BHIVA/BASHH Conference Highlights

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.

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