We agree with the authors of this paper (1) that improved awareness of Primary HIV Infection is of great importance in all areas of medical practice. Nevertheless we feel that there are some observations we wish to make.
In a relatively small study such as this recall bias is likely to influence the findings. Although this point is discussed this bias means that the interpretation of results re...
We agree with the authors of this paper (1) that improved awareness of Primary HIV Infection is of great importance in all areas of medical practice. Nevertheless we feel that there are some observations we wish to make.
In a relatively small study such as this recall bias is likely to influence the findings. Although this point is discussed this bias means that the interpretation of results requires further consideration. It is easy, with the benefit of hindsight, to point the finger at primary care
but, crucially in the study, the opportunity to examine the clinical notes for these patients was apparently not possible.
There is much emphasis in the paper on "missed diagnosis" but the results show that half the study group (52%) were correctly diagnosed with primary HIV infection at first presentation and of this figure general practitioners were successful in 4 patients – making up about a fifth of
cases. These figures, while not optimal, show that a degree of awareness of HIV infection in the community is present, but could be better (as it could in other sectors). That 79% of the missed diagnosis occurred in general practice is surely no surprise – 80% of all care happens here
anyway (2). Obviously a good history, an awareness of HIV risk and an ability to discern flu-like symptoms as possible indicators of acute HIV infection are the requirements any doctor should possess in order to make such diagnoses. Perhaps this is why MEDFASH (Ruth Lowbury, personal
communication) is producing a booklet for hospital doctors which emulates the existing one for general practitioners (3).
Importantly we are not saying that everything is rosy in this particular garden – how could we when at least one study illustrates that in an area of North London over the period from 2003-6 the majority of general practices did not test at all for HIV infection (4). There is still much to do in the field of general practice and sexual health, including HIV infection – but focusing on an area fraught with difficulty (only 1:2 patients sought advice or care at the time of their illness in the study above [1]) will inevitably result in negative outcomes.
Finally, and certainly implied by Sudarshi’s paper, it is essential that we include an awareness of primary HIV infection in the undergraduate medical curricula of all universities and ensure that all doctors who graduate in future are capable of taking an HIV risk history.
References
1. D Sudarshi, D Pao, G Murphy et al. Missed opportunities for diagnosing primary HIV infection. Missed opportunities for diagnosing primary HIV infection Sex Transm Infect 2008; 84: 14-16
2. Keeping it personal: clinical case for change. Report by Dr David Colin-Thomé. Department of Health, London UK 2006
3. Madge, S, Matthews P, Singh S, Theobald N. HIV in Primary Care. MEDFASH Publications, 2004
4. K Sadler, L Sutcliffe C Mercer et al. Variations in Chlamydia and HIV testing in general practices in London, UK: opportunities for increasing access to sexual health care?
(Poster presentation as part of the CaPSTI study – funded by the Medical search Council). International
society for sexually transmitted research 2007.
I read with interest, horror, amazement and a whole myriad of
feelings, an article in the Sunday Times Magazine (July 22 2012) on the
morning after pill in the UK.[1] It prompted me to do a search of your
journal, for research on this issue. Again I felt surprise, at the few
publications on this topic. I tried different search terms, "emergency
contraception", "morning after pill" and "Levonelle" but it yielded only...
I read with interest, horror, amazement and a whole myriad of
feelings, an article in the Sunday Times Magazine (July 22 2012) on the
morning after pill in the UK.[1] It prompted me to do a search of your
journal, for research on this issue. Again I felt surprise, at the few
publications on this topic. I tried different search terms, "emergency
contraception", "morning after pill" and "Levonelle" but it yielded only
one research article by Evans et al. in 1996[2] and two recently published
posters.[3,4]
The Sunday Times article by Eleanor Mills brings many issues to the
fore. The availability of emergency contraception (EC) over the counter
means that the age old problem of unwanted pregnancy is addressed.
However, there has been a change in how and why emergency contraception is
used and if the new attitude prevails, undoubtedly the incidence of STIs
will increase. In 1996, Evans et al.[2] reported that 66% of the 150
women receiving EC in London GUM clinics used it because of contraceptive
failure at the time of last intercourse. However, Mills article [1]
reports on a whole new attitude, the use of EC as an 'easy' option. In
her article, she quotes Sophie, age 17 and taking her A levels, "I've
taken the morning after pill loads, sometimes three times in one cycle.
I've been with my boyfriend for four years, so sometimes it's easier to
have sex and then take it the next day...I hate condoms. Taking the
morning after pill is a really good way of not having to use them". The
attitude amongst her friends is similar. While taking the pill is
convenient for these girls, Mills also reports from the Respond Academy,
established to educate the hardest to reach kids through the arts,
Hastings, South East England. The main discussion amongst the girls here
is the pressure from male partners to have sex, especially because EC is
available. "If you say, but you haven't got a condom, they say, go down
the clinic and get the morning after pill tomorrow".
The availability of emergency contraception over the counter is a
relatively new departure for contraceptive services. Mills' article isn't
an epidemiological study, but the warning signs are there. Studies are
undoubtedly required to assess its usage. Education, it would seem, for
both males and females is a key factor in preventing the use of EC as an
'easy' option. Let's address this issue before it gets out of control and
its consequences become a significant burden on the health service, if
they haven't already become one.
References
1. Mills E. The morning after... The Sunday Times Magazine 2012;July
22:14-19
2. Evans JK, Holmes A, Browning M, Forster GE. Emergency hormonal
contraception usage in genitourinary medicine clinics attenders.
Genitourin Med 1996;72:217:219.
3. Habel M Leichliter JS. The sex lives of emergency contraceptive
users in the USA, 2006-2008. Sex Transm Infect 2011;87:Suppl1 A261-A262.
4. Varma R. Women requiring emergency contraception are a high risk
group for sexually transmitted infections in future. Sex Transm Infect
2012;88:Suppl 1 A42.
What will become of the KC60? In the October 2007 edition of this journal. Hughes et al (1) reported on the KC60 returns from genitourinary medicine (GUM) clinics for 2006. They comment in their conclusion that diagnoses made outside GUM are not included, which is clearly a major deficiency if we are using the KC60 as an epidemiological surveillance
tool.
What will become of the KC60? In the October 2007 edition of this journal. Hughes et al (1) reported on the KC60 returns from genitourinary medicine (GUM) clinics for 2006. They comment in their conclusion that diagnoses made outside GUM are not included, which is clearly a major deficiency if we are using the KC60 as an epidemiological surveillance
tool.
Some community data does find a way in. Lavelle et al (2), in their letter in the December 2007 edition gave an example of this – the National Chlamydia Screening Programme ( N.C.S.P.) in Liverpool offers concomitant Nucleic Acid Amplification Test (N.A.A.T). screening for
gonorrohoea but if treatment is required it is given by the local GUM service. It is still coded as B1 (uncomplicated gonorrohea) and has probably distorted upwards the returns for that clinic, in contrast to the national trend. The authors suggestion is a change in or addition to the
KC60 coding to separate out diagnoses made by community clinics.
Another problem with using the KC60 as a surrogate for full epidemiological monitoring is that GUM clinics routinely report partner diagnoses into the KC60 and, as partners are much more likely to be positive, this distorts upwards prevalence estimates based on this data.
The recently developed Enhanced Sexually Transmitted Infections Surveillance Scheme for Cheshire and Merseyside (3) is an example of what might replace the KC60. Like the KC60 it is based on data collected in GUM, but also collects geographical data (by postcode) and much more
extensive demographic detail. It enables geographical mapping for service planning (by primary care trust) and for comparison with deprivation indices. It can also easily be combined with data from community screening programmes to increase coverage, although with the caveat that double reporting would have to be avoided.
If the KC60 is to be modified rather than replaced then it may be possible to alter its categories to allow unconfounded analyses ( e.g. diagnosed in GUM self-referral / partner of known case/ diagnosed in community but GUM referral etc ). But isn`t it complicated enough already? (4)
References
1. Hughes G, Simms I, Leong G. Data from UK genitourinary medicine clinics, 2006 : a mixed picture. Sex Transm Inf 2007;83:433-435
2. Lavelle S, Mallinson H, Henning S, et al. Impact on gonorrhoea case reports through concomitant/ dual testing in a chlamydia screening population in Liverpool. Sex Trans Inf 2007; 83: 593-594
3. Hargreaves S, Cook P, Bellis M. Enhanced Surveillance of Sexually Transmitted Infections in Cheshire and Merseyside 2006.
http://www.cph.org.uk/showpublication.aspx?pubid=327
4. Coyne K M, Cohen C, Mandalia S et al. KC60 Coding: room for improvement- a study into consistencies and inconsistencies in the use of
diagnosing codes. Int J STD AIDS 2007;18: 118-119
Patel and colleagues describe an audit of antenatal screening in
pregnant women with positive syphilis serology to ensure associated STIs
were diagnosed and treated(1). In July 2012 we conducted a brief audit of
opinions of consecutive pregnant women attending an antenatal clinic at St
Georges' Healthcare NHS Trust. They were asked a single oral question
about whether they would be willing in principle to provide a self-t...
Patel and colleagues describe an audit of antenatal screening in
pregnant women with positive syphilis serology to ensure associated STIs
were diagnosed and treated(1). In July 2012 we conducted a brief audit of
opinions of consecutive pregnant women attending an antenatal clinic at St
Georges' Healthcare NHS Trust. They were asked a single oral question
about whether they would be willing in principle to provide a self-taken
vaginal swab for a study of infection and miscarriage.
The response rate was 96% (24/25). The mean age of responders was
31.5 years (range 18-38), and 60% described their ethnicity as white, 24%
black and 16% as Asian. Of the 25 women, 88% (22) said that they would
agree in principle to provide a self-administered vaginal swab. Most women
were extremely supportive of the prospect of further research into
infections and miscarriage: 72% were women with higher risk pregnancies,
including 40% who had previously had mid-trimester miscarriages. Only two
women said they would not be willing to provide a sample. One said she
would not feel comfortable with performing a self-administered swab and
the other that taking part in a study about miscarriage would be too
distressing.
Current guidelines advise antenatal screening for asymptomatic
bacteriuria, hepatitis B, HIV, rubella and syphilis, as well as Chlamydia
trachomatis in women under 25 years of age (2). Self-taken vaginal swabs
are an economical and efficient method of testing for genital infection.
Our findings are in line with previous studies (3) demonstrating the
acceptability of self-administered vaginal swabs during pregnancy. Patel
and colleagues highlight the importance of coordinated service provision
in engaging high-risk women in antenatal screening. Similarly, the
willingness of pregnant women to provide genital samples could be crucial
for future research on infections and miscarriage.
Eleanor Southgate, Academic Foundation Year 2 Doctor
Pippa Oakeshott, Reader in General Practice
Division of Population Health Sciences and Education, St George's
University of London, Cranmer Terrace, London SW17 0RE
1. Patel S, Aroney R, Bird M. et al. P126 Improving the management of
antenatal women with positive syphilis serology within a genitourinary
medicine service. Sex Transm Infect 2012 88:A51-52
2. National Institute for Health and Clinical Excellence. NICE
Clinical Guideline 62. Antenatal Care: Routine care for the healthy
pregnant woman. March 2008
3. Oakeshott P, Hay P, Hay S, Steinke F, Rink E, Kerry S. Is
bacterial vaginosis or chlamydial infection associated with miscarriage
before 16 weeks gestation? A prospective community based cohort study.
BMJ 2002;325:1334-1336
I was pleased that the authors suggested that missed opportunities for early diagnosis could be reduced by tackling the problem from both the patient and the provider side. They note:
"From a patient perspective, the likelihood of future diagnosis could be improved by encouraging at-risk groups (for example, MSM) to access health care when they experience symptoms of seroconversion or followi...
I was pleased that the authors suggested that missed opportunities for early diagnosis could be reduced by tackling the problem from both the patient and the provider side. They note:
"From a patient perspective, the likelihood of future diagnosis could be improved by encouraging at-risk groups (for example, MSM) to access health care when they experience symptoms of seroconversion or following high risk exposure."
Would it be too much to urge members of groups at high risk for infectious disease to mention to their service provider that they are a member of that group? And would it be too much for doctors who suspect risky behaviours to ask? I understand the importance of patient confidentiality but primary HIV infection is dangerous for behavioural as well as virological reasons, and uninfected people have rights, too. Those rights are best protected by reducing all possible barriers to diagnosing early HIV infection, and providing active prevention services for those diagnosed.
We will try to answer the questions reported by Doctors Taylor-
Robinson and Horner.
i) This study was carried out in a Primary Care Laboratory, not in a
Sexually Transmitted Infection Clinic. This fact could explain the less
percentage of patients with ?5 PMNLs and the difference with other studies
(1-3). The mean age of patients analyzed was 34 years old with a range
between 16- 76.
ii) The symptoms were: pain (17%), di...
We will try to answer the questions reported by Doctors Taylor-
Robinson and Horner.
i) This study was carried out in a Primary Care Laboratory, not in a
Sexually Transmitted Infection Clinic. This fact could explain the less
percentage of patients with ?5 PMNLs and the difference with other studies
(1-3). The mean age of patients analyzed was 34 years old with a range
between 16- 76.
ii) The symptoms were: pain (17%), discharge (40%), itching (21.5%),
dysuria (39.3%) and penile irritation (5.7%). The patients were submitted
to the laboratory, by their doctors, with the diagnosis of urethritis; and
therefore they were included in the study. When these patients attended to
the laboratory, 9.2% of them reported not to have symptoms, but they had
risk sexual relationship or infection in partner.
iii) We did not include this information because we had lacking of this
information in a high percentage of patients.
iv) When the samples were collected, the swabs were listed from 1 to 4 and
number 1 was used for Gram stain.
v) In fact, we used the number of ?5 PMNLs per high-power field in ?5
fields like standard practice (4-5).
vi) We found ?5 PMNLs in 62.7% of men with discharge and 2.1% in men
without discharge.
vii) The study was conducted over two years. For one year and a half, C.
trachomatis detection was performed by immunochromatography (ICT) and the
last 6 months by PCR. Of the 34 C. trachomatis detected, 4 were by ICT and
30 by PCR. One sample of four by ICT had ?5 PMNLs (25%) and 6 of 30 (20%)
by PCR.
viii) Really, urethritis is defined by the presence of urethral
inflammation and as you expose, C. trachomatis and Ureaplasmas do not
always elicit urethral inflammation in men. We decided to use the culture
like reference method, because we wanted to asses the role of isolated
microorganisms, considered unlikely to be causal agents of urethritis and
to compare the number of PMNLs in Gram stain, with the isolation of these
microorganisms in culture.
References
1. Falk L, Fredlund H, Jensen JS. Symptomatic urethritis is more
prevalent in men infected with Mycoplasma genitalium than with Chlamydia
trachomatis. Sex Transm Infect 2004; 80 :289-93.
2. Horner PJ, Thomas B, Gilroy CB et al. Do all men attending departments
of genitourinary medicine need to be screened for non-gonococcal
urethritis? Int J STD AIDS 2002; 13: 667-73.
3. Janier M, Lassau F, Casin I et al. Male urethritis with and without
discharge: a clinical and microbiological study. Sex Transm Dis 1995; 22:
244-52.
4. Shahmanesh M. 2007 UK National Guideline on the Management of
Nongonococcal Urethritis: updated December 2008. http://www bashh
org/guidelines 2008 Available from: URL:http://www.bashh.org/guidelines
5. Shahmanesh M, Moi H, Lassau F, Janier M. 2009 European Guideline on
the Management of Male Non-gonococcal Urethritis. Int J STD AIDS 2009; 20
:458-64.
The report by Grijsen and colleagues documenting the high frequency of unprotected receptive anal intercourse (RAI) in young Kenyans at high risk for HIV infection (1) is a welcome contribution to the small but growing number of studies investigating RAI as a specific risk for HIV in
sub-Saharan Africa (2-7). Their study, however, presents us with yet another anomaly unlikely to be resolved by the assessme...
The report by Grijsen and colleagues documenting the high frequency of unprotected receptive anal intercourse (RAI) in young Kenyans at high risk for HIV infection (1) is a welcome contribution to the small but growing number of studies investigating RAI as a specific risk for HIV in
sub-Saharan Africa (2-7). Their study, however, presents us with yet another anomaly unlikely to be resolved by the assessment of sexual risk factors alone (8). Although the authors found that “RAI was strongly associated with HIV-1 in men (adjusted odds ratio = 3.8)", they also reported that among women, RAI was not associated with prevalent HIV
infection, but that those practicing RAI were much more likely to have syphilis (adjusted odds ratio 12.9). Puzzled, the authors note: “It is not clear why this difference was found…” None of the possible reasons
they propose for this anomaly includes nonsexual HIV transmission. That these women were 10 times more likely to have serological markers of HIV (a sexually transmissible infection) than of current or past syphilis (a sexually transmitted) infection should be viewed as a red flag, even
considering their nonspecific diagnostic criteria for syphilis (classification based on qualitative rapid plasma reagin test and the Treponema pallidum haemagglutination assay, neither of which rules out nonsexually transmitted treponematoses). The magnitude of the difference
between HIV and “syphilis” markers alone suggests that sexual factors may have played a lesser role in observed HIV prevalence than nonsexual ones.
Because the authors apparently did not also assess nonsexual (blood) exposures, this possibility cannot be explored with their data -- a frustratingly common shortcoming in epidemiologic studies conducted in
Africa (9). In addition, a strong association between anal sex and prostitution might mask the association between anal sex and HIV in their women participants. Thus, given a strong association between RAI and prostitution, it is important to report the bivariate relationships among
all predictors and their relationship with prevalent HIV infection. Lastly, Grijsen and colleagues stress the importance of prevention messages about the dangers of unprotected RAI to those high- risk persons
reporting it. Yet because RAI is probably not confined to “high-risk” persons (2), broader community prevention messages might more usefully fit overall HIV prevention objectives. Anal intercourse is common in sub-
Saharan Africa populations (2-7) and is often perceived as involving no risk for HIV transmission (4,7).
John J. Potterat, BA, Colorado Springs, CO, USA
Stuart Brody PhD, University of the West of Scotland, UK
Devon D. Brewer, PhD, Interdisciplinary Scientific Research, Seattle, WA, USA
Stephen Q. Muth, BA, Colorado Springs, CO, USA
References
1. Grijsen MI, Graham SM, Mwangome M, et al. Screening for genital and anorectal sexually transmitted infections in HIV prevention trials in Africa.
Sex Transm Infect (doi: 10.1136/sti2007.028852)
2. Brody S, Potterat JJ. Assessing the role of anal intercourse in the epidemiology of AIDS in Africa.
Int J STD AIDS 2003; 14: 431-436.
3. Lane T, Pettifor A, Pascoe S, Fiamma A, Rees H. Heterosexual anal intercourse increases risk of HIV infection among young South African men.
AIDS 2006; 20: 123-125.
4. Ramjee G, Gouws E, Andrews A, Myer L, Weber AE. The
acceptability of a vaginal microbicide among South African men. Int Fam Plan Persp 2001, 27: 164-170.
5. Simbayi LC, Kalichman SC, Jooste S, Cherry C, Mfecane S, Cain D. Risk factors for HIV-AIDS among youth in Cape Town, South Africa. AIDS Behav 2005; 9: 53-61.
6. Mwakagile D, Mmari E, Makwaya C, et al. Sexual behaviour among youths at high risk for HIV-1 infection in Dar es Salaam, Tanzania. Sex Transm Infect 2001; 77: 255-259.
7. Stadler JJ, Delany S, Matambo M. Sexual coercion and sexual desire: ambivalent meanings of heterosexual anal sex in Soweto, South Africa. AIDS Care 2007; 19: 1189-1193.
8. Brewer DD, Brody S, Drucker E, et al. Mounting anomalies in the epidemiology of AIDS in Africa: cry the beloved paradigm. Int J STD AIDS 2003; 14: 144-147.
9. Gisselquist D, Potterat JJ, Brody S, Vachon F. Let it be sexual: how health care transmission of AIDS in Africa was ignored. Int J STD AIDS 2003; 14: 148-161.
Recently, Gayet-Ageron and colleagues published a systematic review
and meta-analysis to evaluate the diagnostic values of T. pallidum PCR,
and concluded that PCR is a useful additional diagnostic tool.1 However,
the data on examining diagnostic performance of PCR-based methods for
early syphilis are still limited in China although a few studies with the
indirect data from China were included in the literature review.1...
Recently, Gayet-Ageron and colleagues published a systematic review
and meta-analysis to evaluate the diagnostic values of T. pallidum PCR,
and concluded that PCR is a useful additional diagnostic tool.1 However,
the data on examining diagnostic performance of PCR-based methods for
early syphilis are still limited in China although a few studies with the
indirect data from China were included in the literature review.1
During April to September 2009, we conducted a survey among patients
with suspected primary or secondary syphilis recruited from a STI clinic
in Nanjing, China to evaluate the performance of PCR assay for early
syphilis diagnosis. Following ethical review by the CAMS Institute of
Dermatology, all eligible patients who agreed to participate in the survey
were requested to be interviewed with a simple questionnaire and provide
serum specimens for syphilis serologic testing of treponemal (TPPA) and
non treponemal (RPR) antibodies and swab specimens for dark-field
microscopy (DFM) and PCR detection of T. pallidum. We used polA gene for
PCR assay which has been verified and suggested by the US CDC.2
The response rate was 94.8% (110/116), and the median age of
participants was 40 years old with interquartile range of 30 to 47. Out of
110 participants, all provided venous blood, and 62 (56.4%) and 48 (43.6%)
provided samples from chancres and condyloma lata, respectively. PCR had a
higher positive rate than DFM (78.2%, 86/110 vs. 67.3%, 74/110; ?2=6.722,
p=0.008). However, PCR and serological test did not reach a significant
difference (78.2%, 86/110 vs. 76.4%, 84/110; ?2=0.125, p=0.727). We used
combination of clinical sign, positive DFM and/or active serological test
as reference criteria.3 The sensitivity and specificity of PCR assay for
early syphilis were 83.3% and 92.9%; the positive and negative predictive
values were 96.8% and 68.4%; and the positive and negative likelihood
ratios were 11.7 and 0.2. Two specimens from patients who had suspected
clinical signs were positive for amplifications of polA gene, but negative
for both DFM and serological tests. We speculated they were in the very
early stage of the disease.
We agree with Gayet-Ageron and colleagues that PCR can be used as a
complementary tool for diagnosis of early syphilis, especially for those
without serological conversion and visible skin lesions, in settings with
a high prevalence of syphilis. However, the limitations in scaling-up of
this facility-dependent technology may be a concern, especially in those
resource-limited areas with epidemic of syphilis infection.
Funding
This work was supported by the National Institute of Allergy and Infectious Diseases, Sexually Transmitted Infections and Topical Microbicide Cooperative Research Center (5U19AI031496-18).
Reference
1. Gayet-Ageron A, Lautenschlager S, Ninet B, et al. Sensitivity,
specificity and likelihood ratios of PCR in the diagnosis of syphilis: a
systematic review and meta-analysis. Sex Transm Infect. Published Online
First: 28 Sept 2012, doi:10.1136/sextrans-2012-050622.
2. Liu H, Rodes B, Chen CY, et al. New tests for syphilis: rational
design of a PCR method for detection of Treponema pallidum in clinical
specimens using unique regions of the DNA polymerase I gene. J Clin
Microbiol. 2001;39:1941-6.
3. Centers for Disease Control and Prevention. STD Surveillance Case
Definitions. http://www.cdc.gov/std/stats10/CaseDefinitions2010.pdf.
In the editorial Focus on chlamydia(1), screening of asymptomatic individuals to prevent transmission and adverse consequences of chlamydia was discussed. We wish to raise the issue of uncertainty around the appropriate timing of chlamydia tests in relation to exposure.
The National Chlamydia Screening Programme (NCSP) Core Requirements (3rd Edition) states ‘There is no data on the use of nucle...
In the editorial Focus on chlamydia(1), screening of asymptomatic individuals to prevent transmission and adverse consequences of chlamydia was discussed. We wish to raise the issue of uncertainty around the appropriate timing of chlamydia tests in relation to exposure.
The National Chlamydia Screening Programme (NCSP) Core Requirements (3rd Edition) states ‘There is no data on the use of nucleic acid amplification tests (NAATs) and how soon after sex a test may become positive’ and advises to test immediately and repeat the test in 3-5 weeks(2).
A local (i.e. Central Lancashire PCT) NCSP poster states ‘The test should be taken 3 weeks after sexual contact, as the infection may not show immediately’.
The British Association for Sexual Health and HIV (BASHH) UK National STI Screening and Testing Guidelines indicate that the minimum time gap between exposure to a sexually transmitted infection and its successful
detection varies depending on a number of factors including the organism, the size of inoculum and the type of test used. These guidelines highlight that the evidence base for specific recommendations on how long to wait before testing for different STIs is limited, and state ‘for bacterial
STIs, many clinicians would wait 3-7 days before testing (level IV)’(3)
Given pressure to meet GUM 48 hour access targets, it may be that a greater proportion of patients present to GUM clinics too soon after exposure to detect or exclude the infection. The need to consider a second test after baseline testing should therefore be borne in mind. We
would NOT agree with the statement in the local NCSP poster, which effectively advises patients to defer testing, a strategy which runs counter to the public health arguments for rapid access to GUM clinics.
We ask the question ‘What is a suitable “window period” for chlamydial infection?’ We await guidance from those in a position to undertake the research to answer the question.
If service providers undertake a baseline test and, where relevant, consider a repeat test after a suitable period of time, old and recently acquired infection should be excluded. The recommendation by NCSP for a repeat test after 3-5 weeks appears unrealistic.
The discrepancies between BASHH guidelines and the NCSP Core Requirements and in particular, between NCSP Core Requirements and local delivery of the NCSP, are a cause for concern. Currently, service providers are giving mixed messages. It would be helpful if BASHH and NCSP gave the same steer on this in order to facilitate uniformity of
approach at the local level.
Competing interests: None
Corresponding Author:
Dr. Carolyn Rigg
GUM Department,
Southport and Formby District General Hospital
Town Lane
Southport
Merseyside, PR9 7LJ
carolynrigg@doctors.org.uk
Tel: 01704 547471
Co-author:
Dr. Mike Abbott
GUM Department,
Southport and Formby District General Hospital
Town Lane
Southport
Merseyside, PR9 7LJ
References
1. Low N, Ward H. Focus on chlamydia. Sex Transm Infect 2007;83:251-52.
2. National Chlamydia Screening Programme England: Core Requirements (Third Edition). London: HPA, September 2006.
http://www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/SexualHealth/SexualHealthGeneralInformation/SexualHealthGeneralArticle/fs/en?CONTENT_ID=4084098&chk=CSLxsK
3. British Association for Sexual Health and HIV. UK National STI Screening and Testing Guideline, August 2006.
http://www.bashh.org/guidelines.asp
In their stratified random probability survey of 411 men aged 18-35
years, Saunders and colleagues found that 29% had been tested for a STI,
mainly in genitourinary medicine (GUM) clinics (53%) or general practice
(17%)1. In September 2012, for a medical student project, we conducted a
questionnaire survey of young men and women at Lambeth Further Education
College in south London. Lambeth is an area with one of the high...
In their stratified random probability survey of 411 men aged 18-35
years, Saunders and colleagues found that 29% had been tested for a STI,
mainly in genitourinary medicine (GUM) clinics (53%) or general practice
(17%)1. In September 2012, for a medical student project, we conducted a
questionnaire survey of young men and women at Lambeth Further Education
College in south London. Lambeth is an area with one of the highest rates
of STIs in the UK with 9.9% of 15-24 year olds screened testing positive
for chlamydia in 2011 to 20122. Our aim was to find out how many students
had been tested for chlamydia in the past year, where they had been tested
and why they were tested. To make our findings comparable with Saunders
and colleagues we focus mainly on results from male respondents.
The response rate was 79% (89/112). The mean age of participants was
23 years (range 16-54) and 67% were male. The 59 male responders described
their ethnicity as black 55%, (comprising black-Caribbean 22%, black other
17%, black-African 16%), white 25%, Asian 3% and 14% other ethnicities.
Most male responders (80%, 47/59) said they were sexually active of whom
55% (26/47) reported being tested for chlamydia in the past year. Half of
them (50%, 12/24) said they had been tested at a GUM clinic, 17% in
general practice, 12.5% at a Brook clinic, 8% at school, 8% at Tooting Bec
Lido and 4% at a Walk-in clinic. Reasons for testing (n=22) included "for
a check-up" (35%), "out of choice" (50%), "one night stand" (5%), "free
condoms" (5%) and "unprotected sex" (5%).
The proportion of young men in our study who were tested in GUM clinics
and general practice was similar to results from the national survey by
Saunders and colleagues1. In line with NCSP reports3, they point out that
young men are perceived as hard to reach for STI screening1. Based on the
high rates of reported testing found in our small survey of young,
sexually active, mainly black males, we agree there may be potential to
increase STI screening rates.
Ethical review: The protocol, patient information leaflet and
questionnaire were reviewed by Dr Phillip Sedgwick, Reader in Statistics
and course organiser at St George's, University of London.
Acknowledgements:
The authors would like to thank Dionne Konstantinious and staff and
students at Lambeth College for their help with this research.
References:
1. Saunders JM, Mercer CH, Sutcliffe LJ, et al. Where do young men
want to access STI screening? A stratified random probability sample
survey of young men in Great Britain. Sex Transm Infect. 2012 88(6): 427-
432 doi: 10.1136/sextrans-2011-050406
2. National Chlamydia Screening Programme. Chlamydia Testing Data
2011/12 [data tables]. NHS;2012. Available from URL:
http://www.chlamydiascreening.nhs.uk/ps/resources/data-tables/CTD-Q1-4-
2011_2012.pdf
3. National Chlamydia Screening Programme. National Chlamydia
Screening programme data [media information pack]. NHS;2010. Available
from URL:
http://www.chlamydiascreening.nhs.uk/ps/assets/pdfs/press/NCSP_media_pack_2010.pdf
Dear Editor,
We agree with the authors of this paper (1) that improved awareness of Primary HIV Infection is of great importance in all areas of medical practice. Nevertheless we feel that there are some observations we wish to make.
In a relatively small study such as this recall bias is likely to influence the findings. Although this point is discussed this bias means that the interpretation of results re...
I read with interest, horror, amazement and a whole myriad of feelings, an article in the Sunday Times Magazine (July 22 2012) on the morning after pill in the UK.[1] It prompted me to do a search of your journal, for research on this issue. Again I felt surprise, at the few publications on this topic. I tried different search terms, "emergency contraception", "morning after pill" and "Levonelle" but it yielded only...
Dear Editor,
What will become of the KC60? In the October 2007 edition of this journal. Hughes et al (1) reported on the KC60 returns from genitourinary medicine (GUM) clinics for 2006. They comment in their conclusion that diagnoses made outside GUM are not included, which is clearly a major deficiency if we are using the KC60 as an epidemiological surveillance tool.
Some community data does find a way in....
Patel and colleagues describe an audit of antenatal screening in pregnant women with positive syphilis serology to ensure associated STIs were diagnosed and treated(1). In July 2012 we conducted a brief audit of opinions of consecutive pregnant women attending an antenatal clinic at St Georges' Healthcare NHS Trust. They were asked a single oral question about whether they would be willing in principle to provide a self-t...
Dear Editor,
I was pleased that the authors suggested that missed opportunities for early diagnosis could be reduced by tackling the problem from both the patient and the provider side. They note:
We will try to answer the questions reported by Doctors Taylor- Robinson and Horner. i) This study was carried out in a Primary Care Laboratory, not in a Sexually Transmitted Infection Clinic. This fact could explain the less percentage of patients with ?5 PMNLs and the difference with other studies (1-3). The mean age of patients analyzed was 34 years old with a range between 16- 76. ii) The symptoms were: pain (17%), di...
Dear Editor,
The report by Grijsen and colleagues documenting the high frequency of unprotected receptive anal intercourse (RAI) in young Kenyans at high risk for HIV infection (1) is a welcome contribution to the small but growing number of studies investigating RAI as a specific risk for HIV in sub-Saharan Africa (2-7). Their study, however, presents us with yet another anomaly unlikely to be resolved by the assessme...
Recently, Gayet-Ageron and colleagues published a systematic review and meta-analysis to evaluate the diagnostic values of T. pallidum PCR, and concluded that PCR is a useful additional diagnostic tool.1 However, the data on examining diagnostic performance of PCR-based methods for early syphilis are still limited in China although a few studies with the indirect data from China were included in the literature review.1...
Dear Editor,
In the editorial Focus on chlamydia(1), screening of asymptomatic individuals to prevent transmission and adverse consequences of chlamydia was discussed. We wish to raise the issue of uncertainty around the appropriate timing of chlamydia tests in relation to exposure.
The National Chlamydia Screening Programme (NCSP) Core Requirements (3rd Edition) states ‘There is no data on the use of nucle...
In their stratified random probability survey of 411 men aged 18-35 years, Saunders and colleagues found that 29% had been tested for a STI, mainly in genitourinary medicine (GUM) clinics (53%) or general practice (17%)1. In September 2012, for a medical student project, we conducted a questionnaire survey of young men and women at Lambeth Further Education College in south London. Lambeth is an area with one of the high...
Pages