I note Dr Watson wishes to "reserve his judgement" about the Cervarix versus Gardasil decision until he knows the details. Unfortunately he will be reserving his judgment ad infinitum because despite requests from
me and others the Department of Health refused to release the details of the decision. They have issued the criteria and it appears to have been a tick boxing exercise where cost was paramoun...
I note Dr Watson wishes to "reserve his judgement" about the Cervarix versus Gardasil decision until he knows the details. Unfortunately he will be reserving his judgment ad infinitum because despite requests from
me and others the Department of Health refused to release the details of the decision. They have issued the criteria and it appears to have been a tick boxing exercise where cost was paramount.
Dr Watson is also sceptical about additionally vaccinating with HPV types 6 and 11 giving added benefit. There are many studies, showing that Gardasil is almost 100% effective at preventing genital warts the majority
of which are caused by types 6 and 11. Not only that, but many abnormal smears are caused by 6 and 11, although they do not progress to severe dyskaryosis. So there is no question that there would have been an enormous clinical benefit by using Gardasil. It is untrue to say that the
programme was always about cervical cancer, it was about HPV vaccination and indeed in the reply I received from Dawn Primrolo and Alan Johnson in February 2008 (before any decision was made) they encouragingly used the
sentence “It is expected the vaccination of girls would reduce the transmission of infection to boys, by herd immunity, and reduce the number of genital wart cases in boys as well as girls”.
Finally Dr Watson criticises my use of words like "shocked and appalled", but my editorial was only reflecting the opinion of every single Sexual Health/GUM Doctor who has offered me an opinion on this issue. The editorial was approved by the BASHH media committee in response to the outrage expressed by most of the members and other doctors
they had been in touch with. Even in the small hamlet of Aberystwyth in Wales, I am sure Dr Watson spends considerable amount of his clinical time managing genital warts with all their physical and psychological consequences. Sexual Health/GUM Physicians should be advocates for their patient’s misery. Our
patients can not do it for themselves. It is interesting that there are many well funded charities for cervical cancer who can attract publicity and lobby successfully, but there is none for genital warts. We owe it to our patients to complain loudly when political considerations override the benefits that would have accrued to our patients had the quadrivalent vaccine been chosen.
I wish to distance myself from Colm O'Mahony's rather hysterical editorial on the selection of Cervarix for the human papillomavirus immunization programme (O'Mahony C. Government decision on national human papillomavirus vaccine (HPV) programme is a sad day for sexual health. Sex
Transm Infect 2008;84:251). I do not yet know why Cervarix was selected ahead of Gardasil and until I do I wish to reserve my...
I wish to distance myself from Colm O'Mahony's rather hysterical editorial on the selection of Cervarix for the human papillomavirus immunization programme (O'Mahony C. Government decision on national human papillomavirus vaccine (HPV) programme is a sad day for sexual health. Sex
Transm Infect 2008;84:251). I do not yet know why Cervarix was selected ahead of Gardasil and until I do I wish to reserve my judgement on the decision. It is tempting to believe that immunizing against HPV types 6 and 11 in addition to types 16 and 18 would produce an added benefit.
However the aim of the immunization programme is to prevent carcinoma of the cervix and as far as I know there is no evidence that immunizing against HPV types 6 and 11 will achieve that aim. We might argue that there should have been trials to allow the added benefit of immunizing
against HPV types 6 and 11 to be shown but there were not so perhaps in selecting Cervarix the Department of Health has simply practised evidence based medicine.
If MacDonald, Humphreys and Jaffe (2008, STI, 84) are correct in their contention that circumcising men who have sex with men will result in a reduction in HIV incidence among this population, then we would expect circumcised MSM in the UK have a lower incidence of HIV than un-circumcised MSM. This should be reflected in HIV prevalence and since
there is no reason to think that circumcision promotes diag...
If MacDonald, Humphreys and Jaffe (2008, STI, 84) are correct in their contention that circumcising men who have sex with men will result in a reduction in HIV incidence among this population, then we would expect circumcised MSM in the UK have a lower incidence of HIV than un-circumcised MSM. This should be reflected in HIV prevalence and since
there is no reason to think that circumcision promotes diagnoses of HIV, this difference should be reflected in the prevalence of diagnosed HIV.
In 2001 we carried out a short, community-based, self-completion survey among 12,433 White British men aged 16 and over, living in the UK, who had sex with another man in the last year and/or identify as gay or bisexual. Fieldwork was conducted over the summer at Gay Pride events
(52.1% of respondents), on-line through commercial gay web sites (31.6%) and through community based HIV prevention organisations (16.3%). Self report is a valid measure of circumcision in MSM (Termpleton et al., 2008, STI, 84).
Overall, 0.5% (n=64) indicated they did not know whether they had been circumcised or not. Excluding these men, 18.6% (2438/13,127) of respondents said they had been circumcised.
Circumcised men were as a group, older than un-circumcised men (mean age 36.5 years, sd 12.0, median 35, range 16-82 compared with mean 32.3, sd 10.2, median 31, range 16-79). The proportion of men who were circumcised increased step-wise with increasing age (11.9% of teens, 14.7% among those in their 20s, 16.8% in the 30s, 21.7% in the 40s and 38.1% among those 50 and older). More of the circumcised men lived in London (24.8% compare with 19.6% of un-circumcised men ).
Overall, 4.6% of respondents indicated they were living with diagnosed HIV infection. Circumcised men were not more or less likely to be living with diagnosed HIV (5.2% compared with 4.5% in un-circumcised men: chi squared = 1.84, p=0.175). In a multiple logistic regression
controlling for age and living in London, the odds ratio of a circumcised man living with diagnosed HIV to an un-circumcised man doing so was 1.01 (95% confidence interval 0.81-1.25).
This suggests that circumcising MSM will make no difference to HIV incidence in this population. Since HIV acquisition in the UK is highly concentrated in MSM (HPA, 2008) and since identification of future MSM pre
-puberty is not feasible, this suggest circumcision has little part to play in the UK HIV epidemic. Those concerned with the UK epidemic should be looking elsewhere for solutions. We have no doubt that a multi-pronged
approach to minimising HIV infections is required. We also have little doubt that maximising circumcision is not one of them among MSM in the UK. Minimising nitrite inhalant use during unsafe sex might, on the other hand, have a very real effect (McDonald et al. 2008, STI, 84). We support
MacDonald, Humphreys and Jaffe's call for more experimental research about HIV among MSM in the UK but stress that these have yet to be done for much more promising interventions than circumcision.
The recent article published in this journal(1) emphasised the importance of effective planning and implementation for the success of EPR. In 2006 as part of a city wide “collaborative integration “ between sexual health service providers in Salford,we transferred to a “shared electronic record” between Genitourinary medicine(GUM), Family planning(F.P.) and young persons(Y.P.) services as part of a...
The recent article published in this journal(1) emphasised the importance of effective planning and implementation for the success of EPR. In 2006 as part of a city wide “collaborative integration “ between sexual health service providers in Salford,we transferred to a “shared electronic record” between Genitourinary medicine(GUM), Family planning(F.P.) and young persons(Y.P.) services as part of a sexual
health IT network.
The service is provided by 1 GUM clinic , 5 F.P. clinics, and 2 Y.P. clinics all on different sites. The total annual workload is approximately 18,000 attendences a year. Funding was secured for a complete overhaul of IT systems, and both GUM and F.P.services were upgraded to the Blithe “lillie” system version 6.10. Purchase and renewal of all computers within the network took place so that all clinicians and clerical staff had access to a computer.
Diagnostic coded data from the previous seven years were migrated into the Blithe system to reduce use of paper based records in all but the most complex patients returning for follow up or re-book. To secure pt confidentiality , access levels to the system were limited, and was password protected with only senior clinicians gaining access to
all the complete patient records, and other administrative reporting functions .A dedicated “citrix server” was used to store patient database , with no interface to any other healthcare IT systems .
The other main impetus for re-organisation of sexual health, was that all trained nursing staff based in GUM,worked across both F.P. and Y.P.gradually introducing STI level 2 expertise in these clinics. This helped to break down any organisational barriers that existed prior to
integration of services. A “hub and spoke” model was adopted for specialist referral from FP/YP clinics(spokes) into GUM(hub) for level 3 expertise (eg microscopy,warts
treatment). This was facilitated by pts being electronically booked directly from FP/YP into an appointment slot in GUM.The shared electronic record from the initial episode being open and accessible to clinicians in GUM. This precluded the patient having to make there own appointment, with no referral letter required.The attendance rate for such referrals from the spokes were in excess of 90%.
The system has now been running for over 12 months, and we would agree with Brook et al that during the planning phase, modification and amendment to input profiles were needed to adapt to local needs, in particular for sexual health history,sexual health consultation and HIV
pre- test discussion.
In addition the treatment lists for GUM/ HIV needed adding to and modification.
We also found that during implementation use of all standard input profiles consisting of mainly scroll down menus was too time consuming for dealing with the majority of patients especially “asymptomatics”. Frequently 5 separate “consultation” lists were being used.
We have since ceased using these, but continue with essential consultation input profiles such as tests requests, test results and HIV pre test-discussion.
Instead we have adopted free text for each patient episode to describe sexual history, general medical history and examination findings. We found the use of an anatomical genital diagram, incorporated with patient episode(s), greatly enhanced the accuracy of the record.
Clinicians using consultations for contraceptive services have similarly modified their input profiles.
The overall advantages are rapid and remote access to legible patient records for diagnosis and treatments.
In addition ,the improved facility of providing a range of activity reports and audit, together with reduction of storage space. Locally there is ease of cross referral and information sharing between GUM,FP and YP sexual health services within the network.
The next phase is direct input of all laboratory results electronically including microscopy results.All of these are currently inputted manually. This will help reduce both administrative staff time and any potential transcription errors.
There is little doubt that the system as outlined above has been a major contributor in the collaboration and modernisation of sexual health services in Salford.
References
1. M G Brook, J Davies, J McSorley, and S Murphy
Implementation of electronic patient records in a
sexual health clinic
Sex Transm Infect 2008; 84: 155-156.
Gopal Rao et al. found a high prevalence of gonorrhoea infection (3.8%) in women aged <_25 attending="attending" community="community" sexual="sexual" and="and" reproductive="reproductive" health="health" clinics="clinics" in="in" south="south" london.="london." _1="_1" as="as" barlow="barlow" highlights="highlights" his="his" accompanying="accompanying" commentary="commentary" there="there" is="is" a="a" dearth="dearth" of="of" studies="studies" on="on" gonorrhoea="gonorrhoea" prevalence="prevalence" natural="natural" history.2="history.2" our="our" preliminary="preliminary" results="results" from="from" based="based" study="study" similar="similar" part="part" london="london" may="may" provide="provide" comparative="comparative" data.="data." p="p"/>The POPI (Prevention of Pelvic Infection) trial, aims to see if screening and treatment for chlamydia reduces the incidence of pelvic inflammatory disease over 12 months. Participants comprise 2531 sexually active female students, 40% from ethnic minorities, mean age 20.9 years (range 16-27years). They were recruited from 20 universities and Further Education Colleges, mainly in South London in 2004-6.3 At recruitment, participants provided a self taken lower vaginal swab and completed a questionnaire on demographic and sexual behaviour characteristics. Nine hundred and fifty-five participants have returned a repeat postal sample 1-3 years after recruitment.
To date, 286 baseline samples and all 955 follow up samples have been tested for gonorrhoea using Gen-Probe APTIMA Combo 2 Assay (sensitivity 98.7%, specificity 99.6% 4). The positivity rate is 0.7% (2/286 95%CI 0.08-2.5%) at baseline and 0.5% (5/955 95%CI 0.2-1.2%) from repeat samples. Only two women had co-infection with chlamydia.
This positivity rate for gonorrhoea is similar to the 0.5% rate in women screened in the National Chlamydia Screening Programme in Liverpool. However, as in our study, over half the women who are positive for gonorrhoea are negative for chlamydia and would have been missed if only chlamydia positives were screened for gonorrhoea. If dual testing were routinely adopted by the NCSP, it is likely that many more cases of gonorrhoea would be diagnosed and treated.
Our diagnostic test was different to that of Gopal Rao et al. We used Aptima rather than Probe-Tec which we had previously found to assess around 25% of our early chlamydia results as indeterminate or inhibitory. In addition Barlow notes that use of Probe-Tec may lead to a slight overestimate of gonorrhoea prevalence. With participants recruited from non-health care settings, we furthermore expect to find a lower positivity rate than that of Gopal Rao et al. Caution is suggested when considering population based screening for gonorrhoea, since the positive predictive value (PPV) of nucleic acid amplification testing will depend on the prevalence.5 For example, for a gonorrhoea prevalence of 1% and a test sensitivity and specificity of 99%, the PPV may only be 50%.5 However in our study we used the APTIMA Combo2 backed up by confirmatory testing of positives. This has a PPV of 97% even in a low prevalence population. We hope complete data on gonorrhoea status of all 2531 participants will assist in providing an estimation of the burden of gonorrhoea infection in the community.
References
1. Gopal Rao et al. Prevalence of Neisseria gonorrheae infection in young subjects attending community clinics in South London. Sex Transm Inf. 2008;84:117-21
2. Barlow D. Commentary. Sex Transm Inf. 2008;84:121
3. Atherton H et al. Recruitment of young women to a trial of chlamydia screening - as easy as it sounds? Trials 2007: 8:41 Available from URL http://www.trialsjournal.com/content/8/1/41
4. Schachter J. et al. Vaginal swabs are the specimens of choice when screening for chlamydia trachomatis and Neisseria gonorrhoeae: Results from a multicenter evaluation of the APTIMA assays for both infections. Sex Transm Dis. 2005;32:725-728
5. Ison C. GC NAATs: Is the time right? Sex Transm Inf. 2006;82;515
Funding: The BUPA Foundation and The Medical Research Council
We thank Gen-Probe for providing the gonorrhoea testing kits.
Ethical approval: Bromley Research Ethics Committee
In the editorial Focus on chlamydia(1), screening of asymptomatic individuals to prevent transmission and adverse consequences of chlamydia was discussed. We wish to raise the issue of uncertainty around the appropriate timing of chlamydia tests in relation to exposure.
The National Chlamydia Screening Programme (NCSP) Core Requirements (3rd Edition) states ‘There is no data on the use of nucle...
In the editorial Focus on chlamydia(1), screening of asymptomatic individuals to prevent transmission and adverse consequences of chlamydia was discussed. We wish to raise the issue of uncertainty around the appropriate timing of chlamydia tests in relation to exposure.
The National Chlamydia Screening Programme (NCSP) Core Requirements (3rd Edition) states ‘There is no data on the use of nucleic acid amplification tests (NAATs) and how soon after sex a test may become positive’ and advises to test immediately and repeat the test in 3-5 weeks(2).
A local (i.e. Central Lancashire PCT) NCSP poster states ‘The test should be taken 3 weeks after sexual contact, as the infection may not show immediately’.
The British Association for Sexual Health and HIV (BASHH) UK National STI Screening and Testing Guidelines indicate that the minimum time gap between exposure to a sexually transmitted infection and its successful
detection varies depending on a number of factors including the organism, the size of inoculum and the type of test used. These guidelines highlight that the evidence base for specific recommendations on how long to wait before testing for different STIs is limited, and state ‘for bacterial
STIs, many clinicians would wait 3-7 days before testing (level IV)’(3)
Given pressure to meet GUM 48 hour access targets, it may be that a greater proportion of patients present to GUM clinics too soon after exposure to detect or exclude the infection. The need to consider a second test after baseline testing should therefore be borne in mind. We
would NOT agree with the statement in the local NCSP poster, which effectively advises patients to defer testing, a strategy which runs counter to the public health arguments for rapid access to GUM clinics.
We ask the question ‘What is a suitable “window period” for chlamydial infection?’ We await guidance from those in a position to undertake the research to answer the question.
If service providers undertake a baseline test and, where relevant, consider a repeat test after a suitable period of time, old and recently acquired infection should be excluded. The recommendation by NCSP for a repeat test after 3-5 weeks appears unrealistic.
The discrepancies between BASHH guidelines and the NCSP Core Requirements and in particular, between NCSP Core Requirements and local delivery of the NCSP, are a cause for concern. Currently, service providers are giving mixed messages. It would be helpful if BASHH and NCSP gave the same steer on this in order to facilitate uniformity of
approach at the local level.
Competing interests: None
Corresponding Author:
Dr. Carolyn Rigg
GUM Department,
Southport and Formby District General Hospital
Town Lane
Southport
Merseyside, PR9 7LJ
carolynrigg@doctors.org.uk
Tel: 01704 547471
Co-author:
Dr. Mike Abbott
GUM Department,
Southport and Formby District General Hospital
Town Lane
Southport
Merseyside, PR9 7LJ
References
1. Low N, Ward H. Focus on chlamydia. Sex Transm Infect 2007;83:251-52.
2. National Chlamydia Screening Programme England: Core Requirements (Third Edition). London: HPA, September 2006.
http://www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/SexualHealth/SexualHealthGeneralInformation/SexualHealthGeneralArticle/fs/en?CONTENT_ID=4084098&chk=CSLxsK
3. British Association for Sexual Health and HIV. UK National STI Screening and Testing Guideline, August 2006.
http://www.bashh.org/guidelines.asp
The report by Grijsen and colleagues documenting the high frequency of unprotected receptive anal intercourse (RAI) in young Kenyans at high risk for HIV infection (1) is a welcome contribution to the small but growing number of studies investigating RAI as a specific risk for HIV in
sub-Saharan Africa (2-7). Their study, however, presents us with yet another anomaly unlikely to be resolved by the assessme...
The report by Grijsen and colleagues documenting the high frequency of unprotected receptive anal intercourse (RAI) in young Kenyans at high risk for HIV infection (1) is a welcome contribution to the small but growing number of studies investigating RAI as a specific risk for HIV in
sub-Saharan Africa (2-7). Their study, however, presents us with yet another anomaly unlikely to be resolved by the assessment of sexual risk factors alone (8). Although the authors found that “RAI was strongly associated with HIV-1 in men (adjusted odds ratio = 3.8)", they also reported that among women, RAI was not associated with prevalent HIV
infection, but that those practicing RAI were much more likely to have syphilis (adjusted odds ratio 12.9). Puzzled, the authors note: “It is not clear why this difference was found…” None of the possible reasons
they propose for this anomaly includes nonsexual HIV transmission. That these women were 10 times more likely to have serological markers of HIV (a sexually transmissible infection) than of current or past syphilis (a sexually transmitted) infection should be viewed as a red flag, even
considering their nonspecific diagnostic criteria for syphilis (classification based on qualitative rapid plasma reagin test and the Treponema pallidum haemagglutination assay, neither of which rules out nonsexually transmitted treponematoses). The magnitude of the difference
between HIV and “syphilis” markers alone suggests that sexual factors may have played a lesser role in observed HIV prevalence than nonsexual ones.
Because the authors apparently did not also assess nonsexual (blood) exposures, this possibility cannot be explored with their data -- a frustratingly common shortcoming in epidemiologic studies conducted in
Africa (9). In addition, a strong association between anal sex and prostitution might mask the association between anal sex and HIV in their women participants. Thus, given a strong association between RAI and prostitution, it is important to report the bivariate relationships among
all predictors and their relationship with prevalent HIV infection. Lastly, Grijsen and colleagues stress the importance of prevention messages about the dangers of unprotected RAI to those high- risk persons
reporting it. Yet because RAI is probably not confined to “high-risk” persons (2), broader community prevention messages might more usefully fit overall HIV prevention objectives. Anal intercourse is common in sub-
Saharan Africa populations (2-7) and is often perceived as involving no risk for HIV transmission (4,7).
John J. Potterat, BA, Colorado Springs, CO, USA
Stuart Brody PhD, University of the West of Scotland, UK
Devon D. Brewer, PhD, Interdisciplinary Scientific Research, Seattle, WA, USA
Stephen Q. Muth, BA, Colorado Springs, CO, USA
References
1. Grijsen MI, Graham SM, Mwangome M, et al. Screening for genital and anorectal sexually transmitted infections in HIV prevention trials in Africa.
Sex Transm Infect (doi: 10.1136/sti2007.028852)
2. Brody S, Potterat JJ. Assessing the role of anal intercourse in the epidemiology of AIDS in Africa.
Int J STD AIDS 2003; 14: 431-436.
3. Lane T, Pettifor A, Pascoe S, Fiamma A, Rees H. Heterosexual anal intercourse increases risk of HIV infection among young South African men.
AIDS 2006; 20: 123-125.
4. Ramjee G, Gouws E, Andrews A, Myer L, Weber AE. The
acceptability of a vaginal microbicide among South African men. Int Fam Plan Persp 2001, 27: 164-170.
5. Simbayi LC, Kalichman SC, Jooste S, Cherry C, Mfecane S, Cain D. Risk factors for HIV-AIDS among youth in Cape Town, South Africa. AIDS Behav 2005; 9: 53-61.
6. Mwakagile D, Mmari E, Makwaya C, et al. Sexual behaviour among youths at high risk for HIV-1 infection in Dar es Salaam, Tanzania. Sex Transm Infect 2001; 77: 255-259.
7. Stadler JJ, Delany S, Matambo M. Sexual coercion and sexual desire: ambivalent meanings of heterosexual anal sex in Soweto, South Africa. AIDS Care 2007; 19: 1189-1193.
8. Brewer DD, Brody S, Drucker E, et al. Mounting anomalies in the epidemiology of AIDS in Africa: cry the beloved paradigm. Int J STD AIDS 2003; 14: 144-147.
9. Gisselquist D, Potterat JJ, Brody S, Vachon F. Let it be sexual: how health care transmission of AIDS in Africa was ignored. Int J STD AIDS 2003; 14: 148-161.
I was pleased that the authors suggested that missed opportunities for early diagnosis could be reduced by tackling the problem from both the patient and the provider side. They note:
"From a patient perspective, the likelihood of future diagnosis could be improved by encouraging at-risk groups (for example, MSM) to access health care when they experience symptoms of seroconversion or followi...
I was pleased that the authors suggested that missed opportunities for early diagnosis could be reduced by tackling the problem from both the patient and the provider side. They note:
"From a patient perspective, the likelihood of future diagnosis could be improved by encouraging at-risk groups (for example, MSM) to access health care when they experience symptoms of seroconversion or following high risk exposure."
Would it be too much to urge members of groups at high risk for infectious disease to mention to their service provider that they are a member of that group? And would it be too much for doctors who suspect risky behaviours to ask? I understand the importance of patient confidentiality but primary HIV infection is dangerous for behavioural as well as virological reasons, and uninfected people have rights, too. Those rights are best protected by reducing all possible barriers to diagnosing early HIV infection, and providing active prevention services for those diagnosed.
What will become of the KC60? In the October 2007 edition of this journal. Hughes et al (1) reported on the KC60 returns from genitourinary medicine (GUM) clinics for 2006. They comment in their conclusion that diagnoses made outside GUM are not included, which is clearly a major deficiency if we are using the KC60 as an epidemiological surveillance
tool.
What will become of the KC60? In the October 2007 edition of this journal. Hughes et al (1) reported on the KC60 returns from genitourinary medicine (GUM) clinics for 2006. They comment in their conclusion that diagnoses made outside GUM are not included, which is clearly a major deficiency if we are using the KC60 as an epidemiological surveillance
tool.
Some community data does find a way in. Lavelle et al (2), in their letter in the December 2007 edition gave an example of this – the National Chlamydia Screening Programme ( N.C.S.P.) in Liverpool offers concomitant Nucleic Acid Amplification Test (N.A.A.T). screening for
gonorrohoea but if treatment is required it is given by the local GUM service. It is still coded as B1 (uncomplicated gonorrohea) and has probably distorted upwards the returns for that clinic, in contrast to the national trend. The authors suggestion is a change in or addition to the
KC60 coding to separate out diagnoses made by community clinics.
Another problem with using the KC60 as a surrogate for full epidemiological monitoring is that GUM clinics routinely report partner diagnoses into the KC60 and, as partners are much more likely to be positive, this distorts upwards prevalence estimates based on this data.
The recently developed Enhanced Sexually Transmitted Infections Surveillance Scheme for Cheshire and Merseyside (3) is an example of what might replace the KC60. Like the KC60 it is based on data collected in GUM, but also collects geographical data (by postcode) and much more
extensive demographic detail. It enables geographical mapping for service planning (by primary care trust) and for comparison with deprivation indices. It can also easily be combined with data from community screening programmes to increase coverage, although with the caveat that double reporting would have to be avoided.
If the KC60 is to be modified rather than replaced then it may be possible to alter its categories to allow unconfounded analyses ( e.g. diagnosed in GUM self-referral / partner of known case/ diagnosed in community but GUM referral etc ). But isn`t it complicated enough already? (4)
References
1. Hughes G, Simms I, Leong G. Data from UK genitourinary medicine clinics, 2006 : a mixed picture. Sex Transm Inf 2007;83:433-435
2. Lavelle S, Mallinson H, Henning S, et al. Impact on gonorrhoea case reports through concomitant/ dual testing in a chlamydia screening population in Liverpool. Sex Trans Inf 2007; 83: 593-594
3. Hargreaves S, Cook P, Bellis M. Enhanced Surveillance of Sexually Transmitted Infections in Cheshire and Merseyside 2006.
http://www.cph.org.uk/showpublication.aspx?pubid=327
4. Coyne K M, Cohen C, Mandalia S et al. KC60 Coding: room for improvement- a study into consistencies and inconsistencies in the use of
diagnosing codes. Int J STD AIDS 2007;18: 118-119
We agree with the authors of this paper (1) that improved awareness of Primary HIV Infection is of great importance in all areas of medical practice. Nevertheless we feel that there are some observations we wish to make.
In a relatively small study such as this recall bias is likely to influence the findings. Although this point is discussed this bias means that the interpretation of results re...
We agree with the authors of this paper (1) that improved awareness of Primary HIV Infection is of great importance in all areas of medical practice. Nevertheless we feel that there are some observations we wish to make.
In a relatively small study such as this recall bias is likely to influence the findings. Although this point is discussed this bias means that the interpretation of results requires further consideration. It is easy, with the benefit of hindsight, to point the finger at primary care
but, crucially in the study, the opportunity to examine the clinical notes for these patients was apparently not possible.
There is much emphasis in the paper on "missed diagnosis" but the results show that half the study group (52%) were correctly diagnosed with primary HIV infection at first presentation and of this figure general practitioners were successful in 4 patients – making up about a fifth of
cases. These figures, while not optimal, show that a degree of awareness of HIV infection in the community is present, but could be better (as it could in other sectors). That 79% of the missed diagnosis occurred in general practice is surely no surprise – 80% of all care happens here
anyway (2). Obviously a good history, an awareness of HIV risk and an ability to discern flu-like symptoms as possible indicators of acute HIV infection are the requirements any doctor should possess in order to make such diagnoses. Perhaps this is why MEDFASH (Ruth Lowbury, personal
communication) is producing a booklet for hospital doctors which emulates the existing one for general practitioners (3).
Importantly we are not saying that everything is rosy in this particular garden – how could we when at least one study illustrates that in an area of North London over the period from 2003-6 the majority of general practices did not test at all for HIV infection (4). There is still much to do in the field of general practice and sexual health, including HIV infection – but focusing on an area fraught with difficulty (only 1:2 patients sought advice or care at the time of their illness in the study above [1]) will inevitably result in negative outcomes.
Finally, and certainly implied by Sudarshi’s paper, it is essential that we include an awareness of primary HIV infection in the undergraduate medical curricula of all universities and ensure that all doctors who graduate in future are capable of taking an HIV risk history.
References
1. D Sudarshi, D Pao, G Murphy et al. Missed opportunities for diagnosing primary HIV infection. Missed opportunities for diagnosing primary HIV infection Sex Transm Infect 2008; 84: 14-16
2. Keeping it personal: clinical case for change. Report by Dr David Colin-Thomé. Department of Health, London UK 2006
3. Madge, S, Matthews P, Singh S, Theobald N. HIV in Primary Care. MEDFASH Publications, 2004
4. K Sadler, L Sutcliffe C Mercer et al. Variations in Chlamydia and HIV testing in general practices in London, UK: opportunities for increasing access to sexual health care?
(Poster presentation as part of the CaPSTI study – funded by the Medical search Council). International
society for sexually transmitted research 2007.
Dear Editor,
I note Dr Watson wishes to "reserve his judgement" about the Cervarix versus Gardasil decision until he knows the details. Unfortunately he will be reserving his judgment ad infinitum because despite requests from me and others the Department of Health refused to release the details of the decision. They have issued the criteria and it appears to have been a tick boxing exercise where cost was paramoun...
Dear Editor,
I wish to distance myself from Colm O'Mahony's rather hysterical editorial on the selection of Cervarix for the human papillomavirus immunization programme (O'Mahony C. Government decision on national human papillomavirus vaccine (HPV) programme is a sad day for sexual health. Sex Transm Infect 2008;84:251). I do not yet know why Cervarix was selected ahead of Gardasil and until I do I wish to reserve my...
Dear Editor,
If MacDonald, Humphreys and Jaffe (2008, STI, 84) are correct in their contention that circumcising men who have sex with men will result in a reduction in HIV incidence among this population, then we would expect circumcised MSM in the UK have a lower incidence of HIV than un-circumcised MSM. This should be reflected in HIV prevalence and since there is no reason to think that circumcision promotes diag...
Dear Editor,
The recent article published in this journal(1) emphasised the importance of effective planning and implementation for the success of EPR. In 2006 as part of a city wide “collaborative integration “ between sexual health service providers in Salford,we transferred to a “shared electronic record” between Genitourinary medicine(GUM), Family planning(F.P.) and young persons(Y.P.) services as part of a...
Dear Editor,
Gopal Rao et al. found a high prevalence of gonorrhoea infection (3.8%) in women aged...
Dear Editor,
In the editorial Focus on chlamydia(1), screening of asymptomatic individuals to prevent transmission and adverse consequences of chlamydia was discussed. We wish to raise the issue of uncertainty around the appropriate timing of chlamydia tests in relation to exposure.
The National Chlamydia Screening Programme (NCSP) Core Requirements (3rd Edition) states ‘There is no data on the use of nucle...
Dear Editor,
The report by Grijsen and colleagues documenting the high frequency of unprotected receptive anal intercourse (RAI) in young Kenyans at high risk for HIV infection (1) is a welcome contribution to the small but growing number of studies investigating RAI as a specific risk for HIV in sub-Saharan Africa (2-7). Their study, however, presents us with yet another anomaly unlikely to be resolved by the assessme...
Dear Editor,
I was pleased that the authors suggested that missed opportunities for early diagnosis could be reduced by tackling the problem from both the patient and the provider side. They note:
Dear Editor,
What will become of the KC60? In the October 2007 edition of this journal. Hughes et al (1) reported on the KC60 returns from genitourinary medicine (GUM) clinics for 2006. They comment in their conclusion that diagnoses made outside GUM are not included, which is clearly a major deficiency if we are using the KC60 as an epidemiological surveillance tool.
Some community data does find a way in....
Dear Editor,
We agree with the authors of this paper (1) that improved awareness of Primary HIV Infection is of great importance in all areas of medical practice. Nevertheless we feel that there are some observations we wish to make.
In a relatively small study such as this recall bias is likely to influence the findings. Although this point is discussed this bias means that the interpretation of results re...
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