John Richens

Condoms and seat belts: the parallels and the lessons

This paper investigates the relation between behavior adaptation and safety benefits of seat belts and whether condom promotion can be undermined by unintended changes in sexual risk perception and behavior. The comparison between 13 countries that passed seat belt laws and 4 countries without such laws shows a significant number of deaths among countries with seat belt laws. It has been suggested that drivers who wear seat belts feel safer and drive faster and more carelessly compared to those without seat belts. A model of individual risk management, postulating that every individual is comfortable with a certain level of risk and aims to balance the rewards of risk-taking against perceived hazards was developed to describe the behavior. This increase in seat belt use was then paralleled with condom use since the rise of HIV, with 3 ways in which a large increase in condom use could fail to affect transmission: 1) it appeals to risk-averse individuals who contribute little to epidemic transmission; 2) increased use of condom increases the number of transmission caused by condom failure; and 3) the increased use of condoms reflect the change in the decision of individuals from one partner to maintaining higher rates of partners and reliance on condoms. This paper, in conclusion, emphasizes the need for program development and implementation in response to this sexual behavior, particularly among developing countries.

Genital manifestations of tropical diseases.

Genital symptoms in tropical countries and among returned travellers can arise from a variety of bacterial, protozoal, and helminthic infections which are not usually sexually transmitted. The symptoms may mimic classic sexually transmitted infections (STIs) by producing ulceration (for example, amoebiasis, leishmaniasis), wart-like lesions (schistosomiasis), or lesions of the upper genital tract (epididymo-orchitis caused by tuberculosis, leprosy, and brucellosis; salpingitis as a result of tuberculosis, amoebiasis, and schistosomiasis). A variety of other genital symptoms less suggestive of STI are also seen in tropical countries. These include hydrocele (seen with filariasis), which can be no less stigmatising than STI, haemospermia (seen with schistosomiasis), and hypogonadism (which may occur in lepromatous leprosy). This article deals in turn with genital manifestations of filariasis, schistosomiasis, amoebiasis, leishmaniasis, tuberculosis and leprosy and gives clinical presentation, diagnosis, and treatment.

Lymphogranuloma venereum presenting as genital ulceration and inguinal syndrome in men who have sex with men in London, UK

Objectives: To describe a series of lymphogranuloma venereum (LGV) cases presenting as inguinal syndrome and/or genital ulceration seen among men who have sex with men (MSM) in London, UK. Methods: Collaborative retrospective case note review. Clinicians from three London genitourinary medicine (GUM) clinics accessed by large populations of MSM within the current LGV outbreak collected clinical data from confirmed cases of LGV inguinal syndrome or genital ulcer. LGV was confirmed by the detection of LGV-specific DNA from specimens such as bubo aspirates, ulcer swabs, urethral swabs, first void urine and rectal biopsy material. Results: There were 13 cases detected overall: 5 cases of urethral LGV infection with inguinal adenopathy, 3 cases of genital ulcer with LGV inguinal adenopathy, 3 cases of isolated LGV-associated inguinal buboes, 1 case of a solitary LGV penile ulcer and 1 case with a penile ulcer and bubonulus. Only 6 of the 13 were HIV positive and all tested negative for hepatitis C. The majority of cases reported few sexual contacts in the 3 months preceding their diagnosis. Conclusions: Clinical manifestations of LGV in MSM have not been confined to proctitis in the current outbreak in the UK and a small but significant number of inguinogenital cases of LGV have been observed. Epidemiologically, many of the cases described seem to have occurred at the periphery of the current MSM LGV epidemic. Clinicians need to be vigilant for these less common presentations of LGV among MSM and specific diagnostic tests should be done from the relevant lesions.

A randomised controlled trial of computer-assisted interviewing in sexual health clinics

Objectives To assess the impact of computer-assisted interview compared with pen and paper on disclosure of sexual behaviour, diagnostic testing by clinicians, infections diagnosed and referral for counselling. Methods Two-centre parallel three-arm randomised controlled open trial. Computer-generated randomisation with allocation concealment using sealed envelopes. Setting Two London teaching hospital sexual health clinics. Participants 2351 clinic attenders over the age of 16 years. Interventions Computer-assisted self-interview (CASI). Computer-assisted personal interview (CAPI). Pen and paper interview (PAPI). Main Outcome Measures Diagnostic tests ordered, sexually transmitted infections (STI). Secondary Outcomes Disclosure of sexual risk, referral for counselling. Results 801, 763 and 787 patients randomly allocated to receive CASI, CAPI and PAPI. 795, 744 and 779 were available for intention-to-treat analysis. Significantly more diagnostic testing for hepatitis B and C and rectal samples in the CAPI arm (odds for more testing relative to PAPI 1.32; 95% CI 1.09 to 1.59). This pattern was not seen among CASI patients. HIV testing was significantly lower among CASI patients (odds for less testing relative to PAPI 0.73; 95% CI 0.59 to 0.90). STI diagnoses were not significantly different by trial arm. A summary measure of seven prespecified sensitive behaviours found greater reporting with CASI (OR 1.4; 95% CI 1.2 to 1.6) and CAPI (OR 1.4; 95% CI 1.2 to 1.7) compared with PAPI. Conclusion CASI and CAPI can generate greater recording of risky behaviour than traditional PAPI. Increased disclosure did not increase STI diagnoses. Safeguards may be needed to ensure that clinicians are prompted to act upon disclosures made during self-interview. Trial registration ISRCTN: 97674664.

The relative clinical effectiveness and cost-effectiveness of three contrasting approaches to partner notification for curable sexually transmitted infections: a cluster randomised trial in primary care

BACKGROUND Partner notification is the process of providing support for, informing and treating sexual partners of individuals who have been diagnosed with sexually transmitted infections (STIs). It is traditionally undertaken by specialist sexual health services, and may involve informing a partner on a patients behalf, with consent. With an increasing proportion of STIs diagnosed in general practice and other community settings, there is a growing need to understand the best way to provide partner notification for people diagnosed with a STI in this setting using a web-based referral system. OBJECTIVE We aimed to compare three different approaches to partner notification for people diagnosed with chlamydia within general practice. DESIGN Cluster randomised controlled trial. SETTING General practices in England and, within these, patients tested for and diagnosed with genital chlamydia or other bacterial STIs in that setting using a web-based referral system. INTERVENTIONS Three different approaches to partner notification: patient referral alone, or the additional offer of either provider referral or contract referral. MAIN OUTCOME MEASURES (1) Number of main partners per index patient treated for chlamydia and/or gonorrhoea/non-specific urethritis/pelvic inflammatory disease; and (2) proportion of index patients testing negative for the relevant STI at 3 months. RESULTS As testing rates for chlamydia were far lower than expected, we were unable to scale up the trial, which was concluded at pilot stage. We are not able to answer the original research question. We present the results of the work undertaken to improve recruitment to similar studies requiring opportunistic recruitment of young people in general practice. We were unable to standardise provider and contract referral separately; however, we also present results of qualitative work aimed at optimising these interventions. CONCLUSIONS External recruitment may be required to facilitate the recruitment of young people to research in general practice, especially in sensitive areas, because of specific barriers experienced by general practice staff. Costs need to be taken into account together with feasibility considerations. Partner notification interventions for bacterial STIs may not be clearly separable into the three categories of patient, provider and contract referral. Future research is needed to operationalise the approaches of provider and contract partner notification if future trials are to provide generalisable information. TRIAL REGISTRATION Current Controlled Trials ISRCTN24160819. FUNDING This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 5. See the NIHR Journals Library website for further project information.

HIV and STI prevalence and determinants among male migrant workers in India.

Background Our objective was to estimate for the first time the prevalence and determinants of human immunodeficiency virus type 1 (HIV-1) and sexually transmitted infections (STIs) among male migrants in India. Methodology/Principal Findings We conducted a multi-stage stratified probability sample survey of migrant (defined as not born in Surat city) men aged 18 to 49 years working in the diamond and textile industries in Surat city. Behavioural and biological data were collected. Biological data included laboratory diagnosed herpes simplex virus type 2 (HSV-2), syphilis, chlamydia, gonorrhoea, Trichomonas vaginalis (together defined as ‘any STI’) and HIV-1. Likely recently acquired STIs included chlamydia, gonorrhoea, T.vaginalis and syphilis with rapid plasma reagin ≥1∶8. The response rate was 77% (845/1099). Among 841 participants, HIV-1 prevalence was 1.0%, ‘any STI’ prevalence was 9.5% and 38.9% of these STIs were likely to have been recently acquired. Being a diamond worker, Surat resident for 10+ years and recent antibiotic use were each associated with higher odds of ‘any STI’ (aORs 1.83 (95% CI 1.09–3.09), 1.98 (95% CI 1.22–3.22) and 2.57 (95% CI 1 .17–5.64), respectively) after adjusting for the other two factors and age. The main study limitation was social desirability bias for self-reported sexual behaviour; STIs were diagnosed in some self-reported virgins. Conclusions/Significance HIV and STI prevalence were lower than expected, but prevention interventions remain necessary in Surat since almost 40% of STIs among participants were probably recently acquired and sentinel surveillance HIV prevalence remains high. The participants had a similar HIV prevalence to Surat antenatal clinic attendees, a proxy for the general population. This suggests migrants are not always at higher risk of HIV compared to the general population in their migration destination. Our findings highlight the need to contextualise research findings from a specific setting with other local information to guide HIV/STI prevention interventions.

P5-S5.04 Provider and contract referral for bacterial STIs: two sides of the same coin?

Background During the pilot of an RCT of provider, contract and patient referral, for a 66 practice RCT of partner notification in UK primary care, it emerged that there is uncertainty about real life clinical practice. Our objectives are to describe how health advisers negotiate provider, contract and patient partner notification in clinical practice. To determine the feasibility of comparing both provider and contract referral separately against patient referral. Methods We recruited 10 health advisers from contrasting settings to attend a 1-day workshop led by partner notification specialists and researchers. They participated in focus group discussions, observations of practice, role play with each other and with actors. They and the actors then contributed to further focus groups reflecting on their observations and experiences, and advising on feasible strategies for delivering standard partner notification interventions in the RCT context. All discussions were recorded for qualitative analysis. Results All health advisers practised provider referral, but the extent was variable. Contract referral as defined in the UK (a time period is explicitly agreed for the patient to notify, after which provider notification is initiated) is practised for HIV, other bloodborne viruses and sometimes syphilis. However for common bacterial STIs, a patients choice of provider referral often emerges over multiple consultations, and provider referral is not a distinct intervention from contract referral. Health advisers saw their role as helping patients find solutions to partner notification, rather than applying specific interventions. Conclusions Provider and contract referral are not sufficiently distinct to be compared with each other in a trial setting for chlamydia and gonorrhoea. However contract referral does have an important role in management of partner notification for bloodborne viruses.

Sex, Disease and Society. A comparative history of sexually transmitted diseases and HIV/AIDS in Asia and the Pacific; Histories of Sexually Transmitted Diseases and HIV/AIDS in Sub-Saharan Africa 1,2.

These two books provide histories of STDs and HIV in nine sub-Saharan African countries and another 11 countries in the Asia-Pacific region. The contributors are mostly historians or social scientists and the historical accounts take the reader up to 1995. Each volume is divided up into well referenced scholarly monographs on individual countries and individual chapters will be of considerable interest to anyone with an interest in sexual health in the countries studied. The number of readers of this journal who will want to read both books throughout is likely to be much less, given that these books are fairly specialist medical historical studies written mainly by historians for historians. The decision of the editors to treat each country separately has led …