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Hepatitis C

Sexually transmitted infections are amongst the fastest spreading high-incidence notifiable diseases in China

31 May, 17 | by Leslie Goode, Blogmaster

Sexually transmitted infections emerge from a recent epidemiological study as a particularly pressing concern for Chinese public health at the present time.  Yang & Li (Y&L) assess trends in incidence and mortality in 45 notifiable infectious diseases across China over the decade since the SARS tragedy in 2003 brought important changes in Chinese public health strategies (2003-2013). The main interest of the authors is to investigate the effectiveness of the new strategies.  But, for readers of this journal, what will be especially interesting about this study is the unique profile of three sexually transmitted – or potentially sexually transmitted – diseases: syphilis, HCV and HIV.

In terms of current incidence these three occupy 6th, 8th, and 15th place among the 45, with yearly incidence per 100,000 of, respectively, 20.75, 9.33, and 3.11.  In respect to mortality, HIV far outstrips all the others (even TB), with 48,199 deaths over the ten year period.  However, syphilis, HCV and HIV differ from other high-incidence diseases – hepatitis B, TB, mumps and bacterial dysentery (respectively, 2nd to 5th in the incidence table) – in that their year-on-year incidence is increasing, and at an impressive rate (estimated at a yearly 16.3%, 19.2% and 16.3% averaged over the decade).  These increases are unparalled except in the case of hand, foot and mouth.  The trend in STI incidence emerges particularly strongly against the background of overall trends in the other notifiable diseases. These have, on the whole, been towards stabilization in the latter half of the decade (2009-2013), following an earlier rise likely due in part to technological progress in laboratory detection and case identification (2003-2009).

This raises the questions whether, in the case of STIs, there are particular social factors at work.

For the authors of the study, syphilis, HCV and HIV fall into the category of those diseases whose recent spread can be attributed to the enormous demographic upheavals that have brought over 10% of the population from poor rural areas to the big urban centres in search of economic opportunities, and to ‘augmented human connectivity’.  As regards population mobility, the opinion of Y&L is corroborated by Chen & Tucker (STIs), and – in the case of MSM populations – by Yu & Shang (STIs).  Interestingly, Y&S identify a class of ‘recent migrants’ to the big cities, whose risk profile appears to differ very considerably from that of longer-term residents. Young FSM – many of them also recent migrants to urban centres – appear to represent another high-risk group (Zhang & Luchters (STIs)).  As for the related factor of ‘augmented human connectivity’, this has also been strongly corroborated (Tang & Tucker (STIs)).  Other studies, however, have traced regional outbreaks in these infections – syphilis, HCV and HIV – to causes that are less obviously linked to recent demographic change.  Zhang & Tang (STIs), for example, emphasize the part played in Guangxi by female sex workers who are patronized by older rural workers.  Epidemiological factors, especially over such a vast area, will obviously be complex and multifactorial.


ChemSex and HCV transmission among UK MSM

2 Feb, 15 | by Leslie Goode, Blogmaster

Reports of substantial rises in the incidence of HCV among MSM populations in the UK  (STI/Yaphe & KleinSTI/Ghosn & Chaix) have attracted some attention in STI journal.  Not least because intravenous drug use is the most obvious mode of transmission for this blood-borne virus, and MSM have in the past tended not to use this route of administration.  The question then arises what specific factors in the environment of these MSM populations are increasing their risk?  The question is all the more urgent as – whatever those factors may be – MSM populations seem as yet largely incapable of reducing them – to judge by the large proportion of successfully treated MSM who become re-infected within two years (40% according to a N. London hospital). A number of recent contributions to STI journal consider the role of MSM sex in HCV transmission (STI/Stall & McFarland; STI/Valencia & Salas), and what it is in the practices or lifestyle of MSM that puts them at particular risk. Associations have been identified with number of partners, casual anal sex, sex parties (STI/Marcellin & Spire): specific practices such as fisting, rimming, recreational use of intra-nasal drugs (STIs/Turner & Stephenson): interactions between these practices and certain self-described MSM lifestyle groups such as “leather”, or “lycra & rubber” (STI/Matser & van der Loeff).

A recently published guide for health professionals (ChemSex & Hepatitis C), claiming to be based on c.500 conversations with MSM clients, offers an illuminating, ground-level account of one risk environment: events involving “ChemSex”, or the collective use of recreational drugs to enhance sexual experience. The authors claim that ChemSex parties are a growing HCV risk for MSM for three reasons: greater availability of certain non-injection drugs; increased injecting drug use; more widespread use of smartphone Apps and online “hooking-up” sites.  MSM involved in Chemsex, they claim, are a particularly hard-to-reach group for health professionals because of their use of informal private venues (rather than clubs, or the street), and a lack of exposure and openness to IDU service messages owing to a past preference among MSM for non-intravenous drugs.

Before health professionals can communicate effectively with these clients about the potentially stigma-laden issue of HCV they need to develop an awareness of the various elements of risk in the ChemSex environment.     The booklet aims to guide health professionals on this path. This it is does by means of an illustrative “case study”, as well as by a systematic itemization of potential risk factors in the ChemSex environment, including some less obvious transmission routes  – such as blood on douching tools or shower hoses, or blood on the lube pump, or snorting straw.   Language, of course, is at the heart of communication.  The booket, therefore, includes a handy list of current popular terms, as well as suggested  questions to ask at consultations.

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