Our record in the UK is pretty poor for teenage pregnancy and is likely to get worse with more and more free (privatised) schools opting out of sex education. Encourage your teenage children to visit Stay Teen web site and do the quiz.
Category: Public health
CROI 2012 Review web cast
Register now for web-cast education on the most important topics covered by CROI (Conference on Retroviruses and Opportunistic Infections) in February 2012. The web-cast will cover the following topics
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Review the latest data on anti-retroviral medication.
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Describe studies using HCV protease inhibitors in HIV infected patients.
- Describe the latest data on treatment of TB and opportunistic infections in HIV patients.
The target audience are
- Physicians
- Physician Assistants Nurses
- Nurse Practitioners
- Other health care professionals caring for people with HIV
Registration deadline is May 1.
NHS Bill: the case against
As the NHS Bill plods its slow passage into law it has become increasingly clear that a majority of health care workers, both doctors and nurses, do not agree with it in its current form. However most people who oppose the bill are not fully familiar with its details. Dr Clive Peedell, Consultant Clinical Oncologist and member of the NHS Consultant Association has dissected the case against the Bill and presented it in a powerpoint presentation that will be very useful in familiarising opponents of the bill with its details and for arguing the case against it.
Click on Case against NHS Bill to download the powerpoint.
Sexual behaviour as well as HPV types 6 and 11 are associated with genital warts
A recent study by GM Anic et al from the H. Lee Moffitt Cancer Center and Research Institute in Tampa, Fla., have found that human papillomavirus types 6 and 11, as well as recent sexual behavior, are strongly associated with the incidence of genital condyloma (wart) infection.
The strongest associations were found for infections with HPV types 6 and 11. The risk for condyloma also increased with an increasing number of female sexual partners but decreased with age. Sexual behaviors in the previous 3 months were also associated with a high risk for condyloma: a high number of male anal sex partners, more frequent vaginal intercourse and infrequent condom use. Also influencing the incidence of condyloma was ever having a sexually transmitted infection and ever having a partner with condyloma.
Since subclinical infection with HPV is more common than condylomas, this latter finding suggests that patients with visible genital warts are more likely to transmit condylomata to their sexual partner. This finding confirms an old study by the veteran British venerologist JD Oriel in 1971.
Factors strongly associated with condyloma were incident infection with human papillomavirus (HPV) types 6 and 11 (hazard ratio [HR], 12.42 [95% confidence interval {CI}, 3.78–40.77]), age (HR, 0.43 [95% CI, .26–.77]; 45–70 vs 18–30 years), high lifetime number of female partners (HR, 5.69 [95% CI, 1.80–17.97]; ≥21 vs 0 partners), and number of male partners (HR, 4.53 [95% CI, 1.68–12.20]; ≥3 vs 0 partners). The results suggest that HPV types 6 and 11 and recent sexual behavior are strongly associated with incident condyloma.
“The strong association between recent sexual history and incident condyloma after accounting for HPV infection suggests that prevention efforts targeting behavioral modification may be effective at reducing condyloma incidence among men who have not received the HPV vaccine,” the researchers wrote.
New ways of getting treatment to sexual partners of patients infected with chamydia or gonorrhoea
Treating a sexually transmitted infection in a person is incomplete without treating te sexual partner and thus closing the loop. Current forms of partner notification (PN) are not particularly successful with less than one half of sexual partners attending sexual health (genitourinary medicine) clinics.
A recent study by Claudia Escourt and her colleagues has looked at the feasibility of two different approaches to PN. One was to set up a hotine for the partner to phone a health care worker in the sexual health clinic and after appropriate consultation to collect their treatments either at the sexual health clinic and the secone was for the partner go to a a designated pharmacy and obtain treatment from a trained pharmacist. The partners were also asked to provide urine for chlamydia testing and to attend the sexual health clinic at a time of their own convenience for syphilis and HIV testing.
The preliminary results were encouraging and showed that both systems were acceptable to clients and increased uptake of treatment from 36% to 59% in the case of the clinic hotline and 66% in case of pharmacy.
The only drawback of either strategy was that almost none of the partners accessed HIV or syphilis testing at a later date.
Oral human papillomavirus infection more common in US males
Almost 7 percent of American men and women are infected orally with the human papillomavirus (HPV), new research reveals, with men showing significantly higher infection rates than women. Indeed among those between the ages of 14 and 69, men seem to face a nearly threefold greater risk than women for oral HPV infection.
The study was part of the ongoing National Health and Nutrition Examination Survey (NHANES). To better understand that connection, Gillison’s team sifted through data on nearly 5,600 men and women collected between 2009 and 2011 NHANES. All NHANES participants had been examined in person, during which all were tested for HPV.
In a study published in the Journal of the American Medical Association (JAMA) on Janury 26, 2012 Dr. Maura Gillison, chair of cancer research in the department of viral oncology at Ohio State University’s Comprehensive Cancer Center in Columbus reported an overall oral HPV infection rate of 6.9 percent, with HPV-16 being the most common type.
Oral HPV incidence varied with age, however, with peak rates occurring among those between the ages of 30 and 34 (at 7.3 percent) as well as among men and women between 60 and 64 (11.4 percent). Overall, oral HPV infection hit the 10 percent mark among men. Among women it was just shy of 4 percent.
While those with a history of smoking, heavy drinking, and/or marijuana use appeared to face a higher risk for infection, sexual behavior also plays a key role in upping a person’s risk. For example, while those who had never had sex faced less than a 1 percent risk for oral HPV infection, prevalence hit 7.5 percent among those who were sexually active. And the greater the number of sexual partners, the higher the risk.
Measuring Quality in Sexual health Services
There are a number of reasons why providers of sexual health services might wish to measure quality. Advances in technology, economic uncertainty and increased media coverage of medical errors have created a focus on improving quality in healthcare by those commissioning services, and central guidance in many healthcare systems encourages providers to make services more patient centred. The need to improve quality is also driven by funding mechanisms which often reflect the number of patients attracted to a service and increasingly include a penalty for failing to meet minimum quality standards.
Quality encompasses patient safety, patient experience and the effectiveness of care. It is multidimensional and its interpretation may vary between commissioners, providers and patients. Despite this apparent heterogeneity, four key components of quality can be defined: accessibility, acceptability, effectiveness and efficiency.
Accessibility defines how easy it is for patients to get to, and be seen at, a sexual health service. The majority of sexual health patients self-refer, and therefore ease of access is an essential factor when choosing whether to attend a clinic or making a choice between different clinics. Measuring the accessibility of a service can be achieved by formally reviewing clinic location, transport links and parking facilities, although these may not be easily amenable to change. Physical factors, including disabled access, should be easier to change, with the aim of complying with local legislation. Providers have the potentially greatest influence over organisational issues, for example, the percentage of patients seen outside working hours.
Acceptability relates to whether the services provided are perceived to be satisfactory by the patient. Acceptability is also an outcome or consequence of care that may influence subsequent consulting behaviour and health-related decision making. In either case, evaluation of the opinions of both users and providers is needed.
Effectiveness is whether a service delivers care correctly when assessing the patient’s problem, undertaking appropriate investigations and giving the correct treatment. This encompasses clinic systems to deliver care, individual patient management, and ensuring patient safety.
The limited availability of healthcare resources (including funding, technology and labour) requires them to be used in the most efficient way to maximise outcome. A number of techniques have been developed to measure efficiency in healthcare, for example, cost-effectiveness analyses (the change in cost against change in outcome for a specific disease) and quality-adjusted life years (used in cost utility analyses to calculate the ratio of cost to number of years of life gained for a particular health intervention). New technology and changes in working practices offer the greatest opportunities to improve efficiency, but require an assessment of associated costs and benefits, which may be both financial and non-financial, for example, improved patient satisfaction, greater diagnostic sensitivity.
A shift in focus from volume to quality of care is increasingly driving change in sexual health services. However, if measuring quality is to translate into improvement in patient care, a number of key practical questions still remain to be answered, including:
Which bundle of measurements best discriminates between good and poor quality?
How can quality data be most effectively used to effect change and improve outcomes?
Vitamin D deficiency and cardiovascular disease: more information needed
Vitamin D deficiency is common in the general population. It has been linked with hypertension, myocardial infarction, and stroke, as well as other cardiovascular-related diseases, such as diabetes, congestive heart failure, peripheral vascular disease, atherosclerosis, and endothelial dysfunction.
Yet a recent publication in The Annals of Internal Medicine has highlighted the conflicting nature of the information available, as it relates to increased cardiovascular disease, and has called for proper prospective randomised studies.
Vitamin D deficiency, along with cardiovascular disease, diabetes and some malignancies are more commonly seen in HIV infected patients compared to age-matched controls. While the mechanism for the vitamin D deficiency in HIV infection is still unclear, this deficiency has been shown to be associated with an increased prevalence of type 2 diabetes mellitus.
In a cross sectional study of their HIV cohort in Pennsylvania, USA, Guaraldi and colleagues showed an almost doubling (OR 1.85 CI 1.03-3.3) of diabetes mellitus in those with vitamin D levels below 20 ng/ml compared to those with normal levels. The authors controlled for vitamin D supplementation, sex, age, body mass index (BMI), and hepatitis C, all of which are known to effect glucose metabolism.
We urgently need prospective studies to confirm these findings and to answer the question if vitamin D supplementation will prevent these putative complications of vitamin D deficiency.
Antiretroviral prophylaxis: a defining moment in HIV control
According to an editorial by Salim Abdool Karim in the Lancet a defining moment in the global AIDS response has been reached. The discourse is no longer about HIV prevention or HIV treatment; it is now about HIV control through the implementation of antiretroviral treatments as key components of combination interventions.
Barely a year ago, visions of HIV control would have been considered far-fetched. The impetus for this change in mindset, which has been building since the XVIII International AIDS Conference in Vienna last year, emanates from the compelling evidence that antiretroviral drugs prevent HIV infection in the general heterosexual population, which is released this week and presented at the 6th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention in Rome by the Partners PrEP and Botswana TDF2 trials.
The Partners PrEP trial, involving 4758 HIV discordant couples from Kenya and Uganda, found that daily oral tenofovir disoproxil fumarate (TDF) and TDF-emtricitabine reduced HIV transmission by 62% and 73%, respectively. The Bostwana TDF2 trial, in 1200 heterosexual men and women from the general population, found that daily oral TDF-emtricitabine reduced HIV transmission by 63%.
Both these are of a similar order of magnitude to that seen with male circumcision and is probably caused by a significant reduction of HIV in the genital tract.
see fig 1 for comparison between different prevension strategies
Several issues were raised by the authors that need further research. There is now no doubt that antiretroviral drugs prevent HIV infection. However, important scientific questions remain. Does the inclusion of emtricitabine in pre-exposure prophylaxis (PrEP) formulations provide sufficient additional benefit to warrant the additional costs and side-effects? Are levels of effectiveness and safety similar for daily use and use-with-sex of PrEP? Do the safety, effectiveness, cost, and acceptability profiles of oral and topical PrEP merit implementation of both formulations? Does PrEP lead to masking of HIV acquisition that is then revealed once PrEP is withdrawn?
UK NHS finally accepts to use quadrivalent HPV vaccine in girls
From next September girls in the United Kingdom being vaccinated against human papillomavirus (HPV) will receive Gardasil, the vaccine that protects against genital warts as well as cervical cancer.
The Joint Committee on Vaccination and Immunisation recommended that the HPV vaccine should be offered routinely to girls aged 12 to 13 years and in a catch-up programme to those up to 18 years of age. Since then, 1.5 million young women and girls have been protected.
GlaxoSmithKline, which has been providing the Cervarix vaccine to the UK’s HPV vaccination programme since it launched in September 2008, said in a statement that it did not take part in the latest tendering exercise to provide a vaccine for the programme because the government made it clear that it wanted to protect girls against the types of HPV that caused cervical cancer and those that caused genital warts.
Gardasil, which is supplied by Sanofi Pasteur MSD, protects against HPV types 16 and 18, which cause 70% of cervical cancers, and HPV 6 and 11, which are responsible for nine in 10 cases of genital warts. Cervarix protects against HPV types 16 and 18.
When the UK programme launched, health campaigners criticised the choice of Cervarix as being short sighted and a missed opportunity (BMJ 2008;336:a451, doi:10.1136/bmj.a451)
Worldwide Gardasil has been the vaccine of choice. It has been selected by health authorities in the United States, Australia, New Zealand, Canada, Switzerland, Italy, Spain, and Sweden for regional or national vaccination programmes against cervical cancer.
Research from Australia has shown that cases of genital warts have nearly disappeared since 2007 when the national vaccination programme against cervical cancer using Gardasil was introduced (Sexually Transmitted Infectionsdoi:10.1136/sextrans-2011-050234). The study found that new diagnoses of genital warts among women under 21 years attending a sexual health centre in Melbourne fell from 18.6% in 2007-8 to 1.9% in 2010-11 and in heterosexual men aged under 21 from 22.9% to 2.9%. During the period before the introduction of the vaccination programme, new cases of genital warts rose by 1.8%.