A useful tool for practice nurses who want to take sexual history. Click on link below
Category: women’s health
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:
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Having BV can increase a woman’s susceptibility to HIV infection if she is exposed to the HIV virus.
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Having BV increases the chances that an HIV-infected woman can pass HIV to her sex partner.
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Having BV has been associated with an increase in the development of an infection following surgical procedures such as a hysterectomy or an abortion.
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Having BV while pregnant may put a woman at increased risk for some complications of pregnancy, such as preterm delivery.
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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.
Trichomonas vaginalis – a neglected STI with major global health implications
Trichomonas vaginalis (TV) is the most prevalent curable sexually transmitted infection (STI) globally. Yet at least 80% of TV infections are asymptomatic, though even asymptomatic infections are a public health concern.
In addition to the risk of transmission to sex partners, TV infection has been associated with as much as a 2.7-fold increase in the risk of HIV acquisition, a 1.3-fold increase in the risk of preterm labour, and a 4.7-fold increase in the risk of pelvic inflammatory disease.
A recent review in the journal Sexually Transmitted Infections (STI) highlights the current knowledge of the global epidemiology of TV infection. These include sex differences in the incidence and prevalence of infection, and the potentially important role of female sex hormones, and the menstrual cycle in mediating TV susceptibility and natural history.
WHO has estimated that over half the 248 million new TV infections each year occur in men. By contrast, 89% of prevalent TV cases are found among women. Biological differences between the sexes contribute to these striking differences between men and women.
There has also been an increased understanding of the mechanisms underlying resistance to metronidazole – the current sole drug available to eradicate the organism.
Recent innovations in detection, including the availability of nucleic acid amplification tests (NAATs), have improved our understanding of the natural history of TV infections. These innovations and our increased understanding of this common sexually transmitted infection should help us combat the global epidemic in TV.
Human papillomavirus may increase acquisition of HIV
Many sexually transmitted infections (STI) such as herpes and other ulcerative STI’s, chlamydia and gonorrhoea have been known to be associated with increased acquisition of HIV.
A recent meta-analysis in the journal Sexually Transmitted Infections suggests that human papillomavirus (HPV) infections, which is associated with genital warts as well as a number of malignancies, may also be associated with sexual transmission of HIV.
Since HPV is the commonest sexually acquired STI, this association, if confirmed, will have important public health consequences. This is particularly true as most sexually acquired HPV infections can be prevented by vaccinating children.
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.
HIV treatment of infected partner reduces transmission in heterosexual couples
Based on results of randomised clinical trials the World Health Organization recommends antiretroviral drugs for all HIV infected adults in serodiscordant heterosexual relationships at all stages of the disease. But does this strategy work in real life situations?
A recent study published in the Lancet has for the first time reported that such a public health approach is feasible and the outcomes are sustainable at a large scale and in a developing country setting.
New analyses from China look encouraging, say researchers. Between 2003 and 2011, uninfected partners of treated people were significantly less likely to seroconvert than uninfected partners of untreated people (1.3 infections/100 person years (95% CI 1.2 to 1.3) v 2.6 (2.4 to 2.8)). After adjustments, treatment of infected partners was associated with a 26% reduction in risk of transmission to uninfected partners (hazard ratio 0.74, 0.65 to 0.84).
The analyses compared around 24 000 treated couples with nearly 15 000 untreated couples registered in China’s national HIV epidemiology database.
It is hard to say whether treatment was entirely responsible for reducing transmission, because people who were treated were older, sicker, and may have had less sex, or less risky sex, than those who were not yet treated, says a linked comment by the Lancet
But the findings hint at a direct effect. Treated couples looked better protected, despite the relatively low CD4 counts (and presumably higher viral loads) necessary for treatment in China.
Treatment was associated with lower transmission when HIV had been acquired from a transfusion of blood products (50% of the treated couples) or heterosexual sex, but not when it had been acquired from injecting drugs.
Lancet issue on the state of global health
The Lancet has devoted an entire issue to various aspects of global health. The issue is available free for download.
An edited extract from the executive summary follows:
The Global Burden of Disease Study 2010 (GBD 2010) is the largest ever systematic effort to describe the global distribution and causes of a wide array of major diseases, injuries, and health risk factors.
The results show that infectious diseases, maternal and child illness, and malnutrition now cause fewer deaths and less illness than they did twenty years ago. As a result, fewer children are dying every year, but more young and middle-aged adults are dying and suffering from disease and injury.
Thus non-communicable diseases, such as cancer and heart disease, become the dominant causes of death and disability worldwide.
Since 1970, men and women worldwide have gained slightly more than ten years of life expectancy overall, but they spend more years living with injury and illness.