Acute nongonococcal urethritis (NGU) is one of the commonest sexually transmitted infections affecting man and woman. The diagnosis of NGU has traditionally required microscopic evidence of urethritis. However, a significant proportion of patients with urethral symptoms do not have microscopic evidence of urethritis. A recently published article by Orellana MA et al [1] highlighted the low sensitivity of Gram stain in the diagnosis of urethritis in men, and the low negative predictive value of microscopic results in symptomatic patients. Whereas, we recently evaluated the analytical performance of the UF-1000i (Sysmex Co, Japan, Supplied by Dasit SpA, Cornaredo, Italy), a recently introduced fluorescence flow cytometer intended for urinalysis purposes [2], which provides new analytical features that seem particularly suitable for microbiological diagnostics, for ruling out NGU or predicting the presence of infection [3]. The Sysmex UF-1000i is a flow cytometry analyzer capable of quantifying a lot of particles, including bacteria and white blood cells (WBCs). To evaluate the analytical performance of the UF-1000i as a method for ruling out NGU, we examined 200 urethral smear samples, collected in a liquid transport medium (Eswab, Copan, Brescia, Italy). We compared the UF-1000i results with microscopic Gram stain, and with results obtained from standard cultures and molecular methods available in our laboratory to detect NGU main pathogens (Chlamydia trachomatis, Mycoplasma genitalium, Ureaplasma urealyticum, Ureaplasma parvum, Mycoplasma hominis, Trichomonas vaginalis, Adenovirus, Herpes simplex) . With instrument cut-off values of 200 BACT x10^6/L and 500 WBCs x10^6/L, we obtained a sensitivity of 84%, a specificity of 82%, and a high negative predictive value (96%). Our data demonstrated that Sysmex UF-1000i represents a real tool for ruling out NGU, capable of improving the efficiency of NGU presumptive diagnosis, providing results in a few minutes, with a good value of sensitivity and, above all, a very high negative predictive value.

References 1. Orellana MA, Gomez-Lus ML, Lora D. Sensitivit? of Gram stain in the diagnosis of urethritis in men. Sex Transm Infect 2012; 88: 284-287. 2. Grosso S, Bruschetta G, Camporese A. Experimental evaluation of the Sysmex UF-1000i for ruling out non-gonococcal urethritis. Infez Med 2012; 20 (3):188-194. 3. De Rosa R, Grosso S, Bruschetta G, et al. Evaluation of the Sysmex UF1000i flow cytometer for ruling out bacterial urinary tract infection. Clin Chim Acta 2010; 411 1137-1142.

Conflict of Interest:

None declared

Butler and colleagues[1] report convincing results confirming that the availability of HIV prevention tools such as condoms in prisons does not increase sexual activity among inmates but rather increases safe sex. These results represent a major step towards negating the widespread belief that the general availability of prevention measures in prisons increases at-risk practices associated with HIV, Hepatitis and other sexually transmitted infections (STI). Indeed similar ad hoc studies regarding the availability of needles and syringes programs in prisons (NSP) showed no increase in injection but an increase in safe injecting practices.[2] Despite such evidence, NSP continues to be banned in prisons in several countries.

Recommendations by the authors about breaking down the last barriers to condom availability in prisons are particularly significant and timely for several reasons. First, condoms are not always available in prisons and, paradoxically, this is particularly true in countries with a high prevalence of HIV among inmates. When "potentially" available, inmate access to condoms is not always easy both due to a lack of condom machines, and because inmates are reluctant to ask for them out of fear of stigmatization. Moreover, a French study has already shown that HIV post-exposure prophylaxis is neither known nor prescribed to prisoners[3] and this is perhaps the case for many other correctional institutions. Second, the need for condoms in prisons is justified by the recent increase in industrialized countries of HCV permucosal transmission in HIV -positive men who have sex with men (MSM)[4]. This increase is concomitant with increased drug use and high risk sexual practices in this population. Additionally, HIV and other STI, which are frequent in prisoners, appear to be important cofactors in onward transmission of permucosally acquired HCV. Third, the criminalization of drug users and MSM in several countries contributes to promiscuity in prisons, facilitating transmission of HIV and Hepatitis B and C from one group to another. Though sexual violence was infrequent and underreported in the study by Butler et al., this may not be the case for other prisons where overpopulation may amplify such risks.

Assuring the same prevention interventions for prisoners as those enjoyed by the general population is not only a human right but a public health need.

References:

1. Butler T, Richters J, Yap L, et al. Condoms for prisoners: no evidence that they increase sex in prison, but they increase safe sex. Sex Transm Infect. 2013 Jan 7.

2. WHO. Effectiveness of Interventions to Manage HIV in Prisons - Needle and syringe programmes and bleach and decontamination strategies (Evidence for Action Technical Papers). Geneva: WHO, UNAIDS, UNODC; 2007.

3. Michel L, Jauffret-Roustide M, Blanche J, et al. Limited access to HIV prevention in French prisons (ANRS PRI2DE): implications for public health and drug policy. BMC Public Health. 2011;11:400.

4. Bradshaw D, Matthews G and Danta M. Sexually transmitted hepatitis C infection: the new epidemic in MSM? Curr Opin Infect Dis. 2013;26(1):66- 72.

Conflict of Interest:

None declared

In their topical editorial, Jain and Ison state that "testing (for chlamydia) is a crucial part of any effective control strategy"1. In January 2013 we conducted a pilot study of Chlamydia trachomatis and Neisseria gonorrhoea testing in female students at Lambeth Further Education College, London to assess recruitment to a possible POPI (prevention of pelvic infection) 2 screening trial.2

Two female general practitioners approached consecutive female students in the common room and asked them to help with a women's health study. We explained that only women aged 16-27 who were sexually experienced were eligible. Those who consented completed a questionnaire and provided a self-taken vaginal swab. We explained that as samples might not be tested for six months, it was participants' responsibility to get tested independently if they were at risk of STIs. Subjects were given a small honorarium (?5 and a lollipop) when they returned the samples.

Of 40 women approached, eight were aged >27 and seven refused: response rate 78% (25/32). Responders were broadly similar to non- responders in the proportion of black ethnicity (56%, 14/25 versus 86%, 6/7) but were younger (mean (sd) 19.3 (2.7) years versus 22.9 (3.5) years, p<0.01)). Unlike our difficulties in the POPI trial2, we recruited our target of 25 women in 90 minutes and had to turn away potential participants as we had run out of packs. Three women were later excluded as their questionnaire responses showed they had never had sex. Of the 22 sexually active women, 41% reported two or more sexual partners in the previous year and 45% were smokers. Mean age of sexual debut was 15.5 years (range 13 to 19). Four women reported a history of STI.

Within a week, samples were randomly allocated to immediate or deferred testing. Two of 16 participants in the immediate testing group were positive - one for chlamydia and one for gonorrhoea. They were easily contactable by mobile phone and email and referred for treatment. We will return to the college in six months to request a further vaginal swab and questionnaire from the 22 eligible participants. Although we need to ensure only those who are sexually experienced are recruited, our study suggests small financial incentives may be useful.

Ethics review: Bromley REC: 12/LO/0855

Acknowledgements: We thank students and staff at Lambeth College.

References

1. Jain A, Ison CA. Chlamydia point-of-care testing: where are we now? Sex Transm Infect 2013;89(2)88-89.

2. Oakeshott P, Kerry S, Aghaizu A et al. Randomized control trial of screening for Chlamydia trachomatis to prevent pelvic inflammatory disease: the POPI (prevention of pelvic infection) trial. BMJ. 2010;340:c1642

Conflict of Interest:

None declared

We enjoyed reading Dr. Saba's paper[1] and would like to share some opinions about HIV/AIDS related publications in the Middle East and North Arica (MENA). This paper showed a positive trend in the number of annual HIV/AIDS related publications in the MENA, on the other hand, this paper suggests that this number is still very low considering the sharp upward trend of HIV new infections in this region. This gap might be due to several factors. The unsupportive dominant political climate as well as the stigma and sensitivity surrounding at- risk populations such as Men having Sex with Men is very high[2]. Some of these countries have long been struggling with internal wars, uprisings, and terrorism; that may overshadow the importance of this infection in the minds of those in charge.

On the other hand, the dynamic of research have profound pitfalls in the region. The potential research capacity and the availability of funding do differ greatly across the region[2]. Lack of a clear and comprehensive plan in several countries in this region might also be an influencing factor. Last but not least, scarce publications on HIV/AIDS related topics may stem from the policy of credited scientific journals in publishing the findings of researchers from this region. Most scientific journals stick to high international research standards (regarding methodology mainly), while reviewing manuscripts from the MENA region. Some barriers such as low sample size, presence of selection and information biases to some extent might convince journals to reject the papers from this region[3]. However, implementation of high quality studies might be impossible in some of these countries. We think even simple descriptive data using even convenience sampling methods could be an important step forward in enriching the available data in the region[2]. Out of the formerly mentioned factors, we assume changing the viewpoints of journal editors is one of the most feasible options we have ahead. Lastly, although publishing the findings of researches and studies across the region is of importance, the way and to the extent those findings are applied in the countries to make a change and better the situation is much more vital.

References: 1. Hanan F Saba, et al., Characterising the progress in HIV/AIDS research in the Middle East and North Africa. Sex Transm Infect, 2013(0): p. 1-5. 2. Ivana Bozicevic, Gabriele Riedner, and Jesus maria Garcia Calleja, HIV surveillance in MENA: recent developments and results. Sex Transm Infect, 2013(0): p. 1-6. 3. Ghina R Mumtaz, et al., Are HIV epidemics among men who have sex with men emerging in the Middle East and North Africa?: a systematic review and data synthesis. PLoS Med, 2011. 8(8): p. e1000444.

Conflict of Interest:

None declared