A commissioned article in Lancet Infectious Diseases on July 9, 2017 highlights some of the major issues and challenges facing us in the growing global epidemic of sexually transmitted infections (STI). Authors Prof Mabhus Unemo et al summarise the key issues as follows:
WHO estimated that nearly 1 million people become infected every day with any of four curable sexually transmitted infections (STIs): chlamydia, gonorrhoea, syphilis, and trichomoniasis. Despite their high global incidence, STIs remain a neglected area of research.
In this Commission, we have prioritised five areas that represent particular challenges in STI treatment and control.
Chlamydia remains the most commonly diagnosed bacterial STI in high-income countries despite widespread testing recommendations, sensitive and specific non-invasive testing techniques, and cheap effective therapy. We discuss the challenges for chlamydia control and evidence to support a shift from the current focus on infection-based screening to improved management of diagnosed cases and of chlamydial morbidity, such as pelvic inflammatory disease.
The emergence and spread of antimicrobial resistance in Neisseria gonorrhoeae is globally recognised. We review current and potential future control and treatment strategies, with a focus on novel antimicrobials.
Bacterial vaginosis is the most common vaginal disorder in women, but current treatments are associated with frequent recurrence. Recurrence after treatment might relate to evidence that suggests sexual transmission is integral to the pathogenesis of bacterial vaginosis, which has substantial implications for the development of effective management approaches.
STIs disproportionately affect low-income and middle-income countries. We review strategies for case management, focusing on point-of-care tests that hold considerable potential for improving STI control.
Lastly, STIs in men who have sex with men have increased since the late 1990s. We discuss the contribution of new biomedical HIV prevention strategies and risk compensation.
Overall, this Commission aims to enhance the understanding of some of the key challenges facing the field of STIs, and outlines new approaches to improve the clinical management of STIs and public health.
Read full article on Lancet Infectious Diseases
The National Survey of Sexual Attitudes and Lifestyles (NATSAL) is a survey of men and women carried out in the Britain every 10 years. It remains the most extensive and accurate study of sexual behaviour in a carefully selected population of men and women in the UK that reflect the population of sexually active individuals.
Natsal-3 is a sample survey of 15,162 men and women (6,293 men) aged 16–74 years, resident in Britain, undertaken between September 2010 and August 2012. Participants were interviewed using a combination of face-to-face, computer-assisted, personal interviewing (CAPI) and computer-assisted self-interviewing (CASI). The more sensitive questions, including those on paying for sex and sex while outside the UK, were asked in the CASI.
Kyle Jones and her colleagues reported on the results of the questions relating to men who admitted to have paid for sex.
Their results show that round one in 10 men in Britain report having ever paid for sex at some time. These men are more sexually active than men who do not report having had paid for sex. They have a higher number of sexual partners, only a minority (18.4%) of which are paid.
They are also more likely to report a diagnoses of a sexually transmitted infection (STI) even when accounting for their disproportionately larger number of sexual partners (which is considered the most important behavioural variable associated with STI diagnoses).
This evidence strongly supports the idea that this subgroup of men are a bridge for the sort of sexual mixing (dissociative mixing) that increases the spread of STIs.
Men who pay for sex (MPS) are most likely to be aged between 25 and 34 years, single, in managerial or professional occupations, and have high partner numbers.
After adjusting for the key risk behaviour of sexual partner numbers, these men still report many other sexual behaviours, such as having new foreign partners while outside the UK, less attendance at STI clinic and less condom use. They therefore show an increased vulnerability to STI without taking the necessary precautions.
Interestingly, for some reported behaviours, such as sex partners outside the UK, same sex contact, sex partners found online, and concurrent partners (more than one partner at any time), total and paid partner numbers increase.
This suggests that MPS exhibiting these behaviours have higher lifetime partner numbers than other MPS as well as higher paid partner numbers, putting them at a higher risk for STIs than other MPS.
Are sexual health (sexually transmitted infection) clinics a suitable venue to give advise on alcohol abuse? A recently published randomised controlled trial of rapid screening and advise in three London-based sexual health clinics showed little effect of screening and advise on alcohol consumption, or unsafe sexual behaviour six months later.
802 people aged 19 years or over who attended one of three sexual health clinics and were drinking excessively were randomised to either brief advice or control treatment. Brief advice consisted of feedback on alcohol and health, written information and an offer of an appointment with an Alcohol Health Worker. Control participants received a leaflet on health and lifestyle.
The primary outcome was mean weekly alcohol consumption during the previous 90 days measured 6 months after randomisation. The main secondary outcome was unprotected sex during this period.
Among the 402 randomised to brief advice, the adjusted mean difference in alcohol consumption at 6 months was −2.33 units per week (95% CI −4.69 to 0.03, p=0.053) among those in the active compared to the control arm of the trial.
Unprotected sex was reported by 53% of those who received brief advice, and 59% controls (p=0.496).
In a linked leading article in the journal Sexually Transmitted Infections Keith Radcliffe and Nicola Thornley review the links between alcohol misuse and unsafe sexual practices. They report conflicting information as to the benefits of behaviour intervensions, both in terms of reduction in the consumption of alcohol and in unsafe sexual behaviour.
The current study adds to the growing literature on the difficulties of behaviour intervention in having lasting effects on behaviour changes, whether it is sexual or eating habits.
Clearly more work is needed to help translate knowledge into behaviour.
Malcom Gibb who had served on the Board of Trustees since 2009 sadly passed away in early January this year. Malcom not only supported STIRF since its early inception but through his links with the Jo Li Foundation provided regular financial support. Without his help STIRF would not have been able to fund many of the projects that were successfully completed. The board of Trustees of STIRF send their deepest condolences to the family and friends of Malcom. I will miss him, not only as a valued colleague, but even more as a very dear friend.
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/TB care association has launched a Twiter-Facebook campaign in Cape Town to encourage condom use. Under slogan is Love=Condom and with Valentine Day as a prop, the campaign aims to address the rising rates of HIV – especially.
In the UK the relentless rise in HIV in men who have sex with men to record levels in 2012 has also raised concern that the safe sex message is not getting through. The Healthe Protection Agency which provides annual report on rates of HIV and other sexually transmitted infections has made a number of recommendations for controlling the HIV epidemic.
- Implementing safer sex programmes promoting condom use and HIV testing are a priority, particular for higher risk groups, including men who have sex with men and black African communities.
- In areas with high HIV prevalence (prevalence greater than 2 per 1,000 people aged between 15 and 59 years old), routine HIV testing should be performed for all general medical admissions and people registering at GP practices. GPs should offer and recommend HIV testing.
- HIV testing should be offered to people with tuberculosis and people with HIV should be screened for tuberculosis.
- The benefits of treatment with antiretroviral drug treatments should be discussed with all people receiving HIV care.
- HIV care needs to be continually monitored to ensure it continues to be of high quality.
Maybe we should take a leaf out of the South African TB/HIV Care Association.
Vaccination against human papillomavirus (HPV) types 16 and 18 protects women against cervical cancer associated with these two common phenotypes.
A recent study by Oakshott and her colleagues from the UK has found that 18.5% (95% CI 17-20%) of nearly 2,200 women attending a sexually transmitted infection (genitourinary medicine) clinic were positive for HPV types associated with cervical cancer in samples taken from vaginal swabs. These included 327 women (15%) who were positive for HPV genotypes not covered by the current vaccines currently in use.
By sampling twice a median of 16 months apart the authors were able to provide an annual estimate of new infections (incidence) of nearly 13% of carcinogenic genotypes. Reporting two or more sexual partners in the previous year and concurrent Chlamydia trachomatis or bacterial vaginosis were independent risk factors for prevalent vaginal HPV infection.
Of the 143 women with baseline carcinogenic HPV that provided samples later 14% were infeceted by the same HPV genotype.
The study was performed before the introduction of immunisation against HPV types 16 and 18 for schoolgirls. It highlights the continued need to screen women for cervical cancer.
Current findings suggest that the mucosal barrier is the major site of viral selection in sexual transmission of human immunodeficiency virus type 1 (HIV-1), transforming the complex inoculum to a small, homogeneous founder virus population. In a recent study from Zurich the authors analyzed HIV-1 viral seqiuences in the C2-V3-C3 region in 145 patients with characteristics primary HIV-1 infection. They found that the meedian viral diversity within env was 0.39% (range 0.04%–3.23%). Viral diversity did not correlate with viral load, but it was slightly correlated with the duration of infection.
They also found that neither transmission mode, gender, nor STI predicted transmission of more heterogeneous founder virus populations. Only 2 patients (1.4%) were infected with CXCR4-tropic HIV-1 with a duakl-tropic R5/X4-tropic–mixed population. The other patients were infecetd by the CCR5-trophic virus which targets the macrophage series.
The authors concluded that transmission of multiple HIV-1 variants might be a complex process that is not dependent on mucosal factors alone. CXCR4-tropic viruses can be sexually transmitted in rare instances, but their clinical relevance remains to be determined. These results have imprtant implications for vaccine development.
An alternative explanation for these results, not discussed by the authors, is that the individuals were infected by a small number or even a single CCR5-trophic virus which subseqeuntly mutates to the complex virus soup that is seen in long-term infected subjects.