This article, and that by Bradbeer and Mears, are to be applauded.
Their value will be all the greater if specific examples of the
recommendations are shared and adopted by the specialty. In particular I
would be interested to see a brief information sheet that can replace
verbal discussion about HIV testing and still deliver the recommended five
main components of pre-test discussion.[1] I have tried...
This article, and that by Bradbeer and Mears, are to be applauded.
Their value will be all the greater if specific examples of the
recommendations are shared and adopted by the specialty. In particular I
would be interested to see a brief information sheet that can replace
verbal discussion about HIV testing and still deliver the recommended five
main components of pre-test discussion.[1] I have tried to produce such
a document. It has been called many things but never, “brief”!
References
(1) Carne CA. STI services in the United Kingdom: a way forward. Sex Transm Infect 2003; 79: 439-441.
(2) Bradbeer C, Mears A. STI services in the United Kingdom: how shall we cope? Sex Transm Infect 2003 79: 435-438.
It appears as if the lesion is present on the dorsal aspect of the
penis since the fingers at the root of the penis rotating it are not seen.
Actually the lesion was present on the ventral aspect of the penis only.
Since the penis was rotated by 90 degree at its root for easy photography,
in the photograph it looks different. So the legend put for the figure is
correct.
I agree that presenting an appropriate amount of written information
to substitute for an HIV pre-test discussion is problematical. We
introduced such a system with some misgivings but felt that it was the
only way that we could comply with the Royal College of Physicians second
Speciality Specific Standard without seriously disrupting the se...
I agree that presenting an appropriate amount of written information
to substitute for an HIV pre-test discussion is problematical. We
introduced such a system with some misgivings but felt that it was the
only way that we could comply with the Royal College of Physicians second
Speciality Specific Standard without seriously disrupting the service.[1]
In writing our handout I bore in mind the statement in the Department
of Health guideline he refers to that "the extent of provision of pre-test
discussion reflects the varying needs of different clinical situations".[2] I have interpreted this to mean that for low-risk, non-anxious
patients not all five aspects of the pre-test discussion are mandatory.
After reading our handout patients are asked to indicate at the
bottom whether or not they wish to take a test, or whether they would like
further discussion. A sexual history is taken from all patients and all
are asked if they have injected drugs. The health care worker may cover
certain points of the pre-test discussion if they feel it is appropriate
even if the patient has not indicated a wish for this. Having used the
system for over one year my informal assessment is that it works well.
I am happy to provide a copy of our handout on request for what it is
worth. It may be that the HIV Special Interest Group might consider
producing a more definitive version.
I agree with Dr Carne that the requirement to offer 90% (next year
100%) of our new patients an HIV test precludes us from offering everyone
discussion about the HIV test as recommended by the UK Departments of
Health in their Guidelines on HIV Pre-test Discussion.[1] However, the
guidelines still include the statement that for, "individuals actively
seeking an HIV test for the first occasion, here a...
I agree with Dr Carne that the requirement to offer 90% (next year
100%) of our new patients an HIV test precludes us from offering everyone
discussion about the HIV test as recommended by the UK Departments of
Health in their Guidelines on HIV Pre-test Discussion.[1] However, the
guidelines still include the statement that for, "individuals actively
seeking an HIV test for the first occasion, here a pre-test discussion
session involving all 5 stages is desirable, supplemented by written
information." Is it desirable that we feel we can only ignore guidelines
from the Departments of Health?
Of course the guidelines are nearly eight-years-old now and much has
changed in that time. The involvement of the BASHH HIV Special Interest
Group seems a good suggestion; perhaps it would like to collect some
examples of written HIV pre-test information, produce a version that would
be valuable to both Genito-Urinary Medicine and Primary Care and meet with
the Departments of Health to agree 21st century guidelines.
Nicola Low [1] is right to highlight the need to consider the number
of HIV diagnoses made in Britain in each ethnic group in light of the size
of that ethnic group.
For some years we have been told ad infinitum that
the number of diagnoses of heterosexually acquired HIV has ‘out-stripped’
the number of homosexually acquired diagnoses, as if that indicated some
kind of equivalence of impa...
Nicola Low [1] is right to highlight the need to consider the number
of HIV diagnoses made in Britain in each ethnic group in light of the size
of that ethnic group.
For some years we have been told ad infinitum that
the number of diagnoses of heterosexually acquired HIV has ‘out-stripped’
the number of homosexually acquired diagnoses, as if that indicated some
kind of equivalence of impact on heterosexually and homosexually active
adults. Even if all the heterosexually acquired infections being diagnosed
in Britain were acquired in Britain (which they are not), the homosexually
active population is tiny compared to the heterosexually active.
Low herself makes the same oversight among Caribbeans in Britain, not
even alluding to the disproportionate impact of HIV on gay men in the
Caribbean or in the UK. If we estimate that among Caribbeans in Britain:
there are equal numbers of men and women; 75% of the population are adult;
and that the prevalence of male sexual activity is as in the general
population [2] with 91.0% having sex with women and 2.6% having sex with
men, in 2001 [3] the HIV diagnoses rates per 100 000 were 31.1 among all
adult Black Caribbeans, 23.7 among all females and 35.7 among all males.
Further, it was 25.9 among heterosexually active men but 924.4 among
homosexually active men. This latter is 30 times the rate for all
Carribean adults in the UK.
The fact that, among Caribbeans, the majority of heterosexually
acquired infections are migratory and the majority of homosexually
acquired infections occurred in Britain [3] makes this inequality even
more acute. The HIV epidemic among all ethnicities in Britain very
disproportionately effects homosexually active men yet this continue to be
an afterthought for public health and policy. The need to resist this
obscurantism is even greater among Black communities in Britain where
sexism (and the corresponding heterosexism) is even stronger than in the
White majority.
The group most likely to acquire HIV in Britain are Black African gay
men and Black Caribbean gay men. The small size of these groups is no
excuse for ignoring their needs. It is imperative that British HIV prevention programmes for Black people
over-serve gay and bisexual men, and that programmes for gay and bisexual
men over-serve Black men, if these groups are not to continue to be the
least served.
References
1. Low N. HIV infection in black Caribbeans in the United Kingdom.
Sexually Transmitted Infections. 2004; 80, 2-3.
2. Johnson AM, Mercer CH, Erens B et al. Sexual behaviours in Britain:
partnerships, practices and HIV risk behaviours. Lancet. 2001; 358 (9296),
1835-1842.
3. Dougan S, Payne LJC, Brown AE et al. Black Caribbean adults with HIV
in England, Wales and Northern Ireland: an emerging epidemic. Sexually
Transmitted Infections. 2004; 80, 18-23.
The article by Crucitti et al.[1] evaluated five PCR techniques for
Trichomonas vaginalis including the one published by our group (Mayta et al. [2]). The authors however did not follow the protocol we published
and so got results that we consider to be erroneous.
In our work we used
simple Taq polymerase while Crucitti used Taq gold for this purpose. He
did this without chang...
The article by Crucitti et al.[1] evaluated five PCR techniques for
Trichomonas vaginalis including the one published by our group (Mayta et al. [2]). The authors however did not follow the protocol we published
and so got results that we consider to be erroneous.
In our work we used
simple Taq polymerase while Crucitti used Taq gold for this purpose. He
did this without changing or proving that the same cycle conditions will
provide similar sensitivity. In our studies using the same cycles Taq
gold is rarely positive and frequently gives negative results even when
the culture is positive. In addition, they used a DNA extraction that was
different from the one we used for our Trichomonas study.
In the article by Crucitti et al. the primer set TV1/TV2 was found to
be less sensitive presumably due to the use of an untried new protocol.
We feel strongly that unless the authors follow the original protocol
their results for the PCR sensitivity are not valid. In any comparative
study of methods the published protocol should be followed and not
modified without validation. This appears not to be done by Crucitti et al.
References
(1) T Crucitti, E Van Dyck, A Tehe, S Abdellati, B Vuylsteke, A Buve, and M Laga. Comparison of culture and different PCR assays for detection of Trichomonas vaginalis in self collected vaginal swab specimens. Sex Transm Infect 2003; 79: 393-398.
(2) Mayta H, Gilman RH, Calderon MM, et al. 18S Ribosomal DNA-based PCR for diagnosis of Trichomonas vaginalis. J Clin Microbiol 2000;38:2683–7.
The article on Pathways to HIV testing and care by black African and
white patients in London is indeed very interesting.
However,I do not
believe it takes into account the very real differences between the
different African communities in London.
The severe devastation and scale of the HIV/AIDS epidemic in Africa has
not been felt uniformly across the continent.West African countries for
whatev...
The article on Pathways to HIV testing and care by black African and
white patients in London is indeed very interesting.
However,I do not
believe it takes into account the very real differences between the
different African communities in London.
The severe devastation and scale of the HIV/AIDS epidemic in Africa has
not been felt uniformly across the continent.West African countries for
whatever reasons have not suffered as much as countries in East,Central
and Southern Africa.Though the incidence of HIV in West Africa has
increased in recent years it is nowhere near the scale seen in countries
like Zimbabwe.Therefore to group all Africans together under the term
"Black African" when it comes to discussing HIV/AIDS seems a bit
misleading, albeit unintentionally.In Eastern Europe there are massive
problems with HIV but this area is never grouped together with Western
Europe when describing the epidemiology of this disease in Europe.
Africa is a very vast continent and writers would do well to remember
this.
The purpose of our study was to evaluate five different primer sets
described in the literature for the amplification of Trichomonas
vaginalis. We therefore used the same working conditions for the five
primers sets, i.e. the same extraction method, thermocycler, reagents
etc. It was not our aim to re-validate these primer sets.
For all of the five primer sets we used the AmpliTaq Gold poly...
The purpose of our study was to evaluate five different primer sets
described in the literature for the amplification of Trichomonas
vaginalis. We therefore used the same working conditions for the five
primers sets, i.e. the same extraction method, thermocycler, reagents
etc. It was not our aim to re-validate these primer sets.
For all of the five primer sets we used the AmpliTaq Gold polymerase,
which has some advantages compared to the simple Taq polymerase. The
AmpliTaq Gold Polymerase is inactive at ambient temperatures, non-specific
binding is avoided and preparation of reactions is facilitated. Activation
of the AmpliTaq Gold Polymerase occurs only when heated before the thermal
cycling, and is thus similar to a hot-start PCR. The AmpliTaq Gold
Polymerase requires a pre-denaturation step at 95°C for 5 minutes, as
shown in Table 2. The overall PCR product yield is also greater.[1]
In our laboratory the AmpliTaq Gold Polymerase works very well. We
follow strict quality guidelines, meaning that prior to the introduction
of a new batch of AmpliTaq Gold Polymerase we test the quality of the
batch with a panel of known positive and negative specimens. Variability
in Taq polymerase performance based on batch, concentration, and supplier
has been documented.[2] We detected variability in Taq polymerase quality
based on differences between batches.
References
(1) T Moretti, B Koons, and B Budowle. Enhancement of PCR
amplification yield and specificity using AmpliTaq Gold ® DNA polymerase.
BioTechniques 1998; 25: 716-722.
(2) KD Tyler, G Wang, SD Tyler, and WM Johnson. Factors affecting
reliability and reproducibility of amplification-based DNA fingerprinting
of representative bacterial pathogens. J Clin Microbiol 1997; 35:339-346.
We read with interest the trichomonas review written by Swygard et al.[1]
Current BASHH and European STD guidelines for the management of
trichomoniasis state that “tests of cure should be undertaken if the
patient remains symptomatic following treatment, or if symptoms recur”.[2,3] No specific recommendations are made for the follow-up of patients
who were asymptomatic at presentation. Sw...
We read with interest the trichomonas review written by Swygard et al.[1]
Current BASHH and European STD guidelines for the management of
trichomoniasis state that “tests of cure should be undertaken if the
patient remains symptomatic following treatment, or if symptoms recur”.[2,3] No specific recommendations are made for the follow-up of patients
who were asymptomatic at presentation. Swygard et al. state “follow up
unnecessary for men and women who become asymptomatic after treatment or
who are initially asymptomatic”. As 10-50% of women [4,5] and 15-50% of
men [6] are asymptomatic at diagnosis this potentially excludes a large
proportion of patients from follow-up.
In our service we have traditionally performed tests of cure for
Trichomonas vaginalis (TV) in all patients. In order to ascertain whether
our practice should be altered in accordance with current guidelines we
performed a retrospective note review of all patients diagnosed with TV in
2002. Of a total of 36 cases (all female), 25% were asymptomatic at
diagnosis. All were treated with recommended first line therapy, 5 days
Metronidazole 400mg twice daily or a 2g stat dose of either Metronidazole
or tinidazole,[1] and 83% returned for a test of cure. Of the 7 patients
that remained symptomatic, all tested negative for TV, however, 71% had
candidiasis on microscopy. Of note, there were 2 patients with a positive
test of cure but were asymptomatic at diagnosis and follow-up.
We feel that guidelines for treating TV should clarify the importance
of not relying on the presence or absence of symptoms in patients who were
asymptomatic to start with. Our study, albeit small numbers, highlighted
the importance of bringing asymptomatic women back to clinic for a test of
cure.
References
(1) Swygard H, Sena A, Hobbs M, Cohen M. Trichomoniasis: clinical
manifestations, diagnosis and management. Sex Transm Infect 2004;80:91-
95.
(2) British Association for Sexual Health and HIV (BASHH). 2001 National
Guideline on the Management of trichomonas vaginalis (http://www.bashh.org).
(3) European STD guidelines. International Journal of STD & AIDS
2001.12(3) (http://www.iusti.org).
(5) Fouts AC, Kraus SJ. Trichomonas vaginalis: re-evaluation of its
clinical presentation and laboratory diagnosis. J Infect Dis
1980;141(2):137-143.
(6) Krieger J, Jenny C, Verdon M, Siegel N, Springwater R, Critchlow C,
Holmes K. Clinical manifestations of trichomoniasis in men. Ann Int Med
1993;118(11):844-9.
Dave et al's letter about the role of professionals in the HIV-
outpatient setting is aposite and brings up many issues including who
should end up doing this type of 'routine' work.[1] As always GPs are called
in along with other professionals as possible options. However,
communication amongst other problems, continue to be a big challenge.
Dave et al's letter about the role of professionals in the HIV-
outpatient setting is aposite and brings up many issues including who
should end up doing this type of 'routine' work.[1] As always GPs are called
in along with other professionals as possible options. However,
communication amongst other problems, continue to be a big challenge.
I recently reviewed all the notes of the twenty-three registered
patients with known HIV in our small practice in SE London (prevalence
0.5%). This group comprises 15 males and 8 females and includes two
children (overall age range 5-56 yrs). The male-female ratio is 2:1.
This group of patients attends seven different hospitals for their
HIV care and more when other conditions are taken into account. Only 10
patients have an up-to-date letter in the notes, as defined by any letter
mentioning HIV in 2004. The majority do not, and this includes one
patient where there has never been any letter outlining the patient's HIV
status, despite the patient coming to see us regularly for mental health
problems. While the arguments about confidentiality have raged for many
years, surely it it is time for this to be confronted as an excuse (what
else could it be?) for not communicating with GPs and community health
services.
Add to this the fact that providing such services in primary care do
not appear to be attracting any "enhanced funding" in the new GP contract
(yet) and you will understand the caution with which many general
practitioners view this problem. Unfortunately, until these
organisational and funding issues are resolved, it seems that the
traditional roles of primary and secondary care will continue for the
patient with HIV infection.
Reference
1. S S Dave, K Miles, C Griffiths, D E Mercey, and S G Edwards. Is it time to rethink the roles of health professionals in the HIV outpatient setting?
Sex Transm Infect 2004; 80: 153-154.
Dear Editor
This article, and that by Bradbeer and Mears, are to be applauded. Their value will be all the greater if specific examples of the recommendations are shared and adopted by the specialty. In particular I would be interested to see a brief information sheet that can replace verbal discussion about HIV testing and still deliver the recommended five main components of pre-test discussion.[1] I have tried...
Dear Editor
It appears as if the lesion is present on the dorsal aspect of the penis since the fingers at the root of the penis rotating it are not seen. Actually the lesion was present on the ventral aspect of the penis only. Since the penis was rotated by 90 degree at its root for easy photography, in the photograph it looks different. So the legend put for the figure is correct.
Dear Editor
I am grateful for Dr Watson's generous comments.
I agree that presenting an appropriate amount of written information to substitute for an HIV pre-test discussion is problematical. We introduced such a system with some misgivings but felt that it was the only way that we could comply with the Royal College of Physicians second Speciality Specific Standard without seriously disrupting the se...
Dear Editor
I agree with Dr Carne that the requirement to offer 90% (next year 100%) of our new patients an HIV test precludes us from offering everyone discussion about the HIV test as recommended by the UK Departments of Health in their Guidelines on HIV Pre-test Discussion.[1] However, the guidelines still include the statement that for, "individuals actively seeking an HIV test for the first occasion, here a...
Dear Editor
Nicola Low [1] is right to highlight the need to consider the number of HIV diagnoses made in Britain in each ethnic group in light of the size of that ethnic group.
For some years we have been told ad infinitum that the number of diagnoses of heterosexually acquired HIV has ‘out-stripped’ the number of homosexually acquired diagnoses, as if that indicated some kind of equivalence of impa...
Dear Editor
The article by Crucitti et al.[1] evaluated five PCR techniques for Trichomonas vaginalis including the one published by our group (Mayta et al. [2]). The authors however did not follow the protocol we published and so got results that we consider to be erroneous.
In our work we used simple Taq polymerase while Crucitti used Taq gold for this purpose. He did this without chang...
Dear Editor
The article on Pathways to HIV testing and care by black African and white patients in London is indeed very interesting.
However,I do not believe it takes into account the very real differences between the different African communities in London. The severe devastation and scale of the HIV/AIDS epidemic in Africa has not been felt uniformly across the continent.West African countries for whatev...
Dear Editor
The purpose of our study was to evaluate five different primer sets described in the literature for the amplification of Trichomonas vaginalis. We therefore used the same working conditions for the five primers sets, i.e. the same extraction method, thermocycler, reagents etc. It was not our aim to re-validate these primer sets.
For all of the five primer sets we used the AmpliTaq Gold poly...
Dear Editor
We read with interest the trichomonas review written by Swygard et al.[1]
Current BASHH and European STD guidelines for the management of trichomoniasis state that “tests of cure should be undertaken if the patient remains symptomatic following treatment, or if symptoms recur”.[2,3] No specific recommendations are made for the follow-up of patients who were asymptomatic at presentation. Sw...
Dear Editor
Dave et al's letter about the role of professionals in the HIV- outpatient setting is aposite and brings up many issues including who should end up doing this type of 'routine' work.[1] As always GPs are called in along with other professionals as possible options. However, communication amongst other problems, continue to be a big challenge.
I recently reviewed all the notes of the tw...
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