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Sexual health services

UK National Health Service (NHS) kicks PrEP into the long grass

18 Jul, 16 | by Leslie Goode, Blogmaster

A recent BMJ editorial condemns the NHS position that it will not consider PrEP for direct NHS funding.  The decision was first communicated in an NHS statement issued in March, then confirmed by a review on 31st May, following reconsideration in response to objections raised by interested groups.  This brought to an end an eighteen-month process of discussion between Department of Health, doctors and patients groups, Public Health England and other stakeholders.  The NHS decision is currently under judicial review – which no doubt explains the timing of the BMJ editorial.

Advocates of PrEP argue that the NHS has powers under the Health and Social Care Act (2012) directly to commission services ‘prioritized for investment’, and that PrEP should qualify for consideration on this basis.  But the conclusion of the NHS is that PrEP does not qualify to be so considered because the Local Authorities Regulations (2013) clearly stipulate that commissioning for sexual health prevention is legally the responsibility of local government.

Technically, then, the argument turns on whether the NHS can commission for PrEP directly, given that PrEP is a form of sexual health prevention. Needless to say, in the eyes of the advocates of PrEP, this is a mere technicality invoked by the NHS in order to shirk its responsibilities.  The NHS statements also include the proposal to work with local government authorities on exploring how they should go about commissioning PrEP services most effectively, and to dedicate £2m to the establishment of local pilots.  The problem here is that local authorities, having lately had £200m shaved off their funding for sexual health services, are presumably not in a hurry to pick up the tab.

So what about the case for PrEP? As regards effectiveness for high-risk MSM populations, PrEP has emerged with flying colours from recent trials, including the UK PROUD  study (PrEP Highly Effective/STIs/blog; PROUD/STIs/blog) and trials with similar populations undertaken in France (IPERGAY) and California (Volk & Hare).  Cost effectiveness, however, is another matter – and here PrEP has failed to make the grade.  Recent studies have shown that in the UK PrEP is not even borderline cost-effective without substantial reductions in the cost of the drugs (Cambiano & Phillips/STIs; PrEP Highly Effective/STIs/blog; PrEP cost effectiveness study). And, of course, even cost-effectiveness is not the same as affordability.  When it is borne in mind how much in the way of demonstrably very cost effective services have recently been rendered unaffordable by government cuts (Unprotected Nation/Report), the case for PrEP in the present climate does not look strong.

Can we ensure adherence to STI treatment guidelines in a world threatened by antimicrobial resistance?

27 Jul, 15 | by Leslie Goode, Blogmaster

Sexual health care in the UK has traditionally centred on specialist GUM (genitor-urinary medicine) services.  Since the turn of the twenty-first century primary care has played an increasing role, however.  The 2012 Health and Social Care Act is in line with this tendency, with most GP (general practitioner) practices now being commissioned to provide level 1 STI screening.  Questions have recently been raised about the conformity of care provided by GPs to national guidelines, established for the UK by the British Association for Sexual Health and HIV (BASHH) (Trotter & Okunwobi-Smith (STIs)).

So what is currently the extent of GP involvement in the UK in care of infections previously dealt with by specialist services (i.e. Chlamydia and Gonorrhoea), and how is this impacting on the treatment of these conditions?  Wetten & Hughes (W&H), in a population-based study using data from the UK Clinical Practice Research Datalink (CPRD), provide the answers to both questions.  As regards the role of GPs, the proportion of Chlamydia cases they diagnosed varied over the study period (2000-2011) between 16% and 9%, and appeared to be on a downward trajectory, while the proportion of Gonorrhoea cases fluctuated between 6% and 9%.  As for the quality of care received in general practice, there is a marked disparity between the two conditions.  Whereas, in the case of Chlamydia, 90% were prescribed a recommended therapy, of the patients presenting with Gonorrhoea only 40% received the recommended anti-microbial regimen.  Ciprofloxacin continued to used (42% of prescriptions in 2006, 20% in 2011) long after the 2005 change in national treatment guidelines favouring cephalosporins.

These findings appear to corroborate the concerns expressed by UK patients in another recent study that their expectations for appropriate in-house care or referral to specialist services were not always being met (Sutcliffe & Cassell (STIs)).

The issues raised by these UK studies around the adherence to prescribing guidelines by generalist physicians are not, of course, unique to the UK.  Similar concerns have been voiced in studies based on data emerging from the BEACH (Bettering Evaluation and Care of Health) programme in Australia (Santella & Hillman (STIs); Freedman & Mindel (STIs); Johnston & Mindel (STIs), as well as in studies from more diverse settings (Khandwalla & Rahman (STIs)).  Quite apart from the need to optimize patient outcomes and reduce the burden of infection in the population, the problem of adherence by generalists to guidelines raises more general questions.  The issue of antimicrobial resistance has prompted recent national interventions to “steward” our remaining antibiotic defences (Gonorrhoea antimicrobial resistance (STIs/blog).  Such policies will evidently depend on the adherence to guidelines, including by generalists – especially in settings where they are responsible for much of STI care.  In a world where Gonorrhoea – and perhaps one day Chlamydia – is set to become increasingly hard to treat, the problem of ensuring the conformity of generalists to universal standards of treatment is unlikely to go away.

 

 

Why Tanzania seems unlikely to meet UNAIDS targets for HIV/AIDS prevention.

12 Jun, 15 | by Leslie Goode, Blogmaster

The UNAIDS 90-90-90 Target has set the goal that, by 2020, 90% of the HIV infected should know their status, 90% of those diagnosed should be in treatment, and 90% of those in treatment should achieve viral suppression.  The  UNAIDS GAP Report (2014) presses the need for countries to achieve a major redeployment of effort and resources towards tackling HIV among at-risk populations with a view to achieving that target (UNAIDS (STI/blog)).

Redeployment, a report by Congressional staff delegates on a visit to Tanzania hosted by the Infectious Diseases Society of America’s (IDSA) Global Education and Research Foundation gives a detailed account of the practical problems facing the attempt to make such ambitions a reality on the ground – even where UNAIDS recommendations are embedded in official government planning policy.  Evidence from visits of the staff delegates to Dar-es-Salaam, Zanzibar and Mbeya in the rural highlands is illustrated with well-chosen photographs.   These problems fall into three general categories.

First, there is a human resource problem.  At present, there is a 65% vacancy rate for health-care positions in the public sector.  According to the government figures, health workforce capacities have steadily declined from 67,000 in 1994/5 to 54,245 in 2002 to 48,000 in 2015.  The PEPFAR (President’s Emergency Plan For AIDS Relief) operational plan attributes this in some measure to gaps in Tanzania’s education capacities with large classes and poorly trained teachers, leading to pupils leaving school without adequate study, problem solving and analytic skills.

As regards redeployment of these limited resources in line with UNAIDS recommendations, this is hindered by the fact that at risk groups may be criminalized (e.g. drug-users, sex workers, MSM) and are certainly stigmatized.  Much of the outreach to them is through civil society organizations.  While the government has policies to support and defend their efforts, there is little in the way of financial investment.  Civil society organizations are hampered by the largely voluntary nature of their workforce, and the absence of adequate data concerning the size and whereabouts of at-risk populations (though it is estimated that between 2010 and 2015 the number of IDU rose from 25,000 to 50,000).  The prison population seems to be altogether inaccessible.

Thirdly, HIV transmitted to children born to infected mothers is often ignored, and the number of adolescents dying of AIDS has risen by a third since 2005.  This is partly because stigma surrounding a disease associated with IDUs, sex-workers MSM prevents parents from seeking diagnoses for their children.  The situation is not helped be the frequently poor state of record-keeping with no digitalization and folders “jammed into, stacked on top of, and spilling out of record cabinets”.

Though no doubt inadequate, data on “at risk” populations is not altogether absent.  Studies published in STI journal relevant to populations in specific places visited by delegates include an evaluation of surveys of MSM in Zanzibar, Haji & Kibona (STIs), and a discussion of the socio-demographic context of the epidemic in Mbeya, Riedner & Groskurth (STIs), focussing on female bar-workers.  As a poor but high-mobility rural population, Mbeya appears to share some socio-demographic characteristics with Mzanza province in the NW (bordering Lake Victoria) which has figured in a number of studies at the beginning of the last decade.  A number of these focus on barmaids as a particularly high-risk population (Hoffmann & Hoelscher(STIs); Boerma & Mwaluko (STIs); Bloom & Boerma (STIs)).

 

Retention in care rather than diagnosis may prove the ultimate challenge for US HIV response

25 Mar, 15 | by Leslie Goode, Blogmaster

The real challenge which the US HIV/AIDS epidemic poses for the US public health services is not simply to achieve higher levels of diagnosis – but, far more than that, to improve linkage to, and retention in, care.  This claim is hardly controversial. But it is thrown into stark relief in a recent study by Skarbinski & Mermin, which estimates the number of HIV transmissions attributable to non-retention in care for 2009.

The authors employ the notion of a five-phase “care continuum”.  Using population data from the National HIV Surveillance System and medical data from the National HIV Behavioral Surveillance System and the Medical Monitoring Project, they estimate the number of HIV transmissions occurring at each phase.  The phases in the continuum are: (1) infected, but undiagnosed; (2) diagnosed, but not retained in care (attending at least one visit to a medical care provider Jan. – April 2009); (3) diagnosed, retained in care, but not given ART; (4) diagnosed, retained in care, prescribed ART, but not virally suppressed; (5) virally suppressed.

The reduction in attributable transmissions achieved for those diagnosed but not retained in care (phase 2), as compared with those who remain undiagnosed (phase 1), is 19%.  (It is probably due to a decrease in HIV-discordant unprotected sex).  But the reduction achieved for those who achieve viral suppression (phase 5), as compared with those who remain undiagnosed, is 94%.  In estimating the epidemiological impact of these reductions, we need to factor in the percentage of the infected population at each phase.  The large proportion (45.2%) of the HIV infected who are diagnosed but not retained (phase 2) explains the very high proportion of total transmissions (61.3%) attributable to this phase.  By comparison, only 30.2% are attributable to the undiagnosed (phase 1), and 2.5% to the virally suppressed (phase 5).  The low epidemiological impact of those at phases 3 and 4 is due to the relatively low proportion of those infected who remain in these phases.

The message, then, is that achieving greater success in retaining the HIV diagnosed in care may prove the key to combating the epidemic at population level.  Of course, diagnosis remains the indispensable first step.  But the potential gains of diagnosis will be only very partially experienced, so long as such a large proportion of those diagnosed are not retained in care.  Of course, improving retention in care may constitute a somewhat different – and perhaps more difficult – challenge for the US health services from diagnosis.  The specific problems of the US health system in this regard are discussed by Sherer (STI), and the characteristics of individuals “lost to follow up” by Haddow & Mercey (STI) and Lee & Gazzard (STI).  Local attempts to address these problems through a more “wrap-around” approach to health care in the US are described in my blog Bocour & Less (STI/blog) (see Bocour &  Less).  There has also been interest in the computer assisted self-interviewing in order to engage those lost to care (Dombrowski & Golden (STI)).

Trialling innovative approaches to STI partner services: Partner-Delivered vv. Accelerated Partner Therapy

26 Feb, 15 | by Leslie Goode, Blogmaster

It is vital to treat partners of patients with curable STIs as quickly as possible.  But the effectiveness of interventions to achieve this proves hard to measure – and the case for increasing resources correspondingly difficult to make.  The inadequacy of the resources available to existing partner services has led some investigators in the US and UK to seek out innovative approaches to ensuring the treatment of partners which are less expensive.  One option – Patient-Delivered Partner Therapy (PDPT) – is to provide treatment for partners via the patient and without prior medical assessment of the partner.  The problems with this are: first, that PDPT may not conform to legal (Cramer & Leichliter (STI)) or professional guidelines; second, that concomitant infections (e.g. HIV) in the partner may go undiagnosed and untreated. An alternative solution – Accelerated Partner Therapy (APT) – is to treat the partner via the patient, but only after a medical assessment conducted by telephone or with a pharmacist (Golden & Estcourt (STI); Dombrowski & Golden (STI)).

The option of PDPT has been trialled in various US clinics (Mickievicz & Rietmeijer (STI); Sanchez & Schillinger (STI); but its impact is difficult to evaluate on a local level. Now, for the first time, Golden & Holmes have attempted a population-level randomized control trial of uptake and impact across 23 out of the 25 counties of Washington State.  This impressively large-scale operation had two elements.  The first was the provision of free PDPT, and involved: 1. informing all clinicians about the programme; 2. making stocks of free PDPT available to clinicians who had reported ≥ one case of Chlamydia or Gonorrhoea, and to certain large pharmaceutical chains; 3. visiting clinicians reporting frequent cases for the purpose of educating staff about the programme.  The second element was the possibility offered to diagnosing practitioners via routine report forms of having the provision of partner services handled by the state public health department. This intervention was rolled out in four successive waves to different counties in turn, thus enabling the impact of the intervention to be controlled against the default situation in the counties of each wave.

As regards uptake, percentage of persons receiving PDPT from clinicians rose in intervention periods from 18% to 34%, and percentage receiving partner services from 25% to 45%.  This is broadly comparable with what has been achieved by more local interventions in the US.  Unfortunately, it is one thing for a pack to be accepted by the index patient, another for a partner to be successfully treated.  Hence the interest of G&S’s attempt to evaluate population-level impact – through testing in sentinel clinics in the case of Chlamydia, and through incidence of reported infection in the case of Gonorrhoea. It was undoubtedly ambitious of G&S to seek an indicator of population level impact for a comparatively brief intervention.  It is no surprise that the results are less than overwhelming. Chlamydia test positivity and gonorrhoea incidence in women declined respectively from 8.2% to 6.5% and from 59.6 to 26.4 per 100,000. The latter more impressive reduction is unfortunately hard to distinguish from a strong secular trend in the same direction in various states.

There are more general problems, however – such as knowing whether the handing over of PDPT packs is resulting in the successful treatment of disease, or whether it may even be contributing to an ongoing failure to diagnose concomitant partner infections.  These might weigh in favour of the alternative approach recently developed in UK clinics: APT.  Estcourt & Johnson (STI) report uptakes of 66% and 59% for versions of APT as against 36% for conventional PS.  Sending a treatment pack following a telephone interview would seem to offer a better guarantee of partner treatment, than offering a pack on the basis of nothing more than a stated willingness of the index patient to deliver it.  At the same time, interviewing the partner averts the risk of doing harm by pre-empting consultations at which a fuller diagnosis of the partner’s condition would have been possible.  A population-level trial of the impact of APT has yet to be undertaken.

Should bisexuals be considered a population with specific sexual health needs?

28 Jul, 14 | by Leslie Goode, Blogmaster

Across many cultural contexts, men who have sex with both men and women (MSMW) have levels of STIs/HIV comparable to those we find in men who have sex only with men (MSM); but MSMW have often proved particularly hard for health services to access.  Mercer & Cassell (M&C) (UK) and STIs/Beyrer & Baral (B&B) (South Africa) refer to poor rates of HIV testing as compared to MSM (RR 0.31 and 0.62 respectively). Both studies stress the need to find ways of targeting safe-sex messages for MSMW who do not identify as gay.

In an intriguingly entitled reivew of the literature on MSMW sexual health in the US 2008-2013 (“Beyond the bisexual bridge”)  Jeffries  corroborates this general picture of high STI risk and poor accessibility.  But he seeks to get beyond what he considers an obsession on the part of researchers with the role of MSMW as a “bridging” population with women.  He claims this “characterization” is not justified by the research – at least where the US is concerned (Chu & Curran; Satcher & Dean; Kahn & Catania).  He also views it as ultimately detrimental to the sexual health of MSMW, which needs to be founded on the “recognition of MSMW’s unique sexual and social experiences”.

The article reviews both the sexual health, and socio-cultural challenges to MSMW’s health.  Sexual health challenges include: levels of STIs other than HIV equalling and exceeding MSM levels, alongside levels of HIV lower than MSM, yet higher than MSW (as in the UK (see M&C)); also enormously higher levels of injection drug use, sex in exchange for money or drugs, and drug and alcohol use during sex than in MSM; also sex within female networks (as well as male) that imperil sexual health, with a high proportion of female partners having injected drugs, being under influence of drugs during sex, and having concurrent partners.  Socio-cultural challenges include biphobia in society at large, and fairly extreme socio-economic marginalization, as indicated by lack of education, poverty, homelessness and incarceration.

Some corroboration of the role that Jeffries attributes to settled identities in moderating at risk behaviour is provided by the success of a number of ongoing initiatives aimed at black or Latino MSMW.  These all appear to address MSMW’s masculinity concerns and heterosexual identities in a non-judgmental and culturally sensitive manner.  Men of African American Legacy Empowering Self (MAALES) has been evaluated in a RCT discussed in an earlier blog (STI/blog/Are bisexuals well served by interventions that assume gay identity?).  Jeffries also mentions: Hombres Sanos; the Bruthas Project; the Enhanced Sexual health Intervention for Men (ES-HIM).

A puzzle remains in the lower susceptibility of MSMW, as against MSM, to HIV – alongside equivalent or higher susceptibility to other STIs .  Jeffries discusses this, but offers no explanation.  Could the less than expected levels of HIV in MSMW be the result of an association between MSM identity and sexual networks that carry particular risk of HIV transmission?

HIV impact of ObamaCare reduced by US Supreme Court decision

5 Mar, 14 | by Leslie Goode, Blogmaster

What impact will the roll-out of the US Affordable Care Act (ACA) – ObamaCare – have on health insurance coverage of people with HIV?  A recently published “issue brief” on behalf of the US Centers for Disease Control and Prevention (CDC) offers a first estimate (Kates & Garfield (K&G)).

The ACA includes a provision to expand Medicaid 1. by extending it to non-disabled childless adults (a group at present excluded), and 2. by raising the threshold of eligibility from the present 100% of the Federal Poverty Level (FPL) to 138%.  This would have considerable impact on uninsured HIV infected-people, as a large proportion of them are non-disabled childless adults, and relatively poor.  Thanks to a recent Supreme Court decision, responsibility for the implementation of this ACA provision rests ultimately with state legislatures.  Thus far, only 26 of the 51 states have plans to go ahead with it.  The authors of the brief give estimates, firstly for the impact that the ACA would have had but for the Supreme Court ruling, and, secondly, for the impact it will have, assuming implementation by just the 26 states that of stated their intention to go ahead with it.

In the case of full implementation of Medicaid expansion, say K&G, c.47,000 of the c.70,000 uninsured adults retained in HIV care would immediately be brought under Medicaid, while a further c.20,000 could benefit from the second major ACA provision relevant to the HIV-infected – namely, the subsidized insurance coverage which will be supplied by Health Insurance Marketplaces (HIM).

But, with just 26 states planning to expand Medicaid provision, only c.26,500 additional people will be brought under Medicaid.  Of the c.20,000 who ought to have qualified, but will now fail to do so, some 5,000 may be able to gain subsidized cover with HIM (those at between 100% and 138% of FPL), while the remaining c.15,000 (those under the 100% bar for subsidized coverage by HIM) will remain entirely uninsured.  Many people in this situation will seek coverage under the Ryan White HIV/AIDS program, as they have done in the past.

So the beneficiaries of ACA among the HIV-infected will, according to this brief, be considerably reduced by the Supreme Court ruling.  But does it really matter whether the HIV-infected of the US are treated through an expansion of Medicaid, or through the Ryan White program?

The authors of the brief seem to be in no doubt that ACA would represent an improvement on the present arrangements – and principally for two reasons.  The first has to do the 700,000 HIV-infected (63%) who are undiagnosed, or not linked to – or else not retained in – HIV care.  A proportion of these (the authors reckon as many as 124,000), newly eligible for Medicaid under ACA, could have been brought into regular medical care through the program.  This is the first opportunity missed.  The second has to do with the possibility of addressing the unmet needs of a particularly needy population (i.e. the c.200,000 HIV-infected who are currently uninsured but eligible for cover under ACA) on a more general and ongoing basis than is possible through the Ryan White program.  These, according to K&G, are the benefits which will be largely foregone in states that do not to ratify the expansion of Medicaid.

Taking seriously the public health impact of disengagement from HIV care in the US

17 Jun, 13 | by Leslie Goode, Blogmaster

ART as a strategy for “treatment-as-prevention” is frequently acknowledged.  Public health efforts, in the US as elsewhere, have focussed on prompt initiation of ART for the newly-diagnosed so as to shorten the duration of viremia – and thereby also reduce transmission risk.  But what about the public health implications of people living with HIV (PLWH) who have been diagnosed, but are disengaged, or poorly engaged with ART?

Contributions to STIs journal from the UK have discussed disengagement from a clinical perspective, its various social and behavioural concomitants (http://sti.bmj.com/content/early/2013/05/21/sextrans-2012-050966.abstract?sid=a9129e3e-e0b9-4e00-ad11-7023dd74276f; http://sti.bmj.com/content/79/4/349.3.full?sid=a9129e3e-e0b9-4e00-ad11-7023dd74276f).  However, in the US (and no doubt other countries) where the proportion of PLWH with consistently suppressed viral load (VL) is estimated at just 28%, with a large proportion of PLWH lost to follow-up (an estimated 35% in New York City), the public health impact of disengagement also becomes a serious concern.  For a start, the impact of early ART initiation as a “treatment-as-prevention” strategy can only be very limited.

A recent longitudinal study of a New York City (NYC) Health Department intervention to re-engage “persons lost to follow-up” (LTFU), sets out to consider the public health case for deploying resources on the “disengaged”, as well as the “not yet initiated” (http://journals.lww.com/aidsonline/pages/results.aspx?txtKeywords=Udeagu).  Existence of mandatory named HIV and laboratory reporting in NYC makes such an intervention a theoretical possibility. But how useful would surveillance data prove in locating LTFU – and how willing would the LTFU themselves be to re-engage with care?  These were the issues confronting the public health case workers conducting the investigation over the period 2008-2010.

Of the 797 PLWH presumed LTFU 409 (60%) were confirmed LTFU after elimination of those who could not be located, and those who turned out current-to-care after all.  Of these 409, 240 (59%) are classified as having returned to care as a result of the intervention  on the basis of HIV visit confirmed through medical record review or CD4/VL test report; however, most (97%) of the 240 also had at least one CD4 or VL test performed during the 12-months subsequent to their first return-to-care visit.  The returned-to-care group were much more likely to have had CD4/VL reported that those who refused linkage-to-care (95% vs 39%).  More disappointingly – only 65 partners were named in the course of the exercise, and ultimately only 3 newly diagnosed with HIV infection as a direct result of the study intervention.

The most important finding is the willingness of LTFU clients to re-engage with care, and the extent of their successful retention in care after re-engagement.  Other findings relate to the serviceability of the laboratory, surveillance and jurisdictional infrastructure for the purposes of the provision of a more comprehensively “wrap-around” care programs capable of improving retention in care.  Here the issues identified are the timely availability of laboratory information, the potential of linkage between surveillance data and the hospital record system, both of which could have saved expenditure on the location of presumed LTFU who turned out to be “current-to-care”. (The Louisiana Information Public Health Exchange is held up as a potential model of what can be achieved: http://www.lsms.org/site/images/stories/LaPhie-Non-techincal%20Guide.pdf).

Expedited Partner Therapy (EPT): Why in the US and not in the UK?

9 Nov, 12 | by Leslie Goode, Blogmaster

Expedited Partner Therapy (EPT) in sexual health is the practice of prescribing for the partner(s) of the patient without prior medical evaluation.  In many countries (e.g. UK and Australia) the practice is not current, since it does not comply with prescribing guidance.  But in the US it is being actively promoted by professional bodies (e.g. the American Association of Pediatrics (AAP)), and is currently employed in certain states, as a response to serious need which could not otherwise be met.

A recent paper (Hsii, Golden et al.) (http://pediatrics.aappublications.org.libproxy.ucl.ac.uk/search?fulltext=Neville+Golden&submit=yes&x=34&y=9) presents the results of a survey of junior doctors (residents) on pediatric training schemes in California (the first state to clarify the legality of EPT (2001)) regarding their knowledge of – and attitudes to – EPT. This is interesting for two reasons.  Firstly, the light it sheds  on an EPT itself, as one among a number of alternatives to conventional treatment practice sometimes proposed as a more effective means to meet public health need.  Second, on how the policy change required to implement the alternative approach tends to impact professional knowledge and behaviour over the longer term.

Key findings of the paper are: 52% of trainees claim to have used EPT, though 30% felt uncomfortable doing so – and only 8% were “fully aware” of the legal status of EPT in California.  For those of us living in countries where EPT is unfamiliar, the surprise is that EPT should be current practice at all – especially in the context of adolescents with all the associated problems of child protection.  The ill-ease of the trainees seems understandable given the complexity of issues surrounding EPT, which include, in addition to the question of its legal status and child protection issues, also problems around who pays for the prescription and how the partner’s treatment is dealt with administratively (see AAP position paper: http://www.adolescenthealth.org/AM/Template.cfm?Section=Position_Papers&Template=/CM/ContentDisplay.cfm&ContentID=1473).  No doubt an objective of the paper, which is published in the journal of the AAP, is to encourage the further embedding of EPT in the everyday practice of young physicians.

So why is the US heading off down this route faster than everyone else – and what are the chances that the rest of us – the UK, for instance – will one day find ourselves following in its wake?        Golden and Estcourt usefully set out some of the diverse challenges facing  implementation of EPT and related approaches the US and the UK (http://sti.bmj.com/content/87/Suppl_2/ii37.full); they also refer at some length, in the case of the UK, to a related alternative approach, Accelerated Partner Therapy (APT), pioneered in a recent exploratory trial in the UK, in which the medical evaluation of the partner takes place by telephone (see Roberts and Estcourt: http://sti.bmj.com/content/88/1/16.abstract).

The complexities around alternative referral approaches are considerable.  Furthermore, it really is the treatment of the adolescent population that is envisaged by recent US initiatives (a population excluded from the recent UK exploratory trial on account of child protection issues).  Child protection, of course, is no less a concern in the US (http://www.jahonline.org/article/S1054-139X(04)00200-9/fulltext).  If such initiatives are hard to imagine in the UK, this may simply be because the problem of unmet need has nowhere attained the scale it has in the US, where it would justify over-riding the counter-balancing concerns.  Another source of difference between the US and the UK, not mentioned by Golden & Estcourt, may be the absence of a professional interest group (like the paediatricians of the AAP) who feel themselves charged with lobbying specifically on behalf of the sexual health needs of adolescents (12+).  Ultimately, though, it is probably the sheer scale of the US adolescent chlamydia epidemic – as yet unmatched in the UK – that has driven the recourse in the US to unorthodox solutions.  If and when alternative referral practices – APT, for instance – become more widespread in the UK, it may not be in the same contexts as in the US, or for the same purposes.  At least we hope not.

Could Millennium Development Goals be bad for your health?

15 Dec, 11 | by Leslie Goode, Blogmaster

A recent paper by a Belgian team discusses the health impact of the Millennium Development Goals (MDG) in sub-Saharan Africa, and highlights the potential short-termism of a strategic approach focussed on “quick wins”.  Many of the health issues discussed touch on sexual health.

The year 2001 saw poverty become the focus of the global political agenda, when the 189 countries of the UN in the General Assembly established eight goals to be achieved by 2015. The goals (MDG) have given rise to funding instruments called Global Health Initiatives (GHI) which have tended to favour “very high short-term impact that can be immediately implemented” over more complicated and long-term developments.

The MDGs directly affecting sexual health are: MDG 6 – eradicate HIV/AIDS & Malaria; MDG 4 – reduce child mortality (because of vertical transmission of HIV/AIDS); MDG 5 – improve maternal health (because the 2005 World Summit included within this goal “achieving universal access to reproductive health”).  Indirectly and in the longer term, MDG 2 – achieve universal primary education and MDG 3 – empower women affect issues of behaviour change likely to impact on sexual health.  MDG 1 – eradicate hunger, 7 – ensure sustainability, 8 – develop global partnership primarily affect health issues other than sexual health.

In general, the paper argues that an emphasis on “quick impact” interventions is not always beneficial:

–          Initiatives have been developed in parallel to, rather than in integration with, the existing health systems, with resulting distortions in provision of care.

–           The focus on short term, community-based initiatives can result in deployment of resources away from longer-term strategies that require indigenous health services development and inter-sectoral approaches to health planning.

–          The assessment of progress on the basis of data that is not disaggregated for socio-economic status and other equity parameters can result in strategies that achieve global targets at the cost of neglecting the neediest population sub-groups.

A glance at the recent (2011) UNAIDS report will reveals the tension between this “high-

impact intervention” approach and much current thinking in the health policy area.

More specifically, the authors argue that while anti-retrovirals therapy (ART) may appear to be a “quick impact” intervention, sustaining progress in this area is going to require health service development in the longer term.  Expanding access to sexual and reproductive health services, while classed as a health-related “quick win”, has actually suffered a decrease in funding over the decade.  The paper also gives the example of contraceptive use in Kenya as a case of how apparent improvements overall can mask a deterioration in the situation of the most underprivileged (those classed “no education”).

The recommendations of this paper include:

–          More attention to health systems development essential to the future delivery of the aims embodied in MDGs 4, 5 and 6;

–          Not neglecting the role of MDGs 2 & 3 (universal education and empowering women) in securing improved maternal and child health long term;

–          Not allowing achievement of MDGs to be at the expense of continued efforts to improve the social determinants of health.

Fabienne Richard et al., “Sub-Saharan Africa and the health MDGs: the need to move beyond the “quick impact” model”, Reproductive Health Matters, Vol. 19, Issue 38, November 2011

http://www.sciencedirect.com/science/article/pii/S0968808011385795

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