Joseph D. Tucker

Surplus men, sex work, and the spread of HIV in China

While 70% of HIV positive individuals live in sub-Saharan Africa, it is widely believed that the future of the epidemic depends on the magnitude of HIV spread in India and China, the worlds most populous countries. Chinas 1.3 billion people are in the midst of significant social transformation, which will impact future sexual disease transmission. Soon approximately 8.5 million ‘surplus men’, unmarried and disproportionately poor and migrant, will come of age in Chinas cities and rural areas. Meanwhile, many millions of Chinese sex workers appear to represent a broad range of prices, places, and related HIV risk behaviors. Using demographic and behavioral data, this paper describes the combined effect of sexual practices, sex work, and a true male surplus on HIV transmission. Alongside a rapid increase in sexually transmitted disease incidence across developed parts of urban China, surplus men could become a significant new HIV risk group. The anticipated high sexual risk among many surplus men and injecting drug use use among a subgroup of surplus men may create bridging populations from high to low risk individuals. Prevention strategies that emphasize traditional measures – condom promotion, sex education, medical training – must be reinforced by strategies which acknowledge surplus men and sex workers. Reform within female sex worker mandatory re-education centers and site specific interventions at construction sites, military areas, or unemployment centers may hold promise in curbing HIV/sexually transmitted infections. From a sociological perspective, we believe that surplus men and sex workers will have a profound effect on the future of HIV spread in China and on the success or failure of future interventions.

Syphilis and social upheaval in China.

Syphilis was nearly eliminated from China 50 years ago but is now the most commonly reported communicable disease in Shanghai. Dr. Joseph Tucker and colleagues write that the Chinese syphilis epidemic holds important lessons about social and environmental influences on sexual health.

Accelerating worldwide syphilis screening through rapid testing: a systematic review

Syphilis is a persistent public health issue in many low-income countries that have limited capacity for testing, which traditionally relies on a sensitive non-treponemal test and then a specific treponemal test. However, the development of a new rapid treponemal test provides an opportunity to scale up syphilis screening in many settings where traditional tests are unavailable. This systematic review of immunochromatographic strip (ICS) syphilis tests describes the sensitivity and specificity in two important clinical settings: sexually transmitted infection (STI) clinics and antenatal clinics. Clinical data from more than 22 000 whole blood, plasma, or fingerstick ICS tests obtained at STI or antenatal clinics were retrieved from 15 studies. ICS syphilis tests have a high sensitivity (median 0.86, interquartile range 0.75-0.94) and a higher specificity (0.99, 0.98-0.99), both comparable with non-treponemal screening test characteristics. Further research evaluating ICS syphilis tests among primary syphilis cases and among patients infected with HIV will be essential for the effective roll-out of syphilis screening programmes.

Point-of-care testing for sexually transmitted infections: Recent advances and implications for disease control

Purpose of review Sexually transmitted infections (STIs) remain a major global public health issue, with more than 448 million incident bacterial infections each year. We review recent advances in STI point-of-care (POC) testing and implications for STI prevention and control. Recent findings Accurate immunochromatographic assays to detect HIV, hepatitis C virus (HCV) and syphilis antibodies have made home or supervised self-testing possible. Several studies have demonstrated feasibility and excellent test characteristics for HIV, HCV and syphilis POC tests. Rapid oral HIV tests are now available for purchase at retail sites across the United States. Combined HIV and syphilis tests using a single finger prick blood sample are under evaluation. Summary Oral POC STI tests with comparable performance to blood-based POC tests are available for self-testing. POC tests can expand screening, improve syndromic management and reduce loss to follow up. POC STI tests have the potential to facilitate prompt treatment and partner services. POC STI tests create opportunities for new social and financial models of community-based testing services. Increasing equity and access to testing will create challenges in linkage to care, quality assurance, partner services and surveillance. These important developments warrant research to understand appropriate contexts for implementation.

Ocular syphilis among HIV-infected patients: a systematic analysis of the literature

Background Ocular syphilis among HIV-infected patients continues to be a problem in the highly active antiretroviral therapy (HAART) era. However, outside of case reports or small case series, little is known about the clinical, laboratory, and treatment outcomes of these patients. Objective To examine the literature on HIV-infected patients and determine the results of treatment. Methods Systematic review of cases series and case reports among HIV-infected individuals with ocular syphilis. Reviews, languages other than English and pre-1980 reports were excluded. The effect of CD4 count and virological suppression on clinical manifestations and diagnostic laboratory values was evaluated. Results A total of 101 HIV-infected individuals in case series and case reports were identified. Ocular syphilis led to the HIV diagnosis in 52% of cases, including patients with CD4 count >200 cells/mm3. Posterior uveitis was significantly more common in individuals with CD4 count <200 cells/mm3 (p=0.002). Three patients with confirmed ocular syphilis had negative non-treponemal tests. Ninety-seven per cent of patients with visual impairment improved following intravenous penicillin or ceftriaxone. Conclusions Non-treponemal tests may be negative in HIV-infected patients with ocular syphilis. Ocular syphilis remains an important clinical manifestation that can lead to initial HIV diagnosis.

China's syphilis epidemic: epidemiology, proximate determinants of spread, and control responses

Purpose of review China has experienced an increase in the incidence and prevalence of syphilis that is especially remarkable since this infection was virtually eradicated in the country 50 years ago. The purpose of this analysis is to provide an overview of recent literature on syphilis proximate determinants and potential public health responses. Recent findings Per capita syphilis burden is greatest in coastal urban China. There are a number of biological, demographic, geographic, and behavioral/social proximate determinants of syphilis spread that distinguish the Chinese syphilis epidemic. These determinants portend the need for intensified syphilis control efforts, including: comprehensive testing and treatment; integration with HIV, sexually transmitted infection, and antenatal services; scale-up of novel rapid syphilis test technology, and multisectorial support. Summary The Chinese central government recently announced a 10-year syphilis plan to provide clear expectations for evaluating the success of local syphilis control programs and integration with HIV testing programs. Further research is needed to understand the social and behavioral determinants driving the spread of syphilis.

Patient-physician mistrust and violence against physicians in Guangdong Province, China: a qualitative study

Objective To better understand the origins, manifestations and current policy responses to patient–physician mistrust in China. Design Qualitative study using in-depth interviews focused on personal experiences of patient–physician mistrust and trust. Setting Guangdong Province, China. Participants One hundred and sixty patients, patient family members, physicians, nurses and hospital administrators at seven hospitals varying in type, geography and stages of achieving goals of health reform. These interviews included purposive selection of individuals who had experienced both trustful and mistrustful patient–physician relationships. Results One of the most prominent forces driving patient–physician mistrust was a patient perception of injustice within the medical sphere, related to profit mongering, knowledge imbalances and physician conflicts of interest. Individual physicians, departments and hospitals were explicitly incentivised to generate revenue without evaluation of caregiving. Physicians did not receive training in negotiating medical disputes or humanistic principles that underpin caregiving. Patient–physician mistrust precipitated medical disputes leading to the following outcomes: non-resolution with patient resentment towards physicians; violent resolution such as physical and verbal attacks against physicians; and non-violent resolution such as hospital-mediated dispute resolution. Policy responses to violence included increased hospital security forces, which inadvertently fuelled mistrust. Instead of encouraging communication that facilitated resolution, medical disputes sometimes ignited a vicious cycle leading to mob violence. However, patient–physician interactions at one hospital that has implemented a primary care model embodying health reform goals showed improved patient–physician trust. Conclusions The blind pursuit of financial profits at a systems level has eroded patient–physician trust in China. Restructuring incentives, reforming medical education and promoting caregiving are pathways towards restoring trust. Assessing and valuing the quality of caregiving is essential for transitioning away from entrenched profit-focused models. Moral, in addition to regulatory and legal, responses are urgently needed to restore trust.

Detection of acute and established HIV infections in sexually transmitted disease clinics in Guangxi, China: Implications for screening and prevention of HIV infection

BACKGROUND Human immunodeficiency virus (HIV) has spread throughout China and to some degree has penetrated the general heterosexual population in some regions. METHODS A cross-sectional survey of 11,461 sexually transmitted disease (STD) clinic attendees in 8 cities in Guangxi, China, was conducted for syphilis and for acute and established HIV infections. RESULTS The prevalence of acute and established HIV infections was 1.2% among the participants. Five acute (preseroconversion) HIV infections were detected. Multivariate analysis showed that HIV infection was independently related to unmarried status (odds ratio [OR], 1.73 [95% confidence interval {CI}, 1.00-2.99), less education (OR for less than primary school, 4.21 [90% CI, 1.21-14.58]), residence in city A (OR, 11.48 [95% CI, 2.05-64.31]) or city B (OR, 7.93 [95% CI, 1.75-35.91]), working in the entertainment industry (OR, 3.98 [95% CI, 1.14-13.88]), injection drug use (OR, 25.09 [95% CI, 10.43-60.39]), no condom use during most recent sexual intercourse (OR, 4.97 [95% CI, 1.38-17.88]), and syphilitic infection (OR, 1.91 [95% CI, 1.03-3.56]). CONCLUSIONS HIV prevalence in STD clinics is significantly greater than that in the general population, and subjects were identified who would be missed by conventional surveillance. Chinas nationwide system of public STD clinics, which reach down to the township level, should be used for HIV control programs.

HIV self-testing among online MSM in China: Implications for expanding HIV testing among key populations

Abstract:HIV self-testing offers an alternative to facility-based testing that could expand HIV testing among men who have sex with men (MSM). We organized an online survey of MSM in China to better understand the frequency and correlates of HIV self-testing. A total of 1342 individuals completed the survey. About 20.3% of MSM reported previous HIV self-testing. Self-testing was correlated with being married, having 6 or greater male anal sex partners in the past 3 months, and having HIV tested within 12 months in the multivariable analysis. Our study suggests that HIV self-testing may be able to reach subgroups of high-risk MSM and enable more frequent HIV testing.

Azithromycin Treatment Failure Among Primary and Secondary Syphilis Patients in Shanghai

Background: Azithromycin has been used to treat primary and secondary syphilis and as prophylaxis for sexual partners. We evaluated syphilis treatment failure in patients who received azithromycin therapy. Methods: Patients who did not respond to azithromycin therapy were referred to Shanghai Skin Disease and sexually transmitted disease hospital. Treatment failure was defined as follows: (1) persistent ulcers or cutaneous or mucosal lesions 1 month after therapy; or (2) detection of spirochetes in dark-field microscopy examination of a lesion at least 1 week after treatment; or (3) failure of rapid plasma reagin titers to decrease 4-fold at 3 months after treatment. Results: A total of 132 patients with primary and secondary syphilis who failed azithromycin therapy were referred to our hospital between January 2001 and October 2008. Of 132 patients, 42 (31.8%) had primary syphilis and 90 (68.2%) had secondary syphilis. Twenty-six patients with primary syphilis developed multiple lesions or secondary syphilis, or persistent ulcers despite using azithromycin. The skin or mucosal lesions did not resolve in 37 patients with secondary syphilis after azithromycin treatment. Ten patients had a positive dark-field examination for Treponema pallidum (T. pallidum) after treatment. The serum rapid plasma reagin titers studied in all cases had failed to decrease 4-fold at 3 months after therapy. The doses of azithromycin used for treatment ranged from 4 to 30 g. Conclusions: The failure of azithromycin to cure a substantial number of patients with primary and secondary syphilis in Shanghai suggests that azithromycin has limited therapeutic value in this setting.