Dear Editor,
with great interest we read the article by Poynten and collaborators (1),
who investigated the possible relation between recent sexual behaviour and
age-specific prevalence of anal HPV infection in men who have sex with men
(MSM) and cervical HPV infection in women. The authors used the sexual
behavioural data of previously published surveys conducted on these
populations. Their conclusions regarding the assoc...
Dear Editor,
with great interest we read the article by Poynten and collaborators (1),
who investigated the possible relation between recent sexual behaviour and
age-specific prevalence of anal HPV infection in men who have sex with men
(MSM) and cervical HPV infection in women. The authors used the sexual
behavioural data of previously published surveys conducted on these
populations. Their conclusions regarding the association of the age-
specific pattern of sexual behaviour with that of anal HPV prevalence
among MSM are largely consistent with the results of our recent study.
This investigated the association between recent sexual behaviour and anal
HPV infection among 408 HIV-uninfected MSM recruited at a sexual-health
clinic (2). Our results showed an age-independent trend for the prevalence
of any HPV genotype and also for that of high-risk genotypes. Moreover,
the stability of the HPV prevalence trend was supported by a non-
significant change in the median age of sexual partners across different
age groups and by a substantial increase in the median number of recent
sexual partners with age. This indicates that, among MSM, older
individuals still maintain an active sex life, as rightly underlined by
Poynten and collaborators, and that the pattern of mixing-age in sexual
partnership, specific for this population, is an important determinant of
ongoing exposure to HPV throughout life. Thus, as Poynten and
collaborators, we do believe that recent sexual behaviour is the driving
reason for the persistently high prevalence of anal HPV infection in MSM.
However, in addition to the high number of new partners, their age
characteristics are likely to contribute strongly to this phenomenon.
We believe that the study by Poynten and collaborators, together with our
findings, significantly contribute to shedding more light on the reasons
behind the stable prevalence of anal HPV infection among MSM and have
significant implications on the vaccination strategies to be adopted for
these individuals.
1. Poynten IM, Machalek D, Templeton D, et al. Comparison of age-
specific patterns of sexual behavior and anal HPV prevalence in homosexual
men with patterns in women. Sex Trans Infect August 25, 2015:
doi:10.1136/sextrans-2015-052032.
2. Dona' MG, Latini A, Benevolo M, et al. Anal human papillomavirus
infection prevalence in men who have sex with men is age-independent: a
role for recent sexual behavior? Future Microbiol 2014;9:837-44
I read with concern the manuscript by MacLaren DJ et al which
states: "Alternative forms of penile foreskin cutting may be associated
with reduced HIV infection risk in Papua New Guinea." Using data described
in the manuscript, I was able to exactly replicate the authors' primary
numerical finding. However, results of additional analyses not reported in
the manuscript directly conflict with the key message regarding a
po...
I read with concern the manuscript by MacLaren DJ et al which
states: "Alternative forms of penile foreskin cutting may be associated
with reduced HIV infection risk in Papua New Guinea." Using data described
in the manuscript, I was able to exactly replicate the authors' primary
numerical finding. However, results of additional analyses not reported in
the manuscript directly conflict with the key message regarding a
potential association between alternative forms of penile foreskin cutting
and reduced HIV risk.
First, the manuscript does not present individual results according
type of penile foreskin cutting. Neither of the individual associations
between HIV prevalence and prevalence of circumcision or dorsal
longitudinal cut alone reach statistical significance (P=0.1756 and
P=0.1327, respectively).
Second, no results are reported for associations between HIV prevalence and other risk factors for HIV acquisition. Yet, prevalence of condom use
at last sex is significantly associated with HIV prevalence (P=0.0089) and
has a high coefficient of determination (R2=0.9823). Furthermore, the
strength of the association appears to be as strong, or stronger, than
that found for circumcision/dorsal longitudinal cut. The regression
coefficient for condom use at last sex (?=-0.07848) is approximately three
-fold stronger than the coefficient for circumcision/dorsal longitudinal
cut (?=-0.02322).
The manuscript makes bold statements about alternative forms of penile
foreskin cutting and reduced HIV risk. Yet, these claims are not supported
by the individual associations with each type of penile of foreskin
cutting. Additionally, the claims are predicated in part on an apparent
ruling-out of other risk factors for HIV acquisition. Applying the same
analytic approach with prevalence of condom use yields a similar, if not
stronger, association with HIV prevalence. Taken together, I question the
appropriateness of the manuscript's declarative title and the credibility
of its key message regarding alternative forms of penile foreskin cutting
and reduced HIV risk.
1. MacLaren DJ, McBride WJH, Kelly GC, et al. HIV prevalence is
strongly associated with geographical variations in male circumcision and
foreskin cutting in Papua New Guinea: an ecological study. Sexually
Transmitted Infections. Published Online First: 30 June 2015 doi:
10.1136/sextrans-2014-051970.
Yap and colleagues1 suggest that China's labor camps for drug users
present an opportunity to implement universal 'test and treat' programs.
They contend that such a step would be consistent with 'humanitarian'
principles endorsed by The Global Fund and the World Bank.
Their recommendation is surprising and troubling. The paper cited to
support this position (which we co-authored) is not in fact a call to
scale...
Yap and colleagues1 suggest that China's labor camps for drug users
present an opportunity to implement universal 'test and treat' programs.
They contend that such a step would be consistent with 'humanitarian'
principles endorsed by The Global Fund and the World Bank.
Their recommendation is surprising and troubling. The paper cited to
support this position (which we co-authored) is not in fact a call to
scale up HIV treatment in drug detention centers. Rather, it summarizes
the emerging policy consensus among UN agencies and bilateral and
international aid agencies that drug detention centers undermine the fight
against HIV and should be closed.2
The authors make no mention that The Global Fund board recently
adopted a policy explicitly refusing to fund programs in such facilities
(in China and elsewhere).3 They (and other donors) have taken this
position because they recognize that abuses in such centers are routine
and that donors have little ability to ensure independent oversight of
their funds or programmes.4
Since 2008, Human Rights Watch has conducted research into compulsory
drug detention centers in China and Southeast Asia.5 We have found a wide
range of severe human rights abuses, including, in China, the use of HIV
tests, according to one guard "to know which female inmates they could
sleep with without using a condom."6
Yap and colleagues' recommendations for universal testing and
treatment are intended, no doubt, to protect the health and well-being of
those detained. Yet, their research failed to ask the right questions and
consequently prescribes the wrong medicine. Expanded HIV treatment would
aid some concerns of some detainees. Closing these centers down, in line
with the joint views of 12 UN agencies, would advance both public health
and human rights.7
1. Yap, L., Reekie, J., Liu, W., Chen, Y., Wu, Z., Li, J., ... &
Butler, T. HIV testing in re-education through labour camps in Guangxi
Autonomous Region, China (a cross-sectional survey). Sexually transmitted
infections, 2015: sextrans-2014.
2. Amon JJ, Pearshouse R, Cohen JE, et al. Compulsory drug detention
in East and Southeast Asia: evolving government, UN and donor responses.
Int J Drug Policy 2014;25:13-20
3. The Global Fund, Global Fund Calls for End to Compulsory
Treatment. Announcement, November 26, 2014.
http://www.theglobalfund.org/en/mediacenter/announcements/2014-11-
26_Global_Fund_Calls_for_End_to_Compulsory_Treatment/ (accessed June 2,
2105).
4. Garmaise D. Global Fund to End Funding for HIV Services in Drug
Treatment Centers in Viet Nam. Global Fund Observer Newsletter 2014;234
http://www.aidspan.org/gfo_article/global-fund-end-funding-hiv-services-
drug-treatment-centres-viet-nam (accessed June 2, 2105).
5. Amon J, Pearshouse R, Cohen J, Schleifer R. Compulsory drug
detention centers in China, Cambodia, Vietnam, and Laos: health and human
rights abuses. Health Hum Rights 2013;15(2):124-37.
6. Cohen JE, Amon JJ. Health and human rights concerns of drug users
in detention in Guangxi Province, China. PLoS Med 2008;5:e234.
7. International Labour Organization, Office of the High Commissioner
of Human Rights, World Health Organization, et al. Joint statement:
compulsory drug detention and rehabilitation centres. March 2012.
www.unaids.org/sites/default/files/sub_landing/files/JC2310_Joint%20Statement6March12FINAL_en.pdf
(accessed June 2, 2105).
The use of recreational drugs used in sexual contexts by MSM
(referred to in many developed countries as "ChemSex") is of increasing
public health concern; it would be helpful if the abstract was ammended to
include which recreational drugs were being used by the cohort in this
study.
The audit by Clarke et al of 106 patients provides a useful estimate
of the percentage of anogenital warts among GUM clinic attenders that the
patient had not noticed (in 2010), at 12.3%[1]. They suggest that failure
to examine these patients may have accounted for a considerable proportion
of the reduction in anogenital warts diagnoses in GUM seen in England
between 2008 and 2012, of 8% among males and females of all age...
The audit by Clarke et al of 106 patients provides a useful estimate
of the percentage of anogenital warts among GUM clinic attenders that the
patient had not noticed (in 2010), at 12.3%[1]. They suggest that failure
to examine these patients may have accounted for a considerable proportion
of the reduction in anogenital warts diagnoses in GUM seen in England
between 2008 and 2012, of 8% among males and females of all ages[2]. In
our detailed ecological analysis of the declines in anogenital warts
diagnoses in GUM clinics[3], we considered changes in diagnosis and
reporting practices as possible explanatory factors. As far as we were
aware, such changes would likely have affected all GUM clinic attenders,
males and females, of all ages. Decreases, however, have not been seen for
all. We have seen declines of over 20% among young women (under 20years),
smaller declines among young men, and level or increasing rates in older
males and females[2-4]. We have also seen similar declines in diagnosis
made by GPs[3]. This pattern is harder to explain by fewer patients being
diagnosed via examination in GUM, but could be explained by cross-
protection from bivalent HPV vaccination. We found a significant
association between observed declines and estimated HPV vaccination
coverage among young women[3,4]. If Clarke et al, or others, have data
showing that the effect of changes in diagnosis and/or reporting practices
in GUM and GP since 2008 differ by sex and age, this could provide an
alternative explanation for the decreases we have seen in anogenital warts
diagnoses in England.
References
1 Clarke E, Board C, Patel N, et al. Why are anogenital warts
diagnoses decreasing in the UK: bivalent human papillomavirus (HPV)
vaccine cross-protection or failure to examine? Sex Transm Infect
2014;90:587.
2 Public Health England. Table 3: Selected STI diagnoses and rates by
gender, sexual risk and age group, 2009 to 2013.
https://www.gov.uk/government/statistics/sexually-transmitted-infections-
stis-annual-data-tables (assessed 28 Nov 2014).
3 Howell-Jones R, Soldan K, Wetten S, et al. Declining genital Warts
in young women in england associated with HPV 16/18 vaccination: an
ecological study. J Infect Dis 2013 Nov 1;208(9):1397-403.
4 Public Health England. Declines in genital warts since start of the
HPV immunisation programme. Health Protection Report 2014;8(24)
In South Africa, a country that has battled with the HIV and TB co-
epidemic for more than two decades, STI management has received little
attention. We were delighted to read the article by Lurie et al, which
highlights the high burden of STI syndromes in people living with HIV, in
particular, in the period before ART initiation. While we concur with the
authors' conclusions that systematic STI tes...
In South Africa, a country that has battled with the HIV and TB co-
epidemic for more than two decades, STI management has received little
attention. We were delighted to read the article by Lurie et al, which
highlights the high burden of STI syndromes in people living with HIV, in
particular, in the period before ART initiation. While we concur with the
authors' conclusions that systematic STI testing and treatment is
warranted in HIV care programmes, the epidemiological data presented leave
several unanswered questions.
There are major problems with reliance on syndromic management,
particularly with the syndrome of vaginal discharge. STI symptoms poorly
correlate with laboratory diagnoses, illustrated by gonorrhoea and
chlamydia, which are mostly asymptomatic in women. Studies at the Centre
for the AIDS Programme of Research in South Africa (CAPRISA) have shown a
high prevalence of laboratory-diagnosed STIs in women at the time of acute
HIV infection. Further analysis showed that clinical assessment alone
missed 88% of laboratory-diagnosed STIs and 66% received unnecessary
treatment [1].
Furthermore, the commonest cause of vaginal discharge is bacterial
vaginosis (BV), an infection that is associated with sex, but does not
appear to be sexually transmitted. We have found that over 50% of women
had BV at HIV diagnosis which is often persistent [1]. Lurie et al omit
mentioning BV, perhaps misclassifying some of their findings.
While the authors' results are intriguing, a potential mechanism for
the reduction of syndromic STIs on ART is missing. One could hypothesize
that immunosuppression may increase the susceptibility and ability to
clear STIs and BV. However, in this study the reduction in incidence was
independent of CD4 count, in fact, the opposite was true, that a higher
CD4 count was associated with more syndromic STI diagnoses. Alternative
mechanisms namely behavioural change and length of clinical follow-up may
have had a greater impact on the reduction of syndromic STI incidence than
improvement in CD4 count in response to ART.
We hope, that the findings by Lurie et al and the following debate
will contribute to the long overdue implementation of STI testing and
treatment policies in South Africa.
Yours sincerely,
Nigel Garrett and Adrian Mindel
Centre for the AIDS Programme of Research in South Africa (CAPRISA)
1.Mlisana K, Naicker N, Werner L, Roberts L, van Loggerenberg F,
Baxter C, et al. Symptomatic vaginal discharge is a poor predictor of
sexually transmitted infections and genital tract inflammation in high-
risk women in South Africa. J Infect Dis 2012,206:6-14.
The highlights of a strategy endorsed by the World Health
Organization (WHO) in 2010 for Sexually Transmitted Infections (STI)
screening, testing and early initiating into treatment (TnT) to Men that
have Sex with Men (MSM) and transgender people are discussed by Cohen et
al. in their editorial letter entitled "WHO guidelines for HIV/STI
prevention and care among MSM and transgender people: implications for
policy and p...
The highlights of a strategy endorsed by the World Health
Organization (WHO) in 2010 for Sexually Transmitted Infections (STI)
screening, testing and early initiating into treatment (TnT) to Men that
have Sex with Men (MSM) and transgender people are discussed by Cohen et
al. in their editorial letter entitled "WHO guidelines for HIV/STI
prevention and care among MSM and transgender people: implications for
policy and practice" (1,2). In the same line as WHO, the authors call for
improved access to STI screening services for people in low and middle-
income settings regardless of their sexual identity, sexual orientation or
their cultural and socioeconomic characteristics (1,2) Due to the higher
prevalence of STI among these vulnerable groups, compared to the general
population, the uptake of this guideline is recommended to prevent the
transmission of STI and ensure that sexual minorities enjoy their right to
access quality provision of STI healthcare (1,2).
The advantages of this strategy are understandable. This, regardless
of the scarcity of data on the cost-effectiveness, cost-benefit and impact
on community incidence of STI of routine TnT to asymptomatic MSM and
transgender people that the WHO recommends (1). As the raison d'etre of a
public health approach being informed by the evidence seems disregarded,
in this letter we intend to highlight some gendered aspects that also
derive from the WHO guideline and that, in our opinion, Cohen et al. may
have given the same relevance as they had given to the WHO-endorsed TnT
strategy.
STI screening is a secondary prevention strategy. In the scenario we
are discussing, it may be assumed that all MSM and transgender people may
eventually engage in sexual risky behaviours and, as consequence, be
infected with an STI. Hence, the recommendation to screen those targets
populations for STI even if asymptomatic. The pitfall of this
recommendation is that these vulnerable groups may end up dealing with
healthcare providers with prejudices towards them.
The first assumption healthcare providers should have in mind is that
these groups adhere to key messages on how to lead a healthy sexual life.
Hence, Routine STI screening should not be the first step in the cascade
to prevent, detect and treat STI. It can be ventured that STI TnT approach
might result being less cost-effective, potentially more stigmatizing,
and, more distanct from the goal of equity that the traditional primary
prevention strategies hold (2,4).
On the other hand, women are not listed among the beneficiaries of
this prevention strategy. The significance of understanding the
motivations and other factors contributing to sexual risk taking among MSM
that also have sexual intercourse with Women (MSMW) have been highlighted
elsewhere (5,6,7). It must be acknowledged that in many low and middle-
income countries, in order to fulfil with social expectations, many MSM
may also engage, in an casual or in a permanent manner, in heterosexual
relationships (7). To effectively reduce the community-level prevalence of
STI, all asymptomatic women should also be targeted as beneficiaries of
this TnT. In a context where cultural taboos and social stigma,
judgemental attitudes from health workers towards sexual minorities,
repressive policies, and anti-gay legislation, it is very unlikely that
their MSMW might disclose to their female partners or their healthcare
providers that they occasionally engage in unprotected same-sex sexual
intercourse.
Fear to being stigmatized acts as a driving force that leads MSM to
becoming MSMW, keeping their sexual orientation hidden, and hindering them
from accessing and demanding STI healthcare. Acknowledging this leads us
to another worrisome issue that should not be neglected from the umbrella
of responsibilities that lie within the scope of the public health arena;
how many countries with pandemic HIV/AIDS infection figures have actually
decriminalized homosexuality in the last decade? According to the
International Lesbian and Gay Association Report, there were 76 countries
prosecuting people because of their sexual orientation as recent as in
2010. Eleven countries still include death penalty for homosexuals in
their penal code (8). To effectively inform and carry out any health
promotion campaign targeting MSM and transgender people, beyond advocating
for the implementation of massive TnT strategies that capitalize the
potential of new nucleid acid amplification testing technologies, the
international community should move the focus to advocate for low and
middle-income countries? governments to abolish their pre-colonial 'anti-
sodomy laws', build the capacity of their healthcare providers to better
address the health needs of MSM and transgender people, and raise
awareness among the general population to respect the sexual rights of the
most vulnerable ones (9,10).
A behavioural change approach, with the aim to promote adoption of
safer sexual practices and an active demand of HIV/STI healthcare
services, needs to be effectively integrated with any proposed TnT
strategy. Health promotion is a basic public health tool that we find that
it is not referred to in Cohen et al. missive. There is scientific
evidence that behavioural change-based education, community awareness and
advocacy approaches targeting sexual minorities may have a positive impact
-even in budget-constrained settings- in terms of adoption of safer sexual
practices with the ultimate goal to reduce incidence of HIV/STI (11). Why
for Cohen et al. the cornerstone of the cascade of "solutions" to the high
prevalence of STI may lie in targeted routine TnT when there is evidence
on the benefits primary prevention strategies?.
From a primary prevention point of view, other approaches should be
recommended. A public health approach to tackle HIV/STI is necessarily
gendered. The structural gender system has to be taken into account,
including in low and middle-income countries, when designing and endorsing
these types of prevention strategies. It is crucial to understand how
gender constructions are determinant in populations adopting sexual risk
practices, in impeding or facilitating their access to HIV/STI diagnostic
and treatment services, and in influencing government and institutional
policy and decision making processes (12). To have a more comprehensive
picture to inform approaches such as the STI TnT discussed in this letter,
it can be suggested that other subjects such as "masculinities,
transactional sex, infrastructural deficits in health and education (at
all levels), fragile states and global governance" (13) should be studied
and that sexual risk practices should be tackled in a broader context in
which gender equity is pursued and stigma and discrimination are
combatted.
REFERENCES
1. Cohen J, Lo Y, Caceres CF, Klausner JD, for the WHO guideline
working group. WHO guidelines for HIV/STI prevention and care among MSM
and transgender people: implications for policy and practice. Sex Transm
Infect 2013;89:536-538.
2. Gerbase A. Prevention and treatment of HIV and other sexually
transmitted infections among men who have sex with men and transgender
People: Recommendations for a public health approach. Geneva, Switzerland:
WHO, Programme HIV/AIDS, 2011. Report No.: ISBN 978 92 4 150175 0.
3. Starfield B, Hyde J, Gerv?s J, Heath J. The concept of prevention: a
good idea gone astray? J Epidemiol Community Health 2008;62:580-583.
4. Starfield B, Shi L, Macinko J. Contribution of Primary Care to Health
Systems and Health. Milbank Quaterly 2005;83:457-502.
5. Maulsby C, Sifakis F, German D, et al. HIV risk among men who have sex
with men only (MSMO) and men who have sex with men and women (MSMW) in
Baltimore. J Homosex 2013;60:51-68.
6. Harawa NT, McCuller WJ, Chavers C, et al. HIV risk behaviours among
Black/African American and Hispanic/Latina Female partners of men who have
sex with men and women. AIDS Behav 2013;17:848-55.
7. Eaton LA, Pitpitan EV, Kalichman SC, et al. Men who report recent male
and female sex partners in Cape Town, South Africa: an understudied and
underserved population. Arch Sex Behav 2013;42:1299-308.
8. Ottoson D. State-Sponsored Homophobia. A world survey of laws
prohibiting same sex activity between consenting adults. ILGA
(International Lesbian, Gay, Bisexual, Trans and Intersex Association).
2010.
9. Joint United Nations Programme on HIV/AIDS (UNAIDS). UNAIDS Action
Framework: Universal Access for Men who have Sex with Men and Transgender
People. WHO Library Cataloguing-in-Publication Data. 2009.
10. Ripley J, Lauer K, Hebert P, et al. Speaking Out: A Toolkit for MSM-
led HIV/AIDS Advocacy. Levi Strauss Foundation. The Global Forum on MSM
and HIV (MSMGF). 2010.
11. McDaid LM, Hart GJ. Sexual risk behaviour for transmission of HIV in
men who have sex with men: recent findings and potential interventions.
Curr Opin HIV AIDS 2010;5:311-5.
12. Connell R. Gender, health and theory: Conceptualizing the issue, in
local and world perspective. Social Science and Medicine 2012;74:1675-
1683.
13. Phillips AF, Pirkle CM. Moving beyond behaviour: advancing HIV risk
prevention epistemologies and interventions (A report on the state of the
literature). Glob Public Health 2011;6:577-92.
Responding to the editorial by Miller et al regarding the methodology of
our study , we would challenge the assessment of the Zelen design as
representing a form of 'deception'. Zelen design is employed to generate
real life responses to help understand the translation challenges of
introducing any similar or modified intervention across a whole area.
Responding to the editorial by Miller et al regarding the methodology of
our study , we would challenge the assessment of the Zelen design as
representing a form of 'deception'. Zelen design is employed to generate
real life responses to help understand the translation challenges of
introducing any similar or modified intervention across a whole area.
When general practices involved in our study were later informed of their
participation none expressed concern. Qualitative work undertaken with
these practices since the study has further confirmed they were supportive
of the study design selected, and stated it reduced bias. Chlamydia data
from general practice are routinely collected and published in England.
The editorial correctly identifies that levels of chlamydia screening
within general practices in England is currently low. Viewed in this
context, the 60% uptake generated by this intervention is significant. In
terms of the increases in testing observed during and after the
intervention period, our results were reported without inflation. Further,
while the results from the intervention may be modest, repeated on a
national scale a substantial increase in overall testing rates would be
observed.
The National Chlamydia Screening Programme identifies general practice as
an important venue through which opportunistic screening can be offered to
young adults. We also know the most common form of contact young people
have with medical services is with their GP. The results generated through
our intervention represent a positive development in our understanding of
how to increase screening in this setting. By engaging GPs in chlamydia
screening, opportunities are created to discuss wider sexual health issues
with young people, in a familiar and trusted surrounding.
We concur with Miller et al that changing practitioner behaviour is
challenging. General practice is a complex environment where practitioner
behaviour is subject to the influence of previous education and training,
practice managers and partners, competing targets, and other priorities
determined by the NHS. Other further research has shown that sustained
support is important to maintain the impact of any multifaceted
intervention, , and therefore Public Health England is continuing to
provide such support. However, further research into how to sustain and
maximise the impact of interventions to improve the sexual health service
delivered in primary care would also be beneficial.
AUTHOR NAMES; Cliodna A M McNulty 1, Angela H Hogan 2, Ellie J Ricketts 3, Louise Wallace 5, Isabel Oliver 6, Rona Campbell 7, Sebastian Kalwij 8, Elaine O'Connell 4, Andre Charlett 9
Author affiliations
1 Public Health England Primary Care Unit, Microbiology Department, Gloucestershire Royal Hospital, and Cardiff University, Cardiff, UK
2 (Previously) Public Health England Primary Care Unit, (Currently) Integrated Biobank of Luxembourg, Luxembourg, Luxembourg
3 Public Health England Primary Care Unit, Microbiology Department, Gloucestershire Royal Hospital
4 (Previously) Public Health England Primary Care Unit, (Currently) University of Bristol, Bristol, UK
5 Applied Research Centre Health & Lifestyle Interventions, Coventry University, Coventry, UK
6 Field Epidemiology Service, Public Health England, and University of Bristol, Bristol, UK
7 School of Social and Community Medicine, University of Bristol, Bristol, UK
8 Amersham Vale Training Practice, London, UK
9 Statistics, Modelling and Economics Department, Public Health England, 61 Colindale Avenue, London, UK
References
Miller W, Nguyen N. Relative or Absolute? A significant intervention
for chlamydia screening with small absolute benefit. Sex Transm Infec
[Editorial -in print] 2014
McNulty C a M, Hogan AH, Ricketts EJ, Wallace L, Oliver I, Campbell
R, et al. Increasing chlamydia screening tests in general practice: a
modified Zelen prospective Cluster Randomised Controlled Trial evaluating
a complex intervention based on the Theory of Planned Behaviour. Sex
Transm Infec [Internet]. 2013 Sep 4 [cited 2013 Oct 23];1-7. Available
from: http://www.ncbi.nlm.nih.gov/pubmed/24005256
Shafer M-AB, Tebb KP, Pantell RH, Wibbelsman CJ, Neuhaus JM, Tipton
AC, et al. Effect of a clinical practice improvement intervention on
Chlamydial screening among adolescent girls. JAMA?: J. Amer Med Assoc.
2002 p. 2846-52.
Kalwij S, French S, Mugezi R, Baraitser P. Using educational outreach
and a financial incentive to increase general practices' contribution to
chlamydia screening in South-East London 2003-2011. BMC public health
[Internet]; 2012 Jan [cited 2013 Oct 23];12(1):802. Available from:
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3524034&tool=pmcentrez&rendertype=abstract
PHE National Chlamydia Screening Programme (NCSP) website;
http://www.chlamydiascreening.nhs.uk/ps/index.asp accessed on 8th April
2014
Conflict of Interest:
All authors have completed the Unified Competing Interest form at http://www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare that '(1) CM, ER, AH, LW, RC, IS, EO, SK, AC have support from the Public Health England for the submitted work. Dr Cliodna McNulty leads the Public Health England Primary Care Unit that has an ongoing programme of work aimed at improving the management of infectious disease in primary care. Public Health England leads the National Chlamydia Screening Programme in England.
Dear Editor, with great interest we read the article by Poynten and collaborators (1), who investigated the possible relation between recent sexual behaviour and age-specific prevalence of anal HPV infection in men who have sex with men (MSM) and cervical HPV infection in women. The authors used the sexual behavioural data of previously published surveys conducted on these populations. Their conclusions regarding the assoc...
I read with concern the manuscript by MacLaren DJ et al which states: "Alternative forms of penile foreskin cutting may be associated with reduced HIV infection risk in Papua New Guinea." Using data described in the manuscript, I was able to exactly replicate the authors' primary numerical finding. However, results of additional analyses not reported in the manuscript directly conflict with the key message regarding a po...
Yap and colleagues1 suggest that China's labor camps for drug users present an opportunity to implement universal 'test and treat' programs. They contend that such a step would be consistent with 'humanitarian' principles endorsed by The Global Fund and the World Bank.
Their recommendation is surprising and troubling. The paper cited to support this position (which we co-authored) is not in fact a call to scale...
The use of recreational drugs used in sexual contexts by MSM (referred to in many developed countries as "ChemSex") is of increasing public health concern; it would be helpful if the abstract was ammended to include which recreational drugs were being used by the cohort in this study.
Conflict of Interest:
None declared
The audit by Clarke et al of 106 patients provides a useful estimate of the percentage of anogenital warts among GUM clinic attenders that the patient had not noticed (in 2010), at 12.3%[1]. They suggest that failure to examine these patients may have accounted for a considerable proportion of the reduction in anogenital warts diagnoses in GUM seen in England between 2008 and 2012, of 8% among males and females of all age...
Dear Editor,
In South Africa, a country that has battled with the HIV and TB co- epidemic for more than two decades, STI management has received little attention. We were delighted to read the article by Lurie et al, which highlights the high burden of STI syndromes in people living with HIV, in particular, in the period before ART initiation. While we concur with the authors' conclusions that systematic STI tes...
The highlights of a strategy endorsed by the World Health Organization (WHO) in 2010 for Sexually Transmitted Infections (STI) screening, testing and early initiating into treatment (TnT) to Men that have Sex with Men (MSM) and transgender people are discussed by Cohen et al. in their editorial letter entitled "WHO guidelines for HIV/STI prevention and care among MSM and transgender people: implications for policy and p...
Dear editor,
Responding to the editorial by Miller et al regarding the methodology of our study , we would challenge the assessment of the Zelen design as representing a form of 'deception'. Zelen design is employed to generate real life responses to help understand the translation challenges of introducing any similar or modified intervention across a whole area.
When general practices involved in...
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