This report confirms that PID can be often be missed clinically. Other than lowering the threshold for diagnosis, there could be other ways of improving diagnosis of PID. Training background may have contributed to the different rate of diagnosis among doctors. It would be important to review whether high diagnosing doctors were more
likely to have had gynaecology training compared with low diagnosing d...
This report confirms that PID can be often be missed clinically. Other than lowering the threshold for diagnosis, there could be other ways of improving diagnosis of PID. Training background may have contributed to the different rate of diagnosis among doctors. It would be important to review whether high diagnosing doctors were more
likely to have had gynaecology training compared with low diagnosing doctors. Similarly, was there any difference in the gender among high versus low diagnosing doctors?
In response to M O Ramogi on 21st August 2008, it is important to point out that since only patients attending with a new episode were included in the study, those experiencing chronic/recurrent infections or attending solely for treatment were excluded. Therefore the inclusion of patients for who HIV testing is less applicable is unlikely to be the explanation for the association between symptoms of an STI...
In response to M O Ramogi on 21st August 2008, it is important to point out that since only patients attending with a new episode were included in the study, those experiencing chronic/recurrent infections or attending solely for treatment were excluded. Therefore the inclusion of patients for who HIV testing is less applicable is unlikely to be the explanation for the association between symptoms of an STI and a decrease in the likelihood of being offered an HIV test.
With regard to point of care testing (POCT), while anxiety may play a part in the demand from patients for POCT there is evidence that POCT does attract a higher risk population and may lead to an increase in the number
of new HIV diagnoses(1). In a study conducted in Amsterdam average HIV prevalence among MSM receiving one-hour testing with result was 5.2% compared with 3.8% among the control group: those testing with a standard one-week wait. Similar results were found for heterosexuals. In another study among a high risk population utilising a rapid community outreach HIV testing clinic in London, 54% said they would not have tested if a rapid test had not been available(2). Also in London, a recent questionnaire based study found that 51% of high risk patients who declined HIV testing
said they would be more likely to test if POCT was available(3).
In response to M Pammi et al on 16th September 2008, one third of patients reporting a dislike of needles as the reason for declining an HIV test is considerably higher than found in our study. The second most common reason is having “checked recently”. Whether this is truly
reflective of differences in testing among heterosexuals compared with men who have sex with men, or specific to the locality where the study was done, is an interesting point. About two thirds of the patients in the Pammi study gave at least one response that would allow them to be divided
into those who should be tested at the current visit and those who don’t need to be, with those who have recently tested in the latter group. But what to do about those claiming a dislike for needles? Since all respondents in clinics C and D reported one or more reasons for not
testing, is it possible that a dislike of needles is a secondary reason, one not associated with the sensitive issue of actual or perceived risk of HIV exposure? Was there consistency between needle phobia and having
tested before, i.e. none of those reporting needle phobia had tested previously? It would also be interesting to know whether those stating that they have had a recent check have indeed done so within the last 3 months and if they know their status. Of note is the variation even between the two clinics in the proportion who perceived themselves at risk for HIV (the proportion was more than 3-fold higher in clinic U), and in the proportion who were in the window period and who had tested recently (both also higher in clinic U). Does this reflect a difference in the
sexual orientation or the sexual behaviour of the two samples, or merely highlight difficulty in ascertaining valid reasons for not testing? Patients’ reasons for not HIV testing are likely to be an unreliable measure on which to base HIV testing policy recommendations.
With regard to testing within the window period, it is important to note that not testing due to the window in our study was clinician as well as patient driven, which may help explain the higher proportion. In addition, consideration of the window period due to repeat risk may be more relevant to MSM populations than heterosexuals.
References
1. C L J Van Loon, W M E Koevoets. Rapid HIV testing in a one-hour
procedure motivates MSM in the Netherlands to take the test. Oral Abstract
session: The XV International AIDS Conference: Abstract no. TuOrC1197.
2. R Grimes, P Weatherburn, R Mugezi, A Wilkinson, A K Sullivan.
Know4sure: who comes to a rapid HIV testing outreach clinic and why?
Sexually Transmitted Infections 2006;82(Supplement 2 ): P69.
3. S F Forsyth, E A Agogo, L Lau, E Jungmann, S Man, S G Edwards, A J
Robinson. Would offering rapid point-of-care testing or non-invasive
methods improve uptake of HIV testing among high-risk genitourinary
medicine clinic attendees? A patient perspective. Int J STD AIDS 2008;19:
550-552.
Thank you for responding to our manuscript. We have carefully reviewed your comments. Below, please find our responses to the questions raised.
The first comment raised concerns the fact that “sexual factors may have played a lesser role in observed HIV and syphilis prevalence’s than nonsexual factors.”
The sexual transmission of sexually transmitted infections including HI...
Thank you for responding to our manuscript. We have carefully reviewed your comments. Below, please find our responses to the questions raised.
The first comment raised concerns the fact that “sexual factors may have played a lesser role in observed HIV and syphilis prevalence’s than nonsexual factors.”
The sexual transmission of sexually transmitted infections including HIV-1 is a significant risk factor of HIV-1 acquisition in female sex workers and men who have sex with men (MSM), and has been related to HIV-1 acquisition in preliminary analyses from our incidence cohort [1,2]. You
note that the discrepancy between the relationship we found between syphilis and receptive anal intercourse (RAI) and between prevalent HIV-1 and recent RAI among the women is a “red flag.” Please note that our point estimate for the odds of HIV-1 infection among women admitting recent RAI
is 1.2, and has a 95% confidence interval compatible with odds ranging from 0.5 to 2.5. The association between prevalent syphilis on enrolment and recent RAI was based on only 11 cases in women, and the importance of
this finding should not be exaggerated.
Your suggestion that the treponemal disease we have diagnosed in our female sex workers is not syphilis, but rather another treponemal species, is intriguing but very unlikely. Pinta is limited to the Americas, and
endemic syphilis (bejel) is not found in Kenya [3]. Yaws is very uncommon in Kenya [3], and we have seen none of the chronic skin or bone lesions typical of this infection in our clinic population. Other spirochetal illnesses that can lead to positive nontreponemal and treponemal tests
(e.g. relapsing fever, rat-bite fever) are also uncommon and were unsuspected in the clinical context [4]. A non-specific test such as the RPR, followed by a specific treponemal test (TPHA) is the commonly accepted means of diagnosing syphilis [5]. At the same time, syphilis is
the most likely diagnosis in these sexually active young women [6].
Your remark that we did not assess nonsexual (blood) exposures is true, since the focus of this article was on screening for sexually transmitted genital and anorectal infections. While some HIV infections we diagnosed at enrolment into our study population may be due to unsafe
injections, including injection drug use, the prevalence of injection drug use in our population is only 1.4% among MSM [2] and was not reported among women. In a prevalence study, history of any medical injection is not useful because lifetime exposure is very common. Having received a
medical injection in the 3 months preceding enrolment was reported by an equal proportion of HIV negative and positive women (35 vs. 36%). We have included data collection on both injection drug use and a number of other
non-sexual exposures (medical injections, blood transfusion, traditional practices) in our ongoing study of incident HIV-1 infections in this cohort, and hope that your curiosity regarding this factor will be
satisfied in an upcoming publication.
The second remark concerns the fact that “a strong association between anal sex and prostitution might mask the association between anal sex and prevalent HIV-1 in female participants in our cohort”. It is correct that the majority of women (89%) reporting recent RAI,
identified themselves as sex workers. We have also included this in our paper in section ‘results’, in the paragraph on RAI. Please note that table 4 presenting associations between prevalent HIV-1 and RAI are adjusted for age, transactional sex, partner numbers, and unprotected sex.
Finally, a remark was made on the fact that “unprotected receptive anal intercourse is probably not confined to high-risk persons and that broader community prevention messages might more usefully fit overall HIV
prevention objectives.” We agree on the importance of addressing unprotected (receptive) anal
intercourse as a potential risk factor for HIV-1 transmission. We did not mean to imply that this was not important on a population level, but meant
to highlight the urgency of addressing this risk in a targeted setting such as ours.
We trust these answers have addressed the concerns you have raised.
Sincerely,
Marlous Grijsen, MD,
Susan Graham, MD MPH,
Eduard Sanders, MD PhD.
References
1. Grijsen ML, Graham SM, Mwangome M, et al. Screening for genital and anorectal sexually transmitted infections in HIV prevention trials in
Africa. Sex Transm Inf (doi: 10.1136/sti2007.028852)
2. Sanders EJ, Graham SM, Okuku HS, et al. HIV-1 infection in high risk men who have sex with men in Mombasa, Kenya. AIDS 2007;21: 2513-20.
3. Meheus A, Antal GM. The endemic treponematoses: not yet eradicated. World Health Stat Q. 1992;45(2-3): 228-37.
4. Mandell GL, Bennett JE, Dolin R. Principles and practice of infectious diseases. 6th edn. Philadelphia, Pa.: Elsevier Churchill Livingstone; 2005.
5. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2006. MMWR 2006;55(RR-11): 1-94.
6. Holmes KK, Sparling PF, Stamm WE, et al. Sexually transmitted diseases. 4th edn. New York: the McGraw-Hill Companies; 2008.
Although the uptake of the HIV test has increased significantly in recent years, following the introduction of opt-out screening programmes, there is still a substantial number of the HIV population that is still
undiagnosed.1 Therefore, we read with interest the National study of HIV testing in men who have sex with men attending genitourinary clinics in the United Kingdom by H L Munro et el.2 This st...
Although the uptake of the HIV test has increased significantly in recent years, following the introduction of opt-out screening programmes, there is still a substantial number of the HIV population that is still
undiagnosed.1 Therefore, we read with interest the National study of HIV testing in men who have sex with men attending genitourinary clinics in the United Kingdom by H L Munro et el.2 This study focussed on men who have sex with men (MSM) and identified that the most common reason for declining an HIV test was a potential exposure within the three month window period.
We report on a different group of patients, predominantly heterosexual (97%), in whom we conducted a questionnaire survey on the reasons for declining an HIV test. Our study was conducted in two genitourinary medicine clinics over a 10 week period. One clinic was in
based in a University City (Nottingham, Clinic U) and one clinic was based in an urban/semi rural area (Sutton-in-Ashfield, Clinic D). All patients attending the clinics who declined an HIV test were asked to complete a
self-administered questionnaire.
During the study period, 3172 and 1050 new or re-book patients attended Clinic U and Clinic D, respectively, of which 417 (13%) and 211 (20%) declined HIV testing. A total of 231 and 156 questionnaires were filled in by Clinic U and Clinic D respectively. Individuals gave one or
more reasons for declining the test(see Table 1).
In our study the reasons for declining HIV testing in different conurbations and populations appear to be similar in many aspects, for example needle-dislike, regular partner, blood donor. However, variations were seen in relation to result-perception, result-concerns and recent
test history, which indicates the importance of local factors. Unlike Munro et al.2, we identified only 3-6% of individuals who declined an HIV test for reasons related to the window period. This indicates that the reasons for declining an HIV may also differ according to sexual
orientation.
The uptake of HIV testing is a major objective of national strategies across the United Kingdom, with the aim of reducing the undiagnosed disease burden. It would appear that different approaches to encouraging
HIV testing may be required to enable this, taking into account the patient’s sexual orientation and local factors.
References
1. www.hpa.org.uk
2. Munro HL, Lowndes CM, Daniels D et al. National study of HIV testing in men who have sex with men attending genitourinary clinics in the United Kingdom.
Sex Transm Dis 2008; 84: 265-70.
In supporting Colm O’Mahony’s editorial (1), I would like to amplify Karen Rogstad’s concern (2) about the unwitting creation of a two-tier healthcare system for HPV vaccination and the social discord which will inevitably result from the Government’s decision.
Any well-informed parent of sufficient means would want to protect their children against genital warts, so their daughters will necessa...
In supporting Colm O’Mahony’s editorial (1), I would like to amplify Karen Rogstad’s concern (2) about the unwitting creation of a two-tier healthcare system for HPV vaccination and the social discord which will inevitably result from the Government’s decision.
Any well-informed parent of sufficient means would want to protect their children against genital warts, so their daughters will necessarily be involved in the process of obtaining a private prescription for the quadrivalent vaccine: Yet other girls may feel that they have been short-
changed, so this could give rise to a nastier kind of humiliating taunting in the playground, targeted at children of the poor, the ignorant and/or the religiose, thus further exacerbating social class and cultural divisions in schools.
Parents will seek advice, and directly request the vaccine, from their GP. Similar to O’Mahony’s experience, I have yet to meet a GP or other doctor who would chose Cervarix instead of Gardasil for their own children. Thus, on grounds of striving to prevent harm and treating people
with equity, it could be construed as unethical if GPs did not advise parents and their children of the additional benefits of the quadrivalent vaccine.
We must also consider the clinical circumstances where there should be a clear indication for recommending Gardasil instead of Cervarix: Certain children are likely to have a much higher than average risk of suffering from intractable genital warts shortly after sexual debut, as they have conditions where immunity is compromised in a predictably known, therapeutic or idiopathic fashion (categories A-C), and there are others in whom overt genital warts would be especially inconvenient as they have dermatological conditions which may affect genital skin (category D) eg:
A. Type 1 Diabetes, HIV, Primary Immunodeficiency Syndromes (3)
B. Childhood Leukaemias, Juvenile Rheumatoid Arthritis etc
C. History of (or currently extensive) verrucae, hand warts, or recurrent respiratory papillomatosis
D. Psoriasis, Eczema, Lichen Sclerosis etc.
I would be interested to hear from colleagues who have any other conditions or categories to add to the above list.
References
1. O'Mahony C. Government decision on national human papillomavirus vaccine programme is a sad day for sexual health. Sex Transm Infect 2008; 84: 251
2. Rogstad KE. HPV vaccine programme- Increasing inequality in adolescent's sexual health?
STI online (15 August 2008)
An interesting finding in this study was the association between having STI symptoms and less chance of being offered HIV test as compared with the patients with no STI symptoms. However the study fails to describe what symptoms these patients might have had. One explanation could be that
these patients had chronic recurrent symptoms like genital herpes, chronic non specific urethritis or genital warts an...
An interesting finding in this study was the association between having STI symptoms and less chance of being offered HIV test as compared with the patients with no STI symptoms. However the study fails to describe what symptoms these patients might have had. One explanation could be that
these patients had chronic recurrent symptoms like genital herpes, chronic non specific urethritis or genital warts and they were attending clinic for treatments only. It's possible that they did not have new risk factors to warrant any repeat HIV testing.
Secondly regarding whether HIV POC test would be of cost benefit use in GUM setting,its mainly low HIV risk patients with HIV anxiety who are likely to opt for POCT HIV testing in preference of standard HIV testing. Hence while it may increase uptake of HIV test in a certain group of patients attending GUM clinic, there is little evidence to prove that
this will lead to increase in new HIV diagnosis in GUM clinic setting.
When Dr O’Mahony gets round to reading my letter properly he will see that I did not express scepticism about deriving benefit from the addition of HPV types 6 and 11 to types 16 and 18 in the immunization programme. I stated that I know of no evidence that the addition would help in
preventing carcinoma of the cervix. Dr O’Mahony might believe that the immunization programme is about HPV immunization...
When Dr O’Mahony gets round to reading my letter properly he will see that I did not express scepticism about deriving benefit from the addition of HPV types 6 and 11 to types 16 and 18 in the immunization programme. I stated that I know of no evidence that the addition would help in
preventing carcinoma of the cervix. Dr O’Mahony might believe that the immunization programme is about HPV immunization and not cervical cancer but the Green Book states that the objective of the immunization programme
addresses a subsequent risk of cervical cancer 1 and the same Public Health Minister, Dawn Primarolo, stated that the “policy to vaccinate girls against cervical cancer is one of the biggest public health campaigns in recent history.” 2 If the programme were about HPV vaccination, then for every person included in the programme there would be another who could complain about his exclusion on the grounds of his
sex.
Although I think that Dr O’Mahony’s editorial was poor and had no place in a journal that pretends to be scientific, I do not object to him expressing his opinion. However I do object to him extending his opinion to “all of us working in sexual health”. Dr O’Mahony’s reply to my letter suggests that his survey of those working in sexual health did not permit such an extension.
Perhaps those of us working in sexual health need to bear in mind that the immunization programme is aimed at all females of a certain age and not just those females who attend genito-urinary medicine clinics with a first attack of genital warts. Evidence-based medicine can not divorce
itself from cost-effectiveness. 3 Dawn Primarolo is quoted as saying, “By choosing the right vaccine we have been able to make savings which means we can extend the programme to 17 and 18 year olds. This could save an additional 400 lives." 2 Someone had to decide whether it was better to
save a potential 400 lives or prevent an unknown number of cases of genital warts.
O'Mahony's editorial (1) reflects the concern I and others specialising in STIs in young people have about the decision not to vaccinate girls and young women against genital warts types 6 and 11. Others have commented on the biological, psychosocial and cost issues of
external genital warts, and I will not re-iterate these (2,3,4). What has been ignored is that at a time when government is trying to red...
O'Mahony's editorial (1) reflects the concern I and others specialising in STIs in young people have about the decision not to vaccinate girls and young women against genital warts types 6 and 11. Others have commented on the biological, psychosocial and cost issues of
external genital warts, and I will not re-iterate these (2,3,4). What has been ignored is that at a time when government is trying to reduce health inequalities according to social class, the decision to use Cervarix rather than Gardasil for the vaccination programme is almost certainly
likely to increase them.
Most STIs are known to be more prevalent in areas of social deprivation, and to predominantly affect the young, with 55% of genital warts being in young people aged 16-24 (5). O'Mahony has provided the first published evidence of Medical Practitioners in England choosing to pay for the vaccine that will protect their children against a stigmatising and distressing condition. However
the cost of the vaccine for the children of those parents in receipt of benefits or on low incomes is beyond their reach. Health Practitioners are in the impossible position of delivering one vaccine to patients whilst they are recommending another to those who can afford it.
Specialists in Sexually Transmitted Infections care for some of the poorest members of society. We are already aware of the burden of deprivation in these young people with regards to poor housing or homelessness, low educational attainment, drug and alcohol abuse, teenage pregnancies and exploitation. To this will be added the additional burden
of no protection against a preventable STI whilst their peers, whose parents can pay, will also be spared the burden of genital warts.
This potential for health inequality should be monitored. Additionally, consideration should be given to offering vaccination with Gardasil in the catch up programme to young attendees at sexual health clinics, as they are known to be a vulnerable group and at high risk for
STIs.
Competing interests. Advisory work for Sanofi Pasteur and Glaxo SmithKline.
References
1. Colm O'Mahony Government decision on national human papillomavirus vaccine programme is a sad day for sexual health Sex Transm Infect 2008; 84: 251
2. Christopher Sonnex, Immy Ahmed Government decision on national human papillomavirus vaccine programme is a sad day for sexual health
STI online (13 August 2008)
3. Kim JJ. Human papillomavirus vaccination in the UK. BMJ 2008;337:a842
4. Jit M, Choi YH, Edmunds WJ. Economic evaluation of human papillomavirus vaccination in the United Kingdom. BMJ 2008;337:a769
5. Sexually Transmitted Infections and Young People in the United Kingdom: 2008 Report Health protection Agency July 2008 www.hpa.org.uk
I have read the editorial from Dr O’Mahony and the comment from Dr Watson with interest. It may be helpful in this discussion to note that the criteria for selection of an HPV vaccine were spelt out by the Minister Dawn Primarolo on the 2cd of July 2008 in response to a Parliamentary question and is detailed in Hansard
http://www.parliament.the-stationery-office.co.uk/pa/cm200708/cmhansrd/cm080702/text/...
I have read the editorial from Dr O’Mahony and the comment from Dr Watson with interest. It may be helpful in this discussion to note that the criteria for selection of an HPV vaccine were spelt out by the Minister Dawn Primarolo on the 2cd of July 2008 in response to a Parliamentary question and is detailed in Hansard
http://www.parliament.the-stationery-office.co.uk/pa/cm200708/cmhansrd/cm080702/text/80702w0013.htm
It is clear from this that the decisions were not based exclusively on potential effects on HPV 16 and HPV 18 associated cervical disease but also considered the contribution of the low risk types HPV 6 and 11 to
genital disease in women. An analysis of the published literature shows clearly that in the large Phase III trial HPV6/11 related external genital warts and cervical, vulval, vaginal disease was 100% prevented over a 3
year period by immunization with a vaccine containing HPV6/11 L1 VLPs (1 Garland et al 2007). Furthermore the published literature (2 Paavonen et al 2007 3 Ault 2007) if analysed objectively, indicates that there is that
there is no difference between the two commercially available vaccines, in terms of efficacy, against HPV 16 or 18 caused high grade cervical intra-epithelial neoplasia (CIN2/3) the surrogate end point for cervical cancer in the trials.
The quadrivalent vaccine had an advantage from the public health perspective of significantly reducing a common sexually transmitted disease, genital warts, and this was reflected in the cost effectiveness analyses undertaken by the Health Protection Agency and others (4 Jit et al
2008, 5 Kulasingam et al 2008). Cost effectiveness is a critical part of health programmes particularly in the context of vaccine policy (6 Kinman et al 2006). A recent publication in the BMJ (4 Jit et al 2008) described
cost effectiveness models that show the price differential, £13-£ 21 less per dose, that would need to exist for the bivalent vaccine to be as cost effective as the quadrivalent and indeed the cost price of the vaccine was, very sensibly, one of the criteria employed by the Government and its
advisers. In view of all this it does suggest that the decision to buy Cervarix rather than Gardasil was not, as Dr Watson thinks, based entirely on evidence based medicine but that cost was an important, possibly
crucial factor.
References
1. Garland, S et al. N Engl J Med 2007;356:1928-43.
2. Paavonen, J et al. Lancet 2007;369:2161-70
3. Ault, KA. Lancet 2007;369:1861-8.
4. Jit, M et al. BMJ 2008;337:a769
5. Kulasingam S et al. Cost Effectiveness and Resource Allocation 2008;6:4
The points made by Dr O’Mahony in response to the government’s decision to support a bivalent HPV 16/18 prophylactic vaccine in preference to a quadrivalent HPV 6/11/16/18 vaccine are well made and will be appreciated by practitioners managing the wide spectrum of ano-genital
HPV disease.1 The British Association for Sexual Health and HIV (BASHH) has already expressed concerns with respect to the clinica...
The points made by Dr O’Mahony in response to the government’s decision to support a bivalent HPV 16/18 prophylactic vaccine in preference to a quadrivalent HPV 6/11/16/18 vaccine are well made and will be appreciated by practitioners managing the wide spectrum of ano-genital
HPV disease.1 The British Association for Sexual Health and HIV (BASHH) has already expressed concerns with respect to the clinical, psychological and financial implications of HPV 6 and 11 infection. An editorial and article in the British Medical Journal have recently shed light on the
financial reasoning behind a decision seemingly at odds with clinical sense.2,3
Parents and adolescents, in particular, should be made aware of the two available vaccines and of the clinical problems associated with HPV 6,11, 16 and 18 infection. Some parents may subsequently want their daughters protected against genital warts and low grade cervical dysplasia
associated with HPV 6 and 11 infection, in addition to HPV 16 and 18 associated cervical cancer. One suspects this would require opting out of the national HPV vaccination programme and self-payment for the quadrivalent vaccine. This should lead to interesting discussion.
Competing Interests: CS has received lecture fees from Sanofi Pasteur MSD
References
1. O’Mahony C. Government decision on national human papillomavirus vaccine programme is a sad day for sexual health. Sex Transm Infect 2008;84:251
2. Kim JJ. Human papillomavirus vaccination in the UK. BMJ 2008;337:a842
3. Jit M, Choi YH, Edmunds WJ. Economic evaluation of human papillomavirus vaccination in the United Kingdom.
BMJ 2008;337:a769
Chris Sonnex
Chair BASHH HPV Special Interest Group
Department of GU Medicine,
Addenbrooke’s Hospital
Cambridge University Hospitals NHS Foundation Trust
Cambridge CB2 2QQ
Immy Ahmed
President, British Association for Sexual Health and HIV
Dept of GU Medicine
Nottingham University Hospitals
Nottingham City Hospital
Nottingham NG5 1PB
Dear Editor,
This report confirms that PID can be often be missed clinically. Other than lowering the threshold for diagnosis, there could be other ways of improving diagnosis of PID. Training background may have contributed to the different rate of diagnosis among doctors. It would be important to review whether high diagnosing doctors were more likely to have had gynaecology training compared with low diagnosing d...
Dear Editor,
In response to M O Ramogi on 21st August 2008, it is important to point out that since only patients attending with a new episode were included in the study, those experiencing chronic/recurrent infections or attending solely for treatment were excluded. Therefore the inclusion of patients for who HIV testing is less applicable is unlikely to be the explanation for the association between symptoms of an STI...
Dear Dr. Potterat and colleagues,
Thank you for responding to our manuscript. We have carefully reviewed your comments. Below, please find our responses to the questions raised.
The first comment raised concerns the fact that “sexual factors may have played a lesser role in observed HIV and syphilis prevalence’s than nonsexual factors.” The sexual transmission of sexually transmitted infections including HI...
Dear Editor,
Although the uptake of the HIV test has increased significantly in recent years, following the introduction of opt-out screening programmes, there is still a substantial number of the HIV population that is still undiagnosed.1 Therefore, we read with interest the National study of HIV testing in men who have sex with men attending genitourinary clinics in the United Kingdom by H L Munro et el.2 This st...
Dear Editor,
In supporting Colm O’Mahony’s editorial (1), I would like to amplify Karen Rogstad’s concern (2) about the unwitting creation of a two-tier healthcare system for HPV vaccination and the social discord which will inevitably result from the Government’s decision.
Any well-informed parent of sufficient means would want to protect their children against genital warts, so their daughters will necessa...
Dear Editor,
An interesting finding in this study was the association between having STI symptoms and less chance of being offered HIV test as compared with the patients with no STI symptoms. However the study fails to describe what symptoms these patients might have had. One explanation could be that these patients had chronic recurrent symptoms like genital herpes, chronic non specific urethritis or genital warts an...
Dear Editor,
When Dr O’Mahony gets round to reading my letter properly he will see that I did not express scepticism about deriving benefit from the addition of HPV types 6 and 11 to types 16 and 18 in the immunization programme. I stated that I know of no evidence that the addition would help in preventing carcinoma of the cervix. Dr O’Mahony might believe that the immunization programme is about HPV immunization...
Dear Editor,
O'Mahony's editorial (1) reflects the concern I and others specialising in STIs in young people have about the decision not to vaccinate girls and young women against genital warts types 6 and 11. Others have commented on the biological, psychosocial and cost issues of external genital warts, and I will not re-iterate these (2,3,4). What has been ignored is that at a time when government is trying to red...
Dear Editor,
I have read the editorial from Dr O’Mahony and the comment from Dr Watson with interest. It may be helpful in this discussion to note that the criteria for selection of an HPV vaccine were spelt out by the Minister Dawn Primarolo on the 2cd of July 2008 in response to a Parliamentary question and is detailed in Hansard http://www.parliament.the-stationery-office.co.uk/pa/cm200708/cmhansrd/cm080702/text/...
Dear Editor,
The points made by Dr O’Mahony in response to the government’s decision to support a bivalent HPV 16/18 prophylactic vaccine in preference to a quadrivalent HPV 6/11/16/18 vaccine are well made and will be appreciated by practitioners managing the wide spectrum of ano-genital HPV disease.1 The British Association for Sexual Health and HIV (BASHH) has already expressed concerns with respect to the clinica...
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