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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
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
We thank the contributor for his interest in our paper,[1] and for
highlighting the role of oral sex in the transmission of STI.
On a population level, public health intervention tends to focus on
the encouragement of "safer" sexual practices. The British Association for
Sexual Health and HIV defines safer sex as "having sex with less risk of
transmission a sexually transmitted infection," and its guidance states...
We thank the contributor for his interest in our paper,[1] and for
highlighting the role of oral sex in the transmission of STI.
On a population level, public health intervention tends to focus on
the encouragement of "safer" sexual practices. The British Association for
Sexual Health and HIV defines safer sex as "having sex with less risk of
transmission a sexually transmitted infection," and its guidance states
that "The risk of catching an STI through unprotected oral sex is lower
than for unprotected vaginal or anal sex, but is not zero."[2] As such,
unprotected oral sex may be considered as safer sex with respect to
unprotected vaginal or anal intercourse.
Oral sex may include fellatio, cunnilingus and anilingus. While
barrier methods are available for each of these exchanges, literature
suggests they are used infrequently.[3] Including oral sex in our data
analyses is likely to have yielded a higher percentage of 'at risk'
individuals, but without thorough exploration would have confounded our
findings with participants in what are currently understood to be lower-
risk activities. This may have weakened rather than strengthened our
conclusions. Therefore, our data collection tool focused on the higher
risk practices of unprotected vaginal and anal intercourse. No data
pertaining to oral sex were collected.
We acknowledge the need for greater understanding of oral sex as a
conduit for STI transmission, and realise the importance of further
investigation into the role of the oropharynx as a reservoir of disease.
We are grateful that the contributor has brought this to the attention of
the readership, and look forward to future research in this area which
falls outside the scope of our study.
REFERENCES
[1] Lewis CT, de Wildt G. Sexual behaviour of backpackers who visit
Koh Tao and Koh Phangan, Thailand: a cross-sectional study. Sex Transm
Infect. 2016; 92:410-4.
[2] Clutterbuck DJ, Flowers P, Barber T; Clinical Effectiveness Group
of British Association for Sexual Health and HIV (BASHH) and British HIV
Association (BHIVA). UK National Guidelines on safer sex advice. Int J STD
AIDS. 2012; 23:381-8.
[3] Stone N, Hatherall B, Ingham R, et al. Oral sex and condom use
among young people in the United Kingdom. Perspect Sex Reprod Health.
2006; 38:6-12.
The topic of prostitution is of utmost importance to the public
health. The study by Parvez, Katyal, Alper, Leibowitz, and Venters (2013)
thoroughly investigates the population of female sex workers in New York
City who have been arrested for prostitution. This study is seminal
because it is the first one that investigates rates of sexually
transmitted disease infection in female sex workers incarcerated in New
York. Th...
The topic of prostitution is of utmost importance to the public
health. The study by Parvez, Katyal, Alper, Leibowitz, and Venters (2013)
thoroughly investigates the population of female sex workers in New York
City who have been arrested for prostitution. This study is seminal
because it is the first one that investigates rates of sexually
transmitted disease infection in female sex workers incarcerated in New
York. The authors conclude that there are number of risk factors for
transmission that go beyond the mere profession of the workers. The
research provides data needed to make informed policy decisions relating
to programs and interventions that may lower the rate of transmission of
sexual diseases in the prostitution population in New York, and thus
improve the overall health of individuals who come into contact with
female sex workers as customers and partners. By inference the health of
the entire community is better served by interventions suited to the
population. This is an excellent and informative article.
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.
Modifying sexual behavior remains the primary goal of preventing the
transmission of HIV/STIs among populations. However, with the various
borderlines of "safe sex" definition, people sometimes get confused to
describe how to practice low-risk sex activities. In general, safe sex is
defined as sexual activities in which avoiding any bodily fluid exchanges
(sperm, vaginal fluid, blood, and saliva),...
Modifying sexual behavior remains the primary goal of preventing the
transmission of HIV/STIs among populations. However, with the various
borderlines of "safe sex" definition, people sometimes get confused to
describe how to practice low-risk sex activities. In general, safe sex is
defined as sexual activities in which avoiding any bodily fluid exchanges
(sperm, vaginal fluid, blood, and saliva), with the aim of preventing
HIV/STIs transmission (1). According to this definition, we may correlate
safe sex behaviors with the use of condoms during sexual intercourse from
anal, vaginal, and oral sex.
In the study, analysis of measuring safe sex acts with consistent condom
use was devoted to the anal and vaginal sex, yet it excluded oral sex (2).
In fact, oral sex plays a significant role in the transmission of
important STIs, such as syphilis, herpes, warts, and gonorrhea (3). One
case belongs to pharyngeal gonorrhea which is widely spread through
intense oral sex practices (4). Pharyngeal gonorrhea now has been raising
in incidence especially in developed countries (5) as higher oral sex
practices than coital sex (6). Hence, oral sex is closely associated with
further gonorrhea transmission (7), and more importantly, it is highly
likely to induce antimicrobial resistance (super gonorrhea) (8, 9).
Considering the significant role of oral sex, several study included oral
sex variable to define "consistent condom use" criteria (10, 11).
In my opinion, applying the variable of oral sex in the data analysis may
influence the final results and conclusions in this study. Some studies
revealed inconsistent condom use occurred more frequent during oral sex
(12, 13), due to the erroneous perceptions towards the role of oral sex in
spreading STIs (14). This research would give benefits in providing
evidence on traveler's sexual behaviors and provide fundamental inputs to
develop health promotion strategies for this population. More
specifically, the result of the study could help Thailand government in
evaluating the 100% condom program for sex workers (15), by identifying
the rate of condom use among travelers who had sex with local sex workers.
Reference
1.Safe sex [Def. 1]. (n.d.). Merriam-Webster Online. In Merriam-Webster.
Retrieved November 16, 2016, from www.merriam-
webster.com/dictionary/safe%20sex
2.Lewis, C. T., and G. de Wildt. 'Sexual Behaviour of Backpackers Who
Visit Koh Tao and Koh Phangan, Thailand: A Cross-Sectional Study',
Sexually Transmitted Infections, vol. 92/no. 6, (2016), pp. 410-414.
3.Kumar, Tarun, Gagan Puri, Konidena Aravinda, et al. 'Oral Sex and Oral
Health: An Enigma in itself', Indian Journal of Sexually Transmitted
Diseases, vol. 36/no. 2, (2015), pp. 129-132.
4.Wiesner, Paul J., Evelyn Tronca, Paul Bonin, et al. 'Clinical Spectrum
of Pharyngeal Gonococcal Infection', The New England Journal of Medicine,
vol. 288/no. 4, (1973), pp. 181-185.
5.Morris, Sheldon R., Jeffrey D. Klausner, Susan P. Buchbinder, et al.
'Prevalence and Incidence of Pharyngeal Gonorrhea in a Longitudinal Sample
of Men Who have Sex with Men: The EXPLORE Study', Clinical Infectious
Diseases, vol. 43/no. 10, (2006), pp. 1284-1289.
6.Halpern-Felsher, Bonnie L., Jodi L. Cornell, Rhonda Y. Kropp, et al.
'Oral Versus Vaginal Sex among Adolescents: Perceptions, Attitudes, and
Behavior', Pediatrics, vol. 115/no. 4, (2005), pp. 845-851
7.Weinstock, Hillard, and Kimberly A. Workowski. 'Pharyngeal Gonorrhea: An
Important Reservoir of Infection?', Clinical Infectious Diseases, vol.
49/no. 12, (2009), pp. 1798-1800.
8.Deguchi, Takashi, Mitsuru Yasuda, and Shin Ito. 'Management of
Pharyngeal Gonorrhea is Crucial to Prevent the Emergence and Spread of
Antibiotic-Resistant Neisseria Gonorrhoeae', Antimicrobial Agents and
Chemotherapy, vol. 56/no. 7, (2012), pp. 4039-4040.
9.Gratrix, Jennifer, Joshua Bergman, Cari Egan, et al. 'Retrospective
Review of Pharyngeal Gonorrhea Treatment Failures in Alberta, Canada',
Sexually Transmitted Diseases, vol. 40/no. 11, (2013), pp. 877-879
10.Crosby, Richard A., Cynthia A. Graham, William L. Yarber, et al.
'Measures of Attitudes Toward and Communication about Condom use: Their
Relationships with Sexual Risk Behavior among Young Black Men Who have Sex
with Men', Sexually Transmitted Diseases, vol. 43/no. 2, (2016), pp. 94-
98.
11.Fridlund, Veronika, Karin Stenqvist, Monica K. Nordvik, et al. 'Condom
use: The Discrepancy between Practice and Behavioral Expectations',
Scandinavian Journal of Public Health, vol. 42/no. 8, (2014), pp. 759-765.
12.Stone, Nicole, Bethan Hatherall, Roger Ingham, et al. 'Oral Sex and
Condom use among Young People in the United Kingdom', Perspectives on
Sexual and Reproductive Health, vol. 38/no. 1, (2006), pp. 6-12.
13.Noar, Seth M., Elizabeth Webb, Stephanie Van Stee, et al. 'Sexual
Partnerships, Risk Behaviors, and Condom use among Low-Income Heterosexual
African Americans: A Qualitative Study', Archives of Sexual Behavior, vol.
41/no. 4, (2012), pp. 959-970.
14.Minichiello, V., R. Mari?o, and J. Browne. 'Knowledge, Risk Perceptions
and Condom Usage in Male Sex Workers from Three Australian Cities', AIDS
Care, vol. 13/no. 3, (2001), pp. 387-402.
15.Rojanapithayakorn, W., and R. Hanenberg. 'The 100% Condom Program in
Thailand', AIDS (London, England), vol. 10/no. 1, (1996), pp. 1-8.
Lukman Ade Chandra
Postgraduate student of Master of Medicine/Master of Philosophy (HIV, STI,
and Sexual Health), University of Sydney, Australia
38 Cleveland St, Chippendale, Sydney, NSW, Australia 2008
email:
chandralukmanade@gmail.com/lcha8676@uni.sydney.edu.au
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
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.
Thank you very much for carefully reading our article and for your
positive feedback. We have read your E-letter with great interest. We are
pleased that our publication contributed to adjustment of your policy
concerning retesting. Implementing a text message reminder and lengthening
the follow up period to 3 months is likely to elevate the return rate and
positivity rate. According to our research, you may even consider...
Thank you very much for carefully reading our article and for your
positive feedback. We have read your E-letter with great interest. We are
pleased that our publication contributed to adjustment of your policy
concerning retesting. Implementing a text message reminder and lengthening
the follow up period to 3 months is likely to elevate the return rate and
positivity rate. According to our research, you may even consider
lengthening the follow up period to 6 months to yield even more chlamydia
reinfections.
In your letter you show that you already achieve a relatively high
return rate of 26.8% without sending a text message reminder. Also, in
research from Burton et al, 2014, the return rate was high with 35%
without sending a text message reminder. These are much higher return
rates than in our control group (9.2%). In your E-letter (Ahmed et al.
STI, 2016), you question whether patients in the Netherlands are advised
to do a repeat test. We do have an informal guideline concerning this
advice, though it is not certain that every clinic in our study group gave
this advice. Therefore we cannot state that this retest-advice is
consistently given, and that could have (in part) caused our relatively
low return-rates in the control group. Also, you state in the E-letter
that sexual health appointments in your service are available by booking
in advance or on the day. It is unclear to me whether this means that an
appointment for retest is already made after initial consultation or that
patients who want to do a retest can come at any day. In our study,
booking in advance was not done. In our STI clinics, the usual waiting
time for non-emergency sexual health consultations is 2-3 weeks. This
could be an additional factor in the difference between our return rate
and the return rate of the UK research described.
In the Netherlands, the sexual health clinics are exploring and
implementing cost-effective strategies to lower the threshold for (re-
)testing on STI. As an example of how to make retesting more (cost-)
effective, we like to refer to a Dutch article by Gotz, et al [1], where
the retest participation was higher in the patient-group that received a
testkit at their home address (46%, 50/109), compared to the group asked
to visit the STI clinic for retesting without an appointment (23%,
25/107). Home-based testkits can be a good method to increase the re-
attendance rate. Though some STI-clinics in the Netherlands implement this
strategy for low-risk patients, it hasn't yet been implemented for the
purpose of a retest. This might, however, be an interesting cost-effective
way to identify chlamydia reinfections.
[1] G?tz HM, Wolfers MEG, Luijendijk A, van den Broek IVG. Retesting
for genital Chlamydia trachomatis among visitors of a sexually transmitted
infections clinic: randomized intervention trial of home- versus clinic-
based recall. BMC Infectious Diseases 2013, 13:239
I am flabbergasted that this public health article exists at all.
Where is the peer review. The problem lies in the appropriateness of
source data which was used. In an email exchange I confirmed that I
understood that the authors did indeed divide interviewed sex workers into
two groups, one that experienced violence in the single preceding week and
a second group that did not. They then compared health data for
diff...
I am flabbergasted that this public health article exists at all.
Where is the peer review. The problem lies in the appropriateness of
source data which was used. In an email exchange I confirmed that I
understood that the authors did indeed divide interviewed sex workers into
two groups, one that experienced violence in the single preceding week and
a second group that did not. They then compared health data for
differences between the two groups. The source data came from the 2007
Survey of Sexual and Reproductive Health of Sex Workers in Thailand. This
was a huge project with many volunteers to conduct 120 question
interviews. The result is 815 in depth personal interviews. The abstract
of this study I am criticizing says that 14.6% of these 815 experienced
violence on the job in only one week before their interview. This is a
huge red flag for anyone knowledgable regarding this issue. There are
other studies including my own that might agree that violence reported is
in the low to mid teens but that is true when asking about violence over
one year, but not one week. My own micro-research survey of 100 sex
workers in the Nana Plaza area of Bangkok reported 13% violence over a
year. But when the response of "a raised voice or argument" (no physical
contact) was discarded, the level of physical violence in one year dropped
to less than 2% out of 98 good surveys.
This tells me it is time to ask how the 2007 study in Thailand
defined violence. I have a copy. Of 120 questions, only one can claim to
speak to levels of violence. Question Q804 says: In the last seven days,
have any of the following happened to you at work? There are six possible
choices. Only two choices involve physical contact between the sex worker
and her customer. Here are the choices: Yelled at / Hit / Forced to
perform sex acts you did not want to perform / Not paid / Paid less than
agreed / Made to do other things you didn't want to do. Two of the six
choices are about payment. Yet a YES answer to any of these six choices
will put this interviewee in the "violence" group. So, you be the judge.
Is this a proper way to create two discrete groups appropriate for
comparison? When four of the six choices used to define violence do not
necessarily involve any physical contact, at least none that is different
then the other group experienced, there are no grounds to assume anything
about health differences between these fatuously assembled groups based on
violence.
Just my opinion. Respond to tell me what you think.
Conflict of Interest:
My only competing interest is that I oppose the hyperbole and exaggeration surrounding the issues of sex trafficking and sex work. This is a minor offense but claiming 14.6% violence in one week based on only poorly designed question is inflammatory.
Dear editor,
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We thank the contributor for his interest in our paper,[1] and for highlighting the role of oral sex in the transmission of STI.
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Dear Editor,
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Thank you very much for carefully reading our article and for your positive feedback. We have read your E-letter with great interest. We are pleased that our publication contributed to adjustment of your policy concerning retesting. Implementing a text message reminder and lengthening the follow up period to 3 months is likely to elevate the return rate and positivity rate. According to our research, you may even consider...
I am flabbergasted that this public health article exists at all. Where is the peer review. The problem lies in the appropriateness of source data which was used. In an email exchange I confirmed that I understood that the authors did indeed divide interviewed sex workers into two groups, one that experienced violence in the single preceding week and a second group that did not. They then compared health data for diff...
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