We read with much interest the recently published article by Foroughi
et al. [1] in
your journal. They have demonstrated that prevalence of HIV, hepatitis B
virus (HBV), and
hepatitis C virus (HCV) infections among street and labour child are 4.5%,
1.7% and 2.6% in
Iran, respectively and well discussed about HIV infection in this
population, However, we would
like to highlight some points about HBV a...
We read with much interest the recently published article by Foroughi
et al. [1] in
your journal. They have demonstrated that prevalence of HIV, hepatitis B
virus (HBV), and
hepatitis C virus (HCV) infections among street and labour child are 4.5%,
1.7% and 2.6% in
Iran, respectively and well discussed about HIV infection in this
population, However, we would
like to highlight some points about HBV and HCV infections among them.
First of all, we think that they may under-estimate reported
prevalence rates in their study.
only known street and labour children that had consent for enrollment in
the study have been
investigated which may cause a kind of selection bias considering socio-
economic status of
participants.
Treatment of HCV infection has been revolutionized and have provided
an opportunity for its
elimination. Patient finding is one of the major issues in the elimination
program. As screening
in general population is very difficult; therefore, in the first step
prioritizing special groups for
screening seems to be reasonable [2]. Foroughi et al. reported HCV
prevalence rate of 2.6% in
Iranian street and labor children which is approximately five times higher
than general
population in our country [3]. Hence, we think this group of patients
needs special attention for
finding of HCV-infected patients. Furthermore, Authors showed that HCV
infection is six times
higher in HIV-infected children compared to children without this
infection. Fortunately, with
new treatment strategies, HIV/HCV coinfection is not considered a special
condition anymore
and can be treated easily with only considering drug-drug interaction [2].
Finally, all participants were 10-18 years old, so they should have
been vaccinated against HBV
according to the national immunization program for neonates in Iran [4].
But high reported
prevalence of HBV among them and the etiology for lack of enough
immunization should be
more investigated.
References:
1. Foroughi M, Moayedi-Nia S, Shoghli A, et al. Prevalence of HIV,
HBV and HCV among street and labour
children in Tehran, Iran. Sexually Transmitted Infections 2016:sextrans-
2016-052557
2. Hesamizadeh K, Sharafi H, Rezaee-Zavareh MS, Behnava B, Alavian
SM. Next Steps Toward
Eradication of Hepatitis C in the Era of Direct Acting Antivirals.
Hepatitis Monthly 2016;16(4)
3. Hajarizadeh B, Razavi-Shearer D, Merat S, Alavian SM, Malekzadeh
R, Razavi H. Liver Disease Burden
of Hepatitis C Virus Infection in Iran and the Potential Impact of Various
Treatment Strategies on
the Disease Burden. Hepat Mon 2016;16(7):e37234 doi:
10.5812/hepatmon.37234[published
Online First: Epub Date]|.
4. Alavian SM, Zamiri N, Gooya MM, Tehrani A, Heydari ST, Lankarani
KB. Hepatitis B vaccination of
adolescents: a report on the national program in Iran. Journal of public
health policy
2010;31(4):478-93
The authors estimated vertical transmission of Chlamydia trachomatis by a retrospective analysis using national registry data and clinical records and concluded that transmission was much lower (<2%) than the rate commonly quoted (50-70%). Their suggested explanation is that the modern use of highly sensitive NAATs detects nonviable chlamydiae so that mothers testing positive could actually be noninfectious whereas older studies based on use of culture only identified infectious pregnant women. That is not a likely explanation for such a big difference. When NAAT performance with cervical swabs was evaluated about 2/3 of NAAT positive specimens were culture positive.
A more likely explanation comes from examining their case definition. It is not chlamydial infection, but rather laboratory confirmed cases of chlamydial conjunctivitis or pneumonia. And that is very different. When prospective studies were being done in San Francisco 175 infants born to chlamydia infected mothers were followed: 31 (18%) developed pneumonia; 29 (17%) conjunctivitis; 64 (37%) were culture positive and 105 (60%) had serologic evidence of infection. Thus there were many more infections than cases of conjunctivitis and pneumonia. But the difference between cases of disease and infection in the Finnish material is probably greater. In the prospective study there were cases of very mild disease that would likely not have been diagnosed in ordinary circumstances (seeing the whole clinical s...
The authors estimated vertical transmission of Chlamydia trachomatis by a retrospective analysis using national registry data and clinical records and concluded that transmission was much lower (<2%) than the rate commonly quoted (50-70%). Their suggested explanation is that the modern use of highly sensitive NAATs detects nonviable chlamydiae so that mothers testing positive could actually be noninfectious whereas older studies based on use of culture only identified infectious pregnant women. That is not a likely explanation for such a big difference. When NAAT performance with cervical swabs was evaluated about 2/3 of NAAT positive specimens were culture positive.
A more likely explanation comes from examining their case definition. It is not chlamydial infection, but rather laboratory confirmed cases of chlamydial conjunctivitis or pneumonia. And that is very different. When prospective studies were being done in San Francisco 175 infants born to chlamydia infected mothers were followed: 31 (18%) developed pneumonia; 29 (17%) conjunctivitis; 64 (37%) were culture positive and 105 (60%) had serologic evidence of infection. Thus there were many more infections than cases of conjunctivitis and pneumonia. But the difference between cases of disease and infection in the Finnish material is probably greater. In the prospective study there were cases of very mild disease that would likely not have been diagnosed in ordinary circumstances (seeing the whole clinical spectrum is an advantage of prospective studies). I do not know what the triggers would be for laboratory testing in Finland, but there must have been a bias towards more severe cases of conjunctivitis and pneumonia. Thus there would be an underestimation of chlamydia pneumonia and conjunctivitis cases in the population, and no real measure of chlamydia infection. This study did not measure vertical transmission of Chlamydia trachomatis.
The study by Girometti et al(1) on the incidence of human
immunodeficiency virus(HIV) in men that have sex with men(MSM) with early
syphilis illustrated the role syphilis plays in HIV transmission.
However, although syphilis is a risk factor for HIV infection, chlamydia
and gonorrhea are also risk factors for the transmission of HIV(2). Unless
it is clearly stated that the participants that acquired HIV during the
study...
The study by Girometti et al(1) on the incidence of human
immunodeficiency virus(HIV) in men that have sex with men(MSM) with early
syphilis illustrated the role syphilis plays in HIV transmission.
However, although syphilis is a risk factor for HIV infection, chlamydia
and gonorrhea are also risk factors for the transmission of HIV(2). Unless
it is clearly stated that the participants that acquired HIV during the
study only had 'early syphilis', any association between HIV
seroconversion and the stated predictor will be confounded because the
other STIs are also known causes of increased risk for HIV infection(2).
Also, behavior such as the use of condom plays a huge role in HIV
acquisition. Additionally, the practice of oral sex may have different
risk of HIV transmission compared to anal sex, although this risk may be
modified by the presence of oral syphilitic lesions(3). Therefore, an
individual that have syphilis and practices oral sex or uses condom may
have a lesser risk of acquiring HIV than an individual that does not.
Of the 206 MSM that were diagnosed with early syphilis, 191 were
treated, and 26 had reinfection. What is the fate of the 15 cases of
syphilis that weren't treated? How many of these acquired HIV? What is
'early syphilis': Is it early Primary(Chancre), early Secondary or Early
Latent syphilis? Lastly, although the reduction of HIV incidence by Pre-
Exposure Prophylaxis(PreP) in MSM is found to be 86%, and giving PreP to
MSM who have other STIs is ideal, using syphilis or any other STI alone as
a marker for PreP can cause misclassification for PreP use. For instance,
will you prefer to give PreP to an MCM with syphilis from an area with
high syphilis prevalence over someone from a similar area of prevalence
but doesn't have syphilis and consistently refuses to use condom compared
to the former person? Thus, the result of this study may only be useful
for a specific population, most likely where the study was done. With all
the above, the conclusion by the author that early syphilis increases the
incidence of HIV in MCM by 8.3 times may not be practical.
References:
1. Girometti N, Gutierrez A, Nwokolo N, McOwan A, Whitlock G. High
HIV incidence in men who have sex with men following an early syphilis
diagnosis: is there room for pre-exposure prophylaxis as a prevention
strategy? Sex Transm Infect. 2016 Oct 19;sextrans-2016-052865.
2. Hoenigl M, Green N, Mehta SR, Little SJ. Risk Factors for Acute and
Early HIV Infection Among Men Who Have Sex With Men (MSM) in San Diego,
2008 to 2014. Medicine (Baltimore) [Internet]. 2015 Jul 31 [cited 2016 Oct
27];94(30). Available from:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4554110/
3. Transmission of Primary and Secondary Syphilis by Oral Sex ---
Chicago, Illinois, 1998--2002 [Internet]. [cited 2016 Oct 27]. Available
from: https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5341a2.htm
I'm writing to ask if the authors considered an alternate hypothesis:
perhaps the symptoms of primary infection with syphilis are easier to
ignore than chlamydia and gonorrhea--the latter two often cause painful
urination and discharge, while with syphilis (in men) a chancre often
appears in the genital area, usually (but not always) on the penis. These
sores are often painless.
I'm writing to ask if the authors considered an alternate hypothesis:
perhaps the symptoms of primary infection with syphilis are easier to
ignore than chlamydia and gonorrhea--the latter two often cause painful
urination and discharge, while with syphilis (in men) a chancre often
appears in the genital area, usually (but not always) on the penis. These
sores are often painless.
To me it seems quite reasonable that the painless chancre symptoms of
primary syphilis infection would be a lot easier to ignore than those of
chlamydia and gonorrhea, which manifests in pain and quite obvious
discharge. Those with the latter two would likely seek out treatment and
cease sexual activity (and thereby reduce the spread), while individuals
with syphilis may just ignore the comparatively benign symptom, and
continue to spread it to others. So, infection with different diseases
likely results in different behavioral responses, which in turn affect the
rates.
I'm just a layperson so I apologize if this is ridiculous or already
accounted for, but I hope this perspective might help!
The authors impute a biological mechanism to the high incidence of syphilis in men who have sex with men using anti-retroviral drugs (in particular, HAART). We suggest, empiric data do not support the biological hypothesis, and behavioral explanations (i.e. increased condomless sex and selection of higher risk partners) are supported by stronger evidence.
Randomized double-blind trials of pre-exposure prophylaxis (PrEP) for HIV prevention [1] provide a rigorous test of the author’s hypothesis. The methodological strength includes an unconfounded and clearly unexposed control group and an exposed group which received an agent that would putatively increase susceptibility — tenofovir disoproxil fumarate (TDF) co-formulated with emtricitabine (FTC). A unique feature is that these trials were blinded and PrEP was unproven that the time trials were undertaken; hence, we would not expect that the TDF/FTC-exposed group would adopt higher risk practices.
An analysis of the iPrEx trial [2], a randomized PrEP trial in men who have sex with men/trans women, found [1] a relative rate of syphilis acquisition for TDF/FTC of 1.14 with a 0.95 confidence interval (0.90 to 1.45) compared to placebo. Incident syphilis, can be difficult to differentiate from a previous infection. Among those with a negative rapid plasma reagin titer at screening the relative rate of an on-study infection was 1.03, 0.95 CI (0.76 to 1.38). Adherence, was low in the iPrEx study and when pharmaco...
The authors impute a biological mechanism to the high incidence of syphilis in men who have sex with men using anti-retroviral drugs (in particular, HAART). We suggest, empiric data do not support the biological hypothesis, and behavioral explanations (i.e. increased condomless sex and selection of higher risk partners) are supported by stronger evidence.
Randomized double-blind trials of pre-exposure prophylaxis (PrEP) for HIV prevention [1] provide a rigorous test of the author’s hypothesis. The methodological strength includes an unconfounded and clearly unexposed control group and an exposed group which received an agent that would putatively increase susceptibility — tenofovir disoproxil fumarate (TDF) co-formulated with emtricitabine (FTC). A unique feature is that these trials were blinded and PrEP was unproven that the time trials were undertaken; hence, we would not expect that the TDF/FTC-exposed group would adopt higher risk practices.
An analysis of the iPrEx trial [2], a randomized PrEP trial in men who have sex with men/trans women, found [1] a relative rate of syphilis acquisition for TDF/FTC of 1.14 with a 0.95 confidence interval (0.90 to 1.45) compared to placebo. Incident syphilis, can be difficult to differentiate from a previous infection. Among those with a negative rapid plasma reagin titer at screening the relative rate of an on-study infection was 1.03, 0.95 CI (0.76 to 1.38). Adherence, was low in the iPrEx study and when pharmacology is taken into account, the hazard ratio for TDF/FTC among those with drug detected in plasma was 1.00, 0.95 CI (0.62 to 1.61), compared to placebo. Finally, we found that the incidence of syphilis decreased during the period of the trial in the TDF/FTC group (from 6.3 per 100 person years in the first year to 3.7 per 100 person years in subsequent years).
It is unlikely a biological TDF/FTC effect on syphilis acquisition would be missed when effects on HIV replication, bone mineral density, lipids, symptoms (e.g., nausea), and kidney function were readily detected in the iPrEx study even in the presence of suboptimal adherence. Randomized controlled trials are the gold standard in clinical research and this PrEP trial provides formidable evidence against the authors hypothesis.
References
1. Solomon MM, Mayer KH, Glidden DV. Syphilis predicts HIV incidence among men and transgender women who have sex with men in a preexposure prophylaxis trial. Clin Infect Dis. 2014; 59:1020-6. doi: 10.1093/cid/ciu450.
2. Grant RM, Lama JR, Anderson PL, et al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med. 2010;363 :2587-99. doi: 10.1056 NEJMoa1011205.
The editorial by Giffard et al. rightly addresses the issue of the
potential clinical and social response to the detection of C.trachomatis
in urogenital (UGT) specimens from young children. [1] Clinical guidelines
frequently state that detection of a sexually transmissible agent in a UGT
specimen of a child is strongly indicative of sexual abuse (SA), and even
in the absence of disclosure of SA, initiates an investigation...
The editorial by Giffard et al. rightly addresses the issue of the
potential clinical and social response to the detection of C.trachomatis
in urogenital (UGT) specimens from young children. [1] Clinical guidelines
frequently state that detection of a sexually transmissible agent in a UGT
specimen of a child is strongly indicative of sexual abuse (SA), and even
in the absence of disclosure of SA, initiates an investigation by child
protection services. [2] However this may not hold true always, as
detection of sexually transmitted infection (STI) in UGT samples from
young children is not always a consequence of conventional sexual contact.
Potential explanations are autoinoculation from an ocular source,
perinatal mother to child transmission or contamination of specimens. [3]
Autoinoculation of C.trachomatis from the ocular infection to the UGT
site is a well-established phenomenon and leads to the detection of
C.trachomatis in UGT specimens even in the absence of any sexual contact.
[3] This particularly is relevant to a country like India, where trachoma
still remains endemic [4] and is not considered as an STI. As discussed by
Giffard et al, the relevance of genotyping in such situation cannot be
underscored. We support their suggestion of the inclusion of C.trachomatis
genotyping into formal guidelines for examining the source of STIs in
young children in areas where trachoma genotypes may continue to
circulate. The authors further state that it is also important to know the
trachoma and UGT genotypes circulating in the conventional adult sexual
networks in the area, so as to establish the possible route of
transmission. However no studies are available from India for the
frequency of trachoma genotypes in adult and pediatric UGT specimens. This
further confounds the issue whether the detection of C.trachomatis in a
pediatric UGT is a reliable indicator that SA has occurred.
There are reports of trachoma genotypes in UGT specimens, with
genotype B being the most commonly reported. [5,6] If the frequency of
trachoma genotypes detected in pediatric UGT specimens is more in
comparison to the trachoma genotypes from UGT specimens of adults, then
the route of transmission is more in favor of autoinoculation than
transmission from adult sexual networks and this is of potential
significance in the child protection context. However, a UGT genotype in
such case, if detected from the UGT specimens of a child would represent
stronger evidence of abuse.
In conclusion, genotyping of C.trachomatis from pediatric UGT
specimens and correlating it with the circulating genotypes in the adult
sexual networks seems to be a better approach to determine whether the
organism has been acquired through sexual contact or not. Continuous
surveillance of C.trachomatis genotypes in adults and pediatric specimens
can unravel the complex transmission dynamics of this organism.
References
1. Giffard PM, Singh G, Garland SM. What does Chlamydia trachomatis
detection in a urogenital specimen from a young child mean? Sex Transm
Infect. 2016 Apr 15. [Epub ahead of print]
2. Workowski KA, Bolan GA. Sexually transmitted diseases treatment
guidelines, 2015. MMWR Recomm Rep 2015;64:1-137.
3. Giffard PM, Brenner NC, Tabrizi SN, et al. Chlamydia trachomatis
genotypes in a cross-sectional study of urogenital samples from remote
Northern and Central Australia. BMJ Open. 2016 Jan 6;6(1):e009624.
4. WHO Status of endemicity for blinding trachoma data by country,
2012. Available from:
http://www.who.int/gho/neglected_diseases/trachoma/en/. WHO, 2012
5. Psarrakos P, Papadogeorgakis E, Sachse K, et al. Chlamydia
trachomatis ompA genotypes in male patients with urethritis in Greece:
conservation of the serovar distribution and evidence for mixed infections
with Chlamydophila abortus. Mol Cell Probes 2011;25:168-73.
6. Takahashi S, Yamazaki T, Satoh K, et al. Longitudinal epidemiology
of Chlamydia trachomatis serovars in female patients in Japan. Jpn J
Infect Dis 2007;60:374-6.
We read with interest the recent article by Chandrasekaran et al[1],
which analysed national surveillance data on chlamydia testing and
diagnoses among young adults in England in 2012. The paper raises a number
of important points of relevance for the National Chlamydia Screening
Programme in England.
Firstly, the authors' findings further support the known association
between deprivation and chlamydia infection...
We read with interest the recent article by Chandrasekaran et al[1],
which analysed national surveillance data on chlamydia testing and
diagnoses among young adults in England in 2012. The paper raises a number
of important points of relevance for the National Chlamydia Screening
Programme in England.
Firstly, the authors' findings further support the known association
between deprivation and chlamydia infection[2;3]. Although Chandrasekaran
et al present an ecological study, this relationship has also been
demonstrated in individual level analyses and emphasises the importance of
chlamydia screening delivery in socioeconomically deprived areas. For
local authorities thinking about the implications of these findings for
their own populations, it is also worth noting that within a single local
authority area, levels of deprivation will vary. Therefore decisions about
focussing of resources need to be considered at several levels.
The observation that areas with a lower proportion of tests carried
out in GUM clinics were less likely to achieve a detection rate of
2,300/100,000 population is also an important one. Chlamydia infections
are not restricted to young adults with higher risk sexual behaviours,
such as multiple sexual partners, nor to those who attend GUM
clinics[2;3]. Testing in non-GUM clinic settings such as sexual and
reproductive health services, primary care and via the internet is
therefore an essential component of comprehensive chlamydia control.
Along with differences in infection risk in different populations,
the other driver of variation in detection rates is testing coverage, as
the authors themselves point out. Although the relationship between
coverage and detection rates was not explored explicitly in this paper, we
note that coverage was higher in more deprived local authorities. In
national surveillance data from 2015, local authorities with higher
coverage tended to have higher detection rates[4]. This suggests that in
2012, chlamydia screening activity was, to some extent, already focussed
in areas at greatest need. However, more could be done to increase
detection rates as we know that infections go undiagnosed3, with the
consequent potential impact on reproductive health[5]. The old adage of
'seek and ye shall find' holds true to a large extent with chlamydia
testing among young adults; the decision for local authorities is how best
to use the available resources to maximise the benefit of every test.
To that end, we also welcome the authors' recommendation that local
authorities be encouraged to use their data to inform service planning and
evaluation. As the authors conclude, this understanding of the data should
not be limited to a narrow focus on the detection rate indicator alone.
Diagnosis is only one step of the process by which chlamydia screening can
identify and treat infections. Understanding of the population(s) at risk,
rates of testing, diagnosis, treatment, partner notification and re-
testing are all needed to ensure a quality service. In recognition of
this, the NCSP is already working with local authorities and service
providers to use both nationally- and locally-collated data relating to
the whole of the chlamydia care pathway to inform service improvement
activity[6]. We believe this structured approach to service design and
evaluation will ensure that commissioners are best able to allocate
limited resources to achieve the maximum benefit for the population.
References
[1] Chandrasekaran L, Davies B, Eaton JW, Ward H. Chlamydia diagnosis
rate in England in 2012: an ecological study of local authorities. Sex
Transm Infect 2016.
[2] Sonnenberg P, Clifton S, Beddows S, Field N, Soldan K, Tanton C
et al. Prevalence, risk factors, and uptake of interventions for sexually
transmitted infections in Britain: findings from the National Surveys of
Sexual Attitudes and Lifestyles (Natsal). Lancet 2013; 382(9907):1795-
1806.
[3] Woodhall SC, Soldan K, Sonnenberg P, Mercer CH, Clifton S,
Saunders P et al. Is chlamydia screening reaching young adults at risk of
infection? Findings from the third National Survey of Sexual attitudes and
Lifestyles (Natsal-3). Sexually Tranmitted Infections 2016; 92(3):218-227.
[4] Public Health England. Sexually transmitted infections and
chlamydia screening in England, 2015. Health Protection Report 2016;
10(22).
[5] Price MJ, Ades AE, Soldan K, Welton NJ, Macleod J, Simms I et al.
The natural history of Chlamydia trachomatis infection in women: a multi
parameter evidence synthesis. Health Technology Assessment 2016; 20(22).
[6] Public Health England. NCSP: Care pathway. 2016. Available at:
https://www.gov.uk/government/publications/ncsp-chlamydia-care-pathway
Accessed 2 Sep 2016
Conflict of Interest:
All authors are employed by Public Health England and contribute to the implementation, monitoring and/or evaluation of the National Chlamydia Screening Programme in England.
Osterberg et al. [1] assessed the association between pubic hair
grooming and sexually transmitted infections (STIs) using self-reported
data from a cross-sectional survey of adults aged 18 to 65 years in the
United States. The primary result was that individuals who reported ever-
grooming had 1.8 times the odds (odds ratio [OR]=1.8, 95% confidence
limits [CL]: 1.4, 2.2) of a history of STIs compared with individuals who...
Osterberg et al. [1] assessed the association between pubic hair
grooming and sexually transmitted infections (STIs) using self-reported
data from a cross-sectional survey of adults aged 18 to 65 years in the
United States. The primary result was that individuals who reported ever-
grooming had 1.8 times the odds (odds ratio [OR]=1.8, 95% confidence
limits [CL]: 1.4, 2.2) of a history of STIs compared with individuals who
reported never-grooming. The authors thus concluded that pubic hair
grooming is associated with a history of STIs. Nevertheless, these results
may be explained by confounding, selection, misclassification, and
protopathic (i.e. reverse causality) biases. We focus herein on unmeasured
confounding as an alternate explanation for the observed estimates.
The authors adjusted for age and number of sexual partners, but these
covariates are insufficient for adequately reducing confounding bias for
the exposure-outcome association of interest. Confounding pathways include
all common causes of exposure and outcome [2]. For example, gender
influences pubic hair grooming habits [3] and STIs [4], but gender was not
adjusted in the analysis by Osterberg et al. [1]. Therefore, gender is a
source of unmeasured confounding and the consequences may be nontrivial.
We used data reported by Osterberg et al. [1] for a sensitivity
analysis of unmeasured confounding using the following formula by Ding and
Vanderweele [5] to derive an adjustment factor,
(OReu*ORud)/(OReu+ORud-1)
where OReu is the odds ratio for the association between gender
(males as reference) and any grooming (OR=2.67), and ORud is the odds
ratio for the association between gender and STIs (OR=1.43). The observed
OR and corresponding CL (OR=1.8, 95% CL: 1.4, 2.2) are subsequently
divided by the adjustment factor (1.23), which results in an OR=1.5 (95%
CL: 1.1, 1.8) for the estimate after adjustment for gender and the
original covariates (age and number of sexual partners). The adjusted
estimate is attenuated from the authors' reported estimate and may be even
closer to the null if other relevant covariates could be adjusted such as
race/ethnicity and socioeconomic status. In addition, the authors reported
that the survey used sampling probability weights, but these weights did
not seem to be used in the analysis. The consequence is potential bias in
point estimates and overly narrow confidence limits [6], which raises
further questions about the authors' interpretation.
In summary, the interpretation by Osterberg et al. [1] may be based
on biased estimates. Greater attention to unmeasured confounding and other
sources of bias is warranted before attributing STIs to grooming habits.
REFERENCES
[1] Osterberg EC, Gaither TW, Awad MA, Truesdale MD, Allen I,
Sutcliffe S, et al. Correlation between pubic hair grooming and STIs:
results from a nationally representative probability sample. Sex Transm
Infect. 2016.
[2] Greenland S, Pearl J, Robins JM. Causal diagrams for epidemiologic
research. Epidemiology. 1999;10:37-48.
[3] Butler SM, Smith NK, Collazo E, Caltabiano L, Herbenick D. Pubic hair
preferences, reasons for removal, and associated genital symptoms:
comparisons between men and women. J Sex Med. 2015;12:48-58.
[4] Satterwhite CL, Torrone E, Meites E, Dunne EF, Mahajan R, Ocfemia MC,
et al. Sexually transmitted infections among US women and men: prevalence
and incidence estimates, 2008. Sex Transm Dis. 2013;40:187-93.
[5] Ding P, VanderWeele TJ. Sensitivity Analysis Without Assumptions.
Epidemiology. 2016;27:368-77.
[6] Kreuter F, Valliant R. A survey on survey statistics: What is done and
can be done in Stata. Stata Journal. 2007;7:1.
As few studies have examined the relation between pubic hair grooming
and sexually transmitted infections (STIs), we took advantage of
nationally representative survey data to begin to explore this possible
association and to develop hypotheses for future prospective studies. In
our analysis, we observed a positive association between self-reported
pubic hair grooming and STI history, which we interpreted in several
poss...
As few studies have examined the relation between pubic hair grooming
and sexually transmitted infections (STIs), we took advantage of
nationally representative survey data to begin to explore this possible
association and to develop hypotheses for future prospective studies. In
our analysis, we observed a positive association between self-reported
pubic hair grooming and STI history, which we interpreted in several
possible ways given the limitations of our study (e.g., its cross-
sectional study design, self-reported assessment of grooming and STIs, and
lack of information on additional possible confounders, such as condom
use) Interpretations of our findings included: a) grooming-associated
epithelial microtears leading to increased risk of cutaneous STIs; b)
grooming-related protection against lice by pubic hair removal; c)
residual confounding by characteristics common to both grooming and STIs,
such as risky sexual behaviors; and d) what we believe is the most likely
interpretation, a combination of all of these explanations given our
differing magnitudes of association by type of STI. Based on these
interesting hypothesis-generating findings, we recommended that additional
epidemiologic studies be conducted with prospective data collection,
laboratory confirmation of STIs, and collection detailed STI risk
information to elucidate the mechanisms underlying our findings.
In response to Ojha and colleagues' concerns about confounding by
gender, race, income, and sexual frequency, we adjusted our analyses for
these variables: gender (male, female), race (White/Caucasian,
Black/African American, Hispanic/Latino, Mixed Races, or Other), income
(<$50,000, $50,000-74,999, $75,000-99,000, and >$100,000 USD), and
sexual frequency (daily, weekly, monthly, every three months or less). We
also repeated the analyses with and without survey weights. The
association between grooming and a history of STI remained (aOR= 1.71, 95%
CI 1.37-2.15). The other analyses yielded generally similar magnitudes of
association and the same inferences as the results presented in our
manuscript.
Notwithstanding these largely unchanged estimates, we believe that
residual confounding is still a possible interpretation of our findings
and encourage more research on this topic. However, even in the presence
of residual confounding, we would like to reinforce that use of grooming
as a marker of high-risk sexual behaviors may still have value for STI
prevention efforts to help identify individuals who would benefit most
from STI prevention counseling.
Dear Madam, dear Sir:
With interest, we read the paper of Chow et al. (1) reporting that
Listerine antiseptic mouthwash can kill Neisseria gonorrhoeae in vitro and
reduce the amount of gonococci on pharyngeal surfaces. There is no doubt
that measures beyond antibiotic treatment of gonococcal infections
detected clinically or by laboratory testing are needed to reduce the
prevalence of infection and that mouthwash can dimi...
Dear Madam, dear Sir:
With interest, we read the paper of Chow et al. (1) reporting that
Listerine antiseptic mouthwash can kill Neisseria gonorrhoeae in vitro and
reduce the amount of gonococci on pharyngeal surfaces. There is no doubt
that measures beyond antibiotic treatment of gonococcal infections
detected clinically or by laboratory testing are needed to reduce the
prevalence of infection and that mouthwash can diminish the gonococcal
load of the oral cavity. However, we would like to point out that
antiseptic mouthwash is no reliable means to prevent transmission of
gonorrhea and for the following reasons may lead to a false sense of
security in the persons concerned:
i. Although MSM with culture-proven oral gonococcal infection were
significantly less likely culture-positive after rinsing and gargling with
Listerine for one minute, compared to phosphate-buffered saline (PBS),
bacteria were still detected by culture in more than 50%. Daily use of
Listerine mouthwash might reduce the rate of culture positive cases
further, but there are no long-term data about sustained elimination of
Neisseria gonorrhoeae.
ii. It is well known that MSM suffering from gonorrhea are frequently
infected at multiple sites. In several previous studies 20%-70% of cases
with pharyngeal gonococcal infection were concomitantly positive in
urogenital or anorectal specimens (2-6). Thus, even when oral gonococci
will be cleared effectively by Listerine mouthwash, they can still be
transmitted by genito-anal sexual contacts in a number of patients,
especially when considering that the majority of anorectal gonococcal
infections are asymptomatic (2,5,6).
iii. Frequent use of Listerine may also damage the physiological mouth
flora (oral microbiome) and thus may affect susceptibility for other
infections (including HIV).
Even if the reduction of pharyngeal carriage of Neisseria gonorrhoeae will
be confirmed in further investigations, we do not think the use of
antiseptic mouthwash should be included into the prevention strategies to
control gonococcal infections. In particular, it should not be designated
a "non-condom control measure", as this may erroneously be conceived as
condom use is no longer essential after using antiseptic mouthwash.
Furthermore, there is a concern that laboratory test to detect pharyngeal
gonococcal infections and to characterize antibiotic susceptibility will
be performed less frequently when antiseptic mouthwash was used. We
consider it much more advisable to implement effective gonococcal
screening strategies, including testing of pharyngeal, urogenital and
anorectal samples, than gargling with mouthwash, which under the
assumption of clearing the bacteria might adversely affect any efforts to
establish effective gonococcal screening in risk populations.
References
1. Chow EP, Howden BP, Walker S et al. Antiseptic mouthwash against
pharyngeal Neisseria gonorrhoeae: a randomised controlled trial and an in
vitro study. Sex Transm Infect 2016 Dec 20. pii: sextrans-2016-052753.
doi: 10.1136/sextrans-2016-052753. [Epub ahead of print]
2. Kent CK, Chaw JK, Wong W et al. Prevalence of rectal, urethral, and
pharyngeal chlamydia and gonorrhea detected in 2 clinical settings among
men who have sex with men: San Francisco, California, 2003. Clin Infect
Dis 2005;41:67-74.
3. Benn PD, Rooney G, Carder C et al. Chlamydia trachomatis and Neisseria
gonorrhoeae infection and the sexual behaviour of men who have sex with
men. Sex Transm Infect 2007;83:106-12.
4. Ota KV, Tamari IE, Smieja M et al. Detection of Neisseria gonorrhoeae
and Chlamydia trachomatis in pharyngeal and rectal specimens using the BD
Probetec ET system, the Gen-Probe Aptima Combo 2 assay and culture. Sex
Transm Infect 2009;85:182-6.
5. Peters RP, Verweij SP, Nijsten N, et al. Evaluation of sexual history-
based screening of anatomic sites for chlamydia trachomatis and Neisseria
gonorrhoeae infection in men having sex with men in routine practice. BMC
Infect Dis 2011;11:203.
6. Dudareva-Vizule S, Haar K, Sailer A et al. Prevalence of pharyngeal and
rectal Chlamydia trachomatis and Neisseria gonorrhoeae infections among
men who have sex with men in Germany. Sex Transm Infect 2014 90:46-51
Thomas Meyer and Norbert H. Brockmeyer for the German Society of
Sexually Transmitted Infections (DSTIG); Ruhr-University Bochum; St.
Elisabeth-Hospital, Bleichstrasse 15, 44787 Bochum, Germany
Dear editor,
We read with much interest the recently published article by Foroughi et al. [1] in your journal. They have demonstrated that prevalence of HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV) infections among street and labour child are 4.5%, 1.7% and 2.6% in Iran, respectively and well discussed about HIV infection in this population, However, we would like to highlight some points about HBV a...
The authors estimated vertical transmission of Chlamydia trachomatis by a retrospective analysis using national registry data and clinical records and concluded that transmission was much lower (<2%) than the rate commonly quoted (50-70%). Their suggested explanation is that the modern use of highly sensitive NAATs detects nonviable chlamydiae so that mothers testing positive could actually be noninfectious whereas older studies based on use of culture only identified infectious pregnant women. That is not a likely explanation for such a big difference. When NAAT performance with cervical swabs was evaluated about 2/3 of NAAT positive specimens were culture positive.
Show MoreA more likely explanation comes from examining their case definition. It is not chlamydial infection, but rather laboratory confirmed cases of chlamydial conjunctivitis or pneumonia. And that is very different. When prospective studies were being done in San Francisco 175 infants born to chlamydia infected mothers were followed: 31 (18%) developed pneumonia; 29 (17%) conjunctivitis; 64 (37%) were culture positive and 105 (60%) had serologic evidence of infection. Thus there were many more infections than cases of conjunctivitis and pneumonia. But the difference between cases of disease and infection in the Finnish material is probably greater. In the prospective study there were cases of very mild disease that would likely not have been diagnosed in ordinary circumstances (seeing the whole clinical s...
The study by Girometti et al(1) on the incidence of human immunodeficiency virus(HIV) in men that have sex with men(MSM) with early syphilis illustrated the role syphilis plays in HIV transmission. However, although syphilis is a risk factor for HIV infection, chlamydia and gonorrhea are also risk factors for the transmission of HIV(2). Unless it is clearly stated that the participants that acquired HIV during the study...
I'm writing to ask if the authors considered an alternate hypothesis: perhaps the symptoms of primary infection with syphilis are easier to ignore than chlamydia and gonorrhea--the latter two often cause painful urination and discharge, while with syphilis (in men) a chancre often appears in the genital area, usually (but not always) on the penis. These sores are often painless.
To me it seems quite reasonable...
The authors impute a biological mechanism to the high incidence of syphilis in men who have sex with men using anti-retroviral drugs (in particular, HAART). We suggest, empiric data do not support the biological hypothesis, and behavioral explanations (i.e. increased condomless sex and selection of higher risk partners) are supported by stronger evidence.
Randomized double-blind trials of pre-exposure prophylaxis (PrEP) for HIV prevention [1] provide a rigorous test of the author’s hypothesis. The methodological strength includes an unconfounded and clearly unexposed control group and an exposed group which received an agent that would putatively increase susceptibility — tenofovir disoproxil fumarate (TDF) co-formulated with emtricitabine (FTC). A unique feature is that these trials were blinded and PrEP was unproven that the time trials were undertaken; hence, we would not expect that the TDF/FTC-exposed group would adopt higher risk practices.
An analysis of the iPrEx trial [2], a randomized PrEP trial in men who have sex with men/trans women, found [1] a relative rate of syphilis acquisition for TDF/FTC of 1.14 with a 0.95 confidence interval (0.90 to 1.45) compared to placebo. Incident syphilis, can be difficult to differentiate from a previous infection. Among those with a negative rapid plasma reagin titer at screening the relative rate of an on-study infection was 1.03, 0.95 CI (0.76 to 1.38). Adherence, was low in the iPrEx study and when pharmaco...
Show MoreThe editorial by Giffard et al. rightly addresses the issue of the potential clinical and social response to the detection of C.trachomatis in urogenital (UGT) specimens from young children. [1] Clinical guidelines frequently state that detection of a sexually transmissible agent in a UGT specimen of a child is strongly indicative of sexual abuse (SA), and even in the absence of disclosure of SA, initiates an investigation...
We read with interest the recent article by Chandrasekaran et al[1], which analysed national surveillance data on chlamydia testing and diagnoses among young adults in England in 2012. The paper raises a number of important points of relevance for the National Chlamydia Screening Programme in England.
Firstly, the authors' findings further support the known association between deprivation and chlamydia infection...
Osterberg et al. [1] assessed the association between pubic hair grooming and sexually transmitted infections (STIs) using self-reported data from a cross-sectional survey of adults aged 18 to 65 years in the United States. The primary result was that individuals who reported ever- grooming had 1.8 times the odds (odds ratio [OR]=1.8, 95% confidence limits [CL]: 1.4, 2.2) of a history of STIs compared with individuals who...
As few studies have examined the relation between pubic hair grooming and sexually transmitted infections (STIs), we took advantage of nationally representative survey data to begin to explore this possible association and to develop hypotheses for future prospective studies. In our analysis, we observed a positive association between self-reported pubic hair grooming and STI history, which we interpreted in several poss...
Dear Madam, dear Sir: With interest, we read the paper of Chow et al. (1) reporting that Listerine antiseptic mouthwash can kill Neisseria gonorrhoeae in vitro and reduce the amount of gonococci on pharyngeal surfaces. There is no doubt that measures beyond antibiotic treatment of gonococcal infections detected clinically or by laboratory testing are needed to reduce the prevalence of infection and that mouthwash can dimi...
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