Fleiss et al. make several dubious claims in their article [1], but one is of particular interest. Some authors have now begun to rely upon the assertion that the subpreputial wetness contains lysozyme, and suggest that this may help to protect against HIV.[2,3] Although the epidemiological evidence suggests otherwise,2 our understanding of the mechanisms involved is important, and this claim is wo...
Fleiss et al. make several dubious claims in their article [1], but one is of particular interest. Some authors have now begun to rely upon the assertion that the subpreputial wetness contains lysozyme, and suggest that this may help to protect against HIV.[2,3] Although the epidemiological evidence suggests otherwise,2 our understanding of the mechanisms involved is important, and this claim is worthy of careful examination.
Fleiss et al. rely upon two sources.[4,5] One found lysozyme in apocrine glands, among other enzymes.[5] The other is a case report involving an apocrine gland in the prepuce.[4] However, a more recent pathological study,[6] cited by the authors, found that "unlike true skin of the penile shaft and outer surface of the prepuce, the mucosal surface of the prepuce is completely free of lanugo hair follicles, sweat and sebaceous glands."
If the mucosal surface is completely free of such glands, then it must be the outer surface of the prepuce that benefits from the lysozyme. Indeed, if the prepuce functions as a "one way valve" as the authors assert, the subpreputial moisture would be completely unaffected.
With such weak evidence, the assertion that the subpreputial wetness contains lysozyme must be regarded as an untested hypothesis at best.
References
Fleiss P, Hodges F, Van Howe RS. Immunological functions of the human prepuce. Sex Trans Infect. 1998;74(5):364-7
Siegfried N, Muller M, Volmink J, et al. Male circumcision for prevention of heterosexual acquisition of HIV in men (Cochrane Review). The Cochrane Library, issue 3. Oxford: Update Software; 2003.
Hill G, Denniston GC. HIV and circumcision: new factors to consider. Sex Transm Infect. 2003;79:495-496
Ahmed A, Jones AW. Apocrine cystodenoma: a report of two cases occurring on the prepuce. Br J Derm. 1969;81:899-901
Frolich E, Shaumberg-Lever F, Kissen C. Immunelectron microscopic localization of cathepsin B in human apocrine glands. J Cutan Pathol. 1993; 20: 54-60
Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol. 1996;77:591-5
We read with interest the Fox PA et al. paper (2005, 81;142-6) and welcome the clinical attention to genital pre-cancerous conditions; including Anal Intraepithelial Neoplasia (AIN).
Their finding of no correlation between high-risk (hr) HPV genotypes and histological or cytological grades of abnormalities, conflicts strongly with general consensus and other studies. Kreuter A et al. identified hr H...
We read with interest the Fox PA et al. paper (2005, 81;142-6) and welcome the clinical attention to genital pre-cancerous conditions; including Anal Intraepithelial Neoplasia (AIN).
Their finding of no correlation between high-risk (hr) HPV genotypes and histological or cytological grades of abnormalities, conflicts strongly with general consensus and other studies. Kreuter A et al. identified hr HPV in all AIN cases (with up to 7 different high-risk and 5 different low-risk types per lesion, with HPV – 16 always present in verrucous AIN).[1] Similar findings were corroborated by Daling JR et al., who support an important role for HPV in ano-genital cancer, at all sites.[2] They identified HPV in 88% of all histological specimens with HPV - 16 identified in 73%. It also contradicts Frisch M et al. paper, where 95% and 80% of anal canal and 83% and 28% of perianal skin cancers, of women and men respectively, were hr HPV positive.[3]
Van der Snoek EM et al. reported that 64.7% of the HIV positive men have HPV DNA more often in anal specimens than on the coronal sulcus (23.5%). The later finding is plausible, on account of the vulnerability of the squamo columnar junction and transformation zone of the anal canal to harbour and retain HPV particles (with consequent neoplastic transformation).[4] Understandably, the contradiction of the Fox et al. study will raise a prima facie question about their HPV detectability and virological techniques.
The PA Fox study documents the right observations regarding the aceto white areas without making the correct conclusions. We note that histological biopsies of suspicious aceto white areas in the study reports 81% concordance with AIN lesions, which suggests good prediction and appraise the test value.
The factors leading the clinical appraisal of ano-genital pre-cancerous conditions are:
1. They behave similarly: recurrent, multi-focal, potentially cancerous, increasing in incidence and overlooked by cosmetic factors (eg genital warts).
2. The incidence of genital cancer (anal, vulval, penile) is increasing.[5]
3. Patient's age of genital cancer and pre-cancerous conditions is declining, [6] (which brings them into the GUM clinics' age groups).
4. The increase in incidence of HPV related lesions is paralleled with increase in oncogenesis and genital intraepithelial neoplasias.[6] There could be a false increase due to the discovery of a pre-existing lesion (brought about by worries following a sexual encounter).
5. GUM physicians are in a special position, as they deal routinely with the ano genital area, which impose a duty of care to exclude intraepithelial neoplasia between other genital lesions. The similarities of symptoms and signs of AIN with anal warts were confirmed in the PA Fox paper.
6. The natural history is not fully appraised, due to the relative small caseload.
7. Long-term follow-up is prudent, since 23 of 29 HIV positive patients in one study had persistent or recurrent high grade AIN with 12 month mean time of recurrence.[7]
References
1. Kreuter A, Brockmeyer NH, Hochdorfer B, et al: Clinical spectrum
and virologic characteristics of anal intraepithelial neoplasia in HIV
infection.
J Am Acad Dermatol, 2005; 52(4):603-8.
2. Daling JR, Madeleine MM, Johnson LG, et al: Human papillomavirus,
smoking, and sexual practices in the etiology of anal cancer. Cancer,
2004 15;101(2):270-80.
3. Frisch M, Fenger C, van den Brule AJ, et al: Variants of squamous
cell carcinoma of the anal canal and perianal skin and their relation to
human papillomavirus. Cancer Res, 1999 1;59(3):753-7.
4. van der Snoek EM, Niesters HG, Mulder PG, et al: Human
papillomavirus infection in men who have sex with men participating in a
Dutch gay-cohort study. Sex Transm Dis, 2003;30(8):639-44.
5. Johnson LG, Madeleine MM, Newcomer LM, et al: Anal cancer
incidence and survival: the surveillance, epidemiology, and end results
experience, 1973-2000. Cancer, 2004 15;101(2):281-8.
6. Frisch M: On the etiology of anal squamous carcinoma. Dan Med
Bull, 2002;49(3):194-209.
7. Chang GJ, Berry JM, Jay N, et al: Surgical treatment of high-grade
anal squamous intraepithelial lesions: a prospective study. Dis Colon
Rectum, 2002;45(4):453-8.
Ogilvie et al. have published a well-designed meta-analysis of the
diagnostic accuracy of self collected vaginal specimens for human
papillomavirus (HPV) detection, in which they conclude that self-sampling
may be an appropriate alternative for low resource settings or in patients
reluctant to undergo pelvic examinations.[1] However, we have a number of
remarks on the pooled sensitivities and specificit...
Ogilvie et al. have published a well-designed meta-analysis of the
diagnostic accuracy of self collected vaginal specimens for human
papillomavirus (HPV) detection, in which they conclude that self-sampling
may be an appropriate alternative for low resource settings or in patients
reluctant to undergo pelvic examinations.[1] However, we have a number of
remarks on the pooled sensitivities and specificities they present.
First, it is not an optimal strategy to choose clinician-collected vaginal
specimens as the reference standard to compare self-sampled specimens to,
since it is the concordance of self-sampling with presence of HPV-DNA in
the cervical epithelium which determines the usefulness of vaginal
sampling as a screening test for cervical cancer. It would have been more
accurate to assess sensitivity and specificity compared to a cervical
specimen, sampled in a standardized way by a clinician, as the golden
standard.
Second, if guidelines for self-sampling are made, the accuracy of HPV-
detection in a single sample must be maximized. A number of factors that
may affect detection of HPV have been suggested in literature and are
currently under further investigation. Short term fluctuations in
prevalence of HPV within the menstrual cycle have been described.[2]
Hormonal fluctuations within a menstrual cycle may affect HPV detection
since progesterone causes deeper exfoliation of cervical and vaginal
epithelium, where HPV assemblance takes place, whereas estrogens promote
exfoliation of only the superficial layers, which does not allow
maturation of the parabasal cells that is required for HPV assembly and
release.[3,4]
Furthermore, vaginal penetration by coitus [4] could mechanically remove
HPV infected cells, as could hygienic tampon use or vaginal douching. In
case of unprotected intercourse, false positive tests could result from
detecting HPV-DNA from the male partner.[4] Few empirical data confirm
the latter theoretical considerations so far. It has been insufficiently examined
to what extent vaginal lubricants, spermicidal cream or other intimate
products, or even antibiotics, which affect the vaginal micro-climate or pH,
could have an impact on HPV detection.
Finally, we observed in a small study that recent vaginal infections
resulted in discordance of HPV detection between vaginal and cervical
samples.[5] Indeed, it is conceivable that a vaginal infection speeds up
the discharge of exfoliated (HPV-infected) cervical cells, thereby
shortening the period of time these cells are present in the vagina.
It is clear that at least some of these factors will affect sensitivity
and/or specificity of vaginal self-sampling, and it is advisable to
establish their effect on accuracy of vaginal sampling before practice
recommendations are made.
References
1. Ogilvie GS, Patrick DM, Schulzer M, Sellors JW, et al. Diagnostic
accuracy of self collected vaginal specimens for human papillomavirus
compared to clinician collected human papillomavirus specimens: a meta-
analysis. Sex Transm Infect 2005;81:207-12.
2. van Ham MA, Melchers WJ, Hanselaar AG, Bekkers RL, et al. Fluctuations
in prevalence of cervical human papillomavirus in women frequently sampled
during a single menstrual cycle. Br J Cancer 2002;87:373-6.
3. Ferenczy A, Wright TC Jr. Anatomy and histology of the cervix. In:
Kurman R, ed. Blaustein’s Pathology of the female genital tract. 5th ed.
New York, NY: Springer; 2002.
4. Harper DM, Longacre MR, Noll WW, Belloni DR, Cole BF. Factors
affecting the detection rate of human papillomavirus. Ann Fam Med.
2003;1:221-7.
5. Baay M, Verhoeven V, Wouters K, Lardon F, et al. The prevalence of the
human papillomavirus in cervix and vagina in low-risk and high-risk
populations. Scand J Infect Dis 2004; 36:456-9.
I was interested to read a survey of Welsh practice nurses on
chlamydia testing [1]. The authors must be congratulated for demonstrating
a mixed methodology of questionnaires and semi-structured interviews in
their study. The response rate to the questionnaire exceeded 70% and
together, the methods appeared to have elicited issues which should be
considered if chlamydia testing were encouraged in pri...
I was interested to read a survey of Welsh practice nurses on
chlamydia testing [1]. The authors must be congratulated for demonstrating
a mixed methodology of questionnaires and semi-structured interviews in
their study. The response rate to the questionnaire exceeded 70% and
together, the methods appeared to have elicited issues which should be
considered if chlamydia testing were encouraged in primary care settings.
However, I worry the study was less than rigorous, which meant the
conclusions, though important, were derived from a weak evidence base.
Questionnaires, like thermometers, are measuring instruments which
need to be controlled for reliability and validity [2]. The authors gave
little detail on quality control. Although there was mention of piloting
the questionnaire on a sample of “health professionals”, I wonder if these
included practice nurses. If not, this false feedback loop might not have
been helpful. Although the authors made efforts to produce a good return
(71.7%), the respondents left so many questions unanswered (there were
over 50% non-responses to over half of the questions), that this would
have reduced the validity of the study already compromised by the small
sample. For example, “I never test males for genital chlamydia infection”
- 54.5% replied “never”; could the 45.5% of the nurses who did not respond
to the question imply that they do the test? A poorly designed
questionnaire could be one of the reasons for such a non-response rate.
There were further weaknesses with the interviews. The sampling was
not performed in a purposive way that would enrich the data. Very little
was known about the nurses’ characteristics other than some had used urine
chlamydia tests and none had performed urethral tests. The “semi-
structured” nature of the interviews implied there were certain questions
and themes that needed to be explored; there were no details on how these
were derived e.g. from results of this survey or literature review. It was
unclear what methods were used to record the interviews and analyse the
transcripts. We were not told the added value of the interviews; they did
not seem to reveal any more useful information than could have been
elicited from a good questionnaire. It was a missed opportunity not to
explore the divergent views and practices (the “outliers”) e.g. – what
made some nurses test for chlamydia and others not? Why did some nurses
feel they were able to perform partner notification?
Finally, I am worried about the misleading claim that practice nurses
needed “significant investment to train in sexual health”. As far as I
could read, some practice nurses might need training to perform chlamydia
testing in men and partner notification, but extrapolating this to
“significant investment” to train in generic “sexual health” is quite
simply the wrong conclusion. It is ironic to suggest primary care should
apply evidence based care when this paper demonstrates poor quality
evidence.
References
1. Robertson P, Williams OE. Young, male, and infected: the forgotten
victims of chlamydia in primary care. Sex Transm Infect 2005; 81: 31-33.
2. Greenhalgh T. Chapter 11: Papers that go beyond numbers (qualitative
research). In: How to read a paper – the basics of evidence based
medicine. BMJ Publishing Group 1997: 151-162.
In their editorial (Sexually Transmitted Infections 2004;80:331-33)
Kevin Fenton and Helen Ward give a positive and detailed overview of the
Government's policy on chlamydia screening in England. This could have
been balanced by a more critical assessment of the challenges.
The
alarming rise in chlamydia rates in Sweden, where opportunistic screening
has been in place nationally since 1988...
In their editorial (Sexually Transmitted Infections 2004;80:331-33)
Kevin Fenton and Helen Ward give a positive and detailed overview of the
Government's policy on chlamydia screening in England. This could have
been balanced by a more critical assessment of the challenges.
The
alarming rise in chlamydia rates in Sweden, where opportunistic screening
has been in place nationally since 1988, should be seen as a warning about
the problems of this approach. Failures in chlamydia control activities
might well have contributed to these trends [1]. Experience from the USA,
where annual screening in family planning clinics takes place, is mixed:
chlamydia prevalence has decreased in six regions and increased in four
[2].
While the first year of screening has demonstrated feasibility, the
underlying problem remains: no randomised controlled trial has ever shown
that opportunistic screening controls chlamydia transmission or reduces
reproductive tract morbidity in women in the long term [1,3]. The United
Kingdom National Screening Committee states that, “evidence from high-
quality randomised trials that the screening programme is effective in
reducing mortality or morbidity” is essential before a programme can be
introduced (http://www.nsc.nhs.uk/). For chlamydia, the randomised trial
cited to demonstrate effectiveness and justify the current programme
examined a completely different approach: systematic, register-based
screening [4], which the Chief Medical Officer’s advisory group on
Chlamydia trachomatis rejected as being impractical [5]. The Chlamydia
Screening Studies (ClaSS) project (page 342-48 in this issue) and
Department of Health study will answer some operational questions but do
not provide evidence of effectiveness. A randomised trial is therefore
required if the large bill for opportunistic screening is not to be
accompanied (as in Sweden) by persistent uncertainty about exactly what is
responsible for changes in chlamydial prevalence and reproductive
morbidity.
Even assuming opportunistic chlamydia screening is shown to be
effective, the major challenge is ensuring comprehensive and equitable
coverage. Primary care has been dealing with this issue for many years,
for example in screening to reduce cardiovascular risk, where the target
population are older and arguably more accessible. From January to March
2004, the ten programme areas screened 7,672 people in all non-
genitourinary medicine settings. This equates to an average 3,000 tests
per area per year: a level of coverage that unlikely to have a substantial
impact on chlamydia transmission. Furthermore, no general practice is
obliged to provide any local or national enhanced service so, if
vulnerable patients from hard pressed practices in deprived areas cannot
access screening in their own practice, the inverse care law will be
proven once again, and inequalities in health will widen.
It is not too late for cluster-randomised trials to be incorporated
into the phased roll out of screening in this country to determine the
most effective strategy for chlamydia screening and provide the evidence
base that is essential for any national screening programme.
References
(1). Low N. Current status of chlamydia screening in Europe.
Eurosurveillance 2004;8:5.
(2). Centers for Disease Control and Prevention. Sexually Transmitted
Disease Surveillance 2002 Supplement, Chlamydia Prevalence Monitoring
Project. 2003. Atlanta, GA, U.S. Department of Health and Human Services,
Centers for Disease Control and Prevention.
(3). Stephenson J, Hopwood J, Babiker A, Copas A, Vickers M. Recent
pilot studies of chlamydia screening. Sex Transm Infect 2003;79:352.
(4). Scholes D, Stergachis A, Heidrich FE, Andrilla H, Holmes KK, Stamm
WE. Prevention of pelvic inflammatory disease by screening for cervical
chlamydial infection. N Engl J Med 1996;334:1362-6.
(5). CMO's Expert Advisory Group on Chlamydia trachomatis. 1998.
London, Department of Health.
It is interesting to know that John David Oriel had followed his
father George Harold Oriel into Medicine. George has served at Portsmouth
Hasler Hospital during the war years. John's fathers' death (2nd May 1939)
was published in the London Gazette 18 Aug 1939 when he was living at
Heathercliff Langland Swansea although he had previously lived at 19
Carlton Road Sidcup. Medicine was not lost to the...
It is interesting to know that John David Oriel had followed his
father George Harold Oriel into Medicine. George has served at Portsmouth
Hasler Hospital during the war years. John's fathers' death (2nd May 1939)
was published in the London Gazette 18 Aug 1939 when he was living at
Heathercliff Langland Swansea although he had previously lived at 19
Carlton Road Sidcup. Medicine was not lost to the Oriel surname and a
distant nephew of John David Oriel still researches medicine in the USA.
Currently, I can trace John David's ancestors back to circa 1725 in west
Pembrokeshire along with many and varied relations and families.
I would be more than willing to supply any details to any Oriel's
interested.
Dave et al's letter about the role of professionals in the HIV-
outpatient setting is aposite and brings up many issues including who
should end up doing this type of 'routine' work.[1] As always GPs are called
in along with other professionals as possible options. However,
communication amongst other problems, continue to be a big challenge.
Dave et al's letter about the role of professionals in the HIV-
outpatient setting is aposite and brings up many issues including who
should end up doing this type of 'routine' work.[1] As always GPs are called
in along with other professionals as possible options. However,
communication amongst other problems, continue to be a big challenge.
I recently reviewed all the notes of the twenty-three registered
patients with known HIV in our small practice in SE London (prevalence
0.5%). This group comprises 15 males and 8 females and includes two
children (overall age range 5-56 yrs). The male-female ratio is 2:1.
This group of patients attends seven different hospitals for their
HIV care and more when other conditions are taken into account. Only 10
patients have an up-to-date letter in the notes, as defined by any letter
mentioning HIV in 2004. The majority do not, and this includes one
patient where there has never been any letter outlining the patient's HIV
status, despite the patient coming to see us regularly for mental health
problems. While the arguments about confidentiality have raged for many
years, surely it it is time for this to be confronted as an excuse (what
else could it be?) for not communicating with GPs and community health
services.
Add to this the fact that providing such services in primary care do
not appear to be attracting any "enhanced funding" in the new GP contract
(yet) and you will understand the caution with which many general
practitioners view this problem. Unfortunately, until these
organisational and funding issues are resolved, it seems that the
traditional roles of primary and secondary care will continue for the
patient with HIV infection.
Reference
1. S S Dave, K Miles, C Griffiths, D E Mercey, and S G Edwards. Is it time to rethink the roles of health professionals in the HIV outpatient setting?
Sex Transm Infect 2004; 80: 153-154.
We read with interest the trichomonas review written by Swygard et al.[1]
Current BASHH and European STD guidelines for the management of
trichomoniasis state that “tests of cure should be undertaken if the
patient remains symptomatic following treatment, or if symptoms recur”.[2,3] No specific recommendations are made for the follow-up of patients
who were asymptomatic at presentation. Sw...
We read with interest the trichomonas review written by Swygard et al.[1]
Current BASHH and European STD guidelines for the management of
trichomoniasis state that “tests of cure should be undertaken if the
patient remains symptomatic following treatment, or if symptoms recur”.[2,3] No specific recommendations are made for the follow-up of patients
who were asymptomatic at presentation. Swygard et al. state “follow up
unnecessary for men and women who become asymptomatic after treatment or
who are initially asymptomatic”. As 10-50% of women [4,5] and 15-50% of
men [6] are asymptomatic at diagnosis this potentially excludes a large
proportion of patients from follow-up.
In our service we have traditionally performed tests of cure for
Trichomonas vaginalis (TV) in all patients. In order to ascertain whether
our practice should be altered in accordance with current guidelines we
performed a retrospective note review of all patients diagnosed with TV in
2002. Of a total of 36 cases (all female), 25% were asymptomatic at
diagnosis. All were treated with recommended first line therapy, 5 days
Metronidazole 400mg twice daily or a 2g stat dose of either Metronidazole
or tinidazole,[1] and 83% returned for a test of cure. Of the 7 patients
that remained symptomatic, all tested negative for TV, however, 71% had
candidiasis on microscopy. Of note, there were 2 patients with a positive
test of cure but were asymptomatic at diagnosis and follow-up.
We feel that guidelines for treating TV should clarify the importance
of not relying on the presence or absence of symptoms in patients who were
asymptomatic to start with. Our study, albeit small numbers, highlighted
the importance of bringing asymptomatic women back to clinic for a test of
cure.
References
(1) Swygard H, Sena A, Hobbs M, Cohen M. Trichomoniasis: clinical
manifestations, diagnosis and management. Sex Transm Infect 2004;80:91-
95.
(2) British Association for Sexual Health and HIV (BASHH). 2001 National
Guideline on the Management of trichomonas vaginalis (http://www.bashh.org).
(3) European STD guidelines. International Journal of STD & AIDS
2001.12(3) (http://www.iusti.org).
(5) Fouts AC, Kraus SJ. Trichomonas vaginalis: re-evaluation of its
clinical presentation and laboratory diagnosis. J Infect Dis
1980;141(2):137-143.
(6) Krieger J, Jenny C, Verdon M, Siegel N, Springwater R, Critchlow C,
Holmes K. Clinical manifestations of trichomoniasis in men. Ann Int Med
1993;118(11):844-9.
The purpose of our study was to evaluate five different primer sets
described in the literature for the amplification of Trichomonas
vaginalis. We therefore used the same working conditions for the five
primers sets, i.e. the same extraction method, thermocycler, reagents
etc. It was not our aim to re-validate these primer sets.
For all of the five primer sets we used the AmpliTaq Gold poly...
The purpose of our study was to evaluate five different primer sets
described in the literature for the amplification of Trichomonas
vaginalis. We therefore used the same working conditions for the five
primers sets, i.e. the same extraction method, thermocycler, reagents
etc. It was not our aim to re-validate these primer sets.
For all of the five primer sets we used the AmpliTaq Gold polymerase,
which has some advantages compared to the simple Taq polymerase. The
AmpliTaq Gold Polymerase is inactive at ambient temperatures, non-specific
binding is avoided and preparation of reactions is facilitated. Activation
of the AmpliTaq Gold Polymerase occurs only when heated before the thermal
cycling, and is thus similar to a hot-start PCR. The AmpliTaq Gold
Polymerase requires a pre-denaturation step at 95°C for 5 minutes, as
shown in Table 2. The overall PCR product yield is also greater.[1]
In our laboratory the AmpliTaq Gold Polymerase works very well. We
follow strict quality guidelines, meaning that prior to the introduction
of a new batch of AmpliTaq Gold Polymerase we test the quality of the
batch with a panel of known positive and negative specimens. Variability
in Taq polymerase performance based on batch, concentration, and supplier
has been documented.[2] We detected variability in Taq polymerase quality
based on differences between batches.
References
(1) T Moretti, B Koons, and B Budowle. Enhancement of PCR
amplification yield and specificity using AmpliTaq Gold ® DNA polymerase.
BioTechniques 1998; 25: 716-722.
(2) KD Tyler, G Wang, SD Tyler, and WM Johnson. Factors affecting
reliability and reproducibility of amplification-based DNA fingerprinting
of representative bacterial pathogens. J Clin Microbiol 1997; 35:339-346.
The article on Pathways to HIV testing and care by black African and
white patients in London is indeed very interesting.
However,I do not
believe it takes into account the very real differences between the
different African communities in London.
The severe devastation and scale of the HIV/AIDS epidemic in Africa has
not been felt uniformly across the continent.West African countries for
whatev...
The article on Pathways to HIV testing and care by black African and
white patients in London is indeed very interesting.
However,I do not
believe it takes into account the very real differences between the
different African communities in London.
The severe devastation and scale of the HIV/AIDS epidemic in Africa has
not been felt uniformly across the continent.West African countries for
whatever reasons have not suffered as much as countries in East,Central
and Southern Africa.Though the incidence of HIV in West Africa has
increased in recent years it is nowhere near the scale seen in countries
like Zimbabwe.Therefore to group all Africans together under the term
"Black African" when it comes to discussing HIV/AIDS seems a bit
misleading, albeit unintentionally.In Eastern Europe there are massive
problems with HIV but this area is never grouped together with Western
Europe when describing the epidemiology of this disease in Europe.
Africa is a very vast continent and writers would do well to remember
this.
Dear Editor,
Fleiss et al. make several dubious claims in their article [1], but one is of particular interest. Some authors have now begun to rely upon the assertion that the subpreputial wetness contains lysozyme, and suggest that this may help to protect against HIV.[2,3] Although the epidemiological evidence suggests otherwise,2 our understanding of the mechanisms involved is important, and this claim is wo...
Dear Editor,
We read with interest the Fox PA et al. paper (2005, 81;142-6) and welcome the clinical attention to genital pre-cancerous conditions; including Anal Intraepithelial Neoplasia (AIN).
Their finding of no correlation between high-risk (hr) HPV genotypes and histological or cytological grades of abnormalities, conflicts strongly with general consensus and other studies. Kreuter A et al. identified hr H...
Dear Editor,
Ogilvie et al. have published a well-designed meta-analysis of the diagnostic accuracy of self collected vaginal specimens for human papillomavirus (HPV) detection, in which they conclude that self-sampling may be an appropriate alternative for low resource settings or in patients reluctant to undergo pelvic examinations.[1] However, we have a number of remarks on the pooled sensitivities and specificit...
Dear Editor,
I was interested to read a survey of Welsh practice nurses on chlamydia testing [1]. The authors must be congratulated for demonstrating a mixed methodology of questionnaires and semi-structured interviews in their study. The response rate to the questionnaire exceeded 70% and together, the methods appeared to have elicited issues which should be considered if chlamydia testing were encouraged in pri...
Dear Editor,
In their editorial (Sexually Transmitted Infections 2004;80:331-33) Kevin Fenton and Helen Ward give a positive and detailed overview of the Government's policy on chlamydia screening in England. This could have been balanced by a more critical assessment of the challenges.
The alarming rise in chlamydia rates in Sweden, where opportunistic screening has been in place nationally since 1988...
Dear Editor,
It is interesting to know that John David Oriel had followed his father George Harold Oriel into Medicine. George has served at Portsmouth Hasler Hospital during the war years. John's fathers' death (2nd May 1939) was published in the London Gazette 18 Aug 1939 when he was living at Heathercliff Langland Swansea although he had previously lived at 19 Carlton Road Sidcup. Medicine was not lost to the...
Dear Editor
Dave et al's letter about the role of professionals in the HIV- outpatient setting is aposite and brings up many issues including who should end up doing this type of 'routine' work.[1] As always GPs are called in along with other professionals as possible options. However, communication amongst other problems, continue to be a big challenge.
I recently reviewed all the notes of the tw...
Dear Editor
We read with interest the trichomonas review written by Swygard et al.[1]
Current BASHH and European STD guidelines for the management of trichomoniasis state that “tests of cure should be undertaken if the patient remains symptomatic following treatment, or if symptoms recur”.[2,3] No specific recommendations are made for the follow-up of patients who were asymptomatic at presentation. Sw...
Dear Editor
The purpose of our study was to evaluate five different primer sets described in the literature for the amplification of Trichomonas vaginalis. We therefore used the same working conditions for the five primers sets, i.e. the same extraction method, thermocycler, reagents etc. It was not our aim to re-validate these primer sets.
For all of the five primer sets we used the AmpliTaq Gold poly...
Dear Editor
The article on Pathways to HIV testing and care by black African and white patients in London is indeed very interesting.
However,I do not believe it takes into account the very real differences between the different African communities in London. The severe devastation and scale of the HIV/AIDS epidemic in Africa has not been felt uniformly across the continent.West African countries for whatev...
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