Category: Sexual health services

Project on the role of shame in failure to attend for STI and HIV testing shame approved for funding

The 2013 round of applications for funding has resulted in approval for the following pilot project:

Designing a Research project for understanding the role of stigma and shame in STI and HIV testing 

The project will be headed by Phil Hutchinson, Ph.D. (Man.), M.A. (Man.), B.A. (London), Senior Lecturer in Philosophy, Manchester Metropolitan University.

The aim of the preliminary project is to find the methodology to test the hypothesis: is shame one of the reasons for failing  to attend for STI and HIV testing. The project will be completed within six months involving setting up workshops with groups involved with both patient groups and those sexual health care.

HIV testing in the street: a useful tool for widening coverage

The March issue of the journal STI included an article by Sonia Fernandez-Balbuena and colleagues in Madrid which demonstrated that offering HIV testing on the street  may allow a significant number of hard-to reach populations to offer themselves for HIV testing.

Of 7552 persons in various Spanish cities who were asked to full a brief questionnaire and offered HIV testing 3517 participants (47%) were first-time testers. These included 24% of men who have sex with men , 56% of exclusively heterosexual men and 60% of women. 22 undiagnosed HIV infections were detected with a global prevalence of 0.6% and 3.1% in MSM.

The authors concluded that their community programme attracted a substantial number of persons previously untested and particularly hard to reach, such as those with low education and MSM who were least involved in the gay community.

In their view a decisive in decisive factor for almost two of every three persons who had never been tested. was the visibility of the programme.

Sexual behaviour in UK

The National Survey of Sexual Attitudes and lifestyles (Natsal) has been investigating sexual behaviour across a wide range of people, geographical spread and life styles at 10 year intervals since 1990. Natsal is the most extensive, authoritative and accurate investigation of sexual behaviour in the United Kingdom.

The latest report was published as always in the Lancet. The survey shows some interesting changes in sexual behaviour including a narrowing in the gap between men and women in same sex relationships.

Over 15,000 pople were interviewed using validated methodology that minimises bias.  Data were compared between Natsal-1 (1990—91), Natsal-2 (1999—2001), and Natsal-3.

82·1% of men and 77·7%  of women reported at least one sexual partner of the opposite sex in the past year. The proportion generally decreased with age, as did the range of sexual practices with partners of the opposite sex, especially in women.

The increased sexual activity and diversity reported in Natsal-2 in individuals aged 16—44 years when compared with Natsal-1 has generally been sustained in Natsal-3, but in men has generally not risen further. However, there was evidence of increased sexual activity and also increase in same sex activity in women.

In women the number of male sexual partners over the lifetime , proportion reporting ever having had a sexual experience with genital contact with another woman , and proportion reporting at least one female sexual partner in the past 5 years  increased since the last report in 2000.

Interestingly the reported number of occasions of heterosexual intercourse in the past month had reduced but there was a reported expansion of heterosexual sexual repertoires—particularly in oral and anal sex—over time.

Also of note: while acceptance of same-sex partnerships increased so did  intolerance of non-exclusivity in marriage  in men and women in the latest survey.

The authors concluded that:

“Sexual lifestyles in Britain have changed substantially in the past 60 years, with changes in behaviour seeming greater in women than men. The continuation of sexual activity into later life—albeit reduced in range and frequency—emphasises that attention to sexual health and wellbeing is needed throughout the life course.”

Need and acceptability of human papillomavirus (HPV) vaccination in men

HPV vaccination of young women with the quadrivalent vaccine (HPV4) resulted in a dramatic fall in genital warts and cervical cancer rates. However rolling out a similar vaccination in young men has been hampered by arguments that  male HPV4 vaccination programmes exceed cost-effectiveness thresholds.

Unlike the USA and Australia, European countries do not include men in HPV vaccination programmes, instead focusing on achieving expanded coverage among women to promote herd immunity.

Yet there is  evidence that HPV4 vaccination offers substantial clinical benefits to men and is cost effective among men who have sex with men (MSM). MSM have largely been excluded from mathematical models. A recent study in the journal Sexually Transmitted Infections has shown that HPV related conditions such as anal/genital warts and rectal infections are likely to be profoundly underdiagnosed among MSM in most European cities. The paper concluded that there is an urgent need to improve sexual healthcare tailored to MSM at risk for STIs.

There is also the argument  for a gender-neutral (universal) approach to vaccination.

In the same issue of STI a meta-analysis shows that there are currently a number of obstacles to acceptability of HPV vaccination in  men. They concluded that Public health campaigns should aim to promote positive HPV vaccine attitudes and awareness about HPV risk in men. The paper recommended interventions to promote HPV vaccination for boys and to overcome  obstacles to HPV vaccine acceptability for men.

Bacterial vaginosis (BV): a common cause of vaginal discharge in need of more research

Bacterial vaginosis (BV) is a common condition in women presenting as a malodorous vaginal discharge. The  smell is often worse after sex and arround the menstrual period. Occasionally there is an associated  itching or burning sensation although most women with BV only have the discharge. BV can also be detected in women who are totally symptom free.

BV is caused by an imbalance of the normal vagina flora and its mechanism remain poorly understood. An updated review by the Centre for Disease Control (CDC), USA confirms a commonly observation that BV follows sexual intercourse with a new partner and multiple partners as well as vaginal douching.

BV, itself an benign though troublesome nuisance is associated with increased risk of a number of infections or conditions:

  • Having BV can increase a woman’s susceptibility to HIV infection if she is exposed to the HIV virus.

  • Having BV increases the chances that an HIV-infected woman can pass HIV to her sex partner.

  • Having BV has been associated with an increase in the development of an infection following surgical procedures such as a hysterectomy or an abortion.

  • Having BV while pregnant may put a woman at increased risk for some complications of pregnancy, such as preterm delivery.

  • BV can increase a woman’s susceptibility to other STDs, such as herpes simplex virus (HSV),chlamydia, and gonorrhea.

  • The bacteria that cause BV can sometimes infect the uterus (womb) and fallopian tubes (tubes that carry eggs from the ovaries to the uterus). This type of infection is called pelvic inflammatory disease (PID).
  • Pregnant women with BV more often have babies who are born premature or with low birth weight (low birth weight is less than 5.5 pounds). Pregnant women who have had previous premature of low birth weight babies should be tested and treated for BV in third trimester regardless of symptoms.

HPV vaccination has real population effect on genital warts in Australia

A recent editorial by Simon Barton and Colm O’Mahony in the BMJ highlight real and large declines at the population level of genital warts in both sexes in areas where mass vaccination by the quadrivalent vaccine have been implemented. The authors summarise the achievements to date:

1. A study published by Hammad Ali et al in the same issue reports that survey of of 85 770 new patients from six Australian sexual health clinics show a remarkable reduction in the proportion of women under 21 years of age presenting with genital warts—from 11.5% in 2007 to 0.85% in 2011 (P<0.001). Only 13 cases of genital warts were diagnosed in women under the age of 21 across all six health clinics in 2011. There was no observable effect in women over 30.

2. Interestingly, even though only young women were offered vaccination, there was also a significant decline in genital warts in young men. Between 2007 and 2011 there was a decline of 82% in the prevalence of warts presenting to sexual health clinics in heterosexual men under 21 and 51% in heterosexual men aged 21-30. There were no observed change in prevalence of genital warts in men who have sex with men (MSM). This decline of genital warts in young heterosexual men was thought to be caused to increased herd immunity.

3. Based on these and similar findings and also on grounds of equity the Australian government has begun a publicly funded HPV vaccination program for young men. This aims to reduce the prevalence of genital warts in MSM and also hopefully effect the rising rates of oropharyngeal cancers in men. Ali et al commented that “the vaccination program is expected to increase herd immunity and provide further indirect protection to unvaccinated women” hopefully leading to control, if not elimination of teh targeted HPV types.

4. It is believed that  similar falls in HPV-16 and HPV-18 related cancers – such as cervical, anal and oripharyngeal cancers will be reported in the next few years.

5. The editorial expressed the hope that future vaccines will include other potentially harmful HPV types, such as types 31 and 45.

 

What is in the May issue of STI

The latest issue of STI (Sexually Transmitted Infections) contains articles on increasing resistance of bacterial STI’s, a successful  educational interventions in South London to encourage HIV testing and data supporting the willingness by a substantial section of men who have sex with men to use pre-exposure prophylaxis for HIV.

particularly worrying is the emergence of a novel strategy by the gonococcus to avoid detection by the now widely used DNA amplification methods.

Non-disclosure of known HIV status in patients visiting a sexually health clinic

Currently in the UK it is estimated that 24%, approximately 22 200 individuals, are unaware of their HIV infection . These data are derived from statistical modelling of many  surveillance, and survey-based data sources. One of the surveillance programmes used is the unlinked anonymous HIV seroprevalence survey, the GUMAnon Survey, where patients who have blood taken at a sexually health clinic would in addition give an additional sample which is tested for HIV after the sample is completely anonymised. The limited information accompanying the sample includes whether the person is known to be HIV positive, has a test in the clinic or refuses an HIV test.

A recent study published in the journal Sexually Transmitted Infections (STI) attempted to identify HIV-infected individuals who attend a genitourinary clinics in the UK aware of their HIV status but fail to tell the clinic they are infected, or on treatment.  In this study in addition to anonymised HIV testing the positive samples had viral load (VL) estimation and after excluding known HIV positives the remaining the samples were analysed for the presence of a panel of antiretroviral drugs.

The authors identified 130 individuals attending a single London sexually transmitted infection clinic in 2009 who refused an HIV test.  Of 28 patients identified by the anonymised test  as being HIV positive who had not admitted to being infected 10 patients underwent a test at the clinic and received a positive test.

The other 18 had  refused an HIV test, although found to be positive by the anonymised test. Thirteen of these (72%, 95% CI: 47% to 90%) had a blood viral load (VL) below detection level  (n=11) or VL <1000 copies/ml (n=2) suggesting they were on antiretroviral treatment. Eight had sufficient blood to undergo antiretroviral testing, and all were positive for the presence of drug; all with therapeutic levels of clinically appropriate combinations.

Thus nearly three quarters of HIV positive patients (72%) who refused an HIV test, and hence would have been considered as not knowing their HIV status, were indeed aware of their status and are on treatment.

These results “presents a number of challenges and dilemmas both for clinics and surveillance systems” says Jackie Cassell, editor of STI journal, who went on to also points out the difficult issues of confidentiality in sexual health services in the age of electronic health records.

Self-taking vaginal sample best test for chlamydia and gonorrhoea in women

The optimal diagnostic sample for Chlamydia trachomatis detection should detect the maximum number of infected people.  In women without symptoms the sample of choice is a self taken vulvovaginal swab, which can be done in the privacy of one’s home. But it is not clear whether a vulvovaginal swab or an endocervical swab is the optimum sample in women with symptoms requiring speculum examination.

A recent study by Sarah Shoeman and colleagues published in the BMJ compared the two sampling methods. They showed that in women attending a sexual health centre vulvovaginal swabs were significantly better at detecting chlamydia infection than endocervical swabs among women with symptoms of a sexually transmitted infection.

In these cases, using endocervical samples rather than vulvovaginal swabs would have missed 9% of infections, or 1 in 11 cases of chlamydia infection

A  parallel  study by the same group showed that self taken vaginal swabs tested by the  Nucleic acid amplification tests (NAATs) which offer increased sensitivity for detecting gonorrhoea, is significantly more sensitive and offers good specificity for detecting gonorrhoea compared with standard gonorrhoea culture methods.

However  confirmation of positive results with a second NAAT is essential in low prevalence populations such as the UK, to avoid false positive results

Women and clinicians can be confident that self taken vulvovaginal swabs are as accurate as clinician performed tests for the detection of chlamydia and gonorrhoea in women without symptoms and should be the test method of choice in asymptomatic women.

New HIV infection in UK in men who have sex with men exceeds heterosexual transmission after many years

Annual report of HIV infections in the United Kingdom in 2001 published by Health Protection Agency (HPA) show that for the first time in  many years newly diagnosed infections were higher in men who have sex with men (MSM) than transmission through heterosexual intercourse.

By the end of 2011, there were an estimated 96,000 (95% credible interval 90,800 – 102,500) people were living with HIV in the UK. Approximately one quarter (22,600, 24% [19%- 28%]) of these were undiagnosed and unaware of their infection. Fig 1

Fig 1. People infected with HIV at the end of 2011

 

This is an increase from the 91,500 people estimated to have been living with HIV by the end of 2010. The estimated prevalence of HIV in 2011 was 1.5 per 1,000 (1.5-1.6) population of all ages, 2.1 per 1,000 (1.9 – 2.3) men and 1.0 per 1,000 (1.0 – 1.1) women.

The rise in new diagnosis in MSM (Fig 2) is particularly worrying as nearly half the patients (47%) are diagnosed late when their immune system is already compromised increasing the chance of a fatal outcome within one year of diagnosis ten fold. These deaths are totally avoidable with the use of anti-viral therapy early in the infection.

 

Fig 2. New cases of HIV by exposure category