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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)

 

Beyond Boundaries – a meeting of the Scientific Study of Sexuality from Anastasia Eleftheriou

7 Dec, 15 | by Jackie Cassell, Editor of STI

‘Beyond Boundaries’ was the theme of the Annual Meeting of the Society for the Scientific Study of Sexuality (SSSS), in Albuquerque, that took place between 12-15th of November. Sex Researchers, therapists, doctors, educators, biologists and many more attended the conference to explore the emerging dimensions of Sexual Science.

 

Doug P. VanderLaan, recipient of the Ira & Harriet Reiss Theory award, opened the conference with his plenary talk on the development and evolution of male androphilia. Following plenary sessions included Debby Herbenick on Pleasure and Health, Stella Resnick on the Science of the Art of Romance and Stephanie Sanders on The Biology of Pleasure. Osmo Kontula, president of SSSS, gave a talk on the Determinants of Female Sexual Orgasms. Other plenary talks included Robert Hatcher on Condoms with Passion and So Much More and Walter Bockting on Transgender Health. Mandy Carter, an American Black LGBT activist, gave an exceptional plenary talk on Social Justice for which she received a standing ovation.

 

Attendees had a variety of choices of concurrent symposia and workshop sessions they could attend such as Sexual Health Issues, Sexual Experiences, Sex Education, Pornography, Non-Monogamy, LGBT Experiences, Sexual Development, Intimacy issues and Sexuality Among Older Adults. Sessions encouraged discussion between the speakers and attendees. Cynthia Graham, editor of the Journal of Sex Research, also delivered a workshop on publishing in and reviewing for JSR, the official journal of SSSS.

 

I would like to highlight that the conference atmosphere was very welcoming for first-time attendees and students. In addition, orientation events were organised to encourage them to network with professionals and take part in discussions. From my perspective as a student, I found the poster session an extremely useful opportunity to mingle with more experienced professionals. I received valuable feedback for my work on Perceived Attractiveness and Condom Use Intentions, from researchers working in similar areas but also from attendees who found the topic interesting and inspirational. I would encourage students and young professionals to consider presenting their work in future SSSS meetings.

 

The meeting wouldn’t be the same without the exhibitors, who provided the attendees with information about courses and certificates, sexuality books, art, jewellery, and the conference-popular vulva puppets! Additionally, the conference film festival, co-sponsored by Porntopia and Self Serve Toys, presented the films “Gender Affirmation” and “Politics of the Penis” that entertained the attendees during their last conference evening.

 

Save the date – The 2016 annual SSSS conference will take place in Phoenix, Arizona in November 17-20, 2016. Abstract submission begins in January 2016!

 

Anastasia Eleftheriou

So how much do we actually know about the risks posed by ‘chemsex’?

4 Dec, 15 | by Leslie Goode, Blogmaster

A recent BMJ editorial (3rd November) calls for ‘chemsex’ (the term used by the gay community to designate sex under the influence of drugs taken to heighten pleasure) to be made a ‘public health priority’.  The editorial has evidently been triggered by the publication of findings from a research project conducted by Sigma Research and commissioned by the London Boroughs of Lambeth, Southward and Lewisham (LSL).  These have recently appeared both in the official report (Executive Summary), and in papers in various journals, including STIs (see Bourne & Weatherburn (STIs)).

So far as the nature of chemsex itself is concerned, there is an informative short guide produced by 56 Dean Street that offers a down-to-earth insight into the nature of ‘chemsex’ events (ChemSex and heptatis C/STIs/blog).   On importance of the phenomenon for STI transmission within the MSM community, however, there would seem to remain considerable uncertainty – at least according to the editorial.  Evidence for condom use and sero-sorting in this setting would be a helpful indicator of degree of risk, but is apparently a contested issue in the current literature.

So what does the Chemsex Study itself have to contribute on these issues?  Concerning the extent of the chemsex phenomenon, it gives a ‘quantitative context’ on the basis of data from EMIS (European Men-who-have-sex-with men Survey).  The analysis of this data indicates a proportion of MSM living in LSL who have used drugs known to be employed for chemsex that is respectively seven-fold (GHB/GBL), and eight-fold (crystal meth), what we find amongst MSM elsewhere in the UK – as against a proportion for other drugs that is two or three-fold.

Regarding risks posed by behaviours associated with chemsex events – the question discussed by Bourne & Weatherburn (STIs) – the Chemsex Study employs qualitative data from a thematic analysis of 30 interviews conducted with MSM having participated in such events from LSL.

The researchers isolate four key ‘narratives’.  (1) More than a quarter, all sero-positive, had made a conscious decision to engage in unprotected anal intercourse (UAI) with those they believed were sero-concordant. (2) A third found it hard to control their behaviour under the influence of drugs, and took risks they subsequently regretted.  (3) A ‘small sample’ sought out risky sex.  (4) A ‘sizeable minority’ felt perfectly in control of their actions, and relatively safe, while engaging in chemsex.  The authors do not indicate whether, and how far, these four groups overlap, and how the membership of any but the first correlates with HIV sero-status.

They conclude there is little evidence that use of drugs had influenced engagement in UAI, though their use had facilitated sex with more men and for longer.  Much, it would seem, remains to be clarified by future studies.

 

Are health professionals complicit in female genital mutilation (FGM)?

19 Nov, 15 | by Leslie Goode, Blogmaster

The practice of female genital mutilation (FGM) has been a topic of concern to contributors to this journal (Herieka & Dhar (STIs); Dominguez & Jones (STIs); Leighton & Kingston (STIs).  The problem of avoiding extremist or ethnocentric responses to this important and emotive issue is discussed in an earlier blog (Using facts to moderate the message (STI/blog)) – as well as the question of its religious basis in Islam (Sexual health this week (STIs/blog).  The introduction in the UK of mandatory reporting (September 2014) has raised the profile of this issue in this country, as well as raising the question of how professionals – in a sexual health setting as much as elsewhere – should respond (Leighton & Kingston (STIs)).

Of general relevance to this response, therefore, is a recently published review paper (Reig-Alcaraz & Solano-Ruiz) examining the role of health professionals in general, both positive and negative, in relation to FGM.  The study develops a thematic synthesis of relevant studies, descriptive, quantitative and qualitative, and seeks to cover both African countries where these practices are traditional, and American and European countries where migration has brought populations still attached to them.

Underlying the whole study is an idea which the authors argue to be well-supported by the literature: that health professionals – and midwives and nurses especially – are particularly well placed to play a decisive role in relation to FGM.  Sadly, there is little in the way of research to guide ‘holistic interventions for risk-identification, prevention and child safeguarding’.  At least, however, health professionals should be on the side of ‘no harm’.  Yet, sadly, the authors claim, some degree of complicity with FGM often seems widespread among health professionals (and not only in countries of origin) – as is proved, if nowhere else, in the support of health workers for medicalization of the practice.   Medicalization, our authors argue, may be inconsistent with the legal status of FGM (where laws against FGM exist) – and it is certainly incompatible with the ethical principles of human rights which might be supposed to be at the basis of such laws.

This ambivalence in regard to FGM seems consistent with certain weaknesses in the training and culture of health professionals which the authors find to have been identified by their sources.  These include: ignorance of protocols and guidelines where these exist (e.g. Spain); ignorance of national legislation regarding FGM (e.g. in countries of origin that outlaw FGM, as well as in countries of residence); a tendency to categorize the practice of FGM as ‘religious’ (e.g. in Spain); support for medlcalization, both in countries of origin and residence; a general lack of access to information or training on FGM.

The study seems to focus particularly on Spain.  The UK comes out little better than other countries of residence where FGM is illegal, but has not been successfully eliminated.  On a more positive note, the UK intervention described by Dominguez & Jones (STIs)) offers a example of action on the part of sexual health professionals that is ethnically sensitive without compromise on ethical principal, and seems to have had a beneficial impact.

Changes in the WHO Guidelines for treatment of HIV

5 Nov, 15 | by Leslie Goode, Blogmaster

The WHO has released early its revised guidelines on the treatment of those infected with HIV (WHO early release guideline; WHO press release).  There are two important changes.  First, ART is recommended to all HIV infected individuals regardless of their CD4+ count.  Second, PrEP is recommended for people at ‘substantial’ risk of HIV infection as part of a comprehensive package of services.

The first of these revisions comes in the train of repeated rises over recent years in the recommended treatment threshold: first (2010), to350 CD4 per mm3; then (2013), from 350 to 500.  The latest revision is doubtless based on the results of randomized controlled trials (RCT) such as the START (Strategic Timing of Anti-Retroviral Therapy) trial (A Case for Immediate ART Initiation (STI/blog)).  The second builds on a WHO 2014 guideline which already recommended PrEP for MSM populations.  Here again recent RCTs demonstrating the effectiveness of PrEP, such as PROUD and IPERGAY (PrEP highly effective for HIV in MSM (STIs/blog)) will have played their part.

The removal of the threshold has resource implications that will pose a serious challenge in resource poor settings.  Writing in 2010 Hamilton and Crowley (STIs) estimated that setting the threshold for ART initiation at 250 CD4+ would by 2012 increase the need for treatment by a median of 15%, whereas setting at 350 CD4+ would increase it by 42% and 500 CD4+ by 84%. Contributors like Hallett & Garnett (STIs) (Zimbabwe) and Zwahlen (STIs) have sought to develop projections for individual countries.

Also, it has been argued that late diagnosis (even by current standards), and poor retention in care are significant factors in suboptimal health outcomes (Mubezi & Shuha (STIs)Hussey (STIs).  What the revised guidelines will deliver in real terms no doubt depends on the context of implementation.  Yet, even in the relatively more affluent settings (US), some recent research has argued for the reallocation of resources from linkage to retention in HIV care, in order to optimize utilization of scarce resources (Retention in Care (STI/blogs)Sherer (STIs). This could prove hard to square with the prioritization of ever lower thresholds for linkage to care – even if the recommended policy is in the interests of improving individual outcomes.

PrEP highly effective against HIV in MSM and has limited impact on risk compensation

22 Oct, 15 | by Leslie Goode, Blogmaster

The year 2015 is likely to turn out a decisive one for the story of PrEP (pre-exposure prophylaxis for HIV).  After a slow and faltering beginning, with trials in sub-Saharan Africa dogged by problems of poor adherence (Haberer & Bangsburg/STI/blog; VOICE D/STI/blog; Hendrix & Bumpus/STI/blog), this intervention appears at last to have proved its worth – at least in high-risk populations such as MSM in Europe and America.  This is to be seen in a succession of results from recent or still ongoing trials.

Following the report of encouraging headline figures at last February’s Conference on Retroviruses and Opportunistic Infections (CROI), the UK PROUD study (Pre-exposure Option for reducing HIV in the UK immediate or Deferred) has published its results (McCormack & Gill; PROUD/STI/blog).  As stated in my earlier blog, this study, based in 13 UK clinics, aimed, in its design, to replicate real-life conditions in being an ‘open-label’, as opposed to a blind placebo controlled, randomized study.  September also saw the publication of a brief report of a San Francisco based study (Volk & Hare) investigating HIV and STI incidence amongst a comparable number of patients (650) referred for PrEP over 2 and a half year period in a clinical practice under the health insurance provider Kaiser Permanente.  Finally, the PROUD study refers to the still ongoing IPERGAY study run by French and Canadian researchers (IPERGAY; Molina & Delfraissy).  The latter differs from the PROUD study, first in respect to the PrEP regime followed, which is ‘on demand’ (i.e. before and after sex) rather than daily; second, in having a blind placebo controlled, rather than an ‘open-label’, design.

The three studies investigate relatively high-risk, largely MSM, populations – to judge by the high rates (c. 34%-50% within a year of follow-up) of STIs and especially (18%-32%) of rectal STIs.   Rates of HIV transmission, however, were, in all cases, similarly low.  As indicated in my blog (PROUD/STI/blog), the PROUD study headlined an HIV incidence of 1-2 per 100 person years (py) in the immediate initiation, as against 9 per 100 py in the ‘deferred initiation’ arm.  The IPERGAY study saw rates of 0.94 as against 6.75.  The San Francisco study was without a control arm, but saw zero cases of HIV among PrEP users over the two and a half year study period.  All this would suggest that amongst self-selecting high-risk MSM, PrEP interventions can be successful in preventing HIV transmission.  It would, however, be reassuring to know more about the impact of PrEP on risk compensation – always the supposed ‘Achilles heel’ of MSM PrEP (Cassell & Halperin) – especially as rates of STI incidence following PrEP initiation were very high in all studies.  Here the published version of the PROUD study has the advantage of being able to compare incidence of other STIs between the intervention and the control arm of the study.  No significant difference between the two arms was observed.  This was particularly encouraging as the PROUD study was designed to replicate the conditions of a real-life intervention in that those in the intervention arm knew they were taking PrEP, and could have adjusted their behaviour on the basis of this knowledge.

A final issue that PROUD and IPERGAY may begin to help health professionals to address is that of cost effectiveness.  The PROUD researchers calculate that ‘thirteen men in a similar population would need access to 1 year of PrEP to avert 1 HIV infection’.  This would make PrEP targeted at this group cost-effective at current prices if the cost of tenofovir and emtricitibine were halved.  It could also be achieved if the proposed intervention were to adopt the ‘on demand’ regimen trialled by IPERGAY:  namely, two tablets 2-24 hrs before sex, one taken 24hr, and a further tablet 48 hrs. after.  IPERGAY, it will be remembered, demonstrated the same 86% reduction in HIV incidence that was observed by PROUD.

Over-diagnosis of UTIs in Emergency Department leads to STIs going untreated

28 Sep, 15 | by Leslie Goode, Blogmaster

The role of generalists in the care of STIs has always been important, and, in certain contexts – like the UK – looks set to increase. So it is no surprise that recent studies have raised the question of their adherence to sexual health policy guidelines in the matter of treatment regimes (Trotter & Okunwobi-Smith (STIs); Can we Ensure Adherence (STIs/blogs)) – especially given the need to steward antibiotic defences in a world of rising antimicrobial resistance (Gonorrhoea Anti-microbial Resistance (STIs/blogs). But the importance of generalists in the care of STIs also lends a heightened interest to the identification of specific clinical practice and diagnostic protocols among generalists that are associated with the misdiagnosis of – or the failure to diagnose – STIs. For instance, in an analysis of data derived from the Australian BEACH (Bettering the Evaluation and Care of Health) programme, Freedman & Mindel (STIs) (F&M) draw attention to the failure of GPs to undertake tests to exclude specific STIs and the reliance on generic symptomatic management.

Insights into the diagnostic practice of generalists in a rather different setting are provided in a recent observational cohort study of adult women over a two-month period either presenting with, or diagnosed with, genitor-urinary infections at a US Emergency Department (ED) (Tomas & Hecker (T&H)). T&H checked hospital diagnoses against the results of the urine cultures and appropriate Nucleic Acid Amplification Testing (NAAT) which they performed on those participants for whom they had not been performed routinely. They discovered an over-diagnosis of urinary tract infections of between 39% and 52% (depending on whether contaminated cultures were taken into account) and an under-diagnosis of STIs of 37%. Of the 24 missed STI diagnoses represented in the latter figure, 14 involved misdiagnosis as UTIs. What appears to be going on here is that care-providers are treating – and mis-treating – with antibiotics for UTI on the sole basis of urinalysis. Consequently, STIs are going untreated. In fact, empirical therapy for UTI is recommended in the US for women with at least one traditional lower UTI symptom and without complicating factors. But, the results of this study show that 24% of the patients diagnosed with UTI had no possible UTI-related symptoms documented. In other words, an abnormal urinalysis result was being routinely equated with the diagnosis of a UTI.

T&H recommend that urinalysis should be eliminated from triage protocols for women present with only genital symptoms. They also express the view that cost savings from not performing urine cultures may be more than outweighed by the costs of unnecessary antibiotic therapy and the longer-term costs of missed STI diagnoses.

More generally, the poor diagnostic practice exhibited in this study may usefully serve to highlight one of the characteristic failures to which the management of genitor-urinary conditions in general practice – and not just in US Emergency Departments – may be prone.

 

Take a trip to Brisbane – the World STI and HIV Congress

4 Sep, 15 | by Leslie Goode, Blogmaster

Take a trip to Brisbane, Australia in the pages of your STI journal! (ISSTDR Brisbane).

The International Society for STD Research (ISSTDR) is holding its biennial conference down south for the first time ever – 13-16 September 2015.  What’s more, it’s being held back-to-back with the Australasian HIV & AIDS conference (16 -18 September). No surprise, this being the biggest world HIV & STD research event, presentations include papers by a number of September’s STI journal contributors as well as contributors to STI journal Online First.

So, if you don’t belong to an academic institution that will fund your trip, and you can’t afford the air fare, then sit back, and let STI journal blog guide you through some selected highlights!

At the top of the bill for us the issue of PARTNER NOTIFICATION, and – this being a British-based journal – a possible strategy, much discussed in our pages: Accelerated Partner Therapy (APT), involving treatment of contacts, without the latter having to attend a clinic (Patient Delivered v. Accelerated Partner Therapy (STIs/blog); Golden & Estcourt (STIs); Dombrowski & Golden (STIs)).

-Follow the link to find out just how APTHotline (telephone assessment of partners) and APTPharmacy (community pharmacist assessment) compared with standard partner notification in a randomized control trial: BRISBANE: Escourt & Cassell.

Also on the issue of PARTNER NOTIFICATION. Can we predict from certain key facts about contacts, which are most likely to be worth treating presumptively? An Australian cross-sectional questionnaire-based study of 1,500 Chlamydia contacts arriving at a sexual health clinic in Melbourne between 2010 and 2013 investigates predictive factors for transmission.

-Follow the link to find out what we can tell from about a contact from certain key facts about them and their behaviour: BRISBANE: Huffam & Chen

Still on the topic of Chlamydia. The emergence of new POINT-OF-CARE DIAGNOSTICS requires us to consider how they should be used in the most effective and cost-effective way. A study investigates use of Gram-stained urethral smear analysis – to see the effect of restricting the test to male patients currently displaying symptoms rather than routinely administering it to all high risk male patients.

-Follow this link to discover what impact this change in diagnostic algorithm had on diagnostic accuracy, loss to follow-up and cost-effectiveness: BRISBANE: Bartelsman & De Vries

Moving from Chlamydia to HIV/AIDS. The topic of DELAYED LINKAGE TO CARE is one that has occupied our contributors (Lee & Gazzard (STIs)) and seems to have recently come to the forefront of attention (Retention in Care rather than Diagnosis (STIs/blogs)). Skarbinski & Mermin make a case for shifting the focus of public health investment, in the US at least, towards retention and linkage, on the grounds that this could have a more significant impact on onward transmission than simply expanding t testing. This is, of course, not only a problem in the US. A recent STIs Online First contributor is presenting to the conference on a study to quantify the problem of delayed linkage to care in the Netherlands, and to pinpoint its social determinants.

-Follow this link to discover what proportion of newly-diagnosed in the Netherlands are linked to care within four weeks, and what social factors confer vulnerability: BRISBANE: Van Veen & Van der Sande

 

‘Up-stream’ of the above studies that seek to inform clinical practice, the ISSTDR Conference features contributions in the areas of EPIDEMIOLOGY and SOCIAL BEHAVIOUR.

First EPIDEMIOLOGY. The Indigenous peoples of Australia constitute a sub-population with distinct needs which it is no surprise to find receiving some attention at a conference in Brisbane.  A contributor to STIs On Line First addresses the topic of a complication of Gonorrhoea that would be a rarity in other populations, but is apparently “an important differential when dealing with patients with undefined sepsis and associated joint disease” among the Indigenous population of Central Australia: Disseminated Gonococcal Infection (DGI).

-Follow this link to discover how serious a problem Disseminated Gonococcal Infection (DGI) is in this area, and what kind of people are affected: BRISBANE: Tuttle & Maguire

Moving now to SEXUAL BEHAVIOUR . The issue of ‘chemsex’, and its implications for MSM sexual health, has recently been a topical one (Chemsex & HCV Transmission (STI/blogs); Matser & Van der Loeff (STIs)).   A study published On Line First and presented at the Conference traces back an outbreak of Shigella flexneri among MSM to reported social media encounters, chemsex drugs and chemsex parties.

-Follow this link to find out about lifestyle and sexual behaviour factors explored through in-depth quantitative interviews: BRISBANE: Gilbart and Hughes

The final stop in our whistle stop tour is a different kind of SEXUAL BEHAVIOUR study. This is an application of modelling to demographic data relating to non-co-habiting sex partnering in 25 countries of sub-Saharan Africa. What are the roles of men and women, married and unmarried in driving heterogeneity in sexual networks, and how does this vary by country?

-Follow this link for mean values and variances of number of partners by sex, marital status and country: BRISBANE: Omori & Abu-Radadd

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