Category: Sexual health

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.

Calls to immunise teenage boys after huge rise in throat cancer

Cases of oropharyngeal cancer have more than doubled to over 1,000 annually since the mid-1990s after remaining stable for many years, Professor Hisham Mehanna, director of the Institute of Head and Neck Studies in Coventry reports.

The Department of Health requested the latest figures from Professor Hisham Mehanna, who has surveyed the incidence of HPV-related oropharyngeal cancer in the UK and other countries. “We are experiencing a very significant rise in oropharyngeal cancer. It used to be rare in our practice – now [head and neck cancer] is the most common cancer we see. All the studies show there is a strong association with oral sex.” It is also occurring in younger patients.

More than 70 per cent of cases are caused by human papilloma virus (HPV), compared with less than a third a decade ago. HPV is transmitted during sex, including oral sex and also possibly spread by open-mouth kissing. HPV is the main cause of cervical cancer in women, affecting almost 3,000 women a year in the UK.

Currently women are offered HPV vaccine to prevent cervical cancer. The quadrivalent vaccine also protests against genital warts in both women and also their male partners and is now being advocated by the Department of Health.

The US is considering offering HPV vaccine to men.

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?

See: How to assess quality in your sexual health services. Emma Hathorn, Lucy Land , and Jonathan Ross.  Sex Transm Infect 2011;87:508-510 doi:10.1136/sextrans-2011-050107

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%.

WHO asks for 16 days of activism against gender violence

According to the World Health Organisation 1 in 4 women worldwide are physically or sexually abused during pregnancy, usually by her partner. The WHO multi-country study on women’s health and domestic violence against women has highlighted the extent of violence by intimate partners against women across a wide range of societies. WHO has asked for 16  days leading up to December 10, International Human Rights Day, for global activism to counter violence perpetuated against women.

STIRF funds new research on chlamydia and gonorrhoea

Chlamydia and gonorrhoea are the most common treatable bacterial sexually transmitted infections diagnosed within theUnited Kingdom. Most sexual health clinics now use Nucleic Acid Amplification based Tests (NAATs), which test for DNA sequences particular to the organism in question, to diagnose these infections.

These tests are highly sensitive and specific but can remain positive for a while after the infection is successfully treated with antibiotics. This is because NAAT tests, unlike bacterial culture, do not distinguish between live and dead organisms. This means that if individuals are retested too soon after completing treatment, their test result will still be positive from the initial treated infection. We do not know for how long this will be the case, making interpretation of repeat tests difficult.

This is particularly important in clinical practice, where where a test of cure is recommended, such as in pregnancy and after gonorrhoea. The research will allow better interpretation of test of cure results, thereby avoiding the need to retreat individuals and their partners with antibiotics unnecessarily.

The proposed project will follow up individuals known to have chlamydia or gonorrhoea who have been treated as per national guidelines and then retested every week (using NAAT tests) for the initial infection until this is no longer detected. Non-compliance and possible re-infection will be ruled out through structured questionnaires during the follow up period.

This is a collaborative study in conjunction with centres in London. STIRF will be funding the part of the study to be performed in Manchester.

Title of project: Testing for chlamydia and gonorrhoea: persistence of a positive test result after successful treatment.

Lead researcher:   Dr Gabriel Schembri

Place of Research: Manchester Centre for Sexual Health, Manchester Royal Infirmary.

Collaborating Centres: Sexual health centres in London

Proposed Duration of Study: One year

Funding from STIRF: £27,000 (subject to satisfactory report at six months)

 

US Committee recommends HPV vaccine for men

Human papilloma virus (HPV) causes warts but also is the underlying cause of various cancers, particularly cervical cancer in women.  HPV vaccines are now available and recommended for young women to prevent cervical cancer, and in the case of quadrivalent vaccine also genital warts. [see our news item: Quadrivalent wart vaccine would prevent high cost of care for genital warts ] The vaccine is more effective if administered to children aged 11-12 years, before they become sexually active

Now a study published in the New England Journal of Medicine showed that the quadrivalent vaccine can prevent intraepithelial neoplasia, a precursor of anal cancer, in young gay men. anal intraepithelial neoplasia associated with the HPV types linked to cervical cancer (HPV 16 and 18) were reduced by 55% in the vaccinated group. Consequently the US Advisory Committee on Immunisation Practice has recommended the roll out of vaccination to all children aged 11-12, regardless of sex.

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Delay in diagnosis of HIV can cut 15 years off your life

Current treatment with antiviral drugs has changed a previously fatal disease into a chronic condition where those infected can expect to live a normal and healthy life for many years.

Forward projections from a number of large cohorts have, however, suggested that with current treatment regimens patients may still have a slightly shorter life expectancy than uninfected persons. This is because patients with HIV appear to experience diseases associated with aging such as heart attacks, diabetes and cancer at a younger age,

A recent study from a UK-based large cohort by May and colleagues confirm these projections with men expected to do worse than women. They estimated that for an average 20 year old man HIV decreases life expectancy by 18.1 years compared with 11.4 years for women. This may reflect life-style differences between the sexes (alcohol, smoking) but may also be because women of child-baring age are more likely to be diagnosed early during routine antenatal screening.

Their study showed that persons starting antiviral therapy with a low CD4 count of less than 100 – which is sign of severe immunological damage – rather than earlier (CD4 200-350) lose over 15 years of life. Currently guidelines recommend starting antiviral therapy when the CD4 falls at or below 350.

While there are problems with making accurate projections into the future this research further highlights the importance of routinely offering and testing for HIV at all clinical settings in order to identify the infection early and before any significant immunological damage has taken place.

See BMJ 2011:343-d6016

Doi:10.1136/bmj.d6016

Accessibility of genitourinary services uneven across England

The majority of the population in England have good access to genitourinary (GUM) services with only 3% living more than 30 minutes travel away, report Beth Stuart and Andrew Hind. However accessibility is not uniform access the country and people in the South West and East of England have the worse access compared to the national average. This might be important from a pubic health perspective because a study from Southampton showed that only 2% of young people were prepared to travel more than 30 minutes to access sexual health services.