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 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.
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!
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.
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
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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 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 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 MoreI'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...
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 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...
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...
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...
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...
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...
Dear Editor,
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),...
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