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.
We read with interest the recent report by Kampman et al, 2016 [1] on
the effect of text reminders on patients attending for repeat chlamydia
tests and chlamydia diagnosis.
In our service, the St. Ann's Sexual Health Centre, a GUM clinic in
London, UK, our routine practice was to verbally advise patients treated
for chlamydia to re-attend 6-8 weeks after treatment for re-testing.
Sexual health appointments are...
We read with interest the recent report by Kampman et al, 2016 [1] on
the effect of text reminders on patients attending for repeat chlamydia
tests and chlamydia diagnosis.
In our service, the St. Ann's Sexual Health Centre, a GUM clinic in
London, UK, our routine practice was to verbally advise patients treated
for chlamydia to re-attend 6-8 weeks after treatment for re-testing.
Sexual health appointments are available either by booking in advance or
on the day depending on timing and capacity. We reviewed our overall
practice in managing chlamydia infections against the British Association
for Sexual Health and HIV (BASHH) national guidelines, but with a
particular focus on repeat testing. BASHH recommend a test of cure
(testing at 3-5 weeks) in certain groups (e.g. pregnant women) and repeat
testing 3 months after treatment in under 25 year olds, and considered, in
high risk groups. All patients with a positive chlamydia NAAT result over
a two month period in 2014 were identified and their clinical care
evaluated.
108 patients were identified compared to 838 analysed by Kampman et
al spanning over a year as well as from ten STI clinics. Our cohort
represented our local demographics; 54% female, 72.6% under the age of 25
years old, 41.6% of Black Afro-Caribbean or Black British ethnicity and
96.6% heterosexual. 39% were symptomatic compared to 32% in the
Netherlands cohort.
36% (65/180) attended for a repeat test in our cohort compared to the
Netherlands group where 9.2% (140/1530) returned without reminder and
30.6% (253/838) in the study group who received a text message after 6
months. The median time to attendance for a repeat test after treatment
was 6 weeks (IQR (6-8) in our cohort, compared to re-testing being
concentrated within 5-8 months in the study group of Kampman et al. At our
centre only one patient tested positive for CT which was due to re-
infection, whereas 20.4% (56/275) of the Netherlands study group had a
repeat infection.
Our data reflects that of the other UK data highlighted, from Burton
et al, 2014, with a re-test rate in their control group who did not
receive a text message, of 35% (92/226). Although the authors state a
comparison cannot be made given the higher re-test rate of the UK group
compared to their control group, some inferences can be made. It is
interesting that there is an increase of 26.8% in those attending for a
repeat test without a text reminder in our group. Although the total
number included in the Netherlands group is larger compared to ours, the
former was data collated over a year at ten sites, compared to over two
months at our site alone. Kampman et al do not mention whether patients
were advised to have a repeat test, unlike our patients who are all
informed about repeat testing after 6-8 weeks at the time of treatment.
This is a simple intervention which could enhance their rate of re-
attendance. Furthermore, the number of re-infections was significantly
greater than our rate. This may reflect the varying denominators and/or
the greater length of time before re-testing (6 months compared to 6-8
weeks after treatment), as this potentially allows for a greater time
period to acquire re-infection. The higher numbers re-testing in our group
may also be due to the shorter interval between treatment and re-testing.
Overall our centre met the BASHH 2015 standards in the management of
chlamydia. However, we felt that a move from re-testing at 6 weeks to re-
testing at 3 months in high risk groups (patients aged < 25 years and
MSM) would be more cost effective as it will identify any treatment
failures and potentially more re-infections.
We continue to inform patients about re-testing when they are being
treated and have also introduced text reminders at 3 months. Text
reminders are an acceptable, easy and cost-effective strategy to increase
efficiency especially given NHS targets and cuts to public health funding.
References
1)Kampman CJG, Koedijk FDH, Driessen-Hulshof HCM, et al. Retesting young
STI clinic visitors with urogenital Chlamydia trachomatis infection in the
Netherlands; response to a text message reminder and reinfection rates: a
prospective study with historical controls.Sex Transm Infect 2016;92:124-
9.
2) Burton J, Brook G, McSorley J, et al. The utility of short message
service (SMS) texts to remind patients at higher risk of STIs and HIV to
reattend for testing: a controlled before and after study. Sex Transm
Infect 2014;90:11-13.?
I would like to welcome authors interest in analysing the data
regarding knowledge of HPV among the male and females.
HPV is commonly implicated virus in causing cervical cancer.Cervical
cancer acompass top leading cause of cancer deaths in Nepal and other
developing countries.Early age vaccination has shown positive results in
preventing HPV trasmission.However in country like Nepal where there is no
provison of HPV vacc...
I would like to welcome authors interest in analysing the data
regarding knowledge of HPV among the male and females.
HPV is commonly implicated virus in causing cervical cancer.Cervical
cancer acompass top leading cause of cancer deaths in Nepal and other
developing countries.Early age vaccination has shown positive results in
preventing HPV trasmission.However in country like Nepal where there is no
provison of HPV vaccination,awareness programs regarding the HPV
transmission and its role in causing cervical cancer can prevent it in
upcoming days.
since cervical cancer incidence is in middle aged womed,awareness program
regarding the neccessity of pap smear test can help in early diagnosis and
timely intervention.
since multiple sex partner is likely cause for HPV transmisson ,male
should be equally aware of it.
Future research should compare the effectiveness of HPV vaccine vs single
sex partner in prevention of cervical cancer.
Awareness in youngsters regarding HPV and its role in cervical cancer can
be efffective means to control HPV transmission in resource poor
developing countries.Also womens need to be encouraged to do pap smear
test after 35 years in yearly basis.
The editorial by Giffard et al. rightly addresses the issue of the
potential clinical and social response to the detection of C.trachomatis
in urogenital (UGT) specimens from young children. [1] Clinical guidelines
frequently state that detection of a sexually transmissible agent in a UGT
specimen of a child is strongly indicative of sexual abuse (SA), and even
in the absence of disclosure of SA, initiates an investigation...
The editorial by Giffard et al. rightly addresses the issue of the
potential clinical and social response to the detection of C.trachomatis
in urogenital (UGT) specimens from young children. [1] Clinical guidelines
frequently state that detection of a sexually transmissible agent in a UGT
specimen of a child is strongly indicative of sexual abuse (SA), and even
in the absence of disclosure of SA, initiates an investigation by child
protection services. [2] However this may not hold true always, as
detection of sexually transmitted infection (STI) in UGT samples from
young children is not always a consequence of conventional sexual contact.
Potential explanations are autoinoculation from an ocular source,
perinatal mother to child transmission or contamination of specimens. [3]
Autoinoculation of C.trachomatis from the ocular infection to the UGT
site is a well-established phenomenon and leads to the detection of
C.trachomatis in UGT specimens even in the absence of any sexual contact.
[3] This particularly is relevant to a country like India, where trachoma
still remains endemic [4] and is not considered as an STI. As discussed by
Giffard et al, the relevance of genotyping in such situation cannot be
underscored. We support their suggestion of the inclusion of C.trachomatis
genotyping into formal guidelines for examining the source of STIs in
young children in areas where trachoma genotypes may continue to
circulate. The authors further state that it is also important to know the
trachoma and UGT genotypes circulating in the conventional adult sexual
networks in the area, so as to establish the possible route of
transmission. However no studies are available from India for the
frequency of trachoma genotypes in adult and pediatric UGT specimens. This
further confounds the issue whether the detection of C.trachomatis in a
pediatric UGT is a reliable indicator that SA has occurred.
There are reports of trachoma genotypes in UGT specimens, with
genotype B being the most commonly reported. [5,6] If the frequency of
trachoma genotypes detected in pediatric UGT specimens is more in
comparison to the trachoma genotypes from UGT specimens of adults, then
the route of transmission is more in favor of autoinoculation than
transmission from adult sexual networks and this is of potential
significance in the child protection context. However, a UGT genotype in
such case, if detected from the UGT specimens of a child would represent
stronger evidence of abuse.
In conclusion, genotyping of C.trachomatis from pediatric UGT
specimens and correlating it with the circulating genotypes in the adult
sexual networks seems to be a better approach to determine whether the
organism has been acquired through sexual contact or not. Continuous
surveillance of C.trachomatis genotypes in adults and pediatric specimens
can unravel the complex transmission dynamics of this organism.
References
1. Giffard PM, Singh G, Garland SM. What does Chlamydia trachomatis
detection in a urogenital specimen from a young child mean? Sex Transm
Infect. 2016 Apr 15. [Epub ahead of print]
2. Workowski KA, Bolan GA. Sexually transmitted diseases treatment
guidelines, 2015. MMWR Recomm Rep 2015;64:1-137.
3. Giffard PM, Brenner NC, Tabrizi SN, et al. Chlamydia trachomatis
genotypes in a cross-sectional study of urogenital samples from remote
Northern and Central Australia. BMJ Open. 2016 Jan 6;6(1):e009624.
4. WHO Status of endemicity for blinding trachoma data by country,
2012. Available from:
http://www.who.int/gho/neglected_diseases/trachoma/en/. WHO, 2012
5. Psarrakos P, Papadogeorgakis E, Sachse K, et al. Chlamydia
trachomatis ompA genotypes in male patients with urethritis in Greece:
conservation of the serovar distribution and evidence for mixed infections
with Chlamydophila abortus. Mol Cell Probes 2011;25:168-73.
6. Takahashi S, Yamazaki T, Satoh K, et al. Longitudinal epidemiology
of Chlamydia trachomatis serovars in female patients in Japan. Jpn J
Infect Dis 2007;60:374-6.
We thank the author for her interest in our paper and are happy that
she was able to exactly reproduce our findings.
As explicitly stated - ours was an ecological study, and thus used
aggregate data only. Here we comment on the author's additional
statistical analysis and interpretations:
First, the author of the reply apparently did not test "individual
results" which we assume means the single, diff...
We thank the author for her interest in our paper and are happy that
she was able to exactly reproduce our findings.
As explicitly stated - ours was an ecological study, and thus used
aggregate data only. Here we comment on the author's additional
statistical analysis and interpretations:
First, the author of the reply apparently did not test "individual
results" which we assume means the single, different types of foreskin
cutting. The statistical analysis stated in this context do not test the
"single types of foreskin cuttings" vs no cutting, but rather refer to
"circumcision" vs "dorsal/longitudinal cut or no cut at all" and
"dorsal/longitudinal cut" vs "circumcision or not cut at all". These tests
do not confer any additional information: in contrast, if assume that "any
cut" is associated with HIV prevalence (as our results clearly suggest),
then it should logically not come as a surprise that "one specific type of
cut" vs "another type of cut plus no cut at all' is not significant. This
approach is muddling up the baseline of "no cut" with "another type of
cut" and thus will water down any association of penile cutting with HIV.
Second, we point out that the regression coefficient per se cannot be
used to judge the strength of an association (only its direction / slope
of the resulting regression line). It is consequently a misconception
when the author of the reply states - based on regression coefficients -
that the association between condom use and HIV prevalence is stronger
than that between any cuts and HIV. In fact, the reverse can be seen to be
true when correct correlation coefficients (or their squares, the
coefficients of determination) are used.
Finally, more sophisticated multivariate analyses cannot - and should
not - be applied to this type of ecological data to clarify things
further. In contrast to making "bold" and "declarative" statements, every
effort was made to restrict the interpretation of the results to
"association" as opposed to a causal effect. Please see the paragraph
where we explicitly highlight caution with respect to the interpretation
of results in this study (at the end of the discussion). Our paper also
explicitly stated that the study is of "hypothesis generating" character
rather than of any "confirmative" nature.
In the article, the authors' mention this study as being the first to
be carried out on young sexually active women in post-secondary schools in
the UK. They identified pelvic inflammatory disease (PID) in 1.6% of the
individuals recruited for this study which was low because many
individuals were lost during follow-up. However, they mentioned in the
conclusions that medical reports were obtained from clinics for those los...
In the article, the authors' mention this study as being the first to
be carried out on young sexually active women in post-secondary schools in
the UK. They identified pelvic inflammatory disease (PID) in 1.6% of the
individuals recruited for this study which was low because many
individuals were lost during follow-up. However, they mentioned in the
conclusions that medical reports were obtained from clinics for those lost
during follow-up, but made no mention of obtaining individual consents
before accessing their medical information from clinics and doctors. I
identified two sources of error in this study: First, sample collection in
the study was performed by participants and not trained personnel which
will definitely lead to differential bias because the clinical samples
cannot clearly differentiate cases from non-cases. Secondly, potential
confounders were not adjusted which could be a source of bias. A
significant issue in this study was the risk factors proposed for
contracting sexually transmissible disease, hence PIDs among the
participants recruited. Black ethnicity was identified as a risk factor
for this study with no explanation as to why they considered only black
ethnicity (and not ethnicity in general). No information on the diversity
of the population was mentioned which makes their results bias towards a
certain group of individuals. The authors failed to explain why ethnicity
is placed as a risk factor for contracting PIDs in the first place.
Their conclusions for this study could set a damaging public image
for individuals in the specified ethnic group. Questions like, what makes
this ethnic group more susceptible to contracting PID's and why poor
sexual health is associated to blacks in the UK should be thoroughly
explained before conclusions are drawn. To belong to a particular ethnic
group would never place you at risk for developing a particular infection
except for the case of gene involvement in the disease or particular
practices unique to the group which may/or may not predispose you to
developing the disease in question. PIDs are complications of sexually
transmitted diseases which depend on individuals' choices about their
lifestyle and this has nothing to do with your ethnic background, race,
sex or religion. More research on cultural aspects and behaviors in such
groups need to be carried out in order for such conclusions to be made for
any ethnic group studied. Reading this article makes you wonder if the
study was focused only on identifying black women with PIDs in schools or
whether it focused on identifying the prevalence among a diverse group of
young women in the population. It would be best if the authors present
data on the diversity of ethnic groups participating in this study and
then make relative comparisons between the groups in terms of loss to
follow-up and prevalence of PIDs.
While this study contributes greatly in assessing risks for sexually
transmissible diseases and complications among young sexually active
women, it is bias towards a particular group of individuals -black
ethnicity and indirectly places a bad image on this group which could be
detrimental to them if this information is exposed to the public.
By
Akwo Ngwinui Awahsaa
Diploma student Community Health and Humanities
Memorial University of Newfoundland
Canada
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),...
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...
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...
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...
We read with interest the recent report by Kampman et al, 2016 [1] on the effect of text reminders on patients attending for repeat chlamydia tests and chlamydia diagnosis.
In our service, the St. Ann's Sexual Health Centre, a GUM clinic in London, UK, our routine practice was to verbally advise patients treated for chlamydia to re-attend 6-8 weeks after treatment for re-testing. Sexual health appointments are...
I would like to welcome authors interest in analysing the data regarding knowledge of HPV among the male and females. HPV is commonly implicated virus in causing cervical cancer.Cervical cancer acompass top leading cause of cancer deaths in Nepal and other developing countries.Early age vaccination has shown positive results in preventing HPV trasmission.However in country like Nepal where there is no provison of HPV vacc...
The editorial by Giffard et al. rightly addresses the issue of the potential clinical and social response to the detection of C.trachomatis in urogenital (UGT) specimens from young children. [1] Clinical guidelines frequently state that detection of a sexually transmissible agent in a UGT specimen of a child is strongly indicative of sexual abuse (SA), and even in the absence of disclosure of SA, initiates an investigation...
We thank the author for her interest in our paper and are happy that she was able to exactly reproduce our findings.
As explicitly stated - ours was an ecological study, and thus used aggregate data only. Here we comment on the author's additional statistical analysis and interpretations:
First, the author of the reply apparently did not test "individual results" which we assume means the single, diff...
In the article, the authors' mention this study as being the first to be carried out on young sexually active women in post-secondary schools in the UK. They identified pelvic inflammatory disease (PID) in 1.6% of the individuals recruited for this study which was low because many individuals were lost during follow-up. However, they mentioned in the conclusions that medical reports were obtained from clinics for those los...
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