Impact of Expedited Partner Therapy (EPT) Implementation on Chlamydia Incidence in the USA
Letter to the Editor:
Assuming that a sexual partner has only one Sexually Transmitted Infection (STI) is a dangerous practice and should be discouraged. The Expedient Partner Therapy implementation on Chlamydia is one such assumption. In a study conducted by (Zemouri, Wi, Kiarie, Seuc, Moqasale et.al 2016) they highlighted that Sexually Transmitted Infection (STI) case management is one of the top priorities in controlling STIs to break the chain of infection and transmission. They further reiterated that Syndromic case management provides a standardized evidence-based approach using clinical management algorithms, and flowcharts that can be used consistently across providers. Clinicians that treat patients with STIs should be cognizant that Expedited Partner Treatment is inadequate because there is at least a third infected sexual partner other than the partner being treated.
Another factor that should be considered when administering Expedited Partner Therapy is the possibility, of the partner, manifesting other symptoms of a STI to be treated that has not yet been identified in the patient. It is useful to administer the risk score test which is a 6 point research base quiz to each patient being treated for STI. These questions can only be answered by the patient for it to be considered reliable. Each question has a number of points assigned to potential ans...
Impact of Expedited Partner Therapy (EPT) Implementation on Chlamydia Incidence in the USA
Letter to the Editor:
Assuming that a sexual partner has only one Sexually Transmitted Infection (STI) is a dangerous practice and should be discouraged. The Expedient Partner Therapy implementation on Chlamydia is one such assumption. In a study conducted by (Zemouri, Wi, Kiarie, Seuc, Moqasale et.al 2016) they highlighted that Sexually Transmitted Infection (STI) case management is one of the top priorities in controlling STIs to break the chain of infection and transmission. They further reiterated that Syndromic case management provides a standardized evidence-based approach using clinical management algorithms, and flowcharts that can be used consistently across providers. Clinicians that treat patients with STIs should be cognizant that Expedited Partner Treatment is inadequate because there is at least a third infected sexual partner other than the partner being treated.
Another factor that should be considered when administering Expedited Partner Therapy is the possibility, of the partner, manifesting other symptoms of a STI to be treated that has not yet been identified in the patient. It is useful to administer the risk score test which is a 6 point research base quiz to each patient being treated for STI. These questions can only be answered by the patient for it to be considered reliable. Each question has a number of points assigned to potential answers, and higher points mean higher STI risk (Coughlin, 2016). Implementing the expedient partner therapy negate retrieving pertinent information regarding a patient’s sexual behavior and habits.
In managing a patient with STI, health education and promotion should form an integral part of each patient’s management regime. The use of condoms cannot be overemphasized and should form the basis of all discussions when treating patients with STIs. Expedient Partner Therapy decreases the opportunity to give this valuable information to all affected partners.
Zemouri, C., Wi, TE., Kiarie, J., Seuc, A., Mogasale, V., Latif, A., & Broutet. N. (2016). The Performance of the Vaginal Discharge Syndromic Management in Treating Vaginal and Cervical Infection: A Systematic review and Meta-Analysis. https://www.ncbi.nim.nih.gov/pubmed/27706174
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
Error in the calculation of person-time in the before-PrEP period by Beymer et al.
S.H. Hulstein, E. Hoornenborg, M.F. Schim van der Loeff
Department of Infectious Diseases, GGD Amsterdam
Studies on STI incidence and PrEP use are often hampered by the absence of STI incidence data in the period before PrEP; Beymer et al.1 set out to improve on this. They report on the STI incidence before and after initiation of PrEP in a cohort of men who have sex with men (MSM) at the Los Angeles LGBT Center, California, US. We fear that there are some flaws in the analysis, which may affect the conclusions.
The analysis was based on 275 men who were tested at least once in the period before PrEP was started, and at least once after PrEP was started. The reported persontime in the before- PrEP period was just over half the person-time after PrEP initiation (93.60 versus 168.93), but the numbers of tests before and after PrEP initiation were not very different: 755 and 908, respectively. This discrepancy could not be explained by differences in their frequency of STI testing, which were reported to be similar in the before- and after-PrEP period. An explanation is that the person-time before the first STI visit was not taken into account. This would mean that the person-time in the before-PrEP period was underestimated, in turn leading to an artificially high before-PrEP STI incidence....
Error in the calculation of person-time in the before-PrEP period by Beymer et al.
S.H. Hulstein, E. Hoornenborg, M.F. Schim van der Loeff
Department of Infectious Diseases, GGD Amsterdam
Studies on STI incidence and PrEP use are often hampered by the absence of STI incidence data in the period before PrEP; Beymer et al.1 set out to improve on this. They report on the STI incidence before and after initiation of PrEP in a cohort of men who have sex with men (MSM) at the Los Angeles LGBT Center, California, US. We fear that there are some flaws in the analysis, which may affect the conclusions.
The analysis was based on 275 men who were tested at least once in the period before PrEP was started, and at least once after PrEP was started. The reported persontime in the before- PrEP period was just over half the person-time after PrEP initiation (93.60 versus 168.93), but the numbers of tests before and after PrEP initiation were not very different: 755 and 908, respectively. This discrepancy could not be explained by differences in their frequency of STI testing, which were reported to be similar in the before- and after-PrEP period. An explanation is that the person-time before the first STI visit was not taken into account. This would mean that the person-time in the before-PrEP period was underestimated, in turn leading to an artificially high before-PrEP STI incidence. The observed decrease in incidence rates for all STIs (except syphilis) reported in Table 3 would thus be an artefact of the analysis, rather than a real phenomenon.
If the pre-test person-time would have been taken into account, the analyses might have shown that STI incidences in the after-PrEP period would have been similar or higher than in the before-PrEP period.
More studies are needed that examine whether the incidence rate of STIs increases after initiation of PrEP; appropriate analyses of such data are essential.
References
Beymer MR et al. Does HIV pre-exposure prophylaxis use lead to a higher incidence of sexually transmitted infections? A case-crossover study of men who have sex with men in Los Angeles, California. Sex Trans Infect Epub ahead of print. Doi:10.1136/sextrans.2017-053377
Correspondence to: Nicola Low, Professor of Epidemiology and Public Health, Institute of Social and Preventive Medicine, University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland. nicola.low@ispm.unibe.ch; Tel: +41 31 631 30 92
Title: Research on Mycoplasma genitalium is more important than expanding testing
We are glad that Taylor-Robinson and Ong offer some support for the conclusion of our systematic review,1 that asymptomatic populations, in the community or in clinics, should not be tested routinely for M. genitalium. The first British Association of Sexual Health and HIV (BASHH) guideline about the management of Mycoplasma genitalium, published on 8th July 2018, supports this conclusion.2 We would like to clarify, however, that the absence of evidence for clinical and public health benefit of screening3 and the harm of inducing de novo mutations and spreading resistance to macrolide antimicrobials4 are more important than economic considerations.
Taylor-Robinson and Ong’s statement that “testing worldwide should continue to support or modify this conclusion”5 could lead to pro...
Correspondence to: Nicola Low, Professor of Epidemiology and Public Health, Institute of Social and Preventive Medicine, University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland. nicola.low@ispm.unibe.ch; Tel: +41 31 631 30 92
Title: Research on Mycoplasma genitalium is more important than expanding testing
We are glad that Taylor-Robinson and Ong offer some support for the conclusion of our systematic review,1 that asymptomatic populations, in the community or in clinics, should not be tested routinely for M. genitalium. The first British Association of Sexual Health and HIV (BASHH) guideline about the management of Mycoplasma genitalium, published on 8th July 2018, supports this conclusion.2 We would like to clarify, however, that the absence of evidence for clinical and public health benefit of screening3 and the harm of inducing de novo mutations and spreading resistance to macrolide antimicrobials4 are more important than economic considerations.
Taylor-Robinson and Ong’s statement that “testing worldwide should continue to support or modify this conclusion”5 could lead to problems. Uncontrolled testing and treatment of different groups of people will also advance “the seemingly unstoppable march of MG to complete antibiotic resistance” because M. genitalium has an unusually high probability of developing de novo resistance during treatment with a single 1g dose of azithromycin. We found, in a mathematical modelling study, that an estimated probability of resistance of 12% (95% confidence interval 8 to 17%) can explain why 50% or more of detected M. genitalium infections are already resistant to macrolides in some countries.4
The rational use of new commercial molecular tests, for detection of both M. genitalium and its antimicrobial resistance determinants, should be promoted in the context of international programmes of research and surveillance. Experts have prioritised research to determine whether screening of asymptomatic populations will reduce important clinical disease outcomes.3 Systematic reviews can help, by synthesising the existing research literature and highlight gaps in the research base. A forthcoming systematic review, linked to the review of prevalence studies, will address the dynamics and natural history of M. genitalium (PROSPERO protocols CRD42015020420, CRD42015020405, https://www.crd.york.ac.uk/prospero/) and improve the knowledge base for future mathematical modelling studies. Taylor-Robinson and Ong highlight additional basic research questions about the immunology of M. genitalium and the respiratory pathogen M. pneumoniae.
In our view, diagnostic testing accompanied by testing for macrolide resistance should be limited to defined groups of symptomatic patients and treatment algorithms, such as those recommended in the BASHH guideline,2 must be evaluated in randomised controlled trials. The research community should do all it can to ensure that responsible use of testing for M. genitalium advances the objectives of research and public health, whilst mitigating the spread of antimicrobial resistance.
References
1. Baumann L, Cina M, Egli-Gany D, et al. Prevalence of Mycoplasma genitalium in different population groups: systematic review and meta-analysis. Sex Transm Infect 2018 doi: 10.1136/sextrans-2017-053384
2. Soni S, Horner P, Rayment M, et al. 2018 BASHH UK national guideline for the management of infection with Mycoplasma genitalium. 2018.
3. Martin DH, Manhart LE, Workowski KA. Mycoplasma genitalium From Basic Science to Public Health: Summary of the Results From a National Institute of Allergy and Infectious Disesases Technical Consultation and Consensus Recommendations for Future Research Priorities. J Infect Dis 2017;216(suppl_2):S427-S30. doi: 10.1093/infdis/jix147
4. Cadosch R, Garcia V, Althaus CL, et al. De novo mutations drive the spread of macrolide resistant Mycoplasma genitalium: a mathematical modelling study. bioRxiv 2018:321216.
5. Taylor Robinson D, Ong J. Prevalence of Mycoplasma genitalium. Sexually Transmitted Infections 2018 15.06.2018. https://sti.bmj.com/content/94/4/255.responses (accessed 19.07.2018).
The work by Baumann et al.(1) is valuable because it indicates populations for which screening for Mycoplasma genitalium (MG)) is not worthwhile economically. However, as molecular detection tests are now available commercially, testing worldwide should continue to support or modify this conclusion and so help in the development of management guidelines and also provide data for MG modelling.
Another aspect of infection which requires more attention is the precise role of MG in balanoposthitis, epididymitis,, chronic prostatitis, reactive arthritis, and, of course, pelvic inflammatory disease, all of which, apart from chronic prostatitis, have some association with MG (2).
In addition, it is noteworthy that Mycoplasma pneumoniae (MP), which infects the respiratory tract, and is also responsible for some autoimmune side effects, does so in early childhood without causing disease. The latter usually occurs as an immunological response to reinfection later in life. MG is different genomically from MP but has much in common antigenically and might behave in a similar way to MP. Could asymptomatic MG infection, which is seen occasionally, be an example of this? Potentiation or even inhibition of MG infection in the genital tract by MP infection in the respiratory tract earlier in life is also possible. This idea is not supported by studies in mice, but the human situation might be quite different. In this regard, use of an existing specific serological test for MG m...
The work by Baumann et al.(1) is valuable because it indicates populations for which screening for Mycoplasma genitalium (MG)) is not worthwhile economically. However, as molecular detection tests are now available commercially, testing worldwide should continue to support or modify this conclusion and so help in the development of management guidelines and also provide data for MG modelling.
Another aspect of infection which requires more attention is the precise role of MG in balanoposthitis, epididymitis,, chronic prostatitis, reactive arthritis, and, of course, pelvic inflammatory disease, all of which, apart from chronic prostatitis, have some association with MG (2).
In addition, it is noteworthy that Mycoplasma pneumoniae (MP), which infects the respiratory tract, and is also responsible for some autoimmune side effects, does so in early childhood without causing disease. The latter usually occurs as an immunological response to reinfection later in life. MG is different genomically from MP but has much in common antigenically and might behave in a similar way to MP. Could asymptomatic MG infection, which is seen occasionally, be an example of this? Potentiation or even inhibition of MG infection in the genital tract by MP infection in the respiratory tract earlier in life is also possible. This idea is not supported by studies in mice, but the human situation might be quite different. In this regard, use of an existing specific serological test for MG might provide helpful data. In dealing with an infection where there is still much to seek and understand, the seemingly unstoppable march of MG to complete antibiotic resistance is the most worrying aspect. Although vaccination against MP infection has been only partially successful, it must be said again that this approach to prevention should receive urgent attention in the battle agaist MG infection (3).
David Taylor-Robinson (1), Jason J Ong (2)
(1) Section of Infectious Diseases, St Mary's Campus, imperial College London, UK
(2) Department of Clinical Research, London School of Hygiene and Tropical Medicine, UK
REFERENCES
1.Baumann L, Cina M, Egli-Gany D, et al. Prevalence of Mycoplasma genitalium in different population groups: systematic review and meta-analysis. Sex Transm Infect 2018; 94: 255-262.
2.Taylor-Robinson D, Jensen JS. Mycoplasma genitalium; from chrysalis to multicolored butterfly. Clin Microbiol Rev 2011; 24: 498-514.
3.Taylor-Robinson D. Diagnosis and antimicrobial treatment of Mycoplasma genitalium infection: sobering thoughts. Expert Rev Anti Infect Ther 2014; 12: 715-722.
We read with much interest the recently published article by Foroughi
et al. [1] in
your journal. They have demonstrated that prevalence of HIV, hepatitis B
virus (HBV), and
hepatitis C virus (HCV) infections among street and labour child are 4.5%,
1.7% and 2.6% in
Iran, respectively and well discussed about HIV infection in this
population, However, we would
like to highlight some points about HBV a...
We read with much interest the recently published article by Foroughi
et al. [1] in
your journal. They have demonstrated that prevalence of HIV, hepatitis B
virus (HBV), and
hepatitis C virus (HCV) infections among street and labour child are 4.5%,
1.7% and 2.6% in
Iran, respectively and well discussed about HIV infection in this
population, However, we would
like to highlight some points about HBV and HCV infections among them.
First of all, we think that they may under-estimate reported
prevalence rates in their study.
only known street and labour children that had consent for enrollment in
the study have been
investigated which may cause a kind of selection bias considering socio-
economic status of
participants.
Treatment of HCV infection has been revolutionized and have provided
an opportunity for its
elimination. Patient finding is one of the major issues in the elimination
program. As screening
in general population is very difficult; therefore, in the first step
prioritizing special groups for
screening seems to be reasonable [2]. Foroughi et al. reported HCV
prevalence rate of 2.6% in
Iranian street and labor children which is approximately five times higher
than general
population in our country [3]. Hence, we think this group of patients
needs special attention for
finding of HCV-infected patients. Furthermore, Authors showed that HCV
infection is six times
higher in HIV-infected children compared to children without this
infection. Fortunately, with
new treatment strategies, HIV/HCV coinfection is not considered a special
condition anymore
and can be treated easily with only considering drug-drug interaction [2].
Finally, all participants were 10-18 years old, so they should have
been vaccinated against HBV
according to the national immunization program for neonates in Iran [4].
But high reported
prevalence of HBV among them and the etiology for lack of enough
immunization should be
more investigated.
References:
1. Foroughi M, Moayedi-Nia S, Shoghli A, et al. Prevalence of HIV,
HBV and HCV among street and labour
children in Tehran, Iran. Sexually Transmitted Infections 2016:sextrans-
2016-052557
2. Hesamizadeh K, Sharafi H, Rezaee-Zavareh MS, Behnava B, Alavian
SM. Next Steps Toward
Eradication of Hepatitis C in the Era of Direct Acting Antivirals.
Hepatitis Monthly 2016;16(4)
3. Hajarizadeh B, Razavi-Shearer D, Merat S, Alavian SM, Malekzadeh
R, Razavi H. Liver Disease Burden
of Hepatitis C Virus Infection in Iran and the Potential Impact of Various
Treatment Strategies on
the Disease Burden. Hepat Mon 2016;16(7):e37234 doi:
10.5812/hepatmon.37234[published
Online First: Epub Date]|.
4. Alavian SM, Zamiri N, Gooya MM, Tehrani A, Heydari ST, Lankarani
KB. Hepatitis B vaccination of
adolescents: a report on the national program in Iran. Journal of public
health policy
2010;31(4):478-93
The authors estimated vertical transmission of Chlamydia trachomatis by a retrospective analysis using national registry data and clinical records and concluded that transmission was much lower (<2%) than the rate commonly quoted (50-70%). Their suggested explanation is that the modern use of highly sensitive NAATs detects nonviable chlamydiae so that mothers testing positive could actually be noninfectious whereas older studies based on use of culture only identified infectious pregnant women. That is not a likely explanation for such a big difference. When NAAT performance with cervical swabs was evaluated about 2/3 of NAAT positive specimens were culture positive.
A more likely explanation comes from examining their case definition. It is not chlamydial infection, but rather laboratory confirmed cases of chlamydial conjunctivitis or pneumonia. And that is very different. When prospective studies were being done in San Francisco 175 infants born to chlamydia infected mothers were followed: 31 (18%) developed pneumonia; 29 (17%) conjunctivitis; 64 (37%) were culture positive and 105 (60%) had serologic evidence of infection. Thus there were many more infections than cases of conjunctivitis and pneumonia. But the difference between cases of disease and infection in the Finnish material is probably greater. In the prospective study there were cases of very mild disease that would likely not have been diagnosed in ordinary circumstances (seeing the whole clinical s...
The authors estimated vertical transmission of Chlamydia trachomatis by a retrospective analysis using national registry data and clinical records and concluded that transmission was much lower (<2%) than the rate commonly quoted (50-70%). Their suggested explanation is that the modern use of highly sensitive NAATs detects nonviable chlamydiae so that mothers testing positive could actually be noninfectious whereas older studies based on use of culture only identified infectious pregnant women. That is not a likely explanation for such a big difference. When NAAT performance with cervical swabs was evaluated about 2/3 of NAAT positive specimens were culture positive.
A more likely explanation comes from examining their case definition. It is not chlamydial infection, but rather laboratory confirmed cases of chlamydial conjunctivitis or pneumonia. And that is very different. When prospective studies were being done in San Francisco 175 infants born to chlamydia infected mothers were followed: 31 (18%) developed pneumonia; 29 (17%) conjunctivitis; 64 (37%) were culture positive and 105 (60%) had serologic evidence of infection. Thus there were many more infections than cases of conjunctivitis and pneumonia. But the difference between cases of disease and infection in the Finnish material is probably greater. In the prospective study there were cases of very mild disease that would likely not have been diagnosed in ordinary circumstances (seeing the whole clinical spectrum is an advantage of prospective studies). I do not know what the triggers would be for laboratory testing in Finland, but there must have been a bias towards more severe cases of conjunctivitis and pneumonia. Thus there would be an underestimation of chlamydia pneumonia and conjunctivitis cases in the population, and no real measure of chlamydia infection. This study did not measure vertical transmission of Chlamydia trachomatis.
The 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
I'm writing to ask if the authors considered an alternate hypothesis:
perhaps the symptoms of primary infection with syphilis are easier to
ignore than chlamydia and gonorrhea--the latter two often cause painful
urination and discharge, while with syphilis (in men) a chancre often
appears in the genital area, usually (but not always) on the penis. These
sores are often painless.
I'm writing to ask if the authors considered an alternate hypothesis:
perhaps the symptoms of primary infection with syphilis are easier to
ignore than chlamydia and gonorrhea--the latter two often cause painful
urination and discharge, while with syphilis (in men) a chancre often
appears in the genital area, usually (but not always) on the penis. These
sores are often painless.
To me it seems quite reasonable that the painless chancre symptoms of
primary syphilis infection would be a lot easier to ignore than those of
chlamydia and gonorrhea, which manifests in pain and quite obvious
discharge. Those with the latter two would likely seek out treatment and
cease sexual activity (and thereby reduce the spread), while individuals
with syphilis may just ignore the comparatively benign symptom, and
continue to spread it to others. So, infection with different diseases
likely results in different behavioral responses, which in turn affect the
rates.
I'm just a layperson so I apologize if this is ridiculous or already
accounted for, but I hope this perspective might help!
The authors impute a biological mechanism to the high incidence of syphilis in men who have sex with men using anti-retroviral drugs (in particular, HAART). We suggest, empiric data do not support the biological hypothesis, and behavioral explanations (i.e. increased condomless sex and selection of higher risk partners) are supported by stronger evidence.
Randomized double-blind trials of pre-exposure prophylaxis (PrEP) for HIV prevention [1] provide a rigorous test of the author’s hypothesis. The methodological strength includes an unconfounded and clearly unexposed control group and an exposed group which received an agent that would putatively increase susceptibility — tenofovir disoproxil fumarate (TDF) co-formulated with emtricitabine (FTC). A unique feature is that these trials were blinded and PrEP was unproven that the time trials were undertaken; hence, we would not expect that the TDF/FTC-exposed group would adopt higher risk practices.
An analysis of the iPrEx trial [2], a randomized PrEP trial in men who have sex with men/trans women, found [1] a relative rate of syphilis acquisition for TDF/FTC of 1.14 with a 0.95 confidence interval (0.90 to 1.45) compared to placebo. Incident syphilis, can be difficult to differentiate from a previous infection. Among those with a negative rapid plasma reagin titer at screening the relative rate of an on-study infection was 1.03, 0.95 CI (0.76 to 1.38). Adherence, was low in the iPrEx study and when pharmaco...
The authors impute a biological mechanism to the high incidence of syphilis in men who have sex with men using anti-retroviral drugs (in particular, HAART). We suggest, empiric data do not support the biological hypothesis, and behavioral explanations (i.e. increased condomless sex and selection of higher risk partners) are supported by stronger evidence.
Randomized double-blind trials of pre-exposure prophylaxis (PrEP) for HIV prevention [1] provide a rigorous test of the author’s hypothesis. The methodological strength includes an unconfounded and clearly unexposed control group and an exposed group which received an agent that would putatively increase susceptibility — tenofovir disoproxil fumarate (TDF) co-formulated with emtricitabine (FTC). A unique feature is that these trials were blinded and PrEP was unproven that the time trials were undertaken; hence, we would not expect that the TDF/FTC-exposed group would adopt higher risk practices.
An analysis of the iPrEx trial [2], a randomized PrEP trial in men who have sex with men/trans women, found [1] a relative rate of syphilis acquisition for TDF/FTC of 1.14 with a 0.95 confidence interval (0.90 to 1.45) compared to placebo. Incident syphilis, can be difficult to differentiate from a previous infection. Among those with a negative rapid plasma reagin titer at screening the relative rate of an on-study infection was 1.03, 0.95 CI (0.76 to 1.38). Adherence, was low in the iPrEx study and when pharmacology is taken into account, the hazard ratio for TDF/FTC among those with drug detected in plasma was 1.00, 0.95 CI (0.62 to 1.61), compared to placebo. Finally, we found that the incidence of syphilis decreased during the period of the trial in the TDF/FTC group (from 6.3 per 100 person years in the first year to 3.7 per 100 person years in subsequent years).
It is unlikely a biological TDF/FTC effect on syphilis acquisition would be missed when effects on HIV replication, bone mineral density, lipids, symptoms (e.g., nausea), and kidney function were readily detected in the iPrEx study even in the presence of suboptimal adherence. Randomized controlled trials are the gold standard in clinical research and this PrEP trial provides formidable evidence against the authors hypothesis.
References
1. Solomon MM, Mayer KH, Glidden DV. Syphilis predicts HIV incidence among men and transgender women who have sex with men in a preexposure prophylaxis trial. Clin Infect Dis. 2014; 59:1020-6. doi: 10.1093/cid/ciu450.
2. Grant RM, Lama JR, Anderson PL, et al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med. 2010;363 :2587-99. doi: 10.1056 NEJMoa1011205.
Impact of Expedited Partner Therapy (EPT) Implementation on Chlamydia Incidence in the USA
Show MoreLetter to the Editor:
Assuming that a sexual partner has only one Sexually Transmitted Infection (STI) is a dangerous practice and should be discouraged. The Expedient Partner Therapy implementation on Chlamydia is one such assumption. In a study conducted by (Zemouri, Wi, Kiarie, Seuc, Moqasale et.al 2016) they highlighted that Sexually Transmitted Infection (STI) case management is one of the top priorities in controlling STIs to break the chain of infection and transmission. They further reiterated that Syndromic case management provides a standardized evidence-based approach using clinical management algorithms, and flowcharts that can be used consistently across providers. Clinicians that treat patients with STIs should be cognizant that Expedited Partner Treatment is inadequate because there is at least a third infected sexual partner other than the partner being treated.
Another factor that should be considered when administering Expedited Partner Therapy is the possibility, of the partner, manifesting other symptoms of a STI to be treated that has not yet been identified in the patient. It is useful to administer the risk score test which is a 6 point research base quiz to each patient being treated for STI. These questions can only be answered by the patient for it to be considered reliable. Each question has a number of points assigned to potential ans...
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...
Error in the calculation of person-time in the before-PrEP period by Beymer et al.
S.H. Hulstein, E. Hoornenborg, M.F. Schim van der Loeff
Department of Infectious Diseases, GGD Amsterdam
Studies on STI incidence and PrEP use are often hampered by the absence of STI incidence data in the period before PrEP; Beymer et al.1 set out to improve on this. They report on the STI incidence before and after initiation of PrEP in a cohort of men who have sex with men (MSM) at the Los Angeles LGBT Center, California, US. We fear that there are some flaws in the analysis, which may affect the conclusions.
The analysis was based on 275 men who were tested at least once in the period before PrEP was started, and at least once after PrEP was started. The reported persontime in the before- PrEP period was just over half the person-time after PrEP initiation (93.60 versus 168.93), but the numbers of tests before and after PrEP initiation were not very different: 755 and 908, respectively. This discrepancy could not be explained by differences in their frequency of STI testing, which were reported to be similar in the before- and after-PrEP period. An explanation is that the person-time before the first STI visit was not taken into account. This would mean that the person-time in the before-PrEP period was underestimated, in turn leading to an artificially high before-PrEP STI incidence....
Show MorePrevalence of Mycoplasma genitalium
Response to: Taylor-Robinson D and Ong J
Authors: Nicola Low, Lukas Baumann, Manuel Cina, Myrofora Goutaki, Hammad Ali, Dianne Egli-Gany
Correspondence to: Nicola Low, Professor of Epidemiology and Public Health, Institute of Social and Preventive Medicine, University of Bern, Mittelstrasse 43, 3012 Bern, Switzerland. nicola.low@ispm.unibe.ch; Tel: +41 31 631 30 92
Title: Research on Mycoplasma genitalium is more important than expanding testing
We are glad that Taylor-Robinson and Ong offer some support for the conclusion of our systematic review,1 that asymptomatic populations, in the community or in clinics, should not be tested routinely for M. genitalium. The first British Association of Sexual Health and HIV (BASHH) guideline about the management of Mycoplasma genitalium, published on 8th July 2018, supports this conclusion.2 We would like to clarify, however, that the absence of evidence for clinical and public health benefit of screening3 and the harm of inducing de novo mutations and spreading resistance to macrolide antimicrobials4 are more important than economic considerations.
Taylor-Robinson and Ong’s statement that “testing worldwide should continue to support or modify this conclusion”5 could lead to pro...
Show MoreThe work by Baumann et al.(1) is valuable because it indicates populations for which screening for Mycoplasma genitalium (MG)) is not worthwhile economically. However, as molecular detection tests are now available commercially, testing worldwide should continue to support or modify this conclusion and so help in the development of management guidelines and also provide data for MG modelling.
Show MoreAnother aspect of infection which requires more attention is the precise role of MG in balanoposthitis, epididymitis,, chronic prostatitis, reactive arthritis, and, of course, pelvic inflammatory disease, all of which, apart from chronic prostatitis, have some association with MG (2).
In addition, it is noteworthy that Mycoplasma pneumoniae (MP), which infects the respiratory tract, and is also responsible for some autoimmune side effects, does so in early childhood without causing disease. The latter usually occurs as an immunological response to reinfection later in life. MG is different genomically from MP but has much in common antigenically and might behave in a similar way to MP. Could asymptomatic MG infection, which is seen occasionally, be an example of this? Potentiation or even inhibition of MG infection in the genital tract by MP infection in the respiratory tract earlier in life is also possible. This idea is not supported by studies in mice, but the human situation might be quite different. In this regard, use of an existing specific serological test for MG m...
Dear editor,
We read with much interest the recently published article by Foroughi et al. [1] in your journal. They have demonstrated that prevalence of HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV) infections among street and labour child are 4.5%, 1.7% and 2.6% in Iran, respectively and well discussed about HIV infection in this population, However, we would like to highlight some points about HBV a...
The authors estimated vertical transmission of Chlamydia trachomatis by a retrospective analysis using national registry data and clinical records and concluded that transmission was much lower (<2%) than the rate commonly quoted (50-70%). Their suggested explanation is that the modern use of highly sensitive NAATs detects nonviable chlamydiae so that mothers testing positive could actually be noninfectious whereas older studies based on use of culture only identified infectious pregnant women. That is not a likely explanation for such a big difference. When NAAT performance with cervical swabs was evaluated about 2/3 of NAAT positive specimens were culture positive.
Show MoreA more likely explanation comes from examining their case definition. It is not chlamydial infection, but rather laboratory confirmed cases of chlamydial conjunctivitis or pneumonia. And that is very different. When prospective studies were being done in San Francisco 175 infants born to chlamydia infected mothers were followed: 31 (18%) developed pneumonia; 29 (17%) conjunctivitis; 64 (37%) were culture positive and 105 (60%) had serologic evidence of infection. Thus there were many more infections than cases of conjunctivitis and pneumonia. But the difference between cases of disease and infection in the Finnish material is probably greater. In the prospective study there were cases of very mild disease that would likely not have been diagnosed in ordinary circumstances (seeing the whole clinical s...
The 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...
I'm writing to ask if the authors considered an alternate hypothesis: perhaps the symptoms of primary infection with syphilis are easier to ignore than chlamydia and gonorrhea--the latter two often cause painful urination and discharge, while with syphilis (in men) a chancre often appears in the genital area, usually (but not always) on the penis. These sores are often painless.
To me it seems quite reasonable...
The authors impute a biological mechanism to the high incidence of syphilis in men who have sex with men using anti-retroviral drugs (in particular, HAART). We suggest, empiric data do not support the biological hypothesis, and behavioral explanations (i.e. increased condomless sex and selection of higher risk partners) are supported by stronger evidence.
Randomized double-blind trials of pre-exposure prophylaxis (PrEP) for HIV prevention [1] provide a rigorous test of the author’s hypothesis. The methodological strength includes an unconfounded and clearly unexposed control group and an exposed group which received an agent that would putatively increase susceptibility — tenofovir disoproxil fumarate (TDF) co-formulated with emtricitabine (FTC). A unique feature is that these trials were blinded and PrEP was unproven that the time trials were undertaken; hence, we would not expect that the TDF/FTC-exposed group would adopt higher risk practices.
An analysis of the iPrEx trial [2], a randomized PrEP trial in men who have sex with men/trans women, found [1] a relative rate of syphilis acquisition for TDF/FTC of 1.14 with a 0.95 confidence interval (0.90 to 1.45) compared to placebo. Incident syphilis, can be difficult to differentiate from a previous infection. Among those with a negative rapid plasma reagin titer at screening the relative rate of an on-study infection was 1.03, 0.95 CI (0.76 to 1.38). Adherence, was low in the iPrEx study and when pharmaco...
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