Thank you for responding to our manuscript. We have carefully reviewed your comments. Below, please find our responses to the questions raised.
The first comment raised concerns the fact that “sexual factors may have played a lesser role in observed HIV and syphilis prevalence’s than nonsexual factors.”
The sexual transmission of sexually transmitted infections including HI...
Thank you for responding to our manuscript. We have carefully reviewed your comments. Below, please find our responses to the questions raised.
The first comment raised concerns the fact that “sexual factors may have played a lesser role in observed HIV and syphilis prevalence’s than nonsexual factors.”
The sexual transmission of sexually transmitted infections including HIV-1 is a significant risk factor of HIV-1 acquisition in female sex workers and men who have sex with men (MSM), and has been related to HIV-1 acquisition in preliminary analyses from our incidence cohort [1,2]. You
note that the discrepancy between the relationship we found between syphilis and receptive anal intercourse (RAI) and between prevalent HIV-1 and recent RAI among the women is a “red flag.” Please note that our point estimate for the odds of HIV-1 infection among women admitting recent RAI
is 1.2, and has a 95% confidence interval compatible with odds ranging from 0.5 to 2.5. The association between prevalent syphilis on enrolment and recent RAI was based on only 11 cases in women, and the importance of
this finding should not be exaggerated.
Your suggestion that the treponemal disease we have diagnosed in our female sex workers is not syphilis, but rather another treponemal species, is intriguing but very unlikely. Pinta is limited to the Americas, and
endemic syphilis (bejel) is not found in Kenya [3]. Yaws is very uncommon in Kenya [3], and we have seen none of the chronic skin or bone lesions typical of this infection in our clinic population. Other spirochetal illnesses that can lead to positive nontreponemal and treponemal tests
(e.g. relapsing fever, rat-bite fever) are also uncommon and were unsuspected in the clinical context [4]. A non-specific test such as the RPR, followed by a specific treponemal test (TPHA) is the commonly accepted means of diagnosing syphilis [5]. At the same time, syphilis is
the most likely diagnosis in these sexually active young women [6].
Your remark that we did not assess nonsexual (blood) exposures is true, since the focus of this article was on screening for sexually transmitted genital and anorectal infections. While some HIV infections we diagnosed at enrolment into our study population may be due to unsafe
injections, including injection drug use, the prevalence of injection drug use in our population is only 1.4% among MSM [2] and was not reported among women. In a prevalence study, history of any medical injection is not useful because lifetime exposure is very common. Having received a
medical injection in the 3 months preceding enrolment was reported by an equal proportion of HIV negative and positive women (35 vs. 36%). We have included data collection on both injection drug use and a number of other
non-sexual exposures (medical injections, blood transfusion, traditional practices) in our ongoing study of incident HIV-1 infections in this cohort, and hope that your curiosity regarding this factor will be
satisfied in an upcoming publication.
The second remark concerns the fact that “a strong association between anal sex and prostitution might mask the association between anal sex and prevalent HIV-1 in female participants in our cohort”. It is correct that the majority of women (89%) reporting recent RAI,
identified themselves as sex workers. We have also included this in our paper in section ‘results’, in the paragraph on RAI. Please note that table 4 presenting associations between prevalent HIV-1 and RAI are adjusted for age, transactional sex, partner numbers, and unprotected sex.
Finally, a remark was made on the fact that “unprotected receptive anal intercourse is probably not confined to high-risk persons and that broader community prevention messages might more usefully fit overall HIV
prevention objectives.” We agree on the importance of addressing unprotected (receptive) anal
intercourse as a potential risk factor for HIV-1 transmission. We did not mean to imply that this was not important on a population level, but meant
to highlight the urgency of addressing this risk in a targeted setting such as ours.
We trust these answers have addressed the concerns you have raised.
Sincerely,
Marlous Grijsen, MD,
Susan Graham, MD MPH,
Eduard Sanders, MD PhD.
References
1. Grijsen ML, Graham SM, Mwangome M, et al. Screening for genital and anorectal sexually transmitted infections in HIV prevention trials in
Africa. Sex Transm Inf (doi: 10.1136/sti2007.028852)
2. Sanders EJ, Graham SM, Okuku HS, et al. HIV-1 infection in high risk men who have sex with men in Mombasa, Kenya. AIDS 2007;21: 2513-20.
3. Meheus A, Antal GM. The endemic treponematoses: not yet eradicated. World Health Stat Q. 1992;45(2-3): 228-37.
4. Mandell GL, Bennett JE, Dolin R. Principles and practice of infectious diseases. 6th edn. Philadelphia, Pa.: Elsevier Churchill Livingstone; 2005.
5. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2006. MMWR 2006;55(RR-11): 1-94.
6. Holmes KK, Sparling PF, Stamm WE, et al. Sexually transmitted diseases. 4th edn. New York: the McGraw-Hill Companies; 2008.
In response to M O Ramogi on 21st August 2008, it is important to point out that since only patients attending with a new episode were included in the study, those experiencing chronic/recurrent infections or attending solely for treatment were excluded. Therefore the inclusion of patients for who HIV testing is less applicable is unlikely to be the explanation for the association between symptoms of an STI...
In response to M O Ramogi on 21st August 2008, it is important to point out that since only patients attending with a new episode were included in the study, those experiencing chronic/recurrent infections or attending solely for treatment were excluded. Therefore the inclusion of patients for who HIV testing is less applicable is unlikely to be the explanation for the association between symptoms of an STI and a decrease in the likelihood of being offered an HIV test.
With regard to point of care testing (POCT), while anxiety may play a part in the demand from patients for POCT there is evidence that POCT does attract a higher risk population and may lead to an increase in the number
of new HIV diagnoses(1). In a study conducted in Amsterdam average HIV prevalence among MSM receiving one-hour testing with result was 5.2% compared with 3.8% among the control group: those testing with a standard one-week wait. Similar results were found for heterosexuals. In another study among a high risk population utilising a rapid community outreach HIV testing clinic in London, 54% said they would not have tested if a rapid test had not been available(2). Also in London, a recent questionnaire based study found that 51% of high risk patients who declined HIV testing
said they would be more likely to test if POCT was available(3).
In response to M Pammi et al on 16th September 2008, one third of patients reporting a dislike of needles as the reason for declining an HIV test is considerably higher than found in our study. The second most common reason is having “checked recently”. Whether this is truly
reflective of differences in testing among heterosexuals compared with men who have sex with men, or specific to the locality where the study was done, is an interesting point. About two thirds of the patients in the Pammi study gave at least one response that would allow them to be divided
into those who should be tested at the current visit and those who don’t need to be, with those who have recently tested in the latter group. But what to do about those claiming a dislike for needles? Since all respondents in clinics C and D reported one or more reasons for not
testing, is it possible that a dislike of needles is a secondary reason, one not associated with the sensitive issue of actual or perceived risk of HIV exposure? Was there consistency between needle phobia and having
tested before, i.e. none of those reporting needle phobia had tested previously? It would also be interesting to know whether those stating that they have had a recent check have indeed done so within the last 3 months and if they know their status. Of note is the variation even between the two clinics in the proportion who perceived themselves at risk for HIV (the proportion was more than 3-fold higher in clinic U), and in the proportion who were in the window period and who had tested recently (both also higher in clinic U). Does this reflect a difference in the
sexual orientation or the sexual behaviour of the two samples, or merely highlight difficulty in ascertaining valid reasons for not testing? Patients’ reasons for not HIV testing are likely to be an unreliable measure on which to base HIV testing policy recommendations.
With regard to testing within the window period, it is important to note that not testing due to the window in our study was clinician as well as patient driven, which may help explain the higher proportion. In addition, consideration of the window period due to repeat risk may be more relevant to MSM populations than heterosexuals.
References
1. C L J Van Loon, W M E Koevoets. Rapid HIV testing in a one-hour
procedure motivates MSM in the Netherlands to take the test. Oral Abstract
session: The XV International AIDS Conference: Abstract no. TuOrC1197.
2. R Grimes, P Weatherburn, R Mugezi, A Wilkinson, A K Sullivan.
Know4sure: who comes to a rapid HIV testing outreach clinic and why?
Sexually Transmitted Infections 2006;82(Supplement 2 ): P69.
3. S F Forsyth, E A Agogo, L Lau, E Jungmann, S Man, S G Edwards, A J
Robinson. Would offering rapid point-of-care testing or non-invasive
methods improve uptake of HIV testing among high-risk genitourinary
medicine clinic attendees? A patient perspective. Int J STD AIDS 2008;19:
550-552.
We very much appreciate the letter that Dr Haghdoost and colleagues
wrote in relation to some of the issues outlined in our paper HIV
surveillance in MENA: recent developments and results and, in addition,
described some more recent developments in HIV surveillance in Iran.
We would like to reflect on several issues that they raised.
Our paper states that Djibouti, Iran, Morocco and Pakistan can be...
We very much appreciate the letter that Dr Haghdoost and colleagues
wrote in relation to some of the issues outlined in our paper HIV
surveillance in MENA: recent developments and results and, in addition,
described some more recent developments in HIV surveillance in Iran.
We would like to reflect on several issues that they raised.
Our paper states that Djibouti, Iran, Morocco and Pakistan can be
classified as having fully functioning HIV surveillance systems as trends
in HIV prevalence in these countries can be assessed over time for certain
population sub-groups. Surveillance systems in these countries have a
sufficient quantity and quality of the data that can be used to guide the
programmatic responses. We also mentioned other nine countries that have
partially functioning HIV surveillance systems.
As described in the Methods section of our paper, the assessment of
the quality of HIV surveillance systems was based on the questionnaire
sent to National AIDS Programmes (NAPs) of the countries of the WHO
Eastern Mediterranean Region (EMR) in 2009, 2010 and 2011, and not on the
data presented in the paper by Garcia Calleja et al published in Sexually
Transmitted Infections in 2010. As described in our paper, to assess the
quality of HIV surveillance systems we adapted a method developed by WHO
and UNAIDS.123
As one of the limitations, we outlined that data were provided by the
NAPs, which might have missed data sources collected by other agencies
that Haghodoost et al. mention, such as surveys in partners of IDUs.
However, as planning of surveillance and programmatic responses is lead by
the NAPs, we think that collecting data from NAPs gives an appropriate
insight into the type and quality of data that the countries use for
planning and evaluating the national HIV response. We are aware that many
studies might be undertaken in the EMR, but their results are not
disseminated, and this is particularly the case with studies done in
groups at higher risk of HIV that are heavily stigmatized.
In relation to some other issues that the colleagues raised, surveys
using respondent-driven sampling were done in many other countries in the
Region (some of these are referenced in the paper) as well as Mode of
Transmission studies.4
We have not reflected on the reasons for the improvements in HIV
surveillance in North Africa and the Middle East, but we believe this has
been due to greater availability of funding provided by the Global Fund to
Fight AIDS, Tuberculosis and Malaria and capacity building efforts of
numerous international and national agencies.
We agree with Dr Haghdoost and the colleagues that there are
substantial improvements in HIV surveillance in Iran though significant
challenges remain in bridging the gaps that the system still has. One of
them is certainly in conducting studies on HIV and sexually transmitted
infections in MSM and transgendered individuals, which due to prevailing
stigmatization are still lacking throughout the Region.
References:
1. Garcia Calleja JM, Jacobson J, Garg R, et al. Has the quality of
serosurveillance in low- and middle-income countries improved since the
last HIV estimates round in 2007? Status and trends through 2009. Sex
Transm Infect 2010;86(Suppl 2):ii35-42
2. Walker N, Garcia-Calleja JM, Heaton L, et al. Epidemiological
analysis of the quality of HIV sero-surveillance in the world: how well do
we track the epidemic? AIDS 2001;15:1545-54
3. Lyerla R, Gouws E, Garcia-Calleja JM. The quality of sero-
surveillance in low- and middle-income countries: status and trends
through 2007. Sex Transm Inf 2008;84: i85-91.
4. Mumtaz G, Hilmi N, Zidouh A, El Rhilani H, Alami K, Bennani A,
Gouws E, Ghys P, Abu- Raddad L. HIV Mode of Transmission Analysis. Rabat:
Kingdom of Morocco. Ministry of Health, Department of Epidemiology and
Disease Control, 2010.
This report confirms that PID can be often be missed clinically. Other than lowering the threshold for diagnosis, there could be other ways of improving diagnosis of PID. Training background may have contributed to the different rate of diagnosis among doctors. It would be important to review whether high diagnosing doctors were more
likely to have had gynaecology training compared with low diagnosing d...
This report confirms that PID can be often be missed clinically. Other than lowering the threshold for diagnosis, there could be other ways of improving diagnosis of PID. Training background may have contributed to the different rate of diagnosis among doctors. It would be important to review whether high diagnosing doctors were more
likely to have had gynaecology training compared with low diagnosing doctors. Similarly, was there any difference in the gender among high versus low diagnosing doctors?
Trichomonas Vaginalis (TV) is frequently described as being
associated with pre-term delivery and low birth weight - and was again by
Professor Hillier in her editorial in her (unreferenced) introductory
paragraph. As far as I can ascertain, this association appears to be based
on published evidence from the 80s and 90s.
Is it possible, given the more recent understanding of a link between
TV and poverty, that t...
Trichomonas Vaginalis (TV) is frequently described as being
associated with pre-term delivery and low birth weight - and was again by
Professor Hillier in her editorial in her (unreferenced) introductory
paragraph. As far as I can ascertain, this association appears to be based
on published evidence from the 80s and 90s.
Is it possible, given the more recent understanding of a link between
TV and poverty, that these 20 year old studies were confounded?
There is conflicting evidence as to whether the use of metronidazole
is itself associated with worse birth outcomes1,2 and so it is important
to have a full understanding of the role of TV.
In global terms I work and teach in a setting with a low prevalence
of HIV. Can anyone help me find reasonably strong evidence that TV is
other than a harmless commensal for those of my patients who are
asymptomatic?
1.What have we learned about vaginal infections and preterm birth?
Carey JC et al Semin Perinatol 2003 27(3):212-6
2. Investigation of metronidazole use during pregnancy and adverse
outcomes Catherine A Coss et al Antimicrobial Agents and Chemotherapy 2012
56(9) 4800-5
In their letter Aghaizu et al suggest that the differences in the prevalence in their study 1 and our study 2may be attributable to false positive tests using strand displacement assay (ProbeTec, Becton Dickenson). We disagree with these observations. We would like to point out that the populations studied were substantially
different- majority of our subjects attended sexual health and reproduction clinics...
In their letter Aghaizu et al suggest that the differences in the prevalence in their study 1 and our study 2may be attributable to false positive tests using strand displacement assay (ProbeTec, Becton Dickenson). We disagree with these observations. We would like to point out that the populations studied were substantially
different- majority of our subjects attended sexual health and reproduction clinics whereas the population tested in the study by Agaizhu et al was drawn from higher education institutions. Furthermore, in a subsequent study we retested ProbeTec positive specimens from our
laboratory using Gen-Probe APTIMA Combo 2 Assay (Gen-Probe, San Diego, California, USA) at the Health Protection Agency Laboratory, University Hospital Aintree, Liverpool, UK. There was 97.3% concordance between the tests.3 Similarly, in a recent study, Mocanda et al also demonstrated good
concordance between ProbeTec and Gen-Probe APTIMA Combo 2 Assay in a study population that included subjects attending family planning clinic.4
In summary, we are confident that our observations reflect a true prevalence of gonococcal infection in the subjects described in our study.
References
1. A Aghaizu, H Atherton, H Mallinson, I Simms, S Kerry, P E Hay, P Oakeshott. Prevalence of Neisseria gonorrhoeae infection in young women in South London. Sexually Transmitted Infections 2008;84:570
2. Gopal Rao G, Bacon L, Evans J, Dejahang Y, Michalczyk, Donaldson N.
Prevalence of Neisseria gonorrhoeae infection in young subjects attending community clinics in South London. Sex Transm Infect 2007;84:117-121
3. Ruth Hardwick, Guduru Gopal Rao and Harry Mallinson. Confirmation of BD ProbeTec Neisseria gonorrhoea reactive samples by Gen-Probe APTIMA assays
and culture. Sex Transm Inf published online 1 Oct 2008 ;
doi:10.1136/sti.2008.032789
4. Jeanne Moncada, Elizabeth Donegan, and Julius Schachter. Evaluation of CDC
-Recommended Approaches for Confirmatory Testing of Positive Neisseria gonorrhoeae Nucleic Acid Amplification Test Results. J Clin Micro, 2008;46:1614-1619
Phillips and colleagues found a third of in-patients had HIV tests
following implementation of a routine HIV testing policy at Croydon
University Hospital1. We recently found similar rates of HIV testing in
young women in the community in our medical student research projects. In
line with the 2013 Framework for Sexual Health Improvement's "three
specific indicators for sexual health" 2, we investigated reported uptake...
Phillips and colleagues found a third of in-patients had HIV tests
following implementation of a routine HIV testing policy at Croydon
University Hospital1. We recently found similar rates of HIV testing in
young women in the community in our medical student research projects. In
line with the 2013 Framework for Sexual Health Improvement's "three
specific indicators for sexual health" 2, we investigated reported uptake
of HIV testing, chlamydia testing and long acting reversible contraception
(LARC) in young women attending a further education college and a
university in London.
In September 2013 consecutive women in common room areas were invited
to complete a confidential questionnaire on sexual health. The response
rate among women at Lambeth College was 78% (77/99). The mean age of
responders was 18 years (range 16-24), and 43% described themselves as
being of black ethnicity, 19% white, and 38% of other ethnicity. Of the 39
(51%) women who said they were sexually active, 51% (20/39) had been
tested for HIV in the past year and 78% (28/36) for chlamydia. A third
(13/39) were currently using LARC (implant n=10, injection n=3).
The response rate among women at London Southbank University was 92%
(79/86). The mean age of responders was 21 years (range 18-25) and 38%
were from ethnic minorities. In the past year, 32% (25/79) had been tested
for HIV and 34% (26/77) for chlamydia. Only 5% (4/79) reported the use of
LARC in the past year, all of these being the implant.
We agree with Phillips and colleagues that late diagnosis of HIV is a
major public health problem. The recent Natsal report found that 29% of
women but only 14% of men aged 16-24 years reported being tested for HIV
in the past 5 years 3. Although rates of HIV testing in sexually active,
multiethnic young women in our study were encouraging, it is also crucial
to promote HIV testing in young men.
Anne Tear and Jessica Herbert
3rd year Medical Students
Pippa Oakeshott
Reader in General Practice
Population Health Sciences and Education, St George's, University of
London
Correspondence: m1000382@sgul.ac.uk, m1101507@sgul.ac.uk
Acknowledgement
We thank students and staff at Lambeth College and London Southbank
University.
Reference List
(1) Philips. D, Barbour. A, et al, Implementation of a routine HIV testing
policy in an acute medical setting in a UK general hospital: a cross
sectional study, STI 2013, doi: 10.1136/sextrans-2013-051302
(2) Department of Health, Improving outcomes and supporting transparency,
November 2013, pg 53, 91,99
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/263662/2901502_PHOF_Improving_Outcomes_PT2_v1_1.pdf
[Acessed 13th December 2013]
(3) Sonnenberg P, Clifton S, Beddows S, et al, Prevalence, risk factors,
and uptake of interventions for sexually transmitted infections in
Britain: findings from the National Surveys of Sexual Attitudes and
Lifestyles (Natsal), The Lancet, Volume 382, Issue 9907, Pages 1795 -
1806, 30 November 2013 doi:10.1016/S0140-6736(13)61947-9
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.
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.
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.
Dear Dr. Potterat and colleagues,
Thank you for responding to our manuscript. We have carefully reviewed your comments. Below, please find our responses to the questions raised.
The first comment raised concerns the fact that “sexual factors may have played a lesser role in observed HIV and syphilis prevalence’s than nonsexual factors.” The sexual transmission of sexually transmitted infections including HI...
Dear Editor,
In response to M O Ramogi on 21st August 2008, it is important to point out that since only patients attending with a new episode were included in the study, those experiencing chronic/recurrent infections or attending solely for treatment were excluded. Therefore the inclusion of patients for who HIV testing is less applicable is unlikely to be the explanation for the association between symptoms of an STI...
We very much appreciate the letter that Dr Haghdoost and colleagues wrote in relation to some of the issues outlined in our paper HIV surveillance in MENA: recent developments and results and, in addition, described some more recent developments in HIV surveillance in Iran.
We would like to reflect on several issues that they raised.
Our paper states that Djibouti, Iran, Morocco and Pakistan can be...
Dear Editor,
This report confirms that PID can be often be missed clinically. Other than lowering the threshold for diagnosis, there could be other ways of improving diagnosis of PID. Training background may have contributed to the different rate of diagnosis among doctors. It would be important to review whether high diagnosing doctors were more likely to have had gynaecology training compared with low diagnosing d...
Trichomonas Vaginalis (TV) is frequently described as being associated with pre-term delivery and low birth weight - and was again by Professor Hillier in her editorial in her (unreferenced) introductory paragraph. As far as I can ascertain, this association appears to be based on published evidence from the 80s and 90s.
Is it possible, given the more recent understanding of a link between TV and poverty, that t...
Dear Editor
In their letter Aghaizu et al suggest that the differences in the prevalence in their study 1 and our study 2may be attributable to false positive tests using strand displacement assay (ProbeTec, Becton Dickenson). We disagree with these observations. We would like to point out that the populations studied were substantially different- majority of our subjects attended sexual health and reproduction clinics...
Phillips and colleagues found a third of in-patients had HIV tests following implementation of a routine HIV testing policy at Croydon University Hospital1. We recently found similar rates of HIV testing in young women in the community in our medical student research projects. In line with the 2013 Framework for Sexual Health Improvement's "three specific indicators for sexual health" 2, we investigated reported uptake...
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...
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,
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...
Pages