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Conference reports

When an STI doesn’t behave like an STI: the case of Trichomonas

3 Aug, 11 | by Leslie Goode, Blogmaster

The second conference issue to hit the headlines arises from a study led by Charlotte Gaydos of John Hopkins University investigating the prevalence in the US of the parasite trichomonas vaginalis. Not only does overall prevalence prove to be twice what might have been expected (8.7% as opposed to 4%); more surprisingly still, age-specific prevalence shows a progression with age – quite contrary, of course, to what we see in chlamydia or gonorrhea – reaching a peak of 13% in women of over 50 years. These results seem to corroborate the incidental findings arising from a study of the Gen-Probe Aptima, reported in this blog (see Andrea and Chapin).

The Gaydos study is as yet unpublished. It is reported to be based on the re-analysis for Trichomonas of left-over samples – urine, cervical or vaginal swab, or liquid pap smears – obtained, presumably for other purposes, from 7,593 women across 27 US states between July and December 2010, attending a range of health settings including private clinics, emergency departments, hospitals, jails and community health STD clinics. The results, as reported, conform to general expections of an STI in certain respects but not others. Prevalence, though remarkably high for black women (20%, or three times the level for whites) correlates, according to Gaydos, with ethnicity and relative affluence in the manner that earlier studies, relating to chlamydia or gonorrhoea, might lead us to expect. On the other hand, age-specific prevalence is quite at odds with such expectations. Compared with the overall prevalence of 8.7%, rates are lower in younger age groups – 8.5% for 18-19 year olds and 8.3% for those in their twenties – but rise to 11% for the 40s age-group, and 13% for those aged 50 and above.

These discrepancies are most surprising. One response already canvassed in an earlier blog would be to question whether what we are seeing here is an STI at all – or is it time dust down those older theories of transmission via the water-closet (see J.A. Burgess)? At all events, the figures raise questions that can only be answered by a fuller account of the epidemiological issues surrounding transmission – to start with, the issue of potential sampling bias in the trial itself. We look forward eagerly to a fuller discussion of these issues in the published paper.

ScienceDaily, “Sexually Transmitted Parasite Trichomonas Vaginalis Twice as Prevalent in Women Over 40, Study Finds”, 12th July 2011
http://www.sciencedaily.com/releases/2010/03/100329203218.htm

BMJ Group Blogs: Sexually Transmitted Infections, 23rd March 2011
http://blogs.bmj.com/sti/2011/03/23/just-supposing-trichomonas-vaginalis-proved-not-to-be-an-exclusively-sexually-transmitted-infection-after-all/

Sarah B. Andrea & Kimberle C. Chapin, “Comparison of Aptima Trichomonas vaginalis Transcription-Mediated Amplification Assay and BD Affirm VPIII for Detection of T. Vaginalis in Symptomatic Women: Performance Parameters and Epidemiological Implications”, Journal of Clinical Microbiology, March 2011, p.866-869, Vol.49, No. 3
http://jcm.asm.org/

J.A. Burgess, “Trichomonas Vaginalis Infection from Splashing in Water Closets”, British Journal of Venereal Disease, 1963;39:248-250 doi:10.1136/sti.39.4.248

BASHH( British Association for Sexual Health and HIV ) Ordinary General Meeting 11th June 2010 – Highlights blog

17 Jun, 10 | by John Evans-Jones, STI Blogmaster

Lots of very interesting stuff at this 4 times a year single afternoon and evening meeting held at the sumptuous Royal Society of Medicine venue in central London. For me it is certainly worth the 2 hour train journey from the north of England.

The afternoon was hosted by the UK`s Medical Research Council and chaired by Professor Graham Hart. It followed a oral research presentation type format, all studies being funded by the MRC and the UK Department of Health. First up was Pippa Oakeshott with a presentation asking whether Mycoplasma Genitalium ( MG) was the “new chlamydia “.  Her study used  stored samples from college students collected for the POPI ( prevention of pelvic infection) study to seek to understand association between MG and Pelvic Inflammatory Disease ( PID) – a controversial area.  What struck me was their incredible persistence in maintaining good rates of follow up and their highly creative use of other healthcare records, such as hospital notes and primary care records. MG prevalence was found to be 3.3% with black ethnicity, Bacterial Vaginosis and greater than 2 recorded sexual partners being independently associated. PID was more likely with MG but not in a statistically significantly fashion. Prevalence and Incidence were felt to be too low to justify screening so don`t expect that to start happening soon…..This study is due to appear soon in the journal “Clinical Infectious Diseases”.

The Health Protection Agency updated us on their UK surveillance for Antimicrobial resistance in Chlamydia. This was prompted by somewhat worrying reports from Sweden of a “new variant” demonstrating resistance to Azithromycin. Azithromycin is now the cornerstone of Chlamydia treatment in the UK, both within Sexually Transmitted Diseases clinics and in other settings such as England`s national Chlamydia Screening Programme. Thus far the HPA have not managed to directly assess the 18 suspicious samples they have received for direct evidence of resistance ( i.e. using MIC or “Minimum Inhibitory Concentration”, put simply growing the bug in the lab, known as culture, and then adding antibiotics to see if it stops growing). Instead, they have looked for genes in the Chlamydia Trachomatis genome believed to be associated with resistance. There is some evidence of genes associated with Azithromycin resistance and also with Tetracycline resistance ( the other main class of drugs used for Chlamydia in the UK). It is not clear exactly what the relationship is between these genes and treatment failure. They therefore appealed for UK STD clinicians to send them samples from patients where the usual antibiotics appear to have failed. In the meantime they hope to implement MIC assays. More to come on that issue, I think

Giving a public health trial the acronym MSTIC is certainly one way to keep clinicians interested ! Cath Mercer did an excellent ” Maths is fun” turn to demonstrate that a trial named ” how to Maximise STI control and Cost effectiveness” can keep an audience of sexual health doctors awake if in the right hands. Indeed her presentation turned into “tag team health mathematics ” with various mathematical modellers being dragged blinking out of the audience and into the spotlight. Put simply they have developed a web tool which clinicians,  public health doctors and managers can use to decide which arrangement of STD care is most appropriate for their locality. For example, you could use it to show the most cost-effective way to divide STD management between specialist services and primary care. The English part of the UK has an financial arrangement for service procurement know as ” commissioning” and this kind of tool might well be very useful in better informing that process.

LGV-NET is a study of Lymphogranuloma Venereum in the UK, also MRC funded. This once mainly tropical Sexually Transmitted Infection has existed as an epidemic in the UK since 2003, with now over 1000 cases reported. Most cases occur in HIV positive Men who have Sex with Men ( MSM), but is the HIV association a biological or behavioural one ? This case control study compared MSM with confirmed LGV with symptomatic MSM with LGV-like symptoms and also MSM without symptoms attending clinics for screening. Computer assisted self-interviews and lab reports were linked and found that the symptoms of constipation, rectal discharge, rectal pain and tenesmus ( the urge to defaecate without the need to pass stool ) were strongly associated with LGV. HIV was found to be associated ( unsurprisingly, this is well known ) but there was evidence that there was confounding with behavioural risk factors such as unprotected anal sex, “fisting” and multiple partner situations ( sauna, backroom etc.) i.e. the practices which bring HIV also bring LGV. It also be that the phenomenon of “serosorting” ( HIV positive individuals choosing to have sex with other HIV positive individuals) or other HIV related sexual networking may be a factor. This study would seem to be a clear step away from a biological explanation for the strong HIV / LGV association and also help to focus LGV prevention messages towards those very specific risky situations.

The afternoon session finished with two studies looking at the sexual lives of Eastern Europeans in London. Political changes in the former “Eastern Bloc” countries and their entry into the European Union have led to massive social changes and significant migration to other countries within the EU, such as the UK. Fiona Burn presented the SALLEE study ( “Sexual attitudes and lifestyles of London`s Eastern Europeans”). Data collected from a sample of this population drawn by recruitment from a number of different settings were compared with London data from the NATSAL 2000 ( National survey of sexual attitudes and lifestyles, new version begins this year). Overall the Eastern Europeans had had more sexual partners,more experience of injecting drug use and men had more experience of paying for sex but lower rates of STIs reported and lower abortion rates. HIV prevalence was  1.1% , surprisingly higher than the UK average given the lower reported rates of other STIs.

Lucy Platt reported on the second “Eastern Europeans in London” study of the afternoon, looking specifically at females migrant sex workers. Participants were recruited from non clinic settings via social networks and also a variety of specialist commercial sex worker outreach projects. Research consent from this vulnerable group is by neccessity a complex process. Participants again completed computer assisted interviews and for this study screening samples for sexually transmitted infections were obtained. Compared to female sex workers of UK origin their Eastern European counterparts were more likely to be younger, have children,  see more clients and have had an abortion ( and also less likely to use contraception). There was a suggestion that they might be at higher risk of violence, although this was not statistically significant but what was significant was the finding that women who had recently been in contact with an outreach service had a lower rate of infections. This to me would appear to validate the excellent work which these services do and inspire them to redouble their efforts to protect their clients from unwanted pregnancy and threats to their personal safety.

All in all an excellent afternoon, although somewhat disheartening to hear that this public funding stream for UK based sexually transmitted infection public health studies is threatened. It all seemed very relevant to me !

The evening had perhaps more of a private BASHH feel to it, touching as it did upon new educational initiatives. My feeling is that any STI blogreaders out there want barnstorming international public health ! So on that note I would like to mention only the final speaker of the evening, our esteemed editor, Jackie Cassell. She spoke about the new Public Health Curriculum for clinical trainees specialising in sexually transmitted infections.  She evangelised about the need for clinical doctors to understand public health and hopes to catch us early in our careers. I am a convert !

Blog comments gratefully received. Thank you and goodbye !

Specialists produce evidence to show HIV testing in UK hospitals is a ‘lottery’

17 May, 10 | by John Evans-Jones, STI Blogmaster

By Harriet Smith at Munro and Forster, on behalf of the British Association for Sexual Health and HIV ( BASHH):

Three new research studies unveiled at the Second Joint Conference of the British Association for Sexual Health and HIV (BASHH) and the British HIV Association (BHIVA), in Manchester today, revealed that people with HIV infection are still routinely going undiagnosed by healthcare professionals, despite presenting to hospitals in high prevalence HIV areas with HIV-related conditions.

Dr Keith Radcliffe, President of BASHH, has told delegates at the conference (20-23 April) that the lottery of HIV testing guidelines in hospital settings means that over a third of people with an HIV infection are still diagnosed late, causing avoidable morbidity, mortality and onward transmission.

The rate of new HIV infections, especially amongst heterosexuals, has been steadily rising in the past few years, and forty-three English Local Authorities now have a prevalence of diagnosed HIV greater than 2 per 1,000 population. Prevention of 3,550 HIV infections would reduce future HIV-related costs by more than £1.1 billion1. Two separate studies to be presented at the Conference revealed the extent of the lottery:

·       An investigation of HIV testing patterns in a large inner city hospital with high local prevalence found that 41% of HIV positive patients had been in contact with a health professional, for an HIV related reason, in the last two years but had failed to be offered a test2.

·       A six month study of acute general medical admissions found that only one third of undiagnosed HIV positive patients were correctly targeted by clinicians for testing. Implementation of the routine offer of an HIV test would have identified the remaining two thirds which were correspondingly missed3.

One reason for which widespread HIV testing remains low is that often Health Care Professionals feel uncomfortable offering tests to patients as part of a routine diagnosis. A third study being presented to the Conference investigated the feasibility and acceptability, to both patients and staff, of routinely offering HIV tests in an Emergency Department (ED) over a three month period.

·       95% of respondents considered the offer of a test of an HIV test acceptable

·       Post-study focus groups demonstrated a high level of satisfaction amongst staff that the delivery of testing was feasible and acceptable to the majority

·       61% of patients offered an HIV test, accepted it

·       The test acceptance rate was not influenced by ethnicity or sexual orientation, assuaging concerns that higher risks groups may be less likely to accept an HIV test in such settings4.

Dr Keith Radcliffe, said:

“These excellent research studies clearly demonstrate that HIV testing in high prevalence areas remains a ‘lottery’, despite national guidelines which recommend routinely offering an HIV test to adults in high prevalence areas.

These studies add to the overwhelming body of evidence that demonstrates the urgent need to move away from targeted testing, to a system of routine testing in high prevalence areas. It is in the interest of everyone, for local health authorities, and healthcare professionals to take a real stance on this issue”

Dr Ian Williams, Chair of the British HIV Association said:

“It is clear from these and other studies that  opportunities for earlier diagnosis of HIV infection are being missed. Late diagnosis is associated with higher risk of death and severe illness. It is important that more widespread testing is available in both health care and community settings and that there is an acceptance by all clinicians to offer a HIV test routinely when indicated”

Professor Ian Gilmore, President of the Royal College of Physicians:

“Someone in their early twenties promptly diagnosed with HIV can today, with the current treatments available, look forward to a relatively normal life, whereas delayed diagnosis and treatment increase the rate of illness, premature death and the unknowing spread of the disease. Changing patterns of HIV transmission further underscore the need to raise awareness amongst physicians and make the test a standard first-line investigation in many secondary care settings.”

Dr Ewen Stewart, Chair of the Royal College of General Practitioners Sex, Drugs & HIV Group said:

“This is not only an important issue for hospitals but also for general practice as these patients are presenting in primary care as well as in hospitals.  We would encourage people to offer more HIV testing in general practice to try to bring down the numbers of new cases of HIV.”

References:

1.      Health Protection Agency (HPA) “HIV in the United Kingdom: 2009” (November 2009)

Report available at http://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1259151891866

2.      PJ Read, D Armstrong-James, CYW Tong and J Fox, ‘Community and hospital HIV testing in the highest HIV prevalence area in the UK; missed opportunities for earlier diagnoses identified’ Guys and St Thomas’ NHS Foundation Trust, London UK (April 2010) The study set out to discern missed opportunities for HIV testing, by studying HIV testing patterns in a large inner city hospital with high local HIV prevalence.  All HIV tests performed in 2008 were analysed and stratified for location of request, and HIV positive results underwent case note study review to establish circumstances surrounding the test and to identify previous presentation, HIV indicator diseases and missed opportunities for HIV testing. Results: 90% of hospital tests were carried out as part of routine screening. Of the remaining 10% which were carried out outside of routine screening, 1.3% were HIV positive (51/3408) 41% of HIV diagnoses had attended the Trust with HIV indicator diseases within the preceding 24 months, but not tested for HIV.  The Authors conclude that local implementation of HIV testing guidelines would have detected over one third of late presenters earlier, and prevented subsequesnt hospital admission. 

3.      N Perry, L Heald, J Cassell, M Hankins, S Barden, M Cubbon, J Quin, D Richardson, and M Fisher, “HIV testing in acute general medical admissions must be universally offered to reduce undiagnosed HIV” Brighton and Essex University Hospitals NHS Trust, Brighton, UK and Brighton and Sussex Medical School, Brighton (April 2010).  About the study: The study set out to assess the offering rate of HIV tests in areas with high rates of HIV. Study: Individuals not known to be HIV positive eligible to be offered HIV test as routine investigation in AGM (Acute General Medicine).  A parallel anonymous seroprevalence study was undertaken to assess effectiveness of pilot in correctly identifying undiagnosed HIV in hospital: Results: The six month study of acute general medical admissions found that only one third of undiagnosed HIV positive patients were correctly targeted by clinicians for testing. Implementation of the routine offer of an HIV test would have identified the remaining two thirds which were correspondingly missed.  Conclusion: The rate of offering a test during the pilot was low and varied between medical teams.  Although recommended as routine, clinicians appeared to be targeting testing, yet failing to identify majority of undiagnosed infections.

4.      M Rayment, A Thornton, S Gidwani, C Rae, K Phekoo, J Holland, M Atkins, A Nardone, D Asboe, M Tenant-Flowers, J Anderson, P Roberts, and A Sullivan “HIV testing in the emergency department – reporting one arm of the HIV testing in Non-Traditional Settings (HINTS) study” Chelsea and Westminster Hospitals NHS Foundation Trust, Health Protection Agency, NIHR CLAHRC, North West Londond, Feedback South Londond, Kings College Hospitals Foundation Trust, London, Centre for the Study of Sexual Health and HIV, Homerton University Hospital NHS Foundation Trust, London UK (April 2010) About the study: Where National guidelines recommend the routine offer of an HIV test to adults in general healthcare settings when the local diagnosed HIV prevalence exceeds 0.2%, the aim of the study was to assess the feasibility and acceptability to patients and staff of routinely offering HIV tests in an Emergency Department (ED). Method: All patients attending the ED during study hours over a three month period were offered a saliva HIV test. Subsets of patients completed a questionnaire collecting behavioral and attitudinal data, or participated in focus groups or interviews. Results: Of 3459 patients offered an HIV test, 2123 accepted. (61%) Patients were more likely to accept if they were younger or if they were offered a test by clinical rather than non-clinical staff. There was no association observed between ethnicity and test. 95% of respondents to the survey considered the offer of an HIV test in the ED acceptable. The most common reason for declining a test was due to having been recently tested (46%) and self perception of low risk (41%) Reported sexual orientation was not associated with test uptake. Whilst pre study clinical staff had expressed anxieties about the feasibility of delivering the service and its acceptability to patients, post study focus groups showed that there was high levels of satisfaction amongst staff that the delivery of testing was feasible and acceptable to patients. Conclusion: HIV testing in an emergency setting is acceptable to patients and staff and operationally feasible. 

5.      National guidelines for HIV testing, jointly produced by the British Association for Sexual Health and HIV (BASHH), the British HIV Association (BHIVA) and the British Infection Society (BIS) were launched in 2008 and published in the Journal of Clinical Medicine on the 1st October 2009.

6.      BASHH is the lead professional representative body for those managing STIs and HIV in the UK. It seeks to innovate and deliver excellent tailored education and training to healthcare professionals, trainers and trainees in the UK and to determine, monitor and maintain standards of governance in the provision of sexual health and HIV care.  Please click here to download the new UK National Guidelines for HIV Testing 2008 from the BASHH website http://www.bashh.org/

7.      ‘The British HIV association is the leading UK professional association representing professionals in HIV care. It acts as a national advisory body to professions and other organisations advising on all aspects of HIV care. Please click to download the new UK  national guidelines for HIV testing 2008 from the BHIVA website www.bhiva.org

8.      The British Infection Society is the specialist society for Infectious Disease physicians.  Please click here to download the new UK National Guidelines for HIV Testing 2008 from the BIS website www.britishinfectionsociety.org

9.      The Second Joint Conference of the British HIV Association (BHIVA) with the British Association for Sexual Health and HIV (BASHH) is being held at the Manchester Central Convention Complex from 20 to 23 April 2010.  The conference programme includes a number of high-quality plenary sessions presenting the very latest research across a number of fields, including a focus on the ongoing work in the UK. Specialists have been invited to present on topics in HIV medicine, opportunistic infection, HIV co-infection, genito-urinary medicine and sexual health.

PRESS CONTACT DETAILS:

For further information, please contact Harriet Smith, on behalf of BASHH at Munro and Forster, harriet.smith@munroforster.com or 020 7815 3905

BASHH/BHIVA conference – friday

27 Apr, 10 | by cmercer

A remarkably good turn-out given it was the morning after the night before! I won’t dwell on the gala dinner at Manchester Cathedral, although I should say how absolutely beautiful the cathedral looked, with a sea of candles illuminating the gothic structure and its vaulted ceiling. I must admit though, that it was slightly surreal to be feasting and frolicking in a place of worship –especially as the air was heavy with incense! 

As James Bingham had given the Harrison Lecture on Tuesday evening, there was a change to the advertised programme with Professor Andrew Lever (University of Cambridge) kindly stepping in to give this morning’s invited lecture, titled ‘Getting intimate with HIV: the virus in the cell’.

The conference’s last oral research presentation session addressed innovation and maintaining quality in clinical practice. There was a welcome acknowledgement in several of these presentations of a need for economic evaluation with a view to reducing costs but not at the expense of offering a quality service. Equally important, and addressed by Dr Jenny Whetham in her presentation on the role of email consultation in the clinical care of stable HIV-infected patients, was the need to take account of the patient perspective. 

Just before lunch, there were the oral research poster presentations session in which the authors of the six best posters had three minutes each to present. I do not envy the job of judging the 302 posters that have been presented at this year’s conference. As the chairs (Professor Jane Anderson and Dr Elizabeth Carlin) commented they had been spoilt for choice in selecting the winning six, in fact, a further 26 posters were awarded special commendations.

The winning six posters covered a range of topics and were (in numerical order): Poster P98, in which Kober et al recommended that it may not be necessary to undertake routine monitoring for toxicity during PEP -unless there are other concerns (developing signs/symptoms of toxicity, significant co-morbidity, or the potential for drug interactions.) Vanessa Apea presented poster P136 which was a case report of a voltage-gated potassium channel antibody-related limbic encephalitis in a HIV-positive female with dialysis-dependent renal failure. Two of the award-winning posters focused on HIV in children: P144 (Williams et al –who won the award for best poster) looked at the pregnancy outcomes in women growing-up with HIV acquired perinatally/in early childhood, while P156 (Whitfield et al) addressed the need to test the children of HIV-positive patients. Rayment et al’s poster (P255) reported an e-learning tool that Chelsea and Westminster Hospital have developed to train their junior doctors in GUM/HIV, which has proven to both release staff time and be popular with junior doctors (In hindsight I should have asked how this fits with the Department of Health’s Electronic training for Healthcare programme (www.e-lfh.org.uk/) for which there was a stand in the main hall….) Finally, poster P278 looked at the rising costs over the period 1997-2007, for both the population and per patient, of the NHS treating HIV patients, and the need to reduce costs without reducing the quality of services –again broaching the thorny subject of the NHS having finite resources, with implications for how we best manage these resources.

In the closing session, it was the BHIVA/BASHH Oscars –although without the acceptance speeches! I won’t go through all the prizes awarded but I should note that the award for best oral presentation went to Derval Harte for her presentation on a study that looked at recalling MSM diagnosed with bacterial STIs for retesting, in which she concluded that the strategy was both feasible and, given the high rates of STIs and HIV among returning men, is likely to be effective for reducing onward transmission.   

These are just some of my highlights of this the last day of the second joint meeting between BHIVA and BASHH, so as I wait on the concourse at Manchester Piccadilly for the train home with what feels like the majority of delegates, I wonder what they’ll remember about this meeting  –other than it being the ‘volcano conference’!”

BASHH/BHIVA conference – Thursday

22 Apr, 10 | by gbrook

For those of you who think that attending a conference is an excuse to ‘skive’, I’ll have you know that I dutifully got up in time to attend the 8 a.m. Medical Research council meeting discussing the PIVOT (protease monotherapy) trial. However, I declined the champagne with the breakfast. As discussed in yesterdays blog, this trial is doing very well and expected to stop recruiting in June/July. The increased number of patients to be recruited in PIVOT is to offset the lower-than-expected failure rate seen in other PI monotherapy studies, such as the Tibotec MONET study of Darunavir monotherapy.

Following this, despite a few technical glitches, there were two excellent presentations by Graeme Moyle and Jonathon Ross. Graeme gave the historical background to how we are were we are with requirements for testing drugs before they are licensed. It was sobering to be reminded of the patients who have died or have been left permanently disabled as a results of treatment with thalidomide, FIAU (a hepatitis B treatment) and more recently the Parexel TGN1412 study which left six patients seriously ill and some needing ITU care following injection of this monocloncal antibody. He described 3 types of adverse drug reaction: type A due to direct pharmacological/dose related effects of the drug (e.g FIAU and liver failure); type B due to patient-based  responses (e.g Abacavir hypersensitivity in people who are HLA B5701 +ve); and type C due to increased risk of naturally occuring disease brought on by the drug (e.g. Vioxx and cardiovascular disease). Type C reactions are particularly relevant in HIV with the recent discussion about risk of myocardial infarction and certain ARTs. However, he urged caution in coming to conclusions from cohort studies. Abacavir has been linked to a 70% increased risk of MI in the DAD cohort. In the recently published ACTG 5202 study, a randomised controlled trial, Abacavir has a lower risk for MI than tenofovir and so the MI-risk story is not as clear-cut as people thought.

Jonathan gave an excellant review of new technologies for the diagnosis of STIs. Nuclear acid amplification techniques (NAAT) are well embedded for the diagnosis for gonorrhoea and chlamydia now but although NAAT for gonorrhoea is more sensitive than culture, he reminded us that in populations with a prevalence of only 1%, a positive test has a positive predictive value of only 33%. Microarrays seem to be the new technology to look out for. Using this technology it is possible to test for a large range of STIs in a single test. This could also include tests for gonorhoea-resistance mutations. Trichomonas and genital ulcer multiplex (testing for herpes, syphilis and chancroid) assays are also emerging and thus we are not far from a state where culture for organisms will no longer be our routine tests.
The conference though, is more about presentation of new research with 302 posters to look at! You’ll be impressed to read that I have looked at every one of them and here are a few of my highlights. Several posters look at the success of opening Saturday morning STI clinics. In poster 241 from Colchester they diagnosed more chlamydia than usual which they attribute to people coming as couples and so both partners being tested and treated simultaneously. In poster 254 from St Barts hospital in London, they found a doubling in the diagnosis rate of gonorrhoea and a big increase in chlamydia.

Several posters look at self completed triage and self-directed management for STIs. Up to 40% of patients describing themselves as asymptomatic initially required treatment on the day, so self-triage is still pretty inaccurate. Poster 222 form Kings College Hospital in London asserts that 10% of patients can complete a triage and self-direct management. What they don’t say is whether this management was appropriate!
Trying to get HIV+ women to test their existing children was the subject of several studies. Poster 146 reported that 40% of children under 18 were untested in this situation.  One way to overcome this might be to use rapid finger-prick or oral slide tests. In one small study 2/28 children were HIV positive using opportunistic POCT tests at St Marys hospital London.

Finally, two new chronic infections have been described in HIV+ patients. A patient is described with Norovirus-related diarrhoea lasting 18 months in a severly immunocompromised patient at North Manchester (P140). It is also emerging that Hepatitis E can also cause chronic liver disease and possibly cirrhosis, as described in a patient from Truro (P128).

That is just a taster of this, the busiest day of the conference, and proof, if any was needed, that I really am here to work!

BHIVA/BASHH Conference Highlights

22 Apr, 10 | by Jackie Cassell, Editor of STI

After a series of satellite symposia, the programme started today with Steve Taylor’s “Top Ten” papers of the past year.  As Steve acknowledged, a talk like this is something of a poisoned chalice, with the opportunity to alienate friends and enemies alike.

He cheated a bit, choosing a number of major topics and sneaking a few papers in – key reviews, the HSV/acyclovir/HIV developments, developing world issues, Chlamydia, Hepatitis B and C, and HPV. And very sweetly, he included a paper by his SpR Sophie, whose paper is so freshly published I couldn’t track it down (it’s in Current Opinion in HIV and AIDS).

You might want to look up the following (citations and full abstracts at the bottom of the page)……

  • the failure of HSV therapy to prevent transmission – but the potential role of aciclovir in slowing clinical progression of HIV
  • evidence that immediate therapy is beneficial for HIV infected infants
  • evidence that delay of ART initiation during TB therapy is associated with increased mortality and morbidity
  • HIV related internet resources (but i-base was omitted…)
  • a glimpse of our quest for the holy grail – a reviewing the prospects of a cure for HIV
  • the merits of clinically vs  laboratory driven HIV monitoring (the DART study)
  • use of a 7 valent pneumococcal conjugate vaccine in HIV infected adults
  • young people’s feelings about the Chlamydia test
  • Chlamydia and gonorrhoea among MSM – transmission and rates of anorectal Chlamydia in MSM
  • The sad case of the man who said he acquired his LGV from a donkey
  • Delayed HCV antibody responses in incident cases among HIV positive MSM
  • A genetic variation in IL28B which predicts treatment related hepatitis C clearance
  • Boosters are probably not needed for hepatitis B

It was, however, no surprise to the Editors that Steve’s TOP PAPER was one of our own – Kit Fairley’s account of the dramatic reduction in genital warts following the introduction of 4-valent HPV vaccine in Australia.  We need to educate our masters…..

The PIVOT trial has exceeded its  expectations ! Adrian Palfreeman stepped into Nick Paton`s ( presumably volcanic ash ridden ) shoes to kick off the afternoon with a session from the Medical Research Council Clinical Trials Unit updating us on some of their current trial activity in the area of HIV treatment. PIVOT is a study looking at the safety, toxicity and health economics of protease monotherapy as an HIV treatment strategy, with the preservation of future drug options ( i.e. the lack of resistance ) its primary endpoint. What is also striking in addition to the numerical success of recruitment is that more than half the patients in the trial thus far have come from outside of London. Recruitment is remaining open until June 2010 in an attempt to take the statistical power of the study even further although the original recruitment target of the study has already been reached. No such luck for the START trial which is experiencing slow uptake due to problems with the supply of study medication. Aptly named, this trial is an eagerly awaited Randomised Control Trial to determine whether antiretroviral therapy for HIV should be started immediately after diagnosis or deferred until the CD4 count has fallen to below 350 ( in asymptomatic patients ). Both studies have the potential to have a very significant impact on the costs of HIV treatment to healthcare systems. Sheena McCormack, also from the MRC Clinical Trial Unit talked about HIV prevention trials, of which PopART, an African trial looking at universal testing and treating as a prevention strategy really stood out.

The first oral research session of the conference brought us sobering news from Ruth Smith of the UK Health Protection Agency (HPA).  In England, Wales and Northern Ireland 1 in 6 of HIV patients accessing care are now over 50 years of age. Better treatments and fewer deaths play a large part but this new data for the years 2000-2007 identify the contribution of sexual transmission in the over 50s and a high rate of late diagnosis. Nearly half of persons diagnosed with HIV in this time period acquired their infection aged above 50 which suggests that prevention and testing initatives need to be accessible to this age group to prevent the large number of deaths associated with late diagnosis. The session ended with murmurs of excitement as a “late breaker”, also from the HPA, was shoe-horned into 5 minutes at the end. There has been a Western European outbreak of the tropical sexually transmitted infection Lymphogranuloma Venereum (LGV) since 2003 but the reported number of cases for the first quarter of 2010 are 209% up on the same quarter of last year. Cassandra Powers from the agency used this special time slot to bring this to the attention of UK clinicians urgently.  A frankly stunning 84% of cases have an enhanced surveillance form completed, which enables the HPA to know that the UK outbreak is almost exclusively confined to gay men, three quarters of whom are also HIV positive. Swabbing the rectum of STD clinic attenders with proctitis for chlamydia ( a variant of this organism causes LGV ) and the existence of a patient information leaflet produced by the Sexual Health Charity, the Terence Higgins Trust, were also flagged. Real time public health in action!

CITATION AND ABSTRACT OF ALL STEVE’S PAPERS

Authors: Richardson D.  Maple K.  Perry N.  Ambler E.  Jurd C.  Fisher M.
Title: A pilot qualitative analysis of the psychosocial factors which drive young people to decline chlamydia testing in the UK: implications for health promotion and screening.
Source: International Journal of STD & AIDS.  21(3):187-90, 2010 Mar.

Abstract
The main objectives of this study are to investigate the psychosocial issues for young people who decline chlamydia testing as part of the national chlamydia screening programme in the UK and to consider the implications for future opportunistic screening. Transcripts of qualitative semi-structured interviews were analysed using interpretative phenomenological analysis to identify themes. The study involved 14 young people aged 16-24 years who declined chlamydia tests in non-health-care settings as part of the chlamydia screening programme. The study was conducted in educational settings where chlamydia screening is available. Four interlinked themes were identified: stigmatization of young people with chlamydia and who take a test, the feeling of embarrassment, their perception of risk and their beliefs of what the test involves. These beliefs and feelings were pervasive and negatively affected their personal decisions of having a test. In conclusion, understanding psycho social cultural phenomena in the context of screening programmes for sexually transmitted infections (STIs) in young people are important for their success. Chlamydia and STIs remain stigmatized; testing is poorly understood and embarrassing for young people, which impacts the poor uptake for opportunistic screening. Strategies are needed to normalize and de-stigmatize chlamydia and the chlamydia test.

Authors: Lingappa, Jairam R.  Baeten, Jared M.  Wald, Anna.  Hughes, James P.  Thomas, Katherine K.  Mujugira, Andrew.  Mugo, Nelly.  Bukusi, Elizabeth A.  Cohen, Craig R.  Katabira, Elly.  Ronald, Allan.  Kiarie, James.  Farquhar, Carey.  Stewart, Grace John.  Makhema, Joseph.  Essex, Myron.  Were, Edwin.  Fife, Kenneth H.  de Bruyn, Guy.  Gray, Glenda E.  McIntyre, James A.  Manongi, Rachel.  Kapiga, Saidi.  Coetzee, David.  Allen, Susan.  Inambao, Mubiana.  Kayitenkore, Kayitesi.  Karita, Etienne.  Kanweka, William.  Delany, Sinead.  Rees, Helen.  Vwalika, Bellington.  Magaret, Amalia S.  Wang, Richard S.  Kidoguchi, Lara.  Barnes, Linda.  Ridzon, Renee.  Corey, Lawrence.  Celum, Connie.  Partners in Prevention HSV/HIV Transmission Study Team.
Institution: Department of Global Health, Seattle, WA, USA. lingappa@u.washington.edu
Title: Daily aciclovir for HIV-1 disease progression in people dually infected with HIV-1 and herpes simplex virus type 2: a randomised placebo-controlled trial.
Source: Lancet.  375(9717):824-33, 2010 Mar 6.

Abstract
BACKGROUND: Most people infected with HIV-1 are dually infected with herpes simplex virus type 2. Daily suppression of this herpes virus reduces plasma HIV-1 concentrations, but whether it delays HIV-1 disease progression is unknown. We investigated the effect of aciclovir on HIV-1 progression.
METHODS: In a trial with 14 sites in southern Africa and east Africa, 3381 heterosexual people who were dually infected with herpes simplex virus type 2 and HIV-1 were randomly assigned in a 1:1 ratio to aciclovir 400 mg orally twice daily or placebo, and were followed up for up to 24 months. Eligible participants had CD4 cell counts of 250 cells per microL or higher and were not taking antiretroviral therapy. We used block randomisation, and patients and investigators were masked to treatment allocation. Effect of aciclovir on HIV-1 disease progression was defined by a primary composite endpoint of first occurrence of CD4 cell counts of fewer than 200 cells per microL, antiretroviral therapy initiation, or non-trauma related death. As an exploratory analysis, we assessed the endpoint of CD4 falling to <350 cells per microL. Analysis was by intention to treat. The trial is registered with ClinicalTrials.gov, number NCT00194519.
FINDINGS: At enrolment, the median CD4 cell count was 462 cells per microL and median HIV-1 plasma RNA was 4.1 log(10) copies per microL. Aciclovir reduced risk of HIV-1 disease progression by 16%; 284 participants assigned aciclovir versus 324 assigned placebo reached the primary endpoint (hazard ratio [HR] 0.84, 95% CI 0.71-0.98, p=0.03). In those with CD4 counts >or=350 cells per microL, aciclovir delayed risk of CD4 cell counts falling to <350 cells per microL by 19% (0.81, 0.71-0.93, p=0.002)
INTERPRETATION: The role of suppression of herpes simplex virus type 2 in reduction of HIV-1 disease progression before initiation of antiretroviral therapy warrants consideration.
FUNDING: Bill & Melinda Gates Foundation.

Authors: Armstrong WS.  del Rio C.
Institution: nce de Leon Center, Grady Health System, Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30322, USA.
Title: HIV-associated resources on the internet. [Review] [3 refs]
Source: Topics in HIV Medicine.  17(5):151-62, 2009 Dec.

Abstract
The Internet provides easy, widespread access to new developments in the field of medicine. The pace of HIV-related research is rapid and has global relevance, making the Internet a particularly well-suited technology for dissemination of information. The number of sites offering HIV-related information is vast, and the quality is variable. Nevertheless, access to reliable information can be a highly efficient method to acquire up-to-date knowledge about advances in HIV investigation. This review summarizes high-quality HIV-related Web sites, including sites that provide access to HIV-related guidelines, conferences with Web content, images, case studies, and clinical and scientific databases. Also included are HIV-related reference sites, Web sites for journals that publish regularly on HIV- and AIDS-related advances and epidemiology, and policy oriented sites. In addition, Web sites with materials for patient information and advocacy and specialty societies for HIV pract itioners are listed. [References: 3]

Authors: French N.  Gordon SB.  Mwalukomo T.  White SA.  Mwafulirwa G.  Longwe H.  Mwaiponya M.  Zijlstra EE.  Molyneux ME.  Gilks CF.Institution: Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi. neil.french@lshtm.ac.ukTitle: A trial of a 7-valent pneumococcal conjugate vaccine in HIV-infected adults.
Source: New England Journal of Medicine.  362(9):812-22, 2010 Mar 4.

Abstract
BACKGROUND: Streptococcus pneumoniae is a leading and serious coinfection in adults with human immunodeficiency virus (HIV) infection, particularly in Africa. Prevention of this disease by vaccination with the current 23-valent polysaccharide vaccine is suboptimal. Protein conjugate vaccines offer a further option for protection, but data on their clinical efficacy in adults are needed.
METHODS: In this double-blind, randomized, placebo-controlled clinical efficacy trial, we studied the efficacy of a 7-valent conjugate pneumococcal vaccine in predominantly HIV-infected Malawian adolescents and adults who had recovered from documented invasive pneumococcal disease. Two doses of vaccine were given 4 weeks apart. The primary end point was a further episode of pneumococcal infection caused by vaccine serotypes or serotype 6A.
RESULTS: From February 2003 through October 2007, we followed 496 patients (of whom 44% were male and 88% were HIV-seropositive) for 798 person-years of observation. There were 67 episodes of pneumococcal disease in 52 patients, all in the HIV-infected subgroup. In 24 patients, there were 19 episodes that were caused by vaccine serotypes and 5 episodes that were caused by the 6A serotype. Of these episodes, 5 occurred in the vaccine group and 19 in the placebo group, for a vaccine efficacy of 74% (95% confidence interval [CI], 30 to 90). There were 73 deaths from any cause in the vaccine group and 63 in the placebo group (hazard ratio in the vaccine group, 1.18; 95% CI, 0.84 to 1.66). The number of serious adverse events within 14 days after vaccination was significantly lower in the vaccine group than in the placebo group (3 vs. 17, P=0.002), and the number of minor adverse events was significantly higher in the vaccine group (41 vs. 13, P=0.003).
CONCLUSIONS: The 7-valent pneumococcal conjugate vaccine protected HIV-infected adults from recurrent pneumococcal infection caused by vaccine serotypes or serotype 6A.

Authors: Abdool Karim, Salim S.  Naidoo, Kogieleum.  Grobler, Anneke.  Padayatchi, Nesri.  Baxter, Cheryl.  Gray, Andrew.  Gengiah, Tanuja.  Nair, Gonasagrie.  Bamber, Sheila.  Singh, Aarthi.  Khan, Munira.  Pienaar, Jacqueline.  El-Sadr, Wafaa.  Friedland, Gerald.  Abdool Karim, Quarraisha.
Institution: Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa. caprisa@ukzn.ac.za
Title: Timing of initiation of antiretroviral drugs during tuberculosis therapy.
Source: New England Journal of Medicine.  362(8):697-706, 2010 Feb 25.

Abstract
BACKGROUND: The rates of death are high among patients with coinfection with tuberculosis and the human immunodeficiency virus (HIV). The optimal timing for the initiation of antiretroviral therapy in relation to tuberculosis therapy remains controversial.
METHODS: In an open-label, randomized, controlled trial in Durban, South Africa, we assigned 642 patients with both tuberculosis and HIV infection to start antiretroviral therapy either during tuberculosis therapy (in two integrated-therapy groups) or after the completion of such treatment (in one sequential-therapy group). The diagnosis of tuberculosis was based on a positive sputum smear for acid-fast bacilli. Only patients with HIV infection and a CD4+ cell count of less than 500 per cubic millimeter were included. All patients received standard tuberculosis therapy, prophylaxis with trimethoprim-sulfamethoxazole, and a once-daily antiretroviral regimen of didanosine, lamivudine, and efavirenz. The primary end point w as death from any cause.
RESULTS: This analysis compares data from the sequential-therapy group and the combined integrated-therapy groups up to September 1, 2008, when the data and safety monitoring committee recommended that all patients receive integrated antiretroviral therapy. There was a reduction in the rate of death among the 429 patients in the combined integrated-therapy groups (5.4 deaths per 100 person-years, or 25 deaths), as compared with the 213 patients in the sequential-therapy group (12.1 per 100 person-years, or 27 deaths); a relative reduction of 56% (hazard ratio in the combined integrated-therapy groups, 0.44; 95% confidence interval, 0.25 to 0.79; P=0.003). Mortality was lower in the combined integrated-therapy groups in all CD4+ count strata. Rates of adverse events during follow-up were similar in the two study groups.
CONCLUSIONS: The initiation of antiretroviral therapy during tuberculosis therapy significantly improved survival and provides furth er impetus for the integration of tuberculosis and HIV services.
Authors: DART Trial Team.  Mugyenyi P.  Walker AS.  Hakim J.  Munderi P.  Gibb DM.   Et al
Institution: MRC Clinical Trials Unit, 222 Euston Road, London NW1 2DA, UK.
Title: Routine versus clinically driven laboratory monitoring of HIV antiretroviral therapy in Africa (DART): a randomised non-inferiority trial.
Source: Lancet.  375(9709):123-31, 2010 Jan 9.
Source: NLM. PMC2805723

Abstract
BACKGROUND: HIV antiretroviral therapy (ART) is often managed without routine laboratory monitoring in Africa; however, the effect of this approach is unknown. This trial investigated whether routine toxicity and efficacy monitoring of HIV-infected patients receiving ART had an important long-term effect on clinical outcomes in Africa.
METHODS: In this open, non-inferiority trial in three centres in Uganda and one in Zimbabwe, 3321 symptomatic, ART-naive, HIV-infected adults with CD4 counts less than 200 cells per microL starting ART were randomly assigned to laboratory and clinical monitoring (LCM; n=1659) or clinically driven monitoring (CDM; n=1662) by a computer-generated list. Haematology, biochemistry, and CD4-cell counts were done every 12 weeks. In the LCM group, results were available to clinicians; in the CDM group, results (apart from CD4-cell count) could be requested if clinically indicated and grade 4 toxicities were available. Participants switched to second -line ART after new or recurrent WHO stage 4 events in both groups, or CD4 count less than 100 cells per microL (LCM only). Co-primary endpoints were new WHO stage 4 HIV events or death, and serious adverse events. Non-inferiority was defined as the upper 95% confidence limit for the hazard ratio (HR) for new WHO stage 4 events or death being no greater than 1.18. Analyses were by intention to treat. This study is registered, number ISRCTN13968779.
FINDINGS: Two participants assigned to CDM and three to LCM were excluded from analyses. 5-year survival was 87% (95% CI 85-88) in the CDM group and 90% (88-91) in the LCM group, and 122 (7%) and 112 (7%) participants, respectively, were lost to follow-up over median 4.9 years’ follow-up. 459 (28%) participants receiving CDM versus 356 (21%) LCM had a new WHO stage 4 event or died (6.94 [95% CI 6.33-7.60] vs 5.24 [4.72-5.81] per 100 person-years; absolute difference 1.70 per 100 person-years [0.87-2.54]; HR 1.31 [1.14-1.51]; p=0.! 0001). Differences in disease progression occurred from the third year  on ART, whereas higher rates of switch to second-line treatment occurred in LCM from the second year. 283 (17%) participants receiving CDM versus 260 (16%) LCM had a new serious adverse event (HR 1.12 [0.94-1.32]; p=0.19), with anaemia the most common (76 vs 61 cases).
INTERPRETATION: ART can be delivered safely without routine laboratory monitoring for toxic effects, but differences in disease progression suggest a role for monitoring of CD4-cell count from the second year of ART to guide the switch to second-line treatment. FUNDING: UK Medical Research Council, the UK Department for International Development, the Rockefeller Foundation, GlaxoSmithKline, Gilead Sciences, Boehringer-Ingelheim, and Abbott Laboratories. Copyright 2010 Elsevier Ltd. All rights reserved.

Authors: Celum C.  Wald A.  Lingappa JR.  Magaret AS.  Wang RS.  Mugo N.  Mujugira A.  Baeten JM.  Mullins JI.  Hughes JP.  Bukusi EA.  Cohen CR.  Katabira E.  Ronald A.  Kiarie J.  Farquhar C.  Stewart GJ.  Makhema J.  Essex M.  Were E.  Fife KH.  de Bruyn G.  Gray GE.  McIntyre JA.  Manongi R.  Kapiga S.  Coetzee D.  Allen S.  Inambao M.  Kayitenkore K.  Karita E.  Kanweka W.  Delany S.  Rees H.  Vwalika B.  Stevens W.  Campbell MS.  Thomas KK.  Coombs RW.  Morrow R.  Whittington WL.  McElrath MJ.  Barnes L.  Ridzon R.  Corey L.  Partners in Prevention HSV/HIV Transmission Study Team.
Institution: Department of Global Health, University of Washington, Harborview Medical Center, 325 Ninth Ave., Box 359927, Seattle, WA 98104, USA.
Title: Acyclovir and transmission of HIV-1 from persons infected with HIV-1 and HSV-2.Source: New England Journal of Medicine.  362(5):427-39, 2010 Feb 4.

Abstract
BACKGROUND: Most persons who are infected with human immunodeficiency virus type 1 (HIV-1) are also infected with herpes simplex virus type 2 (HSV-2), which is frequently reactivated and is associated with increased plasma and genital levels of HIV-1. Therapy to suppress HSV-2 reduces the frequency of reactivation of HSV-2 as well as HIV-1 levels, suggesting that suppression of HSV-2 may reduce the risk of transmission of HIV-1.
METHODS: We conducted a randomized, placebo-controlled trial of suppressive therapy for HSV-2 (acyclovir at a dose of 400 mg orally twice daily) in couples in which only one of the partners was seropositive for HIV-1 (CD4 count, > or = 250 cells per cubic millimeter) and that partner was also infected with HSV-2 and was not taking antiretroviral therapy at the time of enrollment. The primary end point was transmission of HIV-1 to the partner who was not initially infected with HIV-1; linkage of transmissions was assessed by means of genetic sequenc ing of viruses.
RESULTS: A total of 3408 couples were enrolled at 14 sites in Africa. Of the partners who were infected with HIV-1, 68% were women, and the baseline median CD4 count was 462 cells per cubic millimeter. Of 132 HIV-1 seroconversions that occurred after randomization (an incidence of 2.7 per 100 person-years), 84 were linked within couples by viral sequencing: 41 in the acyclovir group and 43 in the placebo group (hazard ratio with acyclovir, 0.92, 95% confidence interval [CI], 0.60 to 1.41; P=0.69). Suppression with acyclovir reduced the mean plasma concentration of HIV-1 by 0.25 log(10) copies per milliliter (95% CI, 0.22 to 0.29; P<0.001) and the occurrence of HSV-2-positive genital ulcers by 73% (risk ratio, 0.27; 95% CI, 0.20 to 0.36; P<0.001). A total of 92% of the partners infected with HIV-1 and 84% of the partners not infected with HIV-1 remained in the study for 24 months. The level of adherence to the dispensed study drug was 96%. No serious adverse  events related to acyclovir were observed. CONCLUSIONS: Daily acyclovir therapy did not reduce the risk of transmission of HIV-1, despite a reduction in plasma HIV-1 RNA of 0.25 log(10) copies per milliliter and a 73% reduction in the occurrence of genital ulcers due to HSV-2. (ClinicalTrials.gov number, NCT00194519.) 2010 Massachusetts Medical Society

Authors: Dang T.  Jaton-Ogay K.  Flepp M.  Kovari H.  Evison JM.  Fehr J.  Schmid P.  Boffi El Amari E.  Cavassini M.  Odorico M.  Tarr PE.  Greub G.
Institution: Infectious Diseases Service, University Hospital Center, University of Lausanne and University Hospital Center, Lausanne, Switzerland.
Title: High prevalence of anorectal chlamydial infection in HIV-infected men who have sex with men in Switzerland.
Source: Clinical Infectious Diseases.  49(10):1532-5, 2009 Nov 15.

Abstract
Human immunodeficiency virus (HIV)-infected men who have sex with men (MSM) were enrolled in an anorectal Chlamydia trachomatis screening study. Anorectal Chlamydia DNA was detected in 16 (10.9%) of 147 men, mainly among asymptomatic patients and patients having >20 sexual partners. These results support routine anorectal Chlamydia screening in HIV-infected MSM who report unprotected anal intercourse.

Authors: Bernstein KT.  Stephens SC.  Barry PM.  Kohn R.  Philip SS.  Liska S.  Klausner JD.
Institution: STD Prevention and Control Services, San Francisco Department of Public Health, San Francisco, California 94102, USA. kyle.bernstein@sfdph.org
Title: Chlamydia trachomatis and Neisseria gonorrhoeae transmission from the oropharynx to the urethra among men who have sex with men.
Comments: Comment in: Clin Infect Dis. 2009 Dec 15;49(12):1798-800; PMID: 19911969
Source: Clinical Infectious Diseases.  49(12):1793-7, 2009 Dec 15.

Abstract
BACKGROUND: Limited data exist on the risk of Chlamydia trachomatis and Neisseria gonorrhoeae transmission from oropharynx to urethra. We examined urethral C. trachomatis and N. gonorrhoeae positivity among men who have sex with men (MSM) seen at San Francisco City Clinic (San Francisco, CA) during 2007.
METHODS: All patients who sought care at the San Francisco City Clinic (the only municipal sexually transmitted disease clinic in San Francisco) received a standardized interview conducted by clinicians. We estimated urethral C. trachomatis and N. gonorrhoeae positivity for 2 groups of visits by MSM who visited during 2007: (1) men who reported their only urethral exposure was receiving fellatio in the previous 3 months and (2) men who reported unprotected insertive anal sex in the previous 3 months. Additionally, urethral C. trachomatis and N. gonorrhoeae positivity was estimated, stratified by human immunodeficiency virus infection status, urogenital symptom history, and! whether the patient had been a contact to a sex partner with either chlamydia or gonorrhea.
RESULTS: Among MSM who reported only receiving fellatio, urethral C. trachomatis and N. gonorrhoeae positivity were 4.8% and 4.1%, respectively. These positivity estimates were similar to positivity found among MSM who reported unprotected insertive anal sex.
CONCLUSIONS: A more complete understanding of the risks of transmission of C. trachomatis and N. gonorrhoeae from oropharynx to urethra will help inform prevention and screening programs.

Authors: Fairley CK.  Hocking JS.  Gurrin LC.  Chen MY.  Donovan B.  Bradshaw CS.
Institution: Melbourne Sexual Health Centre, Alfred Hospital and School of Population Health, University of Melbourne, Carlton, Australia. cfairley@unimelb.edu.au
Title: Rapid decline in presentations of genital warts after the implementation of a national quadrivalent human papillomavirus vaccination programme for young women.
Source: Sexually Transmitted Infections.  85(7):499-502, 2009 Dec.

Abstract
OBJECTIVE: This study aimed to determine if the Australian human papillomavirus (HPV) vaccination programme has had a population impact on presentations of genital warts.
METHODS: Retrospective study comparing the proportion of new clients with genital warts attending Melbourne Sexual Health Centre (MSHC) from January 2004 to December 2008. Australia provided free quadrivalent HPV vaccine to 12-18-year-old girls in a school-based programme from April 2007, and to women 26 years and younger through general practices from July 2007.
RESULTS: 36,055 new clients attended MSHC between 2004 and 2008 and genital warts were diagnosed in 3826 (10.6%; 95% CI 10.3 to 10.9). The proportion of women under 28 years with warts diagnosed decreased by 25.1% (95% CI 30.5% to 19.3%) per quarter in 2008. Comparing this to a negligible increase of 1.8% (95% CI 0.2% to 3.4%) per quarter from the start of 2004 to the end of 2007 also in women under 28 years generates strong evidence of a difference in these two trends (p<0.001). There was no evidence of a difference in trend for the quarterly proportions before and after the end of 2007 for any other subgroup, and on only one occasion was there strong evidence of a trend different to zero, for heterosexual men in 2008 in whom the average quarterly change was a decrease of 5% (95% CI 0.5% to 9.4%; p = 0.031).
CONCLUSIONS: The data suggest that a rapid and marked reduction in the incidence of genital warts among vaccinated women may be achievable through an HPV vaccination programme targeting women, and supports some benefit being conferred to heterosexual men.

BHIVA/BASHH conference – Tuesday 20th April

20 Apr, 10 | by Jackie Cassell, Editor of STI

Overshadowed by volcanic ash – above the surprisingly bright and cloudless sky of Manchester – the BHIVA/BASHH conference started well if disjointedly, with absent international speakers. Rosella Nappi joined us from Naples to talk about sexual desire disorders in women, like a voice in a Victorian séance, but others were altogether absent.
Tom Quinn was unable to present an opening lecture on “HIV, STIs and transmission: an unfortunate relationship.” James Bingham’s Harrison lecture on “Fear, prostitution, comfort and rape” was consequently rescheduled to this opening evening. James was introduced by BASHH’s president Keith Radcliffe as a father of venereology – indeed he seems gradually to be acquiring mythological status rather like the father of the Marshalsea in “Little Dorrit”, just down the road from St Thomas’s.
The topic was the eternal and complex intermingling of soldiers, sailors, venereology and the place of sex in war. Colonel Harrison, after whom the eponymous lecture is named, was the occasion for a panoramic view of STI control from the mid-Victorian era to the cold war, and more recently, the UN Global Initiative on AIDS and Security. As you will see if you watch the podcast – see the BHIVA/BASHH conference website – James has dug out a number of unforgettable phrases (such as the “400 mounted whores and 800 on foot” who allegedly accompanied the Duke of Alba’s invasion of the Netherlands). But what is extraordinary to us now is the sheer scale of the suffering and damage associated with syphilis, with enormous military Netley military hospital 5/6ths filled with syphilis patients, many in a psychiatric wing termed “The Inferno”. In 1897, the British army in India recorded 508 men hospitalized, to 1000 “on strength” – like all military authorities, they collected excellent statistics.
Accounts of the sexual commerce of the first night in dock for naval carriers (in 1805 HMS Revenge took on board 450 women for a crew of 600 men) reminded us of the roots of contemporary STI control science in an aircraft carrier study, which provided estimates of the transmissibility of gonorrhoea.
We were reminded of the ever-changing and unpredictable nature of medical euphemism in the term “BBC” or “Bitten by Camel” – this connoted venereal disease in World War Two along the North African front. Like many of us, I have BBC in my family history, and like the volcanic cloud it was not an insurable risk for my forebears, though a foreseeable occupational hazard. We hope our colleagues from around the globe will join us soon.

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