Gaydos1 highlights the barriers to discussing sexual health issues
openly and teenagers' lack of awareness of the high prevalence of STIs and
potential adverse reproductive sequelae. Addressing these barriers is one
solution to the 'Hidden Epidemic' of STIs. In the UK as in the USA, STI
rates remain highest among sexually active teenagers, particularly those
from deprived inner city areas and black ethnic minority groups....
Gaydos1 highlights the barriers to discussing sexual health issues
openly and teenagers' lack of awareness of the high prevalence of STIs and
potential adverse reproductive sequelae. Addressing these barriers is one
solution to the 'Hidden Epidemic' of STIs. In the UK as in the USA, STI
rates remain highest among sexually active teenagers, particularly those
from deprived inner city areas and black ethnic minority groups.2 Ensuring
a high standard of Sex and Relationships Education (SRE) may contribute to
reducing risky sexual behaviour.3
During December 2010 for a medical student research project, we
conducted a cross-sectional questionnaire survey to investigate high-risk
teenagers' experience of SRE. Consecutive male and female patients aged
14-19 years attending Adolescent Genito-Urinary Medicine Clinics in
Wandsworth, South London were asked to complete a questionnaire survey on
their experience of SRE at school. The questionnaire asked if they had
received SRE, the topics covered, timings, perceptions of SRE and where
sexual health information was accessed. Data were entered and analysed
using SPSS.
The response rate was 94% (97/103). The mean age of responders was 16
years (range 14-19), and 69% were female. Of 97 responders, 41% described
their ethnicity as white, 49% black and 10% as other ethnic group.
Although 99% had received SRE at school, 69% said the quality of SRE was
average or poor. Median age at first SRE in school was 11 years (range 5-
16). Teenagers reported a desire to be taught earlier (by aged 12) about
menstruation, teenage pregnancy, STIs, HIV and relationships. The
biological topics, menstruation, contraception and STIs were found the
most useful at school, but 30% said they were not taught about emergency
contraception. Sexual health clinics, school lessons and friends were the
main sources of sexual health information (91%, 77% and 74%,
respectively). Only 30% felt comfortable accessing information from
school. Over half the respondents accessed the media and internet which
may not be reliable.
This survey found that most of these high risk, sexually active
teenagers had received some SRE, but the standard was inconsistent and
often too late. It suggests that in the UK, SRE should be taught as a
statutory part of the national curriculum. We agree with Gaydos that
special education tools such as effective SRE are needed to tackle the
epidemic of STIs. In Holland SRE starts at the age of five and the country
has the lowest teenage pregnancy rate in Europe.4 Providing SRE earlier at
school backed up by easily accessible information from sexual health
clinics might help to decrease STI rates among teenagers in the UK, North
America and elsewhere.
Aneeta Kaneshanathan, Katia Prime, Phillip E Hay and Pippa Oakeshott
ACKNOWLEDGEMENTS
We thank staff at Courtyard Clinic, St George's Hospital London - Wendy
Majewska and Charlotte Jackson for their help with this project.
Population Health Sciences and Education, St George's University of
London, London, SW17 ORE, UK
Correspondence to: A Kaneshanathan
Email: m0700538@sgul.ac.uk
REFERENCES
1. Gaydos. STI management and control in North America IUSTI region.
Sex Transm Infect 2011;87:ii2-ii6.
2. Health Protection Agency. Acute STI diagnoses by PCT of residence,
2009 (England). Health Protection Report Vol 4 No. 34 - 27 August 2010.
3. Wellings K, Nanchahal K, Macdowall W, McManus S, Erens B, Mercer
C, Johnson A, Copas A, Korovessis C, Fenton K, Field J. Sexual behaviour
in Britain: early heterosexual experience. Lancet 2001; 358, 1843-1850.
4. UK Youth Parliament. SRE - Are you getting it? London; June 2007
STDs were commonly known as venereal diseases : Veneris is the Latin
genitive form of the name Venus , the Roman goddess of love. Social
disease was another euphemism.
Public health officials originally introduced the term sexually
transmitted infection , which clinicians are increasingly using alongside
the term sexually transmitted disease in order to distinguish it from the
former. According to Ethiopian AIDS Resourc...
STDs were commonly known as venereal diseases : Veneris is the Latin
genitive form of the name Venus , the Roman goddess of love. Social
disease was another euphemism.
Public health officials originally introduced the term sexually
transmitted infection , which clinicians are increasingly using alongside
the term sexually transmitted disease in order to distinguish it from the
former. According to Ethiopian AIDS Resource Center FAQ - Are sexually
transmitted infections (STIs) different from sexually transmitted diseases
(STDs)? , "Sometimes the terms STI and STD are used interchangeably. This
can be confusing and not always accurate, so it helps first to understand
the difference between infection and disease. Infection simply means that
a germ, virus , bacteria , or parasite that can
cause disease or sickness if present inside a person's body. An infected
person does not necessarily have any symptoms or signs that the virus or
bacteria is actually hurting his or her body; they do not necessarily feel
sick. A disease means that the infection is actually causing the infected
person to feel sick, or to notice something is wrong. For this reason, the
term STI which refers to infection with any germ that can
cause an STD, even if the infected person has no symptoms is a
much broader term than STD. " The distinction being made, however, is
closer to that between a colonization and an infection , rather than
between an infection and a disease .
Specifically, the term STD refers only to infections that are causing
symptoms . Because most of the time people do not know that they are
infected with an STD until they start showing symptoms of disease , most
people use the term STD, even though the term STI is also appropriate in
many cases.
Moreover, the term Sexually Transmissible Disease is sometimes used since
it is less restrictive in consideration of other factors or means of
transmission. For instance, meningitis is transmissible by means of sexual
contact but is not labeled as an STI because sexual contact is not the
primary vector for the pathogens that cause meningitis. This discrepancy
is addressed by the probability of infection by means other than sexual
contact . In general, an STI is an infection that has a negligible
probability of transmission by means other than sexual contact, but has a
realistic means of transmission by sexual contact (more sophisticated
means blood transfusion , sharing of hypodermic needles are not taken into account). Thus, one may presume that, if a
person is infected with an STI, e.g., chlamydia , gonorrhea , genital
herpes , it was transmitted to him/her by means of sexual contact.
The English language has short words for two of the most common: "pox" (
syphilis ) and "the clap" ( gonorrhea ).
Your recent major article by Harryman et al 1 assessed the
performance of Aptima Combo 2 (AC2) confirmed by Aptima GC (AGC) versus
culture and concluded that AC2 with AGC confirmation performed well at
genital and extra-genital sites for detection of GC. Culture with
transport swabs was found to perform poorly for asymptomatic men,
symptomatic and asymptomatic women and at extra-genital sites. The authors
conclude that c...
Your recent major article by Harryman et al 1 assessed the
performance of Aptima Combo 2 (AC2) confirmed by Aptima GC (AGC) versus
culture and concluded that AC2 with AGC confirmation performed well at
genital and extra-genital sites for detection of GC. Culture with
transport swabs was found to perform poorly for asymptomatic men,
symptomatic and asymptomatic women and at extra-genital sites. The authors
conclude that consideration should be given into how best to optimise GC
culture in settings where direct plating is not feasible.
We strongly agree with them and are pleased to find the accumulating
evidence for the performance benefits of AC2 confirmed with AGC. They
mentioned that studies by Moss et al and Lavelle et al concluded that AC2
GC positives were likely to be true positives based on culture and partner
data, but point out that both studies confirmed their positives only by
repeating the same assay. However we in our later study confirmed all GC
positives by AC2 by retesting residual sample in the AGC assay 2.
In our study we looked retrospectively at laboratory dual testing
data between August 2006 and April 2008 and reviewed case-notes of all
patients with a positive result for GC (culture or AC2 confirmed by AGC ).
Testing was at Macclesfield genitourinary medicine (GUM) clinic (3589
dual NAATS samples from 1930 females and 2470 dual NAATS sample from 1867
males) and in the corresponding community served by the 'Team Chlamydia'
office of the National Chlamydia Screening Programme (1549 male and 7934
female samples). Of the total of 15, 542 tests performed only one was
positive for GC by AC2 but unconfirmed by AGC. There was no culture
positive but AC2 negative result in any of our patients tested by both
methods. At the GUM clinic, 6 (19%) male cases and 4 (25%) female cases
would have been missed if tested only by culture. Of the 6 males, 3 were
positive at extra-genital sites (pharyngeal swabs) only.
In the community 23 young females would have gone undiagnosed and
untreated for GC infection if tested only for chlamydia infection.
The overall positivity for GC in the GUM clinic was 1.3%, the true
prevalence being 0.9% (after excluding already diagnosed cases referred
from the community and those presenting as contacts) and that in the
community was 0.4%.
Culture alone must now be considered unfit for testing asymptomatic
patients and inadequate to meet the challenge of detecting and managing
the large number of cases that are to be found outside of GUM settings 3.
Following the recent Guideline 4- that GC should always be treated with a
two antibiotic combination - GC culture may retain its importance for
survey and monitoring of changes in antibiotic-susceptibility patterns but
becomes less essential as a test for every individual patient.
Moncado et al 5 evaluated 3 of the CDC approaches for confirming GC
positive NAAT results and concluded that confirmatory testing was not
warranted for genital specimens. With our results and those of Harryman et
al and as more evidence accumulates confidence may grow that, for AC2 at
least, confirmation is unnecessary.
REFERENCES
1. Harryman L, Scofield S, Macleod J, et al. Comparative performance
of culture using swabs transported in Amies medium and the Aptima Combo2
nucleic acid amplification test in detection of Neisseria gonorrhoeae from
genital and extra-genital sites: a retrospective study. Sex Transm Infect
2011; doi;10.1136/sextrans-2011-050075
2. Mahto M, Zia S, Ritchie D, et al. Diagnosis, management and
prevalence estimation of gonorrhoea: influences of Aptima Combo 2 assay
with alternative target confirmation. International Journal of STD &
AIDS 2009;20:315-319
3. Skidmore S, Copley S, Cordwell D et al. Positive nucleic acid
amplification tests for Neisseria gonorrhoeae in young people tested as
part of the National Chlamydia Screening Programme. International Journal
of STD & AIDS 2011; 22: 398-399
4. Bignell C, FitzGerald M. UK national guideline for the management
of gonorrhoea in adults, 2011. International Journal of STD & AIDS
2011;22:541-547
5. Moncada J, Donegan E, Schachter J. Evaluation of CDC- Recommended
approaches for confirmatory testing of positive Neisseria gonorrhoeae
nucleic acid amplification test results. J Clin Microbiol 2008;46:1614-
1619.
Stephanie Dellicour 1,2,3 , Florence Diemo4, Kayla Laserson2,3, Feiko
ter Kuile1, Meghna Desai2,3
1. Child and Reproductive Health, Liverpool School of Tropical Medicine,
UK
2. Kenya Medical Research Institute (KEMRI), Center for Global Health
Research (CGHR), Kisumu, Kenya
3. Centers for Disease Control and Prevention (CDC), Atlanta, USA
4. Rarieda District Medical Officer for Health (DMOH), Nyanza Province,
Kenya
Stephanie Dellicour 1,2,3 , Florence Diemo4, Kayla Laserson2,3, Feiko
ter Kuile1, Meghna Desai2,3
1. Child and Reproductive Health, Liverpool School of Tropical Medicine,
UK
2. Kenya Medical Research Institute (KEMRI), Center for Global Health
Research (CGHR), Kisumu, Kenya
3. Centers for Disease Control and Prevention (CDC), Atlanta, USA
4. Rarieda District Medical Officer for Health (DMOH), Nyanza Province,
Kenya
We read with great interest the article by Otieno-Nyunya and
colleagues1. The authors report low prevalence of syphilis 1.8% (95% CI
1.5% to 2.1%) as detected through the Kenya AIDS Indicator Survey (KAIS)
for 2007. The authors suggest these findings indicate that elimination of
syphilis is a possibility in Kenya. They also show that syphilis testing
is common among women attending antenatal care (ANC) clinics and that
recent estimates suggest that prevalence of syphilis among pregnant women
has declined to less than 1%. Despite this success, we wish to highlight
that there may still be pockets of high syphilis prevalence in Kenya.
As part of an ongoing observational study among pregnant women
attending ANC in Asembo, Rarieda District, western Kenya, we observed an
unexpected high prevalence of syphilis of 11.5% (32/282). The study
participants are women living in 33 villages within a 5km radius of the
study health facility coming for routine antenatal care, representing the
general population in this area (i.e. not selected according to any health
related criteria). Antenatal profile laboratory tests are performed by the
facility laboratory (supplied by the Kenya Medical Supplies Agency (KEMSA)
or Mission for Essential Drugs and Supplies (MEDS)) and are available free
of charge for study participants. Overall 282 first ANC clients have been
tested for syphilis during the period between February and September 2011.
Different tests have been used during that period depending on the
supplies provided as follows: VDRL (from Euromedi Equipment LTD, UK) was
used from February to beginning of May 2011 with an associated syphilis
prevalence of 8% (11/143), treponemal only rapid test (Eurostrip from
Euromedi Equipment LTD, UK) from May to July 2011 with a prevalence of
17% (17/101) and another treponemal only rapid test (from Acon
Laboratories, USA) from August to September 2011 with a prevalence of 11%
(4/38). Note that the latter two treponemal rapid tests show higher
prevalence as these reflect both past and current infections. The
prevalence of HIV infection in this population of pregnant women is 28% by
rapid test (Determine from Alere Medical Company, Japan and Bioline
Standard Diagnostics Inc., South Korea, with Uni-Gold Trinity Biotech PLC,
Ireland as the tie-breaker).
All the 32 women testing positive for syphilis were asymptomatic and
many did not get the prescribed treatment due to costs (one dose of
Benzathine Penicillin and Erythromycin cost Ksh 300 equivalent to ~USD 3);
13 reported no treatment and 11 reported incomplete treatment out of 27
with follow up data. Untreated pregnancies can result in adverse outcomes
due to syphilis, such as spontaneous abortion or stillbirth, neonatal
death, low birth weight/premature birth or congenital infection of the
newborn in up to 80% of cases.23 Furthermore due to the stigma associated
with sexually transmitted infections (STIs), even if pregnant women get
treated, their partners most often will not.
Similar high prevalence has since been reported at the district
level. Collated data from monthly health facility reports in the district
show 23% prevalence of syphilis for 2009/2010 and 12% for 2010/2011 (DMOH
personal communication). These high rates remained unreported as syphilis
is no longer a notifiable disease in Kenya since 2009. Furthermore, the
prominence of HIV indicators at district and provincial level reporting
may also be partly responsible for other STIs being under-reported and
overlooked. The prevalence of syphilis, and of STIs in general, is higher
in antenatal clients compared to the general population as these represent
the sexually active group. Whereas, a few previous studies have shown the
prevalence of syphilis among pregnant women in Kenya to range from 3% to
4%,3 4 Otieno-Nyunya et al report a syphilis prevalence of less than 1%
in recently pregnant women from the KAIS survey and noted the limitation
from this small sub-sample (which included only 1 positive pregnant
woman).
The high rate observed in Rarieda district highlights the fact that
there might be hot spots which will need to be managed in order to achieve
elimination. Screening pregnant women for syphilis provides an important
means to monitor population prevalence and of identifying pockets of high
syphilis prevalence. In 1940s, western European countries introduced
antenatal syphilis screening and management programmes as part of the
strategy for syphilis elimination.5 However implementation of antenatal
screening for syphilis in low income countries is often poor due to
irregular procurement of tests and the additional cost of the syphilis
test incurred by ANC clients. Otieno-Nyunya et al report that antenatal
syphilis screening is common in Kenya. However, there is considerable
variation in the uptake of syphilis testing. In Rarieda district, less
than 10% of first ANC clients are tested for syphilis as reported by the
health facilities in 2009 and 2010. New simple and user-friendly, point-of
-care rapid diagnostic tests for syphilis provide an opportunity to scale-
up antenatal syphilis screening even in facilities without laboratory
capacity.
The low country-wide population prevalence detected by KAIS is
encouraging, but should be interpreted carefully. It will be important to
enhance antenatal syphilis screening both for sentinel surveillance and to
reduce the incidence of adverse pregnancy outcomes attributable to
syphilis as well as congenital syphilis. Maternal syphilis screening and
treatment is among the most cost-effective public health interventions. 6
The effect of the antenatal syphilis screening program could be improved
through earlier antenatal attendance, as well as expansion to cover free
syphilis treatment and explicit efforts to encourage partner notification
and treatment. Operational barriers including procurement inconsistencies
with syphilis test types and stock outs of both tests and treatment should
be addressed. Additionally, more efforts are needed to increase public
and health professional awareness of the potential serious consequences of
syphilis. All these efforts will be required for disease control and
eventually elimination. More emphasis should also be given to HIV
uninfected ANC clients who don't currently benefit from free care and
treatment. As argued previously, there should be stronger integration
between syphilis screening and HIV-PMTCT programmes which have higher
level of funding and political commitment. 7 The Kenyan Division of
Reproductive Health would benefit from additional support to strengthen
national STI program and policies for the antenatal population.
References
1. Otieno-Nyunya B, Bennett E, Bunnell R, Dadabhai S, Gichangi AA, Mugo N,
et al. Epidemiology of syphilis in Kenya: results from a nationally
representative serological survey. Sex Transm Infect 2011;87(6):521-25.
2. Kamb ML, Newman LM, Riley PL, Mark J, Hawkes SJ, Malik T, et al. A road
map for the global elimination of congenital syphilis. Obstet Gynecol Int
2010;2010.
3. Temmerman M, Gichangi P, Fonck K, Apers L, Claeys P, Van Renterghem L,
et al. Effect of a syphilis control programme on pregnancy outcome in
Nairobi, Kenya. Sex Transm Infect 2000;76(2):117-21.
4. Buve A, Weiss HA, Laga M, Van Dyck E, Musonda R, Zekeng L, et al. The
epidemiology of gonorrhoea, chlamydial infection and syphilis in four
African cities. AIDS 2001;15 Suppl 4:S79-88.
5. Deperthes BD, Meheus A, O'Reilly K, Broutet N. Maternal and congenital
syphilis programmes: case studies in Bolivia, Kenya and South Africa. Bull
World Health Organ 2004;82(6):410-6.
6. Vickerman P, Peeling RW, Terris-Prestholt F, Changalucha J, Mabey D,
Watson-Jones D, et al. Modelling the cost-effectiveness of introducing
rapid syphilis tests into an antenatal syphilis screening programme in
Mwanza, Tanzania. Sex Transm Infect 2006;82 Suppl 5:v38-43.
7. Watson-Jones D, Oliff M, Terris-Prestholt F, Changalucha J, Gumodoka B,
Mayaud P, et al. Antenatal syphilis screening in sub-Saharan Africa:
lessons learned from Tanzania. Trop Med Int Health 2005;10(9):934-43.
In a recent letter Oakeshott 1 cited the lack of data on the
prevalence of Trichomonas vaginalis (TV) in young women in the UK. In
their own pilot study of 183 stored self -taken vaginal samples from
multi-ethnic London female students in age group of 16-27, 2 (1.1%, 95%
CI 0.1%-3.9%) were positive by an in house multiplex real-time PCR test.
We in Macclesfield, UK, recently conducted a prospective pilot study to
ga...
In a recent letter Oakeshott 1 cited the lack of data on the
prevalence of Trichomonas vaginalis (TV) in young women in the UK. In
their own pilot study of 183 stored self -taken vaginal samples from
multi-ethnic London female students in age group of 16-27, 2 (1.1%, 95%
CI 0.1%-3.9%) were positive by an in house multiplex real-time PCR test.
We in Macclesfield, UK, recently conducted a prospective pilot study to
gain female positivity data with the use of a Nucleic acid amplification
test (NAAT), the Gen-Probe Aptima TV assay (ATV) in three different
clinical settings - community clinics, genitourinary (GU) medicine clinic
and its satellite prison GU medicine service2.
All women at the three different settings were offered an ATV test on the
residual portions of the Aptima transport medium from any vulvovaginal
swabs or first catch urine samples that had been collected for a routine
Aptima Combo 2 Chlamydia/Gonorrhoea test. Women below the age of 16 were
excluded. Positivity rates at community clinics and GU medicine, were
respectively 0/382 (0%) and 3/358 (0.8%, CI 0% - 1.7%). Positivity was
significantly higher, 29/269 (10.8%, CI 7.1% - 14.5%) - Odds Ratio 14.3
(4.11 < OR < 59.55) - in those tested at the prison. This compares
to overall chlamydia positivity rates of 4.6% in the community, 6.3% in GU
medicine and 5.3% in the prison and overall gonorrhoea positivity rates of
0.09%, 0.2% and 0.2% respectively.
For the 32 ATV positive women, the mean age was 30.6 (range 19 to 48)
years, 27 were White British/Irish, 2 Chinese and 3 were of Black African
origin, 9 (28%) were symptomatic and 3/32 (9.4%) had concomitant
chlamydia. No woman had concomitant gonorrhoea.
We also conducted a questionnaire survey of English GU medicine clinics
and obtained data from the United Kingdom Health Protection agency (HPA)
for England. Both demonstrated the large variation in case rates by region
and testing methods employed. Higher rates were seen in women, in prison
GUM services and in London GUM clinics.
Perry et al3 in a recent ongoing study in a London GUM clinic using the
ATV assay on residual routine samples taken for CT /GC in women found a
positivity rate of 11.8% (36/305, age range for both men and women 24-39
years ), 81% of whom were symptomatic. They concluded that ATV improved
clinical detection by 33% over wet mount microscopy and did not reveal as
many missed diagnoses as predicted. They speculated that this was because
the majority were symptomatic and that the ATV assay may have more
important role in community based screening of asymptomatic women or men.
Consideration of current standards of care may mean more tests should
be offered to a wider population. Monitoring positivity in defined
patient groups where the test might be introduced should lead to cost-
effective application and also help to clarify the levels of asymptomatic
carriage. Use of the new CE marked ATV assay in some populations is
warranted so as to lead to proper detection and treatment of TV and also
possibly the prevention of other co-transmitted infections, such as HIV.
REFERENCES
1. Oakeshott P, Ahmed J, Hay PE et al. Trichomonas vaginalis among multi-
ethnic female UK students. Sex Trans Infect 2011;doi:10.2236/sextrans-2011
-050061
2. Mahto M, Evans-Jones J, Zia S et al Finding cases of Trichomonas
vaginalis infection in England. International Journal of STD and AIDS
2011;22:471-473
3. Perry M, Benzie A, Erasmus K et al Clinical utility of a nucleic acid
amplification test for Trichomonas vaginalis in a targeted urban
genitourinary medicine clinic population. Oral Presentation, British
Association for Sexual Health and HIV (BASHH) Spring Meeting, Gateshead,
11th-13th May 2011.
In the paper from the HPA on cost of treatment of genital warts Woodhall et al come to the extraordinary conclusion that in the UK genital warts only costs £94 per case.1 Why they strip out all the 'on costs' of an NHS visit is hard to understand. All the other studies referred to, are seen as so methodologically flawed that comparison is impossible. One particular study, not referred to, deserves particular mention.2 In this s...
In the paper from the HPA on cost of treatment of genital warts Woodhall et al come to the extraordinary conclusion that in the UK genital warts only costs £94 per case.1 Why they strip out all the 'on costs' of an NHS visit is hard to understand. All the other studies referred to, are seen as so methodologically flawed that comparison is impossible. One particular study, not referred to, deserves particular mention.2 In this study published in 2003, by 2 (CJNL, GK) of the same authors, it was estimated that genital warts cost just over £200 in 'direct costs'. When the patient costs were added in the estimate came to over £500 per case at 2003 prices. Even more significantly this trial excluded the 'heart sink' wart patients we all know and dread in clinic. "Exclusion criteria included known HIV infection or immunosuppression, homosexual men with perianal warts, total lesional area >400 mm2, any individual lesion with an area of >100 mm2, intrameatal or vaginal warts, ulcerative or inflammatory STDs of the anogenital region, and pregnancy........Its size, design, and multicentre nature make it likely that the results are a reasonable reflection of treatment outcomes for first episode genital warts in clinical practice."
Does it really matter that there is one estimate that is only £94 per case? Well yes it does. As chair of BMA Dermatovenereology committee I wrote to Ann Milton MP minister of public health asking her how the review of the HPV vaccine contract would be decided and her reply indicated that recent information from the HPA on economic evaluation would be key. If yet again the NHS costs of HPV 6 and 11 are minimised, the bivalent vaccine need only be slightly cheaper than the quadrivalent vaccine to once again win the contract. If the review considers the true cost effectiveness i.e. genital wart management in GUM and general practice, adult and juvenile respiratory papilloma, abnormal smears due to 6 and 11 and early (within 3 or 4 years) return on investment as 15 and 16 year olds stop turning up with warts to clinics, the quadrivalent vaccine would be chosen. If only the bivalent is used there will be no savings until 13 years later when these 12 year olds eventually have their first smear at age 25.
Australia has shown that vaccination is likely to eliminate genital warts soon, as even males have seen a dramatic reduction from vaccination of young women with the quadrivalent vaccine.3
Indeed the UK is the only developed country in the world (apart from Holland) to be exclusively using the bivalent vaccine. Even some undeveloped countries like Rwanda are doing a national vaccination programme with the quadrivalent vaccine. So within a few years the sexual health of teenagers in Rwanda will be better than that in the UK? Is that our legacy?
References
1. Woodall SC, Jit M, Soldan K et al. The impact of genital warts: loss of quality of life and cost of treatment in eight sexual health clinics in the UK. Sex Transm Infect (2011). doi;10.1136/sextrans-2011-050073
2. Lacey C J N, Goodall RL, Ragnarson Tennvall G et al. Randomised controlled trial and economic evaluation of podophyllotoxin solution, podophyllotoxin cream, and podophyllin in the treatment of genital warts. Sex Transm Infect 2003;79:270-275
3. Christopher K Fairley, Jane S Hocking, Lyle C Gurrin, et al. Rapid decline in presentations for genital warts after the implementation of a national quadrivalent human papillomavirus vaccination program for young women. Sex Transm Inf. doi:10.1136/sti.2009.037788
Conflict of Interest:
I have received lecture fees and sat on advisory boards for GSK ( who make Cervarix - the bivalent vaccine) and Sanofi Pasteur MSD (who make Gardasil - the quadrivalent vaccine) I write prescriptions for £0.3 million worth of GSK drugs per year.
Dear Editor:
I would like to spot two obvious errors at the data extraction in the article by Kalichman et al on the systematic review of the prevalence of sexually transmitted coinfections in people living with HIV/AIDS. First, in Table 1 the study site of the Reference 31 by our study group, was located in Taiwan, instead of China. Second, it is clearly listed in the text of the Reference 31 that 79.7% of the participants had r...
Dear Editor:
I would like to spot two obvious errors at the data extraction in the article by Kalichman et al on the systematic review of the prevalence of sexually transmitted coinfections in people living with HIV/AIDS. First, in Table 1 the study site of the Reference 31 by our study group, was located in Taiwan, instead of China. Second, it is clearly listed in the text of the Reference 31 that 79.7% of the participants had received highly active antiretroviral therapy at enrollment, instead of "NR"in Table 1 - which probably means "not reported", though the author did not mention its meaning.
Madam,
We read with interest a recent article comparing the expectations and
experiences of STI care in general practice(1). The need for appropriate
sexual health services in primary care is clear especially when recent
data show the prevalence of HIV-1 to have reached 2 per 1000 in 37 primary
care trusts (PCTs) in England(2).
Patients interviewed in the study by Sutcliffe et al had initially
presented to general pract...
Madam,
We read with interest a recent article comparing the expectations and
experiences of STI care in general practice(1). The need for appropriate
sexual health services in primary care is clear especially when recent
data show the prevalence of HIV-1 to have reached 2 per 1000 in 37 primary
care trusts (PCTs) in England(2).
Patients interviewed in the study by Sutcliffe et al had initially
presented to general practice and were either recruited directly or had
been advised to attend a genito-urinary medicine (GUM) clinic and were
recruited there. Patients were recruited from areas of both high sexual
health need and differing ethic diversity, but were fundamentally a self-
selected group of patients who preferred to attend their GP over the GUM
clinic. It could be argued that they differ from GUM clinic attendees in
two unmentioned ways: Firstly, the median number of sexual partners in the
3 months prior to presentation in this study was 1 compared to >1 for
our clinic, which likely equates to less risk of having a sexually
transmitted infection (STI); secondly, that men who have sex with men
(MSM) were under-represented.
Data from the Gay Men's Sex Survey in 2003 revealed that while over 90%
were registered with a GP that only 32% from London and 29% from the South
West thought that staff at their surgery were aware of their sexuality(3).
Moreover, in a survey taken in 2009 from a dedicated gay men's clinic at
our centre only 21% of patients would attend their GP for sexual health
needs despite 83% having seen them in the preceding year (data
unpublished). This is all the more significant when MSM represented over
40% of gonorrhoea cases in London and the South West in 2009 (where sexual
orientation data were available) and 32% of HIV cases in the UK in 2010
(2,4).
In summary, whilst we strongly support enhanced links between primary and
secondary care for the provision of sexual health services, general
practice is not currently an acceptable option for all patients including
some of those with the highest need.
References
1. Sutcliffe LJ, Sadler KE, Low N, Cassell JA. Comparing expectations
and experiences of care for sexually transmitted infections in general
practice: a qualitative study. Sex Transm Infect. 2011;87:131-5.
2. Health Protection Agency UK. HIV in the United Kingdom: 2010
Report. Health Protection Report 2010 4(47). 2010.
http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1287145367237 (accessed
12th April 2011)
3. Sigma Research. On the move: findings from the United Kingdom Gay
Men's Sex Survey. 2003.
http://www.sigmaresearch.org.uk/files/local/All_England_2003.pdf (accessed
12th April 2011)
4. Health Protection Agency UK. Number of selected STI diagnoses made
at genitourinary medicine clinics in England, by age group and SHA of
residence. 2009.
http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1281953088000 (accessed
12th April 2011)
E-learning is the modern way of delivering the information required
for the induction programme at many NHS hospitals.
As a junior doctor who has undergone multiple inductions at different
hospital sites and into different specialties, I have found that the
training tracker was always a much better method of delivering induction
material. Having experienced lecture based inductions, which usually end
up with a l...
E-learning is the modern way of delivering the information required
for the induction programme at many NHS hospitals.
As a junior doctor who has undergone multiple inductions at different
hospital sites and into different specialties, I have found that the
training tracker was always a much better method of delivering induction
material. Having experienced lecture based inductions, which usually end
up with a lecture hall full of sleepy heads after 2 days, I wholeheartedly
support the e-learning option.
Not only is it still mandatory but it means that the true practical
induction of getting involved in the daily clinical work can begin much
sooner. It also has the advantage that it can be completed prior to the
start date, thereby facilitating service provision from that junior doctor
much sooner. The onus is on the trainee to identify areas of the induction
they may need further clarification on.
There still requires a system to check that all the junior doctors
have completed the required induction prior to starting and if not, the
trust should complete what is missing or encourage the trainee to complete
it.
Fox, Dunn and O'Shea stressed the importance of diagnosing primary
HIV infecting (PHI) to prevent onward transmission and help control the
HIV epidemic1. They evaluated the 4th generation HIV-1/2 Ag/Ag Determine
Combo assay (Alere) for its ability to detect p24 antigen as a marker of
PHI and have shown its poor sensitivity in detecting PHI and recommended
further evaluations of the assay. Many pati...
Fox, Dunn and O'Shea stressed the importance of diagnosing primary
HIV infecting (PHI) to prevent onward transmission and help control the
HIV epidemic1. They evaluated the 4th generation HIV-1/2 Ag/Ag Determine
Combo assay (Alere) for its ability to detect p24 antigen as a marker of
PHI and have shown its poor sensitivity in detecting PHI and recommended
further evaluations of the assay. Many patients self present to sexual
health clinics for a STI screen soon after an exposure which they perceive
as risky. Many clinics now offer rapid point of care (POCT) HIV testing
and although they are generally aware of the insensitivity of the 3rd
generation (antibody only) tests for PHI diagnosis, they could easily
assume that the new Determine Assay is equivalent in sensitivity to the
4th generation EIAs.
We performed a similar evaluation of the Determine assay at the HPA
Birmingham Public Health Laboratory and recently presented our findings at
the European Society for Clinical Virology winter meeting in London2.
Stored plasma samples were selected from patients who are at risk for HIV-
1 and who were screened between April 2008 and May 2010 using our routine
laboratory assays (Genscreen ULTRA HIV Ag-Ab Assay - Bio-Rad Laboratories
-, VIDAS HIV Duo Ultra HIV5, VIDAS HIV Duo Quick HIV6 p24 assay -
Biomerieux, Marcy l'Etoile, France). We selected 21 samples from patients
who either were diagnosed with acute HIV-1 seroconversion (14 samples) or
had a false positive reaction in one of our screening EIAs (7 samples).
All the samples were classified as either true seroconversion or false
positive by means of follow up samples. All samples were either p24 Ag
positive or equivocal. The definition of equivocal was a p24 Ag signal
value on the Vidas which was too low to be neutralised. For samples which
had enough serum a Vidas p24 Ag neutralising assay was performed of which
7/10 neutralised. All 7 false positive p24 Ag sera were correctly
identified by the Determine Combo test as negative. 5/14 of the p24 Ag
true positive sera (early seroconversion) were missed by the Determine
Combo test and tested negative for both p24 Ag and antibodies i e 64%
sensitivity compared to current laboratory EIA screening methods.
Even though there is a 64% improvement over a third generation (Ab
only) POCT, health care professionals should still be aware that the
Determine HIV-1/2 Ag/Ab Combo is not as sensitive as 4th generation EIAs
in diagnosing primary HIV-1 infections.
Husam Osman MBBCh, PhD, FRCPath
Consultant Virologist
HPA Birmingham, Public Health Laboratory
Heartlands Hospital
Birmingham
B9 5SS
Reference:
1. Fox J, Dunn H, O'Shea S. Low rate of p24 antigen detection using a
fourth generation point of care HIV Test. Sex Transm Infect 2010,Nov 17
2. Smit E, Atherton C, Osman H. Determine HIV-1/2 /Ab/Ag Combo lacks
sensitivity in detecting early HIV infections. European Society for
Clinical Virology Winter meeting, London, 13-15 Jan 2011.
Gaydos1 highlights the barriers to discussing sexual health issues openly and teenagers' lack of awareness of the high prevalence of STIs and potential adverse reproductive sequelae. Addressing these barriers is one solution to the 'Hidden Epidemic' of STIs. In the UK as in the USA, STI rates remain highest among sexually active teenagers, particularly those from deprived inner city areas and black ethnic minority groups....
STDs were commonly known as venereal diseases : Veneris is the Latin genitive form of the name Venus , the Roman goddess of love. Social disease was another euphemism. Public health officials originally introduced the term sexually transmitted infection , which clinicians are increasingly using alongside the term sexually transmitted disease in order to distinguish it from the former. According to Ethiopian AIDS Resourc...
Your recent major article by Harryman et al 1 assessed the performance of Aptima Combo 2 (AC2) confirmed by Aptima GC (AGC) versus culture and concluded that AC2 with AGC confirmation performed well at genital and extra-genital sites for detection of GC. Culture with transport swabs was found to perform poorly for asymptomatic men, symptomatic and asymptomatic women and at extra-genital sites. The authors conclude that c...
Stephanie Dellicour 1,2,3 , Florence Diemo4, Kayla Laserson2,3, Feiko ter Kuile1, Meghna Desai2,3 1. Child and Reproductive Health, Liverpool School of Tropical Medicine, UK 2. Kenya Medical Research Institute (KEMRI), Center for Global Health Research (CGHR), Kisumu, Kenya 3. Centers for Disease Control and Prevention (CDC), Atlanta, USA 4. Rarieda District Medical Officer for Health (DMOH), Nyanza Province, Kenya
...In a recent letter Oakeshott 1 cited the lack of data on the prevalence of Trichomonas vaginalis (TV) in young women in the UK. In their own pilot study of 183 stored self -taken vaginal samples from multi-ethnic London female students in age group of 16-27, 2 (1.1%, 95% CI 0.1%-3.9%) were positive by an in house multiplex real-time PCR test. We in Macclesfield, UK, recently conducted a prospective pilot study to ga...
Madam, We read with interest a recent article comparing the expectations and experiences of STI care in general practice(1). The need for appropriate sexual health services in primary care is clear especially when recent data show the prevalence of HIV-1 to have reached 2 per 1000 in 37 primary care trusts (PCTs) in England(2). Patients interviewed in the study by Sutcliffe et al had initially presented to general pract...
E-learning is the modern way of delivering the information required for the induction programme at many NHS hospitals.
As a junior doctor who has undergone multiple inductions at different hospital sites and into different specialties, I have found that the training tracker was always a much better method of delivering induction material. Having experienced lecture based inductions, which usually end up with a l...
Dear Editor
Fox, Dunn and O'Shea stressed the importance of diagnosing primary HIV infecting (PHI) to prevent onward transmission and help control the HIV epidemic1. They evaluated the 4th generation HIV-1/2 Ag/Ag Determine Combo assay (Alere) for its ability to detect p24 antigen as a marker of PHI and have shown its poor sensitivity in detecting PHI and recommended further evaluations of the assay. Many pati...
Pages