Sexually Transmitted Infections

Hankins, C

doi: 10.1136/sextrans-2011-050102.13pmid: N/A

Randomised controlled trial results can provide the scientific rationale for implementing new biomedical HIV prevention strategies but are not sufficient. Generalisability of trial findings, good participatory trial conduct, acceptability studies, demand creation, costing and impact studies, human resource constraints, supply chain management, risk compensation, gender implications, opportunity costs, regulatory issues, and sociopolitical considerations also influence policy makers and programme planners considering adoption and implementation. Knowledge translation examples drawn from male circumcision, tenofovir gel microbicide, and oral pre-exposure prophylaxis will be presented to illustrate the evidence to be considered in scale-up.

Matogo, J N

doi: 10.1136/sextrans-2011-050108.387pmid: N/A

This research investigated the ways in which Maasai culture, as practiced in a rural and relatively isolated area of Kenya, impacted upon the transmission of HIV/AIDS. The author focused her field research on women aged 16–25, and a range of cultural practices contributing to and influenced by gender roles in Maasai society. Local practice has been addressed and recommendations made in relation to the position of the Maasai community in the wider political economy and Kenya's ethnos cape. The study also investigated strategies the women considered appropriate, practical and effective to cope with these risks. The field study was conducted in the Loitokitok district of Kenya. Methodology The research is within a qualitative paradigm. Choice of methodology was mainly based on ethic consideration of research within cultural context of Maasai Indigenous people. Data was generated through use of focus group discussions, semi structured interviews and informal observation methods. An extensive review of the literature was also conducted. The influence of gender based customs and practices are highlighted in a number of scholarly works, Governmental and non-governmental documents with regard to women's vulnerability to Sexually Transmitted Infections (STIs). The researcher maintained an “insider-outsider” position and a participatory role in order to try to identify the current state of Maasai women's reproductive health at the grass roots level. Findings Research findings have found that there is a challenge in young pastoralist women's reproductive health autonomy. Their risk of STIs especially HIV infection is strongly determined by cultural and sexual practices that are gender related. Existing customs and practices tend to be more repressive to the women's autonomy in sexual health matters as men hold power in most important roles in society. Conclusions The study does not call for cultural change or reformation of traditional culture within the Maasai community; rather it appeals for transformation of customs and practices that cause harm on women's reproductive health. Valuable cultural practices and intentions that recognise women and celebrate their womanhood should be encouraged in a way that is not physically or psychologically daunting experience on their wellbeing. To this end, the understanding and knowledge of the Maasai worldview is critical to the intervention of Maasai women's reproductive health rights. A more cultural approach to Maasai women's reproductive health is suggested to be more effective. In relation to the adoption of STI prevention measures, Maasai culture plays a key role towards identification of preventive measures and strategies.

Blank, S; Borges, C; Kowalski, A; Sebiyam, S; Sweeney, M

doi: 10.1136/sextrans-2011-050109.64pmid: N/A

Background Nucleic acid amplification testing (NAAT) is an important tool for identifying acute HIV infection (AHI), a period of high infectivity when antibody is undetectable. NAAT pooling methods (pNAAT) help contain the costs of screening for AHI. In 2008 NYC STD clinics began routine pNAAT screening for all rapid antibody negative specimens; it was standard of care in all nine clinics by 2009. A pattern of risk factors among AHI cases detected during universal screening suggested the feasibility of using targeted screening to maximise the yield of AHI cases detected while minimising costs of screening. Methods Using medical record data, we reviewed cases of AHI diagnosed in nine NYC STD clinics for 2008–2009. From these we developed targeting criteria for AHI screening, and compared yields and costs before and after targeting.was implemented. Results Targeted screening began in May 2010 and included the following risk criteria: MSM, females who have had sex with MSM, sex with an injection drug user, exchange sex for money or drugs, shared injection drug works, or recent victim of sexual assault. Prior, 42 696 specimens were screened by pNAAT from June through December 2009, yielding 23 AHI cases (5.4 cases/10 000 specimens). Of these cases, there were 21 males, including 15 who have sex with men (MSM) (71%, 15/21), 1 female, and 1 transgender. The mean age for patients was 30 years; racial/ethnic breakdown was: 57% Black, 39% Hispanic, 13% white, 4% other. Subsequently, 5280 specimens were screened by pNAAT from June through December 2010, representing an 88% decrease in testing compared to the same period during the previous year. A total of 18 AHI cases (34.1/10 000 specimens) were detected; all were MSM. The mean age was 29 years and racial/ethnic breakdown was: 44% Black, 28% Hispanic, 28% white, 5% Asian. Cost data are provided in Abstract O1-S11.04 table 1. Abstract O1-S11.04 Table 1 Cost effectiveness of targeted AHI screening Universal Targeted Average pooled AHI specimens per month 5700 770 Annual cost of pooled AHI screening $650 000 $91 296 Annual yield 33 35 Average total cost per month $54 167 $7608 Average cost per AHI case identified $19 697 $2608 Conclusion AHI screening increases case detection compared to using antibody tests alone. After initial investment in the effort, we were able to cut the cost per case identified by over sevenfold. This approach may make AHI screening more feasible/affordable in settings with patients at very high risk of newly-acquiring HIV.

Paavonen, J; Päivi, T; Unkila-Kallio, L

doi: 10.1136/sextrans-2011-050108.473pmid: N/A

Background Vulvar vestibulitis syndrome (VVS) causes severe dyspareunia in young women, but is poorly recognised and managed. We wanted to evaluate safety and effectiveness of posterior vestibulec-tomy in the treatment of VVS. Methods A cohort study of consecutive patients with refractory VVS treated at the University Hospital Vulva Clinic. The study population consisted of 70 women treated by posterior vestibulectomy during 1995–2007. All operated women were invited to participate in a long-term follow-up study. Patient characteristics, baseline visual analogue scale (VAS) for dyspareunia, and data of the postoperative pe-riod were collected. Of the 70 women invited, 57 attended the follow-up, including face-to-face inter-view, gynaecologicalgynaecological examination with swab-touch test for vestibular tenderness, current VAS score for dyspareunia, and McCoy questionnaire for sexual problems. Main outcome measures were short-term and long term complication rates, dyspareunia by VAS score, vestibular tenderness on examination, sexual problem index, and overall patient satisfaction. Results Ninety-one per cent of the patients were satisfied with the outcome. VAS for dyspareunia de-creased from a median of 9 to a median of 3 (66.7% decrease) (p <0.001). Posterior vestibular tender-ness was absent in 34 patients (64.2%). Six (8.6%) patients developed postoperative bleeding and 11 (15.7%) patients developed mild wound infection, and 4 (5.7%) patients developed Bartholin's cysts. Conclusion Posterior vestibulectomy is effective in the treatment of severe VVS and provides long-term patient satisfaction.

Ward, H; Macdonald, N; Ronn, M; Dean, G; Pallawela, S; Sullivan, A; White, J; Smith, A; French, P; Ison, C

doi: 10.1136/sextrans-2011-050109.42pmid: N/A

Background The outbreak of lymphogranuloma venereum (LGV) in men who have sex with men (MSM) in the UK is ongoing, with over 500 cases diagnosed in 2010 alone. Control efforts have been limited by a lack of understanding of the epidemiology, particularly transmission. The majority of cases are rectal with small numbers of urogenital or pharyngeal infections. No significant reservoir of asymptomatic or undiagnosed infection has been identified. The possibility of rectal to rectal transmission is suggested by studies showing an association of LGV with fisting, use of sex toys and enemas. We aim to identify risk factors to better understand transmission. Methods A case control study of LGV in six UK clinics from 2009 to the end of 2010. Confirmed cases of LGV in MSM were compared with symptomatic and asymptomatic controls. Clinical and behavioural data were collected using a web-based computer-assisted self-interview and linked to web-based clinical report forms (CRF). We used a two-stage process to construct multivariable logistic regression models in order to control for confounding and interaction between risk factors. Results We have recruited 99 cases, 86 symptomatic and 88 asymptomatic controls. There were 94 rectal cases (including one who also had pharyngeal LGV), two urethral and one genital ulcer (two CRFs outstanding). In univariate analysis, LGV was significantly associated with many factors; the strongest associations were with HIV infection, specific anal sex practices (including unprotected receptive and insertive intercourse, rimming, use of toys, fisting, douching), meeting partners through the internet or in a backroom, and use of stimulant drugs. In final multivariable logistic regression models HIV-positivity, fisting, younger age at first clinic attendance and recent use of methamphetamine remained significant predictors of LGV when compared to asymptomatic controls. Compared to symptomatic controls, unprotected insertive anal intercourse was the only significant risk factor in the final model. Conclusions Men reporting both insertive and receptive anal sex practices are at highest risk of LGV. Rectal to rectal transmission may be occurring with the organism being transferred via toys, fingers and penises; transient colonisation of the urethra may explain the low incidence of urethral LGV. Improved hygiene measures may have an important role in reducing transmission.

Fine, D; Goldenkranz, S; Adamian, J; Ranjan, S; Pan, A; Baker, J; Rink, E; Tran, N; Johnson, D; Carlon, A

doi: 10.1136/sextrans-2011-050108.249pmid: N/A

Background Women comprise >95% of US family planning (FP) clinic clients. The Male Reproductive Health Project (2008–2013) is a national research demonstration effort implementing empirically-based interventions to increase male FP clients and male testing for sexually transmitted infections (STI). Methods In 2009 interventions at 5 FP grantees included: male outreach via FP clinics' female clients and other agencies serving men, clinic efficiency assessments, FP staff training, and modifying clinic environments. Study population currently includes male FP client visit records (2004–2009) from 2 grantees. In separate analyses for Montana (MT) (2891 visits) and San Diego (SD) (7008 visits) grantees we analysed chlamydia (CT) testing (urine/NAAT) and positivity (CT+) by clinic, age, race/ethnicity, intervention status (pre: 2004–2008; post: 2009), insurance status, new/returning client, and federal Title X FP funding. Multivariate models developed. Results MT-67% of visits aged 20–29 y; 94% non-Hispanic whites. Annual visits increased 60%--pre-intervention (2004–2008) x̄ =438 visits/y; post (2009)=702 visits. CT testing increased 44% (2004–2008 x̄ =58% of visits/y tested; 2009: 78% tested). Significant (p<0.05) multivariate factors related to CT testing: intervention status (AOR=2.21), racial/ethnic minority (AOR=2.06), new client (AOR=5.59), visit's federal funding (AOR=3.04), and clinic (Billings: AOR=0.45). CT+ was 13.9%. Factors related to CT+: age<20 y (AOR=2.44, Ref:>29 y), no insurance (AOR=1.67), and federal funding (AOR=1.76). Annual female FP clients were stable (2004–2008: 5085/y; 2009: 5650). SD-43% of visits aged 20–29 y; 66% Hispanic. Annual visits increased 18%--pre-intervention x̄ =1045/y; post=1235 visits. CT testing increased 41% (pre: x̄ =29% of visits/y tested; post: 41% tested). Factors related to testing: new client (AOR=2.39) and intervention status (AO=1.76). CT+ was 6.4%. Factors related to CT+: age<20 y (AOR=3.13), black race (AOR=2.29), new client (AOR=2.47), and clinic (Beach: AOR=0.40). Annual female FP clients were stable (2004–2008: 4440/y; 2009: 4833). Conclusions Early data indicate FP clinic interventions significantly increased male clients and the proportion tested for CT without reducing female FP clients. Screening prioritised new male patients. Like other CT programs, young and minority males have increased infection risk. CT positivity varied by clinic, supporting use of local data to inform male STI services at FP clinics. Abstract P1-S6.25 Table 1 Characteristics of male family planning client visits, CT testing and positivity—2004–2009† Characteristic No. Percent % CT Tested % CT Positive Grantee: Planned Parenthood of Montana 2891 100 59 13.9 Clinic  Missoula 2009 69 63* 13.6*  Billings 882 31 51 14.6 Age (years)  <20 381 13 67* 17.8*  20–24 1217 42 60 17.3  25–29 700 25 60 10.5  >29 572 20 54 7.6 Race/ethnicity  Non-Hispanic white 2730 94 59 13.7  Minority 161 6 63 16.5 Intervention status  Pre (2004–2008) 2189 76 54* 13.2  Post (2009) 702 24 78 14.9 Insurance  No 1995 69 58* 15.3*  Yes (public or private) 896 31 62 11.0 Client status  New 1316 60 77* 14.8  Continuing 877 40 35 11.4 Federal Title X funding  No 1873 65 49* 11.1*  Yes 1018 35 78 16.1 Grantee: Family Health Centers, San Diego, CA‡ 7008 100 31% 6.4% Clinic  Logan 4732 68 31 7.5*  Beach 2276 32 32 4.3 Age (years)  <20 252 4 25* 14.6*  20–24 1334 19 32 9.7  25–29 1686 24 33 7.8  >29 3736 53 30 3.9 Grantee: FHC, San Diego cont. Race/ethnicity  Non-Hispanic white 1726 27 31 6.4*  Non-Hispanic black 335 5 29 16.4  Hispanic 4428 68 32 6.0 Intervention status  Pre (2004–2008) 5773 82 29* 6.4  Post (2009) 1235 18 41 6.5 Insurance  No 2258 32 35* 2.7*  Yes (public or private) 4749 68 29 7.6 Client status  New 1979 28 44* 9.8*  Continuing 5029 72 26 4.3 *Statistically significant (p<0.05) univariate differences. †Calendar Year 2010 data available March 2011. ‡All FHC San Diego clinic visits are federal Title X funded; measure excluded from this grantee's results.

Brand, J E; Van Der Pol, B

doi: 10.1136/sextrans-2011-050108.400pmid: N/A

Background Herpes simplex virus type 2, the main cause of genital herpes, is found worldwide among populations. US National seroprevalence is estimated at 16.2%, with highest rates among women (20.9%) & non-Hispanic blacks (39.2%). Medical consequences of HSV-2 infection includes a two- to five-fold increased risk for HIV 1 transmission & neonatal herpes. The advent of type-specific HSV serologic tests offers accurate methods of diagnosis for those who are asymptomatic. However, diagnosis of HSV-2 has been noted to be distressing for those who are asymptomatic & unaware of infection. The purpose of this study is to understand social & emotional impact of HSV-2 serodiagnosis on asymptomatic women over time. Methods Purposeful sampling was conducted & 28 women, newly diagnosed as HSV-2 serologic positive & asymptomatic, were recruited from a Midwestern STD clinic & urban community court. A series of three open-ended interviews were conducted over 6-month period. Interviews were audio recorded & transcribed. Important areas explored: emotional & social responses to diagnosis; motivations for (non) disclosure of HSV-2 status; exploration of sexual behaviour post-diagnosis; use of condoms & suppressive therapy. Qualitative analysis was done using manual coding. Results Age of participants ranged from 19 to 61 yrs. Majority were African-American (71%) with 21% white. No participants reported knowledge of HSV-2 status at diagnosis. Five themes emerged during analysis of first interviews: rumination & disclosure anxiety; knowledge deficit anxiety; stigmatisation & alteration in self-concept; fear/apprehension regarding future; impact on sexuality & partnering. With analysis of 6-month interviews there was an iteration of two themes--alteration in self-concept & impact on sexuality & partnering. Of 23 participants who completed three interviews-22% had no plans for sex after diagnosis, 39% never disclosed HSV-2 status to partners & 56% never used suppressive therapy. Conclusions Findings suggest that despite increased public information related to HSV-2, initial diagnosis remains traumatic, & for a small percentage anxiety lingers for at least 6 months. Providers should be aware of need for written information targeted to non-clinicians & that further follow-up should be initiated after diagnosis to reinforce learning, clarify concerns, counsel & support. Providers should plan additional time for client integration of diagnosis, implications & questions.

Chen, X; Jiang, N; Wang, B

doi: 10.1136/sextrans-2011-050109.60pmid: N/A

Objectives The data on STIs control and HIV prevention is limited among MSM population. To examine STIs control strategies for HIV prevention in a community-based cohort of HIV-negative MSM, community intervention trail was conducted between 2009 and 2011. This report mainly discussed baseline survey results. Methods This study was conducted in MSM community of four mid-sized cities from Jul. to Sep. 2009. All participants were recruited through venue-based recruitment, complemented by peer referral using snowball method, Questionnaire were completed in STD clinics or VCT centers. Blood samples were collected for HIV, syphilis and HSV-2 tests, and urine sample for CT/NG PCR tests. Results 35.3% participants self-identified as homosexual and 44.7% bisexual. The most popular way to seek male sexual partners was internet (38.4%). 15.9% of participants had provided or acquired sex services with male, while 19.1% of respondents reported unprotected anal intercourse (UAI) in the last sex services. 3.8% of participants had experienced sadism & masochism(SM). In past 6 months, 80.8% of participants had anal sex with man and 29.0% reported UAI during the last intercourse. 38.5% of participants reported having had sex with woman and only 45.2% of those reported using condom during the last intercourse with woman. 18.0% of participants involved in commercial sex services had taken drugs such as methamphetamine, Ketamine and MDMA.10.6% of participants was HIV infection. 34.4% of participants is TP-ELISA positive results indicated a history of syphilis infection, and 20.9% were both positive results of ELISA and TRUST indicated active syphilis. 3.0% of participants were tested as NG infection, 6.8% was CT infected, and 16.2% were HSV-2 infected. Significant factors associated with HIV infection were self-reported STD infection history [AOR=2.1, 95% CI: 1.29% to 4.26%], syphilis infection [AOR=2.70, 95% CI: 1.81% to 4.04%], and HSV-2 infection [AOR=3.07, 95% CI: 2.09% to 4.50%]. Conclusions MSM have been potential bridge-population for HIV/STIs from most-at-risk population to general population. Intervention activities should target the internet, sexual social networks, and certain subpopulations such as those taking drugs in commercial sex services or infected with STIs. Friendly and high-quality STIs service should reach to MSM who do not attend STD clinics. Campaigns are urgent not only to boost individual condom use but also to create culture for condom use in MSM community.

Bradley, H; Asbel, L; Bernstein, K; Mattson, M; Pathela, P; Pino, R; Samuel, M; Schwebke, J; Stenger, M; Tabidze, I; Zenilman, J; Dowell, D; Weinstock, H

doi: 10.1136/sextrans-2011-050109.171

Johnson, R; Ware, D; Mena, L; Xu, F

doi: 10.1136/sextrans-2011-050108.411pmid: N/A

Background The positive predictive value (PPV) of a screening test (ST) is a function of prevalence and ST specificity and is expected to decrease with decreasing prevalence unless ST specificity approaches 100%. Consequently, an additional test (AT) following positive STs may be indicated if prevalence is low. Our objective was to determine the impact of CT and GC prevalence on per cent AT positive following positive STs by Gen-Probe Combo 2 CT and GC using data from public clinics in the state of Mississippi. Methods Based-on CDC's electronic prevalence monitoring databases from 2005 to 2007, we stratified 126 clinics (with >400 females tested) served by Mississippi State Public Health Laboratory (MSPHL) based on ST positivity. We calculated the per cent AT positive among 6553 CT ST positive and 1841 GC ST positive specimens. We further examined the impact of the quantitative Combo 2 GC results (relative light units (RLU)) for a sample of 508 specimens from clinics with low (<2.0%, family planning) and high (>6.0%, STD) ST positivity by abstracting the RLU values from hard copy records. Results Per cent CT AT positive declined significantly (p<0.0001) from 96.3% for specimens from clinics with >10.0% ST positivity to 90.9% for specimens from a single clinic with <6% ST positivity (see Abstract P3-S1.11 table 1). GC ST positivity was <6% for 109 (87%) of the clinics. In spite of the lower GC ST positivity, the per cent GC AT positive was also >90%, ranging from 95.4% for GC ST positivity <2% to 97.7% for GC ST positivity 3.0%–4.0%. However, the per cent GC AT positive was not associated with GC ST positivity (p=0.17). Discordant GC AT results were confined to GC ST positive specimens with RLU <1 million (results not shown). The per cent of ST specimens with RLU <1million and the per cent AT negative among these lower RLU positives were also not associated with clinic ST positivity (p=0.14 and p=0.78, respectively). Abstract P3-S1.11 Table 1 APTIMA additional test results among women by clinic Combo 2 positivity and organism Mississippi—2007 Organism Clinic Combo 2 % positivity APTIMA AT result p Value Retested # Positive # % 95% CI CT <6.0 11 10 90.9 58.7 to 99.8 <0.0001* 6.0–<8.0 281 261 92.9 89.2 to 95.6 8.0–<10.0 799 745 93.2 91.3 to 94.9 10.0+ 5462 5262 96.3 95.8 to 96.8 Total 6553 6278 95.8 95.3 to 96.3 NG <2.0 196 187 95.4 91.5 to 97.9 0.17* 2.0–<3.0 459 442 96.3 94.1 to 97.8 3.0–<4.0 392 383 97.7 95.7 to 98.9 4.0–<6.0 177 171 96.6 92.8 to 98.8 6.0+ 617 599 97.1 95.4 to 98.3 Total 1841 1782 96.8 95.9 to 97.6 * Cochran-Armitage trend test. Conclusions Performing APTIMA CT or GC ATs added little to Combo 2 ST PPV, although the decrease in per cent AT positive with decreasing ST positivity observed in this study raises concern about Combo 2 PPV at CT prevalence levels lower than 6%. The lack of impact of GC prevalence on GC ST RLU or AT results is unexpected and might indicate that the Combo 2 ST PPV is very high even at the lower GC prevalence. In other words, most negative GC AT results are false rather than true negatives and the patients should be treated.