2002) has been the
predominant risk factor for acquiring HIV infection in Taiwan.[2]
Because HIV prevalence is extremely low, evolution of the HIV epidemic in
Taiwan can be approximated by a simple exponential model defined by the
equation: dN(t)/dt = R*N(t) - m*N(t), where N(t) is the number of
patients with HIV infection at time t, R is the average transmission rate
(new cases per prevalent case per year) and m is the risk of mortality
(deaths per prevalent case per year). The magnitude of the HIV epidemic
will decrease only if R < m.
Using our previously published estimates for R and m values in Taiwan
(R=0.184 and m=0.046 per prevalent case-year, 1998-2002,
respectively)[2], plus the assumption that the value R=0.184 is under
the scenario of 10% condom use with 90% protection efficacy among sexually
active persons with multiple partners, the condom use rate level which is
required to control HIV epidemic can be calculated as below:
Hypothetical R under 0% condom use scenario = 0.184/(1-(10%)*(90%))
= 0.202
Hypothetical R under x % condom use scenario = 0.202*(1-(x%)*(90%))
Solve the x% when R = m = 0.046; we get x% = 85.8%
In another words, the condom use rate must be increased to 86% in
order to turn the tide of the sexually transmitted HIV epidemic.
Sensitivity analysis to assume baseline condom use rates of 5%, 15%, and
45% only shifts the required condom use rates for HIV control to 85%, 87%,
and 95%, accordingly. Thus, an equally high rate of condom use among
sexually active persons with multiple partners is required to control the
HIV epidemic in a low prevalence area like Taiwan in this era of highly
active antiretroviral therapy.
Chi-Tai Fang,1 Yu-Yin Chang,2 Jung-Der Wang1,2
1 Department of Internal Medicine, National Taiwan University
Hospital
2College of Public Health, National Taiwan University.
We declared no competing interests.
References:
1.Brown T, Peerapatanapokin W. The Asian Epidemic Model: a process
model for exploring HIV policy and programme alternatives in Asia. Sex
Transm Infect 2004; 80 (Suppl 1): 19-24.
2.Fang CT, Hsu SM, Twu SJ, et al. Decreased HIV transmission after a
policy of providing free access to highly active antiretroviral therapy in
Taiwan. J Infect Dis 2004; 190: 879-885.
Syphilis has long been an important risk factor for adverse pregnancy
outcome. According to Mullick et al.[1] maternal syphilis is still a major
cause of morbidity and mortality in developing countries. Since there has
been a resurgence of syphilis in many developed countries[2], women
requiring treatment for syphilis during pregnancy are expected to increase
in the United States and Western Europe. In...
Syphilis has long been an important risk factor for adverse pregnancy
outcome. According to Mullick et al.[1] maternal syphilis is still a major
cause of morbidity and mortality in developing countries. Since there has
been a resurgence of syphilis in many developed countries[2], women
requiring treatment for syphilis during pregnancy are expected to increase
in the United States and Western Europe. In Italy[3] the upsurge has been
associated with an increase in HIV infection and immigration.[4] However,
although antenatal screening for syphilis is routine in Italy before the
13th week of pregnancy, to our knowledge no retrospective analysis of
these screening results has ever been carried out and the number of cases
of syphilis detected among pregnant women is unknown.
Siena is a small town but in our venereology unit we recently observed
four cases of syphilis in pregnant women born outside Italy (Ecuador,
Russian Republic, Senegal and Poland). VDRL (Venereal Disease Research
Laboratory) screening was positive in all cases and confirmed by
quantitative VDRL and non-treponemal tests that showed high to moderate
titres. Physical examination was negative in all cases. Although three
patients were multiparous, their children were not born in Italy and none
of the patients had a history or documentation of syphilis infection.
Unfortunately, we were unable to determine when infection occurred, so all
patients were staged ‘secondary latent syphilis of unknown duration’ and
immediately treated with three doses per week of i.m. benzathine
penicillin (2.4 million units), according to WHO guidelines.[5]
Quantitative VDRL repeated monthly showed a significant decrease after 3-6
months. The fetuses were monitored by serial three dimensional
ultrasonography (GE Voluson 730 Expert Probes) at 22, 30 and 35 weeks
(Figure 1). The following parameters were evaluated: biparietal diameter,
head circumference, abdominal circumference, femur length, placental
thickness, liver size, gestational age, fetal blood pressure, presence of
ascites and mucocutaneous manifestations.
All women delivered after 37 weeks and there were no low-birth-weight
infants. Placentas and umbilical cords were normal. The babies were
examined clinically and serologically at delivery and at 6, 12 and 15
months and did not show any signs of congenital syphilis. Blood samples
were negative for FTA-IgM and other blood tests were within normal
limits. The babies were not treated. Passively transferred maternal
lipoidal antibodies (VDRL titres) fell by 75% in the first two months and
disappeared by about 6 months. Our experience shows that the problem of
syphilis in pregnancy is far from solved, even in developed countries.
Cases would therefore be missed if antenatal screening were abandoned,
especially in women born outside Italy. Appropriate early treatment during
pregnancy and meticulous prenatal and postnatal follow up can avoid
congenital syphilis and unnecessary penicillin therapy for the infants.
References:
1) Mullick S, Watson-Jones D, Beksinska M, Mabey D. Sexually transmitted
infections in pregnancy: prevalence, impact on pregnancy outcomes, and
approach to treatment in developing countries. Sex Transm Infect. 2005
;81(4):294-302.
2) Weir E., Fishman D. Syphilis: have we dropped the ball? CMAJ. 2002
26;167(11):1267-8.
3) Cusini M., Ghislanzoni M, Bernardi C, Carminati G, Zerboni R, Alessi E,
Suligoi B. Syphilis outbreak in Milan, Italy. Sex Transm Infect.
2004;80(2):154.
4) Suligoi B, Giuliani M. Sexually transmitted diseases among foreigners
in Italy. Migration Medicine Study Group. Epidemiol Infect. 1997
;118(3):235-41.
5) World Health Organization. Integrating care for reproductive health,
sexually transmitted and other reproductive tract infections; a guide to
essential practice. Geneva WHO, January 2004.
We read with interest the paper by Sadiq et al. on CD4 counts and
viral loads in patients with early syphilis and HIV.[1] We note that they
treated their patients with a single 2.4 MU injection or two weeks of oral
doxycycline. In this regard they are in good company.[2]
Whereas most patients with HIV and early syphilis make a full
recovery on this regimen, there are numerous case reports of...
We read with interest the paper by Sadiq et al. on CD4 counts and
viral loads in patients with early syphilis and HIV.[1] We note that they
treated their patients with a single 2.4 MU injection or two weeks of oral
doxycycline. In this regard they are in good company.[2]
Whereas most patients with HIV and early syphilis make a full
recovery on this regimen, there are numerous case reports of failure,
often resulting in serious CNS and ocular manifestations.[3] Serological
and clinical failure was also reported in the injection only arm of a
controlled trial of 2.4 MU benzathine penicillin versus 2.4MU benzathine
penicillin and high dose amoxicillin.[4]
There are other good theoretical reasons for giving benzathine
penicillin (or other similar regimens) for longer than a week in early
syphilis. These include a longer dividing time for Treponema Pallidum as
the disease stage advances, and inconsistent treponemacidal levels past
one week with one injection of 2.4 MU benzathine, particularly in young
patients.[5]
We consider that syphilis, at any stage of the disease, in the
presence of HIV merits prolonged treatment e.g. benzathine penicillin
given 3 times over 2 weeks.[6]
References:
1. Sadiq ST, McSorley J, Copas AJ, Bennett J, Edwards SJ, Kaye S,
Kirk S, French P, Weller IVD. The effects of early syphilis on CD4 counts
and HIV-1 RNA viral loads on blood and semen. Sexually Transmitted
Infections 2005;81:380-385.
3. Berry CD, Hooton TM, Collier AC, Lukehart SA. Neurologic relapse
after benzathine penicillin therapy for secondary syphilis in a patient
with HIV infection. New England Journal of Medicine 1987;316:1600-1601.
4. Rolfs RT, Joesoef MR, Hendershot EF, Rompalo AM, Augenbraun MH,
Chiu M, Bolan G, Johnson SC, French P, Steen E, Radolf JD, Larsen S. A
randomized trial of enhanced therapy for early syphilis in patients with
and without human immunodeficiency virus infection. The Syphilis and HIV
Study Group. New England Journal of Medicine 1997;337(5):307-14.
5. Collart P, Poitevin M, Milovaovic A, Herlin A, Durel J. Kinetic
study of serum penicillin concentrations after single doses of benzathine
and benethamine penicillins in young and old people. British Journal of
Venereal diseases 1980;56:355-362.
We read with interest the article “Improvement in the clinical cure
rate of outpatient management of pelvic inflammatory disease following a
change in the therapy”.[1]
In most GUM clinics gonorrhoea is identified by microscopy (x 1000)
of Gram stained genital specimens (sensitivity 20%- 51%)[2] and culture
(sensitivity 75%-95%).[3] In the above study gonorrhoea was identified in
12% of c...
We read with interest the article “Improvement in the clinical cure
rate of outpatient management of pelvic inflammatory disease following a
change in the therapy”.[1]
In most GUM clinics gonorrhoea is identified by microscopy (x 1000)
of Gram stained genital specimens (sensitivity 20%- 51%)[2] and culture
(sensitivity 75%-95%).[3] In the above study gonorrhoea was identified in
12% of cases. Inspite of this, the authors found that the clinical cure
rate was better (72%v55%) when single parenteral dose of ceftriaxone was
added to doxycycline and metronidazole regimen (as per UK National
guidelines[4]). This may be due to the effect of ceftriaxone on gonococci as
well as other bacteria less commonly implicated in the pathogenesis of
PID.
We feel that adherence to the UK National guidelines for managing PID
is even more important in settings where there may be limited facilities
for diagnosing gonorrhoea e.g. in GP surgeries or Gynaecology units. An
audit of management of PID in Gynaecology units in North West of England
and North Wales in 2001 showed that management of PID was suboptimal.
Swabs for gonorrhoea were taken by only 34% of doctors. Type and duration
of antibiotic treatment varied considerably (from 1 to 3 weeks).[5]
Cost is often an issue. However we should be looking at long-term
benefits as appropriate management of PID may prevent serious sequelae
like ectopic pregnancy, infertility and chronic pelvic pain which cost
health services about 300 million pounds a year.
Contributors: Both authors have contributed to writing this letter.
Competing interests: None.
References:
1. Piyadigamage A, Wilson J. Improvement in the clinical cure rate of
outpatient management of pelvic inflammatory disease following a change in
therapy.
Sex Transm Infect. 2005 Jun;81(3):233-5.
2. Manavi K, Young H, Clutterbuck D. Sensitivity of microscopy for the
rapid diagnosis of gonorrhoea in men and women and the role of gonorrhoea
serovars.
Int J STD AIDS. 2003 Jun;14(6):390-4.
3. Bignell C. National Guideline on the Management of Gonorrhoeae in
adults (Revised 2004). www.bashh.org , viewed August 2005
4. Ross JDC. The UK national guidelines for the management of pelvic
inflammatory disease (Revised 2005). www.bashh.org, viewed June 2005
5. Gupta M, Kasliwal A. Management of PID : Are we getting it right?
Abstracts: XV11 FIGO World Congress of Gynaecology and
Authors:
1. Corresponding author:
Dr Meena Gupta
Specialist Registrar in Sexual Health
Countess of Chester Hospital
Liverpool Road
Chester, Cheshire
CH2 1UL
UK
e-mail: dr_mgupta@hotmail.com Tel: 01925 861293
Fax: 0151 7065821
2. Dr Asha Kasliwal
Consultant in Community Gynaecology and Reproductive Health Care
Palatine Centre
63-65 Palatine Road
Manchester
M20 3LJ
UK
The engaging editorial by Cassell and Low (STI 2005 Aug; 81(4):285-6)
is timely and highlights a critical issue in the debate about the
effectiveness of screening as an intervention for genital chlamydial
infection. The authors correctly note that ecologic studies are limited in
their inference but have a role to play in suggesting areas for further
research. The authors hypothesize that targeting only...
The engaging editorial by Cassell and Low (STI 2005 Aug; 81(4):285-6)
is timely and highlights a critical issue in the debate about the
effectiveness of screening as an intervention for genital chlamydial
infection. The authors correctly note that ecologic studies are limited in
their inference but have a role to play in suggesting areas for further
research. The authors hypothesize that targeting only women, inferior
intervention coverage, incomplete follow-up of partners, and irregular
screening frequencies have played a role in the subsequent rise of
incident chlamydial infections in Sweden and elsewhere, and infer that the
current efforts in England are headed for similar failure.
However, the authors fail to appreciate the time and resources
required to achieve the standard alluded. What proportion of the
population has to be screened, how frequently does screening need to occur
within that population, and what level of follow-up for partners have been
under considerable debate recently, and the authors make no suggestion as
to answers to these questions.
I contend that if chlamydia screening was given the appropriate
resources and commitment from the start which would guarantee sufficient
levels of uptake, ensure regular screening during the principal at-risk
time (adolescence to young adulthood), treat a high proportion of the most
recent partners, and sustain this effort for a minimum of three years,
then the direct impact of this intervention would be certainly known.
Completed work soon to be published suggests that if 50% of all sexually
active women aged 16-24 years were screened (coverage) at least 4 times
over these years (frequency) with at least 20% of partners successfully
treated (good partner follow-up), reductions in prevalence up to 75% from
baseline would occur within 3 years not only in the targeted populations,
but those not targeted as well (through a 'herd immunity' effect).
The government has only recently committed itself to this effort with
significant resources targeted in their public health white paper
(Department of Health, Nov 2004), after years of debate and discussion. It
would be unwise to suggest failure for a programme that has yet to be
given the commitment necessary to see it a success.
Replicating methods and comparing results across studies are critical
for the resolution of scientific controversies. In a recent report,
Niccolai et al. demonstrated that condoms were effective in preventing
chlamydia among STD clinic patients with known exposure to C.
trachomatis.(1) We were pleased to see the authors apply the methodology
that we first presented for estimating condom effectiveness...
Replicating methods and comparing results across studies are critical
for the resolution of scientific controversies. In a recent report,
Niccolai et al. demonstrated that condoms were effective in preventing
chlamydia among STD clinic patients with known exposure to C.
trachomatis.(1) We were pleased to see the authors apply the methodology
that we first presented for estimating condom effectiveness against
chlamydia and gonorrhea in 2001 (2,3) and published in the American
Journal of Epidemiology last year.(4) Their findings confirm the
importance of restricting the study population to persons with known STI
exposure (i.e., sexual contacts of infected persons) to reduce confounding
on condom effectiveness estimates against bacterial (4) and viral (5,6)
infections.
By focusing their analysis on chlamydia alone, Niccolai et al.
underscore the need for disease-specific estimates of condom
effectiveness. Focusing on a single disease is important because,
although condoms should protect against all infections transmitted via the
male urethra (including gonorrhea and chlamydia) (7), other factors, such
as transmission efficiency, are disease-specific and may influence the
magnitude of the protective effect. We would like to clarify for the
readers, however, that the methodology we described will also allow for
disease-specific estimates of protection when multiple infections are
evaluated among persons with known exposure. As we noted ((4), p. 243)),
the key point is that infections diagnosed among study participants must
be identical to those of the participants’ infected partner. (For
example, the relationship between condom use and risk for gonorrhea should
be assessed only among participants exposed to gonorrhea, likewise for
chlamydia). Maintaining this algorithm, we combined estimates for
chlamydia and gonorrhea after observing the disease-specific point
estimates (0.38 and 0.47, respectively) were neither appreciably nor
significantly different from each other ((4), p. 245)). Thus, application
of this methodology need not be limited to a single infection.
Niccolai et al.’s study represents the most recent application of
this methodology for estimating condom effectiveness among persons with
known STI exposure, and, encouragingly, provides independent confirmation
of the validity of this approach and of our earlier findings. This work
adds to an increasing body of evidence (4,8,9) suggesting that studies
confounded by important differences between consistent users and
inconsistent or nonusers (e.g., degree of STI exposure) tend to
underestimate the protective effect of condoms against bacterial STI.
Studies limited to individuals with known STI exposure are likely to
estimate the protective effect of condom use more accurately. Given that
such studies can be conducted using secondary analyses of existing trial
data (4,8) as well as routinely collected clinic data (1,9), we encourage
investigators to adopt similar methodologies to reduce confounding when
evaluating condom effectiveness.
Finally, restricting the study population to sexual contacts of
infected persons likely has many applications for STI research beyond
assessment of condom effectiveness. This methodology for reducing
confounding also may provide clearer insight into an array of potential
causative and preventive factors for STI, where studies are subject to the
same sources of confounding that have plagued condom effectiveness
research.
References
1. Niccolai L., Rowhani-Rahbar A, Jenkins H, et al. Condom
effectiveness for prevention of Chlamydia trachomatis infection. Sex
Transm Inf 2005;81:323-5.
2. Warner L, Newman D, Peterman T, et al. Uncontrolled confounding:
a methodologic problem in evaluating condom effectiveness for prevention
of sexually transmitted diseases. 2001 National HIV Prevention
Conference, Atlanta, GA, August 12-15.
3. Warner L, Newman D, Peterman T, et al. Project RESPECT Study
Group. Studying condom effectiveness for sexually transmitted disease
(STD) prevention: the importance of knowing partner infection status.
2002 National STD Prevention Conference, San Diego, CA, March 4-7.
4. Warner L, Newman DR, Austin HD, et al. Condom effectiveness for
reducing transmission of gonorrhea and chlamydia; the importance of
assessing partner infection status. Am J Epidemiol 2004;159:242-51.
5. Weller S, Davis K. Condom effectiveness in reducing heterosexual
HIV transmission. Cochrane Database Syst Rev 2001;(3):CD003255.
6. Wald A, Langenberg AG, Link K, et al. Effect of condoms on
reducing the transmission of herpes simplex virus type 2 from men to
women. JAMA 2001;285:3100-6.
7. Centers for Disease Control and Prevention. Sexually transmitted
diseases treatment guidelines 2002. MMWR 2002;51(No. RR-6).
8. Warner L. Macaluso M, Austin HD, et al. Application of the case-
crossover design to reduce unmeasured confounding in studies of condom
effectiveness. Am J Epidemiol 2005;161:1-9.
9. Shlay J, McClung MW, Patnaik JL, et al. Comparison of sexually
transmitted disease prevalence by reported level of condom use among
patients attending an urban sexually transmitted disease clinic. Sex
Transm Dis 2004;31:154-60.
Disclaimer:
The findings and conclusions in this letter are those of the authors and
do not necessarily represent the views of the Centers for Disease Control
and Prevention.
Fleiss et al. make several dubious claims in their article [1], but one is of particular interest. Some authors have now begun to rely upon the assertion that the subpreputial wetness contains lysozyme, and suggest that this may help to protect against HIV.[2,3] Although the epidemiological evidence suggests otherwise,2 our understanding of the mechanisms involved is important, and this claim is wo...
Fleiss et al. make several dubious claims in their article [1], but one is of particular interest. Some authors have now begun to rely upon the assertion that the subpreputial wetness contains lysozyme, and suggest that this may help to protect against HIV.[2,3] Although the epidemiological evidence suggests otherwise,2 our understanding of the mechanisms involved is important, and this claim is worthy of careful examination.
Fleiss et al. rely upon two sources.[4,5] One found lysozyme in apocrine glands, among other enzymes.[5] The other is a case report involving an apocrine gland in the prepuce.[4] However, a more recent pathological study,[6] cited by the authors, found that "unlike true skin of the penile shaft and outer surface of the prepuce, the mucosal surface of the prepuce is completely free of lanugo hair follicles, sweat and sebaceous glands."
If the mucosal surface is completely free of such glands, then it must be the outer surface of the prepuce that benefits from the lysozyme. Indeed, if the prepuce functions as a "one way valve" as the authors assert, the subpreputial moisture would be completely unaffected.
With such weak evidence, the assertion that the subpreputial wetness contains lysozyme must be regarded as an untested hypothesis at best.
References
Fleiss P, Hodges F, Van Howe RS. Immunological functions of the human prepuce. Sex Trans Infect. 1998;74(5):364-7
Siegfried N, Muller M, Volmink J, et al. Male circumcision for prevention of heterosexual acquisition of HIV in men (Cochrane Review). The Cochrane Library, issue 3. Oxford: Update Software; 2003.
Hill G, Denniston GC. HIV and circumcision: new factors to consider. Sex Transm Infect. 2003;79:495-496
Ahmed A, Jones AW. Apocrine cystodenoma: a report of two cases occurring on the prepuce. Br J Derm. 1969;81:899-901
Frolich E, Shaumberg-Lever F, Kissen C. Immunelectron microscopic localization of cathepsin B in human apocrine glands. J Cutan Pathol. 1993; 20: 54-60
Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol. 1996;77:591-5
We read with interest the Fox PA et al. paper (2005, 81;142-6) and welcome the clinical attention to genital pre-cancerous conditions; including Anal Intraepithelial Neoplasia (AIN).
Their finding of no correlation between high-risk (hr) HPV genotypes and histological or cytological grades of abnormalities, conflicts strongly with general consensus and other studies. Kreuter A et al. identified hr H...
We read with interest the Fox PA et al. paper (2005, 81;142-6) and welcome the clinical attention to genital pre-cancerous conditions; including Anal Intraepithelial Neoplasia (AIN).
Their finding of no correlation between high-risk (hr) HPV genotypes and histological or cytological grades of abnormalities, conflicts strongly with general consensus and other studies. Kreuter A et al. identified hr HPV in all AIN cases (with up to 7 different high-risk and 5 different low-risk types per lesion, with HPV – 16 always present in verrucous AIN).[1] Similar findings were corroborated by Daling JR et al., who support an important role for HPV in ano-genital cancer, at all sites.[2] They identified HPV in 88% of all histological specimens with HPV - 16 identified in 73%. It also contradicts Frisch M et al. paper, where 95% and 80% of anal canal and 83% and 28% of perianal skin cancers, of women and men respectively, were hr HPV positive.[3]
Van der Snoek EM et al. reported that 64.7% of the HIV positive men have HPV DNA more often in anal specimens than on the coronal sulcus (23.5%). The later finding is plausible, on account of the vulnerability of the squamo columnar junction and transformation zone of the anal canal to harbour and retain HPV particles (with consequent neoplastic transformation).[4] Understandably, the contradiction of the Fox et al. study will raise a prima facie question about their HPV detectability and virological techniques.
The PA Fox study documents the right observations regarding the aceto white areas without making the correct conclusions. We note that histological biopsies of suspicious aceto white areas in the study reports 81% concordance with AIN lesions, which suggests good prediction and appraise the test value.
The factors leading the clinical appraisal of ano-genital pre-cancerous conditions are:
1. They behave similarly: recurrent, multi-focal, potentially cancerous, increasing in incidence and overlooked by cosmetic factors (eg genital warts).
2. The incidence of genital cancer (anal, vulval, penile) is increasing.[5]
3. Patient's age of genital cancer and pre-cancerous conditions is declining, [6] (which brings them into the GUM clinics' age groups).
4. The increase in incidence of HPV related lesions is paralleled with increase in oncogenesis and genital intraepithelial neoplasias.[6] There could be a false increase due to the discovery of a pre-existing lesion (brought about by worries following a sexual encounter).
5. GUM physicians are in a special position, as they deal routinely with the ano genital area, which impose a duty of care to exclude intraepithelial neoplasia between other genital lesions. The similarities of symptoms and signs of AIN with anal warts were confirmed in the PA Fox paper.
6. The natural history is not fully appraised, due to the relative small caseload.
7. Long-term follow-up is prudent, since 23 of 29 HIV positive patients in one study had persistent or recurrent high grade AIN with 12 month mean time of recurrence.[7]
References
1. Kreuter A, Brockmeyer NH, Hochdorfer B, et al: Clinical spectrum
and virologic characteristics of anal intraepithelial neoplasia in HIV
infection.
J Am Acad Dermatol, 2005; 52(4):603-8.
2. Daling JR, Madeleine MM, Johnson LG, et al: Human papillomavirus,
smoking, and sexual practices in the etiology of anal cancer. Cancer,
2004 15;101(2):270-80.
3. Frisch M, Fenger C, van den Brule AJ, et al: Variants of squamous
cell carcinoma of the anal canal and perianal skin and their relation to
human papillomavirus. Cancer Res, 1999 1;59(3):753-7.
4. van der Snoek EM, Niesters HG, Mulder PG, et al: Human
papillomavirus infection in men who have sex with men participating in a
Dutch gay-cohort study. Sex Transm Dis, 2003;30(8):639-44.
5. Johnson LG, Madeleine MM, Newcomer LM, et al: Anal cancer
incidence and survival: the surveillance, epidemiology, and end results
experience, 1973-2000. Cancer, 2004 15;101(2):281-8.
6. Frisch M: On the etiology of anal squamous carcinoma. Dan Med
Bull, 2002;49(3):194-209.
7. Chang GJ, Berry JM, Jay N, et al: Surgical treatment of high-grade
anal squamous intraepithelial lesions: a prospective study. Dis Colon
Rectum, 2002;45(4):453-8.
Ogilvie et al. have published a well-designed meta-analysis of the
diagnostic accuracy of self collected vaginal specimens for human
papillomavirus (HPV) detection, in which they conclude that self-sampling
may be an appropriate alternative for low resource settings or in patients
reluctant to undergo pelvic examinations.[1] However, we have a number of
remarks on the pooled sensitivities and specificit...
Ogilvie et al. have published a well-designed meta-analysis of the
diagnostic accuracy of self collected vaginal specimens for human
papillomavirus (HPV) detection, in which they conclude that self-sampling
may be an appropriate alternative for low resource settings or in patients
reluctant to undergo pelvic examinations.[1] However, we have a number of
remarks on the pooled sensitivities and specificities they present.
First, it is not an optimal strategy to choose clinician-collected vaginal
specimens as the reference standard to compare self-sampled specimens to,
since it is the concordance of self-sampling with presence of HPV-DNA in
the cervical epithelium which determines the usefulness of vaginal
sampling as a screening test for cervical cancer. It would have been more
accurate to assess sensitivity and specificity compared to a cervical
specimen, sampled in a standardized way by a clinician, as the golden
standard.
Second, if guidelines for self-sampling are made, the accuracy of HPV-
detection in a single sample must be maximized. A number of factors that
may affect detection of HPV have been suggested in literature and are
currently under further investigation. Short term fluctuations in
prevalence of HPV within the menstrual cycle have been described.[2]
Hormonal fluctuations within a menstrual cycle may affect HPV detection
since progesterone causes deeper exfoliation of cervical and vaginal
epithelium, where HPV assemblance takes place, whereas estrogens promote
exfoliation of only the superficial layers, which does not allow
maturation of the parabasal cells that is required for HPV assembly and
release.[3,4]
Furthermore, vaginal penetration by coitus [4] could mechanically remove
HPV infected cells, as could hygienic tampon use or vaginal douching. In
case of unprotected intercourse, false positive tests could result from
detecting HPV-DNA from the male partner.[4] Few empirical data confirm
the latter theoretical considerations so far. It has been insufficiently examined
to what extent vaginal lubricants, spermicidal cream or other intimate
products, or even antibiotics, which affect the vaginal micro-climate or pH,
could have an impact on HPV detection.
Finally, we observed in a small study that recent vaginal infections
resulted in discordance of HPV detection between vaginal and cervical
samples.[5] Indeed, it is conceivable that a vaginal infection speeds up
the discharge of exfoliated (HPV-infected) cervical cells, thereby
shortening the period of time these cells are present in the vagina.
It is clear that at least some of these factors will affect sensitivity
and/or specificity of vaginal self-sampling, and it is advisable to
establish their effect on accuracy of vaginal sampling before practice
recommendations are made.
References
1. Ogilvie GS, Patrick DM, Schulzer M, Sellors JW, et al. Diagnostic
accuracy of self collected vaginal specimens for human papillomavirus
compared to clinician collected human papillomavirus specimens: a meta-
analysis. Sex Transm Infect 2005;81:207-12.
2. van Ham MA, Melchers WJ, Hanselaar AG, Bekkers RL, et al. Fluctuations
in prevalence of cervical human papillomavirus in women frequently sampled
during a single menstrual cycle. Br J Cancer 2002;87:373-6.
3. Ferenczy A, Wright TC Jr. Anatomy and histology of the cervix. In:
Kurman R, ed. Blaustein’s Pathology of the female genital tract. 5th ed.
New York, NY: Springer; 2002.
4. Harper DM, Longacre MR, Noll WW, Belloni DR, Cole BF. Factors
affecting the detection rate of human papillomavirus. Ann Fam Med.
2003;1:221-7.
5. Baay M, Verhoeven V, Wouters K, Lardon F, et al. The prevalence of the
human papillomavirus in cervix and vagina in low-risk and high-risk
populations. Scand J Infect Dis 2004; 36:456-9.
Dear Editor
Mullick, Watson-Jones, Beksinska and Mabey1 have done a great job in summarising the approaches for treatment and control as well as the prevalence and impact of STIs in pregnancy in developing countries. Among the approaches cited is the contact tracing or partner notification as an integral part of STIs control.
Coincidentally we read this article after we discussed cultural sexual prac...
Dear Editor,
We read with interest the paper by Brown and Peerapatanapokin regarding estimated condom use rate required to control the HIV epidemic in Thailand.[1] Their Asian Epidemic Model predicts that a sustained high condom use rate (85% or more) among sexual workers is required to control the HIV epidemic. If the condom use rate drops to 60%, their model predicts a resurgence of the HIV epidemic.[1] We reac...
Dear Editor,
Syphilis has long been an important risk factor for adverse pregnancy outcome. According to Mullick et al.[1] maternal syphilis is still a major cause of morbidity and mortality in developing countries. Since there has been a resurgence of syphilis in many developed countries[2], women requiring treatment for syphilis during pregnancy are expected to increase in the United States and Western Europe. In...
Dear Editor,
We read with interest the paper by Sadiq et al. on CD4 counts and viral loads in patients with early syphilis and HIV.[1] We note that they treated their patients with a single 2.4 MU injection or two weeks of oral doxycycline. In this regard they are in good company.[2]
Whereas most patients with HIV and early syphilis make a full recovery on this regimen, there are numerous case reports of...
Dear Editor,
We read with interest the article “Improvement in the clinical cure rate of outpatient management of pelvic inflammatory disease following a change in the therapy”.[1]
In most GUM clinics gonorrhoea is identified by microscopy (x 1000) of Gram stained genital specimens (sensitivity 20%- 51%)[2] and culture (sensitivity 75%-95%).[3] In the above study gonorrhoea was identified in 12% of c...
Dear Editor,
The engaging editorial by Cassell and Low (STI 2005 Aug; 81(4):285-6) is timely and highlights a critical issue in the debate about the effectiveness of screening as an intervention for genital chlamydial infection. The authors correctly note that ecologic studies are limited in their inference but have a role to play in suggesting areas for further research. The authors hypothesize that targeting only...
Dear Editor
Replicating methods and comparing results across studies are critical for the resolution of scientific controversies. In a recent report, Niccolai et al. demonstrated that condoms were effective in preventing chlamydia among STD clinic patients with known exposure to C. trachomatis.(1) We were pleased to see the authors apply the methodology that we first presented for estimating condom effectiveness...
Dear Editor,
Fleiss et al. make several dubious claims in their article [1], but one is of particular interest. Some authors have now begun to rely upon the assertion that the subpreputial wetness contains lysozyme, and suggest that this may help to protect against HIV.[2,3] Although the epidemiological evidence suggests otherwise,2 our understanding of the mechanisms involved is important, and this claim is wo...
Dear Editor,
We read with interest the Fox PA et al. paper (2005, 81;142-6) and welcome the clinical attention to genital pre-cancerous conditions; including Anal Intraepithelial Neoplasia (AIN).
Their finding of no correlation between high-risk (hr) HPV genotypes and histological or cytological grades of abnormalities, conflicts strongly with general consensus and other studies. Kreuter A et al. identified hr H...
Dear Editor,
Ogilvie et al. have published a well-designed meta-analysis of the diagnostic accuracy of self collected vaginal specimens for human papillomavirus (HPV) detection, in which they conclude that self-sampling may be an appropriate alternative for low resource settings or in patients reluctant to undergo pelvic examinations.[1] However, we have a number of remarks on the pooled sensitivities and specificit...
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