Recently, French et al reported the first cases of lymphogranuloma
venereum (LGV) in the United Kingdom.1 One year further, the LGV outbreak
first noticed in 2003 among MSM has spread beyond the first countries
affected (the Netherlands, Belgium, Germany, France, the UK, Sweden and
the United states) to other European countries like Spain, Italy,
Switzerland, Poland, and outside the continent to A...
Recently, French et al reported the first cases of lymphogranuloma
venereum (LGV) in the United Kingdom.1 One year further, the LGV outbreak
first noticed in 2003 among MSM has spread beyond the first countries
affected (the Netherlands, Belgium, Germany, France, the UK, Sweden and
the United states) to other European countries like Spain, Italy,
Switzerland, Poland, and outside the continent to Australia, USA and
Canada. Moreover, some of the questions raised in the publication of
French et al can now been answered partially.
A retrospective study performed on anal swabs from STI clinic
visitors in Amsterdam and San Francisco has learned us that the LGV strain
which seems to be responsible for the current outbreak (L2b) can be traced
back to at least 1981 in the United States and to 2000 in Europe.2,3 So it
seems more appropriate to speak of a slow epidemic rather than an outbreak
of LGV. What has caused LGV to spread unnoticed within the MSM community
worldwide for many years? In part, this can be attributed to the routine
chlamydia test procedures for MSM before 2003. Anal swabs positive for
chlamydia were recorded as chlamydia proctitis. Since the occurrence of
LGV outside the traditionally epidemic countries was unknown additional
testing for LGV was not performed.
Who should be screened for LGV? Most LGV patients reported
unprotective sex and a history of multiple STI’s. In a retrospective study
we have tried to unravel other clinical and epidemiological criteria for
LGV management in MSM.4 HIV status, proctoscopic findings and results of
Gram stained anorectal smears proof helpful in predicting LGV . LGV
specific tests and syndromic treatment are recommended in MSM with
anorectal chlamydia in combination with either clinical signs of
proctitis, HIV seropositivity or an elevated white blood cell count in
Gram stained anorectal smears. Moreover, it appears that part of the LGV
infections do not cause severe clinical symptoms. This may delay the
diagnosis and hamper screening and prevention measures.
Gőtz et al described a group of 15 LGV patients of whom 6
seroconverted for Hepatitis C (HCV) coinciding with the moment they
contracted LGV.5 It was speculated that sexual techniques that lead to
mucosal damage like fisting and use of sex toys, and a concomitant
ulcerative STI like LGV facilitate the sexual transmission of HCV. Raised
diagnostic problems can now be tackled more easily with a recently by our
group developed fast molecular biological diagnostic test (realtime PCR)
designed specifically for LGV Chlamydia trachomatis strains.6 This test
can be performed under routine microbiological laboratory conditions and
will hopefully facilitate the propagation of LGV screening programmes.
During the last International Society for Sexual Transmitted Disease
Research meeting, July 2005 in Amsterdam, The Netherlands a LGV satellite
workshop was organised under the supervision of the European Surveillance
of Sexually Transmitted Infections (ESSTI) network in order to tackle
urgent LGV related research questions in a multilateral joint effort
(www.isstdr.nl/sat_meet.htm). Supranational collaborations will have to
prove their benefit to increase our understanding of this LGV epidemic.
References
1. French P, Ison CA, Macdonald N. Lymphogranuloma venereum in the
United Kingdom. Sex Transm Infect 2005;81:97-8.
2. Spaargaren J, Fennema HS, Morré SA, de Vries HJ, Coutinho RA. New
lymphogranuloma venereum Chlamydia trachomatis variant, Amsterdam. Emerg
Infect Dis 2005;11:1090-2.
3. Spaargaren J, Schachter J, Moncado J, Fennema HS, de Vries HJ,
Coutinho RA, Morré SA. Slow Epidemic of Lymphogranuloma Venereum L2b
Strain. Emerg Infect Dis 2005;11:1787-8
4. van der Bij AK, Spaargaren J, Morré SA, Fennema HS, Mindel A,
Coutinho RA, de Vries HJ. Predictors for lymphogranuloma venereum in men
having sex with men: diagnostic implications. Clin Infect Dis 2006;42:186-
94.
5. Götz HM, van Doornum G, Niesters HG, den Hollander JG, Thio HB, de
Zwart O. A cluster of acute hepatitis C virus infection among men who have
sex with men--results from contact tracing and public health implications.
AIDS 2005;19:969-74.
6. Morré SA, Spaargaren J, Fennema JS, de Vries HJ, Peña AS. Real-
time polymerase chain reaction to diagnose Lymphogranuloma Venereum. Emerg
Infect Dis 2005;11:1311-2
We read with interest the article by Clarke et al1 regarding
assessing demand for access to sexual health services in a community where
a closed appointment system operates1. The genitourinary medicine (GUM)
clinic in North Worcestershire has been operating this closed system for
at least 3 years whereby, patients are offered an appointment either on
the day or the day after and asked to phone back...
We read with interest the article by Clarke et al1 regarding
assessing demand for access to sexual health services in a community where
a closed appointment system operates1. The genitourinary medicine (GUM)
clinic in North Worcestershire has been operating this closed system for
at least 3 years whereby, patients are offered an appointment either on
the day or the day after and asked to phone back if appointments are
unavailable. The BASHH/HPA surveys have demonstrated that the latest
routine waiting times for patients to be seen within 48 hours in this GUM
clinic was 72% (62% unadjusted). Previously figures have varied from 43
to 62%2. However, this figure has not correlated with patient’s
experiences of obtaining an appointment. To analyse this we have
instituted telephone call logging for appointments over a 1 year period
focussing on the availability of routine appointments. Data referring to
emergency appointments or advice calls, although recorded were excluded
from this study. Furthermore call logging was subdivided by sex as in
Clarke’s study and by days of the week to assess areas of maximum demand
for appointments. These measures had fewer implications for workforce
planning than Clarke’s study as this GU clinic sees around 5000 patients a
year with a new and rebook follow up ratio of 2.31:1.
Table 1 shows the average number of routine appointments offered,
appointments requested by patients but not available and appointments
offered to patients but declined as inconvenient. For the purposes of
this correspondence, the logging of calls according to gender has been
grouped together, monthly data aggregated and the mean sum total
represented. Initial data was first presented at the BASHH/BHIVA Spring
meeting of 20053.
Critically, the average data fails to capture the full range recorded
over the last 12 months, for example: appointments unavailable on Monday
varied from 58-127.
As Clarke correctly points out, to avoid incorrect assumptions that
the 48 hour target is being met, the collection of telephone data from
clinics operating closed appointment systems is essential. Furthermore it
remains unclear whether those who are unsuccessful when they first ring
for an appointment are successful thereafter.
In view of the many pressures on “Choosing Health“monies it is
essential that commissioners are presented with an accurate representation
of the demand for GUM services.
References
1) Clarke J, Christodoulides H and Taylor Y. Sexually Transmitted
Infections 2006; 82: 45-48
3) Bhaduri S, Gosling C. Poster 9-Does a closed appointment system
improve access? 11th Annual Conference of BHIVA (British HIV Association)
and BASHH (British Association for Sexual Health and HIV) 2005: 20-23
April
We read Rana et al’s (1) paper entitled “Sexual behaviour and condom
use among individuals with a history of symptomatic genital herpes” with
interest, and find any paper which helps to describe patient’s behaviours
and beliefs useful.
There appears to be one particular flaw in this paper, and that is
the authors’ assumption that people with a history of herpes should use
condoms at all...
We read Rana et al’s (1) paper entitled “Sexual behaviour and condom
use among individuals with a history of symptomatic genital herpes” with
interest, and find any paper which helps to describe patient’s behaviours
and beliefs useful.
There appears to be one particular flaw in this paper, and that is
the authors’ assumption that people with a history of herpes should use
condoms at all times.
The authors justify this statement by referencing three papers. The
first paper (2) highlights that condoms seem to be protective against HSV
transmission in vitro, but is more pessimistic about evidence in vivo, and
limits its recommendations of ‘consistent and correct condom use’ to
pregnant women at risk of HSV-2. The second paper (3) relates to reducing
HIV transmission in developing countries, and makes little mention and no
recommendations about condom use. The third reference (4) does state that
“condom use should be recommended during sexual intercourse when lesions
or symptoms are not present.” But acknowledges “, the data supporting
condom use for the prevention of genital herpes transmission are weak”.
Indeed in the parent paper of this article (5), the same authors,
analysing the same data in the same population demonstrate that increased
risk of transmission of HSV-2 occurred in those who engaged in vaginal sex
during episodes or ‘never’ used condoms, but failed to demonstrate that
condom use between attacks (“always” used condoms) was protective.
As the participants of this study were all in monogamous
relationships, the assertion that they should use condoms at all times
seems unnecessarily punitive. Indeed, 35% of partners were unknowingly
already HSV-2 Positive, a little higher but consistent with international
prevalence estimates (6) and so protected from further infection. As 80%
of HSV-2 infections are asymptomatic or unrecognised (7), and as
transmission rates in discordant couples seem relatively low (2.2% over 8
months for symptomatic infection, 3.6% for serologically proven infection
(8)) then it might be very reasonable for discordant monogamous couples to
choose not to use condoms, reassured in the knowledge that transmission
between attacks can occur but is less likely than transmission during an
attack; that most transmission results in asymptomatic infection; and that
although symptomatic herpes can be troublesome, it is rarely sinister or
dangerous.
In our view, the medicalisation of genital herpes in these
circumstances is overwhelmingly detrimental to sexual health. Advice that
individuals with genital herpes in monogamous relationships should use
condoms regularly and consistently “during both symptomatic and
asymptomatic periods” seems unfounded in the literature, and unnecessarily
stigmatising. The ongoing medicalisation and stigmatisation of herpes will
not, of course, harm sales of Valaciclovir, and we worry about conflicts
of interest in this paper.
Bibliography
______________________
1. Rana RK, Pimenta JM, Rosenberg DM, Warren T, Sekhin S, Cook SF, et
al. Sexual behaviour and condom use among individuals with a history of
symptomatic genital herpes. Sex Transm Infect 2006;82(1):69-74.
2. Casper C, Wald A. Condom use and the prevention of genital herpes
acquisition. Herpes 2002;9(1):10-4.
3. O'Farrell N. Increasing prevalence of genital herpes in developing
countries: implications for heterosexual HIV transmission and STI control
programmes. Sex Transm Infect 1999;75(6):377-84.
4. Stanberry L, Cunningham A, Mertz G, Mindel A, Peters B, Reitano M,
et al. New developments in the epidemiology, natural history and
management of genital herpes. Antiviral Res 1999;42(1):1-14.
5. Rana RK, Pimenta JM, Rosenberg DM, Tyring SK, Paavonen J, Cook SF,
et al. Demographic, behavioral, and knowledge factors associated with
herpes simplex virus type 2 infection among men whose current female
partner has genital herpes. Sex Transm Dis 2005;32(5):308-13.
6. Barton SE. Reducing the transmission of genital herpes. Bmj
2005;330(7484):157-8.
7. Miyai T, Turner KR, Kent CK, Klausner J. The psychosocial impact
of testing individuals with no history of genital herpes for herpes
simplex virus type 2. Sex Transm Dis 2004;31(9):517-21.
8. Corey L, Wald A, Patel R, Sacks SL, Tyring SK, Warren T, et al.
Once-daily valacyclovir to reduce the risk of transmission of genital
herpes. N Engl J Med 2004;350(1):11-20.
Ward and Robinson in their editorial state that the introduction of
restrictive booking systems in which patients can only book appointments
up to 2 days in advance is a response by some clinics to the 48 hour
access target.[1] They quote the Panorama figures that almost one in
five clinics have introduced restrictive booking.
Three day restrictive booking for appointments was introduced...
Ward and Robinson in their editorial state that the introduction of
restrictive booking systems in which patients can only book appointments
up to 2 days in advance is a response by some clinics to the 48 hour
access target.[1] They quote the Panorama figures that almost one in
five clinics have introduced restrictive booking.
Three day restrictive booking for appointments was introduced in the GU
Clinic at St Helier Hospital in October 2004. This was in response to a
25% defaulter rate with a policy of booking appointments up to 7 days in
advance. Sending reminders to patients was considered, but this would
need additional resources. Clarke et al [2] achieved a fall in the
default rate from 22% to 9.9% after introduction of a 48 hours restrictive
booking system. GUM clinic attendees are in the age range which has been
identified as having the highest defaulter rates in general practice.[3]
The introduction of restrictive booking cannot necessarily be
interpreted as a consequence of the 48 hour access target and it may
increase access by reducing the defaulter rate.
Janet Mantell
Consultant in genitourinary medicine
St Helier Hospital
Carshalton, Surrey SM5 1AA
References
1. Ward H, Robinson A. Still waiting: poor access to sexual health
services in the UK. Sex Transm Infect 2006;82:3.
2. Clarke J, Christodoulides H, Taylor Y. Supply and demand: estimating
the real need for care while meeting the 48-hour waiting time target in a
genitourinary medicine clinic by a closed appointment system. Sex Transm
Infect 2006;82:45-48.
3. Sharp DJ, Hamilton W. Non-attendance at general practices and
outpatient clinics. BMJ 2001;323:1081-2.
We were highly interested by the results obtained by Sethi et al. on hepatitis B vaccination for male sex workers.[1] As the authors report, the national strategy for Sexual Health and HIV in England set the target uptake of the third dose of hepatitis B vaccine in susceptible heterosexual and bisexual men attending genitourinary medicine clinics at 50% by the end of 2004 a...
We were highly interested by the results obtained by Sethi et al. on hepatitis B vaccination for male sex workers.[1] As the authors report, the national strategy for Sexual Health and HIV in England set the target uptake of the third dose of hepatitis B vaccine in susceptible heterosexual and bisexual men attending genitourinary medicine clinics at 50% by the end of 2004 and 70% by the end of 2006.[2] In this study 60% of the eligible men received three vaccine doses; this is a stimulating result, obtained by a focused approach of the target group.
However, we cannot agree with the authors’ definition of complete vaccination. Three doses of hepatitis B vaccine were offered according to a 0,1,2 months schedule. According to the literature on hepatitis B vaccination schedules, a full vaccination course against hepatitis B consists of a an initial series of 2 (0,1 months) or 3 doses (0,1,2 months, or 0,7,21 days in an accelerated schedule), followed by a completing dose given several months thereafter. According to the Centers for Disease Control and Prevention, the usual schedule for adolescents and adults is 2 doses separated by no less than 4 weeks, and a third dose 4-6 months after the second dose; the first and third doses should be separated by no less than 16 weeks; doses given at less than these minimum intervals should not be counted as part of the vaccination series.[3]
Such standard 0,1,6 month, or 0,1,4 month or 0,2,4 month schedules have shown to confer very good protection (90-95% >10 IU/L), comparable to that obtained with a 0,1,2,12 month schedule.[4] In addition, lifelong protection is assumed if at least 10 IU/L is obtained, measured 1 to 3 months after a full hepatitis B vaccination course in healthy individuals.[5] Therefore, no conclusions on long term protection can be drawn from anti-HBs values of 10 IU/L or more after 3 doses offered according a 0,1,2 months schedule.
We agree that a 0,1,2,12 month schedule is hard to implement in this mobile at risk population, and many health services have chosen to offer a 0,1,6 months or even the shortest course 0,1,4 months in hard to reach risk groups.[6-8] Therefore we would recommend to implement the shortest possible full vaccination schedules, in particular in this at-risk population. We are convinced that the focused approach presented in this paper could result in a comparably high uptake of a third dose 4 or 6 months after the first one, without jeopardising the long-term benefits of hepatitis B vaccination.
References
1. Sethi G, Holden BM, Greene L, et al. Hepatitis B vaccination for male sex workers: the experience of a specialist GUM service. Sex Transm Infect 2006;82:84-85.
2. Department of Health. National strategy for sexual health and HIV. London, DoH, 2001 (www.dh.gov.uk)
3. Centers for Disease Control and Prevention. Epidemiology & Prevention of Vaccine-Preventable Diseases (The Pink Book) 9th Edition, January 2006. Chapter 15, p.221. Available online from www.cdc.gov/nip/publications/pink/def_pink_full.htm 4. Mast E, Mahoney F, Kane MA, Margolis HS. Hepatitis B vaccine. In: Plotkin SA and Orenstein WA, editors. Vaccines. Elsevier Inc., USA. 4th Edition, 2004:p.299-337.
5. Kane M, Banatvala J, Van Damme P, et al. Are booster immunisations needed for lifelong hepatitis B immunity? European Consensus Group on Hepatitis B Immunity. Lancet 2000;355:561-565.
6. Jilg W. Vaccination against Hepatitis B: Comparison of three different vaccination schedules. Journal of Infectious Diseases 1989;160:766-69.
7. Van Ardenne N, Roelofs I, Leuridan E, et al. Audit on offering and accepting hepatitis B vaccine by sex workers. Intern J STD AIDS 2004;15:493-494.
8. Jaleel H, Allan PS, Huengsberg M, Natin D. Offering the vaccine and accepting it: an audit of hepatitis B vaccination in West Midlands region. Intern J STD AIDS 2003;14:632-635.
The article on HIV and syphilis among migrants in eastern China (1)
sheds light on a very important topic of great public health import – to
what extent will the enormous rural to urban migration happening across
China affect sexual behaviors, STI risk, and HIV transmission. However,
there are several important caveats that were not discussed in this paper
that should be considered.
The article on HIV and syphilis among migrants in eastern China (1)
sheds light on a very important topic of great public health import – to
what extent will the enormous rural to urban migration happening across
China affect sexual behaviors, STI risk, and HIV transmission. However,
there are several important caveats that were not discussed in this paper
that should be considered.
First, the individuals included under the
umbrella of the term “migrant” are far too numerous and heterogenous to
comprise a single sexual risk-taking profile. Rural to urban migrant
workers in China number number over 100 million, and include populations
like PhD graduates traveling to urban areas to take teaching positions in
addition to female sex workers. Although subsets of migrants (e.g, young,
poor, unmarried females who work in salons) may have increased sexual
risk, the broader groups encompassed by the terms migrant or migrant
worker are too large for meaningful prevention or intervention efforts.
Second, one does not need to invoke comparisons of African nations or
other regions to understand that some subsets of rural to urban migrants
in China likely have increased sexual risk taking and higher STI/HIV
prevalence compared to their rural or urban counterparts. Behavioral
(2,3) and serologic (4) studies suggest that sexual risk taking is
increased among some groups of migrants, including women. Both sexes are
part of China’s rural to urban migrants, and there are plausible social
explanations for both male and female subsets of migrants to have
increased sexual risk, including: 1) migrants are away from their “home
town” and the social structures and cultural norms that curb commercial
sex interactions in rural areas; 2.) migrants lack access to reliable
STI/HIV testing and reproductive health services; 3.) poor rural to urban
female migrants with limited education have problems finding official
jobs, but can earn money by selling sex; 4.) China’s eastern urban regions
have higher STI seroprevalence than most rural areas, making sex in urban
areas potentially more risky. Understanding the sexual risk and STI/HIV
dynamics of China’s migrants requires studies that compare these groups to
their rural and urban counterparts. It is encouraging that some small
studies of migrants in China have revealed low STI and HIV
prevalence,(1,5) but more work needs to be done among high risk subsets
of migrants to understand STI/HIV risk and guide prevention efforts among
these vulnerable groups.
References
1. Hesketh T, Li L, Ye X, Wang H, Jiang M, Tomkins A. HIV and
syphilis in migrant workers in eastern China. Sex Transm Infect 2006;
82:11-14.
2. Hong Y, Stanton B, Li X, Yang H, Lin D, Fang X, et al. Rural-to-
Urban Migrants and the HIV Epidemic in China. AIDS Behav 2006; 19: 1-10.
3. Li X, Stanton B, Fang X, Lin D, Mao R, Wang J. HIV/AIDS risk
behavior and perception among young rural-to-urban migrants in China.
AIDS Educ Prev 2004; 16: 538-56.
4. Liu H, Li X, Stanton B, Liu H, Liang G, Chen X, et al. Risk
factors for sexually transmitted disease among rural-to-urban migrants in
China: implications for HIV/sexually transmitted disease prevention. AIDS
Patient Care STDs 2005; 19: 49-57.
5. He N, Detels R, Zhu J, Jiang Q, Chen Z, Fang Y, et al.
Characteristics and sexually transmitted diseases of male migrants in a
metropolitan area of Eastern China. Sex Transm Dis 2005; 32: 286-92.
AIDS cases were first identified in 1981,in the
United States. Researchers have traced cases back to
1959. There are millions of diagnosed cases
worldwide, but there is no cure. There are about
thirty million people in the world who are currently
infected with HIV. China is the world largest
population country in the world. Potentiality,
manpower & security were able to attract world famous
in...
AIDS cases were first identified in 1981,in the
United States. Researchers have traced cases back to
1959. There are millions of diagnosed cases
worldwide, but there is no cure. There are about
thirty million people in the world who are currently
infected with HIV. China is the world largest
population country in the world. Potentiality,
manpower & security were able to attract world famous
investor. Many foreign investor, invest in here. So
China plays an important role in the world markets.
By the way, AIDS epidemic is knocking the door.
UNAIDS, WHO and Government, the study estimated that
650,000 people have HIV/AIDS in China, down from the
government's 2003 estimate of 840,000 cases. The
revision is due mainly to the earlier study's
overestimation of the number of people infected
through blood-buying schemes, said Deputy Health
Minister Wang Longde.
The HIV/AIDS programme specialist Mr. Mohammad
Khairul Alam said, “several social norms and immature
behavior fueled of this disease to scatter rapidly.
There are several social components link to develop
this harmful situation. Poverty-behind to force it,
Gender discrimination plays a vital role; Frustration
& risk behavior help to sink humanity resulting
infection. The link between poverty & gender
discrimination are help to decline socio economic
prosperity. This link creates several anti social
poisonous issues also. Such as trafficking to
prostitute, sell sex for earn or living, break down
family norm to create frustration and driven drug
point. We notice easily that Illiteracy is the main
watchword of all circumstance. So it is not easy to
remove it from the society, several programs & strategy are needed to
gain sustainable position”.
UN officials said the new figure is more accurate
than past estimates in part because more surveillance
sites have been set up during the last two years. The
figure is within an estimated range of 540,000-
760,000 HIV/AIDS cases, UN officials said.
Of the 25,000 people who died of AIDS in China last
year, 10,000 acquired their infections through blood-
buying schemes, said the Health Ministry. The high
mortality comes despite estimates that those infected
through blood-buying, mostly poor farmers, comprise a
small proportion of total AIDS cases in China.
"Make no mistake, China's AIDS epidemic is growing,"
said Hank Bekedam, WHO's chief China
representative. "With an estimated 70,000 new
infections in 2005, the epidemic here shows no signs
of abating." "The new numbers should not mask the
fact that HIV infections are on the rise. we fear the
number of new infections this year will be even
higher and this trend could continue in the future,"
Bekedam said.
The Rainbow Nari O Shishu Kallyan Foundation
identified four major approaches in a groundbreaking
study on spread out HIV in Asia. This study undertook
by comparing of social-economic norm, family pattern,
economic dependency, cause of mounting sex
industries, gender discrimination status & global
analysis fact. There are four factors that appear to
play a crucial role in HIV transmission in Asian
Countries: Injection/ intravenous drug use (By
sharing needle), female sex work (Due to lack of safe
sex knowledge), gender discrimination (which
indirectly force females commercial or non-commercial
sex), Same sex/ homosexually/ Hizra (Due to lack of
HIV/AIDS information, because they act invisible in
this society). Poverty & illiteracy fueled it
proportionally.
About half the 70,000 new infections were sexually
transmitted, while most others were acquired through
intravenous drug use, the study said. The number of
sexually transmitted cases exceeded the number of
cases through IDU, worrying officials that the
epidemic has moved into the general populace, and it
has killed many people. So people need to be more
aware and protect themselves so they don't become
another statistic, because HIV and AIDS are serious,
deadly, and they will be with us for a long time.
There will not be a cure found anytime soon, but
hopefully there will be a cure found. We have to
think AIDS couldn’t backward the present development
in China.
References
Agence France Presse, Rainbow Nari O
Shishu Kallyan Foundation.
Nucleic acid amplification tests for gonorrhoea are currently
being extensively evaluated on first catch urine samples in men and women,
self taken vaginal swabs and endocervical swabs. There is little doubt
that in the near future we will have a simple urine screening test that
will test for chlamydia and gonorrhoeae and possibly even mycoplasma
genitalium. However, the results published by Stanley...
Nucleic acid amplification tests for gonorrhoea are currently
being extensively evaluated on first catch urine samples in men and women,
self taken vaginal swabs and endocervical swabs. There is little doubt
that in the near future we will have a simple urine screening test that
will test for chlamydia and gonorrhoeae and possibly even mycoplasma
genitalium. However, the results published by Stanley & Todd1 show a
high number of positive NAATs not confirmed by culture. This is in stark
contrast to our one year experience of NAAT, using APTIMA COMBO 2 2.
Of 82 positive NAAT's 74 were confirmed by culture at the same site
giving 8 extra positive NAATs. However, five of these were either positive
by microscopy or culture at a different site, leaving us with just 3 cases
with no culture confirmation. However, checking on contact data, who all
had gonorrhoeae, made us reasonably certain that these 3 extra unconfirmed
NAAT's were true positives. NAAT did not miss a single case of GC that
was culture positive.
The issue of false positives is an experience the specialty is well
used to dealing with, i.e. when chlamydia testing changed from the gold
standard of tissue culture there were also claims of poor sensitivity of
newer tests giving a high false positive rate, but this was later shown to
be untrue.
Our results allow us to continue with confidence in NAAT of first
catch urines, self taken swabs or endocervical swabs for gonorrhoeae and
chlamydia. The urine testing, of course, allows nurse led clinics in GUM
and community settings where examination is unnecessary.
Dr Colm O'Mahony
Countess of Chester Hospital NHS Foundation Trust
Chester CH2 1UL
References
1. Stanley B, Todd A. Testing for Neisseria gonorrhoeae by nucleic acid amplification testing of
chlamydia samples using Roche Cobas Amplicor in a rural area in the north
of England does not find more gonorrhoeae in primary care.
STI 2005 Vol 81.No 6;518.
2. O'Mahony et al. One year experience of APTIMA COMBO 2 transcription mediated amplification (TMA) for chlamydia and gonorrhoeae in a District General Hospital.
Int J STD & AIDS 2006 - in press.
Mullick, Watson-Jones, Beksinska and Mabey1 have done a great job in
summarising the approaches for treatment and control as well as the
prevalence and impact of STIs in pregnancy in developing countries. Among
the approaches cited is the contact tracing or partner notification as an
integral part of STIs control.
Coincidentally we read this article after we discussed cultural
sexual prac...
Mullick, Watson-Jones, Beksinska and Mabey1 have done a great job in
summarising the approaches for treatment and control as well as the
prevalence and impact of STIs in pregnancy in developing countries. Among
the approaches cited is the contact tracing or partner notification as an
integral part of STIs control.
Coincidentally we read this article after we discussed cultural
sexual practices that fuel the epidemic of STIs particularly HIV as part
of a multidisciplinary course on “Integration of HIV/AIDS into the
curriculum for institutions of Higher Learning”, held in Pretoria, South
Africa. As the issue of contact tracing is considered in light of cultural
practices, it seems that the approach would be difficult to enforce in
some African countries where multi-sexual partnerships are expected and
accepted
In a focus group discussion facilitated by the authors, 31
participants whose characteristics are described in Table 1, were asked to
comment on the following statement: “Using examples, describe cultural
sexual practices that increase the spread of sexually transmitted
infections (STIs) particularly HIV in your country, province, or tribe”.
Their responses are summarized in Tables 1 and 2. The practice of
“dry sex”, rites of passage into adulthood, sexual cleansing of widows and
widowers, widow inheritance, wife-sharing, and couple-deceit prostitution
are some of the sexual practices that were mentioned as having the
potential to increase the spread of HIV and other STIs. As pointed out by
Gausset2, these practices cannot be solely held responsible for the spread
of STIs because they are not incompatible with safer sex practices. For
instance, Okeyo and Allen3 reported that lack of condom use among African
widows is related to their lack of knowledge about its ability to prevent
STIs.
Although some of the African cultural sexual practices may seem
strange for other people, their philosophical basis and metaphysical
significance are part of a broader concept of the universe by the people
who practise them. For instance the practice of widow inheritance, or
levirate, is founded on the concept that the dead brother can continue to
live through his living brother who continue to fulfill his duties and
responsibilities towards his wife, children and society at large. This
practice ensures a safety net for children and the widow by guarantying
their economic and social benefits. 4 Similarly, rites of passages and
widow cleansing are milestones in life progression among the living as
also practised in non-African cultures. 5-6
But some of the African cultural sexual practices do not lend
themselves to the idea of contact tracing: How would a 12-year old girl or
boy who contracted an STI from the rite of passage ceremony bring a
partner? The age gap between herself and the man who performed the ritual,
the enforced secrecy, the hurt or shame experienced, and even the fact
that the man (woman) may not be easily identifiable given the
circumstances of the ritual which is generally conducted in the dark. Or
in the case of wife-sharing practice, which partner should a Ankole,
Masai, or Yao woman bring if requested to do so? How would one diffuse the
potential conflict emanating from publicizing what is normally a private
affair?
While we concur with Mullick et al.(2005) that more information is
needed on the acceptability and effectiveness of contact tracing in
Africa, we also add that studies and interventions that seek deeper
understanding of cultural sexual practices need to be undertaken. These
studies should assist in finding ways to accommodate these practices as
they transform in the face of the devastating effects of HIV/AIDS. 7
Table: Participants’ characteristics (n=31)
Age Value (years)
Mean 40.9
Median 39.0
Mode 39.0
Minimum 28.0
Maximum 55.0
Gender Percent
Male 45.2
Female 54.8
Marital status
Married 74.2
Not married 25.8
Level of education
Higher diplomas 22.6
Degrees 77.4
Country of origin
Ethiopia 6.5
Kenya 12.9
Lesotho 12.9
Malawi 16.1
Swaziland 6.5
Tanzania 12.9
Uganda 3.2
Zambia 12.9
Zimbabwe 16.1
Table 2: Cultural sexual practices (n=31)
Men’s demand for “dry sex” : To ensure that there is less lubrification,
and render the vagina as small as possible (Leosotho) Lesotho, Swaziland,
Zimbabwe, Malawi, Zambia, Tanzania
Rites of passage called “washing” in which boys and girls aged 11-15 are
required to sleep either with an old lady (boys) or a old man (girls)
chosen by the community for the purpose ; or pick up any woman during the
closing moments of the ceremony (Luhya tribe-Kenya) Lesotho, Malawi,
Kenya,
Wife’s inheritance (levirate): A brother of the deceased man inherit the
wife and all other family responsibilities Ethiopia, Kenya, Lesotho,
Malawi, Swaziland, Tanzania, Uganda, Zambia, Zimbabwe
The practice of women-sharing based on the concept that it is the “Woman’s
duty” to accept sexual intercourse with any man from the community who
request it – A Yao woman should never say no to a request for sexual
intercourse because sex is a free gift from God! Yao tribes of Malawi and
Tanzania
The practice of giving a sister, cousin or niece to help the breastfeeding
mother and her husband. Once the husband sleeps with sister, … she becomes
automatically his second wife; the man cannot be given another sister or
cousin. Swaziland
The acceptance that a woman must always have 3 stones (men) to sustain
her. The woman must ensure that the three men never know each other.
Zaramo tribes in Tanzania
The practice of sharing wives among all men of the same generation in
Masai tribes (Kenya, Tanzania); or of a wife among sibling men (Ankole
tribe-Uganda) Kenya , Tanzania, Uganda
Couple-deceit prostitution where a man and his wife agree that the wife
must seduce a rich man (who has more cattle) so that the husband can catch
them during the intercourse and oblige the rich man to pay fines (1-5
cows) Zambia, Kenya (Tribes: Wajibana, Nduruma, Ndjibe, ..etc)
Widows’ cleansing ceremony in which a widow is expected to sleep with a
man chosen by the community (Lesotho) or herself (Zimbabwe) to mark the
end of her mourning period. The man chosen for the purpose is somewhat the
one who is known not to mind about doing it. Ethiopia, Kenya, Lesotho,
Malawi, Swaziland, Tanzania, Uganda, Zambia
Table 3: Methods and items used for dry sex (n=31)
Methods and Items used for dry sex and enhance pleasure Country
Douching is done with Coca-Cola, Soda water, snuff, magnesium salts in
solution (from chemists), some mines’residues stones; herbal mixtures
(such as “Mutiburo” means heighten libido; “Chiswabunga” means sexual
prowess or strength for the man; and “Mugondorosi” meaning extend duration
of man’s stay) Lesotho, Zimbabwe, Malawi, Zambia
Insertion into the vagina prior to sexual intercourse of blue soap;
cataplasms made of some herbal mixture made into small balls that are sold
as such and referred to as “baboon urine” in Zimbabwe Lesotho, Zimbabwe,
Malawi, Zambia
References
1. Mullick S, Watson-Jones D, Beksinska M, and MabeyD. Sexuallly
transmitted infections in pregnancy: prevalence, impact on pregnancy
outcomes, and approach to treatment in developing countries. Sex Transm.
Inf. 2005;81;294-302.
2. Gausset Q. AIDS and cultural practices in Africa: the case of the
Tonga (Zambia). Social Science and Medicine 2001;52:509-18
3. Okeyo TM, Allen AK.Influence of widow inheritance on the
epidemiology of AIDS in Africa. Afr J Med Pract. 1994 Mar-Apr;1(1):20-5.
4. Phiri, Z.(2002). Inculturating African widowhood rites. Available
at: http://www.jctr.org.zm/bulletins/incult-widows.htm {Retrieved 21
September 2005)
5. Goseyun, A. E. (2001). Sunrise Ceremonial: An Apache Girl's Coming
of Age White Mountain Apache Reservation, Whiteriver, Arizona, 1990.
Balch Institute. Available at:
http://www.balchinstitute.org/rites/apache.html. [Retrieved on September
21, 2005]
6. Holland, E. (2001). Quinceanera: Latino Sweet Sixteen. Balch
Institute. Available at : http://www.balchinstitute.org/rites/latino.html.
[Retrieved on September 21 , 2005]
7. Malungo J. Sexual cleansing (Kusalazya) and levirate marriage
(Kunjilila mung’anda) in the era of AIDS: changes in perceptions and
practices in Zambia. Social Science and Medicine 2001;53:371-82.
We read with interest the paper by Brown and Peerapatanapokin
regarding estimated condom use rate required to control the HIV epidemic
in Thailand.[1] Their Asian Epidemic Model predicts that a sustained
high condom use rate (85% or more) among sexual workers is required to
control the HIV epidemic. If the condom use rate drops to 60%, their
model predicts a resurgence of the HIV epidemic.[1] We reac...
We read with interest the paper by Brown and Peerapatanapokin
regarding estimated condom use rate required to control the HIV epidemic
in Thailand.[1] Their Asian Epidemic Model predicts that a sustained
high condom use rate (85% or more) among sexual workers is required to
control the HIV epidemic. If the condom use rate drops to 60%, their
model predicts a resurgence of the HIV epidemic.[1] We reached a similar
conclusion using a different model developed for a different situation in
Taiwan[2], where prevalence of HIV infection is as low as 0.019% (end of
2002) and highly active antiretroviral therapy has been freely provided by
the government since 1997.
Sexual contact (96.4%, n=4,390 at the end of 2002) has been the
predominant risk factor for acquiring HIV infection in Taiwan.[2]
Because HIV prevalence is extremely low, evolution of the HIV epidemic in
Taiwan can be approximated by a simple exponential model defined by the
equation: dN(t)/dt = R*N(t) - m*N(t), where N(t) is the number of
patients with HIV infection at time t, R is the average transmission rate
(new cases per prevalent case per year) and m is the risk of mortality
(deaths per prevalent case per year). The magnitude of the HIV epidemic
will decrease only if R < m.
Using our previously published estimates for R and m values in Taiwan
(R=0.184 and m=0.046 per prevalent case-year, 1998-2002,
respectively)[2], plus the assumption that the value R=0.184 is under
the scenario of 10% condom use with 90% protection efficacy among sexually
active persons with multiple partners, the condom use rate level which is
required to control HIV epidemic can be calculated as below:
Hypothetical R under 0% condom use scenario = 0.184/(1-(10%)*(90%))
= 0.202
Hypothetical R under x % condom use scenario = 0.202*(1-(x%)*(90%))
Solve the x% when R = m = 0.046; we get x% = 85.8%
In another words, the condom use rate must be increased to 86% in
order to turn the tide of the sexually transmitted HIV epidemic.
Sensitivity analysis to assume baseline condom use rates of 5%, 15%, and
45% only shifts the required condom use rates for HIV control to 85%, 87%,
and 95%, accordingly. Thus, an equally high rate of condom use among
sexually active persons with multiple partners is required to control the
HIV epidemic in a low prevalence area like Taiwan in this era of highly
active antiretroviral therapy.
Chi-Tai Fang,1 Yu-Yin Chang,2 Jung-Der Wang1,2
1 Department of Internal Medicine, National Taiwan University
Hospital
2College of Public Health, National Taiwan University.
We declared no competing interests.
References:
1.Brown T, Peerapatanapokin W. The Asian Epidemic Model: a process
model for exploring HIV policy and programme alternatives in Asia. Sex
Transm Infect 2004; 80 (Suppl 1): 19-24.
2.Fang CT, Hsu SM, Twu SJ, et al. Decreased HIV transmission after a
policy of providing free access to highly active antiretroviral therapy in
Taiwan. J Infect Dis 2004; 190: 879-885.
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