While sharing Adams and colleagues’ concerns about the use of major outcomes averted, I should like to point out a factual error in their description[1] of the results from the ClaSS model[2]. The definition of major outcome used in that report, which appears in the text on page 107
and in the caption to Figure 18 on page 108 of the report[2] excludes epididymitis. The “seemingly perverse” result that sc...
While sharing Adams and colleagues’ concerns about the use of major outcomes averted, I should like to point out a factual error in their description[1] of the results from the ClaSS model[2]. The definition of major outcome used in that report, which appears in the text on page 107
and in the caption to Figure 18 on page 108 of the report[2] excludes epididymitis. The “seemingly perverse” result that screening males in addition to females is more cost-effective than screening females alone is therefore based on an outcome measure that does not include epididymitis. While it is true that the cost of epididymitis is included in the calculations, the result cited still holds even if the cost of epididymitis is removed. In the interests of further clarity, I should also like to point out that we only considered screening males in addition to females: we never considered screening males alone.
References
[1] Adams E J, Edmunds W J, Turner K M. Commentary on “The cost-effectiveness of opportunistic chlamydia screening in England”. Sex Transm Infect 2007;83:275.
[2] Low N, McCarthy A, Macleod J, et al. Epidemiological, social, diagnostic and economic evaluation of population screening for genital
chlamydial infection. Health Technology Assessment, 2007. Report No. 11(8).
I noticed an error in the editorial "Effective HIV prevention requires gender-transformative work with men" by Kristin L. Dunkle and Rachel Jewkes. The list should indicate that the first article referenced, "How men’s power over women fuels the HIV epidemic" by G.R. Gupta, is from the 324th, not the 321st, volume (issue 7331). At this time, your web site's Crossref link links to a review of a movie, 28...
I noticed an error in the editorial "Effective HIV prevention requires gender-transformative work with men" by Kristin L. Dunkle and Rachel Jewkes. The list should indicate that the first article referenced, "How men’s power over women fuels the HIV epidemic" by G.R. Gupta, is from the 324th, not the 321st, volume (issue 7331). At this time, your web site's Crossref link links to a review of a movie, 28 Days.
In addition to the confusion this may (and has) cause readers, it also detracts from the referenced author's citation record.
Recent Commentary in the journal (1) encourages wider implementation of nucleic acid amplification tests (NAATs) to detect gonorrhoea (GC). We have used GC NAATs (Gen-Probe APTIMA Combo2) since 2003, with high uptake, in a Liverpool chlamydia screening population and with referral of GC
positives to our local Genitourinary Medicine (GUM) clinic for management (2). We have now observed a doubling of femal...
Recent Commentary in the journal (1) encourages wider implementation of nucleic acid amplification tests (NAATs) to detect gonorrhoea (GC). We have used GC NAATs (Gen-Probe APTIMA Combo2) since 2003, with high uptake, in a Liverpool chlamydia screening population and with referral of GC
positives to our local Genitourinary Medicine (GUM) clinic for management (2). We have now observed a doubling of female cases of GC and a reversal of the downward trend for male GC as reported through KC60 - the national
indicator of GC activity which is based on central reporting but essentially only of cases seen at GUM clinics. For females (Fig 1), compared to a four year average baseline (2000-2003) of 101 cases per annum, KC60 reports showed an extra 51 cases in 2004 and an extra 99 cases in 2005. These extra numbers reflect closely the 45 cases in 2004 and the
107 cases in 2005 detected by concomitant screening for GC in the community chlamydia screening programme. For males (Fig 2), the upturn in KC60 reports can be matched to the total of cases detected directly by community screening plus by contact tracing of female community cases (assumed 50% success).
This significant local impact on detection of GC cases suggests that concomitant / dual testing in the community can benefit the wider provision of services for Sexual Health. Empirical evidence gained from screening in Liverpool has been recognised by the Cheshire and Merseyside
Sexual Health Network; the development of a Care Pathway for asymptomatic low-risk individuals recommends concomitant screening for chlamydia and gonorrhoea using APTIMA (3). This facilitates prompt, easy access to more comprehensive screening for sexually transmitted infections at a wide
range of venues, and may also promote opportunities for increased participation in the National Chlamydia Screening Programme.
Also with regard to data collection, KC60 data is an important tool in assessing progress towards the Department of Health target for a twenty-five percent reduction in cases of GC diagnosed at GUM clinics (4). Consideration of changes to KC60 reporting may be needed to prevent increased use of GC NAATs and/or dual testing in the community becoming a confounder to monitoring of this aim.
Figure 1
Figure 2
References
1. Bignell CJ, Sex Transm Infect 2007;83:179-80.
2. Lavelle SJ, Jones KE, Mallinson H et al. Finding, confirming and managing gonorrhoea in a population screened for chlamydia using the Gen-Probe Aptima Combo2 assay. Sex Transm Infect 2006;82:221-4.
3. Abbott, M (on behalf of the Care Pathways Working Group) Cheshire and Merseyside Sexual Health Network: STI Care Pathways explanatory document. 2007. Available at:
http://www.cmshn.nhs.uk/document_uploads/Care%20Pathways/CMSHNCarePath_1.pdf
4. Department of Health, Better prevention better services better sexual health: the national strategy for sexual health and HIV. London: DOH, 2001
In the June 2007 issue of Sexually Transmitted Infections, Dunkle and Jewkes make a much needed case for increased attention to the role of gender-based violence (GBV) in fueling the HIV pandemic. In their editorial, Dunkle and Jewkes assert that "social ideals of asculinity,"
including, inter alia, heterosexual success with women in the context of an entrenched gender hierarchy and the ability to contro...
In the June 2007 issue of Sexually Transmitted Infections, Dunkle and Jewkes make a much needed case for increased attention to the role of gender-based violence (GBV) in fueling the HIV pandemic. In their editorial, Dunkle and Jewkes assert that "social ideals of asculinity,"
including, inter alia, heterosexual success with women in the context of an entrenched gender hierarchy and the ability to control women, is an underlying cause of the observed association between violence perpetration
and sexual risk taking among men. Referring to an article published in the same issue of Sexually Transmitted Infections regarding gender-based violence and STI risk in Bangladesh, they find mounting evidence for national generalizability across a range of cultural settings "supporting the link between perpetration of GBV and STI/HIV risk". Lastly, they recommend replicating gender transformative interventions with men, such as the Stepping Stones program, in order to address the underlying causes
of gendered HIV risk, namely repressive gender norms and socioeconomic inequality that serve to disempower women vis-á-vis men. Their commentary is welcome, especially in a policy climate that is increasingly turning towards biomedical and non-gender transformative solutions to HIV, such as male circumcision to stem the tide of a continually mounting epidemic.
While agreeing with the spirit of their editorial, I question the logic that they use to derive their recommendations and propose an alternative method for analyzing the relationship among social ideals of
masculinity, gender-based violence and HIV/STI transmission using an ecologic and comparative framework to explain population-level variations in GBV and HIV risk.
Dunkle and Jewkes accurately point to the growing body of evidence that demonstrates unequivocally that women who experience GBV and gender inequitable attitudes are at greater risk of HIV at the individual level. However, despite this association at the individual level, at the ecologic level it does not necessarily hold that countries or regions with high rates of GBV/gender inequality experience heightened rates of HIV/STIs. For instance, although the WHO multi-country study on GBV has found that
Bangladesh has among the highest rates of GBV of the countries studied1 (findings reinforced in the Silverman et al study), Bangladesh as of 2005 has a negligible national HIV prevalence rate of <0.1% (see table 1). Evidence suggests that Muslim societies, though often endorsing highly repressive gender norms, have extremely low rates of HIV/STIs.2 In fact, it may be the repressive sexual culture of these countries/regions that is protective against HIV, limiting opportunities for marital infidelity and
sexual liberty.
Likewise, the WHO multi-country study found Ethiopia’s and Peru’s prevalence of intimate partner violence to be the highest of the ten countries under study respectively; yet, adult HIV prevalence was estimated at 4.4% in Ethiopia in 2003 and 0.6% in Peru as of 2005. Countries with higher national HIV prevalence rates, including Namibia
(19.6% in 2005) and Tanzania (6.5% in 2005), exhibited relatively lower rates of GBV (see table 1). Further, whereas HIV prevalence rates tend to be higher in urban areas,3 according to the WHO multi-country study
results, GBV is more common in rural (provincial) settings while urban residence appears to have a protective effect.
In essence, Dunkle and Jewkes’ comment commits the atomistic fallacy, or incorrectly generalizing an individual-level association to the group level.4 In order to assess the contribution of GBV to HIV at the ecologic level, studies must move from thinking about the replication of findings
in different settings to a comparative, population-level framework. The disciplines of sociology, political science and economics routinely use cross-national data to test hypotheses about variations in social phenomena across countries.5 In his classic piece “Sick Individuals and
Sick Populations”, epidemiologist Geoffrey Rose (1985) reminds us that the question,“‘Why do individuals have hypertension?’ is a quite different question from ‘why do some populations have much hypertension, whilst in
others it is rare?’”.6 In order to address this second question, Rose argues that “what distinguishes the two groups is nothing to do with the characteristics of individuals, it is rather a shift of the whole
distribution- a mass influence acting on the population as a whole.” In public health, cross-national comparisons can shed light on a host of important public health questions, including those related to GBV and HIV. To reframe Rose’s question, ‘Why are individuals who experience GBV more
likely to contract HIV?’ is a very different question from ‘Why do some countries experience higher rates of GBV and how does this affect population rates of HIV infection?’
In the case of HIV, it remains somewhat of a mystery how individual HIV risk factors link up to population risk. Ultimately, due to the limited number of transmission routes, some variation in behavior between populations, coupled with a tipping point and possible biomedical
transmissible cofactors must be responsible for the heightened rate of HIV in certain populations. More evidence is needed to explain under what conditions gender inequitable beliefs and behaviors link up with
population-level GBV and HIV risk.
Furthermore, interventions aimed at transforming a group level characteristic, such as repressive gender norms, should focus on interventions that address the ecologic or structural level.7 There is intuitively a contradiction inherent in using individual-level interventions to induce broad, socially transformative gender equality. Social change does not proceed one individual at a time, but rather when, in Rose’s words, there is a “mass influence causing a shift in the whole distribution”. In order to understand what that mass influence is, and to intervene at the population level, one must know what constitute the
population-level risk factors. More research must be conducted on why HIV prevalence rates vary so greatly within and between countries despite similar risk factors, such as high rates of GBV. Differences in collection and reporting of national HIV sero-prevalence estimates previously
hampered comparative research of cross-national HIV prevalence. However, new data sources, notably Demographic and Health Surveys (DHS) with linked HIV testing results are an extraordinarily rich, new data source that has
not yet been fully exploited to address questions regarding the social-structural and population-level determinants of HIV infection and GBV. Further, comparable national probability samples such as those utilized in
the DHS allow for national estimates of GBV that can facilitate cross-national and intra-national comparisons of ecologic-level risk factors.
This comment is in solidarity with Dunkle and Jewkes’ contention that “broad socially transformative programs that promote gender equality and discourage perpetration of gender-based violence and are needed to combat
the global HIV pandemic”. It is clear in countries with highly generalized HIV epidemics that reducing gender inequality and sexually empowering women are crucial to stem the spread of HIV. However, the modes by which to generate social transformation must stem from an understanding of the
macro-level causes of differing social phenomena across populations. Dunkle and Jewkes point to microbicides as a gender-sensitive technology, but one that fails to address the “underlying social constructions of gender”. To this I would add male circumcision, an anti-HIV intervention
increasingly gaining in prominence, which also fails to transform the broader constructions of gender in society and arguably has the potential to actually reinforce entrenched gender norms and male power. In keeping with recent literature, GBV should be addressed as a public health problem and human rights concern in its own right8 and not solely in relation to its instrumental association with reducing HIV and STI prevalence. Public health interventions that reinforce gender inequality and gendered power
relations should be eschewed in favor of gender transformative interventions that proceed at the population level.
References
1. World Health Organization. Summary Report, WHO multi-country study on women’s health and domestic violence against women: initial results on prevalence, health outcomes and women’s responses, 2005. Retrieved June
25, 2007, from
http://www.who.int/gender/violence/who_multicountry_study/en/index.html.
See also, Garcia-Moreno C, Jansen H, Ellsberg M. Prevalence of intimate partner violence: findings from the WHO multi-country study on women’s health and domestic violence, Lancet 2006; 368:1260-1269
2. Gray PB. HIV and Islam: is HIV prevalence lower among Muslims? Soc Sci Med 2004;58:1751–1756.
3. Shelton JD, Cassell MM, Adetunji J. Is poverty or wealth at the root of HIV? Lancet 2005; 366(9491): 1057.
4. Leyland AH, Groenewegen PP. Multilevel modeling and public health policy, Scandinavian Journal of Public Health 2003; 31(4):267-274.
5. e.g., Dogan M, Pelassy D. How to compare nations: strategies in comparative politics. New Jersey: Chatham House Publishers, 1984.
6. Rose G. Sick individuals and sick populations, Int J Epidemiol 2001;30:427-432.
7. Blankenship KM, Friedman SR, Dworkin S, et al. Structural Interventions: Concepts, Challenges and Opportunities for Research,
Journal of Urban Health 2006;83(1):59-72.
8. Brundtland GH. Violence, health, and human rights: toward a shared agenda for prevention, Health and Human Rights: An International Journal 2003;6(2): 11-13.
Steve Slack’s article on “condomophobia” (1) raises important issues about condom use and safer sex. However, it needs qualifying.
A phobia is an irrational fear. Not using condoms because of a fear of them must be very rare- I have never seen a case in 36 years of clinical practice. More likely is fear of erectile failure while putting on a condom. I would suggest another common scenario for no...
Steve Slack’s article on “condomophobia” (1) raises important issues about condom use and safer sex. However, it needs qualifying.
A phobia is an irrational fear. Not using condoms because of a fear of them must be very rare- I have never seen a case in 36 years of clinical practice. More likely is fear of erectile failure while putting on a condom. I would suggest another common scenario for not using a condom
(apart from not having one at hand as Slack correctly suggests may happen) it is that the person, partner or couple are carried away by the heightened feelings of the sexual event. Other possible reasons for not using condoms are fear of the partner’s reaction (“why are you using one
of those, I’m not infected- are you?”), that sex without a condom feels more pleasurable than wearing one, and being romantically in love with the partner (2).
Slack quotes from the ancient Egyptians. At about the same time (i.e. 1300BC) the Bible (Deuteronomy 21.10) discusses what an Israelite should do when he captures a woman in battle and “desires” her . Sexual desire
may be an almost overwhelming urge unless checked by restraining cognitive inputs. Romantic love, sexual desire and arousal are monoamine (principally dopamine and serotonin) associated events in cortical and
limbic system brain areas, some of which are very similar in terms of neurotransmitter profile to obsessive compulsive disorders (2) or hypomania. The themes of desire/arousal/love opposed by cognitive inputs condense at any one sexual scenario to form a final decision pathway i.e. the use or non use of condoms.
Slack sites car seat belt usage and inserting lipstick and mobile phones into personal bags as examples of common automatic practices. I would suggest that personal motivation lies behind most seat belt usage (“this might save my life”) and that anticipated pleasure lies behind
inserting the more personal objects into bags – back to dopamine again!
The war against unsafe sex was temporarily won in the early 1980s in the UK because people feared they would die of HIV. What higher motivation could there be for using a condom? Nowadays all STIs can be treated and have a relatively good prognosis. This means we must again increase
motivation- and this is really the linchpin underlying condom use. Motivational counselling for using condoms (3), as well as putting them in bags as Slack correctly suggests, is the correct way forward.
References
1. Slack S .“Condomophobia”. Sex Transm Infect 2007;83:246
2. Goldmeier D , Richardson D . Romantic love and sexually transmitted infection acquisition: hypothesis and review. Int J STD AIDS 2005;16:585-587
3. Petersen R, Albright J, Garrett JM, Curtis KM Pregnancy and STD prevention couseling using an adaptation of motivational interviewing: a randomised controlled trial. Perspect Sex Reprod Health 2007;39:21-28
Recently the world has seen a growing number of "transformative
programs" engaging men in eradicating gender-based violence and reducing the spread of HIV/AIDS. The global Men as Partners Program (MAP) implemented by EngenderHealth in 20 countries since 1998, primariliy, targets various groups of men through ecological model to transform male gender norms. The purpose of MAP is twofold: 1) to challenge t...
Recently the world has seen a growing number of "transformative
programs" engaging men in eradicating gender-based violence and reducing the spread of HIV/AIDS. The global Men as Partners Program (MAP) implemented by EngenderHealth in 20 countries since 1998, primariliy, targets various groups of men through ecological model to transform male gender norms. The purpose of MAP is twofold: 1) to challenge the
attitudes, values, and behaviors of men that compromise their own health and safety as well as the health and safety of women and children and 2)to encourage men to become actively involved in preventing Gender Based
Violence as well as HIV/AIDS-related prevention, care and support activities.
Results from various pre-workshop and post-workshop evaluations have indicated that men's participation in the MAP workshops have resulted in some attitudinal changes in South Africa. More scientific evaluations in 1). Nepal resulted in increased utilization of Family planning services by men and women and increased utilization of STI services by men. 2.)In Swaziland and Botswana, promoting positive male behavior norms through participatory theatre, resulted in male participants/audience members expressing to be challenged by messages. More than 60% of the audience
believed the elimination of gender-based violence is both critical and urgent.
The need lies with demonstrating the linkages between these programs that target men with the women focused programs for the common cause.
In his first paragraph Gersovitz mis-represents the aim of our paper¹ by suggesting that we set out to “..investigate adoption of the ABC approach..”. In fact, the focus of that paper is on how one should best measure and summarise age at first sex, in the context of the intense interest that HIV prevention efforts have generated. We discussed the relative merits of the different measures and concluded th...
In his first paragraph Gersovitz mis-represents the aim of our paper¹ by suggesting that we set out to “..investigate adoption of the ABC approach..”. In fact, the focus of that paper is on how one should best measure and summarise age at first sex, in the context of the intense interest that HIV prevention efforts have generated. We discussed the relative merits of the different measures and concluded that, for the most informative and unbiased measures, one should use survival analysis to describe age at first sex; a conclusion that Gersovitz dismisses with “A proportion is easier to calculate and sidesteps knowing whether the median is within the age range of the data.”
A life table (survival) approach is not limited to the calculation of medians, it leaves open the choice of summary statistic(s) to be used (we present inter-quartile range as well as medians), and certainly does not preclude the reporting of proportions who have become sexually active by a given age. What it does ensure is that if the analyst needs to combine reports from respondents of different ages this is done with due allowance for censoring. Simpler analytical approaches have their uses, such as in cross-sectional surveys limited to very young respondents or for the accessible presentation of results to non-specialist audiences. However, if we have access to high quality, rich data sources such as the DHS, where we can make comparisons between age groups, cohorts and time periods, and challenge the data to detect reporting errors or selection biases it behoves the research scientist to go beyond the calculation of the simple indicators such as those used for Millennium Development Goals.
The proportion who have had sex by a particular age correlates with the median age at first sex, and other summary measures of this transition, but describes only one aspect. This is illustrated by recent data on age at first sex for women in Kenya and Tanzania (Figure 1). In both countries about 30% of women report first sex before age 16 but in Kenya the median is, at 17.7 years, 6 months later than in Tanzania. Three-quarters of women in Tanzania have had sex by 18.9 years of age, a point reached almost a year later in Kenya.
Figure 1: Cumulative proportion who had had sex by age, women aged 15-49.
In one respect we agree with Gersovitz's standpoint: age at first sex is of critical importance. For effective HIV prevention we must know if age at first sex has changed and whether this has affected HIV transmission. It has become a hot political topic and if science is not to be hijacked by ideology we must honestly and accurately measure and describe what has taken place in Uganda and elsewhere over the last 30 years. The value and feasibility of abstinence, partner reduction and condom use, and the relative importance of each of these in different contexts defies simple packaging and is not well served by promulgation of a simple one size fits all approach2-4.
In our paper we deliberately set out to search for reporting errors and/or selection biases, and we found plenty of evidence of these in many of the series of national surveys that we examined. In the case of Uganda we actually used data from three surveys, going back to the 1988/1989 survey for women. Looking at the experience of different birth cohorts of women (those born in 1971-75, 1976-80, 1981-85) captured at different interview ages in the three surveys (table 4 in our paper) we found no consistent evidence of misreporting by the oldest cohort, for which median age at first sex was calculated as 16.3, 16.0 and 16.4 as they aged from 15-19, to 20-24 and finally 25-29; the middle cohort reported the same median age (16.3) at 15-19 and 20-24 – no different to the older cohort, whereas the youngest cohort, which could only be observed at the last survey when they were aged 15-19 had an older median age at first sex of 17.1, which cannot be assessed for age-related reporting bias until they are questioned again in another survey of this sort. For men we observed a small increase in the reported median age at first sex as the cohorts aged: from 17.4 to 17.9 for the oldest cohort as it moved from 20-24 to 25-29; and from 17.8 to 18.2 for the middle cohort as it aged from 15-19 to 20-24 – these inconsistencies are of the same order of magnitude as the apparent increase in age at first sex between the cohorts, which apparently continues to the youngest cohort which reported a median age at first sex of 18.4 when seen at survey aged 15-19 – again there is no way of checking the consistency of the reports of these youngest male respondents.
Interestingly, when Gersovitz focuses on the group that we refer to as the “middle” birth cohort, he concludes: “Clear significant positive bias is observed only for men for this 5-year group” which does not contradict our conclusion (no bias for women, positive bias for men which is not statistically significant) given that his comparison was confined to transitions to sexual activity occurring before age 16, whereas we considered 50% of all the transitions that could be observed for the cohort.
We allowed for survey design in our analysis of DHS data, and discussed problems that may arise in comparisons between successive sample surveys of the same population which do not use the same panel of respondents. Unlike Gersovitz, we make an attempt to quantify how changes in composition of the sample (by residence and education) and the possible association between age at interview and reported age at sexual debut affect our estimates of trend (table 5 in our paper). In some populations apparent trends disappear when structural factors and reporting biases are allowed for (males in Zambia and Kenya, females in Tanzania and Zimbabwe); in others observed significant differences persist (females in Ghana, Kenya and Uganda) and in a few populations trends that seemed trivial attain statistical significance when these structural and reporting factors are allowed for (males in Tanzania and Uganda).
We do not make any claims, in the case of Uganda, that these findings indicate successes for abstinence campaigns. Indeed, in the case of Ugandan males the significant change appears to be between the middle and eldest cohorts. The majority of the eldest cohort made their sexual debut between 1988 and 1992, and the majority of the middle cohort made their sexual debut between 1994 and 1999; in other words our analysis implies that the biggest changes took place in the early 90s before the “ABC” campaigns really got under way. If we were invited to speculate on the cause of this apparent rise we might put it down to a long-term secular rise in age at marriage, which in Uganda appears to be more closely associated with sexual debut than in other African populations.
Since we undertook similar analyses for Ghana, Kenya, Tanzania, Zambia and Zimbabwe we were able to observe that a rise in the reported age of sexual debut with age at interview (the bias identified by Gersovitz) was quite a common finding for men, whereas the opposite was generally true for women (women from the same birth cohort generally reported earlier sexual debut in later surveys). Although Ugandan women do not follow this pattern, it is worth bearing in mind that “social desirability” biases that may induce misreporting of age at sexual debut in response to abstinence campaigns are not the only source of reporting error. Total denial of sexual activity by young women interviewed at an age when they are reluctant to discuss sexual behaviour, but who are more relaxed about admitting their age at sexual debut when interviewed at a later age, generate reporting inconsistencies of this type, which can also be detected by cohort analyses.
One difference between our findings and those of Gersovitz is his detection of a bias in the women’s reports which we did not identify. This difference arises because our analysis was restricted to respondents born from 1971 onwards. Extending our analysis to the older age groups included by Gersovitz does show evidence of a change in the age at first sex reported in the most recent of the three surveys (Table 1). Reporting bias alone does not seem the most likely explanation for this discrepancy. The differences become apparent when respondents are in their late 30s or older. These cohorts first reported at an age where one would expect them to have already overcome any youthful embarrassment about their early sexual behaviour. In the later survey, when a change is apparent, the respondents are at the age when HIV associated mortality would have taken effect for those who were infected at a young age: very likely those who first had sex at a young age. In other words, mortality selection effects (rather than social desirability bias) may be responsible for much of the apparent difference in reported age at first sex for older women - this should not affect reports by younger women.
Median AFS (approx age at survey)
Pooled
Surveyed in:
1988
1995
2000/2001
Women born in:
1981-1985
17.1 (<20)
17.1
1976-1980
16.3 (<20)
16.3 (˜20-24)
16.3
1971-1975
16.3 (<18)
16.0 (˜20-24)
16.4 (˜25-29)
16.2
1966-1970
15.9 (˜18-22)
15.8 (˜25-29)
16.0 (˜30-34)
15.9
1961-1965
15.5 (˜23-27)
15.6 (˜30-34)
16.1 (˜35-39)
15.7
1956-1960
15.3 (˜28-32)
15.3 (˜35-39)
15.9 (˜40-44)
15.4
1951-1955
15.4 (˜33-37)
15.4 (˜40-44)
16.2 (˜45-49)
15.6
Table 1: Median age at first sex by birth cohort and survey.
There are some trivial reasons for minor differences between our results and Gersovitz's. We used true birth cohorts in our analysis instead of estimated age at survey and have therefore more accurately identified common cohorts of respondents. DHS datasets contain two variables describing age at first sex: one as reported by respondents and an imputed version that has been edited for consistency with answers to other questions. The 2000/2001 data for men were heavily edited using criteria that cannot be applied to the 1995 survey in which age at first birth was not collected. Gersovitz used the imputed variable as provided by Macro and excluded from the analysis 13% of the male respondents from 2000/2001. 7% of these respondents appear to have been wrongly classified as inconsistent. Exclusion of these men from the 2000/2001 analysis results in a slight overestimate of the proportion who had sex by age 16 and makes the comparison with the earlier data set problematic. This does not undermine Gersovitz's conclusions but makes it difficult to compare his results with ours.
In short: we cannot understand why Gersovitz repeatedly asserts that his conclusions are opposite to ours. Where the focus of our study and his are similar the results are not contradictory; however our analytical scope is wider in the sense that we examine several countries, we look at the first 50% of transitions in the cohorts of interest (as opposed to transitions occurring before age 16) and consider not just the transition from virginity to sexual activity, but also the transition to first marriage.
References
1. Zaba, B., Pisani, E., Slaymaker, E. & Boerma, J. T. Age at first sex: understanding recent trends in African demographic surveys. STI80, ii28-ii35 (2004).
2. Barnett, T. & Parkhurst, J. HIV/AIDS: sex, abstinence, and behaviour change. Lancet Infectious Diseases 5, 590-593 (2005).
3. Boerma, J. & Weir, S. Integrating demographic and epidemiologic approaches to research on HIV/AIDS: the proximate determinants framework. Journal of Infectious Diseases 191, S61-S67 (2005).
4. Wellings, K. et al. Sexual behaviour in context: a global perspective. The Lancet 368, 1706-1728 (2006).
In their recent review of gonorrhoea testing published in STI, Bignell et al state that whether or not to perform anal screening for gonorrhoea in men who have sex with men (MSM) should be guided by a sexual history [1]. Both UK [2] and US [3,4] guidelines recommend screening for anal gonorrhoea and chlamydia among men who have sex with men (MSM). US guidelines recommend anal screening only for MSM who re...
In their recent review of gonorrhoea testing published in STI, Bignell et al state that whether or not to perform anal screening for gonorrhoea in men who have sex with men (MSM) should be guided by a sexual history [1]. Both UK [2] and US [3,4] guidelines recommend screening for anal gonorrhoea and chlamydia among men who have sex with men (MSM). US guidelines recommend anal screening only for MSM who report receptive anal sex, while UK guidelines suggest screening based on sexual history, noting that oro-anal transmission of gonorrhoea may occur without penetrative
anal intercourse [2]. However, we believe that current screening guidelines do not acknowledge the possible contribution of a wider variety of receptive anal sexual practices to anal infections among this population.
Our recently published study in Sexually Transmitted Infections [5] examined risk factors for anal gonorrhoea and chlamydia among MSM participants in the community-based Health in Men (HIM) cohort in Sydney, Australia. Among participants with casual male partners who reported no
unprotected receptive anal intercourse (UAI), we found a strong independent association between anal gonorrhoea and receptive oro-anal sex, (p for trend 0.001) which has also been described among MSM in cross sectional studies in clinical settings [6]. In addition, we also found a
strong independent association of anal gonorrhoea with receptive fisting (p for trend 0.001) and receptive anal fingering (p for trend 0.002). Receptive fingering (p for trend 0.038) and being receptive of dildos (p
for trend 0.029) were also independently associated with anal chlamydia infection.
Not only do these anal practices predict anal infection with chlamydia and gonorrhoea, but they are very common among MSM. In the HIM study, among those with regular and casual partners at baseline, most participants reported receptive rimming (66.2% and 69.1% respectively) and
receptive fingering (71% and 66.8% respectively) over the previous 6-month period. Being receptive of a dildo was reported by 27.1% of those with regular partners, and 13.0% of those with casual partners. Receptive fisting was less commonly reported.
The common and diverse nature of receptive anal sexual practices among MSM, and their association with anal gonorrhoea and chlamydia infections, suggests that anal screening for these infections should be performed in all sexually active MSM, not just those reporting receptive
penile- or oro-anal sexual practices. Offering anal STI screening uniformly to all MSM, may also overcome difficulties of risk assessment, given varying depths of sexual history taking skills among clinicians. On
the basis of these data, Australian screening guidelines for MSM [7] are currently being updated to recommend universal anal screening for all sexually active MSM irrespective of their reported sexual practices (Personal communication, Dr Christopher Bourne, 11th May 2007).
David J Templeton 1, 2
Fengyi Jin 1
Basil Donovan 1, 3
Andrew E Grulich 1
1. National Centre in HIV Epidemiology and Clinical Research, The University of New South Wales, Sydney, Australia
2. Sexual Health Service, Sydney South West Area Health Service, Sydney, Australia
3. Sydney Sexual Health Centre, Sydney, Australia
Competing interests: none
References
[1] Bignell C, Ison CA, Jungmann E. Gonorrhoea. Sex Transm Infect 2006;82(Suppl 4):iv6-9.
[2] UK national screening and testing guidelines for sexually transmitted infections, 2006 [accessed 10th May 2007]; Available from:
http://www.bashh.org/guidelines/2006/sti_screening_guidelines_v14_0806.pdf
[3] Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep 2006;55(RR-11):1-94.
[4] Public Health Seattle and King County Sexually Transmitted Diseases Program. STD/HIV Screening Guidelines for men who have sex with men, 2005
[accessed 10th May 2007]; Available from:
http://www.metrokc.gov/health/apu/std/msmstd.htm
[5] Jin F, Prestage GP, Mao L, Kippax SC, Pell CM, Donovan B, et al. Incidence and risk factors for urethral and anal gonorrhoea and chlamydia
in a cohort of HIV-negative homosexual men: the Health in Men Study. Sex Transm Infect 2007;83(2):113-9.
[6] McMillan A, Young H, Moyes A. Rectal gonorrhoea in homosexual men:
source of infection. Int J STD AIDS 2000;11(5):284-7.
[7] Sexually transmitted infections in gay men action group. Sexually transmitted infection testing guidelines for men who have sex with men, 2005 [accessed 10th May 2007]; Available from:
http://www.racp.edu.au/public/SH_MSMguidelines.pdf
We would like to correct the inaccurate comments made in the commentary paper “The National Chlamydia Screening Programme and the NICE guidance on one-to-one interventions: remember the under 25s” from Simms et al, in relation to the National Institute for Health and Clinical Excellence (NICE) guidance ‘Prevention of sexually transmitted infections
and under 18 conceptions’ (Sexually Transmitted Infect...
We would like to correct the inaccurate comments made in the commentary paper “The National Chlamydia Screening Programme and the NICE guidance on one-to-one interventions: remember the under 25s” from Simms et al, in relation to the National Institute for Health and Clinical Excellence (NICE) guidance ‘Prevention of sexually transmitted infections
and under 18 conceptions’ (Sexually Transmitted Infections 2007;83:171, http://sti.bmj.com/cgi/content/full/83/2/171).
The paper states that the draft guidance misses out under 25 year olds as reflected in the paper’s title and in further references within the text in relation to chlamydia screening. This view is not correct – the draft and final NICE guidance identified that those who have ‘early
onset of sexually activity’ and who have ‘unprotected sex and frequent change of and/or multiple sexual partners are at risk’ - under 25 year olds fall into these two categories. These are key risk behaviours for
chlamydia infection. The guidance recommendations for vulnerable young people under 18 also relate to this group.
A second comment “the guidelines appeared to focus exclusively on consultations in which patients are seeking care for an issue related to sexual health” does not represent the guidance. The guidance actually
states that risk assessment can be 'during routine care and or travel immunisation’. The final NICE guidance also states that the recommendations should be implemented alongside the National Chlamydia Screening Programme.
The full NICE guidance ‘‘Prevention of sexually transmitted infections and under 18 conceptions’ is available at http://guidance.nice.org.uk/phi003 .
Yours faithfully,
Dr Catherine Law
Chair
Public Health Interventions Advisory Committee at NICE
Professor Mike Kelly
Director
Centre for Public Health Excellence, NICE
NICE
MidCity Place
71 High Holborn
London
WC1V 6NA
Drs Shamanesh and Radcliffe on the one hand and Dr Horner on the other provide finely balanced arguments for and against screening of asymptomatic men for non-specific urethritis (NSU). Drs Shamanesh and Radcliffe, in addition, slip in their recommendation to abandon examining asymptomatic men and this needs to be challenged. Dr Ross suggests that individual departments may chose whether to continue with...
Drs Shamanesh and Radcliffe on the one hand and Dr Horner on the other provide finely balanced arguments for and against screening of asymptomatic men for non-specific urethritis (NSU). Drs Shamanesh and Radcliffe, in addition, slip in their recommendation to abandon examining asymptomatic men and this needs to be challenged. Dr Ross suggests that individual departments may chose whether to continue with the urethral smear (US) but that may result in some difficulties and it is the pragmatic implications of the change in practice which I would like to address.
It is hard to understand the logic that suggests that a finding in an asymptomatic patient should be interpreted differently in a symptomatic patient. If a man has a discharge and his tests for N gonorrhoeae and C
trachomatis are negative but he has a urethritis, as evidenced by a significant number of pus cells on a US, we would call this NSU. We might believe that M genitalium could be a cause, but clearly according to current data, that infection cannot account for all symptomatic patients.
We would treat him, and in the past would have treated his partner. Our rationale for doing this is to remove his symptoms and to prevent re-infection from his partner and possible harm to her. If he is minimally symptomatic, presumably the same argument applies. At what point does the
argument no longer apply? Can we assume that truly asymptomatic men who do not have a visible urethral discharge but have urethritis on a US do not have M genitalium or any other pathogen? Clearly that is not the case, although the likelihood is relatively small. The pathogenic potential of M genitalium is becoming increasingly apparent and it seems wrong to abandon
the only routine test, albeit a surrogate marker, we have. Thinking back to the early to mid 1980s, we might have made a similar decision about C trachomatis then when we had relatively little evidence of the potential
pathogenicity of C trachomatis. The widespread availability of testing for M genitalium would make a huge difference in progressing this argument but we seem to be someway away from that at the moment.
However the pragmatic problem is how we deal with patients who have had a urethral smear in the past and have been told they had NSU. Are we now to tell them that we no longer believe in that diagnosis, that their
treatment and partner assessment was unnecessary (unless of course they had symptoms, in which case we still believe in the diagnosis). What new evidence can we point to, to enable us to reject our previously held views or are we just seeking to abandon a difficult diagnosis to push people
through our clinics faster and meet DH targets of doubtful value?
If the US is abandoned, clinicians have the option of diagnosing gonorrhoea by taking a urethral culture or using a NAAT urine test. If we continue to test for male gonorrhoea using urethral culture, an examination will be necessary and this will therefore make little
difference to the clinic throughput. Using the “pee and go” approach, men will not be examined. Dr Horner points out that it may be wrong to assume that men who say there are asymptomatic, do not have a urethral discharge. We are all aware of examining men with obvious discharges who are unaware that a discharge is abnormal. How should we manage such men- clearly we should not risk missing a diagnosis of gonorrhoea, so a US is necessary. If we find only NSU, do we ignore the findings?
Furthermore, some men, particularly young men, may be reluctant to express their concerns about particular issues during an interview or in completing a questionnaire and want the opportunity to explore these at the time of examination. Sometimes they don’t have the words to explain
what they perceive might be a problem. While it may not be important in public health terms to reassure a young man that his pearly penile papules are normal or that the dimensions of his penis are perfectly adequate, a
professional opinion may alleviate months of anxiety. Conversely, men with significant disease such as lichen sclerosus, often claim to be asymptomatic. Genital warts may be little more than a cosmetic problem, but the virus is sexually transmitted and we surely have a responsibility
to make the diagnosis, if only to provide reassurance and advice about risk reduction. Finally the opportunity for health promotion, for example teaching testicular self examination, is lost. While “pee and go” may be
ideal for outreach sessions especially in areas of high N gonorrhoeae prevalence where the positive predictive value of the test is likely to be more acceptable, I believe an examination is an integral part of a level 3 specialist service.
Another issue which we may need to consider is the implications of some clinics continuing to test for NSU when other clinics have abandoned the practice as the following recent case illustrates. A young man and his partner presented for a screen before staring a new relationship. He had previously had a negative screen in another clinic a
few weeks after the end of his previous relationship and was only attending at the request of his girl friend who had asked that they should do the tests together. His urethral smear showed more than 20 pus cells. Tests for chlamydial infection and gonorrhoea were negative. We assumed
that the first clinic had used a “pee and go” screening procedure thus missing the diagnosis of asymptomatic NSU.While it could be argued that it would have been better if we had not done a urethral smear and the diagnosis not made, my concern is that inconsistency in practice will make
it very difficult to sustain the confidence of patients in such scenarios. I think we will all need to agree on what constitutes a sexual health screen.
Drs Shamanesh and Radcliffe dismiss the small delay likely to occur if asymptomatic chlamydia positive patients are not detected at their first visit. In most real life settings this is likely to be at least a week, allowing for specimen transport, test performance, result generation, result transmission to the clinician and then the patient and the return of the patient for treatment. During this time the patient may transmit the infection to others. It should be noted that we (and the Department of Health) believe that more than two days is too long to wait
for a GUM appointment in case the patient transmit to others while he is waiting for the appointment. Is there a little hypocrisy here? It should also be noted that the second visit will generate another PBR fee, making the service not only more costly but less cost effective per infection
diagnosis made. The US is our oldest near patient test (apart from the 2 glass test) and at a time when others are seeking to develop near patient testing in order to incorporate treatment into a single visit (one stop
shop) it seems strange that we should be moving away from the concept.
Finally, are we producing “urethral cripples” by diagnosing NGU? A lot depends on what we say to our patients. Clearly in the first instance we do not know whether the patient has chlamydial infection or possibly
gonorrhoea and this needs to be stated. But we could move away from the practice of stating that NGU is almost always sexually transmitted and advise men that if their tests for GC and NG are negative they have a urethritis which may or may not be sexually transmitted. We would then
advise a screen for the partner (which would pick up those cases of NG and CT missed in the index case) and offer treatment, explaining that we are unable to test for M genitalium. This of course, takes a bit more time
than “pee and go”, but seems to me a better way forward than abandoning a diagnosis without firm evidence to do so.
Dear Editor,
While sharing Adams and colleagues’ concerns about the use of major outcomes averted, I should like to point out a factual error in their description[1] of the results from the ClaSS model[2]. The definition of major outcome used in that report, which appears in the text on page 107 and in the caption to Figure 18 on page 108 of the report[2] excludes epididymitis. The “seemingly perverse” result that sc...
Dear Editor
I noticed an error in the editorial "Effective HIV prevention requires gender-transformative work with men" by Kristin L. Dunkle and Rachel Jewkes. The list should indicate that the first article referenced, "How men’s power over women fuels the HIV epidemic" by G.R. Gupta, is from the 324th, not the 321st, volume (issue 7331). At this time, your web site's Crossref link links to a review of a movie, 28...
Dear Editor,
Recent Commentary in the journal (1) encourages wider implementation of nucleic acid amplification tests (NAATs) to detect gonorrhoea (GC). We have used GC NAATs (Gen-Probe APTIMA Combo2) since 2003, with high uptake, in a Liverpool chlamydia screening population and with referral of GC positives to our local Genitourinary Medicine (GUM) clinic for management (2). We have now observed a doubling of femal...
Dear Editor,
In the June 2007 issue of Sexually Transmitted Infections, Dunkle and Jewkes make a much needed case for increased attention to the role of gender-based violence (GBV) in fueling the HIV pandemic. In their editorial, Dunkle and Jewkes assert that "social ideals of asculinity," including, inter alia, heterosexual success with women in the context of an entrenched gender hierarchy and the ability to contro...
Dear Editor,
Steve Slack’s article on “condomophobia” (1) raises important issues about condom use and safer sex. However, it needs qualifying.
A phobia is an irrational fear. Not using condoms because of a fear of them must be very rare- I have never seen a case in 36 years of clinical practice. More likely is fear of erectile failure while putting on a condom. I would suggest another common scenario for no...
Dear Editor,
Recently the world has seen a growing number of "transformative programs" engaging men in eradicating gender-based violence and reducing the spread of HIV/AIDS. The global Men as Partners Program (MAP) implemented by EngenderHealth in 20 countries since 1998, primariliy, targets various groups of men through ecological model to transform male gender norms. The purpose of MAP is twofold: 1) to challenge t...
Dear Editor,
In his first paragraph Gersovitz mis-represents the aim of our paper¹ by suggesting that we set out to “..investigate adoption of the ABC approach..”. In fact, the focus of that paper is on how one should best measure and summarise age at first sex, in the context of the intense interest that HIV prevention efforts have generated. We discussed the relative merits of the different measures and concluded th...
Dear Editor,
In their recent review of gonorrhoea testing published in STI, Bignell et al state that whether or not to perform anal screening for gonorrhoea in men who have sex with men (MSM) should be guided by a sexual history [1]. Both UK [2] and US [3,4] guidelines recommend screening for anal gonorrhoea and chlamydia among men who have sex with men (MSM). US guidelines recommend anal screening only for MSM who re...
Dear Editor,
We would like to correct the inaccurate comments made in the commentary paper “The National Chlamydia Screening Programme and the NICE guidance on one-to-one interventions: remember the under 25s” from Simms et al, in relation to the National Institute for Health and Clinical Excellence (NICE) guidance ‘Prevention of sexually transmitted infections and under 18 conceptions’ (Sexually Transmitted Infect...
Dear Editor,
Drs Shamanesh and Radcliffe on the one hand and Dr Horner on the other provide finely balanced arguments for and against screening of asymptomatic men for non-specific urethritis (NSU). Drs Shamanesh and Radcliffe, in addition, slip in their recommendation to abandon examining asymptomatic men and this needs to be challenged. Dr Ross suggests that individual departments may chose whether to continue with...
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