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Living dangerously in the Dominican Republic and Mexico City: can cash transfer payments be used to counteract the “risk premium”?

17 Dec, 14 | by Leslie Goode, Blogmaster

The Caribbean has the highest levels of HIV outside sub-Saharan Africa – and the Dominican Republic (DR), which together with Haiti accounts for 70% of all people living with HIV in the Caribbean region, is a hotspot.  While there has been a 73% reduction in the rate of new infections in the DR between 2001 and 2011, prevalence of HIV remains high among key populations of MSM (6%) and female sex-workers (3%).  A recent qualitative study has sought to investigate the relations between the drug trade, sex tourism, and risk taking which may hold the secret of the obstinately high-levels of HIV in these key populations (Guillamo-Ramos & Robles).  In-depth interviews, along with drug screening, were conducted with 30 local drug users in Sosua, known for its tourist sex industry.

Three major themes emerge.  First, drugs are freely available as a result of diversion from the major drug routes running from N to S America through the DR.  Second, they have become integral to the local tourist industry – specifically as a vital component of sex work.  Third, the engagement of locals, along with tourists, in commercial sex fuelled by drug use gives rise to the kind high-risk behaviours that sustain the spread of HIV in the local population.

What, from the public health angle, seems particularly challenging in this situation is that the element of risk-taking isn’t merely an incidental effect of the sexual activity; it is precisely the element that makes that activity attractive, and – from the locals’ point of view – lucrative.  Participants associate sex work and drug use with improved livelihood, and describe how risk behaviours are part of the economic negotiating process.

This is the same general kind of problem described in the reported base-line study of a pilot trial of an intervention among male sex workers in Mexico City (STI/Galarraga & Sosa-Rubi).  These male sex-workers are at particular risk of infection because they receive market-based inducements from clients to engage in condomless sex.  It is not simply that MSW are neglecting to take precautions; the average price for a sex transaction is 35% higher for condomless sex – and, given MSW may be unemployed (16%), or dependent for their income on sex work (37%), the economic pressures to engage in unsafe practices are considerable.

The Punto Seguro pilot trial, based at the Clinica Condesa, an HIV centre in Mexico City, is considering as a potential solution the idea of a conditional cash transfer (CCT) whereby MSW are rewarded for keeping themselves free of curable STIs over a six-month period.  Within Mexico CCT has been employed, since the 1990s to provide incentives for poor people to keep their children in school, and to attend preventative check-ups, though not apparently in the sphere of HIV.  In the US, however, it has been used to prevent persistent STIs and pregnancy amongst the Latino population (STI/Minnis & Padian), in Pakistan to encourage infected men to disclose to their wives, and have them tested (STI/Khan & Khan).

The paper sets out the procedures and the baseline data for investigating the effectiveness of a form of this kind of intervention.  The 267 participants have been randomized to four groups: control; medium conditional incentive ($50); high conditional incentive ($75); unconditional incentive ($50). Previous formative work established the incentive levels necessary for behaviour change ($156 per year).  It is also hoped that CCT interventions may benefit participants by helping to link them into care – since of the participants in the trial who knew they were infected with HIV, only 40% were on treated, and of these, only 61% had achieved viral suppression.

Heterosexual transmission of HPV to male oral tract via oral/genital route indicated by partner data

15 Dec, 14 | by Leslie Goode, Blogmaster

The UK Joint Committee for Vaccination and Immunization (JCVI) has not so far decided to extend HPV vaccination to boys, but this possibility remains under consideration (Public Health England Guidance on HPV 2014-15). The potential benefit of protecting males from face and neck cancer will be an important consideration, both in the UK and in other countries contemplating this extension of HPV vaccination programs (STI/Conway & Adams).  Some have attributed the recent tripling in number of cases of these cancers to oral HPV, thus transforming what was formerly a smokers’ disease into an STI outcome.  A figure of 2,000.has been placed on the total of HPV attributable cases in UK males.  Such claims – and their public health policy implications – confer a new importance on research into the risk factors of oral HPV infection among young men.

A recently reported sub-study taking place in the framework of the Montreal based HPV Infection and Transmission among Couples through Heterosexual Activity (HITCH) cohort study claims to be the first to have established the association of oral infection in males with sexual behaviour, not just on the basis of their reported sexual behaviour, but through the collection of data from their partners (Dahlstrom & Franco).   The study administered questionnaires and tests to 222 young men and their partners at baseline and four-months.

Prevalence of oral HPV among male study participants was 7.2%.  Of these 28.6% (2) were found to have a partner with oral HPV infection, and 11.5% (15) to have a partner with genital infection.  The study also investigated type-specific HPV prevalences.  The prevalence among the young men of oral HPV16 (especially associated with head and neck cancer) was 2.3% (5); among the 33 men who had a partner with genital HPV, prevalence was (6.1%) (2/33).  In a rough and ready way, this study also establishes a correlation of oral HPV prevalence in males with frequency of oral sex (RR 1.47 as between rarely/sometimes having oral sex & rarely/never having oral sex).  The potential advance on previous studies is that this correlation is seen to hold only where the partner is genital HPV positive.

The importance of these findings is, first, to corroborate, on the basis of partner data, the conclusion drawn by earlier studies of the relation of oral HPV with reported oral sex, that there is indeed transmission of HPV from the female partner to the male partner’s oral tract, whether through oral or genital routes.  Second, the association of deep kissing with oral HPV infection seen in earlier studies would seem to be confirmed by the higher prevalence among men with oral HPV of female partners with oral HPV.  However, the alternative explanation of auto-inoculation, indicated in the study data by the high prevalence of genital HPV in self, cannot be excluded (STI/Hernandez & Ning).  Third, the possibility of oral sex as a route of transmission is suggested by the increased prevalence of oral HPV among men with a genital HPV partner, and its relationship to frequency of oral sex.


Obituary of Denis Lambert Sugrue

27 Nov, 14 | by Leslie Goode, Blogmaster

Denis Lambert Sugrue

Dr D Sugrue photo

Denis Sugrue was born in Dublin on 10th March 1927. He had a happy childhood in Dublin with his parents, older sister and half-brother. He had a tremendous affection and pride for his father who was a decorated soldier of the First World War.

He was educated at the Catholic University School and Blackrock College. He commenced his medical studies in University College Dublin (UCD) in 1944. The following year he was awarded a Kitchener Scholarship. He qualified MB, BAO, Bch in 1950. He came to England to pursue postgraduate training in ENT. He obtained the DLORCS Eng. in 1953 and the MCH, National University of Ireland in 1954.

Having completed his postgraduate training studies, Denis decided to explore the field of plastic surgery and applied for the post of registrar at Rooksdown House. Three happy and instructive years were spent there, before Denis returned to Ireland. (His famous interview by Sir Harold Giles was recounted in the BMJ volume 314, 11th January 1997). He was appointed consultant plastic surgeon to the Children Hospital, Temple Street, Dublin and to the International Missionary Training Hospital, Drogheda where he pioneered plastic surgery and his work was recognised and published internationally.

At university Denis joined the Boat Club at UCD and he was most fortunate in being a participant in a successful era of UCD rowing, which culminated in 1948 with his selection to cox the Irish Olympic Eight in the London Olympic Games. In 2012 Denis was awarded the medal of honour from the Olympic Council of Ireland.

In 1968 Denis accepted the post of consultant plastic surgeon at the General Hospital in Tripoli, Kingdom of Libya, spending many months with the hospital architects and administrators planning a department of plastic surgery and a burns unit. Denis was invited to join the International Society of Burns Injuries. The work was challenging. He endeavoured to build a team of experts who could provide the appropriate reconstructive surgery. Unfortunately as a result of a radical change of regime, courtesy of Colonel Gaddafi, Denis found himself unceremoniously returned to England.

By now Denis had a wife and a young daughter, so it was urgent that he found employment and a consultant post as quickly as possible. To this end, he was advised to consider a change of speciality by a former mentor from Rooksdown House and thus an opportunity arose for an appointment at St Thomas’ Hospital in what was then classified as venereology. Subsequently, Denis was registrar and then senior registrar at Southampton for training in his new career. He was appointed as consultant venereologist to the North and Mid Staffordshire Hospitals in 1972.

The major task on his appointment was to upgrade the premises as a temporary measure, while pursuing a purpose built department within the main hospital complex, which was essential for recognition for higher training and recruitment. Nationally, there was a movement to change the image of the speciality of venereology which became genitourinary medicine. Denis was active in promoting this new vision and was a founder member as well as first president of the Midlands Society of Genitourinary Medicine.

Denis remained in his post in North Staffordshire Hospital until his retirement in 1992. He was dedicated to the care of his patients and only the best medical practice would suffice. He took delight in developing his staff and teaching his junior colleagues. He gave unflinching support, advice and friendship to his consultant colleagues; friendships that in many instances lasted his lifetime. He was considered by some as their godfather.

He found retirement very enjoyable and travelled frequently. His last trip was to Hong Kong to attend the wedding of his younger daughter in February 2012.

Denis was introduced to his wife Helen at the Hunter Trial held at Castletown House, Celbridge, Co. Kildare in March 1962 and they married in September that year.

Denis died peacefully on 23rd July 2014. He leaves his devoted wife Helen, two daughters, a granddaughter and a grandson.


Dr Taha Wanas FRCOG

Retired consultant in genitourinary medicine

The Royal Wolverhampton Hospitals NHS Trust

Tracking the origin, early spread, and ignition of pandemic #HIV-1 through new approaches to phylogenetic analysis

17 Nov, 14 | by Leslie Goode, Blogmaster

“Distribution of HIV-1 subtypes in a population”, state Mumtaz & Raddad (STI) in a study of the HIV pandemic in the Middle East, “tracks the spread and evolution of the epidemic”.  Various studies covered in our previous blogs have attempted to read the history of the progress of the HIV epidemic through the evidence of the distribution of HIV genetic sub-types: Tatem & Salemi (STI/blogs) have investigated its spread throughout Africa; Zhao & Roca (STI/blogs) pass beyond the human epidemic to consider the genetic evidence for repeated transmission from chimpanzees to humans.

Now Faria & Lemey (F&L), in a paper recently appearing in Science, offer an account of the critical early phase of limited spread within Central Africa and the ignition of pandemic HIV-1 around 1960, bringing statistical approaches to bear to HIV-1 sequence data.  F&L produce a time-scaled phylogenetic “tree” of HIV-1 group M lineages, matching these up in each case with the geographical location of their earliest manifestation.

This approach points to the very strong likelihood (PP = 0.99) of an origin of the HIV1 epidemic in Kinshasa around 1920. Study of lineage migration shows comparatively early spread from Kinshasa to Brazzaville (Republic of Congo (RC)), and Mbuji-Mayi and Lubumbashi (southern Democratic Republic of Congo (DRC)) along the railway network, and its arrival around a decade later in Bwamanda and Kisangani (northern DRC).  The crucial period around 1960 (1952-1968) sees, for group M HIV-1, an exponential growth in levels of M-group transmission, while growth in group O transmission remains at previous levels.

But the most interesting aspect of the study relates to conditions around the sudden surge in group M HIV-1 transmission, as indicated by the accelerated ramification of viral lineages during the crucial period.  The authors consider the hypothesis that associates this ramification with the geographic dispersal of the epidemic, with the lineages emerging in the more widely distributed populations now being infected.  They reject this hypothesis, however, on the grounds that, when the epidemic history of lineages maintaining ancestry within Kinshasa is constructed, these turn out to exhibit phylo-genetic characteristics that are comparable to those of lineages in central Africa.

They conclude that the crucial explosion of pandemic HIV-1 transmission probably occurred in Kinshasa as a result of a historic contingency affecting a particular population subgroup.  Prime contenders are iatrogenic transmission as a result of the administration of unsterilized injections at STI clinics, and/or post-independence changes in sexual behaviour e.g. among commercial sex-workers.  The authors find support for the iatrogenic hypothesis in a study of the hepatitis C virus in the DRC which shows that it exhibits an age cohort effect, and in reports of an epidemic of hepatitis B in Kinshasa around 1951-2.

Failed PrEP trial (VOICE) participants give reasons for their poor adherence

13 Nov, 14 | by Leslie Goode, Blogmaster

Despite indications of the acceptability of Pre-Exposure Prophylaxis (PrEP) among certain populations (MSM in London (STI/Aghaizu & Nardone) 2013, and Australia (STI/Holt & De Wit) 2012), the extremely varied results that have emanated from large studies seeking to determine its efficacy and effectiveness as a preventative intervention remain a concern.  To name the most important examples, levels of risk-reduction were estimated as follows: CAPRISA 004 – 39%; iPrEX – 44%; CDC TDF2 – 62%; Partners-PrEP – 75%; FEM-PrEP – 0%; VOICE– 0%.  The reasons for this variation have been the topic of a number of contributions to this blog (especially: STI/blogs/Hendrix & Bumpus; STI/blogs/Haberer & Bangsberg), with consensus tending towards the poor adherence of study participants.

Last week in Cape Town results were briefly reported from a sub-study (VOICE D) of one of the less successful of these trials (VOICE). Microbicide Trials Network’s (MTN) VOICE study, discontinued in 2011, trialled daily tenofovir, in the form of vaginal gel or tablet, in 5,029 (mostly young) women from a representative range of sub-Saharan countries – S. Africa, Zimbabwe and Uganda. On the basis of self-reporting measures in the original VOICE trial, levels of adherence to the tenofovir regime had been estimated at 90%.  However, blood samples taken from participants found evidence of the drug in less of a third of the participants in the tablet arm, and less of a quarter of the participants in the gel arm, of the study.

After the closure of the VOICE study itself, the sub-study, VOICE D, engaged 127 former VOICE participants in in-depth interviews at which they were challenged with evidence of their poor adherence – with a view to stimulating frank discussion. When confronted with the evidence of blood tests, poor adherers initially expressed surprise and disbelief. Yet, according to the report, the aim of engaging frank discussion would seem to have been met.  The reason most frequently given was fear of the side effects of the drug, fuelled by peer participants and relatives and by the negative attitudes of community members.

Current trials of PrEP have re-evaluated and strengthened efforts to enhance adherence in the light of previous failures.  These include: the Follow-on African Consortium for Tenofovir Studies’ FACTS 001 (tenofovir gel before and after sex), the MTN’s ASPIRE and the International Microbial Partnership’s Ring Study (both the latter of vaginal ring releasing the ARV drug dapivirine) (MTN Trials). It is interesting that the Partners-PrEP study incorporated intensive “adherence interventions” for participants whose adherence levels fell below 80% (STI/blogs/Haberer & Bangsberg).

However, the VOICE D results may have implications for the usefulness of PrEP interventions more generally. At the very least, they discredit any idea that PrEP is able to offer a panacea. The value of PrEP, relative to other preventative interventions, is a contentious issue.  STI/Mukandavire & Vickerman (2013), for example, conclude that a scale-up of condom use is in most circumstances likely to be more effective than PrEP, but that PrEP could have a specific application in the case of female sex workers. STI/Verguet & Walsh (2012) see a future for PrEP in sub-Saharan countries with high HIV prevalence and without circumcision practice, such as S. Africa.  STI/Ying & Barnabas (2013) see targeted PrEP as a cost-effective addition to ARV.


“Hispanic” label masks the specificity of the Puerto Rican #HIV problem in US Northeast

12 Nov, 14 | by Leslie Goode, Blogmaster

Interventions for HIV prevention should be informed by an understanding of the long-term source of infection, and not just by recent distribution (Mishra & Boily (STIs)).  Amongst recent studies that have sought to inform future interventions are investigations of known subgroups thought to be a potential bridge into the wider population – such as migrant workers, or sex workers (STI/Kissinger & Shedlin; STI/Faisel & Cleland).  There are other investigations that seek to refine on the definition of such groups (STIs/Davies & Tucker; STIs/Bayer & Coates).  But could there be instances where classifications established for the purposes of data collection actually mask the existence of the groups that could have epidemiological importance?

Puerto Ricans in the north-east of the US may be an interesting case in point.  A recent article (Deren & Santiago-Negron(D&S)) claims that the classification “Hispanic”, generally applied to Puerto Ricans for the purpose of data collection, may have obfuscated the distinctiveness of a Puerto Rican subgroup with its own specific risk profile, and considerable unmet medical health needs.   As though to illustrate the point, D&S assemble various data relating to strong correlations, for example: between AIDS diagnosis and being Hispanic; between residence in the North East of the US and IDU-associated HIV; between HIV incidence and being a Hispanic IDU.  Cumulatively – and taken along with the concentration of Puerto Ricans in the NE, and what is known of the high incidence of IDU-associated HIV in Puerto Rico itself – these data indicate the probability of a strong association, at least for the US North Eastern states, between Puerto Rican Hispanic identity and a high risk of drug-derived or heterosexually-transmitted HIV.  Furthermore, it is not only the subgroup of US Porto Ricans that have tended to slip under the net, according to D & J; high levels of IDU-transmitted HIV in the island of Puerto Rico itself have failed to attract due attention, on account of the peculiar status of Puerto Rico – which is a US territory, without being a US state.  As a result, Puerto Rico tends to figure neither in statistics for the Caribbean (as a US territory), nor in statistics for the US (since it is not a US state).

For Puerto Ricans – with an AIDS fatality at six times the US average and rates of new IDU and heterosexual infection twice that of the US – the problems of their anomalous status do not end with inadequate reporting.   Budgets for syringe exchange programs (SEPs) are only a fifth of what they are in the US Northeast, while Puerto Rican IDUs are only a fifth as likely to be in treatment.  SEP schemes cannot be funded by the US federal government, while the local Puerto Rican response to the drugs problem has, until recently, been largely provided through faith-based programs, with addiction defined by the Mental Health Law (2000) as a spiritual and social problem rather than a mental disorder.  Relocation to the US Northeast for drug treatment has become a commonly recommended option, with 85% of Puerto Rican admission to drug treatment taking place in the US Northeast.

In view of all this, D&S recommend partnership between federal, local and private entities to develop a cross-regional approach to the Puerto-Rican epidemic.  They also point out the challenges posed for such an approach by the unique status of Puerto Rico as a territory, without the full representation available to states in the Northeast.

“Fast-tracking” the end of the HIV epidemic

8 Oct, 14 | by Leslie Goode, Blogmaster

At a high-level event on the margin of the UN General Assembly meeting in New York last month, convened with the support of UNAIDS, world leaders agreed that ending the AIDS epidemic as a global threat by 2030 was possible, and should be placed at the centre of health development goals.  The brochure, Fast Track (7 pages), sets out the agreed proposals.  The context of the agreement is the General Assembly’s discussion of 17 Sustainable Development Goals for 2015-2030 to replace the Millenium Development Goals that are due to expire in 2015 – and, more specifically, the formulation of targets to accompany the Sustainable Development Goal for health: “To ensure health lives and promote well-being for all at all ages”.  The week before the UN General Assembly saw the early online publication of a paper by 16 international experts (Norheim & Peto)  proposing as a “feasible goal” the overall reduction of pre-mature deaths by 40% – including, as an important element, a reduction by two-thirds of deaths due to HIV.

The proposals contained in Fast Track are in line with the most radical response scenario set out in pp.291-3 of the UNAIDS GAP report (July 2014), involving reduction of new adult infections to 500,000 by 2020, and 200,000 by 2030.  Also reminiscent of the earlier document is the sense of the tide of the epidemic having turned, and of its increasing concentration within the cities of 30 or so nations – and, more specifically, within fairly specific populations of those cities, such as sex workers, intravenous drug-users, etc..  This concentration represents both a challenge and an opportunity (STI/blogs/UNAIDS GAP report).  The new element in Fast Track is a three-fold target of 90%: for the proportion of those infected should know their HIV status, the proportion of those knowing their HIV status who receive anti-retroviral therapy, and the proportion of those on therapy who achieve undetectable levels of viral load – all by 2030.  A glance back at the GAP report itself reveals what a challenge this is likely to be (e.g. at present, 3 in 5 of HIV infected not receiving ART).

Also timed to coincide with the proposals (25th September) was the announcement of a scheme to expand access to viral load testing through an agreement affecting the pharmaceutical Roche’s COBAS® AmpliPrep/COBAS TaqMan HIV-1 Test version 2.0 (see STI/Hatzakis & Kantzanou).  Access to viral load testing is essential to monitoring of HIV-infected people (STI/Hill & Minton), and its high cost has been an obstacle to progress in low and middle income companies up until now.  The new agreement may smooth the way to the achievement of the ambitious targets set out in Fast Track.

Population-based evidence for the preventative efficacy of quadrivalent HPV in Australia

30 Sep, 14 | by Leslie Goode, Blogmaster

The HPV vaccination programmes introduced by many countries over the last few years (since 2007) reveal considerable diversity in the coverage they have achieved, the mode of access (i.e. school, public health, private clinics) and responsibility for cost (i.e. publically vv. privately funded) – even in Europe (see ECDC Guidance).  In the light of the known efficacy of the vaccine, implementation has seemed frustratingly slow – partly, in some cases, due to ungrounded negative public perceptions around safety (e.g. in Japan where the national programme was actually suspended) and the impact on sexual mores (e.g. in the US).  Early indicators of its positive health impacts in countries like Australia – where implementation was early (2007) and wholehearted – are therefore to be welcomed, as favouring the implementation of programmes in the future.  In the absence of evidence of the reduction of cervical and other cancers, evidence of the effectiveness of the quadrivalent vaccine against warts – from clinics (STI/Donovan & Fairley; STI/Garland & Jayasinghe; STI/Fairley & Bradshaw), or pharmacists (STI/Wilson & Baker) – or evidence for the reduction of cervical abnormalities (STI/blogs/Brogly & Yang) – may offer a proxy.

Smith & Canfell (S&C), recently published in Journal of Infectious Diseases, claim to provide the first whole population analysis of the impact on genital warts of a national HPV vaccination programme – and this may be the best predictor of the longer-term, and more important, cancer prevention benefits to be seen in future years.  It is no surprise it derives from Australia, the first (2007) country to introduce routine school-based vaccination of 12-13 yr girls, plus catch-up through to 2009 for girls 13-17 yrs in schools, and young women 18-26 yrs in primary care. Earlier studies in Australia largely relied on data from sexual health clinics; this study is based on national data of all hospital episodes 1999-2011 involving a diagnosis of genital warts.

The findings of S&C show a decline of 89.9% in admissions involving warts from 2006/7 to 2010/11 for girls aged 12-17 yrs, a decline of 72.7% for women aged 18-26, and a decline of 38% for men aged 18-14 (the indirect effect of female vaccination).  The decline of cases in the 18-28 age group occurs from mid-2008. Other age groups do not show the same sharp decline, nor do MSM – to judge from the fact that the decline exclusively concerns warts in non-anal location.

An issue of particular concern to Australia, and one that consequently receives considerable attention in this study, is the impact on the indigenous population, where incidence and mortality rates for cervical cancer are, respectively, 2.8 and 4.7 times higher for the indigenous as for the non-indigenous population.  Reductions for indigenous and non-indigenous females appear to be similar (86.7% and 76.1% respectively) – which is curious, given that data for two Australian states indicate lower rates of course completion (3 doses) by indigenous females.  If the same tendency in uptake were replicated in the other Australian states (which we don’t know) this might suggest the efficacy of ≤2 dose courses of therapy.  Such a result would corroborate the findings of a recent study covered in this blog (STI/blogs/”Catch up” and incomplete HPV vaccination), which investigates the efficacy of ≤2 dose courses of therapy also in the context of socially disadvantaged groups.


Missed HPV vaccination opportunities: a consequence of avoiding awkward conversations

15 Sep, 14 | by Leslie Goode, Blogmaster

In the US, routine administration of quadrivalent HPV vaccine is recommended for girls and boys at 11-12 yrs, with catch-up vaccination recommended up to 26 yrs for girls, and 21 yrs for boys.  The difficulty has been in the implementation of the recommendation: overall rates of initiating and completion among US teenage girls currently stand at 57% and 35% respectively, according to data from NIS-Teen (CDC/MMWR 25.7.14).  This is of particular of concern, since there is evidence both from the US and from the UK that those most at risk (e.g. ethnic minorities) happen also to be those who are most likely to miss out on vaccination (STI/Niccola & Hadler; STI/Sacks & Robinson; STI/Liddon & Hadler). What is the reason for this poor uptake?  NIS-Teen, on the basis of recent survey evidence, claim that the lack of strong provider recommendation may often lead to missed vaccination opportunities (STI/blogs/”catch-up”).  (Kepka & Seraya (STIs) discuss the difficulty of ensuring the conformity of providers with HPV guidelines).  Yet, how, in practice, do these missed vaccination opportunities occur between well intentioned parents and providers who wish to protect adolescents from developing cancer as adults?

A recent qualitative study (Perkins & Pierre-Joseph), based on interviews with 124 parents/guardians and 37 providers in one large public clinic and three smaller private ones, offers an illuminating insight into the conversational moves characterizing the kind of real-life discussions between provider and parent that lead to missed opportunities – most often through the decision to delay the initiation of HPV vaccination.  The report analyzes these in considerable detail.  Typically, however, it is a question of a “complicity” between the conversational partners in respect to broaching the topic of the daughter’s sexual behaviour, taking the form of a tacit agreement to postpone the discussion about vaccination until a more appropriate time.  The script generally runs: “My doctor asked me if I thought if she was sexually active and I said no and then she said that there was plenty of time”.

The authors’ recommendations, based on the strategy of providers achieving rates of ≥ 80%, are: co-adminstration with tetanus and meningococcal vaccine, focussing on cancer prevention benefits and vaccine safety, and expressing a strong recommendation (i.e. “expecting a yes”) – in short, routinizing and normalizing HPV vaccination.

Not the least interesting aspect of their findings was the very considerably greater success of the ethnically diverse public clinic as against the majority white private clinics in initiating vaccination (77% vv. 54%, according to the electronic medical record).  More can be less, it would seem, when it comes to certain public health interventions.


“Catch-up” and incomplete HPV vaccination better than nothing

26 Aug, 14 | by Leslie Goode, Blogmaster

Quadrivalent HPV vaccine (HPV4) has been shown to protect against HPV types 16 & 18, which cause 70% of cervical cancers, and HPV types 6 & 11, which cause 90% of genital warts.  Health authorities in the US and elsewhere have therefore recommended routine vaccination of girls (and more recently boys) at ages 11 & 12, and “catch-up” vaccination for women aged 13 to 26. Vaccination programmes in New Zealand (STIs/Read & Fairley) and Australia (STIs/Fairley and Bradshaw) have indicated what can be achieved, given adequate coverage.

For the US and elsewhere there remains a problem of ensuring coverage.  Recent figures from the US Centers for Disease Control and Prevention National Immunization Survey-Teen (NIS-Teen) for 13-17 year-olds ≥1 dose quadrivalent or bivalent vaccine, CDC/MMWR 25.7.14, show levels that remain obstinately low despite year on year improvement, rising from 53.8% to 57.3% (girls), and from 20.8% to 34.6% (boys) between 2012 and 2013.  By comparison, UK uptake on the first 3 years of its programme was 66% (STIs/Sacks & Robinson).  The low US rate is of particular concern because there is considerable evidence from the US and UK that it is often those who are most at risk, such as racial and ethnic minorities, who are most likely to miss out on vaccination (STIs/Niccola & Hadler; STIs/Sacks & Robinson; STIs/Liddon & Hadler).  Tantalizingly, the Report estimates at 91.3% the coverage for ≥1 dose by age 13, if HPV vaccine had been administered to adolescent girls born in 2000 during health care visits when they received another vaccine.

This, of course, raises the question why this opportunity is being missed.  The authors cite the disquieting datum that, when NIS-Teen asked parents to identify reasons for non-vaccination, one third of parents of girls and over half of parents of boys reported that their child’s clinician had not recommended  that their child receive an HPV vaccination.  They therefore point to the need to address gaps in clinician knowledge and communication skills as well as parental knowledge.  A discussion of apparent difficulty of ensuring the conformity of providers to HPV guidelines has already been discussed by STIs/Kepka & Seraya.


Given poor levels of uptake at age 11-12, especially among some of the needier populations, it becomes important to know the effectiveness of catch-up vaccination and incomplete vaccination.  This is made very evident in a recent US cross-sectional study, Brogly & Shi Yang (B&Y), of the relation of cervical abnormalities to HPV vaccination status amongst 235 minority women undergoing routine cervical cytology testing.  Only 54% of these had initiated, and only 33% completed, vaccination – and of those vaccinated, only 3% had received the vaccination before sexual debut.  Their results appear to show that even a tardy, and frequently incomplete, HPV vaccination confers significant benefits on individual women.  Abnormalities (ASCUS, LSIL or HSIL) proved to be considerably reduced amongst the vaccinated group, even where participants had not completed the full course of three injections – RR 0.35 for ≥1 dose as against no vaccination; RR 0.45 for 1-2 doses as against no vaccination; RR 0.26 for completed vaccine as against no vaccination.  If corroborated in further studies, these findings could reinforce argument in favour of the effectiveness of HPV catch-up against those have placed this in doubt (STs/Chesson & Markowitz).

The study also aimed to examine the relationship between vaccination status and HPV genotype, but the sample size was too small to establish anything very conclusive.  STIs/Nielsen & Kjaer claim to demonstrate, with a far larger Danish sample, that low-risk types are frequent in ASCUS lesions, but scarcely ever occur in isolation from high-risk HPV types, where the lesions are more severe.

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