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Mathematical models say: switching to HPV nonavalent vaccine brings cost benefits.

20 Jun, 16 | by Leslie Goode, Blogmaster

STI journal issues of nearly a decade ago, when HPV vaccination was a relatively new thing, hosted a discussion on the issue of which vaccine to choose. The choice at that time, readers will remember, was between GSK’s Cervarix 2vHPV and Merck’s Gardasil 4vHPV (Morris/STIs)*.  Now, the introduction of a third alternative, Gardasil (9vHPV), seems to have fuelled a similar burst of activity amongst mathematical modellers – at least in the US, where the new vaccine was licensed in 2014.

Gardasil 9vHPV elicits immunity to nine oncogenic (i.e. associated with cancer) serotypes – i.e. five more serotypes than Gardasil 4vHPV, and seven more than Cervatrix 2vHPV.  The nonavalent vaccine (9vHPV) is expected to extend protection from >66% to 80% of cervical cancers.  It will also, it should not be forgotten, have some benefit in preventing HPV-related oropharygneal cancers (Field and Lechner/STIs).  However, Gardasil 9vHPV is approximately $13 per dose more expensive than Gardasil 4vHPV, and $18 more expensive than Cervatrix 2vHPV.  In 2015 the US Centers for Disease Control and Prevention (CDC) recommended vaccination with any of the three alternatives for females aged 9-26yrs, and with 4vHPV or 9vHPV for males aged 11-21yrs.

Once again, then, the question of the relative cost-effectiveness of HPV vaccines raises its head – this time in the US, and in connection with a possible switch from 4vHPV and 2vHPV to 9HPV as the vaccine of choice. Mathematical modellers in the US have risen to the challenge in at least two recent studies.  Brisson & Markowitz conclude that making the switch would be cost-effective ‘under most scenarios’ (Chesson & Saraiya/STIs; Brisson & Markowitz).  Now, Durham and Galvani (D&G), in another US modelling study, have reached the same conclusion.  Not content, however, with a response for current levels of vaccination coverage, they also consider the impact on cost-effectiveness of raising national coverage with 9vHPV to higher levels.  This requires them to take into account the effect of herd-immunity, which ensures that returns on investment diminish to the extent that higher levels of coverage have already been achieved.  They also consider the relative cost-effectiveness of distributing the investment in 9vHPV vaccination in such a way as to bring up the vaccination levels in states where it is low (e.g. Arkansas, Missisipi, Missouri, Kansas) towards the levels already achieved in other states (e.g. Illinois, Montana, N. Carolina, Washington DC), as against that of an even distribution.  (At present, state vaccination rates vary between 20-57% for females, and between 9-43% for males – though inter-state migration rates are such that 29-84% of the long-term health benefits of vaccination will be realized by beyond the boundaries of the state where vaccination took place).

The findings of the study are as follows.  9vHPV is cost-effective – as compared with the alternatives – at any level of coverage.  Comprehensively switching to 9vHPV would yield the same benefit as raising levels of coverage with existing vaccines across the population of the US by 11%.  Second, assuming a comprehensive switch to 9vHPV: a national increase in coverage of 10% would show an incremental cost-effectiveness ratio (ICER) corresponding to a willingness to pay (WTP) of $40,000 per QALY, and increases of 20%, or 40%, ICERs equivalent to WTPs of $53,000 and $106,000, respectively.  Finally, the figure of $40,000 WPT per QALY given above represents only an average, since, in practice, the cost-benefit of an increase of 10% in coverage would differ widely between states with low current levels of coverage, like Arkansas, where the cost-benefit would be around $13,500, and states with high levels, like California, where it would be around $56,400. The authors therefore advocate focussing the investment needed to achieve increases in coverage on states that currently have low levels of coverage.

  • a previous version of this blog mistakenly mistakenly gave the names of the manufacturers of Gardasil and Cervarix as GSK and Merck respectively.  The mistake has recently been brought to our attention, and the manufacturers as given in the emended blog (23.6.16) are the correct ones. (Blogmaster)

Is the UK meeting its national guidelines for HIV testing of MSM?

9 May, 16 | by Leslie Goode, Blogmaster

The potential role of frequent HIV testing in curbing the HIV epidemic among the MSM population has long been recognized. The introduction of the strategy of ‘opt-out’ testing in the UK (2007), as in other countries at around the same time, brought a steep rise in testing, followed by stabilization (McDaid & Hart (STIs); Saxton & Hughes (STIs) (for New Zealand); Heijman & Prins (STIs)  (Netherlands)), and may now ‘have reached its limit in maximizing routine uptake’ (McDaid & Flowers).  Nonetheless, amongst UK MSM at least, HIV incidence is not declining.  UK guidelines currently recommend annual HIV testing for MSM, and three-monthly testing for those ‘at higher risk’.  But how far are these goals being met?  An audit conducted in UK GUM clinics (Desai & Suillivan/STIs) was reassuring;  but a recent (2013) cross-sectional survey of gay bars in Glasgow reports levels of HIV testing over the previous six months of only 37%, and a relatively high proportion of ‘high-risk’ takers figuring among those who had never tested (OR: 0.51)( McDaid & Flowers (STIs)).

Last month saw the publication of study (McDaid & Flowers (M&F)) based on data from three cross-sectional surveys – Glasgow/Edinburgh gay commercial venues; an internet-based Scotland-wide survey; London gay social venues – and including 2409 MSM in total.  Frequency of testing was reckoned over a two-year period, and classified as ‘one or less’, ‘two or three times’, or ‘four or more times’.  On this basis, the study estimates the proportion testing annually at only 54.9%  – and the proportion of those reporting higher risk unprotected anal intercourse (UAI) (=37.8% of the total) who tested four or more times at only 26.7%.  So neither in respect to MSM in general, nor in respect to those ‘at high risk’ are the UK national guidelines being met.  Moreover, involvement in higher risk UAI – unlike number of sexual partners and AI partners – turns out not to be significantly correlated with the highest rates of testing; while more of those reporting higher risk activities claimed to have tested as a result of a perceived risk event, rather than as part of a regular check-up.  The authors conjecture the episodes of higher risk UAI may have been less frequent events (albeit reported by a third of participants) after which the participants, being risk-aware, took appropriate preventative action.  This seems a plausible interpretation.

Studies of HIV testing in other countries published in STI Journal seem to show a broadly comparable situation, with testing levels for MSM and high-risk MSM consistently falling short of respective national guidelines.  Thus Saxton & Hughes (STIs) in location based surveys in Auckland report levels of MSM annual testing rising slowly to 50% in 2011; while Guy & Hellard (STIs) surveying testing in Australian GP clinics give figures for annual testing by MSM, and high-risk MSM, of 35% and 15% respectively as of 2010.  As for the US, Katz & Stekler (STIs) report levels of annual testing of 77%, but, as the location of this survey was GP clinics, an appropriate UK comparator would be the study reported by Desai & Suillivan/STIs, which reports levels of 92%.

In their recommendations M&F stress the importance of reducing the known barriers to HIV testing, and also draw our attention to the key role that testing will have in facilitating the effectiveness of future PrEP interventions, given the need for participants in PrEP to have an accurate knowledge of their HIV status.



Can a case be made for opportunistic testing for Chlamydia?

6 May, 16 | by Leslie Goode, Blogmaster

Last month saw the publication of a revised Guidance on Chlamydia Control in Europe (2016) by the European Centre for Disease Prevention and Control.  This replaces the earlier Guidance on Chlamydia Control in Europe (2009) – though the 2016 document refers the reader to the 2009 one for more detailed descriptions of the epidemiology of the infection in Europe, and of prevention programmes in the various states.  The 2016 Guidance displays a distinct change in tone from the earlier document, reflecting greater scepticism as to the feasibility of an ‘effective Chlamydia control strategy’ and abandoning the earlier ‘step-by-step’ presentation with its suggestion of ascending levels culminating in register-based screening.  The changes concern primarily opportunistic testing and screening (formerly levels C and D in the ascending sequence).  These interventions are now recommended only ‘if resources are available’.

So what sort of case can be made for Chlamydia prevention interventions that go beyond primary prevention to at-risk individuals, evidence-based case management, and partner notification?

In favour of asymptomatic testing it is sometimes argued that the sequelae of Chlamydia such as Pelvic Inflammatory Disease (PID), ectopic pregnancy and tubal infertility largely occur in patients who have experienced only asymptomatic infection; so interventions restricted to treating symptomatic patients and their partners are likely to have limited impact on the prevention of complications (see Low, and response by Joan M. Chow).  On the other hand, it has proved very difficult, in practice, to come up with opportunistic testing interventions that can be shown to be effective (see Low).  As far as concerns the population level impact of such interventions, it seems unreasonable, on current evidence, to expect that they would ever be able to achieve sufficiently high levels of coverage.  However, If we limit our interest to their impact at the individual level, the effectiveness of opportunistic testing turns out to be very difficult to evaluate, because insufficient is known, amongst other things, about the risk of Chlamydia progressing to complications.  And without knowing more about the effectiveness of interventions, it is difficult to produce a robust evaluation of their cost effectiveness.

Some attempts have been made, however.  De Wit & Kretzschmar/STIs (D&K) model various screening scenarios on the basis of data from a three year annual screening programme in an area of the Netherlands that was genuinely register-based – as opposed to the opportunistic testing undertaken by the so-called ‘screening’ programme in the UK.  Andersen & Valkengoed/STIs (A&V) report on the Danish ‘register’ study which randomly assigned 9000 from the public register either to be invited or not invited for a Chlamydia test, and then followed up both arms for Chlamydia sequelae over a nine-year period.  From neither study are the results particularly encouraging.  D&K estimate cost effectiveness, on the most favourable scenario, at over $50,000 per QALY; while A&V report no benefit from participation in the intervention arm which received invitation to a Chlamydia test.

As for opportunistic testing, Johnson & Cassell/STIs (J&C) compare the various institutional settings involved in UK national programme in respect to the number of tests performed and the rates of positivity – as do den Heijer & Dukers- Muijrers/STIs (d&D) for the South Limburg area of the Netherlands in study on a registered based intervention (see also Woodhall & Saunders/STIs).  J&C remark on the relative importance for women of healthcare-based settings along with youth centres, both as regards number of tests performed and positivity.  This happens to agree with the findings of d&D who report 71% of female positive diagnoses in healthcare settings.  For men, non-healthcare related institutional settings were popular, but had considerably lower rates of positivity than healthcare-related settings.

Overall, these papers seem to indicate the likely effectiveness of opportunistic testing through enhanced testing services in healthcare-related settings –a solution that might be achievable without undue cost through existing health services.


Improving Partner Notification with a new online tool from SXT Health CIC – by Anatole Menon-Johansson

5 May, 16 | by Jackie Cassell, Editor of STI

Improving levels of partner notification (PN) is key to reducing the transmission of STIs in the UK, but doing so has proved to be difficult, time consuming, and expensive for many. As few as 25% of sexual health care providers achieve the BASHH target of 0.6 partners seen for every patient diagnosed with an STI [1]. It’s a frustrating situation, but one that could be improved by harnessing the power of modern communications technology in the right way.


Extremely interesting work has already been done in this area, in the UK. In particular on Accelerated Partner Therapy (APT) [2], in which two proactive approaches towards PN have been modelled, shown to work, and to be regulation compliant. These approaches employ many non-standard techniques, including, for example, the use of SMS technology to send PIN numbers to partners. Unfortunately trials of APT have come up against significant recruitment problems and the results have been disappointing, but the new ideas and possibilities APT raises, deserve to be developed further.


This is what we, at SXT Health Community Interest Company (CIC) have been doing. We are a London-based social enterprise, run by sexual and reproductive health professionals, whose sponsors include Public Health England and Big Issue Invest. Our website,, already functions as an online signposting service, directing individuals to the right sexual and reproductive health services, based on their needs and preferences. We have just launched our interactive digital Contact Slip (idCS) – a new PN tool, carried on our website, which allows patients to decide how they want to inform sexual partners of an STI diagnosis. They can choose to do so anonymously or not, by email or text, within the clinic setting (helped by the clinician), or in private. The system gives the partner an ID number and helps them find an appropriate local clinic. It informs that clinic wherever they are in the UK (via the ID number) what the partner has been exposed to and when. It collates information on PN effectiveness (how many have been informed, seen by a health care worker) in one place. And it does all this without storing any personal information about the individuals involved.


We have been running a live pilot of our idCS in Lambeth and Southwark, through providers such as Guy’s & St Thomas’ NHS Foundation Trust (GSTT), King’s College Hospital, SH:24, Burrell Street Clinic and Brook Clinic. Although we know we have a lot more work to do to improve the way the tool works, and to train the staff using it, we have had some encouraging results. Our tool already bears comparison with a more fully developed tool from the Netherlands, which was the subject of a cross sectional pilot study in 2012 [3]. The Dutch tool ‘Suggest-a-test’ (SAT), functioned in a similar way to our idCS – key differences being that it gave index patients the option of delivering PN via postal letter and gay dating site (as well as SMS and email); it named the STI in the initial notification (our idCS tells the partner that they have come into contact with ‘an STI’ – a clinic then uses our ID number to discover which one); and it asked partners to print their code and bring it to the STI testing centre (we assume that partners will be able to show the ID number in the email/SMS show via their smartphones). There are also, altogether, fewer steps to go through with our idCS – so that it can take as little as 60 minutes between a partner being told and being tested. The Dutch (SAT), and our (idCS) results so far, are summarized below.


PN tool

being used









Partners opened

Link (%PT)

Partners seen in clinic (%PT) No. of clinics partners seen in
SAT (91/7) 67 402 213 (53) 124 (56) 45 (20) 2


203 426 149 (35) 90 (60) 35 (23) 14


We are encouraged that the % of contacts opening our link, and then being seen in clinic, are both slightly higher than in the case of SAT. Before our idCS undergoes a fully evaluated trial, we want to improve on these figures, and also address the markedly lower % of ‘Partners Told’ via our tool, compared with SAT. We hope that by doing so, our tool will ultimately out-perform SAT.


To increase number of ‘Partners Told’ via our idCS, we plan to encourage those staff currently trialing the tool to offer provider led PN (which is so far yielding much better results than patient initiated notification). We plan to introduce online training module for the staff currently using the tool. We also plan to use digital signage & marketing in clinics outlining the benefits of PN to patients, and priming them to expect to be asked about this in their consultation.


We hope that after refinement, testing and full evaluation, the idCS will come to be seen as an indispensible tool for the health care worker delivering PN – something that will take some of the more time-consuming aspects of the process out of their hands (the sending of notifications, the tracking of outcomes), that’ll increase their chances of success (with more options to offer patients, including an anonymous embarrassment-free way of telling partners) and will free them up to do the side of their job no online tool can do better than them – the counseling, and informed decision making. We anticipate that our idCS will save health care providers money. Current PN methods are estimated to be (in the case of Chlamydia) between £9-27 per positive index case [1], not including testing or treatment. Our tool will be available to providers at a cost of £2 per index patient they expect to diagnose annually. By taking PN online, and automating those parts of the process that can be automated, we believe we can cut costs, standardize the process across the country, improve data management, and, most important of all, improve PN rates.



1 Turner K, Adams E, Grant A, et al. Costs and cost effectiveness of different strategies for chlamydia screening and partner notification: an economic and mathematical modelling study. BMJ 2011;342:c7250


2 Estcourt CS, Sutcliffe LJ, Copas A, et al. Developing and testing accelerated partner therapy for partner notification for people with genital Chlamydia trachomatis diagnosed in primary care: a pilot randomised controlled trial. Sex Transm Infect 2015;91:548-554


3 Hannelore M Gotz, Martijn S van Rooijen, Pjer Vriens, et al. Initial evaluation of use of an online partner notification tool for STI, called ‘suggest a test’: a cross sectional pilot study. Sex Transm Infect 2014;90(3)195-200

Correction to Gotz et al. 90(3):195


Are you struggling to write for publication? Some great tips from @NatalieEdelman

1 Apr, 16 | by Jackie Cassell, Editor of STI

Academic writing hasn’t come easily to me and I’ve come to realise that learning to write – like most things – is something we never really stop doing. Doing a PhD has given me a great opportunity to think about and improve how I write for academic publication. Here are my top tips:

1. Start to enjoy writing
By changing my expectations of the writing process, and by giving the subject some time and attention, I have genuinely experienced a change in how I feel about academic writing. There are undoubtedly many things you can identify to make your own experience of writing more enjoyable, and taking time to work out what suits you best is a really worthwhile pursuit. ‘Enjoy writing’ is kind of a meta-tip. The tips that follow are all things that have helped me enjoy the process, and to write better along the way….

2. Recognise that academic writing is a form of professional writing
Realising that academic writing is a professional skill has really helped me. I don’t like feeling stupid, and academic writing – because I don’t get it ‘right first time’ – used to make me feel pretty stupid. Therefore I didn’t enjoy writing. But producing a professional level of writing means the bar is set pretty high. Keeping this in mind has stopped me feeling stupid, and has helped me to accept that writing at a professional level is a skill that takes everyone time to develop.

3. Accept that you won’t get it right the first time
People always said this sort of thing to me, and I assumed they were just trying to make me feel better. But it turns out they were just trying to tell me something that is true. No-one sits down and writes a paper, grant or proposal perfectly the first time. This isn’t about lowering your expectations of yourself (which tip no.2 relates to). This is about changing your expectations of the writing process itself. Producing a ‘good’ piece of writing is an iterative process, fact. Once you accept that it’s SUPPOSED to be that way, your attitude towards your less-than-immediately-perfect writing will start to shift.

4. Break it down
A blank sheet is always intimidating, but easily populated by sub-headings. If you’re writing up a piece of research there will be a clear structure to follow (and most journals will specify the sections and even sub-headings they want used). There’s lots of good advice out there on how to write up research, particularly on the order in which you should write those sections – for example most advice suggests that you write the introduction last. Within each section you can then begin to jot down what you need to say and to create a sequence for them – again there are some great articles out there about how to do this and a lot of academic convention which you can follow e.g. This leaves you with a much more manageable task- a series of paragraph headings that need completing.

5. Take every opportunity to learn
The more you write the more confidence you will have and the greater your ability will be. So while you’re writing – or perhaps just thinking about – that paper, take every opportunity to practice your writing. This could include writing up reports and audits, writing opinion pieces for clinical journals, contributing to guidelines and/or writing for its own sake (see the next tip). Also, take opportunities to read the academic writing of others. This could include reading drafts or proofs of others’ papers, grants or offering to act as a reviewer for a nascent journal in your field. It is almost impossible to read without forming some sort of critique – notice what is good and what could be improved about what you’re reading and remember those points when you put pen to paper.

6. Discover that writing leads to insight
When we get the chance to discuss our research or ideas it’s really helpful, and insights and solutions often present themselves as we talk. But opportunities to do this, particularly in a clinical environment, may be hard to realise.

But the wonderful thing is that writing about an idea can provide much of the same functions as talking about it. So if you’ve had a eureka moment – or better still if you’re in need of one – start writing about it, for no-one’s eyes but your own and for no purpose other than to properly figure the thing out. I regularly write messy, stream-of-consciousness narratives of ‘well there’s this issue, and if you address it that way you might get X – which carries the assumption of Y- but alternatively there is Z…. blah blah’. This is invariably cathartic and gives a palpable sense of achievement in itself. What comes out can be surprisingly insightful and often sets things clear in your mind in such a way that you are then ready to start writing ‘properly’ for the eyes of others.
7. If you’re struggling to improve your writing find a critical friend
I was told repeatedly that my academic writing was dense and too onerous to read, and yet I struggled to improve and I kept getting the same feedback. I’m lucky enough to have a supervisor who has taken the time to deconstruct what it is about my writing which makes the reader experience it that way so that I now have a ‘checklist’ of things I actively try to avoid in my writing. If you possibly can, do find someone to do the same for you.

8. Anticipate that you will get feedback in steps
Those things my supervisor told me about my writing didn’t all come my way at once. First I was just advised to shorten my sentences and I naively went away thinking ‘now I’ve got this thing fixed’. So I was disheartened to find that I then needed to work on my language…. A bit like Tip 3 you’re not going to improve your writing in all ways all at once. I’m still working on my flowery language but I now fully expect that when I’ve nailed that there will be something else for me to improve on.

9. Know your audience
You’re much more likely to get a paper accepted for publication if it’s been written with the right audience in mind. So once you have decided what your paper is going to be about and sketched it out (see tip. 4), spend some time researching journals which cover your topic, and find out who their key audiences are. For example, a journal aimed at clinical academics are likely to want papers which place greater emphasis on clinically-relevant findings, and which are pitched at those who combine those sets of knowledge. This applies to topic as well as discipline- if your research bridges both primary care and sexual health you will likely want to foreground one or the other, depending on what journal you aim for.

10. Find your style and know yourself
You will always have your own style of writing, and the best way for you to produce writing will also be unique to you. There’s quite a lot out there on the web about ways of writing which is helpful… this vitae page about generative versus planned writing styles for example

It seems to me that getting to know oneself as a writer comprises three things:

1. Finding out the conditions that make writing enjoyable and productive for you (for many including me that means scheduling carefully for solitude and peace to write).
2. Discovering the tricks that help you personally to write well (e.g. I’ve discovered that giving a sub-heading to mini bits of text helps me to keep track of what I’m writing, and that generating a Table of Contents from those sub-headings then helps me play around with the structure to find a good narrative)
3. Finding the best way to apply feedback (e.g. I have a mental checklist of things to bear in mind as I right but also ‘proof-read’ and reconstruct after).

This blog is adapted from ‘’Writing tips for doctoral students” which was published on the in February 2016




Another failed sub-Saharan #PrEP study: unpicking the disappointing performance of the dapivirine ring

30 Mar, 16 | by Leslie Goode, Blogmaster

The potential value of PrEP as an intervention in Western MSM populations has recently been conclusively demonstrated (PROUD – 86% (PROUD study/STIs/blog)), despite results from a whole series of trials in sub-Saharan African populations that seemed to cast doubt on its likely efficacy (CAPRISA 004 – 39%; iPrEX – 44%; CDC TDF2 – 62%; Partners-PrEP – 75%; FEM-PrEP – 0%; VOICE– 0%). The difference in outcome achieved in these two contexts would seem to have been the result of very different levels of compliance on the part of the study participants (VOICE D/STIs/blog). Evidently, the biologic efficacy of PrEP holds out hope for reducing transmission among MSM populations. But the jury remains out over the potential value of PrEP in combating the 50% of infections represented by the sub-Saharan hetero-sexual epidemic. An approach that has seemed promising in view of the evident problems of compliance posed by a daily or pre-coital regime of oral tenofovir is to deliver the ARV drug in the same way that contraception or HRT is sometimes delivered, via a ring that is inserted monthly into the vagina. Last month saw the final publication of the results of one of the two major studies that have been trialing this technology: MTN-020 – ASPIRE (Baeten & Hillier (B&H)).

The results of B&H – as indeed those of the other major sub-Saharan dapivirine ring study (IPM/Ring Study) – are disappointing and hard to interpret. Disappointing, because HIV incidence in the intervention arm was only 27% lower than in the control arm (though, when data from two (out of 15) study sites were excluded on the grounds of reduced retention and adherence, that figure rose to 37%). Hard to interpret, because – in response to problems of compliance that emerged in the earlier studies mentioned above – the study built in measures for the objective assessment of adherence including quarterly plasma sampling for dapivirine, and, after the first year of the trial, testing for residual dapivirine in used rings; and results from the latter suggested levels of compliance between 70% and 85%, depending on age group (with age positively associated with compliance).

One might be tempted to conclude that the dapivirine ring showed relatively poor efficacy. On the other hand, a post hoc age-stratified analysis of the data indicated levels of protection of 56% among those aged over 21 years, and zero protection for those aged 21 years or under. These figures are most easily interpreted as suggesting that non-compliance was at least an important factor – and, indeed, B&H themselves admit that their thresholds for non-compliance were set too low. If we disregard the objective assessments of compliance, then the post hoc analyses of levels of protection by age group would seem to suggest that the younger participants (aged 21 and under), almost unanimously removed their rings after each clinic visit, only to re-insert them, shortly before the next. The fact that an unknown proportion of the older participants might have been doing the same thing makes it impossible to reach any adequate conclusion as to the biologic efficacy of the dapivirine ring in this population.

Why the non-compliance – especially of younger participants? When VOICE D sought to investigate the non-compliance in earlier trials of oral tenofovir by confronting study participants with the objective evidence, 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. This might explain the positive association between compliance and age, if we assume a greater responsiveness on the part of younger participants to peer pressure. If this is the case, then the solution to these problems may be the development of more accurate measures of objective adherence.


Impressive declines in #HPV types amongst 14-24 yr olds in the US, despite poor vaccination coverage

29 Mar, 16 | by Leslie Goode, Blogmaster

Conclusive demonstration of cancer prevention benefits of HPV vaccination will only be possible in the relatively long term; good indicators of its probable effectiveness are, of course, already available. These include: reduced prevalence of the HPV types that have been vaccinated against; the decline in diagnoses of – or prescription for – genital warts; and even reductions in HPV specific neoplasia.  Conclusive evidence of the first kind has been emerging in Australia, where there has been a quasi-elimination of the vaccination types (Chow & Fairley/2/STIs;  Garland & Jayasinghe/STIs): of the second, in Australia, where presentations of warts have been reduced among the those aged 21 yrs and under by over 90% (Chow & Fairley/STIs ; Ali & Donovan (STIs)), and New Zealand, where there has been a corresponding fall in prescriptions (Wilson & Baker/STIs): of the third, in Finland, where the FUTURE trial showed in the intervention arm the absence of lesions CIN3 and ICC lesions present in the control arm (Paavonen/3/STIs).

Assessment of the impact of HPV vaccination will be harder in health systems where only a relatively more partial coverage is achieved – as in the US (single dose: 57%, triple dose: 38%, according to a 2013 national survey).  Yet Markowitz & Unger – in their recently published study on the basis of data from the CDC based National Health And Nutrition Examination Survey (NHANES) – show evidence of a decline in quadrivalent (4v) HPV types (HPV-6, -11, -16, -18) that is larger than the authors would have predicted, given the inadequacy of coverage.  The reason, the authors suggest, may be the greater than expected efficacy of a single dose of the vaccine.  Data for individual HPV type prevalence in females aged 14-34 years from the four-year period 2009-12 were compared with data for prevalence in the same group from the four year pre-vaccination period 2003-2006. For purposes of analysis the total 14-34 year interval was divided into five-year tranches.  The key findings of the study are that 4vYPV type prevalence has declined from 11.5% to 4.3% (64%) in the 14-19 yr group, and from 18.5% to 12.1% (34%) in the 20-24 yr group.  Equivalent data comparing the pre-vaccination period with the first four years after vaccine introduction (years 2006-2009) are given in an earlier study by the same authors (Markowitz & Unger/STIs).

The study also pursues a number of secondary goals. The most important of these is to use data emanating from sexually active 14-24 yr olds, vaccinated and unvaccinated, to estimate the efficacy of the vaccine (one dose or more), and the evidence for herd immunity.  But it also investigates the possibility of cross protection from 4vHPV vaccine against other (i.e. non-4vHPV) types in the study population at large – especially cross protection against types HPV-31, -33 and -45, for which there has emerged some evidence in past studies.  So far as the sexually active 14-24 yr participants were concerned, 4vHPV type prevalence was found to be 2.1% in vaccinated, as against 16.9% in unvaccinated.  There was no statistically significant evidence for her immunity.  As regards cross protection against HPV types in the participants at large – there was, once against, no statistically significant evidence.

Editor-in-Chief Vacancy, Sexually Transmitted Infections

11 Mar, 16 | by flee

Sexually Transmitted Infections ( is the world’s longest running international journal on sexual health, publishing peer reviewed original research, descriptive epidemiology, evidence-based reviews and comment on the clinical, public health, translational, sociological and laboratory aspects of sexual health from around the world. It also has an active online presence via a regular blog, podcasts, and social media channels. The journal is owned by BMJ and is an official journal of the British Association of Sexual Health and HIV and the Australasian Chapter of Sexual Health Medicine.

Sexually Transmitted Infections seeks a new Editor-in-Chief that understands the impact that a high quality scholarly journal can have on improving knowledge and practice in sexual health. The successful candidate will recognise the need to engage the journal’s audiences at all levels, develop its print and online content, and extend its reach. They will establish a vision for the role that continues the momentum created by the current editorial team, advances the journal’s international reputation and profile, and provides engaging and informed content.
The Editor-in-Chief will report to BMJ but have final responsibility for the editorial content and strategy of the journal, with support from their appointed editorial team and the publishing team. This individual should have stature in the field of sexual health, a distinguished publication record, and editorial experience. Editorial support and training will be provided, as well as an annual honorarium. The Editor-in-Chief should expect to spend up to a day in total each week on journal-related activities.
The main responsibilities of the Editor-in-Chief include, but are not limited to:
1. Providing the highest possible quality of scientific content to augment the knowledge, impact and practice of clinicians involved in the field
2. Developing and maintaining an internationally relevant and coherent scientific strategy and vision for the journal
3. Building and maintaining a supportive team of highly qualified international colleagues to serve as members of the editorial board and reviewers
4. Encouraging submission of high quality papers
5. Ensuring the integrity of the review process and providing guidance to authors, reviewers and editorial team members as appropriate
6. Developing procedures for effective triage and review of scientific manuscripts to ensure timely and excellent support is maintained for authors and reviewers
7. Adding value to the journal by commissioning editorials, reviews, educational material and online content, and seeking opportunities to publish themed issues and supplements
8. Supervising the journal’s response to appeals, complaints, suggestions from readers and ethical problems regarding published work
9. Building and maintaining collaborative relationships with affiliated organisations to enhance the journal’s visibility and ensure it meets the needs of the readership
Joint applications will be considered from two or more individuals willing to act as a team to focus on the professional and academic aspects of the journal. Applicants need not be based in the UK and international applicants (or joint applicants based in different countries) are encouraged.
The closing date for applications is 11th April 2016. Interviews will be held in May in central London, UK, or via videoconference. It is envisaged that the outgoing Editor-in-Chief will gradually hand over responsibility for running the journal over the second half of 2016, with the successful candidate officially taking up the post from 1st January 2017. The term of office will be 5 years in the first instance.
The application should include your CV, a letter explaining your interest in the post, your views of the strengths, weaknesses, opportunities and threats for the journal (a basic analysis of the journal and its competitors), and an outline of what your editorial policy and vision might be.
Applications should be sent to Miss Lindsey Fountain, Associate Publisher at BMJ, at

Modeling the potential effectiveness of PrEP as against other preventative interventions in addressing MSM HIV

1 Mar, 16 | by Leslie Goode, Blogmaster


Despite the known preventative benefits of ART, the incidence of HIV among UK MSM population has remained relatively constant over the last 10 years and looks set to remain so. The UN 90:90:90 target will soon be achieved for this population, yet the goal of eliminating the infection seems no nearer.  Not surprisingly there is an appetite among health professionals for alternative measures – like PrEP.

A recent study (Punyacharoensin & White) claims to be the first to model, on the basis of detailed behavioural and surveillance data, the  impact of seven potential interventions – including PrEP – on HIV incidence in this population.  There is a considerable diversity in the nature of these interventions.  One of them consists in the roll-out of the recent WHO policy of ‘diagnose and treat’: others in the achievement of specific targets, such as yearly HIV testing for a given percentage of MSM: others again in the fulfilment of what seem little more than aspirations, given the absence of any indication of how they might be achieved – such as halving one-time partners or unprotected anal intercourse. The potential impact of each intervention is assessed independently, and then in various combinations with other interventions.

It is evident from the way that the various combinations of interventions are grouped into two sequences that the primary issue for these authors is the potential of PrEP (which happens to be the only genuinely new tool in the box).  The first sequence combines PrEP at varying levels of coverage and effectiveness with the achievement of one-year testing for different proportions of the population, ‘test and treat’, and various levels of risk compensation.  The second sequence goes through much the same process but with PrEP now replaced by a putative 0.5 drop in repeat partnerships.  The main study outcome appears to be the demonstration that introducing PrEP at certain levels of coverage and effectiveness could, in certain combinations, have an impact on incidence (-43.6%) that would be of the same order (-41%) as the achievement (by unspecified means) of a putative 0.5 drop in repeat partnerships.

The biggest problem for the modelers, of course, is the difficulty of predicting the effectiveness of PrEP in a real-life setting.  When empirical evidence of this finally emerges, then the value of this intervention as against traditional interventions will presumably be determined by its relative cost-effectiveness.  In other words, the question to confront health policy makers will be how much of what they would otherwise have spent on traditional interventions should be diverted into PrEP.

In the meantime, if there is key message to emerge from this study, it is that PrEP is worth a try.

Inadequacy of ‘treatment as prevention’ strategy for combating HIV in young US MSM

23 Feb, 16 | by Leslie Goode, Blogmaster

The secret of containing the HIV epidemic is the successful engagement of key populations, we are told. In the case of the US that evidently includes young MSM (YMSM), amongst others.  The scale of the task that confronts public health interventions aimed at prevention in this group is brought out in a recent study by Wilson & Hightow-Weidmann  (W&H) who investigate the behavioural and social correlates of not achieving virological suppression.

If we take the HIV-infected population of the US as a whole, the relative impact on HIV onward transmission of the segment of the population that is infected, but not virologically suppressed (VL+), is critical to the control of the epidemic.  This is on account of the large proportion of total transmissions attributable to it.  One recent modeling study discussed in this blog (Skarbinski & Mermin {STI/blogs) (S&M)) has estimated the proportion of onward transmission attributable to VL+ at 61.3%, as against to 30.2% attributable to the undiagnosed.  (This model also takes account of the greater HIV infectivity of the non-virologically suppressed, through the impact of this is debated (Increased HIV infectivity (STIs/blog)).

So one can imagine the impact on onward transmission of failure to achieve virological suppression among YMSM, given that the proportion of HIV diagnosed who are VL+ is estimated by W&H at c.70%.  Further to this, W&H consider a factor that contributes an additional importance to the low level of viral suppression.  The headline statistic of their study is that the VL+ are considerably more likely to engage in risky sexual behavior than the rest.  Data obtained from the 20 US adolescent clinics that feature in the study show rates of condomless anal intercourse (CAI) for VL+ at 54.7%, as against 44.4% for VL-, and rates of serodiscordant CAI at 34.9%, as against 25%.  Other correlates of being VL+ are drug abuse, daily alcohol use and unemployment, suggesting a pattern or relative social marginalization that would tend to make this group harder to engage.

In their conclusions, W&H highlight the inadequacies of treatment as prevention as the sole risk reduction method.  A more underlying issue would seem to be retention in care and engagement with services, for socially marginalized populations.

Sherer (STIs) analyses the structural factors which make this particularly a problem for the US.  Access to sexual health services has been improved by the Affordable Care Act.  However, there remains considerable debate about how this will affect publically funded STD clinics which seem to have been financially squeezed in recent years.  Also about what role, if any, these clinics will continue to play in the US health system and what the implications of this will be for the accessibility of sexual health services for the socially marginalized (Mettenbrink & Cornelis (STIs); Stephens & Berstein (STIs); Hoover & Gift; Bocour & Shepard).

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