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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. http://abacus.bates.edu/~ganderso/biology/resources/writing/HTWsections.html. 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 https://www.vitae.ac.uk/doing-research/doing-a-doctorate/completing-your-doctorate/writing-and-submitting-your-doctoral-thesis/structuring-your-thesis.

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 sussexresearchhive.wordpress.com 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 (sti.bmj.com) 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 lfountain@bmj.com.

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).

Health professionals violate human rights of sex workers in Kenya

10 Feb, 16 | by Leslie Goode, Blogmaster

 

‘Key’ populations – such as sex workers – are now seen as crucial to turning the tide of the HIV epidemic. Given the recognized epidemiological potential of such marginalized groups to act as ‘bridging populations’ into the wider population, much importance has rightly been attached to countering the kind of routine violations of human rights that can effectively exclude such vulnerable populations from participation in health interventions designed to deal most effectively with the causes of the epidemic (UNAIDS Gap Report; UNAIDS (STI/blog). Amidst the talk of public health ‘strategies’, Speaking Out, a recent report based on the personal testimonies of 30 Kenyan sex workers, offers a powerful reminder that the problem of HIV in key populations is a cultural and social challenge before it is a technical one.  It is also a corrective to any strategy that would underestimate, in these days of expanded ART provision, the apparently softer but more complex challenge of cultural interventions to protect human rights. The report offers the results of one of the local community-led research projects supported in eleven countries by the Global Network for People Living with AIDS (GNP+).

At the heart of the problem of violations to the human rights of sex workers is the behaviour of health professionals. Officially, the human rights of such minorities are protected in Kenya by robust constitutional and legislative provisions; in practice, they are routinely flouted by everybody – including health workers. The authors of the report place violations in the following categories. Around HIV diagnosis. An attendee at an ante-natal clinic is HIV tested without her knowledge, and informed of the result in the presence of her current partner, who subsequently separates from her. Breach of confidentiality. On discovering the sex worker status of a positive-diagnosed attendee, a doctor scrolls down to ‘mama’ on the patient’s mobile and summons her mother to the hospital. Discrimination. A health worker who recognizes the status of a women attending with a stab injury announces to colleagues: ‘This is a sex worker who has been stealing other men’s husbands. Just stitch her. If it heals, well and good. If not, so be it’. Denial of services. A sex worker attending a facility following rape, is abused for her status, laughed at for claiming rape, and refused PEP on the grounds that it was not for ‘people like her’.

Such total disregard for the human rights of sex workers is shared by law enforcement officers who refuse to take seriously accusations or rape, refuse protection before the law for human rights violations, summarily arrest, then extort from, and sexually harass, their sex workers, inflict degrading treatment on them while they are in custody, and deny them access to treatment for the duration of their stay.

It is difficult to see how much progress is likely to be made in turning the tide of HIV in this particular ‘key population’ without a wholesale transformation of attitudes. The kind of abuses this study reveals are evidently paralleled in many countries. For example, Ndondo & Dlovu (STIs) and Jose & Nathan (STIs) draw attention, on the basis of qualitative survey evidence, to similar kinds of violations to sex workers’ human rights by law enforcement officers in Zimbabwe and East Timor, respectively. Mayhew & Hawkes (STIs) discuss violations in respect to a number of vulnerable groups including sex workers by both law enforcement officers and health professionals in Pakistan. It would seem that in many countries the UNAIDS strategy of controlling HIV in key bridging populations will encounter stiff cultural challenges.

Warding off the scourge of untreatable gonorrhoea?

4 Feb, 16 | by Leslie Goode, Blogmaster

 

A recent analysis (Kircaldy & Papp (K&P) of 2006-2014 US CDC (Centre for Disease Control and Prevention) data on Neisseria gonorrhea (NG) susceptibility to cefixime and ceftriaxone in isolates suggests a halt in the drift to resistance over the period 2011-13 followed by a return in 2014 to the upward trend. Among isolates from MSM the proportion with resistance rose from 0.2% in 2008 to 4% in 2010, then fell incrementally to 0.8% in 2013, before rising once again to 1.3%. It is tempting to see a correlation between these resistance trends and recent treatment guideline changes. After all, 2010 – the year before the beginning of this fall in NG resistance – saw the establishment in the US of a therapeutic regime involving combination therapy with cefixime or ceftriaxone plus a second antimicrobial; whereas 2012 – the year before the trend reached its lowest point – saw the further attempt to safeguard cefixime susceptibility through a regime of ceftriaxone-based combination therapy as the single recommended therapy. However, K&P caution against assuming a causal relation between resistance trends and these measures, since various factors might have contributed to the improvement. But, even if we do assume a causal relation, the 2014 data suggest that, as K&P put it, ‘the improvement in susceptibility may be short-lived’.

Nevertheless, experts seem broadly in favour of antimicrobial stewardship – and, more specifically, the currently recommended regime – as a last-ditch attempt to postpone the progress of multi-resistant NG. Yet, the chances of combination therapy achieving more than a temporary reprieve are slender – at least according to a recent comprehensive examination of the question (Rice (STIs). So what is to be done? Much is made in the literature of the role of ‘core’ populations – chiefly MSM and female sex workers – in sustaining epidemics, and of the importance of developing interventions directed specifically to these groups (Lewis/2013 (STIs); Guiguere & Alary (STIs). (For example, the alarmingly increased proportion of resistant isolates registered by K&P has hitherto affected, almost exclusively, MSM in the West of the US.) The problem with this, however, is that, while NG control is achievable only when core groups are treated, the treatment of those groups maximizes dissemination of antimicrobial-resistant strains (Chan & Fisman (STIs). One possible way out of this epidemiological ‘catch-22’ is indicated in another recent paper (Lewis/2015 (STIs). Lewis draws attention to the importance of the oropharyngeal niche in enabling the dissemination of NG resistant-strains, and proposes widespread screening of core populations, using state-of-the-art resistance-detecting NAATs and treatment with those antimicrobials known to be of greater efficacity for the oropharyngeal site – such as ciprofloxacin. Even where such interventions were affordable, however, there remains, given the largely asymptomatic character of oropharyngeal NG, the not inconsiderable problem of defining and accessing the core group (Guiguere & Alary (STIs)) – and time may be short.

Where next for HIV prevention in New Zealand?

29 Jan, 16 | by Leslie Goode, Blogmaster

A recent issue of the New Zealand Medical Journal (NZMJ) (128: vol. 1426) gives pride of place to a series of papers that reconsider the way forward for HIV prevention in New Zealand (NZ) against the background of the past thirty years.  Recent contributions to STI journal by these authors analyse the behavioural surveillance data from NZ (Saxton & Hughes (STIs); Lachowsky & Summerlee (STIs); Lachowsky & Dewey (STIs)); the papers in NZMJ set these findings against a broader background (Saxton & Giola; Hughes & Saxton; Dickson & Saxton; Saxton & Ludlam).

Broadly speaking, the situation in NZ resembles, both in nature and scale, what we find in Western European countries: namely, persistent but relatively low-level epidemics concentrated in the MSM population (above all, in Auckland), and among heterosexual individuals of foreign extraction (Dickson & Saxton).

The distinctiveness of the NZ epidemics, as against those of Western Europe, lies primarily in geo-political factors: such as migration from sub-Saharan Africa, which reached a peak in 2006 before abruptly declining – or the changing demography of Auckland with its large populations of South Asians and people of Pacific origin (Dickson & Saxton: Lachowsky & Summerlee (STIs)).  The main emphasis of the NZMJ papers, however, is on issues that will have a familiar ring to West European readers – such as the importance of achieving a balance between public health and clinic-based approaches to HIV control.

Overall, their account suggests some considerable degree of success on the part of health interventions – but in the face of a public health challenge that is constantly evolving and may yet prove intractable.  As regards the success, some behavioural surveillance data indicate levels of condom use with casual partners of 85% (Hughes & Saxton; Saxton & Hughes (STIs));  The challenge is represented by the growing minority who do not perceive HIV as a threat on account of new treatments (Hughes & Saxton; Saxton & Ludlam). There also remain, as elsewhere, the problems of high levels of undiagnosed HIV (c. 20%) and relatively late presentation to health services (over a third of MSM at CD4=<350/mm3).  A things stand, the worst kind of scenarios seen amongst gay communities in Thailand or the US would appear to have been averted.  Nevertheless, the epidemics show every sign of persisting, and, given a level of diagnosis that it is marginally higher than seen hitherto, may still turn out to be on an upward trajectory.

A key focus of the NZMJ editorial (Saxton & Giola) is on the continued importance of behaviour-based interventions in a world where the momentum seems to have shifted to clinic based control involving pharmaceuticals.  They highlight the danger that the medicalization of HIV prevention could lead to a disinvestment in behaviour-based interventions, which, they imply, would not be conducive to controlling the epidemic.   In this regard, the authors cite Phillips & Cambiano who argue that a mere 10% reduction in condom use would, without improvements in testing levels and ART initiation, result in a doubling of HIV incidence over 15 years.

Sexual and reproductive health in the new migrant “jungle” camp in Calais, France– A perfect storm?

29 Jan, 16 | by flee

written by
Fionnuala Finnerty
Brighton and Sussex University Hospitals
Brighton
fionnuala.finnerty@gmail.com

The new migrant “jungle” camp in Calais, France has been described in a recent environmental health report by the University of Birmingham as a humanitarian emergency1. Due to the recent refugee crisis and tightening border controls, the camp has swollen in size to an estimated 7,000 people2. Another camp close to Calais has seen a swell in numbers to 2,500 people. These are historically fit young men who can survive the treacherous journey.

In the last few months, increasing numbers of young women and unaccompanied children and adolescents are being seen. A large proportion of these people are hoping to get to the United Kingdom. The politics of the camp are vast and complex and beyond the scope of this blog but this camp is a peculiarity compared to refugee camps in other parts of the world. As it is on European soil, it has limited non-governmental (NGO) input and the population do not have a vested interest in improving camp conditions as, for many, the main aim is to get to the United Kingdom. The majority of the camps population originate from Syria, Eritrea, Sudan, Iraq, Afghanistan, Kurdistan, Iran and Somalia3.

The inhabitants are not registered and population data is estimated. Security is very limited. There is inadequate lighting, toilet and washing facilities1. There is a very real risk of violence, sexual assault and exploitation – cases of sexual assault have been disclosed to volunteer nurses in the camp4. Many of the women could also have experienced sexual violence in their country of origin or en route. Some of the African women have originated from countries with very high rate of female genital mutilation and therefore, may have complicated deliveries should they become pregnant.

A recent French study published in AIDS showed that African migrant women in France with insecure housing are eight times more likely to have transactional sex5. Another study showed that at least half to a third of new diagnoses of HIV in Sub Saharan African migrants in France were acquired in France (destitution appears to have contributed to these infections and women were especially vulnerable)6. The migrants in the “jungle” are from African countries with lower HIV rates than the Sub Saharan African nations but the risk is still present for them and for the other inhabitants.

In the “jungle”, MSF (Medecins sans Frontiers) are running an overstretched primary healthcare clinic7. They are unable to provide any form of sexual health testing onsite and women are referred to Calais to get contraception including the morning after pill7. The hospital clinic is located four miles from the camp. There have been a number of crisis pregnancies and referrals for termination of pregnancy7. There is access to pregnancy and antenatal care but women have to travel to the Calais hospital. There is free access to male condoms but no access to female condoms on site.  There is limited information on access to services in Calais available for camp inhabitants.

There are minimum standards (MISP) for sexual and reproductive health in an emergency situation set down by the inter-agency working group (IAWG) in reproductive health. The Minimum Initial Service Package (MISP) for reproductive health (RH) is a coordinated set of priority activities designed to prevent and manage the consequences of sexual violence; reduce HIV transmission; prevent excess maternal and newborn morbidity and mortality; and plan for comprehensive RH services8.  These standards are not met in the jungle camp in Calais9. There is no specialist agency in sexual and reproductive health working in the camp.  This has implications for the long and short term sexual health of all inhabitants and also for the reproductive health of the women living there.

As the European refugee crisis continues, multiple similar camps like the” jungle” are sprouting up in other parts of Europe including Greece and also in the Balkans. In September, the UNFPA projected that 70,000 women would be using the Balkans route between Sept 2015 and March 2016, and that approximately 4,200 of these would be pregnant and 1,400 would be at risk of sexual violence10. This October the UNHCR and Save the Children expressed concerns about the exploitation of women and children in the overstretched refugee reception centre in Lesbos, Greece.11

The current issues In Calais contribute to a perfect storm. The potential for crisis pregnancy, acquisition and transmission of sexually transmitted infections including HIV is high and this seems to be a neglected area in the “jungle” and surrounding camps. This is concerning in a time of unprecedented mass migration of refugees into Europe12.

It seems strange that a camp in Europe (despite its illegality) does not meet basic standards that are insisted upon in the developing world. This is an important human rights issue. The end destination for many of the people living there is the United Kingdom and clearly we may be seeing significant sexual health morbidity associated with this crisis here in the UK in the future.

 

References:

  1. Dhesi S, Isakjee A, Davies T. A. An Environmental Health Assessment of the New Migrant Camp in Calais. University of Birmingham.
  2. Guardian (2015) http://www.theguardian.com/world/2015/nov/03/refugees-horror-calais-jungle-refugee-camp-feel-like-dying-slowly
  3. Salam association. www.associationsalam.org (accessed Dec 2015)
  4. Personal communication.
  5. Desgrées du Loû A et al. Is hardship during migration a determinant of HIV infection? Results from the ANRS PARCOURS study of sub-Saharan African migrants in France. AIDS, online ahead of print, Nov 2015
  6. Desgrées du Loû A et al. Sub Saharan African migrants living with HIV acquired after migration, France, ANRS PARCOURS study, 2012-2013. Euro Surveill Nov 2015; 20(46).
  7. Women’s Health. Internal unpublished document. Medecins Sans Frontieres 2015.
  8. Sphere project. Humanitarian Charter and Minimum Standards in Humanitarian Response [accessed via http://www.spherehandbook.org/en Dec 2015]
  9. Finnerty F, Gilleece Y, Richardson D. Letter: Does the new “jungle” migrant camp in Calais meet the intra-agency working group (IAWG) minimum standards for sexual and reproductive health (MISP) in an emergency situation? STI (in press).
  10. United Nations Population Fund. http://www.unfpa.org/press/europe%E2%80%99s-refugee-crisis-worsens-thousands-women-and-girls-move-urgently-need-reproductive (accessed Dec 2015)
  11. Al Jazeera. http://www.aljazeera.com/indepth/features/2015/12/female-refugees-face-sexual-exploitation-greece-151222191343353.html (accessed Dec 2015).
  12. Human Rights Watch. https://www.hrw.org/report/2015/11/16/europes-refugee-crisis/agenda-action (accessed Jan 2016)

 

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