Sexual Health

Published by CSIRO Publishing
Print ISSN: 1448-5028
Background Human papillomavirus (HPV) DNA is present in the majority of squamous cell cancers of the anus. ADXS11-001 immunotherapy is a live attenuated Listeria monocytogenes (Lm) bioengineered to secrete an HPV-16-E7 fusion protein targeting HPV-transformed cells. The Lm vector infects antigen-presenting cells, stimulating both MHC class 1 and 2 pathways resulting in specific T-cell immunity to tumours. The Brown University Oncology Research Group has initiated a phase I/II study evaluating two treatment schedules of ADXS11-001 with standard chemoradiation for anal cancer. Methods: Patients with newly diagnosed anal cancer with a primary tumour >4cm or lymph node involvement, without distant metastases, are eligible. All patients receive two courses of mitomycin, 5-FU with concurrent radiation (54Gy in 30 fractions by IMRT). Patients receive four treatments of ADXS11-001, 1×10(9) colony-forming units intravenously once approximately every 28 days. In treatment schedule 1, the first dose is given before chemoradiation and the second to fourth doses are given every 28 days after completion of radiation. In treatment schedule 2, the second dose of ADXS11-001 is administered during chemoradiation. Results: Three patients have been treated with ADXS11-001 and chemoradiation on treatment schedule 1. One patient developed grade 3 chills and one patient experienced grade 2 flu-like symptoms post-infusion, both resolved with symptomatic treatment. Conclusions: ADXS11-001 is a highly novel form of immunotherapy designed to generate an immune response against HPV transformed cells. Accrual is continuing to evaluate safety and efficacy for patients with anal cancer.
Background: Chlamydia trachomatis prevalence among 12-17-year-old adolescents in Germany was determined in the present study. Methods: A random age-stratified sample of 1815 urine specimens of boys and girls was selected from a population-based nationwide health survey conducted in 2003-06. Urine samples were pooled and tested for chlamydia using strand displacement amplification. Positive pools were individually retested. Prevalence, prevalence ratios (PR) and corresponding 95% confidence intervals (CI) were calculated. Associations between infection and socio-demographic factors (age, sex, place of residence), sexual activity (defined by oral contraceptive use or gynaecologist visits) and abdominal pain among females were examined in univariate analysis. Results: Sixteen samples (0.9% 95% CI: 0.5-1.3%), all from 15-17-year olds, were positive for chlamydia. Prevalence increased with age to 2% (95% CI: 0.8-3.2%) among 17 year olds and was higher among girls than boys (1.8% v. 0.1%; P < 0.001). A total of 4.6% (95% CI: 1.4-7.7%) of sexually active girls aged 17 were infected and 5/7 of them had no regular abdominal pain. Of all girls with abdominal pains, 52% had visited gynaecologists. Prevalence of infection was higher among those with pains than those without (PR = 3.8, 95% CI: 1.3-11.0). Conclusions: This is the first nationwide study based on a representative sample of boys and girls to measure chlamydia prevalence among adolescents in Germany. Prevalence in Germany is consistent with other countries. Among sexually active females, prevalence was comparable to screening thresholds. As gynaecological visits were common among females, we recommend that gynaecologists should actively offer screening to sexually active females, which would strengthen the newly implemented screening for females under 25 years.
Age-specific incidence (per 100 000 women) of cervical cancer, 2004-07 by age group. Figures are shown for Melanesian Fijian women (dotted line), Indo-Fijian women (dashed line) and both groups combined (solid line). 
Annualised incidence of and mortality rates from cervical cancer in Fiji by ethnicity IQR, interquartile range; CI, confidence interval. P-value compares Melanesian Fijian women with Indo-Fijian women 
Age-specific mortality rate (per 100 000 women) of cervical cancer in Fiji for 2004-07 by age group. Figures are shown for Melanesian Fijian women (dotted line), Indo-Fijian women (dashed line), and both groups combined (solid line). 
Background: There are few population-based data on the disease burden of cervical cancer from developing countries, especially South Pacific islands. This study aimed to determine the incidence and mortality associated with cervical cancer and the coverage of Papanicolaou (Pap) cervical cytology in 20- to 69-year-old women in Fiji from 2004 to 2007. Methods: National data on the incident cases of histologically confirmed cervical cancer and the associated deaths, and on Pap smear results were collected from all pathology laboratories, and cancer and death registries in Fiji from 2004 to 2007. Results: There were 413 incident cases of cervical cancer and 215 related deaths during the study timeframe. The annualised incidence and mortality rates in 20- to 69-year-old Melanesian Fijian women, at 49.7 per 100?000 (95% confidence interval (CI): 43.7-56.4) and 32.3 per 100?000 (95% CI: 26.9-38.4) respectively, were significantly higher than among 20- to 69-year-old Indo-Fijian women at 35.2 per 100?000 (P<0.001, 95% CI: 29.5-41.7) and 19.8 per 100?000 (P=0.002, 95% CI: 15.1-25.5) respectively. Of 330 cases diagnosed between 2004 and 2006, 186 (56%) had died by 31 December 2006. Pap smear coverage for this period was 8.0% (95% CI: 7.9-8.1) of the target population. Conclusions: The incidence and mortality related to cervical cancer in Fiji is high, whereas Pap smear coverage is very low. Greater investment in alternative screening strategies and preventive measures should be integrated into a comprehensive, strategic cervical cancer control program in Fiji.
Chlamydia re-testing rates in 30-120 days by select characteristics, ACCESS sexual health service network, 2004-08 (unknowns excluded) 
To describe the frequency of the 3-month test for re-infection among sexual health service patients in Australia. We assessed the re-testing rates at 30-120 days after chlamydia infection in men who have sex with men (MSM), heterosexual males and females attending sexual health services across Australia between 2004 and 2008. A χ(2)-test was used to determine significant differences in re-testing rates according to demographic characteristics and trends over time. In the 5-year period, 10207 MSM, 28530 heterosexual males and 31190 heterosexual females were tested for chlamydia. Of those tested, 9057 (13.0%) were positive. The proportion of patients with chlamydia infection who were re-tested in 30-120 days was 8.6% in MSM, 11.9% in heterosexual males and 17.8% in heterosexual females. Among MSM, chlamydia re-testing rates were lower in men aged <30 years (8.4%) than ≥30 years (12.5%) (P=0.04) and lower in travellers and migrants (2.9%) than non-travellers (9.9%) (P=0.002). In heterosexual males, chlamydia re-testing rates were lower in men in regional and rural areas (10.5%) than metropolitan areas (13.5%) (P=0.017). There was no increasing trend in re-testing rates between 2004 and 2008 (P=0.787). Of the patients re-tested, 44.1% of MSM were positive, 21.0% of heterosexual males and 16.1% of females. The high chlamydia positivity at 30-120 days support recommendations that call for a 3-month test for re-infection following a positive test. The low re-testing rates highlight the need for innovative strategies to increase re-testing.
Background Anal cancer accounts for 4% of all lower gastrointestinal tract malignancies in the US. One of the most important predictors of prognosis among anal cancer patients is the size of the primary tumour. Tumours with diameters >5cm have poorer disease-free survival than those with smaller tumours. Understanding the biological changes associated with tumour growth may provide information to guide therapy and improve patient outcomes. DNA methylation changes are critical epigenetic events in cancer development. Methods: In this study we sought to characterise the epigenomic signatures associated with anal cancer tumour size (≤5cm vs >5cm) in FFPE tissues from 121 patients (≤5cm=88; >5cm=33) who participated in the RTOG 98-11 cooperative group anal cancer clinical trial. Differential methylation, examined at >450000 CpG loci using the Illumina Human Methylation 450 Array, were compared between the two groups using Mann-Whitney test (significance=P<0.001 and difference in methylation β-value >0.1). Results: This study included 74 women and 47 men with a median age of 54 years. A total of 86 CpG loci were differentially methylated (78 increased and 8 decreased) in large vs small tumours. Genes harbouring CpG sites that were among the most highly differentially methylated included those associated with WNT signalling (FZD10, WNT9A), microRNAs (MIR200A) and novel methylated targets (PON3). Conclusions: These data provide evidence that epigenetic events likely play a significant role in the progression of anal SCC and may serve as biomarkers of prognosis. Similar epigenomic approaches may be useful at earlier stages of anal neoplastic progression for application in screening and early detection.
Background Although anal HPV infection and cytological abnormalities are highly prevalent among HIV-infected MSM patients, there is limited data on HIV-infected heterosexual men and women. Since November 2010 at our clinic, anal cancer screening with both hr-HPV and cytology was routinely performed in all HIV-infected patients. The purpose of the study was to evaluate the prevalence of anal hr-HPV infection and cytological abnormalities among our cohort of HIV-infected MSM, heterosexual men and women. We also evaluated the performance of hr-HPV and abnormal cytology in detecting high-grade dysplasia (AIN2+). Methods: A retrospective cohort study was conducted in HIV patients who underwent routine screening for anal cancer from January 2011 to January 2013. The hr-HPV test is done concomitantly on an anal cytology specimen using the Hybrid Capture 2 assay (Digene Corporation). Medical records of patients who underwent high-resolution anoscopy (HRA) because of abnormal cytology (ASCUS and above) or positive hr-HPV were reviewed. Results: A total of 221 HIV patients underwent screening with both hr-HPV and anal cytology. Among them, 67% were men (73% MSM vs 27% heterosexual). hr-HPV was positive in 43% (54% MSM, 28% non-MSM and 27% women). Anal cytology was abnormal in 39% (48% MSM, 28% non-MSM and 34% of women). Among 117 (53%) patients with an abnormal screening test, 27% had both hr-HPV infection and abnormal cytology, 14% had only hr-HPV infection and 13% had only abnormal cytology. Cytology results were normal in 50%, non-diagnostic in 10%, ASCUS in 23%, LSIL in 14% and HSIL in 2%. Among 68 HIV patients who underwent HRA because of either abnormal anal cytology or hr-HPV infection, 22 patients had AIN2+ (17 were MSM) and all had hr-HPV. None of 14 patients with negative hr-HPV who underwent HRA for abnormal cytology had AIN2+. Paired results of cytology and biopsy did not correlate (rs=-0.13). Conclusions: Anal hr-HPV infection, cytological abnormalities and AIN2+ are prevalent among our cohort of HIV-infected heterosexual men and women. We suggest anal cancer screening for all HIV-infected patients. In our limited sample, hr-HPV performed better than anal cytology in detecting and ruling out AIN2+.
Background High-grade dysplasia (HSIL) is the anal squamous cell carcinoma (ASCC) precursor. Ablation with surgery, electro cautery (ECA) and infrared coagulation (IRC) might prevent ASCC. We endeavoured to determine long-term effectiveness of HSIL ablation and progression to ASCC. Methods: A retrospective chart review of patients undergoing HSIL ablation by any modality between February 1998 until May 2012. Results: In 456 HIV+ MSM (mean age 45 ± 9 years) and 271 HIV- MSM (mean age 41 ± 11years) followed for a mean of 3 (range 0.2-13) years, 1673 HSILs were treated by laser, IRC and/or ECA. ASCC developed in 5 (0.7%) MSM but only one (0.1%) was undergoing active treatment. For HIV+ MSM, recurrence after 1st, 2nd, 3rd and 4th treatment was 66%, 64%, 62% and 54%, respectively. For HIV- MSM, HSIL recurrence after the 1st, 2nd, 3rd and 4th treatment was 59%, 44%, 46% and 50%, respectively. Median number of recurrent lesions was never greater than 2 for HIV+ MSM and 1 for HIV- MSM. The cure rate of lesions treated once in HIV+ and HIV- MSM was 73% and 84%, respectively. KM curves demonstrate that most recurrence occurs within the first 12 months after treatment. Recurrence increased with HIV infection (HR 1.3; 95% CI: 1.1-1.6) and each additional lesion treated (HR 1.6; 95% CI: 1.1-1.2). Age and treatment modality did not affect recurrence. Conclusions: Patients undergoing active ablation for cure of intra-anal HSIL appear to have limited progression to ASCC. Recurrence remains high but falls over time and repeated treatment.
The nef gene from HIV-1 has been shown to be an important pathogenic factor when considering development of AIDS. Detection of nef variants with an effect on immune modulation is important to understand HIV-1 pathogenesis and has possible impact on treatment strategies. The nef gene of HIV-1 isolates from patients in a long-term non-progressor (LTNP) cohort and a slow-progressor (SP) cohort (n = 11) was analysed and compared with isolates from a control patient group of progressors (n = 18). Most of the patients with delayed disease progression had extensive medical records, providing an insight into the LTNP disease profile and allowing for the stratification of patients based on their CD4 cell decline. In sequences from nine patients, most of the functional domains of HIV-1 Nef appeared intact, and no major deletions were observed to possibly account for an effect on the delayed disease status. However, the results demonstrate a high incidence of a single amino acid polymorphism (cysteine 138) in HIV-1 Nef. The allelic frequency of cysteine 138 between the delayed disease progression group and the progressor group was found to be statistically significant (P = 0.0139). The phylogeny of isolates was investigated and the variants harbouring the cysteine 138 mutation clustered independently. The present study describes a viral genetic polymorphism related to AIDS disease progression. The polymorphism (cysteine 138) has previously been reported to confer decreased viral replication (Premkumar DR, et al. AIDS Res Hum Retroviruses 1996; 12(4): 337-45). A sequence database search for comparative mutations revealed a high frequency of cysteine 138 in patients with reported SP AIDS.
Background Screening for the anal cancer precursor HSIL is not recommended in national guidelines. A recent Cochrane review of HSIL treatment concluded there is no evidence of efficacy. In this context, we aimed to describe the natural history of anal HSIL, and association with human papillomavirus (HPV), in a community-recruited cohort of Australian homosexual men. Methods: The SPANC study is a three-year prospective study in men aged ≥35 years. At each visit, men undergo an anal swab for cytology and HPV genotyping (Roche Linear Array), followed by high-resolution anoscopy-aided biopsy. Anal HSIL is defined as having either anal intraepithelial neoplasia grade 2/3 on histology and/or HSIL/ASC-H on cytology. Results: Among 342 men recruited by March 2013, median age was 49 with 29% HIV positive. At baseline, prevalence of anal HSIL was 50% and 44% in the HIV-positive and HIV-negative groups, respectively (P=0.303). Among those without HSIL at baseline, HSIL incidence was 28/100 person-years in both the HIV-positive and HIV-negative groups (P=0.920). Among those with HSIL at baseline, the incidence of change to non-HSIL was 41 and 43/100 person-years (P=0.851). Men with anal HPV16 at baseline were more likely to develop incident HSIL (57 vs 23/100 person-years, P=0.010), and less likely to change to non-HSIL (18 vs 61/100 person-years, P=0.001). Conclusions: Anal HSIL was highly prevalent in these homosexual men. Both incidence of HSIL and change to non-HSIL were common, and were closely associated with HPV16 status. HPV16 positivity may identify men with HSIL at higher risk of anal cancer.
PRISMA flow diagram showing screening process (adapted). 52 RCT, randomised controlled trial. 
Background: Home-based sampling is a strategy to enhance uptake of sexually transmissible infection (STI) screening. This review aimed to compare the screening uptake levels of home-based self-sampling and clinic-based specimen collection for STIs (chlamydia (Chlamydia trachomatis), gonorrhoea (Neisseria gonorrhoeae) and trichomoniasis) in females aged 14-50 years. Acceptability and effect on specimen quality were determined. Methods: Sixteen electronic databases were searched from inception to September 2012. Randomised controlled trials (RCTs) comparing the uptake levels of home-based self-sampling and clinic-based sampling for chlamydia, gonorrhoea and trichomoniasis in females aged 14-50 years were eligible for inclusion. The risk of bias in the trials was assessed. Risk ratios (RRs) for dichotomous outcomes were meta-analysed. Results: Of 3065 papers, six studies with seven RCTs contributed to the final review. Compared with clinic-based methods, home-based screening increased uptake significantly (P=0.001-0.05) in five trials and was substantiated in a meta-analysis (RR: 1.55; 95% confidence interval: 1.30-1.85; P=0.00001) of two trials. In three trials, a significant preference for home-based testing (P=0.001-0.05) was expressed. No significant difference was observed in specimen quality. Sampling was rated as easy by a significantly higher number of women (P=0.01) in the clinic group in one trial. Conclusions: The review provides evidence that home-based testing results in greater uptake of STI screening in females (14-50 years) than clinic-based testing without compromising quality in the developed world. Home collection strategies should be added to clinic-based screening programs to enhance uptake.
In Australia, data for induced abortions (IA) is unreliable, although accurate information is essential for the development of policy and funding for services relating to IA. The rate of induced abortion was an incidental finding from questionnaire data collected for a longitudinal study of chlamydia in young women in Australia. We found a pregnancy rate of 7.2/100 woman years (95% confidence interval (CI): 5.7-9.0) (n=76) and IA rate of 2.1/100 women years (95% CI: 1.4-3.2) (n=22). Differences were found between States and Territories, information which might influence the development of services in regions of Australia.
Previous studies have concluded that transgender people are a marginalised and stigmatised group, with high rates of sexually transmissible infections (STI), sex work, injecting drug use and multiple sexual partners. To our knowledge, this is the first study in Australia to focus on the sexual behaviour and sexual health needs of transgender people attending an urban sexual health clinic. A retrospective case note review was undertaken of the transgender attendees of the Sydney Sexual Health Centre between 1990 and 2006. Demographics, gender characteristics, risk behaviours, sexual health morbidity, psychosocial information and other significant features of the transgender population were assessed. Forty clients were identified as transgender, of whom 36 (90%) were male-to-female and four (10%) were female-to-male. Seventeen (43%) had a history of sex work, 16 (40%) had injected drugs, 14 (35%) had had unprotected anal or vaginal sex in the past 3 months. Twenty (50%) clients had histories of a STI, including three (7.5%) that were HIV positive, and two were co-infected with hepatitis C. Genital warts and chlamydia were the most common diagnoses made during the study period. Physical examination was inadequately documented in 53% of first visits. Psychosocial morbidity was common. Transgender clients presented infrequently at this clinic. Although half reported few risks, the other half reported multiple risk behaviours and had most STI. These findings suggest that there needs to be improved sexual health service for transgender clients at our clinic.
Background: A high incidence of vulvar cancer, and its precursor lesion, high-grade vulvar intraepithelial neoplasia (VIN) has been identified in young Indigenous women living in the Arnhem Land region of the Northern Territory (NT) of Australia. This clustering is restricted to women aged <50 years, suggesting that oncogenic human papillomavirus (HPV) is a key causal factor. This study compared the HPV genotype prevalence, HPV-16 variant distribution and p16(INK4a)expression in stored vulvar cancer and high-grade VIN biopsy specimens from women residing in Arnhem Land, with specimens taken from Indigenous and non-Indigenous women in other regions of NT where there is no observed increase in vulvar cancer incidence. Methods: Twenty high-grade VIN and 10 invasive cancer biopsies were assessed from Arnhem Land along with 24 high-grade VIN and 10 invasive cancer biopsies from other regions of NT. Results: Biopsies from Arnhem Land were similar to those from other regions in the detection of high-risk (HR) or possible HR HPV (VIN: 95% and 84% respectively for Arnhem Land and other regions, P=0.356; invasive cancer: 100% and 80%, P=0.473), HPV-16 (VIN: 60% and 80%, P=0.364; invasive cancer: 70% and 70%, P=1.0) and p16(INK4a) expression (VIN: 90% and 84%, P=0.673; invasive cancer: 100% and 80%, P=0.474). All HPV-16 variants were of the European prototype. Conclusion: Comparison of biopsies revealed no significant difference in the frequency of oncogenic HPVs or HPV-16 variant types between Arnhem Land and other regions, suggesting another cofactor in this cluster.
Background Anal Pap tests have been advocated as a screening tool for anal precancerous lesions. We aimed to ascertain prevalence and correlates of UAPT among homosexual men. Methods: SPANC is a 3-year prospective study of homosexual men aged ≥35 years in Sydney. At baseline, data were collected and study procedures, including an anal swab for ThinPrep(®) cytology, were performed. Results: UAPT initially occurred in 40 (11.7%) of 342 participants (median age 49 years; 28.7% HIV positive) enrolled by the end of March 2013. There was no difference in UAPT by collecting clinician (P=0.669) or reporting pathologist (P=0.267). UAPT occurred more than twice as often among HIV-negative compared with -positive men (13.9% vs 6.1%, P=0.048) and were less likely than satisfactory smears to contain transformation zone (TZ) cells (4.6% vs 35.4%, P<0.001). Having a UAPT was associated with more anal Pap swab discomfort (P=0.037) and feeling more tense during the exam (P=0.008), but not with haemorrhoids or past anal surgery. On multivariate analysis, never douching (P<0.001), soapy water douching (among those who douched; P=0.003), fewer anal HPV types (P=0.005) and feeling more tense during the exam (P=0.039) remained independently associated with UAPT. All UAPT were repeated within a month and results were: 21 (52.5%) again unsatisfactory, 13 (32.5%) negative, 2 (5.0%) ASCUS/LSIL and 4 (10%) ASC-H/HSIL. Conclusions: UAPT are more common among men with less receptive anal sexual experience. Causes of UAPT may be a combination of sampling, behavioural and biological factors.
Background The nucleotide analogue cidofovir has been shown to be effective in treating precancerous HPV-associated lesions located in the respiratory tract, cervix, vulva and anus. Cidofovir has been shown to have a 51% efficacy in the short-term treatment of high-grade perianal squamous intraepithelial lesions in HIV-infected persons. Less is known about the effect of cidofovir in treating more advanced stages of HPV-associated disease such as invasive cancer. Methods: We established an immortalised anal keratinocyte cell line (AKC2) following transfection of the HPV-16 genome into primary anal keratinocytes and long-term culture. AKC2 cells were invasive using in vitro collagen invasion assays. To determine the effect of cidofovir on invasion, AKC2 cells were treated for up to 7 days with different concentrations of cidofovir (10, 25 and 50 µg mL(-1)) and studied using the collagen invasion assays. Untreated cells served as a control. Results: We detected a decrease in invasion of AKC2 cells (50%, 70% and 90% decrease) with 10, 25 and 50 µg mL(-1) cidofovir, respectively. Cellular toxicity was not detected in any of the cidofovir-treated samples. Preliminary data suggest that cidofovir directly or indirectly impairs the formation of actin filaments and cellular filopodia, which are known to play a role in cellular invasion. Conclusions: Cidofovir inhibits invasion of HPV-16-transformed anal keratinocytes potentially through affecting pathways that are involved in actin filament formation. Cidofovir could potentially be useful as an adjuvant treatment for invasive anal cancers, and its mechanism of action in inhibiting cellular invasion requires further study.
Background Human papillomavirus (HPV) types 16/18 are significant causes of female cervical cancers and likely cause most anal cancers. Oestrogen influences HPV-related cervical malignancies; however, the role of testosterone in anal HPV16/18 infections is unknown. Methods: 340 men who have sex with men (MSM) enrolled in the Multicenter AIDS Cohort Study were tested for serum free testosterone (SFT) and, ~24 months later, anal HPV16/18-DNA. Poisson regression with robust error variance analyses estimated prevalence ratios for HPV16/18 infections with the following exposures: log10-transformed SFT, exogenous and supraphysiological testosterone measures, race, age, self-reported number of anal receptive intercourse partnerships ≤24 months before testing, enrolment period, body mass index, hepatitis C infection, tobacco and alcohol, HIV infection, and CD4+ T-cell counts among the HIV-infected. Stratified-tabular analyses also evaluated blood draw timing (AM/PM), study site, and time on study. Results: 89% (304/340) of men provided complete data for all covariates. On average, men were White (263/304), 60 years old (s.d. 5.3; median 60.1 years) with 76.2ngdL(-1) (s.d. 57.1; median 69.0ngdL(-1)) SFT, and 43% (132/304) were HIV infected; 25% (75/304) tested HPV16/18-DNA positive. The fully adjusted model suggests each half-log10 increase of SFT is associated with a 1.69-fold (95% confidence interval (CI): 1.08, 2.64) higher HPV16/18 prevalence. Compared with HIV-uninfected men, HPV16/18 prevalence was 1.81-fold higher (95% CI: 1.08, 3.03) for HIV-infected men with ≤500 CD4+ T-cells mm(-3). No other covariates were significantly associated with HPV16/18 prevalence. Conclusions: Higher free testosterone is associated with increased HPV16/18 prevalence in MSM, independent of sexual behaviour and other potential confounders. The mechanisms underlying this association remain unclear and warrant further study.
Background In this prospective study we evaluate the sampling performance of HPV16 DNA E6 and L1 levels in detecting anal intraepithelial neoplasm using either a moistened Dacron swab (DS) or cytobrush (CB). Methods: We recruited HIV-infected (n=57) and organ-transplanted subjects (n=3) with an abnormal anal Pap smear who presented for high-resolution anoscopy (HRA). Prior to HRA, the first 30 subjects underwent sampling with a moistened DS, and the next 30 with a CB. HRA was then performed in the usual fashion. Samples were tested for HPV16 DNA E6 and L1 DNA using a validated qPCR technique. Anal biopsies were taken as per standard-of-care and categorised as negative, AIN 1/warts, or AIN 2 or 3. Results: 59 of 60 samples had adequate DNA and were evaluated for the comparison of HPV16 E6 and L1 DNA levels. A CB performed better than the DS in detecting low positive and positive levels of HPV16 E6 DNA (P=0.01). We then further evaluated the correlation of HRA-directed biopsies and HPV16 DNA E6 levels. There was a positive correlation of HRA-directed biopsy results stratified by increasing histological levels with HPV16 E6 DNA (P=0.018, Kruskal-Wallis test). Conclusions: A CB performed better than DS for molecular HPV testing. If molecular testing is included in anal cancer screening, consideration should be made for co-sampling with both a DS for cytology and CB for HPV testing. Further studies evaluating the sample yields should be performed to assist in implementation of anal cancer screening programs in defined populations of at-risk individuals.
Vaccines are now available to prevent the development of cervical cancer from genital human papillomavirus (HPV) infection. The decision to vaccinate depends on a vaccine's cost-effectiveness. A rigorous cost-effectiveness model for vaccinated individuals is presented in a companion paper; this paper investigates the additional benefits the community might receive from herd immunity. A mathematical model was developed to estimate the impact of a prophylactic vaccine on transmission of HPV type 16 in Australia. The model was used to estimate the expected reduction in HPV incidence and prevalence as a result of vaccination, the time required to achieve these reductions, and the coverage required for elimination. The modelled population was stratified according to age, gender, level of sexual activity and HPV infection status using a differential equation formulation. Clinical trials show that the vaccine is highly effective at preventing persistent infection and pre-cancerous lesions. These trials do not, however, provide conclusive evidence that infection is prevented altogether. The possible modes of vaccine action were investigated to see how vaccination might change the conclusions. The model predicts that vaccination of 80% of 12-year-old girls will eventually reduce HPV 16 prevalence by 60-100% in vaccinated and 7-31% in unvaccinated females. If 80% of boys are also vaccinated, reductions will be 74-100% in vaccinated and 86-96% in unvaccinated females. A campaign covering only 12-year-old girls would require 5-7 years to achieve 50% of the eventual reduction. With a catch-up campaign covering 13-26-year-olds, this delay would be reduced to only 2 years. Unrealistically high coverage in both sexes would be required to eliminate HPV 16 from the population. Under pessimistic assumptions about the duration of vaccine-conferred immunity, HPV 16 incidence is predicted to rise in some older age groups. Mass vaccination with a highly effective vaccine against HPV 16 has the potential to substantially reduce the incidence and prevalence of infection. Catch-up vaccination offers the potential to substantially reduce the delay before the benefits of vaccination are observed. A booster vaccination might be required to prevent an increase in incidence of infection in women over 25 years of age.
Reproductive control refers to the ability of a man or woman to control his or her own reproduction. Unintended pregnancy is a commonly used proxy measure for reproductive control. Using heterosexually active women participating in the National Survey of Family Growth Cycle 6 (n = 4521), we evaluated unintended pregnancy as a proxy measure for reproductive control. We identified four categories of women by self-reported pregnancy intention: (1) women reporting one unintended pregnancy, (2) women reporting two or more unintended pregnancies, (3) women reporting intentionally having no pregnancies and (4) women who reported that all pregnancies were intended (reference category). Polytomous logistic regression, weighted for the complex sampling design, provided estimates of odds ratios (OR) and 95% confidence intervals (CI). Fifty-one percent of women who reported having one unintended pregnancy went on to experience at least one additional unintended pregnancy. Being black, Hispanic, born to a mother who was <18 years at first birth, having multiple partners and age of first sexual debut (consensual or non-consensual) were significant predictors of multiple unintended pregnancies. Relative to sexual debut after 18 years of age, women reporting a sexual debut at less than 15 years were at increased risk of multiple unintended pregnancies (adjusted OR (reported as consensual): 6.96; 95% CI: 4.26 to 11.39; adjusted OR (reported as non-consensual: 27.10; 95% CI: 11.03-66.57)). Efforts to delay sexual debut and to protect girls from non-consensual sex are sorely needed to prevent a lifelong trajectory of lack of reproductive control.
Background Treatment of anal high-grade squamous intraepithelial lesions (aHSIL) may prevent anal cancer. Options for treatment of diffuse lesions include staged ablation, often requiring surgery, although in-office treatment is preferable. Topical 5% 5-fluorouracil (t5FU) has been used to treat diffuse female genital HPV-associated disease. We report our experience using t5FU for treatment of diffuse aHSIL considered unsuitable for ablation, to evaluate its tolerability and efficacy. Methods: Patients were given t5FU for treatment of diffuse aHSIL in doses of 0.5 mL self-applied 2× daily for 5 days followed by 9 days off. Patients were assessed on average following 4-8 cycles for complete response (CR), defined as the absence of HSIL on exam, cytology and/or histology, or partial response (PR), defined as a reduction in the amount of disease. Patients with PR then received ablative therapy. Results: 73 patients (55 HIV infected, 18 uninfected) were treated, including 13 women and 60 men. In 69 patients who used t5FU for at least one cycle, CR occurred in 8 (~11%) patients, 53 (~77%) had a partial response indicating reduction of disease, 6 (9%) had no response, and 1 had more widespread disease, 1 chart was not evaluable. Treatment was discontinued after <1 cycle in 4 patients due to side effects. Patients with PR were treated successfully with in-office ablation, except 2 patients referred for surgery. Conclusions: t5FU was well tolerated although side effects occur. Most patients had clinical improvement, suggesting that t5FU may play an important role in aHSIL treatment. Further studies may determine its optimal use.
Background: Although the dramatic increase in the incidence of squamous cell carcinoma of the anal canal (SCCA) has been reported in recent publications, changes in the incidence and demographic patterns of adenocarcinoma of the anal canal (AAC) are unknown. Methods: The 1973-2009 SEER public use dataset was analysed to determine incidence trends for and demographic factors characterising AAC. Joinpoint analysis identified time points when the incidence rates changed. Results: Joinpoint analyses identified 1989 as the single inflection point among 1791 AAC cases at which the slope of incidence rates significantly decreased. Annual per cent change (APC) decreased from 3.5% to -1.4% overall. Analysis of demographic factors did not identify specific variables that accounted for the decrease in incidence over time. Conclusions: The incidence of AAC has declined since 1989. No demographic or clinical factor was identified that may account for change in incidence. We postulate that increasing sophistication in diagnostic studies differentiating low rectal cancers from AAC may contribute to the decrease in incidence.
Background: Numerous social determinants of health are associated with violent crime rates and sexually transmissible infection (STI) rates. This report aims to illustrate the potential usefulness of violent crime rates as a proxy for the social determinants of STI rates. Methods: For each year from 1981 to 2010, we assessed the strength of the association between the violent crime rate and the gonorrhoea (Neisseria gonorrhoeae) rate (number of total reported cases per 100?000) at the state level. Specifically, for each year, we calculated Pearson correlation coefficients (and P-values) between two variables (the violent crime rate and the natural log of the gonorrhoea rate) for all 50 states and Washington, DC. For comparison, we also examined the correlation between gonorrhoea rates, and rates of poverty and unemployment. We repeated the analysis using overall syphilis rates instead of overall gonorrhoea rates. Results: The correlation between gonorrhoea and violent crime was significant at the P<0.001 level for every year from 1981 to 2010. Syphilis rates were also consistently correlated with violent crime rates. In contrast, the P-value for the correlation coefficient exceeded 0.05 in 9 of the 30 years for the association between gonorrhoea and poverty, and in 17 of the 30 years for that between gonorrhoea and unemployment. Conclusions: Because violent crime is associated with many social determinants of STIs and because it is consistently associated with STI rates, violent crime rates can be a useful proxy for the social determinants of health in statistical analyses of STI rates.
Crude death rates among cases of diagnosed HIV infection without AIDS and after AIDS, 1981–2003.  
To investigate changes in mortality following HIV and AIDS in Australia. The results of a linkage between HIV/AIDS diagnoses and the National Death Index (NDI) to the end of 2003 were used to estimate mortality rates following HIV/AIDS. Standardised Mortality Ratios (SMRs) were calculated for deaths following HIV, with and without AIDS, in three periods of treatment; before antiretroviral therapy (< or =1989), pre- and early-HAART (1990-1996) and HAART (1997-2003). Crude mortality rates were calculated as the number of deaths per 1000 person-years. The total number of people living with HIV/AIDS was estimated. There were 1789 deaths following HIV without AIDS and 6730 deaths after AIDS. For deaths following HIV without AIDS, the SMRs were 2.99, 1.22 and 1.6 during the periods before 1990, 1990-1996 and 1997-2003. For deaths after AIDS the SMRs were 137.84, 28.64 and 4.55 in the periods one to three, respectively. The crude death rate following HIV without AIDS increased from 16.8 before 1986 to 19.6 in 2003. Death rates after AIDS decreased from 958.7 up to 1986 to 60.4 in 2003. The number of new HIV diagnoses increased to 1276 in 1990 then decreased to 780 in 2003, while AIDS diagnoses increased to 950 in 1994 then decreased to 252 in 2003. The total number of people living with HIV was estimated to be 7873 in 1989, and 12828 in 2003. Mortality following AIDS decreased while deaths before AIDS remained low. The number of people living with HIV/AIDS has increased.
Background PR is one of the US jurisdictions with the highest burden of HIV/AIDS. We describe the proportion of HIV+ anal cancer cases in PR and the impact of HIV status on anal cancer incidence trends, by sex and age. Methods: The PR Central Cancer Registry (PRCCR) and the PR AIDS Surveillance Program databases were linked using a probabilistic linkage algorithm with Link Plus v.2.0 software. The proportion of anal cancer cases with and without HIV in PR were calculated. Temporal trends (1985-2005) in the incidence rates (standardised US 2000 population) of anal cancer (overall and after exclusion of HIV+ cancer cases) were calculated through annual per cent changes (APC) and 95% confidence intervals (CIs), using a Joinpoint log-linear model. Results: From 1985 to 2005, 736 cases of anal cancer were diagnosed in PR; 26 cases were HIV+. While most anal cancer patients were female (70.8%), the proportion of HIV+ patients was higher in males (11.4%) than females (0.77%). In men, incidence increased significantly (APC=3.23, P<0.05) when HIV+ cases were considered; the increase was reduced (APC=0.97) when these were excluded (P>0.05). In females, incidence increased (APC=2.01) when HIV+ cases were considered, whereas the increase was reduced (APC=0.85) when these were excluded; these increases were non-significant (P>0.05). Conclusions: Consistent with data from the US, the increasing anal cancer incidence rates in PR were strongly influenced by the HIV epidemic in males but were independent of HIV infection in females.
Background The incidence of anal cancer (AC) in Canada is 1.5/100000 but HIV-infected individuals have incidence rates from 49-144/100000. It is important to examine risk factors for this difference. Methods: A retrospective chart review was performed to look at risk factors in patients with the diagnosis of 'anal cancer' attending the Toronto General Hospital Immunodeficiency Clinic (TGH-IC) in Toronto, Ontario, Canada, from 1985 to 2013. There were 5200 clinic attendees. Results: 36 (0.96%) males attending TGH-IC were diagnosed with AC between 1985 and 2013; 17 (47%) were diagnosed since 2008. 7 (19.4%) are deceased; 6 (16.7%) as a result of AC. Mean age at diagnosis was 56 ± 9.8 years compared with mean age at TGH-IC of 48 ± 15.9 years (P=0.015). 33 (91.7%) were on anti-retroviral therapy (ART) at time of diagnosis. Compared with current ART use, 30 (90.9%) vs 727 (72.6%; P=0.015) were on nucleoside reverse transcriptase inhibitors (NRTIs); 22 (66.7%) vs 554 (55.3%; P=0.015) were on protease inhibitors; 8 (24.2%) vs 471 (47.0%; P=0.015) were on NNRTIs. Median CD4 count at diagnosis was 265 cells mm(-3), compared with the TGH-IC of 425 cells mm(-3) (P=0.04). A tobacco history (former or current) was found in 24 (72.7%) with AC vs 2232 (41%) without AC (P=0.015). 35 (97.2%) underwent treatment: combination chemotherapy and radiation therapy being the most common in 23 (63.9%). Conclusions: In 28 years, there have been a total of 36 males diagnosed with anal cancer at TGH-IC. They were older, had a lower CD4 count and were more likely to be smokers. Combination chemotherapy and radiation therapy remains the mainstay of treatment for AC.
In Australia, it is unclear if individuals are being recurrently infected with gonorrhoea, a proxy for identifying core groups. We reviewed all notified gonococcal (GC) infections in South Australia between 1987 and 2003. A case of repeated GC infection is one in which at least one further episode of GC infection occurred after 30 days and within 365 days of the first infection. There were 253 recurrent infections (7.26%) from 238 individuals. Men who have sex with men (MSM) and Aboriginal and Torres Strait Islanders (ATSI) were significantly more likely to be recurrently infected with gonorrhoea than the rest of the South Australian population. This method of identifying individuals who have recurrent gonococcal infections can be used to target more frequent screening for individuals in a population who are more likely to be a part of the core group.
The aim of the study was to assess changes in sexual attitudes and sexual behaviour related to HIV/sexually transmissible infections (STI) during a long period of intensive efforts by the Swedish authorities to curb the spread of HIV. We conducted mailed questionnaire surveys in random samples of the Swedish general population in 1989, 1994, 1997, 2000, 2003 and 2007 (total n = 16773). Each sample consisted of some 4000-6000 participants aged 16-44 years, stratified by age: 16-17, 18-19, 20-24, 25-34 and 35-44 years. The overall participation rate was 61.6% (for men, 53.5%; for women, 69.9%). Between 1989 and 1994, the proportion of participants holding a restrictive view on sexual intercourse outside a stable relationship decreased significantly. The surveys since 1994 do not show any change in that respect. The prevalence of several sexual partners increased significantly throughout the period of study. The prevalence of casual sexual intercourse without the use of a condom also increased significantly from 1989 until 2003, but decreased slightly between 2003 and 2007. This change in sexual behaviour was more prominent in women than among men. The prevalence of several sexual partners and casual sexual intercourse without the use of a condom was significantly higher for the younger than for the older age cohorts. The study demonstrates the need for a continuous preventive campaign against HIV/STI in the general population in Sweden, particularly among young people.
Number of infectious syphilis notifications by Aboriginality, WA, 1991–2009.  
Crude notification rate of infectious syphilis by public health unit regions, WA, 2009.  
Number and crude rate of infectious syphilis notifications, WA and Australia, 2005–2009. Notes: n, number of notifications reported to state and territory health authorities; rate, crude rate per 100 000 population. Data sourced from NNDSS, extracted 1 December 2010. Data are provisional and subject to future revision.  
To describe the epidemiology of congenital and infectious syphilis during 1991-2009, examine the impact of public health interventions and discuss the feasibility of syphilis elimination among Aboriginal people in Western Australia (WA). WA congenital and infectious syphilis notification data in 1991-2009 and national infectious syphilis notification data in 2005-2009 were analysed by Aboriginality, region of residence, and demographic and behavioural characteristics. Syphilis public health interventions in WA from 1991-2009 were also reviewed. During 1991-2009, there were six notifications of congenital syphilis (50% Aboriginal) and 1441 infectious syphilis notifications (61% Aboriginal). During 1991-2005, 88% of notifications were Aboriginal, with several outbreaks identified in remote WA. During 2006-2009, 62% of notifications were non-Aboriginal, with an outbreak in metropolitan men who have sex with men. The Aboriginal:non-Aboriginal rate ratio decreased from 173:1 (1991-2005) to 15:1 (2006-2009). These data demonstrate that although the epidemiology of syphilis in WA has changed over time, the infection has remained endemic among Aboriginal people in non-metropolitan areas. Given the continued public health interventions targeted at this population, the limited success in eliminating syphilis in the United States and the unique geographical and socioeconomic features of WA, the elimination of syphilis seems unlikely in this state.
HIV diagnoses associated with heterosexual contact per 100 000 population: New South Wales (NSW), Victoria (Vic.), Queensland (Qld) and Western Australia (WA), 1993-2006. Aust, Australia. 
HIV diagnoses associated with heterosexual contact per 100 000 population: South Australia (SA), Australian Capital Territory (ACT), Northern Territory (NT) and Tasmania (Tas.), 1993-2006. Aust, Australia. 
To describe recent trends in the diagnosis of HIV infection in Australia. National HIV surveillance data from 1993 to 2006 were analysed with a focus on geographic differences by HIV exposure route and late presentation (HIV within 3 months of a first AIDS-defining illness or a CD4 count of less than 200 cells muL(-1)). In 1993-99, the number of HIV diagnoses declined by 32%, and then increased by 39% from 1999 to 2006. From 2000 onwards, rates increased significantly in Victoria, Queensland, South Australia and Western Australia. The most frequently reported routes of HIV exposure were male to male sex (71%) and heterosexual contact (18%), and the population rate of diagnoses have increased in both categories. Among the cases reported as heterosexually acquired (n = 2199), 33% were in people born in a high-prevalence country and 19% in those with partners from a high-prevalence country. Late presentation was most frequent in heterosexually acquired infections in persons who had a partner from a high-prevalence country: 32% compared with 20% overall. Recent increases in annual numbers of HIV diagnoses in Australia underline the continuing need for HIV-prevention programs, particularly among men having male to male sex. Early diagnosis and access to care and treatment should also be emphasised, as a substantial proportion of people with HIV infection are unaware of their status until late in the course of disease.
Factors associated with delayed diagnosis of HIV infection IDU, injecting drug use; MSM AE IDU, male homosexual contact with or without injecting drug use 
The identification of factors associated with delayed diagnosis of HIV infection in Victoria, Australia was the aim of the present study. Demographic and epidemiological characteristics of cases notified to the Victorian HIV surveillance database between 1 January 1994 and 31 December 2006 were analysed. Delayed diagnosis was defined as: CD4 count below 200 cells mm(-3) at HIV diagnosis or diagnosis of AIDS earlier than 3 months after HIV diagnosis. Diagnosis of HIV was delayed in 627 (22.6%) of 2779 cases. Of these, 528 (84.2%) had either a high-risk exposure or were born in a high-prevalence country. The most common exposure was male homosexual contact in 64.3% of cases. Independent risk factors for delayed diagnosis were: older age at diagnosis (30-39 years odds ratio [OR] 2.15, > or = 50 years OR 7.50, P < 0.001), exposure via routes other than male homosexual sex or injecting drug use (heterosexual sex OR 2.51, P < 0.001, unknown/other route OR 4.24, P < 0.001); birth in Southern/Eastern Europe (OR 2.54), South-east Asia (OR 2.70) or the Horn of Africa/North Africa (OR 3.71, P < 0.001), and male gender (OR 0.47 for females, P < 0.001). Delay in the diagnosis of HIV infection is common in Victoria, but potentially avoidable in the majority of cases. Most people with delayed diagnosis had a history of male homosexual contact, injecting drug use, birth in a high-prevalence country or sexual contact with such individuals. An accurate sexual history, together with knowledge of their country of birth, should identify most individuals who should be offered an HIV test.
To determine by systematic review the prevalence of genital chlamydial infection in Australia between 1997 and 2004. Electronic literature databases, reference lists, and conference proceedings were searched and health agencies and jurisdictions were contacted for published and unpublished reports. Studies were eligible if they offered a diagnostic nucleic acid amplification test to consecutive individuals presenting during the study period. As a summary measure of the available data, mean prevalence rates, weighted by sample size and irrespective of participant age, were calculated for the population sub-groups. 40 studies of 50 populations and 40,587 individuals met the inclusion criteria, but only one of these was population-based. The use of non-systematic methodologies prevented an assessment of time trends and a statistical comparison of population sub-groups. The mean overall prevalence of genital chlamydial infection was 4.6% (95% CI 4.4-4.8%), reflecting over-sampling of high-risk groups. The mean community-based rates were 7.5% (95% CI 6.4-8.6%) and 8.7% (95% CI 7.9-9.7%) for Indigenous men and women, and 1.5% (95% CI 1.1-1.9%) and 1.4% (95% CI 0.9-2.0%) for non-Indigenous men and women. The overall mean estimates for other groups were 3.3% (95% CI 3.0-3.7%) for female attendees of sexual health and related clinics, 5.6% (95% CI 4.9-6.4%) for adolescents and young adults, 3.3% (95% CI 2.8-3.9%) for sex workers, and 1.6% (95% CI 1.2-2.0%) for urethral infection in men who have sex with men. Clinic-based estimates were generally, although not consistently, higher than community-based estimates. There is no serial population-based data for sexually active young men and women, but the available age-specific rates suggest under-ascertainment by the routine surveillance systems. The prevalence of genital chlamydial infection in Indigenous Australians and young adults is unacceptably high and quality epidemiological studies are urgently required to supplement the routinely collected national notification data.
In Australia, the HIV epidemic is concentrated among gay men. In recent years, the number of new diagnoses stabilised in New South Wales (NSW), but increased in other states. We reviewed the trends in sexual behaviours to explain this difference. We used the Gay Community Periodic Surveys in NSW, Victoria and Queensland during 1998-2006 and restricted analyses to the 30-49 year olds who contribute most of the HIV cases. We used the chi(2)-test for trends in unprotected anal intercourse with casual partners (UAIC) and regular partners, number of partners, type of relationships, knowledge of HIV serostatus and its disclosure. We compared behaviours of HIV-positive and -negative men and men across states using logistic regression adjusted for the year of report. Trends in behaviours differed across the states: following a period of increase, UAIC prevalence declined in NSW since 2001, but continued to increase in Victoria and Queensland. There were other changes in NSW that were not observed in Victoria and Queensland: a decline in factors increasing HIV risk (the proportions of men with multiple sex partners and men engaging in UAIC and not knowing or not disclosing HIV serostatus) and an increase in behaviours reducing it (the proportions of men in monogamous relationships and men disclosing HIV serostatus while having UAIC). There were patterns of declining HIV risk behaviours in NSW, and increasing risk behaviours elsewhere, that mirrored recent changes in HIV case notifications in Australia. These data suggest that behavioural surveillance can predict changes in HIV epidemiology.
To compare trends in chlamydia (Chlamydia trachomatis) testing and detection with trends in hospital discharge rates of chlamydia-related diseases in the upper North Island of New Zealand during 1998-2008. Analysis of trends in chlamydia testing and detection rates and age-specific hospital admission rates per 100000 females for pelvic inflammatory disease (PID), female infertility and ectopic pregnancy, and per 100000 males for epididymo-orchitis. Regional laboratory testing volumes increased from 3732 tests per 100000 population in 1998 to 9801 tests per 100000 in 2008. Two of three regions had a significant increase in percent test positivity over time. The highest detection rates and greatest increase in reported cases were amongst women aged 15-24 years, at 1992 per 100000 in 1998, to 5737 per 100000 in 2008. For women aged 15-24 years, the rate of hospital admissions for PID and chlamydia-related pelvic infections declined during 1998-2004 but rose in 2005-08, the rate of publicly-funded infertility admissions fell and the ectopic pregnancy rate was unchanged. The age-specific rate for epididymo-orchitis admissions amongst 15-44-year-old men remained stable. Chlamydia testing volumes from three New Zealand regions have trebled since 1998, as have reported infection rates, although disease complication rates do not appear to have increased. Test positivity increases may reflect better targeted testing of those more at risk or a rising chlamydia incidence. The recent rise in hospital admissions for PID among women aged 15-24 is a concern; ongoing monitoring of these trends, despite data limitations, is important.
Over the last decade, significant advances have occurred in the area of chlamydia diagnostics. The relative frequency of different testing methods employed in the diagnosis of Chlamydia trachomatis infection in New South Wales has not been previously reported. Testing methods--both laboratory method and specimen type--employed in the diagnosis of chlamydia cases notified in New South Wales between 1999 and 2002 were collated from Health Department records. During a period of increasing notifications, the proportion of men diagnosed with C. trachomatis using nucleic acid tests (NATs) increased from 36% in 1999 to 90% in 2002. Among women, the proportion diagnosed using NATs increased from 42% in 1999 to 92% in 2002. Urine samples were consistently used in the diagnosis of two-thirds of the men, and one-third of the women. Between 1999 and 2002, a rapid shift towards NATs for genital C. trachomatis took place in New South Wales.
The rise in serious complications of early syphilis, including neurosyphilis, particularly in those with HIV infection and in men who have sex with men (MSM), is of concern. To review the manifestations and management of neurosyphilis in a population of HIV-infected MSM. Retrospective review of patients with HIV and early neurosyphilis in three centres in Melbourne, Australia, in 2000-07. Eighteen male HIV patients met the criteria for diagnosis of early neurosyphilis. Thirteen patients (72.2%) had neurological symptoms: six with headache (33.3%), four with tinnitus (22.2%) and five with impaired vision (27.8%), and one patient each with ataxia, leg weakness and anal discharge with faecal incontinence. Five patients (27.8%) reported no neurological symptoms. All had serum rapid plasma reagin (RPR) titres ≥1:32 and all except one had cerebrospinal fluid positive for syphilis fluorescent treponemal antibodies-absorbed. After treatment with 14-15 days of 1.8 g intravenous benzylpenicillin 4-hourly, 12 of 17 patients (71%) demonstrated a four-fold drop in serum RPR titre over 6-12 months and were considered successfully treated. A rise in RPR was noted in three patients during the 12-month follow-up period, suggesting re-infection or recurrence. HIV-infected patients found to have syphilis either because of symptoms or by routine screening should be carefully assessed for neurological, ophthalmic and otological symptoms and signs. A low threshold for a diagnostic lumbar puncture to exclude the diagnosis of neurosyphilis enables appropriate administration and dose of penicillin for treatment, which appears successful in ~75% of cases.
Sexually transmissible infection (STI) problem management rate. 
Management rate of all six specified sexually transmissible infections combined. Bars indicate 95% confidence intervals. 
Unlabelled: Background In Australia, general practitioners (GPs) manage the majority of sexually transmissible infections (STIs). Most STIs are diagnosed and treated by GPs as a result of symptom recognition or risk identification. We aimed to determine how frequently six common STIs were managed by GPs, the characteristics of the GPs and patients, and any changes over time. Methods: Data from the Bettering the Evaluation and Care of Health (BEACH) program for April 2000-March 2012 were analysed. BEACH is a national study of GP activity. The overall management rates of genital herpes (herpes simplex virus, HSV), genital warts, HIV, chlamydia (Chlamydia trachomatis), gonorrhoea (Neisseria gonorrhoeae) and syphilis were calculated. Results: In total, 11784 GPs recorded details of 1178400 patient encounters. These included: 115 cases of genital HSV per 100000 encounters, 92 of genital warts, 67 of HIV, 39 of chlamydia, 6 of gonorrhoea and 7 of syphilis. Higher management rates occurred among patients who were male, 15-24 years old, more socially advantaged, Aboriginal or Torres Strait Islander, resident in a major city or of English-speaking background. GPs who were female and those aged under 60 years had higher STI management rates than their counterparts. Conclusions: HSV and warts were the most common STIs managed. Lower management rates for the other STIs may reflect lower incidence or lower testing rates, because these other STIs are frequently asymptomatic. It is important to determine whether existing approaches effectively target the most at-risk communities and what barriers to presentation exist.
Chlamydia notifications in women in NSW 2001-2008 for: (a) all women aged 15-44 years; (b) according to age group. 
Chlamydia notifications in women in NSW 2001-2008 for: (a) all women aged 15-44 years; (b) according to age group. 
Women hospitalised for ectopic pregnancy in NSW 2001-2008: (a) all women aged 15-44 years; (b) according to age group. 
Women hospitalised for infertility (female origin) in NSW 2001-2008: (a) all women aged 15-44 years; (b) according to age group. 
As genital chlamydia (Chlamydia trachomatis) notifications have increased in Australia, time trends in hospitalisations for ectopic pregnancy and female infertility between 2001 and 2008 in New South Wales (NSW), Australia, and their relationship to trends in chlamydia notifications in women were assessed. Annual rates of chlamydia notification, and hospitalisations for female infertility or ectopic pregnancy in women aged 15-44 years in NSW were calculated using routinely collected data. Chlamydia notifications and hospital separations occurring within each year belonging to the same woman were linked using probabilistic linkage of identifiers so that multiple notifications and admissions for one woman in each calendar year were only counted once. From 2001 to 2008, the annual rate of chlamydia diagnoses in women increased from 157 to 477 per 100000 population (P(trend)<0.001). Over the same period, the annual hospitalisation rate for women with an ectopic pregnancy decreased from 14.3 to 12.6 per 1000 births (P(trend)<0.001). This decrease was mostly in women aged 25-44 years, with no appreciable fall in women aged 15-24 years (P(trend)=0.8). Meanwhile, the hospitalisation rate for women with infertility of female origin did not follow a consistent trend: between 2001 and 2008, it fluctuated between a low of 479 and a high of 554 per 10000 women who were seeking pregnancy. These trends in ectopic pregnancy and female infertility suggest that the large increase in chlamydia notifications may not reflect hospitalisations for these two proposed chlamydia-related sequelae.
The global community has again failed to significantly confront the AIDS crisis. In the context of a worsening HIV pandemic, the conference highlighted the shortfall in funding, the soaring infection rate in Asia, the need to integrate prevention and treatment and the difficulties in coordinating a global response. To overcome AIDS, the global community must put aside ideology and honour its commitments.
The study aimed to examine the trends in notification and testing for genital gonorrhoea (Neisseria gonorrhoeae) in the Darwin Remote District of Northern Territory, Australia, between 2004 and 2008. Using laboratory testing data and notification data, we calculated the annual sex- and age-specific notification rates, testing rates and positivity rates, and examined their trends. A deterministic matching method was used to identify unique individuals tested in order to estimate the number of years out of five in which each individual was tested. The correlation between testing rates and notification rates was calculated. The notification rates for the 15-24 year age group increased sharply from 2004 to 2005, and then trended downwards between 2005 and 2008, with a decrease of 48.2% in females and 59.9% in males. No evident trends were found in testing rates. The positivity rates for this age group decreased by 46.3% in females (from 8.9% to 4.8%), and by 70.4% in males (from 10.8% to 3.2%) between 2004 and 2008. Over 76% of the population in this age-group had been tested at least once during the study period. A moderate correlation was found between notification rates and testing rates in both sexes. There was a significant decreasing trend in the notification rate of gonorrhoea between 2005 and 2008, which was most probably due to a decrease in prevalence. This study demonstrates the importance and utility of population-level testing data in understanding the epidemiology of common bacterial sexually transmissible infections such as gonorrhoea.
Gonorrhoea is one of the most common sexually transmissible infections in mainland China. Effective spatial monitoring of gonorrhoea incidence is important for successful implementation of control and prevention programs. The county-level gonorrhoea incidence rates for all of mainland China was monitored through examining spatial patterns. County-level data on gonorrhoea cases between 2004 and 2009 were obtained from the China Information System for Disease Control and Prevention. Bayesian smoothing and exploratory spatial data analysis (ESDA) methods were used to characterise the spatial distribution pattern of gonorrhoea cases. During the 6-year study period, the average annual gonorrhoea incidence was 12.41 cases per 100000 people. Using empirical Bayes smoothed rates, the local Moran test identified one significant single-centre cluster and two significant multi-centre clusters of high gonorrhoea risk (all P-values <0.01). Bayesian smoothing and ESDA methods can assist public health officials in using gonorrhoea surveillance data to identify high risk areas. Allocating more resources to such areas could effectively reduce gonorrhoea incidence.
Chart of primary and secondary syphilis morbidity (number per 100 000) from surveillance and MarketScan data by gender, 2005-10. *, P < 0.01 for trend analysis tests.
A composite chart of gonorrhoea morbidity comparing the relative reported case and diagnosis claim rates from surveillance and MarketScan data (continuous enrolees), respectively by gender and age, 2005-10. (a) Relative rates from surveillance data, males; (b) relative rates from MarketScan data, males; (c) relative rates from surveillance data, females; (d) relative rates from MarketScan data, females.
A composite chart of primary and secondary (P&S) syphilis morbidity comparing the relative reported case and diagnosis claim rates from surveillance and MarketScan data (continuous enrolees), respectively by gender and age, 2005-10. (a) Relative rates from surveillance data, males; (b) relative rates from MarketScan data, males; (c) relative rates from surveillance data, females; (d) relative rates from MarketScan data, females.
Background: Given the growing popularity of administrative data for health research, information on the differences and similarities between administrative data and customary data sources (e.g. surveillance) will help to inform the use of administrative data in the field of sexually transmissible infections (STIs). The objective of this study was to compare the incidence rates of three nonviral STIs from a large health insurance administrative database (MarketScan) with surveillance data. Methods: We computed and compared STI rates for 2005-10 from MarketScan and national surveillance data for three major nonviral STIs (i.e. chlamydia (Chlamydia trachomatis), gonorrhoea (Neisseria gonorrhoeae) and syphilis (Treponema pallidum)). For administrative data, we assessed the sensitivity of the rates to enrollee inclusion criteria: continuous (≥320 member-days) versus all enrollees. Relative rates were computed for 5-year age groups and by gender. Results: The administrative database rates were significantly lower (P<0.01) than those in the national surveillance data, except for syphilis in females. Gonorrhoea and syphilis rates based on administrative data were significantly lower (P<0.01) for all enrollees versus continuous enrollees only. The relative STI rates by age group from the administrative data were similar to those in the surveillance data. Conclusions: Although absolute STI rates in administrative data were lower than in the surveillance data, relative STI rates from administrative data were consistent with national surveillance data. For gonorrhoea and syphilis, the estimated rates from administrative data were sensitive to the enrollee inclusion criteria. Future studies should examine the potential for administrative data to complement surveillance data.
Unlabelled: Background Men who have sex with men (MSM) experience disparities in access to healthcare and have specific healthcare needs. Methods: We analysed data from the 2006-10 National Survey of Family Growth (NSFG) to examine differences in access to healthcare and HIV and sexually transmissible infection (STI) related health services by MSM and non-MSM among men in the United States aged 15-44 years who have ever had sex. MSM and sexually active MSM were identified in the NSFG as men who had ever had oral or anal sex with another man, or who had sex in the past 12 months with another man, respectively. Access was measured by the type of health insurance, having a usual place for receiving healthcare and type of usual place. Results: Of men aged 15-44 years who have ever had sex, there were no significant differences between MSM and non-MSM in the three access measures. MSM were more likely than non-MSM to receive HIV counselling (22.5% v. 8.3%) and STI testing (26.2% v. 15.6%) in the past 12 months, or to ever have had HIV testing (67.8% v. 44.6%). STI testing in the past 12 months was reported by 38.7% of sexually active MSM. Conclusion: Our findings show no significant differences in access to healthcare between MSM and non-MSM. MSM were more likely to receive HIV- and STI-related preventive services than non-MSM. However, the low STI testing rate among MSM highlights the need for interventions to increase STI testing, and HIV and STI counselling for MSM.
In the United States, sexually transmissible infection (STI) and family planning (FP) clinics play a major role in the detection and treatment of STIs. However, an examination of the spatial distribution of these service sites and their association with STI morbidity and county-level socioeconomic characteristics is lacking. We demonstrate how mapping and regression methods can be used to assess the spatial gaps between STI services and morbidity. We used 2007 county-level surveillance data on chlamydia (Chlamydia trachomatis), gonorrhoea (Neisseria gonorrhoeae) and syphilis. The geocoded STI service (STI or FP clinic) locations overlaid on the Texas county-level chlamydia, gonorrhoea and syphilis morbidity map indicated that counties with high incidence had at least one STI service site. Logistic regression was used to examine the association between having STI services and county-level socioeconomic characteristics. Twenty-two percent of chlamydia high-morbidity counties (>365 out of 100000); 32% of gonorrhoea high-morbidity counties (>136 out of 100000) and 23% of syphilis high-morbidity counties (≥4 out of 100000 and at least two cases) had no STI services. When we controlled for socioeconomic characteristics, high-morbidity syphilis was weakly associated with having STI services. The percent of the population aged 15-24 years, the percent of Hispanic population, the crime rate and population density were significantly (P<0.05) associated with having STI services. Our results suggest that having an STI service was not associated with high morbidity. The methods used have demonstrated the utility of mapping to assess the spatial gaps that exist between STI services and demand.
Antenatal testing for specified sexually transmissible infections (STIs) and blood-borne viruses (BBVs) is recommended by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). In 2007, the Department of Health, Western Australia (DoHWA) issued an operational directive (OD) recommending universal testing for chlamydia and additional testing for women in the STI endemic regions of Western Australia (WA). To assess adherence to these guidelines, seven WA public hospitals were audited. Demographic details and testing information of the last 200 women who gave birth immediately before 30 June 2007 (baseline audit) and 30 June 2010 (follow-up audit) were obtained from each hospital's antenatal records. Data from 2718 women who delivered at ≥36 weeks' gestation were analysed (baselinen=1353; follow-upn=1365). Testing at the first antenatal visit in accordance with the guidelines improved over time (RANZCOG: 68-74%; χ(2)-test = 13.96, d.f.=1, P<0.001; DoHWA OD: 12-40%; χ(2)-test = 279.71, d.f.=1, P<0.001). Retesting at 28-36 weeks' gestation in the STI endemic regions improved for chlamydia (3-10%; χ(2)-test = 17.40, d.f.=1, P<0.001) and gonorrhoea (3-7%; χ(2)-test=6.62, d.f.=1, P<0.05), but not for syphilis or HIV. Chlamydia prevalence was 3% and 8% among nonAboriginal and Aboriginal women, respectively. The proportion of women delivering in WA public hospitals who had antenatal STI and BBV tests improved after publication and promotion of the OD.
Objectives: To construct an Index of Sexual Health Deprivation (ISHD), examine its sensitivity, investigate the association between the ISHD and the Index of Multiple Deprivation 2010 (IMD2010), and interpret the observed geographic variation. Methods: The modified IMD method was informed by the IMD2010. Thirteen profiles relating to sexual health were selected and grouped into four domains. The observed profile values for each primary care trust (PCT) were smoothed and converted to a normal distribution before principal component analysis. Loadings were used to calculate profile weights. Domain scores were calculated by combining weighted profiles, which were combined to create the ISHD. A Bayesian approach acted as a comparator for the ISHD. Results: Substantial variation in sexual health deprivation was seen across strategic health authorities (SHA). The London SHA had the highest proportion of PCTs (61%) among the most deprived quartile, followed by North-West SHA (29%). More than half of PCTs in East of England (71%), South Central (56%) and South-West (50%) SHAs fell into the least deprived quartile. No PCTs within the East of England, South Central and South-West SHAs were in the most deprived quartile. Only 57% of PCTs were attributed to the same quartile of the ISHD as the IMD2010. The modified IMD method and the Bayesian approach produced consistent results. Conclusions: The ISHD provides a robust picture of the geography of sexual health and shows a weak association with the IMD2010. It can be used to guide public health action to reduce the geographical gradient in sexual health inequality.
Background: Chlamydia (Chlamydia trachomatis) is the most commonly diagnosed sexually transmissible infection (STI) in Singapore, with rising incidence. Method: Random sampling was performed on all chlamydia-positive samples collected from female patients who attended a women's clinic from January 2010 to December 2010. Some 250 electronic medical records were analysed. Population demographics, sexual histories, symptoms, diagnostic methods and management were recorded. Results: One hundred and forty-two (56.8%) patients were under 25 years of age. The predominant race diagnosed with Chlamydia cervicitis were Chinese (116 cases, 46.4%) followed by 86 (34.4%) Malays and 20 (8%) Filipinos. Sixty-three (25.2%) were skilled workers and (47) 18.8% were students. Professionals and office workers together formed 68 (27.2%) of the patients. Some 248 (99.2%) patients were heterosexual and 2 (0.8%) patients were bisexual; 229 (91.6%) patients had regular partners, 18 (7.2%) had casual partners and 3 (1.2%) had both. Concurrency prevalence accounted for 49 cases (19.6%) and condom use was less common. Patients were generally asymptomatic, with 114 (45.5%) presenting with symptoms. One hundred and eight (43.2%) patients had 2-5 sexual partners in their lifetime. Patients with a termination made up 12% of our cohort. This episode of infection was the first diagnosis of an STI for 198 (79.2%) patients; 24 (9.6%) of patients had been previously diagnosed with chlamydia. Conclusion: Chlamydia infection was most prevalent in skilled workers and their regular partners with heterosexual practices under 25 years old. Most patients had 2-5 sexual partners and did not use condoms consistently or at all.
Background: Improving sexual health and blood-borne virus (BBV) outcomes continue to be of high priority within the United Kingdom (UK) and it is evident that the media can and do impact the public health agenda. This paper presents the first large-scale exploration of UK national newsprint media representations of sexual health and BBVs. Methods: Using keyword searches in electronic databases, 677 articles published during 2010 were identified from 12 national (UK-wide and Scottish) newspapers. Content analysis was used to identify manifest content and to examine the tone of articles. Results: Although there was a mixed picture overall in terms of tone, negatively toned articles, which focussed on failures or blame, were common, particularly within HIV/AIDS, hepatitis B and C, and other sexually transmissible infection coverage (41% were assessed as containing negative content; 46% had negative headlines). Differences were found by newspaper genre, with 'serious' newspaper articles appearing more positive and informative than 'midmarket' newspapers or 'tabloids'. Across the sample, particular individuals, behaviours and risk groups were focussed on, not always accurately, and there was little mention of deprivation and inequalities (9%). A gender imbalance was evident, particularly within reproductive health articles (71% focussed on women; 23% on men), raising questions concerning gender stereotyping. Conclusions: There is a need to challenge the role that media messages have in the reinforcement of a negative culture around sexual health in the UK and for a strong collective advocacy voice to ensure that future media coverage is positively portrayed.
Top-cited authors
Andrew Grulich
  • UNSW Sydney
Christopher Fairley
  • Monash University (Australia)
Garrett Paul Prestage
John Kaldor
  • UNSW Sydney
Jane Hocking
  • University of Melbourne